Medicare does cover portable oxygen concentrators, but coverage varies widely between your specific medical condition, your level of mobility, and the Medicare plans under which you have enrolled. Most importantly, you must suffer from hypoxemia, a medical condition caused by any number of pulmonary or cardiac diseases that reduce blood oxygen levels in the body.
You will only qualify for a POC if you can get out of bed and move around independently. You must also have already enrolled in Medicare Part B, as durable medical equipment like wheelchairs, nebulizers, and oxygen delivery systems all fall within Part B coverage.
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Eligibility for POC Coverage Varies
All life requires oxygen, and our world would appear quite different without it. If you suffer from a pulmonary health condition, you may need supplemental oxygen just to get through the day. While stationary stay-at-home oxygen delivery systems typically see coverage through Medicare Part B—eligibility lines get blurrier for patients on the go who require lighter, portable oxygen concentrators.
What is a Portable Oxygen Concentrator, and What Does It Do?
A portable oxygen concentrator is a small device that allows people with respiratory deficiencies to receive supplemental oxygen while out of the house. These compact machines quietly draw in air through a filter and compress it through a purification sieve, ultimately providing the user with 95% pure oxygen. They do not need refills and only require a power source.
People use portable oxygen concentrators to alleviate symptoms of hypoxemia, a below-normal oxygen level in the bloodstream. These symptoms include:
- A pale, blueish tint to the lips or skin
- Shortness of breath
- Faster breathing
- Sweating without much exertion
- Confusion
- Increased heart rate
External elements like altitude, local air purity levels, and certain pre-existing health conditions can further exacerbate the drawbacks of hypoxemia. The fresh flow of purified air provided by a Medicare-approved portable oxygen concentrator should temporarily alleviate these symptoms, allowing one to perform basic daily tasks and exist comfortably.
Types of Oxygen Compressors
Portable oxygen concentrators aren’t the only devices that help with hypoxemia. There are three other types of oxygen compressors:
- Compressed gas systems: Immobile devices prefilled by the supplier, made up of a stationary oxygen concentrator with a 50-foot breathing tube and refillable tanks for temporary outdoor use.
- Home oxygen concentrator: Also known as standard oxygen concentrators, these devices plug into an electrical outlet in your home and purify the air from within to regenerate pure oxygen.
- Liquid oxygen systems: These also utilize refillable tanks that you can refill from a larger at-home tank called an oxygen reservoir.
What Lung Conditions Require a POC?
To qualify for a portable oxygen concentrator, a doctor must certify that your body lacks the appropriate oxygen levels and that you exhibit symptoms of hypoxemia. Many common lung conditions can cause and aggravate hypoxemia, including:
- Asthma
- Chronic obstructive pulmonary disease
- Cystic fibrosis
- Heart failure
- Lung disease
- Pneumonia
- Respiratory trauma
- Sleep apnea
If any of these disorders cause your oxygen saturation level to drop below 88%, you will need supplemental oxygen to exist and operate comfortably. Oxygen concentrators filter out the nitrogen from the air around you, giving your body additional fresh oxygen otherwise lost to such conditions.
How Much Does it Cost to Buy a POC Out of Pocket?
Buying a portable oxygen concentrator without Medicare might seem daunting to many people, as most popular models cost between $1500-$3500, depending on your health needs and associated accessories. Some of the most common models today include:
Portable Oxygen Concentrators | Cost |
|---|---|
CAIRE Freestyle Comfort | $2,995 |
Philips Respironics SimplyGo Mini | $2,595 |
Inogen One G4 | $2,651-$3,344 |
Inogen One G5 | $2,882-$3,586 |
Aftermarket batteries and charging kits for these machines can additionally cost upwards of $500 per set. To work around expensive out-of-pocket costs for a brand-new POC, you might consider buying a gently used device or even renting one for an extended period.
When Does Medicare cover a POC?
Medicare will never cover the costs of purchasing or renting a personal POC but could potentially kick in to cover a long-term rental. To qualify, your doctor must certify that you have a 24/7 need for oxygen and exhibit full mobility. Your durable medical equipment (DME) provider must also agree to provide you with a portable option.
Furthermore, Medicare underwriters will only approve a POC if you exhibit independent mobility and can confidently walk around your home. Immobile patients can still qualify for stationary delivery systems, but small portable devices remain reserved for individuals on the move. All oxygen concentrators should carry an expected lifetime of at least three years under the Medicare Part B bylaws regarding durable medical equipment.
Coverage Differences Between Medicare Plans
Medicare Part B will cover oxygen prescribed by a doctor as long as that doctor and the DME supplier have enrolled in Medicare. Medicare classifies durable medical equipment as items that:
- A patient needs for a medical reason
- A patient can use repeatedly
- A patient uses at home
- Serve no use to individuals who are not sick or injured
- Have an expected lifetime of at least three years
Medicare Advantage plans must legally provide all the same benefits of Original Medicare (Medicare Part A and B) and would therefore cover prescribed DME like oxygen concentrators. Medicare Supplement Plans (Medigap) can subsequently clean up spillover rental costs not covered by Medicare Part B or Medicare Advantage.
