II
119THCONGRESS
1
STSESSION S. 976
To amend the Patient Protection and Affordable Care Act to reduce
fraudulent enrollments in qualified health plans, and for other purposes.
IN THE SENATE OF THE UNITED STATES
MARCH12, 2025
Mr. W
YDEN(for himself, Ms. DUCKWORTH, Ms. HIRONO, Ms. KLOBUCHAR,
Mrs. M
URRAY, Mr. SCHATZ, Mrs. SHAHEEN, Ms. SMITH, Mr. WELCH,
and Mr. V
ANHOLLEN) introduced the following bill; which was read
twice and referred to the Committee on Health, Education, Labor, and
Pensions
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 Representa-1
tives of the United States of America in Congress assembled, 2
SECTION 1. SHORT TITLE. 3
This Act may be cited as the ‘‘Insurance Fraud Ac-4
countability Act’’. 5
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SEC. 2. REDUCTION OF FRAUDULENT ENROLLMENT IN 1
QUALIFIED HEALTH PLANS. 2
(a) P
ENALTIES FORAGENTS ANDBROKERS.—Sec-3
tion 1411(h)(1) of the Patient Protection and Affordable 4
Care Act (42 U.S.C. 18081(h)(1)) is amended— 5
(1) in subparagraph (A)— 6
(A) by redesignating clause (ii) as clause 7
(iv); 8
(B) in clause (i)— 9
(i) in the matter preceding subclause 10
(I), by striking ‘‘If—’’ and all that follows 11
through the ‘‘such person’’ in the matter 12
following subclause (II) and inserting the 13
following: ‘‘If any person (other than an 14
agent or broker) fails to provide correct in-15
formation under subsection (b) and such 16
failure is attributable to negligence or dis-17
regard of any rules or regulations of the 18
Secretary, such person’’; and 19
(ii) in the second sentence, by striking 20
‘‘For purposes’’ and inserting the fol-21
lowing: 22
‘‘(iii) D
EFINITIONS OF NEGLIGENCE , 23
DISREGARD.—For purposes’’; 24
(C) by inserting after clause (i) the fol-25
lowing: 26
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‘‘(ii) CIVIL PENALTIES FOR CERTAIN 1
VIOLATIONS BY AGENTS OR BROKERS .—If 2
any agent or broker fails to provide correct 3
information under subsection (b) or section 4
1311(c)(8) or other information, as speci-5
fied by the Secretary, and such failure is 6
attributable to negligence or disregard of 7
any rules or regulations of the Secretary, 8
such agent or broker shall be subject, in 9
addition to any other penalties that may be 10
prescribed by law, including subparagraph 11
(C), to a civil penalty of not less than 12
$10,000 and not more than $50,000 with 13
respect to each individual who is the sub-14
ject of an application for which such incor-15
rect information is provided.’’; and 16
(D) in clause (iv) (as so redesignated), by 17
inserting ‘‘or (ii)’’ after ‘‘clause (i)’’; 18
(2) in subparagraph (B)— 19
(A) by inserting ‘‘including subparagraph 20
(C),’’ after ‘‘law,’’; 21
(B) by striking ‘‘Any person’’ and insert-22
ing the following: 23
‘‘(i) I
N GENERAL.—Any person’’; and 24
(C) by adding at the end the following: 25
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‘‘(ii) CIVIL PENALTIES FOR KNOWING 1
VIOLATIONS BY AGENTS OR BROKERS .— 2
‘‘(I) I
N GENERAL.—Any agent or 3
broker who knowingly provides false 4
or fraudulent information under sub-5
section (b) or section 1311(c)(8), or 6
other false or fraudulent information 7
as part of an application for enroll-8
ment in a qualified health plan offered 9
through an Exchange, as specified by 10
the Secretary, shall be subject, in ad-11
dition to any other penalties that may 12
be prescribed by law, including sub-13
paragraph (C), to a civil penalty of 14
not more than $200,000 with respect 15
to each individual who is the subject 16
of an application for which such false 17
or fraudulent information is provided. 18
‘‘(II) P
ROCEDURE.—The provi-19
sions of section 1128A of the Social 20
Security Act (other than subsections 21
(a) and (b) of such section) shall 22
apply to a civil monetary penalty 23
under subclause (I) in the same man-24
ner as such provisions apply to a pen-25
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alty or proceeding under section 1
1128A of the Social Security Act.’’; 2
and 3
(3) by adding at the end the following: 4
‘‘(C) C
RIMINAL PENALTIES.—Any agent or 5
broker who knowingly and willfully provides 6
