SOUTH CHARLESTON — Your health insurance changed – or even canceled – without your knowledge.
It’s happened to families here in the Miami Valley, and hundreds of thousands across the country, who rely on the Affordable Care Act (ACA) Marketplace.
A News Center 7 I-Team investigation uncovered how rouge insurance agents made millions by taking advantage of consumers and your tax dollars.
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The I-Team’s lead investigative reporter, John Bedell, found out how bad actors were able to pull this off with very little information.
Lorie and Randy Delaney, from South Charleston, say a rouge insurance agent treated their healthcare like a pinball – bouncing them around from one plan to another to make money.
“I have insurance PTSD from dealing with all of this,” Lorie said during a recent interview with the I-Team at their home in Clark County.
“Every month I had to check insurance (with Marketplace).” Delaney said. “I pick up the phone. I call. I’m like, ‘Do we have coverage?’ And they’re like, ‘Yep, you got coverage, but it’s with United Healthcare.’ I’m like, how is it with United Healthcare? I put it back to Medical Mutual. Why is it with United Healthcare?”
The Delaneys got an Affordable Care Act (ACA) plan when Lorie was working as a contractor and not eligible for her employer’s healthcare plans.
“To make sure both of our medicines were covered, I signed us up for Marketplace,” Lorie said.
But it was a trip to the pharmacy to pick up Randy’s insulin for his diabetes that let them know something was wrong.
“And when I got to the pharmacy, you can imagine my shock when they told us it was $1,096,” Lorie said. “I was like, ‘uh, what? Yeah, there’s no way we’re picking that up today.’”
An insurance broker in Texas had enrolled Lorie and Randy in a new plan without their knowledge.
The I-Team has talked with people across the country who have had their health insurance hijacked.
Tiesha Foreman lives in Douglasville, Georgia. She told the I-Team the first sign of trouble for her was when her daughter’s pediatrician thought the family had no insurance.
“It’s stressful,” Foreman said. “And scary. And it’s embarrassing because you have them looking back at you like, ‘Why are you giving us this card saying that you’re covered and you’re not again?”
She later found out she had several policies at the same time after brokers she never met enrolled her.
“For three months, I kept trying to call on the phone, trying to talk to the marketplace to get them to understand I wasn’t doing these applications,” Foreman said. “I didn’t know who this agent was.”
Ashley Akra lives in Mint Hill, North Carolina, and told the I-Team it happened to her too.
“End of February 2023, someone signed us up – back up – to the Marketplace insurance without our knowledge or consent and for a full government subsidy as well,” Akra told the I-Team. “Our newborn needed medication. So we went to the pharmacy and they were like, ‘she’s not on your insurance. You have this plan,’ which was not my plan through my job. And that’s how we found out.”
A class action lawsuit the I-Team reviewed claims families who rely on the Affordable Care Act Marketplace for healthcare are victims of a multimillion-dollar health insurance fraud scheme.
The companies named in the lawsuit have denied wrongdoing.
“I believe this is the largest health insurance fraud case ever,” attorney Jason Doss told the I-Team. Doss is a lawyer for one of the plaintiffs in the case.
Doss says rogue insurance agents exploited a provision added during COVID aimed at letting low-income Americans switch their coverage any time, not just during open enrollment.
“The problem is: what if the bad guy owns the enrollment platform? They have the keys to the castle,” Doss said.
If insurance companies switch your ACA plan, they make money – a monthly commission of about $20 per policy.
“All they need is a first name, last name, date of birth, and state,” said insurance agent Callie Navrides, who is also one of the class action plaintiffs.
Navrides says her clients kept getting switched without her knowledge. “Over and over and over again,” she said. “And like a dozen times with just one person, like one client.”
The lawsuit says they got Navrides’ clients’ information using popup ads online advertising free money. Many customers thought they were just requesting information but got signed up for health coverage instead.
