BILL ANALYSIS Ó
AB 2392
Page 1
Date of Hearing: April 17, 2012
ASSEMBLY COMMITTEE ON HEALTH
William W. Monning, Chair
AB 2392 (John A. Pérez) - As Introduced: February 24, 2012
SUBJECT : Medi-Cal: interpreter services.
SUMMARY : Requires the Department of Health Care Services (DHCS)
to seek federal funding to establish a program to provide and
reimburse certified medical interpretation services to Medi-Cal
beneficiaries with limited English proficiency (LEP).
Specifically, this bill :
1)Requires the program to offer medical interpreter services to
Medi-Cal providers serving Medi-Cal beneficiaries in
fee-for-service (FFS) or Medi-Cal managed care (MCMC) and
allows Medi-Cal approved providers and MCMC contracting and
subcontracting plans to utilize the program to provide
interpreter services to Medi-Cal beneficiaries.
2)Requires all contracts between MCMC plans and subcontractors,
including those with providers and other plans, to include
provisions describing access to medical interpreter services
under this program.
3)Requires DHCS to pursue all available sources of funding to
establish and administer this program and to seek any federal
approvals necessary.
4)Specifies legislative intent including: to create a program to
provide reliable access to language interpretation to Medi-Cal
beneficiaries who are LEP; to enable trained and qualified
interpreters to meet the demand for language services; and, to
facilitate accurate and timely communication between LEP
patients and their health care providers.
EXISTING LAW :
1)Establishes the federal Medicaid program (Medi-Cal in
California) under which qualified low-income persons receive
health care benefits.
2)Prohibits under federal law, guidelines, and executive orders,
public and private entities that receive federal funds from
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discriminating based on race, color, or national origin, and
requires these entities to provide LEP individuals with
language assistance, to ensure they have equal access to
programs and services.
3)Requires, under federal law, all recipients of federal
financial assistance from the U. S. Department of Health and
Human Services to provide meaningful assistance to LEP
persons.
4)Requires that state and local agencies provide bilingual
services to non-English-speaking persons.
5) Requires licensed general acute care hospitals to meet
several requirements related to language assistance for
persons with language or communication barriers, such as:
adopting and annually reviewing a policy for providing
language assistance services; posting notices that advise
patients and their families of the availability of
interpreters; identifying and recording a patient's primary
language; notifying employees of the hospital's commitment to
provide interpreters to all patients who request them; and,
preparing and maintaining a list of proficient interpreters.
FISCAL EFFECT : This bill has not been analyzed by a fiscal
committee.
COMMENTS :
1)PURPOSE OF THIS BILL . According to the author, this bill is
to require DHCS to explore options for obtaining federal
matching funds in the Medi-Cal program for the reimbursement
of medical interpretation services to beneficiaries who are
LEP. The author points out that more than 40% of Californians
speak a language other than English at home. Furthermore,
almost seven million Californians are estimated to speak
English "less than very well." The author states that
research has found 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. The author further points out that
currently language assistance in medical settings is provided
by trained or untrained staff or in an informal manner by
family members or friends. The author argues that with this
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bill, 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)BACKGROUND . In 2006 various stakeholders created a task force
charged with developing recommendations for a system to
provide language services for California Medi-Cal enrollees,
which evolved into the Medi-Cal Language Access Services
(MCLAS) Taskforce. The ultimate vision of this effort was to
design a system that could accommodate large numbers of
persons whose primary language was other than English and to
generate federal financial participation for reimbursement of
State expenditures. According to 2009 MCLAS Report,
"Providing Language Services for Limited English Proficient
Patients in California" more than 25 languages are recorded as
Medi-Cal beneficiaries' preferred language. Almost half
(45.2%) speak a language other than English. The top five
non-English languages in Medi-Cal are Spanish (36.9%),
Vietnamese (1.9%), Cantonese (1.2%), Armenian (0.9%), and
Russian (0.6%), according to the report.
