Staffing Your Health Plan for ACA Success

Staffing doesn’t usually get the spotlight in conversations about Affordable Care Act (ACA) strategy—but it should. As enrollment surges and filing requirements grow more complex, having the right structure in place is one of the most critical factors for staying compliant, competitive and confident throughout the annual filing cycle.

In the latest episode of Regulatory Joe, ClearFile President Joe Boyle breaks down the key differences between role-based and market staffing models, when to use each and how to future-proof your organizational design for long-term ACA success.

Why Staffing Matters More Than Ever

What used to be a seasonable process has grown into a year-round focus with a compounding workload. More state-specific nuances, stricter CMS oversight, and growing membership all demand a staffing strategy that can keep up with the pace of change.

Historically, most issuers have leaned on one of two models:

  • Role-based staffing: Centers ACA work within a core team that coordinates with internal stakeholders as needed
  • Market-based staffing: Distributes responsibility across dedicated teams by region or state

Each has its place, but the key is understanding which model aligns with your organization’s current footprint and where you’re heading next.

Role-Based Staffing: A Central Hub for Coordination

A role-based staffing approach works best for new or smaller issuers operating in 1-2 states. In this model, a dedicated ACA team serves as the central driver, coordinating with departments like pharmacy, marketing, actuarial and care management throughout the process.

Benefits of role-based staffing include:

  • Consistent coordination and project management
  • Tighter quality control and fewer communication breakdowns
  • Deepening SME knowledge and legacy expertise over time

For plans focused on steady, contained operations rather than multistate expansion, this model can be efficient and effective.

Market-Based Staffing: Built to Scale

Once your organization spans multiple states or lines of businesses, role-based staffing can quickly become a bottleneck. That’s where market-based staffing comes into play.

With a market-based staffing model, filing responsibility is distributed by geography or market segment. Each regional team oversees filings and collaborates with SMEs in their dedicated areas.

This structure brings:

  • Clear accountability for deadlines and deliverables across multiple states
  • Better alignment with regional regulatory nuances
  • More scalable workflows that grow with your organization

Making the Transition

Not every health plan makes a clean jump from one model to the other. For many, it’s a multi-year evolution. If you’re a smaller issuer planning to grow, now is the time to:

  • Start documenting roles, processes and timelines
  • Identify what staffing structure supports expansion goals
  • Develop onboarding plans that reduce ramp-up time and knowledge loss

Core Competencies for Your ACA Team

Whether centralized or regionalized, successful ACA staffing depends on hiring the right people with the right strengths.

Look for candidates with:

  • Regulatory experience (even outside of ACA—think P&C, Medicare, life, etc.)
  • Strong coordination and communication skills
  • The ability to document, track and optimize repeatable processes

And once you’ve hired your team, don’t stop there. Create 30/60/90-day onboarding plans that cover ACA basics, internal tools, templates, timelines and expectations so new members can hit the ground running.

A Final Note: Think Beyond the Filing Season

ACA staffing shouldn’t be treated as a six-month spring. Market changes, filing timelines and team dynamics shift year-round, and your staffing model should flex with them.

Now is the time to evaluate where you stand and how to build a more durable staffing strategy that supports your business in every season.



Transcript

Hey everybody, welcome to Regulatory Joe. I’m Joe Boyle, and on today’s episode, 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 bubbles up into two primary reasons. Explosive enrollment and complex regulatory guidance.

So, it’s interesting because entering 2026, we can all make the assumption that each issuer we work with has a staffing plan and organizational plan in place today.

But, this is the first year that we see a heightened exponential growth of enrollment, explosive for plan year 26, and we see a heightened sense of plan requirements for issuers, both from CMS and DOIs.

What we’ve seen, historically speaking, is two primary methods of staffing your organization. Role-based staffing, as well as market-based staffing. Now if you’re a new issuer entering the ACA for the first time, or an existing issuer only offering your products within one or two states, we really would recommend role-based staffing.

The way I could best describe role-based staffing is similar to a Venn diagram, where you have your core ACA product team in the center and each respective individual business area for your stakeholders surround you and overlap in your overall implementation one at a time. Your pharmacy team, your marketing team, utilization and care management team, even down to such functions such as your actuarial team, doing your price setting and premium rating.

This allows your product team to have a central location and communication across all stakeholders through your implementation, similar to centralized project management or product management.

Now where it gets tricky and why we would not recommend role-based models for larger organizations that are participating in multiple states and segments, both individual, group, on and off the exchange, is because you’re entering a space where you grow from a one to one organization to a one to many organization.

When you’re working with so many stakeholders across so many different departments and when you are accountable for that work, having multiple people or, per se, too many hands in the pot working with implementation and project management could be very detrimental to you meeting your deadlines both internally and also externally.

And the value add and additional pro to having this model here for, let’s just say a single state or up to two states, is really honing in your operations and codifying your strategy.

If you are a smaller issuer participating in one state or up to two states, and you do have plans to grow in the future, year over year, entering new markets or expanding your footprint with your existing market, we would recommend arranging a multi year staffing model that would evolve role-based staffing into market-based staffing.

