CHAPTER 308—Qualified Disabled and Working Individual (QDWI)

308.01 Introduction 444

308.02 Eligibility Criteria 444

308.03 Eligibility Determination 444

308.04 Application Process 444

308.01 Introduction

(Eff. 12/01/05)

Section 6408 of the Omnibus Budget Reconciliation Act of 1989 requires state Medicaid programs to pay the Medicare Part A premiums for persons who meet certain criteria. The provision became effective July 1, 1990. These individuals would be eligible only for payment of their Part A premium and no other Medicaid benefits. These individuals are called Qualified Disabled and Working Individuals (QDWI’s).

308.02 Eligibility Criteria

(Rev. 04/01/10, Eff. 01/01/10)

To be eligible, an individual must meet the following criteria:

Be disabled (that is, must have been entitled to disability insurance benefits under Title II);

Be less than 65 years of age;

Have been terminated from Medicare solely because earnings exceeded the substantial gainful activity amount as used in the Social Security disability determination process;

Have income at or below 200% of the federal poverty level;

His/her countable resources are below $4,000 for an individual and $6,000 for a couple; and

Not be otherwise eligible for Medicaid; and

Continue to have a disabling physical or mental condition.

308.03 Eligibility Determination

(Eff. 12/01/05)

The Social Security Administration (SSA) will determine disability and decide if an applicant/beneficiary qualifies for Qualified Disabled Working Individual (QDWI) status. Persons who have lost or are losing their Medicare benefits due to their income exceeding the SGA amount, and who wish to apply for Medicaid as a QDWI, must first apply for Part A coverage through the SSA. Application must be made during the initial enrollment period, which will be identified in the notice sent from SSA. If application is not made during the specified time frame, the applicant/beneficiary must wait until the general enrollment period, which is January through March, of the following year to apply.

If the applicant/beneficiary is accepted as a Part A enrollee, the SSA will do a cursory review of his/her income and resources and, if deemed appropriate, make a referral to the Department of Health and Human Services for a determination of Medicaid eligibility as a QDWI.

308.04 Application Process

(Eff. 10/01/10)

Financial eligibility for QDWI is determined based on income being at or below 200% of the Federal Poverty Level for the individual. Non-financial requirements for eligibility must also be met (such as, furnishing of or application for a Social Security number, citizenship, residency and assignment of rights to medical support. Refer to MPPM Section 102.01.)

The effective date of benefits under this coverage group is based on the date of application and the date on which all eligibility criteria are satisfied.

Eligibility as a QDWI may terminate because the applicant/beneficiary no longer meets any eligibility factor. These include termination because Medicare Part A benefits have been reinstated as an entitlement, countable income exceeds 200% of poverty; countable resources exceed $4,000 for an individual or $6,000 for a couple; applicant/beneficiary moves out of state or becomes eligible under another coverage group.

A State Verification and Exchange System (SVES) match must be completed on each QDWI applicant/beneficiary.

Individuals determined eligible, as a QDWI are not eligible for the full range of Medicaid benefits. These individuals are only eligible for Medicaid to pay their Medicare Part A premium. A Medicaid card will not be issued.