Department of Health and Human Services


OFFICE OF 

INSPECTOR GENERAL 

MEDICARE HOME OXYGEN 


EQUIPMENT:


COST AND SERVICING 


Daniel R. Levinson


Inspector General 


September 2006


OEI-09-04-00420 

Office of Inspector General 
 http://oig.hhs.gov 

The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, 

as amended, is to protect the integrity of the Department of Health and Human Services 

(HHS) programs, as well as the health and welfare of beneficiaries served by those 

programs. This statutory mission is carried out through a nationwide network of audits, 

investigations, and inspections conducted by the following operating components: 

Office of Audit Services 

The Office of Audit Services (OAS) provides all auditing services for HHS, either by 

conducting audits with its own audit resources or by overseeing audit work done by others. 

Audits examine the performance of HHS programs and/or its grantees and contractors 

in carrying out their respective responsibilities and are intended to provide independent 

assessments of HHS programs and operations. These assessments help reduce waste, 

abuse, and mismanagement and promote economy and efficiency throughout HHS. 

Office of Evaluation and Inspections 

The Office of Evaluation and Inspections (OEI) conducts national evaluations to provide 

HHS, Congress, and the public with timely, useful, and reliable information on 

significant issues. Specifically, these evaluations focus on preventing fraud, waste, or 

abuse and promoting economy, efficiency, and effectiveness in departmental programs. 

To promote impact, the reports also present practical recommendations for improving 

program operations. 

Office of Investigations 

The Office of Investigations (OI) conducts criminal, civil, and administrative 

investigations of allegations of wrongdoing in HHS programs or to HHS beneficiaries 

and of unjust enrichment by providers. The investigative efforts of OI lead to criminal 

convictions, administrative sanctions, or civil monetary penalties. 

Office of Counsel to the Inspector General 

The Office of Counsel to the Inspector General (OCIG) provides general legal services to 

OIG, rendering advice and opinions on HHS programs and operations and providing all 

legal support in OIG's internal operations. OCIG imposes program exclusions and civil 

monetary penalties on health care providers and litigates those actions within HHS. 

OCIG also represents OIG in the global settlement of cases arising under the Civil False 

Claims Act, develops and monitors corporate integrity agreements, develops compliance 

program guidances, renders advisory opinions on OIG sanctions to the health care 

community, and issues fraud alerts and other industry guidance. 
Δ EXECUTIVE SUMMAR Y 

OBJECTIVE 

To (1) compare Medicare spending for oxygen concentrators with 

suppliers’ average purchase price and (2) determine the nature and 

frequency of servicing for concentrators and portable equipment. 

BACKGROUND 

Section 1834(a)(5) of the Social Security Act authorizes Medicare 

payment for home oxygen equipment under its durable medical 

equipment (DME) benefit. DME is defined as equipment that can 

withstand repeated use, is used primarily to serve a medical purpose, 

and is appropriate for use in a beneficiary’s home. Medicare covers both 

stationary and portable oxygen delivery systems, which were payable on 

a rental-only basis from 1989 (the year in which Medicare implemented 

the DME fee schedule) until 2006. 

The monthly allowance for stationary oxygen equipment covers the 

oxygen equipment; oxygen contents including all refills for stationary 

and portable systems; equipment delivery, setup, and maintenance; 

accessories and supplies; patient education;, and other services 

associated with furnishing home oxygen. Medicare pays an additional 

amount for portable equipment that a beneficiary rents to provide 

mobility in the home. Typically, beneficiaries rent both stationary and 

portable units. 

Although Medicare has reduced the payment rates for home oxygen 

equipment three times since 1989, this equipment still consumes a large 

share of Medicare spending for DME. The Balanced Budget Act of 1997 

reduced the rates by 25 percent effective January 1, 1998, and an 

additional 5 percent effective January 1, 1999. In 2005, Medicare 

further reduced payment rates by an average of 8.6 percent for 

stationary oxygen equipment and 8.1 percent for portable oxygen 

equipment. In 2004, home oxygen equipment accounted for 24 percent 

($2.7 billion of $11.1 billion) of all Medicare spending for DME, 

prosthetics, orthotics, and supplies. 

The Deficit Reduction Act (Public Law 109-171), signed into law on 

February 8, 2006, ended the longstanding rental-only payment policy 

for home oxygen equipment. The law limits rental payments to 36 

months of continuous use. After this threshold is reached, suppliers 

must transfer title of the equipment to the beneficiary; however, under 

a proposed rule that the Centers for Medicare & Medicaid Services 

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EXE CUTIVE S U MMAR Y 

(CMS) published in August 2006, suppliers would receive payments for 

certain maintenance and servicing. The President’s fiscal year 2007 

budget proposes further reform and would limit the rental period to 13 

months. 

We used a mail survey to collect information from suppliers that 

furnished oxygen equipment to 150 Medicare beneficiaries who rented 

oxygen equipment in 2004. Using a standardized data collection 

instrument, we asked suppliers to report all services they provided to 

the beneficiaries for the entire rental period and to submit 

documentation supporting each service. We also requested that 

suppliers report the price they paid for oxygen concentrators, which are 

stationary equipment, and submit a copy of the invoice. We visited 

suppliers in California and Florida to obtain detailed information about 

their operations, servicing and maintenance practices, and relationships 

with patients. We also accompanied suppliers on visits to patients’ 

homes to observe delivery and setup practices as well as ongoing 

maintenance for oxygen equipment. 

FINDINGS 

Based on the 2006 median fee schedule amount, Medicare will allow 

$7,215 for 36 months for concentrators that cost $587, on average, 

to purchase. At today’s median monthly rental rates, Medicare will 

allow $7,215 for beneficiaries who started renting in January 2006 and 

continue renting for 36 months. Beneficiaries will incur $1,443 in 

coinsurance over this period. If Medicare rental payments for oxygen 

concentrators were limited to 13 months, the program and its 

beneficiaries would save approximately $3.2 billion over 5 years. 

Based on our analysis, minimal servicing and maintenance for 

concentrators and portable equipment are necessary. Beneficiaries 

typically receive a concentrator, which is stationary equipment, and a 

portable cylinder system. Suppliers train beneficiaries to perform 

limited routine maintenance. Based on our survey, suppliers check 

concentrators every 4 months on average, a frequency that exceeds 

manufacturers’ guidelines. Maintenance for a portable system 

primarily consists of picking up empty cylinders and delivering full 

ones. 

