Month: July 2023

What Should I do if Someone Signed me up for Health Insurance Marketplace Coverage Without my Consent?

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Page last updated on March 10, 2025

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Did your federal income tax return for last year indicate that you had health insurance coverage through the Marketplace (also referred to as Obamacare, Healthcare.gov and Affordable Care Act) and/or you owe IRS a repayment of premium tax credit, but you did not sign up for coverage?

If you were enrolled in a health plan in the Marketplace by another person (an insurance agent or broker) without your consent and knowledge, you should report this to the Marketplace and submit the claim for agent fraud.

On this page, you can find information on the following topics:

North Carolina residents, if you would like assistance with this process, our Health Insurance Navigators can provide you with free help.

Mecklenburg, Cabarrus and Union Co. residents, please call 980-256-3782

North Carolina residents in other counties, please call 1-855-733-3711

Visit ncnavigator.net

Next steps to follow if you were enrolled in a plan on the Health Insurance Marketplace without your consent

  1. Call the Health Insurance Marketplace (aka Obamacare) Call Center at 1-800-318-2596 to find the status of your enrollment. Even if you did not sign up of your own will, you may owe the IRS money back for premium tax credits you received.
  2. If the Marketplace reports you did not have coverage in 2024 and/or 2025, there is nothing else you need to do.
  3. If the Marketplace confirms you had coverage that you did not consent to AND you did not willingly use this coverage for your doctor or hospital visits, follow these steps….
  • Ask the Marketplace representative to cancel/terminate any current active coverage you were fraudulently enrolled in, so that you do not continue receiving premium tax credits that you may not be eligible for.
  • Contact an Affordable Care Act Health Insurance Navigator to assist you with reporting your enrollment without a consent to the Center for Medicaid and Medicare, the federal government agency overseeing Marketplace, and to submit an agent fraud claim so that your coverage may be terminated retroactively (which would allow you to cancel your entire coverage from the original issue date). To receive assistance from a Health Insurance Navigator, call 980-256-3782 (Mecklenburg, Cabarrus and Union Co. residents) or 1-855-733-3711 (NC residents in other counties) for free assistance.
  • Next, the Marketplace will investigate your claim either through the escalation for unauthorized enrollment or through a Complex Case Help Center online form submission. We recommend that you work with the Navigator to submit unauthorized enrollment report to ensure that it is fully processed and, if outcome is successful, your coverage has been cancelled and a voided 1095A tax form issued so you do not have tax liability. Escalations are done through Marketplace Call Center and only Navigators can submit complex case online form to report unauthorized enrollment. Upon investigation, you will be informed of the outcome and the next steps. 
  • Depending on the fraud claim outcome, you may receive an amended 1095A tax form that you may need to file with your federal income tax return. Make sure the Marketplace has the correct mailing address for you. Charlotte Center for Legal Advocacy Low-Income Taxpayer Clinic may be able to provide guidance with tax questions regarding your 1095A form. You can contact the clinic at 980-202-7329.
  • It is recommended that you file an agent fraud claim with the NC Department of Insurance as well. Visit ncdoi.gov or call 919-807-6840 (Toll-Free 888-680-7684). Your Navigator can assist you with this process. 
  • If you believe your identity has been stolen, you should report it to IdentityTheft.gov.
  • If you have questions about this process, want assistance or just want to understand your options for health coverage, Affordable Care Act Health Insurance Navigators can help. Call 980-256-3782 (Mecklenburg, Cabarrus and Union Co. residents) or 1-855-733-3711 (NC residents in other counties) for free assistance.

Who are Health Insurance Navigators and how can they help me with this process?

Health Insurance Navigators are licensed by the Center for Medicaid and Medicare, a federal agency that also administers Health Insurance Marketplace. Their services are FREE for everyone, and they do not get any financial incentives for their assistance. They help consumers understand what health options they are eligible for and assist with enrollment in Medicaid and Marketplace coverage. They cannot choose a health plan for you but can help answer questions about health coverage and guide a consumer through the enrollment process. Navigator services include reasonable accommodations for non-English speaking consumers or consumers with visual, hearing, or other impairments with no cost to consumers.

No, Health Insurance Navigators are not an insurance agent or broker. Navigators are federally licensed and provide free, unbiased help to consumers to help individuals understand their health options eligibility and assist with enrollment in Medicaid and Marketplace coverage. Navigators can also assist with processes concerning the Health Insurance Marketplace, such as enrollment in a plan without consent. Navigators receive no direct compensation for assisting an individual with the Health Insurance Marketplace or Medicaid.

Why is it important to report fraudulent enrollment in Marketplace coverage?

Every time someone applies for coverage through Marketplace, they are also applying for government financial assistance through advance premium tax credit to help lower your monthly health insurance payment (or “premium”). Advance Premium Tax Credit is approved based on the estimate of your expected income, the tax filing status, and other criteria for the year you will have coverage. This is reported on your Marketplace application.

If you qualify for a premium tax credit based on your estimate, tax filing status, and ineligibility for other health coverage, you can use it to lower the cost of your monthly premium for the plan you enrolled in.

You are legally required to file a federal income tax return for the year you had Marketplace coverage and reconcile the advance premium tax credit with your actual income for that year:

  • If at the end of the year you have received more premium tax credit than you are due based on your final income, you will have to pay back the excess when you file your federal tax return.
  • If you have received less than you qualify for, you will get the difference back.

If you were eligible for premium tax credits when you had coverage on Marketplace and you received the correct amount, all you need to do is submit this information with your tax return.

There are several reasons someone is not eligible for premium tax credits, for example you may not have an eligible immigration status, or you had an offer of or enrolled in an employer sponsored insurance (some exceptions apply). If you were eligible/ enrolled in Medicaid, Medicare, or other health coverage that meets the minimum essential coverage requirement, you WERE NOT eligible for premium tax credits.

What is not a fraudulent enrollment?

You cannot claim that you were fraudulently enrolled in a Marketplace health plan if:

  1. You agreed to be enrolled in Marketplace plan after you talked to a health insurance agent or broker.
  2. You willingly enrolled into the Marketplace plan with the help of an agent/broker, but later changed your mind and decided you do not want this coverage.
  3. You used your Marketplace health plan at any point to cover the cost of any medical services provided during the coverage year to you or any other tax household member listed on your Marketplace application.
  4. Your health plan premium cost was not fully subsidized (you were paying a portion of the premium).

What If I was enrolled in health coverage on Marketplace without my consent, but now I want to keep it?

If you have been enrolled without consent to a Marketplace health plan for 2025 and you decide that you may want to keep that plan, you should:

  1. Ask the Marketplace representative for the details of the plan (monthly premium, deductible amount, copays amount, out-of-maximum amount for 2025) so that you can understand the cost of this coverage and make an informed decision.
  2. Ask the representative to update your 2025 application to make sure you report any offer of insurance elsewhere (employer sponsored insurance, Medicare, Medicaid, TRICARE or VA Healthcare, etc..), your accurate tax filing status and your income for coverage year to make sure you will receive an accurate premium tax credit to lower you monthly premium. *Please note that if you are legally married you will need to include your spouse’s income on the Marketplace application and file jointly with your spouse for the year you had coverage, even if you do not live with your spouse. Some exceptions apply.
  3. If your employer offers health insurance, you are not eligible to be on Marketplace and receive premium tax credit unless the lowest premium cost of the plan your employer offers is more than 9.02% of your income.
  4. If you already enrolled in health insurance offered by your employer (or are eligible for any other minimum essential coverage, e.g., Medicaid, Medicare, or TRICARE), you are NOT eligible for Marketplace coverage and you should immediately cancel the Marketplace plan you were enrolled in for 2025. Otherwise, you may have to re-pay your premium tax credit when you file taxes.
  5. Make sure Marketplace has correct contact information to mail you your 1095A for 2025 coverage.
  6. Use your 1095A to reconcile any premium tax credits you received on your federal tax return.

Qué hacer si fui inscrito en la cobertura de salud en el Mercado (Obamacare) sin mi consentimiento

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¿Su declaración federal de impuestos del año pasado indicó que tenía cobertura de salud a través del Mercado (Obamacare) y/o que debe un reembolso del crédito fiscal premium al IRS, pero usted no se inscribió en la cobertura?

Si alguien más (un agente o corredor de seguros) lo inscribió en un plan de salud del Mercado sin su consentimiento y conocimiento, debe informar esto al Mercado y presentar una reclamación por fraude de agente.

Por favor, siga estos pasos:

  1. Comuníquese al Centro de Llamadas del Mercado de Seguros Médicos (también conocido como Obamacare)  al 1-800-318-2596 para conocer el estado de su inscripción. Es posible que deba realizar un reembolso al IRS si se le otorgó un crédito tributario de prima para el que no era elegible.
  2. Si le informan que no tuvo cobertura en 2022 y/o 2023, no debe hacer nada más.
  3. Si el Mercado confirma que usted tenía cobertura sin consentimiento y no utilizó esta cobertura para visitas al médico y/u hospital, siga estos pasos:
  • Informe sobre su inscripción sin consentimiento y presente una reclamación por fraude de agente para que su cobertura sea cancelada retroactivamente. Pida al Mercado que cancele cualquier cobertura activa actual en la que lo inscribieron fraudulentamente, para que no siga recibiendo créditos fiscales premium para los cuales puede no ser elegible.
  • A continuación, el Mercado investigará su reclamación. Esto tomará al menos 30 días, pero puede tomar más tiempo. Tras la investigación, recibirá una carta con la resolución de la reclamación por fraude. Si no recibe noticias de ellos en un plazo de 30 días, puede llamar al Mercado para verificar el estado de la reclamación.
  • Según el resultado de la reclamación por fraude, es posible que reciba el formulario fiscal de impuestos 1095A enmendado que deberá ser presentado con su declaración de impuestos federales. La Clínica de Contribuyentes de Bajos Ingresos del Centro de Apoyo Legal de Charlotte puede responder preguntas relacionadas con el formulario 1095A. Si lo requiere puede contactarse al: 980-202-7329.
  • Se recomienda que presente una reclamación por fraude de agente ante el Departamento de Seguros de Carolina del Norte también. Visite ncdoi.gov o llame al 919-807-6840 (Llamada gratuita 888-680-7684).
  • Si cree que su identidad ha sido robada, debe informarlo en IdentityTheft.gov.
  • Si tiene preguntas sobre este proceso o sus opciones de cobertura de salud, los Navegadores de Seguros de Salud de la Ley de Cuidado de Salud a Bajo Precio pueden ayudarlo. Llame al 980-256-3782 para obtener asistencia gratuita.

Los Navegadores de Seguros de Salud pueden ayudarlo con este proceso. Puede llamar al 980-256-3782 para obtener asistencia gratuita.

Los Navegadores de Seguros de Salud están licenciados por el Centro de Medicaid y Medicare, una agencia federal que también administra el Mercado de Seguros de Salud. Sus servicios son gratuitos para todos, y no reciben incentivos financieros al ofrecer su ayuda. Ayudan a los consumidores a comprender las opciones de salud para las que son elegibles y los asisten en la inscripción en Medicaid y en la cobertura del Mercado. No pueden elegir un plan de salud por usted, pero pueden ayudarlo a responder preguntas sobre la cobertura de salud y guiar al consumidor a través del proceso de inscripción. Los servicios del Navegador incluyen adaptaciones razonables para consumidores que no hablan inglés o que tienen discapacidades visuales, auditivas u otras discapacidades sin costo para los consumidores.

¿Por qué es importante informar la inscripción fraudulenta en la cobertura del Mercado?

Cada vez que alguien solicita cobertura a través del Mercado, también está solicitando asistencia financiera gubernamental a través del crédito fiscal premium por adelantado para ayudar a reducir su pago mensual del seguro de salud (o “prima”). El Crédito Fiscal Premium por Adelantado se aprueba en función de la estimación de sus ingresos esperados, el estado civil para efectos de declaración de impuestos y otros criterios para el año en que tendrá la cobertura. Esto se informa en su solicitud al Mercado.

Si califica para un crédito fiscal premium en función de su estimación, estado civil para efectos de declaración de impuestos y la falta de elegibilidad para otra cobertura de salud, puede utilizarlo para reducir el costo de su prima mensual del plan en el que se inscribió.

Está legalmente obligado a presentar una declaración de impuestos federales del año en que tuvo cobertura del Mercado y conciliar el crédito fiscal premium por adelantado con sus ingresos reales de ese año:

  • Si al final del año ha recibido más crédito fiscal premium del que le corresponde según sus ingresos finales, deberá devolver el excedente cuando presente su declaración de impuestos federales.
  • Si ha recibido menos de lo que califica, recibirá la diferencia.

Si fue elegible para créditos fiscales premium cuando tenía cobertura en el Mercado y recibió la cantidad correcta, todo lo que necesita hacer es presentar esta información con su declaración de impuestos.

