ModifiedHealth NetPolicy N/A

Authorization Guide for Asthma Remediation

Defines coverage, eligibility, allowable interventions, restrictions, provider requirements, and lifetime maximums for Asthma Remediation Community Support services (home supplies and physical modifications) for members; clarifies that in-home environmental trigger assessments and asthma self-management education are covered under the Asthma Preventive Services (APS) State Plan benefit effective Jan 1, 2026.

Policy Summary

PayerHealth Net

PolicyAuthorization Guide for Asthma Remediation

Policy CodePolicy N/A

Change TypeService transfer to APS

Effective DateJan 1, 2026

Next Review Date

Key ActionProviders must submit the Asthma Remediation Authorization Form including a completed in-home environmental trigger assessment (within 12 months) that identifies medically appropriate remediations and justification for the interventions.

SourceLink

POLICY UPDATE CHANGES

Effective January 1, 2026, DHCS is removing in-home environmental trigger assessments and asthma self-management education from the Asthma Remediation Community Support program and requiring these services to be covered under the APS benefit.

Asthma Remediation Community Support must supplement, not supplant, state/local/federal programs per CalAIM Special Terms and Conditions.

$7,500Total lifetime maximum

12 monthsAPS assessment recency requirement

Coverage Summary

Overview: Asthma Remediation Community Support provides supplies and physical home modifications to reduce the likelihood of acute asthma episodes and prevent emergency services and hospitalization in homes owned, rented, leased, or occupied by the member or their caregiver. Services supplement the Asthma Preventive Services (APS) State Plan benefit and other state-plan services and must not supplant those programs. Effective 2026-01-01, the program is modified so that clinic- and home-based asthma self-management education and in-home environmental trigger assessments are covered under the APS benefit rather than under Asthma Remediation Community Support. Coverage stance: covered_with_criteria.

Surface thresholds and high-level stats

In-home environmental trigger assessment recencycompleted within the last 12 months

Total lifetime maximum$7,500

APS transition dateEffective 2026-01-01

Eligibility and Covered Criteria

Eligibility (Members eligible for Asthma Remediation)

Members are eligible when ALL of the following are met:

APS assessment recency: Completed an in-home environmental trigger assessment within the last 12 months through the APS benefit.completed within the last 12 months
Assessment content: The assessment must identify medically appropriate asthma remediations and specify how these interventions meet the member's needs related to this service.
Residence requirement: Services are provided in a home that is owned, rented, leased, or occupied by the member or their caregiver.

Covered Interventions

Asthma Remediation covers supplies and physical modifications that are medically appropriate and cost-effective; examples include:

Allergen-impermeable covers: Allergen-impermeable mattress and pillow dustcovers
HEPA vacuums: High-efficiency particulate air (HEPA) filtered vacuums
IPM services: Integrated pest management (IPM) services
De-humidifiers
Mechanical air filters/air cleaners

Lifetime Maximum / Exception

Lifetime maximum: Asthma remediations are payable up to a total lifetime maximum of $7,500.$7,500
Exception for significant change: Exception: Additional modifications beyond the $7,500 total maximum may be covered if the member's condition has changed so significantly that additional modifications are necessary to ensure health, welfare and safety, or to enable greater independence in the home and avoid institutionalization or hospitalization.

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Provider and Operational Requirements

Required documentation: Asthma Remediation Authorization Form including a completed in-home environmental trigger assessment within the last 12 months through APS that identifies medically appropriate remediations and how they meet member needs.assessment within 12 months
Allowable providers: Examples include lung health organizations, healthy housing organizations, local health departments, community-based providers and organizations; all allowable providers must be approved/enrolled by the MCP and meet MCP minimum standards for experience and quality.
Providers must enroll in Medi-Cal to provide APS services as applicable.
Contractor license: Asthma Remediation home modifications must be performed by an individual holding a California contractor's license.

Coding

Covered HCPCS (example provided)HCPCSCovered

S5165 U5

Home modifications; per service

Background

Background: Asthma Remediation Community Support supplies and/or performs physical home modifications that are medically necessary to ensure a member's health, welfare, and safety or to enable the member to function in the home with reduced likelihood of acute asthma episodes. These services are intended to supplement APS and other state-plan services and are available in homes occupied by the member or caregiver.

