Ambetter Health Broker Agent Compliance Memo
Updated May 6, 2025
No Tolerance of Prohibited Activities
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, recoupment and cancelation of commissions and the ability to utilize National Producer Number (NPN) overrides.
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 (with IP address if signed digitally), or digital communication, i.e., 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.
- Collecting consumer information and some version of consent via online forms or social media ads asking the Member to check the box to enroll in the best no-cost health plan with no other form of communication with the Member.
- 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 unnecessary changes to an existing Ambetter Health member’s application who has another agent to gain the AOR. 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.
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.
- The Agent must explain that My Health Pays rewards must be earned, and the maximum amount is $500 annually.
Fabricating or falsifying member eligibility information, including documentation, recordings and digital proof.
All application fields must be accurate at the time of submission. Verification of identity may be required.
- 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.
- Enrolling member when they have other health insurance coverage, i.e., Medicaid, Medicare, Employer Insurance.
- Not verifying or falsifying the enrollee’s demographic information, including address, phone number and email address. We must be able to reach the member to provide member materials and coordinate care.
- Enrolling fictitious members. i.e., lead source fraudulently obtains consumer information and uses another person to impersonate the enrollee on the recorded call or the Center for Medicare & Medicaid Services (CMS) 3-way call. It is the responsibility of the agency and agent to ensure their lead sources are trustworthy and credible.
- Enrolling immigrants that are not lawfully present at the time of enrollment. Immigrants must have qualifying status and provide documentation at the time of enrollment.
- Omitting or fabricating documents, consent forms, recordings or digital proof of a Member’s enrollment to avoid a violation
- Knowingly creating a duplicate enrollment for a Member
Use of NPN overrides where permissible by laws and regulations.
In some cases, CMS allows the agencies use of NPN overrides to have their direct downline producers write with a principal NPN. When using the NPN override, producers must comply with the Marketplace requirements, including the standards of conduct under 45 CFR 155.220(j), Marketplace agreements and applicable state laws and regulations. It is the responsibility of the producer to review all state requirements to ensure they are complying with state regulations related to NPN override and any other state specific requirements.
Besides the CMS and state requirements, per our producer contract, Ambetter Health requires all producers, including writing agents, actively assisting the consumer with the application, plan selection or enrollment to be licensed, contracted and appointed in all states conducting business.
- If utilizing the NPN override, the writing agent’s NPN must be submitted on the enrollment application.
- Upon suspected abuse and to monitor the compliance, Ambetter Health reserves the right to prohibit an agency or agent from using NPN overrides.
Failure to provide required documentation or not responding timely during an investigation will result in suspension of commission and the complaint 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. With cause terminations are reported to state agencies and commission ceases.
Fraudulent activity will be reviewed at the agency level and will result in actions up to and including agency termination.