[Congressional Bills 118th Congress]
[From the U.S. Government Publishing Office]
[H.R. 10095 Introduced in House (IH)]
<DOC>
118th CONGRESS
2d Session
H. R. 10095
To amend the Patient Protection and Affordable Care Act to reduce
fraudulent enrollments in qualified health plans, and for other
purposes.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
November 1, 2024
Ms. Ross (for herself and Ms. Castor of Florida) introduced the
following bill; which was referred to the Committee on Energy and
Commerce
_______________________________________________________________________
A BILL
To amend the Patient Protection and Affordable Care Act to reduce
fraudulent enrollments in qualified health plans, and for other
purposes.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE.
This Act may be cited as the ``Insurance Fraud Accountability
Act''.
SEC. 2. REDUCTION OF FRAUDULENT ENROLLMENT IN QUALIFIED HEALTH PLANS.
(a) Penalties for Agents and Brokers.--Section 1411(h)(1) of the
Patient Protection and Affordable Care Act (42 U.S.C. 18081(h)(1)) is
amended--
(1) in subparagraph (A)--
(A) by redesignating clause (ii) as clause (iv);
(B) in clause (i)--
(i) in the matter preceding subclause (I),
by striking ``If--'' and all that follows
through the ``such person'' in the matter
following subclause (II) and inserting the
following: ``If any person (other than an agent
or broker) fails to provide correct information
under subsection (b) and such failure is
attributable to negligence or disregard of any
rules or regulations of the Secretary, such
person''; and
(ii) in the second sentence, by striking
``For purposes'' and inserting the following:
``(iii) Definitions of negligence,
disregard.--For purposes'';
(C) by inserting after clause (i) the following:
``(ii) Civil penalties for certain
violations by agents or brokers.--If any agent
or broker fails to provide correct information
under subsection (b) or section 1311(c)(8) or
other information, as specified by the
Secretary, and such failure is attributable to
negligence or disregard of any rules or
regulations of the Secretary, such agent or
broker shall be subject, in addition to any
other penalties that may be prescribed by law,
including subparagraph (C), to a civil penalty
of not less than $10,000 and not more than
$50,000 with respect to each individual who is
the subject of an application for which such
incorrect information is provided.''; and
(D) in clause (iv) (as so redesignated), by
inserting ``or (ii)'' after ``clause (i)'';
(2) in subparagraph (B)--
(A) by inserting ``including subparagraph (C),''
after ``law,'';
(B) by striking ``Any person'' and inserting the
following:
``(i) In general.--Any person''; and
(i) by adding at the end the following:
``(ii) Civil penalties for knowing
violations by agents or brokers.--
``(I) In general.--Any agent or
broker who knowingly provides false or
fraudulent information under subsection
(b) or section 1311(c)(8), or other
false or fraudulent information as part
of an application for enrollment in a
qualified health plan offered through
an Exchange, as specified by the
Secretary, shall be subject, in
addition to any other penalties that
may be prescribed by law, including
subparagraph (C), to a civil penalty of
not more than $200,000 with respect to
each individual who is the subject of
an application for which such false or
fraudulent information is provided.
``(II) Procedure.--The provisions
of section 1128A of the Social Security
Act (other than subsections (a) and (b)
of such section) shall apply to a civil
monetary penalty under subclause (I) in
the same manner as such provisions
apply to a penalty or proceeding under
section 1128A of the Social Security
Act.''; and
(3) by adding at the end the following:
``(C) Criminal penalties.--Any agent or broker who
knowingly and willfully provides false or fraudulent
information under subsection (b) or section 1311(c)(8),
or other false or fraudulent information as part of an
application for enrollment in a qualified health plan
offered through an Exchange, as specified by the
Secretary, shall be fined under title 18, United States
Code, imprisoned for not more than 10 years, or
both.''.
(b) Consumer Protections.--
(1) In general.--Section 1311(c) of the Patient Protection
and Affordable Care Act (42 U.S.C. 18031(c)) is amended by
adding at the end the following:
``(8) Agent- or broker-assisted enrollment in qualified
health plans in certain exchanges.--
``(A) In general.--For plan years beginning on or
after such date specified by the Secretary, but not
later than January 1, 2028, in the case of an Exchange
that the Secretary operates pursuant to section
1321(c)(1), the Secretary shall establish a
verification process for new enrollments of individuals
in, and changes in coverage for individuals under, a
qualified health plan offered through such Exchange,
which are submitted by an agent or broker in accordance
with section 1312(e) and for which the agent or broker
is eligible to receive a commission.
