Is Your NDIS Claim Reasonable and Necessary?
Families of those with disabilities lodge NDIS claims for all kinds of items and services, from finding and keeping employment services, to house cleaning, to equine therapy. Many activities are covered under the broad NDIS umbrella of "reasonable and necessary" supports.
But it’s important to understand the criteria and limitations so you have the right expectations about what you can and can’t claim.
How does NDIS define “reasonable and necessary”?
Every Australian has a network of formal supports, such as healthcare and education, and informal supports, like family and community services. NDIS seeks to provide further supports to people living with a disability, to fill the gaps that these supports don’t cover.Understanding what is “reasonable and necessary” can help determine what supports you may need in your plan and what you may be able to claim.
Reasonable – a service or item that is considered to be fair.
Necessary – a service or item you need because of your disability.
While each claim and case is individual, the NDIS will generally cover supports that
allow people with disabilities to:
- Pursue goals, objectives and aspirations
- Increase independence
- Increase community and workplace participation, and
- Develop their ability to actively participate in the community
NDIS guidelines for claimable supports
Under NDIS guidelines, claimable supports must meet the following criteria.
1. Be related to a person's disability
Anything claimed under NDIS needs to be directly related to the claimant’s disability. People with disabilities may have specific needs for certain types of equipment, resources and services that are individual to their disability.
For example, podiatry - which refers to specialised treatments for foot, ankle,
and leg needs - isn’t claimable for people with general disabilities, but is applicable for those who have cerebral palsy or Down’s Syndrome. NDIS
provides some flexibility when there is proof that certain treatments benefit
people with specific disabilities.
2. Be related to a person's disability and not be a normal day-to-day living cost.
Items like food, clothing and shelter are fundamental costs that everyone generally incurs and there are other private and government programs that exist to help families with these items if needed. NDIS covers a broad range of items and services however to be claimable they must be relevant to the individual's disability and plan. As an example, whilst items like food are not covered by the NDIS, the preparation and delivery of food may be claimable. Each claim is assessed on a case-by-case basis, and your NDIS plan manager will be able to answer questions about what may or may not be covered.
3. Represents value for money
Value for money is not necessarily about purchasing a less-expensive product or service. A support that is more expensive in the short-term, but will save money in the long-term, may represent value for money. However, where a cheaper alternative exists, which can do the same job as a more expensive version, the NDIS may require participants to explore that option.
For example, headphones purchased at a variety store may have been cheap, but the sound quality and buzzing noise makes it impossible to hear the music.
4. Be considered effective
Some supports aren’t covered under the NDIS because there isn’t enough evidence to support their widespread effectiveness. NDIS has rigid guidelines about what constitutes an effective treatment - and the treatment must be considered effective for the individual in question.It’s worth noting that some items of equipment are considered high risk and cannot be funded without prior approval from NDIA. For example, weighted blankets and body socks are considered high risk, but consideration will be given if you seek approval before purchasing them.
5. Not provided by other government departments
Australia has a robust network of financial, emotional, educational and medical resources designed to help people with disabilities. NDIS was built to fit in alongside these programs; not to replace them. Before committing to a service or item for someone who is disabled, and expecting that NDIS will cover it, make sure that resource isn’t already offered by a different agency.
For example, doctor’s visits are claimed under Medicare. If there is a gap, it is not covered under NDIS. If you’re utilising a service you normally claim under your health fund, the gap is not covered under NDIS either. In many cases, NDIS will deny claims for items or services that are covered by other government agencies.
How do you know if your claim is reasonable or necessary?
The NDIS can feel overwhelming sometimes, but when it comes to assessing whether a claim is reasonable and necessary, your plan manager can help you determine what may or may not be covered.If you need help understanding what is or isn’t covered under NDIS, talk to our professional team at All Disability Plan Management. We work with participants and providers across Australia, and our client-focus approach ensures that you always get independent, professional and reliable service. Get in touch with us today at [email protected].
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