Essential Community Providers (ECP) and Network Adequacy (NA) FAQs

Key Updates for Network Adequacy and Essential Community Providers Standards

Q1: What key changes to network adequacy (NA) policy and operations will take place beginning in Plan Year (PY) 2023?
  • To ensure that qualified health plan (QHP) enrollees have sufficient access to providers, CMS will conduct network adequacy reviews beginning in PY 2023 with key updates that include the following:
    • CMS will evaluate all plans submitted by an issuer in a Federally-facilitated Exchange (FFE) applying for QHP certification for compliance with network adequacy standards based on time and distance standards.
    • CMS will collect information from QHPs on whether providers participating in their network offer telehealth services.
    • QHP applicants that receive a correction notice from CMS pertaining to an unmet NA standard during QHP certification reviews will retrieve their NA Justification Form reflecting their needed corrections from the PM Community, complete the form offline, and then submit their completed form to the PM Community by the required deadline.
Q2: What key changes to essential community provider (ECP) policy and operations will take place beginning in PY2023?
  • To ensure that QHP enrollees have sufficient access to ECPs, CMS will conduct ECP reviews with key updates for PY2023 that include the following:
    • 35 percent ECP threshold: CMS has increased the required provider participation threshold from 20 percent to 35 percent of available ECPs in the plan’s service area, including approved ECP write-ins that would also count toward the issuer’s satisfaction of the 35 percent threshold.
    • Network Tiering: For plans that use tiered networks, to count toward the issuer’s satisfaction of each element of the ECP standard, ECPs must be contracted within the network tier that results in the lowest cost-sharing obligation for the respective plan’s enrollees. This means that issuers must list on the ‘Facility ECPs’ tab of the ECP/NA Template only their contracted providers that result in the lowest cost-sharing obligation for the respective plan’s enrollees. For example, a QHP issuer cannot use the number of ECPs contracted with their PPO network when certifying their HMO network, if use of 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 the preferred network would be counted towards satisfying the ECP standards.
    • Other ECP Providers Category: CMS has added Substance Use Disorder Treatment Centers to the ECP Category of “Other ECP Providers”. Furthermore, CMS has defined the “Other ECP Providers” to include the following provider types: Substance Use Disorder Treatment Centers, Community Mental Health Centers, Rural Health Clinics, Black Lung Clinics, Hemophilia Treatment Centers, Sexually Transmitted Disease Clinics, and Tuberculosis Clinics.
    • QHP applicants that receive a correction notice from CMS pertaining to an unmet ECP standard during QHP certification reviews will retrieve their ECP Justification Form from the PM Community, complete the form offline, and then submit their completed form to the PM Community by the required deadline. 
Network Adequacy and Essential Community Provider Data Collection & Reviews

Q1: Do all issuers have to submit network adequacy (NA) and essential community provider (ECP) data? 
  • Yes, all FFE issuers submitting plans for QHP certification review are required to complete and submit both NA and ECP data via the ECP/NA template.  This includes the ‘Individual Providers (NA)’ tab, the ‘Facility Providers (NA)’ tab, and the ‘Facility ECPs’ tab within the ECP/NA Template. This requirement applies to both medical QHP and stand-alone dental plan (SADP) issuers and all FFE issuers, including in states performing plan management functions. 
Q2: Will CMS evaluate network adequacy for all plans offered as QHPs through the FFEs?
  • Issuers in all FFE states, including states performing plan management functions, will need to submit their network adequacy data to CMS via the ECP/NA Template.  CMS will evaluate network adequacy for all plans to be offered as QHPs through the FFEs, except in certain states that perform plan management functions that elect to perform their own NA reviews, so long as the state applies and enforces quantitative network adequacy standards that are at least as stringent as the federal network adequacy standards under 45 C.F.R. 156.230, and the state’s reviews are conducted prior to plan confirmation in support of QHP certification.
Q3: If an issuer uses an integrated delivery model or is in an exclusivity contract with a health system or group of providers, what network adequacy standards does the issuer have to meet for QHP certification?
  • All issuers must meet all network adequacy standards for QHPs, regardless of whether they use an integrated delivery model or have exclusivity contracts with providers. If you are in an exclusivity contract with a provider or group of providers that is hindering your ability to satisfy the network adequacy standards by limiting your ability to contract with a sufficient number of providers within the time and distance parameters for the respective specialty type, such exclusivity contracts do not exempt an issuer from the NA requirements. You will need to either: 1) identify additional providers with whom you could contract without violating the exclusivity contract; or 2) consider modifying the terms and/or conditions of your exclusivity contract such that it allows for contracting with other providers when the exclusivity arrangement fails to satisfy QHP Certification requirements.
Q4: Which states performing plan management will conduct the primary network adequacy reviews for QHP certification purposes?
  • Please see the table below that details whether CMS or the state will conduct the network adequacy reviews for QHP certification purposes for your state for Plan Year (PY) 2023, as outlined in the 2023 Notice of Benefit and Payment Parameters final rule.

