BSBMED301 Readings

Fremgen, B. F., & Frucht, S. S. (2019). Medical terminology: A living language (7th ed.). Pearson.

Building Medical Terms From Word Parts

Four different word parts or elements can be used to construct medical terms:

1. The word root is the foundation of the word. cardiogram = record of the heart
2. A prefix is at the beginning of the word. pericardium = around the heart
3. A suffix is at the end of the word. carditis = inflammation of the heart
4. The combining vowel is a vowel (usually o) that links the word root to another word root or a suffix. cardiomyopathy = disease of the heart muscle

The following sections on word roots, combining vowels and forms, prefixes, and suffixes consider each of these word parts in more detail and present examples of some of those most commonly used.

Word Roots

The word root is the foundation of a medical term and provides the general meaning of the word. The word root often indicates the body system or part of the body being discussed, such as cardi for heart. At other times, the word root may be an action. For example, the word root cis means to cut (as in incision).

A term may have more than one word root. For example, osteoarthritis (osstee-oh-ar-THRY-tis) combines the word root oste meaning bone and arthr meaning joint. When the suffix -itis, meaning inflammation, is added, we have the entire word, meaning an inflammation involving bone at a joint.

Combining Vowel/Form

A combining vowel makes it possible to pronounce long medical terms with ease and to combine several word parts. This is most often the vowel o. Combining vowels are utilized in two places: between a word root and a suffix or between two word roots.

To decide whether or not to use a combining vowel between a word root and a suffix, first look at the suffix. If it begins with a vowel, do not use the combining vowel. If, however, the suffix begins with a consonant, then use a combining vowel. For example: To combine arthr with -scope will require a combining vowel: arthroscope (AR-throh-skohp). But to combine arthr with -itis does not require a combining vowel: arthritis (ar-THRY-tis).

The combining vowel is typically kept between two word roots, even if the second word root begins with a vowel. For example, in forming the term gastroenteritis (gas-troh-en-ter-EYE-tis), the combining vowel is kept between the two word roots gastr and enter (gastrenteritis is incorrect). As you can tell from pronouncing these two terms, the combining vowel makes the pronunciation easier.

When writing a word root by itself, its combining form is typically used. This consists of the word root and its combining vowel written in a word root/vowel form, for example, cardi/o. Since it is often simpler to pronounce word roots when they appear in their combining form, this format is used throughout this book.

Common Combining Forms

What follows are some commonly used word roots in their combining form, their meaning, and examples of their use. Review the examples to observe when a combining vowel was kept and when it was dropped according to the rules presented above.

Combining Form	Meaning	Example (Definition)
bi/o	life	biology (study of life)
carcin/o	cancer	carcinoma (cancerous tumor)
cardi/o	heart	cardiac (pertaining to the heart)
chem/o	chemical	chemotherapy (treatment with chemicals)
cis/o	to cut	incision (process of cutting into)
dermat/o	skin	dermatology (study of the skin)
enter/o	small intestine	enteric (pertaining to the small intestine)
gastr/o	stomach	gastric (pertaining to the stomach)
gynec/o	female	gynecology (study of females)
hemat/o	blood	hematic (pertaining to the blood)
immun/o	protection	immunology (study of protection)
laryng/o	larynx	laryngeal (pertaining to the voice box)
nephr/o	kidney	nephromegaly (enlarged kidney)
neur/o	nerve	neural (pertaining to a nerve)
ophthalm/o	eye	ophthalmic (pertaining to the eye)
ot/o	ear	otic (pertaining to the ear)
path/o	disease	pathology (study of disease)
rhin/o	nose	rhinoplasty (surgical repair of the nose)

Prefixes

Adding a prefix to the front of a term forms a new medical word. Prefixes frequently provide information about the location of an organ, the number of parts, or time (frequency). For example, the prefix bi- stands for two of something, such as bilateral (bye-LAT-er-al), meaning to have two sides. However, not every term will have a prefix.

Common Prefixes

What follows are some of the more common prefixes, their meanings, and examples of their use. When written by themselves, prefixes are followed by a hyphen.

Prefix	Meaning	Example (Definition)
a-	without	aphasia (without speech)
an-	without	anoxia (without oxygen)
anti-	against	antibiotic (against life)
auto-	self	autograft (a graft from one's own body)
brady-	slow	bradycardia (slow heartbeat)
de-	without	depigmentation (without pigment)
dys-	painful; difficult; abnormal	dysuria (painful urination); dyspnea (difficulty breathing); dystrophy (abnormal development)
endo-	within; inner	endoscope (instrument to view within); endocardium (inner lining of heart)
epi-	above	epigastric (above the stomach)
eu-	normal	eupnea (normal breathing)
ex-	outward	exostosis (condition of outward, or projecting, bone)
extra-	outside of	extracorporeal (outside of the body)
hetero-	different	heterograft (graft [like a skin graft] from another species)
homo-	same	homograft (graft [like a skin graft] from the same species)
hyper-	excessive	hypertrophy (excessive development)
hypo-	below; insufficient	hypodermic (below the skin); hypoglycemia (insufficient blood sugar)
in-	not; inward	infertility (not fertile); inhalation (to breathe in)
inter-	between	intervertebral (between the vertebrae)
intra-	within	intravenous (within a vein)
macro-	large	macrotia (having large ears)
micro-	small	microtia (having small ears)
neo-	new	neonatology (study of the newborn)
para-	beside; abnormal; two like parts of a pair	paranasal (beside the nose); paresthesia (abnormal sensation); paraplegia (paralysis of two like parts of a pair [the legs])
per-	through	percutaneous (through the skin)
peri-	around	pericardial (around the heart)
post-	after	postpartum (after birth)
pre-	before	preoperative (before a surgical operation)
pro-	before	prolactin (before milk)
pseudo-	false	pseudocyesis (false pregnancy)
re-	again	reinfection (to infect again)
retro-	backward; behind	retrograde (to move backward); retroperitoneal (behind the peritoneum)
sub-	under	subcutaneous (under the skin)
tachy-	fast	tachycardia (fast heartbeat)
trans-	across	transurethral (across the urethra)
ultra-	beyond	ultrasound (beyond sound [high-frequency sound waves])
un-	not	unconscious (not conscious)

Number Prefixes

What follows are some common prefixes pertaining to the number of items or measurement, their meanings, and examples of their use.

Prefix	Meaning	Example (Definition)
bi-	two	bilateral (two sides)
hemi-	half	hemiplegia (paralysis of one side/half of the body)
mono-	one	monoplegia (paralysis of one extremity)
multi-	many	multigravida (woman with many [two or more] pregnancies)
nulli-	none	nulligravida (woman with no pregnancies)
pan-	all	pansinusitis (inflammation of all the sinuses)
poly-	many	polymyositis (inflammation of many muscles)
quadri-	four	quadriplegia (paralysis of all four limbs)
semi-	partial	semiconscious (partially conscious)
tetra-	four	tetraplegia (paralysis of all four limbs)
tri-	three	triceps (muscle with three heads)

Suffixes

A suffix is attached to the end of a word to add meaning, such as a condition, disease, or procedure. For example, the suffix -itis, meaning inflammation, when added to cardi forms the new word carditis (kar-DYE-tis), meaning inflammation of the heart. Every medical term must have a suffix. Most often the suffix is added to a word root, as in carditis above; however, terms can also be built from a suffix added directly to a prefix, without a word root. For example, the term dystrophy (DIS-troh-fee), meaning abnormal development, is built from the prefix dys- (meaning abnormal) and the suffix -trophy (meaning development).

Common Suffixes

What follows are some common suffixes, their meanings, and examples of their use. When written by themselves, suffixes are preceded by a hyphen.

