DOCUMENT 1

From: [[s47F - personal privacy](/foi-library/releases/759e22e37354-foi-24-25-0593-decision-document/release-materials/material-001__s47f-personal-privacy/)](/foi-library/releases/759e22e37354-foi-24-25-0593-decision-document/release-materials/material-001__s47f-personal-privacy/) To: [s47F - personal privacy](/foi-library/releases/759e22e37354-foi-24-25-0593-decision-document/release-materials/material-001__s47f-personal-privacy/) Subject: FW: Would We Fund It? CEO Endorsed (tranche 1) [SEC=OFFICIAL] Date: Friday, 26 February 2021 9:17:00 AM Attachments: image004.png, Would We Fund It - Launch items FINAL CEO Endorsed.docx

Hi s47F - personal priv,

Please see final clean version of the Would We Fund It guide.

Can you indicate how we progress from here for internal release publishing? Are we just following normal internal publishing processes as I am unclear of our role vs Strategy branch here?

Kind regards s47F - personal privacy Service Guidance and Practice Branch – Service Guidance Resources Participant Experience Design National Disability Insurance Agency T s47F - personal privacy M s47F - personal privacy (I work part time – unavailable on Thursdays)

From: s47F - personal privacy <s47F - personal privacy > Sent: Wednesday, 24 February 2021 10:35 AM To: s47F - personal privacy <s47F - personal privacy > Subject: RE: Would We Fund It? CEO Endorsed (tranche 1) [SEC=OFFICIAL]

Hi s47F - person, that sounds great. I’m hoping there’s very little clean-up required as all the content has been through the copywriters, and the CEO has signed off on the wording. Feel free to do what you need with it, but if you think there are any significant copy changes, would you be happy to check in before you make them? Thanks s47F - person s47F - personal privacy National Disability Insurance Agency M: s47F - personal privacy | E: s47F - personal privacy

FOI 23/24-0269

NDIA acknowledges the traditional owners of country throughout Australia, and their continuing connection to land, sea and community. We pay our respects to them and their cultures, and to elders both past and present.

From: [[s47F - personal privacy](/foi-library/releases/759e22e37354-foi-24-25-0593-decision-document/release-materials/material-001__s47f-personal-privacy/)](/foi-library/releases/759e22e37354-foi-24-25-0593-decision-document/release-materials/material-001__s47f-personal-privacy/) <s47F - personal privacy > Sent: Wednesday, 24 February 2021 10:05 AM To: s47F - personal privacy <s47F - personal privacy > Subject: FW: Would We Fund It? CEO Endorsed (tranche 1) [SEC=OFFICIAL]

Hi s47F - perso,

Just circling back on this; while the next lot of examples are being worked through, are you happy for me to get someone in my team to clean this CEO endorsed version and get ready for internal pre-release?

Kind regards

s47F - personal privacy Service Guidance and Practice Branch – Service Guidance Resources Participant Experience Design National Disability Insurance Agency T s47F - personal privacy M s47F - personal privacy (I work part time – unavailable on Thursdays)

From: s47F - personal privacy <s47F - personal privacy > Sent: Monday, 15 February 2021 9:01 AM To: s47F - personal privacy <s47F - personal privacy >; s47F - personal privacy <s47F - personal privacy >; s47F - personal privacy <s47F - personal privacy >; s47F - personal privacy <s47F - personal privacy >; <s47F - personal privacy >; s47F - personal privacy <s47F - personal privacy >; s47F - personal privacy , s47F - pers <s47F - personal privacy >; s47F - personal privacy <s47F - personal privacy >; s47F - personal privacy <s47F - personal privacy >; s47F - personal privacy <s47F - personal privacy >; <s47F - personal privacy <s47F - personal privacy >; s22(1)(a)(ii) - irrelevant material, s47 <s47F - personal privacy > Cc: s47F - personal privacy <s47F - personal privacy > Subject: Would We Fund It? CEO Endorsed (tranche 1) [SEC=OFFICIAL]

Morning all,

Page 2 of 45

FOI 23/24-0269

Even with many of us back in mini-lockdown, it’s a happy Monday – I’m excited to attach the CEO-endorsed version of Would We Fund It (launch items x 10). With the delayed launch date, we’re well placed to deliver these with the R&N OG when it goes live internally on 1-Mar. The focus for this week is now tranche 2, as already discussed.

Amazing work everyone – thanks for the ongoing hustle to push through these!

[[[s47F - personal privacy](/foi-library/releases/759e22e37354-foi-24-25-0593-decision-document/release-materials/material-001__s47f-personal-privacy/)](/foi-library/releases/759e22e37354-foi-24-25-0593-decision-document/release-materials/material-001__s47f-personal-privacy/)](/foi-library/releases/759e22e37354-foi-24-25-0593-decision-document/release-materials/material-001__s47f-personal-privacy/)

National Disability Insurance Agency

M: s47F - personal privacy | E: s47F - personal privacy

cid:image001.jpg@01D530EF.D9C43850

NDIA acknowledges the traditional owners of country throughout Australia, and their continuing connection to land, sea and community. We pay our respects to them and their cultures, and to elders both past and present.

From: s11(c)(1)(a)-personal info , Martin <s47F - personal privacy > Sent: Sunday, 14 February 2021 7:33 AM To: s11(c)(1)(a)-personal informatio Sumone <s47F - personal privacy >; s11(c)(1)(a)-perso, Oliver <s47F - personal privacy > Cc: s11(c)(1)(a)-pe Deb <s47F - personal privacy >; s47F - personal privacy <s47F - personal privacy >; s47F - personal , s47F - personal pr <s47F - personal privacy >; s47F - personal privacy <s47F - personal privacy >; s47F - personal privacy <s47F - personal privacy >; s11(c)(1)(a)-personal , Jo <s47F - personal privacy > Subject: RE: Links updated for [SEC=OFFICIAL]

Thanks Sumone. All good from me now. Regards Martin

From: s11(c)(1)(a)-personal informatio, Sumone <s47F - personal privacy > Sent: Thursday, 11 February 2021 8:56 AM To: s11(c)(1)(a)-personal info Martin <s47F - personal privacy >; s11(c)(1)(a)-perso, Oliver <s47F - personal privacy > Cc: s11(c)(1)(a)-p, Deb <s47F - personal privacy >; s47F - personal privacy <s47F - personal privacy >; s47F - personal , s47F - personal pr <s47F - personal privacy >; s47F - personal privacy <s47F - personal privacy >; s47F - personal privacy <s47F - personal privacy >; s11(c)(1)(a)-personal in Jo <s47F - personal privacy > Subject: Links updated for [SEC=OFFICIAL]

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FOI 23/24-0269

Dear Martin,

Please find attached the “would we fund it” document with updated energy links.

