50-state desk · HI
Hawaii
Federal FAP onlyNo statutory FPL write-off floor. Hawaii uses higher HHS poverty guidelines. Employer coverage via the Prepaid Health Care Act is unusually strong; Medicaid is expanded.
I.R.C. § 501(r); Hawaii Prepaid Health Care Act · compiled September 2026
| Rule | This state |
|---|---|
| Free-care floor | — |
| Discount / eligibility floor | — |
| Covers insured patients | Yes, if they otherwise qualify |
| Which hospitals | Nonprofit / 501(c)(3) hospitals via federal 501(r) |
| Medicaid expansion | Yes — adults to 138% FPL |
| Screen before collections | Not required by state law |
| Credit reports | No state ban |
| Debt sales | Not banned |
| Home liens | Not banned |
| Wage garnishment | Tighter than the federal 25% cap |
| Interest on medical debt | No special cap located |
| Collection hold | No extra state waiting period |
| Lawsuit clock | 6 years · Haw. Rev. Stat. § 657-1 |
2026 poverty line here
Alaska and Hawaii use their own HHS tables. Everyone else uses the 48-state and D.C. figures, effective January 2026.
| Household | 100% | Free floor | Discount floor |
|---|---|---|---|
| 1 | $18,360 | — | — |
| 2 | $24,890 | — | — |
| 3 | $31,420 | — | — |
| 4 | $37,950 | — | — |
| 5 | $44,480 | — | — |
| 6 | $51,010 | — | — |
What to do
- 01 Use Hawaii FPL, not the 48-state table.
- 02 If this should have been prepaid-health-care employer coverage, say so on the appeal letter.
- 03 Itemize. Neighbor-island transfers often double-bill facility fees.
- 04 Apply for the hospital FAP; there is no state write-off statute.
Appeals
Federal No Surprises Act.
Insurance: Hawaii Insurance Division — external review
Medicaid: Med-QUEST fair hearing.
Medicare is federal regardless of state: redetermination, reconsideration, ALJ, Appeals Council, then district court.
Cite this in a letter
I request a FAP determination under Internal Revenue Code section 501(r), scored against Hawaii’s 2026 HHS poverty guideline.
Put a Hawaii bill in the machine.
The estimate will use this state’s floors. The letters will cite I.R.C. § 501(r); Hawaii Prepaid Health Care Act.
Start a Hawaii caseFederal overlay — every state
501(r)
501(c)(3) hospital organizations must publish a Financial Assistance Policy, a plain-language summary, and generally may not take extraordinary collection actions (selling the debt, reporting it, liens, lawsuits) until they have made reasonable efforts to determine FAP eligibility.
No Surprises Act
Emergency services, air ambulance, and many out-of-network clinicians at in-network facilities cannot balance-bill beyond in-network cost-sharing. Independent dispute resolution is between the plan and the provider — not a reason to pay the sticker rate.
FDCPA
15 U.S.C. § 1692g. Within 30 days of first collector contact, demand validation. Until validated, collection and credit reporting should stop. Partial payment can restart a state’s statute of limitations.
EMTALA
Emergency departments must screen and stabilize regardless of ability to pay. An ER bill is not an agreement that chargemaster rates are the cash price.
Medicare appeals
Five levels: redetermination (MAC, 120 days), reconsideration (QIC), ALJ at OMHA, Medicare Appeals Council, then federal district court. A remaining patient balance is often a claim the provider still needs to work.
Credit bureaus
The CFPB’s 2025 medical-debt reporting rule was vacated in July 2025. Industry practice still generally omits paid medical collections and unpaid balances under $500. Unpaid medical debt over $500 can appear after a delay unless a state ban applies. FCRA-preemption fights over those state bans are ongoing.