Hay varias razones por las que alguien no es elegible para créditos fiscales premium, por ejemplo, es posible que no tenga un estatus migratorio elegible o que haya recibido una oferta o se haya inscrito en un seguro patrocinado por el empleador (con algunas excepciones). Si fue elegible/inscrito en Medicaid, Medicare u otra cobertura de salud que cumple con el requisito de cobertura esencial mínima, NO será elegible para créditos fiscales premium.

¿Qué no es una inscripción fraudulenta?

No puede afirmar que fue inscrito fraudulentamente en un plan de salud del Mercado si:

  1. Aceptó ser inscrito en un plan del Mercado después de hablar con un agente o corredor de seguros de salud.
  2. Se inscribió voluntariamente en el plan del Mercado con la ayuda de un agente/corredor, pero luego cambió de opinión y decidió que no desea esta cobertura.
  3. Utilizó su plan de salud del Mercado en algún momento para cubrir el costo de cualquier servicio médico proporcionado durante el año de su cobertura o si cualquier otro miembro del hogar fiscal mencionado en su solicitud al Mercado hizo uso de este servicio.
  4. El costo de la prima de su plan de salud no estaba completamente subsidiado (usted estaba pagando una parte de la prima).

¿Qué sucede si fui inscrito en cobertura de salud en el Mercado sin mi consentimiento, pero ahora quiero mantenerla?

Si fue inscrito sin consentimiento en un plan de salud del Mercado para 2023 y decide que podría querer mantener ese plan, deberá:

  1. Solicitar al representante del Mercado los detalles del plan (prima mensual, monto del deducible, monto de copagos, monto máximo fuera de bolsillo para 2023) para que pueda comprender el costo de esta cobertura y tomar una decisión informada.
  2. Solicitar al representante que actualice su solicitud de 2023 para asegurarse de informar cualquier oferta de seguro en otro lugar (seguro patrocinado por el empleador, Medicare, Medicaid, TRICARE o VA Healthcare, etc.), su estado civil y sus ingresos exactos para el año de cobertura, para asegurarse de que reciba un crédito fiscal premium preciso para reducir su prima mensual. *Tenga en cuenta que si está legalmente casado, deberá incluir los ingresos de su cónyuge en la solicitud del Mercado y presentar una declaración conjunta con su cónyuge para el año en que tuvo cobertura, incluso si no vive con su cónyuge. Se aplican algunas excepciones.
  3. Si su empleador ofrece seguro de salud, no es elegible para estar en el Mercado y recibir créditos fiscales premium a menos que el costo de la prima más bajo del plan que ofrece su empleador sea superior al 9,12% de sus ingresos.
  4. Si ya se inscribió en un seguro de salud ofrecido por su empleador (o es elegible para cualquier otra cobertura esencial mínima, como Medicaid, Medicare o TRICARE), NO es elegible para la cobertura del Mercado y debe cancelar inmediatamente el plan del Mercado en el que se inscribió para 2023. De lo contrario, es posible que deba reembolsar el crédito fiscal premium cuando presente sus impuestos.
  5. Asegúrese de que el Mercado tenga la información de contacto correcta para enviarle su formulario 1095A para la cobertura de 2023.
  6. Use su formulario 1095A para conciliar cualquier crédito fiscal premium que haya recibido en su declaración de impuestos federales.

El mercado de salud y los impuestos

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By Equipo Buenas Finanzas

Durante la temporada de impuestos VITA Latino 2023 varios clientes compartieron su interés en conocer más sobre el acceso a un seguro auspiciado por el Mercado de Salud (www.HealthCare.gov o www.cuidadodesalud.gov ) y como puede afectar sus impuestos.

Dada la importancia de contar con un seguro médico en los Estados Unidos, además de cumplir con el deber ciudadano de pagar impuestos, decidimos consultar con los expertos del programa de acceso a la salud, “Health Insurance Navigator”, en el Centro de Apoyo Legal de Charlotte.

En el siguiente video, entrevistamos a Natalie Marles, supervisora del programa de Navegadores de Salud. Ella responde a preguntas como: ¿Qué es el mercado de seguros y quiénes califican?, ¿Cómo afecta mi seguro médico a mis impuestos? Y más importante, ¿debo tener alguna precaución al adquirir mi seguro médico?

Algunos de los puntos más importantes a destacar son:

  • Las personas pueden calificar para un seguro médico asequible teniendo en cuenta el número de miembros de su familia, el ingreso que la familia reciba y si son fumadores o no.
  • Las personas que califican deben tener algún estado migratorio legible (proceso de visa, residentes legales, etc.) y no deben tener cobertura médica bajo ningún otro programa medico (como Medicare o Medicaid).

