Some medical equipment makes your life easier and helps you stay independent. And some medical equipment can literally save and prolong your life. Continuous positive airway pressure (CPAP) machines fall into the latter category. Sleep apnea is a serious condition that can cause heart damage and even death if left untreated. Fortunately, once you are diagnosed, you can use a CPAP machine to maintain your breathing and help prevent serious complications. If Medicare is your primary insurance coverage, you might wonder “Does Medicare cover CPAP?” This guide will help you understand the coverage you can get and how much you can expect to pay out of pocket. Here’s what you need to know.
Does Medicare Pay for CPAP?
If you’ve been diagnosed with obstructive sleep apnea by your doctor, you’ll be prescribed a CPAP machine. Original Medicare will cover a CPAP as durable medical equipment (DME) under Medicare Part B. If you have a Medicare Advantage plan, you will also get coverage, but the out-of-pocket costs and requirements may be different.
Medicare has some requirements before they cover your CPAP machine long-term. First, you’ll have coverage for a three-month trial period. After that, coverage can continue if you meet with your doctor in person and they document your medical record that the treatment is benefiting you and you meet the requirements to continue.
As with all Medicare coverage, you’ll need to use a Medicare-enrolled doctor and DME provider. If you have an Advantage plan, your doctor and DME provider need to be within the plan’s provider network.
How Much Does Medicare Pay for CPAP Machines?
Original Medicare covers all durable medical equipment under Medicare Part B. That means that you’ll first pay your deductible, which is $233 in 2022. Then, you’ll pay 20% of the Medicare-approved amount for the device. Medicare pays the other 80%.
If you have a Medicare Advantage plan, you might have a different deductible and out-of-pocket cost. For example, you might pay a flat copayment for DME instead of a percentage. You’ll want to talk to your insurer before you commit to a purchase or rental.
Different parts of a CPAP device need replacement at different times. Medicare does provide coverage for new hoses, masks, and machines at specific intervals.
For example, you can often get coverage for a new mask every six months. With Original Medicare, you’ll pay 20% of the Medicare-approved cost, and Medicare will pay the rest. If you have Medicare Advantage, you’ll want to check what your copayment will be.
A CPAP machine generally lasts three years before needing replacement. Original Medicare pays for machines by renting them for 13 months, and you pay 20% of that cost. At the end of that period, you own the machine.
A CPAP is the most common treatment for sleep apnea, but it’s not the only option. If you don’t tolerate a CPAP well, your doctor may recommend a bi-level positive airway pressure (BPAP) machine. Another option is an oral appliance that’s similar to a mouthguard, which can help you breathe better.
If your medical practitioner determines that these devices are better options than a CPAP, or the CPAP isn’t working, Medicare can help cover the cost. The same standards apply — your doctor must prescribe them, they need to create a positive change, and you’ll need to use Medicare-enrolled doctors and equipment providers.
If medically necessary, Medicare may help pay for treatments such as surgery to remove obstructing tissue, smoking cessation, and weight loss counseling or surgery. You’ll want to work closely with your doctor to determine the best course of action for your needs.
Getting treatment for obstructive sleep apnea can dramatically improve your quality of life and even save you from severe health complications. Work with your Medicare-enrolled doctor (or one in your Advantage plan network) to get the care you need.
If you have more questions about Medicare cover or would like to compare Medicare plans, we’re here to help. Contact us today to speak to a licensed agent!
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