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MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 101 – Coverage Groups and Processing Applications and Reviews Page |204

Effective Month: December 2016 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 in behalf of the applicant or recipient in all matters with the Division of Medicaid without limitation.