COFA migrants and Medicare/Medicaid in Hawaii

Citizens of the Compact of Free Association (COFA) nations — the Federated States of Micronesia, the Republic of the Marshall Islands, and the Republic of Palau — have unique status under U.S. immigration and health programs. Hawaii is home to the largest COFA population in the United States.

Who COFA migrants are

The Compact of Free Association is a series of agreements between the United States and three Pacific island nations: the Federated States of Micronesia (FSM), the Republic of the Marshall Islands (RMI), and the Republic of Palau. Under the Compacts, citizens of these nations can live, work, and study in the United States indefinitely without a visa.

The Compacts originated in part as compensation for the U.S. nuclear testing program in the Marshall Islands (1946-1958) and ongoing U.S. military access to the region. In return, the U.S. has unrestricted military access to roughly 2 million square miles of the Pacific.

Hawaii is home to the largest COFA migrant population in the U.S. — particularly Marshallese and Chuukese (FSM) communities concentrated in Honolulu County, with significant numbers in Waipahu, Kalihi, and on neighbor islands.

The history of COFA federal benefits eligibility

COFA migrants were originally eligible for federal benefits, including Medicaid. In 1996, the Personal Responsibility and Work Opportunity Reconciliation Act stripped that eligibility — meaning for nearly 25 years, COFA migrants were excluded from federal Medicaid even though they paid taxes.

During those years, Hawaii partially filled the gap with state-funded coverage, but access was limited and inconsistent.

In December 2020, Congress restored Medicaid eligibility to COFA migrants as part of the Consolidated Appropriations Act. In March 2024, the Compact Impact Fairness Act (signed by President Biden) made COFA migrants explicitly eligible for full federal benefits including Medicaid, SNAP, and SSI on the same terms as other qualified non-citizens — without any 5-year waiting period.

2026 federal eligibility — COFA migrants remain protected

Major federal changes taking effect in October 2026 (under the 2025 Budget Reconciliation Law / H.R. 1) restrict Medicaid eligibility for many lawfully present immigrants. COFA migrants are explicitly preserved in the new rules — they remain eligible for federal Medicaid, alongside lawful permanent residents and Cuban/Haitian entrants. Many other immigrant groups lose federal Medicaid eligibility under the new law.

The same protection applies to Medicare under section 71201 of the law: COFA migrants remain Medicare-eligible if they meet the standard age, work history, and disability requirements.

How to apply for Med-QUEST as a COFA migrant

If you are a citizen of FSM, RMI, or Palau living in Hawaii and meet the income and residency requirements, you can apply for Med-QUEST:

1. Online: medical.mybenefits.hawaii.gov
2. Phone (Oahu): (808) 524-3370
3. Phone (Neighbor Islands): 1-800-316-8005
4. Med-QUEST Community Partners: Free help with applications, available in multiple Pacific languages

You'll need:

• Documentation of your COFA nation citizenship — passport or I-94 record
• Proof of Hawaii residency
• Income documentation (pay stubs, tax records)
• For ABD or HCBS: bank statements and asset records

COFA migrants and Medicare

COFA migrants who reach age 65 in the U.S. and have the required work credits qualify for Medicare on the same basis as U.S. citizens. Hawaii has a growing population of COFA elders becoming Medicare-eligible — many of whom have been Hawaii residents for decades.

If you're a COFA migrant approaching 65:

• Apply for Medicare through Social Security at age 65 (or earlier with disability)
• Sign up at ssa.gov or call 1-800-772-1213
• Bring documentation of work history and COFA citizenship
• If income-eligible, also apply for Med-QUEST — dual-eligible status combines both

Language access

Med-QUEST and Medicare both provide free language services. Common COFA-area languages include Marshallese, Chuukese, Pohnpeian, Yapese, Kosraean, and Palauan. Free interpreters are available for Med-QUEST applications and Medicare calls — you should never be charged for interpretation, and family members should not be required to interpret medical conversations.

See our multilingual Medicare resources guide for details.

Community resources for COFA migrants

• We Are Oceania (WAO) — Honolulu-based COFA community organization providing health enrollment and advocacy
• Waipahu Safe Haven — community resource hub serving COFA migrants
• Pacific Islander Health Partnership
• Marshallese Community Health Worker programs through Hawaii community health centers
• Med-QUEST Community Partners — list at medquest.hawaii.gov
• Sage PLUS Hawaii for Medicare counseling: 1-888-875-9229

Health considerations specific to COFA communities

COFA migrants in Hawaii face disproportionate rates of certain health conditions, including diabetes (a particular legacy of mid-20th-century dietary changes), hypertension, and end-stage renal disease. Marshallese in particular have elevated rates of cancers linked to nuclear testing exposure. Medicare and Med-QUEST coverage are essential to addressing these health disparities, which is why the restoration of federal eligibility has been so significant for these communities.