Ambetter Health is issuing a reminder of its no-tolerance policy for agents engaging in prohibited activities. Any prohibited activities discovered by Ambetter Health will result in issuance of a Notice of Action (NOA) letter and will lead to review, which may result in actions up to and including agent termination, and recoupment and cancelation of commissions.
Prohibited Activities Include:
Lack of member review and confirmation of any changes to the application.
The agent must provide proof of consent by either a recording, signed consent form or digital communication (text or email) when enrolling a new member or when there are material changes to an existing member’s application, including changes to the Agent of Record (AOR), health plan product or carrier, income, enrollment date, term date or any other change that may affect the member and their access to care. The member must review and agree on the accuracy of the application information before any change is made.
- This requirement will not be satisfied by providing an old consent. The member must review and confirm the accuracy of any proposed change before it is submitted, and the agent must have the ability to supply proof.
Any enrollment generated from an online advertisement, form or social media lead requires the agent to conduct a thorough assessment with the member and the agent must have the ability to provide proof of review and confirmation by the member of the enrollment. - Soliciting and submitting changes to an existing Ambetter Health member’s application who is locked in with another agent is prohibited. In certain circumstances a member may have a valid reason that warrants an AOR or plan change. The new agent must make changes that are in the best interest of the member and reviewed and confirmed by the member. The AOR lock policy will prevent payment of these enrollments unless the member formally requests an AOR change through the Member Services phone number located on the back of their card. Only the member can request the AOR change.
CMS Guidance:
CMS Statement on Agent and Broker Marketplace Activity
CMS FAQ Application or Plan Changes
CMS FAQ Consent and Review of Accuracy
Misrepresentation, misleading prospective members or implying inaccurate plan offerings, incentives or monetary gifts in any form.
- In all cases, the agent must correct any misperception regarding benefits and clarify the accurate benefits to the member. During the sales process, including when purchasing leads from a third party, the agent and agency are responsible for clarifying accurate plan offerings and ensuring the consumer understands they will not receive cash, gift cards or monetary gifts for enrolling in the plan.
- Agents must ensure the member knows they are enrolling in Marketplace health insurance and not in a government program to receive direct monetary support. Advanced Premium Tax Credit (APTC) and Cost-sharing Reduction (CSR) subsidies are used for health plan premiums and costs, and cannot be directly used for rent, groceries or other household expenses.
- All wellness benefits rewards must be described as earned.
Fabricating or falsifying member eligibility information, including documentation, recordings and digital proof.
This includes leading the member to agree or answer an eligibility question to receive a desired result or inaccurately estimating income on the member’s behalf to qualify or increase APTC subsidies. All application fields must be accurate at the time of submission.
Failure to provide required documentation during an investigation will result in the compliant being deemed substantiated.
This list is not all inclusive. Any other form of fraudulent activity will result in actions up to and including agent termination.
Fraudulent activity will be reviewed at the agency level and will result in actions up to and including agency termination.
For any questions you may have about compliance, please feel free to reach out to Agility at [email protected].
This information is confidential and intended solely for broker use. Distribution to Medicare beneficiaries is not permitted.
