Essential Community Providers and Network Adequacy

Essential Community Providers (ECP)

All issuers must submit ECP information as part of their QHP Application. Issuers must have a sufficient number and geographic distribution of ECPs, where available. CMS has established two ECP standards: the general ECP standard and the alternate ECP standard.

To satisfy the general ECP standard, QHP issuers must:

  1. Contract with at least 20 percent of available ECPs in each plan’s service area to participate in the plan’s provider network
  2. Offer contracts in good faith to all available Indian health care providers in the plan’s service area for the respective QHP certification plan year
  3. Offer contracts in good faith to at least one ECP in each ECP category in each county in the service area for the respective QHP certification plan year, where an ECP in that category is available

To satisfy the alternative ECP standard, QHP issuers must:

  1. Contract with at least 20 percent of available ECPs in each plan’s service area to participate in the plan’s provider network
  2. Offer all of the categories of services provided by entities in each of the ECP categories in each county in the plan’s service area as outlined in the general ECP standard, or otherwise offer a contract to at least one ECP outside of the issuer’s integrated delivery system per ECP category in each county in the plan’s service area

Key Changes for PY18:

  • Issuers will be evaluated against a 20 percent ECP standard.
  • Issuers will provide hospital bed count information in the ECP portion of their template.

Network Adequacy

QHP issuers are also required to maintain a network with sufficient number and types of providers to ensure that all covered services will be accessible to enrollees without unreasonable delay. All issuers applying for QHP certification must attest that they meet this standard as part of their QHP Application.

Key Changes for PY18:

  • Except for issuers in Network Breadth Pilot states, issuers are not required to submit network adequacy data (individual and facility/pharmacy) via the ECP/Network Adequacy Template. Issuers in Network Breadth Pilot states will be required to provide Network Adequacy data via the ECP/Network Adequacy Template, and will be notified directly by email.
  • CMS will not request network adequacy justifications. 
  • QHP and SADP issuers may be required to submit an access plan with a cover sheet.  Access plans must be uploaded as supporting documents. Issuers who are required to submit an access plan will be notified directly by email.

Tips for the ECP/Network Adequacy Section

  • Issuers must complete the Issuer Information section on the User Control tab before creating and entering the rest of their data into the other tabs.
  • Issuers should not change the file names on their ECP/Network Adequacy files after finalizing the template. This file-naming convention allows CMS to easily identify an issuer’s ECP/Network Adequacy Template. Changing the file name could cause the issuer to receive a correction notice.
  • Complete the Network ID Template before completing the ECP/Network Adequacy Template.
  • The PY2018 ECP/Network Adequacy Template includes the ability to delete rows.

Tips for the Network ID Section

  • The URL to the provider directory is the only network identification information made public.
  • Dual-product issuers offering QHPs and SADPs must create two different network IDs for use with the two plan types, regardless of whether the network is intended to serve QHPs and SADPs.
  • Dual-product issuers must use the word “dental” in the network area name for their dental service area to distinguish the QHP network from the dental network.

Application Resources

HHS also maintains a list of approved ECPs. This list is released annually to help issuers comply with the requirements of the Affordable Care Act (ACA) in serving low-income, medically underserved individuals. The most recent list and a full description of ECPs can be found below.

HPSA Zip Code Listing

HHS periodically designates health professional shortage areas (HPSAs). Areas must fulfill 3 criteria to receive HPSA designation:
  1. The geographic area involved must be rational for the delivery of health services
  2. A specified population-to-practitioner ratio representing shortage must be exceeded within the area
  3. Resources in contiguous areas must be shown to be overutilized, excessively distant, or otherwise inaccessible
The latest list of HPSA zip codes is provided below.