The Centers for Medicare & Medicaid Services (CMS) is ushering in a new phase of Medicare Advantage (MA), one that places stronger emphasis on data integrity, outcomes, value-based care, and genuine member engagement. In this environment, success hinges less on benefit design and more on a plan’s ability to activate its members to utilize available supplemental benefits, with clear instructions for access.
At the same time, evolving value-based care models are pivoting to a total cost of care focus. Risk and Quality metrics and analytics alone, measuring ‘stuff’ and interpreting results, are no longer enough.
Why? Because nothing happens until the patient sees the doctor. Health plans and health systems are increasingly incentivized to connect patients with high performing physicians. Those who deliver better results and lower costs by matching patients to the right type of care, whether it’s medical, behavioral, or SDoH support.
Access and referrals for real people with real physicians is the human part of healthcare and equity beyond analytics. Making it easier for patients to complete screenings and attend appointments, and truly engage meaningfully with their physicians and referral specialists is what leads to better outcomes and optimal performance.
So, while CMS policy shifts are creating both pressure and opportunity, the industry is finally recognizing what ReferWell has long understood: patients must be thoughtfully engaged to close care gaps and ensure they utilize their benefits.
The Challenge: Awareness ≠ Action
Health plans have made major strides in using data to identify member needs, but that alone doesn’t drive impact. Members often know they need a screening, follow-up, or chronic care visit, but too many still don’t act. The result is fragmented care, higher downstream costs, and missed quality targets.
Plans invest heavily in member outreach letters, texts, and calls designed to remind members of what care they’re due for, but traditional outreach stops short of the real goal: completed care. In this environment, rethinking how to help members take the next step is critical, and properly tracking that process to protect data integrity is vital.
Coordination as the New Benchmark
With CMS spotlighting utilization as a driver of its rule changes, MA plans can no longer afford to think of member engagement and care navigation as “nice-to-have.” MA plans are now instructed to deliver personalized mid-year member notifications outlining unused supplemental benefits, with clear instructions for access.
MA plans that connect members directly to high-value, in-network providers not only reduce fragmentation; they also strengthen continuity of care and use of benefits, while improving Star Ratings, CAHPS, and HEDIS performance.
ReferWell helps plans do this seamlessly; with human-led engagement that provides clear instructions for care access to guide members to utilize supplemental benefits, from outreach to scheduled appointments, directly addressing this persistent operational gap in managed care. By replacing passive reminders with the required mid-year engagement and personalized active scheduling, plans can ensure that identified needs translate into completed visits.
ReferWell’s smart scheduling platform also enables value-based care alignment. By matching members to the right interventions with the right in-network, high-value providers who are best equipped to meet their care needs, ReferWell reduces leakage and drives measurable value back to the plan. It’s a practical mechanism to operationalize value-based alignment, one that complements, rather than competes with, a plan’s existing engagement tools.
From Outreach to Impact
As policymakers and industry leaders double down on the importance of member care utilization and behavior change, MA plans face a critical question: How do you move members from awareness to action?
ReferWell partners with health plans to make that transition simple and scalable. Instead of stopping at a reminder, ReferWell personalizes engagement to close the loop, connecting with members at the moment of decision and converting intent into completed care. That difference, outreach vs. impact, is what sets ReferWell apart.
Strategic Takeaway for Health Plans
CMS’s evolving member engagement expectations present a moment of strategic clarity: tomorrow’s high-performing MA plans will be the ones that treat personalization as the path to care access. Making it easier for members to act on their health needs and utilize supplemental benefits isn’t just a service, it’s a lever for quality improvement and higher satisfaction scores.
ReferWell helps plans achieve success as benefit design requirements and regulations evolve: turning enterprise-level goals into member-level action.
