Did You Know: Marketplace Health Insurance Agent Fraud

March 14, 2024by HPCNEF Staff0

The Affordable Care Act (ACA), signed into law in 2010, is the name for the comprehensive health care reform law and its amendments. The law addresses health insurance coverage, health care costs, and preventive care. Consumers can enroll in health insurance plans through the ACA Marketplace on HealthCare.gov.

What is insurance agent fraud?

Fraud happens when an insurance agent enrolls someone in an insurance plan without their knowledge or gives them misleading information in order to make a sale. They may also make unauthorized changes to your plan.

Why does agent fraud occur?

Insurance brokers and agents are paid large commissions on health insurance plans. Currently, there’s little policing or penalizing of this practice. Since people are earning a lot of money from it, fraud happens more often.

What should I do if I think I am a victim?

Contact your local ACA Navigator. Navigators are not insurance agents. We play a vital role in helping consumers prepare applications to establish eligibility and enroll in coverage through the Marketplace and potentially qualify for insurance affordability programs. Navigators will help you to report insurance agent fraud.

How will it be resolved?
At our first meeting, we will
  • Call the Marketplace together
  • Verify your phone number
  • Verbally register a complaint about agent fraud
  • File an appeal to remedy the tax issue
Complex Case filing

Your Navigator will then file a complex case online and may need some information from you.

Expect a phone call

You must be available for a phone interview from the Centers for Medicare and Medicaid (CMS). They will make three attempted calls. After the third call, if you don’t respond, your case will be closed.

Download: Insurance Agent Fraud Handout (English & Spanish)


If you need help or have questions, contact your local HPCNEF Navigators for free!


The project described was supported by Funding Opportunity Number NAVCA210430-03-00 from the U.S. Department of Health & Human Services, Centers for Medicare & Medicaid Services. The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.




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