Understanding the NDIS reasonable and necessary criteria: An essential guide for Support Coordinators

The NDIS reasonable and necessary criteria is highly complex, but it is imperative that Support Coordinators understand the principle. In this article, we untangle its intricacies.

By Mary Ingerton, Managing Director at Support Coordination Academy.

NDIS reasonable and necessary criteria.

It’s a phrase that gives Support Coordinators plenty of headaches.

What does it mean exactly? Why is it important? And what are some practical examples of how it is applied?

In this comprehensive article, we answer these questions and much more.

Here is what you need to know about the NDIS reasonable and necessary criteria in the role of a Support Coordinator.

What does reasonable and necessary mean?

As you are likely aware, the NDIS funds various supports and services, primarily related to employment, education, social activities, independence, living arrangements and health and wellbeing.

To be considered ‘reasonable and necessary’, as defined by the NDIS, each support or service:

• Must relate to a participant’s disability
• Is linked to a participant’s goal
• Should represent value for money
• Must be effective and beneficial for the participant
• Should account for and not replace support provided by other government services as well as family, carers, networks and the community

How does the criteria relate to the Support Coordinator role?

A Support Coordinator must assess whether a support would likely meet the reasonable and necessary criteria, as part of the broader role of building the capacity of NDIS participants and their support network.

However, it is not the role of a Support Coordinator to determine what is reasonable and necessary.

How is reasonable and necessary criteria applied?

The NDIS reasonable and necessary criteria is legislated under the NDIS Act 2013.

In short, an NDIA delegate needs to justify the funding of a participant’s NDIS plan, providing evidence that each and every support meets all of the reasonable and necessary criteria.

Approval or rejection of supports are determined by accounting for the plan as a whole rather than looking at individual supports in isolation.

The NDIA also considers:

• A participant’s goals and aspirations
• Strengths, capacity and individual circumstances
• Barriers to accessing support
• Disability related support needs
• If there are any risks or safeguards

Let’s look at some of these considerations in greater detail, with tangible examples.

Supports related to a participant’s disability

Firstly, and most importantly, when a support has been requested by a provider or a participant, the first question a Support Coordinator should ask is: how does this support relate to the functional impact of the participant’s disability?

A Support Coordinator must gather evidence to demonstrate how the person’s disability impacts on their functional capacity to complete everyday activities and how the support will enable the participant to overcome these barriers.

Let’s look at an example:

A Support Coordinator is working with a participant who has an intellectual disability that impacts their ability to process and retain new information and problem-solve complex situations.

The individual’s goal is to increase their capacity to actively participate in their local community.

After planning with the participant and their support network, the individual decides that they want to volunteer at a local dog shelter, as they are passionate about caring for animals.

It will likely be assessed that the participant will require a Support Worker to help them to access, manage and maintain this opportunity and build their confidence, skills and capacity to achieve their goal.

Supports related to a participant’s goals

The next step is to link the support being requested to a participant’s goals.

There is a need to demonstrate how the requested support will help a participant to overcome barriers and have increased independence and capacity to pursue their goals and lead an ‘ordinary life’.

The NDIA refers to an ordinary life as ‘when a participant has the same opportunities as people without a disability, where they can pursue their potential and participate in society on an equal basis with others’.

Common indicators of improvements to the quality of people’s lives and outcomes achieved include:

• Positive relationships
• A sense of belonging
• Individual autonomy
• Active involvement in decision making
• Development of skills and strengths
• Active involvement in society

Supports that enhance social and economic participation

This criteria requires evidence of how a support will increase a participant’s capacity to access their community and actively participate in society.

A Support Coordinator needs to understand the barriers that a participant experiences in accessing their community, and how the support will overcome these barriers.

Let’s look at another example:

A Support Coordinator is working with a participant with a psychosocial disability whose goal is to increase their capacity to maintain their tenancy.

The person’s disability impacts their ability to initiate and follow through with tasks, which has resulted in the person becoming homeless.

A Support Worker is being requested to help the person develop a routine to pay their bills on time and maintain their home independently.

Achieving this goal will increase the person’s capacity to access their community and actively participate in society.

Supports that are likely to be effective and beneficial

For this criteria, the NDIA will consider if there is evidence that the support being requested is:

• Current good practice, meaning the support is commonly used, with evidence that positive outcomes can be achieved for people with similar impairments
• Both effective and beneficial for the participant, based on their unique disability related support needs.

An Occupational Therapy Functional Capacity Assessment (OT FCA) provides evidence of the functional impact of a person’s disability. It recommends supports that will be effective to overcome barriers and demonstrates how the supports will benefit a participant to achieve their goals and live an ordinary life.

The NDIA also states that for a support to be approved, there must be a consensus of expert opinions.

For example, if an OT FCA recommends psychology as a means for a participant to increase their capacity to manage their emotions and behaviours, then a psychology assessment would be required to substantiate the recommendation.

Supports that are value for money

The NDIA will assess whether the cost of the support is reasonable when considering the benefits of the support and the cost of other supports.

