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

• To ensure that QHP enrollees have sufficient access to providers, including ECPs, CMS will conduct network adequacy and ECP reviews with key updates for PY2024 that include the following:
  
  • All Individual Market QHPs, including individual market stand-alone dental plans (SADPs), and all Small Business Health Options Program (SHOP) plans, including SHOP SADPs, across all Marketplace-types must use a network of providers that complies with the network adequacy and ECP standards in accordance with 45 CFR 156.230 and 156.235. CMS has removed the exception that these sections do not apply to plans that do not use a provider network, with the limited exception of 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. CMS does not accept requests for this limited exception directly from SADP issuers. Once an eligible State department of insurance 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 are not required to use a provider network or submit an ECP/NA Template.
  • Two major ECP categories have been added: 1) Mental Health Facilities; and 2) Substance Use Disorder (SUD) Treatment Centers. There are now a total of eight major ECP categories for which issuers are required to offer a contract in good faith to at least one ECP in each of the eight ECP categories, where available, in each county in the plan's service area.
  • Rural Emergency Hospitals have been added as a new provider type to the "Other ECPs" major ECP category.
  • While retaining the overall 35 percent ECP participation threshold, issuers must also satisfy a separate 35 percent ECP participation threshold requirement for each of the following two major ECP categories: Federally Qualified Health Centers (FQHCs) and Family Planning Providers.

• 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 'Network Adequacy Provider' 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.

• Issuers in all FFE states, including states performing plan management functions, must submit their network adequacy data to CMS via the ECP/NA Template. CMS evaluates network adequacy for all plans to be offered as QHPs through the FFEs, except in certain states that perform plan management functions that elect and are approved by CMS to perform their own NA reviews in lieu of CMS 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.

• 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. The provider specialty lists are 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.

• CMS will assess QHP time and distance standards at the county level. In alignment with Medicare Advantage’s approach, CMS classifies 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 that 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 Medicare Advantage HSD Reference file is not applicable to QHP NA certification.

• CMS uses industry standard technology to calculate estimated driving time and distance between target consumers (see FAQ describing the target QHP Sample Population File) and provider locations. Street addresses for consumers (based on census data sampling) and providers 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 time and distance metric standards for the respective provider specialty type and county type to determine if the standard is met.

• 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.

• 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. 

• CMS evaluates QHP issuer compliance with network adequacy time and distance standards by reviewing provider data for in-network providers that QHP issuers submit via the ECP/NA Template. For each provider specialty, CMS reviews the QHP issuer-submitted data to ensure that the plan provides access to at least one provider for each of the provider specialty types for at least 90 percent of the target QHP-eligible population in the county (see FAQ describing the target QHP Population Sample File). In order to satisfy this standard, the issuer may be required to contract with more than one provider of a given provider specialty type if more than one provider is needed to ensure that at least 90 percent of the target QHP-eligible population in the county can access such a provider.
  
  For example, in a large metro county type, the issuer must ensure that at least 90 percent of the target population in the county has reasonable access to at least one endocrinologist within 15 miles and 30 minutes. Note that for network adequacy standards, the provider may be located outside of the county in which the target population resides, so long as the provider's location is within the time and distance requirements of the target population for the given provider specialty type.

• In the HHS Notice of Benefit and Payment Parameters for 2023, CMS finalized a short list of provider specialty types for which appointment wait time (AWT) standards would be assessed starting in PY2024. Table 3.4 in the 2023 Letter to Issuers displays the list of provider specialty types and quantitative metric requirements for the AWT standards.

While both medical QHPs and SADP QHPs will be assessed for compliance with AWT standards, only the dental provider specialty within the Specialty Care (non-urgent) category of AWT standards will apply to SADP QHPs. To count towards meeting AWT standards, providers must be appropriately licensed, accredited, or certified to practice in their state, as applicable, and must offer in-person services.

For the 2024 plan year, CMS will evaluate QHPs for compliance with network adequacy standards based on time and distance standards but will delay applicability of the appointment wait time standards until plan year 2025. Accordingly, QHP issuers in FFEs will have one additional plan year before being required to attest to meeting appointment wait time standards.

