Reviewed October 7, 2026
The 150% FPL monthly Special Enrollment Period does not return in 2027 under the current final rule. Low income by itself no longer gives a consumer that monthly opportunity to enroll in or change Marketplace coverage. The removal applies to all Exchanges. www.govinfo.gov
That does not end every enrollment option for a low-income client. Other qualifying SEPs remain, Medicaid and CHIP accept applications year-round, and members of federally recognized Tribes and ANCSA shareholders have a separate enrollment opportunity. HealthCare.gov
The useful question for an agent is: What enrollment opportunity does this particular person have, and what must happen before it closes?
What changed, and what agents should avoid assuming
The 2027 Payment Notice removed the earlier provision that would have allowed the income-based monthly SEP to return after 2026. Congress also separately restricted premium tax credits for enrollment through certain income-only SEPs. www.govinfo.gov
Keep three questions separate:
- Is the consumer eligible to buy Marketplace coverage?
- Is there an enrollment period available now?
- Does the consumer qualify for premium tax credits or other financial help?
An estimate showing an affordable premium does not answer the enrollment-period question. Paying the full premium also does not, by itself, create a Marketplace enrollment opportunity outside open enrollment. HealthCare.gov
Another update matters for agency procedures: the expanded federal SEP-verification policy and its 75% requirement are stayed. CMS says existing loss-of-coverage SEP verification continues. Do not treat the original 2027 verification rollout as an active requirement. cms.gov
Start with the Marketplace, the household, and the date
Before selecting an SEP category, establish which Marketplace serves the consumer, whether the person is already enrolled, and the relevant event dates.
Check Medicaid and CHIP for each potentially eligible household member. A child may qualify even when a parent does not. Eligibility depends on state rules and individual circumstances; 150% FPL is not a universal Medicaid cutoff. Applications are available throughout the year. HealthCare.gov
Then ask:
- What coverage does each person have now, and when did or will it end?
- Has there been a marriage, birth, adoption, placement, or permanent move?
- Was there a recent Medicaid/CHIP application, denial, or termination?
- Has an actual income or eligibility change occurred?
- Is there qualifying Tribal/ANCSA status or another special circumstance?
- Did an error, disaster, or serious incapacity interfere with an available enrollment opportunity?
Record dates before concluding that a client missed a deadline. The last day worked, last day insured, application date, and denial date can be different.
SEP alternatives: a quick reference for agents
This table summarizes common HealthCare.gov screening rules. It is not an exhaustive list. Independent state Exchanges can have different permitted procedures, and already-enrolled consumers may face restrictions on which plans or household members can change.
| Client situation | What to check | Typical federal enrollment window |
|---|---|---|
| Loss of qualifying health coverage | Coverage type, reason for loss, and last covered day. | Generally 60 days before or after loss. |
| Loss of qualifying Medicaid or CHIP coverage | Actual termination date and whether coverage ended. | 60 days before or 90 days after loss. |
| Marriage | Generally, at least one spouse had qualifying coverage for at least one day during the preceding 60 days; check exceptions. | Generally 60 days after marriage. |
| Birth, adoption, or placement for adoption or foster care | Event date and household members affected. | Generally 60 days after the event; coverage can begin on the event date. |
| Permanent move | The move provides access to new Marketplace plans; prior qualifying coverage is generally required, subject to exceptions. | Generally 60 days after the move. |
| COBRA exhaustion or complete end of an employer/government COBRA contribution | Whether coverage or the contribution actually ends. | Generally 60 days before or after the qualifying event. |
| Income change after being in the non-expansion Medicaid coverage gap | Prior ineligibility and whether the change makes the person newly eligible for APTC. | Generally 60 days after the qualifying change. |
| Federally recognized Tribal membership or ANCSA shareholder status | Qualifying status and the rules for family members on the application. | Enrollment throughout the year; plan changes up to once monthly. |
Sources: 45 C.F.R. § 155.420 and HealthCare.gov’s event, Medicaid-transition, COBRA, and Tribal guidance. ecfr.gov
Marriage and move exceptions can apply, including for specified recent residence abroad or in a U.S. territory and qualifying Tribal status. Check the full exception criteria in section 155.420(a)(5). A vacation or a move solely for medical treatment does not qualify as a permanent-move SEP. ecfr.gov
Agent action: Identify the specific qualifying circumstance and its requirements. A life-event label alone is not enough to decide the case.
Two low-income enrollment opportunities that deserve a closer look
1. An income increase after being in the Medicaid coverage gap
An actual income change can still matter. The separate coverage-gap SEP applies when a person previously:
- Was ineligible for APTC solely because household income was below 100% FPL; and
- Was simultaneously ineligible for Medicaid because the person lived in a non-expansion state.
An income change or move to another state must then make the person newly eligible for APTC. The usual window is 60 days after the qualifying change. (45 C.F.R. § 155.420, subds. (c)(1), (d)(6)(iv).) ecfr.gov
Agent action: Establish the reason for the earlier ineligibility, the actual change, and the date. Do not assume that any raise—or simply revising an income estimate above 100% FPL—creates an SEP.
