The Affordable Care Act (ACA) marketplace is experiencing record-high enrollment, expanding state-based exchanges, and surging demand for compliant, competitive health plans. For health plans weighing whether—and how—to invest in ACA growth for 2026 and beyond, the answer is clear: opportunity is knocking. But seizing it takes strategy. 

In the latest episode of Regulatory Joe, Joe Boyle outlines what it takes to build and scale a successful ACA portfolio—from financial decisions to operational infrastructure. 

Why Invest in the ACA? 

Some issuers hesitate to dive into ACA markets due to perceived complexity or cost. But the data tells a different story: 

• Enrollment is at an all-time high, despite the looming and potential changes with Advance Premium Tax Credits (APTCs) in PY2026 

• States are actively converting to state-based marketplaces 

• ACA is driving product innovation like ICRA, supplemental dental, etc. 

• Media visibility and member awareness are growing 

Health plans that invest now in scalable, compliant infrastructure will be positioned to capture market share as competition heats up. 

3 Core Areas to Anchor Your ACA Growth Strategy 

1. Network Development: Build vs. Rent 

Establishing a complaint provider network is non-negotiable—but how you do it matters. 

• Building in-house offers long-term control and alignment across lines of business (ACA, MA, Medicaid) 

• Renting a network may be the right move if you need speed to market or lack internal provider contracting capacity. 

Regulatory Joe Pro Tip: It can take 12-18 months to build a compliant ACA network from scratch. Start as soon as you can if you’re trying to enter during the next plan year. 

2. Service Operations: Scale Smart 

Operational readiness isn’t just about call centers—it includes billing, enrollment reconciliation and member support. And it impacts everything from regulatory compliance to brand perception. 

• Options include in-house teams, offshore partners or hybrid staffing models. 

• Consider seasonal needs like Open Enrollment when evaluating staffing levels. 

Regulatory Joe Pro Tip: Offshoring can unlock capital for other strategic investments, but may not align with your company’s strategy or brand, causing issues. 

3. Competitive Intelligence: Keep It Continuous 

Competitive intelligence isn’t just a pre-filing exercise—it’s a year-round advantage. 

• Analyze rate filings, product designs and benefit differentials monthly. 

• Track competitors in your market using SERFF and CMS databases. 

• Build or outsource a team to manage this function and align with product strategy. 

Regulatory Joe Pro Tip: Codify your competitive analysis process now so you’re not reinventing the wheel each season. 

Don’t Overlook Non-Financial Strategies for ACA Success 

Not every investment has a line item on a budget sheet. Some of the most impactful strategies involve: 

• Codifying business processes (filing timelines, CMS communications) 

• Building internal knowledge around deadlines, SERFF access and template management 

• Creating cross-functional teams that span product, operations and network development 

Having these strategies in place reduces errors, rework and last-minute surprises—especially as CMS continues to roll out new changes. 

The Bottom Line for ACA Success: Stay Ahead, Plan Smarter 

ACA market growth isn’t slowing down, and neither are the regulatory demands on issuers. Whether you’re entering a new state or refining your existing portfolio, now is the time to reassess your ACA investments holistically.  

Your next steps? Focus on scalable infrastructure, build internal alignment and adopt a forward-looking strategy. The health plans that succeed won’t just be compliant: they’ll be competitive, member-focused and ready to grow. 

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Transcript

Hey everybody. Welcome to Regulatory Joe. I’m Joe Boyle. On today’s episode, we’ll be discussing 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 successful if I spend all this money and time trying to develop a product? Well, there is actually a lot of good and 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 we never knew existed before, such as ICHRA We’re seeing the ACA in the news more than ever before with the media.

And we’re seeing more membership through the roof in new states, and states are even converting to state-based exchanges, one after the other, to keep up with the ACA.

And that’s exactly why you should be considering your strategy for plan year 26 and beyond.

