Special Enrollment Periods (SEPs) and SEP Verification Issues (SVIs)

A Special Enrollment Period (SEP) allows clients to enroll in or change their Marketplace health plan outside of the annual Open Enrollment Period (OEP) when they experience a qualifying life event. When a client applies for a Marketplace plan through an SEP, the Marketplace may require them to submit documents to confirm their SEP eligibility before coverage can begin. This requirement is called a SEP Verification Issue (SVI).

A Special Enrollment Period (SEP) is a window of time outside of Open Enrollment when a client can enroll in, change, or add dependents to a Marketplace health plan. A client generally has 60 days from the date of their qualifying life event to select a Marketplace plan through an SEP.

Clients already enrolled in a Marketplace plan should report qualifying life event changes as soon as possible, generally within 30 days of the change.

There are six categories of qualifying events that may make a client eligible for an SEP.

A client (or anyone in their household) lost minimum essential coverage (MEC). This includes losing coverage through an employer, aging off a parent's plan at 26, losing Medicaid or CHIP coverage, or losing Medicare Part A or Medicare Advantage (Part C). Clients can report a loss of qualifying coverage up to 60 days before the coverage ends.

Note: A client is generally not eligible for this SEP if they voluntarily dropped their coverage, failed to pay premiums, lost coverage due to fraud, or lost coverage that did not qualify as minimum essential coverage (for example, short-term limited duration insurance does not count).

A client (or anyone in their household) got married, had a baby, adopted a child, placed a child for foster care, or gained or became a dependent through a court order. Note that for marriage, at least one spouse generally must have had qualifying health coverage for at least one day in the 60 days prior to the marriage (with limited exceptions).

A client (or anyone in their household) moved to a new ZIP code or county, moved to the U.S. from a foreign country or U.S. territory, or moved to or from a school, seasonal employment location, shelter, or transitional housing. To qualify, the client generally must have had qualifying health coverage for at least one day in the 60 days before their move (with limited exceptions). Moving for medical treatment or vacation does not qualify.

A client who is already enrolled in a Marketplace plan experiences a change that makes them newly eligible or ineligible for financial help (Advanced Premium Tax Credits or cost-sharing reductions), or becomes newly eligible for Marketplace coverage because they gained citizenship or lawful presence status.

A client was not enrolled in a plan, or was enrolled in the wrong plan, due to an error by the Marketplace, a technical issue, misinformation or misconduct by an agent, broker, or other assister, or a plan display error on HealthCare.gov.

This category includes exceptional circumstances such as a serious medical condition or natural disaster that prevented enrollment, domestic abuse or spousal abandonment situations, Medicaid or CHIP denial after Open Enrollment ends, and COBRA coverage where employer contributions have completely ceased.

A SEP Verification Issue (SVI) is a requirement for a client to submit documents to the Marketplace to confirm their eligibility for the SEP they attested to before coverage can begin. Not every SEP triggers an SVI. The Marketplace determines whether a client needs to resolve an SVI based on their SEP type and enrollment status.

When an SVI is generated, the Marketplace places the client's plan selection on hold (called a pended plan selection). Coverage is not effectuated until the SVI is resolved and the enrollment is fully processed by the insurance carrier.

Coverage cannot become active until:

There are three separate time clocks that may apply to a client enrolling through an SEP.

SEP window — 60 days The client has 60 days from the date of their qualifying life event to select a Marketplace plan. If the client does not select a plan within 60 days, they lose the SEP and generally cannot enroll until the next Open Enrollment Period or another qualifying event occurs.

SVI clock — 30 days Once the client selects a plan, they generally have 30 days to submit the required documents to resolve the SVI. If the SVI is not resolved within 30 days of plan selection, the client's pended plan selection may be canceled and they may not be enrolled in coverage.

DMI clock — Generally 90–95 days A Data Matching Issue (DMI) is separate from an SVI. A DMI occurs when information on a client's Marketplace application cannot be verified against federal data sources (for example, income or citizenship). Generally, a client receives about 90 days to resolve an annual income DMI and about 95 days to resolve a citizenship or immigration DMI. A client can have both an SVI and a DMI at the same time. The SVI must be resolved before coverage can be effectuated, even if the DMI is still pending.

