The Centers for Medicare & Medicare Services (CMS) on Monday revealed the extent of consumer complaints about agent and broker fraudulent behavior and the actions it is taking to resolve the issues and crackdown on “bad actors” in the marketplace.
CMS said it received approximately 40,000 complaints of unauthorized plan switches and 50,000 complaints of unauthorized enrollments in the Affordable Care Act (ACA) marketplace in the first three months of 2024. The incidents involve consumers being switched from their selected ACA plan into a new one or signed up for coverage without their knowledge or consent.
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Roughly 39,000 (more than 97 percent) of the complaints of unauthorized plan switches have been resolved, according to the federal agency’s announcement. CMS said it resolved the cases through a combination of verification that the switch was unauthorized, reinstatement of enrollment to the correct plan, reimbursement by the insurer of any claims-related costs, and providing updated tax forms and information to consumers and the Internal Revenue Service.
CMS is still working to resolve approximately 1,000 unauthorized plan switch cases. It has taken up to 20 calendar days to resolve the complaints but to expediate the turn-around time, CMS has accelerated the review of complaints and is currently resolving cases in fewer than 11 calendar days.
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The agency has resolved approximately 44,000 (88 percent) of the unauthorized enrollment complaints. About 6,500 unauthorized enrollment cases are still pending resolution. The overall resolution time for an unauthorized enrollment case from January to March was approximately 27 calendar days. CMS said it aims to shorten the resolution time for the complaints.
Meanwhile, the agency said it will accelerate review and resolution for all new complaints related to unauthorized plan switches and enrollments.
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CMS staff are also focused on stopping “bad actors in the marketplaces. They are accelerating monitoring and oversight of agents and brokers and are working with state and insurer partners. Specifically, CMS is ramping up its review of alleged fraudulent or abusive conduct and issuing suspensions and terminations of these agents’ and brokers’ marketplace agreements with the Department of Health and Human Services when appropriate, barring them from being able to enroll consumers in HealthCare.gov coverage and insurance affordability programs.
CMS also plans to add new technological protections to prevent these unauthorized activities from occurring in the future. It also is considering imposing civil monetary penalties on agents and brokers who commit fraudulent or abusive conduct.