BILL ANALYSIS Ó
SENATE COMMITTEE ON HEALTH
Senator Ed Hernandez, O.D., Chair
BILL NO: AB 635
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|AUTHOR: |Atkins |
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|VERSION: |February 24, 2015 |
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|HEARING DATE: |June 24, 2015 | | |
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|CONSULTANT: |Scott Bain |
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SUBJECT : Medical interpretation services.
SUMMARY : Requires the Department of Health Care Services to seek
federal funding to establish a program to provide and reimburse
for certified medical interpretation services for Medi-Cal
beneficiaries who are limited English proficient. Requires the
program to offer medical interpreter services to Medi-Cal
providers serving beneficiaries on either a fee-for-service or
managed care basis.
Existing state law:
1)Establishes the Medi-Cal program, which is administered by the
Department of Health Care Services (DHCS), under which
qualified low-income individuals receive health care services.
2)Requires commercial health plans to assess their members'
language preference and provide interpretation and translation
services in threshold languages.
3)Requires hospitals to provide language services, interpreters,
or bilingual staff, under specified circumstances, and to
identify and record patients' primary languages in hospital
records.
4)Requires state and local agencies providing services to a
substantial number of non-English speaking people to provide
bilingual services.
AB 635 (Atkins) Page 2 of ?
Existing federal law:
1)Provides increased federal matching funding 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 (CHIP was previously known as the Healthy Families
Program in California; these children are now enrolled in
Medi-Cal).
2)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:
1)Requires DHCS to seek federal funding to establish a program
to provide and reimburse for certified medical interpretation
services to Medi-Cal beneficiaries who are limited English
proficient.
2)Requires the program to offer medical interpreter services to
Medi-Cal providers serving beneficiaries on either a
fee-for-service or managed care basis.
3)Permits a health care provider or entity entering into a
Medi-Cal provider agreement or Medi-Cal managed care contract
with the state, including Medi-Cal managed care organizations
(MMCOs) and their subcontracting plans, and fee-for-service
providers, to utilize the program to provide medical
interpreter services to Medi-Cal beneficiaries.
4)Requires all contracts between MMCOs and their subcontractors,
including health providers and other health plans, to include
provisions describing access to medical interpreter services
under the program.
5)Requires DHCS to pursue all available sources of federal
funding to establish and administer the program and to seek
federal approvals necessary to implement this article.
AB 635 (Atkins) Page 3 of ?
6)Requires DHCS to create a community advisory committee,
consisting of stakeholders and health care providers, to
advise on the implementation of this bill.
7)Exempts from this bill sign language interpretation services.
FISCAL
EFFECT : According to the Assembly Appropriations Committee:
1)One-time administrative costs in the range of $1 million
(General Fund (GF)/federal) to DHCS to seek federal approvals,
create system protocols, develop an information technology
infrastructure, design communications and guidance, promulgate
regulations, and other initial program development activities.
2)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.
3)Medi-Cal costs would be at a 50% GF, 50% federal funds
matching rate, except for costs for individuals at higher
matching rates.
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.
PRIOR
VOTES :
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|Assembly Floor: |72 - 2 |
AB 635 (Atkins) Page 4 of ?
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|Assembly Appropriations Committee: |13 - 1 |
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|Assembly Health Committee: |16 - 0 |
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COMMENTS :
1)Author's statement. According to the author, more than 40% of
Californians speak a language other than English at home.
Almost seven million Californians are estimated to speak
English "less than very well." Research finds that language
barriers can contribute to inadequate patient evaluation and
diagnosis, lack of appropriate and/or timely treatment, or
other medical errors that can jeopardize patient safety and
lead to unnecessary procedures and costs. Today language
assistance in medical settings is provided by trained or
untrained staff, or in an informal manner by family members or
friends. California has an opportunity to develop a more
comprehensive language assistance program by seeking
additional federal funding for medical interpreter services in
the Medi-Cal program.
2)Enhanced federal matching funds for translation and
interpretation services. The Children's Health Insurance
Program Reauthorization Act (CHIPRA), Public Law 111-3,
enacted on February 4, 2009, contains provisions that affect
both CHIP and Medicaid. In July 2010, the Centers for Medicare
and Medicaid Services (CMS) provided guidance on the
implementation of Section 201(b) of CHIPRA, which provides
increased administrative funding for translation or
interpretation services provided under CHIP and Medicaid.
Under Medicaid, increased federal funding for translation and
interpretation services available under CHIPRA is limited to
children and family members of those children. Under CHIP,
increased federal funding for translation and interpretation
services is not just limited to children, and includes
pregnant women receiving CHIP coverage.
Prior to CHIPRA, states could claim federal matching funds for
translation or interpretation costs as either an
administration expense or as a medical assistance-related
expense, and were reimbursed at the standard Federal Medical
Assistance Percentage (regular FMAP) rate (which is typically
50% in California for Medi-Cal and 65% for the Healthy
AB 635 (Atkins) Page 5 of ?
Families Program).
CHIPRA provides increased federal matching funding for
translation or interpretation services provided to eligible
individuals for whom English is not their primary language.
The increased federal match for translation or interpretation
services differs for Medicaid and CHIP. For Medicaid, the
increased match is 75% of allowable expenditures. For CHIP,
the increased match is 75%, or the state's enhanced FMAP plus
5%, whichever is higher (in California, it would be 75%).
However, the increased federal match is only available for
eligible expenditures claimed for administration of the
Medicaid or CHIP plan, and not expenditures claimed for
benefits (which are matched at the state's usual FMAP rate of
50% for Medi-Cal and 65% for CHIP). In addition, the
expenditures that qualify for the increased match under CHIP
are subject to the 10% cap on administrative expenditures.
