are married. Employer mandate Businesses that employ 50 or more people but do not offer health insurance to their full-time employees are assessed additional tax if the government has subsidized a full-time employee's healthcare through tax deductions or other means. This is commonly known as the employer mandate. This provision was included to encourage employers to continue providing insurance once the exchanges began operating. Delivery system reforms The act includes delivery system reforms intended to constrain costs and improve quality. These include Medicare payment changes to discourage hospital-acquired conditions and readmissions, bundled payment initiatives, the Center for Medicare and Medicaid Innovation, the Independent Payment Advisory Board, and Accountable care organizations. Hospital quality Health care cost/quality initiatives included incentives to reduce hospital infections, adopt electronic medical records, and to coordinate care and prioritize quality over quantity. The Hospital Readmissions Reduction Program (HRPP) was established to reduce costly hospital readmissions. This program penalizes hospitals with higher than expected readmission rates by decreasing their Medicare reimbursement rate. Bundled payments Medicare switched from fee-for-service to bundled payments. A single payment was to be paid to a hospital and a physician group for a defined episode of care (such as a hip replacement) rather than separate payments to individual service providers. Accountable Care Organizations The Act allowed the creation of Accountable Care Organizations (ACOs), which are groups of doctors, hospitals and other providers that commit to give coordinated care to Medicare patients. ACOs were allowed to continue using fee for service billing. They receive bonus payments from the government for minimizing costs while achieving quality benchmarks that emphasize prevention and mitigation of chronic disease. Missing cost or quality benchmarks subjected them to penalties. Unlike Health Maintenance Organizations, ACO patients are not required to obtain all care from the ACO. Also, unlike HMOs, ACOs must achieve quality of care goals. Medicare drug benefit (Part D) Medicare Part D participants received a 50% discount on brand name drugs purchased after exhausting their initial coverage and before reaching the catastrophic-coverage threshold. By 2020, the "doughnut hole" would be completely filled. State waivers From 2017 onwards, states can apply for a "waiver for state innovation" that allows them to conduct experiments that meet certain criteria. To obtain a waiver, a state must pass legislation setting up an alternative health system that provides insurance at least as comprehensive and as affordable as PPACA, covers at least as many residents and does not increase the federal deficit. These states can escape some of PPACA's central requirements, including the individual and employer mandates and the provision of an insurance exchange. The state would receive compensation equal to the aggregate amount of any federal subsidies and tax credits for which its residents and employers would have been eligible under PPACA, if they cannot be paid under the state plan. Other insurance provisions The Community Living Assistance Services and Supports Act (or CLASS Act) established a voluntary and public long-term care insurance option for employees, The program was abolished as impractical without ever having taken effect. Consumer Operated and Oriented Plans (CO-OP), member-governed non-profit insurers, could start providing health care coverage, based on a 5-year federal loan. As of 2017, only four of the original 23 co-ops were still in operation. Menu calorie listings Nutrition labeling requirements officially took effect in 2010, but implementation was delayed, and they actually took effect on May 7, 2018. Legislative history PPACA followed a long series of unsuccessful attempts by one party or the other to pass major insurance reforms. Innovations were limited to health savings accounts (2003), medical savings accounts (1996) or flexible spending accounts, which increased