Practice Guide – Eligibility Reassessment Process

Interim Guidance for NDIA Delegates Service Delivery Support Alliance Team

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Contents

Practice Guide – Eligibility Reassessment Process……………………………………………… 1 Audience …………………………………………………………………………………………………………………. 4 Introduction …………………………………………………………………………………………………………… 4 Note: If there is no information currently available to indicate the participant may not meet the eligibility criteria, you will continue planning without further reference to this Practice Guide.Defined Programmes ……………………………………………………………………………………. 5 Delegate for revocation ………………………………………………………………………………………….. 5 Considerations when decision making …………………………………………………………………… 6 Law: …………………………………………………………………………………………………………………. 7 Policy: ………………………………………………………………………………………………………………. 7 Evidence …………………………………………………………………………………………………………… 7 Types of evidence ………………………………………………………………………………………………. 8 Eligibility reassessment process ………………………………………………………………………………. 9 Continues to meet eligibility …………………………………………………………………………………. 9 Unlikely to meet eligibility – Opportunity to respond …………………………………………………. 9 Review any additional information provided ………………………………………………………….. 11 Continues to meet eligibility ……………………………………………………………………………….. 12 Unable to contact ……………………………………………………………………………………………… 13 Does not meet eligibility - decision to revoke ………………………………………………………… 13 Information, Linkages and Capacity Building (ILC) ……………………………………………………. 15 Version change control …………………………………………………………………………………………. 15 Appendix A – Guide to Disability requirements ………………………………………………………… 16 Disability requirements ………………………………………………………………………………………. 16 Disability - Evidence of impairment on List A ………………………………………………………… 17 Disability - Evidence of impairment on List B ………………………………………………………… 17 Disability - All other impairments …………………………………………………………………………. 18 Appendix B- Evidence Protocol for Sect.24 Decision Making – review of ‘disability requirements’ ………………………………………………………………………………………………………. 19 Appendix C – Guide to the ‘early intervention requirements’ ………………………………………. 27 Early intervention requirements ………………………………………………………………………….. 27 Child under 6 years with evidence of Developmental Delay ……………………………………. 28 Child under 7 without Developmental Delay and condition not on List A or List D ………. 28 Practice Guide – Eligibility Reassessment v2.0 APPROVED 2019-02-15 Page 2 of 38 Page 2 of 260

Appendix D – Evidence Protocol for Sect.25 Decision Making – for Review of ‘early

intervention requirements’

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Audience

This document is to support:

• Delegates for revocation

Note: A Standard Operating Procedure has been drafted to support referrals to the delegate for action.

Introduction

The purpose of this Interim Practice Guide is to assist the Service Delivery Support Alliance (SDSA) Team in the process to reassess a participant’s eligibility where evidence currently exists on the participant record suggesting the participant may no longer meet the eligibility requirements. Eligibility should only be reassessed when there is information to indicate the participant may not meet the eligibility requirements for the NDIS. If there is insufficient evidence, eligibility should not be reassessed and the planning/plan review process should continue.

As part of the development of a participants plan or plan review you may become aware of new evidence which gives cause to consider whether a participant should remain a participant of the NDIS. That is, there is information available or attached to the participant’s record which indicates they may not meet the residence requirements, disability requirements or early intervention requirements.

You cannot reassess a participants eligibility on a hunch or from an opinion, there must be existing evidence available on the participant’s record.

The SDSA team has been allocated the work of eligibility reassessment as an interim measure to ensure an independent delegate, unrelated to the plan development, is reassessing the participant’s eligibility.

For the purpose of this Practice Guide, the independent delegate for revocation refers to a delegate in the SDSA team responsible for eligibility reassessment.

They have the delegation to revoke a participant’s status as a participant of the Scheme. Do not confuse this with the National Access Workload Management delegates who are not involved in this process.

Refer to the Instrument of Delegation on the Delegations and authorisations intranet page.

As part of this reassessment of eligibility, it is really important the process leading to a revocation decision is procedurally fair. For example, the participant should be given reasonable opportunities to provide additional information to support their continued eligibility. In order to achieve a procedurally fair process, the delegate for revocation needs to take into account the participant’s individual circumstances. For example, some participants may require more time than others, and some participants may require additional support throughout the process.

As you can imagine, this may be difficult to understand for the participant who thought they gained access to the NDIS for their lifetime. It is an important factor for Scheme sustainability

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that all participants in the Scheme meet the eligibility requirements. Additionally, those participants who will transition from the Scheme must be offered the opportunity or supported to link with supports across mainstream and their community. If, after assessing all available evidence, a delegate for revocation is satisfied the participant does not meet the residence requirements, disability requirements or early intervention requirements based on the evidence, the delegate may decide to revoke the participant’s status as a participant. Note - for NSW participants only : If you consider that a participant who entered the Scheme in NSW does not meet the residence requirements, please contact the Director, State Operations to discuss before progressing the revocation. These participants will be transitioned from the Scheme to be supported by Mainstream, Informal and Community Supports with support of a Local Area Co-ordinator (LAC). The decision to revoke a participant’s status as a participant is a reviewable decision. This means that the decision may be internally reviewed by a delegate of the CEO, or externally reviewed by the Administrative Appeals Tribunal (AAT). Note: If there is no information currently available to indicate the participant may not meet the eligibility criteria, you will continue planning without further reference to this Practice Guide.

Defined Programmes

Many participants transitioned to the NDIS from Defined programs. As these participants had to meet the eligibility criteria to access the defined programs, they were presumed to have met the disability requirements for the NDIS. This means they did not have to provide evidence of their impairment/s or the impact of those impairments on their functional capacity. However there may now be evidence to suggest they may not meet the requirements for the NDIS. A participant’s eligibility can be reassessed if there is existing information to indicate they may not meet the eligibility criteria for the NDIS. Note: You should not reassess the participant’s eligibility unless evidence already exists to indicate they may not meet the eligibility criteria for the Scheme. In the NDIS Business System (system), you can determine if someone has a defined status by going to the Internal Use section and expand the State and Territory Load section, where defined in programs will have either yes or no. A yes next to Defined in Program means the participant is a defined participant.

Delegate for revocation

As a delegate you have the authority to make the revocation decision to change the status as a participant of the NDIS. It is important that for any one participant you are either the plan delegate or the delegate for revocation and you can never be both. This means if you make a decision to revoke a participant’s eligibility and the decision is overturned on internal review or by the AAT, or you

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are considering revocation and the participant remains in the Scheme, you can never be the plan delegate who approves this participant’s plan. Your first action when you receive a referral for reassessment is to contact the participant and advise them of the eligibility reassessment. You can use the script below as a guide;

“A normal part of the NDIS planning process is to review information regarding your function and needs. While I will not be involved in the development of your plan/plan review, my role is to reassess your eligibility to the NDIS. I’ll be considering the information we have and I will be in contact with you again regarding any further information you may wish to provide.

I know this may come as a bit of a shock and you may be worried about what this might mean. Before any decision is made I will be in contact with you and provide you with the opportunity to res pond. I’m also going to send you a letter outlining what we have just discussed. Do you have any questions?” You will need to send the letter – Eligibility Reassessment (s30) and update the interaction titled Eligibility Reassessment to confirm you have contacted the participant to explain the eligibility reassessment is underway and the letter has been sent to the participant/nominee or child representative.

Description: Eligibility Reassessment - Channel: Internal Notes Category: Non ATHM Artefact Status: Open

Notes: Confirm you have contacted the participant and advised them an eligibility reassessment is underway. Confirm the letter has also been sent to participant.

Considerations when decision making

As a delegate for revocation, you will need to consider all information in the system; Interactions, Inbound Documents and any other information the participant, their nominee or child representative has provided. You will need to be mindful additional information for consideration may be provided during the course of your decision.

Any decision you make as a delegate regarding the participant’s eligibility must be based on evidence and this decision should not come as a surprise to the participant, as you have kept them informed along the way.

For the NDIA to revoke a participant’s status as a participant in the NDIS, the Agency must have sufficient evidence to demonstrate the participant no longer satisfies:

• the residence requirements, or
• the disability requirements or early intervention requirements.

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When you consider the available information, if there is insufficient evidence regarding the participant’s continued eligibility they must remain as a participant in the Scheme. This guidance sets out how you might obtain further evidence or information from the participant on whether the participant continues to meet the residence requirements and early intervention requirements or disability requirements. When making a decision to revoke a participant’s status as a participant, delegates must have regard to:

• The Law National Disability Insurance Scheme Act 2013 (NDIS Act) and National Disability Insurance Scheme (Becoming a Participant) Rules 2016 (Becoming a Participant Rules);
• Policy (NDIS Operational Guidelines)
• Evidence.

Law:

• Section 30 of the NDIS Act (Revocation of participant status)
• Section 23 of the NDIS Act (Residence requirements)
• Section 24 of the NDIS Act (Disability requirements)
• Section 25 of the NDIS Act (Early intervention requirements)
• Becoming a Participant Rules.

Policy:

• Part 13.4 of the Access Operational Guidelines
• Part 7 The residence requirements of the Access Operational Guidelines
• Part 8 The Disability Requirements of the Access Operational Guidelines
• Part 9 Early Intervention Requirements of the Access Operational Guidelines.

Evidence You will need to review all evidence provided to determine if the participant continues to meet the residence requirements, disability requirements or early intervention requirements. The participant may require assistance to obtain additional evidence and while the NDIS would not cover the cost of providing additional information, they could obtain a progress report from the treating therapist or a Care Plan from their GP to assist with the cost of obtaining additional information. Before finalising your decision you should be satisfied and be able to demonstrate you have given the participant the flexibility and support, if required, to provide additional information.

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Refer to the following guidance and tools to assist with knowing what evidence to look for and what to consider in your decision making:

• Appendix B – Evidence Protocol for Sect.24 Decision Making – review of eligibility

• Appendix D – Evidence Protocol for Sect.25 Decision Making – for Review of an Existing Participant’s Eligibility.

Types of evidence

This could be any diagnostic information supported by clinical evidence in:

• medical or clinical reports, diagnosis or assessments

• provider progress reports and assessments

• the Access Request Form (ARF)

• EC partner documents.

Look for

• diagnostic information

• evidence of permanency

• recent evidence of functional impact in relation to the participants primary and/or secondary disability

• any other reference to functional impact determined through screening assessments by the appropriate allied health professional

• recommendations and specific goals for further intervention to address functional limitations in the listed areas

• references of existing and continued need for supports for extended duration e.g. more than 6 months

• information about current functional status and capacity in relation to the person interacting with their social network, getting out into the community, meeting with family and friends.

For psychosocial conditions you should refer to the Practice Guide - Access Psychosocial Disability for additional considerations.

For more detailed guidance on types of evidence and what to look for, refer to the attached Appendices A through D.

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Eligibility reassessment process

It is really important as the delegate for revocation to work through each step of the Decision Tree. This will help you to make a thorough assessment of the disability requirements and early intervention requirements. If this leads you to make a decision to revoke the participant’s status as a participant in the NDIS, you will have prepared a clear record of the reasons that support your decision.

Continues to meet eligibility

If you have considered all available information against the criteria in the Decision Tree and you are satisfied the participant meets the residence requirements, disability requirements or early intervention requirements, you will need to follow the process described below in Finalise your decision – Continues to meet eligibility and the participant will remain in the NDIS.

Unlikely to meet eligibility – Opportunity to respond

By now you have worked through each section of the Decision Tree and recorded your considerations against each criteria. You should have a reasonable idea of the specific residence requirements, disability requirements or early intervention requirements which may form an adverse decision for the participant.

If there is evidence to suggest the participant may not meet the eligibility requirements of the Scheme you will need to do the following:

1. Contact the participant and provide an opportunity to respond. You need to be clear and specific with the evidence you have used and relate this to the eligibility criteria being reassessed. This will guide the participant about the type of information they may wish to provide in their response. You also need to be flexible if the participant requires support from their LAC and/or additional time to respond to your request.

Use the script below as a guide.

“As you are aware, the NDIA is currently reassessing your eligibility for the NDIS. Based on the information and evidence we have, your residence/impairment doesn’t meet the ‘residence requirements’, ‘disability requirements’ or the ‘early intervention requirements’. Before I make my decision, I wanted to give you an opportunity to respond and provide any additional evidence or information you think might be relevant to this decision.

“Shortly, I will send you a letter addressing which residence requirements, disability requirements or early intervention requirements are being reassessed and what evidence we have on record to undertake the reassessment.

“The letter will contain all of the information I have explained to you during this phone call. It will mention you have `delegate to provide timeframe, not

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less than 28 days to respond and if you choose, to provide any additional information or evidence. If we don’t receive anything further from you I will finalise my decision. Should you have any further questions about this process, please get in touch with us. Do you have any questions?” 2. The delegate is to specify which criteria is being reassessed and advise the participant on the evidence or information the Agency is relying on in reaching this view. These will be the ‘residence’, ‘disability requirements’ or ‘early intervention requirements’ you have identified as not being met when you worked through your Decision Tree. For more information you can refer to Appendix B – Evidence Protocol for Sect.24 Decision Making – review of ‘disability requirements’ and Appendix D – Evidence Protocol for Sect.25 Decision Making – review of ‘early intervention requirements’.

3. Prepare the letter – Participant Eligibility Reassessment – Opportunity to Respond.

4. It’s important to include the specific information you are asking for in relation to the eligibility criteria being reassessed. For example if you do not have information on the permanency of the participant’s impairment you should be advising:

   • To remain eligible for the NDIS, criteria to meet disability requirements includes that your impairment(s) is permanent (or likely to be permanent)

   • In assessing this criteria we refer to the medical report from DR XXX, dated 00/00/00 which does not satisfy that this criterion is met.

   • We would like to provide you with the opportunity to respond and provide any additional information which may be relevant to this criteria.

5. Your Team Leader needs to proof read this letter prior to sending.

6. Add notes from this contact to the Open Interaction titled Eligibility Reassessment

7. The participant needs to be given a reasonable opportunity to respond and provide any additional information or evidence relevant to the decision. Send the letter – Participant Eligibility Reassessment – Opportunity to Respond and update the Interaction titled Eligibility Reassessment

Description: Eligibility Reassessment - Channel: Internal Notes Category: Non ATHM Artefact Status: Open Notes: Confirm you have contacted the participant and advised them an eligibility reassessment is underway and it looks as though on the information we have on the Practice Guide – Eligibility Reassessment v2.0 APPROVED 2019-02-15 Page 10 of 38

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participants record they may not meet eligibility for the Scheme. Confirm a letter

explaining the details of the information we require has also been sent to participant.

Note: Even if you have sufficient information to confirm a decision to revoke, the participant must still be provided with the opportunity to respond and if they choose, to provide additional information. Review any additional information provided Once the time period has passed, check Inbound Documents and Interactions for any new evidence which may have been provided. Review all evidence and again work through the Decision Tree recording your justification and all evidence you have considered.

Note: You should not proceed until either the participant provides additional information or the <reasonable period, not less than 28 days> has passed for the participant to provide additional information and you are satisfied the participant does not want to provide anythingurther. As a result of providing the opportunity to respond there are two possible outcomes;

• the participant continues to be eligible, see Finalise your decision – Continues to meet eligibility or

• the participant is not eligible. Refer to the Technical Advisory Team (TAT) Following consultation with your team leader if you would like some further guidance before finalising the decision you can refer to the TAT by submitting a TAT Request Form. It is expected that requests to the TAT will most likely be for interpreting a clinical diagnosis. Finalise your decision By now you have had several conversations with the participant, their nominee or child epresentative, had phone calls clearly explaining the eligibility criteria being reassessed, the evidence being used and provided an opportunity to respond and followed this up in writing. You need to be confident you have given the participant, their nominee or child epresentative sufficient opportunity to respond and be satisfied that they understand that in the absence of additional information or evidence, an adverse decision is likely. You may have received additional information from the participant, nominee or child epresentative. You should work through each criteria again in the Decision Tree in light of the new information and evidence, considering all information available to you against the residence requirements, disability requirements and early intervention requirements. Before finalising your decision, you should put yourself in the position of the participant and consider:

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1. Has the process leading to my decision been procedurally fair (i.e. has the participant been given a reasonable opportunity to respond and provide further evidence or information relevant to the decision? Was the participant given adequate notice that an adverse decision was likely, if they did not respond to the opportunity given to provide additional information according to the specific criteria being reassessed);

2. Is my decision based on proper evidence and is this demonstrated in the reasons for my decision?; and

3. Does the participant have enough information to understand the reasons for my decision, such that the participant can easily determine whether they should seek an internal review of the decision?

Note: If after following all attempts to obtain additional information your decision is unclear you must not revoke the participant status. In order to make a decision to revoke the participant’s status as a participant, you need to be ‘satisfied’ that the participant does not meet the residence, disability or the early intervention requirements. If you are unsure you should not revoke the participant’s status. Continues to meet eligibility After working through the Decision Tree and considering all evidence, if you decide the participant continues to meet the residence requirements, and disability requirements or early intervention requirements, you will need to;

1. Contact the participant and advise them the eligibility reassessment process has concluded. Use the following script as a guide.

   “As you know, the NDIA has been considering your eligibility for the Scheme. This is now complete and I am calling to let you know you are still a participant in the NDIS. I’m going to send you a letter to confirm this. Do you have any questions?”:

2. Send the letter – Eligibility Reassessment - Reaffirming Participant Status. Save a copy of the letter as an Inbound Document

3. Attach your reasons against the Decision Tree as an Inbound Document

4. Update the open interaction – Eligibility reassessment and record your conversation with the participant and your decision using the templates below.

Based on the information provided, <Person’s name> meets the ‘disability requirements’ as set out in s24 of the NDIS Act 2013 based on the following:

• For Disabilities on List A (includes children)

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Attached evidence from <Name and discipline of Health Professional> indicates that <participant name> has a diagnosis of <disability/ies>. This is a List A condition and no further assessment is required. <Logon ID>

• For Disabilities on List B

Attached evidence from <Name and discipline of Health Professional> indicates that <participant name> has a diagnosis of <condition/s>. This is a List B condition that results in substantially reduced functional capacity in (select relevant) <mobility/communication/social interaction/learning/self-care/self-management> affecting <social and/or economic participation> and is likely to require supports under NDIS for their lifetime. <Logon ID>

• For all other Disabilities

Attached evidence from <Name and discipline of Health Professional> indicates that <participant name> has a diagnosis of <impairment/s>, that is likely to be permanent and results in substantially reduced functional capacity in <domain- select relevant: mobility/communication/social interaction/learning/self-care/self-management> affecting <social and economic participation> and is likely to require supports under NDIS for their lifetime. <Logon ID>

• Include confirmation you have sent the letter confirming they will remain a participant. Then reassign the Interaction to the original sender for their information.

Unable to contact

If you have been unable to make contact with the participant once you have documented all your attempts to make contact, you should not proceed with a revocation. Despite the evidence on the participant’s record they must remain as a participant in the Scheme. Refer to the Task Card – Unable to contact to guide you through the next steps.

Does not meet eligibility - decision to revoke

After working through the Decision Tree and considering all the evidence, if you decide the participant does not meet the residence requirement, disability requirements or early Intervention requirements, you will need to progress to make a decision to revoke their status as a participant;

1. Clearly set out the full reasons for the decision in writing including a cover letter (Letter – Eligibility Reassessment Decision – not eligible) and Eligibility Reassessment - Decisions Report. Save Letter 5 and the Statement of Reasons as an Inbound Document on the participant’s record.

Every delegate who exercises the CEO’s power to revoke a participant’s status as a participant must take ownership over their decision and clearly set out the full reasons for their decision in writing. You should provide a copy of the Statement of Reasons to the

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1. Send a letter to the participant with the letter to the participant advising them they are no longer a participant in the NDIS.

2. Call the participant and advise of the decision that you are about to make and the reasons for your decision. In this phone call advise the participant of the date the NDIS support will cease. You will also need to advise the participant to contact their service providers to advise they will no longer be able to provide services under the NDIS from that date.

Note: The date the delegate performs the steps in the system to revoke is the date the participant’s funded supports are ceased. Providers will not be able to claim for supports provided past this date.

Use the following script as a guide:

“As you know, the NDIA has been reassessing your eligibility to access the Scheme. The reassessment is now complete and I am calling to let you know that a decision has been made to transition you from the NDIS. This means you will no longer be a participant of the NDIS. <ONLY Advise a date if the decision will be made that day. “This means that you will cease to be a participant in the NDIS on . Your plan will cease to be in effect on .”>. This is a reviewable decision which means if you are not satisfied with the decision, you can request an internal review of the decision. If you request a review, this will be conducted by an independent delegate who was not involved in the original decision. After this call, I will send you a letter notifying you of the decision and explaining the reasons for the decision. The letter will also tell you how to apply for an internal review of this decision if you don’t agree with the decision I have made. Do you have any questions?”

3. You can then revoke the participant’s status in the system following the SOP- SDSA Team – Transition the Participant from the NDIS

4. Update the Interaction titled Eligibility Reassessment

Description: Eligibility Reassessment Channel: Internal Notes Category: Non ATHM Artefact Status: Completed Notes: Record all information you have considered in making your decision

5. Once you have made the decision to revoke a participant’s status as a participant, contact the LAC to inform them of your decision and advise them to commence linking the participant with Mainstream and community supports.

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6. Participants Granted Eligibility Under a Defined Program

For participants who were granted eligibility under a defined program, provide the relevant State based Service Delivery Director with the participant’s details to inform their discussions with government around ongoing eligibility to continuity of supports.

Information, Linkages and Capacity Building (ILC)

All Participants who have been assessed as no longer meeting the eligibility requirements and have been sent a letter of revocation must be supported with a referral to their Local Area Coordinator to ensure they are connected to mainstream and community supports.

Version change control

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Appendix A – Guide to Disability requirements

In order to revoke access, you must be satisfied that the participant does not meet both the disability requirements and the early intervention requirements.

For a person to not meet the disability requirements you must be satisfied that the participant does not meet one or all of the requirements/criteria.

Please note, if the person does not meet the disability requirements, the person should then be assessed under the early intervention requirements.

Disability requirements

Section 24(1)(a) – Impairment attributable to disability

Refer to Operational Guidelines – Access to the NDIS – Part 8.1 – What is a disability attributable to impairment?

Section 24(1)(b) - Permanency

Refer to Operational Guidelines – Access to the NDIS - Part 8.2 – When is an impairment permanent or likely to be permanent?

Section 24(1)(c) – Substantially reduced functional capacity

Refer to Operational Guidelines – Access to the NDIS – Part 8.3 – Substantially reduced functional capacity to undertake relevant activities

Section 24(1)(d) – Social and economic participation

Refer to Operational Guidelines – Access to the NDIS – Part 8.4 – When does an impairment affect a person’s capacity for social or economic participation?

Section 24(1)(e) – Lifetime support & most appropriate service system

Refer to Operational Guidelines – Access to the NDIS – Part 8.5 – When is a person likely to require support under the NDIS for their lifetime?

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Disability - Evidence of impairment on List A

Refer to Operational Guidelines – Access to the NDIS – Part 8.6 – Streamlined process for determining the disability requirement

• Refer to List A of the Operational Guidelines - Access to the NDIS for a list of conditions likely to meet the disability requirements in s24. • People with impairments on List A will generally meet the disability requirements following evidence of their condition. • Evidence should be sought from an appropriate Treating Professional related to the person’s condition/s on List A (Refer to the Disability evidence from your treating health professional guide). • Meets disability requirement: no further evidence of permanency or functional impairment required.

