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Reminder: Check Three Items to Verify Ambetter Health Member Eligibility

Date: 10/09/25

Open Enrollment is around the corner, and recent changes for the 2026 Health Insurance Marketplace may affect eligibility for members at health plans across the nation.

One important update is the way in which current and future Marketplace beneficiaries will apply for Advanced Premium Tax Credits (APTCs) in 2026 and beyond. That’s why PA Health & Wellness is sharing a quick reminder with our participating providers on the best way to confirm Member eligibility in the Availity Essentials platform and other secure portals.

Grace Periods for Members receiving an APTC

Members enrolled in a Marketplace health plan are responsible for completing their premium payments each month. Members that do not make their premium payments in a timely manner enter a Grace Period, which begins with the first month a payment is missed.

The way in which PA Health & Wellness pays out claims during the Grace Period is different for members depending upon whether they receive an APTC.

Claims submitted with dates of service for members that do not receive an APTC for the entire duration of the Grace Period are placed into a ‘pend’ – or ‘pending’ status. For members that do receive an APTC, claims with dates of service during the initial phase of the Grace Period are considered for payment even though the premium has not been paid. Claims with dates of service submitted after the initial phase of the Grace Period are placed into a ‘pending’ status.

Claims in a ‘pending’ – status are considered for payment only after the Member returns to good standing with their premium payments. Should a member not return to good standing and the Grace Period expires, those claims will be denied, and the member’s coverage is terminated. (Visit healthcare.gov – or – your state exchange website for more information on the Grace Period in your market.)

Checking Eligibility, Premium Paid Through Date & Claims Paid Through Date

Ambetter Health encourages our provider partners to review Member Eligibility status, Premium Paid Through Date, and Claims Paid Through Date to identify when it may or may not be appropriate to request payment in advance of an appointment.

Consider the following statuses when reviewing ‘Member Eligibility’ on the Availity Essentials and/or other secure portals:

  • Active: The member is in good standing and has paid premiums in full.
  • Active – Pending Investigation (Availity Only): The member is behind in paying the premium.
  • Delinquent (non-Availity Secure Portals Only): The member is behind in paying the premium and the Claims Paid Through Date is in the future.
  • Suspended (non-Availity Secure Portals Only): The member is behind in paying the premium and the Claims Paid Through Date is in the past.
  • Inactive: The member is ineligible, and coverage has been terminated.

The ‘Premium Paid Through Date’ identifies the latest date through which premiums have been paid.

The ‘Claims Paid Through Date’ indicates the last date for which a claim for rendered services has been paid or will be considered for payment. Claims submitted after this date will be pended until the member pays any outstanding premium balances or the grace period ends. Claims submitted for dates of service after this date are at risk for nonpayment/rejection should the member not return to good standing prior to the end of the grace period.

If your patient is an PA Health & Wellness member and is not in good standing with a premium payment, providers may collect the full billed charges for the services rendered. In the event a Member returns to good standing by paying any outstanding premiums, the provider may submit a claim that will be considered for payment by the health plan. If that claim is paid by the health plan, then the provider is required to reimburse the member in accordance with the terms of the Provider Agreement.

Members in an Active – Pending Investigation, Suspended, or Delinquent status are encouraged to refer to their responsibilities in the PA Health & Wellness Member Handbook.

If you have additional questions or want to learn more about changes to the 2026 Health Insurance Marketplace, checking eligibility or submitting claims via the secure portal, we are here to help. Contact your PA Health & Wellness provider representative by calling 1-833-510-4727 Relay 711 or send us a message through the provider portal.

Thank you for your commitment to providing access to quality care to your patients, our members, and for your partnership as we work to improve the health of the communities we serve, one person at a time.

Scenarios: Will My Claim Be Considered for Payment?

Scenario No. 1

  • Date of Service: Sept. 1, 2025
  • Member Receives APTC: Yes
  • Member Eligibility Status: Active
  • Premium Paid Through Date: Sept. 30, 2025
  • Claims Paid Through Date: Oct. 31, 2025
  • Claim Status: Considered for Payment

The member is in good standing with premium payments, and the claim is considered for payment. The Date of Service is prior to the Premium Paid Through Date and Claims Paid Through Date, which is 30 days after the Premium Paid Through Date because the member receives an APTC.

Scenario No. 2

  • Date of Service: Sept. 1, 2025
  • Member Receives APTC: No
  • Member Eligibility Status: Active
  • Premium Paid Through Date: Sept. 30, 2025
  • Claims Paid Through Date: Sept. 30, 2025
  • Claim Status: Considered for Payment

The member is in good standing with premium payments, and the claim is considered for payment. The Date of Service is prior to the Premium Paid Through Date and Claims Paid Through Date. The Premium Paid Through Date and Claims Paid Through Date are the same because the member does not receive an APTC.

Scenario No. 3

  • Date of Service: Sept. 1, 2025
  • Member Receives APTC: No
  • Member Eligibility Status: Active – Pending Investigation or Delinquent
  • Premium Paid Through Date: Aug. 30, 2025
  • Claims Paid Through Date: Aug. 30, 2025
  • Claim Status: Pending

The member is not in good standing with premium payments and has entered the Grace Period. The claim is placed into a ‘pending’ status because the member is behind in their premium payment, does not receive an APTC, and the Claims Paid Through Date is in the past. This claim will be considered for payment only if the outstanding premium balance is paid in full during the Grace Period. If the outstanding balance is not paid before the end of the Grace Period, the claim will be denied.

Scenario No. 4

  • Date of Service: Sept. 1, 2025
  • Member Receives APTC: Yes
  • Member Eligibility Status: Active – Pending Investigation or Delinquent
  • Premium Paid Through Date: Aug. 30, 2025
  • Claims Paid Through Date: Sept. 30, 2025
  • Claim Status: Considered for Payment

The member is not in good standing with premium payments and has entered the initial phase of the Grace Period. The claim is considered for payment even though the Date of Service is after the Premium Paid Through Date because the member receives an APTC and Claims Paid Through Date is in the future. The member remains responsible for the outstanding premium payment.

Scenario No. 5

  • Date of Service: Sept. 1, 2025
  • Member Receives APTC: Yes
  • Member Eligibility Status: Active–Pending Investigation or Suspended
  • Premium Paid Through Date: July 31, 2025
  • Claims Paid Through Date: Aug. 30, 2025
  • Claim Status: Pending

The member is not in good standing with their premium payments and is in the latter phase of the Grace Period. The claim is placed into a ‘pending’ status. While the Claims Paid Through Date is after the Premium Paid Through Date because the member receives an APTC, the Claims Paid Through Date is prior to the Date of Service. The claim will be considered for payment only if the outstanding premium balance is paid in full during the Grace Period. If the outstanding balance is not paid, the claim will be denied.

Scenario No. 6

  • Date of Service: Sept. 1, 2025
  • Member Receives APTC: Yes
  • Member Eligibility Status: Inactive
  • Premium Paid Through Date: May 31, 2025
  • Claims Paid Through Date: June 30, 2025
  • Claim Status: Denied

The member did not pay the outstanding balance, the Grace Period has expired, and coverage has been terminated. The claim is denied because the member is no longer covered by the health plan.