Section 1311(c)(1)(C) of the ACA requires that all Qualified Health Plan, including Stand Alone Dental Plan, issuers include in their network Essential Community Providers (ECPs) which are healthcare providers that predominantly serve low-income, medically-underserved populations.
- Health and Human Services (HHS) has determined the criteria for certification of QHPs, including what criteria are required to meet the ECP inclusion requirement.
- To meet this criteria, issuers must submit an ECP Template as part of their QHP application that lists the ECPs that they contract with to provide health care to low-income, medically-underserved individuals in their service areas.
HHS has a list compiled from a petition that providers submitted and CMS approved through their ECP review process, which is updated annually.
- The ECP Categories used by the federal government are: Black Lung Clinics, Community Mental Health Centers, Dental Providers, Family Planning Providers, Federally Qualified Health Centers, Inpatient Hospitals (other than children’s hospitals), Outpatient Hospital Clinics, Programs operated by the Indian Health Service, Programs operated by a Tribe or Tribal organization under the authority of the Indian Self-Determination and Education Assistance Act, Programs operated by an urban Indian organization under the authority of Title V of the Indian Health Care Improvement Act, Rural Health Clinics, Ryan White Providers, Sexually Transmitted Disease Clinics, Tuberculosis Clinics, and Other ECP Providers.
- We use the same categories plus an “Expanded ECP category” as defined by 45 CFR § 156.235(c), which can be; a local health department, an outpatient mental health center or substance use disorder treatment provider (as described at COMAR 10.09.80.03.B(1) & B(3)) that is licensed or approved by DH as a program or facility, or a school-based health center.
- We require that issuers contract with at least 35% of the ECPs in each plan’s service area and we provide an alternative standard to help issuers meet this requirement, allowing them to provide us with a list of the providers that they were unable to contract with and the denominator used to calculate the 35% requirement is reduced by the number of “Uncontracted ECPs” listed on their ECP Template.
- The ECP list is a database we create with all the contact info and ECP type data for ECPs that contract with insurance carriers in MD. The list is utilized in the MD ECP Template, where the carriers identify which ECPs they contract with and what network the ECP is covered under.