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The Role of AI in Personalized Health Insurance

The role of artificial intelligence (AI) in shaping healthcare for insured individuals is changing. The health insurance industry is identifying specific areas like claim processing and patient care service and exploring the ability to predict which future health insurance coverages may be key to you in their quest for AI usage. Using AI software tools, insurance companies can use patient data to guide applicants through health insurance buying. These are AI innovations that positively affect health insurance customers. Customized health insurance tailored to you and your family.

Health insurance shopping and AI innovation

The search for healthcare AI innovations for insured individuals is growing. The healthcare industry, including insurance companies, is looking for AI-driven positive changes in the healthcare experience for insured individuals. The starting point for change is with the health insurance application. Customizing a health insurance plan using AI tools can produce a more accurate application match for an insured individual.

This starts with AI software vendors and insurance companies integrating systems with patient data and AI support, resulting in improved online application comparison and shopping. This approach should lower premiums and improve patient care due to benefit options.

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Health insurance systems and AI

Several years ago, the Department of Health and Human Services developed a playbook for Trustworthy AI regarding the advancement in health insurance. It is designed to support healthcare leadership in the application and implementation of AI. In addition, the Centers for Medicare and Medicaid Services (CMS) has recently been asked by over 30 members of the House of Representatives to review algorithms looking for AI barriers that may exist in products like Medicare Advantage. The influence of artificial intelligence on health insurance outcomes may be questionable for Medicare beneficiaries. Care and coverage denial guidelines may be impacted if the correct controls are not in place.

Federal guidelines for health insurance and AI

Federal regulators encourage CMS to set guidelines for AI engagement, specifically in Medicare Advantage plans. The following are sample policy suggestions on AI usage for insurance companies that offer Medicare Advantage products:

AI guidelines for usage in health insurance:

  • Report prior authorization denial and the reason (the denial may be AI-generated).
  • Confirm coverage guidelines regarding AI decision-making are not more restrictive than a traditional model.
  • Compare AI-generated decisions with traditional decisions and make any adjustments for errors noted due to AI.

CMS manages an enormous amount of information, with nearly 150 million Americans enrolled in its programs. CMS will continue exploring the positive impact of AI on health insurance services while expanding its mission as an agency. Part of the changing mission includes the evolving landscape of health insurance with the integration of AI.

Safe and secure AI in health insurance

The current administration has commitments from over 28 healthcare entities promising to engage in safe and secure AI usage as the industry evolves and grows. Medicare/Medicaid plans and Affordable Care Act (ACA) policies will not be the only health insurance options utilizing AI. The evolving landscape of private health insurance carriers integrating AI will be watched closely by privacy advocates for discrimination and HIPPA violations involving patient medical data. The privacy and security of patient data are of the utmost importance to all stakeholders.

The benefit of AI in prescription coverage

Managing prescription coverage benefits can be challenging today, especially if patient care involves a complicated illness or injury and multiple types of medication. As the industry began exploring positive changes in customer healthcare with AI innovations, the prescription coverage benefit highlights the advantage of AI in consumer choices for health insurance. Each health insurance carrier approaches coverage and pricing for medication differently. AI can assist in the purchase of health insurance and guide an applicant to the insurance company that best matches their prescription needs, including affordability.

The influence of artificial intelligence on health insurance outcomes will continue to change. Medication decisions, costs, and delivery systems may be disrupted by AI software in the future. However, the future of AI may also include a software tool programmed to alert a patient taking multiple prescriptions of a side effect severity from that medication group and offer less harmful options where appropriate.

AI in health insurance and the traditional agent

The intersection of health insurance and AI in customer well-being can be supplemented with the advice of a professional health insurance agent. Gathering information about coverage and medication benefits, deductible choices, or copays is a great starting point for a purchase. But, understanding restrictions or exclusions in health insurance benefits including provider access may be more complicated.

Adding a local health insurance agent to the health application enrollment process may improve the purchase experience. Having a professional confirm your choices and offering a local resource can be invaluable in the long term.

AI integration and the future of healthcare systems

The future of health insurance and AI integration includes how we purchase health insurance and interact with a healthcare team. AI use cases in health insurance, as AI tools become more accurate and widespread, consumers will be offered engagement with these tools for many services. Stakeholders involved in the process may have different perspectives on the value of AI. Each sees the pros and cons of AI health insurance and AI in healthcare in general differently.

Healthcare AI innovations will continue to evolve. Enhancing healthcare with artificial intelligence will improve both patient care and healthcare management. When all stakeholders work together towards a cohesive and secure system, the industry will see positive outcomes of AI in customer healthcare.


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