Sec. 201 Definitions
In this title, the definitions contained in section 3400 of the Public Health Service Act, as added by section 202, shall apply.
Title II — Culturally and linguistically appropriate health care
II Culturally and linguistically appropriate health care
Sec. 202 Amendment to the Public Health Service Act
Findings— Congress finds the following:
Effective communication is essential to meaningful access to quality physical and mental health care.
Research indicates that the lack of appropriate language services creates language barriers that result in increased risk of misdiagnosis, ineffective treatment plans and poor health outcomes for limited-English-proficient individuals and individuals with communication disabilities such as hearing, vision, or print impairments.
The number of limited-English-speaking residents in the United States who speak English less than very well and, therefore, cannot effectively communicate with health and social service providers continues to increase significantly.
The responsibility to fund language services in the provision of health care and health-care-related services to limited-English-proficient individuals and individuals with communication disabilities such as hearing, vision, or print impairments is a societal one that cannot fairly be visited solely upon the health care, public health, or social services community.
Title VI of the Civil Rights Act of 1964 prohibits discrimination based on the grounds of race, color, or national origin by any entity receiving Federal financial assistance. In order to avoid discrimination on the grounds of national origin, all programs or activities administered by the Department must take adequate steps to ensure that their policies and procedures do not deny or have the effect of denying limited-English-proficient individuals with equal access to benefits and services for which such persons qualify.
Linguistic diversity in the health care and health-care-related-services workforce is important for providing all patients the environment most conducive to positive health outcomes.
All members of the health care and health-care-related-services community should continue to educate their staff and constituents about limited-English-proficient and disability communication issues and help them identify resources to improve access to quality care for limited-English-proficient individuals and individuals with communication disabilities such as hearing, vision, or print impairments.
Access to English as a second language and sign language instructions is an important mechanism for ensuring effective communication and eliminating the language barriers that impede access to health care.
Competent language services in health care settings should be available as a matter of course.
Amendment— The Public Health Service Act (42 U.S.C. 201 et seq.) is amended by adding at the end the following:
“XXXIV CULTURALLY AND LINGUISTICALLY APPROPRIATE HEALTH CARE
“3400. Definitions
“In this title:
“(1) Bilingual—The term bilingual with respect to an individual means a person who has sufficient degree of proficiency in two languages.
“(2) Community health worker—The term community health worker includes a community health advocate, a lay health educator, a community health representative, a peer health promoter, a community health outreach worker, and in Spanish, promotores de salud.
“(3) Competent interpreter services—The term competent interpreter services means a translanguage rendition of a spoken or signed message in which the interpreter—
“(A) comprehends the source language and can communicate comprehensively in the target language to convey the meaning intended in the source language; and
“(B) knows health and health-related terminology and provides accurate interpretations by choosing equivalent expressions that convey the best matching and meaning to the source language and capture, to the greatest possible extent, all nuances intended in the source message.
“(4) Competent translation services—The term competent translation services means a translanguage rendition of a written document in which the translator—
“(A) comprehends the source language and can write or sign comprehensively in the target language to convey the meaning intended in the source language; and
“(B) knows health and health-related terminology and provides accurate translations by choosing equivalent expressions that convey the best matching and meaning to the source language and capture, to the greatest possible extent, all nuances intended in the source document.
“(5) Cultural competence—The term cultural competence means a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals that enables effective work in cross-cultural situations. In the preceding sentence—
“(A) the term cultural refers to integrated patterns of human behavior that include the language, thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic, religious, or social groups, including lesbian, gay, bisexual, transgender, and intersex individuals, and individuals with physical and mental disabilities; and
“(B) the term competence implies having the capacity to function effectively as an individual and an organization within the context of the cultural beliefs, behaviors, and needs presented by consumers and their communities.
“(6) Effective communication—The term effective communication means an exchange of information between the provider of health care or health-care-related services and the recipient of such services who is limited in English proficiency, or has a communication impairment such as a hearing, vision, or learning impairment, that enables access, understanding, and benefit from health care or health-care-related services, and full participation in the development of their treatment plan.
“(7) Grievance resolution process—The term grievance resolution process means all aspects of dispute resolution including filing complaints, grievance and appeal procedures, and court action.
“(8) Health care group—The term health care group means a group of physicians organized, at least in part, for the purposes of providing physicians’ services under the Medicaid, SCHIP, or Medicare programs and may include a hospital and any other individual or entity furnishing services covered under the Medicaid, SCHIP, or Medicare programs that is affiliated with the health care group.
“(9) Healthcare services—The term health care services means services that address physical as well as mental health conditions in all care settings.
“(10) Health-care-related services—The term health-care-related services means human or social services programs or activities that provide access, referrals or links to health care.
“(11) Indian tribe—The term Indian tribe means any Indian tribe, band, nation, or other organized group or community, including any Alaska Native village or group or regional or village corporation as defined in or established pursuant to the Alaska Native Claims Settlement Act (85 Stat. 688) (43 U.S.C. 1601 et seq.), which is recognized as eligible for the special programs and services provided by the United States to Indians because of their status as Indians.
“(12) Integrated health care delivery system—The term integrated health care delivery system means an interdisciplinary system that brings together providers from the primary health, mental health, substance use and related disciplines to improve the health outcomes of an individual. Providers may include but are not limited to hospitals, health, mental health or substance use clinics and providers, home health agencies, ambulatory surgery centers, skilled nursing facilities, rehabilitation centers, and employed, independent, or contracted physicians.
“(13) Interpreting/interpretation—The terms interpreting and interpretation mean the transmission of a spoken, written, or signed message from one language or format into another, faithfully, accurately, and objectively.
“(14) Language access—The term language access means the provision of language services to an LEP individual or individual with communication disabilities designed to enhance that individual’s access to, understanding of, or benefit from health care or health-care-related services.
“(15) Language or language access services—The term language or language access services means provision of health care services directly in a non-English language, interpretation, translation, signage, video recording, and English or non-English alternative formats.
“(16) LEP—The term LEP means limited-English-proficient.
“(17) Medicare, Medicaid, and SCHIP—The terms Medicare, Medicaid, and SCHIP mean the respective programs under titles XVIII, XIX, and XXI of the Social Security Act.
“(18) Minority
“(A) In general—The terms minority and minorities refer to individuals from a minority group.
“(B) Populations—The term minority, with respect to populations, refers to racial and ethnic minority groups.
“(19) Minority group—The term minority group has the meaning given the term racial and ethnic minority group.
“(20) Racial and ethnic minority group—The term racial and ethnic minority group means American Indians and Alaska Natives, African-Americans (including Caribbean Blacks, Africans, and other Blacks), Asian-Americans, Hispanics (including Latinos), and Native Hawaiians and other Pacific Islanders.
“(21) Onsite interpretation—The term onsite interpretation means a method of interpreting or interpretation for which the interpreter is in the physical presence of the provider of health care or health-care-related services and the recipient of such services who is limited in English proficiency or has a communication impairment such as hearing, vision, or learning.
“(22) Secretary—The term Secretary means the Secretary of Health and Human Services.
“(23) Sight translation—The term sight translation means the transmission of a written message in one language into a spoken or signed message in another language, or an alternative format in English or another language.
“(24) State—The term State means each of the several States, the District of Columbia, the Commonwealth of Puerto Rico, the Indian tribes, the United States Virgin Islands, Guam, American Samoa, and the Commonwealth of the Northern Mariana Islands.
“(25) Telephonic interpretation—The term telephonic interpretation (also known as over the phone interpretation or OPI) means a method of interpreting/interpretation for which the interpreter is not in the physical presence of the provider of health care or related services and the limited-English-proficient recipient of such services but is connected via telephone.
“(26) Translation—The term translation means the transmission of a written message in one language into a written or signed message in another language, and includes translation into another language or alternative format, such as large print font, Braille, audio recording, or CD.
“(27) Video interpretation—The term video interpretation means a method of interpreting/interpretation for which the interpreter is not in the physical presence of the provider of health care or related services and the limited-English-proficient recipient of such services but is connected via a video hook-up that includes both audio and video transmission.