Disability - Evidence of impairment on List B

Refer to Operational Guidelines – Access to the NDIS – Part 8.6 - Streamlined process for determining the disability access requirement.

• Refer to List B of the Operational Guidelines – Access to the NDIS for a list of conditions considered to be permanent without further evidence

• People with impairments on List B will not need to provide evidence that their disability is attributable to a permanent impairment (refer to paragraph 8.6.2 of the Access Operational Guidelines). You will still need evidence to determine that as a result of impairment, the person: • has an impairment/s that result in substantially reduced functional capacity to perform one or more activities; • has impairment/s which affect the person’s capacity for social and economic participation; and • is likely to require support under the NDIS for the person’s lifetime in order for the participant to meet the disability requirements.

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Disability - All other impairments

Refer to Operational Guidelines – Access to the NDIS – Part 8 – The disability requirements.

• Assess evidence provided by a treating health or educational professional of impairment against each of the disability requirements (see paragraph 8 of the Access Operational Guidelines). Supportive evidence can be provided by the participant and/or their representative.

• Use the Appendix A - Guide to disability requirements and Appendix B – Evidence Protocol for Sect.24 Decision Making – review of ‘disability requirements’.

• Where the person does not meet the criteria under Sect 24 (1)(a), (b) (c), (d) or (e), consider the evidence against the ‘early intervention requirements’ use Appendix C – Guide to the early intervention requirements and Appendix D - Protocol for Sect.25 Decision Making – review of ‘early intervention requirements’.

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Appendix B - Evidence Protocol for Sect.24 Decision Making – review of disability requirements

Purpose: This protocol is used to review an existing participant’s continued eligibility for the NDIS. It aims to assist the delegate to apply the criteria of Sect.24 of the NDIS Act 2013 when reviewing an existing participant’s current functional capacity and ongoing support needs if any, and provide policy guidance to what information about the participant’s disability and function must be considered for them to continue to satisfy the disability requirements. This Protocol should be considered alongside the NDIS Operational Guidelines (OGs) (this Protocol does not replace the OGs).

Frame of reference: When the CEO’s delegate makes a decision to revoke a participant’s status as a participant in the NDIS, the delegate must be able to explain the reasons for their decision. If the CEO’s delegate is unsure whether the participant meets the disability requirements or early intervention requirements due to a lack of information, no decision should be made until the CEO’s delegate is satisfied that the participant does not meet both the disability requirement and early intervention requirements. If there is insufficient up-to-date information to enable the CEO’s delegate to make a decision about one of the parts of section 24, it cannot be assumed that the criteria is not met. There must be evidence which shows that the criteria is no longer met.

Decisions must be based on up-to-date information which details the participant’s ongoing functional deficits and recommendations about future interventions.

Note:

1. For episodic psychosocial diagnoses, take care not to revoke just because the participant has not had an episode in the period since entering the Scheme. Seek advice from TAT or Advisory Services – Mental Health team, if you require support with your decision making. Do not assess participants who meet the criteria of List A of the Access Operational Guideline.

2. Always consider the initial documentation submitted with the participant’s access request as well as up to date information. This allows the delegate to consider change as the initial information can be used as a baseline.

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Section 24.Disability requirements

(a) the person has a disability that is attributable to one or more intellectual, cognitive, neurological, sensory or physical impairments or to one or more impairments attributable to a psychiatric condition; and | Look for current diagnostic information supported by clinical evidence on Medical or clinical documents Provider reports Info on the ARF | Be aware that signs eg. pathology findings, and symptoms e.g. pain, limping or swelling, are not impairments. Consider whether there is a diagnosis and how the impairment relates. Note: diagnoses are labels. Whilst many describe an impairment, even with a diagnosis, there still may not be an impairment for that person. | If unable to get up-to-date evidence to review original decision — criteria remains same as per original decision. If information is unclear — seek advice from TAT. |

(b) the impairment or impairments are, or are likely to be, permanent; and | Look for diagnostic information on updated medical/clinical | If unable to get up-to-date evidence to review original decision — criteria | Likelihood of permanence for a psychosocial disability is very hard to determine in this age group. | Likelihood of permanence for a psychosocial disability is very hard to determine in this age group however if | Consider the history of the condition, if the participant’s current function is significantly greater than it was

Legislation

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ndis

Considerations for 0-6 cohort ### Considerations for 7-14 cohort ### Considerations for over 14yo

(c) the impairment or impairments resulting in substantially reduced functional capacity to undertake, or psychosocial functioning in undertaking, one or more of the following activities:

(i) communication; (ii) social interaction;

Consider using the Pedicat to reassess

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Legislation

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Legislation

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

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

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(2) For the purposes of subsection (1), an impairment or impairments that vary in intensity may be permanent, and the person is | Where the person’s condition and function appears to be episodic or variable, look for information relating to their functional condition when they | Most likely to be psychosocial conditions so ensure that the NDIS is the most appropriate provider of supports rather than the | Unlikely to be relevant for children. | Unlikely to be relevant for the younger participants of this group but may start to be seen with older children. |

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Appendix C – Guide to the ‘early intervention requirements’ In order to revoke access, you must be satisfied that the participant does not meet both the disability requirements and the early intervention requirements. A participant will not meet the early intervention requirements if the participant does not meet one or all of the requirements/criteria.

Early intervention requirements Refer to Operational Guidelines – Access to the NDIS – Part 9 - Early intervention requirements Section 25(1)(a) – Permanency and Developmental Delay Refer to Operational Guidelines – Access to the NDIS – Part 9.1 – When is an impairment permanent or likely to be permanent for the early intervention requirements. Refer to Operational Guidelines – Access to the NDIS – Part 9.2 – Developmental delay (early intervention in early childhood) Section 25(1)(b) and (c) – Likely to benefit the person Refer to Operational Guidelines – Access to the NDIS – Part 9.3 – Determining whether early intervention supports are likely to benefit the person Section 25(3) – Most appropriate service system Refer to Operational Guidelines – Access to the NDIS – Part 9.4 – Is the support most appropriately funded or provided through the NDIS? Guide to Early Intervention - Developmental Delay (under 6 years only) Refer to Operational Guidelines – Access to the NDIS – Part 9.2 – Developmental delay (early intervention in early childhood) Early intervention - Child under 7 years with evidence of impairment on List D Refer to Operational Guidelines – Access to the NDIS – Part 9.5 – Streamlined process for determining the early intervention requirements for children under 7 years of age.

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Child under 6 years with evidence of Developmental Delay

• Refer to List D of the Operational Guidelines – Access to the NDIS for a list of conditions likely to meet the early intervention requirements.

• Children under 7 with an impairment directly matching the condition and assessment type listed on List D will generally meet the early intervention requirements.

• Meets ‘early intervention requirements’: no further evidence of permanency or functional impairment required.

Child under 6 years with evidence of Developmental Delay Refer to Operational Guidelines – Access to the NDIS – Part 9.2 – Developmental delay (early intervention in early childhood).

• Use Appendix C - Guide to ‘early intervention requirements’ to assist your decision making and Appendix D – Evidence Protocol for Sect.25 Decision Making – for review of early intervention requirements.

• If standardised tests are either not available or other assessment methods are considered best practice, you can use milestone inventories or other functionally based assessments performed by a qualified professional. You should seek reports on the child’s current level of functioning, and comparison to normative data on the domain of development.

Child under 7 without Developmental Delay and condition not on List A or List D

Refer to Operational Guidelines – Access to the NDIS – Part 9 – Early intervention requirements and Operational Guidelines – Access to the NDIS – Part 8 – The disability requirements.

• Assess against the Early Intervention criteria first using Appendix C - Guide to early intervention requirements to assist your decision making and Appendix D – Evidence Protocol for Sect.25 Decision Making – for review of an early intervention requirements’.

If the participant does not meet these requirements, you should consider if the participant otherwise meets the ‘disability requirements.

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Appendix D – Evidence Protocol for Sect.25 Decision Making – for Review of early intervention requirements

Purpose: This protocol is used to review an existing participant’s continued eligibility for the NDIS. It aims to assist the delegate to apply the criteria of Sect.25 of the NDIS Act 2013 when reviewing an existing participant’s current functional capacity and ongoing support needs if any, and provide policy guidance to what information about the participant’s disability and function must be considered for them to continue to satisfy the early intervention requirements.

Frame of reference: When the CEO’s delegate makes a decision to revoke a participant’s status as a participant in the NDIS, the delegate must be able to explain the reasons for their decision. If the CEO’s delegate is unsure whether the participant meets the disability requirements or early intervention requirements due to a lack of information, no decision should be made until the CEO’s delegate is satisfied that the participant does not meet both the disability requirements and the early intervention requirements. When reviewing eligibility, up-to-date evidence needs to be obtained since the original decision and within the last 2 years. If there is insufficient up-to-date information to enable the delegate to make a decision about one of the parts of section 25, it cannot be assumed that the criteria is not met ie. there must be evidence which shows that the criteria is no longer met.

Decisions must be based on up-to-date information which details the participant’s ongoing functional deficits and recommendations about future interventions. TAT advice should be sought where evidence is unclear.

Note:

1. Children who entered the NDIS under the age of 6yo with diagnoses of developmental delay must have their eligibility reviewed when they turn 6yo.

2. For episodic psychosocial diagnoses, take care not to revoke just because the participant has not had an episode in the period since entering the Scheme. Seek advice from TAT, ECEI team or Advisory Services – Mental Health team, if you require support with your decision making.

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Section 25. Early intervention requirements.

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

(a) the person:

• has one or more identified intellectual, cognitive, neurological, sensory or physical impairments that are, or are likely to be, permanent.

  Where and what evidence to look for: Look for current diagnostic information supported by clinical evidence on:

  • Medical or clinical documents
  • Provider reports
  • Info on the ARF.

  General considerations: Be aware that signs eg. pathology findings, and symptoms e.g. pain, limping or swelling, are not impairments. Consider whether there is a diagnosis and how the impairment relates. Note: diagnoses are labels. Whilst many describe an impairment, even with a diagnosis, there still may not be an impairment for that person.

  What to do: If unable to get up-to-date evidence to review original decision — criteria remains same as per original decision. If information is unclear — seek advice from TAT.

  Considerations for 0-6 cohort: redacted

  Considerations for 7-14 cohort: redacted

  Considerations for over 14yo: redacted

(ii) has one or more identified impairments that are attributable to a:

**Where and what evidence to look for:** Look for diagnostic information on updated medical/clinical.

**General considerations:** `redacted`

**What to do:** If unable to get up-to-date evidence to review original decision — criteria.

**Considerations for 0-6 cohort:** Likelihood of permanence for a psychosocial disability is very.

**Considerations for 7-14 cohort:** Likelihood of permanence for a psychosocial disability is very.

**Considerations for over 14yo:** Consider the history of the condition and if the participant’s current

| psychiatric condition and are, or are likely to be, permanent; or | documents or provider reports. Need to consider if there is an ongoing impairment and if that impairment is, or is likely to be, permanent. Research permanence against the criteria outlined in the Rules/OG’s. Understand whether there may be further relevant research, treatments or development that may impact on permanence. For psychosocial conditions refer to Psychosocial Disability Practice Guide. If participant appears to have improved and you are unable to find up-to-date information about likely permanence,

| remains same as per original decision.

| hard to determine in this age group. Further information may be required.

| hard to determine in this age group however if participant has been in Scheme for over 2 years and continues to have constant, ongoing difficulties, this may indicate high probability of permanence. See advice from psychosocial team.

| function is significantly greater than it was previously.

For recurring diagnoses e.g. Bipolar Disorder, look for confirmed recurrences.

| request an updated report. | Consider sending any psych condition to NAT psychosocial SME or TAT or Psychosocial team. | (iii) is a child who has developmental delay. | Look for evidence of ongoing functional impact to determine developmental profile in medical/clinical information, including ECEI partner information, documents. Search for and review evidence of functional impact of disability and/or developmental delay and use same thinking as used for sect.24.1c. Look for reference to continued dysfunction in these areas in up-to-date documents or as determined. | Developmental delay and Global Developmental Delay (GDD) are very different. Do not assume that if the child has had only one type of intervention then they don’t need more than one. There may have been funding limitation. Look at what is recommended for future intervention. Take care not to simply consider provider’s recommendations for care e.g. recs for hours of care for children, without consideration of | If child previously assessed as meeting the definition of developmental delay and is now 6yo or older, criteria cannot be met. | If child is under 6yo and further information is required to demonstrate ongoing delay, request they get this from providers. If no indication or evidence of continued functional impact in new information, request details about these areas. Refer to the | Check age of the child. If 6yo or older, cannot meet the definition of DD. | Developmental delay is not a diagnosis nor a disability, but rather a descriptive term for when a child’s developmental is slower compared to other children of the same age. This means that the evidence for developmental delay will often take the form of descriptions of how a child is progressing with developmental milestones and

| person’s future needs for supports in relation to disability; and | over 2 years in NDIS, consider this as a critical time for review against sect 25 and sect.24. Consider reported benefit of interventions provided to date and how participant is now functioning. Consider provider progress reports and recommendations for further intervention. Look for evidence that ongoing and future support is needed. Look for information re: potential for functional outcomes and proposed impact on future needs | (c) the CEO is satisfied that provision of early intervention supports for the person is likely to | Look for up-to-date information about continued deficits in these areas and for recommendations | For relevant age group: conduct the Pedicat to assist with a current review of functional | Functional capacity of the person to undertake communication, social interaction, learning, mobility, Functional capacity of the person to undertake communication, social interaction, learning, mobility,

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| benefit the person for interventions specific to these impact of impairment. self-care or self-management, and whether early intervention is likely to benefit the participant in these areas on a more holistic basis should be considered, relevant to age. Remember affected learning must be due to an identifiable impairment, not just a learning or attention issue. | If not present, seek additional information from participant or rep about participant’s capacity in these areas | If up-to-date information states there is no further impact of impairment, criteria is likely to not be met. | (ii) preventing the deterioration of such functional capacity; or Consider whether there is still risk of deterioration and whether appropriate supports can be put in place to prevent this e.g. provision of AT to reduce further functional loss eg. use of a power wheelchair can reduce risk of shoulder overuse injury common with SCI caused by self-propelling. | If up-to-date info states there is no further risk of deterioration – criteria is likely not met.

Note: In certain circumstances, a person with a degenerative condition could • Look for references to ongoing support needs in up-to-date clinical and | Examples would be diagnoses with low severity levels where the person has the diagnosis |

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Early Intervention Requirements and Participant

meet the early intervention requirements and therefore become a participant.

• For children, look for information where ongoing intervention will prevent or delay impact of degenerative condition.

(2) The CEO is satisfied as referred to rules 6.10-taken to be 6.11 that has satisfied as mentioned in paragraphs (1)(b) and (c) if one or more of the person’s impairments are prescribed by the National Disability Insurance Scheme rules for the purposes of this subsection.

(3) Despite subsections (1) and (2), the person does not meet the early intervention requirements if the CEO is satisfied that early intervention support documents are not functional. For example: Autism Spectrum Disorder.

Review up-to-date recommendations for ongoing treatment/interventions and determine whether most appropriately funded or provided by the NDIS. If supports are most appropriately provided by another service, consider COAG Principles relating to Education. If up-to-date information shows that no further interventions recommended or best provided by another service, consider what is recommended for them and whether any other system can provide this – whether they are accessing it or not.

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Eligibility Reassessment

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[Image not converted to Markdown – “Page Image” – check the source PDF page for the actual content]

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.

education i.e. Relate to learning at school incl reading and writing, person is likely to be best supported by Education and so not meet sect.25(c)

system, criteria is likely not met.

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Access and Eligibility Reassessment (ER) Practice Guide

FOI 22/23-1046 DOCUMENT 2

For Internal Use Only

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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

2. Checklist

• Section 21, 22, 23, 24 and 25 of the National Disability Insurance Scheme Act 2013
• NDIS Becoming a Participant Rules 2016
• Operational Guidelines - NDIS | | Actions | You are working through:
• Access and ER Decision Tree
• 3. Are you making an Access or ER decision
• 4. Access — Age Requirements
• 5. Access — Residence Requirements
• 6. Access — Streamlined Decisions
• 7. Access — Disability Requirements
• 8. Access — Early Intervention Requirements
• 9. ER — Residence Requirements |

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Checklist

• 10. ER— Streamlined Decisions
• 11. ER—Disability Requirements
• 12. ER—Early Intervention Requirements
• 13. Related procedures or resources
• 14. Feedback
• 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);
• The applicant is non-defined and their data was received by the NDIA prior to their 65^th 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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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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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?](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

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 Go to Section 8.2 - Does the applicant meet Section hearing impairment criteria 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

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

Applicants aged 7 or over

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

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

Applicants aged 7 and over

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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

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

Applicants aged 7 and over

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.

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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 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 Go to Section 6.4 - 0-25 Hearing Impairments 24(1)(e)

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?

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

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

For applicants aged 7 and over

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

For applicants aged 7 and over

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

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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 Are not eligible for disability or early intervention 25(3) 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; • is an Australian Citizen; • is the holder of a permanent visa; • 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 issues 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?](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

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

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);
• the impairment is intellectual, cognitive, neurological, sensory, or physical in nature;
• 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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Action Call Back Request for an Eligibility Reassessment

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This Standard Operating Procedure (SOP) will help you action an Eligibility Reassessment (ER) call back request to the participant or their representative.

1. Recent updates

2. Checklist

3. Procedure

3.1 Review the Call back Request

Note: ER Call back Requests are allocated via the Ready for Work button. The work item will be the next available in the queue.

1. Review the ER Outcome, Interactions, Inbound Documents and notes on the participant’s record about the ER. Use this and the relevant conversation script to help you prepare for your call with the participant.
2. Locate the relevant conversation script: • If status is Commence Eligibility Reassessment

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o Refer to Step 3.6.3 of Standard Operating Procedure – Consider commencement of Eligibility Reassessment or Access Status Change. • If status is Opportunity to Respond

o Refer to Step 3.5.3 of Standard Operating Procedure – Consider Eligibility Reassessment outcome following 1st chance to respond. • If status is Revoke, Maintain Access Status or Change Access Status

o Refer to Step 3.9.3 (Revoke) or

o Refer to Step 3.16.3 (Maintain or Change Access Status) of Standard Operating Procedure – Make Eligibility Reassessment decision.

Note: Refer to Standard Operating Procedure – Action Evidence Extension Request for an Eligibility Reassessment where necessary.

If the participant advises they do not have a copy of any of the documents used to determine the ER outcome, you can provide copies of these documents to them.

3.2 Contact participant or representative: Call back Request

3.2.1 Contact the person

1. Refer to Standard Operating Procedure – Send SMS using Whispir messenger to send ‘Contact attempt SMS template’ to advise you will be calling.

Note: Only send this SMS before your first attempt to call the person.

Do not contact the person by SMS if they have told the Agency that they do not consent to this form of communication.

2. Make 5 telephone contact attempts (over a 3-day period, at different times of day) to the participant, nominee or child representative. If you reach their voicemail and the person identifies themselves, leave a brief message requesting they contact the NDIA on 1800 800 100. You must complete all required contact attempts, even if the number is disconnected.

3.2.2 If contact attempt is unsuccessful

Update Follow-up Request task following every unsuccessful call attempt.

Note: Do not update the status to Completed until you have spoken with the person or made all contact attempts.

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Standard Operating Procedure

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1. In the NDIS Account screen: Select Internal Use.

2. In Internal Use: Select Open Activities.

3. In the Transaction Id column: Select the hyperlinked Transaction Id that corresponds with the Follow-up Request activity.

4. In Status:

   • If first, second, third or fourth contact attempt, leave as Open • If fifth contact attempt, update to Completed.

5. In Notes:

Choose an item. phone call attempt made to <Person> on <Date> at <Time> on all available numbers.

Call not answered.

<Enter your User ID>.

6. Select Submit.

3.2.3 If all 5 contact attempts are unsuccessful

1. Refer to Standard Operating Procedure – Send SMS using Whispir messenger to send ‘Unsuccessful contact attempt’ SMS to advise you tried to call.

   Note: Only send this SMS after you make all required call attempts.

Do not contact the person by SMS if they have told the Agency that they do not consent to this form of communication.

3.2.4 If the call is answered

Update Follow-up Request.

1. In the NDIS Account screen: Select Internal Use.

2. In Internal Use: Select Open Activities.

3. In the Transaction Id column: Select the hyperlinked Transaction Id that corresponds with the Follow-up Request activity.

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4. In Status: Select Completed.

5. In Notes:

6. Select Submit.

Related procedures or resources

• Our Guideline – Leaving the NDIS
• Standard Operating Procedure – Consider commencement of Eligibility Reassessment or Access Status Change
• Standard Operating Procedure – Consider Eligibility Reassessment outcome following 1st chance to respond
• Standard Operating Procedure – Make Eligibility Reassessment decision
• Standard Operating Procedure – Action evidence extension request for an Eligibility Reassessment

Feedback

If you have any feedback about this Standard Operating Procedure, please complete our Feedback Form.

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Action evidence extension request for an Eligibility Reassessment

This Standard Operating Procedure (SOP) will help you action a request for more time to provide evidence for an Eligibility Reassessment (ER).

During an ER, it is the participant’s responsibility to provide sufficient evidence they still meet the eligibility requirements. If we are not satisfied that they meet the requirements, they may no longer remain a participant of the NDIS.

Recent updates

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Standard Operating Procedure

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Date | What’s changed

• Updates to generally only approve one extension of time request throughout the entire ER. Subsequent requests require endorsement from a Team Leader.
• Increased contact attempts to 5 for a declined extension request.
• If unable to contact the participant after a declined extension request, you should seek approval from Team Leader before closing the follow-up work item.

Checklist

Topic | Checklist

Pre-requisites | You have read and understood:

• Our Guideline — Leaving the NDIS

You have:

• drawn down a work item that states in Type — Eligibility Reassessment Evidence Extension Request

Or

The participant or representative has:

• asked for more time to give us evidence to support their continued eligibility.

Actions |

• 3.1 Receive Evidence Extension Request
• 3.2 Consider Evidence Extension Request
• 3.3 Contact participant or representative: Evidence Extension Request
• 3.4 Update ER request due date (if approved)
• 3.5 Add Interaction: Notify plan developer — Evidence Extension Request

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Standard Operating Procedure

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3. Procedure

3.1 Receive Evidence Extension Request

3.1.1 If the request is received in a Follow-up Request work item

An Access Officer or plan developer can create a Follow-up Request work item to assess an extension of time request. To locate information about the participant’s request, review the interactions on their record.

1. Go to Step 3.2 Consider Evidence Extension Request

3.1.2 If the request is received during phone call

The participant or their representative may make a request during a phone call with an Access Assessor. This allows you to ask for any additional information you require to consider the request during the call.

1. Ask for information about the request to decide whether to approve the request.

Explain that you need additional information about the reason for requesting an extension of time to provide evidence to support an eligibility reassessment.

Ask questions relevant to the request.

For example:

• What is the reason for the extension request?
• Has an appointment been booked?
• What is the date of the appointment?
• Who will the appointment be with?
• Is the appointment with a regular appointment with an existing treating professional?
• Is the appointment with a new treating professional?
• Is the person on a waitlist for an assessment to confirm a permanent impairment? (ask for specific details – date, type of health professional, is it routine or is it an appointment that will likely provide evidence for ER decision?)
• Is the person waiting on an appointment for an assessment that may change the outcome of the decision? (ask for specific details as above)

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Standard Operating Procedure

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• If the participant is experiencing difficulties securing a face-to-face appointment with the health professional, are alternative options suitable and have these been explored with the health professional (e.g. telehealth, video appointments)?

