II 

118TH CONGRESS 

2D SESSION S. 4767 

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 

JULY 24, 2024 

Mr. WYDEN (for himself, Mr. BROWN, Ms. DUCKWORTH, Mrs. MURRAY, Mr. 

SCHATZ, and Mr. VAN HOLLEN) 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. 

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’’. 


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1 SEC. 2. REDUCTION OF FRAUDULENT ENROLLMENT IN 

2 QUALIFIED HEALTH PLANS. 

3 (a) PENALTIES FOR AGENTS AND BROKERS.—Sec4 tion 1411(h)(1) of the Patient Protection and Affordable 

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

6 (1) in subparagraph (A)— 

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

8 (iv); 

9 (B) in clause (i)— 

10 (i) in the matter preceding subclause 

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

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

13 following subclause (II) and inserting the 

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

15 agent or broker) fails to provide correct in16 formation under subsection (b) and such 

17 failure is attributable to negligence or dis18 regard of any rules or regulations of the 

19 Secretary, such person’’; and 

20 (ii) in the second sentence, by striking 

21 ‘‘For purposes’’ and inserting the fol22 lowing: 

23 ‘‘(iii) DEFINITIONS OF NEGLIGENCE, 

24 DISREGARD.—For purposes’’; 

25 (C) by inserting after clause (i) the fol26 lowing: 


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1 ‘‘(ii) CIVIL PENALTIES FOR CERTAIN

2 VIOLATIONS BY AGENTS OR BROKERS.—If 

3 any agent or broker fails to provide correct 

4 information under subsection (b) or section 

5 1311(c)(8) or other information, as speci6 fied by the Secretary, and such failure is 

7 attributable to negligence or disregard of 

8 any rules or regulations of the Secretary, 

9 such agent or broker shall be subject, in 

10 addition to any other penalties that may be 

11 prescribed by law, including subparagraph 

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

13 $10,000 and not more than $50,000 with 

14 respect to each individual who is the sub15 ject of an application for which such incor16 rect information is provided.’’; and 

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

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

19 (2) in subparagraph (B)— 

20 (A) by inserting ‘‘including subparagraph 

21 (C),’’ after ‘‘law,’’; 

22 (B) by striking ‘‘Any person’’ and insert23 ing the following: 

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

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


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1 ‘‘(ii) CIVIL PENALTIES FOR KNOWING

2 VIOLATIONS BY AGENTS OR BROKERS.— 

3 ‘‘(I) IN GENERAL.—Any agent or 

4 broker who knowingly provides false 

5 or fraudulent information under sub6 section (b) or section 1311(c)(8), or 

7 other false or fraudulent information 

8 as part of an application for enroll9 ment in a qualified health plan offered 

10 through an Exchange, as specified by 

11 the Secretary, shall be subject, in ad12 dition to any other penalties that may 

13 be prescribed by law, including sub14 paragraph (C), to a civil penalty of 

15 not more than $200,000 with respect 

16 to each individual who is the subject 

17 of an application for which such false 

18 or fraudulent information is provided. 

19 ‘‘(II) PROCEDURE.—The provi20 sions of section 1128A of the Social 

21 Security Act (other than subsections 

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

23 apply to a civil monetary penalty 

24 under subclause (I) in the same man25 ner as such provisions apply to a penVerDate Sep 11 2014 22:32 Aug 26, 2024 Jkt 049200 PO 00000 Frm 00004 Fmt 6652 Sfmt 6201 E:\BILLS\S4767.IS S4767

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1 alty or proceeding under section 

2 1128A of the Social Security Act.’’; 

3 and 

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

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

6 broker who knowingly and willfully provides 

7 false or fraudulent information under sub8 section (b) or section 1311(c)(8), or other false 

9 or fraudulent information as part of an applica10 tion for enrollment in a qualified health plan of11 fered through an Exchange, as specified by the 

12 Secretary, shall be fined under title 18, United 

13 States Code, imprisoned for not more than 10 

14 years, or both.’’. 

15 (b) CONSUMER PROTECTIONS.— 

16 (1) IN GENERAL.—Section 1311(c) of the Pa17 tient Protection and Affordable Care Act (42 U.S.C. 

18 18031(c)) is amended by adding at the end the fol19 lowing: 

20 ‘‘(8) AGENT- OR BROKER-ASSISTED ENROLL21 MENT IN QUALIFIED HEALTH PLANS IN CERTAIN

22 EXCHANGES.— 

23 ‘‘(A) IN GENERAL.—For plan years begin24 ning on or after such date specified by the Sec25 retary, but not later than January 1, 2028, in 


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1 the case of an Exchange that the Secretary op2 erates pursuant to section 1321(c)(1), the Sec3 retary shall establish a verification process for 

4 new enrollments of individuals in, and changes 

5 in coverage for individuals under, a qualified 

6 health plan offered through such Exchange, 

7 which are submitted by an agent or broker in 

8 accordance with section 1312(e) and for which 

9 the agent or broker is eligible to receive a com10 mission. 

