Prevent Respiratory Deaths: Get Your Oxygen Concentrator Covered Now!

Every year, hundreds of thousands of preventable deaths occur due to respiratory diseases (1). But there's hope! Oxygen concentrators can provide the life-sustaining treatment needed, potentially covered by your insurance plan and Medicare. Don't wait for tragedy to strike—discover how you can secure coverage for this life-saving equipment today.

Medicare Coverage

With the rising costs of healthcare equipment, it's no surprise that many are left gasping at the price tags - especially for oxygen concentrators, which can easily exceed $2,000, not to mention the pile-up of ongoing expenses (1) (2). Luckily, Medicare Part B covers oxygen equipment and accessories as durable medical equipment (DME) for home use when it's prescribed by a doctor for medical reasons. The specifics include:

Eligibility

Medicare Part B covers oxygen equipment and accessories as durable medical equipment for home use when prescribed by a healthcare provider. To qualify, the items must be prescribed by a doctor, and the supplier must be enrolled in Medicare. This ensures that the equipment provided meets Medicare's standards and is from a reputable source (3).

Coverage Details

Medicare's coverage extends to the rental of oxygen equipment for a period of 36 months. Beneficiaries must meet specific medical criteria concerning their oxygen levels to qualify for coverage. After the 36-month rental period, the supplier retains ownership of the equipment but is required to continue providing the necessary oxygen and related supplies for an additional 24 months if the beneficiary's need persists. After this total of five years, if there is still a medical necessity, the beneficiary can choose to receive new equipment or continue with the old, subject to potential adjustments in how payments are handled. Included in this coverage are the oxygen concentrator, containers for storing oxygen, tubing, and masks (4) (5).

Costs

For those covered under Medicare Part B, there is a cost-sharing arrangement for the rental of oxygen equipment. Beneficiaries are responsible for paying 20% of the Medicare-approved amount, while Medicare covers the remaining 80%. The Part B deductible also applies. This out-of-pocket cost is an important consideration for many, particularly because it recurs with the rental payments.

Private Health Insurance

Coverage for oxygen concentrators under private health insurance varies significantly depending on the insurer and the specific policy. In general, most health insurance policies cover oxygen concentrators under the following conditions:

Varies by Policy

The specifics of coverage for oxygen concentrators can vary widely among different private health insurance policies. However, most plans do provide coverage for durable medical equipment (DME), including oxygen concentrators, as long as they are prescribed by a healthcare provider and deemed medically necessary. These conditions typically align with those set by Medicare, ensuring that the equipment is necessary for the patient's health and well-being (6).

Pre-authorization May Be Required

Many private insurance plans require pre-authorization to cover an oxygen concentrator. This process involves the healthcare provider submitting evidence of medical necessity, which may include detailed medical records and justifications for the prescribed therapy. This step is crucial as it confirms to the insurer that the equipment is essential for the patient's treatment and is not merely optional (7).

Cost-Sharing Details

The cost-sharing aspect of oxygen concentrators under private health insurance also varies. Depending on the insurance plan, you may be responsible for deductibles, copayments, or coinsurance. The extent to which these costs apply can differ based on whether the plan covers the rental or purchase of the equipment—or potentially both. Understanding the specifics of your insurance policy is key to anticipating out-of-pocket expenses.

Medicaid

Medicaid coverage for oxygen concentrators can vary by state, but generally, if covered, it follows similar guidelines to Medicare (9):

State-Specific Eligibility

Each state operates its own Medicaid program, which includes setting its own criteria and procedures for the approval of durable medical equipment (DME) like oxygen concentrators. These state-specific eligibility criteria can significantly affect access to such equipment. While all states must meet federal minimum standards, they can vary in terms of the thoroughness of the documentation required, conditions approved for treatment with an oxygen concentrator, and the eligibility criteria for recipients.

Cost Sharing

Regarding the cost of oxygen concentrators, state Medicaid programs also differ. Some states require a co-payment for DME, which can be a fixed amount or a percentage of the equipment's cost. In contrast, other states may cover the full cost, making the equipment completely free to the user. This variance can impact the out-of-pocket expenses for Medicaid beneficiaries needing oxygen therapy.

Additional Tips for Navigating Coverage

Ensuring all necessary medical documentation, including prescriptions and test results, is accurate and up-to-date is crucial. This not only helps to prevent delays in obtaining your equipment but also supports the justification of medical necessity to your insurance provider. Detailed and current documentation can expedite approvals and prevent unnecessary complications.

Choose to work with suppliers who have experience in dealing with insurance and Medicare claims. These suppliers will be more familiar with the nuances of paperwork and can help guide you through the process, making it less burdensome. They can also act as intermediaries, ensuring that all forms meet specific requirements and are submitted on time.

Understanding the details of your insurance policy is essential. Know what your policy covers and the conditions under which it provides coverage. If your claim for an oxygen concentrator is denied, be prepared to appeal the decision. Familiarize yourself with the appeals process of your insurer or Medicare; this could involve submitting additional documentation or obtaining letters from your healthcare providers to reinforce the necessity of the equipment.