    As a reminder, all issuers submitting plans for QHP certification review in FFE states, including states performing plan management that are conducting their own reviews, must submit network adequacy data to CMS via the ECP/NA Template.

State Performing Plan Management

Network Adequacy Regulator for Plan Year 2023 QHP Certification

Delaware

CMS

Hawaii

CMS

Illinois

CMS

Iowa

CMS

Kansas

CMS

Michigan

Michigan

Montana

CMS

Nebraska

CMS

New Hampshire

New Hampshire

Ohio

CMS

South Dakota

South Dakota

Utah

CMS

West Virginia

West Virginia


Network Adequacy Time and Distance Standards

Q1: How do the time and distance standards for PY2023 compare to previous years’ requirements? 
  • Similar to our approach in prior years, CMS will adopt time and distance standards to assess whether QHPs in FFEs fulfill the network adequacy regulatory requirements. CMS seeks to ensure that QHP networks will be more robust, comprehensive, and responsive to QHP enrollees’ needs. Consequently, for PY2023, the provider specialty lists will cover more provider types than previously evaluated under FFE standards. The provider specialty lists were informed by prior HHS network adequacy requirements, consultation with stakeholders, and other federal and state health care programs, such as Medicare Advantage and Medicaid. The provider specialty lists are generally consistent with standards for plans in the Medicare Advantage program, with a few exceptions. The additional specialties unique to the QHP network adequacy reviews are emergency medicine, outpatient clinical behavioral health, pediatric primary care, and urgent care. The category of inpatient psychiatric facility services has also been broadened to inpatient or residential behavioral health services.

    Tables 3.1 and 3.2 in the 2023 Letter to Issuers in the Federally-facilitated Exchanges list the time and distance standards for medical QHPs and the provider types to which they apply. For medical QHPs, CMS will only assess compliance for the dental provider type for medical QHPs that have embedded dental services as a benefit. For SADPs, table 3.3 in the 2023 Letter to Issuers lists the time and distance standard for the dental provider type. To count towards meeting the time and distance standards, individual and facility providers must be appropriately licensed, accredited, or certified to practice in their state, as applicable, and must have in-person services available.
Q2: At what geographic level will QHPs be assessed for time and distance standards?
  • CMS will assess QHP time and distance standards at the county level. In alignment with Medicare Advantage’s approach, CMS will classify counties into five county type designations: Large Metro, Metro, Micro, Rural, or Counties with Extreme Access Considerations (CEAC). Designations for each county are available from the latest Medicare Advantage Health Services Delivery (HSD) Reference file on CMS’s website at Medicare Advantage Applications. These parameters are foundationally based on approaches used by the Census Bureau and the Office of Management and Budget.

    Please note: the HSD Reference file should only be used to reference the "Provider Time & Distance" tab columns A through E for QHP county type designations. Other information in the HSD Reference file is not applicable to QHP NA certification.
Q3: How are the time and distance standards calculated and measured?
  • CMS uses industry standard technology to calculate estimated driving time and distance between target consumers and provider locations. Street addresses for consumers (based on census data sampling) are compiled into the QHP Population Sample File. Addresses for consumers in the QHP Population Sample File and addresses for in-network providers submitted by an issuer are assigned latitude and longitude geocodes.  Once those coordinates are created, estimated driving time and distance are calculated between consumers and providers. Time is calculated using the estimated distance and applying a driving speed based on the geographic area, and distance is measured by determining the estimated driving distance between the geocodes and the average number of consumers in the designated geographic areas. Finally, the results are compared against the target time and distance standards for the relevant specialty and county to determine if the standard is met. 
Q4: How is the QHP Population Sample File created?
  • The QHP population file is based on US Census data. For each county, an eligible population sample is identified based on age and income requirements for consumers to qualify for health coverage through the Exchange. The population file is used to measure provider access to potential members in that county and certify provider networks offered by QHPs meet network adequacy requirements.
Q5: How can issuers and states access the QHP Population Sample File?
  • The QHP Population Sample File can be downloaded from the ECP/NA Application Resources section of the QHP Certification website. If states or issuers use a network adequacy tool to assess a plan’s compliance with network adequacy standards and use a population file as part of that process, the QHP Population Sample File can be used for this purpose. These results would only be for informational purposes and would not be used in place of CMS’ network adequacy review results unless the plan is in a State Exchange or an FFE state that performs plan management functions that has been approved to conduct their own reviews for the given PY certification cycle. 
Q6: How will CMS evaluate compliance with time and distance standards?
  • To assess whether QHPs comply with time and distance standards, CMS will review provider data for in-network providers that QHP issuers submit in the ECP/NA Template. For each specialty and standard, CMS will review the issuer-submitted data to ensure that the plan provides access to at least one provider in each of the provider type categories for at least 90 percent of enrollees.

