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As a Medicare beneficiary, where you live – meaning your state of residence – can have a significant impact on the care that you receive and how you pay for that care during your “golden years.” This page explains how Hawaii’s regulations and policies are likely to affect your bottom line.
Many Medicare beneficiaries who struggle to afford the cost of Medicare coverage are eligible for help through a Medicare Savings Program (MSP). In Washington, D.C., this program pays for Medicare Part B premiums, Medicare Part A and B cost-sharing, and – in some cases – Part A premiums.
MSP asset limits: Hawaii uses the federal asset limits for QMB, SLMB and QI – what are $7,860 if single and $11,800 if married. The asset limit for QDWI is $4,000 if single and $6,000 if living with others.
Medicare covers a great number services – including hospitalization, physician services, and prescription drugs – but Original Medicare doesn’t cover important services like vision and dental benefits. Medicare beneficiaries can also face large cost sharing expenses.
Beneficiaries whose incomes and assets make them eligible for Medicaid can receive coverage for Medicare cost sharing and services that only Medicaid covers through Medicaid for the aged, blind and disabled (ABD).
The income limits for Medicaid and QMB are the same in Hawaii (and only the asset limits are different), meaning that many enrollees have both programs. The principal benefit for Hawaii residents who receive full Medicaid benefits (in addition to QMB) would be dental coverage, but Hawaii’s Medicaid program has not covered that benefit since 2009.
In Hawaii, the Medicaid program covers a vision exam and one pair of eyeglasses every two years for adult members, and also pays for contact lenses.
Income eligibility: The income limit is $1,224 a month for individuals and $1,653 a month for spouses.
Asset limits: The asset limit is $2,000 for single applicants and $3,000 for couples.
Applicants with incomes too high to qualify for Medicaid for the aged, blind and disabled can qualify by enrolling in Hawaii’s Medicaid spend-down, which is known as the “Medically Needy” program.
When an applicant is approved for the spend-down, Medicaid calculates the portion of their monthly income above the income limit for the spend-down (known as “excess income”). Enrollees activate their coverage by submitting medical bills equal to this amount.
In Hawaii, the Medicaid spend-down program covers Long Term Services and Supports (LTSS).
Income eligibility: The income limit is $469 a month if single and $632 a month if married. (This is equal to 40 percent of the federal poverty level.)
Asset limits: The asset limit is $2,000 if single and $3,000 if married.
This website has more information about Medicaid benefits in Hawaii, including the spend-down program.
Medicare beneficiaries who have Medicaid, an MSP, or Supplemental Security Income (SSI) also receive Extra Help – a federal program that limits prescription drug expenses under Medicare Part D. Enrollees who don’t receive this benefit automatically can apply for it through the Social Security Administration (SSA). The income limit is $1,615 a month for singles and $2,175 a month for couples, and the asset limit is $14,610 for individuals and $29,160 for spouses.
Medicare beneficiaries increasingly rely on long-term services and supports (LTSS) – or long-term care – which is mostly not covered by Medicare. In fact, 20 percent of Medicare beneficiaries who lived at home received some assistance with LTSS in 2015. Medicaid fills this gap in Medicare coverage for long-term care, but its complex eligibility rules can make qualifying for benefits difficult. What’s more – eligibility rules vary significantly from state to state.
Income limits: There is no income limit for Medicaid nursing home benefits in Hawaii.
However, this doesn’t mean nursing home enrollees can keep most of this income. Instead, they pay all but a small portion of it to their nursing home (although they can keep a small personal needs allowance of $50 each month and money to pay for health insurance premiums, such as Medicare Part B and Medigap).
Each state’s Medicaid program offers community-based long-term care services, which are provided in an enrollee’s home, adult day care center or an assisted living facility. Programs covering these services are known as Home and Community Based Services (HCBS) waivers because recipients continue living in the community, rather than entering a nursing home.
Income limits: The income limit is $1,224 a month. Even if an applicant is married, only income received by the applying spouse is counted.
