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How do I qualify for coverage?

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How do I qualify for coverage?

Let’s explore the criteria you must meet for Medicare to cover your home oxygen therapy rental equipment:
To ensure your oxygen therapy is covered under Medicare Part B you must be diagnosed with a qualifying medical condition and have a physician’s order for oxygen therapy. You must undergo certain tests that demonstrate your need for oxygen therapy. One is blood gas testing and your results must fall into a specified range. Your doctor has to order the specific amount duration and frequency of oxygen you need. Orders for oxygen on an as-needed basis don’t typically qualify for coverage under Medicare Part B. To qualify for coverage Medicare may also require your doctor to show that you’ve tried alternative therapies such as pulmonary rehabilitation without complete success.You have to get your rental equipment though a supplier that participates in Medicare and accepts assignment. You can find Medicare-approved suppliers here.

What equipment and accessories are covered?

Medicare will cover a portion of the cost for rental equipment that provides stores and delivers oxygen. Several types of oxygen systems exist including compressed gas liquid oxygen and portable oxygen concentrators.
Here’s an overview of how each of these systems works:
Compressed gas systems. These are stationary oxygen concentrators with 50 feet of tubing that connects to small prefilled oxygen tanks. The tanks are delivered to your home based on the amount of oxygen needed to treat your condition. Oxygen runs from the tank through a regulating device that conserves the oxygen. This allows it to be delivered to you in pulses rather than a continuous stream.Liquid oxygen systems. An oxygen reservoir contains liquid oxygen that you use to fill a small tank as required. You connect to the reservoir through 50 feet of tubing.Portable oxygen concentrator. This is the smallest most mobile option and can be worn as a backpack or moved on wheels. These electric units don’t require tanks to be filled and come with only 7 feet of tubing. But it’s important to know that Medicare covers portable oxygen concentrators only in very specific circumstances.
Medicare will cover stationary oxygen units for use at home. This coverage includes:
oxygen tubingnasal cannula or mouthpieceliquid or gas oxygenmaintenance servicing and repairs of the oxygen unit
Medicare also covers other oxygen-related therapies such continuous positive airway pressure (CPAP) therapy. CPAP therapy might be needed for conditions like obstructive sleep apnea.

Does Medicare cover home oxygen therapy?

Medicare covers home oxygen therapy under Part B. Medicare Part B covers the cost of outpatient care and certain home therapies.
Basic requirements for coverage
To have home oxygen needs covered through Medicare you must:
be enrolled in Part Bhave a medical need for oxygenhave a doctor’s order for home oxygen.
The Centers for Medicare & Medicaid Services (CMS) clearly outlines specific criteria that must be met in order for Medicare to cover home oxygen. Requirements include:
appropriate Medicare coveragemedical documentation of an applicable medical conditionlaboratory and other test results that confirm the need for home oxygen
We’ll cover the details of how to qualify for coverage later in this article.
Medical necessity
Home oxygen is often prescribed for conditions like heart failure and chronic obstructive pulmonary disease (COPD).
The medical necessity of home oxygen is determined by testing to see whether your condition is causing hypoxemia. Hypoxemia occurs when you have low levels of oxygen in your blood.
Conditions like shortness of breath without low oxygen levels likely won’t be covered by Medicare.
Your doctor’s order must include information about your diagnosis how much oxygen you need and how often you need it. Medicare doesn’t usually cover orders for PRN oxygen which is oxygen required on an as-needed basis.
If your condition meets the CMS criteria you must first fulfill your Medicare Part B deductible. This is the amount of out-of-pocket costs you must pay before Medicare begins to cover approved items and services.
The Part B deductible for 2020 is $198. You must also pay a monthly premium. In 2020 the premium is typically $144.60 — though it may be higher depending on your income.
Once you’ve met your Part B deductible for the year Medicare will pay for 80 percent of the cost of your home oxygen rental equipment. Home oxygen equipment is considered durable medical equipment (DME). You’ll pay 20 percent of the costs for DME and you must obtain your rental equipment through a Medicare-approved DME supplier.
Medicare Advantage (Part C) plans may also be used to pay for oxygen rental equipment. These plans are required by law to cover at least as much as original Medicare (parts A and B) covers.
Your specific coverage and costs will depend on the Medicare Advantage plan you choose and your choice of providers may be limited to those in the plan’s network.

The takeaway

Oxygen should always be used under the supervision and direction of your doctor.Be careful when using oxygen and follow all safety precautions.If you need home oxygen and are enrolled in Part B Medicare should cover the majority of your costs.Medicare might not cover some oxygen equipment like portable concentrators.Work with your doctor to find the best therapy for your condition and coverage.Always talk with your doctor if you think your oxygen needs have changed.

More about oxygen therapy

You may need oxygen therapy to treat one of many different conditions.
In some cases trauma or severe illness could lessen your ability to breathe effectively. Other times a disease like COPD might change the chemistry of the gases in your blood lowering the amount of oxygen your body can use.
Here’s a list of some conditions that may require you to use occasional or continuous oxygen therapy at home:
COPDpneumoniaasthmaheart failurecystic fibrosissleep apnealung diseaserespiratory trauma
To determine whether your condition requires oxygen therapy at home your doctor will perform a variety of tests that measure the effectiveness of your breathing. Symptoms that may lead your doctor to suggest these tests include:
shortness of breathcyanosis which is a pale or blueish tone to your skin or lipsconfusioncoughing or wheezingsweatingfast breathing or heart rate
If you have these symptoms your doctor will perform certain tests. These may include breathing activities or exercises blood gas testing and oxygen saturation measurements. Special tools may be used in the activity tests and blood gas testing requires a blood draw.
Testing oxygen saturation with a pulse oximeter on your finger is the least invasive way to check your oxygen level.
Typically people whose oxygen drops to between 88 percent and 93 percent on the pulse oximeter will require oxygen therapy at least occasionally. Guidelines for how much oxygen to use and when will depend on your specific condition.
In some cases your doctor may prescribe pulmonary rehabilitation in addition to oxygen therapy.
Pulmonary rehab helps people with a condition like COPD learn to manage it and enjoy a better quality of life. Pulmonary rehab often includes education on breathing techniques and peer support groups. This outpatient therapy is typically covered by Medicare Part B.
Oxygen therapy should be treated like any other medication. You need to work with your doctor to find the right treatment dosage and duration for your specific condition. Just as too little oxygen can harm you too much oxygen can also carry risks. Sometimes you only need to use oxygen for a short time. Be sure to talk with your doctor and check in regularly if you need — or think you may need — home oxygen therapy.

How does equipment rental work?

When you qualify for oxygen therapy Medicare doesn’t exactly buy the equipment for you. Instead it covers the rental of an oxygen system for 36 months.
During that period you’re responsible for paying 20 percent of the rental fee. The rental fee covers the oxygen unit tubing masks and nasal cannula gas or liquid oxygen and the costs of service and maintenance.
Once the initial 36-month rental period ends your supplier is required to continue supplying and maintaining the equipment for up to 5 years as long as you still have a medical need for it. The supplier still owns the equipment but the monthly rental fee ends after 36 months.
Even after the rental payments have ended Medicare will continue paying its share of the supplies needed to use the equipment such as the delivery of gas or liquid oxygen. As with the equipment rental costs Medicare will pay 80 percent of these ongoing supply costs. You will pay your Medicare Part B deductible monthly premium and 20 percent of the remaining costs.
If you still need oxygen therapy after 5 years a new 36-month rental period and 5-year time line will begin.

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