I 

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. 

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled, 

3 SECTION 1. SHORT TITLE. 

4 This Act may be cited as the ‘‘Insurance Fraud Ac5 countability Act’’. 

6 SEC. 2. REDUCTION OF FRAUDULENT ENROLLMENT IN 

7 QUALIFIED HEALTH PLANS. 

8 (a) PENALTIES FOR AGENTS AND BROKERS.—Sec9 tion 1411(h)(1) of the Patient Protection and Affordable 

10 Care Act (42 U.S.C. 18081(h)(1)) is amended— 


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1 (1) in subparagraph (A)— 

2 (A) by redesignating clause (ii) as clause 

3 (iv); 

4 (B) in clause (i)— 

5 (i) in the matter preceding subclause 

6 (I), by striking ‘‘If—’’ and all that follows 

7 through the ‘‘such person’’ in the matter 

8 following subclause (II) and inserting the 

9 following: ‘‘If any person (other than an 

10 agent or broker) fails to provide correct in11 formation under subsection (b) and such 

12 failure is attributable to negligence or dis13 regard of any rules or regulations of the 

14 Secretary, such person’’; and 

15 (ii) in the second sentence, by striking 

16 ‘‘For purposes’’ and inserting the fol17 lowing: 

18 ‘‘(iii) DEFINITIONS OF NEGLIGENCE, 

19 DISREGARD.—For purposes’’; 

20 (C) by inserting after clause (i) the fol21 lowing: 

22 ‘‘(ii) CIVIL PENALTIES FOR CERTAIN

23 VIOLATIONS BY AGENTS OR BROKERS.—If 

24 any agent or broker fails to provide correct 

25 information under subsection (b) or section 


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1 1311(c)(8) or other information, as speci2 fied by the Secretary, and such failure is 

3 attributable to negligence or disregard of 

4 any rules or regulations of the Secretary, 

5 such agent or broker shall be subject, in 

6 addition to any other penalties that may be 

7 prescribed by law, including subparagraph 

8 (C), to a civil penalty of not less than 

9 $10,000 and not more than $50,000 with 

10 respect to each individual who is the sub11 ject of an application for which such incor12 rect information is provided.’’; and 

13 (D) in clause (iv) (as so redesignated), by 

14 inserting ‘‘or (ii)’’ after ‘‘clause (i)’’; 

15 (2) in subparagraph (B)— 

16 (A) by inserting ‘‘including subparagraph 

17 (C),’’ after ‘‘law,’’; 

18 (B) by striking ‘‘Any person’’ and insert19 ing the following: 

20 ‘‘(i) IN GENERAL.—Any person’’; and 

21 (i) by adding at the end the following: 

22 ‘‘(ii) CIVIL PENALTIES FOR KNOWING

23 VIOLATIONS BY AGENTS OR BROKERS.— 

24 ‘‘(I) IN GENERAL.—Any agent or 

25 broker who knowingly provides false 


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1 or fraudulent information under sub2 section (b) or section 1311(c)(8), or 

3 other false or fraudulent information 

4 as part of an application for enroll5 ment in a qualified health plan offered 

6 through an Exchange, as specified by 

7 the Secretary, shall be subject, in ad8 dition to any other penalties that may 

9 be prescribed by law, including sub10 paragraph (C), to a civil penalty of 

11 not more than $200,000 with respect 

12 to each individual who is the subject 

13 of an application for which such false 

14 or fraudulent information is provided. 

15 ‘‘(II) PROCEDURE.—The provi16 sions of section 1128A of the Social 

17 Security Act (other than subsections 

18 (a) and (b) of such section) shall 

19 apply to a civil monetary penalty 

20 under subclause (I) in the same man21 ner as such provisions apply to a pen22 alty or proceeding under section 

23 1128A of the Social Security Act.’’; 

24 and 

25 (3) by adding at the end the following: 


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1 ‘‘(C) CRIMINAL PENALTIES.—Any agent or 

2 broker who knowingly and willfully provides 

3 false or fraudulent information under sub4 section (b) or section 1311(c)(8), or other false 

5 or fraudulent information as part of an applica6 tion for enrollment in a qualified health plan of7 fered through an Exchange, as specified by the 

8 Secretary, shall be fined under title 18, United 

9 States Code, imprisoned for not more than 10 

10 years, or both.’’. 

