Disclaimers

These can be found on page 32 of NDIS Pricing Arrangements and Price Limits under “Other Considerations”.

Suuports must be Reasonable and Necessary
The NDIS proives funding to participants for supports and services aimed at increasing their independence, inclusion, and social and economic participation.

Supports funded by the NDIS need to:

  • Be related to the participant’s disability

  • Not include day-to-day living costs that are not related to a participant’s disability support needs

  • Represent value for money; and

  • Be likely to be effective and beneficial to the participant

Providers should not claim for supports from a participant’s plan where the support is not in line with the participant’s goals, objectives and aspirations as set out in their plan or where the support is not reasonable and necessary. Providers should also not claim for supports from a participant’s plan where the support is more appropriately funded or provided through other serivce systems. Further information on when a support is considered reasonable and necessary can be found on the NDIS website.

Medicare and Insurance
Some elements of a participant’s care may be covered by funds outside the NDIS. These expenses arecommonly medical, including those covered by private health insurance or Medicare. These medical expenses are not funded under the NDIS, even if they are related to, or a symptom of, the disability. These expenses should be claimed under the relevant healthcare scheme or insurance policy. Some providers (e.g. therapists) may need to distinguish between health services and disability supports that they provide to a single client, and make separate payment claims to, for example, Medicare and the NDIS.

Expenses Related to Recreational Pursuits
Providers should not claim payment from participant’s plans for:

  • Expenses related to recreational pursuits, such as event tickets for the participant, as they are not covered by the NDIS; or

  • The cost of entry for a paid support worker to attend a social or recreational event.

Prepayments
In general, Registered Providers can only make a claim for payment once a service booking has been created and the support has been delivered or provided.

For higher cost supports, the cost of the support may be claimed in stages in some circumstances, and before the support is finally delivered to the participant.

Prepayments represent funds paid in advance of the provider delivering the agreed support to the participant. Sometimes providers require prepayment(s) as collateral and/or to cover their expenses in order to source, build or talor the support to meet the participant’s unique needs.

In general, prepayments should only be sought where a business will incur unrecoverable costs should delivery of the support to the requesting participant not proceed (e.g. a custom made support).

Prepayments are subject to all of the following condistions:

  • The support item is an assistive technology (including vehicle modification), or a home modification

  • The support item value exceeds $1,500 or is custom made to adderss the participant’s disability related requirements, and a valid quote has been provided and accepted by the participant (or their nominee);

  • a service agreement between the provider and the participant (or nominee) outlines the requirement of a prepayment (e.g. deposit) or milestone payments, in line with normal business practice; and

  • The final payment of not less than 10% of the total cost, may not be claimed until the participant has received the support ready for use.

A participant is entitled to a refund of any balance of prepayment(s) less the actual unrecoverable expense incurred by the business to that point when supply is terminated. The participant remains fully entitled to their rights under Australian Consumer Law in all circumstances.

Prepayments can be claimed by providers for a support where that support is specifically identified as eligible for prepayments in the NDIS Pricing Arrangements and Price Limits. Other supports may be eligible for prepayment where the NDIA has given prior written approval (including conditions) to the registered provider to claim for prepayments.

Subscription services
in some cases, a provider may claim for a serivce agreed with a participant using a subscription model of payment. In these cases, the participant is paying to be able to use that service (on the terms/hours agreed) for the period of the subscription. Subscriptions may only be used for the supply of the following supports: Consumables (Support Category 03) and Assistive Technology (Support Category 05).

Providers wanting to claim for a subscription based service must make sure that:

  • A plain English service agreement has been accepted by the participant, that makes clear to the participant the service and its costs (including any extra fees), as well as reasonable exit conditions

  • The maximum price limit for a subscription is $5,000 per annum.

  • Subscriptions are to be charged monthly (paid at or bfore the start of the service period). Small subscriptions, where the annual cost is not more than $1,500, may be charged less frequently (quarterly or annually). For example, if a subscription service costs $199 per year, it could be charged for just once per year.

  • There are no penalties (for example exit fees) should a participant with to cancel a subscription (with reasonable on month’s notice) on or prior to the end of the paid subscription period.

  • Invoices for the subscription to be paid, clearly describe the supports for the participant to be delivered/available aduring the subscription period. For monthly subscriptions, participant’s may agree in writing to be billed quarterly (in advance of the quarter), but must be refunded any unused months if they cancle the subscription with due notice (as stated above)

Co-payments for Capital items, including Assistive Technology
In general, providers are not permitted to request a co-payment by the participant for a support. However, where a participant would like a customisation to a support or assistive technology that is not considered reasonable or necessary, they are required to pay for these themselves. These may include an aesthetic customisation to an assistive technology or modifications to a vehicle that are additional to the assistive components.

Other Fees and Charges
All registered providers must not add any other charge to the cost of the supports they provide to any participant, such as credit card surcharges, or any additional fees including any ‘gap’ fees, late payment fees or cancellation fees, unless otherwise permitted by the NDIS Pricing Arrangements and Price Limits. Participants are generally not rquired to pay exit fees, even when changing provider’s part way through a plan. A core principle of the NDIS is choice and control for participants, allowing them to change providers without expense.

Goods and Services Tax (GST)
Many, but not all, NDIA supports provided to NDIS participants are GST-free. Further information about the NDIS and GST can be accessed on the Australian Taxation Office website. Providers should seek independent legal or financial advice if they require assistance with tax law compliance. If GST is applicable to a support, the price limit is inclusive of GST.