What Medicare covers for CPAP machines

Medicare Part B covers CPAP machines (continuous positive airway pressure devices) for sleep apnea, but you will pay a share of the cost. Medicare pays 80 percent of the approved amount after you meet your Part B deductible. You pay the remaining 20 percent, which is called coinsurance. The actual dollar amount depends on what the machine costs and which supplier you use.

The approved amount — the price Medicare uses to calculate its share — typically ranges from $500 to $3,000 for a CPAP machine, though this varies by supplier and machine type. Your out-of-pocket cost will be 20 percent of whatever amount Medicare approves, not 20 percent of the retail price. If a supplier charges more than Medicare's approved amount, you are responsible only for the coinsurance on the approved amount, not the difference.

Medicare also covers replacement machines every five years and replacement supplies (masks, tubing, filters) on a schedule set by your doctor. You pay coinsurance on those items too, following the same 80/20 split after your deductible.

Key Takeaways

  • Medicare Part B covers 80 percent of the approved cost for a CPAP machine after you meet your annual deductible, leaving you to pay 20 percent coinsurance.
  • Your out-of-pocket cost depends on the approved amount Medicare sets, not the full retail price a supplier charges.
  • You must have a doctor's order for sleep apnea and use a Medicare-enrolled supplier to receive coverage.
  • Medicare covers replacement machines every five years and replacement supplies on a schedule your doctor sets, with the same coinsurance rules.
  • If you have a Medigap or Medicare Advantage plan, your coinsurance cost may be lower or covered differently depending on your plan.

How to find your actual out-of-pocket cost

To know what you will actually pay, you need three pieces of information: your Part B deductible status for the year, the Medicare-approved amount for the specific machine, and whether you have supplemental coverage.

Start by calling a Medicare-enrolled CPAP supplier in your area and asking them for the Medicare-approved amount for the machine your doctor prescribed. Tell them your machine type and brand if you have a preference. The supplier can tell you the approved amount over the phone. Multiply that number by 0.20 to find your 20 percent coinsurance cost.

Then check whether you have already met your Part B deductible this year. If you have not, you will pay the full deductible amount (currently $226 per year, though this changes annually) before coinsurance kicks in. Once you have met the deductible, you pay only the 20 percent coinsurance on the approved amount.

If you have a Medigap policy (supplemental insurance), it may cover some or all of your coinsurance. If you have a Medicare Advantage plan, your cost structure is different — call your plan to ask what you will pay for a CPAP machine, because Advantage plans set their own costs.

What you need to do before ordering

Medicare will not cover a CPAP machine without a doctor's order. Your doctor must document that you have sleep apnea, usually based on a sleep study. If you have not had a sleep study, ask your doctor whether one is needed before ordering equipment.

Once you have the order, you must use a Medicare-enrolled supplier. Not all medical equipment companies are enrolled with Medicare. You can search for enrolled suppliers on Medicare.gov using their supplier directory, or ask your doctor's office for a referral to a supplier they work with regularly.

Tell the supplier upfront that you want to know the Medicare-approved amount before you commit. Some suppliers will also ask whether you want to rent or purchase the machine. Medicare covers both options, but the cost structure is different — renting typically costs less upfront but adds up over time, while purchasing has a higher initial cost but no ongoing rental fees.

Renting versus buying a CPAP machine

Medicare covers both rental and purchase, and the choice affects what you pay. If you rent, you pay a monthly fee (typically $50 to $100 per month under Medicare's approved amount) for up to 13 months. After 13 months of rental payments, the machine becomes yours at no additional cost. If you stop renting before 13 months, you own nothing.

If you purchase outright, you pay the full approved amount upfront (your deductible plus 20 percent coinsurance). You own the machine when ready and can keep it as long as it works. Medicare will cover a replacement machine five years later if you still need one.

