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

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.

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 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 shifting state and federal requirements with a complete compliance toolkit. 👉 Explore more episodes and resources at regulatoryjoe.com

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 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. Watch the full episode and get more resources: https://www.regulatoryjoe.com

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 reduced passive renewals📌 The operational moves that can make or break your filings and compliance Subscribe to ahead of regulatory change with insights that matter most to your team: regulatoryjoe.com

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 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

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 compliance gaps Why collaboration across legal, finance, and analytics matters How to evaluate licensure costs strategically And more! Listen to the full episode and get more insights at regulatoryjoe.com

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, 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 reporting strategy matters What new trends are reshaping PBM compliance in 2025 Stay in the loop with Regulatory Joe: https://www.regulatoryjoe.com

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. 💭 Check out all of Regulatory Joe's insights: regulatoryjoe.com

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 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 growth. 📌 Key Topics Covered: ACA marketplace growth trends and issuer opportunity Financial vs. non-financial investment strategies What a smart "build vs. buy" analysis looks like How competitive intel should shape your plan design Timing, staffing, and infrastructure tips for entering new markets Don’t fall behind on ACA strategy. Get clear, actionable insights from someone who’s helped dozens of health plans grow their QHP footprint.

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 doing now to prepare for every scenario.

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 How to use CMS validation tools to avoid rework Why cross-validation errors can still cost you—even if your template looks “clean” What to expect from CMS as MPMS continues to evolve Practical tips for internal coordination and compliance Whether you're a seasoned filer or new to regulatory operations, this episode offers actionable insight to help you stay compliant, avoid objections, and file with confidence. 🎧 Listen now and future-proof your pharmacy benefit template strategy.

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 issuers and compliance teams looking to streamline filings and reduce last-minute surprises.

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 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

🚨 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 Periods (SEPs) and subsidy expansion✔️ What new call center standards mean for issuers✔️ How state-based marketplaces (SBMs) are evolving 🔗 For more insights, visit: regulatoryjoe.co

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 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 new market, this episode is packed with actionable insights and practical recommendations to help you stay compliant, optimize processes, and prepare for the future of risk adjustment. 🎧 Listen now and make sure your team is ready for the 2025 submission season. Subscribe to Regulatory Joe for updates on regulatory filing for health plans, compliance tips, and more.

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 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 preparing for an SBM transition or want to better understand these hybrid models, this episode provides valuable insights for health plan professionals. Listen now to stay informed, and don’t forget to like, share, and subscribe!

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 data accuracy and avoiding common RBIS submission errors And more! 🔔 Subscribe for more regulatory insights and health plan updates!

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 documentation when running the AV calculator And more! 🔔 Subscribe for more regulatory insights and health plan updates!

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 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!