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Health plans face a variety of challenges when it comes to contract modeling, negotiations, and reviews. A reliance on manual processes and disparate tools can make it difficult to accurately evaluate the financial impacts of new provider contracts.

In a recent webinar, healthcare industry experts shared their experiences working with health plans to improve accuracy and scalability in the contract review process. This blog highlights key insights from the virtual session that can help transform hypothetical conversations into actionable, data-driven negotiations.

5 Challenges Health Plans Face During Contract Negotiations

During the webinar, we polled the audience to better understand their major challenges. 80% of respondents said, “inefficiencies due to manual processes” were their primary concerns, followed by “lack of accurate insights into contract terms.”

What is the biggest challenge your health plan faces during contract negotiations?

• Inefficiencies due to manual processes (80%)
• Lack of accurate insights into contract terms (20%)

1. Manual Processes: Many health plans still rely on outdated tools, such as spreadsheets and pivot tables, to model contract scenarios. These manual methods are error-prone, time-consuming, and inflexible, leading to delays in negotiations and decision-making.

2. Lack of Accurate Insights: Without timely and accurate information, health plans struggle to understand the financial implications of certain contract terms. This includes challenges in analyzing how payment term changes affect reimbursements or savings, hindering their ability to make informed decisions.

3. Disjointed Systems and Data Sources: The workflows for contract negotiations often involve disparate tools and systems. These siloed environments make it hard to analyze and reconcile data, leading to unnecessary complexity when assessing contractual impacts.

4. Configuration Challenges: After contracts are finalized, health plans sometimes discover that the terms cannot be efficiently configured into their existing claims processing systems, causing operational bottlenecks and delays in implementation.

5. Lag Time Between Contract Finalization and Execution: There is often a gap between signing a contract and getting it fully operational. This lag time can result in delays in reimbursement or improper payments, creating friction between stakeholders.

These challenges not only create inefficiencies that cost time and resources but also compromise the accuracy of contract modeling.

What-If Modeling: Our Vision for a Better Solution

At HealthEdge Source™, our team is developing a solution to eliminate these challenges by bringing advanced technology and seamless workflows into the contract negotiation process. The HealthEdge Source What-If Modeling tool will allow health plans to envision, evaluate, and execute contract scenarios with unprecedented precision.

During the webinar, we demonstrated the solution and asked what participants found most valuable about the tool for their organizations. The top answers were:

• Real-time modeling of contracting change (33%)
• Comprehensive variance reports (33%)
• User friendly interface and ease of use (33%)

Increasing Contract Value for Health Plans 

• Automation and Real-Time Modeling: HealthEdge Source What-If Modeling is designed to replace manual processes with automated workflows, allowing health plans to build, test, and analyze contract configurations in minutes. Health plans will also be able to model complex scenarios in real time, significantly reducing the time and effort required to optimize contracts.
• Precision in Financial Insights: With penny-precise modeling for various reimbursement terms, health plans will be able to better anticipate the financial impacts of their contracts with greater accuracy, increasing confidence in projections and negotiations.
• Unified Platform for Disparate Processes: The new tool will bring together all critical functions—such as claims editing, pricing, and advanced analytics into a single platform. This will eliminate the need for multiple disparate systems and create a cohesive environment for assessing data and contracts.
• Self-Service Accessibility: With a user-friendly interface, the solution will empower contract negotiation teams to independently configure, compare, and adjust contract terms. Teams will be able to run “what-if” scenarios to evaluate potential impacts without relying on external support.
• Seamless Integration with Existing Systems: It will integrate smoothly as a modular component of  HealthEdge Source. It can also function as a standalone system, allowing health plans to leverage the tool within their existing ecosystems.
• Reduced Lag Time: The tool will directly convert modeled contracts into production-ready configurations, significantly reducing the time needed to operationalize agreements. This will help ensure accurate reimbursements from the start, while preventing downstream inefficiencies and rework.

