The NDIS reasonable and necessary criteria are something that you’ve probably heard about, but what actually are they!? If you are an OT who is new to working in an NDIS caseload, understanding what these criteria are is something that you will need to learn ASAP!

What are the NDIS ‘reasonable and necessary’ criteria?

These are the rules that we need to follow when requesting funding for supports such as support workers, allied health therapy, or assistive devices. It isn’t a subjective judgement call about whether a request sounds ‘reasonable’, it is actually referring to Section 34 of the NDIS Act 2013. 

In order to be considered ‘reasonable and necessary’, an NDIS funded support:

•       Must be linked to the participant’s NDIS goals, as outlined in their NDIS plan paperwork.

•       Must facilitate the participant’s social and economic participation.

•       Should represent value for money, in terms of the benefits achieved and the costs of alternatives.

•       Must be likely to be effective and work for the participant.

•       Should take into account support given to the participant by other informal supports, such as family, friends or the community.

•       Should be most appropriately funded by the NDIS, rather than some other mainstream service such as education departments or the public health system.

So, what does this actually mean?

Here is a little more detail about each criteria, to help you understand how they may apply to OT recommendations:

•       Must be linked to the participant’s NDIS goals, as outlined in their NDIS plan paperwork. When preparing our reports to request a particular support, make sure you explain how it will help the participant reach their NDIS goal (and actually quote the relevant goal!). Most NDIS participants have broad, generic goals, rather than SMART goals, so this is usually achievable even if you weren’t involved with helping the participant to write their goals.

•       Must facilitate the participant’s social and economic participation. Remember your justification should focus on how it will improve the participant’s overall participation in activities, rather than only how it will improve a particular body function (e.g. you may say a powered wheelchair will increase the distance the person can independently mobilise, but then go on to say something like: “which will facilitate their ability to attend gardening club without support worker assistance”).

•       Should represent value for money, in terms of the benefits achieved and the costs of alternatives. This is highly relevant for OTs prescribing Assistive Technology (AT). For example, you can’t request a super fancy expensive option if the standard model will meet the client’s needs. If special features are required, you need to justify how these features are essential to allow the participant to achieve their goals, and/or explain how lesser cost features are not appropriate for the person’s needs.

•       Must be likely to be effective and work for the participant. That is, you need to provide evidence that what you are requesting is expected to provide positive outcomes for the client’s function and overall participation. This evidence could be in the form of the person’s previous experience with similar supports (e.g. the success that has been achieved in therapy sessions so far or previous AT trials), or evidence from research or clinical guidelines.

•       Should take into account support given to the participant by other informal supports, such as family, friends, or the community. An example could be that if the person lives in a home with their partner and adult children, it is not reasonable to expect the NDIS to pay for support workers to complete ALL the domestic duties of that household, even if the person with a disability can’t do this, as it is reasonable to expect that other adults in the house would also contribute to completing these duties. Instead, the NDIS may fund a smaller amount of support worker assistance to cover the proportion that would have been reasonable for the person with a disability to complete.

•       Should be most appropriately funded by the NDIS, rather than some other mainstream service such as education departments or the public health system. Often this line can be very blurry, but for public health versus NDIS, often it comes down to whether the need is health specific or disability specific. For example, a psychiatrist review for diagnostics and/or managing medications would NOT be funded (considered health related) but a psychology appointment would be funded to work on things like developing coping strategies or social skills, if this was appropriate for the client and related to their NDIS goals.

Where can I find out more?

If you visit the NDIS website and watch the video on ‘reasonable and necessary supports’ (https://www.ndis.gov.au/understanding/supports-funded-ndis/reasonable-and-necessary-supports), it is also emphasised that requested supports need to be linked to the participant’s disability and it can also not be an everyday living cost that anyone has to pay. For example, common whitegoods like a fridge or TV won’t be funded, but something like a robot vacuum may be funded for someone with an upper limb impairment if it means they can vacuum their home independently, rather than have a support worker do it for them. The key is in the justification; that is, can you clearly justify how the “reasonable and necessary criteria” have been met in relation to that particular person’s functional needs?

And a final thing to remember is that unfortunately there is still lots of inconsistency in the interpretation and application of NDIS rules, such as these ‘reasonable and necessary’ criteria. What is judged to be ‘reasonable and necessary’ for one participant, may not be for another participant, even if their functional needs and goals are very similar. If you’re not sure if your clinical reasoning is sound, then ensure you seek clinical supervision and/or peer mentoring to allow you to get another perspective.

If you found this post helpful, then consider checking out the new online course: The OT Guide to Completing a Functional Capacity Assessment, where there is a whole module on writing your recommendations in line with the ‘reasonable and necessary’ criteria. You can also continue to follow ‘Your OT Tutor’ or visit the website and sign-up to the mailing list – there will be more helpful tips and online learning opportunities to come throughout 2023!

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