Hawaii’s 1115 waiver renewal extension request: Housing support, SUD treatment, Native Hawaiian healing, and more


Hannah Saunders


With Hawaii’s current 1115 demonstration waiver expiring on July 31st, 2024, the state is seeking a five-year extension with several new initiatives. With the waiver, Hawaii is focused on improving health outcomes for individuals enrolled in Medicaid, and addressing social determinants of health to lower healthcare costs. 

The Hawaii Department of Human Services’ (DHS) public comment period for the waiver extension will remain open until Nov. 16th. The 1115 waiver extension renewal request is due to the Centers of Medicare & Medicaid Services (CMS) by Feb. 1st, 2024. From there, CMS will initiate their own public comment period, and if approved, the new waiver would go into effect on Aug. 1st, 2024. 

The MedQUEST Advisory Health Committee is hosting their second public forum regarding the 1115 demonstration renewal waiver on Tuesday, Oct. 24th at 6:00 PM local time.

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Judy Mohr Peterson, PhD, Med-QUEST Division Administrator for DHS, told State of Reform one of the waiver renewal’s goals is supporting individuals experiencing housing insecurity through Community Integration Services Plus

“What we’re hoping to do is expand our rental assistance activities to include six months of rental and utility assistance, including back payment of both utilities and rent,” Peterson said. 

This initiative would also provide tenancy support and medical respite services for individuals who are experiencing or at risk of homelessness. Peterson explained how some individuals who are discharged from hospitals don’t have a house or safe space to recover, but still require some care. She said the waiver extension is seeking to provide recuperative care and short-term post-hospitalization housing for up to six months to assist with recovery. 

The waiver also aims to increase Hawaiians’ access to healthcare coverage—especially for Keiki, or children. 

“What we’re looking to do is to extend that coverage so that the continuous eligibility is from zero to six [years old] for kids, so they would have continuous coverage from that time period. [For] ages six to 19, they would have two years of continuous coverage.”

— Peterson

Peterson hopes to continue increasing the high healthcare coverage rates in the state, noting how the COVID-19 pandemic allowed for three years of continuous Medicaid coverage for individuals on Med-QUEST. The continuous coverage period ended earlier this year, and MedQUEST has resumed eligibility redeterminations. 

“We believe that we’re in an excellent position to be able to sustain this, and make sure that kids have access to coverage—which is so important—especially in the early years to make sure that kids get the care that they need,” Peterson said. 

DHS also hopes to pilot a contingency management initiative for members with a qualifying substance use disorder, including stimulant use disorders and opioid use disorders. Contingency management is known to be one of the most effective interventions for individuals living with substance use disorders—particularly those who consume meth, according to Peterson. 

“In our state, meth use is the primary substance for illegal drug use. It far outpaces opioids.” 

— Peterson

Contingency management services include offering motivational incentives to advance substance use disorder goals, like cash equivalence for negative drug tests. 

“Our intention if it gets approved is to then supplement other evidence-based treatment and therapies, and pilot it and see how it goes, and then expand out depending on how it goes,” Peterson said.

The waiver extension seeks to provide Medicaid coverage to incarcerated individuals 90 days prior to release—similar to what states like California and Washington have done. Pre-release services would include case management and care coordination, physical and behavioral health clinical consultations, lab and radiology services, durable medical equipment, and a 30-day minimum supply of medications. 

“There’s a lot of excitement about this particular possibility for the initiative. Our philosophy in approaching this is to be as broad as we can,” Peterson said. 

Leaning into addressing social determinants of health, Hawaii is seeking approval for nutrition support under Medicaid. Peterson explained how the state piloted a program in Oahu at hospitals, clinics, and community health centers, to screen for social determinants of health. 

“One of the things that we found in the project is that food insecurity wound up being the top—by a lot—the top health-related social need that was affecting our population.” 

— Peterson 

Nutrition supports are intended to increase the consumption of nutritious foods, and individuals must have a health-related need for these services. Nutrition supports include nutrition education with up to 12 educational sessions, a one-time provision of cooking and gardening supplies to provide access to nutritional foods, fruit and vegetable prescriptions, and protein boxes.

Nutrition supports also include medically tailored meals and groceries—premade meals or groceries that support adherence to medically appropriate meal plans. A restock pantry support would assist with providing groceries—three meals per day up to seven days per week—which would particularly benefit children and pregnant women. 

With other states, like Arizona, seeking coverage of Indigenous and Native healing practices under Medicaid, DHS is seeking to gain approval to cover Native Hawaiian healing practices through the waiver extension. 

“It would be unique in the sense of these particular practices—which are Native Hawaiian—to be healing practices. We have a lot of information about Native Hawaiian healing practices, and we would be putting those forward. We hope to be able to lead the country in this.”

— Peterson

While there are six different types of Native Hawaiian healing practices DHS seeks to gain coverage for, if approved, Peterson said she does not expect to move forward with all of them at once.

These healing practices include lomilomi, a practice of massage of physiotherapy; hula, which is a traditional form of dance that increases mindfulness, physical movement, and social interaction; and ho’oponopono, which is the practice of peacemaking and is intended to restore and maintain healthy relationships. 

Other traditional Hawaiian healing practices include ‘ai pono, or the practice of holistic nutrition therapy; Lā’au lapa’au, which is the practice of herbalist healing; and Hāpai hānau, which are Native Hawaiian birthing practices and midwifery. 

“I do want to note that it would not be limited to those who identify as Native Hawaiian,” Peterson said. 

Peterson is excited about the potential this waiver extension has for Hawaiians’ health and looks forward to continuing to collaborate with stakeholders on the initiative.

“So far, there’s been nothing but a great amount of support,” Peterson said. “People are super excited about these opportunities.”