CurrentHealth NetPolicy N/A

Asthma Remediation Community Support — Coverage Criteria

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Governs authorization, covered services, limits, and provider requirements for home-based asthma remediation supplies and physical modifications for Medi-Cal members in California (applies to Health Net/CalViva members).

Policy Summary

PayerHealth Net

PolicyAsthma Remediation Community Support — Coverage Criteria

Policy CodePolicy N/A

Change TypePhase-out of in-home assessments and educationlifetime maximum added

Effective DateJan 1, 2025

Next Review DateN/A

Key ActionSubmit the Asthma Remediation Referral Form with required supporting documentation (poorly controlled asthma evidence, ACT ≤19, or licensed provider recommendation) to request authorization.

SourceLink

POLICY UPDATE CHANGES

In-home environmental trigger assessments and asthma self-management education are removed from the Asthma Remediation Community Support effective January 1, 2026 and will be offered under the Asthma Preventive Services (APS) program.

Through 2025, MCPs may still cover in-home environmental trigger assessments and asthma self-management education under Community Support if members meet specified eligibility criteria.

A total lifetime maximum of $7,500 applies to asthma remediations, with limited exception if member condition changes significantly.

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CurrentHealth NetPolicy N/A

Asthma Remediation Community Support — Coverage Criteria

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Policy Summary

PayerHealth Net

PolicyAsthma Remediation Community Support — Coverage Criteria

Policy CodePolicy N/A

Change TypePhase-out of in-home assessments and educationlifetime maximum added

Effective DateJan 1, 2025

Next Review DateN/A

SourceLink

POLICY UPDATE CHANGES

Through 2025, MCPs may still cover in-home environmental trigger assessments and asthma self-management education under Community Support if members meet specified eligibility criteria.

A total lifetime maximum of $7,500 applies to asthma remediations, with limited exception if member condition changes significantly.

Coverage criteria for Asthma Remediation Community Support

Eligibility for in-home assessment and education (transition period)

Covered when ANY of the following are met (through Dec 31, 2025 for in-home assessments and self-management education):

Eligibility criteria for coverage of in-home assessments and asthma self-management education during 2025 phase-out: Member has poorly controlled asthma defined as an emergency department visit or hospitalization for asthma, or two sick/urgent care visits for asthma in the past 12 months; OR Asthma Control Test score ≤ 19; OR Recommendation from a licensed health care provider (e.g., physician, nurse practitioner, or physician assistant) that the service will likely prevent asthma-related hospitalizations, emergency department visits, or other high-cost services.

Applies to coverage of in-home environmental trigger assessments and asthma self-management education under Community Support through 12/31/2025.

Covered supplies and physical modifications

Covered remediations (examples):

Examples of covered supplies and modifications: Allergen-impermeable mattress and pillow dustcovers; High-efficiency particulate air (HEPA)–filtered vacuums; Integrated pest management (IPM) services; De-humidifiers; Mechanical air filters/air cleaners; Other moisture-controlling interventions; Minor mold removal and remediation services; Ventilation improvements; Asthma-friendly cleaning products and supplies; Other medically appropriate, cost-effective interventions identified to manage and treat asthma.

List is illustrative, not exhaustive; remediations must be of direct medical or remedial benefit to the member and comply with applicable building codes.

Limits and exceptions

Coverage limits and exceptions:

Lifetime maximum and exception: Asthma remediations are payable up to a total lifetime maximum of $7,500; the only exception is when the member's condition has changed so significantly that additional modifications are necessary to ensure health, welfare, safety, or to enable functioning in the home and avoid institutionalization or hospitalization.$7,500

Reauthorization and additional review required for exceptions; services may be provided over time subject to the lifetime maximum.

Exclusions and conduct requirements: Remediations are limited to interventions of direct medical or remedial benefit and exclude adaptations or improvements of general utility to the household and aesthetic embellishments; permanent physical adaptations require written notice to owner/member that the state is not responsible for maintenance/repair and must be performed by a California Contractor's License holder.