“(28) Vital document—The term vital document includes but is not limited to applications for government programs that provide health care services, medical or financial consent forms, financial assistance documents, letters containing important information regarding patient instructions (such as prescriptions, referrals to other providers, and discharge plans) and participation in a program (such as a Medicaid managed care program), notices pertaining to the reduction, denial, or termination of services or benefits, notices of the right to appeal such actions, and notices advising limited-English-proficient individuals and individuals with communication disabilities of the availability of free language services, alternative formats, and other outreach materials.
“3401. Improving access to services for individuals with limited English proficiency
“(a) Purpose—As provided in Executive Order 13166, it is the purpose of this section—
“(1) to improve Federal agency performance regarding access to federally conducted and federally assisted programs and activities for individuals who are limited in their English proficiency;
“(2) to require each Federal agency to examine the services it provides and develop and implement a system by which limited-English-proficient individuals can obtain cultural competence and meaningful access to those services consistent with, and without substantially burdening, the fundamental mission of the agency;
“(3) to require each Federal agency to ensure that recipients of Federal financial assistance provide cultural competence and meaningful access to their limited-English-proficient applicants and beneficiaries;
“(4) to ensure that recipients of Federal financial assistance take reasonable steps, consistent with the guidelines set forth in the Limited English Proficient Guidance of the Department of Justice (as issued on June 12, 2002), to ensure cultural competence and meaningful access to their programs and activities by limited-English-proficient individuals; and
“(5) to ensure compliance with title VI of the Civil Rights Act of 1964 and that health care providers and organizations do not discriminate in the provision of services.
“(b) Federally conducted programs and activities
“(1) In general—Not later than 120 days after the date of enactment of this title, each Federal agency that carries out health-care-related activities shall prepare a plan to improve access cultural competence to the federally conducted, health-care-related programs and activities of the agency by limited-English-proficient individuals. Not later than one year after the date of enactment of this title, each such Federal agency shall ensure that such plan is fully implemented.
“(2) Plan requirement—Each plan under paragraph (1) shall include—
“(A) the steps the agency will take to ensure that limited-English-proficient individuals have access to the agency’s federally conducted health care and health-care-related programs and activities;
“(B) the policies and procedures for identifying, assessing, and meeting the language needs and cultural competence needs of its limited-English-proficient beneficiaries served by federally conducted programs and activities;
“(C) the steps the agency will take for its federally conducted programs and activities to improve cultural competence to provide a range of language assistance options, notice to limited-English-proficient individuals of the right to competent language services, periodic training of staff, monitoring and quality assessment of the language services and, in appropriate circumstances, the translation of written materials;
“(D) the steps the agency will take to ensure that applications, forms, and other relevant documents for its federally conducted programs and activities are competently translated into the primary language of a limited-English-proficient client where such materials are needed to improve access to federally conducted and federally assisted programs and activities for such a limited-English-proficient individual;
“(E) the resources the agency will provide to improve cultural competence to assist recipients of Federal funds to improve access to health care or health-care-related programs and activities for limited-English-proficient individuals;
“(F) the resources the agency will provide to ensure that competent language assistance is provided to limited-English-proficient patients by interpreters or trained bilingual staff; and
“(G) the resources the agency will provide to ensure that family, particularly minor children, and friends are not used to provide interpretation services, except—
“(i) in the case of a medical emergency where delay directly associated with obtaining a competent interpreter would jeopardize the health of the patient; or
“(ii) on request of the patient, who has been informed in his or her preferred language of the availability of free interpretation services, if the health care services provider has determined that the family or friend can provide competent interpreter services as defined in section 3400.
“(3) Submission of plan to DOJ—Each agency that is required to prepare a plan under paragraph (1) shall send a copy of such plan to the Department of Justice, which shall serve as the central repository of such plans.
“(4) Rule of construction—Paragraph (2)(G)(i) shall not be construed to mean that emergency rooms or similar entities that regularly provide health care services in medical emergencies are exempt from legal or regulatory requirements related to competent interpreter services.
“(c) Federally assisted programs and activities
“(1) In general—Not later than 120 days after the date of enactment of this title, each Federal agency providing health-care-related Federal financial assistance shall ensure that the guidance for recipients of Federal financial assistance developed by the agency to ensure compliance with title VI of the Civil Rights Act of 1964 (42 U.S.C. 2000d et seq.) is specifically tailored to the recipients of such assistance. Each agency shall send a copy of such guidance to the Department of Justice which shall serve as the central repository of the agency’s plans. After approval by the Department of Justice, each agency shall publish its guidance document in the Federal Register for public comment.
“(2) Requirements—The agency-specific guidance developed under paragraph (1) shall take into account the types of health care services provided by the recipients, the individuals served by the recipients, and other factors set out in such standards.
“(3) Existing guidances—A Federal agency that has developed a guidance for purposes of title VI of the Civil Rights Act of 1964 shall examine such existing guidance, as well as the programs and activities to which such guidance applies, to determine if modification of such guidance is necessary to comply with this subsection.
“(4) Consultation—Each Federal agency shall consult with the Department of Justice in establishing the guidances under this subsection.
“(d) Consultations
“(1) In general—In carrying out this section, each Federal agency that carriers out health care and health-care-related activities shall ensure that stakeholders, such as limited-English-proficient individuals and their representative organizations, recipients of Federal assistance, and other appropriate individuals or entities, have an adequate opportunity to provide input with respect to the actions of the agency.
“(2) Evaluation—Each Federal agency described in paragraph (1) shall evaluate the—
“(A) particular needs of the limited-English-proficient individuals served by the agency;
“(B) particular needs of the limited-English-proficient individuals served by the agency’s recipients of Federal financial assistance; and
“(C) burdens of compliance with the agency guidance and this section for the agency and its recipients.
“3402. National standards for culturally and linguistically appropriate services in health care
“(a) Applicability—This section applies to any health program or activity, any part of which is receiving Federal financial assistance, including credits, subsidies, or contracts of insurance, or any program or activity that is administered by an executive agency or any entity established under title I of the Patient Protection and Affordable Care Act (or amendments made thereby), as such programs, activities, agencies, and entities are described in section 1557(a) of the Patient Protection and Affordable Care Act.
“(b) Standards—The programs, activities, agencies, and entities described in subsection (a) shall—
“(1) implement strategies to recruit, retain, and promote individuals at all levels to maintain a diverse staff and leadership that can provide culturally and linguistically appropriate health care to patient populations of the service area of the programs, activities, agencies, and entities;
“(2) educate and train governance, leadership, and workforce at all levels and across all disciplines of the programs, activities, agencies, and entities in culturally and linguistically appropriate policies and practices on an ongoing basis;
“(3) offer and provide language assistance, including trained bilingual staff and interpreter services, to individuals who have limited-English proficiency or other communication needs, at no cost to them at all points of contact, and during all hours of operation, to facilitate timely access to all health care and services;
“(4) notify patients, in a culturally appropriate manner, of their right to receive language assistance services in their primary language, verbally and in writing;
“(5) ensure the competence of language assistance provided to limited-English-proficient patients by interpreters and bilingual staff, and ensure that family, particularly minor children, and friends are not used to provide interpretation services—
“(A) except in case of emergency; or
“(B) except on request of the patient, who has been informed in his or her preferred language of the availability of free interpretation services if the health care services provider has determined that the family or friend can provide competent interpreter services as defined in section 3400;
“(6) for each eligible LEP language group that constitutes 5 percent or 500 individuals, whichever is less, of the population of persons eligible to be served or likely to be affected or encountered in the service area of the organization, make available—
“(A) easily understood patient-related materials, including print and multimedia materials;
“(B) information or notices about termination of benefits; and
“(C) signage;
“(7) develop and implement clear goals, policies, operational plans, and management, accountability, and oversight mechanisms to provide culturally and linguistically appropriate services and infuse them throughout the organization’s planning and operations;
“(8) conduct initial and ongoing organizational assessments of culturally and linguistically appropriate services-related activities and integrate valid linguistic, competence-related National Standards for Culturally and Linguistically Appropriate Services (CLAS) measures into the internal audits, performance improvement programs, patient satisfaction assessments, continuous quality improvement activities, and outcomes-based evaluations of the organization and develop ways to standardize the assessments;
“(9) ensure that, consistent with the privacy protections provided for under the regulations promulgated under section 264(c) of the Health Insurance Portability and Accountability Act of 1996, data on an individual required to be collected pursuant to section 3101, including the individual’s alternative format preferences and policy modification needs, are—
“(A) collected in health records;
“(B) integrated into the organization’s management information systems; and
“(C) periodically updated;
“(10) maintain a current demographic, cultural, and epidemiological profile of the community, conduct regular assessments of community health assets and needs, and use the results to accurately plan for and implement services that respond to the cultural and linguistic characteristics of the service area of the organization;
“(11) develop participatory, collaborative partnerships with communities and utilize a variety of formal and informal mechanisms to facilitate community and patient involvement in designing, implementing, and evaluating policies and practices to ensure culturally and linguistically appropriate service-related activities;
“(12) ensure that conflict and grievance resolution processes are culturally and linguistically sensitive and capable of identifying, preventing, and resolving cross-cultural conflicts or complaints by patients;
“(13) regularly make available to the public information about their progress and successful innovations in implementing the standards under this section and provide public notice in their communities about the availability of this information; and
“(14) if requested, regularly make available to the head of each Federal entity from which Federal funds are received, information about their progress and successful innovations in implementing the standards under this section as required by the head of such entity.