Suffix	Meaning	Example Definition
-algia	pain	gastralgia (stomach pain)
-cele	protrusion	cystocele (protrusion of the bladder)
-cyte	cell	erythrocyte (red cell)
-dynia	pain	cardiodynia (heart pain)
-ectasis	dilation	bronchiectasis (dilated bronchi)
-gen	that which produces	pathogen (that which produces)
-genic	producing	carcinogenic (cancer producing)
-ia	condition	bradycardia (condition of slow heart)
-iasis	abnormal condition	lithiasis (abnormal condition of stones)
-ism	state of	hypothyroidism (state of low thyroid)
-itis	inflammation	dermatitis (inflammation of skin)
-logist	one who studies	cardiologist (one who studies the heart)
-logy	study of	cardiology (study of the heart)
-lytic	destruction	thrombolytic (clot destruction)
-malacia	abnormal softening	chondromalacia (abnormal cartilage softening)
-megaly	enlarged	cardiomegaly (enlarged heart)
-oma	tumor, mass	carcinoma (cancerous tumor)
-opsy	view of	biopsy (view of life)
-osis	abnormal condition	cyanosis (abnormal condition of
-pathy	disease	myopathy (muscle disease)
-plasm	formation	neoplasm (new formation)
-plegia	paralysis	laryngoplegia (paralysis of larynx)
-ptosis	drooping	blepharoptosis (drooping eyelid)
-rrhage	abnormal flow	hemorrhage (abnormal flow of blood)
-rrhagia	abnormal flow condition	cystorrhagia (abnormal flow from the bladder)
-rrhea	discharge	rhinorrhea (discharge from the nose)
-rrhexis	rupture	hysterorrhexis (ruptured uterus)
-sclerosis	hardening	arteriosclerosis (hardening of an artery)
-stenosis	narrowing	angiostenosis (narrowing of a vessel)
-therapy	treatment	chemotherapy (treatment with chemicals)
-trophy	development	hypertrophy (excessive development)

Adjective Suffixes

The following suffixes are used to convert a word root into an adjective. Each of these suffixes is usually translated as pertaining to.

Suffix	Meaning	Example (Definition)
-ac	pertaining to	cardiac (pertaining to the heart)
-al	pertaining to	duodenal (pertaining to the duodenum)
-an	pertaining to	ovarian (pertaining to the ovary)
-ar	pertaining to	ventricular (pertaining to a ventricle)
-ary	pertaining to	pulmonary (pertaining to the lungs)
-atic	pertaining to	lymphatic (pertaining to lymph)
-eal	pertaining to	esophageal (pertaining to the esophagus)
-iac	pertaining to	chondriac (pertaining to cartilage)
-ic	pertaining to	gastric (pertaining to the stomach)
-ical	pertaining to	chemical (pertaining to a chemical)
-ile	pertaining to	penile (pertaining to the penis)
-ine	pertaining to	uterine (pertaining to the uterus)
-ior	pertaining to	superior (pertaining to above)
-nic	pertaining to	embryonic (pertaining to an embryo)
-ory	pertaining to	auditory (pertaining to hearing)
-ose	pertaining to	adipose (pertaining to fat)
-ous	pertaining to	intravenous (pertaining to within a vein)
-tic	pertaining to	acoustic (pertaining to hearing)

Surgical Suffixes

The following suffixes indicate surgical procedures.

Suffix	Meaning	Example (Definition)
-centesis	puncture to withdraw	arthrocentesis (puncture to withdraw fluid from a joint)
-ectomy	surgically create an	gastrectomy (surgical removal of the stomach)
-ostomy	fluid	colostomy (surgically create an opening for the colon [through the abdominal wall])
-otomy	surgical removal	thoracotomy (cutting into the chest)
-pexy	opening	nephropexy (surgical fixation of a kidney)
-plasty	cutting into	dermatoplasty (surgical repair of the skin)
-rrhaphy	surgical fixation	myorrhaphy (suture together muscle)
-tome	instrument to cut	dermatome (instrument to cut skin)

Procedural Suffixes

The following suffixes indicate procedural processes or instruments.

Suffix	Meaning	Example (Definition)
-gram	record	electrocardiogram (record of heart's electricity)
-graphy	process of recording	electrocardiography (process of recording the heart's electrical activity)
-meter	instrument for measuring	audiometer (instrument for measuring hearing)
-metry	process of measuring	audiometry (process of measuring hearing)
-scope	instrument for viewing	gastroscope (instrument for viewing stomach)
-scopic	pertaining to visually examining	endoscopic (pertaining to visually examining within)
-scopy	process of visually examining	gastroscopy (process of visually examining the stomach)

Cross, N., & McWay, D. (2020). Stanfield’s essential medical terminology (5th ed.). Jones & Bartlett Learning.

Healthcare professionals frequently use abbreviations in their work as a means to communicate information in a succinct manner. For those healthcare professionals involved in documenting the delivery of patient care, abbreviations improve workflow and efficiency, allowing more work to be performed in less time. The danger in using abbreviations is that some healthcare professionals may not rely upon a standard compilation of abbreviations or may even be unfamiliar with standard abbreviations, thereby causing confusion. This confusion can lead to misinterpretation, which in turn may lead to negative consequences for a patient.

Learning abbreviations as part of a future healthcare professional’s education is time well spent. By learning abbreviations early in training, the future healthcare professional is able to apply this knowledge to multiple science classes and practical learning experiences. Further, time is made available so the student can focus on other matters, such as clinical rotations, knowing that medical abbreviations are understood thoroughly.

Some abbreviations are considered acronyms, meaning the initial letters of words in a sequence are combined together and pronounced as a single word. While an individual may wish to pronounce each word in the sequence separately, it is often easier to pronounce the acronym. Some examples of acronyms are included in the tables in this chapter.

Abbreviations for Services or Units in a Healthcare Facility

Some of the various abbreviations for the services and units in a healthcare facility are listed in Table 7-1.

TABLE 7-1 Abbreviations for Services or Units in a Healthcare Facility

Abbreviation	Definition
A&D	admitting and discharge
CS	central service (or supply)
OR	operating room (surgery); MOR, minor surgery
RR	recovery room
PT & OT	physical therapy and occupational therapy (may be under PM & R, physical medicine and rehabilitation)
X-ray	radiology
Lab	medical laboratory
MR	medical records
peds	pediatrics
Med-Surg	ward for medical and surgical patients (may be combined or separate)
OB	obstetrics (includes labor and delivery rooms, postpartum ward, and newborn nursery for healthy babies)
ICN or NICU	intensive care nursery or newborn intensive care unit (for premature or unhealthy babies)
OPD	outpatient department
ER	emergency room; ED, emergency department
ENT	ear, nose, and throat
GU	genitourinary
NP	neuropsychiatric
SS	social service
CCU or ICU	coronary care unit or intensive care unit
DOU	definitive observation unit (less than intensive care, but more than "floor" care)
dietary (FS)	food service/dietary department
housekeeping	janitorial service
pharmacy	drugstore
morgue	unit for autopsies/holding the deceased
pathology (path)	laboratory for study of diseased tissues, including blood

Abbreviations Commonly Used in Health Records

Abbreviations that are commonly found in health records of patients are listed in Table 7-2.

TABLE 7-2 Abbreviations Commonly Used in Health Records

Abbreviation	Definition
CC	chief complaint of patient
EHR	electronic health record
H&P	history and physical
HPI	history of present illness
NKDA	no known drug allergies
PE	physical examination
PMHx	past medical history
PSHx	past surgical history
ROS	review of systems
SHx & FHx	social history and family history

Abbreviations for Frequencies

Abbreviations used to indicate the frequency of administering a treatment (drugs, etc.) are listed in Table 7-3.

