CurrentHealth NetPolicy N/A

Asthma Remediation Community Support — Coverage Criteria

Customize your policy alerts

Sign up for all Health Net policy alerts

Know when Health Net releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Defines Health Net's coverage, eligibility, and administrative requirements for in-home asthma remediation supplies and home modifications (Community Support) for Medi-Cal members in California, including limits and documentation needed for authorization.

Policy Summary

PayerHealth Net

PolicyAsthma Remediation Community Support — Coverage Criteria

Policy CodePolicy N/A

Change TypeProgram transition to APS (phased)

Effective Date

Last ReviewJul 25, 2025

Next Review Date

Key ActionComplete and submit the Asthma Remediation Referral Form with the Medi‑Cal Prior Authorization Request Form Outpatient; member consent to referral is required.

SourceLink

POLICY UPDATE CHANGES

From January 1, 2025 to December 31, 2025 managed care plans should transition in-home environmental trigger assessments and asthma self-management education to the Asthma Preventive Services (APS) program but may continue covering them under Community Support through December 2025.

Effective January 1, 2026 DHCS removed in-home environmental trigger assessments and asthma self-management education from the Asthma Remediation Community Support program and shifted them to the Asthma Preventive Services (APS) program.

$7,500

OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

CurrentHealth NetPolicy N/A

Asthma Remediation Community Support — Coverage Criteria

Customize your policy alerts

Sign up for all Health Net policy alerts

Know when Health Net releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerHealth Net

PolicyAsthma Remediation Community Support — Coverage Criteria

Policy CodePolicy N/A

Change TypeProgram transition to APS (phased)

Effective Date

Last ReviewJul 25, 2025

Next Review Date

Key ActionComplete and submit the Asthma Remediation Referral Form with the Medi‑Cal Prior Authorization Request Form Outpatient; member consent to referral is required.

SourceLink

POLICY UPDATE CHANGES

$7,500

Jan 1–Dec 31, 2025transitional period

Jan 1, 2026APS effective

Coverage and Medical Necessity Criteria

Medical necessity criteria

Covered when ANY ONE of the following is met:

Poorly controlled asthma: Member has poorly controlled asthma defined as an emergency department visit, hospitalization, or two sick/urgent care visits due to asthma in the past 12 months

supported by clinical documentation

ACT score: Member has an Asthma Control Test score of 19 or lowerACT ≤ 19

score documented in submission

Provider recommendation: Licensed healthcare provider (e.g., physician, nurse practitioner, or physician assistant) recommends the service will likely avoid asthma-related hospitalizations, emergency department visits, or other high-cost services

signed recommendation required

Covered supplies and modifications

Covered interventions may include, but are not limited to:

Supplies and interventions: Allergen-impermeable mattress and pillow dustcovers; minor mold removal and remediation services; asthma-friendly cleaning products and supplies; moisture-controlling interventions; dehumidifiers; ventilation improvements; HEPA-filtered vacuums; integrated pest management (IPM) services; mechanical air filters/air cleaners; other medically appropriate interventions

Items may be provided as supplies or permanent modifications per clinical need

Asthma remediation services under Community Support are limited to items that are medical or remedial benefits to the member and must comply with applicable State and local building codes. Remediations may include necessary finishing (for example, drywall and painting) to return the home to a habitable condition, but explicitly exclude adaptations or improvements that are general household utilities or aesthetic embellishments. A total lifetime maximum of $7,500 applies to asthma remediation home modifications; an exception to this maximum may be made only if the member’s condition has changed significantly such that additional modifications are necessary to ensure health, welfare, safety, or to avoid institutionalization or hospitalization.

Electronic air cleaners that generate ozone or ions are not permitted for asthma remediation. Only air cleaners classified as mechanical—those that use physical filtration such as pleated or HEPA-style filters and do not generate ozone or ions—are allowed. For device certification information, refer to the California Air Resources Board list of certified air cleaning devices.

If another State Plan service (for example, durable medical equipment) is available and would accomplish the same prevention of asthma emergencies or hospitalizations, that State Plan service must be accessed first rather than granting remediation under Community Support. Failure to use the applicable State Plan benefit first may place the remediation request at risk of denial.

Codes, Tests, and Clinical Thresholds

Covered items (examples listed)mixedCovered

No codes listed

Asthma Control Test (ACT) threshold

ACT thresholdAsthma Control Test score of 19 or lower (ACT ≤19)

Acceptable documentationACT score must be documented in the prior authorization submission

Alternative criteriaAn ACT ≤19 satisfies one of multiple eligibility criteria (poor control or licensed provider recommendation)

Authorization, Documentation, and Administrative Steps

Prior Authorization

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 at 800‑743‑1655. Member consent to the asthma remediation referral is required. Initial and extension requests must be indicated on the referral.

