Medicare Part B covers sleep apnea equipment, but only after a doctor's diagnosis and a sleep study

Yes, Medicare Part B will pay for a CPAP machine, BiPAP machine, or APAP machine if your doctor documents that you have obstructive sleep apnea. Medicare also covers the mask, tubing, and filters that go with the machine. However, coverage is not automatic — you need a sleep study first, your doctor must order the equipment as durable medical equipment (DME), and you must use a Medicare-approved supplier.

Medicare pays 80 percent of the approved amount for the machine itself after you meet your Part B deductible. You pay the remaining 20 percent. Masks, tubing, and replacement parts are covered separately, also at 80 percent after deductible. The exact dollar amount you pay depends on what your supplier charges and what Medicare's approved amount is in your area.

Key Takeaways

  • You must have a sleep study ordered by your doctor before Medicare will cover any sleep apnea equipment.
  • The equipment must be ordered by your doctor as durable medical equipment and obtained from a Medicare-approved DME supplier.
  • Medicare Part B pays 80 percent of the approved amount; you pay 20 percent after meeting your deductible.
  • Masks, tubing, filters, and other supplies are covered separately and replaced on a schedule set by Medicare.
  • If you have a Medigap or Medicare Advantage plan, your out-of-pocket costs may be lower than the standard 20 percent.

What the sleep study requirement means

Medicare requires that a doctor order a sleep study before approving any CPAP or similar equipment. The sleep study can happen in a sleep lab (attended study) or at home (home sleep apnea test). Your doctor interprets the results and, if obstructive sleep apnea is confirmed, writes an order for the equipment.

If you already had a sleep study done before you turned 65 or before you enrolled in Medicare Part B, that study may still count — but your current doctor needs to review it and confirm the diagnosis is still valid. Medicare will not cover equipment based on a study older than five years without a new evaluation.

How to order equipment through Medicare

Once your doctor has ordered the equipment, you cannot buy it from any supplier and expect Medicare to pay. You must use a Medicare-approved DME supplier. Your doctor's office usually has a list of approved suppliers in your area, or you can search the Medicare supplier directory online at the Centers for Medicare & Medicaid Services (CMS) website.

Contact the supplier directly and give them your Medicare number, your doctor's order, and your sleep study results. The supplier will submit the paperwork to Medicare for approval before you receive the equipment. This step takes one to two weeks. Do not pay out of pocket before Medicare approves the order — if Medicare denies it, you may not be reimbursed.

Once approved, you will owe your 20 percent coinsurance at the time you pick up or receive the equipment. If you have already met your Part B deductible for the year, you pay only the 20 percent. If you have not met the deductible, you pay the full deductible first, then 20 percent of the approved amount.

What equipment and supplies Medicare covers

Medicare covers the machine itself — CPAP, BiPAP, or APAP — as well as the mask, headgear, tubing, and filters. Humidifiers that attach to the machine are also covered if your doctor orders them as medically necessary.

Replacement masks and tubing are covered on a schedule. Medicare typically allows one mask per month and one set of tubing per month. Filters are usually covered once per month. If you need replacements more often because of wear or damage, you may have to pay out of pocket, though some suppliers will work with you on this.

Batteries, power cords, and travel cases are generally not covered by Medicare. Chin straps and other accessories beyond the basic mask and headgear may not be covered either, depending on whether your doctor documents them as medically necessary.

How much you will pay

The amount you pay depends on three things: your Part B deductible status, the Medicare-approved amount in your area, and what your supplier charges. Medicare sets an approved amount for each type of equipment in each region. Your supplier can charge more than the approved amount, but Medicare only pays based on the approved amount — you would owe the difference.

For example, if the Medicare-approved amount for a CPAP machine is $800 and your supplier charges $900, Medicare pays 80 percent of $800 (which is $640) after your deductible. You owe 20 percent of $800 (which is $160) plus the $100 difference between the approved amount and what the supplier charged — a total of $260 out of pocket.

If you have a Medigap policy, it may cover some or all of your 20 percent coinsurance. If you have a Medicare Advantage plan, your costs depend on your plan's rules — some plans cover DME at a lower coinsurance rate, and some have a copay instead. Check your plan documents or call the plan before you order.

What happens if Medicare denies the order

Medicare may deny coverage if the sleep study does not show obstructive sleep apnea, if the study is too old, or if your doctor's order does not include enough medical information. The supplier will tell you if Medicare denies the claim and explain the reason.

If you disagree with the denial, you have the right to appeal. The supplier can help you file an appeal, or you can contact Medicare directly. Appeals can take several weeks, so ask the supplier whether you can rent or borrow equipment while the appeal is pending.

Renting versus buying equipment

Medicare covers purchase of the equipment, not rental. However, some suppliers offer a rent-to-own arrangement where your rental payments count toward the purchase price. Ask your supplier about this option if you want to try the equipment before committing to buy.

If you cannot afford the 20 percent coinsurance upfront, some suppliers offer payment plans. This is a private arrangement between you and the supplier — Medicare does not set the terms. Ask about this when you contact the supplier.

Frequently Asked Questions

Do I need a new sleep study every year to keep my equipment covered?

No. Once Medicare approves your equipment based on a sleep study, you do not need a new study every year to continue using it. However, if you switch equipment types (for example, from CPAP to BiPAP) or if there is a gap of several years without using the equipment, your doctor may need to order a new study or at least document that the diagnosis is still current.

What if I have Medicare Advantage instead of Original Medicare?

Medicare Advantage plans must cover the same durable medical equipment as Original Medicare Part B, including sleep apnea equipment. However, your out-of-pocket costs, deductibles, and the suppliers you can use may be different. Check your plan's coverage details or call the plan before you order equipment.

Can I buy a CPAP machine on my own and ask Medicare to reimburse me?

No. Medicare will not reimburse you for equipment you buy on your own, even if you have a prescription from your doctor. You must order through a Medicare-approved DME supplier and let them submit the paperwork to Medicare before you pay. This protects you from paying for equipment Medicare will not cover.

Are travel CPAP machines covered by Medicare?

Travel CPAP machines are covered the same way as standard machines — through a Medicare-approved DME supplier with a doctor's order. However, travel accessories like carrying cases and battery packs are usually not covered. Ask your supplier which travel models are in stock and what the Medicare-approved amount is.

What if my CPAP machine breaks and needs repair?

Repairs are typically covered by the supplier's warranty during the first year. After that, Medicare does not cover repairs — you would pay out of pocket or replace the machine. If the machine is no longer working and cannot be repaired, your doctor can order a replacement, and Medicare will cover it the same way as the original machine.