false or fraudulent information under sub-7
section (b) or section 1311(c)(8), or other false 8
or fraudulent information as part of an applica-9
tion for enrollment in a qualified health plan of-10
fered through an Exchange, as specified by the 11
Secretary, shall be fined under title 18, United 12
States Code, imprisoned for not more than 10 13
years, or both.’’. 14
(b) C
ONSUMERPROTECTIONS.— 15
(1) I
N GENERAL.—Section 1311(c) of the Pa-16
tient Protection and Affordable Care Act (42 U.S.C. 17
18031(c)) is amended by adding at the end the fol-18
lowing: 19
‘‘(8) A
GENT- OR BROKER-ASSISTED ENROLL-20
MENT IN QUALIFIED HEALTH PLANS IN CERTAIN 21
EXCHANGES.— 22
‘‘(A) I
N GENERAL.—For plan years begin-23
ning on or after such date specified by the Sec-24
retary, but not later than January 1, 2029, in 25
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the case of an Exchange that the Secretary op-1
erates pursuant to section 1321(c)(1), the Sec-2
retary shall establish a verification process for 3
new enrollments of individuals in, and changes 4
in coverage for individuals under, a qualified 5
health plan offered through such Exchange, 6
which are submitted by an agent or broker in 7
accordance with section 1312(e) and for which 8
the agent or broker is eligible to receive a com-9
mission. 10
‘‘(B) R
EQUIREMENTS.—The enrollment 11
verification process under subparagraph (A) 12
shall include— 13
‘‘(i) a requirement that the agent or 14
broker provide with the new enrollment or 15
coverage change such documentation or 16
evidence (such as a standardized consent 17
form) or other sources as the Secretary de-18
termines necessary to establish that the 19
agent or broker has the consent of the in-20
dividual for the new enrollment or coverage 21
change; 22
‘‘(ii) a requirement that any commis-23
sions due to a broker or agent for such 24
new enrollment or coverage change are 25
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paid after the enrollee has resolved all in-1
consistencies in accordance with para-2
graphs (3) and (4) of section 1411(e); 3
‘‘(iii) a requirement that the informa-4
tion required under clause (i) and, as ap-5
plicable, the date on which inconsistencies 6
are resolved as described in clause (ii), is 7
accessible to the applicable qualified health 8
plan through a database or other resource, 9
as determined by the Secretary, so that 10
any commissions due to a broker or agent 11
for such enrollment can be effectuated at 12
the appropriate time; 13
‘‘(iv) a requirement that individuals 14
are notified of any changes to enrollment, 15
coverage, the agent of record, or premium 16
tax credits in a timely manner and that 17
such notice provides plain language in-18
structions on how individuals can cancel 19
unauthorized activity; 20
‘‘(v) a requirement that individuals be 21
able to access their account information on 22
a website or other technology platform, as 23
defined by the Secretary, when used to 24
submit an enrollment or plan change, in 25
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lieu of the Exchange website described in 1
subsection (d)(4)(C), including information 2
on the agent of record, the qualified health 3
plan, and when any changes are made to 4
the agent of record or the qualified health 5
plan, on a consumer-facing website or 6
through a toll-free telephone hotline; and 7
‘‘(vi) a requirement that the agent or 8
broker report to the Secretary any third- 9
party marketing organization or field mar-10
keting organization (as such terms are de-11
fined in section 1312(e)) involved in the 12
chain of enrollment (as so defined) with re-13
spect to such new enrollment or coverage 14
change. 15
‘‘(C) C
ONSUMER PROTECTION .—The Sec-16
retary shall ensure that the enrollment 17
verification process under subparagraph (A) 18
prioritizes continuity of coverage and care for 19
individuals, including by not disenrolling indi-20
viduals from a qualified health plan without the 21
consent of the individual, regardless of whether 22
the broker, agent, or qualified health plan is in 23
violation of any requirement under this para-24
graph.’’. 25
