DOCUMENT 6

FOI 22/23-0942

What principles do we follow to create your plan?

The NDIS was set up as a world first approach to disability support. It puts people with disability at the centre of decision-making, through the principles of reasonable and necessary supports and individual choice and control.

As an insurance-based scheme, we take a lifetime approach to a participant’s support needs. We provide assurance to people with permanent and significant disability or developmental delay, and to people who might acquire disability or developmental delay, that they will get the support they need. Individual funding means we help participants to purchase services and supports from a competitive and consumer-driven marketplace.

What supports can we fund?

NDIS supports should complement, not replace, other supports available to you. That’s why we consider:

the things you’re able to do for yourself
support you have from others in your network, including family members, relatives, friends, local community services and mainstream government services.

One of our aims is to help maximise your independence by working with the local mainstream government and community services that help you live an ordinary life. We all do best when we’re connected to our communities.

And as an active consumer, it’s important you are able to shop for and access providers who meet your needs. We can help you find providers who meet your needs.

Once we’ve considered your circumstances, we need to follow the rules determined under the law for the NDIS in our planning decisions.¹ We fund supports that are reasonable and necessary. This means we will only fund a support if it meets all of the following criteria:

the support is related to your disability²
the support will help you pursue your goals and aspirations³
the support will help you undertake activities that will increase your social and economic participation⁴
the support is value for money,⁵ which means that the costs are reasonable:

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            This document is correct at the date of publication.

       Always visit ourguidelines.ndis.gov.au for the latest version.

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when compared to the benefits to be achieved, for example, whether purchasing the support is likely to reduce the cost of funding other supports in the long term6
when compared to alternative options that may provide you with the same outcome at a similar or cheaper cost7

 the support is likely to be effective and beneficial for you, having regard to good practice and evidence8

 the support is required to complement the informal supports you have available, by taking into account what is reasonable for families, carers, informal networks and the community to provide9

 the support is most appropriately funded or provided by the NDIS10

 the support is not more appropriately funded by another service system, agency, person or body, such as the education system or the health system.11 We can’t fund a support if it’s the responsibility of another service system.

What supports don’t we fund?

We do not fund a support if:12

 it is likely to cause harm to you or others13

 it is not related to your disability14

 it duplicates other supports delivered by the NDIS15

 it is considered a day-to-day living cost (for example, rent, groceries or utility costs like your water bill) that are not attributable or caused by your disability support needs16

 providing the support would be against the law17

 it consists of income replacement18

 it is the responsibility of other service systems to provide (for example, your state government, the education system, or the health system).19 These different systems have different responsibilities, and are designed to complement each other to form a government safety net. Like all Australians, NDIS participants continue to have access to these systems. We can’t fund a support if it’s the responsibility of another service.

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How do we manage the financial sustainability of the NDIS?

The NDIS is an insurance scheme, and one of our core functions is to manage the financial sustainability of the Scheme.²⁰

When we make decisions about the supports we fund in your plan, we must also consider our need to ensure the financial sustainability of the NDIS.²¹ This means we must work within our funding budget, set through agreements between the Australian, and State and Territory governments.

It’s also important to know the NDIS is only one part of the broader National Disability Strategy that supports people living with disability. The overall success and sustainability of the National Disability Strategy relies on:

people accessing their informal support network to get the help they need from day to day
people using their personal income to pay for their day to day living expenses, as is expected of all Australians
mainstream and community services being available from state and territory governments, and other federal government programs such as Medicare
a fair distribution of NDIS supports to those who need them, provided within our funding budget.

Staying within our budget ensures the NDIS will be here to support generations of Australians and their families.

What principles do we use to create your plan?

We use the following 7 principles, to create plans that help you get the reasonable and necessary supports you need, and to make sure the Scheme is financially sustainable:

Fair for everyone, both today and for future generations
Fair funding to pursue your goals
Evidence-based best practice
Fair early investments
Fair support across service systems
Fair supports for your disability needs

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Fair assistance from multiple programs

Fair for everyone, both today and for future generations

While we need to consider your individual circumstances and disability needs, we also need to make consistent decisions and treat people fairly.

This means participants with similar circumstances and disability needs should receive similar amounts of supports in their plans. We also need to ensure the total cost of all participant plans are within the overall NDIS budget set by governments.

We use Typical Support Packages to help us do this. The Typical Support Package gives us an indication of what supports we’d usually expect to include in your plan, based on your situation and disability support needs.

Each support in your plan must be reasonable and necessary, but they also need to be reasonable and necessary as a package of supports. We approve your whole plan, not the individual supports in your plan in isolation.²² The Typical Support Package helps guide this validation process.

The Typical Support Package also helps to guide the consistency of our decision-making process. We use these to check your overall plan to make sure that all your supports make sense together, and that your support types and amounts will complement each other to help you fulfil an ordinary life.

We may then increase or decrease the funding in your plan based on:

our discussion with you
any reports or other information we have
applying the NDIS funding criteria.

This helps keep the system fair for everyone, and ensure we remain financially sustainable.

Fair funding to pursue your goals

Goals are important.²³ The supports we fund need to help you increase your independence and pursue your goals.²⁴ This means your supports should help overcome any disability-specific barriers which may be stopping you pursuing your goals.

This doesn’t mean we fund all support costs associated with you pursuing your goals. Also, you may have goals and aspirations we can’t fund supports for. This is because helping you pursue your goals is only one of the NDIS funding criteria, so not all supports that help you to pursue your goals will be reasonable and necessary.

