Frequently asked questions about health insurance
coverage options in Hawaii
Most non-elderly Americans get their health coverage from an employer, but for people who have retired early, are self-employed, or employed by a small business that doesn’t offer health insurance benefits, individual/family health plans are available through the marketplace in Hawaii.
After two years of using a technologically troubled state-based enrollment system, Hawaii began using the HealthCare.gov enrollment platform for the open enrollment period that began in the fall of 2015. At that point, the state had what’s called a state-run marketplace using the federal enrollment platform, or SBM-FP.
In November 2016, Hawaii switched to a fully federally run health insurance marketplace, or FFM, although that state still oversees the plans that are sold in the exchange. And consumers only really noticed a difference in the fall of 2015, when Hawaii transitioned from using its own enrollment platform to using HealthCare.gov. Hawaii residents have continued to use HealthCare.gov ever since.
Hawaii no longer has a SHOP exchange for small businesses. But employees receive stronger consumer protections for health coverage in Hawaii than they do in other states under federal rules.
To address the ongoing COVID pandemic and to give people an opportunity to take advantage of the premium subsidy enhancements created by the American Rescue Plan, a special enrollment period is open through August 15, 2021, and there is no need for a qualifying event during this window.
Outside of the open enrollment period, which runs from November 1 to December 15, Hawaiians can normally only enroll in individual major medical health coverage if they experience a qualifying event. But the COVID-related enrollment window in 2021 is functioning more like an open enrollment window, giving people an opportunity to newly enroll in individual and family health plans, or to switch to a different plan if it will better suit their needs (in some cases, switching plans will allow people to best utilize the additional premium subsidies under the American Rescue Plan).
Hawaii’s health insurance marketplace has two insurers that offer individual and family health plans: Kaiser and HMSA.
Average full-price premiums decreased in Hawaii’s individual marketplace for 2020 and again for 2021.
22,903 people enrolled in 2021 coverage through Hawaii’s health insurance marketplace during the open enrollment period that ended in December 2020. Hawaii is one of just a few states where enrollment in the marketplace grew each year from 2014 through 2019. Although it dropped slightly for 2020, it reached a record high for 2021.
And it’s likely to continue to increase in 2021, during the COVID-related enrollment period. During the first several weeks of this enrollment window, 1,238 people enrolled in plans through Hawaii’s exchange, which was double the prior year’s special enrollment period enrollment numbers for the same time frame.
Transitional (grandmothered) health insurance plans are those that took effect after the ACA was signed into law in March 2010, but before the bulk of its provisions went into effect in 2014. These plans were initially slated to terminate at the end of 2013 or at their renewal dates in 2014, but a series of federal extensions have allowed them to continue to renew, at each state’s discretion.
As recently as the regulation they published in 2018 (which allowed transitional plans to extend through the end of 2019), Hawaii was going along with the federal extensions, allowing transitional plans in both the individual and small group markets to remain in force .
But the state’s extension for 2020 and for 2021 only apply to small group plans. Although individual market transitional plans were allowed to remain in force in Hawaii in 2019, HMSA opted to terminate all of their individual market transitional plans at the end of 2018 (see SERFF filing HMSA-131977825; the insurer clarifies that about two-thirds of their transitional plan enrollees subsequently enrolled in ACA-compliant HMSA plans for 2019).
Hawaii has long supported broad access to medical insurance. The state’s historically low uninsured rate is largely the result of the Hawaii Prepaid Health Care Act, which was enacted in 1974 and requires most employers to provide health insurance to employees who work more than 20 hours a week.
The Hawaii Prepaid Health Care Act has much stronger requirements for employer-provided coverage than the ACA. Hawaii’s 1332 waiver to eliminate the SHOP exchange (which was the first 1332 waiver approved in the nation) was a direct result of the state’s success under the Hawaii Prepaid Health Care Act .
