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. 
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
SECTION 1. SHORT TITLE. 
This Act may be cited as the ‘‘Insurance Fraud Ac-
countability Act’’. 
SEC. 2. REDUCTION OF FRAUDULENT ENROLLMENT IN 
QUALIFIED HEALTH PLANS. 
(a) PENALTIES FOR AGENTS AND BROKERS.—Sec-
tion 1411(h)(1) of the Patient Protection and Affordable 
Care Act (42 U.S.C. 18081(h)(1)) is amended— 
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(1) in subparagraph (A)— 
(A) by redesignating clause (ii) as clause 
(iv); 
(B) in clause (i)— 
(i) in the matter preceding subclause 
(I), by striking ‘‘If—’’ and all that follows 
through the ‘‘such person’’ in the matter 
following subclause (II) and inserting the 
following: ‘‘If any person (other than an 
agent or broker) fails to provide correct in-
formation under subsection (b) and such 
failure is attributable to negligence or dis-
regard of any rules or regulations of the 
Secretary, such person’’; and 
(ii) in the second sentence, by striking 
‘‘For purposes’’ and inserting the fol-
lowing: 
‘‘(iii) DEFINITIONS OF NEGLIGENCE, 
DISREGARD.—For purposes’’; 
(C) by inserting after clause (i) the fol-
lowing: 
‘‘(ii) CIVIL PENALTIES FOR CERTAIN 
VIOLATIONS BY AGENTS OR BROKERS.—If 
any agent or broker fails to provide correct 
information under subsection (b) or section 
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1311(c)(8) or other information, as speci-
fied by the Secretary, and such failure is 
attributable to negligence or disregard of 
any rules or regulations of the Secretary, 
such agent or broker shall be subject, in 
addition to any other penalties that may be 
prescribed by law, including subparagraph 
(C), to a civil penalty of not less than 
$10,000 and not more than $50,000 with 
respect to each individual who is the sub-
ject of an application for which such incor-
rect information is provided.’’; and 
(D) in clause (iv) (as so redesignated), by 
inserting ‘‘or (ii)’’ after ‘‘clause (i)’’; 
(2) in subparagraph (B)— 
(A) by inserting ‘‘including subparagraph 
(C),’’ after ‘‘law,’’; 
(B) by striking ‘‘Any person’’ and insert-
ing the following: 
‘‘(i) IN GENERAL.—Any person’’; and 
(i) by adding at the end the following: 
‘‘(ii) CIVIL PENALTIES FOR KNOWING 
VIOLATIONS BY AGENTS OR BROKERS.— 
‘‘(I) IN GENERAL.—Any agent or 
broker who knowingly provides false 
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or fraudulent information under sub-
section (b) or section 1311(c)(8), or 
other false or fraudulent information 
as part of an application for enroll-
ment in a qualified health plan offered 
through an Exchange, as specified by 
the Secretary, shall be subject, in ad-
dition to any other penalties that may 
be prescribed by law, including sub-
paragraph (C), to a civil penalty of 
not more than $200,000 with respect 
to each individual who is the subject 
of an application for which such false 
or fraudulent information is provided. 
‘‘(II) PROCEDURE.—The provi-
sions of section 1128A of the Social 
Security Act (other than subsections 
(a) and (b) of such section) shall 
apply to a civil monetary penalty 
under subclause (I) in the same man-
ner as such provisions apply to a pen-
alty or proceeding under section 
1128A of the Social Security Act.’’; 
and 
(3) by adding at the end the following: 
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‘‘(C) CRIMINAL PENALTIES.—Any agent or 
broker who knowingly and willfully provides 
false or fraudulent information under sub-
section (b) or section 1311(c)(8), or other false 
or fraudulent information as part of an applica-
tion for enrollment in a qualified health plan of-
fered through an Exchange, as specified by the 
Secretary, shall be fined under title 18, United 
States Code, imprisoned for not more than 10 
years, or both.’’. 
(b) CONSUMER PROTECTIONS.— 
(1) IN GENERAL.—Section 1311(c) of the Pa-
tient Protection and Affordable Care Act (42 U.S.C. 
18031(c)) is amended by adding at the end the fol-
lowing: 
‘‘(8) AGENT- OR
BROKER-ASSISTED
ENROLL-
MENT IN QUALIFIED HEALTH PLANS IN CERTAIN 
EXCHANGES.— 
‘‘(A) IN GENERAL.—For plan years begin-
ning on or after such date specified by the Sec-
retary, but not later than January 1, 2028, in 
the case of an Exchange that the Secretary op-
erates pursuant to section 1321(c)(1), the Sec-
retary shall establish a verification process for 
new enrollments of individuals in, and changes 
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in coverage for individuals under, a qualified 
health plan offered through such Exchange, 
which are submitted by an agent or broker in 
accordance with section 1312(e) and for which 
the agent or broker is eligible to receive a com-
mission. 
