Like many chronic conditions, getting Medicare coverage for sleep apnea treatment can be a struggle. Let’s be honest! Navigating medical insurance sometimes feels like taking a walk in the Amazon rainforest. It sounds like it shouldn’t be too difficult, but then you’re in the middle of it and left feeling confused, frustrated, and probably a bit lost.
The good news is there are a lot of options when it comes to treating sleep apnea. But one common question is, “Does Medicare cover CPAP machines?”. The answer to that is yes, they do. However, there are a few things you should probably know before starting your Medicare CPAP journey.
If you go through Medicare to get your CPAP machine, we want to help make that process as smooth as possible. So today, we’re here to answer all your questions about CPAP coverage, including the approval process, how much they cover for CPAP therapy, and whether it’s worth paying for your CPAP on your own.
Does Medicare Pay for CPAP Equipment?
Medicare covers a range of equipment necessary for CPAP therapy, including your CPAP machine, mask, tubing, and other supplies. Keep in mind that not everything is included, such as cleaning supplies.
Also, your insurance will replace these parts on a scheduled basis. For example, your machine will most likely be replaced after five years, while your CPAP mask will be replaced at least twice a year!
Does Medicare Cover CPAP Machines?
CPAP machines are covered by the Medicare Part B plan under the Durable Medical Equipment coverage. However, to qualify for coverage, you must first be diagnosed with sleep apnea and agree to use your CPAP machine consistently.
Additionally, your chances of getting your CPAP approved by insurance will probably depend on a few factors, including the following:
- Severity: If you have moderate or severe sleep apnea, you can most likely be approved for your CPAP without trying other solutions first. However, people with very mild sleep apnea may be encouraged to try lifestyle changes and Positional Therapy before moving to CPAP therapy. In some cases, they may also suggest Oral Appliance Therapy.
- Type of Sleep Apnea: CPAP is often highly effective for people with mild to severe Obstructive Sleep Apnea. Healthcare providers also prescribe it for mild to moderate cases of Central Sleep Apnea, but more severe cases may require a different approach.
Does Medicare Cover CPAP Supplies?
While there are a handful of items that this insurance doesn’t pay for, Medicare covers the majority of the equipment that you need for CPAP therapy, including your machine, mask, and related supplies.
Below is a list of CPAP supplies that Medicare covers, including replacement parts!
- CPAP Mask
- Humidifier Chamber
- CPAP Filters (Disposable or Non-Disposable)
- Chinstrap for Holding Your Mouth Closed
- CPAP Headgear
- CPAP Heating Element
- CPAP Tubing/Hoses
- Nasal CPAP Mask Interface
- Full Face Mask Interface
- Nasal Pillows
- CPAP Mask Cushions
How Much Does CPAP Therapy Cost With Medicare?
If you have Medicare, your out-of-pocket costs for CPAP therapy will differ depending on the total price of your CPAP equipment. If you qualify for CPAP therapy coverage, you are responsible for paying 20% of the total cost of their treatment.
Remember that this coverage does not kick in until you have met your annual Medicare Part B deductible of $226 in 2023. Depending on when you begin your CPAP journey, you will most likely have met that deductible after completing your initial doctor’s visit or sleep study.
How Much Does CPAP Therapy Cost Out-of-Pocket?
With Medicare, you pay 20% for your necessary CPAP equipment. So, if the average CPAP machine costs between $500 and $1,200, you’ll pay between $100 and $240. Similarly, CPAP masks cost anywhere from $70 to over $200, so you would pay $14 to $40+.
On another note, while Medicare does replace essential CPAP equipment, including masks and hoses, it does not usually pay for extra CPAP accessories or equipment deemed unnecessary. So, keep in mind that you may completely be on the hook for things like CPAP cleaning supplies or comfort accessories.
To understand how much CPAP therapy could cost you out-of-pocket after Medicare, let’s look at some of the most popular CPAP products.
- ResMed AirSense 11 AutoSet CPAP Machine: The ResMed Airsense 11 is not only our favorite CPAP machine but also one of the most popular! It runs for just under $1,000 before tax. If you were to buy this machine with Medicare, it would cost you $200 out of pocket.
- ResMed AirFit F20 Full Face CPAP Mask: Another fan favorite, this mask currently costs $155, pre-tax, meaning you would pay $31 through Medicare.
- CPAP Accessories: Costs can vary here depending on the accessory, but the basics should cost you less than $100 per year.
How to Qualify for CPAP Therapy With Medicare
If you are interested in getting your CPAP therapy covered by Medicare, there are a few steps that you will need to take. Let’s discuss this process a little more!
1. Schedule an Evaluation With a Medicare-Approved Provider
Start by scheduling a trip to your doctor’s office to discuss your concerns about sleep apnea. This appointment is necessary not only for your sleep study to be approved by insurance but also for your doctor to begin documenting the effects of sleep apnea on your health and wellness.
