It's always easy to come up with a CPAP article to write about. All I have to do is think about the common questions we field on the phone every day. One of the most common questions relates to insurance, and whether Medicare will pay for CPAP equipment. So here's the skinny on Medicare.
Many new Medicare beneficiaries mistakenly believe that Medicare will start paying for their CPAP equipment. For Medicare to start covering the cost of much-needed CPAP equipment sounds reasonable, but it's not how it works. Even if a Medicare beneficiary has been using CPAP for 20 years, and even if that beneficiary is holding a current prescription for a CPAP machine or other CPAP supplies, Medicare won't cover it until the beneficiary jumps through some hoops.
Medicare requires a beneficiary to submit a sleep study conducted within the last two years. They'll check the sleep study to make sure the beneficiary meets the severity requirements, and if the requirements are met, Medicare will then allow the beneficiary to proceed to the second stage (or hoop, as I like to call it). If, in Medicare's opinion, the beneficiary doesn't have sleep apnea to a severe enough extent, Medicare will simply state that they will not pay for CPAP equipment. Last I checked, a patient had to have at least 15 breathing events per hour for CPAP therapy to be considered medically necessary by Medicare. Of course, you should always check with Medicare for the most current guidelines
After meeting Medicare's severity standard, a beneficiary will be allowed to rent a CPAP machine for a period of 13 months. The rental period is designed by Medicare to check on a beneficiary's compliance over a relatively long period of time. The supplier renting the machine must report compliance data back to Medicare periodically. In the case of non-compliance, Medicare will stop paying the 80% they've been paying up to that point. In the case of compliance, Medicare will continue to pay 80% throughout the rental period.
After the sleep study and a successful 13 month rental period, the Medicare beneficiary will become eligible for reimbursement of CPAP equipment. The coverage is 80% after the deductible has been met, so the beneficiary is always on the hook for 20%. This 20% can be paid for out-of-pocket, or it can be covered by supplemental insurance.
Without supplemental insurance using the Medicare benefit can actually be quite costly. Imagine a $2,000 sleep study and a rental fee of even just $100 per month for 13 months. 20% of that is $660. So, generally speaking, this would probably be an average minimum cost for a Medicare beneficiary to become eligible for the reimbursement of CPAP equipment. Supplemental insurance can cover this cost, so this might be a deciding factor for the CPAP user considering buying supplemental insurance coverage.
Medicare can also be a sleep disorder in and of itself. Imagine the sleepless nights while you lie awake horrified that you allowed our government to massively overpay for your CPAP equipment. Medicare doesn't cover the therapy required for that sleep disorder, at least not as of now. But seriously, even in light of some recent changes in Medicare's reimbursement schedules - the October 2013 changes that made Medicare's guidelines for reimbursement a bit more stringent than they had been in the past - Medicare's overpayment and the frequency with which they allow for overpayment is astronomical, and absolutely every Medicare beneficiary should consider the cost of the equipment, even if none of that cost is coming out of their own pocket. The money's coming from tax payers.
If you want to avoid another sleep study, and if you want to avoid the hassle of getting Medicare to pay for overpriced supplies for which you'll have to pay 20%, then skip the Medicare benefit and use your INTERNET benefit instead. That's right. The internet itself is a benefit that can potentially save you even more money than Medicare can.
Thoughts? Anything else to add to the discussion? Let us know.
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