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Last Updated on 20 January 2019

What Are Health Insurance Member Networks And How Do They Work?


Health insurance member networks in Australia

Extras policies cover Australians for the medical services they use everyday. If you visit the dentist, optometrist, massage therapist, or another specialist, extras cover can help you with costs.

While we often discuss the services covered by extras cover, there’s another aspect that isn’t discussed as frequently: the member network system. In this guide, we’ll take a deeper look at member networks and whether they’re a positive or negative part of extras cover.

Key Points
  • Member networks allow health funds to save money by making agreements with some extras providers.
  • Member networks limit your choice of provider, but can also save you money on out of pocket expenses.
  • Your individual health needs determine whether or not member networks will benefit you.

What Are Member Networks?

Member networks are a group of specialists who have an agreement with a particular health fund. These specialists provide services that fall under extras cover, and include dentists, massage therapists, and chiropractors.

Member networks go by many names, and they’re often specific to individual health funds. Bupa, for instance, calls their member network ‘Members First.’ Member networks are sometimes called preferred providers.

How Member Networks Work

A practitioner or provider that is part of a member network will have an agreement with a certain health fund.

Say, for instance, you are interested in visiting a dentist for a routine checkup. You want your health fund to cover this visit, so you check to see whether or not the fund uses a member network.

For this example, we’ll say that the health fund has agreements with a network of dentists. You can do a quick search on your health fund’s website to find a network dentist that is close to you. Now, you can visit the dentist knowing the service is covered.

Member networks often give you an out-of-pocket discount for visiting. Your health fund will pay a large portion—if not all—of your out-of-pocket expenses for visiting one of their participating members.

Now, say that you have a regular dentist you really like. You’ve been seeing him or her for years, and want to continue your visits after signing up for a new health fund.

Unfortunately, this health fund isn’t in the member network. Your health fund will either cover a lower percentage of the dentist’s fee or require you to pay the entire bill yourself.

As you can see, there are both positives and negatives when it comes to health insurance and member networks. For this reason, check your health fund’s terms and conditions before making a commitment. Look closely at their member network and their policy on coverage for non-network providers.

The Bright Side of Member Networks

While health funds often promote the benefits of member networks—often making them seem like the best choice for customers—they benefit the health fund much more than they benefit you.

There are some benefits to the practice, especially if your preferred dentist, massage therapist, chiropractor, etc. is already part of the member network of your health fund.

If this is the case, you stand to save money on your treatment. Your costs for a visit are likely to be reduced because they’re part of the health fund’s member network. You will also likely receive greater rebates for visiting this practitioner than you otherwise would.

Visiting an in-network provider can help you avoid bill shock. Fees are often more transparent, so you know how much you’ll pay and how much you will receive as a rebate before you visit. This eliminates the concern of receiving a bill that is much more than you expected.

The member network claim system is another benefit of member networks. It’s usually easier and faster to make claims with member network providers. Your health fund already has all of the necessary information for the provider, making the claims process and receiving your rebate quick and painless.

The Downside of Member Networks

As we touched on earlier, member networks aren’t always best for health fund customers. They limit your choices, which isn’t typically good for consumers.

Health funds might advertise that they want their members to receive the best possible care as their reason for creating member networks. Unfortunately, this isn’t always the case.

Health funds create member networks—no matter what specific name they use—as a way to save money. They make agreements with certain providers to send patients their way and pay less money as a result. This scheme is how they’re able to pay more of your bill.

So, you can’t be sure that your member network provider is a good fit for you, beyond the fact that they’re a member of the network. Additionally, there’s a chance your current provider isn’t participating in the particular member network of each health fund.

You’ll have to pay higher out-of-pocket costs if you like your dentist and they aren’t part of your member network. This can sometimes defeat the purpose of having extras cover in the first place.

Member Networks for Hospitals and Doctors

Member networks are usually associated with extras cover, but there are some health funds with preferred hospitals and doctors for hospital cover. Visiting an out of network doctor in these cases may come with a higher cost.

These hospital cover member networks are a bit more common for gap cover, which can be beneficial to members. You can save money by visiting these practitioners if you have a policy with a high deductible.

Should You Choose a Health Fund with a Member Network?

While it’s true that member networks aren’t the most customer-friendly approach to extras cover, they can have their benefits if you use them properly.

You might not have a preferred dentist or massage therapist, for instance, and receive extras cover with a member network attached. You won’t be losing out if you don’t already have a preferred practitioner, so you might end up saving some money.

Check the locations and availability of providers within a member network before committing. Some might not be accepting new patients or will have a long wait time, which can impact your decision.

If you have established relationships with preferred extras providers you might not be interested in member networks. However, you could still benefit from the scheme if your provider is part of the network.

The decision whether or not to use a member network is ultimately your own. Want to get started comparing different extras policies with or without member networks? Take a look at our comparison tool below.

Disclaimer: The above information is correct and current at the time of publication


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