How is Sleep specialist Sleep study and CPAP and supplies covered under Medicare?
Medicare and You 2019 #10050 - Everything you want to know * See their section on closing the donut hole
Sleep apnea & Continuous Positive Airway Pressure (CPAP) devices & accessories
How often is it covered?
Medicare covers a 3-month trial of CPAP therapy if you’ve been diagnosed with obstructive sleep apnea. (Sleep Apnea.org)
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 a replacement CPAP machine rental and/or CPAP accessories if you meet certain requirements.
Your doctor or other health care provider may recommend you get services more often than Medicare covers. Or, they may recommend services that Medicare doesn’t cover. If this happens, you may have to pay some or all of the costs. Ask questions so you understand why your doctor is recommending certain services and whether Medicare will pay for them.
Your costs in Original Medicare
You pay 20% of the Medicare-approved amount
***Thus a Medi Gap plan would pay that. Check the Summary of Benefits for a Medicare Advantage to see the Co Pay. MAPD must pay as least as good as Original Medicare.
for rental of the machine and purchase of related supplies (like masks and tubing). The Part B deductible applies. Medicare pays the supplier to rent the machine for the 13 months if you’ve been using it without interruption. After you’ve rented the machine for 13 months, you own it. Medicare will only cover your durable medical equipment (dme) (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.
Competitive Bidding Program
If you live in or visit certain areas, you may be affected by Medicare’s Competitive Bidding Program. In most cases, Medicare will only help pay for these equipment and supplies if they’re provided by contract suppliers when both of these apply:
- You have
- You get competitively bid equipment and supplies in competitive bidding areas.
Contract suppliers can’t charge you more than the 20% coinsurance and any unmet yearly deductible for any equipment or supplies included in the Competitive Bidding Program.
If your current supplier isn’t a Medicare contract supplier, you may still be able to stay with that supplier if they decide to participate in the program as a “grandfathered” supplier. Suppliers that don’t get Medicare contracts can decide to become “grandfathered” suppliers. This means a supplier may continue to rent equipment to you if you were renting the equipment when the program started. This rule applies to oxygen, oxygen equipment, and certain rented equipment. You may continue using the “grandfathered” supplier until the rental period for your equipment ends. If you start renting additional equipment from a “grandfathered” supplier after the program starts, Medicare won’t pay for the new equipment. If you’re renting equipment that’s eligible for grandfathering, your supplier will let you know in writing 30 business days before the program begins whether it will or won’t become a “grandfathered” supplier.
What happens if my supplier decides not to become a grandfathered supplier?
You need to decide whether to continue to rent from your current supplier and pay all the costs, or switch to a Medicare contract supplier. A supplier that doesn’t have a contract and decides not to become a grandfathered supplier is required to notify you and pick up the item from your home after the program starts. Your supplier must notify you these 3 ways before it can pick up the item:
- The supplier must send you a letter at least 30 business days before the program starts telling you that it will no longer provide rental items to you after a certain date. This letter will tell you the date that a Medicare contract supplier must start to provide you with the rented item.
- The supplier must call you 10 days before picking up the item to make arrangements for pick up at an agreed upon time.
- The supplier must call you again 2 business days before picking up the item.
A supplier that isn’t grandfathered can’t pick up a medically necessary item before the end of the last rental month for which the supplier is eligible to get a rental payment. If you change to a Medicare contract supplier, your old supplier should work with the contract supplier so there isn’t a break in service. Keep the pickup slip or other documentation from the old supplier that shows you no longer have the item.
Under current Medicare rules, you own these types of equipment after renting for 13 months. When you switch to a Medicare contract supplier instead of using a “grandfathered” supplier or other non-contract supplier, your 13-month rental period will start over. So, you won’t own the equipment until after the new rental period ends. This will extend your rental period and result in additional months of coinsurance. However, the amount you pay may be lower because the amount you’ll pay will be based on the new payment rates under the new program.
- Once you own the equipment, you must get replacement supplies and accessories for the equipment from a contract supplier in order for Medicare to help you pay for these items. You may get repairs for the equipment you own from any Medicare-approved supplier (even a non-contract supplier), including replacement parts needed for the repair.
- If you already own your equipment, you must use a Medicare contract supplier for your replacement supplies and accessories.
To find out how much your test, item, or service will cost, talk to your doctor or health care provider. The specific amount you’ll owe may depend on several things, like:
- Other insurance you may have
- How much your doctor charges
- Whether your doctor accepts assignment
- The type of facility
- Where you get your test, item, or service