Since 2015, Hawaii switched to a federally-run health exchange, Healthcare.gov, after difficulties sustaining the Hawaii-based exchange. Two insurers offered plans in the Hawaii exchange in 2017: Kaiser Permanente, and Hawaii Medical Service Association (HMSA), the Blue Cross, Blue Shield affiliate. Hawaii’s enrollment numbers for private plans offered through the exchange remains relatively small. In 2017, 18,938 people enrolled in private plans through the exchange during open enrollment, which ended January 31st. This was a 30% increase over the previous year, when 14,564 Hawaii residents enrolled. Across all states that use HealthCare.gov, there was an average decrease in enrollment for 2017, making Hawaii’s enrollment increase significant.

The Title V agency continues to work on advancing the implementation of the Affordable Care Act (ACA) in Hawaii.  Most Hawaii Title V programs that provide direct and enabling services encouraged families and individuals served to enroll for health insurance through the federally-run exchange.

The Title V agency’s role in ACA is focused on working with stakeholders (including Medicaid) to promote expanded preventive benefits under ACA among consumers and service providers, and assure continued access to care.

The state expanded Medicaid under the ACA. Total net enrollment in Hawaii’s Medicaid program grew by more than 53,000 people from the fall of 2013 through March 2017—an 18% increase.

Hawaii’s uninsured rate has long been lower than the U.S. average, due to the Hawaii Prepaid Health Care Act. Enacted in 1974, the Act requires employers to provide a group health plan for employees working at least 20 hours a week for at least four straight weeks and earn a minimum of $542/month.  The law also mandates a generous set of benefits that must be provided.

Hawaii lawmakers passed Act 111 (2018) to ensure that the following ACA benefits, which may not otherwise be available under the State's Prepaid Health Care Act, remain available under Hawaii law:

• Extending dependent coverage for adult children until the children turn twenty-six years of age;
• Prohibiting health insurance entities from imposing a preexisting condition exclusion; and
• Prohibiting health insurance entities from using an individual's gender to determine premiums or contributions.

Another critical policy passed that will improve Hawaii’s healthcare system is Act 55 (2018) which establishes a new Health Analytics Program in the state Medicaid Office and allows the Medicaid program to maintain an All Payers Claims Database (APCD). The APCD is a joint initiative started in 2016 by the DOH, the Office of Enterprise Technology Services, the Department of Human Services, the State Health Planning and Development Agency, the Hawaii Employee-Union Health Benefits Trust Fund, the Department of Commerce and Consumer Affairs Insurance Division, the Department of Budget and Finance, and the University of Hawaii. The database will house information from insurers contracted to provide health benefits financed by the State, primarily health care claims for public employee unions and Medicaid beneficiaries.  Act 55 creates the dedicated health analytics capacity needed to analyze the data to improve transparency in the healthcare sector and improve understanding of healthcare costs, quality, population health conditions, and healthcare disparities.

As part of the Department of Human Services (DHS) health transformation efforts Ohana Nui (ON), the state Medicaid program (‘QUEST’) released a new waiver application/plan for public review and input: the Hawaii Ohana Nui Project Expansion (HOPE) program. The HOPE plan is a five-year initiative to develop and implement a roadmap to achieve the vision of healthy families and healthy communities. To accomplish this overall goal, it was necessary to align government agencies and funding around a common framework: a multigenerational, culturally appropriate approach that invests in children and families over the life-cycle to nurture well-being, and improve individual and population health outcomes. In vison and purpose, the HOPE plan mirrors the DOH strategic plan. The following guiding principles describe the overarching framework that will be used to develop a transformative healthcare system that focuses on healthy families and healthy communities:

• Assuring continued access to health insurance and health care
• Emphasis on whole person and whole family care over their life course
• Address the social determinants of health
• Emphasis on health promotion, prevention and primary care
• Emphasis on investing in system-wide changes

To accomplish the vision and goals, HOPE activities are focused on four strategic areas:

• Invest in primary care, prevention, and health promotion
• Improve outcomes for high-need, high-cost individuals
• Payment reform and alignment
• Support community driven initiatives to improve population health

In addition, HOPE activities are supported by initiatives that enhance three foundational building blocks:

• Health information technology that drives transformation
• Increase workforce capacity and flexibility
• Performance measurement and evaluation

FHSD is aligning Title V goals and objectives with the Medicaid program around this groundbreaking initiative.  FHSD will continue to explore opportunities for collaboration and partnerships around the four strategic areas and three foundational building blocks. Examples of current Title V partnerships include:

Current Agreements

• CSHNB/Early Intervention Services (EIS) is working with DHS/Med-QUEST Division (MQD) to amend/update the DHS-DOH MOA related to Medicaid payment for early intervention (EI) services.  An amendment to include the provision of EI services via telehealth is under consideration.
• CSHNB/EIS collaborated with DHS/MQD on guidelines and role delineation for collaboration between EIS and QUEST Integration (QI) health plans.  A 3/3/17 DHS MQD memo specifies a simple workflow outlining how and when information will be exchanged, and a detailed side by side role delineation of the EIS Care Coordinator and the QI health plan Service Coordinator.
• DHS/MQD clarified in its 5/31/17 memo that EIS may provide Intensive Behavioral Therapy (IBT) services to EI Medicaid children and will transition EI Medicaid children to QI health plans to cover Applied Behavior Analysis (ABA) services for Autism Spectrum Disorder (ASD).  An EI Care Coordinator and QI health plan Service Coordinator will collaborate on the transition. 

Current Activities

• In 2017, MQD issued two provider memos supporting best practices promoted by the Hawaii Maternal and Infant Health Collaborative (HMIHC) and the DOH Strategic Plan. Memo # QI-1613 supports the One Key Question® (OKQ) screening approach, Long Acting Reversible Contraception (LARC), and expanded access to contraception. Memo QI-1612 supports prenatal Screening, Brief Intervention and Referral to Treatment (SBIRT) pilot project requiring training and reimbursements for participating obstetricians. MQD is now assisting with evaluation of the policies.
• FHSD requests to DHS/MQD for data for Title V annual report/application
• FHSD participates as a member of the EPSDT Advisory Committee.
• Working collaboratively with MQD to process reimbursements for telehealth including the teledentistry pilot.
• With the inclusion of the Project ECHO telehealth program in the HOPE plan, several Medicaid insurance plans have invested funding to sustain and expand the telehealth curriculum offered by the project to rural health providers. In FY 2019 a new training series on pediatric health issues is being developed with this new funding. The project is supported by the FHSD Rural Health office and State Rural Health Association.

Opportunities

• Medicaid is conducting a cost analysis to reinstate adult preventive dental benefits.
• Medicaid payment for specialty formulas and medical foods.  WIC is expected to be the payer of last resort for specialty formulas and medical foods.  Depending on medical plan and diagnosis, DHS/MQD will pay for entirely tube-fed WIC clients and possibly oral feeding.
• Medicaid payment for childhood lead poisoning prevention activities such as follow-up of elevated blood lead levels.  Two states are using Medicaid funding for the state childhood lead funding. http://www.astho.org/Programs/Environmental-Health/Built-and-Synthetic-Environment/Healthy-Communities/State-Stories--Medicaid-Reimbursement-for-Childhood-Lead-Poisoning-Services.  Texas has Medicaid reimbursement for childhood blood lead surveillance, data management, case coordination, provider and parent education and environmental lead investigation.
• A new Title V - Title XIX agreement is being developed with our State’s Medicaid agency (DHS/MQD). The last agreement was dated 1995. A draft is attached in section IV.