What does Medicare pay for sleep appliances?
Like commercial medical insurers, Medicare offers coverage for custom-made oral appliances to treat Obstructive Sleep Apnea (OSA). It is important to know that the patient must have Part B benefits in order to be eligible for coverage. So how do you know if the patient has Part B coverage? Good news is it is easy to tell, because “Part B” will be listed on the front of the Medicare ID card! If only “Part A” is listed, the patient will not have coverage for an oral sleep appliance. Please note the dental practice location must be properly enrolled as either a participating or non-participating Durable Medical Equipment (DME) supplier to successfully bill Medicare for oral sleep appliances.
Although the patient must have Part B benefits in order to obtain coverage for an oral sleep appliance, claims for these appliances are billed to Medicare DME. Medicare DME is split into 4 geographical regions: Jurisdictions A, B, C and D. Below is a map of the Medicare DME jurisdictions, last updated June 2021):
Each jurisdiction has a different allowed amount for oral sleep appliances, and some allowed amounts within the jurisdictions vary slightly by state. The allowed amounts have not yet been officially published on any of the four Medicare DME fee schedules. Luckily, we know the allowed amounts based on processed claims from our DentalWriter Software clients and Nierman Medical Billing Service clients, and we are happy to share this information!
- Jurisdiction A: $1900-1975
- Jurisdiction B: $1280-1450
- Jurisdiction C: $1100-1250
- Jurisdiction D: $1250-1550
Keep in mind, that Medicare covers 80% of the allowed amount, so the numbers listed above are not the amounts that Medicare will cut the check or electronic funds transfer for.
- Medicare will reimburse 80% of the allowed amount (less any remaining deductible, if any)
- The patient or the secondary insurance (if applicable) will cover the other 20%
If the practice location is enrolled as a non-participating DME supplier, they have the option on a claim-by-claim basis to “accept assignment” or not, which is indicated in field 27 of the CMS1500 medical claim. If “no” is selected in field 27 when the claim is submitted, the practice may then collect the remaining balance from the patient (or even collect the full amount up front, as the patient receives the reimbursement when assignment is not accepted).
If the practice location is enrolled as a participating DME supplier (or selected “yes” as a non-participating DME supplier on the medical claim), then the remaining balance must be written off as a contractual provider write-off.
Ready to get enrolled in Medicare for sleep appliances? Reach out to us for more information on Nierman Practice Management’s Medicare DME application service! We have helped over a thousand dental practices successfully enroll.
Please feel free to contact us with any questions related to this article. We host a variety of online and in-person courses for dentists, including topics such as dental sleep medicine, TMJ, craniofacial pain, and medical billing in dentistry. We also have a comprehensive, online course series for medical billing in dentistry. For more information, contact Nierman Practice Management at 1-800-879-6468 option 1, by sending us an email at email@example.com, or by visiting niermanpm.com.
Article by: Rose Nierman & Courtney Snow