Thank you, Sumone

Sumone redacted: s11(c)(1)(a) - personal information no

Branch Manager | Agency Strategy | Design, Digital & Strategy National Disability Insurance Agency

M: s47F - personal privacy | E: s47F - personal privacy

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Would we fund it?

Contents

• Introduction …2
  • Purpose of this document …2
  • What does the NDIS fund? …2
  • What doesn’t the NDIS fund? …3
• Assistive Technology …4
  • Generators …4
  • Modified Vehicle Repairs and Maintenance …7
  • Non-Standard Mattresses …11
  • Wheelchair modifications …17
  • Sensory Equipment …21
• Improved health and wellbeing …25
  • Swimming lessons in early childhood …25
  • Gym membership …29
• Consumables …32
  • Early Childhood Continence Consumables …32
  • Continence Consumables …35
  • Home Enteral Nutrition (HEN) …37

1. Introduction

Sometimes it’s hard to understand why the NDIS has made a decision to fund or not fund a particular support or why decisions appear to be different for people with the same or similar disability to you.

When we make a Reasonable and Necessary (R&N) decision, it is based on many different things; including what your disability support needs are, your living arrangements and what is reasonable for informal supports, like families and carers to provide – everyone is different.

1.1 Purpose of this document

On the following pages you will find some examples of commonly requested items that we find cause the most confusion. For each item, we explain how we make R&N decisions about them and provide an overview of whether or not we typically fund them. This guide is intended to be read alongside the R&N Our Guideline, and new items will be added to this resource as they are developed.

1.2 What does the NDIS fund?

We would typically fund a requested support if it: (insert hyperlinks to Leg for all criteria)

• Is related to your disability needs; AND
• Meets ALL of the following as outlined in the NDIS Funding Criteria (insert link to R&N OG):
  • It will help with your individual goals and aspirations
  • It will help your social and/or economic participation
  • It is value for money, which means that:
    • The cost of the support is similar to or cheaper than alternative options that can provide you with the same outcome (NDIS Supports for Participants Rule 3.1(a)); and/or
    • Purchasing the support is likely to reduce the costs of funding for other supports in the long term (NDIS Supports for Participants Rule 3.1(c)).

What doesn’t the NDIS fund?

We would typically not fund a requested support if:

• it is likely to cause harm to you or others
• it is not related to your disability
• it provides the same benefit as another support already funded by the NDIS in your plan
• it relates to a day-to-day living cost (for example, rent, groceries or utility costs like your water bill) that are not directly related to your disability support needs (NDIS Supports for Participants Rule 5.1(d)); or
• it is being used as income replacement (NDIS Supports for Participants Rules 5.3(b))

2. Assistive Technology

People use equipment, technology and devices every day to make their lives easier. When we talk about assistive technology, we mean equipment, technology and devices that help you do things you can’t do because of your disability. Or, things that help you do something more easily or safely. Assistive technology involves things designed to improve your daily life and help you do everyday things.

You can browse the Assistive Technology Our Guideline here (insert link to AT OG).

2.1 Generators

Case

Jing’s disability means he has trouble breathing and keeping his airways clear and free from infection. He needs to regularly use life support equipment. He lives in an area that can have an unreliable power supply. Jing asks for funding for a generator to back up his power supply. This is because he’s worried that without the life support equipment he’ll get sick and need to go into hospital.

Would we fund this?

No, we would not typically fund a generator for Jing. This is because supports related to the provision of power sources are the responsibility of the states and territories. This includes backup generators to run assistive technology for people who live in areas that may have unreliable power supply. Under section 34(1)(f) of the National Disability Insurance Scheme Act 2013, we don’t fund supports that are more appropriately funded or provided through other general systems of service delivery or support.

Why wouldn’t we fund it?

The states and territories are responsible for making sure everyone has a power supply. This may include backup generators where supply can’t be guaranteed.

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Also, there are registers for emergency medical essential power to make sure the power

suppliers are aware of people with disabilities who have specific power needs. Please talk to your myNDIS contact if you need help to get on to another government scheme. For more information about emergency medical essential power in your area please refer to the links below, or your state or territory government website:

• Life support equipment – be prepared and make a plan | Energy Made Easy
• Customers using life support equipment | Energy Made Easy

When we work out whether a support is reasonable and necessary for you, we consider the information you’ve provided against the NDIS Funding Criteria (insert link to OG). Under our funding, a back-up generator is not likely to meet the reasonable and necessary criteria. This is because it’s more appropriately funded or provided through other general systems of service delivery or support.

What other related supports might we fund?

Some assistive technology devices, such as respiratory equipment, are supplied with backup batteries for emergencies or to make them easier to carry on short trips. We may provide funding for batteries for some types of assistive technology, to support the operation of the equipment.

Case Example

Jane is 7 years old. She has an acquired brain injury and is paralysed on one side of her body. This means she has difficulty breathing. Jane relies on suctioning equipment to keep her airways clear and prevent aspiration pneumonia. The suction equipment is powered by electricity and she needs access to it wherever she goes.

There have been a series of power disruptions in the area where Jane lives. Her mother, who is Jane’s child representative, asks us for funding for:

• a back-up generator
• petrol to fuel the generator

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• a replacement rechargeable battery for Jane’s 2 year old suction equipment as the existing battery is no longer charging effectively.

To work out whether funding for the generator and its operating costs is reasonable and necessary, we’ll look at the information Jane’s mother provided against the NDIS Funding Criteria (insert link to OG). Along with other reasonable and necessary criteria, we think about whether:

• the need for the generator is solely and directly due to Jane’s disability needs,
• the generator is most appropriately funded by the NDIS and not by other general systems of service delivery

In Jane’s case, the planner decides that a generator is not reasonable and necessary because:

• states and territories, not the NDIS, are responsible for the provision of power supply and to provide support for emergency medical essential power.
• the need for the generator is not solely and directly as a result of the participant’s disability needs. This is because a generator will provide power for the household in the event of a power outage.