    For example, for endocrinology in a large metro county type, at least 90 percent of enrollees will be required to have reasonable access to at least one provider within 15 miles and 30 minutes.
Q7: What are Network Adequacy Data Integrity (DI) Reports?
  • Network Adequacy Data Integrity (DI) Reports are produced as the initial step when CMS processes provider data submitted on the ECP/NA template. The NA DI reports can be retrieved from the PM Community. The report informs the issuer which provider records CMS has not been able to validate – meaning the National Provider Identifier (NPI) was not present and active in NPPES. Any providers listed on the DI report do not count towards the issuer’s satisfaction of network adequacy standards. 
The ‘Summary’ tab of the DI Report shows the number of provider records that were submitted on the ECP/NA Template and the number of records removed that could not be either found or were marked as inactive in NPPES. The ‘Providers Removed’ tab of the DI Report contains each provider record submitted on the ‘Individual Providers (NA)’ and ‘Facility Providers (NA)’ tabs of the ECP/NA Template that has failed validation. For each record, column R shows why the record was removed. 

CMS requests that issuers review the report and if they disagree with the proposed removal of any of the providers, immediately notify CMS so the data can be discussed. It is critical that issuers work with CMS to resolve any issues since these data are used for network adequacy and network breadth calculations. Any NPI-related data integrity issues that you are able to resolve by updating or correcting the provider information should be submitted by updating your ECP/NA Template and submitting via the HIOS Issuer Module prior to the final submission deadline. Any NPI-related data integrity issues that are unresolvable (i.e., a provider’s NPI has been reported accurately, but confirmed to be inactive in NPPES) do not need to be addressed by the issuer, as CMS will simply remove the respective NPI from counting towards the issuer’s satisfaction of the network adequacy standards.

Network Adequacy Appointment Wait Time Standards

Q1: What are the appointment wait time standards for QHPs?
  • In the HHS Notice of Benefit and Payment Parameters for 2023, CMS finalized a short list of critical service categories for which appointment wait time standards will be assessed. Starting in PY2024, CMS will implement these appointment wait time standards to assess whether QHPs offered through the FFEs fulfill network adequacy standards applicable to plans that use a provider network.

    Table 3.4 in the 2023 Final Letter to Issuers shows the list of provider specialties and parameters for this standard. While both medical QHPs and SADP QHPs will be assessed for compliance with appointment wait time standards beginning in PY2024, only the dental provider specialty within the Specialty Care (Non-Urgent) category of appointment wait time standards will apply to SADP QHPs. To count towards meeting appointment wait time standards, providers must be appropriately licensed, accredited, or certified to practice in their state, as applicable, and must have in-person services available.
Q2: What will the appointment wait time be measuring beginning in PY2024?
  • The quantitative standard will be measuring the time it takes an enrollee or member to schedule an appointment with an in-network provider, not the amount of time waiting for treatment while inside a provider office. For example, the appointment wait time standards do not apply to urgent or emergency providers/facilities because those services do not require appointments and therefore do not require time to schedule an appointment to be seen by an in-network provider. 
Q3: Will the appointment wait time standards apply to new patients, existing patients, or both?
  • Both. Starting in PY2024, CMS will implement and assess appointment wait time standards as applied to new and existing patients requesting appointments with the provider.
Q4: How will appointment wait time standards be assessed beginning in PY2024?
  • CMS will propose our methodology for assessing FFE issuer compliance with appointment wait time standards in future rulemaking. 
Network Adequacy Telehealth Requirements

Q1: What new telehealth requirements will go into effect for PY2023?
  • For PY2023, CMS will collect from QHPs via the ECP/NA Template information on whether individual providers participating in their network offer telehealth services. For each provider, issuers will indicate whether that provider offers telehealth by selecting one of the following responses: ‘Yes’, ‘No’, or ‘Requested information from provider and awaiting their response.’

    Issuers that do not already have data on whether their providers offer telehealth will need to collect this information prior to QHP certification. QHP issuers that do not currently collect this information may do so using the same means and methods by which they already collect information from their network providers relevant to time and distance standards and provider directory information. Issuers that do not have the information available by the time of the QHP certification process will be able to respond that they have requested the information from the provider and are awaiting the provider’s response. 
For PY2023, these data will inform network adequacy standards for future plan years and will not be made available to the public.

