If you have a problem with a HealthCare.gov plan — coverage you never signed up for, a plan that got switched without your permission, a denied claim, or a 1095-A that doesn’t match what you know — health care marketplace complaints go to different places depending on what happened. Unauthorized enrollments and plan switches go to the federal Marketplace Call Center at 1-800-318-2596 first, then to CMS and your state insurance department. Denials, network problems, and billing disputes go through your insurer’s internal appeal before reaching a regulator. The order matters, and so does the timing, because the longer an unauthorized plan sits active, the bigger the tax bill you may owe next spring.
Signs Someone Enrolled You or Switched Your Plan
The two most common fraud patterns on the federal marketplace are unauthorized enrollments, where a broker signs a consumer up for coverage they never requested, and unauthorized plan switches, where an existing enrollee is moved to a different plan. In both cases the broker collects a commission from the insurer.1KFF. Fraud in Marketplace Enrollment and Eligibility: Five Things To Know
You may find out because an unfamiliar 1095-A arrives at tax time, because Medicaid tells you a marketplace plan is now the primary payer, or because a doctor’s office says you have coverage you didn’t know about. Fraudulent brokers sometimes change the contact information on the account, so notices from the insurer go to a different address or email and you never see them.2NC Department of Insurance. Health Insurance Fraud The schemes often start with social media ads promising cash rewards or gift cards; consumers who respond hand over identifying information that later gets used to complete an enrollment through a private platform connected to HealthCare.gov’s back end.3Georgetown University Center on Health Insurance Reforms. Federal Efforts Ostensibly Aimed at Marketplace Fraud Ignore Obvious Strategies To Counter Broker Misconduct
The scale is not small. Between January and August 2024, CMS received more than 183,000 complaints about unauthorized enrollments and about 91,000 about unauthorized plan switches, up from roughly 73,000 combined in fiscal year 2023.4CMS.gov. CMS Update on Actions To Prevent Unauthorized Agent Broker Marketplace Activity1KFF. Fraud in Marketplace Enrollment and Eligibility: Five Things To Know
Step One: Cancel the Unauthorized Coverage
Call the Health Insurance Marketplace Call Center at 1-800-318-2596. Verify what plan is showing under your name, and request cancellation of any active coverage you did not authorize.5AHCCCS. Unauthorized Marketplace Enrollment Do this before anything else. Every month the plan stays active is another month of Advance Premium Tax Credits paid to an insurer in your name, and those credits are your problem to reconcile at tax time whether you asked for the coverage or not.
If you’re on Medicaid, the unauthorized marketplace plan can push Medicaid into a secondary-payer position and threaten your marketplace subsidy eligibility, since Medicaid enrollment generally disqualifies you from those subsidies.5AHCCCS. Unauthorized Marketplace Enrollment That’s another reason not to wait.
Step Two: File the Complaint
After the plan is canceled, the unauthorized enrollment needs to be reported to CMS as a “complex case.” A Health Insurance Navigator can submit that report for you. Navigators are federally licensed, provide free assistance, and — unlike insurance agents — earn no commission tied to enrollment, so there’s no incentive conflict.6Charlotte Center for Legal Advocacy. What Should I Do if Someone Signed Me Up for Marketplace Coverage Without My Consent
File a parallel complaint with your state Department of Insurance. States license brokers and can pursue disciplinary action against them, which the federal marketplace cannot do directly. The National Association of Insurance Commissioners keeps a directory of state regulators if you don’t know where your state’s complaint form lives.7NAIC. Consumer Resources
If your personal information was misused — a Social Security number, a date of birth, contact details changed without your knowledge — report the incident at IdentityTheft.gov. Suspected fraud can also be reported to the HHS Office of Inspector General, which uses the same 1-800-318-2596 line.8HHS Office of Inspector General. Consumer Fraud Alert: Health Insurance Marketplace
When CMS resolves a complex case successfully, the marketplace voids or amends the 1095-A tied to the unauthorized coverage. If you already filed your taxes using the incorrect form, you’ll likely need to file an amended return.6Charlotte Center for Legal Advocacy. What Should I Do if Someone Signed Me Up for Marketplace Coverage Without My Consent
Why Timing Affects What You Owe the IRS
Marketplace plans are usually subsidized through Advance Premium Tax Credits, paid directly to the insurer based on projected income. At tax time you reconcile those advance payments against actual income using IRS Form 8962. If the advance credits exceeded what you were entitled to, you owe the difference back.9IRS. Questions and Answers on the Premium Tax Credit
For someone who never knew they were enrolled, the return can show subsidies received for coverage they never used. The budget reconciliation law signed on July 4, 2025 removed the repayment caps that had previously limited how much lower-income filers had to return.10IRS. Fact Sheet 2025-10 Starting with the 2026 tax year, the full excess is repayable with no income-based cap. Skipping Form 8962 entirely isn’t an option either: consumers who don’t file it lose eligibility for future advance credits, which means owing the full monthly premium going forward.9IRS. Questions and Answers on the Premium Tax Credit
That’s the reason canceling and reporting quickly matters. Every month of unauthorized coverage adds to the eventual reconciliation, and after 2025 there’s no cushion built into the tax rules.
