Nursing Home Support
Fair Deal
The Nursing Home Support Scheme is commonly referred to as Fair Deal. It provides financial support for persons in need of long-term nursing home care. The Scheme is administered by the Health Service Executive.
The Scheme covers care in private nursing homes, public nursing homes and voluntary nursing homes. There is a list of approved nursing homes published by the HSE. Under the Scheme, a resident must make a contribution to their own costs and the Scheme covers the balance.
The Nursing Home Support Scheme covers long-term support only. It does not cover convalescence and short-term stays.
Long-term residential care services are maintenance care and personal services. This includes bed and board, nursing and personal care, laundry service, basic aid and appliances necessary for assistance with daily living activities. The person would continue to be entitled to a medical card if he otherwise qualified.
The Nursing Home
A person may apply for any nursing home on the approved list provided it has a place and can cater for the applicant’s needs.
In a public or voluntary nursing home, the applicant pays a contribution to the HSE, and the State pays the balance.
The Nursing Home Support Scheme replaced the prior nursing home subvention in 2009. Existing recipients may be entitled to continue to receive the nursing home’s subventions.
Application
The application under the Scheme commences with a care-needs assessment. This involves an assessment as to whether the person can continue to live at home or whether long-term nursing home care is required.
An application for financial assistance under the Scheme would consider the applicant’s assets and income. Based on the rules of the Scheme, this is determined by the level of contribution required. The HSE pays the balance.
The element of assessed contribution is based on the value of the applicant’s home and may be deferred. The application may be made by the applicant or by a person on his or her behalf.
Needs
The Subvention requires that the person is sufficiently dependent, requires maintenance in a nursing home and is unable to pay the costs from his means. An assessment of dependency was undertaken by HSE doctors, occupational therapists, and physiotherapists. The ability to undertake tasks of daily living was assessed.
Consideration is given to
- the person’s social support, including housing conditions,
- the ability of household members to care for the person,
- the extent of support from the community and
- services being received.
Care Needs Assessment
The care-needs assessment is carried out by appropriate health professionals appointed by the HSE. This may be completed in the hospital or in the community setting by a nurse. The assessment involves consideration of
- the ability to deal with the activities of daily living, such as bathing, shopping, dressing, and moving around.
- medical and social services provided or available.
- family and community support available.
- wishes and preferences.
The HSE determines the requirement for long-term nursing home care based on the assessment. The assessment may identify other health or personal social service needs.
There is an appeal process if the applicant is unsatisfied with the care-needs assessment or the financial assessment. Care-needs assessments may be reviewed after six months if there is a material change in the circumstances or a registered doctor states that in his opinion that there has been a material change in health and circumstances. The Nursing Home Support Office undertakes the review.
Financial Assessment
The financial assessment considers income and assets. In the case of a married couple,e half of the means is assessed.
Income includes all income, earnings, pensions, social welfare benefits, allowances, profits, rents and other income. It also assesses income deprived of or alienated in the previous five years.
Cash and “relevant assets” are considered. They include all property, including a principal private dwelling house. The income of children and relatives is not assessed.
Assets which are charged are assessed at their net asset value. Deductible borrowings must be attributable to a purchase or improvement.
Contributions
The contribution is 80 percent of income less deductions and 5 percent of asset value. The first €36,000 of assets (€ 72,000 for a couple are disregarded.) In the case of land and property, the five percent contribution may be deferred and paid on death to Revenue. This is deemed a nursing home loan.
The principal residence is included in the assessment for the first three years of care only. This is a maximum of 22.5 percent or 5 percent per annum. This applies regardless of the length of time which the person stays in the nursing home.
The contribution is limited to 7.5 percent where the other partner remains in the home. In the case of a couple, the spouse can defer payment for his or her lifetime.
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 the applicant opts for the Nursing Home Loan in respect of his or her principal residence, his or her spouse or partner can also apply to have the repayment of the Loan deferred for their lifetime.
Once the person has resided for three years, the five per cent of the residence contribution is not payable. The three-year cap applies irrespective of whether the nursing home loan is applied for or not. It also applies to certain farms and businesses. The legislation provides that nobody must pay more than the actual cost of care.
The 2024 Act amends the definition of those eligible to be considered as a ‘family successor’ to a family farm or productive business assets to include cousins, great- nephews and great-nieces, and great-grandchildren. Under the Nursing Home Support Scheme (Amendment) Act 2021, contributions from these farm and business assets can be capped after 3 years in care on the condition that a ‘family successor’ is appointed who continues to run the farm or business for a period of time.
