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

Medicare will pay for a CPAP (continuous positive airway pressure) machine if your doctor documents that you have obstructive sleep apnea and prescribes the device as medically necessary. Part B covers 80 percent of the approved amount after you meet your deductible. You pay the remaining 20 percent, plus any difference between what Medicare approves and what the supplier charges — unless you use a Medicare-contracted supplier.

The catch is that Medicare requires a sleep study first. Your doctor must order either an in-lab sleep study at a hospital or sleep center, or a home sleep apnea test. The results have to show that you have obstructive sleep apnea before Medicare will cover the machine itself. Without documented sleep apnea, Medicare will not pay, even if a doctor thinks you need one.

Key Takeaways

  • You need a sleep study showing obstructive sleep apnea before Medicare will cover a CPAP machine — a doctor's opinion alone is not enough.
  • Medicare Part B pays 80 percent of the approved amount after your deductible; you pay 20 percent plus any charges above the Medicare-approved price.
  • You must rent or purchase the machine from a Medicare-contracted supplier to avoid paying the full difference between the supplier's price and Medicare's approved amount.
  • Medicare covers the machine itself, the mask, tubing, and filters, but coverage rules differ slightly for rental versus purchase.

How the sleep study requirement works

Before your doctor can write a prescription for a CPAP machine, Medicare requires evidence that you have obstructive sleep apnea. This means you need a sleep study. Your doctor will order one of two types: an in-lab study at a hospital or accredited sleep center, where you sleep overnight while technicians monitor your breathing and oxygen levels, or a home sleep apnea test, which you do at home using a portable device that records the same information.

The sleep study results must show that you stop breathing repeatedly during sleep — a condition called apnea — or that your breathing becomes very shallow (hypopnea). The study measures how many times per hour this happens. Medicare uses these numbers to confirm the diagnosis. If the study shows you do not have obstructive sleep apnea, Medicare will not cover the CPAP machine, even if you have symptoms like loud snoring or daytime sleepiness.

Your primary care doctor can order the sleep study, or you may be referred to a sleep medicine specialist. Either way, the study must be done before the CPAP prescription is written. Some suppliers will not even rent or sell you a machine without proof of the study results.

What Medicare pays for and what you pay

Medicare Part B covers the CPAP machine, the mask, tubing, filters, and other supplies needed to use it. If you rent the machine, Medicare pays 80 percent of the approved rental amount each month for up to 13 months. After 13 months of rental payments, Medicare switches to covering purchase of the machine instead — you then own it outright.

You are responsible for 20 percent of the Medicare-approved amount. If your supplier charges more than Medicare approves, you also pay that difference — unless the supplier is contracted with Medicare and has agreed to accept Medicare's approved amount as payment in full. Always ask the supplier whether they are a Medicare-contracted provider before you rent or buy.

Your Part B deductible applies to CPAP coverage. Once you meet your deductible for the year, the 80/20 split begins. If you have a Medigap or Medicare Advantage plan, your supplemental coverage may help pay your 20 percent share, depending on your plan.

Renting versus buying a CPAP machine

Medicare's approach to CPAP machines is different from many other medical equipment. When you first need a CPAP, you rent it from a supplier. Medicare pays 80 percent of the approved rental fee each month. You pay 20 percent. This continues for 13 months.

After 13 months of rental, Medicare switches to a purchase model. At that point, Medicare pays 80 percent of the approved purchase price, and you pay 20 percent. You then own the machine. This means you do not pay monthly rental fees anymore — you own the equipment outright.

Some people choose to buy a CPAP machine outright before the 13-month rental period ends, or they buy a different machine than the one they rented. If you do this, you pay the full cost yourself; Medicare will not reimburse you for a purchase made before the rental period is complete. Talk to your supplier about the timeline and costs before you decide to buy early.

