From Friction to Fulfillment: Leveraging AI to Boost MA Plan Success

As Medicare Advantage (MA) enrollment soars, health plans face growing pressure to streamline the member experience while keeping costs in check and boosting Star ratings. That means going beyond basic member portals or call centers. Today’s older adults increasingly expect convenient, personalized, and immediate support for everything from benefit questions to guidance on healthy living.

This is where an AI-driven solution—such as Helen from GetSetUp—can help. Helen offers an “Apple Genius” style concierge for older adults, providing easy access to resources, benefits, and personalized coaching on how to live healthier, more independent lives. By leveraging AI, MA plans can continuously reduce friction, elevate satisfaction, and help members better manage their care.

Friction Points in the Member Experience

Older adults often run into frustrations when interacting with health plans:

• Complex Program Navigation: Many members struggle to identify which benefits—like vision, dental, or fitness—apply to them or how to enroll.
• Prolonged Call Center Wait Times: When members can’t find answers online, they turn to phone support. Lengthy hold times can lead to dissatisfaction and discourage preventive care.
• Limited Digital Tools: Some MA plans rely on outdated portals or limited FAQ pages that fail to address members’ real-life questions.
• Confusion Over Supplemental Benefits: Even when plans offer robust benefits (e.g., transportation, OTC allowances), many older adults remain unaware or find the sign-up process daunting.

These friction points reduce plan loyalty and can diminish Star ratings if they affect CAHPS measures around member satisfaction. The good news? Advances in AI and chat-based assistants directly target these pain points.

Introducing Helen: A Concierge for Healthy Living

GetSetUp’s Helen is an AI assistant trained with years of insights on how older adults learn and engage with digital tools. She acts as a comprehensive guide, offering:

1. On-Demand Answers: Members can ask Helen about coverage, preventive care scheduling, or healthy lifestyle tips and get instant responses.
2. Personalized Prompts: Helen uses a library of conversation starters—based on common health inquiries and life scenarios—to proactively guide members, reducing guesswork.
3. Resource Discovery: From mental health sessions to SilverSneakers gym classes, Helen can direct members to the best-fit programs—and even remind them about enrollment steps.
4. Support on Their Terms: Whether through chat, voice, or a mobile-friendly interface, older adults can engage with Helen using whatever format feels most comfortable.

By reducing complexity and offering individualized coaching, Helen acts like the “Apple Genius” for Medicare Advantage—leading members step by step toward the resources that keep them independent and healthy.

How AI Solutions Boost Star Ratings and Retention

1. Enhanced Member Engagement & Satisfaction

• Fewer Complaints: Quick, helpful AI responses reduce the need to call member services—leading to more positive experiences and fewer complaint-driven disenrollments.
• Proactive Health Actions: With personalized nudges, members are more likely to book screenings or annual wellness visits. These boosts can improve measures on HEDIS and CAHPS, key components of Star ratings.

2. Efficient Problem Solving

• 24/7 Support: Members can get help anytime, not just during call center hours—greatly improving accessibility and trust.
• Less Manual Admin: Each routine question handled by Helen means fewer calls or forms to process manually, helping plans reduce administrative overhead.

3. Higher Utilization of Supplemental Benefits

• OTC and Wellness: By guiding members to available benefits—like meal delivery or transportation—Helen ensures more people use them, increasing both satisfaction and perceived plan value.
• Cost of Care Reduction: People who effectively leverage these benefits often stay healthier and avoid costly medical episodes, improving outcomes and reducing overall spending.

4. Data-Driven Improvements

• Behavioral Insights: AI interactions can help MA plans learn what members frequently ask about. Plans can tailor benefits or create targeted campaigns based on real-time usage trends.
• Refined UX: Over time, gleaned data can inform continuous improvements to digital portals, resulting in even smoother member experiences.

Scaling the “Apple Genius Bar” Experience

Apple’s Genius Bar is synonymous with customer service that’s friendly, expert, and personalized. Bringing that ethos to Medicare Advantage might seem lofty, but AI solutions like Helen make it achievable:

• Personalized Scripting: Helen can adapt how it speaks to different member profiles, acknowledging unique needs such as hearing impairment or language preferences.
• Guided Triaging: Before escalating to a live agent or nurse line, Helen gathers essential details to ensure that human teams focus on complex tasks rather than repeating standard info.
• Emphasis on Education: Through regular “check-ins,” an AI can prompt members about important screenings or immunizations—driving better care outcomes.
• Community Integration: Beyond coverage questions, Helen can recommend local community centers, peer-support groups, or GetSetUp classes—fostering social engagement and mental well-being.

This concierge-style approach sets the stage for better health literacy, improved retention, and a stronger bond between member and plan.

Real-World Example

Mary, a 71-year-old who recently joined an MA plan, feels overwhelmed by new coverage details. Rather than calling a helpline, she chats with Helen. The AI quickly explains her OTC benefits and how to order supplies online, points her to a local fall prevention class, and even sets a reminder for her annual wellness exam—all in one session.

What would have been multiple phone calls and possibly months of confusion becomes a seamless, empowering experience, boosting Mary’s confidence in her MA plan. Over time, that translates to higher retention and a good chance of positive CAHPS survey responses.

Next Steps for MA Plans

1. Identify Key Pain Points: Examine call center logs, survey data, and Star rating components to see where friction is highest.
2. Pilot an AI Assistant: Start with a small cohort of members or a specific benefit (e.g., mental health, medication management) and measure improvements in satisfaction and usage.
3. Refine & Scale: Use analytics from AI interactions to fine-tune prompts, add new content, or expand to additional plan features.
4. Integrate Human Touch: AI works best hand in hand with human support. Ensure smooth escalation paths for complex issues that require a member rep or clinical team.
5. Promote Awareness: Communicate the AI’s availability. Encourage members to “ask Helen” for benefit guidance and see how quickly they come to prefer self-service.

Medicare Advantage plans striving to reduce member friction and improve Star ratings must look beyond traditional solutions. AI-driven assistants like Helen can serve as a concierge, anticipating members’ needs and guiding them toward the benefits that keep them healthy, informed, and satisfied.

From answering benefit questions in real time to nudging older adults about preventive care, AI can drive measurable improvements in engagement, retention, and cost savings. It’s a transformative approach that aligns perfectly with modern expectations for convenient, personalized service—setting the stage for future success in a competitive MA landscape.

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