What do short-term waiver extensions mean for hospital-at-home?
Though the hospital-at-home waiver has been extended through September 2025, the short-term extensions create an uncertain landscape for leaders and stakeholders.
In the funding bill Congress passed last week, which narrowly averted a government shutdown, lawmakers extended Medicare telehealth flexibilities and the Acute Hospital Care at Home (AHCAH) waiver through Sept. 30, 2025.
Virtual care and hospital-at-home program stakeholders celebrated the federal waiver's extension. However, unless Congress plans to further extend the waiver by several years -- or, better yet, make it permanent -- hospital-at-home program leaders must navigate this gray area of short-term extensions.
The AHCAH waiver has undoubtedly had a pronounced impact on the nationwide adoption of the hospital-at-home model. Though the model has been around since the mid-2000s, CMS launching the waiver in November 2020 enabled hundreds of facilities to implement it. The waiver suspends several Medicare Hospital Conditions of Participation, including requiring nursing services to be provided on premises 24 hours a day, seven days a week. As of March 12, 2025, 391 healthcare facilities across 39 states have received waiver approval.
The waiver and growing adoption also prompted commercial health plans to expand their support of hospital-at-home.
"What we saw was not just that more patients could access it, but that it also sent a significant signal to the rest of the market that this is a real way to deliver care," said Stephen Dorner, M.D., chief clinical and innovation officer of Healthcare at Home, Mass General Brigham. "And so, you started seeing that more commercial payers entered this space and wanted contracts or developed policies to support this kind of care. They developed their own conditions of participation, oftentimes aligning with the federal waiver."
This indicates that the government plays a key role in influencing adoption through the waiver. However, the reluctance to move forward with a longer-term extension for the waiver indicates that health system leaders must tread carefully with their hospital-at-home efforts.
Cost and quality concerns may be driving the shorter extensions
The waiver has been extended several times. Prior to the most recent extension, Congress had included it in its year-end funding bill that prevented a government shutdown in December 2024. Initially set to expire at the end of 2024, the bill extended the waiver and other telehealth flexibilities through March 2025.
Having a short-term extension really does not provide the bandwidth or on-ramp for hospitals to be able to develop these types of programs.
Jennifer HollomanSenior associate director of policy,American Hospital Association
Though relieved, hospital-at-home proponents were also disappointed because an earlier version of the funding bill included a five-year extension for the waiver. In February, the home-based care advocacy group Moving Health Home sent a letter signed by nearly 100 stakeholders urging congressional leaders to include a five-year extension for the hospital-at-home waiver in the funding package. But, once again, lawmakers have only extended the waiver by a few months.
Despite federal research linking the waiver to high-quality care, American Hospital Association (AHA) leaders noted that Congress likely wants more research to confirm these positive outcomes before issuing a longer extension.
"I mean, it's a bit of a scary proposition when you talk about taking someone who is sick enough that they should be hospitalized, and you're going to put them in a location that's maybe 5 or 10 miles away from the hospital," said Nancy Foster, vice president of quality and patient safety policy at AHA. "So how is CMS, which is by law responsible for making sure the care of Medicare patients is conducted in a safe and effective manner, how are [they] going to make sure that the hospital has all the right things in place?"
Lawmakers are also looking to ensure that hospital-at-home care does not result in any unintended consequences, like adding to family caregiver burdens or widening health equity gaps, she added.
Further, there are the perennial concerns regarding cost. According to Thom Bales, PwC's Health Services Advisory leader, the federal government is looking to determine the cost benefits of hospital-at-home care.
"Practically speaking, in the world where there are value-based care health systems, and so fully capitated health systems that integrate the health plan and the hospital, they are looking at the relative cost trade-off of advanced care at home versus the inpatient setting," he said.
There has been little conclusive research on this issue so far. Even the federal research noted above could not conclude that the waiver "resulted in lower Medicare spending overall as compared to brick-and-mortar inpatient care."
Still, the patient care and experience benefits have been robust enough that the waiver is unlikely to be eliminated entirely. However, the short-term extensions could prove challenging for those operating and leading hospital-at-home programs.
