OMB control number 0938-1295
Expiration Date: 12/31/2021

Congratulations you have successfully submitted your petition!

Background

Instructions

Petition Form

About You

Qualified petitioners include providers petitioning to make a change to their own HHS ECP listing, providers petitioning to be added to or removed from the HHS ECP list, or individuals explicitly authorized by the provider to submit the petition on behalf of the provider. CMS is not accepting petitions from unauthorized third-party entities, including insurance companies (i.e., issuers), advocacy groups, state Departments of Health, state-based provider associations, and providers other than the provider that is the subject of the petition. However, if any of the above entities owns or is the authorized legal representative of an ECP, it may submit a petition on behalf of a provider.

Requested Action

Select Add if you wish to be newly added to the HHS ECP List, including additional provider site locations. Affiliated practitioners located at same street location will appear only once on the ECP List, so please list the facility rather than individual practitioners located at same facility, indicating the number of qualified FTE practitioners available at the facility in questions 15 and 16. Solo practitioners may submit the petition under their individual provider location.

Select Change if you are a provider that already appears on the ECP List and you wish to change/update or add missing required data (e.g., NPI, POCs, FTEs) to your facility row. If you are unsure of whether you appear on the ECP List, click the button labeled “Check to see if you are on the list” and enter your site name using the search functionality to identify your ECP Reference Number. Note that the ECP Reference Number for each facility on the ECP list appears in column A titled “ECP Reference Number of the Excel spreadsheet, rather than referring to the electronic row number assigned by Excel.

Select Remove if you wish to be removed from the HHS ECP List. If you are requesting to be removed, please enter your ECP Reference Number in question 7 from the ECP List embedded within this petition by clicking the button labeled “Check to see if you are on the list” and enter your site name using the search functionality. Note that the ECP Reference Number for each facility on the ECP list appears in column A titled “ECP Reference Number of the Excel spreadsheet, rather than referring to the electronic row number assigned by Excel.

Please note that if you return to this question to revise your selection, any data that you have entered for questions 7-46 will be deleted.Check to see if you are on the list
If you are a provider that already appears on the ECP List published with this petition, please identify the correct ECP Reference Number on which your facility is listed by clicking the button labeled “Check to see if you are on the list” (available in question 6) and enter your site name using the search functionality. Note that the ECP Reference Number for each facility on the ECP list appears in column A titled “ECP Reference Number of the Excel spreadsheet, rather than referring to the electronic row number assigned by Excel. Enter your ECP Reference Number and click elsewhere on the screen, and the petition will auto-populate many of the data fields that currently appear on the ECP List. Please do not include commas or spaces in your ECP Reference Number, only numbers. Check that the auto-populated data from the ECP List are correct, correct any errors, and provide missing data fields (e.g., NPI, ECP Category, Site County, etc.) by proceeding through the petition. If the ECP Reference Number field does not appear, you have selected Add in question 6, indicating that you do not appear on the ECP List and are petitioning to be newly added to the list, so this ECP Reference Number field would not be applicable. Click here after entering ECP Reference Number
Select Yes to consent to be included on the HHS ECP List. Inclusion on the annually updated ECP list requires each provider to proactively review and refresh its data, as necessary, on an annual basis to ensure accuracy. If you do not yet appear on the HHS ECP list and do not consent to be added to the list for the purpose of receiving contract offers from Marketplace Qualified Health Plan Issuers, then you should not submit this provider petition. If you currently appear on the ECP List, selecting No for this question means that you should return to question 6 and select Remove to ensure that your data are removed from the HHS ECP list. If you are requesting to be removed, please enter your correct ECP Reference Number in question 7 from the ECP List embedded within this petition by clicking the button labeled “Check to see if you are on the list” and enter your site name using the search functionality. Note that the ECP Reference Number for each facility on the ECP list appears in column A titled “ECP Reference Number of the Excel spreadsheet, rather than referring to the electronic row number assigned by Excel.

