(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.