If you have heard of the NDIS you will probably have heard of the term “Reasonable and Necessary”
Many people request supports in their planning meeting that they consider to be reasonable and necessary, only to have them denied when it comes to plan approval. So what does “reasonable and necessary” actually mean through the eyes of the NDIS?
The NDIS is based on the National Disability Insurance Scheme Act 2013. Section 34 of the Act discusses “Reasonable and Necessary Supports”; it is this section of the Act and the operational guidelines that funding decisions are based on.
Section 34
When plans are being approved NDIS must be satisfied that ALL of the following criteria are met in order for a support to be considered “reasonable and necessary” and be funded:
- will assist the participant to meet the associated goal, objective or aspiration written in the participant statement
- will assist the participant’s social and economic participation
- represents value for money; must be reasonable relative to both the benefit achieved and the cost of alternative support
- will be effective and beneficial to the participant and representative of good current practice
- is most appropriately provided through NDIS funding and is not more appropriately funded or accessed through other channels like the healthcare system
- takes into account what it is reasonable to expect families, carers, informal networks and the community to provide.
What types of support are likely to be funded?
Once NDIS staff are confident that the support requested meets all of the guidelines they are likely to approve funding for:
- Daily personal activities
- Transport related to community, social, economic and daily life participation
- Workplace assistance to enable the participant to secure or retain employment
- Therapeutic supports
- Assistance to maintain the home environment
- Assessment, setup and training for aids and equipment
- Home modifications
- Mobility aids
- Vehicle modifications
Using these criteria it is pretty easy to see that not everything that a person with disability accesses in the course of an average life would be NDIS funded. For instance, the new whizz-bang wheelchair may be refused because it is not the most cost-effective option; the more run of the mill wheelchair with a much cheaper price tag that will still get the participant from point A to point B has a much higher chance of being funded. Similarly, the cost of an integration aid would not be covered as this is a support that is accessed through the Education system.
What won’t the NDIS fund?
The operational guidelines are also very clear in what supports will not be funded by the NDIS and they include:
- Supports or services not related to the participant’s disability
- Anything that is the same as other supports delivered under a different funding scheme
- Relates to day to day living costs, that are not related to the individual’s support needs
- Supports, equipment or services likely to cause harm to the participant or pose a risk to others.
What about “Choice and Control?”
The other key principle of the NDIS is “Choice and Control”.
It is easy to look at the restrictions placed on funding approval by the operational guidelines and consider that they limit the choice and control of the participant by being so prescriptive. However, choice and control relate to the decision making around how a plan is going to be utilised, not funded.
Once a plan has been approved the participant can exercise choice and control by self-directing their plan, ensuring they are able to make the decisions around what a ‘good life’ means to them and source providers who will provide support in a manner that aligns with their lifestyle.
