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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, eligibility, allowable services, limits, and operational requirements for Asthma Remediation Community Support for Medi‑Cal members in Imperial County served by CHPIV/Health Net.

    Policy Summary
    Payermhn
    PolicyAsthma Remediation Community Support — Coverage Criteria
    Policy CodePolicy N/A
    Change TypeMaterial — coverage reassignment to APS
    Effective DateDec 16, 2025
    Last ReviewDec 16, 2025
    Next Review Date
    Key ActionObtain a completed in-home environmental trigger assessment from APS within the last 12 months to establish member eligibility and submit the Asthma Remediation Authorization Form with supporting documentation.
    SourceLink
    POLICY UPDATE CHANGES

    Asthma self-management education and in-home environmental trigger assessments will be covered under the Asthma Preventive Services (APS) benefit and no longer under Community Supports effective January 1, 2026.

    $7,500total lifetime maximum per member

    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
    1/1/2026APS takeover date
    S5165 U5example billing code

    Coverage Criteria

    Covered Asthma Remediation

    Covered when ALL of the following are met

    Eligibility and prerequisites: Member has a completed in-home environmental trigger assessment through the APS benefit within the last 12 months that identifies medically appropriate asthma remediations and specifies how the interventions meet the member's needsassessment within 12 months

    The APS assessment conducted at the member's residence may be used if medically appropriate

    Service setting and provider: Services are provided in a home owned, rented, leased, or occupied by the member or caregiver; allowable providers must be approved by the MCP and include lung health organizations, healthy housing organizations, local health departments, and community-based providersMCP approval

    Providers must meet MCP minimum standards

    Covered interventions: Supplies and physical modifications identified as medically appropriate and cost‑effective to reduce asthma triggers (examples include allergen‑impermeable mattress/pillow covers, HEPA vacuums, integrated pest management services, dehumidifiers, mechanical air filters, moisture‑control interventions, minor mold remediation, ventilation improvements, asthma‑friendly cleaning products)medically appropriate and cost-effective

    List is not exhaustive

    Limits: Total lifetime payments for remediations do not exceed $7,500 except when a member's condition has changed significantly requiring additional modifications to ensure health, safety, independence, or to avoid institutionalization or hospitalization$7,500

    Exception allowed for significant clinical change

    Asthma Remediation covers only physical changes or supplies that provide a direct medical or remedial benefit to the member. Adaptations or improvements that are of general utility to the household are excluded. Remediations may include necessary finishing (for example, drywall and painting) to return a home to habitable condition when directly related to the remediation, but specifically exclude aesthetic embellishments. Permanent physical adaptations must be performed in accordance with applicable state and local building codes and by a licensed California contractor; providers must also inform owners and members in writing that the state is not responsible for maintenance, repair, or removal if the member stops residing at the residence.

    If an equivalent state plan service (beyond APS) is available and would accomplish the same goals—such as durable medical equipment (DME)—that state plan service must be accessed first rather than duplicating it through Asthma Remediation. Asthma Remediation should not supplant or interfere with other state, local, or federally funded programs and must be complementary to EPSDT and other appropriate services.

    Coding and Limits

    Example covered procedure codemixedCovered
    S5165 U5Home modifications; per service
    In-home environmental trigger assessment recency
    Recency requirementCompleted in-home environmental trigger assessment through APS within the last 12 months
    Assessment contentAssessment must identify medically appropriate asthma remediations and specify how interventions meet the member's needs
    Source of assessmentAPS in-home assessment may be used from the member's residence if it meets medical appropriateness criteria
    Total lifetime maximum
    Total lifetime maximum$7,500
    Exception to maximumException allowed if member's condition changed significantly requiring additional modifications to ensure health, safety, independence, or to avoid institutionalization/hospitalization

    Provider Actions and Authorization

    Prior Authorization

    Authorization and lifetime maximum — Prior authorization required

    Asthma remediations require prior authorization and are subject to a total lifetime maximum. Home modifications and supplies are billed per service and are payable up to a total lifetime maximum of $7,500. An exception to the $7,500 total maximum may be made only if the member's condition has changed so significantly that additional modifications are necessary to ensure health, welfare, or safety, or to enable the member to function with greater independence in the home and avoid institutionalization or hospitalization.

