Medical Assessment Team (MAT) 008-20102224

Item

Description

Permanently blind

To be manifestly eligible for DSP because of permanent blindness, a customer must have:

• visual acuity on the Snellen Scale after correction by suitable lenses of less than 6/60 in both eyes, or
• constriction to within 10 degrees of fixation in the better eye irrespective of corrected visual acuity, or
• a combination of visual defects resulting in the same degree of visual impairment as that occurring in the above points

While a Request for Ophthalmologist/Optometrist Report' (SA013) is preferred, any report which provides the equivalent information requested by the SA013 is acceptable.

Terminally ill

A customer is medically manifestly eligible for DSP if the medical evidence clearly indicates:

• their current medical condition is chronic and debilitating, and
• there is a terminal prognosis, that is, where the average life expectancy of a patient with this condition is 24 months or less, and
• there is a significant reduction in work capacity within this period

Note: if not terminal within 2 years, the impact of these conditions may mean a person requires nursing home level care, which is also a DSP manifest category.

Intellectual disability

A customer with a diagnosed intellectual disability may be manifestly granted DSP if they have a valid IQ assessment of less than 70 or provide evidence they are unable to undergo testing because of the severity of their disability.

Acceptable forms of evidence may include:

• a current assessment of intellectual function conducted by a psychologist using the WAIS IV or equivalent contemporary assessment
• a report provided by a school attended by the customer advising their diagnosis, IQ score and assessment of adaptive behaviour, or inability to undergo testing

Give attention to a reported Full Scale IQ (FSIQ) range/percentile that is indicative of a FSIQ less than 70. Reports where the FSIQ score is under 70, or in the 1st percentile or in the extremely low range, or that identify that the customer has a moderate intellectual disability, are all indicative of a score less than 70. Whilst a specific score may not be provided, the history and other supporting information may indicate that the score is less than 70.

Consider if adapting recognised assessments of intellectual function for use with Aboriginal and Torres Strait Islander peoples is required. This can include psychometric tests undertaken by an appropriately qualified health professional with consideration of testing conditions and factors that may affect results, for example, primary language other than English cultural background, concurrent mental health condition, medication and illicit drug use.

In some cases, a report from the customer's school or psychologist may indicate IQ testing was unable to be undertaken due to the severity of the intellectual disability. Clearly document this in the evidence provided as these customers meet the manifest medical criteria for intellectual disability.

Category 4 HIV/AIDS

Customers with category 4 HIV/AIDS are considered manifestly medically eligible for DSP.

The medical evidence must clearly state Category 4.

Note: all potential manifest cases for Category 4 HIV/AIDS must be referred to the Health Professionals Advisory Unity (HPAU) for consideration.

Department of Veterans' Affairs (DVA) Disability Compensation Payment at Special Rate (Totally and Permanently Incapacitated (TPI))

Customers receiving a DVA Disability Compensation Payment at Special Rate (TPI), paid under the Veterans' Entitlements Act 1986, have already had their impairment rating and work capacity determined by DVA and listed in the Special Rate decision letter provided to the customer. View this on the DVA screen in Customer First.

Note: Military Rehabilitation Compensation Act (MRCA) Special Rate Disability Pension recipients claiming DSP are not considered manifest and must provide medical evidence.

Customer requires nursing home level care or profoundly disabled child turning 16

Customers are accepted as manifestly eligible for DSP where evidence clearly indicates they:

• are a long-term patient of a hospital or nursing home because of illness or infirmity and are unlikely to be discharged in the foreseeable future, or
• are not in a nursing home/hospital but require the same level of nursing home care (usually provided by carer/s) because of illness or infirmity

Unless the customer has a List 1 condition, supporting medical evidence generally needs to provide details of the:

• nature of the impairment
• reason for long-term hospitalisation/nursing home care
• likelihood of discharge
• customer's ability to perform activities of daily living

Some of these requirements may not apply for List 2 conditions.

Profoundly disabled child turning 16

The nursing home level care manifest criteria may be met by a care receiver assessed as a profoundly disabled child where their carer claimed Carer Payment (CP) for them:

• before 1 July 2009 and have been in receipt of Carer Payment for care provided to the care receiver up until the time they turned 16, or
• on or after 1 July 2009, and the care receiver has a Treating Health Professional (THP) score of 4 or more, and an Assessment of Care Load (ACL) score of 300 or more

If the care receiver is eligible to use the DSP abridged claim process, relevant claim forms and information are auto-sent when the care receiver turns 15 years and 10 months. The customer is generally not required to provide medical evidence with their DSP claim.

To check if the child care receiver turning 16 has a 'profoundly disabled condition' in Customer First, access the carer's record:

• navigate to the Care Receiver Summary screen
• select the care receiver:
• select the Child Disability Assessment Tool Summary screen, or
• open the Carer Summary workflow

Item

Description

List 1 conditions

Includes medical conditions which are accepted as manifest for DSP based on diagnosis alone. Provided the diagnosis is confirmed by medical evidence and the customer meets all non-medical criteria, manifestly grant the customer's DSP claim without confirmation from the treating doctor that the customer:

• has a terminal condition
• requires nursing home level care, or
• has an intellectual disability

List 2 conditions

Includes medical conditions that may:

• be terminal (terminal within 2 years for DSP purposes)
• require nursing home level care, or
• indicate manifest intellectual disability

If the DSP customer's medical evidence lists such a condition, the Assessor must contact the customer's treating doctor about the likely prognosis and level of care required. Seek advice about a condition from the Health Professional Advisory Unit (HPAU) if required. The HPAU may be able to confirm the expected prognosis, that is, clarify whether terminal or nursing home level care is required, or may contact the treating doctor to clarify, and expedite the claim without the need for a further assessment.

Additional action for List 2 conditions

The additional action is to obtain information on the prognosis or severity of the condition so a decision can be made as to whether manifest medical criteria is met.

For potentially terminal cancers, if the treating doctor indicates the condition has reached the grade or stage indicated in the List 2 conditions, manifest medical criteria is considered to have been met even if the doctor will not state the condition is likely to be terminal within 2 years.

For other conditions, information must be obtained indicating nursing home level care is required or a manifest intellectual disability eligibility is met. If manifest medical criteria is not met, a Job Capacity Assessment (JCA) referral must be made.

Note: if not terminal within 2 years, the impact of a condition may mean the customer requires nursing home level care, which is also a DSP manifest category.