Crooks are already bypassing new ACA fraud protections

ATLANTA — Some rogue insurance agents may already be finding ways around new protections the federal government put in place to prevent fraud on the Affordable Care Act Marketplace, Channel 2 Action News has learned.

“My health insurance was canceled. I am very confused and concerned because I did not authorize the cancellation,” wrote Georgia resident Veronica King in a signed legal declaration in October.

That cancellation took place after the federal government made a series of new rules and restrictions designed to prevent incidents like this.

In a Channel 2 Action News investigation, we showed how hundreds of thousands of families are having their health insurance switched or changed without their knowledge or consent.

“All they need is a first name, last name, date of birth, and state,” Georgia insurance agent Callie Navrides said.

The Center for Medicare and Medicaid Services has taken steps in recent months to address the fraud concerns.

In a statement, CMS told Channel 2 consumer investigator Justin Gray: “From June 2024 through October 2024, CMS suspended 850 agents’ and brokers’ Marketplace agreements for reasonable suspicion of fraudulent or abusive conduct related to unauthorized enrollments or unauthorized plan switches.”

CMS said new security steps include blocking agents and brokers from making changes unless they are already associated with the consumer’s account and requiring new agents to have a three-way call with the marketplace and the consumer before allowing them to switch a plan.

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But King wrote in her declaration on Oct. 15, that agents she never heard of or communicated with canceled her insurance.

“They are not my agents and have never been authorized to make changes to my health insurance,” King said in the declaration.

Navrides said she believes the criminal agents are having someone impersonate customers on the three-way calls to circumvent the new protections.

Another potential way they could be getting around the new rules is that they are already associated fraudulently with the account.

King said in her declaration that she has reason to believe the agents who canceled her insurance in October, “Were involved in other previous unauthorized changes to my health insurance.”

Channel 2 Action News requested a comment from CMS about that potential loophole but has not heard back.

Attorney Jason Doss filed a class action lawsuit on behalf of ACA customers and says what happened to King shows that some agents are already finding ways around the new CMS protections.

“Don’t switch the policy. Just cancel it and sell a new policy later or just enroll them in a new one. And you can bypass the three-way call requirement that CMS is trying to put in place to stop it,” Doss said.

CMS said new proposed rules for 2026 would give it even more authority to suspend agents and brokers suspected of wrongdoing.

Georgia is launching its own state-run marketplace for 2025, so Georgians will no longer use the federal marketplace where the rogue agents were primarily operating.

Insurance Commissioner John King told Gray that he has the power to go after bad agents criminally if they conduct fraud in the new Georgia marketplace.

But there could be many Georgians who were already victims in the federal marketplace this year and won’t know it until they get a surprise tax bill in January.

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