TABLE 7-3 Abbreviations for Frequencies

Abbreviation	Definition
q	every
qd	once a day
qod	every other day
q___h	every ___ hours (insert hours)
bid	twice a day
tid	three times a day
qid	four times a day
hs	at bedtime (hour of sleep)
ac	before meals
pc	after meals
prn	when needed
ad lib	as desired
stat	immediately

Abbreviations for Units of Measure

Abbreviations that are used as units of measure are as shown in Table 7-4

TABLE 7-4 Abbreviations for Units of Measure

Abbreviation	Definition
tabs.	tablets, pills
g, gm	grams
gr.	grains
cc	cubic centimeters
mL, ml	milliliters
L	liter (1,000 cc or ml)
mEq	milliequivalent
U	units
gtts	drops
oz	ounces
dr.	drams

Abbreviations for Means of Administering Substances Into the Body

Abbreviations for the means of administering substances into the body of a patient are listed in Table 7-5.

TABLE 7-5 Abbreviations for Means of Administering Substances into the Body

Abbreviation	Definition
PO	by mouth (per os)
IV	intravenously (into a vein; usually a peripheral vein)
IM	intramuscularly (into a muscle)
H	hypodermically (with a needle)
subcu, subq	subcutaneously (through the skin, into the fatty tissue)
subling	sublingually (under the tongue)
R	rectally (by rectum)
parenteral	a solution given intravenously
enteral	tube feeding (into stomach or small intestine)
D5W	5% glucose in distilled water; use IV
caps.	capsules
supp	suppository
SS	one-half
mg	milligrams
N.S.	normal saline solution: isotonic solution
clysis	fluids given by needle, under skin (not in vein)
TKO	to keep open (vein)
KVO	keep vein open

Abbreviations for Diet Orders

Abbreviations that are used in diet orders for patients are listed in Table 7-6.

TABLE 7-6 Abbreviations for Diet Orders

Abbreviation	Definition
NPO	nothing peros (nothing to eat or drink orally)
I & O	intake and output (measured)
Cl Liq	clear liquids only: ginger ale, tea, broth, Jell-O, 7-Up, coffee
F Liq	full liquid: addition of milk and milk products; liquid at body temperature
Lo Salt, Low Na, Salt Free	restricted in sodium: ordered by mg or g of sodium desired, e.g., 2 g Na, 500 mg Na
NAS	no added salt packet, usually 4-6 g Na (mild restriction)
reg	regular diet ("house" or "normal" sometimes used): a balanced diet without restrictions as to the type of food texture, seasoning, or preparation method
mech soft	mechanical soft: a regular diet with alteration in texture only; sometimes called "edentulous"
med soft	medical soft: alterations in texture, preparation methods, and seasonings
bland	a medical soft diet further altered to omit acid-producing beverages and restrict seasonings; altered feeding intervals
Lo res	low residue: alteration in texture and a limited food selection to yield little intestinal residue
high fiber	a regular diet with increased amounts of foods containing dietary fiber
FF or PF	force or push fluids: increasing the liquid intake by addition of extra fluids
int fdg or int nour	interval feeding: supplemental nourishment served between meals
DAT	diet as tolerated
dysphagia pureed	regular diet pureed to a smooth, homogeneous, and cohesive consistency like pudding
consistent or controlled carbohydrate (CCHO)	consistent amounts of carbohydrate at meals and snacks to regulate blood glucose levels primarily for diabetes
Lo Fat, Lo Chol	low saturated fat, low cholesterol: a "Healthy Diet, based on The Dietary Guidelines for Americans, 2010, to reduce the risk of heart disease

Abbreviations for Activity and Toiletry

Abbreviations related to activity and toiletry are listed in Table 7-7.

TABLE 7-7 Abbreviations for Activity and Toiletry

Abbreviation	Definition
CBR	complete bed rest; ABR, absolute bed rest
dangle	sit at edge of bed, legs over the side
ambulate	walk
OOB	out of bed
BRP	bathroom privileges; may be up to bathroom only
commode	bedside toilet

Abbreviations for Laboratory Tests, X-Ray Studies, and Pulmonary Function

Abbreviations related to laboratory tests, X-ray studies, and pulmonary function are included in Table 7-8.

TABLE 7-8 Abbreviations for Laboratory Tests, X-Ray Studies, and Pulmonary Function

Abbreviation	Definition
AP and Lat	routine X-ray picture of chest (front to back and side view)
up	upright X-ray picture
decub	decubitus (lying) position
IVP	intravenous pyelogram (kidney)
BE	barium enema (colon)
2GI series	upper (barium swallow): X-ray of stomach/duodenum lower (same as BE): X-ray of lower bowel/colon
GB series	gallbladder X-ray picture
MRI	magnetic resonance imaging: noninvasive procedure using a magnetic field that yields images for diagnosis
RAI, RAIU	radioactive iodine (uptake) for diagnosing thyroid function
SCAN	CT, CAT: computed tomography, computerized axial tomography
CBC	complete blood count
UA	urinalysis
VC	vital capacity (lungs)

Abbreviations for Miscellaneous Terms

Abbreviations of some miscellaneous terms used in the field of medicine are listed in Table 7-9.

TABLE 7-9 Abbreviations for Miscellaneous Terms

Abbreviation	Definition
qns	quantity not sufficient (lab requires a larger specimen); also refers to insufficient food/liquid intake
c̅	with (con)
s̅	without (sans)
dc	discontinue
TLC	tender loving care
stat	immediately
ASAP	as soon as possible
CPR	cardiopulmonary resuscitation
EUA	examination under anesthesia
DOA	dead on arrival
OD	overdose; also means right eye (refer to context where used)
prep	prepare
V/S	vital signs
ECG, EKG	electrocardiogram
EEG	electroencephalogram
Dx	diagnosis
Tx	treatment
Rx	prescription
Sx	symptoms
Na+	natrium: sodium (chemical symbol for)
K+	potassium (chemical symbol for)
Ca**	calcium (chemical symbol for)
ры	phosphorus (chemical symbol for)
CH-	chloride (chemical symbol for)
Fe++	iodine (chemical symbol for)
Hg"	iron (chemical symbol for)
DS	double strength
O.S.	left eye
PDR	Physicians' Desk Reference

Australian Bureau of Statistics. (2022, March 21). Health conditions prevalence: Key findings on selected long-term health conditions and prevalence in Australia.

Key statistics

• Over three quarters (78.6%) of Australians had at least one long-term health condition in 2020-21
• Nearly half had at least one chronic condition (46.6% or 11.6 million)
• Mental and behavioural conditions (20.1%), Back problems (15.7%) and Arthritis (12.5%) were the most common chronic conditions

Health influences, and is influenced by, how we feel and how we interact with the world around us. Health is broader than just the presence or absence of disease, it reflects the complex interactions of an individual’s genetics, lifestyle and environment[1]. In 2020-21 more than half (56.6%) of people aged 15 years and over considered themselves to be in excellent or very good health, while 13.8% considered their health to be fair or poor.

Chronic conditions

Long-term health conditions are conditions which were current at the time of the survey interview and had lasted, or were expected to last, 6 months or more. Selected chronic conditions are a subset of long-term health conditions that are common, pose significant health problems, and have been a focus of ongoing public health surveillance[2].

Definitions

Selected chronic conditions includes 10 chronic condition groups:

• Arthritis
• Asthma
• Back pain
• Cancer
• Cardiovascular disease
• Chronic Obstructive Pulmonary Disease (COPD)
• Diabetes
• Kidney disease
• Mental health conditions, and
• Osteoporosis.

Nearly half of Australians of all ages (46.6%) had one or more chronic condition, and almost one in five (18.6%) had two or more chronic conditions. Almost half (49.0%) of all females had one or more chronic conditions, and one in five (20.7%) had two or more. Similarly, 43.9% of males had one or more chronic conditions and 16.4% had two or more.

Overall, women aged 18 years and over were more likely than men to have one or more chronic conditions (56.5% compared to 49.5%).

