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Those three important words: reasonable and necessary

A woman playing with a child on an indoor swing. They are both wearing face masks.

Since its inception, the National Disability Insurance Scheme (NDIS) has provided funding for people with disability who qualify for an NDIS plan. However, in order for supports to be funded by your plan, they must be a type that can, by law, be funded or provided, and they have to meet the NDIS reasonable and necessary criteria.

So, what is reasonable and necessary?

In its own summary, the National Disability Insurance Agency (NDIA) says:

“The Australian Government made laws about what we can fund under the NDIS. All supports need to meet the criteria in these laws before we can fund them in your plan. We call these the NDIS funding criteria.”

“For example, supports need to be related to your disability, value for money, effective and beneficial, and most appropriately funded or provided by us. Each support must meet these criteria individually, but the supports must also meet the criteria when considered as a package.”

Want to know more? Here’s six key points about what’s considered to be reasonable and necessary.

1. The support will help you to work towards the goals in your plan. Remember, you can set any goals you like, and you can change your goals whenever you want to. But it’s important to know that the NDIA isn’t obligated to fund all your goals.

2. The support will help you to participate socially or economically. It will help reduce the barriers to participation that exist because of the intersection of your disability and community access.

Social participation includes the things you like to do – like playing sport, meeting up with friends or attending events. Social participation support is also funded to help you do the things you need to do, like attending medical appointments or going to school.

Economic participation means the things that will help you get or keep a job. It could be training and studying outside of high school, volunteering, learning new skills or doing work experience.

3. The support is value for money and what it costs is reasonable in terms of the benefits you’ll receive and the cost of a different support. The NDIA says this important so the NDIS will continue to be financially sustainable for you and current participants as well as future participants – recognising that anyone can acquire a disability at any time.

When looking at value for money, the Agency says it takes a long term view on supports and how they’ll benefit you – for example, a home modification may reduce your need for other supports, so if the NDIA plans to fund a home modification, it will need to take that into account when considering what other supports are reasonable and necessary, such as the amount of care you need at home.

If the home modification will reduce your care needs, the Agency may need to reduce the amount of care it funds, as a higher amount may not be reasonable and necessary when the whole package of supports is considered.

4. The support will be effective and beneficial for you and is deemed to be of current good practice. This means the NDIA will consider if other participants with similar disability support needs as you are also using the supports successfully. It also means you may not need an expert report for every single support if there’s evidence of other participants with similar disability support needs as you also getting benefit from the support you’ve requested.

5. The funding of the support looks at what it’s reasonable to expect society at large to provide. This is where the Agency looks at what it’s reasonable to expect of your informal supports – family (if you’re in contact with them), carers, friends, neighbours and community groups, taking into account your age.

The thinking is if you’d like to widen your social circle, it makes more sense for a friend to help you with that rather than a paid support worker. The NDIA will also look at whether the capacity of your informal supports is decreasing – for example, if your parents are ageing, and finding it harder to support you.

6. Finally, the NDIA checks that the support is most appropriately funded by the NDIS. It won’t fund you for things that should be provided elsewhere (even if they’re not) or supports that everyone is eligible for, like mainstream healthcare, education, justice, housing and more.

Your local area coordinator or NDIS planner will look at each support’s reasonable and necessary criteria as well as the reasonable and necessary nature of your entire plan and its benefit to you holistically.

And there’s more information on the NDIS website about each of these six points, including case-study style examples.

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My Plan Manager acknowledges the objectives of the United Nations Convention on the Rights of Persons with Disabilities.

My Plan Manager acknowledges the Traditional Owners of Country throughout Australia, and their continuing connection to land, sea and community. We pay our respects to them and their cultures, and to Elders both past and present.
© My Plan Manager 2020
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