State of Wisconsin Department of Health Services

Release 24-01 April 03, 2024

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34.1 Authorized Representatives

Applicants or members can appoint either an individual or an organization as authorized representative. An authorized representative can be appointed through any of the following means:

• ACCESS, when applying
• Federally Facilitated Marketplace (Note: When a Marketplace application is processed by the agency and an applicant has appointed an authorized representative in the application, the agency must honor this appointment of an authorized representative.)
• Paper form (signed in writing or electronically):
  • Appoint, Change, or Remove an Authorized Representative: Person (F-10126A)
  • Appoint, Change, or Remove an Authorized Representative: Organization (F-10126B)

If an applicant or member is represented by a guardian of the person and the estate, guardian of the estate, or conservator, the guardian or conservator must appoint the authorized representative. A guardian of the person can appoint the authorized representative only if the court document appointing the guardian of the person grants them the authority to enroll the person in BadgerCare Plus, Medicaid, or public assistance programs.

If the applicant or member only has a guardian of the person, and the applicant’s guardian does not have the authority to enroll the person in BadgerCare Plus, Medicaid, or public assistance programs, the applicant or member must appoint the guardian of the person as an authorized representative if the applicant or member would like the guardian of the person to act on their behalf. If the applicant or member has a power of attorney, the applicant or member can still appoint an authorized representative.

A valid authorized representative appointment requires all contact information of the authorized representative and the signatures of the applicant or member, the authorized representative, and a witness. If the applicant or member is signing with an “X,” a valid appointment requires two witness signatures. If any of the required signatures are missing, the following three conditions apply:

• The authorized representative appointment is not valid.
• This authorized representative cannot take action on behalf of the applicant or member.
• The agency cannot disclose information about the case to the invalid authorized representative.

For other valid signature requirements, refer to Section 25.5 Valid Signature.

There can only be one authorized representative at a time on a case. There is no time limit on how long a person or organization can act as authorized representative. The appointment of the authorized representative is valid until the applicant or member notifies the agency of a change or removal in writing. Once appointed, the authorized representative has ability to act for all open programs on the case.

Organizations acting as authorized representatives must provide the name and contact information of a person from the organization. Once the organization has been appointed as the authorized representative, anyone from the organization will be able to take action on behalf of the applicant or member (not just the person who signed the form on behalf of the organization). If an organization is only changing the contact person for the organization, the member is not required to complete a new Appoint, Change or Remove Authorized Representative form if the organization is going to remain as the authorized representative.

The authorized representative should be familiar with the applicant or member’s household situation and is expected to fulfill their responsibilities to the same extent as the individual being represented. An authorized representative is limited to doing any or all of the following on behalf of the applicant or member:

• Apply for or renew benefits
• Report changes in the applicant or member’s circumstances or demographic information
• Receive copies of the applicant or member’s notices and other communications from the agency
• Work with the IM agency on any benefit related matters
• File grievances or appeals regarding the applicant or member’s eligibility

To change an authorized representative, the member must complete and submit the Appoint, Change, or Remove an Authorized Representative form to their IM agency. To remove an authorized representative, the member needs to let the agency know of the removal in writing, for example completing Section 1 of the Appoint, Change, or Remove an Authorized Representative form or submitting a signed letter indicating the removal. The member does not need to gather additional signatures from the authorized representative or a witness to complete the removal of an authorized representative. Authorized representatives can also request in writing (for example, a signed statement) to be removed if they no longer want to act as the authorized representative. If an authorized representative is requesting to be removed, a signed statement is not needed by the member. An authorized representative designation is valid on a case until a written and signed request is received for removal.

Example 1

Penny is due for renewal of her BadgerCare Plus benefits on August 31. In July, she receives her case summary as part of the administrative renewal process. Penny’s case summary lists her mom, Darlene, as her authorized representative. Penny no longer wants Darlene to be her authorized representative. Penny crosses out the authorized representative information on the case summary, signs it, and mails it to the IM agency. The IM agency receives the case summary on August 3. Based on Penny’s handwritten update on the case summary, the IM agency removes Darlene as Penny’s authorized representative effective on August 3.

34.1.1 Additional Responsibilities

The applicant or member can choose to appoint the person who is acting as their authorized representative to receive the member’s ForwardHealth card and is also allowed to do the following tasks:

• Enroll the applicant or member in an HMO
• Contact Member Services or the HMO about a bill, service or other medical information, including Protected Health Information (PHI)

An authorized representative who is appointed by the member to have these additional functions is coded in CARES as a Medicaid (MA) Payee. The authorized representative and the MA Payee must be the same person, and the MA Payee cannot be an organization. If the member’s authorized representative is an organization and the member wants to appoint a MA Payee, the member must change the authorized representative to a person and authorize that person to have the MA Payee functions.  

The applicant or member can appoint their authorized representative to fulfill the additional responsibilities on Section 1 Part C of the Appoint, Change or Remove Authorized Representative: Person form (F-10126). The applicant or member acknowledges that they are authorizing the disclosure of PHI to the authorized representative since the authorized representative will have access to medical information such as health care services or treatments, medical bills, etc.

There is no time limit on the MA Payee designation. An applicant or member can request removal of the MA Payee in writing at any time. For example, the applicant or member can submit the Appoint, Change or Remove Authorized Representative form or write a letter indicating the MA Payee removal.

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The information concerning the BadgerCare Plus program provided in this handbook release is published in accordance with: Titles XI, XIX and XXI of the Social Security Act; Parts 430 through 481 of Title 42 of the Code of Federal Regulations; Chapter 49 of the Wisconsin Statutes; and Chapters HA 3, DHS 2 and 101 through 109 of the Wisconsin Administrative Code.

Notice: The content within this manual is the sole responsibility of the State of Wisconsin's Department of Health Services (DHS). This site will link to sites outside of DHS where appropriate. DHS is in no way responsible for the content of sites outside of DHS.

Publication Number: P-10171