Cleaning Up Fraud and Abuse In Exchange Plans

I applaud our governemnt taking steps to reduce enrollment fraud and aubuse in the Exchange Based Individual Health Insurance Market. Next steps should be for the ICHRA community to lobby for it’s own risk pool for Off Exchange plans. Along with pending State and Federal ICHRA enrollment tax credit incentives, lower cost of coverage will provide a huge tail wind to help grow more market share and help employers and employees afford healthcare better. See below…

New Rule Cracks Down on Improper Enrollments, Protects Patient and Taxpayer Dollars, and Restores Marketplace Integrity

The Centers for Medicare & Medicaid Services (CMS) is finalizing a major rule that will lower individual health insurance premiums by approximately 5% on average. It is also projected to save taxpayers up to $12 billion in 2026 by combating the surge of improper enrollments in the Affordable Care Act (ACA) Exchanges, reining in wasteful federal spending, and refocusing on making health insurance markets more affordable and sustainable for hardworking American families. The 2025 Marketplace Integrity and Affordability Final Rule restores oversight, strengthens accountability, and ensures taxpayer dollars are used only for those who are truly eligible.

“We are strengthening health insurance markets for American families and protecting taxpayer dollars from waste, fraud, and abuse,” said U.S. Health and Human Services Secretary Robert F. Kennedy, Jr. “With this rule, we’re lowering marketplace premiums, expanding coverage for families, and ensuring that illegal aliens do not receive taxpayer-funded health insurance.”

Improper ACA enrollments, enabled by weakened verification processes and expanded premium subsidies, have triggered widespread fraud. Research shows that in 2024 alone, an estimated 5 million people may have been improperly enrolled, costing taxpayers as much as $20 billion. “CMS is restoring integrity to ACA Exchanges by cracking down on fraud, protecting American taxpayer dollars, and ensuring coverage is there for those who truly need it,” said CMS Administrator Dr. Mehmet Oz. “This is about putting patients first, stopping exploitation of the system, and realigning the program with the values of personal responsibility and fiscal discipline.”