ModifiedHealth NetPolicy N/A

Authorization Guide for Asthma Remediation

Defines coverage, eligibility, allowable services, restrictions, provider requirements, and lifetime maximums for Asthma Remediation community supports for Medi‑Cal members administered by the plan (CalViva/Health Net). Governs supplies and home physical modifications to reduce asthma triggers; excludes services migrated to the APS benefit effective Jan 1, 2026.

Policy Summary

PayerHealth Net

PolicyAuthorization Guide for Asthma Remediation

Policy CodePolicy N/A

Change TypeModified coverage and provider requirements

Effective DateJan 1, 2026

Next Review DateN/A

Key ActionProviders must submit the Asthma Remediation Authorization Form with supporting documentation 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.

SourceLink

POLICY UPDATE CHANGES

Asthma Remediation services must supplement, not supplant APS or other state/local/federally funded programs.

$7,500Total lifetime maximum

12 monthsRequired APS assessment recency

2026-01-01

Coverage Summary

Asthma Remediation Community Support covers supplies and home physical modifications to reduce environmental asthma triggers and prevent acute episodes that could require emergency care or hospitalization. It is intended to complement — not replace — the Asthma Preventive Services (APS) Medi‑Cal State Plan benefit, and must supplement other state, local, or federally funded programs per CalAIM Special Terms and Conditions. The policy stance is mixed, with specific coverage when eligibility and program criteria are met.

Effective January 1, 2026, in‑home environmental trigger assessments and asthma self‑management education are removed from Asthma Remediation Community Support and must be provided under the APS benefit; Asthma Remediation therefore focuses on remediation supplies and physical home modifications while relying on a recent APS assessment to authorize services.

Policy-level thresholds and headline limits

Total lifetime maximum$7,500

Required APS assessment recencyCompleted within the last 12 months

Policy change effective dateJanuary 1, 2026

Medical Necessity / Eligibility and Covered Services

Eligibility / Covered When ALL of the Following Are Met

Covered when ALL of the following are met:

ALL of the following

Member has a completed in-home environmental trigger assessment through the Asthma Preventive Services (APS) benefit within the last 12 months.
Assessment must have been completed via APS (not Community Support) as of effective 2026-01-01.
The APS assessment identifies medically appropriate asthma remediations and specifies how the recommended interventions meet the member's needs related to asthma management.
Documentation must be retained on the Asthma Remediation Authorization Form and supporting records.
The member resides in the dwelling where the remediation will occur (owned, rented, leased, or occupied by the member or their caregiver).
The requested remediation is medically appropriate and cost-effective to prevent acute asthma episodes, reduce emergency services or hospitalization, and is not available under another State Plan service (beyond APS).

Exclusions and Not Covered Services

Exclusions / Not Covered

Services not covered under Asthma Remediation Community Support:

APS migration of assessments and education: Asthma self-management education and in-home environmental trigger assessments are no longer covered under Community Supports effective January 1, 2026; these services must be covered under the APS benefit.Effective January 1, 2026

Asthma Remediation providers must enroll in Medi‑Cal to continue providing these services under APS.

Household utility and aesthetic exclusions: Adaptations or improvements of general household utility or aesthetic embellishments are excluded from Asthma Remediation coverage.

Finishing to return home to habitable condition allowed; aesthetic embellishments excluded.

Provider Actions & Administrative Requirements

Prior Authorization

Authorization form and supporting documentation required

Submit the Asthma Remediation Authorization Form with supporting documentation, 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.

Affected code: S5165

Documentation Required

Written notice to owner before permanent modifications

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

Not applicable to non-permanent supplies (e.g., mattress covers, HEPA vacuums, portable filters, dehumidifiers, cleaning products).

Codes

Service HCPCSHCPCSCovered

S5165	Home modifications; per service
U5	Modifier/other code as presented in document (S5165 U5 listed)

Background and Provider/Program Requirements

The program purpose is to provide medically appropriate, cost‑effective supplies and minor home modifications that reduce asthma triggers and prevent acute asthma events. Allowable providers include lung health organizations, healthy housing organizations, local health departments, community‑based providers and similar organizations, but all allowable providers must be approved by the Medi‑Cal Managed Care Plan (MCP) to ensure adequate experience and acceptable quality of care; MCPs must apply minimum standards and monitor service provision.

Enrollment and documentation requirements tie Asthma Remediation to APS: members must have a completed in‑home environmental trigger assessment through APS within the last 12 months that identifies medically appropriate remediations and specifies how the interventions meet the member's needs. To authorize Asthma Remediation, providers must submit the Asthma Remediation Authorization Form with supporting documentation, including the APS assessment. Additionally, Asthma Remediation providers must enroll in the Medi‑Cal program to continue providing APS‑related services where applicable.

Definitions

Asthma Preventive Services (APS)Medi-Cal State Plan benefit that includes clinic- and home-based asthma self-management education and in-home environmental trigger assessments identifying physical modifications or supplies to reduce likelihood of acute asthma episodes.

Revision History

2026-01-01material_revisionLatest

Effective January 1, 2026, in-home environmental trigger assessments and asthma self-management education are removed from Asthma Remediation Community Support and must be covered under the APS benefit. APS now covers clinic-based and home-based asthma self-management education and in-home environmental trigger assessments; Asthma Remediation now requires an APS assessment within the last 12 months to authorize remediation (assessment must identify medically appropriate remediations and specify how interventions meet member needs).

2026-01-01clarificationLatest

CalAIM Special Terms and Conditions requirement implemented: Asthma Remediation services must supplement, not supplant APS or other state/local/federally funded programs. Providers must ensure Community Supports enhance but do not replace state plan services; Asthma Remediation providers must enroll in Medi-Cal to continue providing in-home trigger assessments and asthma self-management education under APS.

Limits / Exceptions

Limits and exceptions (ALL of the following apply):

ALL of the following

Total lifetime maximum payment for Asthma Remediation is $7,500 per member.
An exception to the $7,500 total maximum may be granted only if the member's condition has changed so significantly that additional modifications are necessary to ensure health, welfare and safety, or to enable the member to function with greater independence and avoid institutionalization or hospitalization.
Asthma Remediation must supplement and not supplant services available under APS or other State Plan services; if an equivalent State Plan service is available, that service must be accessed first.
APS provides in-home trigger assessments and asthma self-management education; these services are not covered under Community Support as of 2026-01-01.
All physical remediations must comply with applicable state and local building codes.
Permanent physical adaptations or installations require prior written notice to the owner and member stating the modifications are permanent and the state is not responsible for maintenance or repair, including removal if the member ceases residency.
Permanent physical adaptations or installations must be performed by an individual holding a valid California contractor's license.
This requirement does not apply to non-permanent supplies (e.g., mattress covers, portable HEPA vacuums, de‑humidifiers, portable air filters, asthma-friendly cleaning supplies).
Asthma Remediation home modifications are limited to those of direct medical or remedial benefit to the member and exclude adaptations or improvements of general household utility or aesthetic embellishment.
Finishing (e.g., drywall and painting) may be included only to return the home to a habitable condition as part of a medically necessary remediation, but not for cosmetic enhancements.
Providers and programs must meet MCP approval and monitoring requirements to ensure adequate experience and quality of care; allowable provider types include, but are not limited to, lung health organizations, healthy housing organizations, local health departments, and community-based providers and organizations.
All providers performing APS assessments or delivering remediation must be enrolled/approved per Medi‑Cal and MCP requirements.