The federal government says between January and August this year, nearly 275,000 people complained they were changed from or enrolled in plans without their consent. Each switch meant potential gaps in their health insurance coverage.
“It’s just like somebody is in there just messing with your life every day,” Delaney told the I-Team.
The Feds have now suspended 850 agents and brokers for “reasonable suspicion of fraudulent or abusive conduct” related to “unauthorized enrollments” or “plan switches.”
Since the lawsuit, any new agent on a policy must conduct a three-way call with the Marketplace and the customer.
The Delaneys said their plan became such a hassle and so expensive that they’re now going without health insurance until December 1 when Lorie’s insurance kicks in from her new job.
“I want to be an advocate for other people to help them navigate through this awful process with Marketplace,” Lorie said.
And the Delaneys are afraid this hassle isn’t over for them. Even after their new insurance starts, they’re worried they’ll get a surprise bill during tax season in the spring. Lorie said that rogue broker incorrectly adjusted their income several times, which can cause IRS penalties of thousands of dollars – something she worries she’ll also have to fight.
In a statement sent to the I-Team, a spokesperson for the Centers for Medicare & Medicaid Services (CMS), which operates the Health insurance Marketplace created by the ACA, said:
CMS continues to exercise its full statutory and regulatory authority to protect the integrity of the Federally Facilitated Marketplace (FFM), which include FFM platform and State-based Marketplaces that operate on the federal platform.
CMS continues to protect consumers from unauthorized changes to their FFM enrollments. This includes reviewing and addressing consumer complaints as quickly as possible, updating Marketplace systems to prevent unauthorized changes, including unauthorized cancellations, with as little disruption to consumer access to Marketplace enrollment as possible, arming consumers with resources and information to help them avoid and report unauthorized plan changes by agents and brokers, and suspending and terminating the Marketplace agreements of agents and brokers who have engaged in fraud or abusive conduct. Beginning July 19, 2024, CMS began blocking agents and brokers from making changes to a consumer’s FFM enrollment, unless the agent or broker is already associated with the consumer’s enrollment.
If a consumer would like to work with an agent or broker not already associated with their profile, the consumer must conduct a three-way call with the Marketplace Call Center and the “new” agent or broker. The consumer can also submit the change to their enrollment directly through the Marketplace Call Center, HealthCare.gov, or an approved Classic Direct Enrollment or Enhanced Direct Enrollment partner website with a consumer pathway. This same logic prevents agents and brokers from canceling a consumer’s enrollment if they are not already associated with the enrollment unless the consumer conducts a three-way call with the Marketplace Call Center and the agent or broker. The agency continues to conduct robust oversight and monitoring of agents and brokers on the FFM and is evaluating additional technological solutions to preserve access to high-quality, person-centered, and affordable healthcare coverage — a critical priority for CMS and the Biden-Harris Administration.
In addition to these actions, CMS has proposed additional measures to prevent unauthorized Marketplace activity among agents and brokers in the Notice of Benefit and Payment Parameters for 2026 Proposed Rule. This includes strengthening review and enforcement actions, expanding authority to suspend agents and brokers, and updates to consumer consent forms.
Protecting the millions of people served by CMS programs remains the agency’s top priority. CMS continues to leverage a broad array of resources to warn FFM consumers about potentially fraudulent agent or broker activity and misleading marketing websites.
Consumers who believe they may have been the victim of unauthorized FFM agent or broker activity should call the Marketplace Call Center at 1-800-318-2596 (TTY: 1-855-889-4325) to resolve any coverage issues promptly.
From June 2024 through October 2024, CMS suspended 850 agents’ and brokers’ Marketplace agreements for reasonable suspicion of fraudulent or abusive conduct related to unauthorized enrollments or unauthorized plan switches. Agents and brokers who are suspended are prohibited from participating in Marketplace enrollment, including receiving related commissions.
For additional information about CMS actions to prevent unauthorized agent and broker Marketplace activity, see the statement we issued Oct. 17, 2024.
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