Fraud in Marketplace Enrollment and Eligibility: Five Things to Know

(By Kaye Pestaina, Rayna Wallace, Michelle Long, Meghan Salaga, and Emma Lee for The Kaiser Family Foundation Published: Jun 30, 2025)

Rooting out fraud has been one of the primary reasons given for changes to Marketplace enrollment and eligibility standards included in the Trump administration’s final Marketplace integrity and affordability rule (“final regulation”), and budget reconciliation legislation, named the “One Big Beautiful Bill Act,” passed in the U.S. House of Representatives and moving its way through the Senate. In the final regulation, the Centers for Medicare and Medicaid Services (CMS) points to “dramatic levels of improper enrollment” in Marketplace plans that CMS says have involved fraudulent actions by some agents, brokers, and web brokers. The final regulation and the budget reconciliation legislation seek to address alleged fraud by instituting new standards for consumers to enroll in Marketplace coverage, from additional paperwork requirements to “verify” a consumer’s estimated household income to obtain advanced premium tax credits (APTC) to significant new administrative steps and new payments for consumers to continue Marketplace coverage. Few changes are made in the final regulation concerning oversight of entities alleged to have engaged in fraudulent activities, and none are proposed in the budget reconciliation legislation. Continue reading here…

Notice: The link provided above connects readers to the full content of the posted article. The URL (internet address) for this link is valid on the posted date; medicarereport.org cannot guarantee the duration of the link’s validity. Also, the opinions expressed in these postings are the viewpoints of the original source and are not explicitly endorsed by AMAC, Inc.; the AMAC Foundation, Inc.; or medicarereport.org.