NHeLP comments to the Department of Labor on the interim final rule for Group Health Plans and Health Insurance Issuers Relating to Internal Claims and Appeals and External Review Processes Under the Patient Protection and Affordable Care Act

Executive Summary

NHeLP comments to the Department of Labor on the interim final rule for Group Health Plans and Health Insurance Issuers Relating to Internal Claims and Appeals and External Review Processes Under the N NHeLP comments to the Department of Labor on the interim final rule for Group Health Plans and Health Insurance Issuers Relating to Internal Claims and Appeals and External Review Processes Under the Affordable Care Act.

Office of Health Plan Standards and Compliance Assistance
Employee Benefits Security Administration, Room N-5653
U.S. Department of Labor
Attn: RIN 1210-AB45
200 Constitution Avenue, NW
Washington, DC 20210
Re: RIN 1210-AB45
Dear Sir/Madam:
The National Health Law Program (NHeLP) is a national public interest law firm that seeks to improve health care for America?s working and unemployed poor, minorities, the elderly and people with disabilities. NHeLP serves legal services programs, community-based organizations, the private bar, providers and individuals who work to preserve a health care safety net for the millions of uninsured or underinsured low-income people. As the health care system changes during the implementation of the new health reform law, it is critical to focus on ensuring that the private market can improve health delivery for all populations, including diverse and low-income vulnerable populations. Accordingly, NHeLP is pleased to offer our comments on the Department of Labor?s (DOL?s) interim final rule for Group Health Plans and Health Insurance Issuers Relating to Internal Claims and Appeals and External Review Processes Under the Patient Protection and Affordable Care Act (PPACA).
In the discussion below, we first offer comments related to language access. Thereafter, we offer more general suggestions relating to the internal and external claim reviews.
COMMENTS RELATED TO LANGUAGE AND CULTURE
Background
NHeLP?s interest in these regulations derives in large part from our focus on improving access and quality of care for low/limited-income and underserved populations. In particular, we have significant experience in the area of language access and have focused much of our comments on that area.
Language Access
Almost 20% of the population speaks a language other than English at home. Over 24 million, or 8.7% of the population, speak English less than very well and should be considered limited English proficient (LEP) for healthcare purposes.1 This includes 47% of Spanish speakers, 33% of speakers of other IndoEuropean languages, 49% of speakers of Asian and Pacific Islander languages, and 30% of speakers of other languages. Numerous studies have documented the problems associated with a lack of language services, including one by the Institute of Medicine, which stated that:
Language barriers may affect the delivery of adequate care through poor exchange of information, loss of important cultural information, misunderstanding of physician instruction, poor shared decision-making, or ethical compromises (e.g. difficulty obtaining informed consent). Linguistic difficulties may also result in decreased adherence with medication regimes, poor appointment attendance, and decreased satisfaction with services. (Cites omitted.) 2
Over one quarter of LEP patients who needed, but did not get, an interpreter reported they did not understand their medication instructions, compared with only 2% of those who did not need an interpreter and those who needed and received one.3
Indeed, language barriers have been found to be as significant as the lack of insurance in predicting use of health services. Health care providers surveyed in four major metropolitan areas identified language difficulties as a major barrier to immigrants? access to health care and a serious threat to medical care quality. These providers also expressed concern that they could not get information to make good diagnoses and that patients might not understand prescribed treatment.4 On the other hand, while Latino children generally have much less access to medical care than do white children, that gap becomes negligible when their parents? English-speaking skills are comparable to those of Whites.5

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