During this visit, you will undergo a physical exam and an interview to determine whether you have any risk factors for sleep apnea, including advanced age, obesity, or underlying conditions associated with sleep-disordered breathing.
Arrive at your appointment prepared to discuss the signs and symptoms that you are exhibiting that make you think that you have sleep apnea. It may be helpful to document any issues you may be experiencing regularly, such as loud snoring, fatigue, or morning headaches.
2. Complete a Sleep Test
Once your provider establishes that you are at risk for sleep apnea, your healthcare provider will order a traditional sleep study or a Home Sleep Apnea Test (HSAT). These tests will determine whether or not you are experiencing sleep apnea episodes and, if so, how much they impact your sleep quality.
Below are the standard guidelines for a sleep apnea diagnosis, plus Medicare’s policies for CPAP therapy coverage. These test results are based on the Apnea-Hypopnea Index, which measures the number of sleep apnea episodes you experience during sleep.
|AHI Score||Sleep Apnea Severity||Medicare CPAP Therapy Coverage|
|0 to 4 AHI||Normal||CPAP therapy not required.|
|5 to 15 AHI||Mild Sleep Apnea||Qualifies for Medicare’s CPAP therapy coverage if your life is impacted by sleep apnea or you have a co-existing condition related to sleep apnea.|
|16 to 30 AHI||Moderate Sleep Apnea||Qualifies for Medicare’s CPAP therapy coverage.|
|30 or More AHI||Severe Sleep Apnea||Qualifies for Medicare’s CPAP therapy coverage.|
3. Obtain a Prescription for a Medicare-Approved CPAP Machine
If your sleep study results suggest that you need CPAP therapy, your doctor will most likely want to discuss your treatment options. Experts usually suggest that most people with Obstructive Sleep Apnea start by treating their condition with Continuous Positive Airway Pressure. This may also be true for those with mild to moderate Central Sleep Apnea.
If your provider agrees that you would benefit from starting CPAP therapy, they will write you a prescription for a CPAP machine and any necessary accessories. Once you receive your CPAP prescription, you can start shopping for your CPAP equipment.
4. Submit Medicare Documentation Requirements
After completing the above steps, it is time to submit the documentation to Medicare to inform them that you need to start CPAP therapy. During this time, you will be asked to submit relevant medical records, sleep study results, and CPAP prescription. Your insurance will then review this information and decide whether or not you have met the requirements for starting CPAP therapy.
5. Prove Medicare CPAP Compliance After 90 Days
Although Medicare covers CPAP machines, it has a unique approach. This process is based on the expectation that many people find CPAP therapy difficult to adjust to. Despite being highly effective, up to 50% of those who require Continuous Positive Airway Pressure end up quitting their treatment within the first week of use.
To remedy this issue, Medicare approves your CPAP coverage in stages. Usually, this means that Medicare agrees to cover your sleep apnea treatment, including your machine, CPAP mask, and any necessary accessories, for a trial period of three months. During this time, they will track your CPAP compliance rate, which measures how often you use your equipment.
Your insurance will then use this information to determine how effective this solution is for you and whether you are sleeping with your CPAP device often enough to justify continuing to cover the cost of your therapy.
So, what is your insurance company looking for when deciding whether or not a CPAP machine is right for you? To be considered CPAP compliant, most health insurance providers ask that you sleep with your CPAP equipment for at least 21 nights per month for a minimum of four hours per night.
6. Attend a Follow-Up Visit Within 3 Months of Starting CPAP Therapy
Once you have used your CPAP machine for a couple of months, you will return to your doctor’s office for a follow-up evaluation. Much of this appointment will be a repeat of your first appointment.
You will once again discuss your sleep apnea signs and symptoms and be asked if they are improving. It may be helpful to keep a log of how you feel in those early days of CPAP therapy, as it will help your doctor decide whether or not you are seeing any benefits from CPAP.
Additionally, your provider will check the data from your CPAP machine to determine if your condition is improving. Specifically, they are looking for a significant reduction in the number of sleep apnea episodes you experience per hour, commonly called your AHI score.
In most cases, the goal is to reduce these episodes to less than five, but this depends on the severity of your condition. If you have severe sleep apnea, Medicare may be satisfied with an AHI score of ten. But as a general rule, your insurance will most likely be satisfied if you continue to significantly improve your sleep apnea.
How Does Medicare Cover CPAP Therapy?
It may seem like Medicare CPAP coverage is complicated, but it isn’t so bad once you understand how and what they cover!
When Does Medicare CPAP Coverage Kick In?
