Health Equity
Beyond the Insurance Card
Why Essential Community Provider
Requirements Matter
Arlene Murphy
Access Health CT Consumer Advisory Committee
1/24/2014
Making Access Real
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Health Equity and Essential Community
Providers
• Purpose of ECP Requirements
• How Requirements Work
• Why They Are Important
• Keys to advocacy
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1/24/2014
Know the Rules
Know the List
Know the Barriers
Monitor & Evaluate Implementation
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Network Adequacy 45 CFR Section 156.230
(a) General requirement. A QHP Issuer must ensure that the provider
network of each of its QHPs, as available to all enrollees, meets
the following standards.
(1) Includes essential community providers in accordance with
Section 156.235.
(2) Maintains a network in number and types of provides including
providers that specialize in mental health, substance abuse
services to assure that all services will be accessible without
unreasonable delay; and,
(3) Is consistent with the network adequacy provisions of Section
2702 (c) of the PHS Act.
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Network Adequacy 45 CFR Section 156.235
(a) General requirements
(1) A QHP must have a sufficient number and geographical
distribution of essential community providers, where available, to ensure
reasonable and timely access to a broad range of such providers for lowincome, medically underserved individuals in the QHP’s service area, in
accordance with the Exchange’s network adequacy standards.
(2) Definition. Essential community providers are providers that
serve predominantly low-income, medically underserved individuals,
including provides that meet the criteria of paragraph (c) (1) or (2) of this
section on the publication date of this regulation unless the provider lost
its status under paragraph (c) (1) or (2) of this section thereafter as a
result of violating Federal law:
1) Health care provides defined in Section 340B (a) (4) of the PHS
Act; and
(2) Provides described in Section 1927 (c) (1) (D) (i) (IV) of the Act
as set forth by Section 221 of Public Law 111-8.
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CCIIO Exchange Guidance
Network includes sufficient number and geographic distribution of ECPs to
ensure reasonable and timely access to a broad range of providers
Issuer must meet one of the following standards
• Safe Harbor – At least 20% ECP participation in network in the service
area. Agrees to offer contracts to al least one ECP of each type available
by county and agrees to offer contracts to all available Indian providers
• Minimum Expectations – At least 10% ECP participation in network in the
service area and submits a satisfactory narrative justification as part of its
application
Source: CMS’ “Letter to Issuers on Federally facilitated and State Partnership Exchanges”, available at:
http://cciio.cms.gov/resources/regulations/Files/2014_letter_to_issuers_04052013.pdf
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Types of Essential Community Providers
• Federally Qualified Health Centers (FQHC) - FQHC and FQHC “Look Alike”
• Ryan White Providers – Ryan White HIV/AIDS programs
• Family Planning Providers – Title X Family Planning Providers and Title X
“Look Alike” Family Planning Providers
• Indian Providers - Tribal and Urban Indian Organization Providers
• Hospitals – DSH Hospitals, Children’s Hospitals ,Rural Hospitals, Referral
Centers, Sole Community Hospitals, Free-standing Cancer Centers, Critical
Access Hospitals
• Other - STD Clinics, TB Clinics, Hemophilia Treatment Centers, Black Lung
Clinics, and other entities that serve predominantly low-income, medically
underserved individuals
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Connecticut Essential Community
Provider Requirements
Access Health CT Network Adequacy Criteria
• At least 90% of Federally Qualified Health Centers
(FQHCS) or FQHC “look alike” health centers in CT
• At least 75% of essential community providers
• The network is consistent with network adequacy
provisions of Section 2702 of the PHSA
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Essential Community Providers:
Which List?
• CMS 340B Provider List
• CMS Non-Exhaustive List updated in March 2013
• Essential Community Provider List as defined by the
state
Source: CMS Non-Exhaustive Database of ECPs can be found at
https://data.cms.gov/dataset/Non-Exhaustive-List-of-Essential-Community-Provide/ibqy-mswq
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Connecticut Phase-In
• Qualified Health Plans must contract with 75% of the
CMS Non -Exhaustive List by January 1, 2014*
• Two Year Phase-In for Expanded List **
– 35% of the providers on that list will be contracted by
1/1/2014
– 75% by January 1, 2015
* Percentages to be taken net of the March 2013 CMS non - exhaustive list (no duplication)
** *Carriers must show consideration for geography and access to the variety of provider types and
contract for the full range of services included in the essential health benefits (EHB). Consideration
will be given for demonstration of a good faith effort to accomplish these standard
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Connecticut Essential Community Providers
Preliminary Progress
ECP Participation Target
January 2014
ECP Participation
December 2013 *
*estimates based on preliminary reports
Federally Qualified
Health Centers
90%
90%
CMS NonExhaustive List
Connecticut ECP
List
75%
62%
35%
52%
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Resources for more information
• http://www.hrsa.gov/affordablecareact/
• http://hab.hrsa.gov/affordablecareact/ecp.html
• https://data.cms.gov/dataset/Non-ExhaustiveList-of-Essential-Community-Provide/ibqy-mswq
• http://www.naic.org/documents/committees_b_
related_wp_network_adequacy.pdf
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