Personal Health and fitness Coverage: Results of Covert Tests for Chosen Product sales Representatives Shown on Health

What GAO Observed

Since 2014, millions of consumers have bought unique current market well being insurance plan options as a result of the wellness insurance coverage exchanges—or marketplaces—established under the Affected person Defense and Reasonably priced Treatment Act (PPACA). Profits associates detailed on Division of Wellness and Human Services’ (HHS) web-site can also promote other styles of well being protection preparations that might cost less but may perhaps not cover all pre-present situations as detailed PPACA-compliant strategies do. GAO performed 31 covert checks on picked sales reps shown on health These assessments involved stating that the (fictitious) applicant had pre-current conditions—either diabetic issues or coronary heart disease—and requesting protection for these circumstances to see if the profits consultant directed the applicant to a detailed PPACA-compliant system or a PPACA-exempt plan that does not cover what the fictitious applicant requested. As aspect of these exams, GAO gauged no matter whether the chosen profits reps engaged in possibly deceptive procedures, these kinds of as making wrong or misleading statements about protection or omitting substance data about coverage.

All 31 income representatives GAO contacted properly referred GAO’s fictitious applicant to a PPACA-compliant prepare. The vast majority of product sales reps also discussed that a PPACA-exempt strategy would not cover the applicant’s pre-existing condition. None of the product sales reps GAO contacted engaged in perhaps misleading marketing practices that misrepresented or omitted info about the merchandise they were being offering. The effects of GAO’s covert exams are not generalizable to all sales associates stated on

Why GAO Did This Analyze

PPACA directed each individual condition to establish an exchange—referred to as a state-based exchange—or elect to use the federally facilitated exchange established by HHS. Every year the exchanges offer an open enrollment time period during which qualified consumers may perhaps enroll in or adjust their protection. Consumers enroll in the federally facilitated exchange as a result of HHS’s web site, and some point out-centered exchanges have picked out to use this site for enrollment.

Although specific overall health insurance policies coverage is frequently regulated by states, beginning in 2014, PPACA founded a amount of new federal requirements for person overall health insurance policy protection. For case in point, PPACA prohibited insurers from excluding protection or charging bigger premiums for pre-current ailments. HHS polices also involve sales associates that support with or aid enrollment in PPACA-compliant plans bought by health to supply consumers with suitable info, without having omission of content reality, and chorus from marketing or carry out that is misleading.

Revenue representatives that are stated on may also market other kinds of health coverage arrangements that do not have to comply with some or all of PPACA’s unique industry specifications. As a end result, the arrangements may well be considerably less expensive, but give less added benefits in comparison to PPACA-compliant ideas.

PPACA-exempt wellbeing coverage preparations might be attractive to shoppers, specifically those who come across it challenging to pay for PPACA-compliant plans. Even so, such arrangements generally do not need to have to adhere to PPACA’s prerequisite that designs in the person marketplace be offered to shoppers in outlined categories outlining the extent to which they are anticipated to address medical care. As a end result, depending on how they are marketed and bought, PPACA-exempt arrangements could existing hazards for people, if, for example, they buy these programs mistakenly believing that protection is as complete as for PPACA-compliant designs.

GAO was requested to obtain insights on the marketing and gross sales tactics of income reps specifically detailed on In this report, GAO describes the results of covert checks it done involving chosen gross sales representatives listed on health when contacted by GAO undercover investigators posing as individuals needing to obtain overall health insurance coverage to protect pre-current situations.

GAO investigators done these covert exams (i.e., undercover cellular phone phone calls) from November 2020 to February 2021. GAO also talked about the oversight of PPACA-exempt arrangements with senior officials from the Facilities for Medicare & Medicaid Solutions within just HHS, as properly as officers from the Countrywide Affiliation of Coverage Commissioners, and reviewed facts they furnished.

For a lot more information and facts, get in touch with Seto J. Bagdoyan at (202) 512- 6722 or or Howard Arp at