Payments and funding amounts (Section 45)

DOCUMENT 17 25/26-0657OFFICIAL

                    Staff Talking Points and Q&As

The contents of this document are OFFICIAL

Background only – for verbal distribution only. Document strictly not for external distribution. Payments and funding amounts (Section 45)

Version control: V2.0 – 22 July 2025

General Talking Points

Understanding payments and funding in NDIS plans

• An NDIS plan is designed to support a participant’s goals and help them live the life they want. • To make the most of their plan, it’s important that participants understand how their funding works—and how to manage it well.

What’s changed in NDIS plans

• Since October 2024, new and reassessed NDIS plans may include:  Funding component amounts – funding for a specific support or group of reasonable and necessary supports.  Funding periods – the time that a part of a participant’s funding becomes available and how long it needs to last. • Funding periods break the total funding into smaller amounts over time—usually every 3 months. Participants still receive their full plan funding, but it’s distributed to help:  Plan ahead  Use supports consistently  Avoid running out of funds too early

Why spending within the plan matters

• Spending within the plan has always been important – now it’s even clearer. • The Government has introduced stronger safeguards to ensure payments do not exceed the funding amounts in a participant’s plan. This includes:  Funding component amounts  Funding periods • Funding periods help protect participants and their plans. They make sure funding is spread out over time, rather than providing the full amount at the start of a plan. This helps prevent financial exploitation and provider fraud. • Payments cannot exceed these amounts, unless there are expectational circumstances, such as to protect a participant’s safety.

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25/26-0657 • Once the funding for a period runs out, no further payments can be made for that period— even if supports are still being delivered. • Participants, nominees, and plan managers must carefully monitor spending to ensure supports are delivered within the available funding and periods. • This applies to anyone managing funds on a participant’s behalf, including plan nominees and child representatives. • These changes support responsible use of NDIS funding and help participants make informed choices, stay on track with their goals, and manage their plans with confidence.

Payments cannot exceed funding amounts

• Previously, some plans may have received additional funding when the original budget ran out. This no longer occurs • These changes do not affect how payments are currently claimed or processed, but they do mean:  The NDIA is legally required to ensure payments do not go over the total funding amount, funding component amounts, or funding periods in a plan  Participants and providers must work together to ensure supports are delivered within the plan’s funding amounts

Exceptional circumstances when extra payments may be considered

• Under the Act there are only very limited circumstances where a payment may be made above the funding amount. • The 4 specific situations where the NDIA may approve extra payments are:  There is evidence that the participant has experienced fraud or financial exploitation.  The payment is needed to prevent or reduce an imminent threat to the participant’s life, health, or safety.  The participant was unable to request a plan change due to their impairment or lack of decision-making support.  The NDIA has not yet made a decision on a request for urgent funding due to a significant change in the participant’s support needs. • Where one of these 4 limited situations exist, participants or providers can submit a manual claim request to the NDIA for consideration. • These decisions are made by an NDIA delegate. They are not reviewable and do not increase the plan’s overall funding. • The person who made the claim will receive correspondence once a decision has been made. • If someone is unhappy with their NDIS experience, they can make a complaint. • The NDIA takes complaints seriously and uses feedback to improve its services. • Complaints can be made online, by phone, email or post. • For more information or to fill out the complaint form, visit: Contact | NDIS

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Safeguarding and system alignment

• The NDIS funds supports that are reasonable and necessary. The Scheme is designed to work alongside other services like health, housing, and emergency support—not replace them. • The NDIA is not a crisis response agency. • If a participant’s support needs have changed significantly, they must submit a change of circumstances request: Change in circumstances | NDIS • Early and proactive contact is encouraged if there’s a risk of overspending or a change in a participant’s circumstances. • Partners in the Community can help connect participants to appropriate mainstream and community services. • Not all urgent or unmet needs will meet the criteria for payments above plan funding.

Where to get help

• The NDIA is available to support participants with their plans, but it is not a crisis service. For urgent help, contact:  Lifeline – 13 11 14 (24/7 crisis support)  Beyond Blue – 1300 22 4636 (mental health support)  1800RESPECT – 1800 737 732 (family violence and abuse support)  National Debt Helpline – 1800 007 007 (free financial counselling) • If a participant is experiencing financial stress or mental health concerns, the NDIA can also help connect them with free support services.

Participants

Understanding and managing your NDIS plan and funding

• Spending within your NDIS plan is important. The NDIA can only pay for supports that are funded in your plan.

What’s changed in your plan?

