We recently held a health care reform roundtable where our clients and friends were able to share ideas about their preparations for upcoming Patient Protection and Affordable Care Act compliance. Below is an implementation timeline that we shared with those in attendance. We hope you find it useful as well.

Health Care Reform: Moving Forward From 2012 to 2018

Implementation Timeline


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ª Regulations have yet to be issued defining “essential health benefits”, but we know that they include items and services in the following general categories: (i) ambulatory patient services; (ii) emergency services; (iii) hospitalization; (iv) maternity and newborn care; (v) mental health and substance use disorder services, including behavioral health treatment; (vi) prescription drugs; (vii) rehabilitative and habilitative services and devices; (viii) laboratory services; (ix) preventive and wellness services and chronic disease management; and (x) pediatric services, including oral and vision care.

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AUTOMATIC ENROLLMENT: Employers that: (i) are subject to the Fair Labor Standards Act; (ii) have more than 200 full-time employees; and (iii) have at least one health benefit plan must automatically enroll full-time employees in one of the health benefit plans (subject to any waiting period) and provide “adequate notice” to employees (with an opportunity for employees to opt out of coverage).However, the DOL has indicated that employers are not required to comply with this requirement before final regulations are issued, which is not expected in time to implement by 2014.

ADDITIONAL REPORTING: Non-grandfathered group health plans are subject to the following additional reporting requirements:

  • § Annual report filed with HHS addressing whether plan or coverage benefits (and provider reimbursement structures) satisfy various criteria related to the cost and quality of health care, such as whether the plan or coverage: (i) improves health outcomes for treatment or services through certain activities; (ii) implements activities to prevent hospital re-admissions; (iii) improves patient safety and reduces medical errors through best clinical practice, evidence-based medicine, and health information technology; and (iv) implements wellness and health promotion activities. However, a due date by which the first report must be submitted to HHS has not yet been specified.
  • § Transparency in coverage reporting in which plans must disclose to HHS and the state insurance commissioner (and make available to the public) the following information: (i) claims payment policies and practices; (ii) periodic financial disclosures; (iii) data on enrollment and disenrollment; (iv) data on the number of claims denied; (v) data on rating practices; (vi) information on cost-sharing and payments regarding any out-of-network coverage; (vii) information on enrollee and participant rights under Title I of PPACA; and (viii) other information as determined by HHS. Plans subject to this reporting requirements must also provide certain cost-sharing information upon request from an individual. Although this requirement was effective beginning for plan years after September 23, 2010, it is unlikely to be enforced before state exchanges are effective in 2014.

ELECTRONIC TRANSACTION RULES: Health care reform expanded HIPAA’s electronic transaction rules. Beginning in 2013, electronic eligibility and claims status transactions must be conducted in accordance with the standards and operating rules adopted by HHS. In 2014, the standards and operating rules for electronic funds transfer (EFT) and remittance advice will apply. The standards and operating rules for health claims or equivalent encounter information, enrollment and disenrollment, health plan premium payments, referral certification and authorization and health claims attachments are scheduled to be effective January 1, 2016

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