The National Health Law Program MAKING LANGUAGE SERVICES A REALITY 2005 CHILD HEALTH SERVICES RESEARCH MEETING

PART I Current Payment Methods for Language Services

What Funding Is Available for Providing Linguistic Access? Federal Sources Offices of Refugee Resettlement State/County Departments of Health/Social Services Local foundations Non-profit organizations

What Funding Is Available – Federal Sources? Medicaid/SCHIP – CMS Letter 8/20/00 OMH Bilingual/Bicultural Demonstration Program HRSA “Models that Work” Campaign HRSA – HIV/AIDS Bureau

CMS Letter to State Officials Reimbursement is available for language assistance including translation and interpreters to Medicaid/SCHIP enrollees States can draw down federal funds at either their administrative match rate (50%) or their “covered service” match rate (50-77% Medicaid, 65-84% SCHIP) depending on how language services are provided

Statewide Medicaid/SCHIP Programs Only a handful of states have set up programs to provide direct reimbursement using federal matching funds to pay for language services Four models – contract with language service agencies reimburse providers for hiring interpreters certify interpreters as Medicaid providers provide access to language line

Model 1 – Language Service Agencies HI, WA and UT contract with interpreter organizations; providers schedule interpreters who bill the state WA offers testing and certification – interpreters must be certified (7 prominent languages) or qualified (other languages) HI & UT – reimbursed as “covered service”

Model 2 – Provider Reimbursement ME and MN require providers to pay for interpreters and then reimburse providers Providers have discretion on who to hire ME – interpreters must sign code of ethics; cannot use family members/friends Considerations – state oversight; quality of interpreters; provider concerns

Model 3 – Payments to Interpreters NH requires interpreters to become Medicaid providers Interpreters submit bills directly to the state Considerations – requirements of becoming a provider; low reimbursement rates

Model 4 – Language Line Kansas –state pays for a telephonic language line which fee-for-service providers can access for Medicaid/SCHIP patients Coordinated through the state’s fiscal agent (EDS); providers receive a code for access Estimated budget – $275,000 for first year (FY O4)

Current State Reimbursement $30 for business hours; $40 non-business hours ** Or usual and customary fee, whichever is less. *** 2002 data StateEnrollees Covered Providers CoveredWho the State PaysReimbursement Rate Admin or Service HI ***FFS Lang. agencies$36/hrService IDFFS Providers$7/hrService MAAllHospitals VariesAdmin MEFFS Providers$30-$40/hr*Service MNFFS Providers$50/hr**Admin MT ***All MedicaidAllInterpreters$6.25/15 minutesAdmin NHFFS Interpreters$15/hrAdmin UTFFS Lang. agencies$22 (phone) $39 (in-person) Service VAFFS Area Health Ed. Ctr. & 3 Health Depts. Still undeterminedAdmin WAFFS Brokers up to $36/hrAdmin WAFFSPublic entities 50% expensesAdmin

Other State Reimbursement Massachusetts Emergency Room Interpreter Law – payments to hospitals for costs of language services; based on one hospital’s expenses compared to all MA hospitals expenses Covers emergency departments and in- patient psychiatric facilities

Part II Language Services Implementation Strategies

Issues to Consider How can providers work with advocates and policy makers to improve language access and funding? What model would be most appropriate in your state? What data can providers collect to augment advocacy for improved language access and funding? Is legislative or administrative action needed? What are actual costs and estimated cost savings? How do we improve the workforce – number of and training for interpreters?

Medicaid and SCHIP Reimbursement – Considerations Discuss what model would be most appropriate Identify related issues – Training/assessment of interpreters Contract amendments between state and providers Determine whether legislative and/or administrative action is needed Analyze cost implications – actual costs and estimated cost savings Formulate action plan for advocacy efforts

Medicaid and SCHIP Reimbursement – Considerations Who will be covered? Enrollees – FFS, managed care, hospitals Providers – FFS, managed care, hospitals Which model should be used? What is the reimbursement rate? Must be sufficient to attract interpreters Travel time, waiting time, administrative time

Medicaid and SCHIP Reimbursement – Considerations Managed Care Plans – does current capitation rate include language services? if so, is consideration sufficient? should managed care plans receive specific reimbursement on top of capitation rate? Hospitals – should hospitals receive specific reimbursement separate from administrative expenses? does current rate sufficiently address language services? direct reimbursement or inter-local/government agreement?

