N.H. Admin. Code § He-W 803.01

Current through Register No. 50, December 12, 2024

Section He-W 803.01 - Authorized Representative

(a) A individual who chooses an authorized representative (AR), as defined in He-W 601.01(w) , to help with some or all the responsibilities of applying for or receiving medical assistance shall provide all of the following information in writing:

(1) The name, address, and telephone number of the AR;

(2) The duties that the AR will carry out, as specified in (c) below;

(3) The individual's relationship to the AR;

(4) A statement signed and dated by the individual acknowledging:

a. His or her responsibility for any errors, omissions, failures to report information to DHHS, or inaccurate information reported to DHHS by the AR;

b. That if the AR uses the individual's benefits without permission, these benefits will not be replaced by DHHS;

c. That the person the individual names as the AR will continue to act for the individual until the individual or the AR tells DHHS of a change; and

d. Comprehension of the individual's choice of AR and the duties assigned to that AR; and

(5) A statement signed and dated by the AR:

a. Agreeing to accept the responsibilities designated by the individual;

b. Acknowledging that the AR understands that:

1. Proof of the AR's identity is required;

2. If disqualified for a program violation, the person identified as the AR can no longer act as an AR unless there is no one else suitable to represent the individual; and

3. The AR will continue to act as an AR for the individual until the AR or the individual tells DHHS of a change.

(b) To qualify as an AR, an individual shall be an adult who has:

(1) Expressed concern for the individual's wellbeing;

(2) Sufficient knowledge about the individual's circumstances to assist the individual in applying for or receiving assistance; and

(3) The capability to obtain information about the individual's circumstances.

(c) The individual may authorize an AR to carry out one or more of the following responsibilities:

(1) Obtaining DHHS applications and other forms or DHHS paperwork, and completing these for the individual;

(2) Attending eligibility interviews for the individual;

(3) Providing DHHS with verification of the individual's income, resources and other case circumstances;

(4) Reporting and verifying changes in the individual's case circumstances to DHHS;

(5) Receiving the individual's medical assistance identification card and other DHHS mail;

(6) Asking for, attending, and representing the individual at administrative appeals for the individual;

(7) Communicating with the individual's managed care organization or qualified health plan; and

(8) Any other duties regarding eligibility for medical assistance an individual chooses to designate to an AR.

(d) If designated pursuant to (a) (2) above, ARs shall:

(1) Sign DHHS forms completed on behalf of the individual; and

(2) Co-sign DHHS forms they assist the individual in completing.

N.H. Admin. Code § He-W 803.01

Derived From Volume XXXVI Number 10, Filed March 10, 2016, Proposed by #11042, Effective 2/24/2016, Expires 2/24/2026.