FOI 24/25-2381 DOCUMENT 4
Overview of Eligibility Reassessments
Monday, 3 February 2025
10:50 AM
The content of this document is OFFICIAL
This page contains the following guidance on Eligibility Reassessments:
• What is an Eligibility Reassessment?
• Is an eligibility reassessment just making another access decision?
• When should you commence an Eligibility Reassessment?
• When shouldn’t you commence an Eligibility Reassessment?
• When should you maintain the participant’s eligibility status?
• When should you change the participant’s eligibility status?
• When should you revoke the participant’s eligibility status?
• Can you commence or revoke a participant that met under the disability requirements?
• Can you commence or revoke a participant with a degenerative condition?
• What should I consider when assessing Early Intervention for a permanent impairment?
• Does functional information need to be from the last 12 months?
• Do early intervention recommendations need to be from the last 12 months?
• What do we consider ‘within 12 months’?
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What is an Eligibility Reassessment?
The Agency may reassess a participant’s eligibility if evidence suggests they may no longer be eligible for the NDIS. This could mean they no longer meet:
• the residence requirements, and/or
• the disability requirements and early intervention requirements.
This process is done through an Eligibility Reassessment. Eligibility Reassessments are a normal process undertaken by the Agency and can occur at any time.
More information on Eligibility Reassessments can be found in Our Guidelines: Leaving the NDIS > Are you still eligible for the NDIS? and subsection What happens if we check your NDIS eligibility?.
Is an eligibility reassessment just making another access decision?
While we need to be satisfied that the person meets the eligibility criteria, an eligibility reassessment decision is not the same as an access decision. At the time of the access decision, an access delegate has determined that the person met the eligibility requirements based on the evidence provided. This decision was made using a pre-access lens.
When you are making an eligibility reassessment decision you should be aware that the person is a current participant. This means they already have an approved plan, and are already receiving funded supports.
You should use a person-centred, holistic approach when completing an Eligibility Reassessment. This means starting with a point of view that the person has already been deemed eligible, and we’re reviewing the evidence to be satisfied that they continue to be eligible. Assess and interpret the evidence in a big-picture way by completing a broad review of a participant’s record to gain insight into their circumstances.
We need to consider evidence on a case-by-case basis. This means we need to consider each person’s individual circumstances. We must not take a one-rule-fits-all approach.
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When should you commence an Eligibility Reassessment?
You should only commence an Eligibility Reassessment if:
• the evidence indicates that the participant does not meet the residence and/or disability and early intervention requirements; or
• there is no information or insufficient information to determine if the participant meets the residence and disability or early intervention requirements.
Note: This may be applicable if the participant transitioned onto the Scheme from a Defined program (List C)
The reasons for commencing an Eligibility Reassessment should align with what is communicated to the participant. If an Eligibility Reassessment is commenced, the participant will be advised that they no longer meet the eligibility requirements based on the information we have. This will be communicated to the participant via their preferred communication method (e.g. phone call) and the commence letter (Letter – Eligibility reassessment – Opportunity to respond). Refer to call scripting in the article Contact to Advise Eligibility Check Outcome to assist your conversation.
When shouldn’t you commence an Eligibility Reassessment?
You should not commence an Eligibility Reassessment to allow participants to provide further evidence to:
• meet the disability and/or early intervention requirements for an additional impairment, when we have evidence they continue to meet the eligibility requirements for an existing impairment.
• change a participant’s eligibility status from early Intervention to disability, when there is existing evidence that they continue to meet the early intervention requirements.
Please note this is not an exhaustive list. Please refer to the section ‘When should you commence an Eligibility Reassessment?’ for guidance on when you should commence an eligibility reassessment.
If a participant has a degenerative condition, please refer to the section Can you commence or revoke a participant with a degenerative condition?
When should you maintain the participant’s eligibility status?
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You should maintain the participant’s status if the evidence indicates that the participant continues to meet the same eligibility requirements they previously met access for.
When should you change the participant’s eligibility status?
A participant who entered the NDIS may have evidence that they now meet different eligibility criteria from the criteria that they currently meet. You should change the participant’s eligibility status in the following scenarios:
• The participant’s current eligibility status is disability and now they meet for:
• early intervention
OR
• disability and early intervention
• The participant’s current eligibility status is early intervention and now they meet for:
• disability
OR
• disability and early intervention
• The participant’s current eligibility status is disability and early intervention and now they meet for either:
• disability
OR
• early intervention
When should you revoke the participant’s eligibility status?
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A decision to revoke a participant’s status can only be made at stage 2 (ER Outcome) of an Eligibility Reassessment. This is after the participant has been provided an opportunity to respond with more evidence about their NDIS eligibility. It is also necessary to check that manual procedural fairness has been followed. Refer to article Finalise an Eligibility Reassessment decision.
It is also important to be mindful that the decision made at stage 1 (Eligibility Check) to commence an eligibility reassessment may not have been in line with the evidence available on the record, the reason for the referral or the purpose of an eligibility reassessment. This means you should be checking why an eligibility reassessment referral was created, even if you are at the ER Outcome stage.
