Does Medicaid Pay for Oxygen and Related Equipment?

Medicaid, a joint federal and state program, provides healthcare coverage to millions of Americans, including those with limited income and resources. Within its comprehensive scope, Medicaid often covers medically necessary durable medical equipment (DME), which includes oxygen and related supplies. This coverage is important for individuals managing chronic respiratory conditions that necessitate supplemental oxygen therapy at home. While federal guidelines establish a framework, specific coverage criteria and processes can vary by state Medicaid program.

Qualifying for Oxygen Coverage

To qualify for Medicaid coverage of oxygen therapy, a beneficiary must demonstrate medical necessity, evidenced by specific diagnostic criteria and a physician’s order. A physician’s prescription is a requirement, detailing the prescribed oxygen flow rate, duration, and method of delivery. This prescription often needs to be signed and dated by the physician within a certain timeframe.

Medical necessity is established through objective measurements of blood oxygen levels. Common criteria include arterial blood gas (ABG) readings or pulse oximetry (SpO2) results. Many programs consider coverage for individuals with an arterial partial pressure of oxygen (PaO2) at or below 55 mmHg, or an arterial oxygen saturation (SpO2) at or below 88% while at rest and breathing room air. Some programs also cover oxygen for individuals with slightly higher readings, such as a PaO2 of 56-59 mmHg or SpO2 of 89%, if accompanied by evidence of conditions like dependent edema suggesting congestive heart failure, pulmonary hypertension, or erythrocythemia with a hematocrit greater than 56%. These laboratory values must be obtained at the “time of need.”

Oxygen therapy may also be covered for use during sleep or exercise if qualifying desaturation levels are documented during these activities. For example, a decrease in SpO2 to 88% or less during exercise, with documented improvement when oxygen is applied, could qualify a beneficiary for coverage during ambulation. Similarly, nocturnal oxygen may be covered if overnight oximetry studies show desaturation below specified values for a cumulative time period. The physician’s documentation must support the medical condition necessitating oxygen, such as chronic obstructive pulmonary disease (COPD), severe asthma, or other conditions that impair breathing.

Covered Oxygen Equipment and Supplies

Medicaid covers a range of oxygen delivery equipment and related supplies once medical necessity is established. Durable medical equipment (DME) like oxygen concentrators, which extract oxygen from the air, are covered. These can be stationary units for home use or portable concentrators for individuals who are mobile and require oxygen outside the home. Coverage often extends to oxygen tanks or cylinders, including their refilling, and liquid oxygen systems.

Beyond the primary oxygen delivery devices, Medicaid also covers accessories for effective therapy. These supplies include tubing, nasal cannulas, masks, and humidifiers. Other related accessories, such as trans-tracheal catheters and oxygen conserving devices, are included in the overall coverage. While some items of DME may be purchased, oxygen equipment is often covered through a rental model for a specified period, with the supplier continuing to provide maintenance and supplies as long as medical necessity continues. This rental approach includes the cost of oxygen contents, maintenance, and repairs.

Selecting a Durable Medical Equipment Supplier

Choosing an appropriate Durable Medical Equipment (DME) supplier is an important step in obtaining oxygen therapy through Medicaid. Select a supplier that is approved by or in-network with the specific state Medicaid program or managed care plan. Verification of a supplier’s approval status can be done through state Medicaid provider directories or by contacting the state Medicaid office directly.

Factors to consider include the supplier’s reputation, responsiveness to customer service inquiries, and the availability of the specific types of oxygen equipment required. Delivery services and emergency support are also considerations. Beneficiaries should inquire about the supplier’s billing practices and their experience working with Medicaid beneficiaries to ensure a smooth process. Suppliers must meet quality standards, including having a physical location, displaying all necessary licenses, and providing clear instructions on equipment use and maintenance. They should also provide information regarding expected delivery timeframes and maintain accurate records of equipment delivered.

The Process of Obtaining Oxygen

After medical necessity is established and a suitable Durable Medical Equipment (DME) supplier is chosen, obtaining oxygen therapy involves several steps. The physician’s prescription, along with all supporting medical documentation, must be submitted to the selected DME supplier.

A key step in this process is prior authorization (PA), often required by Medicaid for oxygen services. Prior authorization is a pre-approval from Medicaid, signifying that the requested oxygen therapy meets the program’s medical necessity criteria.

The DME supplier submits the necessary forms and medical records to Medicaid for review. These forms may include a Prior Authorization Request Form and an Oxygen Attachment, along with supporting clinical notes and laboratory results. Timelines for approval can vary, but beneficiaries should be prepared for a review period. Coordination among the physician, DME supplier, and the Medicaid program is important to ensure all required information is submitted.

Upon approval, the DME supplier arranges for the delivery and setup of the oxygen equipment in the beneficiary’s home. This includes providing instructions on how to properly use and maintain the equipment, as well as guidance on adhering to the prescribed oxygen therapy regimen. Ongoing maintenance, provision of supplies like tubing and cannulas, and refills of oxygen contents are handled by the DME supplier as part of the rental agreement.

If a prior authorization request is denied, beneficiaries have the right to appeal the decision. The appeal process generally involves requesting a fair hearing. Beneficiaries may also have the right to continued services during the appeal process.