How Does Medicare Cover Sleep Apnea?

By August 1, 2018August 20th, 2018Uncategorized
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How Does Medicare Cover Sleep Apnea?

Sleep Apnea becomes more common as individuals age and is most prevalent among men over age 40. More than 50% of adults over 65 have some form of sleep-related concerns. Weight, smoking, alcohol use and other factors can also play a part in causing sleep apnea.

Fortunately, Medicare does provide benefits for the diagnosis and treatment of sleep apnea. You can qualify for Medicare if you are age 65 and older or if you are younger than 65 on Social Security Disability Income benefits for more than 24 months.

Medicare breaks its coverage down into two main parts: Part A hospital benefits and Part B outpatient benefits. Here’s how these parts work to provide coverage for healthcare related to sleep apnea.

Original Medicare

Since Part A covers hospital benefits, most treatment for sleep apnea falls under Medicare Part B. This program pays for 80% of your outpatient medical services including preventive care, doctor appointments, lab testing, diagnostic testing, medical equipment, ambulance, urgent care, outpatient surgery and many other services.

If your physician suspects that you may have sleep apnea, he can order a sleep study that Medicare will cover. This may be a Type 1 sleep study performed at a certified lab where you will be monitored as you sleep, or it might be a home sleep test where you wear a monitor and then return that to the lab for interpretation of results.

If you diagnosed with obstructive sleep apnea, Medicare Part B will cover an oral appliance, which is an alternative to a CPAP machine, or Continuous Positive Airway Pressure. Your doctor must prescribe the appliance.

Oral appliances are preferred by many beneficiaries because a CPAP machine can be bulky and cause discomfort while trying to fall asleep. These individuals can benefit from an oral appliance like those developed by Somnomed. These devices help to keep your airway open while you sleep.

Your physician must prescribe an oral appliance that is on Medicare’s approved PDAC list. You will then order your appliance from an approved Durable Medical Equipment provider that is contracted with Medicare.

Using these providers also ensures the best pricing for your equipment.

Your Medical Cost-Sharing

Since Part B only covers 80% of your outpatient costs, you will be expected to pay the other 20%. This is called your coinsurance. Part B also has a small annual deductible that you must satisfy at the beginning of each year. In 2018, this deductible is $183 and then Part B begins to kick in at 80%.

Most Medicare beneficiaries enroll in supplemental coverage to help them pay for their deductibles, coinsurance, and copays under Medicare. Your Medicare supplement plan will cover the gaps in Medicare and allow you to see any physician that accepts Medicare. It does not matter which insurance company that you buy your plan from. A Medicare insurance broker can help you compare plans and prices in your area.

Since Medicare supplements only cover hospital and outpatient expenses, you have the option to add a standalone Part D drug plan if you also need retail prescription drug coverage. This is a voluntary pharmacy card that will give you access to medications at just a copay level rather than paying full price.

Another option to Original Medicare plus a supplement is a Part C Medicare Advantage plan. These plans pay instead of Medicare and have networks of local providers. If you enroll in one, you’ll need to use the durable medical equipment vendors in their network to order your oral appliance or CPAP machine.

Some Medicare Advantage plans include Part D drug coverage built into the plan design, making it convenient to use just the same member ID card at both the doctor and the pharmacy.


This post was written by Danielle Kunkle Roberts, a Medicare insurance expert based in Fort Worth, TX, where she and her team help beneficiaries navigate Medicare in 47 states.


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