Navigating the uncertain hospital-at-home landscape
Mass General Brigham started its hospital-at-home efforts nearly a decade ago, well before the waiver existed. Even so, the waiver spurred adoption and utilization to new heights, allowing the health system to include Medicare and Medicaid patients in the program.
According to Dorner, the health system's hospital-at-home program has cared for more than 5,000 patients since its inception. However, the uncertainty of the waiver's future and the short-term extensions make it hard for the organization to plan for the future of the program, which, according to Dorner's account, has been highly beneficial to patients.
That's exactly why this waiver was created in the first place -- in recognition of the fact that hospitals don't have adequate capacity and that this is a critical release valve to those hospitals to meet patient care needs. And it would be a shame for it to go away.
Stephen Dorner, M.D.Chief clinical and innovation officer of Healthcare at Home, Mass General Brigham
"As I've talked to other health systems and hospitals around how they're preparing for these plans and what they've built, there's a lot of fear and uncertainty about [the waiver being eliminated] because we know that it would mean changing the way that we're delivering care today to something else," he said. "We know that means that we're going to lose potentially the benefits that we know are delivered through this care model today."
Jennifer Holloman, senior associate director of policy at AHA, echoed this, adding that hospital-at-home programs require significant infrastructure and resources.
"There are things like remote patient monitoring equipment that hospitals need to acquire, facilitating meal delivery services, as well as just the general staffing and workflow redesign that simply providing a few months extension or a one-year extension doesn't provide [the time for]," she said.
"Having a short-term extension really does not provide the bandwidth or on-ramp for hospitals to be able to develop these types of programs," she continued.
Additionally, the lack of federal support for the program could result in less support from commercial health plans. Without a definite return on investment, Bales said that health systems will be less likely to invest in hospital-at-home programs, hampering the growing adoption.
"[Hospitals are] going to invest in the replacement of their metal equipment," he said. "They're going to invest in what is it they need to do in order to keep their EHRs up and running to keep the hospital staff. And so, subsequently, there will likely be a stall in the migration to the home setting until the reimbursement balances back out."
Not only that, but the short-term extensions are exacerbating concerns about capacity management. If the waiver expires in September, hospitals will be expected to move their patients back into their brick-and-mortar facilities immediately until they receive further guidance from the government.
"We will make plans to bring those patients back to the hospital in compliance with the CMS guidance, but we don't have a ready way for us to just create additional capacity in short order," Dorner said. "That's exactly why this waiver was created in the first place -- in recognition of the fact that hospitals don't have adequate capacity and that this is a critical release valve to those hospitals to meet patient care needs. And it would be a shame for it to go away."
Amid the unknowns about the waiver's future, Mass General's strategy is to continue focusing on its overarching plan to provide a home-based complement to in-person care services where necessary.
"We'll look at that broad continuum opportunity and where we can intervene if there's compression at any point along that continuum, like a restriction of the waiver's conditions of participation," Dorner said. "We know that the further you can intervene upstream, the better you can try to intervene upon utilization patterns and improve overall health for patients. And so, we've long been working in that space, and we'll continue to do so."
However, it will also become increasingly crucial for hospital-at-home stakeholders to advocate for the waiver.
"There's certainly a big piece of the advocacy side here as well, and educating members of Congress about the value that this program provides and highlighting the patient stories, success stories…that's how Congress learns more, but it's also helpful and as they deliberate to connect that back to the impact it's having in each of their congressional districts," said Rachel Jenkins, senior associate director of federal relations at AHA.
The hospital-at-home waiver is among many federal health agencies and programs in upheaval as the Trump administration solidifies its agenda. Still, the bipartisan support for hospital-at-home, combined with provider and patient advocacy for the waiver, could help embed the model further into the healthcare delivery system, which Dorner sees as a net positive for the industry and Americans' health.
"I think at a time that there's great interest in trying to find beneficial ways that bolster the economy and improve quality of life for Americans, [hospital-at-home] is a very clear win-win opportunity sitting in front of us," said Dorner.
Anuja Vaidya has covered the healthcare industry since 2012. She currently covers the virtual healthcare landscape, including telehealth, remote patient monitoring and digital therapeutics.
