Medicare and sleep: what’s covered under your plan – and what isn’t

Getting a good night’s sleep becomes even more important as we age, and our bodies need the time to rest, rejuvenate and heal. At the same time, up to 70% of people over the age of 65 have ongoing sleep challenges. As many as half of those might have an undiagnosed condition. Blue Cross and Blue Shield of Kansas is here to support sleep cycles and maximize the benefits of Medicare so recipients can get the rest their bodies desperately need

Most common sleep struggles for senior citizens

You’ve heard the phrase, “which came first, the chicken or the egg?” before, and a similar concept can happen in aging bodies. We must explore “which comes first, the sleep or the health issue?”

The most common sleep challenges include: 

  • Obstructive Sleep Apnea: Breathing stops up to 100 times per night due to a collapse in the airway. This leads to micro-awakenings, increased blood pressure, memory issues, and higher stroke risk. 
  • Restless Leg Syndrome: This condition can make legs and feet painful, tingling, and twitching. A brain focused on the uncomfortable sensation in the legs can’t allow the body to fall asleep or stay asleep. 
  • Incontinence: As bodies age, the urinary system can weaken, leading to bladder leaks or intense sensations to “go.” This cycle can walk people up several times a night. 
  • Pain & Medication: Chronic pain and medication side effects can impact how well a person can fall asleep or how long they can stay asleep. 
  • Insomnia: Stress and mental health issues can exacerbate any of the above sleep issues.

Medicare coverage for CPAP machines

A lack of sleep can cause irritability and mood changes, so we won’t delay in getting you important information about one of the top solutions for sleep apnea. To optimize your Medicare coverage for sleep apnea and the popular CPAP treatment, it is critical to remain in close contact with your doctor. 

WARNING: Obstructive Sleep Apnea (OSA) is a serious condition and should be treated as soon as possible. An individual experiencing OSA will not breathe for 10 seconds or more at a time up to hundreds of times while sleeping. 

What is a CPAP? 

CPAP stands for Continous Positive Airway Pressure. These devices work with your upper airway to avoid a collapse and keep a steady stream of air flowing in and out of your nasal passages throughout the night. This prevents oxygen disruption, repeated awakenings, and poor sleep quality. 

FACT: Just because you snore doesn’t mean you have sleep apnea, but loud snoring is one key indicator of sleep apnea, followed by periods of not breathing. 

Medicare step-by-step guide to CPAP coverage

The CPAP machine isn’t a device you can order on Amazon or get over the counter. Devices range in styles and pressures for nose breathers, mouth breathers, and those with apnea or hypopnea. 

  1. Patients should talk with their doctor about their sleep struggles. Bringing spouse feedback or recordings of sleep noises can help support your concerns. 
  2. The doctor will likely order a sleep study, and there are four versions they can choose from to help figure out what’s happening during your sleeping hours. 
  3. If the sleep study results show Obstructive Sleep Apnea (OSA), the doctor will report the formal diagnoses and order CPAP therapy. 
  4. You will be given a prescription for your CPAP device and must get it from a Medicare-approved provider who accepts these assignments. 

CPAP usage is critical to maintain coverage

It’s not just enough to get the diagnosis and the device. You must continuously use the device under specific rules to continue getting coverage. 

Medicare will only cover a 3-month trial period if a person has been diagnosed with OSA, and only if the CPAP was not carried over from before Medicare. The patient will document successes and challenges with their doctor. During this time, it’s important to do the following:

  • Use the CPAP at least four hours a night
  • Use the CPAP at least 70% of the nights in the three-month period
  • That must include one span of nightly usage for 30 days in a row. 

From there, patients will meet with their doctor and report the findings. If a patient follows all the compliance period rules and finds CPAP therapy to be beneficial, Medicare will cover another 13 months of the CPAP. It is important to note that the Medicare Part B deductible also has to be met, and then the member would pay 20% of the “Medicare Approved Amount” to the DME if the doctor and supplier are enrolled in Medicare. At the end of the therapy, the patient will own the CPAP machine. 

How much does CPAP therapy cost? 

CPAP equipment is covered under Medicare Part B, meaning a patient must meet the deductible. After the deductible is met, Medicare may cover 80% of the costs. 

CPAP machines last about five years; in many cases, Medicare plans will cover a replacement in that same timeframe. Medicare Advantage patients could also get coverage assistance with accessories and cleaners for the CPAP machine. 

Does Medicare cover sleep study options?

Since patients need a sleep study even to be considered for CPAP coverage, it’s important to know what coverage limits apply to sleep studies

There are four types of sleep studies, each measuring different parts of a patient’s body during sleep. Some studies are done in a laboratory setting, while others can be done at a patient’s home, assuming they can attach the devices and follow the basic testing instructions. 

