| 1 | 1 | | II |
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| 2 | 2 | | 119THCONGRESS |
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| 3 | 3 | | 1 |
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| 4 | 4 | | STSESSION S. 976 |
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| 5 | 5 | | To amend the Patient Protection and Affordable Care Act to reduce |
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| 6 | 6 | | fraudulent enrollments in qualified health plans, and for other purposes. |
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| 7 | 7 | | IN THE SENATE OF THE UNITED STATES |
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| 8 | 8 | | MARCH12, 2025 |
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| 9 | 9 | | Mr. W |
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| 10 | 10 | | YDEN(for himself, Ms. DUCKWORTH, Ms. HIRONO, Ms. KLOBUCHAR, |
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| 11 | 11 | | Mrs. M |
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| 12 | 12 | | URRAY, Mr. SCHATZ, Mrs. SHAHEEN, Ms. SMITH, Mr. WELCH, |
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| 13 | 13 | | and Mr. V |
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| 14 | 14 | | ANHOLLEN) introduced the following bill; which was read |
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| 15 | 15 | | twice and referred to the Committee on Health, Education, Labor, and |
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| 16 | 16 | | Pensions |
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| 17 | 17 | | A BILL |
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| 18 | 18 | | To amend the Patient Protection and Affordable Care Act |
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| 19 | 19 | | to reduce fraudulent enrollments in qualified health |
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| 20 | 20 | | plans, and for other purposes. |
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| 21 | 21 | | Be it enacted by the Senate and House of Representa-1 |
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| 22 | 22 | | tives of the United States of America in Congress assembled, 2 |
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| 23 | 23 | | SECTION 1. SHORT TITLE. 3 |
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| 24 | 24 | | This Act may be cited as the ‘‘Insurance Fraud Ac-4 |
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| 25 | 25 | | countability Act’’. 5 |
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| 27 | 27 | | kjohnson on DSK7ZCZBW3PROD with $$_JOB 2 |
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| 28 | 28 | | •S 976 IS |
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| 29 | 29 | | SEC. 2. REDUCTION OF FRAUDULENT ENROLLMENT IN 1 |
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| 30 | 30 | | QUALIFIED HEALTH PLANS. 2 |
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| 31 | 31 | | (a) P |
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| 32 | 32 | | ENALTIES FORAGENTS ANDBROKERS.—Sec-3 |
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| 33 | 33 | | tion 1411(h)(1) of the Patient Protection and Affordable 4 |
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| 34 | 34 | | Care Act (42 U.S.C. 18081(h)(1)) is amended— 5 |
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| 35 | 35 | | (1) in subparagraph (A)— 6 |
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| 36 | 36 | | (A) by redesignating clause (ii) as clause 7 |
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| 37 | 37 | | (iv); 8 |
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| 38 | 38 | | (B) in clause (i)— 9 |
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| 39 | 39 | | (i) in the matter preceding subclause 10 |
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| 40 | 40 | | (I), by striking ‘‘If—’’ and all that follows 11 |
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| 41 | 41 | | through the ‘‘such person’’ in the matter 12 |
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| 42 | 42 | | following subclause (II) and inserting the 13 |
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| 43 | 43 | | following: ‘‘If any person (other than an 14 |
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| 44 | 44 | | agent or broker) fails to provide correct in-15 |
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| 45 | 45 | | formation under subsection (b) and such 16 |
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| 46 | 46 | | failure is attributable to negligence or dis-17 |
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| 47 | 47 | | regard of any rules or regulations of the 18 |
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| 48 | 48 | | Secretary, such person’’; and 19 |
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| 49 | 49 | | (ii) in the second sentence, by striking 20 |
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| 50 | 50 | | ‘‘For purposes’’ and inserting the fol-21 |
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| 51 | 51 | | lowing: 22 |
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| 52 | 52 | | ‘‘(iii) D |
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| 53 | 53 | | EFINITIONS OF NEGLIGENCE , 23 |
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| 54 | 54 | | DISREGARD.—For purposes’’; 24 |
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| 55 | 55 | | (C) by inserting after clause (i) the fol-25 |
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| 56 | 56 | | lowing: 26 |
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| 59 | 59 | | •S 976 IS |
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| 60 | 60 | | ‘‘(ii) CIVIL PENALTIES FOR CERTAIN 1 |
