10 Colo. Code Regs. § 2505-10-8.580

Current through Register Vol. 47, No. 16, August 25, 2024

Section 10 CCR 2505-10-8.580 - DURABLE MEDICAL EQUIPMENT - OXYGEN AND OXYGEN EQUIPMENT

8.580.1DEFINITIONS

8.580.1.A. Concentrator means an oxygen delivery system that operates electrically to concentrate oxygen from room air.

8.580.1.B. Hypoxemia means deficient oxygenation of blood.

8.580.1.C Nursing Facility means nursing facilities, intermediate nursing facilities, and skilled nursing facilities that receive facility payment reimbursement for care.

8.580.1.D. Oxygen Concentrator is the same as a concentrator.

8.580.1.E. Oxygen Delivery System means the method by which oxygen is delivered to the client.

8.580.1.F. Portable Oxygen System means an oxygen delivery system, utilizing either concentrators or tanks, that can be easily moved with the client on a frequent basis.

8.580.1.G. Post-Acute Oxygen Therapy means providing short term oxygen lasting three months or less to address a client's acute condition that is expected to resolve.

8.580.1.H. Stationary Oxygen Delivery System means an oxygen delivery system that cannot be easily moved with the client on a frequent basis and does not concentrate oxygen from room air.

8.580.1.I. Ventilator means a device to assist or control ventilation for a client who is unable to maintain spontaneous ventilation unassisted.

8.580.2CLIENT ELIGIBILITY

8.580.2.A. All Colorado Medicaid clients are eligible for oxygen therapy and oxygen equipment deemed medically necessary, as defined in Section 8.076.1.8.

8.580.3PROVIDER ELIGIBILITY

8.580.3.A. Ordering, Prescribing, Referring (OPR) Providers

1. The following providers are eligible to order, prescribe, or refer oxygen therapy and oxygen equipment when the provider is enrolled with Colorado Medicaid and licensed by the Colorado Department of Regulatory Agencies, or the licensing agency of the state in which they are licensed:

a. Doctors of Medicine (MD)

b. Doctors of Osteopathy (DO)

c. Physician Assistants

d. Nurse Practitioners

8.580.3.B. Rendering Providers

1. The following providers are eligible to render oxygen therapy and oxygen equipment when the provider is enrolled with Colorado Medicaid and licensed by the licensing agency of the state in which they do business:

a. Durable Medical Equipment (DME) Providers enrolled in Colorado Medicaid, otherwise referred to as "suppliers."

8.580.4PLACES OF SERVICES

8.580.4.A. Eligible Places of Services

1. The following places are eligible for a client to receive oxygen and oxygen equipment:

a. Home

b. Nursing Facilities and group homes

c. Intermediate care facilities for individuals with intellectual disabilities

d. Hospitals

i. Oxygen contents and oxygen equipment provided to hospitalized clients must be provided by the hospital and cannot be submitted for direct payment by the supplier. Reimbursement for oxygen and oxygen equipment in hospitals is provided under Section 8.580.8.A.5.

8.580.5COVERED SERVICES AND EQUIPMENT

8.580.5.A. The following clients require a prescription for oxygen therapy and oxygen equipment, but are otherwise exempt from the coverage requirements of this subsection at Section 8.580.5:

1. Ventilator-dependent clients; and

2. Clients covered under the child health component of Medicaid known as Early and Periodic Screening, Diagnosis and Treatment (EPSDT), as identified in Section 8.280.

8.580.5.B. Post-Acute Oxygen Therapy

1. Post-Acute Oxygen Therapy may be provided to clients for up to ninety days with a prescription from an OPR provider identified in Section 8.580.3.A.

a. Post-Acute Oxygen Therapy requires a documented assessment of Hypoxia.

8.580.5.C.Long Term Oxygen Therapy Prescription

1. Long Term Oxygen Therapy may be provided to clients for greater than ninety days with a prescription from an OPR provider identified in Section 8.580.3.A.

a. Review and renewal of the prescription required under Section 8.580.5.C.1 is required every twelve months or when the client's condition changes, whichever comes first. Pursuant to Public Law 116-127, the Families First Coronavirus Response Act, § 6008, continued coverage of oxygen was required during the Coronavirus Disease 2019 (COVID-19) public health emergency as it was covered prior the emergency. For the duration of the COVID-19 public health emergency, the review required every twelve months under this section, and the requirement for annual review pursuant to 42 C.F.R. 440.70(b)(3)(iii), was suspended.

2. Suppliers must have a completed and current prescription on file to support claims for oxygen therapy and oxygen equipment for non-ventilator dependent clients aged twenty and older requiring long term oxygen therapy lasting ninety days or more. For clients certified for twenty-four consecutive months, the most recent annual review pursuant to 42 C.F.R. 440.70(b)(3)(iii) must be on file.

8.580.5.D. Portable Oxygen Systems

1. Clients aged twenty-one and above may qualify for a Portable Oxygen System either by itself or to use in addition to a Stationary Oxygen Delivery System if the following requirements are met:

a. The Section 8.580.5.B or Section 8.580.5.C requirements are satisfied, and

b. The medical documentation indicates the client is mobile in their residence or mobile in the community and would benefit from the use of a Portable Oxygen System.