Q2: How does CMS define telehealth for purposes of this Marketplace QHP data collection requirement?
  • For the purposes of network adequacy, CMS is defining telehealth as “professional consultations, office visits, and office psychiatry services through brief communication technology-based service/virtual check-in, remote evaluation of pre-recorded patient information, and inter-professional internet consultation.” 
ECP/NA Template

Q1: Why was the ‘Individual ECPs’ tab removed from the ECP/NA template?
  • The ‘Individual ECPs’ tab within the ECP/NA template has been retired to reflect that CMS assesses issuer satisfaction of the ECP standard at the facility level rather than at the individual clinician level. If an issuer selects a provider facility with one or fewer FTE staff from the ‘Select ECPs’ tab and adds the provider to its template, the provider will populate within the ‘Facility ECPs’ tab alongside providers with more than one FTE staff reflected on the ‘Select ECPs’ tab. In other words, all of an issuer’s selected ECPs that are added to its template will appear within the ‘Facility ECPs’ tab, regardless of the number of FTE staff reported by the provider.
Q2: How does an issuer align Taxonomy codes to Specialty Codes?  
  • Taxonomy codes that map to each individual provider and facility specialty type are listed in the ECP/NA Template and the Network Adequacy Justification Form so that issuers know which providers to include in which individual provider and facility specialty categories. 
Q3: How should an issuer assign specialties that are not listed in the Specialty Types Tab of the ECP/NA Template? 
  • If an issuer does not see a specific specialty type listed in the ‘Specialty Types’ tab, it should refer to the ‘Taxonomy Codes’ tab in ECP/NA Template to select the correct specialty type. If the issuer cannot locate a taxonomy code, the provider type has not been approved as an appropriate type for QHP certification review. 
Q4: How should an issuer report in-network physical therapy (PT), occupational therapy (OT), and speech therapy (ST) providers, and emergency medicine physicians who are contracted at the facility or group level but whose specialty type is categorized under the individual provider specialty list for QHP network adequacy requirements? For example, how should an issuer include a physical therapy provider who is contracted at the facility level and for whom the issuer does not have a list of individual providers associated with the facility? 
  • For issuers seeking QHP certification of plans to be offered on the FFEs, data on in-network providers of PT, OT, and ST providers, and emergency medicine physicians must be entered on the 'Individual Providers (NA)' tab of the ECP/NA Template. If an issuer contracts with PT, OT, ST, or emergency medicine physicians at the facility or group level and an enrollee can access that facility and only be charged in-network costs for services from the providers in question, use the facility's NPI and enter the facility name in the first and last name fields. If there are specialty types other than PT, OT, ST, and emergency medicine that are required to be reported on the ‘Individual Providers (NA)’ tab of the ECP/NA Template and are difficult for you to report at the individual provider level, please contact the CMS Help Desk at CMS_FEPS@cms.hhs.gov or 1-855-CMS-1515 for further guidance.
Q5: Within the Network Adequacy tabs, can an issuer list a facility or an individual provider multiple times in the ECP/NA Template to enter multiple Specialty Types? 
  • Issuers should not list a single facility or an individual provider with the same address multiple times in the ECP/NA Template. Multiple Individual/Facility Specialty Types can be assigned to a provider in two ways. 
    • The first way is to use the selection box feature that is built into the ECP/NA Template. The selection box allows users to select as many Individual/Facility Specialty Types as are applicable to the selected provider. 
    • The second way is to manually create a list of each Individual/Facility Specialty Type separated by commas. The process for doing this is described on the ‘Specialty Types’ tab of the ECP/NA Template. Users should be careful when using this method that they match the Individual/Facility Specialty Type listed in the ‘Specialty Types’ tab exactly or they will receive a template validation error. For instance, if a user would like to assign the Facility Specialty Types of Cardiac Surgery Program and Cardiac Catheterization Services to a facility, they should enter "041 Cardiac Surgery Program, 042 Cardiac Catheterization Program." 
Q6: When completing the ‘Individual Providers (NA)’ and ‘Facility Providers (NA)’ tabs of the ECP/NA Template, how many providers of each specialty type does an issuer need to submit? Why is it especially important for issuers in the Network Breadth pilot states (Tennessee and Texas for PY2023) to submit all their in-network providers on the ‘Individual Providers (NA)’ and ‘Facility Providers (NA)’ tabs of the ECP/NA Template?
  • As explained in the ECP/NA section of the PY2023 QHP Issuer Application Instructions, issuers should include a list of all the providers in each of the proposed networks for which CMS is conducting network adequacy reviews, even those outside of the immediate geographic area meeting time and distance requirements, as well as ECPs, even when also included in the ECP tab. Providers must meet the following requirements: be appropriately licensed, accredited, or certified to practice in their state, as applicable; and offer in-person services. 
For purposes of the network adequacy time and distance standards, CMS will review issuer-submitted data to ensure that the issuer provides access to at least one provider in each of the provider specialty types for at least 90 percent of consumers. There is not currently a requirement regarding a certain number of in-network providers of a given specialty type; rather, the requirement is reasonable access, which requires sufficient distribution of providers so that 90% of consumers could access a provider of that type within the time and distance standards for that county type. 

For issuers in states participating in the Network Breadth Pilot, issuers benefit from including data on all in-network providers for which CMS is conducting network adequacy reviews (that meet the above criteria) on the network adequacy tabs of the ECP/NA Template since their network breadth classifications depend on the number of providers they submit for each relevant provider specialty type (e.g., hospitals, adult primary care, and pediatric primary care).

