CurrentmhnPolicy N/A

Asthma Remediation Referral Form – English (PDF)

Authorization/referral form and program guidance for Asthma Remediation Community Support services (home supplies and physical modifications) for Medi‑Cal members, including eligibility, required documentation, allowable interventions, restrictions, lifetime maximums, and provider/contractor requirements.

Policy Summary

Payermhn

PolicyAsthma Remediation Referral Form – English (PDF)

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionConfirm and document a completed in-home environmental trigger assessment from APS within the past 12 months that identifies appropriate interventions and explains how they meet the member's needs before authorizing Asthma Remediation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes identified in this brief.

$7,500Lifetime maximum payable

12APS assessment lookback (months)

mechanicalPermitted air cleaners

Policy summary

Asthma Remediation Community Support provides necessary supplies and/or physical home modifications to prevent acute asthma episodes and reduce the need for emergency services or hospitalization. Services are available in a residence owned, rented, leased, or otherwise occupied by the member or their caregiver. Supplies and physical modifications may be provided over time and are subject to a lifetime maximum. The high-level purpose of the program is to ensure the member's health, welfare, and safety or to enable the member to function in the home with reduced likelihood of acute asthma episodes.

Eligibility and covered interventions

Eligibility criteria

Member must meet ALL of the following:

ALL of the following

Member has completed an in-home environmental trigger assessment within the past 12 months through the Asthma Preventive Services (APS) benefit.
The assessment identifies which asthma remediation interventions are medically appropriate.
The assessment explains how these interventions address the member's specific needs related to the service.
When authorizing physical modifications or supplies for Asthma Remediation, Managed Care Plans (MCPs) must confirm and document that the assessment was completed as outlined above.
If residence unchanged
- If the member's residence has not changed, the assessment performed within the last 12 months under the APS benefit is sufficient to establish medical appropriateness for Asthma Remediation.
- If residence unchanged, MCPs do not need any additional documentation to authorize these services.

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Covered interventions (types of request)

Interventions that may be requested (check all that apply):

ANY of the following

Allergen-impermeable mattress and pillow dustcovers.
Asthma-friendly cleaning products and supplies.
De-humidifiers.
High-efficiency particulate air (HEPA) filtered vacuums.
Integrated pest management (IPM) services.

Required documentation, authorization, and provider responsibilities

Documentation required with authorization

Required documents to upload with authorization form:

ALL of the following

Completed in-home environmental trigger assessment within the last 12 months through the APS benefit that identifies which Asthma Remediation services are medically appropriate and specifies how these interventions meet the member's specific needs.
Member consent to asthma remediation referral (required).
Provider attestation/attestations related to permanent modifications (owner/member written documentation that modifications are permanent and state is not responsible for maintenance/repair), unless item is a non‑permanent supply.

Prior Authorization

Authorization required with uploaded assessment

A completed in‑home environmental trigger assessment through the Asthma Preventive Services (APS) benefit must be uploaded with the authorization form for Asthma Remediation. The assessment must have been completed within the last 12 months.

APS assessment upload required with authorization form
Assessment must be within 12 months

Documentation Required

Confirm and document APS assessment

Managed Care Plans (MCPs) must confirm and document that a completed in‑home environmental trigger assessment within the past 12 months through APS identifies which interventions are medically appropriate and explains how those interventions meet the member's specific needs before authorizing Asthma Remediation.

Documentation Required

Member consent

Obtain and document member consent to the asthma remediation referral. Member consent is required and must be recorded with the authorization.

Documentation Required

Owner/member written notification for permanent modifications

Before performing any permanent adaptations or installations (e.g., exhaust fan, replacement of moldy drywall), provide the owner and member written documentation 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.

Documentation Required

Contractor licensing and MCP approval

Ensure that physical adaptations to a residence are performed by an individual holding a California contractor's license, and that all providers are approved by the MCP and enrolled in the Medi‑Cal program as required.

California contractor's license required for physical adaptations
Providers must be approved by the MCP and enrolled in Medi‑Cal

Billing Rule

Lifetime maximum

Apply a lifetime maximum payable total of $7,500 for Asthma Remediation services. An exception to this maximum is allowed if the member's condition has changed significantly and additional modifications are necessary to ensure the member's health, welfare, safety, or to avoid institutionalization or hospitalization.

Lifetime maximum: $7,500
Exception: significant change in member's condition justifying additional modifications

Limitations, conditions, and coding note

Limitations and conditions

Services are subject to ALL of the following limitations:

ALL of the following

If another state plan service beyond the APS (e.g., durable medical equipment) is available and would accomplish the same goals, the state plan service should be accessed first.
Asthma remediations must comply with applicable state and local building codes.
Asthma remediations are payable up to a total lifetime maximum of $7,500.
Exception to $7,500 lifetime maximum: allowed if the member's condition has changed significantly requiring additional modifications to ensure health/welfare/safety or to help the member function with greater independence in the home and avoid institutionalization or hospitalization.
Home modifications are limited to those that are of direct medical or remedial benefit to the member and exclude adaptations/improvements of general utility to the household.
Remediations may include finishing (e.g., drywall and painting) to return home to habitable condition, but do not include aesthetic embellishments.
Before starting a permanent physical adaptation or installation (e.g., exhaust fan, replacement of moldy drywall), the MCP must provide the owner and member with written documentation that modifications are permanent and the state is not responsible for maintenance/repair/removal if member ceases to reside at residence. (Does not apply to non‑permanent supplies such as dust covers, HEPA vacuum, dehumidifiers, portable air filters, asthma cleaning products.)
Physical adaptations to a residence must be performed by an individual holding a California contractor's license.
All allowable providers must be approved by the MCP to ensure adequate experience and appropriate quality of care standards are maintained; providers must enroll in the Medi‑Cal program to continue providing in‑home trigger assessments and asthma self‑management education under APS.
MCPs shall monitor the provision of all included services.

No codes provided in source formmixed

No codes listed

OpenPayer

Asthma Remediation Referral Form – English (PDF)

Policy summary

Eligibility and covered interventions

Required documentation, authorization, and provider responsibilities

Limitations, conditions, and coding note

Definitions

Document changes