Healthcare payer technology trends offer a glimpse of tomorrow’s health plans

• Payer digital transformation enhances member satisfaction through retail-inspired experiences, seamless interoperability and proactive AI-driven operations.
• Autonomous AI tools help health plans boost efficiency, proactively detect fraud, strengthen member engagement and streamline underwriting—all without requiring human intervention.
• Healthcare payer technology trends in 2025 prioritize internet of medical things (IoMT) integration, virtual-first care and cybersecurity to reduce costs, personalize care and retain members.

Across the U.S., small and midsize health plans face mounting strain. Rising costs, workforce gaps and shifting member expectations are testing the limits of legacy systems and manual operations. Competing in this environment takes more than efficiency. It takes a smarter and more connected model built on AI, interoperability and real-time data to help plans proactively reduce costs and better retain members.

To drive sustainable growth and meet members’ increasing expectations for digital and AI-driven healthcare experiences, small and midsize plans should not follow the strategies of large national payers. Instead, they can craft agile, community-focused technology strategies anchored in AI, driven by data and built on trust.

Five clearly defined healthcare payer technology trends offer accessible pathways to alleviate current pressures and fuel future-ready performance. These are not merely technological innovations—they are critical strategic enablers that will directly affect payer operations, member experience and competitive differentiation:

1. IoMT and remote monitoring. Real-time biometric data captured from wearables and home-based devices is reshaping chronic care management, enabling early medical interventions and supporting dynamic pricing models.
2. Agentic AI for health plans. AI agents proactively identify fraud, streamline underwriting processes and engage members personally and proactively, optimizing efficiency without relying solely on manual human workflows.
3. Retail-like digital experiences. Transparent pricing, intuitive digital navigation and simplified preservice coordination meet consumer-driven expectations and distinguish leading health plans in a competitive marketplace.
4. Healthcare data interoperability. Meeting and driving beyond Centers for Medicare and Medicaid (CMS) interoperability mandates enable business value. Payers are leveraging Fast Healthcare Interoperability Resources (FHIR) standards to enable seamless information exchange between payers, providers and third-party apps, and to identify and close care gaps, accelerating authorizations, reducing unnecessary testing and deepening collaboration.
5. Cloud cost optimization for AI. As payers invest in AI to streamline operations and deliver more personalized member experiences, many are encountering a new challenge: escalating cloud costs. AI’s promise is real, but so is its price tag. Unlike traditional IT infrastructure, AI workloads demand significant computing power, memory and storage. And that demand doesn’t just show up in big one-time purchases. It manifests as ongoing cloud service costs that scale with usage. For payers, the question becomes not just whether to adopt AI but how to do so cost-effectively. Yet few payers have mature frameworks to forecast, track or optimize cloud spending tied specifically to AI use cases.

These five payer industry trends can be organized into three strategic focus areas—how members engage, how work processes evolve and how systems interconnect—that have the potential to position health plans for sustainable growth. By targeting specific use cases, small and midsize payers can reduce operational costs, enhance care quality and differentiate themselves within competitive markets.

Members increasingly demand retail-like experiences similar to those from Amazon or Netflix: upfront pricing, clear preservice steps and intuitive digital tools that boost satisfaction and loyalty. They’ll switch plans to get them. Health plans must digitally transform their member-facing journeys, ensuring pricing transparency, intuitive navigation and efficient preservice coordination. New strategies will need to be deployed across marketing, sales and member engagement to improve acquisition, retention and conversion.

Key use cases include:

• AI-directed virtual care: Automatically identify members who would benefit from virtual or hybrid care settings, helping direct them to more accessible, cost-effective options while improving outcomes.
• Retail-like digital front doors: Create member journeys that mimic retail—from discovery to payment—with transparency and ease.
• Remote monitoring and IoMT integration: Use biometric insights for early intervention, reducing admissions and supporting dynamic pricing.
• Member-facing AI navigation tools: Build guided self-service tools, deploy virtual assistants that help members understand coverage, schedule care or get triage recommendations that reduce confusion and call volume while improving satisfaction.
• Digital plan extensions: Develop new product lines such as virtual primary care, health wallets or behavioral health bundles.
• Omnichannel AI personalization: Use AI to meet existing and prospective members where they are—nudging healthy behaviors and surfacing relevant health actions in the right channel at the right moment.
• Digital onboarding and activation journeys: Convert new members faster and engage them early through smart onboarding experiences.

By implementing these emerging technology use cases, small and midsize local plans can meet rising member expectations while positioning themselves for growth. This includes expanding beyond traditional insurance products into digital-first offerings and health-adjacent services.

As health plan leaders seek new ways to improve margins and drive efficiency, technologies like automation, AI agents and generative AI present powerful opportunities. These tools can help reinvent operating models and organizational design by minimizing repetitive tasks and enhancing overall productivity.

Beyond meeting CMS interoperability mandates, payers are now integrating diverse member data—from administrative, clinical, financial, social drivers of health, wearables and more—to generate deeper insights and drive business value. Clinical data is no longer viewed in isolation; instead, it’s combined with third-party sources to create a comprehensive view of each member’s health journey over time.

Key use cases for driving business value include using AI to minimize manual medical record reviews and streamline prior authorization decisions. Payers are also identifying and closing actionable care gaps based on clinical guidelines, while reducing waste and duplicate testing through real-time interoperability and data exchange.

For small and midsize community-driven health plans, the future isn’t built through a single, giant leap forward. Instead, by intelligently and incrementally embracing these healthcare payer technology trends, they can remain community-focused, efficient and competitive—not necessarily the largest, but certainly the most trusted and responsive.

To start, small and midsize health plans should explore partnerships—with other plans, tech vendors or digital health innovators—to pool resources and invest in shared AI, automation and interoperability infrastructure like FHIR hubs or data utilities. Leaders should focus on quick wins and foundational upgrades, including interoperability, API enablement and cloud-native systems. Most importantly, aligning around a few high-impact, enterprisewide use cases will help drive meaningful change without spreading their efforts too thin.

In the AI era, success isn’t just about data—it’s about advancing data with impact. ZS achieves real breakthroughs by helping you combine three things: high-quality data, a deep understanding of functional workflows and the skill to shape the outcomes you want with scalable AI capabilities. The trends are clear, the technology is here and the moment for smart transformation is now.