CMS Actions to Protect Consumers and Strengthen Exchange Program Integrity

As outlined below, the Centers for Medicare & Medicaid Services (CMS) is exercising its full statutory and regulatory authority to protect consumers from unauthorized enrollment activity and safeguard the integrity of the Affordable Care Act (ACA) Exchanges. CMS’s comprehensive action plan includes rapid complaint resolution, Federally-facilitated Exchange (FFE) system enhancements, targeted oversight, strong enforcement measures to prevent unauthorized enrollments and plan changes, and processes to ensure consumers can confidently access the coverage they chose.

This fact sheet provides an overview of program integrity and consumer protection actions CMS took over the past year on the FFE platform. These actions are rooted in federal law and required by regulation but have largely gone unenforced since 2021. As a result of these actions, over the past year, CMS ended premium subsidies for nearly 1.5 million people found to be ineligible for financial assistance or enrolled without their authorization on the FFE platform. More than one million of the enrollees whose premium subsidies were removed were concurrently enrolled in either Medicaid or CHIP and Exchange coverage with advance payment of the premium tax credit (APTC) or failed to file and reconcile previously received tax credits. An additional quarter million enrollees who had been enrolled without their authorization had their unwanted coverage cancelled, allowing CMS to pull back unwarranted tax credits. Combined, these actions amount to nearly $10 billion in savings on an annualized basis.

CMS is also taking action to protect consumers from unauthorized plan switching activity. In 2025, CMS estimates that approximately 200,000 consumers had their desired plan selection changed without their consent. For consumers impacted by an unwanted plan change during the year, CMS has worked with issuers to confirm and restore these consumers’ chosen plan selections.

The rest of this fact sheet provides further details on these actions and other steps CMS is taking to protect consumers and the integrity of the ACA Exchanges.

Key Actions to Protect Consumers and Taxpayer Dollars

Marketplace Integrity and Affordability Final Rule (June 25, 2025)

CMS finalized new regulations designed to reduce incentives for improper enrollments and strengthen verification. This includes:

• Eliminating the 150% Federal Poverty Level (FPL) Special Enrollment Period (SEP), which CMS identified as a major driver of unauthorized enrollments.
• Ending the automatic 60-day extension to income Data Matching Issue resolution timeframes, which had extended the timeframe for income document submission beyond the limit granted by our statutory authority.
• Establishing a preponderance of the evidence standard for terminating agent or broker Exchange Agreements for noncompliance with CMS requirements and applicable laws and regulations. 

CMS also finalized regulations to reinstate income verifications when the IRS does not have tax return data, or when an applicant attests to having projected household income over the minimum income level for tax credit eligibility, but data sources indicate an income below it. The rule would also reinstate regulations to require the removal of APTC after an enrollee fails to file their taxes and reconcile their APTC. Current regulations delay the removal of APTC until an enrollee fails to file and reconcile for two consecutive years. In addition, the rule would require Exchanges to verify eligibility for SEPs and require fully subsidized enrollees who fail to update their eligibility information for a new plan year to pay a nominal $5 monthly premium until they do so. This policy aimed to ensure that enrollees who paid no premium were aware of their enrollment during the annual reenrollment process. 

Currently, a federal district court has “stayed” (meaning put on hold) some of these provisions., leaving the Exchanges vulnerable to future improper enrollments. If these policies were in place, they were projected to save $3.1 billion in 2026. 

Rapid Response to Consumer Complaints

CMS has strengthened its ability to review and resolve consumer complaints swiftly and thoroughly. This includes:

• Investigating unauthorized plan switches and unauthorized enrollments.
• Reducing the average time needed to resolve unauthorized plan switch cases in issuers’ systems to approximately 7 days from receipt of complaint, and unauthorized enrollment cases to 5 days from receipt of complaint, which are both notable improvements from 2024. 
• Reducing the time required to cancel policies associated with complaints.