Eligibility

Select Yes if you are one of the following types of providers: (1) eligible for or participating in the 340B program; (2) a Rural Health Clinic; (3) an Indian Health Care Provider; or (4) a State-owned family planning service site, governmental family planning service site, or not-for-profit family planning service site that does not receive Federal funding under special programs, including under Title X of the PHS Act or other 340B-qualifying funding. For a complete list of organizations that are eligible for the 340B program, see http://www.hrsa.gov/opa/eligibilityandregistration/index.html. Select No if you are not one of the following types of providers: (1) eligible for or participating in the 340B program; (2) a Rural Health Clinic; (3) an Indian Health Care Provider; or (4) a State-owned family planning service site, governmental family planning service site, or not-for-profit family planning service site that does not receive Federal funding under special programs, including under Title X of the PHS Act or other 340B-qualifying funding.
Select Yes only if you are located in a low-income ZIP code or Health Professional Shortage Area (HPSA), based on the HHS "Low-Income and HPSA ZIP Code Listings" available at https://www.qhpcertification.cms.gov/s/ECP%20and%20Network%20Adequacy. Selecting No to this question means that you do not qualify as an ECP for purposes of being added to the ECP list, unless you are one of the following types of providers: (1) eligible for or participating in the 340B program; (2) a Rural Health Clinic; (3) an Indian health care provider; or (4) a State-owned family planning service site, governmental family planning service site, or not-for-profit family planning service site that does not receive Federal funding under special programs, including under Title X of the PHS Act or other 340B-qualifying funding.
Select Yes only if you are willing to accept patients regardless of ability to pay and offer a sliding fee schedule.

Selecting No to this question means that you do not qualify as an ECP for purposes of being added to the ECP list, unless you are one of the following types of providers: (1) eligible for or participating in the 340B program; (2) a Rural Health Clinic; (3) an Indian health care provider; or (4) a State-owned family planning service site, governmental family planning service site, or not-for-profit family planning service site that does not receive Federal funding under special programs, including under Title X of the PHS Act or other 340B-qualifying funding.
Select Yes only if you are willing to accept patients regardless of coverage source (i.e., Medicare, Medicaid, CHIP, private health insurance, etc.). Selecting No to this question means that you do not qualify as an ECP for purposes of being added to the ECP list. If you already appear on the ECP List that was published with this petition, then you should return to question 6 and select Remove and then enter the correct ECP Reference Number in question 7 to ensure that your data are removed from the HHS ECP list. Your correct ECP Reference Number can be identified from the ECP List embedded within this petition by clicking the button labeled “Check to see if you are on the list” and enter your site name using the search functionality. Note that the ECP Reference Number for each facility on the ECP list appears in column A titled “ECP Reference Number of the Excel spreadsheet, rather than referring to the electronic row number assigned by Excel.
Select Yes only if you are willing to be listed in a consumer-facing directory of ECPs by an issuer with whom you have contracted to deliver health care services to their enrollees. CMS will continue to post the HHS ECP list on our publicly available website as a resource for QHP issuers, providers, and consumers seeking providers who are willing to serve low-income and medically underserved populations.