Regardless of the size of your issuer or organization, it’s really important to think about strategic investments, both financially and non-financially, regardless of where you’re at in the process.

When having these conversations and making these decisions, it really revolves around three or four primary categories that drive an organization entering an ACA book of business or renewing an ACA book of business. You need to make sure you conduct a codified build versus buy analysis around a few topics such as service operations, building or renting a network, optimizing your business infrastructure, staffing your plan and organization, and going to market with your sales strategy.

If you don’t have those five core capabilities in force prior to offering your plan for enrollment, you’re gonna have a very challenging time entering the ACA marketplace.

So, starting off with some key financial investments that you should really be thinking about now for your plan. The first one’s going to be network development and the question of whether you should buy a network, rent a network. Or if you have the capabilities internally to build and sustain that network over time.

At baseline, you should start by evaluating the provider contractors you have on staff and the products that they serve.

Now, while it’s possible that you can cross train different contractors to serve ACA, you have to understand, is this role important enough to have a shared resource or a dedicated resource to build my ACA contracts with the providers and the facilities that I need to contract a compliant network?

Or is it more worthy of an investment for 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 18 months to contract a compliant network in any one state that you plan to enter if it’s a new market entrant.

Now, if it’s a renewal market that you’re already participating in, that’s okay. You have a little bit more of flexibility to move around and to fill gaps that may have fallen out of adequacy the prior year.

At this point in the planning process, your product strategy team should be already communicating with your network strategy team to understand how the product portfolio is going to be set up, the product and benefits that are important to the members in that certain geography or in those zip codes.

So what’s important to those members? Is it seeing a chiropractor for certain specialist services? Is it seeing a PCP for routine care?

So also considering in terms of network development, while we are talking today about the ACA products, communicate with your other product development partners. As you grow Medicare Advantage, is it consistent to grow your product with ACA? As you’re growing your network for Medicare and Medicaid, should you grow your ACA network the same way?

Well, it’s interesting because based on those conversations and strategies, we would recommend if the organization’s outlook is to consistently grow your product portfolios across all your lines of business, regardless if it’s an ACA qualified health plan product, Medicare Advantage product or other, we recommend investing in those resources on staff to actually have the capabilities in-house to build and grow your business.

Now it’s important to note in that same breath that if you’re at a race against the clock in terms of meeting commitments to enter a new market or to develop a new product, renting a network while also staffing for your business in the future to then convert that could be a wise decision as well.

Because at the end of the day, it’s really important to have a talented group of provider contractors to keep up with the ever-changing daily environment of turnover.

One of the second most important capabilities that we find issuers have the most significant investment in is service operations. Service operations can mean a number of different things from administering your call center to take calls from your members during the enrollment period, from November 1st to January 15th on an annual basis and also throughout the year to service your member questions as they dial in about the plan.

It could also mean such things as administering enrollment, and billing to making sure premium payments are being transacted correctly from the Federal Exchange, the state-based exchange, to the health plan, to making sure the transfer of funds is reconciled and appropriate for each member.While we understand there’s many different ways to administer your service operations and call center, what it really boils down to is cost and price.

The financial implications are very large because when you think about the ways you can administer such programs, you can build an organization in-house with onshore representatives that can be codified, dedicated resources for your teams. You could also make a decision to cross train 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 be very successful hiring temp staff, for certain peaks and valleys of busy seasons, such as enrollment from November 1st to January 15th.

In contrast to organizations who build and staff their teams in-house and onshore, we’ve also seen issuers be very successful by subcontracting offshore organizations to help stand up and stabilize their call center services.

Now while we recognize some issuers across the country prefer to have their operations in-house, we’ve also seen it be very cost favorable to utilize offshore resourcing to making sure you stay in budget.

 Depending how large a part service operations is to your plan strategy and to your brand recognition of your organization, we’ve also seen it be utilized as a large lever to pull in terms of financial savings and investment in other key capabilities. For example, by offshoring service operations to an offshore entity that could give my organization more dollars to spend and invest into network development or competitive intelligence.

