Does Medicare Pay for BiPAP Machines?
Understand Medicare coverage for BiPAP machines. Learn about eligibility, how to acquire one, and your financial responsibilities.
A BiPAP (Bilevel Positive Airway Pressure) machine is a non-invasive medical device that delivers pressurized air through a mask to assist individuals with breathing difficulties. It provides different pressure levels during inhalation and exhalation to help keep airways open. BiPAP machines are commonly used for conditions such as obstructive sleep apnea, central sleep apnea, chronic obstructive pulmonary disease (COPD), and other respiratory insufficiencies.
Medicare Coverage for BiPAP Machines
Medicare provides coverage for BiPAP machines, categorizing them as Durable Medical Equipment (DME). DME refers to items that are durable, used for a medical reason, and used in the home. Medicare Part B (Medical Insurance) covers BiPAP machines when a physician prescribes them as medically necessary for use in the patient’s home. This coverage generally involves either renting the equipment or, in some cases, purchasing it, depending on the specific item and Medicare’s guidelines.
Medical Eligibility for Coverage
To qualify for Medicare coverage of a BiPAP machine, a formal diagnosis of a qualifying condition is required, such as obstructive sleep apnea, central sleep apnea, or certain respiratory insufficiencies. This diagnosis requires a Medicare-covered sleep test, which can be an in-lab polysomnogram or a home sleep test. Sleep study results must meet specific criteria, such as an Apnea-Hypopnea Index (AHI) or Respiratory Disturbance Index (RDI) of 15 events or more per hour. An AHI/RDI between 5 and 14 events per hour may also qualify if accompanied by documented symptoms like excessive daytime sleepiness, impaired cognition, mood disorders, insomnia, hypertension, ischemic heart disease, or a history of stroke.
A treating physician must provide a detailed prescription or order for the BiPAP machine, outlining the specific type of machine and settings. Medicare often requires an initial trial period, typically 3 months, to assess the effectiveness of the therapy. During this period, and for continued coverage, patients must demonstrate compliance by using the machine for at least 4 hours per night on 70% of nights within a 30-day period. Failure to meet these compliance requirements can result in Medicare discontinuing coverage, potentially requiring the patient to return the machine or bear the full cost.
Steps to Acquire Your Machine
The process of obtaining a BiPAP machine with Medicare coverage begins with your treating physician. Your doctor will conduct necessary evaluations, including ordering a sleep study, and provide a detailed prescription. Once medical necessity is established, select a Durable Medical Equipment (DME) supplier enrolled in Medicare that accepts assignment. Choosing a Medicare-approved supplier helps ensure your equipment is covered and avoids unexpected costs.
The DME supplier will handle administrative work, including submitting necessary paperwork to Medicare. Medicare’s policy often involves an initial rental period for the BiPAP machine, which typically lasts for 13 months. During this rental period, Medicare pays its share, and after 13 continuous rental payments, you generally gain ownership of the machine. Regular follow-up appointments with your doctor and the DME supplier help ensure proper machine function, address any issues, and verify compliance with usage requirements.
Your Financial Responsibility
Even with Medicare coverage, you will have certain financial responsibilities for your BiPAP machine. Medicare Part B requires you to meet an annual deductible before coverage begins. For 2025, the Medicare Part B annual deductible is $257. After meeting this deductible, Medicare generally pays 80% of the Medicare-approved amount for Durable Medical Equipment, including BiPAP machines.
This means you are typically responsible for the remaining 20% coinsurance. This 20% coinsurance applies to the monthly rental payments during the 13-month rental period. For example, if the Medicare-approved rental amount is $100 per month, you would pay $20, and Medicare would pay $80. Medicare Supplement (Medigap) plans or Medicare Advantage plans may offer additional benefits that can help cover these out-of-pocket costs, such as deductibles and coinsurance.