FEDERAL FUNDING FOR LANGUAGE ASSISTANCE SERVICES
FOR LIMITED ENGLISH PROFICIENT HEALTH CARE CONSUMERS
ISSUE: How can the State of California, health plans and health care providers in California maximize federal funding and/or reimbursement for language assistance services for Limited English Proficient health care consumers in California?
ANSWER: Federal funding and/or reimbursement for language assistance services for Limited English Proficient health care consumers in California is available through several mechanisms.
DISCUSSION
Background on Federal Requirements for Language Assistance Services for Limited English Proficient Health Care Consumers
Title VI of the Civil Rights Act of 1964 prohibits discrimination on the basis of national origin by any recipient of federal funding. 42 United States Code Section 2000d; 45 Code of Federal Regulations Part 80. The United States Supreme Court decision in Lau v. Nichols , 414 U.S. 563 (1974), clearly established that Title VI prohibits discrimination based on Limited English Proficiency.
There have been several policy developments affirming language access for Limited English Proficient health consumers. Executive Order 13166, 65 Federal Register 50121 (August 16, 2000), affirmed the prohibition against discrimination based on Limited English Proficiency and the requirement of equal access to federally funded health care and services for individuals with Limited English Proficiency. The Executive Order also applied the Title VI protections to all federal departments and agencies themselves.
The Department of Justice has recently affirmed Executive Order 13166 and has instructed all federal departments and agencies implement the Executive Order. It has finalized its own Policy Guidance on Title VI and language access. 67 Federal Register 41455 (June 18, 2002). In response to the Executive Order, the Department of Health and Human Services also published a Policy Guidance on Title VI and language access, 65 Federal Register 52762 (August 30, 2000) and then sought additional public comments. 67 Federal Register 4968 February 1, 2002). As of the publication of this Policy Brief, the Department of Health and Human Services has not yet published a final Policy Guidance.
In addition, the Center for Medicare and Medicaid Services has issued a final regulation for Medicaid managed care programs that includes a requirement of linguistic access that incorporates Title VI. 42 Code of Federal Regulations Part 438.109(c); 67 Federal Register 40989 (June 14, 2002).
Medicaid (MediCal) Managed Care
In the counties in California in which there is Medicaid (MediCal) managed care, health plans and health care providers are required to comply with Title VI and other requirements for language assistance services within their current capitation rates. No additional direct cost reimbursement or funding currently is available for language assistance services.
There is some confusion whether health plans or individual providers are responsible for providing language assistance services. This is a particular issue for specialists who may not otherwise serve many Limited English Proficient health care consumers. Some health plans have centralized interpreter and other language assistance services. Others expect providers to obtain their own interpreters.
California always has the option of increasing the capitation rate for managed care health plans and providers that serve Limited English Proficient health consumers. Health plans and/or providers that serve Limited English Proficient members could receive an enhanced capitation rate. The state would have to adjust its overall Medicaid managed care cost estimate submitted to the Department of Health and Human Services (DHHS) Center for Medicare and Medicaid Services (CMS) and receive CMS approval for the enhancement.
CMS has clarified that language assistance services provided under Medicaid could be partially reimbursable either as an administrative expense or as part of covered medical services. (Health Care Financing Administration Center for Medicaid and State Operations Letter, August 31, 2000). California is now able to collect from the federal government an average of 50 cents for every dollar spent on MediCal. If claimed as an administrative expense, the expenses must be incorporated into the overall limits on administrative expenses. The state as a whole, health plans or providers may have to adjust their existing administrative expenses in order to add any new expenses for language assistance services. This change also would require re-negotiation of the capitation rates and contracts with current managed care health plans and providers.
In any case, it may be in the interest of each managed care health plan or health care provider to conduct its own cost analyses comparing the relative costs and effectiveness of different types of language assistance services (e.g. using the AT&T Language Line compared to hiring health interpreters or using bilingual health providers). Tracking and analyzing these costs may also assist in justifying future increases in capitation rates.
It is important to note that even in counties with MediCal managed care, there are either individual health care consumers or types of medical services that are "carved out" and still reimbursed on a fee-for-service basis (e.g. certain children's services, certain long-term care services, etc.). The issues related to reimbursement for language assistance services as a fee-for-service discussed in the next section would apply to these carved out health consumers and services.
