According to J.D. Power, only 38 percent of first-year Medicare Advantage members say their insurer meets their service expectations. The most common challenges they cite are understanding their benefits, finding in-network doctors, navigating deductibles, and managing prior authorizations. Many of these questions start with a phone call to member services.
Most inbound member services volume is predictable. Eligibility verification. Claim status. ID card requests. PCP changes. Benefit questions. None of these require clinical judgment or emotional nuance. They are system lookups. They follow repeatable patterns. They happen on an enormous scale.
Most payers still staff for these reactively. They hire and train agents for baseline volume, then scramble when open enrollment hits; billing cycles spike, or a policy change floods the queue with the same five questions. Hold times climb when it matters most. Capacity sits idle for the rest of the time.
This is not a new problem. What has changed is that it is now solvable. A Fortune 100 insurer deployed AI for front-end call handling and automated 95 percent of identity verification across millions of calls per year. Not a pilot. Production at scale, proving that the bulk of this volume never needed a human agent in the first place.
Despite years of investment in digital self-service, only 20 percent of Medicare Advantage members use their plan’s app, and that number is declining, according to the J.D. Power 2026 U.S. Healthcare Digital Experience Study. Most of the volume still lands on the phone.
Picture what happens when a member calls about a claim. An agent answers, verifies identity, opens the claims system, reads a status, and closes the call. No judgment is applied. No clinical decision was made. No discretion is exercised. Just a lookup.
AI digital workers handle that end to end. They understand the question. They pull the data. They resolve the request. They log into the interaction. No hold time. No business hours.
What matters is what happens at the edge. When a call involves a disputed claim, a grievance, or a member in distress, the AI routes it to a human agent with context already captured. The members do not repeat themselves. The agent does not burn three minutes on verification. The handoff is clean, and the human’s time goes to work that actually needs a human.
Plans deploying AI in member services report 60 to 85 percent of call containment and up to 40 percent lower operational costs. Not projections. Operating results.
This is not about replacing people. It is about pulling trained staff off screen reads and putting them where their skills matter.
Cost savings get the conversation started. They are not the full case.
For payers in Medicare Advantage, member experience carries financial weight through Star Ratings. CMS cut CAHPS weighting from 4x to 2x for the 2026 Star Year, but the weight is projected to increase again. By 2029, CAHPS and HOS measures are projected to account for nearly 40 percent of total Star weight, according to Press Ganey’s analysis of the proposed CMS rule.
Within the Star Ratings system, member experience and clinical measures like medication adherence are structurally linked. Medication adherence functions as a force multiplier across Star Ratings, with cascading impact on CAHPS and related quality measures, according to AJMC. Plans that improve service and access tend to see corresponding gains in adherence.
Faster and more accurate service also address operational risk. It reduces member switching during open enrollment, when one bad call triggers a disenrollment. It absorbs volume surges from annual enrollment, formulary changes, and regulatory updates without emergency staffing. And it produces structured, consistent data on what members need, where processes break, and which benefits cause the most confusion.
Manual calls rarely generate that kind of data. Automated interactions do, consistently, at scale. That data feeds directly into plan design, communications, and operational decisions.
Member services sits at the front of the health plan experience. Every eligibility call, every claim inquiry, every ID card request shapes how a member feels about their coverage. That volume is predictable, and the technology to handle it at scale already exists.
An AI workforce handles predictable work. Your people handle complex work. Both operate at the same time, through the same workflows.
YANA means “You Are Not Alone.” For a Medicare Advantage member sorting out a denied claim on a Sunday night, that is the only thing they need to know.
ThoughtFocus deploys YANA and the AI Workforce behind it under outcome-based agreements tied to deflection, CAHPS movement, and cost per contact. We carry the result, not the license fee.
The conversation usually starts with a 60-day baseline that maps your top call drivers to deflection potential and projected Star impact.
