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State of California–Health and Human Services Agency Department of Health Care Services
QUALIFIED DISABLED WORKING INDIVIDUAL
INFORMATION NOTICE
This notice is to help you decide whether to apply for the Qualified Disabled Working Individual (QDWI) program. People
eligible for this program will have their Medicare Part A premiums paid by the Medi-Cal program. You may apply for the QDWI
program at your local county department of social services.
There are four requirements which you must meet if you want to be a QDWI.
HERE ARE THE FOUR REQUIREMENTS:
1. A QDWI must be eligible for Medicare Part A (Hospital Insurance) as a disabled working individual.
2. A QDWI must have a monthly income which is equal to or less than $1,265 if he/she is a single person or $1,692 if
he/she is married and living with a spouse.
3. A QDWI must have property which is equal to or less than $4,000 if he/she is single or $6,000 if he/she is married and
living with a spouse.
4. A QDWI must meet certain other requirements and conditions which are part of the Medi-Cal program, such as being a
California resident.
The following gives more information about the four QDWI requirements:
REQUIREMENT 1
A QDWI must be under age 65 and eligible for Medicare Part A with a premium.
¢ I already have Part A Medicare Hospital Insurance.
¢ I do not have Part A Hospital Insurance, but I understand I must apply for Part A at the Social Security Administration.
¢ I have already applied for Part A.
REQUIREMENT 2
A QDWI who is not married or not living with a spouse must have countable income which is equal to or less than $1,265 per
month. A QDWI living with a spouse must have countable income which is equal to or less than $1,692 per month. These
amounts are expected to increase sometime in April.
The following are examples of some types of income that count toward the QDWI income limit. When a person applies to be a
QDWI at the county department of social services, the county will also look at other types of income and may treat the income
differently from what is on this sheet. For example, if there is a minor child or children in the home, there may be deductions
allowed which would reduce the amount of countable income.
Fill in the amounts to see if you are close to the limit.
A. Fill in the MONTHLY amounts for the person who wants to be a QDWI.
1. Social Security check $ ____________
2. VA benefits $ ____________
3. Monthly interest $ ____________
4. Retirement income $ ____________
5. Any other unearned income $ ____________
6. Total – Add lines 1 through 5. $ ____________
B. If you are married and living with your spouse, complete the following
MONTHLY amounts for your spouse even if this spouse also wants to
be a QDWI:
7. Social Security check $ ____________
8. VA benefits $ ____________
9. Interest from bank accounts or certificates
of deposit $ ____________
10. Retirement income $ ____________
11. Any other unearned income $ ____________
12. Total – Add lines 7 through 11. $ ____________
MC 010 (05/07)
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