In November 2020, the Centers for Medicare & Medicaid Services (CMS) announced a new waiver program, called Acute Hospital Care At Home (AHCAH), aimed at “providing eligible hospitals with unprecedented regulatory flexibilities to treat eligible patients in their homes.”
More specifically, CMS began “accepting waiver requests to waive §482.23(b) and (b)(1) of the Hospital Conditions of Participation, which require nursing services to be provided on premises 24 hours a day, 7 days a week and the immediate availability of a registered nurse for care of any patient.”
Instead, for patients treated through the AHCAH program, “A registered nurse will evaluate each patient once daily either in person or remotely, and two in-person visits will occur daily by either registered nurses or mobile integrated health paramedics, based on the patient’s nursing plan and hospital policies,” according to November 2020 announcement.
This allowed hospitals to receive Medicare (and certain Medicaid) payments for such home care. Per a NEJM Catalyst article reviewing the program, “This represented the first example of payment for this level of care at home for beneficiaries with Medicare Fee-for-Service (FFS) and — in certain states — non–managed care Medicaid.” (According to CMS, “Medicare inpatient payments to a hospital will be the same as they would have been if the care was provided in a traditional inpatient setting.”)
The waiver program is split into two tiers: Tier 1 waivers, available to hospitals that “provided at home acute hospital services to at least 25 patients previously,” and Tier 2 waivers, provided to those that had not. The application for Tier 1 waivers is simpler, and those hospitals have to report their key AHCAH metrics only monthly, rather than weekly.
In order to continue participating in the program, hospitals with AHCAH waivers must submit weekly/monthly metrics (called “measures”) to CMS, indicating the number of AHCAH patients discharged from the hospital’s care, the number that died unexpectedly, and the number that required “escalation” back into a traditional hospital setting.
When first issued in 2020, waivers were only meant to last for the duration of the COVID-19 Public Health Emergency (PHE). The PHE officially ended on May 11, 2023. The 2023 Consolidated Appropriations Act, however, extended the AHCAH program until December 31, 2024.
On January 27, 2023, the Data Liberation Project (DLP) — in collaboration with researcher Maddy Varner, then a journalist at The Markup — filed a FOIA request to CMS, seeking all database records representing AHCAH waiver requests received by CMS (and the agency’s processing of those requests), all AHCAH reporting measures submitted by hospitals (with the exception of patient-identifiable information), and all database documentation relevant to those records.
On June 26, 2023, CMS provided a response to the DLP’s FOIA request. It contained four CSV spreadsheets, corresponding to:
- Tier 1 waiver requests (undated, but likely through mid/late April, 2023)
- Tier 2 waiver requests (undated, but likely through mid/late April, 2023)
- Tier 1 reporting measures (through March 2023)
- Tier 2 reporting measures (through the week of April 10–16, 2023)
On October 2, 2023, CMS provided an updated set of records — all waiver requests and reporting measures submitted through September 14, 2023 — with several improvements:
- Each set of records now contains a Status and Created column, reflecting the waiver/measure status and the date the entry was created.
- The new release fixes an issue with the prior release, in which Measure 1c was missing for Tier 1 hospitals’ reported measures.
- A series of internal identifiers, which had led the Data Liberation Project to release only a (lightly) redacted version of the previous files, have been removed; the raw files in the new release are available to the public in full.
To access these resources and learn essential context about them, visit our main documentation for the data.