The most prevalent chronic conditions experienced in Australia in 2020-21 were:

• Mental and behavioural conditions – 20.1%
• Back problems – 15.7%
• Arthritis – 12.5%
• Asthma – 10.7%
• Diabetes – 5.3%, comprised of Type 1 diabetes (0.6%) and Type 2 diabetes (4.5%)
• Heart, stroke and vascular disease – 4.0%
• Osteoporosis – 3.6%
• Chronic Obstructive Pulmonary Disease (COPD) – 1.5%
• Cancer – 1.6%
• Kidney disease – 1.1%.

Many people with chronic conditions have more than one condition at the same time (multimorbidity)[2]. For example, in 2020-21 of those who had COPD, nine in ten (91.3%) had another condition. The prevalence of multimorbidity varied across chronic conditions:

• COPD – 91.3%
• Heart, stroke and vascular disease – 82.7%
• Kidney disease – 77.8%
• Cancer – 75.0%
• Osteoporosis – 73.9%
• Diabetes – 71.0%
• Arthritis – 70.7%
• Back problems – 64.4%
• Asthma – 57.9%
• Mental and behavioural problems – 49.5%

 

The prevalence of chronic conditions and multimorbidity was more common with age.

 

Half (50.4%) of people of all ages who lived in areas of most disadvantage had one or more chronic conditions, and one in four (24.9%) had two or more. For people who lived in areas of least disadvantage, two in five (41.4%) had one or more chronic conditions and one in eight (12.8%) had two or more.

 

(a) A lower index of Disadvantage quintile (e.g. the first quintile) indicates relatively greater disadvantage and a lack of advantage in general. A higher Index of Disadvantage (e.g. the fifth quintile) indicates a relative lack of disadvantage and greater advantage in general. See Socio-Economic Indexes for Areas (SEIFA), Australia, 2016 (abs.gov.au).

Mental and behavioural conditions

Mental health is a key component of overall health and wellbeing. A mental illness can be defined as ‘a clinically diagnosable disorder that significantly interferes with a person’s cognitive, emotional or social abilities’. The term itself covers a range of illnesses including anxiety disorders, affective disorders, psychotic disorders and substance use disorders[3].

A person does not need to meet the criteria for a mental illness or mental disorder to be negatively affected by their mental health. Mental health affects and is affected by multiple socioeconomic factors, including a person’s access to services, living conditions and employment status, and affects not only the individual but also their families and carers[3]. In 2020-21:

• One in five (20.1% or 5.0 million) people of all ages experienced a mental or behavioural condition
• Females were more likely than males to have reported a mental or behavioural condition (22.8% compared to 17.3%).

 

• People aged 15-24 years and 25-34 years had higher rates of mental or behavioural conditions (27.5% and 25.3% respectively) than people aged 55-64 years (18.9%), 65-74 years (15.8%) and 75 years and over (15.7%)
• The most common mental or behavioural conditions were anxiety (12.7%) and depression (10.1%)
• Females were more likely than males to have anxiety (15.7% compared to 9.4%) or depression (12.3% compared to 7.8%).

 

Arthritis and Osteoporosis

Arthritis refers to a range of musculoskeletal conditions where a person's joints become inflamed, which may result in pain, stiffness, disability, or deformity. In 2020-21:

• One in eight (12.5%) people of all ages had arthritis
• Rates of arthritis increased with age, particularly for females
• People living in areas of most disadvantage were more likely than those living in areas of least disadvantage to have arthritis (15.3% compared to 9.5%).

Of people aged 18 years and over with arthritis, 93.9% experienced bodily pain in the four weeks prior to interview. More than one in three (36.0%) people aged 18 years and over with arthritis experienced moderate bodily pain and 17.7% experienced severe or very severe pain in the four weeks prior to interview.

 

Osteoporosis is a condition where a person’s bones become fragile and brittle, with an increased risk of fractures. Osteoporosis can be managed with medications and lifestyle changes such as increasing exercise and stopping smoking[4].

In 2020-21, 889,400 (3.6%) people of all ages had osteoporosis, with females being more likely than males (5.9% compared with 1.1%) to be diagnosed.

• Osteoporosis was more common in older age groups, increasing from 5.6% of people aged 55-64 years to 20.1% of people aged 75 years and over
• Nine in ten (90.3%) people aged 18 years and over with osteoporosis experienced bodily pain in the four weeks prior to interview
• One in three (33.8%) people aged 18 years and over with osteoporosis experienced moderate bodily pain, while 13.7% experienced severe or very severe pain.

Asthma

Asthma is a lung condition caused by narrowing of the airways when they become inflamed[5]. People with asthma experience difficulty breathing and the most common symptoms are wheezing, coughing, breathlessness and chest tightness.

Just under 2.7 million (10.7%) Australians had asthma. Females were more likely than males to have asthma (12.0% compared to 9.4%).

See Asthma for further information.

Diabetes

Diabetes is a chronic condition where the body cannot produce enough insulin, a hormone essential for converting glucose into energy.

One in twenty (5.3% or 1.3 million) people had diabetes, with Type 2 diabetes most common. The rate of diabetes increased with age.

See Diabetes for further information.

Heart, stroke and vascular disease

Heart, stroke and vascular disease encompasses a range of circulatory conditions including:

• Ischaemic heart diseases (angina, heart attack and other ischaemic heart diseases)
• Cerebrovascular diseases (stroke and other cerebrovascular diseases)
• Oedema
• Heart failure
• Diseases of the arteries, arterioles and capillaries.

This group of conditions is commonly referred to under the broader term of ‘heart disease’ or cardiovascular disease. In 2020, ischaemic heart diseases were the leading cause of death (followed by dementia) while cerebrovascular diseases (including stroke) were the third leading cause of death[6]. In 2020-21:

• The rate of heart disease was 4.0%, representing 1.0 million people
• Heart disease was more common in males than females (4.9% compared to 3.1%)
• Heart disease increased with age, from 2.3% of people aged 45-54 years through to 23.2% of people aged 75 years and over
• Males aged 65-74 years were more than twice as likely as females to have heart disease (17.4% compared to 7.6%)
• Similarly, males aged 75 years and over were almost twice as likely as females to have heart disease (31.4% compared to 15.9%).

 

• Males were more than twice as likely as females to have had a heart attack or other ischaemic heart disease (2.1% compared to 0.8%)
• Almost one in fourteen (6.7%) people had hypertension
• Hypertension rates increased with age, with more than one in four (27.4%) people aged 75 years and over reporting they had hypertension.

Chronic Obstructive Pulmonary Disease (COPD)

Chronic Obstructive Pulmonary Disease (COPD) covers a range of conditions including emphysema, chronic bronchitis and chronic asthma. The condition causes narrowing of the bronchial tubes in the lungs (sometimes called bronchi or airways) which makes breathing difficult[7].

In 2020-21, 375,800 people (1.5%) of all ages had COPD.

• Females were more likely than males to have COPD (2.0% compared to 0.9%)
• COPD was more common in older age groups, with 5.2% of people aged 75 years and over having COPD
• Almost one in five (19.8%) people aged 18 years and over with COPD experienced severe or very severe bodily pain in the four weeks prior to interview.

Cancer

Cancer is a condition in which the body's cells grow and spread in an uncontrolled manner. A cancerous cell can arise from almost any cell, and therefore cancer can be found almost anywhere in the body.

Cancer was the leading cause of total burden of disease in 2018, accounting for 18% of the total disease burden[8]. During 2020, there was a reduction in cancer related diagnostic procedures and therapeutic procedures[9]. This may have contributed to delayed diagnosis and management of cancer in Australians.

This analysis focuses on cancer expected to last for six months or more – including non-melanoma skin cancer (basal cell carcinoma (BCC) and squamous cell carcinoma (SCC)).

In 2020-21, 410,900 (1.6%) people of all ages had cancer.

