The document discusses language access requirements under the Affordable Care Act (ACA) and opportunities and challenges for enrolling limited English proficient (LEP) individuals in health insurance exchanges. It notes that 23% of expected exchange applicants speak a language other than English and that 95% of uninsured LEP individuals will be eligible for financial assistance. While the ACA includes nondiscrimination protections and data collection requirements to support LEP individuals, some federal regulations have adopted a 10% language threshold that excludes many needed translations. Stakeholders are urged to get involved now to ensure exchanges are designed to effectively enroll and service LEP populations.

1. Health Reform & Language Access
Mara Youdelman
Managing Attorney, DC office
youdelman@healthlaw.org
NCIHC AMM – June 7, 2013

2. National Health Law Program
• NHeLP protects and advances the health rights
of low income and underserved individuals
• The oldest non-profit of its kind, NHeLP
advocates, educates and litigates at the federal
and state level
• Our language access work spans over 2
decades and focuses on improving policies &
funding for language access at the federal level

3. What is “health reform”?
• “Affordable Care Act”, “ACA” or “Obamacare”
– will provide health insurance to virtually
everyone in U.S. through public or private
insurance
• October 1, 2013 is the start of the first “open
enrollment” period to apply for insurance
• January 1, 2014 is when coverage starts
• Goal is to streamline applications and make
healthcare more affordable

4. What is an Exchange or
Marketplace?
• Individuals who do not have insurance can go
to an “exchange” or “marketplace” to buy
insurance
 If you have insurance through your employer,
Medicaid/CHIP, Medicare, you don’t have to go to
an Exchange
 One stop shopping to apply & pick a plan
• Help paying premiums and cost-sharing is
available for individuals under 400% FPL

5. LEP Enrollees
• 23% of expected Exchange applicants speak a
language other than English at home
• About 95% of uninsured LEP individuals are <
400% FPL and will be eligible for help paying for
insurance
• Exchanges must not discriminate against LEP
individuals to comply with Title VI and ACA’s sec.
1557
• Exchanges also have to comply with relevant
state laws

6. Nondiscrimination – ACA sec. 1557
• Extends federal civil rights laws prohibiting
discrimination on basis of race, color, national origin,
gender and disability to:
 any health program or activity receiving Federal financial
assistance – Exchanges, Medicaid/CHIP agencies, QHPs,
navigators, etc.
 any program or activity administered by a federal Executive
agency – FFE, Medicare
 any entity established under Title 1 of PPACA – Exchanges
 based on statutes in existence, inc. Title VI, Title IX, 504 of
Rehab Act
• HHS OCR to issue regulations, likely this year

7. Data Collection – ACA sec. 4302
• Applies to health care/public health
programs, activities, and surveys
 Collect race, ethnicity, primary language, sex,
disability status of all applicants, recipients or
participants
 Collect sufficient data for statistically reliable
estimates for subgroups
 Medicaid to use OMB standards for race & ethnicity
 CHIP to collect language data of enrollees &
parents/guardians
 Medicare to collect data

8. The Opportunities
• New legal requirements
 Sec. 1557 & 4302
 Specific ACA mentions of C&L
• New systems being built
• New requirements for health plan
participation

9. The Problems – Thresholds
• Adoption of 10% threshold for translation
AND oral communication for:
 Summary of Benefits & Coverage
 Appeals Notices

10. The Problems – Thresholds
• Recent federal regulations adopted 10%
threshold for language services
• A 10% threshold leaves out millions of LEP
individuals!
10%
5%
500
# Counties
255
565
1,284
# States
23
37
50 states plus
DC, PR

11. The Problems – Enrolling
• Selection & training of “assisters”
• Training for call centers
• Health plan networks may not include sufficient
bilingual/bicultural providers or provide
language services to treat LEP patients

12. The Problems – The Application
• Failure to collect language data from all
applicants, only household contact
• Failure to provide translated application into
any language other than Spanish
 CMS will develop a “tool” in 7 languages (Vietnamese,
French Creole, Chinese, Korean, Arabic, Portuguese &
Polish)
 CMS will support creation of similar tools in 17
languages

13. Now is the Time!
• Right now, decisions are being made at federal
and state level to implement health reform &
language services
• If we do not act quickly, it will be too late
because adding/changing systems later costs $
• If your state has a state-based Exchange, get
involved – send in your comments, talk at public
meetings, organize others to provide input
• If your state will use the “FFE”, get involved with
federal policymaking

14. Resources
• Language Access Checklist for Marketplace
Implementation
• Translation Glossaries: The Need for
Standardization of ACA-related Terms
• Short Paper 6: The ACA and Application of §
1557 and Title VI of the Civil Rights Act of 1964
to the Health Insurance Exchanges
• Short Paper 5: The ACA and Language Access

15. THANK YOU!
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ph: (310) 204-6010
fx: (213) 368-0774
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ph: (919) 968-6308
fx: (919) 968-8855
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www.healthlaw.org