Editor’s Comment: One Year and Counting

Posted on March 23, 2011 | No Comments
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Editor's Comment

Implementation Briefs

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Key Developments

By The Editors

One Year and Counting

March 23, 2011, marks the one-year anniversary of the Affordable Care Act, and the Administration’s first year implementation effort spans the full scope of the law. Major areas of implementation encompass the full range of reforms under the Act: improving performance in the private insurance and employer-sponsored health plan markets; strengthening Medicare, Medicaid and CHIP; improving health care access and building a stronger health workforce; improving health care quality and accountability; increasing investments in public health; strengthening health care fraud and abuse controls; and reforming federal policies applicable to tax-exempt hospitals.

Health Reform GPS reported on the first six months of implementation efforts here. This updated table sets forth the major provisions of the Act as well as key agency implementation actions since our initial implementation table was published. Updates appear in italics.

ACA implementation efforts in Year Two can be expected to begin to reach the core of the reforms. Among other topics will be regulations delineating the contours of “essential health benefits” for health plans sold in the individual and small group markets, regulations governing state health insurance Exchanges and Qualified Health Plans, and federal policies on the ACA’s principal Medicaid expansion to reach all low income non-elderly persons by January 2014. Regulations aimed at curbing payment for unnecessary hospital care also can be expected, along with federal standards governing Accountable Care Organizations and other health care integration arrangements. Federal standards aimed at promoting disclosure of nutritional content for vending machine and restaurant food are anticipated as well.