Selecting No to this question means that you do not qualify as an ECP for purposes of being added to the ECP list. If you already appear on the ECP List that was published with this petition, then you should return to question 6 and select Remove and then enter the correct ECP Reference Number in question 7 to ensure that your data are removed from the HHS ECP list. Your correct ECP Reference Number can be identified from the ECP List embedded within this petition by clicking the button labeled “Check to see if you are on the list” and enter your site name using the search functionality. Note that the ECP Reference Number for each facility on the ECP list appears in column A titled “ECP Reference Number of the Excel spreadsheet, rather than referring to the electronic row number assigned by Excel.
For inpatient hospitals, including children’s hospitals, please indicate the number of staffed hospital beds. If the facility is not an inpatient hospital or children’s inpatient hospital, please enter 0.
For inpatient hospitals, including children’s hospitals, please enter 0. For all other ECP categories, please enter number of FTEs representing MDs, DOs, PAs and NPs authorized by the State to independently treat and prescribe medication within the listed facility at this street location, as of the date of your petition submission. Two part-time practitioners can be counted as one FTE and fractional FTEs up to two decimal places can be reported (e.g., 0.75). Multiple affiliated MDs, DOs, PAs and NPs practicing within the same provider facility located at the same street location (regardless of different suite/floor number) will appear on one row on the HHS ECP List, so please list the facility and indicate number of affiliated FTE practitioners located at the facility rather than submitting a petition for each individual practitioner. Also, practitioners who practice within a multi-practitioner facility should not submit a petition under their individual practitioner NPI independent of the facility in which they practice; rather, only individuals authorized by the facility should submit the petition using the facility-level NPI and indicate the number of affiliated FTE practitioners practicing within the facility. Multi-practitioner facilities with multiple locations should submit a petition for each site location, entering the NPI associated with each of its facility-specific site locations, and indicating the number of affiliated FTE practitioners practicing only within the facility-specific site location. In contrast, solo practitioners may submit the petition under their individual practitioner NPI. If you have only dentists (DMDs and DDSs) at this facility, please enter zero in this field.
For inpatient hospitals, including children’s hospitals, please enter 0. For all other ECP categories, please enter number of FTEs representing DMDs and DDSs practicing at your facility at this street location, as of the date of your petition submission. Two part-time practitioners can be counted as one FTE and fractional FTEs up to two decimal places can be reported (e.g., 0.75). Multiple affiliated dentists practicing within the same provider facility located at the same street location (regardless of different suite number) will appear on one row on the HHS ECP List, so please list the facility and indicate number of affiliated FTE dentists located at the facility rather than submitting a petition for each individual dentist. Also, dentists who practice within a multi-practitioner facility should not submit a petition under their individual practitioner NPI independent of the facility in which they practice; rather, only individuals authorized by the facility should submit the petition using the facility-level NPI and indicate the number of affiliated FTE dentists practicing within the facility. Multi-practitioner facilities with multiple locations should submit a petition for each site location, entering the NPI associated with each of its facility-specific site locations, and indicating the number of affiliated FTE dentists practicing only within the facility-specific site location. In contrast, solo practitioners may submit the petition under their individual practitioner NPI. If you are have only medical practitioners (MDs, DOs, PAs and NPs) at this facility, please enter zero in this field.
Enter the number of contracts that you have currently executed with QHP insurance companies (i.e., issuers) that you expect to continue for the upcoming plan year.
Enter the number of contract offers that you have received from QHP issuers and were offered in good faith that you have rejected for the upcoming plan year, as of the date of your petition submission. As stated in the Final 2017 Letter to Issuers, a good faith contract should offer terms comparable to terms that it offers to a similarly-situated non-ECP provider, except for terms that would not be applicable to an ECP, such as by virtue of the type of services that an ECP provides. Collecting this information will assist CMS in better determining issuer compliance with the ECP requirements pertaining to the offering of contracts in good faith to qualified ECPs.

Provider Site Information

Enter the Provider Site Name at which you provide health care services to patients.
Enter the Organization Name that the insurance companies (i.e., issuers) would contact for purposes of contract negotiations.
Enter NPI in a 10-digit format (no hyphens). Affiliated practitioners who practice within a multi-practitioner facility should not submit a petition under their individual practitioner NPI; rather, only individuals authorized by the facility should submit the petition using the facility-level NPI, site name, and indicate the number of FTE practitioners practicing within the facility. In contrast, solo practitioners may submit the petition under their individual practitioner NPI.
22. ECP Category
(Select All that Apply) Select all categories that describe the health care services that you provide. For example, if the contracted provider is a Federally Qualified Health Center (FQHC) that is also a Ryan White HIV/AIDS provider, select both the FQHC and Ryan White Provider categories. However, if you are a dental provider and provide no non-dental medical services at your facility, please select only the “Dental Providers” ECP category or the “FQHC – Dental Services” ECP category (i.e., all of the non-dental ECP categories require the petitioner to enter the FTE counts in question 15 for medical practitioners at the respective facility and the MD, DO, NP, and PA counts would not be applicable to a dental provider). If HHS is unable to verify your provision of these services with our Federal partners, we may default your listing to the “Other ECP Providers” category until such verification can be made.
23. Which of these services, if any, do you provide to patients with opioid use disorder? (Select all that apply)
Enter the street address at which you provide health care services to patients. If an individual provider practices in the same group or company at the same street location with other affiliated providers, the facility should submit only one petition, indicating the number of qualified FTE practitioners available at the facility in questions 15 and 16.
Enter the suite number, floor number, or other secondary address information (associated with the same street location in Site Street Address Line 1) at which you provide health care services to patients. [Please do not enter a separate street location in this field if your facility offers multiple locations; instead, submit a separate petition for any additional practice sites.] If an individual provider practices in the same group or company at the same street location with other affiliated providers, the facility should submit only one petition, indicating the number of qualified FTE practitioners available at the facility in questions 15 and 16.
Enter the Site City in which you provide health care services to patients.
Enter the Site State in which you provide health care services to patients.
Enter the Site ZIP code in which you provide health care services to patients. Your ZIP code must be located within a low-income ZIP code or Health Professional Shortage Area (HPSA), based on the HHS "Low-Income and HPSA ZIP Code Listings" available at https://www.qhpcertification.cms.gov/s/ECP%20and%20Network%20Adequacy. You are exempt from this requirement if you are one of the following types of providers: (1) eligible for or participating in the 340B program; (2) a Rural Health Clinic; (3) an Indian health care provider; or (4) a State-owned family planning service site, governmental family planning service site, or not-for-profit family planning service site that does not receive Federal funding under special programs, including under Title X of the PHS Act or other 340B-qualifying funding.
Enter the Site County in which you provide health care services to patients. Site county information is used for purposes of insurance companies (i.e., issuers) meeting the requirement in the Federally-facilitated Marketplace to offer a contract in good faith to at least one ECP in each ECP category in each county in the service area.

