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    v1.0.28
    OpenPayerPolicy UpdatesPulmonologymhn Asthma Remediation Coverage Update | OpenPayer
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    CurrentmhnPolicy N/A

    Asthma Remediation Community Support — Coverage Criteria

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    Defines coverage, provider requirements, allowable interventions, eligibility, lifetime maximums, and restrictions for Asthma Remediation services for Medi-Cal members served by the plan in California (Imperial County local context noted).

    Policy Summary
    Payermhn
    PolicyAsthma Remediation Community Support — Coverage Criteria
    Policy CodePolicy N/A
    Change TypeRevised coverage assignment (APS)
    Effective DateJan 1, 2026
    Next Review DateN/A
    Key ActionObtain and include a completed APS in-home environmental trigger assessment within the last 12 months when submitting authorization for Asthma Remediation.
    SourceLink
    POLICY UPDATE CHANGES

    Asthma self-management education and in-home environmental trigger assessments are removed from Community Support and must be covered under the Asthma Preventive Services (APS) benefit effective January 1, 2026.

    $7,500lifetime maximum ($)

    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.

    12 months
    assessment recency
    Jan 1, 2026policy change effective
    S5165 U5example billing code
    Imperial Countylocal context

    Coverage Criteria

    Initial Eligibility

    Covered when ALL of the following are met:

    Eligibility requirements: Member has a completed in-home environmental trigger assessment within the last 12 months through the APS benefit that identifies medically appropriate asthma remediations and specifies how interventions meet the member's needs; member resides in the home owned, rented, leased, or occupied by the member or their caregiver; interventions are medically appropriate and cost-effective12 months

    Assessment from APS may be used to determine eligibility

    Covered Interventions

    Covered items include, but are not limited to:

    Interventions: Allergen-impermeable mattress and pillow dustcovers; High-efficiency particulate air (HEPA) filtered vacuums; Integrated pest management (IPM) services; De-humidifiers; Mechanical air filters/air cleaners; Other moisture-controlling interventions; Minor mold removal and remediation services; Ventilation improvements; Asthma-friendly cleaning products and supplies; Other medically appropriate and cost-effective interventions

    Supplies and physical modifications listed are examples, not exhaustive

    Coverage Limits

    Coverage limit:

    Lifetime maximum: Asthma remediations are payable up to a total lifetime maximum of $7,500 per member$7,500

    Exception: additional modifications may be approved 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

    Asthma Remediation home modifications are restricted to interventions that provide a direct medical or remedial benefit to the member. Modifications that constitute adaptations or improvements of general utility to the household are excluded from coverage. Covered remediations may include necessary finishing (for example, drywall and painting) to return a home to a habitable condition, but do not include aesthetic embellishments.

    Physical adaptations that are primarily of general household utility or are aesthetic in nature are not medically necessary and are excluded from Asthma Remediation coverage. Prior to any permanent adaptation or installation (such as an exhaust fan or replacement of moldy drywall), the managed care plan must provide the owner and member with written documentation that the modification is permanent and that the state is not responsible for maintenance, repair, or removal if the member no longer resides at the residence.

    Coding & Limits

    Example billing code for home modificationsHCPCS
    S5165 U5Home modifications; per service
    inv-07: Assessment recency — completed within the last 12 months
    Assessment recencyCompleted within the last 12 months via an APS in‑home environmental trigger assessment
    Assessment content requirementAssessment must identify medically appropriate asthma remediations and specify how interventions meet the member's needs
    Eligible assessment sourceAssessment must be completed through the Asthma Preventive Services (APS) benefit
    inv-08: Total lifetime maximum — $7,500
    Total lifetime maximumAsthma remediations are payable up to a total lifetime maximum of $7,500 per member
    Exception to maximumAdditional modifications may be approved if the member's condition changes significantly such that extra modifications are necessary to ensure health, welfare, safety, or to avoid institutionalization or hospitalization

    Provider Actions & Requirements

    Prior Authorization

    Prior Authorization & Billing

    Prior authorization is required. Submit an Asthma Remediation Authorization Form with supporting documentation, including a completed APS in‑home environmental trigger assessment conducted within the last 12 months that identifies medically appropriate remediations and explains how each intervention meets the member's needs. Authorization requests for home modifications must document the medical necessity and itemize costs. Billing note: use S5165 U5 for home modification services where applicable and follow payer billing guidance for units and modifiers.

