CMS Introduces Integrity-Focused Actions to Protect Consumers in Exchange Programs

The Centers for Medicare and Medicaid Services (CMS) has really stepped up enforcement and monitoring activities to safeguard consumers against unauthorized enrollments in health plans and further enhance the integrity of the Affordable Care Act (ACA) Exchanges. These measures, as reported in a new CMS fact sheet, have already led to almost $10 billion of annualized savings and a significant reduction of fraudulent and improper enrollment activity on the Federally-facilitated Exchange (FFE) platform.

During the last year, CMS used all its statutory and regulatory authority to deal with unauthorized enrollments, inappropriate switching of plans, and ineligible receipt of advance premium tax credit (APTC). As part of these, CMS terminated premium subsidies for almost 1.5 million individuals who were discovered to be ineligible to receive financial assistance or signed up without their approval.

Over one million of them were both enrolled in Medicaid or the Children's Health Insurance Program (CHIP) and receiving Exchange subsidies, or did not file and reconcile previously-received tax credits.

Moreover, CMS suspended the coverage of about 250,000 consumers who enrolled in Exchange plans without permission, enabling the agency to reclaim unnecessary federal subsidies. According to CMS, all these actions produced nearly 10 billion dollars in savings on an annualized basis.

Program Integrity Measures

CMS provided several initiatives that would protect consumers and taxpayer funds:

Marketplace Integrity and Affordability Final Rule (June 25, 2025):

CMS finalized regulations to reduce incentives for improper enrollments and strengthen eligibility verification. Key provisions include:

• Removal of the 150% Federal Poverty Level Special Enrollment Period, which has been one of the key factors in unauthorized enrollments.
• Elimination of automatic extensions on solving income data identical matters.
• Adoption of a "preponderance of the evidence" standard for terminating noncompliant agent and broker Exchange Agreements.
• Reinstatement of income verification requirements and fast elimination of APTC to consumers who do not submit and reconcile tax credits.

Faster Consumer Complaint Resolution

CMS has enhanced its response to consumer complaints of unauthorized enrollments and plan switches. CMS also reduced the period of time it took to cancel policies that were associated with confirmed complaints.

Medicaid, CHIP, and Exchange Coordination

CMS also restored bi-annual Medicaid and CHIP Periodic Data Matching (PDM) tests that had been suspended in the COVID-19 public health crisis. These screenings found and rectified cross-enrollments in Medicaid, CHIP, and Exchange coverage with APTC.

The CMS also collaborated with 20 state-based Exchanges (SBEs) to determine their progress in preventing concurrent enrollments. The states that had integrated Medicaid systems resolved at least 98 percent of the identified cases, whereas the rest were instructed to adopt corrective action plans.

Resumption of Failure-to-File-and-Reconcile Process

CMS reinstated the removal of APTC in 2025 for consumers who did not submit tax returns and reconcile subsidies for two consecutive years. This measure eliminated subsidies for almost 200,000 households within the states of the HealthCare.gov. CMS has already eliminated APTC on about 366,000 households through the 2026 auto-reenrollment process and is continuing.

Enforcement Against Agents and Brokers

CMS continues to monitor agent, broker, and enhanced direct enrollment entity performance and has taken enforcement action where necessary. In December, CMS ended an 18-month investigation of subsidiaries of Speridian Technologies, including Benefitalign and TrueCoverage.

Consumer Resources

CMS continues to educate consumers on avoiding fraudulent enrollment practices and encourages individuals who believe they were enrolled or switched without consent to contact the Marketplace Call Center at 1-800-318-2596. Suspected fraud can also be reported to the HHS Office of Inspector General Hotline.