Many people over 65 on Medicare have some form of chronic sleep apnea and need a CPAP machine. Most go undiagnosed so only a small percentage use a CPAP. According to the UCLA Sleep Center “It is very common for people over the age of 65 to have problems with their sleep. Insomnia is their most common complaint. Many drugs used to treat medical problems can also disrupt your sleep. Some people are able to sleep better by using sleeping pills from time to time. But many older people rely too much upon drugs to help them sleep. Studies show that some common drugs may not even work well in older people. In fact, they may even make sleep problems worse.”.
A Continuous Positive Airway Pressure device known as a CPAP machine can remedy many of the problems associated with Obstructive Sleep Apnea (OSA). Not everyone can use the machine and with prices anywhere from $500 to over $3,000 coming up with the money to pay for the machine may be difficult.
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Medicare Coverage for CPAP
With so many people over 65 having OAS you would think Medicare would pay for your machine. Actually, Medicare has some of the strictest guidelines for coverage of any health insurance plan. Perhaps that has something to do with also having the most generous coverage with Medicare picking up 80% of the cost of your machine under Part B.
Under the Obama administration the OIG (Office of Inspector General) was directed to find ways to eliminate waste, fraud and abuse in the Department of HHS (Health and Human Services). That report, released in June of 2013, found that “beneficiaries receiving CPAP treatment may have received more supplies than were medically necessary”.
Even though the report showed that the number of supplies did not exceed the recommended replacement schedule it also stated that if someone DID receive more supplies than necessary that would be wasteful spending.
Let that sink in for a moment.
Medicare covers a 3-month trial of CPAP therapy if you’ve been diagnosed with obstructive sleep apnea.
Medicare may cover it longer if you meet in person with your doctor, and your doctor documents in your medical record that the CPAP therapy is helping you.
If you had a CPAP machine before you got Medicare, Medicare may cover rental or a replacement CPAP machine and/or CPAP accessories if you meet certain requirements.
If you had a CPAP before going on Medicare and your doctor states that the machine is helping you, Medicare MAY pay for the rental or replacement of the machine.
Your doctor and the AASM (American Academy of Sleep Medicine) may say you have sleep apnea but Medicare may say you don’t.
In other words, until Medicare says you have OSA you don’t have a medical problem that requires a CPAP. You can get the machine if you want, but Medicare won’t pay for it.
Competitive DME Bidding
The folks at Medicare want to make sure they get the best price on Durable Medical Equipment so they make supplies bid on contracts for their business. But the game doesn’t stop there.
Medicare will only cover your durable medical equipment (DME) if your doctor or supplier is enrolled in Medicare. If a DME supplier doesn’t accept assignment, Medicare doesn’t limit how much the supplier can charge you. You may also have to pay the entire bill (your share and Medicare’s share) at the time you get the DME.
In an attempt to save money, Medicare imposes a competitive bidding process where DME (Durable Medical Equipment) supplies must compete if they want to be a sanctioned Medicare supplier.
What could possibly go wrong there?
Competitive bidding means fewer suppliers participating in the DME process. Fewer suppliers means delays in getting your equipment. Without a CPAP any related medical conditions can get worse.
But hey, at least Medicare is saving money, right?
Getting Medicare to Pay for a CPAP
The good news is, you can get Medicare to pay for your nightly breathing assistance machine. All you have to do is follow their guidelines.
If you are able to convince Medicare you do in fact have apnea, and that your condition will IMPROVE by using a CPAP, they will cover 80% of the cost under Medicare Part B. If you also have a Medigap plan your out of pocket cost could be $0 or limited to your annual Part B deductible.
Advantage plans do cover a CPAP in most cases but your out of pocket cost for the machine and supplies under most plans is 20%. That could amount to several hundred dollars per year. Even more if you fail to use a network approved DME supplier.
Georgia Medicare Plans specializes in helping seniors find Medicare supplement plans with the lowest premiums in their area. Our exclusive report shows you every Medigap plan in your area based on your age and gender. No need to waste time searching for the best rates. We shop, you compare. Call or email.
You can also run your own Medigap quotes from the comfort of your home.
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