HealthEdge Source What-If Modeling will support various complex contract structures, including carve-outs for specific services (e.g., ER visits) or alternative payment models like capitation. These features were developed to make it easier for health plans to negotiate and model deals that align with their financial objectives and operational capacities.

Supporting a Collaborative Approach to Change 

With the tool, health plans can bridge the gap between contracting and configuration teams, encouraging collaboration that helps determine whether contract terms are feasible. By identifying potential configuration issues during the modeling phase, health plans can minimize surprises and shorten implementation time. This approach can also help reduce provider abrasion and better inform contracting teams of the potential impact of custom configurations.

The Road Ahead for What-If Modeling

We invite you to watch the webinar recording to see a demo of the HealthEdge Source What-If Modeling tool in action and learn more about its functionalities. Discover how this innovative solution can transform your contract modeling process and deliver unparalleled precision and efficiency. Watch the webinar on-demand

Together, we can transform the way health plans approach contract modeling and create impactful results. If you’d like to contribute feedback or participate in our beta testing phase, we’d love to hear from you! Current customers can reach out to their Customer Success Managers for more inform

The complex landscape of state and federal healthcare regulations continues to evolve, requiring payers to invest in technologies that support their compliance efforts. Next-generation Core Administrative Processing Systems (CAPS) can be adaptable and scalable solutions that help provide resilience to market changes.

1. Coverage and Pricing Transparency

Regulations like the No Surprises Act (NSA) and Transparency in Coverage Final Rule focus on protecting health plan members from surprise out-of-network costs. Compliance requires that payers have access to accurate and updated pricing data in order to configure relevant services and deliver personalized information to members. To ensure compliance, health plans must be able to easily implement payment policies and deliver accurate and automated payments.

2. Interoperability and Prior Authorization

Increasingly, healthcare regulators are emphasizing the importance of interoperability and streamlined data sharing. Technology adoption skyrocketed after the COVID-19 pandemic, highlighting the need for integration between care management solutions and other health technologies. This includes leveraging Fast Healthcare Interoperability Resources (FHIR) across digital solutions to enable seamless and secure data exchange, as well as support compliance to the CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F).

2025 is also a year of preparation for health plans, as they improve prior authorization processes ahead of the finalized enforcement anticipated in 2027.

3. Increase Market Visibility with New Lines of Business

Health plan members—especially Medicare members—have a variety of choices when it comes to healthcare coverage. And their expectations for a health plan experience are high. To retain and attract members, payers are increasingly looking for ways to improve member experiences and build their trust.

Health plans have new opportunities to debut and expand lines of business. Whether to meet new demands from the Centers for Medicare & Medicaid Services (CMS) or take advantage of the rise of individual products and exchanges, health plans must stay on top of industry shifts to maintain their market positions. Updated healthcare CAPS can help payers bring new and differentiated benefits to the market in less time, giving payers more flexibility to meet a variety of member needs while remaining competitive.

Next-Generation CAPS Features that Support Compliance

These are just a few of the regulations health plans must abide by. Noncompliance results in expensive fines and increases abrasion with providers and members—especially when it comes to government lines of business. To meet these demands, payers are investing in digital technologies that can break down data siloes, deliver actionable insights, and streamline workflows to reduce manual operations.

Three key CAPS features that support regulatory compliance include:

Flexible configuration options. Payers must be able to easily configure payment policies for NSA, out-of-network, and emergency services based on member needs.

Automated claims adjudication. Flexible payment structures allow payers to make accurate and automated payments using accurate and timely data.

Personalized price comparison tool. A next-generation CAPS can empower payers to deliver personalized cost-sharing information to members.

Gain Access to Advanced Compliance Support with HealthRules® Payer

The HealthRules® Payer solution delivers the agility and adaptability payers need to maintain regulatory compliance, design and implement benefit plans, and serve the needs of members and stakeholders. Real-time API empowers payers to generate accurate claims details before scheduled services and increase payment automation.

