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

Blue Cross and Blue Shield of Kansas

Senior man looking out of window at home

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: 

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:

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: 

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: 

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. 

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. 

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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