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| 61 | 61 | | VIOLATIONS BY AGENTS OR BROKERS .—If 2 |
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| 62 | 62 | | any agent or broker fails to provide correct 3 |
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| 63 | 63 | | information under subsection (b) or section 4 |
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| 64 | 64 | | 1311(c)(8) or other information, as speci-5 |
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| 65 | 65 | | fied by the Secretary, and such failure is 6 |
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| 66 | 66 | | attributable to negligence or disregard of 7 |
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| 67 | 67 | | any rules or regulations of the Secretary, 8 |
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| 68 | 68 | | such agent or broker shall be subject, in 9 |
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| 69 | 69 | | addition to any other penalties that may be 10 |
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| 70 | 70 | | prescribed by law, including subparagraph 11 |
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| 71 | 71 | | (C), to a civil penalty of not less than 12 |
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| 72 | 72 | | $10,000 and not more than $50,000 with 13 |
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| 73 | 73 | | respect to each individual who is the sub-14 |
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| 74 | 74 | | ject of an application for which such incor-15 |
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| 75 | 75 | | rect information is provided.’’; and 16 |
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| 76 | 76 | | (D) in clause (iv) (as so redesignated), by 17 |
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| 77 | 77 | | inserting ‘‘or (ii)’’ after ‘‘clause (i)’’; 18 |
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| 78 | 78 | | (2) in subparagraph (B)— 19 |
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| 79 | 79 | | (A) by inserting ‘‘including subparagraph 20 |
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| 80 | 80 | | (C),’’ after ‘‘law,’’; 21 |
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| 81 | 81 | | (B) by striking ‘‘Any person’’ and insert-22 |
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| 82 | 82 | | ing the following: 23 |
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| 83 | 83 | | ‘‘(i) I |
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| 84 | 84 | | N GENERAL.—Any person’’; and 24 |
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| 85 | 85 | | (C) by adding at the end the following: 25 |
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| 88 | 88 | | •S 976 IS |
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| 89 | 89 | | ‘‘(ii) CIVIL PENALTIES FOR KNOWING 1 |
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| 90 | 90 | | VIOLATIONS BY AGENTS OR BROKERS .— 2 |
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| 91 | 91 | | ‘‘(I) I |
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| 92 | 92 | | N GENERAL.—Any agent or 3 |
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| 93 | 93 | | broker who knowingly provides false 4 |
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| 94 | 94 | | or fraudulent information under sub-5 |
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| 95 | 95 | | section (b) or section 1311(c)(8), or 6 |
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| 96 | 96 | | other false or fraudulent information 7 |
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| 97 | 97 | | as part of an application for enroll-8 |
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| 98 | 98 | | ment in a qualified health plan offered 9 |
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| 99 | 99 | | through an Exchange, as specified by 10 |
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| 100 | 100 | | the Secretary, shall be subject, in ad-11 |
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| 101 | 101 | | dition to any other penalties that may 12 |
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| 102 | 102 | | be prescribed by law, including sub-13 |
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| 103 | 103 | | paragraph (C), to a civil penalty of 14 |
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| 104 | 104 | | not more than $200,000 with respect 15 |
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| 105 | 105 | | to each individual who is the subject 16 |
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| 106 | 106 | | of an application for which such false 17 |
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| 107 | 107 | | or fraudulent information is provided. 18 |
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| 108 | 108 | | ‘‘(II) P |
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| 109 | 109 | | ROCEDURE.—The provi-19 |
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| 110 | 110 | | sions of section 1128A of the Social 20 |
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| 111 | 111 | | Security Act (other than subsections 21 |
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| 112 | 112 | | (a) and (b) of such section) shall 22 |
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| 113 | 113 | | apply to a civil monetary penalty 23 |
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| 114 | 114 | | under subclause (I) in the same man-24 |
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| 115 | 115 | | ner as such provisions apply to a pen-25 |
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| 117 | 117 | | kjohnson on DSK7ZCZBW3PROD with $$_JOB 5 |
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| 118 | 118 | | •S 976 IS |
