400.05.05 MEDICARE COST-SHARING GROUP – QUALIFIED WORKING DISABLED

INDIVIDUALS (QWDI) COE-035 Section 6408 of the Omnibus Budget Reconciliation Act of 1989 (P.L. 101-239) requires states to provide Medicaid to certain qualified disabled and working individuals for the purpose of paying certain Medicare cost-sharing expenses effective July 1, 1990. For eligible QWDI’s, Medicare cost-sharing expenses are limited to payment of Medicare Part A premiums only. Although QWDI’s are one of the Medicare cost-sharing groups, individuals who qualify for QWDI are not subject to liberalized policy as are QMB, SLMB and QI. There is also a resource test for QWDI’s that is equal to twice the SSI resource limit, or $4,000 for an individual and $6,000 for a couple. All QWDI applications must be referred to the Central Office for clearance of QWDI status. Very few individuals seek coverage as a QWDI since the Division of Medicaid covers the optional Working Disabled COE that provides full Medicaid benefits plus Medicare cost-sharing benefits for dually eligible individuals. In addition, the Working Disabled coverage group offers higher income and resource limits as a work incentive for disabled workers. SSA Eligibility Criteria for a QWDI Section 6012 of OBRA-89 makes Medicare available for the working disabled who lose Medicare entitlement because their work exceeds the substantial gainful activity (SGA) levels after an extended period of eligibility. Section 6012 allows the disabled individual to purchase Medicare Part A, Hospital Insurance (HI). SSA will make the initial determination for individuals potentially eligible for Premium HI as follows: • The individual must be under age 65, and, • The individual must have been entitled to disability insurance benefits (DIB) under title II, but DIB ended due to earnings exceeding the SGA limit, and, • The individual must continue to have a disabling condition and, • The individual must not be otherwise eligible for Medicaid. An individual who loses DIB due to SGA but continues to be disabled can continue Medicare coverage for up to 24 months. Premiums for Medicare, Part B, Supplemental Medical Insurance (SMI) are payable by the disabled individual during this time. At the time this extended free Medicare Part A coverage ends, SSA will mail the disabled individual a notice informing him/her of the right to enroll in Premium HI under this federal law. The individual has 7-months to enroll in Premium HI beginning with the month of the notice. If the individual does not enroll during this 7-month period, the next enrollment period is the general enrollment period which is January – March of each year. Delayed enrollment during general enrollment will result in a delay in entitlement effective the following July 1. A disabled individual who meets all of the criteria used by SSA can enroll and pay his/her Medicare Part A and B premium after DIB terminates and free Medicare Part A terminates. Out of this group of disabled working individuals, certain ones can qualify for Medicaid to pay their Medicare Part A premiums if all Medicaid criteria is met, as discussed below. Medicaid Eligibility Criteria for a QWDI A QWDI, as defined by SSA above, can apply for Medicaid to pay the Medicare Part A premiums if all of the following criteria is met: • The individual must be entitled to enroll in Medicare Part A under Section 6012 of OBRA-89, • The individual must have countable income that does not exceed 200% FPL, • The individual is eligible on countable resources and all other non-financial Medicaid criteria is met (excluding a DDS decision which is not required due to continuing Medicare entitlement), • The individual is not eligible for free Medicare Part A, and • The individual is not otherwise eligible for Medicaid. Effective Date of QWDI Benefits The effective date of Medicaid’s payment of the Medicare Part A premium for a QWDI is based on the date of application and the date all eligibility criteria is met. If an individual is already enrolled in Medicare Part A at the time of application, QWDI status can begin with the date that all criteria is met, including retroactive Medicaid for up to 3 months prior to the month of application. However, if the individual’s enrollment in Medicare Part A is not effective until a future month, eligibility for QWDI cannot begin until the month Medicare Part A will be effective. Dual Eligibility There is no dual eligibility for QWDI and any other full-service COE. A QWDI is a stand-alone eligibility status for individuals who are not eligible for coverage in any other available COE. Termination of QWDI Benefits When a QWDI reaches age 65 or otherwise becomes eligible for free Medicare Part A, eligibility for QWDI must be terminated after advance notice. In addition, if any other factor of eligibility is not met the individual’s eligibility for QWDI must be terminated.