BILL ANALYSIS �
AB 505
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Date of Hearing: April 23, 2013
ASSEMBLY COMMITTEE ON HEALTH
Richard Pan, Chair
AB 505 (Nazarian) - As Amended: April 17, 2013
SUBJECT : Medi-Cal: managed care: language assistance services.
SUMMARY : Requires the Department of Health Care Services (DHCS)
to require all Medi-Cal managed care (MCMC) plans (MCPs)
contracted to provide Medi-Cal services to provide language
assistance to limited- English-proficient (LEP) enrollees as
specified. Specifically, this bill :
1)Requires interpretation services to be provided by the MCPs on
a 24 hour basis at all points of service.
2)Requires translation services to be provided to the language
groups identified by DHCS.
3)Requires DHCS to determine when an LEP population meets the
requirement for translation services using one of the
following numeric thresholds:
a) Three thousand LEP persons eligible for Medi-Cal reside
in the plan's service area, or 1,000 LEP persons eligible
for Medi-Cal reside in a single zip code; or,
b) Two contiguous zip codes with 1,500 LEP persons eligible
for Medi-Cal are in a health plan's service.
EXISTING LAW :
1)Under the federal Civil Rights Act, prohibits discrimination
based on race, national origin or color in federal assistance
programs.
2)Under federal regulations, requires federal agencies to ensure
meaningful access to services for persons with LEP.
3)Under state law, prohibits discrimination based on race,
national origin, ethnic group identification, religion, age,
sex, sexual orientation, color, genetic information, or
disability in any program or activity operated of administered
by a state agency.
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4)Under the Dymally-Alatorre Bilingual Services Act, requires
state and local agencies providing services to a substantial
number of non-English speaking people to provide bilingual
services.
5)Under SB 1840( Kopp), Chapter 672, Statutes of 1990, requires
hospitals to provide language services, interpreters, or
bilingual staff under specified circumstances and to identify
and record patients' primary languages in hospital records.
6)Under state law and regulation, requires commercial health
plans to assess their members language preference and provide
interpretation and translation services in threshold languages
for enrollees, other than Medi-Cal.
7)Establishes the Medi-Cal program, which is administered by
DHCS, under which qualified low-income individuals receive
health care services.
8)Authorizes DHCS to enter into contracts with managed care
organizations to provide health care services to Medi-Cal
enrollees, requires most persons eligible for Medi-Cal to
enroll in a MCP, and establishes a process for informing
enrollees regarding plan selection.
9)Provides, under federal law, increased federal matching funds
for translation and interpretation services provided in
connection with the enrollment, retention, and use of services
under Medicaid (Medi-Cal in California) and the Children's
Health Insurance Program known as the Healthy Families Program
(HFP) in California.
10)Defines for purposes of the Steven M. Thompson Physician
Corps Loan Repayment Program (STLRP) and the Steven M.
Thompson Medical School Scholarship Program (STMSSP), Medi-Cal
threshold languages as primary languages spoken by LEP
population groups meeting a numeric threshold of 3,000 LEP
individuals eligible for Medi-Cal residing in a county, 1,000
LEP individuals eligible for Medi-Cal residing in a single ZIP
Code, or 1,500 LEP individuals eligible for Medi-Cal residing
in two contiguous ZIP Codes.
FISCAL EFFECT : This bill has not been analyzed by a fiscal
committee.
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COMMENTS:
1)PURPOSE OF THIS BILL . According to the author, this bill is
intended to codify current language assistance requirements in
current contracts between DHCS and MCPs, in order to
strengthen these access standards. The author points out
that, more than 40% of Californians speak a language other
than English at home, and an estimated six to seven million
people (one in five) are LEP, meaning they speak English less
than "very well. The author states that for over a decade,
DHCS has required MCPs to provide language assistance to LEP
members. MCPs must provide oral interpretation services, in
all languages, on a 24 hour basis. Currently, by contract,
translation services of written documents, such as application
for enrollment or notice of benefits, must be provided when
the LEP population meets one of the numeric thresholds
specified in this bill. According to the author, the
following languages meet the current threshold required for
translation services: Arabic; Armenian; Cambodian; Cantonese;
Farsi; Hmong; Korean; Mandarin; Russian; Spanish; Tagalog;
and, Vietnamese. The author explains that DHCS instructs the
MCPs on how to provide both the oral interpretation and
written translation services, through policy letters and
contract requirements. The author states that in 2003,
languages assistance requirements were codified for commercial
plans licensed by the Department of Managed Health Care (DMHC)
or at the California Department of Insurance (CDI), but not
for MCPs.