• Males were twice as likely as females to have cancer (2.2% compared with 1.1%)
• People aged 65 years and over were more likely than any other age group to have cancer (5.6%).

More than one in four (26.5%) people aged 18 years and over with cancer experienced moderate bodily pain in the four weeks prior to interview, while 18.3% experienced severe or very severe bodily pain.

 

Kidney disease

Kidney disease is a chronic condition in which a person's kidney function is reduced or damaged. The kidney’s main task is to clean blood and filter waste out through urine. When kidneys aren't functioning as they should, waste gradually builds up in a persons' body, and this can have a devastating impact on their health. This condition is called kidney disease - the loss of normal kidney function over time. It can also be called kidney failure, which is the end-stage of kidney disease[10]. Kidney disease is also often associated with other chronic diseases such as diabetes and cardiovascular disease. People aged 75 years and over experience high fatal burden from chronic kidney disease[11].

In 2020-21, 1.1% of Australians of all ages (264,900 people) had kidney disease.

• Rates for males and females were similar (1.1% and 1.0%)
• Rates of kidney disease increased from 65-74 years to 75 years and over (2.6% compared to 5.0%).

Other long-term health conditions

Some long-term health conditions may not be considered chronic but can impact daily life. More than three quarters (78.6%) of Australians had at least one long-term health condition. Common long-term conditions in 2020-21 outside of chronic conditions included:

• Over one quarter (25.6%) of people were short sighted, while around one in five (21.9%) were long sighted
• One in five (20.3%) people experienced hayfever or allergic rhinitis
• More than one in ten (11.2%) people had an allergy, with 6.1% reporting food allergies
• One in twelve (8.7%) people had a hearing impairment (partial or complete deafness)
• About one in fifteen (6.4%) people experienced severe or very severe bodily pain in the 4 weeks prior to interview.

Footnotes

1. Australian Institute of Health and Welfare, ‘Australia’s health 2020 data insights’, accessed 28/02/2022.
2. Australian Institute of Health and Welfare, ‘Chronic conditions and multimorbidity’, accessed 26/05/2022.
3. Australian Institute of Health and Welfare, ‘Mental health’, accessed 01/03/2022.
4. Health Direct, ‘Osteoporosis’, accessed 18/02/2022.
5. Department of Health, ‘What we’re doing about lung and respiratory conditions’, accessed 09/02/2022.
6. Australian Bureau of Statistics, ‘Causes of Death, Australia, 2020’, accessed 16/02/2022.
7. Lung Foundation, ‘Overview – Chronic Obstructive Pulmonary Disease’, accessed 01/02/2022.
8. Australian Institute of Health and Welfare, 'Cancer overview'.
9. Cancer Australia, ‘The impact of COVID-19 on cancer-related medical services and procedures in Australia in 2020’, accessed 16/02/2022.
10. Kidney Health Australia, 'What is kidney disease?', accessed 17/03/2022.
11. Australian Institute of Health and Welfare, ‘Australian Burden of Disease Study: impact and causes of illness and death in Australia 2018’, accessed 21/02/2022.

Australian Government. (n.d.). How health insurance works. https://www.privatehealth.gov.au/health_insurance/index.htm

How Health Insurance Works

This website aims to answer your questions about private health insurance by explaining how it works, and who and what is covered. You can also compare policies from different Health insurers to help you choose a policy that is right for you.

In Australia, private health insurance is 'community rated'. This means that everyone is entitled to buy the same product, at the same price (except for Lifetime Health Cover and Age-based Discounts), and is guaranteed the right to renew their policy. A health insurer cannot refuse to insure you or refuse to sell you any policy you want to buy.

Some of the things to consider when looking into private health insurance include:

• What is covered? In Australia, the public health system, Medicare, covers most Australian residents for health care. However, Medicare does not cover everything and you can choose to take out private health insurance to give yourself a wider range of health care options and more comprehensive cover.
• How does it work? There are two types of health insurance: hospital and general treatment (ancillary or extras) cover. You can buy policies for these types of cover separately or most insurers offer combined policies. There will be limitations on what and when you can claim with any policy you buy.
• What government incentives and surcharges affect my insurance? The Private Health Insurance Rebate, the Lifetime Health Cover rules, and Age-based discount affect how much you pay for private health insurance. The Medicare Levy Surcharge affects people earning above a certain threshold who don't hold private hospital cover.
• Overseas visitors & students If you are in Australia on a temporary visa, you should consider taking out some form of visitor's health cover for the duration of your stay. On some visas, you may be required to take out a form of visitor's health insurance.

Overview of Health System

Medicare is a universal health care system that delivers affordable, accessible and high-quality health care for most Australian residents. You can also choose to take out private health insurance to give you more health care options and to cover items which are not covered by Medicare.

You can get a Medicare card if you live in Australia or Norfolk Island and meet certain criteria.

You may be eligible for a Medicare card if you visit from certain countries. You should note that some limits may apply. If you are visiting from overseas and are a reciprocal Medicare card holder, see Overseas visitors & overseas students health cover.

Below is a summary of what is covered by private health insurance and Medicare for hospital, medical services and general treatment, pharmaceutical benefits and ambulance.

Hospital

Private Cover	Medicare
Provided your policy covers the service that is being treated in hospital: You can choose to be treated as a private patient in either a public or a private hospital. You can choose your own doctor. On most policies you can decide whether you will go to a public hospital, or a private hospital which has an agreement with your insurer. You may also have more choice as to when you are admitted to hospital. If you are a private patient in a public hospital, public hospital waiting lists still apply. If you choose to be treated as a private patient in a hospital (public or private), Medicare will cover you for 75% of the Medicare Benefits Schedule (MBS) fee for associated medical costs.	You can be treated as a public patient in a public hospital by a doctor appointed by the hospital. You cannot choose your own doctor and you may not have a choice about when you are admitted to hospital. You can choose to be treated as a public patient even if you are privately insured.
The remaining hospital and medical costs will be charged to you - some or all of these costs may be covered by your private health insurance, depending on your policy. The remaining costs include 25% of the MBS fee for doctors' services and any amount the doctors charge above the MBS fee, plus some or all the costs of: hospital accommodation; theatre fees; intensive care; drugs, dressings and other consumables; prostheses (surgically implanted): diagnostic tests; pharmaceuticals; and any additional doctor's fees.	As a public patient you will be treated at no charge. Medicare does not cover private patient hospital costs (for example, theatre fees or accommodation) medical and hospital costs incurred overseas medical and hospital services which are not clinically necessary, or surgery solely for cosmetic reasons examinations for life insurance, superannuation or memberships for which someone else is responsible (for example, a compensation insurer, employer, or government authority) emergency department administration or facility fees.

For further information please see:

• What is covered by Medicare?
• What is covered by private health insurance?

Medical Services and General Treatment

Private Cover	Medicare
If you visit a doctor outside a hospital, Medicare will reimburse 100% of the MBS fee for a general practitioner and 85% of the MBS fee for a specialist - this applies whether or not you hold private health insurance. If your doctor bills Medicare directly (bulk billing), you will not have to pay anything.
Medicare does not provide benefits for the following: most dental examinations and treatment most physiotherapy, occupational therapy, speech therapy, eye therapy, chiropractic services, podiatry or psychology services acupuncture (unless part of a doctor's consultation) glasses and contact lenses hearing aids and other appliances home nursing You can arrange private health insurance to cover many of these services. Most insurers will have limits on how much you can claim per service and per year.	Medicare provides benefits for: consultation fees for doctors, including specialists tests and examinations by doctors needed to treat illnesses, such as x-rays and pathology tests eye tests performed by optometrists most surgical and other therapeutic procedures performed by doctors in public hospitals some surgical procedures performed by approved dentists specific items under the Cleft Lip and Palate Scheme specific items under the Enhanced Primary Care (EPC) program specific items for allied health services as part of the Chronic Disease Management Plan

For further information please see:

• What is covered by Medicare?
• What is covered by private health insurance?

