Does Medicare Cover APAP Machines?

An Automatic Positive Airway Pressure (APAP) machine is a medical device designed to treat obstructive sleep apnea (OSA), a condition where breathing repeatedly stops and starts during sleep. These machines deliver pressurized air through a mask to keep the airway open, preventing interruptions to sleep. Unlike Continuous Positive Airway Pressure (CPAP) machines that provide a fixed air pressure, APAP devices automatically adjust the pressure level throughout the night based on the user’s breathing patterns and needs. This automatic adjustment helps ensure the lowest effective pressure is used, potentially increasing comfort for some individuals.

Medicare is a federal health insurance program that primarily serves individuals aged 65 or older, though it also covers younger people with certain disabilities or specific medical conditions like End-Stage Renal Disease. The program aims to assist with healthcare costs, providing coverage for a range of medical services and equipment. Understanding Medicare coverage for devices like APAP machines is important for beneficiaries.

Medicare Part B Coverage for APAP Machines

Medicare covers APAP machines as Durable Medical Equipment (DME) under Medicare Part B, which is the medical insurance component of Original Medicare. Durable Medical Equipment refers to items that are used for a medical reason, can withstand repeated use, are appropriate for use in the home, and are expected to last at least three years. This classification includes various devices like wheelchairs, oxygen equipment, and hospital beds.

For an APAP machine to be covered, it must be prescribed by a physician and deemed medically necessary for use in the home. Medicare Part B helps cover outpatient medical services and certain medical equipment. While Original Medicare directly provides this coverage, Medicare Advantage plans are required to provide at least the same level of coverage.

Qualifying for Coverage

To qualify for Medicare coverage of an APAP machine, a formal diagnosis of obstructive sleep apnea (OSA) is required. This diagnosis necessitates a sleep study, also known as polysomnography, which can be performed in a sleep lab or at home. Medicare Part B covers the cost of these sleep studies if there are clinical signs and symptoms of a sleep disorder.

Following a confirmed diagnosis, a doctor’s prescription for the APAP machine is required. Medicare often requires a trial period, typically 3 months, during which the beneficiary uses the APAP machine to demonstrate its effectiveness and adherence to therapy. If the doctor documents that the therapy is beneficial and the patient is consistently using the machine, Medicare will continue coverage. Work with a doctor and Durable Medical Equipment (DME) supplier who are enrolled in and accept Medicare assignment.

Patient Costs and Covered Items

When Medicare Part B covers an APAP machine, beneficiaries share in the cost. After meeting the annual Medicare Part B deductible, which is $257 in 2025, individuals are responsible for 20% of the Medicare-approved amount for Durable Medical Equipment. Medicare Part B pays the remaining 80%.

Medicare covers the rental of the APAP machine for a period, often 13 months, after which the patient owns the machine. In addition to the machine itself, Medicare Part B’s DME benefit also covers supplies needed for APAP therapy. These include items such as masks, tubing, and filters. Medicare covers the replacement of these supplies on a regular schedule, with frequencies varying based on the item, ranging from every two weeks to every six months. Medicare Supplement (Medigap) policies or Medicare Advantage plans may help cover some of these out-of-pocket costs, though their specific benefits and cost-sharing structures vary.

Process for Obtaining Your APAP Machine

After meeting qualifying criteria, obtaining an APAP machine through Medicare involves a clear process. The initial step is to select a Durable Medical Equipment (DME) supplier that is enrolled in Medicare and agrees to accept assignment. Accepting assignment means the supplier agrees to accept the Medicare-approved amount as full payment for the equipment and can only charge the beneficiary the coinsurance and Part B deductible.

Once a supplier is chosen, the doctor will send the prescription for the APAP machine and the results of the sleep study to the selected DME supplier. The DME supplier will then contact the patient to arrange for the fitting of the mask and provide instructions on how to properly use the machine. The supplier is also responsible for submitting the claim directly to Medicare on the patient’s behalf.