The MCLAS Taskforce Report included a recommendation to DHCS
described as a hybrid Brokerage/Direct Provider Reimbursement
model to finance the provision of language services within the
Medi-Cal FFS program. This recommendation was based on a
review of four reimbursement models that 13 states and the
District of Columbia utilize: a) telephonic interpreter
reimbursement; b) direct interpreter reimbursement model; c)
direct provider reimbursement model; and, d) language services
agency/broker reimbursement model. The MCLAS Taskforce
analyzed the positive aspects and the challenges of each model
generally and also specifically in light of California's
Medi-Cal program.
The MCLAS Taskforce proposed a two-year pilot project in ten
counties to sufficiently test the model. However, at the time
of the analysis, more than half of the Medi-Cal population was
receiving benefits through FFS. Since then, DHCS has
implemented mandatory enrollment of seniors and people with
disabilities and by July 1, 2012 less than 20% will be
receiving services on a FFS basis. Additional initiatives may
result in an even smaller FFS population. The approach taken
by this bill does not limit the model and does include
providers which contract with MCMC plans as well as those who
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provide services on a FFS basis.
3)LANGUAGE SERVICES IN MEDI-CAL . In 2002, the federal Centers
for Medicare and Medicaid Services (CMS) released a letter to
all state Medicaid directors reminding states that Federal
matching funds are available for States' expenditures related
to the provision of oral and written translation
administrative activities and services provided for Medicaid
recipients. According to the letter, FFP is available for
such activities or services whether provided by staff
interpreters, contract interpreters, or through a telephone
service. Nonetheless, in California there is no mechanism to
reimburse for language services in the FFS system as there is
no billing code. Some safety net providers, a source of care
for many LEP populations, may have language service costs
partially or wholly covered in their unique payment
mechanisms. For instance Federally Qualified Health Centers
(FQHC) may have language service costs included in their
Prospective Payment System rate. Public hospitals Ýcounty and
University of California (UC) operated] are reimbursed using a
cost-based payment system in which the source of non-federal
matching funds are certified public expenditures (CPEs). CPEs
are public funds (non-federal) that are certified by the
contributing public agency, in this case the participating
counties or UC, as representing expenditures eligible for
federal Medicaid matching under the Section 1115(a) Medicaid
waiver. For public hospitals, Medi-Cal language services
costs are included in the CPE reimbursement for inpatient and
outpatient hospital services. If the public hospital has an
FQHC, it is in the FQHC rate for clinic costs.
Under MCMC, DHCS contracts require all participating health
plans to ensure compliance with Title VI of the Civil Right
Act of 1964, which prohibits federal fund recipients from
discriminating against persons based on race, color, or
national origin. MCMC contractors must also follow cultural
and linguistic competency requirements outlined in the
contract and a series of policy letters issued by DHCS. All
plans must develop and implement policies and procedures for
ensuring access to interpreter services for all LEP members.
The contract specifically requires plans to:
a) Ensure equal access to health care services for LEP
Medi-Cal members through the provision of high quality
interpreter and linguistic services;
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b) Provide no cost, 24 hour access to interpreter services
for all monolingual, non-English-speaking, or LEP Medi-Cal
beneficiaries at all key points of contact either through
interpreters or telephone language services;
c) Provide that oral interpreters or bilingual providers or
provider staff, in all languages spoken by Medi-Cal
beneficiaries, are made available and not limited to those
languages that meet the numeric threshold or concentration
standards which only apply to written translations;
d) Provide referrals to culturally and linguistically (C&L)
appropriate community service programs;
e) Monitor, evaluate, and take effective action to address
any needed improvement in the delivery of C&L appropriate
services and implement a written description of its
Cultural and Linguistic Services Program;
f) Conduct a group needs assessment of its members every
three years, and review and update their cultural and
linguistic services;
g) Assess, identify and report the language capability of
interpreters or staff (clinical and non-clinical); and,
h) Implement and maintain standards and performance
requirements for the delivery of C&L appropriate health
care services.
According to the MCLAS Taskforce, DHCS affirmed that the
administrative cost portion of rates will reflect those costs
within reason. The Taskforce members acknowledged that there
may be a perceived question as to whether adequate payment
flows downstream to a plan's contracted providers or the
degree to which downstream providers are actually providing
language services or utilizing health plan-provided language
services to ensure language access for LEP enrollees.
