Eligibility criteria
Introduction
2.1
This chapter examines the eligibility criteria for determining access
to, and service needs of, deaf and hard of hearing people under the National
Disability Insurance Scheme (NDIS).
2.2
During the course of the inquiry, two main issues arose in relation to
eligibility criteria: firstly, the lack of publicly available information on
the criteria used to assess eligibility for NDIS services for deaf and hard of
hearing people, and secondly, the repercussions for deaf and hard of hearing
people deemed not eligible for NDIS services.
2.3
In March 2017, the NDIA indicated it was going to release guidance
material for access decision making for implementing the NDIS access criteria
for deaf and hard of hearing people toward the end of April 2017.[1]
2.4
In August 2017, the NDIA provided to the committee the reviewed guidance
for determining access to the NDIS for deaf and hard of hearing people. On
1 September 2017, the NDIA publically released the document.[2]
2.5
Late August 2017, the committee sought the views of the hearing services
sector on the reviewed guidance and changes.
2.6
This chapter first outlines the issues raised during the inquiry in
relation to eligibility criteria due to the lack of guidelines. Then, it
discusses the changes to the eligibility criteria that are coming to effect now
and how they are likely to alleviate the access issues faced to date by deaf
and hard of hearing people.
Eligibility criteria
2.7
Sections 22 to 25 of the NDIS Act 2013 detail the criteria for access to
the Scheme. To become an NDIS participant a person must:
-
have a permanent impairment that significantly affects their
ability to take part in everyday activities, or have a developmental delay;
-
be aged less than 65 when first applying to enter the NDIS and
meet additional age requirements if living in SA or TAS;
-
live in Australia in an NDIS area on a specified date; and
-
be an Australian citizen or hold a permanent visa or a Protected
Special Category visa.
2.8
An impairment that varies in intensity, for example when an impairment
is of a chronic episodic nature may still be permanent, and may meet the
eligibility requirements for the Scheme.
2.9
In addition to these eligibility criteria there are also Early
Intervention Requirements. A prospective participant will meet the early
intervention requirements if they meet each of the following requirements::
-
the person:
- has one or more identified intellectual, cognitive,
neurological, sensory or physical impairments that are, or are likely to be,
permanent (section 25(1)(a)(i)); or
- has one or more identified impairments that are attributable
to a psychiatric condition that are, or are likely to be, permanent (section
25(1)(a)(ii)); or
- is a child who has developmental delay (section
25(1)(a)(iii)); and
-
the NDIA is satisfied that provision of early intervention
supports is likely to benefit the person by reducing their future needs for
disability related supports (section 25(1)(b)); and
-
the NDIA is satisfied that provision of early intervention
supports is likely to benefit the person by:
- mitigating or alleviating the impact of the person's
impairment upon their functional capacity to undertake communication, social
interaction, learning, mobility, self-care or self-management (section
25(1)(c)(i)); or
- preventing the deterioration of such functional capacity
(section 25(1)(c)(ii)); or
- improving such functional capacity (section 25(1)(c)(iii);
or
- strengthening the sustainability of informal supports
available to the person, including through building the capacity of the
person's carer (section 25(1)(c)(iv)); and
-
the NDIA is satisfied that early intervention support for the
person is most appropriately funded or provided through the NDIS (section
25(3)).[3]
2.10
Until now, the continuing lack of clear eligibility criteria for access
to NDIS services for deaf and hard of hearing people was of significant
concern, with inquiry participants describing the negative impact that this uncertainty
was having within the deaf and hard of hearing community.
2.11
In regard to the criteria to be used, the majority of inquiry
participants argued that eligibility should be based on a holistic assessment
of need rather than an arbitrary audiological measure. There was also
widespread support for the eligibility criteria to capture children with
unilateral as well as bilateral hearing loss.
