How Often Does Medicare Pay for CPAP Supplies?

Continuous Positive Airway Pressure (CPAP) therapy is a common and effective treatment for individuals diagnosed with obstructive sleep apnea (OSA). Medicare covers the necessary equipment and supplies, playing a significant role in helping beneficiaries manage this condition. Understanding Medicare’s specific coverage rules, including supply replacement frequency, is important for effective therapy management.

Medicare Coverage for CPAP Therapy

Medicare classifies CPAP machines and their associated supplies as Durable Medical Equipment (DME). DME refers to items that can withstand repeated use, are primarily for a medical purpose, are generally not useful to someone without an illness or injury, are used in the home, and are expected to last for at least three years. This classification means CPAP equipment falls under Medicare Part B, which covers outpatient medical services and supplies.

For coverage, the CPAP machine and accessories must be medically necessary. This includes the CPAP machine itself, along with essential components such as masks, tubing, filters, and humidifier water chambers.

Eligibility for Coverage

To qualify for Medicare coverage of CPAP therapy and supplies, a beneficiary must meet specific medical criteria. A diagnosis of obstructive sleep apnea (OSA) is required, which must be confirmed by a sleep study. This sleep study can be either an in-laboratory polysomnography or an approved at-home sleep test.

Following the diagnosis, a physician’s prescription for CPAP therapy is necessary to initiate coverage. Medicare also has compliance requirements to ensure the therapy is being used effectively. Beneficiaries typically undergo an initial 90-day trial period, during which they must demonstrate consistent usage. This means using the CPAP machine for at least four hours per night on 70% of nights within a consecutive 30-day period. If this compliance is met and the physician documents that the therapy is beneficial, Medicare will continue to cover the equipment.

Replacement Schedules for Supplies

Medicare has established general guidelines for how often CPAP supplies can be replaced to ensure hygiene and effective therapy. These schedules are based on medical necessity and typical wear and tear of the components. A new prescription may be required for replacement supplies.

Specific replacement frequencies generally followed by Medicare include:
CPAP Masks (complete mask): Every three months.
Mask Cushions/Pillows: Every two weeks for nasal pillows; monthly for full-face mask cushions.
Headgear: Every six months.
Tubing (standard and heated): Every three months.
Filters (disposable): Every two weeks.
Filters (non-disposable): Every six months.
Humidifier Water Chambers: Every six months.
CPAP Machine: Every five years, or sooner if no longer functional due to irreparable damage or malfunction.

Obtaining Supplies and Managing Coverage

Acquiring and maintaining CPAP supplies through Medicare involves working with approved providers and ensuring proper documentation. The first step is to locate a Durable Medical Equipment (DME) supplier that is enrolled in Medicare. Beneficiaries can find Medicare-approved suppliers through the Medicare Supplier Directory on Medicare.gov or by calling 800-MEDICARE.

Once a supplier is chosen, the physician’s prescription or order for the CPAP equipment and supplies must be submitted. The DME supplier is responsible for having all necessary documentation on file, including sleep study results and physician orders, to justify Medicare coverage. For ongoing replacement supplies, beneficiaries can typically order them from their supplier according to the established replacement schedules. Some items or specific circumstances may require prior authorization from Medicare before coverage is approved.

Your Share of Costs

When Medicare covers CPAP supplies, beneficiaries are responsible for a portion of the costs. These costs typically include an annual deductible and coinsurance. For 2025, the annual Medicare Part B deductible is $257. This deductible must be met before Medicare begins to pay its share of covered services, including DME.

After the deductible is satisfied, Medicare typically pays 80% of the Medicare-approved amount for Durable Medical Equipment. The beneficiary is then responsible for the remaining 20% coinsurance. It is important to choose a DME supplier who accepts “assignment.” This means the supplier agrees to accept the Medicare-approved amount as full payment and can only bill the patient for the deductible and coinsurance, preventing unexpected higher charges. Supplemental insurance plans, such as Medigap policies, or other health coverage may help cover this 20% coinsurance, reducing the out-of-pocket expenses for the beneficiary.