In accordance with section 1311(c)(1)(C) of the Affordable Care Act (ACA), Qualified Health Plan (QHP) issuers, including Stand-alone Dental Plan (SADP) issuers, are required to include within their networks essential community providers (ECPs), where available. ECPs are providers that serve predominantly low-income, medically underserved individuals. Under this same section of the ACA, the Secretary of the Department of Health and Human Services (HHS) is charged with establishing criteria for certification of health plans as QHPs. One of these criteria is the inclusion of ECPs in QHP and SADP issuers’ networks.
Under 45 CFR 156.235, ECPs are defined as health care 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; entities described in section 1927(c)(1)(D)(IV) of the Social Security Act (SSA), including State-owned family planning service sites, governmental family planning service sites, not-for-profit family planning service sites that do not receive Federal funding under special programs, including under Title X of the PHS Act or other 340B- qualifying funding; or Indian health care providers, unless any of the above providers has lost its status under either of these sections, 340B of the PHS Act or 1927 of the SSA, as a result of violating Federal law.