Has anyone or a family member been on oxygen therapy for over five years?

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Has anyone or a family member been on oxygen therapy for over five years?

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My husband has been on oxygen therapy for over five years. Our insurance is an Advantage Care. The supplier no longer wants, it seems, to delivery portable oxygen tanks and will no longer provide a portable oxygen concentrator POC. I have read the Medicare website about the five year rule and have called Medicare but they will not talk to me because we are in an Advantage Care plan.
What options do I have? I have sent a grievance letter to our plans member services and requested a new supplier for both tanks and POC that we will pay for. The issue with that is that this company only has one supplier contract. My husband's doctor will not write a prescription for outside supplier/vendor. This is a real mess!!
Without either or both of these supply items and services my husband is not able to go out of the house and is a shut-in. He has an oxygen concentrator in our home.

Family Caregiver Health Insurance Medical Equipment and Supplies Medicare Advantage Plans

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The Federal Law gives patients the right of choice that includes choice about whether or not you choose to be treated for a condition or not and who provides the treatment or services. It is a requirement that to be a Medicare provider is conditional on they must agree to patient’s choosing healthcare providers or services.
Solution. Call the hospital social worker. Tell them you need a list of oxygen providers for an oxygen concentrator. Oxygen cylinders are provided for use if you lose power or your concentrator does not work.
When you get the list contact your insurance company. Your Medicare Advantage Plan. Ask which providers they will work with…they probably have preferred providers with a contract for a negotiated lower price to save money. Large volume of patients provides efficiencies and reduces cost.
Next call several oxygen providers. Ask if they work with your insurance company. If you like them and they work with your insurance company ask them to call your doctor for an order. Before they bring equipment to your home, ask the price. Both to start and then monthly. They will call your insurance company for authorization to provide your service. Make sure your insurance will cover their services. Make sure you know how much it will cost you. Make sure they will accept your insurance company’s allowable and hou only pay your deductible and copay.
If your doctor refuses file a complaint thru your insurance or who they tell you to contact. You can call Medicare and ask how to file an expedited complaint. Keep appealing the decision until Medicare themselves are doing the review. Best chance is keep pushing it up the ladder of appeals. Then report the doctor to the practice manager, hospital and AMA.
References
Federal Regulations
Patients' Bill of Rights (PBR)
AMA Patient Bill of Rights and Responsibility.
Patient Rights under HIPAA

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My thanks to each of you who wrote a response to my question about five years on oxygen therapy. This is a awesome site. People on this site know and have experienced a lot about healthcare. I got the information I needed.

Current status is that after my grievance letter hit member relations. Things started to move in the right direction. It was my husbands pulmonary doctor who said he could not fill out forms or write a prescription. WELL, that changed but put his nurse in charge of getting it done. My rep for the new oxygen concentrator finally got what he need by primary doctor who was out of the county. He came back June 10 and in one day got it done. I have spent two weeks talking with administration who would not answer my question--WHY DID MY HUSBANDS BENEFITS CHANGE? Also 6 portable oxygen tanks were delivered.
To those who think lawyers are the answer. Well I have a fancy lawyer who will not go after the FEDS just medicaid. So I did this on my own just working the "system" of Advantage Care.
My husbands condition is severe and I can't take the risk changing insurance.
It is hard for me as a caregiver to keep up with all the daily Agingcare emails but I do read many. My heart and love goes out to all of you who are caregivers. IT'S HARD WORK. SELFLESS work. I felt like I had gone through a "ringer" (some of you are old enough to know what that is) after two weeks of this. So I'm resting as much as possible.
THANK YOU...ALL!

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NancyLU: Thank you for your response.

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Advantage Plans can impose whatever limitations they choose. Saving money on premiums is sometimes not worth it b/c things yu need maynot be covered. At Medicare enrollment timenext fall, maybe you should look into returning to traditional Medicare with an additional supplemental plan. It will cost you more in premiums, but might cover more of the medical expenses you encoutner along the way.

