National Disability Insurance Scheme. Frequently asked questions as at October 2013

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1 National Disability Insurance Scheme Frequently asked questions as at October Current October 2013

2 National Disability Insurance Agency (NDIA) Processes Q: What is the role of the planner? The planner s first task is to confirm the eligibility of the person for the NDIS. Some people will have completed an online self-reporting tool My Access Checker ( ) prior to meeting the planner. This will have indicated whether they are likely to be eligible for NDIS; the planner will confirm this. Secondly, the planner will discuss with the participant their needs, goals and aspirations. This will inform the development of a statement of goals and aspirations for the participant. Following this, the planner and participant will work together to identify what current and future supports will be required to make progress on the participant s goals. This part of the plan, the statement of participant s supports, sets out the supports that will be provided or funded by the NDIA. These two statements make up the plan for each participant. The plan is owned by the participant and is based on what is regarded as reasonable and necessary to enable a good life. It could include one-off and/or ongoing funded supports. What is a reasonable and necessary support is checked against a set of reference packages that the NDIA has developed. For more detail on NDIA s Operational Guidelines about planning refer to: disabilitycareaustralia.gov.au/document/323 Q: What tool(s) will the agency use to help them develop a plan? The National Disability Insurance Agency (NDIA) recognises that one tool will not always provide all the necessary information required. An assessment tool (a version for children and adults) has been developed for planners that will be evaluated during the Launch period. The tool is based on the International Classification of Functioning Disability and Health (ICF) and guides the conversation with participants. The Assessment tool involves the planner using a strength based approach to identify support needs necessary to make progress on goals and aspirations. These questions are designed to guide the conversation. They evaluate the areas and nature of support needed across ten domains. The Assessment tool is structured in a way that allows a more detailed consideration of need where any one of the 10 domains or core areas of functional capacity is significantly and permanently impaired and identified by the participant as presenting specific challenges that would need to be addressed to enable them to achieve their goals and aspirations. 2 Current October 2013

3 The 10 domains capture a range of important life functions including: 1. Learning and applying knowledge (e.g. understanding and remembering information, learning new things, practicing and using new skills and ideas). 2. General tasks and demands (e.g. doing daily tasks, managing daily routine, handling problems, making decisions). 3. Communication (e.g. being understood and understanding other people). 4. Mobility (e.g. getting in or out of bed or a chair and moving around in your home and community). 5. Self-care and special health care needs (e.g. showering/bathing, dressing, eating, toileting). 6. Domestic life activities (e.g. preparing meals, cleaning, housekeeping and home maintenance). 7. Interpersonal interactions and relationships (e.g. making and keeping friends and relationships, coping with feelings and emotions). 8. Community, social and civic life (e.g. community activities, recreation and leisure). 9. Education and training. 10. Employment. The NDIA does not intend to make public a copy of the assessment tool nor do they expect to give the participant a copy to complete. However, for more detail about the above 10 domains or core areas that are covered in this tool to assist and guide the planning conversation, refer to: document/324 The NDIA expects planners to draw upon other assessments that have been completed to help them make decisions about supports and services that are needed. The NDIA may request additional specialist assessments to be completed to help with the development of the plan. The NDIA is keen that the participant only has to tell their story once and therefore is keen, with the consent of the participant, to have service providers share information and assessments that they have about the participant. Q. Can a provider be involved in the planning meeting? The planning and assessment conversation leads to what many participants will see as the most important decision that the National Disability Insurance Agency (NDIA) will make the decision about their plan and their supports. This decision is typically made over a series of meetings. It is a critical time for participants to develop a relationship with someone new, the NDIA planner and other NDIA staff such as Local Area Coordinators. Among other things, planners will be discussing with participants if they want to continue their current supports. If they do not, the planner will want to have a discussion about other suitable supports before the plan is finalised. The NDIA is concerned that the involvement of providers in planning meetings may place pressure on participants to continue with their current supports. The NDIA 3 Current October 2013