11 (b) CONSUMER PROTECTIONS.— 

12 (1) IN GENERAL.—Section 1311(c) of the Pa13 tient Protection and Affordable Care Act (42 U.S.C. 

14 18031(c)) is amended by adding at the end the fol15 lowing: 

16 ‘‘(8) AGENT- OR BROKER-ASSISTED ENROLL17 MENT IN QUALIFIED HEALTH PLANS IN CERTAIN

18 EXCHANGES.— 

19 ‘‘(A) IN GENERAL.—For plan years begin20 ning on or after such date specified by the Sec21 retary, but not later than January 1, 2028, in 

22 the case of an Exchange that the Secretary op23 erates pursuant to section 1321(c)(1), the Sec24 retary shall establish a verification process for 

25 new enrollments of individuals in, and changes 


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1 in coverage for individuals under, a qualified 

2 health plan offered through such Exchange, 

3 which are submitted by an agent or broker in 

4 accordance with section 1312(e) and for which 

5 the agent or broker is eligible to receive a com6 mission. 

7 ‘‘(B) REQUIREMENTS.—The enrollment 

8 verification process under subparagraph (A) 

9 shall include— 

10 ‘‘(i) a requirement that the agent or 

11 broker provide with the new enrollment or 

12 coverage change such documentation or 

13 evidence (such as a standardized consent 

14 form) or other sources as the Secretary de15 termines necessary to establish that the 

16 agent or broker has the consent of the in17 dividual for the new enrollment or coverage 

18 change; 

19 ‘‘(ii) a requirement that any commis20 sions due to a broker or agent for such 

21 new enrollment or coverage change are 

22 paid after the enrollee has resolved all in23 consistencies in accordance with para24 graphs (3) and (4) of section 1411(e); 


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1 ‘‘(iii) a requirement that the informa2 tion required under clause (i) and, as ap3 plicable, the date on which inconsistencies 

4 are resolved as described in clause (ii), is 

5 accessible to the applicable qualified health 

6 plan through a database or other resource, 

7 as determined by the Secretary, so that 

8 any commissions due to a broker or agent 

9 for such enrollment can be effectuated at 

10 the appropriate time; 

11 ‘‘(iv) a requirement that individuals 

12 are notified of any changes to enrollment, 

13 coverage, the agent of record, or premium 

14 tax credits in a timely manner and that 

15 such notice provides plain language in16 structions on how individuals can cancel 

17 unauthorized activity; 

18 ‘‘(v) a requirement that individuals be 

19 able to access their account information on 

20 a website or other technology platform, as 

21 defined by the Secretary, when used to 

22 submit an enrollment or plan change, in 

23 lieu of the Exchange website described in 

24 subsection (d)(4)(C), including information 

25 on the agent of record, the qualified health 


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1 plan, and when any changes are made to 

2 the agent of record or the qualified health 

3 plan, on a consumer-facing website or 

4 through a toll-free telephone hotline; and 

5 ‘‘(vi) a requirement that the agent or 

6 broker report to the Secretary any third7 party marketing organization or field mar8 keting organization (as such terms are de9 fined in section 1312(e)) involved in the 

10 chain of enrollment (as so defined) with re11 spect to such new enrollment or coverage 

12 change. 

13 ‘‘(C) CONSUMER PROTECTION.—The Sec14 retary shall ensure that the enrollment 

15 verification process under subparagraph (A) 

16 prioritizes continuity of coverage and care for 

17 individuals, including by not disenrolling indi18 viduals from a qualified health plan without the 

19 consent of the individual, regardless of whether 

20 the broker, agent, or qualified health plan is in 

21 violation of any requirement under this para22 graph.’’. 

23 (2) REQUIRED REPORTING.—Section 

24 1311(c)(1) of the Patient Protection and Affordable 

25 Care Act (42 U.S.C. 18031(c)(1)) is amended— 


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1 (A) in subparagraph (H), by striking 

2 ‘‘and’’ at the end; 

3 (B) in subparagraph (I), by striking the 

4 period at the end and inserting ‘‘; and’’; and 

5 (C) by adding at the end the following: 

6 ‘‘(J) report to the Secretary the termi7 nation (as defined in section 1312(e)(4)(C)) of 

8 an issuer.’’. 

