Fraudsters duping homeless people into ACA plans they can’t afford

Mary Zhelyaskova was surprised when a pharmacist at Florida’s largest Safety Net hospital told her she couldn’t fill her prescriptions.

Zhelyazkova, 40, lives in a homeless shelter and needed Saboxson, a drug to manage opioid withdrawal symptoms.

She said she had gotten Saboxson for free at the Jackson Memorial Hospital pharmacy. Ryan White HIV/AIDS Programprovides little or free healthcare to people living with HIV.

But in late 2021, she said, a strange man approached her on the street and demanded $5 to sign up for a “free” health insurance plan. florida blue. That person instructed her to use her false address and misrepresent her income so that she would be considered insured, she said.

When the plan went into effect the following year, Zhelyaskova learned of the downside.

Taking out private insurance disqualified her from Ryan White’s insurance. And Florida Blue’s provider didn’t include hospital pharmacies in her network. She needs to go to Walgreens and to do that she needs transportation. She also had to provide a $20 co-payment, which she couldn’t afford.

“I had to withdraw. It was terrible,” said Zhelyazkova, adding that she went without medicine for several days until a nonprofit needle exchange program paid for it.

Zhelyazkova, one of potentially hundreds of homeless people in Florida who were approached by agents and brokers asking for commissions, said state insurance regulators, doctors and policyholders said they were justified in paying their medical bills. He says he is enrolled in a zero-cost medical plan at Kaho Market. counselor.

It is speculated that rogue agents and brokers register homeless people in order to earn a commission on the sale, and are fraudulent by lying about their income and home address.

The federal government also pays monthly premiums to eligible low-income consumers on the ACA plan, but the insurance comes with copayments, deductibles, and other copayments, and little or no income. People often cannot pay.

In a growing number of reports, state and federal regulators are investigating incidents in which agents and brokers provided fraudulent information regarding ACA compensation applications.

In the fiscal year ending September 30, 2022, the federal agency that oversees the ACA market received 25,000 complaints from people alleging they took out insurance without their consent or that false information was submitted on their policy documents. It announced that it had received more complaints. Application by Agent or Broker. The Centers for Medicare and Medicaid Services also said it conducted more than 700 license authorizations during the same period to identify potentially problematic brokers.

States such as Florida, which is one of ten states with ACA plans, are most likely to opportunistically recruit homeless people into ACA plans. Refused to extend Medicaid eligibility to nearly all low-income adults. In one of his 2015 cases, a North Carolina agent Hundreds of homeless people registered As for the scope of coverage of the ACA. The state introduced expanded Medicaid in March, but it has yet to go into effect.

In the expanded nation, most single adults in poverty would be eligible for Medicaid. In non-expansion states, including Florida, consumers generally must earn at least 100% of their income. federal poverty level It is eligible for tax deduction under the Health Act, and monthly insurance premiums and copayments are reduced. In 2023, per person he will equate to $14,580 and for a family of three he will equal $24,860.

but, No income for the current year This does not prevent consumers from predicting that they will earn enough to qualify for tax credits next year. Consumers are not required to document their income in Marketplace applications if government data indicates that they have been inadequate in the last few years.

On the surface, it may look like the uninsured homeless are covered, he said. Sabrina Corlette, a health insurance policy expert at Georgetown University. “It’s not that bad,” she said.

But that doesn’t make it a victimless crime. The federal government will eventually subsidize health insurance companies to cover people not covered by the plan. Homeless people, on the other hand, are disqualified from more appropriate programs such as hospital charity care and Ryan White. “It’s a serious problem,” Corlett said.

Physicians caring for homeless people also say the interruption in care has forced homeless patients to relapse into drug use, suffer mental health crises, and stop treating chronic conditions such as cancer and diabetes. He said there is a risk of

“Patients are stuck in a situation where they can’t afford the out-of-pocket costs under their insurance plans,” he said. David Serota, an infectious disease specialist at the University of Miami Miller School of Medicine. “But they also cannot access those services through programs for the uninsured poor.”

Serota sees patients at the Jackson Memorial, a Miami-Dade County hospital that provides charity care. At least 20 patients have been affected in the past three years, and “many more” his colleagues have seen, he said.

It may take weeks or months to cancel your new health insurance policy and reapply for public benefits. And Erin Richards, certification application counselor and ACA program coordinator in Pinellas County, near Tampa, said the turmoil could heighten the skepticism that marginalized communities have about the program. She has helped many reapply. Local programs for the homeless Residents tricked into enrolling in the ACA plan.

“We are working to get them to trust the system again and get the care they need and have long neglected,” Richards said.

Agent and broker registered unqualified consumer Since marketplace registration began in the fall of 2013, ACA coverage has expanded. “It’s not at the level we’ve seen recently,” he said. Katie Lauders Turneris an enrollment navigator and executive director of the Family Health Care Foundation, a Tampa non-profit organization that helps low-income residents receive free or low-cost care.

Richards and Turner said the most common health insurance provider among homeless people is Florida Blue, the state’s largest health insurer. In Florida he has 15 companies offering plans on his ACA Marketplace. Only Florida Blue covers the following areas: All 67 counties in the state.

Florida Blue executives said the company’s compliance team is investigating “individuals who fraudulently enroll consumers in health insurance,” but when asked how often such scams occur did not respond.

The most common way agents receive commissions is by member, by month. In other words, the agent or broker will receive a monthly commission for each registered consumer for as long as the consumer remains registered.

Estimated to pay $20-30/month per member for most plans Dave Sherrillis an insurance broker and executive director of the Florida Association of Insurance Underwriters.

Florida’s insurance regulator said it was investigating the incident with police and CMS. Devin GarettaDirector of Communications and Chief Financial Officer of the State Financial Services Authority.

Since 2020, the state has received three consumer complaints about the issue in the South Florida, Tampa, and Gainesville areas, Garetta said. No “arrests or administrative actions” have been taken, he said.

But Turner is concerned that the incident has gone unreported. This type of fraud can be difficult to investigate because homeless victims may fear law enforcement or be unwilling or unable to make the necessary reports to document such crimes. She said there is.

“It was a big challenge,” Turner said.

new federal ruleThe law, completed in April, requires agents and brokers to document that consumers who enroll in insurance are eligible and to verify the accuracy of application information.

CMS investigates agents and brokers identified as potentially problematic through data analysis and consumer complaints. Ellen MontzCMS deputy administrator and director of the Consumer Information and Insurance Surveillance Center said in an email.

Government agencies can suspend or terminate the ability of agents and brokers to sell plans on the market or refer them to law enforcement, Montz said.

But Georgetown expert Corlett was surprised how long it took CMS to require agents and brokers to document consumer consent for marketplace coverage. rice field. “It’s remarkable that we’ve been here for almost 10 years, and they’re starting to work on it now,” she said.

Daniel Chang

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KFF Health News

Montz said CMS has worked with health insurers in the market to cancel more than 34,000 fraudulent claims in 2022, but it’s unclear how many of them involved homeless consumers.

Richards, an ACA program coordinator near Tampa, said he drafted the bill because of the high frequency of scams against the homeless these days. consumer warning March warns against “bad guys”.

In Miami, Zhelyazkova has re-enrolled with Ryan White and is also participating in an opioid use disorder treatment program at a homeless shelter. Among the many problems she has to overcome, she said, are frequent pitches from strangers offering cash to get her “free insurance.”

Sheryazkova’s shelter roommate, Kathryn Knox, 53, echoed her appeal.

“They’re constantly recruiting,” Ms. Knox said, adding that she’s been paid “probably five times” to sign up for the ACA plan over the years.

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