Medicare and Sleep Apnea

What is Sleep Apnea?

Sleep apnea is a condition that interrupts your breathing while you sleep. What happens is that people with the condition will stop breathing several times in an hour and up to hundreds of times a night. The stoppages can last for a second or two, or they can last for 60 seconds or more at a time. Since the body and the brain require oxygen during the night to replenish the body, the lack of oxygen flow can cause several physical problems. The blockage is caused by the collapse of the tissue and muscles in the back of the throat as the person sleeps. The muscles have lost the ability to hold the tissue in place, or weight gain has added more tissue than the muscles can handle. As the person sleeps, the tissue blocks the airways and the brain has to rouse the person to get breathing going again.

The immediate effects of sleep apnea are persistent fatigue and the inability to fight off illness. Long-term effects include heart disease, high blood pressure and internal organ failure. It is not uncommon for people who experience sleep apnea for several years to die from the condition.

What is a CPAP Machine?

The machine that used to help correct sleep apnea is known as a CPAP machine. This is a device that forces air through the air passages in the body by pumping air through the nose. It is a device that patients wear while sleeping at night. It not only helps to improve breathing, but it also eliminates snoring and can reduce restlessness during the night. If you are on Medicare as your primary medical insurance, then you may be wondering if Medicare covers a CPAP machine. Medicare requires that the CPAP machine be prescribed by a certified physician for the purpose of treating sleep apnea. If a physician prescribes the CPAP, then Medicare will cover rental costs for three months. If your physician determines that you need to keep the machine beyond three months, then he can prescribe it for another three month rental that Medicare will cover.

Do I Qualify for a CPAP Machine?

The process for qualifying for a CPAP machine requires significant interaction with a doctor and a sleep lab. The first step is to make an appointment with a doctor that is authorized by Medicare to prescribe CPAP machines. The doctor will be unable to diagnose your sleep apnea in that first appointment, but he can determine if you could potentially have sleep apnea by examining you and asking you pertinent questions. If the doctor feels that you may be suffering from sleep apnea, then he has to order a sleep study to confirm the diagnosis.

A sleep study is an overnight evaluation of your sleeping habits as observed by a sleep lab certified by Medicare to perform valid testing. Your doctor will refer you to a qualified sleep lab. You must remind your doctor that you need a sleep lab that is certified by Medicare in order to have your expenses reimbursed. The sleep lab will give you all of the instructions you will need prior to your test and then you will show up to spend the night in the lab. Most sleep labs are set up like hotel rooms with comfortable beds. You will be hooked up to machines and your breathing during sleep will be monitored. The results of the test will be sent to your doctor.

After your sleep test, you will have a follow-up appointment with your doctor and he will let you know if you have sleep apnea or not. If your doctor determines that you have sleep apnea, then he will put together the information you will need to get a CPAP machine from Medicare.

Will Medicare Pay for My CPAP Machine?

As anyone that has Medicare knows, there is a deductible that must be met each year with Medicare services before Medicare will cover the majority of the costs. In 2011, that deductible was $162. You will need to check with the Medicare office to see what the deductible is for the current year. Once the deductible is met, Medicare will then cover 80 percent of the rental costs for the CPAP machine for three months. This includes approved supplies such as filters, new mask parts and hoses. The patient will be responsible for paying the remaining 20 percent. A patient can get a supplemental form of health insurance that will cover that 20 percent and leave the patient with no out of pocket costs. The deductible is renewed each year.

How Can I Get a CPAP Machine from a Medicare Approved Supplier?

After you have been properly diagnosed with sleep apnea and presented a Medicare-approved script from your doctor for a CPAP machine, you can then take that script to a medical equipment supplier to get your machine. Many suppliers offer a rent to own system that would pay the machine off and allow you to own it outright after a predetermined period of time. Be sure that the medical equipment supplier is a participating Medicare organization. If the supplier is a participating provider, then it has to accept your script and help you to bill Medicare for your CPAP machine. If the provider is not part of the Medicare network, then you will be responsible for all costs.