Depending on the Medicare plan you have, you may be responsible for a portion of the cost.
Sleep apnea means you involuntarily stop breathing while you are asleep. Your breathing may stop for a minute or longer, and you may stop breathing multiple times during the night.
Sleep apnea without treatment can lead to high blood pressure, heart disease, stroke, sleepiness, diabetes, and depression.
Sleep apnea is more common in men than in women. Hispanic and African American men, overweight people, and people over 40 seem to be at higher risk, although sleep apnea can occur at any age.
Symptoms include loud snoring, obesity, sleepiness during the day, and waking up at night feeling out of breath. Regularly waking up with a dry mouth or headache can indicate sleep apnea.
The most common type of sleep apnea is obstructive sleep apnea; this is where the soft tissue at the back of the throat collapses during sleep.
Medicare Coverage for Sleep Apnea Treatment
When it comes to sleep apnea, Medicare covers 80% of an oral appliance or CPAP machine as “Durable Medical Equipment.” To avoid additional costs, be sure your equipment comes from a supplier accepting Medicare assignment.
In some states, you must get equipment from a supplier who participates in Medicare’s bidding program. If you have Medicare Advantage, copays, network restrictions, and deductibles could apply.
Check with your provider before scheduling a sleep study or getting apnea treatment equipment.
Does Medicare Pay for the Sleep Apnea Test
Medicare can offer coverage for sleep studies; however, before treatment, there are specific requirements. Part B of Medicare can cover a sleep study test that is medically necessary.
Even with coverage, you may be responsible for some of the costs; after deductibles, Medicare only covers 80%. If you have a Medicare Advantage plan, talk to your plan provider about in-network providers, coverage, and costs.
Those with a Medigap policy may pay little to nothing out of pocket when receiving treatment.
How Often Will Medicare Allow you to be Tested for Sleep Apnea
Testing frequency depends significantly on the reasons behind needing a new study. There isn’t a lifetime limit on sleep studies.
You may need a new study if you discontinue CPAP therapy or fail during the 3-month trial period; that’s when testing and trials restart.
Sleep Apnea Treatment
The most common treatment for sleep apnea is continuous positive airway pressure, or CPAP, machine. Patients are using this machine with a breathing mask during sleep.
CPAP machines send pressurized air into the throat to stop the airway from collapsing.
With a CPAP machine, sleep apnea sufferers can:
- Sleep better
- Snore less
- Avoid the more severe side effects of sleep apnea.
People who have mild to moderate sleep apnea or cannot tolerate a CPAP machine are good candidates for oral appliances.
Like a sports mouth guard, the oral appliance holds the jaw forward in a way that keeps the airway open. Oral appliances are comfortable to wear and are quieter and more portable than CPAP machines.
Does Medicare Cover in-home Sleep Apnea Testing
When you meet specific requirements, an in-home sleep apnea study could have coverage through Medicare. Home studies provide a way for portable monitoring; this has been around as long as the CPAP.
According to the National Coverage Determination, a doctor must order and supervise an in-home sleep study. Also, when you do an in-home sleep study, the initial coverage for a CPAP is only a 12-week trial period instead of the 3-month trial period.
Does Medicare Cover CPAP Machines for Sleep Apnea
Medicare does cover CPAP Machines for sleep apnea; you need to purchase a CPAP machine through a Medicare supplier. If Medicare approves the claim, the Medigap carrier approves.
Those with Medicare Advantage plans should check the plans network, coverage, and costs before undergoing a sleep study.
Medicare Guidelines for CPAP
- There is a three-month trial period. During this time, Medicare pays 80% of the cost of renting the CPAP machine; plus, 80% of the cost of masks, tubing, and other necessary supplies.
- Medicare continues covering your CPAP machine after the first three months if your doctor confirms that CPAP therapy is helping.
- Medicare pays the CPAP supplier a rental fee for 13 months. After that, you own the machine.
- If you have a CPAP machine from before Medicare, there may be Medicare coverage for replacement machine rental or accessories.
How Much Does Medicare Pay for CPAP
Medicare covers 80% of the cost of a CPAP machine that is medically necessary for the treatment of Sleep Apnea. Beneficiaries with Medigap coverage might not have to pay the 20% of the bill.
Advantage plans have their fee schedule, check with your insurance to find out how your coverage works.
Does Medicare Cover CPAP Cleaning Machines
Medicare doesn’t pay for a CPAP cleaner; no coverage is available for SoClean or Lumin. Medicare beneficiaries can easily clean the CPAP device with mild antibacterial soap and water.
The CPAP machine should receive a cleaning at least once a week; although, once a day is allowable.
Of course, only ever put distilled water in the humidifier. The humidifier should also receive weekly cleanings.
Does Medicare Cover the Sleep Apnea Mouthpiece
Yes, Medicare covers oral appliances for obstructive sleep apnea when you meet specific criteria. To receive reimbursement, a dentist must be a DME Medicare Supplier.
Meeting Medicare standards and guidelines for coverage is a requirement; if the claim receives a denial, you can always file an appeal.
What Sleep Apnea Pumps Will Medicare Pay For
Medicare will cover an implantable pump refill when a physician orders, or personally furnishes a pump.
How Often Can I Get Sleep Apnea Supplies Paid for by Medicare
Replacement supplies are available depending on the supplies you need. Some supplies, like full-face cushions, Medicare allow replacements for monthly.
Medicare beneficiaries can receive new disposable filters and nasal cushions twice a month. While other supplies, like a replacement CPAP Machine, only allow replacements every five years.
Failing to meet Medicare guidelines for coverage could cause your supplies not to have coverage. You must follow the steps set forth by Medicare to receive coverage.
If a diagnosis wasn’t up to Medicare guidelines, you might need to start the process over with a new sleep study; followed by a compliance period.
What Other Sleep Apnea Devices Does Medicare Cover
Position therapy devices for sleep apnea likely have coverage with a doctor’s prescription and Medicare DME supplier. Those that have sleep apnea primarily when back sleeping, could benefit from the “supine” positioning device.
The wearable device will go around the waist and position you to sleep and stay sleeping on your side. Another option goes on the back of the neck to gently vibrate when you start to roll to your back; this is “vibrotactile feedback” technology; without waking you, the vibrations alert the body to not rollover.
Lifestyle changes can reduce snoring and improve symptoms of sleep apnea. These changes can include quitting smoking, quitting drinking alcohol, and staying with your treatment plan.
Does Medicare Cover Sleep Apnea Surgery
Medicare covers essential surgical procedures. When you meet specific criteria, Medicare should cover the surgery.
If Medicare covers uvulopalatopharyngoplasty (UPPP), a Medigap plan covers the surgery. Those with a Medicare Advantage plan need to contact their insurer about coverage.
Medicare considers Laser-Assisted Uvuloplatoplasty (LAUP) ineffective, and thus there is no coverage available.
Additional Medicare Coverage for Sleep Apnea
Medicare Supplement plans can cover the expenses Medicare doesn’t, such as deductibles, coinsurance, and copayments you’d otherwise pay. With Medigap, you can choose any doctor that accepts Medicare in the nation.
Also, Medigap always approves services that Medicare approves, and they cover the way they say the cover. Never question your coverage, enroll in Medigap.
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