‘‘(B) 
REQUIREMENTS.—The 
enrollment 
verification process under subparagraph (A) 
shall include— 
‘‘(i) a requirement that the agent or 
broker provide with the new enrollment or 
coverage change such documentation or 
evidence (such as a standardized consent 
form) or other sources as the Secretary de-
termines necessary to establish that the 
agent or broker has the consent of the in-
dividual for the new enrollment or coverage 
change; 
‘‘(ii) a requirement that any commis-
sions due to a broker or agent for such 
new enrollment or coverage change are 
paid after the enrollee has resolved all in-
consistencies in accordance with para-
graphs (3) and (4) of section 1411(e); 
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‘‘(iii) a requirement that the informa-
tion required under clause (i) and, as ap-
plicable, the date on which inconsistencies 
are resolved as described in clause (ii), is 
accessible to the applicable qualified health 
plan through a database or other resource, 
as determined by the Secretary, so that 
any commissions due to a broker or agent 
for such enrollment can be effectuated at 
the appropriate time; 
‘‘(iv) a requirement that individuals 
are notified of any changes to enrollment, 
coverage, the agent of record, or premium 
tax credits in a timely manner and that 
such notice provides plain language in-
structions on how individuals can cancel 
unauthorized activity; 
‘‘(v) a requirement that individuals be 
able to access their account information on 
a website or other technology platform, as 
defined by the Secretary, when used to 
submit an enrollment or plan change, in 
lieu of the Exchange website described in 
subsection (d)(4)(C), including information 
on the agent of record, the qualified health 
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plan, and when any changes are made to 
the agent of record or the qualified health 
plan, on a consumer-facing website or 
through a toll-free telephone hotline; and 
‘‘(vi) a requirement that the agent or 
broker report to the Secretary any third- 
party marketing organization or field mar-
keting organization (as such terms are de-
fined in section 1312(e)) involved in the 
chain of enrollment (as so defined) with re-
spect to such new enrollment or coverage 
change. 
‘‘(C) CONSUMER PROTECTION.—The Sec-
retary 
shall 
ensure 
that 
the 
enrollment 
verification process under subparagraph (A) 
prioritizes continuity of coverage and care for 
individuals, including by not disenrolling indi-
viduals from a qualified health plan without the 
consent of the individual, regardless of whether 
the broker, agent, or qualified health plan is in 
violation of any requirement under this para-
graph.’’. 
(2) 
REQUIRED
REPORTING.—Section 
1311(c)(1) of the Patient Protection and Affordable 
Care Act (42 U.S.C. 18031(c)(1)) is amended— 
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(A) in subparagraph (H), by striking 
‘‘and’’ at the end; 
(B) in subparagraph (I), by striking the 
period at the end and inserting ‘‘; and’’; and 
(C) by adding at the end the following: 
‘‘(J) report to the Secretary the termi-
nation (as defined in section 1312(e)(4)(C)) of 
an issuer.’’. 
(c) AUTHORITY TO REGULATE FIELD MARKETING 
ORGANIZATIONS AND THIRD-PARTY MARKETING ORGANI-
ZATIONS.—Section 1312(e) of the Patient Protection and 
Affordable Care Act (42 U.S.C. 18032(e)) is amended— 
(1) by redesignating paragraphs (1) and (2) as 
subclauses (I) and (II), respectively, and adjusting 
the margins accordingly; 
(2) in subclause (II) (as so redesignated), by 
striking the period at the end and inserting ‘‘; and’’; 
(3) by striking the subsection designation and 
heading and all that follows through ‘‘brokers—’’ 
and inserting the following: 
‘‘(e) REGULATION OF AGENTS, BROKERS, AND CER-
TAIN MARKETING ORGANIZATIONS.— 
‘‘(1) AGENTS, BROKERS, AND
CERTAIN
MAR-
KETING ORGANIZATIONS.— 
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‘‘(A) IN
GENERAL.—The Secretary shall 
establish procedures under which a State may 
allow— 
‘‘(i) agents or brokers—’’; and 
(4) by adding at the end the following: 
‘‘(ii) field marketing organizations 
and third-party marketing organizations to 
participate in the chain of enrollment for 
an individual with respect to qualified 
health plans offered through an Exchange. 
