Scammers are already bypassing the new ACA fraud protections

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

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

That cancellation occurred after the federal government introduced a series of new rules and restrictions to prevent these types of incidents.

In one Channel 2 Action News investigationwe showed how hundreds of thousands of families have 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,” said Georgia insurance agent Callie Navrides.

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

CMS reported this in a statement Channel 2 consumer researcher Justin Gray: “From June 2024 through October 2024, CMS suspended the marketplace agreements of 850 agents and brokers due to reasonable suspicion of fraudulent or abusive conduct related to unauthorized enrollments or unauthorized subscription changes.”

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 conversation with the marketplace and the consumer before switching plans can exchange.

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But King wrote in her Oct. 15 statement that agents she had never heard of or communicated with had canceled her insurance.

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

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

Another possible way they can get around the new rules is if they have already been fraudulently linked to the account.

King said in her statement that she has reason to believe that the agents who canceled her insurance in October were “involved in other prior unauthorized changes to my health insurance.”

Channel 2 Action News has asked CMS for comment on this potential loophole, but has not yet heard back.

Attorney Jason Doss has filed a class action lawsuit on behalf of ACA clients, saying what happened to King shows that some agents are already finding ways to circumvent the new CMS protections.

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

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

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

Insurance Commissioner John King told Gray he has the power to criminally go after bad cops if they commit fraud in Georgia’s new market.

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