Finding a Medicare-contracted CPAP supplier

Not all medical equipment suppliers are contracted with Medicare. If you use a non-contracted supplier, you may have to pay the full bill upfront and then submit it to Medicare for reimbursement — and Medicare will only reimburse based on its approved amount, not what you actually paid. You could end up paying hundreds of dollars out of pocket.

To find a contracted supplier, use the Medicare Supplier Directory at dmepos.cms.gov (DMEPOS stands for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies). Enter your ZIP code and search for "CPAP" or "respiratory equipment." The directory shows which suppliers in your area are contracted with Medicare and what type of equipment they provide.

You can also call your doctor's office and ask which suppliers they work with. Many offices have a list of Medicare-contracted providers they refer patients to. Using a contracted supplier protects you from surprise bills and ensures Medicare's payment goes directly to the supplier.

What to ask your doctor before getting a CPAP machine

Before you move forward, ask your doctor these questions: Do I need a sleep study, and will you order one? If I already had a sleep study, can you send me the results? Which suppliers do you recommend, and are they contracted with Medicare? What should I expect to pay out of pocket, and does my plan cover any of the 20 percent?

Also ask whether your doctor thinks you should rent first or purchase outright. Some doctors recommend renting to make sure the machine works well for you before you own it. Others think buying sooner makes sense if you know you will use it long-term. Your doctor can help you weigh the costs and benefits based on your situation.

If you have a Medigap or Medicare Advantage plan, call your plan before you get the machine and ask what your out-of-pocket cost will be. Plans vary in how much they cover beyond Medicare's 80 percent.

When to seek care or contact Medicare

Contact your doctor if you have symptoms of sleep apnea — loud snoring, gasping for air during sleep, daytime sleepiness even after a full night's sleep, or waking up with a dry mouth or sore throat. These are signs you may need a sleep study. Do not wait; untreated sleep apnea increases the risk of heart attack and stroke.

If Medicare denies coverage for your CPAP machine, you have the right to appeal. You will receive a notice explaining why coverage was denied. You can ask your doctor to provide additional information or clarification about your diagnosis. Contact Medicare at 1-800-MEDICARE (1-800-633-4227) to ask about the appeal process, or visit medicare.gov for detailed instructions.

If you already have a CPAP machine and your mask or tubing wears out, contact your supplier to order replacements. Medicare covers these supplies as part of your CPAP coverage, though there are limits on how often you can get new ones — usually a new mask every month and tubing every three months.

Frequently Asked Questions

Do I have to have a sleep study done at a hospital, or can I do it at home?

Medicare covers both in-lab sleep studies at a hospital or sleep center and home sleep apnea tests. Your doctor will decide which is appropriate for you based on your health and symptoms. Home tests are often faster and less expensive, but some people need an in-lab study if the home test results are unclear or if you have other health conditions.

What if I already own a CPAP machine and want Medicare to cover it?

Medicare will not reimburse you for a machine you already bought out of pocket. Coverage begins only after a doctor prescribes it based on a sleep study, and you must rent or purchase it from a Medicare-contracted supplier going forward. If you bought a machine before getting a sleep study, talk to your doctor about whether you still need one to confirm the diagnosis.

Will my Medicare Advantage plan cover CPAP the same way as Original Medicare?

Medicare Advantage plans must cover at least what Original Medicare covers, but they may have different rules about which suppliers you can use or require prior authorization before you rent or buy. Contact your plan before you start the process to understand your specific coverage and out-of-pocket costs.

Can I get a new CPAP machine if my old one breaks?

If your machine breaks after you own it, Medicare does not automatically cover a replacement. You would need to work with your supplier and doctor to determine whether a repair is possible or whether a new prescription and purchase is medically necessary. Keep your machine in good working order to avoid this situation.

What happens if I stop using my CPAP machine?

If you stop using your CPAP machine, you still own it, but Medicare will not cover a replacement or rental unless your doctor prescribes a new one based on a new sleep study. If you are having trouble using the machine, talk to your doctor or supplier — they may be able to adjust the settings or try a different mask to make it more comfortable.