Submit referral with Medi‑Cal Prior Authorization Request Form (Outpatient).
Online submission recommended: provider.healthnetcalifornia.com
Fax: 800-743-1655
Member consent required; indicate initial or extension request.

Note

Access other State Plan services first

If an equivalent State Plan service (for example, durable medical equipment or other State Plan benefit) is available and would accomplish the same goal of preventing asthma emergencies or hospitalizations, that State Plan service must be accessed first before using Asthma Remediation Community Supports.

Key Definitions

Mechanical air cleaners — permitted vs prohibited

Permitted typesMechanical air cleaners that use only physical filtration (pleated or HEPA-style filters)

Examples of permitted itemsHEPA-filtered vacuums and mechanical air filters/air cleaners listed as mechanical

Prohibited typesElectronic air cleaners that generate ozone or ions (ozone/ion generators) are not permitted

Poorly controlled asthma definition

Primary definitionPoorly controlled asthma is defined as an emergency department visit, hospitalization, or two sick/urgent care visits due to asthma in the past 12 months

Alternate qualifying evidenceAn ACT score of 19 or lower (ACT ≤19) may alternatively indicate poor control

Background and Scope

Asthma remediation services provide supplies and home modifications intended to reduce environmental triggers and prevent acute asthma episodes that could lead to emergency department visits or hospitalization. Interventions range from non‑permanent supplies (for example, allergen‑impermeable mattress and pillow covers, HEPA‑filtered vacuums, dehumidifiers, portable air filters, and asthma‑friendly cleaning products) to necessary physical home adaptations (for example, minor mold remediation, ventilation improvements, moisture control, or exhaust fan installation) when clinically indicated. Prior to starting any permanent home adaptation or installation, the owner and member must receive written notification that the modifications are permanent and that the State is not responsible for maintenance, repair, or removal of the modification if the member ceases to reside at the residence; this notification requirement does not apply to non‑permanent supplies.

Policy Summary

PayerHealth Net

PolicyAsthma Remediation Community Support — Coverage Criteria

Policy CodePolicy N/A

Change TypeProgram transition to APS (phased)

Effective Date

Last ReviewJul 25, 2025

Next Review Date

Key ActionComplete and submit the Asthma Remediation Referral Form with the Medi‑Cal Prior Authorization Request Form Outpatient; member consent to referral is required.

SourceLink

On This Page

Access available State Plan services first if they accomplish the same prevention goals.
This precedence applies to services beyond the Community Supports program such as durable medical equipment.

Documentation Required

Required clinical documentation

Document one or more of the following to support medical necessity: (1) evidence of poorly controlled asthma (ED visit, hospitalization, or two sick/urgent care visits for asthma in the past 12 months); OR (2) Asthma Control Test score ≤ 19; OR (3) recommendation from a licensed health care provider that the remediation will likely avoid asthma‑related hospitalizations, ED visits, or other high‑cost services. Include any additional documentation from the Community Supports provider or others, and the results/date of in‑home environmental trigger assessment or scheduled home visit.

Document at least ONE of: poorly controlled asthma (ED visit, hospitalization, or two sick/urgent care visits in past 12 months); ACT score ≤ 19; or licensed provider recommendation.
Include additional supporting documentation from Community Supports provider or others.
Include date and findings of in‑home environmental trigger assessment or scheduled home visit.

Documentation Required

Owner/member notification for permanent modifications

Before beginning any permanent physical adaptation or installation (for example, installation of an exhaust fan or replacement of moldy drywall), the managed care plan must provide the owner and member written notification 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 owner/member notification requirement does not apply to non‑permanent supplies (for example: allergen‑impermeable mattress and pillow covers, HEPA vacuums, dehumidifiers, portable air filters, and asthma‑friendly cleaning supplies).

Provide written documentation to owner and member that: modifications are permanent and State is not responsible for maintenance, repair, or removal if member no longer resides at residence.
Requirement excludes non‑permanent supplies (e.g., mattress/pillow covers, HEPA vacuums, dehumidifiers, portable air filters, cleaning supplies).

Note

State Plan service precedence

Asthma remediations must comply with applicable State and local building codes and are payable up to a total lifetime maximum of $7,500, except when the member's condition has significantly changed requiring additional modifications. Remediations are limited to items that are a medical or remedial benefit to the member and exclude general household improvements or aesthetic embellishments.

Remediations must meet State and local building codes.
Lifetime maximum payable: $7,500 (exceptions if member condition significantly changes).
Modifications limited to medical/remedial benefit; exclude general utility or aesthetic improvements.

Provider attestationA licensed health care provider's recommendation that the service will likely avoid asthma-related hospitalizations or ED visits also qualifies