Exceptions
What is the 5th of the Month rule?
Policies with a start date of the 1st of the month have until the 5th of the same month to make a Binder Payment.
How will the potential expiration of the Federal Enhanced APTC affect exchange members?
They may receive lower APTC for 2026 causing higher premiums.
What is happening to Kids Plans in 2026?
They are being transitioned into Individual Plans.
What is the difference between a Cancelation and a Termination?
Cancelation refers to removing an applicant prior to effectuation or canceling coverage as never active.
Termination refers to removing an applicant after the policy has been effectuated or terminating the policy after it has been in effect for that plan year.
An Exchange member calls on January 5th to make their binder payment and set up Epay for their new policy effective 01/01/2026. What is the effective date of the billing method change?
01/01/2026 as the policy has not officially billed yet. We will create the 1st bill after the binder payment is made.
What is the 20-day rule?
The member may make the binder payment by the 20th day from the Payment Pending/File Load Date. Count to Payment Pending/File Load Date as Day 1.
An APTC member's grace period ended 1/31/26 terminating the policy back to 11/30/25. They only have an auto-renewal for 2026. Can we reinstate the policy?
Yes. Auto-renewals can be reinstated.
When is a $25 fee applied on a returned binder payment?
It applies to commercial policies if the payment returns for non-sufficient funds.
How does the 10-day Free Look work?
If the policy is within 10 days from the Contract mail date, the member can request to cancel their policy as never in effect per the 10-day Free Look.
A commercial member terminates for nonpayment of January back to 12/31/2025. Where do we look for the rate to calculate the reinstatement?
Billing Management. It will show the rate billed for January and February 2026.
What is the No Welcome Letter rule?
The member may make the binder payment within a month/30 days from which the new policy starts if a Welcome Letter was not generated for a new policy.
*Wrong address does not qualify for this exception.
A non-APTC member's policy terminates for nonpayment of February. They have a passive enrollment for 2026. Can we reinstate the policy?
Yes. If a non-APTC member's policy terminates for nonpayment of February, it will terminate back to the last month paid in full 1/31/26, which is during the current plan year.
How do we find the rate on a new commercial policy starting 1/1/2026?
Select Health LINK
A member's binder payment reversed. How do we proceed after taking payment?
Send a Chorus Reinstatement ticket.
What is the key indicator for a Passive Enrollment?
The Application Origin ID ends in -11.
What is the Subscriber Flip rule?
If the roles between the Main Subscriber and Dependent swap, it causes the Dependent to be put on a different policy with a new Subscriber ID. If this happens, the member is entitled to process a binder payment within a month/30 days from which the new policy starts.
An APTC member's grace period ended 1/31/26 terminating the policy back to 11/30/25. They have a CSR Variant Change with an Application Origin ID ending in -11 effective 1/1/26. Can we reinstate the policy?
No, we can't reinstate for 2026. We can reinstate through 2025. The -11 indicates this is a Passive Enrollment which cannot be reinstated if it terminates back to the previous plan year.
Where can we view the Payment Pending date in LINK? (2)
By viewing messages or locating the yellow Payment Pending status box.
What should we tell members, and notate, that are requesting a Break in Coverage, 10-day Free Look Cancelation, or Passive Termination?
If they have had any claims, they will be fully responsible for them.
An exchange member has an SEP for a new policy due to a baby add effective 1/21/26. We receive the file on 1/26/26. The binder due date is 2/14/26 per the 20-day rule. There is no Welcome Letter in ACA or Correspondence Inquiry. They call in 2/17/26 to make their binder payment. Can we accept the payment?
Yes. The No Welcome Letter exception allows the member to pay within the month the policy becomes effective or within 30 days of the effective date. Per the No Welcome Letter Rule, the member can make their binder payment by 2/20/26.
When is a ticket needed to activate the policy? (3)
Subscriber Flip Exceptions
Replacement Binder Payments
No Welcome Letter Exceptions
An APTC member's policy is subject to term back to 11/30/25 for nonpayment. They have a passive enrollment for 1/1/26 and an active enrollment for 2/1/26. They cannot afford to pay current. How can we assist the member?
We can send a BIC request for review as the new effective date on the active enrollment is after the grace period end date of 1/31/26.
A commercial member's policy terminates 1/31/26, as the main subscriber transitioned to Medicare. The dependent is enrolled into a new commercial plan with a new ID effective 2/1/26. Would the Subscriber Flip exception apply to this policy?
No. The Subscriber Flip exception only applies to exchange plans.
How are C4HC members made aware of the binder deadline and how to make their binder payment? (2)
They are sent both a Welcome Letter and an email within 24 business hours from the file load date with information on how to make their binder payment.
We receive a NVH application effective 1/1/26 with a $0 premium on 12/10/25. We receive a change file with a $13 premium effective 1/1/26 on 12/31/25. The policy already effectuated and billed due to the previous $0 premium. The member calls 1/2/26 to make their payment and set up Epay. What is the effective date of the added generation?
2/1/26. The policy already billed January at $0 therefore the effective date would be for the following month 2/1/26.