2. A Medicaid/CHIP denial that arrives after the enrollment window closes
A delayed eligibility determination can create another enrollment opportunity. The regulation describes two routes:
- The consumer applied through the Exchange during open enrollment or because of a qualifying event, was assessed as potentially eligible for Medicaid/CHIP, and the state determined the consumer ineligible after open enrollment ended or more than 60 days after the qualifying event.
- The consumer applied directly to Medicaid/CHIP during open enrollment, and the state determined the consumer ineligible after open enrollment ended.
The ordinary selection window is 60 days after the triggering determination. (45 C.F.R. § 155.420, subds. (c)(1), (d)(11).) ecfr.gov
Agent action: Save the original application date, application route, relevant enrollment opportunity, state determination date, date the notice was received, and denial reason. A Medicaid denial by itself is not a universal SEP.
Protect three separate deadlines
Do not let a request for paperwork obscure the deadline to select coverage.
| Step | What to track |
|---|---|
| Plan selection | The applicable SEP deadline. Starting an application is not the same as selecting a plan. |
| Verification | Whether the Eligibility Notice requests documents, exactly what it requests, and the response deadline. |
| Coverage activation | The assigned effective date, resolution of required verification, and payment of any required first premium by the insurer’s deadline. |
HealthCare.gov tells consumers to pick a plan first and submit requested SEP documents afterward. When documents are requested, the stated submission period is 30 days after plan selection. The Eligibility Notice determines whether documents are needed; agents should not impose a universal upload requirement before selection. HealthCare.gov
The October 2026 CMS Enrollment Manual confirms that federal loss-of-coverage verification continues while the expanded policy is stayed. Track a separate income or other data matching issue separately from the SEP request. See CMS, FFE Enrollment Manual, printed pages 65–66.
Agent action: Collect useful evidence early, preserve the selection deadline, and follow the actual notice. A plan selection alone does not establish that coverage is ready to use. HealthCare.gov
Three client examples
These are illustrative scenarios, assuming the consumer otherwise meets the applicable Marketplace requirements.
A Medicaid loss more than 60 days ago
Elena’s Medicaid ends June 30, 2027. She contacts an agent on September 10 and lives in a HealthCare.gov state.
She is still within the 90-day Medicaid-loss window. If she selects a plan on September 10 and completes the applicable requirements, coverage generally starts October 1. The additional enrollment time does not automatically fill the earlier coverage gap. HealthCare.gov
What changes the answer: Applying the federal Medicaid-loss window instead of assuming every loss case closes after 60 days.
Employer help with COBRA ends
David’s former employer contributes toward his COBRA premium through June 30, 2027, then stops contributing entirely. He can use that qualifying event and select a Marketplace plan in June for July 1 coverage, assuming the other requirements are met.
Choosing to cancel unchanged COBRA coverage because it is expensive does not itself create a new SEP. Also check whether the original job-coverage-loss window remains open. HealthCare.gov
What changes the answer: The complete end of the contribution, rather than the consumer’s decision to stop paying.
Income rises after a period in the coverage gap
Rosa lives in a non-expansion state. She previously could not get APTC solely because her income was below 100% FPL and could not get Medicaid because of the state’s non-expansion status. A new job raises her expected household income and makes her newly APTC-eligible.
Screen the separate coverage-gap SEP and its deadline. The removed 150% FPL monthly SEP is not the basis for this application. HealthCare.gov
What changes the answer: A qualifying change that creates new APTC eligibility, rather than low income that simply continues unchanged.
Handle complicated cases through the correct channel
Ask the Marketplace to evaluate cases involving a serious incapacity, qualifying disaster, enrollment-helper misconduct, technical failure, or other recognized special circumstance that affected enrollment. Other specific pathways can apply, including domestic abuse or spousal abandonment. Document the relevant facts and avoid promising an exception before the Marketplace determines eligibility. HealthCare.gov
For federal cases requiring agent assistance beyond an EDE website, CMS identifies the Agent/Broker Partner Line: 1-855-788-6275. Agents should enter their personal NPN and follow the current authorization process.
CMS’s September 2026 instructions also clarify:
- Routine agent-assisted applications and enrollments generally cannot be submitted through the Call Center.
- NPN additions and changes must be authorized by the consumer through an approved EDE website.
- Call Center authorization is separate from the agency’s consent and application-review records. The consumer can authorize one call or a period of up to 365 days. Check whether that authorization is still valid before calling without the consumer. cms.gov
If an SEP is denied and the decision appears wrong, preserve the Eligibility Notice and assess an appeal. HealthCare.gov generally allows 90 days from the notice to request one. A successful appeal may support an earlier coverage effective date; follow the decision rather than promising a particular retroactive date. HealthCare.gov
Keep a case file that explains the decision
On the federal platform, document consent before covered assistance and the consumer’s affirmative review and confirmation before submitting a new or updated eligibility application. Keep both categories of documentation for at least 10 years.
