DOCUMENT 1

Eligibility Reassessment Recommencement Phase 2 – Frequently Asked Questions

Tuesday, 8 April 2025

Please note: Question 1, 2 and 6 have been removed, as related to holding bay process (now not used). Question 3 has been removed to align with System updates.

Q4: What do I do if the evidence of functional capacity is older than 24 months?

Note: Age of evidence is only relevant for evidence of functional capacity. Evidence of a permanent impairment can be of any age.

Our Guidelines How do we weigh evidence of disability? explain that 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.

Q5 If I am making an ER stage 1 decision, from which date do I consider whether the evidence of functional capacity is older than 12 months?

It is 12 months from the date the Eligibility Reassessment Assessor makes the proposed decision to maintain or change the participant’s access status, or commence an eligibility reassessment. This means if you are making a stage 1 decision today, you will count back 12 months from today.

The date the information was uploaded into the business system or the date the ER referral was created have no bearing on considering whether the evidence of functional capacity is older than 12 months.

This information can be found under AA OneNote > ER Decision Support > Overview of Eligibility Reassessments. This is answered in the final question on that page.

Q7 How should I consider functional capacity evidence from a Treating Health Professional in conjunction with information in a participant’s plan?

When you are considering evidence of functional capacity from a Treating Health Professional (THP) alongside information in participant’s plan, you should look at the evidence from the THP first. THPs are qualified to assess and provide evidence regarding a participant’s functional capacity. Their clinical expertise and direct engagement with the participant form the foundation of any reliable assessment of functional capacity.

If the evidence from the THP is unclear, you should then look at the participant’s record to build a broader picture.

It’s important to remember that a planner’s decision on whether or not to include a support in a participant’s plan isn’t based on whether they agree or disagree with the THP’s substantial reduction in functional capacity (SRFC) recommendation. Planners will make a decision on whether or not to fund a support, and the extent to which it is funded, based on factors such as whether the reasonable and necessary supports criteria are met, including it being an NDIS support and that it is value for money.

Therefore, you should always consider the evidence from the THP first before looking at the participant’s record.

Q8 Evidence from Treating Health Professional states the participant has a Substantial Reduction in Functional Capacity, but the plan utilisation is low in areas such as capacity building supports. What do I do?

You should always look at the evidence from the Treating Health Professional (THP) first. THPs are qualified to assess and provide evidence regarding a participant’s functional capacity. If the evidence from the THP is unclear, you should then look at the participant’s record to build a broader picture. Some useful places to view on the record are other documents on file or the information in My Profile tab located on the participant’s Person Account, including the About Me, the Goals and the Informal Community and Mainstream Supports (ICM Supports) tabs.

It is important to remember that plan utilisation is not always an indication of whether or not the participant has a substantial reductional in functional capacity (SRFC). A participant not utilising supports in their current or previous plans should not automatically be interpreted as evidence that the supports are no longer required. There can be a variety of reasons why capacity building supports were not accessed, such as difficulty finding a suitable provider, long waits, long hospital stays, personal circumstances, or a lack of support to coordinate or understand how to implement the plan. These barriers do not reflect a lack of need but rather challenges in access or execution of these supports. In these situations, we must be cautious not to infer the participant’s current functional capacity based on plan usage data or the absence of specific support requests.

Our role is to consider the evidence provided by qualified professionals such as a THP and not only rely on plan usage or outcomes as indicative of a participant’s capacity where evidence from their THP appears to be in conflict.

Therefore, you should always consider the evidence from the THP first before looking at the participant’s record.

FOI 24/25-2261 DOCUMENT 2

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’?

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.

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?

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?

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.

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.

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:

• 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.

FOI 24/25-2261	DOCUMENT 3	OFFICIAL	2.1
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Contact to advise Eligibility Check outcome

This article provides guidance for an access delegate (assessor) to:

• contact the person to notify them of the Eligibility Check outcome.
• record the contact attempts.

Recent updates

July 2025

• Updated to reflect that a person can meet under early intervention or disability requirements, or both.
• Clarified that when communicating the date that a revocation decision is made, this will be 28 days from the date the decision is made, or from their plan reassessment date, whichever is earlier.
• Updated talking points to allow for ability to be able to grant an evidence extension during the first call attempt at the eligibility check stage.

Before you start

You have read and understood:

• Our Guideline - Applying to the NDIS including section: What happens after we decide?

• Our Guidelines - Leaving the NDIS including section:

  • Are you still eligible for the NDIS?

• guide Conversation style guide

• article Check a participant’s preferred contact method

• article Log an activity or internal note.

You have:

• followed article Maintain or change eligibility criteria at the Eligibility Check stage or article Commence an Eligibility Reassessment.

Create the Call task

If the decision outcome of the Eligibility Check is:

1. To commence an eligibility reassessment:

   • a Contact with Participant task will auto-generate in the Eligibility Reassessment case. You do not need to create a new Task.
   • go to section Contact Participant.

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• an eligibility criteria change, you need to create a contact Task. To do this, complete the following:

  • In the Person Account, select the Cases tab.
  • Select the Cases sub-tab and select the down-arrow next to All Cases.
  • Select the relevant Eligibility Reassessment case.
  • In the Eligibility Reassessment case: Select the Case Activity tab.
  • In Open Activities, select New Task.
  • Select General Task and select Next.
  • In Activity Type select Internal Note.
  • In Subject select Call.
  • Select Save.
  • go to section Contact Participant.

Contact Participant

Before contacting a person, you must first check their preferred communication method and authorisations. Read the article Check a participant’s preferred contact method for more information.

Required contact attempts

You must attempt to call the person about the outcome of their Eligibility Check, even if the person’s preferred communication method is not phone.

The only time you won’t call is if:

• the person has requested no phone calls (for example, they are Deaf and have requested we communicate with them in writing), or
• they have not provided a phone number.

If the above do not apply, attempt to contact the participant, nominee, or child representative.

Contact attempts for an eligibility criteria change

If your decision for an Eligibility Check is an eligibility criteria change, you must:

• make the call attempt on the day of the decision.
• make 1 contact attempt.

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• leave a message if you reach voicemail and the person identifies themselves, asking they contact the NDIA on 1800 800 110.

Contact attempts for a Commence decision

If your decision for an Eligibility Check is to commence an eligibility reassessment, you must:

• make the first call attempt when you reach the Additional information step in the Eligibility Check tab and before you complete the step.
• make any subsequent call attempts after completing the Additional information step in the Eligibility Check tab.
• make 3 contact attempts (over a 2-day period, at different times of day).
• leave a message if you reach voicemail and the person identifies themselves, asking they contact the NDIA on 1800 800 110.
• repeat call attempts until all required attempts to the participant or authorised representatives have been completed.

Before making the call

Refer to article Send an SMS in PACE to send an SMS alert before making a call attempt.

Making the Call

When making the call, make sure you follow the guidelines in the NDIS Conversation style guide.

If the call is successful, you will need to:

• Introduce yourself and confirm if this is a suitable time for the call.
• Perform a security check to verify you’re speaking to the correct person. For more information, refer to section How to complete a security check in article Consider a request for personal information.

Talking points for an eligibility criteria change outcome

You must help the participant understand that they joined the NDIS under early intervention requirements, or disability requirements, or both, and you’ve decided they now meet either:

• the early intervention requirements

• the disability requirements

• both the early intervention and disability requirements

  Explain:

• What the early intervention and disability requirements are, using Our Guideline – Applying to the NDIS.

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• Why their eligibility requirements have changed and how the evidence and information you used shows this.
• Their My NDIS contact will contact them if any changes are needed to current NDIS supports.
• How to connect with their My NDIS contact if they have questions about their plan or funding.

Talking points for commencing an eligibility reassessment

You must help the person understand why the NDIS is reconsidering their eligibility.

To do this, explain:

• that you are calling to discuss their NDIS eligibility.
• the NDIS invests in people with a disability to build capacity based on their individual goals. Some people achieve their goals and leave the NDIS with our support.
• we reconsider eligibility requirements at plan reassessments and at other times, like when a person’s circumstances change.
• that a person must continue to meet the residence requirements as well as either disability or early intervention requirements, or both, to remain a NDIS participant. If there is information that a person may no longer meet the eligibility requirements, or if there is not enough information to determine their ongoing eligibility, we need to do an Eligibility Reassessment.
• you have reviewed all information/evidence on their record.
• you have found that there is insufficient evidence that the participant continues to meet the eligibility criteria.
• a decision has not yet been made – they are being given an opportunity to explain why they think they continue to meet the requirements and, if they would like, respond with evidence.
• You must help the participant understand what happens next.

To do this, explain:

• they will receive a letter which explains what eligibility criteria they currently do not meet.
• if they do not wish to respond with evidence, we will use the evidence we already have to decide if they are eligible.
• we will decide if they are eligible in 90 days.
• they can continue to use their plan throughout the eligibility reassessment.

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• if a revocation decision is made, it will take effect 28 days from the date the decision is made, or from their plan reassessment date, whichever is earlier.
• if a revocation decision has taken effect, they will no longer have access to NDIS funds to purchase NDIS supports.
• their My NDIS contact can support them with their community connections and assistance throughout the eligibility reassessment process.
• if the participant or their authorised representative advise that they no longer require NDIS supports and would like to leave the NDIS, refer to article Progress a voluntary leaving request during an eligibility reassessment.
• if during the first contact attempt and the participant or their authorised representative request more time to respond, go to section Talking points for more time requested to respond.
• if during the second or third contact attempt, the participant or their authorised representative request more time to respond, refer to Create and action an Evidence Extension request.

Talking points for more time requested to respond

If the participant or their authorised representative request more time to respond during the first contact attempt, follow the instructions below to determine the next steps.

If the extension request is:

1. reasonable and up to an additional 28 days:

   • confirm the extension and advise the due date will reflect on their Eligibility reassessment - Opportunity to respond letter
   • go to section Record contact attempts.

2. reasonable but is for longer than 28 days, explain:

   • you will lodge their request for consideration
   • you are unable to provide a decision on the request for more time during this call
   • the due date for them to provide evidence will display on their Eligibility reassessment - Opportunity to respond letter
   • if the extension request is approved, this will reflect on the due date in the letter
   • if the extension request is declined, they will receive a follow up call to explain this and the due date in the letter will still provide them with 90 days to respond
   • if they have any evidence to support their request, they are encouraged to email it to enquiries@ndis.gov.au
   • go to section Record contact attempts.

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3. unreasonable and either within or outside 28 days, explain:

   • the request to extend their time to respond is not yet active
   • they can request an extension of time to respond by sending an email to enquiries@ndis.gov.au or calling 1800 800 110
   • they will need to provide evidence for their extension request
   • they can request an evidence extension by following these steps at any time up until their current due date
   • go to section Record contact attempts.

Record contact attempts

After attempting to contact the person (successfully or not), you must log an activity to record this. Follow guidance in article Log an activity or internal note.

Record the contact attempt using the relevant template:

Eligibility Criteria Change

Unsuccessful contact attempt

Phone call attempt made to <Participant/Authorised Representative> on all available numbers, to advise them that the participant’s eligibility criteria has been changed from <early intervention/ disability/ both disability and early intervention> to <early intervention/ disability/ both disability and early intervention>.

Call not answered.

Successful contact attempt

Phone call made to <Participant/Authorised Representative> to advise them that a decision has been made to update their eligibility criteria based on the available evidence. Participant’s eligibility criteria has been changed from <early intervention/ disability/ both disability and early intervention> to <early intervention/ disability/ both disability and early intervention>.

.

Commence Eligibility Reassessment

Unsuccessful contact attempt

Eligibility Reassessment commenced on .

<First/second/third> phone call attempt made to <Participant/Authorised Representative> on all available numbers to advise that the participant may no longer be eligible and we are providing an opportunity to respond.

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Call not answered.

Successful first contact attempt

Eligibility Reassessment Commenced on .

Phone call made to <Participant/Authorised Representative> to advise that they may no longer be eligible and are being provided with an opportunity to respond.

.

<If applicable: Participant/ Authorised representative> requested an additional to provide evidence.

Request for more time to respond <granted/ declined> in Eligibility Check tab. <Participant/ Authorised representative> notified that their due date to respond will display on their Opportunity to respond letter.

<Participant/ Authorised representative> advised they can request an evidence extension any time up until their due date. Information provided on how to request an evidence extension.

Successful second or third contact attempt

Eligibility Reassessment Commenced on .

Phone call made to <Participant/Authorised Representative> to advise that they may no longer be eligible and are being provided with an opportunity to respond.

.

Complete the Call task

Once you have completed all required contact attempts, or you have made contact:

1. In the Eligibility Reassessment case: Select the Case Activity tab.

2. Under Open Activities, if the outcome is:

   • eligibility criteria change, select the Call task
   • to commence an eligibility reassessment, select the Contact with Participant task

3. Select Edit.

4. At Activity Type select Internal Note.

5. If all call attempts are:

   • unsuccessful, copy and paste the final Unsuccessful contact attempt template from the Activity Log into the Comments field.
   • successful, copy and paste the relevant Successful contact attempt template from the Activity Log into the Comments field.

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6. Under Additional Information: In the Status field, select Completed from the drop-down options.

7. Select Save. The task is now closed.

Next steps

The next steps will depend on the outcome of the Eligibility Reassessment case and your call attempt/s:

If you have submitted an Eligibility Criteria Change, the MyNDIS contact will be notified of the change and consider any changes which may be needed to the participant’s plan. No further action is required.

If you have commenced an eligibility reassessment, and you have made your:

• first contact attempt — return to article Commence an Eligibility Reassessment, section Additional information to continue progressing the case.

