Introduction

The Nursing Homes Support Scheme, also known as the “Fair Deal”, provides financial support to people who need long-term nursing home care. The scheme is operated by the Health Service Executive (HSE).

Under this scheme, you make a contribution towards the cost of your care and the State pays the balance. The scheme covers approved private nursing homes, voluntary nursing homes and public nursing homes. You can get the list of approved nursing homes from the HSE – see Where to Apply.

Anyone who is ordinarily resident in the State and is assessed as needing long-term nursing home care can apply for the scheme.

When you apply for the scheme your care needs are assessed to confirm that long-term nursing home care is the most appropriate option for you.

Your financial situation is also assessed to see how much you will have to contribute towards your nursing home fees. If your contribution is less than the amount of the fees, the HSE will pay the rest.

Assets, such as savings and property, are taken into account when assessing your financial situation. You can apply for the Nursing Home Loan if you want to defer making the part of your contribution that is based on your home or other property.

Nursing Home Subvention
This subvention has been replaced by the Nursing Homes Support Scheme. The Nursing Home Subvention scheme closed on 27 October 2009. If you were getting a subvention on that date, you can choose to continue to receive it or you can move to the Nursing Homes Support Scheme.

What is covered by the NHSS

The scheme covers long-term nursing home care only. It does not cover short-term care such as respite, convalescent care or day care although these types of services may be provided in some nursing homes.

The Act defines “long-term residential care services” as maintenance, health and personal care services. The Department of Health has further clarified that this includes: bed and board, nursing and personal care appropriate to the level of care needs of the person, laundry service, and basic aids and appliances necessary to assist a person with the activities of daily living.

Other goods and services may be available under schemes such as the Medical Card or Drugs Payment Scheme.

There is a set level of funding for the scheme each year, so there may be situations where a person’s name must go onto a waiting list until funding becomes available. If this is the case the HSE will let you know when it writes to advise you whether you are eligible for State support.

Moving from hospital care to long-term care

If you are in hospital, but no longer need acute care, then you can be charged for long-term care in that hospital. If, for example, you are waiting to move to long-term care, then you should apply for the NHSS scheme as soon as possible.

Rules

 You must apply to the HSE on the standard application form.

There are 3 steps in the application process:

• Step 1 is an application for a Care Needs Assessment – see below. The Care Needs Assessment identifies whether or not you need long-term nursing home care, that is, whether you can be supported to continue living at home or whether long-term nursing home care is more appropriate.
• Step 2 is an application for State support – see below. The information that you give will be used to complete the Financial Assessment – see below – which decides how much you contribute to your care and how much State support you get. The Financial Assessment looks at your income and assets in order to work out what your contribution to the cost of your care will be. The HSE will then pay the balance of your cost of care. This payment by the HSE is called State support.

All applicants must complete Steps 1 and 2.

• Step 3 is an optional application for the Nursing Home Loan, that is, if you want to defer paying the part of your contribution which is based on your home or other property.

The application form should be completed and signed by the person who is applying for nursing home care. However, in certain cases, another person, called a Specified Person may apply on their behalf (see below).

Care Needs Assessment

The Care Needs Assessment will be carried out by appropriate healthcare professionals appointed by the HSE, for example, a nurse. It can be completed at any time in a hospital or a community setting such as your own home and may involve a physical examination.

The assessment will take into account:

• Your ability to carry out the activities of daily living, for example, bathing, shopping,dressing and moving around
• The medical, health and personal social services being provided to you or available to you both at the time of the carrying out of the assessment and generally
• The family and community support available to you
• Your wishes and preferences

When the Care Needs Assessment has been completed a report will be prepared. Based on the report, the HSE must decide whether or not long-term nursing home care is the most appropriate option. Once a decision is made, you will be notified in writing within 10 working days. You will be given a copy of the report and the reasons for the decision.

You must be assessed as needing nursing home care in order to be eligible for either State support or the Nursing Home Loan.

The HSE may use the Care Needs Assessment to identify other health or personal social service needs. However, there is no legal requirement for them to provide the services identified.

Financial Assessment

The Financial Assessment looks at your income and assets in order to work out what your contribution to care will be. The HSE will then pay the balance of your cost of care. For example, if the cost of your care was €1,000 and your weekly contribution was €300, the HSE will pay the weekly balance of €700. This payment by the HSE is called State support.

The Financial Assessment looks at all of your income and assets.

In the case of a member of a couple, the assessment will be based on half of the couple’s combined income and assets.

