Medicare covers some durable medical equipment (DME), including a continuous positive airway pressure (CPAP) machine, when a doctor prescribes it for home use. Medicare Advantage plans may also cover CPAP therapy.
This article discusses the types of sleep apnea and some of the treatments for the condition. It also looks at Medicare coverage.
We may use a few terms in this piece that can be helpful to understand when selecting the best insurance plan:
- Deductible: This is an annual amount that a person must spend out of pocket within a certain time period before an insurer starts to fund their treatments.
- Coinsurance: This is a percentage of a treatment cost that a person will need to self-fund. For Medicare Part B, this comes to 20%.
- Copayment: This is a fixed dollar amount that an insured person pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
Sleep apnea is a condition in which a person temporarily stops breathing while asleep. The pauses in breathing are usually at least 10 seconds long and may last for more than a minute, according to the American Sleep Apnea Association (ASAA). These pauses may occur hundreds of times a night.
Types of sleep apnea
The three main types of sleep apnea are:
- Obstructive sleep apnea: This condition happens when a person’s airway becomes blocked during sleep. It can occur if the soft tissue at the back of the throat collapses and creates a blockage.
- Central sleep apnea: This condition happens when a person’s brain does not send the appropriate signal to the muscles that play a role in breathing.
- Mixed sleep apnea: This condition is a combination of obstructive and central sleep apnea.
Obstructive sleep apnea is the most common type of sleep apnea.
Causes of sleep apnea
According to the National Heart, Lung, and Blood Institute (NHLBI), the causes of obstructive sleep apnea include:
- large tonsils
- heart or kidney failure, which may cause fluid buildup in the neck
- genetic syndromes that affect facial structure
A person with sleep apnea may not know that they have the condition. They might only become aware of it because a partner or family member notices that the person’s breathing is irregular while sleeping.
Sleep apnea typically prevents a person from having deep, restful sleep.
Symptoms of sleep apnea
According to the NHLBI, the signs and symptoms of sleep apnea may include:
- excessive daytime sleepiness
- loud snoring
- gasping for air while asleep
- morning headaches
- trouble concentrating
Sleep apnea may also increase a person’s risk for certain conditions, including:
The most common treatment for someone with moderate-to-severe sleep apnea is a breathing device, such as a CPAP machine. CPAP therapy delivers a flow of air through a mask to help keep the airway open while a person is asleep.
Other potential treatments for sleep apnea include:
- Oral appliance therapy: A person wears a custom-fitted mouthpiece that moves the tongue or jaw to help keep the airway open during sleep.
- Nerve stimulation: A surgeon inserts a device that stimulates the hypoglossal nerve, which goes to the tongue muscles, and helps move the tongue to a position that keeps the airway open.
- Positional therapy: A person who experiences sleep apnea only while sleeping on their back can learn to sleep on their side instead.
- Surgery: A doctor might recommend surgery for people with severe sleep apnea that has not responded to other treatments. The surgery might involve removing the tonsils or realigning the jaw.
- Weight loss: Losing weight may help alleviate sleep apnea in people with obesity.
A CPAP machine provides airflow at pressure to keep a person’s airway open.
CPAP equipment includes a machine, tubing, and a mask that a person wears while sleeping. Different types of masks include:
- a mask that fits over the nose
- a mask that covers the nose and mouth
- nasal pillows that fit in the nostrils
CPAP machines may also have a humidifier attachment to help ease discomfort in a person’s nose or throat.
Federally managed Medicare has four parts, which include Part A (hospital insurance) and Part B (medical insurance), together known as original Medicare. The two other parts of Medicare are Part C, also known as Medicare Advantage, and Part D (prescription drug coverage).
A person with a diagnosis of obstructive sleep apnea generally gets Medicare coverage for a 3-month trial of CPAP therapy. Medicare may extend coverage for CPAP if a person’s doctor reports that the therapy is helping alleviate the condition.
Medicare Advantage plans may cover CPAP therapy, as the plans must offer at least the same coverage as original Medicare.
In addition, a Part D plan may offer coverage for doctor-prescribed nasal decongestants, although a person would need to check the list of drugs, called a formulary, that their plan includes.
What other sleep apnea therapies will Medicare cover?
There are other tests, appliances, treatments, and counseling that Medicare may cover.
Medicare Part B may cover different types of sleep tests for someone who has symptoms of sleep apnea.
The Food and Drug Administration (FDA) have approved more than 100 different oral appliances to treat obstructive sleep apnea and snoring, according to the ASAA. Medicare may cover oral appliances under the DME benefit in Part B, as long as a person’s doctor and the DME supplier are both enrolled in Medicare.
A person enrolled in a Medicare Advantage plan may have coverage for medically approved hypoglossal nerve stimulation for sleep apnea, although they would need to check this with the plan provider.
Medicare Part B may cover obesity counseling for people whose body mass index (BMI) is 30 or higher.
Medication is usually not a primary focus of sleep apnea treatment. However, a doctor may prescribe drugs, such as nasal decongestants, to combat excessive daytime sleepiness in a person getting treatment for sleep apnea.
A person enrolled in a Part D drug plan can check with their plan provider to see whether it covers the medication.
A person enrolled in original Medicare will pay 20% of the Medicare-approved amount for DME, such as a CPAP machine, if the supplier accepts Medicare. The Part B deductible applies, which is $203 in 2021.
However, supplemental medical insurance plans, known as Medigap, may help cover out-of-pocket expenses, such as copays, coinsurance, and deductibles. Private companies offer the plans, which are available to a person with original Medicare.
In addition, a person enrolled in Medicaid may get help with out-of-pocket costs.
Sleep apnea is a condition that may seriously affect a person’s health. The medical community considers CPAP an effective therapy for obstructive sleep apnea, and Medicare may offer coverage under certain conditions.
Anyone who is unsure whether their plan covers CPAP machines can speak to their plan provider.
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