Note: This information will be recorded in an interaction later in Step 3.3.4.2: Add interaction.

If you consider the request reasonable based on their circumstances and you require Team Leader or Assistant Director endorsement, you will need to call the person back to provide the outcome.

3.2 Consider Evidence Extension Request

1. Review Interactions.

3.2.1 Consider Evidence Extension Request

You may grant an extension of time for the participant to provide information or evidence. The request must be reasonable based on the participant’s individual circumstances. There must be clear information for why they require additional time and a timeframe for when the information will be available.

1. Consider if the extension request is reasonable.

2. Consider the appropriate timeframe for the participant’s extension request.

   • For examples of reasonable requests, refer to Our Guideline – Leaving the NDIS.

3. Do you need Team Leader or Assistant Director endorsement for this request?

Note: Generally, we will only approve one extension request throughout the ER process.

• If the ER is not at the revocation stage, you have the discretion to apply an extension up to 28 days if there is evidence of a reasonable request.

The following evidence extension requests require endorsement from a Team Leader and/or Assistant Director:

• a second extension request at any stage requires TL approval • an extension request at any stage between 28 days and 3 months requires TL approval • an extension request at any stage more than 3 months requires TL and AD approval

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Standard Operating Procedure

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• any extension request at the revocation stage requires TL approval; however, AD approval is also required for extensions of more than 3 months.

4. If you receive a request that you find reasonable due to the participant’s circumstances and TL or AD endorsement is required, seek assistance from your Team Leader.

5. If you receive a request during a phone call and do not require TL or AD endorsement, you can provide the outcome during the call. Go to Step 3.3.4 If the call is answered.

6. Consider if you need additional information to decide whether to grant the extension.

Note: Further information may be required if the request is received in a Follow-up Request work item or if the request required Team Leader endorsement and the Team Leader suggested further information is required.

7. Do you need additional information?

• Yes: Go to next step (step 8) • No: Go to Step 3.3: Contact participant or representative: Evidence Extension Request.

8. Refer to Standard Operating Procedure – Send SMS using Whispir messenger to send ‘Contact attempt SMS template’ to advise you will be calling.

Note: Only send this SMS before your first attempt to call the person.

Do not contact the person by SMS if they have told the Agency that they do not consent to this form of communication.

9. Make one telephone contact attempt to the participant, nominee, or child representative. If you reach their voicemail and the person identifies themselves, leave a brief message requesting they contact the NDIA on 1800 800 110.

3.2.2 If the call is answered

Explain that you need additional information about the reason for requesting an extension of time to provide evidence to support an eligibility reassessment.

Ask questions relevant to the request.

For example:

• What is the reason for the extension request? • Has an appointment been booked? • What is the date of the appointment?

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• Who will the appointment be with?
• Is the appointment with a regular appointment with an existing treating professional?
• Is the appointment with a new treating professional?
• Is the person on a waitlist for an assessment to confirm a permanent impairment? (ask for specific details – date, type of health professional, is it routine or is it an appointment that will likely provide evidence for ER decision?)
• Is the person waiting on an appointment for an assessment that may change the outcome of the decision? (ask for specific details as above)
• If the participant is experiencing difficulties securing a face-to-face appointment with the health professional, are alternative options suitable and have these been explored with the health professional (e.g. telehealth, video appointments)?

Note: This information will be recorded in an interaction later in Step 3.3: Contact participant or representative: Evidence Extension Request.

1. Go to Step 3.2 Consider Evidence Extension Request.

3.3 Contact participant or representative: Evidence Extension Request

3.3.1 Send letter

1. Send Letter – ER in progress – consider request for more time to send evidence.

3.3.2 Contact the person

1. Refer to Standard Operating Procedure – Send SMS using Whispir messenger to send ‘Contact attempt SMS template’ to advise you will be calling.

Note: Only send this SMS before your first attempt to call the person.

Note: Do not contact the person by SMS if they have told us they do not consent to this form of communication.

If the extension request has been approved

1. Make one telephone contact attempt to the participant, nominee or child representative. If you reach their voicemail and the person identifies themselves, leave a brief message requesting they contact the NDIA on 1800 800 110.

If the extension request has been declined

1. Make 5 telephone contact attempts (over a 3-day period, at different times of day) to the participant, nominee or child representative. If you reach their voicemail and the person

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identifies themselves, leave a brief message requesting they contact the NDIA on 1800 800 110. You must complete all required contact attempts, even if the number is disconnected.

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3.3.3 If contact attempts are unsuccessful

If the extension request has been declined and you are unable to contact the participant after 5 contact attempts, over different days, escalate to your Team Leader prior to closing off the follow-up work item.

Update Follow-up Request work item

Note: Do not update the status to Completed until you have spoken with the person or made all contact attempts.

1. In the NDIS Account screen: Select Internal Use.
2. In Internal Use: Select Open Activities.
3. In the Transaction Id column: Select the hyperlinked Transaction Id that corresponds with the Follow-up Request work item.
4. In Channel:
   • If request is declined
     • If first, second, third or fourth contact attempts, leave as Open
     • If fifth contact attempt, and your TL has endorsed closing the task, update to Completed.
   • If request is approved
     • Select Completed.
5. In Notes:

ER – Evidence Extension Request <Approved/Declined>

Choose an item. phone call attempt made to <Person> on <Date> to advise that the request for an extension of time to provide information/evidence to support their continued eligibility has been Choose an item.

Evidence Due Date: <Date>

`.

<If further information was requested, note the details of the conversation>`

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<Reasons for approval / decline of request including details of upcoming assessments and appointments if relevant>.

.

.

, Team Leader, endorsed the request. OR , Assistant Director endorsed the request.

6. Select Submit.
7. Go to Step 3.4: Update ER request due date (if approved).

3.3.4 If the call is answered

1. Advise the person:

   • Explain that their extension request has been approved or declined.
   • : Explain reasons for the decision.
   • : Confirm the date that the information is due, and explain that a decision will be made after this date.
   • Explain that it is their (participant’s) responsibility to provide sufficient evidence that they still meet the eligibility requirements. If we are not satisfied that they meet the requirements, they may no longer remain a participant of the NDIS.
   • Encourage them to contact their plan developer or <local area coordinator / early childhood partner> if they have questions about their plan, or need support with any matters relating to their plan during the eligibility reassessment process.

2. If the request was received in a Follow-up Request work item, go to Step 3.3.4.1: Update Follow-up Request.

3. If the request was received during phone call, go to Step 3.3.4.2 Add interaction.

Update Follow-up Request

1. In the NDIS Account screen: Select Internal Use.
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1. In the Transaction Id column: Select the hyperlinked Transaction Id that corresponds with the Follow-up Request work item.

2. In Channel: Select Completed.

3. In Notes:

ER – Evidence Extension Request - <Approved/Declined>

requested an extension of time to provide evidence to support their continued eligibility.

I called on to advise that the request for an extension of time to provide information/evidence to support their continued eligibility has been Choose an item.

Evidence Due Date: .

.

<If further information was requested, note the details of the conversation>

<Reasons for approval / decline of request including details of upcoming assessments and appointments if relevant>.

.

, Team Leader, endorsed the request.

OR

, Assistant Director endorsed the request.

Standard Operating Procedure

For Internal Use Only

6. In Channel: Select Internal Notes.

7. In Status: Select Completed.

8. In Notes:

ER – Evidence Extension Request. <Approved/Declined>

redacted: requested an extension of time to provide evidence to support their continued eligibility.

I called redacted on <Date> to advise that the request for an extension of time to provide information/evidence to support their continued eligibility has been Choose an item.

Evidence Due Date: <Date>.

<Reasons for extension request>.

<If further information was requested, note the details of the conversation>.

<Reasons for approval / decline of request including details of upcoming assessments and appointments if relevant>.

<If relevant: This is a subsequent request and exceptional circumstances apply>.

<Team Leader logon ID>, Team Leader, endorsed the request.

OR

<Assistant Director logon ID>, Assistant Director endorsed the request.

<Details of conversation> OR <Call not answered>.

9. Select Submit.

• If approved, go to Step 3.4: Update ER request due date (if approved).
• If declined, go to Step 3.5: Add Interaction: Notify plan developer – Evidence Extension Request.

3.4 Update ER request due date (if approved)

1. In the NDIS Account screen: Select Internal Use.

2. In Internal Use: Select Open Activities.

3. In the Open Activities list: Select the Transaction Id associated with the Access Eligibility Re-Assessment Request.

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4. In the ER Request: Select Edit.

5. In Due Date: Select the new due date from the drop-down calendar.

6. In Supporting Info:

ER – Evidence Extension Request Approved.

redacted requested an extension of time to provide evidence to support their continued eligibility.

Extension approved.

Evidence Due Date: redacted.

redacted

redacted: This is a subsequent request and exceptional circumstances apply.

redacted, Team Leader, endorsed the request.

OR

redacted, Assistant Director endorsed the request.

Enter your User ID.

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7. Make sure the Outcome field is blank. If this field contains decision information:
   • the person will not have the time they need to provide their evidence
   • the decision will be completed without procedural fairness.
8. Select Submit.

3.5 Add Interaction: Notify plan developer – Evidence Extension Request

1. In the NDIS Account screen:
   • Select Add Items and then select Interactions.
   • In Category 1: Select Pathway.
   • In Category 2: Select Review.
   • In Category 3: Select Eligibility Reassessment.
   • In Channel: Select Internal Notes.
   • In Status: Select Open.
   • In Notes:

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ER – Evidence Extension Request

On requested an extension to provide information to support their continued eligibility based on .

Extension Choose an item.

<Reasons for approval / decline of request>.

<If approved: Advised that information is due and will be considered by the Delegate on or after .

2. Select Submit.
3. Select Edit.
4. Select Assign.
5. Select Employee.
6. In Employee: Enter plan developer’s name (Contact with relationship type My NDIS Contact).

Note: Where there is no My NDIS Contact, assign interaction to the National Delivery Inbox (Return to SDP Inboxes) within the person’s geographical location. 7. Select Assign.

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Assign To

Team: redacted Employee: redacted

| & |

Assign Cancel

8. Select Submit.

4. Related procedures or resources

• Our Guideline – Leaving the NDIS
• Standard Operating Procedure – Consider commencement of Eligibility Reassessment or Access Status Change
• Standard Operating Procedure – Consider Eligibility Reassessment outcome following 1^st chance to respond
• Standard Operating Procedure – Make Eligibility Reassessment decision

5. Feedback

If you would like to provide feedback about this guidance material, please complete our Feedback form.

6. Version control

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Check for procedural fairness in an Eligibility Reassessment

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This Standard Operating Procedure (SOP) will help Access Assessors check for any missed steps during an eligibility reassessment to ensure a participant has procedural fairness during this process.

1. Recent updates

2. Checklist

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3. Procedure

Note: It is important, from an administrative law perspective, that the process leading to a revocation decision is procedurally fair. This includes giving the participant reasonable opportunity to provide information, and to present a case to support their continued eligibility.

3.1 All relevant information has been reviewed

1. Check that all relevant information was reviewed from the ER Request, Interactions, NAT Inbox, Documents, and any other available information on the participant’s record such as the planning conversation tool, plan value, plan usage and supports in place.

2. Complete any missing tasks, refer to SOP — [Complete eligibility reassessment missed steps](SOP — Complete eligibility reassessment missed steps).

3.2 Sufficient contact attempts were made

1. Check that sufficient attempts were made to contact the participant or their representative:

   • when the ER commenced, and
   • about the potential for adverse decision.

2. Check that contact attempts were made using the person’s preferred contact method.

3. Complete any missing tasks, refer to SOP — [Complete eligibility reassessment missed steps](SOP — Complete eligibility reassessment missed steps).

3.3 A clear explanation about why the participant may not be eligible

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If phone contact attempts were successful:

1. Check that a clear explanation was provided about what information indicated that the participant may not be eligible.
2. Complete any missing tasks, refer to SOP – [Complete eligibility reassessment missed steps](SOP – Complete eligibility reassessment missed steps).

3.4 Relevant correspondence was sent

1. Check the following letters were sent to the participant:
   • Letter – [Eligibility Reassessment – Commencement – 1st opportunity to respond](Eligibility Reassessment – Commencement – 1st opportunity to respond)
   • Letter – [Eligibility Reassessment – Potential for adverse decision – 2nd opportunity to respond](Eligibility Reassessment – Potential for adverse decision – 2nd opportunity to respond)
2. Complete any missing tasks, refer to SOP – [Complete eligibility reassessment missed steps](SOP – Complete eligibility reassessment missed steps).

3.5 Sufficient time was given to provide information

1. Check that the participant was given at least 28 days from the date of each letter to provide information.
2. Complete any missing tasks, refer to SOP – [Complete eligibility reassessment missed steps](SOP – Complete eligibility reassessment missed steps).

3.6 Extensions of time requests were considered

1. If the participant asked for an extension of time, if this was:
   • Approved: check this was reasonable based on the individual circumstances.
   • Declined:
     • check this was reasonable based on the individual circumstances, and
     • check this was explained to the person, or
     • escalated to a Team Leader.
     • Complete any missing tasks, refer to SOP – [Complete eligibility reassessment missed steps](SOP – Complete eligibility reassessment missed steps).

3.7 Next steps

Procedural fairness is checked at each stage of the Eligibility Reassessment, so next steps may be:

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• e commence the ER, or
• e determine there is potential for an adverse decision, or
• e submit a revocation decision.

4. Related procedures or resources

• SOP — Complete Eligibility Reassessment missed steps

5. Feedback

If you would like to provide feedback about this guidance material, please complete our Feedback form.

6. Version control

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Consider commencement of Eligibility Reassessment or Access Status Change

Use this Standard Operating Procedure (SOP) to determine whether to commence an Eligibility Reassessment (ER).

This involves considering if a participant continues to meet the:

• residence and disability requirements, or
• early intervention requirements (EI).

This SOP has 3 outcomes.

1. Commence ER:
   • request further information from the participant to inform a decision about whether they continue to meet the eligibility requirements, or
2. Maintain Access Status:
   • the participant maintains the status they entered the NDIS under, or
   • the participant entered the NDIS under disability and now meets the early intervention requirements, or
3. Change Access Status:
   • the participant entered the NDIS under early intervention and now meets the disability requirements.

Note: Maintain Access Status and Change Access Status are not reviewable decisions under the NDIS Act.

Recent updates

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Date What’s changed

e Standard Operating Procedure — Cease participant status has been divided into 3 SOPs:

• Standard Operating Procedure — Ask for an Access Request to be withdrawn
• Standard Operating Procedure — Finalise the plan before a participant leaves the NDIS
• Standard Operating Procedure — Cease the participant status to leave the NDIS.

e New link to Standard Operating Procedure — Finalise the plan before a participant leaves the NDIS.

e Improved messaging about the participant’s responsibility to provide information to support their eligibility.

e Improved messaging about our responsibility to help the participant understand the type of information we need to assess eligibility.

e Standard Operating Procedure — Undertake eligibility reassessment separated into 8 SOPs:

• Standard Operating Procedure - Consider commencement of Eligibility Reassessment or Access Status Change
• Standard Operating Procedure — Consider Eligibility Reassessment outcome following 1st chance to respond
• Standard Operating Procedure — Action evidence extension request for an Eligibility Reassessment
• Standard Operating Procedure — Action Call back Request for an Eligibility Reassessment
• Standard Operating Procedure — Make Eligibility Reassessment decision
• Standard Operating Procedure — Refer request to cease participant status during Eligibility Reassessment
• Standard Operating Procedure — Check for procedural fairness in an Eligibility Reassessment
• Standard Operating Procedure — Complete Eligibility Reassessment missed steps

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• the Referral Checklist is not attached to the record
• the participant has not received 12 months of funded supports (except for maintain or change access decisions for participants with primary disability of developmental delay)
• an ER Request has been created in error
• increased contact attempts to 5 when an ER is commenced.

2. Checklist

✓ Our Guideline — Applying to the NDIS
✓ Our Guideline — Leaving the NDIS.
✓ An ER Request has been created.
✓ You have an ER Request work item and the Outcome is not displayed. |

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Topic: Checklist

3. Procedure

During the ER process, do not reassign the application in the System. The application must remain assigned to the plan developer so they can continue with planning activities throughout the ER process.

Note: Maintain Access Status and Change Access Status are not reviewable decisions under the NDIS Act.

3.1 Determine ER Request status

You may receive an ER Request at different points of the process and may complete one or more of these steps.

3.1.1 Obtain work item

1. In My Inbox: Select Ready for Work. Note: This will allocate a work item to your inbox.
2. Select the work item.

If the work item relates to an access decision:

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• Refer to Standard Operating Procedure – Progress NDIS application in the system.

If you made the original access decision:

• You are not an independent delegate. • Do not commence ER. • Talk to your team leader about the conflict of interest. They will Re-assign the work item to another Access Delegate.

If there is an alert for Younger People in Residential Aged Care (YPIRAC):

• Re-assign the work item to Nicola King (NK0019).

If the participant resides in an area that is classified as remote or very remote (Refer to Standard Operating Procedure – Check for remote or very remote address for more information):

• Re-assign the work item to Danika Sharpe (DJS497).

3. Check work item Type.

3.1.2 If ER Request

1. Review Outcome to determine the next steps.

If Outcome is not displayed:

• Go to Step 3.2: Complete pre-checks.

If Outcome states Commence Eligibility Reassessment:

• Refer to Standard Operating Procedure – Consider Eligibility Reassessment outcome following 1st chance to respond.

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If Outcome states Opportunity to Respond:

• Refer to Standard Operating Procedure – Make Eligibility Reassessment decision.

3.1.3 If Eligibility Reassessment Evidence Extension Request

1. Refer to Standard Operating Procedure – Action evidence extension request for an Eligibility Reassessment.

3.1.4 If Eligibility Reassessment Call Back Request

1. Refer to Standard Operating Procedure – Refer an Eligibility Reassessment (ER) call back or evidence extension request to NARB.

Complete pre-checks

3.2.1 Check for Independent Delegate

1. Have you:

   • got a personal interest in the participant’s status, or
   • got a personal relationship with the participant (outside the NDIA), or
   • been involved in making the original access decision or any planning decisions?

Yes:

• you are not an independent delegate
• do not commence ER
• talk to your team leader, about the conflict of interest. They will Re-assign the work item to another Access Delegate.

No:

• Go to Step 3.2.2: Check UTC for plan reassessment.

3.2.2 Check UTC for plan reassessment

If a plan developer is unable to contact (UTC) the participant for their scheduled plan reassessment they cannot make an ER referral and must follow the Standard Operating Procedure – Unable to contact the participant. If the plan developer marks the record as UTC throughout the plan reassessment process:

• do not commence ER
• go to Step 3.14 Withdraw ER request.

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If the record is not marked as UTC, continue with the ER, even if you are unable to contact the participant after making all reasonable contact attempts as required during the ER process.

1. Has the plan developer been able to contact the participant for their plan reassessment?

   Yes: • Go to Step 3.2.3: Check Referral Checklist is completed and attached.

   No: • Do not commence an ER. • Go to Step 3.14 Withdraw ER request.

3.2.3 Check Referral Checklist is completed and attached

1. In the NDIS Account screen: Select Documents.

2. Check Inbound Documents to locate the Referral Checklist.

   If the checklist is completed and attached: • Go to Step 3.2.4: Check if primary disability is developmental delay.

   If the checklist is not attached: • Do not commence an ER. • Go to Step 3.14 Withdraw ER request.

   If the ER Request was created incorrectly (instead of recording an interaction advising ER is not required): • Do not commence an ER. • Go to Step 3.14 Withdraw ER request.

     If the participant is over the age of 65, and is in residential aged care or receiving an aged care package:
       • Do not commence an ER.
       • Go to Step 3.14 Withdraw ER request.

3.2.4 Check if primary disability is developmental delay

1. If the participant’s primary disability is developmental delay, you:

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• must not start an eligibility reassessment until they have received 12 months of funded support. Provide an ER extension until the date the participant will have received 12 months support.
• can update their disability or change their access status to disability before they have received 12 months of funded support.

2. Is the participant’s primary disability developmental delay?

   Yes: * Go to Step 3.3 Consider if residence and disability or EI requirements are met.

   No: * Go to Step 3.2.5 Confirm 12 months of funded supports has been received.

3.2.5 Confirm 12 months of funded supports has been received

1. Has the participant received 12 months of supports?

Yes:

    * Go to Step 3.3: Consider if residence and disability or EI requirements are met.

No:
    * The participant must receive 12 months of funded supports before you consider an ER.
    * If the original access decision was recorded correctly, go to Step 3.14 Withdraw ER request.
    * If the original access decision was recorded incorrectly, seek advice from your Team Leader to determine next steps.

3.3 Consider if residence and disability or EI requirements are met

1. Review the Referral Checklist to determine the reason for the ER referral.

   Note: This will determine the criteria you assess, and the order in which to assess them, to see if the participant continues to meet the eligibility requirements.

   In cases where there is insufficient evidence to determine eligibility, commence an ER.

2. If the checklist indicates that the participant:

   • may not meet residence requirements:
     • assess residence, disability and EI criteria

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• may not meet disability requirements: • assess disability and EI criteria. • may not meet EI requirements: • assess EI and disability criteria. • may now meet disability requirements (after joining the NDIS under EI requirements): • assess EI and disability criteria.

3. Review all the participant’s information (including Interactions, Inbound Documents, the NAT inbox, and any other available information on the participant’s record such as the planning conversation tool, plan value, plan usage and supports in place). Notify your Team Leader if you identify any integrity issues then continue with ER.

4. Assess the evidence in the right order. For steps, go to P2.2.4 Make Access Decision Under Seven Years of Age or P2.2.3 Make Access Decision Aged Seven and Over in ARIS process connect.

5. Refer to available resources as required, such as: • Our Guideline – Applying to the NDIS • Our Guideline – Leaving the NDIS • Technical Advisory Branch (TAB) Digest – Published Advice

6. Consider if the NSW Prescribed Program applies (relevant to the residence requirements only).

7. Consider if an AAT determination was previously made about the participant’s access to the NDIS.

8. Consider if there is sufficient evidence to decide if the participant meets the residence and disability or early intervention requirements (if the participant joined the NDIS under one of the NSW prescribed programs, only consider the disability and EI requirements and do not consider the residence requirements).

3.3.1 Consider if you need technical support or if you can make a decision to maintain access, change access status or commence an ER

Consider these questions: • Do you need to ask for QDO technical support to decide the next step? • Do you need mandatory QDO Team Leader advice because there has been an AAT determination about the participant’s access to the NDIS?

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• Do you need mandatory TAB advice?

Note: If a participant has a primary disability that is a chronic health condition and TAB advice was not obtained at the point of an access – mandatory TAB advice is required before maintaining or changing access status.

1. If you answered yes to any of the questions refer to Standard Operating Procedure – Request technical advice to progress an Eligibility Reassessment before you continue.

3.3.2 If ER not required – Maintain Access Status

If the information indicates the participant:

• meets the residence and disability or early intervention requirements that they joined the NDIS under, or • joined the NDIS under the disability requirements and now meets early intervention requirements

AND

• does not have a primary disability that is a chronic health condition, or • has a primary disability that is a chronic health condition, and you confirmed TAB advice was obtained at the point of access or you obtained mandatory TAB advice to support your Maintain Access Status outcome.

