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Enrollment periods determine when consumers can enroll in Affordable Care Act (ACA) coverage or change ACA plans. Outside of Open Enrollment, a consumer typically needs a Qualifying Life Event (QLE) to qualify for a Special Enrollment Period (SEP).
In this article, we’ll cover:
Open Enrollment Period (OEP)
Open Enrollment Period (OEP) is the annual window when consumers can enroll in an Affordable Care Act (ACA) plan for the upcoming plan year.
For states that use the Federally-Facilitated Marketplace (FFM), OEP dates are:
Plan year 2026: November 1, 2025 - January, 15 2026
Plan year 2027: November 1, 2026 - December 15, 2026
State-Based Marketplaces (SBM) can have different Open Enrollment dates.
Outside of OEP, consumers can enroll in ACA coverage or change ACA plans as long as they qualify for a Special Enrollment Period (SEP).
Special Enrollment Periods (SEPs)
Special Enrollment Periods (SEPs) are additional enrollment windows available during the plan year. SEPs allow a consumer to enroll in an Affordable Care Act (ACA) plan or change ACA coverage when a Qualifying Life Event (QLE) occurs.
SEPs are available year round and can be pursued any time a consumer seeks an effective date other than the next available Open Enrollment Period (OEP) effective date.
Any out-of-pocket expenses a consumer has already paid during the plan year, such as the deductible or out-of-pocket maximum, may reset if the consumer changes plans during that same plan year.
Qualifying Life Events (QLEs)
Qualifying Life Events (QLEs) are specific life events that can open an SEP.
Not every change a consumer could experience during the year is a QLE, and a QLE must meet specific rules for SEP eligibility.
Review the QLE chart for the list of qualifying events and the SEP eligibility requirements for each.
QLE chart
SEP eligibility requirements vary depending on the qualifying event a consumer experiences. Review the QLE chart for the list of qualifying events and the SEP eligibility requirements for each.
The QLE chart applies to states that use the FFM. States that use an SBM may have a different list of qualifying events. When assisting consumers in SBM states, HealthSherpa recommends checking with the SBM for their full list of QLEs.
How to use the QLE chart
When assisting consumers seeking SEPs, use the QLE chart to confirm the consumer’s change matches an event listed. Then review any prior coverage and timing requirements to determine SEP eligibility.
Step 1: Determine the QLE
Step 1: Determine the QLE
The Qualifying Life Event column lists each available qualifying event.
Review the events in the Qualifying Life Event column and ask consumers if they have experienced any of these events. After confirming the consumer experienced an event listed in the Qualifying Life Event column, continue to Step 2.
If the consumer has not experienced an event listed on the QLE chart, they are not SEP eligible.
Step 2: Review prior coverage requirements
Step 2: Review prior coverage requirements
The Requirement of prior coverage column indicates whether prior or current coverage may be required for the qualifying event to be SEP eligible. This column may also indicate how recently prior coverage must have been active.
Using the identified QLE, determine whether the consumer meets the prior coverage requirements. If the consumer:
Meets these requirements: Continue to Step 3.
Does not meet these requirements: Return to step 1 to review other QLEs.
Step 3: Verify timing
Step 3: Verify timing
The Timing column specifies how long the SEP window remains available from the date the qualifying event occurred.
Using the identified QLE, determine whether the consumer meets the timing requirements. If the consumer:
Meets these requirements: The consumer may be SEP eligible. Continue to Step 4.
Does not meet these requirements: Return to step 1 to review other QLEs.
Step 4: Set expectations
Step 4: Set expectations
Once it is determined that the consumer may be SEP eligible, use the remaining columns to set expectations around coverage effective dates, any plan selection limitations, and other items to note.
Using the identified QLE, review remaining columns:
Coverage effective dates: Explains how the effective date is determined after plan selection is submitted.
Plan selection limitations: Shows whether there are restrictions on plan selection while using the SEP.
Notes: Includes additional details, such as how the SEP is typically triggered.
