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Key takeaways
- To improve margins, carriers need to educate, engage, and empower Episodically Engaged members who overindex for emergency care use.
- Carriers need to take a three-pronged approach by empowering agents, collaborating with providers, and enhancing their member outreach.
- Heinrich has the strategic and executional experience to help in one, two, or all three areas.
As Medicare carriers shift from membership growth to margin discipline, care utilization rates and costs continue to rise. In 2023 (the most recent data available), 110 contracts (17%) operated at a loss while 211 contracts (33%) operated on razor-thin margins per Medicare Market Insights. Carriers continue to shepherd beneficiaries into Special Needs Plans to minimize risk. But that’s not enough.
Too many high-cost members in general market plans don’t engage in preventive, coordinated care. It’s not just an issue of access leading to avoidable, reactive care—it’s also a lack of consumer confidence. These members don’t have the right guidance to navigate an overwhelming system. They don’t have the advocates they need.
Carriers have the power to create positive change by joining forces with agents and providers. When the healthcare system—carriers, agents, and providers— comes together to deliver a coordinated experience, consumers have the support system they need to improve their health outcomes and quality of life. That has the potential to lower costs and improve population health at scale.
The Medicare carrier hand-off problem
The past two Annual Election Periods (AEPs) have seen major disruption as carriers expand and contract their footprints from one year to the next. It’s been hard on beneficiaries and agents alike.
The carriers who “won” AEP 2025 by membership numbers pulled back in 2026 to improve margins and shed unprofitable markets (i.e., high-cost beneficiaries). The ones who “lost” 2025 expanded aggressively in 2026 likely picking up the higher utilizing, more reactive members other carriers let go.
Basically, carriers pass this set of beneficiaries between them from year to year. I have no doubt this trend will continue if carriers don’t address the root cause of the issue.
Deft Research calls them the “Episodically Engaged”
Deft Research is known for illuminating Medicare Advantage data. Their latest segmentation study breaks the Medicare population into six segments.
The ones Deft calls the Episodically Engaged tend to manage five conditions, on average. They are less likely to get annual wellness visits, have yearly physicals, or see their primary care provider (PCP) regularly. That means they use more emergency care, leading to higher costs, more in-patient admissions, and more surgeries. This is why this segment erodes margins and why so many carriers let them go.
Episodically Engaged beneficiaries also switch plans at higher rates than average (36% compared to 29%). Some of this is forced due to plan exits or benefit degradations, but some of it is likely due to a lack of member communication, support, and engagement.
What Episodically Engaged members need from their carriers
Episodically Engaged members likely feel overwhelmed by the healthcare system and making changes to their lifestyles. They may not know what to do or even where to start. They may see healthcare as reactive, using it mostly for acute needs rather than prevention.
That’s why carriers need to make accessing preventive care a top priority for this segment. Above all else, it’s got to be easy for the Episodically Engaged. Here’s how to do it.
Empower brokers to consult with confidence
The trend of the role of an agent/broker moving away from pure selling to trusted health resource has accelerated. Carriers like Humana have long encouraged agents to focus on improving the member experience with concierge-level service. SCAN Health took it a step further, creating a formal Brokers as Health Navigators program.
Carriers can streamline the agent learning curve and speed up their effectiveness by giving agents the right tools and materials. Here are some examples:
- Give them scripts to help beneficiaries find a primary care provider (PCP) and schedule their first appointment.
- Make onboarding simple and turnkey with a self-serve portal checklist that explains:
- How to know what’s covered by their plan and what benefits they have.
- How to find in-network care to lower costs.
- How to comparison shop for covered prescriptions at in-network pharmacies.
- When to use telehealth, home-based care, or urgent care instead of going to the emergency room.
- Send every member a magnet with their agent of record’s contact information and a reminder to call them first for any Medicare plan needs.
Exceptional agent education and sales enablement is one of Heinrich’s core competencies. We take an agent-centric approach to lead carriers in solving their toughest problems—like tackling high costs and utilization rates with a key member segment.
Collaborate with PCPs to drive care consistency
Alert PCPs to pay special attention to patients who overuse emergency care in lieu of primary care. Encourage them to explain why prevention matters to these patients.
You can join forces by co-marketing annual wellness visits, screenings, and vaccinations. Encourage PCPs to send these beneficiaries personalized schedules and reminders. See how a co-marketing plan comes to life here.
A simple yet effective tactic could be sending a co-branded exam prep postcard at the first of the year. It can have quick tips on gathering the beneficiary’s medical history, medications, and any health concerns. Add a QR code to make booking the appointment quick and easy.
Rethink your member messaging to boost confidence
As more member communication moves to email and social, carriers need to keep other channels like SMS and direct mail top of mind to increase member confidence. Here’s why.
According to Pew Research, 95% of Americans aged 65 or older have a cell phone and 78% have a smartphone. Carriers can use SMS to encourage member plan and PCP engagement for member portal activation and annual wellness visits. Simple prompts like “tap to call your doctor’s office,” “reply 1 to schedule your check-up,” or “tap to call us for help” make immediate action a no-brainer.
Direct mail can be a useful tool to get members to take essential actions like confirming their PCP and scheduling appointments, especially with QR codes or smart-assistant instructions like, “Siri, call Dr. Regina Brown in Denver to schedule my annual wellness exam.”
This kind of outreach proves to members that you have their best interest at heart and that you’re there for them. This increases their confidence in you, which then increases their confidence in the system at large.
Heinrich can help you improve your margins by engaging your membership
The future of Medicare Advantage isn’t margins over membership—it’s margins plus member engagement. Heinrich can help you enhance your member engagement strategy from one, two, or three angles: agents, providers, and/or member communications. Send me an email to schedule a complimentary 30-minute consultation today.