Medicare Advantage Plans in Hawaii

checkmark Fact checked Contributing expert: Roseann Birch; Reviewed by: Leron Moore - Updated: Jul 06, 2021

 

Medicare Advantage plans, which are healthcare insurance policies offered by private Medicare-approved companies, give Hawaii's seniors an all-in-one alternative to Medicare Parts A and B. Benefits include medical and hospitalization coverage similar to that of federally managed Original Medicare plans, but these plans may bundle in additional options. Some insurers offer benefits for fitness programs, over-the-counter drugs, and medical transportation. Premiums, covered services, and out-of-pocket costs for care vary considerably by type of plan, region, and individual insurer, although all Medicare Advantage plans must cover urgent and emergency medical care.

Key Points

  • 1 In 2019, there were 20 Medicare Advantage plans available in Hawaii.
  • 2 45% of the total Medicare population in Hawaii is enrolled in Medicare Advantage plans as of 2018.
  • 3 In 2018, Original Medicare spent an average of $6,971 per beneficiary in Hawaii, which is 31% lower than the national average.
  • 4 Available Medicare Advantage plans range from six to 20 across Hawaii’s five counties.

MA plans must comply with Medicare-set rules, so members can expect the same rights and protections they receive with Original Medicare. By limiting out-of-pocket expenses and providing a wide array of coverage options, Medicare Advantage can help seniors manage their healthcare expenses. Potential enrollees should consider each plan’s specifications before selecting coverage, as some policies require members to declare a PCP, seek treatment from in-network practitioners, or obtain referrals for specialist visits. Plans may not be available in all geographic areas.

Medicare Advantage Plans in Hawaii

Types of Medicare Advantage Plans

Through Hawaii’s Medicare Advantage program, seniors can select coverage from an array of plan types, including numerous HMO and PPO options, and more limited PFFS plans. Individuals who have special needs related to a medical diagnosis, such as cancer or dementia, or who require long-term residential care may be entitled to enrollment in an SNP if one is available in their area. Coverage rules vary by plan type and insurer, and some policies may bundle in prescription drug coverage.

Health Maintenance Organizations (HMO)

Enrollees who opt for HMO plans receive most of their care through networks of plan-approved providers, which include physicians, specialists, and hospitals. Upon enrollment, members must select or be assigned an in-network primary care physician, who’s responsible for general and preventative health care, initiating treatment plans, and providing referrals to specialists. Out-of-network care is generally not covered through an HMO, except for emergencies. Compared to other types of MA plans, HMOs are typically considered the most affordable option. They usually have low premiums and often have small deductibles and copays or none at all. Many HMO plans are bundled with prescription drug coverage.

Preferred Provider Organizations (PPO)

PPO plans are typically more flexible than HMOs but often come with higher premiums and deductibles. Most PPOs don’t require members to select a PCP, but they do maintain a network of preferred providers. Seniors may stay in-network to keep costs down, or opt for higher-cost, out-of-network care with their choice of physicians and hospitals. Referrals aren’t required for visits to specialists. Some PPO plans may bundle in additional services, such as prescription drug plans, for a higher monthly premium.

Private Fee-For-Service Plans (PFFS)

PFFS plans let members receive care from any Medicare-approved healthcare provider that agrees to the plan’s coverage terms, but this flexibility comes with higher premiums. Medicare ultimately determines the cost to the patient, and out-of-network providers may refuse services to plan participants at their discretion. Some PFFS plans maintain a list of preferred practitioners, letting seniors keep costs low by receiving care from in-network providers. PFFS plan participants don’t have to select a PCP, and referrals aren’t required for visits to specialists. Prescription drug coverage may be bundled with these policies, or members can opt to purchase a supplemental Medicare Part D plan.

Special Needs Plans (SNP)

SNPs are targeted at specific groups of people, including those with chronic or disabling conditions such as HIV, heart failure, and diabetes. These plans may also be available to individuals with drug or alcohol dependencies, residents of long-term care facilities, and dual Medicare/Medicaid-eligible seniors. SNPs are designed for the unique health care needs of members, and often feature special drug formularies and tailored networks of providers that include specialists in the condition. Members receive services through in-network providers, and designated care coordinators often oversee treatment. Referrals are required for most specialist visits, and participants may only go out of network in an emergency or for out-of-area dialysis in cases of ESRD. Plan availability may vary widely by region each year.