The planner then looks at the request for the replacement battery and decides:

• as we funded the direct cost of the suctioning equipment due to Jane’s disability, the replacement battery is an additional cost of maintaining it. It’s a reasonable and necessary support that keeps the suctioning equipment in good working order. The back-up battery also provides sufficient power to allow time for Jane to get help if there was a prolonged power outage.
• the rechargeable battery will help Jane go to school and take part in social activities.

The planner decides:

• the back-up generator and fuel consumables are not reasonable and necessary, and funding was not approved

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Modified Vehicle Repairs and Maintenance

Case

Anthony has an accident in his vehicle which has been modified to support his disabilities. He asks us to fund the costs of the vehicle repairs and maintenance.

Would we typically fund this?

No, we would not typically not fund the general maintenance and repair costs of your vehicle. This is because it is not likely to meet the criteria of an “additional living cost” that is required “solely and directly” as a result of your disability needs. We would, however, typically fund the repair and maintenance costs of the vehicle modifications installed to support your disability needs.

Why wouldn’t we fund it?

Most Australians use a car or a motorbike for transport. This means the purchase, running costs, registration and insurance of vehicles are considered day-to-day living costs not related to someone’s disability. We do not fund these everyday expenses.1

1 Rule 5.1(d) NDIS (Supports for Participants) Rules 2013

We do typically fund the maintenance, repair and insurance of a vehicle that supports your disability needs.

For example, the maintenance and repair of vehicle modifications needed so that you can:

• get in and out of the vehicle with or without a wheelchair
• carry your wheelchair in or on the vehicle without lifting
• be transported safely whilst seated in your wheelchair
• drive with specialised controls or other adaptations.

When we work out whether a support is reasonable and necessary for you, we consider the information you’ve provided against the NDIS Funding Criteria (insert link to OG). We usually include funding for the maintenance and insurance of your disability-related vehicle modifications in your plan when we approve funding for your modifications. If you have a car accident, we would expect your insurance policy to cover most of the costs for the repair of your vehicle modifications.

In most cases, you can use the maintenance allowance already in your plan to cover the extra costs of any repair of your vehicle modifications. If the repairs cost more than the funding you already have, or you need to replace the equipment, contact us or your planner for advice. If the costs to repair or replace your vehicle modifications is going to be more than $1,500, you will also need to give us a quote and make sure we accept it before you go ahead with the repairs.

What other related supports might we fund?

While we won’t fund the general maintenance and repair of your vehicle, we will typically fund maintenance and repair costs of modifications made to the vehicle to support your disability. This includes:

• servicing the suspension or undercarriage if the floor has been lowered or 4-point suspension or height-adjustable kneeling fitted for disability reasons
• damage to vehicle interior, such as floor relining due to wheelchair access
• seat belt stalks and replacing customised seat belt systems

• servicing the power system if there are power modifications to support power ramps or other vehicle-powered assistive technology.

For more information on vehicle modifications, please refer to the operational guidelines - vehicle modifications.

Case example

Raja is paraplegic. He uses a wheelchair and drives a vehicle modified to support his disability. We funded these modifications. Recently, while visiting his doctor, an unknown driver crashed into the side of Raja’s car and drove off. Raja had parked in a disabled parking spot.

The accident caused damage to the:

• front and side panels
• front wheel
• modifications that allow Raja to drive without pedals.

Raja contacts his vehicle insurance provider and finds out that, as the driver of the other vehicle is unknown, the excess on his policy will be $2000. As Raja needs his vehicle to access his supports, he contacts the NDIS to fund the:

• $2000 excess
• transport for his regular essential transport needs
• costs to travel to and from his support services for the 6 weeks it will take to repair his vehicle.

Raja gives us a costing from the insurer’s approved panel beater. The price includes the itemised costing from a vehicle modifications dealer to replace the driving modifications and repair the vehicle. It also specifies how long the vehicle will be off the road.

To work out whether funding for Raja’s request is reasonable and necessary, the planner

considers the information provided against the NDIS Funding Criteria (insert link to OG). In doing so the planner considers whether:

• Raja has provided a quote for the repairs or replacement of the vehicle modifications
• the $2000 excess relates to the total cost of the damage to the vehicle or just the cost to repair the damage to the vehicle modifications
• Raja’s plan includes funding for the maintenance and repair of vehicle modifications
• Raja’s NDIS supports, mainstream and community supports and regular essential transport needs are documented so they can work out transport costs while Raja’s vehicle was being repaired.

In Raja’s case, the planner decides:

• the excess is the same no matter what repairs are made to the vehicle, so Raja would need to pay it even if there was no damage to the modifications
• they need more information about whether Raja’s insurance covers alternative transport such as a loan vehicle
• without an alternative means of transport while his vehicle is being repaired, Raja’s request for transportation funding to cover his regular essential transport needs and the transport costs to his funded supports would be reasonable and necessary.

After they get more information, the planner decides:

• Raja’s request for the funding of the excess is not a reasonable and necessary support that the NDIS can provide.
• Six weeks of transportation costs so Raja can travel while his vehicle is repaired was reasonable and necessary, and approves funding for this.

For more information, refer to;

• Operational Guideline - Reasonable & Necessary
• Operational Guideline – vehicle modifications

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Non-Standard Mattresses

Case

Josie feels her disability means her mattress doesn’t suit her needs. She thinks a pressure or hygiene mattress would help her sleep better or more comfortably. It would also help her to more safely and independently manage her bed transfers.

Would we typically fund this?

Yes, we typically approve funding for a pressure or hygiene mattress if you need it because of your disability.

You will need to give us evidence or information that the mattress you want:

• relates to your disability²
• is value for money compared with alternatives³
• is effective and beneficial⁴.

Why would we fund this?

Mattresses are a common item in Australian homes. Household items that most people are likely to have in their homes are unlikely to be disability-related supports. This means we are unlikely to fund them.⁵

If, however, you need a particular item because of your disability support needs, then we may consider it a reasonable and necessary support. For example, you might need specialist

_{² See Rule 5.1(b), NDIS (Supports for Participants) Rules 2013. ³ See Subsection 34(1)(c), NDIS Act. ⁴ See Subsection 34(1)(d), NDIS Act. ⁵ See Rule 5.1(b), NDIS (Supports for Participants) Rules 2013.}

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furniture designed for people with disability, or regular furniture that can be modified to help you do everyday tasks.

