Smarter Plan Decision Support with Generative AI
A GenAI agent that turns confusing open enrollment decisions into simple, personalized recommendations
Challenge
Open enrollment overwhelms employees and other health plan consumers. Dozens of near-identical plan options, confusing marketing names, shifting networks, and narrow pharmacy tiers create a painful decision experience. Most employees make choices based on premium alone, leading to hidden costs, unexpected out-of-network bills, and frustration months later.
Traditional decision-support tools offer basic filters and yes/no lookups — but they can’t explain tradeoffs, reveal hidden risks, or adapt to real-life needs. As a result, employees frequently choose suboptimal plans based on premium alone and only discover the true cost of their plan after receiving treatment with unexpected copays. HR and Customer Service teams face a surge of questions and confusion during open enrollment combined with lower employee satisfaction and higher downstream healthcare costs once employees are enrolled.
Solution
Our AI agent embeds healthcare-specific logic (to understand how benefits actually work, not just what the plan brochures say) with pre-loaded plan benefits, premiums, provider and formulary directory data to turn any LLM into a health benefits reasoning engine, not just a text generator. Our AI agent asks the employee basic questions to household context to connect providers, formulary and estimating healthcare usage. This simplifies plan selection for consumers using natural language, deep plan literacy, and advanced reasoning.
- Plain-language conversation: Users describe doctors they see, medications they take, upcoming procedures, and risk tolerance.
- Real-time reasoning: AI interprets these inputs and maps them to provider directories, specialty participation, formulary tiers, cost-sharing rules, and exclusions.
- Scenario simulation: The AI agent estimates expected costs, potential risks, pharmacy exposure, and specialty-specific network gaps.
- Clear explanations: Users receive tailored, human-readable reasoning on the best plan fit for their needs. Our agent synthesizes all data inputs in seconds to create a transparent, informative enrollment experience that requires minimal input from the user.
Results
Employees have 24/7 access to their own personalized plan decision support agent for smarter plan choices. Reducing the risk of health plan surprises including co-pays while providing a clear understanding of tradeoffs depending on user priorities. This dramatically reduces decision anxiety and last minute passive, or expensive, enrollment selections.
Employers receive fewer HR/Customer Service support tickets during open enrollment when Employees have a stringer understanding of health benefits and Employer contributions. This leads to increased employee satisfaction with benefits and reduced post-enrollment complaints and requests from dissatisfied employees to switch plans.
Let us help you implement your own Generative AI agent enrollment decision support.