Waivers' End Pushes Healthcare Leaders to Make Tough Decisions on Telehealth, Hospital at Home

With pandemic-era telehealth and Hospital at Home waivers expiring, executives are curtailing or ending some virtual care services. Supporters, meanwhile, are lobbying to extend those flexibilities or make them permanent.

Health system and hospital leaders are cutting telehealth and Hospital at Home programs following the expiration of pandemic-era CMS waivers, but that doesn't necessarily mean those programs are gone for good.

Healthcare leaders say they're looking only at short-term strategies as advocates, led by the American Telemedicine Association and the Alliance for Connected Care, lobby Congress to reinstate the waivers in any spending bill to end the federal shutdown. And while aiming to restore the waivers for the time being, the ultimate goal of advocates is to make those freedoms permanent.

For now, however, telehealth policy reverts to pre-COVID rules.

Drawing on a post from Foley & Lardner LLP's Health Care Law Torday site, the biggest changes are as follows:

Originating site. The waiver allowed for telehealth services to be delivered at any U.S. location, including the patient's home. Restrictions are now back in place, limiting telehealth to certain locations, including the provider's office, hospital, SNF, and home if the patient is receiving home dialysis for end-stage renal disease (ESRD), treatment for substance use disorder (SUD)  or diagnosis, evaluation and treatment for a mental health disorder (provided the in-person visit requirement is met).

Geographic restrictions. The waiver eliminated those restrictions. Now, telehealth services are limited to a rural health professional shortage area or a county not included in a Metropolitan Statistical Area. Exceptions are made for patients with ESRD receiving dialysis at home or at a hospital or critical-access hospital-based renal dialysis facility, as well as patients receiving diagnosis, evaluation or treatment for an acute stroke, those receiving for SUD or a co-occurring mental health disorder, and those receiving diagnosis, evaluation and treatment for a mental health disorder (provided the in-person visit requirement is met).

Audio-only visits (such as via telephone). These were allowed through the waiver for any clinically appropriate telehealth services. Now, they're limited only to patients receiving telehealth services at home if the care provider has the technology to conduct an audio-visual visit but the patient can't or won't use video.

Provider types. The waiver expanded the list of healthcare providers able to bill Medicare for the use of telehealth to include occupational therapists, physical therapists, speech and language pathologists and audiologists, among others. Now that list is limited to physicians, PAs, NPs, clinical nurse specialists, nurse-midwives, clinical psychologists, clinical social workers, registered dietitians or nutrition professionals, certified registered nurse anesthetists, marriage or family therapists and mental health counselors.

Federally Qualified Health Centers (FQHCs) and Rural Health Centers (RHCs) as a distant site. The waiver enabled FQHCs and RHCs to bill Medicare for telehealth services as eligible distant sites. This is no longer allowed.

In-Person Mental Health Treatment. The waiver enabled mental healthcare providers to use telehealth without first conducting an in-person assessment with the patient. Now, an in-person visit is required for patients receiving diagnosis, evaluation or treatment for a mental health disorder before telehealth can be used. That visit must take place within six months prior to the first telehealth visit and every 12 months thereafter while the patient is receiving treatment. An exception can be made if the provider and patient agree that the risks of an in-patient visit outweigh the benefits and the provider documents that decision in the patient's medical record.

CMS has also updated its guidance on Medicare telehealth claims during the ongoing shutdown.

According to the Center for Connected Policy, the guidance, released on October 1, directs Medicare Administrative Contractors (MACs) to implement a temporary claims hold, which can last as long as 10 business days.

"The hold is meant to prevent a large reprocessing of claims if Congress acts after the statutory expiration date, which was September 30, 2025," CCHP reports. "CMS also suggested that without further Congressional action, providers that deliver telehealth services and are now not eligible for Medicare payment as of October 1, 2025, may want to provide patients with an Advance Beneficiary Notice of Noncoverage."

Why Were the Waivers Enacted?

The waivers were launched during the height of the COVID-19 pandemic in 2020 to boost telehealth coverage and access by giving providers more opportunities to use virtual care. That increase, in part, helped fuel a surge in telehealth programs that carried over into the post-pandemic era.

