Shows
Regulatory JoeHealthcare Interoperability Explained (feat. Will Tesch)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 interoperability efforts often stall after go-live, what semantic accuracy really means in practice, and how CMS requirements like CMS-9115-F and the upcoming CMS-0057-F rule are raising the bar for operationa...
2026-01-0724 minRegulatory Joe2025 Regulatory Highlights for Health Plans, PBMs and TPAs2025 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 and TPAs, and operational pressures tied to a shortened OEP. You’ll also hear how organizations approached risk adjustment, strategic market planning and data validation across the year’s episodes.
If you’re responsible for regula...
2025-12-1813 minRegulatory JoeMCAS 101: What ACA Health Plans Need to Know About Market Conduct Annual StatementsIn 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 validate data across departments, and reduce the risk of outlier findings that could lead to deeper scrutiny.
Whether your plan has never received a call letter or manages MCAS annually, this episode helps yo...
2025-12-0308 minRegulatory JoeRisk Adjustment in a Post-Subsidy ACA Health Plan MarketplaceAfter 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 morbidity trends may move, and why Plan Year 2027 becomes the first true impact year for ACA risk adjustment. Joe also shares what regulators may focus on next — from MLR volatility to URRT projections and...
2025-11-1909 minRegulatory JoeThe Future of TPA Compliance and Training (feat. Jennifer S. Berman)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 ahead of state and federal oversight shifts
Watch now to learn what will define next-generation TPA leadership.
Subscribe and learn more at: regulatoryjoe.com
2025-10-3016 minRegulatory JoeHow Employers & Brokers Can Avoid Costly ACA Reporting Mistakes (feat. Jordan O. Smith)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 letter arrives
The difference between penalties—and how to avoid both
Watch the full episode and subscribe for more insights.
2025-10-0835 minRegulatory JoeACA Compliance Toolkit: 5 Essentials for Health PlansACA 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 role of technology in reducing filing errors and rework
How strong reporting protects expansion opportunities
When and how to leverage vendor support
Stay ahead of sh...
2025-10-0115 minRegulatory JoeTPA Licensure 101: What Every Third-Party Administrator Needs to KnowTPA 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 payer market strategy, and centralize your process so approvals move faster and renewals don’t become fire drills.
Clear, actionable takeaways for leaders who own compliance and market entry.
Wa...
2025-09-0313 minRegulatory JoeThe Big ACA Reset: What Health Plans Need to Know (feat. Wesley Sanders)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, and the sustainability of the individual market. You’ll learn:
📌 Why ACA membership will shift and how plans should target long-term, sustainable growth
📌 How to prepare retention strategies in the face of redu...
2025-08-2035 minRegulatory JoeWinning ACA Strategies for a Shortened Open Enrollment WindowThe 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 early, and acting on competitive intel is more important than ever.
▶️ Don’t miss a key update—subscribe for more insights: https://www.regulatoryjoe.com
2025-08-1316 minRegulatory JoeThe Proactive PBM: Why Compliance Is Now a Strategic Priority (feat. Mallory Mojarro)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 to the growing influence of state-level legislation, Mallory shares practical steps PBMs can take to stay ahead of the curve—and avoid costly mistakes.
You’ll learn:
What systems help PBMs avoid compli...
2025-07-3027 minRegulatory JoePBM Licensure 101: What Every Pharmacy Benefit Manager Needs to KnowPBM 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, how to avoid common mistakes, and why proactive PBMs are gaining a strategic edge. 🔍
You’ll learn:
The difference between registration and full licensure
How to build trust with regulators and avoid delays
Why staffing and rep...
2025-07-1615 minRegulatory JoeStaffing Your Health Plan for ACA SuccessACA 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.
💭 Check out all of Regulatory Joe's insights: regulatoryjoe.com
2025-07-0209 minRegulatory JoeInside the ACA Investment Playbook: Key Moves for Health Plans in 2026In 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 strategy)
– Competitive intelligence (why it must be continuous, not episodic)
Joe also discusses non-financial investments that are often overlooked, including codified business processes, SERFF expertise, and interdepartmental coordination—all essential for regulatory success and long-term...
