Most people know the frustration of calling customer service with a simple question, only to be transferred or left on hold as minutes tick by. What starts as a small issue can quickly become draining when it’s hard to get a definitive answer.

That same uncertainty shows up in health care, where the questions carry more weight.

For many, navigating health care starts long before they see a doctor. It begins with trying to understand coverage, costs, and what comes next. A benefit isn’t clear. A simple question doesn’t have a simple answer. A bill arrives later and doesn’t add up.

In those moments, experience matters. Confusion can delay care, complicate decisions, or stop them altogether. Clarity helps people move forward. Health plans are part of these interactions, shaping how people make sense of care and what they do next.

Why the member experience matters

Those moments of confusion have real consequences. Research has consistently shown that when people struggle to understand their health coverage or anticipate costs, they are more likely to delay or avoid care — even when they believe it’s necessary. 

This is where the member experience comes into focus. It reflects how people encounter the system in real life: whether information is accessible, whether questions are answered clearly, and whether support is available when it’s needed. These interactions often happen outside of clinical settings, yet they affect how people experience care.

Health plans are frequently involved in these moments, often serving as the point of contact when the system feels hardest to navigate. 

“Building trust with our members starts with being brilliant at the basics,” says Lynn Bowman, senior vice president of service and experience at Point32Health, the parent company of Harvard Pilgrim Health Care and Tufts Health Plan. “When interactions with us are easy, empathetic, and effective, people feel supported and confident taking their next step.” 

From uncertainty to understanding 

Questions about coverage or costs can linger, especially when information comes from multiple sources that don’t always align. That’s when clarity is especially reassuring.

Reassurance doesn’t usually come from reading a policy or scrolling a website — it comes from talking to another person who can help.

One Harvard Pilgrim Health Care member described reaching out after trying unsuccessfully to resolve a payment issue through a state marketplace. What stood out wasn’t just getting an answer but trusting it was correct.

“The representative listened to my problem and took a detailed look at our situation,” the member shared. “Not only did she assure me that I was correct in my understanding but provided me documentation and I was able to know that the payment I made following was correct.”

When you’re not sure what to ask

Most people don’t call their health plan because they know exactly what they need, they call because something doesn’t make sense. Getting a clear answer isn’t always straightforward, especially when it’s hard to explain what feels confusing in the first place.

What often makes the difference is feeling understood. 

One Harvard Pilgrim member described a similar experience with a member services representative: “Though I wasn’t even quite sure what I was asking, she was able to decipher it by asking me a few simple questions,” the member shared. “She explained everything I needed in simple English. She was completely transparent about the pricing processes.”

Another member highlighted the value of having extra support while navigating benefits online: “She guided me through the website; she introduced me to benefits I was not aware of.”

Support in high-stakes moments

Not every interaction with a health plan is about getting an exact answer. Some happen when decisions feel heavy and deeply personal. Questions about out-of-pocket costs or coverage can carry added weight when timing matters or uncertainty is already high.

In those moments, support can be less about the answer and more about advocacy. 

A Harvard Pilgrim member described reaching out with questions about treatment costs: “The representative I spoke with offered to make a call for me or remain on the line while I contacted the financial office of the treatment facility to clarify the out-of-pocket expenses,” the member shared. “She was so kind and expressed words of support as well.”

Staying engaged in moments like these can matter as much as the answer itself. When decisions feel personal, having someone stay with you through the process makes a difference.

In the exam room, questions focus on diagnosis and treatment. Outside it, they turn to coverage, costs, and next steps. While coverage sets the framework, a member’s experience shapes how they understand their options — and the confidence to make decisions. In those moments, not having to navigate alone can make a complex system feel less overwhelming and more human.

Harvard Pilgrim Health Care, a Point32Health company, provides nationally ranked health plans and care-based programs and services to nearly 900,000 members in New England and beyond. Founded by doctors more than 50 years ago, it builds on that legacy and partnerships through an expansive network of doctors and hospitals nationwide to improve health outcomes and lower costs through clinical quality and innovative care management. A leading, not-for-profit health and well-being company, Harvard Pilgrim Health Care guides members — and the communities it serves — to better health each day.