Medical Financial Assistance Program

Having trouble paying for your Kaiser Permanente medical and pharmacy expenses?

Kaiser Foundation Hospitals and Kaiser Foundation Health Plans, collectively referred to as Kaiser Permanente, are committed to providing programs that facilitate access to care for vulnerable populations. This commitment includes providing financial assistance to qualified low income, uninsured and underinsured patients when the ability to pay for services is a barrier to accessing emergency and medically necessary care. Patients must meet the eligibility requirements below to qualify.

What's new?

Beginning August 1, 2022, when applying for medical financial assistance, award amounts will be based on your gross household income (before taxes) as a percentage of the federal poverty level. If your household has a higher income, you may qualify for an award equal to a maximum of 50% of your share of eligible medical expenses. Households with lower incomes can qualify for an award covering up to 100% of their share of eligible medical costs.

Award amounts will be based on your household income as a percentage of the 2022 federal poverty levels:

  • 100% of your share of eligible costs for households with incomes at or below 200% of the federal poverty level
  • 50% of your share of eligible costs for households with incomes between 201% and 300% of the federal poverty level

If your household or family size is:
2022 federal poverty guidelines

100% award for gross annual income at or below 200% of FPG

50% award for gross annual income between 201% and 300% of FPG
1 $31,260 $31,261 to $46,890
2 $42,120 $42,121 to $63,180
3 $52,980 $52,981 to $79,470
4 $63,840 $63,841 to $95,760
5 $74,700 $74,701 to $112,050
6 $85,560 $85,561 to $128,340

Visit aspe.hhs.gov/poverty to find the guidelines for larger households.

Note: Past MFA award recipients aren’t guaranteed future awards. Kaiser Permanente reserves the right to change the terms and conditions of the MFA program at any time. The MFA award is not a covered benefit and will not impact your existing plan coverage.

Who is eligible for Financial Assistance and what are the requirements?

The Medical Financial Assistance (MFA) program helps low-income, uninsured, or underinsured patients who need help paying for all or part of their medical care received from Kaiser Permanente. Patients are eligible for financial assistance when their family income is at or below 300% of the Federal Poverty Guidelines (FPG). Patients should consult with a counselor to determine eligibility and for assistance applying. Patients who have experienced unusually high medical expenses may be eligible for the program, regardless of household income. Refer to the MFA Policy for a complete description of the program eligibility requirements.

What does the program cover?

The MFA program covers emergency and medically necessary health care services, pharmacy services and products, and medical supplies provided at Kaiser Permanente facilities (i.e. hospitals, medical centers, and medical office buildings), at Kaiser Permanente outpatient pharmacies, or by Kaiser Permanente providers. Services that are not considered emergent or medically necessary as determined by a Kaiser Permanente provider include, but are not limited to cosmetic surgery or services, infertility treatments, retail medical supplies, surrogacy services, and services related to third party liability, or workers’ compensation cases. Refer to the MFA Policy for a complete list of eligible and ineligible services.

Which providers are and are not covered under the program?

The list of providers in Kaiser Foundation Hospitals that are and are not covered under the MFA policy can be found in our Kaiser Permanente provider list for Hawaii.

How can I get program information?

Copies of the MFA policy, application forms, instructions, and plain language summaries (such as policy summaries or program brochures) are available to the general public, without charge, from Kaiser Permanente’s website, by email, in person, by telephone, or by U.S. postal mail.

Download program information: Electronic copies of program information are available:

Medical Financial Assistance Policy (English) Chinese, Japanese, Korean, Laotian, Spanish, Tagalog, Vietnamese
Program Summary (English) Chinese, Japanese, Korean, Laotian, Spanish, Tagalog, Vietnamese
Program Application (English) Chinese, Japanese, Korean, Laotian, Spanish, Tagalog, Vietnamese

Request program information electronically: Electronic copies of program information are available by email upon request. Call 1-808-432-7940 or 1-800-598-5928 to request electronic copies. Please be prepared to provide an email address that the information can be sent to when calling.

