Are you struggling to understand the many components of regulatory filing for health plans? Regulatory Joe demystifies these complexities with clarity and insight for everyone from seasoned managers to new professionals in the industry. Subscribe to stay up to date with the ever-evolving landscape of new guidelines for health plans.
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2025 Regulatory Highlights for Health Plans, PBMs and TPAs
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2025 brought major ACA, PBM and TPA regulatory shifts—and teams across the healthcare ecosystem felt the impact. This episode recaps the year’s most important compliance lessons and what every organization must prepare for in 2026. Joe breaks down the themes that defined the year: evolving CMS rules, new MPMS processes, tighter pharmacy benefit ove…
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MCAS 101: What ACA Health Plans Need to Know About Market Conduct Annual Statements
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In this episode of Regulatory Joe, ClearFile president Joe Boyle down the fundamentals of Market Conduct Annual Statements (MCAS) for ACA health plans—what triggers an annual call, how regulators use the data, and why organizational readiness determines whether a review stays routine or escalates to a formal market conduct exam. He also covers how …
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Risk Adjustment in a Post-Subsidy ACA Health Plan Marketplace
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After APTCs will likely expire at the end of this year, ACA risk adjustment is set to shift significantly—and health plans need to prepare now. In this episode of Regulatory Joe, ClearFile President Joe Boyle explains how a post-subsidy marketplace will impact risk pools, filings and business processes through 2027. He breaks down what happens when…
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The Future of TPA Compliance and Training (feat. Jennifer S. Berman)
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In this episode of Regulatory Joe, Joe Boyle talks with Jennifer S. Berman, Chief Legal Officer at Lumelight, about how TPAs can strengthen compliance through operational discipline, smarter training, and proactive regulatory monitoring. The pair discuss how to: – Build repeatable, measurable processes that ensure ERISA compliance – Modernize train…
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How Employers & Brokers Can Avoid Costly ACA Reporting Mistakes (feat. Jordan O. Smith)
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ACA reporting mistakes are more common—and more costly—than most employers realize. In this episode, Joe Boyle talks with Jordan Smith of Lumelight about how automated IRS enforcement is catching even well-intentioned employers and what brokers can do to protect their clients. You’ll learn: Why payroll and ben-admin systems alone can’t guarantee ac…
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ACA Compliance Toolkit: 5 Essentials for Health Plans
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ACA compliance for health plans is more complex than ever. In this episode of Regulatory Joe, ClearFile President Joe Boyle shares five essentials every issuer needs to streamline filings, strengthen regulator relationships, and gain speed to market. You’ll learn: How proactive regulator engagement prevents delays and hearings Why association partn…
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TPA Licensure 101: What Every Third-Party Administrator Needs to Know
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TPA licensure and compliance essentials for administrators Learn core requirements, surety bonds, timelines, renewals, and exemptions. In this episode, ClearFile President Joe Boyle walks through what states actually ask for, how long licensure can take, why Q1 renewals catch teams off guard, and when ERISA self-funded work may be exempt. You’ll le…
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The Big ACA Reset: What Health Plans Need to Know (feat. Wesley Sanders)
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The ACA individual market is facing its biggest shakeup yet. With the elimination of enhanced subsidies, a shorter Open Enrollment window, and sweeping reforms under the “One Big Beautiful Bill,” health plans must rethink their strategies. In this episode of Regulatory Joe, Joe Boyle sits down with Wesley Sanders, founder of Evensun Health, to disc…
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Winning ACA Strategies for a Shortened Open Enrollment Window
16:51
16:51
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The ACA Open Enrollment Period is changing—are you ready? Millions of members typically enroll after December 15, but that window is now gone. In this episode of Regulatory Joe, Joe Boyle breaks down what health plans need to do to protect enrollment, adjust crosswalk strategies, and seize growth opportunities heading into Plan Year 2026. You'll le…
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The Proactive PBM: Why Compliance Is Now a Strategic Priority (feat. Mallory Mojarro)
27:57
