Does Medicare Pay For a CPAP

Does Medicare Pay for CPAP

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.

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.

Here are Medicare guidelines with regard to CPAP machines.

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.

Georgia Medicare Supplement Rates

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Medicare Part B – What Does Part B Cover?

Medicare Part B. What does it cover? Do you need Medicare Part B? If you don’t buy Medicare Part B what is my exposure? Can you buy a Medigap plan if you don’t have Part B? Are you turning 65Medicare Part B - Turning 65

Medicare Part B is thought of as covering doctor visits. Truth is, Part B covers much more than just a visit to the doctor.

Part B covers outpatient doctor services including office visits.

 

Medicare Part B Durable Medical Equipment

Most durable medical equipment (DME) is covered under Medicare Part B.  Medically necessary medical equipment can be purchased or rented  from an approved Medicare DME provider.

Not all DME is covered by Medicare {art B. Before Medicare will pay for your durable medical equipment it must meet the following criteria.

  • The equipment cannot be designed solely for single use
  • Your DME must be medically necessary and serve a specific medical purpose
  • The equipment should be designed to last 3 or more years
  • They equipment must be distributed by an approved Medicare DME supplier

Examples of DME covered by Medicare include oxygen equipment, wheelchairs, walkers, hospital beds and scooters . . . but not hearing aids.

Most preventive services, including those available at no charge to you, are covered under your Part B benefits.

Outpatient services, such as speech or physical therapy are included in your Part B benefits.

Some services by medical transport companies (ambulance) are included in Part B.

Medically necessary spinal manipulation as performed by a chiropractor is a Part B covered item.

Some outpatient psychiatric care, including group and individual counseling or therapy is covered by Medicare Part B.

X-rays, CT scans, MRI, PET and lab tests are included in your  Part B benefit package.

Home health services and medically necessary services provided by a skilled nursing facility (SNF) are part of your Medicare Part B coverage.

Most drugs are paid by your Medicare Part D, but drugs administered in a clinical setting, such as chemotherapy, are included in Medicare Part B.

 

Other Part B Covered Expenses

Sleep apnea may require the use of a CPAP machine. But not all machines are eligible and some DME providers are not approved by Medicare.

Diabetic insulin is normally a Part D covered item. But if you have a pump your insulin may be a Medicare Part B covered item.

 

Lower Out of Pocket Costs

Most people fear huge hospital bills. When you have original Medicare your OOP (out of pocket) for most hospital charges is limited to your deductible.

Huge medical bills running $20,000 and more are usually incurred as outpatient Part B expenses. Unlike health insurance you had in the past there is no OOP limit. Medicare pays 80% of approved charges after your calendar year deductible. You are responsible for the remaining 20%.

There is no cap.

You continue paying until you get well, run out of money or die.

Medicare supplement plans F and G limit your Part B exposure to less than $200 in 2017. For a few dollars a day in Medigap premiums you can have peace of mind.Turning 65 GA Medicare supplement plans

There are more than 170 different approved Medicare supplement plans in Georgia. Which one is right for you?

Give us a call. We are glad to help.

Georgia Medicare Plans has affordable Medigap rates for seniors on Medicare Part A and Part B.

 

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