Creating a voice for the Disability Sector
Creating a voice for the Disability Sector
NEW TO THE NDIS: What will the NDIS cover and what won’t be covered?

NEW TO THE NDIS: What will the NDIS cover and what won’t be covered?

17 September 2021

The National Insurance Scheme (NDIS) will provide more than $22 billion in funding a year over the next five years to an estimated 500,000 Australians who have permanent and significant disability.

There are around 4.3 million Australians who have a disability.

The NDIS can provide all people with a disability with information and connections to services in their communities such as doctors, sporting clubs, support groups, libraries and schools, as well as information about what support is provided by each state and territory government.

To be eligible to receive NDIS funding, you must be aged between 7 and 65, live in Australia and have Australian residency and need support because of a permanent and significant disability.

Children with a disability aged between 0-6 can also access the NDIS through the NDIS Early Childhood Early Intervention (ECEI) part of the scheme. Visit Help for children under 7 for more details.

You may also be eligible if you have to use certain equipment or aids as part of your disability and if you need support now to help you further down the track.

It is important to note the NDIS is completely separate from the disability support pension.

These payments, along with carer’s support pension or carer’s allowance and the child disability assistance payment etc, will not be affected if a person qualifies for the NDIS.

To qualify for the NDIS, a participant needs to meet one of the following disabilities or conditions:

  • Intellectual disability
  • Autism
  • Cerebral palsy
  • Genetic conditions which result in permanent and severe intellectual and physical impairments
  • Spinal Muscular Atrophies
  • Spinal cord or brain injuries resulting in paraplegia, quadriplegia or tetraplegia, or hemiplegia.
  • Permanent blindness
  • Permanent bilateral hearing loss
  • Deaf blindness
  • Amputation

There are some conditions which may require further assessment, these include:

  • Some types of intellectual disabilities
  • Chromosomal abnormalities such as Down syndrome, Prader- Willi and Charge Syndrome to name a few
  • Neurological impairment such as Alzheimer’s dementia or Parkinson's disease
  • Physical impairment like amputation, congenital absence of limbs and some forms of arthritis.
  • Speech or hearing impairments
  • A combination of the above

A comprehensive list of the types of conditions likely to be covered under the NDIS can be found at List B – Permanent conditions for which functional capacity are variable and further assessment of functional capacity is generally required or

List A – Conditions which are likely to meet the disability requirements in section 24 of the NDIS Act

In each case, every application to the NDIS must have supporting evidence that there disability meets the criteria for funding approval.

A person may satisfy the NDIS access requirements regardless of whether their impairment came about through birth, disease, injury or accident.

To be eligible for NDIS funding, the condition must cause permanent impairment (physical, intellectual, cognitive, neurological, visual, hearing or psychosocial), resulting in significant disability.

For example, stroke leading to hemiparesis (the resulting physical impairment substantially reduces mobility) or severe emphysema causing irreversible lung damage (chronic dyspnoea substantially reduces mobility, self-care and participation in community life).

However, not all types of support required by a person living with a disability fall under the responsibility of the NDIS.

Some supports are funded by other areas of government (e.g. state health systems) or existing public/community services.

In general, the NDIS will fund reasonable and necessary supports that help a person living with a disability enjoy an ordinary life.

These supports and services fall into three categories.

Core

A support that assists with activities of daily living.

Capital

A support for an investment, such as assistive technologies; equipment and home or vehicle modifications; or funding for capital costs (e.g. to pay for Specialist Disability Accommodation).

Capacity building

A support that helps build independence and skills.

Common examples of supports provided or funded by the NDIS include:

  • Help with personal care activities and/or household tasks
  • Home and vehicle modifications
  • Assistive technology, aids and mobility equipment, including set up and training by skilled personnel
  • Transport to enable participation in community, social, economic and daily life activities, e.g. workplace, gym or places of learning
  • Support to find and keep a job
  • Therapeutic supports like occupational therapy, speech therapy and behaviour support
  • Health-related supports (as long as they are a regular part of your patient’s life and the need for them arises from a disability), e.g. continence, diabetic management, dysphagia, epilepsy, nutrition, podiatry, respiratory and wound and pressure care supports (see the Disability-related health supports page for full details).

If you are uncertain if the support you require is funded by the NDIS, a Local Area Coordinator can provide further advice before proceeding with an Access Request, as other public or community services may be more appropriate.

The Scheme does not fund the cost of medical care such as diagnostic assessments, treatment, medication, hospital/doctor visits or Medicare gaps.

It is not designed to fund support more appropriately funded or provided by the health system.

Assessment, diagnosis and treatment of health conditions, along with medications and hospital care, remain the responsibility of the health system.

As a general guide, the following health-related services and supports are not provided or funded through the NDIS:

  • Items and services covered by the Medicare Benefits Schedule (MBS) and Pharmaceutical Benefits Scheme (PBS), nor Medicare gap fees.
  • Treatment, services or support delivered by a doctor or medical specialist, including diagnosis and assessment of a health condition.
  • Items and services provided as part of diagnosis, early intervention and treatment of health conditions, including ongoing care of chronic health conditions.
  • Medically prescribed care, treatment or surgery for an acute illness or injury including post-acute care, convalescent care and rehabilitation.
  • Sub-acute care including palliative care, end of life care and geriatric care.

For example, while visits to psychiatrists are not covered, certain aspects of on-going care by a psychologist can be as long as they can safely and professionally deliver support included in your NDIS plan.

The National Disability Insurance Agency (NDIA) has support specifically designed for those who have been diagnosed with mental health conditions which resulted in long-term disabilities.

However, it is important to distinguish that not everyone with a mental health condition will experience disability.

The type of disability the NDIA provides NDIS supports for is classified as a psychosocial disability.

Anyone older than 65 are also not eligible for NDIS funding, unless they have received the funding prior to turning 65 in which case they will be eligible for support for the duration of their lifetime, if they met the access requirements prior to turning 65.

Contact your Local Area Coordinators for alternative community referral pathways outside of the NDIS.


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