Obtain program information in person: Program information is available at Admitting and Emergency Room Departments in Kaiser Foundation Hospitals. Financial Counselors are also available at Kaiser Permanente medical centers and medical office buildings to provide program information and to quickly determine MFA eligibility. Financial Counselors are available Monday through Friday, 8:30 a.m. to 5 p.m. at the Business Services Office in each of the following Kaiser Permanente facilities:

Moanalua Medical Center
3288 Moanalua Road
Honolulu, HI 96819

Honolulu Medical Office Building
1010 Pensacola Street
Honolulu, HI 96813

Waipio Medical Office Building
94-1480 Moaniani Street
Waipahu, HI 96797

Mapunapuna Medical Office Building 
2828 Pa’a Street
Honolulu, HI 96819

Request program information by telephone: Financial counselors are available by telephone to provide information, determine MFA eligibility, and assist a patient to apply for MFA. Financial counselors can be reached Monday through Friday, 8:30 a.m. to 5 p.m. Hawaii time, at 1-808-432-7940 or 1-800-598-5928.

Request program information by mail: A patient can request program information by mail. Information requests can be mailed to:

Kaiser Permanente
Attention: MFA Program – Business Services 
3288 Moanalua Road
Honolulu, HI 96819

How do I apply?

You can apply for medical financial assistance through Kaiser Permanente during or following a course of care or treatment received from Kaiser Permanente. To be eligible for the program, you must demonstrate an immediate need caused by a bill for an outstanding balance for Kaiser Permanente services, a scheduled appointment with Kaiser Permanente, or a pharmacy prescription ordered by a Kaiser Permanente provider for eligible services and meet income qualifications.

When you apply, you will be asked to list your household size and total gross household income, which will be validated by an external data source. Applying online is the quickest and easiest way to apply. If your income recently changed or you prefer to submit current financial documentation, you can fax or mail your MFA program application, along with your supporting financial documentation, as specified below. 

Household income source

Financial documentation to submit
Employment income wages Current pay stub with pay period and year-to-date gross wages
Business income/rental property Most recent tax return and all schedules
Unemployment benefits/disability income Unemployment Benefit Payment Summary showing your gross weekly benefits
Alimony/child support Court Divorce Decree/amount awarded
Pension or retirement/annuities Monthly gross benefit letter or most recent tax return and all schedules filed
Social Security/Supplemental Security Income/veterans benefits

Social Security and/or monthly veterans benefit letter showing the gross benefit

Important: Any missing or unclear information may delay the application process or result in a denial.

What should I expect after I apply?

After we review your completed application, we’ll send you a decision within 30 days of receipt. If it is not approved, we will provide a reason for the denial and instructions on how to appeal the decision if you disagree. 

 
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Apply online

  • Before starting the online application process, be prepared to provide all the information listed on the MFA application.
  • To begin your application, please provide your full name and email in the form below. Once submitted, you will receive instructions via email on how to complete your application. 

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Meet with a financial counselor

Meet with a financial counselor at one of our designated facilities, Monday through Friday, 8:30 a.m. to 5 p.m. Hawaii time.

  • Moanalua Medical Center
  • Waipio Medical Office Building
  • Honolulu Medical Office Building
  • Mapunapuna Medical Office Building

Be prepared to provide all the information listed on the MFA application.

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Call us

  • Call us at 1-808-432-7940 or 1-800-598-5928 (TTY 711), Monday through Friday, 8:30 a.m. to 5 p.m. Hawaii time.
  • Be prepared to provide the information listed on the MFA application.
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Mail it

  • Complete the MFA application on the following page.
  • Mail your completed application to: 
  • Kaiser Permanente
    Attention: MFA Program — Business Services
    3288 Moanalua Road
    Honolulu, HI 96819
Icon of a fax machine with a sheet of paper in it.