1. Go to Step 3.8: Submit ER outcome: Maintain Access Status.

3.3.3 If ER not required – Change Access Status

If the information indicates that the participant:

• joined the NDIS under the early intervention requirements and now meets disability requirements

AND

• does not have a primary disability that is a chronic health condition, or • has a primary disability that is a chronic health condition, and you obtained mandatory TAB advice to support your Change Access Status outcome.

1. Go to Step 3.9: Submit ER outcome: Change Access Status (from EI to disability).

3.3.4 If ER required

If the information you have indicates that:

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• The participant is unlikely to meet the residence, and disability or 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

AND

• The AAT has not previously made a determination relating to the participant’s access to the NDIS, or • The AAT has previously made a determination relating to the participant’s access to the NDIS, and you have obtained technical advice from a QDO Team Leader to proceed

AND

• The NSW Prescribed Program exception does not apply (relevant to the residence requirements only).

1. Go to Step 3.4: Update ER Request: Commence ER and provide 1st opportunity to respond.

Update ER Request: Commence ER and provide 1st opportunity to respond

3.4.1 Prepare Request Further Information Template

1. Open Template – Eligibility Reassessment – 1st and 2nd opportunity to respond.
2. Complete fields in the templates for all requirements unlikely to be met (including both disability and EI criteria).
3. Save the completed template as a Word document to your desktop or OneDrive. Note: This will be used to populate the ER letter in a later step.
4. Copy the completed template to paste into the Outcome Justification.

3.4.2 Update ER Request: Commence Eligibility Reassessment

1. In the NDIS Account screen: Select Internal Use.
2. In Internal Use: Select Open Activities.
3. In the Transaction Id column: Select the hyperlinked Transaction Id that corresponds with the Eligibility Re-Assessment Request activity.

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Select Edit.

5. In Outcome: Select Commence Eligibility Reassessment.

6. In Outcome Justification:

There is not enough information to indicate that <Participant> meets the eligibility requirements. I have commenced an Eligibility Reassessment and the participant now has an opportunity to respond.

Primary Disability: <Primary Disability>

I have received and considered the following evidence:

<List the information and evidence that has already been considered for eligibility> reassessment>.

I have requested the following information:

<Paste the completed eligibility reassessment opportunity to respond template>

<Enter your User ID>

7. In Supporting Info:

Refer to Outcome Justification.

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8. Select Submit.
9. Select Edit.
10. In Due Date: Update to 29 days after the date of the letter.

Note: This stops the ER work item from being allocated on the 28th day. 11. In Supporting Info:

Due date updated to 29 days after the date of the letter. This allows the system to give the participant the full 28 days to provide information. 12. Select Back.

3.4.3 Add Alert: Eligibility Reassessment in Progress

1. Select Add Items and then select Alert.
2. Select the Primary checkbox.
3. In Alert: Select Eligibility Reassessment.
4. In Additional Information:

Eligibility is currently being reassessed.

For ER enquiries, follow instructions in Standard Operating Procedure – Refer an Eligibility Reassessment (ER) call back or evidence extension request to NARB. 5. Select Submit.

Send Letter: Commence Eligibility Reassessment

1. Open and edit Letter – Eligibility Reassessment – Commencement – 1st Opportunity to Respond.
2. Copy and paste the completed decision templates into the letter.

Note: The template was saved to your desktop or OneDrive earlier. 3. Send letter to the participant or representative via their preferred correspondence method. 4. Delete the template saved to your desktop or OneDrive after you have completed this step.

3.5.1 Attach the letter to Inbound Documents

1. In the NDIS Account screen: Select Documents.
2. Select Add Items and then select Inbound Document.

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3. In Description: Letter – ER – 1st opportunity to respond.

4. In Status: Select Completed.

5. In Category 1: Select NDIA Service.

6. In Category 2: Select Other Correspondence

Employee Responsible

Enter your details.

Note:

Letter <emailed/mailed> to redacted on by .

9. Select Upload File button under Attachments.

10. In File Explorer window: Select the relevant document.

11. Select Save.

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Standard Operating Procedure

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Note: The letter is an important part of procedural fairness. You must make sure it can be viewed in inbound documents. Read Standard Operating Procedure – Check for procedural fairness in an Eligibility Reassessment for more information.

Contact participant or representative: ER commenced

Note: A representative could be the participant’s nominee or child representative. If the participant has a nominee, they will be listed as a contact as a Plan Nominee.

If the person’s preferred correspondence method is email/letter, you must still attempt to call them about the commencement of an ER. The exception is if the person has requested no phone calls (for example, they are Deaf and have requested written communication only), or if they have not provided a phone number.

Contact person: ER commenced

1. Refer to Standard Operating Procedure – Send SMS using Whisper messenger to send ‘Contact attempt SMS template’ to advise you will be calling.

   Note: Only send this SMS before your first attempt to call the person.

Do not contact the person by SMS if they have told the Agency that they do not consent to this form of communication.

2. Prepare for your call:

   • Read Section 8.1 – Sensitive conversations in the Conversation Style Guide.
   • Review the relevant evidence on the participant’s record, and your reasons why further information is required.
   • Have the Letter – Eligibility Reassessment – Commencement – 1st Opportunity to Respond handy for reference during the call.

3. Make 5 telephone contact attempts (over a 3-day period, at different times of day) to the participant, nominee or child representative. The first call should be made on the day of the decision. If you reach voicemail and the person identifies themselves, leave a brief message requesting they contact the NDIA on 1800 800 110. You must complete all required contact attempts, even if the number is disconnected.

4. Record an Interaction following each unsuccessful call attempt.

5. In the NDIS Account screen: Select Interactions.

6. Select Add Items and then select Interaction.

7. In Category 1: Select Pathway.

8. In Category 2: Select Review.

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9. In Category 3: Select Eligibility Reassessment.

10. In Channel: Select Internal Notes.

11. In Status: Select Completed.

12. In Notes:

Choose an item. phone call attempt made to <Person> on <Date> at <Time> to advise that Eligibility Reassessment process has commenced. Call not answered.

13. Select Submit.

3.6.2 If all 5 contact attempts are unsuccessful

1. Refer to Standard Operating Procedure – Send SMS using whisper messenger to send ‘Unsuccessful contact attempt’ SMS to advise you tried to call.

   Note: Only send this SMS after you make all required call attempts.

Do not contact the person by SMS if they have told the Agency that they do not consent to this form of communication.

2. Go to Step 3.7: Add Interaction: Notify plan developer – ER commenced.

3.6.3 If the call is answered

1. Guide a respectful and transparent conversation, using the script.

   Note: Extension of time requests can be considered based on the participant’s individual circumstances. For more information, refer to Standard Operating Procedure – Action evidence extension request for an Eligibility Reassessment.

Advise the participant that you are calling to discuss their NDIS eligibility.

Explain that 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.

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Advise them that we reconsider eligibility requirements at plan reassessments and at other times, like when a person’s circumstances change.

Explain that a person must continue to meet the residence and disability or early intervention requirements to remain an 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.

Explain that you have reviewed all information/evidence on their record.

Using the letter as a guide, outline the information that indicates the participant may no longer meet the and/or requirements. This means that we have commenced an Eligibility Reassessment.

Advise them that 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 provide any further supporting information.

Explain that we will consider if the participant continues to meet these requirements using both their existing information and any new information they provide. Using the letter as a guide, explain what information we need based on the specific requirements that they may no longer meet eligibility, or where we do not have enough information to determine their eligibility.

Describe the types of information that will help us determine if they still meet the eligibility requirements.

Explain that it is the participant’s responsibility to provide sufficient evidence they still meet the eligibility requirements. If we are not satisfied they meet the requirements, they are likely to leave the NDIS.

Explain that it is our responsibility to help them understand the information we need to assess eligibility.

Inform them that they will soon receive a letter explaining what has been discussed today and how they can provide more information.

Advise them that they have 28 days to provide more information. After this, they will hear from us within 28–56 days with an outcome or a second opportunity to respond. If we do not receive any information, we will use the evidence we have to make the decision.

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Assure them that there will be no change to the participant’s plan or supports during the Eligibility Reassessment process.

Encourage them to contact their plan developer or <local area coordinator / early childhood partner / support coordinator> if they have questions about their plan or need support during the Eligibility Reassessment process.

Ask if they have any questions or if they would like more information about the eligibility requirements and the reassessment process.

Ask if there is someone else they would like us to contact to explain the process. Ask if they provide consent for you to contact this person.

If the participant has a support coordinator: Ask if they would like us to contact their support coordinator to explain the process. Advise them that their support coordinator may be able to help them with the process too. If yes, ask if they provide consent for you to contact their support coordinator.

Advise them that they can contact us if they have any further questions.

If the person asks for more time to submit information: To consider and action this request, refer to Standard Operating Procedure – Action evidence extension request for an Eligibility Reassessment.

If they no longer wish to be a participant of the NDIS: They will need to make this request in writing. Complete steps outlined in Standard Operating Procedure – Refer request to cease participant status during Eligibility Reassessment.

The Eligibility Reassessment process will continue until we receive the written request. This includes receiving any letters generated as part of this process.

2. Go to Step 3.6.4: Add Interaction: ER commenced.

3.6.4 Add Interaction: ER commenced

1. In the NDIS Account screen: Select Interactions.
2. Select Add Items and then select Interaction.
3. In Category 1: Select Pathway.
4. In Category 2: Select Review.
5. In Category 3: Select Eligibility Reassessment.
6. In Channel: Select Internal Notes.
7. In Status: Select Completed.

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8. In Notes:

Phone call made to <Person> to advise that the Eligibility Reassessment process has commenced.

<Details of conversation, including a Request to Cease Participant Status (if applicable)>.

9. Select Submit.

10. Select Back.

Add Interaction: Notify plan developer – ER commenced

1. In the NDIS Account screen: Select Interactions.

2. Select Add Items and then select Interaction.

3. In Category 1: Select Pathway.

4. In Category 2: Select Review.

5. In Category 3: Select Eligibility Reassessment.

6. In Channel: Select Internal Notes.

7. In Status: Select Open.

8. In Notes:

Interaction to notify plan developer that Eligibility Reassessment has commenced.

Refer to Eligibility Re-Assessment Request for information about the status of the request.

Refer to SOP – Refer Participant for an Eligibility Reassessment or Access Status Change for further information.

Plan developer to note and close interaction.

9. Select Submit.

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10. Select Edit.

11. Select Assign.

12. Select Employee.

13. In Employee: Enter the plan developer’s name (Contact with relationship type My NDIS Contact).

Note: Where there is no My NDIS Contact, assign the interaction to the National Delivery Inbox (Return to SDP Inboxes) within the person’s geographical location.

14. Select Assign.

15. Select Submit.

The ER Request will now be on hold for 28 days (or longer if the person has been given more time to provide information).

Submit ER outcome: Maintain Access Status

Maintaining the participant’s access status is not a decision under the NDIS Act. This means it is not a reviewable decision.

3.8.1 Prepare Decision Template

1. Open Template – Eligibility Reassessment – Maintain or Change Access Status.

2. Complete fields in the relevant templates.

3. Copy the completed template to paste into the Outcome Justification.

3.8.2 Update ER Request: Maintain Access Status

1. In the Eligibility Reassessment Request: Select Edit.

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2. In Outcome: Select Maintain Access Status.

3. In Outcome Justification:

.

4. In Supporting Info:

Refer to Outcome Justification.

5. In Reason for Maintain Access Status: Select reason from drop-down menu:

• Disability and Residence Valid: Sufficient evidence available to confirm residence and disability requirements are met.
• Early Intervention and Residence Valid: Sufficient evidence available to confirm residence and early intervention requirements are met.

Note: Do not use Insufficient Evidence to Alter Decision, Record Ceased or Invalid Checklist/Checklist Not Provided.

6. Select Submit.

7. If your Maintain Access Status decision:

• is not sent for quality checking:

  o Go to Step 3.12: Check/update primary and secondary disabilities.

• is sent for quality checking:

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o Start working on another work item. Once quality feedback is returned, go to

Step 3.10: Review quality check feedback: Maintain/Change Access Status (if sent for quality checking).

Submit ER outcome: Change Access Status (from EI to disability)

Changing the participant’s access status from early intervention to disability is not a decision under the NDIS Act. This means it is not a reviewable decision.

If the participant joined the NDIS under disability requirements and now meets the early intervention requirements, their access status must be maintained. You won’t need to change their access status.

3.9.1 Prepare Decision Template

1. Open Template – Eligibility Reassessment – Maintain or Change Access Status.
2. Complete fields in the relevant templates.
3. Copy the completed template to paste into the Outcome Justification.

3.9.2 Update ER Request: Change Access Status

1. In the Eligibility Reassessment Request: Select Edit.
2. In Outcome: Select Change Access Status.

In Outcome Justification:

.

4. In Supporting Info:

Refer to Outcome Justification.

5. In Access Decision Reason: Select Disability Met.

Note: Benefit from Early Intervention, Exceptional Circumstances and Continuity of Supports are not applicable.

6. In Access Decision Notes add:

Status Change from EI to Disability.

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7. Select Submit.

Note: Your decision may be referred to a QDO for quality checking.

8. If your Change Access Status decision:

• is not sent for quality checking: o Go to Step 3.11: Contact participant or representative: Explain Change Access Status outcome (only).
• is sent for quality checking: o Start working on another work item. Once quality feedback is returned, go to Step 3.10: Review quality check feedback: Maintain/Change Access Status (if sent for quality checking).

Review quality check feedback: Maintain/Change Access Status (if sent for quality checking)

After receiving the feedback, you are still responsible for making, documenting, and implementing the decision.

1. In the Business System Inbox: Select Quality Check Act task.

2. Review the quality feedback provided.

If you agree with the feedback:

• Next to Acknowledged: Select Yes.
• Select Submit.
• Go to Step 3.

If you need further clarification of the feedback, do not acknowledge it. Discuss it with your Team Leader, and if applicable, follow the reconsideration process. Do not proceed to Step 3 until this is resolved.

3. Finalise the ER outcome, taking into consideration the quality check feedback.

If you continue with the Maintain Access Status decision:

• Go to Step 3.12: Check/update primary and secondary disabilities.

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If you continue with the Change Access Status decision:

• Go to Step 3.11: Contact participant or representative: Explain Change Access Status outcome (only).

Contact participant or representative: Explain Change Access Status outcome (only)

Note: A representative could be the participant’s nominee or child representative. If the participant has a nominee, they will be listed as a contact as a Plan Nominee.

3.11.1 Contact the participant or their representative

1. Refer to Standard Operating Procedure – Send SMS using Whispir messenger to send ‘Contact attempt SMS template’ to advise you will be calling.

Note: Do not contact the person by SMS if they have told the Agency that they do not consent to this form of communication.

2. Make one telephone contact attempt to the participant, nominee or child representative. If you reach voicemail and the person identifies themselves, leave a brief message requesting they contact the NDIA on 1800 800 110.

3.11.2 If unsuccessful contact attempt

1. Refer to Standard Operating Procedure – Send SMS using Whispir messenger to send ‘Unsuccessful contact attempt’ SMS to advise you tried to call.

Note: Do not contact the person by SMS if they have told the Agency that they do not consent to this form of communication.

2. Go to Step 3.11.4: Add Interaction: Change Access Status.

3.11.3 If the call is answered

1. Guide a respectful and transparent conversation, using the script:

Advise the person that they originally met the early intervention requirements and based on the available information, they now meet the disability requirements. Explain that there will be no change to their current NDIS supports. Explain what information was used to make this update and the difference between early intervention and disability. Refer the person to their plan developer if they have questions about their plan or funding.

2. Go to Step 3.11.4: Add Interaction: Change Access Status.

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3.11.4 Add Interaction: Change Access Status

1. In the NDIS Account screen: Select Interactions.
2. Select Add Items and then select Interaction.
3. In Category 1: Select Pathway.
4. In Category 2: Select Review.
5. In Category 3: Select Eligibility Reassessment.
6. In Channel: Select Internal Notes.
7. In Status: Select Open.
8. In Notes:

Phone call made to redacted on redacted at redacted to advise that the participant’s access status has been changed from Early Intervention to Disability. redacted

9. Select Submit.
10. Go to Step 3.12: Check/update primary and secondary disabilities.

3.12 Check/update primary and secondary disabilities

The Disabilities tab needs to reflect only the disabilities where the participant meets disability or early intervention requirements, as this is important for the planning stage.

You need to confirm that their eligible impairments are reflected correctly in the System. This includes listing any other eligible impairments in both the Primary Disability and Secondary Disabilities tab.

3.12.1 View Disabilities screen

1. In the NDIS Account screen: Select Disabilities.

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2. In Disabilities: Select the > next to Secondary.

3. In Disabilities: Select the > next to Primary.

Note: To view both the primary and secondary disabilities at the same time, open the Secondary tab first, followed by the Primary.

Note: This screen will list all current and previous primary and secondary disabilities. Take note of the Effective Start and Effective End dates to determine what disabilities are current.

3.12.2 Consider if the listed primary disability still meets eligibility requirements

1. Consider if the listed primary disability meets the disability or early intervention requirements.

   If primary disability no longer meets the disability or early intervention requirements: • Go to Step 3.12.3: Update primary disability.

   If primary disability continues to meet the disability or early intervention requirements: • Go to Step 3.12.4: Consider if any secondary disabilities no longer meet the eligibility requirements.

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Note: If the existing primary disability continues to meet the eligibility requirements, and there are additional disabilities that also meet eligibility, do not change the primary disability.

3.12.3 Update primary disability

Do not delete the previous primary disability. When the primary disability is changed, this will automatically apply an end date to the previous primary disability.

If the primary disability is listed as a secondary disability:

• In Secondary: Select the Convert to Primary Disability icon.
• Complete additional fields (if known).
• Select Submit.

If the primary disability is not listed as a secondary disability:

• In the NDIS Account screen.
• Select Add Items and then select Disability.
• In Reported Impairment: Start typing the disability and select when displayed. Note: Alternatively, select from the list of disabilities.
• Next to Primary: Select the checkbox.
• Complete additional fields (if known).

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Select Submit

3.12.4 Consider if any secondary disabilities no longer meet the eligibility requirements

1. Consider if there is sufficient evidence that any secondary disabilities continue to meet the eligibility requirements.

If a secondary disability no longer meets the disability or early intervention requirements:

• Go to Step 3.12.5: Update Effective End Date for secondary disability.

If the secondary disabilities continue to meet the disability or early intervention requirements:

• Go to Step 3.12.6: Consider if additional secondary disabilities meet the disability or early intervention requirements.

If there are no secondary disabilities listed:

• Go to Step 3.12.6: Consider if additional secondary disabilities meet the disability or early intervention requirements.

3.12.5 Update Effective End Date for secondary disability

1. Select relevant disability.

2. In the Effective End date: Update to current date.

Standard Operating Procedure

For Internal Use Only

3. Select Submit.

Note: The disability will show within Secondary Disabilities with an end date.

3.12.6 Consider if additional secondary disabilities meet the disability or early intervention requirements

1. Consider if there is sufficient evidence that an additional secondary disability meets the disability or early intervention requirements.

2. If an additional secondary disability meets the disability or early intervention requirements:

• Go to Step 3.12.7: Add secondary disability.

If there is insufficient evidence that any additional disabilities meet the disability or early intervention requirements:

• Go to Step 3.13: Add Interaction: Notify plan developer – ER outcome.

3.12.7 Add secondary disability

1. In the NDIS Account screen.

2. Select Add Items and then select Disability.

3. In Reported Impairment: Start typing the disability and select when displayed.

Note: Alternatively, select from the list of disabilities.

4. Next to Primary: Do not select the checkbox.

5. Complete additional fields (if known).

Note: Do not adjust the Effective End date as it will auto-populate with 31.12.9999.

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6. Select Submit.

7. Go to Step 3.13: Add Interaction: Notify plan developer – ER outcome.

Add Interaction: Notify plan developer – ER outcome

1. In the NDIS Account screen: Select Interactions.

2. Select Add Items and then select Interaction.

3. In Category 1: Select Pathway.

4. In Category 2: Select Review.

5. In Category 3: Select Eligibility Reassessment.

6. In Channel: Select Internal Notes.

7. In Status: Select Open.

8. In Notes:

Interaction to notify plan developer of Eligibility Reassessment update.

Refer to Eligibility Re-Assessment Request for information about the status of the request.

Refer to Standard Operating Procedure – Refer Participant for Eligibility Reassessment or Access Status Change ER for information about the process.

No action required. Plan developer to note and close interaction.

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9. Select Submit.

10. Select Edit.

11. Select Assign.

12. Select Employee.

13. In Employee: Enter the plan developer’s name (Contact with relationship type My NDIS Contact).

Note: Where there is no My NDIS Contact, assign the interaction to the National Delivery Inbox (Return to SDP Inboxes) within the person’s geographical location.

14. Select Assign.

15. Select Submit.

End of process.

3.14 Withdraw ER Request

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In some instances, the ER request may have been created in error, or there may be situations where it should not proceed. For example, if no Referral Checklist is attached to the record, or the participant has not had 12 months of funded supports (except for maintain or change access decisions for participants with primary disability of developmental delay).

1. In ER Request: Select Withdraw.
2. In Requested By: Select your name.
3. In Withdraw Reason: Select Request Recorded in Error.
4. In Supporting Info:

NARB delegate unable to proceed with ER.

ER request invalid:

<Referral Checklist not attached>

OR

<Participant has not had 12 months of funded supports>

OR

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Interaction to notify plan developer of Eligibility Reassessment update.

ER Request invalid:

• <Participant has not had 12 months of funded supports>

• <The participant is over the age of 65 and is in residential aged care or receiving an aged care package. Plan developer to follow instructions in Standard Operating Procedure – Finalise the plan before a participant leaves the NDIS>.

Refer to SOP – Refer Participant for an Eligibility Reassessment (ER) or Access Status Change for information about the ER process.

Action required: <N/A / For example, Referral Checklist to be attached to record and new ER Request to be created>.

Plan developer to note, take any required actions and close interaction.

9. Select Submit.
10. Select Edit.
11. Select Assign.
12. Select Employee.
13. In Employee: Enter the plan developer’s name (Contact with relationship type My NDIS Contact).

Note: Where there is no My NDIS Contact, assign the interaction to the National Delivery Inbox (Return to SDP Inboxes) within the person’s geographical location. 14. Select Assign.

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15. Select Submit.

End of process – no further steps to be completed.

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Appendices

4. The Legislation

While the NDIS provides lifetime disability support for many participants, others build capacity and achieve their goals to the extent that they no longer meet the eligibility requirements and leave the NDIS.

This SOP provides instructions for when an Access Assessor (AA) receives an ER referral from a plan developer indicating that the participant:

• may not meet the residence requirements (section 23),

OR

• may not meet the disability requirements (section 24) and early intervention requirements (section 25),

OR

• joined the NDIS under the early intervention requirements (section 25) and may now meet the disability requirements (section 24).

All participants must continue to meet the residence requirements and the disability or the early intervention requirements.

There are some exceptions to when an ER should be undertaken:

• If the participant joined the NDIS under the NSW Prescribed Program Rules, their NDIS access should not be revoked based on residence requirements. This also includes participants who joined the NDIS under these rules, but now reside in another state or territory. For these participants, ER can only be based on the disability and early intervention requirements.
• If the AAT has previously made a determination relating to the participant’s access to the NDIS, seek advice from a QDO Team Leader before commencing an ER. The QDO Team Leader will seek advice from TAB/Legal as required. QDO Team Leader advice is not required if you are maintaining or changing access status.

