Commonwealth of Massachusetts 
Executive Office of Health and Human Services 
Office of Medicaid 
www.mass.gov/masshealth 



MassHealth 
Long Term Care Facility Bulletin 104 
May 2011 

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

FROM: Terence G. Dougherty, Medicaid Director 

RE: 
2011 Annual Accounting for Personal Needs Account Funds 

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

Deadline for PNA-1 Submissions 

To comply, providers must use the PNA-1 form. This form must be dated 
and signed by the administrator, under the pains and penalties of perjury, 
and sent to the following address by July 1, 2011. 

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’ MassHealth ID numbers; 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 February 28, 2011. 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 may use their own reconciliation form or may use 
the PNA-2 form included with this bulletin. 

Providers using Microsoft software to maintain listings of patient balances 
may submit the files in electronic format to PNAreview@umassmed.edu or 
include the required files on a CD. 

MassHealth encourages providers to take precautions appropriate to the 
transmission of personal information. When submitting PNA-related 
documents, MassHealth recommends that all providers encrypt electronic 

(continued on next page) 




MassHealth 
Long Term Care Facility Bulletin 104 
May 2011 
Page 2 

Deadline for PNA-1 Submissions 
(cont.) 

communications or mail required documents via certified mail. 

If the provider does not handle PNA funds for any members, it must state 
this on the PNA-1. The form must then be dated and signed by the 
administrator, and sent to the Financial Compliance Unit address listed 
above. The PNA-1 and PNA-2 forms can be downloaded from the 
MassHealth Web site at www.mass.gov/masshealthpubs. Click on the link 
to MassHealth Provider Forms in the lower right panel of the home page. 

Deadlines 
And Penalties

If a provider does not submit the PNA-1 and, if applicable, the PNA-2 by July 1, 
2011, 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 617-886-8106. 




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 
on this form, and any attachments that I have provided has been reviewed, and is 
true, accurate, and complete, to the best of my knowledge. I understand that I 
may be subject to civil penalties or criminal prosecution for any falsification, 
omission, or concealment of any material fact contained herein. 
(Signature and date stamps, or the signature of anyone other than the preparer 
and the administrator, are not acceptable.) 


Prepared by (please print) Signature Date 


Administrator (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. Use the PNA-2 form, or identical 
electronic format, and include: 
Member name (first and last); 
MassHealth ID number; 
Account balance as of February 28, 2011; 
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 February 28, 2011. 
(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. CD 
2. Electronic files — e-mail to: 
PNAreview@umassmed.edu 
3. 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, 3 rd Floor • 
Charlestown, MA 02129 

PNA-1 (Rev. 05/11) 




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

Bank Reconciliation for MassHealth Members' 
Personal Needs Account Funds 
as of February 28, 2011 


Name of Facility: 
________________________________________________________________ 

BALANCE PER BANK AS OF FEBRUARY 28, 2011:  $ 

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 aff ect 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.

PNA-2 (Rev. 05/11)



Listing of MassHealth Members' Personal Needs Account Funds as of FEBRUARY 28, 
2011 

MassHealth Member's Name

MassHealth ID Number  


Bank Book No. and/or 
Aggregate Trustee Bank 
Account No. 
PNA Balance 

$ , . 
$ , . 
$ , . 
$ , . 
$ , . 
$ , . 
$ , . 
$ , . 
$ , . 
$ , . 
$ , . 
$ , . 
$ , . 
$ , . 
$ , . 
$ , . 
$ , . 
$ , . 
$ , . 
$ , . 
$ , . 
$ , . 
$ 
$ 


Total This Page $

Please attach additional sheets if needed. 

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