Oxygen Therapy

I’ve been prescribed supplemental oxygen. What do I need to know?
Nimi Tarango, RN, MS, NP-BC

What is oxygen therapy?

Oxygen therapy is a medical treatment prescribed by a physician and administered through a cannula or face mask. A typical prescription details what type of oxygen system should be used, the level of intensity (liters per minute) to be applied and when the oxygen should be administered (e.g., during exercise or sleep). More information from the American Thoracic Society about oxygen therapy and children.

How is oxygen given?

Supplemental oxygen is supplied in tanks which must be prepared and delivered by an oxygen supply company. The oxygen is inhaled by patients via a nasal cannula (a lightweight tube) or a face mask which is attached to the oxygen tank by plastic tubing. At home, many PHers use a machine called a condenser or concentrator, which supplies oxygen indefinitely, although it requires electricity to work. When patients are outside of the home, oxygen is supplied by portable tanks that last for a few hours only, depending upon how much oxygen is required. The rate at which oxygen is set to flow varies from person to person and is prescribed by a physician.

Will my insurance cover my oxygen?

Medicare covers oxygen through a five-year contract with your home oxygen supplier. This contract begins once an oxygen supplier bills Medicare for your oxygen. Medicare pays 80% of the supplier’s charges, and you are responsible for paying the remaining amount. However, a supplemental Medicare plan may cover the 20% difference, so check with your supplemental plan provider for more information.

*Over the past few years, Medicare has been changing the way it pays for oxygen. Some oxygen suppliers have been taking advantage of patients’ confusion to bend, and even break, the rules governing what they must provide. To learn more, please see the Supplemental Oxygen Guide listed below.

As many as 80-85 percent of oxygen users rely on Medicare, so many insurance providers model their plans off of Medicare’s policies. If you have an alternative insurance provider that is not Medicare, please refer to your provider’s Summary of Benefits and Coverage for more information.

The Supplemental Oxygen Guide

Version 1.1 – Updated 6/26/15

Q&A for Every Supplemental Oxygen User

Talk with your doctor. Ask what type of delivery system is best for you. Talk about your needs not only at home, but also what you need when you’re exercising or otherwise exerting yourself. Your doctor will provide a certificate of medical necessity, saying that you require supplemental oxygen. Make sure this certificate of medical necessity includes exactly what your doctor told you that you need.

Next, find an oxygen supplier that can provide what is in the certificate of medical necessity. Know that your oxygen supplier is not your doctor and cannot make decisions about the type of equipment you require. Only you and your doctor may do this!

Once you have your equipment, you cannot, in most cases, change the type of equipment or type of delivery system for a term of five (5) years. This is why it’s important to choose the type of equipment and delivery system that will work best for your lifestyle! Note: If your oxygen requirements change or your doctor feels you require different equipment or delivery system, your certificate of medical necessity should be changed. With a new certificate of medical necessity your oxygen supplier must provide equipment that fits that need.

There are two main types of supplemental oxygen, also called “modalities:” gaseous and liquid. These systems work differently. There are pros and cons with each system.

In the past, many oxygen users were given both a home concentrator (for use while at home) and an “E” tank (for going out). One problem with this arrangement was that a user had to pull the tank on a cart when going outside their home. Inside the home a user could move only as far as the tubing would go.

A newer type of oxygen system is the “trans-fill” unit. In this system gaseous oxygen can be produced in the home by a concentrator and stored in a refillable tank. These “M” tanks are small and light. They can be easily carried in a shoulder case. The length of time these smaller tanks last varies on your liter flow and the pressure with which the tanks are filled. Note: some trans-fill units will fill at 2000 psi (pounds per square inch) while others fill at 3000 psi. The higher pressure provides more capacity. This system helps you move around easier outside and inside your home. You don’t have to rely on the home care supplier to replace tanks when you need them. This type of system puts you in control of filling your own tanks for increased mobility. The entire system can be moved if you need to leave your home for extended periods like relocating to a summer home.