9 (c) AUTHORITY TO REGULATE FIELD MARKETING

10 ORGANIZATIONS AND THIRD-PARTY MARKETING ORGANI11 ZATIONS.—Section 1312(e) of the Patient Protection and 

12 Affordable Care Act (42 U.S.C. 18032(e)) is amended— 

13 (1) by redesignating paragraphs (1) and (2) as 

14 subclauses (I) and (II), respectively, and adjusting 

15 the margins accordingly; 

16 (2) in subclause (II) (as so redesignated), by 

17 striking the period at the end and inserting ‘‘; and’’; 

18 (3) by striking the subsection designation and 

19 heading and all that follows through ‘‘brokers—’’ 

20 and inserting the following: 

21 ‘‘(e) REGULATION OF AGENTS, BROKERS, AND CER22 TAIN MARKETING ORGANIZATIONS.— 

23 ‘‘(1) AGENTS, BROKERS, AND CERTAIN MAR24 KETING ORGANIZATIONS.— 


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1 ‘‘(A) IN GENERAL.—The Secretary shall 

2 establish procedures under which a State may 

3 allow— 

4 ‘‘(i) agents or brokers—’’; and 

5 (4) by adding at the end the following: 

6 ‘‘(ii) field marketing organizations 

7 and third-party marketing organizations to 

8 participate in the chain of enrollment for 

9 an individual with respect to qualified 

10 health plans offered through an Exchange. 

11 ‘‘(B) CRITERIA.—For plan years beginning 

12 on or after such date specified by the Secretary, 

13 but not later than January 1, 2028, the Sec14 retary, by regulation, shall establish criteria for 

15 States to use in determining whether to allow 

16 agents and brokers to enroll individuals and 

17 employers in qualified health plans as described 

18 in subclause (I) of subparagraph (A)(i) and to 

19 assist individuals as described in subclause (II) 

20 of such subparagraph and field marketing orga21 nizations and third-party marketing organiza22 tions to participate in the chain of enrollment 

23 as described in subparagraph (A)(ii). Such cri24 teria shall, at a minimum, require that— 


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1 ‘‘(i) an agent or broker act in accord2 ance with a standard of conduct that in3 cludes a duty of such agent or broker to 

4 act in the best interests of the enrollee; 

5 ‘‘(ii) a field marketing organization or 

6 third-party marketing organization agree 

7 to report the termination of an agent or 

8 broker to the applicable State and the Sec9 retary, including the reason for termi10 nation; and 

11 ‘‘(iii) an agent, broker, field mar12 keting organization, or third-party mar13 keting organization— 

14 ‘‘(I) meet such marketing re15 quirements as are required by the 

16 Secretary; 

17 ‘‘(II) meet marketing require18 ments in accordance with other appli19 cable Federal or State law; 

20 ‘‘(III) does not employ practices 

21 that are confusing or misleading, as 

22 determined by the Secretary; 

23 ‘‘(IV) submit all marketing mate24 rials to the Secretary for, as deterVerDate Sep 11 2014 18:09 Nov 04, 2024 Jkt 059200 PO 00000 Frm 00011 Fmt 6652 Sfmt 6201 E:\BILLS\H10095.IH H10095

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1 mined appropriate by the Secretary, 

2 review and approval; 

3 ‘‘(V) is a licensed agent or broker 

4 or meets other licensure requirements, 

5 as required by the State; 

6 ‘‘(VI) register with the Secretary; 

7 and 

8 ‘‘(VII) does not compensate any 

9 individual or organization for referrals 

10 or any other service relating to the 

11 sale of, marketing for, or enrollment 

12 in qualified health plans unless such 

13 individual or organization meets the 

14 criteria described in subclauses (I) 

15 through (VI). 

16 ‘‘(C) DEFINITIONS.—In this paragraph: 

17 ‘‘(i) CHAIN OF ENROLLMENT.—The 

18 term ‘chain of enrollment’, with respect to 

19 enrollment of an individual in a qualified 

20 health plan offered through an Exchange, 

21 means any steps taken from marketing to 

22 such individual, to such individual making 

23 an enrollment decision with respect to such 

24 a plan. 


