Hawaii’s Medicaid program, called Med-QUEST, updated its fee schedule for 2026. Most provider payments are based on 100% of Medicare’s 2025 rates.
Understanding how to check eligibility and calculate your reimbursement is crucial for providers and beneficiaries alike.
Quick Summary:
- Hawaii Medicaid bases 2026 rates on 2025 Medicare fees
- Physicians receive 100% of Medicare rates for most services
- New rates for nursing, hospice, and FQHCs started January 1, 2026
- Most patients use QUEST Integration managed care plans
- Fee schedules vary by provider type and service category
- Official calculators help determine exact reimbursement amounts
How the Hawaii Medicaid Fee Schedule Works
Hawaii doesn’t publish one master PDF with all CPT codes. Instead, Med-QUEST uses a calculation system. This system bases payments on Medicare’s previous year rates.
The state administers two main programs. QUEST Integration covers managed care services. Fee-For-Service handles traditional Medicaid payments. Both programs follow specific payment rules.
Payment Formula for Providers
Different provider types receive different payment percentages. Here’s the breakdown for 2026:
- Physicians (MD/DO): 100% of 2025 Medicare rates
- Non-Physician Practitioners: 60% of 2025 Medicare rates
- Vaccines: 100% of Medicare rates
- Nurse Practitioners (APRNs): 60% unless mandated higher
These percentages apply to the Medicare Physician Fee Schedule base. Providers must check their specific category eligibility. Not all provider types qualify for 100% rates.
Medicare-Based Calculation
Hawaii Medicaid lags one year behind Medicare. The 2026 fee schedule uses 2025 Medicare values. This approach keeps rates stable and predictable.
Providers need to understand this lag time. You won’t find “2026” Medicare rates listed anywhere. Always reference the previous calendar year’s Medicare schedule.
Finding Your CPT Code Rates
Looking up a specific CPT code takes four simple steps. You’ll need access to Medicare’s fee schedule tools. Most providers can complete this process in under five minutes.
Step-by-Step Lookup Process
Step 1: Visit the CMS Physician Fee Schedule Search tool.
Step 2: Set the year to 2025 (not 2026). Remember the one-year lag.
Step 3: Select Hawaii as your location. Use locality code 01 or 010901.
Step 4: Enter your CPT code (like 99213). Look at the “Non-Facility Price.” Multiply by your provider percentage.
Example Calculation:
- CPT 99213 Medicare rate (2025): $93.00
- Physician payment: $93.00 × 100% = $93.00
- APRN payment: $93.00 × 60% = $55.80
If you’re enrolled in a QUEST Integration plan, your contract may differ. Check with your specific managed care organization.
To understand if you qualify for these rates, review the Hawaii Medicaid eligibility requirements for 2026 requirements.
2026 Rate Updates by Service Type
Several service categories received new rates effective January 1, 2026. These updates came through official Med-QUEST provider memos. Each category has unique payment rules.
Nursing and Hospice Facilities
New per diem rates took effect January 1, 2026. All nursing facilities received updated reimbursement amounts. Hospice services in nursing facilities receive special rates.
Key Rates:
- General Nursing Facilities: New per diem (Memo QI-2532)
- Hospice in Nursing Facilities: 95% of facility rate
- Standalone Hospice: Updated October 2025 rates (Memo QI-2522)
FQHC and Rural Health Clinics
Federally Qualified Health Centers use Prospective Payment System rates. These rates are effective from January 1 through December 31, 2026.
Updates Include:
- Memo QI-2533: Standard FQHC/RHC rates
- Memo QI-2603: Special rates for Waianae Coast Comprehensive Health Center
- Rates cover primary care, dental, and behavioral health services
Professional Services
Most professional services follow the Medicare percentage formula. Primary care providers often receive enhanced reimbursement. Specialty services vary by type.
Telehealth visits are paid at the same rate as in-person visits. This payment parity continues through 2026. Virtual visits must meet specific documentation requirements.
For information about provider payment levels in other states, see Medicaid Fee Schedule 2026 Comparisons.