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EXE CUTIVE S U MMAR Y

RECOMMENDATIONS 

Recent legislation limits the rental period for home oxygen equipment 

and directs the Secretary to pay for maintenance and servicing after the 

rental period ends if the Secretary determines such payments are 

reasonable and necessary. Concentrators require and receive limited 

servicing in beneficiaries’ homes. Medicare will continue to pay for 

portable contents. Therefore, we recommend that CMS: 

Work with Congress to further reduce the rental period for oxygen 

equipment. The Deficit Reduction Act ended the longstanding rental-only 

payment policy for oxygen equipment, but further reform is warranted. 

Medicare and its beneficiaries will continue to pay more than 12 times the 

purchase price for concentrators under the new 36-month rental 

limitation. 

Determine the necessity and frequency of nonroutine maintenance 

and servicing for concentrators. Suppliers most commonly perform 

routine servicing that Medicare does not cover for DME that beneficiaries 

own. CMS needs to determine the necessity and frequency of nonroutine 

servicing, which is covered by Medicare, and appropriate reimbursement. 

Determine if a new payment methodology is appropriate for portable 

oxygen systems. Unlike concentrators, portable oxygen systems require 

refills and suppliers pick up empty cylinders and deliver full ones. 

Ongoing monthly payments for cylinder contents only may not adequately 

reimburse suppliers for providing refills. 

AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL 

RESPONSE 

CMS concurred with our recommendations. The agency noted that the 

President’s budget for fiscal year 2007 proposed reducing the rental 

period for oxygen equipment to 13 months. Furthermore, CMS stated 

that its proposed rule, published on August 3, 2006, addresses the 

payment methods for nonroutine maintenance and servicing, as well as 

for portable oxygen systems. 

CMS expressed concern that our savings estimate for a 13-month rental 

limit is too high, because it includes beneficiaries’ savings and does not 

reflect payments for maintenance and servicing, potential shifts in 

utilization, or factors that the Congressional Budget Office (CBO) and 

CMS’s Office of the Actuary would consider. We acknowledge that, 

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EXE CUTIVE S U MMAR Y 

based on these factors, our calculation would likely result in a higher 

estimate than CBO or CMS estimates. 

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Δ T ABLE OF CONTENTS 

EXECUTIVE SUMMARY ..................................... i

INTR O D U C T I ON ........................................... 1

FINDI NGS ................................................. 8

Medicare Spending for Oxygen Concentrators ................ 8

Minimal Servicing for Equipment ......................... 11

RECOM M E NDATI O NS ..................................... 14

Agency Comments and OIG Response ...................... 15

APPENDIXES ............................................. 16

A: Confidence Intervals for Selected Statistics ............... 16

B: Methodology for Savings Calculation .................... 17

C: Agency Comments ................................... 19

ACKN O W LEDGMENTS .................................... 23
Δ INTRODU C TION 

OBJECTIVE 

To (1) compare Medicare spending for oxygen concentrators with 

suppliers’ average purchase price and (2) determine the nature and 

frequency of servicing for concentrators and portable equipment. 

BACKGROUND 

Section 1834(a)(5) of the Social Security Act (the Act) authorizes 

Medicare payment for home oxygen equipment under its durable 

medical equipment (DME) benefit. DME is defined as equipment that 

can withstand repeated use, is used primarily to serve a medical 

purpose, and is appropriate for use in a patient’s home 

(42 CFR § 414.202). Medicare Part B covers both stationary and 

portable oxygen delivery systems. 

Stationary systems include concentrators, which concentrate the oxygen 

in room air, and stationary gas and liquid systems. Portable systems 

include portable concentrators, as well as gas and liquid oxygen 

systems. A portable gas system consists of a cylinder, which stores 

pressurized oxygen, and a regulator, which controls the flow of oxygen 

from the cylinder. A portable liquid oxygen unit is a small unit filled 

with oxygen cooled to a very low temperature.1 

Until January 1, 2006, Medicare paid a monthly rental fee for home 

oxygen equipment as long as it was medically necessary. Section 

5101(b)(1) of the Deficit Reduction Act (DRA) eliminated indefinite 

rental for this equipment and limited it to 36 months, effective 

January 1, 2006. 

Rental payments for oxygen equipment are based on monthly fee 

schedule allowances that vary by State. The basis for these allowances 

is the average payment that Medicare made in each State in 1986. The 

fee schedule amounts generally are adjusted annually based on the 

change in the Consumer Price Index (42 CFR § 414.226). The fee 

schedule amounts are limited by a ceiling (upper limit) and floor (lower 

limit) equal to 100 percent and 85 percent, respectively, of the median of 

the statewide fee schedule amounts. Medicare pays 80 percent of the 

1 Centers for Medicare & Medicaid Services, Coverage Issues Manual, DME: Home Use 

of Oxygen, 60-4. 

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fee schedule amount and beneficiaries are responsible for 20-percent 

coinsurance as long as they rent oxygen equipment. 

The monthly allowance for stationary oxygen equipment covers the 

oxygen equipment; oxygen contents including all refills for stationary 

and portable systems; equipment delivery, setup, and maintenance; 

accessories and supplies; patient education; and other services 

associated with furnishing home oxygen. Medicare pays an add-on, or 

additional amount, for portable equipment that a beneficiary rents to 

provide mobility in the home. Typically, beneficiaries rent both 

stationary and portable units. Suppliers of oxygen equipment submit 

claims to the DME Regional Carriers for processing and payment. 

Since implementation of the fee schedule, Medicare has reduced the 

payment rates for home oxygen equipment three times. The Balanced 

Budget Act of 1997 reduced the rates by 25 percent effective January 1, 

1998, and an additional 5 percent effective January 1, 1999. Section 

302(c)(2) of the Medicare Prescription Drug, Improvement, and 

Modernization Act of 2003 (MMA) required the Centers for Medicare & 

Medicaid Services (CMS) to reduce payments for oxygen and oxygen 

equipment based on the percentage difference between the 

2002 Medicare fee schedule amount for each State and the median 

prices paid by Federal Employees Health Benefits (FEHB) plans. In 

2005, Medicare reduced payment rates by an average of 8.6 percent for 

stationary oxygen equipment and 8.1 percent for portable oxygen 

equipment based on the Office of Inspector General (OIG) report 

“Medicare and FEHB Payment Rates for Home Oxygen Equipment” 

(OEI-09-03-00160, Revised), which compared Medicare payments to the 

rates paid by FEHB plans. 

