Implementing Health Reform. On February 17, 2016, the Centers for Medicare and Medicaid Services (CMS) released a final updated list of over 19,000 essential community providers (ECPs) to assist insurers in complying with the ECP requirements that apply to qualified health plans (QHPs). CMS also published a guidance describing how the list is to be used.
ECPs are providers that serve predominantly low-income, medically underserved individuals. Under the 2017 draft letter to issuers, which should be finalized shortly, insurers must contract with 30 percent of available ECPs in their service area, offer contracts in good faith to all Indian health providers in their service area, and offer contracts in good faith to at least one ECP in each of six categories of ECPs (family planning providers, federally qualified health centers, hospitals, Indian health care providers, Ryan White providers, and “other” ECPs).
The final list is non-exhaustive. QHP insurers may write in additional ECPs not on the list as long as the written-in ECP meets ECP requirements and itself petitions for ECP status no later than August 22, 2016. Insurers that do not meet the 30 percent standard may submit a narrative justification explaining how they adequately meet the needs of their low-income and medically underserved enrollees and how they intend to increase ECP participation in the future. Plans that provide services through employed or contracted medical groups or hospitals, such as staff model HMOs must meet alternative ECP standards.
Standalone dental plans must offer good faith provider contracts to at least 30 percent of the dental ECPs in its service area and to all available Indian dental health care providers in its service area. As with health insurers, a standalone dental plan unable to satisfy the 30 percent requirement may offer a narrative justification meeting specified standards.
In December of 2015 CMS undertook an initiative to update and expand the ECP list. In response to public comments received on the 2017 proposed payment rule and letter to issuers, CMS also changed the format of the ECP list for benefit year 2017 to add provider data, including the National Provider Identifier (NPI), the number of full-time equivalent (FTE) practitioners available at each facility, additional ECP category indicators, and points of contacts and phone numbers for each ECP type listed in the ECP list.