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| 119 | 119 | | alty or proceeding under section 1 |
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| 120 | 120 | | 1128A of the Social Security Act.’’; 2 |
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| 121 | 121 | | and 3 |
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| 122 | 122 | | (3) by adding at the end the following: 4 |
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| 123 | 123 | | ‘‘(C) C |
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| 124 | 124 | | RIMINAL PENALTIES.—Any agent or 5 |
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| 125 | 125 | | broker who knowingly and willfully provides 6 |
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| 126 | 126 | | false or fraudulent information under sub-7 |
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| 127 | 127 | | section (b) or section 1311(c)(8), or other false 8 |
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| 128 | 128 | | or fraudulent information as part of an applica-9 |
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| 129 | 129 | | tion for enrollment in a qualified health plan of-10 |
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| 130 | 130 | | fered through an Exchange, as specified by the 11 |
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| 131 | 131 | | Secretary, shall be fined under title 18, United 12 |
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| 132 | 132 | | States Code, imprisoned for not more than 10 13 |
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| 133 | 133 | | years, or both.’’. 14 |
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| 134 | 134 | | (b) C |
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| 135 | 135 | | ONSUMERPROTECTIONS.— 15 |
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| 136 | 136 | | (1) I |
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| 137 | 137 | | N GENERAL.—Section 1311(c) of the Pa-16 |
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| 138 | 138 | | tient Protection and Affordable Care Act (42 U.S.C. 17 |
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| 139 | 139 | | 18031(c)) is amended by adding at the end the fol-18 |
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| 140 | 140 | | lowing: 19 |
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| 141 | 141 | | ‘‘(8) A |
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| 142 | 142 | | GENT- OR BROKER-ASSISTED ENROLL-20 |
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| 143 | 143 | | MENT IN QUALIFIED HEALTH PLANS IN CERTAIN 21 |
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| 144 | 144 | | EXCHANGES.— 22 |
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| 145 | 145 | | ‘‘(A) I |
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| 146 | 146 | | N GENERAL.—For plan years begin-23 |
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| 147 | 147 | | ning on or after such date specified by the Sec-24 |
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| 148 | 148 | | retary, but not later than January 1, 2029, in 25 |
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| 150 | 150 | | kjohnson on DSK7ZCZBW3PROD with $$_JOB 6 |
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| 151 | 151 | | •S 976 IS |
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| 152 | 152 | | the case of an Exchange that the Secretary op-1 |
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| 153 | 153 | | erates pursuant to section 1321(c)(1), the Sec-2 |
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| 154 | 154 | | retary shall establish a verification process for 3 |
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| 155 | 155 | | new enrollments of individuals in, and changes 4 |
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| 156 | 156 | | in coverage for individuals under, a qualified 5 |
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| 157 | 157 | | health plan offered through such Exchange, 6 |
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| 158 | 158 | | which are submitted by an agent or broker in 7 |
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| 159 | 159 | | accordance with section 1312(e) and for which 8 |
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| 160 | 160 | | the agent or broker is eligible to receive a com-9 |
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| 161 | 161 | | mission. 10 |
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| 162 | 162 | | ‘‘(B) R |
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| 163 | 163 | | EQUIREMENTS.—The enrollment 11 |
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| 164 | 164 | | verification process under subparagraph (A) 12 |
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| 165 | 165 | | shall include— 13 |
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| 166 | 166 | | ‘‘(i) a requirement that the agent or 14 |
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| 167 | 167 | | broker provide with the new enrollment or 15 |
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| 168 | 168 | | coverage change such documentation or 16 |
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| 169 | 169 | | evidence (such as a standardized consent 17 |
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| 170 | 170 | | form) or other sources as the Secretary de-18 |
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| 171 | 171 | | termines necessary to establish that the 19 |
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| 172 | 172 | | agent or broker has the consent of the in-20 |
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| 173 | 173 | | dividual for the new enrollment or coverage 21 |
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| 174 | 174 | | change; 22 |
