Honolulu Senior AdvisorBy Honolulu Senior Advisor Care Team · October 7, 2026
A foster family home normally cares for up to two adults at nursing level, at least one on Medicaid, with a third Medicaid resident by approval. Since Act 30 (2017), the department may allow two private-pay residents in a three-bed home if they are a married couple or in a civil union, among other conditions.
The basic rule
Hawaii's statute, HRS 321-481, defines a community care foster family home as a home certified to provide 24-hour living accommodations, including personal care and homemaker services, for not more than two adults at a time who are at nursing facility level of care, unrelated to the family and receiving services from a licensed case management agency, with at least one of them a Medicaid recipient.
The department may certify a home for a third adult at nursing facility level of care who is a Medicaid recipient, once the home has operated for a year and its primary and substitute caregivers meet nurse aide training requirements.
What Act 30 added
The legislature found in 2017 that private-pay families also had limited long-term care options, and that couples in long relationships wanted to stay together. Act 30 lets the department, in consultation with the Department of Human Services, allow two private-pay individuals in the same home, considering several factors.
| Act 30 factor | What it means in practice |
|---|---|
| The home is certified for three beds | Two-bed homes do not qualify |
| A Medicaid bed has been vacant at least six months | The private-pay exception fills beds Medicaid has not |
| No Medicaid or private-pay client is moved out to make room | Existing residents are protected |
| The two private-pay residents are a married couple or in a civil union | It is a couples provision, not a general private-pay rule |
The department also considers the home's admission history and current client mix. In other words, private pay in a foster family home remains the exception.
What that means for families
On the March 2026 roster, 580 of Oahu's 1,111 foster family homes are certified for three beds. Only those can use the couples provision, and only when the other conditions are met. A single private-pay resident can sometimes be placed in a foster family home's non-Medicaid bed, because only one of the two residents must be on Medicaid, but openings depend on each home's mix.
If you are paying privately and want a foster family home, say so at the start when you talk to a case management agency. They will know which homes can consider it.
Why foster family homes stay Medicaid-centered
Foster family homes grew as a Medicaid alternative to nursing homes: a way for Med-QUEST members at nursing level to live in a family setting at lower cost to the state. The rules reflect that, from the Medicaid-bed requirement to the case management agency that oversees every resident. For private-pay families, care homes, especially expanded ARCHs, are usually the easier route to nursing-level care in a home.
Who oversees foster family homes
Foster family homes are certified rather than licensed. OHCA has designated Community Ties of America to perform certification for foster family homes, case management agencies and adult day care centers, and to take complaints about them at (808) 234-5380. Every resident also has a licensed case management agency, whose case manager assesses the resident, writes the service plan and visits regularly. Inspection reports for foster family homes are posted on OHCA's website.
What daily life looks like
A foster family home is a working household. The primary caregiver lives there and must be a nurse aide, LPN or RN with at least a year of home-setting experience, with an approved substitute who covers absences. Residents usually have their own bedroom and share meals with the family. For a parent who would be lost in a large building, that can be a good fit; for a parent who values privacy or wants company of their own age, a care home or assisted living may suit better.
If a private-pay placement is not possible
If no foster family home can take your parent as a private-pay resident, the closest alternative is usually an expanded ARCH, which can care for nursing-level residents and takes private-pay residents routinely. Some families pay privately in an expanded home until savings fall near the Med-QUEST limit and then apply, staying in the same home if it works with Med-QUEST. Others choose a nursing home for the first months and move to a foster family home once Med-QUEST is in place. A case management agency can lay out the options for your parent's care level and finances.
How to approach a placement
Ask a case management agency to assess your parent and explain which home types fit. Ask how payment would work in each. If your parent is likely to need Med-QUEST within a few years, a foster family home or an expanded ARCH that accepts Med-QUEST can avoid a forced move later.
Frequently asked questions
Can a private-pay resident live in a foster family home?
Sometimes, because only one of two residents must be on Medicaid; openings depend on each home.
What did Act 30 of 2017 change?
It lets the department allow two private-pay residents who are a married couple or in a civil union in a three-bed home, under conditions.
How many Oahu foster family homes have three beds?
580 of 1,111 on the March 2026 roster.
Who certifies foster family homes?
Community Ties of America, OHCA's designee, performs certification and takes complaints: (808) 234-5380.
