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Feds: HHS exchange agent who fibs could owe $250,000 fine

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Want to lie about your age to a Patient Protection and Affordable Care Act (PPACA) public exchange, or help consumers jiggle their income to qualify for better premium subsidy tax credits?

Know that the cost of getting caught could be high.

The Center for Consumer Information & Insurance Oversight (CCIIO) — the agency that runs the PPACA exchange system for the U.S. Department of Health and Human Services (HHS) — has made a point of warning agents and brokers about the dangers of exchange fraud in a new draft document aimed at the insurers that might sell plans through the exchanges in 2016.

If adopted as written, the “draft letter to issuers” would apply directly to the insurers that sell qualified health plans (QHPs) through the exchanges managed by HHS. The letter could also influence the rules set by the states with state-based PPACA exchanges.

HHS issued similar letters for the 2014 plan year and the 2015 plan year.

In the new draft letter, CCIIO officials have added a more detailed list of the agreements producers need to execute when they register to sell QHP coverage for the HHS exchange issuers. 

CCIIO also has added a stern summary of the penalties for giving a public exchange inaccurate information.

“HHS may impose a civil money penalty of up to $25,000 for each application for failure to provide correct information to the marketplace, or for improper use or disclosure of consumer [personally identifiable information], where such failure is attributable to negligence or disregard of any HHS rules or regulations,” officials say. “HHS may impose a civil money penalty of up to $250,000 for knowingly and willfully providing false or fraudulent information to the marketplace.”

CCIIO officials also are continuing to include a requirement that producer agreements, and consumer marketing materials, state that each QHP “does not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation, or health status” — even though HHS officials themselves have repeatedly encouraged paid and volunteer exchange helpers to try to recruit more young adult applicants.

Managers of the HHS Small Business Health Options Program (SHOP) posted a slidedeck emphasizing that the HHS exchange system clearly warns business owners about the risks of giving brokers access to their SHOP accounts.

“Once you authorize a SHOP agent or broker to access your account, he or she will be able to see your business and employee information,” the site warns business owners. “For your privacy and security, confirm that your preferred agent or broker is licensed and in good standing with your state department of insurance before finalizing your authorization.”

Some observers said the warning was a simply a standard disclaimer, but Health Agents for America say one broker member has reported that a client ran into a negative attitude from a public exchange call center rep when she tried to help a broker get access to her account.

The call center rep reportedly told the broker’s client that insurance agents “are all about the money.”

The call center rep told the client, “You should be careful about any type of personal information that you give to your agent, and you need to make sure that your agent doesn’t have any control over your health care choices,” according to HAFA.


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