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PBM compliance is changing fast. Licensure, reporting, and state regulations now require more than just a checklist—proactive PBMs must treat compliance as strategy. In this episode of Regulatory Joe, Joe Boyle sits down with Mallory Mojarro of True Rx Health Strategists to break down how pharmacy benefit managers can build smarter compliance opera…
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PBM Licensure 101: What Every Pharmacy Benefit Manager Needs to Know
15:22
15:22
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PBM licensure requirements are evolving fast—and compliance mistakes are getting costly. In this episode, we break down what every pharmacy benefit manager needs to know to stay licensed and competitive. From rising state fees to unpredictable reporting timelines, regulators are putting more pressure on PBMs than ever before. Joe Boyle, President o…
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ACA staffing strategy is now mission-critical for health plans. In this episode of Regulatory Joe, Joe Boyle explores how health plans can align their staffing models with enrollment growth, new filing demands, and evolving regulatory oversight. From role-based to market-based models—and everything in between—Joe breaks down what works, when to tra…
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Inside the ACA Investment Playbook: Key Moves for Health Plans in 2026
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In this episode of Regulatory Joe, Penstock’s Joe Boyle outlines how health plans can make smart, scalable ACA investments now to capture market share in 2026, 2027 and beyond. Whether you're a new issuer or optimizing your current ACA portfolio, this playbook covers the three most critical pillars: – Network development (build vs. rent decisions) …
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What’s Next for APTCs and CSR Funding? (feat. Jeff Grant)
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The ACA marketplace is heading into one of its most uncertain years yet. In this episode, Joe Boyle is joined by Jeff Grant—former Deputy Director of Operations at CCIIO and now president of Schedule F Consulting—to unpack what 2026 could bring for health plans. They explore the potential expiration of enhanced premium tax credits (APTCs), the deba…
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Preventing Pharmacy Template Objections (feat. Bryan Connole)
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11:52
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On this episode of Regulatory Joe, Joe Boyle is joined by Penstock’s Director of Plan Management, Bryan Connole, to dive into one of the biggest pain points in ACA regulatory filing: the pharmacy benefit template. As Plan Year 2026 approaches, CMS and state agencies are tightening expectations—especially around prior authorization and template accu…
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Reconciliation & Validation Strategies for ACA Plan Year 2026
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In this episode, Regulatory Joe walks through the critical roles of reconciliation and validation in preparing ACA plans for the 2026 plan year. Joe covers: How to balance required CMS changes with strategic updates What’s new in MPMS and CMS templates Why treating draft templates as final saves time Tips to align cross-functional teams and avoid s…
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CMS is Moving Plan and Benefit Justification Forms to MPMS
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A major change is coming for health plan issuers—CMS is restructuring how Plan and Benefit Justification Forms are handled. Starting in 2026, issuers will no longer upload Justification Forms alongside their Plan and Benefit Templates. Instead, CMS will generate them post-submission through the MPMS portal, limiting issuer control and introducing n…
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2026 NBPP: What Health Plans Need to Know
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🚨 The 2026 Notice of Benefit and Payment Parameters (NBPP) is here! What does it mean for health plans? In this episode of Regulatory Joe, we break down the latest ACA compliance updates for 2026, including key changes in AV calculations, special enrollment periods, state-based marketplace transitions, and income verification requirements. With CMS…
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Navigating Risk Adjustment in 2025: A Guide for Health Plans
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Join Joe Boyle, President of Regulatory Solutions at Penstock, as he breaks down CMS’s risk adjustment and user fee updates for benefit year 2025. This episode is your go-to guide for navigating the evolving regulatory landscape. Here’s What You’ll Learn: How CMS’s use of 2019–2021 data impacts 2025 submissions The role of the American Rescue Plan …
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SBM-FPs Explained: What Health Plans Need to Know
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SBM-FPs Explained: What Health Plans Need to Know What are state-based marketplaces operating on the federal platform (SBM-FPs), and why are they becoming a popular choice for states? In this episode, Joe Boyle breaks it all down. Learn the fundamentals of SBM-FPs, including how they operate, why states choose them, and the financial and operationa…
