As Federal Government Hurtles Towards a Shutdown, Telehealth Is Endangered

On Tuesday, September 30, as the impasse in Congress over budget priorities rolled forward, and the nation lumbered towards a federal government shutdown at midnight eastern time [EDITOR'S NOTE: The shutdown began at 12 midnight eastern time on Wednesday], hospital-at-home and other telehealth programs were in a particular spotlight, as reimbursement for remotely delivered care needed to be renewed by Congress, and was not automatic.

As the Washington Post’s Lauren Weber and Trisha Thadani reported on Tuesday morning, “Millions of American seniors could lose access to telehealth appointments with their doctors if Congress fails to fund them amid a looming government shutdown, while thousands more who have been receiving high-level, acute care at home face being sent back to the hospital or discharged. While most Medicare reimbursements to doctors and hospitals will continue in the event the government shuts down Wednesday, payments for video health care visits — which gained in popularity during the pandemic and must be separately authorized for an extension by Congress — face elimination.”

Indeed, Weber and Thadani wrote, “Without getting paid or receiving some assurance they would be compensated retroactively, doctors and hospitals say they will be unable to provide services. Particularly for elderly people with limited mobility or transportation hurdles, telehealth has become a vital service improving their access to care, advocates say. Losing these benefits will “exacerbate all types of problems in our health care system,” said Kyle Zebley, executive director of ATA Action, the advocacy arm of the American Telemedicine Association. “It’s going to diminish capacity at a point in time when we don’t have enough.”

Indeed, they noted, “More than 6.7 million seniors received care through a telehealth service visit last year, according to the federal Centers for Medicare & Medicaid Services (CMS), which is a quarter of eligible Medicare beneficiaries. During the pandemic, the number was even higher, with 14.8 million eligible Medicare beneficiaries receiving telehealth services in 2020. The funding cliff for the telehealth and home-hospital care programs is separate from shutdown negotiations, but both programs are caught up waiting for congressional action. Some providers have been warning patients for months that their appointments may no longer be reimbursed, while others are remaining hopeful that Congress will come through with a last-minute funding plan. The biggest impact would be in urban and suburban areas, according to medical groups, while patients in rural areas that were eligible before the pandemic would continue to receive coverage. CMS and the Department of Health and Human Services did not respond to requests for comment,” they added.

Per that, STATNews’s John Wilkerson and Mario Aguilar confirmed on Sep. 26 that, “If Congress doesn’t fund the government by the end of the day on Tuesday, patients across the country who have been receiving hospital-level care at home will be placed back in hospitals. The Acute Hospital Care at Home initiative allows Medicare to waive certain rules so hospitals may provide inpatient hospital care in patients’ homes. The program was launched in response to the Covid pandemic, and like many other Medicare and Medicaid programs, it’s typically renewed in government-funding bills.” But, they noted, “The expiration of the hospital-at-home program would immediately disrupt care for patients. The Centers for Medicare and Medicaid Services has sent guidance to participating hospitals stating that in the absence of Congressional action, “All inpatients must be discharged or returned to the hospital on September 30, 2025.”

Were the government not poised to shutdown at midnight on Tuesday, both the Republicans’ and the Democrats’ proposed continuing resolutions (CRs) would have made provisions for telehealth and hospital-at-home. As Julia Ivanova wrote in telehealth.org on Tuesday, “House Republicans’ proposed CR would have extended a suite of Medicare telehealth flexibilities through November 21, 2025. Their plan included using patients’ homes as originating sites, suspending geographic restrictions, preserving FQHC and RHC distant-site billing, and maintaining expanded practitioner eligibility. It would have allowed audio-only visits and prolonged the Acute Hospital Care at Home waiver through November 21, 2025. It also delayed Medicare’s in-person telemental-health requirement until November 22, 2025.” Meanwhile, she wrote, “Senate Democrats offered a parallel measure with nearly identical provisions, but with a shorter end date of October 31, 2025. That package similarly extended Hospital-at-Home and telehealth flexibilities.”

