Current through Register Vol. 24-18, September 15, 2024
(1) The medicaid agency covers oxygen and
oxygen equipment as provided in this chapter.
(2) The agency pays for the rental of a
stationary oxygen system and/or a portable oxygen system, as follows:
(a) For clients, age 20 and younger, when
prescribed by the client's treating practitioner; or
(b) For clients, age 21 and older, when
prescribed by a practitioner and the client meets:
(i) Medicare's Group I or Group II clinical
criteria; or
(ii) The Group III
clinical criteria described in WAC
182-552-0005.
(c) If a client age 21 and older does not
meet the clinical criteria in this subsection, prior authorization is required.
The agency reviews requests for prior authorization under WAC
182-501-0165.
(3) Oxygen and oxygen equipment - Capped
rental:
(a) Capped rental applies to in-home
oxygen use only;
(b) The medicaid
agency's payment for stationary oxygen system equipment and/or portable oxygen
system equipment is limited to 36-monthly rental payments. During the rental
period, the medicaid agency's payment includes any supplies, accessories,
oxygen contents, delivery and associated costs, instructions, maintenance,
servicing, and repairs;
(c) Oxygen
systems are deemed capped rental (provider continues to own the equipment)
after 36 months.
(i) The supplier who
provides the oxygen equipment for the first month must continue to provide any
necessary oxygen equipment and related items and services through the 36-month
rental period unless one of the exceptions in (e) of this subsection is
met.
(ii) The same provider is
required to continue to provide the client with properly functioning oxygen
equipment (including maintenance and repair), and associated supplies for the
remaining 24 months of the equipment's reasonable useful lifetime
(RUL).
(iii) The same provider may
bill the medicaid agency for oxygen contents, disposable supplies, and
maintenance fees only. Maintenance fee payment is limited to one every six
months.
(d) At any time
after the end of the five-year RUL for the oxygen equipment, the provider may
replace the equipment, thus beginning a new 36-month rental period.
(e) A 36-month rental period may restart
before the end of the five-year RUL in the following situations only. Providers
must follow the medicaid agency's expedited prior authorization process, see
WAC 182-552-1300, Respiratory
care-Authorization.
(i) The initial provider
is no longer providing oxygen equipment or services;
(ii) The initial provider's core provider
agreement with the medicaid agency is terminated or expires;
(iii) The client moves to an area which is
not part of the provider's service area (this applies to medicaid only
clients);
(iv) The client moves
into a permanent residential setting; or
(v) The pediatric client is transferred to an
adult provider.
(f) The
medicaid agency may restart the 36-month rental period when equipment is
replaced under WAC
182-501-0050(7).
Providers must obtain prior authorization from the medicaid
agency.
(4) Stationary
oxygen systems/contents.
(a) The medicaid
agency pays a maximum of one rental payment for stationary oxygen systems
including contents, per client, every 30 days. The medicaid agency considers a
stationary oxygen system as one of the following:
(i) Compressed gaseous oxygen;
(ii) Stationary liquid oxygen; or
(iii) A concentrator.
(b) Contents only: The medicaid agency pays a
maximum of one payment for stationary oxygen contents, per client, every 30
days, when the client owns the stationary oxygen system or the capped monthly
rental period is met.
(c)
Maintenance: The medicaid agency pays for one maintenance fee of 50 percent of
the monthly rental rate for a stationary oxygen concentrator and oxygen
transfilling equipment every six months only when the capped rental period is
met or the client owns the stationary oxygen concentrator.
(5) Portable oxygen systems/oxygen contents:
(a) The medicaid agency pays a maximum of one
rental payment for portable oxygen systems including oxygen contents, per
client, every 30 days. The medicaid agency considers a portable oxygen system
to be either gas or liquid.
(b)
Contents only: The medicaid agency pays a maximum of one payment for portable
oxygen contents, per client, every 30 days, when the client owns the portable
oxygen system or when the capped monthly rental period is met.
(c) Maintenance: The medicaid agency pays for
one maintenance fee of 50 percent of the monthly rental rate for a portable
oxygen concentrator and oxygen transfilling equipment every six months only
when the capped rental period is met or the client owns the portable oxygen
concentrator.
(6) The
medicaid agency does not pay for oxygen therapy and related services, equipment
or supplies for clients 21 years of age and older, with, but not limited to,
the following conditions:
(a) Angina pectoris
in the absence of hypoxemia;
(b)
Dyspnea without cor pulmonale or evidence of hypoxemia; and
(c) Severe peripheral vascular disease
resulting in clinically evident desaturation in one or more extremities but in
the absence of systemic hypoxemia.
(7) The medicaid agency does not pay
separately for humidifiers with rented oxygen equipment. All accessories, such
as humidifiers necessary for the effective use of oxygen equipment are included
in the monthly rental payment.
(8)
The medicaid agency does not pay separately for spare tanks of oxygen and
related supplies as backup or for travel.
(9) The medicaid agency requires a valid
prescription for oxygen in accordance with WAC 182-552-200.
(a) For both initial and ongoing
prescriptions for the use of oxygen, the medicaid agency requires documented
verification that oxygen saturations or lab values substantiate the need for
continued oxygen use for each client.
(b) The medicaid agency does not accept
lifetime certificates of medical need (CMNs).
(10) The medicaid agency requires that
documentation of oxygen saturation and lab values taken to substantiate the
medical necessity of continued oxygen be kept in the client's record.
(11) Oxygen supplies - Replacement. The
medicaid agency pays for replacement oxygen supplies after the 36 month capped
rental period or if the client owns the equipment as follows:
(a) Nasal cannula, limited to two per client
every 30 days;
(b) Tubing (oxygen),
limited to one replacement per client every 30 days; and
(c) Variable concentration mask, limited to
two per client every 30 days.
(12) See WAC
182-552-1200, Respiratory
care-Noncovered services.
Statutory Authority:
RCW
41.05.021. 12-14-022, §182-552-0800,
filed 6/25/12, effective 8/1/12.
