Expanded List of Essential Community Providers Released by CMS

February 23, 2016

Under the Affordable Care Act (ACA), only insurance plans that meet specific requirements can be sold on the exchange. These certified plans, known as Qualified Health Plans (QHPs), must meet cost sharing requirements, cover essential benefits, and include providers in their networks that cater to low-income or other medically underserved communities. Providers that cater to such demographics are called Essential Community Providers (ECPs).

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According to a post on Health Affairs Blog, the Centers for Medicare and Medicaid Services (CMS) has released a list of 19,000 qualifying ECPs in order to assist insurers with staying in compliance with ACA regulations for QHPs. In addition to expanding the list from previous years, CMS has included more detailed provider information and taken measures to ensure that the list provides an accurate account of the available ECPs in a given area. This is important because QHPs are required to contract with 30% of the ECPs available in their location. QHPs must include within that 30% at least one provider from each of the 6 categories of ECPs. These are federally qualified health centers, Indian health care providers, family planning providers, Ryan White HIV/AIDs providers, safety net hospitals and other ECPs, which can include any medical entity that serves populations that struggle to obtain health care.

While CMS has greatly expanded its list of ECPs for 2016, it is not comprehensive. QHPs have the opportunity to write in other ECPs as long as they meet the requirements. Plans that do not meet the 30% benchmark, such as HMO plans, will have the opportunity to demonstrate how they are serving the low-income population in other ways. Dental plans on the exchange must also contract with 30% of the ECPs in their area.—Katie Grosso

Reference: Jost T. CMS releases final list of 19,000 essential community providers. Health Affairs Blog. February 17, 2016.