When we work out whether a pressure or hygiene mattress is reasonable and necessary for you, we assess the information you give us against the NDIS Funding Criteria (insert link to OG). You will need to give us evidence or information that shows the mattress is a reasonable and necessary support.

This means the evidence or information must show that you need the mattress as a direct result of your disability⁶. This may include information such as an assessment or report from a registered therapist about your disability support needs. We may already have some of this information.

You would also need to show that the mattress:

• is value for money⁷, including information about the cost and benefits of the mattress and why cheaper alternatives are not fit for purpose⁸
• is effective and beneficial⁹, such as information that the type of mattress has worked for you in the past, or is designed to work for people with similar support needs to you¹⁰
• will be installed correctly and operated safely to ensure it doesn’t cause harm to you or your carers.¹¹

6 See Rule 5.1(b), NDIS (Supports for Participants) Rules 2013. 7 See Subsection 34(1)(c), NDIS Act. 8 See Subsection 34(1)(c), Rule 3.1(a), NDIS (Supports for Participants) Rules 2013. 9 See Subsection 34(1)(d), NDIS Act. 10 See Rule 3.2, NDIS (Supports for Participants) Rules 2013. 11 See Rule 5.1(a), NDIS (Supports for Participants) Rules 2013.

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What else do we think about?

In most cases, if we decide to fund a pressure mattress, we will also fund delivery and installation costs.

Your planner will determine if the mattress is a reasonable and necessary support based on the NDIS Funding Criteria (insert link to OG).

The mattress must be ‘value for money’.12 When we think about the benefits and costs of the mattress, we consider:

• whether the mattress will be effective and beneficial for you
• the costs and benefits of the mattress, including how long it is likely to last, compared with other supports that would achieve the same outcome.13
• if the mattress is likely to reduce the long-term cost of other supports, for example fewer home-care support hours14
• whether it’s possible and more cost-effective to rent the mattress.15

We won’t fund extra items that are not reasonable and necessary. You may choose, however, to pay out of your own pocket for:

• a particular brand, model or design of an item
• special features not related to your disability needs, for example hypoallergenic.

Case example

Sam has a progressive muscle weakness and degenerative spinal condition. He finds it hard to sit up from a lying position and needs help from another person to do so. He often wakes up because he is uncomfortable, and finds it easier to breathe if he sleeps with his upper body slightly elevated at an angle, rather than flat. He can’t independently shift his weight to reduce pressure. Sam needs to use a bed rail to roll to his side. His sleeping problems make him tired, which means it’s hard for him to do daily activities independently.

Sam applies for funding of a Hi-Lo bed with rails, and a gel-infused pressure prevention mattress. Sam supports his funding request with a letter from his therapist, which also recommends a gel-infused pressure prevention mattress. Sam’s therapist believes this mattress will make sleeping more comfortable for Sam, minimise the risk of pressure problems and reduce his sleeping problems.

Based on available information, the planner is satisfied the bed meets the NDIS Funding Criteria (insert link to OG), including that it is related to his disability16. She lists the make and model of the mattress and bed to be purchased and includes funding in Sam’s plan.

However due to the cost of the requested mattress, she needs more information to work out if the gel-infused pressure prevention mattress requested by the therapist is:

• value for money17
• likely to be effective and beneficial18 in meeting Sam’s current and long-term pressure care needs.

There are different ways to provide the extra information needed for us to make a funding decision.

Sam chooses to trial the mattress with the help of his therapist to show its effectiveness. Trials can typically be arranged with equipment suppliers at no cost. In Sam’s case, the mattress was available from the local supplier so Sam could try out the mattress for 10 days. The trial report showed that Sam was able to move around the bed independently and sleep the entire night without interruption because he was more comfortable.

To work out whether the funding for the mattress is reasonable and necessary for Sam, the planner assesses the information provided against the NDIS Funding Criteria (insert link to OG).

When deciding if the mattress is reasonable and necessary19, the planner thinks about such things as whether:

• there is a cheaper pressure mattresses available with the same performance and function20
• the mattress Sam’s therapist requests has higher functionality than the base model needed for Sam to achieve his desired outcome
• other options, such as renting the mattress, are better value for money21
• funding the mattress may reduce the cost of other supports in the long term.22

She also considers information from the trial, current good practice, or other expert opinion to work out whether the mattress will achieve the desired option.23

19 See Subsection 34(1)(c), NDIS Act. 20 See Rule 3.1(a), NDIS (Supports for Participants) Rules 2013. 21 See Rule 3.1(d)(i), NDIS (Supports for Participants) Rules 2013. 22 See Rule 3.1(c), NDIS (Supports for Participants) Rules 2013. 23 See Rule 3.2 and 3.3, NDIS (Supports for Participants) Rules 2013.

In Sam’s case, following the trial, the planner decides that the gel-infused pressure prevention mattress is value for money.

The costs are reasonable relative to the benefits achieved.24

Cheaper options are:

• unlikely to meet Sam’s support needs or achieve the same outcomes
• not as safe when Sam’s transfers from a power chair
• not suitable.25

In making her decision she notes that:

• the mattress will help Sam manage bed transfers and reduce the cost of other supports in the long term26
• renting the mattress is more expensive than buying it27
• the mattress will be effective and beneficial for Sam based on the therapist’s advice and the trial.

The planner assesses Sam’s gel-infused pressure prevention mattress as a reasonable and necessary support and approves funding for Sam to buy the mattress. The planner also includes funding for mattress delivery and installation.

For more information, refer to:

• Operational Guideline - Reasonable & Necessary
• Operational Guideline - Assistive Technology

Wheelchair modifications

Case

Leroy needs a power assist system added to his wheelchair to support his disability. The add-on will allow him to travel medium to long distances, increasing his independence and mobility.

Would we typically fund this?

Yes, we would typically fund wheelchair modifications as they likely meet the NDIS Funding Criteria (insert link to R&N OG). You may need to provide evidence, such as a report from an occupational therapist, to show the equipment:

• is appropriate
• is value for money compared with alternatives²⁸
• relates to your disability support needs.²⁹

Why would we fund this?

