13 CSR 40-2.015 - Authorized Representatives
PURPOSE: This amendment adds the Adult Expansion Group (AEG) to the list of groups that constitute "MO HealthNet programs" for purposes of this rule. The AEG was created by Amendment 2, which was passed by referendum on August 4, 2020, and which created Article IV, Section 36(c) of the Missouri Constitution, which requires the department to extend MO HealthNet coverage to Missourians ages 19-64 whose income is below 133% of the federal poverty level. This amendment also incorporates three (3) federal regulations and one (1) subpart of the Code of Federal Regulations (CFR). First, the rule governing authorized representatives (42 CFR 435.923). Second, the rule governing the privacy and security of personally identifiable information (45 CFR 155.260), which authorized representatives must honor. Third, the rule governing the entities who may receive a reassigned claim from a Medicaid provider (42 CFR 447.10). Finally, the amendment incorporates the subpart in federal rules- 42 CFR 431 Subpart F-on safeguarding information on Medicaid participants. Authorized representatives must agree to adhere to these rules as a condition of their representation.
PUBLISHER'S NOTE: The secretary of state has determined that the publication of the entire text of the material which is incorporated by reference as a portion of this rule would be unduly cumbersome or expensive. This material as incorporated by reference in this rule shall be maintained by the agency at its headquarters and shall be made available to the public for inspection and copying at no more than the actual cost of reproduction. This note applies only to the reference material. The entire text of the rule is printed here.
(1) Scope. This regulation defines the
procedures for the appointment of an authorized representative for participants
in MO Health-Net programs and specifies the parameters of the authorized
representative's powers and authority. This regulation shall only apply to MO
HealthNet programs.
(2) For
purposes of this rule, the following terms shall mean:
(A) "Attorney-in-fact" shall mean an
individual or corporation appointed to act as agent of a principal in a written
power of attorney that may be durable or not durable. The written power of
attorney shall comply with Chapter 404, RSMo;
(B) "Authorized representative" shall mean an
individual person at least eighteen (18) years of age or an organization
designated by the participant to act on behalf of the participant, the
participant's children, or any members of the MO HealthNet household at any
time for any MO HealthNet program;
(C) "Conservator" or "Guardian" shall mean
one appointed by a Missouri court under the authority of Chapter 475, RSMo or
if a foreign guardian or conservator is in compliance with the authority of
Chapter 475, RSMo to have the care and custody of the estate of a minor or a
disabled person;
(D) "MO HealthNet
programs" shall mean the MO HealthNet benefits provided to participants under
the MO HealthNet programs including, but not limited to, MO HealthNet for the
Aged, Blind, and Disabled (MHABD) program, MO HealthNet for Families (MHF)
program, the Adult Expansion Group (AEG) pursuant to Article IV Section 39(c)
of the Missouri Constitution, MO HealthNet for Kids (MHK) program, MO HealthNet
for Pregnant Women (MPW) program, and Uninsured Women's Health Services (UWHS)
program. MO HealthNet programs also include presumptive eligibility for any of
the above programs; and
(E)
"Participant" shall mean any adult, or emancipated minor individual who has
applied for, or is receiving, or has been denied benefits from the MO HealthNet
programs administered by the division.
(3) The appointment of an authorized
representative shall comply with the following requirements:
(A) A participant must knowingly designate
the appointment of an authorized representative;
(B) A participant is permitted at the time of
application and at any other time to appoint an authorized
representative;
(C) The participant
may at any time designate a person or organization to serve as authorized
representative by a document that complies with subsection (3)(D) submitted by
mail, in-person, facsimile, or electronically. The appointment of the
authorized representative shall be signed by the participant. The appointment
may, but is not required to be, on a form provided by the division. The
participant's signature can be handwritten, stamped, electronic, telephonically
recorded, or by any other method accepted by the division; and
(D) The designation of authorized
representative under subsection (3)(C) shall include the following information:
1. The name of the person or organization
designated to serve as the authorized representative;
2. The address of the authorized
representative and the mailing address of the authorized representative (if
different);
3. A phone number for
the authorized representative; and
4. An attestation substantially in the
following format: "In appointing my authorized representative, I understand
that I will be legally bound and responsible for the actions of my appointed
representative with respect to my application for or participation in the MO
HealthNet program." The attestation shall also contain or be accompanied by a
signed authorization compliant with the Health Insurance Portability and
Accountability Act (HIPAA) for the Department of Social Services to release
protected health information to the authorized representative.
(4) The division shall
not release participant information to an authorized representative until the
division has received a HIPAA compliant authorization and designation of
authorized representative. This section shall not apply to a request for
release of participant information from the participant's attorney,
participant's spouse, attorney-in-fact, guardian or conservator, or court
appointed public administrator.
(5)
The participant cannot designate an authorized representative if the
participant is incompetent as determined by a court of competent jurisdiction
or the participant's cognitive function is impaired to the extent the
participant lacks the ability to make a willful, knowing decision.
(6) An authorized representative designation
is void to the extent its creation was induced by fraud, duress, or undue
influence or at the time of creation, the participant was incompetent or
impaired.
(7) The participant may
designate more than one (1) individual or organization to serve as the
authorized representative at any given time to assist with MO HealthNet
programs.