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| 175 | 175 | | ‘‘(ii) a requirement that any commis-23 |
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| 176 | 176 | | sions due to a broker or agent for such 24 |
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| 177 | 177 | | new enrollment or coverage change are 25 |
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| 179 | 179 | | kjohnson on DSK7ZCZBW3PROD with $$_JOB 7 |
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| 180 | 180 | | •S 976 IS |
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| 181 | 181 | | paid after the enrollee has resolved all in-1 |
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| 182 | 182 | | consistencies in accordance with para-2 |
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| 183 | 183 | | graphs (3) and (4) of section 1411(e); 3 |
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| 184 | 184 | | ‘‘(iii) a requirement that the informa-4 |
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| 185 | 185 | | tion required under clause (i) and, as ap-5 |
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| 186 | 186 | | plicable, the date on which inconsistencies 6 |
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| 187 | 187 | | are resolved as described in clause (ii), is 7 |
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| 188 | 188 | | accessible to the applicable qualified health 8 |
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| 189 | 189 | | plan through a database or other resource, 9 |
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| 190 | 190 | | as determined by the Secretary, so that 10 |
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| 191 | 191 | | any commissions due to a broker or agent 11 |
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| 192 | 192 | | for such enrollment can be effectuated at 12 |
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| 193 | 193 | | the appropriate time; 13 |
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| 194 | 194 | | ‘‘(iv) a requirement that individuals 14 |
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| 195 | 195 | | are notified of any changes to enrollment, 15 |
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| 196 | 196 | | coverage, the agent of record, or premium 16 |
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| 197 | 197 | | tax credits in a timely manner and that 17 |
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| 198 | 198 | | such notice provides plain language in-18 |
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| 199 | 199 | | structions on how individuals can cancel 19 |
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| 200 | 200 | | unauthorized activity; 20 |
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| 201 | 201 | | ‘‘(v) a requirement that individuals be 21 |
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| 202 | 202 | | able to access their account information on 22 |
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| 203 | 203 | | a website or other technology platform, as 23 |
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| 204 | 204 | | defined by the Secretary, when used to 24 |
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| 205 | 205 | | submit an enrollment or plan change, in 25 |
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| 207 | 207 | | kjohnson on DSK7ZCZBW3PROD with $$_JOB 8 |
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| 208 | 208 | | •S 976 IS |
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| 209 | 209 | | lieu of the Exchange website described in 1 |
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| 210 | 210 | | subsection (d)(4)(C), including information 2 |
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| 211 | 211 | | on the agent of record, the qualified health 3 |
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| 212 | 212 | | plan, and when any changes are made to 4 |
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| 213 | 213 | | the agent of record or the qualified health 5 |
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| 214 | 214 | | plan, on a consumer-facing website or 6 |
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| 215 | 215 | | through a toll-free telephone hotline; and 7 |
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| 216 | 216 | | ‘‘(vi) a requirement that the agent or 8 |
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| 217 | 217 | | broker report to the Secretary any third- 9 |
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| 218 | 218 | | party marketing organization or field mar-10 |
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| 219 | 219 | | keting organization (as such terms are de-11 |
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| 220 | 220 | | fined in section 1312(e)) involved in the 12 |
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| 221 | 221 | | chain of enrollment (as so defined) with re-13 |
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| 222 | 222 | | spect to such new enrollment or coverage 14 |
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| 223 | 223 | | change. 15 |
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| 224 | 224 | | ‘‘(C) C |
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| 225 | 225 | | ONSUMER PROTECTION .—The Sec-16 |
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| 226 | 226 | | retary shall ensure that the enrollment 17 |
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| 227 | 227 | | verification process under subparagraph (A) 18 |
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| 228 | 228 | | prioritizes continuity of coverage and care for 19 |
