Common use of Essential Community Providers Clause in Contracts

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 distribution of Contractor’s ECP contracting arrangements in each geographic rating region where Contractor’s QHPs provide Covered Services to Covered California Enrollees; 2. The balance of hospital and non-hospital ECPs in each geographic rating region where Contractor’s QHPs provide Covered Services to Covered California Enrollees; and 3. The extent to which the providers in Contractor’s network are accessible to and provide services that meet the needs of Low-income and Medically Underserved populations. c) Alternate ECP standard. A Contractor that Covered California determines qualifies under the alternate ECP standard, due to its integrated delivery structure, must satisfy the requirement in (a) by providing services to the Low-income and Medically Underserved populations served by the entities listed in each of the ECP categories in (d). It must demonstrate that it does so in each geographic rating region where Contractor’s QHPs provide services to Covered California Enrollees, either through its own system or by offering a contract to at least one ECP outside of its system in each such category. d) ECP categories. ECPs shall include the following categories of entities: i. Entities 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 Entities”). ii. Entities that participate in the program described in Public Health Service Act § 1927(c)(1)(D)(i)(IV). iii. Entities that participate in California’s Disproportionate Share Hospital (DSH) Program, per the final DSH Eligibility List for the current fiscal year. iv. Federally designated 638 Tribal Health Programs and Title V Urban Indian Health Programs.

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 distribution of Contractor’s ECP contracting arrangements in each geographic rating region where Contractor’s QHPs provide Covered Services to Covered California Enrollees; 2. The balance of hospital and non-hospital ECPs in each geographic rating region where Contractor’s QHPs provide Covered Services to Covered California Enrollees; and 3. The extent to which the providers in Contractor’s network are accessible to and provide services that meet the needs of Low-income and Medically Underserved populations. c) Alternate ECP standard. A Contractor that Covered California determines qualifies under the alternate ECP standard, due to its integrated delivery structure, must satisfy the requirement in (a) by providing services to the Low-income and Medically Underserved populations served by the entities listed in each of the ECP categories in (d). It must demonstrate that it does so in each geographic rating region where Contractor’s QHPs provide services to Covered California Enrollees, either through its own system or by offering a contract to at least one ECP outside of its system in each such category. d) ECP categories. ECPs shall include the following categories of entities: i. Entities 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 Entities”). ii. Entities that participate in the program described in Public Health Service Act § 1927(c)(1)(D)(i)(IV). iii. Entities that participate in California’s Disproportionate Share Hospital (DSH) Program, per the final DSH Eligibility List for the current fiscal year. iv. Federally designated 638 Tribal Health Programs and Title V Urban Indian Health Programs.