4)SUPPORT . The California Pan-Ethnic Health Network (CPEHN)
writes in support that California's population is one of the
most diverse in the country with over 100 different languages
spoken. CPEHN supports this bill, in concept, because it will
assist the state in meeting the demands of its diverse
Medi-Cal population. According to CPEHN, despite California's
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diversity, the state currently does not have a comprehensive
delivery or reimbursement system for language services. CPEHN
argues this is especially true for the Medi-Cal FFS population
who seek services from a wide range of providers with no
consistent approach to the provision of language access
services. CPEHN further supports this bill because it
requires DHCS to create a state program that will provide and
reimburse for this critical service expanding access for all.
CPEHN points out there are currently only a handful of states
taking advantage of federal dollars for this purpose. In
support, CPEHN also states that California can use additional
federal dollars to pay for services it is already required to
provide.
The American Federation of State, County and Municipal
Employees, AFL-CIO (AFSCME) writes in support that this bill
will make it possible for the 2.5 million Medi-Cal patients
who are LED to communicate with health care providers,
reducing medical errors and improving the standard of care, by
providing access to trained interpreters. AFSCME writes that
it believes that communication is critical to quality of care
and cultural competency in our state's Medicaid program.
According to AFSCME, 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 to allow
patients and providers to clearly communicate with each other.
AFSCME further argues in support, that during these difficult
fiscal times the state should seek to maximize all available
federal dollars to assist the Medi-Cal program. According to
AFSCME, a national study found that doctors who are unable to
communicate effectively with their patients were found to
compensate by engaging in costly practices such as more
diagnostic procedures, more invasive procedures, and the
overprescribing of medications.
The National Association of Social Workers, California Chapter
(NASW-CA) , also in support, writes that today, language
assistance in medical settings is provided by trained or
untrained staff in an informal manner by family members or
friends. NASW-CA, states that 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.
The California Academy of Family Physicians (CAFP) writes in
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support that communication in health care makes a difference.
According to CAFP, studies have shown that Spanish-speaking
Latinos are less likely to have physician visits, flu shots,
or mammograms than English-speaking Latinos or non-Latino
whites. Spanish speakers are also less likely to be
discharged from an emergency room with a full understanding of
their medications, special instructions, and follow-up care,
according to these studies. Furthermore, flu shot and
colorectal cancer screening disparities between LEP and
non-LEP patients decrease after implementation of an
interpreter services program.
5)PREVIOUS LEGISLATION .
a) 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 patients and 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.
a) SB 1405 (Soto) 2006 required the Department of Health
Services (now DHCS) to create the Task Force on
Reimbursement for Language Services (task force), as
specified, to develop a mechanism for seeking federal
matching funds from CMS to pay for language assistance
services, as specified.
b) AB 800 (Yee), Chapter 313, Statutes of 2005, requires
all health facilities (i.e., 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.
c) 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.
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d) SB 1840 (Kopp), Chapter 672, Statutes of 1990, requires
hospitals to adopt and review annually, a policy for
providing language assistance services to patients with
language or communication barriers, defined as barriers
faced by individuals who are limited- or
non-English-speaking who speak the same primary language
and who comprise at least 5% of the population served by
the hospital or the actual patient population served.
6)TECHNICAL AMENDMENT .
a) On page 2, lines 24 and 25 include an erroneous cross
reference to federal law. The author has agreed to correct
this by deleting:
"under Section 1903 of the federal Social Security Act
(42 U.S.C. Sec. 1396b(a)(2)(E)."
REGISTERED SUPPORT / OPPOSITION :
Support
American Federation of State, County and Municipal Employees,
AFL-CIO
California Academy of Family Physicians
California Pan-Ethnic Health Network
Health Access California
National Association of Social Workers, California Chapter
Western Center on Law & Poverty
Opposition
None on file.
Analysis Prepared by : Marjorie Swartz / HEALTH / (916)
319-2097