Posted in: Madison Park


Mon, Dec 4 at 12:02 PM

A Message from Commissioner of Insurance Mike Causey regarding Medicare and ACA fraud


Dear Friends,


Just a word of caution as we near the end of the open enrollment period for both Medicare and health insurance on the federal marketplace (Affordable Care Act or ACA). We are getting numerous complaints from ACA consumers across the state who believe their plan was changed without their authorization. As for Medicare beneficiaries, we are getting reports they have been billed for equipment and supplies they never ordered.


According to complaints by consumers who bought health insurance on the federal marketplace (ACA), they did not know their plan was changed until they visited a medical provider and discovered they didn’t have the coverage they thought they had.


Our Consumer Services Division and Agent Services Division found out, in some instances, unscrupulous agents would re-enroll their clients into a new plan to collect the commission all the while changing their mailing address, email, phone number, etc. so they would not be alerted to this fraudulent behavior by being contacted by the new company. This also affects their taxes as they will receive a 1095A tax statement on the new plan for the premium tax credit. 


Another avenue for such unauthorized activity occurs when consumers mistakenly click on an ad on Facebook, or other social media. Apparently, when they do so, these agents or agencies connected to the ads will enroll the consumer into a plan and collect a fee. 


Since we have limited authority with these federal plans, we facilitate the consumer by getting their original plan reinstated without a break in coverage. We have been in regular contact with the Centers for Medicare and Medicaid Services (CMS) in Washington, D.C., and U.S. Sen. Ted Budd’s office to keep them abreast of the situation.


As for Medicare fraud, we have received nearly 9,500 complaints already in 2023. Most of these complaints involve being billed for supplies and equipment they did not order or need. There are also reports of beneficiaries being charged twice for a service or item they only needed once. 


Again, we have limited authority on the Medicare plans since they are federally regulated, but in all these situations, our Seniors’ Health Insurance Information Program or SHIIP has worked with the beneficiaries to report the fraud to CMS. We also hold outreach events across the state to keep our seniors informed.


Remember, never give your Medicare card, number, Social Security number to anyone except your doctor or people you know you should have it; don’t accept offers of money or gifts for free medical care; don’t allow anyone except your doctor or other Medicare providers to review your medical records or recommend service; and finally, don’t join a Medicare health or drug plan over the phone unless you call them.


The department’s regional directors out in the field have reported that this type of fraudulent activity is ramping up across the state as we near the end of the open enrollment period.


Please stay alert and if you have any questions, please call us at 855-408-1212. We’re here to help.


Thank you and God bless,


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