What are the NDIS eligibility requirements?

Eligibility for the NDIS depends on three 'access criteria' that are legislated in the 'National Disability Insurance Scheme Act 2013' and supplementary 'National Disability Insurance Scheme (Becoming a Participant) Rules 2016' The criteria are designed to determine whether people with disability have one or more permanent impairments that have consequences for their daily living and social and economic participation. The three access criteria a person must satisfy include:

1. Age requirements - are aged under 65 when the access request is made;
2. Residence requirements are an Australian citizen, permanent resident or special category visa holder who is residing in Australia and during the transition period a person must reside in an area that has transitioned to NDIS;
3. Disability requirements – satisfy either the permanent and significant disability or early intervention requirements.

The NDIA's 'Operational Guideline - Access to the NDIS' contains detailed policy information about the criteria that must be established to determine if a person is eligible to access the NDIS as a participant. Once a person has been deemed eligible and becomes a participant of the NDIS the person will generally be a participant for life. The diagram below provides an overview of NDIS eligibility requirements.

NDIS Eligibility Requirements

¹ Information about the role of the Early Childhood Partner can be located at ndis.gov.au/ecei 
² Paediatricians, GPs or maternal child health practitioners can refer through existing referral pathways into early childhood intervention or families can self-refer to their Early Childhood Partner or make contact with the NDIA to be directed to their local Early Childhood Partner

How can a physician or paediatrician assist patients to check their eligibility for the NDIS? 

Healthcare providers may encounter opportunities to support persons with disability by assisting them with eligibility and access matters. A physician can assist their patient to understand the three access criteria and/or can refer a patient and/or their family or carer to the NDIS Eligibility Checklist to enquire about eligibility. Physicians and paediatricians are also able to assist their patients with regard to understanding whether they meet the disability requirement access criterion. Detailed information is provided below to understand this requirement. 

What are the disability requirements that make a person eligible for the NDIS? 

The NDIS access criteria require that participant has one or more intellectual, cognitive, neurological, sensory, physical or psychiatric impairments that:

1. Under the disability stream:
   • are, or likely to be, permanent;
   • are likely to mean the person will require NDIS support for a lifetime;
   •  affect the person’s capacity for social or economic participation;
   • result in substantially reduced functional capacity, or psychosocial functioning, to undertake one or more of the following activities:
     • communication,
     • social interaction,
     • learning,
     • mobility,
     • self-care, or
     • self-management.
2. Under the early intervention stream:
   •  are, or are likely to be, permanent; or
   •  apply to a child who has a developmental delay; 
   • early intervention support for the person is likely to reduce their future needs for supports in relation to disability and mitigate/alleviate the impact of the impairment on their functionality or strengthen the sustainability of their informal supports, including building the capacity of the person’s carer; and
   •  early intervention support for the person is most appropriately funded or provided through the NDIS

 

What does impairment mean in an NDIS context?

It is helpful to understand what ‘impairment’ means in an NDIS context. In general the term “impairment” means a loss of, or damage to, sensory, physical or mental function. ^[1]  The NDIS takes a functional definition of disability that is slightly narrower than that provided in Article 1 of the UNCRPD in order to respond to people that are in the most need. 

The NDIS focuses on the level of functional capacity as it relates to disability and how substantially reduced functional capacity, or psychosocial functioning, impacts on the individual undertaking one or more of the following activities:

• communication,
• social interaction,
• learning,
• mobility,
• self-care, or
• self-management.

Substantially reduced functional capacity to undertake any one of these activities is considered to affect a person’s capacity to participate fully in the social and economic life of the community.

Where the impairment is not considered to substantially reduce a person’s functional capacity to undertake these activities yet they have a disability, the person is unlikely to be eligible for an individual NDIS funding package. However, the NDIS can still provide information and referrals and connect people with disability, their families and carers, to disability and mainstream supports in their community. 

A person may satisfy the access requirements regardless of whether the impairment came about through birth, disease, injury or accident. ^[2] Therefore, the cause of disability or impairment is not a factor in access requirements. 

When is impairment considered ‘permanent’?

The NDIA must be satisfied that a participant's impairment/s are, or are likely to be, permanent. In general, impairment is accepted as permanent if: 

• there are no appropriate evidence based treatments that could cure or substantially improve it;
• it does not require further medical treatment or review before it can be demonstrated to be permanent (notwithstanding that it may continue to be treated after its permanency has been medically demonstrated);
• it is of a degenerative nature and medical or other treatment would not, or would be unlikely to, improve the condition.

Please note that impairments may be permanent notwithstanding:

• a variation in intensity (e.g. of a chronic episodic nature); or
• fluctuating severity of the impact of the impairment on a person’s functional capacity; or 
• that there are prospects that the severity of the impact of the impairment on a person’s functional capacity, including their psychosocial functioning,  may improve.

If a prospective participant has multiple impairments the NDIA will assess those impairments separately, however in order to satisfy this access criteria the NDIA only needs to be satisfied that at least one of a prospective participant's impairments are, or are likely to be permanent.

Where there is a possibility of medical treatment with some prospect of success, the NDIA should wait until the outcome of the treatment is known before providing an access request decision. <sup>[1]

[1]</sup> Mulligan and NDIA [2015] AATA 974 at [71]

How does the NDIA respond to mental health recovery and permanent disability?

The NDIA Psychosocial disability, recovery and the NDIS (PDF) information sheet provides information about how the NDIS responds to the needs of people with psychosocial disability. Not all people with mental health issues will have access to the NDIS however people with a significant disability that is likely to be permanent may qualify for NDIS support.