Medicare Spends $2.3 Billion To Rent Oxygen Concentrators for 

Approximately 1.3 Million Beneficiaries 

Nearly all Medicare beneficiaries who rent home oxygen equipment rent 

concentrators. Approximately 1.3 million beneficiaries rented them in 

2004. Based on Medicare paid claims data, Medicare spends 

significantly more money on concentrators than on any other type of 

home oxygen equipment. In 2004, concentrator rentals accounted for 

84 percent, or $2.3 billion, of all Medicare spending for home oxygen 

equipment and supplies. 

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Figure 1 

Oxygen Concentrator 

The concentrator is a 

stationary device that 

concentrates the oxygen 

in room air. 

A typical concentrator weighs 

approximately 50 pounds and is 

approximately 2 feet high. (See 

Figure 1.) In addition to the 

concentrator, Medicare pays for a 

portable cylinder system, which 

provides backup in the event of a 

power outage as well as mobility in 

the home. The cylinder is filled with 

gaseous oxygen. When suppliers 

deliver the stationary and portable 

Source: Patient Instructions from Oxygen systems, they also furnish accessories, 

 Supplier, 2005. including oxygen tubing and a nasal 

cannula. The tubing is attached to the outlet on the concentrator or 

cylinder and the oxygen is delivered through the nasal cannula, which 

the patient wears. The tubing, available in different lengths, allows the 

patient to move around the home. Portable oxygen cylinders are 

available in different sizes. Patients transport the cylinders in a cart or 

carrying case, such as a shoulder bag. 

Payment Categories for DME 

Under Medicare Part B, all DME is classified into one of several 

payment categories. Each payment category has distinct payment 

methodologies that govern how Medicare pays for the equipment (see 

section 1834(a) of the Act and 42 CFR § 414.210.) 

Oxygen and oxygen equipment. Medicare pays for oxygen contents (liquid 

and gas) and oxygen equipment on a monthly basis. Until Congress 

modified the longstanding payment method in 2006, Medicare allowed 

indefinite rental for stationary and portable equipment. (See discussion 

of this new method on the following page.) Effective January 1, 2006, 

payments for stationary and portable equipment will cease after 

36 months of continuous rental. Medicare has and will continue to pay 

separately for portable oxygen contents based on a beneficiary’s 

continuing need. 

Inexpensive or other routinely purchased items. Inexpensive DME is 

defined as equipment for which the purchase price does not exceed 

$150. Routinely purchased DME is defined as equipment acquired by 

purchase at least 75 percent of the time. Medicare will purchase or rent 

equipment in this category; however, total payments may not exceed 

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the fee schedule purchase amount. Examples of items in this category 

include canes, walkers, and crutches. 

Items requiring frequent and substantial servicing. This category includes 

items requiring frequent and substantial servicing in order to avoid risk 

to the beneficiary’s health. Examples include passive motion exercise 

devices and infusion pumps used for administration of certain 

medication. For these items Medicare pays for rental only. 

Customized items. This category includes items uniquely constructed or 

substantially modified to meet the specific needs of an individual 

beneficiary. For these items Medicare pays for purchase only. 

Capped rental. The capped rental category includes all other equipment 

that does not fall into one of the other payment categories. Medicare 

currently limits, or caps, rental payments for approximately 149 items, 

including hospital beds and wheelchairs. Effective January 1, 2006, 

carriers pay monthly fee schedule amounts for these items for a period 

not to exceed 13 consecutive months, at which time title to the 

equipment transfers to the beneficiary. Medicare will continue to pay 

for reasonable and necessary servicing and maintenance after the end 

of the rental period. 

Other covered items (other than DME). This category includes supplies 

that are payable for purchase. 

New Payment Methodologies 

The DRA, signed into law on February 8, 2006, changed the 

reimbursement methodology for home oxygen equipment from 

continuous rental to capped rental, effective January 1, 2006. The DRA 

limits rental payments for home oxygen equipment to 36 months of 

continuous use. After 36 months, suppliers must transfer title of the 

equipment to the beneficiary, but they may receive payments for 

nonroutine maintenance and servicing. 

The President’s proposed budget for fiscal year 2007 would further 

reform the payment methodology for all home oxygen equipment. The 

budget proposes limiting rental payments for home oxygen equipment 

to 13 months of continuous use. 

In August 2006, CMS issued a proposed rule implementing DRA’s 

provisions governing Medicare payment for oxygen equipment and 

capped rental DME (71 FR 44082, August 3, 2006). CMS proposes to 

establish a new variable rate structure for different classes of oxygen 

and oxygen equipment, with monthly payments tied more closely to the 

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INTROD UCT ION 

costs of each class. For example, under this proposed rule, the monthly 

payment rate for stationary concentrators would be reduced to $177, 

while payments for portable concentrators and transfilling systems 

would increase. Medicare would also cover nonroutine maintenance for 

beneficiary-owned equipment that an authorized technician would need 

to perform. Pursuant to current policy, CMS would not cover routine 

maintenance, including testing, cleaning, and changing filters, after 

beneficiaries reach the 36-month cap and assume ownership of their 

equipment. 

Alternative Payment Methodologies 

Section 302(b)(1) of the MMA mandated competitive bidding for certain 

DME in urban areas beginning in 2007. One aim of the initiative is to 

reduce Medicare payments. CMS tested the feasibility of competitive 

bidding at two sites from 1999 to 2002 and achieved average price 

reductions ranging from 19 percent to 22 percent for home oxygen 

equipment. 

The Veterans Affairs (VA) Medical Center in Tampa, Florida, was the 

first VA facility in the United States to purchase concentrators rather 

than renting them indefinitely or capping the rental period. This 

facility, which started buying concentrators in 1999, now purchases 

from a local manufacturer and contracts with a supplier to deliver and 

maintain the equipment. VA has contracted with the same supplier for 

servicing since the program began and pays $895 to purchase a 

concentrator, $90 for delivery, and $48 for annual maintenance. 

VA acknowledges that $895 is not the lowest price available but pays 

more because the manufacturer is nearby, and the proximity facilitates 

communication and exchanges of equipment. The VA Medical Center 

serves an average of 825 oxygen patients per month, two-thirds of whom 

are eligible for Medicare. 