HealthRules Payer, designed specifically for complex needs of healthcare payers, leverages the exclusive HealthRules Language™ to facilitate necessary configuration changes.

What else is HealthEdge doing to support health plans to maintain regulatory compliance? When it comes to the HealthRules Payer solution, our team is dedicated to monitoring state and federal regulations to identify new guidance that may impact our payer customers.

See how your health plan can leverage a modern CAPS to stay flexible and maintain a competitive edge in the healthcare market. Read our blog post to learn more: Leverage Next-Generation CAPS to Drive Competitive Advantage and Adaptability

The Centers for Medicare & Medicaid Services (CMS) has raised performance benchmarks for Medicare Advantage (MA) and Part D plans, raising the bar for achieving high Star Ratings. By excluding the lowest-performing plans from calculations, CMS has effectively raised the “cut points,” meaning that health plans must improve their performance across multiple measures to attain or sustain a 4+ Star Rating each year.

Adjustments to the 2025 CMS Star Ratings

Due to annual adjustments to CMS Star Ratings, health plans are operating in an increasingly competitive environment and must elevate their overall performance to succeed. Examples of the impact of the 2025 Star Ratings include:

• Decline in High-Rated Plans. In 2025, only 40% of MA plans with drug coverage earned four stars or higher, compared to 42% in 2024. Yet, when weighted by enrollment, about 62% of Medicare Advantage-Prescription Drug (MA-PD) enrollees are in plans with four or more stars, a drop from 74% the previous year.
• Fewer 5-Star Plans. Only seven contracts received a 5-star rating in 2025, down from 38 in 2024. This signals a dramatic shift for some health plans, potentially affecting new member enrollment and CMS payments.

The decline in quality ratings reflects that CMS continues to focus on improving overall healthcare quality rather than measuring the advances of individual health plans.

Implications of CMS Star Rating Changes for Health Plans

The 2025 Star Ratings pose several challenges for health plans:

• Difficulty and Volatility to Achieve High Star Ratings. Over 60% of cut points have risen, which means plans must improve performance across many measures to maintain ratings.
• Reduced Bonus Payments. Fewer plans are expected to achieve 4+ stars, limiting bonus payments and potentially funds for supplemental benefits, which are important for attracting and retaining members.
• More Focus on Member Experience and Care Management Quality. With increased emphasis on member service, access, and medication adherence, plans need more robust digital engagement and personalized care to enhance outcomes.
• Need for Real-Time Adjustments. Ongoing regulatory changes demand real-time analytics to identify care gaps and adjust strategies quickly.
• Competitive Landscape. Stricter standards may prompt members to switch to higher-rated plans, complicating the member retention efforts of health plans.

How GuidingCare® and Wellframe™ Support Star Rating Improvement

Health plans can enhance Star Ratings by focusing on improving member engagement and streamlining care management to improve the quality of care. By adopting next-generation digital solutions, health plans can improve performance through exceptional care coordination, personalized member outreach, and data-driven insights that directly address key Star Rating measures.

Care-Wellframe is an integrated solution that combines HealthEdge’s care management platform, GuidingCare, with the Wellframe digital member experience platform to transform how health plans serve their members. The following are key ways that the integrated Care-Wellframe solution helps health plans elevate performance:

Enhanced Member Engagement

• Personalized Digital Care:Wellframe’s mobile-first programs and daily checklists improve member engagement, satisfaction, and outcomes, which are vital to Star Ratings. By providing reminders and self-service content tailored to individual needs, Wellframe enhances engagement.
• Medication Adherence: Wellframe’s tools include medication reminders, improving adherence which directly impacts Star Ratings.
• Access to Care: Digital communication channels reduce barriers to quick intervention and enhance member satisfaction by enabling seamless access to care teams.

