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Medicare and Sleep Apnea

If a doctor has recently diagnosed you with sleep apnea, a major question you probably have is, “Will insurance help cover treatment?” If you’re over 65, you are definitely wondering “will Medicare cover CPAP?”

The good news is yes — Medicare covers sleep apnea treatment. In fact, Medicare covers 80% of your bill for CPAP equipment. There are also affordable Medigap plans which will pick up the other 20%.

Medicare Sleep Apnea Tests

To qualify for a CPAP through Medicare, you need to be diagnosed with obstructive sleep apnea. If you are enrolled in Original Medicare (Part A and Part B) and have clinical signs of obstructive sleep apnea, you may be covered. There are different types of sleep studies, and Medicare requirements are specific. Make sure to talk to your healthcare professional. Medicare covers the PSG test (type 1) only if it is performed in a certified sleep lab. Certain types of home sleep studies are also covered if you have clinical signs of and symptoms of obstructive sleep apnea.

Medicare CPAP Guidelines

Medicare has set guidelines for durable medical equipment coverage (DME), which falls under your Part B outpatient coverage. After a small annual deductible, Medicare covers 80% of sleep apnea cost if the following conditions have been satisfied:

  • A doctor diagnoses you with obstructive sleep apnea, usually after a sleep study
  • You are enrolled in Medicare Part B
  • You must have a face-to-face visit with your primary care physician (PCP) who is enrolled in Medicare. Otherwise, you will be responsible for payment.
  • Your PCP must document in his office notes/medical records that you are in need of a PAP (positive airway pressure) device and it is beneficial to your health.
  • After the initial setup on the CPAP or BiPAP device, you can receive Continuous Positive Airway Pressure therapy for a three-month trial. This compliance period lasts for 90 days. You must meet with your PCP for a follow-up visit the 31st day after the compliance period has started (and no later than the 90th day).
  • During this 90-day compliance period, you must also demonstrate daily usage of the machine for at least 70-80% of the time frame. Using it a minimum of 4+ hours per night will help ensure this.
  • To continue care beyond the initial 90 days, your doctor must document that a CPAP machine is medically necessary and is helping you. He must also document that you have complied with the above standards in order for Medicare to continue paying their portion for the device and for sleep therapy.

What You Pay

If you adhere to the above guidelines, then you pay 20% of the total amount. Medicare sleep apnea coverage will pay 80%. Medicare might cover the cost of a CPAP rental or CPAP replacement if you had another insurance provider before switching to Medicare. The rental time frame is 13 months, and after this period, the machine belongs to you. Again, you would have to meet specific guidelines.

You must change out your CPAP supplies regularly to ensure they are sanitary and safe. Medicare covers CPAP supplies on a specific timeframe.

How Often Medicare Covers CPAP supplies:

Disposable Filters 2 Times Every Month
CPAP Nasal Cushions and Pillows 2 Times Every Month
Full Face Cushions 1 Time Every Month
Oral, Nasal, Nasal Pillow, Full Face Masks 1 Time Every 3 Months
CPAP Tubing 1 Time Every 3 Months
Headgear and Chinstraps 1 Time Every 6 Months
CPAP Non-Disposable Filters 1 Time Every 6 Months
CPAP Humidifier Chamber 1 Time Every 6 Months

Competitive Bidding Area (CBA)

If you live in or visit certain areas, Medicare’s Competitive Bidding Program will affect who can supply your CPAP machine and supplies. Medicare will only cover CPAP supplies from contracted suppliers with Medicare. These supplies must be current winners of the Medicare CBA program.

For more information concerning CPAP supplies and Medicare, contact us directly at 1-888-345-1780. We’ll be glad to assist you!

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