BY Kianna Sitarski, Esq. and Michael Alexander, Esq.,
Brown & Fortunato, P.C.
In the wake of the COVID-19 pandemic, and with the rise of healthcare costs, healthcare providers and patients alike have been focused on identifying safer and cheaper avenues for the delivery of high-quality healthcare.
One model gaining traction since 2020 is Hospital at Home (“HAH”). HAH generally refers to programs by which hospitals admit, and provide eligible patients with, acute in-patient level care at the patient’s residence, and submit claims for, and receive reimbursement from, Medicare as if 
the patient was admitted and receiving treatment within the four walls of the hospital. Importantly, the state and federal regulations, and payor guidelines, are rapidly evolving as HAH becomes a more permanent fixture of the healthcare landscape. To best take advantage of this new model, and to ensure that hospital systems remain compliant with HAH moving forward, it is important to understand basics and the most recent developments related to HAH.
Though American healthcare administrators and legislators have analyzed various versions and iterations of the HAH since the 1990s, the onset of the COVID-19 pandemic required a renewed focus and added a sense of urgency to identifying ways in which hospitals could provide acute care to patients while reducing the risk of spreading infection.
HAH was substantively launched by the Centers for Medicare & Medicaid Services’ (“CMS”) utilization of its authority to waive select hospital facility standards in the “Hospital Without Walls” initiative in March 2020. By November 25 2020, under the “Acute Hospital Care at Home” (“AHCAH”) initiative, CMS expanded the waivers provided under the Hospital Without Walls initiative to permit hospitals to seeks waivers of § 482.23(b) and (b)(1) of Medicare Conditions for Participation (requiring the availability of nursing services on site 24 hours a day, 7 days a week and for a registered nurse to be immediately available), and other Conditions of Participation concerning “Physical Environment” and “Life Safety Code” (collectively, the “AHCAH Waivers”). Importantly, allowances provided under the AHCAH Waivers are not applicable to all Medicare-enrolled hospital systems; rather, each hospital must submit a separate waiver request for CMS approval, demonstrating the hospital’s capacity to provide safe and effective acute care at home. Once AHCAH Waiver approval is granted, qualifying hospitals may admit patients, and deliver acute care in the patient’s home, so long as (i) the AHCAH Waivers are effective and (ii) hospitals continue to satisfy all other Medicare Conditions of Participation and comply with ongoing monitoring and reporting requirements related to patient safety and treatment quality metrics.
When initially implemented, the AHCAH Waivers were effective only for the duration of the declared COVID-19 Public Health Emergency (“PHE”). However, in recognition of the ongoing need for alternative care models, Congress has extended the AHCAH Waivers on five occasions: (i) the Consolidated Appropriations Act of 2023, for two years, (ii) the American Relief Act, for 90 days; (iii) the Full-Year Continuing Appropriations and Extensions Act, for six months; (iv) the 2026 Continuing Appropriations, Agriculture, Legislative Branch, Military Construction and Veterans Affairs, and Extensions Act, which extended the waivers for 78 days; and (v) the 2026 Consolidated Appropriations Act, until September 30, 2030.
With the stability provided under the Consolidated Appropriations Act through September 2030, for claims submitted for treatment of Medicare beneficiaries, we anticipate that hospitals will begin expanding their HAH programs. Hospitals and hospital administrators should carefully review and analyze related healthcare regulations to ensure that their HAH program includes a robust compliance plan that considers not only the AHCAH Waiver eligibility criteria, but also captures (i) state regulations pertaining to hospital and practitioner scope of licensure/practice and, (ii) applicability of payor contracts with state healthcare programs and commercial payors.
For example, in Texas, prior to administering a HAH program, the hospital must submit an application (consisting of Form 3230, a copy of the hospital’s current AHCAH Waiver approval from CMS, and an application fee) for consideration and approval of the Texas Health and Human Services Commission (“TX HHSC”), as required under Section 505.54 of the Texas Administrative Code. Importantly, these Texas HAH regulations do not provide any waivers or exceptions to the scope of licensure restrictions, or telehealth requirements, set forth in other regulations or in the rules promulgated by other agencies, such as the Texas Board of Nursing or Texas Medical Board. Therefore, to the extent that a hospital intends to utilize telehealth services or utilize its staff in the delivery of HAH services, compliance officers should ensure that no policies or procedures of the HAH program run afoul of these related regulations.
On the payor side, Texas is one of only 12 states (as of September 2025) to implement Medicaid reimbursement for HAH programs. To be eligible to receive Fee-for-Service reimbursements from Texas Medicaid, the hospital’s HAH program must be approved by TX HHSC. Though approval provides hospitals the opportunity to submit Fee-For-Service claims to Texas Medicaid for reimbursement, each hospital will need to work closely with its Medicaid Managed Care, Medicare Advantage, and private/commercial payors to negotiate HAH reimbursement rates to best ensure coverage for the hospital’s payor mix.
There are sure to be significant developments in HAH regulation at both the federal and state level in the near future as patients and administrators become more aware of its availability and positive patient outcomes. As with anything in the healthcare space, hospitals should carefully structure their HAH programs to best ensure compliance with all statutes and regulations.