Contrary to that, by investing into building my organization of service operations onshore and in-house, that could also increase the value of my brand recognition with the members and clients that I serve within the states that we participate in.

Another core competency that I personally think is one of the most important financial or non-financial decisions to invest into that an issuer can make is competitive intelligence.

Some issuers consider competitive intelligence as a one-time exercise that really drives their initial plan portfolio strategy and decision making. What it really should be considered as is an ongoing, iterative process that is always being looked at each month, throughout each year. I think the question that really needs to be asked to each issuer is: how much am I willing to spend to differentiate my product from the primary competitors in the marketplaces that I’m participating in? And it really boils down to a race against time and a race against filing and submissions to your state divisions of insurance as well as CMS.

There are certainly lots of benefits to subcontracting and partnering with an outside organization or consulting firm to help you codify your competitive intelligence strategy, including speed to market, and frankly, the confidence of harnessing your plan strategy for a new plan year, especially if you’re a brand new issuer doing this for the first time.

Now in that same breath, even being a brand new issuer, it could also be a very wise decision to invest in a homegrown team to build your operations and competitive intelligence from the ground up.

Having resources internally that’s familiar with how you transact your business day-to-day and execute operationally could also build value in other areas of your organization, such as working with your pharmacy team or your utilization or care management team, or even your product team to making sure that data being analyzed and collected is utilized appropriately that aligns with your values of the organization.

So even if you’re not close to the financial piece of the investment strategy of your organization, there are also many non-financial strategies as a part of this process.

Other non-financial strategies can also include establishing codified business processes. So from a competitive intelligence standpoint, that could be having a resource understanding how to access the SERFF filing system, download competitor carrier filings, extract needed documents within the scope of your strategic engagement, and help present that to your executive leadership team.

A process like that will help build knowledge within your organization and the knowledge base across your teams. That’s investment that’s not necessarily financially-based, but non-financially that grows as your business grows.

Having someone who truly understands your business process, who is versatile in these tools, that understands the content that’s being presented to executive leadership to make those informed decisions about your product would be highly valuable even in a non-financial sense. Now that being said, that person, that same resource who you’re training, to have that legacy knowledge to learn the book of business for your ACA portfolio, can also be that same person to understand state deadlines and understand the federal deadlines that are posed to your issuer.

All that wraps around the timing of how you deliver, capture and present your competitive intelligence.

Believe it or not, let’s walk it back. That actually is going to wrap the timeline around your network development. And delivery of service operations as well.

So, to round it all out, I think we can all agree that there’s lots of moving pieces and parts to the strategic planning process for any ACA issuer , new or existing.

So it’ll be very important to take a step back and to truly evaluate all components, financially and non-financially, prior to making planned portfolio strategies for your company.

We recommend evaluating the low and high end of the investment and the cost of each of your core capabilities.

And throughout the process of evaluating the low and high end of all your capabilities, regardless of network development, service operations, or competitive intelligence, always have a good pulse with your finance organization to truly understand the price and how the cost will impact internal operations. And what I mean by that is a lot of the capabilities that we’ve discussed today are priced differently, whether it’s a PMPM per member per month model, which arguably could be very hard to calculate and project from a future state perspective, not knowing how many members you may have in your products and plans, ultimately hindering and impacting 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. I don’t think anybody ever said the process was going to be easy. Always remember that you will have an opportunity to revise your plan strategy both financially and non financially for your next plan year ahead.

 While we are in plan year 2026, really encourage issuers to step back and to think about the markets that you’ll be most competitive in that would yield the most membership growth, not just for 26, but 27 and also plan year 2028. We do see that the marketplace is shifting quite rapidly , as CMS is releasing new federal guidance.

Please try to make some anticipated decisions or even assumptions as those pending decisions do come to life. That being said, thanks everybody for listening in today. Give us a like, give us a share, and we’ll see you next time.