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 risk shows up when enrollment patterns, premium payment behavior, repeated plan switching or grace period activity don’t align with normal member behavior.

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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, reshapes the risk pool, and creates downstream pressure on risk scores, quality strategy, and operational capacity.

You’ll learn where plans feel the impact first (membership projections, rate/benefit planning, cross-functional alignment) and how to stay filing-ready while federal and state guidance develops: anchor to last year’s approved baseline, stress-test multiple scenarios, plan for uneven state responses, and set internal decision cutoffs early to avoid late-cycle filing churn.

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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 EHB benchmark plans, even as assumptions continue to evolve

 Joe also walks through how to model multiple cost-sharing scenarios, use available competitive data to inform decisions, and manage changes through version control and clear cutoff dates so plan and benefits templates stay aligned through submission.

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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 operational readiness.

They also explore single sources of truth, canonical data models, and why prior authorization workflows will be one of the biggest interoperability challenges facing health plans in the years ahead.

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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 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 regulatory strategy, filings, licensure or ACA operations, this recap gives you the context and next steps that matter most.

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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 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 you build a more predictable, efficient compliance process.

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 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 RADV readiness — and how issuers can start modeling different scenarios before the delayed NBPP lands.

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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:

Watch now to learn what will define next-generation TPA leadership.

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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:

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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 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.