Does Medicare Cover CPAP Supplies and Equipment?

Continuous Positive Airway Pressure (CPAP) therapy offers an effective treatment for obstructive sleep apnea, a condition characterized by repeated breathing interruptions during sleep. CPAP machines deliver a steady airflow through a mask, maintaining open airways. Understanding Medicare’s role in covering associated equipment and supplies is important for managing healthcare expenses. Medicare covers medically necessary durable medical equipment, including CPAP devices, under specific conditions.

Medicare Part B Coverage for CPAP

Medicare Part B covers CPAP machines and related supplies when certain criteria are met. Coverage begins with a physician’s diagnosis of obstructive sleep apnea, typically confirmed through a sleep study. This diagnostic process can occur in a laboratory setting or through an approved at-home sleep test.

Before a sleep study, a beneficiary must undergo a face-to-face evaluation with a physician. This evaluation involves documenting the individual’s symptoms of obstructive sleep apnea, assessing their Epworth Sleepiness Scale score, and noting their body mass index and neck circumference. A focused cardiopulmonary and upper airway examination completes this initial assessment, which establishes the medical need for further testing.

Following this initial consultation, the sleep study results must demonstrate specific findings, such as an Apnea-Hypopnea Index (AHI) or Respiratory Disturbance Index (RDI) of 15 or more events per hour. Alternatively, an AHI or RDI between 5 and 14 events per hour may qualify if accompanied by symptoms like excessive daytime sleepiness, impaired cognition, or existing conditions such as hypertension. A prescription for the CPAP machine from a doctor is also required to proceed with coverage.

Medicare initiates CPAP coverage with a 3-month trial period. During this time, Medicare helps cover the CPAP device and its necessary accessories. For Medicare to continue coverage beyond this initial period, the individual must demonstrate consistent use of the machine.

Specific Covered CPAP Equipment and Supplies

Medicare Part B covers specific CPAP equipment and supplies. This includes the CPAP machine, humidifier, mask, headgear, tubing, and air filters. These items are essential for delivering continuous positive airway pressure necessary for effective sleep apnea treatment.

Medicare establishes a replacement schedule for these supplies to ensure optimal performance and hygiene. The CPAP machine is generally eligible for replacement every five years. Smaller components, which experience more wear and tear, have more frequent replacement allowances.

• Masks typically qualify for replacement every three months.
• Mask cushions can be replaced monthly.
• Disposable filters are usually covered for replacement every month.
• Non-disposable filters every six months.
• Tubing and hoses are typically replaceable every three months.
• The water chamber for the humidifier can be replaced every six months.

Beneficiary Costs and Payment Structure

After the annual Medicare Part B deductible is satisfied, Medicare typically covers 80% of the Medicare-approved amount for these items. For 2025, the Part B deductible is $257.

Beneficiaries are responsible for the remaining 20% coinsurance of the Medicare-approved amount. This coinsurance applies to the rental costs of the CPAP machine and the purchase of replacement supplies. To avoid potentially higher out-of-pocket expenses, it is advisable to obtain equipment and supplies from suppliers that accept Medicare assignment.

Medicare Advantage (Part C) plans must provide at least the same level of coverage as Original Medicare. Their cost-sharing structures, such as deductibles, copayments, and coinsurance, may vary from those of Original Medicare. Individuals enrolled in a Medicare Advantage plan should consult their specific plan details for information on their financial responsibilities.

Maintaining Ongoing Coverage

Maintaining Medicare coverage for CPAP equipment and supplies requires adherence to ongoing requirements. Medicare considers the CPAP machine a rental for the first 13 months of continuous use. After this rental period, if all requirements are met, the beneficiary owns the machine.

A primary condition for continued coverage is consistent use of the CPAP machine. Medicare defines compliance as using the device for at least four hours per night on 70% of nights within any consecutive 30-day period. This usage data is typically downloaded directly from the CPAP machine.

Between the 31st and 90th day of CPAP use, a follow-up face-to-face re-evaluation with a physician is necessary. During this appointment, the physician reviews the compliance data and documents that the individual’s symptoms of obstructive sleep apnea have improved with the therapy. This medical documentation is important for verifying ongoing medical necessity.

Failure to meet these compliance standards or to provide the necessary medical documentation can result in the cessation of Medicare coverage for the CPAP equipment. If coverage stops due to non-compliance, individuals may need to undergo a new face-to-face evaluation and potentially another sleep study to re-establish eligibility for Medicare coverage.