The Advanced Premium Tax Credit (APTC) is part of the Patient Protection and Affordable Care Act (PPACA). The APTC helps qualifying individuals and families obtain individual health insurance through the Health Insurance Exchanges (HIX) System by reducing monthly premiums.

As a reminder, PPACA requires a three-month grace period for members who receive APTC and are delinquent in paying their portion of their health insurance premiums before the member?s health insurance can be terminated. Please note that members must first pay their initial premium payment to be eligible for the grace period.

Under this mandate, insurers are required to pay medical claims received during the first 30 days of the grace period, but may pend medical claims for services rendered to those members and their eligible dependents during the second and third months of the grace period. Insurers are also required to notify affected providers when a member receiving APTC enters the grace period. If the member does not pay all outstanding premiums by the end of the grace period, the pended claims will be denied and the member's policy will be terminated.

If claims incurred in the second and third month are denied due to non-payment of premium by the end of the grace period, and the member's policy is terminated, providers may seek reimbursement directly from the member. However, if the premium is paid in full by the member before the grace period ends, any pended claims will be processed in accordance with the terms of the member?s insurance contract and your Provider Agreement.

Delinquent payment indicator

Changes were made in 2016 as to how to identify when an APTC member is in a delinquent payment status. An indicator within the Eligibility and Benefits Inquiry transaction on the NaviNet^? web portal alerts providers when an AmeriHealth member is in the grace period and provides a status of the member's claims.

When an APTC member is delinquent on his or her monthly insurance premiums, a yellow banner with an alert icon and message indicating ?Pending Investigation? will display on the Eligibility and Benefits Details screen. Note: You will need to select the benefit category labeled Health Benefit Plan Coverage (i.e., the system default benefit category) on the left side of the display and scroll to the bottom of the screen to view additional details.

One of the below messages will display depending upon the period of delinquency:

• HIX GRACE PERIOD 1ST MONTH OF DELINQUENCY ? ELIGIBLE CLAIMS WILL BE PAID;
• HIX GRACE PERIOD 2ND MONTH OF DELINQUENCY ? ALL CLAIMS WILL BE SUSPENDED;
• HIX GRACE PERIOD DELINQUENT GREATER THAN 3 MONTHS ? ALL CLAIMS WILL BE DENIED.

Note: Refer to the bottom of the screen when viewing the benefit category labeled Health Benefit Plan Coverage for all detailed APTC indicator information related to the member?s record.

For more information on using this transaction, please refer to the Eligibility and Benefits Inquiry Guide.

If you have any questions about this mandate, please call Customer Service at 1-888-YOUR-AH1 for AmeriHealth New Jersey or at 1-800-275-2583 for AmeriHealth Pennsylvania. If you have questions regarding NaviNet transactions, please call the eBusiness Hotline at 609-662-2565 for AmeriHealth New Jersey or at 215-640-7410 for AmeriHealth Pennsylvania.

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