B-3300, Authorized Representative

Revision 21-1; Effective March 1, 2021

An authorized representative (AR) is a person who is familiar with the applicant and knowledgeable of the applicant’s financial affairs.

An applicant, person receiving benefits, head of household (HOH), or someone with legal authority to act on their behalf (e.g., legal guardian or power of attorney) may designate a person or organization as an AR.

When applying for benefits, an AR must be verified using one of the following:

applicant's or recipient’s signature on one of the following HHSC applications for benefits containing the AR designation: Form H1200, Application for Assistance — Your Texas Benefits ; Form H1200-MBI, Application for Benefits — Medicaid Buy-In ; Form H1200-MBIC, Application for Benefits — Medicaid Buy-In for Children ; or Form H1206, Health Care Benefits Renewal;

applicant's signature on a Marketplace application for health care benefits that is transferred to HHSC and contains the AR designation;

legal documentation that the AR has authority to act on behalf of the applicant or recipient under state law (e.g., legal guardianship or power of attorney);

letter designating AR authority and containing the applicant's or recipient’s signature, in addition to the name, address and signature of the AR;

completed Form H1003, Appointment of an Authorized Representative ;

applicant’s or recipient’s electronic signature designating the AR on an application, renewal or reported change submitted through YourTexasBenefits.com ; or

applicant’s or recipient’s telephonic signature submitted by calling 2-1-1.

If a person or organization submits an application on behalf of an applicant and indicates they wish to be the AR but the application is not signed by the applicant, send correspondence to both the unverified AR and the applicant to request the verification.

Send the following to the applicant: Form H1020, Request for Information or Action , listing the missing information needed before eligibility can be determined. Form H1003, to capture the AR designation and the signatures of the applicant and the AR.

Send the following to the unverified AR: Form H1004, Cover Letter: Authorized Representative Not Verified , explaining what is needed to verify the AR. Form H1003, to capture the AR designation and the signatures of the applicant and the AR.

For the AR to be verified, either the AR or the applicant must return the completed Form H1003 within 10 days (or 39 days from the file date). All missing information listed on the Form H1020 must also be returned timely. If the AR verification is not received by the due date, do not designate an AR.

The AR designation is effective from the date the AR is verified until:

the applicant or recipient notifies HHSC that the AR is no longer authorized to act on their behalf;

the AR notifies HHSC that they no longer wish to act as the AR for the applicant or recipient; Note : The AR will not be able to do this during the redetermination process if the AR is the person completing and signing the redetermination.

there is a change in the legal authority (i.e., legal guardianship or power of attorney) on which the AR’s designation is based; or

the applicant or recipient designates a new AR to act on their behalf. If there is an existing AR designated on a case, the person or organization most recently designated as the AR will replace the existing AR on the case.

Requests to end the designation of an AR must include the signature of the applicant, the recipient or the AR as appropriate.

Note : An AR is not automatically a personal representative.

An AR is designated at the case level to have access to all benefit information for that case. A verified AR may:

sign an application on behalf of an applicant;

complete and submit a renewal form;

receive copies of notices or renewal forms in the preferred language selected on the application, and other communications from HHSC;

designate a health plan; and

act on behalf of the applicant or the recipient in all other matters with HHSC.

The applicant, recipient or AR may also request that the AR receive the recipient’s Medicaid ID card and enrollment-related agency correspondence.