On the contrary, if you’re a smaller regional issuer participating in one or two states and your intention is to only continue to participate in those one or two states based on your market share, continue to strengthen your role-based staffing model and increase the subject matter expertise of your product team and your project team running that central hub for all your stakeholders.

This will increase your legacy knowledge year over year and help boost, even create, a career development roadmap for this person and the people supporting your product. Now on the flip side, when we talk about the movement from a role-based staffing model to a market-based staffing model, we can consider this in two different ways.

Emerging issuers that are growing from a small issuer to a larger issuer as they obtain membership or existing issuers that are larger organizations that have actually been playing in this space for multiple years, that may just have been treating this work as seasonal. In the past, the ACA filing work really has been looked at the first six months of the year.

Once you file, your products go under review. My resources can now spend their time elsewhere on other products that’s not specific to the ACA. Maybe other products such as Medicare Advantage, Medicaid, or even something completely entirely unrelated in the health insurance business.

Now what we’ve seen is as groups grow from role-based staffing models to market-based staffing models, at the end of the day, based on the number of states you participate in today and where they fall throughout the country, it should be fairly easy for your team to split the country up into regions.

This allows a dedicated resource to work on multiple states with less responsibility to be able to project manage the subject matter expert stakeholders who are responsible for providing the materials for your filing submission. So rather than having one single person in the role-based model doing the majority of the work on behalf of all of your stakeholders, you’re engaging the subject matter experts of your team across multiple states and holding them accountable.

And accountability is a huge part of making sure you meet your deadlines and commitments, especially with CMS and DOI.

What this will also do is help establish business process, not from your internal product organization, but for your external stakeholders. Each one of your accountable team members should be documenting business process as they provide the materials and templates for your submission.

And you should be tracking that. So by developing workflows, you’ll ultimately see how this builds and grows with your organization over time. And you’ll understand the value add. You could actually, quite frankly, measure it. And measure their performance of your team’s speed to market, downtime, rework, or error reconciliation.

The person leading this effort should also be thinking about those items as they work in their roles. While each issuer and organization likely has your own organizational and cultural fit, there are a lot of competencies that we really look for for both roles.

Some of the key core competencies that we really look for in candidates, regardless of if it’s for a role-based model or a market-based model, they’re relatively consistent across the two, are regulatory expertise. So look for anybody even outside of the core health insurance industry can still provide a large value add to your organization, even if it’s interpretation of life insurance guidelines or property and casualty insurance guidelines. Really, any contract experience and that legacy knowledge can be transferable with those skills to the ACA interpretation of federal guidance and state policies.

Really, it’s very different, but the same concepts apply and apply to plan filing, which is what we’re talking about today.

And understanding, regardless of which model, role-based or market-based, the people doing this work are going to be working with a lot of other people. So making sure you understand you have somebody that you can rely on, that you can trust, that can coordinate and confidently communicate across multiple stakeholders on an ongoing basis is going to be critical to your success.

So that being said, staffing is iterative. You should always be thinking about staffing, not just a point in time in each year. Definitely some actionable steps that you can take going forward are evaluate your needs for plan year 2026 and plan year 2027. Once you’ve harnessed your needs, if you do have existing job descriptions in place, take a look.

Do those descriptions and JDs line up with the needs of your organization for this year? And if not, do I have to update those job descriptions or do I have to write a brand new one?

Hiring takes a long time, I think we can all agree on that, and to find the right candidate for the right fit. So, post the job, start to solicit candidates, collect the resumes, and build your network of people that you could utilize. What we’ve learned in the ACA process as we file across the country is the health insurance industry is very small.

So the more we can retain the talent that we’ve created, specifically for the ACA, to support our business and to support our members for the next number of years, is only going to add value to your organization and to your members.

It may seem very simple or rudimentary, but if you do not have a codified onboarding plan, a 30 day, a 60 day, 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 a training team or talent organization to partner with your product team and product organization to collect policies and procedures, to collect product overview, history of the ACA, and other standard operating procedures that can be value added or even media content such as videos or recordings of different actions or items or steps that team members are taking so that any new team member will feel welcome, confident, and ready to complete the work that they’re tasked with.

We all know needs change all the time, so understanding what the strategy is and outlook for your organization beyond one year is going to be very important.

Because the last thing you’d want is that 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 make sure your hiring follows those changes. So that you’re not over hiring for the work that’s coming in, and that you’re not understaffed for the work that’s not anticipated. We also recognize that even if you do have a team in place, which is great, circumstances do change over time throughout the plan year, so we should be prepared for that. Familiarize yourself with the industry and the core capabilities that your core team provides to you today, and evaluate If there’s a risk or if there were a gap, what would I need to be successful?

Understand the price point of the suppliers that could help you if you need them in a pinch, how quickly they can stand up their business processes to help your organization and what that cost and price point is to implement. I think we all can agree on a couple things. Staffing is hard, staffing takes time, and staffing is expensive. So getting ahead of it will be very important, and I hope 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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