The other modality is liquid oxygen, a popular option with high liter flow users. In this system the oxygen is stored in liquid form in a home reservoir which must be filled on a regular basis. You can use the reservoir to fill smaller containers. These smaller oxygen containers offer longer use times even at high liter flows. The other advantage of this system is that it does not depend on electricity like a home concentrator. This means that oxygen use will not add to your utility bills and you will continue to have oxygen if the power goes out.

The main disadvantage of liquid oxygen is that the reservoir is not portable with travel (unless your oxygen provider allows you the use of a travel reservoir). You must make arrangements to have a different reservoir in place at your destination.

In some areas it is very difficult to obtain liquid oxygen. Check with suppliers in your area before deciding on liquid oxygen to make sure it is available. Be sure to discuss all of these options with your doctor!

A recent change in Medicare as a result of the new competitive bidding sets new rules and regulations as to how your oxygen provider is paid.

If you have Medicare and use oxygen you will have a five-year contract with Medicare and your home oxygen supplier. The contract begins the first month the oxygen supplier bills Medicare for your oxygen. In the first 36 months of the contract the oxygen supplier is paid for rental of the equipment. In the last 24 months of the contract the oxygen supplier is paid only for providing refilled tanks, hoses and other supplies. The oxygen supplier is responsible for maintaining and repairing the equipment for the entire length of the contract.

Medicare pays 80% of the charges billed by the oxygen supplier and you are responsible for the remaining amount. A supplemental plan provider plan may offset or cover this 20% difference, so check with your supplemental plan provider.

It used to be that the oxygen user would own the equipment at the end of the five-year period. Now, the oxygen supplier owns the equipment throughout, and after the five-year period.

Your oxygen supplier must keep on supplying replacement accessories for the rest of your five year contract. Your supplier is also required to service and repair your equipment at no charge. During this time, the oxygen supplier will bill Medicare for these supplies and tank refills.

The pros of the five-year contract are:

  • Your oxygen supplier cannot drop you, change your equipment or delivery system without approval from you and your doctor.
  • After the first 36 months, your billing will be lower for the remaining 24 months.

The cons of the five year contract are:

  • It is hard to make any “non-necessity” changes to your equipment – things you want, but don’t medically need.
  • If you decide to change to another oxygen supplier, depending on where you are in your contract, it may be difficult to find another supplier. Many new suppliers will not accept a patient late in their contract period. This is because the supplier might not get paid for the equipment they would have to give you.

YES. According to a clarification of the latest CMS rules dated spring 2015, the useful lifetime of a concentrator begins when the equipment is delivered to you, and is not the age of the equipment. The equipment is required to be serviceable and in good working order. The hour meter of a concentrator does not determine the proper operation of oxygen equipment. It is important for you to understand three factors that determine proper operation.

  1. The oxygen purity should be measured by a technician at regular service intervals and produce 85% or greater oxygen purity on the maximum setting.
  2. The outlet pressure should be within specification according to the manufacturer. A technician will be able to measure and determine this value.
  3. The oxygen delivered from the machine should be odorless.
    Often times, the equipment has built in safety devices and alarms to notify you that something is wrong. Please report any alarms to your oxygen supplier and request a service check to determine if the equipment is operating properly.

If your doctor decides that your oxygen equipment can no longer provide what you need, he/she may notify the oxygen supplier with a new letter of medical necessity for different equipment. The oxygen supplier must provide you with new equipment. In this case, your contract period does not change even after the 36 month period.

When your five-year contract is about to run out, your oxygen supplier is required to let you know. Your doctor will then need to provide a new letter of medical necessity. This may include an updated evaluation of your oxygen needs. This is the perfect time to talk with your doctor about other types of oxygen systems that might work better for you. You should NEVER enter into a new contract period without first consulting the doctor who writes orders for your oxygen! Also, if for any reason you are not satisfied with your oxygen supplier, now is the time to change to a new supplier.

