CMS restricts broker access to Healthcare.gov

Photo: Mo Mo Productions/Getty Images

In response to a wave of consumer complaints, the Centers for Medicare and Medicaid Services has put in place rigid restrictions meant to prevent insurance brokers from switching consumers' Affordable Care Act plans without their permission.

Starting late last week, CMS said it will now block an agent or broker from making changes to a consumer's Federally-facilitated Marketplace (FFM) enrollment unless the agent is already associated with the consumer's enrollment.

Previously, CMS had worked to suspend and terminate agents and brokers who perform unauthorized Marketplace activity.

An agent or broker who is not already associated with a consumer's enrollment will now have to take additional steps to update a consumer's marketplace enrollment, even with their consent, CMS said. 

Unassociated, or "new," agents and brokers will be required to conduct a three-way call with the consumer and the Marketplace Call Center, or to direct the consumer to submit the change themselves through HealthCare.gov or via an approved Classic Direct Enrollment or Enhanced Direct Enrollment partner website with a consumer pathway.

CMS anticipates these updates will help block unauthorized changes by agents and brokers to FFM enrollments, and said it would continue to monitor any malicious activity and take appropriate action against those engaged in misconduct.

WHAT'S THE IMPACT?

In the first six months of the year, CMS received 73,884 complaints of situations in which a consumer alleged that their plan was changed without their consent; the agency said it has resolved 72,381, or 97.97%, of these complaints.

It added that it continues to work on resolving the remaining cases of unauthorized plan switches within approximately 18 calendar days for complaints that were received between January and June of this year.  

CMS also received 134,368 complaints of situations in which a consumer alleged that they were enrolled without their consent in the first six months of 2024; 130,187 of these cases, or 96.89%, have been resolved.

About 4,181 unauthorized enrollment cases are still pending resolution. The overall resolution time for an unauthorized enrollment case received between January and June was 53 calendar days.

AGENT SUSPENSIONS

Between June 21 and July 10, CMS issued 200 suspensions of agent or broker Marketplace Agreements for reasonable suspicion of fraud or abusive conduct related to unauthorized enrollments or unauthorized plan switching.

When an agent or broker's Marketplace Agreement is suspended, they're prohibited from participating in the marketplace enrollment process and, as such, from receiving commission payments for enrollments through the Marketplace.

THE LARGER TREND

Also this month, CMS began social media outreach to warn marketplace consumers about potentially fraudulent activity by agents and brokers and misleading marketing sites.

Consumers who believe they may have been the victim of unauthorized agent or broker activity should call the Marketplace Call Center at 1-800-318-2596.
 

Jeff Lagasse is editor of Healthcare Finance News.
Email: jlagasse@himss.org
Healthcare Finance News is a HIMSS Media publication.