Lack of a clear, shared understanding of what is considered ‘reasonable and necessary’ leads to complexity, confusion, conflict and inconsistency.
What you told us is not working
From what you told us we understand:
- Participants are confused about what the NDIA considers reasonable and necessary. They are also frustrated by inequitable funding decisions based on this concept.
- While the criteria for reasonable and necessary have deliberately been kept broad to make sure support can be tailored to the individual, it has made it difficult for NDIA decision makers to make consistent decisions.
- Being fair and consistent is particularly challenging in a large scheme with participants who have a wide variety of disability types, co-occurring conditions and many experience intersectionality and then which needs to assess individual circumstances.
- It is not clear to participants how plans are assessed, how funding is calculated and what exactly it can be used for once it is allocated.
- It is not clear to participants how ‘Typical Support Packages’ have been put together or how they have been used.
- There is insufficient guidance for health professionals assessing support needs. This means they don’t know what they need to include in reports to ensure people get the support they need.
- It is unclear to participants why advice from health professionals is not always supported by NDIA decision makers.
- Most Administrative Appeals Tribunal appeals relate to disagreements about reasonable and necessary
Arbitrary rules - what is reasonable and necessary to me is not the same as it is to my planner… Being told a service is not reasonable and necessary by your planner but knowing someone (whom is in the exact same situation) else's planner has approved it.
What I see is a necessary item and helps me significantly (plus supported by allied health), the NDIS doesn’t. Having the flexibility to understand what is important to a person in their life.
The onus must be reversed so that planners must prove why their decisions of what is reasonable and necessary disagrees with that of a qualified professional.
What we want to know now
How would you define reasonable and necessary, and put it into practice?
Prompts to help you answer this question:
- How can reasonable and necessary be more clearly defined so that there is a shared understanding between participants and the Agency and participants have certainty about future funding?
- What would help you understand how reasonable and necessary applies to you?
- What steps could the NDIA take to make decisions about reasonable and necessary which are more consistent and fair?