4 would therefore prefer that providers are not involved in the meetings where support arrangements are being discussed and particularly when budget plans are being finalised. The NDIA recognises that providers can play an important role in supporting the participant to prepare for their meetings with the NDIA planner. This can be done by providing the participant with information about their disability, copies of any relevant assessments/ service plans and helping them to understand the purpose and the way the planning conversation will be conducted. There may be some exceptions to the above position. For example, if an adult participant does not currently have a plan nominee who can assist them, the NDIA may ask a suitable staff person from a current provider to fill this gap until a suitable nominee can be arranged. Or, if a parent of a child is concerned about being able to confidently describe their child s needs, the parent may request the NDIA planner to invite a therapist to one of the planning meetings to help explain their child s condition and current service goals. Or, if there is an individual who has long resided in a group home, without family or guardian, and is known well only by the service provider, the NDIA planner may ask a suitable staff person to attend one of the planning meetings. As with all exceptions, the NDIA will need to deal with this on a case by case basis. The decision about the funding of reasonable and necessary supports is for the NDIA to make in accordance with known facts, the Act, Rules and Operating Guidelines. It is important that the NDIA has available all essential information to inform that decision. Hence it is critical that the planning conversation/s be conducted in a positive and constructive manner that allows freedom to explore choices for the participant and their family. Q. Will there be an appeals mechanism? Yes, if a participant disagrees with a decision made by the National Disability Insurance Agency (NDIA) they can request to have this decision reviewed by the NDIA. This is an internal review. The decisions that are reviewable are listed in the NDIS Act 2012 (Chapter 4, Part 6). If, after this review, the participant still disagrees they can apply to the Administrative Appeals Tribunal (AAT) for an external merits review. If a participant needs requires independent support with their application to the AAT they can approach one of the following organisations who have been selected to provide External Merits Review Support Services (EMRSS): Hunter (NSW): Disability Advocacy NSW, South Australia: Brain Injury Network SA, Tasmania: Advocacy Tasmania Inc., Barwon (VIC): Regional Information and Advocacy Council (03) The NDIA Operational Guidelines about review of decisions have yet to be loaded onto the web site. 4 Current October 2013

5 Funding, pricing and payments Q. Why has the National Disability Insurance Agency (NDIA) set prices for supports? The National Disability Insurance Agency (NDIA) has confirmed that at least for the commencement of the Launch, it will take the role of setting prices for most of the supports. There are two types of price setting. 1. For clusters of supports that can be described as high frequency or high volume a maximum price will be set by the NDIA. The provider can claim payment up to this price but not beyond. 2. The other type of price will be a benchmark price. This is a price that is indicative of the cost but will be subject to confirmation of a quote from a supplier. This will mainly relate to items of support such as equipment, accommodation supports and home and vehicle modifications. A benchmark price will be included in the participant s plan to allow the full funding package to be developed. However, the price finally paid by the NDIA will be confirmed once a quote has been obtained and approved. Innovative supports, those that are unique to the participant, may also attract a benchmark price in the plan until confirmation is received from the provider/supplier and approved by the NDIA. The decision to set prices has been based on the NDIA s view that the market is still immature and that until the development of greater demand and supply factors, it is better to intervene with market price setting. Click here to download the full list of the prices set for each of the Launch sites: Since the release of the price list, NDS has been working with the NDIA for the review the adequacy of the prices of various supports. Q. Why are there some prices differences across the Launch sites? The reason for the variation across the sites is that the National Disability Insurance Agency ( NDIA) adopted a principle of pricing in accordance with local markets so as not to become a competitor to others purchasers in that market place. Due to historical purchasing arrangements there is therefore some variation in local states and territories. The NDIA wanted to avoid too much disruption to these existing markets. In establishing prices in local areas, the NDIA researched what was being paid by third party payers and fixed prices in an accordance or used the information to establish a benchmark price. For supports with high labour involvement, additional work was undertaken by independent actuaries to work through the costs of service provision and the NDIA believe their hourly rate includes the cost of wages, salary on costs, the 5 Current October 2013