• Your plan may now include:  Funding component amounts – funding for a specific support or group of supports.  Funding periods – the time that a part of your funding becomes available and how long it needs to last. • These changes help you understand:  How much funding you have  What it’s for  How long it needs to last

Managing your budget

• To make the most of your plan:

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25/26-0657  Know your funding – Understand how much funding is available for each funding component and how it’s distributed across funding periods.  Track your spending – Keep an eye on what you’ve spent and what’s left in each funding component and funding period.  Plan ahead – Always check your available funding before agreeing to new supports with providers or when scheduling your supports.  Reach out early – If your needs change or you’re at risk of running out of funds, contact the NDIA as soon as possible. • You’re in control – understanding your plan helps you make informed choices, manage your supports confidently, and stay on track with your goals. • You can manage your budget using:  The my NDIS portal  The my NDIS app  The Plan Implementation Directory • Need help? Partners in the Community, or NDIA staff can support you.

Why this matters

• The NDIA can only pay for supports that are included in your approved plan. If you use your funding early, we cannot provide additional funding. • There are very limited circumstances where the NDIA may consider extra payments. • Careful budgeting helps make sure your supports last for the full length of your plan.

If your funds run out

• If a claim goes over your plan’s:  Total funding amount  Funding component amounts or  Funding periods • …it will not be paid • In the past, some plans may have received extra funding when it ran out. This is no longer possible. • Once the funding for a funding period is used up, no more payments can be made for that period. • That’s why tracking your spending and planning ahead is important.

When extra payments may be considered

• If a claim is not paid because it goes over your plan’s funding amounts, you or your provider can ask the NDIA to consider whether an exception applies. • The NDIA may approve a payment only if the situation meets one of the following 4 specific criteria: o there is evidence you’ve experienced fraud or financial exploitation o there’s an immediate risk to your life, health or safety, and payment for an NDIS support is necessary to reduce or prevent this risk

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25/26-0657 o you couldn’t request a plan change because of your impairment or lack of decision- making support o you’re waiting for an NDIA decision about urgent funding after a significant change in your support needs • If your situation meets one of these criteria, the NDIA may approve the payment and update your plan to reflect your current needs. • If it doesn’t, the payment will remain rejected, and you’ll need to work with your provider to find another way to pay for the support.

Who makes the decision?

• An NDIA delegate will decide if one of the 4 exceptions applies. • This decision is final and cannot be reviewed. • You’ll be notified of the outcome through your preferred communication method (for example a phone call or a letter).

Understanding reviewable decisions

• Some NDIA decisions can be reviewed under the NDIS Act. These are called reviewable decisions and include:  Whether someone is eligible for the NDIS  What supports are included in a plan  Whether a plan should be changed or replaced • However, not all decisions can be reviewed.

What’s not reviewable

• If a delegate decides whether a payment can be made above your plan’s funding: o The decision cannot be appealed o There is no internal or external review o The decision is final and based on whether one of the legal exceptions applies • You will be notified of the outcome, but there is no formal review process. • This decision is made under Section 45(5) of the NDIS Act. • For more information, visit: Request a review of a decision | NDIS

Where to get help

• The NDIA is here to support you with your plan, however we’re not a crisis service. If you need urgent help, contact:  Lifeline – 13 11 14 (24/7 crisis support)  Beyond Blue – 1300 22 4636 (mental health support)  1800RESPECT – 1800 737 732 (family violence and abuse support)  National Debt Helpline – 1800 007 007 (free financial counselling) • If you’re experiencing financial stress or mental health concerns, the NDIA can also connect you with free support services.

Staying informed

• You’ll be kept up to date through:

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25/26-0657  The NDIS Newsletter – Sign up at: NDIS Newsletter Signup Page  The NDIS website: National Disability Insurance Scheme (NDIS)  FAQs: Frequently asked questions about legislation | NDIS  Community events: Latest events | NDIS • We’re here to help you understand your plan and make sure your supports are working for you. • Help is always available from your providers, Partners in the Community, or NDIA staff.

Providers

Provider responsibilities

• Providers are responsible for delivering supports in line with the participant’s plan. • All providers, especially Plan Managers and Support Coordinators, need to understand how funding is defined and managed in NDIS plans. • You must understand:  how funding components and funding periods work  How rules around service claims (like Section 45(5)) can affect what services you can deliver and when you can claim for them

Understanding funding in NDIS plans

• NDIS plans may now include:  Funding component amounts – funding for a specific support or group of reasonable and necessary supports.  Funding periods – the time that a part of your funding becomes available and how long it needs to last. • Claims that exceed funding available in a participant’s plan will not be paid.

Specific circumstances for exceeding funding

• In specific situations, the NDIA may approve payment for some NDIS supports that go over the funding in a participant’s plan. • These situations are outlined in the NDIS Act (section 45(5)). This helps protect participants from gaps in essential support when certain criteria are met. • If a participant experiences one of 4 specific circumstances in the legislation, the NDIA may approve payment for some of the supports claimed —even if they exceed the plan’s funding limits. These are:  There is evidence the participant has experienced fraud or financial exploitation.  The payment is needed to prevent or reduce an imminent threat to the participant’s life, health, or safety.  The participant was unable to request a plan change due to their impairment or lack of decision-making support.  The NDIA has not yet made a decision on a request for urgent funding due to a significant change in the participant’s support needs.

