Breathing Easier With the Right Sleep Therapy
A CPAP machine is one of the most effective treatments for obstructive sleep apnea (OSA) — a condition where breathing repeatedly stops and starts during sleep. Untreated sleep apnea can lead to serious health issues, including high blood pressure, heart disease, stroke, daytime fatigue, and cognitive decline.
The good news for seniors is that Medicare helps cover CPAP machines, supplies, and related sleep studies for those who qualify. Understanding how coverage works can help beneficiaries get the therapy they need with minimal out-of-pocket cost.
What Medicare Covers for CPAP Therapy
Medicare provides coverage for CPAP machines under Medicare Part B (Medical Insurance) because CPAP devices are considered Durable Medical Equipment (DME).
Medicare Part B Covers:
- A CPAP or APAP machine
- Masks, tubing, filters, and other accessories
- Replacement supplies on an approved schedule
- Sleep studies needed to diagnose obstructive sleep apnea
- Follow-up appointments related to CPAP therapy
Medicare typically covers 80% of the approved cost, after the Part B deductible is met. The remaining 20% is the patient’s responsibility unless they have supplemental insurance that covers the difference.
The 13-Month Rental Rule
Medicare does not purchase a CPAP machine outright in most cases. Instead, beneficiaries go through a 13-month rental program:
- Medicare rents the CPAP machine for 13 consecutive months.
- After 13 months of continuous use, Medicare purchases the machine on your behalf.
- The device becomes yours as long as you continue to use it.
This process helps ensure the equipment is medically necessary and beneficial before full coverage is provided.
Requirements to Qualify for a Medicare-Covered CPAP
To be eligible for CPAP coverage, you must meet these conditions:
1. Have a Sleep Apnea Diagnosis
You must be diagnosed with obstructive sleep apnea through one of the following:
- An in-lab overnight sleep study
- A Medicare-approved home sleep test
Your doctor must document that the test results confirm sleep apnea.
2. Receive a Prescription From a Medicare-Approved Provider
Your physician must:
- Perform a face-to-face evaluation
- Confirm the CPAP machine is medically necessary
- Provide a written order or prescription
3. Meet Medicare’s Compliance Requirements
To continue receiving coverage, you must show that you’re using the CPAP machine regularly. Medicare defines this as:
- Using the machine at least 4 hours per night
- For at least 70% of nights
- Over a consecutive 30-day period within the first 90 days
Your CPAP supplier may monitor usage through a built-in modem or memory card to report data to Medicare.
Failing to meet compliance may stop coverage, but you can restart the process with a new evaluation if needed.
How Much Does a Medicare-Covered CPAP Cost?
Typical costs may include:
- 20% coinsurance on machine rental
- Replacement supply copays (after Medicare covers 80%)
- Annual Part B deductible (if not already met)
If you have a Medigap plan, most will cover the 20% coinsurance — dramatically reducing out-of-pocket costs. Medicare Advantage (Part C) plans may offer additional benefits or different cost-sharing rules depending on the plan.
Replacement Schedule for CPAP Supplies
Medicare follows a supply replacement schedule to ensure equipment stays sanitary and effective:
- Mask: Every 3 months
- Tubing: Every 3 months
- Filters: Every 2 weeks to 6 months, depending on type
- Headgear: Every 6 months
- Cushions and nasal pillows: Monthly
- Water chamber: Every 6 months
These supplies are also covered at 80% under Part B.
How to Get Started
Here’s how seniors can begin the process:
- Schedule an appointment with your doctor to discuss sleep apnea symptoms.
- Undergo a Medicare-approved sleep study.
- Receive a prescription for a CPAP device.
- Choose a Medicare-approved DME supplier.
- Begin treatment and meet compliance requirements within 90 days.
- Replace supplies regularly to maintain comfort and effectiveness.
Better Sleep, Better Health
Medicare’s coverage for CPAP therapy helps millions of seniors treat sleep apnea affordably. With proper diagnosis, the right equipment, and consistent use, CPAP therapy can dramatically improve sleep quality, energy levels, and overall health.
Understanding the rules and coverage options makes the process simple — and ensures you receive the care you need without unnecessary financial burden.