    • Billed per service (example HCPCS S5165 U5 - Home modifications; per service)
    • Allowable providers include lung health organizations, healthy housing organizations, local health departments, and other community-based providers
    Denial Risk

    Missing required APS assessment — Eligibility denied without APS assessment

    A completed in-home environmental trigger assessment through the Asthma Preventive Services (APS) benefit within the last 12 months is required for eligibility. If there is no completed APS assessment within the prior 12 months, the member is not eligible for Asthma Remediation under this benefit.

    Background

    The purpose of Asthma Remediation is to reduce environmental triggers in the home and thereby prevent acute asthma episodes that could require emergency services or hospitalization. Covered interventions consist of supplies and physical modifications that are medically appropriate and intended to lower the risk of asthma exacerbations (examples include allergen‑impermeable mattress/pillow covers, HEPA vacuums, dehumidifiers, mechanical air filters, moisture control, minor mold remediation, ventilation improvements, and integrated pest management). Remediations are intended to supplement clinic‑ or home‑based asthma education and in‑home environmental trigger assessments provided under the APS benefit and to support member health, safety, and independence in the home.

    Definitions

    Asthma Remediation Community Support — definition
    DefinitionNecessary supplies and/or physical modifications to a member's home to ensure health, welfare, and safety or to enable functioning with reduced likelihood of acute asthma episodes
    Supply examplesAllergen‑impermeable mattress/pillow covers, HEPA vacuums, dehumidifiers, portable air filters, asthma‑friendly cleaning products
    Physical modification examplesMinor mold remediation, moisture control, ventilation improvements, finishing (e.g., drywall and painting) when medically necessary
    Installation and code requirementsPhysical adaptations must comply with state/local building codes and be performed by a California licensed contractor when permanent
    APS (Asthma Preventive Services)
    APS definition
    Policy Summary
    Payermhn
    PolicyAsthma Remediation Community Support — Coverage Criteria
    Policy CodePolicy N/A
    Change TypeMaterial — coverage reassignment to APS
    Effective DateDec 16, 2025
    Last ReviewDec 16, 2025
    Next Review Date
    Key ActionObtain a completed in-home environmental trigger assessment from APS within the last 12 months to establish member eligibility and submit the Asthma Remediation Authorization Form with supporting documentation.
    SourceLink
    On This Page
    Coverage CriteriaCoding and LimitsProvider Actions and AuthorizationBackgroundDefinitions
    Billing impactPayments for remediations are subject to this lifetime cap unless exception applies
    • Assessment must identify medically appropriate asthma remediations and specify how interventions meet the member's needs related to the service
    • If the APS-covered assessment documents medical appropriateness for the member's residence, it can be used to determine eligibility
    Documentation Required

    Authorization documentation — Submit completed form and APS assessment

    Authorization documentation is required prior to services. Submit a completed Asthma Remediation Authorization Form and supporting documentation, including a completed in-home environmental trigger assessment (performed through APS within the last 12 months) that specifies medically appropriate remediations and explains how the interventions meet the member's clinical needs.

    • Completed Asthma Remediation Authorization Form
    • Completed in-home environmental trigger assessment through APS within the last 12 months that identifies medically appropriate remediations
    • Assessment must specify how interventions meet the member's needs related to the service
    Medi‑Cal State Plan benefit covering clinic‑based and home‑based asthma self‑management education and in‑home environmental trigger assessments
    APS roleIn‑home assessments identify physical modifications or supplies that would reduce the likelihood of acute asthma episodes
    Operational noteEffective Jan 1, 2026, APS will cover education and in‑home trigger assessments; providers must enroll in Medi‑Cal to provide these APS services