AMA advocacy on ACA implementation
The AMA has responded, and continues to respond, regularly to detailed policy proposals being issued by the federal agencies charged with implementing the ACA.
Affordable Care Act refinements
The passing of the Affordable Care Act (ACA) was only the 1st step toward a better performing health care system. The AMA continues to work with Congress and the Administration (PDF) to refine provisions within it.
Late on Friday, Dec. 15, a federal district court in Texas struck down the Affordable Care Act (ACA) in its entirety, finding that the 2017 Tax Cuts and Jobs Act (TCJA), which zeroed out the tax penalties associated with the ACA’s individual mandate, renders the mandate unconstitutional.
Texas v. Azar Decision
Late on Friday, Dec. 15, a federal district court in Texas struck down the Affordable Care Act (ACA) in its entirety, finding that the 2017 Tax Cuts and Jobs Act (TCJA), which zeroed out the tax penalties associated with the ACA’s individual mandate, renders the mandate unconstitutional. The judge further concluded that since the individual mandate is “essential” to the ACA, it could not be severed from the rest of the ACA, and the entire ACA was therefore unconstitutional. The AMA disagrees strongly with the district court’s decision. The AMA will continue to be a champion for access to affordable and meaningful health insurance coverage for all Americans, joining patient and other health stakeholder groups in pursuing an appeal and reversal of this regrettable decision.
Independent payment advisory board
One of the main ACA provisions the AMA is working to refine has been the creation of the Independent Payment Advisory Board (IPAB). The AMA is working with members of the House and Senate to secure its repeal and ensure seniors’ access to their physicians. Read about the AMA's work to repeal the Independent Payment Advisory Board.
Protecting seniors’ access to Medicare
H.R. 1190, which would repeal the IPAB, passed the House in June 2015 by a 244 to 154 vote. However, the final version of the bill would offset the cost of the legislation by cutting $7 billion+ in public health and prevention funding. The AMA is looking for more appropriate offsets. To secure repeal of IPAB and ensure seniors’ access to their physicians, AMA is working with Sen. Cornyn (R-TX), the sponsor of companion legislation in the Senate, and others.
Antidiscrimination provisions for health plans
The ACA includes a provision stating that health plans may not discriminate against any health care provider—acting within its state scope-of-practice laws—that wants to participate in the plan. AMA policy is to repeal this provision. Until that can be accomplished, the AMA has sought clarification, through the regulatory process, that this provision does not allow expansion of the scope of practice for nonphysician allied health practitioners.
Use of HSAs/FSAs to pay for over-the-counter drugs
The ACA includes a provision that requires individuals with tax-preferred accounts, such as health savings accounts (HSAs) or flexible spending accounts (FSAs), to obtain a prescription before using such accounts to pay for over-the-counter medications and certain supplies. The AMA is supporting pending legislation in Congress to repeal this provision.
See Advocating for improvements to the ACA (2011) (PDF) to learn more about major provisions that are generally supported by the AMA, changes already accomplished and additional changes the AMA supports.
View 2014-2015 ACA correspondence. To view related letters previous to 2014, please use the Federal and State Correspondence Finder.
- June 16, 2015 Letter to U.S. House of Representatives supporting H.R. 1190, the Protecting Seniors’ Access to Medicare Act of 2015 (PDF)
- March 4, 2015 Letter to Rep. Phil Roe (R-TN) supporting H.R. 1190, the Protecting Seniors’ Access to Medicare Act of 2015 (PDF)
- March 4, 2015 Letter to Rep. Linda Sanchez (D-CA) supporting H.R. 1190, the Protecting Seniors’ Access to Medicare Act of 2015 (PDF)
- Jan. 29, 2015 Letter to Sen. Cornyn Supporting S. 141, the Protecting Seniors' Access to Medicare Act of 2015 (PDF)
- Sept. 17, 2015 Health Choices Coalition letter in support of H. R. 1270 (PDF)
- March 3, 2014 Letter supporting H.R. 2194, the Family and Retirement Health Investment Act of 2013 (PDF)
- June 5, 2014 Letter to CMS Re: request for information regarding provider nondiscrimination (CMS-9942-NC) (PDF)
AMA comments on ACA implementation regulations
As implementation of Affordable Care Act (ACA) provisions proceeds, the AMA is rapidly responding to regulatory proposals being issued by various federal agencies. Following is a summary of key regulations and opportunities for public comment that have been issued so far, with links to relevant federal documents and comments submitted by the AMA.
Meaningful administrative simplification would result in significant savings and benefits to physicians and the health care delivery and payment system.
Antitrust relief and removal of other legal barriers
Legal barriers need to be removed in order for physicians to participate in the models of patient care, such as Accountable Care Organizations (ACOs), which will be tested under the new health care law.
Basic health program
The ACA offers states the option of implementing the Basic Health Program (BHP), which provides states 95% of what the federal government would have spent on tax credits and subsidies for out-of-pocket costs for adults with incomes between 133 and 200% of the federal poverty level (FPL), and for legally resident immigrants with incomes below 133% FPL who do not qualify for Medicaid. Individuals eligible for the BHP cannot receive subsidized coverage in the state exchange.
Consumer health plan appeals
Consumers are given the right to appeal health plan decisions.
Coverage of preventive services
Insurers are required to cover certain evidence-based preventive services at no cost to plan enrollees.