• second or third contact attempt — return to article Commence an Eligibility Reassessment, section Next Steps.

Version control

Version	Amended by	Brief Description of Change	Status	Date
1.0	CHO0026	New instructions for completing contact attempt/s for eligibility checks.	APPROVED	2024-01-16
2.0	CHO0026	Updates to incorporate legislation changes while ER case remains unchanged in system.	APPROVED	2024-10-02
3.0	CHO0026	Class 2 Approval	APPROVED	2025-03-06
4.0	CHO0026	Class 2 Approval	APPROVED	2025-05-20
5.0	LXO0144	Class 2 approval	APPROVED	2025-07-04

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Finalise Eligibility Reassessment decision

This article provides guidance for an access delegate to:

• complete a manual procedural fairness check.
• consider if eligibility requirements are met.
• complete a review of submitted evidence for an eligibility reassessment (ER).
• complete the initial steps required to progress the ER Outcome tab for an ER that has previously been commenced.

Recent updates

July 2025

• Changed the wording of certain system questions to align with the July system updates to the Eligibility Reassessment case.
• Expanded the scenarios in which a Change eligibility criteria decision can be submitted to reflect that a participant can meet both early intervention and disability.
• Switched the Disability and Early Intervention questions around as Early Intervention will always appear first.
• Added a note under Progress ER Outcome tab to note that both Early Intervention and Disability should be assessed in all instances, even if the participant continues to meet one or the other criterion.
• Removed the instruction to add an internal note regarding the current version of the NDIS Act. As the wording of the questions now reflects the current legislation, this is no longer required.

Before you start

You have read and understood:

• Our Guideline - Applying to the NDIS including section: What happens after we decide?
• Our Guidelines - Leaving the NDIS including section:

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• Are you still eligible for the NDIS?
• article Understand procedural fairness for eligibility reassessments

You have:

• accepted an Eligibility Reassessment case and completed the procedural fairness checklist in PACE.
• followed the steps in Accept a case from an Eligibility Reassessment queue and been instructed to go to this knowledge article.

Check for an ongoing ART case

An ER decision cannot progress while there is an ongoing Administrative Review Tribunal (ART) case for any NDIA decision (including planning decisions). Active ART cases will be noted as an Alert in PACE or in SAP-CRM.

1. Check if the participant has an account in SAP-CRM.

2. If the participant:

   • does not have an account in SAP-CRM – go to step 5.
   • has an account – go to step 3.

3. From the Participant NDIS Account Screen, check for active Alerts relating to an ART case.

4. If there is:

   • an alert indicating an ART case (it will be recorded as the previously used name Administrative Appeals Tribunal (AAT)) – refer to your Team Leader.

     Note: Your Team Leader will discuss the case with the ART case manager to determine if the ER can be progressed.

   • no alert – go to step 5

5. In PACE, review Alerts on the Person Account

   Note: Active alerts should automatically populate when you enter a record and can also be viewed under Activity tab > Alerts History.

6. If the participant:

   • does not have an active ART case – go to section Review the Eligibility Check tab.

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• has an active ART case – refer to your Team Leader.

  Note: Your Team Leader will discuss the case with the ART case manager to determine if the ER can be progressed.

Review the Eligibility Check tab

1. Navigate to the Referral tab within the Eligibility Reassessment case. This tab outlines:

   • why the Eligibility Reassessment case was created.

2. Navigate to the Eligibility Check tab. This tab outlines:

   • why the previous access delegate progressed the Eligibility Reassessment case.
   • the eligibility criteria the participant has been given an opportunity to provide further evidence for to demonstrate they continue to meet the eligibility requirements.

3. If the Referral or Eligibility Check tabs indicate the participant may not meet the:

   • residence requirements – assess the residence, disability and early intervention criteria.
   • disability and early intervention requirements – assess the disability and early intervention criteria.

Check for outstanding evidence

It is important to review all evidence relating to eligibility to ensure you are making an accurate decision.

1. Refer to article Check for outstanding evidence related to eligibility to complete the following actions:

   • action relevant emails in the Enquiries and NAT inboxes,

   • add and link evidence to the Eligibility Reassessment case under the Documents tab (if applicable),

   • action the Enquiry case (if applicable), and

   • review relevant evidence in SAP CRM.

     Note: You do not need to transfer documents from SAP CRM to PACE.

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Note: For new evidence you will need to verify the details of any health care professional through AHPRA. Follow the Knowledge Article Check treating professional details for more details.

Link evidence to case

Existing evidence in SAP CRM does not need to be linked to the PACE account or Eligibility Reassessment case. However, all evidence on the person’s PACE account that is related to an ER decision must be added and linked in:

• Person Account > Documents
• Eligibility Reassessment case > Documents

Note: This includes any relevant emails from the Enquiries and NAT inboxes.

1. Link evidence to Eligibility Reassessment case > Documents. Refer to Add documents to a case, section Link documents to a case.

   Note: This will not be applicable if outstanding evidence has been added to Eligibility Reassessment case > Documents.

Consider if eligibility requirements are met

During an ER, it is the participant’s responsibility to provide evidence that they continue to meet the eligibility requirements. If we do not have clear evidence that the person continues to meet all eligibility criteria, their eligibility needs to be reassessed.

Note: The current version of the NDIS Act 2013 applies to all ER Outcome decisions made on or after 3 October 2024, regardless of when the ER was referred.

At the ER Outcome stage of an ER, there are three possible decisions:

• maintain the participant’s eligibility criteria, or
• change the participant’s eligibility criteria, or
• revoke the participant’s eligibility status.

1. Determine the ER Outcome decision:

   • Maintain the participant’s status if the participant:

     o meets the residence requirements (if assessed)

     AND

     o the disability and/or early intervention requirements that reflect their current PACE eligibility status

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AND

o   does not have a primary disability that is a chronic health condition and is not receiving or requiring palliative or end-of-life care; or

o   has a primary disability that is a chronic health condition or is receiving or requiring palliative or end-of-life care, and you confirmed Technical Advice and Practice Improvement Branch (TAPIB) advice was obtained at the point of access or you obtained mandatory TAPIB advice to support maintaining the participant’s status.

    **Note:** Decisions for participants who are living with terminal illness must only be completed by delegates in the Priority Health Access Team. If TAPIB advice is required, refer to Create a technical advice case.

• Change the participant’s eligibility criteria if the participant:

  o meets the residence requirements (if assessed)

  AND

  o the participant’s current eligibility status is different from their current criteria.

  **Note:** This includes any of the following scenarios. The participant's current eligibility status is:
  *   **disability** and now they meet for **early intervention** OR **disability and early intervention**
  *   **early intervention** and now they meet for **disability** OR **disability and early intervention**
  *   **disability and early intervention** and now they meet for either **disability** OR **early intervention**

  AND

  o does not have a primary disability that is a chronic health condition and is not receiving or requiring palliative or end-of-life care; or

  o has a primary disability that is a chronic health condition or is receiving or requiring palliative or end-of-life care, and you obtained mandatory TAPIB advice to support a change in eligibility criteria.

  **Note:** Decisions for participant’s who are living with terminal illness must only be completed by delegates in the Priority Health Access Team. If TAPIB advice is required, refer to Create a technical advice case.

• Revoke the participant’s status if:

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o   the participant does not meet the residence and/or disability and early intervention requirements; or

o   there is no information or insufficient information to determine if the participant meets the residence and disability or early intervention requirements

AND

o   the NSW Prescribed Program exception does not apply (relevant to the residence requirements under 23(1)b only).

    **Note:** The current version of the **NDIS Act 2013** should be applied for all ER Outcome decisions regardless of when the ER was commenced.

Complete a manual procedural fairness check

The activities listed below must be completed prior to finalising a revocation decision to ensure procedural fairness. If you are not revoking the participant’s status, go to section Progress ER Outcome tab.

Check correspondence

1. Check:

   • the letter was sent to the participant or authorised representative to notify them about the ER.
   • the participant was given at least 90 days + the number of days for which an access delegate has previously granted an extension, from the date of the letter to provide information.

2. You can view the letter by completing the following steps:

   • For participants: Go to Person Account > Documents. Select the relevant letter to view.
   • For participants with a correspondence nominee (including most children): Go to Person Account > Relationships > Authorised Reps. Select the representative’s name. This will open the representative’s Person Account. Select the Documents tab and select the relevant letter to view.

3. If the letter has not been sent to the participant or authorised representative, follow the steps outlined in the Missed steps process page of the AA OneNote. .

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Check contact attempts

1. Check if sufficient attempts were made to contact the participant or their representative when the ER commenced by going to the open Eligibility Reassessment Case > Case Activity > Activity History.
2. If one or more phone call attempts have not been completed, follow the steps outlined in the Missed steps process page of the AA OneNote.

Check for outstanding enquiries

1. Check if the participant has any outstanding ER enquiries.

   • Go to Person Account > Cases > Cases > All Cases
   • In the Case Record Type column, check for any open Enquiry cases created after the ER was commenced.

2. If there are any outstanding ER enquiries, ensure they are actioned before proceeding.

Check evidence extension requests

1. Check if the participant has any outstanding evidence extension requests.

   • Go to Person Account > Cases > All Cases

   • In the Case Record Type column, check for evidence extension request by reviewing Enquiry and Evidence Extension cases created after the ER was commenced.

     Note: NCC may create Enquiry cases for Extension Requests.

2. If there are any outstanding evidence extension requests, ensure they are actioned before proceeding.

Progress ER Outcome tab

1. Navigate to the ER Outcome tab in the Eligibility Reassessment case.

   Note: Ensure that you are confident in your final decision and enter it accurately into the ER Outcome tab. Do not select Back at any point. Selecting Back may prevent the case from progressing. If you need to make changes to the decision after you have entered it into the ER Outcome tab, do not select Back. Instead, contact your Team leader for support.

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Note: A participant can meet the eligibility requirements for both Early Intervention and Disability. You will need to answer either Yes or No to all Section 24 and 25 questions, regardless of if they continue to meet either Section 24 or 25.

Impairment Assessment

1. At Does the reassessment impairment belong to list A, B, or D? select the relevant option from the dropdown list.
2. Select Next.

Residence Section 23 Sub Criterion

Residence Sub Criterion 1: Section 23(1)(a)

1. At Is there evidence that the participant does not live in Australia? select the relevant option from the dropdown list. Note: If the Eligibility Check or Referral tabs indicated the participant may not meet the residence requirements, select Yes or No. Otherwise, select N/A.

Residence Sub Criterion 2: Section 23(1)(b)

1. At Is there evidence that the participant is not an Australian citizen, permanent resident or from a NSW Prescribed Program? select the relevant option from the dropdown list.

   Note: If the Eligibility Check or Referral tabs indicated the participant may not meet the residence requirements, select Yes or No. Otherwise, select N/A.

2. Select Next.

Early Intervention Section 25 Sub Criterion view:

All eligibility criteria sections must be answered. If selected No for any criteria, select the correct justification from the dropdown options.

Note: If section 25(1)(a) is not met, then the remaining criteria will not be met.

Early Intervention Section 25 Sub Criterion 1: Section 25(1)(a)

1. At The participant has one or more identified intellectual, cognitive, neurological, sensory or physical impairments that are, or are likely to be permanent; or one or more identified impairments that are attributable to a psychiatric condition that are, or are likely to be, permanent select Yes or No.

   Note: If you answer Yes, sub criteria 2, 3, and 4 will not appear.

Early Intervention Section 25 Sub Criterion 2: Section 25(1)(a)

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1. At The participant is a child under 6 with a delay that is attributable to a mental and/or physical impairment select Yes or No.

Early Intervention Section 25 Sub Criterion 3: Section 25(1)(a)

1. At The delay results in substantially reduced functional capacity in one or more major life activities select Yes or No.

   Note: If the participant is over the age of 6, do not select N/A as this will cause Early Intervention to display as N/A on the summary screen. Instead, select No.

Early Intervention Section 25 Sub Criterion 3: Section 25(1)(a)

1. At The delay results in the need for an individual transdisciplinary approach over an extended period select Yes or No.

   Note: If the participant is over the age of 6, do not select N/A as this will cause Early Intervention to display as N/A on the summary screen. Instead, select No.

Early Intervention Section 25 Sub Criterion 5: Section 25(1)(b)

1. At Early intervention supports are likely to benefit the participant by reducing their future need for supports in relation to disability select Yes or No.

Early Intervention Section 25 Sub Criterion 6: Section 25(1)(c)

1. At Early intervention supports are likely to benefit the participant by alleviating the impact, preventing deterioration or improving functional capacity of the participant’s impairment or by strengthening the sustainability of informal supports select Yes or No.

Early Intervention Section 25 Sub Criterion 7: Section 25(1)d

1. At Are any early intervention supports, that would be likely to benefit the person as mentioned in paragraphs 25(1)b and c, NDIS supports? select Yes or No.
2. Select Next.

Disability Section 24 Sub Criterion

All eligibility criteria sections must be answered. If you select No for any criteria, select the correct justification from the dropdown options.

Note: If section 24(1)(b) is not met, then the remaining criteria will not be met.

Disability Sub Criterion 1: Section 24(1)(a)

1. At The participant has a disability attributable to one or more intellectual, cognitive, neurological, sensory or physical impairment, or to one or more impairments attributable to a psychiatric condition select Yes or No.

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Disability Sub Criterion 2: Section 24(1)(b)

1. At the impairment or impairments are permanent, or are likely permanent select Yes or No.

Disability Sub Criterion 3: Section 24(1)(c)

1. At The impairment, or impairments (when combined) result in a substantial reduction in functional capacity select Yes or No.