Definition (APS): Asthma Preventive Services (APS) is the Medi‑Cal State Plan service covering clinic- and home-based asthma self-management education and in-home environmental trigger assessments that identify physical modifications or supplies to reduce the likelihood of acute asthma episodes. Note: Effective January 1, 2026, APS will cover clinic- and home-based asthma self-management education and in-home environmental trigger assessments; providers must enroll in Medi‑Cal to continue providing these services under APS.

Revision History

2026-01-01revisedLatest

Effective January 1, 2026, DHCS removed in-home environmental trigger assessments and asthma self-management education from the Asthma Remediation Community Support program; these services must instead be covered by Managed Care Plans under the Asthma Preventive Services (APS) State Plan benefit. Providers continuing to provide in-home trigger assessments and asthma self-management education must enroll in the Medi‑Cal program.

clarifiedLatest

CalAIM Special Terms and Conditions clarified that Community Supports must supplement, not supplant, services received through state, local, or federally funded programs; if another state plan service beyond APS (e.g., DME) would accomplish the same goals, the state plan service should be accessed first.

Policy Summary

PayerHealth Net

PolicyAuthorization Guide for Asthma Remediation

Policy CodePolicy N/A

Change TypeService transfer to APS

Effective DateJan 1, 2026

Next Review Date

SourceLink

On This Page

Moisture control: Other moisture-controlling interventions

Mold removal: Minor mold removal and remediation services

Ventilation improvements

Cleaning products: Asthma-friendly cleaning products and supplies

Other medically appropriate: Other interventions identified to be medically appropriate for the management and treatment of asthma and which are cost effective

title": "Covered Interventions"

intro": "Asthma Remediation covers supplies and physical modifications that are medically appropriate and cost-effective; examples include:",

Permanent-modification notice: Before starting permanent physical adaptations or installation of equipment (e.g., exhaust fan, replacement of moldy drywall), the MCP must provide the owner and member written documentation that modifications are permanent and that the state is not responsible for maintenance or repair (including removal if member ceases to reside).

This requirement does not apply to non-permanent supplies (e.g., mattress covers, HEPA vacuums, de-humidifiers, portable air filters, asthma-friendly cleaning products and supplies).

Building-code requirement: Asthma remediations must be conducted in accordance with applicable state and local building codes.

Supplement not supplant: Community Supports must supplement and not replace services provided through state, local or federally funded programs; if another state plan service beyond APS (e.g., DME) is available and would accomplish the same goals, the state plan service should be accessed first.

Prior Authorization

Authorization form and supporting documentation required

Providers must submit the Asthma Remediation Authorization Form and include a completed in-home environmental trigger assessment performed through the APS benefit within the prior 12 months that identifies medically appropriate remediations and justifies the interventions.

Documentation Required

APS assessment required for eligibility

Eligibility requires an in-home environmental trigger assessment performed through the APS benefit within the prior 12 months. The APS assessment must identify medically appropriate asthma remediations and specify how the interventions meet the member's needs. No additional medical documentation is required beyond this assessment.

Billing Rule

Lifetime maximum applies

Asthma Remediation claims are payable up to a total lifetime maximum of $7,500. An exception to the $7,500 limit may be allowed if the member's condition has changed so significantly that additional modifications are necessary to ensure the member's health, welfare, and safety or to enable greater independence and avoid institutionalization or hospitalization; such exceptions must be documented and justified.

Documentation Required

Owner/member written notification for permanent modifications

Before starting permanent physical adaptations or installation of equipment in the home, the MCP must provide written documentation to both the owner and the member that the modifications are permanent and that the state is not responsible for maintenance, repair, or removal if the member ceases to reside at the residence. This written-notice requirement does not apply to non-permanent supplies (for example: mattress covers, HEPA vacuums, de-humidifiers, portable air filters, or asthma-friendly cleaning products).

Documentation Required

Contractor license for physical adaptations

Physical adaptations to a residence covered by Asthma Remediation must be performed by an individual holding a California contractor's license.

Documentation Required

Provider enrollment and MCP approval

Allowable providers must be approved/enrolled by the MCP and meet MCP minimum standards. Providers continuing to perform in-home trigger assessments and asthma self-management education must enroll in the Medi-Cal program to deliver these services under the APS benefit effective January 1, 2026.