Unless Congress acts by Sept. 30, the Acute Hospital Care at Home (AHCaH) waiver that allows hospitals to provide hospital-level care in patients’ homes will expire, disrupting programs in 39 states. If no waiver extension happens by that date, patients who still need inpatient care would have to be moved from their homes back to brick-and-mortar hospitals and the programs paused or shut down. 

During a Sept. 11 Hospital at Home Users Group webinar, Ashby Wolfe, M.D., M.P.P., M.P.H., regional chief medical officer at the Centers for Medicare & Medicaid Services, spoke about the potential fall-out of congressional inaction. 

CMS officials said that 413 hospitals have been approved to participate in the waiver program, and they have served 48,500 patients in the program since November 2020. 

Wolfe reminded the webinar participants that the waiver, which originated with the COVID-19 public health emergency, was originally designed to decompress acute care hospitals and expand capacity during COVID-19 surges under the declared public health emergency. 

The waiver is tied to hospital payment requirements under authority CMS can use when there is a declared national public health emergency. “The emergency authority is what allows us to waive these conditions of participation and allows for payment at the DRG [Diagnosis Related Group] level for hospital care to be provided in the home,” Wolfe said. “Our waivers are also tied to Inpatient Prospective Payment System payment flexibilities for the telehealth component of acute hospital care at home, among other things, which then allows hospitals to deliver that care in the home on a 24/7 basis." 

The COVID-19 public health emergency was declared ended in May 2023, yet Congress has extended CMS’ authority to do this work several times, first through December 2024 and then again into March 2025, and now until Sept. 30. 

“We are very much aware that this sort of piecemeal approach to extensions and the short extension time is very challenging, not only for program operations in general, but for long-term planning,” Wolfe said. “Obviously, that ability to plan long term is preferable for a number of reasons, sustainability being one, program development and operations planning being another.” She said CMS has communicated those concerns that they have heard from the practice community to Congress.

Wolfe added that CMS is also aware that there are concerns about hospitals that are excluded from the Inpatient Prospective Payment System and so have not been able to participate in the acute hospital care-at-home initiative as it currently stands.  

“We continue to examine these issues to understand what our current authorities are, whether a future statutory or regulatory solution or both, is needed,” Wolfe added. “We continue to engage with our colleagues within the CMS Office of Legislation, and, of course, with our colleagues on the Hill in Congress who are considering what to do after September.”

So what is CMS going to do? "The answer is, right now we don't know,” Wolfe said. “CMS' authority is tied to whether or not Congress tells CMS to do something different than we have been doing, whether there is just a blanket extension or something else. In the event that there is an extension, this work, of course, will continue, and depending on what Congress directs CMS to do, we have been brainstorming ways to develop best-practice discussions and further engage you all as a hospital-at-home community in ongoing dialog. As this care environment is evolving on a daily basis, we're learning lots of different best practices and lessons learned, and we're particularly interested in understanding how we can further support our rural communities and patients who may not be able to take advantage of these opportunities right now because of geographical concerns.”

However, she stressed that if Congress has not acted on this by the Sept. 30 date, and there's a lapse in CMS’ authority to do hospital at home, all Medicare fee for service and non-managed Medicaid patients who are being cared for in the home under an approved waiver must have some form of disposition before October 1.“That means that if they are expected to continue to be inpatient, there must be a plan to transport those patients back to the appropriate inpatient unit of the hospital within the brick and mortar facility. If the patient was planning toward discharge on September 30, then those plans can continue as long as the patient is discharged from inpatient care and they clinically do not need inpatient care on October 1.”

Moderator Lisa Tripp J.D., a partner at Tripp Hollander Advisors LLC, said, “It's my opinion that because the waiver legislation is budget-neutral — it does not cost the taxpayers any additional money for hospital at home — and because of the bipartisan support, it is very, very likely that Congress will continue to extend. It just isn't clear how long the extensions can be.”