BILL ANALYSIS �
SENATE COMMITTEE ON HEALTH
Senator Ed Hernandez, O.D., Chair
BILL NO: AB 505
AUTHOR: Nazarian
AMENDED: June 4, 2013
HEARING DATE: June 12, 2013
CONSULTANT: Bain
SUBJECT : Medi-Cal: managed care: language assistance services.
SUMMARY : Requires the Department of Health Care Services to
require all managed care plans contracting with Department of
Health Care Services to provide Medi-Cal services to provide
language assistance services to limited-English-proficient
Medi-Cal beneficiaries who are mandatorily enrolled in managed
care by requiring interpretation services to be provided in any
language on a 24-hour basis at all points of service, and
requiring translation services to be provided to the language
groups identified by Department of Health Care Services meeting
specified numeric thresholds.
Existing law:
1.Establishes the Medi-Cal program, which is administered by
Department of Health Care Services (DHCS), under which
qualified low-income individuals receive health care services.
2.Permits the director of DHCS to contract, on a bid or non-bid
basis, with any qualified individual, organization, or entity
to provide services to, arrange for or case manage the care of
Medi-Cal beneficiaries. Permits, at the director's discretion,
the contract to be exclusive or non-exclusive, statewide or on
a more limited geographic basis, and include provisions to
provide for delivery of services in a manner consistent with
managed care principles, techniques, and practices directed at
ensuring the most cost-effective and appropriate scope,
duration, and level of care.
3.Prohibits, under Title VI of the Civil Rights Act of 1964, a
person in the United States, on the grounds of race, color, or
national origin, from being excluded from participation in,
denied the benefits of, or subjected to discrimination under
any program or activity receiving federal financial
assistance.
This bill:
Continued---
AB 505 | Page 2
1.Requires DHCS to require all managed care plans contracting
with DHCS that provide Medi-Cal services to provide language
assistance services to limited-English-proficient (LEP)
beneficiaries who are mandatorily enrolled in managed care in
the following manner:
a. Interpretation services in any language on a
24-hour basis at all points of service.
b. Translation services to the language groups
identified by DHCS.
2.Requires DHCS to determine when an LEP population meets the
requirement for translation services using one of the
following numeric thresholds:
a. A population group of 3,000 Medi-Cal
beneficiaries who are mandatorily enrolled in managed
care, reside in the service area, and who indicate
their primary language as other than English; or,
b. A population group of Medi-Cal beneficiaries
who are mandatorily enrolled in managed care, reside
in the service area, who indicate their primary
language as other than English, and that meet a
concentration standard of 1,000 beneficiaries in a
single ZIP Code or 1,500 beneficiaries in two
contiguous ZIP Codes.
3.Requires DHCS to make this determination if any of the
following occurs:
a. A nonmanaged care county becomes a new managed
care county;
b. A new population group becomes a mandatory
Medi-Cal managed care beneficiary population; or,
c. A period of three years has passed
since the last determination.
4.Requires DHCS to instruct managed care plans of the language
groups that meet the numeric threshold by means of
incorporating this requirement into plan contracts, all-plan
letters or similar instructions.
5.Designates a person as "limited English proficient" if an
individual speaks English less than very well.
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FISCAL EFFECT : According to the Assembly Appropriations
Committee, this bill has minor and absorbable costs to DHCS, as
this bill essentially codifies current practice.
PRIOR VOTES :
Assembly Health: 18- 0
Assembly Appropriations:17- 0
Assembly Floor: 72- 0
COMMENTS :
1.Author's statement. This bill achieves the goals of the
federal Affordable Care Act (ACA) to increase access and
availability of health care options and strengthens consumer
protections for Medi-Cal managed care LEP enrollees by
codifying in state law the language assistance requirements in
Medi-Cal managed care. The author states language barriers
limit access to health care at every level, from scheduling an
appointment to receiving a medical diagnosis. This bill would
ensure that necessary protections for LEP individuals are not
lost in the process of implementing the changes made by the
ACA.
2.Federal anti-discrimination law. Title VI of the Civil Rights
Act of 1964 and its implementing regulations provide that no
person shall be subject to discrimination on the basis of
race, color, or national origin under any program or activity
that receives federal financial assistance. The federal
Department of Health and Human Services (HHS) Office for Civil
Rights (OCR) responsibilities include enforcing the Civil
Rights Act, the Americans with Disabilities Act, and the Age
Discrimination Act. Any organization or individual who
receives monies through HHS-health departments, health plans,
social service agencies, nonprofits, hospitals, clinics, and
physicians-is subject to OCR oversight. The OCR has the
authority to investigate complaints related to linguistic
barriers, to initiate its own reviews, and to withhold federal
funds for noncompliance.
Federal guidance to OCR staff states that recipients of federal
funding have the responsibility for ensuring that their
policies and procedures do not deny LEP individuals equal
access to federally assisted health, medical and social
service programs. The guidance states the key to ensuring
equal access to benefits and services for LEP individuals is
to ensure the service provider and the LEP client be given
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information about, and be able to understand, the services
that can be provided. The guidance states that achieving
effective communication with LEP persons may require the
recipient of federal funding to take all or some of the
following steps at no cost or additional burden to the LEP
beneficiary:
a. Have a procedure for identifying the language needs
of patients/clients;
b. Have ready access to proficient interpreters, and
provide services, in a timely manner during hours of
operation;
c. Develop written policies and procedures regarding
interpreter services; and,
d. Disseminate interpreter policies and procedures to
staff and ensure staff awareness of these policies and
procedures and of their Title VI obligations to LEP
individuals.
