NHeLP Letter to CMS Supporting Interpreter Services
Dear Mr. Scully:
The undersigned organizations write to express our support for the Centers for Medicare &Medicaid Services’ (CMS) “Dear State Medicaid Director” letter (August 31, 2000) outlining the availability of federal matching funds for state expenditures related to providing oral interpretationand written translation services to Medicaid and State Child Health Insurance Program (SCHIP) enrollees. Given the low number of states accessing these funds, however, we request that CMS provide further clarification as well as technical assistance to state officials.
We know that CMS is already aware of the growing need to provide language services to the more than 44 million people living in the United States who speak a language other than English at home. In addition to the letter referenced above, CMS has recognized the importance of providing language assistance in Medicaid, SCHIP and other federally funded programs by including the non-discrimination requirements of Title VI in all its contracts with states, thereby prompting states to mandate that providers do so as well.
Not surprisingly, language barriers are a primary reason why non-English speaking populations disproportionately underutilize cost-effective care. The provision of language services is one key factor necessary to providing quality and cost-effective health care to limited English speaking individuals. Evidence suggests that there are cost-savings associated with providing interpreters in the health care setting from which CMS in particular, and the nation as a whole, can ultimately benefit. For instance, when interpreters are provided, fewer diagnostic tests may be necessary due to a better understanding of the patient?s medical condition by both the patient and provider. Similarly, the existence of medical errors based on misunderstanding will decrease, thus reducing the risk of malpractice claims and enhancing the ability to obtain informed consent. Finally, increased use of cost-effective preventive care can also be expected, thereby reducing visits to emergency rooms. Indeed, a study released in the Archives of Pediatrics and Adolescent Medicine earlier this month found that non-English-speaking pediatric patients undergo more routine testing and incur higher medical costs in emergency rooms, largely because of language barriers and limited access to interpreters. To the extent that more cost-effective care can be provided, CMS would benefit from states encouraging the use of interpreters for Medicaid and SCHIP enrollees. This encouragement can be facilitated by reimbursing providers for their costs.
To date, only a few states have mechanisms in place to receive federal reimbursement, despite the distribution of the “Dear State Medicaid Director”letter. We believe this is due, in part, to the lack of specific examples that states can use to evaluate what methods of interpreter payments are most suitable for them. After the National Health Law Program and The Access Project issued reports addressing the possibility of Medicaid/SCHIP reimbursement for language interpretation, these organizations received numerous calls seeking more information about what states are currently doing and what options exist. Unfortunately, too little public information and technical assistance exists to assist them in assessing their options. We believe, based on conversations with state officials, policymakers, providers (including hospitals, community health centers, and solo practitioners), advocates and others, that states need additional information about how best toestablish these mechanisms.
For example, some officials have asked whether states can receive reimbursement for providing language services as a covered/medical service. The “Dear State Medicaid Director” letter is somewhat ambiguous on this point, yet some states already receive reimbursement from CMS at the covered service rate. We believe states should have flexibility to design their reimbursement mechanisms and also hope that CMS will clarify other issues related to the reimbursement of language services, including:
are there other options for Medicaid/SCHIP payments for language services?
if a state wishes to cover language assistance as a medical service, would a state plan amendment be required?
what flexibility do states have to decide the method of paying for language services (e.g. direct payment to interpreters or language service agencies, reimbursing providers, utilizing contract brokers)?
can states reimburse managed care organizations separately for language services on top of the capitation rate? Is it dependent on whether they carve out this service?
in what ways can states offer hospitals funding for language services ? direct reimbursement and/or reimbursing hospitals directly for administrative expenses including language services?
how does a state’s use of a DRG, prospective payment system, or similar per-case rate impact its options to reimburse hospitals, health centers and/or managed care plans subject to these systems?
can a state reimburse federally qualified health centers for language services through Medicaid/SCHIP?
what other requirements must be met to obtain the federal matching funds?
what reimbursement is available in Medicare and other federal health programs?
Further, we believe CMS should offer states specific examples of the available options to assist them in evaluating what methods of payment would best suit their state. This information should include the different ways states can structure reimbursements for language services.
In the end, effective reimbursement of language services will ensure that providers have a necessary tool to ensure meaningful access for LEP individuals, thus taking a major step forward in the effort to eliminate health disparities based on race and national origin. The results will also increase LEP patients’ access to and use of preventive care, and allow them to better understandmedical diagnoses and conditions, to make more informed decisions about treatment options and to increase compliance with recommended treatments.