Let’s look at five scenarios:

1. Would other supports achieve the same result at a substantially lower cost?

For example, is it more beneficial to repair a wheelchair that is still appropriate and meets the person’s disability related needs or does the person need a new wheelchair because their support needs have changed?

2. Is there evidence that the support will substantially improve a person’s life stage outcomes and benefit the participant long term?

Take the example of psychology for a participant who is transitioning from high school and wants to gain employment.

The support will likely help the participant to overcome psychological barriers that impact on their ability to manage their emotions and behaviours when experiencing a change in their environment.

3. Will the support likely reduce the cost of other supports over time?

For instance, providing speech therapy for a participant to increase their capacity to communicate their needs independently.

This should reduce the reliance on a Support Worker to help the person to access and communicate their needs in their community.

4. How does the cost compare to other supports of the same kind in the person’s geographical area?

As one example, the cost of equipment and services is often more expensive in rural and remote areas compared to urban areas.

5. Will the support increase a participant’s independence? In effect, will it reduce the need for other supports in the future?

Consider modifications to a bathroom to make it more accessible, increasing a participant’s independence and ability to meet their own needs.

These modifications should reduce the reliance on a Support Worker to provide this support.

Reasonable expectations of informal supports

Informal supports refer to the natural supports that family, friends and others in a support network provide for a participant.

This could include the likes of transport, assistance with grocery shopping or emotional support, to help participants understand complex situations.

For this criteria, the NDIA will consider:

• What the person can do for themselves
• Any support the participant receives from others in their informal network

It is helpful to understand how the NDIA applies this criteria to participants under the age of 18, and for those aged 18 years and older.

Informal supports for under 18s

For participants under the age of 18, the NDIA will consider if:

1. The participant’s support needs are substantially greater due to the functional impact of their disability, compared to children of the same age without a disability.

Example: It is a societal expectation that parents will care for their child within the family home and provide accommodation and support when staying outside the family home.

Considerations:

• If requesting short-term accommodation and support outside the family home, evidence of the functional impact of the child’s disability and how this requires a substantially greater level of support – e.g. due to challenging behaviours – and how this has placed significant pressure on the caring role – e.g. reduced capacity to manage behaviours – needs to be provided; and
• How the support will relieve the pressure on and increase the carer’s capacity to parent the child safely within the family home has to be determined.

2. There are any risks to the wellbeing of those providing informal support to the participant.

Example: A child’s challenging behaviours have significantly impacted a parent’s capacity to keep the child safe, and there is an increased risk of relinquishment.

Outcome: A request is made for a psychologist to complete an assessment and Positive Behaviour Support Plan, to increase the parent’s capacity to manage the challenging behaviours safely and continue to care for the child within the family home.

3. The support will help the participant to build their skills and capacity in the future or reduce risks to the participant.

Example: A 15-year-old participant’s functional impairment has resulted in inappropriate behaviours in the community and involvement with the justice system.

Outcome:

• A request is made for psychology to support the participant to understand social norms and to develop skills to self-manage behaviours; and
• A request is made for training to upskill a Support Worker’s ability to reinforce appropriate social skills when in the community.

Informal supports for over 18s

For a person over the age of 18 years, the NDIA will consider if:

1. There are risks to the participant’s informal supports if they rely on them to provide support.

Example: A participant has elderly carers who are no longer able to support the person with transfers to and from their wheelchair.

Outcome:

• A request is made for Assistive Technology – e.g. a hoist – to assist the parents to continue to provide this support to the participant; or
• A request is made for a Support Worker to provide this support to the participant if the parents are unable to safely use a hoist.

2. The support from an informal network is sustainable.

Example: The participant’s sister is providing in-home support and helping with transporting the participant to access their community.

However, due to a deterioration in the sister’s health, or a breakdown in the sibling relationship, the support is no longer sustainable.

Outcome: A request is made for a Support Worker to meet this gap in support needs.

3. A participant may be socially isolated and does not have any informal supports.

Example: A participant has a physical disability and needs support to access their community.

The participant’s goal is to increase their connection to their local community and build a resilient network of supports, as they are socially isolated and do not have any informal supports.

Outcome: A request is made for a Support Worker to assist the participant to access and participate in social activities within their community.

Is the NDIS the right funding option?

Another consideration of the NDIS reasonable and necessary criteria is whether funding should be provided by another service system.

The NDIS Operational Guidelines detail the responsibilities of each service system.

Also, the NDIS will consider if the support being requested can be accessed through community supports.

For example, a workplace might fund a specialised desk and computer software for an employee with disability, so they can adequately perform their role.

But the NDIS might fund support to help that person to meet their personal hygiene needs while in the workplace, if they require this support due to the functional impact of their disability.

Additionally, the NDIS won’t fund duplicate supports – those that are already funded through other sources.

As an example, if a participant is receiving compensation to pay for rehabilitation after an accident, so they can return to work, the NDIS will not fund what they consider are similar supports.

Need more information?

There is a lot to get your head around when it comes to the NDIS reasonable and necessary criteria.

If you have any questions about this topic or require other assistance as a Support Coordinator, contact us today.

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