Once again, Medicare has a unique approach to CPAP coverage. Medicare’s Part B Durable Medical Equipment policy covers CPAP machines and related CPAP equipment. That means you will qualify for coverage if the following requirements are met:
- Your provider participates in the Medicare program.
- You have met all of the requirements to qualify for CPAP therapy.
- Your CPAP machine and supplies have been approved for Medicare coverage.
- You have successfully completed your 90-day CPAP trial.
- You have met your Medicare Part B deductible of $226 (as of 2023).
How Does Medicare Cover CPAP Machines?
Medicare utilizes a rent-to-own program for covering CPAP machines. So once you are approved for CPAP coverage, you will enter into a 13-month payment plan agreement between your insurance and the CPAP vendor. After these payments have been made, you become the full owner of your machine and may continue using it until the manufacturer says it must be replaced, usually in about five years.
Remember that your CPAP machine and other supplies will only be covered if your doctor and the vendors are involved in the Medicare program. So, be sure to do your research before selecting these medical devices, as you could be left on the hook for the full cost of your CPAP.
Benefits and Drawbacks of Purchasing Your CPAP With Medicare
There are many factors to consider when deciding whether buying a CPAP machine with or without Medicare is right for you. Here are some factors you may wish to consider!
Pros of Purchasing a CPAP With Medicare vs Out-of-Pocket
- Financial Assistance: Medicare can help offset the cost of a CPAP machine, making it more affordable for individuals who may not have the means to purchase it outright.
- Comprehensive Coverage: Medicare typically offers coverage for the CPAP machine along with accessories and supplies, such as masks, tubing, filters, and humidifiers.
- Professional Guidance: With Medicare, you may have access to more healthcare experts experienced in sleep medicine who can guide you through selecting the right CPAP equipment and providing ongoing support.
Cons of Purchasing a CPAP Machine With Medicare vs Out-of-Pocket
- Eligibility Criteria: You must meet certain eligibility requirements to qualify for Medicare coverage, which may vary depending on your state. Not everyone may qualify for this assistance.
- Limited Options: Medicare may have specific guidelines on which CPAP machines and accessories are covered, limiting your choices compared to purchasing independently.
- Long Administrative Processes: Obtaining Medicare coverage for a CPAP machine can involve paperwork, documentation, and potential delays, which may require time and effort.
- Availability of Providers: Depending on your location, you may have limited options regarding healthcare providers or Durable Medical Equipment (DME) suppliers who accept Medicare.
Frequently Asked Questions About Medicare Coverage of CPAP
Does Medicare Cover CPAP Accessories Such as CPAP Cleaners and CPAP Batteries?
In most cases, insurance companies, including Medicare, do not cover unnecessary CPAP equipment and supplies. Unfortunately, this includes CPAP cleaners and CPAP batteries, as you can use gentle soap and water for cleaning, and the need for extra batteries is rare.
Does Medicare Cover Replacement Supplies?
According to the Department of Health and Human Services, Medicare regularly replaces necessary CPAP supplies as recommended per manufacturer standards. This includes things like your CPAP mask, hoses, and CPAP mask cushions.
Does Medicare Pay for CPAP Machines?
Yes! Medicare usually covers 80% of the cost of your CPAP machine, so long as you qualify for Medicare coverage of CPAP therapy. This means you should expect to pay for the remaining 20%. This policy also goes for CPAP supplies, such as masks and tubing.
How Much Does CPAP Cost Without Insurance?
The average CPAP machine costs anywhere from $300 to over $1000 without insurance. So, while it is probably much easier to purchase your CPAP machine outright without insurance, it is substantially more expensive.
Does Medicare Cover Travel Machines?
Travel CPAP machines are covered through Medicare Part B’s Durable Medical Equipment policy, just like any other machine. However, if you choose to go with a travel machine, remember that Medicare will only cover one machine every five years, so if you want a regular CPAP device, you will need to purchase it out of pocket.
How Much Does Medicare Pay for CPAP Machines?
Medicare Part B does not pay a set dollar amount for most medical devices. Usually, it covers a specific percentage of your CPAP machine and supplies. Medicare covers 80% of the total cost of CPAP, meaning you pay the other 20%. If your CPAP machine costs $900, you pay $180.
Does CPAP.com Accept Medicare Coverage?
Unfortunately, we do not accept Medicare payments for our CPAP machines or other equipment. Working with insurance requires additional resources, which our site does not currently have. However, we are always happy to assist you with any questions, no matter where you have purchased your CPAP equipment!
Purchasing a CPAP machine with Medicare can take time and patience, but treating your sleep apnea is always worth it! We hope this article helps make your CPAP journey a little bit easier. Remember that it is important to check with your local Medicare office or healthcare provider to understand the specific coverage and limitations related to purchasing a CPAP machine with Medicaid in your area.