Common use of Fraud or Abuse Clause in Contracts

Fraud or Abuse. When the Enrollee provides fraudulent information on an Enrollment form or the Enrollee willfully misuses or permits another person to misuse the Enrollee’s ID card. 2.3.5.7.4.1. The STAR+PLUS MMP may submit a request that an Enrollee be involuntarily disenrolled if an Enrollee knowingly provides, on the election form, fraudulent information that materially affects the individual’s eligibility to enroll in the STAR+PLUS MMP’s plan; or if the Enrollee intentionally permits others to use their Enrollment card to obtain services under the STAR+PLUS MMP’s plan. 2.3.5.7.4.2. Prior to submission, the STAR+PLUS MMP must have and provide to CMS/HHSC credible evidence substantiating the allegation that the Enrollee knowingly provided fraudulent information or intentionally permitted others to use their card. 2.3.5.7.4.3. The STAR+PLUS MMP must immediately notify the CMT so that the Enrollment broker and the HHS Office of the Inspector General may initiate an investigation of the alleged Fraud and/or Abuse. 2.3.5.7.4.4. The STAR+PLUS MMP must provide notice to the Enrollee prior to submission of the request outlining the intent to request disenrollment with an explanation of the basis of the STAR+PLUS MMP’s decision and information on the Enrollee’s access to Grievance procedures and a Fair Hearing.