TITLE AND ISSUE	AGENCY ACTION
Title I. Quality Affordable Health Care for All Americans
Immediate Improvements in Health Care Coverage for All Americans (§1001)	Implementation of provisions aimed at improving coverage either immediately or within 6 months of date of enactment: extending dependent coverage to children to age 26; prohibiting rescissions (retroactive cancellation of coverage) in the absence of fraud; prohibiting lifetime coverage limits; barring annual benefit limits to no less than $750,000 as of September 23, 2010 and rising to no less than $2 million before being fully phased out January 1, 2014; prohibiting the use of pre-existing condition exclusions for children under age 19; assuring patients the right to choose their participating primary care provider, including pediatricians; assuring patients direct access to obstetrical and gynecological services; coverage of emergency services without prior authorization and with in-network cost-sharing protections; for plan years that begin on or after September 23, 2010, coverage of evidence-based preventive items and services with an A and B rating currently recommended by the United States Preventive Services Task Force, immunizations recommended by the Advisory Committee on Immunization Practice, and pediatric and women’s health services recommended by the Health Resources and Services Administration. In the case of new recommendations not in place as of September 23, 2010, coverage must begin for plan years that begin within a year of the date on which the recommendation is issued; and establishing minimum federal standards for internal appeals involving claims for benefits as well as external review of claims denials by health plans and insurers. Medical loss ratio standards governing insurer expenditures on health benefits under development through joint activities between HHS and NAIC, including approval by NAIC of the MLR reporting form.
Immediate Actions to Preserve and Expand Coverage (§§1101-1105)	Pre-existing condition plan regulations governing comprehensive coverage and subsidized premiums issued, covering individuals who have lost insurance coverage and who have pre-existing conditions. (July 30, 2010) Establishment of insurance pricing reporting requirements as well as a federal and state rate review process to curb unreasonable price increases; $46 million in premium oversight grants awarded to states. (August 18, 2010) Early Retiree Insurance Program implemented, making available $5 billion in temporary assistance to support preservation of early retiree benefits; approximately 2,000 employers and unions approved as of August 31. Premium rate review process moved into implementation phase through state grants and the development of comprehensive information aimed at measuring unreasonable rate increases. Healthcare.gov launched in both English and Spanish to assist consumers find affordable coverage and care; site includes insurance finder tools. (June 30, 2010) Early Retiree Insurance Program adds additional employers to the list; more than 3,600 approved as of November 1, 2010. HHS issued a proposed rule to include student health insurance policies in health reform, giving college students the same consumer protections as others under the Affordable Care Act (February 10, 2011).
Preserving the Right to Maintain Existing Coverage (Grandfathered Health Plans) (§1253)	Standards established to measure whether health plans qualify for grandfathered status. Standards are designed to protect continuously existing plans while assuring disclosure of grandfathered status, and preventing abuse of grandfathering status in order to avoid compliance with key patient protections such as preventive benefit coverage, appeals rights and restrictions on annual coverage limits. (June 17, 2010) Multiple Frequently Asked Questions (FAQs) issued by Department of Labor on Grandfathered Plans (September and October, 2010). Amendment to Interim Final Rule on Grandfathered Plans issued, allowing employers to change issuers without losing grandfathered status (November 17, 2010).
Consumer Choices and Insurance Competition Through Health Benefit Exchanges (§§1301-1321)	State planning grants totaling $51 million awarded to begin the Exchange developmental process. Standard-setting process initiated through a Request for Comments on the development of implementation policy. (August 3, 2010) $49 million in grants awarded to states for health insurance exchange planning Final rule on elimination of cost-sharing for preventive services (November 29, 2010) HHS issued guidance on the Establishment of State Exchanges (November 18, 2010) Interim Final rule on Medical Loss Ratio (MLR) requirements issued by HHS (November 22, 2010) $241 million in “Early Innovator” grants announced by HHS for states to design health I.T. systems for use in Exchanges (February 17, 2011). HHS announced a propose rule that would allow states to apply for State Innovation Waivers, exempting them from certain statutorily-required exchange provisions (March 17, 2011).
Small Business Tax Credit (§1421)	Small business tax credits for firms of fewer than 25 full-time employees and average annual wages of under $50,000 made available through implementing IRS guidance. (May 18, 2010)
Title II. Role of Public Programs
Improvements in Public Programs including Medicaid and Title V (§§2301-2406)	CMCS implements state option to expand Medicaid to all low income adults prior to effective date of coverage mandate. (May, 2010) State Medicaid Directors Letter explaining new state options under the home and community based services reforms issued, including elimination of “institutional” level of care need and expanded services for persons with mental illness and substance abuse needs. (August 6, 2010) Medicaid family planning coverage option guidance issued. (July, 2010) $2.25 billion in Money Follows the Person grants awarded. (July, 2010) $88 million awarded in maternal and child health home visiting grants; separate program also established for tribal home visiting programs. Enhanced 90 percent federal match rate (FMAP) announced for Medicaid Eligibility and Enrollment systems (November 3, 2010) HHS issues additional guidance on Maintenance of Effort (MOE) requirements, which require states to ensure continuity of coverage for Medicaid beneficiaries while implementing the new eligibility changes authorized of health reform (February 26, 2011).
Improving Medicare for Patients and Providers; Medicare part D Improvements (§§3101-3114; 3301-3315)	$250.00 prescription drug coverage gap rebate checks issued to program beneficiaries in several rounds of mailings beginning July, 2010. Discount drug rebate agreement for Medicare Part D prescription drugs implemented. (July 2010) CMS proposes new preventive health coverage standards for Medicare beneficiaries, including annualized wellness visit and personal prevention plan as well as expanded preventive procedures with no cost sharing. (June 28, 2010) $68 million to support community living for seniors and individuals with disabilities
Title III. Improving the Quality and Efficiency of Health Care
Patient Centered Outcomes Research (§6301)	$14.2 million awarded by HHS to develop and test interventions based on patient-centered outcomes research among racial and ethnic minority populations. (September 15, 2010)
Improving Payment Accuracy (§§3131-3143)	Medicare home health payment reduction of 4.75% for FY 2011 implemented. Hospital Outpatient PPS payment rule proposed. (July 6, 2010) Final Rule on Home Health Prospective Payment System issued (November 3, 2010) Final Rule on Outpatient Hospital Prospective Payment System (OPPS) issued by CMS (November 24, 2010)