3)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. Each federal
department has a civil rights office that is charged with
ensuring that its programs are free of discrimination. 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, non-profits, 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.
4)OCR policy guidance. CMS issued a State Medicaid Director
letter on August 31, 2000, that informed states of the policy
guidance that the OCR had issued on the prohibition against
national origin discrimination as it affects persons with LEP,
pursuant to Title VI of the Civil Rights Act of 1964.
OCR Policy Guidance requires recipients of federal assistance to
take reasonable steps to ensure meaningful access to their
programs and activities by LEP persons. The Guidance explains
AB 635 (Atkins) Page 6 of ?
that the obligation to provide meaningful access is
fact-dependent and starts with an individualized assessment
that balances four factors:
a) The number or proportion of LEP persons eligible to
be served or likely to be encountered by the program or
grantee;
b) The frequency with which LEP individuals come into
contact with the program;
c) The nature and importance of the program, activity
or service provided by the grantee/recipient to its
beneficiaries; and,
d) The resources available to the grantee/recipient and
the costs of interpretation/ translation services.
CMS states there is no "one size fits all" solution for Title
VI compliance with respect to LEP persons, and what
constitutes "reasonable steps" for large providers may not be
reasonable where small providers are concerned.
5)Current DHCS health plan contractual requirements. DHCS' model
contract with Medi-Cal managed care plans requires plans to
ensure equal access to health care services for its members
without regards to a member's proficiency in the English
language. This includes ensuring that all monolingual,
non-English-speaking or LEP Medi-Cal beneficiaries receive
24-hour oral interpreter services at all key points of
contact. Key points of contact include medical care settings
(telephone, advice and urgent care transactions, and
outpatient encounters with health care providers including
pharmacists) and non-medical care setting (member services,
orientations, and appointment scheduling). A June 2015 Bureau
of State Audits audit entitled "Department of Health Care
Services: Improved Monitoring of Medi-Cal Managed Care Health
Plans Is Necessary to Better Ensure Access to Care" found DHCS
did not review plan's language assistance programs.
6)Data on language in California. According to the US Census
Bureau 2010 American Community Survey, 43.7% of Californians
over the age of 5 speak a language other than English, and
19.9% of Californians over the age of 5 speak English "less
than very well." According to the California Health Interview
Survey, of the 3.5 million adults in the Medi-Cal program,
about 281,000 (8.1%) had difficulty understanding their doctor
and/or needed another person to help them understand their
AB 635 (Atkins) Page 7 of ?
doctor. Among the parents of 1.8 million children under age 12
in the Medi-Cal program, about 135,000 (7.4%) had difficulty
understanding the child's doctor and/or needed another
person's help to understand the doctor.
7)Prior legislation. AB 2325 (John A. Pérez, 2014) would have
established 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 23235 would have established a certification
process and registry of CommuniCal certified medical
interpreters (CCMI) at DHCS and granted CCMI collective
bargaining rights. AB 2325 was vetoed by Governor Brown who
cited the increased costs to the Medi-Cal program and the
extent of the collective bargaining rights afforded to
interpreters under the program.
AB 1263 (Pérez, 2013) was similar to AB 2325. AB 1263 was
vetoed by Governor Brown. In his veto message, Governor Brown
stated California has embarked on an unprecedented expansion
to add more than a million people to our Medi-Cal program.
Given the challenges and the many unknowns the state faces in
this endeavor, I don't believe it would be wise to introduce
yet another complex element.
AB 2392 (Pérez, 2012), would have required DHCS to establish
the CommuniCal program to provide and reimburse for certified
medical interpretation services provided to Medi-Cal
beneficiaries who are LEP. AB 2392 would have established the
State Personnel Board (SPB) as the certifying body for the
CommuniCal certified medical interpreter (CCMI), and would
have required CommuniCal to be administered by a
patient-centered communication broker that is a third-party
administrator. AB 2392 was moved to the Assembly inactive file
on concurrence.
SB 442 (Calderon, 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. SB 442 would have required hospitals' policies on
language assistance services to include criteria on
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proficiency similar to those that apply to health plans. SB
442 was vetoed by the Governor.
SB 1405 (Soto, 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.
8)Support. The California Pan-Ethnic Health Network writes that
California's population is one of the most diverse in the
country with over 100 different languages spoken and an
estimated six to seven million Californians LEP. Barriers to
communication in the health care setting can result in
increased risk of misdiagnoses and misunderstandings,
resulting in lower quality care and reduced adherence to
medication. The American Federation of State, County and
Municipal Employees argue that communication is critical to
quality of care and cultural competency in our state's
Medicaid program. With the expansion of Medi-Cal and the
exchange market under the Affordable Care Act, the state has a
clear opportunity to create an interpreters program that will
allow patients and providers to clearly communicate with each
other.
SUPPORT AND OPPOSITION :
Support: AARP
American Cancer Society Cancer Action Network
American Federation of State, County and Municipal
Employees, AFL-CIO
California Academy of Family Physicians
California Academy of Physician Assistants
AB 635 (Atkins) Page 9 of ?
California Black Health Network
California Chapter of the National Association of
Social Workers
California Immigrant Policy Center
California Pan-Ethnic Health Network
California Workers' Compensation Interpreter's
Association
Community Clinic Association of Los Angeles County
County Welfare Directors Association of California
Health Access
Planned Parenthood Affiliates of California
United Domestic Workers of America, AFSCME Local 3930,
AFL-CIO Western Center on Law and Poverty
Oppose: None received
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