Invalid switch from Affordable Care Act plans appear to have been tapered off in recent weeks based on a drop of almost one-third in casework associated with consumer complaints, said the federal regulator. The Centers for Medicare & Medicaid Services, which oversees the ACA, credits measures taken to prevent enrollment and switching problems that led to more than 274,000 complaints this year through August.
Now, in ACA opens enrollment annually the period that started November 1 presents a real world test: Will the changes prevent fraud by rogue agents or brokerages without unduly slowing down the enrolling process or reducing the total number of sign-ups for 2025 coverage?
“They really have this tightrope to walk,” said Sabrina Corlette, co-director of the Center for Health Insurance Reform at Georgetown University. “The more you tighten to prevent fraud, the more barriers there are to preventing enrollment among those who need coverage.”
CMS said in July that some types of policy changes — in which the agent is not “affiliated” with an existing plan — would face other requirements, such as three-way calls with consumers, brokers, and healthcare.gov calls. central representative.
In August, the agency banned two private-sector online enrollment platforms from linking to healthcare.gov because of concerns related to improper changes.
And CMS has suspended 850 agents suspected of illegally switching plans from accessing the ACA marketplace.
Still, the clampdown can add complexity to enrollment and slow down the process. For example, consumers may have to wait in line for a three-way phone call, or scramble to find a new agent because the one they worked with previously has been suspended.
Because the phone lines with healthcare.gov staff have been busy — especially in mid-December — agents and policy analysts are advising consumers not to bother this year.
“Get on the field,” said Ronnell Nolan, president and CEO of Health Agents for America, a professional organization for brokers.
Meanwhile, reports are emerging that some rogue entities have identified workarounds that could undermine some of the anti-fraud protections CMS has in place, Nolan said.
“The bottom line is: Fraud and abuse still happen,” Nolan said.
Brokers help the majority of people actively enroll in ACA plans and are paid monthly commissions by insurers for their efforts. Consumers can compare plans or enroll online through federal or state marketplace websites. They can also get help from people called assistants or navigators – certified helpers who are not paid a commission. Under the “find local help” button on the federal and state ACA websites, consumers can search for a broker or navigator near them.
CMS said it has “provided support operations” at the healthcare.gov marketplace call center, which is open 24/7, in anticipation of increased demand for three-way calls, and expects “minimum wait times,” said Jeff Wu, deputy director for policy at the CMS Center. for Consumer Information and Insurance Oversight.
Wu said a three-way call is only necessary when an agent or broker not yet associated with the consumer’s enrollment wants to change the consumer’s enrollment or terminate the consumer’s coverage. It does not apply to people who are seeking coverage for the first time.
Organizations paid by the government to offer navigator services have special phone lines for the federal market, and callers now don’t have to wait long, said Xonjenese Jacobs, director of Florida Covering Kids & Families, a program based at the University of South Florida that coordinates enrollment across the state through the navigator program. Covering Florida.
The navigator can assist with three-way calls if the consumer’s situation requires it.
“Because we have a fast line, there’s no waiting time,” Jacobs said.
The problem of illegal switching has been going on for some time but stopped when the registration season opened last year.
Brokers generally blame much of the problem on the ease with which rogue agents can access ACA information on the federal marketplace, requiring only a person’s name, date of birth, and state of residence. Although federal regulators have worked to tighten that access with three-way phone requirements, they have stopped short of enforcing what some agent groups say is necessary: ​​two-factor authentication, which can involve a code accessed by consumers via smartphone.
Unauthorized switching can cause many problems for consumers, from higher deductibles to landing in a new network that doesn’t include their preferred doctor or hospital. Some people have received tax bills when invalid policies come with premium credits that they do not qualify for.
The illegal switch caused political liability for the Biden administration, handicapping it for two years record ACA enrollment. The practice drew criticism from lawmakers on both sides of the aisle; Democrats are demanding more oversight and punishment of rogue agents, while Republicans say fraud efforts are fueled by the Biden administration’s more generous permitting moves. premium subsidy and special enrollment periods. The fate of the added subsidies, which are set to expire, will be decided by Congress next year as the Trump administration takes office. But the premiums and subsidies that come with the 2025 plan that people sign up for now will remain in effect for the rest of the year.
Actions taken this year to prevent unauthorized enrollment apply to the federal marketplace, used by 31 states. The remaining states and the District of Columbia run their own websites, with many having additional layers of security.
For its part, CMS says its efforts are working, showing a 30% drop in complaint cases. The agency also noted a 90% drop in the number of times agents’ names were changed to other names, which it said made it harder for competing agents to steal clients to earn the monthly commission paid by insurers.
However, the move to suspend 850 agents has drawn pushback from the group of agents that initially brought the issue to the attention of federal regulators. He said some of the accused were suspended before they had a chance to respond to the charges.
“There are some agents and brokers who will be suspended without due process,” said Nolan, with a group of health agents. He said that asking for higher protection against unauthorized switching and two-factor authentication, as used in some state markets or in the financial sector, would be more effective than what has been done.
“Now we have to jump through so many hoops that I’m not sure we’ll survive,” his agent said. “They’re just throwing things against the wall to see what sticks when they can only do two factors.”
The agency did not respond to questions requesting information on how the 850 agents suspended since July were selected, the country where they are located, or how many have had suspensions reversed after providing additional information.
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