Medicaid (MediCal) Fee-for-Service
CMS' clarification that language assistance services are eligible for partial federal reimbursement also covers fee-for-service Medicaid, either as an administrative expense or as part of covered medical services. (Health Care Financing Administration Center for Medicaid and State Operations Letter, August 31, 2000).
Unfortunately, in California, there currently is no billing code that health plans and health care providers can use to claim fee-for-service Medicaid reimbursement for language assistance services. There is a billing code for sign language interpretation, reimbursable at a $64.55/two hours for interpreters certified in American Sign Language and $38.73/two hours for non-certified interpreters. Physicians must pay the interpreter first and then can claim reimbursement. However, the reimbursements are only available to physicians and physician groups with 15 or less employees.
The state of California would have to establish a new billing code (or add language assistance services to the sign language interpretation billing code) and establish a mechanism for certifying eligible expenses (for example, minimum qualifications for a health interpreter and an hourly rate or rate scale). Although technical approval by CMS would be required, the California Department of Health Services (DHS) can add the billing code and estimated expenses as part of its annual Medicaid application submitted to CMS each November. No state legislation or other state regulatory authorization is required. However, the state must demonstrate that it has budgeted for the non-federal share of the new expenses.
Alternatively, the California DHS could establish its own statewide or local language assistance services, made available to health plans and health providers either at state expense (as part of DHS' own administrative Medicaid expenses) or for fees to be paid by plans and/or providers. These services might include centralized written translation services or a pool of health interpreters. Several years ago, DHS had been in discussions with the California Medical Association about establishing a pilot project in Fresno county which would provide certain local specialty health care providers access to health interpreters, with all the costs to be assumed by DHS. However, the project was never implemented.
State Children's Health Insurance Program (Healthy Families Program)
Similar to Medicaid managed care, federal funding for the State Children's Health Insurance Program - the Healthy Families Program in California - is provided through a managed care mechanism. California is now able to collect from the federal government an average of 66 cents for every dollar spent on Healthy Families.
Health plans participating in the Healthy Families Program are required to comply with Title VI and other requirements for language assistance services using their existing capitated funds. No additional direct cost reimbursement or funding currently is available for language assistance services. However, the Managed Risk Medical Insurance Board (MRMIB) that administers the Healthy Families Program also could choose to provide an enhanced capitation rate for health plans and health providers serving Limited English Proficient health consumers.
The same clarification from CMS regarding partial federal reimbursement for language assistance services also covers the State Children's Health Insurance Program. (Health Care Financing Administration Center for Medicaid and State Operations Letter, August 31, 2000).
Medicare
The State of California has a minimal role in Medicare financing because the federal government contracts directly with health plans and health care providers under Medicare. CMS has not yet issued any explicit instructions to Medicare providers regarding reimbursement for language assistance services. The situation may be distinct for Medicare providers operating under a capitated managed care plan and those billing CMS for reimbursement under a fee-for-service mechanism here in California.
Federally Qualified Health Centers and Community Health Centers
Federally Qualified Health Centers (FQHCs) currently receive enhanced MediCal reimbursement through a complicated formula called the Prospective Payment System (PPS). If language assistance services were added as a new MediCal-covered benefit, FQHCs with managed care contracts would be reimbursed on either a captivated or fee-for-service basis for these services. For FQHCs that do not have managed care contracts, they would be required to seek reimbursement through a rate change based on a change in the "scope of services" provided by the health center. While existing federal law requires the state to reimburse FQHCs for most MediCal covered services through a scope of services adjustment to their per-visit rate, the state currently has no mechanism in place to account for rate changes for such services. Requiring the state to reimburse FQHCs in California for language assistance services on a fee-for-service basis would remove a significant obstacle from delays or inadequacies in the scope of service rate adjustment process.
Legislation reauthorizing federal Community Health Centers authorizes additional federal grants for enabling services, including language assistance services, provided by Community Health Centers. Federal dollars have to be appropriated each fiscal year to fund the grant program.
LANGUAGE ASSISTANCE SERVICES IN OTHER STATES
California should consider the experience of other states in providing language assistance services to Limited English Proficient health consumers. Several states are utilizing federal matching funds to support these language assistance services.