    • Required: Asthma Remediation Authorization Form
    • Required: Completed APS in‑home environmental trigger assessment within 12 months
    • Provider examples: lung health organizations, healthy housing organizations, local health departments, community‑based providers (not exhaustive)

    Definitions

    inv-14: Asthma Remediation Community Support — definition of necessary supplies and physical modifications
    Definition (core)Necessary supplies and/or physical modifications to a home environment to ensure the health, welfare, and safety of a member, or to enable the member to function in the home with reduced likelihood of an acute asthma episode
    Example suppliesAllergen‑impermeable mattress and pillow dustcovers; HEPA‑filtered vacuums; asthma‑friendly cleaning products and supplies
    Example physical modifications/servicesIntegrated pest management (IPM); dehumidifiers; mechanical air filters; minor mold removal and remediation; ventilation improvements
    inv-15: Asthma Preventive Services (APS) — definition and note that asthma education and in-home assessments moved to APS
    APS definitionMedi‑Cal State Plan services that include clinic‑based and home‑based asthma self‑management education and in‑home environmental trigger assessments identifying physical modifications or supplies to reduce acute asthma episodes

    Background

    Asthma Remediation provides supplies and physical home modifications intended to reduce environmental triggers and prevent acute asthma episodes that could lead to emergency services or hospitalization. The program covers interventions that are of direct medical or remedial benefit to the member and must be performed in accordance with applicable state and local building codes; permanent adaptations require prior written notice to the owner and member clarifying that the state is not responsible for maintenance or repair. Examples of non-permanent supplies (which do not trigger the permanent-adaptation notice requirement) include allergen-impermeable mattress and pillow covers, HEPA-filtered vacuums, dehumidifiers, portable air filters, and asthma-friendly cleaning products.

    Policy Summary
    Payermhn
    PolicyAsthma Remediation Community Support — Coverage Criteria
    Policy CodePolicy N/A
    Change TypeRevised coverage assignment (APS)
    Effective DateJan 1, 2026
    Next Review DateN/A
    Key ActionObtain and include a completed APS in-home environmental trigger assessment within the last 12 months when submitting authorization for Asthma Remediation.
    SourceLink
    On This Page
    Coverage CriteriaCoding & LimitsProvider Actions & RequirementsDefinitionsBackground
    Scope of limitLifetime maximum applies to Asthma Remediation Community Support services
    Billing Rule

    Preference for State‑Plan Services

    If a comparable state plan service is available and would accomplish the same clinical goals (for example, Durable Medical Equipment or other APS‑provided services), that state plan service must be accessed first before using Asthma Remediation Community Support.

    • APS (Asthma Preventive Services) — clinic‑based and home‑based education and in‑home environmental trigger assessments are covered under the State Plan and should be used when applicable
    • If DME or another state plan benefit covers the needed intervention, bill the state plan service rather than Community Support
    Documentation Required

    Required Documentation

    A completed APS in‑home environmental trigger assessment within the last 12 months is required to support authorization. The assessment must identify medically appropriate remediations and specify how the interventions meet the member's needs. If the APS assessment meets medical appropriateness criteria, it may be used to determine eligibility for Asthma Remediation without additional medical documentation.

    • Include the APS assessment date and summary with the Authorization Form
    • If the APS assessment was completed through the APS benefit and documents medical appropriateness, no additional medical documentation is required
    Denial Risk

    Denial / Ineligibility Triggers

    Failure to document a completed APS in‑home environmental trigger assessment within the prior 12 months or failure to show how proposed remediations are medically appropriate may result in denial of the authorization. Home modifications that are not of direct medical/remedial benefit or that duplicate state plan services are not eligible.

    • Missing or outdated APS assessment (>12 months) — denial risk
    • Proposed remediations that are general household improvements or aesthetic — not eligible
    • If a state plan service would cover the intervention, authorization may be denied in favor of that service
    Policy change effective dateAs of January 1, 2026, asthma self‑management education and in‑home environmental trigger assessments must be covered under APS rather than Community Supports
    Provider requirementAsthma Remediation providers must enroll in Medi‑Cal to provide in‑home trigger assessments and asthma self‑management education under APS