Note: When we say disability support needs, we mean supports you need for the impairments that meet the disability or early intervention requirements, or both.
Case
Cynthia requests funding for a medication that is likely to help her manage her disability. She provides a letter from her clinician to support her request.
The letter highlights that the medication has been trialled by people with disabilities similar to Cynthia, who have observed improved outcomes from the medication.
Would we fund this?
No, we would not fund pharmaceuticals as they are not an NDIS support. We’re not the most appropriate agency to fund this type of support.
The health system funds or provides medications and pharmaceuticals as part of a universal service obligation.
This includes those subsidised or made available to all Australians through Medicare and the Pharmaceutical Benefits Scheme (PBS).
Why wouldn’t we fund this?
NDIS laws determine what we can and can’t fund. Things we can fund are called NDIS supports. You can only use the funding in your plan to buy NDIS supports if they are related to your disability and are in-line with your plan.
To work out whether a support is an NDIS support for you, we look at the information you give us against the NDIS funding criteria.
We can fund supports that:
- are related to your disability support needs
- will help you to pursue your goals in your plan
- will help you to take part in social or recreational activities
- represent value for money. This means we need to consider the costs
- and benefits of the support, as well as the costs and benefits of alternative supports
- are likely to be effective and beneficial for you, having regard to current good practice.
This includes supports you get from doctors or health practitioners that directly relate to your disability support needs, and help you live in the community and take part in education and employment.
However, we can’t fund supports that are more appropriately funded or provided by the health system.
This includes pharmaceuticals and medications subsidised and provided by Medicare and the PBS.
We think about a number of things when we look at whether it’s appropriate for us, rather than the health system, to fund or provide a support.
We are not responsible for:
- the clinical treatment of health conditions, including ongoing or chronic health conditions
- other activities that aim to improve the health status of Australians, including preventive health and pharmaceuticals
- funding time-limited, goal-oriented services and therapies where the main purpose is related to your health status
This means that if you need or want a medicine not funded through the PBS, we are not the right agency to fund this support, even if it:
- relates to your disability support needs
- is likely to be effective and beneficial
- may be value for money.
What else do we think about?
We don’t fund pharmaceuticals, whether prescribed or over the counter, as they are not NDIS supports. This includes things like paracetamol.
We also don’t fund medicinal cannabis products, as these are also pharmaceuticals. If you are eligible and may benefit from access to medicinal cannabis products outside the PBS, you may be able to get these through an alternative scheme via the Therapeutic Goods Administration.
This means the health system is likely to be more appropriate.
We are also unlikely to be the most appropriate agency to fund trials of non-PBS-listed medications as they are also unlikely to be most appropriately funded by the NDIS.
These are a ‘time-limited, goal-oriented service or therapy’ where the main purpose is related to improving or treating your health status.
Case example
Jenny is 50 years old and has been diagnosed with Multiple Sclerosis (MS). She lives at home with her husband and adult daughter. Jenny is independent, needing very little help with her self-care activities.
She does need her husband and daughter to manage all the household domestic tasks.
Jenny is very distressed about the affect her disability has upon her family. She begins to look into things that might improve her function. Jenny’s neurologist tells her about a preventative medication recently found to have good results with improving the capacity of people with MS.
The medication is new, expensive and is currently not funded or subsidised through the PBS.
Keen to increase her independence, Jenny asks us to fund her trial of this medication. With her application, she includes a recommendation from her neurologist that the medication is likely to be both effective and beneficial.
The planner looks at the information Jenny provides against the NDIS funding criteria.
In Jenny’s case, the planner decides that medication is not an NDIS support, therefore we wouldn’t fund it.
Even though the medication was likely to be beneficial and could increase Jenny’s independence, we are not the most appropriate agency to fund medication.
Preventative medication and pharmaceuticals are more appropriately provided or funded by the health system.
The NDIS is not responsible for activities that aim to improve the health status of Australians, including providing preventative medication and pharmaceuticals.
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