Enrollment & Eligibility for Medicare Advantage Plans in Hawaii

Eligibility

Enrollment in Medicare may occur automatically or be initiated by the applicant, depending on the situation. To enroll in Hawaii’s Medicare Advantage program, applicants must meet strict eligibility guidelines:

  • They must qualify for Medicare Parts A and B
  • They must be U.S. citizens or legal residents
  • They must be aged 65 or older (younger applicants must have a qualifying disability)
  • Medicare Advantage plans must be available where the applicant resides
  • Applicants must not be enrolled in Medigap insurance

Seniors who’ve been diagnosed with End Stage Renal Disease aren’t eligible for most Medicare Advantage plans, except for applicable SNPs. Automatic enrollment in Original Medicare occurs when a senior has received Social Security or Railroad Retirement Board benefits for at least four months prior to their 65th birthday. These participants may elect to get coverage through an Advantage plan initially or change to an MA plan during the annual enrollment period.

Enrollment Periods

Medicare has four designated enrollment periods each year, during which participants may enroll in Medicare Advantage for the first time, drop coverage, revert back to Original Medicare, or switch insurance companies. Medicare Advantage also offers special enrollment periods for seniors who’ve experienced specific life events, such as release from jail, loss of current healthcare coverage, or enrollment in a PACE program.

  • Initial coverage election period: This seven-month period includes a senior’s 65th birthday month plus the three months before and after. Individuals aging into the program may enroll in Medicare Advantage at this time.
  • Annual election period: Running from October 15th through December 7th, this period offers current Medicare Parts A and B recipients the opportunity to switch to an MA plan. Members who already participate in an MA plan may change insurers or enroll in a prescription drug plan.
  • Open enrollment period: Beginning on January 1st and running through March 31st, current members may change insurers or plans or revert to Original Medicare during this period.
  • General enrollment period: Seniors who’ve been enrolled in Medicare Part A and have added Part B during the recent open enrollment period may switch from Original Medicare to an MA plan between April 1st and June 30th.

Prescription Drug Coverage

Medicare Advantage members may receive prescription drug coverage through Medicare Advantage Prescription Drug plans (MA-PDs). Many HMOs and PPOs include prescription drug coverage, and members who want this benefit should opt for a plan that bundles in this coverage. Participants may not add on a separate Medicare Part D prescription drug plan to HMOs or PPOs, as attempts to do so result in forfeiture of Medicare Advantage. PFFS plans may bundle in prescription drug coverage, but if not, members may elect to receive benefits through a separate Medicare Part D plan. Due to their nature, SNPs, by law, require the inclusion of prescription drug coverage. Prices and coverage of specific medications vary by insurer and individual plan.

Medicare Advantage Resources in Hawaii

Through Medicare Advantage, Hawaiian seniors have a wide array of available coverage options, and selecting the right plan can be challenging, especially for first-time enrollees. For vulnerable seniors, getting the right healthcare coverage is vital. State and local resources can help current MA members and potential applicants better understand the eligibility requirements and available coverage options, so they can determine which plan best suits their needs and budget.

Hawaii State Health Insurance Assistance Program (SHIP)

SHIP is a federally funded program administered by the Hawaii State Department of Health that offers no-cost, one-on-one benefits counseling to current and potential Medicare beneficiaries and their families and caregivers. Certified counselors are trained to help seniors make informed decisions about Medicare coverage by providing general information and education, and answering questions about Original Medicare, Medicare Advantage, and Medicare Part D prescription drug benefits. SHIP may also supply referrals to other organizations and community resources, as needed. Local counselors are available for residents on Oahu and the neighboring islands.

Contact Information: Website | 808-586-7299

Aging and Disability Resource Center (ADRC)

Sponsored by Honolulu’s Elderly Affairs Division, ADRC Hawaii helps seniors and disabled individuals assess their healthcare and budget needs so they can make informed decisions about Medicare benefits. ADRC Hawaii representatives are available through a free telephone helpline, offering benefits counseling services, and providing information, referrals, and assistance to seniors who need help enrolling in government programs such as Medicare.

Contact Information: Website | 808-768-7700

LASH is a not-for-profit law firm that provides legal advocacy and education to seniors aged 60 and older. The firm consults with seniors on an array of legal issues, including topics related to public benefits such as Medicare. Through the Senior Legal Hotline, Medicare members and potential enrollees may request advice and counsel and may receive referrals to other agencies, as applicable. In some cases, LASH may offer full representation at no cost. The hotline is available Monday through Friday. Seniors should leave a message by 1 p.m. and can expect a callback the same day.

Contact Information: Website | 888-536-0011

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Contributing Expert:

Roseann Birch, Medicare Consultant

With experience in the insurance field since 1986, Roseann Birch is a seasoned Medicare consultant who is passionate in educating and guiding seniors through their Medicare and Medicare Advantage journey.

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Reviewed by:

Leron Moore, Medicare Consultant

With over 10 years of experience in the Medicare industry, Leron Moore has dedicated his career to effecting change, educating, informing, and resolving issues for Medicare patients and their families.