Essential Community Providers are medical care providers who serve predominantly low-income, or medically underserved patient populations.
One of the requirements the QHPS must satisfy is providing for a sufficient number, and geographic distribution of Essential Community Providers (ECPs) in their plan networks.
In order to ensure that QHPs meet network adequacy standards (including ECP inclusion), CMS will use a tiered approach, referred to as the “safe harbor standard.”
To meet this requirement, at least 20% of available ECPs in the plan’s service area must be included in the provider network, including at least one ECP per type (includes Ryan White Program provider), per county where.
Plans that cannot meet this standard must submit to CCIIO a narrative justification describing how they will ensure access to care for low-income, medically underserved ,and vulnerable populations, and also how they intend to increase ECP participation in their network in future years.
Definition of ECPs
ECPs are providers with experience caring for medically underserved populations or low-income populations.
For states with a federally-run Exchange, or federal-state partnership, the definition of Essential Community Providers, as determined by The Centers for Medicare and
Medicaid Services (CMS) Center for Consumer Information & Insurance Oversight (CCIIO) includes:
Providers who qualify for 340B drug purchase prices
Ryan White HIV/AIDS providers
Federally Qualified Health Centers (FQHCs) and FQHC “Look-Alikes”
Family Planning Providers (Title X Family Planning Clinics)
Safety-net hospitals (hospitals that receive Disproportionate Share Hospital funding)
TB Clinics, Hemophilia Treatment Centers, and Black Lung Clinics
other entities that serve predominantly low-income, medically-underserved individuals
States that are administering their own state-run Insurance Exchange will set their own ECP requirements for their state. However, the ACA definition of ECPs as providers eligible to participate in the 340B program applies.
The list included some information on HRSA grantees, including Ryan White Providers, but did not incorporate many providers, and included inaccurate contact information for others.