Pharmaceutical

Private Cover	Medicare
Under the Pharmaceutical Benefits Scheme (PBS), you pay only part of the cost of most prescription medicines purchased at pharmacies in Australia. The rest of the cost is covered by the PBS. You must present your Medicare card to obtain this benefit. The amount you pay varies with the medicine, up to a standard maximum. People with Government-issued concession cards have a lower maximum payment.
You can arrange private health insurance to cover many prescription medicines which aren't listed on the PBS. Most insurers will require you to make a co-payment towards the cost and will have limits on how much you can claim. Some prescription medicines are not listed on the PBS. You pay the full amount for these non-PBS items.	Some prescription medicines are not listed on the PBS. You pay the full amount for these non-PBS items.

Ambulance

Private Cover	Medicare
In Queensland and Tasmania, emergency ambulance services are provided to residents for free by the State Government. New South Wales and Australian Capital Territory provide free emergency ambulance services for Pensioners and Concession Card Holders. In the Northern Territory, NT Centrelink Pensioner Concession Card or Health Care Card holders are exempt from ambulance fees. Victorian Pension Concession/Healthcare Card holders are also covered for clinically necessary ambulance transport but Commonwealth Seniors Health Card holders are not covered.
If you do not fall into any of the categories mentioned above, you can arrange ambulance cover from the ambulance authority in your state or territory, or from a health insurer.	Medicare does not cover the cost of emergency or other ambulance services.

For further information please see:

• Ambulance

What is covered by Medicare?

Medicare is the basis of Australia's health care system and covers many health care costs. Most Australian residents are eligible for Medicare.

You can get a Medicare card if you live in Australia or Norfolk Island and meet certain criteria. You may also get a reciprocal Medicare card if you visit from certain countries.

You can choose whether to have Medicare cover only, or a combination of Medicare and private health insurance.

The Medicare system has three parts: hospital, medical and pharmaceutical.

Hospital

Under Medicare you can be treated as a public patient in a public hospital, at no charge, by a doctor appointed by the hospital. You can choose to be treated as a public patient, even if you are privately insured.

As a public patient, you cannot choose your own doctor and you may not have a choice about when you are admitted to hospital because you may be placed on a public hospital waiting list.

Medicare does not cover:

• private patient hospital costs (for example, theatre fees or accommodation) - you can purchase private hospital insurance to cover this item;
• medical and hospital costs incurred overseas;
• medical and hospital services which are not clinically necessary, or surgery solely for cosmetic reasons;
• ambulance services; and
• emergency department administration or facility fees.

Medical

When you visit a doctor outside a hospital, Medicare will reimburse 100% of the Medicare Benefits Schedule (MBS) fee for a general practitioner and 85% of the MBS fee for service provided by a specialist. If your doctor bills Medicare directly (bulk billing), you will not have to pay anything.

Medicare provides benefits for:

• consultation fees for doctors, including specialists;
• tests and examinations by doctors needed to treat illnesses, such as x-rays and pathology tests;
• eye tests performed by optometrists;
• most surgical and other therapeutic procedures performed by doctors;
• some surgical procedures performed by approved dentists;
• specific items under the Cleft Lip and Palate Scheme;
• specific items under the Enhanced Primary Care (EPC) program; and
• specific items for allied health services as part of the Chronic Disease Management Plan.

Medicare does not cover:

• examinations for life insurance, superannuation or memberships for which someone else is responsible (for example, a compensation insurer, employer or government authority);
• ambulance services;
• most dental examinations and treatment;
• most physiotherapy, occupational therapy, speech therapy, eye therapy, chiropractic services, podiatry or psychology services;
• acupuncture (unless part of a doctor's consultation);
• glasses and contact lenses;
• hearing aids and other appliances; and
• home nursing.

Many of these items can be covered on private health insurance general treatment (extras) policies. Most insurers will have limits on how much you can claim per service and per year.

Pharmaceutical

Under the Pharmaceutical Benefits Scheme (PBS) you pay only part of the cost of most prescription medicines purchased at pharmacies. The rest of the cost is covered by the PBS. You must present your Medicare card to obtain this benefit.

The amount you pay varies, and is dependent on the type of medicine, up to a standard maximum. People with Government-issued concession cards have a lower maximum payment.

What is covered by private health insurance?

Private health insurance cover is generally divided into hospital cover, general treatment cover (also known as ancillary or extras cover) and ambulance cover. Ambulance cover may be available separately, combined with other policies, or in some cases is covered by your state government.

In Australia, private health insurance is 'community-rated', rather than 'risk-rated' like most forms of insurance. Private health insurers cannot refuse to insure any person, and must charge everyone the same premium for the same level of cover, despite their risk profile and likelihood of using health services.

There are different types of cover that offer different benefits. Check with your health insurer to be sure of exactly what you are covered for.

Hospital Cover

With hospital cover you have the right to choose your own doctor, and decide whether you will be treated at a public or a private hospital that your doctor attends. If you are a private patient at a private hospital, you may also have more choice as to when you are admitted to hospital. If you are a private patient in a public hospital, public hospital waiting lists still apply.

When you are admitted to hospital, you have the following treatment options:

Accommodation Type	Choice of hospital	Choice of doctor
Public patient, public hospital	No	No
Private patient, public hospital	No	Yes
Private patient, private hospital	Yes	Yes

Generally, any medical services which Medicare covers and are listed under the Medicare Benefits Schedule (MBS) can also be covered to some extent by private hospital insurance. Services which are not listed on the MBS, such as elective cosmetic surgery or laser eye surgery, are only covered by private hospital insurance to a limited extent or may not be covered at all, depending on the policy.

What is covered by private hospital policies?

Every health insurer offers policies with different levels of cover. Generally, the more expensive policies cover a wider range of services, while the lower cost policies will limit what services will be covered in a private hospital.

Four new tiers of hospital cover began rolling out from 1 April 2019 and became mandatory from 1 April 2020. All hospital insurance policies are classified as Gold, Silver, Bronze or Basic. For more information about the new tiers, see Product tiers & Clinical categories.

As with any other insurance policy, you can manage your cover by choosing comprehensive cover with higher premiums, or pay lower premiums for reduced cover. You can also reduce your premiums by opting to pay some of the costs through an excess or co-payment.

For more information about hospital cover, see Private Health Insurance Basics.

What may not be covered?

The health insurance policy you buy will have some limitations on hospital treatment, which might include:

• Exclusions - specific services that are not covered at all.
• Restrictions - services that are covered to a limited extent, which means you will have greater out-of-pocket expenses. Restricted benefits are not sufficient to cover the full hospital cost of a private hospital admission and you will need to pay for the difference in cost.
• Surgery or hospital treatment that Medicare does not pay a benefit for - Medicare pays a benefit on all medical services necessary to maintain your health, but does not cover optional treatments such as elective cosmetic surgery.
• Long stay patients - If you are in hospital for more than 35 days in succession, you will be regarded as a long stay or nursing home type patient, unless your doctor specifies otherwise. This means you will have to pay more for the cost of hospital accommodation after the initial period. Health insurance regulations do not allow health insurers to insure for this cost.
• Single vs shared rooms – some hospital policies cover the full cost of a shared room, but not a single room. Depending on your policy, this limitation can apply in a private hospital, or a public hospital, or both. If you are admitted to a single room and your policy does not fully cover the cost, the hospital should inform you that you will need to pay the difference between the insurer’s benefit and the hospital’s charge. Your health insurer can also provide more information about your cover.

For more advice about exclusions and restrictions, see the Ombudsman's factsheet. For information about other expenses you may have to pay, see Out of pocket expenses (gap cover).