Income and assets 
Income includes any earnings, pension income, social welfare benefits or allowances, rental income, income from holding an office or directorship, income from fees, commissions, dividends or interest, or any income which you have deprived yourself of in the 5 years leading up to your application.

An asset is any material property or wealth, including property or wealth outside of the State. Assets are divided into two distinct categories, namely cash assets and relevant assets.

Cash assets include savings, stocks, shares and securities. Relevant assets include all forms of property other than cash assets, for example a person’s principal residence or land. In both cases, the assessment will also look at assets that you have deprived yourself of since applying for State support or in the 5 years before the application.

The assessment will not take into account the income of other relatives such as your children.

Your contribution to care

Having looked at your income and assets, the Financial Assessment will work out your contribution to care. You will contribute:

• 80% of your income (less deductions below) and
• 5% of the value of any assets per annum (5% if the application was made before 25 July 2013)

However, the first €36,000 of your assets, or €72,000 for a couple, will not be counted at all in the Financial Assessment.

Where your assets include land and property, the 7.5% contribution based on such assets may be deferred and paid to Revenue after your death. This is known as the Nursing Home Loan. You can read more about the repayment of the Nursing Home Loan in the FAQs on the Nursing Homes Support Scheme (pdf).

Your principal residence will only be included in the financial assessment for the first 3 years of your time in care. This is known as the 22.5% or ‘three-year cap’ (the cap is 15% for applications made before 25 July 2013). It means that you will pay a 7.5% contribution based on your principal residence for a maximum of 3 years regardless of the length of time you spend in nursing home care.

In the case of a couple, the contribution based on the principal residence will be capped at 11.25% (7.5% for applications before 25 July 2013) where one partner remains in the home while the other enters long-term nursing home care, that is, the ‘three-year cap’ applies. If you opt for the Nursing Home Loan in respect of your principal residence, your spouse or partner can also apply to have the repayment of the Loan deferred for their lifetime

If you have already been in a nursing home for 3 years when you apply for the scheme, then you do not pay the 7.5% on your principal residence.

After 3 years, even if you are still getting long-term nursing home care, you will not pay any further contribution based on the principal residence. This ‘three-year cap’ applies regardless of whether you choose to opt for the Nursing Home Loan or not.

All other assets will be taken into account for as long as you are in care.

The ‘three-year cap’ also extends to farms and businesses in certain circumstances.

There are safeguards built in to the Financial Assessment which ensure that:

• Nobody will pay more than the actual cost of care
• You will keep a personal allowance of 20% of your income or 20% of the maximum rate of the State Pension (Non-Contributory), whichever is the greater
• If you have a spouse or partner remaining at home, they will be left with 50% of the couple’s income or the maximum rate of the State Pension (Non-Contributory), whichever is the greater

A couple is defined as a married couple who are living together. It also includes a heterosexual or same-sex couple who are cohabiting as life partners for at least 3 years.

Summary table for 7.5% yearly contribution re assets

Deductions 
In relation to income, the following deductions are allowed:

• Income tax, social insurance contributions and levies actually paid
• Where a person owns their principal residence, interest on loans for the purchase, repair or improvement of the principal residence
• Where a person rents their principal residence (i.e. is living in rented accommodation), rental payments in respect of the residence can be deducted where the person’s partner or a child aged under 21 of the couple lives in the residence
• Health expenses allowable for tax purposes, excluding contributions payable under the Nursing Homes Support Scheme
• Maintenance payments in respect of a child, spouse or former spouse made under a separation agreement or a court order

In the case of assets the net value of the asset is assessed, that is, its value minus any borrowings incurred specifically for the purchase or improvement of the asset.

Payment of your contribution

Public Nursing Home: You pay the assessed contribution to the HSE. 
Private Nursing Home: You pay the assessed contribution directly to the nursing home. The HSE pays the balance of the cost of care to the private nursing home.

Financial support will only be paid where a nursing home is identified as being appropriate to your needs. 

Existing nursing home residents

You will not be affected if you were already in a public nursing home or a HSE contract bed in a private nursing home before the Nursing Homes Support Scheme started. You can contribute to your care on the same basis as before.

If you were already in an approved private nursing home before the start of the scheme you can transfer to the Nursing Homes Support Scheme or keep your existing payment arrangements. If you have been resident in the nursing home for three years or more, the financial assessment will only be based on income and assets other than your principal residence (and your farm/business in certain circumstances), that is, the ‘three year’ cap will apply.

