Understanding ‘reasonable and necessary’ criteria in the NDIS
Published at 03-06-2024 12:00:00
Understanding ‘reasonable and necessary’ criteria in the NDIS
The ‘reasonable and necessary’ criteria determines what the NDIS can fund and helps ensure participants receive the supports they truly need. In this article today, we take a look at the concept of reasonable and necessary supports, explaining what these criteria mean, what they entail and who is responsible for making these decisions.
What does ‘reasonable and necessary’ mean?
The NDIS supports a wide range of supports and services that are aimed to help participants achieve their goals, live more independently and participate in the community. A support must be deemed reasonable and necessary for the NDIS to fund for it, which takes several key factors into account.
This includes:
- Informal supports that might already be available to the participant, such as family, friends, or community services
- Other formal supports, such as health and education
According to the NDIS, a support must meet the following criteria to be considered reasonable and necessary:
Related to the participant’s disability: The support must directly relate to the participant’s disability and address their specific needs.
Not related to everyday expenses: The support should not include everyday living costs that are unrelated to the participants’ disability, such as groceries or rent.
Good value for money: The support should offer benefits that justify its cost, ensuring that the funds will be used efficiently.
Effective and beneficial: The support must be likely to be effective at helping the participant improve their disability or achieve their goals and improve their quality of life.
Most appropriate option: The support should be the best option available for meeting the participants’ needs, considering other supports already provided by the NDIS or other systems.
Not funded by other systems: The support should not be something that would be better funded or provided by another service system, such as medicare or other mainstream and community supports.
Who decides what is ‘reasonable and necessary’?
The NDIA bases its decisions on what is deemed reasonable and necessary on the NDIS Act and the NDIS operational guidelines for each type of support. This ensures that the decisions are consistent, fair and aligned with the legal framework and practical guidance provided by the NDIS.
NDIS planners and Local Area Coordinators (LACs) are aware of these criteria and work closely with participants to understand their needs, goals, and the specific impacts of their disability. The planner or LAC will also review the participant’s information and any supporting evidence, such as reports from healthcare professionals, to determine the appropriate reasonable and necessary supports during the planning stage.
Do Plan Managers have a say in what is ‘reasonable and necessary’?
No, Plan Managers do not have a say in what is reasonable and necessary. As per the NDIS Plan Management Guidelines, Plan Management and Support Coordination roles do not extent to determining whether supports or services are deemed reasonable and necessary as this criteria is determined solely by the NDIS delegate.
There is often some confusion surrounding this topic, especially regarding the role of Plan Managers as they handle the invoicing and budgeting for NDIS funding. Although Plan Managers are highly skilled and knowledgeable on NDIS criteria, they cannot use the reasonable and necessary test to approve supports that are not specified in the participant’s plan. Their role is to ensure that all expenses align with the approved plan and NDIS guidelines, not make exceptions or changes to what is funded.
Plan Managers:
- Ensure the plan is implemented as intended
- Enforce the price guide
- Support participants to understand their plan and understand the rules of the plan
- Prevent fraud and misuse of funds
Plan Managers do not:
- Determine what is reasonable and necessary
- Decide what supports a person can access
Why is understanding ‘reasonable and necessary’ important?
For participants, understanding what is considered reasonable and necessary helps in planning and requesting the right supports! It ensures that all the supports included in their NDIS plan are truly beneficial and tailored to their needs.
What if I am still unsure?
If you have read through the criteria and feel like you don’t have an exact yes or no to some of the criteria, don’t worry! The criteria can sometimes be difficult to interpret depending on the support. Whilst the ultimate decision is mad by the NDIS, the best thing to do if you feel unsure is to reach out for professional advice.
Your Plan Manager can offer you guidance and support in interpreting the criteria. At Just Plan Managers, we have a lot of experience with the NDIS requirements and can help you navigate through any uncertainties!
Your NDIS planner and LAC can also help to clarify certain things and help you to understand how the criteria might apply to your specific situation.
Get in touch
If you have any questions, we’d love to help you out, call us on 1300 217 037 or email us at info@justplanmanagers.com.au and our friendly team will get back to you in no time.