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25/26-0657 • This provision does not change what is funded in the plan. It is a way the NDIS can pay for supports in specific circumstances. • It helps safeguard participants by allowing payment for essential supports that were not available in the plan for specific reasons.

Before entering into service agreements

• Service agreements are made between participants and providers. • To help avoid rejected claims and support continuity of care, make sure the agreement:  Aligns with the participant’s available funding  Reflects the timing and duration of funding periods • This helps avoid rejected claims and supports continuity of care.

If a claim is not paid due to funding limits

• You may need to:  Reschedule supports within the participant’s available budget and funding periods  Submit a Claims and Payment Enquiry if: ▪ the participant’s circumstances meet the criteria under Section 45(5) • If Section 45(5) does not apply, the claim will still not be paid. In that case:  Discuss alternative payment options with the participant (e.g. private payment)  Adjust future service delivery to align with available funding  Support the participant to understand their options, including whether a plan change may be requested if their support needs have changed

Changes for providers and plan managers

• Plan managers and support coordinators are responsible for:  helping participants plan their spending and understand their budgets  explaining the risks of overspending and support participants to use their funding over the length of their plan. • Plan Managers will need to adjust their approach under the new process. • Previously:  Claims that would exhaust available funding were avoided  A Claims and Payment Enquiry (CPE) was submitted instead • Now:  Submit the claim first  If rejected due to insufficient funding, you can only submit a CPE to request consideration under Section 45(5) if the participant’s circumstances meet one of the 4 specific criteria.  Do not submit a claim if the participant’s funding is exhausted and their situation does not meet the criteria, these will not be paid.

Claim processing and funding periods

• To avoid claims not being paid and to protect participant funding:

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25/26-0657  Deliver services within the participant’s approved budget and funding periods. Claims that exceed these limits will be rejected first. They may then be considered under Section 45(5) if the participant’s situation meets one of the 4 specific criteria and a request is made.  Avoid scheduling supports that exceed current funding periods or components. Claims are processed based on available funds at the time of processing, not the date the support was delivered.  Support participants early. If their needs change, help them contact the NDIA before delivering additional services. • Over-servicing can leave participants without enough funding for the rest of their plan.

Support for providers

• To help you adjust, the NDIA will provide:  Information sessions: Latest events | NDIS  Provider newsletters: Subscribe here: NDIS Newsletter Signup Page  FAQs: Frequently asked questions about legislation | NDIS  Updates to the Provider Portal and APIs  Updated information in the Provider Learning Environment

Partners

• You’ll play a key role in helping participants understand their plans and how to manage their own budgets. • You’ll need to explain total funding, funding components, and funding periods clearly and confidently. • You’ll also need to understand the Section 45(5) exemption pathway and how to support participants if a payment is rejected. • You can expect more questions from participants and providers during the transition. • You’ll be supported through:  New and updated KAs  Intranet notices  Team huddles  Awareness communications  Leadership updates via the Partner Change Leads Forum

Staff

Overview of the changes

• In August 2025, updates will be made to PACE and NDIS digital systems to make it easier to manage participant plans and budgets. These changes will help staff work more efficiently and improve the experience for participants and providers. • These updates will make it easier to:

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25/26-0657  Review and confirm budgets before plan approval  See how funding was used in previous plans  Use a clearer claims view and updated digital tools • Updated guidance and knowledge articles to support the exceptional claims process under Section 45(5) will be published in August.

Planning delegates

• As a planning delegate, you’ll need to understand how funding components and funding periods are applied in PACE. • You’ll be responsible for explaining the structure of participant plans, including total funding amounts, funding component amounts and funding periods amounts. • You’ll also need to understand the exceptions pathway in Section 45(5), including when payments can be made under Section 45(5). This includes knowing whether you hold the appropriate delegation to consider and decide on these payments. • Not all Section 45(5) payments will require a plan amendment. However, where a plan amendment is needed, you’ll need to understand how to manage that process. • Information will be provided through awareness communications and updated guidance.