2)BACKGROUND . Currently MCMC in California serves about 5.2
million enrollees in 30 counties, or about 69% of the total
Medi-Cal population. There are three models. The oldest
model is the County Operated Health System (COHS). COHS plans
serve about one million enrollees through six health plans in
14 counties: Marin, Mendocino, Merced, Monterey, Napa, Orange,
San Mateo, San Luis Obispo, Santa Barbara, Santa Cruz, Solano,
Sonoma, Ventura, and Yolo. In the COHS model, DHCS contracts
with a health plan created by the County Board of Supervisors
and all Medi-Cal enrollees are in the same health plan. The
second model is the two-Plan model in which there is a "Local
Initiative" and a "commercial plan" (CP). DHCS contracts with
both plans. The Two-Plan model serves about 3.6 million
beneficiaries in 14 counties: Alameda, Contra Costa, Fresno,
Kern, Kings, Los Angeles, Madera, Riverside, San Bernardino,
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San Francisco, San Joaquin, Santa Clara, Stanislaus, and
Tulare. Two-counties employ the Geographic Managed Care (GMC)
model: Sacramento and San Diego. In the GMC model, DHCS
contracts with several commercial plans and there are
approximately 600,000 enrollees. Beginning September 1, 2013,
DHCS will expand MCMC into the remaining 28 mostly rural
counties. Enrollees in nine of the counties will become
members of existing COHS. Eighteen counties will become a new
two-plan rural region with a choice between two CPs. The
final county is still in the process of a plan selection.
DHCS has embarked upon an ambitious array of initiatives that
could result in over two million new enrollees into MCPs in
2012 and 2013. These program changes include all age groups
and all geographic regions. For example, DHCS is currently in
the process of transitioning approximately 860,000 HFP
children statewide to the Medi-Cal program in four phases
throughout 2013. In November of 2010, California obtained
federal approval for a Section 1115(b) Medicaid Demonstration
Waiver from the Centers for Medicare and Medicaid Services
(CMS) entitled "A Bridge to Reform Waiver." Among other
provisions, this waiver authorized mandatory enrollment into
MCPs of over 600,000 low-income seniors and persons with
disabilities (SPDs) who are eligible for Medi-Cal only (not
Medicare) in the 14 two-plan and 2 GMC counties. Enrollment
was phased in over a one-year period in the affected counties;
beginning on June 1, 2011. Prior to this, mandatory
enrollment was limited to children and their families for 30
counties and SPDs in the 14 counties served by COHS. In eight
counties, DHCS will begin adding Long-Term Services and
Supports (LTSS), previously carved out of managed care and
largely provided through fee-for-service (FFS), as services
provided through the MCPs. The counties include two COHS
counties, one GMC county, and the other five are two-plan
model.
Under the Federal Affordable Care Act (ACA), states must expand
Medicaid eligibility up to 138% of the Federal Poverty Level
(FPL) for families, pregnant women, and children. States also
have the option to cover childless adults between ages 19 and
65 with incomes under 138% who are not currently Medi-Cal
eligible. This expansion is estimated to result in between
one million and 1.4 million more Californians enrolling in
Medi-Cal by 2019. Most of these newly eligible will be
enrolled in MCMC.
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3)MEDI-CAL THRESHOLD . According to the sponsors, the thresholds
were developed as part of a MCMC work group convened by DHCS
in the early '90s when California was planning to transition
the majority of their Medi-Cal beneficiaries into managed
care. Work group members, in partnership with the Office of
Multicultural Health, reviewed Medi-Cal data on the language
needs of the beneficiaries and determined that setting the
threshold at 3,000 in a county would provide translated
materials to two-thirds of the beneficiaries whose primary
language is other than English. This threshold has been
codified for purposes of STLRP and STMSSP. Both programs
require priority consideration to applicants who speak a
Medi-Cal threshold language, along with those coming from an
economically disadvantaged background or having experience in
a medically underserved area or with medically underserved
populations.
With regards to Medi-Cal, these thresholds appear to have been
adequate to serve the existing populations when needed, as
indicated by an inquiry to DHCS regarding recent complaints to
the MCMC ombudsmen. The ombudsman reported no complaints
relating to insufficient provision of translation and
interpretation services by MCPs or providers.
