Understanding CPAP Insurance Coverage: The Basics

CPAP is covered by most insurance. But the details are confusing.

Here's what you need to know to avoid surprises.

Medicare Coverage

The Basics

Medicare covers CPAP if:

• You have a qualifying diagnosis (AHI ≥5)
• You have a valid prescription
• You meet compliance requirements

The 90-Day Rule

Critical: Medicare requires you to demonstrate compliance in the first 90 days

What it means:

• Use CPAP 4+ hours per night
• On 70% or more of nights
• During a consecutive 30-day period within first 90 days

If you don't meet this: Coverage may end at 3 months

Rental Structure

Medicare rents CPAP equipment:

• Months 1-13: Monthly rental payments
• Month 13: You own the equipment

During rental period:

• Supplier maintains equipment
• Some supplies included

Supplies

Covered separately:

• Masks and cushions
• Tubing
• Filters
• Humidifier supplies

On a schedule: Each item has a replacement frequency

Private Insurance

Varies Widely

Every plan is different. Common patterns:

Deductible:

• You pay first $X of the year
• CPAP may apply to deductible

Coinsurance:

• You pay percentage (often 20%)
• After deductible met

Copay:

• Fixed amount per item/visit

Maximum out-of-pocket:

• Most you'll pay in a year

Prior Authorization

Many plans require:

• Insurance approves before you get equipment
• Based on sleep study results
• May delay getting equipment

In-Network vs. Out-of-Network

In-network (contracted suppliers):

• Lower costs
• Simpler process
• Pre-negotiated rates

Out-of-network:

• Higher costs
• May have to pay upfront
• May not be covered at all

What You Pay

Typical Costs (with insurance)

Initial equipment (your portion):

• CPAP machine: $50-300
• Mask: $20-100
• Setup: Often included

Monthly supplies:

• Varies by plan
• Usually $10-50/month when needed

Without Insurance

Full retail:

• CPAP machine: $600-1,500
• Masks: $80-200
• Supplies: $100-300/year

Getting the Most from Coverage

Know Your Plan

Questions to ask:

• What's my deductible for DME?
• Do I need prior authorization?
• What suppliers are in-network?
• What's my coinsurance/copay?

Keep Records

Save:

• Sleep study results
• Prescriptions
• Receipts
• Explanation of Benefits (EOB) statements

Understand Replacement Schedules

Insurance covers replacements:

• Masks: Every 3 months
• Cushions: Monthly or quarterly
• Tubing: Quarterly
• Filters: Monthly

Don't over-order (insurance tracks)

Don't under-order (worn supplies affect therapy)

Common Problems

Denied for Non-Compliance

If Medicare denies continuation:

• Review your usage data
• Talk to your provider
• Appeal if you have documentation

Surprise Bills

To avoid:

• Verify coverage before getting equipment
• Use in-network suppliers
• Understand your deductible status

Wrong Equipment

If you get wrong item:

• Contact supplier immediately
• Don't open packaging if possible
• Document everything

Tips for Success

Before starting CPAP:

• Verify coverage
• Understand your costs
• Ask about compliance requirements

During first 90 days:

• Use consistently
• Document any problems
• Communicate with provider

Ongoing:

• Reorder supplies on schedule
• Keep using CPAP
• Review coverage annually

Questions about coverage? Your Drift care team can help clarify. [Log in →](/patient/login)