Common use of Essential Community Providers Clause in Contracts

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 shall notify the Exchange with respect to any material changes as of and throughout the term of this Agreement to its contracting arrangements, geographic distribution, percentage coverage, ECP classification type (e.g., 340B), and other information relating to ECPs from prior disclosures made by Contractor in its Proposal to Section II.B.3 of Solicitation and related attachments. (d) 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. 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 Health Care 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 Health Care 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” 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 shall notify the Exchange with respect to any material changes as of and throughout the term of this Agreement to its contracting arrangements, geographic distribution, percentage coverage, ECP classification type (e.g., 340B), and other information relating to ECPs from prior disclosures made by Contractor in its Proposal to Section II.B.3 of Solicitation and related attachments. (d) 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. 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 Health Care ServicesCovered Services to low- 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 Health Care ServicesCovered 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.. Covered California – Final Health Plan Contract – May 202117, 2013 10 (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 shall notify the Exchange with respect to any material changes as of and throughout the term of this Agreement to its contracting arrangements, geographic distribution, percentage coverage, ECP classification type (e.g., 340B), and other information relating to ECPs from prior disclosures made by Contractor in its Proposal to Section II.B.3 of Solicitation and related attachments. (d) 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. 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 Health Care 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 providers 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 Health Care 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” 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 shall notify the Exchange with respect to any material changes as of and throughout the term of this Agreement to its contracting arrangements, geographic distribution, percentage coverage, ECP classification type (e.g., 340B), and other information relating to ECPs from prior disclosures made by Contractor in its Proposal to Section II.B.3 of Solicitation and related attachments. (d) 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. 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 rating region in which Contractor’s QHPs provides Covered Services to Enrollees, (ii) the balance of hospital and non-hospital ECPs in each geographic rating region, (iii) the inclusion in Contractor’s provider contracting network of at least 15% of entities in each applicable geographic rating 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, 340B Entity (ii) California Disproportionate Share Hospital Program, per the Final DSH Eligibility List FY (CA DHCS 20112012-1213), (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. Covered California will post a non-exhaustive essential community provider list annually. (c) Contractor shall notify the Exchange with respect to any material changes as of and throughout the term of this Agreement to its contracting arrangements, geographic distribution, percentage coverage, ECP classification type (e.g., 340B), and other information relating to ECPs from prior disclosures made by Contractor in its Proposal to Section II.B.3 of Solicitation and related attachments. (d) 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. (e) For Contractor’s provider contracts entered into on or after January 1, 2015, Contractor shall reference the Centers for Medicare & Medicaid Services Model QHP Addendum for Indian Health Care Providers (“Addendum”) along with the Overview of the Model QHP Addendum for Indian Health Care Providers (“CMS Overview”) attached hereto as Attachment 12. Contractor is encouraged to adopt the Addendum whenever it contracts with those Indian health care providers specified in the Addendum. Adoption of the Addendum is not required; it is offered as a resource to assist Contractor in including specified Indian providers in its provider networks.

Essential Community Providers. Covered California – Draft Health Plan Contract -- April 22, 2013April 298, 2013 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 Health Care 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 providers 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 Health Care 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” 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 shall notify the Exchange with respect to any material changes as of and throughout the term of this Agreement to its contracting arrangements, geographic distribution, percentage coverage, ECP classification type (e.g., 340B), and other information relating to ECPs from prior disclosures made by Contractor in its Proposal to Section II.B.3 of Solicitation and related attachments. (d) 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.