CMS has extended the deadline for comments regarding the Draft Non-Exhaustive Health and Human Services List of Essential Community Providers (ECPs) for Plan Year 2016 ("DRAFT-non-exhaustive-HHS-List-of-ECPs-PY-2016 [XLS, 7MB]") to Friday, January 9th (the deadline was originally Friday, January 2nd).
The extension for comments on this list (which was just released in late December) means it’s possible to still review the list and provide comments this week! Comments can either correct data that is already there, such as updating information or adding service site locations for providers already on the list, or (more importantly) petition for your behavioral health agency's services to be included on the list for the first time if your agency meets ECP criteria, such as if you serve a predominantly low-income client population.
As background, the concept of ECPs originated with unsuccessful health reform attempts under President Clinton, and the idea of ECPs was later incorporated into the Patient Protection and Affordable Care Act of 2010, in order to protect access to care through the marketplace Qualified Health Plans (QHPs) for low-income, medically-underserved individuals (Sonfield, 2013). Sonfield (2013) provides thorough additional background information here.
For the 2015 and 2016 plan years, insurance agencies that offer plans on a federally administered marketplace (which is how it works here in Texas—for other states see here) must offer contracts to at least 30% of the providers listed on the "non-exhaustive" list:
The extension for comments on this list (which was just released in late December) means it’s possible to still review the list and provide comments this week! Comments can either correct data that is already there, such as updating information or adding service site locations for providers already on the list, or (more importantly) petition for your behavioral health agency's services to be included on the list for the first time if your agency meets ECP criteria, such as if you serve a predominantly low-income client population.
As background, the concept of ECPs originated with unsuccessful health reform attempts under President Clinton, and the idea of ECPs was later incorporated into the Patient Protection and Affordable Care Act of 2010, in order to protect access to care through the marketplace Qualified Health Plans (QHPs) for low-income, medically-underserved individuals (Sonfield, 2013). Sonfield (2013) provides thorough additional background information here.
For the 2015 and 2016 plan years, insurance agencies that offer plans on a federally administered marketplace (which is how it works here in Texas—for other states see here) must offer contracts to at least 30% of the providers listed on the "non-exhaustive" list:
Because the list is "non-exhaustive," there are many more agencies meeting the criteria of serving low-income clients than are included on the list.
When the list is more representative of the safety-net services actually being provided in a given county (a.k.a.: more "exhaustive"), that means that Qualified Health Plans (QHPs) have to offer more contracts to more providers, because they have to offer contracts to 30% of the providers included on the list. Therefore, the more inclusive the list is, the more contracts will need to be offered overall across a given area, such as Harris County. When QHPs are required to network with more service providers serving a low-income client base (which otherwise they are somewhat dis-incentivized from doing out of business interests to cut costs), the services available to the low-income client community grow. This is in the best interest of area low-income clients, and in the best interest of local public health as well.
As the Greater Houston Behavioral Health Affordable Care Act (BHACA) Initiative, we encourage area behavioral health providers to review the list and submit comment for inclusion if they may possibly meet the criteria. Having a higher number of total providers on the "official" "non-exhaustive" list (the denominator in the equation above) creates a higher saturation of overall access to services by county by increasing the numerator in the equation above, as QHPs have to meet the 30% threshold.
Please review CMS instructions for providing comments here. To quote from this document (Description-and-Purpose-of-Draft-HHS-List-of-ECPs_12-24-14 [PDF, 110KB]):
"PURPOSE OF DRAFT HHS LIST OF ECPs:
"CMS is publishing this draft HHS list of ECPs to provide entities on the list an opportunity to notify CMS of any necessary corrections. CMS is soliciting public comments until 5 p.m. EST on January 9, 2015 to improve the accuracy of the list.
"CMS considers the following to be within the scope of this solicitation:
"1. Detailed corrections to the draft ECP list, including documentation that points CMS to a valid source of data that supports the correction; and
"2. Additions to the draft ECP list that contain sufficient data for inclusion in the list, as well as documentation that points CMS to a valid source of data that confirms that the added entity is a member of one of the ECP groups listed above.
"Please send corrections or additions to the ECP electronic mailbox at: [email protected]. Commenters should write in the subject line of the email the following: "Comments on draft ECP list." Do note that CMS, while always interested in optimizing our policy regarding ECPs, will not be able to respond to policy suggestions or other concerns beyond improving the accuracy of the ECP list."
