Essential Community Providers a) ECP standard. Unless Covered California determines that Contractor has qualified under the alternate standard for essential community providers pursuant to the Affordable Care Act, Contractor shall maintain a network that includes a sufficient geographic distribution of care, including essential community providers (“ECP”), and other providers available to provide reasonable and timely access to Covered Services for low-income, vulnerable, or medically underserved populations in each geographic region where Contractor’s QHPs provide services to Covered California Enrollees. Contractor shall comply with other laws, rules and regulations relating to arrangements with ECPs, as applicable, including, those rules set forth at 45 C.F.R. § 156.235.
i. Reporting requirements for the ECP standard are contained within the required monthly provider data submission pursuant to Section 4.4.4. The Contractor must provide a provider data file to Covered California upon request for the purpose of determining compliance with the ECP standard. This file is separate and distinct from the files provided to the Integrated Health Care Association’s Symphony Provider Directory as described in Section 4.4.5. Reporting requirements for the ECP standard are as follows:
1. Contractor to demonstrate provider agreements with at least fifteen percent (15%) of 340B non-hospital providers in each applicable rating region.
2. Contractor to demonstrate provider agreements that reflect a mix of essential community providers (hospital and non-hospital) reasonably distributed to serve the low-income, vulnerable, or medically underserved populations.
Essential Community Providers. Except if Contractor has qualified under the alternate standard for essential community providers provided by the Affordable Care Act as has been determined by the Exchange, Contractor shall maintain a network that includes a sufficient geographic distribution of essential community providers (“ECP”) that are available through Contractor to provide reasonable and timely access to Covered Services to low- income populations in each geographic region where Contractor’s QHPs provide services to Enrollees.
(a) For purposes of this Section, “sufficient geographic distribution” of ECP shall be determined by the Exchange in its reasonable discretion in accordance with the conditions set forth in the Solicitation and based on a consideration of various factors, including, (i) the nature, type and distribution of Contractor’s ECP contracting arrangements in each geographic region in which Contractor’s QHPs provides Covered Services to Enrollees, (ii) the balance of hospital and non-hospital ECPs in each geographic region, (iii) the inclusion in Contractor’s provider contracting network of at least 15% of entities in each applicable geographic region that participate in the program for limitation on prices of drugs purchased by covered entities under Section 340B of the Public Health Service Act (42 U.S.C. § 256B) (“340B Entity”), (iv) the inclusion of at least one ECP hospital in each region, (v) the inclusion of Federally Qualified Health Centers, school-based health centers and county hospitals, and (vi) other factors as mutually agreed upon by the Exchange and the Contractor regarding Contractor’s ability to serve the low income population.
(b) “Low-income populations” shall be defined as families living at or below 200% of Federal poverty level. ECPs shall consist of participating entities in the following programs: (i) 340B, per the providers list as of November 9, 2012, (ii) California Disproportionate Share Hospital Program, per the Final DSH Eligibility List FY (CA DHCS 2011-12), (iii) Federally designated 638 Tribal Health Programs and Title V Urban Indian Health Programs, (iv) Community Clinic or health centers licensed as either a “community clinic” or “free clinic”, by the State under Health and Safety Code section 1204(a), or is a community clinic or free clinic exempt from licensure under Health and Safety Code Section 1206, and (v) Providers with approved applications for the HI-TECH Medi-Cal Electronic Health Record Incentive Program.
(c) Contractor...
Essential Community Providers. Article 3, Section 3.3.3 10% of total performance penalty at risk. Expectation: Contractor shall maintain a network that includes a sufficient geographic distribution of care, including essential community providers, and other providers, to provide reasonable and timely access to Covered Services for low income, vulnerable, or medically underserved populations in regions served by Contractor. Contractor to demonstrate provider agreements with at least 15% of 340B non-hospital providers in each applicable rating region. Contractor to demonstrate provider agreements that reflect a mix of essential community providers (hospital and non-hospital) reasonably distributed to serve the low-income, vulnerable, or medically underserved populations. Performance Level: 1. Sufficient ECP participation: 10% performance credit. 2. Developing ECP participation: no penalty or credit.