Step 5: Enrollment submission
Step 5: Enrollment submission
An enrollment submission takes place once the subsidy application is submitted, or re-submitted with updates, and plan selection is finalized. With consent, agents can assist consumers with enrollment submission.
Data Matching Issues (DMIs) & SEP Verification Issues (SVIs)
The Marketplace may require documentation to resolve Data Matching Issues (DMIs) or SEP Verification Issues (SVIs).
Data Matching Issue (DMI)
Data Matching Issue (DMI)
A DMI means the information entered on a consumer’s subsidy application does not match what is on file with the government, or is not available within their records, and needs to be verified.
A DMI can occur when:
Information is incorrect or missing on the consumer’s application
The Marketplace application is inconsistent with data from trusted sources, such as Internal Revenue Service (IRS) databases
Trusted sources do not have data for the consumer
DMIs can occur during OEP and when consumers seek SEPs.
Deadlines
Consumers have 90 to 95 days to resolve a DMI based on the date the application was submitted, not the effective date. Consumers typically need to upload documents to resolve DMIs.
Consequences
If a DMI is not resolved, the consumer may lose their subsidy or coverage eligibility for coverage.
SEP Verification Issue (SVI)
SEP Verification Issue (SVI)
An SVI occurs when a consumer is eligible for an SEP and is asked to verify they experienced the QLE.
SVIs can occur when consumers seek SEPs.
Deadlines
Consumers have 30 days to resolve an SVI based on the date they select a plan, not the effective date. Consumers typically need to upload documents to resolve SVIs. Consumers cannot make a binder payment or use new or updated coverage until all SVIs have been satisfied.
Consequences
If an SVI is not resolved, the consumer may lose SEP eligibility.
DMIs and SVIs can occur on any platform a Marketplace enrollment is submitted.
Required documentation
Consumers may need to upload documents to resolve DMI and SVI follow-ups.
The list of acceptable documents varies based on the specific follow-up item being resolved. A DMI follow-up asks the consumer to verify a specific piece of information. An SVI follow-up asks the consumer to provide proof that their qualifying life event occurred.
The lists of acceptable documents are available here:
Review the list to see what is acceptable, then select the appropriate documentation to upload. Each Verify page within HealthSherpa also shows the acceptable documents for the follow-up item selected.
Frequently asked questions
What is a subsidy?
A subsidy is federal financial assistance designed to lower the cost of health insurance purchased through the Marketplace. Subsidy eligibility can consist of both advance premium tax credit (APTC) and cost-sharing reduction (CSR).
APTC: Refers to a dollar amount that may be applied on a consumer’s behalf to their monthly health insurance premium. APTC can be applied to all metal levels and may appear as Estimated savings in HealthSherpa.
CSR: A discount applied to silver level plans that lowers deductibles and out-of-pocket costs for care and prescription drugs. Consumers who are eligible for APTC may also be eligible for CSR. Consumers who are not eligible for APTC are not eligible for CSR.
Are consumers still SEP eligible if their income is at or below 150% of the Federal Poverty Level (FPL)?
No. Effective August 25, 2025, the Centers for Medicare & Medicaid Services (CMS) discontinued the SEP for individuals at or below 150% of the FPL.
Do consumers need an enrollment period to enroll in dental coverage?
No. Off-exchange dental plans can be sold year-round and are not contingent on enrollment periods.
Can SEP enrollments be submitted on HealthSherpa?
SEP enrollments can be submitted on HealthSherpa year-round until the CMS cutoff date for the current plan year. After that date, consumers should reach out to the Marketplace Call Center for assistance. The cutoff date changes each year. For plan year 2025, SEP enrollments were no longer possible on HealthSherpa after December 15, 2025.
Additional resources
For help using HealthSherpa or for other assistance, contact Agent Support. Agent Support is available by phone at (888) 684-1373, by email at Agent_Support@HealthSherpa.com, or by chat directly from your account.