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. Note: State-Based Marketplaces (SBM) can have different Open Enrollment dates. See more information on Marketplace type by state here.
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:
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 (DMI) or an SEP Verification Issue (SVI). An SEP Verification Issue (SVI) occurs when a Consumer is eligible for an SEP due to a Qualifying Life Event (QLE), such as losing coverage, and is asked to verify they have experienced the QLE.
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. For states who use the FFM, reference the QLE chart here.
When assisting consumers seeking SEPs, leverage the events listed in the QLE chart to ask your consumers questions around potential changes in circumstance.
Initial questions could include:
Have you recently lost coverage or will you be losing coverage soon?
Have you recently been married?
Have you recently had a child or adopted a child?
Have you recently gained or become a dependent?
Have you recently moved?
Have you recently had any financial changes within your household?
Have you recently gained eligibile immigration status?
Are you a member or did you recently become a member of a federally-recognized Native American tribe or an Alaska Native?
Have you recently been released from incarceration?
Have you recently been determined ineligible for Medicaid or CHIP?
Did you recently have a DMI get resolved after the resolution window closed?
If the answer is yes to any of the above, continue leveraging the QLE chart to ask follow-up questions.
Ensure the consumer's unique circumstance falls into one of the QLE categories listed on the chart, determine whether the QLE took place within the allotted time frame, and ensure any requirement of prior coverage requirements can be met. If these requirements can be met, your consumer may be SEP eligible!
Set expectations with your consumer about follow-up documents that may be required in order to secure their SEP.
DMIs & SVIs
A Data Matching Issue (DMI) means that the information entered on a consumer's subsidy application doesn't match what is on file with the government (or may not be available within their records) and therefore needs to be verified.
A DMI occurs in the following 3 situations:
Incorrect or missing information on the client’s application
An inconsistency between the client’s Marketplace application and existing information from trusted sources, like IRS databases.
Trusted sources do not have data for the client.
When a DMI is not resolved your client may lose their subsidy or eligibility for health coverage. Clients have 90-95 days to resolve a DMI based on the date their application was submitted (not the effective date). Consumers typically need to upload documents to resolve DMIs.
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.
An SEP Verification Issue (SVI) occurs when a Consumer is eligible for an SEP due to a Qualifying Life Event (QLE), such as losing coverage, and is asked to verify they have experienced the QLE.
When an SVI is not resolved your client may lose their SEP eligibility. Clients 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. Additionally, consumers cannot make a binder payment or use their new or updated coverage until all SVIs have been satisfied.
DMIs & SVIs can happen on HealthCare.gov, HealthSherpa, and anywhere else you may complete Marketplace enrollments.
Required documentation
Consumers often need to upload documents to resolve Data Matching Issues (DMIs) and SEP Verification Issues (SVIs). Getting documents uploaded on time ensures your client keeps their subsidy and/or coverage.
The list of acceptable documents to select from varies based on the type follow-up item you are resolving:
Each verify page within HealthSherpa contains the embedded list of acceptable documents you may choose from to satisfy the specific follow-up item selected. Learn more about uploading follow-up documents here.
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.