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Federal and State Standards for "Essential Community Providers" under the ACA and Implications for Women's Health

Issue Brief
  1. PPACA § 1311 (c)(1)(C); 45 CR 156.235, Essential Community Providers. The regulation allows for an Alternative Federal ECP standard, which is only applicable for issuers who provide a majority of covered services through physicians employed by the issuer or a single contracted medical group.

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  2. Rosenbaum, S., Essential Community Providers, Health Reform GPS, 2011.

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  3. Section 1927 allows the Secretary of HHS to identify any “safety net facility or entity” that would benefit from nominal drug pricing under the Medicaid program.

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  4. These standards apply to the Federally-facilitated Marketplace as well as the State-Partnership Marketplace. For a full list of state decisions on Marketplace type see: KFF State Health Insurance Marketplace Types, 2015.

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  5. Centers for Medicare and Medicaid Services, 2015. QHP Application Instructions: Chapter 7: Instructions for the Essential Community Providers Application Section

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  6. These standards have been incorporated into proposed regulations issued by the Department of Health and Human Services on November 26, 2014 applicable to the 2016 plan year.

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  7. Centers for Medicare and Medicaid Services, March 2014. 2015 Letter to Issuers in the Federally-facilitated Marketplaces, page 22, table 2.1.

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  8. The District of Columbia does not require offering contracts with Indian health services provider as there is no Indian health service provider within the district.

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  9. Minn. Stat. § 62Q.19

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  10. Wash. Rev. Code §284-43-221; Colo. Rev. Stat. § 25.5-5-4

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  11. Covered California, 2014. Notice Regarding Covered California's Consolidated Essential Community Provider List.

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  12. KFF, 2015. Contract Offering and Signing Standards for Essential Community Providers (ECPs) in Marketplaces and KFF, 2015. Definition of Essential Community Providers (ECPs) in Marketplaces.

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  13. US Department of Health and Human Services Center for Medicare and Medicaid Services, March 2014. 2015 Letter to Issuers in the Federally-facilitated Marketplaces.

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  14. PPACA § 1311 (c)(1)(C); 45 CR 156.235, Essential Community Providers

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  15. Out of these 17 states, 3 states (Nevada, New Mexico and Oregon) use the federally supported state-based marketplace model.

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  16. California, Connecticut, Kentucky, Minnesota, New York and Washington.

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  17. Some states have expanded the categories of ECPs beyond the federal regulation, while others have provided more detailed definition or expanded the categories beyond the six categories identified in the 2015 CMS letter to FFM issuers, issued March 2014.

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  18. Covered California, Title 10, California Code of Regulations Section 6420: Qualified Health Plan Issuer 2015 Renewal Application

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  19. Access Health CT, 2014. Connecticut Health Insurance Exchange: Solicitation to Health Plan Issuers for Participation in SHOP Marketplace.

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  20. Rosenbaum, S., Essential Community Providers, Health Reform GPS, 2011 citing Institute of Medicine, America’s Health Care Safety Net: Intact but Endangered (Washington D.C. 2000); D. Hurwitz et al., Essential Community Provider Initiative, Enhancing Access, quality, and Cost Effectiveness of Health Care for MassHealth Members and Other Low Income Residents (Commonwealth Medicine, Boston, MA. 2004).

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  21. Fowler, CI., Gable, J., Wang, J., and McClure, E., “Family Planning Annual Report: 2012 National Summary” Research Triangle Park, NC: RTI International, 2013.

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  22. Gold, R. B., Besieged Family Planning Network Plays Pivotal Role. Guttmacher, 2013.

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  23. Families USA, 2014. Network Adequacy and Health Equity: Improving Private Health Insurance Provider Networks for Communities of Color.

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