To work out whether a support is reasonable and necessary for you, we think about the information you give us against the NDIS Funding Criteria (insert link to OG). To do this, we need you to give us evidence or information that shows the wheelchair modification is a reasonable and necessary support.

This evidence needs to show a number of things:

• why you need the wheelchair modification
• why the modification is appropriate for you

²⁸ See Subsection 34(1)(c), NDIS Act.
²⁹ See Rule 5.1(b), NDIS (Support for Participants) Rules 2013.

• how the modification relates to your disability support needs,30 such as an
• assessment or report from a registered therapist. We may already have this information.
• that the wheelchair modifications can be properly installed and safely operated.31
• how the wheelchair modification is value for money. This includes evidence or information to show the cost of the proposed option is reasonable in relation to its benefits as well as the cost of alternatives32, and that the support is fit for purpose. We will also look at evidence or information about whether the modifications are likely to increase your independence and reduce the long-term cost of other supports, such as home care support hours or supports that help you access your community.33
• how the wheelchair modifications are effective and beneficial in helping you move around.
• how the wheelchair modifications help you take part in social and economic activities.

What don’t we fund?

We won’t fund extra items that are not reasonable and necessary. You may however choose to pay for these with your own money. This might be if you want:

• a particular brand, model or design of an item
• special features not related to your disability needs.

30 See Rule 5.1(b), NDIS (Support for Participants) Rules 2013. 31 See Rule 5.1(a), NDIS (Supports for Participants) Rules 2013. 32 See Subsection 34(1)(d), NDIS Act. 33 See Rule 3.1(c), NDIS (Supports for Participants) Rules 2013.

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Case example

Billy is 9 years old and has congenital muscular dystrophy. While he can walk indoors, he needs a power wheelchair for medium to long distances. Billy’s therapist says Billy is expected to experience more loss of mobility and will need to use a power wheelchair for all activities within 2 years.

Billy is outgrowing his current wheelchair and has asked for funds to replace it. He hopes to actively participate in sports such as basketball and power soccer.

Billy supports his request with a therapist report recommending we fund a new power wheelchair with custom seating, posterior tilt and extra features such as seat elevation, recliner capacity and leg elevation.

In principle, based on available information, this request meets our NDIS Funding Criteria. Billy has previously had a wheelchair with custom seating and a power tilt. We need more information, however, to work out if the extra features of seat elevation, recliner capacity and leg elevation will:

• be effective and beneficial
• meet Billy’s current and future needs.

To support the request, we need evidence of a successful trial that shows whether the extra features are effective with regard to Billy’s:

• current and future needs
• range of motion and strength measurements.

The trial also needs to show:

• how the extra features improve Billy’s function when using them
• whether Billy needs supervision to operate the elevated seating or reclining function

• any expected outcomes Billy is likely to achieve relating to these extra additional
• features.

To work out whether the funding for the additional wheelchair modifications are reasonable and necessary, the planner considers the information Billy gives us against the NDIS reasonable and necessary criteria (insert link to OG). In doing so the planner thinks about things such as:

• the benefits of the requested power wheelchair add-ons in meeting Billy’s desired outcome, as well as the cost.
• whether the wheelchair is value for money based on Billy’s continued growth and future support needs34
• other services available, such as variations to his care support hours, which may also achieve the desired outcome
• if there is enough evidence that the extra features will substantially improve Billy’s life stage outcomes, reduce his need for different kinds of supports and be of long-term benefit.

In Billy’s case, following the trial, the planner decides the proposed modifications are likely to:

• meet Billy’s support needs
• represent value for money
• be safe when operating the wheelchair
• be the most suitable option.

34 See Rule 3.1(d)(ii), NDIS (Supports for Participants) Rules 2013.

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Sensory Equipment

Case

Maria asks for funding for lycra bedsheets and a trampoline to help her 4 year old son manage his developmental delay or disability. She mentions he needs help with:

• emotional regulation
• sensory processing
• sleeping
• general behaviour.

Would we fund this?

No, we would not typically fund this equipment to support a child with a developmental delay or disability. This is because it’s not likely to meet our criteria that “the support will be, or is likely to be, effective and beneficial for the participant, having regard to current good practice.“35

35 See Subsection 34(1)(d), NDIS Act.

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Why wouldn’t we fund it?

There isn’t enough research or evidence that tells us this type of sensory equipment is effective. In fact, some research shows that this sensory equipment isn’t likely to help improve functional capacity. Some equipment, such as trampolines and weighted blankets, may even be harmful for children younger than 6 years old. Other research shows there are better methods.

This means these supports are not likely to be “reasonable and necessary”. But as you can see below, we balance this against other evidence. This includes trials that test whether the equipment is effective for you.

There are also some other things we’ll take into account:

• many sensory supports such as balls, fidgets, trampolines and swing sets are difficult to separate from everyday household items. This means they are things that most people are likely to have in their home. They could be seen as day-to-day living costs, which can’t be funded by us.
• sensory supports such as swings, trampolines and splash pools are often available and accessible in the community or through community providers. As they’re publicly available for a low cost, the benefits of these supports are generally not enough to justify funding them. So they’re not value for money under our criteria.36

To decide if a support is reasonable and necessary for you, we also think about the information you give us under the other NDIS Funding Criteria (insert link to OG).

36 See Subsection 34(1)(c), NDIS Act.

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What else do we think about?

We may look at funding sensory equipment for you where there’s evidence that shows it:

• is value for money compared with alternatives
• is effective and beneficial
• provides better support than other options more commonly available.

To support your request, you need to give us evidence from before and after a trial that shows you’ve seen beneficial results from these supports. This evidence must come from a therapist.

You’ll also need to meet other reasonable and necessary criteria in the NDIS Funding Criteria (insert link to R&N OG).

Example

Waru is a 4 year old child with Autism Spectrum Disorder (ASD). His family would like him to continue developing how he manages his emotions (emotional regulation). They would also like support to help him sleep, and manage his behaviour.

His family has asked for:

• a weighted blanket and lycra bed sheets to improve sleep
• a swing set and massage ball to help with emotional regulation

To work out if this sensory equipment is reasonable and necessary, we look at the information Waru’s parents give us against the NDIS Funding Criteria (insert link to OG). Along with other reasonable and necessary criteria, we think about whether:

• Waru needs the sensory equipment directly because of his disability needs
• we have evidence from an individual trial that shows the sensory equipment is effective or beneficial for Waru
• other evidence shows the equipment is safe and will not cause Waru harm.

