17 18 19 20 23 24 25 26 27 30 31 1 2 3 Continuing NHS Healthcare. Retrospective Claims for Reimbursement Frequently Asked Questions August 2016
What is Continuing NHS Healthcare and how do I know if I, or the person I care for, might be eligible? Continuing NHS Healthcare (CHC) is the name given to one or more services arranged and funded solely by the NHS for people who have been assessed as having a primary health need. You can receive CHC in any setting including your own home or in a care home. In your own home, this means the NHS will pay for healthcare (for example, services from a community nurse or specialist therapist) and personal care (such as help to wash and dress), but this does not include the costs of: food accommodation or general household support. In a care home, if you are eligible for CHC, the NHS pays for your care home fees in total. CHC is funded by the NHS, unlike the help from social services for which a charge may be made depending on your income, savings and capital assets. If assessments by a range of professionals show that your primary need, or the person you care for, is a health need then you/they should be eligible for CHC. It does not depend on an individual s particular condition, disease or diagnosis, or on who provides the care, or where it is provided. People can require a lot of help and support as a result of an illness or condition, but may not be assessed as having a primary health need. For more information on CHC please see the public information leaflet, which you can find on the Welsh Government website; www.gov.wales/topics/health/nhswales/healthservice/chcframework/?lang=en Alternatively please contact your Health Board (HB) for a copy. For details on Health Boards go to: www.wales.nhs.uk/directory.cfm
I/my relative live in a care home. Should I/they have been assessed for CHC already? Welsh Government guidance expects anyone requiring long-term care to have had a thorough assessment of their needs. If they require care in a nursing home, CHC should be ruled out before NHS funded nursing care is granted. This is where nursing homes employ registered nurses to provide nursing care to those who need it. NHS funded nursing care is the payment the NHS makes towards these costs. You should have been involved in the assessment and have been informed in writing of the outcome. Whilst the NHS will do what it can to get it right first time, there may be occasions where people slip through the net. If you are unsure, contact your HB and ask. How will I be assessed? The assessment of any individual for CHC is based on their health and social care needs and their desired outcomes needs. To aid this, practitioners use a Decision Support Tool (DST). It does not form part of the assessment in itself; the final assessment is based on a rounded and holistic assessment of the individual rather than DST scores in isolation. The DST notes personal information about the patient and records the recommendation of the assessor(s) and the evidence to support that judgement. This evidence is set out under 12 areas of need or care domains. At the end of the DST, there is a summary sheet which provides an overview of the levels chosen and a summary of the person s needs, along with the final recommendation about eligibility. The assessor must complete all of the DST and collate this to ensure the CHC process and the outcomes can be easily identified through a clear audit trail. A copy should be forwarded to the individual (or, where appropriate, their representative) together with the final decision made by the HB, along with the reasons for this decision.
For further information on the Decision Support Tool, please visit the Complex Care and Information Support Site or contact your local health board. Details are given at the end of this leaflet. Under what circumstances can I make a claim for retrospective reimbursement? An individual or their representative may request a retrospective review where they have contributed to the costs of their care, but have reason to believe that they may have met the eligibility criteria for CHC which were applicable at the time. A retrospective review claim is different from an appeal against a current CHC assessment and decision on eligibility. How do I make a claim? If you think you may be entitled to make a claim contact your HB. Details at the end of leaflet. They will send you the Claimant Information Leaflet, which sets out the process and asks you for some basic information. If you are a representative you must be able to provide evidence of your right to make the claim, such as Power of Attorney, or if the person is no longer alive, Grant of Probate. All claimants are also required to present evidence of fees paid to the care home or domiciliary agency. Do I need a solicitor? This is not a legal process and there is no requirement to appoint a solicitor. The NHS will complete all of the work required to review a case free of charge. If you decide to engage a solicitor to represent you, any legal costs will not be reimbursed. Do I have to apply within a certain timescale? Yes. Welsh Government has previously publicised cut-off dates for retrospective reviews and its latest guidance sets an annual rolling cut off date for applications.
The timescales for submitting applications and for the NHS to respond are set out in the table below: Summary Table CHC Retrospective Reviews Cut-off dates and Timescales Claim Period 1 April 2003 to 31 July 2013 1 August 2013 to 30 September 2014 From 1 October 2014 Intent to Claim to be submitted by: 31 July 2014 2 years 31 October 2015 1 year Claim period to be considered will be no longer than 12 months back from the date of application for review. Case to be reviewed within: 6 months The timescale for reviewing the case commences from the date on which the HB sends you a letter confirming that you have the authority to claim and that you have provided sufficient proof of payment. How much time am I allowed to provide evidence of my authority to claim and proof of payment? When you request a retrospective review, the HB managing your claim will write to you within 6 weeks requesting that you provide this information and the completed application form. If you are experiencing problems accessing any of the evidence asked for, it is important that you contact the HB and let them know. They will decide if it is appropriate to grant an extension. If they don t hear from you, they will assume that you are unable to provide the required information or no longer wish to pursue the application, and will close the case.
My personal circumstances mean that I need my claim to be reviewed more quickly. What can I do? In order to ensure fairness, claims will normally be dealt with in date order (the date on which they are submitted). The HB will only consider prioritising cases where the claimant can demonstrate extenuating circumstances such as severe financial hardship or diagnosis of a terminal illness. If you believe extenuating circumstances apply in your case, please let your HB know. Is there anyone who can help me with the process? The NHS is working to make the process as easy as possible for claimants. However, if you do feel that you need some support there are advocacy agencies who can provide this free of charge. Please note that these agencies are different from those who may advertise themselves as claims agencies. Claims agencies will usually charge for their services. For further information For further information please contact your HB or see the following links to the Welsh Government website in English and Welsh. www.gov.wales/topics/health/nhswales/healthservice/chcframework/?lang=en www.gov.wales/topics/health/nhswales/healthservice/chcframework/?lang=cy Alternatively please see the Complex Care Information and Support Site www.cciss.org.uk www.gcsgc.org.uk
Aneurin Bevan Complex Care Cwmbran House Mamhilad Park Estate Pontypool IRP Administrator 01495 332173 Business & Performance Manager 01495 332358 Abertawe Bro Morgannwg University Health Board Retrospective Claims Administrator Long Term Care Team Block A, Neath Port Talbot Hospital Baglan Way Port Talbot SA12 7BX Tel: 01639 684561 Betsi Cadwaladr Keeley McKenna Retrospective CHC Review Office The Old Creche Building Ysbyty Glan Clwyd Rhyl Denbighshire LL18 5UJ Cardiff and Vale Retrospective Continuing Care South East Locality Cardiff Royal Infirmary Glossop Terrace Cardiff CF24 0SZ
Cwm Taf Geraldine Thomas Registered Nurse Reviewer Cwm Taf Local Health Board Headquarters Ynysmeurig House Unit 3 Navigation Park Abercynon Rhondda Cynon Taf CF45 4SN Hywel Dda Aldyth King Long Term Care Administrator (Carmarthenshire Locality) Hywel Dda University Health Board Block 6 Prince Philip Hospital Bryngwynmawr, Dafen Llanelli SA14 8QF Powys Complex Care c/o Hafren Ward Bronllys Hospital Bronllys Brecon Powys LD3 0LS Mae r ddogfen yma hefyd ar gael yn Gymraeg. This document is also available in Welsh. Crown copyright 2016 WG29058 Digital ISBN 978-1-4734-7322-5 Print ISBN 978-1-4734-7332-4