If your private nursing home is not approved for this scheme you can retain your current subvention arrangements or you can opt to apply for the scheme and change to a nursing home which is on the list.

If you were in an approved private nursing home before the start of the scheme, you do not need to apply for a Care Needs Assessment. You can commence the process by applying for the Financial Assessment.

How to apply

You can fill in the application form yourself, or ask someone else to help to fill it in. If a person has reduced mental capacity, then a Specified Person (see ‘Further information’ below) can apply on their behalf.

Applying on behalf of someone else 
If the applicant is not able to apply his/herself, a Specified Person can act on his/her behalf for Steps 1 and 2 of the application process.

Only a court appointed Care Representative (see ‘Further information’ below) can act on the applicant’s behalf for the Nursing Home Loan.

After you send in the application form 
When the Care Needs and Financial Assessments have been completed, the HSE will write to you and inform you of your contribution to care, and your eligibility for State support and the Nursing Home Loan (if applicable).

At this stage you will also be provided with the list of nursing homes that are participating in the scheme. This list will include public nursing homes, voluntary nursing homes and approved private nursing homes.

You may choose any nursing home from the list subject to the following conditions:

• The home must have a place for you.
• The home must be able to cater for your particular needs. The nursing home will have to carry out an assessment to determine whether it can meet your particular needs.

Your choice of nursing home is not connected in any way to the level of your contribution to care.

Payment by the HSE

Since 1 October 2011 the date of payment of State support and ancillary State support (nursing home loan) will be paid either from the date that the application is approved, or date of admission to the nursing home whichever is the later. (People who applied before 1 October 2011 received the payment from the date of application or the date of admission to the nursing home whichever was the later.)

The HSE is provided with a set level of funding for the scheme each year and applicants may be put on a national placement list until funding becomes available. If this is the case the HSE will notify you when it writes to advise you whether you are eligible for financial support. You will subsequently be notified by the HSE when you have been approved for financial support under the scheme.

Paying your contribution 
If you select a public or voluntary nursing home, you will pay your contribution to the HSE or voluntary nursing home as appropriate each week and the State will pay the balance on your behalf.

If you select an approved private nursing home, you will pay your contribution to the nursing home provider each week and the State will pay the balance on your behalf.

Where to apply

You can download an application form (pdf). They are also available from any health care setting in your area, including your Local Health Office and hospitals.

There is more information on the scheme provided online by the Department of Health and HSE. These information pages include links to download the following documents:

• Quick Guide on the Nursing Homes Support Scheme (pdf)
• Information Booklet on the Nursing Homes Support Scheme (pdf)
• FAQs on the Nursing Homes Support Scheme (pdf)

If you have any questions you can contact your local Nursing Homes Support Office or contact the HSE Infoline on Callsave 1850 24 1850 or on (041) 685 0300.

Appeals and reviews

Appeals: The HSE will inform you of the appeals process and provide details of your local Appeals Office when it writes to you to inform you of the outcome of your Care Needs and Financial Assessments.

If, for example, your Care Needs Assessment found that you did not need long-term nursing home care you can appeal the decision to your local Appeals Office.

Reviews: Any Care Needs Assessment can be reviewed six months after a previous assessment or earlier if either: 
• The HSE is satisfied that there has been a material change in your health or circumstances or 
• A registered medical practitioner states that in his/her opinion there has been a material change in your health or circumstances since your most recent care needs assessment

Reviews are carried out by your local Nursing Home Support Office and you should contact them if you want to have your Care Needs or Financial Assessment reviewed.

Once the HSE has made a decision regarding the review, you will be notified of the decision and the reasons for the decision, in writing, within 10 working days.

Further information

Role of the Specified Person

Where a person may need care, and because of ill-health, a physical disability or a mental condition, is unable to make an application for a care needs assessment, a specified person may apply for a care needs assessment on their behalf.

Where a person has reduced ability to make decisions (that is, diminished mental capacity), the specified person may also make the application for State support on their behalf.

A specified person is: 
A. If you are a ward of court, your Committee 
B. A person appointed under a valid, registered enduring power of attorney who is not restricted from applying for the scheme 
C. A Care Representative appointed under the Nursing Homes Support Scheme Act 2009 

D. Your spouse or partner, 
E. A relative of yours who is 18 years of age or over 
F. A ‘next friend’ appointed by a court 
G. Your legal representative, or 
H. A registered medical practitioner, nurse or social worker.

The people listed at A-C have first priority over those listed at D-H. This means that they have the right to act as a specified person ahead of the other categories. However, the people listed at A-C may consent in writing to a person with lesser priority acting as the specified person.

