The health insurance open-enrollment period is known to be a notoriously stressful time for payers and members alike. In 2026, health plans nationwide are facing historically high call volumes amidst surging ACA premiums and general volatility in the individual marketplace, stemming from the passage of the OBBBA in July 2025. Case in point is Michigan, where Blue Cross Blue Shield of Michigan (BCBSM) has seen its marketplace call center volumes surge by 20% due to unprecedented ACA premium spikes and the expiration of enhanced subsidies. Michigan’s surge is a microcosm of what’s happening nationwide. BCBSM has already exceeded 10,000 marketplace-related calls and tripled call center staffing to more than 100 individuals to keep up. Expected marketplace customers for 2026 may reach over 310,000.
Healthcare Pressures Are Fueling Member Confusion Everywhere
This challenge, however, is not unique to Michigan. Across the country, rising premiums, shrinking subsidies, and massive enrollment churn are creating operational strain for health plans of every size. ACA premium increases are contributing to a surge in consumer confusion and service volume. Fitch Ratings reports widespread ACA marketplace disruption across the U.S., driving risk pool deterioration and insurer reevaluations.
When premiums spike and subsidies shrink, health plan demand surges. These cost spikes are driving unprecedented consumer confusion — and confusion drives calls. Mitigating the surges and their associated costs is possible with immediate and extended strategies. A combination of short- and longer-term structural strategies ensures the most complete solution — one focused on member behavior, workflow optimization, and technology intervention, not just staffing levels.
Immediate Strategies to Mitigate the Effects from the Surge in Volume
Sagility’s short-term surge strategy combines people-powered expertise with rapid digital support to stabilize operations fast. We immediately deploy staff with deep knowledge and training to deal with surges to prevent errors and repeat calls. These tactical fixes handle the escalations related to disruptions and regulatory changes with or without permanent staff. Some specific remedies include:
- Elastic staffing model: We maintain a pool of staff who already understand payer operations, including terminology and regulatory guardrails. These cross-trained individuals can ramp rapidly across geographies, so payers do not carry FTEs annually. Intraday management with rapid reforecasting including AI-assisted forecasting, can rebalance staffing hour by hour. For enrollment deadlines and renewal cycles, we implement extended hours.
- Rapid micro training on surge intents: Sagility’s domain experts can deliver short, targeted refreshers: new benefit year changes, prior authorization updates, PCP/network changes, state-level coverage updates, and common misstatements to avoid. This micro-training helps to prevent repeat calls and compliance risks during spikes.
- Tiered routing: Organizing call flows so that each call reaches the right “tier” ensures that calls reach the right level of expertise the first time, including routing “deflection-friendly” intents to self-service channels before hitting live reps. Tier 1 handles high-volume “how do I…” and status calls. Tiers 2 and 3 handle more complex eligibility, tax-credit questions, and escalations.
- AI-Powered short-term digital relief: Digital entry points to absorb a large share of repetitive, high-volume intents, which can reduce live traffic by 15–35%.
- Interactive voice response tuning: Adjustments can address top healthcare intents and add surge-specific options, such as, “Press 2 for billing changes.”
- AI targeting: Sagility pairs Agent Assist with humans for high-volume, low-risk intents. Virtual agents handle top intents. Fewer calls reach humans, and the calls that do reach humans are shorter and better prepared — reducing abandonment drivers.
These short-term actions ensure fast stabilization, lower abandonment rates, and consistent, accurate communication during spikes. Short-term remedies deliver expanded capacity, the ability to maintain SLA performance, and the ability to contain the surge.
Longer-Term Strategies: How Sagility Uses AI to Contain and Prevent Spikes Term Strategies
As healthcare organizations look beyond short-term surge response, real transformation comes from building an operating model that reduces call volumes at the source and prevents future spikes altogether. Sagility enables this shift by combining deep healthcare domain expertise with advanced AI and structural modernization — redesigning digital pathways, strengthening knowledge and compliance systems, optimizing workforce models, and predicting demand with far greater accuracy.
- Modernizing and simplifying digital member pathways: The redesign of digital experiences across benefits, claims, eligibility, pharmacy, and prior authorization helps members self-resolve issues without calling. These tactics surface real-time information, embed AI explanations, streamline navigation, and improve mobile access to common questions, reducing the friction across digital journeys.
- Strengthening knowledge, policy, and compliance systems: To ensure clarity and consistency across all channels, Sagility modernizes the entire knowledge ecosystem. We transform outdated SOPs into policy locked, AI-accessible guidance, along with explainability scripts for complex topics. Unified knowledge feeds chat, voice, and digital tools, and automatic updates reflect benefit changes, premium adjustments, or regulatory requirements — keeping every channel accurate and aligned.
- Identifying and preventing spikes: AI and analytics help us identify issues early and prevent call spikes before they occur. Anomaly detection highlights problematic issues in real time, while predictive models forecast volume by intent. Automated, trigger‑based outreach helps preempt member confusion, and real‑time dashboards continuously monitor friction points across digital channels and the contact center to enable fast intervention.
- Creating high-trust self-service with intelligent automation: Sagility builds intelligent self-service tools that reliably address high-volume needs. Virtual agents handle common claims, benefits, PA, pharmacy, and provider inquiries; automated workflows simplify routine actions; and machine learning improves accuracy over time — building trust in digital channels and reducing reliance on live support.
The combination of short- and long-term strategies creates a resilient, digitally enabled ecosystem to anticipate member needs, instill trust in self-service alternatives, and resolve operational complexity upstream. These strategies result in sustainably lower call volumes, improved member experiences, a more stable, efficient service environment, and more predictable operating costs because the system is built to handle complexity before it ever reaches a contact center. Sagility is uniquely positioned to help provide the right blend of experienced staff, technology-led transformation to address extreme fluctuations in demand, and trusted collaboration to deliver the right set of solutions.
