CMS clamps down on unauthorized Marketplace activity

Answering a complaint that’s been sucking up lots of oxygen in Marketplace discussions, CMS is now limiting health insurance agents’ abilities to adjust consumers’ applications. The move is meant to combat an alarming trend where bad actors on the Marketplace would fraudulently change the broker of record and/or an enrollee’s plan – compromising both agent compensation and consumer coverage.

Generally speaking, the scam involves brokers using a loophole in some Enhanced Direct Enrollment pathways (outside of healthcare.gov) to access Marketplace applications. With a consumer’s name, address, and other info in hand, the broker would make unauthorized changes to the application. These changes give the broker credit for the application and would dump consumers in plans that may not cover the drugs, doctors, or treatments they need.

Since July 19, CMS has been blocking agents or brokers from changing Marketplace enrollments unless the agent is already associated with that enrollment.

Agents not associated with the enrollment must take new steps to update the Marketplace application – even if they have collected the consumer’s consent. The new agent will be required to conduct a three-way call with the consumer and the Marketplace Call Center, or to direct the consumer to submit changes themselves. Those changes can be submitted via Healthcare.gov or other Classic Direct Enrollment or Enhanced Direct Enrollment pathways (e.g. – HealthSherpa).

If one of your clients thinks their plan may have been changed without their knowledge, they should contact the Marketplace immediately. CMS has published a helpful flyer in both English and Spanish to help.

And, be sure you stay compliant, too.

Remember, you must get consent from each consumer you help with a Marketplace enrollment. Spouses and those with dependents may give consent for others in their household. This consent is valid until the consumer withdraws it, or until a date you specify in your documentation. CMS does not prescribe a form for collecting that consent, but we’ve crafted a fillable sample for you here.

And, when you assist consumers with changing information on their application, you must document that they have reviewed and understand those changes. Plan enrollments aren’t the only time you must collect this – you’re on the hook for collecting documentation after updating demographics, income, and other Marketplace information, too. Again, CMS does not mandate a particular form, but we’ve also made a fillable template for this purpose.

If you’ve got questions about Marketplace compliance, or need consent and review forms customized for your agency, just drop us a line. We’re here to help.