A dermatology practice we support ran eligibility on a Marketplace patient on March 10, 2026. Active, effective January 1, deductible partly met. The visit happened, a biopsy was done, and the claim went out the next day. Three weeks later the claim status showed "pending, awaiting premium payment." The biller had never seen that status. She called the plan and was told the patient had not paid a premium since January, was in the second month of a grace period, and that the claim would be paid or denied depending on what happened by April 30.
By the end of March the same practice had eleven claims in that state across three plans. Every one of them had passed an eligibility check. This is not a payer error. It is the Marketplace 90-day grace period working exactly as the regulation says, and in 2026, with enhanced premium tax credits gone and premiums up sharply for subsidized enrollees, practices are seeing far more of it than they did a year ago.
Key takeaways
- Under 45 CFR 156.270(d), a Marketplace plan must give an enrollee who receives advance premium tax credits (APTC) a three-consecutive-month grace period for nonpayment, as long as the enrollee has paid at least one full month's premium in the benefit year.
- The plan must pay claims for services in the first month of the grace period, may pend claims for services in the second and third months, and must notify providers of the possibility of denial when the enrollee is in months two and three.
- If the enrollee does not pay in full by the end of month three, coverage terminates retroactively to the last day of month one, and the pended claims are denied. The patient becomes self-pay for those dates.
- The enhanced premium tax credits expired on December 31, 2025. Subsidized enrollees are paying much more in 2026, so nonpayment and grace-period pends rose in February and March.
- Protection is procedural: ask about premium status at check-in, flag grace-period patients, track pended claims separately from denials, and have the financial conversation before month three ends.
What the Marketplace 90-day grace period actually requires
A qualified health plan (QHP) is a plan sold on the federal or a state Marketplace under the Affordable Care Act. Most Marketplace enrollees receive advance premium tax credits, the subsidy paid directly to the plan each month to lower the enrollee's premium. For those enrollees, the regulation at 45 CFR 156.270(d) requires the plan to hold coverage open for three consecutive months when the enrollee stops paying, provided the enrollee paid at least one full month of premium earlier in the year. Enrollees without a subsidy get whatever grace period state law requires, commonly 30 or 31 days, with no pending rule.
During the three months, the plan continues to collect the tax credit from the Treasury. If the enrollee pays all outstanding premiums before the period ends, coverage continues as if nothing happened and the pended claims are released. If not, the plan terminates coverage effective the last day of the first month, returns the tax credits for months two and three, and denies the claims it pended. The enrollee owes the premium for month one and owes providers for everything after it.
| Grace period month | Coverage status shown | What the plan does with claims | Your exposure |
|---|---|---|---|
| Month one | Active | Must pay appropriate claims | None beyond normal cost sharing |
| Month two | Active, often with a grace-period message | May pend claims | Full charge if coverage is later terminated |
| Month three | Active, often with a grace-period message | May pend claims | Full charge if coverage is later terminated |
| After month three, unpaid | Terminated retroactive to end of month one | Denies pended claims | Bill the patient as self-pay for months two and three |
| After month three, paid in full | Active, continuous | Releases and pays pended claims | Normal cost sharing only |
The regulation also requires the plan to notify providers of the possibility of denied claims when the enrollee is in months two and three. In practice that notice arrives inconsistently: sometimes as a message on the eligibility response, sometimes as a portal flag, sometimes only when you call. The rule puts an obligation on the plan, but the practice that relies on it will be surprised.
Why 2026 is a bad year for grace-period pends
The enhanced premium tax credits created in 2021 and extended through 2025 expired on December 31, 2025. Congress did not extend them before the year ended. The House passed a three-year extension on January 8, 2026, by a vote of 230 to 196, but the Senate has not passed a matching bill as of this writing, and a December 2025 Senate attempt failed to reach 60 votes. The effect on enrollees is well documented: KFF estimated that without the enhancement, average premium payments for subsidized Marketplace enrollees would more than double.
The billing consequence is arithmetic. A patient who paid $60 a month in 2025 and is now billed $180 is far more likely to miss a payment. Many enrollees paid January to keep the coverage they selected during open enrollment, then missed February. Under the rule, that puts them in month one in February, month two in March and month three in April. Claims for March and April visits are the ones being pended right now, and the reckoning comes at the end of April. If Congress acts later in the year, the relief will not reach the premiums already missed.
How to spot a grace-period patient before the visit
The eligibility transaction (the 270 request and 271 response most practice management systems run automatically) will usually show the patient as active throughout the grace period, because the patient is active. Some plans add a message segment that says "grace period" or "premium delinquent"; many do not. So the check has to go one step further for Marketplace plans. We do three things.