Like Medicare, the VA Medical Center in Atlanta, Georgia, rents all of 

its equipment and pays twice as much per month as the Tampa medical 

center. Tampa’s monthly costs are $100.27; Atlanta’s monthly costs are 

$217. 

Prior Inspector General Work 

OIG has previously examined the servicing and payment methods for 

respiratory equipment, which includes home oxygen equipment and 

other respiratory devices. In addition to the report comparing Medicare 

payment rates for home oxygen equipment to the rates paid by FEHB 

plans (mentioned on page 2), OIG assessed the servicing for a 

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INTROD UCT ION 

respiratory assist device with bilevel capability and a backup rate in the 

June 2001 report, “Respiratory Assist Devices With Back-up Rate” 

(OEI-07-99-00440). OIG concluded that the equipment belonged in the 

capped rental payment category rather than the frequent and 

substantial servicing category. OIG recommended that CMS reclassify 

the device. In January 2006, CMS issued a final rule implementing 

OIG’s recommendation (71 FR 4518, January 27, 2006). 

In June 1999, OIG issued the report, “Home Oxygen Therapy Profiles” 

(OEI-03-96-00092), which assessed the nature and frequency of 

servicing for home oxygen equipment. In November 1994, OIG issued 

“Oxygen Concentrator Services” (OEI-03-91-01710), which documented 

the wide variation in the servicing that suppliers provided. 

METHODOLOGY 

We based this review on a simple random sample of Medicare 

beneficiaries who rented home oxygen equipment in calendar year 

(CY) 2004 and information about the cost and rental history of the 

concentrators these beneficiaries used. 

Scope 

This review is national in scope and focuses on the cost of concentrators 

that beneficiaries rent, as well as the nature and frequency of services 

that oxygen equipment suppliers provide to beneficiaries in their homes. 

This report addresses neither the cost of providing these services nor 

such ancillary expenses as billing, processing the physician’s order, 

regulatory compliance, and equipment maintenance outside the home. 

These costs are reflected in the fee schedule amounts, which are based 

on historical charges by suppliers. 

Sample Selection 

Using the 100-percent National Claims History database for services 

rendered in CY 2004, we selected a simple random sample of 

150 Medicare beneficiaries. We selected this sample from a population 

of 448,974 beneficiaries for whom Medicare paid a monthly rental for an 

oxygen concentrator (E1390) during 2004 but not for any stationary 

oxygen equipment during 2003 (E1390, E0439, E0424) so that the 

sample would consist of new users of oxygen concentrators. 

Data Collection and Analysis 

We surveyed by mail all of the suppliers that provided equipment to the 

beneficiaries in our sample. Using a standardized data collection 

instrument, we requested that suppliers report all services they 

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INTROD UCT ION 

provided to the beneficiaries for the entire rental period and submit 

documentation supporting each service. We counted services if the 

supplier documented them but did not report them on the instrument. 

We also asked suppliers to report and document the price that they paid 

for the concentrator that the sampled beneficiary used, as well as the 

number of previous users of the equipment (both Medicare and nonMedicare). The suppliers provided data on 145 of the 150 beneficiaries 

in our sample, which yielded a 97-percent response rate. 

In addition to surveying suppliers by mail, we visited several suppliers 

in California and Florida to obtain detailed information about their 

operations, servicing and maintenance practices, and relationships with 

beneficiaries. We visited suppliers in California because of their 

proximity to our office and suppliers in Florida because of their location 

near the VA Medical Center in Tampa. All of the suppliers invited us to 

accompany them during routine patient visits to observe delivery and 

setup practices as well as ongoing maintenance. We visited the VA 

Medical Center in Tampa to interview staff about their longstanding 

purchase program for home oxygen equipment. Finally, we 

accompanied VA staff on home visits to oxygen patients. 

We also analyzed National Claims History data from CYs 1994 to 2004 

for a 1-percent sample of Medicare beneficiaries to estimate the savings 

associated with different payment methods. 

See Appendix A for the confidence intervals for selected statistics and 

Appendix B for the methodology for calculating the savings associated 

with limiting the rental period for oxygen concentrators to 13 months. 

This study was conducted in accordance with the “Quality Standards for 

Inspections” issued by the President’s Council on Integrity and 

Efficiency and the Executive Council on Integrity and Efficiency. 

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ΔF I NDING S 

 FINDINGS

Based on the 2006 median fee schedule 

amount, Medicare will allow $7,215 for 

36 months for concentrators that cost 

$587, on average, to purchase 

The DRA limits rental payments 

for oxygen equipment to 

36 months of continuous use. 

Based on our analysis of 

Medicare paid claims data, 

approximately 46 percent of beneficiaries who started renting their 

equipment in 2001 rented continuously for at least 12 months, while 

22 percent rented for 36 months or longer. 2 (See Figure 2.) 

Figure 2 

Duration of Rental 

Twenty-two 

percent of 

Medicare 

beneficiaries rent 

for 36 months or 

longer. 

Percent of beneficiaries 

Duration of Oxygen Concentrator Rental by 

Medicare Beneficiaries Who Started Renting in 2001 

100

90

80

70

60

50

40

30

20

10

0 

0 10 20 30 

Number of months rented 

Source: Office of Inspector General analysis, 2006. 

The median Medicare monthly fee schedule allowance for concentrators 

is $200.41 as of January 2006. The monthly rental payment is the same 

for both new and used concentrators. Based on this fee schedule 

amount, Medicare will allow $7,215 for beneficiaries who started 

renting in January 2006 and continue renting for 36 months. 

The average cost of a new concentrator is $587 

Based on invoices and other documentation from suppliers and 

manufacturers associated with our sample of beneficiaries, new oxygen 

concentrators cost $587 each, on average. (See Appendix A for 

2 We used the definition of continuous use found in the Medicare Claims Processing 

Manual (publication 100-04), chapter 20, section 30.5.4. A rental period is continuous even 

if there are gaps of up to 60 days between rental months. 

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F I NDING S 

confidence interval.) We based this estimate on the prices for new 

concentrators purchased between 2000 and 2004 and rented to 

beneficiaries in our sample. These prices reflect volume discounts that 

manufacturers offer routinely. Suppliers reported that they also 

received prompt pay discounts and rebates for one-third of the 

concentrators that sampled beneficiaries rented. The prices that 

suppliers reported typically did not reflect these prompt pay discounts 

and rebates and, therefore, are not included in our estimate of the 

average concentrator price. 

