Are you eligible for NHS Continuing Healthcare?

If you demonstrate a primary health need then the NHS must pay for your care in full under the Continuing Healthcare scheme, regardless of your personal wealth. However proving and gaining eligibility can be difficult. To qualify, you must demonstrate your needs are:

  • Complex, intense or unpredictable;
  • Not incidental or ancillary to the accommodation your local authority is under a duty to provide; and
  • Not of a nature typically provided for by a social services department.

Therefore, if someone is in a nursing or care home because of physical or mental health needs they may be paying fees that should be funded by the NHS.

To claim retrospective eligibility, we need to show that an individual’s health and nursing care needs were more than what a social services department could provide. If that’s the case, then their primary need would be for health and they would have been entitled to full NHS funding.

The test for eligibility

There are two key stages when applying for NHS Continuing Healthcare eligibility:

  1. Checklist assessment:
    This is a screening tool which determines whether an individual’s needs warrant completing the Decision Support Tool.
  2. Completion of a Decision Support Tool (DST):
    This is an assessment tool which is conducted to investigate whether an individual’s needs are primarily healthcare needs that would qualify for NHS Continuing Healthcare. The assessment looks at the full range of care needs, but focuses on 12 care domains which include cognition, behaviour, nutrition and mobility.
    As part of the DST, the individual in question will be given a level of need in each of the 12 care domains. There are six levels, ranging from no needs to priority.

If a patient’s level of need is assessed as being priority in any area, eligibility for full funding is automatic (however you should note that the priority level of need is only applicable to four of the care domains – behaviour, breathing, medication and altered states of consciousness). If a patient’s level of need is assessed as being severe in any two areas, eligibility for full funding is also automatic.

It is still possible to be found eligible without a priority or two severe measurements, however the rules are open to interpretation. However the higher the level of need, the more likely it is that an individual will be found eligible for NHS Continuing healthcare.

What if you are not eligible for NHS Continuing Healthcare?

It is the local authority (social services), rather than the NHS who are responsible for care if you are found not eligible for NHS Continuing Healthcare. Unlike the NHS, social services are able to assess the individual’s ability to pay. This will mean that they will conduct a financial assessment.

There is an upper and lower capital limit. This means that if a person has savings which amount to more than the upper capital limit, they will have to pay the full cost of their care home placement until their savings reduce to that limit. If an individual has savings which are worth less than the lower capital limit, then a local authority social services department will fund the cost of care. A person who is in between the capital limits will have to make a contribution to their care costs on a tariff rate depending on how much they exceed the minimum.

Your savings include any money in bank and building society accounts, stocks and shares, and property (land and buildings). Any joint ownership is counted according to that person’s share.

The capital limits are different in England and Wales. Please check the Government website to find the capital limits where you live.

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