An existing authorization can cover later assistance only while it remains valid and within scope. It does not remove the application-review requirement when an update is submitted. www.ecfr.gov
For 2028 enrollments and renewals, including automatic re-enrollments, prepare for the prescribed HHS form during fall 2027. Use the official implementation instructions when updating your process. www.ecfr.gov
Suggested agency case-file checklist
| Record | What it should help you establish |
|---|---|
| Consumer and application | Marketplace, application identifier, household members affected, and assisting agent. |
| Consent | The consumer’s action, authorization date, authorized recipient, scope, purpose, duration, and rescission process. |
| SEP assessment | Qualifying circumstance, relevant dates, prior-coverage facts where required, and selection deadline. |
| Application review | The consumer’s confirmation, review date, agent, and explanation of the application attestations. |
| Notices and follow-up | Requests received, response deadlines, submissions, case numbers, and resolution. |
| Enrollment result | Selected plan, expected effective date, required premium follow-up, and confirmed outcome. |
| Next step | Responsible person, follow-up date, and what remains unresolved. |
This is a recommended agency checklist. It is not a statement that every item must be uploaded to CMS or that every item independently carries the consent/review ten-year retention requirement.
What to say when no SEP is available
Be clear about the current result while giving the client a concrete next step.
“The monthly enrollment option based only on low income is no longer available. Let’s check your coverage history, household changes, and any Medicaid decision to see whether another enrollment opportunity applies. If none applies today, we can check other coverage options and set a date to prepare for the next Marketplace enrollment period.”
Document which routes were screened, explain what future changes the consumer should report, and obtain permission for any planned follow-up. Keep the client’s current status distinct from a final conclusion that no coverage option will ever be available.
Use the correct calendar for 2027 coverage
For HealthCare.gov, open enrollment for 2027 coverage runs from November 1, 2026, through January 15, 2027. The deadline for a January 1 start is December 15, 2026; later selections through January 15 generally start February 1. www.healthcare.gov
Covered California’s calendar differs: November 1, 2026, through January 31, 2027, with December 31 as the deadline for a January 1 start. www.coveredca.com
Use the applicable Marketplace’s dates in outreach and client reminders. For a client without an SEP later in 2027, schedule follow-up using the announced calendar for the next coverage year rather than reusing these 2027-coverage dates.
Frequently asked questions
Does the 150% FPL SEP return in 2027?
No. The current final rule removes that monthly income-based SEP beyond 2026. A future policy change could alter the rule, so use the article’s review date and current official sources. www.govinfo.gov
Can someone under 150% FPL still enroll during the year?
Yes, if another applicable enrollment opportunity exists. Check the consumer’s circumstances, Medicaid/CHIP eligibility, and any qualifying separate monthly enrollment right. HealthCare.gov
Does an income increase create an SEP?
Sometimes. The coverage-gap SEP has specific prior-ineligibility and new-eligibility requirements. Other financial-eligibility changes can also matter. An income increase is not a universal enrollment event. ecfr.gov
Should the agent wait for all SEP documents before selecting a plan?
No universal rule requires that. Screen eligibility accurately, protect the selection deadline, and follow the Marketplace’s actual document request and deadline. HealthCare.gov
Does the removal affect the Tribal monthly SEP?
The Tribal/ANCSA opportunity is separate. Members of federally recognized Tribes and ANCSA shareholders can enroll throughout the year and change plans up to once monthly. Check the applicable household and documentation rules. HealthCare.gov
Can a client create an SEP by cancelling existing coverage?
Voluntarily dropping COBRA or simply stopping its premium payments generally does not create a new SEP. Losing job-based insurance after leaving a job—even voluntarily—is a different situation and can qualify. Check the coverage type, reason, and dates. HealthCare.gov
Keep the next step connected to the client record
Informed + Choice helps licensed agents organize ACA consent, eligibility application-review records, recordings, and supporting Marketplace documents for retrieval and export. informedpluschoice.com
Explore ACA consent and application-review tools for your workflow. For related registration, marketing, and 2028 preparation issues, see the 2027 ACA Marketplace final-rule guide.
Sources
- 2027 Payment Notice final rule : Federal Register
- Medicaid and CHIP coverage : HealthCare.gov
- Getting coverage outside Open Enrollment : HealthCare.gov
- CMS statement on City of Columbus litigation : Centers for Medicare & Medicaid Services
- 45 C.F.R. § 155.420: Special enrollment periods : eCFR
- Documents to confirm a Special Enrollment Period : HealthCare.gov
- FFE Enrollment Manual, October 2026 : Centers for Medicare & Medicaid Services
- Staying covered after Medicaid or CHIP loss : HealthCare.gov
- COBRA coverage when unemployed : HealthCare.gov
- Special Enrollment Periods for complex issues : HealthCare.gov
- Marketplace Call Center Tip Sheet : Centers for Medicare & Medicaid Services
- Marketplace decisions you can appeal : HealthCare.gov
- 45 C.F.R. § 155.220: Agents and brokers : eCFR
- Marketplace dates and deadlines : HealthCare.gov
- Covered California Open Enrollment : Covered California
- Coverage for American Indians and Alaska Natives : HealthCare.gov
Medicare and ACA Compliance Expert
Christian Rodgers is a Medicare and ACA compliance expert with over 30 years in the healthcare industry, having worked for some of the largest health plans in the United States. He has provided Medicare sales training to hundreds of agents in California and Florida.
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