A Continuous Positive Airway Pressure (CPAP) machine is a standard treatment for obstructive sleep apnea (OSA). For Medicare beneficiaries, these devices are classified as Durable Medical Equipment (DME). Medicare generally covers CPAP machines and related supplies under Part B, which covers outpatient services and medical equipment. Understanding the structure of this coverage, including the specific requirements and financial obligations, is necessary for managing therapy costs.
Establishing Coverage Eligibility
Coverage for a CPAP machine requires a definitive diagnosis of obstructive sleep apnea. This diagnosis must be confirmed through a sleep study, such as an in-lab polysomnography or an approved home sleep test. The beneficiary must then obtain a prescription, sometimes referred to as a Certificate of Medical Necessity, from a treating physician, confirming the CPAP therapy is medically necessary.
The equipment must be obtained from a supplier enrolled in and participating with Medicare. A Medicare-enrolled supplier agrees to follow the program’s rules and billing practices. Meeting these preliminary requirements sets the stage for Medicare to authorize payment.
The Standard Financial Breakdown
Medicare Part B determines an approved amount for the CPAP machine and its accessories. Once the annual Part B deductible is met, Medicare pays 80% of this approved amount. The beneficiary is responsible for the remaining 20% coinsurance, which applies to rental payments and covered supplies.
Out-of-pocket cost is significantly influenced by whether the supplier accepts Medicare assignment. A supplier who accepts assignment agrees to accept the Medicare-approved amount as the full payment. If a supplier does not accept assignment, they can charge the beneficiary more than the approved amount, resulting in substantially higher costs. The beneficiary may also have to pay the entire bill upfront and wait for Medicare to reimburse its 80% share.
The 13-Month Rental-to-Purchase Rule
Medicare’s payment model for CPAP machines follows a “capped rental” schedule. Medicare covers the device through continuous monthly rental payments for a total of 13 months, after which the beneficiary assumes ownership.
A significant condition for continued payment is the compliance requirement, assessed during an initial 90-day trial period. To prove compliance, the beneficiary must use the CPAP machine for at least four hours per night on 70% of nights within a consecutive 30-day period. The machine’s internal data-tracking capabilities verify this usage.
A follow-up appointment with the prescribing doctor is required between the 31st and 90th day to document the therapy’s effectiveness. If the patient fails to meet the minimum usage requirement, Medicare ceases rental payments, and the beneficiary becomes responsible for the full cost of the machine, highlighting the importance of adherence to the prescribed use.
Coverage for Replacement Supplies
The ongoing costs of CPAP therapy include necessary replacement supplies, which are covered under Medicare Part B’s DME benefit. These accessories include masks, tubing, filters, and water chambers. The beneficiary is responsible for the 20% coinsurance and any unmet deductible for these items.
Medicare establishes specific replacement schedules for each supply item to ensure the equipment remains effective and hygienic. Adhering to these set schedules is necessary for Medicare to authorize payment.
Replacement schedules vary by item:
- Disposable filters can typically be replaced twice a month.
- Non-disposable filters may be replaced every six months.
- Mask cushions are often replaced every few months.
- The full mask assembly is typically eligible for replacement every three months.