ModifiedHealth NetPolicy N/A

Asthma Remediation Community Support (in-home remediation, supplies, and education)

Defines eligibility, covered services, documentation, restrictions, lifetime maximums, provider requirements, and transition timeline for Asthma Remediation Community Support for Medi‑Cal managed care plan members in California, including temporary coverage of in-home environmental trigger assessments and asthma self-management education through 2025 and their transition to the Asthma Preventive Services (APS) program effective 2026-01-01.

Policy Summary

PayerHealth Net

PolicyAsthma Remediation Community Support (in-home remediation, supplies, and education)

Policy CodePolicy N/A

Change TypeTransition of services to APS

Effective DateJan 1, 2026

Next Review DateN/A

Key ActionProviders must submit an Asthma Remediation Referral Form with required supporting documentation (poorly controlled asthma evidence, ACT score, or licensed provider recommendation) to obtain authorization.

POLICY UPDATE CHANGES

In‑home environmental trigger assessments and asthma self‑management education will be transitioned from Asthma Remediation Community Support to the Asthma Preventive Services (APS) program effective 2026-01-01.

Phase‑out period through 2025 allows non‑enrolled Community Supports providers opportunity to enroll with Medi‑Cal and seek reimbursement under APS.

$7,500Total lifetime maximum

2025Temporary coverage period

2026-01-01Transition effective

Coverage Summary

The Asthma Remediation Community Support provides temporary coverage for Medi‑Cal managed care plan (MCP) members for in‑home environmental trigger assessments, asthma self‑management education, supplies, and physical home modifications intended to reduce asthma triggers and prevent high‑cost services. DHCS is allowing a phase‑out period through 2025: MCPs may continue to cover in‑home trigger assessments and self‑management education under Community Support through December 31, 2025 when eligibility and documentation criteria are met. Effective 2026-01-01, in‑home environmental trigger assessments and asthma self‑management education will transition to the Asthma Preventive Services (APS) benefit and must be billed under APS by providers enrolled in Medi‑Cal. Coverage under Community Support remains subject to the program’s limits, including a total lifetime maximum of $7,500.

Key thresholds and program stats

Asthma Control Test score threshold<= 19

Poorly controlled asthma (utilization definition)ED visit or hospitalization or 2 sick/urgent care visits for asthma in past 12 months

Total lifetime maximum$7,500

Temporary coverage period for trigger assessments and education under Community Support2025-01-01 to 2025-12-31

Effective date of transition to APS2026-01-01

Notes on transitionThroughout 2025 MCPs may still cover in-home trigger assessments and asthma self-management education under Community Support; beginning 2026 these services must be provided under APS and providers must enroll in Medi‑Cal to bill APS.

Medical Necessity & Allowable Services

Eligibility for Asthma Remediation Community Support (Jan 1, 2025 - Dec 31, 2025)

Covered when ANY of the following are met:

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Provider Actions & Billing Requirements

Prior Authorization

Submit Asthma Remediation Referral Form

Providers must submit an Asthma Remediation Referral Form along with the required supporting documentation (see required documentation) to obtain authorization for asthma remediation services.

Documentation Required

Required supporting documentation

Acceptable supporting evidence includes documentation of poorly controlled asthma (ED visit or hospitalization or two sick/urgent care visits for asthma in the past 12 months), a score of 19 or lower on the Asthma Control Test, or a recommendation from a licensed health care provider (physician, nurse practitioner, or physician assistant). For in‑home assessments, document the date of the home visit or the scheduled home visit.

Poorly controlled asthma utilization (ED visit, hospitalization, or two sick/urgent care visits in past 12 months)

Coding

Example HCPCS / service code referencedHCPCS

S5165 U5

Home modifications; per service (listed in document as an example)

Background & Definitions

DHCS is phasing out asthma self‑management education and in‑home environmental trigger assessments from the Asthma Remediation Community Support to ensure these services are provided through the Medi‑Cal Asthma Preventive Services (APS) benefit and to give current Community Supports providers time to enroll in Medi‑Cal and seek reimbursement under APS. The Community Support has covered in‑home environmental trigger assessments (identification of allergens and irritants in and around the home), asthma self‑management education (including inhaler technique and identifying triggers), and medically appropriate supplies and physical home modifications (examples include allergen‑impermeable mattress and pillow covers, HEPA vacuums and air cleaners, dehumidifiers, integrated pest management, minor mold remediation, and ventilation improvements) to reduce environmental triggers and prevent emergency department visits and hospitalizations. Permanent home adaptations remain subject to restrictions (building codes, contractor licensing, and written notice to owners/members) and the program’s lifetime maximum of $7,500.

Definitions

Revision History

2026-01-01revisedLatest

In-home environmental trigger assessments and asthma self-management education will be transitioned from Asthma Remediation Community Support to the Asthma Preventive Services (APS) program effective 2026-01-01. Detail: The DHCS removed these services from the Asthma Remediation Community Support program; MCPs must instead cover them under the APS benefit, and asthma remediation providers must enroll in the Medi-Cal program to provide these services under APS.

2025-12-31clarified

Phase-out period through 2025 allows non-enrolled Community Supports providers opportunity to enroll with Medi-Cal and seek reimbursement under APS. Detail: Throughout 2025, MCPs may still cover asthma self-management education and in-home environmental trigger assessments under the Asthma Remediation Community Support if the member meets the eligibility criteria; MCPs should transition coverage to APS but may continue coverage through December 31, 2025 while providers enroll in Medi-Cal.

Policy Summary

PayerHealth Net

PolicyAsthma Remediation Community Support (in-home remediation, supplies, and education)

Policy CodePolicy N/A

Change TypeTransition of services to APS

Effective DateJan 1, 2026

Next Review DateN/A

On This Page

Allowable Services under Community Support (through 2025)

Covered as medically necessary through 2025 when eligibility met:

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Asthma Control Test (ACT) score ≤ 19

Recommendation from a licensed health care provider (physician, NP, or PA)

Date of home visit or date of scheduled home visit for in‑home assessments

Billing Rule

Lifetime maximum enforcement

Claims for asthma remediation are payable up to a total lifetime maximum of $7,500. An exception to the $7,500 limit is allowed only if the member's condition has changed so significantly that additional modifications are necessary to ensure health, welfare, safety, or to avoid institutionalization or hospitalization.

Documentation Required

Written notice for permanent modifications

Before performing permanent physical adaptations or installations in a residence, the MCP must provide the owner and the member written documentation stating that the modifications are permanent and that the state is not responsible for maintenance, repair, or removal if the member ceases residency.

Billing Rule

Provider enrollment for APS

Beginning January 1, 2026, in‑home environmental trigger assessments and asthma self‑management education must be provided under the Asthma Preventive Services (APS) benefit. Providers who wish to bill APS for these services must enroll in the Medi‑Cal program to continue providing them after 2026-01-01.

Documentation Required

Contracting/approval of providers

All allowable providers must be approved by the MCP; MCPs must apply minimum standards and monitor provision of services to ensure adequate experience and acceptable quality of care.

Billing Rule

Qualified contractor requirement

Physical adaptations to a residence covered by asthma remediation must be performed by an individual holding a California Contractor's License.