Independent Delegate

The AA that decides whether to commence or undertakes an ER must be independent. That is, they will not have:

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• a personal interest in the participant’s status, or
• a personal relationship with the participant (outside the NDIA), or
• must not have been involved in making the original access decision or any planning decisions.

An AA can be involved in any or all stages of the ER process.

4.3 ER Outcomes

There are 2 ER outcomes under (s 30(1), NDIS Act). They are:

• To exercise the power to revoke a person’s access, which includes:
  • revoking participant status.
• To not exercise the power to revoke a person’s access, which includes:
  • maintaining access status, or
  • changing access status.

Note: To not exercise the power to revoke a person’s access is not a reviewable decision.

4.3.1 Maintain Access Status

A person maintains their participant status when they continue to meet the access requirements they joined the NDIS under. Or, if they joined the NDIS under disability requirements and now meet the early intervention requirements.

4.3.2 Change Access Status

A person’s status is changed from early intervention to disability when the participant who joined the NDIS under early intervention requirements now meets the disability requirements.

Note: Changing access status is not a decision under the NDIS Act. It is also considered maintaining access status.

4.3.3 Decision to Revoke

If an AA is satisfied a person no longer meets the residence and/or disability and early intervention requirements, their status as a participant will be revoked (section 30).

A person ceases to be a participant in the NDIS when their status is revoked under section 30. A revocation decision will take effect from the date of the decision notice.

A person must not use NDIS funds to purchase reasonable and necessary supports for the participant after they cease to be an NDIS participant (section 29(2)).

The decision to revoke a person’s status as a participant is a reviewable decision (section 99, Item 3). This means that the decision may be internally reviewed by a delegate of the CEO

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(section 100) and subsequently externally reviewed by the Administrative Appeals Tribunal (AAT) (section 103).

It is very important, from an administrative law perspective, that the process leading to a revocation decision is procedurally fair. Procedural fairness includes a variety of actions and may change dependent on the participant’s individual situation. Some of these actions relating to ER may include:

• ensuring a clear explanation outlining the reasons for a potential revocation decision
• providing the participant with a reasonable opportunity to provide information to present their case
• providing guidance to the participant around the types of information/evidence which may assist their case
• properly considering any Extension of Time Request and granting this request where reasonable.

The Process

4.4.1 Plan developer refers the participant for ER or Access Status Change

A person’s NDIS participant status may be reassessed:

• as part of the plan reassessment process, or
• at any other time.

Plan developers must consider whether the participant should be referred for ER, or an Access Status Change is required, as part of the plan reassessment process. This involves completion of the:

• Referral Checklist: Eligibility Reassessment – Disability, or
• Referral Checklist: Eligibility Reassessment or Access Status Change – Early Intervention.

The plan developer completes the right check list with reference to relevant information on the participant’s record. The checklist is attached to the participant’s record before the plan developer completes an ER referral.

Note: An AA must not commence the ER process if there is no checklist attached.

4.4.2 Access Assessor determines if ER is required

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Upon receipt of an ER referral, the AA will consider whether the participant is likely to continue to meet the residence and disability or early intervention requirements. They do this by assessing all available information against the legislative requirements.

4.4.3 Access Assessor completes ER

An ER is commenced when the information indicates that the participant may not meet the eligibility criteria. The AA will contact the participant (or their representative) by phone and in writing to outline the reasons why the person may not meet eligibility criteria. It is important that the participant understands the specific reasons why they may not meet these criteria, and what information they can provide to support their case.

The AA must explain to the participant that it is their responsibility to prove they meet the eligibility criteria. It is the AA’s responsibility to help the participant understand the type of information we need to assess eligibility. If we do not have clear information that the person continues to meet the eligibility criteria, their access will be revoked.

The plan developer will also be notified of the progress of the ER request and any required actions via an Interaction. The AA also has the option to contact the plan developer by phone if there are any sensitivities or risks.

During the ER process, the participant will have two, 28 day opportunities to provide further information to support their continued eligibility. In exceptional circumstances, they can request an extension of time to provide this information.

4.4.4 Access Assessor determines outcome

The AA will assess all available information against the legislative requirements and decide if the participant’s access status should be:

• maintained, (including disability to early intervention), or
• changed from early intervention to disability, or
• revoked.

All revocation decisions, and some maintain or change status decisions, will be referred to a QDO for quality checking before being finalised.

The AA will explain the reasons for the outcome to the participant (or their representative) by having a conversation (where required contact attempts are successful) and sending them a letter. The plan developer will also be notified of the ER outcome. If the participant’s status is revoked, the plan developer must support them to leave the NDIS and find other community and government supports.

Throughout the ER process, it’s important there is no disruption to the participant’s supports and services during this time.

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5. Related procedures or resources

• Our Guideline – Applying to the NDIS
• Our Guideline – Leaving the NDIS
• Referral Checklist: Eligibility Reassessment – Disability
• Referral Checklist: Eligibility Reassessment or Access Status Change – Early Intervention
• Standard Operating Procedure – Ask for an Access Request to be withdrawn
• Standard Operating Procedure – Finalise the plan before a participant leaves the NDIS
• Standard Operating Procedure – Support the former participant to leave the NDIS after a revocation decision
• Standard Operating Procedure – Cease the participant status to leave the NDIS
• Standard Operating Procedure – Request technical advice to progress an Eligibility Reassessment
• Standard Operating Procedure – Action evidence extension request for an Eligibility Reassessment
• Standard Operating Procedure – Consider Eligibility Reassessment outcome following 1st chance to respond
• Standard Operating Procedure – Make Eligibility Reassessment decision

6. Feedback

If you would like to provide feedback about this guidance material, please complete our Feedback form.

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Consider Eligibility Reassessment outcome following 1^st chance to respond

This Standard Operating Procedure (SOP) will help you consider the outcome of the Eligibility Reassessment (ER), following the participant’s first chance to respond.

This involves considering if a participant meets the:

• residence and disability requirements, or
• early intervention requirements.

This SOP has three outcomes.

1. Potential for an adverse decision:
   • the participant is unlikely to meet the residence, disability or early intervention requirements, or
2. Maintain Access Status:
   • the participant still meets the eligibility requirements they joined the NDIS under, or
   • the participant now meets the early intervention requirements when they joined the NDIS under disability, or
3. Change Access Status:
   • the participant now meets the disability requirements when they joined the NDIS under early intervention.

Note: Maintain Access Status and Change Access Status are not reviewable decisions under the NDIS Act.

Recent updates

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Date | What’s changed

e Improved formatting to highlight pre-checks.

e Link to new SOPs:

• SOP - Check for procedural fairness in an Eligibility Reassessment
• SOP — Check for Eligibility Reassessment missed steps
• SOP - Complete Eligibility Reassessment missed steps
• SOP - Check for remote or very remote address.

2. Checklist

Topic | Checklist

Pre-requisites | You have:

• read and understood Our Guideline — Applying to the NDIS
• read and understood Our Guideline — Leaving the NDIS
• an ER task with an Outcome to Commence Eligibility Reassessment
• checked all pre-checks were completed using SOP - Consider commencement of Eligibility Reassessment or Access Status Change. The pre-checks are:
  • independent Delegate
  • unable to contact for plan reassessment
  • ER checklist is complete and attached
  • 12 months of funded supports have been received
  • check if primary disability is developmental delay
• completed any missed steps using SOP - Complete Eligibility Reassessment missed steps
• confirmed a minimum of 28 days (plus any approved extension of time request) have passed since the Letter — Eligibility Reassessment — Commencement - 1st Opportunity to Respond was sent to the participant.

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Topic: Checklist

3. Procedure

During the ER process, do not reassign the application in the Business System. The application must remain assigned to the plan developer so they can continue with planning activities throughout the ER process.

3.1 Check for ER request

You might receive an ER request at different points in the process. So, you might complete one or more of the following steps.

3.1.1 Obtain work item

1. In My Inbox: Select Ready for Work

Note: This will allocate a work item to your inbox.

2. Select the work item.

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3. Is it an ER work item:

• No: For access decisions: Refer to SOP – Progress NDIS application in the system.
• Yes: Go to Step 3.2: Complete pre-checks.

3.2 Complete pre-checks

3.2.1 Check for an independent delegate

1. Did you make the original access decision?

• No: Go to Step 3.2.2: Check for YPIRAC.
• Yes: Ask your team leader to Re-assign the work item to another Access Assessor.

End of process.

3.2.2 Check for YPIRAC

1. Is there an alert for Younger People in Residential Aged Care (YPIRAC)?

• No: Go to Step 3.2.3: Check for remote or very remote.
• Yes: Re-assign the work item to Nicola King (NK0019).

End of process.

3.2.3 Check for remote or very remote

1. Does the participant live in a remote or very remote area? Refer to SOP - Check for remote or very remote address.

• No: Go to Step 3.2.4: Check ER work item.
• Yes: Re-assign the work item to Danika Sharpe (DJS497).

End of process.

3.2.4 Check ER work item

1. Check work item Type.

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2. Check Outcome to determine the next steps.

3. If Outcome is:

• not displayed: Go to SOP - Consider commencement of Eligibility Reassessment or Access Status Change.
• Commence Eligibility Reassessment: Go to Step 3.3 Consider residence and disability or EI requirements
• Opportunity to Respond: Go to SOP - Make Eligibility Reassessment decision.

3.2.5 Check for a request for more time to send evidence

1. Go to SOP - Action Evidence Extension Request for an Eligibility Reassessment.

3.2.6 Check for a call back request

1. Go to SOP - Action Call back Request for an Eligibility Reassessment.

3.3 Consider residence and disability or Early Intervention (EI) requirements

It is the participant’s responsibility to provide evidence that they continue to meet eligibility requirements. It is our responsibility to help the participant understand the evidence we need.

1. Check the ER Request work item Outcome Justification.

Note: This will determine the eligibility criteria you consider, and the order to consider them.

2. If the Outcome Justification states that the participant may:

• not meet residence (only): consider residence requirements.
• not meet residence and disability and EI: consider residence, disability and EI requirements.

3. Review the ER Checklist and all relevant participant information including:

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• Interactions • Inbound Documents • NAT inbox, and • other available information on the participant’s record such as the planning conversation tool, plan value, plan usage and supports in place.

4. Notify your Team Leader if you notice any integrity issues then proceed with ER.

3.4 Consider ER likely outcome

1. Assess the evidence against the eligibility requirements in the right order. For steps, go to ARIS process connect:

   • P2.2.4 Make Access Decision Under 6 Years of Age or • P2.2.3 Make Access Decision Aged 6 and Over.

2. Refer to available resources as required, such as:

   • Our Guideline – Applying to the NDIS • Our Guideline – Leaving the NDIS • Technical Advisory Branch (TAB) Digest – Published Advice

3. Check if the NSW Prescribed Program exception applies (relevant to the residence requirements only).

4. Consider if there is sufficient evidence to decide if the participant meets the residence and/or disability or early intervention requirements (if the participant joined the NDIS under one of the NSW prescribed programs, only consider the disability and EI requirements and do not consider the residence requirements).

5. Consider if you need technical support or if you can make a decision to maintain access status, change access status or make a potential for adverse decision.

6. Revisit SOP - Check for procedural fairness in an Eligibility Reassessment to make sure the process leading to a revocation is procedurally fair.

3.4.1 If technical support or advice is required

1. Refer to SOP – Request technical advice to progress an Eligibility Reassessment if you:

   • want to ask for QDO technical support to decide the next step, or • require mandatory TAB advice.

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Note: If a participant has a primary disability that is a chronic health condition and TAB advice was not obtained at the point of access – mandatory TAB advice is required before maintaining or changing access status.

3.4.2 If ER outcome – Maintain Access Status

1. Refer to Step 3.9 Submit ER outcome: Maintain Access Status, if:

The information indicates that the participant:

• meets the residence and disability or early intervention requirements that they joined the NDIS under, or
• joined the NDIS under the disability requirements and now meets early intervention requirements

And

• does not have a primary disability that is a chronic health condition, or
• has a primary disability that is a chronic health condition, and you confirmed TAB advice was obtained at the point of access or you obtained mandatory TAB advice to support your Maintain Access Status outcome.

3.4.3 If ER outcome – Change Access Status

1. Refer to Step 3.10: Submit ER outcome: Change Access Status (from EI to disability), if:

The information indicates that the participant:

• joined the NDIS under the early intervention requirements and now meets the disability requirements

And

• does not have a primary disability that is a chronic health condition, or
• has a primary disability that is a chronic health condition, and you confirmed TAB advice was obtained at the point of access or you obtained mandatory TAB advice to support your Change Access Status outcome.

3.4.4 If Potential for Adverse Decision

1. Refer to Step 3.5: Update ER request: 2nd chance to send evidence, if:

The information indicates that:

• the participant is unlikely to meet the residence and disability or early intervention requirements, or

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

And • the NSW Prescribed Program exception does not apply (relevant to the residence requirements only).

3.5 Update ER request: 2nd chance to send evidence

3.5.1 Prepare Request Further Information template

1. Open Template – Eligibility Reassessment – 1st and 2nd opportunity to respond.
2. Complete fields in the templates for all requirements unlikely to be met (including both disability and EI criteria).
3. Save the completed template as a Word document to your desktop or OneDrive. Note: This will be used to populate the ER letter in a later step.
4. Copy the completed template to paste into the Outcome Justification.

3.5.2 Update ER request outcome: Opportunity to Respond

1. In the NDIS Account Screen: Select Internal Use.
2. In Internal Use: Select Open Activities.
3. In the Transaction Id column: Select the hyperlinked Transaction Id that corresponds with the Eligibility Re-Assessment Request Activity.
4. In the Eligibility Reassessment Request: Select Edit.

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5. In Outcome: Select Opportunity to Respond.

6. In Outcome Justification:

There is not enough information to indicate that <Participant’s name> meets the eligibility requirements. I have made a Potential for Adverse Decision.

Primary Disability: <Participant’s primary Disability>

I have received and considered the following evidence:

<List the information and evidence that has already been considered for eligibility reassessment>.

I have requested the following information:

<Paste the completed eligibility reassessment opportunity to respond template>

<Enter your User ID>

7. In Supporting Info:

Refer to Outcome Justification.

8. Select Submit.

9. Select Edit.

10. In Due Date: Update to 29 days after the date of the letter.

Note: This stops the ER work item from being allocated on the 28th day.

11. In Supporting Info:

Due date updated to 29 days after the date of the letter. This allows the system to give the participant the full 28 days to provide information.

12. Select Back.

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Send Letter: 2nd Chance to Send Evidence

1. Open and edit the Letter – Eligibility Reassessment – Potential for adverse decision – 2nd opportunity to respond.
2. Copy the completed decision templates into the letter.

Note: The template was saved to your desktop or OneDrive earlier. 3. Send letter to the participant or their representative via their preferred correspondence method. 4. Delete the template saved to your desktop or OneDrive after you have completed this step.

3.6.1 Attach Letter to Inbound Documents

1. In the NDIS Account screen: Select Documents.
2. Select Add Items and then select Inbound Document.
3. In Description: Letter – ER – Potential for adverse decision.
4. In Status: Select Completed.
5. In Category 1: Select NDIA Service.
6. In Category 2: Select Other Correspondence.
7. In Employee Responsible: Enter your details.

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8. In Note: Letter <emailed/mailed> to on by .

9. Select the Upload File button under Attachments.

10. In the File Explorer window: Select the relevant document.

11. Select Save.

3.7 Contact participant or representative: 2nd chance to send evidence

Note: A representative could be the participant’s authorised representative, nominee or child representative. If the participant has a nominee, they will be listed as a contact as a Plan Nominee.

If the person’s preferred correspondence method is email/letter, you must still attempt to call them about the potential for adverse decision. The exception is if the person has requested no phone calls (for example, they are Deaf and have requested written communication only), or if they have not provided a phone number.

3.7.1 Contact person: 2nd chance to send evidence

1. Refer to SOP – Send SMS using Whispir messenger to send ‘Contact attempt SMS template’ to advise you will be calling.

Note: Only send this SMS before your first attempt to call the person.

Do not contact the person by SMS if they have told the Agency that they do not consent to this form of communication.

2. Prepare for your call:

• Read 8.3: Sensitive conversations in the Conversation Style Guide
• Review the relevant evidence on the participant’s record, and your reasons why they are unlikely to meet the eligibility requirements.
• Have the Letter – Eligibility Reassessment – Potential for adverse decision – 2nd opportunity to respond handy for reference during the call.

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3. Make 5 telephone contact attempts (over a 3-day period, at different times of day) to the participant or their representative. The first call should be made on the day of the decision. If you reach voicemail and the person identifies themselves, leave a brief message requesting they contact the NDIA on 1800 800 110. You must complete all required contact attempts, even if the number is disconnected.

Record an Interaction after each unsuccessful call attempt

1. In the NDIS Account screen: Select Interactions.
2. Select Add Items and then select Interaction.
3. In Category 1: Select Pathway.
4. In Category 2: Select Review.
5. In Category 3: Select Eligibility Reassessment.
6. In Channel: Select Internal Notes.
7. In Status: Select Completed.
8. In Notes:

<First/Second/Third/Forth/Fifth> phone call attempt made to <Participant or representative’s name> on at to advise of the potential for an adverse decision and opportunity to respond.

Call not answered.

9. Select Submit.

3.7.2 If all 5 contact attempts are unsuccessful

1. Refer to SOP – Send SMS using Whispir messenger to send ‘Unsuccessful contact attempt’ SMS to advise you tried to call.

Note: Only send this SMS after you make all required call attempts.

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Do not contact the person by SMS if they have told the Agency that they do not consent to this form of communication.

2. Go to Step 3.8: Add interaction: Notify plan developer – Potential for adverse decision.

3.7.3 Call is answered

1. Guide a respectful and transparent conversation, using the script:

• Notify the participant that you are calling to update them about the progress of their eligibility reassessment.
• Explain that we have considered all the available information (including new information if provided).
• Note that the Eligibility Reassessment Commencement Letter was sent on , and call attempts were made on <date/s>.
• Using the letter as a guide, explain that there is information that the participant may no longer meet the and/or requirements.
• Explain that 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.
• Explain that it is the participant’s or their representative’s responsibility to provide sufficient evidence that they still meet the eligibility requirements. If we do not receive this information, they may leave the NDIS.
• Explain that it is our responsibility to help them understand what information we need to assess eligibility.
• Explain that they have 28 days to provide further information. We will then contact them with an outcome.
• Describe the types of information that would help to determine if they still meet the eligibility requirements.
• Explain that if a participant is no longer eligible, their plan developer or <local area coordinator/early childhood partner> will support them to leave the NDIS and connect with community and government supports. Refer them to the plan developer or <local area coordinator/early childhood partner> for information about their plan and to prepare for the potential eligibility reassessment outcome.

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• Inform them that they will soon receive a letter explaining what has been discussed today and how they can provide more information. • After 28 days, we will make a decision based on the available information and let them know the outcome. • If the person asks for more time to provide information: Refer to SOP - Action evidence extension request for an Eligibility Reassessment. An extension of time will only be granted in exceptional circumstances. • If they no longer wish to be a participant of the NDIS: They will need to make this request in writing. Refer to SOP - Refer request to cease participant status during Eligibility Reassessment. The eligibility reassessment process will continue until we receive the written request. This includes receiving any letters generated as part of this process.

2. Go to Step 3.7.4: Add interaction: ER – Potential for Adverse Decision

3.7.4 Add interaction: ER – Potential for Adverse Decision

1. In the NDIS Account screen: Select Interactions.
2. Select Add Items and then select Interaction.
3. In Category 1: Select Pathway.
4. In Category 2: Select Review.
5. In Category 3: Select Eligibility Reassessment.
6. In Channel: Select Internal Notes.
7. In Status: Select Completed.
8. In Notes:

Phone call made to redacted to advise of second chance to send evidence and the potential for an adverse decision. redacted

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9. Select Submit.

3.8 Add interaction: Notify plan developer – Potential for adverse decision

1. In the NDIS Account screen: Select Interactions.
2. Select Add Items and then select Interaction.
3. In Category 1: Select Pathway.
4. In Category 2: Select Review.
5. In Category 3: Select Eligibility Reassessment.
6. In Channel: Select Internal Notes.
7. In Status: Select Open.
8. In Notes:

Interaction to notify plan developer of Eligibility Reassessment update.

Refer to Eligibility Re-Assessment Request for information about the status of the request.

Refer to SOP – Refer Participant for an Eligibility Reassessment or Access Status Change for information about the process. No action required. Plan developer to note and close interaction.

9. Select Submit.
10. Select Edit.
11. Select Assign.
12. Select Employee.

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13. In Employee: Enter plan developer’s name with relationship type ‘My NDIS Contact’.

Note: Where there is not My NDIS Contact, assign interaction to the National Delivery Inbox (Return to SDP Inboxes) within the person’s geographical location.

14. Select Assign.

15. Select Submit.

The ER Request will now be on hold for 28 days (or longer if the person has been given more time to provide information).

3.9 Submit ER outcome: Maintain Access Status

3.9.1 Prepare decision template

1. Open Template - Eligibility Reassessment - Maintain or Change Access Status.

2. Complete fields in the relevant templates.

3. Copy the completed template to paste into the Outcome Justification.

3.9.2 Update ER request: Maintain Access Status

1. In Eligibility Reassessment Request: Select Edit.

2. In Outcome: Select Maintain Access Status.

3. In Outcome Justification:

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.

.

4. In Supporting Info:

Refer to Outcome Justification.

5. In Reason for Maintain Access Status: Select reason from drop-down menu.

• Disability and Residence Valid: Sufficient evidence the residence and disability requirements are met.
• Early Intervention and Residence Valid: Sufficient evidence residence and early intervention requirements are met.

Note: Do not use Insufficient Evidence to Alter Decision, Record Ceased or Invalid Checklist/Checklist not provided.

6. Select Submit.

7. If your Maintain Access Status decision:

   • is not sent for quality checking: o Go to Step 3.12: Send letter: Access Status outcome.
   • is sent for quality checking: o Start working on another work item. Once quality feedback is returned, go to Step 3.11: Review quality check feedback: Access Status outcome (if sent for quality checking).

3.10 Submit ER outcome: Change Access Status (from EI to disability)

Changing the participant’s access status from early intervention to disability is not a decision under the NDIS Act. This means it is not a reviewable decision.

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If the participant joined the NDIS under disability requirements and now meets the early intervention requirements, their access status must be maintained. Do not change their access status.

3.10.1 Prepare Decision Template

1. Open Template - Eligibility Reassessment - Maintain or Change Access Status.
2. Complete fields in the relevant templates.
3. Copy the completed template to paste into the Outcome Justification.

3.10.2 Update ER Request: Change Access Status

1. In Eligibility Reassessment Request: Select Edit.

2. In Outcome: Select Change Access Status.

3. In Outcome Justification:

   .

   .

4. In Supporting Info:

   Refer to Outcome Justification.

5. In Access Decision Reason: Select Disability Met.

   Note: Benefit from Early Intervention, Exceptional Circumstances and Continuity of Supports are not applicable.

6. In Access Decision Notes: Status Change from EI to Disability.

7. Select Submit.

8. If your change access status decision:

   • is not sent for quality checking:

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• Go to Step 3.12: Send letter: Access Status outcome.

• is sent for quality checking:

• Go to Step 3.11: Review quality check feedback: Access Status outcome (if sent for quality checking).

3.11 Review quality check feedback: Access Status outcome (if sent for quality checking)

After receiving the feedback, you are still responsible for making, documenting and implementing the decision.

