Ambetter from Sunshine Health

P.O. Box 25408

Little Rock, AR 72221

09/06/2020
NANCY BRICENO 221325308
117 SW 10TH ST
APT 509
MIAMI, FL 33130
ATTN: NANCY BRICENO

YOUR PAYMENT INFORMATION - THIS IS A BILL

Invoice Number: 20250537250 Previous Balance: $ 44.06
Invoice Date: 09/06/2020 Payments: $ (44.06)
Plan Name: 21663FL0130019-06 Past Due / (Credit Balance): $ 0.00
Member ID: U9304547001 Monthly Premium: $ 830.06
Policy #: 93045470 Adjustments: $ 0.00
Coverage Period: 10/01/2020 - 10/31/2020 Tax Credit: $ (786.00)
TOTAL AMOUNT DUE: $ 44.06
Due Date: 09/30/2020

Payment Options - We have several ways for you to pay your premium - Online, Auto Bill Pay, Phone, Mail and more! Ways to pay
are listed on the back of this invoice. Thank you for enrolling in Auto Bill Pay. To make a change to any of your bill pay settings, please
log in to your online member account at Ambetter.SunshineHealth.com.

Paperless Options - Go paperless! Sign up for Paperless Billing today and receive a monthly email when your invoice is ready to
view. All you need is a valid email address. Get started today at Ambetter.SunshineHealth.com

Notes: Any past due amounts are due immediately. It is important to pay any past due amounts as soon as possible in order to keep
your health insurance coverage active. Please do not wait until the due date for your current premium to pay your past due amounts.
Payments made after 6PM Eastern time will be processed on the next business day and will be reflected on your account within 24
hours.
TO AVOID PROCESSING DELAYS, PLEASE REMEMBER TO INCLUDE THE
ATTACHED PAYMENT COUPON WITH YOUR CHECK OR MONEY ORDER.

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Address Changed? Visit www.healthcare.gov or contact

1-800-318-2596.

RETURN THIS WITH PAYMENT

NANCY BRICENO
117 SW 10TH ST
Total Amount Due: $44.06 APT 509
MIAMI, FL 33130
System ID: 157250289
Policy #: 93045470
Payment Due By: 09/30/2020
Invoice Number: 20250537250
Invoice Date: 09/06/2020
Coverage Period: 10/01/2020 - 10/31/2020
Enrollment Type: I SEND PAYMENT TO:
Ambetter from Sunshine Health
PO Box 743948
0000001572502890000004406I9 Atlanta, GA 30374-3948

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Your Monthly Member Detail

The following people listed are covered under this plan.

Subscriber/Dependent Member ID
(S) BRICENO, NANCY U93045470
(D) BRICENO, GERCY U9304547002

Reminder
Your payment must be made by 09/30/2020 for coverage to be effective beginning 10/01/2020. Once you pay in full, we will send your
welcome materials. If you have already paid the full premium, please disregard this notice.
Premium payments are due in advance, on a calendar month basis. Your monthly payments are due before the first day of each month
so that your coverage is effective during that month. This means once the policy is effectuated if any required premium is not paid
before the due date, your policy will be subject to a grace period. Refer to your Evidence of Coverage for details on the grace period
that applies to you. During a grace period your policy will stay in force, however, claims may not be processed for covered services
provided to you during the grace period. Ambetter will notify you, the Federal Marketplace, and providers about the non-payment of
premiums and the possibility of denied claims when you are in the grace period.

If you are terminated for not paying your premium, you are not eligible to enroll with Ambetter again until open enrollment, unless you
have a Special Enrollment Period.
Premium Payment Options:
1. Online (our recommendation!). Log in to your member account at Ambetter.SunshineHealth.com to:
• Choose online monthly bill payment by following the "pay online" instructions.
• Enroll in automatic bill pay using your prepaid debit card, bank account or credit card. After your auto bill pay account is set
up, all future premiums will be charged to that card or account.
2. Mail:
Send a check or money order to the address below. Make your check payable to “Ambetter” and remember to write your policy
number on your check or money order.

Ambetter from Sunshine Health

PO Box 743948
Atlanta, GA 30374-3948
3. Phone:
Call us at 1-844-PAY-BETTER (729-2388) and use our Interactive Voice Response (IVR) system. It's quick and available 24/7!
You can also call 1-877-687-1169 (Relay FL 1-800-955-8770) between 8 a.m. and 5 p.m. EST to make your payment.
4. MoneyGram®:
Find a MoneyGram location near you by visiting MoneyGram.com/BillPayLocations or calling 1-800-926-9400.
Remember to bring:

• Cash for your premium payment. Ambetter will pay your MoneyGram transaction fee!
• Your Ambetter member ID number
• Receive Code: 15514
• Fill out the blue MoneyGram ExpressPayment® form and use the MoneyGram phone or kiosk to complete your payment.
• Ask a store associate if you need any help in making your payment.

To learn more about making your Ambetter invoice payment using MoneyGram, visit www.moneygram.com//us/en/how-to-pay-bills
The Subscriber is responsible for paying Premiums and remains responsible for their timely payment if Ambetter from Sunshine
Health rejects a payment from a third party. Ambetter from Sunshine Health does not accept direct or indirect Premium payments
from any person or entity other than the Subscriber, a Dependent, or an Acceptable Third-Party Payor. Ambetter from Sunshine
Health does not accept Premium payments from providers of Covered Services and Supplies. Please refer to your Evidence of
Coverage for a list of Acceptable Third Party Payors.

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