Impact of uncertainty
2.12
The ongoing lack of publically available eligibility criteria has caused
considerable consternation within the deaf and hard of hearing community. One
parent of a child with a profound hearing loss in one ear and a mild-severe
hearing loss in the other ear described the situation:
The uncertainty of whether [name withheld] will be eligible
for NDIS is very concerning. Is she ‘deaf enough’ to qualify for services? I
believe that any child who has a hearing loss, whether in one ear or two, who
requires hearing aids or cochlear implants in order to fully access sound
should be automatically eligible for NDIS.[4]
2.13
Children and Young People with Disability Australia also noted the
impact of this uncertainty, stating that:
It is critical that information about eligibility for the
NDIS for people who experience deafness is made available as soon as possible. The
lack of information is a key concern to children, young people and families who
need to make decisions around services, supports and access to devices without
knowing whether they will be supported into the future through government
funded programs.[5]
2.14
This uncertainty has also had consequences for businesses that provide
services to the deaf and hard of hearing community. For example, the Hearing
Business Alliance observed:
Our members would also like clarity from NDIA as to what
criteria are proposed for determining eligibility for the provision of hearing
services to clients? To date information provided to us through NDIS
information meetings has been unclear, inconsistent and conflicting.[6]
2.15
Similarly, Country Hearing Care, a small family-owned private,
independent practice, situated in a relatively remote rural location in
northern Victoria said that the uncertainty had resulted in a feeling of
financial vulnerability:
There has been a significant amount of confusion regarding
the patient eligibility criteria for determining access to services. We have
received conflicting information during NDIS presentations...This confusion,
along with rumours and speculation about possible subsequent changes to Office
of Hearing Services (OHS), including the revision of OHS fees, has made us, as
small business owners, feel financially vulnerable, insecure and concerned as
we try to plan ahead in an uncertain business landscape.[7]
2.16
Neurosensory, a provider of comprehensive hearing and balance services indicated
that due to the lack of established eligibility criteria, it is impossible for
clinicians to determine who may be able to access hearing and other hearing
related services.[8]
Holistic assessment of need
2.17
The majority of inquiry participants argued strongly that any eligibility
criteria for deaf and hard of hearing people to access the NDIS should be based
on a holistic assessment of need, rather than a simple measure of a hearing
loss threshold. For example, Deafness Forum Australia articulated the case for
broad-based eligibility criteria:
Eligibility for the NDIS should not be based on hearing
threshold levels alone. This measure does not provide any information on the
impact of the hearing loss on a person’s ability to undertake activities, or
participate in employment or socially. An average hearing threshold level can
be misleading if viewed in isolation especially if the person has other
disabilities. When a person has their hearing assessed the determination of a
hearing threshold level is only one component of the assessment process.
Audiological assessment includes a broad range of information gathering
including, a discussion of the impact of the hearing loss on the person’s
functioning, a discussion of the individual’s needs and goals, as well as a
diagnostic hearing assessment to determine the degree and type of hearing loss.[9]
2.18
The Deafness Forum of Australia said that it supported a holistic
approach to eligibility based on the WHO International Classification of
Functioning, Disability and Health and that it would be concerned if
eligibility was reduced to an average hearing threshold level for people with
hearing loss.[10]
2.19
The Australian Society of Rehabilitation Counsellors (ASORC) also argued
in support of a holistic assessment rather than an 'abstract measure' of
clinical impairment:
ASORC is concerned that NDIS’ existing assessment processes
do not assess the individual’s experience of overall disability but focuses on
assessing disability within a compartmentalized approach, therein excluding
people from the system when their whole-of- life experience of disability is
severe-profound in its impacts on education, employment and social inclusion.[11]
2.20
ASORC contended that if a 'narrowly-framed approach was pursued, it
would have significant economic impacts on Australia’s productivity and
frustrate the capacity of the NDIS to achieve the national impact it was
designed to achieve'.[12]
2.21
The Independent Audiologists Australia Inc concurred with this view,
stating: 'Functional ability, not a measure of impairment should determine
eligibility for the NDIS'.[13]
2.22
Can:Do Group, a provider of specialist services for people with hearing
and vision impairments in South Australia, supported the use of functional
outcomes to determine eligibility for the NDIS, particularly for children with
unilateral hearing loss:
For some clients a mild hearing loss is devastating to their
