Mo. Code Regs. tit. 13 § 40-2.015

Current through Register Vol. 49, No. 23, December 2, 2024

Section 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.

13 CSR 40-2.015

Adopted by Missouri Register November 16, 2015/Volume 40, Number 22, effective 12/31/2015

Repealed by Missouri Register July 1, 2021/Volume 46, Number 13, effective 8/31/2021

Amended by Missouri Register March 15, 2022/Volume 47, Number 6, effective 4/30/2022