Man has medicare and sleep apnea

How To Get Medicare Covered Sleep Apnea Equipment

As a patient diagnosed with sleep apnea that recently turned 65 or will be 65 soon, you might be wondering if Medicare will cover CPAP? The answer is yes. Medicare will cover CPAP machines and equipment up to 80% of the cost after you’ve met the part B deductible. Therefore you’ll only have to pay 20% of the cost, instead of 80%. Good deal, right? Yes, it is, as long as you qualify through Medicare.

Qualifying For CPAP Through Medicare

Step 1: Enrolling in Medicare

First, to qualify for CPAP treatment through Medicare, you need to eligible and to enroll. The be eligible for Medicare Part A and B you must be a U.S. citizen or permanent legal resident for five consecutive years. You must also be age 65 or older.

You may automatically receive Medicare part A if you already receive Social Security or Railroad Retirement Board (RRB) benefits. If that’s the case, you’ll automatically receive part A and B the first day of the month that you turn 65.

If you do not automatically receive Medicare part A and B you’ll need to enroll during the initial enrollment period (IEP). This period is three months before you turn 65, the month you turn 65, and the three months following your 65th birth month. The date when your coverage starts depends on when you sign up during your 7-month long IEP.

Step 2: Being Tested For Sleep Apnea

To be eligible for sleep apnea treatment through Medicare you need to be diagnosed with sleep apnea. There are two main sleep apnea tests that have to be prescribed by your doctor to meet Medicare eligbility:

Medicare will cover sleep apnea supplies after a sleep apnea testAt Home Sleep Apnea Test: You can take an at-home sleep apnea test. These devices are shipped to your home for you to wear for a night. In the morning pack up the device and the results will be evaluated by a qualified sleep physician. They will determine if you have sleep apnea, it’s severity, and if you need further testing or not.

Lab Sleep Study: In a lab sleep study you will stay overnight in a sleep clinic as machines monitor your quality of sleep. This is a more thorough and detailed way to detect sleep apnea but can be more expensive. Type 1 will be covered by Medicare if it’s performed in a sleep study if your doctor orders the test.

Ask your doctor about testing options and what exactly Medicare will cover to fully understand the costs.

Step 3: Meeting The Guidelines With CPAP Compliance

After being enrolled in Medicare Part B and receiving a sleep apnea test you must:

Be diagnosed with sleep apnea by your primary care physician (PCP) in person that’s enrolled in Medicare. During this face to face visit, make sure your doctor takes notes to provide medical records that indicate the need for a CPAP device and how it will be beneficial for your health. 

Medicare covered CPAP equipment requires a doctor visit

After the device is set up, you will use it for a three month trial period. This CPAP compliance period lasts for 90 days, and you must have a follow-up visit with your PCP between the 31st 90th day after the period has started.

This is so your doctor can document that you’re benefiting from CPAP therapy and to review usage evidence to prove that the device is medically necessary and helping you.

For CPAP medical compliance you must demonstrate that you use your CPAP machine daily for at least four hours a night during 70% of the 90 days. This means that your equipment must be used for at least 21 nights during each month.

CPAP compliance is tracked by the CPAP machine either on an SD card or via blue tooth. It measures your apnea-hypoxia index (AHI) or sleep apnea severity, and how long the machine is used.

Step 4: Receiving Your Equipment

Once the guidelines above have been met Medicare will cover 80% of your CPAP supplies. But you will need to receive your items through a CPAP medical supplier or durable medical equipment provider (DME), like Aeroflow. Your CPAP supplies will be replaced based on the following schedule:

What If I’m Switching To Medicare?

If you’re switching from another insurance plan to Medicare, you may receive coverage for your CPAP equipment if you were diagnosed accordingly to Medicare’s guidelines. Otherwise, you’ll need to start the process over with a new test and compliance period.

What If I Don’t Meet CPAP Compliance?

If you fail to meet Medicare’s guidelines during the initial CPAP compliance period, your supplies will not be covered. However, you can start the process over.

We’re Here To Help

You don’t have to navigate your coverage on your own! Connect with an Aeroflow sleep specialist to help guide you through the process of obtaining a prescription, meeting compliance, and receiving equipment at little to no cost!

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