Streamlined Care Management and Coordination

• Efficient Workflows: Care-Wellframe centralizes member data to enable seamless coordination and reduce administrative burdens.
• Automated Processes: GuidingCare supports care teams by streamlining caseload management, assisting with adherence to CMS requirements, and facilitating consistent follow-ups with members.
• Integrated Communication: Care-Wellframe enables seamless communication among members, care teams, and providers. This facilitates proactive management of high-risk conditions, screenings, and overall care quality.
• Holistic Care Management: By integrating physical, behavioral, and social determinants of health (SDOH) data, Care-Wellframe provides a comprehensive view of member needs, supporting coordinated, whole-person care.

Continuous Quality Improvement

• Real-time Analytics: Care-Wellframe offers advanced analytics that help health plans track compliance and close care gaps.
• Predictive Tools: The solution’s predictive capabilities help identify high-risk members and prioritize interventions, helping care teams take the right actions to improve compliance with care plans and achieve better outcomes.

Digital care management supports improved member experiences,

better outcomes, and high Star Ratings.

With CMS raising the bar for Star Ratings, health plans need comprehensive, adaptive solutions to stay competitive. Leveraging Care-Wellframe’s next-generation capabilities enables health plans to continuously improve member care and engagement, putting plans in the best position to thrive and enhance competitiveness in the ever-evolving healthcare landscape.

See how your health plan can improve Star Ratings by improving member engagement and satisfaction. Read our blog, “How health plans can increase member satisfaction and engagement using digital care management.”

Visit healthedge.com to discover how the integrated Care-Wellframe solution can help your plan achieve its Star Rating goals.

Managing pediatric health within today’s healthcare landscape requires precision, innovation, and unwavering dedication to excellence. Health plans face the dual imperative of delivering tailored, preventive care to children while navigating complex regulations such as the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) program. This Medicaid requirement underscores a commitment to comprehensive and preventive services—ensuring children get timely screenings, diagnostics, and care to address their evolving health needs.

The Complexity of Pediatric Population Health Management

Pediatric health management goes far beyond routine check-ups. It requires tracking developmental milestones, maintaining vaccination schedules, and managing chronic conditions in children—a reality only magnified by new post-pandemic health challenges. Additionally, navigating the EPSDT program alongside state-level mandates adds layers of administrative complexity.

For health plans, addressing these diverse needs while ensuring compliance is no small feat. The stakes are high; at the core is the responsibility to deliver exceptional care while adhering to evolving regulation, improving outcomes, and maintaining operational efficiency.

GuidingCare®, a leading care management solution, is specifically designed to address these challenges. Equipped with tools that simplify complex workflows, support compliance, and unlock the power of data, GuidingCare empowers health plans to deliver smarter, member-first pediatric care with confidence.

How GuidingCare Transforms Pediatric Population Health Management

1. Streamlined Workflows and Automation

GuidingCare helps eliminate inefficiencies by streamlining the day-to-day processes critical to pediatric care. From automating EPSDT schedules to coordinating vaccinations, screenings, and follow-up appointments, this platform allows care teams to focus on what they do best—providing first-rate care. With reduced administrative burdens, workflows become faster and simpler, leaving more time for member engagement and proactive intervention.

2. Comprehensive Compliance Support

Meeting EPSDT and other pediatric regulatory requirements isn’t just a necessity—it’s a moral obligation to the youngest and often most vulnerable populations. The American Academy of Pediatrics (AAP) maintains a list of required and recommended pediatric interventions and updates the requirements annually. GuidingCare is updated annually to align with the AAP list.

GuidingCare simplifies compliance support by tracking and reporting detailed state and federal regulatory data in real time. Whether it’s managing diagnostic services, recommended treatments, or preventive screenings, the solution helps ensure nothing is missed. Through automated tracking, health plans reduce the risk of noncompliance while prioritizing the care that matters most.