We decide that the supports are not reasonable and necessary, and we don’t fund them.

There are several reasons for our decision:

• Waru already receives NDIS funding for early childhood intervention, with a team that’s working together to support him and his family. Funding for this sensory equipment would duplicate those supports.
• the swing set falls under the category of play equipment. This means it doesn’t meet the criteria of an “additional living cost” that’s needed “solely and directly” because of Waru’s disability.37
• evidence has shown that weighed blankets may cause harm. We won’t provide or fund a support that “is likely to cause harm to the participant or pose a risk to others”.38
• a therapist hasn’t done a trial of the lycra bed sheets and massage ball with Waru. There’s also no evidence from clinical studies that lycra bed sheets and a massage ball are likely to be any more effective or beneficial for Waru than his current supports.

For more information, refer to:

• Operational Guideline - Reasonable & Necessary
• Operational Guideline - Assistive Technology

Improved health and wellbeing

Improved health and wellbeing supports are capacity building supports that help build your independence and skills to help you reach your long-term goals. It includes exercise or diet advice to manage the impact of your disability.

Swimming lessons in early childhood

Case

Samantha asks for funding for private swimming lessons for her 4 year old son, Patrick. Patrick has a developmental delay or disability and is unable to fully take part in lessons without support.

Would we fund this?

No, we would not usually fund private swimming lessons. These supports are unlikely to be value for money. Australian parents and carers are responsible for the cost associated with making sure their children are safe in and around water.

Under the Act, supports need to help the participant take part in social and economic activities. They do this through helping the participant access age-appropriate social opportunities. The supports must show value for money in relation to both benefits of the support and the cost of similar supports. We must also consider what families and other informal supports would usually provide.

Why don’t we fund this?

We don’t fund supports if there are likely to be more cost-effective things that help the participant access social activities.

If you have a goal for your child to do swimming lessons, we might fund the developmental delay or disability-related supports or assistive technology to help your child have the same

What else do we think about?

We recognise the importance for all children to have the chance to take part in group activities. Group swimming lessons are a social activity and promote vital learning and development of skills in children.

We do not fund group swimming lessons as these are day-to-day living costs. Everyone has to pay for them whether or not they have a developmental delay or disability.

Case example

For school-aged children, we need to consider the state-government funded swimming program run through the child’s school. This, or other mainstream services, might be a more appropriate way to fund or provide swimming lessons for your child.

Tommy’s case

Tommy is four years old and has recently been diagnosed with Autism Spectrum Disorder (ASD). His family are supporting him to increase his participation in community activities. This includes group-based swimming lessons that other children his age typically do. Due to Tommy’s sensory sensitivities and communication barriers, his behaviour escalates during his swimming lessons. This leads to emotional and behavioural outbursts that pose significant safety risks and disruptions to the class.

Tommy’s mother asks us for funding so Tommy can do private swimming lessons to:

• learn to swim
• build his capacity to take part in future social and community activities.

To work out whether the funding for private swimming lessons is reasonable and necessary, we’ll look at the information Tommy’s mother gives us against the NDIS Funding Criteria (insert link to OG), such as:

• Are these supports needed solely and directly because of Tommy’s developmental delay or disability needs?
• Is there evidence that Tommy’s family or early intervention team explored all reasonable alternatives and mainstream options? Have they considered all reasonable adjustments to mainstream options?
• Is it reasonable to expect families or carers to give extra help for a 4-year-old during a swimming lesson? If so, is there evidence that Tommy’s parents or carers can’t do this due to pool restrictions or other responsibilities such as caring for a sibling during the swimming lesson?

In Tommy’s case, the planner decides private swimming lessons are not reasonable and necessary. This is due to a number of factors:

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• There is no evidence that the private swimming lessons would help Tommy take part in social and community activities. Taking Tommy out of group swimming lessons would, in fact, limit his opportunities to take part in social and community activities.
• There is no evidence that all reasonable alternatives and mainstream options have been explored.
• Given that alternative options for Tommy remaining in the group lessons had not been fully explored, the planner does not think private swimming lessons are the most effective and beneficial option to help Tommy learn to swim. They also aren’t the best value for money in relation to benefits provided.
• It would be reasonable to expect a parent or carer to continue to support Tommy with learning to swim. The planner sees no evidence or any reason Tommy’s parents or carers couldn’t help him in the pool.

In Tommy’s case, the planner:

* declined funding for private swimming lessons
* told Tommy’s child representative there was already funding in the plan for capacity building supports for early childhood intervention
* recommended the family could use this funding to pay for an early intervention therapy provider to help build Tommy’s capacity to tolerate being in the water before he begins swimming lessons.

The planner also suggested the family could use Tommy’s capacity building funding so the early intervention therapy provider can share strategies to support the swim program to make reasonable adjustments. The therapist could attend the group sessions to teach the swimming instructor and Tommy’s parents some techniques to best support Tommy in the swimming lesson.

For more information, refer to:

* Operational Guideline - Reasonable & Necessary
* Operational Guideline - Including Specific Types of Supports in Plans – Recreation Supports

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Gym membership

Case

Suresh wants to improve his personal fitness to help manage the effects of his disability.

Would we fund this?

No, we would not fund a gym membership. It is a day-to-day living cost not related to Suresh’s disability support needs.

Why don’t we fund this?

We don’t fund supports that are day-to-day living costs for people whether or not they have a disability. If one of your goals is to get fit by going to a gym or playing sport, we may fund a support or assistive technology to help you to do these activities, but not the gym membership itself.

Under the Act, supports need to help you take part in activities that will help you with your social and economic life. The supports must show value for money in relation to both benefits of the support and the cost of similar supports. We must also consider what families and other informal supports would usually provide.

To work out whether a support to help your health and wellbeing goal is reasonable and necessary, we look at the information you give us against the NDIS Funding Criteria (insert link to R&N OG). You would need to give us evidence, such as assessments from a registered therapist, to show you need the support for your disability needs.

What related supports might we fund?

