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CMS Gives Insurers Guidance for Marketplace Participation



This week in Washington—CCIIO sends a detailed letter on QHPs. You are tuning in to the National Association of Public Hospitals and Health Systems health policy update for the week of April 15, 2013.

On April 5, the federal Centers for Medicare & Medicaid Services’ (CMS’) Center for Consumer Information and Insurance Oversight (CCIIO) sent a letter to issuers who are seeking to offer qualified health plans (QHPs) in the federally-facilitated and state partnership exchanges. The letter offers issuers operational and technical guidance on how to successfully participate in the exchanges. The policies outlined in the letter apply to the 2014 coverage year and CCIIO noted that similar letters will be issued, likely on an annual basis, to provide operational updates to the QHP issuers.

Included in the letter is guidance on QHP compliance with network adequacy, which includes compliance with essential community provider (ECP) standards. Issuers will indicate the ECPs in their provider networks when they submit their QHP applications to CMS. CMS has created a template for the ECP section of the application and will provide detailed instruction on how to complete the template. CMS will monitor ECP sufficiency in the applications. Applications must demonstrate that at least 20 percent of available ECPs in the plan’s service area participate with the issuer’s provider network. CCIIO has designated six major ECP categories and each QHP must include at least one ECP in each category to meet CMS’ standards. For hospitals, the ECP provider types include disproportionate share hospital (DSH) and DSH-eligible hospitals, children’s hospitals, rural referral centers, sole community hospitals, free-standing cancer centers and critical access hospitals. More information and a database of ECPs are available by searching “non-exhaustive list of essential community providers” at

For more health policy news this week, visit the “Latest from Newsline” section of the NAPH website at Thanks for listening to another edition of This Week in Washington. I’m Zina Gontscharow; join us next week for another update.



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