Commonwealth of Massachusetts 

Executive Office of Health and Human Services 

Office of Medicaid 

www.mass.gov/masshealth 



 MassHealth 

 Long Term Care Facility Bulletin 102 

 October 2010 

 

 

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

 

FROM: Terence G. Dougherty, Medicaid Director 

 

 RE: Patient-Paid-Amount Adjustments for MassHealth Members in Nursing Facilities, 
Chronic Disease and Rehabilitation Inpatient Hospitals, and Psychiatric Inpatient 
Hospitals, Including Adjustments for Adult Dental Expenses Not Covered by 
MassHealth as of July 1, 2010 

 

 



Background The purpose of this bulletin is to provide clarification on MassHealth’s 
existing procedures for adjustment of the member’s patient-paid amount 
(PPA). The PPA adjustment procedures allow a member receiving 
services in certain long term care facility settings to account for the cost of 
incurred noncovered expenses, including adult dental services, in 
computing the member’s contribution to the costs of care. These rules 
apply to members who are residing in nursing facilities or who are 
inpatients in chronic disease and rehabilitation (CDR) hospitals or 
psychiatric hospitals. 

 

Effective July 1, 2010, MassHealth eliminated coverage for certain adult 
dental services for certain MassHealth members aged 21 and older. 
Information about these changes can be found in MassHealth regulation 
130 CMR 420.000, and in MassHealth Transmittal Letter DEN-84, dated 
July 2010. 

 

As a result of these changes, the member’s adult dental expenses for 
services that are no longer covered by MassHealth may be allowed as a 
deduction in determining the member’s PPA. The reduction to the PPA is 
made prospectively. Expenses incurred for adult dental services provided 
before July 1, 2010, may not be allowed as a deduction in determining the 
member’s PPA. 

 

 

Prospective MassHealth’s regulations at 130 CMR 520.026(E)(2) specify that 

Adjustment to the a deduction for a member’s necessary medical or remedial-care 

Patient-Paid Amount expenses may be applied in determining a member’s financial eligibility, 
including any patient-paid amount. To be counted as a deduction, 
necessary medical or remedial-care expenses must be for services not 
payable by a third party and not covered by MassHealth. 

 

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Prospective Additionally, a member’s necessary medical or remedial-care 
Adjustment to the expenses must 

Patient-Paid Amount 

(cont.) • not be covered by the MassHealth payment rate paid to the 

 nursing facility, chronic disease and rehabilitation hospital, 

 or psychiatric hospital; 

• be certified by a treating physician or other medical provider as being 
medically necessary; 

• not be payable by MassHealth or by any other health insurance or 
other liable third-party coverage; 


• be reasonable, and 


.. be the responsibility of the member. 




Reminder: Nursing facilities, chronic disease and rehabilitation hospitals, 
and psychiatric hospitals are not allowed to deduct noncovered medical 
or remedial-care expenses from a member’s personal needs allowance 
(PNA) unless explicitly directed to do so by a member. 

 

PPA Adjustments for If a medical expense exceeds the amount of the PPA determined by 
Multiple Months MassHealth for a particular month, MassHealth may allow an 

adjustment to the PPA for the next month and any subsequent month to 
account for the total necessary medical expenses incurred by a member 
in a particular month. 

 

 

Rules for Accepting In determining an adjustment to the PPA, a member’s necessary medical 
Incurred Medical or or remedial expenses 

Remedial Care 

Expenses .. 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 documented to the MassHealth Enrollment Center (MEC), 

 on a legible claim, or receipt, from the dental provider for the service. 
Paid bills may be used as documentation only if paid by the member 
after July 1, 2010. Documentation must include the following. 

.. name and address of the MassHealth member; 


.. name and address of the dental provider; 


.. description of the service provided; 


.. cost of the service provided; and 


.. date the service was provided to the member. 




 

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Questions If you have any questions about the information in this bulletin, please 
contact MassHealth Customer Service at 1-800-841-2900, e-mail your 
inquiry to providersupport@mahealth.net, or fax your inquiry to 

617-988-8974.