Most of the provisions in the Affordable Care Act will be implemented between 2010 and 2014, but a few will take place in 2015 and beyond, pertaining to insurance and hospital-acquired conditions as well as another tax revenue provision. In this wind-up of the provisions contained in the act, below are a summary of the changes to take effect beyond implementation of the exchanges in 2014.

Insurance Reforms

--States will be allowed to form health care compacts that will take effect in 2016. By 2013, the U.S. Department of Health and Human Services will issue regulations for the creation of the health care choice compacts. Under those compacts, two or more states may agree to offer one or more qualified health plans in individual markets in all states. The plans would still be subject to the laws and regulations of the state in which the plan was issued. The issuer of the plan would also be subject to regulation of unfair trade practices and consumer protection standards. Any state participating must enact a law to authorize it to enter a compact agreement.

HHS may approve the compacts if the agency determines that the compact:

--Will provide coverage that is at least as comprehensive as the coverage offered through the exchanges to be set up in 2014;

--Will provide coverage and cost sharing protections against excessive out-of-pocket spending;

--Will not increase the federal deficit; and

--Will not weaken enforcement of laws and regulations relating to insurance in any state that is included in the compact.

Medicare

--The amount of payment to hospitals in the top 25th percentile of rates for hospital-acquired conditions will be reduced by one percent with respect to discharges occurring during fiscal year 2015 and subsequent years. For some hospitals, an exemption may be given if the state can submit an annual report to HHS describing how a similar program in the state for participating hospitals achieves or surpasses the measured results of the national program with patient health outcomes and cost savings.

--HHS will make information available to the public regarding hospital-acquired conditions on each applicable hospital posted on the Hospital Compare Internet website.

--HHS will also conduct a study on expanding the health care-acquired conditions policy to payments made to other facilities under the Medicare program, including payments made to inpatient rehabilitation facilities, long-term care hospitals, hospital outpatient departments, skilled nursing facilities, ambulatory surgical centers and health clinics. The study will include an analysis of how such policies could impact quality of patient care, patient safety and spending under the Medicare program, and HHS must submit a report on the study to Congress by Jan. 1, 2012.

Tax Changes

--Effective Jan. 1, 2018, an excise tax will be imposed on health insurance companies and plan administrators for any so-called Cadillac plan that is above the threshold of an annual cost of $10,200 for individual coverage and $27,500 for family plans. The tax will be applied to the premium amount above the individual or family threshold. There is a higher threshold level allowed for employers who have higher costs due to age and gender demographics.

In other health reform news, HHS has released guidance on a waiver for insurance companies regarding the restriction of annual limits on the dollar value of health benefits in an individual market plan that was part of the Affordable Care Act. HHS may waive the restricted annual limits if compliance would result in a significant decrease in access to benefits or a significant increase in premiums.

The waiver only applies to plans or coverage offered before Sept. 23, 2010, for the plan or policy year beginning between Sept. 23, 2010 and Sept. 23, 2011. The issuer must submit an application at least 30 days before the beginning of the plan or policy year, or in the case of a plan or policy year that begins before Nov. 2, 2010 at least 10 days before. The application must include the terms of the plan or policy forms for which a waiver is sought; the number of individuals covered in the plan; the annual limits; and a brief description of why compliance with the interim final regulations would result in a significant decrease in access to benefits for those currently covered, or a significant increase in premiums paid by those covered by the plans.

More on the guidance can be found at http://www.hhs.gov/ociio/regulations/patient/ociio_2010-1_20100903_508.pdf