FACT SHEET
Why the Affordable Care Act Matters for
Women: Access to Essential Community
Providers
OCTOBER 2015
The Affordable Care Act (ACA) is the greatest advance for women’s health in a generation.
Not only does the ACA provide more affordable, comprehensive health care options, but it
also helps ensure that women have access to key community health providers and
hospitals, known as essential community providers (ECPs).
Essential Community Providers and the Affordable Care
Act
ECPs play a critical role in delivering a variety of necessary health services to medically
underserved and lower-income individuals.1 These clinics and hospitals – family planning
clinics, sexually transmitted infection clinics and community health centers, among other
facilities – help guarantee that all women have access to appropriate local health care. The
ACA requires plans sold in the marketplace to contract with ECPs to help ensure that
women and men are able to access these community providers. The requirements take the
form of contracting standards, which direct health plans on how many ECPs they must
include as part of their networks.
General ECP Standard
The ACA requires all qualified health plans (QHPs) that use a provider network to include
a sufficient number and geographic distribution of ECPs in their networks, ensuring that
low-income people or those living in health professional shortage areas (HPSAs) have
reasonable, timely access to the providers they need.2 These health plans must also meet
the marketplace’s network adequacy standards.
In addition, under the federal standard for the 2016 plan year, QHPs sold through
HealthCare.gov are required to:
 Include in their networks at least 30 percent of ECPs in each plan’s service area;
 Offer good-faith contracts to all Indian health care providers in the service area; and
 Provide good-faith contracts to at least one ECP in each specified category in each
county in the service area, as long as an ECP in that category is available and provides
services by the insurer’s plan type.3
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(States that run their own marketplaces do not have to abide by these additional federal
rules and may establish their own specific guidelines for ECP contracting.4)
All HealthCare.gov QHPs must contract with specific categories of ECPs: Family planning
providers, federally qualified health centers, hospitals, Indian health care providers, Ryan
White providers (HIV/AIDS care providers) and other ECP providers (which may include
STD clinics, community mental health centers and others).5 Family planning clinics and
women’s health centers, in particular, are a very important part of the ECP network.
Family planning centers serve millions of people and provide essential health services.6 For
many women, these clinics are their only source of health care.
If a QHP sold through HealthCare.gov fails to meet the general ECP standard, it must
provide a written justification describing (1) how its network provides an adequate level of
services for low-income enrollees and enrollees living in HPSAs, and (2) how the plan will
strengthen its provider network toward meeting the ECP standard before the beginning of
the next benefit year.7
Alternative ECP Standard
In addition to the general ECP standard, there is also an alternative ECP standard for
certain types of QHPs. QHP issuers that provide most covered services through physicians
employed by the insurance company or a single contracted medical group (integrated
delivery systems) are most likely to use the alternative ECP standard. They must have a
sufficient number and geographic distribution of providers and hospitals to make sure that
low-income individuals or people living in HPSAs have reasonable, timely access to
services.8 They must also meet the marketplace’s network adequacy standards.
In addition, under the alternative federal standard for the 2016 plan year, QHPs sold
through HealthCare.gov are required to show that:
 Looking at the issuer’s employed or contracted providers that are located in HPSAs of
low-income zip codes (zip codes where 30 percent or more of residents fall below 200
percent of the federal poverty level), the plan includes in its network at least 30 percent
of its employed or contracted providers located in a HPSA or low-income zip code in the
plan’s service area (where multiple providers at a single location count as one ECP);9
and
 The integrated delivery system provides access to all categories of services provided by
entities in each of the ECP categories in each county in the plan’s service area. For
example, the delivery system has to provide family planning services as well as
HIV/AIDS services. Alternatively, if the issuer cannot show it provides all categories of
services within its integrated delivery system, it must offer a contract to at least one
ECP in each ECP category in each county in the plan’s service area to provide required
services.10
(Again, states that run their own marketplaces do not have to abide by these
additional requirements and may establish their own specific guidelines.11)
As with the general ECP standard, HealthCare.gov QHPs that opt for the alternative ECP
standard but fail to meet its requirements must provide a written justification describing
(1) how its network provides an adequate level of services for low-income enrollees and
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enrollees living in HPSAs, and (2) how the plan will strengthen its provider network toward
meeting the ECP standard before the beginning of the next benefit year.12
These standards are essential to ensuring that everyone receives timely and appropriate
health care services. Requiring QHPs to contract with ECPs establishes critical protections
for the insured by facilitating patient access to local, community-based primary and
preventive care.
1 The Henry J. Kaiser Family Foundation. (2015 January). Federal and State Standards for “Essential Community Providers” under the ACA and Implications for Women’s Health.
Retrieved 9 October 2015, from: http://kff.org/womens-health-policy/issue-brief/federal-and-state-standards-for-essential-community-providers-under-the-aca-andimplications-for-womens-health/
2 Dept. of Health and Human Services. (2015 February). Patient Protection and Affordable Care Act; HHS Notice of Benefit and Payment Parameters for 2016. Retrieved 9 October
2015, from https://www.federalregister.gov/articles/2015/02/27/2015-03751/patient-protection-and-affordable-care-act-hhs-notice-of-benefit-and-payment-parameters-for2016
3 Dept. of Health & Human Services, Centers for Medicare & Medicaid Services. (2015 February). FINAL 2016 Letter to Issuers in the Federally-facilitated Marketplaces. Retrieved 9
October 2015, from https://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/2016-Letter-to-Issuers-2-20-2015-R.pdf
4 See note 1.
5 See note 3.
6 Dept. of Health and Human Services, Office of Population Affairs. Title X Family Planning. Retrieved 9 October 2015, from http://www.hhs.gov/opa/title-x-family-planning/
7 See note 2.
8 See note 2.
9 See note 2.
10 See note 2.
11 See note 1.
12 See note 2.
The National Partnership for Women & Families is a nonprofit, nonpartisan advocacy group dedicated to promoting fairness in the workplace, access to quality health care and
policies that help women and men meet the dual demands of work and family. More information is available at www.NationalPartnership.org.
© 2015 National Partnership for Women & Families. All rights reserved.
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