Essential community providers (ECPs) are providers that historically serve medically needy or medically indigent patients and demonstrate a commitment to serve low-income and medically indigent populations who comprise a significant portion of the patient population.
The Department designates ECPs, based on Colorado’s ECP definition, for the purposes of administering the Health First Colorado program. A provider’s designation as a state ECP is also recognized by the Colorado Division of Insurance, which is responsible for ensuring private insurance carriers offering ACA plans include an adequate number of ECPs in their provider networks.
Frequently Asked Questions (FAQs)
What is the State of Colorado’s definition of an essential community provider (ECP)?
Essential community providers, as defined in Colorado law, are providers that: (a) have historically served medically needy or medically indigent patients and that demonstrate a commitment to serve low income and medically indigent populations who comprise a significant portion of the patient population, or in the case of a sole community provider, serve the medically indigent patients within its medical community, and (b) waive charges for services on a sliding scale based on income and do not restrict access or services because of a member’s financial limitations (§ 25.5-5-403, C.R.S).
What is the federal definition of ECP in the Affordable Care Act (ACA)?
Essential community providers, as defined in federal law, are providers that serve predominantly low income, medically underserved individuals. The provider categories that qualify as ECPs based on the federal definition are listed in45 CFR § 156.235.
The ACA requires that private health insurance carriers include a certain percentage of qualified ECPs in their provider networks. The U.S. Department of Human Services (HHS) compiles and maintains a non-exhaustive list of ECPs that health insurance carriers can use to identify providers that qualify as ECPs and will help them meet the required percentage. Types of providers that are eligible for including on the HHS ECP List include:
- Federally Qualified Health Centers (FQHCs) and FQHC look-alikes;
- Dental clinics providing dental services to low-income consumers in low-income ZIP codes or Health Professional Shortage Areas;
- Specific types of Inpatient Hospitals: Critical Access Hospitals, Rural Referral Centers, Disproportionate Share Hospitals Children’s Hospitals, Sole Community Hospitals, Free-standing Cancer Centers;
- Indian health care providers (including inpatient hospital services), which include providers participating in programs operated by 1) the Indian Health Service; 2) a Tribe or Tribal organization under the authority of the Indian Self-Determination and Education Assistance Act; and 3) an urban Indian organization under the authority of Title V of the Indian Health Care Improvement Act;
- Ryan White HIV/AIDS Program providers;
- Family planning providers receiving Federal funding under Title X of the PHS Act and not-for-profit or governmental family planning service sites that do not receive Federal funding under Title X of the PHS Act or other 340B-qualifying funding;
- Other providers that serve predominantly low-income, medically underserved individuals, including Black Lung Clinics, Community Mental Health Centers, Hemophilia Treatment Centers, Rural Health Clinics, Sexually Transmitted Disease Clinics, Substance Use Disorder Treatment Centers, and Tuberculosis Clinics.
The federal ACA definition (and the application for the federal HHS ECP List) has different types of clinics and hospitals than those that are included in the state definition of ECP (and on the HCPF ECP application). How will this affect the state designation?
If your provider type is not listed on the State ECP application, but you meet the federal ACA definition and/or are included as one of the eligible provider types on the application for the Federal HHS ECP List, you will mark “other” on the State ECP application, list your provider type, and submit the required documentation listed on the application.
Who can be designated as an ECP?
Any provider that serves, and shows a commitment to serve low income, medically needy or medically indigent patients, and meets either the federal or state definition.
What are the benefits of being designated as an ECP?
For the purposes of the Department and the Health First Colorado program, the following are benefits when becoming a designated ECP:
a. provides recognition in your community as a valuable asset serving the most vulnerable Coloradans assisting in receiving community support; and
b. promotes your organization when seeking funding.
For the purposes of private health insurance, carriers offering ACA-compliant plans must ensure their provider networks include “a sufficient number and geographic distribution of ECPs, where available, to ensure reasonable and timely access to a broad range of such providers for low-income individuals or individuals residing in Health Professional Shortage Areas within the [plan’s] service area” (45 CFR 156.235). To meet this standard, federal and state laws require carriers to include 35% of the ECPs that are available within a plan’s service area in their provider network.
By becoming designated as an ECP, and appearing on either the federal HHS ECP List or the State ECP list maintained by HCPF, carriers who are seeking to identify ECPs to satisfy the ECP requirements will have a place to find your organization, clinic, or practice. The fact that your organization, clinic, or practice appears on the Federal HHS List or the State ECP List does not guarantee that a private health insurance carrier will contract with you; it does, however, make your organization visible to carriers looking to include such providers in their networks.
Do I need to be designated by both the State and the Federal Government as an ECP?
No, you do not need to be designated as an ECP by both the State and Federal Government as an ECP. If your organization, clinic, or practice is already included in the federal HHS ECP List, you do not need to apply for State designation. Conversely, if your organization applies for and is approved as a State ECP by HCPF, you do not need to apply for the HHS ECP List.
For the purposes of State ECP designation, If I am part of a health network, with several clinics, does each clinic need to be designated as an ECP?
Yes, as long as all clinics in the health network serve and show a commitment to serve low income, medically needy or medically indigent patients.
Apply
Application to be designated as an Essential Community Provider
More Information on the Federal ECP Designation Program
The Centers for Medicare and Medicaid Services (CMS) designates ECPs according to federal requirements specified in QHP Instructions. Under that regulation, ECPs are defined as providers who serve predominantly low-income, medically underserved individuals. They include health care providers defined in section 340B(a)(4) of the Public Health Service (PHS) Act and described in section 1927(c)(1)(D)(i)(IV) of the Social Security Act (SSA). The Colorado Division of Insurance ensures that private insurers in the ACA markets are in compliance with federal and state ECP standards requirements each year as part of the annual ACA plan filing process.