“3403. Robert T. Matsui Center for Cultural and Linguistic Competence in Health Care
“(a) Establishment—The Secretary, acting through the Director of the Agency for Healthcare Research and Quality, shall establish and support a center to be known as the Robert T. Matsui Center for Cultural and Linguistic Competence in Health Care (referred to in this section as the Center) to carry out the following activities:
“(1) Interpretation services—The Center shall provide resources via the Internet to identify and link health care providers to competent interpreter and translation services.
“(2) Translation of written material
“(A) The Center shall provide, directly or through contract, vital documents from competent translation services for providers of health care and health-care-related services at no cost to such providers. Materials may be submitted for translation into non-English languages. Translation services shall be provided in a timely and reasonable manner. The quality of such translation services shall be monitored and reported publicly.
“(B) For each form developed or revised by the Secretary that will be used by LEP individuals in health care or health-care-related settings, the Center shall translate the form, at a minimum, into the top 15 non-English languages in the United States according to the most recent data from the American Community Survey or its replacement. The translation must be completed within 45 days of the Secretary receiving final approval of the form from the Office of Management and Budget.
“(3) Toll-free customer service telephone number—The Center shall provide, through a toll-free number, a customer service line for LEP individuals—
“(A) to obtain information about federally conducted or funded health programs, including Medicare, Medicaid, and SCHIP;
“(B) to obtain assistance with applying for or accessing these programs and understanding Federal notices written in English; and
“(C) to learn how to access language services.
“(4) Health information clearinghouse
“(A) In general—The Center shall develop and maintain an information clearinghouse to facilitate the provision of language services by providers of health care and health-care-related services to reduce medical errors, improve medical outcomes, to improve cultural competence, reduce health care costs caused by miscommunication with individuals with limited-English proficiency, and reduce or eliminate the duplication of effort to translate materials. The clearinghouse shall make such information available on the Internet and in print. Such information shall include the information described in the succeeding provisions of this paragraph.
“(B) Document templates—The Center shall collect and evaluate for accuracy, develop, and make available templates for standard documents that are necessary for patients and consumers to access and make educated decisions about their health care, including the following:
“(i) Administrative and legal documents, including—
“(I) intake forms;
“(II) Medicare, Medicaid, and SCHIP forms, including eligibility information;
“(III) forms informing patient of HIPAA compliance and consent; and
“(IV) documents concerning informed consent, advanced directives, and waivers of rights.
“(ii) Clinical information, such as how to take medications, how to prevent transmission of a contagious disease, and other prevention and treatment instructions.
“(iii) Public health, patient education, and outreach materials, such as immunization notices, health warnings, or screening notices.
“(iv) Additional health or health-care-related materials as determined appropriate by the Director of the Center.
“(C) Structure of forms—In operating the clearinghouse, the Center shall—
“(i) ensure that the documents posted in English and non-English languages are culturally appropriate;
“(ii) allow public review of the documents before dissemination in order to ensure that the documents are understandable and culturally appropriate for the target populations;
“(iii) allow health care providers to customize the documents for their use;
“(iv) facilitate access to these documents;
“(v) provide technical assistance with respect to the access and use of such information; and
“(vi) carry out any other activities the Secretary determines to be useful to fulfill the purposes of the clearinghouse.
“(D) Language assistance programs—The Center shall provide for the collection and dissemination of information on current examples of language assistance programs and strategies to improve language services for LEP individuals, including case studies using de-identified patient information, program summaries, and program evaluations.
“(E) Cultural and linguistic competence materials—The Center shall provide information relating to culturally and linguistically competent health care for minority populations residing in the United States to all health care providers and health-care-related services at no cost. Such information shall include—
“(i) tenets of culturally and linguistically competent care;
“(ii) cultural and linguistic competence self-assessment tools;
“(iii) cultural and linguistic competence training tools;
“(iv) strategic plans to increase cultural and linguistic competence in different types of providers of health care and health-care-related services, including regional collaborations among health care organizations; and
“(v) cultural and linguistic competence information for educators, practitioners, and researchers.
“(F) Information about progress—The Center shall regularly collect and make publicly available information about the progress of entities receiving grants under section 3404 regarding successful innovations in implementing the obligations under this subsection and provide public notice in the entities’ communities about the availability of this information.
“(b) Director—The Center shall be headed by a Director who shall be appointed by, and who shall report to, the Director of the Agency for Healthcare Research and Quality.
“(c) Availability of language access—The Director shall collaborate with the Deputy Assistant Secretary for Minority Health, the Administrator of the Centers for Medicare & Medicaid Services, and the Administrator of the Health Resources and Services Administration to notify health care providers and health care organizations about the availability of language access services by the Center.
“(d) Education—The Secretary, directly or through contract, shall undertake a national education campaign to inform providers, LEP individuals, health professionals, graduate schools, and community health centers about—
“(1) Federal and State laws and guidelines governing access to language services;
“(2) the value of using trained interpreters and the risks associated with using family members, friends, minors, and untrained bilingual staff;
“(3) funding sources for developing and implementing language services; and
“(4) promising practices to effectively provide language services.
“(e) Authorization of appropriations—In addition to the amounts authorized under subsection (e)(8)(F), there are authorized to be appropriated to carry out this section such sums as may be necessary for each of fiscal years 2015 through 2019.
“3404. Innovations in cultural and linguistic competence grants
“(a) In general—The Secretary, acting through the Director of the Agency for Healthcare Research and Quality, shall award grants to eligible entities to enable such entities to design, implement, and evaluate innovative, cost-effective programs to improve cultural competence and language access in health care for individuals with limited-English proficiency. The Director of the Agency for Healthcare Research and Quality shall coordinate with, and ensure the participation of, other agencies including the Health Resources and Services Administration, the Center on Minority Health and Health Disparities at the National Institutes of Health, and the Office of Minority Health, regarding the design and evaluation of the grants program.
“(b) Eligibility—To be eligible to receive a grant under subsection (a) an entity shall—
“(1) be—
“(A) a city, county, Indian tribe, State, territory, or subdivision thereof;
“(B) an organization described in section 501(c)(3) of the Internal Revenue Code of 1986 and exempt from tax under section 501(a) of such Code;
“(C) a community health, mental health, or substance use center or clinic;
“(D) a solo or group physician practice;
“(E) an integrated health care delivery system;
“(F) a public hospital;
“(G) a health care group, university, or college; or
“(H) other entity designated by the Secretary; and
“(2) prepare and submit to the Secretary an application, at such time, in such manner, and accompanied by such additional information as the Secretary may require.