``(B) Requirements.--The enrollment verification
process under subparagraph (A) shall include--
``(i) a requirement that the agent or
broker provide with the new enrollment or
coverage change such documentation or evidence
(such as a standardized consent form) or other
sources as the Secretary determines necessary
to establish that the agent or broker has the
consent of the individual for the new
enrollment or coverage change;
``(ii) a requirement that any commissions
due to a broker or agent for such new
enrollment or coverage change are paid after
the enrollee has resolved all inconsistencies
in accordance with paragraphs (3) and (4) of
section 1411(e);
``(iii) a requirement that the information
required under clause (i) and, as applicable,
the date on which inconsistencies are resolved
as described in clause (ii), is accessible to
the applicable qualified health plan through a
database or other resource, as determined by
the Secretary, so that any commissions due to a
broker or agent for such enrollment can be
effectuated at the appropriate time;
``(iv) a requirement that individuals are
notified of any changes to enrollment,
coverage, the agent of record, or premium tax
credits in a timely manner and that such notice
provides plain language instructions on how
individuals can cancel unauthorized activity;
``(v) a requirement that individuals be
able to access their account information on a
website or other technology platform, as
defined by the Secretary, when used to submit
an enrollment or plan change, in lieu of the
Exchange website described in subsection
(d)(4)(C), including information on the agent
of record, the qualified health plan, and when
any changes are made to the agent of record or
the qualified health plan, on a consumer-facing
website or through a toll-free telephone
hotline; and
``(vi) a requirement that the agent or
broker report to the Secretary any third-party
marketing organization or field marketing
organization (as such terms are defined in
section 1312(e)) involved in the chain of
enrollment (as so defined) with respect to such
new enrollment or coverage change.
``(C) Consumer protection.--The Secretary shall
ensure that the enrollment verification process under
subparagraph (A) prioritizes continuity of coverage and
care for individuals, including by not disenrolling
individuals from a qualified health plan without the
consent of the individual, regardless of whether the
broker, agent, or qualified health plan is in violation
of any requirement under this paragraph.''.
(2) Required reporting.--Section 1311(c)(1) of the Patient
Protection and Affordable Care Act (42 U.S.C. 18031(c)(1)) is
amended--
(A) in subparagraph (H), by striking ``and'' at the
end;
(B) in subparagraph (I), by striking the period at
the end and inserting ``; and''; and
(C) by adding at the end the following:
``(J) report to the Secretary the termination (as
defined in section 1312(e)(4)(C)) of an issuer.''.
(c) Authority To Regulate Field Marketing Organizations and Third-
Party Marketing Organizations.--Section 1312(e) of the Patient
Protection and Affordable Care Act (42 U.S.C. 18032(e)) is amended--
(1) by redesignating paragraphs (1) and (2) as subclauses
(I) and (II), respectively, and adjusting the margins
accordingly;
(2) in subclause (II) (as so redesignated), by striking the
period at the end and inserting ``; and'';
(3) by striking the subsection designation and heading and
all that follows through ``brokers--'' and inserting the
following:
``(e) Regulation of Agents, Brokers, and Certain Marketing
Organizations.--
``(1) Agents, brokers, and certain marketing
organizations.--
``(A) In general.--The Secretary shall establish
procedures under which a State may allow--
``(i) agents or brokers--''; and
(4) by adding at the end the following:
``(ii) field marketing organizations and
third-party marketing organizations to
participate in the chain of enrollment for an
individual with respect to qualified health
plans offered through an Exchange.