‘‘(B) CRITERIA.—For plan years beginning 
on or after such date specified by the Secretary, 
but not later than January 1, 2028, the Sec-
retary, by regulation, shall establish criteria for 
States to use in determining whether to allow 
agents and brokers to enroll individuals and 
employers in qualified health plans as described 
in subclause (I) of subparagraph (A)(i) and to 
assist individuals as described in subclause (II) 
of such subparagraph and field marketing orga-
nizations and third-party marketing organiza-
tions to participate in the chain of enrollment 
as described in subparagraph (A)(ii). Such cri-
teria shall, at a minimum, require that— 
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‘‘(i) an agent or broker act in accord-
ance with a standard of conduct that in-
cludes a duty of such agent or broker to 
act in the best interests of the enrollee; 
‘‘(ii) a field marketing organization or 
third-party marketing organization agree 
to report the termination of an agent or 
broker to the applicable State and the Sec-
retary, including the reason for termi-
nation; and 
‘‘(iii) an agent, broker, field mar-
keting organization, or third-party mar-
keting organization— 
‘‘(I) meet such marketing re-
quirements as are required by the 
Secretary; 
‘‘(II) meet marketing require-
ments in accordance with other appli-
cable Federal or State law; 
‘‘(III) does not employ practices 
that are confusing or misleading, as 
determined by the Secretary; 
‘‘(IV) submit all marketing mate-
rials to the Secretary for, as deter-
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mined appropriate by the Secretary, 
review and approval; 
‘‘(V) is a licensed agent or broker 
or meets other licensure requirements, 
as required by the State; 
‘‘(VI) register with the Secretary; 
and 
‘‘(VII) does not compensate any 
individual or organization for referrals 
or any other service relating to the 
sale of, marketing for, or enrollment 
in qualified health plans unless such 
individual or organization meets the 
criteria described in subclauses (I) 
through (VI). 
‘‘(C) DEFINITIONS.—In this paragraph: 
‘‘(i) CHAIN
OF
ENROLLMENT.—The 
term ‘chain of enrollment’, with respect to 
enrollment of an individual in a qualified 
health plan offered through an Exchange, 
means any steps taken from marketing to 
such individual, to such individual making 
an enrollment decision with respect to such 
a plan. 
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‘‘(ii) FIELD
MARKETING
ORGANIZA-
TION.—The term ‘field marketing organi-
zation’ means an organization or individual 
that directly employs or contracts with 
agents and brokers, or contracts with car-
riers, to provide functions relating to en-
rollment of individuals in qualified health 
plans offered through an Exchange as part 
of the chain of enrollment. 
‘‘(iii) MARKETING.—The term ‘mar-
keting’ means the use of marketing mate-
rials to provide information to current and 
prospective enrollees in a qualified health 
plan offered through an Exchange. 
‘‘(iv) MARKETING
MATERIALS.—The 
term ‘marketing materials’ means mate-
rials relating to a qualified health plan of-
fered through an Exchange or benefits of-
fered through an Exchange that— 
‘‘(I) are intended— 
‘‘(aa) to draw an individual’s 
attention to such plan or the pre-
mium tax credits or cost-sharing 
reductions for such plan or plans 
offered through an Exchange; 
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‘‘(bb) to influence an indi-
vidual’s decision-making process 
when selecting a qualified health 
plan in which to enroll; or 
‘‘(cc) to influence an enroll-
ee’s decision to stay enrolled in 
such plan; and 
‘‘(II) include or address content 
regarding the benefits, benefit struc-
ture, premiums, or cost sharing of 
such plan. 
‘‘(v) TERMINATION.—The term ‘ter-
mination’, with respect to a contract or 
business arrangement between an agent or 
broker and a field marketing organization, 
third-party marketing organization, or 
health insurance issuer, means— 
‘‘(I) the ending of such contract 
or business arrangement, either uni-
laterally by one of the parties or on 
mutual agreement; or 
‘‘(II) the expiration of such con-
tract or business arrangement that is 
not replaced by a substantially similar 
agreement. 
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‘‘(vi) THIRD-PARTY MARKETING ORGA-
NIZATION.—The term ‘third-party mar-
keting organization’ means an organization 
or individual that is compensated to per-
form lead generation, marketing, or sales 
relating to enrollment of individuals in 
qualified health plans offered through an 
Exchange as part of the chain of enroll-
ment.’’. 
(d) TRANSPARENCY.—Section 1312(e) of the Patient 
Protection and Affordable Care Act (42 U.S.C. 18032(e)) 
(as amended by subsection (c)) is amended by adding at 
the end the following: 
‘‘(2) AUDITS.— 
‘‘(A) IN GENERAL.—For plan years begin-
ning on or after such date specified by the Sec-
retary, but not later than January 1, 2028, the 
Secretary, in coordination with the States and 
in consultation with the National Association of 
Insurance Commissioners, shall implement a 
process for the oversight and enforcement of 
agent and broker compliance with this section 
and other applicable Federal and State law (in-
cluding regulations) that shall include— 
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‘‘(i) periodic audits of agents and bro-
kers based on— 
‘‘(I) complaints filed with the 
Secretary by individuals enrolled by 
such an agent or broker in a qualified 
health plan offered through an Ex-
change; 
‘‘(II) an incident or enrollment 
pattern that suggests fraud; and 
‘‘(III) other factors determined 
by the Secretary; and 
‘‘(ii) a process under which the Sec-
retary shall share audit results and refer 
potential cases of fraud to the relevant 
State department of insurance. 
‘‘(B) EFFECT.—Nothing in this paragraph 
limits or restricts any referrals made under sec-
tion 1311(i)(3) or any enforcement actions 
under section 1411(h). 
‘‘(3) LIST.—The Secretary shall develop a proc-
ess to regularly provide to qualified health plans, 
Exchanges, and States a list of suspended and ter-
minated agents and brokers.’’. 
Æ 
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