The Affordable Care Act (ACA) requires Qualified Health Plans (QHPs) in the State Insurance Exchanges to contract with an adequate network of “Essential Community Providers” (ECPs).
Essential Community Providers are medical care providers who serve predominantly low-income, or medically underserved patient populations.
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)
- Indian Providers
- Safety-net hospitals (hospitals that receive Disproportionate Share Hospital funding)
- STD Clinics
- 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.
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.
On March 26, 2013 CMS/CCIIO issued a “non-exhaustive list” of ECPs to assist health insurance issuers in locating ECPs: http://cciio.cms.gov/programs/exchanges/qhp.html.
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.
Many insurers are still using this list to determine networks of care. HIV providers may want to contact CCIIO Ryan White providers at EssentialCommunityProviders@cms.hhs.gov if they are not on the list or if their contact information is incorrect.
ECP Frequently Asked Questions - CCIIO
Letter to Essential Community Providers - CCIIO
Essential Community Providers – HRSA
Fact sheet for Ryan White Providers – HIV Health Reform.com
Health Care Reform & Essential Community Providers: Information for Ryan White Providers – HIVMA
Affordable Exchanges Guidance: CMS Letter to Issuers on Federally-facilitated and State Partnership Exchanges - CMS
Non-Exhaustive List of Essential Community Providers - The Center for Consumer Information