15. Reviewing and changing a participant’s plan
The information in this section relates to the ways in which a participant’s plan can be reviewed and changed.
A participant’s plan cannot be varied or amended (section 37(2)).
There are certain specific circumstances where the NDIA is required to create a new plan for a participant. When a new plan is created, it replaces the old plan with a new plan.
A new plan can be created in one of the following ways:
- by a participant changing their statement of goals and aspirations (section 47); or
- the NDIA conducting a review of a participant’s plan (section 48). A review of a participant’s plan can occur:
A scheduled plan review takes place when the NDIA reviews a participant’s plan as part of the normal planning cycle.
However, where the NDIA decides to review a participant’s plan at the participant’s request (i.e. following a request from a participant to review their plan because their circumstances have changed), or decides to review a participant’s plan earlier on its own initiative a process referred to as an unscheduled plan review will take place.
Importantly, the process for reviewing and changing a participant’s plan, described below, should not be confused with the separate process of “Review of Decisions”. See what is the difference between a plan review and an internal review?
When a participant requests a review of their plan it is important to determine the type of request being made (ie a request for a plan review or a request for an internal review of a decision–and the correct type of review to undertake (see determining the type of request being made).
15.1 Participant changes their statement of goals and aspirations
A participant may give the NDIA a changed version of their statement of goals and aspirations at any time (section 47(1)).
Generally, a participant would not be expected to change their statement of goals and aspirations until the review date specified in their plan. However, there may be circumstances where a participant chooses to change their statement of goals and aspirations, for example where a participant’s living arrangements, informal supports or overall goals change.
When a participant gives the NDIA a changed version of their statement of goals and aspirations the participant’s plan is replaced with a new plan consisting of:
- the changed version of the participant’s statement of goals and aspirations (section 47(2)(a)); and
- the statement of participant supports in the existing plan (section 47(2)(b)).
Therefore, whilst a participant may change their statement of goals and aspirations at any time resulting in the creation of a new plan, this process does not result in any change to the statement of participant supports.
A change to the participant’s statement of goals and aspirations does not automatically lead to a review of the plan. However, a changed statement of goals and aspirations may prompt the participant to request a review of the participant’s plan, or the NDIA to conduct a review on its own initiative.
The NDIA must provide a copy of the new plan to the participant with 7 days of receiving the changed version of the participant’s statement of goals and aspirations (section 47(3)).
15.2 Participant requests a review of their plan (Request for an unscheduled plan review)
A participant, or a participant’s plan nominee may request that the NDIA conduct a review of their plan at any time (section 48(1)).This generally occurs when a participant’s circumstances have changed and their current plan no longer meets their needs or they request a change to their plan management type.
However, a participant is not able to request that the NDIA conduct a review of their plan when their statement of participant of supports has been suspended (see what is the effect of suspending a participant’s plan? (section 41(c)).
Where a participant makes a request, the NDIA must decide whether or not to conduct the review within 14 days of receiving the request.
If the NDIA does not make a decision within this period, the NDIA will be taken to have decided not to conduct the review, and an internal review of that decision will automatically commence (sections 48(2) and 100(5)).
If a decision is made to review a participant’s plan, the NDIA must commence reviewing the participant’s plan within 14 days of deciding to conduct the review (section 48(3)).
The outcome of the review will then result in the NDIA preparing a new plan for the participant (section 49).
Generally, participant’s request for a review of their plan will not be accepted where:
- a participant is unable to demonstrate that their circumstances have changed to the extent required to warrant a change to their statement of participant supports. For example:
- there is minimal or no change , to a participant’s informal supports, living arrangements, disability or functional capacity; or
- a change to a participant’s financial circumstances alone does not warrant a review - e.g. a participant has sustained a large gambling loss, one of their parents has ceased employment, a taxi subsidy has been removed or their car has broken down and requires repairs.
- there is no new information available which is likely to affect the NDIA’s assessment of a participant’s needs. For example:
- there is no evidence from a therapeutic assessment warranting increased supports;
- the participant has had a change of mind regarding their desired supports following plan approval – For example, a participant wanting to attend a camp a provider has commenced advertising and organising \ after the commencement of their plan
- the participant advises they have been diagnosed with an additional disability but have not provided sufficient evidence of this disability; or
- the participant has not provided sufficient evidence to increase therapy supports or to fund the purchase f of additional assistive technology equipment;
- the request for review simply reflects the participant’s desire to have increased supports, or supports of a nature similar to other participants. For example:
- the participant is requesting additional funding as they have exhausted their budget on other flexible support categories in their plan;
- the participant is requesting new equipment such as an IPAD or a new therapy because they have become aware another participant has been funded for these supports;
- the participant has requested funding for activity costs such as swimming lessons be added to their plan without providing appropriate supporting evidence that this is reasonable and necessary or
- the participant’s requested funded supports do not relate to the participant’s goals.