3. Data-Driven Insights for Superior Outcomes

GuidingCare stands apart with its data-driven focus, helping health plans gain actionable insights into the needs and experiences of their pediatric populations. Powerful analytics help providers identify gaps in care, allowing care teams to address challenges sooner. By monitoring health trends and analyzing member data, GuidingCare makes it easier to tailor interventions to pediatric populations, delivering measurable results.

The platform also enhances family engagement with efficient digital tools, empowering caregivers and creating an ecosystem where preventive care thrives. With these capabilities, GuidingCare doesn’t just drive pediatric outcomes—it builds stronger relationships between members and their care teams.

Building a Healthier Tomorrow with Care Management

GuidingCare is more than a care management platform—it’s a gateway to healthier futures. By automating routine yet crucial tasks, supporting compliance with precision, and leveraging insights to inform better decision-making, GuidingCare equips health plans with the tools to elevate the health of the most vulnerable pediatric populations. It empowers organizations to go beyond maintaining compliance and instead become champions of accessible, preventive, high-quality care.

Learn more about how the Pediatric Population Health module from GuidingCare can help your health plan improve outcomes and comply with EPSDT requirements. Download the data sheet: Addressing the Unique Challenges of Pediatric Population Health

Navigating healthcare regulations and compliance is an intricate challenge. To optimize the use of healthcare dollars and more effectively address population health, The Office of the National Coordinator for Health Information Technology (ONC) is passing regulations to support the improvement of interoperability and prior authorization operations. To comply with these new rules, health plans are turning to advanced, integrated technologies.

This forward-looking blog dives into the most compelling regulatory trends of 2025 and changes on the horizon, offering actionable insights to help organizations adapt and thrive. By the end of this post, you’ll better understand what’s coming and how you can actively prepare your team and strategies.

Trend 1: Interoperability Redefines Healthcare Connectivity

Across the healthcare industry, siloed health information prevents health plans and providers from anticipating member needs and offering proactive interventions. In the years since the COVID-19 pandemic, the healthcare industry has seen more widespread use of digital health tools, and the integration of these tools into care management.

For health plans, leveraging Fast Healthcare Interoperability Resources (FHIR) offers a path forward—but adoption won’t be without challenges.

Key Interoperability Milestones

2025 is shaping up to be a critical year for assessing improvements in interoperability and payer technology adoption as part of regulatory trends in 2025.

By January 2027, APIs (Application Programming Interfaces) facilitating real-time data exchange between patients, providers, and payers will become enforceable, setting a new standard for seamless information sharing.

The Problem With Siloed Data

The lack of accessible, unified healthcare data presents hurdles to both operational efficiency and patient care. Without an intentional focus on interoperability, the growth of technology use at health plans and for members can lead to internal data silos. By themselves, these pockets of information can’t tell the whole story—but collectively they could help health plans and providers better understand and anticipate the needs of various populations.

How to Prepare:

• Partner with vendors offering FHIR-compliant APIs to centralize your data strategy.
• Conduct annual interoperability assessments to ensure systems are scaling effectively to meet compliance.

Strategic Advantage of Interoperability

Beyond mere compliance, interoperability lays the groundwork for comprehensive analytics and improved member engagement, making it a long-term investment in competitive differentiation.

Trend 2: Modernizing Prior Authorization Processes

Another significant aspect of regulatory trends in 2025 is the modernization of prior authorization processes. Prior authorization workflows remain outdated, heavily paper-based, and inefficient. The lack of electronic communication not only delays care but also wastes resources for providers and payers.

Key Prior Authorization Milestones

• 2025 will serve as a prep year as health organizations monitor the progress of prior authorization improvements ahead of finalized enforcement in 2027.
• 2026 will focus on API development tailored to new advanced Explanation of Benefits (EOB) regulations.

Shifting Toward Real-Time Decisions

Mandatory FHIR APIs and shortened authorization turnaround times will accelerate data tracking and approval workflows. However, many organizations remain underprepared for these rapid shifts.