Washington
As part of a settlement of a Title VI complaint in 1983 (amended in 1987) and subsequent state legislation, the state of Washington has implemented a comprehensive language assistance program, the Language Interpreter Services and Translation (LIST) program. The state's Department of Social and Health Services contracts with thirteen language assistance service organizations for interpretation services and with three language assistance service organizations for translation services. These language assistance service organizations provide services to several state government departments, including its Medical Assistance Administration (which administers Washington's Medicaid, State Children's Health Insurance Program and SSI programs), the Economic Services Administration (which administers Temporary Assistance for Needy Families and child support), the Health and Rehabilitative Services Administration (which administers mental health, alcohol, substance abuse, vocational rehabilitation and developmental disability programs and services for the deaf and hard of hearing), Juvenile Rehabilitation, the Children's Administration, Aging and Adult Services and the Management Services Administration.
The state tests and certifies interpreters and translators in the following languages and dialects: Cambodian, Cantonese, Korean, Lao, Mandarin, Russian, Spanish and Vietnamese. The written part of the test includes sections on ethics, medical terminology, clinical and medical procedures, English language syntax and grammar, and syntax and grammar in the non-English language. The oral part of the test includes sections on sight translation and consecutive interpretation. For other languages (over 80 other languages plus major dialects), there is a "qualification" process that includes a written test on ethics, medical terminology, clinical and medical procedures and translational writing in English; the oral part of the screening test includes sight translation, memory retention and back interpretation from the non-English language to English. For translators, the state tests qualifications through independent reviews.
Providers request language assistance services from the language assistance agencies. The language assistance agencies bill the state and are paid $33.60-39.00/hour for interpreter services.
WA |
HI |
UT |
ME |
MN |
|
|---|---|---|---|---|---|
State Tests interpreters |
Yes |
No |
No |
No |
No |
State Certifies interpreters |
Yes |
No |
No |
No |
No |
Quality Assurance for Interpreters |
Yes |
Yes |
Yes |
Yes |
Yes |
Language Assistance Agencies |
Yes |
Yes |
Yes |
No |
No |
Direct Billing by Providers |
No |
No |
No |
Yes |
Yes |
Available for Fee-for-Service |
Yes |
Yes |
Yes |
Yes |
Yes |
Available for Managed Care |
Yes |
No |
No |
Yes |
Yes |
Available for Bilingual Providers |
No |
No |
No |
No |
No |
Rate for Oral Interpreta-tion |
$33.60-39.00 /hour |
$25-45/hour |
$22/ hour phone; $35/hour in-person |
$30/ hour |
$12.50/ 15 minutes |
Rate for Written Translation |
$35-45/ flat rate |
? |
$35/ page |
? |
$25-100/ page |
Hawaii
The Hawaii Department of Health had also been the subject of a Title VI complaint in the 1970's. The state of Hawaii has contracts with language assistance service organizations such as Helping Hands Hawaii. These organizations provide services in the following languages: Cambodian, Cantonese, French, German, Ilokano, Japanese, Korean, Laotian, Mandarin, Marshallese, Portuguese, Samoan, Spanish, Tagalog, Taiwanese, Thai, Tongan, Truckese, Vietnamese and Visayan.
The state of Hawaii does not have a training or certification for interpreters and translators, but it requires the contracting language assistance service organizations to assess the qualifications of their interpreters and monitor quality.
Providers may utilize the language assistance service organizations for patients in fee-for-service Medicaid and disabled children under the State Children's Health Insurance Program. There are no reimbursements for bilingual providers or staff interpreters. Managed care plans and providers are not included in the reimbursements.
The state pays the language assistance service organizations $24-45/hour (including travel and waiting time) for interpreter services.
Utah
The state of Utah has contracts with five language assistance service organizations: Catholic Community Services of Utah, International Rescue Committee, Passport to Languages, Pentskiff Interpreting Services and Language Line Services. These organizations provide services in the following languages and dialects: Alcholi, Albanian, Arabic, Armenian, Bari, Belorussian, Bosnian, Cantonese, Dinka, Farsi, French, German, Hmong, Italian, Japanese, Kakwa, Madi, Mandarin, Nuir, Persian, Russian, Serbo-Croatian, Somali, Spanish, Swahili, Ukranian and Vietnamese.
Although the state of Utah does not have a training or certification for interpreters and translators, it does require the contracting language assistance service organizations to provide information on quality assurance, including ethics standards, confidentiality, cultural competence and training in medical terminology.
