Medicare covers continuous positive airway pressure (CPAP) equipment when a doctor prescribes it. A person must have sleep apnea and meet other conditions. Medicare Advantage plans may also cover CPAP therapy.
Medicare often covers CPAP therapy for people with obstructive sleep apnea (OSA) if they meet certain requirements.
In OSA, a person’s breathing stops and restarts repeatedly during sleep, preventing the body from getting enough oxygen.
Along with certain lifestyle changes and other treatments, continuous positive air pressure (CPAP) machines commonly help treat OSA.
This article looks at the conditions a person must meet for Medicare to cover CPAP therapy and the costs and processes involved.
Glossary of Medicare terms
We may use a few terms in this article that can be helpful to understand when selecting the best insurance plan:
- Out-of-pocket costs: An out-of-pocket cost is the amount a person must pay for medical care when Medicare does not pay the total cost or offer coverage. These costs can include deductibles, coinsurance, copayments, and premiums.
- Deductible: This is an annual amount a person must spend out of pocket within a certain period before an insurer starts to fund their treatments.
- Coinsurance: This is the percentage of treatment costs that a person must self-fund. For Medicare Part B, this is 20%.
- Copayment: This is a fixed dollar amount a person with insurance pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
If a doctor diagnoses OSA after a sleep study, Medicare may cover a 3-month trial of CPAP therapy. This includes the CPAP machine, mask, tubing, and nasal pillows that fit in the nostrils.
After the 3-month trial, if a doctor states on a person’s medical record that CPAP therapy is working, Medicare may continue to cover 80% of the rental costs for the following 13 months. After 13 months, a person will own the machine.
Medicare classifies CPAP machines and accessories as durable medical equipment.
Original Medicare, which includes parts A and B, may cover different uses of CPAP machines.
Part A is hospital insurance. It covers the use of a CPAP machine during hospital stays or while in short-term healthcare facilities. Part B is medical insurance. It covers the use of a CPAP machine at home if a doctor says it is medically necessary.
Medicare Advantage plans are provided by private insurers. These plans vary in the services and equipment they cover. However, they typically cover CPAP therapy, as Advantage plans must offer at least the same coverage as Original Medicare.
The amount a person pays for a CPAP machine and accessories depends on their Medicare coverage and whether they have met their deductible.
After paying their Part B deductible for the year, a person with Original Medicare typically pays 20% of the Medicare-approved amount. Medicare pays the remaining 80%. Some Medigap or Medicaid plans may help pay the 20% coinsurance.
The Medicare-approved amount is sometimes less than a provider would normally charge for the equipment, but if the provider “accepts assignment,” they agree to accept payment for the amount Medicare suggests.
If a doctor or provider does not accept the assignment, a person is responsible for the total cost of the CPAP equipment when they buy it.
Medicare Advantage plans have differing rules about equipment brands, suppliers, and medical approval, so people must check with their insurer before they buy.
The table below shows how much Medicare may pay toward CPAP therapy.
| Area of Medicare | Deductible amount | Copayment of the Medicare-approved amount | Does it cover CPAP therapy? |
|---|---|---|---|
| Part A | $1,632 per benefit period | 20% | Part A covers CPAP therapy during stays in a hospital or short-term healthcare facility, such as a nursing facility or hospice. |
| Part B | $240 | 20% | Part B covers CPAP therapy for home use. |
| Medicare Advantage | varies by plan | varies by plan | Medicare Advantage must at least match the coverage of parts A and B (Original Medicare). |
Medicare Part B only covers CPAP therapy when the prescribing doctor and CPAP equipment supplier are enrolled in Medicare.
A person must pay their annual deductible of $240 before Medicare will cover a 3-month trial of CPAP therapy.
3-month CPAP trial
Once a person meets the conditions above, they will qualify for the 3-month trial if:
- A doctor diagnoses OSA after a sleep test in a sleep lab or at home using a qualifying sleep monitoring device (type II, III, or IV home sleep device).
- Their apnea-hypopnea index (AHI) or respiratory disturbance index (RDI) score is:
- 15 events per hour or more
- between 5 and 14 events per hour
- They have other symptoms, such as daytime fatigue, high blood pressure, or heart disease.
After the 3-month trial, Medicare may continue to pay to rent the CPAP equipment for a further 13 months. Medicare will pay 80% of the Medicare-approved amount. The recipient will pay the remaining 20% as coinsurance. After 13 months, the recipient will own the equipment.
13-month CPAP trial
A person must meet certain criteria to qualify for the 13-month trial:
- The recipient must have completed the 3-month trial.
- A doctor must state in a person’s medical record that the CPAP therapy is working and that they are adhering to therapy. Adherence means using the machine for at least 4 hours per day for 70% of days.
During the 13-month trial, a person must use the CPAP equipment without interruption, or Medicare may stop their rental payments. This may mean a person has to return the machine or pay the remainder of the balance themselves.
Medicare Part B usually covers most of the cost of CPAP equipment when a person has sleep apnea and meets certain criteria.
A person will have a 3-month trial using CPAP equipment. If the person adheres to therapy, Medicare will continue to pay for the equipment for 13 months following the trial.
Medicare Advantage plans usually cover CPAP therapy, as they must at least match the coverage of Original Medicare.
A person must work closely with a doctor to ensure they meet all documentation and compliance requirements for Medicare CPAP therapy.