How Much Coverage Does Medicare Provide?
After meeting your deductible—the amount you must pay before your insurance kicks in—Medicare Part B will cover 80% of a POC, leaving you to pay the remaining 20% of the Medicare-approved amount.
A rental agency will supply you oxygen for 36 months for a monthly fee, typically included within your Medicare coverage. These monthly premiums pertain to the oxygen, its delivery equipment, and other required oxygen accessories and services like mouthpieces, machine maintenance, and repairs. If your 36-month period ends and you still need oxygen, your DME provider must continue to refill your stock and maintain your equipment free of charge for another two years.
When is a POC Not Covered by Medicare?
For Medicare to cover a POC, you must receive a prescription from your doctor and provide the following:
- Documentation from a physician proving you have severe lung disease or currently lack proper oxygen intake
- Evidence that you can improve your health through oxygen therapy
- Arterial blood gas readings that fall within a lower range
- Documentation proving all other treatment methods have failed
As stated previously, you must also prove that you can easily move around your home. Those who do not meet all the above criteria will not see approval for a POC.
Additionally, Medicare patients can only rent equipment through Medicare-approved suppliers. Individuals who desire to purchase a POC must do so out-of-pocket. Even then, Medicare will still help pay for the oxygen refills, machine contents, and supplies for patients who own their equipment.
Why POC Claims Are Denied More Often Than They Used To Be
Unfortunately, more POC claims have seen rejection in recent years than ever before. Medicare cut its reimbursement rate by 50% in 2013, leading many oxygen suppliers to end their contracts with Medicare.
The cost of supplying portable oxygen to consumers became more expensive to these suppliers than the reimbursement they would ever receive from Medicare—especially considering that they traditionally front the cost of oxygen and bill Medicare later. Consequentially, the few remaining Medicare-certified POC providers often decline business, much to the detriment of patients in need.
What You Can Do if Medicare Will Not Cover Compressed Oxygen Treatments
Between stringent medical requirements and the lack of DME suppliers willing to supply portable oxygen concentrators, securing one through Medicare may feel nearly impossible. Luckily, alternatives exist.
Rentals
Many DME suppliers offer rental programs for people who cannot afford to purchase POCs. While fees vary between suppliers, renting a portable oxygen concentrator typically costs around $250 a week or $35 a day for a standard model. Renting can prove helpful for people who think they may only need oxygen for a temporary stretch—such as immediately following surgery. You may also have the option to “rent to own” your POC, meaning you’ll pay fees and can eventually own it outright.
Keep in mind that rental payments over the long term can often cost more than buying a POC upfront. Determine precisely how long you need a POC before committing to a rental model.
Used Models
Sometimes, you can find lightly used or refurbished POCs through reputable online dealers. While your options remain limited to whatever models these websites list as readily available, you can save hundreds of dollars on a unit that would break the bank new. Ensure any used device has endured proper testing, and ask about any existing warranties before purchasing.
Never purchase a used POC off Craigslist or Facebook marketplace, as there exists no accurate method of verifying the proper condition or legitimacy of these machines. Additionally, buying used person-to-person negates any possibility of securing a product warranty.
Financing
Many DME suppliers allow you to finance a new portable oxygen concentrator through incremental monthly payments, alleviating the immediate financial burden a single lump sum payment would incur. Financing plans always include interest fees.
Make sure to read the fine print and determine your level of comfort with the interest you’ll need to pay over time before agreeing to a POC financing plan. Even if the interest comes at a steep long-term cost, needing oxygen now might outweigh future financial implications.
Purchase Another Similar Product
If you cannot find an affordable portable oxygen concentrator, you might look into plug-in home oxygen concentrators or stationary compressed gas machines. Each would at least ensure you had oxygen while you were at home, though the latter option includes refillable tanks for limited portability.
Liquid oxygen systems operate pretty similarly. Whether you decide upon a liquid system or a stationary at-home machine, obtaining either through Medicare should prove more straightforward than locking down a POC. If you have hypoxemia and need oxygen now, securing any clean air delivery system should benefit you for the time being, regardless of portability.
How To Appeal a Denied Medicare Equipment Claim
If you disagree with any decision made by Medicare regarding your coverage, you hold the right to appeal that decision. To do so, look over your Medicare Summary Notice to discover your appeal deadline. Fill out a Redetermination Request Form and send it to the company that handles appeals claims for Medicare, which you can also find on the Summary Notice.
You should typically know your appeal results within 60 days of a claim. While appeals for Medicare equipment do not often get overturned, you might still consider filing one if you believe you can put together a bulletproof case in your defense.