101.03.04 REPRESENTATIVES AUTHORIZED TO ACT FOR AN APPLICANT

There are three (3) types of representatives allowed to act on behalf of an applicant or recipient in filing an application for health coverage through DOM: 1. Authorized Representative An authorized representative is a person or employee of an organization who is acting responsibly for the applicant with his knowledge and written consent. The MAGI-related application form allows the head of household to designate an authorized representative with no separate written authorization required except in cases where the head of household has a legal representative who is required to act on his/her behalf. ABD applications require the use of a separate authorization form (DOM-302A) for an applicant or recipient to appoint an authorized representative. The authorized representative has knowledge of the applicant’s circumstances and is usually a relative or close friend but may be a designee of an organization if the applicant or recipient permits. The authorized representative must be authorized in writing by the applicant to act on his behalf. The application is filed in the name of the applicant. The authorized representative can provide eligibility information and sign the application form and receive all eligibility notices; however, the applicant or recipient has the right to limit the authority of their authorized representative. The appointment of an authorized representative does not prevent the Division of Medicaid from communicating directly with the applicant or recipient as deemed appropriate. NOTE: In instances where the applicant or recipient designates an authorized representative but places a limit on the receipt of notices by the representative, maintain the authorized representative information in the case record rather than entering the representative information in the system. If representative information is entered into the system, the representative will receive all letters and notices issued by the system. When an organization or other individual assisted with the completion of an application and their primary need is access to case record information rather than function as a case representative, completion of the “Authorization for the Use/Disclosure of Protected Health Information” form may be more appropriate to allow access to information while the applicant or recipient represents themselves. Contact with the applicant or recipient is needed to make this determination, which must be documented in the case record. 2. Self-Designated Representative A self-designated representative is a person acting responsibly for an applicant or recipient because the physical or mental condition of the applicant/recipient is such that he cannot authorize anyone to act for him nor can he act for himself. Family members or non-relatives with knowledge of the applicant’s or recipient’s circumstances are allowed to self-designate in writing with the use of a form designed for this purpose (DOM-302B). A representative of an organization or a provider cannot self-designate to represent an applicant or recipient, except in cases where the self-designating individual is an owner, operator or employee of a state-owned long term care healthcare facility. All other individuals representing an organization or provider must become legally appointed to represent an individual for health care decisions, in which case the individual becomes the Legal Representative of the applicant or recipient. A self-designated representative must file an application or review form in the name of the applicant/recipient with the self-designated representative providing required information to determine or re-determine eligibility and sign all eligibility-related forms that are required. The self-designated representative will receive all eligibility notices and letters. NOTE: A parent or primary caretaker relative is allowed to apply for a child without signing the self-designation form authorizing themselves as a representative. 3. Legal Representative A legal representative is someone who has been legally appointed to act on behalf of an applicant or representative. The legal representative must provide documentation of their legal authorization to act for the applicant or recipient, such as a Power of Attorney document, legal guardianship decree, conservatorship decree, a custody decree or other type of court order, and complete a Legal Representative form (DOM- 302C). All such documents must specify that the legally appointed individual has the right to make health care decisions for the applicant or recipient. If an applicant or recipient is deceased, proof that the individual is the executor or administrator of the applicant’s or recipient’s estate is required if eligibility is needed in the month of death and/or retroactive period. The legally appointed representative will act on behalf of the applicant or recipient in all matters with the Division of Medicaid without limitation.