6 administration and other infrastructure costs plus a margin for the return to the provider. However, the data analysis underpinning the NDIA prices has not been released and NDS expects that some assumptions made do not reflect a complete understanding of existing pricing arrangements. NDS has urged the NDIA to review the approved prices and NDIA actuaries are currently examining additional information provided by NDS in relation to a number of current prices. Q. Will a provider be able to charge a higher price than the maximum price? If a provider is a Registered Provider of Supports and will be claiming a payment from the National Disability Insurance Agency (NDIA) through its Provider portal, the provider will not be able to charge a price higher than the maximum price. The NDIA will not permit a Registered Provider of Supports to request a co-payment from participants. Registered Providers are advised to read carefully the Terms of Business document which clearly states that Registered Providers are not permitted to add charges to the prices of the support including credit card surcharges. Q. What does a plan management provider do? Plan management describes the processes of organising the financial and administrative aspects of the plan, such as paying supplier invoices, developing service agreements with providers, assisting with the hiring and paying of staff, and preparing reports on how funds are being used. This is referred to as a financial intermediary function. A registered Plan Management Provider may be able to provide limited case management support and also assist and train the participant to take greater control of managing their supports. This is referred to as a service intermediary function. A provider can be registered for both management of funds under a participant s plan and for the delivery of other supports. In registering, the provider would need to demonstrate their management of any perceived conflict of interest in such cases and their suitability for the different requirements of the two roles. For more information about plan management providers refer to: disabilitycareaustralia.gov.au/providers/what-registered-plan-management-provider Q. As a plan manager, can I help a participant with hiring staff if they ask me to? The legislation allows a provider both to provide supports and be a Plan Management Provider managing all conflict of interest, of course. The National Disability Insurance Agency (NDIA) envisages two types of plan management providers: 6 Current October 2013

7 those who undertake the financial transactions for a participant those who source/supply the labour and then take responsibility for all the administrative arrangements with the providers and participants. The NDIA has priced the two types of services accordingly. Q. As a plan manager, do I lodge a claim for payment from the National Disability Insurance Agency (NDIA) or does the provider of the supports do this? This is an area that NDIA still needs to work through. It has been suggested that it could operate like this: The plan manager would pay invoices sent to them from the providers that the participant has chosen to deliver their supports. These invoices from providers will most likely be on 7 or 30 day terms, but the plan manager could make a legitimate claim to the NDIA for payment within 2 days based on the fact they have received an invoice for supports delivered. It is our understanding that the NDIA has not reached a definitive position on this process yet. Q. Does the plan manager become the plan nominee? No, a plan nominee is someone who is not paid to manage the plan. So if the plan manager is helping a participant coordinate services and what is included in the service agreement, they cannot sign the service agreement on behalf of the participant. It should be either the participant or their plan nominee. Q. As a plan manager, why would I need to provide a monthly statement to the participants of the expenses if DCA will be doing this as well? Wouldn t it be the same information? Yes, but as a plan management provider you need to demonstrate that you have an orderly accounting system for the supports you pay and coordinate. It is good business practice for a plan manager to supply monthly statements to participants. Q. Is there anything in the operational guidelines of the National Disability Insurance Agency (NDIA) that prevents a participant from having an immediate family member or a relative being employed as a paid support worker? The NDIA s position is that this is strongly discouraged, even in self-management situations. If a self-managing participant wants to employ a family member, the NDIA would still encourage them not to take on the role of employer and to have that family member join an organisation that can provide all the appropriate training, workers compensation cover, etc. Q: How will the National Disability Insurance Agency (NDIA) fund respite services for carers? Under the NDIA, the participant is always the person under 65 with a disability who 7 Current October 2013

8 is funded. So a carer, unless they too have a disability and meet the NDIA s access requirements, cannot be a NDIA participant in their own right. However, the NDIA recognises the vital role that respite plays and aims to support families and carers in their caring role. Recognition of support for carers is in fact a legislative requirement. The NDIA will do this through discussions in the planning process where they will identify supports for the participant that may have a direct or indirect benefit for the family and carer. These could include funding supports in the participant s plan such as: personal care for the participant to be delivered in their home or the community; overnight assistance to stay in a centre or group residence; supports to assist the participant enjoy social and community activities without relying solely on the family to provide this; assistance with daily living tasks to improve a participant s ability to do things around the home; supporting the participant to use employment services so that they can move to into work; specific training relating to the caring role that may help improve the family and carer s ability to provide care. In addition, there may be situations where the NDIA, taking into account what is reasonable to expect families, carers and informal networks to provide, may consider supports that maintain a carer s health and wellbeing. For example, they may fund a carer to participate in a support group or special interest network for a time limited period. It will be important for providers of traditional models of respite to think about how they will promote and engage participants to understand how the purchase of these supports benefit the individual, their family and carer. Q. What choice and flexibility will there be about what can be purchased with the funds? The participant s funding package may be divided into two parts. Some funds may be fixed so that they will need to be spent on specified supports such as equipment, home modifications or certain types of early intervention services. These will tend to be those services which are deemed necessary to ensure a participant s goal or outcome can be met, or require certain skills or qualifications of the provider of supports. Other supports will be prescribed in general terms and are deemed flexible. These supports will allow the participant greater flexibility in the purchasing of the types of supports they may want. Q. What types of supports and services will be funded? Only those supports and services that are deemed reasonable and necessary will be funded by the National Disability Insurance Agency (NDIA). This is determined using a set of criteria which take into account whether: 8 Current October 2013