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| 229 | 229 | | individuals, including by not disenrolling indi-20 |
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| 230 | 230 | | viduals from a qualified health plan without the 21 |
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| 231 | 231 | | consent of the individual, regardless of whether 22 |
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| 232 | 232 | | the broker, agent, or qualified health plan is in 23 |
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| 233 | 233 | | violation of any requirement under this para-24 |
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| 234 | 234 | | graph.’’. 25 |
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| 236 | 236 | | kjohnson on DSK7ZCZBW3PROD with $$_JOB 9 |
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| 237 | 237 | | •S 976 IS |
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| 238 | 238 | | (2) R EQUIRED REPORTING .—Section 1 |
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| 239 | 239 | | 1311(c)(1) of the Patient Protection and Affordable 2 |
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| 240 | 240 | | Care Act (42 U.S.C. 18031(c)(1)) is amended— 3 |
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| 241 | 241 | | (A) in subparagraph (H), by striking 4 |
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| 242 | 242 | | ‘‘and’’ at the end; 5 |
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| 243 | 243 | | (B) in subparagraph (I), by striking the 6 |
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| 244 | 244 | | period at the end and inserting ‘‘; and’’; and 7 |
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| 245 | 245 | | (C) by adding at the end the following: 8 |
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| 246 | 246 | | ‘‘(J) report to the Secretary the termi-9 |
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| 247 | 247 | | nation (as defined in section 1312(e)(4)(C)) of 10 |
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| 248 | 248 | | an issuer.’’. 11 |
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| 249 | 249 | | (c) A |
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| 250 | 250 | | UTHORITYTOREGULATEFIELDMARKETING 12 |
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| 251 | 251 | | O |
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| 252 | 252 | | RGANIZATIONS ANDTHIRD-PARTYMARKETINGORGANI-13 |
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| 253 | 253 | | ZATIONS.—Section 1312(e) of the Patient Protection and 14 |
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| 254 | 254 | | Affordable Care Act (42 U.S.C. 18032(e)) is amended— 15 |
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| 255 | 255 | | (1) by redesignating paragraphs (1) and (2) as 16 |
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| 256 | 256 | | subclauses (I) and (II), respectively, and adjusting 17 |
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| 257 | 257 | | the margins accordingly; 18 |
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| 258 | 258 | | (2) in subclause (II) (as so redesignated), by 19 |
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| 259 | 259 | | striking the period at the end and inserting ‘‘; and’’; 20 |
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| 260 | 260 | | (3) by striking the subsection designation and 21 |
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| 261 | 261 | | heading and all that follows through ‘‘brokers—’’ 22 |
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| 262 | 262 | | and inserting the following: 23 |
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| 263 | 263 | | ‘‘(e) R |
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| 264 | 264 | | EGULATION OFAGENTS, BROKERS, ANDCER-24 |
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| 265 | 265 | | TAINMARKETINGORGANIZATIONS.— 25 |
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| 268 | 268 | | •S 976 IS |
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| 269 | 269 | | ‘‘(1) AGENTS, BROKERS, AND CERTAIN MAR -1 |
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| 270 | 270 | | KETING ORGANIZATIONS .— 2 |
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| 271 | 271 | | ‘‘(A) I |
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| 272 | 272 | | N GENERAL.—The Secretary shall 3 |
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| 273 | 273 | | establish procedures under which a State may 4 |
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| 274 | 274 | | allow— 5 |
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| 275 | 275 | | ‘‘(i) agents or brokers—’’; and 6 |
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| 276 | 276 | | (4) by adding at the end the following: 7 |
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| 277 | 277 | | ‘‘(ii) field marketing organizations 8 |
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| 278 | 278 | | and third-party marketing organizations to 9 |
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| 279 | 279 | | participate in the chain of enrollment for 10 |
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| 280 | 280 | | an individual with respect to qualified 11 |
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| 281 | 281 | | health plans offered through an Exchange. 12 |
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| 282 | 282 | | ‘‘(B) C |
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| 283 | 283 | | RITERIA.—For plan years beginning 13 |
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| 284 | 284 | | on or after such date specified by the Secretary, 14 |
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| 285 | 285 | | but not later than January 1, 2029, the Sec-15 |
