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| Georgia Access has culled the EDE crop |
Speridian, TrueCoverage, BenefitAlign, and Inshura are principle defendants in a putative class action lawsuit alleging a massive fraud scheme in which insurance agents used BenefitAlign to switch the plan selections of hundreds of thousands of marketplace enrollees without their knowledge or consent.*
In a September letter explaining the suspension, CMS states that it has reason to believe the BenefitAlign is hosting CMS data, including personally identifiable information (PII) at Speridian data centers located overseas, in violation of CMS regulations. The suspension letter also cites the lawsuit’s allegations:
Further, the Speridian Companies, BenefitAlign and True Coverage dba Inshura, are defendants in a pending lawsuit, filed by private parties in 2024, alleging that they engaged in a variety of illegal practices, including violations of the RICO Act, misuse of consumer PII, and insurance fraud that they allegedly carried out by misusing BenefitAlign’s access to the Marketplace. Plaintiffs in the lawsuit likewise claim that BenefitAlign allows access to the Exchange from abroad and houses CMS data overseas.
Rather incredibly, CMS notes that Speridian Companies (TrueCoverage and BenefitAlign) have been terminated or suspended four times since 2018.**
BenefitAlign has been a major player in broker-assisted ACA enrollment. In a suit filed on Sept. 6 seeking to force CMS to end Benefitalign’s suspension, Benefitalign [sic - the suit does not capitalize the “a”] and TrueCoverage aver that in OEP 2024, “Benefitalign’s Enhanced Direct Enrollment platform accounted for at least 1.2 million ACA applications, making it the second largest channel for ACA enrollments” (p. 4). (Note that the count is of “applications,” not “enrollments.”) By comparison, HealthSherpa, the dominant EDE in the federal exchange, says it executed 6.6 million enrollments in 2024 — slightly more than half of the 12.7 million “active” enrollments registered in HealthCare.gov states. (“Active enrollments” excludes passive auto re-enrollments, which constitute 22% of total enrollment on HealthCare.gov and which are not credited to any EDE.)
Enter now Georgia Access, the newest-minted state-based exchange (SBD), launching today. GA is the first SBE (there are now 20) to enable EDE, which will make it easier for agents serving the Georgia marketplace to transition to the state exchange. In states using the federal marketplace, some 80% of agent-assisted enrollment is via EDE — and in 2024, 78% of active enrollments were agent-assisted.
Georgia is ideologically committed to EDE. In 2020, it filed a waiver proposal that would have eliminated any government-run exchange for the state (along with, in one early iteration, allowing premium subsidies to be credited to ACA-noncompliant plans, which would have created a market something like what JD Vance has sketched out). The Trump administration approved that waiver, but the Biden administration suspended most of it (except for a reinsurance program). Georgia came back with a more conventional EDE proposal, which CMS conditionally approved this past August. While establishing a conventional state-based exchange, the Georgia initiative remains largely focused on EDEs. The state has approved virtually all of the EDE platforms — and until this week, the list included BenefitAlign and Inshura.
This apparent inclusion of the suspended EDEs was an ongoing mystery that I’ve been tracking. Some weeks ago, a spox at Georgia’s Office of the Commissioner of Insurance and Safety Fire, Ethan Stiles, told me, “BenefitAlign’s license has been suspended, not terminated. We are monitoring the situation and do not foresee changing tack. BenefitAlign met all of our standards.” At the same time, Stiles said, “We will work with CMS. I have no reason to think GA would use products not of the highest quality. “
Two subsequent voicemails to the Department went unanswered. Could Georgia, a champion of free enterprise in health insurance, be dismissing CMS’s security concerns about a major player in the ACA marketplace that’s also a suspected engine of large-scale fraud? Fortunately, no.
Yesterday, I caught up with Bryce Rawson at the Office of the Commissioner, who told me that Georgia Access had waited until BenefitAlign’s 45-day curative period under the CMS suspension was complete. As BenefitAlign/Inshura was unable to to allay CMS’s concerns, Georgia Access has “frozen” both EDEs. The Atlanta Journal-Constitution learned this a day ahead of me and reported yesterday:
King’s office told the AJC on Thursday that two of the web brokers that the state originally approved, Benefitalign and Inshura, will be blocked from Georgia’s website barring further developments. Those two are also banned by the federal site and have been sued for allegedly unethical practices. They deny wrongdoing.
Interestingly, though, CMS had previously told me that an SBE could deploy an EDE not approved by CMS. A spokesperson wrote: “states that utilize a direct enrollment technology do so under their own rules, though some follow federal rules. Please reach out to Georgia directly regarding its enhanced direct enrollment partners.”
That seemed a surprising response to my query (sent when BenefitAlign and Inshura were still on Georgia Access’s approved EDE list) as to whether GA could in fact deploy the two suspended EDEs. As I pointed out in my query, CMS’s August letter of conditional approval authorizing Georgia Access to deploy for OEP 2025 states, in a chart itemizing “notable requirements Georgia Access must maintain or continue to meet, to keep conditional approval:
FFE certification as an EDE is a core requirement for application as a GAEDE partner, so organizations failing to pass FFE review for compliance are not considered for certification with GA.
I have asked CMS to clarify how Georgia might go its own way on EDE approval, given that strict requirement — which, as it turns out, is specific to CMS’s dealings with Georgia Access.
For SBEs generally, while CMS’s 2025 Notice of Benefit and Payment Parameters (NBPP) for the ACA marketplace took pains to specify that web-brokers commissioned by state-based exchanges must conform to an array of CMS standards for display of information and consumer protection, and also specifies that the state exchange must be solely responsible for eligibility determinations (with EDEs interfacing with the state’s “centralized eligibility and enrollment platform”), the NBPP did not delegate to CMS the certification of web-brokers and other EDEs (e.g., single-insurer EDEs). That is, while the rule took pains to spell out that states cannot replace a state exchange with an array of EDEs, it also affirmed SBEs’ right to contract with rule-compliant EDEs as it sees fit.
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* The fraud alleged in the suit — and similar fraud documented by CMS — was enabled by the ability of agents registered with the federal exchange, HealthCare.gov, to access and make changes to enrollee accounts via the commercial EDE platforms, needing only the enrollee’s name, date of birth, and state of enrollment. In July, CMS shut down that ability; agents purporting to newly represent enrollees with an existing current account must now either engage the new client in a three-way call with the marketplace, or use a newly launched rather elaborate workaround on an EDE platform, in which the application must be finalized by the enrollee herself (after identity proofing).
** Re Speridian’s four terminations/suspensions,, here is CMS’s summary:
The Speridian Companies have a history of noncompliance with CMS regulations and agreements dating back to 2018. On April 19, 2018, TrueCoverage had its 2018 CMS agreements terminated, which ended their ability to transact information with the Marketplace, due to the severe nature of its suspected and, in some cases, admitted violations of CMS regulations.5 After the termination, the Speridian Companies were not registered with the Exchanges or permitted to assist with or facilitate enrollment of qualified individuals through the Exchange, including direct enrollment. The Speridian Companies admitted that their agents and brokers submitted false Social Security Numbers in connection with Marketplace eligibility applications, and CMS had reasonable suspicions of other fraud, improper enrollments, and misconduct by the Speridian Companies. The Speridian Companies regained their connection to CMS in 2019 after CMS, satisfied with the good-faith evidence provided, entered into Exchange agreements in Plan Year 2019
Photo by Markus Spiske
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