BIP Summer 2024

Industry Innovation

CMS addresses unauthorized Marketplace activity By Dean Mohs

The Centers for Medicare & Medicaid Services (CMS) is concerned about activity by some agents and brokers who assist consumers in the Marketplaces that use HealthCare.gov related to unauthorized plan switches and unauthorized enrollments. Health insurance agents and brokers have also reported to CMS that their national producer number (NPN) is being updated without consent. This is done to take the agents’ or brokers’ commissions. These actions disrupt consumers’ access to care and impact the livelihoods of agents and brokers complying with CMS rules. CMS is acting swiftly to protect consumers and root out bad actors. Agents and brokers have always been required to obtain consumer consent before submitting a Marketplace eligibility application or updating a client’s coverage. In 2023, CMS finalized regulations requiring agents and brokers to document consumer consent and application accuracy before assisting a consumer with enrollment or applying for insurance affordability programs through the Marketplaces. The consent documentation requirements must be satisfied before an agent or broker can search for a consumer’s eligibility application, update information,

or submit an enrollment with a plan selection or change on behalf of a consumer. As a reminder, agents and brokers must be prepared to submit documentation to CMS on request or risk having their Marketplace privileges suspended

or revoked and may be subject to additional compliance actions. CMS is working closely with Marketplace issuers, State Departments of Insurance, and law enforcement so that those who violate CMS rules face consequences. CMS also

CMS is evaluating all regulatory, operational, and technological options to prevent unauthorized activity. CMS’



technical teams are working to implement additional system

controls to block

unauthorized or fraudulent Marketplace activity.

10 bip magazine Summer 2024