Asset limits: The asset limit is $2,000 if single and $4,000 if married (and both spouses are applying). If only one spouse has Medicaid, the other spouse can keep up to $128,640.
Eligibility rules for Medicaid LTSS programs are different than other Medicaid benefits when only one spouse needs long-term care. When that occurs, only income received by the applying spouse is counted. With other Medicaid benefits, the income of both spouses is counted regardless of who applies.
Federal spousal impoverishment rules allow the spouses of Medicaid LTSS recipients to keep a Minimum Monthly Maintenance Needs Allowance (MMMNA) from their Medicaid spouse’s monthly income, along with resource and housing allowances. These rules apply when one spouse receives Medicaid coverage for LTSS, and the other spouse doesn’t have Medicaid.
In Hawaii in 2020, these “community spouses” are allowed to keep:
Federal law requires states to limit the home equity that Medicaid nursing home and HCBS applicants can have. In 2020, states set these home equity limits based on a federal minimum of $595,000 and a maximum of $893,000.
In Hawaii, applicants for Medicaid LTSS can’t have more than $893,000 in home equity.
Because long-term care is expensive, individuals can have an incentive to give away or transfer assets to others so they can become eligible for Medicaid LTSS benefits. To curb this incentive, federal law requires states to have a penalty period for Medicaid LTSS applicants who give away or transfer assets for less than their value. States can also have a penalty period for HCBS. Applicants are not eligible for Medicaid long-term care benefits during their penalty period.
Hawaii has chosen to have an asset transfer penalty for nursing home care and HCBS. This penalty is based on a 5-year lookback period when asset transfers and gifts are prohibited. The penalty’s length is calculated by dividing the amount of money given away or transferred during the lookback period by the average cost for nursing home care (and this is $8,850 a month in Hawaii in 2020).
A state’s Medicaid agency is required to attempt to recover the cost of long-term care and related medical services received beginning at age 55. States can choose to also recover Medicaid benefits that are unrelated to LTSS. This is called estate recovery.
Hawaii has chosen to only pursue estate recovery from enrollees who received LTSS beginning at age 55. But the state also recovers from a small number of younger enrollees who were permanently institutionalized.
In Hawaii, estate recovery is waived for enrollees who are survived by their spouse, or by a child who is under 21, blind, or disabled.
Congress exempted Medicare premiums and cost sharing from Medicaid estate recovery starting with benefits paid after December 31, 2009, but states can recover the cost of MSP benefits received until that date. In Hawaii, this could only occur if an enrollee received LTSS.
You can receive free volunteer Medicare counseling through Hawaii’s State Health Insurance Assistance Program (SHIP). The phone number is 808-586-7299 on Oahu and 888-875-9229 on the other islands.
SHIPs can help beneficiaries enroll in Medicare, compare and change Medicare Advantage and Part D plans, and answer questions about state Medigap protections. They may also be able to offer you referrals to local agencies for services like home care and long-term care. This website has more information about the Hawaii SHIP.
Elder law attorneys can help individuals plan for Medicaid long-term care benefits. You can use the National Academy of Elder Law Attorneys (NAELA) online search feature to find an elder attorney locally.
Hawaii’s Long Term Care Ombudsman helps beneficiaries understand their options for long-term care and investigates complaints made regarding a person who is receiving LTSS. This program is offered through the state’s Aging and Disability Resource Centers (ADRC).
You can contact that program by calling 808-643-ADRC (643-2372) or visiting its website.
Medicaid is administered by the Department of Human Services (DHS) in Hawaii. You can apply for Medicaid ABD or an MSP:
Josh Schultz has a strong background in Medicare and the Affordable Care Act. He coordinated a Medicare expert technical assistance contract at the Medicare Rights Center in New York City, where he also represented clients in extensive Medicare claims and appeals. In addition to advocacy work, Josh helped implement federal and state health insurance exchanges at the technology firm hCentive. He has also held consulting roles, including at Sachs Policy Group, where he worked with hospital, insurer and technology clients.