Oxygen and Oxygen Equipment

Coverage policy

PROPRIETARY INFORMATION OF UCARE | Page 1 of 4

Policy Number: CP-MCR23-009A Effective Date: January 1, 2024

The purpose of this policy is to provide clarity and specificity for coverage of Oxygen and

Oxygen Equipment for the Medicare Plan.

DISCLAIMER

Coverage Policies are developed to assist in identifying coverage for UCare benefits under UCare’s health

plans. They are intended to serve only as a general reference regarding UCare’s administration of health

benefits and are not intended to address all issues related to coverage for health services provided to

UCare members.

These services may or may not be covered by all UCare products (refer to product section of individual

coverage policy for product-specific detail). Providers are encouraged to have their UCare patient refer

to their UCare plan documents (Evidence of Coverage/Member Handbook/Member Contract) for specific

coverage information. If there is a conflict between a coverage policy and the UCare plan documents,

the UCare plan documents prevail.

Coverage Policies do not constitute medical advice. Providers are responsible for submission of accurate

and compliant claims.

Product Summary

This coverage policy applies to the following UCare products:

UCare product Applies to

UCare Individual & Family Plans (IFP), UCare IFP with M Health Fairview

UCare Medicare Plans, UCare Medicare with M Health Fairview & North

Memorial Health, UCare Advocate Plus (HMO I-SNP), EssentiaCare



UCare’s Minnesota Senior Health Options (MSHO) (HMO D-SNP)



Prepaid Medical Assistance Program (PMAP), MinnesotaCare

UCare Connect + Medicare (HMO D-SNP)



UCare Connect (SNBC)

Prepaid Medical Assistance Program (PMAP), MinnesotaCare

Minnesota Senior Care Plus (MSC+)

Benefit category:

Durable Medical Equipment and related supplies

Coverage policy

PROPRIETARY INFORMATION OF UCARE | Page 2 of 4

Definitions or summary

UCare’s payment for oxygen equipment is limited to 36 monthly rental payments. Payment

for accessories (for example, cannula, tubing, etc.), delivery, back-up equipment,

maintenance and repairs is included in the rental allowance.

Payment for oxygen contents (stationary and/or portable) is included in the allowance for

stationary equipment After 36 months of continuous use, Medicare stops making

rental payments for the oxygen equipment, but, in almost all circumstances, the member

will continue to get the oxygen equipment, accessories and supplies from the oxygen supplier

with no rental charge until the end of the reasonable useful lifetime (RUL) of the

oxygen equipment (generally 5 years after the date that the equipment was delivered).

When the stationary and the portable oxygen equipment are replaced, a new 36-month rental

period and new RUL is started for both the replacement stationary oxygen equipment and the

replacement portable oxygen equipment.

 REASONABLE USEFUL LIFETIME (RUL): The reasonable useful lifetime for oxygen

equipment is 5 years. The RUL is not based on the chronological age of the equipment. It

starts on the initial date of service and runs for 5 years from that date.

o RUL also does not take into account exchanges of equipment, new suppliers, or

changes of modality (concentrator, gaseous, liquid).

Oxygen equipment must be obtained from a Medicare certified oxygen supplier.

Coverage policy

 UCare coverage from a Medicare-certified oxygen supplier:

o Rental of oxygen equipment

o Delivery of oxygen and oxygen contents

o Tubing and related oxygen accessories for the delivery of oxygen and oxygen

contents

o Maintenance and repairs of oxygen equipment

 UCare requires a Medicare certified oxygen supplier to cover member

services for five years (60 Months).

o During the first 36 months (3yrs):

 Oxygen equipment is limited to 36 monthly rental payments. Payment

for accessories (e.g., cannula, tubing, etc.), delivery, back-up

equipment, maintenance, and repairs is included in the rental allowance.

Coverage policy

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o During months 37- 60 (2yrs):

 There is no further payment for oxygen equipment during the 5-year

reasonable useful lifetime (RUL) of the equipment after 36 rental

payments have been made

 The oxygen supplier who provided the equipment during the 36th rental

month period is required to continue to provide the equipment,

accessories, contents (if applicable), maintenance, and repair of the

oxygen equipment during the 5-year reasonable useful lifetime of the

equipment

o At the end of 5 years (61 months and after):

 At any time after the end of the 5-year reasonable useful lifetime for

oxygen equipment, the member may elect to receive new

equipment, thus beginning a new 36-month rental period.

 If the member elects not to receive new equipment after the end of the

5-year reasonable useful lifetime and if the oxygen supplier retains

ownership of the equipment, all elements of this coverage policy

for months 37-60 remain in effect.

 There is no separate payment for accessories or repairs.

 If the member was using gaseous or liquid oxygen equipment

during the 36th rental month, payment can continue to be made

for oxygen contents.

 If the member elects not to receive new equipment after the end of the

5-year reasonable useful lifetime and if the oxygen supplier

transfers ownership of the equipment to the member,

accessories, maintenance, and repairs are non-covered.

 Contents are separately payable for member-owned gaseous or

liquid systems.

 What happens after 36 months equipment rental?

o The oxygen supplier must continue to maintain the oxygen equipment (in good

working order) and furnish the equipment and any necessary supplies and

accessories, as long as medically necessary or until the 5-year period ends.

(The oxygen supplier cannot charge for performing these services).

o If the member uses oxygen tanks or cylinders that requires delivery of gaseous

or liquid oxygen contents, the Plan will continue to pay each month for the

delivery of contents after the 36-month rental period.

o The oxygen supplier that delivers the equipment to the member in the last

month of the 36-month rental period must continue to provide these items

Coverage policy

PROPRIETARY INFORMATION OF UCARE | Page 4 of 4

(gaseous or liquid oxygen contents), as long as medically necessary, up to 5

years.

o The oxygen supplier owns the equipment during the entire 5-year period.

 If the members medical need continues past the 5-year period, the supplier is no

longer required to provide the member with oxygen and oxygen equipment, and the

member has the option to get replacement equipment from any supplier.

 A new 36-month payment period and 5-year supplier obligation period starts once the

previous 5-year period ends and the member receives

new oxygen and oxygen

equipment.

Not Covered

o Oxygen services furnished by an airline to a member are not covered.

 Payment for oxygen furnished by an airline is the responsibility of the

member and not the responsibility of the supplier.

 UCare does not cover items or services provided/used outside the

United States and its territories.

Prior authorization

Not required