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LEP HMO Enrollees Communication Barriers

LEP HMO Enrollees Communication Barriers

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Published by: iggybau on Apr 25, 2013
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Health Policy Brie 
February 2013
Limited English Profcient HMOEnrollees Remain Vulnerable toCommunication Barriers DespiteLanguage Assistance Regulations
Max W. Hadler, Xiao Chen, Erik Gonzalez and Dylan H. Roby
HMO enrollees with limitedEnglish profciency, and particularly those inpoorer health, ace communication barriersdespite language assistance regulations. Morethan 1.3 million Caliornia HMO enrollees ages18 to 64 do not speak English well enough tocommunicate with medical providers and mayexperience reduced access to high-quality healthcare i they do not receive appropriate languageassistance services. Based on analysis o the 2007and 2009 Caliornia Health Interview Surveys(CHIS), commercial HMO enrollees with limitedEnglish profciency (LEP) in poorer health aremore likely to have difculty understandingtheir doctors, placing this already vulnerablepopulation at even greater risk. The analysis alsouses CHIS to examine the potential impact o health plan monitoring starting in 2009 (due to a2003 amendment to the Knox-Keene Health CareServices Act) requiring health plans to provideree qualifed interpretation and translationservices to HMO enrollees. The authorsrecommend that Caliornia’s health planscontinue to incorporate trained interpreters intotheir contracted networks and delivery systems,paying special attention to enrollees in poorerhealth. The results may serve as a planning toolor health plans, providing a detailed snapshoto enrollee characteristics that will help designeective programs now and prepare or a likelyincrease in insured LEP populations in theuture, as ull implementation o the AordableCare Act takes place over the next decade.
lmost two-thirds o limited Englishprocient commercial HMOenrollees who reported communicationbarriers were in air or poor health. Therecent implementation o regulations toimprove commercial HMO provision o language assistance services may eventuallyhelp increase understanding, but in therst year o implementation, it does notappear that HMO policies ensuring accessto language-appropriate services have led toimmediate improvements in communicationor the sickest enrollees.
Requirements or HMOs to ProvideLanguage Access Services
In response to the passage o the Knox-Keene amendment in 2003, languageaccess regulations were established in 2007or all health plans covered by Caliornia’sDepartment o Managed Health Care (DMHC)and select plans covered by the CaliorniaDepartment o Insurance (CDI). The newregulations require insurers to assess theirmembers’ languages o preerence and provideverbal interpretation in all languages, andwritten translation in threshold languages.Threshold languages generally include Spanishand Chinese and, or some health plans,
HMO enrolleesin poorer healthexperience thebiggest languagebarriers.
Funded by the Caliornia Ofceo the Patient Advocate
Vietnamese, Russian, Korean, Tagalog, Khmer,Armenian, Arabic, and/or Hmong.
DMHCbegan monitoring health plan compliance in January 2009, when all HMOs were requiredto have ully implemented language accesspolicies and procedures.The law is particularly important in the currenthealth policy environment as LEP populationswill make up a signicant portion o the newlyinsured ater implementation o the AordableCare Act, including via the state’s healthbenets exchange, Covered Caliornia. A recentUC Berkeley and UCLA analysis estimated that29% to 36% o non-elderly adults who take-upsubsidized coverage in Covered Caliornia willbe LEP.
 In this study, we examine the LEP HMOenrollee population and attempt to measurecommunication barriers and early progresssince the Knox-Keene amendment wentinto eect. A limiting actor is that datarom 2009 may reer to language barriersthat existed as early as September 2007 andas late as April 2010 since respondents are
This publication containsdata rom the CaliorniaHealth Interview Survey(CHIS), the nation’s largeststate health survey.Conducted by the UCLACenter or Health PolicyResearch, CHIS data givea detailed picture o thehealth and health careneeds o Caliornia’s largeand diverse population.Learn more at:
 LEPCaliornianswill make up a signifcant  portion o thenewly insured under healthcare reorm.
Threshold languages
Determined by the demographic makeupo a health plan’s membership, these arelanguages or which plans must providetranslated vital documents, includingapplications, consent orms, letters abouteligibility or participation criteria, andnotices advising changes in benets andavailability o ree language assistance.
Knox-Keene Health Care Services Act
 Caliornia law established in 1975 thatregulates managed care plans. The law hasbeen amended multiple times since itsinception, including in 2003 to addresslanguage access issues as a result o SenateBill 853.
Limited English Profciency (LEP)
 Individuals who reported speaking Englishnot well or not at all.
Fee-or-Service (FFS)
A method o payment in which health careproviders are paid per service rendered.In Caliornia, most ee-or-service care isdelivered to Medicare beneciaries andMedicaid enrollees living in rural areas.
Preerred Provider Organization (PPO)
 A health insurance plan that encouragesmembers to seek care through contractedproviders by requiring patients to pay alarger share or services delivered outsideo its contracted network o providers. Forexample, a patient can see an in-networkprovider and pay 20% o the provider’s ee,or see an out-o-network provider and pay40% o that provider’s ee.
Health Maintenance Organization (HMO)
A health plan that requires members toseek care in a contracted network. HMOstypically use primary care physicians andother protocols to authorize specialty careand medical procedures. Care deliveredout-o-network is not covered except inemergency situations.
Percent o Enrollees Who Are Limited English Profcient by Type o Insurance, Ages 18-64,Caliornia, 2007-2009Exhibit 1
35%30%25%20%15%10%5%0%Commercial HMO Commercial PPO Public HMO Public FFS8.3% 9.0%4.4%4.8%23.9%27.2%23.8%27.2%2007 2009
Note: Based on chi-square test o proportions or each insurancecategory between 2007 and 2009. See Appendix 1 orurther details.Sources: 2007 and 2009 Caliornia Health Interview Surveys
 LEP enrolleesrepresent a substantial  portion o membershipin manyHMO plans.
asked about experiences up to two yearsprior to being surveyed. Although theregulations were published in early 2007,some o the results reported here preceded theimplementation deadline in 2009. These dataare an intermediate measure o progress towardimproved language access ater 2009.
Limited English Profcient a SubstantialProportion o HMO Membership
In 2009, nearly one in eight HMO enrolleesin Caliornia was LEP. A much largerproportion o enrollees in public programssuch as Medicare and Medicaid (27.2%) wereLEP when compared to those in commercialplans (9.5%), but the total number o LEPenrollees in commercial HMOs (842,000)was substantially larger than in public HMOs(460,000) given the greater number o peoplewith commercial coverage (Exhibit 1 andAppendix 1). Examining large commercialinsurers individually, LEP enrollees representeda substantial proportion o membership inmany HMO plans (Exhibit 2 and Appendix 2).The change in LEP as a percentage o allenrollees did not change signicantly rom2007 to 2009 or commercial or publicHMOs. This suggests that the plans have arelatively consistent membership prole togauge demand and plan or language assistanceservices or language concordance with healthcare providers.

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