Using MEDES

Background information related to the Missouri Eligibility Determination and Enrollment System (MEDES) Using MEDES Brian Kinkade, Director, Missouri Department of Social ServicesAlyson Campbell, Director, Missouri Family Support Division1Table of ContentsOverview page 3Background page 6Implementation of New Requirements page10 Using the New System page 16Helping Others Use the New System page 20Authorized Representatives page 25Presumptive Eligibility Update page 39 Transferring Records from FAMIS to MEDES page 41 Implementing Non-MAGI Medicaid page 43Medical Review Team Update page 45 Attachments page 46

2Overview3Overview4Basic information on the three phases of the planned implementation of the new system and the reorganization of the Family Support Division;

Information to assist the new Modified Adjusted Gross Income (MAGI) Medicaid population to complete the new single streamlined application;

Information to support those who help applicants complete the new MEDES application; and,

Information related to the eligibility processes for other populations and programs sharing this eligibility determination platform, including resource limit requirements and income standards.

Background5Background: What Is Medicaid?Medicaid is a joint federal-state program Covers a broad range of medically necessary health care and long-term care services for certain low income populations. The Missouri Department of Social Services (DSS) administers the program in a partnership with the federal Centers for Medicare and Medicaid Services (CMS). Eligibility determinations are made by the Family Support Division (FSD). The Medicaid program is administered by the MO HealthNet Division (MHD).

6Background: What is MAGI?Modifications to income include: (total income less allowable tax deductions and credits), modified by adding back

(i) any foreign earned income or housing costs ; and(ii) tax-exempt interest received or accrued by the taxpayer.

The term household income means the MAGI of the individual plus the MAGI of other individuals in the household who are required to file tax returns.A resource limit is not imposed for MAGI applicants

7Background: New RequirementsThe Affordable Care Act (ACA) requires states to modernize their eligibility and enrollment systems to:Allow a single streamlined application to serve as a single gateway to multiple health and human service programs across multiple IT platforms;

Accept applications through a public web portal and in person, by mail, or by phone;

Make real-time eligibility determinations;

Be paperless and available 24/7

Be transparent and seamless to the applicant

Maximize the consumers ability to complete the application process

8Background: New RequirementsBeginning in 2014 FSD must use new MAGI rules to process all applications for parents, caregivers, pregnant women and children

2014 2015 FSD will be phasing out its old eligibility determination system known as the Family Assistance Management Information System (FAMIS)

During that period eligibility for beneficiaries will be transitioned by FSD to the new Missouri Eligibility Determination and Enrollment System (MEDES); and, During that period and beyond, processing of applications will occur at designated offices that specialize in specific case determinations. 9Implementation of New Requirements10Implementation of New Requirements: Project PhasesProject I incorporating Medicaid parents, caregivers and children (the new MAGI population) into the new systemLaunch date: July 2013 Expected completion date: September 2014

Project II incorporating the Medicaid aged, blind and disabled populations into the new systemLaunch date: May 2014 expected completion date: August 2015

Project III incorporating the Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance to Needy Families (TANF) and other human service programs into the new systemLaunch date: October 2014 Expected completion date: September 201511Implementation of New Requirements: Electronic VerificationsRemote ID Proofing Launch date: Not yet determined

Federal Hub Verifications:Legal presence operationalIncarceration status operationalSocial Security Administration operational IRS Income Verification pending Confirmation of Minimum Essential Coverage (MEC) operational

State database verification real time pending

Account Transfers from the Federally Facilitated Marketplace (FFM) operational

Account Transfers to the FFM pending12Implementation of New Requirements: Electronic VerificationsOnce all electronic verifications are in place we anticipate that eligibility determinations will be made real time

We anticipate that a significant part of the volume will be processed without the intervention of a caseworker

Caseworkers will use the caseworker portal to adjudicate claims13Implementation of New Requirements: FSD ReorganizationMissouri is in the process of transitioning from a local county office structure where all offices provide a full range of services to a more specialized structure where some local offices will be organized to process only a specific type of case.