Solutions to Consider:

• Equip your team with tools that support real-time communication between health plans and providers.
• Invest in AI-powered automation to process authorizations quickly and with greater accuracy.

Long-Term Impact of FHIR APIs:

Payers aligning their tech stack with FHIR standards stand poised to rapidly enhance provider relations, reduce administrative costs, and ultimately deliver better member experiences.

Trend 3: Data Privacy and Artificial Intelligence (AI)

The increased adoption of disparate technology systems leaves the door open for data privacy and security risks. But AI is entering the healthcare regulatory space, revolutionizing how fraud, waste, abuse (FWA), and early spending trends are identified. Health plans can leverage AI features like predictive analytics and natural language processing to identify waste and potential fraud—leading to cost savings and fewer manual reviews.

Privacy Implications

With healthcare data becoming more interconnected and accessible, regulations must evolve to protect sensitive information from breaches. Health plans must address questions such as:

• Where is sensitive health data stored?
• Who can access specific data?
• How long is the data protected once shared externally?

To maintain data security, health plans can invest in data encryption and cybersecurity infrastructure for their entire organization. They can also help ensure compliance readiness by adopting technology solutions with natively embedded data security and privacy measures.

Opportunities With AI:

Beyond security concerns, AI presents tools for streamlining compliance processes, enhancing analytics-driven strategies, and improving fraud detection. Read our recent blog to see 6 key ways AI can improve payment integrity at your health plan.

Trend 4: Transparency and Enrollment Regulation

Increasing regulatory scrutiny on enrollment and data collection procedures demands health plans revisit how they handle and present information to consumers. Advanced Explanation of Benefits and the No Surprises Act are paving the way for heightened transparency in billing and claims processing.

Upcoming Transparency and Enrollment Guidelines

• Automated Solutions for Comprehensive Enrollment Oversight.
• Addressing redundancies to streamline enrollment workflows.
• Clarity on AI’s role in administering and standardizing enrollment regulations.

Supporting Health Equity

Regulation updates also emphasize reducing barriers to care—be it geographic, financial, or systemic. Responding proactively and fostering a “patient-first” approach will be integral for retaining member trust.

Action Plan for Health Plan Executives

Invest Early in Innovation

Whether you’re considering the latest FHIR API or exploring AI-driven fraud detection, early adopters will capitalize most effectively on these opportunities.

Build Strong Vendor Relationships

Strong partnerships with tech providers will ensure efficient deployment of compliant solutions, keeping operations well ahead of evolving regulations.

Develop a Long-Term Roadmap for Readiness

Map out regulatory milestones through 2028, with annual evaluations to ensure progress toward compliance and interoperability goals.

By taking a strategic, forward-looking approach, organizations can transform compliance into an operational strength.

Driving Progress through Proactive Adoption

The future of healthcare compliance lies in proactive innovation. The regulatory changes on the horizon offer payers a unique opportunity to reimagine processes, adopt cutting-edge technology, and position their organizations as leaders in the industry.

By prioritizing interoperability, leveraging AI responsibly, and addressing the critical areas of data transparency and security, health plan leaders can achieve more efficient operations while keeping patient outcomes at the center of their strategies.

Want to stay ahead of regulatory trends in 2025 and maintain your market position? Download the complimentary HealthEdge Annual Payer Market Planning Report 2025.

Section Guide:

Key investments for member engagement

Overcoming barriers to member satisfaction

7 Key strategies for boosting member engagement

Impacts of transforming member engagement

Key investments for member engagement

Today’s healthcare consumer expects seamless, digital-first interactions with their health plan. They demand transparency, self-service options, and personalized experiences—which required a departure from traditional in-person and telephonic member engagement methods. In addition to improving satisfaction and clinical outcomes, maximizing member engagement can enable health plans to meet strategic business goals.

