BILL ANALYSIS Ó
AB 635
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Date of Hearing: April 22, 2015
ASSEMBLY COMMITTEE ON APPROPRIATIONS
Jimmy Gomez, Chair
AB
635 (Atkins) - As Introduced February 24, 2015
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Urgency: No State Mandated Local Program: NoReimbursable: No
AB 635
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SUMMARY:
This bill establishes a medical interpretation services program
at the Department of Health Care Services (DHCS) to provide and
reimburse for certified medical interpretation (CMI) services to
limited English proficient (LEP) Medi-Cal enrollees in both the
fee-for service and managed care. Additionally, this bill:
1)Authorizes Medi-Cal providers and any providers contracting
with Medi-Cal managed care organizations (MCOs) to use the
program.
2)Requires all contracts between MCOs and their subcontractors
to include provisions describing access to CMI services under
the program.
3)Requires DHCS to create a community advisory committee
consisting of stakeholders and health care providers to advise
DHCS on the program's implementation.
FISCAL EFFECT:
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1)One-time administrative costs in the range of $1 million
(GF/federal) to DHCS to seek federal approvals, create system
protocols, develop an IT infrastructure, design communications
and guidance, promulgate regulations, and other initial
program development activities.
2)An exact estimate of the cost of language services is
difficult given a lack of accurate projections about how, by
whom, and with what frequency a centralized system would be
used. Assuming 2 million LEP individuals receive one
additional office visit annually with interpretive services
provided through this program at a cost of $20 per visit,
additional costs would be about $40 million annually. This
overall cost increase would be experienced as direct costs in
the case of fee-for-service Medi-Cal, and cost pressure on
rates in the case of Medi-Cal managed care. The majority of
enrollees are now in managed care plans.
3)Medi-Cal costs would be at a 50% GF, 50% federal funds
matching rate, except for the following:
a) Costs associated with individuals found newly
eligible for Medi-Cal pursuant to the expansion related
to the Patient Protection and Affordable Care Act and
subsequent 2013 state legislation, which expanded
Medi-Cal to childless adults. Costs for these
individuals are funded at a rate of 100% federal funds
until 2017, after which the federal matching rate
gradually decreases to 90% for 2020 and beyond.
b) Costs associated with services provided to CHIP- and
Medi-Cal eligible children. CHIP provides federal
reimbursement for health care for low-income children up
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to 250% of the federal poverty level. A 75% federal
funds matching rate is available for language services
for CHIP- and Medi-Cal eligible children, pursuant to the
Children's Health Insurance Program Reauthorization Act
of 2010 (CHIPRA), and a two-year funding extension until
federal fiscal year 2017 signed into law April 16, 2015.
The law authorizing the higher matching rate does not
expire, but in practical terms the availability of
enhanced match is contingent on CHIP funding.
4)Improved access to high-quality interpretive services is
likely to improve access to care and increase overall medical
costs to the Medi-Cal program for LEP beneficiaries. It would
also likely result in some offsetting cost savings associated
with the provision of higher-quality care and fewer medical
errors. The magnitude of savings as compared to costs is
unknown, but evidence suggests that, on balance, the Medi-Cal
program would experience increased medical costs if
centralized, high-quality interpretive services were
available.
COMMENTS:
1)Purpose. Various federal and state laws require health
providers and health plans receiving federal funding to
provide interpreter services to patients. Despite these
requirements in law, there are indications not all Medi-Cal
beneficiaries receive care in a linguistically appropriate
manner. The author notes, "Language barriers can contribute to
inadequate patient evaluation and diagnosis, lack of
appropriate and/or timely treatment or other medical errors
than can jeopardize patient safety." Enhanced federal
funding opportunities allow California to develop a more
comprehensive language assistance program.
2)Background. It is well-documented that limited proficiency in
English is a risk factor for reduced access to health
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services, decreased satisfaction with care, poor understanding
of instructions, longer hospital stays, and increased risk of
medical errors and misdiagnoses. A recent study found LEP
hospital patients are more likely than their English-speaking
counterparts to experience adverse events that result in harm,
and the severity of that harm is often greater.
Title VI of the federal Civil Rights Act of 1964 requires
health care providers accepting federal funds to provide
linguistically accessible services to all patients. Linguistic
accessibility standards have been upheld and further clarified
through a number of related court decisions, regulations,
guidance, and executive orders. However, these standards
appear flexible and do not appear adequate to ensure
high-quality services are available everywhere. For example,
the Federal Health and Human Services Agency (HHS) guidance
indicates smaller recipients of federal funds with more
limited budgets are not expected to provide the same level of
language services as larger recipients with larger budgets.
The provision of language services in current practice appears
to be highly variable across the state, varying based on the
proportion of LEP persons served, health care
provider/facility priorities, and available resources.
This bill intends to establish medical interpreter services as
a separate program that would be made uniformly available to
all LEP Medi-Cal beneficiaries.
3)Prior legislation.
a) AB 2325 (John A. Pérez) of 2014, AB 1263 (John A. Pérez)
of 2013, and AB 2392 (John A. Pérez) of 2012, were similar
to this bill in the creation of a medical interpreter
program, but also included registration and certification
provisions for interpreters, as well as collective
bargaining provisions.
1) AB 2392 passed both houses of the legislature but
was not taken up for concurrence in the Assembly.
2) AB 1263 was vetoed by the governor, citing his
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concern about introducing yet another complex element as
the state embarks on an unprecedented expansion of
Medi-Cal.
3) AB 2325 was vetoed by the Governor, citing ongoing
challenges in Medi-Cal and concerns about the scope of
collective bargaining allowed under the bill. The veto
message indicated a willingness to "work together on
appropriate cost-effective initiatives to help patients
in need, to the extent that interpretation services under
Medi-Cal are insufficient."
a) AB 505 (Nazarian), Chapter 788, Statutes of 2014,
codified existing Medi-Cal MCO requirements to provide
language assistance, translation, and interpretation
services when populations reach specified thresholds.
b) 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.
1)Staff Comments.
a) Potential Cost Shift. The program envisioned in this
bill may increase the availability and improve the quality
of language services to Medi-Cal enrollees, but it also
would encourage a significant cost shift from private
providers, who are currently required to provide these
services under federal law and/or managed care plan
contracts. In addition, some of the providers that do
offer quality interpretive services already receive
indirect reimbursement for these services. For example,
public hospitals have well-established interpretive
networks. These hospitals have unique funding arrangements
whereby they do not receive direct reimbursement from the
state, but instead certify their own expenditures for
language services as eligible for federal matching dollars.
Many federally qualified health centers (FQHCs) also
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provide interpretive services, and receive reimbursement
for these services as part of an all-inclusive per-visit
rate that is based on the FQHC's total costs.
b) Increased Access = More Medical Costs. Increasing access
to high-quality language services in the Medi-Cal program
would likely reduce health disparities, improve LEP patient
satisfaction, improve the quality of care provided to LEP
patients, and increase the use of preventative care.
However, it is also likely to increase total medical
expenditures for LEP patients.
Analysis Prepared by:Lisa Murawski / APPR. / (916)
319-2081