June 25, 2025 • 11 mins
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.
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:00):
Hey everybody.
Welcome to Regulatory Joe.
I'm Joe Boyle, president ofRegulatory Solutions here at Penstock.
And on today's episode, we'll bediscussing ACA investments and how
to grow your portfolio strategy.
Some of you out there may be wondering,well, why even invest in the ACA?
It's so expensive, it's challenging,it's complicated, and how do I
know if I will even be successfulif I spend all this money and
(00:20):
time trying to develop a product?
Well, there is actually a lot of goodand a lot of pros to investing and to
taking the time and the money to do this.
Enrollment's at an all time high.
The ACA has created new products wenever knew existed before, such as ICRA.
We're seeing the ACA in the newsmore than ever before with the media.
And we're seeing more membershipthrough the roof in new states,
and states are even converting tostate-based exchanges, one after
(00:44):
the other, to keep up with the ACA.
And that's exactly why you shouldbe considering your strategy
for plan year 26 and beyond.
Regardless of the size of yourissuer or organization, it's really
important to think about strategicinvestments, both financially and
non-financially, regardless ofwhere you're at in the process.
When having these conversations andmaking these decisions, it really
revolves around three or four primarycategories that drive an organization
(01:07):
entering an ACA book of business orrenewing an ACA book of business.
You need to make sure you conduct acodified build versus buy analysis around
a few topics such as service operations,building or renting a network, optimizing
your business infrastructure, staffingyour plan and organization, and going
to market with your sales strategy.
If you don't have those five corecapabilities in force prior to
(01:28):
offering your plan for enrollment,you're gonna have a very challenging
time entering the ACA marketplace.
So, starting off with some key financialinvestments that you should really
be thinking about now for your plan.
The first one's going to be networkdevelopment and the question of whether
you should buy a network, rent a network.
Or if you have the capabilitiesinternally to build and
sustain that network over time.
(01:49):
At baseline, you should startby evaluating the provider
contractors you have on staffand the products that they serve.
Now, while it's possible that you cancross train different contractors to
serve ACA, you have to understand, isthis role important enough to have a
shared resource or a dedicated resourceto build my ACA contracts with the
providers and the facilities that Ineed to contract a compliant network?
(02:10):
Or is it more worthy of an investmentfor me to rent that network from a larger
carrier such as a big four or a big three?
When you're in this position,you have to also evaluate time.
How fast is your speed to market?
Do you have the time to build a network?
We estimate that it takes up to 18months to contract a compliant network
in any one state that you plan toenter if it's a new market entrant.
Now, if it's a renewal market that you'realready participating in, that's okay.
(02:33):
You have a little bit more offlexibility to move around and
to fill gaps that may have fallenout of adequacy the prior year.
At this point in the planning process,your product strategy team should be
already communicating with your networkstrategy team to understand how the
product portfolio is going to be setup, the product and benefits that
are important to the members in thatcertain geography or in those zip codes.
(02:55):
So what's important to those members?
Is it seeing a chiropractor forcertain specialist services?
Is it seeing a PCP for routine care?
So also considering in terms of networkdevelopment, while we are talking today
about the ACA products, communicate withyour other product development partners.
As you grow Medicare Advantage, is itconsistent to grow your product with ACA?
(03:16):
As you're growing your network forMedicare and Medicaid, should you
grow your ACA network the same way?
Well, it's interesting because based onthose conversations and strategies, we
would recommend if the organization'soutlook is to consistently grow your
product portfolios across all yourlines of business, regardless if it's
an ACA qualified health plan product,Medicare Advantage product or other, we
(03:38):
recommend investing in those resources onstaff to actually have the capabilities
in-house to build and grow your business.
Now it's important to note in thatsame breath that if you're at a race
against the clock in terms of meetingcommitments to enter a new market or
to develop a new product, renting anetwork while also staffing for your
(03:58):
business in the future to then convertthat could be a wise decision as well.
Because at the end of the day, it'sreally important to have a talented
group of provider contractors tokeep up with the ever-changing
daily environment of turnover.
One of the second most importantcapabilities that we find
issuers have the most significantinvestment in is service operations.
(04:18):
Service operations can mean a numberof different things from administering
your call center to take calls from yourmembers during the enrollment period,
from November 1st to January 15th onan annual basis and also throughout the
year to service your member questionsas they dial in about the plan.
