BILL ANALYSIS Ó ----------------------------------------------------------------- |SENATE RULES COMMITTEE | AB 635| |Office of Senate Floor Analyses | | |(916) 651-1520 Fax: (916) | | |327-4478 | | ----------------------------------------------------------------- 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: AB 635 Page 2 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. AB 635 Page 3 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 AB 635 Page 4 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 AB 635 Page 5 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 AB 635 Page 6 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 AB 635 Page 7 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, AB 635 Page 8 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 **** END ****