We may fund things such as:

• transport to and from the gym, if your family or the community can’t provide it and you aren’t able to use public transport independently
• funding for a care worker to help you to use the gym equipment

Case example

We can also fund “recreation supports” but only if they relate to your disability. You are still responsible for registration fees, uniforms or any other costs that everyone pays when playing sport, whether or not they have a disability.

Case example

Sue’s genetic condition causes intellectual disability, behavioural and learning issues. She wants to improve her personal fitness. She has been unable to join a gym as most gyms can’t accept a member who needs someone supporting her at all times while she exercises.

Sue applies for funding for gym membership and for a support worker to help her at the gym.

To work out whether the funding for gym membership and for a support worker is reasonable and necessary for Sue, the planner looks at the information provided against the NDIS Funding Criteria (insert link to R&N OG). When deciding if the supports are reasonable and necessary³⁹, the planner thinks about such things as whether:

• the supports are needed solely and directly because of Sue’s disability needs
• funding for Sue’s gym membership and support worker is value for money in relation to both benefits of the support and the cost of similar supports
• an exercise program is likely to help Sue improve her fitness and become more independent in physical activity
• Sue is able to take part in other exercise programs, for example walking groups
• the gym membership is a day-to-day living costs not directly related to Sue’s disability support needs.

³⁹ See Section 34, NDIS Act.

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In Sue’s case the planner decides:

• there is enough evidence from an exercise physiologist that taking part in her gym program is likely to have long term benefits for Sue, which may include reducing her need for support in future
• the need for a support worker to help Sue to improve her personal fitness at the gym is needed solely and directly because of Sue’s disability needs
• using a support worker to help Sue access and use the gym represents value for money in relation to both the benefits of the support and the cost of alternate available supports
• the cost of the gym membership is a day-to-day living cost not solely and directly needed due to Sue’s disability support needs. It is a cost that anyone would have to pay for regardless of their disability needs.

In Sue’s case the planner decides:

• funding for gym membership is not reasonable and necessary, and funding was not approved
• if Sue chooses to self-fund her gym membership, we will fund a support worker to help her pursue her personal fitness goal and use the gym equipment.

For more information, refer to;

• Operational Guideline - Reasonable & Necessary
• Operational Guideline - Including Specific Types of Supports in Plans – Recreation Supports

Consumables

Consumables are everyday items you may need because of your disability support needs. For example, continence products or low-cost assistive technology and equipment to improve your independence and/or mobility.

Early Childhood Continence Consumables

Case

Julie asks for funding for continence supports for her 5-year-old daughter, Ashleigh, who has a developmental delay or disability. This means Ashleigh’s continence needs are well above what is typical for other children her age.

Would we typically fund this?

Yes, we would typically fund continence supports for participants five or older who regularly experience incontinence, day or night. The cost is likely to meet our funding criteria. We suggest Ashleigh’s plan includes funding for a continence assessment as well as continence products. This means Julie can get expert help to:

• explore any medical cause for the incontinence
• support her with toileting strategies
• advise her on products.

Why would we fund this?

Australian families typically toilet train their young children, and pay for nappies, pull-ups, wipes and mattress protectors. It is not unusual for typically developing children to use nappies at times up until age 5.

Most children are toilet trained by 5 years old, with some still wetting the bed. This means that children 5 and older who still need continence supports due to developmental delay or disability are likely to meet the criteria. It is an additional living cost incurred solely and directly as a result of their disability needs.

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Our funding for early childhood continence usually covers:

• a continence assessment from a clinical nurse
• everyday items such as nappies, disposal wipes and mattress protectors.

It may also include:

• access to additional support from professionals to help parents with toileting strategies,
• assistive technology support.

To work out whether a support is reasonable and necessary for your child, we look at the information you give us against the NDIS Funding Criteria (insert link to R&N OG).

What else might we fund?

We may fund children younger than 5 if their disability-related medical condition means they need:

• more expensive continence support or have higher care needs than children of a similar-age
• disposable urinary catheters, please refer to Continence Consumable Guide. (insert link to Continence Consumables)

Case example

Five-year old Kirra has been diagnosed with autism. Her family has been helping her increase her self-care skills. While she is starting to show some toileting awareness, she is still needs pull-up nappies through both day and night.

Based on Kirra’s mother’s report, we include funding in Kirra’s plan for three hours of support for a continence nurse to:

• undertake a continence assessment

• support the family with strategies to help Kirra with self-care.

We also include funding, based on Kirra’s age and current level of functioning, to cover:

• five pull-up nappies a day
• one pull up nappy a night
• mattress protectors
• continence aids, such as bags and wipes.

Kirra and her mother attend a continence clinic for the continence assessment with a nurse. The nurse assesses Kirra and gives her mother advice on strategies to help Kirra develop better self-care with toileting. Kirra and her mother also work with an occupational therapist who helps them incorporate strategies into daily routines. We fund this through the allocated capacity building budget in Kirra’s plan.

To work out whether extra funding for continence supports are reasonable and necessary, the planner considers the information and recommendation from Kirra’s mother against the NDIS Funding Criteria (insert link to R&N OG).

In Kirra’s case, the planner decides:

• Kirra needs the items as a direct result of her disability
• Kirra’s needs are substantially greater than other children her age
• the NDIS is the most appropriate way to fund the supports as they relate to her ongoing functional impairment and Kirra needs them to help with daily life
• the continence assessment will provide more evidence of Kirra’s progress and future support needs at the next scheduled plan review.

The planner decides that Kirra’s supports are reasonable and necessary and approved funding for continence consumables. The planner recommends that Kirra’s family buy the consumables month-by-month. This means they get the right amount and pull-up nappy size doesn’t change.

Continence Consumables

Case

Roger’s disability means he needs to use single-use disposable urinary catheters.

Would we typically fund this?

Yes, we would typically fund urinary catheters and continence consumables. This expense is likely to meet our funding criteria. Roger would need to give us evidence the expense relates to his regular disability support needs.

Why do we fund this?

To work out whether a support is reasonable and necessary, we would consider the information you give us against the NDIS Funding Criteria (insert link to OG). We would also need some evidence, such as assessment from a registered nurse, to show you need the support for your disability.

This evidence needs to show:

• you need disposable urinary catheters or continence consumables to support your disability needs
• the annual costs for your disposable urinary catheters and continence consumables based on quotes from local suppliers
• whether you need other support care, such as training by a continence nurse in how to manage these yourself or funding for support to help you with your daily continence needs.

