Essential Community Providers List for ACA Plan Year 2019 Released

Essential Community Providers List for ACA Plan Year 2019 Released

Thursday, December 14, 2017
TARGET Center

From the SPNS Listserv - Dear Colleagues:

On December 12, 2017, DHHS' Centers for Medicare and Medicaid Services (CMS), Center for Consumer Information and Insurance Oversight (CCIIO) released a draft list of Essential Community Providers (ECP) for ACA Plan Year 2019.  This list assists qualified health plan issuers with identifying providers that can count toward satisfaction of the ECP standard for the 2019 plan year. ECPs are defined as providers who serve predominantly low-income, medically underserved individuals and include Ryan White HIV/AIDS Program providers.  

Recipients should check their information on the draft ECP list (please see the instructions on this link on how to access the draft ECP list). This list reflects those providers who submitted an online ECP petition between December 9, 2015 and September 17, 2017 and were approved by CMS through the ECP petition review process.   If you need to make a correction or add your information to the list, you should submit the request to CMS/CCIIO through the online ECP petition no later than December 22, 2017 to be considered for the final list for 2019 plan year.  More information about the draft ECP list is attached. 

Description and Purpose of the Draft CMS Essential Community Providers List for the 2019 Plan Year 

DESCRIPTION OF DRAFT CMS LIST OF ESSENTIAL COMMUNITY PROVIDERS: 

For the 2019 plan year, the Centers for Medicare & Medicaid Services (CMS) is releasing a draft list of Essential Community Providers (ECPs) to assist issuers with identifying providers that qualify for inclusion in a qualified health plan issuer’s plan network toward satisfaction of the ECP standard under 45 CFR 156.235 for the 2019 plan year. Under that regulation, ECPs are defined as providers who serve predominantly low-income, medically underserved individuals. They include health care providers defined in section 340B(a)(4) of the Public Health Service (PHS) Act and entities described in section 1927(c)(1)(D)(i)(IV) of the Social Security Act (SSA). 

This draft CMS ECP list contains the following types of essential community providers: 

  • Federally Qualified Health Centers (FQHCs) and FQHC look-alikes 
  • Health centers providing dental services 
  • Hospitals: Critical Access Hospitals, Rural Referral Centers, Disproportionate Share (DSH), DSH-eligible Hospitals, Children’s Hospitals, Sole Community Hospitals, Free-standing Cancer Centers 
  • Indian health care providers, which include providers participating in programs operated by 1) the Indian Health Service; 2) a Tribe or Tribal organization under the authority of the Indian Self-Determination and Education Assistance Act; and 3) an urban Indian organization under the authority of Title V of the Indian Health Care Improvement Act 
  • Ryan White HIV/AIDS Program providers 
  • Family planning providers receiving Federal funding under Title X of the PHS Act and not-for-profit or governmental family planning service sites that do not receive Federal funding under Title X of the PHS Act or other 340B-qualifying funding 
  • Other providers that serve predominantly low-income, medically underserved individuals, including Black Lung Clinics, Community Mental Health Centers, Hemophilia Treatment Centers, Rural Health Clinics, Sexually Transmitted Disease Clinics, Tuberculosis Clinics 

Providers included on the draft CMS ECP list for the plan year 2019 reflect those providers who submitted an online ECP petition between December 9, 2015 and September 17, 2017 and were approved by CMS for inclusion on the ECP list through the ECP petition review process. 

This draft CMS list of ECPs for the plan year 2019 is not exhaustive and does not include every provider that participates or is eligible to participate in the 340B drug program, every provider that is described under section 1927(c)(c)(1)(D)(i)(IV) of the SSA, or every provider that may otherwise qualify under 45 CFR 156.235. While CMS is providing this updated draft list for the 2019 plan year, CMS encourages providers who do not appear on the ECP list but believe they satisfy the ECP inclusion criteria, as outlined within the ECP petition, to submit an online ECP petition to CMS by no later than December 22, 2017, for inclusion on the ECP list for the plan year 2019. The ECP petition is available at https://data.healthcare.gov/cciio/ecp_petition. 

CMS collects provider data directly from providers through the ECP petition and does not accept petitions from third-party entities on behalf of the provider. Third-party entities include issuers, advocacy groups, State departments of health, State-based provider associations, and providers other than the provider that is the subject of the petition. However, if one of the above entities owns or is the authorized legal representative of an ECP, it may submit a petition on behalf of the provider. For example, a local health department that operates its own family planning clinics may appropriately petition for those clinics.

PURPOSE OF CMS LIST OF ECPs: 

CMS will use this draft ECP list as the basis for determining the number of available ECPs in the Qualified Health Plan’s (QHPs) service area. In other words, the denominator of the percentage of available ECPs included in the issuer’s provider network(s) includes ECPs in the QHP’s service area that are listed on the CMS list of ECPs. All providers included in a QHP issuer’s application and that meet the Federal regulatory standard and appear on this final CMS ECP list for the 2019 plan year will count toward the numerator of the ECP evaluation percentage. Additionally, issuers may use the provider points of contacts on the list to aid in provider network development. 

UPDATES TO CMS LIST OF ECPs: 

CMS has conducted provider outreach throughout the year to update provider data on the ECP list for the 2019 plan year. These revisions have included updating provider contact information, modifying the types of health services displayed on the list as available at specific provider facilities, and removing provider practices that are no longer in business or no longer accepting plans purchased through an Exchange. In addition to ongoing provider outreach that CMS conducts, CMS launched the ECP petition initiative in early December 2015 to solicit qualified providers to correct and update their provider data on the ECP list, and solicit qualified providers to petition to be added to the ECP list to ensure a more accurate reflection of the available ECPs in a given service area. 

Providers who wish to submit corrections, updates, and requests for inclusion on the CMS ECP list for the 2019 plan year must submit an online ECP petition by December 22, 2017. The ECP petition is available at https://data.healthcare.gov/cciio/ecp_petition. The ECP petition process will remain open throughout the year for providers to correct and update their data for future plan year ECP list releases. 

CMS endeavors to continue improving the ECP list for future years. These efforts include direct provider outreach to ECPs themselves, as well as reviewing the provider data with our Federal partners. We recommend that individual ECPs regularly review their provider data on the CMS ECP list to ensure that their information is up to date. We ask that issuers, trade associations, and other third parties refer concerns about individual provider listings to the respective providers themselves.