What is ‘Reasonable and Necessary’?

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One thing you’ll hear a lot on your NDIS journey is the term ‘reasonable and necessary’. These three golden words are the benchmark by which NDIS will assess every request for funding you submit for your NDIS plan. But what does it actually mean?

The term ‘reasonable and necessary’ actually comes out of the NDIS legislation itself (if you’re so inclined, have a read here), and sets out criteria which must all be met for a support to be funded. As there are no hard and fast rules for these six criteria (i.e. a particular support might be funded for one person but not another even if they have the same disability), there is often a lot of debate about what is reasonable and necessary between participants, LAC’s, support coordinators, plan managers and the NDIA.

1. Is the support related to your disability?

In other words – would you have to purchase this good or service regardless of whether you had a disability? If the answer to that question is yes, it won’t meet this criteria. This also means that your day-to-day living costs – like clothes, food, your internet bill, etc. – also cannot be claimed using your NDIS funding.

E.g. NDIS might agree to fund a communication device for you, which might be an iPad. However, the cost of connecting said iPad to wifi, or purchasing a data plan won’t be something NDIS is likely to pay for, as the majority of people pay for their own internet bills, regardless of whether they have a disability.

2. Does it help you achieve your goals, or participate in the community more?

You must be able to describe how the support you’re requesting helps you to achieve a goal you have in your NDIS plan, or how it helps you to participate more in your community. The actual words that the NDIS Act use are ‘facilitate the participant’s social and economic participation’ – but this doesn’t mean that you need to find a job, or go out partying each weekend. Social and economic participation means that you are able to access community groups and events, spend your money how you like, and join activities that you are interested in.

We recommend having quite broad NDIS goals, so that you can justify more supports under a single goal. E.g. “I would like to be supported to participate in a range of activities in my community” is better than “I would like to continue going to swimming lessons each week”. With the second example, it will be harder for you to justify using for funds to attend a music group each week, as your goal only mentions swimming lessons.

It’s good to note here, that NDIS may not necessarily pay for the actual cost of an activity or group (e.g. the ticket for a concert you want to go to, or the entry fee for your local swimming pool) but will pay for the support you need to attend it if they deem it reasonable and necessary. In other words – you foot the bill for your ticket to the Fremantle Dockers game, and NDIS will fund a support worker to go with you if you need one. For a lot of places, entry is free for your support worker if you have a companion card.

3. Is the support value for money?

This one is a fairly simple one – the NDIS wants to know that this is the most cost effective product or service to support you. If there’s a cheaper option that will suit your needs just fine, you’ll need to pick this over something that is more expensive. In most cases, you can contribute your own money to customise or upgrade the product if you want to (e.g. you might want metallic paint on your wheelchair – NDIS might pay for the wheelchair, and you can pay for the metallic paint yourself).

NDIS might also consider whether it's better value for money for you to rent the item for the period you need it, rather than purchasing it (especially for expensive items). NDIS will still consider the quality of the support you’re requesting, so they may approve items that may be more expensive upfront, but will save money in the long run. Having quotes comparing products, or doing the maths about how much it will cost NDIS if you don’t have the support can really come in handy.

E.g. modifying your bathroom so that you can shower on your own may be reasonable and necessary – as the cost of having a support worker assist you with showering everyday over the course of your lifetime would far exceed the cost of modifying your bathroom.

4. Is the support likely to be beneficial?

This means that you should have evidence that what you’re asking for is likely to improve your condition or assist you with meeting your NDIS goals. This might be a supporting letter from a therapist, like an OT or a physio. NDIS won’t fund something if there is evidence that it won’t work, so the more evidence you have from multiple different sources, the better – especially if NDIS have said no already, and you’re going for a review.

NDIS also states that “where lived experience is consistent with reliable, relevant, independent evidence, it will likely be given a good deal of weight” – in other words, if you can prove that your requested support (or something similar) has worked for you in the past, NDIS will consider this as pretty solid evidence.

E.g. NDIS won’t fund hypnotherapy, as there is not enough evidence that this works.

5. Can your informal supports provide this?

Informal supports are people like family members, friends, partners, or community members – people who support you in some capacity but don’t get paid for it. If there is someone who can realistically provide this support to you, then NDIS may decide not to fund it. There are times where it is reasonable to expect that the participant’s informal supports will deliver most of their care needs – when a child is under 18 years old, for example – and so it may be harder to get your requested support across the line.

When considering whether it would be reasonable for your informal supports to provide a support, NDIS will also look at:

• whether there might be a risk to a participant’s wellbeing, if their informal supports were to provide the requested support rather than someone else
• whether your informal supports are suitable to provide this support (in relation to their age, gender, or capacity)
• whether there would be long-term risks to the informal support if they were to provide this care (e.g. if they had to give up work or study opportunities to provide this care)
• whether it might decrease your independence, if your informal support was to provide this care for you rather than someone else.

6. Is NDIS the best system to fund this?

Think about other government schemes and systems – Centrelink, Medicare, the education system, Department of Transport, the justice system. Is there another body that might be better suited to fund the support you’re requesting?

It’s important to note, though, that just because another government body doesn’t fund the support you’re requesting it doesn’t mean that the NDIS will. All government bodies need to make sure their services are accessible to people with a disability, and NDIS won’t necessarily fill the gap if they don’t. There’s more information here (scroll down to 10.8) about what NDIS is and isn’t responsible for in different sectors.

E.g. if your child needs an Educational Assistant (EA) in class because of issues directly related to their disability, often it will be up to the Department of Education to provide this, rather than NDIS.

What is reasonable and necessary for some people may not be reasonable and necessary for others – it depends a lot on your personal situation. There are a lot of supports that fall into a ‘grey area’, where the answer often isn’t a clear yes or no. Having evidence before you purchase a support will help you in the long run, if NDIS ask you to justify what you’ve paid for using NDIS funds. Your plan manager can help you to understand what is reasonable and necessary, and answer any questions you might have.

Got questions? We’ve got the knowledge and experience, and we’re here to help. Give us a ring on 1800 024 000, or send us an email at hello@plancare.com.au.