Complaints about enrollment fraud in Affordable Care Act health insurance coverage have bedeviled the federal marketplace for years.
Now, the Trump administration is claiming wins in reducing the problem while simultaneously saying more controls are needed.
It has proposed a sweeping set of ACA regulations for next year, including stepped-up requirements for some applicants to prove eligibility for subsidies or enrollment and new scrutiny of sales agents and marketing practices.
While there is a general acknowledgment that there is fraud in the ACA marketplace, some health policy analysts say these new requirements miss that mark and instead will make it harder for people who are eligible to enroll.
“There is a trade-off, particularly with the provisions focused on consumers, that maybe it will prevent some fraudulent enrollment, but also potentially a large number of valid applicants,” said Matthew Fiedler, a senior fellow with the Center on Health Policy at the Brookings Institution.
In its proposal, though, the administration expresses optimism that efforts already in place will continue to pay off, despite the fact that the number of complaints about unauthorized enrollment or switching rose to 341,906 in 2025, compared with 229,734 the year before Donald Trump took office. Still, according to the rule, “program integrity measures implemented during the past year,” along with the expiration of enhanced tax credits, “are likely to lead to a decrease” in complaints in 2026.
The end of those tax credits also means the amount people pay toward their coverage has increased. Data released Jan. 28 by federal officials showed a year-over-year drop of about 1.2 million enrollments across the federal healthcare.gov marketplace and those run by states. And a recent poll from KFF, a health information nonprofit that includes KFF Health News, found that of those who remained covered this year, 80% said their premiums or other costs are higher than they were last year, with 51% saying they are “a lot higher.”
Katie Keith, a director at Georgetown University’s O’Neill Institute for National and Global Health Law, said the administration was sending mixed messages, on one hand “talking about its fraud-fighting efforts” being successful, but releasing a proposed rule “that says we have to have all these restrictions on consumers because of fraud.”
Closing Consumer Windows
Last year, the Trump administration reversed some of the Biden administration’s ACA efforts, including eliminating a special enrollment period for low-income people that let them sign up year-round.
This year’s rule includes proposed changes aimed at preventing people from fudging their incomes — higher or lower — to qualify for subsidies.
For instance, applicants whose federal data shows they were previously below the poverty level — and thus not eligible for subsidies — would have to submit additional income verification to show they expect to earn above the poverty level in the coming year.
Another part of the proposed rule would require the federal marketplace, used by 30 states, to step up verification efforts for people who want to sign up outside of the ACA’s annual open enrollment period, for reasons including getting married, adopting a baby, or losing other coverage. Currently, the marketplaces conduct such reviews only when people say they qualify because they lost other insurance, according to an analysis of the proposal by Keith.
The income verification requirements “will be burdensome,” she said.
Some ACA applicants, especially those running small businesses or working several part-time jobs, find it more difficult to estimate or document their anticipated income and might find they’re prevented from getting subsidies, Keith and other analysts said.
These proposals are among policies reprised from last year’s ACA rule and initially intended to take effect in 2026. But several cities filed a lawsuit to challenge those regulations. The judge overseeing the case put the changes on hold pending its outcome.
In his order issuing a temporary stay, U.S. District Judge Brendan Hurson questioned whether the government adequately responded to questions about the accuracy of data it used in citing widespread fraud.
Additionally, many of the provisions purportedly targeting fraud are “unsupported by data showing that if enacted, they will, in fact, reduce any such fraud,” the judge wrote.
The proposal for 2027 has “new supporting information since the original policies were established” that includes clarifying what documentation is needed for some of the verification processes, Centers for Medicare & Medicaid Services spokesperson Catherine Howden said in an email. In addition, she said that CMS is now reviewing public comments that have been submitted before finalizing the provisions.
Targeting Fraud by Agents, Marketers
Critics of the ACA argue that more-generous subsidies put in place as a response to the covid pandemic, in addition to other changes during the Biden administration, led rogue brokers to enroll or switch people without their consent, seeking to collect commissions. That could be done easily, critics say, because with many plans, subsidies covered the entire premium. The lack of a monthly bill made it easier to sign people up without their knowledge — a long-running problem that ramped up in 2024. When that happens it can leave people unable to access their coverage or with tax bills they did not expect.
Those expanded subsidies have now expired, but the administration’s proposed rule would still add requirements for agents. For example, they would be barred from providing cash or most other freebies as incentives to enroll, have to use a standard consent form that must be signed by the consumer, and be held responsible if they hired a marketing firm that used questionable advertising to lure customers. That includes touting nonexistent gift cards or making websites look like official government ACA portals. Such websites would have to be removed.
“This would help ensure no additional consumers would see the advertisement and be misled,” the proposal says.
Insurance agents told KFF Health News that some of the proposals, such as delineating what counts as a misleading marketing effort, are good first steps but might not fully address concerns about unauthorized enrollment.
It doesn’t “address all the system vulnerabilities,” said Jason Fine, who runs a brokerage in Florida. He said he has filed more than 100 reports about unauthorized rivals accessing his clients’ coverage over the past two years but has yet to see any of those agents removed from the federal marketplace.
More than 850 agents had their certification suspended with little notice in late 2024 under the Biden administration, which said it was looking into complaints about them. The Trump administration told the Government Accountability Office in May that it had reinstated all or most of those agents to fulfill its “statutory and regulatory” responsibilities, according to a preliminary report from the independent oversight group. The report, which outlined long-running fraud problems in the ACA, noted that CMS would continue to monitor those agents and could take “further enforcement action” against them.
Another Biden rule, this one aimed at combating unauthorized sign-ups, remains in place and requires agents to have three-way calls with the client and a federal marketplace call center representative for some enrollments or plan changes.
But Fine and other agents said bad actors are finding ways around that requirement, including by faking that they are the customer during the calls. That contention is backed up in the administration’s new proposal, which notes that federal regulators have received reports that some brokers “may be using artificial intelligence to impersonate consumers and falsely attest to household income.”
Still, the proposal does not include some of the measures agents say would improve the situation.
Fine, for example, said the federal marketplace should more proactively flag unusual activity on consumer accounts, such as multiple agent changes or switches to new insurers within a short period of time, or changes made in the dead of night.
“Overnight is when a lot of this fraud occurs,” Fine said. “No one is changing their insurance at 4 a.m., and that should trigger an automatic fraud alert.” He also wants to see a proposal to rein in overseas call centers that contact U.S. residents — often repeatedly, sometimes making claims about free gift cards or other nonexistent perks — then send their information to agents looking to enroll them or switch their ACA plans.
Others, including Ronnell Nolan, president of Health Agents for America, have also long called for two-factor authentication, similar to what banks require, to confirm that enrollments or switches are approved by the consumer. The 20 states, plus the District of Columbia, that run their own marketplaces incorporate additional measures, including two-factor authentication, and have reported few of the types of problems that the federal market has seen, Nolan said. The administration’s proposed rule does not call for this protection.
A conservative think tank, the Paragon Health Institute, estimates there are several million fraudulent enrollments, but other groups — including the GAO, using a different methodology — have put the estimate far lower.
Based on its preliminary analysis, the GAO estimated there were “at least 160,000 applications in plan year 2024 that had likely unauthorized changes,” representing about 1.5% of all applications.
Meanwhile, Brookings’ Fiedler said the debate around the proposal highlights an ongoing question — not just how much fraud exists or what to do about it, but “how much government should help people get covered at all.”
KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.
USE OUR CONTENT
This story can be republished for free (details).