Beneficiaries’ coinsurance for a 36-month rental is more than twice the 

average cost of a new concentrator 

Based on a 36-month rental period at the 2006 median fee schedule 

amount, beneficiaries will incur $1,443 in coinsurance. Since the 

average cost of a concentrator is $587, the coinsurance exceeds the 

average cost of two concentrators by $269. 

If Medicare rental payments for oxygen concentrators were limited to 

13 months, the program and its beneficiaries would realize considerable 

savings 

The DRA changed the reimbursement methodology for capped rental 

items, except oxygen equipment, by reducing the rental period from 

15 months to 13 months. The President’s budget for fiscal year 2007 

would limit the rental period for oxygen equipment to 13 months. 

We calculated potential savings for concentrators if the rental period 

were 13 months instead of 36 months and found that Medicare and its 

beneficiaries would save approximately $3.2 billion over 5 years. To 

estimate these savings, we used the 2006 median fee schedule amount 

of $200.41 for rental of an oxygen concentrator. Our estimate does not 

include any allowances for maintenance and servicing or potential shifts 

in utilization to other oxygen modalities such as portable concentrators 

and transfilling systems. These factors would likely result in lower 

savings than our estimate. In addition, our estimate includes 

beneficiaries’ coinsurance and premium-related costs, which amount to 

approximately 40 percent of our calculated savings. (See Appendix B 

for a more detailed discussion of our methodology.) 

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F I NDING S 

Suppliers commonly provide used concentrators to Medicare beneficiaries 

Suppliers rented used concentrators to 73 percent of sampled 

beneficiaries. On average, the concentrators were 21⁄2 years old. For 

example: 

 One beneficiary in our sample was the 17th person to rent a 

concentrator that the supplier purchased in 1996. 

 Another beneficiary was the 16th person to use a concentrator that 

was purchased in 1997. 

 One beneficiary rented a concentrator that the supplier purchased in 

1988 for $745. The supplier calculated that revenue from that 

concentrator totaled $11,530.58. 

 Medicare allowed $7,554 for another unit rented by a sampled 

beneficiary. The supplier paid $546 for the concentrator in 2002. 

The sampled beneficiary rented it for 11⁄2 months. Another Medicare 

beneficiary had rented this concentrator for 21⁄2 years before the 

sampled beneficiary started renting it. 

 Medicare allowed $7,260 for a single concentrator that one sampled 

beneficiary rented. This total reflects the allowance for one previous 

Medicare beneficiary who rented the equipment for 21⁄4 years. The 

supplier bought this equipment for $617 in 2001. 

Despite the fact that suppliers routinely rent used equipment to 

Medicare beneficiaries, only 6 percent of the concentrators used by 

sampled beneficiaries malfunctioned at any time during their rental 

period. Based on our sample and discussions with suppliers, when a 

concentrator malfunctions, the supplier typically replaces it with 

another unit rather than repairing the malfunctioning unit and 

returning it to the same beneficiary. 

Suppliers reported that they exchanged the malfunctioning 

concentrators that were rented by 12 of 145 beneficiaries 

(12 concentrators). The number of previous users of the concentrators 

that malfunctioned ranged from 1 to 16. In at least 8 of the 12 cases, 

suppliers replaced the defective equipment with used concentrators (we 

do not have information on the remaining 4 cases). 

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F I NDING S 

Figure 3 

Patients 

perform 

routine 

maintenance 

Suppliers 

train patients 

to change 

their tubing 

and cannula 

and to clean 

the external 

filter. 

Based on our analysis, minimal servicing and 

maintenance for concentrators and portable 

equipment are necessary 

Source: Patient Instructions from Oxygen Supplier, 2005. 

Suppliers train beneficiaries 

to perform routine 

maintenance. Based on 

instructions in the 

educational materials that 

suppliers provide to 

beneficiaries at the time of 

delivery, patients must 

clean and change their 

tubing and nasal cannula 

on a regular basis. In 

addition, suppliers instruct 

patients to clean the 

concentrator’s external 

(dust) filter, which can be 

washed in a sink with soap 

and water. (See Figure 3.) 

Suppliers check concentrators every 4 months on average 

Among beneficiaries in our sample who rented continuously for 1 year 

or longer, suppliers checked their concentrators approximately once 

every 4 months on average.3 Suppliers typically perform the same 

services during every visit. These services include checking the flow 

rate (liters per minute) prescribed by the physician and checking the 

concentration of oxygen delivered by the unit. 

When suppliers visit beneficiaries, they often perform services that a 

beneficiary has been instructed to do. For example, based on our 

sample, 50 percent of the visits to service the concentrators included 

cleaning the external filter, which the beneficiary is trained to 

maintain. 

When we accompanied suppliers on their visits to beneficiaries’ homes, 

we observed that routine maintenance for a concentrator consists of 

checking the filter to make sure it is clean and checking the oxygen 

3 When we counted services and calculated the statistics in this paragraph, we excluded 

the services provided on the first and last day of the rental period (i.e., delivery and pickup). 

 OE I-09-04-00 420 MEDI C ARE H O M E OX Y G E N E Q U I PM E N T: C O S T AND S E R V I C I NG 11 
F I NDING S 

concentration and flow rate using handheld instruments—tasks that 

can be performed in less than 5 minutes. 

Although suppliers checked concentrators every 4 months, this 

frequency exceeds the guidelines of two major manufacturers that 

accounted for two-thirds of the concentrators rented by sampled 

beneficiaries. According to these guidelines, comprehensive preventive 

maintenance need only be performed annually or after several thousand 

hours of use. Similarly, the VA Medical Center in Tampa covers annual 

maintenance only. 

Suppliers often use the visits to deliver accessories, typically new tubing 

and cannula, that they could mail to the beneficiary. Ongoing patient 

education is uncommon; only 18 percent of these visits included 

educating beneficiaries. Furthermore, 21 percent of these visits 

occurred when the supplier was scheduled to deliver oxygen cylinders to 

the home. 

Initial delivery and setup are more time-consuming because suppliers 

have to find appropriate places for the concentrator and portable 

equipment in the home and educate beneficiaries and their caregivers 

about the new equipment. These visits can take as long as 1 hour. 

Suppliers deliver cylinders once every 3 months 

Figure 4 Approximately 83 percent of supplier visits 

Oxygen Cylinder related to portable equipment are to “switch 

Cylinders are available out” empty cylinders with full ones. (See Figure in different sizes. 

