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April 11, 2025

Mehmet Oz, M.D.
Administrator
Centers for Medicare & Medicaid Services
Hubert H. Humphrey Building
200 Independence Avenue, S.W., Room 445-G
Washington, DC 20201

RE: Patient Protection and Affordable Care Act; Marketplace Integrity and Affordability (CMS-9884-P)

Dear Administrator Oz:

On behalf of the ���������� Association’s (AHA) nearly 5,000 member hospitals, health systems and other health care organizations, including approximately 90 that offer health plans, and our clinician partners — including more than 270,000 affiliated physicians, 2 million nurses and other caregivers — and the 43,000 health care leaders who belong to our professional membership groups, we thank you for the opportunity to respond to the Centers for Medicare & Medicaid Services (CMS) rule on marketplace integrity and affordability.

We appreciate CMS’ attention to concerns regarding the inappropriate enrollment of large numbers of low-income individuals into Health Insurance Marketplace coverage by certain brokers. As detailed in the proposed rule, it appears that in several states, some brokers have enrolled cohorts of low-income individuals (including, at times, Medicaid enrollees) into marketplace plans without the individuals’ knowledge. This has led to patient confusion, barriers to care and financial pressure on hospitals.

These impacts have been confirmed by AHA member hospitals. In these instances, hospitals scheduled services for patients when their coverage indicated Medicaid. In one example, the hospital only learned that the patient’s coverage had changed upon submitting the bills for care to the appropriate Medicaid agency, which then denied the claims due to the patient having marketplace coverage. The patients were completely unaware of this change in their coverage, and, unfortunately, in many instances, the hospital was not in-network with the marketplace plan, leaving the care uncovered. This change in coverage without the patients’ consent is interfering with patients' access to care, including services being postponed or canceled. One health system shared that they have found 2,500 unique patients with this issue, resulting in over $45 million in outstanding claims going unpaid as a result. A separate health care system estimates the financial impact on their hospitals is much greater.

The agency has proposed several policy changes to address this issue. While we appreciate the agency taking action to stop these inappropriate enrollments, we are concerned that the proposed changes will create barriers for truly eligible marketplace consumers without sufficient focus on the agents and brokers instigating these enrollments. Taken with other policies in the rule, CMS estimates that between 750,000 to 2 million consumers could lose their coverage. We are deeply concerned by these estimates of coverage loss, particularly as we have seen no credible evidence to support that such a high number of individuals have been impacted by inappropriate broker enrollments.

Coverage loss of this magnitude would have substantial consequences for patient access to care, as well as the financial stability of hospitals, health systems, and other providers. As CMS notes in the rule, “some enrollees, particularly those facing financial constraints, might need to adjust their household budgeting to maintain coverage or, if they are not able to, become uninsured. Depending on the circumstances, these enrollees, if they become uninsured, could face higher costs for care and medical debt if care is needed. These costs could in turn be incurred by hospitals and municipalities in the form of uncompensated care” (emphasis added). These new costs to hospitals would come at a time when many hospitals and health systems, particularly critical access hospitals and those in rural areas, are operating with little to no margin. They cannot absorb further losses without consequences on access to care that will be felt by everyone in a community, not just those enrolled in marketplace coverage.¹

For these reasons, we encourage the agency to pause finalizing many of these policies to give it and stakeholders additional time to consider the impacts while simultaneously investigating and taking appropriate action to stop the specific agents and brokers responsible for these inappropriate enrollments. In addition, we urge the agency to address reimbursement for services rendered to those impacted patients.

Thank you for your consideration, and we look forward to working with the administration to ensure efficient and affordable marketplaces. Please contact me if you have questions, or feel free to have a member of your team contact Ariel Levin, AHA’s director of coverage policy, at 202-626-2335 or alevin@aha.org.

Sincerely,

/s/

Ashley Thompson
Senior Vice President
Public Policy Analysis and Development