House Judiciary Committee Investigates Health Insurance Firms for ACA Fraud

On February 10, the House Judiciary Committee, under the leadership of Chair Jim Jordan of Ohio and Subcommittee Chairs Scott Fitzgerald of Wisconsin and Jeff Van Drew of New Jersey, issued subpoenas to eight major health insurance firms. These companies, including Blue Shield of California, Centene Corporation, CVS Health, Elevance Health, GuideWell, Health Care Service Corporation, Kaiser Permanente, and Oscar Health, have been asked to provide information regarding potential fraud involving Affordable Care Act (ACA) advanced premium tax credits (APTCs). APTCs are essential for aiding consumers in purchasing health insurance through Marketplace Exchanges.

The committee's action stems from a December 2025 report by the Government Accountability Office, which suggested vulnerabilities in APTCs related to misuse and fraud. The 2025 Marketplace Integrity and Affordability rule, implemented during the Trump administration, aimed to address these issues but has encountered delays due to ongoing legal challenges. The discussions surrounding these regulations coincide with the lapsed Enhanced Premium Tax Credits (EPTCs), which, during the COVID-19 pandemic, increased eligibility and subsidy amounts for higher income households and were extended through the 2022 Inflation Reduction Act.

For insurance industry professionals, these investigations are crucial, affecting regulatory compliance requirements and market operations. The scrutiny on APTCs underscores the necessity for robust internal controls to ensure compliance with federal laws and mitigate financial and reputational risk associated with potential fraud investigations. Understanding the regulatory landscape can aid in effective risk management for payers, providers, and carriers alike.