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Life Health > Health Insurance > Your Practice Managers See Signs of Sham Plan Sales

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Agents may have enrolled some consumers in health coverage through for 2016 or 2017 without the consumers’ permission, according to officials at the Centers for Medicare and Medicaid Services.

Officials at CMS, the agency that runs, talk about the allegations in a webinar slidedeck posted July 31, and in a memo sent to plan issuers July 31. 

(Related: Trump’s Explains Enrollment Changes)

CMS is encouraging health insurers to review policyholder information, and to rescind any unwanted policies issued to consumers as a result of enrollments that appear to have been completed without the consumers’ authorization.

A rescission cancels an insurance policy sales and is supposed to restore both the insurer and the consumer to their original states, as if the policy had never existed. Basics

The drafters of the Affordable Care Act created the public health insurance exchange system to give consumers a web-based system for shopping for health coverage, and to administer the ACA premium tax credity subsidy and cost-sharing reduction subsidy programs.

The U.S. Department of Health and Human Services, the parent of CMS, created, to provide exchange plan enrollment and account administration services for residents of states that are unwilling or unable to handle the exchange management tasks themselves.

Shopping (Image: Thinkstock)

Shopping (Image: Thinkstock)

The suppliers of the plans are private insurers, such as Anthem Inc. and Kaiser Permanente, not government agencies.

The administration of President Donald Trump has been trying to change the Affordable Care Act, but, for now, Trump administration CMS officials appear to be running roughly the same way former President Barack Obama’s CMS team ran it.

Possible Signs of Unauthorized Enrollments

The CMS officials in charge of running say in the slidedeck that the call center has received “numerous calls” from consumers who reported that they were enrolled in exchange plan coverage for 2016 or 2017 without their permission.

The callers told that they learned they had exchange plan coverage only when they received notices about exchange plan coverage reporting problems from the Internal Revenue Service.

CMS officials say many of the callers share the following similarities:

  • The callers had health coverage from another source, such as an employer or Medicare.

  • The callers’ enrollments were effectuated by an agent or broker.

  • Income information on the callers’ applications was misstated in ways that maximized premium tax credit subsidy amounts and eliminated any need for monthly out-of-pocket premium payments.

  • Applications included incorrect data elements, such as incorrrect contact information.

Even though the consumers who reported being affected by the enrollments did not have to pay any premiums out of pocket while the coverage was in effect, they may now face tax bills and tax filing problems because of the unauthorized enrollments, officials say.

CMS is asking health insurers to go through a five-step review process to decide whether consumers asking for rescissions based on unauthorized enrollments should get the rescissions.

To qualify for a rescission through the process, a consumer cannot have filed any claim for any enrollee covered by the policy being questioned.

The first contacts the consumer had with the coverage issuer must be in connection with the consumer’s efforts to show that the consumer did not know about the coverage.

— Read Expects to Fire About 45 Agents Per Year on ThinkAdvisor.


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