With the rise of fraud and scams surrounding the health insurance industry, Health Agents for America (HAFA) has created this reporting form and compiled this free guide for all agents and consumers regarding what actions to take when fraud, scams or deceptive marketing practices have impacted a member’s health insurance policy through the Health Insurance Marketplace or other state-based exchanges. In aligning with the core principles of HAFA, we strive to keep our industry an ethical, professional and trusted resource for consumers seeking health insurance services. It is important for agents and consumers alike to be vigilant regarding suspicious activity affecting their Marketplace application, and take proper action when necessary.
Health Agents for America, Inc. “HAFA” was formed in November 2012 to answer a need for Independent Health Agents to provide exclusive representation, in order to address matters such as commissions, the ACA and our inclusion in the Marketplace(s). If you appreciate our efforts and want to offer support or join our cause, please consider becoming a member HERE! You will have access to many more resources and important legislative updates affecting our industry now and in the future.
STEP 1: Confirm with the consumer they have not worked with a different agent. This includes submitting their information on any online form. Before submitting a fraud complaint, you should verify that the other agent did not get proper authorization from the consumer. Agents are required to document consent prior to working with a client or accessing their application, AND also document that the consumer has reviewed and confirmed their application information is accurate (45 C.F.R § 155.220(j)(2)(ii)(A)(1)-(2)). Read about the current rules and regulations in the 2022 Understanding Marketplace Compliance Rules & Regulations slides and the 2023 Understanding Key CMS Rules and Regulations to Maintain Marketplace Compliance slides.
STEP 2: Revoke Access in Writing. Once you have the AOR name/NPN of the other agent, you can find their license and/or contact information by using Licensee Look Up tools such as State Based Systems or Florida Licensee Search, for example. We recommend that the consumer sends a written request to the other party that formally revokes any further access to their application(s) on the Marketplace, and demands that all of their contact information be deleted from their systems.
STEP 3: Inform the Marketplace Call Center. CMS requests that agents/brokers conduct a 3-way call with the consumer and the Marketplace Call Center at 1-800-318-2596 to report the unauthorized changes.
STEP 4: File A Report. If the above steps reveal that another agent has worked on the consumer’s application without their consent, please complete the form provided below. Once this form is submitted, a copy of your responses will be automatically emailed to CMS, HealthSherpa and your State’s DOI. Please do not include any PII or PHI in your report. Use identifiers such as application numbers or NPNs instead.
STEP 5: Build a Case. This information needs to be compiled and filed with the State Fraud Department in which the fraud case occurred.
Steps to Filing Fraud with Your State Department of Fraud
- Provide a Copy of the Initial Applications: Ensure you include the original application documents that were submitted for the insurance policy.
- Include Copies of Each Supplement Application/Change: Submit all supplementary applications or any changes made to the initial application.
- Provide a History of Changes Made to the Consumer’s Policy: Detail the changes made to the policy over time, highlighting any suspicious or unauthorized modifications.
- Provide Consumer Information: In the absence of the above documents, include the consumer’s names, telephone numbers, addresses, email addresses, etc. It would be beneficial to have a formal letter from each consumer affected, detailing their experience.
- Submit Recorded Conversations: Provide any recorded conversations between the insured and the producer or any other relevant parties.
- Provide Correspondence from Insureds: Include any correspondence from the insureds indicating that they did not agree to the suspected fraudulent policies.
- Explain Access to Insured’s Information: Provide a detailed explanation of how someone could access and change an insured’s information in the marketplace. Outline the methods through which this information was likely obtained.
- Complete and Notarize an Affidavit: Have both the consumer and the agent sign and notarize an affidavit detailing the fraudulent activity and confirming that the information provided is accurate and truthful.
- Download Affidavit for Agent
- Download Affidavit for Consumer
By following these steps, you will help the State Department of Fraud “The State Department of Fraud build a robust case against fraudulent activities.
The contents of this webpage are for informational purposes only and are not meant to be nor should be construed to be legal advice by HAFA as well as any of its employees, volunteers or members. If you require legal advice, please contact your legal counsel.