What Medicare, Medicaid, and Dual Eligible Members Want from Their Health Plan: Key Findings from the HealthEdge® 2025 Consumer Study
In today’s evolving healthcare landscape, understanding what members want and need is more important than ever. To uncover those insights, HealthEdge conducted its 2025 Healthcare Consumer Study, collecting feedback from more than 4,500 healthcare consumers nationwide.
This summary focuses on a crucial subset of that group: the 2,210 respondents enrolled in Medicare, Medicaid, or those who are Dual Eligible. These populations face more complex health challenges and greater systemic barriers, making their experiences critical for health plans aiming to improve satisfaction, loyalty, and retention.
Why Being a Partner in Care Matters for Health Plans
Health plans that go beyond paying claims and act as partners in care to their members are rewarded with stronger member relationships.
Survey data shows that:
- 60% of Dual Eligible,
- 54% of Medicaid, and
- 53% of Medicare members already see their plan as a care partner, not just a payer.
This shift delivers measurable business benefits:
- 52% of partner-oriented members say they’re unlikely to switch plans (vs. 40% of payer-oriented members).
- 75% would recommend their plan to others (vs. 58%).
4 Common Member Pain Points and Barriers to Care
Despite growing digital engagement, members still face persistent challenges with cost and access to care.
- High Costs - 17% of Medicare and Medicare Advantage members cite insurance premiums and out-of-pocket costs as a primary concern.
- Limited provider choice - 15% of Medicaid and 13% of Dual Eligible members are frustrated by narrow provider networks, which can make it harder to access timely care.
- Surprise billing - Unexpected medical bills are a significant issue for 31% of Medicaid members, leading to confusion and financial stress.
- Access delays - 43% of Medicaid members say they “never” or only “sometimes” receive timely healthcare, compared to 31% of the general member population, putting them at greater risk of complications later in life.
What Members Want Most from their Health Plan Experience
When asked which innovations would most improve their experience, members ranked the following offerings as their top choices:
- 24/7 access to knowledgeable support reps
- Greater focus on preventive care and wellness
- Proactive, transparent communication about available resources
Digital tools and AI-driven solutions play a growing role in meeting member expectations for more accessible and personalized healthcare conversations.
Mobile app usage is rising across member populations: 81% of Medicaid, 77% of Dual Eligible, and 68% of Medicare members say they already use or are open to using mobile apps for managing benefits and care. While AI adoption is still emerging among these populations (25% Medicaid, 21% Duals, 16% Medicare), members show strong interest in AI-powered assistants that offer tailored support and insights.
Better Serve High-Risk Members with AI-Powered Insights
To better serve and retain Medicare, Medicaid, and Dual Eligible members, health plans must shift from being seen as just a payer of claims to a true partner in care. Health plans that deliver personalized support, clear communication, and timely access to care earn more trust and loyalty.
By combining integrated data, AI-driven insights, and a human-centered approach, health plans can improve care coordination and scale outreach that drives member satisfaction and long-term retention. This is not just a member experience strategy; it’s a growth strategy.
To explore the full findings and actionable insights from the 2025 HealthEdge Consumer Study, watch an on-demand recording of the Association of Community Affiliated Plans (ACAP) webinar, From Payers of Claims to Partners in Care.
