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Choice of Essential Community Providers in Marketplace Plans Could Challenge Hospitals



This week in Washington—including essential community providers in health plans sold through the exchanges. You are tuning in to the health policy update from America’s Essential Hospitals for the week of August 19.

Last week we discussed the requirements that health plans must meet in order to be sold through the exchanges. One of those requirements is that health plans sold through the exchanges must contract with essential community providers as part of their networks.

Essential community providers are defined by the federal government as providers “that service predominately low-income, medically-underserved individuals.”

The federal Center for Consumer Information & Insurance Oversight (CCIIO) outlined the standards for including essential community providers in federally-facilitated and partnership exchanges. Plans sold through these exchanges must demonstrate they meet these standards through an application process. States, however, may establish their own standards for state-run exchanges.

The most rigorous standard from the federal guidelines is the safe harbor standard, which requires that qualified health plans demonstrate at least 20 percent of available essential community providers in the plan’s service area participate in the provider network. It also requires plans to offer contracts to at least one essential community provider in each category of providers in each county in the service area. These specific provider categories are hospitals, federally-qualified health centers (FQHCs), Ryan White HIV/AIDS providers, family planning providers, Indian providers, and other entities that serve predominantly low-income, medically underserved patients.

Establishing standards for including essential community providers in these networks is critical. Essential community providers have expertise in serving many of the people who will enroll in health insurance plans sold through the exchanges— especially those who have low-incomes, are medically underserved, or have complex or chronic conditions. What’s more, including the providers these patients are already seeing in their communities means they can continue to see the same health service professionals where they are comfortable.

Yet even with these standards, it is not certain that an adequate number of essential community providers will actually be included in these networks. Many of these providers have actually reported that plans have not engaged them regarding network participation, or have offered participation options that require them to accept low rates or exclude certain services.

Limiting the inclusion of essential community providers could put vulnerable patients’ health at risk by disrupting their relationships with their essential community providers and restricting them from choosing a provider that best meets their needs. We will continue to follow this issue, in particular as enrollment in these health plans begins Oct. 1.

Thanks for listening to another edition of This Week in Washington. I’m Erin Richardson; join us next week as we continue our discussion of health insurance exchanges.


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