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
	Long Term Care Bulletin 80
	July 2002

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

	FROM:	Wendy E. Warring, Commissioner

	RE:	Patient-Paid-Amount (PPA) Adjustments for Residents of Long-Term-Care (LTC) Facilities, Including Adjustments 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.

Prospective	The Division’s current regulations at 130 CMR 520.026(E) specify that
Reduction to the	a deduction for a member’s incurred medical or remedial-care expenses
Patient-Paid Amount	may be used in determining the LTC member’s patient-paid amount 
	(PPA).  These expenses must be for services not payable by a third party and not covered by MassHealth—in the case of dental expenses, either 

		

Prospective			because the dental service is a non-covered service for any adult, or 
Reduction to the		because the service is covered by MassHealth only for members 
Patient-Paid Amount	designated as SC and the member does not qualify for SC designation.  
(cont.)				Additionally, these expenses must be:

•	not covered by the MassHealth per diem rate (PDR) paid to the LTC facility, and
•	certified by a treating physician or other medical provider as being medically necessary.

Effective March 15, 2002, the member’s adult dental expenses for services that are no longer covered by MassHealth may be allowed as a deduction from the LTC member’s PPA.  The reduction to the PPA is made prospectively.

Reminder: The deduction is allowed only from the member’s PPA.  It is impermissible for LTC facilities to deduct non-covered dental expenses from a member’s personal needs allowance.

When the		If the amount of the incurred dental expense is more than the member’s
Dental Expense		PPA, the PPA may be reduced for subsequent consecutive months until 
Incurred Is		the expense incurred is satisfied.  The member’s PPA must be reduced 
Greater Than		by the maximum monthly computable amount before applying any
The PPA		remaining deduction to the subsequent month’s PPA.

If the member’s PPA is already zero, there is no PPA dental expense deduction.

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;
•	must be the responsibility of the member;
•	must not be incurred for adult dental services rendered prior to March 15, 2002 that were covered by MassHealth prior to March 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

	

Rules for Accepting 	    must be submitted to the MassHealth Enrollment Center (MEC), 
Incurred Adult Dental 	on a legible unpaid bill, or a paid receipt, from the dental provider 
Expenses 	for the service.  Paid bills may be used to adjust the PPA only if 
(cont.)	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 LTC facility, by accepting the temporarily adjusted PPA and the 
resulting increased DMA payment toward the cost of the member’s care 
in the LTC facility, attests that:

•	the medically necessary service is not covered by the LTC facility’s PDR, and
•	the service is not covered by MassHealth, and the dental provider has indicated that all other avenues of payment for the service have been exhausted, including:
o	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
o	the dental provider made a clinical determination that the member would not qualify for SC designation; and
o	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	
	Dental Manual: 130 CMR 420.409(B)-Noncovered Circumstances-Substitutions (www.mass.gov/dma/providers/regulations/regs_dental.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.