These specialized offices will be identified by the type of eligibility determination assigned to them. Initially FSD will establish 10 MAGI Processing Centers

Later FSD will add the following specialized processing centers:Non-MAGI Medicaid Processing Centers 8 SNAP/Food Stamp Processing Centers 5 TANF Processing Centers 1

14Implementation of New Requirements: FSD ReorganizationThe MAGI Processing Centers will be phased in beginning in late 2013, and throughout 2014, as existing MAGI populations are transferred/converted from the existing FAMIS eligibility determination system to the new MEDES system.

When the reorganization is completed, every county will have a local Resource Center. At these centers individuals may obtain general information and submit applications for all programs that FSD administers.

15Using the New System16Using the New SystemApplicants may complete an electronic MAGI application on-line at www.mydss.mo.gov

Paper applications are available over the internet or at local county resource centers. Applicants may pick up and drop off a paper application at any county resource center

Applicants may mail paper applications to the MAGI processing centers

Applicants may complete an application by phone by contacting FSDs contact center (this method will not be fully functional until September 2014)

17Using the New SystemMissouri receives Account Transfers from the FFM which allows applications to be transferred between the FFM and state Medicaid programs

MEDES is not yet sending Account Transfers to the FFM

Missouri also confirms enrollment in Medicaid and other Minimum Essential Coverage (MEC) for the FFM

18Using the New SystemPublic Web Portal: www.mydss.mo.gov

The portal provides a MAGI calculator that allows visitors to the web site to estimate whether they are eligible for Medicaid coverage

If eligible for Medicaid, visitors to the portal will be able to complete the single streamlined application online

If not eligible for Medicaid, visitors to the portal will be able to click on a link to connect to the FFM.19Helping Others Use the New System20Helping others use the New System: www.mydss.mo.gov If you are assisting a client who appears to be eligible for a subsidy through the FFM, then click on the link to the FFM that is available on the mydss web portal. Following are some of the choices that will be available to the client:Complete the single streamlined application through the FFM web portal (preferred option);

Create a My Account and return to the FFM web portal later to complete the single streamlined application; or,

Use the FFM Call Center to complete an application.21Helping others use the New System:Applicants who are eligible for Medicaid are encouraged to use www.mydss.mo.gov to create a MyAccount.

Password protected area where the Medicaid program and the applicant can exchange important information regarding Medicaid benefits and eligibility standards.

22Helping others use the New System:Missouris consumer-centric system is designed to allow anyone to provide assistance to potential Medicaid beneficiaries who:

Are comfortable using internet web portals; and,

Have access to the internet

Agents, Brokers, Navigators, Certified Assistance Counselors, provider employees who help patients complete Medicaid applications and other assistors are invited by FSD to provide assistance to potential Medicaid beneficiaries. 23Helping others use the New System:Agents, Brokers, Navigators and Certified Assistance Counselors are required to complete the section of the application indicating they provided assistance to the applicant

All Certified Application Counselors, Navigators, Agents and Brokers are expected to comply with all applicable laws and regulations

Other individuals, including hospital and clinic employees assisting patients with Medicaid applications, providing assistance that includes establishing the MyAccount and creating a password for the MyAccount shall complete the Authorized Representative section of the application

24Authorized Representatives25Authorized RepresentativesBy checking the appropriate box on the electronic application you can register as the patients Authorized Representative. This status allows you to monitor the progress of the application through the approval process.

You will be authorized to receive copies of follow up communications between DSS and the client until a final determination has been made and any appeal period for the beneficiary has been exhausted. The original documents are directed to the beneficiarys household.