Thank you for considering our concerns in this matter. We hope that, once you have evaluated all of the financial and ethical benefits that can be achieved through meaningful interpretation services, you will have CMS issue further guidance clarifying how states can best avail themselves of funding for such services. If you have additional questions, please contact Mara Youdelman at 202-289-7661.
The Access Project (Boston, MA)
Action Alliance for Virginia’s Children and Youth (Richmond)
Albert Einstein Medical Center (Philadelphia, PA)
The Arc of the United States
Asian American Community Service Association, Inc (Tulsa, OK)
Asian American Legal Defense and Education Fund (New York, NY)
Asian Health Services (Oakland, CA)
Asian Law Alliance (San Jose, CA)
Asian Pacific American Legal Center (Los Angeles, CA)
Asian Pacific Islander American Health Forum
Bi-State Primary Care Association (Concord, NH)
California Association of Public Hospitals and Health Systems
California Healthcare Interpreters Association
California Immigrant Welfare Collaborative (Sacramento)
California Pan-Ethnic Health Network (Oakland)
California Primary Care Association
Catholic Charities USA
Cambridge Health Alliance (Somerville, MA)
Center for Adolescent Health & the Law (Chapel Hill, NC)
Center for Civil Justice (Saginaw, MI)
Community Health Access Network (Raymond, NH)
Community Healthcare Network (New York, NY)
Community Legal Services, Inc. (Philadelphia, PA)
Coordinating Council of Broward Multicultural Board (Coral Springs, FL)
Cross-Cultural Communications (Ellicott City, MD)
The Endowment for Health (Concord, NH)
Evangelical Lutheran Church in America
Farmworker Justice Fund, Inc.
Florida Legal Services
Greater Hartford Legal Aid (CT)
Haitian-American Grassroots Coalition (Miami, FL)
Health Care for All (Boston, MA)
Health Consumer Alliance (Los Angeles, CA)
Immigrant Legal Resource Center
Jewish Vocational Service (Kansas City, Missouri) Khmer Health Advocates (West Hartford, CT)
Legal Aid Foundation of Los Angeles
LUNA (Latinas Unidas por un Nuevo Anamecer) (Des Moines, IA)
MAGNUS Translating – Interpreting – Contact Center (Walnut, CA)
Massachusetts Medical Interpreters Association
Mercy Medical Center (Des Moines, IA)
Mexican American Legal Defense and Educational Fund (MALDEF)
National Asian Pacific American Legal Consortium
National Association of Community Health Centers
National Association of Public Hospitals
National Council of La Raza
National Council on Interpreting in Health Care
National Employment Law Program
National Immigration Law Center
National LEP Advocacy Task Force
National Health Law Program
National Senior Citizens Law Center
New Haven Legal Assistance Association (Connecticut)
New Hampshire Legal Assistance (Manchester)
New Hampshire Minority Health Coalition (Manchester)
New Jersey Immigration Policy Network (Newark)
New York City Health and Hospitals Corporation
New York Immigration Coalition
New York Lawyers for the Public Interest, Inc.
North Carolina Health Access Coalition
North Carolina Justice and Community Center
North Carolina Latino Health Task Force
Ocean State Action Fund’s Health Care Organizing Project (Cranston, RI)
PALS for Health (Los Angeles, CA)
Public Justice Center (Baltimore, MD)
Southern New Hampshire Area Health Education Center
State Public Policy Group (Des Moines, IA)
Statewide Parent Advocacy Network of NJ
Unitarian Universalist Service Committee (Cambridge, MA)
University of Wisconsin Hospitals and Clinics (Madison, WI)
Virginia Interfaith Center for Public Policy (Richmond)
Virginia Poverty Law Center (Richmond, VA)
Virginia Primary Care Association (Richmond, VA)
William F. Ryan Community Health Center (New York, NY)
Richard Campanelli, Director, Office for Civil Rights
Ruben King-Shaw, Deputy Administrator and Chief Operating Officer
1. Statistic taken from The Census 2000 Supplementary Survey Summary Table that profiles selected social characteristics such as information on school enrollment, educational attainment, marital status, disability status, migration, place of birth, language spoken at home, ancestry and additional topics. The summary table is available at http://factfinder.census.gov/home/en/c2ss.html.