Your Medicare Coverage
Is my test, item, or service covered?
Sleep apnea & Continuous Positive Airway Pressure (CPAP) therapy
How often is it covered?
People with Medicare who’ve been diagnosed with obstructive sleep apnea are eligible to get a 3-month trial of CPAP therapy.
Medicare may cover it longer if you meet these requirements:
- You must meet in person with your doctor, and your doctor must document in your medical record that the CPAP therapy is helping you. You must meet with your doctor no sooner than 31 days and no later than 91 days after starting the CPAP therapy for Medicare to cover it without a break in coverage.
- Your doctor must document in your medical record that you’ve been using the CPAP device at least 4 hours per night on 70% of nights during a period of 30 days in a row.
If you had a CPAP machine before you got Medicare, Medicare may cover rental or a replacement CPAP machine and/or CPAP accessories if you meet certain qualifications.
Your doctor or other health care provider may recommend you get services more often than Medicare covers. Or, they may recommend services that Medicare doesn’t cover. If this happens, you may have to pay some or all of the costs. It’s important to ask questions so you understand why your doctor is recommending certain services and whether Medicare will pay for them.
People with Medicare who’ve been diagnosed with obstructive sleep apnea.
Your costs in Original Medicare
Medicare pays the supplier to rent the machine for the 13 months if you’ve been using it without interruption. After you’ve rented the machine for 13 months, you own it.
Medicare will only cover your durable medical equipment(DME) if your doctor or supplier is enrolled in Medicare. If a DME supplier doesn't accept assignment, Medicare doesn't limit how much the supplier can charge you. You may also have to pay the entire bill (your share and Medicare's share) at the time you get the DME.
Competitive Bidding Program
If you live in or visit certain areas, you may be affected by Medicare's Competitive Bidding Program. In most cases, if you have Original Medicare and get competitively bid equipment and supplies in competitive bidding areas, Medicare will only help pay for these equipment and supplies if they're provided by contract suppliers. Contract suppliers can't charge you more than the 20% coinsurance and any unmet yearly deductible for any equipment or supplies included in the Competitive Bidding Program.
If your current supplier doesn’t get a new contract, you may still be able to stay with that supplier if they decide to participate in the program as a “grandfathered” supplier. Suppliers that don’t get Medicare contracts can decide to become "grandfathered" suppliers. This means a supplier may continue to rent equipment to you if you were renting the equipment when the program started. This rule applies to oxygen, oxygen equipment, and certain rented equipment. You may continue using the “grandfathered” supplier until the rental period for your equipment ends.
If you start renting additional equipment from a “grandfathered” supplier after the program starts, Medicare won’t pay for the new equipment.
If you’re renting equipment that’s eligible for grandfathering, your supplier will let you know in writing 30 business days before the program begins whether it will or won’t become a “grandfathered” supplier.
If your supplier doesn’t choose to grandfather, you’ll need to use a new contract supplier for Medicare to help pay for your equipment.
Under current Medicare rules, you own these types of equipment after renting for 13 months. When you switch to a Medicare contract supplier instead of using a "grandfathered" supplier or other non-contract supplier, your 13-month rental period will start over, so you won't own the equipment until after the new rental period ends. This will extend your rental period and result in additional months of coinsurance. However, the amount you pay may be lower because the amount you'll pay will be based on the new payment rates under the new program.
- Once you own the equipment, you must get replacement supplies and accessories for the equipment from a contract supplier in order for Medicare to help you pay for these items. You may get repairs for the equipment you own from any Medicare-approved supplier (even a non-contract supplier), including replacement parts needed for the repair.
- If you already own your equipment, you must use a Medicare contract supplier for your replacement supplies and accessories.
To find out how much your specific test, item, or service will cost, talk to your doctor or other health care provider. The specific amount you’ll owe may depend on several things, like other insurance you may have, how much your doctor charges, whether your doctor accepts assignment, the type of facility, and the location where you get your test, item, or service.