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NM Resource Assistance » Health Care Programs » Medicaid » Coverage Types » Working Disabled Individuals (Medicaid Category 043)

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Working Disabled Individuals (Medicaid Category 043)

What is Medicaid Category 043?

What are the eligibility requirements?

Are there other requirements?

What benefits will I receive?

What does it cost?


NOTE: Glossary words are underlined. Place cursor over any glossary word to see its meaning.

What is Medicaid Category 043?

Medicaid Category 043, or WDI, covers disabled individuals who are employed, or those who have lost eligibility for Supplemental Security Income (SSI) and Medicaid due to the initial receipt of Social Security Disability Insurance (SSDI) and who do not yet qualify for Medicare.


What are the eligibility requirements?

Individuals must meet the SSA’s criteria for disability “without regard to substantial gainful activity,” and does cover those individuals with recent attachment into the workforce. Individuals eligible for Medicaid coverage under the Working Disabled Individuals program must be at least 18 years of age and meet the following:

  • Social Security Administration disability criteria without regard to "substantial gainful activity" and

  • Have a recent attachment to the workforce, defined as

    • Having sufficient gross earnings in a quarter to meet the Social Security Administration's definition of a qualifying quarter, or

    • Have lost SSI and Medicaid due to initial receipt of SSDI benefits, and be within the 24-month waiting period for Medicare.

The income ceiling for WDI is 250% of the federal poverty guidelines. Depending on your situation and your spouse's gross income, a spouse's income may or may not be included in the determination of eligibility.

Additionally, an applicant must meet resource limits, which apply to  an applicant couple, even if the spouse is ineligible.

Retroactive benefits can be recovered for up to three months for applicants who have received Medicaid-covered services during the retroactive period. Applicants must demonstrate that they qualified for Medicaid Category 043 during the three months prior to the month of application. There is no retroactive Medicaid coverage prior to WDI program implementation.

Applicants are responsible for reporting changes affecting eligibility to their local ISD office at the end of the calendar quarter in which the change occurred.

To be eligible for Medicaid, an individual must be a citizen of the United States, or a qualified alien. Contact your local ISD office if you are unsure if you qualify.


Are there other requirements?

If an individual becomes eligible for Medicare, he or she must be employed to continue eligibility under Category 043.


What benefits will I receive?

An individual who receives Medicaid under Category 043 is eligible to receive the full range of Medicaid covered services. This usually includes the following services:

  • Inpatient hospital

  • Transplants (heart, lung, heart-lung, liver, bone marrow, kidney, and corneal)

  • Outpatient hospital

  • Case management and specific case management programs

  • Emergency

  • Physical health

  • Laboratory

  • Diagnostic imaging and therapeutic radiology

  • Anesthesia

  • Vision

  • Audiological

  • Dental

  • Dialysis

  • Pharmacy

  • Durable medical equipment and medical supplies

  • Early periodic screening, diagnostic and treatment (EPSDT) for young children

  • Tot-to-teen health checks

  • Services provided in schools

  • Nutritional

  • Home health

  • Hospice

  • Ambulatory surgical

  • Rehabilitation

  • Reproductive health

  • Pregnancy termination procedures

  • Emergency and non-emergency transportation for medically necessary health services

  • Prosthetics and orthotics

  • Behavioral health


What does it cost?

Eligible WDI recipients have co-payment responsibilities, as follows:

  • $5 per prescription

  • $7 per dental visit

  • $7 per outpatient visit, except for clinic visits, urgent care visits, outpatient therapy sessions, or behavioral health sessions

  • $20 per emergency room visit

  • $30 per inpatient hospital admission

There is a co-payment maximum per year for eligible WDI recipients.

  • For individuals who make under 100% of the federal poverty guidelines, co-payments are limited to $600 per year.

  • For individuals who make 100% to 250% of the federal poverty guidelines, co-payments are limited to $1,500 per year.

It is important to know that the recipient must track the amount of co-payments made and notify the Medical Assistance Division when the maximum has been reached. Be sure to keep documentation. See the Income Support Division for local office contacts.