Case Management Guide
Compensation
OFFICIAL For internal Use Only
| Field | Content | Reference Documents |
|---|---|---|
| Title | Compensation | |
| Purpose | This document is part of a suite of guidance documents for case managers to use in formulating their approach to managing individual cases before the Administrative Review Tribunal (ART). | |
| Scope | For the purposes of this document, compensation refers to any payment for personal injury that is made wholly or partly in relation to the cost of disability supports that a participant requires as the result of the personal injury that they have sustained. Compensation payments may arise under: - a judgment, consent judgment or settlement of a claim for personal injury; or - a scheme of insurance under Commonwealth, State or Territory law, including under a contract entered into under such an insurance scheme – such as the Department of Veterans’ Affairs (DVA), the Scheme for Compensation for Detriment caused by Defective Administration (CDDA Scheme), Disability Support Pension (DSP), or Jobseeker Payments, among others. It is not relevant to the definition of compensation whether a payment carries with it an admission of liability, whether payment is identified as being partly or wholly for the cost of supports a participant may need, the method in which payment is made, whether payment is made within or outside Australia, or to which account payment is made. For the purposes of this document, the ‘NDIS component’ of an amount of compensation under a judgment or settlement means the component that relates to the provision of supports of a kind that may be funded by the NDIS. | Operational Guideline – Compensation |
| Section 11 of the National Disability Insurance Scheme Act 2013 | ||
| Rule 4.4 of the National Disability Insurance Scheme (Supports for Participants—Accounting for Compensation) Rules 2013 | ||
| What a DVA health card covers | ||
| Department of Veterans’ Affairs | ||
| Factsheet – Scheme for Compensation for Detriment caused by Defective Administration | Ombudsman | |
| Disability Support Pension | Services Australia | |
| JobSeeker Payment | Services Australia | |
| Escalation to Appeals and Litigation Oversight | If a matter is within the parameters of this document, the Administrative Review Branch Manager may approve proceeding to hearing. Where there is substantial risk or the matter is outside the |
Case Management Guide
Compensation
OFFICIAL For internal Use Only
| Committee (ALOC) | parameters of this document, the matter should be referred to ALOC. |
|---|---|
| Current National Disability Insurance Agency (NDIA) policy on the subject | The ART process is often seen as stressful and adversarial by the participants and our focus should be on resolving issues as practicably and quickly as possible. The role of the NDIA is to assist the ART and the participant in reaching the best possible resolution for the participant by agreement. |
The NDIS is designed to complement, where necessary, but not replace existing compensation arrangements for personal injury, and will not duplicate the funding for supports already provided for by these payments.
NDIA Dispute Resolution Policy Appendix B to the Legal Services Directions 2017 Rule 1.1 of the National Disability Insurance Scheme (Supports for Participants—Accounting for Compensation) Rules 2013 Chapter 5 of the National Disability Insurance Scheme Act 2013
| Subtitle | Compensation Reduction |
|---|---|
| Scope | This section concerns matters in which a participant receives compensation for personal injury prior to receiving NDIS support funding for a related disability. |
The ART process is often seen as stressful and adversarial by the participants and our focus should be on resolving issues as practicably and quickly as possible. The role of the NDIA is to assist the ART and the participant in reaching the best possible resolution for the participant by agreement.
The NDIA may reduce the amount of funding provided for reasonable and necessary supports to account for the compensation a participant receives.
The NDIA does this by applying a calculated compensation reduction amount (‘CRA’) to one or multiple plans, having regard to a participant’s remaining life expectancy, any payments they may have made for like supports prior to becoming a participant, as well as any compensation reduction amounts applied to previous plans.
NDIA Dispute Resolution Policy Appendix B to the Legal Services Directions 2017 Operational Guideline — Compensation Rules 3.1, 3.7 and 3.11 – 3.18 of the National Disability Insurance Scheme (Supports for Participants—Accounting for Compensation) Rules 2013
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Case Management Guide
Compensation
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| NDIA Posture in relation to this subject | Where compensation is received under a judgment or settlement and the NDIS component is objectively identifiable, the CRA will be calculated in accordance with Rules 3.11 and 3.12. Where compensation is received under a judgment or settlement and the NDIS component is not objectively identifiable, the CRA will be calculated in accordance with Rules 3.13 - 3.16. Where compensation is received under a scheme of insurance under Commonwealth, State or Territory law, the CRA will be calculated in accordance with Rules 3.17 and 3.18. The NDIA will generally not apply a CRA to reduce the funding in a particular plan where the reduction would be less than 10% of the total plan funding. A key consideration of doing so is the financial sustainability of the NDIS.
| | Operational Guideline — Compensation Rules 3.1 and 3.11 - 3.18 of the National Disability Insurance Scheme (Supports for Participants—Accounting for Compensation) Rules 2013
Subtitle
Compensation Recovery
Scope This section concerns matters in which a participant receives NDIS support funding for a related disability prior to receiving compensation for personal injury.
| Current National Disability Insurance Agency (NDIA) policy on the subject | The ART process is often seen as stressful and adversarial by the participants and our focus should be on resolving issues as practically and quickly as possible. The role of the NDIA is to assist the ART and the participant in reaching the best possible resolution for the participant by agreement. Once compensation has been paid or becomes payable, the NDIA may also recover from a participant, compensation payer or insurer, amounts paid by the NDIA from the date a participant first began receiving support funding in respect of the disability for which they are compensated until the day before compensation is fixed. The recoverable amount is a debt which is payable to the NDIA. Where the terms of compensation identify a NDIS component, the NDIA is unable to recover more than that NDIS component — even if the sum of NDIS
| | Operational Guideline — Compensation
Case Management Guide
Compensation
OFFICIAL For internal Use Only
payments made prior to compensation being fixed exceeds the NDIS component. In those circumstances, the debt payable is only the full NDIS component. Where no NDIS component is identifiable, the NDIS is able to recover the full sum of payments made, up to the total amount of compensation payable. The NDIA is unable to recover an amount greater than the amount which is objectively identifiable as the NDIS component in the final compensation payable. Similarly, the NDIA cannot recover an amount greater than any amounts paid, even if the identifiable NDIS component exceeds the amounts paid previously. In those circumstances, the NDIA will apply a CRA to future plans until the relevant compensation amount is reduced to nil. The recoverable amount must also account for any contributory negligence found by the Court on the part of a participant. For example, if a participant was found to bear 25% liability for their personal injury, the recoverable amount is only 75% of that paid by the NDIA.
Sections 106 and 107 of the National Disability Insurance Scheme Act 2013
Evidence recommended to inform NDIA position in a specific matter before the Administrative Review Tribunal (ART) In circumstances where a participant has made a compensation claim, the NDIA will require a copy of a participant’s statement of claim and the particulars of their claim, copies of any clinical evidence provided in support of their claim, as well as a copy of the final judgment, decision, or terms of settlement. In circumstances where a participant has failed to make a claim for compensation, the NDIA will require particulars of the personal injury sustained, as well as any corroborating clinical evidence. The NDIA will also require a Centrelink Charge or Preclusion Notice, a Medicare Notice of Past Benefits or Notice of Charge, details of any supports provided or funded by a scheme of insurance as well as invoices, receipts, bank records or expense statements for all support expenses incurred prior to becoming a participant of the NDIS.
