Concerns Regarding Unauthorized Marketplace Qualified Health Plan Change
Published June 19, 2024

Concerns Regarding Unauthorized Marketplace Qualified Health Plan Change

Please share this alert with members of your Financial Services team, including registration, insurance verification, and financial counseling. PYA is concerned that providers, both hospitals and physician practices, could be left without payment for services due to unauthorized activity on the part of some Marketplace agents and brokers.

A number of patients and providers across the country have raised concerns regarding individuals who have been unknowingly “switched” by some agents and brokers from their selected qualified health plan (QHP) to a new plan or signed up for coverage without the enrollee’s knowledge or consent. Hospitals and other providers are seeing the impact of these unauthorized transfers/new enrollments as patients present for services with extremely high out-of-pocket costs that they are unable to pay. Some providers have reported Medicaid enrollees being enrolled in a QHP, without the knowledge of the patient and resulting in Medicaid becoming the secondary payer. In other instances, patients are denied non-emergency care or denied a prescription refill by their established provider who is not a contracted provider with the new plan.

The Centers for Medicare & Medicaid Services (CMS) is aware of the issue and originally stated in a May 6, 2024, press release that CMS had received approximately 40,000 complaints of unauthorized plan transfers in the first three months of 2024. The agency also stated approximately 97% of the complaints had been resolved. CMS noted the complaints were resolved through the following actions:

  • CMS reviewed the complaint to verify the consumer’s plan switch was unauthorized and identified the plan selected by the consumer.
  • CMS instructed the issuer offering the consumer’s selected plan to reinstate the consumer’s enrollment in that plan as if it had not been terminated. The insurer is instructed to cover all eligible claims incurred and required to accumulate all cost-sharing amounts toward applicable deductibles and annual
  • Consumers and the Internal Revenue Service (IRS) received updated tax forms and information to prevent adverse tax implications because of the unauthorized plan switch activity. 

Most of the patients impacted by these abusive practices are not aware of the issue until they seek care, making the initial complaints only the tip of the iceberg. Some patients owe the IRS, at least until the issue is resolved, for premium tax credits paid to the insurers on their behalf.

In its May press release, CMS urged consumers who believe they have been the victim of an unauthorized agent or broker to call the Marketplace Call Center at (800) 318-2596 for resolution of any coverage issues.

If you have specific questions regarding issues impacting the revenue cycle and managed care, our executives are happy to assist.

Executive Contacts

Interested in Learning More?

Sign Up for Our Latest Thought Leadership!

    Select Your Subscriptions