Complaints That Aren’t About Fraud
Plenty of marketplace complaints have nothing to do with rogue brokers. A 2023 KFF survey found that 20 percent of marketplace enrollees said their insurer denied or delayed a prior authorization, 20 percent said a doctor or hospital they needed was out of network, and 18 percent said the insurer refused to pay for a service they believed was covered. Nearly half — 46 percent — said it was somewhat or very difficult to understand what their plan covered, and 76 percent of insured adults said they didn’t know which agency to call for help.11KFF. Navigating the Maze: A Look at Health Insurance Complexities and Consumer Protections
The formal complaint categories cover claim denials, eligibility denials, denied special enrollment periods, incorrect 1095-A forms, cost-sharing reduction disputes, prescription coverage refusals, provider directory errors, and mid-year coverage terminations. For most of these, you generally have to exhaust the insurer’s internal appeals process first before a state regulator will act on the complaint.12National Health Law Program. Appeals Fact Sheet
Where To Send Each Type of Complaint
- Unauthorized enrollment or plan switch on HealthCare.gov: Marketplace Call Center at 1-800-318-2596, then the state insurance department.8HHS Office of Inspector General. Consumer Fraud Alert: Health Insurance Marketplace
- Broker misconduct or insurer conduct: state Department of Insurance, findable through the NAIC directory.7NAIC. Consumer Resources
- Suspected fraud: HHS Office of Inspector General, same 1-800-318-2596 line.8HHS Office of Inspector General. Consumer Fraud Alert: Health Insurance Marketplace
- Employer-sponsored self-funded plans: U.S. Department of Labor, Employee Benefits Security Administration. Marketplace complaint channels don’t apply to these plans.
- Surprise medical bills: CMS No Surprises Help Desk at 1-800-985-3059.13CMS.gov. Submit a Complaint
What Changed in 2024 and 2025 That Affects Your Case
CMS made a system change on July 19, 2024 that directly affects unauthorized switches. Agents and brokers can no longer modify a consumer’s enrollment unless they’re already associated with that account. A new broker has to complete a three-way call with the consumer and the Marketplace Call Center before making changes. After that change, consumer reports of unauthorized plan changes fell about 30 percent, total broker-initiated plan changes dropped nearly 70 percent, and unauthorized changes to commission information fell almost 90 percent.4CMS.gov. CMS Update on Actions To Prevent Unauthorized Agent Broker Marketplace Activity
Between June and October 2024, CMS suspended 850 agents and brokers from marketplace participation based on reasonable suspicion of fraudulent conduct, and revoked authorization for two Enhanced Direct Enrollment platforms, Benefitalign and Inshura, both subsidiaries of Speridian Global Holdings. The suspension letter cited unauthorized overseas access to CMS data from IP addresses in India and Pakistan, data security lapses, enrollment without consent, and misleading advertising.14KFF Health News. ACA Obamacare Plan Switching Fraud Lawsuit Benefitalign Inshura Blocked Access15Fierce Healthcare. Biden Administration Blocks Two Private-Sector Enrollment Sites From ACA Marketplace By March 2025, CMS had reinstated at least some of the suspended brokers, and in June 2025 released an FAQ document about the removal of more than 1,000 brokers from the suspension and termination list. Whether reinstated brokers had to fix the underlying causes of their suspensions was unclear.1KFF. Fraud in Marketplace Enrollment and Eligibility: Five Things To Know
The 2025 Marketplace Integrity and Affordability Final Rule, effective August 25, 2025, adds enrollment friction that will affect anyone signing up or renewing coverage:16CMS.gov. 2025 Marketplace Integrity and Affordability Final Rule
- The monthly special enrollment period for people at or below 150 percent of the federal poverty level is repealed.
- Federal marketplaces must verify SEP eligibility before enrollment and verify at least 75 percent of new SEP enrollments starting in plan year 2026.
- Self-attestation of income is no longer accepted when IRS data is unavailable; documentary evidence is required.
- CMS can terminate a broker’s marketplace agreement on a “preponderance of the evidence” standard for noncompliance.
- Consumers auto-renewed into fully subsidized plans without confirming eligibility face a $5 monthly premium until they verify their information.
CMS estimated about 5 million people may have been improperly enrolled in 2024, at a cost of up to $20 billion, and projected the rule would save up to $12 billion in 2026. The American Hospital Association warned that between 750,000 and 2 million consumers could lose coverage as a result. Several provisions are set to sunset at the end of the 2026 plan year.17Healthcare Finance News. CMS Final Rule Cracks Down on Improper ACA Enrollments
KFF’s analysis observed that the final rule contains “few changes concerning the oversight of entities alleged to have engaged in fraudulent activities,” and Georgetown’s Center on Health Insurance Reforms noted that CMS did not adopt measures such as a standardized consent form, insurer verification of documented consent before paying commissions, or a federal “best interest” standard for brokers.1KFF. Fraud in Marketplace Enrollment and Eligibility: Five Things To Know3Georgetown University Center on Health Insurance Reforms. Federal Efforts Ostensibly Aimed at Marketplace Fraud Ignore Obvious Strategies To Counter Broker Misconduct Practically, that means the burden of catching an unauthorized enrollment early still falls largely on the consumer.
The federal workforce handling these cases also shrank in 2025. CMS lost roughly 300 workers, including about 30 caseworkers who had resolved complicated enrollment problems in an average of 14 days, with urgent cases handled in two to three business days. Caseworkers were already handling more than 45 issues per day before the cuts, up from 30.18NPR. CMS ACA HHS Federal Layoffs Expect longer waits than those older averages suggest, and keep records of every call: the date, the representative’s name, any confirmation number, and copies of any correspondence you send to CMS, your state insurance department, or the IRS.