As the individual states are working to comply with the provisions of the 2010 Patient Protection and Affordable Care Act, insurance regulations regarding pre-existing conditions will be among the first to change. Currently children cannot be denied coverage on the basis of such conditions, and adults will enjoy the same level of protection by 2014. Children can also remain on their parents health coverage through age 26, even if they are no longer in school or have married. Initially, the states were charged with getting high-risk insurance pools in place and working out plans to implement the required health care exchanges.
General Insurance Regulations
Health insurance regulations in Hawaii require group health carriers to insure individuals with pre-existing medical conditions. Currently, carriers may include an exclusion on the policy for a pre-existing condition for a period of time, but they cannot deny coverage. Employers who pay a portion of the premium of employee health care benefits receive a tax credit for the payments.
At present, Hawaii has no regulations for insurance applications, and individuals can be turned down for coverage for any reason. Rates can be based on gender, family medical history, age and other factors which make up the applicant’s risk profile. In their present form, Hawaiian regulations make no provision for individuals who are unable to find health insurance.
Hawaii does have a state government program called HawaiiQuest, which offers assistance to individuals and families whose income is less than 185% of the Federal Poverty Level. The HawaiiQuest program is limited to 125,000 people, but some people, like children and pregnant women, may be covered under the exception rule.
In Hawaii, all health care insurance policies must state the inception and expiration dates of the policy and the amount of the policy limit. If the application for the policy contains a material misrepresentation, the company has 3 years to challenge the validity of the contract. A material misrepresentation is a lie or omission on the application which might have caused the company to decline the policy if they had been aware of the truth. If the misrepresentation was deliberate (fraud), the insurer can deny a claim even after the three year limit.
Health Care Exchange
The Hawaii Health Connector insurance exchange was established on July 11, 2011, and will operate as a clearing house, which will include all qualified insurance plans.
Pre-Existing Condition Insurance
Hawaii’s Pre-Existing Condition Insurance Plan program, administered by the U.S. Department of Health and Human Services covers primary and specialty care, with benefits for hospitalization and prescription drugs. Depending on age and option chosen, monthly premiums fall in the range of $116 to $500 with deductibles of $1000 to $3000. (Medications may be covered under a separate drug deductible.) Combined out-of-pocket expenses may not exceed $7000 for care inside and out of the approved network.
Medicaid eligibility is set according to a determined percentage of the Federal Poverty Level, the same measurement used to disburse benefits through the Children’s CHIP-funded Medicaid Expansions. In Hawaii, infants under 1 year of age qualify for Medicaid at 185% FLP and for CHIP at 300%. For the 1-5 age group the percentages are 133 and 300 respectively. For age 6-19, Medicaid qualification is 100% and CHIP is 300%.
Pregnant women can access Medicaid at 185% FPL, parents at 300%, and childless adults (via a state program only) at 100%.
Hawaii also offers Medicare Assistance programs to help low-income Hawaiian residents with expenses like co-payments, deductibles, and prescription drug costs. More than 193,000 Hawaiians are enrolled in Medicare with 195,000 accessing Medicare prescription drug coverage.
Hawaii also offers various Medicare Saving Plans to address out-of-pocket expenses, which can also be defrayed by benefits through the Participating Patient Assistance Programs.