What does the term Reasonable and Necessary really mean?

By July 9, 2018News

Reasonable and Necessary is one of the first terms people hear about when they start to engage with the NDIS. While it’s a well-known term, participants and Support Coordinators regularly ask us “what does it really mean?”

Reasonable and Necessary (R&N) is covered in Section 34 of the NDIS Act which guides what the NDIA can include in a participant’s plan, as well as what they can’t fund. The NDIS Act can be accessed here: https://www.legislation.gov.au/Details/C2014C00386

Only the NDIA can make Reasonable and Necessary decisions. Local Area Coordinators (LACs) gather information from participants in the planning process, but they don’t have authority under the act to make the ultimate decision about what is funded.
When approving a plan, the NDIA must be satisfied that all R&N criteria are met. If even one of the criteria isn’t met, a funded support cannot be approved.

Like LACs, Support Coordinators don’t make R&N decisions. However, understanding how the criteria are applied is valuable for Support Coordinators who often have to help participants understand their plan and the reviewable decisions process which we have previously written about here: https://scacademy.com.au/reviews-blog-reviewable-decisions-and-what-i-need-to-know-as-a-support-coordinator-part-2/

Additionally, Support Coordinators need to assist participants through unscheduled and scheduled review processes. Supporting participants and families to understand the R&N criteria helps them build capacity to participate in review processes, plan ahead and think critically about NDIA funding decisions.

Translating the criteria into every day language
Legislation is often written in formal language that’s hard to engage with. There have been many attempts both within the NDIA and by other parties to make the R&N criteria easier to understand. Sometimes you will read that “reasonable” means something that is fair, and “necessary” means something you need. While this is true, this definition doesn’t tell the whole story, and often leaves participants scratching their heads when a specific support isn’t approved.

That’s why it’s important to understand the source material – Section 34 of the NDIS Act. Let’s go through the R&N criteria:

“Related to Goals”
the support will assist the participant to pursue the goals, objectives and aspirations included in the participant’s statement of goals and aspirations;

Translation: To be funded, a support needs to relate to one or more of the participant’s goals that are documented in their “Participant Statement” (Part 1 and Part 2 of the participant’s NDIS plan). For capacity building supports this relationship is often direct (for example when Speech & Language Pathology is funded for someone whose goal is “I want my speech to be more easily understood by others”).
When it comes to Core supports the NDIA understand that goal achievement requires you to have your fundamental needs met. For example – you might not need to have a goal “I want to have a shower regularly” in order for personal care style supports to be funded, if you had a goal related to participating in the community.

“Social & economic participation”
the support will assist the participant to undertake activities, so as to facilitate the participant’s social and economic participation;

Translation: The funded support needs to support the participant improve or maintain their social and economic participation. This could be support to get out into their local community, support to explore opportunities to volunteer or undertake paid employment.

“Value for money”
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;

Translation: This does not mean that the NDIA will fund the cheapest option – but it does mean the planner will weigh up all options and decide on the best value option. Value for money can be relevant to both what type of support is provided, and how much of the support is provided. The NDIA can think of value beyond the life of the plan – for example, they may fund an expensive ceiling hoist that reduces other support needs because over several years it will prove to be good value.

“Effective and beneficial”
the support will be, or is likely to be, effective and beneficial for the participant, having regard to current good practice;

Translation: In order to fund a support the NDIA needs to make sure that the support is evidence based and the intervention or support is in keeping with current practice. Evidence could include research conducted by universities of the benefit of a support, it could include evidence from the participant or medical professional about the positive outcomes that have been achieved.

“Reasonable expectations of informal supports”
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;

Translation: When considering what is reasonable for families or other networks to provide the NDIA could take in to account the participant’s age, their relationship to informal supports, and the capacity of the families, carers and informal supports. For example, a young child would require more supports from their family based on their age than an adult and the NDIA plan for a participant should reflect this.

Most appropriately funded through the NDIS

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:
(i) as part of a universal service obligation; or
(ii) in accordance with reasonable adjustments required under a law dealing with discrimination on the basis of disability.

Translation: This criterion relates to what the NDIA refer to as the “mainstream interface” principles, which can be found here: https://www.coag.gov.au/sites/default/files/communique/NDIS-Principles-to-Determine-Responsibilities-NDIS-and-Other-Service.pdf

There are 11 mainstream interface agreements that set out the relative responsibilities of the NDIS and other systems such as Health, Education, and Housing, etc.

If an interface agreement says a particular support should be provided by another service system the NDIS won’t fund the support. This can be difficult for participants and Support Coordinators because just because the NDIS wont fund a support, there is no guarantee it will be available, or there may be a wait list to access the support.

A common example is funding for teachers’ aides. This is the responsibility of the education system. However, families often feel that the education system does not adequately meet the needs of their children. Regardless – the NDIS will not provide funding for teachers’ aides.

Additional information – things the NDIS won’t fund
The NDIS will not fund supports that:
• are likely to cause harm to the participant or pose a risk to others
• are not related to the participant’s disability (eg standard furniture, or household appliances such as microwaves)
• relate to day to day living costs – such as rent, groceries or utility fees that are not attributable to a participant’s disability.
• are part of universal obligation such as accessibility requirements under a relevant building code or any reasonable adjustment that is required by law.

Further guidance
As mentioned earlier in this blog, there are numerous fact sheets and explanations of R&N. For more information we recommend reading the Planning section of the NDIS Operational Guidelines, which can be accessed here: https://www.ndis.gov.au/operational-guideline/planning/deciding-supports-plan.html

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