- the request could be met by existing informal, community or mainstream supports. For example:
- a participant request to include funding for the cost of medical treatment, school fees or childcare; or
- there is a short term interruption to a participant’s informal support arrangements due to a carer’s illness but the participant’s support needs can be met via an alternative informal support person.
A decision by the NDIA not to review a participant’s plan is a reviewable decision (section 99(f)).
Therefore, the NDIA must notify a participant in writing of the decision not to review their plan, including a statement to the effect that the participant may request that the NDIA review the decision (section 100(1)).
15.2.1 Determining the type of request being made
It is important to note that, in some circumstances, it is unlikely that a participant will understand the difference between making a request to have their plan reviewed and the separate type of request they can make when they disagree with a decision and would like to have that decision reviewed (see what is the difference between a plan review and an internal review.
Occasionally it will unclear which type of review request is being made by a participant, or which type of review the NDIA should undertake. For example, a participant may simply ask for a ‘review’ without specifying the type of review they require. This is known as an “unspecified request for a review”. In other cases, a participant may request a ‘plan review’, however, in actual fact they are intending to request an internal review.
Where there is any doubt about the type of review a participant is requesting the NDIA will contact the participant to clarify the nature of their request and explain their options.
As a general rule, where a participant was generally satisfied with, an approved NDIA plan and subsequently makes an unspecified request for a review (for example, due to a change circumstances) this will indicate that a participant is requesting that the NDIA review their plan. In these circumstances, the NDIA will need to decide whether or not proceed to undertake a review of the participant’s plan.
However, where a participant is unhappy or dissatisfied with the NDIA’s decision to approve their plan and subsequently makes a request that their plan be reviewed, as a general rule, this will indicate that a participant is requesting an internal review of a decision.
Also, sometimes the timing of a request from a participant may provide an indication of the type of request being made, or the type of review being sought. For example, an unspecified request for a review made by a participant immediately after the participant receives a copy of their plan will, as a general rule, indicate that a participant is requesting an internal review of a decision.
If a request for a review is made three months after the date the participant received a copy of their plan, the NDIA is not able to proceed with an internal review (section 100(2)). In this circumstance, the participant will be limited to requesting the NDIA undertake a review of their plan.
Accordingly, if a participant requests a review of their plan within 3 months of the decision to approve their statement of participant supports, it will be important for NDIA staff to carefully determine, where necessary in consultation with the participant, whether the participant is requesting that the NDIA review their plan (usually because their circumstances have changed) or that the NDIA perform an internal review of the decision to approve their plan (because they are dissatisfied with that decision).
15.3 Participant’s plan reviewed at the initiative of the NDIA (unscheduled plan review)
The NDIA may decide to conduct a review of a participant’s plan at any time (section 48(4)).
A review of this kind is conducted at the initiative of the NDIA and is distinct from a review conducted because a participant has requested a review, or because the review date specified in the participant’s plan has arrived.
It may be appropriate for the NDIA to initiate a review of a participant’s plan when there are, or is expected to be, significant changes to a participant’s circumstances or where a significant event is expected to occur or has occurred. For example, a participant may commence paid employment for the first time which may make reviewing the supports under their plan appropriate or following an internal review of the decision where the original decision has been varied or set aside and a new decision substituted. Other examples include but are not limited to:
- adding Assistive Technology or home modifications or increases to therapy following an assessment;
- material error in the plan;
- an internal review of decision where a decision regarding supports in the plan is varied or set aside;
- quotes above benchmark for SIL ;
- corrections of system limiting errors; or
- review of circumstances following reporting of a Critical Incident.
The NDIA may also decide to initiate a review of a plan, where a participant changes their statement of goals and aspirations or in light of information received as part of its feedback and monitoring activities.
The information obtained from NDIA’s feedback and monitoring activities is intended to assist the NDIA to ensure plans meet intended outcomes and continue to be relevant to participants’ evolving needs. The NDIA’s feedback and monitoring strategies include feedback from participant’s (and other significant people in a participant’s life) about the quality and effectiveness of supports and outcomes under NDIS plans, monitoring expenditure of NDIS amounts and utilising the Local Area Coordinator network effectively.
