How Health Plans Can Scale Engagement with AI (and Why It Matters)
Healthcare consumers are raising the bar for what they expect from their health plans. Members want experiences that are personalized, convenient, and responsive. Meeting these expectations across large, diverse member populations is a growing challenge for health plans. That’s where artificial intelligence (AI) can make a meaningful impact.
By using AI to scale member engagement and streamline interactions, health plans have the opportunity to deliver more relevant, proactive, and efficient experiences, without adding administrative burden. Yet according to the 2025 Healthcare Consumer Study from HealthEdge®, only 21% of healthcare consumers say they’ve used—or even know they have access to—AI-powered tools from their health plan.
These survey findings show a big opportunity for health plans. Consumers are ready to embrace AI assistance—but health plans must make it accessible, trustworthy, and demonstrate its value. Below, we explore what the data tells us, the strategies health plans can use to meet rising expectations, and why HealthEdge is uniquely positioned to help with solutions like GuidingCare® and AI-powered workflow tools.
Survey reveals strong interest in AI, despite low user adoption
The 2025 Healthcare Consumer Study highlights a clear disconnect between interest and usage. Only 1 in 5 members have already used an AI tool offered by their health plan—but 64% say they’re open to it.
The members interested in these tools place particular value on AI features like:
- Chatbots, virtual assistants, and coaches (94%)
- Personalized health education and resource suggestions (92%)
- Cost-saving benefit tools and provider recommendations (90%)
- Tracking health goals and progress (86%)
So why is adoption of AI tools still so low?
The answer lies in how health plans have historically implemented AI. To date, most AI investment has focused on supporting backend operations, such as improving claims processing, ensuring payment accuracy, and detecting fraud. While these applications are important, they’re often invisible to members.
Even when health plans do use member-facing AI-driven tools, they may not provide information on the technologies behind AI or machine learning (ML) tools. As a result, healthcare consumers are largely unaware of how AI is currently being used across the industry and what value it brings—or could bring—to their experience.
To bridge this gap, health plans need to shift more of their AI focus to member-facing tools that directly enhance engagement, education, and care navigation—which impact health plan costs and operational savings.
Consumer skepticism remains a barrier to AI adoption
Despite their openness to using AI, many healthcare consumers still have reservations. The survey uncovered several key concerns:
- 26% worry about the quality and accuracy of AI-generated health information
- 20% are concerned about data privacy
- 20% cite data security as a barrier to using AI tools from their health plan
To overcome this skepticism, healthcare consumers said health plans could earn their trust by increasing transparency on how and when AI tools are being used, as well as providing data privacy certifications and explanations on how personal data is used and protected.
Ultimately, health plans that take a thoughtful, transparent approach can turn AI from a point of hesitation into a driver of member confidence.
Why now is the right time for AI-powered member engagement
There are several industry trends converging to make AI a strategic priority. Consumer expectations have shifted—they want self-service tools, quick answers, and proactive engagement. At the same time, health plans face rising cost pressures and administrative complexity. AI-driven tools can help summarize and surface key member information to help providers prioritize member outreach.
Evolving healthcare regulations aim to encourage payers to streamline workflows, improve data transparency, and enhance proactive care coordination and delivery. AI-powered solutions can help reduce administrative burden while giving payers more effective ways to engage and retain members.
By deploying AI thoughtfully, health plans can meet members’ expectations and operational needs at the same time.
HealthEdge solutions for AI-driven engagement
HealthEdge is leading the way in delivering AI-powered tools that help health plans transform care and services, while keeping member needs at the center.
Enterprise AI strategy for health plans
At HealthEdge, our comprehensive approach to AI focuses on using these tools responsibly, building trust, and layering capabilities incrementally. This ensures health plans don’t treat AI as a bolt-on feature, but as a core capability embedded across care and operations.
GuidingCare leverages AI for care coordination
GuidingCare uses AI to simplify complex care pathways: triaging cases, identifying care gaps, and summarizing key clinical data. This allows care teams to focus on high-impact interactions while AI handles routine administrative details. It drives both efficiency and personalization in member outreach.
Wellframe’s AI-driven member engagement
Wellframe leverages AI to transform member engagement, creating concise, actionable summaries of member data. This empowers care teams to deliver personalized, timely support, focus on high-impact interactions, and drive greater efficiency and improved member outcomes.
Transforming operations with HealthRules® Payer
Within HealthRules Payer, our core administrative processing system (CAPS), AI helps payers streamline and accelerate workflows, reduce administrative costs, and modernize member experiences.
AI-powered workflow in HealthEdge Source
HealthEdge Source integrates machine learning to improve payment integrity and claims processing. AI-driven analytics detect patterns, highlight high-risk claims, and enable faster, more accurate reviews, improving the overall member experience.
Intelligently merge data with AI-powered Provider Data Management
The HealthEdge® Provider Data Management solution leverages advanced AI that enables payers to develop a single source of truth for provider data. AI-driven data ingestion and matching help ensure accuracy, consistency, and complete data lineage across all health plan operations.
Dig deeper on the benefits of AI-powered tools
The 2025 Healthcare Consumer Survey shows that healthcare consumers are ready for more intuitive, digital-first engagement powered by AI, but they also want reassurance, clarity, and trust.
HealthEdge leads the way, embedding AI into core platforms like HealthRules Payer, HealthEdge Source, HealthEdge Provider Data Management, GuidingCare, and Wellframe to empower health plans to modernize operations and meet rising expectations. By focusing on transparency, accuracy, and member value, health plans can build confidence while scaling their impact.
To explore these insights and more, download the full 2025 Healthcare Consumer Survey report here.
