Obstructive sleep apnea affects many seniors in the United States. Medicare can be a beneficial tool in your tool chest when facing the symptoms and treatments for sleep apnea. Not only does Medicare work to cover doctors’ appointments relating to sleep apnea.
It also covers sleep studies and any medical equipment you may need with this condition. Sleep apnea treatments can add up quickly, so good healthcare coverage is essential. Let’s dive into all that’s covered through Medicare for sleep apnea.
Medicare coverage for sleep apnea devices
One of the most popular sleep apnea devices to treat patients is a Continuous Positive Airway Pressure (CPAP) machine. A CPAP machine uses positive airway pressure to help patients whose soft tissues collapse while asleep in the back of the throat. CPAPs use a mask that patients wear while they sleep.
Medicare Part B also helps pay for other styles of PAP machines, like a BIPAP or APAP machine. Different types of sleep apnea devices include implanted muscle stimulation devices, oral appliances, and EPAP valves.
All of these are covered through Medicare, but additional requirements for specific devices to receive Medicare coverage may exist. Medicare considers CPAP, as well as other PAP machines, as a necessary piece of equipment, known as Durable Medical Equipment (DME).
Medicare will also cover any accessories you’d use with the CPAP machine. Part B benefits will cover your DME; of course, you must pay applicable deductibles and coinsurance costs. Medicare Part B pays 80 percent of the expenses if your DME supplier is Medicare-approved. You’ll then pay the remaining 20 percent of the coinsurance costs.
How much does Medicare pay for a CPAP machine?
Medicare Part B will pay 80 percent of the costs related to your CPAP machine. Part B will help rent your machine from a DME supplier for 13 months. If you have required the use of the device for the past 13 months, you’ll own your CPAP machine.
Medicare Supplement policies help cover your portion of the coinsurance cost (20 percent) of your DME bill. Medicare Advantage plans offer the same coverage as Original Medicare. Still, depending on your specific plan and insurance carrier, they may cover more.
How many hours does Medicare require for CPAP?
You must adhere to specific requirements when continuing coverage of your CPAP machine. You’ll need to meet the following to ensure you’re sticking to the CPAP guidelines.
- Use the CPAP device for at least 4 hours each night
- For 70% of the nights
- During a consecutive 30-day timeframe within your first three months of using a CPAP
Your doctor must supply written documentation dictating that you adhere to these requirements.
Medicare coverage of sleep studies
Sleep studies are ordered through your doctor and are usually done to diagnose or evaluate your progress when undergoing treatment. Sleep studies can help diagnose sleep apnea, narcolepsy, panic disorders, asthma, and depression. Should you require a sleep study, you’ll need to make sure that you follow all the necessary steps to receive coverage.
Medicare requires that you, as the beneficiary, first and foremost, obtain a referral from your doctor. Then, all sleep must be documented and recorded. Medicare often has different requirements for each sleep study. Discussing these options with your provider ahead of time is essential to ensure you have optimal medical insurance. Depending on what sleep disorder your doctor is trying to diagnose, you may undergo one of the following types of sleep studies:
- Actigraphy: When taking an Actigraphy test, you’ll wear a small device that measures daytime sleepiness. This device is similar to a smartwatch. This test usually lasts for a few days.
- Polysomnogram (PSG): A PSG study in a sleep lab facility is used to diagnose sleep apnea. You’ll be hooked up to machines that record the amount of oxygen in your blood, brain activity, and more.
- Home Sleep Test (HST): An HST is conducted at home by you, the Medicare beneficiary. You’ll connect to a monitor while you sleep, and it’ll measure your heart rate and blood oxygen levels.
- Multiple Sleep Latency Test (MSLT): The MSLT usually occurs the day following your PSG. It’ll check your fatigue and monitor whether you fall asleep and how many stages of sleep you fall into.
- Maintenance Of Wakefulness Test (MWT): This test occurs the day after a PSG and checks to see if you can stay awake during the day.
Medicare limits for sleep studies
Medicare coverage of sleep studies may depend on several factors, including why you require the sleep study. There isn’t a limit on how many studies they’ll pay for. But usually, an initial examination is conducted, followed by a follow-up study several months later to determine any progress.
Suppose more progress is needed during your follow-up sleep studies. In that case, Medicare will approve additional sleep studies as long as necessary, so long as your doctor and you adhere to Medicare’s requirements.
Cost of a sleep study with Medicare
Since sleep studies fall under Medicare Part B coverage, you’ll owe a coinsurance amount rather than a fixed copay amount. First, you must ensure you meet your Part B deductible ($240). You’ll pay your Part B monthly premium each month and have a coinsurance of 20 percent of your sleep study bills, and Medicare Part B will pay for 80 percent of the sleep study expenses.
Medicare coverage of bi-level machines
Medicare covers bi-level respiratory devices over a three-month trial period for those with sleep apnea as long as beneficiaries meet all requirements. Some of these include whether you’ve tried and failed CPAP therapy or other treatment options and experience at least 15 events per hour while sleeping. You must also have documentation proving excessive fatigue throughout the day, mood disorders, a history of strokes, or impaired cognition.
Medicare coverage of mouth guards for sleep apnea patients
Medicare Part B covers oral appliances for sleep apnea. Since oral appliances are medical equipment, your doctor must indicate that the equipment is medically necessary for your health. The average price of a mouth guard for sleep apnea usually ranges from around $1,800 – $2,000. Once you meet your Part B annual deductible, Part B will pay 80 percent of the mouth guard expenses. This leaves you to pay a 20 percent coinsurance of the Medicare-approved amount.
FAQs
Let’s examine some of our frequently asked sleep apnea and Medicare questions.
How long are sleep studies good for Medicare?
While different health insurance companies have other requirements, Medicare requires no more than 12 months old sleep studies.
Does Medicare cover inspire for sleep apnea?
Inspire is a popular alternative to the CPAP machine. It’s a small device that operates remotely to help open your airways while you sleep, helping to make you sleep better at night. The Medicare program will cover those who require the use of Inspire.
What criteria does Medicare use for coverage of sleep apnea?
To qualify for Medicare coverage of your sleep apnea, you and your doctor must prove that; while you sleep, you have interrupted breathing for more than 10 seconds, at least five times per hour.
What is the maximum amount of time that Medicare will pay for CPAP?
When you receive a diagnosis of sleep apnea, Medicare Part B covers a three-month trial of CPAP therapy. Suppose you require more than three months of treatment. In that case, Medicare will pay for it if your doctor can document that treatment is necessary for your health and well-being.
Find a Medicare plan today that covers sleep apnea
Sleep apnea treatments can add up quickly. But you don’t have to go it alone! Medicare Supplement policies (Medigap) and Medicare Advantage plans are excellent avenues to travel when getting the most coverage for the best pricing. Call our team of licensed agents today, or complete an online quote request to see how much we can save you. We’ll compare prices and insurance plans and ensure you get exactly what you need at a price you can afford.