Health Care Quality Improvement (§3001)	Hospital Compare quality tool launched at CMS website www.healthreform.gov. CMS launched Physician Compare tool at Medicare.gov website (December 2010). CMS issued proposed rule on hospital value-based purchasing, under which hospitals can receive incentive payments for meeting or exceeding certain performance standards (January 11, 2011). HHS released the National Strategy for Quality Improvement in Health Care (National Quality Strategy), aimed at improving health care quality in the United States (March 21, 2011).
Health Care Delivery System Research (§3501)	Expanded multi-payer advanced primary care practice demonstration program launched by CMS to improve, on a statewide basis, the quality of primary health care across payers. (June 3, 2010)
Title IV. Prevention of Chronic Disease and Improving Public Health
National Prevention, Health Promotion, and Public Health Council (§4001)	National Prevention, Health Promotion, and Public Health Council Established. National Prevention and Public Health Council Issues first Report to Congress. (July 30, 2010)
Prevention and Public Health Trust Fund (§4002)	$15.4 million from Prevention and Public Health Trust Fund ($16.8 million in all) awarded to support 27 Public Health Training Centers. (September 15, 2010). $31 million from the Prevention and Public Health Fund awarded by HHS to reduce obesity and smoking, increase physical activity, and improve nutrition. The funds supplement an initial $491.8 million investment. $30 million from the Prevention and Public Health Trust Fund awarded to support President Obama’s National HIV/AIDS Strategy $100 million from the Prevention and Public Health Trust Fund awarded to support state efforts at curbing obesity and smoking, strengthen epidemiologic disease surveillance, and increase public health infrastructure capacity $320 million from the Prevention and Public Health Trust Fund awarded to expand primary care workforce $250 million in new funding from the Prevention and Public Health Trust Fund to strengthen clinical and community prevention efforts and public health infrastructure (February 10, 2011).
Spending for Federally Qualified Health Centers (§5601)	Health Center New Access Point Grants ($250 million) issued. (August 9, 2010). $727 million in grants made available to upgrade and expand health centers (October 8, 2010). An additional $335 million in grants awarded to boost primary care under the Expanded Services (ES) Initiative (October 26, 2010). $8 million in grants made available to community-based organizations that support health centers (November 19, 2010).
Food Labeling (§4205)	FDA implements food labeling requirements through a request for comment. (July 7, 2010)
Pregnancy Assistance (§§10211-10214)	Implementation of 10-year pregnancy assistance grant program launched. (July 2, 2010)
Prevention and Public Health Investments (§4002)	$250 million in community grants for community investments in prevention and public health made available for projects related to community clinical care, public health infrastructure, research and tracking, and public health training. (June 18, 2010) Strategic Framework on Multiple Chronic Conditions issued by HHS to help coordinate efforts to combat chronic disease (December 14, 2010).
Title V. Health Care Workforce
Increasing the Supply of the Health Care Workforce (§§5201-5210)	$250 million awarded for expansion of primary care workforce for primary care residencies, physician assistant and nurse practitioner training, nurse-led clinics, and state workforce planning. (June 16, 2010). $290 million in new funding for National Health Service Corps (NHSC) Loan Repayment Program (November 22, 2010). HRSA announced grant opportunity for Teaching Health Centers primary care medical residencies (November 29, 2010).
Title VI. Transparency and Program Integrity
Targeting Enforcement: Civil Money Penalties (§6111)	Regulations proposed establishing new nursing home civil money penalties policy aimed at improving quality and efficiency. (July 12, 2010).
National Background Check Program (§6201)	$13 Million awarded to states to help combat elder abuse in long-term care by performing background checks on caregivers.
Fraud Prevention	National fraud prevention effort in connection with donut-hole rebate checks launched. (June, 2010). Proposed rule on additional provider screening, additional fraud prevention activities issued (September 26, 2010). $ 9 million in grants awarded to Senior Medicare Patrol (SMP) programs.
Title VII. Improving Access to Innovative Medical Therapies
More Affordable Medicines for Children and Medically Underserved Communities (§§7101-7103)	Expanded 340B drug discount program launched by Health Resources and Services Administration. (July, 2010). Regulations proposed by HRSA for a dispute resolution process that can be used by safety net providers who suspect they have been overcharged for 340B drugs and by manufacturers who think safety net providers are in violation of the program prohibition on duplicate discounts or rebates, or the prohibition on resale of drugs purchased through the program. (September 20, 2010). Regulations proposed by HRSA setting standards for civil monetary penalties for manufacturers that “knowingly and intentionally overcharge” a 340B provider. (September 20, 2010).
Title VIII. CLASS Act
Independence Advisory Council (§3207)	CLASS Independence Advisory Council established (November 15, 2010). HHS places CLASS program administration within the Administration on Aging (AoA) (January 5, 2011). Administration on Aging (AoA) establishes the Office of Community Living Assistance Services and Supports (CLASS Office) (January 28, 2011).
Title IX. Revenue Provisions
Requirements for Charitable Hospitals (§9007)	Regulatory development process initiated through a Request for Comments issued by the IRS and aimed at developing standards to ensure compliance by nonprofit hospitals with new federal community benefit obligations in the areas of community public health needs assessment and provision of discounted care to the uninsured. (May 27, 2010) IRS issued request for comment on the requirements for tax-exemption for qualified non-profit health insurers, including how and when they can apply (February 15, 2010).
Limits on Health Flexible Spending Arrangements under Cafeteria Plans (§9005)	IRS guidance issued to implement revised standards governing coverage of over-the-counter drugs in flexible spending plans. (August 2010)
Qualifying Therapeutic Discovery Project Program (§9023)	IRS issues policy standards for tax credits for qualifying therapeutic discovery projects, with available credits of up to $5 million per firm and $1 billion overall. (May 2010).
Tax benefits for providers working in medically underserved areas (§10908 )	IRS issues policy expanding tax benefits for health care professionals practicing in underserved communities. (June 16, 2010
Refundable tax credit for adoption expenses (§10909)	IRS guidance issued on adoption tax credit. (September 29, 2010)
Indoor tanning tax (§9017)	IRS guidelines on new tax policy issued. (June 2010)
Title X. Strengthening Quality, Affordable Health Care
Advisory Committee on breast cancer in young women (§10413)	CDC creates Advisory Committee on Breast Cancer in Young Women (October 14, 2010)

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