Other factors that influence coverage and/or reimbursement: 

  • Length of time test is completed. Anything less than six hours could impact reimbursement. 
  • Certification levels of sleep study at-home provider or sleep study location. 
  • If the facility accepts the assignment of Medicare-covered sleep studies. 

Medicare Part B will cover 80% of the costs once the deductible has been met. Confirm the sleep lab accepts Original Medicare Parts A and B before moving forward with the study. To transition to a CPAP machine, a sleep study must be done within 12 months of the CPAP prescription. 

Innovation in sleep apnea treatments

Hypoglossal Nerve Stimulation for OSA (HGNS) is a new implant treatment for those who can’t tolerate a CPAP machine or aren’t getting any benefits from it after regular and dedicated use. HGNS requires an implant in the upper chest that stimulates the hypoglossal nerve to stop the patient’s airway from collapsing. 

Medicare updated the coverage policy for HGNS in June of 2022. While the procedure is covered, every condition must be met for Medicare to pay for it under Part B or Medicare Advantage. 

Here are just a few of those requirements: 

  • BMI less than 35
  • AHI score of 15 to 65 (15 to 65 apnea incidents per hour as determined during sleep study)
  • A sleep physician and otolaryngologist agree that the patient regularly uses CPAP with failure or intolerance.

It’s important for a patient to understand the process, as steps for coverage cannot be skipped. For example, a patient cannot go from a sleep study to HGNS or get a CPAP without a sleep study if they want maximum coverage.

FAQ: coverage for other sleep assistance products

Let’s look at some of the other frequently used sleep assistance. Keep in mind all answers require a doctor to deem the treatment or device “Medically Necessary,” and the provider or vendor must accept the assignment.

Sleep chairs 

These chairs offer the comfort of sleep while lifting a patient up and down to avoid pain and improve mobility. The Perfect Sleep Chair Medicare patients love comes with Zero Gravity technology for maximum comfort. 

Medicare Part B generally covers the lifting mechanism but not the chair itself. Supplemental Medicare coverage might help with chair costs on a case-by-case basis. 

Please note that “extras” like vibrating or heated chairs with upgraded leather won’t be covered. 

Sleep telemedicine 

Telehealth visits are when patients and doctors meet via remote technology, like mobile devices or computers. Medicare Part B could cover the costs under the 80/20 model, but Medicare Advantage policyholders will have greater access to sleep telemedicine. 

The telehealth offerings are expanded during the Public Health Emergency (PHE) of COVID-19 and through the five months after the PHE ends. Before booking a telehealth visit, check with the Blue Cross and Blue Shield of Kansas team to check your specific policy. 

BOOKMARK THIS LINK: Check here to see the latest PHE updates from the Department of Health and Human Services.

Sleep medications 

Medications would be covered under Medicare Part D and most Medicare Advantage plans, but you’ll need to check the formulary specific to your plan. Please discuss with your doctor how the sleep medication could interact with other drugs you take. 

Signs of a possible sleep disorder

Being tired can feel normal for some people, especially from medication side effects or mental health struggles. Here are a few defining characteristics of a sleep disorder to discuss with your doctor. 

  • Unusual daytime sleepiness: This goes beyond a regular feeling of being tired. The fatigue is so intense that naps are usually required throughout the day. 
  • Night sweats: While medications and hormonal changes can cause night sweats, sleep apnea can also. If night sweats are paired with being a loud snorer, it’s time to see a doctor. 
  • Insomnia: If it takes you 30 minutes or longer to fall asleep, or you have challenges staying asleep for a full seven to nine hours, it’s time to talk to your doctor.
  • Mental Changes: Increased depression or anxiety without provocation, reduced cognition, memory loss, or debilitating headaches in the morning. 
  • Dry Mouth: Sleep apnea and snoring can lead to a very dry mouth or throat with potential swelling of glands and uvula. 

The benefits of great sleep

Getting regular uninterrupted sleep has so many health benefits that it just makes sense to address sleep problems as soon as possible. 

  • Lower blood pressure
  • Improved cognition and memory
  • Lowered mood swings and mental health challenges like anxiety or depression
  • Reduce stroke risk 
  • Improve metabolism
  • Reduce obesity risks
  • Lower risk of stroke and diabetes

Patients suffering from sleep challenges should also remember how snoring and apnea can impact their spouse or family members, creating health risks for them as well. 

MORE: 5 Habits to Keep Your Mind Sharp

Don’t sleep on it – call Blue Cross and Blue Shield of Kansas today

There is too much at stake for Medicare patients to ignore insomnia or sleep struggles. If you aren’t sleeping well, your patience and moods are likely being tested, and our team is here to help find you the plan that best suits your needs or guide you through the specifics of your own plan. We offer support via the phone, virtual consultations, and in person. Call Blue Cross and Blue Shield of Kansas today at (866) 627-6705.

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