Q7: What specialties can an issuer list for each in-network provider on the network adequacy tabs of the ECP/NA Template?
  • Issuers should only list the provider specialties that a provider currently practices and is licensed, accredited, or certified to practice in their state, as applicable. For example, if a provider previously completed a fellowship in cardiology, but currently works only as an emergency medicine physician, the provider should only be listed under emergency medicine.
Q8: In the ECP/NA Template, should issuers enter only facilities and individual providers that are located in the same state? 
  • For the Network Adequacy side of the ECP/NA Template, the issuer should enter information for all facilities and individual providers located in the network because reasonable access is based on time and distance from the consumers in that state which may include providers in nearby states.

    For the ECP side of the ECP/NA template, in order to count toward satisfaction of any of the three elements of the ECP standard, providers must be located in the state corresponding to the issuer’s service area for the respective plan ID and network ID combination, as the ECP standards are not based on time and distance standards. 
Q9: Do issuers in states performing plan management functions use the same ECP/NA Template as issuers in FFE states that are not performing plan management functions? 
  • Yes, issuers in states performing plan management functions should use the same ECP/NA Template as issuers in FFE states that are not performing plan management functions. 
Q10: On the ECP/NA Template, how should issuers enter providers that practice from multiple locations? 
  • For the Network Adequacy side of the ECP/NA Template, issuers can enter providers that practice from multiple locations without adding "001" or "002" at the end of the provider's last name for each location (as had been done previously), as indicated in the Network Adequacy instructions. A complete set of instructions for the QHP Application, including the Network Adequacy instructions, is available on the QHP Certification website.

    For the ECP side of the ECP/NA template, issuers must submit ECPs at the facility level rather than at the individual clinician level.  For ECP facilities that are operated by a solo practitioner that practices from multiple locations, the issuer should list each facility location and the provider site name associated with each facility that appears on the HHS Final ECP List or ECP Write-in List for the respective plan year. 
Q11: Is there a limit to the number of unique locations at which a provider can be listed on the network adequacy tabs of the ECP/NA Template? 
  • Yes, individual providers should not be reported as practicing at more than 10 unique locations on the network adequacy tabs of the ECP/NA Template. 
Q12: What happens if an issuer submits an NPI for an in-network provider that is not present and active in NPPES or submits a dummy NPI (like all 0’s or X’s)?
  • If an issuer submits any providers on the network adequacy tabs of the ECP/NA Template that do not have an NPI that is both present and active in NPPES, including providers submitted with dummy NPIs (like all 0’s or X’s), these providers will also appear on the DI Report and will not count towards the issuer’s satisfaction of network adequacy standards.
Q13: On the network adequacy tabs of the ECP/NA Template, how should issuers document in-network provider specialties (such as cardiac surgery program, cardiac catheterization services, mammography, etc.) that are commonly offered within an acute inpatient hospital? 
  • Issuers must list all in-network individual providers on the ‘Individual Providers (NA)’ tab and all in-network facility providers on the ‘Facility Providers (NA)’ tab of the ECP/NA Template. When completing the Specialty Type column on those tabs, the issuer should select all specialties offered at the identified provider location. If a provider has multiple specialties at the same address, select all the specialties in the same record. If entering more than one facility type, each facility type must be separated by a comma and a space. For example, if an issuer has an in-network hospital where cardiac surgery is also available in-network, that facility can be listed on one row of the ‘Facility Providers (NA)’ tab of the ECP/NA Template with both acute inpatient hospital and cardiac surgery program selected for the Specialty Type column. If an issuer only lists acute inpatient hospital as the Specialty Type and does not list cardiac surgery program, that facility will only count towards meeting the time and distance standards for acute inpatient hospitals. 
Q14: If an issuer has different networks for dental and medical, should both be submitted? 
  • Yes, issuers should submit all networks. Each QHP must be associated with a single Network ID. If an issuer has dental and medical networks for a QHP offering two types of benefits, provider data for both networks should be included on their template. An issuer offering embedded dental benefits should also include its dental providers in the ECP and the NA tabs in the ECP/NA Template.
Q15: If an issuer embeds dental benefits in a medical QHP, what does the issuer need to do on the ECP/NA Template?
  • For all issuers that embed dental benefits in medical QHPs, CMS assesses network adequacy compliance with the time and distance standard for dental providers. If an issuer embeds any dental benefits in a medical QHP – adult, pediatric, or both – the issuer must include all in-network dental providers on the ‘Individual Providers (NA)’ tab of the ECP/NA Template. Currently, the essential community provider standard does not apply to dental services that are embedded within a medical QHP.
Q16: On the ECP side of the ECP/NA template, is the count of full-time equivalent (FTE) practitioners (MDs, DOs, NPs, PAs, DMDs, DDSs) a combined count of all providers or are there subtotals for each type of provider? If a combined count, how will issuers know the subtotal by provider type for comparison and reconciliation purposes?
  • Except in the case of inpatient hospitals, including children’s hospitals, where this field contains the number of staffed beds, the FTE practitioner counts for each provider on the ECP List reflect a combined total of all licensed MDs, DOs, NPs, PAs, DMDs, and DDSs authorized by the state to independently treat and prescribe medication at the respective facility. CMS’s utilization of these practitioner counts for purposes of the ECP standard is currently limited to assessing ECP participation within an issuer’s networks, rather than for assessing participation by practitioner type.
Q17: Since multiple Network IDs can be shown on any given row for an ECP provider in the ECP/NA template, how should issuers report any variances in the FTE practitioner counts by network?
  • When practitioner network inclusion variances for a given ECP facility exist among the issuer’s networks, the issuer may report the highest FTE count of practitioners (among its network variations) at a given ECP facility that the issuer has included in the provider network for its member enrollees. That number must not exceed the number of available FTE practitioners reported to the Department of Health & Human Services (HHS) by the ECP facility through the online ECP petition process, as displayed within the ‘Number of Medical FTEs’ and ‘Number of Dental FTEs’ columns within the Final HHS ECP List and the ‘Select ECPs’ tab of the ECP/NA template for the respective plan year.
Q18: If a particular state does not authorize PAs or NPs as being able to independently treat and prescribe medication, must issuers exclude such mid-level providers from the FTE practitioner counts on the ECP side of the ECP/NA template?
  • An issuer should include in the practitioner counts only those FTE practitioners that hold an MD, DO, NP, PA, DMD, or DDS license and are authorized by the state to independently treat and prescribe medication within the listed facility at the street location provided on the HHS ECP List for the respective provider. The available FTE counts reflected on the HHS ECP List already take this requirement into consideration and include only those practitioners authorized by the respective state to independently treat and prescribe medication.
Q19: Where do issuers upload the ECP/NA template in the Health Insurance Oversight System (HIOS)? 
  • FFE issuers must upload their completed ECP/NA template through the Issuer Module in HIOS as described in the ECP/NA Instructions found on the QHP Certification website
Q20: If an Issuer is in a State Exchange that does not require submission of network adequacy data on the ECP/NA Template, how should an issuer validate the ECP/NA Template without network adequacy data?
  • In this situation, issuers should first confirm with their state what data the state requires to be submitted on the ECP/NA Template. If the state confirms that submission of network adequacy data on the ECP/NA Template is not required, issuers should open the ‘User Control’ tab of the ECP/NA Template, create both the ‘Individual Providers (NA)’ and ‘Facility Providers (NA)’ tabs, and enter the dummy data as described below. Issuers must also complete the ‘Facility ECPs’ tab prior to validating the ECP/NA Template. 
IndividualProviders(NA) tab:

 Column Heading Dummy Data (to be Entered)
 National Provider Identifier (NPI)* 0000000000
 Provider Name Prefix [Leave Blank]
 First Name of Provider* Dummy
 Middle Initial of Provider [Leave Blank]
 Last Name of Provider* Provider
 Specialty Type  (area of medicine)* Select 001 General Practice 
 Does this provider offer telehealth?* No
 Street Address* Street
 Street Address 2 [Leave Blank]
 City* City
 State*  Select the state used in the User Control tab 
 County* Select the first county from the dropdown
 Zip* 11111
 Network IDs* Select the first network from the dropdown

FacilityProviders(NA) tab:

 Column Heading Dummy Data (to be entered)
 National Provider Identifier (NPI)*  0000000000
 Facility Name* Facility
 Facility Type* Select 040 Acute Inpatient Hospital (Must have Emergency services available 24/7)
 Street Address* Street
 Street Address 2 [Leave Blank]
 City* City
 State* Select the state used in the User Control tab 
 County* Select the first county from the dropdown
 Zip* 11111
 Network IDs* Select the first network from the dropdown

Justification Forms to Address Unmet Network Adequacy and Essential Community Provider Standards

Q1: What will happen if a QHP applicant does not meet one or more of the Network Adequacy and/or ECP standards?
  • If CMS determines that a QHP applicant does not meet one or more ECP/NA standards, the issuer can:
    1. Add more contracted providers to the network to come into alignment with the unmet standard(s) and resubmit an updated ECP/NA template and/or ECP Write-in Worksheet via the HIOS Issuer Module that includes these additional providers; and/or 
    2. Retrieve a partially pre-populated Justification Form from CMS via the PM Community, complete all required fields within the form, and then submit the completed Justification Form to CMS via the PM Community by the required deadline. Note that the NA Justification Form is separate from the ECP Justification Form.  Issuers should upload the applicable Justification Form to the PM Community tab associated with the correction notice received. 
While issuers are working to come into compliance, they should submit a completed Justification Form. Note that for both ECP and NA, CMS will only accept the official respective Justification Form in macro-enabled Excel format that CMS has generated for the issuer’s retrieval from the PM Community. CMS will not accept individually customized supplemental response forms as a substitute for the official Excel form. CMS will use any updated provider data submitted on: 1) the ECP/NA template via the HIOS Issuer Module; and 2) the respective completed Justification Form submitted via the PM Community as part of the certification process in assessing whether the issuer meets the ECP/NA regulatory requirements, prior to making the certification decision.  CMS will continue to monitor ECP/NA compliance throughout the year and will coordinate with state Departments of Insurance should it be necessary to remedy potential instances of noncompliance.