Operational Guideline — Compensation Other considerations The NDIA may direct a participant to seek, or continue to seek, compensation if the participant:
Operational Guideline — Compensation 4 Page 4 of 38
Case Management Guide
Compensation
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- has a right to do so; and
- fails to make a claim for compensation; or
- abandons an existing compensation claim; or
- enters into an agreement to surrender a right to compensation, which is void, ineffective or enforceable.
If a participant fails to comply with a direction of the NDIA to do so, the NDIA may:
- refuse or suspend a participant’s plan; or
- bring a compensation claim in the participant’s name; or
- take over conduct of a participant’s compensation claim, subject to limitation periods, jurisdictional challenges, evidentiary barriers, liability disputes, and reasonable grounds for a lack of due dispatch (e.g., difficulties in obtaining legal advice).
If a participant forgoes compensation, the NDIA must take account of the likely amount of forgone compensation for the purposes of calculating a CRA, and any recoverable amount payable to the NDIA.
A participant forgoes compensation when:
- they have a right to compensation; and
- they fail to make a compensation claim, which can no longer be made; or
- they abandon their compensation claim once made, which cannot be continued or which the NDIA is unable to take over; or
- they enter into a valid, effective, and enforceable agreement surrendering their right to compensation which prevents them from receiving their full entitlement (wholly or partially), and which the CEO considers was unreasonable to have entered into.
Where possible, the NDIA will first seek to have compensation fixed before taking account of the amount of forgone compensation as a last resort. Compensation is not forgone where a participant brings a claim for compensation, but the claim is unsuccessful before a Court or Tribunal.
Chapter 5 of the National Disability Insurance Scheme Act 2013 Rules 3.1, 3.2 and 3.19—3.21 of the National Disability Insurance Scheme (Supports for Participants—Accounting for Compensation) Rules 2013
Previous matters that A NDIS component is ‘objectively identifiable’ within a judgment or settlement if it is ‘capable of being identified without influence from personal beliefs, or
Whittaker v NDIA [2022] AATA 729
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Case Management Guide
Compensation
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| may advise the | feelings, and not dependent upon the mind for its |
|---|---|
| NDIA position | existence.’ |
Document Continuous Improvement, Legal Practice and admin Capability Branch
Approved Branch Manager, Administrative Review Branch
AAT Case Management Guide
Support Workers
Activities Daily Living (ADL)
OFFICIAL For Internal Use Only
DOCUMENT 2
| Field | Content | Reference Documents |
|---|---|---|
| Title | Support Workers Activities Daily Living (ADL) | - |
| Purpose | This document is part of a suite of guidance documents for case managers to use in formulating their approach to managing individual cases before the Administrative Appeals Tribunal (AAT). | - |
| Scope | Activities of daily living (ADL) are the basic self-care tasks which a person performs on a daily basis. Due to the impact of a participant’s disability on their functional capacity, they may require assistance or supervision by a support worker to perform these tasks themselves. These tasks include: * bathing/showering * dressing * functional mobility (the ability to move from one place to another) * continence/incontinence care * meal preparation and feeding * personal hygiene, oral care and grooming | [Activities for daily living |
| Escalation to Hearing Oversight Committee (HOC) | If a matter is within the parameters of this document, the AAT Case Management Branch Manager may approve proceeding to hearing. Where there is substantial risk or the matter is outside the parameters of this document, the matter should be referred to HOC. | - |
| Current National Disability Insurance Agency (NDIA) policy on the subject | The AAT process is often seen as stressful and adversarial by participants and our focus should be on resolving issues as practically and quickly as possible. The role of the NDIA is to assist the AAT and the participant in reaching the best possible resolution for the participant by agreement. |
The NDIA will provide funding for a support worker to assist with ADL, as a support, if the support: * directly relates to a participant’s disability; * will help a participant to achieve their goals, objectives as aspirations; | NDIA Dispute Resolution Policy Appendix B to the Legal Services Directions 2017 Section 34 (1) of the National Disability Insurance Scheme Act 2013
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AAT Case Management Guide
Support Workers
Activities Daily Living (ADL)
OFFICIAL For Internal Use Only
| - will help to facilitate a participant’s social and economic participation; |
- is effective and beneficial;
- represents good value for money, compared to alternative supports which would produce a similar outcome at a lesser cost;
- takes account of what is reasonable to expect families, carers, informal support networks and the community to provide; and
- is most appropriately funded by the NDIA, as opposed to another mainstream service delivery system. | Rules 3.4 and 5 of the National Disability Insurance Scheme (Supports for Participants) Rules 2013|
| | - The NDIA will fund a support worker where it is reasonable and necessary to do so, unless:
- there is a risk of harm or neglect to the participant as a result; or
- there are religious or cultural reasons which make it more appropriate for a family member to act as a support worker; or
- the participant has strong personal views which would make funding for a support worker inappropriate, such as around their privacy or dignity. | How do we decide what reasonable and necessary supports to include in your plan? | NDIS Including Specific Types of Supports in Plans Operational Guideline - Sustaining informal supports | NDIS|
| | - The NDIA will refer to the available evidence when considering whether it would be reasonable and necessary to provide funding for a support worker.
- In particular, the NDIA will closely examine evidence which speaks to a participant’s functional capacity and disability support needs, as well as evidence from the participant themselves around their own choices and preferences.