lifestyle, while for others a severe hearing loss is manageable without
devices...We have supported some families who have not been deemed eligible for
NDIS supports due to having a unilateral loss. We have also supported three
families that went through an appeal process with the NDIA which they found
incredibly stressful. Two of the three of them ultimately received an NDIS
package for their child with a unilateral loss. It is important to acknowledge
that although this may require less intensive intervention or less funding,
early intervention support and funding allocated for families to access support
is important to minimise the need for further intervention and supports later
on.[14]
Unilateral hearing loss
2.23
A second issue relating to eligibility arose as to whether or not
children diagnosed with unilateral hearing loss should be eligible for
assistance under the NDIS, with the majority of inquiry participants arguing
strongly for the inclusion of such children in the NDIS. For example, Professor
Greg Leigh, Director, Royal Institute for Deaf and Blind Children, argued that
given the ability to identify children with mild and unilateral levels of
hearing loss it would be 'indefensible' to deny them the support they needed to
achieve development milestones:
A fundamental precept of any screening program is that you do
not screen and identify something that you do not have the potential to do
something about. With the advent of newborn hearing screening, for the first
time we can identify children with very mild and unilateral levels of hearing
loss very early in their life span...The notion that, as a society, we do
actively seek to identify those children and then do not put in place something
that puts the minimum standards of support in place to ensure developmental
outcomes for them is, frankly, indefensible.[15]
2.24
Mr Chris McCarthy, Chief Executive Officer, Hear and Say, similarly
argued for the inclusion of children with unilateral hearing loss within the
eligibility criteria:
For me, eligibility really does need to be around all
children with hearing loss. It is very important that, for those first years,
it does not matter what level of hearing loss a child has. We have gone to the
effort of investing in a universal newborn-hearing screening program, and I
think it would be foolish for us as a society not to actually act on the
information that we are given when we have identified those children.[16]
2.25
Ms Margaret Dewberry, Adviser, Deafness Forum Australia, considered that
'any child who is diagnosed with a hearing loss is going to need intervention.
I think it should be the default position—because
it is now—that
somebody with the right expertise assesses what that intervention needs to be'.[17]
2.26
First Voice suggested that it was critical that all children developing
permanent hearing loss prior to age six be eligible for early intervention
services under the NDIS.[18]
First Voice said that the 'scale of such supports would then be proportional to
their current or expected reduction in functional capacity due to their hearing
loss'. [19]
2.27
The Shepherd Centre expressed similar sentiments, arguing that all
children developing permanent hearing loss prior to age six should be eligible
for early intervention services under the NDIS, with the scale of support
proportional to need.[20]
2.28
In his appearance before the committee, Mr Michael Forwood, Chief
Executive Officer, Cora Barclay Centre, and Chair, First Voice, continued to
advocate for the inclusion of children with unilateral hearing loss into the
NDIS, observing that relatively low-cost early intervention would have
beneficial outcomes over the long term:
If the NDIS were to rule out of eligibility for funding
children with unilateral hearing loss, we would be faced with taking them on
service without any funding, because the families want the service and we know
there are significant improvements, so it is a significant NDIS issue... In terms
of the insurance principle, this would have to be the lowest-hanging fruit for
the NDIS. Thirty to 40 per cent of kids are going to perform poorly and
possibly end up on disability services and pensions, and, to me, in terms of
economics, an early intervention that might cost $3,000 or $5,000 and monitoring
in case they have progressive hearing loss is a no-brainer.[21]
2.29
The Shepherd Centre also highlighted the 'false economy' of not supporting
children diagnosed with unilateral hearing loss as early as possible:
However, even children born with a mild hearing loss, or a
loss affecting only one ear, are at high risk of developing communication,
educational and social delays once they enter school. Once these deficits are
apparent the children would then be eligible under the NDIS. However, it would
be a false economy to not provide expert early support to these children, only
for them to fall behind and then having to subsequently receive much greater
support to try and help them catch up. Unfortunately this is the current
situation – some children with unilateral loss or with mild bilateral loss are
being denied NDIS access, not due to their functional need but solely due to an
arbitrary audiological measure.[22]
2.30
The inclusion of unilateral hearing loss within the NDIS eligibility
criteria was supported by a large number of inquiry participants, including Deaf
Australia, Aussie Deaf Kids and Parents of Deaf Children, Telethon Speech and
