This has been a big year for the Affordable Care Act.

It survived a Supreme Court challenge and another during the presidential election. With President Obama in office for another four years, the health reform law will continue down the road to take full effect in 2014. But there is much work yet to be done, and 2013 promises to be a very active year.

Health Insurance Exchanges Go Online

The big story to watch in 2013 will be the development of state-based health insurance exchanges. These marketplaces will allow uninsured people and small businesses to shop for, compare, and enroll in health plans. Only through the exchanges will people learn if they qualify for and can take advantage of  federal tax subsidies to help cover the cost of insurance. Exchanges must be up and running by Oct. 1, 2013, and it’s going to be a mad rush to get the job done.

States were given the option to build their own exchanges and had until Dec. 14 to decide. Just 18 states and the District of Columbia agreed to build their own. Seven states have opted for a partnership exchange, a model where the states and federal government work together to operate the marketplace. That leaves the federal government to put in place health insurance exchanges in the remaining 25 states that declined to participate. 

Increased Medicare Taxes on the Wealthy

If you have Medicare coverage and earn more than $200,000 a year or are part of a married couple earning more than $250,000 annually, get ready to pay higher taxes for Medicare hospital insurance (Medicare Part A) in 2013.

Starting in January, taxes will rise by 0.9%, up to 2.35%, on earnings above $200,000 for individual taxpayers. In addition, income earned from investments (as opposed to salary) will face a 3.8% tax assessment.

Together, these two Medicare tax increases are expected to raise a total of $210 billion over 10 years to help pay for the changes brought by the health reform law.

Changes to Itemized Medical Deductions

For years we’ve been allowed to deduct unreimbursed medical costs that amount to 7.5% of our adjusted gross income. Starting next year, anyone under the age of 65 will see that threshold increase to 10%.

Limits to FSA Contributions

Flexible spending accounts (FSAs) allow people to set aside pre-tax salary dollars to pay for medical expenses not covered by insurance. Starting in January, contributions to these accounts will be limited to $2,500 a year.

Medicaid Expansion Becomes Optional

The Supreme Court’s ruling earlier this year brought changes to the part of the law that expanded the Medicaid program to include more low income Americans. The expansion allows for individuals who earn about $15,400 a year and families that earn about $26,300 annually to participate. In its decision, the court said the Medicaid expansion will be optional for states, not a requirement.

In response, many governors opposed to the law said they would refuse to expand their Medicaid programs. To date, 18 states have agreed to broaden rules for their Medicaid program, 11 states have said they would not expand their programs, and 16 remain undecided.