- Evidence may be tendered in the form of clinical reports, opinion evidence, expert evidence and witness statements. | Persons Giving Expert and Opinion Evidence Guideline | Administrative Appeals Tribunal|
| | - The NDIA will also consider whether assistive technology, home modifications or other supports could more effectively support a participant by reducing their need for future supports. | |
AAT Case Management Guide
Support Workers
Activities Daily Living (ADL)
OFFICIAL For Internal Use Only
| Previous matters that may advise the NDIA position | The AAT could not be satisfied, on the available evidence, that it would be reasonable or necessary to provide funding for a support worker for 18 hours. The AAT affirmed the decision under review. — | Hollis and National Disability Insurance Agency [2021] AATA 2888 Document admin | Quality, Strategy and Training Approved | Matthew Swainson, Chief Counsel
Case Management Guide
Support Workers Activities Daily Living (ADL)
| Field | Category | Reference Documents |
|---|---|---|
| Title | Support Workers Activities Daily Living (ADL) | - |
| Purpose | This document is part of a suite of guidance documents for Case Managers to use in formulating their approach to managing individual matters before the Administrative Review Tribunal (ART). This Guide applies nationally to the conduct of all matters within the Administrative Review Tribunal Case Management Branch. | - |
| Scope | Activities of daily living (ADL) are the basic self-care tasks which a person performs on a daily basis. | |
| Due to the impact of a participant’s disability on their functional capacity, they may require assistance or supervision by a support worker to perform these tasks themselves. These tasks include: |
- bathing/showering
- dressing
- functional mobility (the ability to move from one place to another)
- continence/incontinence care
- meal preparation and feeding
- personal hygiene, oral care and grooming | Activities for daily living | Activities of Daily Living (ADLs) | | NDIA policy on this subject | The ART process is often seen as stressful and adversarial by participants and prospective participants of the Scheme. The NDIA will adopt a participant-focused approach to resolving disputes before the ART, and will work directly with participants and prospective participants to provide better and earlier outcomes, where possible. The role of the NDIA is to assist the ART in reaching the correct and preferable decision, including by assisting participants and prospective participants in reaching the best possible resolution by agreement. The NDIA will provide funding for a support worker to assist with ADL, as a support, if the support:
- directly relates to a participant’s disability; | NDIA Dispute Resolution Policy | Appendix B to the Legal Services Directions 2017 Section 34 (1) of the National Disability Insurance Scheme Act 2013 Rules 3.4 and 5 of the National Disability Insurance Scheme (Supports for Participants) Rules 2013|
Case Management Guide
Support Workers Activities Daily Living (ADL)
| Field | Category | Reference Documents |
|---|---|---|
| - will help a participant to achieve their goals, objectives as aspirations; |
- will help to facilitate a participant’s social and economic participation;
- is effective and beneficial;
- represents good value for money, compared to alternative supports which would produce a similar outcome at a lesser cost;
- takes account of what is reasonable to expect families, carers, informal support networks and the community to provide; and
- is most appropriately funded by the NDIA, as opposed to another mainstream service delivery system. | | | NDIA posture in relation to this subject | The NDIA will fund a support worker where it is reasonable and necessary to do so, unless:
- there is a risk of harm or neglect to the participant as a result; or
- there are religious or cultural reasons which make it more appropriate for a family member to act as a support worker; or
- the participant has strong personal views which would make funding for a support worker inappropriate, such as around their privacy or dignity. | How do we decide what reasonable and necessary supports to include in your plan? | NDIS Including Specific Types of Supports in Plans Operational Guideline - Sustaining informal supports | | Evidence recommended to inform NDIA position in a matter before the ART | The NDIA will refer to the available evidence when considering whether it would be reasonable and necessary to provide funding for a support worker. In particular, the NDIA will closely examine evidence which speaks to a participant’s functional capacity and disability support needs, as well as evidence from the participant themselves around their own choices and preferences. Evidence may be tendered in the form of clinical reports, opinion evidence, expert evidence and witness statements. | | | Other considerations | The NDIA will also consider whether assistive technology, home modifications or other supports | |
OFFICIAL For Internal Use Only
Case Management Guide
Support Workers Activities Daily Living (ADL)
Category Reference Documents
could more effectively support a participant by reducing their need for future supports. Previous The AAT could not be satisfied, on the available Hollis and National matters that | evidence, that it would be reasonable or necessary to | provide funding for a support worker for 18 hours. Agency [2021] AATA 2888 The position The AAT affirmed the decision under review. Document Control Responsible Person Date Document author Continuous Improvement October 2024 Document approver Director, Continuous Improvement [date] NDIA-ART CM-GDE-009-DRAFT OFFICIAL Page 3 of 3 Page 12 of 38
Case Management Guide
Home and Living
OFFICIAL For Internal Use Only
| Field | Content | Reference Documents |
|---|---|---|
| Title | Home and Living | |
| Purpose | This document is part of a suite of guidance documents for case managers to use in formulating their approach to managing individual cases before the Administrative Review Tribunal (ART). | |
| Scope | Home and living supports are intended to help a participant pursue their goals and improve or maintain their independence. Home and living supports are also intended to reduce a participant’s need for person-to-person supports, and create better connections with their families, communities, and their health, education, and employment services. | |
| The NDIA fund a range of home and living supports, | ||
| For the purposes of this document, this includes: |
- Specialist Disability Accommodation (SDA);
- Individualised Living Options (ILO);
- Supported Independent Living (SIL); and
- Medium Term Accommodation (MTA). For the purposes of this document, home and living supports exclude home modifications, assistive technology, short term accommodation, and personal care supports. The Integrated Home and Living Team and the Home and Living Panel are responsible for making recommendations to the delegate/s regarding the provision of home and living supports. Where the advice provided by either the Integrated Home and Living Team or the Home and Living Panel conflicts with legal or other technical advice received in a particular matter, the matter is to be escalated to a Director, Administrative Review Branch. The Director is to then liaise with Technical Advice and Practice Improvement Branch (TAPIB) to remedy any conflict between the advice(s). | Home and living supports | NDIS What housing supports are included | NDIS Home and Living (internal) Standard Operating Procedure – Setting up a Home and Living Panel Meeting (internal) | | Escalation to Appeals and Litigation | If a matter is within the parameters of this document, the Administrative Review Branch Manager may approve proceeding to hearing. Where there is substantial risk or the matter is outside the | |
Case Management Guide
Home and Living
OFFICIAL For Internal Use Only
| Oversight Committee (ALOC) | parameters of this document, the matter should be referred to ALOC. |
|---|
The ART process is often seen as stressful and adversarial by the participants and our focus should be on resolving issues as practicably and quickly as possible. The role of the NDIA is to assist the ART and the participant in reaching the best possible resolution for the participant by agreement. The NDIA will fund home and living supports which:
- relate to a participant’s disability; and
- meet the NDIS funding criteria; and
- are most appropriately funded by the NDIS. Home and living supports meet the NDIS funding criteria if they:
- will assist a participant to pursue their goals, objectives, and aspirations; and
- will assist a participant to facilitate their social and economic participation; and
- are effective and beneficial; and
- represent good value for money, compared to other supports that may achieve the same outcome or reduce a participant’s need for future supports; and
- take account of what is reasonable for families, carers, informal networks, and the community to provide; and
- are legal and safe to provide. Note: The NDIA will not provide funding for day-to-day living costs unrelated to a participant’s disability, such as groceries, rent and utilities. Different types of home and living supports will be better suited to different participants. It is important that the NDIA closely consider a participant’s unique circumstances, including their functional impairment and their individual goals and aspirations. It is also important that the NDIA consider whether home and living supports represent value for money, having regard to a participant’s disability support needs.
References:
- NDIA Dispute Resolution Policy Appendix B to the Legal Services Directions 2017
- Section 34(1) of the National Disability Insurance Scheme Act 2013
- Rules 3.1–3.7, 5.1–5.3 and 7.19–7.20 of the National Disability Insurance Scheme (Supports for Participants) Rules 2013
- How we work out if a support meets the funding criteria | NDIS
References:
Home and living supports | NDIS Operational Guideline — Specialist Disability Accommodation Rules 11–15 of the National Disability Insurance Scheme (Specialist Disability
Case Management Guide
Home and Living
OFFICIAL For Internal Use Only
SDA funding is available to participants who require specialised accommodation so that other supports can be delivered more safely and effectively. It is usually the most expensive home and living support on offer. SDA funding is based on the design category and building type of the building in which a participant lives, ordinarily with other participants. It is usually only suitable to participants with extreme functional impairment, or very high support needs.