9 the supports are effective and beneficial and are based on current good practice; the supports represent value for money; and what is reasonable to expect from family carers, other informal supports, and from community and mainstreams services. The NDIA has indicated that: where there are two options for support which would achieve the same outcome, they will fund the lower cost option; a support which reduces the cost of future or longer term supports for the participant is favoured over a support which results in the same or increased long term cost; the cost of the support must be comparable to the cost of the same support provided in the area where the participant resides; all the supports together must represent value for money; and increased independence including paid employment will result in cost offsets and scheme savings. For more detail on the NDIA Operational Guidelines on which supports are included in the plan refer to: Q. What types of supports and services will not be funded or provided? Supports that will not be funded include those that are: likely to cause harm to the participant or pose a risk to others; unrelated to the participant s disability; duplicated by other supports provided under alternative funding; part of the day-to-day living expenses that are incurred by the general public (eg rent, groceries, household bills) and not related to disability support needs; related to income replacement. The National Disability Insurance Agency (NDIA) has also made it clear that providers are not permitted to make claims for services and supports that are not delivered as a result of a cancellation or no show. Providers and participants are encouraged to enter into an agreement to clarify the arrangements that will prevail in these circumstances. Providers and participants should agree on the period of notification that is required if either party is unable to keep an appointment and what the terms of business are for the payment of any cancellation fees. Q. What happens in the situation of an emergency or crisis for a participant; how do additional supports get funded? When planners initially work with the participant to develop their plan, there may be a discussion about this as a possibility. If required, there will be an allocation of funding to assist with this included in the plan. This is more likely to be included within a participant s plan if they have a high level of informal supports. The NDIS Act allows for plans to be reviewed at any point that circumstances change. 9 Current October 2013

10 Q. How do providers receive payments? There are three main ways providers can be paid. If the National Disability Insurance Agency (NDIA) or a Plan Management Provider is managing the funds, the provider can either: 1. Make a claim online using the claim payment system (it is anticipated that payment will be made within two working days) or, 2. Send a paper invoice to the NDIA (payment made within 30 days). Where a participant self-manages the funding for their supports: 1. The participant will pay providers directly. The provider will need to ensure that the participant understands and agrees to the provider s terms of payment for any services delivered. For example, payment within 7, 14 or 30 days of receipt of invoice by cheque, EFT etc. For more detail about payments and claims refer to: Q. Is there funding for capital items such as equipment or buildings? The National Disability Insurance Agency (NDIA) will provide funding for capital items such as equipment and for vehicle/home modifications for participants who require them. They will not provide funds for the purchase of vehicles or houses. The benchmark prices that the NDIA has set for equipment items and home/ vehicle modifications can be found in the price guide, refer to: disabilitycareaustralia.gov.au/providers/pricing-and-payment-supports. Final prices paid to providers will be based on the receipt of approved supplier quotes. Currently, there is a high need for capital investment in affordable and accessible housing (to meet demand) and the NDIA will have to respond to this. Its preferred option would be to leverage housing investment from other sources. 10 Current October 2013

11 Monitoring and evaluation Q. What are the long term arrangements for ensuring quality service providers? At the start of the Launch, the National Disability Insurance Scheme (NDIA) will recognise the quality management systems currently in place within each jurisdiction (for service providers currently funded by state or territory governments to provide disability services and supports). Therefore, when first registering as a Provider of Supports, there will not be a requirement from the NDIA for the existing government-funded providers to prove they have a quality system in place. However, over the Launch period, the NDIA will develop a national quality system that will be used for the ongoing registration of providers of supports. Q. Can a Registered Provider use the National Disability Insurance Agency logo on their promotional material? This is not allowable under the Terms of Business that providers agree to when the register. Registered providers may identify their National Disability Insurance Agency registration by stating <Organization/person s name> is registered to provide supports for National Disability Insurance Agency participants. The National Disability Insurance Agency logo is not to be used by a provider in any publicity material. Contact Deborah Hoffman - NDIS Launch Coordinator National Disability Services Ph: deborah.hoffman@nds.org.au 11 Current October 2013