Essential Community Providers

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, in accordance with 45 CFR 156.235. CMS has established two ECP standards: the General ECP Standard and the Alternate ECP Standard.

To satisfy the General ECP Standard, the applicant has satisfied the following requirements: 

  1. Use a provider network that complies with 45 CFR 156.235, subject to a limited exception for certain SADPs as described in the 2024 Letter to Issuers;
  2. Contract with at least 35 percent of available ECPs in each plan’s service area to participate in the plan’s provider network,* including contract with 35 percent of available Family Planning Providers (not applicable to SADP applicants) and 35 percent of available Federally Qualified Health Centers (FQHCs) in the plan’s service area; 
  3. Offer contracts in good faith to at least one ECP in each ECP category in each county in the service area to participate in the plan’s provider network for the respective QHP certification plan year, where an ECP in that category is available (not applicable to SADP applicants);* and 
  4. Offer contracts in good faith to all available Indian health care providers in the plan’s service area to participate in the plan’s provider network for the respective QHP certification plan year. 

To satisfy the Alternate ECP Standard, the applicant has satisfied the following requirements:** 

  1. Use a provider network that complies with 45 CFR 156.235, subject to a limited exception for certain SADPs as described in the 2024 Letter to Issuers;
  2. Contract with at least 35 percent of available ECPs in each plan’s service area to participate in the plan’s provider network that are located within health professional shortage areas (HPSAs) or low-income ZIP Codes in which 30 percent or more of the population falls below 200 percent of the federal poverty level, including contracts with 35 percent of available Family Planning Providers (not applicable to SADP applicants) and 35 percent of available Federally Qualified Health Centers (FQHCs) in the plan’s service area; and 
  3. 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 to participate in the plan’s provider network 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 for the respective QHP certification plan year, where an ECP in that category is available (not applicable to SADP applicants). 

* For plans that use tiered networks, ECPs must be contracted within the network tier that results in the lowest cost-sharing obligation to count toward the issuer's satisfaction of each element of the ECP standard. For example, a QHP issuer cannot use the number of ECPs contracted with their PPO network to certify their HMO network if using the PPO network providers would result in higher cost- sharing obligations for HMO plan enrollees. For plans with two network tiers (for example, participating providers and preferred providers), such as many PPOs, where cost sharing is lower for preferred providers, only preferred providers would be counted toward ECP standards.
**Issuers that qualify to submit under the Alternate ECP Standard are exempt from the Indian health care provider ECP 
requirement.

Key Changes for PY2025
  • All medical QHP and stand-alone dental plan (SADP) issuers operating on the Federally-facilitated Exchange, including issuers in states performing plan management functions and State-based Exchanges on the Federal Platform (SBE-FP), must use the new User Interface (UI) in the ECP section of MPMS to submit their provider networks. The Facility ECPs tab within the Network Adequacy (NA) Template will only be available to collect ECP data for issuers in State-Based Exchanges (SBE) submitting through the System for Electronic Rates & Forms Filing (SERFF). 
  • The ECP Write-in Worksheet used in previous years has been retired. Its functions have been integrated into the MPMS UI.
  • Issuers applying under the Alternate ECP Standard will submit ECP Write-ins using the MPMS UI. Issuers can only qualify to apply under the Alternate ECP Standard if they provide the majority of their covered professional services through providers that the issuer directly employs or through a single contracted medical group, as such providers do not qualify for inclusion on the Final ECP List. See Figure 2I-4a and 2I-4b.
  • Issuers applying under the General ECP Standard have the option of contracting with Available ECP Write-ins to help them meet the ECP requirements. Available ECP Write-ins are providers that have been approved by CMS for inclusion on the subsequent plan year’s Final ECP List. Both Alternate and General ECP Standard Issuers will receive credit toward satisfaction of the ECP standard for any providers they include as ECP Write-ins using the MPMS UI.
  • The ECP Justification Form used in previous years has been retired. Issuers will report information previously contained in the ECP Justification Form in the ECP section of the MPMS UI.
Tips for the ECP Section
  • General
    • Complete the Network ID Template before beginning the ECP section of the MPMS UI.
    • Issuers must only include providers in the ECP section of the MPMS UI that are not at known risk for potential contract termination for the upcoming plan year.
    • Issuers operating in SBEs will submit their completed NA Template (which will include ECP data for SBE issuers only) via SERFF.
    • The ECP Justification Form will no longer be provided to the issuer through the Plan Management (PM) Community for retrieval and submission; the information previously collected via the ECP Justification Form will now be collected from the issuer through the ECP section of the MPMS UI.
  • Essential Community Providers 
    • Issuers will no longer be able to select a “dummy” provider record (ECP reference number ZZ-000001). 
    • There is a limited exception to the provider network requirement for SADPs that sell plans in areas where it is prohibitively difficult for the issuer to establish a network of dental providers as determined by CMS; this exception is not available to medical QHP issuers. 
      • Under this limited exception, an area is considered “prohibitively difficult” for the SADP issuer to establish a network of dental providers based on attestations from state departments of insurance (DOIs) with at least 80 percent of their counties classified as counties with extreme access considerations (CEAC) that at least one of the following factors exists in the area of concern: a significant shortage of dental providers, a significant number of dental providers unwilling to contract with Marketplace issuers, or significant geographic limitations impacting consumer access to dental providers. 
      • CMS will not be accepting requests for this limited exception directly from SADP issuers. Once an eligible state DOI submits to CMS an attestation that they consider the area to be prohibitively difficult to establish a network of dental providers, CMS will review the attestation to determine if an exception will be granted. CMS will notify the SADP issuer directly if they qualify for this limited exception. SADP issuers that qualify for this limited exception will not be required to use a provider network or submit ECP data.
              Application Resources
              • Templates
                • Starting in PY2025, issuers in Federally-facilitated Exchanges (FFE) states, states performing plan management functions, and State-based Exchanges on the Federal Platform (SBE-FPs), will submit ECP data to CMS through the user interface in the ECP section of the Plan Attributes group in the HIOS MPMS Module.

              • Supporting Documents
                • PY2025 ECP Write-in Worksheet & Available ECP Write-in List (Updated 5/24/24)
                  • This file should only be used by issuers operating in State-based Exchanges (SBEs).
                  • Issuers in Federally-facilitated Exchange states, states performing plan management functions, and State-based Exchanges on the Federal Platform (SBE-FPs) must use the HIOS MPMS Module to submit available ECP write-in providers. 
                • PY2025 Available ECP Write-in List
                  • This list will be accessible within the ECP section of MPMS for issuers in FFE states, states performing plan management functions, and SBE-FPs states. CMS is providing this file as a standalone resource for issuers to access the list of available write-in ECPs outside of the system.
              • PY2025 Low-income ZIP Code List – applicable to QHP issuers that qualify for the Alternate ECP Standard, specifically those issuers that provide the majority of their covered professional services through physicians employed by the issuer or through a single contracted medical group, as described in 45 CFR 156.235(a)(5).