Due to the potential impact of systems limitations on SDA providers, it is preferable that SDA funding is Agency managed, and included in plans with a duration of 12 months. If the agreed plan duration is greater than 12 months, ensure that the participant understands that additional invoicing actions may be required at the end of the first 12 months.
SDA funding does not include funding for any at-home supports, such as support workers.
ILO is designed to promote a participant’s choice and is available to participants seeking to explore their home and living needs. ILO funding is cheaper than SDA, and unlike SDA, covers at-home supports (but does not include funding for supports delivered outside the home). ILO is best suited to participants who do not need specialist accommodation, but who still require at least 6 hours of at-home help a day.
ILO may be offered to participants residing alone, with friends or housemates, or with a host family.
SIL, like ILO, SIL is best suited to participants who do not require SDA. Unlike ILO, SIL is bests suited to participants with significant support needs — being at least 8 hours of active support, and some level of support throughout the remainder of the day, every day. SIL funding is based on the ratio and number of hours of support a participant requires. Like SDA, SIL is usually delivered in shared accommodation amongst participants (unless it would be reasonable and necessary to do so for participants living alone).
MTA funding will meet the temporary cost of accommodation for participants have, but are unable to move into, long term housing because their disability supports are not yet ready. To receive MTA funding, participants must also be unable to remain in
Accommodation) Rules 2020
Operational Guideline — Individualised Living Options
Operational Guideline — Supported Independent Living
Operational Guideline — Medium Term Accommodation
Case Management Guide
Home and Living
OFFICIAL For Internal Use Only
| their current accommodation until they can move into their long-term housing. The NDIA will fund MTA for the number of days that meet the NDIS funding criteria, usually up to 90 days. Like SDA, MTA funding does not cover the cost of personal supports. |
| Evidence recommended to inform NDIA position in a specific matter before the Administrative Review Tribunal (ART) | Participants requesting home and living supports must complete a Supporting Evidence Form — Home and Living. The NDIA also requires evidence from allied health professionals which details the impact of a participant’s disability on their functional capacity, as well as their current and future daily support and housing needs. This may include, where possible, a roster of care and, in the context of MTA, evidence of a participant’s long-term accommodation (such as a tenancy agreement) together with evidence substantiating their inability to move in. | Home and living supporting evidence form | Types of disability evidence | Operational Guideline — Supported Independent Living | Operational Guideline — Medium Term Accommodation | Persons Giving Expert and Opinion Evidence Guideline |
| Other considerations | Besides MTA, home and living supports are typically only available to participants aged 18 years or older. The home and living supports funded by the NDIA are intended to complement, but not replace, existing mainstream services, such as community housing initiatives, Commonwealth Rent Assistance, the Housing Affordability Fund, and the National Rent Affordability Scheme, among others. When the NDIA provides funding for home and living supports, the NDIA may need to reduce funding previously provided for supports that are no longer needed in the participant’s new living environment. | What housing supports are included |
| Previous matters that may advise the NDIA position | |
| Document admin | Assistant Director, Policy, Continuous Improvement |
Case Management Guide
Home and Living
OFFICIAL For Internal Use Only Approved Director, Continuous Improvement 5 Page 17 of 38
Case Management Guide
Vehicle Modifications
| Field | Category | Reference Documents |
|---|---|---|
| Title | Vehicle Modifications | |
| Purpose | This document is part of a suite of guidance documents for Case Managers to use in formulating their approach to managing individual matters before the Administrative Review Tribunal (ART). This Guide applies nationally to the conduct of all matters within the ART Case Management Branch. | |
| What are Vehicle Modifications? | Due to a person’s disability, they may require that modifications be made to a vehicle, to enable them to drive or travel in the vehicle on a regular basis. | |
| For the purposes of this document, vehicle modifications include: |
- making changes to a vehicle to allow a participant to drive the vehicle or travel as a passenger of the vehicle (including fitting assistive technology);
- the transfer of modifications from one vehicle to another, usually newer, vehicle;
- the cost of modifications already performed on a vehicle, where that vehicle is being purchased second-hand by a participant;
- the cost of a driver trained occupational therapist assessment and driving instructor for the on-road part of an assessment, if the participant is to drive the modified vehicle;
- assessment and trial of passenger modifications;
- additional insurance costs relating to modifications to a particular vehicle.
- assistance in obtaining an engineering certificate or authorisation report in order to register a vehicle with funded modifications;
- tangential transport costs, while a participant’s vehicle is being modified;
- maintenance and repair of modifications installed in a particular vehicle;
- the cost of inspection for a vehicle condition report for vehicles older than 5 years which | |
Case Management Guide
Vehicle Modifications
| Field | Category | Reference Documents |
|---|---|---|
| are no longer subject to warranty, in order to ensure the vehicle is safe and reliable for regular use, and suitable for modification. | ||
| Policy statement | The ART process is often seen as stressful and adversarial by participants and prospective participants of the Scheme. The NDIA will adopt a participant-focused approach to resolving disputes before the ART, and will work directly with participants and prospective participants to provide better and earlier outcomes, where possible. | |
| The role of the NDIA is to assist the ART in reaching the correct and preferable decision, including by assisting participants and prospective participants in reaching the best possible resolution by agreement. The NDIA can only fund vehicle modifications that directly relate to a participant’s disability. This means that the NDIA will fund vehicle modifications for participants who would otherwise be unable to drive a particular vehicle, or travel in that vehicle as a passenger. | ||
| A participant or a member of their family will need to own the vehicle to be modified, or will need to have identified a suitable vehicle to purchase or lease. Where the vehicle has already been purchased, evidence of vehicle registration and permission to modify the vehicle must be obtained from the owner of the vehicle. Where the vehicle is yet to be purchased, written intent to purchase the vehicle and permission to modify the vehicle must be obtained from the intended owner of the vehicle. | NDIA Dispute Resolution Policy | |
| Appendix B to the Legal Services Directions 2017 | ||
| Section 34(1) of the National Disability Insurance Scheme Act 2013 | ||
| Rule 5.1 of the National Disability Insurance Scheme (Supports for Participants) Rules 2013 | ||
| Approach to ART matters | The NDIA will fund vehicle modifications which meet the NDIS funding criteria, which is to say they: |
- directly relate to a participant’s disability; and
- will assist a participant to pursue their goals, objectives, and aspirations; and
- will help facilitate a participant’s social and economic participation; and
- are effective and beneficial; and | What vehicle modifications and driving supports do we fund? | NDIS How do we fund assistive technology? | NDIS |
Case Management Guide
Vehicle Modifications
| Field | Category | Reference Documents |
|---|---|---|
| - represent value for money compared to other supports which may achieve a similar outcome at a lesser cost; and - would not be more appropriately funded by another mainstream service delivery system; and - are legal and safe to provide. |
[Assistive technology explained | |
