The Affordable Care Act requires qualified health plans participating in health insurance marketplaces (aka Exchanges) to maintain a sufficient number of Essential Community Providers (ECP) in their provider network. ECPs are safety-net providers within the following categories: federally qualified health centers, family planning clinics, Ryan White HIV/AIDS centers, American Indian health providers, public or non-profit hospitals, and others such as mental health and substance abuse providers and STD Clinics. They are the ‘essential’ and trusted source of primary care for poor and low-income communities with the greatest health needs. Many of them work to reduce health disparities as well as provide culturally and linguistically competent services.

“A remarkably generous policy”

Earlier this month, the Department of Health and Human Services (HHS) released its final Letter to Issuers on Federally-Facilitated and State Partnership Exchanges. This letter provides directions to insurers that want to participate in the Federally-Facilitated Exchanges. Compared to the draft version published for comments on March 1, this letter establishes much weaker standards for the inclusion of ECPs—essentially giving a free pass for insurers to sidestep building a robust network of providers for populations at risk.

According to the final letter, there are two levels of standards issuers need to meet. The ‘safe harbor’ standard is granted to participating health plans that contract with at least 20 percent of all ECPs in each county in the area the plans serve, meaning all available American Indian health providers and at least one ECP in each category mentioned above. In cases where a health plan fails to meet the safe harbor standard, an even less demanding option exists. In this instance, at the minimum the plan needs only to contract with 10 percent of these providers as long as it can present a justification as to how low-income and underserved communities can access needed care under its approach.

In addition, despite the low bar, HHS continues to offer further flexibility. While the draft letter suggested that health plans would not likely be certified if they did not meet the minimum expectation, the final letter suggests otherwise. Instead, HHS promises to “take into account factors and circumstances” in evaluating compliance. This suggests health plans are allowed to go below the 10 percent minimum expectation.

What can advocates do?

Advocate for a higher minimum standard to at least 50 percent

The safe harbor standard and the minimum expectation plainly fail to ensure reasonable and timely access to a broad range of providers for low-income, medically underserved individuals, and could prevent vulnerable individuals from getting adequate care. In a geographically large rural county, one health center located in one corner of the county may not be accessible for those who reside in the other side of the county. Therefore, a more rigorous minimum standard of at least 50 percent is needed. The Connecticut Health Insurance Exchange requires qualified health plans to contract with at least 75 percent of the essential community providers in any county and at least 90 percent of the federally qualified health centers or “look-alike” health centers in the state. In addition to the 50 percent rule, it is important to include specific criteria on enrollee to provider ratios, travel time and distance to providers.

Help safety-net providers build relationships and start the negotiation process with issuers

Safety-net providers are not automatically included in qualified health plans’ provider networks. Recently, the Center for Consumer Information and Insurance Oversight (CCIIO) published a list of essential community providers. As stated in the notification letter, the list does not include all eligible providers and will not be updated prior to 2014. A starting point is to review the list to identify any missing qualified ECPs. The next is to work with state insurance commissioners and other state officials to help build relationships and begin the negotiation process between safety net providers and qualified health plans. In Maryland, the Maryland Health Benefit Exchange, along with the Maryland Community Health Resource Commission and the Maryland Department of Health and Mental Hygiene will host several regional “Meet and Greet”sessions to help safety-net providers and qualified health plans begin discussions on contracting.

 — Quynh Chi Nguyen, Program and Policy Associate