CMS Faces Scrutiny Over Broker Fraud in ACA Marketplace Amid GAO Report

A recent U.S. Government Accountability Office (GAO) report has uncovered persistent issues with agent and broker fraud in the Affordable Care Act (ACA) Marketplace, highlighting significant failures by federal oversight under the previous administration. The report found tens of thousands of unauthorized plan enrollments and switches had occurred, many without consumer consent, raising concerns about the effectiveness of fraud prevention mechanisms within CMS. In response, Representative Lloyd Doggett, Ranking Member of the Ways and Means Health Subcommittee, has sought direct answers from CMS Administrator Dr. Oz regarding CMS's handling of these fraud cases. Key findings reveal that CMS suspended 850 agents and brokers suspected of fraudulent behavior but later reinstated them without clear justification or evidence of comprehensive investigations. This move has raised questions about CMS's enforcement rigor and commitment to accountability. CMS's oversight capabilities appear further compromised by workforce reductions, including layoffs in the Office of Program Operations and Local Engagement, the division responsible for monitoring Marketplace fraud. These staffing cuts may undermine the agency's ability to conduct timely investigations, provide relief to affected consumers, and hold fraudulent actors accountable. GAO findings also criticize CMS for not updating its fraud risk assessments following major Marketplace changes and for lacking a robust anti-fraud strategy aligned with established fraud risk frameworks. The GAO's analysis points to systemic weaknesses in CMS’s fraud risk management, including inadequate evaluation of existing fraud controls and failure to identify state-specific risks. As a result, CMS's capacity to proactively prevent and address fraud is limited. Representative Doggett urges the agency to fully exercise its enforcement powers, including imposing civil monetary penalties under the ACA, to reinforce the integrity of the Marketplace. This inquiry underscores the ongoing challenges in regulating broker and agent conduct within ACA exchanges and the importance of comprehensive oversight and enforcement to protect consumers and maintain market stability. The response from CMS by December 19, 2025, is anticipated to clarify the agency’s current policies and actions to mitigate fraud risks effectively.