July 2, 2025 • 9 mins
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
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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, and on today'sepisode, we'll be discussing
staffing for ACA success.
And I think we can ask the question,why is staffing so important now
more than ever in plan year 2026?
I think it really bubblesup into two primary reasons.
Explosive enrollment andcomplex regulatory guidance.
So, it's interesting becauseentering 2026, we can all make
(00:21):
the assumption that each issuer wework with has a staffing plan and
organizational plan in place today.
But, this is the first year that wesee a heightened exponential growth
of enrollment, explosive for planyear 26, and we see a heightened
sense of plan requirements forissuers, both from CMS and DOIs.
What we've seen, historicallyspeaking, is two primary methods
of staffing your organization.
(00:42):
Role-based staffing, as wellas market-based staffing.
Now if you're a new issuer entering theACA for the first time, or an existing
issuer only offering your productswithin one or two states, we really
would recommend role-based staffing.
The way I could best describe role-basedstaffing is similar to a Venn diagram,
where you have your core ACA productteam in the center and each respective
(01:02):
individual business area for yourstakeholders surround you and overlap in
your overall implementation one at a time.
Your pharmacy team, your marketingteam, utilization and care management
team, even down to such functionssuch as your actuarial team, doing
your price setting and premium rating.
This allows your product team to havea central location and communication
(01:22):
across all stakeholders through yourimplementation, similar to centralized
project management or product management.
Now where it gets tricky and why wewould not recommend role-based models
for larger organizations that areparticipating in multiple states and
segments, both individual, group,on and off the exchange, is because
you're entering a space where yougrow from a one to one organization
(01:46):
to a one to many organization.
When you're working with so manystakeholders across so many different
departments and when you are accountablefor that work, having multiple people
or, per se, too many hands in the potworking with implementation and project
management could be very detrimentalto you meeting your deadlines both
internally and also externally.
And the value add and additional proto having this model here for, let's
(02:08):
just say a single state or up totwo states, is really honing in your
operations and codifying your strategy.
If you are a smaller issuer participatingin one state or up to two states,
and you do have plans to grow in thefuture, year over year, entering new
markets or expanding your footprintwith your existing market, we would
recommend arranging a multi year staffingmodel that would evolve role-based
(02:29):
staffing into market-based staffing.
On the contrary, if you're a smallerregional issuer participating in one or
two states and your intention is to onlycontinue to participate in those one or
two states based on your market share,continue to strengthen your role-based
staffing model and increase the subjectmatter expertise of your product team
and your project team running thatcentral hub for all your stakeholders.
(02:52):
This will increase your legacyknowledge year over year and help
boost, even create, a career developmentroadmap for this person and the
people supporting your product.
Now on the flip side, when we talk aboutthe movement from a role-based staffing
model to a market-based staffing model, wecan consider this in two different ways.
Emerging issuers that are growing from asmall issuer to a larger issuer as they
(03:13):
obtain membership or existing issuersthat are larger organizations that have
actually been playing in this spacefor multiple years, that may just have
been treating this work as seasonal.
In the past, the ACA filing workreally has been looked at the
first six months of the year.
Once you file, yourproducts go under review.
My resources can now spend theirtime elsewhere on other products
(03:35):
that's not specific to the ACA.
Maybe other products such as MedicareAdvantage, Medicaid, or even something
completely entirely unrelated inthe health insurance business.
Now what we've seen is as groups growfrom role-based staffing models to
market-based staffing models, at theend of the day, based on the number
of states you participate in today andwhere they fall throughout the country,
(03:56):
it should be fairly easy for your teamto split the country up into regions.
This allows a dedicated resourceto work on multiple states with
less responsibility to be ableto project manage the subject
matter expert stakeholders whoare responsible for providing the
materials for your filing submission.
So rather than having one singleperson in the role-based model
(04:16):
doing the majority of the work onbehalf of all of your stakeholders,
you're engaging the subject matterexperts of your team across multiple
states and holding them accountable.
And accountability is a huge part ofmaking sure you meet your deadlines and
commitments, especially with CMS and DOI.
What this will also do is helpestablish business process, not from
your internal product organization,but for your external stakeholders.
