CMS Finalizes Plan on ESSENTIAL Community Providers

May 24, 2023 | Insights and Highlights

The Biden-Harris Administration has made expanding access to behavioral health care and as part of that effort, the proposed rule includes two new major essential community provider categories:  Substance Use Treatment Centers and Mental Health Facilities.  CMS is looking to expand access to behavioral health services by making mental health and substance use disorder treatment centers into Essential Community Providers (ECP).

This new rule, part of the Notice of Benefit and Payment Parameters for 2024, expands the current 35% provider participation threshold to federally qualified health centers (FQHCs) and family planning providers (FPPs).  FQHCs and FPPs are two of six types of providers designated as Essential Community Providers (ECPs).

The new rule affects the 14.5 million people who are enrolled in health plans through the marketplace, the bulk of whom are individuals who do not qualify for Medicare, Medicaid, or CHIP coverage. The final rule will also help expand access to care by extending the requirement for plans to contract with at least 35% of available ECPs in a plan’s service area to apply to two individual ECP categories: Federally Qualified Health Centers and Family Planning Providers.

The overall 35% threshold requirement also remains in place. These changes, in conjunction with other expanded Network Adequacy requirements in the final rule, increase provider choice, advance health equity, and expand access to care for consumers who have low incomes, complex or chronic health care conditions, or who reside in underserved areas, as these consumers are often disproportionately affected by unanticipated costs associated with out-of-network providers and limited access to providers.