Disability Sub Criterion 4: Section 24(1)(d)

1. At The impairment or impairments affects the participant’s social and/or economic participation select Yes or No.

Disability Sub Criterion 5: Section 24(1)(e)

1. At The participant is likely to require lifetime supports under the NDIS select Yes or No.
2. Select Next.

Sub Criterion and Overall Criteria Summary

The following questions will automatically be completed with Met, Not Met, or N/A:

• Does the person meet Residency Criteria
• Does the person meet Disability Criteria
• Does the person meet Early Intervention Criteria
• Overall Criteria

1. If the decision is:

   • not correct, contact your team leader for support.
   • correct, select Next.

Next Steps

If your decision is to:

• Maintain or Change the participant’s status – go to article Maintain or change eligibility criteria at the ER Outcome stage.
• Revoke the participant’s status – go to article Complete a revocation during an eligibility reassessment.

Version Control

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Version	Amended by	Brief Description of Change	Status	Date
1.0	CH0026	Class 2 approval	APPROVED	2023-12-15
2.0	CHO0026	Class 2 approval	APPROVED	2024-01-16
3.0	CH0026	Class 2 approval	APPROVED	2024-04-17
4.0	GMQ132	Class 2 approval	APPROVED	2024-06-27
5.0	CHO0026	Class 2 approval	APPROVED	2024-10-02
6.0	CHO0026	Class 2 approval	APPROVED	2024-11-29
7.0	CHO0026	Class 2 approval	APPROVED	2025-03-06
8.0	LXO144	Class 2 approval	APPROVED	2025-07-04

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Access and Eligibility Reassessment (ER) Practice Guide

The content of this document is OFFICIAL.

This guide assists the National Access Team (NAT) to assess new applicants’ eligibility and determine if existing participants remain eligible for the National Disability Insurance Scheme (NDIS).

This guide is designed to be used with the Access and Eligibility Reassessment (ER) Decision Tree to make legislatively correct access decisions.

1. Recent updates

What’s changed

Date	What’s changed
October 2022	This is a new resource

2. Checklist

Topic	Checklist
Pre-requisites	You have read:

Q Section 21, 22, 23, 24 and 25 of the National Disability Insurance Scheme Act 2013

Q NDIS Becoming a Participant Rules 2016

QO Operational Guidelines - NDIS

You are working through:

U) Access and ER Decision Tree | | Actions | Q 3. Are you making an Access or ER decision

QU) 4. Access — Age Requirements

QO) 5. Access — Residence Requirements

QO) 6. Access — Streamlined Decisions

QO) 7. Access — Disability Requirements

Q) 8. Access — Early Intervention Requirements

OU 9. ER— Residence Requirements |

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Checklist

Topic	Checklist
	QO 10. ER— Streamlined Decisions

QO) 11. ER— Disability Requirements

QO 12. ER— Early Intervention Requirements

W 13. Related procedures or resources

Q 14. Feedback

Q 15. Version control |

3. Are you making an Access or ER decision?

For Access decisions, go to Section 4. Access — Age Requirements

For ER decisions, go to Section 9. ER - Residence Requirements

4. Access — Age Requirements

4.1 Does the applicant meet the age requirements?

Legislation

Section 22 Age requirements

A person meets the age requirements if the person was aged under 65 when the access request in relation to the person was made.

When is this criterion considered met?

This criterion is considered met if evidence on the record shows:

• the applicant was aged under 65 when their access request was received as valid (that is, complete); or
• the applicant is non-defined and their data was received by the NDIA prior to their 65th birthday.

Applicants that meet the age requirements	Go to Section 5.1 Does the applicant meet the residence requirements?
Applicants that do not meet the age requirements	Are not eligible for disability or early intervention support from the NDIS.

Please follow the process in SOP - Finalise Access Not Met Decision |

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5. Access – Residence Requirements

5.1 Does the applicant meet the residence requirements?

Legislation

Section 23 Residence requirements

(1) A person meets the residence requirements if the person: (a) resides in Australia; and (b) is one of the following: (i) an Australian citizen; (ii) the holder of a permanent visa; (iii) a special category visa holder who is a protected SCV holder.

(2) In deciding whether or not a person resides in Australia, regard must be had to: (a) the nature of the accommodation used by the person in Australia; and (b) the nature and extent of the family relationships the person has in Australia; and (c) the nature and extent of the person’s employment, business or financial ties with Australia; and (d) the nature and extent of the person’s assets located in Australia; and (e) the frequency and duration of the person’s travel outside Australia; and (f) any other matter relevant to determining whether the person intends to remain permanently in Australia.

When is this criterion considered met?

This criterion is considered met if evidence on the record shows the applicant:

• lives in Australia for most of the year; and
• is an Australian Citizen; or
• is the holder of a permanent visa; or
• is the holder of a protected Special Category Visa (SCV)

Applicants that meet the residency requirements	Go to Section 6.1 - List A
Applicants that do not meet the residency requirements	Are not eligible for disability or early intervention support from the NDIS.

Please follow the process in SOP - Finalise Access Not Met Decision |

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6. Access – Streamlined Decisions

6.1 List A

Where an applicant has been diagnosed with a condition on List A they will meet the disability requirements without further assessment (unless there are an document integrity issues pending investigation).

Note: A person does not need to have a condition on List A to become a participant of the NDIS.

For further information, refer to Our Guidelines - Do you meet the disability requirements?

Applicants under the age of 7

| Applicants that have a condition on List A | Meet the disability requirements.

Please follow the process in SOP - Finalise Access Met Decision | |—|—| | Applicants that do not have a condition on List A | Go to Section 6.3 - List D |

Applicants aged 7 and over

| Applicants that have a condition on List A | Meet the disability requirements.

Please follow the process in SOP - Finalise Access Met Decision | |—|—| | Applicants that do not have a condition on List A | Go to Section 6.2 - List B |

6.2 List B

Where an applicant has been diagnosed with a condition on List B, they will be considered to have a disability attributable to one or more impairments that is, or is likely to be, permanent without further assessment.

For applicants diagnosed with a condition on List B, you will only need to assess whether the applicant:

• has substantially reduced functional capacity to perform one or more activities;
• is affected in their capacity for social or economic participation; and

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• is likely to require support under the NDIS for their lifetime.

Note: A person does not need to have a condition on List B to become a participant in the NDIS.

For further information, refer to Our Guidelines - Is your impairment likely to be permanent?

For applicants under the age of 7

Applicants that have a condition on List B	Go to Section 8.3 - Does the applicant meet Section 25(1)(b)?
Applicants that do not have a condition on List B	Go to Section 8.1 - Does the applicant meet Section 25(1)(a)?

For applicants aged 7 and over

Applicants that have a condition on List B	Go to Section 7.3 - Does the applicant meet Section 24(1)(c)?
Applicants that do not have a condition on List B	Go to Section 7.1 - Does the applicant meet Section 24(1)(a)?

6.3 List D

Where a child under the age of 7 has been diagnosed with a condition on List D, they will meet the early intervention requirements without further assessment.

Note: A child does not need to have a List D condition to become a participant of the NDIS.

For further information, refer to Our Guidelines - Do you need early intervention?

For applicants under the age of 7

| Applicants that have a condition on List D | Meet the early intervention requirements.

Please follow the process in SOP - Finalise Access Met Decision | |—|—| | Applicants that do not have a condition on List D | Go to Section 8.1 - Developmental Delay |

6.4 0-25 Hearing Impairments

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An applicant meets the early intervention requirements without further assessment if they:

• are aged between birth and 25 years of age; and
• have confirmed results from a specialist audiological assessment (including electrophysiological testing when required) consistent with auditory neuropathy or hearing loss ≥ 25 decibels in either ear at 2 or more adjacent frequencies, which is likely to be permanent.

What to consider

This streamlined access approach for early intervention acknowledges a rich body of evidence that recognises that early intervention supports up to and including the age of 25 is critical for people with hearing impairment as the developing brain requires consistent and quality sound input and other support over that period to develop normally and ameliorate the risk of lifelong disability.

This same body of evidence suggests that brain development and language capability have been achieved by the age of 26. Therefore, adults aged 26 years and over are not immediately accepted to be likely to benefit from the same early intervention approach because there is no requirement to support the development of the auditory pathways. Adults aged 26 years and over with hearing impairment will therefore be assessed normally, on a case-by-case basis, having regard to the availability of all relevant evidence.

For further information, refer to Our Guidelines - What about people aged between 0 and 25 with a hearing impairment?

For applicant aged under 7

| Applicants that meet the hearing impairment criteria | Meet the early intervention requirements.

Please follow the process in SOP - Finalise Access Met Decision | |—|—| | Applicants that do not meet the hearing impairment criteria | Go to Section 6.2 - List B impairments |

For applicants aged 7 and over

| Applicants that meet the hearing impairment criteria | Meet the early intervention requirements.

Please follow the process in SOP - Finalise Access Met Decision | |—|—|

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Applicants that do not meet the hearing impairment criteria	Go to Section 8.2 - Does the applicant meet Section 25(1)(a)?

7. Access – Disability Requirements

7.1 Does the applicant meet Section 24(1)(a)?

Legislation

Section 24 Disability requirements

(1) A person meets the disability requirements if:

(a) the person has a disability that is attributable to one or more intellectual, cognitive, neurological, sensory or physical impairments or the person has one or more impairments to which a psychosocial disability is attributable

…

When is this criterion considered met?

This criterion is considered met if evidence on the record shows:

• the applicant has a disability (a reduction or loss in their ability to do things); and
• their disability is caused by an impairment (a loss or significant change in their body’s functions or structure, or how they think and learn); and
• the impairment is intellectual, cognitive, neurological, sensory, or physical in nature.

Note: Where an applicant has been diagnosed with a List A or List B condition, they will meet this criterion without further assessment.

What to consider

• Does the evidence demonstrate both that the applicant has an impairment, and that the impairment is resulting in a disability?
• Does the evidence demonstrate that the applicant is reduced in their ability to do things, however this reduction cannot be reasonably attributed to an impairment?
• Does the evidence demonstrate that the applicant has a loss or significant change in one of their body’s functions or structure, or in how they think and learn; however, there is no indication that this is causing a reduction or loss in their ability to do things?

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Note: A diagnosis is not required to meet this criterion: if the evidence shows the person has a disability caused by a relevant impairment, then they will meet 24(1)(a) – this is because we assess based on the impairment/functional impact.

For further information, refer to Our Guidelines - Is your disability caused by an impairment?

Applicants under the age of 7

Applicants that meet Section 24(1)(a)	Go to Section 7.2 - Does the applicant meet Section 24(1)(b)?
Applicants that do not meet Section 24(1)(a)	Are not eligible for disability or early intervention support from the NDIS.

Please follow the process in SOP - Finalise Access Not Met Decision |

Applicants aged 7 or over

Applicants that meet Section 24(1)(a)	Go to Section 7.2 - Does the applicant meet Section 24(1)(b)?
Applicants that do not meet Section 24(1)(a)	Go to Section 6.4 - 0-25 Hearing Impairments

7.2 Does the applicant meet Section 24(1)(b)?

Legislation

Section 24 Disability requirements

(1) A person meets the disability requirements if:

(b) The impairment or impairments are, or are likely to be, permanent

…

When is this criterion considered met?

This criterion is considered met if evidence on the record shows the applicant has a:

• permanent impairment; or
• likely permanent impairment.

Note: Where an applicant has been diagnosed with a List A or List B condition, they will meet this criterion without further assessment.

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What to consider

• Does the evidence demonstrate that the applicant has completed all available and appropriate treatment options, and that there are no recommended treatment options likely to remedy the impairment?
• Does the evidence contain recommendations for treatments which have not been demonstrated to have been explored?
• Does the evidence indicate that the applicant requires further treatment, and that this treatment has some prospect of success?
• Does the evidence demonstrate that the applicant requires ongoing treatment, but that it is for maintenance purposes only?
• Does the evidence demonstrate that the impairment is degenerative in nature, and that treatment will not improve the impairment?

In answering the above questions, does the evidence contain sufficient information addressing:

• What treatments have been undertaken and what were the outcomes?
• If there are evidence-based treatments not undertaken, why were they considered and deemed unsuitable?
• What further/ongoing treatments have been recommended and what are the expected outcomes of these treatments?

For further information, refer to Is your impairment likely to be permanent? | NDIS

Applicants under the age of 7

Applicants that meet Section 24(1)(b)	Go to Section 7.3 - Does the applicant meet Section 24(1)(c)?
Applicants that do not meet Section 24(1)(b)	Are not eligible for disability or early intervention support from the NDIS.

Please follow the process in SOP - Finalise Access Not Met Decision |

Applicants aged 7 and over

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Applicants that meet Section 24(1)(b)	Go to Section 7.3 - Does the applicant meet Section 24(1)(c)?
Applicants that do not meet Section 24(1)(b)	Are not eligible for disability or early intervention support from the NDIS.

If they do not meet this criterion, they automatically do not meet Section 25(1)(a).

Please follow the process in SOP - Finalise Access Not Met Decision |

7.3 Does the applicant meet Section 24(1)(c)?

Legislation

Section 24 Disability requirements

(1) A person meets the disability requirements if:

(c) The impairment or impairments result in substantially reduced functional capacity to undertake one or more of the following activities: The impairment or impairments result in substantially reduced functional capacity to undertake one or more of the following activities:

    (i) communication;

    (ii) social interaction;

    (iii) learning

    (iv) mobility

    (v) self-care

    (vi) self-management

…

When is this criterion considered met?

