Optimizing a Health Plan’s Product Portfolio with Generative AI
A carrier-grade AI engine that uses claims insights to design better plans, refine messaging, and improve enrollment in preferred products.
Challenge
Health plans design products for specific populations — but consumers seldom choose the plans intended for them. Confusion over plan naming, complex benefit designs, network nuances, and pharmacy tiers leads to enrollment mismatches that inflate medical loss ratios (MLR), create unpredictable risk pools, and reduce member satisfaction.
Carriers have detailed claims and utilization data, but this intelligence rarely shapes enrollment behavior or plan selection. The result: good plans underperform, risk pools destabilize, and consumers remain confused (at best), or totally dissatisfied with their health plan benefits.
Solution
Our carrier-facing AI augments customer data with business rules to unlock the value of claims data to improve product performance and optimize enrollment distributions.
• Claims-aware segmentation: our AI identifies utilization clusters, value segments, risk patterns, specialty demand, and pharmacy cost drivers.
• Plan-specific ideal customer profiles (ICPs): Each plan receives a clear definition of which member types it serves best — not for individual steering, but for better design and clearer marketing.
• Portfolio optimization: AI recommends benefit and network refinements, formulary strategies, and pricing adjustments backed by real utilization behavior.
• Sharper plan explanations: Carriers glean clearer insights for improved messaging, educational content, and broker-ready guidance that helps consumers understand the value of each plan.
This enhances enrollment alignment, improves financial performance, and reduces plan confusion.
Results
Health Plans through AI-driven product design improvements and tailored member / broker engagement strategies can better align member enrollment with plan goals. Better alignment means lower MLR volatility and more predictable risk pools as well as improved member satisfaction and retention for sustainable business growth.
Let us help you optimizing your product portfolio with Generative AI.