Where a person has reduced ability to make decisions and wishes to apply for the Nursing Home Loan, only the people listed at A-C above may make the application.

Nursing Home Loan

Where your assets include land and property, the contribution based on these may be deferred until after your death. If you are approved for the Nursing Home Loan, the HSE will pay the money to the nursing home on your behalf and it will be collected after your death.

In certain circumstances the payment may be deferred for a longer period, for example, if a spouse or partner or your former carer is still living in your principal private residence.

You can apply for the Loan when you first apply for the Nursing Homes Support Scheme or at any stage while resident in the nursing home.

In order to apply for the Nursing Home Loan you must provide written consent to having a Charging Order registered against your asset. If you are part of a couple, your spouse/partner must also provide written consent.

The Charging Order is a simple type of mortgage which secures the money loaned by the HSE.

Subject to your consent, the HSE is responsible for making the Charging Order, registering it against your asset and making Nursing Home Loan payments on your behalf. You will not need to do anything (although the HSE may need to check with you about the information in your application).

If a person does not have the capacity to consent to the Nursing Home Loan and the Charging Order, a Care Representative will need to be appointed to act on his/her behalf.

The legislation underpinning the Scheme sets out specific timeframes for repayment of the loan (depending on what has caused the repayment to arise). As long as the repayment is made within the specified timeframes (that is, 12 months where repayment arises because the person in the nursing home has passed away and 6 months if the property is sold or transferred), interest does not have to be paid. If, however, repayment is not made within the specified timeframes, interest applies and the HSE will apply the Consumer Price Index to the loan to take account of the time value of money (that is, inflation or deflation) since the loan was made. The Revenue Commissioners notify people in advance of the deadlines of the need to pay on time so as to avoid paying interest

For more information on repayment of the Nursing Home Loan, see FAQs on the Nursing Homes Support Scheme (pdf)

Care Representative

A Care Representative is only required where a person has reduced capacity to make certain decisions (that is, diminished mental capacity) and wishes to apply for the Nursing Home Loan.

The Care Representative is appointed by the Circuit Court. Their role is to act on behalf of the person in respect of the Nursing Homes Support Scheme and especially in respect of the Nursing Home Loan. They can also act on behalf ofthe person in relation to making an application for a Care Needs Assessment, State support, or any other matter relating to the scheme. The list of people who can apply to be a Care Representative is set out below.

Proof of diminished mental capacity 
A person is considered to be of diminished mental capacity if, in relation to a decision on applying for the Nursing Home Loan and consenting to the Charging Order, he or she is unable: 
A. To understand the information relevant to the decision 
B. To retain that information 
C. To use or weigh that information as part of the process of making the decision, or 
D. To communicate his or her decision (whether by talking, using sign language, communicating through a third party or any other means).

Two reports from two separate registered medical practitioners are required by the court as evidence that a person is of diminished mental capacity.

Persons who can apply for appointment as a Care Representative 
The following persons, in order of priority, may apply to be appointed as a Care Representative once they are 18 years of age or over: 
1. Your spouse/partner 
2. Your parent 
3. Your child 
4. Your brother or sister (whether a full or half sibling) 
5. Your niece or nephew 
6. Your grandchild 
7. Your grandparent 
8. Your aunt or uncle 
9. A person who appears to the court to have a good and sufficient interest in your welfare, other than the owner of a nursing home in which you reside or are likely to reside or a medical practitioner who examined you and prepared a report for the court in relation to your capacity.

Procedure for appointment as a Care Representative 
The application for appointment must be made to the County Registrar in any county in the Circuit in which the person requiring a Care Representative now lives or in which he/ she has lived at any time during the past three years.

You do not need to obtain legal representation in order to be appointed as a Care Representative. However, anyone who wishes to seek legal advice/representation is free to do so.

For more information on the legal procedure, see Information Booklet on the Nursing Homes Support Scheme (pdf.

Exemptions to requirement for appointment as a Care Representative 
A Care Representative is not needed in order to apply for the Nursing Home Loan in any of the following cases:

• Where the applicant is of full mental capacity
• Where the applicant is a Ward of Court (in such cases the Committee of the applicant may apply where he/she has been authorised to do so by the President of the High Court)
• Where a person is appointed under a valid, registered enduring power of attorney to act on behalf of the applicant and is not restricted by the terms of the power of attorney from applying for the Nursing Home Loan
• Where another person is already permitted by law to act on behalf of the applicant