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| 286 | 286 | | retary, by regulation, shall establish criteria for 16 |
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| 287 | 287 | | States to use in determining whether to allow 17 |
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| 288 | 288 | | agents and brokers to enroll individuals and 18 |
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| 289 | 289 | | employers in qualified health plans as described 19 |
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| 290 | 290 | | in subclause (I) of subparagraph (A)(i) and to 20 |
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| 291 | 291 | | assist individuals as described in subclause (II) 21 |
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| 292 | 292 | | of such subparagraph and field marketing orga-22 |
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| 293 | 293 | | nizations and third-party marketing organiza-23 |
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| 294 | 294 | | tions to participate in the chain of enrollment 24 |
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| 297 | 297 | | •S 976 IS |
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| 298 | 298 | | as described in subparagraph (A)(ii). Such cri-1 |
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| 299 | 299 | | teria shall, at a minimum, require that— 2 |
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| 300 | 300 | | ‘‘(i) an agent or broker act in accord-3 |
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| 301 | 301 | | ance with a standard of conduct that in-4 |
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| 302 | 302 | | cludes a duty of such agent or broker to 5 |
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| 303 | 303 | | act in the best interests of the enrollee; 6 |
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| 304 | 304 | | ‘‘(ii) a field marketing organization or 7 |
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| 305 | 305 | | third-party marketing organization agree 8 |
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| 306 | 306 | | to report the termination of an agent or 9 |
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| 307 | 307 | | broker to the applicable State and the Sec-10 |
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| 308 | 308 | | retary, including the reason for termi-11 |
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| 309 | 309 | | nation; and 12 |
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| 310 | 310 | | ‘‘(iii) an agent, broker, field mar-13 |
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| 311 | 311 | | keting organization, or third-party mar-14 |
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| 312 | 312 | | keting organization— 15 |
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| 313 | 313 | | ‘‘(I) meet such marketing re-16 |
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| 314 | 314 | | quirements as are required by the 17 |
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| 315 | 315 | | Secretary; 18 |
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| 316 | 316 | | ‘‘(II) meet marketing require-19 |
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| 317 | 317 | | ments in accordance with other appli-20 |
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| 318 | 318 | | cable Federal or State law; 21 |
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| 319 | 319 | | ‘‘(III) does not employ practices 22 |
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| 320 | 320 | | that are confusing or misleading, as 23 |
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| 321 | 321 | | determined by the Secretary; 24 |
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| 324 | 324 | | •S 976 IS |
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| 325 | 325 | | ‘‘(IV) submit all marketing mate-1 |
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| 326 | 326 | | rials to the Secretary for, as deter-2 |
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| 327 | 327 | | mined appropriate by the Secretary, 3 |
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| 328 | 328 | | review and approval; 4 |
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| 329 | 329 | | ‘‘(V) is a licensed agent or broker 5 |
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| 330 | 330 | | or meets other licensure requirements, 6 |
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| 331 | 331 | | as required by the State; 7 |
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| 332 | 332 | | ‘‘(VI) register with the Secretary; 8 |
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| 333 | 333 | | and 9 |
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| 334 | 334 | | ‘‘(VII) does not compensate any 10 |
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| 335 | 335 | | individual or organization for referrals 11 |
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| 336 | 336 | | or any other service relating to the 12 |
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| 337 | 337 | | sale of, marketing for, or enrollment 13 |
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| 338 | 338 | | in qualified health plans unless such 14 |
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| 339 | 339 | | individual or organization meets the 15 |
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| 340 | 340 | | criteria described in subclauses (I) 16 |
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| 341 | 341 | | through (VI). 17 |
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| 342 | 342 | | ‘‘(C) D |
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| 343 | 343 | | EFINITIONS.—In this paragraph: 18 |
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| 344 | 344 | | ‘‘(i) C |
