The Difference Between What NDIS Will Fund and What They Consider Medical Expenses

NDIS Plan Manager

Lainey is the mother of a son who was recently diagnosed with autism. She and her son live in Australia, and his diagnosis wasn’t an easy journey. After years of seemingly unrelated signs that her child might have a disability, Lainey was relieved to finally discover the root cause of her son’s sensory issues and developmental delays.

Because her son’s autism requires substantial support, doctors recommended Lainey apply for NDIS funding. However, she is overwhelmed by the process and doesn’t completely understand which expenses qualify for NDIS funding and which are considered medical expenses.

We often find parents who feel the same as Lainey. It’s hard to advocate for your children, and it’s even harder when you don’t fully understand the ins and outs of a complicated system. While funding is often based on individual circumstances, there are some guidelines to help parents better understand NDIS vs. health system coverage.

What is the purpose of NDIS funding?

Australia’s National Disability Insurance Scheme (NDIS) is designed to help people with disabilities have the same quality of life as those without disabilities. Funds are available to help participants acquire the supports and services they need to reach that goal.

Types of NDIS Supports

Parents are often surprised to learn that supports must fall into one of three categories:

  • Core
  • Capital
  • Capacity building

Each type of support has a specific goal, and most expenses qualify for NDIS funding as long as they meet the necessary criteria.

Core supports are expenses that are necessary for daily living.

Capital supports are larger expenses, such as home modifications to meet a disability need.

Capacity building supports are items that help the person develop life skills or foster greater independence.

NDIS vs. Health System Coverage

The NDIS is not designed to handle all aspects of a person’s disability, however. Most medical expenses won’t be covered by NDIS funding. These items should qualify for health system coverage instead. You can find a more comprehensive list of health system expenses here, but the general rule is that items directly related to either diagnosing or medically treating your disability do NOT qualify for NDIS funding. NDIS funds are for items related to your quality of life.

Quality of Life Goals

More specifically, NDIS funding covers supports that help participants attain certain life goals. These are:

  • Assistance with Daily Life
  • Transport
  • Consumables
  • Assistance with Social & Community Participation
  • Assistive Technology
  • Home Modifications
  • Coordination of Supports
  • Improved Living Arrangements
  • Increased Social and Community Participation
  • Finding and Keeping a Job
  • Improved Relationships
  • Improved Health and Wellbeing
  • Improved Learning
  • Improved Life Choices
  • Improved Daily Living​

Each support must also be considered “reasonable and necessary” to qualify for NDIS funding. NDIS funding doesn’t cover items that are considered typical living expenses; they must be specialised expenses directly related to the person’s disability. The NDIS also doesn’t cover items that are covered by other systems, such as education.

NDIS Pricing Limits

It’s important to note that there are also pricing limitations. Thankfully, the NDIS provides a full catalog of supports with pricing limits. The catalog is fairly easily to navigate, and it’s pretty extensive. You can find the most recent NDIS pricing catalog here.

How can you tell if an expense is covered by NDIS funding vs. health system coverage?

Sometimes, an expense clearly qualifies for NDIS vs. health system coverage (or vice versa). Other expenses are harder to classify, however.

For example, when Lainey’s pediatrician ordered tests to diagnose her son’s autism, the tests were covered by the health system. Now that he’s diagnosed, however, Lainey wonders whether his aides will be covered by NDIS or the health system. The truth is that it depends on several factors, including the type of assistance he needs, why he needs the assistance, and whether it’s considered a treatment or simply a means to improve his quality of life.

Final Thoughts

If you’re a parent who’s confused and frustrated with NDIS vs. health system coverage, please let us know. We’re here to help NDIS participants understand the system and advocate for their disability-related expenses. We can look at your individual situation and help determine whether an expense should qualify for NDIS funding or health system coverage. When you’re fighting for your child, it’s sometimes easy to feel like you’re completely alone and no one cares about your child or their disability. That couldn’t be further from the truth. The truth is that NDIS funding is a complicated topic, but we are on your side. Please don’t hesitate to reach out when you need us. 



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