Criteria for ECP status--Six categories of essential community providers (providers can be in more than one category):
1. FQHC (and FQHC "Look-Alike")
2. Ryan White HIV/AIDS Program Providers
3. Family Planning Proivder -- Title X Family Planning Clinics and Title X "Look-Alikes"
4. Indian Health Provider
5. Hospitals -- Disproportionate Share Hospital (DSH) and DSH-eligible Hospitals, Children's Hospitals, Rural Referral Centers, Sole Community Hospitals, Free-standing Cancer Centers, Critical Access Hospitals
6. Other ECP Providers -- STD Clinics, TB Clinics, Hemophilia Treatment Centers, Black Lung Clinics, and other entities that serve predominantly low-income, medically underserved individuals
We have not seen where CMS explicitly defines what it means to "serve predominantly low-income, medically underserved individuals," but we have several suggestions.
CMS defines low-income zip codes as those with greater than 30% of the population living below 200% of the federal poverty level (FPL). Based on this reference point, if your agency is able to cite that it serves a significant percentage of clients that have incomes below 200% of the FPL, then this may be criteria enough to fall into category 6 above. It is unclear what that percentage would need to be, but probably over 30% of the total clients served (or perhaps over 50%), depending on how "predominantly" is interpreted. In either case, you could include a de-identified summary of overall client demographic data in your email to CMS and ask them if that is sufficient data, and/or ask for more clarity on what data is required to prove that an agency serves "predominantly low-income, medically underserved individuals." Doing this before the January 9th deadline would seem to give you some room to have an ongoing conversation with CMS about your agency's reasons for meriting inclusion on the ECP list.
As well, if your agency already receives funding from a funding source that is tied to the agency's provision of services to "predominantly low-income, medically underserved individuals," then that is another possible piece of evidence/documentation to include when emailing CMS regarding inclusion on the ECP list.
Thanks. We hope this information has been of value to you.
(These are the opinions of the BHACA staff based on our research concerning current guidelines. Please seek independent counsel as appropriate.)
Further Reading:
Sonfield, A. (2013). “Vigilance Needed to Make Health Reform Work for ‘Essential Community Providers,’” Guttmacher Policy Review, 16 (2). Retrieved online: www.guttmacher.org/pubs/gpr/16/2/gpr160217.html.
The CMS attachments linked above came from this CMS website page, under "Other QHP Application Resources:" www.cms.gov/cciio/programs-and-initiatives/health-insurance-marketplaces/qhp.html
Addendum--January 12, 2015:
CMS has replied to our request for clarification on the criteria for valid documentation regarding a behavioral health entity citing qualification for category 6:
"Behavioral health care providers generally have not been included on the HHS ECP list, because they do not generally include providers described in section 340B of the PHS Act or section 1927(c)(1)(D)(i)(IV) of the Social Security Act. The definition of an ECP is set forth in section 1311(c)(1)(C) of the Affordable Care Act. However, we have allowed Community Mental Health Centers located in a low-income or HPSA zip code to be counted as an ECP write-in if a particular issuer writes in the provider on their ECP template as a part of the issuer’s QHP application." -- CMS, January 8, 2015
When the list is more representative of the safety-net services actually being provided in a given county (a.k.a.: more "exhaustive"), that means that Qualified Health Plans (QHPs) have to offer more contracts to more providers, because they have to offer contracts to 30% of the providers included on the list. Therefore, the more inclusive the list is, the more contracts will need to be offered overall across a given area, such as Harris County. When QHPs are required to network with more service providers serving a low-income client base (which otherwise they are somewhat dis-incentivized from doing out of business interests to cut costs), the services available to the low-income client community grow. This is in the best interest of area low-income clients, and in the best interest of local public health as well.
As the Greater Houston Behavioral Health Affordable Care Act (BHACA) Initiative, we encourage area behavioral health providers to review the list and submit comment for inclusion if they may possibly meet the criteria. Having a higher number of total providers on the "official" "non-exhaustive" list (the denominator in the equation above) creates a higher saturation of overall access to services by county by increasing the numerator in the equation above, as QHPs have to meet the 30% threshold.
