Member Experience in Medicare Advantage: The Power of Proactive Navigation 

By:

Ryan Peterson

Vice President of Payor Innovations

A Healthcare Experience That Inspires Confidence 

Millions of Medicare Advantage members enroll in plans with valuable benefits, yet too many struggle to use them effectively. Unclear coverage details, provider access issues, and lack of care coordination lead to missed care, frustration, and even plan switching. This confusion affects both members and the financial and operational stability of health plans. 

Proactive, year-round care navigation is the key to solving this problem. When health plans shift from reactive to proactive engagement, they transform member confusion into confidence and long-term loyalty. Instead of waiting for members to encounter difficulties, health plans that anticipate their needs and offer ongoing support build trust, improve engagement, and foster long-term retention. This approach enhances the member experience while strengthening Star Ratings, optimizing costs, and solidifying loyalty. 

The Confidence Gap in Medicare Advantage 

For Medicare Advantage plans, achieving and maintaining a 4-star or higher rating is more than a metric. It is a financial necessity. Plans that fall below this threshold risk losing millions in CMS incentives, which impacts their ability to support members and stay competitive. Many rely on fragmented vendor solutions for compliance and gap closures, but these quick fixes do not build long-term member trust. Sustainable success demands a unified, proactive strategy that fosters engagement, improves satisfaction, and strengthens plan performance. 

Healthcare decisions are complex, and for many MA members, the lack of clear guidance is a major barrier to feeling in control. While some navigate the system with ease, a significant portion struggles to understand their benefits and make informed choices. More than half of MA members feel confident in using their plan, but nearly 27% report uncertainty or confusion. 

This uncertainty leads to real-world consequences. Members who do not fully grasp their coverage often delay essential care, resulting in worsened health outcomes and costly emergency interventions. Health plans that take a passive approach risk member disengagement, dissatisfaction, and increased churn. 

But confidence is not an inherent trait. It is built through clear communication, accessible resources, and a seamless member experience. By prioritizing proactive engagement, health plans can create an environment where members feel empowered rather than overwhelmed. 

Elevating Member Engagement Through Proactive Navigation 

Traditionally, health plans interact with members only when issues arise, such as a denied claim, an unpaid bill, or a missed appointment. This reactive model places the burden on members to seek answers, leading to confusion and frustration. A proactive approach ensures members receive guidance before they even realize they need it. 

A truly proactive care navigation model integrates member education, benefit optimization, and care coordination seamlessly into the healthcare journey. Consider Maria, a newly enrolled Medicare Advantage member. When she schedules a routine checkup with her primary care physician, she does not realize that her plan also includes free vision and dental screenings. Months later, an undiagnosed eye condition worsens, leading to an emergency visit that could have been avoided. Without proactive navigation, Maria never knew these benefits were available, resulting in unnecessary costs for both her and her plan. Dedicated Care Coordinators help bridge this gap by providing timely, personalized support that prevents common pitfalls. 

Navigating healthcare services can also be overwhelming when scheduling care. Many members struggle to make appointments for preventive screenings and chronic condition management. Proactively reaching out to assist with scheduling and follow-ups ensures that members receive the necessary care at the right time. 

Finding in-network providers presents another challenge. Members who have difficulty locating an in-network physician or specialist may unknowingly seek out-of-network care, leading to unexpected expenses. Real-time provider matching and scheduling assistance alleviate this burden, improving access to care while reducing unnecessary spending. 

Supporting At-Risk Populations with Tailored Navigation 

Certain member groups face greater challenges in accessing and utilizing their healthcare benefits. These populations require a more targeted approach to ensure they receive the care and support they need. 

For instance, research shows that non-White MA members are more likely to experience care delays due to provider access barriers. Without proactive navigation, these disparities widen, leading to increased emergency care use and worse health outcomes. Culturally competent engagement strategies, including multilingual support and tailored outreach, are critical in addressing these gaps and improving health equity. 

The Impact of Proactive Navigation on Health Plan Success 

Members do not feel that health plans are doing enough to assist them in understanding and using their benefits. A reactive approach leaves members feeling unsupported, leading to higher costs and lower satisfaction scores. Proactive engagement fills this gap by ensuring that members receive the right information at the right time, preventing frustration and enhancing their healthcare experience. 

Health plans that invest in consistent, proactive engagement see significant improvements across multiple performance metrics. 

Higher Star Ratings 

Member satisfaction is a core component of CMS Star Ratings. Plans that actively guide members through their healthcare journey consistently achieve higher ratings, leading to increased financial incentives and stronger market positioning. 

Strategic Cost Containment and Efficiency 

Missed screenings and unmanaged chronic conditions drive costly ER visits and preventable hospitalizations. Each inpatient stay averages $11,700. Proactive navigation reduces these expenses by ensuring members receive timely care, adhere to medications, and engage in preventive health actions. By guiding members to the right care at the right time, health plans can drive measurable cost savings and improve long-term outcomes. 

Improved Retention and Member Loyalty 

First-year attrition remains a challenge for many MA plans, with 13% of members leaving their plan annually. By providing clear, ongoing support from the beginning, health plans can significantly reduce churn and build long-term loyalty. 

The Future of Medicare Advantage: Setting a New Standard for Engagement 

The future of Medicare Advantage belongs to plans that lead in proactive engagement instead of simply reacting to member needs. Plans that leverage predictive analytics, AI-driven insights, and real-time member support will redefine the standard of care. Success will be measured by their ability to anticipate needs, prevent care gaps, and create seamless healthcare experiences. 

Proactive engagement has transitioned from a competitive advantage to an industry expectation. The future of Medicare Advantage will be shaped by the plans that anticipate member needs before they arise, setting a new benchmark for success. Health plans must now decide how quickly they can implement proactive navigation to remain effective. 

About the Author 

Ryan Peterson is the VP of Payor Innovations at Quantum Health, working at the intersection of healthcare technology and health plan operations. He has deep expertise in risk adjustment, quality improvement, and payer-provider collaboration, with a proven track record of scaling multiple health tech startups. Previously, he served as SVP of Strategy & Growth at Reveleer and VP of Business Development at Advantmed. He holds a bachelor’s degree from Kent State University and an MBA from the University of Wisconsin–Eau Claire. Outside of work, he enjoys running, hiking, and collecting vinyl records.