Other components in the law that remain unfinished, experts say, include final rules on the so-called employer mandate—which imposes financial penalties on some businesses if any employees seek subsidized coverage on the state exchange. Proposed rules on coverage provided or limitations and taxes assessed when coverage is deemed insufficient were issued earlier this year.
Like many nonhealthcare businesses, skilled-nursing facilities are watching for clarifications on employer reporting provisions related to the employer mandate, said Erin Sutton, a senior director at the American Health Care Association, a trade group for skilled-nursing facilities. For instance, they are looking for clarification on the manner in which employees need to be told about coverage options. SNFs are among the least likely healthcare providers to offer employee health benefits that meet the coverage standards necessary to avoid federal penalties, according to health industry experts.
“It's hard for employers to inform employees about coverage options when the exchanges are not up and running in every state and it's not known what plans are going to be offered,” said Julie Scott Allen, a government relations director for Drinker, Biddle & Reath, a law firm that lobbies on healthcare issues.
HHS is expected to provide many of the remaining details implementing ACA statutory language through “guidance” that does not follow the formal rulemaking process. Those less formal methods of implementing statutory language have drawn provider criticism in the past over concerns that they lack a process to review and account for unintended adverse impacts.
“Right now we are in the land of bulletins and guidance and Q&As that help flesh out what the rule couldn't have done because we are in a state of flux,” Barnes said.
For example, critical details are still awaited on the operation of the federal data-services hub. That hub will bring together information on each insurance exchange applicant from disparate federal databases, and make it available to the state insurance exchanges to determine eligibility for exchange coverage and subsidies. States and insurers are waiting for guidance on what information the data hub will require, and by when.
“This is the most unsung part of what needs to happen before the exchanges are possible,” Barnes said.
Additional health law-related details will be finalized as part of the annual inpatient prospective payment system update. Federal officials will need to finalize a proposed rule issued on April 26 that offered changes to the Medicare disproportionate-share hospital payment system and proposed cuts based on incidence of hospital-acquired conditions.
“With many of these measures, there are questions about how reliable they are,” said Daniel Hettich, a senior associate at King & Spalding, a law firm that lobbies on healthcare issues. “It'll be interesting to see how (HHS) responds to comments in the final rule.”
Follow Rich Daly on Twitter: @MHrdaly