How GoHealth uses AI and automation to help health plan consumers and licensed insurance agents

How GoHealth uses AI and automation to help health plan consumers and licensed insurance agents

Millions of Medicare Advantage customers could see significant changes to their plans during the upcoming Annual Enrollment Period, which runs from October 15 to December 7. The rising cost of care delivery coupled with slight decreases in federal reimbursements has caused some insurers to rethink their approach to Medicare Advantage in 2025.

Amid this uncertainty, the market is still poised for growth. Most consumers still have access to dozens of Medicare Advantage plans with a range of additional benefits, offering more choices than ever before. In this environment, it’s all the more important for licensed insurance agents to have technology and insights at their disposal to provide consumers with the guidance they need.

As CEO of GoHealth, a leading Medicare Advantage marketplace, Vijay Kotte sees the vital role that artificial intelligence and automation will play in connecting consumers with the best health coverage for them, even as the market continues to transform.

“As the industry leader in implementing technology and automation, we are dedicated to continued innovation that elevates the consumer experience, boosts agent efficiency, and enhances overall quality,” Kotte said.

A market growing, shrinking, and evolving all at once

Earlier this year, the Centers for Medicare & Medicaid Services (CMS) announced a 0.16% decrease in base payments to Medicare Advantage plans. The response from major insurers has been mixed. While some have signaled plans to scale back their Medicare Advantage business, others have shown a willingness to fill the void. This is why Medicare Advantage is still projected to make up 64% of all Medicare enrollment by 2034, a significant increase from 54% today.   

In recent years, the supplemental benefits in Medicare Advantage plans have proliferated. Carriers have attracted consumers by offering additional support (like transportation, gym memberships, and companion care) on top of the more standard additions of dental, vision, and hearing coverage.

Now, the calculations for many insurance carriers have shifted because of factors like high care utilization coming out of the pandemic and the new $2,000 cap on out-of-pocket costs for covered Part D drugs. Insurers are pulling out of certain markets and looking for ways to limit spending. That includes rethinking their approach to supplemental benefits, including scaling back plan offerings with lagging enrollment, limited impact on member experience metrics, or low return on investment.

In this rapidly transforming marketplace, GoHealth is dedicated to helping consumers weather changes in Medicare and get the health coverage they need.

Making sense of Medicare Advantage for consumers

The licensed insurance agents at GoHealth use proprietary technology to explore consumers’ options, with no pressure to enroll in a specific plan. For example, GoHealth’s Encompass Solution has facilitated agent workflows for consumer health plan selection, enrollment, and activation since 2020. Agents using the solution have seen a 20% reduction in rapid disenrollments—a clear sign that members are able to make more informed decisions about plan choices—and in 2024 the streamlined Encompass Express model reduced consumer on-phone time by about a quarter.

Ahead of last year’s Annual Enrollment Period, GoHealth introduced PlanFit technology. This proprietary tool makes evidence-based plan recommendations based on the factors that matter most to consumers. Agents conduct PlanFit CheckUps in which they review a beneficiary’s plan options to discover whether they’re already enrolled in the best plan or if a different one will better suit their needs.

PlanFit Checkup is meant to be used for more than a single enrollment decision. GoHealth encourages beneficiaries to re-evaluate their plans annually, since benefits, costs, and coverage can change every year. In fact, agents are compensated for completing a PlanFit Checkup regardless of whether the assessment leads to a new enrollment.

PlanFit Checkups not only reflect GoHealth’s commitment to doing what’s right for the consumer, but they also incentivize licensed insurance agents to stay focused on providing the best advice to consumers—forming a relationship that lasts beyond the current enrollment period.

Going beyond the PlanFit Checkup for the AEP in 2024

To address the uncertainty of the Plan Year 2025 Annual Enrollment Period, GoHealth has introduced two offerings that build on PlanFit’s foundation:

  • An AI-powered sales coach that helps agents-in-training roleplay realistic, highly specific scenarios that they may face while working with a consumer. Agents practice offering compassionate service to people who face difficult, potentially life-changing choices.
  • PlanGPT uses a large language model to retrieve key information from plan documentation (which can be 200+ pages long) to help agents quickly and accurately compare plans and offer personalized guidance. Agents are able to serve more consumers even during busy enrollment periods, while helping consumers make educated decisions without a lengthy shopping experience. 

“With streamlined processes for agent onboarding and precise, data-driven insights, we will build lasting relationships and improve the Medicare consumer journey,” Kotte explained. “We are committed to supporting the consumer, and we believe that doing the right thing for their needs will ultimately increase engagement and retention.”

A trusted partner for the road ahead

Medicare Advantage has gone through dramatic expansion and constant change since exploding in popularity during the late 1990s. As enrollment grows and plans continue to evolve in 2025 and beyond, both consumers and agents will benefit from technology that guides informed, timely decision-making.

By developing tools to meet consumers’ specific health plan needs, GoHealth positions licensed insurance agents for success during the Annual Enrollment Period while setting the stage for long-term customer loyalty. 

The editorial staff had no role in this post's creation.