What else do we consider?

We might also provide funding for:

• mattress protectors
• continence pads or absorbent pull-ups or briefs
• continence aids, such as change kits
• support workers to help with your continence needs if you are unable to do them independently.

We calculate the funding allowance for urinary catheters and continence consumables on a per-day basis in line with your needs. We assess quotes to decide if the consumables you ask for are:

• appropriate,
• value for money.

Case Example

Aamira has Spina Bifida which has caused a neurogenic bladder disorder. She needs to use a urinary catheter to empty her bladder. Aamira uses single-use catheters and other continence consumables such as absorbent pull-ups or briefs.

To support Aamira’s funding request, the spinal nurse advisor gives us a breakdown of Aamira’s continence needs as well as quotes from several local suppliers.

To work out whether the funding for the single-use catheters and other continence consumables is reasonable and necessary, the planner considers the nurse advisor’s information and recommendation against the NDIS Funding Criteria (insert link to OG).

In Aamira’s case, the planner decides:

• Aamira needs the support solely and directly because of her disability
• she needs the supports regularly
• the nurse advisor’s evidence and recommendations appear appropriate

Home Enteral Nutrition (HEN)

Case

Danielle can’t eat, swallow and tolerate normal food because of her disability. This means she needs an alternative food such as HEN to make sure she gets the nutrition she needs.

Would we typically fund this?

Yes, we would typically fund HEN products to support Danielle’s disability needs, if the HEN formula she’s prescribed isn’t covered under the Pharmaceutical Benefits Scheme (PBS, which is part of the Australian health system).

Why would we fund this?

Food is an everyday living cost which isn’t related to your disability support needs⁴⁰, nor to your disability.⁴¹ Therefore, we don’t generally fund it.⁴²

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⁴⁰ See rule 5.1(d) and 5.2, NDIS (Supports for Participants) Rules 2013. ⁴¹ See rule 5.1(b), NDIS (Supports for Participants) Rules 2013. ⁴² See rule 5.1(b) and (d), NDIS (Supports for Participants) Rules 2013.

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However, we do generally fund HEN products and formula if you need them because of your disability support needs.

For example, we will usually fund HEN products or formula if your disability means you can’t eat or swallow everyday food.

To work out whether the HEN product or formula is reasonable and necessary for you, we’ll look at the information you give us against the NDIS Funding Criteria (insert link to OG).

We’ll also look at whether the PBS funds the HEN product or formula prescribed for you. If it does, then the support may be more appropriately funded through the PBS.

To decide whether the support is most appropriately funded by us or the health system, we have to think about Schedule 1 of the NDIS (Supports for Participants) Rules 2013. In particular, there’s a principle that we are not responsible for pharmaceuticals.

If you have either full or partial HEN feeding needs, and the PBS does not subsidise your prescribed formula, HEN products are likely to meet the reasonable and necessary requirements. If this is the case, it will generally be more appropriate for us to fund the support.

If, on the other hand, the PBS will cover or subsidise the cost of the HEN product, it will generally be more appropriate for the PBS, not us, to fund the support. In this case it is unlikely to meet the NDIS Funding Criteria and unlikely to be reasonable and necessary for you.

43 See rule 3.5, 7.4 and 7.5, NDIS (Supports for Participants) Rules 2013. 44 See rule 7.5(b), NDIS (Supports for Participants) Rules 2013. 45 See subsection 34(1)(f), NDIS Act. 46 See subsection 34(1)(f), NDIS Act.

What related supports might we fund?

We may also fund supports that are additional to your HEN formula and nutritional supplement⁴⁷ needs, as long as these additional supports relate to your disability⁴⁸⁴⁹. These supports may include:

• HEN and Percutaneous Endoscopic Gastrostomy (PEG) equipment and maintenance
• HEN and PEG consumables such as feeding tubes and feed bags or bottles
• a support worker if you can’t independently manage your HEN requirements, or to help with PEG maintenance and care.

We won’t fund nutrition supports that aren’t directly related to your disability.⁵⁰ For example where you have a poor diet for reasons that aren’t to do with your disability.

We generally won’t fund dietetic supports for health issues such as:

• food allergies
• diabetes
• cardiovascular (heart) disease
• kidney disease
• polycystic ovary syndrome
• irritable bowel syndrome.

Case Example

Ella is 4 years old and has Muscular Dystrophy, which means she can’t eat enough to make sure she stays in good health. Ella’s mother trialled making suitable food using a blender. But homemade food doesn’t meet Ella’s nutritional needs and gives her stomach pains. Her doctors suggest that she needs HEN formula to supplement her meals and give her enough nutrition. Her paediatrician recommends a specialised PEG tube formula to improve her tolerance, growth and energy levels.

To support her funding request Ella’s mother gives us a report from her paediatrician. The report shows that capacity building measures to increase Ella’s food intake by mouth have been put into place. But because she can’t tolerate blended food, she needs to use PEG tube formula. The report also includes the quoted cost of the formula and PEG equipment that’s needed for Ella’s support.

To work out whether the funding for Ella’s HEN formula and PEG equipment is reasonable and necessary, the planner looks at the information provided against the NDIS Funding Criteria (insert link to OG). Some of the things the planner thinks about are:

• whether the need for the HEN formula is solely and directly because of Ella’s disability

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• whether there are other more suitable options to give Ella the necessary nutrition for a child her age, that represent better value for money relative to the benefits achieved
• whether the PBS funds the HEN formula Ella’s paediatrician recommends, or it should be funded through us.

In Ella’s case, the planner decides that the funding for the HEN Formula and PEG Equipment is reasonable and necessary because:

• the HEN formula and PEG equipment is needed solely and directly because of Ella’s disability
• other nutritional options have been trialled by her mother and have been found to be clinically unsuitable
• the cost of the prescribed HEN formula and the PEG equipment is value for money, relative to the benefits achieved and the cost of other HEN formulas available on the market
• as the HEN formula Ella needs to support her disability related food intolerance is not funded by the PBS or other system, the support is most appropriately funded by the NDIS.

The Planner approves funding for the HEN formula and PEG equipment in Ella’s plan.

For more information, refer to;

• Operational Guideline - Reasonable & Necessary
• Operational Guideline – Disability Related Health supports