CurrentmhnPolicy N/A

Authorization Guide for Environmental Accessibility Adaptations (Home Modifications)

Defines authorization, eligibility, documentation, allowable services, provider requirements, limits, and billing codes for Environmental Accessibility Adaptations (EAAs) / home modifications to ensure member safety and independence and avoid institutionalization.

Policy Summary

Payermhn

PolicyAuthorization Guide for Environmental Accessibility Adaptations (Home Modifications)

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionProvider must submit a provider order and a physical or occupational therapy evaluation/report demonstrating medical necessity (unless plan approves without evaluation).

POLICY UPDATE CHANGES

No material clinical or coverage changes

1Lifetime maximum tiers

7500Total lifetime maximum ($)

90Assessment timeframe (days)

Coverage Summary

Scope: Environmental Accessibility Adaptations (EAAs), also called home modifications, are physical modifications to a member's residence intended to ensure health, welfare and safety and to enable greater independence so the member can avoid institutionalization. Key services are limited to those of direct medical or remedial benefit and must meet authorization, eligibility, documentation, provider and building-code requirements.

Authorization & Medical Necessity Criteria

General Authorization Criteria

Members must meet ALL of the following to qualify:

Home occupancy: Service is provided in a home that is owned, rented, leased or occupied by the member.
Risk of institutionalization: Member is at risk for institutionalization in a nursing facility.
Medical necessity / purpose: Requested EAAs are necessary to ensure health, welfare and safety of the individual or enable the individual to function with greater independence in the home and avoid institutionalization.
Provider order specifying the requested equipment or service from the member's current primary care physician or other qualified health professional (MD, PA, NP).
Therapy evaluation: A physical or occupational therapy evaluation and report to evaluate medical necessity, unless the managed care plan approves without an evaluation.
Bids / cost estimates: Bids or cost estimates for the requested service including itemized services, cost, labor, and warranties; if possible, a minimum of two bids.
Home visit to determine suitability of requested equipment or service.
Owner consent: For homes not owned by member, written consent from owner for physical adaptations or for equipment physically installed in the home.
Contractor license: Provider performing physical adaptations must hold a California Contractor's License, except for PERS installation which follows system installation requirements.
Building codes: EAAs must be conducted in accordance with applicable state and local building codes.

Service and Scope Limitations / Exclusions

EAAs are subject to the following limitations and exclusions:

Direct medical benefit only: Services are limited to those of direct medical or remedial benefit to the member and exclude adaptations or improvements of general household utility.
No added square footage except when necessary: Adaptations that add to the total square footage of the home are excluded except when necessary to complete an adaptation (e.g., to improve entrance/egress or configure a bathroom to accommodate a wheelchair).
Finishing allowed, not aesthetic: May include finishing (e.g., drywall and painting) to return the home to a habitable condition but does not include aesthetic embellishments.
Use other State Plan services when available: If another State Plan service (e.g., Durable Medical Equipment) is available and would accomplish the same goals, that service should be used instead of EAAs.

Initial Authorization and Timeframes

Members must meet ALL of the following to qualify:

90-day assessment requirement: Community Support provider has 90 days to conduct the initial assessment and begin modifications; assessment and authorization must take place within a 90-day time frame beginning with the request for the EAA unless more time is required for homeowner consent or patient-requested longer timeframe.
Lifetime maximum coverage: Service is covered until the total lifetime maximum of $7,500 is met.$7,500

Exceptions to Lifetime Maximum

Members must meet ANY of the following to qualify for an exception:

Change of residence: Exception if the member's place of residence changes.
Significant condition change: Exception if the member's condition has changed so significantly that additional modifications are necessary to ensure health, welfare and safety or to enable greater independence and avoid institutionalization or hospitalization.

Provider Actions & Requirements

Prior Authorization

Authorization required and initial assessment timeframe

Community Support (CS) provider must conduct the initial assessment and begin modifications within 90 days of the request. Initial authorization is required and services are covered up to a total lifetime maximum of $7,500.

Documentation Required

Submit provider order and therapy evaluation

Provider must submit a provider order from the member's current primary care physician or another qualified clinician (MD, PA, NP). A physical or occupational therapy evaluation and report demonstrating medical necessity must be provided unless the managed care plan approves without an evaluation.

Documentation Required

Submit bids and home visit documentation

Provider must submit bids or cost estimates for the requested service that include an itemized list of services, costs, labor, and applicable warranties. If possible, a minimum of two bids is preferred. Documentation of a home visit to determine the suitability of the requested equipment or service is also required.

Documentation Required

Owner consent for non-owned homes

When the residence is not owned by the member, written consent from the property owner is required for physical adaptations or for equipment that is physically installed in the home.

Billing Rule

Contractor licensing requirement

All physical adaptations to a residence must be performed by an individual holding a California Contractor's License, except for PERS installations which may follow the system's installation requirements.

Prior Authorization

Reauthorization submission

If a service extension is needed, the provider must submit a new authorization that includes verification of the work performed to date and the reason for the extension (for example, more time to receive homeowner consent or a member-requested longer timeframe).

Background & Definitions

Background: EAAs (home modifications) are physical changes to a member's home to ensure safety and independence and to avoid institutionalization. Typical services and examples include ramps and grab bars to assist access, doorway widening for wheelchair access, stair lifts, making bathrooms wheelchair accessible such as constructing a roll-in shower, and installation of specialized electrical and plumbing systems necessary to accommodate medical equipment.

Additional program details: For homes not owned by the member, written owner consent is required for physical adaptations or equipment installations; permanent modification notices must be provided to owner and member; physical adaptations must generally be performed by a California Contractor except for PERS installations.

Billing/coding: Home modifications are billed under HCPCS code S5165 (with modifiers referenced in the program guidance).

Term	Definition
Environmental Accessibility Adaptations (EAA)	Physical home modifications necessary to ensure the health, welfare and safety of the individual or enable the individual to function with greater independence in the home.
Community Support (CS) provider	Provider responsible for conducting initial assessment and beginning modifications within the required timeframe (90 days) and for initiating modifications as part of the EAA authorization process.

S5165	Home modifications
U6	Modifier/descriptor listed in document (paired with S5165 in text)
U1	Deposit (listed in document)

OpenPayer

Authorization Guide for Environmental Accessibility Adaptations (Home Modifications)

Coverage Summary

Authorization & Medical Necessity Criteria

Billing Codes

Provider Actions & Requirements

Background & Definitions

Revision History