Regulatory Joe

This year's PY2027 NBPP didn't just arrive late. It compressed the entire ACA filing season for issuers nationwide. CMS didn't finalize the rule until May 15, weeks after the QHP application window opened and past some states' own filing deadlines for rates, forms and binders. In this episode, ClearFile President Joe Boyle breaks down what happened this filing season and what it means heading into...

QHP filings touch five systems. A missed handoff between any of them can delay certification. Here's how data moves from SERFF through to CMS. In this episode, ClearFile President Joe Boyle maps the full QHP filing ecosystem: how CMS, state divisions of insurance, SERFF, HIOS, and MPMS each play a distinct role, where data moves between them, and where issuers most often lose track. He also covers...

Filing season can move quickly, especially when federal guidance arrives late, state deadlines shift and filing updates create downstream changes across documents, templates and systems. In this episode of Regulatory Joe, ClearFile President Joe Boyle breaks down how health plans can retain control during ACA filing season by prioritizing state filing risk, strengthening version control, managing...

ICHRA adoption is accelerating—but for health plans, the real challenge isn’t strategy. It’s execution. In this episode of Regulatory Joe, ClearFile’s Joe Boyle sits down with Lindsey Miller of Softheon to break down what ICHRA actually changes for health plans across enrollment, billing, member experience, and long-term individual market strategy. They explore where operational complexity is alre...

In this episode of Regulatory Joe, Joe Boyle sits down with Greg Fann of Axene Health Partners to break down what the proposed 2027 NBPP could mean for catastrophic plans and ACA market strategy. The conversation explores how expanded eligibility could affect bronze plan relevance, low-premium positioning, and decision-making for issuers heading into the 2027 filing cycle. It also looks at where c...

ICHRA can introduce operational risk long before it shows up in membership. For health plans, it functions as a new distribution pathway inside the individual market, which means added complexity across enrollment, billing, and premium flow—not a separate product strategy. This episode of Regulatory Joe focuses on where that complexity actually shows up, including enrollment pathways, payment coor...

The PY2027 Notice of Benefit and Payment Parameters (NBPP) introduces several proposed policy changes that could reshape ACA marketplace strategy for health plans. In this episode of Regulatory Joe, Joe Boyle breaks down the most important provisions in the 2027 NBPP and what they could mean for issuer portfolio strategy, enrollment operations, and marketplace participation across states. The prop...

Ghost enrollees in the ACA marketplace can distort enrollment reporting, affect risk adjustment transfers and increase CMS scrutiny. Even small pockets of unsupported enrollment can ripple through operations and financial reconciliation. In this episode of Regulatory Joe, Joe Boyle breaks down what ghost enrollees actually are — and what they are not. Low utilization alone isn’t the issue. The ris...

Enhanced APTCs expired at the end of 2025, shaping ACA 2027 filing assumptions. With no subsidy extension in place (and any new legislation still uncertain), issuers have to build Plan Year 2027 assumptions off current law—not best-case scenarios. In this episode of Regulatory Joe, Joe Boyle explains why APTC expiration is more than an affordability headline: it changes enrollment behavior, reshap...

Cost sharing has always been foundational to plan design. But heading into the 2027 filing cycle, it’s carrying more weight (and more risk!) than usual. In this episode of Regulatory Joe, Joe Boyle breaks down how issuers should be thinking about cost sharing heading into the next filing cycle. He explains why plans should anchor decisions to last year’s final, state-approved designs and federal E...

Healthcare interoperability isn’t just about standing up APIs—it’s about ensuring the data being exchanged is accurate, consistent, and usable across systems. In this episode of Regulatory Joe, we’re chatting with Will Tesch (CEO of TESCHGlobal and HealthLX) about how health plans can meet interoperability requirements and prepare what for what’s coming next. Joe Boyle and Will break down why inte...

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 oversight, complex licensure requirements for PBMs an...

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 to structure your internal workgroup, collect and...

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 subsidy support shifts, how membership and morbid...

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 training to transfer institutional knowledge – Stay ahe...

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 accuracy How to catch errors before a 5699 or 226J l...

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 partnerships amplify your voice on policy changes The r...

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 learn how to budget for bonding, align filings to pa...

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 discuss what these changes mean for carriers, members,...

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 learn why revalidating assumptions, preparing ops ea...

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 operations. From the role of centralized tracking tools...

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),...