“(c) Use of funds—An entity shall use funds received under a grant under this section to—
“(1) develop, implement, and evaluate models of providing competent interpretation services through onsite interpretation, telephonic interpretation, or video interpretation;
“(2) implement strategies to recruit, retain, and promote individuals at all levels of the organization to maintain a diverse staff and leadership that can promote and provide language services to patient populations of the service area of the organization;
“(3) develop and maintain a needs assessment that identifies the current demographic, cultural, and epidemiological profile of the community to accurately plan for and implement language services needed in service area of the organization;
“(4) develop a strategic plan to implement language services;
“(5) develop participatory, collaborative partnerships with communities encompassing the LEP patient populations being served to gain input in designing and implementing language services;
“(6) develop and implement grievance resolution processes that are culturally and linguistically sensitive and capable of identifying, preventing, and resolving complaints by LEP individuals; or
“(7) develop short-term medical mental health interpretation training courses and incentives for bilingual health care staff who are asked to interpret in the workplace;
“(8) develop formal training programs, including continued professional development and education programs as well as supervision, for individuals interested in becoming dedicated health care interpreters and culturally competent providers;
“(9) provide staff language training instruction, which shall include information on the practical limitations of such instruction for non-native speakers;
“(10) develop policies that address compensation in salary for staff who receive training to become either a staff interpreter or bilingual provider;
“(11) develop other language assistance services as determined appropriate by the Secretary;
“(12) develop, implement, and evaluate models of improving cultural competence; and
“(13) ensure that, consistent with the privacy protections provided for under the regulations promulgated under section 264(c) of the Health Insurance Portability and Accountability Act of 1996 (42 U.S.C. 1320d–2 note) and any applicable State privacy laws, data on the individual patient or recipient’s race, ethnicity, and primary language are collected (and periodically updated) in health records and integrated into the organization’s information management systems or any similar system used to store and retrieve data.
“(d) Priority—In awarding grants under this section, the Secretary shall give priority to entities that primarily engage in providing direct care and that have developed partnerships with community organizations or with agencies with experience in improving language access.
“(e) Evaluation
“(1) By grantees—An entity that receives a grant under this section shall submit to the Secretary an evaluation that describes, in the manner and to the extent required by the Secretary, the activities carried out with funds received under the grant, and how such activities improved access to health and health-care-related services and the quality of health care for individuals with limited-English proficiency. Such evaluation shall be collected and disseminated through the Robert T. Matsui Center for Cultural and Linguistic Competence in Health Care established under section 3403. The Director of the Agency for Healthcare Research and Quality shall notify grantees of the availability of technical assistance for the evaluation and provide such assistance upon request.
“(2) By Secretary—The Director of the Agency for Healthcare Research and Quality shall evaluate or arrange with other individuals or organizations to evaluate projects funded under this section.
“(f) Authorization of appropriations—There is authorized to be appropriated to carry out this section, $5,000,000 for each of fiscal years 2015 through 2019.
“3405. Research on cultural and language competence
“(a) In general—The Secretary, acting through the Director of the Agency for Healthcare Research and Quality, shall expand research concerning language access in the provision of health care.
“(b) Eligibility—The Director of the Agency for Healthcare Research and Quality may conduct the research described in subsection (a) or enter into contracts with other individuals or organizations to do so.
“(c) Use of funds—Research under this section shall be designed to do one or more of the following:
“(1) To identify the barriers to mental and behavioral services that are faced by LEP individuals.
“(2) To identify health care providers’ and health administrators’ attitudes, knowledge, and awareness of the barriers to quality health care services that are faced by LEP individuals.
“(3) To identify optimal approaches for delivering language access.
“(4) To identify best practices for data collection, including—
“(A) the collection by providers of health care and health-care-related services of data on the race, ethnicity, and primary language of recipients of such services, taking into account existing research conducted by the Government or private sector;
“(B) the development and implementation of data collection and reporting systems; and
“(C) effective privacy safeguards for collected data.
“(5) To develop a minimum data collection set for primary language.
“(6) To evaluate the most effective ways in which the Department can create or coordinate, and then subsidize or otherwise fund telephonic interpretation providers for health care providers, taking into consideration, among other factors, the flexibility necessary for such a system to accommodate variations in—
“(A) provider type;
“(B) languages needed and their frequency of use;
“(C) type of encounter;
“(D) time of encounter, including regular business hours and after hours; and
“(E) location of encounter.
“(d) Authorization of appropriations—There are authorized to be appropriated to carry out this section such sums as may be necessary for each of fiscal years 2015 through 2019.”
Sec. 203 Pilot program for improvement and development of State medical interpreting services
Grants authorized— The Secretary shall award one grant in accordance with this section to each of three States to assist each such State in designing, implementing, and evaluating a statewide program to provide onsite interpreter services under Medicaid.
Grant period— A grant awarded under this section is authorized for a period of three fiscal years beginning on October 1, 2014.
Preference— In awarding a grant under this section, the Secretary shall give preference to a State—
that has a high proportion of qualified LEP enrollees, as determined by the Secretary;
that has a large number of qualified LEP enrollees, as determined by the Secretary;
that has a high growth rate of the population of LEP individuals, as determined by the Secretary; and
that has a population of qualified LEP enrollees that is linguistically diverse, requiring interpreter services in at least 200 non-English languages.
Use of funds— A State receiving a grant under this section shall use the grant funds to—
ensure that all health care providers in the State participating in the State plan under Medicaid have access to onsite interpreter services, for the purpose of enabling effective communication between such providers and qualified LEP enrollees during the furnishing of items and services and administrative interactions;
establish, expand, procure, or contract for—
a statewide health care information technology system that is designed to achieve efficiencies and economies of scale with respect to onsite interpreter services provided to health care providers in the State participating in the State plan under Medicaid; and
an entity to administer such system, the duties of which shall include—
procuring and scheduling interpreter services for qualified LEP enrollees;
procuring and scheduling interpreter services for LEP individuals seeking to enroll in the State plan under Medicaid;
ensuring that interpreters receive payment for interpreter services rendered under the system; and
consulting regularly with organizations representing consumers, interpreters, and health care providers; and
develop mechanisms to establish, improve, and strengthen the competency of the medical interpretation workforce that serves qualified LEP enrollees in the State, including a national certification process that is valid, credible, and vendor-neutral.
Application— To receive a grant under this section, a State shall submit an application at such time and containing such information as the Secretary may require, which shall include the following:
A description of the language access needs of individuals in the State enrolled in the State plan under Medicaid.
A description of the extent to which the program will—
use the grant funds for the purposes described in subsection (d);
meet the health care needs of rural populations of the State; and
collect information that accurately tracks the language services requested by consumers as compared to the language services provided by health care providers in the State participating in the State plan under Medicaid.
A description of how the program will be evaluated, including a proposal for collaboration with organizations representing interpreters, consumers, and LEP individuals.
Definitions— In this section:
Qualified LEP enrollee— The term qualified LEP enrollee means an individual—
who is limited-English-proficient; and
who is enrolled in a State plan under Medicaid.
State— The term State has the meaning given the term in section 1101(a)(1) of the Social Security Act (42 U.S.C. 1301(a)(1)), for purposes of title XIX of such Act.
United States— The term United States has the meaning given the term in section 1101(a)(2) of the Social Security Act (42 U.S.C. 1301(a)(2)), for purposes of title XIX of such Act.
Funding—
Authorization of appropriations— There is authorized to be appropriated $5,000,000 to carry out this section.
Availability of funds— The funds authorized by paragraph (1) shall be available without fiscal year limitation.
Increased Federal financial participation— Section 1903(a)(2)(E) of the Social Security Act (42 U.S.C. 1396b(a)(2)(E)), as amended by section 205(d)(1) of this Act, is further amended by inserting “(or, in the case of a State receiving a grant under section 203 of the Health Equity and Accountability Act of 2014, 100 percent for each quarter occurring during the grant period)” after “90 percent”.