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Navigating RBIS in 2025: Essential Tips for Health Plans
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In today’s episode of Regulatory Joe, we’re diving into the 2025 Rates and Benefits Information System (RBIS) updates, highlighting what health plans need to know to ensure accurate and compliant submissions. 📌 Key Takeaways: The new four-window CMS schedule and how to stay ahead of critical deadlines Updated URL submission criteria and best practi…
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What Health Plans Need to Know About the AV Calculator
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In today’s episode of Regulatory Joe, we’re taking listeners through the 2025 Actuarial Value (AV) calculator, a tool that ensures plans meet standards for each metallic tier. 📌 Key Takeaways: Consistent AV ranges for 2025 across all metallic tiers, with no major changes Early testing with the draft AV calculator to stay on track with compliance Be…
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How the 2024 Election Could Shape the Future of the Affordable Care Act
38:21
38:21
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In this episode of Regulatory Joe, we break down the critical changes to Healthcare.gov that will reshape health plans in 2025. From streamlined enrollment to simplified plan selection, we dive into how these updates will impact issuers and plan operations in both federally facilitated and state-based marketplaces. 📌 Key Takeaways: How the election…
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How Healthcare.gov 2025 Changes Will Impact Your Health Plan Strategy
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In this episode of Regulatory Joe, we break down the critical changes to Healthcare.gov that will reshape health plans in 2025. From streamlined enrollment to simplified plan selection, we dive into how these updates will impact issuers and plan operations in both federally facilitated and state-based marketplaces. 📌 Key Takeaways: Consistent user …
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2025 NBPP Changes Explained: Key Updates for Health Plans
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In this episode of Regulatory Joe, we cover the critical changes coming in 2025 for the Notice of Benefit and Payment Parameters (NBPP). Learn how telehealth, prescription drug access, re-enrollment rules, and network adequacy standards will shape health plans next year. 📌 Key Takeaways: Expanded telehealth documentation requirements Prescription d…
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What Do the New CMS EHB Benchmark Updates Mean for Your Health Plan?
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11:57
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In today’s episode of Regulatory Joe, we’re diving into an important topic that is shaping the future of health plan offerings: Essential Health Benefit (EHB) benchmark updates. Don't miss an episode! Hit subscribe or get email notifications by signing up at regulatoryjoe.co today.By Penstock
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How Routine Adult Dental Will Change Health Plans in 2025 and Beyond
8:21
8:21
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In today's episode of Regulatory Joe, we cover a timely and impactful topic: the consideration of routine adult dental as an Essential Health Benefit (EHB) starting in 2025. This policy change by CMS poses significant implications for health plans and their members—let’s explore what this means and how health plans can prepare. 💡 Check out all of o…
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Standard and Non-Standard Plan Options: What Your Health Plan Needs to Know
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In today’s episode of Regulatory Joe, we’re discussing standard/non-standard plan options and potential changes on the horizon for 2025 and beyond. Don't miss an episode! Hit subscribe or get email notifications by signing up at regulatoryjoe.co today.By Penstock
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Network Adequacy and What Health Plans Need to Know for 2025
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15:35
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In today’s episode of Regulatory Joe, we’re diving into the important topic of network adequacy and significant changes that health plans need to be aware of for 2025 and beyond. Don't miss an episode! Hit subscribe or get email notifications by signing up at regulatoryjoe.co today.By Penstock
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Everything You Need to Know About State-Mandated Defrayal in 2025
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In today’s episode of Regulatory Joe, we’re discussing state-mandated benefit defrayal and potential changes on the horizon for 2025 and beyond. Don't miss an episode! Hit subscribe or get email notifications by signing up at regulatoryjoe.co today.By Penstock
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