26Authorized Representatives

Hospital and Clinic employees who assist patients with Medicaid applications should check the box indicating that they are an Authorized Representative of the beneficiary when helping patients complete the online application. By checking this box:

27Authorized RepresentativesAfter checking the Authorized Representative box, you need to have the applicant sign FSD form IM-6AR confirming that they have designated you as their Authorized Representative.Form IM-6AR must be submitted to FSD along with other verifying and supporting documentationForm IM-6AR may be downloaded from: http://dss.mo.gov/fsd/formsmanual/volume1/ 28Authorized RepresentativesProcess for downloading IM-6ARClick on link and go to FSD Forms ManualScroll down to IM-6ARClick on WordClick on RunThe Publisher could not be verified message appearsClick on RunEazy Zip Self-Extractor Box opensOn line that reads Extract to: and click on box with 3 dotsHighlight Desktop as the area where the file should be downloaded and click OkClick on StartClick on Ok after file is downloadedCloseout FSD Forms ManualGo to DesktopDouble click on im-6arForm opensClick in shaded area and complete formHave the applicant sign the IM-6ARFile the IM-6AR along with other verifications by emailing to: FSD.MEDES@dss.mo.gov 2930

Authorized RepresentativesHospital and Clinic employees who assist patients with Medicaid applications will be asked: Check the box if you are authorized to receive copies of notifications and communications sent to household. By checking this box:

31Authorized RepresentativesYou will be required to complete the Sign and Submit portion of the application in your name rather than the name of the beneficiary.The two following slides illustrate that:Electronic applications are in the MEDES system as soon as you hit sign and submitPaper applications have to go through several additional steps before being entered in the MEDES system

32

33New Slide

34Authorized RepresentativesAs an Authorized Representative you will be able to electronically send along proof of identity, proof of pregnancy, verification of income and other required documentation by emailing such documentation to FSD.MEDES@dss.mo.gov. Once your supporting documentation is received a casework will open the application and affix the supporting documentation to the case.

At that point, if all required documentation is present, the application will be approved.

35Authorized RepresentativesPlease reference the clients name and DCN or Social Security Number when submitting supporting documentation.

NOTE: Materials submitted by email must be encrypted. When contacting MEDES about specific applications it is important to include the clients name and DCN or Social Security Number.36Authorized Representatives Submitting Supporting Documentation:Submitting Supporting Documentation: FSD.MEDES@dss.mo.govSubmitting Emergency Medicaid Applications for Pregnant Women: FSD.MEDES@dss.mo.govSubmitting Newborn applications: FSD.MEDES@dss.mo.govTextTelephone: 800-735-2966 FAX: 573-751-0282 Magi Processing Centers: 1-855-373-9994Link to Medicaid Application: www.mydss.mo.gov

37Authorized Representatives Submitting Newborn Applications:Report newborns on excel spreadsheet that can be found at:http://dss.mo.gov/provider-services/health/hospital-report-mohealthnet-newborn-coverage.xlsx Enter required information on spreadsheetSubmit to FSD.MEDES@dss.mo.gov

38Presumptive Eligibility Update39Presumptive Eligibility Update State Plan Amendment Filed March 31, 2014Regulation being draftedApplication DesignProcessStandards

