Hawaii provides long-term care resources to seniors through the Department of Health, Executive Office on Aging (EOA). The EOA provides services through its four-county offices on aging for seniors over 60. Some services include Adult Day Care/Adult Day Health – Personal care for dependent older adults in a supervised, protective, and group setting during some portion of the day; Assisted Transportation – Door-to-door transit service, including escort, for those who have difficulties (physical or cognitive); Attendant Care– Companion assistance/oversight of older adults who are frail or have one or more disabling conditions; Case Management – Assistance to identify needs, explore options, and develop a care plan to achieve greater independence; Chore Services – Assistance for those unable to perform yard and heavy housework; Congregate Meals – A meal provided to an older adult in a group setting.

Home Delivered Meals – Meals delivered to frail and vulnerable older adults at their place of residence; Homemaker/Housekeeper – Help in preparing meals, grocery shopping, managing money, using the telephone, doing housework, and taking medication; Information and Assistance – A service that provides older adults information on services available within their communities and links them to these services; Legal Assistance– Legal advice, counselling, and representation by an attorney or legal assistant; Nutrition Education– Culturally sensitive health information and instruction on maintaining good nutrition; Personal Care – Assistance to older adults who are unable to bathe, eat, dress, toilet, and/or transfer from bed to chair by themselves; and Transportation– Transportation from one location to another.

For seniors who receive Medicaid for long-term care in a nursing facility, the state offers a Medicaid waiver program, known as a Section 1115 Demonstration Waiver, to allow participants to receive services at home or in a community-based setting rather than in a nursing facility. The Medicaid waiver in Hawaii is simply known as “Med-QUEST.” In 2009, the DHS implemented its QUEST Expanded Access (QExA) program that allowed its aged, blind, or disabled (ABD) population to also benefit from managed care.

Medicaid Waiver Program for Assisted Living and In-Home Care

Hawaii Med-QUEST Medicaid Waiver (Section 1115 Demonstration Waiver)

Medicaid-eligible aged, blind, and disabled and recipients of home and community-based services participate in the demonstration and receive coverage for Medicaid services, including long-term care. Hawaii’s QUEST Integration provides all services as defined in the Medicaid state plan to all individuals enrolled in the demonstration (except for the Affordable Care Act childless adults, who will receive benefits under the alternative benefit plan). The state provides additional benefits based on medical necessity and clinical criteria (including HCBS, cognitive rehabilitation, habilitation, and specialized behavioral health services). Benefits are provided through an integrated managed care delivery system.

Services

Services for HCBS participants who qualify through the “at-risk” category include: Personal assistance, Adult day care; Adult day health; Home delivered meals; Personal emergency response system (PERS); and Skilled Nursing.

Services for HCBS participants who qualify for the nursing home level of care include: Adult day care; Adult day health; Assisted living facility; Community care foster family homes; Counseling and training; Environmental accessibility adaptations; Home delivered meals; Home maintenance; Moving assistance; Non-medical transportation; Personal assistance; Personal emergency response system (PERS); Residential care; Respite care; Skilled nursing; Specialized case management; and Specialized medical equipment and supplies.

Eligibility

  1. Health: Applicants must meet a nursing home level of care or be “at risk” of needing an institutional level of care.
  2. Financial: The applicant must meet certain income and asset limits to qualify for Med-QUEST waiver services. For 2022, the income limit is equal to 138% of the Federal Poverty Level, which is $1,303 for an individual. The asset limits follow the same rules as Medicaid for the Aged (65+), Blind, and Disabled and for an individual is $2,000 (or $3,000 for a married couple). Hawaii also offers the medically-needy pathway for eligibility. For 2022, the income limit for the HCBS medically needy spend-down category of eligibility is $469 per month, based on 64% of the Federal Poverty Level.  The traditional spousal protection rules apply, and this means a non-applicant spouse may keep up to $137,400 in assets and receive a maximum of $3,435 in monthly income for expenses.

Practical Considerations

The four previous HCBS waivers operated by Hawaii’s Department of Health have been integrated into the single Med-QUEST Integration program. The practical issues that arise include that determination of eligibility are more complicated, and the income and asset limits have been decreased, meaning it is available to fewer people. However, the Med-QUEST Integration program specifically does not include any enrollment limit and anticipates serving more of the target populations than the previous HCBS waiver had. Med-QUEST services are provided through specific health plans, which maintain their own waiting lists by health plan program; however, the state reserves the right to monitor the waiting lists.

Conclusion

Hawaii’s Section 1115 Demonstration Waiver is a confusing Medicaid waiver program. Still, it will eventually help more seniors access Medicaid for long-term care due to some major revisions to the traditional HCBS waivers. In particular, the lack of an enrollment cap means that if a senior meets the financial and health criteria, then they can choose a health plan and start the enrollment process. Because Hawaii is not a special income limit state but uses specific SSI-related income criteria for determining income limits, Medicaid Planning would be very helpful in navigating the application process and ensuring that you can receive benefits as soon as possible.

Access all state Medicaid Waiver pages.