For many people, renting makes sense if they are unsure whether they will use the machine consistently, because they can return it without losing money. Purchasing makes sense if you know you will use it long-term and want to avoid monthly payments. Ask your supplier what the total rental cost would be over 13 months, then compare it to the purchase price to decide which works better for your budget.

What happens if you use an out-of-network supplier

If you order a CPAP machine from a supplier who is not enrolled with Medicare, Medicare will not cover any of the cost. You will pay the full retail price yourself. This is why checking enrollment status before ordering is important — it can save you hundreds of dollars.

Some people choose non-enrolled suppliers because they offer a specific brand or model they prefer, or because they live in an area with few enrolled suppliers nearby. If that is your situation, ask your doctor whether they can write an order that an enrolled supplier can fill, even if it is not the exact brand you wanted. Often a different brand will work just as well.

If no enrolled suppliers are available in your area, contact Medicare directly at 1-800-MEDICARE to ask about exceptions or to find the nearest enrolled supplier outside your when ready area.

How your deductible and other costs affect the total

Your Part B deductible resets every January 1. If you order a CPAP machine early in the year before meeting your deductible, you will pay the full deductible amount plus 20 percent coinsurance on the approved amount. If you order later in the year after already meeting your deductible through other medical services, you pay only the 20 percent coinsurance.

For example, if the Medicare-approved amount is $1,000 and you have not met your deductible, you would pay $226 (deductible) plus $155 (20 percent of the remaining $775) for a total of $381. If you had already met your deductible, you would pay only $200 (20 percent of $1,000).

Replacement supplies — masks, tubing, and filters — are also subject to the same deductible and coinsurance rules. However, Medicare sets limits on how often you can receive replacements. Your doctor will specify the replacement schedule, and you can order new supplies on that schedule without additional doctor's orders each time.

When to contact Medicare or your supplier with questions

Before you order, contact your supplier to confirm the Medicare-approved amount and ask whether you meet any criteria for a lower cost (some suppliers offer discounts for cash payment or bundled supplies). Contact Medicare at 1-800-MEDICARE if you want to verify that a supplier is enrolled or if you have questions about your deductible status.

After you receive your machine, check your Medicare Summary Notice (the bill Medicare sends you) to make sure the approved amount and your coinsurance match what the supplier quoted. If something looks wrong, contact the supplier first — billing errors happen and are usually corrected quickly.

If you have a Medigap or Advantage plan, contact your plan's customer service before ordering to ask what your out-of-pocket cost will be. Plans vary widely in how they cover CPAP equipment, and your plan may cover costs that Original Medicare does not.

Frequently Asked Questions

Will Medicare cover a CPAP machine if I have not had a sleep study?

No. Medicare requires a doctor's order based on a sleep study diagnosis of sleep apnea. If you have not had a sleep study, ask your doctor whether one is needed. Your doctor can order a study, which Medicare also covers, before you order the machine.

What if the CPAP machine costs more than Medicare's approved amount?

You pay coinsurance only on the approved amount, not on the difference. If a supplier charges $2,500 but Medicare's approved amount is $1,200, you pay 20 percent of $1,200 (after your deductible), not 20 percent of $2,500. The supplier absorbs the extra cost.

Can I buy a CPAP machine online or from a retail store instead of a medical supplier?

Medicare will not cover a machine purchased outside the Medicare supplier network, even if you have a doctor's order. You would pay the full retail price yourself. Always order through a Medicare-enrolled supplier to receive coverage.

Does Medicare cover the mask and tubing separately from the machine?

Yes. Masks, tubing, filters, and other supplies are covered separately with their own approved amounts and coinsurance. Your doctor will set a replacement schedule, and you can order supplies on that schedule without additional orders each time.

What if I want to switch to a different CPAP machine after Medicare covers one?

Medicare covers a replacement machine every five years. If you want a different machine before five years have passed, you would pay for it yourself. After five years, you can order a new machine through a Medicare-enrolled supplier and receive coverage again.