In the HealthEdge® Annual Payer Market Planning Report 2025, we uncovered the key areas health plans are focusing on to enhance member engagement. Improving health equity and addressing disparities came in as the top priority for health plan executives (59%). The dual focus on equity (59%) and transparency (51%) signals a broader commitment to bridging care gaps while building trust. Plans that prioritize equitable access to information and services position themselves as true partners in health.

To achieve these goals, payers are investing in the following solutions to help educate and empower members while streamlining processes for payers and providers:

• Member Portals – Centralized digital hubs that give members easy access to their benefits, claims, and personal health information.
• Mobile Apps – User-friendly mobile apps designed to bridge gaps between members, payers, and providers by enabling seamless outreach and communication.
• Enhanced Member Service Centers – Deliver personalized, real-time support to resolve issues effectively.
• Overcoming Barriers to Member Satisfaction

Despite advancements in member engagement technologies, several challenges still inhibit scalability and member impact:

Legacy core administrative processing system (CAPS) can cause data sharing bottlenecks that create inefficiencies and frustrate members with inconsistent, disconnected healthcare experiences. Health plans without access to updated, integrated data and analytics will be stuck reactively addressing gaps in care.

Social determinants of health (SDoH) add layers of complexity to healthcare access and engagement, making one-size-fits-all solutions ineffective. Tailoring member engagement efforts to diverse populations is critical to earn members’ trust and build lasting relationships. But gathering and analyzing the data necessary to provide a personalized experience can be challenging with outdated and disparate systems.

In addition to data access and analysis, health plans and members are increasingly concerned about data privacy. While members expect tailored interactions, concerns about data usage and security persist. Regulations from the Centers for Medicare and Medicaid Services (CMS) encourage health plans to be transparent about data use and security measures to reduce cybersecurity risks.

Health plans must adopt modern technology to make healthcare more accessible and empower members to engage with their plans and take an active role in their wellness.

[H2] 6 Key Strategies for Boosting Member Engagement

To meet member demands and overcome barriers to member engagement, health plan leaders are developing proactive, technology-forward strategies. Based on their priorities for 2025 and beyond, we suggest 6 strategic solutions health plans can adopt to meet member engagement goals.

1. Enhance Accessibility with Self-Service Tools

Customer experience has evolved beyond face-to-face interactions, with technology playing a crucial role in customer service. This shift aligns with consumer preferences —an estimated 73% of customers prefer the ability to resolve issues on their own.

According to the Market Planning Report, 45% reported the “inability to self-serve” was one of the biggest hurdles to member satisfaction. Providing members with user-friendly tools can help give them control over their health and make more informed care decisions. Platforms like GuidingCare® and Wellframe integrate personalized health information with streamlined care workflows, helping members manage their health and benefits from a mobile device.

Self-service tools, such as member portals, digital care programs, and care management, allow members to easily:

• Check benefits and coverage.
• Access educational content tailored to their health conditions.
• Reach out to care teams and health plan representatives.

Where can we go next?

Streamlining Member Touchpoints: Focus on reducing friction in member interactions, whether digital or in-person, by eliminating silos and simplifying processes.

2. Personalize the Member Journey

Each member has unique health and wellness needs, and engagement preferences. Advanced artificial intelligence (AI) and integrated data analytics enable health plans to offer personalized health recommendations and prioritize member outreach.

AI-powered tools are helping plans stay ahead of industry shifts by anticipating member needs, simplifying care management, and creating more personalized experiences. By automating workflows, these solutions help reduce inefficiencies and reallocate vital resources. In fact, AI-enabled solutions are well received among consumers— 65% expressed a preference for health plans that leverage AI to create a more personalized experience for members.

Leveraging insights from platforms like Wellframe, health plans can suggest tailored care programs based on a member’s demographics, health goals, and survey responses—improving member engagement and satisfaction.

Where can we go next?

Deepening Personalization Through Data: Use AI and advanced analytics to deliver relevant, contextual information to improve member experiences while maintaining transparency around data use.