This criterion is considered met if evidence on the record shows the permanent impairment, or permanent impairments combined, results in substantially reduced functional capacity in one or more of the following activities:

• Communication: how they speak, write or use sign language and gestures.
• Social interaction: how they make and keep friends, interact with the community, and cope with feelings and emotions in social situations.

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• Learning: how they learn, understand and remember new things, and practise and use new skills.
• Mobility: how they move around home and the community and how they get in and out of bed or a chair.
• Self-care: how they partake in personal care, hygiene, grooming, eating and drinking, and health.
• Self-management (if older than 6): how they organise their life, make decision, solve problems and manage money.

Note: When an applicant has been diagnosed with a List A condition, they will meet this criterion without further assessment.

What to consider

• Does the evidence demonstrate that the applicant is unable to participate effectively or completely (i.e., across the whole or majority of tasks) in one or more activities, without formally prescribed equipment?
• Does the evidence demonstrate that the applicant is unable to participant effectively or completely in one or more activities, and usually requires the assistance of another person?
• Does the evidence demonstrate that the applicant would be unsafe to complete one or more tasks required to participate in an activity without formally prescribed equipment or assistance from another person?
• Does the evidence indicate that the applicant is able to participate in each activity effectively by using commonly used items?
• Does the evidence indicate that the applicant is able to participate in each activity effectively, albeit more slowly or in a different way?
• Would completing tasks more slowly or in a modified way, or using commonly used items, relieve the applicant’s need for personal assistance?

In answering the above questions, does the evidence contain sufficient information addressing:

• What specific tasks the applicant cannot complete without support?
• Why the applicant requires support?

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• How often the applicant requires support, and what that support looks like?

For further information, refer to Our Guidelines - Does your impairment substantially reduce your functional capacity?

Applicants under the age of 7

Applicants that meet Section 24(1)(c)	Go to Section 7.4 - Does the applicant meet Section 24(1)(d)?
Applicants that do not meet Section 24(1)(c)	Are not eligible for disability or early intervention support from the NDIS.

Please follow the process in SOP - Finalise Access Not Met Decision |

Applicants aged 7 and over

Applicants that meet Section 24(1)(c)	Go to Section 7.4 - Does the applicant meet Section 24(1)(d)?
Applicants that do not meet Section 24(1)(c)	Go to Section 6.4 - 0-25 Hearing Impairments

7.4 Does the applicant meet Section 24(1)(d)?

Legislation

Section 24 Disability requirements

(1) A person meets the disability requirements if:

(d) The impairment or impairments affect the person’s capacity for social or economic participation.

When is this criterion considered met?

This criterion is considered met if evidence on the record shows the permanent impairment, or permanent impairments combined, affects the applicant’s social or economic participation.

Note: Where an applicant has been diagnosed with a List A condition, they will meet this criterion without further assessment.

What to consider

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• Does the evidence demonstrate that the applicant’s social participation (e.g., their capacity to play sport, go to the movies, see friends, etc.) is affected by their permanent impairment/s - in any way?
• Does the evidence demonstrate that the applicant’s economic participation (e.g., their capacity to travel, to find or maintain voluntary or paid work, etc.) is affected by their permanent impairment - in any way?
• Does the evidence demonstrate that the applicant’s social and economic participation is not impacted in any way, and that they can fully engage without any assistance?

For further information, refer to Our Guidelines - Does your impairment affect your social, work or study life?

Applicants under the age of 7

Applicants that meet Section 24(1)(d)	Go to Section 7.5 - Does the applicant meet Section 24(1)(e)?
Applicants that do not meet Section 24(1)(c)	Are not eligible for disability or early intervention support from the NDIS.

Please follow the process in SOP - Finalise Access Not Met Decision |

Applicants aged 7 and over

Applicants that meet Section 24(1)(d)	Go to Section 7.5 - Does the applicant meet Section 24(1)(e)?
Applicants that do not meet Section 24(1)(d)	Go to Section 6.4 - 0-25 Hearing Impairments

7.5 Does the applicant meet Section 24(1)(e)?

Legislation

Section 24 Disability requirements

(1) A person meets the disability requirements if:

(e) The person is likely to require support under the National Disability Insurance Scheme for the person’s lifetime.

When is this criterion considered met?

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This criterion is considered met if evidence on the record shows the applicant:

• will require the support of the NDIS for their lifetime; or
• is likely to require the support of the NDIS for their lifetime.

Note: Where an applicant has been diagnosed with a List A condition, they will meet this criterion without further assessment.

What to consider

• Does the evidence demonstrate that the applicant is likely to require disability supports that are not clinical in nature, and that focus on their functional ability, for their lifetime?
• Does the evidence demonstrate that the applicant will likely be substantially reduced in their functional capacity (in a relevant activity) for their lifetime, despite any interventions?
• Are there any recommendations for interventions that are likely to improve the applicant’s functional capacity, and reduce their future need for disability related supports?
• If the applicant is a child or young adult, does the evidence indicate that significant functional improvements can be expected - either as they develop, or through interventions?
• Does the applicant’s need for support relate to a health condition, and is that support more appropriately funded by the health system?

For further information, refer to Our Guidelines - Does your impairment affect your social, work or study life?

Applicants under the age of 7

| Applicants that meet Section 24(1)(e) | Meet the disability requirements.

Please follow the process in SOP - Finalise Access Met Decision | |—|—| | Applicants that do not meet Section 24(1)(e) | Are not eligible for disability or early intervention support from the NDIS.

Please follow the process in SOP - Finalise Access Not Met Decision |

Applicants aged 7 and over

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| Applicants that meet Section 24(1)(e) | Meet the disability requirements.

Please follow the process in SOP - Finalise Access Met Decision | |—|—| | Applicants that do not meet Section 24(1)(e) | Go to Section 6.4 - 0-25 Hearing Impairments |

8. Access - Early Intervention Requirements

For children under the age of 7 they are first assessed against the early intervention criteria. If they do not meet, then assess them against the disability requirements.

For applicants aged 7 or above, only assess their eligibility for early intervention supports if they have not met the disability requirements.

Before you commence the assessment, you must ensure the applicant meets both the age requirements and residency requirements.

8.1 Developmental Delay

Legislation

Section 25 Early intervention requirements

(1) A person meets the early intervention requirements if: (a) the person: (iii) is a child with who has developmental delay

Section 9 Definitions

Developmental delay means a delay in the development of a child under 6 years of age that:

(a) is attributable to a mental or physical impairment or a combination of mental and physical impairments; and

(b) results in substantial reduction in functional capacity in one or more of the following areas of major life activity:

(i) self-care;

(ii) receptive and expressive language;

(iii) cognitive development;

(iv) motor development; and

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(c) results in the need for a combination and sequence of special interdisciplinary or generic care, treatment or other services that are of extended duration and are individually planned and coordinated.

When is this criterion considered met?

This criterion is considered met if evidence on the record shows the child is younger than 6 on the day we determine they have developmental delay.

For further information, refer to Our Guidelines - What about children younger than 6 with developmental delay?

| Applicants that meet the Developmental Delay criteria | Meet the early intervention requirements.

Please follow the process in SOP - Finalise Access Met Decision | |—|—| | Applicants that do not meet the Developmental Delay criteria and do not have a hearing impairment | Go to Section 6.2 - List B | | Applicants that do not meet the Developmental Delay criteria and have a hearing impairment | Go to Section 6.4 - 0-25 Hearing Impairments |

8.2 Does the applicant meet Section 25(1)(a)?

Legislation

Section 25 Early intervention requirements

(1) A person meets the early intervention requirements if:

(a) the person:

    (i) has one or more identified intellectual, cognitive, neurological, sensory or physical impairments that are, or are likely to be, permanent; or

    (ii) has one or more identified impairments to which a psychosocial disability is attributable and that are, or are likely to be, permanent

…

When is this criterion considered met?

This criterion is considered met if evidence on the record shows:

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• the applicant has an impairment (a loss or significant change in their body’s functions or

  structure, or how they think and learn); and

• the impairment is intellectual, cognitive, neurological, sensory, or physical in nature; and

• the impairment is, or is likely to be, permanent.

Note: When an applicant is diagnosed with a condition on List B or List D, they meet this

criterion without further assessment.

What to consider

• Does the evidence demonstrate that the applicant has completed all available and

  appropriate treatment options, and that there are no recommended treatment options likely

  to remedy the impairment?

• Does the evidence contain recommendations for treatments which have not been

  demonstrated to have been explored?

• Does the evidence indicate that the applicant requires further treatment, and that this

  treatment has some prospect of success?

• Does the evidence demonstrate that the applicant requires ongoing treatment, but that it is

  for maintenance purposes only?

• Does the evidence demonstrate that the impairment is degenerative in nature, and that

  treatment will not improve the impairment?

In answering the above questions, does the evidence contain sufficient information addressing:

• What treatments have been undertaken and what were the outcomes?

• If there are evidence-based treatments not undertaken, why were they considered and

  deemed not suitable?

• What further/ongoing treatments have been recommended and what are the expected

  outcomes of these treatments?

For further information, refer to Our Guidelines - Do you need early intervention?

Applicants aged under 7

Applicants that meet Section 25(1)(a)	Go to Section 8.3 - Does the applicant meet Section 25(1)(b)?

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| Applicants that do not meet Section 25(1)(a) | Are not eligible for early intervention.

You will now assess them against the disability requirements.

Go to Section 7.1 - Does the applicant meet Section 24(1)(a)? | | :— | :— |

Applicants aged 7 and over

Applicants that meet Section 25(1)(a)	Go to Section 8.3 - Does the applicant meet Section 25(1)(b)?
Applicants that do not meet Section 25(1)(a)	Are not eligible for disability or early intervention
support from the NDIS.

Please follow the process in SOP - Finalise Access Not Met Decision |

8.3 Does the applicant meet Section 25(1)(b)?

Legislation

Section 25 Early intervention requirements

(1) A person meets the early intervention requirements if:

(b) the CEO is satisfied that provision of early intervention supports for the person is
     likely to benefit the person by reducing the person’s future needs for supports in
    relation to disability

…

When is this criterion considered met?

This criterion is considered met if evidence on the record shows that early intervention supports for the applicant’s permanent impairment/s will reduce their need for disability-related supports in the future.

Note: If an applicant has been diagnosed with a condition on List D, they meet this criterion

without further assessment.

What to consider

• Does the evidence contain specific recommendations for early intervention, and indicate

  that this intervention will mean the applicant needs less disability supports in the future?

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• Does the evidence note which specific supports the applicant 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 applicant?

• If the applicant 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 applicant’s impairment is likely to impact them over time?

• What supports the applicant will require if they don’t receive intervention?

• What supports the applicant currently requires, and what supports (if any) the applicant is

  likely to require after intervention?

For further information, refer to Our Guidelines - How will early intervention help you?

For applicants aged under 7

Applicants that meet Section 25(1)(b)	Go to Section 8.4 - Does the applicant meet Section 25(1)(c)?
Applicants that do not meet Section 25(1)(b)	Are not eligible for early intervention.

You will now assess them against the disability requirements.

Go to Section 7.1 - Does the applicant meet Section 24(1)(a)? |

For applicants aged 7 and over

Applicants that meet Section 25(1)(b)	Go to Section 8.4 - Does the applicant meet Section 25(1)(c)?
Applicants that do not meet Section 24(1)(c)	Are not eligible for disability or early intervention
support from the NDIS.

Please follow the process in SOP - Finalise Access Not Met Decision |

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8.4 Does the applicant meet Section 25(1)(c)?

Legislation

Section 25 Early intervention requirements

(1) A person meets the early intervention requirements if:

 (c) the CEO is satisfied that provision of early intervention supports for the person is
     likely to benefit the person by:

        (i) mitigating or alleviating the impact of the person’s impairment upon the functional
        capacity of the person to undertake communication, social interaction, learning,
        mobility, self‑care or self‑management; or

         (ii) preventing the deterioration of such functional capacity; or

          (iii) improving such functional capacity; or

      (iv) strengthening the sustainability of informal supports available to the person,
       including through building the capacity of the person’s carer.

…

When is this criterion considered met?

• This criterion is considered met if evidence on the record shows early intervention supports will help the applicant by:

• addressing the impact of their impairment on their ability to move around, communicate,

  socialise, learning, look after themselves, or organise their life

• preventing their functional capacity from getting worse

• improving their functional capacity

• supporting their informal supports to build their skills to help the applicant.

Note: If an applicant has been diagnosed with a condition on List D, they meet this criterion

without further assessment.

What to consider

• Does the evidence contain specific recommendations for early intervention, and detail how

  this intervention will mitigate or alleviate the impact of the applicant’s permanent

  impairment on their functional capacity?

• Does the evidence contain specific recommendations for early intervention, and detail how

  this intervention will prevent the applicant’s functional capacity from declining?

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• Does the evidence contain specific recommendations for early intervention, and detail how

  this intervention will improve the applicant’s functional capacity?

• Does the evidence indicate that intervention is likely to strengthen the sustainability of

  informal supports available to the person, and result in a decreased need for formal

  disability related supports?

In answering the above questions, does the evidence contain sufficient information addressing:

• How the applicant’s impairment is likely to impact them over time?

• What supports the applicant will require if they don’t receive intervention?

• What supports the applicant currently requires, and what supports (if any) the applicant is

  likely to require after intervention?

For further information, refer to Our Guidelines - How will early intervention help you?

For applicants aged under 7

Applicants that meet Section 25(1)(c)	Go to Section 8.5 - Does the applicant meet Section 25(3)?
Applicants that do not meet Section 25(1)(c)	Are not eligible for early intervention.