Essential Community Providers.
a) Contractor must provide reasonable and timely access to Covered Services for Low-income, and Medically Underserved populations in each geographic rating region where Contractor’s QHPs provide services to Covered California Enrollees, by providing access to Essential Community Providers (ECPs) as specified in this Section. Contractor shall comply with other laws, rules and regulations relating to arrangements with ECPs, as applicable, including those rules set forth at 45 C.F.R. § 156.235. For the purposes of this Section the following definitions shall apply:
i. “Low-income” populations are individuals and families living at or below 200% of Federal Poverty Level.
ii. “Medically Underserved” populations are:
1. Individuals with HIV/AIDS,
2. American Indians and Alaska Natives,
3. Individuals living in Maternity Care Target Areas, as published by the Health Resources and Services Administration (HRSA),
4. Individuals living in designated Health Professional Shortage Areas, as published by HRSA,
5. Individuals living in designated Medically Underserved Areas, as published by HRSA, and
6. Individuals belonging to designated Medically Underserved Populations, as published by HRSA.
b) General ECP standard. Contractor shall maintain in its provider network a sufficient number and sufficient geographic distribution of ECPs, as specified below. A Contractor that provides a majority of Covered Services through providers employed by the Contractor or through a single contracted medical group, as determined by Covered California, may instead comply with the Alternate ECP standard, specified in (c).
i. Provider sufficiency. Contractor’s provider network must, at a minimum:
1. Include a mix of ECPs (hospital and non-hospital) reasonably distributed to serve Low-income and Medically Underserved populations.
2. Include at least one ECP hospital in each county, or, in counties with more than one geographic rating region, one ECP hospital in each geographic rating region, where Contractor’s QHPs provide Covered Services to Covered California Enrollees.
3. Include at least fifteen percent (15%) of 340B non-hospital providers in each applicable geographic rating region where Contractor’s QHPs provide Covered Services to Covered California Enrollees.
ii. Sufficient geographic distribution. Covered California shall determine whether Contractor provides sufficient geographic distribution of care based on a consideration of factors, not limited to:
1. The nature, type, and ...
Essential Community Providers. Contractor shall maintain a network compliant with all applicable Laws, that includes a sufficient geographic distribution of essential community providers (“ECP”.)
Essential Community Providers a) ECP standard. Unless the Exchange determines that Contractor has qualified under the alternate standard for essential community providers pursuant to the Affordable Care Act, Contractor shall maintain a network that includes a sufficient geographic distribution of care, including essential community providers (“ECP”), and other providers available to provide reasonable and timely access to Covered Services for low-income, vulnerable, or medically underserved populations in each geographic region where Contractor’s QHPs provide services to Enrollees. Contractor shall comply with other laws, rules and regulations relating to arrangements with ECPs, as applicable, including, those rules set forth at 45 C.F.R. §156.235.
Essential Community Providers. Contractor shall maintain a network compliant with all applicable Laws.
Essential Community Providers. The final budget accepts the Governor's proposal to set aside no less than $10 million (total Medicaid) in VAP funds for rural and essential community providers, including hospitals, nursing homes, diagnostic and treatment centers, ambulatory surgery centers, and clinics. This was a HANYS' advocacy priority as well. If federal financial participation (FFP) is not available, the non- federal share shall be made as state grants. Additionally, 30 days prior to distribution of funds, DOH must provide the Legislature with information about the methodology and its fiscal implications, as well as quarterly and other reports. The final budget accepts the Governor's proposal to increase the annual VAP set-aside for CAHs from $5 million to $7.5 million (total Medicaid) and to require an examination of permanent Medicaid rate methodology changes. HANYS has been pressing for additional support for CAHs for several years. Additionally, 30 days prior to distribution of funds, DOH must provide notice to the Legislature with specific information about the methodology and its fiscal implications, as well as quarterly and other reports.
Essential Community Providers a) ECP standard. Unless Covered California determines that Contractor has qualified under the alternate standard for essential community providers pursuant to the Affordable Care Act, Contractor shall maintain a network that includes a sufficient geographic distribution of care, including essential community providers (“ECP”), and other providers available to provide reasonable and timely access to Covered Services for low-income, vulnerable, or medically underserved populations in each geographic region where Contractor’s QHPs provide services to Covered California Enrollees. Contractor shall comply with other laws, rules and regulations relating to arrangements with ECPs, as applicable, including, those rules set forth at 45 C.F.R. § 156.235.
i. Reporting requirements for the ECP standard are contained within the required monthly provider data submission pursuant to Section 34.4.4. The Contractor must provide a provider data file to Covered California upon request for the purpose of determining compliance with the ECP standard. This file is separate and distinct from the files provided to the Integrated Health Care Association’s Symphony Provider Directory as described in Section 34.4.5. Reporting requirements for the ECP standard are as follows:
