ACA marketplace commissions: auditing flat per-member fees month after month

Small lines, large totals

Most marketplace carriers pay a flat fee per enrolled member per month rather than a percentage of premium. The fee is typically a low double-digit dollar amount, so no single line is worth studying. Across a few hundred members and twelve months, the same book is worth tens of thousands of dollars.

That asymmetry is the whole problem. A member who quietly stops appearing on the statement costs you the fee every month until someone notices, and nobody notices a number that was small to begin with.

What to check each month

Because the rate is flat, the audit is a headcount and a multiplication:

• Member count on the statement versus effective members in your own book
• Per-member amount paid versus the amount in your agreement, including any mid-year change
• Members who appeared last month and are missing this month, with no termination on file
• Dependents counted or not counted — carriers differ, and a per-member basis and a per-subscriber basis produce very different totals
• Effective-date timing — a mid-month effective date paid as a partial month when the agreement says full

Mixed ACA and Medicare statements

Plenty of health carriers pay ACA and Medicare business on one statement. Pricing every line the same way is the most common cause of false findings and of real ones being missed: an ACA line judged against a Medicare amount looks enormously short, and a Medicare line judged against an ACA fee looks fine when it is not.

Set the rate type per product — flat fee for ACA, the CMS maximum or your contracted share of it for Medicare — and the statement reconciles cleanly. Commission Guardian suggests flat-fee pricing automatically for ACA-named products and prices Medicare lines per member against the full CMS maximum unless you set your own percent or flat rate.