You will now assess them against the disability requirements.

Go to Section 7.1 - Does the applicant meet Section 24(1)(a)? |

For applicants aged 7 and over

Applicants that meet Section 25(1)(c)	Go to Section 8.5 - Does the applicant meet Section 25(3)?
Applicants that do not meet Section 25(1)(c)	Are not eligible for disability or early intervention
support from the NDIS.

Please follow the process in SOP - Finalise Access Not Met Decision |

8.5 Does the applicant meet Section 25(3)?

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Legislation

Section 25 Early intervention requirements

(3) … the person does not meet the early intervention requirements if the CEO is satisfied that early intervention support for the person is not most appropriately funded or provided through the National Disability Insurance Scheme, and is more appropriately funded or provided through other general systems of service delivery or support services offered by a person, agency or body, or through systems of service delivery or support services offered:

  (a) as part of a universal service obligation; or

  (b) in accordance with reasonable adjustments required under a law dealing with
      discrimination on the basis of disability.

When is this criterion considered met?

This criterion is considered met if evidence on the record shows early intervention supports are most appropriately funded by the NDIS.

Note: If an applicant has been diagnosed with a condition on List D, they meet this criterion

without further assessment.

What to consider

Whether or not funding is available through other general systems is not the test of whether it is most appropriately funded or provided through the NDIS. For example, the fact that the health system does not adequately fund what is essentially clinical treatment (or some other form of support that is more appropriately funded through the health system) does not make it the responsibility of the NDIS.

For further information, refer to Our Guidelines - Is your early intervention most appropriately funded by the NDIS?

For applicants aged under 7

| Applicants that meet Section 25(3) | Meet the early intervention requirements.

Please follow the process in SOP - Finalise Access Met Decision | | :— | :— | | Applicants that do not meet Section 25(3) | Are not eligible for early intervention.

You will now assess them against the disability requirements.

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	Go to Section 7.1 - Does the applicant meet Section 24(1)(a)?

For applicants aged 7 and over

| Applicants that meet Section 25(3) | Meet the early intervention requirements.

Please follow the process in SOP - Finalise Access Met Decision | | :— | :— | | Applicants that do not meet Section 25(3) | Are not eligible for disability or early intervention support from the NDIS.

Please follow the process in SOP - Finalise Access Not Met Decision |

9. ER – Residence Requirements

9.1 Does the participant continue to meet the residence requirements?

Legislation

Section 23 Residence requirements

(1) A person meets the residence requirements if the person: (a) resides in Australia; and (b) is one of the following: (i) an Australian citizen; (ii) the holder of a permanent visa; (iii) a special category visa holder who is a protected SCV holder.

(2) In deciding whether or not a person resides in Australia, regard must be had to: (a) the nature of the accommodation used by the person in Australia; and (b) the nature and extent of the family relationships the person has in Australia; and (c) the nature and extent of the person’s employment, business or financial ties with Australia; and (d) the nature and extent of the person’s assets located in Australia; and (e) the frequency and duration of the person’s travel outside Australia; and (f) any other matter relevant to determining whether the person intends to remain permanently in Australia.

When is this criterion considered met?

This criterion is considered met if evidence on the record shows the participant:

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• lives in Australia for most of the year; and

• is an Australian Citizen; or

• is the holder of a permanent visa; or

• is the holder of a protected Special Category Visa (SCV)

Participants that continue to meet the residence requirements	Go to Section 10.1 - List A
Participants that no longer meet the residence requirements	Are not eligible for disability or early intervention
support from the NDIS.

Please follow the process in:

• SOP - Consider commencement of eligibility reassessment or access status change, or
• SOP - Consider ER outcome following 1st chance to respond, or
• SOP - Make an eligibility reassessment decision |

10. ER - Streamlined Decisions

10.1 List A

Where a participant has been diagnosed with a condition on List A they will continue to meet the disability requirements without further assessment (unless there are an document integrity istues pending investigation).

Note: A person does not need to have a condition on List A to continue to be eligible for the

NDIS.

For further information, refer to Our Guidelines - Do you meet the disability requirements?

For participants under the age of 7

| Participants that have a condition on List A | Meet the disability requirements.

Please follow the process in:

• SOP - Consider commencement of eligibility reassessment or access status change, or

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| | - SOP - Consider ER outcome following 1st chance to respond, or

• SOP - Make an eligibility reassessment decision | | :— | :— | | Participants that do not have a condition on List A | Go to Section 10.3 - List D |

For participants aged 7 and over

| Participants that have a condition on List A | Meet the disability requirements.

Please follow the process in:

• SOP - Consider commencement of eligibility reassessment or access status change, or
• SOP - Consider ER outcome following 1st chance to respond, or
• SOP - Make an eligibility reassessment decision | | :— | :— | | Participants that do not have a condition on List A impairment | Go to Section 10.2 - List B |

10.2 List B

Where a participant has been diagnosed with a condition on List B, they will be considered to have a disability attributable to one or more impairments that is, or is likely to be, permanent without further assessment.

For participants diagnosed with a condition on List B, you will only need to assess whether the participant:

• has an impairment that results in substantially reduced functional capacity to perform one

  or more activities;

• has an impairment which affect their capacity for social or economic participation; and

• is likely to require support under the NDIS for their lifetime.

Note: A person does not need to have a condition on List B to continue to be eligible for the

NDIS.

For further information, refer to Our Guidelines – Is your impairment likely to be permanent?

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For participants under the age of 7

Participants that have a condition on List B	Go to Section 12.3 – Does the participant meet Section 25(1)(b)?
Participants that do not have a condition on List B	Go to Section 12.2 – Does the participant meet Section 25(1)(a)?

For participants aged 7 and over

Participants that have a condition on List B	Go to Section 11.3 – Does the participant meet Section 24(1)(c)?
Participants that do not have a condition on List B	Go to Section 11.1 – Does the participant meet Section 24(1)(a)?

10.3 List D

Where a child under the age of 7 has been diagnosed with a condition on List D, they will continue to meet the early intervention requirements without further assessment.

Note: A child does not need to have a condition on List D to continue to be eligible for the

NDIS.

For further information, refer to Our Guidelines – Do you need early intervention?

For participants under the age of 7

| Participants that have a condition on List D | Meet the early intervention requirements.

Please follow the process in:

• SOP - Consider commencement of eligibility reassessment or access status change, or
• SOP - Consider ER outcome following 1st chance to respond, or
• SOP - Make an eligibility reassessment decision | | :— | :— | | Participants that do not have a condition on List D | Go to Section 12.1 – Developmental Delay |

10.4 0-25 Hearing Impairments

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A participant continues to meet the early intervention requirements without further assessment if they:

• are aged between birth and 25 years of age; and

• have confirmed results from a specialist audiological assessment (including

  electrophysiological testing when required) consistent with auditory neuropathy or hearing

  loss ≥ 25 decibels in either ear at 2 or more adjacent frequencies, which is likely to be

  permanent.

What to consider

This streamlined access approach for early intervention acknowledges a rich body of evidence that recognises that early intervention supports up to and including the age of 25 is critical for people with hearing impairment as the developing brain requires consistent and quality sound input and other support over that period to develop normally and ameliorate the risk of lifelong disability.

This same body of evidence suggests that brain development and language capability have been achieved by the age of 26. Therefore, adults aged 26 years and over are not immediately accepted to be likely to benefit from the same early intervention approach because there is no requirement to support the development of the auditory pathways. Adults aged 26 years and over with hearing impairment will therefore be assessed normally, on a case-by-case basis, having regard to the availability of all relevant evidence.

For further information, refer to Our Guidelines - What about people aged between 0 and 25 with a hearing impairment?

For participants under the age of 7

| Participants that meet the hearing impairment criteria | Meet the early intervention requirements.

Please follow the process in:

• SOP - Consider commencement of eligibility reassessment or access status change, or
• SOP - Consider ER outcome following 1st chance to respond, or
• SOP - Make an eligibility reassessment decision | | :— | :— | | Participants that do not meet the hearing impairment criteria | Go to Section 10.2 - List B |

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For applicants aged 7 and over

| Participants that meet the hearing impairment criteria | Meet the early intervention requirements.

Please follow the process in:

• SOP - Consider commencement of eligibility reassessment or access status change, or
• SOP - Consider ER outcome following 1st chance to respond, or
• SOP - Make an eligibility reassessment decision | | :— | :— | | Participants that do not meet the hearing impairment criteria | Go to Section 12.2 – Does the participant meet Section 25(1)(a)? |

11. ER - Disability Requirements

11.1 Does the participant meet Section 24(1)(a)?

Legislation

Section 24 Disability requirements

(1) A person meets the disability requirements if:

  (a) the person has a disability that is attributable to one or more intellectual, cognitive,
      neurological, sensory or physical impairments or the person has one or more
     impairments to which a psychosocial disability is attributable

…

When is this criterion considered met?

This criterion is considered met if evidence on the record shows:

• the participant has a disability (a reduction or loss in their ability to do things); and

• their disability is caused by an impairment (a loss or significant change in their body’s

  functions or structure, or how they think and learn); and

• the impairment is intellectual, cognitive, neurological, sensory, or physical in nature.

Note: Where a participant has been diagnosed with a List A or List B condition, they will meet

this criterion without further assessment.

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What to consider

• Does the evidence demonstrate both that the participant has an impairment, and that the

  impairment is resulting in a disability?

• Does the evidence demonstrate that the participant is reduced in their ability to do things,

  however this reduction cannot be reasonably attributed to an impairment?

• Does the evidence demonstrate that the participant has a loss or significant change in one

  of their body’s functions or structure, or in how they think and learn; however, there is no

  indication that this is causing a reduction or loss in their ability to do things?

Note: A diagnosis is not required to meet this criterion: if the evidence shows the person has

a disability caused by a relevant impairment, then they will meet 24(1)(a) – this is because

we assess based on the impairment/functional impact.

For further information, refer to Our Guidelines - Is your disability caused by an impairment?

For participants under the age of 7

Participants that meet Section 24(1)(a)	Go to Section 11.2 - Does the participant meet Section 24(1)(b)?
Participants that do not meet Section 24(1)(a)	Are not eligible for disability or early intervention
support from the NDIS.

Please follow the process in:

• SOP - Consider commencement of eligibility reassessment or access status change, or
• SOP - Consider ER outcome following 1st chance to respond, or
• SOP - Make an eligibility reassessment decision |

For participants aged 7 and over

Participants that meet Section 24(1)(a)	Go to Section 11.2 - Does the participant meet Section 24(1)(b)?
Participants that do not meet Section 24(1)(a)	Go to Section 10.4 – 0-25 Hearing Impairments

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11.2 Does the participant meet Section 24(1)(b)?

Legislation

Section 24 Disability requirements

(2) A person meets the disability requirements if:

  (b) The impairment or impairments are, or are likely to be, permanent

…

When is this criterion considered met?

This criterion is considered met if evidence on the record shows the participant has a:

• permanent impairment; or
• likely permanent impairment.

Note: Where a participant has been diagnosed with a List A or List B condition, they will meet

this criterion without further assessment.

What to consider

• Does the evidence demonstrate that the participant has completed all available and

  appropriate treatment options, and that there are no recommended treatment options likely

  to remedy the impairment?

• Does the evidence contain recommendations for treatments which have not been

  demonstrated to have been explored?

• Does the evidence indicate that the participant requires further treatment, and that this

  treatment has some prospect of success?

• Does the evidence demonstrate that the participant requires ongoing treatment, but that it

  is for maintenance purposes only?

• Does the evidence demonstrate that the impairment is degenerative in nature, and that

  treatment will not improve the impairment?

In answering the above questions, does the evidence contain sufficient information addressing:

• What treatments have been undertaken and what were the outcomes?

• If there are evidence-based treatments not undertaken, why were they considered and

  deemed unsuitable?

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• What further/ongoing treatments have been recommended and what are the expected

  outcomes of these treatments?

For further information, refer to Is your impairment likely to be permanent? | NDIS

For participants under the age of 7

Participants that meet Section 24(1)(b)	Go to Section 11.3 - Does the participant meet Section 24(1)(c)?
Participants that do not meet Section 24(1)(b)	Are not eligible for disability or early intervention
support from the NDIS.

Please follow the process in:

• SOP - Consider commencement of eligibility reassessment or access status change, or
• SOP - Consider ER outcome following 1st chance to respond, or
• SOP - Make an eligibility reassessment decision |

For participants aged 7 and over

Participants that meet Section 24(1)(b)	Go to Section 11.3 - Does the participant meet Section 24(1)(c)?
Participants that do not meet Section 24(1)(b)	Are not eligible for disability or early intervention
support from the NDIS.

If they do not meet this criterion, they automatically do not meet Section 25(1)(a).

Please follow the process in:

• SOP - Consider commencement of eligibility reassessment or access status change or
• SOP - Consider ER outcome following 1st chance to respond
• SOP - Make an eligibility reassessment decision |

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11.3 Does the participant meet Section 24(1)(c)?

Legislation

Section 24 Disability requirements

(2) A person meets the disability requirements if:

   (c) The impairment or impairments result in substantially reduced functional capacity to
     undertake one or more of the following activities: The impairment or impairments
      result in substantially reduced functional capacity to undertake one or more of the
      following activities:

          (i) communication;

           (ii) social interaction;

            (iii) learning

        (iv) mobility

       (v) self-care

        (vi) self-management

…

When is this criterion considered met?

This criterion is considered met if evidence on the record shows the permanent impairment, or permanent impairments combined, results in substantially reduced functional capacity in one or more of the following activities:

• Communication: how they speak, write or use sign language and gestures.

• Social interaction: how they make and keep friends, interact with the community, and cope

  with feelings and emotions in social situations.

• Learning: how they learn, understand and remember new things, and practise and use new

  skills.

• Mobility: how they move around home and the community and how they get in and out of

  bed or a chair.

• Self-care: how they partake in personal care, hygiene, grooming, eating and drinking, and

  health.

• Self-management (if older than 6): how they organise their life, make decision, solve

  problems and manage money.

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Note: When a participant has been diagnosed with a List A condition, they will meet this

criterion without further assessment.

What to consider

• Does the evidence demonstrate that the participant is unable to participate effectively or

  completely (i.e., across the whole or majority of tasks) in one or more activities, without

  formally prescribed equipment?

• Does the evidence demonstrate that the participant is unable to participant effectively or

  completely in one or more activities, and usually requires the assistance of another

  person?

• Does the evidence demonstrate that the participant would be unsafe to complete one or

  more tasks required to participate in an activity without formally prescribed equipment or

  assistance from another person?

• Does the evidence indicate that the participant is able to participate in each activity

  effectively by using commonly used items?

• Does the evidence indicate that the participant is able to participate in each activity

  effectively, albeit more slowly or in a different way?

• Would completing tasks more slowly or in a modified way, or using commonly used items,

  relieve the participant’s need for personal assistance?

In answering the above questions, does the evidence contain sufficient information addressing:

• What specific tasks the participant cannot complete without support?
• Why the participant requires support?
• How often the participant requires support, and what that support looks like?

For further information, refer to Our Guidelines - Does your impairment substantially reduce your functional capacity?

For participants under the age of 7

Participants that meet Section 24(1)(c)	Go to Section 11.4 - Does the participant meet Section 24(1)(d)?

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| Participants that do not meet Section 24(1)(c) | Are not eligible for disability or early intervention support from the NDIS.

Please follow the process in:

• SOP - Consider commencement of eligibility reassessment or access status change, or
• SOP - Consider ER outcome following 1st chance to respond, or
• SOP - Make an eligibility reassessment decision | | :— | :— |

For participants aged 7 and over

Participants that meet Section 24(1)(c)	Go to Section 11.4 - Does the participant meet Section 24(1)(d)?
Participants that do not meet Section 24(1)(c)	Go to Section 10.4 – 0-25 Hearing Impairments

11.4 Does the participant meet Section 24(1)(d)?

Legislation

Section 24 Disability requirements

(1) A person meets the disability requirements if:

  (d) The impairment or impairments affect the person’s capacity for social or economic
      participation.

When is this criterion considered met?

This criterion is considered met if evidence on the record shows the permanent impairment, or permanent impairments combined, affects the participant’s social or economic participation.

Note: Where a participant has been diagnosed with a List A condition, they will meet this

criterion without further assessment.

What to consider

• Does the evidence demonstrate that the participant’s social participation (e.g., their

  capacity to play sport, go to the movies, see friends, etc.) is affected by their permanent

  impairment/s - in any way?

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• Does the evidence demonstrate that the participant’s economic participation (e.g., their

  capacity to travel, to find or maintain voluntary or paid work, etc.) is affected by their

  permanent impairment - in any way?

• Does the evidence demonstrate that the participant’s social and economic participation is

  not impacted in any way, and that they can fully engage without any assistance?

For further information, refer to Our Guidelines - Does your impairment affect your social, work or study life?

For participants under the age of 7

Participants that meet Section 24(1)(d)	Go to Section 11.5 - Does the participant meet Section 24(1)(e)?
Participants that do not meet Section 24(1)(d)	Are not eligible for disability or early intervention
support from the NDIS.

Please follow the process in:

• SOP - Consider commencement of eligibility reassessment or access status change, or
• SOP - Consider ER outcome following 1st chance to respond, or
• SOP - Make an eligibility reassessment decision |

For participants aged 7 and over

Participants that meet Section 24(1)(d)	Go to Section 11.5 - Does the participant meet Section 24(1)(e)?
Participants that do not meet Section 24(1)(d)	Go to Section 10.4 – 0-25 Hearing Impairments

11.5 Does the participant meet Section 24(1)(e)?

Legislation

Section 24 Disability requirements

(1) A person meets the disability requirements if:

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  (e) The person is likely to require support under the National Disability Insurance
   Scheme for the person’s lifetime.

When is this criterion considered met?

This criterion is considered met if evidence on the record shows the participant:

• will require the support of the NDIS for their lifetime; or
• is likely to require the support of the NDIS for their lifetime.

Note: Where a participant has been diagnosed with a List A condition, they will meet this

criterion without further assessment.

What to consider

• Does the evidence demonstrate that the participant is likely to require disability supports

  that are not clinical in nature, and that focus on their functional ability, for their lifetime?

• Does the evidence demonstrate that the participant will likely be substantially reduced in

  their functional capacity (in a relevant activity) for their lifetime, despite any interventions?

• Are there any recommendations for interventions that are likely to improve the participant’s

  functional capacity, and reduce their future need for disability related supports?

• If the participant is a child or young adult, does the evidence indicate that significant

  functional improvements can be expected - either as they develop, or through

  interventions?

• Does the participant’s need for support relate to a health condition, and is that support

  more appropriately funded by the health system?

For further information, refer to Our Guidelines - Does your impairment affect your social, work or study life?

For participants under the age of 7

| Participants that meet Section 24(1)(e) | Continue to be eligible for the NDIS under the disability requirements.

Please follow the process in:

• SOP - Consider commencement of eligibility reassessment or access status change, or

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| | - SOP - Consider ER outcome following 1st chance to respond, or

• SOP - Make an eligibility reassessment decision | | :— | :— | | Participants that do not meet Section 24(1)(e) | Are not eligible for disability or early intervention support from the NDIS.

Please follow the process in:

• SOP - Consider commencement of eligibility reassessment or access status change, or
• SOP - Consider ER outcome following 1st chance to respond, or
• SOP - Make an eligibility reassessment decision |

For participants aged 7 and over

| Participants that meet Section 24(1)(e) | Continue to be eligible for the NDIS under the disability requirements.

Please follow the process in:

• SOP - Consider commencement of eligibility reassessment or access status change, or
• SOP - Consider ER outcome following 1st chance to respond, or
• SOP - Make an eligibility reassessment decision | | :— | :— | | Participants that do not meet Section 24(1)(e) | Go to Section 10.4 – 0-25 Hearing Impairments |

12. ER – Early Intervention Requirements

12.1 Developmental Delay

Legislation

Section 25 Early intervention requirements

(2) A person meets the early intervention requirements if:

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  (a) the person:
            (iii) is a child with who has developmental delay

Section 9 Definitions

Developmental delay means a delay in the development of a child under 6 years of age that:

(a) is attributable to a mental or physical impairment or a combination of mental and physical impairments; and

(b) results in substantial reduction in functional capacity in one or more of the following areas of major life activity:

     (i) self-care;

     (ii) receptive and expressive language;

      (iii) cognitive development;

    (iv) motor development; and

(c) results in the need for a combination and sequence of special interdisciplinary or generic care, treatment or other services that are of extended duration and are individually planned and coordinated.

When is this criterion considered met?

This criterion is considered met if evidence on the record shows the child is younger than 6 on the day we determine they have developmental delay.

For further information, refer to Our Guidelines - What about children younger than 6 with developmental delay?

| Participants that are under 6 with Developmental delay | Meet the early intervention requirements.

Please follow the process in:

• SOP - Consider commencement of eligibility reassessment or access status change, or
• SOP - Consider ER outcome following 1st chance to respond, or
• SOP - Make an eligibility reassessment decision | | :— | :— | | Participants that do not meet the Developmental Delay criteria and do not have a hearing impairment | Go to Section 10.2 – List B |

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Participants that do not meet the Developmental Delay criteria and have a hearing impairment	Go to Section 10.4 – 0-25 Hearing Impairment

12.2 Does the participant meet Section 25(1)(a)?

Legislation

Section 25 Early intervention requirements

(1) A person meets the early intervention requirements if:

  (a) the person:

          (i) has one or more identified intellectual, cognitive, neurological, sensory or
         physical impairments that are, or are likely to be, permanent; or

           (ii) has one or more identified impairments to which a psychosocial disability is
          attributable and that are, or are likely to be, permanent

…

When is this criterion considered met?

This criterion is considered met if evidence on the record shows:

• the participant has an impairment (a loss or significant change in their body’s functions or

  structure, or how they think and learn); and

• the impairment is intellectual, cognitive, neurological, sensory, or physical in nature; and

• the impairment is, or is likely to be, permanent.

Note: Where a participant is diagnosed with a condition on List B or List D, they meet this

criterion without further assessment.

• What to consider

• Does the evidence demonstrate that the participant has completed all available and

  appropriate treatment options, and that there are no recommended treatment options likely

  to remedy the impairment?

• Does the evidence contain recommendations for treatments which have not been

  demonstrated to have been explored?

• Does the evidence indicate that the participant requires further treatment, and that this

  treatment has some prospect of success?

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• Does the evidence demonstrate that the participant requires ongoing treatment, but that it

  is for maintenance purposes only?

• Does the evidence demonstrate that the impairment is degenerative in nature, and that

  treatment will not improve the impairment?

In answering the above questions, does the evidence contain sufficient information addressing:

• What treatments have been undertaken and what were the outcomes?

• If there are evidence-based treatments not undertaken, why were they considered and

  deemed not suitable?

• What further/ongoing treatments have been recommended and what are the expected

  outcomes of these treatments?

For further information, refer to Our Guidelines - Do you need early intervention?

For participants under the age of 7

Participants that meet Section 25(1)(a)	Go to Section 12.2 - Does the participant meet Section 25(1)(b)?
Participants that do not meet Section 25(1)(a)	Go to Section 11.1 - Does the participant meet Section 24(1)(a)?

For participants aged 7 and over

Participants that meet Section 25(1)(a)	Go to Section 12.2 - Does the participant meet Section 25(1)(b)?
Participants that do not meet Section 25(1)(a)	Are not eligible for disability or early intervention
support from the NDIS.

Please follow the process in:

• SOP - Consider commencement of eligibility reassessment or access status change, or
• SOP - Consider ER outcome following 1st chance to respond, or
• SOP - Make an eligibility reassessment decision |

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12.3 Does the participant meet Section 25(1)(b)?

Legislation

Section 25 Early intervention requirements

(2) A person meets the early intervention requirements if:

  (b) the CEO is satisfied that provision of early intervention supports for the person is
       likely to benefit the person by reducing the person’s future needs for supports in
      relation to disability

…

When is this criterion considered met?

This criterion is considered met if evidence on the record shows that early intervention supports for the participant’s permanent impairment/s will reduce their need for disability- related supports in the future.

Note: Where a participant has been diagnosed with a condition on List D, they meet this

criterion without further assessment.

What to consider

• 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?

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For further information, refer to Our Guidelines - How will early intervention help you?

For participants under the age of 7

Participants that meet Section 25(1)(b)	Go to Section 12.4 - Does the participant meet Section 25(c)?
Participants that do not meet Section 25(1)(b)	Go to Section 11.1 - Does the participant meet Section 24(1)(a)?

For participants aged 7 and over

Participants that meet Section 25(1)(b)	Go to Section 12.4 - Does the participant meet Section 25(c)?
Participants that do not meet Section 25(1)(b)	Are not eligible for disability or early intervention
support from the NDIS.

Please follow the process in:

• SOP - Consider commencement of eligibility reassessment or access status change, or
• SOP - Consider ER outcome following 1st chance to respond, or
• SOP - Make an eligibility reassessment decision |

12.4 Does the participant meet Section 25(1)(c)?

Legislation

Section 25 Early intervention requirements

(1) A person meets the early intervention requirements if:

   (c) the CEO is satisfied that provision of early intervention supports for the person is
       likely to benefit the person by:

          (i) mitigating or alleviating the impact of the person’s impairment upon the functional
         capacity of the person to undertake communication, social interaction, learning,
          mobility, self‑care or self‑management; or

           (ii) preventing the deterioration of such functional capacity; or

            (iii) improving such functional capacity; or

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        (iv) strengthening the sustainability of informal supports available to the person,
         including through building the capacity of the person’s carer.

…

When is this criterion considered met?

• This criterion is considered met if evidence on the record shows early intervention supports will help the participant by:

• addressing the impact of their impairment on their ability to move around, communicate,

  socialise, learning, look after themselves, or organise their life

• preventing their functional capacity from getting worse

• improving their functional capacity

• supporting their informal supports to build their skills to help the participant.

Note: Where a participant has been diagnosed with a condition on List D, they meet this

criterion without further assessment.

What to consider

• Does the evidence contain specific recommendations for early intervention, and detail how

  this intervention will mitigate or alleviate the impact of the participant’s permanent

  impairment on their functional capacity?

• Does the evidence contain specific recommendations for early intervention, and detail how

  this intervention will prevent the participant’s functional capacity from declining?

• Does the evidence contain specific recommendations for early intervention, and detail how

  this intervention will improve the participant’s functional capacity?

• Does the evidence indicate that intervention is likely to strengthen the sustainability of

  informal supports available to the person, and result in a decreased need for formal

  disability related supports?

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?

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For further information, refer to Our Guidelines - How will early intervention help you?

For participants under the age of 7

Participants that meet Section 25(1)(c)	Go to Section 12.5 - Does the participant meet Section 25(3)?
Participants that do not meet Section 25(1)(c)	Go to Section 11.1 - Does the participant meet Section 24(1)(a)?