11 ‘‘(B) REQUIREMENTS.—The enrollment 

12 verification process under subparagraph (A) 

13 shall include— 

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

15 broker provide with the new enrollment or 

16 coverage change such documentation or 

17 evidence (such as a standardized consent 

18 form) or other sources as the Secretary de19 termines necessary to establish that the 

20 agent or broker has the consent of the in21 dividual for the new enrollment or coverage 

22 change; 

23 ‘‘(ii) a requirement that any commis24 sions due to a broker or agent for such 

25 new enrollment or coverage change are 


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1 paid after the enrollee has resolved all in2 consistencies in accordance with para3 graphs (3) and (4) of section 1411(e); 

4 ‘‘(iii) a requirement that the informa5 tion required under clause (i) and, as ap6 plicable, the date on which inconsistencies 

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

8 accessible to the applicable qualified health 

9 plan through a database or other resource, 

10 as determined by the Secretary, so that 

11 any commissions due to a broker or agent 

12 for such enrollment can be effectuated at 

13 the appropriate time; 

14 ‘‘(iv) a requirement that individuals 

15 are notified of any changes to enrollment, 

16 coverage, the agent of record, or premium 

17 tax credits in a timely manner and that 

18 such notice provides plain language in19 structions on how individuals can cancel 

20 unauthorized activity; 

21 ‘‘(v) a requirement that individuals be 

22 able to access their account information on 

23 a website or other technology platform, as 

24 defined by the Secretary, when used to 

25 submit an enrollment or plan change, in 


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1 lieu of the Exchange website described in 

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

3 on the agent of record, the qualified health 

4 plan, and when any changes are made to 

5 the agent of record or the qualified health 

6 plan, on a consumer-facing website or 

7 through a toll-free telephone hotline; and 

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

9 broker report to the Secretary any third10 party marketing organization or field mar11 keting organization (as such terms are de12 fined in section 1312(e)) involved in the 

13 chain of enrollment (as so defined) with re14 spect to such new enrollment or coverage 

15 change. 

16 ‘‘(C) CONSUMER PROTECTION.—The Sec17 retary shall ensure that the enrollment 

18 verification process under subparagraph (A) 

19 prioritizes continuity of coverage and care for 

20 individuals, including by not disenrolling indi21 viduals from a qualified health plan without the 

22 consent of the individual, regardless of whether 

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

24 violation of any requirement under this para25 graph.’’. 


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1 (2) REQUIRED REPORTING.—Section 

2 1311(c)(1) of the Patient Protection and Affordable 

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

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

5 ‘‘and’’ at the end; 

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

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

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

9 ‘‘(J) report to the Secretary the termi10 nation (as defined in section 1312(e)(4)(C)) of 

11 an issuer.’’. 

12 (c) AUTHORITY TO REGULATE FIELD MARKETING

13 ORGANIZATIONS AND THIRD-PARTY MARKETING ORGANI14 ZATIONS.—Section 1312(e) of the Patient Protection and 

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

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

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

18 the margins accordingly; 

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

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

21 (3) by striking the subsection designation and 

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

23 and inserting the following: 

24 ‘‘(e) REGULATION OF AGENTS, BROKERS, AND CER25 TAIN MARKETING ORGANIZATIONS.— 


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1 ‘‘(1) AGENTS, BROKERS, AND CERTAIN MAR2 KETING ORGANIZATIONS.— 

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

4 establish procedures under which a State may 

5 allow— 

6 ‘‘(i) agents or brokers—’’; and 

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

8 ‘‘(ii) field marketing organizations 

9 and third-party marketing organizations to 

10 participate in the chain of enrollment for 

11 an individual with respect to qualified 

12 health plans offered through an Exchange. 

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

14 on or after such date specified by the Secretary, 

15 but not later than January 1, 2028, the Sec16 retary, by regulation, shall establish criteria for 

17 States to use in determining whether to allow 

18 agents and brokers to enroll individuals and 

19 employers in qualified health plans as described 

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

21 assist individuals as described in subclause (II) 

22 of such subparagraph and field marketing orga23 nizations and third-party marketing organiza24 tions to participate in the chain of enrollment 


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1 as described in subparagraph (A)(ii). Such cri2 teria shall, at a minimum, require that— 

3 ‘‘(i) an agent or broker act in accord4 ance with a standard of conduct that in5 cludes a duty of such agent or broker to 

6 act in the best interests of the enrollee; 

7 ‘‘(ii) a field marketing organization or 

8 third-party marketing organization agree 

9 to report the termination of an agent or 

10 broker to the applicable State and the Sec11 retary, including the reason for termi12 nation; and 

13 ‘‘(iii) an agent, broker, field mar14 keting organization, or third-party mar15 keting organization— 

16 ‘‘(I) meet such marketing re17 quirements as are required by the 

18 Secretary; 

19 ‘‘(II) meet marketing require20 ments in accordance with other appli21 cable Federal or State law; 