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(2) R EQUIRED REPORTING .—Section 1
1311(c)(1) of the Patient Protection and Affordable 2
Care Act (42 U.S.C. 18031(c)(1)) is amended— 3
(A) in subparagraph (H), by striking 4
‘‘and’’ at the end; 5
(B) in subparagraph (I), by striking the 6
period at the end and inserting ‘‘; and’’; and 7
(C) by adding at the end the following: 8
‘‘(J) report to the Secretary the termi-9
nation (as defined in section 1312(e)(4)(C)) of 10
an issuer.’’. 11
(c) A
UTHORITYTOREGULATEFIELDMARKETING 12
O
RGANIZATIONS ANDTHIRD-PARTYMARKETINGORGANI-13
ZATIONS.—Section 1312(e) of the Patient Protection and 14
Affordable Care Act (42 U.S.C. 18032(e)) is amended— 15
(1) by redesignating paragraphs (1) and (2) as 16
subclauses (I) and (II), respectively, and adjusting 17
the margins accordingly; 18
(2) in subclause (II) (as so redesignated), by 19
striking the period at the end and inserting ‘‘; and’’; 20
(3) by striking the subsection designation and 21
heading and all that follows through ‘‘brokers—’’ 22
and inserting the following: 23
‘‘(e) R
EGULATION OFAGENTS, BROKERS, ANDCER-24
TAINMARKETINGORGANIZATIONS.— 25
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‘‘(1) AGENTS, BROKERS, AND CERTAIN MAR -1
KETING ORGANIZATIONS .— 2
‘‘(A) I
N GENERAL.—The Secretary shall 3
establish procedures under which a State may 4
allow— 5
‘‘(i) agents or brokers—’’; and 6
(4) by adding at the end the following: 7
‘‘(ii) field marketing organizations 8
and third-party marketing organizations to 9
participate in the chain of enrollment for 10
an individual with respect to qualified 11
health plans offered through an Exchange. 12
‘‘(B) C
RITERIA.—For plan years beginning 13
on or after such date specified by the Secretary, 14
but not later than January 1, 2029, the Sec-15
retary, by regulation, shall establish criteria for 16
States to use in determining whether to allow 17
agents and brokers to enroll individuals and 18
employers in qualified health plans as described 19
in subclause (I) of subparagraph (A)(i) and to 20
assist individuals as described in subclause (II) 21
of such subparagraph and field marketing orga-22
nizations and third-party marketing organiza-23
tions to participate in the chain of enrollment 24
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as described in subparagraph (A)(ii). Such cri-1
teria shall, at a minimum, require that— 2
‘‘(i) an agent or broker act in accord-3
ance with a standard of conduct that in-4
cludes a duty of such agent or broker to 5
act in the best interests of the enrollee; 6
‘‘(ii) a field marketing organization or 7
third-party marketing organization agree 8
to report the termination of an agent or 9
broker to the applicable State and the Sec-10
retary, including the reason for termi-11
nation; and 12
‘‘(iii) an agent, broker, field mar-13
keting organization, or third-party mar-14
keting organization— 15
‘‘(I) meet such marketing re-16
quirements as are required by the 17
Secretary; 18
‘‘(II) meet marketing require-19
ments in accordance with other appli-20
cable Federal or State law; 21
‘‘(III) does not employ practices 22
that are confusing or misleading, as 23
determined by the Secretary; 24
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‘‘(IV) submit all marketing mate-1
rials to the Secretary for, as deter-2
mined appropriate by the Secretary, 3
review and approval; 4
‘‘(V) is a licensed agent or broker 5
or meets other licensure requirements, 6
as required by the State; 7
‘‘(VI) register with the Secretary; 8
and 9
‘‘(VII) does not compensate any 10
individual or organization for referrals 11
or any other service relating to the 12
sale of, marketing for, or enrollment 13
in qualified health plans unless such 14
individual or organization meets the 15
criteria described in subclauses (I) 16
through (VI). 17
‘‘(C) D
EFINITIONS.—In this paragraph: 18
‘‘(i) C
HAIN OF ENROLLMENT .—The 19
term ‘chain of enrollment’, with respect to 20
enrollment of an individual in a qualified 21
health plan offered through an Exchange, 22
means any steps taken from marketing to 23
such individual, to such individual making 24
