Do I Need To Pay Care Home Fees Whilst I Am Awaiting An Appeal?

Do I Need To Pay Care Home Fees Whilst I Am Awaiting An Appeal?

NHS Continuing Healthcare solicitor or advisorThe National Framework NHS Continuing Healthcare Funding and NHS-Funded Nursing Care (revised 1st October 2018) states that when an individual is discharged from hospital to their previous residential setting (eg back to their own home or care home), the NHS should arrange an interim package of care to support them whilst they are awaiting an assessment for NHS Continuing Healthcare Funding (CHC).  If this interim package is missing, quote paragraph 112 of the Framework, which says, “There must be no gap in the provision of appropriate support to meet the individual’s needs.

Therefore, unless there is no need for the NHS to carry out an initial Checklist assessment, because the individual meets the various exceptions in paragraph 91 of the NHS National Framework, then all the individual’s healthcare needs should be funded by the NHS until at least the Checklist assessment has taken place and the outcome confirmed.

So, it’s more likely now, under the revised NHS National Framework, that the NHS will action Checklist assessments more promptly upon discharge from hospital, in order to save funds and reduce the risk of funding interim care packages unnecessarily, in case the individual does not ultimately qualify for CHC.  For further reading on the subject: Can the NHS refuse to carry out an initial Checklist?

However, if the Checklist assessment is negative, then you can ask for it be redone (at a later date) if you feel that the outcome is manifestly wrong, or it wasn’t carried out fairly and robustly. In the meantime, your relative will have to make arrangements to pay for their care until such time as CHC may eventually be awarded.  Read our blog: What to do when an NHS Continuing Healthcare Checklist is rejected.

If, however, your relative has scored a positive Checklist, and is now moving forward to a full assessment by a Multi-Disciplinary Team (MDT), then we would expect the CCG to continue providing funding and support until the outcome of the MDT has been communicated to the parties.  For more information as to what to expect at an MDT, read our blog: What Happens At The Multi-Disciplinary Team Meeting?

If your relative is then rejected for funding following the MDT assessment and wishes to appeal, then again they will have to make arrangements to pay for their care in the meantime.

Therefore, there can be periods between assessments and appeals where your relative falls between two stools, and may be forced to use private funds to pay for their care.

According to the National Framework, once CHC Funding is in place, the NHS should carry out a review at 3 months, and thereafter, annually.

What happens if CHC Funding is in place and is then withdrawn at a reassessment?

Waiting for a reassessment can be a very worrying and stressful time for families. Even if CHC is in place, they know there is always a real risk that it could be withdrawn.

If the individual’s position is found to have improved, making CHC no longer justifiable and then it is withdrawn, there can be no complaints. That’s perfectly reasonable. Why should the NHS pay care home fees for someone who is no longer eligible for this free funding?

However, the greater risk to families lies in the fact that the criteria for assessing eligibility for CHC Funding are open to subjective interpretation.  A new NHS assessor could, therefore, take an alternative view of your relative’s healthcare picture, and recommend that they are no longer eligible for free funded CHC, and it should therefore be withdrawn immediately.  If this happens, your relative suddenly has to find huge funds to pay for their care, often forcing the sale of their own home to raise funds, whilst considering an appeal.

How often do we hear anecdotally of ‘horror’ stories at a reassessment? Stories, where an individual’s needs have not changed whilst waiting for a reassessment, or else, have got worse – yet the NHS assessor unilaterally makes a recommendation that their needs have improved, and no longer meet the eligibility criteria for CHC! Funding is then withdrawn and the family now have to muster fortitude and resolve to prepare for a lengthy appeal battle, often lasting years rather than months, whilst funding care home fees in the meantime!

Your relative may well eventually succeed with their appeal and have the CHC Funding reinstated, with a repayment of funds that were wrongly charged, plus interest. But, the anxiety and untold stress caused to families in the interim, having to fight an uphill battle to secure CHC, can often take its toll whilst processing an appeal.

Some families seek independent advice, or instruct specialist lawyers to fight their relative’s case and act as an advocate at any appeal, to give them the best chance of getting CHC funding reinstated.  A good legal advisor will take the strain and stress of the situation on their shoulders, as they know how the system works and the standards expected to achieve a successful outcome.

Remember, you are entitled to have an advocate support you along the way. For further information read:

Can The MDT Panel Refuse To Proceed If I Have An Advocate?

We also recommend you visit our one-to-one webpage, if you need specialist support at any stage.

Suggestion: If forced to pay care home fees whilst waiting an appeal, you can always try and negotiate with the care home manager and see if they will hold care fees in abeyance, pending the outcome of any further assessment or appeal.  Some care homes may be sympathetic, but most will be sure to want to plug the gap, so that there is no shortfall in their weekly income.

For further reading around the subject: Rejected for CHC Funding? Part 1: How To Appeal The MDT Decision;

Appealing A CHC Funding Decision, Not To Grant or To Withdraw Funding

Rejected for CHC Funding? Part 2: How to appeal the Local Resolution Decision

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