According to U.S. Census data, Hawaii’s uninsured rate was 6.7% in 2013 (far lower than the national average of 14.5%), and had fallen to 4% by 2015 (again, less than half the national average of 9.4% by that point). It had climbed slightly, to 4.%, by 2019, mirroring the nationwide trend of increasing uninsured rates under the Trump administration.
Many states had much more significant drops in their uninsured rates, but they also started with a much higher percentage of the population without health insurance in 2013. As of 2019, only Massachusetts, Rhode Island, and the District of Columbia had lower uninsured rates than Hawaii; the national average uninsured rate at that point was 9.2%.
A total of 379,818 people – more than a quarter of Hawaii’s population – were enrolled in Medicaid or CHIP coverage as of November 2020. About 110,089 people had gained coverage in the state by 2019 as a result of Medicaid coverage expansion. Nationwide, Medicaid enrollment has increased sharply as a result of the widespread job and income losses caused by the COVID pandemic, and total Medicaid/CHIP enrollment in Hawaii was 32% higher in late 2020 than it had been in late 2013.
Medicaid coverage expansion has certainly benefited low-income Hawaii residents, particularly those with low or no employment and no access to the employer-based health insurance that most Hawaii residents enjoy (in Hawaii, people employed at least 20 hours per week get very affordable health coverage through their employers). Medicaid expansion is particularly important during the COVID pandemic, as it provides a true safety net for people who lose their jobs, and in many cases, also lose their employer-sponsored health insurance.
A 2018 Hawaii law prohibits the purchase of a short-term health insurance plan by anyone eligible to buy a plan in the state’s health insurance marketplace during the previous calendar year.
The law effectively eliminated the market for short-term health insurance plans in Hawaii, and they are no longer for sale in the state.
Read more about short-term health insurance in Hawaii.
As of January 2021, 283,635 Hawaii residents were enrolled in Medicare plans.
Hawaii has the smallest percentage of Medicare enrollment as a result of a disability – just 9%. The other 91% of recipients qualify for Hawaii Medicare plans based on age alone (ie, being at least 65).
As of 2019, per-beneficiary Medicare spending in Hawaii was $ $7,143 – the lowest in the nation. (The national average was $10,409.)
Learn more about Medicare enrollment in Hawaii, including the state’s rules for Medigap plans.
Here’s a look at recent state-level health care reform in Hawaii:
Hawaii partially addressed this issue many years ago, when the state required all state-regulated employer-sponsored health plans to cover the full range of FDA-approved contraceptives, starting in 2000 (the initial impacts of this change are discussed here).
Hawaii’s new law, which took effect immediately, allows pharmacists to dispense up to 12 months of contraceptives, even if the patient does not have a prescription from a physician. The pharmacist must have the patient complete a “self-screening risk assessment tool” and refer the patient to a primary care physician, but must also provide the contraceptives regardless of whether the patient follows through on the referral.
Hawaii law, along with the ACA, requires health plans to cover contraceptives, but S.B.513 extends the coverage to include reimbursement for pharmacists who prescribe and dispense contraceptives.
During the legislative session, H.B.513 received widespread support, but also some opposition. The Hawaii section of the American College of Obstetricians and Gynecologists (ACOG) opposed the legislation because they felt that it didn’t go far enough in terms of expanding access to contraceptives. ACOG felt that birth control should be available over-the-counter, and that even requiring a visit with a pharmacist was too restrictive.
Hawaii enacted legislation in 2017 that created a working group that was tasked with making recommendations for codifying ACA protections into state law. In 2018, acting on the recommendations of the working group, Hawaii enacted legislation that prohibits gender rating, pre-existing condition exclusions, and application denials based on medical history. The legislation also protects parents’ ability to keep their children on their health plan until age 26.
In addition, Hawaii enacted legislation in 2018 that sharply limited the short-term insurance market. As a result, there were no longer any insurers offering short-term plans in Hawaii as of late 2018.