4)SUPPORT . The California Pan-Ethnic Health Network (CPEHN),
sponsor of this bill, writes in support that currently, DHCS
requires MCPs to provide translated documents when a LEP
population makes up a certain percentage or a "threshold" of
the enrollee population. MCPs will see an influx of LEP
enrollees after 2014. Over 1.42 million individuals from
communities of color will be newly eligible for Medi-Cal under
the federal ACA, over one-third will speak English less than
very well. CPEHN argues that the time is ripe to codify the
State's decades-long language assistance policies that have
helped to provide better access to health care for millions of
LEP patients. CPEHN further states this bill protects the
rights of LEP communities by codifying existing language
assistance requirements in the MCMC program.
The Asian Law Alliance (ALA) writes in support that without
linguistically and culturally competent interpretation, many
patients do not understand their health care provider or how
their health insurance works. ALA further states that as a
result, without competent interpreters who understand medical
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terminology and understand the patient's culture, a patient
may end up with the wrong diagnosis or fail to comply with the
doctor's orders. In addition, ALA states that it has seen
several clients end up with huge medical bills which are not
covered by the HMOs simply because the client did not
understand or comply with evidence of coverage.
5)RELATED LEGISLATION .
a) AB 411 (Pan) provides that the DHCS shall require all
MCPs to analyze quality performance measures, by race,
ethnicity, and primary language to identify disparities in
medical treatment and to implement strategies to reduce
disparities. Requires MCPs to link individual level data
to patient identifiers in order to allow for an analysis of
disparities in medical treatment by race, ethnicity, and
primary language and provide the information annually to
DHCS. Requires DHCS to make the data available for
research in a method that complies with the Health
Insurance Portability and Accountability Act of 1996.
b) AB 1263 (John A. P�rez) establishes the Medi-Cal Patient
Centered Communication (CommuniCal) program at DHCS to
provide and reimburse for certified medical interpretation
services to LEP Medi-Cal enrollees. Establishes a
certification process and registry of CommuniCal certified
medical interpreters at the California Department of Human
Resources and grants CommuniCal certified medical
interpreters collective bargaining rights with the state.
6)PREVIOUS LEGISLATION .
a) AB 2392 (John A. P�rez) of 2012, was substantially
similar to AB 1263. AB 2392 died on the Assembly inactive
file.
b) SB 442 (Calderon) of 2011 would have required general
acute care hospital policies for the provision of language
assistance to patients with language or communication
barriers to include procedures for discussing with the
patient any cultural, religious, or spiritual beliefs or
practices that may influence care and to increase the
ability of hospital staff to understand and respond to the
cultural needs of patients. Would have required hospitals'
policies on language assistance services to include
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criteria on proficiency similar to those that apply to
health plans. SB 442 was vetoed by the Governor.
c) SB 1405 (Soto) of 2006 would have required the
Department of Health Services (now DHCS) to create the Task
Force on Reimbursement for Language Services, as specified,
to develop a mechanism for seeking federal matching funds
from CMS to pay for language assistance services, as
specified. SB 1405 was placed on the inactive file.
d) AB 800 (Yee), Chapter 313, Statutes of 2005, requires
all health facilities (hospitals, skilled nursing
facilities, intermediate care facilities, and correctional
treatment centers) and all primary care clinics to include
a patient's principal spoken language on the patient's
health records.
e) SB 853 (Escutia), Chapter 713, Statutes of 2003,
requires DMHC and CDI to adopt regulations to ensure
enrollees have access to language assistance in obtaining
health care services
REGISTERED SUPPORT / OPPOSITION :
Support
California Pan-Ethnic Health Network (sponsor)
American Federation of State, County and Municipal Employees,
AFL-CIO
Asian Law Alliance
Asian Pacific Community in Action
Asian Pacific Islander Caucus for Public Health
California Children's Health Coverage Coalition
California Health Advocates
California Immigrant Policy Center
Health Access California
Health Through Action Arizona
National Association of Social Workers - California Chapter
Southeast Asia Resource Action Center
Street Level Health Project
Worksite Wellness L.A.
One Individual
Opposition
AB 505
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None on file
Analysis Prepared by : Marjorie Swartz / HEALTH / (916)
319-2097