Commonwealth of Massachusetts
Executive Office of Health and Human Services
Division of Medical Assistance
600 Washington Street
Boston, MA  02111
www.mass.gov/dma	
	MassHealth
	Dental Bulletin 27
	July 2002

	TO:	Dental Providers Participating in MassHealth

	FROM:	Wendy E. Warring, Commissioner

	RE:	Patient-Paid-Amount (PPA) Adjustment for Residents of Long-Term-Care Facilities for Adult Dental Expenses Not Covered by MassHealth as of 
March 15, 2002

Background	Recently, the Division sent dental providers notification and two informational packets about the restructuring of the MassHealth adult dental program, which affects members aged 21 and older.  Effective March 15, 2002, MassHealth eliminated coverage for certain adult dental services, unless the member is designated under “Special Circumstances,” as described in the Division’s dental regulations at 130 CMR 420.410(D).  Because of these changes, the Division has received several inquiries from nursing facilities, including requests for adjustment to the patient-paid-amount (PPA) for members residing in LTC facilities who incur dental expenses for non-covered services.

The purpose of this memo is to clarify the Division’s existing procedures for reduction of the member’s PPA.  Please note that it is not lawful to resort first to an adjustment to the PPA for dental services available to MassHealth members if there is a possibility that the member could qualify for Special Circumstances designation.  These procedures allow the member to temporarily retain income, where possible, in an amount equal to the cost of the non-covered dental services, to cover these incurred costs.

Rules for Accepting	For consideration in determining the PPA, these adult dental expenses:
Incurred Adult Dental	
Expenses		    must not be covered by MassHealth (if a member is 
		designated as SC, the member is eligible for certain dental 
		services not otherwise covered for members aged 21 and older);
•	must not be payable by any other health insurance or other liable third party coverage;

	

Rules for Accepting 	    must be the responsibility of the member;
Incurred Adult Dental	    must not be incurred for adult dental services rendered prior to 
Expenses	March 15, 2002 that were covered by MassHealth prior to March 
(cont.)	15, 2002;
	    must not have been used to become eligible for MassHealth under 
130 CMR 520.004 (asset reduction) or 520.032 (income deductible); and
	    must be submitted to the MassHealth Enrollment Center (MEC)
on a legible unpaid bill, or a paid receipt, from the dental provider for the service.  Paid bills may be used to adjust the PPA only if paid by the member.  Documentation must include:
o	name and address of the MassHealth member;
o	name and address of the dental provider;
o	description (name) of the service provided;
o	cost of the service provided; and
o	date the service was provided to the member.

The dental provider must ensure that all other avenues of payment for the service have been exhausted, including:
•	the dental provider made a clinical determination that the member may meet the criteria for SC designation, but the provider’s request to the Division for SC designation was denied by the Division; or
•	the dental provider made a clinical determination that the member would not qualify for SC designation; and
•	the member has no available insurance coverage or other liable third party coverage for the service.

Related Documents	In addition, providers should pay special attention to the following
Available on the	Division regulations, which are available on the DMA Web site:
DMA Web Site	
Transmittal Letter DEN-59:  Revisions to the MassHealth Dental Program
(www.mass.gov/dma/providers/dental/TL_dental.pdf)

Dental Manual: 130 CMR 420.000 Program Regulations
(www.mass.gov/dma/providers/regulations/regs_dental.pdf)

Dental Bulletin 26:  Important Information About Special Circumstances and Dental Group Practices
(www.mass.gov/dma/providers/bulletins/bull_2002_pdf/DEN-26.pdf)

All Provider Manual: 130 CMR 450.203-Payment in Full
(www.mass.gov/dma/providers/regulations/regs_allprovider.pdf)

Questions	For questions about MassHealth claims, please contact MassHealth Provider Services at 617-628-4141 or 1-800-325-5231.