Organization Information

Enter the Organization Street Address that the insurance companies (i.e., issuers) would use to contact you for purposes of contract negotiations.
Enter the secondary Organization Street Address (associated with the same street location in Org Street Address Line 1) that the insurance companies (i.e., issuers) would use to contact you for purposes of contract negotiations.
Enter the Organization City that the insurance companies (i.e., issuers) would use to contact you for purposes of contract negotiations.
Enter the Organization State that the insurance companies (i.e., issuers) would use to contact you for purposes of contract negotiations.
Enter the Organization ZIP code that the insurance companies (i.e., issuers) would use to contact you for purposes of contract negotiations.
Enter the Organization County that the insurance companies (i.e., issuers) would use to contact you for purposes of contract negotiations. Organization county information is not used for purposes of issuers meeting the requirement in the Federally-facilitated Marketplace to offer a contract in good faith to at least one ECP in each ECP category in each county in the service area. Instead, the Site County in question 29 is used for purposes of that ECP requirement.

Point of Contact (POC) 1 Information

Enter the Primary Point of Contact Name that the insurance companies (i.e., issuers) would use to contact you for purposes of contract negotiations.
Enter the Primary Point of Contact Title that the insurance companies (i.e., issuers) would use to contact you for purposes of contract negotiations.
Enter the Primary Point of Contact Phone # that the insurance companies (i.e., issuers) would use to contact you for purposes of contract negotiations.
Enter the Primary Point of Contact Phone Ext that the insurance companies (i.e., issuers) would use to contact you for purposes of contract negotiations.
Enter the Primary Point of Contact Email that the insurance companies (i.e., issuers) would use to contact you for purposes of contract negotiations.

Point of Contact (POC) 2 Information

Enter the Alternate Point of Contact Name that the insurance companies (i.e., issuers) would use to contact you for purposes of contract negotiations.
Enter the Alternate Point of Contact Title that the insurance companies (i.e., issuers) would use to contact you for purposes of contract negotiations.
Enter the Alternate Point of Contact Phone # that the insurance companies (i.e., issuers) would use to contact you for purposes of contract negotiations.
Enter the Alternate Point of Contact Phone Extension that the insurance companies (i.e., issuers) would use to contact you for purposes of contract negotiations.
Enter the Alternate Point of Contact Email that the insurance companies (i.e., issuers) would use to contact you for purposes of contract negotiations.

Provider Website URL Information

Enter the provider website that the insurance companies (i.e., issuers) can visit to learn more about the services you offer at your facility.
PRA Disclosure Statement:
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1295, expiration date is 12/31/2021. The time required to complete this information collection is estimated to take up to 60 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. This estimate does not include time for training. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.