CurrentHealth NetPolicy N/A

Asthma Remediation Referral Form

Policy Summary

PayerHealth Net

PolicyAsthma Remediation Referral Form

Policy CodePolicy N/A

Change TypeRevised – transition to APS

Effective DateN/A

Next Review DateN/A

Key ActionComplete and submit the Asthma Remediation Referral Form with the Medi‑Cal Prior Authorization Request Form (Outpatient) online or by fax to 800-743-1655.

SourceLink

POLICY UPDATE CHANGES

Updated guidance noting transition of in-home environmental trigger assessments and asthma self-management education to APS between Jan 1, 2025 and Dec 31, 2025 and removal from Community Support effective Jan 1, 2026.

$7,500Lifetime maximum per member

<=19ACT score threshold

Jan 1, 2026APS transition effective date

Coverage Summary

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Defines eligibility, required documentation, allowed interventions, restrictions, lifetime maximums, and referral/authorization process for Asthma Remediation Community Support for Medi‑Cal members; includes transition timing for in-home assessments and asthma self-management education to the Asthma Preventive Services (APS) program. Coverage stance: covered_with_criteria. Status: CURRENT. Services are subject to a per-member lifetime maximum of $7,500 (exception only for significant change in condition). 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 these services move to the APS program per DHCS.

Eligibility and Medical Necessity

Eligibility / Medical Necessity for Asthma Remediation Community Support (through Dec 31, 2025 for certain services)

Covered when ANY of the following are met:

ANY of the following

Poorly controlled asthma: Member has 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: Member has a score of 19 or lower on the Asthma Control Test<= 19
Provider recommendation: Recommendation from a licensed health care provider (physician, nurse practitioner, or physician assistant) that the service will likely avoid asthma-related hospitalizations, emergency department visits, and/or other high-cost services

Service Availability / Location

Covered when ALL of the following are met:

Service location and timing

Home occupancy: Services provided in a home that is owned, rented, leased or occupied by the member or their caregiver
Provided over time subject to lifetime maximums: Services may be provided over time and need not be concurrent, subject to lifetime maximums$7,500 lifetime

Allowed Interventions and Items

Allowed Interventions / Items

Covered as medically necessary interventions under Asthma Remediation Community Support (check all that apply):

Allowed interventions

Dustcovers: Allergen-impermeable mattress and pillow dustcovers
Mold remediation: Minor mold removal and remediation services
Cleaning products: Asthma-friendly cleaning products and supplies
Moisture interventions: Other moisture-controlling interventions
Dehumidifiers: De-humidifiers
Ventilation improvements
HEPA vacuums: High-efficiency particulate air (HEPA) filtered vacuums
Other medically appropriate: Other interventions identified to be medically appropriate for the management and treatment of asthma
IPM: Integrated pest management (IPM) services
Mechanical air cleaners: Mechanical air filters/air cleaners (mechanical only; non-ozone-generating)

Restriction: only mechanical air cleaners are permitted (defined as devices using physical filtration such as pleated or HEPA filters). Electronic air cleaners that generate ozone or ions are excluded because they can produce ozone and other reactive compounds that harm health.

Transition: In‑home Assessments & Asthma Self‑Management Education

Transition for In-home Assessments and Asthma Self-management Education (Jan 1, 2025 to Dec 31, 2025)

During transition period, managed care plans may cover the following under Community Support as medically necessary through 12/31/2025; coverage requires the member to meet eligibility criteria above:

Transition services (through 12/31/2025)

In-home assessments: In-home environmental trigger assessments
Asthma education: Asthma self-management education

Operational note: Per DHCS guidance, managed care plans should transition in-home environmental trigger assessments and asthma self-management education out of the Asthma Remediation Community Support program; these services may be covered under Community Support through December 31, 2025 but will be provided under the Asthma Preventive Services (APS) program effective January 1, 2026.

Exclusions and Limitations

Exclusions / Limitations

Not covered or limited when any of the following apply:

Exclusions

General utility or aesthetic: Asthma remediations that are general utility household adaptations or aesthetic embellishments (not a medical/remedial benefit to the member)
Electronic air cleaners excluded: Electronic air cleaners that generate ozone or ions (only mechanical air cleaners permitted)

Provider Actions and Documentation Requirements

Prior Authorization

Submit referral with prior authorization request

Complete and submit Asthma Remediation Referral Form with the Medi‑Cal Prior Authorization Request Form (Outpatient) online at provider.healthnetcalifornia.com or by fax to 800-743-1655.

Documentation Required

Member clinical documentation required

Provide documentation of poorly controlled asthma (ED/hospitalization/two sick or urgent visits in 12 months) OR Asthma Control Test score <=19 OR a licensed provider recommendation that the service will likely avoid high-cost asthma services.

Documentation Required

Home visit documentation for in-home assessments

Document date of home visit or scheduled home visit when in-home environmental trigger assessments are performed to determine suitability of requested remediations.

Billing Rule

Owner notification for permanent modifications

Before starting permanent physical adaptations or installations, provide owner and member written documentation that modifications are permanent and State is not responsible for maintenance/repair or removal if member ceases residency (does not apply to non-permanent supplies).

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

Step Therapy

State Plan service precedence

If another State Plan service (e.g., durable medical equipment) is available and would accomplish the same prevention of asthma emergencies, that State Plan service should be accessed first.

Definitions & Background

Asthma Remediation Community Support provides supplies and/or physical home modifications to reduce environmental triggers and prevent acute asthma episodes leading to high-cost services. Only mechanical air cleaners (no ozone/ion-generating devices) are permitted. Services are available in member-occupied homes (owned, rented, leased, or occupied by the member or caregiver) and may be provided over time, subject to the $7,500 lifetime maximum.

Definitions

In-home environmental trigger assessmentsIdentification of environmental asthma triggers commonly found in and around the home (allergens and irritants) to guide supplies, home modifications, and education.

Mechanical air cleanersAir cleaners that only use physical filtration (e.g., pleated or HEPA filters) and do not generate ozone or ions.

Poorly controlled asthmaAn ED visit or hospitalization or two sick or urgent care visits due to asthma in the past 12 months.