(04:41):
Each one of your accountable teammembers should be documenting business
process as they provide the materialsand templates for your submission.
And you should be tracking that.
So by developing workflows, you'llultimately see how this builds and
grows with your organization over time.
And you'll understand the value add.
You could actually, quitefrankly, measure it.
And measure their performance of yourteam's speed to market, downtime,
(05:02):
rework, or error reconciliation.
The person leading this effortshould also be thinking about those
items as they work in their roles.
While each issuer and organization likelyhas your own organizational and cultural
fit, there are a lot of competenciesthat we really look for for both roles.
Some of the key core competenciesthat we really look for in candidates,
regardless of if it's for a role-basedmodel or a market-based model,
(05:24):
they're relatively consistent acrossthe two, are regulatory expertise.
So look for anybody even outside ofthe core health insurance industry can
still provide a large value add to yourorganization, even if it's interpretation
of life insurance guidelines or propertyand casualty insurance guidelines.
Really, any contract experience and thatlegacy knowledge can be transferable with
(05:46):
those skills to the ACA interpretationof federal guidance and state policies.
Really, it's very different, but the sameconcepts apply and apply to plan filing,
which is what we're talking about today.
And understanding, regardless of whichmodel, role-based or market-based, the
people doing this work are going tobe working with a lot of other people.
So making sure you understand you havesomebody that you can rely on, that
(06:08):
you can trust, that can coordinate andconfidently communicate across multiple
stakeholders on an ongoing basis isgoing to be critical to your success.
So that being said, staffing is iterative.
You should always be thinkingabout staffing, not just a
point in time in each year.
Definitely some actionable stepsthat you can take going forward
are evaluate your needs for planyear 2026 and plan year 2027.
(06:31):
Once you've harnessed your needs,if you do have existing job
descriptions in place, take a look.
Do those descriptions and JDsline up with the needs of your
organization for this year?
And if not, do I have to updatethose job descriptions or do I
have to write a brand new one?
Hiring takes a long time, I think wecan all agree on that, and to find
the right candidate for the right fit.
So, post the job, start tosolicit candidates, collect the
(06:53):
resumes, and build your networkof people that you could utilize.
What we've learned in the ACA processas we file across the country is the
health insurance industry is very small.
So the more we can retain the talentthat we've created, specifically for
the ACA, to support our business and tosupport our members for the next number
of years, is only going to add value toyour organization and to your members.
(07:14):
It may seem very simple or rudimentary,but if you do not have a codified
onboarding plan, a 30 day, a 60day, or a 90 day plan for a staff
member of any level, entry level,manager level, even executive level,
we recommend that you develop them.
Work with your HR partners or atraining team or talent organization
to partner with your product teamand product organization to collect
(07:37):
policies and procedures, to collectproduct overview, history of the ACA,
and other standard operating proceduresthat can be value added or even media
content such as videos or recordingsof different actions or items or steps
that team members are taking so thatany new team member will feel welcome,
confident, and ready to completethe work that they're tasked with.
(07:59):
We all know needs change all the time,so understanding what the strategy is
and outlook for your organization beyondone year is going to be very important.
Because the last thing you'd want isthat if your plan portfolio strategy is
to successively expand year over year,and if that strategy shifts and changes
to not expanding, you want to makesure your hiring follows those changes.
(08:19):
So that you're not over hiringfor the work that's coming in, and
that you're not understaffed forthe work that's not anticipated.
We also recognize that even if youdo have a team in place, which is
great, circumstances do change overtime throughout the plan year, so
we should be prepared for that.
Familiarize yourself with the industryand the core capabilities that your core
team provides to you today, and evaluateIf there's a risk or if there were a
(08:43):
gap, what would I need to be successful?
Understand the price point of thesuppliers that could help you if you
need them in a pinch, how quickly theycan stand up their business processes
to help your organization and what thatcost and price point is to implement.
I think we all can agreeon a couple things.
Staffing is hard, staffing takestime, and staffing is expensive.
So getting ahead of it willbe very important, and I hope
(09:04):
some of these tips are helpful.
Thanks everybody for watching.
