Regulatory Joe

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 of ClearFile, explains the full licensure process,...

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 transition, and how to onboard for long-term success....

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) – Service operations (in-house vs. offshore strate...

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 debate over re-funding cost-sharing reductions (CSRs),...

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 accuracy. Bryan shares what tripped up issuers last ye...

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 submission rework This episode is a must-listen for...

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 new timing challenges. In this episode, we break do...

🚨 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 moving up the timeline for finalizing regulation...

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 in shaping membership trends and user fees Key str...

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 operational implications for health plans. Joe also explains...

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 practices for mapping and validation Tips for ensuring...

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 Best practices for version control and documentatio...

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 results could reshape federal and state control...

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 experience across Healthcare.gov and state exchan...

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 drug coverage updates New re-enrollment hierarchy...

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.

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 our insights, videos and podcast episodes: regulat...

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.

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.

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.