When beginning a new contract, your oxygen supplier must provide new equipment specified by your doctor in the new letter of medical necessity. Even though your contract period is ending, it is assumed that you are planning to implement a new 5 year contract through your contracted supplier. If they no longer wish to handle your contract, they must help you find another supplier. If they are unable to do this, they must continue to provide your services. If your oxygen supplier renews your contract based on your request to keep the existing equipment in place, this may lower your payment of the 20% billable services, but the supplier will not be able to bill Medicare for rental on your old equipment. If you agree to receive new equipment the oxygen provider will start a new five-year contract with Medicare.

NO. They may not change the type of equipment or number of tank refills you receive unless ordered by your doctor and approved by you. The Medicare CMS Supplier Handbook states: “Suppliers must provide whatever quantity of oxygen contents are needed for a beneficiary’s activities both inside and outside the home.”

Once your oxygen supplier starts to bill Medicare, they must fulfill the contract for the entire five years. If you find the need for more tank refills, your doctor simply has to submit an updated letter of medical necessity. The oxygen supplier must comply.

If your oxygen supplier tries to change the number of tank refills you get, consider filing a Medicare complaint by calling 1-800-MEDICARE (1-800-633-4227).

According to the Medicare CMS Supplier Handbook:

“Suppliers voluntarily exiting the Medicare program are reminded that they are in violation of their regulatory and statutory obligations. Section 1834(a)(5)(F)(ii)(I) requires that the supplier that received the 36th month rental payment continue furnishing the oxygen equipment during any period of medical need for the remainder of the equipment’s reasonable useful lifetime.

Further, 42 CFR 414.226(g)(1) requires, barring a few exceptions, that the supplier that furnishes oxygen equipment in the first month during which payment is made must continue to furnish the equipment for the entire 36-month period of continuous use, unless medical necessity ends. S

Suppliers leaving the program must give you a ninety-day notice, in writing, that they can no longer provide oxygen therapy services. This notice must be in one of two forms:

  1. A letter to the patient notifying them of the supplier’s intent to stop oxygen therapy services. The letter must specify a date upon which this will occur.
  2. A letter to a new supplier chosen by the patient, transferring the responsibility for oxygen therapy services to the new supplier on a specific date.

In the case of number one above, work with your supplier to find a new oxygen supplier in your area and request that they send a letter to the new supplier on your behalf. This will ensure no interruption in service and a transfer of your medical records to the new supplier within that 90 day period.

Medicare regulations state:

“Providing different oxygen equipment/modalities (e.g., concentrator [stationary or portable], gaseous, liquid, trans-filling equipment) is not permitted unless one of the following requirements is met:

  • Supplier replaces the equipment with the same or equivalent item
  • Physician orders different equipment
  • Patient chooses to receive an upgrade and signs an Advance Beneficiary Notice of Non-coverage (ABN)”

Since liquid oxygen is very different from compressed or gaseous oxygen, the supplier cannot provide a “same or equivalent” system when changing modalities. Changing from one brand of liquid system to another is considered “same or equivalent.”

The Medicare CMS Handbook also states: “The supplier must have a prescription and/or CMN (certificate of medical necessity) to change modalities.”

If you are told that your oxygen supplier will no longer provide your prescribed therapy (liquid) and you have NOT completed your five-year contract, you should do the following:

  1. Do not allow any removal of equipment from your home.
  2. Refuse any unfair changes of equipment or coverage by providing the supplier with a written notice of refusal and requesting that they provide you with documentation of their proposed changes. You will need this information to file a complaint with Medicare.
  3. Contact your physician to inform him/her of the situation and ensure that he/she has sent the most recent letter of medical necessity to your supplier.
  4. File a Medicare complaint through 1-800-MEDICARE (633-4227). A Medicare representative can put you in contact with the Competitive Acquisition Ombudsman (CAO) if problems persist.
  5. Involve the local media if your supplier continues to break the rules. Contact Katherine Kroner at MediaAction@PHAssociation.org for assistance.
  6. File an Americans with Disabilities Act Complaint at www.ada.gov/filing_complaint.htm

If your oxygen provider states they are no longer providing the specific equipment/modality you are prescribed, your oxygen provider must find another contractor that does provide what you require, and if unable, they must continue to provide those services.