Submit Presumptive Eligibility Applications To: Presumptive.elig@dss.mo.gov

40Transferring Records from FAMIS to MEDES41Transferring Records from FAMIS to MEDESApplications will be processed using the new MAGI eligibility rules as required by the ACA.As MAGI beneficiaries (parents, caregivers and children) who are already enrolled in Medicaid through the FAMIS system interact with the new system through redeterminations and changes in life events, their records will be transferred from the FAMIS system to the new MEDES system. This will require caseworker intervention in one of the new MAGI Processing Centers. As a result the new MEDES system will not be fully automated until a beneficiarys file has been moved to the new system. It may take a full year to complete this process.Such caseworker intervention also will be required in cases where newborns are being added to a Mothers file that is located in the FAMIS system. The Mothers file may need to be moved to the new MEDES system before the child is added to the file.42Implementing Non-MAGI Medicaid43Implementing Non-MAGI MedicaidNon-MAGI populations will not be integrated into the new MEDES eligibility system until Project II is completed August 2015Processing of Non-MAGI Medicaid applications remains unchangedIf you are helping someone complete an application for coverage as Non-MAGI Medicaid, you will still complete the single, streamlined application.You will be expected to check appropriate boxes indicating the applicant is seeking assistance with one of the activities of daily living, etc.Once youve completed the electronic application, it will be transferred to the worker portal where a caseworker will compile the balance of the information required for consideration for Non-MAGI coverage44Medical Review Team Update45Count of 1st RequestTotal Unfilled Within 30 DaysPercent Unfilled Within 30 Days57,95414,81926%For the period: 12/1/2011 through 3/20/2014:Attachments46Contact InformationConfidentialityMAGI MedicaidNon-MAGI MedicaidNewborn Instructions and Excel SpreadsheetContact InformationAttachment 147Contact Information:

Filing MAGI Applications Electronically:www.mydss.mo.gov MAGI Processing Centers:1-855-373-9994Mailing Address for MAGI Applications:PO Box 1010Union, MO 63084Link to Paper Application:http://dss.mo.gov/mhd Click on: MO HealthNet ApplicationThen click on: Download and print the application

48Contact Information:

Link to Newborn Form for Submitting Applications: http://dss.mo.gov/provider-services/health/hospital-report-mohealthnet-newborn-coverage.xlsx Submitting Newborn applications:FSD.MEDES@dss.mo.gov - (See Attachment 3 for instructions related to filing newborn applications)FAX:573-751-0282 TextTelephone:800-735-2966

49Contact Information:

MHD Contact Information:MO HealthNet Division615 Howerton CourtP.O. Box 6500JeffersonCity,MO 65102-6500Telephone:573-751-3425Link to MO HealthNet Division:http://dss.mo.gov/mhd/ Frequently Asked Questions:https://mydss.mo.gov/CitizenPortal/FrequentlyAskedQuestionsPage.do#Question1

50Other Resources:

The Federal Health Insurance Marketplace www.HealthCare.gov here you can get information regarding the Marketplace in your state, including Marketplace insurance plans, information for individuals who dont have health insurance in 2014, and much more.Missouri Childrens Division www.dss.mo.gov/cd Community health centers offer health care on a sliding scale basis to Missourians without insurance: http://findahealthcenter.hrsa.gov/Search_HCC.aspx?byCounty=1 Missouri Primary Care Association: http://www.mo-pca.org Missouri Hospital Association: http://www.mhanet.com Missouri Rx Plan: www.morx.mo.gov GovBenefits.gov - U.S. Department of Labor website providing information about social service programs in all states. This is especially useful for families relocating to another state. 51ConfidentialityAttachment 252Confidentiality

Confidentiality:All Medicaid information is confidential. Anyone gathering or receiving information connected to a Medicaid application may share client information only for purposes directly connected with the administration of the Medicaid programs with other federal programs and certain entitled entities.

53MAGI Medicaid PopulationsAttachment 354Attachment 3MAGI Medicaid Populations

55Screening for Medicaid Eligibility

Ask the following questions to determine if the individual may fit into one of the groups described below:MAGI Medicaid:Are you pregnant?Do you have related minor children in your home?Are you under the age of 19?Are you under the age of 26 and a former foster care child?Non-MAGI Medicaid:Are you 65 or older?Have you been determined disabled through Social Security?