For participants aged 7 and over

Participants that meet Section 25(1)(c)	Go to Section 12.5 - Does the participant meet Section 25(3)?
Participants that do not meet Section 25(1)(c)	Are not eligible for disability or early intervention
support from the NDIS.

Please follow the process in:

• SOP - Consider commencement of eligibility reassessment or access status change, or
• SOP - Consider ER outcome following 1st chance to respond, or
• SOP - Make an eligibility reassessment decision |

12.5 Does the participant meet Section 25(3)?

Legislation

Section 25 Early intervention requirements

(3) … the person does not meet the early intervention requirements if the CEO is satisfied that early intervention support for the person is not most appropriately funded or provided through the National Disability Insurance Scheme, and is more appropriately funded or provided through other general systems of service delivery or support services offered by a person, agency or body, or through systems of service delivery or support services offered:

  (a) as part of a universal service obligation; or

  (b) in accordance with reasonable adjustments required under a law dealing with
      discrimination on the basis of disability.

When is this criterion considered met?

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This criterion is considered met if evidence on the record shows early intervention supports are most appropriately funded by the NDIS.

Note: Where a participant has been diagnosed with a condition on List D, they meet this

criterion without further assessment.

What to consider

Whether or not funding is available through other general systems is not the test of whether it is most appropriately funded or provided through the NDIS. For example, the fact that the health system does not adequately fund what is essentially clinical treatment (or some other form of support that is more appropriately funded through the health system) does not make it the responsibility of the NDIS.

For further information, refer to Our Guidelines - Is your early intervention most appropriately funded by the NDIS?

For participants under the age of 7

| Participants that meet Section 25(3) | Continue to be eligible for the NDIS under the early intervention requirements.

Please follow the process in:

• SOP - Consider commencement of eligibility reassessment or access status change, or
• SOP - Consider ER outcome following 1st chance to respond, or
• SOP - Make an eligibility reassessment decision | | :— | :— | | Participants that do not meet Section 25(3) | Go to Section 11.1 - Does the participant meet Section 24(1)(a)? |

For participants aged 7 and over

| Participants that meet Section 25(3) | Continue to be eligible for the NDIS under the early intervention requirements.

Please follow the process in:

• SOP - Consider commencement of eligibility reassessment or access status change, or

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| | - SOP - Consider ER outcome following 1st chance to respond, or

• SOP - Make an eligibility reassessment decision | | :— | :— | | Participants that do not meet Section 25(1) | Are not eligible for disability or early intervention support from the NDIS.

Please follow the process in:

• SOP - Consider commencement of eligibility reassessment or access status change, or
• SOP - Consider ER outcome following 1st chance to respond, or
• SOP - Make an eligibility reassessment decision |

13. Related procedures or resources

• National Disability Insurance Scheme Act 2013
• National Disability Insurance Scheme (Becoming a Participant) Rules 2016
• Our Guidelines - Applying to the NDIS
• SOP – Progress NDIS Application in the System
• SOP - Finalise Access Met Decision
• SOP - Finalise Access Not Met Decision
• Access and ER Decision Tree

14. Feedback

If you would like to provide feedback about this guidance material, please discuss with your team leader who can send a request to NARB.BUSINESSIMPROVEMENT@ndis.gov.au.

15. Version control

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Version	Amended by	Brief Description of Change	Status	Date
1.0	CHO0026	New resource	APPROVED	2022-10-31
2.0	GMQ132	Updated hyperlink	APPROVED	2023-02-16

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PLE’RA G7

FOI 24/25-2261 DOCUMENT 6

ER Phone Call - Common Questions

The content of this document is OFFICIAL

Question	Key Information to Convey	Sample Response
Will this affect my current plan?	- Explain that nothing will change in their current plan until the Eligibility Reassessment process is complete.	Nothing will change with your current plan and funding whilst the Eligibility Reassessment process is in place. You will be notified when the Eligibility Reassessment has been completed and given the opportunity to talk to us for further clarification should you require.
I’ve just completed a review for my plan, or my plan has just been approved. What is the purpose of this?	- Plan Reviews and Eligibility Reassessments are two different things:

• Plan Reviews determine the funding package and supports
• Eligibility Reassessments are to ensure that the access criteria are still met
• Explain Eligibility Reassessments can occur at any time and is a normal process undertaken by the Agency. | Eligibility Reassessments and Plan Reviews are two separate things. The purpose of the plan review is to determine the funding and types of supports for your new plan, whereas the purpose of the Eligibility Reassessment is to determine whether you continue to meet the access requirements to remain on the scheme.

Suggest we add a point about planning steps and access to support needing to continue until an ER decision is finalised. |

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Question	Key Information to Convey	Sample Response
I have permanent condition, why do you still need further info?	- Explain that the NDIS definition of permanency is different to the medical definition

• Briefly explain the permanency criteria, and what we would require | The way NDIS looks at permanency is a bit different to how a doctor would look at it. You may have a condition that you will have for your whole life, but if there are treatments or interventions that can substantially improve your ability to function, then this may not meet the NDIS permanency criteria.

So, what we would need to see for the permanency criteria to be met is that all of the recommended treatment options for the impairment have been utilised and that there are no further treatments or interventions which are likely to improve their ability to function. | | My child already turned 7 or 8, how come the Eligibility Reassessment didn’t commence earlier | - Explain that the process for conducting Eligibility Reassessments has recently changed

• If appropriate/necessary, explain that children can be eligible if they have a developmental delay (under 6 years) or Global Developmental Delay (under 7 years), and that the access requirement is that children over the age of 6/7 must provide evidence that they meet the disability and/or early intervention requirements to remain on the scheme | NDIS has always reassessed eligibility but the process for how we do that has recently changed, and this has caused some delays. Your child initially met access under the developmental delay criteria, which is designed for providing early intervention supports for children under the age of 6. As your child is now over the age of 6, this criterion does not apply anymore, so we will be reassessing them against the appropriate access criteria. |

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Question	Key Information to Convey	Sample Response
What type of evidence do you need?	- The information provided will depend on individual circumstances

• Evidence relating to functional capacity and early intervention recommendations should generally be less than 12 months old to ensure accuracy (as per Our Guidelines)
• Describe the evidence required in relevance to criteria in question as per letter | This will depend on your individual circumstances and whether we ask you for specific information, or provide you with an opportunity to give us information you already have. However, if you choose to provide evidence describing how your impairment impacts you, or that you need early intervention, it should generally be from the last 12 months to ensure it is reflective of your current situation. You will receive a letter which will outline the eligibility requirements you currently do not meet, and you can choose to provide evidence to explain why you think you meet these requirements. | | Why is this happening? | - To ensure participants still meet the NDIS criteria, and if they don’t to support them to access mainstream services. | All NDIS participants need to meet the eligibility criteria to remain on the scheme. Eligibility Reassessments are a normal process undertaken by the agency to ensure this. The Eligibility Reassessment process gives our participants a chance to have all of their impairments reviewed and make sure that you/your child are/is receiving the right level of supports for your/their needs. If you wish, you can provide us with supporting documents from your treating health professionals and specialists to consider in our decision about your continued eligibility.

While the Eligibility Reassessment process is taking place, your plan continues as normal, and we will communicate with you over the phone and in writing at commencement and to advise the outcome. |

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Question	Key Information to Convey	Sample Response
		If at any time you have questions or would like an extension to provide supporting documents, we can be contacted on our 1800 number (1800 800 110).
If my/my child’s access to NDIS is ceased, who will provide support to me/my child? Or what should I do as I/my child still requires allied health support?	- Explain that their Early Childhood Partner/Local Area Coordinator (their MyNDIS Contact) will support them to exit the scheme and link with community and other government supports

• Explain that the support will depend on the services available in their area
• Assure participant that NDIS will assist with the transition | If we determine that you/your child no longer meet/s access, you will be supported by your Childhood Partner/Local Area Coordinator (their MyNDIS Contact) to exit the scheme. They will support you to transition from NDIS to mainstream services based on your individual needs and circumstances. In future, should there be a change in circumstances, you can always reapply for NDIS. | | What does a revocation mean for me/my child? Can I continue to access NDIS until the end of current plan? What happens to my/my child’s current plan? | - From the , participant will no longer be able to claim through the participant portal for services or supports | Based on the current evidence you/your child are/is no longer eligible to access the scheme, which means your/your child’s current plan will end and you/your child will no longer be able to access the plan from . Please contact your/your child’s service providers to let them know that from , you/your child are/is no longer a participant of the NDIS and they will need to finalise all claims for services before that date. Your Childhood Partner/Local Area Coordinator (their MyNDIS Contact) will support you/your child to transition from NDIS to community and other government supports. In future, should there be a change in circumstance, you can always reapply for NDIS. |

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Question	Key Information to Convey	Sample Response
I disagree with the decision made. I believe the evidence provided should be sufficient to meet NDIS criteria.	- Participant has an option to request for internal review within 3 months of revocation.

: If participant still disagrees with the Internal Reviewer’s decision, then participant may ask the Administrative Review Tribunal (ART), an independent tribunal to review the decision within 28 days of the internal review. | I acknowledge that this is not the outcome that you were looking for. If you disagree with this decision, you can ask for an internal review within three months from the date on the decision letter. The information regarding applying for review is on the decision letter sent to you on . When asking for an internal review you should explain why you think the decision is incorrect. The staff member who works on the internal review (the Internal Review Officer) will be independent from person who completed the revocation decision. | | What if I can provide evidence to establish the eligibility criteria? We are still on waiting list for diagnosis. | - Provide options for internal review /new application

• Ensure all relevant correspondence was sent | The Eligibility Reassessment decision has been finalised. However, you can ask for an internal review within three months from the date on decision letter. If you’d like, you can send through the additional evidence to be reviewed during the internal review. The information on how you can do this this is on the decision letter. You can also contact your Early Childhood Partner or Local Area Coordinator (myNDIS Contact) about making a new access request at any time. | | I have accessed supports after/on the effective date. Should I be able to claim for it? | - Funding will still be in place until the date of the participant’s next plan reassessment OR for 28 days after date of revocation, whichever is earlier.
• Participants will have access to the participant portal for 90 days after revocation and must complete all payment requests within 90 days | This decision takes effect on <date of the participant’s next plan reassessment OR 28 days after the date of revocation, whichever is earlier>. At that time, you can no longer use NDIS funds to purchase supports, however you can still access the myplace portal to complete all outstanding payment requests. |

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Question	Key Information to Convey	Sample Response
I have never received any correspondence from you?	- Express empathy and understanding of current situation

• Confirm address/email/phone and update if required | I acknowledge your frustration on not receiving our correspondences. I can see on your record that we have mailed the correspondences to the address you provided us, which is (if applicable: to the email address you provided us, which is ). Are these details still current or would you like me to update them? Would you like me to re-send the correspondences to you? I can also see on your record that we communicated with you over the phone on (if applicable: we tried contacting you on ). (If the decision was to revoke:) You can ask for an internal review within three months from the date of decision. You can send through any new evidence for review. The information regarding applying for review is on the decision letter sent to you on . | | How long do I have to provide new information? | - When an Eligibility Reassessment has been commenced, the participant is provided with an opportunity to explain why they think they continue to meet the eligibility requirements and, if they would like, respond with evidence within 90 days.
• If additional time is required to provide the evidence, the participant may request an extension. When considering this request, we may request evidence of the reason, such as proof of an upcoming appointment. | When we commence an Eligibility Reassessment, we provide you with an opportunity to explain why you think you continue to meet the requirements and, if you choose, you can respond with evidence within 90 days from the date of commencement.

If we request specific information from you, or that you undergo an assessment in order to make the decision, we will request this in writing and provide a timeframe of 90 days. I have looked at the record and we have not made such a request in your case.

You should have received a letter explaining that you have 90 days to provide any information, if you wish to do so. The due date in the letter is . Do you have a copy of this letter, or would you like me to re-send it to you? |

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Question	Key Information to Convey	Sample Response
	- s30 relates to a request from the Agency for the participant to provide specific information or undergo an assessment, that has been deemed as necessary to make a decision regarding their eligibility	I can also see on your record that we communicated this timeframe to you over the phone on . (If applicable: I can also see on your record that we tried contacting you multiple times).

You can find out more information in section How much time will you have to give us more information? of Our Guidelines – Leaving the NDIS on the NDIS website. This resource explains the difference between these two situations and provides some examples to help understanding. |

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FOI 24/25-2261 DOCUMENT 7

Eligibility Reassessment FAQs

Does an Eligibility Reassessment checklist need to be completed with every plan review?

Yes. The checklist is to be completed at each participant plan review to ensure the Agency are compliant with our ANAO regulations. This will also ensure any participants who no longer meet the Scheme eligibility criteria are identified for potential review. Please note that this excludes first plans for all participants.

An ER referral may be raised outside of Plan Review cycle where appropriate.

Can I create an Eligibility Reassessment Request if I am a Planner approving a plan?

Planners who are approving a plan you will be able to create an Eligibility Reassessment Request. A Planner who is creating an ER Request at this stage should complete their own version of the Eligibility Reassessment Checklist and attach it to CRM. Planners who take this measure should inform the person who submitted the plan for approval why they are doing so.

Will all ER referrals to the NAWMB result in an ER being commenced?

No. At the submission of the ER referral to the NAWMB, an Access Assessor will further review the checklist & all information provided to understand if further evidence would be required to support Scheme Eligibility. If the Assessor determines further information is required, a review will commence.

If there is sufficient evidence held, the Access Assessor will contact the referring LAC/Planner to advise no further action will take place and interaction will be closed.