Limitation— No Federal funds under this section may be used to provide interpreter services from a location outside the United States.
Sec. 204 Training tomorrow’s doctors for culturally and linguistically appropriate care: graduate medical education
Direct graduate medical education— Section 1886(h)(4) of the Social Security Act (42 U.S.C. 1395ww(h)(4)) is amended by adding at the end the following new subparagraph:
“(L) Treatment of culturally competency training—In determining a hospital’s number of full-time equivalent residents for purposes of this subsection, all the time that is spent by an intern or resident in an approved medical residency training program for education and training in cultural competency and linguistically appropriate service delivery shall be counted toward the determination of full-time equivalency.”
Indirect medical education— Section 1886(d)(5)(B) of the Social Security Act (42 U.S.C. 1395ww(d)(5)(B)) is amended by adding at the end the following new clause:
“(xii) The provisions of subparagraph (L) of subsection (h)(4) shall apply under this subparagraph in the same manner as they apply under such subsection.”
Effective date— The amendments made by subsections (a) and (b) shall apply with respect to payments made to hospitals on or after the date that is one year after the date of the enactment of this Act.
Sec. 205 Federal reimbursement for culturally and linguistically appropriate services under the Medicare, Medicaid, and State Children’s Health Insurance Programs
Language Access grants for Medicare Providers—
Establishment—
In general— Not later than 6 months after the date of the enactment of this Act, the Secretary of Health and Human Services, acting through the Centers for Medicare & Medicaid Services and in consultation with the Center for Medicare and Medicaid Innovation, shall establish a demonstration program under which the Secretary shall award grants to eligible Medicare service providers to improve communication between such providers and limited-English-proficient Medicare beneficiaries, including beneficiaries who live in diverse and underserved communities.
Application of innovation rules— The demonstration project under subparagraph (A) shall be conducted in a manner that is consistent with the applicable provisions of subsections (b), (c), and (d) of section 1115A of the Social Security Act (42 U.S.C. 1315a).
Number of grants— To the extent practicable, the Secretary shall award not less than 24 grants under this subsection.
Grant period— Except as provided under paragraph (2)(D), each grant awarded under this subsection shall be for a 3-year period.
Eligibility requirements— To be eligible for a grant under this subsection, an entity must meet the following requirements:
Medicare provider— The entity must be—
a provider of services under part A of title XVIII of the Social Security Act;
a provider of services under part B of such title;
a Medicare Advantage organization offering a Medicare Advantage plan under part C of such title; or
a PDP sponsor offering a prescription drug plan under part D of such title.
Underserved communities— The entity must serve a community that, with respect to necessary language services for improving access and utilization of health care among limited-English-proficient individuals, is disproportionally underserved.
Application— The entity must prepare and submit to the Secretary an application, at such time, in such manner, and accompanied by such additional information as the Secretary may require.
Reporting— In the case of a grantee that received a grant under this subsection in a previous year, such grantee is only eligible for continued payments under a grant under this subsection if the grantee met the reporting requirements under paragraph (9) for such year. If a grantee fails to meet the requirement of such paragraph for the first year of a grant, the Secretary may terminate the grant and solicit applications from new grantees to participate in the demonstration program.
Distribution— To the extent feasible, the Secretary shall award—
at least 6 grants to providers of services described in paragraph (2)(A)(i);
at least 6 grants to service providers described in paragraph (2)(A)(ii);
at least 6 grants to organizations described in paragraph (2)(A)(iii); and
at least 6 grants to sponsors described in paragraph (2)(A)(iv).
Considerations in awarding grants—
Variation in grantees— In awarding grants under this subsection, the Secretary shall select grantees to ensure the following:
The grantees provide many different types of language services.
The grantees serve Medicare beneficiaries who speak different languages, and who, as a population, have differing needs for language services.
The grantees serve Medicare beneficiaries in both urban and rural settings.
The grantees serve Medicare beneficiaries in at least two geographic regions, as defined by the Secretary.
The grantees serve Medicare beneficiaries in at least two large metropolitan statistical areas with racial, ethnic, and economically diverse populations.
Priority for partnerships with community organizations and agencies— In awarding grants under this subsection, the Secretary shall give priority to eligible entities that have a partnership with—
a community organization; or
a consortia of community organizations, State agencies, and local agencies,
Use of funds for competent language services—
In general— Subject to subparagraph (E), a grantee may only use grant funds received under this subsection to pay for the provision of competent language services to Medicare beneficiaries who are limited-English-proficient.
Competent language services defined— For purposes of this subsection, the term competent language services means—
interpreter and translation services that—
subject to the exceptions under subparagraph (C)—
if the grantee operates in a State that has statewide health care interpreter standards, meet the State standards currently in effect; or
if the grantee operates in a State that does not have statewide health care interpreter standards, utilizes competent interpreters who follow the National Council on Interpreting in Health Care’s Code of Ethics and Standards of Practice; and
that, in the case of interpreter services, are provided through—
onsite interpretation;
telephonic interpretation; or
video interpretation; and
the direct provision of health care or health-care-related services by a competent bilingual health care provider.
Exceptions— The requirements of subparagraph (B)(i)(I) do not apply, with respect to interpreter and translation services and a grantee—
in the case of a Medicare beneficiary who is limited-English-proficient if—
such beneficiary has been informed, in the beneficiary’s primary language, of the availability of free interpreter and translation services and the beneficiary instead requests that a family member, friend, or other person provide such services; and
the grantee documents such request in the beneficiary’s medical record; or
in the case of a medical emergency where the delay directly associated with obtaining a competent interpreter or translation services would jeopardize the health of the patient.
Medicare advantage organizations and PDP sponsors— If a grantee is a Medicare Advantage organization offering a Medicare Advantage plan under part C of title XVIII of the Social Security Act or a PDP sponsor offering a prescription drug plan under part D of such title, such entity must provide at least 50 percent of the grant funds that the entity receives under this subsection directly to the entity’s network providers (including all health providers and pharmacists) for the purpose of providing support for such providers to provide competent language services to Medicare beneficiaries who are limited-English-proficient.
Administrative and reporting costs— A grantee may use up to 10 percent of the grant funds to pay for administrative costs associated with the provision of competent language services and for reporting required under paragraph (9).
Determination of amount of grant payments—
In general— Payments to grantees under this subsection shall be calculated based on the estimated numbers of limited-English-proficient Medicare beneficiaries in a grantee’s service area utilizing—
data on the numbers of limited-English-proficient individuals who speak English less than “very well” from the most recently available data from the Bureau of the Census or other State-based study the Secretary determines likely to yield accurate data regarding the number of such individuals in such service area; or
data provided by the grantee, if the grantee routinely collects data on the primary language of the Medicare beneficiaries that the grantee serves and the Secretary determines that the data is accurate and shows a greater number of limited-English-proficient individuals than would be estimated using the data under clause (i).
Discretion of Secretary— Subject to subparagraph (C), the amount of payment made to a grantee under this subsection may be modified annually at the discretion of the Secretary, based on changes in the data under subparagraph (A) with respect to the service area of a grantee for the year.
Limitation on amount— The amount of a grant made under this subsection to a grantee may not exceed $500,000 for the period under paragraph (1)(D).
Assurances— Grantees under this subsection shall, as a condition of receiving a grant under this subsection—
ensure that clinical and support staff receive appropriate ongoing education and training in linguistically appropriate service delivery;
ensure the linguistic competence of bilingual providers;
offer and provide appropriate language services at no additional charge to each patient with limited-English proficiency for all points of contact between the patient and the grantee, in a timely manner during all hours of operation;
notify Medicare beneficiaries of their right to receive language services in their primary language;
post signage in the primary languages commonly used by the patient population in the service area of the organization; and
ensure that—
primary language data are collected for recipients of language services and such data are consistent with standards developed under title XXXIV of the Public Health Service Act, as added by section 202 of this Act, to the extent such standards are available upon the initiation of the demonstration program; and
consistent with the privacy protections provided under the regulations promulgated pursuant to section 264(c) of the Health Insurance Portability and Accountability Act of 1996 (42 U.S.C. 1320d–2 note), if the recipient of language services is a minor or is incapacitated, primary language data are collected on the parent or legal guardian of such recipient.