Staff with delegation for s45(5) Exceptional Circumstance decision

• You’ll have a new responsibility to assess claims and payment enquiries where a claim has been rejected because it exceeds the relevant funding component, funding period, or total funding amount in a participant’s plan. • Your role will include:  Investigating the participant’s circumstances  Engaging directly with participants or their representatives  Assessing risks and recommending appropriate supports  Making decisions on whether to approve or reject claims under the Section 45(5) exceptions  Inform the claimant of the outcome  Document the outcome of your assessment. • You’ll need to take time off tools to complete training for this new responsibility. • Training and support will be provided to help you: • Understand the Section 45(5) exceptions pathway • Apply consistent decision-making processes • Communicate clearly and empathetically with participants

National Contact Centre (NCC) staff

• You may experience a higher volume of calls from participants, families or carers seeking clarification about changes to their NDIS plan. • You’ll need to be confident in explaining:

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25/26-0657  How plans are now structured including total funding, funding components, and funding periods.  What Section 45(5) means for participants and when exceptions may apply. • You’ll continue to create Claims and Payment Enquiries (CPEs) as usual. • When a participant requests consideration under Section 45(5), they are not required to provide evidence with the request. However, if they have any relevant information or documents, it’s helpful to include them. Evidence may be required for other processes, such as reporting fraud or requesting a plan reassessment. • Support will be provided to help you:  Understand the changes and their impact on participants  Provide accurate, consistent and clear advice  Respond confidently to questions about plan structure and funding limits • These changes are part of a broader effort to improve the NDIS and ensure participants can manage their supports with greater clarity and confidence.

Claims and Payments (SC&P) staff

• You’ll be managing 2 different processes depending on whether a participant’s plan was approved before or after 9 October 2024. • A new skill tag and process will be introduced for payment officers to manage claims assessed under Section 45(5) of the NDIA Act. • All potential exceptional circumstances claims under Section 45(5) claims will require a delegate’s decision. As SC&P staff you will need to:  Work closely with officers who have delegated authority, such as those in the Scheme Integrity Response Team.  Support the delegate in finalising the case • The delegate will be responsible for informing the claimant of the outcome. • You may experience:  Longer case durations as claims are assessed  A need for strong process knowledge, including triage checks and claim progression steps • You’ll need to set aside dedicated training time to become familiar with the new processes. • Training will cover:  The Section 45(5) exceptions pathway  Updated workflows and decision points  How to communicate outcomes clearly and consistently

Q&As

What are the key changes to NDIS plans since October 2024?

New and reassessed plans now include:

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25/26-0657 • Funding component amounts – funding for a specific support or group of reasonable and necessary supports. • Funding periods – the time that a part of a participant’s funding becomes available and how long it needs to last.

Why are funding periods important?

Funding periods help participants:

• Plan ahead • Use supports consistently • Avoid running out of funds too early

They also help prevent financial exploitation and provider fraud.

Can participants spend more than the funding in a period?

No. Once the funding for a period is exhausted, no further payments can be made for that period—even if supports are still being delivered.

What happens if a participant overspends their plan?

The NDIA is legally required to ensure payments do not exceed:

• The total plan funding • Funding component amounts • Funding periods

Previously, some plans may have received extra funding when it ran out. This no longer occurs.

Who is responsible for monitoring spending?

Anyone managing a participant’s funds—including participants, plan nominees, child representatives, and plan managers—must ensure spending stays within the available funding and periods.

Are there any exceptions where extra payments may be approved?

Yes, in 4 specific situations, the NDIA may approve extra payments, These are:

• There is evidence that the participant has experienced fraud or financial exploitation. • The payment is needed to prevent or reduce an imminent threat to the participant’s life, health, or safety. • The participant was unable to request a plan change due to their impairment or lack of decision-making support. • The NDIA has not yet made a decision on a request for urgent funding due to a significant change in the participant’s support needs.

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25/26-0657 These exceptions help safeguard participants by allowing payment for essential supports that were not available in the plan for specific reasons.

Each claim is assessed by an NDIA delegate and are not reviewable or added to the plan’s total funding.

How can a participant or provider request an extra payment if they meet one of the specific

criteria?

Clear evidence will be required before a manual payment can be considered. A provider may submit a manual claim request to the NDIA only if it meets one of the four criteria above. The person who submitted the claim will be notified of the outcome of the decision.

What should staff do if a participant is at risk of overspending?

Encourage early and proactive contact with the NDIA or Partners in the Community. A change of circumstances request may be needed if support needs have changed.

What if a participant needs urgent help?

The NDIA is not a crisis service. For urgent support, refer participants to:

• Lifeline – 13 11 14 • Beyond Blue – 1300 22 4636 • 1800RESPECT – 1800 737 732 • National Debt Helpline – 1800 007 007

How can participants make a complaint?

Participants can lodge a complaint via:

• Online: NDIS Contact Page • Phone, email, or post

The NDIA values feedback and uses it to improve services.

Further information

For further information, contact redacted: s47E(d) - certain operations of agencies@ndis.gov.au

Clearance

Drafting officer: Hayley redacted: s22(1)(a)(ii) - irrelevant Cleared by BM: Elyse redacted: s22(1)(a)(ii) - irrelevant Date: 22/07/2025 Version: 2.0 Review date: 11/10/2025

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