First, identify Marketplace patients at registration. The insurance card usually does not say "Marketplace," but the plan name and the group number pattern often do; on-exchange individual plans typically carry no employer group, and many carriers use a distinct product name for exchange plans. Your payer grid should list, per carrier, how to recognize its Marketplace products. Second, for those patients, check the carrier portal, which more often than the 271 shows premium status or a grace-period indicator. Third, when the portal is silent and the service is expensive, call. A five-minute call before a $900 procedure is cheap.
At check-in, ask a plain question: "Are your premium payments up to date?" Patients usually know. Those who say no, or who are unsure, get the financial conversation before the visit rather than after the denial.
Protecting the practice without turning patients away
Most participation agreements prohibit balance billing a covered patient for covered services while coverage is active, and during the grace period coverage is active. That limits what you can collect on the day of service to the normal copay, coinsurance estimate and deductible. What the contract does not prevent is telling the patient the truth: that if the premium is not paid by the end of the grace period, the coverage will be cancelled back to the first month and the patient will owe the full charge for today's visit. Put that in a one-paragraph acknowledgment the patient signs, and give them a copy. When the denial comes, the conversation has already happened.
For elective, non-urgent services scheduled for a patient known to be in month two or three, it is reasonable to offer to reschedule until the premium is paid, or to collect a deposit against the self-pay charge where the contract allows, refundable if the claim pays. Urgent care is different, and most practices we work with treat it as they would any patient and accept the risk. Whatever you decide, write it into the financial policy so the front desk is not improvising.
On the billing side, pended claims are not denials and should not sit in the denial queue where a biller will "correct and resubmit" them. Create a separate work status, "pending grace period," with the grace-period end date on each claim, and review the list the first week of every month. When the end date passes, check coverage: if the plan shows active, request release and payment; if terminated, the remittance will carry a coverage-terminated reason code, most often CO-27 or PR-27 (expenses incurred after coverage terminated), and the balance moves to the patient. Bill the patient promptly and offer a payment plan. Timely filing is preserved by the original submission, but a claim you never followed up on is a claim you forgot.
A worked example
A patient enrolled effective January 1, 2026 in a silver plan with a subsidy, paid January, and missed the February 1 premium.
- February is grace month one. A February 12 office visit, 99214, is paid by the plan less the copay.
- March is month two. A March 10 visit with a biopsy (99213-25 and 11104) is pended. The practice flags the patient at a March 24 follow-up and has the patient sign the acknowledgment.
- April is month three. An April 7 visit for results is pended. The grace period ends April 30.
- Outcome A: the patient pays February through April premiums on April 22. All pended claims are released and paid in May.
- Outcome B: the patient does not pay. Coverage terminates effective February 28. The March and April claims deny CO-27. The practice bills the patient the contracted or self-pay amount, for illustration $410, with a payment plan offered.
In outcome B the practice's protection was the March 24 conversation and signature. Without it, the April bill is a surprise, the patient disputes it, and the balance ages into bad debt.
Questions we hear
Can we refuse to see a patient who is in the grace period?
The patient is covered during the grace period, and your participation agreement likely requires you to treat covered members. Refusing care is the wrong tool. Rescheduling elective services with the patient's agreement, collecting what the contract permits, and documenting the financial conversation are the right tools. When in doubt about what a specific contract allows, ask counsel or the plan's provider relations representative and keep the answer in writing.
The plan says the patient is active. Why should we do anything differently?
Because "active" is true today and may be false retroactively in six weeks. The grace period is the one common situation in which an eligibility check that was accurate when you ran it does not protect you. Treat a Marketplace patient with a pended claim or a grace-period flag as a patient with uncertain coverage until the plan confirms the premium is paid.
We have denied grace-period claims from last fall. Are they collectible?
From the patient, yes, as self-pay balances for dates after month one, subject to your financial policy and any state consumer protection rules. From the plan, no, unless the plan pended or denied a first-month claim, which the rule does not allow; appeal those with the enrollment dates. Our denial management team separates the two before anything is written off, because first-month denials are more common than plans admit.
What to do this week
- Pull every claim with a pending or "awaiting premium" status from Marketplace plans and put them in a dedicated work status with the grace-period end date.
- Add "Are your premium payments up to date?" to the check-in script for Marketplace patients and train the front desk on why.
- Write the one-paragraph grace-period acknowledgment and add it to the intake packet.
- Update the payer grid with how each carrier identifies Marketplace products and where in its portal premium status appears.
- Decide, in writing, how the practice handles elective services for patients in months two and three, and put it in the financial policy.
- Review your eligibility verification workflow so Marketplace patients get the portal check, not only the automated 271.
