Anti-fraud efforts are being tested in the real world during the ACA enrollment period

Unauthorized switching of Affordable Care Act plans appears to have declined in recent weeks, based on a nearly one-third drop in consumer complaint cases, say federal regulators. The Centers for Medicare and Medicaid Services, which oversees the ACA, touts steps taken to prevent enrollment and transition problems that caused more than 274,000 complaints this year through August.

Now, the ACA’s annual open enrollment period, which began Nov. 1, presents the real test: Can the changes curb fraud by rogue agents or brokerages without unduly slowing the enrollment process or reducing the total number of enrollments for coverage in 2025?

“They really have to walk a tightrope,” said Sabrina Corlett, co-director of Georgetown University’s Center for Health Insurance Reform. “The more you tighten it to prevent fraud, the more barriers you create that can prevent enrollment among those who need coverage.”

In July, CMS announced that certain types of policy changes — those in which the agent is not “affiliated” with an existing plan — face greater requirements, such as a three-way call with the consumer, a broker and a call with Healthcare.gov. representative of the center.

In August, the agency named after banned two out of about a dozen private sectors online enrollment platforms from linking to healthcare.gov due to mis-transition concerns.

In addition, CMS suspended access to the ACA marketplace for 850 agents suspected of engaging in unauthorized plan switching.

However, restrictions can make registration difficult and slow down the process. For example, a consumer may have to wait in line for a three-way call or try to find a new agent because the one they used to work with has been suspended.

With healthcare.gov’s staffed phone lines already busy — especially in mid-December — agents and policy analysts are advising consumers not to delay this year.

“Get started,” said Ronnell Nolan, president and CEO of Health Agents for America, a professional organization for brokers.

Meanwhile, there are reports that some fraudulent organizations are already finding workarounds that can undermine some of the anti-fraud protections CMS has in place, Nolan said.

“The bottom line is that fraud and abuse are still happening,” Nolan said.

Brokers help most people actively enroll in ACA plans, and insurers receive a monthly commission for their efforts. Consumers can compare plans or enroll online through federal or state marketplace websites. They can also ask for help from people called assistants or navigators—certified assistants who don’t get paid a commission. Under the “find local help” button on the federal and state ACA websitesconsumers can search for the nearest brokers or navigators.

CMS says it has “expanded support operations” at its 24/7 Healthcare.gov Marketplace call centers in anticipation of increased demand for three-way calls, and expects “minimum wait times,” said Jeff Wu, deputy director of policy issues of the Center for Consumer Information and Insurance Supervision CMS.

Wu said these three-way calls are only necessary when an agent or broker not already associated with a consumer’s enrollment wants to change that consumer’s enrollment or end that consumer’s coverage. This does not apply to people looking for coverage for the first time.

Organizations paid by the government to provide navigation services have a dedicated phone line to reach the federal marketplace, and callers currently don’t have long waits, said Xongenes Jacobs, director of Florida Covering Kids & Families, a program based at the University of South Florida that coordinates enrollment. statewide through its Covering Florida navigation program.

Navigators can help with three-way calls if the consumer’s situation requires it.

“Because we have a fast line, the wait time doesn’t increase,” Jacobs said.

The problem of unauthorized switches has been around for a while, but it came to a head during last year’s open enrollment season.

Brokers tended to blame this for much of the problem about the ease with which fraudulent agents can access ACA information in the federal marketplace, requiring only an individual’s name, date of birth, and country of residence. While federal regulators have worked to strengthen that access with a three-way call requirement, they have not implemented what some agent groups say is necessary: two-factor authentication, which could include a code that the consumer accesses through a smartphone.

Unauthorized switching can lead to a host of problems for consumers, from higher deductibles to ending up in new networks that don’t include their favorite doctors or hospitals. Some people received tax bills when unauthorized policies came with premium credits they weren’t entitled to.

The unauthorized switches were a political liability for the Biden administration, a blot on two years of record ACA enrollment. The practice drew criticism from lawmakers on both sides of the aisle; Democrats demanded more control and punishment scammers, while Republicans claimed fraud the effort was fueled by moves by the Biden administration to allow generous premium subsidies and special enrollment periods. The fate of those increased, expiring subsidies will be decided by Congress next year when the Trump administration takes office. But the premiums and subsidies that come with 2025 plans that people are signing up for now will remain in place throughout the year.

Measures taken this year to prevent unauthorized registrations apply to the federal market, used by 31 states. The rest of the states and the District of Columbia have their own websites, many of which have additional layers of security.

For its part, CMS says its efforts are working, citing a 30 percent drop in complaints. The agency also noted a 90% drop in the number of times an agent’s name was changed to something else, which it said indicates that it’s harder for rival agents to steal customers to collect the monthly commission paid by insurers.

Still, the decision to suspend 850 agents drew backlash from agent groups, which initially drew attention to the problem from federal regulators. They say some of the accused were suspended before they had a chance to answer the charges.

“There will be a number of agents and brokers who will be suspended without due process,” said Nolan of the Health Agents Group. She said this requires stronger protections against unauthorized switching and that two-factor authentication, similar to that used in some government markets or the financial sector, would be more effective than what has been done.

“We have so many hoops to jump through right now that I’m not sure we’re going to survive,” she said of agents in general. “They’re just throwing things against the wall to see what sticks when they could just do a two-factor.”

The agency did not respond to questions about details of how the 850 agents suspended since July were selected, the states they were in, or how many had their suspensions lifted after more information was provided.

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