Advocates say the waivers are crucial to enabling health systems and hospitals, especially those in rural and underserved regions, to improve access and clinical outcomes. Without them, it's expected that many providers will scale back their telehealth services or even end them altogether.

[Also read: Can Virtual Health Make A Profit?]

In letters to Congressional leaders and President Trump, ATA Action, the ATA's lobbying arm, called for both the telehealth waivers and the Acute Hospital Care at Home (AHCaH) waiver to be reinstated, saying healthcare providers have been building strong programs since they were enacted in 2020.

"Most providers and hospital systems are taking calculated risks to continue care during this time, but long-term continuity depends on action by our telehealth champions in Washington to restore these flexibilities and ensure retroactive reimbursement," said Kyle Zebley, ATA Action's executive director and the ATA's senior vice president of public policy. "Medicare patients woke up this morning without telehealth coverage for the first time since the pandemic, five years ago. Our healthcare services are regressing, falling woefully short for millions of patients in need."

The Hospital at Home Waiver

Roughly 400 health systems and hospitals were participating in CMS' AHCaH model as of September 30. Some have shut down their programs or let them lie dormant after patients transitioned out.

One of those is Advocate Health, whose Hospital at Home platform included the nation's first pediatric Hospital at Home program, launched earlier this year at Atrium Health's Levine Children's Hospital.

"Like many other healthcare organizations across the country, all of our patients who were receiving hospital at home care have been either appropriately discharged to outpatient status or transferred to brick-and-mortar inpatient care," the health system said in a statement to HealthLeaders. "Extension of the waiver, or even better a permanent authorization, is essential to allow our patients to continue to have access to this program that has improved patient outcomes, expanded access for rural communities and enabled greater flexibility in how care is delivered."

[Also read: Defining the Benefits of the Hospital at Home Strategy.]

Others, especially larger organizations, say they'll continue with a model that they feel is a key element to the future of healthcare.

Executives at Mass General Brigham, one of the front-runners in the acute care at home movement, have also altered their program.

"While there continues to be strong bipartisan support for the Acute Hospital Care at Home Waiver extension, it is unfortunate that the timing of its expiration was tied to the broader government funding debate," a spokesperson said in an e-mail to HealthLeaders. "Fortunately, the steps we have taken over the last year have enabled us to pivot our operations to provide advanced care at home for patients after a hospital stay during this pause. This framework enables us to support patients outside of the inpatient waiver while maintaining the structure we need to provide exceptional acute care in the home."

"The future of healthcare is in the home and we are invested in our efforts to see this through," the spokesperson continued. "We will continue to advocate for a multi-year waiver extension to reduce the capacity strain on our brick-and-mortar hospitals and ensure our patients receive this safe, effective and exemplary care where they want it, surrounded by their family and loved ones."

The concept has a lot of supporters, and studies are showing the value in delivering acute-level care at home. MGB, for instance, has published reports noting clinical and financial benefits in caring for patients in their homes instead of a hospital, and the health system's announcement that it will continue the program points to an opportunity to show that this strategy can survive beyond the waivers.

"We're in this journey to build out the whole continuum of care in the home" Stephen Dormer, MD, MPH, MSc, chief clinical and innovation officer for MGB's Healthcare at Home program, told HealthLeaders during the HIMSS 2025 event this past spring in Las Vegas.

But he also noted that the CMS model isn't perfect.

"I don't think that the way it's structured now is necessarily that way it will be structured forever," he said. "We need more of a critical mass of information" to prove what works and what doesn't.

"Research shows that hospital at home models yield positive health outcomes," the Bipartisan Policy Center stated in an August 2024 report calling for continued support for the program. That report cited a small study which found that the program led to shorter hospital stays, lower readmission rates, fewer diagnostic tests, and lower costs compared to patients admitted to the hospital for the same health concerns.

"Initial data show promise, including the potential for cost savings," the report added. "But more research is needed on patient and caregiver experiences, access and patient selection, the cost impact on Medicare and Medicaid, hospital expenses, and service delivery across diverse populations. Research is also needed on whether the relatively small number of hospitals participating is nonrepresentative and unique. … Congress needs more clarity about the likely financial effects of the model if it were to move from a model with low uptake, which is the case today, to something that would be implemented on a larger scale."