Q2: Where can issuers obtain the Network Adequacy and Essential Community Provider Justification Forms, and where do issuers submit their completed forms?  
  • For issuers that receive a notice of required corrections pertaining to unmet ECP/NA standards, CMS will provide a partially pre-populated Justification Form via the PM Community within the Corrections Notice tab after each QHP certification review round. Note that the NA Justification Form is separate from the ECP Justification Form. Issuers must download the respective form from the PM Community, complete all required fields within the form, and then upload the completed Excel form to the PM Community by the required deadline. 
Q3: What is included and required in the Network Adequacy and Essential Community Provider Justification Forms? 
  • The ECP/NA Justification Forms contain partially prepopulated information for each unmet ECP/NA standard. Issuers are required to provide information regarding:
    • the reasons the standard(s) was not met; 
    • the mitigating measures the issuer is taking to ensure enrollee access to respective provider specialty types and/or ECPs, as applicable; 
    • enrollee complaints regarding access to the respective provider specialty types and/or ECPs, as applicable; 
    • the issuer’s efforts to recruit additional providers; and 
    • an attestation regarding the provider’s contribution to meeting the standards. 
Q4: Where can issuers find instructions on completing the Network Adequacy and Essential Community Provider Justification Forms? 
  • Please see the instructional guidance on Completing the ECP and Network Adequacy Justification Forms on the ECP/NA Application Resources section of the QHP Certification website
Q5: When are ECP and NA Justification Forms due to CMS?
  • Completed ECP and NA Justification Forms are due to CMS on the same timeline as the ECP/NA Template and other QHP Issuer Application documentation, so by each review round deadline (Initial Round if the issuer submitted their application during Early Bird; Second Round; and Final Round). 
Q6: How should issuers prioritize responding to network adequacy (NA) and essential community provider (ECP) corrections in terms of updating the ECP/NA Template and completing the NA and ECP Justification Forms?
  • CMS strongly encourages issuers to first prioritize any provider updates to the NA and ECP tabs of the ECP/NA Template. Issuers should then use the NA and ECP Justification Forms to provide information on any corrections that issuers believe will take longer to remedy or that cannot be fully remedied due to local conditions (like topographic features or provider shortages, etc. for the NA Justification) or ECP facility status changes (like ECP facility closures or relocations outside of the service area, etc. for the ECP Justification).
Q7: Can issuers submit an NA or ECP Justification with Missing Data (i.e., as the Justification Status within column AD on the NA Justification tab)?
  • It is acceptable to submit to CMS a completed NA or ECP Justification that has ‘Missing Data’ (i.e., as the Justification Status column AD on the NA Justification tab). It is expected that issuers continue to make incremental progress toward compliance with NA and ECP standards during the QHP certification process by submitting updated ECP/NA Templates and NA and/or ECP Justifications until all corrections are addressed and standards are met. If an issuer believes they have addressed all corrections within their updated ECP/NA Template that they have submitted via the HIOS Issuer Module, the issuer is not required to submit completed NA and/or ECP Justifications for that round. 
Q8: On the NA Justification Form, which option for “Primary Reason for Unmet Standard” should issuers choose if they have contracted with all available providers in a given county/specialty combination but are still unable to satisfy the 90% standard?
  • Issuers in this situation should select the following response option within the NA Justification: "The provider network is still under development. The provider network must be in compliance with network adequacy standards prior to open enrollment." The issuer should continue to investigate their service area for new providers that may have recently started practicing and should inform CCIIO of this issue via an outreach call, their Account Manager, or the CMS Help Desk. If the issuer is still not able to satisfy the 90% standard by the QHP Final Round deadline, the issuer will be enrolled into the Compliance Review process, during which they would be expected to continue monitoring their service area for additional providers that would help them meet the time and distance standards. 
Q9: On the partially pre-populated ECP Justification Form, what is meant by the “Facility Not Interested in Contracting with Medical QHP Issuers” (for medical QHP issuers) and “Facility Not Interested in Contracting with SADP Issuers” (for SADP issuers) options in the dropdown menu under the “Status of Negotiations” column? When should an issuer select these statuses on their partially pre-populated ECP Justification Form?
  • The “Facility Not Interested in Contracting with Medical QHP Issuers” (for medical QHP issuers) and “Facility Not Interested in Contracting with SADP Issuers” (for SADP issuers) options on the “Status of Negotiations” dropdown menu indicate that the issuer has reached out to that provider about contracting and the provider has responded that they are not interested in contracting with any QHP issuer (medical QHP or SADP, as applicable) for the respective plan year. This could be the case because, for example, the provider only accepts Medicaid patients, or doesn’t accept any health insurance at all. When an issuer reports this to CMS, and CMS is able to verify that the provider is not interested in contracting with any QHP issuers, that provider will be removed from the issuer’s denominator so that the issuer will not be penalized for being unable to contract with that provider.
Issuers should not select the “Facility Not Interested in Contracting with medical QHP/SADP Issuers” statuses if the issuer has reached out to a provider, and the provider has responded that they are not interested in contracting with that particular issuer for the plan year, because of the terms and conditions of the offered contract or for other reasons. In such a case, the issuer should report that the provider has rejected their contract offer, rather than that the provider is not interested in contracting with any QHP issuers. Under such circumstances, the issuer should reach out to other providers to offer and/or execute contracts and work toward compliance with the ECP standards. 