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1 ‘‘(ii) FIELD MARKETING ORGANIZA2 TION.—The term ‘field marketing organi3 zation’ means an organization or individual 

4 that directly employs or contracts with 

5 agents and brokers, or contracts with car6 riers, to provide functions relating to en7 rollment of individuals in qualified health 

8 plans offered through an Exchange as part 

9 of the chain of enrollment. 

10 ‘‘(iii) MARKETING.—The term ‘mar11 keting’ means the use of marketing mate12 rials to provide information to current and 

13 prospective enrollees in a qualified health 

14 plan offered through an Exchange. 

15 ‘‘(iv) MARKETING MATERIALS.—The 

16 term ‘marketing materials’ means mate17 rials relating to a qualified health plan of18 fered through an Exchange or benefits of19 fered through an Exchange that— 

20 ‘‘(I) are intended— 

21 ‘‘(aa) to draw an individual’s 

22 attention to such plan or the pre23 mium tax credits or cost-sharing 

24 reductions for such plan or plans 

25 offered through an Exchange; 


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1 ‘‘(bb) to influence an indi2 vidual’s decision-making process 

3 when selecting a qualified health 

4 plan in which to enroll; or 

5 ‘‘(cc) to influence an enroll6 ee’s decision to stay enrolled in 

7 such plan; and 

8 ‘‘(II) include or address content 

9 regarding the benefits, benefit struc10 ture, premiums, or cost sharing of 

11 such plan. 

12 ‘‘(v) TERMINATION.—The term ‘ter13 mination’, with respect to a contract or 

14 business arrangement between an agent or 

15 broker and a field marketing organization, 

16 third-party marketing organization, or 

17 health insurance issuer, means— 

18 ‘‘(I) the ending of such contract 

19 or business arrangement, either uni20 laterally by one of the parties or on 

21 mutual agreement; or 

22 ‘‘(II) the expiration of such con23 tract or business arrangement that is 

24 not replaced by a substantially similar 

25 agreement. 


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1 ‘‘(vi) THIRD-PARTY MARKETING ORGA2 NIZATION.—The term ‘third-party mar3 keting organization’ means an organization 

4 or individual that is compensated to per5 form lead generation, marketing, or sales 

6 relating to enrollment of individuals in 

7 qualified health plans offered through an 

8 Exchange as part of the chain of enroll9 ment.’’. 

10 (d) TRANSPARENCY.—Section 1312(e) of the Patient 

11 Protection and Affordable Care Act (42 U.S.C. 18032(e)) 

12 (as amended by subsection (c)) is amended by adding at 

13 the end the following: 

14 ‘‘(2) AUDITS.— 

15 ‘‘(A) IN GENERAL.—For plan years begin16 ning on or after such date specified by the Sec17 retary, but not later than January 1, 2028, the 

18 Secretary, in coordination with the States and 

19 in consultation with the National Association of 

20 Insurance Commissioners, shall implement a 

21 process for the oversight and enforcement of 

22 agent and broker compliance with this section 

23 and other applicable Federal and State law (in24 cluding regulations) that shall include— 


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1 ‘‘(i) periodic audits of agents and bro2 kers based on— 

3 ‘‘(I) complaints filed with the 

4 Secretary by individuals enrolled by 

5 such an agent or broker in a qualified 

6 health plan offered through an Ex7 change; 

8 ‘‘(II) an incident or enrollment 

9 pattern that suggests fraud; and 

10 ‘‘(III) other factors determined 

11 by the Secretary; and 

12 ‘‘(ii) a process under which the Sec13 retary shall share audit results and refer 

14 potential cases of fraud to the relevant 

15 State department of insurance. 

16 ‘‘(B) EFFECT.—Nothing in this paragraph 

17 limits or restricts any referrals made under sec18 tion 1311(i)(3) or any enforcement actions 

19 under section 1411(h). 

20 ‘‘(3) LIST.—The Secretary shall develop a proc21 ess to regularly provide to qualified health plans, 

22 Exchanges, and States a list of suspended and ter23 minated agents and brokers.’’. 

Æ 


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