The MassHealth PSI form, short for Personal Services Item form, is an authorization slip a Massachusetts nursing facility uses to document a purchase made from a resident’s Personal Needs Allowance (PNA) account. It isn’t a statewide MassHealth document. Each facility writes its own version to comply with the state rules on handling resident money, so the layout you see will depend on where the resident lives. The information it collects, though, is the same everywhere: who the resident is, what is being bought, from whom, for how much, and the signatures of the resident (or representative) and the facility’s account manager.
What the Form Is Authorizing
A nursing home resident on MassHealth keeps $72.80 of their monthly income as a Personal Needs Allowance before the rest goes toward the cost of care. The amount has not changed since 2008.1Mass.gov. Program Financial Guidelines for Certain MassHealth Applicants and Members If a resident’s income doesn’t reach $72.80, MassHealth makes up the difference so every long-term care resident has at least that much to spend.2Commonwealth of Massachusetts Executive Office of Health and Human Services. MassHealth Eligibility Letter 182 – Increase in Personal Needs Allowance for Nursing Home Residents The PNA pays for personal items the facility does not provide: clothing, haircuts, a favorite lotion, a magazine.3Mass.gov. Paying for a Stay in a Nursing or Rest Home
The PSI form exists so each withdrawal from that small account is documented, authorized by the resident, and not quietly used for something the facility should already be providing.
Charges the Facility Cannot Put on the Form
Before you sign anything, know what cannot legally be billed to a PNA account. Massachusetts regulation 130 CMR 456.424 limits facilities to items the resident specifically requests, and the facility must disclose the cost first. Several categories are off limits entirely:4Mass.gov. Program Regulations 130 CMR 456.000 – Long-Term Care Services
- Group activities, entertainment, or facility-organized parties
- Medically necessary drugs, supplies, or services
- Funeral expenses
- Room and board
- Wheelchair purchase, rental, or repair
- Transportation to necessary medical treatment
- Service or maintenance charges on the PNA account itself
Personal laundry also cannot be charged to the PNA.3Mass.gov. Paying for a Stay in a Nursing or Rest Home If any of these show up on a PSI form put in front of you, do not sign.
What to Put on the Form
The exact boxes vary by facility, but the same pieces of information appear on every version. Gather them before you sit down with the form:
- Resident’s full legal name and 12-digit MassHealth ID number from the member card.5Mass.gov. All Provider Bulletin 191 – New MassHealth Member ID Card
- A specific description of the item or service. Not “electronics.” Something closer to “portable radio, Sony model ICF-306.” Vague entries get kicked back.
- Vendor name and address — the store, online retailer, barber, or service provider.
- Exact cost including tax. If you only have an estimate, expect to be asked for a written quote or invoice.
- A short reason for the purchase, which matters most for adaptive equipment or specialized personal care products.
The resident or an authorized legal representative signs to confirm the purchase is voluntary and the information is accurate. A facility staff member who manages resident accounts signs too, confirming the funds are available and that the item is not already covered by the facility’s daily rate.
Attach anything that supports the dollar figure: a printout from the retailer’s website, a written estimate from the barber, an invoice from a medical supply company. Supporting documents cut down on follow-up questions and move the approval along.
Where to Get the Form and Where It Goes
Ask the facility’s social worker or business office for a blank PSI form. Because it is not a MassHealth-issued document, you will not find it on the MassHealth website. Some facilities tuck a copy into the admission packet; others keep them at the nurses’ station or in the business office.
Return the completed and signed form to the resident fund manager or business office, the same department that holds the PNA account. The facility checks that the item is not already covered by the daily rate, confirms the balance, and either approves it or asks for more information. Routine purchases like shoes or a haircut usually clear in a few business days. Higher-cost or unusual requests can take longer while pricing is verified.
Once approved, the facility normally pays the vendor directly by check or electronic payment. The resident does not handle cash. The signed PSI form, the vendor receipt, and any attachments go into the resident’s permanent financial file, where they are available for state audits and for your review.
Checking That It Posted Correctly
A PSI form is only as good as the ledger entry that follows it. Under 130 CMR 456.610, the facility must make PNA account records available within one working day of a request.4Mass.gov. Program Regulations 130 CMR 456.000 – Long-Term Care Services Ask for a copy of the ledger from time to time and line it up against your PSI forms and receipts. Watch for charges you don’t recognize, amounts that don’t match an approved form, or any account-maintenance fee, which is prohibited. Raise discrepancies with the facility administrator right away, in writing.
When a Charge Is Wrong and the Facility Won’t Fix It
Start with a written complaint to the facility administrator so there is a paper trail. If that doesn’t resolve it, the Massachusetts Long-Term Care Ombudsman Program investigates complaints about nursing homes, rest homes, and assisted living facilities on behalf of residents, and unauthorized use of PNA funds falls within that scope.6Mass.gov. Massachusetts Long-Term Care Ombudsman Program The resident, a family member, or a friend can file. The program can be reached at 617-222-7495, and it is empowered to pursue administrative or legal remedies when needed.7Administration for Community Living. Long-Term Care Ombudsman Program If you suspect outright theft or financial exploitation, a report to the Massachusetts Attorney General’s Elder Abuse Hotline is also appropriate.