Hearing, Canberra Deaf Children’s Association and National Disability Services.[23]
Impact on people not eligible for
the NDIS
2.31
Inquiry participants also identified a need to clarify the services that
would remain available for people deemed ineligible for the NDIS. Carers
Australia NSW and Carers Australia Victoria highlighted that between 1 July
2016 and 30 September 2016, the National Disability Insurance Agency (NDIA)
received 665 requests for access to the NDIS on the basis of a hearing
impairment. Of this number 72 were deemed ineligible.[24]
The organisation continued:
Our first concern is for the ineligible applicants. No further
demographic information about these individuals is available, so we cannot be
sure why they were denied access. However, this shows a substantial number of
people with a hearing impairment may be excluded from the individualised,
self-directed support offered by the NDIS. This is particularly concerning in
states and territories rolling their entire disability support system into the
NDIS, such as NSW.[25]
2.32
The Royal Institute for Deaf and Blind Children shared these concerns, observing
that there was a 'critical need to ensure that there is no diminution of the
Federal Government’s commitment to the provision of free and universally
available access to hearing services' following the full NDIS rollout.[26]
The Institute said:
Any change to eligibility criteria will necessitate that the
Government consider alternative arrangements for those young adults (under 26)
with less complex hearing needs who are currently CSO clients eligible for
services under the Hearing Services Program but who may be ineligible for
services under the NDIS. This is an issue that requires Government policy
consideration in light of its promise that no current recipients of Hearing
Services would be worse off under the transition from the Hearing Services
Program to the NDIS.[27]
2.33
Vicdeaf expressed concerns that deaf and hard of hearing individuals
from migrant backgrounds who are not eligible for the NDIS due to their
residency status may go without access to any supports or services as state
funded programs are transitioning to the NDIS:
Many of these migrants are presently accessing vital services
through Department of Health and Human Service (DHHS) block funded programs. As
this funding slowly dwindles with more rollout zones occurring within years to
come, if no provisions are put in place, a disadvantaged sub-community within
the Deaf and hard of hearing cohort may go without access to any supports or
services.[28]
2.34
The Royal Institute for Deaf and Blind Children expressed grave concern
that 'assistance could become worse for those who do not qualify for the NDIS',[29]
arguing that:
Hearing services and funding should not go backwards, as
appears to be happening under the NDIS. Australia will lose its reputation as a
world leader in hearing services and research, to the detriment of our population
under the current policy settings.[30]
NDIA reviewed guidance for eligibility criteria
2.35
The NDIA recently completed the revised guidance for determining access
to the scheme and reasonable and necessary supports for hearing impairment. The
NDIA updated guidance for determining access for hearing impairment, both under
section 24 and section 25 of the NDIS Act 2013.
2.36
The NDIA publically released the amendments to the operational
guidelines on 1 September 2017.
2.37
The amendments clarify the access criteria for early intervention as
well as the requirements for eligibility for adults over 25 years of age.
Early intervention for deaf or hard
of hearing people aged 0–25
2.38
The revised guidance for early intervention requirements are:
The NDIA will be satisfied that a person meets the early
intervention requirements without further assessment when the person:
-
is aged between birth and 25 years of age; and
-
has 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 or long term; and
-
the hearing loss of the person necessitates the use of personal
amplification.[31]
2.39
The NDIA provided the following information:
This streamlined access approach for early intervention
acknowledges a rich body of evidence that recognises that early intervention
support 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.[32]
2.40
The effect of this change is that prospective participants who are aged
0–25 (inclusive) who
meet the audiometric criteria will meet the early intervention requirements
without further assessment.
2.41
Overall, experts from the hearing sector have found these access
requirements appropriate.[33]
First Voice and the Shepherd Centre described the requirements as 'reflecting
the current practices of Australian Hearing'.[34]
2.42
However, Aussie Deaf Kids, a not-for-profit parent organisation that
aims to empower parents raising a child with hearing loss through support,
information and advocacy, raised some concerns about the requirement that 'the
hearing loss of the person necessitates the use of personal amplification'.[35]Aussie
Deaf Kids stated:
There are three points that need consideration with this
statement:
- This
denies culturally Deaf parents the right to choose not to use personal
amplification for their child. While many Deaf parents choose listening devices
for their children, the child’s right to the NDIS should not be premised on
their use of a device.
