BILL ANALYSIS                                                                                                                                                                                                    Ó






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                                   THIRD READING 


          Bill No:  AB 635
          Author:   Atkins (D)
          Introduced:2/24/15  
          Vote:     21  

           SENATE HEALTH COMMITTEE:  7-1, 6/24/15
           AYES:  Hernandez, Nguyen, Mitchell, Monning, Pan, Roth, Wolk
           NOES:  Nielsen
           NO VOTE RECORDED:  Hall

           SENATE APPROPRIATIONS COMMITTEE:  5-2, 8/27/15
           AYES:  Lara, Beall, Hill, Leyva, Mendoza 
           NOES:  Bates, Nielsen

           ASSEMBLY FLOOR:  72-2, 6/2/15 - See last page for vote

           SUBJECT:   Medical interpretation services


          SOURCE:    Author

          DIGEST:   This bill 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. This bill requires the program to offer medical  
          interpreter services to Medi-Cal providers serving beneficiaries  
          on either a fee-for-service or managed care basis.

          ANALYSIS:
               
          Existing federal law:









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          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.

          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.

          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.







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          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.

          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.

          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)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  







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            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. 

          3)OCR policy guidance.  The Centers for Medicare and Medicaid  
            Services (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 limited  
            English proficient (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  
            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  







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            VI compliance with respect to LEP persons, and what  
            constitutes "reasonable steps" for large providers may not be  
            reasonable where small providers are concerned.

          4)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.

          5)Data on language in California. According to the US Census  
            Bureau 2010 American Community Survey, 43.7% of Californians  
            over the age of five speak a language other than English, and  
            19.9% of Californians over the age of five 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  
            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.

          FISCAL EFFECT:   Appropriation:    No          Fiscal  
          Com.:YesLocal:   No

          According to the Senate Appropriations Committee:

          1)One-time costs of $1.4 million to develop program guidelines,  
            seek necessary federal approvals, and develop billing systems  
            (50% General Fund, 50% federal funds).

          2)Ongoing administrative costs of about $600,000 per year for  







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            oversight by DHCS (General Fund and federal funds).

          3)Ongoing costs of about $30 million per year to provide  
            translation services in fee-for-service Medi-Cal, based on  
            estimates of the existing Medi-Cal fee-for-service population  
            with limited English proficiency (General Fund and federal  
            funds).

          4)Unknown costs in Medi-Cal managed care (General Fund and  
            federal funds). Under existing law, health plans are required  
            to provide interpretation services, including managed care  
            plans that contract with DHCS. It is unclear whether this  
            bill's requirement to provide "certified medical  
            interpretation services" through the program would increase  
            costs above the costs already being incurred. 

          5)The federal financial participation rate for the costs above  
            may vary. Generally, the federal government pays for 50% of  
            Medi-Cal costs. However, the federal government pays an  
            increased reimbursement rate the former Healthy Families  
            population of 65%. Finally, for the Medi-Cal expansion  
            population, the federal government pays 100% of the cost,  
            declining to 90% by 2020. Federal law allows for a 75% match  
            for certain costs of interpretation that are considered  
            administrative costs. However, DHCS indicates that the  
            provision of interpretation services under this bill will be  
            considered Medi-Cal benefits and would be subject to the  
            normal federal match.


          SUPPORT:   (Verified8/28/15)


          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
          California Black Health Network
          California Chapter of the National Association of Social Workers
          California Equity Leaders Network
          California Immigrant Policy Center
          California Pan-Ethnic Health Network







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          California Workers' Compensation Interpreter's Association
          Community Clinic Association of Los Angeles County
          County Welfare Directors Association of California
          Health Access California
          Planned Parenthood Affiliates of California
          United Domestic Workers of America, AFSCME Local 3930, AFL-CIO 
          Western Center on Law and Poverty


          OPPOSITION:   (Verified8/28/15)


          Department of Finance
          Department of Health Care Services


          ARGUMENTS IN 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.


          ARGUMENTS IN OPPOSITION:     DHCS writes this bill is  
          unnecessary as LEP Medi-Cal beneficiaries currently have  
          reliable access to language interpretation services, and this  
          bill creates an administratively costly system for the provision  
          of medical interpreter services that would duplicate services  
          currently available and could not be absorbed with existing  
          staff and resources.

          ASSEMBLY FLOOR:  72-2, 6/2/15
          AYES:  Achadjian, Alejo, Travis Allen, Baker, Bigelow, Bloom,  
            Bonilla, Bonta, Brown, Burke, Calderon, Campos, Chang, Chau,  
            Chiu, Chu, Cooley, Cooper, Dababneh, Daly, Dodd, Eggman,  







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            Frazier, Gallagher, Cristina Garcia, Eduardo Garcia, Gatto,  
            Gipson, Gomez, Gonzalez, Gordon, Gray, Grove, Hadley, Roger  
            Hernández, Holden, Irwin, Jones-Sawyer, Kim, Lackey, Levine,  
            Linder, Lopez, Low, Maienschein, Mathis, Mayes, McCarty,  
            Medina, Mullin, Nazarian, O'Donnell, Olsen, Patterson, Perea,  
            Quirk, Rendon, Ridley-Thomas, Rodriguez, Salas, Santiago,  
            Steinorth, Mark Stone, Thurmond, Ting, Wagner, Waldron, Weber,  
            Wilk, Williams, Wood, Atkins
          NOES:  Beth Gaines, Harper
          NO VOTE RECORDED:  Brough, Chávez, Dahle, Jones, Melendez,  
            Obernolte

          Prepared by:Scott Bain / HEALTH / 
          8/30/15 19:42:19


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