No. A client should select a plan as soon as possible, but coverage is not effectuated until the SVI is resolved and any required premium payment is made. The coverage effective date is based on the client's SEP type and the date of plan selection, but coverage cannot become active until the SVI is cleared.

If the client's assigned coverage effective date passes before the SVI is resolved, coverage may become retroactive to that date once the SVI is approved. The client may owe premiums for any retroactive period.

The specific documents required depend on the client's SEP type. The client's Eligibility Determination Notice (EDN) will list acceptable documents and submission deadlines.

For loss of qualifying coverage, documents should show the name of the person who lost coverage and the date coverage ended or will end.

For a change in primary place of living (move), documents should show the name of the person who moved and the date of the move. The client must also show they had qualifying coverage for at least one day in the 60 days before the move (unless an exception applies).

Documents should be clear, legible, and contain enough information for the Marketplace to verify the qualifying event.

Clients can find a complete list of acceptable documents for each SEP type Here.

The Marketplace contacts clients at multiple points during the SVI process. Clients can view and download notices through their HealthCare.gov account or receive them by mail if they have requested paper notices.

After completing the application, the client receives an Eligibility Determination Notice (EDN) explaining their eligibility for coverage, financial help, and an SEP. The EDN also describes the SVI requirement, including acceptable documents and submission deadlines.

After selecting a plan, the client receives a Pended Plan Selection (PPS) notice confirming that the SVI deadline has started and listing acceptable documents and next steps. If documents are not submitted, the Marketplace may send reminder or warning notices.

After the client submits documents, the Marketplace sends either a resolution notice confirming the SVI is resolved, or an insufficient document notice explaining why the documents were not accepted and requesting additional documentation.

If the client does not submit documents or does not submit acceptable documents by the deadline, the Marketplace may send an expiration notice confirming the plan selection is canceled, followed by a final eligibility notice with information on how to appeal.

Agents and brokers can actively assist clients throughout the SVI process. The SVI is tied to the client's Marketplace application, and the client is ultimately responsible for providing accurate verification documents. However, agents can take the following steps on behalf of or alongside clients.

Help the client prepare documents before plan selection

Advise clients who are applying through an SEP to gather supporting documents before selecting a plan. This reduces the risk of missing the 30-day SVI deadline. For loss of coverage SEPs, documents should show the name of the person who lost coverage and the coverage end date.

Help the client upload documents

Agents can assist clients in uploading SEP verification documents to the Marketplace through the client's HealthCare.gov account or through the EDE platform being used for enrollment. Uploading documents is generally faster than mailing them.

Help the client correct their Marketplace application if information was entered incorrectly and is contributing to the SVI.

Communicate with the Marketplace about the SVI on the client's behalf if needed.

Track the status of the SVI and follow up with the client if they have not received a resolution notice.

For DMIs in MyMFG: If a client's enrollment in MyMFG has a Data Matching Issue (DMI), agents can upload the required DMI documents directly on behalf of the client within MyMFG.

Clients who are already enrolled in a Marketplace plan and qualify for an SEP are generally limited to selecting a plan within their current plan metal category (Bronze, Silver, Gold, or Platinum). For example, a client currently enrolled in a Bronze plan can generally only switch to another Bronze plan during an SEP window.

Exceptions that allow a client to change to a different metal category include becoming newly eligible or ineligible for cost-sharing reductions (CSRs), gaining access to an Individual Coverage HRA or QSEHRA, and certain complex situations such as enrollment errors.

Clients who are newly enrolling in Marketplace coverage through an SEP are not subject to plan category limitations and may choose any available plan.

If the Marketplace denies a client's SEP request, the client has the right to file an appeal. If the appeal is successful, coverage may be restored back to the date the SEP was denied.

To appeal, the client can download the appeal form for their state at: healthcare.gov/marketplace-appeals/appeal-forms

Or mail the appeal to:

Health Insurance Marketplace Attn:

Appeals 465 Industrial Blvd London, KY 40750-0062

The client should include a copy of any EDN or official Marketplace notice they received when submitting the appeal.