No Cost-Sharing— Limited-English-proficient Medicare beneficiaries shall not have to pay cost-sharing or co-payments for competent language services provided under this demonstration program.
Reporting Requirements for grantees— Not later than the end of each calendar year, a grantee that receives funds under this subsection in such year shall submit to the Secretary a report that includes the following information:
The number of Medicare beneficiaries to whom competent language services are provided.
The primary languages of those Medicare beneficiaries.
The types of language services provided to such beneficiaries.
Whether such language services were provided by employees of the grantee or through a contract with external contractors or agencies.
The types of interpretation services provided to such beneficiaries, and the approximate length of time such service is provided to such beneficiaries.
The costs of providing competent language services.
An account of the training or accreditation of bilingual staff, interpreters, and translators providing services funded by the grant under this subsection.
Evaluation and report to Congress— Not later than 1 year after the completion of a 3-year grant under this subsection, the Secretary shall conduct an evaluation of the demonstration program under this subsection and shall submit to the Congress a report that includes the following:
An analysis of the patient outcomes and the costs of furnishing care to the limited-English-proficient Medicare beneficiaries participating in the project as compared to such outcomes and costs for limited-English-proficient Medicare beneficiaries not participating, based on the data provided under paragraph (9) and any other information available to the Secretary.
The effect of delivering language services on—
Medicare beneficiary access to care and utilization of services;
the efficiency and cost effectiveness of health care delivery;
patient satisfaction;
health outcomes; and
the provision of culturally appropriate services provided to such beneficiaries.
The extent to which bilingual staff, interpreters, and translators providing services under such demonstration were trained or accredited and the nature of accreditation or training needed by type of provider, service, or other category as determined by the Secretary to ensure the provision of high-quality interpretation, translation, or other language services to Medicare beneficiaries if such services are expanded pursuant to subsection (c) of section 1907 of this Act.
Recommendations, if any, regarding the extension of such project to the entire Medicare program, subject to the provisions of section 1115A(c) of the Social Security Act.
Appropriations— There is appropriated to carry out this subsection, in equal parts from the Federal Hospital Insurance Trust Fund under section 1817 of the Social Security Act (42 U.S.C. 1395i) and the Federal Supplementary Medical Insurance Trust Fund under section 1841 of such Act (42 U.S.C. 1395t), $16,000,000 for each fiscal year of the demonstration program.
Language services under the Medicare program—
Inclusion as rural health clinic services— Section 1861 of the Social Security Act (42 U.S.C. 1395x) is amended—
in subsection (aa)(1)—
in subparagraph (B), by striking the “and” at the end;
in subparagraph (C), by inserting “and” after the comma at the end; and
by inserting after subparagraph (C) the following:
“(D) language services as defined in subsection (iii)(1),”
by adding at the end the following new subsection:
“(iii) Language services and related terms
“(1) Language services defined—The term language services has the same meaning given “language or language access services” in section 3400 of the Public Health Service Act.
“(2) Interpreter services defined—For the purposes of this subsection, the term interpreter services has the meaning given competent interpreter services under section 3400(3) of the Public Health Service Act.
“(3) Interpreter defined—The term interpreter—
“(A) means an individual—
“(i) who faithfully, accurately, and objectively transmits a spoken message from one language into another language; and
“(ii) who knows health and health-related terminology in both languages; and
“(B) includes individuals who provide in-person, telephonic, and video interpretation.
“(4) Translation defined—The term translation means the transmission of a written message in one language into a written message in another language that retains the intended meaning of the original message.
“(5) Limited-English-Proficient and LEP defined—The terms limited-English-proficient and LEP have the meaning given the term limited english proficient under section 9101(25) of the Elementary and Secondary Education Act of 1965, except that subparagraphs (A), (B), and (D) of such section not apply.”
by striking “and” at the end of subparagraph (I);
by striking the period at the end of subparagraph (J) and inserting “; and”; and
by adding at the end of subparagraph (J) the following:
“(K) language services (as defined in paragraph (1) of section 1861(iii)) furnished by an interpreter (as defined in paragraph (3) of such section) or translator.”
by striking “and” at the end of paragraph (8);
by redesignating paragraph (9) as paragraph (10); and
by inserting after paragraph (8) the following new paragraph:
“(9) in the case of language services described in section 1861(iii)(1), 100 percent of the reasonable charges for such services, as determined in consultation with the Medicare Payment Advisory Commission; and”
Waiver of budget neutrality— For the 3-year period beginning on the date of enactment of this section, the budget neutrality provision of section 1848(c)(2)(B)(ii) of the Social Security Act (42 U.S.C. 1395w–4(c)(2)(B)(ii)) shall not apply with respect to language services (as such term is defined in section 1861(iii)(1) of such Act).
Medicare parts C and D—
In general— Medicare Advantage plans under part C of the Social Security Act and prescription drug plans under part D of such Act shall comply with title VI of the Civil Rights Act of 1964 and section 1557 of the Patient Protection and Affordable Care Act to provide effective language services to enrollees of such plans.
Medicare Advantage plans and prescription drug plans reporting requirement— Section 1857(e) of the Social Security Act (42 U.S.C. 1395w–27(e)) is amended by adding at the end the following new paragraph:
“(5) Reporting requirements relating to effective language services—A contract under this part shall require a Medicare Advantage organization (and, through application of section 1860D–12(b)(3)(D), a contract under section 1860D–12 shall require a PDP sponsor) to annually submit (for each year of the contract) a report that contains information on the plan’s internal policies and procedures related to recruitment and retention efforts directed to workforce diversity and linguistically and culturally appropriate provision of services in each of the following contexts:
“(A) The collection of data in a manner that meets the requirements of title I of the Health Equity and Accountability Act of 2014, regarding the enrollee population.
“(B) Education of staff and contractors who have routine contact with enrollees regarding the various needs of the diverse enrollee population.
“(C) Evaluation of the health plan’s language services programs and services with respect to the plan’s enrollee population, such as through analysis of complaints or satisfaction survey results.
“(D) Methods by which the plan provides to the Secretary information regarding the ethnic diversity of the plan’s enrollee population.
“(E) The periodic provision of educational information to plan enrollees on the plan’s language services and programs.”
Improving language services in Medicaid and CHIP—
Payments to States— Section 1903(a)(2)(E) of the Social Security Act (42 U.S.C. 1396b(a)(2)(E)) is amended by—
striking “75” and inserting “90”;
striking “translation or interpretation services” and inserting “language services”; and
striking “children of families” and inserting “individuals”.
State plan requirements— Section 1902(a)(10)(A) of the Social Security Act (42 U.S.C. 1396a(a)(10)(A)) is amended by striking “and (28)” and inserting “(28), and (29)”.
Definition of medical assistance— Section 1905(a) of the Social Security Act (42 U.S.C. 1396d(a)) is amended by—
in paragraph (28), by striking “and” at the end;
by redesignating paragraph (29) as paragraph (30); and
by inserting after paragraph (28) the following new paragraph:
“(29) language services, as such term is defined in section 1861(iii)(1), provided in a timely manner to limited-English-proficient individuals who need such services; and”
Use of deductions and cost sharing— Section 1916(a)(2) of the Social Security Act (42 U.S.C. 1396o(2)) is amended by—
by striking “or” at the end of subparagraph (D);
by striking “; and” at the end of subparagraph (E) and inserting “, or”; and
by adding at the end the following new subparagraph:
“(F) language services described in section 1905(a)(29); and”
in subsection (a), in the matter before paragraph (1), by striking “and (7)” and inserting “(7), and (9)”; and
in subsection (c), by adding at the end the following new paragraph:
“(9) Language services—The child health assistance provided to a targeted low-income child shall include coverage of language services, as such term is defined in section 1861(iii)(1), provided in a timely manner to limited-English-proficient individuals who need such services.”
in subsection (e)(2)—
in the heading, by striking “Preventive” and inserting “Certain”; and
by inserting “, subsection (c)(9),” after “subsection (c)(1)(C)”.