Per all this, Kyle Zebley, executive director of ATA Action, the American Telehealth Association’s advocacy arm, wrote a letter on Sep. 18 to Rep. Jason Smith (R-Mo.), in his capacity as Chair of the House Ways and Means Committee, and Rep. Richard Neal (D-Mass), Ranking Member of the Committee, in which he implored the Ways and Means Committee’s leaders not only to preserve the telehealth flexibilities for the moment, but indeed, to make them permanent. “On behalf of ATA Action, the affiliated trade organization of the American Telemedicine Association,” Zebley wrote, “thank you for holding a markup on critical legislation including H.R. 4313, the Hospital Inpatient Services Modernization Act, and H.R. 5343, the Ensuring Patient Access to Critical Breakthrough Products Act. These bipartisan bills represent important steps toward expanding access to care and medical innovation for Medicare beneficiaries. Hospital Inpatient Services Modernization Act (H.R. 4313) This legislation would extend the Acute Hospital Care at Home (AHCaH) Program for five years, through 2030. Launched in 2020, AHCaH has demonstrated tremendous benefits1: Improved patient experience and higher physical activity levels. Lower rates of mortality and hospital readmission. Reduced discharges to skilled nursing facilities. The program allows patients to receive hospital-level care in the comfort of their own homes, an approach that improves outcomes and reduces costs. Today, over 300 hospitals across 37 states participate in AHCaH, underscoring its value and scalability. AHCaH is a foundational flexibility for our members and a top priority for ATA Action. Without congressional action, the program along with other critical Medicare telehealth flexibilities will expire at the end of September. We urge the House to bring this bill to the floor as quickly as possible and ultimately make the program permanent,” Zebley wrote.

Also, leaders at the Center for Connected Health Policy, a program of the Oakland, California-based Public Health Institute, sent out a detailed explanation of the situation as of Tuesday afternoon. The CCHP’s leaders wrote that “Today, September 30th, is the last day before the Medicare telehealth waivers expire, unless Congress is able to pass an extension before midnight tonight. As many readers are already aware, on March 14, 2025, the federal telehealth waivers applicable to Medicare, which have been in place since the pandemic, were extended for an additional six months, until September 30, 2025. In recent weeks, several proposed extensions of these waivers have been made within recent budget talks. If no final deal materializes, the result will not only be an expiration of the Medicare telehealth waivers, but a federal government shutdown.”

Though the CCHP’s leaders noted that some temporary solutions “are on the table,” they added that, “As of today, it remains uncertain if any of the bills have enough votes to pass in Congress. Right now, you may be wondering what will it mean for telehealth in Medicare if none of these bills or another extension passes before midnight tonight. In short, Medicare policies will revert back to permanent Medicare telehealth policies starting tomorrow, October 1, 2025. This means that certain restrictions will again apply including those on patient location, which providers can act as distant site providers and be reimbursed by Medicare, as well as several other policies that, since the pandemic, have not been enforced.”

Most notably, they wrote, “If the deadline does indeed come to pass, the shift back to permanent telehealth policies will be a significant change for both patients and providers, and the scope of the impacts of the reversion back is currently unknown. For example, if the waiver deadline passes and there is a return to permanent Medicare telehealth policy, but a few days later Congress does pass a bill and a new extension (or permanent change) is enacted, those few days, or the ‘gap’ between expired waivers and any new policy, may not have too significant of an impact, as providers might be able to reschedule most patient visits for a later date. However, the longer the ‘gap’ continues, the more patients and providers will feel the effects. As time goes on, it will become increasingly difficult to reschedule patients, and the uncertainty regarding a resolution will grow. Providers then may only be able to offer an in-person option, which may be difficult for a patient to attend due to time and/or distance, and as a result, the patient may opt to do without the visit or miss it entirely. An additional potential scenario that holds great uncertainty is if there is a significant ‘gap’ period, and down the road another extension is eventually granted, will that gap period be retroactively covered under any new waiver? For example, if a new extension is given for Medicare telehealth policies, but already a month has elapsed during the “gap” period, will Congress include language ensuring the coverage extension captures services provided starting October 1, 2025? At this point, the answer to these and other questions are unknown.”

For now, the CCHP leaders wrote, providers are left to consider “rescheduling ineligible telehealth visits as in-person appointments, or waiting to hold the telehealth visit at a later date entirely. Patients should consult with their providers regarding their options.” And, they noted, “For providers, as noted earlier, the extent of the impact will likely depend on the length of any gap period.  A ‘gap’ that only lasts a few days, while causing some inconvenience, could be mitigated by rescheduling appointments to minimize disruptions. However, the longer the ‘gap’ continues, the more difficult the decisions will become. If a provider continues to provide telehealth services that would not ultimately qualify for coverage under permanent telehealth Medicare policy, providers risk not getting paid (keep in mind while its possible some policy is put into place to cover any ‘gap’ period by having an extension cover services retroactively, at this point there’s no guarantee that will occur). 

Meanwhile, as of Tuesday afternoon, a shutdown appeared imminent. And, if the two political parties cannot resolve their impasse by midnight on Tuesday, the federal government will go into shutdown.

This is a developing story. Healthcare Innovation will update its readers on new developments, as they emerge.