How to Get Medicare to Pay for Oxygen

Medicare, the federal health insurance program, covers durable medical equipment, including oxygen therapy, for eligible beneficiaries. This coverage primarily falls under Medicare Part B, which addresses outpatient medical services and supplies. This article aims to guide individuals through securing Medicare coverage for oxygen therapy, detailing the criteria, covered items, supplier selection, and cost management.

Meeting Medicare’s Criteria

For Medicare to cover oxygen therapy, certain requirements must be met to establish medical necessity. A Medicare-enrolled doctor must determine that oxygen therapy is medically necessary due to a severe lung disease, such as Chronic Obstructive Pulmonary Disease (COPD), emphysema, or other hypoxia-related symptoms. This requires objective evidence, often through blood gas studies or pulse oximetry readings.

Specific oxygen saturation levels are required for coverage. An arterial partial pressure of oxygen (PO₂) of 55 mm Hg or less, or an oxygen saturation (SpO₂) of 88% or less on room air at rest, qualifies. If these levels are not met at rest, testing during exercise or sleep may be considered, with similar saturation thresholds. The physician’s medical records must also indicate that other treatments, such as medications or pulmonary rehabilitation, have been tried and found unsuccessful or insufficient.

A detailed physician’s order is essential, serving as the prescription for oxygen therapy. This order must come from a treating physician, such as a Medical Doctor (MD) or Doctor of Osteopathy (DO), and needs to specify the diagnosis requiring oxygen, the prescribed oxygen flow rate, the frequency and duration of use, and the estimated duration of need. Orders for “oxygen as needed” or “PRN” do not meet Medicare’s requirements. The oxygen supplier must also be enrolled in Medicare and meet its quality standards for coverage to apply.

Understanding Covered Items

Once Medicare’s eligibility criteria are satisfied, Medicare Part B covers various types of oxygen equipment and related supplies. This includes oxygen delivery systems like concentrators, which extract oxygen from the air, and oxygen tanks, which store compressed or liquid oxygen. These systems can be stationary for home use or portable for mobility.

Medicare covers the rental of oxygen equipment rather than its purchase. Along with the primary equipment, Medicare covers necessary supplies and accessories. These include items like tubing, masks, nasal cannulas, and humidifiers, which are integral to the safe and effective delivery of oxygen.

Medicare’s coverage extends to the maintenance, servicing, and delivery of oxygen and associated equipment. If a humidifier is used with a respiratory assist device or CPAP, Medicare may also cover its rental or purchase.

Choosing a Medicare-Approved Supplier

Choosing the correct oxygen supplier is an important step in ensuring Medicare coverage. You must choose a supplier that is enrolled in Medicare. You can verify a supplier’s Medicare enrollment using Medicare’s official supplier directory or by directly asking the supplier. This enrollment confirms the supplier adheres to Medicare’s operational and quality standards.

A key consideration is whether the supplier “accepts assignment.” When a supplier accepts assignment, they agree to accept Medicare’s approved amount as full payment. This limits your out-of-pocket costs to the deductible and coinsurance, preventing balance billing for amounts above Medicare’s approved rate. Medicare-enrolled suppliers are also required to be accredited by an organization approved by Medicare, adding another layer of quality assurance. Comparing suppliers for service quality, equipment offerings, and adherence to Medicare’s regulations helps ensure a smooth experience.

Initiating Oxygen Coverage

The process of initiating Medicare coverage for oxygen therapy begins with your physician. After determining medical necessity and completing the required medical documentation, your physician sends a detailed order directly to your chosen Medicare-approved oxygen supplier. This communication is important for the supplier to proceed with providing the equipment.

The supplier obtains all necessary documentation from your physician, including the detailed prescription and supporting medical records. The supplier sets up the oxygen equipment in your home and instructs you on its proper use and maintenance. Subsequently, the supplier submits the claim to Medicare on your behalf, managing the billing process directly with Medicare.

Medicare’s coverage for oxygen equipment operates on a rental basis. The initial rental period for oxygen equipment is 36 months, during which Medicare makes monthly rental payments to the supplier. These payments encompass the equipment, oxygen contents, and necessary maintenance and servicing. After 36 months, if you still require oxygen, the supplier must continue to provide the equipment and service it for an additional 24 months, totaling a five-year period, without further rental payments from Medicare. After five years, if oxygen therapy is still needed, a new 36-month rental period for new equipment begins.

Managing Costs and Denials

Understanding the financial obligations associated with Medicare oxygen coverage is important. Under Medicare Part B, you are responsible for an annual deductible, which must be met before Medicare begins to pay. For example, in 2025, the Part B deductible is $257. After the deductible is satisfied, Medicare covers 80% of the Medicare-approved amount for oxygen equipment and supplies. You are responsible for the remaining 20% coinsurance.

Supplemental insurance, such as Medigap policies, or other coverage like Medicaid or employer-sponsored health plans, can help cover these out-of-pocket costs, including the Part B deductible and coinsurance. Always ensure your supplier accepts “assignment” to avoid unexpected charges, as this means they agree to Medicare’s approved payment amount as full payment, preventing balance billing.

Should Medicare deny coverage for oxygen therapy, you have the right to appeal the decision. First, understand the specific reason for the denial, outlined in the Medicare Summary Notice (MSN) or Explanation of Benefits (EOB). The Medicare appeals process has several levels:
Redetermination by a Medicare Administrative Contractor (MAC).
Reconsideration by a Qualified Independent Contractor (QIC).
A hearing before an Administrative Law Judge (ALJ).
Review by the Medicare Appeals Council.
Judicial review in federal court.

Adhering to strict deadlines for each appeal level and providing comprehensive medical documentation supports a successful appeal.