Read more at: El mercado de salud y los impuestos

Introducing Our New Board Chair: Gwendolyn Lewis

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As a non-profit organization dedicated to pursuing justice for those in need, we are constantly striving to make a positive impact in our community. The Charlotte Center for Legal Advocacy is pleased to introduce our newly elected Board Chair 2023-2024, Gwendolyn W. Lewis. With her at the helm, we are confident that the Advocacy Center will reach new heights and continue to create lasting change.

Gwendolyn is an attorney and problem-solver that is passionate about assisting her clients with resolving issues using creative processes. She assists businesses, healthcare professionals, educational institutions, and a wide range of companies with advice and counsel, civil litigation, complex labor and employment litigation and professional liability litigation, among other matters.

In addition to her primary role, and on top of her current dedication to the Charlotte Center for Legal Advocacy’s Board of Directors, Gwendolyn is a current member of the Lifespan Services Board of Directors and a former member of the North Carolina Bar Association’s Board of Governors and Foundation Board of Directors. She promotes pro bono and public service in many of her community activities and leads the NCBA’s Charlotte region of its 4ALL Statewide Day of Service.

Gwendolyn values her relationships with her colleagues and the community and has been recognized by North Carolina Super Lawyers in Employment Law Defense, has been elected to Business North Carolina magazine’s Legal Elite for Employment Law, Litigation and Young Guns. She has been selected as a Leader in the Law and recognized by Best Lawyers in America in Healthcare Litigation, Labor and Employment Litigation and Employment Law Management.

Gwendolyn hails from Richmond, Virginia, where her father was a minister and entrepreneur and her mother a long-time child-care provider. She earned her B.S. in Criminal Justice from North Carolina A&T State University and her J.D. from Elon University School of Law.

Gwendolyn will be supported by the following newly appointed 2023-2024 Board Members and Officers. We invite all our supporters, volunteers, and community members to join us in congratulating Gwendolyn on their new role!

To meet our Board of Directors, please click here.

As States Purge Medicaid Rolls, Legal Aid Groups Step Up

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By Alison Knezevich

Read more at: As States Purge Medicaid Rolls, Legal Aid Groups Step Up

North Carolina resident Anthony Brooks spent the last few weeks rushing to schedule doctor’s appointments and procedures to treat his chronic heart problems.

The 57-year-old is set to lose his health care coverage through Medicaid at the end of the month, so he is racing to set up surgery to implant a defibrillator his doctors said Brooks needs.

“I can’t afford insurance,” said Brooks, who worked as a traveling home health aide for the elderly until he suffered a heart attack last September. “This is devastating to me.”

Meanwhile, in Florida, Gillian Sapia was shocked when her 5-year-old daughter Penelope’s occupational therapist texted her the day before a scheduled session in May to tell her Penelope was no longer covered by Medicaid.

Penelope, who has been on Medicaid her whole life, has a rare metabolic disorder called classic galactosemia, as well as other health conditions. After the message from her daughter’s therapist, Sapia began a frustrating pursuit to get answers from the state’s Department of Children and Families.

“I spent like a week trying to get somebody, and it was just hours and hours of phone calls,” Sapia said, only to eventually receive conflicting information.

Brooks and Penelope are among the millions of Americans who have recently faced losing their coverage as states have started to review eligibility for the first time since 2020.

During the COVID-19 pandemic, the federal government prohibited states from kicking people off Medicaid because of a “continuous coverage requirement” linked to the federal health emergency. But that requirement ended March 31, allowing states to once again start cutting Medicaid rolls.

Both Brooks and Gillian Sapia turned to legal aid organizations for help.

Across the country, nonprofit legal groups are working to raise awareness about the changes, help people appeal coverage terminations and educate beneficiaries about their rights.

Attorneys report that as states undertake the massive review, beneficiaries are experiencing confusion, difficulty getting answers and processing errors.

“This is a very complex process that states have to implement,” said Cassidy Estes-Rogers, an attorney and program director with the Charlotte Center for Legal Advocacy, the North Carolina organization Brooks went to for guidance. As renewal paperwork has started to go out, “at the beginning of the month, we see a huge volume of calls with just absolutely confused people.”

As States Purge Medicaid Rolls, Legal Aid Groups Step Up