56Who Might Be Eligible for MAGI Medicaid:Parents and Caregivers with dependent children, who have income under about 19% of the Federal Poverty Level (FPL):$ 241/month or $ 2,892/year for a family of two$ 353/month or $ 4,236/year for a family of fourPregnant women who have income of 196% FPL or less:$1,907/month or $22,884/year for an individual$2,570/month or $30,840/year for a family of twoChildren under age 19 may be eligible for MO HealthNet for Kids with incomes at or below 148% FPL:$ 1,941/month or $ 23,292/year for a family of two$ 2,942/month or $ 35,304/year for a family of fourChildrens Health Insurance Program (CHIP) Children under age 19 if family income is under 300% FPL: $ 3,933/month or $ 47,196/year for a family of two$ 5,963/month or $ 71,556/year for a family of four57Who Might Be Eligible for MAGI Medicaid:Women with certain cancerous or precancerous conditions of the breast and/or cervix with income of 201% FPL or less:$1,955/month or $23,460/year for an individual$2,635/month or $31,620/year for a family of twoFormer foster care children who are currently less than 26 years old and who left foster care on or after their 18th birthday regardless of incomeWomen age 19-55 who are not currently pregnant may be eligible for Family Planning services with income of 201% FPL or less:$1,955/month or $23,460/year for an individual$2,635/month or $31,620/year for a family of two

58MAGI POPULATIONS:

Temporary MO HealthNet During Pregnancy (TEMP) Pregnant women may be determined eligible by qualified providers for temporary eligibility during pregnancy until they can apply for and begin receiving full MO HealthNet benefits. TEMP is "state only" from the time a participant is found ineligible for regular MO HealthNet until the end of the TEMP eligibility period. The designation may be used only once during a pregnancy.Presumptive Eligibility For Children. Provides a period of presumptive eligibility to children in families with income below 150% of the Federal Poverty Level. Children under the age of 19 may be determined eligible by qualified entities for MO HealthNet on a temporary basis prior to having a formal eligibility determination completed.For Adults. Under the ACA adults may be determined eligible by qualified entities for MO HealthNet on a temporary basis prior to having a formal eligibility determination completed.59MAGI POPULATIONS:

Womens Health Services Program (1115 Demonstration Waiver) Uninsured women who lose MO HealthNet healthcare coverage sixty (60) days after the birth of their child are covered for womens health services for an additional year, regardless of the income level. Coverage is limited to family planning, and testing and treatment of Sexually Transmitted Diseases. Also, women who are age 18 through 55, have a family income at or below 196 percent of the federal poverty level, have assets totaling less than $250,000, and are not otherwise eligible for Medicaid, the Children's Health Insurance Program, Medicare, or health insurance coverage that provides family planning services are eligible for this program. Newborn - Automatic Eligibility Newborns are automatically eligible for assistance if their mother is receiving a federally matched category of assistance at the time of birth (except TEMP - See Temporary MO HealthNet During Pregnancy below).

60MAGI POPULATIONS:

MO HealthNet for Kids (MHK) Includes the following: Infants under the age of one whose family income is less than 196% of the federal poverty level may be eligible; children under the age of six at 148%; and,children ages six through eighteen at 100%.Uninsured children with gross family income up to 300 percent of the federal poverty level. "Uninsured Children" are persons under nineteen years of age who have not had employer-subsidized health care insurance or other health care coverage for six months prior to application.MO HealthNet for Families (MHF) The Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (P.L. 104-193) eliminated the link between Aid to Families with Dependent Children (AFDC) and Medicaid and replaced it with Section 1931 of the Social Security Act to provide Medicaid to low-income families with children.Transitional MO HealthNet (TMH) Provides healthcare coverage to a family for up to 12 months, after the closing of an MHF case due to employment or increased earnings. MO HealthNet for Pregnant Women (MPW) This program is intended to provide MO HealthNet benefits to low-income pregnant women. A woman whose family income does not exceed 196% of poverty may qualify.61Non-MAGI Medicaid PopulationsAttachment 462Attachment 4Non-MAGI Medicaid

63Who Might Be Eligible for Non-MAGI Medicaid:Adults age 65 or older these are generally beneficiaries who meet Medicaid requirements to receive long-term care and in-home care services through the Medicaid programIndividuals who have been determined to be blind or disabled by the Social Security Administration or by the Medical Review Team (MRT)

64NON-MAGI POPULATIONS:

MO HealthNet for the Aged, Blind, and Disabled (MHABD) MO HealthNet coverage for persons who meet the requirements of: Old Age Assistance (OAA); Permanently and Totally Disabled (PTD) and Aid to the Blind. Persons must be over age 65 or meet the Supplemental Security Income (SSI) definition of disabled or the state definition of blindness. Persons receiving Supplemental Security Income (SSI) or Social Security based on age or disability are automatically qualified for Medical Assistance on those factors. Persons determined by Social Security to meet 1619 A or B status are eligible as non-spend down. Homeless, Dependent, Neglected Children Provides assistance for children in care and custody of the Childrens Division (CD). Medical Assistance for Children in Care Children in the custody of Division of Youth Services (DYS) or a juvenile court. Breast and Cervical Cancer Treatment Program MO HealthNet coverage for uninsured women under age 65 screened for breast or cervical cancer by Missouris Breast and Cervical Cancer Control Project (BCCCP). (Note: The BCCCP Program has requirements including income limits that must be met to get the screening. Screening services are provided by the Department of Health and Senior Services.)

65NON-MAGI POPULATIONS:

Supplemental Nursing Care Provides a state grant and MO HealthNet benefits to elderly, blind, and disabled persons in licensed residential care facilities and non-MO HealthNet nursing homes.Supplemental Aid to the Blind Provides assistance to needy blind persons.Qualified Medicare Beneficiary Pays for Medicare premiums, deductible and coinsurance for eligible persons enrolled in Medicare part A with income up to 100% of poverty. Specified Low Income Medicare Beneficiary Provides payment of Medicare Part B premiums to individuals who would be eligible for the Qualified Medicare Beneficiary program except for excess income. Income must be more than 100% of the Federal Poverty Level, but not exceed 120%. 66NON-MAGI POPULATIONS:

Refugee Assistance Persons who are admitted to the United States with an immigration status of refugee or asylum may qualify for a short period of time in order to establish self-sufficiency if they do not meet eligibility for another category. MO HealthNet for Disabled Children (MHDC) A disabled child may be eligible for Medical Assistance. The income and resources of the parents are taken into consideration. Psychiatric Services 21 years and under Provides assistance to individuals under 21 in a psychiatric facility.IV/E Alternative Care provides assistance to children in the CD foster care and adoptive homes.67Newborn Instructions and Excel SpreadsheetAttachment 568Attachment 5 Newborn Instructions and Excel Spreadsheet

69Role of Authorized Representative Submitting Newborn Applications:Report newborns on excel spreadsheet that can be found at:http://dss.mo.gov/provider-services/health/hospital-report-mohealthnet-newborn-coverage.xlsx Enter required information on spreadsheetSubmit to FSD.MEDES@dss.mo.gov 70MISSOURI DEPARTMENT OF SOCIAL SERVICESFAMILY SUPPORT DIVISIONAPPOINTMENT OF AUTHORIZED REPRESENTATIVE

You do not need to sign this form to apply for or receive MO HealthNet benefits. You may contact the Family Support Division to apply for benefits, complete your annual review, or conduct other business on your own; or you may appoint an authorized representative to represent you, as provided by 42 CFR 435.908. To appoint an authorized representative, you must complete this form and the person you appoint to be your authorized representative must acknowledge and accept the appointment. Notwithstanding the availability of the authorized representative, the Family Support Division may communicate directly with you as the division may determine appropriate.

I,TELEPHONE:

ADDRESS:

DCN or SSN:

hereby appoint:

NAME:TELEPHONE:

ADDRESS:

to act as my authorized representative.

This individual is designated as my primary authorized representative to receive correspondence from the Family Support Division:

Division|_| YES|_| NO

The appointed individual will act with a responsibility and obligation to me for the following purpose:

|_| APPLICATION |_| ANNUAL REVIEW |_| AGENCY ACTION

The person I have appointed has knowledge of my circumstances necessary to complete an application, annual review or act on my behalf and shall not willfully make a false statement, misrepresentation, conceal information, or fail to report any fact or event required to be reported by any law, regulation or rule of this State or the United States.

