6 November 2018 | Firm news | Article by Lisa Morgan

NHS Continuing Healthcare – when can I claim from? The differences between England and Wales

Introduction

When a loved one enters a care home, you can request that the local health authority assesses your relative’s needs against the criteria for NHS continuing healthcare. You can also request that the local health authority undertake a retrospective review of your relative’s needs to ascertain whether they met the criteria for NHS continuing healthcare at an earlier point in time if, for example, they were paying for care that they received at home or in sheltered accommodation prior to their admission into the care home. However, due to previous deadlines set by the Department of Health and the Welsh Government, there are limitations on how far back you can request a retrospective review of a person’s needs. This blog aims to clarify from when you can request a retrospective review in both England and Wales.

NHS continuing healthcare is a package of care funded by the NHS for individuals who have a primary health need. Please see our previous blog for an explanation of what makes someone eligible for NHS continuing healthcare.

When can I claim from?

In England, a retrospective review of someone’s eligibility for NHS continuing healthcare can be requested from 1 April 2012 onwards in respect of previously unassessed periods of care. Any claims for periods of care prior to 31 March 2011 would have had to be registered with the local health authority by 30 September 2012 and periods of care between 1 April 2011 and 31 March 2012 would have had to be registered with the local health authority by 31 March 2013. Therefore, it is now not possible to request a retrospective review of someone’s eligibility for NHS continuing healthcare in England for a period of care prior to 1 April 2012. It is, however, possible to request that an English health authority undertake a retrospective review of eligibility for a period after 1 April 2012.

In Wales, the position is very different. The NHS will only retrospectively review a person’s eligibility for NHS continuing healthcare for a period of no longer than 12 months from the date that an application for a retrospective review was submitted to the local health authority. For example, if a person resided in care from January 2017, and you had registered a retrospective review with the local health authority in July 2018, the local health authority would only review that person’s eligibility for NHS continuing healthcare from July 2017.

It is therefore very important that, if you have a relative that resides in a care home in Wales, you take steps to register a retrospective review for NHS continuing healthcare with the local health authority as soon as possible. This is to ensure that your opportunity to retrospectively claim for NHS continuing healthcare for any particular period of care is not lost.

I live on the England/Wales border, how do I know whether my claim is an English claim or a Welsh claim?

Normally, the matter of whether a claim is English or Welsh is very straightforward. It is based on residence, therefore if a person’s care home is located in England; their claim is an English claim. This is known as the ‘residence’ rule.

However, when a person resides near the England/Wales border, the residence rule does not apply and whether a claim is English or Welsh depends on where that person’s GP is located. For example, we have had cases where a person has resided in England, but their GP is in Wales. These cases are to be considered by the Local Health Board in Wales, as the person’s GP was located in Wales.

Conclusion

The Nursing Care team has vast experience of registering retrospective claims with the appropriate health authority. If you think you may have wrongly paid care fees, call the Hugh James Nursing Care Team today for a free initial assessment or click here for more information and to complete an enquiry form.

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