The NDIS does not cover services that are already claimable under Medicare, including any gap fees from those services.
❌ What the NDIS won’t pay for:
The Medicare gap fee for GP visits, specialists, or allied health services (including occupational therapy, podiatry, psychology, speech pathology).
Any service that is eligible for Medicare funding, even if Medicare doesn’t cover the full cost.
Pharmaceutical Benefits Scheme (PBS) medications.
✅ When the NDIS may pay:
The NDIS can fund services when they are:
Directly related to a participant's disability, and
Not covered under another government system (e.g. Medicare or public health), and
Considered a reasonable and necessary support in the participant’s NDIS plan.
Example: If a psychology session is covered partially by Medicare, the NDIS won’t cover the gap. But if psychology support is related to functional disability needs (not general mental health), and the therapist is not billing Medicare, it might be claimable under the NDIS instead.
✔️ What to do instead:
Choose a provider who doesn’t bill Medicare and instead charges the full amount under the NDIS.
Or, decide whether to claim via Medicare or NDIS — not both.
Ensure the provider’s invoice does not mention Medicare if submitting to the NDIS.
Summary:
| Service Type | Claim from Medicare | Claim from NDIS | Claim Gap from NDIS |
|---|---|---|---|
| GP Visit | ✅ Yes | ❌ No | ❌ No |
| Allied Health (e.g. physio) | ✅ Yes | ✅ Maybe* | ❌ No |
| Psychology (Medicare) | ✅ Yes | ✅ Maybe* | ❌ No |
* Only if not claimed through Medicare, and related to disability.