I understand that I am responsible for the information provided by my authorized representative, including any information that may be incorrect.

APPLICANT/PARTICIPANT SIGNATUREDATE

Acknowledgement and Acceptance of Appointment of Authorized Representative:

I,TELEPHONE:

ADDRESS:

am age 18 or older and have knowledge of the applicant/participants circumstances necessary to complete an application, annual review or agency action on their behalf. I shall not willfully make a false statement, misrepresentation, conceal information, or fail to report any fact or event required to be reported by any law, regulation or rule of this State or the United States.

I hereby accept this appointment of authorized representative for the duration and purpose stated above.

AUTHORIZED REPRESENTATIVE SIGNATUREDATE

MO 866-2817 E 11/2012IM-6AR

IM6-AR INSTRUCTIONS IM AUTHORIZED REPRESENTATIVE APPOINTMENT (MO HealthNet Programs)

Purpose: To provide a signed statement for an applicant/participant designating an individual 18 years or older to be their authorized representative to apply for MO HealthNet programs on the behalf of an applicant/participant, to assist the participant with the annual review process or a specific agency action.

This form is required to be completed if the MO HealthNet application is made by an authorized representative (individual) or if the applicant/participant wishes to appoint an authorized representative to assist them with an annual review or agency action.

This form does not authorize an authorized representative access to protected health information that may be contained in a record with the Family Support Division. If applicant/participant wishes to have protected health information released to their authorized representative, they must request this release and disclosure of information by completing the Department of Social Services HIPAA compliant release form 650-2616 (HIPPA) Authorization of Disclosure of Consumer Medical/Health Information.

An applicant or participant cannot appoint an authorized representative if the applicant or participant already has a guardian and/or conservator recognized under Missouri law or an attorney-in-fact appointed by a valid Power of Attorney recognized under Missouri law. The attorney-in-fact, guardian or conservator may authorize an individual to act as an authorized representative.

The authorized representative must be an individual person at least eighteen (18) years of age. The authorized representative must be an individual person and not a firm, partnership, legal corporation or other organization. However, the applicant or participant may consent to the release or disclosure of his or her records to an entity.

Number of Copies and Distribution: This form is available in hard copy or PDF. The original is completed by the applicant/participant and is filed in the record as a permanent part of the record. A copy of the original must be given to the applicant/participant. The individual appointed as authorized representative may request or keep a copy for their records.

Instructions for Completion of Authorized Representative appointment: The IM Authorized Representative section of the form is completed by the applicant/participant. It may be completed up to 30 days prior to the application date, annual review date or agency action date.

The applicant/participant must complete the form as follows:

1. print their name, telephone number, address, and DCN or SSN in the first four blanks. 1. print the name, telephone number, and address of the individual they are appointing to be their representative in the next three blanks. 1. complete the Purpose of Authorized Representative Appointment section; indicate the purpose for which they are appointing an authorized representative by checking Application, Annual Review, or Agency Action .1. sign and date; the applicant/participant must sign to appoint the named Authorized Representative. The individual the applicant/participant appoints as an authorized representative must sign and date the form appointing the individual named as their authorized representative.

The individual appointed as authorized representative must complete the form as follows:

print their name, telephone number and address in the first three blanks. sign and date; the individual appointed as authorized representative must sign and date the acknowledgment and acceptance of authorized representative appointment.

Duration of Appointment: The authorization will remain in effect for one year after the notice of eligibility determination has been issued and the Divisions appeal process has been exhausted or until:Thirty (30) days after the authorization is signed, if no application is received; orThe Division receives a new authorization form designating a new authorized representative; orThe Division receives written notice that the authorization has been revoked by the applicant or participant; orThe Division receives notice that the applicant or participant is deceased.