Ghost Enrollees in the ACA Marketplace Explained

Ghost enrollees in the ACA marketplace can distort enrollment reporting, affect risk adjustment transfers and increase CMS scrutiny. Even small pockets of unsupported enrollment can ripple through operations and financial reconciliation.

In this episode of Regulatory Joe, Joe Boyle breaks down what ghost enrollees actually are — and what they are not. Low utilization alone isn’t the issue. The risk shows up when enrollment patterns, premium payment behavior, repeated plan switching or grace period activity don’t align with normal member behavior.

EPISODE GUIDE:
00:00 Defining Ghost Enrollees and What’s Normal
02:00 Point of Sale and Broker-Driven Root Causes
05:00 How CMS Identifies Ghost Enrollee Patterns
10:00 How Health Plans Can ID Ghost Enrollee Patterns
12:00 Root Cause Review: Welcome Packets, Grace Periods, Reinstatement
16:00 Best Practices for Health Plans

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