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, and on today'sepisode, we'll be discussing
staffing for ACA success.
And I think we can ask the question,why is staffing so important now
more than ever in plan year 2026?
I think it really bubblesup into two primary reasons.
Explosive enrollment andcomplex regulatory guidance.
So, it's interesting becauseentering 2026, we can all make
(00:21):
the assumption that each issuer wework with has a staffing plan and
organizational plan in place today.
But, this is the first year that wesee a heightened exponential growth
of enrollment, explosive for planyear 26, and we see a heightened
sense of plan requirements forissuers, both from CMS and DOIs.
What we've seen, historicallyspeaking, is two primary methods
of staffing your organization.
(00:42):
Role-based staffing, as wellas market-based staffing.
Now if you're a new issuer entering theACA for the first time, or an existing
issuer only offering your productswithin one or two states, we really
would recommend role-based staffing.
The way I could best describe role-basedstaffing is similar to a Venn diagram,
where you have your core ACA productteam in the center and each respective
(01:02):
individual business area for yourstakeholders surround you and overlap in
your overall implementation one at a time.
Your pharmacy team, your marketingteam, utilization and care management
team, even down to such functionssuch as your actuarial team, doing
your price setting and premium rating.
This allows your product team to havea central location and communication
(01:22):
across all stakeholders through yourimplementation, similar to centralized
project management or product management.
Now where it gets tricky and why wewould not recommend role-based models
for larger organizations that areparticipating in multiple states and
segments, both individual, group,on and off the exchange, is because
you're entering a space where yougrow from a one to one organization
(01:46):
to a one to many organization.
When you're working with so manystakeholders across so many different
departments and when you are accountablefor that work, having multiple people
or, per se, too many hands in the potworking with implementation and project
management could be very detrimentalto you meeting your deadlines both
internally and also externally.
And the value add and additional proto having this model here for, let's
(02:08):
just say a single state or up totwo states, is really honing in your
operations and codifying your strategy.
If you are a smaller issuer participatingin one state or up to two states,
and you do have plans to grow in thefuture, year over year, entering new
markets or expanding your footprintwith your existing market, we would
recommend arranging a multi year staffingmodel that would evolve role-based
(02:29):
staffing into market-based staffing.
On the contrary, if you're a smallerregional issuer participating in one or
two states and your intention is to onlycontinue to participate in those one or
two states based on your market share,continue to strengthen your role-based
staffing model and increase the subjectmatter expertise of your product team
and your project team running thatcentral hub for all your stakeholders.
(02:52):
This will increase your legacyknowledge year over year and help
boost, even create, a career developmentroadmap for this person and the
people supporting your product.
Now on the flip side, when we talk aboutthe movement from a role-based staffing
model to a market-based staffing model, wecan consider this in two different ways.
Emerging issuers that are growing from asmall issuer to a larger issuer as they
(03:13):
obtain membership or existing issuersthat are larger organizations that have
actually been playing in this spacefor multiple years, that may just have
been treating this work as seasonal.
In the past, the ACA filing workreally has been looked at the
first six months of the year.
Once you file, yourproducts go under review.
My resources can now spend theirtime elsewhere on other products
(03:35):
that's not specific to the ACA.
Maybe other products such as MedicareAdvantage, Medicaid, or even something
completely entirely unrelated inthe health insurance business.
Now what we've seen is as groups growfrom role-based staffing models to
market-based staffing models, at theend of the day, based on the number
of states you participate in today andwhere they fall throughout the country,
(03:56):
it should be fairly easy for your teamto split the country up into regions.
This allows a dedicated resourceto work on multiple states with
less responsibility to be ableto project manage the subject
matter expert stakeholders whoare responsible for providing the
materials for your filing submission.
So rather than having one singleperson in the role-based model
(04:16):
doing the majority of the work onbehalf of all of your stakeholders,
you're engaging the subject matterexperts of your team across multiple
states and holding them accountable.
And accountability is a huge part ofmaking sure you meet your deadlines and
commitments, especially with CMS and DOI.
What this will also do is helpestablish business process, not from
your internal product organization,but for your external stakeholders.