YES. Your supplier must continue to provide prescribed services to you either directly or by contracting with another supplier for the remainder of your contract period. If your new home is outside the area covered by your supplier, they must make arrangements for a supplier who will be able to take care of your oxygen needs where you are. You do not have to pay any additional money to the new supplier.

The certificate of medical necessity from your doctor should address your mobility needs both inside and outside your home. Your oxygen supplier is required to supply the items you need for such mobility. Talk with your doctor about your concerns and request a new letter of medical necessity that details your needs.

Medicare will pay for your main source of oxygen. Your oxygen supplier is allowed to bill only for this main source. If, at the beginning of your contract, you say that a portable concentrator would be your primary source of oxygen, Medicare might pay for it, but then you would be responsible to pay for any other equipment such as a home concentrator.

NO. Your oxygen supplier may not reduce the number of tank refills they have delivered in the past or the type of tanks prescribed to you, and they may not make you pick up your own tanks. The type and amount of equipment they deliver at the start of your contract must be the same throughout the five-year contract. If you have this situation you should file a Medicare complaint right away by calling 1-800-MEDICARE (1-800-633-4227).

Your oxygen supplier must furnish you with supplies to take care of your needs for safe and healthy oxygen therapy. Write a letter to your oxygen supplier saying why you feel that they are not giving you all the supplies you need (keep a copy of this letter). If they don’t fix this issue right away, you should file a Medicare complaint by calling 1-800-MEDICARE (1-800-633-4227).

YES. Your oxygen supplier is responsible for providing you with working equipment, and is required to make repairs. Call your oxygen supplier and tell them that you feel your equipment is unsafe. If a piece of equipment is determined to be unrepairable, your oxygen supplier may replace the equipment, or in some cases Medicare may allow a new contract to start under the “lost or unrepairable” clause. The oxygen supplier cannot change the modality under these terms. They must use the same or equivalent equipment.

Some brands of concentrators run quieter, produce less heat, or use less electricity than others. Oxygen concentrators can be very expensive to run and the cost of electricity is not covered under Medicare reimbursement. Your oxygen supplier may have a purchase agreement with a certain company in order to get lower pricing. That does not mean you can’t request particular equipment! This is when it pays to do your homework. Ask other oxygen users about their equipment. Ask about reliability, noise level, cost of running it, and if it produces a lot of heat. However, they are also not obligated to go out and buy a brand of equipment that you request. Your choice is still dependent on their current inventory.

Medicare will not pay for any utility bills as a result of the use of your oxygen equipment. In some cases, the direct costs of operating your oxygen equipment are deductible as a medical expense. Some utilities have programs to help lessen this cost. Check with your electricity provider.

Here is how you do it, step by step.

1) The label on your concentrator shows the volts and amps used. Multiply the volts by the amps.
For instance: 115 volts at 6 amps = 690 watts.

2) Multiply the watts by .001 to obtain kilowatt hours.
690 x .001 = .69 KWH

3) Multiply KWH by the number of hours per year that you use your concentrator. For instance, if you use it 24 hours a day, that equals 8,760 hours per year.
.69 KWH x 8,760 = 6,044

4) Find the cost of electricity per kilowatt from your power company. For example, 12 cents.
6,044 x .12 = $752.28 cost per year

NO. Your oxygen supplier is not required to furnish you with an airline-approved portable oxygen concentrator and Medicare will not pay for any oxygen related to air travel. You might be able to rent a portable oxygen concentrator from your oxygen supplier. Rentals are also available through online companies where they work with most airlines and provide the documentation required for your travel.

PHA and the COPD Foundation are making every effort to ensure continued delivery of oxygen therapy to all individuals with pulmonary hypertension (PH). We are providing information such as this guide and working with legislative leaders to address problems with the new competitive bidding law. In order for our efforts to become successful, it is vital that we hear your story.

To learn more about Medicare’s rules and tell PHA about your oxygen experience, please call 301-565-3004 x749.

The Supplemental Oxygen Guide was created by the COPD Foundation

COPD Foundation