Common use of Qualification to Participate Clause in Contracts

Qualification to Participate. Participant and Preferred Provider shall participate in each ACO Program that qualifies for All Payer Model Scale Targets, for which a Program Addendum is provided within the time frames set forth in paragraph 3.1 (“Core ACO Programs”) and that is offered by a Payer for which Participant or Preferred Provider is an enrolled provider and in good standing, by signing an ACO Program Addendum for each such ACO Program. A Participant or Preferred Provider may, with ACO’s approval, choose not to participate in a Core ACO Program if: (1) it shows good cause as determined by the ACO Core Program Exceptions Policy; (2) it demonstrates to the Board’s reasonable satisfaction that the financial risk would jeopardize financial solvency thresholds established by Payer, ACO Program or the ACO; or (3) it demonstrates to the Board’s reasonable satisfaction that the operational demands would materially negatively impact its operations or there is no resource capacity to fully participate in the clinical and quality programs of ACO. Additionally, ACO may offer non-Core ACO Programs which Participant and Preferred Provider may choose not to participate in for any reason. Participants, Providers and Preferred Providers will maintain good standing to provide services with each ACO Program Payer for which it is enrolled and will remain duly licensed in good standing to practice their professions in each state in which they practice. Any Participant who is eligible to align or attribute lives may only participate in one ACO Program per Payer, for example if an eligible aligning Participant is in Medicare NextGen or Vermont Medicare ACO Initiative, it may not be in MSSP. Nothing in this Agreement supersedes any of the terms and conditions of Participant’s or Preferred Provider’s enrollment in a Payer’s insurance program unless the Payer’s requirements have been waived or modified in the Program Agreement between ACO and Payer. ACO, may, in its discretion, require additional reasonable verification of professional qualifications. Providers who are denied status as Participants or Preferred Providers, those who are not renewed for any reason and those who are terminated from OneCare will receive a written notice explaining the reason for denied status with instruction on how to appeal the decision to ACO, consistent with the ACO’s Appeals Policy.

Qualification to Participate. Participant and Preferred Provider shall participate in each ACO Program that qualifies for All Payer Model Scale Targets, for which a Program Addendum is provided within the time frames set forth in paragraph 3.1 (“Core ACO Programs”) and that is offered by a Payer for which Participant or Preferred Provider is an enrolled provider and in good standing, by signing an ACO Program Addendum for each such ACO Program. A Participant or Preferred Provider may, with ACO’s approval, choose not to participate in a Core ACO Program if: (1) it shows good cause as determined by the ACO Core Program Exceptions Policy; (2) it demonstrates to the Board’s reasonable satisfaction that the financial risk would jeopardize financial solvency thresholds established by Payer, ACO Program or the ACO; or (3) it demonstrates to the Board’s reasonable satisfaction that the operational demands would materially negatively impact its operations or there is no resource capacity to fully participate in the clinical and quality programs of ACO. Additionally, ACO may offer non-Core ACO Programs which Participant and Preferred Provider may choose not to participate in for any reason. Participants, Providers and Preferred Providers will maintain good standing to provide services with each ACO Program Payer for which it is enrolled and will remain duly licensed in good standing to practice their professions in each state in which they practice. Any Participant who is eligible to align or attribute lives may only participate in one ACO Program per Payer, for example if an eligible aligning Participant is in Medicare NextGen or Vermont Medicare ACO Initiative, it may not be in MSSP. Nothing in this Agreement supersedes any of the terms and conditions of Participant’s or Preferred Provider’s enrollment in a Payer’s insurance program unless the Payer’s requirements have been {B1876340.1 11080-0200} Page 4 of 16 OneCare Vermont FY 2022 ACO Budget Submission - Section 2, Attachment C 6 waived or modified in the Program Agreement between ACO and Payer. ACO, may, in its discretion, require additional reasonable verification of professional qualifications. Providers who are denied status as Participants or Preferred Providers, those who are not renewed for any reason and those who are terminated from OneCare will receive a written notice explaining the reason for denied status with instruction on how to appeal the decision to ACO, consistent with the ACO’s Appeals Policy.