Noncovered Circumstances

(A) Conditions. The MassHealth agency does not pay for dental services under any of the following conditions: (1) services provided in a state institution by a state-employed dentist, dental consultant, or public health dental hygienist; (2) services provided by a provider whose salary includes compensation for professional services; (3) if, under comparable circumstances, the provider does not customarily bill individuals who do not have health insurance; and (4) if the member is not an eligible MassHealth member on the date of service. The provider must verify the member’s eligibility for MassHealth on the date of service even if the provider has obtained prior authorization for the service. (B) Substitutions. (1) If a member desires a substitute for, or a modification of, a covered service, the member must pay for the entire cost of the service. The MassHealth agency does not pay for any portion of the cost of a substitute for, or modification of, a covered service. In all such instances, before performing services not covered for the member, the provider must inform the member both of the availability of covered services and of the member’s obligation to pay for those that are not covered services. (2) It is unlawful (M.G.L. c. 6A, § 35) for a provider to accept any payment from a member for a service or item for which payment is available under MassHealth. If a member claims to have been misinformed about the availability of covered services, it will be the responsibility of the provider to prove that the member was offered a covered service, refused it, and chose instead to accept and pay for a service that MassHealth does not pay for. (3) Providers may upgrade medically necessary services at no additional cost to the MassHealth agency or the member. (C) For members 21 years of age and older who are not DDS Clients, coverage of dental services is subject to a Benefit Year maximum of $1,750 per member, based on the rates established in 101 CMR 314.00: Rates for Dental Services. (1) Coverage of services described in 130 CMR 420.409(C)(1)(a) and (b) counts towards the Benefit Year maximum, and such services are payable beyond the Benefit Year maximum. (a) Initial complete denture services after full arch extractions. (b) Services identified as payable beyond the Benefit Year maximum in MassHealth billing instructions, provider bulletins, or other written issuances. (2) Coverage of services identified as not subject to the Benefit Year maximum in MassHealth billing instructions, provider bulletins, or other written issuances does not count towards the Benefit Year maximum, and such services are payable beyond the Benefit Year maximum.