Sleep disorders, including sleep apnea, have become a significant health issue in the U.S.
According to a 2021 survey by the American Sleep Association, 50 to 70 million adults in the U.S. are affected by a sleep disorder. Of these, 25 million adults have obstructive sleep apnea.
This is why there were more than 8 million CPAP users in the U.S. in 2018, with the numbers climbing by 9% yearly.
In this article, we will discuss Medicare, their CPAP coverage, how much it costs, and alternative options for coverage.
Medicare is a federal health insurance program for people aged 65 or older, individuals with disabilities, and people of any age with End-Stage Renal Disease.
To help cover various medical services, the federal Medicare program is made up of different parts:
Part A (Inpatient care) covers the care and treatment of patients in hospitals and other medical facilities. For example, hospice care and skilled nursing facility care.
A skilled nursing facility (SNF) is a place where people go when they require medical care if, for example, recovery following a stroke.
Part B (Outpatient care) covers outpatient care and services. This includes bills for specialist consultations, screenings, vaccines, and durable medical equipment such as wheelchairs and walkers.
Part D covers the cost of prescription drugs. Instead of being run by the government, these plans are run by private insurance companies.
A continuous positive airway pressure (CPAP) machine is the most commonly prescribed device for treating sleep apnea disorders.
CPAP machines help people who have sleep apnea breathe more easily during sleep. The machine increases air pressure in your throat so that your airway doesn't collapse when you breathe in.
It does so by sending a steady flow of oxygen into your nose and mouth as you sleep. This keeps your airways open and helps you breathe normally.
All CPAP devices have the same basic components:
A motor inside the base unit
A cushioned mask
A tube that connects the motor to the mask
A piece of headgear that goes around the head
“Elbow” pieces that act as joints
Adjustable straps to make the device fit better.
Sleep apnea is a sleep disorder that can cause a lot of health problems, like high blood pressure and heart trouble, if it's not treated.
Untreated sleep apnea can cause breathing to stop repeatedly while you sleep, which causes loud snoring and makes you feel tired during the day, even after a good night's sleep.
Anyone can get sleep apnea, but it's most common in older men who are overweight.
There are three main types: central, obstructive, and complex. Obstructive sleep apnea (OSA) is the most common type.
OSA causes interruptions or pauses in your breathing, often because your throat or airways briefly collapse, or something temporarily blocks them.
Central sleep apnea is a disorder in which your breathing repeatedly stops and starts during sleep. It occurs because your brain doesn't send proper signals to the muscles that control your breathing.
A type of sleep-disordered breathing in which there are more than five central apneas, which are periods of slowed or stopped breathing, an hour. This happens even when the obstructive events are stopped with positive airway pressure (PAP). There are no clear causes for the central apneas, such as narcotics or systolic heart failure.
Sleep-Disordered Breathing (SDB) is when upper-airway obstruction occurs during sleep. It's a group of conditions that cause an abnormal breathing pattern when you're asleep. They can happen on their own or they can be linked to other respiratory, nervous, cardiovascular, or endocrine diseases.
Positive Airway Pressure (PAP) is a form of respiratory ventilation used in the treatment of sleep apnea.
If you have Original Medicare you’ll be able to get coverage for CPAP machines with Medicare Part B.
This is because CPAP machines are classified as covered durable medical equipment (DME) by the Centers for Medicare and Medicaid Services (CMS).
DME is equipment and supplies ordered by a health care provider for everyday or extended use.
Coverage for DME may include:
To get your CPAP machine covered by Medicare, you need to make sure that your doctor and the company that sells the machine both participate in the program. You can look for Medicare-approved providers and suppliers in your area on the Medicare site.
Importantly, make sure that you have paid your Medicare Part B premiums and met your deductible for the year before you buy your CPAP machine. If you haven’t, then Medicare won’t refund your purchase.
Premium: A regular payment made to an insurance company in exchange for insurance coverage.
Beneficiary: A nominated person who will receive either the full or a portion of a life insurance contract’s death benefit.
Deductibles: Amounts that people have to cover before their Medicare plan or insurance starts to pay for medical expenses.
Coinsurance: The part of the costs that beneficiaries must pay for medical treatments, services, and tests.
You will have to pay 20% of the Medicare-approved amount for covered equipment, including:
CPAP machine rental for a 3-month trial if you’re newly diagnosed
CPAP rental for 13 months if you’ve been using it consistently. After 13 months, you’ll own the CPAP machine
Masks or nose pieces you wear when using the machine
Tubing to connect the mask or nose piece to the machine
To get Medicare to pay for a CPAP machine, your doctor has to say that you have obstructive sleep apnea (OSA). Most of the time, such a diagnosis needs to be confirmed with a sleep study, which Medicare Part B also pays for.
After you have been prescribed a CPAP machine by your physician, Medicare will pay for you to use it to see if it helps you sleep.
If your doctor says that CPAP therapy is working for you and that you should keep using it, Medicare will continue to cover the costs of your device.
Medicare Advantage (or Part C) may offer additional coverage for medical equipment and services that fall under Medicare Part B coverage.
By law, Medicare Advantage Plans must offer the same benefits as the government-run program in order to be recognized by the Centers for Medicare and Medicaid Services (CMS). This is called equivalent coverage.
The amount you’ll pay for the CPAP machine will depend on the plan you choose and how much you can afford to pay in monthly premiums for the added coverage.
However, some Medicare Advantage Plans may place additional restrictions and conditions on the suppliers and providers you can choose from, based on their network.
Certain CPAP parts need to be replaced regularly. Take a look at the table below to see how many times each year Medicare will help pay for some CPAP supplies.
|Twice a year||Quarterly||Monthly||Biweekly|
|Humidifier water chamber||CPAP tubing with heating element||Full face mask interface||Cushion for nasal mask interface|
|Nondisposable filters||Combination oral/nasal CPAP mask||Nasal pillows|
|Chinstrap||Full face mask||Disposable filter|
|Headgear||Nasal interface||Replacement oral cushion for oral/nasal mask|
|Tubing||Replacement nasal pillows for oral/nasal mask, one pair|
Some CPAP parts need to be replaced regularly. The replacement time ranges from two weeks to six months.
A CPAP machine isn't something you can buy at any store. Most of the time, your doctor or respiratory therapist will make a specific device recommendation for you.
They might even point you to a supplier. Here are some things to keep in mind if you're thinking about buying or renting a CPAP machine:
Your individual preferences about wearing a nose piece versus a full face mask
Your living situation and sleep habits
Your medical needs
Any specific features you may prefer, like:
Compact size for travel
Low motor noise
A built-in humidifier to prevent dry mouth and nose
If you think a CPAP machine is the right solution for you, it will be covered by Medicare Part B, as long as your doctor and supplier participate in Medicare.
If you need help, head over to PolicyScout to find the best coverage for you.
If you are looking for up-to-date and accurate information about Original Medicare, Medicare Advantage Plans, or anything Medicare-related, head to PolicyScout’s Medicare hub to compare your options and find the best plan in your area.