When it comes to understanding the responsibility split between NDIS and the health system, it is not a straightforward topic. This has caused much confusion for many people including participants and the professionals within the scheme. Hence, one may find it difficult to easily grasp answers for the questions as to who funds what.
What is NDIS?
This is my favorite question. National Disability Insurance Scheme (NDIS) is a federal government-funded scheme. NDIS is responsible for funding supports required due to the impact of a person’s impairment on their functional capacity.
Who is eligible to receive NDIS funding for supports?
The NDIS only provides individual funding for Scheme participants. To become a participant, people need to meet the NDIS eligibility criteria:
Be aged under 65 at the time of NDIS access
Have an impairment or condition that is likely to be permanent (lifelong)
Be an Australian citizen or Permanent Resident or hold a Protected Special Category visa.
So when would one expect NDIS to fund supports?
Supports funded within NDIS are not designed to substantially change a person's functional capacity, but they are meant to support people to live an ordinary life with the functional capacity they have.
In General, NDIS funding responsibility is based on the following principles:
Supports that are needed due to the impact of their impairment on their functional capacity and their ability to undertake activities of daily living.
Supports that are required to maintain the care, that is delivered or supervised by a clinically trained or qualified health professional.
Funding supports that enables a person with a disability to participate in activities of daily living, more specifically for people whose impairment has reached a point where they cannot participate on their own and the improvement to their capacity to participate is improbable.
Funding supports that are related to the management of a person’s health condition if a person is unable to do it independently because of their disability.
Examples of these support types are as follows:
Aids and equipment that may improve the independent functioning of a person in their home and/or in the community.
Early intervention for children aimed at enhancing their functioning.
Nursing and other personal care supports to enable participation in community, education & employment e.g. PEG feeding, catheter care, skin integrity checks, tracheostomy care
Nutrition and dysphagia equipment and consumable funding including PEG and HEN consumables, thickeners.
Allied health consultations and therapeutic supports.
Epilepsy supports, including monitoring with assistive technology
Respiratory supports- including CPAP machines, tracheostomy changes, portable suction machines, and more.
Past 1st Oct 2019, there has been a big change, where more than 90 disability-related health supports were announced to be funded under the NDIS including (but not limited to) supports for:
Wound & Pressure Care
So what are the responsibilities of the Health system?
A document published by the Council of Australian Governments (COAG) can be a vital reading resource for one willing to dive more into understanding the responsibilities of NDIS compared to all other mainstream services, including:
Early childhood development
Child protection and family support
Higher education and Vocational Education and Training (VET)
Housing and community infrastructure
I have found the COAG document very helpful, as it provides guiding principles, separating NDIS responsibilities from other parties (list above) in an easy read table format. The document can be downloaded from here.
In General, the Health system’s responsibility is for diagnosis and treatment of health conditions that include services aimed at recovery and restoration of health (rehab), and it may involve the following:
Diagnosis of health conditions and disabilities
Early intervention and treatment of health conditions, including ongoing or chronic health conditions
Medically prescribed care, treatment, or surgery for acute illness or injury
Treatments or supports delivered by a doctor or medical specialist
Time-limited, recovery-oriented services and therapies (i.e. rehabilitation) aimed primarily at restoring health or improving functioning after a recent medical or surgical treatment intervention
Palliative care, except for supports that assist in daily living for people with life-ending conditions
Anything covered by the Medicare Benefits Scheme (MBS) or Pharmaceuticals Benefits Scheme (PBS).
The NDIS does not replace the responsibility of Health and must make its services accessible to people with disabilities.
The Scheme is not designed to mitigate problems with accessibility in other services or fill gaps where existing funding is insufficient.
However sometimes the NDIS may be responsible to fund support in health-related matters, and this includes situations as below-
If a person exhibits complex communication needs or challenging behaviors in the health setting
In general, NDIS will not fund daily living supports for a person in a health care setting, such as a hospital excepting in two situations. One if a person has complex communication needs and therefore may require extra support and the second being a person requiring extra support because of complex behavior support needs.
Coordination of NDIS supports within the health system
Certainly funding for intensive case coordination for health supports is the responsibility of the Health system however NDIS can fund support coordination for disability supports and other services. The NDIS Support Coordinator can thus support a Participant to adjust their supports should they have an extended stay in the hospital.
Support required to plan and transition, pre-hospital discharge
If a person is in hospital after developing a disability, it will be the health care department's responsibility to support the person to apply for the NDIS.
Once the person is an NDIS Participant, the Scheme can then fund support coordination for participants, as they will need to transition from hospital to home.
In particular, the NDIS may be involved in discharge planning when:
Discharge is conditional to additional NDIS supports being available
There is a risk of inappropriate admission to the residential care facility
The participant will require reinstatement of disability supports post-discharge
Participant requires both health and disability-related supports to enable discharge