1. In the Business System Inbox: Select Quality Check Act task.
2. Review the quality feedback provided:
3. If you agree with the feedback:
   • Next to Acknowledged: Select Yes
   • Select Submit
   • Go to Step 5.
4. If you need further clarification of the feedback, do not acknowledge it. Discuss it with your Team Leader, and if applicable, follow the reconsideration process. Do not proceed to Step 5 until this is resolved.
5. Finalise the ER outcome, taking into consideration the quality check feedback.
6. If the outcome continues to be either maintain or change access status, go to Step 3.12: Send letter: Access Status outcome.

3.12 Send letter: Access Status outcome

3.12.1 Prepare and send letter to participant

1. Open and edit Letter – Eligibility Reassessment – Maintain or change access status.
2. Send the letter to the participant or representative via their preferred correspondence method.

3.12.2 Attach letter to Inbound Documents

1. Go to the NDIS Account screen: Select Documents.
2. Select Add Items and then Inbound Documents.
3. In Description: Letter – ER – Access Status outcome.

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4. In Status: Select Completed.

5. In Category 1: Select NDIA Service.

6. In Category 2: Select Other Correspondence.

Employee Responsible: Enter your details.

Note: Letter <emailed/mailed> to <redacted> on <Date> by <User ID>.

9. Select Upload File button under Attachments.

10. In File Explorer window: Select the relevant document.

11. Select Save.

12. Go to Step 3.13: Contact participant or representative: Explain Access Status outcome.

3.13 Contact participant or representative: Explain Access Status outcome

Note: A representative could be the participant’s nominee or child representative. If the participant has a nominee, they will be listed as a contact as a Plan Nominee.

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3.13.1 Contact the participant or their representative

1. Refer to SOP – Send SMS using Whispir messenger to send ‘Contact attempt SMS template’ to advise you will be calling.

Note: Do not contact the person by SMS if they have told the Agency that they do not consent to this form of communication.

2. Make one telephone contact attempt to the participant, nominee or child representative. If you reach voicemail and the person identifies themselves, leave a brief message requesting they contact the NDIA on 1800 800 110.

3.13.2 If unsuccessful contact attempt

1. Refer to SOP – Send SMS using Whispir messenger to send ‘Unsuccessful contact attempt’ SMS to advise you tried to call.

Note: Do not contact the person by SMS if they have told the Agency that they do not consent to this form of communication.

2. Go to Step 3.13.4: Update the ER Alert End Date.

3.13.3 If the call is answered

1. Guide a respectful and transparent conversation. Use the letter and script as a guide:

• Notify the person that you are calling to update them on the outcome of their Eligibility Reassessment.
• Advise the person that we have completed a review of their eligibility, and that they continue to meet the eligibility requirements.
• If Change Access Status: Advise the person that they originally met the requirements for early intervention and based on the available information, they now meet the disability requirements.
• If Maintain Access Status: Advise the person that based on the available information, they continue to meet the residence and or requirements.
• This means that they will continue to be a participant of the NDIS and there will be no change to their current supports.
• If the person has any questions about their plan or funding, refer them to their <local area coordinator/early childhood partner/NDIA planner>.

3. Go to Step 3.13.4 Update the ER Alert End Date

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3.13.4 Update the ER Alert End Date

1. In the NDIS Account screen: Select Internal Use.
2. Select Plan Alerts.
3. Select the Eligibility Reassessment alert.
4. In End Date: Edit to today’s date.
5. Select Submit.

3.13.5 Add Interaction: Maintain or Change Status

1. In the NDIS Account screen: Select Interactions.
2. Select Add Items and then select Interaction.
3. In Category 1: Select Pathway.
4. In Category 2: Select Review.
5. In Category 3: Select Eligibility Reassessment.
6. In Channel: Select Internal Notes.
7. In Status: Select Completed.
8. In Notes:

Phone call made to redacted to advise them that the Eligibility Reassessment is now complete.

redacted access status has been <maintained/changed from early intervention to disability>. redacted OR .

9. Select Submit.

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10. Go to Step 3.14: Check/update primary and secondary disabilities.

3.14 Check/update primary and secondary disabilities

The Disabilities tab needs to reflect only the disabilities where the participant meets disability or early intervention requirements, as this is important for the planning stage.

You need to confirm that their eligible impairments are reflected correctly in the business system. This includes listing any other eligible impairments in both the Primary Disability and Secondary Disabilities tab.

3.14.1 View Disabilities screen

1. In the NDIS Account screen: Select Disabilities.
2. In Disabilities: Select the > next to Secondary.
3. In Disabilities: Select the > next to Primary.

Note: To view both the primary and secondary disabilities at the same time, open the Secondary tab first, followed by the Primary.

Note: This screen will list all current and previous primary and secondary disabilities. Take note of the Effective Start and Effective End dates to determine what disabilities are current.

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3.14.2 Consider if the listed primary disability still meets the eligibility requirements

1. Consider if there is sufficient evidence the primary disability meets the eligibility requirements:

2. If primary disability no longer meets the disability or early intervention requirements:

   • Go to Step 3.14.3: [Update primary disability](Step 3.14.3).

3. If primary disability continues to meet the disability or early intervention requirements:

   • Go to Step 3.14.6: Consider if any secondary disabilities no longer meet the eligibility requirements.

Note: If the existing primary disability continues to meet the eligibility requirements, and there are additional disabilities that also meet eligibility, do not change the primary disability.

3.14.3 Update primary disability

Do not delete the previous primary disability. When the primary disability is changed, this will automatically apply an end date to the previous primary disability.

3.14.4 If primary disability is listed as a secondary disability:

4. In Secondary: Select the Convert to Primary Disability icon.

5. Complete additional fields (if known).

6. Select Submit.

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3.14.5 If the primary disability is not listed as a secondary disability

1. In the NDIS Account screen.
2. Select Add Items and then select Disability.
3. In Reported Impairment: Start typing the disability and select when displayed. Note: Alternatively, select from the list of disabilities.
4. Next to Primary: Select the checkbox.
5. Complete additional fields (if known).
6. Select Submit.

3.14.6 Consider if any secondary disabilities no longer meet the eligibility requirements

1. Consider if there is sufficient evidence that any secondary disabilities continue to meet the eligibility requirements:
2. If a secondary disability no longer meets the disability or early intervention requirements: • Go to Step 3.14.7: Update Effective End date for secondary disability.
3. If the secondary disabilities continue to meet the disability or early intervention requirements: • Go to Step 3.14.8: Consider if additional secondary disabilities meet the disability or early intervention requirements.

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4. If there are no secondary disabilities listed:

• Go to Step 3.14.8: Consider if additional secondary disabilities meet the disability or early intervention requirements.

3.14.7 Update Effective End date for secondary disability

1. Select relevant disability.

2. In the Effective End date: Update to current date.

3. Select Submit.

Note: The disability will show within Secondary Disabilities with an end date.

3.14.8 Consider if additional secondary disabilities meet the disability or early intervention requirements

1. Consider if there is sufficient evidence that an additional secondary disability meets the disability or early intervention requirements:

2. If an additional secondary disability meets the disability or early intervention requirements:

• Go to Step 3.14.9: Add secondary disability.

3. If there is insufficient evidence that any additional disabilities meet the disability or early intervention requirements:

• Go to Step 3.15: Add interaction: Notify plan developer – ER outcome.

3.14.9 Add secondary disability

1. In the NDIS Account screen.

2. Select Add Items: Select Disability.

Standard Operating Procedure

For Internal Use Only

3. In Reported Impairment: Start typing the disability and select when displayed.

Note: Alternatively, select from the list of disabilities.

4. Next to Primary: Do not select the checkbox.

5. Complete additional fields (if known).

Note: Do not adjust the Effective End date as it will auto-populate with 31.12.9999.

6. Select Submit.

7. Go to Step 3.15: Add interaction: Notify plan developer – ER outcome.

3.15 Add interaction: Notify plan developer – ER outcome

1. In the NDIS Account screen: Select Interactions.

2. Select Add Items and then select Interaction.

3. In Category 1: Select Pathway.

4. In Category 2: Select Review.

5. In Category 3: Select Eligibility Reassessment.

6. In Channel: Select Internal Notes.

7. In Status: Select Open.

8. In Notes:

Interaction to notify plan developer of Eligibility Reassessment update.

Refer to Eligibility Re-Assessment Request for information about the status of the request.

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Refer to SOP – Refer Participant for Eligibility Reassessment or Access Status Change ER for information about the process.

No action required. Plan developer to note and close interaction.

9. Select Submit.
10. Select Edit.
11. Select Assign.
12. Select Employee.
13. In Employee: Enter the plan developer’s name (Contact with relationship type My NDIS Contact).

Note: Where there is no My NDIS Contact, assign the interaction to the National Delivery Inbox (Return to SDP Inboxes) within the person’s geographical location. 14. Select Assign.

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15. Select Submit.

End of process – no further steps to be completed.

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Appendices

4.1 The Legislation

While the NDIS provides lifetime disability support for many participants, others build capacity and achieve their goals to the extent that they no longer meet the eligibility requirements and leave the NDIS.

This SOP provides instructions for when an Access Assessor (AA) receives an ER referral from a plan developer indicating that the participant:

• may not meet the residence requirements (section 23)

Or

• may not meet the disability requirements (section 24) and early intervention requirements (section 25)

Or

• joined the NDIS under the early intervention requirements (section 25) and may now meet the disability requirements (section 24).

All participants must continue to meet the residence requirements and the disability or the early intervention requirements.

There are some exceptions to when an ER should be undertaken:

• If the participant joined the NDIS under the NSW Prescribed Program Rules, their NDIS access should not be revoked based on residence requirements. This also includes participants who joined the NDIS under these rules, but now reside in another state or territory. For these participants, ER can only be based on the disability and early intervention requirements.
• If the AAT has previously made a determination relating to the participant’s access to the NDIS, seek advice from a QDO Team Leader before commencing an ER.

The QDO Team Leader will seek advice from TAB/Legal as required. QDO Team Leader advice is not required if you are maintaining or changing access status.

4.2 Independent Delegate

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The AA that decides whether to commence or undertakes an ER must be independent. That is, they will not have:

• a personal interest in the participant’s status, or
• a personal relationship with the participant (outside the NDIA), or
• must not have been involved in making the original access decision or any planning decisions.

An AA can be involved in any or all stages of the ER process.

4.3 ER Outcomes

There are 2 ER outcomes under (s 30(1), NDIS Act). They are:

1. To exercise the power to revoke a person’s access, which includes:
   • revoking participant status.
2. To not exercise the power to revoke a person’s access, which includes:
   • maintaining access status, or
   • changing access status.

Note: To not exercise the power to revoke a person’s access is not a reviewable decision.

4.3.1 Access status outcome

• Maintain: A person maintains their participant status when they continue to meet the access requirements they joined the NDIS under. Or, if they joined the NDIS under disability requirements and now meet the early intervention requirements.
• Change: A person’s status is changed from early intervention to disability when the participant who joined the NDIS under early intervention requirements now meets the disability requirements.

Note: Changing access status is not a decision under the NDIS Act. It is also considered maintaining access status.

4.3.2 Revoke outcome

If an AA is satisfied a person no longer meets the residence and/or disability and early intervention requirements, their status as a participant will be revoked (section 30).

A person ceases to be a participant in the NDIS when their status is revoked under section 30. A revocation decision will take effect from the date of the decision notice.

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A person must not use NDIS funds to purchase reasonable and necessary supports for the participant after they cease to be an NDIS participant (section 29(2)).

The decision to revoke a person’s status as a participant is a reviewable decision (section 99, Item 3). This means that the decision may be internally reviewed by a delegate of the CEO (section 100) and subsequently externally reviewed by the Administrative Appeals Tribunal (AAT) (section 103).

It is very important, from an administrative law perspective, that the process leading to a revocation decision is procedurally fair. Procedural fairness includes a variety of actions and may change dependent on the participant’s individual situation. Some of these actions relating to ER may include:

• ensuring a clear explanation outlining the reasons for a potential revocation decision
• providing the participant a reasonable opportunity to provide information to present their case
• providing guidance to the participant around the types of information/evidence which may assist their case
• properly considering any Extension of Time Request, and granting this request where reasonable.

4.4 The Process

4.4.1 Plan developer refers the participant for ER or Access Status Change

A person’s NDIS participant status may be reassessed:

• as part of the plan reassessment process, or
• at any other time.

Plan developers must consider whether the participant should be referred for ER, or an Access Status Change is required, as part of the plan reassessment process. This involves completion of Checklist – Eligibility Reassessment – Disability or Checklist – Eligibility Reassessment or Access Status Change – Early Intervention with reference to relevant information on the participant’s record. The checklist is attached to the participant’s record before the plan developer completes an ER referral.

Note: An AA must not commence the ER process if there is no checklist attached.

4.4.2 Access Assessor determines if ER is required

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Upon receipt of an ER referral, the AA will consider whether the participant is likely to continue to meet the residence and disability or early intervention requirements. They do this by assessing all available information against the legislative requirements.

4.4.3 Access Assessor completes ER

An ER is commenced when the information indicates that the participant may not meet the eligibility criteria. The AA will contact the participant (or their representative) by phone and in writing to outline the reasons why the person may not meet eligibility criteria. It is important that the participant understands the specific reasons why they may not meet these criteria, and what information they can provide to support their case.

The AA must explain to the participant that it is their responsibility to prove they meet the eligibility criteria. It is the AA’s responsibility to help the participant understand the type of information we need to assess eligibility. If we do not have clear information that the person continues to meet the eligibility criteria, their access will be revoked.

The plan developer will also be notified of the progress of the ER request and any required actions via an Interaction. The AA also has the option to contact the plan developer by phone if there are any sensitivities or risks.

During the ER process, the participant will have two, 28-day opportunities to provide further information to support their continued eligibility. In exceptional circumstances, they can request an extension of time to provide this information.

4.4.4 Access Assessor determines outcome

The AA will assess all available information against the legislative requirements and decide if the participant’s access status should be:

• Access status outcome:
  • maintained (including disability to early intervention),
  • changed from early intervention to disability,
  • Revoked outcome.

All revocation decisions, and some maintain or change status decisions, will be referred to a QDO for quality checking before being finalised.

The AA will explain the reasons for the outcome to the participant (or their representative) by having a conversation (where required contact attempts are successful) and sending them a letter. The plan developer will also be notified of the ER outcome. If the participant’s status is revoked, the plan developer must support them to leave the NDIS and find other community and government supports.

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Throughout the ER process, it’s important there is no disruption to the participant’s supports and services.

5. Related procedures or resources

• Our Guideline – Applying to the NDIS
• Our Guideline – Leaving the NDIS
• SOP – Request technical advice to progress an Eligibility Reassessment
• SOP - Consider commencement of Eligibility Reassessment or Access Status Change
• SOP - Make Eligibility Reassessment decision
• SOP - Action evidence extension request for an Eligibility Reassessment
• SOP - Action call back request for an Eligibility Reassessment
• SOP - Refer request to cease participant status during Eligibility Reassessment
• SOP - Check for procedural fairness in an Eligibility Reassessment
• SOP - Complete Eligibility Reassessment missed steps
• SOP - Check for remote or very remote address
• Letter – Eligibility Reassessment – Commencement - 1st opportunity to respond
• Letter – Eligibility Reassment – Potential for adverse decision – 2nd opportunity to respond

6. Feedback

If you have any feedback about this Standard Operating Procedure, please complete our Feedback Form.

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Version control

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| V2.0 | EMN960 | Class 1 approved. Update Checklist — Pre-requisites “checked all pre-checks were completed using SOP — Check for Eligibility Reassessment missed steps” to SOP - Consider commencement of Eligibility Reassessment or Access Status Change. | APPROVED | 2022-11-03 |

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• e outcome justification template to include evidence that was considered when making decision
• e notes sections ‘choose an item’ field is not currently a drop down
• e introduction to strengthen intent of SOP
• e formatting, screenshots, links and grammar. | APPROVED | 2022-11-29 |

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The contents of this document are OFFICIAL.

Make Eligibility Reassessment decision

This Standard Operating Procedure (SOP) will help you finalise an Eligibility Reassessment (ER) decision in the Business System.

This involves considering if the participant continues to meet the residence and disability or early intervention (EI) requirements. The outcome of this SOP will be one of the following:

1. Maintain Access Status: the participant still meets the eligibility requirements they joined the NDIS under; or the participant now meets the early intervention requirements when they joined the NDIS under disability.
2. Change Access Status: the participant now meets the disability requirements when they joined the NDIS under early intervention.
3. Revocation decision: the participant does not meet the residence, disability or early intervention requirements and will be supported to leave the NDIS.

Note: Maintain Access Status and Change Access Status are not reviewable decisions under the NDIS Act.

1. Recent updates

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Date

What’s changed

Updates to provide more information about the reasons for a revocation decision. The letters list the information that indicates they are no longer eligible for the NDIS and the reasons for the decision.

Instructions about when to request technical advice from a Quality Development Officer (QDO) or the Technical Advisory Branch (TAB).

Increased contact attempts to 5 for when participant status is revoked.

Additional step to contact the plan developer by phone after a revocation decision, where there are sensitivities, or the plan developer is not the local area coordinator or early childhood partner.

Additional step to add an alert after a revocation decision for a person that joined the NDIS from a defined program.

Additional checks to make sure the ER process has been procedurally fair before making a revocation decision.

2. Checklist

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Checklist

• 3.1 Determine ER Request status
• 3.2 Complete pre-checks
• 3.3 Consider if residence and disability or El requirements are met
• 3.4 Check ER process resulting in revocation is procedurally fair
• 3.5 Submit revocation decision for quality check
• 3.6 Review quality check feedback: Revocation decision
• 3.7 Update plan nominee or child representative contact end dates
• 3.8 Send letter: Revocation decision
• 3.9 Contact former participant or representative: Revocation decision
• 3.10 Update alerts on record
• 3.11 Notify plan developer — Revocation
• 3.12 Submit ER outcome: Maintain Access Status
• 3.13 Submit ER outcome: Change Access Status (from El to disability)
• 3.14 Review quality check feedback: Maintain/Change Access Status (if sent for quality checking)
• 3.15 Send letter: Maintain or Change Access Status
• 3.16 Contact participant or representative: Explain Maintain/Change Access Status outcome
• 3.17 Check/update primary and secondary disabilities
• 3.18 Add Interaction: Notify plan developer — ER outcome
• 4.0 Appendices

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3. Procedure

During the ER process, do not reassign the application in the Business System.

3.1 Determine ER Request status

An Access Assessor (AA) may receive an ER Request at different points of the process and may complete one or more of these steps.

3.1.1 Obtain work item

1. In My Inbox: Select Ready for Work.

   Note: This will allocate a work item to your inbox.

2. Select the work item:

   • If it relates to an access decision: refer to SOP – Progress NDIS application in the system.
   • If you made the original access decision: inform your Team Leader of the conflict of interest and they will re-assign the work item to another Access Delegate.
   • If there is an alert for a Younger People in Residential Aged Care (YPIRAC): Re-assign the work item to Nicola King (NK0019).
   • Check if the person lives in a remote or very remote area: refer to SOP – Check for remote or very remote address. If they live in an area classified as Remote or Very Remote (‘M M 6’ or ‘M M 7’ under the Modified Monash Model): Re-assign the work item to Danika Sharpe (DJS497).

3.1.2 If ER Request

1. Select the work item.
2. Review Outcome to determine the next steps.

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| Status: | Open | |—|| | Channel: | LAC Partner | | Original Decision Maker: | M | | Outcome: | Commence Eligibility Reassessment |

3. If Outcome is:

• Opportunity to Respond: Go to Step 3.2: Complete pre-checks.
• Commence Eligibility Reassessment: Refer to SOP - Consider Eligibility Reassessment outcome following 1st chance to respond.
• Not displayed: Refer to SOP – Consider commencement of Eligibility Reassessment or Access Status Change.

3.1.3 If Eligibility Reassessment Evidence Extension Request

1. Refer to SOP - Action Evidence Extension Request for an Eligibility Reassessment.

3.1.4 If Eligibility Reassessment Call Back Request

1. Refer to SOP – Action Call back Request for an Eligibility Reassessment.

3.2 Complete pre-checks

1. Have all the pre-checks been completed?

   • Yes: Go to Step 3.3: Consider if residence and disability or EI requirements are met.
   • No: To complete the missed steps, refer to SOP - Consider commencement of Eligibility Reassessment or Access Status Change.

3.3 Consider if residence and disability or EI requirements are met

Note: It is the participant’s responsibility to provide evidence that they continue to meet eligibility requirements.

1. Review notes in the ER Request work item Outcome Justification to determine the reason for the potential for adverse decision.

   Note: This will determine which eligibility criteria you consider, and the order to consider them.

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2. If the Outcome Justification states that the participant:

• may not meet residence requirements (only): consider residence criteria.

• may not meet residence and disability and EI requirements: consider residence, disability and EI criteria.

3. Review all the participant’s information (including Interactions, Inbound Documents, the NAT inbox, and any other available information on the participant’s record such as the planning conversation tool, plan value, plan usage and supports in place). Notify your Team Leader if you identify any integrity issues then continue with ER.

4. Assess the evidence against the residence (s23), disability (s24) and EI (s25) requirements, if required use the ARIS process map eligibility decision steps to consider:

• First: List A

• Second: Criteria that the participant originally met (regardless of age)

• Third: The remaining criteria.

5. For more information to assist you with your decision making, refer to:

• Appendices

• Our Guideline – Applying to the NDIS

• Our Guideline – Leaving the NDIS

• Technical Advisory Team (TAT) Digest – Published Advice

6. Consider if the NSW Prescribed Program exception applies (relevant to the residence requirements only).

7. Consider if there is sufficient evidence to decide whether the participant meets the residence and/or disability or EI requirements (if the participant joined the NDIS under one of the NSW prescribed programs, only consider the disability and EI requirements and do not consider the residence requirements).

8. Consider if you require technical support or if you can make a decision to maintain access status, change access status or revoke participant status.

3.3.1 If technical support or advice is required

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Note: If a participant has a primary disability that is a chronic health condition and TAB advice was not obtained at the point of access – mandatory TAB advice is required before maintaining or changing access status.

• If you want to ask for QDO technical support to decide the next step; or • If you require mandatory TAB advice.

1. Refer to SOP – Request technical advice to progress an Eligibility Reassessment.

3.3.2 If ER outcome – Maintain Access Status

The information indicates that the participant:

• meets residence and disability or early intervention requirements that they joined the NDIS under; or • joined the NDIS under the disability requirements and now meets early intervention requirements

AND

• does not have a primary disability that is a chronic health condition; or • has a primary disability that is a chronic health condition, and you confirmed TAB advice was obtained at the point of access or you obtained mandatory TAB advice to support your Maintain Access Status outcome.

1. Go to Step 3.12: Submit ER outcome: Maintain Access Status.

3.3.3 If ER outcome – Change Access Status

The information indicates that the participant:

• joined the NDIS under early intervention requirements and now meets disability requirements

AND

• does not have a primary disability that is a chronic health condition; or • has a primary disability that is a chronic health condition, and you obtained mandatory TAB advice to support your Change Access Status outcome.

1. Go to Step 3.13: Submit ER outcome: Change Access Status (from EI to disability).

3.3.4 If ER outcome – Revoke Participant Status

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The information 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 AND
• the NSW Prescribed Program exception does not apply (relevant to the residence requirements only) AND
• the participant has received 12 months of funded supports.

