December 2025 | By Softheon
Key takeaways for health plans investing in AI:
- Agentic AI is transforming health plan operations with orchestrated agents that deliver near-perfect accuracy.
- Softheon’s patented framework powers 1,300+ agents across enrollment, billing, and member engagement.
- AI will accelerate consumer-directed models like ICHRA, helping members compare and choose plans with confidence.
Artificial intelligence (AI) has been part of healthcare conversations for years, but the industry has always been cautious about what it can safely automate. Accuracy, compliance, member rights, and financial accountability are not optional. They are the foundation of every decision a health plan makes.
“AI is not a tool, is not a technology. In our view, AI is a way of thinking, a new way of doing things.” – Eugene Sayan
That is exactly why Softheon’s approach to AI is different. Long before AI was a headline, Softheon was building the groundwork for agentic systems that make healthcare simpler, safer, and more intuitive. And that story starts more than two decades ago with Softheon’s founder and CEO, Eugene Sayan.
A Patent That Became the Blueprint for Agentic AI
When Eugene came to the United States to continue his education, he was drawn to early computer automation. He later joined a startup backed by IBM, where he and his colleagues explored the idea of software agents that could independently manage parts of a system. When that work ended, he carried the concepts forward and filed a patent in 1998 focused on autonomous and semi-autonomous agents that could manage complex digital environments.
That patent became the foundation of Softheon’s technology.
“These semi-autonomous, in some cases autonomous agents, is the foundation of the patent that we have filed. I am proud to say that we implemented many critical parts of the patent as the foundation of Softheon’s technology.” – Eugene Sayan
Fast forward 25 years. Softheon now uses more than 1,300 agentic services to support the enrollment, billing, payment, eligibility, reconciliation, and member engagement operations of health plans across the country. The same ideas explored in the late 1990s now shape the next era of consumer-directed healthcare.
Why AI Matters in Healthcare
Healthcare has zero room for error. A one percent mistake rate is unacceptable when a single miscalculation can affect someone’s coverage, medical care, or financial stability. Eugene often compares it to aviation. If one percent of flights failed, hundreds of planes would crash each day. The same expectation applies to insurance operations, even though the failures look different.
This is why Softheon focuses on semi-autonomous, supervised agentic systems rather than fully autonomous AI. Every decision must align with federal rules, ethical standards, member protections, and clinical logic. Every action must be traceable. And every outcome must be correct.
AI is not a buzzword at Softheon. It is a way of thinking about automation: Break down complexity into smaller, accountable decisions that work together to support the entire member experience.
How Softheon’s Agentic Framework Works Behind the Scenes
On the surface, member interactions look and feel simple. Someone checks their eligibility. Someone compares plans. Someone pays their premium. Someone gets a digital notice.
Behind the scenes, hundreds of coordinated agents manage each step. This is the evolution that brought the industry from:
- Early websites
- To mobile-first design
- To the next stage: Conversational interfaces powered by AI
Members will increasingly interact with health plans through natural language, not traditional forms. But the real magic happens underneath. Softheon’s agentic system handles the calculations, validations, verifications, workflows, and compliance logic that make the experience safe, accurate, and fast.
Health plans are now ready for this shift. They no longer view AI as science fiction. They want to understand how it can support members in real time and reduce operational strain. Softheon is meeting that moment.
The Member Experience Is Changing
In the past, health insurance felt opaque. The ACA brought tens of millions of people into the individual market, and consumers now shop for coverage the same way they shop for flights. Price matters. Transparency matters. Local networks matter. Digital experiences matter.
AI will accelerate that shift. With guided plan selection, personalized recommendations, and conversational support, members will not need to decode healthcare terminology or guess which benefits matter most. AI can ask questions, understand preferences, and help individuals make informed decisions.
Softheon is designing its agentic system to remove the mystery from coverage choices and help members navigate the system with confidence.
ICHRA Will Push AI Adoption Even Faster
The rise of Individual Coverage Health Reimbursement Arrangements (ICHRA) is one of the most important trends reshaping the market. Instead of employers choosing a single group plan for everyone, companies can now give employees a set monthly contribution and allow them to shop for the plan that fits them best.
“ICHRA is a way for employers to empower their employees by providing them a contribution, we call it a defined contribution, every month. And then employees are now empowered to decide which health plan they want that best fits their needs.” – Eugene Sayan
It is the health insurance version of the shift from pensions to 401(k)s. More choice. More flexibility. More personalization.
For ICHRA to succeed, employees need help understanding their options. That is where AI becomes essential. Plan matching, subsidy determination, network guidance, and benefit navigation are too complex for a self-serve experience without support. AI closes that gap and brings ICHRA to scale.
Accountability, Safety, and Accuracy Are the Core of AI at Softheon
Everything Softheon builds follows one principle. Do no harm. Agents must:
- Independently orchestrate multi-step tasks and include checkpoints for human review.
- Avoid hallucination or incorrect recommendations.
- Follow all federal and state regulations.
- Protect members and patient rights.
- Deliver accuracy levels that approach perfection.
Eugene often says that 100 percent accuracy is idealistic, but Softheon’s systems are designed to operate at 99.99 percent accuracy. That level is essential in healthcare, where trust is non-negotiable. Agentic AI is not simply a tool. It is the architecture that will define how health plans operate for decades to come.
The Future of Health Plans Is Here
Healthcare is evolving, and so are the expectations of employers, members, and regulators. AI has moved from theory to reality, and Softheon is helping health plans use it safely and responsibly. The work that began with a patent 25 years ago is now shaping the future of enrollment, engagement, and coverage choice.
With over 1,300 agents running behind the scenes and new conversational interfaces guiding members, Softheon is the trusted, digital backbone leading the transformation toward a more intuitive, compliant, and personalized experience.
The next era of healthcare is consumer-directed, AI-supported, and built for accuracy. Softheon is ready for it, and we are helping health plans get ready too. If you want support bringing safe, supervised AI into your operations, we would love to talk.
Thank you to the The Healthcare AI Podcast and Oksana Meier for hosting the great conversation with Eugene! Watch the full Podcast here.