- It
is essential children with absent or underdeveloped auditory nerves should
receive automatic eligibility; these children do not benefit from
amplification.
- There
is minimal empirical evidence as to the efficacy of amplification devices for
babies and young children with MBHL or UHL. Parents should not feel pressured
to use a device simply to access NDIS funding. These children, however, do
require ongoing audiological management and access to early childhood
intervention and should, therefore, be eligible to receive early childhood intervention
through the NDIS, irrespective of their use of a listening device.[36]
2.43
Additionally, Aussie Deaf Kids suggested to include the terms bilateral
and unilateral in the section relating to the level of hearing loss as these
terms are understood by parents and used to describe their child's hearing
loss.[37]
2.44
Whilst the hearing sector welcomes the reviewed guidelines for early
intervention requirements, The Shepherd Centre stressed that 'appropriate
National Reference Packages are still required to ensure that the required
early intervention support is funded as required'.[38]
Additional guidance for hearing
impairments for adults over 25
2.45
The NDIA advised that it also made the following changes:
the following text will be removed from List D, Section 4:
“Deafness/hearing loss – a 45 decibels or greater hearing
impairment in the better ear, based on a 4 frequency pure tone average (using
500, 1000, 2000 and 4000Hz)”
An Additional Section entitled ‘Additional guidance for
hearing impairments’ has been added at 8.3.3:
“8.3.3. Additional guidance for hearing impairments
Hearing impairments may result in reduced functional capacity
to undertake communication, social interaction, learning and self-management
activities. Generally, the NDIA will be satisfied that hearing impairments of
≥ 65 decibels in the better ear (pure tone average of 500Hz, 1000Hz,
2000Hz and 4000Hz) result in substantially reduced functional capacity to
perform one or more activities. This audiometric criterion reflects the lower
limit of what is likely to constitute a substantially reduced functional
capacity to undertake relevant activities.
Hearing impairments < 65dB decibels in the better ear
(pure tone average of 500Hz, 1000Hz, 2000Hz and 4000Hz) in conjunction with
other permanent impairments (for example vision or cognitive impairments), or
where there is evidence of significantly poorer than expected speech detection
and discrimination outcomes, may also be considered to result in substantially
reduced functional capacity to undertake relevant activities.”[39]
2.46
Some submitters[40]
raised concerns about the changes to the requirement of a hearing impairment of
>65 decibels in the better ear, based on a 4 frequency pure tone average to access
the Scheme. The Royal Institute for Deaf and Blind Children explained:
There is a significant variation with the access for adults
aged 26 years and over who will only be accepted with a hearing impairment of
≥ 65 decibels in the better ear, based on a 4 frequency pure tone
average. An adult with a hearing impairment of ≥ 45 decibels in the
better ear will experience a reduced functional capacity to undertake relevant
activities. However, to gain access to the NDIS they would need to have another
permanent impairment. A hearing impairment of this level does require hearing
aids in order to undertake communication, social interaction, learning and
self-management activities.[41]
2.47
The Shepherd Centre and First Voice articulated the potential
consequences of this requirement:
The effect of the eligibility threshold is that a person who
is profoundly deaf in one ear (that is, cannot hear anything at all on that
side) and has a hearing loss of 60dB in the other ear (often referred to as
severe hearing loss) would not be automatically eligible.
A person with this level of hearing loss is totally dependent
on devices for their functional access to sound – either hearing aids or
cochlear implants. If these devices are appropriately provided and fitted the
person should have sufficient access to sound to be able to hold spoken
conversations and to be able to participate through their hearing in society
and the workforce.