Managed Care vs Fee-For-Service
Most Hawaii Medicaid patients enroll in QUEST Integration. This managed care model covers approximately 90% of beneficiaries. Only certain services remain in Fee-For-Service.
Five QUEST Integration Plans:
- HMSA (Blue Cross Blue Shield of Hawaii)
- Kaiser Permanente
- AlohaCare
- ‘Ohana Health Plan (WellCare)
- UnitedHealthcare Community Plan
Managed care plans negotiate their own provider rates. However, they must pay at least the FFS rate. For emergency care, plans follow strict minimum payment rules.
Fee-For-Service covers carved-out services. These include some dental care and behavioral health. Long-term care services often use FFS payment methods.
Important Payment Rules and Exceptions
Several special rules affect Medicaid reimbursement. Understanding these exceptions prevents payment surprises. Providers should review these carefully.
| Rule | Payment Impact |
|---|---|
| Waitlisted Patients | Lower sub-acute per diem rate for patients waiting for long-term care placement |
| Dual Eligibles | Medicaid pays only the balance after Medicare; may be $0 if Medicare exceeds Medicaid rate |
| Telehealth | Same rate as in-person visits for standard CPT codes |
| APR DRG Hospital | Special calculator required (effective July 1, 2022) |
Zero Dollar Codes: A $0.00 fee doesn’t always mean no coverage. Contact your QUEST Integration plan to verify coverage. Some codes require prior authorization despite showing zero.
Income requirements also affect coverage eligibility. Check Medicaid income limits by state for 2026.
Where to Access Official Fee Schedules
Official resources provide the most accurate information. Always verify rates before submitting claims. Med-QUEST updates schedules throughout the year.
Primary Resources:
- Official Fee Schedule Page: Med-QUEST Fee Schedules
- Provider Memos: Med-QUEST Provider Memos
- Help Line: (800) 235-4378 or (808) 952-5570
- Email Support: [email protected]
Key 2026 Documents:
- QI-2604: Home and Community-Based Services rates
- QI-2533: FQHC/RHC payment rates
- QI-2532: Nursing and hospice facility rates
- QI-2341: Professional fee schedule eligibility list
Download the Hawaii January 2026 DRG Calculator v.1.0 for inpatient hospital claims.
Frequently Asked Questions
Q: How do I find the 2026 Medicaid rate for CPT code 99213?
Look up the 2025 Medicare fee for Hawaii locality 01. Multiply that rate by your provider percentage (100% for physicians, 60% for most non-physician practitioners). Use the CMS Physician Fee Schedule tool for accurate amounts.
Q: Does Hawaii Medicaid pay the same as Medicare?
For physician services, Hawaii Medicaid pays 100% of Medicare’s previous year rates. Non-physician practitioners typically receive 60% of Medicare. Actual payments may vary based on managed care contracts and specific service categories.
Q: What is QUEST Integration and how does it affect payments?
QUEST Integration is Hawaii’s Medicaid managed care program. Most beneficiaries enroll in one of five health plans. Providers receive payment from the health plan, not directly from Medicaid, based on negotiated contract rates.
Q: Are telehealth visits paid the same as in-person visits?
Yes, Hawaii Medicaid pays telehealth visits at the same rate as in-person visits for 2026. The service must meet documentation requirements and use appropriate CPT codes. Payment parity continues from previous years.
Q: When do 2026 fee schedule updates take effect?
Most 2026 updates became effective January 1, 2026. This includes nursing facilities, hospice services, and FQHC rates. Professional services follow the 100% Medicare formula that started January 2024 and continues through 2026.
Q: Where can I download the complete Hawaii Medicaid fee schedule?
Hawaii doesn’t publish one complete PDF. Visit the official Med-QUEST fee schedules page for service-specific schedules. Use the Medicare lookup tool for professional service rates. Each service category has separate documentation and provider memos.
Last Updated: February, 2026
Sources: Hawaii Med-QUEST Division, Centers for Medicare & Medicaid Services (CMS)
Note: Medicaid rates and policies change regularly. Always verify current information with the official Med-QUEST Division website or contact Med-QUEST directly for provider-specific questions.