| Evidence recommended | Before the NDIA is able to fund vehicle modifications, the NDIA requires evidence:
If the participant is to be the driver of the modified vehicle, the NDIA will also require evidence that:
|
Persons Giving Expert and Opinion Evidence Guideline, [Administrative Appeals Tribunal Assessing Fitness to Drive |
| Other considerations | The NDIA will not fund:
|
Schedule 2, Item 6, NDIS (Getting the NDIS Back on Track No. 1) (NDIS Supports) Transitional Rules 2024 |
Case Management Guide
Vehicle Modifications
| Field | Category | Reference Documents |
|---|---|---|
| - non-standard equipment for modifications; |
- costs to upgrade a commercial vehicle to a passenger vehicle;
- modifications to public vehicles, such as busses or taxis; or
- vehicle modifications which are not legal for use in the relevant state or territory. | What do we mean by vehicle modifications and driving supports? NDIS | | Relevant previous decisions | The AAT affirmed a decision of the NDIA to decline funding for vehicle modifications on the basis that the participant did not hold a current driver licence (nor had he taken the necessary steps to obtain a driver licence) and had not undertaken a medical and driving assessment by an occupational therapist. The AAT also held that vehicle modifications were not a reasonable and necessary support because the participant owned a vehicle that was capable of transporting himself and his wheelchair, which could be driven by family, friends, or an NDIS-funded carer. | McPherson and National Disability Insurance Agency [2018] AATA 4393 |
| Document Control | Responsible Person | Date |
|---|---|---|
| Document author | Continuous Improvement | November 2024 |
| Document approver | Director, Continuous Improvement | 29 November 2024 |
Case Management Guide
Home Modifications
| Field | Category | Reference Documents |
|---|---|---|
| Title | Home Modifications | |
| Purpose | This document is part of a suite of guidance documents for Case Managers to use in formulating their approach to managing individual matters before the Administrative Review Tribunal (ART). This Guide applies nationally to the conduct of all matters within the ART Case Management Branch. | |
| What are home modifications? | Due to a participant’s disability, they may require home modifications to alter the structure, layout, or fittings of their home to allow them to safely access and move around frequently used areas. Minor home modifications are home modifications that do not change the structural components of a home, or which cost less than $20,000. Complex home modifications involving modifications to a few areas of the home. | What do we mean by home modifications? |
| Policy statement | The ART process is often seen as stressful and adversarial by participants and prospective participants of the Scheme. The NDIA will adopt a participant-focused approach to resolving disputes before the ART, and will work directly with participants and prospective participants to provide better and earlier outcomes, where possible. The role of the NDIA is to assist the ART in reaching the correct and preferable decision, including by assisting participants and prospective participants in reaching the best possible resolution by agreement. The NDIA will fund all requests for home modifications which meet the NDIS funding criteria. | NDIA Dispute Resolution Policy |
| Approach to ART matters | Home modifications meet the NDIS funding criteria if: - they directly relate to a participant’s disability, or the impact of their disability on their functional capacity; and - they will assist a participant to pursue their objectives, goals, and aspirations. | What home modifications do we fund? |
Case Management Guide
Home Modifications
| Field | Category | Reference Documents |
|---|---|---|
| - they will help to facilitate a participant’s social and economic participation; and - they are effective and beneficial; and - they represent good value for money compared to other supports that may achieve the same outcome at a lessor cost, or which may reduce a participant’s need for future supports; and - they take account of what is reasonable for families, carers, informal networks, and the community to provide; and - they are most appropriately funded by the NDIS, and not any other mainstream service delivery system; and - they are legal and safe to provide. |
Section 34(1) of the National Disability Insurance Scheme Act 2013 Rules 5.1 of the National Disability Insurance Scheme (Supports for Participants) Rules 2013 National Construction Code |
|
| Evidence recommended | There is no singular approach to matters before the ART involving home modifications, nor any standard approach to the calculation of home modification funding to be provided. Instead, the NDIA will be informed by evidence from: - A suitably qualified occupational therapist who which outlines the need for and benefit of particular proposed home modifications, in light of a particular participant’s functional impairment; - evidence from the legal homeowner and/or other relevant body (e.g. body corporate/strata), indicating their consent to modifications to the home; - for complex home modifications, at least 2 itemised quotes or cost estimates provided by a qualified building cost estimator or quantity surveyor |
Persons Giving Expert and Opinion Evidence Guideline Administrative Appeals Tribunal NDIS Providing Home Modifications NDIS Guidance for Home Modification Assessors NDIS Home Modification Guidance for Builders and Designers |
| Other considerations | In addition to capital funding to cover the cost of home modifications, the NDIA may, based on the available evidence, additionally fund the following: - the cost of a building construction practitioner to provide advise and support develop of scope of work; |
Home Modifications (NDIA intranet) Knowledge Article: Add minor home modification funding |
Case Management Guide
Home Modifications
| Field | Category | Reference Documents |
|---|---|---|
| - The cost of a building works project manager to oversee home modifications which have been approved, usually for complex home modifications or if an occupational therapist has recommended doing so or if there are identified risks to the participant; ancillary costs to have modifications completed in a compliant manner, e.g. the cost of an independent building certifier to assess and certify completed modifications prior to final payment being made; or asbestos removal within the immediate area where modifications will occur; and/or - The cost of an occupational therapist with expertise as a home modification assessor to help a participant use their new home, and to confirm that the home modifications effectively contribute towards delivering the desired outcomes. | Knowledge Article: Add complex home modifications funding | |
| Appendix A: Providers and their roles, NDIS Home Modification Guidance | ||
| Relevant previous decisions | MDCT sought funding for a jetty to enable him to go paddle boarding, and a new galvanised staircase to replace an existing staircase which had fallen into disrepair, rendering it unsafe for use by all persons (able-bodied and not able-bodied alike). The AAT affirmed a decision of the NDIA, which declined to fund the requested home modifications, on the basis that the requested home modifications were unrelated to the participant’s disability. | MDCT and National Disability Insurance Agency [2022] AATA 697 |
| Document Control | Responsible Person | Date |
|---|---|---|
| Document author | Continuous Improvement | November 2024 |
| Document approver | Director, Continuous Improvement | 29 November 2024 |
Case Management Guide
Community Supports
| Field | Category | Reference Documents |
|---|---|---|
| Title | Community Supports | |
| Purpose | This document is part of a suite of guidance documents for Case Managers to use in formulating their approach to managing individual matters before the Administrative Review Tribunal (ART). This Guide applies nationally to the conduct of all matters within the Administrative Review Tribunal Case Management Branch. | |
| Scope | For the purposes of the document, community supports refer to supports provided by: - families; - carers; - informal networks; or - the community as per section 34(1)(e); or - general systems of support offered by a person, agency, or body (for example, allied health providers); - systems of support offered as part of a universal obligation (for example, Services Australia); or - systems of support offered in accordance with reasonable adjustments required under a law dealing with disability-based discrimination (for example, employers) as per section 34(1)(f). | Sections 34(1)(e) and 34(1)(f) of the National Disability Insurance Scheme Act 2013 |