Tiered Networks for Issuer Satisfaction of Essential Community Provider Standards

Q1: Can a QHP that offers a tiered network count any provider, regardless of the provider’s contracted network, toward the issuer’s satisfaction of the ECP standards?
  • No, for plans that use tiered networks in PY2023 and beyond, 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. 
Network Transparency

Q1: Will CMS continue the Network Breadth Pilot in PY 2023?
  • Yes, for PY 2023, CMS will continue the network breadth pilot for all QHP issuers in states participating in the network breadth pilot. As in previous years, each QHP network’s breadth will be compared to the network breadth of other QHPs available in the same geographic area. This information will be publicly reported on HealthCare.gov, along with additional guidance, once participating states are announced. 
Q2: How will data on network breadth be collected?
  • CMS will identify network breadth based on analysis of QHP provider and facility data. Issuers will submit QHP provider and facility data as part of the PY2023 certification process via the ECP/NA Template.
Q3: How will network breadth be determined?
  • CMS will determine network breadth by comparing an issuer’s contracted providers to the number of specific providers and facilities included across all QHP networks available in a county. The rating will focus on hospitals, adult primary care, and pediatric primary care with a separate classification for each of the three categories. The classifications of network breadth for each plan will be at the county level.

    CMS will determine these classifications by calculating the percentage of providers in a plan’s network compared to the total number of providers in QHP networks available in a county based on a time and distance calculation. To calculate network breadth, CMS will divide the number of each QHP’s servicing providers at the issuer, network, county, and specialty combination level by the total number of all available QHP servicing providers for that county, including ECPs. The resulting number will be the Provider Participation Rate (PPR).

    Based on this calculation, networks will be classified into one of three classifications: 
    • Basic = fewer than 30 percent of available providers
    • Standard = 30-69 percent of available providers
    • Broad = 70 percent or more of available providers
ECP Tools

Q1: Why are certain ECPs included on the Final Plan Year ECP List and ECP/NA Template, but not recognized by the Medical QHP and/or SADP ECP Tools?

The Final Plan Year ECP List reflects the universe of ECPs at a particular snapshot in time, but the reality of the ECP landscape changes regularly. Therefore, at times, providers may appear on the Final Plan Year ECP List (and in the corresponding Plan Year ECP/NA Template) that are not recognized by the updated ECP List embedded within the Medical QHP and SADP ECP Tools, resulting in error messaging.

To keep the ECP List as accurate as possible, CMS routinely performs research and outreach to providers on the ECP List to verify information about ECPs collected via the ECP petition site. During these efforts, CMS sometimes identifies providers requiring removal from the ECP List, usually for one of the following reasons:
  • The provider has closed
  • The provider has undergone a status change, such as termination of participation in the 340B program, that has made them ineligible for inclusion on the ECP List
  • The provider has been found not to be open year-round, making them ineligible for inclusion on the ECP List
  • The provider has temporarily or permanently stopped providing either medical or dental services at a facility that once offered both medical and dental services, and therefore may no longer be recognized by the Medical QHP ECP Tool (if they now only provide dental services) or the SADP ECP Tool (if they now only provide medical services)
When CMS discovers such provider status changes after the Final Plan Year HHS ECP List has been released, and prior to or during QHP certification, the providers remain on the Final Plan Year ECP List and the ECP/NA Template, but are removed from the corresponding Medical QHP and/or SADP ECP Tools. When providers are removed from the Tools, issuers will not receive credit toward meeting the ECP standards for these providers, nor will they be penalized for inability to contract with these providers.

The latest versions of the ECP Tools, available on the QHP certification website have been updated to provide issuers with clearer messaging about provider status changes that may result in removal of providers from the ECP Tools.