Definition of child health assistance— Section 2110(a)(27) of the Social Security Act (42 U.S.C. 1397jj) is amended by striking “translation” and inserting “language services as described in section 2103(c)(9)”.
State data collection— Pursuant to the reporting requirement described in section 2107(b)(1) of the Social Security Act (42 U.S.C. 1397gg(b)(1)), the Secretary of Health and Human Services shall require that States collect data on—
the primary language of individuals receiving child health assistance under title XXI of the Social Security Act; and
in the case of such individuals who are minors or incapacitated, the primary language of the individual’s parent or guardian.
in subsection (a)(1) by striking “75” and inserting “90”; and
in subsection (c)(2)(A), by inserting before the period “, except that expenditures pursuant to clause (iv) of subparagraph (D) of such paragraph shall not count towards this total”.
Funding language services furnished by providers of health care and health-Care-Related services that serve high rates of uninsured LEP individuals—
Payment of costs—
In general— Subject to subparagraph (B), the Secretary of Health and Human Services shall make payments (on a quarterly basis) directly to eligible entities to support the provision of language services to limited-English-proficient individuals in an amount equal to an eligible entity’s eligible costs for such services for the quarter.
Funding— Out of any funds in the Treasury not otherwise appropriated, there are appropriated to the Secretary of Health and Human Services such sums as may be necessary for each of fiscal years 2012 through 2016.
Relation to Medicaid DSH— Payments under this subsection shall not offset or reduce payments under section 1923 of the Social Security Act, nor shall payments under such section be considered when determining uncompensated costs associated with the provision of language services.
Methodology for payment of claims—
In general— The Secretary shall establish a methodology to determine the average per person cost of language services.
Different entities— In establishing such methodology, the Secretary may establish different methodologies for different types of eligible entities.
No individual claims— The Secretary may not require eligible entities to submit individual claims for language services for individual patients as a requirement for payment under this subsection.
Data collection instrument— For purposes of this subsection, the Secretary shall create a standard data collection instrument that is consistent with any existing reporting requirements by the Secretary or relevant accrediting organizations regarding the number of individuals to whom language access are provided.
Guidelines— Not later than 6 months after the date of enactment of this Act, the Secretary of Health and Human Services shall establish and distribute guidelines concerning the implementation of this subsection.
Reporting requirements—
Report to Secretary— Entities receiving payment under this subsection shall provide the Secretary with a quarterly report on how the entity used such funds. Such report shall contain aggregate (and may not contain individualized) data collected using the instrument under paragraph (3) and shall otherwise be in a form and manner determined by the Secretary.
Report to Congress— Not later than 2 years after the date of enactment of this Act, and every 2 years thereafter, the Secretary shall submit a report to Congress concerning the implementation of this subsection.
Definitions— In this subsection:
Eligible costs— The term eligible costs means, with respect to an eligible entity that provides language services to limited-English-proficient individuals, the product of—
the average per person cost of language services, determined according to the methodology devised under paragraph (2); and
the number of limited-English-proficient individuals who are provided language services by the entity and for whom no reimbursement is available for such services under the amendments made by subsections (a), (b), (c), or (d) or by private health insurance.
Eligible entity— The term eligible entity means an entity that—
is a Medicaid provider that is—
a physician;
a hospital with a low-income utilization rate (as defined in section 1923(b)(3) of the Social Security Act (42 U.S.C. 1396r–4(b)(3))) of greater than 25 percent; or
a federally qualified health center (as defined in section 1905(l)(2)(B) of the Social Security Act (42 U.S.C. 1396d(l)(2)(B)));
provide language services to at least 8 percent of the entity’s total number of patients, not later than 6 months after the date of the enactment of the Act; and
prepare and submit an application to the Secretary, at such time, in such manner, and accompanied by such information as the Secretary may require to ascertain the entity’s eligibility for funding under this subsection.
Language services— The term language services has the meaning given such term in section 1861(iii)(1) of the Social Security Act.
Application of Civil Rights Act of 1964 and other laws— Nothing in this section shall be construed to limit otherwise existing obligations of recipients of Federal financial assistance under title VI of the Civil Rights Act of 1964 (42 U.S.C. 2000(d) et seq.) or other laws that protect the civil rights of individuals.
Effective date—
In general— Except as otherwise provided and subject to paragraph (2), the amendments made by this section shall take effect on January 1, 2013.
Exception if State legislation required— In the case of a State plan for medical assistance under title XIX of the Social Security Act which the Secretary of Health and Human Services determines requires State legislation (other than legislation appropriating funds) in order for the plan to meet the additional requirement imposed by the amendments made by this section, the State plan shall not be regarded as failing to comply with the requirements of such title solely on the basis of its failure to meet this additional requirement before the first day of the first calendar quarter beginning after the close of the first regular session of the State legislature that begins after the date of the enactment of this Act. For purposes of the previous sentence, in the case of a State that has a 2-year legislative session, each year of such session shall be deemed to be a separate regular session of the State legislature.
Sec. 206 Increasing understanding of and improving health literacy
In general— The Secretary, acting through the Director of the Agency for Healthcare Research and Quality and the Administrator of the Health Resources and Services Administration, in consultation with the Director of the National Institute on Minority Health and Health Disparities and the Office of Minority Health, shall award grants to eligible entities to improve health care for patient populations that have low functional health literacy.
Eligibility— To be eligible to receive a grant under subsection (a), an entity shall—
be a hospital, health center or clinic, health plan, or other health entity (including a nonprofit minority health organization or association); and
prepare and submit to the Secretary an application at such time, in such manner, and containing such information as the Secretary may require.
Use of funds—
Agency for healthcare research and quality— Grants awarded under subsection (a) through the Agency for Healthcare Research and Quality shall be used—
to define and increase the understanding of health literacy;
to investigate the correlation between low health literacy and health and health care;
to clarify which aspects of health literacy have an effect on health outcomes; and
for any other activity determined appropriate by the Director of the Agency.
Health resources and services administration— Grants awarded under subsection (a) through the Health Resources and Services Administration shall be used to conduct demonstration projects for interventions for patients with low health literacy that may include—
the development of new disease management programs for patients with low health literacy;
the tailoring of existing disease management programs addressing mental, physical, oral, and behavioral health conditions for patients with low health literacy;
the translation of written health materials for patients with low health literacy;
the identification, implementation, and testing of low health literacy screening tools;
the conduct of educational campaigns for patients and providers about low health literacy; and
other activities determined appropriate by the Administrator of the Health Resources and Services Administration.
Definitions— In this section, the term low health literacy means the inability of an individual to obtain, process, and understand basic health information and services needed to make appropriate health decisions.
Authorization of appropriations— There are authorized to be appropriated to carry out this section, such sums as may be necessary for each of fiscal years 2015 through 2019.
Sec. 207 Assurances for receiving Federal funds
In general— Any health program or activity, any part of which is receiving Federal financial assistance, including credits, subsidies, or contracts of insurance, and any program or activity that is administered by an executive agency or any entity established under title I of the Patient Protection and Affordable Care Act (or amendments made thereby), as such programs, activities, agencies, and entities are described in section 1557(a) of the Patient Protection and Affordable Care Act (42 U.S.C. 18116), in order to ensure the right of LEP individuals to receive access to quality health care, shall—
ensure that appropriate clinical and support staff receive ongoing education and training in linguistically appropriate service delivery;
offer and provide appropriate language services at no additional charge to each patient with limited-English-proficiency at all points of contact, in a timely manner during all hours of operation;
notify patients of their right to receive language services in their primary language; and
utilize only competent interpreter or translation services, as defined in section 3400 of the Public Health Service Act.