It could also mean such things asadministering enrollment, and billing to
making sure premium payments are beingtransacted correctly from the Federal
(04:42):
Exchange, the state-based exchange,to the health plan, to making sure
the transfer of funds is reconciledand appropriate for each member.
While we understand there's manydifferent ways to administer your service
operations and call center, what itreally boils down to is cost and price.
The financial implications arevery large because when you think
about the ways you can administersuch programs, you can build an
(05:05):
organization in-house with onshorerepresentatives that can be codified,
dedicated resources for your teams.
You could also make a decision to crosstrain those staff, to ensure that they're
blending their time across other products,to making sure they're maximizing their
capacity, for your organization as well.
We've also seen organizations bevery successful hiring temp staff,
for certain peaks and valleys ofbusy seasons, such as enrollment
(05:28):
from November 1st to January 15th.
In contrast to organizations who buildand staff their teams in-house and
onshore, we've also seen issuers be verysuccessful by subcontracting offshore
organizations to help stand up andstabilize their call center services.
Now while we recognize some issuersacross the country prefer to have
their operations in-house, we'vealso seen it be very cost favorable
(05:50):
to utilize offshore resourcing tomaking sure you stay in budget.
Depending how large a part serviceoperations is to your plan strategy
and to your brand recognition of yourorganization, we've also seen it be
utilized as a large lever to pullin terms of financial savings and
investment in other key capabilities.
For example, by offshoring serviceoperations to an offshore entity that
(06:14):
could give my organization more dollarsto spend and invest into network
development or competitive intelligence.
Contrary to that, by investing intobuilding my organization of service
operations onshore and in-house, thatcould also increase the value of my
brand recognition with the membersand clients that I serve within
the states that we participate in.
Another core competency that Ipersonally think is one of the most
(06:35):
important financial or non-financialdecisions to invest into that an issuer
can make is competitive intelligence.
Some issuers consider competitiveintelligence as a one-time exercise
that really drives their initial planportfolio strategy and decision making.
What it really should be consideredas is an ongoing, iterative process
that is always being looked ateach month, throughout each year.
(06:56):
I think the question that reallyneeds to be asked to each issuer
is (06:59):
how much am I willing to spend to differentiate my product from
the primary competitors in themarketplaces that I'm participating in?
And it really boils down to arace against time and race against
filing and submissions to your statedivisions of insurance as well as CMS.
There are certainly lots of benefitsto subcontracting and partnering with
an outside organization or consultingfirm to help you codify your competitive
(07:22):
intelligence strategy, including speedto market, and frankly, the confidence of
harnessing your plan strategy for a newplan year, especially if you're a brand
new issuer doing this for the first time.
Now in that same breath, evenbeing a brand new issuer, it could
also be a very wise decision toinvest in a homegrown team to build
your operations and competitiveintelligence from the ground up.
(07:44):
Having resources internally that'sfamiliar with how you transact your
business day-to-day and executeoperationally could also build value in
other areas of your organization, such asworking with your pharmacy team or your
utilization or care management team, oreven your product team to making sure
that data being analyzed and collectedis utilized appropriately that aligns
(08:05):
with your values of the organization.
So even if you're not close to thefinancial piece of the investment
strategy of your organization,there are also many non-financial
strategies as a part of this process.
Other non-financial strategiescan also include establishing
codified business processes.
So from a competitive intelligencestandpoint, that could be having a
resource understanding how to accessthe SERFF filing system, download
(08:30):
competitor carrier filings, extractneeded documents within the scope of your
strategic engagement, and help presentthat to your executive leadership team.
A process like that will help buildknowledge within your organization and
the knowledge base across your teams.
That's investment that's not necessarilyfinancially-based, but non-financially
that grows as your business grows.
Having someone who truly understandsyour business process, who is versatile
(08:53):
in these tools, that understandsthe content that's being presented
to executive leadership to makethose informed decisions about your
product would be highly valuableeven in a non-financial sense.
Now that being said, that person, thatsame resource who you're training, to have
that legacy knowledge to learn the bookof business for your ACA portfolio, can
(09:13):
also be that same person to understandstate deadlines and understand the federal
deadlines that are posed to your issuer.
