A Guide to Medicare Coverage of CPAP Machines and Supplies in 2024

Key Takeaways

• Most insurance companies, including Medicare, cover the cost of some CPAP machines and supplies.
• The out-of-pocket costs you’ll be responsible for paying will vary based on your insurance provider, your plan, and whether you choose an enrolled doctor and supplier.
• If you are an Original Medicare beneficiary going through an enrolled doctor and supplier, you can expect to pay 20% of the Medicare-approved amount for the CPAP machine and supplies.
• After you’ve confirmed that your doctor and the supplier are enrolled and you’ve paid a deductible, Medicare Part B typically covers a three-month trial of CPAP therapy.
• For Medicare coverage, you’ll need a diagnosis of OSA from a sleep study.

More than 29 million Americans experience poor sleep quality due to obstructive sleep apnea (OSA), but only about 20% of those people have been diagnosed, according to the American Academy of Sleep Medicine.¹ The idea that treatment will be expensive and not covered by insurance is one barrier that prevents people from diagnosis and seeking care, according to a study in the Journal of Clinical Sleep Medicine.² Despite this perception, Medicare and most private insurance companies offer some degree of coverage for CPAP (continuous positive airway pressure) therapy, which includes CPAP machines and supplies and is a highly effective treatment for managing sleep apnea.³ In fact, when our Reviews Team surveyed 600 CPAP users in July 2023, 28.5% of respondents used Medicare, Medicare Part B, or Medicare Advantage to help pay for a CPAP machine. Another 28.33% used private insurance, while the remaining 43.17% used no insurance to pay for their equipment. This article discusses how and when Medicare covers CPAP therapy for first-time patients as well as how to replace your CPAP machine and supplies using Medicare.

Does Medicare cover CPAP machines?

The first thing to know about CPAP therapy and Medicare coverage is that the amount you’ll pay varies depending on the type of Medicare coverage you have and whether you have met your deductible. CPAP machines and other accessories are covered under durable medical equipment (DME).⁴

Table 1 Comparing different Medicare enrollment options, as of July 2023

* CPAP machines and other supplies fall under Medicare Part B.

** Deductible for the 2023 year (deductible changes annually starting Jan. 1, or whenever your plan year begins). For Part A, the deductible is for each inpatient period, not the year.

When does Medicare cover CPAP machines?

Original Medicare Part B will only cover your CPAP therapy devices and accessories if, after a diagnostic sleep study, your prescribing doctor and the CPAP equipment supplier are enrolled in Medicare.⁵ Doctors and supplies enrolled with Medicare agree to accept the Medicare-approved amount for the service or product provided. This is called “accepting assignment.”

At times, the Medicare-approved amount may be less than the amount the provider would normally charge, but the provider agrees to accept the set amount as full payment for services. If your doctor or supplier doesn’t agree to be paid by Medicare directly, you’ll be responsible for the total cost of your CPAP supplies at the time of purchase.

If you have Medicare Advantage, coverage of DME varies by plan. Your plan may have specific rules about getting approval, selecting a brand, and choosing a supplier that you must follow to get coverage. Reach out to your plan for more information before ordering your CPAP supplies.

How does Medicare coverage work for CPAP machines?

After you’ve confirmed that your doctor and the supplier are enrolled and you’ve paid the $226 deductible, Medicare Part B will cover a three-month trial of CPAP therapy. This includes the machine and accessories, like tubing, filters, and masks.

To qualify for the three-month CPAP therapy trial, you must:

• Use a doctor and supplier enrolled with Medicare (accept Medicare as payment)
• Be diagnosed with OSA after clinical evaluation in a sleep lab or by an at-home sleep test using a qualifying sleep monitoring device (Type II, III, or IV home sleep device)⁶
• Have an apnea-hypopnea index (AHI) or respiratory disturbance index (RDI) of at least 15 events per hour or between five and 14 events per hour, along with other documented symptoms (like excessive daytime sleepiness, hypertension, or heart disease)

After the three-month trial period, Medicare pays 80% of the Medicare-approved amount to rent the machine for 13 months. You pay the remaining 20% as coinsurance. Medigap plans and other supplemental health insurance plans often cover the 20% copay. Following the 13-month CPAP machine rental, you’ll own it.

To qualify for the 13-month CPAP equipment rental (and ultimate purchase), you must:

• Complete the three-month trial and provide documentation
• Meet with your doctor in person, and your doctor must document in your medical record that CPAP therapy is helping you and you were compliant (sometime after day 31 of usage but no later than day 91)

You’ll need to use the CPAP machine without interruption throughout the 13-month rental period for Medicare to continue paying each month. If at any point you stop using the machine on a regular basis, Medicare can stop paying the rental, and you’ll need to return the machine to the supplier or pay the remaining balance in full.

Medicare CPAP documentation and compliance requirements

Medicare pays for the three-month trial period but will only rent and eventually pay for the machine if you follow compliance and documentation standards.⁷ The compliance period starts 31 days after starting CPAP therapy but must begin before day 90 of therapy (so between days 31 and 89 of therapy). During this period, you must meet with your doctor in person, and they must document that you have been adhering to therapy and it has helped you.

Adherence to therapy is defined as using your machine at least four hours per day for 70% of days. For example, if you use your CPAP machine for four hours per night for 22 days out of 30 days, you’ve adhered to therapy and are compliant. Anything less than that is considered non-compliant. If you’re not compliant, your doctor will report it, and Medicare will deny your CPAP coverage. If you want to try to qualify for coverage again, you’ll have to repeat the trial qualification process.