Exemptions— The requirements of subsection (a)(4) shall not apply as follows:
When a patient (who has been informed in his or her primary language of the availability of free interpreter and translation services) requests the use of family, friends, or other persons untrained in interpretation or translation if the following conditions are met:
The interpreter requested by the patient is over the age of 18.
The recipient informs the patient that he or she has the option of having the recipient provide an interpreter for him or her without charge, or of using his or her own interpreter.
The recipient informs the patient that the recipient may not require an LEP person to use a family member or friend as an interpreter.
The recipient evaluates whether the person the patient wishes to use as an interpreter is competent. If the recipient has reason to believe that the interpreter is not competent, the recipient provides the recipient’s own interpreter to protect the recipient from liability if the patient’s interpreter is later found not competent.
If the recipient has reason to believe that there is a conflict of interest between the interpreter and patient, the recipient may not use the patient’s interpreter.
The recipient has the patient sign a waiver, witnessed by at least 1 individual not related to the patient, that includes the information stated in subparagraphs (A) through (E) and is translated into the patient’s language.
When a medical emergency exists and the delay directly associated with obtaining competent interpreter or translation services would jeopardize the health of the patient, but only until a competent interpreter or translation service is available.
Rule of construction— Subsection (b)(2) shall not be construed to mean that emergency rooms or similar entities that regularly provide health care services in medical emergencies are exempt from legal or regulatory requirements related to competent interpreter services.
Sec. 208 Report on Federal efforts to provide culturally and linguistically appropriate health care services
Report— Not later than 1 year after the date of enactment of this Act and annually thereafter, the Secretary of Health and Human Services shall enter into a contract with the Institute of Medicine for the preparation and publication of a report that describes Federal efforts to ensure that all individuals with limited-English proficiency have meaningful access culturally competent to health care and health-care-related services. Such report shall include—
a description and evaluation of the activities carried out under this Act;
a description and analysis of best practices, model programs, guidelines, and other effective strategies for providing access to culturally and linguistically appropriate health care services;
recommendations on the development and implementation of policies and practices by providers of health care and health-care-related services for limited-English-proficient individuals;
a description of the effect of providing language services on quality of health care and access to care; and
a description of the costs associated with or savings related to the provision of language services.
Authorization of appropriations— There are authorized to be appropriated to carry out this section such sums as may be necessary for each of fiscal years 2015 through 2019.
Sec. 209 English for speakers of other languages
Grants authorized— The Secretary of Education is authorized to provide grants to eligible entities for the provision of English as a second language (hereafter referred to as ESL) instruction and shall determine, after consultation with appropriate stakeholders, the mechanism for administering and distributing such grants.
Eligible entity defined— For purposes of this section, the term eligible entity means a State or community-based organization that employs, and serves, minority populations.
Application— An eligible entity may apply for a grant under this section by submitting such information as the Secretary may require and in such form and manner as the Secretary may require.
Use of grant— As a condition of receiving a grant under this section, an eligible entity shall—
develop and implement a plan for assuring the availability of ESL instruction that effectively integrates information about the nature of the United States health care system, how to access care, and any special language skills that may be required for them to access and regularly negotiate the system effectively;
develop a plan, including, where appropriate, public-private partnerships, for making ESL instruction progressively available to all individuals seeking instruction; and
maintain current ESL instruction efforts by using the additional funds to supplement rather than supplant any funds expended for ESL instruction in the State as of January 1, 2015.
Additional duties of the secretary— The Secretary of Education shall—
collect and publicize annual data on how much Federal, State, and local governments spend on ESL instruction;
collect data from State and local governments to identify the unmet needs of English language learners for appropriate ESL instruction, including—
the preferred written and spoken language of such English language learners;
the extent of waiting lists including how many programs maintain waiting lists and, for programs that do not have waiting lists, the reasons why not;
the availability of programs to geographically isolated communities;
the impact of course enrollment policies, including open enrollment, on the availability of ESL instruction;
the number individuals in the State and each participating locality;
the effectiveness of the instruction in meeting the needs of individuals receiving instruction and those needing instruction;
as assessment of the need for programs that integrate job training and ESL instruction, to assist individuals to obtain better jobs; and
the availability of ESL slots by State and locality;
determine the cost and most appropriate methods of making ESL instruction available to all English language learners seeking instruction; and
within 1 year of the date of enactment of this Act, issue a report to Congress that assesses the information collected in paragraphs (1), (2), and (3) and makes recommendations on steps that should be taken to progressively realize the goal of making ESL instruction available to all English language learners seeking instruction.
Authorization of Appropriations— There are authorized to be appropriated to the Secretary of Education for each of fiscal years 2015 through 2018 $250,000,000 to carry out this section.
Sec. 210 Implementation
General provisions—
A State shall not be immune under the Eleventh Amendment of the Constitution of the United States from suit in Federal court for failing to provide the language access funded pursuant to this title.
In a suit against a State for a violation of this title, remedies (including remedies at both at law and in equity) are available for such a violation to the same extent as such remedies are available for such a violation in the suit against any public or private entity other than a State.
Rule of construction— Nothing in this title shall be construed to limit otherwise existing obligations of recipients of Federal financial assistance under title VI of the Civil Rights Act of 1964 (42 U.S.C. 2000(d) et seq.) or any other statute.
Sec. 211 Language access services
Essential benefits— Section 1302(b)(1) of the Patient Protection and Affordable Care Act (42 U.S.C. 18022(b)(1)) is amended by adding at the end the following:
“(K) Language access services, including oral interpretation and written translations.”
Employer-Sponsored minimum essential coverage— Section 36B(c)(2)(C) of the Internal Revenue Code of 1986 is amended by adding at the end the following:
“(v) Coverage must include language access and services—Except as provided in clause (iii), an employee shall not be treated as eligible for minimum essential coverage if such coverage consists of an eligible employer-sponsored plan (as defined in section 5000A(f)(2)) and the plan does not provide coverage for language access services, including oral interpretation and written translations.”
Quality Reporting— Section 2717(a)(1) of the Public Health Service Act (42 U.S.C. 300gg–17(a)(1)) is amended—
by striking “and” at the end of subparagraph (C);
by striking the period at the end of subparagraph (D) and inserting “; and”; and
by adding at the end the following new subparagraph:
“(E) reduce health disparities through the provision of language access services, including oral interpretation and written translations.”
Regulations regarding internal claims and appeals and external review processes for health plans and health insurance issuers— The Secretary of the Treasury, the Secretary of Labor, and the Secretary of Health and Human Services shall amend the regulations in section 54.9815–2719T(e) of title 26, Code of Federal Regulations, section 2590.715– 2719(e) of title 29, Code of Federal Regulations, and section 147.136(e) of title 45, Code of Federal Regulations, respectively, to require group health plans and health insurance issuers offering group or individual health insurance coverage to which such sections apply—
to provide oral interpretation services without any threshold requirements;
to provide in the English versions of all notices a statement prominently displayed in not less than 15 non-English languages clearly indicating how to access the language services provided by the plan or issuer; and
with respect to written translations of notices, to apply a threshold that 5 percent of the population or at least 500 individuals per service area are literate only in the same non-English language in lieu of 10 percent or more residing in a county.
Data collection and reporting— The Secretary of Health and Human Services shall—
amend the single streamlined application form developed pursuant to section 1413 of the Patient Protection and Affordable Care Act (42 U.S.C. 18083) to collect the preferred spoken and written language for each household member applying for coverage under a qualified health plan through an Exchange under title I of the Patient Protection and Affordable Care Act;
require navigators, certified application counselors, and other enrollment assisters to collect and report requests for language assistance; and
require the Federal and State call centers established pursuant to section 1311(d)(4)(b) of the Patient Protection and Affordable Care Act (42 U.S.C. 18031(d)(4)(b)) to submit an annual report documenting the number of language assistance requests, the types of languages requested, the range and average wait time for a consumer to speak with an interpreter, and any steps the call center and language line have taken to actively address some of the consumer complaints.
Effective date— The amendments made by this section shall apply to plan years beginning after the date of the enactment of this Act.