Providers can utilize the language assistance service organizations to provide interpretation and translation services for patients under Utah's fee-for-service Medicaid, State Children's Health Insurance Program and medically indigent programs. There are no reimbursements for bilingual providers or staff interpreters. Managed care plans and providers are not included in the reimbursements but the state requires plans to ensure the provision of interpreters.
The state of Utah pays an average of $22/encounter for phone interpretation services, $35/hour for in-person interpretation services (with a one-hour minimum) and $35/page for written translation services.
Maine
Maine began reimbursing Medicaid and State Children's Health Insurance Program providers for language assistance services beginning in January 2001. The state broadened its billing codes and procedures that had been in place for sign language interpretation services. Providers may use either in-person or telephonic interpretation services and are reimbursed up to $30/hour for interpretation provided during normal business hours and up to $40/hour for interpretation during non-business hours. Written translation services are also reimbursable when necessary to provide a direct medical service covered by Medicaid or the State Children's Health Insurance Program.
Minnesota
In part due a settlement of a Title VI complaint, the state of Minnesota has recently enhanced its language assistance services. Beginning July 2001, Minnesota reimburses providers for the costs of interpreters under its fee-for-service and managed care Medicaid program and State Children's Health Insurance Program. There are no reimbursements for bilingual providers or staff interpreters. The state has established a new billing code for interpretation. Interpreters will be paid the lesser of actual charges or $12.50 per fifteen-minute unit.
The Minnesota Department of Human Services will continue to be responsible for translating applications, forms, brochures and booklets into Arabic, Cambodian (Khmer), Croatian, Hmong, Lao, Oromo, Russian, Somali, Spanish and Vietnamese. The state also maintains a toll-free telephone service for patients to ask questions about health services in their own primary languages. The number is listed on all notices, applications, and case-specific forms.
The state reimburses approximately $25-100/page for written translations, depending on the language and the complexity of the document.
POLICY OPTIONS FOR CALIFORNIA
1) The California Department of Health Services should immediately issue a MediCal Managed Care Policy Letter clarifying that MediCal managed care health plans and providers are expected to provide language assistance services as required by Title VI and other laws, regulations and contractual provisions within existing capitation rates. However, the Department of Health Services should offer technical assistance to MediCal managed care health plans and providers in tracking and analyzing these language assistance services costs.
2) The California Department of Health Services should immediately establish a fee-for-service billing code and procedures for billing for language assistance services and incorporate the billing code and estimated expenses in its annual Medicaid application to be submitted to the Department of Health and Human Services Center for Medicare and Medicaid Services.
3) Once a fee-for-service billing code for language assistance services is established, the California Department of Health Services should examine an enhanced capitation rate for managed care plans and providers that provide language assistance services to Limited English Proficient health care consumers.
4) The California Managed Risk Medical Insurance Board should immediately clarify in writing that Healthy Families managed care health plans and providers are expected to provide language assistance services as required by Title VI and other laws, regulations and contractual provisions within existing capitation rates. Managed Risk Medical Insurance Board should offer technical assistance to Healthy Families managed care health plans and providers in tracking and analyzing these language assistance services costs.
5) The California Department of Health Services and the California Managed Risk Medical Insurance Board should explore more cost-effective and efficient mechanisms to ensure the provision of language assistance services, including but not limited to state-funded and state-operated interpreter and translation services.
REFERENCES
California Primary Care Association, "Providing Health Care to Limited English Proficient Patients: A Manual of Promising Practices" (2001).
Maine Medical Assistance Manual, Chapter 101, Section 1.06-3 (2001).
Maine Revised Statutes Annotated, Title 32, Chapter 22 (2001).
Minnesota Statutes 2001, Chapter 256B.0625, Subdivision 18a(d).
Revised Code of Washington 74.04.025.
The Commonwealth Fund, "Providing Language Interpretation Services in Health Care Settings: Examples from the Field" (2002).
Utah Medicaid Provider Manual, Chapter 6-12 (2001).
Washington Administrative Code Sections 388-555-1000 through –1450, 388-200-1200.
Washington Department of Social and Health Services Administrative Policy 7.21.
Thanks to Vivian Huang from the California Primary Care Association and Mara Youdelman from the National Health Law Program for conducting research about the state models and for their helpful editorial comments.
This Policy Brief was funded by The California Endowment.
Revised November 2002