4.) Other visits involve educating patients and 

delivering accessories. Among beneficiaries 

who rented concentrators for 1 year or more, 

65 percent received two or fewer cylinders from 

their suppliers in the first year of rental 

(excluding the initial cylinder delivery). We 

observed that beneficiaries do not need to be at 

home when suppliers deliver the cylinders. In 

Source: Patient Instructions from addition, we reviewed documentation indicating 

Oxygen Supplier, 2005. that, in some cases, suppliers left cylinders on 

the beneficiary’s porch. 

The DRA mandates capped rental for both stationary and portable units 

after 36 months of continuous rental. Medicare will continue to pay for 

portable contents after 36 months on a monthly basis as long as the 

beneficiary requires oxygen. Currently, suppliers must provide 

OE I-09-04-00 420 MEDI C ARE H O M E OX Y G E N E Q U I PM E N T: C O S T AND S E R V I C I NG 12 
F I NDING S 

whatever quantity of oxygen the beneficiary uses. Medicare 

reimbursement is the same, regardless of quantity. In 2006, the median 

monthly allowance for portable contents is $21.41. 

 OE I-09-04-00 420 MEDI C ARE H O M E OX Y G E N E Q U I PM E N T: C O S T AND S E R V I C I NG 13 
Δ RECOMME NDA TIONS 

The DRA limits the rental period for home oxygen equipment and 

directs the Secretary to pay for maintenance and servicing if the 

Secretary determines that such payments are reasonable and necessary 

after the rental period ends. In a proposed rule, CMS indicated that it 

will make such payments. Concentrators are reliable equipment that 

require limited servicing, as evidenced by instructions from 

manufacturers, the common practice of providing used equipment to 

beneficiaries, and the age of the concentrators that some sampled 

beneficiaries use. We recommend that CMS: 

Work with Congress To Further Reduce the Rental Period for Oxygen 

Equipment 

Medicare and its beneficiaries will continue to pay more than 12 times 

the purchase price for concentrators under the new 36-month rental 

limitation. Therefore, a shorter rental period may be warranted. 

Determine the Necessity and Frequency of Nonroutine Maintenance and 

Servicing for Concentrators 

Medicare does not cover routine servicing for DME that beneficiaries own 

but will cover nonroutine maintenance. Based on our sample, suppliers 

most commonly perform routine servicing that Medicare does not cover. 

However, CMS needs to determine the extent and frequency of nonroutine 

servicing and maintenance, as well as the appropriate reimbursement. 

Determine if a New Payment Methodology Is Appropriate for Portable 

Oxygen 

Unlike concentrators, portable oxygen systems require refills, and 

suppliers pick up empty cylinders and deliver full ones. Currently, 

Medicare pays an add-on amount for portable systems; however, 

payment for the contents of the cylinders is bundled into the monthly 

rental amount for the concentrator. When beneficiaries reach the 

36-month rental limit, Medicare will no longer pay for concentrators or 

portable systems but will pay for cylinder contents only. The monthly 

payment for contents (currently $21.41 per month) does not vary based 

on the amount of oxygen a beneficiary requires. This payment may not 

adequately reimburse suppliers for providing portable refills and related 

services once a beneficiary has reached the 36-month rental limit. (We 

note that CMS included a variable rate structure in its proposed rule.) 

 OE I-09-04-00 420 MEDI C ARE H O M E OX Y G E N E Q U I PM E N T: C O S T AND S E R V I C I NG 14 
R E C O MMENDA T I O N S 

AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL 

RESPONSE 

CMS concurred with our recommendations and noted that the 

President’s budget for fiscal year 2007 proposed reducing the rental 

period for oxygen equipment to 13 months. CMS noted that its 

proposed rule, published on August 3, 2006, addresses nonroutine 

maintenance and servicing and that it would be interested in receiving 

comments during the comment period on the appropriate frequency of 

servicing schedules. The proposed rule also addresses the payment 

methodology for portable oxygen systems and proposes to increase the 

monthly payment for contents from $21 to $55. 

In CMS’s comments on the draft report, the agency expressed concern 

that our savings estimate for a 13-month rental limit is too high, 

because it does not include adjustments to payments for maintenance 

and servicing or potential shifts to oxygen modalities other than 

concentrators. We acknowledge that our estimate did not include the 

effect of maintenance and servicing payments or potential shifts to other 

types of equipment. These factors would likely result in lower savings 

than our estimate. CMS also notes that our methodology differs from 

the way that the CBO or CMS’s Office of the Actuary would calculate 

savings. We acknowledge that CBO and CMS estimates exclude 

beneficiaries’ coinsurance and premium-related costs, which amount to 

approximately 40 percent of our calculated savings. CMS’s comments 

are included in their entirety in Appendix C. 

 OE I-09-04-00 420 MEDI C ARE H O M E OX Y G E N E Q U I PM E N T: C O S T AND S E R V I C I NG 15 
Δ APPENDIX~A 

Confidence Intervals for Selected Statistics 

Statistic N Point Estimate 95% Confidence Interval 

Average (mean) purchase price for new 

oxygen concentrators that were purchased 

from 2000 to 2004 and used by 

beneficiaries whose Medicare payments for 

concentrators began in 2004 

119 concentrators $587 $570–603 

Of beneficiaries whose Medicare payments 

for oxygen concentrators began in 2001, 

proportion who rented continuously for at 

least 12 months 

3,754 beneficiaries 46.3% 44.7–47.9% 

Of beneficiaries whose Medicare payments 

for oxygen concentrators began in 2001, 

proportion who rented continuously for at 

least 36 months 

3,754 beneficiaries 22.0% 20.7–23.3% 

Of beneficiaries whose Medicare payments 

for oxygen concentrators began in 2004, 

proportion who received at least one used 

concentrator 

145 beneficiaries 73.1% 65.9–80.3% 

Average (mean) number of months from 

purchase or lease of equipment to 

beneficiary’s rental of concentrator, for 

concentrators rented to beneficiaries whose 

Medicare payments for the units began in 

2004 

177 concentrators 32.1 months 26.5–37.6 months 

Percentage of concentrators (rented to 

beneficiaries whose Medicare rental 

payments for the units began in 2004) that 

malfunctioned 

203 concentrators 5.9% 2.9–8.9% 

 OE I-09-04-00 420 MEDI C ARE H O M E OX Y G E N E Q U I PM E N T: C O S T AND S E R V I C I NG 16 
—

Δ APPENDIX~B 

Methodology for Savings Calculation 

The table below shows potential savings for concentrators (code E1390) 

if the rental period were 13 months rather than 36 months. 

