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Understanding how NDIS funding decisions are made
October 25, 2022

NDIS language and legislation can be hard to decipher, but understanding how decisions are made is vital. When you know who is responsible for NDIS funding decisions, and how decision-makers arrive at these decisions, you can target the language you use to get better outcomes for your plan.

Who makes decisions, and with what authority? A glossary of terms
Confused by terms such as NDIA vs NDIS? Planner vs Local Area Coordinator? This glossary and list of useful links will help you make sense of it all.

Section 34 – the six reasonable and necessary criteria and what they mean

The six “reasonable and necessary” criteria are outlined in Section 34 of the NDIS Act 2013. This is the most crucial part of NDIS legislation to understand and interpret correctly. Every NDIS funded support that you request at each planning meeting must be found to meet all six of the reasonable and necessary criteria described below – so make yourself very familiar with them! Whether you are providing a clinical report or an impact statement as evidence for a support requested, it must demonstrate how the support meets these criteria.

a. the support will assist the participant to pursue the goals, objectives and aspirations included in the participant’s statement of goals and aspirations;

To be funded by the NDIS, supports must align with your NDIS goals, and help you achieve them. For advice about writing goal statements to meet your needs, check out this blog.

b. the support will assist the participant to undertake activities, so as to facilitate the participant’s social and economic participation;

It is important here to explain all supports you are requesting in terms of how they will help you to be more included in society. They should support you to live an “ordinary life” (a life where you have the same opportunities as someone without a disability). You can help your practitioners use this language in their reports. For example, if you are receiving physiotherapy, encourage your physio to write that their treatment is designed to support your mobility, so that you can access the community independently, or have more independence over daily life in your own home.

c. 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;

Here, it helps to look at the support requested as an investment in increasing your capacity, and/ or reducing your need for other supports. For example, if you are requesting the cost of some modifications to your home, you could show value for money by demonstrating these will reduce your need for support workers, and therefore save money over time.

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

This criterion refers to providing evidence. Encourage your practitioners to reference academic research in their reports, to demonstrate successful outcomes for the treatments they are recommending. Alternatively, you could provide evidence on an individual level e.g. in the form of an impact statement describing how receiving a particular support has supported you to reach your goals.

e. 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;

When thinking about what support is reasonable for family, carers or other “informal supports” to provide, consider the impact on their employment, social connections, relationships, health and wellbeing, and family. Family and carers can submit a carer impact statement outlining what is reasonable for them. This may change over time and with the life stage of both the NDIS participant, and their carer. There is some useful information on this in the NDIS document “Reasonable and Necessary Support Across the Lifespan: An Ordinary Life for People with Disability.”

f. 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

      • as part of a universal service obligation; or
      • in accordance with reasonable adjustments required under a law dealing with discrimination on the basis of disability;

“Who is responsible for the supports you need?” is a useful page of the NDIS Operational Guidelines to help you understand whether a support is most appropriately funded by the NDIS or another organisation or government department. If you are requesting a support outlined as part of the NDIS’ responsibility on this page, don’t be afraid to reference the operational guidelines as evidence for your request.

Let’s draw all this together, using an example goal, and an example requested support.

Goal: ‘I would like the necessary support to build my confidence and independence to access and navigate my community so that I can try new activities, make new friends and build my peer network.’

Support requested: funding for a support worker to access activities and services in the community.

a. Will the support requested assist you to pursue your goals?

Yes, the support requested is directly related to your goal to access and navigate your community. Perhaps, even, over time, accessing the community with a support worker will build your confidence and skills so that there are certain activities you can participate in without a support worker. If this is the case for you, mention this link to your long-term goals.

b. Will the support facilitate your social and/or economic participation?

Absolutely, the way you have phrased the goal makes it clear that the ultimate aim, and the supports attached to it, are to ensure your inclusion. You can be specific about some of the ways in which accessing activities with a support worker will, or has, supported you to build peer networks and make new friends, or some of the new activities you will/have tried.

c. Does the support represent value for money?

This is a little bit harder to demonstrate for this example – so, perhaps, think through what the alternative would be. If the alternative is to stay at home, you could outline how this exclusion might impact your mental and/or physical health and therefore cause you to need further, more expensive supports in the future.

d. Is the support likely to be beneficial according to current good practice? (Remember this criterion is around presenting evidence.)

For clinical or allied health supports requested, it is great to provide academic research as evidence. However, the type of evidence you present to request a support worker may work better as a statement of the impact on your life. Think of what you have been able to achieve whilst accessing the community with a support worker, and outline how this is different to what you could have achieved without the support.

e. Is it reasonable to expect this support to be provided by your informal support network?

Depending on your life stage, maybe. However, let’s assume you are an adult requesting support to live your life with the same opportunities as someone without disability. Would an adult without disability be accompanied by a family member to all their social events and outings in the community? Or would this limit their independence? You have the same right to independence, so in this case, you could argue that it is not appropriate for your informal support network to provide this support.

f. Is this support most appropriately funded by the NDIS?

Yes, a disability support worker for community participation is most appropriately funded by the NDIS. It doesn’t fall under any other government department or sector such as health, education or employment.

In summary

We may not be National Disability Insurance Agency delegates with authority to make decisions about NDIS plans and funding, but by speaking the language of the decision-makers, and referencing their decision-making tools, you can build your own capacity to translate the NDIS and self-advocate.

There is a good chance that you will need to translate these tools to the support team and treating professionals in your NDIS-funded world, for example therapists. This may include being confident in requesting and suggesting edits to their reports. Being familiar with the language and legislations (glossary and links here) will support you to understand and be the boss of your NDIS plan and your interactions with the NDIS.

Remember, you can also watch and listen to the webinar via the link below. 

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