Medicare Advantage, also called MA or Medicare Part C, is private health insurance that seniors can purchase through Medicare-approved companies. Medicare Advantage is an alternative to Original Medicare, or Medicare Parts A and B. Unlike the federal government’s Original Medicare, Medicare Advantage plans offer additional coverage, which may include prescription medications and hearing and vision care, along with limited dental care. Benefits vary between insurance providers and plans, and premiums also vary depending on the insurance company, plan and co-pay levels.
Nationwide, Medicare Advantage enrollment varies by state. According to the Kaiser Family Foundation, 39% of all Medicare beneficiaries are enrolled in Medicare Advantage plans, up 13% from 2019. In Hawaii, approximately 47% of eligible seniors have a Medicare Part C plan. MA penetration rates are the highest in Maui County at 51% and lowest in Hawaii County at 36%. Medicare Advantage enrollment in Hawaii is dramatically different than in many other states, such as Alaska, which has the lowest enrollment rates in the nation at just 1% and Maryland, where enrollment rates are 13%.
Seniors in Hawaii who want to enroll in a Medicare Advantage plan can choose from a number of different plans and insurance providers. PPO and HMO plans are available, as well as SNPs, which include Medicare Part D prescription drug coverage. In this guide, we cover the different MA types, as well as the enrollment and eligibility criteria for each. We also highlight statewide and local programs that can help Hawaii seniors decide which Medicare Part C plan best fits their needs.
There are numerous options available to seniors seeking Medicare Advantage coverage in Hawaii, although the plans and providers are relatively limited when compared to other states. Beneficiaries can choose between a Preferred Provider Organization (PPO) and a Health Maintenance Organization (HMO). Special Needs Plans (SNPs), which include prescription drug coverage, are available to those who meet strict eligibility requirements. Plan availability varies between counties, and Medicare Advantage members who move to a different county within Hawaii may be required to switch their MA plan.
Preferred Provider Organizations (PPO)
Approximately 62% of Medicare Advantage members in Hawaii have coverage through PPOs. The cost of PPO plans are generally higher than HMO plans; however, PPO members can access out-of-network service providers while maintaining some coverage. In order to pay the lowest available co-pays, PPO members need to see in-network doctors and specialists. Unlike with Medicare Plan C coverage through an HMO, PPO members can usually self-refer to specialists, rather than seeing their primary care provider for a referral.
Health Maintenance Organizations (HMO)
HMOs offer plans with premiums that are usually lower than PPO plans. This lower cost means beneficiaries are subject to restrictions on which doctors they can see. To have costs covered by the insurance provider, HMO plan members can only see in-network providers. Otherwise, members are responsible for the full cost of any out-of-network care. Another important consideration with HMO Medicare Advantage plans is that specialist care is usually only covered when a referral is made through the members’ primary care physician.
Special Needs Plans (SNP)
In Hawaii, less than 1% of Medicare Advantage candidates qualify for an SNP, which is sometimes called a Dual Special Needs Plan (D-SNP). Those who qualify for both Medicare and Medicaid (dual-eligible), reside in an institution or have been diagnosed with a chronic health condition, such as end-stage renal disease, may be eligible for enrollment in an SNP. By law, all SNPs must include prescription drug coverage, commonly known as Medicare Part D. Services covered under an SNP are coordinated between in-network medical providers and the insurance company to reduce redundancies and improve care delivery.
Prior to enrolling in Medicare Advantage, seniors must first be enrolled in Original Medicare. Anyone who is eligible for Medicare Parts A and B is also eligible to enroll in Medicare Advantage. However, certain Medicare Advantage plans, such as SNPs, may have additional eligibility requirements.
Medicare Advantage has specific enrollment periods. One can only join a Medicare Advantage plan during the following periods:
Additionally, Medicare Advantage plan participants can change their plan outside of these enrollment periods under certain qualifying circumstances, such as moving to a new state.
