Commonwealth of Massachusetts 

Executive Office of Health and Human Services 

Office of Medicaid 

600 Washington Street 

Boston, MA 02111 

www.mass.gov/masshealth 



 

 MassHealth 

 Long Term Care Facility Bulletin 100 

 June 2009 

 

 

 TO: Nursing Facilities, Chronic Disease and Rehabilitation Inpatient Hospitals, and 
Psychiatric Inpatient Hospitals Participating in MassHealth 

 

FROM: Tom Dehner, Medicaid Director 

 

 RE: Annual Accounting for Personal Needs Account Funds 

 

 

 



Background MassHealth requires that nursing facilities, chronic disease and 
rehabilitation inpatient hospitals, and psychiatric inpatient hospitals 
account for the balances of personal needs account (PNA) funds (see 
130 CMR 456.615). 

 

 

Deadline for PNA-1 To comply, providers must use the PNA-1 form. This form must be dated 

Submissions and signed by the administrator, under the pains and penalties of perjury, 

 and sent to the following address by June 1, 2009. 

 

Financial Compliance Unit 

529 Main Street, 3rd Floor 

Charlestown, MA 02129 

 

The PNA-1 seeks information about PNA funds managed by the provider, 
including: members’ names; members’ social security numbers; the 
amount of petty cash held in the facility for the members; the amount held 
in individual bank accounts for the members; the balance held in the 
trustee account for the members; information about any other money 
being held for the members by the facility; and bank account information 
for individual and trustee bank accounts as of January 31, 2009 
Additionally, copies of bank statements and a reconciliation of the trustee 
account (if one is used) must be attached to the PNA-1. 

 

The reconciled bank balance must agree with the total PNA balance on 
the PNA-1 form. 

 

 Providers using Microsoft software to maintain listings of patient balances 
may submit the files in electronic format to PNAreview@umassmed.edu. 

 The PNA-1 form can be downloaded from the MassHealth Web site at 
www.mass.gov/masshealthpubs. Click on Provider Library, then on 
MassHealth Provider Forms. 

 (continued on back) 

 



 

Deadline for PNA-1 If the provider does not handle PNA funds for any members, it must state 

Submissions this on the PNA-1. The form must then be dated and signed by the 

(cont.) administrator, and sent to the address listed in this bulletin. 

 

Providers may use their own reconciliation form or may use the PNA-2 
form included with this bulletin. This form is available online on the 
MassHealth Web site at www.mass.gov/masshealthpubs. Click on 
Provider Library, then on MassHealth Provider Forms. 

 

 

Deadlines If a provider does not submit the PNA-1 and, if applicable, the PNA-2 by 
and Penalties June 1, 2009, or if the forms are incomplete and not reconciled to the 

 bank statement, the provider may be subject to administrative sanction. 

 

 A copy of the PNA-1 and the PNA-2 are attached to this bulletin. These 
forms may be photocopied as needed. 

 

 

Questions If you have any questions about the information in this bulletin, please call 
the MassHealth Financial Compliance Unit at 617-886-8129. 

 

 



 
MassHealth
Commonwealth of Massachusetts • EOHHS
www.mass.gov/masshealth

Statement of MassHealth Members' 
Personal Needs Account Funds

Commonwealth of Massachusetts • Executive Office of Health and Human Services • Office of Medicaid

Name of Facility		Provider Number/NPI
Address	 			Business Phone No.
City/Town	State	Zip	Business Fax No.

I hereby certify under the pains and penalties of perjury that the information in this 
report and any attachments hereto is true and correct to the best of my knowledge and belief.

Prepared by (please print)	Signature	Date
Prepared by (please print)	Signature	Date

Please check here if you do not maintain PNA accounts for MassHealth members.

THE FOLLOWING INFORMATION IS REQUIRED IN ADDITION 
TO A COMPLETED PNA-1.

1.	A listing of all MassHealth members whose PNA funds are 
	managed by the facility.
This must include:
	Member name (first and last);
	Social security number;
	Account balance as of January 31, 2009;
	Bank book number or aggregate trustee bank
	account number.

2.	A COPY of the aggregate trustee bank statement or individual 
	member account statements as of January 31, 2009. 
	(Only bank issued statements will be accepted.)

3.	An account reconciliation. If individual accounts are held 
	for members, an account reconciliation is not necessary.

Please submit the patient balances in one of the following 
formats. (Circle your choice.)

1.	3˝" disk
2.	CD
3.	Electronic files—e-mail to: 
	PNAReview@umassmed.edu
4.	Handwritten on the enclosed PNA-2 form


COMPLETE THIS SECTION
Total number of MassHealth members listed:
List should NOT include private patients.

__ __ __
         
Total PNA balance of MassHealth members
Total PNA balance should equal the reconciled bank balance.

$__ __ __ , __ __ __ . __ __
         
Date of PNA balance:	
Date of bank statement: 
Name of bank(s):

Return to: Financial Compliance Unit • 529 Main Street, 3rd Floor • Charlestown, MA 02129

PNA-1 (Rev. 04/09)	






MassHealth
Commonwealth of Massachusetts • EOHHS
www.mass.gov/masshealth

Bank Reconciliation for MassHealth Members' 
Personal Needs Account Funds 
as of January 31, 2009

BALANCE PER BANK AS OF JANUARY 31, 2009: $__ __ __ , __ __ __ . __ __         

ADD DEPOSITS IN TRANSIT  (+)
Date	Amount
	
	
	
	
TOTAL DEPOSITS IN TRANSIT: $__ __ __ , __ __ __ . __ __         
          
DEDUCT OUTSTANDING CHECKS  ( - )
Date	Check Number	Amount	Date	Check Number	Amount
					
					
					
					
TOTAL OUTSTANDING CHECKS: $__ __ __ , __ __ __ . __ __         
          
ADD/DEDUCT OTHER RECONCILING ITEMS
Description	Amount	

Please indicate any funds that are held in the listed 
bank account(s) other than those for MassHealth 
members. For example, if any money is held for private 
patients, please indicate this amount, as well as any 
cash on hand, interest, service charges, etc. that may 
affect the account balance. The reconciled bank 
balance must equal the total PNA balance as 
stated on the PNA-1.
		
		
		
		
TOTAL OTHER RECONCILING ITEMS: $__ __ __ , __ __ __ . __ __         
     
ENDING BALANCE: $__ __ __ , __ __ __ . __ __         
      
The reconciled bank balance must equal the total PNA balance as stated on the PNA-1.

Return to: Financial Compliance Unit • 529 Main Street, 3rd Floor • Charlestown, MA 02129

PNA-2 (Rev. 04/09)



Listing of MassHealth Members' Personal Needs Account Funds as of JANUARY 31, 2009

MassHealth Member's Name	Social Security Number	PNA Balance	Bank Book No. and/or 
									Aggregate Trustee Bank 
									Account No.

Total This Page $

Return to: Financial Compliance Unit • 529 Main Street, 3rd Floor • Charlestown, MA 02129