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| 345 | 345 | | HAIN OF ENROLLMENT .—The 19 |
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| 346 | 346 | | term ‘chain of enrollment’, with respect to 20 |
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| 347 | 347 | | enrollment of an individual in a qualified 21 |
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| 348 | 348 | | health plan offered through an Exchange, 22 |
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| 349 | 349 | | means any steps taken from marketing to 23 |
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| 350 | 350 | | such individual, to such individual making 24 |
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| 353 | 353 | | •S 976 IS |
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| 354 | 354 | | an enrollment decision with respect to such 1 |
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| 355 | 355 | | a plan. 2 |
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| 356 | 356 | | ‘‘(ii) F |
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| 357 | 357 | | IELD MARKETING ORGANIZA -3 |
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| 358 | 358 | | TION.—The term ‘field marketing organi-4 |
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| 359 | 359 | | zation’ means an organization or individual 5 |
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| 360 | 360 | | that directly employs or contracts with 6 |
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| 361 | 361 | | agents and brokers, or contracts with car-7 |
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| 362 | 362 | | riers, to provide functions relating to en-8 |
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| 363 | 363 | | rollment of individuals in qualified health 9 |
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| 364 | 364 | | plans offered through an Exchange as part 10 |
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| 365 | 365 | | of the chain of enrollment. 11 |
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| 366 | 366 | | ‘‘(iii) M |
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| 367 | 367 | | ARKETING.—The term ‘mar-12 |
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| 368 | 368 | | keting’ means the use of marketing mate-13 |
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| 369 | 369 | | rials to provide information to current and 14 |
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| 370 | 370 | | prospective enrollees in a qualified health 15 |
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| 371 | 371 | | plan offered through an Exchange. 16 |
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| 372 | 372 | | ‘‘(iv) M |
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| 373 | 373 | | ARKETING MATERIALS .—The 17 |
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| 374 | 374 | | term ‘marketing materials’ means mate-18 |
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| 375 | 375 | | rials relating to a qualified health plan of-19 |
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| 376 | 376 | | fered through an Exchange or benefits of-20 |
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| 377 | 377 | | fered through an Exchange that— 21 |
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| 378 | 378 | | ‘‘(I) are intended— 22 |
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| 379 | 379 | | ‘‘(aa) to draw an individual’s 23 |
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| 380 | 380 | | attention to such plan or the pre-24 |
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| 381 | 381 | | mium tax credits or cost-sharing 25 |
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| 384 | 384 | | •S 976 IS |
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| 385 | 385 | | reductions for such plan or plans 1 |
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| 386 | 386 | | offered through an Exchange; 2 |
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| 387 | 387 | | ‘‘(bb) to influence an indi-3 |
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| 388 | 388 | | vidual’s decision-making process 4 |
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| 389 | 389 | | when selecting a qualified health 5 |
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| 390 | 390 | | plan in which to enroll; or 6 |
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| 391 | 391 | | ‘‘(cc) to influence an enroll-7 |
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| 392 | 392 | | ee’s decision to stay enrolled in 8 |
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| 393 | 393 | | such plan; and 9 |
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| 394 | 394 | | ‘‘(II) include or address content 10 |
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| 395 | 395 | | regarding the benefits, benefit struc-11 |
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| 396 | 396 | | ture, premiums, or cost sharing of 12 |
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| 397 | 397 | | such plan. 13 |
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| 398 | 398 | | ‘‘(v) T |
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| 399 | 399 | | ERMINATION.—The term ‘ter-14 |
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| 400 | 400 | | mination’, with respect to a contract or 15 |
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| 401 | 401 | | business arrangement between an agent or 16 |
|---|
| 402 | 402 | | broker and a field marketing organization, 17 |
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| 403 | 403 | | third-party marketing organization, or 18 |
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| 404 | 404 | | health insurance issuer, means— 19 |
