Medicare Part B covers CPAP machines, but only after a doctor diagnoses obstructive sleep apnea and you meet specific requirements

Medicare Part B will pay for a CPAP machine if your doctor documents that you have obstructive sleep apnea and prescribes the device as treatment. You do not pay the full cost upfront — instead, Medicare covers 80 percent of the approved amount after you meet your Part B deductible. The remaining 20 percent is your responsibility, though a Medigap or Medicare Advantage plan may cover some or all of that cost.

The catch is that Medicare requires a sleep study first. Your doctor must order either an in-lab sleep study or a home sleep apnea test, and the results must show that you have obstructive sleep apnea before Medicare will pay for the machine. Without documented sleep apnea, Medicare will not cover the CPAP device.

Key Takeaways

  • Medicare Part B covers 80 percent of the cost of a CPAP machine after you meet your deductible, but only if a sleep study confirms you have obstructive sleep apnea.
  • Your doctor must order a sleep study — either in a lab or at home — and the results must show sleep apnea before Medicare will pay for any CPAP equipment.
  • You pay 20 percent of the Medicare-approved amount for the machine, plus any amount above what Medicare considers reasonable and necessary.
  • Medicare also covers CPAP supplies like masks and tubing, following the same 80/20 split after your deductible.
  • If you have a Medicare Advantage plan, your coverage rules may differ, so check your plan documents or call your plan before ordering a machine.

How the sleep study works and what Medicare requires

Before Medicare will cover a CPAP machine, your primary care doctor or a sleep specialist must order a sleep study. You have two options: an in-lab study at a sleep center, where you spend the night hooked to monitoring equipment, or a home sleep apnea test that you perform at home with a portable device. Both are covered by Medicare Part B, and your doctor will decide which is appropriate for you.

The sleep study measures how many times per hour your breathing stops or becomes shallow during sleep — this is called the apnea-hypopnea index, or AHI. Medicare requires an AHI of 15 or higher to cover a CPAP machine, or an AHI of 5 to 14 if you also have symptoms like daytime sleepiness, witnessed breathing pauses, or high blood pressure. Your sleep study report must include these specific numbers and findings for Medicare to process the claim.

Once your doctor has the sleep study results and confirms obstructive sleep apnea, they will write a prescription for a CPAP machine. This prescription is what you take to a durable medical equipment (DME) supplier — a company Medicare contracts with to rent or sell medical devices. Not all suppliers are Medicare-approved, so ask your doctor for a referral to one that is.

What Medicare pays and what you pay out of pocket

Medicare Part B covers CPAP machines under the durable medical equipment benefit. The way payment works depends on whether you rent or buy the machine. If you rent, Medicare typically covers the rental for up to 13 months, and you pay 20 percent of the monthly rental cost after your deductible. After 13 months, Medicare stops paying for rental, and you own the machine.

If you buy a machine outright, Medicare covers 80 percent of the approved amount after you meet your Part B deductible (which is $240 in 2024, though this amount changes yearly). You pay the remaining 20 percent. If the DME supplier charges more than Medicare's approved amount, you may owe the difference on top of your 20 percent — this is called balance billing. Ask the supplier upfront what the Medicare-approved amount is and what you will owe.

Medicare also covers CPAP supplies — masks, tubing, filters, and humidifier cartridges — under the same 80/20 split. Supplies are typically covered for one year, and you can order replacements as needed during that time. After one year, you start a new benefit period and can order supplies again.

Medicare Advantage plans and CPAP coverage

If you have a Medicare Advantage plan (Part C) instead of Original Medicare, your CPAP coverage may work differently. Some Advantage plans cover CPAP machines with little or no out-of-pocket cost, while others have higher copays or require prior authorization from the plan before you order the machine. A few plans may not cover CPAP at all, though this is rare.

Before you order a CPAP machine, call your Medicare Advantage plan and ask about their coverage for CPAP devices and supplies. Ask whether you need prior authorization, what your copay or coinsurance will be, and which DME suppliers are in-network. Ordering from an in-network supplier usually costs you less than going out-of-network.

Choosing a DME supplier and ordering your machine

Once you have your sleep study results and prescription, you will work with a DME supplier to get your CPAP machine. Medicare has a list of approved suppliers on its website, or your doctor can refer you to one. Call a few suppliers and ask what they charge, whether they are in-network with your insurance, and what happens if you need to return or exchange the machine.

The supplier will verify your Medicare coverage, collect any upfront payment you owe, and arrange delivery of the machine. Most suppliers also provide training on how to use the CPAP machine and how to care for it. Ask the supplier whether they offer 24/7 support if you have problems with the machine — this matters because CPAP machines can be uncomfortable at first, and you may need help adjusting settings or trying different mask styles.

Keep your prescription and sleep study results. If you switch suppliers or need to prove your coverage to a new provider, you will need these documents. Medicare keeps a record of what it paid, but having your own copies speeds things up.

What to do if Medicare denies your claim

Sometimes Medicare denies a CPAP claim because the sleep study results do not meet the AHI threshold, the prescription is incomplete, or the DME supplier submitted the paperwork incorrectly. If this happens, you will receive a notice called an Explanation of Benefits (EOB) that explains why the claim was denied.

Read the EOB carefully. If you disagree with the denial, you have the right to appeal. You can ask your doctor or the DME supplier to resubmit the claim with additional information, or you can file a formal appeal with Medicare. The appeal process has several levels, and you have important date to meet at each one — usually 120 days from the date on your EOB. If the denial was due to incomplete information from your doctor, ask them to send a corrected prescription or a letter explaining your sleep apnea diagnosis.

Frequently Asked Questions

Do I need a sleep study if my doctor thinks I have sleep apnea?

Yes. Medicare requires a sleep study with documented results showing obstructive sleep apnea before it will pay for a CPAP machine. Your doctor cannot prescribe a CPAP based on symptoms alone. The sleep study is the only way to confirm the diagnosis and measure the severity.

What if I cannot afford the 20 percent I owe?

Talk to your DME supplier about payment plans — many offer monthly payments instead of one lump sum. If you have limited income, you may also be may be able to access for Medicaid or other information programs that can help cover your share. Your local Area Agency on Aging can point you toward resources in your community.

Can I buy a CPAP machine without a prescription and use my Medicare later?

No. Medicare will not reimburse you for a machine you bought on your own without a prescription and sleep study. You must follow Medicare's process — sleep study, doctor's prescription, and ordering through a Medicare-approved DME supplier — for Medicare to pay.

What happens to my CPAP coverage if I switch from Original Medicare to a Medicare Advantage plan?

Your coverage may change. Contact your new plan before the switch takes effect and ask about CPAP coverage. If your new plan covers CPAP differently, you may need to reorder supplies or switch suppliers. Keep your prescription and sleep study results so you can transfer your care smoothly.

Does Medicare cover CPAP machines for central sleep apnea?

Medicare covers CPAP for obstructive sleep apnea. For central sleep apnea or mixed sleep apnea, coverage may be different — your doctor and DME supplier will need to work with Medicare to determine what is covered. Ask your doctor which type of sleep apnea you have and whether CPAP is the right treatment for you.