Income
The applicant is allowed to keep an allowance of 20 percent of income or 20 percent of the maximum rate of state non-contributory pension, whichever is higher. The spouse or partner remaining in the home is left with 50 percent of the income or the maximum rate of state pension non-contributory, whichever is greater.
A couple includes a married couple living together and persons cohabiting, including heterosexual and same-sex couples who have lived together for at least three years as life partners.
Deductions are allowable from income, including
- tax, social insurance contributions, and levies paid.
- Interest on home loans and the loans for repair and improvement of residence
- rental payment where the person’s partner or child under 21 lives in the residence.
- health expenses which are allowed for tax purposes.
- maintenance payments.
Representative
Where a person may need care but is unable to do so, a specified person may make the application. Where the person is a ward of court, it may be the Committee.
It may be the person appointed under an enduring power of attorney. A representative may be appointed under the Nursing Home Support Scheme Act 2009 who may be a spouse, relative, next friend, or registered medical practitioner/doctor. More closely related persons have priority over others.
The application for the nursing home loan is made at the same time as the Nursing Home Support Scheme application. It may be later.
Care Representative
A care representative must be appointed by the Circuit Courts where it is necessary to apply for the nursing home loan in circumstances where the person does not have mental capacity.
A person has diminished mental capacity if he is unable to understand information relative to this decision. Retain, use and weigh it and communicate his decision. Opinions of two separate registered medical practitioners are required as evidence of diminished mental capacity. The persons who may be appointed are broadly relatives in order of priority as above.
A care representative is not required where a person has been made a ward of court because the person lacks mental capacity or where there is a valid enduring power.
Scheme Payment Disregarded
Health (Miscellaneous Provisions) Act 2017 amended the Nursing Homes Support Scheme Act 2009 in order to exclude certain ex-gratia payments which have been, or will in the future be made to individuals under specific schemes approved by the Government, for the purpose of assessment of means under the Nursing Homes Support Scheme Act 2009; Otherwise, medical card patients would have had no way to access such products without charge (other than the prescription charge);
The Health (Miscellaneous Provisions) Act 2017 gave regulation-making power to the Minister to allow for an exemption for other similar groups that may receive ex-gratia payments from being taken into consideration for support under the Nursing Homes Support Scheme (Fair Deal), provided such schemes have been approved by Government.
A person should not be disadvantaged because of acceptance of an award under these Schemes. Applications under Fair Deal are means tested, and the individuals or their partners could be over the income threshold for availing of the Nursing Homes Support Scheme (NHSS) support because of their ex-gratia awards. The Health (Miscellaneous Provisions) Act 2017 does not give access to free nursing home care to the various groups, but it will merely mean that the awards/payments they receive are ignored for the purpose of assessment under the NHSS.
Older Subvention
The Nursing Home Subvention Scheme applied until 2009 and is closed to new applicants. It is designed to assist persons with nursing home costs. The maximum payment was €300, which may be increased in certain cases. 2007 rules deal with the Nursing Home Subvention.
If the person’s means were less than the weekly rate of a non-contributory pension, the HSE may pay additional amounts. It is the only income if the non-contributory pension means are assessed at a sum equivalent to 4/5th of the state pension.
The HSE may pay the full costs of a private nursing home in some cases. Enhanced payments may be paid in respect of contracted beds in private nursing homes. There is no entitlement to enhanced subvention, and it is discretionary.
A person assessed for a subvention is generally entitled to keep a sum equivalent to 1/5th or the state non-contributory pension.
An eligible person could be offered a place in a private nursing home or HSE institution. Payments could be reassessed if there is a change in means and circumstances.
Older Subvention Means Test
The means test described here applies only to people who continued on the subvention scheme after the Nursing Home Support Scheme was introduced on 27 October 2009. It takes into account your and your spouse’s (or partner’s) income. It may also take account of your assets (but not those of a spouse or partner). Assets in joint names are assessed proportionately.
All income was assessed. The assessed means must take into account the income of the spouse. It took account of assets, including joint assets.
Assets were taken into account, including assets disposed of within five years. The first €11,000 was disregarded. The principal private residence is not taken into account if occupied before the application and continues to be used by spouse, children or persons in receipt of certain disability illnesses, pensions, etc.
The notional income is based on five per cent of the market value, net of mortgages. If the house is sold, the proceeds are taken into account. This differs from the general means test position for social welfare.
The HSE might refuse to pay subvention if the residence was valued at more than €500,000 in Dublin or €365,000 in the rest of the country. When the income is greater than the State Non-Contributory pension or if the value of assets exceeds €36,000.
Under the Nursing Home Support Scheme (Amendment) Act 2021 contributions from these farm and business assets can be capped after 3 years in care, on the condition that a ‘family successor’ is appointed who continues to run the farm or business for a period of time.