Timeline: Rollout of federal health care law

It's been nearly two years since the sweeping national health care overhaul spearheaded by President Barack Obama and congressional Democrats became law.

In that time, consumers, insurers and health providers already have seen changes affecting their pocketbooks and the way they do business.

More is on tap for 2012 and beyond - assuming the law survives. The U.S. Supreme Court is expected to render a decision later this year on constitutional challenges, including whether most individuals can be required to carry insurance or face a penalty. Republican presidential candidates have vowed to repeal the law if elected in November.

For now, here's a look at what's happened and what's scheduled to happen under the Patient Protection and Affordable Care Act.

Took effect in 2010

- Filling the doughnut hole. A $250 rebate check was sent to 3.8 million people covered by Medicare who reached the prescription drug coverage gap known as the "doughnut hole."

- Created temporary high-risk pool. The Pre-Existing Condition Insurance Plan, also known as the national "high-risk pool," was created for people denied insurance or quoted extremely high rates because of pre-existing medical conditions. Virginia and 22 other states opted for the federal government to run their plans, while the other states manage their own.

Last summer, the government reduced premium prices in Virginia by about 40 percent. Though enrollment in the commonwealth continues to lag behind projections, it nearly tripled between March and November to 799 members.

- Launched consumer website. The federal government established a consumer-focused health care website at healthcare.gov.

- Imposed indoor tanning tax. A 10 percent tax on payments for indoor tanning services took effect.

- Extended coverage for adult offspring. Private insurers were required to extend dependent coverage for adult children up to age 26 for all individual and group policies created or renewing after Sept. 23, 2010.

- Insured children with pre-existing conditions. Insurers were prohibited from denying coverage to children due to pre-existing medical conditions.

- Established consumer protections in insurance. Individual and group health plans were prohibited from placing lifetime limits on the dollar value of coverage, and insurers were allowed to rescind coverage only in cases of fraud.

- Covering some preventive services. Job-related health plans and individual policies created after March 2010 are required to provide coverage of certain preventive services without additional cost to members. Services include, among others, flu shots, vision screening for children and cholesterol screenings for adults of certain ages or at higher risk.

Last summer, the federal government added a requirement that insurers cover birth control and other women's preventive services for plans renewed or created after Aug. 1, 2012. Group health plans sponsored by certain religious employers and related coverage are exempt from the requirement to cover contraceptive services.

Took effect in 2011

- Closing the doughnut hole. People on Medicare who reached the gap in prescription drug coverage saved 50 percent on brand-name medicines and 7 percent on generics. Drug discounts for Medicare recipients in the doughnut hole will continue to increase until 2020, when they'll pay 25 percent of the cost for both brand-name and generic medicines.

- Covering preventive services for Medicare recipients. Patients' payment responsibilities were eliminated for certain preventive services, such as a yearly wellness exam and mammograms for women 40 and older, for people on Medicare's fee-for-service program. As of the end of November, more than 24.2 million people with Medicare had received at least one free preventive benefit, according to the federal government.

- Changing flexible spending accounts. The costs of over-the-counter drugs not prescribed by a doctor cannot be reimbursed through a health flexible spending account. The tax on distributions from a health savings account not used for qualified medical expenses increased to 20 percent.

- Required nutrition labeling. Standard menu items at chain restaurants and vending machines must include nutritional content.

- Spending requirements. Health plans must report the proportion of premium dollars spent on health care and improving the quality of care versus what is spent on administrative and other costs, a percentage known as the "medical loss ratio." If the share spent on health care is less than 85 percent for large-group plans and 80 percent for individual and small-group plans, then the insurer must provide a rebate for consumers. The requirement begins with coverage purchased in 2011; any rebates for that year will be provided in 2012.

- Reviewing increases. The federal government worked with the states to create a process in which insurers must justify premium increases over 10 percent for individual and small-group policies. Reviews of proposed premium increases for 2012 were to start in September.

Scheduled to take effect in 2012

- Paying based on quality. Starting Oct. 1, Medicare will pay hospitals based on their performance on quality measures.

Scheduled to take effect in 2013

- Capping flexible spending accounts. The amount of contributions to a flexible spending account for medical expenses will be limited to $2,500 a year, to be increased annually.

- Reporting financial relationships. Disclosure of financial relationships between health entities, such as physicians and hospitals, and manufacturers and distributors of drugs and other medical supplies will be required.

Scheduled to take effect in 2014

- Insurance requirement. Most U.S. citizens and legal residents will be required to have health insurance. For those who don't, a penalty tax will be phased in, with some exceptions.

- Eliminating annual limits. New plans and existing group plans cannot impose annual dollar limits on the amount of coverage an individual may receive.

- Health insurance exchanges. State-based exchanges will begin operating and offer a marketplace for individuals and small businesses with fewer than 100 employees to purchase coverage.

- Pre-existing conditions. Insurers will not be allowed to deny or limit coverage or charge higher premiums to anyone because of a pre-existing medical condition. The temporary Pre-Existing Condition Insurance Plan will end.

- Medicaid expansion. Medicaid eligibility will expand to include all individuals under 65 with incomes up to 133 percent of the federal poverty level who are not eligible for Medicare.

- Tax credits. If an affordable plan is not available, families with incomes between 133 and 400 percent of the federal poverty level will be eligible for tax credits or possibly cost-sharing subsidies to help purchase insurance through an exchange.

Businesses with 50 or more full-time workers will be assessed fees if one or more employee receives a premium tax credit to buy their own insurance.

Compiled by Pilot writer Amy Jeter from information from the Kaiser Family Foundation and the U.S. Department of Health and Human Services