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I'm not an expert. I was a CNA on a critical care unit and I worked in nursing homes. It was widely reported when I worked that people get used to oxygen therapy and that was why we tried always to keep them on the lowest possible level of oxygen. Too much can also cause serious problems. That said, you could switch off your Medicare advantage plan. That's an option. You should discuss it. In my state they have multiple avenues for this and I don't know how good they are. They have a state agency that is supposed to intervene with Medicare beneficiaries and help them make insurance decisions. There are ombudsman. I'm sorry to say this is sometimes a volunteer position. A doctor can sometimes write a note to Medicare requesting they override a new policy as it would benefit a patient. ... You may qualify for Medicaid in addition to Medicare. States tend to make this a process you have to apply for instead of automatic, much as they do with covering you premiums and deductible for you; in my state this isn't automatic and they might not even let you know you are eligible, although it can potentially sav you a couple hundred bucks a month. One place to check with us social security because sometimes things get routed there. Another is the website benefits.gov, which lets you fill out online your information and tells you what you may be eligible for. Obviously any local agencies with an emphasis on the elderly may be helpful. You could also try local politicians. If he's been on oxygen a long time like you said there may be laws they are violating by refusing to deliver oxygen and those laws may be state or federal. For example I know there is, I believe, a federal law that says pharmacies cannot refuse a necessary medication even if insurance is having an issue with it over the weekend; they have to give the patient enough to carry them through a weekend because insurance is likely to be largely inaccessible over the weekend anyway. The idea probably was presented as a way of keeping people out of ER unnecessarily and saving money (goddamn US). I am aware this is probably not terribly helpful. Good luck. As I said - people get accustomed to their oxygen levels they're on and get pretty cranky off it. I know too much oxygen can kill people but I'm unaware of possible effects of not enough except the fairly obvious ones like dizziness fainting probably crabbiness. I know doctors can order blood tests to measure levels of oxygen and gasses in blood. Hope it doesn't come to that.

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You shouldn’t have to pay out of pocket for covered services. This could be a contract issue between the supplier and your health plan. That said, it is a quality of care issue since the health plan doesn’t have another vendor to meet your needs. You can call either Livanta or Kepro to file a quality of care issue. They are a quality improvement organization that does medical case review for Medicare beneficiaries, including those with MA plans. And I agree with others who recommend going back to traditional Medicare.

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NancyLU: Perhaps your husband needs a specialist. In this case, it would be a pulmonologist. Also, IMO, Medicare Advantage plans are not all they're touted to be. Quite possibly, when open enrollment comes around, maybe you can switch to Original Medicare as well as a Medicare Supplemental plan.

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Buy a used oxygen concentrator on eBay or Craig’s list.

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In four or five months Medicare open enrollment period begins and IMO you should shift to straight Medicare. There will not be any problem doing so. A supplement is a different matter. I will be surprised if you can get one. I had an opportunity to speak to hospital administrator and she told me hospitals would rather take straight Medicare and no supplement over advantage plans. Much less hassle and the reimbursement is about the same. You will be responsible for the twenty percent that Medicare doesn’t pay which can be costly but IMO is better then advantage plans.
if your doctor feels you need a certain treatment or medication and your insurance company doesn’t pay you should file an on line complaint with your state insurance commissioner. Your advantage plan will see this in real time or within a few days. Be sure to include your telephone number.The insurance companies take these complaints seriously and I predict they you will hear from them within a few days most likely with a favorable response. Over the years I had to resort to double this and was always satisfied with the outcome.
i do not get why your doctor just can’t write a generic prescription and you find the company you want to fulfill it. I hope things turn around for both of you.