(04:41):
Each one of your accountable teammembers should be documenting business
process as they provide the materialsand templates for your submission.
And you should be tracking that.
So by developing workflows, you'llultimately see how this builds and
grows with your organization over time.
And you'll understand the value add.
You could actually, quitefrankly, measure it.
And measure their performance of yourteam's speed to market, downtime,
(05:02):
rework, or error reconciliation.
The person leading this effortshould also be thinking about those
items as they work in their roles.
While each issuer and organization likelyhas your own organizational and cultural
fit, there are a lot of competenciesthat we really look for for both roles.
Some of the key core competenciesthat we really look for in candidates,
regardless of if it's for a role-basedmodel or a market-based model,
(05:24):
they're relatively consistent acrossthe two, are regulatory expertise.
So look for anybody even outside ofthe core health insurance industry can
still provide a large value add to yourorganization, even if it's interpretation
of life insurance guidelines or propertyand casualty insurance guidelines.
Really, any contract experience and thatlegacy knowledge can be transferable with
(05:46):
those skills to the ACA interpretationof federal guidance and state policies.
Really, it's very different, but the sameconcepts apply and apply to plan filing,
which is what we're talking about today.
And understanding, regardless of whichmodel, role-based or market-based, the
people doing this work are going tobe working with a lot of other people.
So making sure you understand you havesomebody that you can rely on, that
(06:08):
you can trust, that can coordinate andconfidently communicate across multiple
stakeholders on an ongoing basis isgoing to be critical to your success.
So that being said, staffing is iterative.
You should always be thinkingabout staffing, not just a
point in time in each year.
Definitely some actionable stepsthat you can take going forward
are evaluate your needs for planyear 2026 and plan year 2027.
(06:31):
Once you've harnessed your needs,if you do have existing job
descriptions in place, take a look.
Do those descriptions and JDsline up with the needs of your
organization for this year?
And if not, do I have to updatethose job descriptions or do I
have to write a brand new one?
Hiring takes a long time, I think wecan all agree on that, and to find
the right candidate for the right fit.
So, post the job, start tosolicit candidates, collect the
(06:53):
resumes, and build your networkof people that you could utilize.
What we've learned in the ACA processas we file across the country is the
health insurance industry is very small.
So the more we can retain the talentthat we've created, specifically for
the ACA, to support our business and tosupport our members for the next number
of years, is only going to add value toyour organization and to your members.
(07:14):
It may seem very simple or rudimentary,but if you do not have a codified
onboarding plan, a 30 day, a 60day, or a 90 day plan for a staff
member of any level, entry level,manager level, even executive level,
we recommend that you develop them.
Work with your HR partners or atraining team or talent organization
to partner with your product teamand product organization to collect
(07:37):
policies and procedures, to collectproduct overview, history of the ACA,
and other standard operating proceduresthat can be value added or even media
content such as videos or recordingsof different actions or items or steps
that team members are taking so thatany new team member will feel welcome,
confident, and ready to completethe work that they're tasked with.
(07:59):
We all know needs change all the time,so understanding what the strategy is
and outlook for your organization beyondone year is going to be very important.
Because the last thing you'd want isthat if your plan portfolio strategy is
to successively expand year over year,and if that strategy shifts and changes
to not expanding, you want to makesure your hiring follows those changes.
(08:19):
So that you're not over hiringfor the work that's coming in, and
that you're not understaffed forthe work that's not anticipated.
We also recognize that even if youdo have a team in place, which is
great, circumstances do change overtime throughout the plan year, so
we should be prepared for that.
Familiarize yourself with the industryand the core capabilities that your core
team provides to you today, and evaluateIf there's a risk or if there were a
(08:43):
gap, what would I need to be successful?
Understand the price point of thesuppliers that could help you if you
need them in a pinch, how quickly theycan stand up their business processes
to help your organization and what thatcost and price point is to implement.
I think we all can agreeon a couple things.
Staffing is hard, staffing takestime, and staffing is expensive.
So getting ahead of it willbe very important, and I hope
(09:04):
some of these tips are helpful.
Thanks everybody for watching.
Give us a like, give us a share,and we'll see you next time.
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