Please review CMS instructions for providing comments here. To quote from this document (Description-and-Purpose-of-Draft-HHS-List-of-ECPs_12-24-14 [PDF, 110KB]):
"PURPOSE OF DRAFT HHS LIST OF ECPs:
"CMS is publishing this draft HHS list of ECPs to provide entities on the list an opportunity to notify CMS of any necessary corrections. CMS is soliciting public comments until 5 p.m. EST on January 9, 2015 to improve the accuracy of the list.
"CMS considers the following to be within the scope of this solicitation:
"1. Detailed corrections to the draft ECP list, including documentation that points CMS to a valid source of data that supports the correction; and
"2. Additions to the draft ECP list that contain sufficient data for inclusion in the list, as well as documentation that points CMS to a valid source of data that confirms that the added entity is a member of one of the ECP groups listed above.
"Please send corrections or additions to the ECP electronic mailbox at: [email protected]. Commenters should write in the subject line of the email the following: "Comments on draft ECP list." Do note that CMS, while always interested in optimizing our policy regarding ECPs, will not be able to respond to policy suggestions or other concerns beyond improving the accuracy of the ECP list."
Criteria for ECP status--Six categories of essential community providers (providers can be in more than one category):
1. FQHC (and FQHC "Look-Alike")
2. Ryan White HIV/AIDS Program Providers
3. Family Planning Proivder -- Title X Family Planning Clinics and Title X "Look-Alikes"
4. Indian Health Provider
5. Hospitals -- Disproportionate Share Hospital (DSH) and DSH-eligible Hospitals, Children's Hospitals, Rural Referral Centers, Sole Community Hospitals, Free-standing Cancer Centers, Critical Access Hospitals
6. Other ECP Providers -- STD Clinics, TB Clinics, Hemophilia Treatment Centers, Black Lung Clinics, and other entities that serve predominantly low-income, medically underserved individuals
We have not seen where CMS explicitly defines what it means to "serve predominantly low-income, medically underserved individuals," but we have several suggestions.
CMS defines low-income zip codes as those with greater than 30% of the population living below 200% of the federal poverty level (FPL). Based on this reference point, if your agency is able to cite that it serves a significant percentage of clients that have incomes below 200% of the FPL, then this may be criteria enough to fall into category 6 above. It is unclear what that percentage would need to be, but probably over 30% of the total clients served (or perhaps over 50%), depending on how "predominantly" is interpreted. In either case, you could include a de-identified summary of overall client demographic data in your email to CMS and ask them if that is sufficient data, and/or ask for more clarity on what data is required to prove that an agency serves "predominantly low-income, medically underserved individuals." Doing this before the January 9th deadline would seem to give you some room to have an ongoing conversation with CMS about your agency's reasons for meriting inclusion on the ECP list.
As well, if your agency already receives funding from a funding source that is tied to the agency's provision of services to "predominantly low-income, medically underserved individuals," then that is another possible piece of evidence/documentation to include when emailing CMS regarding inclusion on the ECP list.
Thanks. We hope this information has been of value to you.
(These are the opinions of the BHACA staff based on our research concerning current guidelines. Please seek independent counsel as appropriate.)
Further Reading:
Sonfield, A. (2013). “Vigilance Needed to Make Health Reform Work for ‘Essential Community Providers,’” Guttmacher Policy Review, 16 (2). Retrieved online: www.guttmacher.org/pubs/gpr/16/2/gpr160217.html.
The CMS attachments linked above came from this CMS website page, under "Other QHP Application Resources:" www.cms.gov/cciio/programs-and-initiatives/health-insurance-marketplaces/qhp.html
Addendum--January 12, 2015:
CMS has replied to our request for clarification on the criteria for valid documentation regarding a behavioral health entity citing qualification for category 6:
"Behavioral health care providers generally have not been included on the HHS ECP list, because they do not generally include providers described in section 340B of the PHS Act or section 1927(c)(1)(D)(i)(IV) of the Social Security Act. The definition of an ECP is set forth in section 1311(c)(1)(C) of the Affordable Care Act. However, we have allowed Community Mental Health Centers located in a low-income or HPSA zip code to be counted as an ECP write-in if a particular issuer writes in the provider on their ECP template as a part of the issuer’s QHP application." -- CMS, January 8, 2015