1. Go to Step 3.4 Check ER process resulting in revocation is procedurally fair.

3.4 Check ER process resulting in revocation is procedurally fair

1. Refer to SOP - Check for procedural fairness in an Eligibility Reassessment.

3.5 Submit revocation decision for quality check

3.5.1 Prepare Decision Template

1. Open Template – Eligibility Reassessment – Revocation decision.
2. Complete fields in the relevant templates.
3. Save the completed template as a Word document to your desktop or OneDrive. Note: This will be used to populate the ER letter in a later step.
4. Copy the completed template to paste into the Outcome Justification.

3.5.2 Update ER Request: Revoke

1. In Eligibility Reassessment Request: Select Edit.
2. In Outcome: Select Revoke.
3. In Outcome Justification:

The information indicates that does not meet the eligibility requirements. I have made a decision to revoke their participant status.

<Paste the completed eligibility reassessment decision – revocation template>.

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.

4. In Supporting Info:

Refer to Outcome Justification.

5. In Reason for Revoke: Select appropriate reason from drop-down.

6. In Date of Decision: Select today’s date.

7. Select Submit.

Note: The ER Request will be drawn down by a QDO for quality checking.

8. Start working on a new work item while waiting for this to be completed.

9. Once quality feedback is returned, go to Step 3.6: Review quality check feedback: Revocation decision to finalise the decision.

3.6 Review quality check feedback: Revocation decision

After receiving the feedback, you are still responsible for making, documenting and implementing the decision.

1. In the Business System Inbox: Select Quality Check Act task.

2. Review the quality feedback provided:

   • If you agree with the feedback:

     o Next to Acknowledged

     o Select Submit

     o Go to Step 3.

   • If you need further clarification, do not acknowledge the feedback:

     o Discuss feedback with your Team Leader.

     o If required, follow the reconsideration process.

     o Do not proceed to Step 3 until this is resolved.

3. Finalise the ER decision, taking into consideration the quality check feedback.

3.7 Update plan nominee or child representative contact end dates

Note: You must do this so the nominee or child representative can still use the participant portal to finalise payments and accounts for the next 90 days.

1. From the NDIS account screen, select Contacts.

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2. Select the Plan Nominee or Child Representative contact.

3. At Valid To: Enter the date 90 days after revocation decision.

Note: You can use the Time and Date website to help calculate 90 days.

4. Select Submit.

Note: There is no requirement to extend other relationships as they do not impact portal access. For example: mother or father.

3.8 Send letter: Revocation decision

1. Open and edit [Letter – Eligibility Reassessment – Revocation decision]([Letter – Eligibility Reassessment – Revocation decision]).

2. Copy the completed decision templates into the letter.

Note: The template was saved to your desktop or OneDrive earlier.

3. Send letter to the participant or representative via their preferred correspondence method.

4. Delete the template saved to your desktop or OneDrive after you have completed this step.

3.8.1 Attach the letter to Inbound Documents

1. In the NDIS Account screen: Select Documents.

2. Select Add Items and select Inbound Document.

3. In Description: Letter – ER – Revocation decision.

4. In Status: Select Completed.

5. In Category 1: Select NDIA Service.

6. In Category 2: Select Other Correspondence.

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Contact former participant or representative: Revocation decision

Note: A representative could be the former participant’s nominee or child representative. If the former participant has a nominee, they will be listed as a contact as a Plan Nominee.

If the person’s preferred correspondence method is email or letter, you must still attempt to call them about the revocation decision. The exception is if the person has requested no phone calls (for example, they are Deaf and have requested written communication only), or if they have not provided a phone number.

7. In Employee Responsible: Enter your details.

8. In Note: Letter <emailed/mailed> to on by .

9. Select the Upload File button under Attachments.

10. In the File Explorer window: Select the relevant document.

11. Select Save.

Standard Operating Procedure

For Internal Use Only

3.9.1 Contact person: Revocation decision

1. Refer to SOP – Send SMS using Whispir messenger to send ‘Contact attempt SMS template’ to advise you will be calling.

   Note: Only send this SMS before your first attempt to call the person.

2. Do not contact the person by SMS if they have told the Agency that they do not consent to this form of communication.

3. Prepare for your call:

   • Review the relevant evidence on the person’s record, and your reasons for the revocation decision.

   • Have the Letter – Eligibility Reassessment – Revocation decision handy for reference during the call.

   • Read Sensitive conversations in the Conversation Style Guide.

4. Make 5 telephone contact attempts (over a 3-day period, at different times of day) to the former participant, nominee or child representative. The first call should be made on the day of the decision. If you reach voicemail and the person identifies themselves, leave a brief message requesting they contact the NDIA on 1800 800 110. You must complete all required contact attempts, even if the number is disconnected.

3.9.1.1 Record an Interaction following each unsuccesful call attempt

1. In the NDIS Account screen: Select Interactions.

2. Select Add Items and then select Interaction.

3. In Category 1: Select Pathway.

4. In Category 2: Select Review.

5. In Category 3: Select Eligibility Reassessment.

6. In Channel: Select Internal Notes.

7. In Status: Select Completed.

8. In Notes:

   Revocation decision made on .

   Choose an item. phone call attempt made to on at to advise that the eligibility requirements have not been met and a decision has been made to revoke the person’s status as a participant.

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Call not answered.

9. Select Submit.

3.9.2 If all 5 contact attempts are unsuccessful

1. Refer to SOP – Send SMS using Whispir messenger to send ‘Unsuccessful contact attempt’ SMS to advise you tried to call.

   Note: Only send this SMS after you make all required call attempts.

2. Do not contact the person by SMS if they have told the Agency that they do not consent to this form of communication.

3. Continue with ER process.

4. Go to Step 3.9.4: Add Interaction: ER revocation outcome.

3.9.3 If the call is answered

• Notify the person that you are calling to let them know about their Eligibility Reassessment outcome.

• Explain that we provided opportunity for the participant to provide further information to show they continue to meet the eligibility requirements.

• Note that the Eligibility Reassessment Commencement Letter was sent on , the Second Opportunity to Respond Letter was sent on , and call attempts were made on <date/s>.

• .

• Explain that we have considered their information against the eligibility requirements (including any new information provided).

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• Advise the person that they do not meet the <residence> and/or their impairment

does not meet the <disability and early intervention> requirements, so we will

support them to leave the NDIS and connect with community and other government

supports.

Using the letter as a guide:

• Outline the specific information/evidence we considered to make the decision.

• Explain which eligibility requirement/s are not met. Refer to relevant information to

explain the decisions reasons.

• Encourage them to contact their plan developer or <local area coordinator (LAC) / early childhood partner (ECP)> for information about their plan, and to connect

them with community and government services.

• If you need further support to explain the decision to the person, seek assistance

from your Team Leader.

• Advise the person of their review rights.

• Advise the person that the decision takes effect from <Date of letter>, and that they

will receive a letter shortly which explains the decision and their review rights.

• Advise the person that from <Date of letter>, they can no longer use NDIS funds to

purchase supports as they are no longer a NDIS participant.

• If they had access to the myplace Participant Portal, access will end 90 days after

the date of the letter, on <90 days from date of letter>.

• Advise the person that providers must complete all payment requests within the 90

days. After this time, providers will not be able to make any further requests. Only

claims for supports received prior to <Date of letter> can be claimed.

• Ask if they have any questions.

1. Go to Step 3.9.4: Add Interaction: ER revocation outcome.

3.9.4 Add Interaction: ER revocation outcome

1. In the NDIS Account screen: Select Interactions.

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1. Select Add Items and then select Interaction.

2. In Category 1: Select Pathway.

3. In Category 2: Select Review.

4. In Category 3: Select Eligibility Reassessment.

5. In Channel: Select Internal Notes.

6. In Status: Select Completed.

Revocation decision made on .

Phone call made to to advise that the eligibility requirements have not been met, and that a decision has been made to revoke the person’s status as a participant.

I advised the person that from the date of the letter, they can no longer use NDIS funds to purchase supports as they are no longer an NDIS participant.

I advised the person to contact their plan developer or <local area coordinator (LAC) / early childhood partner (ECP)> for information about their plan and community and government services.

I advised the person of their review rights.

Standard Operating Procedure

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4. In End Date: Edit to today’s date.

5. Select Submit.

6. If the person:

• was a defined participant, go to Step 3.10.2: Add alert for defined records (if required).
• was not a defined participant, go to Step 3.11: Notify plan developer – Revocation.

3.10.2 Add alert for defined records (if required)

Note: This is an important step to make sure that any future applications from the person are considered as new (not defined).

1. Select Add Items and then select Alert.

2. Select the Primary checkbox.

3. In Alert: Select Eligibility Reassessment.

4. In Additional Information:

redacted They are no longer a defined participant.

Any future applications should be treated as new and evidence of disability must be provided.

5. Select Submit.

3.11 Notify plan developer – Revocation

3.11.1 Add Interaction: Notify plan developer – Revocation

1. In the NDIS Account screen: Select Interactions.

2. Select Add Items and then select Interaction.

3. In Category 1: Select Pathway.

4. In Category 2: Select Review.

5. In Category 3: Select Eligibility Reassessment.

6. In Channel: Select Internal Notes.

7. In Status: Select Open.

8. In Notes:

Interaction to notify plan developer that Eligibility Reassessment is complete.

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Refer to Eligibility Re-Assessment Request for information about status of the request.

For Action: Follow instructions in SOP – Finalise the plan before a participant leaves the NDIS, to finalise the plan and support the former participant to leave the NDIS.

<If relevant: Please note there is no <LAC / ECP> in their area, and in this scenario, it has been agreed that national delivery will complete the relevant steps to support the former participant.

9. Select Submit.
10. Select Edit.
11. Select Assign.
12. Select Employee.
13. In Employee: Enter the plan developer’s name (Contact with relationship type My NDIS Contact).

Note: Where there is no My NDIS Contact, assign the interaction to the National Delivery Inbox (Return to SDP Inboxes) within the person’s geographical location. 14. Select Assign. 15. Select Submit.

• If there are sensitivities/concerns with the revocation or the plan developer is not an local area coordinator/early childhood partner: Go to Step 3.11.2: Contact the local area coordinator or early childhood partner.

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• If there is no local area coordinator or early childhood partner in their area: Go to Step 3.11.3: Email the relevant Operations Director.
• If there are no sensitivities and the plan developer is the local area coordinator or early childhood partner:

End of process.

3.11.2 Contact the local area coordinator or early childhood partner

Note: Only complete this step if the plan developer is not a local area coordinator or early childhood partner, or if there are sensitivities/concerns.

3.11.2.1 Check if the plan developer is a local area coordinator or early childhood partner.

1. From the NDIS Account screen, select Contacts.
2. Select the My NDIS Contact to view the Contact details.

Note: Click on the row and not on any hyperlinks within the row to view the details in Contacts. 3. The Update Relationship detail will open. Check the Position field to see if they are a local area coordinator or early childhood partner.

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3.11.2.2 Contact the local area coordinator early childhood partner

• Make one contact attempt to the local area coordinator or early childhood partner via phone or Microsoft Teams.

  • Advise them that <Person’s> access has been revoked on .

  • Advise them of any sensitivities/risks you are aware of.

  • Advise them to make sure that relevant community and other government service connections are in place.

3.11.2.3 Update Notify plan developer interaction.

Note: You do not need to create a new interaction, as you will update the existing interaction to notify the plan developer. The interaction should still remain Open.

1. Open the Notify plan developer Interaction you created in Step 3.11.1.

2. Select Edit.

3. In Notes: I contacted <LAC / ECP> <LAC / ECP name> via <phone/MS Teams> to advise that has had their participant status revoked.

   OR .

4. Select Submit.

Note: Keep the interaction Open to make sure the plan developer receives it. End of process.

3.11.3 Email the relevant Operations Director

Note: Only complete this step if there is no local area coordinator or early childhood partner available in the former participant’s area.

1. Refer to the National Delivery intranet page.
2. Select the state or territory where the former participant lives.
3. Find the name of the Operations Director in the Our Team table. Note: for Victoria and Tasmania, this is in the Our Workgroups and Team menu.
4. Open Email Template – Eligibility Reassessment – Decision to revoke and no PITC in local area.
5. Complete fields in the body of the email.

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6. Select Send.

3.11.3.1 Update Notify plan developer interaction

Note: You do not need to create a new interaction, as you will update the existing interaction to notify the plan developer. The interaction should remain Open.

1. Open the Notify plan developer Interaction you created in Step 3.11.1.

2. Select Edit.

3. In Notes:

I sent an email sent to Operations Director, <Operations Director’s name> to advise:

• there is no <LAC / ECP> available in the former participant’s area to support them to link with community and other government services.
• that I have assigned an interaction to the RTS inbox to request support for the former participant to leave the NDIS.

4. Select Submit.

Note: Keep the interaction Open to make sure the plan developer receives it.

End of process.

3.12 Submit ER outcome: Maintain Access Status

3.12.1 Prepare Decision Template

1. Open Template – Eligibility Reassessment – Maintain or Change Access Status.
2. Complete fields in the relevant templates.
3. Copy the completed template to paste into the Outcome Justification.

3.12.2 Update ER Request: Maintain Access Status

1. In Eligibility Reassessment Request: Select Edit.

2. In Outcome: Select Maintain Access Status.

3. In Outcome Justification:

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.

.

4. In Supporting Info, copy and paste the content from Outcome Justification.

Note: The content in Outcome Justification and in Supporting Info must be identical. The Supporting Info content will make up the history log of the Eligibility Reassessment.

5. In Reason for Maintain Access Status: Select reason from drop-down menu.

• Disability and Residence Valid: Sufficient evidence the residence and disability requirements are met.
• Early Intervention and Residence Valid: Sufficient evidence residence and early intervention requirements are met.

Note: Do not use Insufficient evidence to Alter Decision, Record Ceased or Invalid Checklist/Checklist not provided.

6. Select Submit.

7. If your Maintain Access Status decision:

   • is not sent for quality checking: o Go to Step 3.15: Send letter: Maintain or Change Access Status.
   • is sent for quality checking:

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o Start working on another work item. Once quality feedback is returned, go to Step 3.14: Review quality check feedback: Maintain/Change Access Status (if sent for quality checking).

3.13 Submit ER outcome: Change Access Status (from EI to disability)

Changing the participant’s access status from early intervention to disability is not a decision under the NDIS Act. This means it is not a reviewable decision.

If the participant joined the NDIS under disability requirements and now meets the early intervention requirements, their access status must be maintained. Do not change their access status.

3.13.1 Prepare Decision Template

1. Open Template – Eligibility Reassessment – Maintain or Change Access Status.
2. Complete fields in the relevant templates.
3. Copy the completed template to paste into the Outcome Justification.

3.13.2 Update ER Request: Change Access Status

1. In Eligibility Reassessment Request: Select Edit.
2. In Outcome: Select Change Access Status.

3.13.3 In Outcome Justification:

. .

3.13.4 In Supporting Info:

Refer to Outcome Justification.

3.13.5 In Access Decision Reason: Select Disability Met

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Note: Benefit from Early Intervention, Exceptional Circumstances and Continuity of Supports are not applicable.

6. In Access Decision Notes: Status Change from EI to Disability.

7. Select Submit.

8. If your change access status decision:

   • is not sent for quality checking: o Go to Step 3.15: Send letter: Maintain or Change Access Status.

   • is sent for quality checking: o Go to Step 3.14: Review quality check feedback: Maintain/Change Access Status (if sent for quality checking).

3.14 Review quality check feedback: Maintain/Change Access Status (if sent for quality checking)

After receiving the feedback, you are still responsible for making, documenting and implementing the decision.

1. In the Business System Inbox: Select Quality Check Act task.

2. Review the quality feedback provided:

   • If you agree with the feedback: o Next to Acknowledged: Select Yes o Select Submit o Go to Step 3.

   • If you need further clarification of the feedback, do not acknowledge it. Discuss it with your Team Leader, and if applicable, follow the reconsideration process. Do not proceed to Step 3 until this is resolved.

3. Finalise the ER outcome, taking into consideration the quality check feedback:

   • If the outcome continues to be either maintain or change access status, go to Step 3.15: Send letter: Maintain or Change Access Status.

3.15 Send letter: Maintain or Change Access Status

3.15.1 Prepare and send letter to participant

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1. Open and edit Letter – Eligibility Reassessment – Maintain or change access status.

2. Send the letter to the participant or representative via their preferred correspondence method.

3.15.2 Attach letter to Inbound Documents

1. Go to the NDIS Account screen: Select Documents.

2. Select Add Items and then Inbound Documents.

3. In Description: Letter – End of Eligibility Reassessment Process.

4. In Status: Select Completed.

5. In Category 1: Select NDIA Service.

6. In Category 2: Select Other Correspondence.

| Document Type | | | Site Location | | | Priority | Low | | Status | Completed | | Reason | |

Category 1: NDIA Service

Category 2: Other Correspondence

7. In Employee Responsible: Enter your details.

8. In Note: Letter <emailed/mailed> to on by .

Standard Operating Procedure

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9. Select Upload File button under Attachments.

10. In File Explorer window: Select the relevant document.

11. Select Save.

12. Go to Step 3.16: Contact participant or representative: Explain Maintain/Change Access Status outcome.

3.16 Contact participant or representative: Explain Maintain/Change Access Status outcome

A representative could be the participant’s nominee or child representative. If the participant has a nominee, they will be listed as a contact as a Plan Nominee.

3.16.1 Contact the participant or their representative

1. Refer to SOP – Send SMS using Whispir messenger to send ‘Contact attempt SMS template’ to advise you will be calling.

Note: Do not contact the person by SMS if they have told the Agency that they do not consent to this form of communication.

2. Make one telephone contact attempt to the participant, nominee or child representative. If you reach voicemail and the person identifies themselves, leave a brief message requesting they contact the NDIA on 1800 800 110.

3.16.2 If unsuccessful contact attempt

1. Refer to SOP – Send SMS using Whispir messenger to send ‘Unsuccessful contact attempt’ SMS to advise you tried to call.

Note: Do not contact the person by SMS if they have told the Agency that they do not consent to this form of communication.

2. Go to Step 3.15.4: Update the Alert’s End Date.

3.16.3 If the call is answered

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• Using the letter as a guide, notify the person that you are calling to update them on the outcome of their Eligibility Reassessment.

• Advise the person that we have completed a review of their eligibility, and that they continue to meet the eligibility requirements.

• If Change Access Status: Advise the person that they originally met the requirements for early intervention and based on the available information, they now meet the disability requirements.

• If Maintain Access Status: Advise the person that based on the available information, they continue to meet the residence and <disability> or <early intervention> requirements.

• This means that they will continue to be a participant of the NDIS and there will be no change to their current supports.

• If the person has any questions about their plan or funding, refer them to their <local area coordinator/early childhood partner/NDIA planner>.

1. Go to Step 3.16.4: Update the Alert’s End Date.

3.16.4 Update the Alert’s End Date

1. In the NDIS Account screen: Select Internal Use.
2. Select Plan Alerts.
3. Select the Eligibility Reassessment alert.
4. In End Date: Edit to today’s date.
5. Select Submit.

3.16.5 Add Interaction: Maintain or Change Status

1. In the NDIS Account screen: Select Interactions.
2. Select Add Items and then select Interaction.
3. In Category 1: Select Pathway.
4. In Category 2: Select Review.
5. In Category 3: Select Eligibility Reassessment.
6. In Channel: Select Internal Notes.

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7. In Status: Select Completed.

8. In Notes:

Phone call made to <Person> to advise them that the Eligibility Reassessment is now complete.

<Person’s> access status has been <maintained/changed from early intervention to disability>.

Standard Operating Procedure

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Note: To view both the primary and secondary disabilities at the same time, open the Secondary tab first, followed by the Primary.

Note: This screen will list all current and previous primary and secondary disabilities. Take note of the Effective Start and Effective End dates to determine what disabilities are current.

3.17.2 Consider if the listed primary disability still meets the eligibility requirements

1. Consider if there is sufficient evidence the primary disability meets the eligibility requirements:

   • If primary disability no longer meets the disability or early intervention requirements: Go to Step 3.17.3: Update primary disability.
   • If primary disability continues to meet the disability or early intervention requirements: Go to Step 3.17.4: Consider if any secondary disabilities no longer meet the eligibility requirements.

Note: If the existing primary disability continues to meet the eligibility requirements, and there are additional disabilities that also meet eligibility, do not change the primary disability.

3.17.3 Update primary disability

Do not delete the previous primary disability. When the primary disability is changed, this will automatically apply an end date to the previous primary disability.

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3.17.3.1 If primary disability is listed as a secondary disability

1. In Secondary: Select the Convert to Primary Disability icon.
2. Complete additional fields (if known).
3. Select Submit.

3.17.3.2 If the primary disability is not listed as a secondary disability

1. In the NDIS Account screen.
2. Select Add Items and then select Disability.
3. In Reported Impairment: Start typing the disability and select when displayed. Note: Alternatively, select from the list of disabilities.
4. Next to Primary: Select the checkbox.
5. Complete additional fields (if known).

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6. Select Submit.

3.17.4 Consider if any secondary disabilities no longer meet the eligibility requirements

1. Consider if there is sufficient evidence that any secondary disabilities continue to meet the eligibility requirements:

   • If a secondary disability no longer meets the disability or early intervention requirements: Go to Step 3.17.5: Update Effective End Date for secondary disability.
   • If the secondary disabilities continue to meet the disability or early intervention requirements: Go to Step 3.17.6: Consider if additional secondary disabilities meet the disability or early intervention requirements.
   • If there are no secondary disabilities listed: Go to Step 3.17.6: Consider if additional secondary disabilities meet the disability or early intervention requirements.

3.17.5 Update Effective End date for secondary disability

1. Select relevant disability.
2. In the Effective End date: Update to current date.

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3. Select Submit.

Note: The disability will show within Secondary Disabilities with an end date.

3.17.6 Consider if additional secondary disabilities meet the disability or early intervention requirements

1. Consider if there is sufficient evidence that an additional secondary disability meets the disability or early intervention requirements:

   • If an additional secondary disability meets the disability or early intervention requirements: Go to Step 3.17.7: Add secondary disability.
   • If there is insufficient evidence that any additional disabilities meet the disability or early intervention requirements: Go to Step 3.18: Add Interaction: Notify plan developer – ER outcome.

3.17.7 Add secondary disability

1. In the NDIS Account screen.

2. Select Add Items: Select Disability.

3. In Reported Impairment: Start typing the disability and select when displayed.

   Note: Alternatively, select from the list of disabilities.

4. Next to Primary: Do not select the checkbox.

5. Complete additional fields (if known).

   Note: Do not adjust the Effective End date as it will auto-populate with 31.12.9999.

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6. Select Submit.

7. Go to Step 3.18: Add Interaction: Notify plan developer – ER outcome.

3.18 Add Interaction: Notify plan developer – ER outcome

1. In the NDIS Account screen: Select Interactions.

2. Select Add Items and then select Interaction.

3. In Category 1: Select Pathway.

4. In Category 2: Select Review.

5. In Category 3: Select Eligibility Reassessment.

6. In Channel: Select Internal Notes.

7. In Status: Select Open.

8. In Notes:

Interaction to notify plan developer of Eligibility Reassessment update.

Refer to Eligibility Re-Assessment Request for information about the status of the request.

Refer to SOP – Refer Participant for an Eligibility Reassessment (ER) or Access Status Change for information about the process.

No action required. Plan developer to note and close interaction.

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9. Select Submit.