All that wraps around the timing ofhow you deliver, capture and present
your competitive intelligence.
Believe it or not, let's walk it back.
That actually is going to wrap thetimeline around your network development.
And delivery of serviceoperations as well.
So, to round it all out, I thinkwe can all agree that there's lots
(09:35):
of moving pieces and parts to thestrategic planning process for
any ACA issuer , new or existing.
So it'll be very important to takea step back and to truly evaluate
all components, financially andnon-financially, prior to making planned
portfolio strategies for your company.
We recommend evaluating the low andhigh end of the investment and the
cost of each of your core capabilities.
And throughout the process of evaluatingthe low and high end of all your
(09:57):
capabilities, regardless of networkdevelopment, service operations, or
competitive intelligence, always have agood pulse with your finance organization
to truly understand the price and howthe cost will impact internal operations.
And what I mean by that is a lot ofthe capabilities that we've discussed
today are priced differently, whetherit's a PMPM per member per month model,
(10:20):
which arguably could be very hard tocalculate and project from a future
state perspective, not knowing how manymembers you may have in your products
and plans, ultimately hindering andimpacting your decision making process.
Or for the more simple capabilities,where it's more flat fee or
investing in a standardized resource.
We recognize this is challenging.
(10:40):
I don't think anybody ever saidthe process was going to be easy.
Always remember that you will havean opportunity to revise your plan
strategy both financially and nonfinancially for your next plan year ahead.
While we are in plan year 2026, reallyencourage issuers to step back and to
think about the markets that you'll bemost competitive in that would yield
the most membership growth, not justfor 26, but 27 and also plan year 2028.
(11:04):
We do see that the marketplace isshifting quite rapidly , as CMS
is releasing new federal guidance.
Please try to make some anticipateddecisions or even assumptions as those
pending decisions do come to life.
That being said, thankseverybody for listening in today.
Give us a like, give us a share,and we'll see you next time.
Hey everybody.
Welcome to Regulatory Joe.
I'm Joe Boyle, president ofRegulatory Solutions here at Penstock.
And on today's episode, we'll bediscussing ACA investments and how
to grow your portfolio strategy.
Some of you out there may be wondering,well, why even invest in the ACA?
It's so expensive, it's challenging,it's complicated, and how do I
know if I will even be successfulif I spend all this money and
(00:20):
time trying to develop a product?
Well, there is actually a lot of goodand a lot of pros to investing and to
taking the time and the money to do this.
Enrollment's at an all time high.
The ACA has created new products wenever knew existed before, such as ICRA.
We're seeing the ACA in the newsmore than ever before with the media.
And we're seeing more membershipthrough the roof in new states,
and states are even converting tostate-based exchanges, one after
(00:44):
the other, to keep up with the ACA.
And that's exactly why you shouldbe considering your strategy
for plan year 26 and beyond.
Regardless of the size of yourissuer or organization, it's really
important to think about strategicinvestments, both financially and
non-financially, regardless ofwhere you're at in the process.
When having these conversations andmaking these decisions, it really
revolves around three or four primarycategories that drive an organization
(01:07):
entering an ACA book of business orrenewing an ACA book of business.
You need to make sure you conduct acodified build versus buy analysis around
a few topics such as service operations,building or renting a network, optimizing
your business infrastructure, staffingyour plan and organization, and going
to market with your sales strategy.
If you don't have those five corecapabilities in force prior to
(01:28):
offering your plan for enrollment,you're gonna have a very challenging
time entering the ACA marketplace.
So, starting off with some key financialinvestments that you should really
be thinking about now for your plan.
The first one's going to be networkdevelopment and the question of whether
you should buy a network, rent a network.
Or if you have the capabilitiesinternally to build and
sustain that network over time.
(01:49):
At baseline, you should startby evaluating the provider
contractors you have on staffand the products that they serve.
Now, while it's possible that you cancross train different contractors to
serve ACA, you have to understand, isthis role important enough to have a
shared resource or a dedicated resourceto build my ACA contracts with the
providers and the facilities that Ineed to contract a compliant network?
(02:10):
Or is it more worthy of an investmentfor me to rent that network from a larger
carrier such as a big four or a big three?
When you're in this position,you have to also evaluate time.
How fast is your speed to market?
Do you have the time to build a network?
