Understanding ‘reasonable and necessary’ criteria in the NDIS

Published at 07-05-2025 12:00:24

Tags: #ForParticipants

The NDIS aims to provide participants with supports that help them achieve their goals, live independently, and engage fully in their communities. The ‘reasonable and necessary’ criteria play a key role in determining which supports can be funded, ensuring they align with the participant’s needs and the scheme’s objectives.

In this guide, we’ll break down what reasonable and necessary supports mean, the factors considered, and the roles of NDIS planners and Plan Managers in this process.

What Does ‘Reasonable and Necessary’ Mean?

For a support to be funded by the NDIS, it must meet specific criteria that assess its relevance, effectiveness, and appropriateness for the participant’s needs. These criteria include:

1. Related to the Participant’s Disability: The support must directly address the participant’s disability-related needs.
2. Not Everyday Expenses: General living costs like groceries or rent are excluded unless directly linked to the participant’s disability.
3. Good Value for Money: The support must justify its cost by providing measurable benefits.
4. Effective and Beneficial: It should demonstrate a clear potential to improve the participant’s quality of life or achieve their goals.
5. Most Appropriate Option: Among available options, the support must be the best fit, considering other NDIS-funded or community supports.
6. Not Funded by Other Systems: Supports covered by other mainstream systems, like Medicare, are generally not funded by the NDIS.

Who Decides What is ‘Reasonable and Necessary’?

The NDIA makes decisions based on the NDIS Act and operational guidelines, ensuring consistency and alignment with legal frameworks.

NDIS planners and Local Area Coordinators (LACs) evaluate a participant’s needs, goals, and supporting evidence—such as healthcare reports—during the planning process. This thorough assessment ensures that approved supports are both suitable and beneficial.

The Role of Plan Managers

Plan Managers do not determine whether supports are reasonable and necessary. Their role is administrative and compliance-focused, ensuring that:

• Expenses align with the participant’s approved plan.
• The NDIS Price Guide is followed.
• Participants understand how to manage their funding effectively.
• Fraud or misuse of funds is prevented.

Plan Managers do not:

• Approve or reject supports based on the reasonable and necessary criteria.
• Decide what supports participants can access.

Why is Understanding ‘Reasonable and Necessary’ Important?

For participants, knowing these criteria empowers them to:

• Plan effectively for their supports.
• Request services that are likely to be approved.
• Advocate for their needs during planning and reassessments.

What If I’m Unsure?

If you’re unclear about whether a support meets the criteria, don’t worry—interpreting these guidelines can sometimes be challenging. Here’s what you can do:

1. Seek Professional Advice:
2. Your Plan Manager can guide you in understanding how supports align with NDIS requirements. At Just Plan Managers, we help participants navigate the rules and make informed decisions.
3. Consult Your Planner or LAC:
4. Reach out to your NDIS planner or LAC for clarification on specific supports and how the criteria apply to your situation.

Remember, the ultimate decision lies with the NDIS. Clear communication and supporting evidence can help ensure the best outcome for your plan.