If one buys an APAP, will Medicare pay for supplies?

[SleepingUgly]

If someone were to buy an APAP outright, will Medicare pay for supplies? I'm imagining there must be a way to do this as, for example, some people may be on CPAP prior to being on Medicare and then become eligible for Medicare. If they will pay for supplies, what kind of documentation is necessary? Thanks!

[JohnBFisher]

I don't see why not. If you use a DME to purchase your supplies, they can just file them as they normally would. There's not really any difference between the CPAP and APAP (from an insurance prospective). I would check with your DME.

[archangle]

They might want sleep study results or some other documentation of a particular AHI, but I'm guessing.

[Fitness Seeker2]

Great Question. I'm also interested in whether Medicare pays for all or most of the costs for sleep studies and treatment. Can someone tell me? Since i recently got diagnosed, I have been preaching to my older family mbrs (mom, uncles, aunt) that they need to get themselves checked out. However, highly unlikely they'd be motivated unless it's covered.

[SleepingUgly]

Just to clarify, my question is whether Medicare would pay for CPAP/APAP supplies on a machine they are not paying to rent out (therefore the person wouldn't be going through the Medicare compliance rules for the machine--eg, minimum 4 hours use, face to face contact with an MD within 90 days, etc.).

Yes, Medicare will pay for a sleep study.

[avi123]

I am sorry that I did not understand the question. But now I agree with John Fisher.

[Janknitz]

Not from Santa Maria and not an expert, but I know where to look things up most of the time.

Medicare DOES pay for sleep studies and equipment, with the proper physician's orders.

Part B Medicare covers the outpatient testing and Durable Medical Equipment (DME) including machine, humidifier and supplies (masks, hose, filters, and replacements). Medicare SETS the fee for DME (it varies by state) and pays 80%. The remaining 20% is either paid out of pocket or by Supplemental Insurance (Medigap), depending on your policy. If you have Medicare Part C, also known as Medicare Advantage, you get similar coverage, but you may be more limited in your choice of doctors, testing centers, equipment providers, and the types of machines and masks available to you.

If you buy your own machine, Medicare will still pay for supplies (mask, filter, hoses) IF you have the proper prescription from a physician and if you buy from a Medicare provider. I do not believe (could be wrong) that Medicare will reimburse you for supplies obtained from a non-Medicare provider (e.g. from CPAP.com) but there are a few online certified Medicare providers.

I think Medicare's concern about compliance has to do with the machine, since it's an expensive piece of DME. If you buy your own machine out of pocket, I don't think they can require compliance proof to pay for supplies, but I don't know for certain that this is true, just a guess. But I don't think they will pay for the supplies unless your sleep apnea has been documented via a Medicar approved sleep study.

[archangle]

Just to clarify, my question is whether Medicare would pay for CPAP/APAP supplies on a machine they are not paying to rent out (therefore the person wouldn't be going through the Medicare compliance rules for the machine--eg, minimum 4 hours use, face to face contact with an MD within 90 days, etc.).

Yes, Medicare will pay for a sleep study.

This sounds like the answer is "no."

"Medicare covers accessories used with the CPAP if the CPAP is covered by Medicare."

Of course, Government documentation is always clear and is interpreted correctly by the administrators. Not that this statement doesn't technically say "accessories are not covered if the CPAP is not paid for by Medicare."

I suspect the answer will be no. You're a square peg. Government round holes generally aren't willing to deal with square pegs.

[archangle]

By the way, I read somewhere that Medicare will now pay for Home Sleep Tests (HST) and accept the results for qualification to get a CPAP. Doctor visits and compliance checks still needed.

[codinqueen]

If your Dr says the supplies are MEDICALLY NECESSARY, and provides a diagnosis that is covered, by Medicare coverage policies, then Medicare should pay if you are a Medicare beneficiary. If Medicare WON'T cover a supply that is being provided by a DME or Dr office, they should have a Medicare beneficiary sign an ABN that shows the patient is aware Medicare will not (or might not, I think) cover it, so the provider can bill the patient then.

[archangle]

If your Dr says the supplies are MEDICALLY NECESSARY, and provides a diagnosis that is covered, by Medicare coverage policies, then Medicare should pay if you are a Medicare beneficiary. If Medicare WON'T cover a supply that is being provided by a DME or Dr office, they should have a Medicare beneficiary sign an ABN that shows the patient is aware Medicare will not (or might not, I think) cover it, so the provider can bill the patient then.

Sounds good in theory. Anyone done it in practice without a medicare provided CPAP and/or results of a sleep test?

[Slinky]

SU, I don't know how closely this parallels what you are asking but: as you are aware I have a Medicare provided 02 concentrator. I want a portable 02 concentrator. The type I want can be plugged in and used as a regular concentrator or run on battery whilst out and about, the battery charges even while being used when the concentrator is plugged in.

I talked to my local DME provider about getting one. I was told Medicare would not pay for the portable concentrator of the type I want except if I give up my current 02 concentrator and all my portable tanks. So I asked about buying one on my own out of pocket. Would they service it when and if needed. I was told that Medicare would not pay for service for the portable concentrator since they didn't buy it and were or had paid for my regular concentrator. Yes, the DME would service it as needed for me but I would have to pay out of pocket for the service.

Still, I would think that if my doctor writes me a script for it, and I buy it out of pocket, and I give them a copy of the script despite I bought it elsewhere they could bill and be paid by Medicare for its repair. Maybe not. And that takes us to a similar situation as what you are asking does it not?

Not quite the same, of course, since Medicare is paying for any repairs & maintenance on the concentrator they bought for me. Paying for my out of pocket portable concentrator repair & maintenance could easily be seen as "double-dipping".

[imsleepynomore]

I had purchased my machine 1 year prior to medicare and medicare has paid for all my CPAP supplies since starting medicare I was able to furnished original copies of sleep studies and reports to my new physician and he provided new rx as my original dated rx was before I was 65 and medicare needed an rx that was after I turned 65 I have been receiving all my supplies and no problem.

[Fitness Seeker]

So Medicare will pay for the home sleep study. What about the type where you stay overnight? I guess on my next appt to the pulmonologist I can also ask him. That is if i can motivate my old-schooled uncle to actually go and need to accompany him to translate.

[SleepingUgly]

Yes, Medicare will pay for the overnight study in the lab.