We estimate that it takes up to 18months to contract a compliant network
in any one state that you plan toenter if it's a new market entrant.
Now, if it's a renewal market that you'realready participating in, that's okay.
(02:33):
You have a little bit more offlexibility to move around and
to fill gaps that may have fallenout of adequacy the prior year.
At this point in the planning process,your product strategy team should be
already communicating with your networkstrategy team to understand how the
product portfolio is going to be setup, the product and benefits that
are important to the members in thatcertain geography or in those zip codes.
(02:55):
So what's important to those members?
Is it seeing a chiropractor forcertain specialist services?
Is it seeing a PCP for routine care?
So also considering in terms of networkdevelopment, while we are talking today
about the ACA products, communicate withyour other product development partners.
As you grow Medicare Advantage, is itconsistent to grow your product with ACA?
(03:16):
As you're growing your network forMedicare and Medicaid, should you
grow your ACA network the same way?
Well, it's interesting because based onthose conversations and strategies, we
would recommend if the organization'soutlook is to consistently grow your
product portfolios across all yourlines of business, regardless if it's
an ACA qualified health plan product,Medicare Advantage product or other, we
(03:38):
recommend investing in those resources onstaff to actually have the capabilities
in-house to build and grow your business.
Now it's important to note in thatsame breath that if you're at a race
against the clock in terms of meetingcommitments to enter a new market or
to develop a new product, renting anetwork while also staffing for your
(03:58):
business in the future to then convertthat could be a wise decision as well.
Because at the end of the day, it'sreally important to have a talented
group of provider contractors tokeep up with the ever-changing
daily environment of turnover.
One of the second most importantcapabilities that we find
issuers have the most significantinvestment in is service operations.
(04:18):
Service operations can mean a numberof different things from administering
your call center to take calls from yourmembers during the enrollment period,
from November 1st to January 15th onan annual basis and also throughout the
year to service your member questionsas they dial in about the plan.
It could also mean such things asadministering enrollment, and billing to
making sure premium payments are beingtransacted correctly from the Federal
(04:42):
Exchange, the state-based exchange,to the health plan, to making sure
the transfer of funds is reconciledand appropriate for each member.
While we understand there's manydifferent ways to administer your service
operations and call center, what itreally boils down to is cost and price.
The financial implications arevery large because when you think
about the ways you can administersuch programs, you can build an
(05:05):
organization in-house with onshorerepresentatives that can be codified,
dedicated resources for your teams.
You could also make a decision to crosstrain those staff, to ensure that they're
blending their time across other products,to making sure they're maximizing their
capacity, for your organization as well.
We've also seen organizations bevery successful hiring temp staff,
for certain peaks and valleys ofbusy seasons, such as enrollment
(05:28):
from November 1st to January 15th.
In contrast to organizations who buildand staff their teams in-house and
onshore, we've also seen issuers be verysuccessful by subcontracting offshore
organizations to help stand up andstabilize their call center services.
Now while we recognize some issuersacross the country prefer to have
their operations in-house, we'vealso seen it be very cost favorable
(05:50):
to utilize offshore resourcing tomaking sure you stay in budget.
Depending how large a part serviceoperations is to your plan strategy
and to your brand recognition of yourorganization, we've also seen it be
utilized as a large lever to pullin terms of financial savings and
investment in other key capabilities.
For example, by offshoring serviceoperations to an offshore entity that
(06:14):
could give my organization more dollarsto spend and invest into network
development or competitive intelligence.
Contrary to that, by investing intobuilding my organization of service
operations onshore and in-house, thatcould also increase the value of my
brand recognition with the membersand clients that I serve within
the states that we participate in.
Another core competency that Ipersonally think is one of the most
(06:35):
important financial or non-financialdecisions to invest into that an issuer
can make is competitive intelligence.
Some issuers consider competitiveintelligence as a one-time exercise
that really drives their initial planportfolio strategy and decision making.
What it really should be consideredas is an ongoing, iterative process
that is always being looked ateach month, throughout each year.
(06:56):
I think the question that reallyneeds to be asked to each issuer
is (06:59):
how much am I willing to spend to differentiate my product from
the primary competitors in themarketplaces that I'm participating in?
And it really boils down to arace against time and race against
filing and submissions to your statedivisions of insurance as well as CMS.