3. Address Health Equity

Closing the health equity gap is one of the most critical initiatives for health plans. This involves ensuring that all members, regardless of socioeconomic background or geographic location, have equal access to high-quality care. By investing in digital health management solutions, health plans can expand their reach to underserved populations.

Learn more about how digital care programs can improve outcomes for high-risk maternity populations by reading our blog, Reduce Maternal Morbidity Risk for Black Women with Digital Care Management.

Where can we go next?

Embedding Health Equity into Core Strategies: Ensure your health plan’s member engagement strategies account for potential disparities and help create equitable experiences for all members.

4. Simplify Healthcare Communications and Information Access

Healthcare data is often difficult for members to understand, which contributes to confusion and frustration. There are a few ways health plans can help members better navigate the healthcare system. Health plans should consider making the member communications and educational materials easier to understand and more accessible.  Leverage plain language, visual aids, and interactive elements to explain complex health information. This approach can help members feel more confident in managing their health and make informed decisions.

Health plans can also focus on simplifying access to key healthcare and coverage documents, including:

• Real-time benefits information
• Detailed explanations of out-of-pocket costs
• Resources for making better health and financial decisions

Clear and accessible information about healthcare coverage and access builds trust between health plans and their members. It also empowers members to make more informed and confident decisions about their health .

Where can we go next?

Promote Health Literacy and Improve Healthcare Navigation: Develop member communications and documents with the intent of improving health literacy. This helps members understand what to expect when it comes to making appointments and using their coverage.

5. Streamline Claims and Administrative Processes

Efficient claims processing ensures that members receive timely and accurate reimbursements, which directly impacts their perception of care and coverage. When claims are processed smoothly, members experience fewer billing errors, delays, and frustrations, leading to a more positive overall experience.

Transparency in billing and claims processing is equally vital, as it helps members understand their financial responsibilities and prevents surprises. By providing clear, detailed explanations of benefits, coverage, and out-of-pocket costs, health plans can build trust and reduce anxiety about unexpected bills. This transparency fosters collaboration and leads to stronger partnership, ultimately improving health outcomes.

Where can we go next?

Streamline Claims and Simplify Billing: Implement efficient claims processing and enhance transparency in billing for accurate reimbursements and clear communication. Utilize advanced solutions to manage complex needs and ensure a seamless healthcare experience for members.

6. Leverage Mobile Apps for Omnichannel Engagement

Mobile apps are more than just convenient—they’re essential. Up to 64% of health plan members are comfortable using mobile apps to engage with their health plans. This gives  health plans more opportunities to learn about members’ unique needs and provide proactive support. Integrated digital health apps combine communication tools (such as HIPAA-compliant messaging) with biometrics and activity tracking to keep members engaged and on track with their health goals.

Wellframe, for example, creates an average of 34 digital touchpoints per member per month through the mobile app. Touchpoints include a combination of high-value interactions such as:

• Dismissing medication reminders
• Logging biometrics or physical activity
• Completing digital surveys

Where can we go next?

Building Proactive Engagement Models: Shift from reactive service to proactive outreach, using insights to address potential engagement gaps before they become issues.

Impacts of transforming member engagement

When health plans integrate intelligent engagement strategies, the impact is clear:

• Higher Member Satisfaction – Clear communication, self-service tools, and accurate claims lead to decreased frustration.
• Improved Health Outcomes – Care management workflows and personalized actions encourage better adherence to care plans.
• Greater Retention – Positive experiences cultivate loyalty, ensuring members remain with their health plans longer.

By meeting members where they are and aligning strategies with consumer expectations, health plans have an opportunity to redefine their relationships with members. The integration of innovative technologies and personalized experiences will be critical in 2025 and beyond, allowing health plans to differentiate themselves in an increasingly competitive landscape.

Are you ready to make member engagement your competitive advantage?