Is CPAP Covered by Medicare?

Continuous Positive Airway Pressure (CPAP) therapy is a widely recognized treatment for obstructive sleep apnea, a condition where breathing repeatedly stops and starts during sleep. Medicare provides coverage for CPAP machines and related supplies, though specific conditions and requirements must be met.

Medicare’s Approach to CPAP Coverage

Medicare classifies CPAP machines and their accessories as Durable Medical Equipment (DME). DME includes items that are durable, used for a medical reason, used in the home, and expected to last at least three years. CPAP devices fulfill these criteria, making them eligible for coverage under Medicare Part B.

Medicare Part B generally covers 80% of the Medicare-approved amount for DME, including CPAP equipment, after the annual Part B deductible is satisfied. The beneficiary is then responsible for the remaining 20% coinsurance.

Fulfilling Medicare’s Eligibility Requirements

To qualify for Medicare coverage of a CPAP device, a diagnosis of obstructive sleep apnea (OSA) is required, typically confirmed by a sleep study. This diagnosis must be made by a physician, who will then provide a prescription for the CPAP machine. The sleep study can be conducted in a laboratory setting or through an approved at-home test.

The results of the sleep study must meet specific Medicare criteria. An Apnea-Hypopnea Index (AHI) or Respiratory Disturbance Index (RDI) of 15 or more events per hour qualifies for coverage. Alternatively, an AHI or RDI between 5 and 14 events per hour may qualify if accompanied by documented symptoms such as excessive daytime sleepiness, impaired cognition, mood disorders, insomnia, or conditions like hypertension or ischemic heart disease. The CPAP machine and all related supplies must be obtained from a supplier enrolled in Medicare.

Medicare also mandates a trial period for CPAP therapy, typically 12 weeks or three months, to determine its effectiveness. During this period, the beneficiary must demonstrate compliance with the therapy, which means using the machine for at least four hours per night on 70% of nights within a 30-day period. Continued coverage beyond this period depends on the physician documenting that the therapy is helping and that compliance standards are maintained.

Steps to Obtain Your CPAP Device

The process of obtaining a CPAP device begins with consulting a doctor about sleep apnea symptoms. The physician will then order a sleep study, which can be performed either in a sleep laboratory or at home using a Medicare-approved device. After the sleep study results confirm an obstructive sleep apnea diagnosis and meet Medicare’s specific criteria, the doctor will issue a prescription for the CPAP machine.

Upon receiving the prescription, individuals should work with a Medicare-approved supplier to obtain the device. The supplier will handle the direct billing to Medicare, provided they accept assignment. The supplier will also provide the device, offer instructions for its use, and assist with the initial setup. The CPAP machine typically functions as a rental for 13 months, during which Medicare makes payments, and if compliance requirements are consistently met, ownership of the device transfers to the beneficiary after this period.

Managing Ongoing Costs and Supplies

Even after the initial acquisition, there are ongoing financial considerations and supply management for CPAP therapy. Beneficiaries are responsible for the 20% coinsurance of the Medicare-approved amount for the CPAP machine and its supplies, after meeting their Part B deductible. For example, if a CPAP machine costs $900, the coinsurance could be around $180.

Medicare provides coverage for various CPAP supplies, including masks, tubing, filters, and humidifier water chambers, recognizing that these items require regular replacement for hygiene and effectiveness. The frequency of replacement varies by item; masks may be replaced every three to six months, while tubing and filters have their own schedules. Medicare typically covers the replacement of the entire CPAP machine every five years, assuming continued medical necessity. It is advisable to confirm coverage details with the supplier and Medicare to understand potential out-of-pocket costs before acquiring replacement supplies or a new device.