Case
Danielle can’t eat, swallow and tolerate normal food because of her disability. This means she needs an alternative food such as Home Enteral Nutrition (HEN) to make sure she get the nutrition she needs.
Would we typically fund this?
Yes, we would typically fund HEN products to support Danielle’s disability needs, if the HEN formula she’s prescribed isn’t covered under the Pharmaceutical Benefits Scheme (PBS, which is part of the Australian health system).
Why would we fund this?
Food is an everyday living cost which isn’t related to your disability support needs, nor to your disability. Therefore, we don’t generally fund it.
However, we do generally fund HEN products and formula if you need them because of your disability support needs. For example, we will usually fund HEN products or formula if your disability means you can’t eat or swallow everyday food.
To work out whether the HEN product or formula is reasonable and necessary for you, we’ll look at the information you give us against the NDIS Funding Criteria.
We’ll also look at whether the PBS funds the HEN product or formula prescribed for you. If it does, then the support may be more appropriately funded through the PBS.
To decide whether the support is most appropriately funded by us or the health system, we have to think about Schedule 1 of the NDIS (Supports for Participants) Rules 2013. In particular, there’s a principle that we are not responsible for pharmaceuticals.
If you have either full or partial HEN feeding needs, and the PBS does not subsidise your prescribed formula, HEN products are likely to meet the reasonable and necessary requirements. If this is the case, it will generally be more appropriate for us to fund the support.
If, on the other hand, the PBS will cover or subsidise the cost of the HEN product, it will generally be more appropriate for the PBS, not us, to fund the support. In this case it is unlikely to meet the NDIS Funding Criteria and unlikely to be reasonable and necessary for you.
If your prescribed formula is not covered by the PBS, your planner will review your request individually. You plan will include reasonable and necessary funding so you can buy disability-related food substitute in the form of HEN.
What related supports might we fund?
We may also fund supports that are additional to your HEN formula and nutritional supplement needs, as long as these additional supports relate to your disability. These supports may include:
- HEN and Percutaneous Endoscopic Gastrostomy (PEG) equipment and maintenance
- HEN and PEG consumables such as feeding tubes and feed bags or bottles
- a support worker if you can’t independently manage your HEN requirements, or to help with PEG maintenance and care.
We won’t fund nutrition supports that aren’t directly related to your disability. For example where you have a poor diet for reasons that aren’t to do with your disability.
We generally won’t fund dietetic supports for health issues such as:
- food allergies
- diabetes
- cardiovascular (heart) disease
- kidney disease
- polycystic ovary syndrome
- irritable bowel syndrome.
These are not usually related to your disability and are more appropriately funded through the health system or through mainstream supports.
Case example
Ella is 4 years old and has Muscular Dystrophy, which means she can’t eat enough to make sure she stays in good health. Ella’s mother trialled making suitable food using a blender. But homemade food doesn’t meet Ella’s nutritional needs and gives her stomach pains. Her doctors suggest that she needs HEN formula to supplement her meals and give her enough nutrition. Her paediatrician recommends a specialised PEG tube formula to improve her tolerance, growth and energy levels.
To support her funding request Ella’s mother gives us a report from her paediatrician. The report shows that capacity building measures to increase Ella’s food intake by mouth have been put into place. But because she can’t tolerate blended food, she needs to use PEG tube formula. The report also includes the quoted cost of the formula and PEG equipment that’s needed for Ella’s support.
To work out whether the funding for Ella’s HEN formula and PEG equipment is reasonable and necessary, the planner looks at the information provided against the NDIS Funding Criteria. Some of the things the planner thinks about are:
- whether the need for the HEN formula is solely and directly because of Ella’s disability
- whether there are other more suitable options to give Ella the necessary nutrition for a child her age, that represent better value for money relative to the benefits achieved
- whether the PBS funds the HEN formula Ella’s paediatrician recommends, or it should be funded through us
In Ella’s case, the planner decides that the funding for the HEN Formula and PEG Equipment is reasonable and necessary because:
- the HEN formula and PEG equipment is needed solely and directly because of Ella’s disability
- other nutritional options have been trialled by her mother and have been found to be clinically unsuitable
- the cost of the prescribed HEN formula and the PEG equipment is value for money, relative to the benefits achieved and the cost of other HEN formulas available on the market
- as the HEN formula Ella needs to support her disability related food intolerance is not funded by the PBS or other system, the support is most appropriately funded by the NDIS.
The planner approves funding for the HEN formula and PEG equipment in Ella’s plan.
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