CCIIO chief: ‘Still a lot of fraud’ in the ACA marketplace

Crushing fraud is one of the main priorities for Medicaid and the Affordable Care Act marketplace, according to the deputy administrator and director of the Center for Consumer Information and Insurance Oversight.

Peter J. Nelson discussed his agency’s efforts to prevent fraud, waste and abuse in health care during the AHIP Medicare, Medicaid, Duals and Commercial Markets Forum in Washington.

About 1.5 million fewer ACA enrollees were eligible for premium subsidies for 2026 than for the previous year, Nelson said, and he said that decline was “because there is still a lot of fraud in the system.”

CCIIO plans to implement identity proofing by the next open enrollment period. “We are taking active steps to add integrity to the system,” he said. “That is what will lead to a more stable market going forward.”

Congress enacted legislation requiring ACA enrollees to verify their income each year to determine their eligibility for premium subsidies.

“This will be an important part of market integrity going forward,” Nelson said. “It will guarantee you are actually eligible for premium tax credits. We will require people to confirm their information is fair and accurate for next year.”

Nelson said ACA enrollees will be able to begin the income verification process on Aug. 1 instead of waiting until open enrollment begins in October.

“It is critically important we get these income verifications correct so people don’t end up with a big tax bill,” he said.

ICHRA enrollment eyed

Individual coverage health reimbursement arrangements are gaining steam, but Nelson said enrollment in this type of coverage “is not as robust as we had hoped.”

Most ICHRA enrollment happens away from the ACA exchanges, and Nelson said enrollment platforms are being developed to make ICHRA enrollment more seamless.

“This space is where new people will enroll in coverage,” he said. “You’ll have real competition in the individual market and it will deliver higher-value coverage.”

More choice in health plans

The Trump administration is looking at ways to give consumers more choice in health insurance plans, Nelson said. Among the plans being considered are multiyear health insurance plans, non-network plans and disease-specific coverage.

“We want to eliminate provisions on standardized plans to allow for more innovation,” he said.

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