However if the person does not have these devices they will
probably not be able to have effective spoken conversations or be able to
participate in society or the workforce through their hearing.[42]
2.48
The Royal Institute for Deaf and Blind Children raised the issue of the
potential risk for people not meeting the criterion to be unable to fund their
required hearing aids:
This cohort of hearing impaired adults may not be in a
position to fund their required hearing aids and are not eligible for the
Australian Government Hearing Services Program. For those of working age they
may be unable to find employment as they are unable to fund the hearing supports
they need.[43]
2.49
Taralye expressed 'extreme concern that the removal from the guidelines
of the pure tone average range, for a moderate hearing loss to be replaced with
audiometric readings consistent with a severe or worse hearing loss do not take
cognisance of the impaired functional capacity of clients with unilateral, mild
and moderate hearing losses in spite of this being well documented in research'.[44]
2.50
The Cora Barclay Centre found 'a lack of clarity in the proposed changes
to the Operational Guidelines that Section 8.3.3 pertains to adult hearing loss
only'.[45]
Committee view
Eligibility criteria
2.51
In light of the evidence received throughout the inquiry on the issues
and lack of clarity pertaining the access requirements to the NDIS for deaf and
hard of hearing people, the committee welcomes the release of the NDIA's
reviewed operational guidelines to determine access to the NDIS for deaf and
hard of hearing people.
2.52
The committee notes that there are early indications from the sector[46]
that the recently released access criteria for deaf and hard of hearing people
aged 0-25 appear to be technically consistent with the current practices of
Australian Hearing, and are therefore welcomed.
2.53
For the criteria of hearing impairment for those 26 years or older, the
committee is concerned that the access requirement of more than 65 decibels in
the better ear, based on a 4 frequency pure tone average, may leave some people
with no access to supports. Ineligibility to the Scheme may negatively impact
on the social and economic participation of this cohort. The committee recommends
the NDIA monitors eligibility rates for adults with hearing impairments to build
a clearer picture of the number and needs of the people who have been found
ineligible for NDIS services and reports on its finding in 12 months.
Deaf and hard of hearing people ineligible for the NDIS
2.54
The committee is concerned about the deaf and hard of hearing people,
especially children who have been denied access to the NDIS since the beginning
of the Scheme rollout because of the lack of clear NDIS operational guidelines.
For example, the committee heard that children were denied access to the NDIS
because of unilateral hearing loss or mild hearing loss despite their high risk
of developing communication, educational and social delays. The committee is
concerned that some people, including children, are currently left with no
access to support. To ensure consistency and equity of access to the Scheme, the
committee recommends the NDIA reviews the cases of people with hearing
impairment who were previously found ineligible. The committee recommends the
NDIA tests their eligibility against the revised guidelines.
2.55
The committee is also concerned that with the transition of Australian,
state and territory government programs to the NDIS, some people are at risk of
being left with no services. Given that governments contributed to services
before the NDIS, it is not clear how services will be delivered to people not
eligible. This cohort may include some individuals over the age of 65 and
disadvantaged groups such as migrants and refugees because of the NDIS
eligibility criteria around age and residency status. The committee recommends the
Australian, state and territory governments clarify and make public how they
will provide services for people who are deaf and hard of hearing who are not
participants in the NDIS.
NDIA capacity to address
operational issues
2.56
The committee is concerned about the NDIA not addressing in a timely
manner the emerging and ongoing operational issues associated with the
implementation and rollout of the NDIS. Indeed, along with other examples of
operational issues the committee has been made aware of through the other
inquiries it has conducted, the lengthy process and series of delays that
occurred between the time the NDIA started to work on the guidelines and their
public release are raising doubts about the capacity of the NDIA to address its
current operational issues.
Recommendation 1
2.57
The committee recommends the NDIA monitors eligibility rates for adults
with hearing impairments to build a clearer picture of the number and needs of
the people who have been found ineligible for NDIS services and reports on its
finding in 12 months.
Recommendation 2
2.58
The committee recommends the NDIA reviews immediately the cases of
people with hearing impairment who were previously found ineligible and tests
their eligibility against the revised guidelines.
Recommendation 3
2.59
The committee recommends the Australian, state and territory governments
clarify and make public how they will provide services for people who are deaf
and hard of hearing who are not participants in the NDIS.
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