(8) If the division
receives conflicting instructions or information from more than one (1)
authorized representative, the division will consult with the authorized
representatives to resolve the conflict. The division may also consult directly
with and request instructions from the participant or the participant's court
appointed legal guardian or conservator or attorney-in-fact. If the participant
is represented by an attorney who has filed a written entry of appearance, the
division will consult with the attorney first before consulting with the
participant. The division may require the participant, the participant's
guardian or conservator, attorney-in-fact, and/or the authorized
representatives to provide documentation, additional information and written
confirmation of instructions. The division shall make the final decision
resolving the conflict between the authorized representatives where consensus
cannot be reached. The division shall issue written findings resolving any
factual dispute and issue a written decision. If the individual/applicant is
aggrieved by the decision, he/she may request administrative review pursuant to
section 208.080, RSMo.
(9) The participant's designation of an
authorized representative by mail, telephone, or any commonly available
electronic means, other than social media, shall be accepted and treated the
same as an in-person designation as long as the designation complies with
subsection (3)(D).
(10) A
participant shall be bound and liable for all actions taken or facts submitted
by any of the participant's authorized representatives.
(11) The authorized representative shall not
make a false statement or misrepresentation, willfully conceal information, or
fail to report or disclose any fact or event required to be reported by any
law, regulation, or rule of this state or the United States.
(12) If an organization is appointed as an
authorized representative-
(A) The
organization shall provide in writing the name, address, and phone number of an
individual within the organization who shall serve as a contact person for the
division within ten (10) days of appointment of the organization as the
authorized representative, if not provided by the participant. The organization
shall notify the division in writing of any change in the name and contact
information for the contact person within ten (10) days of the
change;
(B) An organization shall
provide within ten (10) days upon request by the division written verification
that an individual purporting to be a member or employee of the organization
acting as an authorized representative is acting within the authority of the
organization. The verification shall be provided by another member or employee
of the organization and cannot be provided by the individual who is the subject
of the request by the division; and
(C) As required by
42 CFR
435.923(e), the provider,
staff member, or volunteer of the organization shall affirm and agree that, as
a condition of serving as an authorized representative, he or she will adhere
to section 208.155, RSMo, 42 CFR part 431,
subpart F, and
45 CFR
155.260(f) (relating to
confidentiality of information),
42 CFR
447.10 (relating to the prohibition against
reassignment of provider claims as appropriate for a facility or an
organization acting on the facility's behalf), as well as other relevant state
and federal laws concerning conflicts of interest and confidentiality of
information.
(13)
Department of Social Services employees may contact the participant to verify
the appointment of an authorized representative, discuss with the participant
information provided by the authorized representative, and for any other
purposes and, notwithstanding the availability of the authorized
representative, may communicate directly with the participant at any time the
department deems appropriate.
(14)
Subject to the requirements of section (3), the participant may revoke or
modify the designation of an authorized representative and appoint another
authorized representative to represent him or her at any time. The participant
may modify the authority of the authorized representative to act at any time.
To revoke or modify the authority of an authorized representative the
participant shall submit a signed and dated statement revoking or modifying the
designation of the authorized representative or the authority to act to the
division and the authorized representative. The revocation shall be effective
on the date that it is received by the division.
(15) No authorized representative shall make
willfully false statements, coerce, threaten, or harass any participant who
wishes to revoke or modify the authority of the authorized representative in
order to prevent or dissuade the individual from revoking or modifying the
authorized representative relationship. The division will no longer accept the
authorized representative as acting on behalf of the participant should the
division determine this has occurred.
(16) The death of the participant shall
terminate the authority of the authorized representative to act as of the day
of the participant's death. However, the death of the participant shall not
stay the authority of the authorized representative to assist with an
application filed with the family support division prior to the participant's
death until the application is approved or rejected and any hearing rights have
expired. The death of the participant shall also not stay the authority of the
authorized representative to assist with payment of MO HealthNet benefits owed
prior to the participant's death.
(17) An appointment as an authorized
representative is non-transferrable and may not be delegated by the individual
or the organization acting as an authorized representative to another
individual or organization.
(18) A
court-appointed legal guardian and/or conservator; a public administrator who
has been appointed a participant's legal guardian; participant's spouse; an
attorney-in-fact; and an attorney at law, authorized to practice in the state
of Missouri, may represent a participant and receive information about the
participant's application for a MO HealthNet program or hearing at any stage of
the application process without having to submit an authorized representative
form, but shall-
(A) Notify the division when
the authority to represent the participant changes or terminates for any
reason. The authority to act as the participant's representative shall
terminate upon death of the participant;
(B) Provide the division in writing a current
address, phone number, and e-mail or facsimile number. An attorney shall
provide his or her Missouri bar number;
(C) A court-appointed legal guardian or
public administrator who has been appointed a participant's legal guardian
shall submit to the division a copy of his or her letters of appointment or a
copy of the court order appointing him or her to act as the participant's legal
guardian;
(D) A participant who has
a court-appointed guardian and/or conservator cannot revoke or limit the
authority of the guardian and/or conservator absent a court order;
and
(E) An attorney-in-fact shall
submit to the division the powers or authority of the attorney-in-fact to
represent the participant or act as the authorized representative. An
attorneyin-fact other than a durable power of attorney shall not represent the
participant or serve as an authorized representative if the authority to so act
is not included within the terms of his or her appointment .
(19) This rule hereby incorporates
by reference the following provisions and definitions from the Code of Federal
Regulations (CFR) listed below as published by the Office of the Federal
Register, 800 North Capitol St. NW, Suite 700, Washington, DC 20408, and which
is located on the website of the U.S. Government Publishing Office at
https://www.govinfo.gov/app/collection/CFR.
This rule does not incorporate any subsequent amendments or additions:
(A)
42 CFR
435.923, October 20, 2021;
(B)42 CFR 431 Subpart F, October 20,
2021;
(C)
45 CFR
155.260, October 20, 2021; and
(D)
42 CFR
447.10, October 20, 2021.
Notes
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