3.Percentage of Californians who are LEP and current DHCS
standards. According to the US Census Bureau 2010 American
Community Survey, 43.7 percent of Californians over the age of
5 speak a language other than English, and 19.9 percent of
Californians over the age of 5 speak English "less than very
well."
DHCS' Medi-Cal Managed Care Division is responsible for
determining statewide translation threshold languages and
their numeric estimate for Medi-Cal managed care counties.
DHCS establishes the thresholds through its contractual
language with plans and through DHCS-issued All Plan Letters
(APLs). Through contract, DHCS requires its Medi-Cal managed
care plans to ensure equal access to health care services for
its members without regards to a member's proficiency in the
English language.
A June 2002 APL requires plans to provide 24 hour interpreter
service for all LEP members at all provider sites within the
plans' service areas. In addition, plans are required to
provide translation services to their Medi-Cal LEP members
based on certain population levels, which this bill codifies.
Plans must provide interpreter and translation services when a
LEP member population meets a numeric threshold of 3,000
members residing in its service area. Both services must be
provided to LEP member populations meeting concentration
standards of 1,000 members in a single zip code, or 1,500
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members in two contiguous zip codes. There are currently 13
Medi-Cal threshold languages (English, Arabic, Armenian,
Cambodian, Cantonese, Farsi, Hmong, Korean, Mandarin, Russian,
Spanish, Tagalog, and Vietnamese).
DHCS' APL and contract does not define LEP. This bill defines
LEP as an individual who speaks English less than very well,
which is the definition used by the United State Census.
4.Related legislation.
a. AB 411 (Pan) requires all Medi-Cal managed care
plans to analyze quality performance measures, by race,
ethnicity, and primary language to identify disparities
in medical treatment and to implement strategies to
reduce disparities. In addition, AB 411 requires Medi-Cal
managed care plans 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. Finally, AB 411 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. AB
1263 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.
5.Prior legislation.
AB 2392 (John A. P�rez) of 2012, was substantially similar to
AB 1263. AB 2392 died on the Assembly inactive file.
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
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patients. SB 442 would have required hospitals' policies on
language assistance services to include criteria on
proficiency similar to those that apply to health plans. SB
442 was vetoed by the Governor.
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.
AB 800 (Yee), Chapter 313, Statutes of 2005, requires all
health facilities (hospitals, skilled nursing facilities,
intermediate care facilities, correctional treatment centers)
and all primary care clinics to include a patient's principal
spoken language on the patient's health records.
SB 853 (Escutia), Chapter 713, Statutes of 2003, requires the
Department of Managed Health Care and the California
Department of Insurance to adopt regulations to ensure
enrollees have access to language assistance in obtaining
health care services.
6.Support. This bill is sponsored by the California Pan-Ethnic
Health Network (CPEHN) to strengthen consumer protections for
Medi-Cal managed care enrollees who speak English less than
very well by codifying current language assistance
requirements in Medi-Cal managed care. CPEHN states
California's population is one of the most diverse in the
country, with more than 40 percent of Californians speaking a
language other than English at home. An estimated 6 to 7
million Californians are LEP, and over 1.4 million individuals
will be newly eligible for Medi-Cal, over one-third of whom
will speak English less than very well. CPEHN states language
barriers limit access to quality health care at every level,
from scheduling an appointment to receiving an improper
medical diagnosis.
In addition, CPEHN states federal and state laws require health
plans to meet the language needs of LEP persons as Title VI of
the 1964 Civil Rights Act prohibits discrimination against
persons based upon national origin, which has been interpreted
to include people who do not speak English very well. CPEHN
states that DHCS requires Medi-Cal managed care plans to
provide translated documents when a LEP population makes up a
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certain percentage or a "threshold" of the enrollee
population. The provision of oral interpretation is required
24 hours at all points of contact in all languages. The
current thresholds were developed as part of a Medi-Cal
Managed Care work group convened by the Department of Health
Care Services in the early 1990s 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. By codifying these
current language assistance requirements, CPEHN argues this
bill will ensure LEP members' access to quality health care.
7.Drafting issues. This bill as drafted affects managed care
plans contracting with DHCS to provide Medi-Cal services and
is intended to codify existing translation and interpretation
requirements. However, as drafted, it is unclear whether this
bill would affect the translation and interpretation
requirements for county Medi-Cal specialty mental health
plans, which have a threshold language standard in regulation
that is defined as a language that has been identified as the
primary language, as indicated on the MEDS, of 3,000
beneficiaries or five percent of the beneficiary population,
whichever is lower, in an identified geographic area.
SUPPORT AND OPPOSITION :
Support: California Pan-Ethnic Health Network (sponsor)
American Civil Liberties Union of California
American Federation of State, County and Municipal
Employees, AFL-CIO
California Association of Public Authorities
California Coverage and Health Initiatives
California Immigrant Policy Center
Children Now
Children's Defense Fund - California
Children's Partnership
Health Access California
National Association of Social Workers
National Health Law Program
PICO California
Southeast Asia Resource Action Center
Street Level Health Project
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United Ways of California
Western Center on Law and Poverty
100% Campaign
Oppose: None received.
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