| NDIA policy on this subject | The ART process is often seen as stressful and adversarial by participants and prospective participants of the Scheme. The NDIA will adopt a participant-focused approach to resolving disputes before the ART, and will work directly with participants and prospective participants to provide better and earlier outcomes, where possible. The role of the NDIA is to assist the ART in reaching the correct and preferable decision, including by | NDIA Dispute Resolution Policy |
| Appendix B to the Legal Services Directions 2017 | ||
| Sections 34(1)(e) and 34(1)(f) of the National Disability Insurance Scheme Act 2013 | ||
| Rules 3.4—3.7 and Schedule 1 of the National Disability |
Case Management Guide
Community Supports
| Field | Category | Reference Documents |
|---|---|---|
| assisting participants and prospective participants in reaching the best possible resolution by agreement. | ||
| The NDIA will fund all reasonable and necessary supports. In particular, in the context of community supports, the NDIA must be satisfied that funding: |
- takes account of what is reasonable to expect families, carers, informal networks, and the community to provide; and
- is the responsibility of the NDIS, and that the support in question would not be more appropriately funded or provided by other systems of service delivery or support. | Insurance Scheme (Supports for Participants) Rules 2013 | | NDIA posture in relation to this subject | The NDIA cannot fund supports which replace the responsibility of families, carers, informal networks, and the community in supporting a participant. What can reasonably be expected of them to provide must be determined objectively on a case-by-case basis, and will be informed by such factors as:
- the extent of any risk to a participant’s wellbeing because of their reliance on community supports;
- the suitability of family members, carers, informal networks, and the community based on their age, gender, and any risks to their long-term wellbeing, as well as the age or gender of a participant, and the intensity of support which a participant requires;
- the extent to which community supports increase or decrease a participant’s independence; and
- the desirability of supporting and developing the potential contributions of informal support networks. For example, the NDIA can reasonably expect parents to provide transport for their child to and from school but cannot reasonably expect adult or minor children to transport their parents to and from work or other appointments. The NDIA can also reasonably | Rule 3.4 of the National Disability Insurance Scheme (Supports for Participants) Rules 2013 Operational Guideline — Reasonable and Necessary Supports Schedule 1 of the National Disability Insurance Scheme (Supports for Participants) Rules 2013 Operational Guideline — Reasonable and Necessary Supports Operational Guideline — Mainstream and Community Supports Overview Operational Guideline — Mainstream and Community Supports Interfaces Council of Australian Governments (COAG) — Principles to determine responsibilities of the |
Case Management Guide
Community Supports
| Field | Category | Reference Documents |
|---|---|---|
| expect a greater level of physical support from younger parents than from aging grandparents. The NDIA also cannot fund supports which are more appropriately funded by another service delivery system. What would most appropriately be funded by another service delivery systems will depend on the particular support and system in question. | ||
| For example, the health system is responsible for providing care to participants requiring hospitalisation. However, the NDIA may agree to fund a support worker who is able to assist in training hospital staff on a participant’s specific needs (for example, training on the use communication devices). | ||
| Note: Schedule 1 of the National Disability Insurance Scheme (Supports for Participants) Rules 2013 sets out matters for consideration when assessing whether a support is most appropriately funded by the NDIS, based on the role of particular service delivery systems. | expect friends, family or the community to provide?’ | |
| Evidence recommended to inform NDIA position in a matter before the ART | The NDIA bears the burden of proof in establishing that a particular support would more appropriately funded by another service delivery system. Where necessary, advice should be sought from the Technical Advisory Branch and Mainstream Interface Team. | |
| The NDIA must also find, as a matter of fact and on the evidence available, whether and how much support families, carers, informal networks, or the community can provide in meeting a participant’s disability support needs. This can be informed by clinical reports, opinion evidence, expert evidence, and witness statements. | Persons Giving Expert | |
| and Opinion Evidence | ||
| Guideline | ||
| Administrative Appeals | ||
| Tribunal | ||
| Other considerations | Section 34(1)(e) calls for an objective test: ‘what would an ordinary person think is reasonable to expect friends, family or the community to provide?’’ | Operational Guideline — |
| Reasonable and | ||
| Necessary Supports |
Case Management Guide
Community Supports
| Field | Category | Reference Documents |
|---|---|---|
| Section 34(1)(f) calls for application of the relevant legislative framework, not an objective test. It is a blanket prohibition on funding for supports which are more appropriately funded through other systems, regardless of whether those supports are actually funded through those other systems. | Rules 3.5—3.7 and Schedule 1 of the National Disability Insurance Scheme (Supports for Participants) Rules 2013 | |
| Previous matters that may inform the NDIA position | A decision maker is required to find, as a matter of fact, whether and how much support families, carers, informal networks, or the community can provide in meeting a participant’s disability support needs, prior to making a reasonable and necessary decision. Section 34(1)(e) does not permit that a co-contribution be applied to reduce the level of funding the NDIA must provide for a support that has been determined reasonable and necessary. | McGarrigle v National Disability Insurance Agency [2017] FCA 308 at [100] and [103] |
| The NDIA cannot fund a particular support which would more appropriately be funded by another service delivery system, even if that systems does not actually provide funding for that particular support. The test is not whether the support is available through other systems, but whether it would be most appropriately funded through other systems. | Young v National Disability Insurance Agency [2014] AATA 401 at [41] |
Document Control
| Responsible Person | Date |
|---|---|
| Document author | Continuous Improvement |
| Document approver | Director, Continuous Improvement |
Case Management Guide
Transport Supports for Adult Participants
| Field | Category | Reference Documents |
|---|---|---|
| Title | Transport Supports for Adult Participants | |
| Purpose | This document is part of a suite of guidance documents for Case Managers to use in formulating their approach to managing individual matters before the Administrative Review Tribunal (ART). | |
| Scope | This Guide applies nationally to the conduct of all matters within the Administrative Review Tribunal Case Management Branch. For the purposes of this guide, participants are taken to be 18 years of age or older. | |
| What are transport supports? | Transport supports include supports that assist and/or enable participants to access work, study or community activities. Generally, core transport costs refer to the cost of taxis, rideshares or other private transport, if a participant is not able to use public transport without substantial difficulty because of their disability. It may also include provider non-labour costs for activity-based transport where the provider transports the participant to the activity. Provider travel costs associated with a provider going to the location of a participant to deliver the support (such as therapy or assistance with self-care) are not covered by this Guide. Nor are vehicle modifications. | Rules 7.21 and 7.22 of the National Disability Insurance Scheme (Supports for Participants) Rules 2013 Transport |
