New ACA Broker Regulations to Combat Fraud and Enrollment Drops

Federal regulators are implementing new procedures for brokers handling Affordable Care Act (ACA) applications as the upcoming open enrollment period approaches. Brokers who do not adhere to enhanced documentation requirements may encounter application rejections, flagged accounts, and increased scrutiny of their National Producer Numbers (NPN).

These regulatory changes are a response to declining ACA enrollment figures and efforts to eliminate fraudulent policy enrollments, as reported by the Department of Health and Human Services (HHS). An HHS report from June 2026 indicated that enrollment dropped by nearly three million to approximately 19.2 million. The report identified 5.6 million individuals as having been fraudulently enrolled in 2025, with the previous administration removing 2.9 million of these enrollments.

While administration officials attribute the enrollment decrease to a fraud crackdown, analysts have pointed to rising premiums and deductibles as contributing factors. Data from KFF shows a 58% increase in average monthly premiums and a 37% rise in deductibles.

Stricter Verification Measures

The Centers for Medicare & Medicaid Services (CMS) intends to implement stricter identity verification measures for brokers enrolling individuals in ACA plans. Brokers will have limited access to consumer accounts unless explicitly authorized to act on a consumer's behalf, according to CMS spokesperson Christopher Krepich.

Beginning this summer, CMS will reject ACA applications lacking a Social Security number or other appropriate identification for the applicant. Accounts flagged will involve brokers, reflect zero premiums, and be missing required documentation numbers. Insurers are instructed to contact these policyholders for verification, with consequences for unverified policies including potential cancellation by CMS after a 60-day period.

Enhanced Compliance Requirements

These increased documentation and verification requirements align with a broader strategy by CMS to heighten broker oversight. Recent regulations have clarified restrictions on broker marketing and established standardized consumer consent procedures.

The targeted fraud includes unlawful actions by agents enrolling unaware consumers to collect commissions while the enrollees filed no claims. The HHS report associates zero-claim beneficiaries and those in zero-premium plans with potential broker misconduct.

Transparency in enforcement actions against fraudulent enrollment practices is evident. AssuredPartners of South Florida agreed in 2026 to a guilty plea and a $160 million payment related to a fraud scheme. More broadly, 194 individuals faced charges with losses exceeding $15 billion in ACA-related crimes in 2025, per the Department of Justice's Health Care Fraud Unit.

Advocacy for Better Security Measures

Honest brokers linked to flagged accounts still face investigation, whether or not fraud was intended. Florida agent Jason Fine suggests enforcement should target confirmed offenders: "I would not immediately assume that a person who went from a silver plan to a bronze plan, that it's fraud."

Brokers have advocated for enhanced security measures on healthcare.gov, such as multifactor authentication. Legislation introduced by Rep. Glenn Grothman (R-Wis.) in June aims to address this, though CMS has not implemented such measures under recent administrations.

For brokers operating within the ACA framework, compliance demands have evolved. They must document consumer consent prior to submissions, ensure Social Security information is accurate, and verify income details for each application during the enrollment season.