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The NDIS Act: Understanding what’s reasonable and necessary

Making sense of the NDIS support criteria to ensure you get the plan you want

The complexity of the National Disability Insurance Scheme (NDIS) was inevitable. This is because the support criteria needs to maintain its ability to provide equitable opportunities for everyone, no matter what your individual needs or circumstances are. And there are an infinite number of ways people live with, and are affected by their disability.

Unfortunately, I’ve seen many cases where even the Support Coordinators and Planners from within the National Disability Insurance Agency (NDIA), have got it wrong as well. As a participant it can feel almost impossible to try and find the information you need if the experts aren’t even getting it right. So, here we’ll run through some of the basics of the 2013 NDIS Act, and the Support Rules that govern your proposed plan.

The NDIS Act: Where the rules come from

When you’re starting to put together your pre-plan for the NDIS, it’s best to begin where you feel most comfortable – without thinking too much about the rules. It’s far easier to edit what you have later, than to get bogged down in all the details at the beginning.

You can use the pre-plan template inside First2Care to begin building a picture of your life right now, writing down the support you have, what’s working and what isn’t. The First2Care template has prompts to help you get started. Then you can start thinking about your goals for your life.

Once you’ve filled in a rough draft of your pre-plan, I’d recommend learning what you can about how the NDIA will assess your plan. This will help you understand if the support your asking for will meet their criteria, and help you provide evidence that it does – if you need to.

The NDIA assesses your criteria against the Rules from Sections 33 and 34 of the NDIS Act.

These Rules determine what support is reasonable and necessary to provide participants, and to give them maximum choice and control over how they pursue their goals and live their life.

So, what does ‘reasonable and necessary’ mean for you?

Basically, the NDIS will fund reasonable and necessary supports that help you (the participant) to:

· Reach your goals, objectives and aspirations

· Maximise your independence and undertake activities to enable you to participate in the mainstream community and in employment

They take into account your informal (unpaid) supports in place already. This is support that is part of normal family life, or natural connections with friends, family or community services. They also take into account the formal (paid) support services such as health and education.

They won’t replace funding or support for areas outside the NDIS unless it is unreasonable for that existing support to continue to do so.

Reasonable and necessary supports must tick ALL of these boxes (which means you need to be able to say yes to all of these things for the NDIS to fund it)

1. What the NDIS Act says: the support will assist the participant to pursue the goals, objectives and aspirations included in the participant’s statement of goals and aspirations;

Which means: The support will help you, as the participant, pursue your goals as included in the participant’s ‘Statement of Goals and Aspirations’ (which is a fancy way of saying a summary of your goals). You must be able to show how your supports are tied to achieving your goals in order for the NDIS to fund them.

Do your supports help you reach your goals?

Yes – I can show how my support request helps me access employment/travel independently/prepare my own meals etc. Great, move on to the next point.

No – Go back and reconsider this support request. If it doesn’t link directly to your goals it may not be relevant to your disability.

2. What the NDIS Act says: the support will assist the participant to undertake activities, so as to facilitate the participant’s social and economic participation;

Which means: The support you engage will have a significant positive impact on your ability to engage socially in the mainstream community and/or enable you to contribute to your community via economic means (ie. employment). For example, any support that would assist you to communicate with peers, and regulate your emotions in a positive way, would contribute to your ability to maintain positive relationships. In this case, if you could demonstrate your individual need, the NDIA would consider behavioural therapy, or speech therapy to assist you to communicate positively with peers, because it helps you engage socially.

Does your support help you participate socially and/or economically?

Yes – I can show how my support request helps me access employment and participate in the mainstream community.

No – Go back and reconsider this support request. If it doesn’t help you realise your social or economic potential, it may not be relevant.

3. What the NDIS Act says: the support represents value for money in that the costs of the support are reasonable, relative to both the benefits achieved and the cost of alternative support;

Which means: The support you engage represents value for money, compared to similar supports that can be provided – but also takes into account the benefits you may achieve. So, if you can demonstrate that a qualified Occupational Therapist, (which costs more than an Assistant Therapist) has more benefit to you because of the results achieved, then the NDIS would consider this reasonable and necessary. However, if you could get similar results from a Personal Trainer, as you could from engaging a (more costly) Exercise Physiologist, then the NDIS might not fund your request for the specialised support.