CPAP machines will automatically transmit usage data to your CPAP supplier and, upon request, your prescriber and insurance company. Depending on your machine, this information can also be available using a smartphone app, so you can access and track your sleeping data as well.

Patients currently using a CPAP who become Medicare patients

If you’re currently using CPAP therapy and you’re new to Medicare, you might be able to qualify for CPAP machine and accessory replacements. To meet eligibility, you must have a sleep study on record that meets the Medicare qualifications for new CPAP users (positive diagnosis of OSA with threshold AHI or RDI events per minute or symptoms), and your enrolled physician must confirm and document that CPAP use helps you.⁸

Does Medicare cover CPAP supplies?

Medicare covers accessories, like tubing, filters, humidification chambers, and CPAP masks. The same rules that apply to machines, including travel CPAP machines, apply to these items as well. For Original Medicare to cover your items, the supplier must be enrolled with Medicare, and you’ll be responsible for a 20% copayment. Most supplies are also eligible for regular replacement, so long as the frequency matches the Medicare guidelines.

Does Medicare cover replacement supplies?

If you’re a current CPAP user who is new to Medicare, you can get your equipment replaced if you qualify under the new CPAP patient guidelines and your equipment is due for replacement under the Medicare standards.⁹ If you’re a new CPAP patient, you can replace your supplies as frequently as Medicare suggests.

Table 2: Medicare guidelines for replacing common CPAP equipment

* Medicare only covers replacement after you’ve reached the estimated lifetime (five years for DME).¹⁰ Until then, Medicare will pay for repairs needed to meet that lifetime (which may include total replacement).

What are the best CPAP machines?

CPAP machines come in many varieties and brands based on the sleeper’s unique needs. The three main types of machines are:

• CPAP (continuous positive airway pressure) machine: Disperses air at a consistent and fixed pressure throughout the night.
• APAP (automatic positive airway pressure) machine: Automatically adjusts the pressure level according to the sleeper’s needs throughout the night.
• BiPAP (bilevel positive airway pressure) machine: Delivers constant airflow set to receive a higher level of air while inhaling and a lower level of air while exhaling.

Your doctor will prescribe you a machine type based on your sleep lab results and common sleeping positions. They range in price from around $500–$1,000 or more. We’ve researched dozens of brands of CPAP machines based on quality, affordability, and reliability. Additionally, CPAP machines require a mask for use, so consider what CPAP mask might be best for you.

Bottom line

Before Medicare will cover the cost of your CPAP machine and accessories, you must be diagnosed with obstructive sleep apnea by a Medicare-enrolled doctor, which requires an overnight sleep study. Your device and accessories must come from a Medicare-enrolled supplier. If you used a CPAP machine before getting Medicare and you meet certain requirements, your replacement machine and accessories may be covered. If you qualify for coverage, Medicare doesn’t pay the total cost for your CPAP machine upfront. Instead, Medicare pays 80% of the rental payment cost for 13 months, which gives you ownership of the machine.

Additional sleep resources

• Alternative CPAP treatments
• Best CPAP supplies
• Best CPAP masks for side sleepers
• Best mattress for side sleepers
• Best mattress for back pain
• Best mattress

Have questions about this review? Email us at reviewsteam@ncoa.org.

Sources

1. American Academy of Sleep Medicine. Hidden Health Crisis Costing America Billions. Aug. 8, 2016. Found on the internet at https://aasm.org/resources/pdf/sleep-apnea-economic-crisis.pdf
2. Journal of Clinical Sleep Medicine. Facilitators and barriers to getting obstructive sleep apnea diagnosed: perspectives from patients and their partners. March 1, 2022. Found on the internet at https://jcsm.aasm.org/doi/10.5664/jcsm.9738
3. American Lung Association. Treating and Managing Sleep Apnea. Found on the internet at https://www.lung.org/lung-health-diseases/lung-disease-lookup/sleep-apnea/treating-and-managing
4. Centers for Medicare & Medicaid Services. Medicare Coverage of Durable Medical Equipment & Other Devices. Found on the internet at https://www.medicare.gov/media/publication/11045-medicare-coverage-of-dme-and-other-devices.pdf
5. Medicare.gov. Search for Medical Equipment & Suppliers. Found on the internet at https://www.medicare.gov/medical-equipment-suppliers/
6. Centers for Medicare & Medicaid Services. Continuous Positive Airway Pressure (CPAP) Therapy For Obstructive Sleep Apnea (OSA). Found on the internet at https://www.cms.gov/medicare-coverage-database/view/ncd.aspx?ncdid=226
7. Centers for Medicare and Medicaid Services. Medicare Quarterly Provider Compliance Newsletter: Guidance to Address Billing Errors. April 2021. Found on the internet at https://www.cms.gov/files/document/medicare-quarterly-provider-compliance-newsletter-volume-11-issue-3-print-friendly.pdf
8. University of Michigan Health. Medicare and CPAP Compliance. Found on the internet at https://www.uofmhealth.org/conditions-treatments/brain-neurological-conditions/medicare-and-cpap-compliance
9. Department of Health and Human Services. Replacement Schedules for Medicare Continuous Positive Airway Pressure Supplies. June 2013. Found on the internet at https://oig.hhs.gov/oei/reports/oei-07-12-00250.pdf
10. Medicare Interactive. Replacing DME. Found on the internet at https://www.medicareinteractive.org/get-answers/medicare-covered-services/durable-medical-equipment-dme/replacing-dme
11. NCOA CPAP Survey. 600 respondents. Conducted using Pollfish. Launched July 25, 2023.