For states who use the Federally-Facilitated Marketplace (FFM) the annual Open Enrollment Period (OEP) for Affordable Care Act (ACA) plans begins on November 1st and ends on January 15th. Outside of OEP, consumers can enroll in ACA coverage or change ACA plans as long as they qualify for a Special Enrollment Period (SEP).
In this article, we’ll cover:
State-Based Marketplaces (SBM) can have different Open Enrollment dates. See more information on Marketplace type by state here.
Special Enrollment Periods (SEPs)
Special Enrollment Periods (SEPs) are certain timeframes outside of the annual Open Enrollment Period (OEP) when a consumer can can enroll in ACA coverage or change ACA plans.
Consumers can only become eligible for an SEP if they have a Qualifying Life Event (QLE) or their household income falls at or below 150% of the Federal Poverty Level.
Consumers who are SEP eligible may need to upload follow-up documents to resolve Data Matching Issues (i.e. proof of income) or an SEP Verification Issue (i.e. proof of loss of coverage). Learn more about uploading follow-up documents here.
Note: Any out of pocket expenses (e.g. deductible, out-of-pocket maximum) a consumer has already paid during a plan year may reset when a plan change occurs.
Qualifying Life Events (QLEs)
Consumers may experience many changes throughout the year. Some changes fall under a unique list of Qualifying Life Events (QLE) which trigger an SEP. For states who use the FFM, there are 19 different QLEs that break down into the following categories:
Loss of qualifying health coverage
Change in household size
Change in primary place of living
Change in eligibility for Exchange coverage or help paying for coverage
Enrollment or plan error
Other qualifying changes
States who use an SBM may have a slightly different lists of QLEs. When assisting consumers in states who use an SBM, we recommend checking with the SBM to obtain their full list of QLEs.
QLE chart
Details surrounding SEP eligibility vary depending on which QLE a consumer experiences. Reference this QLE chart below to view important details.
Household income at or below 150% Federal Poverty Level (FPL)
Beginning March 2022, consumers with household incomes that fall at or below 150% of the Federal Poverty Level (FPL) are eligible for an SEP. Eligibility is based on the previous year’s FPL chart.
Chart Source: March 2025, KFF Explaining Health Care Reform: Questions About Health Insurance Subsidies, , https://www.kff.org/affordable-care-act/issue-brief/explaining-health-care-reform-questions-about-health-insurance-subsidies/
Eligibility for this SEP will be automatically detected within the HealthSherpa application as well as within the quoter; there are no steps you will need to take when working with Consumers who may qualify for this SEP. Consumers are eligible for this SEP if they:
Have an estimated annual household income at or below 150% FPL and
Are eligible for APTC. Note: Consumers with income below 100% FPL but who do not qualify for Medicaid due to immigration status may still be eligible for APTC if they meet all other Marketplace eligibility requirements. They would also qualify to use this SEP.
Consumers who are ineligible for this SEP include those who:
are offered Medicaid or offered affordable employer-sponsored coverage
Fall into the Medicaid Gap (i.e. make less than 100% FPL in states that did not participate in Medicaid expansion)
Consumers with existing ACA coverage are able to switch to another plan in their current metal level or switch to a silver metal level plan. (e.g. consumers already enrolled in a bronze plan can switch to a bronze or silver plan, but cannot switch to a gold plan).
Consumers may utilize this SEP as often as they'd like and their effective dates will follow "accelerated effective date" rules. "Accelerated effective date" rules mean you can enroll a consumer any day of the month and their coverage will start the first day of the next month (e.g. if you enroll your client in a plan on 3/30/25, their coverage will begin on 4/1/25).
After submitting a consumer's application, the eligibility results page will display “due to estimated household income (≤150% FPL)” as an SEP reason if your consumer has qualified for the ≤150% FPL SEP.
Completing SEP enrollments
During enrollment
On HealthSherpa, quoting and completing an application for a client with a SEP is very similar to Open Enrollment.
The main difference is that you will need to select your client’s QLE in the ‘Additional Questions’ section of our application. You can see an example of what this looks like around the 6:45 mark of this video:
Post-enrollment
Consumers who are SEP eligible may need to upload follow-up documents to resolve Data Matching Issues (DMIs) or an SEP Verification Issues (SVIs):
DMI follow-ups must be uploaded within 90 days of enrollment. If the deadline is missed, the client can lose some or all of their subsidy – or in some cases, lose coverage entirely.
SVI follow-ups must be uploaded within 30 days. If the deadline is missed, the client will lose their coverage entirely.
It can be challenging to keeping track of follow-up tasks so HealthSherpa makes this easy to manage within your account. Learn more about uploading follow-up documents here.