| Policy Statement | The ART process is often seen as stressful and adversarial by participants and prospective participants of the Scheme. The NDIA will adopt a participant-focused approach to resolving disputes before the ART, and will work directly with participants and prospective participants to provide better and earlier outcomes, where possible. The role of the NDIA is to assist the ART in reaching the correct and preferable decision, including by assisting participants and prospective participants in reaching the best possible resolution by agreement. | NDIA Dispute Resolution Policy Appendix B to the Legal Services Directions 2017 Including Specific Types of Supports in Plans Operational Guideline — Transport Section 34(1) of the National Disability Insurance Scheme Act 2013 |
Case Management Guide
Transport Supports for Adult Participants
| Field | Category | Reference Documents |
|---|---|---|
| Transport Supports for Adult Participants The Agency will only fund transport supports if such supports manifest as a cost incurred solely and directly because of a participant’s disability support needs, or where transport is ancillary to another funded support, and arise as costs that the participant would not otherwise incur. There are 2 models of funding transport costs, which are generally mutually exclusive: * Calculated as a set amount on a 3-tier scale, paid as a periodic payment each fortnight into the participant’s bank account (tiered); or * Calculated at a per km rate and paid as a reimbursement (pro-rata). The NDIA is not responsible for funding mainstream transport costs such as public transport options or the compliance of public transport and providers with universal transport obligations. | Operational Guideline – Principles we follow to create your plan Transport funding | |
| Where a participant can use public transport or other means or transport independently, core transport supports are not usually reasonable and necessary. The Agency will fund participant requested transport when the participant cannot use public transport due to the functional impact of their disability, and the transport support will enable their social and economic participation. Transport supports are not usually funded in circumstances where they relate to day-to-day living costs. The NDIA’s preference is to provide tiered transport funding, as opposed to pro-rata funding. Where possible, the NDIA will use its best judgment to determine the best level of tiered funding, also taking account of a participant’s goals and their individual aspirations and objectives. | Rules 5.1(d) and 5.2 of the National Disability Insurance Scheme (Supports for Participants) Rules 2013 |
Case Management Guide
Transport Supports for Adult Participants
| Field | Category | Reference Documents |
|---|---|---|
| Evidence recommended | The Agency’s position usually hinges around the participant’s capacity to independently use public transport, regardless of whether there is public transport available. Evidence which reports the participant’s functional capacity for public transport should be obtained. Relevant evidence should outline the assessments or observations of the barriers and any limiting factors which may prevent the participant from using public transport independently. Information should also be obtained which speaks to the participant’s capacity to learn to use public transport independently in future. In some cases, it may be preferable to engage an independent Occupational Therapist. The focus of their assessment should be directly related to the physical, cognitive and social skills which relate to the participant’s ability to use public transport. Where the “per km” method of calculating transport costs is used, evidence to support the quantum of costs may include a completed transport log, such as the ATO vehicle log. Other evidence may include witness statements by carers and support workers. | Persons Giving Expert |
| and Opinion Evidence | ||
| Guideline | ||
| Administrative Appeals | ||
| Tribunal | ||
| JQJT and National | ||
| Disability Insurance | ||
| Agency [2016] AATA 478 at [12], [13] and [18] | ||
| Logbook method | ||
| Australian Taxation Office | ||
| Section 34(1) of the | ||
| National Disability | ||
| Insurance Scheme Act | ||
| 2013 | ||
| Rules 3.4(a), 3.4(c) and 5.1 (c) of the National | ||
| Disability Insurance | ||
| Scheme (Supports for | ||
| Participants) Rules 2013 | ||
| Including Specific Types | ||
| of Supports in Plans | ||
| Operational Guideline — | ||
| Transport |
Case Management Guide
Transport Supports for Adult Participants
| Field | Category | Reference Documents |
|---|---|---|
| Mainstream Interface Team will work closely with the TAPIB to provide further advice, where required. There are a number of contingencies available to people with disability via the transport service to address bus or train closures/delays. It is recommended to get detailed information on those strategies as part of the consideration. | ||
| Previous matters that may inform the NDIA position | A decision maker is required to find, as a matter of fact, whether and how much families, carers or informal support networks can provide the requested transport supports and apply this thinking prior to making a reasonable and necessary decision. Section 34(1)(e) of the National Disability Scheme Act 2013 does not permit that a co-contribution to transport supports is applied after the support has been determined reasonable and necessary. | McGarrigle v National Disability Insurance Agency [2017] FCA 308 at [100] and [103] |
Case Management Guide
Plan Management
| Field | Category | Reference Documents |
|---|---|---|
| Title | Plan Management | |
| Purpose | This document is part of a suite of guidance documents for Case Managers to use in formulating their approach to managing individual matters before the Administrative Review Tribunal (ART). This Guide applies nationally to the conduct of all matters within the Administrative Review Tribunal Case Management Branch. | |
| Scope | There are three strategies available for the participant to manage the funding in their plans: - Self-managed (by the participant, nominee, or child representative) - Plan managed (by a registered plan management provider) - Agency managed (by the NDIA) | [Self-managed |
| NDIA policy on this subject | The ART process is often seen as stressful and adversarial by participants and prospective participants of the Scheme. The NDIA will adopt a participant-focused approach to resolving disputes before the ART, and will work directly with participants and prospective participants to provide better and earlier outcomes, where possible. | |
| The role of the NDIA is to assist the ART in reaching the correct and preferable decision, including by assisting participants and prospective participants in reaching the best possible resolution by agreement. If a participant does not specify how they would like their plan managed, or if there are certain aspects which a participant is unable to manage, the NDIA will make the decision on their behalf. | ||
| The NDIA must agree to a participant’s request to change their plan management strategy. | ||
| There are no restrictions on how often a participant can request to change their plan management. | NDIA Dispute Resolution Policy, Appendix B to the Legal Services Directions 2017, How do we decide who manages your funding? | NDIS |
Case Management Guide
Plan Management
| Field | Category | Reference Documents |
|---|---|---|
| NDIA posture in relation to this subject | The NDIA will only decline a request to change a participant’s plan management strategy if: * there is a nominee (who did not initiate the request); * doing so may cause unreasonable risk to the participant; * a participant seeking to self-manage their plan has been declared bankrupt, or their elected plan management provider is insolvent or under administration; or if the change is for in kind supports, or cross-billing payments for younger participants in residential aged care. | Sections 43 - 44 of the National Disability Insurance Scheme Act 2013 |
| National Disability Insurance Scheme (Plan Management) Rules 2013 | ||
| Evidence recommended to inform NDIA position in a matter before the ART | The NDIA will refer to any available evidence which indicates bankruptcy or insolvency on the part of the proposed entity to manage plan funds. The NDIA will also refer to any requests for plan review made under section 48 of the NDIS Act. | Persons Giving Expert and Opinion Evidence Guideline |