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| 405 | 405 | | ‘‘(I) the ending of such contract 20 |
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| 406 | 406 | | or business arrangement, either uni-21 |
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| 407 | 407 | | laterally by one of the parties or on 22 |
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| 408 | 408 | | mutual agreement; or 23 |
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| 409 | 409 | | ‘‘(II) the expiration of such con-24 |
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| 410 | 410 | | tract or business arrangement that is 25 |
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| 413 | 413 | | •S 976 IS |
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| 414 | 414 | | not replaced by a substantially similar 1 |
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| 415 | 415 | | agreement. 2 |
|---|
| 416 | 416 | | ‘‘(vi) T |
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| 417 | 417 | | HIRD-PARTY MARKETING ORGA -3 |
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| 418 | 418 | | NIZATION.—The term ‘third-party mar-4 |
|---|
| 419 | 419 | | keting organization’ means an organization 5 |
|---|
| 420 | 420 | | or individual that is compensated to per-6 |
|---|
| 421 | 421 | | form lead generation, marketing, or sales 7 |
|---|
| 422 | 422 | | relating to enrollment of individuals in 8 |
|---|
| 423 | 423 | | qualified health plans offered through an 9 |
|---|
| 424 | 424 | | Exchange as part of the chain of enroll-10 |
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| 425 | 425 | | ment.’’. 11 |
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| 426 | 426 | | (d) T |
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| 427 | 427 | | RANSPARENCY.—Section 1312(e) of the Patient 12 |
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| 428 | 428 | | Protection and Affordable Care Act (42 U.S.C. 18032(e)) 13 |
|---|
| 429 | 429 | | (as amended by subsection (c)) is amended by adding at 14 |
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| 430 | 430 | | the end the following: 15 |
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| 431 | 431 | | ‘‘(2) A |
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| 432 | 432 | | UDITS.— 16 |
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| 433 | 433 | | ‘‘(A) I |
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| 434 | 434 | | N GENERAL.—For plan years begin-17 |
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| 435 | 435 | | ning on or after such date specified by the Sec-18 |
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| 436 | 436 | | retary, but not later than January 1, 2029, the 19 |
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| 437 | 437 | | Secretary, in coordination with the States and 20 |
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| 438 | 438 | | in consultation with the National Association of 21 |
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| 439 | 439 | | Insurance Commissioners, shall implement a 22 |
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| 440 | 440 | | process for the oversight and enforcement of 23 |
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| 441 | 441 | | agent and broker compliance with this section 24 |
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| 444 | 444 | | •S 976 IS |
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| 445 | 445 | | and other applicable Federal and State law (in-1 |
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| 446 | 446 | | cluding regulations) that shall include— 2 |
|---|
| 447 | 447 | | ‘‘(i) periodic audits of agents and bro-3 |
|---|
| 448 | 448 | | kers based on— 4 |
|---|
| 449 | 449 | | ‘‘(I) complaints filed with the 5 |
|---|
| 450 | 450 | | Secretary by individuals enrolled by 6 |
|---|
| 451 | 451 | | such an agent or broker in a qualified 7 |
|---|
| 452 | 452 | | health plan offered through an Ex-8 |
|---|
| 453 | 453 | | change; 9 |
|---|
| 454 | 454 | | ‘‘(II) an incident or enrollment 10 |
|---|
| 455 | 455 | | pattern that suggests fraud; and 11 |
|---|
| 456 | 456 | | ‘‘(III) other factors determined 12 |
|---|
| 457 | 457 | | by the Secretary; and 13 |
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| 458 | 458 | | ‘‘(ii) a process under which the Sec-14 |
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| 459 | 459 | | retary shall share audit results and refer 15 |
|---|
| 460 | 460 | | potential cases of fraud to the relevant 16 |
|---|
| 461 | 461 | | State department of insurance. 17 |
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| 462 | 462 | | ‘‘(B) E |
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| 463 | 463 | | FFECT.—Nothing in this paragraph 18 |
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| 464 | 464 | | limits or restricts any referrals made under sec-19 |
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| 465 | 465 | | tion 1311(i)(3) or any enforcement actions 20 |
|---|
| 466 | 466 | | under section 1411(h). 21 |
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| 467 | 467 | | ‘‘(3) L |
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| 468 | 468 | | IST.—The Secretary shall develop a proc-22 |
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| 469 | 469 | | ess to regularly provide to qualified health plans, 23 |
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| 472 | 472 | | •S 976 IS |
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| 473 | 473 | | Exchanges, and States a list of suspended and ter-1 |
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| 474 | 474 | | minated agents and brokers.’’. 2 |
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| 475 | 475 | | Æ |
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