2. Portable Oxygen Systems are not covered for clients who qualify for oxygen solely based on blood gas studies obtained during sleep unless the client resides in a Nursing Facility.

3. If a client resides in a Nursing Facility and receives portable oxygen while sleeping outside their room, the client should be assessed for continuous oxygen need.

8.580.6PRIOR AUTHORIZATION REQUIREMENTS

8.580.6.A. There are no prior authorization requirements for oxygen therapy and oxygen equipment.

8.580.7.A NON-COVERED SERVICES

1. Oxygen therapy and oxygen equipment is not covered if a client exhibits any of the following conditions:

a. Chronic angina pectoris in the absence of Hypoxemia.

b. Breathlessness without cor pulmonale or evidence of Hypoxemia.

8.580.8.A REIMBURSEMENT

1. To receive reimbursement, provider records must include, but are not limited to:

a. All oxygen therapy and oxygen equipment orders and prescriptions;

i. Oxygen therapy and oxygen equipment provided for Post Acute Oxygen Therapy of less than ninety days requires a documented assessment of Hypoxia under Section 8.580.5.B.1.a.

b. Record of oxygen-related items provided;

c. Documentation that the client, or the client's caregiver, was provided with manufacturer instructions, warranty information, service manual, and operating instructions for the rendered oxygen therapy and oxygen equipment.

2. Medicaid will not reimburse as primary payer for DME oxygen for clients that are:

a. Dually eligible for Medicare and Medicaid,

b. Aged twenty-one or above, and

c. Not receiving benefits in a Nursing Facility or intermediate care facility for individuals with intellectual disabilities.

3. Medicaid will not reimburse as a primary payer for DME oxygen for clients that are:

a. Dually eligible for Medicare and Medicaid,

b. Aged twenty-one or above, and

c. Receiving Medicare-covered skilled nursing services in a Nursing Facility.

4. Oxygen therapy and oxygen equipment provided in a client's home:

a. Suppliers must directly bill the Department for medically necessary liquid or gaseous oxygen equipment provided in a client's home or place of residence, not to include Nursing Facilities.

b. Reimbursement to a rendering provider for Oxygen Therapy or Oxygen Equipment must be the lower of the provider's billed charge or the Department's fee schedule.

5. Oxygen therapy and oxygen equipment provided to hospitalized clients a. Oxygen therapy and oxygen equipment, when medically necessary and prescribed by an OPR provider for any form of oxygen for a client a hospital setting, inpatient or outpatient, must be provided by the hospital and is included in the Medicaid payment for inpatient hospital services.

6. Oxygen therapy and oxygen equipment provided to Nursing Facility and group home clients

a. Suppliers must bill the Department directly for medically necessary liquid or gaseous oxygen therapy, and oxygen equipment needed for the administration of liquid or gaseous oxygen, if provided to clients residing in Nursing Facilities that are reimbursed at a per diem amount.

b. Oxygen Concentrators for use by clients residing in a Nursing Facility or group home being reimbursed at a per diem rate must be provided in one of the following ways:

i. Oxygen Concentrators purchased by the Nursing Facility or group home must be included in the facility cost report and reimbursed through the per diem rate. All necessary oxygen-related supplies must be provided by the facility in accordance with Section 8.441.5.K.

ii. Clients residing in Nursing Facilities or group homes that do not purchase oxygen Concentrators must obtain equipment and supplies from an authorized supplier. The supplier must provide equipment, oxygen and supplies for use by a specific client, as ordered by the client's OPR provider, and must bill on the state approved form.

c. Nursing Facilities and group homes must provide the following information in a certification statement to suppliers within twenty (20) days of the date the supplier delivers the oxygen therapy or oxygen equipment:

i. The name and Medicaid identification number for all Medicaid clients provided liquid or gaseous oxygen, or the equipment or supplies necessary for administration by the supplier;

ii. An indication of whether any Medicaid clients identified in (i) have Medicare Part A or Medicare Part B, or any other third-party resources;

iii. The name and state identification number for all Medicaid clients identified in (i) that utilize an oxygen concentrator rented, but not purchased, from the supplier. This applies only to clients in Nursing Facilities or group homes that do not purchase oxygen Concentrators;

iv. A certification guaranteeing that oxygen therapy and oxygen equipment obtained from the supplier was used only by the individual Medicaid client for which it was supplied. Where centralized oxygen systems are utilized, each Medicaid client's oxygen usage must be documented and identified in the certification statement in liters.

d. Rendering providers (suppliers) must bill the Department for oxygen therapy and oxygen equipment based on the information provided by the Nursing Facility or group home in the Certification Statement, as required by Section 8.580.8.A.6.c. A rendering provider's reimbursement rate for oxygen therapy and oxygen equipment must be the lower of the provider's billed charges or the Department's fee schedule.

10 CCR 2505-10-8.580

46 CR 19, October 10, 2023, effective 10/30/2023