| Bankruptcy Register Search - AFSA | ||
| Other considerations | The NDIA can consider funding supports such as ‘budget training’ to assist a participant in managing their own plan. | |
| Previous matters that may inform the NDIA position | The AAT set aside a decision of the NDIA, to have plan funding partially self-managed and partially plan-managed. The AAT considered doing so raised significant risk, and ordered that funding be managed by a registered plan manager. | QHFQ and National Disability Insurance Agency [2021] AATA 256 |
Case Management Guide
Decision Making
| Field | Category | Reference Documents |
|---|---|---|
| Title | Decision Making | |
| Purpose | This document is part of a suite of guidance documents for Case Managers to use in formulating their approach to managing individual matters before the Administrative Review Tribunal (ART). | Decision-Making Authority for Case Managers |
| Scope | This Guide applies nationally to the conduct of all matters within the Administrative Review Tribunal Case Management Branch. | |
| Making Decisions | Good decision making is evidence-based, factual, consistent, applies the legislative framework, and is logical. Objectively, a good decision: ¥ is evidence-based if it explicitly and judiciously considers the best available evidence; ¥ is factual if it accounts for the facts which are unique to the matter, and to the participant or prospective participant; ¥ is consistent and fair if it aligns with the Model Litigant Obligations and NDIA policy framework; ¥ applies the legislative framework if it explicitly and judiciously considers the specific criteria prescribed by the Act and the Rules; and ¥ is logical if it is clear, and well-informed by the available evidence, the facts, and the law. | NDIS Act 2013 |
| NDIS Rules | ||
| NDIA Dispute Resolution Policy | ||
| Appendix B to the Legal Services Directions 2017 | ||
| Section 56 of the Administrative Review Tribunal Act 2024 | ||
| Case Management Guide: Model Litigant Obligations | ||
| Administrative Review Branch Guidance Library and Directory | ||
| Recording Decisions | Case Managers must record all decisions as a file note in LEX. A well-recorded decision objectively defines: ¥ what decision is made; ¥ under what authority the decisions is made — including where a decision is supported by legal or internal specialist advice, and has been reviewed by an Assistant Director, Director, Pre-ALOC or ALOC; and ¥ what evidence is relied upon to form the basis of that decision (and whether that evidence is new or existing evidence). Example file notes are contained at Annexure A. | Decision-Making Authority for Case Managers |
| Standard Operating Procedure: Resolved by Consent |
Case Management Guide
Decision Making
Annexure A - File Note Examples
While note prescriptive, the below examples are indicative of the minimum standard which is to be expected of Case Managers when recording a decision as a file note in LEX. At a minimum, Case Managers are expected to identify what the decision is, under what authority the decision is made, and what evidence is relied upon in making that decision (including any new or existing evidence).
The below examples are based on the Updated Position file note template in LEX.
Example 1
Support(s) in dispute:
- 28 days per year (24 hours per day) Assistance with Self-Care Activities, comprising: a. 16 hours per day of 1:1 support worker assistance; and b. 8 hours per day of 1:1 inactive overnight support;
- $1,425.78 per year for Nutritional Supplements; and
- Transport Level 1.
Evidence (new or existing):
- OT report dated 26/05/2023 (new)
- Supplementary OT report dated 5/06/2023 (new)
- Letter from Gastroenterologist dated 29/04/2023 (new)
- Letter form Dietitian dated 18/04/2023 (existing)
Authority:
- External legal advice received on 31/05/2023 (Nutritional Supplements)
- TAPIB advice received on 22/05/2023 (Transport Level 1)
- TAPIB advice received on 22/05/2023 (24 hours of 1:1 support for 28 days per year)
Case manager decision and next steps: My decision is to approve all supports, in line with external legal advice and TAPIB advice. Offer to be presented to participant, and s103(2) ToA to be drafted.
Case Management Guide
Decision Making
Example 2
Support(s) in dispute:
- STAx 12 days per year (6 x weekends)
- Funding for linen service x 3 hours per week
Background:* Participant resides in a granny flat by himself on his mum’s propertyParticipant is highly dependent on his mum as his sole carerParticipant’s mum is experiencing carer burn out*Participant requires daily support for all ADLs
Evidence (new or existing):* Statement of lived experience dated 01/07/2023 (existing)*Carer impact statement dated 01/07/2023 (existing)
Authority:* ALOC (chaired by DCEO, Governance, Risk and Legal) on 24/08/2023*Legal advice dated 01/08/2023
Case manager decision and next steps: My decision is to fund STA to alleviate pressure on the participant’s mum as sole carer and to mitigate any potential risk to the participant. This is unsupported by legal advice received on 01/08/2023, but is supported by ALOC (DCEO Governance, Risk and Legal). Offer to be presented to participant, and s85(1) ToA to be drafted to narrow the issues in dispute prior to potential Hearing.
Further information to be obtained in relation to the request for funding for linen service x 3 hours per week, noting the participant is still seeking this support and will not resolve on the basis of the above offer. ALOC supported maintaining the Agency position that funding for linen service x 3 hours per week is not reasonable and necessary.
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Case Management Guide Decision Making
Example 2
Support(s) in dispute:
- STAx 12 days per year (6 x weekends)
- Funding for linen service x 3 hours per week
Background: — Participant resides in a granny flat by himself on his mum’s property — Participant is highly dependent on his mum as his sole carer — Participant’s mum is experiencing carer burn out — Participant requires daily support for all ADLs
Evidence (new or existing): — Statement of lived experience dated 01/07/2023 (existing) — Carer impact statement dated 01/07/2023 (existing)
Authority: — ALOC (chaired by DCEO, Governance, Risk and Legal) on 24/08/2023 — Legal advice dated 01/08/2023
Case manager decision and next steps: My decision is to fund STA to alleviate pressure on the participant’s mum as sole carer and to mitigate any potential risk to the participant. This is unsupported by legal advice received on 01/08/2023, but is supported by ALOC (DCEO Governance, Risk and Legal). Offer to be presented to participant, and s85(1) ToA to be drafted to narrow the issues in dispute prior to potential Hearing.
Further information to be obtained in relation to the request for funding for linen service x 3 hours per week, noting the participant is still seeking this support and will not resolve on the basis of the above offer. ALOC supported maintaining the Agency position that funding for linen service x 3 hours per week is not reasonable and necessary.
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Case Management Guide
Decision Making
Example 3
Support(s) in dispute:
- Participant seeks an extension of time (50 days) in which to apply to the ART for review
Evidence (new or existing):
- Application for review of a decision lodged on 01/08/2023 (new)
Authority:* Standard Operating Procedure: EOT (standing instructions)
Decision and next steps: My decision is not to oppose the EOT, in accordance with the EOT SOP. Approved by my EL1. I advise the ART that EOT is not opposed. Matter to be triaged, and allocated to EA.
Example 4
Support(s) in dispute:
- Participant seeks an extension of time (94 days) in which to apply to the ART for review
Evidence (new or existing):
- Application for review of a decision lodged on 01/08/2023 (new)
- Email from the participant’s advocate to the ART dated 01/08/2023 (new)
Authority:* Legal advice received on 10/08/2023
Decision and next steps: My decision is to oppose the EOT, in line with legal advice. Approved by my line manager. I will instruct the LWC to advise the ART that the EOT is opposed.
| Document Control | Responsible Person | Date |
|---|---|---|
| Document author | Continuous Improvement | October 2024 |
| Document approver | Director, Continuous Improvement |