ExchangeCoverageHigh impact
ACA Individual Network Change
HMSA·HI·Network
Effective date
Jan 1, 2027
We identified it
Oct 4, 2026
Summary
Effective January 1, 2027, ACA Individual plans will transition to a Hawaii-only provider network. Out-of-state coverage will be limited to emergency services, urgent care, and prior-authorized medically necessary services unavailable in Hawaii. Non-emergency, non-urgent out-of-state services will no longer be covered.
Action Required
By December 31, 2026: (1) Billing team must update billing software to flag ACA Individual claims for out-of-state services and require prior authorization documentation before claim submission. (2) Update encounter forms and referral templates to require providers to confirm prior authorization status before arranging out-of-state care. (3) Create checklist for front-desk staff to verify member eligibility and out-of-state coverage limitations during scheduling. (4) Train all clinical and billing staff on new network restrictions and prior authorization requirements for out-of-state referrals. (5) Establish process to review membership cards for updated benefit language before providing or arranging care. Failure to obtain prior authorization for covered out-of-state services or billing non-emergency out-of-state services without authorization will result in claim denials.