Another consideration is that the support will provide substantial benefit to you over the course of your life. A higher outlay for your initial plan, might provide greater long-term benefits. For example, some early intervention supports may be value for money given their potential to avoid or delay reliance on more costly supports over your lifetime.

The same applies to equipment and modifications. If the NDIS invest in modifications to your home, do they reduce your need to rely on other ongoing (and costly) care?

Does your support represent value for money when you consider the benefits you’ll receive?

Yes – I can show how my support request is the best value for money for me and my circumstances

No – Go back and reconsider whether an alternative support might provide more benefit and value

4. What the NDIS Act says: the support will be, or is likely to be, effective and beneficial for the participant, having regard to current good practice;

Which means: the support is evidence-based, has been proven to be effective through consensus of expert opinion and research, in the NDIA’s experience, or in your experience – therefore demonstrating that it’s current good practice for you. They won’t fund experimental therapies or assistive technology that is not yet proven to provide safe, quality support for participants.

I have heard participants say they’ve been told the NDIS won’t fund Sensory Equipment prescribed by an Occupational Therapist. However, it should be noted that if you can provide evidence that the participant will receive significant benefits from that equipment, then they might fund it. For example, a weighted blanket for an autistic child who struggles with sensory processing might have this equipment funded if his parents can show how it benefits him. It might assist him to remain calm, and feel in control of his body in social situations, thereby helping him to participate in the community, and achieve his goal of building and maintaining close friendships.

The important thing will be for you to provide sufficient evidence and reports from specialists, and documented proof from home to prove the benefits you’ll receive from your suggested supports.

Is your support proven to be beneficial for you, or can you show how it might be?

Yes – I can show evidence as to how my support request will provide benefits for me/the participant

No – Go back and reconsider whether an alternative support might provide more benefit and value

5. What the NDIS Act says: the funding or provision of the support takes account of what it is reasonable to expect families, carers, informal networks and the community to provide;

Which means: the support will not overtake the normal caring activities expected of families, carers or informal networks. For example if the participant is your child, you will be expected to continue to care for your child in a reasonable way but they will fund support for times when this support becomes unreasonable. For example it’s reasonable to expect a family to cook an evening meal for their 7 year old autistic daughter every night, but it’s not reasonable for the family to continue to provide cooked meals for a 25 year old autistic daughter who now lives in her own accommodation.

Another consideration is the extent of any risks to the wellbeing of a participant’s family members and existing carers. Is it appropriate, given the age and gender of the care giver, to continue to provide support to the participant? It might be unreasonable to expect aging parents to continue to care for an adult with high needs as the risk is two-fold – for both the participant and the carers. Especially if it impacts the ability of the participant to function as an independent adult.

Is the support you’re requesting reasonable, when you take into account the normal caring activities provided by friends and family?

Yes – The support is not reasonable for family members or friends to provide

No – Go back and reconsider whether the support you need is something you’d normally be expected to provide

6. What the NDIS Act says: the support is most appropriately funded or provided through the National Disability Insurance Scheme, and is not more appropriately funded or provided through other general systems of service delivery or support services offered by a person, agency or body, or systems of service delivery or support services offered:

a) as part of a universal service obligation; or

b) in accordance with reasonable adjustments required under a law dealing with discrimination on the basis of disability.

Which means: The support is deemed the responsibility of the NDIS, and not more general support services offered by a person, agency or body (such as the Departments of Health or Education, Mental health, Child protection, Early Childhood development, Employment, Housing and community infrastructure, Transport or Justice). For example, it’s the responsibility of the Education Department to fund school-related supports to provide the same standard of education to all children, even if they have a disability. That’s not the responsibility of the NDIS.

Should the support be provided by the NDIS and not other service systems (above)?

Yes – The support is directly related to my disability AND is not the responsibility of means other support services offered by a person, agency or body, or systems of service delivery or support services offered

No – Go back and reconsider whether you could approach other general systems of service delivery

You can see how important it is to know whether or not the support your requesting is reasonable and necessary and if questioned, be able to supply evidence to your NDIA planner that it is.

After you’ve entered in all your goals and supports in the First2Care Pre-planning Template, why not go back and use this checklist to see if your support requests match this criteria?

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We’d love to know if this checklist was helpful for you or not. Let us know in the comments.