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Suffering With Sleep Apnea? Rest Assured Medicare Has Many Items Covered

October 19, 2023

Obstructive Sleep Apnea (OSA) occurs due to tissue relaxation that blocks the airway while we sleep

There is no substitute for a good night's sleep. For those with Sleep Apnea, not getting enough sleep can bleed into other areas and impact your health negatively. Finding the right Sleep Apnea treatment can change your life. More than 29 million Americans experience poor sleep quality due to Obstructive Sleep Apnea (OSA), but only about 20% of those people have been diagnosed, according to the American Academy of Sleep Medicine.

The first thing to know about CPAP therapy and Medicare coverage is that the amount you’ll pay varies depending on the type of Medicare coverage you have and whether you have met your deductible. CPAP machines and other accessories are covered under durable medical equipment (DME).

When does Medicare cover CPAP machines?
Original Medicare Part B will only cover your CPAP therapy devices and accessories if, after a diagnostic sleep study, your prescribing doctor and the CPAP equipment supplier are enrolled in Medicare. Doctors and suppliers enrolled with Medicare agree to accept the Medicare-approved amount for the service or product provided. This is called “accepting assignment.”

At times, the Medicare-approved amount may be less than the amount the provider would normally charge, but the provider agrees to accept the set amount as full payment for services. If your doctor or supplier doesn’t agree to be paid by Medicare directly, you’ll be responsible for the total cost of your CPAP supplies at the time of purchase.

If you have Medicare Advantage, coverage of DME varies by plan. Your plan may have specific rules about getting approval, selecting a brand, and choosing a supplier that you must follow to get coverage. Reach out to your plan for more information before ordering your CPAP supplies.

How does Medicare coverage work for CPAP machines?
After you’ve confirmed that your doctor and the supplier are enrolled and you’ve paid the deductible, Medicare Part B will cover a three-month trial of CPAP therapy. This includes the machine and accessories, like tubing, filters, and masks.

To qualify for the three-month CPAP therapy trial, you must:

• Use a doctor and supplier enrolled with Medicare (accept Medicare as payment).

• Be diagnosed with OSA after clinical evaluation in a sleep lab or by an at-home sleep test using a qualifying sleep monitoring device (Type II, III, or IV home sleep device).

• Have an Apnea-Hypopnea Index (AHI) or Respiratory Disturbance Index (RDI) of at least 15 events per hour or between five and 14 events per hour, along with other documented symptoms (like excessive daytime sleepiness, Hypertension or Heart Disease).

After the three-month trial period, Medicare pays 80% of the Medicare-approved amount to rent the machine for 13 months. You pay the remaining 20% as coinsurance. Medigap plans and other supplemental health insurance plans often cover the 20% copay. Following the 13-month CPAP machine rental, you’ll own it.

To qualify for the 13-month CPAP equipment rental (and ultimate purchase), you must:

• Complete the three-month trial and provide documentation.

• Meet with your doctor in person, and your doctor must document in your medical record that CPAP therapy is helping you and you were compliant (sometime after day 31 of usage but no later than day 91).

• You’ll need to use the CPAP machine without interruption throughout the 13-month rental period for Medicare to continue paying each month. If at any point you stop using the machine on a regular basis, Medicare can stop paying the rental, and you’ll need to return the machine to the supplier or pay the remaining balance in full.

Does Medicare cover CPAP supplies?
Medicare covers accessories, like tubing, filters, humidification chambers, and CPAP masks. The same rules that apply to machines, including travel CPAP machines, apply to these items as well. For Original Medicare to cover your items, the supplier must be enrolled with Medicare, and you’ll be responsible for a 20% copayment. Most supplies are also eligible for regular replacement, so long as the frequency matches the Medicare guidelines.

Mouth Guards for Sleep Apnea
Medicare will cover mouth guards for Sleep Apnea as DME (durable medical equipment) if your doctor considers it medically necessary. Although, some other treatments might get preferential treatment on Medicare. Mouth guards for Sleep Apnea are plastic devices that fit over the teeth. Also known as mandibular advancement devices, they work by holding your jaw forward, helping to open the airway and reduce snoring and/or improving Sleep Apnea-related breathing issues. Mouth guards can help people with mild to moderate Sleep Apnea get a better night's rest without resorting to CPAP or other breathing devices.

If your doctor has diagnosed you with Sleep Apnea, they will likely recommend a mouth guard as part of the treatment plan. Your doctor may also order a sleep study to determine if a mouth guard is necessary.

Using a mouth guard for Sleep Apnea can help you enjoy a better night's rest, as it helps keep your airways open during the night. In addition to improved sleep quality, using a mouth guard can also lead to less daytime drowsiness and fatigue, improved cognitive performance, reduced risk of Heart Attack or Stroke, and improved overall health.

Your doctor will need to determine if a mouth guard is medically necessary for you, and you may require an overnight sleep study before they can do so. If the test shows that your Sleep Apnea is severe enough that it could cause serious health issues, then your doctor may prescribe a mouth guard as part of your treatment plan. Medicare will then cover the cost of the mouth guard. CPAP machines might be seen as the more reliable option when treating Sleep Apnea, so you need to try that first before getting Medicare approval for a mouth guard or other oral devices.

Finally, it's important to note that even if you have Medicare coverage for a mouth guard for Sleep Apnea, you may still need to pay out-of-pocket costs such as copays or coinsurance when purchasing one. You could pay up to 20% of the Medicare-approved amount through Medicare Part B.

Not using a mouth guard for Sleep Apnea can have serious consequences. Without proper treatment, your Sleep Apnea can worsen and lead to more severe health problems.

Medicare will cover mouth guards for Sleep Apnea if they are deemed medically necessary by your doctor. Using a mouth guard for Sleep Apnea can help improve your sleep quality, reduce daytime fatigue, and may even lower your risk of Stroke or Heart Attack.

If you are experiencing any symptoms associated with Sleep Apnea, it is important to speak to your doctor to help find the right treatment for you.

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