Health Equity Beyond the Insurance Card

1. Health Equity Beyond the Insurance Card Why Essential Community Provider Requirements Matter Arlene Murphy Access Health CT Consumer Advisory Committee Making Access Real

2. Health Equity and Essential Community Providers • Purpose of ECP Requirements •  How Requirements Work • Why They Are Important • Keys to advocacy • Know the Rules • Know the List • Know the Barriers • Monitor & Evaluate Implementation Making Access Real

3. Network Adequacy 45 CFR Section 156.230 • General requirement. A QHP Issuer must ensure that the provider network of each of its QHPs, as available to all enrollees, meets the following standards. (1) Includes essential community providers in accordance with Section 156.235. (2) Maintains a network in number and types of provides including providers that specialize in mental health, substance abuse services to assure that all services will be accessible without unreasonable delay; and, (3) Is consistent with the network adequacy provisions of Section 2702 (c) of the PHS Act. Making Access Real

4. Network Adequacy 45 CFR Section 156.235 (a) General requirements (1) A QHP must have a sufficient number and geographical distribution of essential community providers, where available, to ensure reasonable and timely access to a broad range of such providers for low-income, medically underserved individuals in the QHP’s service area, in accordance with the Exchange’s network adequacy standards. (2) Definition. Essential community providers are providers that serve predominantly low-income, medically underserved individuals, including provides that meet the criteria of paragraph (c) (1) or (2) of this section on the publication date of this regulation unless the provider lost its status under paragraph (c) (1) or (2) of this section thereafter as a result of violating Federal law: 1) Health care provides defined in Section 340B (a) (4) of the PHS Act; and (2) Provides described in Section 1927 (c) (1) (D) (i) (IV) of the Act as set forth by Section 221 of Public Law 111-8. Making Access Real

5. CCIIO Exchange Guidance Network includes sufficient number and geographic distribution of ECPs to ensure reasonable and timely access to a broad range of providers Issuer must meet one of the following standards • Safe Harbor – At least 20% ECP participation in network in the service area. Agrees to offer contracts to al least one ECP of each type available by county and agrees to offer contracts to all available Indian providers • Minimum Expectations – At least 10% ECP participation in network in the service area and submits a satisfactory narrative justification as part of its application Source: CMS’ “Letter to Issuers on Federally facilitated and State Partnership Exchanges”, available at: http://cciio.cms.gov/resources/regulations/Files/2014_letter_to_issuers_04052013.pdf Making Access Real

6. Types of Essential Community Providers • Federally Qualified Health Centers (FQHC) - FQHC and FQHC “Look Alike” • Ryan White Providers – Ryan White HIV/AIDS programs • Family Planning Providers – Title X Family Planning Providers and Title X “Look Alike” Family Planning Providers • Indian Providers - Tribal and Urban Indian Organization Providers • Hospitals – DSH Hospitals, Children’s Hospitals ,Rural Hospitals, Referral Centers, Sole Community Hospitals, Free-standing Cancer Centers, Critical Access Hospitals • Other - STD Clinics, TB Clinics, Hemophilia Treatment Centers, Black Lung Clinics, and other entities that serve predominantly low-income, medically underserved individuals Making Access Real

7. Connecticut Essential Community Provider Requirements Access Health CT Network Adequacy Criteria • At least 90% of Federally Qualified Health Centers (FQHCS) or FQHC “look alike” health centers in CT • At least 75% of essential community providers • The network is consistent with network adequacy provisions of Section 2702 of the PHSA Making Access Real

8. Essential Community Providers:Which List? • CMS 340B Provider List • CMS Non-Exhaustive List updated in March 2013 • Essential Community Provider List as defined by the state Source: CMS Non-Exhaustive Database of ECPs can be found at https://data.cms.gov/dataset/Non-Exhaustive-List-of-Essential-Community-Provide/ibqy-mswq Making Access Real

9. Connecticut Phase-In • Qualified Health Plans must contract with 75% of the CMS Non -Exhaustive List by January 1, 2014* • Two Year Phase-In for Expanded List ** • 35% of the providers on that list will be contracted by 1/1/2014 • 75% by January 1, 2015 * Percentages to be taken net of the March 2013 CMS non - exhaustive list (no duplication) ** *Carriers must show consideration for geography and access to the variety of provider types and contract for the full range of services included in the essential health benefits (EHB). Consideration will be given for demonstration of a good faith effort to accomplish these standard Making Access Real

10. Connecticut Essential Community ProvidersPreliminary Progress Making Access Real

11. Resources for more information • http://www.hrsa.gov/affordablecareact/ • http://hab.hrsa.gov/affordablecareact/ecp.html • https://data.cms.gov/dataset/Non-Exhaustive-List-of-Essential-Community-Provide/ibqy-mswq • http://www.naic.org/documents/committees_b_related_wp_network_adequacy.pdf Making Access Real