Local Health Departments as Essential Community Providers for Health Benefits Exchange Plans

摘要

The Affordable Care Act requires health plans’ networks to include “essential community providers” (ECPs). Local health departments (LHDs) can be ECPs, typically for tuberculosis and sexually transmitted disease–related services or family planning. An ECP status may be controversial if it jeopardizes core population health services or competes with community partners. Some LHDs already bill for ECP services, but independent billing functions could exceed projected revenue. Thus, LHDs may wish to investigate contractual arrangements as alternatives to billing multiple issuers. The Affordable Care Act requires health plan issuers to include some essential community providers (ECPs) in their networks to qualify for participation in health benefit exchanges. Essential community providers are entities that help meet the needs of historically underserved areas and populations 1 ; the classification includes federally qualified health centers, critical access hospitals, Ryan White grantees for HIV/AIDS services, and entities that provide services related to tuberculosis and sexually transmitted diseases (STDs), among others. Qualified health plans are required to contract with at least 20% of the ECPs in their service areas and with at least 1 in each service category, or document that doing so is not feasible. 2 The rationale for requiring inclusion of ECPs is to ensure continuity of service for newly insured individuals who had received services from ECPs, and to support the health care safety net after Affordable Care Act implementation increases access to third-party coverage. 2 The following brief review points to opportunities, challenges, and controversies that the ECP option raises for local health departments (LHDs).