DOCUMENT 4 FOI 24/25-1284
OFFICIAL For Internal Use Only
Case Management Guide Access for Chronic Health Conditions
Category Reference Documents Title Access for Chronic Health Conditions 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 External Review Branch.
Scope For the purposes of this guidance document, chronic health conditions refer to a broad range of chronic National Strategic
(longstanding) and complex health conditions. Some | Framework for Chronic examples of common chronic conditions reported on | Conditions | DOHAC by the Australian Institute of Health and Welfare are arthritis, asthma, back pain, cancer, cardiovascular About chronic conditions
disease, chronic obstructive pulmonary disease, | DOHAC diabetes. NDIA policy The ART process is often seen as stressful and NDIA Dispute Resolution on this subject | adversarial by participants and prospective Policy participants of the Scheme. The NDIA will adopt a Appendix B to the Legal participant-focused approach to resolving disputes Services Directions 2017
before the ART, and will work directly with participants and prospective participants to provide better and earlier outcomes, where possible. Sections 24 and 25 of
The role of the NDIA is to assist the ART in reaching the National Disability the correct and preferable decision, including by Insurance Scheme Act assisting participants and prospective participants in 2013
reaching the best possible resolution by agreement. Rules 5, 6 and 7 of the
To be eligible for access to the Scheme on the basis National Disability
. ngs . : : Insurance Scheme of a chronic health condition, an applicant’s chronic ; _ health condition must satisfy the disability (Becoming a Participant) Rules 2016
requirements. A chronic health condition satisfies the disability requirements if: Operational Guideline —
e itis caused by an intellectual, cognitive, Applying for the NDIS
neurological, sensory, psychological, or Eligibility and medical physical impairment; and conditions FAQ | NDIS
e itis likely to be permanent; and e it substantially reduces an applicant’s functional capacity; and
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FOI 24/25-1284 OFFICIAL For Internal Use Only
Case Management Guide
Access for Chronic Health Conditions
Category
Reference Documents
e it affects an applicant’s ability to work, study or take part in their social life; and e an applicant will likely need the support of the Scheme for the remainder of their life. Alternatively, an applicant will be eligible for access to the Scheme if they satisfy the early intervention requirements on the basis of their chronic health condition, meaning: e the chronic health condition is likely to be permanent; e early intervention supports are likely to reduce the need for need future supports; e the early intervention needed is an NDIS support. NDIA posture | It is important that each matter is determined on its Inquiry report - Disability in relation to own merit, based on the available evidence. There is | Care and Support | this subject not a blanket ‘yes’ or ‘no’ response to the question of | Productivity Commission whether individuals with chronic health conditions Council of Australian should be permitted access to the Scheme. The Governments (COAG) — response will primarily rely on whether the Scheme IS | Drinciples to determine the most appropriate system to fund an individual’s responsibilities of the disability support needs. NDIS and other service Case Managers must ensure that where the access systems matter involves chronic health conditions that Case Management mandatory TAPIB advice is requested. Guide — Access to the NDIS Evidence To consider an applicant’s eligibility to access the recommended | Scheme, the NDIA requires recent evidence from a Providing evidence of to inform health care professional which confirms an our disability | NDIS NDIA position | applicant’s disability, its impacts on the applicant’s in a matter functional capacity, previous treatments, and Types of disability before the outcomes, as well as future treatment options and evidence | NDIS ART expected outcomes. Administrative Review It is important that the health care professional giving | Lbunal Guideline on evidence is the most appropriate person to provide _| Persons Giving Expert that evidence, and that they have treated the and Opinion Evidence applicant for a significant period of time. NDIA-ERB-GDE-007-FINAL OFFICIAL Page 2 of 4
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FOI 24/25-1284 OFFICIAL For Internal Use Only
Case Management Guide
Access for Chronic Health Conditions
Field Category Reference Documents Notices of From 1 January 2025, all new participants will receive | Section 32BA of the Impairment a Notice of Impairment. National Disability Insurance Scheme Act The Notice of Impairment sets out the categories of 2013 impairment(s) for which the participant meets the — disability or early intervention requirements. Frequently asked ; a questions about For a detailed descriptions of each of these legislation — Notice of categories of impairment(s), please refer to the Case Impairments (s 32BA) | Management Guide: Access to the NDIS. NDIS Other To satisfy the access requirements, a participant’s considerations | chronic health condition must be evidenced to substantially reduce their functional capacity. Section 24(1)(c) of the The NDIA will not fund supports for chronic health National Disability conditions that are unrelated to a participant’s Insurance Scheme Act disability. For example, the NDIA may approve 2013 access to the Scheme on the basis of a limb Rule 5.8 of the National amputation as a result of peripheral arterial disease Disability Insurance within the setting of diabetes but will not fund Scheme (Becoming a supports related to the treatment or management of Participant) Rules 2016 peripheral arterial disease or diabetes. Where a participant’s primary or secondary disability results in | Eliaibility and medical difficulty managing a chronic health condition, support | £20ditions FAQ | NDIS with this may be considered as a Disability Related Health Support. Previous The determination of the AAT regarding whether an matters that applicant’s chronic health condition satisfies the CKJW and National may inform requirements for access to the Scheme will usually Disability Insurance the NDIA turn on the question of a substantial reduction in an | Agency [2021] AATA position applicant’s functional capacity. 3983 The test is not whether or not the chronic health Mulligan and National condition is significant, but whether or not the Disability Insurance legislative requirements for access are met on the Agency [2015] AATA 974 balance of the available evidence. Nika and National In each of these cases, the AAT affirmed the decision | Disability Insurance under review on the basis that the AAT was not Agency [2021] AATA satisfied that the applicants’ chronic health condition | 2127 substantially reduced their functional capacity. NDIA-ERB-GDE-007-FINAL OFFICIAL Page 3 of 4
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FOI 24/25-1284
OFFICIAL For Internal Use Only
Case Management Guide
Access for Chronic Health Conditions
Document Control Responsible Person Date
Document author Continuous Improvement May 2025
Document approver Director, Policy, Continuous Improvement 19 May 2025 NDIA-ERB-GDE-007-FINAL OFFICIAL Page 4 of 4
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