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an enrollment decision with respect to such 1
a plan. 2
‘‘(ii) F
IELD MARKETING ORGANIZA -3
TION.—The term ‘field marketing organi-4
zation’ means an organization or individual 5
that directly employs or contracts with 6
agents and brokers, or contracts with car-7
riers, to provide functions relating to en-8
rollment of individuals in qualified health 9
plans offered through an Exchange as part 10
of the chain of enrollment. 11
‘‘(iii) M
ARKETING.—The term ‘mar-12
keting’ means the use of marketing mate-13
rials to provide information to current and 14
prospective enrollees in a qualified health 15
plan offered through an Exchange. 16
‘‘(iv) M
ARKETING MATERIALS .—The 17
term ‘marketing materials’ means mate-18
rials relating to a qualified health plan of-19
fered through an Exchange or benefits of-20
fered through an Exchange that— 21
‘‘(I) are intended— 22
‘‘(aa) to draw an individual’s 23
attention to such plan or the pre-24
mium tax credits or cost-sharing 25
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reductions for such plan or plans 1
offered through an Exchange; 2
‘‘(bb) to influence an indi-3
vidual’s decision-making process 4
when selecting a qualified health 5
plan in which to enroll; or 6
‘‘(cc) to influence an enroll-7
ee’s decision to stay enrolled in 8
such plan; and 9
‘‘(II) include or address content 10
regarding the benefits, benefit struc-11
ture, premiums, or cost sharing of 12
such plan. 13
‘‘(v) T
ERMINATION.—The term ‘ter-14
mination’, with respect to a contract or 15
business arrangement between an agent or 16
broker and a field marketing organization, 17
third-party marketing organization, or 18
health insurance issuer, means— 19
‘‘(I) the ending of such contract 20
or business arrangement, either uni-21
laterally by one of the parties or on 22
mutual agreement; or 23
‘‘(II) the expiration of such con-24
tract or business arrangement that is 25
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not replaced by a substantially similar 1
agreement. 2
‘‘(vi) T
HIRD-PARTY MARKETING ORGA -3
NIZATION.—The term ‘third-party mar-4
keting organization’ means an organization 5
or individual that is compensated to per-6
form lead generation, marketing, or sales 7
relating to enrollment of individuals in 8
qualified health plans offered through an 9
Exchange as part of the chain of enroll-10
ment.’’. 11
(d) T
RANSPARENCY.—Section 1312(e) of the Patient 12
Protection and Affordable Care Act (42 U.S.C. 18032(e)) 13
(as amended by subsection (c)) is amended by adding at 14
the end the following: 15
‘‘(2) A
UDITS.— 16
‘‘(A) I
N GENERAL.—For plan years begin-17
ning on or after such date specified by the Sec-18
retary, but not later than January 1, 2029, the 19
Secretary, in coordination with the States and 20
in consultation with the National Association of 21
Insurance Commissioners, shall implement a 22
process for the oversight and enforcement of 23
agent and broker compliance with this section 24
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and other applicable Federal and State law (in-1
cluding regulations) that shall include— 2
‘‘(i) periodic audits of agents and bro-3
kers based on— 4
‘‘(I) complaints filed with the 5
Secretary by individuals enrolled by 6
such an agent or broker in a qualified 7
health plan offered through an Ex-8
change; 9
‘‘(II) an incident or enrollment 10
pattern that suggests fraud; and 11
‘‘(III) other factors determined 12
by the Secretary; and 13
‘‘(ii) a process under which the Sec-14
retary shall share audit results and refer 15
potential cases of fraud to the relevant 16
State department of insurance. 17
‘‘(B) E
FFECT.—Nothing in this paragraph 18
limits or restricts any referrals made under sec-19
tion 1311(i)(3) or any enforcement actions 20
under section 1411(h). 21
‘‘(3) L
IST.—The Secretary shall develop a proc-22
ess to regularly provide to qualified health plans, 23
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Exchanges, and States a list of suspended and ter-1
minated agents and brokers.’’. 2
Æ
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