What happens if I raise an ER referral in error?

You will be able to withdraw the request in CRM before a delegate has drawn it down in WLM.

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If the participant is no longer eligible for NDIS support, who will contact the participant?

The Access Assessor completing the review within the NAWMB will conduct all communications directly with the Participant. This includes advising of a review outcome.

Will I know of a review is taking place?

An alert will be placed on the participant profile to advise any ER review is underway. There will also be updates provided to the LAC/ECEI/Planner working with the participant

Do I continue developing a Plan knowing the participant may not meet NDIS Eligibility criteria?

Yes, you should maintain planning with the participant, with consideration of Reasonable & Necessary guidelines in the approval of any supports.

This will ensure independence is maintained in the ER review process, and maintain supports for participants through the ER process being progresses.

What if a participant disagrees with the result of the ER checklist?

At the point of completion of the checklist, the participant shouldn’t know a review referral has been raised.

If the participant disagrees with the outcome of an ER review, they will have full access to NDIS appeal & review rites. The participant will be advised of this at the time of the decision being communicated.

What training will I get to support me in this process?

National, face to face training has been conducted with nominated PITC & SD&P representatives over recent months. This has been all states & territories except NSW.

Prior to go live, your representatives will conduct local training on the new process, which will be supported by a new LEAP e-learn module.

Why are Access Officers from the NAWMB completing the ER review? They don’t know the participant and their circumstances

Access Assessors are highly experienced & supported in the making of Eligibility decisions for the Agency. As this process currently combines

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analysis of condition/medical evidence and interpretation of the NDIS Act, the team will be well placed to make these decisions.

When will access to supports cease if a participant has Scheme

access revoked?

Any decision to revoke access to the scheme will take effect on the date the decision is conveyed to the participant. It is critical all the LAC/Planner & participant are engaged throughout the review process to support this cessation, if it is looking likely.

Will providers be paid for services provided to a revoked

participant?

Any supports or services provided to the participant up to, and on, the day of the revoke will be paid by the Agency if sufficient plan funds are available. Providers will have up to 90 days after the revocation to claim for services rendered prior to the revocation.

Some disabilities fluctuate in severity. What happens if we review a

participant when they are well, and they become disabled again at a later stage?

The Access Assessor will complete a holistic review as part of the ER review process. This will take in to account any fluctuation of condition and ensure this captures appropriately within Eligibility guidelines.

If a participant has access to the Scheme revoked, they may make a new Access Request at any time, should their condition change.

Why are there different checklists? It would be easier to just have

one.

There are four different checklists;

-  0-6 years – Early Intervention
-  0-6 years – Disability
-  7+ years – Early Intervention
-  7+ years – Disability
-

It is important to complete the checklist appropriate to the status of the participant. The four checklists are developed to ensure any specific and unique Eligibility criteria are analysed to ensure accuracy in each ER checklist completed.

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Can I send a participant for a review without completing the ER

checklist?

No. All ER referrals raised and sent to the NAWMB require a checklist completed & attached.

If a referral is sent without a checklist, this will be returned to the LAC/Planner for completion.

Can I revoke a participant access if I know they are no longer

eligible?

No. All Eligibility decisions, for Access Requests or Eligibility Reviews, will be completed & actioned by the NAWMB.

Informal review & AAT decisions are the only exceptions.

How much notice will the participant have to provide any Evidence

of Disability (EOD)?

Upon commencement of the review, the Access Assessor will make contact (verbal & written as appropriate) with the participant to detail the evidence required and the ER process, including timeframes. The participant will be given an initial 28 days to collect evidence required. At that point, the participant will contacted again to discuss the progress and advised a further 28 days will be taken to finalise the decision.

How do I know the status of a participant on CRM?

To check a participants access status click on the application pathway in CRM and go to Determine Access Decision. The reason code will either say Disability Met or Benefit from Early Intervention. Please go to the Refer Participant for Eligibility Reassessment SOP for further details. Please note the Access Decision Reason on the Overview screen is not accurate and does not reflect the correct access status of the participant.

What happens to a participant if their NDIS Access is revoked?

If it is likely that a participant will have their access to the Scheme revoked, the Assessor within the NAWMB will make contact with the LAC/ECEI/Planner to advise. We will seek the support of the LAC to work with the participant to identify & access mainstream supports within the local community.

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The Agency are also updating information on the NDIA website to provide further guidance to anyone in the community seeking guidance around supporting individuals transition from the Scheme.

Is it my responsibility to support the participant if they get access

revoked?

If a participant is found no longer eligible to access the scheme, the support of LAC’s and Early Childhood Partner’s will be sought to support individuals’ transition in to mainstream supports.

When will the new ER process commence??

The roll out of the new ER process is scheduled to commence 3 February 2020.

WA are just starting to build the Scheme. Do we need to commence

this process yet?

Yes. The ER process should form a part of any review undertaken with Scheme Participants.

If my participant asks me for details of the ER review, where can I

refer them??

A link to the Eligibility Reassessment Operating Guideline will be available on ndia.gov.au from the date of commencement.

If a participant is seeking an update on their individual review, there will be interactions available on CRM or a request for contact can be sent to the NAWMB to make contact with the participant.

This process doesn’t seem fair to participants. Why are we kicking

people out of the scheme when we are still growing?

The ER process is not a new policy or process, as the Agency has historically been revoking access on an ad hoc basis. The implementation of the new ER process is to centralise this process & ensure a fair & consistent approach is applied to any participant who may no longer meet thee Eligibility criteria to access the scheme.

The identification of individuals no longer requiring support of the Scheme, or no longer eligible for access to the scheme, is important to ensure the sustainability of the scheme for participants requiring our support in the future.

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Where can I access the checklists??

All SOP’s & checklists are available on the Review page on the NDIA Intranet

Can I give the checklists to a provider/treater to complete?

No. ER checklists are a tool for the completion of NDIA staff/representatives and are not to be distributed externally.

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FOI 24/25-2261 DOCUMENT 8

FAQs

Phase 2: Eligibility Reassessment TAS Pilot

Information for Service Delivery staff delivering Phase 2: ER Pilot in Tasmania including Local Area Coordinators (LAC), Early Childhood Partners (ECP), ER Assessors and Quality Development Officers (National Access and Workload Management staff).

Questions

1. What is the purpose of the Eligibility Reassessment (ER) Pilot?

The ER Pilot will test enhancements to our processes, communication and resources when reassessing a participant’s eligibility for the National Disability Insurance Scheme (NDIS). The ER pilot outcomes will inform further enhancements to the ER process to deliver a nationally consistent and fairer approach for participants and will address the Agency’s responsibilities to ensure only people who continue to meet NDIS eligibility requirements access funded supports.

2. Why are eligibility reassessments important to the Agency?

Small numbers of participants are expected to achieve their goals and build capacity to the point that they no longer meet NDIS eligibility requirements. This achievement is an important success measure for the person, their family/carers, the community and Scheme.

This also contributes to Scheme sustainability by ensuring that only people who continue to meet NDIS eligibility requirements access funded supports.

3. Which participants will be involved in the ER Pilot?

The ER Pilot commenced in March 2019 and will involve 1,270 NDIS participants from Tasmania who are due for a plan review in the next few months.

4. Are there any exceptions to making an ER referral or decision?

The ER process assists the NDIA to identify where a participant no longer meets the residence, or the disability and early intervention requirements, and when their participant status must be revoked, aligned with the legislation (s30, NDIS Act).

There are two main exceptions when making an ER referral or decision:

• Residence requirements - NSW Prescribed Program Rules: A person who entered the NDIS under the NSW Prescribed Program Rules must not have their participant status revoked based on residence requirements. This includes

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FAQs

  participants who now live in another state or territory. Eligibility re-assessments for
 these participants may only consider the disability and early intervention
  requirements.

• Administrative Appeals Tribunal (AAT) determination: The QDO Team Leader must consider all ER referrals where the AAT has previously made a determination in relation to the participant’s access. If required they will seek advice from the Technical Advisory Team (TAT) and/or Legal Team to make the ER decision.

5. What is the role of Tasmanian LAC and ECP in the ER Pilot?

When conducting plan reviews Tasmanian LAC and ECP staff involved in the Pilot:

• use the ER Checklist to identify whether a participant should be referred for eligibility reassessment;

• complete ER referrals using the LAC and EC Partner SOPs;

• continue to support the participant during the ER process including by monitoring the plan

• support people who no longer meet NDIS eligibility requirements to connect with suitable mainstream and community supports.

Note: All other ER referrals, including those from Tasmanian Planners must follow the Phase 1: Interim process using the SOP – Refer Eligibility Reassessment.

6. What is the role of ER Assessor in the ER Pilot?

National ER Assessors involved in the pilot will follow the SOP – Undertake Eligibility Reassessment to:

• process ER referrals;

• decide whether to progress the ER;

• inform the person, LAC and ECP staff about key steps in the ER process;

• make ER decisions against legislative requirements;

• explain revocation decisions and the next steps to the person.

If an ER Assessor determines that an ER is not required, they will provide feedback to

the LAC or ECP but will not contact the participant.

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FAQs

7. What is the role of ER Quality Development Officer in the ER Pilot?

As a quality assurance measure, all ER decisions will be pre-checked by an ER Quality Development Officer (QDO) prior to finalisation. National ER Quality Development Officers involved in the ER pilot will follow the SOP – Quality Check Eligibility Reassessment to:

•  complete quality audit pre-checks of all ER decisions;

•    if required, make ER decisions;

•    if required, explain ER decision outcomes and the next steps to the person.

8. What happens to participant’s existing NDIS supports during and after ER?

A participant’s current plan and funded supports do not change during ER.

When an ER Assessor confirms that a participant continues to meet the NDIS eligibility requirements, the current plan and funded supports do not change.

However, when an ER Assessor makes a decision to revoke a person’s participant status, they will advise the date this will take effect. From this date, all NDIS funded supports will cease.

9. How are participants supported during and after ER?

   During the ER process, LAC and ECP staff continue as the key NDIA contact for the participant with planning related matters. This ensures participants have a consistent independent support person during the ER. LAC and ECP staff may follow ER progress and interact with the ER Assessor through the NDIS Business System.

ER Assessors support the participant with telephone conversations to understand the ER process, decision outcomes and next steps. They also send letters to the participant at key stages of the process, such as when:

•  the eligibility reassessment process starts

•  there is potential for a revocation decision;

•  the ER process is complete, or a revocation decision is made.

 At the end of the ER, participants will either:

•  remain in the Scheme and continue with planning; or

•  be supported to transition from the Scheme to community and mainstream
    supports.

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FAQs

   If a person no longer meets NDIS eligibility requirements:

•  the ER Assessor will explain the reasons for the decision and review rights

•  LAC and ECP staff will provide support to link with community and mainstream
    services

    If a person is not satisfied with the ER outcome they may request an internal review
  deed of the ER decision.

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FOI 24/25-2261 DOCUMENT 9

Frequently asked questions about legislation

•   Eligibility reassessments (s30)

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Eligibility reassessments (S30)

Why are new letters being sent to participants about the eligibility

reassessment process?

We have made some immediate changes to improve the process for eligibility reassessment for participants, families and their carers.

We understand eligibility reassessments can feel overwhelming, and we want you to know what information is required to support your eligibility reassessment.

We have now introduced new eligibility reassessment letters which outline more detail about the types of information you may wish to provide.

This also gives you the opportunity to provide us with information we can’t reasonably get in a different way.

The new letters:

® tell you an eligibility reassessment has started, and why

® are clearer about the information you may wish to provide

® tell you that you have 90 days to supply this information.

The new letters are the second step in our plans to address feedback from the disability community.

We will continue to streamline and simplify the eligibility reassessment process to ensure you can easily understand and navigate it.

If you need more time, you can call us on 1800 800 100 or contact us for help.

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What are the new timeframes to provide additional information and when does this change commence?

Will the timeframe extension apply if I am currently undergoing an eligibility reassessment on 30 January 2025?

Yes, participants who have already received a request to provide information due to their eligibility being reassessed and need more time, can contact us or their my NDIS Contact for help.

What is the purpose of an eligibility reassessment?

Eligibility reassessments help us understand if a participant’s support needs have changed and whether they still meet the eligibility criteria for the Scheme, particularly if they have received early intervention support through the NDIS Early Intervention pathway.

The NDIS Early Intervention pathway is mainly accessed by children in recognition that when we support children early, it can improve outcomes and reduce their need for supports later in life.

While eligibility reassessments have always been a part of the NDIS, we acknowledge the experience may be new for some participants.

We understand these requests can feel overwhelming and takes time to get information.

Participants will now have more time to get information to us.

How does the eligibility reassessment process work?

We send a letter to a participant (or nominee) to let them know about the eligibility reassessment and that they can provide additional information.

We understand that it can take time to get this information. That’s why we have extended the timeframe for participants to provide additional documentation to support eligibility reassessments from 28 to 90 days. If the information isn’t available in 90 days, the participant (or nominee) can ask for more time.

If we decide someone isn’t eligible or they don’t respond to our request within the timeframe, we may cease their access to the NDIS. But we will make multiple efforts to contact you so we can talk to you about support needs.

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Why is this changing?

We understand these requests can feel overwhelming and it takes time to get information.

Participants will now have more time to get information to us. We recognise there is work to be done with participants and the disability sector to improve the eligibility reassessment process.

We are working to strengthen our approach through:

® better communication with participants and families about what is involved during an eligibility reassessment

® providing more time for people to supply the agency with relevant information about their evidence of eligibility and whether it has changed

® improving the communication and resources participants receive when they undergo the reassessment process.

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