Improving Access to Health Care for Limited ... - Hablamos Juntos

Improving Access to Health Care forLimited English Proficient Health Care Consumers:Options For Federal Funding For Language Assistance ServicesApril 2003 Volume: 2 Issue: 1HEALTH...IN BRIEFPOLICY ISSUES FACING A DIVERSE CALIFORNIACalifornia is home to the most ethnically andlinguistically diverse population in the country.Approximately one out of every five Californians– over six million persons – do not speak Englishvery well and are considered “Limited EnglishProficient.” Limited English Proficient health careconsumers experience barriers to obtaining highquality, timely access to health services.Studies have shown that without languageassistance services, such as medical interpretingand translation of written health informationmaterials, the quality of health care for suchLimited English Proficient consumers suffers.Without effective health provider and patientcommunication in a language both canunderstand, there is an increased risk ofmisdiagnosis, misunderstanding about the propercourse of treatment and poorer adherence tomedication and discharge instructions.Federal Legal Requirements forLanguage Assistance Services forLimited English Proficient HealthCare ConsumersTitle VI of the Civil Rights Act of 1964 prohibitsdiscrimination on the basis of national origin byany recipient of federal funding. Federal courtshave ruled that Title VI prohibits discriminationbased on Limited English Proficiency. Today,almost all health care providers receive some typeof federal funding and must comply with Title VI.Executive Order 13166, issued by the ClintonAdministration in 2000, affirmed the prohibitionagainst discrimination based on Limited EnglishProficiency and the requirement of equal accessto federally funded health care and services forindividuals with Limited English Proficiency. TheExecutive Order also applied the Title VIprotections to all federal departments andagencies themselves.The Bush Administration Department of Justicesupports Executive Order 13166 and hasinstructed all federal departments and agenciesto continue its implementation. In June 2002, itfinalized its own Policy Guidance on Title VI andlanguage access. Although the Department ofHealth providers that receive federal funding maynot discriminate against Limited English Proficienthealth care consumers. Here in California, there areother requirements for managed health care plansto provide culturally and linguistically appropriateservices. While many providers believe thatlanguage assistance services are costly, they oftenoverlook the costs of not providing such services asa result of decreased patient satisfaction, medicalerrors and avoidable complications (and increasedhealth care costs) arising from miscommunication.There are several options to obtain federalfunding for language assistance services. Thisbrief identifies policy options for California thatwould allow the state, health plans and providersto maximize federal funding. This brief alsoprovides an in-depth analysis of how eight stateshave used federal funding to help implementlanguage assistance services for Limited EnglishProficient health care consumers (see insert).Counties with the Highest Percentages ofPeople with Limited English ProficiencyPercentage whospeak a languageother than EnglishPercentage whospeak English lessthan “very well”California (statewide) 39.5 20.0Imperial County 67.8 34.3Los Angeles County 54.1 28.9Monterey County 47.3 26.8San Francisco County 45.7 25.0Merced County 45.2 23.4Tulare County 43.8 22.4Orange County 41.4 22.4Santa Clara County 45.4 22.0Fresno County 40.8 20.7San Mateo County 41.5 18.5Health and Human Services has also publisheda Policy Guidance on Title VI and languageaccess, as of the publication of this brief, it hasnot yet been finalized.In June 2002, the Bush Administration Center forMedicare and Medicaid Services issued a finalregulation for Medicaid managed care programsthat includes a requirement of linguistic accessthat incorporates Title VI.(continued next page)

ate scale). Although technical approval by CMS would berequired, the California Department of Health Services(DHS) can add the billing code and estimated expensesas part of its annual Medicaid application submitted toCMS each November. No state legislation or other stateregulatory authorization is required. However, the statemust demonstrate that it has budgeted for the nonfederalshare of the new expenses.Alternatively, the California DHS could arrange to directlypay individual interpreters and translators or languageservice agencies for language assistance servicesprovided to MediCal beneficiaries who are not enrolledin a managed care plan. Individual interpreters could beenrolled as MediCal providers or the state could contractwith language service agencies. Quality assurance forinterpreter qualifications and skills could be overseen bythe state or by the contracted language service agency.It is important to note that even in counties withMediCal managed care, there are either individual healthcare consumers or types of medical services that are"carved out" and still reimbursed on a fee-for-servicebasis (e.g. certain children's services, certain long-termcare services, etc.).Policy Options to Ensure Language Accessand to Maximize Federal Funding forLanguage Assistance ServicesThere are several options that would ensure languageaccess for California’s Limited English Proficient healthconsumers and would maximize federal funding forlanguage assistance services.• To ensure compliance with federal law and regulation,the California DHS should issue a Medi-Cal ManagedCare Policy Letter clarifying that Medi-Cal managed carehealth plans and providers are required to providelanguage assistance services within existing capitationrates. The Managed Risk Medical Insurance Board(MRMIB) should issue a similar clarification to theplans and providers participating in the HealthyFamilies program.• DHS and MRMIB should offer technical assistance tomanaged care health plans and providers in trackingand analyzing the need for and costs of these languageassistance services.• The California DHS should consider an enhancedcapitation rate for Medi-Cal managed care plans andproviders offering language assistance services toLimited English Proficient health care consumers.Similarly, MRMIB should consider providing anenhanced capitation rate for plans and providersparticipating in the Healthy Families Program.• The California DHS should engage providers andinterpreters in determining the best method forreimbursing language assistance services in fee-forserviceMediCal. Options include establishing a billingcode and procedures for billing for language assistanceservices, contracting with language services agencies, orcontracting directly with interpreters.• The California DHS and MRMIB should explore morecost-effective and efficient mechanisms to ensure theprovision of language assistance services, including butnot limited to, state-funded and state-operatedinterpreter and translation services.