In relation to the NDIS, mental health recovery does not necessarily mean there is a permanent absence of the symptoms, impairments and/or disabilities that people can experience. Rather it is understood that psychosocial disabilities can be “…episodic or persistent, debilitating and long lasting”^[1]. The NDIA states, “[r]ecovery is about achieving an optimal state of personal, social and emotional wellbeing, as defined by each individual, whilst living with or recovering from mental health issues”^[2].

The nature of psychosocial disability requires that there is flexibility built into the design of the scheme. The NDIA therefore can reflect accommodations in a participant’s individualised plan with regard to the episodic nature of psychosocial disability in numerous ways. A flexible budget can allow for supports and services to decrease when a person is well and increase when a person requires more support including for example when an individual experiences crisis^[3].

The NDIS is designed to work in partnership with existing government service systems including health and mental health specific treatment services and private mental health services. It is not intended that the NDIS will replace existing mainstream services.

^{[1] - [3]} Source - NDIA Psychosocial disability, recovery and the NDIS (PDF)

Which medical conditions are likely to meet access requirements?

The access process may be streamlined if a person has been diagnosed with certain conditions. These circumstances are not a requirement of eligibility however the access request and decision process may be simplified as these conditions are considered likely to meet the disability requirements.

Children under 7 years diagnosed with any medical condition on List D of the NDIA’s Operational Guideline – Access to the NDIS will satisfy the early intervention requirements without further assessment being required.

People diagnosed with medical conditions in List A of the NDIA’s Operational Guideline – Access to the NDIS are likely to meet the disability requirements without being required to provide additional evidence as the conditions listed are considered to cause disability and permanent impairment resulting in substantially reduced functional capacity.

People diagnosed with medical conditions in List B of the NDIA’s Operational Guideline – Access to the NDIS are likely to meet the disability requirements however as the severity of the impairment is variable, they may need to demonstrate that as a result of the impairment:

• they have substantially reduced functional capacity or psychosocial functioning;
• their capacity for social or economic participation is affected; and
• they are likely to require support under the NDIS for the duration of their lifetime.

What other circumstances provide streamlined access requirements?

The eligibility assessment process may be streamlined if a person has been diagnosed with a condition in List A, List B or List D, or if they have received support under certain state, territory or Commonwealth schemes. Existing clients of the state, territory and Commonwealth programs provided in List C of the NDIA’s Operational Guideline – Access to the NDIS will meet the disability requirements without further assessment as these programs have disability requirements equivalent to the NDIS.

These circumstances are not a requirement of eligibility, but are conditions under which the eligibility assessment process might be simplified. These state, territory and Commonwealth programs have eligibility assessments that include a person being assessed as having a disability that is attributable to a permanent impairment that results in substantially reduced functional capacity. The eligibility criterial of these programs is similar to the NDIS access and eligibility criteria and therefore requires no further assessment.

People who have already been considered eligible for the various state, territory and federal schemes listed in List C of the NDIA’s Operational Guideline – Access to the NDIS are likely to be eligible for the NDIS.

How does a person provide evidence of their disability to the NDIA? 

To enable the NDIA to determine whether a person with a disability satisfies access requirements to the NDIS, the person needs to provide evidence of their disability. The NDIA will seek information in relation to the person’s disability that answers the following questions:

• What is the person’s disability?
• Is the disability permanent? 
• What is the impact of the condition?
• What treatments is the person receiving?

The formal NDIA access process refers to a person with a disability and/or their family or carer completing an Access Request Form. The Access Request Form contains a section relating to the provision of evidence of the person’s disability. The person can approach their treating doctor or specialist to complete the Professional’s Report in Part F of the Access Request Form, the NDIS Supporting Evidence Form or the same evidence via alternative formats. Alternative formats can include copies of assessments, medical reports, medical diagnosis and similar documents. The NDIA provides this fact sheet for health professionals (PDF)

What evidence is required of the person’s disability? 

The provision of evidence of diagnosis is an important step. Where a person has a diagnosis that is noted in the list of ‘Permanent impairment/functional capacity – no further assessment required’ this is indicative of positive eligibility. In these cases no further evidence needs to be provided for eligibility purposes.

The information provided to the NDIA will need to contain details of diagnosis and treatments the person is receiving.

What evidence is required of the impact of the condition on the person? 

In cases where a person has a condition that is not included in the list of ‘Permanent impairment/functional capacity – no further assessment required’ a person must provide evidence of the impact of the condition on their life. The specific areas of a person’s life that the NDIA need to understand the impacts on include:

• a person’s mobility,
• communication,
• social interaction,
• learning,
• self-care, and
• self-management.

The person can approach their treating doctor, specialist or allied health professional to provide information about the impact of their condition. This can be done by requesting that the doctor, specialist or health professional complete the Professional’s Report in Part F of the Access Request Form, the NDIS Supporting Evidence Form or provide the same evidence via alternative formats. The Access Request Form is not publicly available rather can be provided to potential participants by the NDIA.

A 'health professional' includes a physiotherapist, an occupational therapist, speech pathologist, psychologist or a nurse.

What types of information are health professionals asked to provide? 

For a person’s access request to be considered complete it must include all of the evidence the NDIA requires. A participant can choose to provide medical information in a range of formats. The medical information the NDIA will be seeking from participants will include information that provides evidence of the person’s disability, functional impairment and the impact on the participant’s day to day life.

Where a health professional is providing information they will be asked to provide medical assessment information related to the following areas:

• Mobility
• Communication
• Social interaction
• Learning
• Self-care
• Ability to self-manage

A health professional will be asked to provide information about the nature of functional impairment in relation to each of these areas as it relates to their disability and the type of assistance (e.g. a person, assistive technology, special equipment) and a description of the assistance that the participant will require to support them in this area.