Gather Available Data Collect information on the need for language services State agencies and departments Community based organizations providing health and human services Data on primary language spoken in local schools Local institutions (health, financial, etc)

Identify Potential Allies Who might support the expansion of language services in the medical setting? Diverse Populations Health & Human Service Providers Civic Leaders Education Leaders

Link Language Services to Quality and Patient Safety Build the “Business Case” for Patient Safety Attracting new patients Avoiding costly lawsuits Joint Commission on Accreditation of Healthcare Organizations – standards, training for surveyors

Part III National Language Access Advocacy Project Funded by The California Endowment

National Activities Coalition -- convened by NHeLP in partnership with APIAHF, MALDEF, NAPALC, NCLR, NILC Participants -- health care provider organizations, advocates, language companies, interpreters and interpreter organizations, accrediting organizations Goals -- heighten language access awareness among providers, policymakers and LEP communities; identify issues, solutions, funding sources and effective strategies for engaging others

Coalition’s Statement of Principles 1. Effective communication between health care providers and patients is essential to facilitating access to care, reducing health disparities and medical errors, and assuring a patient’s ability to adhere to treatment plans. 2. Competent health care language services are essential elements of an effective public health and health care delivery system in a pluralistic society. 3. The responsibility to fund language services for LEP individuals in health care settings is a societal one that cannot fairly be visited upon any one segment of the public health or health care community. 4. Federal, state and local governments and health care insurers should establish and fund mechanisms through which appropriate language services are available where and when they are needed. 5. Because it is important for providing all patients the environment most conducive to positive health outcomes, linguistic diversity in the health care workforce should be encouraged, especially for individuals in direct patient contact positions 6. All members of the health care community should continue to educate their staff and constituents about LEP issues and help them identify resources to improve access to quality care for LEP patients. 7. Access to English as a Second Language instruction is an additional mechanism for eliminating the language barriers that impede access to health care and should be made available on a timely basis to meet the needs of LEP individuals, including LEP health care workers. 8. Quality improvement processes should assess the adequacy of language services provided when evaluating the care of LEP patients, particularly with respect to outcome disparities and medical errors. 9. Mechanisms should be developed to establish the competency of those providing language services, including interpreters, translators and bilingual staff/clinicians. 10. Continued efforts to improve primary language data collection are essential to enhance both services for, and research identifying the needs of, the LEP population. 11. Language services in health care settings must be available as a matter of course, and all stakeholders – including government agencies that fund, administer or oversee health care programs – must be accountable for providing or facilitating the provision of those services.

Statement of Principles Endorsers American Academy of Family Physicians American Association of Physicians of Indian Origin American Civil Liberties Union American College of Physicians American Counseling Association American Hospital Association American Medical Student Association Asian Pacific Islander America Health Forum American Psychological Association Association of Asian Pacific Community Health Organizations Association of Community Organizations for Reform Now Association of Language Companies Association of University Centers on Disabilities Bazelon Center for Mental Health Law California Association of Public Hospitals and Health Systems California Health Care Safety Net Institute California Healthcare Association California Healthcare Interpreting Association Catholic Charities USA Catholic Health Association Children’s Defense Fund Center on and Health Cuban American Budget and Policy Priorities Center on Disability National Council District of Columbia Language Access Coalition District of Columbia Primary Care Association Families USA Family Voices Greater New York Hospital Association HIV Medicine Association Institute for Reproductive Health Access Joint Commission on the Accreditation of Health Care La Clinica del Pueblo Latino Coalition for a Healthy California Medicare Rights Center Mexican American Legal Defense and Educational Fund

Statement of Principles Endorsers (cont.) Migrant Legal Action Program National Asian American Pacific Islander Mental Health Association National Asian Pacific American Legal Consortium National Association of Community Health Centers National Association of Mental Health Planning and Advisory Councils National Association of Public Hospitals and Health Systems National Association of Social Workers National Council of La Raza National Council on Interpreting in Health Care National Family Planning and Reproductive Health Association National Health Law Program National Immigration Law Center National Hispanic Medical Association National Latina Institute for Reproductive Health National Mental Health Association National Partnership for Women and Families National Respite Coalition National Senior Citizens Law Center National Women’s Law Center Northern Virginia Area Health Education Center Physicians for Human Rights Presbyterian Church (U.S.A.) Society of General Internal Medicine - Washington Office Summit Health Institute for Research and Education USAction Welfare Law Center

Resources NHeLP Language Access website, NHeLP, Promising Practices for Providing Language Services in Health Care Settings: Examples from the Field, (May 2002), or NHeLP, Promising Practices for Providing Language Services in Small Health Care Settings: Examples from the Field (forthcoming early 2005), or NHeLP, Ensuring Linguistic Access: Legal Rights and Responsibilities (2004), NHeLP & The Access Project, The Language Services Action Kit (2004), or

Contact Information Mara Youdelman or Steve Hitov National Health Law Program th Street NW, Suite 405 Washington, DC Ph: Fax: