CurrentHealth NetPolicy N/A

Asthma Remediation Community Support

Defines authorization, eligibility criteria, allowable interventions, documentation, limits, and restrictions for Asthma Remediation Community Support services (home environmental modifications, supplies, and IPM) for Medi-Cal members managed by Health Net/CalViva Health, including transitional rules for in-home assessments and asthma self-management education through Dec 31, 2025 and a DHCS change effective Jan 1, 2026.

Policy Summary

PayerHealth Net

PolicyAsthma Remediation Community Support

Policy CodePolicy N/A

Change TypeClarified; Revised (program shift to APS)

Effective DateJan 1, 2026 (program change); Transitional coverage through Dec 31, 2025

Next Review Date

Key ActionComplete and submit the Asthma Remediation Referral Form with the Medi‑Cal Prior Authorization Request Form (Outpatient) online or by fax; include required clinical documentation (poor control OR ACT ≤19 OR provider recommendation).

POLICY UPDATE CHANGES

Effective Jan 1, 2026, DHCS removed in-home environmental trigger assessments and asthma self-management education from Asthma Remediation Community Support.

$7,500Lifetime maximum benefit

2025Transitional coverage period

2026-01-01APS effective date

Coverage Summary

Asthma Remediation Community Support provides supplies and physical home modifications to reduce environmental asthma triggers and prevent acute asthma episodes that could lead to emergency department visits or hospitalization. Covered interventions include items and services such as allergen-impermeable mattress and pillow dustcovers, HEPA-filtered vacuums, dehumidifiers, ventilation improvements, mechanical air cleaners, integrated pest management (IPM), minor mold removal and remediation, asthma-friendly cleaning products and other medically appropriate home interventions. Services may be delivered in homes owned, rented, leased or occupied by the member or their caregiver and can be provided over time subject to a total lifetime maximum of $7,500 (exceptions possible if the member's condition changes significantly). The program is offered to Medi‑Cal enrollees managed by CalViva Health via Health Net Community Solutions and requires prior authorization and member consent via the Asthma Remediation Referral Form and Medi‑Cal Prior Authorization Request Form.

Key thresholds and policy numbers

Asthma Control Test (ACT) score<= 19

Poor control definitionED visit or hospitalization or two sick/urgent care visits in past 12 months

Lifetime maximum benefit$7,500

Transitional coverage window2025-01-01 to 2025-12-31

APS effective date2026-01-01

Eligibility and Authorization Criteria

Eligibility / Authorization Criteria for Asthma Remediation Community Support

Covered when ALL of the following are met:

ALL of the following

Member is enrolled in Medi-Cal through the plan (CalViva Health via Health Net Community Solutions)
Services are provided in a home owned, rented, leased or occupied by the member or their caregiver
Requested services are medically necessary to ensure the health, welfare and safety of the member or to enable the member to function in the home with reduced likelihood of acute asthma episodes
Documentation requirement (ONE of)
- Poorly controlled asthma defined as an emergency department visit or hospitalization or two sick or urgent care visits due to asthma in the past 12 months
- Asthma Control Test (ACT) score of 19 or lower<=19
- Recommendation from a licensed health care provider (physician, nurse practitioner, or physician assistant) that the service will likely avoid asthma-related hospitalizations, ED visits, or other high-cost services

Transitional Coverage (Jan 1, 2025 to Dec 31, 2025)

For members receiving in-home environmental trigger assessments or asthma self-management education during the transition period, coverage may be provided under Community Support if additional criteria met:

ALL of the following

Request date between 2025-01-01 and 2025-12-31
Member meets eligibility criteria above (poor control OR ACT <= 19 OR provider recommendation)

Effective Jan 1, 2026 - Program Change

From 2026-01-01 onward:

In-home environmental trigger assessments and asthma self-management education are removed from Asthma Remediation Community Support and instead provided under the Asthma Preventive Services (APS) program

Effective January 1, 2026

Provider Actions & Requirements

Prior Authorization

Referral and Prior Authorization Submission

Complete and submit the Asthma Remediation Referral Form with the Medi‑Cal Prior Authorization Request Form (Outpatient) either online at provider.healthnetcalifornia.com or by fax to 800-743-1655. Member must consent to the referral. Indicate whether this is an initial request or an extension request.

Submit Asthma Remediation Referral Form with Medi‑Cal Prior Authorization Request Form (Outpatient) online or by fax to 800-743-1655
Member must consent to the referral
Indicate initial request or extension request

Documentation Required

Clinical Documentation Required

Attach documentation showing one of the following: poorly controlled asthma (ED visit or hospitalization or two sick/urgent care visits for asthma in the past 12 months), an Asthma Control Test (ACT) score of 19 or lower, or a written recommendation from a licensed health care provider that the service will likely avoid asthma-related hospitalizations, ED visits, or other high‑cost services.

Documentation of poorly controlled asthma (ED/hospitalization or two sick/urgent care visits in 12 months)
ACT score ≤ 19
Written recommendation from a licensed provider that the service will likely avoid high‑cost asthma services

Documentation Required

Home Visit / Assessment Documentation

For in‑home environmental trigger assessments, document the date of the home visit (or date the home visit is scheduled) and record findings that guide the requested remediations. Note that in‑home assessments are available under Community Support only through December 31, 2025; after that (effective January 1, 2026) these assessments move to the Asthma Preventive Services (APS) program.

Document date of home visit or scheduled home visit
Document findings from the assessment to support requested remediations
Transitional availability through 2025; APS responsible from Jan 1, 2026 onward

Documentation Required

Owner Notification for Permanent Modifications

Before starting permanent physical adaptations or installations (for example, exhaust fans or replacement of moldy drywall), provide the owner and member with written documentation that the modifications are permanent and that the State is not responsible for maintenance, repair, or removal of the modification if the member ceases residence. This written notification requirement does not apply to non‑permanent supplies (e.g., mattress/pillow dust covers, HEPA vacuums, dehumidifiers, portable air filters, asthma‑friendly cleaning products).

Provide owner and member written documentation before permanent adaptations/installations
State not responsible for maintenance/repair/removal if member leaves residence
Exemption: requirement does not apply to non‑permanent supplies

Billing Rule

Lifetime Maximum and Exception Process

Asthma remediation services are payable up to a total lifetime maximum of $7,500. An exception to the $7,500 total maximum may be authorized if the member’s condition has changed significantly such that additional modifications are necessary to ensure the member’s health, welfare, or safety, or to help the member function in the home and avoid institutionalization or hospitalization.

Total lifetime maximum payable: $7,500
Exception possible if member’s condition changed significantly requiring additional modifications

Documentation Required

Compliance with Building Codes

Asthma remediations must be performed in accordance with applicable State and local building codes and must be limited to medical or remedial benefits for the member (excluding general utility or aesthetic improvements).

Follow applicable State and local building codes
Limit remediations to medical/remedial benefit; exclude general utility or aesthetic improvements

Denial Risk

Access State Plan Service First

If an equivalent State Plan service (for example, durable medical equipment) would accomplish the same goal of preventing asthma emergencies or hospitalizations, that State Plan service should be accessed first. Failure to access the applicable State Plan service before Community Supports may affect coverage.

Access available State Plan service first (e.g., durable medical equipment) if it would achieve the same prevention of asthma emergencies/hospitalizations
Not following this may affect coverage under Community Supports

Background

In‑home environmental trigger assessments are defined as the identification of environmental asthma triggers commonly found in and around the home, including allergens and irritants, conducted to guide supplies, home modifications, and asthma self‑management education. Mechanical air cleaners are defined as air cleaners that only use physical filtration (e.g., pleated or HEPA filters), do not generate ozone or ions, and are permitted for asthma remediation; electronic cleaners that generate ozone are not permitted. Poorly controlled asthma is defined as an emergency department visit or hospitalization or two sick or urgent care visits due to asthma in the past 12 months. The purpose of the Asthma Remediation Community Support program is to reduce environmental triggers through targeted supplies, IPM, and home modifications to prevent asthma exacerbations that result in ED visits or hospitalizations. During the transitional period, managed care plans may cover in‑home environmental trigger assessments and asthma self‑management education under Community Support as medically necessary through December 31, 2025; effective January 1, 2026, DHCS removed in‑home environmental trigger assessments and asthma self‑management education from Asthma Remediation Community Support and these services will instead be provided under the Asthma Preventive Services (APS) program.

Revision History

2025-12-31clarified

Transitional allowance: managed care plans may cover in-home environmental trigger assessments and asthma self-management education under Community Support as medically necessary through Dec 31, 2025. Detail: From January 1, 2025 to December 31, 2025, managed care plans should transition coverage for these services to the Asthma Preventive Services (APS) program but may continue to cover in‑home environmental trigger assessments and asthma self‑management education under Community Support if medically necessary; transitional eligibility requires poorly controlled asthma OR ACT score ≤19 OR provider recommendation.

2026-01-01revisedLatest

Removal effective Jan 1, 2026: DHCS removed in‑home environmental trigger assessments and asthma self‑management education from Asthma Remediation Community Support. Detail: Effective January 1, 2026, these services will instead be offered under the Asthma Preventive Services (APS) program per DHCS; CalAIM Special Terms and Conditions require the shift.

OpenPayer

Asthma Remediation Community Support

Coverage Summary

Eligibility and Authorization Criteria

Provider Actions & Requirements

Coding

Background

Revision History