Fax it

  • Complete the MFA application.
  • Fax your completed application to 1-808-432-7950.
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Drop it off

  • Complete the MFA application.
  • Drop off your completed application at any Kaiser Permanente facility.

How do I appeal?

If your application was recently denied or you believe you qualify for a larger award, you can appeal the decision by providing the following:

  1. A letter indicating why you’re appealing (job loss, for example)
  2. Current financial documentation of your total gross household income to support your appeal; Refer to the table below for the required documentation of your income source

Household income source

Financial documentation to submit
Employment income wages Current pay stub with pay period and year-to-date gross wages
Business income/rental property Most recent tax return and all schedules
Unemployment benefits/disability income Unemployment Benefit Payment Summary showing your gross weekly benefits
Alimony/child support Court Divorce Decree/amount awarded
Pension or retirement/annuities Monthly gross benefit letter or most recent tax return and all schedules filed
Social Security/Supplemental Security Income/veterans benefits

Social Security and/or monthly veterans benefit letter showing the gross benefit

You may also file an appeal if your medical expenses exceed 10% of your annual gross household income over the previous 12 months. To do this, you should provide the following:

  • Proof of income for your annual gross household income
  • Proof of non-Kaiser Permanente medical and/or dental expenses
    • You must provide an itemized bill with the following information:
      • Provider’s name and address
      • Patient’s name
      • Description of services or supplies provided

Any payments you make before an appeal is approved and will not be refunded.

How long do I have to appeal?

  • To appeal a denial:
    • You have 30 days to file an appeal.
    • After 30 days, you will be asked to submit a new MFA application.
  • To appeal for a larger award:
    • You may appeal at any time before the award end date.

If you didn’t provide the requested financial documentation or if you have experienced a change in income, you can provide current or updated documentation, as listed in the financial documentation table above.

How do I submit an appeal letter and documentation?

To submit your appeal letter and documentation, please fax or mail using the contact information below:

  • By fax: 1-808-432-7950
  • By mail:
    Kaiser Permanente​
    Attention: MFA Program - Business Services​
    3288 Moanalua Road​
    Honolulu, HI 96819​

Send copies of official documents; originals are not required.

Write the following information on the first page of your proof of income:

  • First and last name
  • Medical record number (if any)
  • Home address
  • Date of birth

How long will it take for my appeal to be reviewed?

Once we receive the requested documentation, we’ll send you a decision about your appeal within 30 days. If you file an appeal without including any additional information with your request, we’ll automatically deny your appeal. All appeal decisions are final.

Amounts Generally Billed

Amounts Generally Billed is based on the lowest average of the amounts that were paid to a Kaiser facility by Medicare fee-for-service and Medicaid fee-for-service (and co-pays and deductibles) for emergency or medically necessary services, based on actual claim data from October 1, 2020, to September 30, 2021, which is consistent with the look-back method. Total expected payment from allowed claims was divided by total billed charges for such claims, and that number was subtracted from 1 to calculate the AGB percentage. The 2022 AGB reduction to gross charges is 69% for hospital charges.

Is there language assistance?

Interpreters are available to you at no cost. The medical financial assistance application, policy, and policy summary may be available in your language. For more information, call 1-808-432-5955.

Other beneficial programs and extra resources:

If you don’t have health care coverage and would like more information, call us at 1-800-479-5764 (TTY 711) Monday through Friday between 9 a.m. and 5 p.m. to learn more about your coverage options.

We’re here to support you however we can. If you need help with essentials like housing, child care, or food, Thrive Local Connections can help connect you to resources in your community. Call 1-800-443-6328 (TTY 711), Monday through Friday between 8 a.m. and 5 p.m.

Need help?

For help or questions about the Medical Financial Assistance application process or other questions, please call 1-808-432-7940 or 1-800-598-5928, or speak to a financial counselor within the Business Services Department at the Kaiser Permanente hospital.