HHZ Respiratory Review

Medicare Advantage vs Original Medicare for DME

3 min read By HHZ Editorial Next review

Both must cover medically necessary DME such as CPAP and home oxygen, but the rules differ. Original Medicare: any Medicare-enrolled supplier, usually 20% coinsurance after the Part B deductible, rarely prior authorization, no out-of-pocket cap unless you add Medigap. Medicare Advantage: you must use the plan's approved suppliers (CMS), may need prior authorization, costs vary, and there's a yearly out-of-pocket limit. If you rely on DME, compare each plan's supplier list and DME cost-sharing before you enroll.

If you use CPAP, home oxygen or other durable medical equipment (DME), how you get Medicare matters day to day: which supplier you can call, what you pay, and whether you need approval first. Here’s the comparison from Medicare.gov and CMS.

Side-by-side for DME users

IssueOriginal MedicareMedicare AdvantageSource
Is DME covered?Part B covers medically necessary DME ordered for home usePlans must cover all medically necessary services Original Medicare coversMedicare.gov DME, Medicare.gov compare
Which suppliers?Any Medicare-enrolled supplier; ask whether it accepts assignmentMust get DMEPOS from the plan’s approved suppliersMedicare.gov DME, CMS MLN8659122
Your shareUsually 20% of the approved amount after the Part B deductible (with an assigned supplier)Varies by planMedicare.gov compare
Yearly out-of-pocket limitNone, unless you have Medigap or other coverageYes, for covered servicesMedicare.gov compare
Prior authorizationIn most cases not neededMay be required for certain services or suppliesMedicare.gov compare
MedigapCan buy to cover the 20%Can’t buy MedigapMedicare.gov compare
Outside the U.S.Generally not coveredGenerally not covered; some plans offer emergency travel benefitsMedicare.gov compare

What Original Medicare looks like for CPAP and oxygen

  • CPAP: coverage follows the national and DME MAC policies: in-person evaluation, qualifying sleep test, 12-week adherence trial (Medicare CPAP coverage).
  • Oxygen: 36-month rental with ongoing supplier obligations up to 5 years (Medicare home oxygen coverage, switching oxygen suppliers).
  • Assignment matters: a participating supplier must accept assignment and can charge you only the coinsurance and deductible on the approved amount (Medicare.gov).

What to check in a Medicare Advantage plan

QuestionWhere to find it
Is my current CPAP or oxygen supplier in the plan’s approved list?Plan provider/supplier directory; call the plan
What’s the DME cost-sharing (coinsurance or copay)?Evidence of Coverage / Summary of Benefits
Is prior authorization needed for CPAP, oxygen or resupply?Evidence of Coverage; call the plan
How are replacement masks and supplies handled?Plan rules; compare with the replacement schedule
What’s the yearly out-of-pocket maximum?Summary of Benefits
How does the plan handle travel?Plan’s rules on out-of-network and out-of-area care

Who tends to do better where

These are trade-offs, not rules. Check real plan documents.

  • Original Medicare (plus Medigap) suits people who want the widest supplier choice, travel within the U.S., or use expensive DME long term and want the 20% covered by Medigap.
  • Medicare Advantage can suit people whose preferred suppliers are in-network and who value the yearly out-of-pocket cap and extra benefits. Confirm DME cost-sharing and prior authorization rules first.

Verdict

For DME, the biggest practical differences are supplier choice and prior authorization. If you depend on CPAP or oxygen, look at each Medicare Advantage plan’s approved supplier list and DME cost-sharing before enrolling, and compare that with Original Medicare’s 20% coinsurance plus any Medigap premium. If you have Medicaid too, see Medicaid CPAP and DME coverage.

Related: VA CPAP and oxygen benefits, CPAP without insurance, HSA/FSA for CPAP and oxygen.

See also: Medicare Advantage prior authorization rules.

Frequently asked questions

Does Medicare Advantage cover CPAP and oxygen?
Yes, in the sense that Medicare.gov says Medicare Advantage plans must cover all medically necessary services that Original Medicare covers. But the plan sets its own costs and rules: you may need prior authorization, and CMS says MA patients must get DME items from the plan's approved suppliers.
Is DME cheaper on Original Medicare or Medicare Advantage?
It depends on the plan. Original Medicare usually means 20% of the Medicare-approved amount after the Part B deductible, with no yearly out-of-pocket limit unless you have Medigap or other coverage. Medicare Advantage costs vary by plan, but plans have a yearly out-of-pocket limit for covered services.
Can I use any DME supplier with Medicare Advantage?
Generally no. CMS's MLN fact sheet says MA plan patients must get DMEPOS items from their plan's approved suppliers. With Original Medicare you can use any Medicare-enrolled supplier; ask whether it accepts assignment.
Do I need prior authorization for a CPAP on Medicare Advantage?
You may. Medicare.gov says MA plans may require prior authorization before covering certain services or supplies, while Original Medicare in most cases doesn't. Check your plan's Evidence of Coverage or call the plan.
Can I buy Medigap with a Medicare Advantage plan?
No. Medicare.gov says you can't buy Medigap to cover out-of-pocket costs in a Medicare Advantage plan, though you may be able to use employer, union or Medicaid coverage.

Advance Beneficiary Notice (ABN) for CPAP and oxygen

What a Medicare Advance Beneficiary Notice of Non-coverage (ABN) means when a CPAP, oxygen or DME supplier gives you one: the 3 options, appeal rights, unassigned suppliers and when no ABN is needed. From Medicare.gov and CMS.

Medicare Advantage appeal for CPAP or oxygen (2026)

How to appeal a Medicare Advantage plan's denial of CPAP, oxygen or other DME: organization determinations, the 65-day deadline, 30-day, 60-day and 72-hour timelines, automatic IRE review and the 2026 ALJ threshold. From Medicare.gov.

Medicare Advantage prior authorization for CPAP

Prior authorization for CPAP, oxygen and DME in Medicare Advantage vs Original Medicare: CMS-4201-F coverage-criteria limits, the 90-day transition, 2026 decision timeframes and denial reasons under CMS-0057-F, and the Original Medicare required list.

Medicare DME appeal: CPAP and oxygen step by step

How to appeal a denied Medicare claim for CPAP, oxygen or other durable medical equipment in Original Medicare: the 5 levels, deadlines, 2026 dollar thresholds, what to include and how long each step takes. From Medicare.gov.