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It sounds like you’re in a difficult situation with your husband’s Advantage plan and oxygen supplier. You do have a couple of options coming up during Medicare’s Open Enrollment period, which runs from October 15 through December 7 each year. During this time, you can either:

1. Switch to a different Advantage plan that uses a different oxygen supplier.

2. Switch to Original Medicare (Part A and Part B). If you choose this option, you will also need to select a standalone prescription drug plan (Part D) to cover his medications. However, please note that because of his preexisting condition, he might not be able to get a Medigap (Medicare Supplement insurance policy, which helps cover some of the costs that Original Medicare doesn’t. This means you may have to pay 20 percent of the cost of his medical care out of pocket.

Additionally, I recommend calling Medicare directly at (800) 633-4227. They can help you find a new doctor, locate a new oxygen supplier and assist in choosing a prescription drug plan if you decide to switch to Original Medicare.

I hope this information helps and you can get the necessary support and equipment for your husband soon.

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Get a second opinion and make sure it's scientific quantative not rag tag opinions qualitative. I got anti dementia daily patches due to 3rd party hearsay to the so called shrink. Use to be senior moments now it's dementia with Billable hours.

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I'm so sorry. That is an awful predicament! Unfortunately, that is a drawback of Advantage plans. They are branded as being "advantageous" but they're only seemingly so for the consumer. They actually give the advantage to the insurer because they have total control and autonomy to change the plan at any time. And once you have chosen an "Advantage" plan there is no real option to go the Medicare/Supplement route. Thank you, Congress. Remember, folks! Your votes have consequences.

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Medicare will underwrite the client when they want to move from an advantage plan back to original Medicare. With her husband’s preexisting conditions ie oxygen use I doubt Medicare will will enroll him now. That’s one of the reasons we never went to the advantage plans

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Looks like you need to ask his doc for a new prescription? https://www.medicare.gov/coverage/oxygen-equipment-accessories

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At 5 years he owns the concentrator. If it becomes non functional then take him to the ER as an acute crisis. Insurance does not pay for a POC. That is private pay.The visit should tick off as a new problem. You can check about changing insurance during re enrolment, but this is a CMS problem,

This oxygen problem is a product of a legislation bill several years ago. DME suppliers have been going out of business because CMS reimbursement is upside down. There is SOARS act just introduced in Congress and supported by medical organizations such a ATS, AARC,and others. Many people are suffering, especially in rural locations. He routinely should be getting re supplied with nasal cannula. Your situation is getting out of hand and is not unique

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Did you try to get him re tested for recertification?

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The 5 year rule is a Medicare rule? Then your Advantage probably can do nothing either. Medicare Advantages are contracted out to supply the same services that A & B regular Medicare provides.

"If you have Medicare and use oxygen, you can rent oxygen equipment from a supplier for as long as you have a medical need, but payments for the equipment stop after 36 months of continuous use."

I also found this. Seems if you rent you own after 36 months.

"Section 5101 of the Deficit Reduction Act (DRA) requiring suppliers to transfer title of oxygen equipment to the beneficiary after 36 continuous months and capped rental items after 13 continuous months of rental payments."

So seems you can pay a supplier out of pocket. So I don't understand why the doctor can't write a script to another supplier.

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So Joann if I’m understanding this correctly ... if you’re on original Medicare with a Supplemental coverage ... After 36 months of continuous use the equipment (say an oxygenator) is no longer paid for by Medicare or the supplement coverage but the patient then owns the oxygenator???? If that’s the case then if something goes wrong with the equipment that’s your problem and Medicare will not cover another machine for your use? Just trying to understand the gist of all this. Thanks!

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I am having a hard time understanding a doctor who will not write a prescription for needed O2 your hubby has been on for some 5 years now.

This is where I would start, and I would go directly to the Medical Licensing Board for him, if I had to.

Can you tell me a bit about what the doctor says about his REASONING in not ordering O2?
Does he not believe your husband "needs it"? I would ask him to put in writing his refusal to order the O2.

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This doesn't solve your immediate problem but when open enrollment comes around, change to a supplemental plan for both of you (we have BCBS). Advantage plans are for healthy people who don't need any medical help.

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Has anyone or a family member been on oxygen therapy for over five years?

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