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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.

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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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Reply to Geaton777
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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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Reply to HaveYourBack
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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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Reply to AlvaDeer
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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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Reply to MACinCT
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MACinCT Jun 3, 2024
Did you try to get him re tested for recertification?
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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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Reply to Deb4Mom
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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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Reply to NancyLU
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Llamalover47 Jun 12, 2024
NancyLU: Thank you for your response.
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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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Reply to JoAnn29
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Pegshere Jun 9, 2024
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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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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Reply to Patch76
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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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Reply to Llamalover47
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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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