Understanding CPAP Insurance Coverage
Getting a CPAP machine and supplies involves insurance in ways that can feel confusing. But the basics are straightforward once you understand how coverage works.
This guide explains the different types of coverage and what they mean for you as a patient.
Medicare Coverage
If you have Medicare (usually age 65+ or certain disabilities), here's how CPAP coverage works:
The Rental Period
Medicare doesn't buy your CPAP machine outright. Instead:
Months 1-13: You rent the machine. Medicare pays the rental fee (after deductible and coinsurance).
After 13 months: If you've been using it consistently, you own the machine. No more rental payments.
The Compliance Requirement
This is important: Medicare has a compliance requirement in the first 90 days.
What you need to do:
Use your CPAP at least 4 hours per night on 70% of nights during a consecutive 30-day period within your first 90 days of therapy.
What happens if you meet it:
Medicare continues paying for your equipment and supplies.
What happens if you don't:
Medicare may stop covering your equipment. This doesn't mean you can't use CPAP—it means you may have to pay yourself.
For detailed guidance, see [Medicare CPAP Compliance Requirements](/blog/medicare-cpap-compliance-requirements-2026).
Supply Coverage
Once you're established on CPAP, Medicare covers replacement supplies on a schedule:
- Mask cushions: Monthly
- Full masks: Every 3 months
- Tubing: Every 3 months
- Filters: Monthly (disposable) or every 6 months (reusable)
- Headgear: Every 6 months
- Humidifier chamber: Every 6 months
What you pay:
Medicare Part B typically covers 80% of the approved amount. You pay 20% coinsurance (unless you have supplemental insurance that covers it).
What Affects Your Medicare Costs
Your deductible: You pay the first $240 or so (the amount varies by year) before Medicare kicks in.
Your coinsurance: After deductible, you pay 20% of Medicare-approved amounts.
Medigap policies: If you have supplemental insurance, it may cover some or all of your 20%.
Medicare Advantage: If you have a Medicare Advantage plan instead of Original Medicare, coverage rules may differ—check your specific plan.
Commercial Insurance Coverage
If you have insurance through an employer, marketplace, or private plan:
How Coverage Works
Commercial plans vary significantly, but most cover CPAP as "durable medical equipment" (DME).
Typical structure:
- You may need prior authorization (your provider handles this)
- You'll have deductible and coinsurance or copay
- There may or may not be a compliance requirement
What you pay:
This depends entirely on your specific plan. Some people pay nothing; others pay hundreds of dollars.
Before You Get Equipment
Ask these questions:
- Does my plan require prior authorization for CPAP?
- What's my deductible, and have I met it?
- What's my coinsurance or copay for DME?
- Is there a compliance requirement?
- Are supplies covered on the same schedule as Medicare?
Your CPAP provider can help you understand your benefits, but you can also call the member services number on your insurance card.
Supply Coverage
Most commercial plans cover supplies on schedules similar to Medicare, but verify your specific plan. Some plans are more generous; some are more restrictive.
Medicaid Coverage
If you have Medicaid (income-based coverage):
State Variations
Medicaid rules vary by state. What's covered in one state may not be covered in another.
Generally:
- CPAP equipment is often covered
- You may need prior authorization
- Your out-of-pocket costs are typically very low
- Supply schedules may differ from Medicare
Best approach:
Work with a CPAP provider experienced with Medicaid in your state. They'll know the specific rules and requirements.
Understanding Your Costs
The Deductible
This is the amount you pay before insurance starts covering costs. It resets each year (usually January 1).
Example: If your deductible is $500 and you haven't met it, you pay the first $500 of your CPAP costs. After that, your plan's coinsurance kicks in.
Coinsurance vs. Copay
Coinsurance: You pay a percentage (like 20%) of the cost.
Copay: You pay a fixed amount (like $30) regardless of the actual cost.
Different plans use different approaches—some use both for different services.
Out-of-Pocket Maximum
This is the most you'll pay in a year. Once you hit this amount, your plan covers 100% of additional costs.
If you have high medical expenses, you may hit this limit, making subsequent CPAP supplies free.
Working With Your Provider
Your CPAP provider should:
Verify your coverage before providing equipment
Handle prior authorization if required
Bill your insurance directly
Tell you your expected costs before you receive equipment
Help with appeals if coverage is denied
What to Ask Your Provider
- "Have you verified my insurance coverage?"
- "What will I owe for the equipment?"
- "What will supplies cost me each time I order?"
- "Is there anything that might cause my coverage to be denied?"
Good providers are transparent about costs and won't surprise you with bills.
If Your Coverage Is Denied
Insurance denials happen. Common reasons:
Missing documentation: The insurer needs more information from your doctor.
Prior auth not obtained: The required pre-approval wasn't completed.
Not medically necessary: The insurer questions whether you need CPAP.
Compliance issues: For Medicare, you didn't meet the usage requirement.
What to Do
Don't panic. Denials can often be overturned.
Ask your provider. They deal with denials regularly and know how to appeal.
Provide information. If more documentation is needed, help gather it.
Appeal. You have the right to appeal, and many appeals succeed.
Maximizing Your Benefits
Order Supplies Regularly
If your insurance covers replacement supplies, use that benefit. Don't let eligibility windows pass unused.
Stay Compliant
Especially with Medicare, consistent CPAP use protects your coverage. The [compliance requirement](/blog/why-cpap-compliance-matters) isn't just bureaucratic—it keeps your benefits active.
Understand Your Plan Year
If you've met your deductible, the end of the year is a good time to order supplies (before it resets). If you haven't, you might wait until after January 1 to start fresh.
Keep Records
Save Explanation of Benefits statements, receipts, and correspondence with your insurer. This helps if you ever need to dispute a charge or track your spending.
Common Questions
"My insurance changed. What do I do?"
Tell your CPAP provider immediately. They'll verify your new coverage and update their records. Don't wait until you need supplies.
"I have two insurance plans. How does that work?"
One plan is "primary" (pays first) and one is "secondary" (pays some of what primary doesn't). Your provider can coordinate this.
"I lost my insurance. Can I still get supplies?"
Yes, but you'll pay out of pocket. Ask your provider about cash pricing or payment plans.
"My spouse and I have different insurance. Whose do I use?"
Generally, you use your own plan as primary. But if you're covered under your spouse's plan too, that may be secondary. Check with both insurers.
The Bottom Line
Insurance can feel complicated, but the key points are simple:
- Verify coverage before getting equipment
- Understand your costs (deductible, coinsurance, copay)
- Stay compliant with any usage requirements
- Order supplies when you're eligible
- Ask questions if anything is unclear
Your CPAP provider is a resource—don't hesitate to ask them about your coverage.
Related articles:
- [Medicare Compliance Requirements](/blog/medicare-cpap-compliance-requirements-2026)
- [Understanding Your Resupply Schedule](/blog/understanding-cpap-resupply-schedule)
- [Why Compliance Matters](/blog/why-cpap-compliance-matters)