It is a question often asked that often results in a myriad of answers – what does the National Disability Insurance Scheme (NDIS) pay for and what does it not cover?

The question is often clouded in confusion but, simply put, medication, general medical and dental services and treatment, specialist services, hospital care, surgery and rehabilitation, for example, are NOT covered by the NDIS.

The NDIS also will not pay for items or support not directly related to your disability.

Generally speaking, the NDIS will not cover medical costs incurred by a participant where other government-funded health schemes and funding are available, such as:

• Government health departments.
• Hospitals and community health care centres.
• Doctors and health care professionals, such as general practitioners and paediatricians.
• Medicines and treatments, for example through Medicare.

However, it MAY fund access to “reasonable and necessary” services and support in plans to help participants pursue their goals.

For example – Sami is quite sick and needs to go to hospital as an inpatient. The hospital staff say he will need to be admitted to hospital for a few days. Sami uses a communication device and needs help to speak to the hospital staff.

The health system should provide all the support he needs for the illness. For example, hospital staff may do medical tests, provide medicine, and perform any surgery Sami needs.

The health system may also have a follow-up appointment a few weeks after he leaves hospital, to make sure he is well. The health system should provide any rehabilitation Sami needs to recover from the illness.

However, the NDIS may fund training for hospital staff about Sami’s disability support needs. For example, the Scheme may fund a support worker to handover communication information, and help staff learn how Sami uses his communication device.

The NDIS Act and the NDIS Rules state what support is not funded by the NDIS.

A support will NOT be funded if it:

• Is not related to the participant’s disability.
• Is the same as other supports delivered under different funding through the NDIS.
• Relates to day-to-day living costs that are not related to a participant’s support needs.
• Is likely to cause harm to the participant or pose a risk to others.
• Can be more appropriately or effectively delivered by another system, such as health or education.

Examples of support the NDIS MAY fund:

• Support to help you live at home, such as personal care support, help to learn how to manage your personal care, and home modifications.
• Regular therapy that’s directly related to the things you can and can’t do because of your disability – for example, occupational therapy, physiotherapy or speech pathology.
• Help to plan the ongoing disability-specific supports you’ll need, after you’re discharged from a hospital or other inpatient health service.
• Prosthetics and orthotics that relate to your disability – artificial limbs and aids to help make your arms, legs and other body parts stronger, such as leg braces.
• Hearing and vision supports that relate to your disability.
• Training, delegation and supervision of care for disability-related health supports – that is, a registered nurse may train an enrolled nurse, support worker or informal supports, and provide periodic supervision and oversight.
• Communication or behaviour support when you’re going to a health service, or go to hospital but not admitted as an inpatient.
• Training for hospital staff in your disability specific needs if you’re admitted in hospital as an inpatient.
• Training NDIS funded support staff so that they understand your needs.
• Assistive technology to help you be as independent as possible at home and in the community, including for disability-related health supports such as a respirator or suction equipment.
• Regular supports you need for your disability, if you’re already a participant and start receiving palliative or end-of-life care – these supports work alongside the palliative care you get from the health system.
• Assessment by health professionals to help us plan and think about your disability support needs.
• Help to plan and coordinate your supports if you need both health and disability services – this could be an early childhood partner, Local Area Coordinator or Support Coordinator.

For example, while medications are not funded by NDIS, the Scheme would typically fund urinary catheters and continence consumables.

This expense is likely to meet our funding criteria providing there is evidence the expense relates to the participant’s regular disability support needs.

Under the above scenario, he NDIS might also provide funding for:

• Mattress protectors.
• Continence pads or absorbent pull-ups or briefs.
• Continence aids, such as change kits.
• Support workers or continence nurses to help with your continence needs if you are unable to do them independently.

The NDIS will calculate the funding allowance for urinary catheters and continence consumables on a per-day basis in line with your needs and assess quotes to decide if the consumables you ask for are appropriate and are value for money.

This link might help answer some of your questions of what you may be able to claim as part of your plan.

If all else fails and you are still confused or unsure of what you are eligible to claim on your plan – talk to your plan manager, or, if self-managed, your Local Area Coordinator or even the NDIS.

Remember, Australians aged over 65 are not eligible to receive help or support from the NDIS. If they apply and are accepted before 65 years of age, NDIS will continue to fund them past 65 but they cannot apply after 65.

However, what NDIS will and will not fund is not set in concrete. If participants and their carers believe the wrong decision has been made, they can challenge that through the Administrative Appeals Tribunal.