Dependent coverage of children under Age 26
Individual and new employer health plans are required to make dependent coverage available until a child reaches the age of 26.
Essential health benefits
Effective in 2014, all qualified health benefits plans, including those offered in exchanges and in the individual and small group markets outside of exchanges, with the exception of grandfathered individual and employer-sponsored plans, will be required to offer at least the essential health benefits package.
Expanded form 1099 reporting requirements
Effective for payments made after Dec. 31, 2011, section 9006 of the ACA (incorporated as section 6041 of the internal Revenue Code) requires all businesses that pay any amount greater than $600 during the year to corporate and noncorporate providers of property, goods and services to file an information report—Form 1099—with the IRS.
"Grandfathered" health plans
Individuals and businesses may keep their current health plans during the transition to making coverage available through health insurance exchanges.
Health insurance exchanges
View AMA health insurance exchanges correspondence. To view related letters previous to 2014, please use the Federal and State Correspondence Finder.
- Jan. 14, 2016 Letter to CMS on Draft 2017 letter to issuers in the federally facilitated marketplaces (PDF)
- Dec. 21, 2015 Comments on the CMS proposed rule regarding notice of benefit and payment parameters for 2017 (PDF)
- Dec. 22, 2014 Comments on the CMS proposed rule regarding notice of benefit and payment parameters for 2016 (PDF)
- April 21, 2014 Comments on CMS proposed rule on exchange and insurance market standards for 2015 and beyond (PDF)
- Feb. 25, 2014 Response to CMS’ letter to issuers in the federally facilitated marketplace (PDF)
HHS initial core set of health quality measures for Medicaid-eligible adults
Sec. 2701 of ACA requires the Secretary of HHS to develop an initial core set of health quality measures recommended for Medicaid-eligible adults.
HHS national health care quality strategy and plan
Sec. 3011 of ACA requires the HHS Secretary to establish and deliver a National Health Care Quality Strategy and Plan to Congress by Jan. 1, 2011.
The ACA extends and simplifies Medicaid eligibility beginning in 2014 to cover all individuals under age 65 with incomes below 133 percent of the Federal Poverty Level; replaces the current standards and methods for evaluating income eligibility, and simplifies eligibility determination and enrollment and re-enrollment procedures.
Medical loss ratios
Health insurers offering individual or group coverage will be required to submit annual reports on the percentages of premiums spent on health care and quality improvement, and to provide rebates to enrollees if this spending does not meet minimum standards.
Medicare and Medicaid program enrollment and documentation requirements for ordering and referrals
Physicians and eligible professionals who order and refer covered items and services for Medicare beneficiaries are required to be enrolled in Medicare. Providers and suppliers participating in the Medicare program must also provide documentation on referrals to programs at high risk of waste and abuse.
Payment adjustment for provider-preventable conditions (PPCs)
Section 2702 of ACA directs the Secretary of HHS to identify current state practices that prohibit payment for Health Care-Acquired Conditions (HCACs) and incorporate the practices identified, or elements of such practices, which the secretary determines appropriate for application to the Medicaid program in regulations to be effective as of July 1, 2011.
This proposed rule includes provisions to implement new limitations on certain physician referrals to hospitals in which they have an ownership or investment interest.
Preexisting condition exclusions, lifetime and annual limits, rescissions and patient protections
Preexisting condition exclusions or denials, lifetime dollar limits on benefits and rescissions are banned except in clear cases of fraud. Patients are also protected with respect to choice of health care professionals and no prior authorization requirements for emergency care, including services provided out of network.
Premium review process
The Secretary of HHS is required to work with states to establish an annual review of unreasonable insurance rate increases, to monitor premium increases, and to award grants to states to carry out their rate review processes.
Public reporting and data release
A number of critical factors must be considered as CMS develops an implementation plan for ACA transparency reporting:
- Section 6002 of ACA calls for Reporting of Physician Ownership or Investment Interests
- Section 10331 of ACA requires CMS to establish a Physician Compare website by Jan. 1, 2011
- Section 10332 of ACA calls for the availability of Medicare Data for Performance Measurement
Risk adjustment, reinsurance and risk corridors
The ACA requires the creation of programs for risk adjustment, transitional reinsurance, and temporary risk corridors to mitigate the impact of potential adverse selection and stabilize premiums in the individual and small group markets as i
Table of Contents
- AMA advocacy on ACA implementation
- Affordable Care Act refinements
- Texas v. Azar Decision
- Independent payment advisory board
- Protecting seniors’ access to Medicare
- Antidiscrimination provisions for health plans
- Use of HSAs/FSAs to pay for over-the-counter drugs
- Download resources
- AMA comments on ACA implementation regulations
- Administrative simplification
- Antitrust relief and removal of other legal barriers
- Basic health program
- Consumer health plan appeals
- Coverage of preventive services
- Dependent coverage of children under Age 26
- Essential health benefits
- Expanded form 1099 reporting requirements
- "Grandfathered" health plans
- Health insurance exchanges
- HHS initial core set of health quality measures for Medicaid-eligible adults
- HHS national health care quality strategy and plan
- Medical loss ratios
- Medicare and Medicaid program enrollment and documentation requirements for ordering and referrals
- Payment adjustment for provider-preventable conditions (PPCs)
- Physician-owned hospitals
- Preexisting condition exclusions, lifetime and annual limits, rescissions and patient protections
- Premium review process
- Public reporting and data release
- Risk adjustment, reinsurance and risk corridors