22 ‘‘(III) does not employ practices 

23 that are confusing or misleading, as 

24 determined by the Secretary; 


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1 ‘‘(IV) submit all marketing mate2 rials to the Secretary for, as deter3 mined appropriate by the Secretary, 

4 review and approval; 

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

6 or meets other licensure requirements, 

7 as required by the State; 

8 ‘‘(VI) register with the Secretary; 

9 and 

10 ‘‘(VII) does not compensate any 

11 individual or organization for referrals 

12 or any other service relating to the 

13 sale of, marketing for, or enrollment 

14 in qualified health plans unless such 

15 individual or organization meets the 

16 criteria described in subclauses (I) 

17 through (VI). 

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

19 ‘‘(i) CHAIN OF ENROLLMENT.—The 

20 term ‘chain of enrollment’, with respect to 

21 enrollment of an individual in a qualified 

22 health plan offered through an Exchange, 

23 means any steps taken from marketing to 

24 such individual, to such individual making 


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1 an enrollment decision with respect to such 

2 a plan. 

3 ‘‘(ii) FIELD MARKETING ORGANIZA4 TION.—The term ‘field marketing organi5 zation’ means an organization or individual 

6 that directly employs or contracts with 

7 agents and brokers, or contracts with car8 riers, to provide functions relating to en9 rollment of individuals in qualified health 

10 plans offered through an Exchange as part 

11 of the chain of enrollment. 

12 ‘‘(iii) MARKETING.—The term ‘mar13 keting’ means the use of marketing mate14 rials to provide information to current and 

15 prospective enrollees in a qualified health 

16 plan offered through an Exchange. 

17 ‘‘(iv) MARKETING MATERIALS.—The 

18 term ‘marketing materials’ means mate19 rials relating to a qualified health plan of20 fered through an Exchange or benefits of21 fered through an Exchange that— 

22 ‘‘(I) are intended— 

23 ‘‘(aa) to draw an individual’s 

24 attention to such plan or the pre25 mium tax credits or cost-sharing 


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1 reductions for such plan or plans 

2 offered through an Exchange; 

3 ‘‘(bb) to influence an indi4 vidual’s decision-making process 

5 when selecting a qualified health 

6 plan in which to enroll; or 

7 ‘‘(cc) to influence an enroll8 ee’s decision to stay enrolled in 

9 such plan; and 

10 ‘‘(II) include or address content 

11 regarding the benefits, benefit struc12 ture, premiums, or cost sharing of 

13 such plan. 

14 ‘‘(v) TERMINATION.—The term ‘ter15 mination’, with respect to a contract or 

16 business arrangement between an agent or 

17 broker and a field marketing organization, 

18 third-party marketing organization, or 

19 health insurance issuer, means— 

20 ‘‘(I) the ending of such contract 

21 or business arrangement, either uni22 laterally by one of the parties or on 

23 mutual agreement; or 

24 ‘‘(II) the expiration of such con25 tract or business arrangement that is 


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1 not replaced by a substantially similar 

2 agreement. 

3 ‘‘(vi) THIRD-PARTY MARKETING ORGA4 NIZATION.—The term ‘third-party mar5 keting organization’ means an organization 

6 or individual that is compensated to per7 form lead generation, marketing, or sales 

8 relating to enrollment of individuals in 

9 qualified health plans offered through an 

10 Exchange as part of the chain of enroll11 ment.’’. 

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

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

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

15 the end the following: 

16 ‘‘(2) AUDITS.— 

17 ‘‘(A) IN GENERAL.—For plan years begin18 ning on or after such date specified by the Sec19 retary, but not later than January 1, 2028, the 

20 Secretary, in coordination with the States and 

21 in consultation with the National Association of 

22 Insurance Commissioners, shall implement a 

23 process for the oversight and enforcement of 

24 agent and broker compliance with this section 


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1 and other applicable Federal and State law (in2 cluding regulations) that shall include— 

3 ‘‘(i) periodic audits of agents and bro4 kers based on— 

5 ‘‘(I) complaints filed with the 

6 Secretary by individuals enrolled by 

7 such an agent or broker in a qualified 

8 health plan offered through an Ex9 change; 

10 ‘‘(II) an incident or enrollment 

11 pattern that suggests fraud; and 

12 ‘‘(III) other factors determined 

13 by the Secretary; and 

14 ‘‘(ii) a process under which the Sec15 retary shall share audit results and refer 

16 potential cases of fraud to the relevant 

17 State department of insurance. 

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

19 limits or restricts any referrals made under sec20 tion 1311(i)(3) or any enforcement actions 

21 under section 1411(h). 

22 ‘‘(3) LIST.—The Secretary shall develop a proc23 ess to regularly provide to qualified health plans, 


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1 Exchanges, and States a list of suspended and ter2 minated agents and brokers.’’. 

Æ 


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