CurrentHealth NetPolicy N/A

Authorization Guide for Environmental Accessibility Adaptations (Home Modifications)

Policy Summary

PayerHealth Net

PolicyAuthorization Guide for Environmental Accessibility Adaptations (Home Modifications)

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionObtain authorization and submit required documentation (provider order, PT/OT evaluation unless waived, bids/cost estimates, home visit report, and owner consent if home not owned by member); Community Support provider must begin assessment and modifications within 90 days.

POLICY UPDATE CHANGES

No material clinical/coverage changes in this update.

$7,500Lifetime maximum

90 daysInitial assessment timeframe

Per serviceUnit of service

Coverage Summary

Defines authorization criteria, documentation, provider requirements, coding, coverage limits, and reauthorization rules for Environmental Accessibility Adaptations (EAAs)/home modifications to maintain safety, independence, and avoid institutionalization. EAAs are physical home modifications necessary to ensure the health, welfare and safety of the individual or to enable the individual to function with greater independence in the home who would otherwise require institutionalization.

Medical Necessity & Coverage Criteria

General Eligibility and Coverage Criteria

Covered when ALL of the following are met:

Member resides in a home (owned, rented, leased, or occupied by the member).

Modification is necessary to ensure the health, welfare and safety of the individual or to enable the individual to function with greater independence in the home and avoid institutionalization.

Member is at risk for institutionalization in a nursing facility.

Services must be performed in accordance with applicable state and local building codes.

For homes not owned by the member: written consent from the owner for physical adaptations or for equipment physically installed in the home must be provided.

All physical adaptations must be performed by an individual holding a California Contractor's License, except for PERS installation which may be performed per system installation requirements.

Required documentation: provider order specifying requested equipment/service.

Required documentation: physical or occupational therapy evaluation and report to evaluate medical necessity unless the managed care plan determines approval without an evaluation.

Required documentation: bids or cost estimates including itemized services, cost, labor, warranties; if possible, a minimum of two bids.

Required documentation: home visit to determine suitability of requested equipment or service.

Coverage Limit / Timeframe

Community Support (CS) provider must conduct the initial assessment and begin modifications within 90 days of the request.90 days

Service is covered until the total lifetime maximum of $7,500 is met, subject to stated exceptions.$7,500

Reauthorization / Extensions

If a service extension is needed, the provider must submit a new authorization including verification of work performed to date and the reason for the extension (e.g., need more time to receive homeowner consent or member requests a longer timeframe).

Assessment and authorization must take place within the 90-day timeframe beginning with the request unless more time is required to receive homeowner consent or the member requests a longer timeframe.90 days

Exclusions and Limitations

Adaptations or improvements that are of general utility to the household are excluded.

Adaptations that add to the total square footage of the home are excluded except when necessary to complete an adaptation (e.g., to improve entrance/egress or configure a bathroom to accommodate a wheelchair).

Aesthetic embellishments are excluded; finishing is limited to returning the home to habitable condition (e.g., drywall and painting) only when of direct medical or remedial benefit.

If another state plan service (e.g., Durable Medical Equipment) would accomplish the same goals of independence and avoid institutional placement, that service should be used instead of EAAs.

Exception to Lifetime Maximum

Exception allowed if ANY of the following apply:

Member's place of residence changes.
Member's condition has changed so significantly that additional modifications are necessary to ensure health, welfare and safety or to enable greater independence and avoid institutionalization or hospitalization.

Provider Actions & Requirements

Prior Authorization

Authorization required for EAAs

Provider must obtain prior authorization for Environmental Accessibility Adaptations (EAAs). Use HCPCS code S5165 for home modifications. Community Support (CS) provider has 90 days to conduct the initial assessment and begin modifications. Services are covered until the lifetime maximum is met.

Codes: S5165
Community Support provider timeframe: 90 days to conduct initial assessment and begin modifications
Coverage subject to lifetime maximum (see policy limits)

Documentation Required

Required documentation for authorization

Required documentation to support an authorization includes: a provider order specifying the requested equipment or service; a physical or occupational therapy evaluation and report to evaluate medical necessity unless the managed care plan approves without an evaluation; bids or cost estimates for the requested service (including itemized services, cost, labor, and warranties) — if possible provide a minimum of two bids; a home visit report to determine suitability of the requested equipment or service; and, for homes not owned by the member, written owner consent for physical adaptations or installed equipment.

Provider order specifying requested equipment/service
Physical or occupational therapy evaluation and report (unless waived by plan)
Bids/cost estimates including itemized services, cost, labor, warranties (preferably minimum of two)
Home visit report
Owner written consent for homes not owned by the member

Billing Rule

Unit of service

Unit of service for EAAs is billed Per service. Use HCPCS code S5165 for home modifications.

Unit = Per service
Code: S5165

Documentation Required

Contractor requirement

All physical adaptations to a residence must be performed by an individual holding a California Contractor's License, except for PERS installations which may be performed per the system's installation requirements.

California Contractor's License required for adaptations (except PERS installations)

Prior Authorization

Reauthorization requirements

To request a service extension or reauthorization, submit a new authorization that includes verification of the work performed to date and the reason for the extension (for example, additional time needed to obtain homeowner consent or the member requests a longer timeframe).

Submit new authorization
Include verification of work performed to date
Include reason for extension (e.g., awaiting homeowner consent or member requests longer timeframe)

Background & Definitions

Environmental Accessibility Adaptations (EAAs), also known as Home Modifications, are physical changes to a residence required to ensure health, welfare and safety or to enable greater independence and avoid institutionalization. Services are available in homes that are owned, rented, leased, or occupied by the member.

Examples of covered services include ramps, grab bars, doorway widening for wheelchair access, stair lifts, making bathrooms and showers wheelchair accessible (for example, constructing a roll-in shower), and installation of specialized electrical and plumbing systems necessary to accommodate the member's medical equipment and supplies.

Additional service requirements: modifications must be performed by an individual holding a California Contractor's License (except PERS installations per system requirements); for homes not owned by the member, written owner consent is required; and providers must supply documentation such as a provider order, PT/OT evaluation (unless plan waives), bids/cost estimates (preferably two), and a home visit report.

Term	Definition
Environmental Accessibility Adaptations (EAAs)
Physical home modifications necessary to ensure the health, welfare and safety of the individual or to enable the individual to function with greater independence in the home; examples include ramps, grab bars, doorway widening, stair lifts, roll-in showers, and specialized electrical/plumbing for medical equipment.
Community Support (CS) provider
Provider responsible for conducting the initial assessment and initiating modifications within 90 days; allowable CS providers include area agencies on aging, local health departments, and community-based providers/organizations.

S5165	Home modifications
U6	Modifier/place-of-service indicator listed next to S5165 in source
U1	Deposit (U1)

OpenPayer

Authorization Guide for Environmental Accessibility Adaptations (Home Modifications)

Coverage Summary

Medical Necessity & Coverage Criteria

Coding

Provider Actions & Requirements

Background & Definitions