Potential Savings for Oxygen Concentrators 13-Month Limitation4 

Duration of 

Rental Year 1 Year 2 Year 3 Year 4 Year 5 

13 months 0 $1.0 billion $1.0 billion $0.6 billion $0.6 billion 

Source: Office of Inspector General analysis of 1 percent of National Claims History for DME, prosthetics, orthotics, and supplies, 

2006. 

We performed the following calculations to estimate the potential 

savings. We used CY 2004 claims to calculate this estimate. 

1. We used a 1-percent sample of allowed claims for DME, 

prosthetics, orthotics, and supplies rendered during CY 2004. This 

sample contained 102,086 E1390 claims for 12,619 beneficiaries. 

For each of these beneficiaries, we obtained claims data for all 

E1390 claims during CYs 2000 through 2004. 

2. To estimate the potential savings during the second year of 

implementation, we used the database created in step 1. For each 

claim for E1390 for 2004, we determined the number of claims for 

the first month of rental (disregarding any concentrator rental 

before 2003) and similarly for months 2 through 24. In counting 

these beneficiary rental months, we reset the counter to month 1 if 

there was a break of more than 60 days in the beneficiary’s rental 

of the oxygen concentrator. We used this criterion so that our 

estimate would correspond to the definition of continuous use 

found in the Medicare Claims Processing Manual (publication 

100-04), chapter 20, section 30.5.4. We assumed that portable 

oxygen contents would be paid for separately after month 13, so 

we included in our estimate a separate monthly payment of 

$21.41, which is the median among State fee schedule amounts for 

 OE I-09-04-00 420 

4 These potential savings reflect savings to both Medicare and its beneficiaries. If 

savings were limited to Medicare, they would be approximately 60 percent of the savings in 

the table, because beneficiaries’ coinsurance and premium-related costs would be excluded 

from the calculation. CBO and CMS exclude coinsurance and premium-related costs from 

their savings estimates. For example, total savings to Medicare would be approximately 

$0.6 billion in each of Years 2 and 3 and approximately $0.4 billion in each of Years 4 and 5. 

MEDI C ARE H O M E OX Y G E N E Q U I PM E N T: C O S T AND S E R V I C I NG 17 
APP E N D I X ~B 

E0443 and E0444 (portable oxygen contents). Using these 

amounts, we calculated savings per E1390 claim as follows: 

Beneficiary’s oxygen rental, months 1 through 13: 

Medicare payment under 13-month limit: 

Median 2006 fee schedule amount = $200.41 

Medicare payment without 13-month limit: 

Median 2006 fee schedule amount = $200.41

Medicare savings: $200.41–$200.41 = $0 

Beneficiary’s oxygen rental, months 14 through 24:

Medicare payment under 13-month limit: 

Portable contents = $21.41 

Medicare payment without 13-month limit: 

Median 2006 fee schedule amount = $200.41 

Medicare savings: $200.41–$21.41 = $179.00 

To estimate the potential savings during the second year of 

implementation, we multiplied the savings above by the number of 

E1390 claims during CY 2004 for each of months 1 through 24 of 

rental, and we multiplied the result by 100 (because these 2004 

claims were from a 1-percent sample). This resulted in savings of 

approximately $1.0 billion. 

The estimated savings for the third and subsequent years after 

implementation were calculated similarly. 

 OE I-09-04-00 420 MEDI C ARE H O M E OX Y G E N E Q U I PM E N T: C O S T AND S E R V I C I NG 18 
.. A P PEN D x c

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DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services

Administrator

Washington, OC 20201

DATE: SEP 7 20

TO: Daniel R. Levinson

Inspector General

Offce of Inspector General

FROM: Mark B. McClellan, M.D., Ph.D.

Administrator

1f ~

SUBJECT: Offce of Inspector General (OIG) Draft Report: "Medicare Home Oxygen

Equipment: Cost and Servicing," (OEI-09-04-00420)

Than you for the opportunity to review and comment on this oiG report which compares

Medicare spending on oxygen concentrators with suppliers' average purchase price and

describes the nature and frequency of servicing concentrators and portable equipment.

Regarding equipment costs, the report found that the average purchase price for concentrators is

$587; under the current payment system suppliers would receive a tota of$7,2l5 for 36 months,

a figure significantly in excess of the equipment acquisition costs. Indeed, the report finds that

Medicare beneficiar coinsurance during a 36 month rental period of$I,443 would be in excess

of twce the equipment purchase price. Regarding servicing, the report finds that minimal

servicing and maintenance is necessary for concentrators and portble equipment and that

servicing tasks can be performed in less than 5 minutes. Notably, the report found suppliers

performing services that a beneficiary could be doing. This is an importt report by the OIG

that concludes Medicare will continue to pay excessively for oxygen equipment, even after

implementation ofthe provisions of the Deficit Reduction Act of2005 (ORA) affecting oxygen

equipment.

Home oxygen equipment and oxygen contents are covered under the durable medical equipment

(DME) benefit and payment is made on the basis of monthly fee schedule amounts that are

modality neutral (i.e. the same payment amount applies regardless of whether the patient uses a

gaseous, liquid or concentrator system). Prior to passage of the ORA, these monthly payments

continued for as long as medically necessar. The ORA limited Medicare payment to 36

monthly rental payments after which equipment ownership transfers to the beneficiary. The

ORA did not change Medicare's current fee schedule amount of about $200 per month. Of the

$200, Medicare pays 80 percent or $160, and the beneficiary pays 20 percent or $40.

The draft report provides valuable insight for the Centers for Medicare & Medicaid Services

(CMS) on the suppliers' average purchase price for oxygen concentrators. The OIG report found

that concentrators cost about $587, on average, to purchase. The report also found that suppliers

rented used concentrators to about 73 percent of the sampled beneficiaries. With the curent

$200 monthly payment amount, suppliers would receive a total of$7,215 for 36 months, a figure

significantly in excess of the equipment acquisition costs. Medicare beneficiary coinsurance

OEI-09.04.00420 MEDICARE HOME OXYGEN EQUIPMENT: COST AND SERVICING 19
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Page 2 - Daniel R. Levinson

during a 36 month rental period would be $ i ,443 and the coinsurance payments exceed the costs

of purchasing two concentrators.

