A family practice in Ohio ran eligibility on Monday for a patient it has seen for six years. In December she had a silver marketplace plan with a $40 copay. The January response came back active on a different plan from a different carrier, with a $7,000 deductible, and the practice is not in that carrier's network. She did not mention any of this when she booked. She may not know.
The enhanced premium tax credits that had been in place since 2021 expired on December 31, 2025. The original ACA credits still exist for households below 400 percent of the federal poverty level, but the enhanced amounts are gone and the income cap is back. For many enrollees the monthly premium roughly doubled at renewal, and the early reports from the open enrollment period that ended January 15 show sign-ups running well behind last year. The people who stayed often moved to cheaper bronze plans with far higher deductibles. The people who left did not necessarily tell their doctor's office.
From the practice side this shows up three ways: a patient with a new plan and possibly a new network, a patient whose coverage has lapsed, and a patient in a premium grace period whose claims will pend and may later be reversed. Each needs a different response, and the front desk needs to know which one they are looking at.
Key takeaways
- The enhanced premium tax credits ended December 31, 2025, so more marketplace patients than usual changed plans, changed carriers, moved to bronze deductibles or dropped coverage at the January renewal.
- Run eligibility on every 2025 marketplace patient at scheduling and again the day before the visit, and read plan name, effective date and premium status, not just the active flag.
- Subsidized enrollees who stop paying get a three-month grace period during which claims may pend and then reverse retroactively; treat the grace-period message as a signal to collect.
- A retroactive termination arrives as CO-27 or a takeback; confirm the date, move the balance, check for other coverage and document timely filing to the original payer.
- A patient who lost coverage may qualify for Medicaid or a special enrollment period, and pointing them there gets the practice a covered patient back.
Step one: verify every marketplace patient, not just new ones
Flag every patient whose 2025 coverage was a marketplace plan. Your practice management system can identify them from the payer ID or plan name; if it can't, the eligibility response usually identifies exchange plans. Run a 270/271 check on each one at scheduling and again the day before the visit. Read the response for four fields: coverage status, plan name, effective date, and any message about premium payment status. Do not rely on the active flag alone.
Step two: read the response for the three scenarios
| What the 271 shows | What it means | What the front desk does |
|---|---|---|
| Active, same plan as December | Patient renewed; deductible has reset | Update the estimate for the new deductible and collect at time of service |
| Active, different plan or carrier | Patient changed plans at renewal | Confirm network participation before the visit; get the new card; update the account |
| Inactive or terminated | Coverage ended, usually for non-payment or non-renewal | Call the patient before the visit; discuss self-pay, a good faith estimate, or Medicaid screening |
| Active with a premium delinquency or grace period message | Patient has not paid the premium; coverage may be terminated retroactively | Treat the visit as at risk; collect the estimated patient responsibility; note the account |
The grace period problem, explained
Marketplace enrollees who receive an advance premium tax credit and have paid at least one month's premium get a three-consecutive-month grace period if they stop paying. During the first month the plan pays claims. During months two and three the plan may pend claims. If the patient catches up, the pended claims pay. If the patient does not, coverage terminates retroactively to the end of the first month, and the plan reverses or denies the pended claims. The practice then has a patient balance for a visit that happened two or three months ago, and a patient who has lost coverage.
Enrollees who do not receive a tax credit have a shorter grace period set by state law, often around 30 days, and the same retroactive risk on a shorter timeline. This year there are more unsubsidized enrollees than last year because of the income cap returning, so expect more of the shorter version.
The operational answer is to treat the grace period message as a signal to collect. A patient in a grace period is legally covered, so you cannot refuse them as uninsured, but you can and should collect the estimated patient responsibility at the visit, explain that the insurer has flagged the premium as unpaid, and ask the patient to contact the carrier. Note the account so the billing team recognizes the pended claim when it arrives.
What the remit will show, and how to work it
A claim reversed after retroactive termination typically comes back with CO-27 (expenses incurred after coverage terminated) or a takeback on a later remit. When you see it, do four things. First, confirm the termination date from the payer; sometimes a termination is later reversed when the patient pays. Second, move the balance to patient responsibility and send a statement that explains why in one sentence. Third, check whether the patient has other coverage for that date of service, including retroactive Medicaid, which several states grant back to the application date. Fourth, if the visit is now beyond a timely filing window for a new payer, document the original submission date; most payers accept proof of timely filing to the prior payer.
Patients who lost coverage entirely
A patient whose plan terminated is a self-pay patient until something changes. Two things might change it. Loss of marketplace coverage can qualify them for Medicaid if their income is low enough, and the state agency will screen them; have the enrollment phone number or the state website handy at the front desk. Loss of coverage also triggers a special enrollment period, so a patient who dropped coverage over a premium increase may be able to re-enroll in a different plan. Neither is the practice's job to arrange, but pointing the patient in the right direction gets the practice a covered patient back.
For the visit itself, provide the No Surprises Act good faith estimate for uninsured and self-pay patients and offer your self-pay rate. A written estimate before the visit, in our experience, is the single thing that most improves collection from a patient who has just lost coverage.
The medical billing team at Revelrex builds the eligibility workflow this way for every practice we bill for, and the January report separates marketplace patients so the practice can see how many changed plans or lost coverage. The earlier article on what to include in an eligibility verification workflow covers the general process; this is the marketplace-specific layer for this year.
Questions we hear
Can we refuse to see a patient who is in a grace period?
The patient is covered during the grace period, so treating them as uninsured is a contract problem with the plan and possibly a state law problem. You can require payment of the estimated patient responsibility as you would for any covered patient, and you can explain the risk. Check your payer contract language on grace periods, and involve counsel before making a refusal policy.
How long do we have to bill the patient after a retroactive termination?
Your own financial policy and state law govern patient billing timelines, not the payer. Send the statement promptly with an explanation. Patients pay these balances more often when the statement arrives within a couple of weeks of the reversal than when it arrives months later with no context.
The 271 response does not show premium status for one of our carriers. How do we find it?
Not every payer returns the grace period message in the standard eligibility transaction, and a few return it only in a free-text segment your system may not display. Call the payer's provider line for any marketplace patient whose response looks incomplete, and ask your clearinghouse whether the carrier's 271 includes the premium payment status at all. Where it does not, the fallback is the payer portal, which usually shows it. Write down which carriers show it where, so the front desk is not rediscovering this every week.
What to do this month
- Flag all 2025 marketplace patients and run eligibility at scheduling and again the day before the visit.
- Train the front desk on the four 271 scenarios in the table and what to do for each.
- Confirm network participation for any new carrier that appears in the responses.
- Collect estimated patient responsibility for every patient with a grace period message.
- Set up a work queue for CO-27 and retroactive takebacks so the billing team catches them within a week.
- Keep Medicaid and marketplace enrollment contact information at the front desk.