There are certainly lots of benefitsto subcontracting and partnering with
an outside organization or consultingfirm to help you codify your competitive
(07:22):
intelligence strategy, including speedto market, and frankly, the confidence of
harnessing your plan strategy for a newplan year, especially if you're a brand
new issuer doing this for the first time.
Now in that same breath, evenbeing a brand new issuer, it could
also be a very wise decision toinvest in a homegrown team to build
your operations and competitiveintelligence from the ground up.
(07:44):
Having resources internally that'sfamiliar with how you transact your
business day-to-day and executeoperationally could also build value in
other areas of your organization, such asworking with your pharmacy team or your
utilization or care management team, oreven your product team to making sure
that data being analyzed and collectedis utilized appropriately that aligns
(08:05):
with your values of the organization.
So even if you're not close to thefinancial piece of the investment
strategy of your organization,there are also many non-financial
strategies as a part of this process.
Other non-financial strategiescan also include establishing
codified business processes.
So from a competitive intelligencestandpoint, that could be having a
resource understanding how to accessthe SERFF filing system, download
(08:30):
competitor carrier filings, extractneeded documents within the scope of your
strategic engagement, and help presentthat to your executive leadership team.
A process like that will help buildknowledge within your organization and
the knowledge base across your teams.
That's investment that's not necessarilyfinancially-based, but non-financially
that grows as your business grows.
Having someone who truly understandsyour business process, who is versatile
(08:53):
in these tools, that understandsthe content that's being presented
to executive leadership to makethose informed decisions about your
product would be highly valuableeven in a non-financial sense.
Now that being said, that person, thatsame resource who you're training, to have
that legacy knowledge to learn the bookof business for your ACA portfolio, can
(09:13):
also be that same person to understandstate deadlines and understand the federal
deadlines that are posed to your issuer.
All that wraps around the timing ofhow you deliver, capture and present
your competitive intelligence.
Believe it or not, let's walk it back.
That actually is going to wrap thetimeline around your network development.
And delivery of serviceoperations as well.
So, to round it all out, I thinkwe can all agree that there's lots
(09:35):
of moving pieces and parts to thestrategic planning process for
any ACA issuer , new or existing.
So it'll be very important to takea step back and to truly evaluate
all components, financially andnon-financially, prior to making planned
portfolio strategies for your company.
We recommend evaluating the low andhigh end of the investment and the
cost of each of your core capabilities.
And throughout the process of evaluatingthe low and high end of all your
(09:57):
capabilities, regardless of networkdevelopment, service operations, or
competitive intelligence, always have agood pulse with your finance organization
to truly understand the price and howthe cost will impact internal operations.
And what I mean by that is a lot ofthe capabilities that we've discussed
today are priced differently, whetherit's a PMPM per member per month model,
(10:20):
which arguably could be very hard tocalculate and project from a future
state perspective, not knowing how manymembers you may have in your products
and plans, ultimately hindering andimpacting your decision making process.
Or for the more simple capabilities,where it's more flat fee or
investing in a standardized resource.
We recognize this is challenging.
(10:40):
I don't think anybody ever saidthe process was going to be easy.
Always remember that you will havean opportunity to revise your plan
strategy both financially and nonfinancially for your next plan year ahead.
While we are in plan year 2026, reallyencourage issuers to step back and to
think about the markets that you'll bemost competitive in that would yield
the most membership growth, not justfor 26, but 27 and also plan year 2028.
(11:04):
We do see that the marketplace isshifting quite rapidly , as CMS
is releasing new federal guidance.
Please try to make some anticipateddecisions or even assumptions as those
pending decisions do come to life.
That being said, thankseverybody for listening in today.
Give us a like, give us a share,and we'll see you next time.
Popular Podcasts
Stuff You Should Know
If you've ever wanted to know about champagne, satanism, the Stonewall Uprising, chaos theory, LSD, El Nino, true crime and Rosa Parks, then look no further. Josh and Chuck have you covered.
24/7 News: The Latest
The latest news in 4 minutes updated every hour, every day.
Dateline NBC
Current and classic episodes, featuring compelling true-crime mysteries, powerful documentaries and in-depth investigations. Follow now to get the latest episodes of Dateline NBC completely free, or subscribe to Dateline Premium for ad-free listening and exclusive bonus content: DatelinePremium.com