Common use of Material Modification of Provider Clause in Contracts

Material Modification of Provider. Network means 1) a change that would result in an Enrollee having only three remaining choices of a Primary Care Provider within thirty (30) miles or thirty (30) minutes; 2) a change that results in the discontinuation of a Primary Care Provider who is responsible for Primary Care for one third (1/3) or more of the Enrollees in the applicable area (the same area from which the affected Enrollee chose their Primary Care Provider or sole source Provider, prior to the Material Modification); 3) a change that involves a termination of a sole source Provider where the termination is for cause. Such changes include both Medicare and Medicaid Providers, and pharmacy benefit managers as applicable, or 4) loss of the contractual agreement with a major subcontractor providing a network of providers, including but not limited to the MCO’s dental or behavioral health network, pharmacy benefit manager, care systems and care coordination entities. For purposes of this section, termination of a Provider for cause does not include the inability to reach agreement on contract terms.

Material Modification of Provider. Network means 1) a change that would result in an Enrollee having only three remaining choices of a Primary Care Provider within thirty (30) miles or thirty (30) minutes; 2) a change that results in the discontinuation of a Primary Care Provider who is responsible for Primary Care for one third (1/3) or more of the Enrollees in the applicable area (the same area from which the affected Enrollee chose their Primary Care Provider or sole source Provider, prior to the Material Modification); 3) a change that involves a termination of a sole source Provider where the termination is for cause. Such changes include both Medicare and Medicaid Providers, and pharmacy benefit managers as applicable, or 4) loss of the contractual agreement with a major subcontractor providing a network of providers, including but not limited to the MCO’s dental or behavioral health network, pharmacy benefit manager, care systems and care coordination entities. For purposes of this section, termination of a Provider for cause does not include the inability to reach agreement on contract terms.terms.‌