Medicare Advantage

Member Engagement

Star Ratings

Health Insurance

Quality Improvement

Mobile App

Transforming Medicare member engagement for a regional health plan

How personalized digital experiences drove 4.5-star quality ratings and $12M in retained revenue

Client

Horizon Health Plans

Type

Medicare Advantage Insurer

Transforming Medicare member engagement for a regional health plan

4.5★

Star Rating

Up from 3.5 stars in 18 months

67%

Portal Engagement

Monthly active users, up from 12%

-58%

Call Center Volume

For routine inquiries

$12M

Quality Bonuses Retained

Annual CMS payments secured

89%

Medication Adherence

For targeted chronic conditions

78%

AWV Completion

Annual Wellness Visits, up from 41%

+34

Member NPS

Up from -8 baseline

23%

Enrollment Growth

During next AEP cycle

The Challenge

Problem

Horizon Health Plans, a regional Medicare Advantage insurer with 180,000 members, was struggling with declining Star Ratings and member satisfaction. Their digital experience was fragmented across multiple legacy systems, making it nearly impossible for members to manage their health benefits effectively.

Star Rating dropped from 4.0 to 3.5 over two years, putting $18M in quality bonus payments at risk

Member portal had 12% monthly active usage—far below the 35% industry benchmark

Average handle time for member services calls was 14 minutes, driving up operational costs

No mobile app—members relied on phone calls for even simple tasks like finding providers

Medication adherence programs had only 23% engagement, impacting quality measures

Annual wellness visit completion rate was 41%, well below CMS targets

Member complaints about difficulty understanding benefits increased 67% year-over-year

The combination of declining Star Ratings and poor member engagement was creating an existential threat. Horizon faced losing $18M annually in CMS quality bonuses while spending $4.2M on call center operations for issues that could be resolved digitally. Competitor plans with better digital experiences were winning during Annual Enrollment Period.

Our Approach

Strategy

We developed a comprehensive member engagement platform strategy centered on personalized health actions, proactive outreach, and simplified benefit navigation—all designed to improve both member experience and clinical quality measures simultaneously.

Member Journey Mapping

Conducted extensive research with 200+ Medicare members across demographics to understand their unique needs, technology comfort levels, and preferred communication channels. Created detailed personas for each member segment.

Quality-Driven Design

Aligned every feature with specific Star Rating measures—HEDIS quality metrics, CAHPS survey dimensions, and medication adherence programs. Every interaction was designed to move the needle on measurable outcomes.

Omnichannel Personalization

Built an intelligent engagement engine that delivers the right message, through the right channel, at the right time—coordinating outreach across app, web, email, SMS, and phone based on member preferences.

Accessibility-First Approach

Designed for Medicare population needs: large text options, high contrast modes, voice navigation, simplified language at 6th-grade reading level, and integration with screen readers and assistive technologies.

Care Gap Closure System

Created automated workflows to identify members with care gaps, deliver personalized outreach, facilitate scheduling, and track completion—turning passive data into proactive health interventions.

Provider Network Integration

Built real-time provider directory with availability, integrated scheduling, and transportation assistance to remove barriers between members and the care they need.

How We Did It

Execution

The 32-week engagement transformed Horizon's member experience through phased delivery, starting with quick wins to build momentum and progressively adding sophisticated engagement capabilities.

Discovery & Strategy

Conducted 200+ member interviews and surveys across all demographics
Analyzed 3 years of call center data to identify top member pain points
Mapped current state journey across all member touchpoints
Benchmarked against top-performing Medicare Advantage plans
Developed comprehensive quality improvement roadmap aligned with Star Ratings
Created business case with projected ROI and quality score impact

Platform Foundation

Designed unified member data platform integrating claims, clinical, and engagement data
Built personalization engine with rule-based and ML-driven recommendations
Created design system optimized for Medicare population accessibility needs
Developed API layer connecting to eligibility, claims, and provider systems
Implemented HIPAA-compliant communication infrastructure
Established analytics foundation for measuring engagement and outcomes

Core Experience Build

Launched redesigned member portal with personalized health dashboard
Built native iOS and Android apps with offline benefit card access
Created intelligent provider search with real-time availability
Implemented digital ID cards with Apple Wallet and Google Pay integration
Developed medication management with refill reminders and pharmacy finder
Built secure messaging with care team and member services integration

Engagement Engine Launch

Deployed care gap identification and outreach automation
Launched Annual Wellness Visit scheduling campaign with transportation booking
Implemented medication adherence program with smart reminders
Created personalized health content library based on conditions and interests
Built rewards program for completing health activities
Integrated telehealth for on-demand virtual care access

Optimization & Scale

Conducted A/B testing across all outreach channels and messages
Refined personalization algorithms based on engagement data
Expanded self-service capabilities to reduce call center volume
Implemented predictive analytics for at-risk member identification
Launched caregiver access features for family member involvement
Developed provider-facing tools for care gap visibility

What We Built

Solution

The Horizon Member Engagement Platform became a comprehensive digital health hub that simplified benefits, personalized health guidance, and proactively helped members stay healthy—while making every interaction count toward quality improvement.

Personalized Health Dashboard

AI-powered home screen showing each member's most important health actions: upcoming appointments, overdue screenings, medication refills due, and personalized wellness recommendations. Content adapts based on health conditions, risk factors, and engagement history.

Smart Benefits Navigator

Conversational interface that helps members understand their coverage in plain language. Ask questions like 'Is my diabetes medication covered?' or 'How much will a knee replacement cost?' and get instant, personalized answers with cost estimates.

Care Gap Closure Engine

Automated system that identifies members needing preventive care, delivers personalized outreach through preferred channels, facilitates appointment scheduling with in-network providers, arranges transportation if needed, and tracks completion—closing the loop on every care gap.

Medication Adherence Hub

Comprehensive medication management including regimen tracking, smart refill reminders, pharmacy price comparison, mail-order enrollment, and drug interaction alerts. Integrated with pharmacies for real-time fill status and home delivery tracking.

Provider Connection Suite

Enhanced provider directory with real-time availability, online scheduling, quality ratings, and patient reviews. Includes telehealth integration for virtual visits and transportation booking for in-person appointments.

Wellness Rewards Program

Gamified engagement program that rewards members for completing health activities like annual wellness visits, screenings, and health assessments. Points redeemable for gift cards, premium credits, and OTC benefit items.

Caregiver Portal

Secure access for family members and caregivers to help manage a member's health, view appointments, track medications, and coordinate care—with granular permission controls to protect member privacy.

24/7 Virtual Assistant

AI-powered chatbot trained on Medicare benefits, available around the clock to answer questions, help with common tasks, and seamlessly escalate to human agents when needed—reducing call volume while improving satisfaction.

The Outcome

Results

Within 18 months, Horizon transformed from a struggling 3.5-star plan to a top-performing 4.5-star plan, retained $12M in quality bonuses, and became the member experience leader in their region—driving growth during Annual Enrollment Period.