Did you know that you may be able to reclaim your care home fees? Not many people know that they may have already paid care home fees unnecessarily over a long period, and may be entitled to a full refund, plus interest!
If your relative has a ‘primary health need’ i.e. the main reason for their care is due to health needs (not social care needs provided by the local authority) then they may be entitled to NHS Continuing Healthcare Funding (‘CHC’). This is free funding from the NHS that is intended to cover ALL their assessed healthcare needs (including social care needs) and accommodation. If awarded CHC Funding, that could potentially save a fortune every month in care fees!
Indeed, many older retrospective claims have amounted to large six figure pay-outs by the NHS – especially with accrued interest at 8% per annum (pre -1st April 2015). It was not uncommon for interest on these historic cases to add another 50% to the principal CHC awarded. Eye-watering sums for the NHS to repay.
So if your relative has been in receipt of care, whatever the care setting – whether in their own home, or a care/nursing home – and have not previously been assessed, they (or their estate, if deceased) may be entitled to make a retrospective claim for care fees going as far back as April 2012. We strongly recommend that you ask your local Integrated Care Board (ICB) NHS Continuing Healthcare Department to arrange an immediate assessment.
However, be aware that claiming CHC funding retrospectively will involve a careful analysis of medical and care home records to which you will need to have access.
Don’t be under any illusions – the retrospective review process is complex and extremely time-consuming. Unfortunately, you need to have patience and perseverance in spades. ICBs don’t give out CHC awards lightly and will make you fight for every penny of any entitlement to CHC.
If you are eventually successful in getting the ICB to agree to a retrospective repayment, the burden is on you to prove your loss. For the retrospective period under consideration, you will usually need to provide the ICB with invoices and a statement of account from the care home, and bank statements. If you don’t have this information, you may face strong opposition from the ICB and struggle to get payment at all or in full. There are ways round this if you don’t have the requisite paperwork to satisfy the ICB’s bureaucracy, but the amount of reimbursement is likely to be a lot less, as you are relying on the ICB’s agreed ‘bed rate’ for that care home, which will inevitably be far lower than the actual fees paid.
Then there is the issue of checking the ICB’s retrospective award and whether they’ve added the appropriate amount of interest. This is an area where you may wish to seek legal advice, so that you’re not short-changed.
However, the majority of retrospective claims currently left in the ICB’s pipeline are now more likely to arise in the following situations:
a) Those patients who were waiting for an assessment pre-Covid i.e before March 2020 – and have got held up in a backlog of cases pending CHC review; or
b) Those patients post-Covid who have not yet been reviewed for CHC;
c) Patients in receipt of Funded Nursing Care
As such, given the shorter periods of cases undergoing retrospective reviews, the value of those retrospective awards will obviously be far smaller than the historic cases dating back to April 2012.
Are you in receipt of Funded Nursing Care (FNC)?
FNC is a weekly sum paid by the NHS as a contribution to the cost of nursing care provided by a registered nurse at a care home with nursing.
FNC should be reviewed annually or when considering CHC Funding. However, some patients remain on FNC for much longer than 12 months without ever being reassessed. If their healthcare needs had materially changed in the meantime and became more challenging, then they could be entitled to make a retrospective claim for CHC funding and seek a refund.
Annual Reviews of CHC Funding
Similarly, for those patients already in receipt of CHC Funding, that too, should be reviewed at least every 12 months according to paragraph 201 of the National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care.
The purpose of the review is to appraise the package of care in place and to see if it is still fit for purpose and is meeting the assessed care needs. Again, if the patient’s needs have become more challenging, the NHS package of CHC care may need increasing to meet those changing needs.
If your relative is in receipt of CHC Funding and it is working well, beware of pushing for an annual review as the ICB may reassess them and unilaterally find that their needs are not as severe as you believe, and could remove funding.
The review process is entirely subjective. According to paragraph 203 of the NHS National Framework, the purpose of a review is “to focus on whether the care plan or arrangements remain appropriate to meet the individual’s needs. It is expected that in the majority of cases there will be no need to reassess for eligibility”. However, despite the stated guidance, CHC Funding is a big financial drain on the ICB budget. ICBs have to make savings and any sceptics could worry that it might seek to use the opportunity to try and withdraw funding upon reassessment!
Reassessments generally cause families a lot of anxiety and stress as there is always the chance that funding could be withdrawn, even if you believe your relative’s needs have not materially changed since the last review, or indeed, have become more challenging and needy. Some families take the view that if the ICB aren’t pressing for an annual review, it is better to lie low and keep the status quo.
Should funding be wrongly removed following a review, you may have a lengthy appeal battle to get it reinstated whilst having to fund your relative’s care in the meantime from private means – even selling their home. You can access professional support and advocacy to accompany you at any review. The cost may justify the outcome and give you peace of mind.
We recommend you press for a retrospective assessment for past periods of unassessed periods of care, or if you are in a queue waiting for a CHC assessment, or are in receipt of FNC.
Don’t be afraid to seek professional help as the retrospective assessment process is daunting and time-consuming. They understand what is required to achieve success and will take the strain off your shoulders.
If your relative is undergoing an annual review, consider getting professional advocacy to support you at the review to ensure it is carried out fairly and robustly and, so that your relative gets the package of care they need – and moreover, it doesn’t get wrongly withdrawn!
If your relative has had their funding incorrectly removed at an annual review, leave a comment below and tell us about your experience.