Supplies that are not permanent adaptations (e.g., mattress covers, HEPA vacuum, portable dehumidifiers/air filters, cleaning supplies) are exempt from the written-notice requirement.

Asthma remediation home modifications are limited to interventions that provide a direct medical or remedial benefit to the member. Adaptations or improvements of general utility to the household, aesthetic embellishments, and non-medical home improvements are excluded. While remediations may include necessary finishing (for example, drywall and painting) to return the dwelling to a habitable condition, purely cosmetic work is not covered. Before initiating any permanent physical adaptation or installation (for example, exhaust fan installation or replacement of moldy drywall) the plan must provide the owner and member written notice that the modification is permanent and that the state is not responsible for maintenance or repair (including removal if the member no longer resides at the residence). Permanent physical adaptations must be performed by an individual holding a California Contractor's License.

If an equivalent state plan service (for example, Durable Medical Equipment or Asthma Preventive Services) is available and would accomplish the same preventive goals—such as preventing asthma emergencies or hospitalizations—those state plan services should be accessed first. Services that duplicate available state plan benefits may be considered not medically necessary and therefore not provided under Community Support.

Coding and clinical thresholds

Example allowed procedure codeHCPCSCovered

S5165 U5

Home modifications; per service

inv-07: Asthma Control Test score — ≤ 19

ThresholdAsthma Control Test score ≤ 19

Use in eligibilityA score of 19 or lower on the Asthma Control Test qualifies a member for in-home assessments and asthma self-management education during the 2025 transition period.

DocumentationAsthma Control Test result must be included on the Asthma Remediation Referral Form as supporting documentation.

Provider actions, documentation, and authorization

Prior Authorization

Authorization and Reauthorization required; include referral and reason for extension

Authorization (initial) requires submission of the Asthma Remediation Referral Form and supporting documentation. Reauthorization requires submission of a new referral form that includes the reason for the authorization extension; reauthorization periods vary based on remediation needs. Services may be provided over time subject to the total lifetime maximum of $7,500.

Include applicable HCPCS code S5165 U5 when requesting authorization.

Step Therapy

Use state-plan services (DME/APS) before Community Support

If an equivalent state plan service (for example, durable medical equipment or APS) is available and would accomplish the same goals of preventing asthma emergencies or hospitalizations, that state plan service should be accessed before requesting Community Support asthma remediations.

Duplication of services available under the state plan may be considered not medically necessary.

Key definitions

inv-13: Asthma Remediation Community Support — Supplies and/or physical home modifications

DefinitionSupplies and/or physical home modifications to ensure member health, welfare, safety, or to enable functioning in the home with reduced likelihood of acute asthma episodes; available for homes owned, rented, leased, or occupied by the member or caregiver.

Example suppliesAllergen‑impermeable mattress and pillow dustcovers; HEPA‑filtered vacuums; asthma‑friendly cleaning products; mechanical air filters/air cleaners; dehumidifiers.

Example physical modificationsMinor mold removal/remediation, moisture‑controlling interventions, ventilation improvements, and other medically appropriate, cost‑effective home modifications.

inv-14: Poorly controlled asthma — ED visit/hospitalization or two sick/urgent care visits in past 12 months

Poorly controlled asthma (definition)An emergency department visit or hospitalization for asthma, or two sick/urgent care visits for asthma in the past 12 months.

Background

Asthma remediation consists of supplies and physical home modifications intended to reduce environmental triggers and prevent acute asthma episodes, with the clinical goal of reducing emergency department visits and hospitalizations. Covered interventions are limited to those of direct medical or remedial benefit to the member and may include temporary supplies (for example, allergen-impermeable mattress and pillow covers, HEPA-filtered vacuums, dehumidifiers, portable air filters, and asthma‑friendly cleaning supplies) as well as limited physical remediation necessary to restore habitability. All remediations must comply with applicable state and local building codes; permanent adaptations require owner/member notice about maintenance responsibility and must be completed by a California Contractor's License holder. Services must be coordinated so they do not interfere with EPSDT benefits, and equivalent state plan services should be accessed before Community Support remediations when available.