Does Medicare Cover a Sleep Study?
Key Takeaways
- Medicare covers sleep studies in situations when they are medically necessary, such as to diagnose sleep apnea.
- Certain types of sleep studies must be conducted in a medical setting, but patients can sometimes complete sleep apnea testing at home.
- Original Medicare covers diagnostic testing and durable medical equipment to treat sleep apnea.
- Medicare Advantage plans must at least match Original Medicare coverage, but may offer additional benefits for diagnosing and managing sleep disorders.
Many older adults struggle to fall or stay asleep for reasons like pain, illness, and medication side effects. Sleep disorders, medical conditions that prevent a person from following a normal sleep pattern, affect millions of Americans. A sleep disorder can significantly impact your quality of life and contribute to chronic health problems like heart disease or diabetes.
Your healthcare provider may recommend a diagnostic procedure called a sleep study to determine whether a medical condition is interfering with the rest you need.
Medicare, the insurance program for U.S. adults who are over 65 or have certain disabilities, covers hundreds of thousands of sleep studies a year when they are considered medically necessary. This article explores Medicare’s coverage for sleep studies, related treatments, and associated costs.
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What Are Sleep Studies and Who Needs Them?
A sleep study, or polysomnography, is a medical test to diagnose sleep disorders. While you sleep in a medical facility, a healthcare provider applies sensors to monitor your body’s functions, such as brain waves, oxygen levels, heart rate, and breathing patterns.
Using the data from these sensors, a specialist can diagnose conditions like:
- Chronic insomnia: Difficulty falling or staying asleep that occurs at least three times a week and lasts for three months or more.
- Narcolepsy: Uncontrollable daytime sleepiness.
- Restless leg syndrome (RLS): A persistent urge to move the legs, disrupting sleep.
- Parasomnia: Disruptions to the sleep cycle like sleepwalking, sleep terrors, and rapid eye movement sleep behavior disorders.
- Sleep apnea: A condition where breathing repeatedly stops and starts during sleep.
Healthcare providers often use a simpler procedure to check for sleep apnea. In a home sleep apnea test (HSAT), you stay in your own bed with sensors to measure your breathing, heart rate, and related functions.
Who Should Consider a Sleep Study?
Sleep disorders are common, with studies showing that 50-70 million Americans suffer from chronic sleep issues. If you experience any of the following symptoms, a sleep study may be worthwhile:
- Loud, frequent snoring.
- Gasping or choking during sleep.
- Excessive daytime fatigue.
- Difficulty concentrating or memory issues.
Since sleep issues can worsen existing health conditions like high blood pressure and diabetes, you should talk with your doctor if you have concerns. A healthcare provider may first suggest trying changes in your lifestyle or habits to improve your rest. Those changes could involve quitting smoking, drinking less alcohol and caffeine, and maintaining a regular schedule
How Original Medicare Covers Sleep Studies
Medicare Part B, the part of the federally administered Original Medicare program that provides medical insurance, covers sleep studies when they’re medically necessary. A physician must order the sleep study after evaluating symptoms caused by one of these conditions:
- Sleep apnea
- Narcolepsy, if the condition significantly affects your health
- Parasomnia, if the symptoms seem to be caused by seizures
You’ll have the study in a Medicare-approved sleep center or use an approved home sleep apnea test (HSAT).
Original Medicare covers 80% of the Medicare-approved cost for testing, leaving you responsible for 20% after meeting the annual Part B deductible. If you receive care for services that aren’t covered by Medicare, or get care more often than Medicare covers, you may be responsible for some or all of the cost.
How Medicare Advantage Covers Sleep Studies
Medicare Advantage plans, or Medicare Part C, are offered by private insurers and must provide at least the same coverage as Original Medicare. However, these plans often include additional benefits such as Medicare Part D prescription drug coverage, dental, vision, and hearing. Plan availability depends on where you live, and the premiums, benefits, and cost-sharing vary by plan.
Plans may set broader criteria for covering sleep studies than Original Medicare and offer additional benefits, such as reduced out-of-pocket costs for medical equipment. To get the most out of their coverage, people on Medicare Advantage plans must visit doctors who are in their provider network.
Compare plans to learn about the coverage available for sleep disorders in your ZIP code.
How Much Do Sleep Studies Cost with Medicare?
With Medicare Part B:
- In-lab sleep study: The Medicare-approved amount varies based on the range of sensors being used and whether the patient needs to be attended by a technologist. The Centers for Medicare and Medicaid Services estimated the cost for a covered sleep study at $920. Medicare covers 80% of the approved amount.
- Home sleep apnea test: Less expensive, and it may be as low as $150. Medicare also covers 80%.
You will pay the remaining 20% after the Part B deductible is met.
Costs With Medicare Advantage
Medicare Advantage plans may have different copay or coinsurance structures from Original Medicare, often lowering your out-of-pocket expenses for diagnostic procedures like sleep studies. To use their coverage, people on Medicare Advantage plans must see doctors and specialists in their provider network.
Out-of-Pocket Costs Without Medicare
Without insurance, sleep studies can be prohibitively expensive:
- In-lab sleep study: Can be upwards of $10,000.
- CPAP machine: $500–$1,000 upfront, plus $100–$200 annually for supplies.
Medicare coverage can significantly reduce these costs, making diagnostic and treatment options more accessible.
Putting It All Together
Medicare does cover sleep studies, sleep apnea testing, and equipment like CPAP machines, but coverage depends on meeting specific criteria. Medicare Advantage plans may offer additional benefits.
If you’re considering a sleep study or need equipment for sleep apnea, consult your physician and explore your plan details to determine your coverage and costs. Consider speaking with a licensed insurance agent to explore your plan options.
Sources
Polysomnography and Sleep Studies. CMS.
Sleep studies. Medicare.gov.
Enough to Wreck Their Rest: $10,322 for a Sleep Study. KFF Health News.
How Much Do CPAP Machines Cost? Sleep Foundation.