The federal government shutdown is forcing a reckoning for two remote health care programs because they automatically expired Oct. 1.

The telehealth and in-home hospital care programs were both temporary — but increasingly popular — options for Medicare recipients. They allowed doctors and hospitals to bill Medicare for telehealth appointments and in-home visits from nurses to provide care that is generally only available in hospitals.

The shutdown has prevented Congress from extending them.

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More than 4 million Medicare beneficiaries used telehealth services in the first half of the year, according to Brown University’s Center for Advancing Health Policy through Research.

As of last fall, 366 hospitals had participated in the hospital-at-home program, serving 31,000 patients, according to a federal report. The program, officially called Acute Hospital Care at Home, allows patients who would otherwise be hospitalized to get inpatient care at home with a combination of nurse visits, monitoring equipment and remote doctor visits.

The programs have their roots in the pandemic, when doctors and hospitals wanted to keep patients safe from the risks of travel and hospital stays. Both are for Medicare recipients, generally people over 65 or who are disabled. But since many private insurers follow federal guidelines, some physicians have stopped booking telemedicine appointments for non-Medicare patients, rather than risk a change in insurance coverage.

Alexis Wynn, who is in her mid-30s and covered by private insurance through her employer, tried to switch an in-person doctor appointment in Pennsylvania to a video visit last week. The office told her that “all telemedicine is uncovered by insurance as of Oct. 1” — so she had to cancel the routine appointment.

“It was just a follow-up appointment to make sure the dosing of my medication was still accurate, nothing that was pertinent to being face-to-face,” Wynn said. Her health insurance company later told her it still covered telehealth visits.

There have been other reports of insurers turning down non-Medicare telehealth appointments, said Alexis Apple, director of federal affairs for the American Telemedicine Association, a trade group.

“It’s a misunderstanding,” Apple said. “I’m not really sure what’s happening, but it’s unfortunate and very scary. There’s so much uncertainty out there now, and we see insurance payers start to pull back.”

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Both telehealth and home hospital services can be a lifeline for older people, especially in rural areas, where residents may struggle to travel long distances for health care in person.

“In rural America, it’s often telemedicine or no medicine at all,” said Dr. David Newman, chief medical officer of virtual care at Sanford Health in South Dakota, in a September statement supporting congressional action to make Medicare telehealth permanent. Bipartisan bills that would have allowed telehealth to continue stalled in committee earlier this year in the Senate and House.

There’s an exception for telehealth rural residents — but only if they travel to a brick-and-mortar health care facility to get the remote health care service.

“The patients have to go to a clinic to receive that telehealth visit from a provider in a different location,” Apple said. “It kind of defeats the purpose.”

According to the Brown University report, California had the highest rate of Medicare telehealth usage in the first six months of this year, with 26 percent of beneficiaries using at least one telehealth appointment, followed by 23 percent in Massachusetts and 21 percent in Hawaii.

There’s no reason for non-Medicare insurers to stop covering any telehealth visits during the shutdown, and even most Medicare Advantage programs will continue to cover telehealth, according to Tina Stow, a spokesperson for AHIP, a health industry trade association.

Nevertheless, at least some health care centers are refusing to take new telehealth appointments or are converting existing ones to office visits.

“This is causing a lot of confusion. We are still working with our members who are insurers and providers to get a gauge on what folks are doing — because at this point reports we’ve seen seem to suggest it is company by company, provider by provider,” said Sean Brown, a spokesperson for the Health Leadership Council, representing CEOs of health care firms and insurers.

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The hospital-at-home program serves a smaller number of patients but its pause has caused more disruption: The federal government requiredpatients to be discharged from the program or transferred to a brick-and-mortar hospital by Oct.1.

The Minnesota-based Mayo Clinic had 30 patients in the program in Arizona, Florida and Wisconsin — all of whom either had to be released from the program or sent to brick-and-mortar hospitals. One of Mayo’s hospitals in Florida was already over capacity and had no room for transfers, according to reporting by Becker’s Hospital Review.

In Massachusetts, which requires commercial insurers to follow Medicare guidelines, all insured patients had to leave the program. Mass General Brigham, which operates many hospitals in the state, has rejiggered its plans to create more home care without relying on the hospital-at-home program, according to the Becker’s report.

Congress was unable to avert a shutdown by late September, and some individual providers and patients were caught unawares.

Nurses on social media discussed losing home-care jobs or being reassigned overnight when the hospital-at-home program closed Oct. 1. They worried about patients being taken away from children at home, or placed in hallway beds at overcrowded emergency rooms because of the abrupt change.

“Management scheduled a random call this morning with a super vague title. Then drop the bomb on us,” wrote one poster in Texas. “So no job. Perfect!”

In a direct message, the poster, who didn’t want their name used for fear of getting in trouble at their hospital, told Stateline, “This obviously wasn’t ideal for the patients. One of them had four children and now could no longer be home with them. Some didn’t even get to have a bed in the hospital because there were none available and had to stay in the ER in a hallway bed.”

Parkland Health System in Dallas started tapering off its hospital-at-home program in September because of the impending shutdown, and the last patients were discharged from the program by Sept. 30 without returning to the hospital, spokesperson Wendi Hawthorne said.

“We are hopeful that Congress will renew this innovative model of care in the future,” Hawthorne said.

Likewise, OSF Healthcare in Peoria, Illinois, had started to wind down its hospital-at-home program “to avoid needing to return multiple patients to a very crowded facility,” said Jennifer Junis, president of OSF OnCall, which handles home hospital care.

There were only three patients in the program Sept. 30, all of whom were ready to be discharged without returning to the hospital, Junis said. Since the program’s start in 2020, it has helped 980 patients with home care through OSF’s Saint Francis Medical Center in Peoria.

“It is unfortunate that we will not be able to benefit by treating qualifying patients at home, where they are most comfortable and recover faster,” Junis said. “Our digital hospital program has allowed us to free up beds for our sickest patients who need them most.”