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A CPAP machine is a device that is specifically designed for the therapeutic treatment of a common condition known as sleep apnea.
Original Medicare may cover CPAP therapy if certain conditions are met and the device is deemed medically necessary by a doctor.
It is possible to receive more comprehensive coverage for CPAP equipment and therapy via a Medicare Advantage plan.
You can learn more about your eligibility for varying degrees of CPAP coverage under Medicare by reaching out to the licensed insurance agents at MedicareInsurance.com today.
Sleep apnea is a common condition that often plagues older adults. It is a potentially serious disorder that is characterized by repeated breathing disruptions during sleep, when one’s breathing may start and stop irregularly. Sleep apnea is officially diagnosed when one’s airflow stops for at least ten seconds.
Common symptoms of sleep apnea include:
Sleep apnea most commonly occurs in those who are overweight, suffer from certain medical conditions (such as congestive heart failure, use tobacco, or regularly use alcohol or other sedative drugs. Sleep apnea is more common in men than women, but can affect both sexes.
There are two primary types of sleep apnea: Obstructive Sleep Apnea (OSA), in which the airway at the back of one’s throat becomes blocked during sleep, and Central Sleep Apnea (CSA), which occurs when there is a miscommunication between one’s brain and the control of their breathing during sleep.
Both forms of sleep apnea are typically treated through the use of a Continuous Positive Airway Pressure, or CPAP, machine, which delivers a flow of pressurized air through a mask that fits over your mouth and nose during sleep. This treatment, known as CPAP therapy, helps to keep your airway open and assist you in breathing more easily during sleep.
CPAP machines may also include tubing that connects the machine to the facemask. Some models may also include a humidifier attachment as well.
The good news is, Original Medicare may cover certain aspects of CPAP machines, CPAP supplies, and CPAP therapy depending on several conditions. First, you must have been formally diagnosed with sleep apnea by a doctor who deems CPAP therapy to be a medically necessary treatment.
After this condition is met, Original Medicare Part B will usually cover a three-month trial of CPAP therapy, but this duration may be extended if you meet in person with your doctor to assess the level of need you require and it is determined that CPAP therapy is an effective treatment for you.
In addition to the costs associated with CPAP therapy itself, you may be wondering “does Medicare cover CPAP machine supplies as well?” You may be surprised to learn that the answer is yes; at least 80 percent of equipment costs will be covered under Original Medicare Part B in accordance with the following replacement schedule:
Please note that Original Medicare will not typically pay for items and services that exceed this replacement schedule under most circumstances. In addition, Original Medicare does not cover the following CPAP supplies:
In addition to medically necessary CPAP machines, equipment, and treatment, Original Medicare Part B may also cover sleep studies that relate to the diagnosis and management of sleep apnea.
In order to formally diagnose you with the condition, your doctor will need to run a few tests and order a sleep study. This study may either be conducted at-home or may require you to undergo a formal lab sleep study at an overnight clinic.
Generally, original Medicare Part B will cover 80 percent of the approved cost for this study, and the Part B deductible does apply.
As stated above, Original Medicare generally covers 80 percent of the costs associated with sleep apnea machines. For this coverage, the Part B deductible applies. If you happen to also be a Medicaid recipient, you may pay less or owe nothing if Medicaid is your secondary payer.
Keep in mind that because CPAP therapy is not always an effective treatment for everyone, Original Medicare, only a three-month trial period is covered initially following a formal diagnosis. After this period, additional CPAP therapy will need to be proven effective and be ordered by a doctor before Medicare will extend coverage.
If your coverage is extended through Original Medicare, you will owe 20 percent of the Medicare-approved cost to rent the machine as durable medical equipment. At this point, the equipment supplier will provide you instructions on how to use the machine.
In order to receive coverage, the CPAP machine supplier from which you obtain the machine must be enrolled in Medicare, as must the doctor who orders your machine. Original Medicare will pay its share of the costs to rent your CPAP machine for 13 months, after which you will own the machine outright.
Through Original Medicare, the cost of a new CPAP machine will usually be covered once every five years. In the event that you already had a CPAP machine prior to enrolling in Original Medicare, some replacement costs and accessories may be covered if you meet certain requirements.
While Original Medicare coverage may prove to be extremely beneficial in your ability to acquire and utilize a CPAP machine, the fact remains that Traditional Medicare Parts A and B do not always provide the level of coverage that you may require. This is where Medicare Part C, also known as Medicare Advantage, comes into play.
Although Medicare Advantage plans are sold by private insurance companies with varying degrees of benefits, availability, and pricing, they are still required by law to provide the same level of coverage as Original Medicare plans. In many cases, they may also include additional perks or better pricing bundle options for your specific coverage needs.
When asking yourself, “does Medicare cover CPAP machines?” you may find that the level of coverage provided by a comprehensive Medicare Advantage plan may fit better for your specific healthcare needs and lifestyle.
Most Medicare Advantage plans will also provide additional coverage for common needs such as vision care, hearing care, and dental care as well.