The draft report also provides details for eMS on the maintenance and servicing that is actually

done during a supplier's visit. The report finds that minimal servicing and maintenance is

necessar for concentrators and portable equipment. The report found suppliers performing

services that a beneficiar could do, such as a cleaning a concentrator's external fiter. This

finding is based on reports from suppliers, on actual on-site observation and accompanying

suppliers on their visits to beneficiaries' homes.

The report also found that suppliers checked concentrators every 4 months but it does not

indicate whether servicing every 4 months is an appropriate servicing schedule. It points out

that these servicing tasks take minimal time to perform and can be performed in less than 5

minutes, however, the initial delivery and set-up can tae as long as one hour. Also, according to

manufacturer guidelines, more comprehensive preventive maintenance need only be performed

anually or after several thousand hours of use. This report substatiates that oxygen

concentrators are sturdy and long lasting equipment that require minimal maintenance and

servicing. This information is very useful as CMS develo'ps policy on maintenance and servicing

for beneficiar-owned oxygen equipment.

The draft report also provides information on the refillng of contents for portable systems.

Unlike concentrators, most portble oxygen systems require refillng tans. The exceptions are

the new technology of oxygen equipment such as the transfillng machines and the portable

concentrators. The report found that suppliers picked up empty tank and delivered full ones

once every 3 months. As the report indicates, after ownership of equipment, Medicare wil make

a separate payment for refillng portble tans, currently about $21 per month and that such

payment amount may not be an adequate amount to reimburse suppliers for providing portable

refills. The appropriateness of current payment structure for beneficiary owned oxygen

equipment has been amplified in light of the recent changes by the ORA. This is critical

information as CMS develops policy for beneficiary-owned equipment, specifically for portable

systems.

Finally, the report contains an estimate ofthe savings for a policy that would reduce the number

of months for which Medicare would make rental payments for oxygen concentrators from 36 to

l3 months. We are concerned that the savings estimate presented in Table i for such policy is

too high. As the report indicates, this estimate does not include an offset for separate payments

that Medicare would make for maintenance and servicing after ownership transfers to a

beneficiary after i 3 months under such policy. Also, the estimate is for a policy that would

reduce the number of monthly rental payments from 36 to l3 for concentrators only. As such,

there could be incentives for suppliers to switch oxygen modality to oxygen tanks in order to

continue to receive the $200 monthly payment amounts from Medicare for months 14 through

36. The estimate does not make an adjustment for such potential behavior shift or any other

potential behavior changes. Savings are typically presented by the Congressional Budget Offce

OEI.09.04.00420 MEDICARE HOME OXYGEN EQUIPMENT: COST AND SERVICING 20
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Page 3 - Daniel R. Levinson

(CBO) and the eMS Offce of the Actuary (OAeT) as estimates of Federal budget savings, that

is excluding coinsurance and Part B premium savings to beneficiaries. As footnote 3 indicates,

sllch Federal savings are tyically 60 percent of savings without these offsets. Thus, the figures

presented in Table i are higher than would be presented by CBO or OACT. eBO and OACT

also present savings on a fiscal year basis and on a cash rather than incurred basis which would

also reduce the estimates presented in Table 1.

The Deparent of Health and Human Services is committed to ensurng that changes in

Medicare payment rules for home oxygen affecting Medicare beneficiaries and suppliers are

implemented in a way that fosters access to needed items and services in a cost effective maner.

This commitment is reflected in the proposed rule that was published on August 3, 2006 at CMS

1304-P (71 Fed Reg 44082 (August 3, 2006)), that would establish certain policies designed to

implement the DRA changes and other changes in a way that safeguard beneficiary access to

quality items and new technology and ensure access to oxygen contents and maintenance and

servicing of beneficiary owned equipment.

OIG Recommendation

Recommends that CMS work with Congress to furter reduce the rental period for oxygen

equipment.

CMS ResDonse

We agree. The Administration's fiscal year 2007 budget contained a proposal to reduce the

monthly rental limit for oxygen from 36 to 13 months.

OIG Recommendation

Recommends that CMS determine the necessity and frequency ofnonroutine maintenance and

servicing for concentrators.

CMS ResDonse

In the proposed rule published on August 3, 2006, CMS proposed to pay for reasonable and

necessary nonroutine service and maintenance for oxygen concentrators. Nonroutine service and

maintenance would cover tasks that a trained technician needs to perform such as the

concentrator flow rate prescribed by the physician and checking the concentration of oxygen

delivered by the unit but would exclude tasks that a beneficiar does such as cleaning the

concentrator's external (dust) fiter. The proposed rule did not propose a specific frequency

schedule though we would be interested to receive comments during the comment period on

servicing schedules.

"--

OEI-09.04.00420 MEDICARE HOME OXYGEN EQUIPMENT: COST AND SERVICING 21
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OIG Recommendation

Recommends that eMS determine if a new payment methodology is appropriate for portable

oxygen systems.

eMS ResDonse

In the proposed rule published on August 3, 2006, CMS proposed to revise payment for refillng

portable oxygen tanks after ownership. The rule proposes to raise the payment amount from $2 I

to $55. We are accepting comments on the appropriateness of this payment amount for the

refilling of portble contents after ownership.

We conclude by offering thans to the oiG for this informative report that provides essential

information that eMS can use to achieve the goals of the Agency to improve beneficiar access

to necessar equipment and services and implement cost effective Medicare payments for home

oxygen equipment. Over the past several years we have worked closely with the DIG on issues

affecting Medicare payment for oxygen equipment and we look forward to continuing this

collaboration on these very important issues.

OEI.09.04.00420 MEDICARE HOME OXYGEN EQUIPMENT: COST AND SERVICING 22
Δ ACKNOWLEDGMENTS 

This report was prepared under the direction of Paul A. Gottlober, 

Regional Inspector General for Evaluation and Inspections in the San 

Francisco regional office, and Deborah W. Harvey, Assistant Regional 

Inspector General. Other principal Office of Evaluation and Inspections 

staff who contributed include: 

Cindy Lemesh, Project Leader 

Camille Harper, Project Leader 

China Eng, Program Analyst 

Scott Hutchison, Program Analyst 

Scott Manley, Program Specialist 

Tricia Davis, Director, Medicare Branch 

Rob Gibbons, Mathematical Statistician 

 OE I-09-04-00 420 MEDI C ARE H O M E OX Y G E N E Q U I PM E N T: C O S T AND S E R V I C I NG 23