As we noted in the 2023 Payment Notice, specific guidelines for complying with appointment wait time standards will be released in later guidance. This will allow HHS additional time to develop specific guidelines for how issuers should collect the requisite data from providers, how the metrics should be interpreted, and for public comment on the proposed guidance. Issuers that do not yet meet the appointment wait time standards, once implemented in PY2025, will be able to use the justification process to update HHS on the progress of their contracting efforts for the respective plan year.

• 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. 

• 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.

• The ‘Individual ECPs’ tab within the ECP/NA Template was retired beginning PY2023 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.

• Taxonomy codes that map to each individual provider and facility provider 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 provider specialty categories.. 

• 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. 

• Issuers should not list a single individual practitioner or facility provider with the same address multiple times within the 'Network Adequacy Provider' tab of the ECP/NA Template. Instead, issuers may assign multiple NA Individual/Facility Specialty Types to a single individual practitioner or facility provider in two ways:
• The first way is to use the selection box feature that is built into the 'Network Adequacy Provider' tab of 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."

• 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. 

• 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.

• For the Network Adequacy side of the ECP/NA Template, the issuer should enter information for all facilities and individual providers participating in the network because reasonable access is based on time and distance from the target consumers (see FAQ describing the QHP Population Sample file) residing within the respective county of that state, rather than the providers having to be located in the respective county or state. In other words, for network adequacy standards, the issuer may receive credit towards satisfaction of the NA time and distance standards for an in-network provider located outside the county and even outside the state in which the target population resides, so long as the provider's location is within the time and distance requirements of the target population for the given provider specialty type.
  
  In contrast, for the ECP side of the ECP/NA Template, in order for the issuer to receive credit towards 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. Furthermore, in order for the issuer to receive credit towards satisfaction of the requirement that an issuer offers a contract to at least one ECP in each ECP category in each county, where available, the provider must be located in the respective county.
  

• 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. 

• For the Network Adequacy side of the ECP/NA Template, issuers can enter providers that practice in multiple locations without adding "001" or "002" at the end of the provider's last name for each location (as had been done in much earlier years), 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 practitioner 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.

• Yes, individual providers should not be reported as practicing at more than 10 unique locations on the ‘Network Adequacy Provider’ tab of the ECP/NA Template. 

• Except in the case of inpatient hospitals where this field contains the number of staffed hospital 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.

• If an issuer submits any providers on the ‘Network Adequacy Provider’ tab 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 NPI Validation Report and will not count towards the issuer’s satisfaction of network adequacy standards.

• Issuers must list all in-network individual and facility providers on the ‘Network Adequacy Provider’ 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 ‘Network Adequacy Provider’ 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. 

• 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 ‘Network Adequacy Provider’  tab of the ECP/NA Template. In contrast, the essential community provider standard does not apply to dental services that are embedded within a medical QHP.

• 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.

• 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.

• FFE issuers must upload their completed ECP/NA Template and the ECP Write-in Worksheet, as applicable, through the Marketplace Plan Management System (MPMS) Module within HIOS, as described in the ECP/NA Instructions found on the QHP certification website.

• 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). 

• No, 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.

• Yes, for PY2024, CMS will continue the Network Breadth Pilot for all QHP issuers in states participating in the Network Breadth Pilot, which include Tennessee and Texas for PY2024. 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. 

• CMS will assess network breadth based on analysis of a QHP issuer's individual and facility provider data. Issuers will submit QHP individual and facility provider data as part of the PY2024 certification process via the ECP/NA Template.

• CMS determines network breadth classifications by comparing an issuer’s contracted providers to the number of specific individual practitioner and facility providers included across all QHP networks available in a county. The rating focuses on inpatient hospitals, adult primary care, and pediatric primary care with a separate classification for each of these three provider specialty types. CMS calculates the classifications of network breadth for each plan at the county level.
  

• 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)