In Hawaii, seniors who want prescription drug coverage must enroll in a Medicare Advantage plan that includes it. Otherwise, they must pay out-of-pocket for prescription medications. Seniors cannot be enrolled in both Medicare Part D and a separate Medicare Advantage plan at the same time. Medicare Advantage plan members who fail to comply with this rule will be automatically disenrolled from their Medicare Advantage plan. The only exception to this rule is SNPs, which must include Medicare Part D coverage.
Navigating the various Medicare plans, benefits and coverage options can be challenging. Before enrolling in a Part C plan, seniors should take the time to weigh their options, consider their needs and assess their budget. We’ve prepared a list of local and statewide resources that can help seniors decide which Medicare plan is right for their specific needs.
Hawaii’s State Health Insurance Assistance Program (SHIP) is a federally funded program that provides free Medicare counseling. Administered through the Hawaii State Department of Health, SHIP is open to Medicare beneficiaries, their families and their caregivers, as well as those seniors who will soon be eligible for Medicare. SHIP Medicare counseling is delivered through a network of trained and vetted volunteers. SHIP volunteer counselors can give seniors information on Medicare and Medicare Advantage, as well as programs that help low-income seniors. This free MA counseling is presented via small group sessions and on a one-to-one basis through in-person meetings and phone calls.
To connect with a local SHIP volunteer counselor, seniors can call Hawaii SHIP at 1-808-586-7299 on the Island of Oahu. Seniors who reside on neighboring islands can also call the statewide number at 1-888-875-9229. They can also complete an online contact form on the SHIP Hawaii website.Visit Website
The Legal Aid Society of Hawaii assists low-income seniors with issues related to Medicare Advantage. MA beneficiaries can access free and low-cost legal advice related to health insurance, and service is generally delivered through one-on-one appointments. Legal Aid counselors can also refer seniors to local resources related to Medicare.
The Legal Aid Society of Hawaii can be reached by phone at 1-808-536-4302.
Senior Medicare Patrols (SMPs) are federally-funded, state-regulated volunteer groups that work to improve Medicare for seniors by preventing, detecting and reporting health care fraud, abuse and billing errors. There are more than 40 SMP volunteers in Hawaii who provide free one-on-one counseling to help beneficiaries correct Medicare billing errors. SMPs also deliver free information workshops throughout the state and make referrals to state and federal agencies when Medicare abuse or fraud is suspected.
To contact the Hawaii Senior Medicare Patrol, Oahu seniors can call 1-808-586-7281. Those who live on neighboring islands can call the statewide toll-free number at 1-800-296-9422.
Hawaii’s Aging and Disability Resource Center provides seniors and their caregivers with help finding long term supports, services and resources related to health and wellness. Funded by the State of Hawaii, as well as each county, ADRC staff can assess each seniors’ eligibility for government-funded programs, help seniors find service providers and make referrals to local resources. ADRC workers can also work with seniors and their families to develop a long-term care plan that includes coverage through a Medicare Advantage plan.
To connect with a local ADRC staff member, seniors can call the ADRC statewide phone number at 1-808-643-2372.
The Hawaii County Office of Aging is the Area Agency on Aging for Hawaii County. The office works to plan, coordinate and administer programs and services for seniors, as well as to advocate for services that help older adults live with dignity. Seniors, adults with disabilities and their families can use the online needs assessment tool, use the eldercare search to find local resources and apply for country-funded services, such as transportation, adult day care and home-delivered meals.
To contact the Hawaii County Office of Aging, seniors can call either the Hilo or the Kona office. The contact number in Hilo is 1-808-961-8626, while the contact number for the Kona office is 1-808-323-4390.
The Country of Kauai Agency on Elderly Affairs (AEA) is the local Area Agency on Aging for Kauai. The AEA administers transportation, homemaker, personal care, respite and elderly nutrition programs for seniors aged 60 and older. The AEA also provides caregiver counseling, case management and referrals, with a focus on those seniors with low-incomes and those seniors who are socially isolated. Seniors and their caregivers can access many of AEA’s resources through Kauai’s virtual Aging and Disability Resource Center, and the AEA hosts a number of public education events throughout the year.