2025-06-2511 minRegulatory JoeWhat’s Next for APTCs and CSR Funding? (feat. Jeff Grant)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), and how these shifts could reshape affordability, enrollment behavior, and silver loading strategies.
Plus: insights on rate setting amid uncertainty, the evolving role of ICHRAs, and what plans should be doin...
2025-06-1835 minRegulatory JoePreventing Pharmacy Template Objections (feat. Bryan Connole)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 year, what tools are critical for success, and how internal misalignment (especially with PBMs and pharmacy teams) can derail your entire submission.
In this episode:
The top objection trends from Plan Year 2025
...
2025-04-1611 minRegulatory JoeReconciliation & Validation Strategies for ACA Plan Year 2026In 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 issuers and compliance teams looking to streamline filings and reduce last-minute surprises.
2025-04-0209 minRegulatory JoeCMS is Moving Plan and Benefit Justification Forms to MPMSA 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 down:
How the new MPMS Justification Form process works
What issuers need to do to prepare for compliance changes
Why early validation and version control will be critical moving forward
#CMSRegulations #HealthPlans #MPMS #PlanSubmission #HealthcareCompliance
2025-03-1210 minRegulatory Joe2026 NBPP: What Health Plans Need to Know🚨 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 regulations, issuers have more time than ever to strategize—but also more details to analyze.
Key Topics Covered:
✔️ The impact of the finalized 2026 NBPP on health plan filings
✔️ CMS’s latest approach to AV calculator updates
✔️ Special Enrollment...
2025-02-1912 minRegulatory JoeNavigating Risk Adjustment in 2025: A Guide for Health PlansJoin 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 strategies for issuers entering new markets
Tips for compliance when serving AI/AN populations
Why predictive modeling is the future of risk adjustment
Whether you’re an established issuer or entering a n...
2025-01-2909 minRegulatory JoeSBM-FPs Explained: What Health Plans Need to KnowSBM-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 the transition process to standalone state-based marketplaces, the role of enhanced direct enrollment in maintaining a seamless member experience, and how carriers can align strategies to navigate these changes.
Whether you're...
2025-01-0807 minRegulatory JoeNavigating RBIS in 2025: Essential Tips for Health PlansIn 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 data accuracy and avoiding common RBIS submission errors
And more!
🔔 Subscribe for more regulatory insights and health plan updates!
2024-12-0408 minRegulatory JoeWhat Health Plans Need to Know About the AV CalculatorIn 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 documentation when running the AV calculator
And more!
🔔 Subscribe for more regulatory insights and health plan updates!
2024-11-1307 minRegulatory JoeHow the 2024 Election Could Shape the Future of the Affordable Care ActIn 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 over ACA marketplaces
The future of American Rescue Plan (ARP) insurance subsidies
What will happen with the newly released draft of the 2026 NBPP
And more!
🔔 Subscribe for more regulatory insights and health plan updates!
2024-10-2938 minRegulatory JoeHow Healthcare.gov 2025 Changes Will Impact Your Health Plan StrategyIn 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 exchanges
Simplified plan selection to reduce confusion for enrollees
Best practices for testing and syncing plan data
And more!
🔔 Subscribe for more regulatory insights and health plan updates!
2024-10-0906 minRegulatory Joe2025 NBPP Changes Explained: Key Updates for Health Plans
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 rules
Stricter network adequacy standards
🎧 Listen to the podcast version on Spotify, Apple Podcasts, or wherever you get your podcasts!
🔔 Subscribe for more health plan regulatory updates! #2025NBPP #HealthPlans #RegulatoryJoe
2024-09-1813 minRegulatory JoeWhat Do the New CMS EHB Benchmark Updates Mean for Your Health Plan?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.
2024-08-0711 minRegulatory JoeHow Routine Adult Dental Will Change Health Plans in 2025 and BeyondIn 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: regulatoryjoe.co.
2024-08-0708 minRegulatory JoeStandard and Non-Standard Plan Options: What Your Health Plan Needs to KnowIn 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.
2024-08-0706 minRegulatory JoeNetwork Adequacy and What Health Plans Need to Know for 2025In 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.
2024-08-0715 minRegulatory JoeEverything You Need to Know About State-Mandated Defrayal in 2025In 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.
2024-08-0606 min