Does Medicare Cover CPAP Machines?

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Medicare CPAP Coverage

Original Medicare (including Part B) covers CPAP therapy for OSA if you meet specific requirements Trusted Source Centers for Medicare and Medicaid View Source . These requirements include:

• Having a Medicare-enrolled doctor: Medicare will only provide coverage for tests and treatment that are ordered by a doctor who is enrolled in the Medicare program. 
• Having a diagnosis of OSA: You must be diagnosed with OSA based on an overnight or at-home sleep study. In addition, Medicare requires that you have a minimum number of breathing disruptions per hour of sleep to qualify for coverage.

If you meet these conditions, Medicare will pay for a 12-week trial rental of a CPAP machine. The device must come from a durable medical equipment (DME) supplier that is enrolled in Medicare. 

At the end of the trial, your doctor will look at data from the device to determine whether CPAP therapy is helping you. If you’re using and benefitting from the CPAP machine, Medicare will continue to cover its rental cost for another 10 months. 

After 13 total months of Medicare payments, you become the owner of the CPAP machine. Medicare will pay for essential replacement CPAP supplies for as long as you have a medical need .

Who’s Eligible?

Anyone with Medicare or a Medicare Advantage Trusted Source Medicare.gov Medicare.gov provides essential information about signing up for and using Medicare, which is health insurance for people 65 or older. View Source plan is eligible for coverage of CPAP therapy if they are diagnosed with OSA by a doctor enrolled in Medicare. 

For Medicare to recognize a diagnosis, it needs to come after a doctor’s appointment and a sleep test. The test must measure the average number of breathing disruptions you have during sleep, and Medicare only covers CPAP therapy if you’ve recorded a minimum number of these disruptions.

What’s Covered?

Medicare covers the CPAP device and any supplies that are necessary to use it. These supplies include a mask, filter, and tubing. Medicare will also pay to replace these supplies over time if you have an ongoing need for CPAP therapy.

It’s important to note that while Medicare covers CPAP therapy, it doesn’t pay all the costs. You have to meet your Medicare Part B deductible first, and then Medicare will cover 80% of CPAP equipment.

How Do You Qualify?

To qualify for Medicare coverage of CPAP therapy, you have to follow a series of steps: 

1. Doctor visit: Start by meeting with a Medicare-enrolled doctor to discuss your symptoms.
2. Testing: Take a doctor-prescribed test for OSA, such as a sleep study.
3. Diagnosis: Receive a diagnosis of OSA and an order for CPAP therapy from your doctor.
4. Locating a CPAP supplier: Find a Medicare-enrolled durable medical equipment (DME) supplier who tells you directly that they will accept assignment of your Medicare claim.
5. Ordering: Order a CPAP machine and necessary accessories from the supplier.
6. Follow up: Meet with your doctor after three months to determine if ongoing CPAP therapy is medically beneficial.

If you’re new to Medicare and already using a CPAP device, you’ll need to start by having an appointment with a Medicare-enrolled doctor to document your medical need for CPAP therapy. If your previous sleep test meets Medicare criteria for coverage, you won’t need a new test.

Medicare and CPAP Compliance

Medicare only covers a CPAP device if you use it regularly. This is called CPAP compliance or adherence.

Under Medicare rules, you must use the device for a minimum of four hours per night on at least 70% of nights Trusted Source Journal of Clinical Sleep Medicine (JCSM) JCSM is the official, peer-reviewed journal of the American Academy of Sleep Medicine. View Source . Your doctor will look at data from the CPAP machine to determine if you meet these CPAP compliance requirements.

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Does Medicare Cover CPAP Supplies?

Medicare covers essential CPAP supplies, such as humidifiers, masks and headgear, hoses, and filters, provided you have a documented medical need. 

A properly maintained CPAP machine is expected to last for about five years, but other supplies need to be replaced more often. If your doctor has written an order for CPAP therapy, Medicare will pay for replacement supplies that you need to properly operate your CPAP device. Check your equipment’s replacement schedule to ensure each component is changed out as needed.

Medicare CPAP Supplies Replacement Schedule

Medicare won’t pay for an unlimited amount of CPAP supplies. Instead, Medicare covers supplies according to an established schedule.

If you want or need any supplies more frequently, you’ll have to pay for them out of your own pocket.

Even though Medicare will cover items on a recurring basis, you can’t set up automatic orders. Medicare requires that you approve each specific order for the supplies to be covered.

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