✅ FREE 20-min Ghost Provider Analysis for MA Networks

5 Key Pillars for Crafting
Winning Medicare Advantage Plans

5 Key Pillars for Crafting Winning Medicare Advantage Plans

Designing a winning Medicare Advantage (MA) plan can be tricky and at times, seemingly impossible. There are countless Pillars to consider and endless streams of data to comb through in order to ensure you’re providing the best possible coverage at an affordable rate for your members. In this article, we’ll discuss 5 key pillars to keep in mind while designing your MA plans, including a few great examples.

Key Pillar #1 : Know Your Member Profile & Target The Population Better

best medicare advantage plans

First and foremost, it is crucial to understand the unique makeup of your membership and targeted population, including demographics, utilization behavior, social determinants & other environmental insecurities, the propensity of chronic conditions, and various other market-related insights.

This will help ensure that the plan offers the right mix of benefits and services that are most relevant and valuable to beneficiaries.

For example, a plan designed for retired seniors who live in a rural area may need to include coverage for meals to address food insecurities or effective at-home benefits to address transportation challenges. In contrast, urban residents’ plans may prioritize coverage for transportation and/or Over-the-Counter (OTC) benefits.

best medicare advantage plans
best medicare advantage plans

Key Pillar #2 : Find an Affordable Balance in Healthcare Benefits

best medicare advantage plans

Understanding the design of your market will help you with the second (critical) pillar; determining the projected out-of-pocket costs of the plan.

With hundreds of cost factors influencing the project costs for members, Medicare Advantage plans must weigh the impact of their premiums, max out-of-pocket, copayments & coinsurances for each benefit, and deductibles against the projected utilization and risk.

Then strike a balance between offering a comprehensive set of benefits, keeping the plan affordable for beneficiaries, and remaining financially viable.

One great way of improving the balance of cost to value is understanding the cost elasticity of each benefit in your market – the degree of impact (enrollment) of each unit (dollar) change.

Key Pillar #3 : Examine Your Provider Networks' Marketability and Competitiveness

best medicare advantage plans

In addition to cost, it is also important to consider the marketability & competitiveness of the plan’s provider network.

Beneficiaries will want to be able to access a wide range of high-quality providers, including primary care physicians, specialists, hospitals, and pharmacies. The challenge is to design a network that is appealing to your target market while controlling provider rates.

In general, network selection is extremely personal to each beneficiary, often preferential to 3-5 physicians that must be available in a network for the plan to be considered. One trick to balancing the network is to better understand each physician’s (or group’s) influence within the market to determine their incremental membership potential.

best medicare advantage plans
best medicare advantage plans

Key Pillar #4 : Create an Easier Journey for Beneficiaries

best medicare advantage plans

Another important aspect of designing the best Medicare Advantage plan is ensuring that it is easy for beneficiaries to understand and navigate.

This means providing clear and concise information about the plan’s benefits and costs, encouraging healthy utilization, as well as making it simple for beneficiaries to access services, speak with trained representatives, and settle claim disputes quickly.

It is also helpful to offer tools and resources, such as online portals and customer support hotlines, to assist beneficiaries with any questions they may have related to their coverage, costs, and options.

Key Pillar #5 : Regular Reviews of Plans to Maximize Beneficiary Value

best medicare advantage plans

Finally, it is important to regularly review and evaluate the plan to ensure that it meets the beneficiaries’ needs and delivers value. Staying ahead of the market utilizing analytics and projections will ensure the highest probability of success.

This may involve primary research and focus groups to gather feedback from beneficiaries, analyzing basic market data to understand the competitive environment, or moving into advanced analytics with predictive forecasting to reduce unknowns and increase potential growth.

Predicting market evolution through advanced analytics allows a Payor to better understand the future impact of plan changes and weigh the cost against the potential membership growth.

best medicare advantage plans


Overall, designing the best Medicare Advantage plan requires a thorough understanding of the target population, a focus on affordability and access, and a commitment to ongoing evaluation and improvement.

By considering these Pillars, payors can offer Medicare Advantage plans that provide beneficiaries with high-quality, comprehensive, and cost-effective healthcare.

If you need help constructing or strengthening any one or all of these pillars, our xAI-powered platform will help. 

If you need help formulating successful Medicare Advantage plans, get in touch with us.

Share this insight!

4 Reasons why the top healthcare payors use NetworkIntel™:

& experience faster network building & optimizing!

Request A Personalized Demo
Let us show you how HealthWorksAI can optimize your Medicare Advantage product design efforts at every stage through actionable insights by leveraging public and private healthcare data.