General Treatment Cover

General treatment cover (also called ancillary cover or extras cover) provides insurance against some or all costs of treatment by ancillary health service providers. The extent of your cover depends on the type of policy you select and may include services such as:

• dental treatment;
• chiropractic treatment;
• home nursing;
• podiatry;
• physiotherapy, occupational therapy, speech therapy and eye therapy;
• glasses and contact lenses; and
• prostheses (e.g. hearing aids).

For more about General treatment cover, see Private Health Insurance Basics.

What may not be covered?

Nearly all services covered under general treatment are only covered to a limited extent. There are various limits that may apply, for example a limit per service, per year, or lifetime limits. Some services may not be covered at all.

You should check the Private Health Information Statement about any policy you are interested in, and seek information from your insurer for details of these limitations.

Ambulance

Medicare does not cover the cost of emergency or other ambulance services. You can organise cover for this service as part of your hospital or general treatment cover, or as a stand-alone cover.

The options for ambulance cover vary depending on what state or territory you live in. For further information please see the Ambulance section of the website.

Broader Health Cover

Private health insurers can cover a wide variety of clinically appropriate alternatives to hospital treatment. This can include treatment provided in your own home or in community healthcare clinics (known as hospital substitute treatment), as well as programs to manage or prevent chronic disease.

It is not mandatory for health insurers to offer cover for these services. Participation in these programs may be subject to your level of cover and eligibility criteria, so check with your insurer for more information.

• wound care;
• IV therapy; and
• early discharge.

Common examples of hospital substitute treatment include:

• heart/cardiovascular health;
• risk factors for chronic disease; and
• diabetes management/education.

Ambulance

Medicare does not cover the cost of emergency transport or other ambulance services. You can organise ambulance cover, through a health insurer or in some states and territories, from the state ambulance authority. Health insurers may pay for or reimburse you for all or part of your annual subscription to your state or territory ambulance authority or the costs associated with transportation.

Depending on your state or territory of residence, you may be eligible for a discount or may not need cover at all. Note that the information below applies while in your state of residence and may not apply if you are interstate.

State	Ambulance Cover arrangements in your state of residence
All states and territories	Department of Veterans Affairs Health Card holders are covered for state ambulance services in every state and territory. This website gives details about conditions and restrictions.
Australian Capital Territory (ACT)	ACT residents who are Pensioner, Concession or Health Care card holders are entitled to free emergency ambulance services. If you are not eligible for a concession and want to be covered, you can purchase cover from a private health insurer.
New South Wales (NSW)	NSW residents who are Health Care Card, Pensioner Concession Card, or Commonwealth Seniors Health Care Card holders can use some ambulance services free of charge. If you are not eligible for a concession and want to be covered, you can purchase cover from a private health insurer.
Northern Territory (NT)	NT residents who are Centrelink Pensioner Concession Card or Health Care Card holders are entitled to free ambulance transport services. If you are not eligible for a concession and want to be covered, you can purchase cover from a private health insurer or a subscription through the territory ambulance service.
Queensland (QLD)	Emergency pre-hospital ambulance treatment and transport costs for Queensland residents are covered by the state government.
South Australia (SA)	SA residents who want ambulance cover can purchase cover from a private health insurer or a subscription through the state ambulance service.
Tasmania (TAS)	Ambulance costs for Tasmanian residents are covered by the state government.
Victoria (VIC)	Victorian Pensioner Concession Card or Health Care Card holders are entitled to free, clinically necessary ambulance transport services. However, if you are a concession card holder and you are transported from a private healthcare facility, the sending private facility is responsible for payment. This includes registered private hospitals and registered private day procedure centres. The private healthcare facility decides whether or not to pass this cost onto you. If you are not eligible for a concession and want to be covered, you can purchase cover from a private health insurer or a subscription from the state ambulance service.
Western Australia (WA)	WA residents who are over 65 years and receive an Australian Government pension are entitled to free medically necessary, emergency and urgent ambulance services. If you are not eligible for a concession and want to be covered, you can purchase cover from a private health insurer or a subscription from the state ambulance service.

If you are travelling interstate, check with your state ambulance service, concession card provider or health insurer about how you are covered for ambulance services while travelling.

What may not be covered?

Ambulance cover can vary. Some insurers provide cover for all ambulance travel, while others only provide for ground travel or have other limitations - for example, they may cover you in your state of residence only, or they may not cover 'call out' fees (when an ambulance treats you at the scene but does not transport you to hospital).

Check with your insurer about which type of ambulance cover best suits your needs.

Contact your state or territory government for more information on the arrangements that apply in your state.

Questions to ask about your ambulance cover

Some questions you can ask before joining include:

• Will this policy cover me when I'm travelling interstate?
• Does this policy cover emergency situations only, or will it cover non-emergency as well? How does the insurer define an emergency?
• Will this policy cover me for the ambulance 'call-out' fee if I need ambulance treatment but do not require transportation?
• What is the waiting period?
• Will I need to make any co-payments towards the ambulance fee?
• What types of ambulance transport will this cover - for example, will it cover air ambulance? Will it cover transports provided by state-approved private providers or other private providers?

Private Health Insurance Basics

There are generally three types of private health insurance - hospital policies cover you when you go to hospital, while general treatment policies (sometimes known as ancillary or extras) cover you for ancillary treatment (e.g. dental, physiotherapy), and ambulance policies cover you for ambulance transport.

Most health insurers offer combined policies that provide a packaged cover for both hospital and general treatment services, or you can buy separate hospital and general treatment policies to 'mix and match'.

What should I consider when purchasing health insurance?

• Waiting periods: If you are purchasing cover for the first time or upgrading your plan, you need to serve a waiting period before you can claim your benefits. During the waiting period, you do not receive any benefits for certain treatments or you receive lower benefits for a period of time.
• What isn't covered on my policy: You should take note of what is and isn't covered on your policy - not all policies are comprehensive. Depending on your level of cover, you may not be fully covered against all costs associated with your treatment and will have to pay some out-of-pocket expenses.
• Your healthcare needs: You should review your cover from time to time to ensure it still meets your needs. If the premium has become a concern for you, there are a number of ways you may be able to manage your policy and lower costs. If you already have private health insurance, you can also consider moving to a different insurer.
• Comparing health insurance policies: every policy available for sale in Australia is summarised on this website in the form of a Private Health Information Statement (PHIS) to make it easier to compare policies. For private hospital cover, standard Clinical categories specify what is and is not covered on each policy.

Out of pocket costs

When being admitted to hospital as a private patient, you may have to contribute toward the cost of your treatment. In most cases, these out of pocket costs relate to medical fees charged by your treating doctors and health care providers. You may also incur out of pocket costs for hospital fees and prostheses.

In Australia, doctors and health care providers decide how much to charge for their services. Before you receive your treatment you are entitled to ask your doctor or health care provider, your health insurer and your hospital about any costs you may have to pay out of your own pocket, commonly known as a ‘gap’ payment.

Medical gaps

If you decide to be treated as a private patient, in a public or private hospital, each of the doctors and health care providers involved in your care may charge a fee. This can include medical specialists, surgeons, assistant surgeons, anaesthetists, physiotherapists, pathologists and radiologists. These fees are referred to as your medical fees, which are separate to the fees the hospital may charge for accommodation, time in theatre and other hospital services.

When you are admitted to hospital as a private patient, Medicare will pay 75 per cent of the Medicare Benefit Schedule (MBS) fee for each MBS item. Your health insurer will pay the additional 25 per cent (if you are eligible for benefits for those items under your health insurance policy).

However, doctors and health care providers are free to charge more than the MBS fee and many do. In Australia, doctors and health care providers take into account their particular costs in delivering services and may have differing views about what represents a reasonable return for their time and skill. This means that there is no cap on the amount a doctor or health care provider can charge for their services.

If your doctor charges above the MBS fee, you may have to pay the extra amount. This extra amount is sometimes known as a 'gap'. If you do not do check with your doctors and insurer what this amount is, you may be faced with significant out of pocket costs for your treatment.