The California Endowment’s Initiative toEnsure Access to Care for Limited EnglishProficient Health Care ConsumersSince 1999, The California Endowment has invested morethan $15 million to support equal access to health care forLimited English Proficient health care consumers inCalifornia. The California Endowment’s efforts have focusedon three key strategies:Improving the training and professionalization ofmedical interpreters.Grants have supported the development ofinterpreter training curricula for communitycolleges and community-based organizations, thedevelopment of standards of practice by theCalifornia Healthcare Interpreters Association, andthe development of language proficiency tests forbilingual providers.Strengthening applied research and evaluation oflanguage assistance services.Grants have supported the evaluation of remotesimultaneous medical interpretation and videoconferencingmedical interpretation technologies,the development of tools and processes fortranslation of written materials, and thecommissioning of several studies on languageassistance services in California.Promoting policy and health delivery systems changeto ensure language access.Grants have supported the monitoring ofcompliance with current federal and Californialaws and regulations regarding language access,analysis of policy options to finance languageassistance services, convenings of a MedicalLeadership Council on Language Access, and theconducting of a social marketing campaign inpartnership with ethnic media focusing onLimited English Proficient health consumers.Thanks to John Dufner (Minnesota), Peter Ezzy (Maine),Lloyd Forbes (Idaho), Joyce Gaufin (Utah), Nora Guzman-Dyrseth (Washington), Lynette Honbo (Hawaii), Lucinda Reid(New Hampshire), Tim Roth (Washington), and JacklynnThiel (Montana), who provided valuable information on theirrespective state programs.Special thanks to Vivian Huang from the California Primary CareAssociation and Mara Youdelman from the National Health LawProgram for conducting background research about the statemodels and for their helpful editorial comments.Prepared by Ignatius Bau, The California Endowment andAlice Chen, former Health Policy Scholar in Residence at TheCalifornia Endowment and currently Soros PhysicianAdvocacy Fellow at the Asian and Pacific Islander AmericanHealth Forum.This publication was supported in part by a grant from theMedicine as a Profession Program of the Open Society Institute.Health ...In Brief is a publication of The CaliforniaEndowment. No part of this publication may bereproduced without attribution to The CaliforniaEndowment. To obtain additional copies, or torequest a copy be sent to a colleague or associate,please contact us at:info_publications@calendow.orgwww.calendow.orgor call800-449-4149, ext. 3513(Please specify electronic or printed version.)The California Endowment21650 Oxnard St., Suite 1200Woodland Hills, CA 91367Established by Blue Cross of CaliforniaCMPA / PBLA 04/03

MontanaMontana reimburses for language assistance servicesprovided to eligible Medicaid and State Children’sHealth Insurance Program recipients in conjunctionwith an otherwise covered medical service. Clients inboth the fee-for-service and Primary Care CaseManagement Medicaid program are eligible forlanguage assistance services.The provider is responsible for arranging for a qualifiedinterpreter, who is defined as “a person who speaksEnglish and another language fluently…. Fluency includesan understanding of nonverbal and cultural patternsnecessary to effectively communicate in that language.”There are no formal measures of qualifications.Both the provider and interpreter must attest that theinterpreter is qualified to provide medical interpretation,and must sign and date an invoice for submission to thestate. The state then reimburses the interpreter directly.Client family members and paid employees of the medicalprovider are not eligible for reimbursement.MinnesotaIn 2001, Minnesota began to reimburse its fee-for-serviceproviders, with the exception of inpatient hospitals, for thecost of interpreters under the state’s Medicaid program.Providers arrange and pay for interpreting services inconjunction with a covered medical service; writtentranslations and appointment scheduling are not covered.The providers can then bill the state the lesser of actualcharges or $12.50/quarter hour.There are no qualifications or standards for training,competency or ethical conduct of interpreters. However,client family members cannot serve as paid interpreters.There is no reimbursement for bilingual providers or staffinterpreters. Managed care organizations are required toprovide oral interpretation services to their enrollees undertheir current state contracts; many have establishedrelationships with interpreting agencies to providelanguage assistance services to their enrollees.Eligible interpreters are reimbursed at the lesser rate of$6.25/quarter hour or the usual and customary charge.Payment for travel or wait time is not permitted;interpreters are also not paid for “no-show” appointments.Interpreters are allowed to bill for one quarter hour perclient per day for time spent outside the provider office,specifically to exchange health care information, forexample, regarding medication use.