AI in 2026: Are Health Plans and Members Aligned on the Future?
Health plans are racing ahead with artificial intelligence (AI). Members are moving more cautiously. In 2026, the question is no longer whether AI will shape healthcare. It’s whether payers and members are aligned on how it should.
According to the 2026 Healthcare Payer Survey Report from HealthEdge®, 94% of payers are either live with or actively adopting AI, and nearly half (47%) report widespread or departmental use. But as adoption accelerates inside health plans, a critical question emerges:
Are members ready for the AI-powered experiences payers are building?
And more importantly, what will it take for health plans to succeed with AI in 2026 and beyond?
Where the Industry Stands: AI Is Moving Fast
The survey data makes one thing clear: AI momentum is strong among healthcare leaders.
- 47% of executives reported widespread or departmental use.
- Mid-size payers (supporting 2-10M lives) are 30% more likely than their peers to report widespread adoption of AI.
- Executive leaders report the highest confidence in AI maturity, with 31% claiming widespread adoption of AI vs. only 3% of operational and regulatory leaders.
Health plans are not just using AI to improve internal efficiency—they are applying it to member-facing experiences. Member engagement is tied with claims processing for the highest reported use of AI, signaling that personalization and digital interaction are central to payer strategy. Yet adoption alone does not define readiness.
Where Is AI Being Applied Most Often?
AI Adoption Is Outpacing Governance
While nearly all payers are deploying AI, only 31% report having fully defined governance models and controls in place.
This governance gap introduces strategic tension. AI is being deployed into high-impact workflows (claims adjudication, prior authorization, engagement), but oversight frameworks are still maturing.
Without governance clarity, transparency, and cross-functional alignment, even well-intentioned AI initiatives risk eroding trust or creating compliance exposure. When trust begins to erode, the effects don’t stay contained within a single workflow. Member satisfaction declines. Call center volumes increase. Complaints rise. And during open enrollment, members who feel uncertain or unsupported are more likely to explore alternatives.
Over time, that erosion shows up in retention rates, HEDIS and Star ratings, and organizational growth. AI initiatives that lack transparency or governance can unintentionally create the very friction they were meant to eliminate.
This brings us to the member side of the equation.
The Member Perspective: Open to AI, But Not Fully Convinced
While payer adoption is accelerating, member adoption is more measured.
According to the 2025 HealthEdge Healthcare Consumer Study:
- Only 21% of members report using AI-powered tools offered by their health plan
- 58% have not used AI tools
- 21% are unsure whether they’ve used AI tools
- Among non-users, 64% say they would be open to using AI tools in the future
Members are not rejecting AI. But they are not embracing it at the pace at which payers are deploying it.
When asked what types of AI tools they would most likely use, members expressed strong interest in:
- Chatbots and virtual assistants
- Personalized education and resource recommendations
- Cost-saving benefit and provider tools
- Health tracking and coaching tools
The demand signal is there. But so is hesitation.
The Trust Barrier: What Members Need
While 23% of members report no concerns about AI use by their health plan, the majority cite specific issues:
- 26%: Quality and accuracy
- 20%: Privacy
- 20%: Data security
- 11%: Not knowing how to use it
More revealing is what would increase consumers’ comfort, as shown in this chart. This is where the readiness gap becomes clear. Payers are accelerating deployment. Members are asking for transparency and guardrails. Adoption appears to be ahead of trust.
Where Payer and Member Readiness Diverge
Comparing the two surveys reveals three critical gaps.
1. Operational Readiness vs. Experiential Readiness: Payers are embedding AI into claims, care management, and engagement workflows. Members are still deciding whether AI improves or complicates their experience.
2. Efficiency vs. Confidence: Health plans prioritize efficiency, automation, and cost containment. Members evaluate AI through accuracy, fairness, privacy, and clarity.
3. Investment vs. Communication: Payers are investing heavily in AI capabilities. Members are asking to be informed when AI is used, and why. This is not a technology gap. It is a perception gap.
What Will It Take to Succeed with AI in 2026 and Beyond?
The data from both surveys point to four imperatives for health plans:
- Strengthen governance alongside deployment. AI maturity must include oversight, ethical controls, and auditability.
- Make AI visible and explainable. Members want transparency, not hidden automation.
- Focus on high-friction use cases. Cost clarity, claims accuracy, and benefit navigation are where AI can immediately build trust.
- Balance AI and human collaboration. Technology should reinforce—not replace—the human relationship between a health plan and its members.
The Bottom Line: Readiness Needs to Even Out
AI adoption across health plans is accelerating. But technology readiness and trust readiness are not the same thing.
The fact is: Members stay with plans they trust. They leave when they don’t. If AI makes it easier to understand benefits, resolve a claim, or get timely support, it strengthens that trust. If it feels confusing, inconsistent, or opaque, it creates friction, and that friction shows up during open enrollment.
The risk isn’t that health plans are moving too fast with AI. The risk is deploying it in ways that outpace governance, transparency, and operational alignment. That’s where execution matters.
At HealthEdge, we focus on embedding AI directly into core workflows — not as a bolt-on, but as part of how claims are adjudicated, care is managed, and payment integrity is enforced. That means building governance into the system, designing for auditability, and aligning automation with real operational outcomes.
Download the Full Research Reports
To explore the complete survey findings, including adoption trends, governance maturity insights, and detailed consumer sentiment, download the full report, The Great Rebalancing: Inside the New Realities Shaping Health Plan Performance, 2026 Healthcare Payer Survey Report.
