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Conditions that Require Oxygen Therapy
Medicare provides coverage in the home for oxygen therapy for people who have low levels of blood gases and for those who have other conditions (under specific circumstances). Common conditions that are covered are:
- Chronic Obstructive Pulmonary Disease (COPD) - a group of diseases that includes emphysema, chronic bronchitis, and asthmatic bronchitis which affect the ability to breathe.
- Sleep-related breathing disorders - disorders that affect breathing during sleep.
- Asthma - a long-lasting respiratory condition that causes the lungs' airways to become inflamed, swollen, and narrowed, making breathing difficult.
- Some heart conditions - under certain condition people with heart conditions may be prescribed oxygen therapy.
If Covered, Where Do I Buy the Oxygen Equipment and Supplies?
You will save money if you order from a Medicare-approved provider. Suppliers must meet strict standards to qualify as a Medicare supplier and will have a Medicare supplier number. You may also buy your oxygen from any store that sells them. However, if the supplier from which you order your oxygen equipment and supplies is not enrolled in Medicare, Medicare will not pay for the equipment.
Things you should think about before you choose a supplier:
- There are two types of Medicare suppliers: participating suppliers, and those who are enrolled but have chosen not to participate.
- Participating suppliers will not charge more than the Medicare allowed amount.
- A Medicare-approved supplier who does not want to participate can charge more than the Medicare-approved amount. However, they cannot charge more than 15% above the Medicare-approved amount. They may also ask you to pay the entire bill when you pick up the equipment. In this situation Medicare will send the reimbursement directly to you. However, be prepared to wait; it may take a couple of months to receive payment.
- If you receive your Medicare coverage through a Medicare Advantage Plan (like an HMO or PPO), it is likely that the plan will have its own steps for equipment purchases. In addition, the plan may have restrictions on the supplier from which you can buy. It is important to know that your health plan must supply at least what Medicare covers -- they cannot supply less. Depending on your plan you may actually receive more coverage than you would get with Medicare alone. It is wise to call your Medicare Advantage Plan's customer service and ask about your coverage before you order any oxygen equipment and supplies.
Medicare payment for oxygen therapy is subject to the requirement that it is necessary and reasonable for treatment of an illness or injury and/or to improve the functioning of the patient. To ensure that Medicare pays for the oxygen therapy, you must follow the steps below:
- Only your doctor can prescribe oxygen therapy for you, so do not order anything until you have visited your doctor, no matter what the sales person tells you.
- The doctor must document the need for oxygen therapy by writing information in your medical records that supports the need for it. The doctor must also give you a signed and dated order (prescription) for it.
- The supplier must receive the order before Medicare is billed and the supplier must keep it on file.
- If you receive your Medicare through a Medicare Advantage Plan (like an HMO or PPO), it is likely you will have to follow the plan's steps for approval and purchase. Make a point of calling your plan's customer service number and ask about their steps for coverage for oxygen therapy.
Oxygen Therapy Costs
How much you pay will depend on whether or not you have Part B coverage and where you buy your equipment. However in general if you are enrolled in Medicare Part B:
- You will pay 20% of the approved Medicare amount after you have paid your yearly deductible.
- You will pay less if you buy from a supplier who accepts assignment. Participating suppliers will not charge more than the Medicare allowed amount.
- If you have a MediGap/Medicare Supplemental policy you may pay little to no cost.
- If you receive your Medicare through a Medicare Advantage Health Plan, you may owe little to nothing depending on the plan with which you have signed up and your benefits with the plan.
Medicare will help pay for oxygen as a rental for the first 36 months. After that time if you still need the equipment and all your deductible and copays are met, the equipment title will transfer to you. Medicare will then pay for refilling your oxygen cylinders and for repairs and service of your equipment. Medicare will also separately pay for oxygen accessories such as tubing, masks and cannulas after the purchase price has been met.
It is important to do your homework. Review your plan benefits to learn the factors that affect how much coverage you will receive. Make sure all paperwork is completed correctly and that you buy your equipment through an approved supplier that accepts assignment.
Part B Coverage and Oxygen Therapy
You must have Medicare Part B coverage and your doctor must have documented your need for oxygen therapy. The doctor must also write you an order (prescription) for the equipment. Your doctor will know what is necessary to qualify for the type of oxygen therapy prescribed for you. In order for any item to be covered under Medicare, it has to meet the test of durability. Medicare will pay for medical equipment when the item:
- Withstands repeated use
- Is used for a medical purpose
- Is useless in the absence of illness or injury
- Is for use in the home
To qualify for oxygen therapy:
- Your doctor must document a severe lung disease or other condition that interferes with you getting enough oxygen.
- Your condition might improve with oxygen therapy.
- Your blood gas level falls within certain ranges.
- Other alternative measures have been tried and failed, or were not helpful for you.
Under the above conditions, Medicare helps pay for:
- Systems for furnishing oxygen
- Containers that store oxygen
- Tubing and related supplies for the delivery of oxygen
- Oxygen contents
Medicare will not pay for:
- Oxygen for use during sleep only
- Portable oxygen when provided only as a backup to a stationary oxygen system