Other things to know about when setting your goals:

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Setting more goals or bigger goals doesn’t mean we’ll provide more funding or fund more supports. For example, if your goal is to live independently in a house with a swimming pool, we may fund home modifications that address your disability related needs. This might be a home modification to make your bathroom accessible.

We won’t fund the swimming pool because this isn’t related to your disability support needs. The funding in your plan might be similar to someone else who has a goal of ‘to have a more accessible bathroom’.

Setting a goal doesn’t mean we have an obligation to fund supports that help you pursue that goal. For example, if your goal is to get a gym membership to get fit, we wouldn’t usually fund this. Gym memberships are things that all people, with or without disability, might want or need.
Setting a goal about an explicit type or amount of support you might want doesn’t mean we have an obligation to fund that support or provide that amount of funding. For example, you may tell us your goal is ‘to get a top model shower commode’ and you show us the one you want costs $4,000.

If there is a shower commode that costs $3,000, and your occupational therapist confirms this one will meet your needs, we are more likely to fund this one instead because it is likely to deliver the same result at a lower cost. We may also look at alternatives.

Evidence-based best practice

We only fund supports that will be, or are likely to be, effective and beneficial for you, having regard to current good practice.25 This means we consider if there is evidence that the support is effective and beneficial for someone with similar disability support needs.

We will consider different types of evidence when making decisions and we won’t need an expert report for every support, as we can often rely on other information or evidence.

For example, we may already have information about whether the support is widely accepted to suit someone with your disability support needs.26 The primary source of evidence we rely on, and give the greatest weight to, is evidence from sources that are reliable and widely recognised. This includes published and refereed literature, and any consensus of expert opinions. If there is no evidence to show a support is reasonable and necessary,27 we won’t fund the support.

You can find the types of evidence we need on our website, and in Our Guidelines.

Fair early investments

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Having access to capacity-building supports early in your NDIS journey is considered to be an early investment. This early investment is intended to help increase your independence, and reduce your reliance on NDIS funding over time.

This is an important concept that we consider when we create your plan, and again at future plan reassessments. When we reassess your plan, we reassess all the supports you require to meet your disability support needs at that time.

Over time, your capacity building supports may no longer be reasonable and necessary, in regard to your current functional capacity, the effectiveness of the capacity building supports,²⁸ and value for money.²⁹

If your overall funding level goes down from one plan to the next, it may be because you no longer need the same type or amount of supports, such as capacity building supports. Also, if the capacity building investment has been successful at building your independence, then your need for other supports may also decrease, for example core supports.

So other things being equal, you should expect your overall plan value to reduce over time as the benefits of capacity building are realised.

Fair support across service systems

The support you need may be the responsibility of another government service, such as education or health. We don’t fund these services and need to consider the supports you should receive from these services when determining the supports in your plan.

Fair supports for your disability needs

When we make decisions about which supports we can fund, we consider whether a support is reasonable and necessary for you and apply the NDIS funding criteria. Sometimes, you might ask for supports to help with impairments that were not part of your Access eligibility assessment. When this happens, we need to make sure the support will help you address needs that arise from an impairment that meets the same eligibility criteria we consider at Access.

You don’t need to make a new Access request if you ask for supports to help with an impairment that was not part of your Access eligibility assessment. We will work out if you need the support you have asked for to address an impairment that would meet our Access criteria. We may ask you to provide evidence to help us work this out. We will decide if the requested support is reasonable and necessary. We will apply the NDIS funding criteria based on the impairments that would meet our Access criteria.

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            This document is correct at the date of publication.

       Always visit [ourguidelines.ndis.gov.au](https://ourguidelines.ndis.gov.au) for the latest version.

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Fair assistance from multiple programs

NDIS funding can’t duplicate other funding or supports you may receive due to your disability.

For example, you may have received a lump-sum payment or receive regular payments as a form of compensation for an accident. Or, you may be receiving ongoing supports from another program or insurance scheme, for example, Worksafe or the Transport Accident Commission.

We don’t duplicate this funding or these supports. We may reduce the total value of your NDIS plan to account for compensation you receive, or we may not fund certain supports.

References

NDIS Act and delegated legislation made under the NDIS Act, especially NDIS (Supports for Participants) Rules and NDIS (Plan Management) Rules.
NDIS (Supports for Participants) Rules r 5.1(b).
NDIS Act s34(1)(a).
NDIS Act s34(1)(b).
NDIS Act s34(1)(c).
NDIS (Supports for Participants) Rules r 3.1(c).
NDIS Act s34(1)(c); NDIS (Supports for Participants) Rules r 3.1(a).
NDIS Act s34(1)(d).
NDIS Act s34(1)(e).
NDIS Act s34(1)(f).
NDIS Act s34(1)(f).
NDIS (Supports for Participants) Rules part 5.
NDIS (Supports for Participants) Rules r 5.1(a).
NDIS (Supports for Participants) Rules r 5.1(b).
NDIS (Supports for Participants) Rules r 5.1(c).
NDIS (Supports for Participants) Rules r 5.1(d).
NDIS (Supports for Participants) Rules r 5.3(a).
NDIS (Supports for Participants) Rules r 5.3(b).
NDIS Act s34(1)(f).
NDIS Act s118(1)(b).
NDIS Act s4(17)
NDIS Act s33(2).
NDIS Act s33(5)(a).
NDIS Act s34(1)(a).
NDIS Act s34(1)(d).
NDIS (Supports for Participants) Rules r 4.1(d).
NDIS Act s34(1).
NDIS Act s34(1)(d); NDIS (Supports for Participants) Rules, rr 3.2-3.3.
NDIS Act s34(1)(c); NDIS (Supports for Participants) Rules r 3.1.

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            This document is correct at the date of publication.

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