10. Select Edit.

11. Select Assign.

12. Select Employee.

13. In Employee: Enter the plan developer’s name (Contact with relationship type My NDIS Contact).

Note: Where there is no My NDIS Contact, assign the interaction to the National Delivery Inbox (Return to SDP Inboxes) within the person’s geographical location.

14. Select Assign.

15. Select Submit.

End of process.

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4. Appendices

4.1 The Legislation

While the NDIS provides lifetime disability support for many participants, others build capacity and achieve their goals to the extent that they no longer meet the eligibility requirements and leave the NDIS.

This SOP provides instructions for when an Access Assessor (AA) receives an ER referral from a plan developer indicating that the participant:

• may not meet the residence requirements (section 23);

OR

• may not meet the disability requirements (section 24) and early intervention requirements (section 25);

OR

• was granted access to the NDIS under the early intervention requirements (section 25) may now meet the disability requirements (section 24).

All participants must continue to meet the residence requirements and the disability requirements or early intervention requirements.

There are some exceptions to when an ER should be undertaken:

• If the participant joined the NDIS under the NSW Prescribed Program Rules, their NDIS access should not be revoked based on residence requirements. This also includes participants who joined the NDIS under these rules, but now reside in another state or territory. For these participants, ER can only be based on the disability and early intervention requirements.

• If the AAT has previously made a determination relating to the participant’s access to the NDIS, seek advice from a QDO Team Leader before commencing an ER. The QDO Team Leader will seek advice from TAB/Legal as required. QDO Team Leader advice is not required if you are maintaining or changing access status.

4.2 Independent Delegate

The AA who decides whether to commence or undertakes an ER must be independent. That is, they will not have:

• a personal interest in the participant’s status; or

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• a personal relationship with the participant (outside the NDIA);
• must not have been involved in making the original access decision or any planning decisions.

An AA can be involved in any or all stages of the ER process.

4.3 ER Outcomes

There are 2 ER outcomes under (s 30(1), NDIS Act). They are:

• To exercise the power to revoke a person’s access, which includes:
  • revoking participant status.
• To not exercise the power to revoke a person’s access, which includes:
  • maintaining access status; or
  • changing access status.

Note: To not exercise the power to revoke a person’s access is not a reviewable decision.

4.3.1 Maintain Access Status

A person maintains their participant status when they continue to meet the access requirements they joined the NDIS under. Or, if they joined the NDIS under disability requirements and now meet the early intervention requirements.

4.3.2 Change Access Status

A person’s status is changed from early intervention to disability when the participant who joined the NDIS under early intervention requirements now meets the disability requirements.

Note: Changing access status is not a decision under the NDIS Act. It is also considered maintaining access status.

4.3.3 Decision to Revoke

If an AA is satisfied a person no longer meets the residence and/or disability and early intervention requirements, their status as a participant will be revoked (section 30).

A person ceases to be a participant in the NDIS when their status is revoked under section 30. A revocation decision will take effect from the date of the decision notice.

A person must not use NDIS funds to purchase reasonable and necessary supports for the participant after they cease to be an NDIS participant (section 29(2)).

The decision to revoke a person’s status as a participant is a reviewable decision (section 99, Item 3). This means that the decision may be internally reviewed by a delegate of the CEO

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(section 100) and subsequently externally reviewed by the Administrative Appeals Tribunal (AAT) (section 103).

It is very important, from an administrative law perspective, that the process leading to a revocation decision is procedurally fair. Procedural fairness includes a variety of actions and may change dependent on the participant’s individual situation. Some of these actions relating to ER may include:

• ensuring a clear explanation outlining the reasons for a potential revocation decision;
• providing the participant a reasonable opportunity to provide information to present their case;
• providing guidance to the participant around the types of information/evidence which may assist their case;
• properly considering any Extension of Time Request and granting this request where reasonable.

4.4 The Process

4.4.1 Plan developer refers the participant for ER or Access Status Change

A person’s NDIS participant status may be reassessed:

• as part of the plan reassessment process; or
• at any other time.

Plan developers must consider whether the participant should be referred for ER, or an Access Status Change is required, as part of the plan reassessment process. This involves completion of the Eligibility Reassessment Checklist, with reference to relevant information on the participant’s record. The checklist is attached to the participant’s record before the plan developer completes an ER referral.

Note: An AA must not commence the ER process if there is no checklist attached.

4.4.2 Access Assessor determines if ER is required

Upon receipt of an ER referral, the AA will consider whether the participant is likely to continue to meet the residence and disability or early intervention requirements. They do this by assessing all available information against the legislative requirements.

4.4.3 Access Assessor completes ER

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An ER is commenced when the information indicates that the participant may not meet the eligibility criteria. The AA will contact the participant (or their representative) by phone and in writing to outline the reasons why the person may not meet eligibility criteria. It is important that the participant understands the specific reasons why they may not meet these criteria, and what information they can provide to support their case.

The AA must explain to the participant that it is their responsibility to prove they meet the eligibility criteria. If we do not have clear information that the person continues to meet the eligibility criteria, their access will be revoked.

The plan developer will also be notified of the progress of the ER request and any required actions via an Interaction. The AA also has the option to contact the plan developer by phone if there are any sensitivities or risks.

During the ER process, the participant will have 28 days to provide further information to support their continued eligibility. In exceptional circumstances, they can request an extension of time to provide this information.

Access Assessor determines outcome

The AA will assess all available information against the legislative requirements and decide if the participant’s access status should be:

• maintained, (including disability to early intervention); or
• changed from early intervention to disability; or
• revoked.

All revocation decisions, and some maintain or change status outcomes, will be referred to a QDO for quality checking before being finalised.

The AA will explain the reasons for the outcome to the participant (or their representative) by having a conversation (where required contact attempts are successful) and sending them a letter. The plan developer will also be notified of the ER outcome. If the participant’s status is revoked, the plan developer must support them to leave the NDIS and find other community and government supports.

Throughout the ER process, it is important there is no disruption to the participant’s supports and services during this time.

5. Related procedures or resources

• Our Guideline – Applying to the NDIS
• Our Guideline – Leaving the NDIS

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Standard Operating Procedure

For Internal Use Only

• SOP – Request technical advice to progress an Eligibility Reassessment
• SOP – Consider commencement of Eligibility Reassessment or Access Status Change
• SOP - Consider Eligibility Reassessment outcome following 1st chance to respond
• SOP - Action Evidence Extension Request for an Eligibility Reassessment
• SOP – Action Call back Request for an Eligibility Reassessment
• SOP – Refer request to cease participant status during Eligibility Reassessment
• SOP – Request technical advice to progress an Eligibility Reassessment
• SOP- Check for remote or very remote address
• SOP – Check for procedural fairness in an Eligibility Reassessment
• SOP – Complete Eligibility Reassessment missed steps

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6. Feedback

If you would like to provide feedback about this guidance material, please complete our Feedback form.

7. Version control

Updates about the participant’s responsibility to provide information to support their eligibility, and to provide more information about the reasons for a revocation decision.

New instructions about requesting technical advice, increased contact attempts, to contact the plan developer by phone after a revocation decision, to add an alert after a revocation decision, and additional checks to make sure the ER process has been procedurally fair before making a revocation decision | | V2.0 | EMN960 | Class 1 approval | | | | Updated linked SOP | | V3.0 | EMN960 | Class 1 approval | | | | New instructions included for determining the Operations Director in each state/territory, and whether the plan developer is an LAC/ECP. |

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Refer an Eligibility Reassessment (ER) call back or evidence extension request to NARB

The content of this document is Official: Sensitive. Use this Standard Operating Procedure (SOP) to either:

• request a call back from a National Access and Reviews Branch (NARB) delegate

• request an extension of time for the participant to provide further supporting evidence to the NARB. Request a NARB delegate to contact the participant if they:

• ask to speak to a NARB delegate

• have specific questions about the eligibility criteria

• have specific questions about the eligibility reassessment decision.

Note: The plan developer should answer questions about the participant’s plan, funding and supports during the ER process.

1. Recent updates

• SOP - Refer participant for an Eligibility Reassessment (ER) or Access Status Change
• SOP — Refer an Eligibility Reassessment (ER) call back or evidence extension request to NARB
• SOP — Support the former participant to leave the NDIS after a revocation decision. |

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Standard Operating Procedure

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Official: Sensitive

2. Checklist

* Access to the NDIS Operational Guideline.

| Actions | QO) 3.1 Request a NARB delegate to contact the participant QO) 3.2 Request a NARB delegate to consider extension to provide evidence |

3. Procedure

3.1 Request a NARB delegate to contact the participant

3.1.1 Add Follow-up Request — Call back

1. In the NDIS Account screen: Select Add Items and then select Follow up Request.

   [Image not converted to Markdown – “Screenshot of NDIS Account screen with Add Items highlighted” – check the source PDF page for the actual content]

2. The Create Interaction screen will display. Complete the interaction using the following:

   • Category 1: Select Specialised

   • Category 2: Select Eligibility Reassessment

   • Category 3: Select Call Back

   • Channel: Select Internal Notes

   • Status: Select Open

   • Notes:

     redacted

Standard Operating Procedure

For Internal Use Only

Official: Sensitive

3. Select Submit.

3.2 Request a NARB delegate to consider extension to provide evidence

The participant may ask for more time to provide information or evidence to support their continued eligibility. In this instance, create a Follow-up Request for a NARB delegate to assess the extension request and contact the participant.

3.2.1 Add Follow-up Request – Evidence Extension Request

1. In the NDIS Account screen: Select Add Items and then select Follow up Request.

   [Image not converted to Markdown – “Screenshot of NDIS Account screen with ‘Add Items’ and ‘Follow up Request’ highlighted” – check the source PDF page for the actual content]

2. The Create Interaction screen will display. Complete the interaction using the following:

   • Category 1: Select Specialised

   • Category 2: Select Eligibility Reassessment

   • Category 3: Select Evidence Extension Request

   • Channel: Select Internal Notes

   • Status: Select Open

   • Notes:

     <Participant / Nominee / Child representative> requested an extension to submit documents due to .

3. Select Submit.

Note: The NDIA will not reimburse participants for any costs to get reports, assessments or examinations to support their continued eligibility. However, we may look at reports that have already been funded as part of their NDIS plan, along with any other relevant information and evidence on their record.

4. Related procedures or resources

• NDIS Act 2013
• Access to the NDIS Operational Guideline

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Official: Sensitive

5. Feedback

If you have any feedback about this SOP, please complete our [Feedback Form](Feedback Form).

6. Version control

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Refer request to cease participant status during Eligibility Reassessment

The contents of this document are OFFICIAL.

This Standard Operating Procedure (SOP) will help you refer a request from the participant or their representative to cease their participant status while an Eligibility Reassessment (ER) is in progress.

This process does not apply if you receive the request verbally at the time of making a revocation decision.

In this case, progress with the revocation decision. If you receive the request in writing before considering a revocation decision, follow the instructions in this SOP to refer the request to cease participant status.

1. Recent updates

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Standard Operating Procedure

For Internal Use Only

What’s changed

• Standard Operating Procedure – Refer request to cease participant status during Eligibility Reassessment

Checklist

Procedure

• If you receive a verbal request to cease participant status, go to Step 3.1: Action verbal request to cease participant status.
• If you receive a written request to cease participant status, go to Step 3.2: Refer written request to cease participant status.

3.1 Action verbal request to cease participant status

The participant or their representative must provide the request to cease access to the NDIS in writing.

If you receive a request verbally, you need to send a letter and form to the participant or their representative for written confirmation. In the interim, the ER process will continue. A representative could be the participant’s:

• Authorised representative
• Child representative
• Nominee

To check the authority of a representative, refer to Standard Operating Procedure – Check third party consent or authority.

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Standard Operating Procedure

For Internal Use Only

Note: If the participant has a nominee, they will be listed as a contact as a Plan Nominee.

3.1.1 Send letter and form: Cease to be a Participant Request

1. Open and edit Letter – Cease to be a Participant – Request Confirmation.
2. Attach Notification: Cease to be a Participant – Adult or Notification: Cease to be a Participant – Child form.
3. Send the letter and form via the participant’s preferred communication method.

3.1.2 Attach the letter to Inbound Documents

1. In the NDIS Account screen: Select Inbound Documents.
2. Select Add Items and then Inbound Document.
3. In Description: Letter – Cease Participant Request.
4. In Status: Select Completed.
5. In Category 1: Select NDIA Service.
6. In Category 2: Select Other Correspondence.
7. In Employee Responsible: Enter your details.
8. In Note: Letter and form <mailed/emailed> to on by .
9. Select Upload File button under Attachments.
10. In File Explorer window: Select the relevant document.
11. Select Save.

End of process – no further steps to be completed.

Note: The ER process continues until the written request is received.

3.2 Refer written request to cease participant status

3.2.1 Add interaction: Cease to be a Participant Request

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Standard Operating Procedure

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Only commence this step once you have confirmed the participant or their authorised representative have made a written request to leave the NDIS.

1. In the NDIS Account screen: Select Interactions.

2. Select Add Items then select Interaction.

3. In Category 1: Select Pathway.

4. In Category 2: Select General.

5. In Category 3: Select Cease participant status.

6. In Channel: Select Internal Notes.

7. In Status: Select Open.

8. In Notes:

   Reason for Request: <Participant> is currently going through the Eligibility Reassessment process. They have advised in writing that they no longer wish to be a participant because Click or tap here to enter text.

   Written request received on Click or tap to enter a date. and uploaded to Inbound Documents on Click or tap to enter a date.

   Requested by: <Person’s Name>.

9. Select Submit.

10. Select Edit.

11. Select Reassign.

12. Select Employee.

13. In Employee: Reassign the interaction to the National Delivery Inbox within the participant’s geographical location (Return to SDP Inboxes).

14. Select Assign.

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15. Select Submit.

3.2.2 Update the Alert End Date

1. In the NDIS Account screen: Select Internal Use.
2. Select Plan Alerts.
3. Select the Eligibility Reassessment Alert.
4. In End Date: Edit to today’s date.
5. Select Submit.

3.2.3 Add interaction: Notify plan developer of Cease to be a Participant Request

Note: Only complete this step if there is plan developer with the relationship type My NDIS Contact.

1. In the NDIS Account screen: Select Interactions.
2. Select Add Items then select Interaction.
3. In Category 1: Select Pathway.
4. In Category 2: Select General.
5. In Category 3: Select Cease participant status.
6. In Channel: Select Internal Notes.
7. In Status: Select Open.
8. In Notes:

For information only:

<Participant/Authorised representative> have made a written request to leave the NDIS and that the person doesn’t want to be a participant anymore. The request has been forwarded to the National Delivery Inbox for action.

Written request received on Click or tap to enter a date.

Plan developer to note and close the interaction.

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Standard Operating Procedure

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9. Select Submit.

10. Select Edit.

11. Select Reassign.

12. Select Employee.

13. In Employee: Enter the name of the plan developer (Contact with relationship type My NDIS Contact).

14. Select Assign.

Note: National Delivery will complete the next steps to cease participant status and the system will then automatically close off the ER Request task.

4. Related procedures or resources

• Our Guideline – Leaving the NDIS
• Standard Operating Procedure – Consider commencement of Eligibility Reassessment or Access Status Change
• Standard Operating Procedure – Consider Eligibility Reassessment outcome following 1st chance to respond
• Standard Operating Procedure - Action Call back Request for an Eligibility Reassessment
• Standard Operating Procedure – Make Eligibility Reassessment decision
• Standard Operating Procedure – Refer request to cease participant status during eligibility reassessment

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Standard Operating Procedure

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Reassessment

5. Feedback

If you have any feedback about this Standard Operating Procedure, please complete our Feedback Form.

6. Version control

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Request technical advice to progress an Eligibility Reassessment

The contents of this document are OFFICIAL.

This Standard Operating Procedure (SOP) will help you request technical advice to progress an Eligibility Reassessment (ER) work item.

The types of support you may need are:

• QDO - Technical support from a Quality Development Officer (QDO) to progress a complex ER decision.
• TAB — Mandatory advice from the Technical Advisory Branch (TAB) to support a Maintain Access Status outcome, for a participant with a primary disability that is a chronic health condition, where TAB advice was not obtained at the point of access.
• QDO TL - Technical support from a QDO Team Leader before commencing an ER, where the AAT has previously made a determination relating to the participant’s

access to the NDIS. This is only applicable if considering commencing an ER.

Recent updates

        | Standard Operating Procedure — Undertake eligibility reassessment separated into 7 SOPs: |
        | * Standard Operating Procedure — Consider commencement of Eligibility Reassessment or Access Status Change |
        | * Standard Operating Procedure — Consider Eligibility Reassessment outcome following 1st chance to respond |
        | * Standard Operating Procedure — Action Call back Request for an Eligibility Reassessment |

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Standard Operating Procedure

For Internal Use Only

What’s changed

• A standalone SOP for technical support when progressing an ER decision.
• Updates for obtaining mandatory advice from TAB for chronic health conditions when deciding to maintain access status.
• Instructions for how and when to request technical advice from a QDO, QDO Team Leader, or the TAB.

2. Checklist

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3. Procedure

Note: After receiving any technical advice, you are still responsible for making, documenting and implementing your decision. Seek support from your Team Leader (TL) if you require further clarification of the advice.

• If you require technical support from a QDO, go to Step 3.1: Request technical support from a QDO.
• If you require QDL TL technical support of proposed Commence ER decision after AAT determination, go to Step 3.2: Request QDO TL technical support of proposed Commence ER decision after AAT determination.
• If you require mandatory advice from the Technical Advisory branch, go to Step 3.2: Request mandatory advice from the Technical Advisory Branch.

3.1 Request technical support from a QDO

You should use this process when you require additional support to progress a complex ER decision.

1. Open Email Template – Request technical advice from a QDO.
2. Complete fields in the subject line and body of the email.
3. Select Send.

Note: A QDO will contact you via your preferred method to provide advice.

4. If you do not receive technical advice by the end of the day, allocate the work item to your TL.

5. Review the advice to determine the next step:

   • If you are able to progress the ER work item: o Go to Step 3.4: Progress ER work item.
   • If you require mandatory advice from the Technical Advisory Branch: o Go to Step 3.3: Request mandatory advice from the Technical Advisory Branch.

3.2 Request QDO TL technical support of proposed Commence ER decision after AAT determination

Seek technical support from a QDO TL before commencing an ER, where the AAT has previously made a determination relating to the participant’s access to the NDIS.

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Standard Operating Procedure

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1. Open Email Template – QDO TL Technical Advice Request – Commence ER after AAT determination.

2. Complete the fields in the subject line and the body of the email. The date field in the subject line must be updated.

3. Select Send.

4. A QDO TL will review your request and will seek TAB/Legal advice as required. Do not commence an ER until you receive a response.

5. If you do not receive a response by the end of the day, allocate the work item to your TL. You can progress with the work item when you receive a response.

6. Review advice to determine the next step.

   • If you are able to progress the eligibility work item: o Go to Step 3.4: Progress ER work item. • If you require clarification on the advice, discuss this with a QDO. If required, the QDO will escalate to the QDO TL.

3.3 Request mandatory advice from the Technical Advisory Branch

The TAB provides specialist support for more complex decisions.

You must request advice from the TAB to support a Maintain Access Status or Change Access Status decision for participants with a primary disability that is a chronic health condition, where TAB advice was not obtained at the point of access. Refer to Step 3.1: Request technical support from a QDO for all other technical advice requests.

For more information about the TAB, refer to Technical Advisory Team – Requesting Advice.

Note: You must first obtain QDO endorsement before requesting TAB advice.

1. Open Email Template – Request QDO endorsement for mandatory TAB Advice.

2. Follow the instructions listed at the top of the email.

3. Complete the fields in the subject line and body of the email and list yourself (logon ID) as the requester.

4. Press Send.

5. A QDO will review your request:

   • If endorsed, the QDO will reply to your email and provide endorsement for you to contact the Technical Advice Phone Support (TAPS).

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Standard Operating Procedure

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• If not endorsed, the QDO or TL will discuss with you what action is required.

6. Phone the TAPS line on 1800 956 342 to discuss your case.

7. Consider the information discussed in your call.

• If you are satisfied with the information received from the TAPS representative,

progress the ER work item:

o Go to Step 3.4: Progress ER work item.

• If you require further clarification of the information provided by the TAPS representative, discuss it with your QDO or TL. • If you were unable to receive TAPS advice by the end of the day, allocate the work item to your TL to follow up the next business day.

3.4 Progress ER work item

After you have obtained the required technical support or endorsement, progress the work item.

3.4.1 Progress an Eligibility Reassessment work item

• If you are able to make a Maintain or Change Access Status decision:

o refer to SOP – Consider commencement of Eligibility Reassessment or Access
  Status Change, or

o refer to SOP – Consider Eligibility Reassessment outcome following 1st chance
  to respond, or

o refer to SOP – Make Eligibility Reassessment decision.

• If you are able to commence an ER process:

o refer to SOP – Consider commencement of Eligibility Reassessment or Access
  Status Change.

• If you are able to make a potential for adverse decision:

o refer to SOP – Consider Eligibility Reassessment outcome following 1st chance
  to respond.

• If you are able to make a revocation decision:

o refer to SOP – Make Eligibility Reassessment decision.

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Related procedures or resources

• Our Guideline — Applying to the NDIS
• SOP – Consider commencement of Eligibility Reassessment or Access Status Change
• SOP – Consider Eligibility Reassessment outcome following 1st chance to respond
• SOP – Make Eligibility Reassessment decision

Feedback

If you have any feedback about this Standard Operating Procedure, please complete our [Feedback Form](Feedback Form).

Version control

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DOCUMENT 12

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dis Standard Operating Procedure For Internal Use Only

Support the former participant to leave the NDIS after a revocation decision

The contents of this document are OFFICIAL

Use this Standard Operating Procedure (SOP) to support a person to leave the NDIS after a decision was made to revoke their participant status after an eligibility check.

1. Recent updates

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Checklist

Topic: Checklist

Pre-requisites

You have read and understood:

• [Our Guideline — Applying to the NDIS](Our Guideline — Applying to the NDIS)

You have:

• been notified that a participant status was revoked after an eligibility check

Actions

• 3.1 Contact participant: [Revocation of participant status](Revocation of participant status)
• 3.2 Action outstanding review payments or service bookings

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Standard Operating Procedure

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For Internal Use Only

3. Procedure

When a NARB delegate makes a revocation decision, they will:

• contact the former participant, nominee or child representative to explain the decision and next steps
• assign an Interaction to the plan developer to advise them of the outcome.

You should follow up with the participant to support them to leave the NDIS by linking them with community and other government services.

3.1 Contact participant: Revocation of participant status

3.1.1 Review relevant information about the revocation decision

1. In the NDIS Account screen: Select Internal Use.

2. Select Completed Eligibility Re-Assessment Requests.

3. Select the hyperlinked Request Id with Request Outcome that states Revoke. Note: This will open the Eligibility Re-Assessment Request.

4. Review relevant information about the revocation decision, including the following:

   • Eligibility Re-Assessment Request
   • Letter – Eligibility Reassessment – Revocation decision attached to Inbound Documents
   • Interactions to consider if the NARB delegate was able to notify the person of the decision by phone.

3.1.2 Contact the former participant, nominee or child representative

1. Do the Interactions show the NARB delegate was able to notify the person of the decision by phone?

   • If Yes: Make 5 phone contact attempts, over different days and times.
   • If No: Wait 5 business days to allow time for the decision letter to arrive before attempting contact. Make 5 phone contact attempts, over different days and times.