NDIA Accountability Project

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When to refer the participant for an eligibility reassessment

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When to refer the participant for an eligibility reassessment

This article provides guidance for a local area coordinator, early childhood partner or planner delegate to:

  • consider an eligibility reassessment
  • complete an eligibility pre-check by reviewing available information
  • understand when to refer the participant for an eligibility reassessment.

Recent updates

3 October 2024

Guidance updated:

  • to reflect legislation changes from 3 October 2024
  • title has been updated from ‘Understand eligibility reassessment referral requirements’ to ‘When to refer the participant for an eligibility reassessment’
  • content from article Complete and eligibility reassessment referral, relating to referral decisions has been placed here
  • content on creating the case and contacting the participant has been moved to article Complete an eligibility reassessment referral.

Before you start

You have read and understood:

  • Our Guideline – Applying to the NDIS (external)
  • Our Guideline – Leaving the NDIS (external) section Are you still eligible for the NDIS?

Early childhood partners have read and understood articles:

  • EC: Guide – Check-in eligibility conversations for children younger than 6 with developmental delay

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  • EC: Guide – Evidence sources to demonstrate if an impairment is likely to be permanent for children who previously met access for developmental delay.

To learn more about leaving the NDIS read:

  • Our Guideline – Reviewing our decisions (external)
  • article Understand the leaving case.

Consider an eligibility reassessment

We may need to check a participant’s eligibility if information shows they may no longer be eligible, or their disability support needs, or situation has changed. We call this an eligibility reassessment. For more information see Our Guideline – Leaving the NDIS (external).

If the participant met disability requirements, we don’t need to check their eligibility at every plan reassessment. We only need to check if we get evidence they may no longer be eligible.

If the participant met the early intervention requirements, an automatic referral may be created.

Automatic eligibility reassessment referrals

An eligibility reassessment case will be generated automatically when the participant:

  • with developmental delay turns 6
  • with global development delay turns 7
  • who is eligible under the early intervention requirement has a primary impairment of hearing loss and turns 26.

If an automatic case has been generated, the participant’s my NDIS contact will be notified via the Omni-Channel to start an eligibility reassessment checklist. They will consider all information to determine if an eligibility reassessment is needed.

When completing an automatic referral, check for more information about the participant before completing the referral.

  1. Complete section Review evidence on the participant record.

  2. Complete section Review the participants original access decision and information.

  3. Then continue to article Complete an eligibility reassessment referral.

Manual eligibility reassessment referrals

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Sometimes you will need to manually create an eligibility reassessment referral. For example, if you receive a report from the participant’s treating professional that says their disability support needs have changed.

If the participant’s situation has changed and you think they need an eligibility reassessment, you can manually make an eligibility reassessment referral. This can take place:

  • as part of the plan reassessment process
  • at check-in
  • at any other time.

First you need to complete an eligibility pre-check to confirm whether you need to create an eligibility reassessment referral. Continue to section Complete an eligibility pre-check by reviewing available information.

Complete an eligibility pre-check by reviewing available information

Check the participant has received funding for 14 months

  1. Go to the participant’s Person Account.

  2. Go to the Account Timeline in the navigation pane.

  3. Find the first Plan Approval case in the Timeline.

    Note: this will usually be at the bottom of the list.

  4. Check the date of the Access Decision date. Is this more than 14 months ago?

    Note: If there is no date in PACE, check SAP CRM for this information. If:

    • Yes: continue to section Check for any open ER or Leaving cases.
    • No: the eligibility reassessment will not continue to be considered until after the participant has received NDIS funding for 14 months. It will remain in the Eligibility Reassessment Hold Queue until the 14 months are up. If you choose to continue with the referral, go to section Check for any open ER or Leaving cases.

Check for any open ER or Leaving cases

  1. Go to the participant’s Person Account, Cases tab.

  2. Check Open Cases for an existing:

    • Eligibility Reassessment case

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  • Leaving the NDIS case

  1. Is there an existing case in progress? If:

    • Yes: they cannot be referred for an eligibility reassessment. End of process.
    • No: continue to section Review evidence on the participant record.

Review evidence on the participant record

  1. Check all available information to make sure you give an accurate referral based on the participant’s current situation. Check:

    • any relevant documents on the participant’s record
    • medical, clinical, diagnostic or assessment reports
    • provider reports and assessments such as progress reports
    • early childhood partner documents
    • information from family members and carers, such as a carer impact statement.

    Note: You don’t need to ask the participant to give any new or additional information to pre-check eligibility.

Review the participants original access decision and information

The Decisions, Justifications and Evidence (DJE) framework of the Access Decision case records evidence used. It helps record decisions to meet the requirements of the participant service guarantee and the NDIS Act (2013).

  1. Go to the participant’s Person Account, Decisions tab.

  2. In the Decision Name column, select Access Decision.

  3. Review all information within the Details tab to understand how the participant met the access criteria for the NDIS.

  4. Go to the Decisions tab, and review all Justifications and sub-criterion decisions made for the access decision.

  5. Review all Evidence/explanation, read the type of evidence and documents recorded to support the access decision.

  6. In Sub-decisions, read the Decision Name and how the participant met the access criteria for the NDIS.

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  1. Has the participant’s support needs or circumstances changed? If:

    • Yes, continue to step 2.
    • No, they cannot be referred for an eligibility reassessment. End of process.

  2. Check whether the participant that met access under the disability requirements, now appears to no longer meet residence requirements, or no longer meet the disability and early intervention requirements. If:

    • Yes: continue to section Commence an eligibility reassessment referral.
    • No: they cannot be referred for an eligibility reassessment. End of process.

  3. Check whether the participant that met access under the early intervention requirements, and now they are likely to no longer meet residence requirements, or no longer meet the early intervention requirements, and now meet disability requirements. If

    • Yes, go to section Commence an eligibility reassessment referral.
    • No, they cannot be referred for an eligibility reassessment. End of process.

    Note: A participant can meet both the disability and early intervention requirements.

Commence an eligibility reassessment referral

  1. Create a new eligibility reassessment case using article Complete an eligibility reassessment referral.

Article topics and case names – internal use only

PACE user role names

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Topics

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Case names

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Version control

Version Amended by Brief Description of Change Status Date
1.0 CW0032 Class 2 approved APPROVED 2023-03-31
2.0 AGK382 Amended and re-approved for publication

Fixed formatting errors- inconsistent use of capitals and full stops for dot-points

Fixed typo for ‘participant’

Added steps for creating an eligibility reassessment case

Changed term ‘open’ case to ‘create’ case		 APPROVED 2023-04-07
3.0 ENM960 Class 1 approved APPROVED 2023-10-25
4.0 EMN960 Class 1 approved APPROVED 2024-04-09
5.0 JC0088 Class 2 approved

Removed instruction to create a community connections plan if the person is no longer eligible. Replaced with instruction to link the person with any additional community and mainstream supports.		 APPROVED 2024-05-21

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Version Amended by Brief Description of Change Status Date
6.0 JC0088 Class 3 approved.

Guidance updated to reflect legislation changes from 3 October 2024

Title updated from ‘Understand eligibility reassessment referral requirements’.

New content transferred to and from article: ‘Complete and eligibility reassessment referral’.		 APPROVED 2024-09-19

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