Where the NDIA initiates a review of a participant’s plan, the NDIA must prepare a new plan for the participant as soon as is reasonably practicable (section 49).
If the participant does not wish to change their statement of goals and aspirations, the NDIA will use the participant’s existing statement when preparing the new plan.
15.4 Participant’s plan reviewed as part of the planning cycle
All participants will have a plan review date (or circumstance) specified in their plan by the NDIA (see setting the plan review date) (section 33(2)(c)).
The NDIA must conduct a review of a participant’s plan before the plan’s review date, and in the circumstances if any, specified by the plan (section 48(5)).
15.5 Requesting further information or reports for the purposes of reviewing a participant’s plan
For the purposes of reviewing a participant’s plan, the NDIA may request:
- that the participant, or another person, provide information that is reasonably necessary for the purposes of reviewing the participant’s plan (section 50(2)(a)); or
- that the participant do either or both of the following:
- undergo an assessment and provide to the NDIA the report of the person who conducts the assessment (section 50(2)(b)(i); or
- undergo a medical, psychiatric, psychological or other examination, conducted by an appropriately qualified person, and provide to the NDIA the report of the person who conducts the examination (sections50(2)(b(ii)).
The NDIA will only request further information or require a participant to undergo an assessment or examination where it is reasonably necessary for the purposes of reviewing a participant’s plan
Also, before requesting further information or requiring that a participant undergo an assessment or examination, the NDIA will review existing information. Where existing information is inadequate or inconsistent, for example where older assessments do not accurately reflect a participant’s current support needs, the NDIA will consider making one of the requests outlined above.
The NDIS Act does not specify a timeframe in which a participant must provide to the NDIA information or reports in response to one of the requests outlined above.
The NDIA may review a participant’s plan before all the information and reports requested above are received, but must give the participant a reasonable opportunity to comply with any request (section 50(3)).
Where it is expected that further information and/or reports requested from a participant are likely to take a long time to produce, the NDIA will consider finalising the review of the participant’s plan and then initiating a further review of the participant’s plan when the further information and/or report is received.
Where the NDIA has made a request that a participant undergo an assessment or examination, the NDIA will support the participant to comply with the request by providing assistance, including financial assistance where appropriate (section 6).
The NDIA will not reimburse participants for any costs associated with obtaining assessments or examinations which were not directly requested by the NDIA. For example, costs incurred relating to reports, assessments or examinations which were previously obtained for other incidental purposes.
15.6 What happens when a participant’s plan is reviewed?
Where the NDIA conducts a review of a participant’s plan, this will involve the NDIA developing a new plan for the participant having regard to the same matters, and using the same approach employed when preparing the existing plan.
However, reviews of a participant’s plan will often vary in complexity and length depending on the specific circumstances of a participant, and the circumstances which prompted the review.
For example, reviews may be complex in nature and require the NDIA to perform a new support needs assessment, including re-assessing risks and safeguards and considering whether the appointment of a new or different nominee is necessary.
Conversely, reviews can be brief and routine in nature. In these instances, a phone call from the NDIA may suffice as a review. For example, where a review is prompted because a participant has made a new plan management request, the plan review conducted by the NDIA may simply involve the NDIA giving effect to the participant’s plan management request, and preparing a new plan which reflects how the management of the funding for supports under the new plan will be managed.
The NDIA will also use the plan review process to evaluate a plan’s effectiveness in assisting the participant to move towards their individualised goals and aspirations.
15.7 What is the difference between a plan review and an internal review
A plan review is a process in which the NDIA performs a re-assessment of a participant’s support needs and prepares a new plan on behalf of the participant (section 48).
A plan review can take place:
- as part of the planning cycle (a scheduled plan review); or
- at any time, on the initiative of the NDIA (an Agency initiated unscheduled plan review); or
- at any time, where a participant requests a review ¬¬and the NDIA decides to conduct a review of the participant’s plan (an unscheduled plan review).
In each of the above situations, a new plan is prepared on behalf of a participant.
In an internal review of a decision an NDIA staff member who was not involved in the making of the original decision re-considers the facts, law and policy aspects of a decision and determines what the correct or preferable decision is. (Section 100). For more information, see internal review by the NDIA and the Operational Guideline on Review of decisions.
A reviewable decision is a decision made by the National Disability Insurance Agency (NDIA) which carries formal rights of review under the NDIS Act.
Decisions by the NDIA to approve a plan, or to refuse to review a plan are both reviewable decisions. However, there are many decisions under the NDIS Act which can be reviewed (see Which decisions can be reviewed).