Strengthening Program Integrity Across Medicaid, CHIP, and the Exchanges

Resumption of Medicaid/CHIP Periodic Data Matching (PDM)

• CMS reinstated twice-yearly PDM checks—paused during the COVID-19 Public Health Emergency—to prevent concurrent enrollments in Medicaid or CHIP and Exchange coverage with APTC (“concurrent enrollments”).
• Over 550,000 enrollees had their APTC ended in 2025 after CMS identified concurrent enrollments in HealthCare.gov states.  
• CMS implemented a new initiative in 2025 with the 20 State-based Exchanges (SBEs)[10] to confirm their progress on preventing concurrent enrollments and found: 
  • SBEs that operate integrated systems with Medicaid or CHIP confirmed that at least 98%, or 100,000, of CMS-identified concurrent enrollments in those states have already been resolved[11].
  • Most SBEs that have an account transfer process with their state Medicaid or CHIP program conducted at least twice-yearly PDM checks to end concurrent enrollments for about 4,000 enrollees total in their latest PDM checks. Other SBEs received a corrective action plan to implement a similar process.

Restart of Failure-to-File-and-Reconcile (FTR) Process

In 2025, CMS resumed removing APTC from consumers who failed to file tax returns and reconcile prior APTC for two consecutive years, offering critical financial protection for consumers. This process removed premium subsidies from nearly 200,000 households in HealthCare.gov states. While SBEs administer the FTR process in their respective states, CMS has continued to provide technical assistance and oversight of SBE resumption of this process.

Moving into 2026, as part of the auto-reenrollment process during Open Enrollment, CMS removed APTC from consumers who were identified as failing to file and reconcile their APTC for two consecutive years and did not attest to filing and reconciling. Although this round of the FTR process is ongoing, CMS has removed APTC for approximately 366,000 households thus far. 

Upcoming Improvements Under the Working Families Tax Cut Legislation (Public Law 119-21)

CMS is working to implement key provisions of the Working Families Tax Cut (WFTC) legislation that will require verification of certain eligibility elements before APTCs are issued. Verifying important eligibility information upfront before paying out subsidies will substantially strengthen program integrity, build on CMS’s existing improvements, and safeguard taxpayer dollars.

Data Trends Demonstrating Progress

Significant Reduction in Unauthorized Activity Complaints

• 31% decrease in consumer complaints of unauthorized enrollments and unauthorized plan switches from January to October 2024 (180,750) compared to the same period in 2025 (124,533).[12]
• Improved case resolution times reflect streamlined operational processes. 

Substantial Shifts in Enrollments Canceled for Unauthorized Activity

• After a steep rise in 2023–2024, the volume of enrollment cancelations in 2025 dropped as system and operational improvements took effect and fewer policies required cancelation due to an unauthorized enrollment or unauthorized plan switch.
• Many 2025 cancelations stem from auto-renewals of coverage already identified as fraudulent, not new incidents. 

Enforcement Actions Against Agents, Brokers, and Enhanced Direct Enrollment Entities

CMS monitors agent and broker performance using enrollment data, operational indicators, and consumer feedback. When performance issues are identified, CMS works with agents, brokers, and enhanced direct enrollment entities to address concerns and improve service quality. CMS evaluates cases and may take enforcement action when appropriate, including the suspension or termination of Exchange Agreements.

In December, CMS took action against subsidiaries of Speridian Technologies, including Benefitalign and TrueCoverage, that formerly operated in HealthCare.gov states[13].  This was the conclusion of an eighteen-month investigation that found Speridian subsidiaries actively misled consumers and failed to protect consumers' personally identifiable information (PII) from possible foreign access. CMS issued a determination of noncompliance and a denial of right to enter into future Exchange Agreements with Speridian, cutting off Speridian’s ability to sell insurance on the Exchanges and access consumers’ PII used to enroll consumers in plans.

Consumer Information and Resources

CMS is actively educating consumers on how to avoid fraudulent agent or broker activity through targeted communications and public resources. CMS has issued prior public statements and provides educational materials such as the Marketplace consumer assistance infographic. 

CMS is fully committed to safeguarding the ACA Exchanges, protecting consumers, and holding agents and brokers accountable for noncompliant, fraudulent, or abusive activity. Ongoing oversight, advancements in technology, stronger policies, and proactive enforcement continue to reduce unauthorized enrollments and restore confidence in ACA coverage.

Consumers who believe they may have been enrolled in an Exchange plan or switched without their consent should contact the Marketplace Call Center at 1-800-318-2596 (TTY: 1-855-889-4325) for immediate assistance. 

The HHS-OIG Hotline is the central point for reporting fraud, waste, abuse, and mismanagement in Medicare, Medicaid, and other HHS programs. The Hotline is accessible via their website (oig.hhs.gov/fraud/report-fraud) or by calling 1-800-HHS-TIPS (1-800-447-8477).