Does Medicare Cover a CPAP Machine?

Medicare generally covers Continuous Positive Airway Pressure (CPAP) machines for obstructive sleep apnea. This coverage falls under Medicare Part B, which handles durable medical equipment (DME), provided certain conditions are met. Individuals diagnosed with obstructive sleep apnea can typically receive coverage for their CPAP machine and related supplies. This support ensures access to therapy that helps manage sleep apnea.

Eligibility for CPAP Coverage

To qualify for Medicare coverage of a CPAP machine, a confirmed diagnosis of obstructive sleep apnea (OSA) from a qualified physician is required. This diagnosis must be supported by a sleep study, which can be conducted either in a sleep laboratory or as an approved home sleep test. The physician must then provide a prescription for the CPAP machine, detailing specific settings and accessories.

Medicare mandates that the prescribing physician documents the medical necessity for CPAP therapy and assesses the initial response to treatment. Following an initial three-month trial period, continued coverage depends on demonstrating compliance with the therapy. This typically involves using the CPAP machine for at least four hours per night on 70% of nights within a consecutive 30-day period. Compliance data is often reviewed by the physician to ensure the therapy remains effective. If compliance requirements are not met, Medicare may discontinue coverage for the CPAP device.

Medicare Coverage Specifics and Costs

CPAP machines are categorized as Durable Medical Equipment (DME) under Medicare Part B, which covers certain medical equipment. After the annual Part B deductible is met, Medicare typically covers 80% of the Medicare-approved amount for the CPAP machine and associated supplies. The beneficiary is then responsible for the remaining 20% coinsurance. The Part B deductible for 2025 is $257.

Medicare generally covers CPAP machines through a rental-purchase model, where the machine is rented for 13 months. After 13 months of rental payments, the beneficiary owns the machine. Medicare continues to cover accessories and supplies beyond this period, such as masks, tubing, filters, water chambers, and headgear. Replacement schedules for these supplies vary:

• Filters and cushions are often replaceable every one to three months.
• Tubing is replaceable every three months.
• Headgear is replaceable every six months.

Obtain equipment from suppliers enrolled in Medicare who accept assignment, meaning they agree to the Medicare-approved payment amount.

Obtaining Your CPAP Machine and Supplies

Once eligibility is established, the next step involves finding a Medicare-approved Durable Medical Equipment (DME) supplier. Your physician can often provide recommendations, or you can utilize the Medicare website’s supplier directory to locate authorized providers. Confirm the chosen supplier accepts Medicare assignment to ensure your costs are limited to the deductible and coinsurance.

Upon selecting a supplier, you will provide them with your physician’s prescription and medical documentation. The DME supplier will assist with the initial setup of your CPAP machine, including proper mask fitting and instructions on how to use and maintain the device. They will also educate you on how to order replacement supplies according to Medicare’s approved schedule. If your machine requires repair or maintenance, the supplier can guide you through the process, which may be covered if the cost of repair exceeds certain limits.

Medicare Plan Differences

CPAP machine coverage can vary depending on whether you have Original Medicare or a Medicare Advantage Plan. Original Medicare, which includes Part A and Part B, provides standard coverage for CPAP machines under Part B. This means the 80/20 coverage split and rental-purchase model apply uniformly.

Medicare Advantage Plans (Part C) are offered by private insurance companies and must cover at least the same benefits as Original Medicare, including CPAP machines. However, these plans often have different out-of-pocket costs, such as copayments, deductibles, and coinsurance amounts. Medicare Advantage plans require beneficiaries to use a specific network of doctors and DME suppliers for coverage, and prior authorization requirements can also differ between plans. Individuals with a Medicare Advantage Plan should review their specific plan documents or contact their plan provider directly to understand coverage details and network restrictions.