You should revoke the participant’s status at the ER Outcome stage if:
• the evidence indicates that the participant does not meet the residence and/or disability and early intervention requirements; or
• there is no information or insufficient information to determine if the participant meets the residence and disability or early intervention requirements.
Note: This may be applicable if the participant transitioned onto the Scheme from a Defined program (List C) and met the Disability requirements.
Can you commence or revoke a participant that met under the disability requirements?
If a participant was granted access under the disability requirements, a decision was made at initial access with the evidence provided that the individual is likely to require NDIS Supports for their lifetime. This means we would not expect their functional capacity to change.
Commencing an eligibility reassessment for a participant that met under the disability requirements (or disability and early intervention requirements) would only be appropriate if there is evidence:
• that the participant’s functional capacity has increased significantly to the point where they no longer meet the disability requirements,
• of a change in diagnosis that demonstrates the eligibility requirements are no longer met e.g. impairment is not likely to be permanent due to available and appropriate evidence-based clinical, medical or other treatments that would likely remedy the impairment, or
• the participant transitioned from a Defined program (List C) and there is no information or insufficient information to determine if they continue to meet the residence and disability or early intervention requirements.
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This also applies to participants with degenerative conditions. Please see the section Can you commence or revoke a participant with a degenerative condition?
Can you commence or revoke a participant with a degenerative condition?
For participants with degenerative conditions, such as Motor Neuron Disease, Multiple Sclerosis, Dementia, Parkinson’s, and Huntington’s Disease, their functional capacity is expected to decline. Therefore, it is unlikely that they will reach a point where they no longer require NDIS supports and be revoked from the Scheme.
Participants with degenerative conditions might enter the Scheme through early intervention rather than disability requirements. Early intervention may be more appropriate to help limit their functional decline and build capacity of the person’s carer, delaying the need for disability supports.
If a participant with a degenerative condition initially met the early intervention criteria, it might be appropriate to change their eligibility status to disability if their functional capacity has deteriorated and they now demonstrate a substantial reduction in functional capacity.
We should only be commencing an eligibility reassessment for a participant with a degenerative condition under exceptional circumstances. This would include evidence demonstrating:
• that the participant’s functional capacity has increased significantly to the point where they no longer meet the eligibility requirements (disability or early intervention).
• a change in diagnosis that demonstrates the eligibility requirements are no longer met e.g. impairment is not likely to be permanent due to available and appropriate evidence-based clinical, medical or other treatments that would likely remedy the impairment.
It is recommended you seek technical support if you are considering commencing an eligibility reassessment for a participant with a degenerative condition.
What should I consider when assessing Early Intervention for a permanent impairment?
When assessing Early Intervention, you should consider the guidance that is available in the Access and ER Practice Guide which is available in the Access Assessor OneNote.
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The following dot points can be found under the section for 25(1)b:
• Does the evidence contain specific recommendations for early intervention, and indicate that this intervention will mean the participant needs less disability supports in the future?
• Does the evidence note which specific supports the participant will no longer require should early intervention be undertaken?
• Does the evidence indicate that early intervention is likely to result in greater independence for the participant?
• If the participant has accessed intervention before, is the outcome noted? Did previous intervention reduce their need for disability related supports?
• Is the recommended support of a functional nature, or capacity building in nature?
In answering the above questions, does the evidence contain sufficient information addressing:
• How the participant’s impairment is likely to impact them over time?
• What supports the participant will require if they don’t receive intervention?
• What supports the participant currently requires, and what supports (if any) the participant is likely to require after intervention?
Keep in mind that at least some recommendations that meet the rest of the Early Intervention criteria must be considered ‘NDIS Supports’. To find out more about NDIS Supports you can go to the NDIS website page What does the NDIS fund?
Does functional information need to be from the last 12 months?
According to the Applying to the NDIS Guidelines section, How do we weigh evidence of disability?, information on how a person’s impairment impacts their functional capacity should generally be from within the last 12 months. This is because a person’s functional capacity may change over time, even if their impairment doesn’t. However, it is not a requirement for functional information to be within 12 months for participants undergoing eligibility reassessment.
If the participant:
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• met access under the disability requirements (or disability and early intervention requirements), refer to section Can you commence or revoke a participant that met under the disability requirements?
• has a degenerative condition, refer to section Can you commence or revoke a participant with a degenerative condition?
Do early intervention recommendations need to be from the last 12 months?
According to the Applying to the NDIS Guidelines section, How do we weigh evidence of disability?, recommendations for early intervention generally need to be from within the last 12 months. This is because a participant’s functional capacity may change over time – even if their impairment does not. It’s important that we have evidence of current circumstances to ensure we understand a person’s support needs.
If the participant has a degenerative condition, refer to section Can you commence or revoke a participant with a degenerative condition?
What do we consider ‘within 12 months?’
“Within 12 months” refers to the period from the date the evidence was signed, or in the case of an assessment, the date the assessment was completed, up to the date you are making your eligibility reassessment decision. This timeframe does not consider the date the information was uploaded into the business system or when the ER referral was created.
Created with OneNote.
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