``(B) Criteria.--For plan years beginning on or
after such date specified by the Secretary, but not
later than January 1, 2028, the Secretary, by
regulation, shall establish criteria for States to use
in determining whether to allow agents and brokers to
enroll individuals and employers in qualified health
plans as described in subclause (I) of subparagraph
(A)(i) and to assist individuals as described in
subclause (II) of such subparagraph and field marketing
organizations and third-party marketing organizations
to participate in the chain of enrollment as described
in subparagraph (A)(ii). Such criteria shall, at a
minimum, require that--
``(i) an agent or broker act in accordance
with a standard of conduct that includes a duty
of such agent or broker to act in the best
interests of the enrollee;
``(ii) a field marketing organization or
third-party marketing organization agree to
report the termination of an agent or broker to
the applicable State and the Secretary,
including the reason for termination; and
``(iii) an agent, broker, field marketing
organization, or third-party marketing
organization--
``(I) meet such marketing
requirements as are required by the
Secretary;
``(II) meet marketing requirements
in accordance with other applicable
Federal or State law;
``(III) does not employ practices
that are confusing or misleading, as
determined by the Secretary;
``(IV) submit all marketing
materials to the Secretary for, as
determined appropriate by the
Secretary, review and approval;
``(V) is a licensed agent or broker
or meets other licensure requirements,
as required by the State;
``(VI) register with the Secretary;
and
``(VII) does not compensate any
individual or organization for
referrals or any other service relating
to the sale of, marketing for, or
enrollment in qualified health plans
unless such individual or organization
meets the criteria described in
subclauses (I) through (VI).
``(C) Definitions.--In this paragraph:
``(i) Chain of enrollment.--The term `chain
of enrollment', with respect to enrollment of
an individual in a qualified health plan
offered through an Exchange, means any steps
taken from marketing to such individual, to
such individual making an enrollment decision
with respect to such a plan.
``(ii) Field marketing organization.--The
term `field marketing organization' means an
organization or individual that directly
employs or contracts with agents and brokers,
or contracts with carriers, to provide
functions relating to enrollment of individuals
in qualified health plans offered through an
Exchange as part of the chain of enrollment.
``(iii) Marketing.--The term `marketing'
means the use of marketing materials to provide
information to current and prospective
enrollees in a qualified health plan offered
through an Exchange.
``(iv) Marketing materials.--The term
`marketing materials' means materials relating
to a qualified health plan offered through an
Exchange or benefits offered through an
Exchange that--
``(I) are intended--
``(aa) to draw an
individual's attention to such
plan or the premium tax credits
or cost-sharing reductions for
such plan or plans offered
through an Exchange;
``(bb) to influence an
individual's decision-making
process when selecting a
qualified health plan in which
to enroll; or
``(cc) to influence an
enrollee's decision to stay
enrolled in such plan; and
``(II) include or address content
regarding the benefits, benefit
structure, premiums, or cost sharing of
such plan.
``(v) Termination.--The term `termination',
with respect to a contract or business
arrangement between an agent or broker and a
field marketing organization, third-party
marketing organization, or health insurance
issuer, means--
``(I) the ending of such contract
or business arrangement, either
unilaterally by one of the parties or
on mutual agreement; or
``(II) the expiration of such
contract or business arrangement that
is not replaced by a substantially
similar agreement.
``(vi) Third-party marketing
organization.--The term `third-party marketing
organization' means an organization or
individual that is compensated to perform lead
generation, marketing, or sales relating to
enrollment of individuals in qualified health
plans offered through an Exchange as part of
the chain of enrollment.''.
(d) Transparency.--Section 1312(e) of the Patient Protection and
Affordable Care Act (42 U.S.C. 18032(e)) (as amended by subsection (c))
is amended by adding at the end the following:
``(2) Audits.--
``(A) In general.--For plan years beginning on or
after such date specified by the Secretary, but not
later than January 1, 2028, the Secretary, in
coordination with the States and in consultation with
the National Association of Insurance Commissioners,
shall implement a process for the oversight and
enforcement of agent and broker compliance with this
section and other applicable Federal and State law
(including regulations) that shall include--
``(i) periodic audits of agents and brokers
based on--
``(I) complaints filed with the
Secretary by individuals enrolled by
such an agent or broker in a qualified
health plan offered through an
Exchange;
``(II) an incident or enrollment
pattern that suggests fraud; and
``(III) other factors determined by
the Secretary; and
``(ii) a process under which the Secretary
shall share audit results and refer potential
cases of fraud to the relevant State department
of insurance.
``(B) Effect.--Nothing in this paragraph limits or
restricts any referrals made under section 1311(i)(3)
or any enforcement actions under section 1411(h).
``(3) List.--The Secretary shall develop a process to
regularly provide to qualified health plans, Exchanges, and
States a list of suspended and terminated agents and
brokers.''.
<all>