Before you go to hospital, you should ask your doctor for the MBS item numbers for the services they will perform and an estimate of your out of pocket costs. You should also ask the doctor if there will be other doctors or health care providers involved in your care (for example, anaesthetist or an assistant surgeon) and how you can get an estimate of their fees. Estimates should preferably be provided in writing. For more information, see the Ombudsman's factsheet on Informed Financial Consent.

Once you have your MBS item numbers, you should then check with your health insurer to find out exactly how much is covered on your hospital policy for that procedure.

Not all medical services are listed in the MBS. You should check with your doctor or health care provider and your insurer whether your medical treatment is listed in the MBS. If it is not listed your health insurer may not pay benefits and you may face significant out-of-pocket costs for your treatment.

If you do not have hospital cover for a particular condition or medical service, you cannot claim, from your health insurer, the fees associated with your hospital stay for that treatment.

If you are not an admitted hospital patient, then your fees may only be claimable with Medicare.

Medical gap cover schemes

Some health insurers have gap cover agreements made with particular doctors or health care providers. The agreement allows health insurers to provide benefits to cover some or all of the gap fees for your in-patient hospital treatment. If you receive treatment from a doctor or health care provider who charges above the MBS fee and who does not have a gap cover agreement with your health insurer, you may face significant out-of-pocket expenses for your treatment.

There is no requirement for any doctor to participate in an insurer’s gap cover agreement. Doctors and health care providers are free to decide on a case-by-case basis whether to use an insurer's gap cover arrangement. You should check with your doctor or health care provider and insurer whether you can be treated under this agreement. If you cannot be treated under a gap cover arrangement, you will have to contribute towards the medical fee out of your own pocket, for the amount that is billed over and above the MBS fee.

Medical costs finder

To help you find out more about the cost of specialist medical services, the Department of Health and Aged Care has introduced the Medical Costs Finder.

The Medical Costs Finder is an online tool that you can use to:

• see how much people have paid out of pocket for a procedure
• compare the costs estimated by your specialists and other health providers for a hospital procedure with the typical costs for the procedure in your area.

This helps you better understand what is typically paid and whether your likely out of pocket costs are high or low, compared with what others have paid for the treatment.

Hospital gaps

The benefits paid for hospital services such as accommodation, time in theatre and labour ward fees will depend on the type of cover you purchase and whether your insurer has an agreement in place with the hospital in which you are treated.

When there is an agreement between your insurer and your private hospital, you will have either no out-of-pocket expenses or you will be provided with details of your out-of-pocket expenses. Public hospitals don't have agreements with specific insurers but are generally treated as though they are agreement hospitals.

If you are treated in a hospital that does not have an agreement with your health insurer, you may face significant out of pocket costs for your treatment.

Find private hospitals that have an agreement with your insurer using the Agreement hospitals tool.

You are entitled to and should always ask your hospital or health insurer for an estimate in advance of the costs of your treatment, in both private and public hospitals.

If your hospital policy has an excess or co-payment, you have to pay the agreed excess or co-payment amount for hospital treatment out of your own pocket, even if your hospital has an agreement with your insurer.

• An excess is the set amount that you are obliged to pay towards the cost of hospital treatment. You, and anyone else listed on your hospital policy, may be required to pay an excess every time you go to hospital, or less often, depending on your policy.
• A co-payment is the set amount you are obliged to pay for each day you are in hospital. For example, you, and anyone else listed on your hospital policy, may be required to pay the first $50 per day in hospital, depending on your policy.

Prostheses

A prosthesis is an artificial substitute or replacement for a body part attached or applied to the body to replace a missing part. Surgically implanted prostheses are sometimes required, such as a replacement cornea, a hip joint replacement device, a pacemaker, or a heart valve.

• If you are having surgery to implant or apply a prosthesis, your private health insurer must pay a benefit if you have the correct hospital cover and the product is on the Prostheses List. If you are covered, your health insurer will pay at least the minimum benefit listed on the Protheses List.
• If the minimum benefit does not cover the cost of the prosthesis, you might need to pay all or part of the gap to the hospital.
• Before you have surgery, you should ask your health insurer if you are covered, how much your policy will pay for a particular prosthesis, and whether you will have any 'gap' to pay for the prosthesis.
• Before you have surgery, you should also ask your doctor if the prosthesis is on the Prostheses List. If it is not on the list, you should ask your doctor if there is a prosthesis on the list that can be used instead. You should ask your doctor if you will have any 'gap' to pay for the prosthesis.
• Before you have surgery, you should ask your hospital if you will have any 'gap' to pay for the prosthesis.

How can I avoid unexpected out of pocket costs?

We recommend that you ask about fees as soon as possible when consulting with a doctor or health care provider ahead of a hospital admission, or as soon as practicable if you need to be admitted to hospital urgently.

If your doctor arranges for your admission to a hospital or day surgery as a private patient, we recommend that you ask your doctor or your doctor’s office staff the following questions:

• What are the MBS item numbers for the services the doctor is going to perform and what will be the charge for each of these services?
• Does the doctor participate in my health insurer’s gap cover scheme and will the doctor treat me under this arrangement?
• Will I incur any personal out of pocket expenses and, if so, how much? (You should confirm this with your health insurer.)
• Who are the other doctors treating me during the admission (e.g. anaesthetist, assistant surgeon) and how can I get an estimate of their fees?
• Will the doctor provide me with a written estimate of any costs I’ll have to pay so I can consider this when agreeing to the treatment?
• How will the doctor bill me?
• Which hospital will be admitted to and does this hospital have an agreement with my insurer?
• When will I have to pay?

If you can’t afford the treatment, discuss alternative treatment options with your specialist or GP. You may also consider shopping around to see what other specialists charge or consider being treated as a public patient at a public hospital.

You should contact your health insurer to ask about benefits for your hospitalisation and your medical bills.

Medicare can confirm the amount they will pay for the medical services provided if necessary. You can visit your local Medicare Office, contact them on 132 011 or online at Services Australia.

What can I do if my bill is much higher than expected?

In the first instance, we suggest you contact your doctor’s or health care provider’s office to check whether you agreed to these charges before treatment, and discuss the reasons for the various charges.

If you still consider that the charge is unfair or significantly more than you were advised, we suggest that you pay at least part of the bill. For instance, pay the amount that you were expecting to pay or find out what the MBS fee is for the procedure(s) and pay that amount.

When you make that payment, provide a letter to your doctor or health care provider. This letter could include the following points:

• State the amount you are paying and explain why you are paying that amount, for now.
• Indicate what amount you were expecting to pay and why you expected to pay that amount.
• Ask if any procedures have been performed other that the ones you were expecting or if a case can be made for the unexpected charge.
• Indicate any personal circumstances that affect your ability to pay the higher fee.
• Suggest what further amount you would be prepared to pay (if any) and what payment arrangements you would like to make.
• Ask for a written response to your letter.

Where can I seek further assistance?

If you can’t resolve your issue directly with your doctor or health care provider, you can seek assistance from another organisation:

Type of issue	Who to contact
A private health insurance-related matter, such as a dispute over the fee charged by a doctor or health care provider for in-patient treatment or a private patient hospital gap fee	Private Health Insurance Ombudsman
A competition or fair trade issue	Australian Competition and Consumer Commission
A health practitioner standards complaint	Australian Health Practitioner Regulation Agency
A complaint about the provision of healthcare, in a public or private setting, including disputes about medical bills	State and territory healthcare complaint bodies: ACT: Health Services Complaints Commissioner NSW: Health Care Complaints Commission NT: Health and Community Services Complaints Commissioner QLD: Office of the Health Ombudsman SA: Health and Community Services Complaints Commissioner TAS: Health Care Complaints Commissioner VIC: Health Complaints Commissioner WA: Health and Disability Services Complaints Office