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Title II — Culturally and linguistically appropriate health and health care

S. 4819 · 116th Congress · Oct 20, 2020 · Lineage

II Culturally and linguistically appropriate health and health care

Sec. 201 Definitions; findings

(a)
Definitions— In this title, the definitions in section 3400 of the Public Health Service Act, as added by section 204, shall apply.
(b)
Findings— Congress finds the following:
(1)
Effective communication is essential to meaningful access to quality physical and mental health care.
(2)
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 individuals with limited English proficiency and individuals with communication disabilities such as cognitive, hearing, vision, or print impairments.
(3)
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.
(4)
The responsibility to fund language services in the provision of health care and health-care-related services to individuals with limited English proficiency and individuals with communication disabilities such as cognitive hearing, vision, or print impairments is a societal one that cannot fairly be placed solely upon the health care, public health, or social services community.
(5)
Title VI of the Civil Rights Act of 1964 (42 U.S.C. 2000d et seq.) 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 Federal Government must take adequate steps to ensure that their policies and procedures do not deny or have the effect of denying individuals with limited English proficiency with equal access to benefits and services for which such persons qualify.
(6)
Both the Americans with Disabilities Act of 1990 (42 U.S.C. 12101 et seq.) and the Rehabilitation Act of 1973 (29 U.S.C. 701 et seq.) prohibit discrimination on the basis of disability and require the provision of appropriate auxiliary aids and services necessary to ensure effective communication with individuals with disabilities. The type of auxiliary aid or service necessary to ensure effective communication will vary in accordance with the method of communication used by the individual; the nature, length, and complexity of the communication involved; and the context in which the communication is taking place. A public accommodation should consult with individuals with disabilities whenever possible to determine what type of auxiliary aid is needed to ensure effective communication. The public accommodation should use the individual's preferred method of communication whenever possible, unless it would be an undue burden to the public accommodation and an alternative would provide an equally effective means of communication. The ultimate decision as to what measures to take rests with the public accommodation, provided that the method chosen results in effective communication.
(7)
Section 1557 of the Patient Protection and Affordable Care Act (42 U.S.C. 18116) builds on title VI of the Civil Rights Act of 1964 (42 U.S.C. 2000d et seq.) and section 504 of the Rehabilitation Act of 1973 (29 U.S.C. 794), prohibits discrimination on the basis of race, color, national origin, disability, sex, and age, requires the provision of language services to ensure effective communication with individuals with limited English proficiency, and requires the provision of appropriate auxiliary aids and services necessary to ensure effective communication with individuals with disabilities.
(8)
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.
(9)
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 individuals with limited English proficiency and individuals with communication disabilities such as cognitive, hearing, vision, or print impairments.
(10)
Access to English as a second language, foreign language, and sign language interpreters, translated and alternative format documents, readers, and other auxiliary aids and services, are essential to ensure effective communication and eliminate the language barriers that impede access to health care.
(11)
Competent language services in health care settings should be available as a matter of course.

Sec. 202 Improving access to services for individuals with limited English proficiency

(a)
Purpose— Consistent with the goals provided in Executive Order 13166 (42 U.S.C. 2000d–1 note; relating to improving access to services for persons with limited English proficiency), 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 with limited English proficiency;
(2)
to require each Federal agency to examine the services it provides and develop and implement a system by which individuals with limited English proficiency can obtain culturally competence services 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 culturally competence services and meaningful access to applicants and beneficiaries that are individuals with limited English proficiency;
(4)
to ensure that recipients of Federal financial assistance take reasonable steps, consistent with the guidelines set forth in the “Guidance to Federal Financial Assistance Recipients Regarding Title VI Prohibition Against National Origin Discrimination Affecting Limited English Proficient Persons (67 Fed. Reg. 41455 (June 18, 2002))”, to ensure culturally and linguistically appropriate access to their programs and activities by individuals with limited English proficiency; and
(5)
to ensure compliance with title VI of the Civil Rights Act of 1964 (42 U.S.C. 2000d et seq.) and section 1557 of the Patient Protection and Affordable Care Act (42 U.S.C. 18116) as published in the Federal Register on May 18, 2016, 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 Act, each Federal agency providing financial assistance to, or administering, a health program or activity described in section 203(a) shall prepare a plan or update a plan to improve culturally and linguistically appropriate access to such program or activity with respect to individuals with limited English proficiency. Not later than 1 year after the date of enactment of this Act, 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 individuals with limited English proficiency have access to each health program or activity supported or administered by the agency;
(B)
the policies and procedures for identifying, assessing, and meeting the culturally and linguistically appropriate language needs of its beneficiaries that are individuals with limited English proficiency served by such program or activity;
(C)
the steps the agency will take for such program or activity to be culturally and linguistically appropriate by providing a range of language assistance options, notice to individuals with limited English proficiency 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 for such program or activity to provide reasonable accommodations necessary for individuals with limited English proficiency, including those individuals with a communication disability, to understand communications from the agency;
(E)
the steps the agency will take to ensure that applications, forms, and other relevant documents for such program or activity are competently translated into the primary language of a client that is an individual with limited English proficiency where such materials are needed to improve access of such client to such program or activity;
(F)
the resources the agency will provide to improve cultural and linguistic appropriateness to assist recipients of Federal funds to improve access to health care related programs and activities for individuals with limited English proficiency;
(G)
the resources the agency will provide to ensure that competent language assistance is provided to patients that are individuals with limited English proficiency by interpreters or trained bilingual staff; and
(H)
the resources the agency will provide to ensure that family, particularly minor children, and friends are not used to provide interpretation services, except as permitted under regulations implementing section 1557 of the Patient Protection and Affordable Care Act (42 U.S.C. 18116) as published in the Federal Register on May 18, 2016.
(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 Attorney General, which shall serve as the central repository of all such plans.

Sec. 203 Ensuring standards for culturally and linguistically appropriate services in health care

(a)
Applicability— This section shall apply 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 (42 U.S.C. 18001 et seq.) (or amendments made thereby).
(b)
Standards— Each program or activity described in subsection (a)—
(1)
shall 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 program or activity;
(2)
shall educate and train governance, leadership, and workforce at all levels and across all disciplines of the program or activity in culturally and linguistically appropriate policies and practices on an ongoing basis at least annually;
(3)
shall offer and provide language assistance, including trained and competent bilingual staff and interpreter services, to individuals with limited English proficiency or who have other communication needs, at no cost to the individual at all points of contact, and during all hours of operation, to facilitate timely access to health care services and health-care-related services;
(4)
shall for each language group consisting of individuals with limited English proficiency 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 program or activity, make available at a fifth grade reading level—
(A)
easily understood patient-related materials, including print and multimedia materials, in the language of such language group;
(B)
information or notices about termination of benefits in such language;
(C)
signage; and
(D)
any other documents or types of documents designated by the Secretary;
(5)
shall 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 planning and operations of the program or activity;
(6)
shall conduct initial and ongoing, at least annually, 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 program or activity and develop ways to standardize the assessments;
(7)
shall 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. 1320–2 note), 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 management information systems of the program or activity; and
(C)
periodically updated;
(8)
shall maintain a current demographic, cultural, and epidemiological profile of the community, conduct regular assessments of community health assets and needs, and use the results of such assessments to accurately plan for and implement services that respond to the cultural and linguistic characteristics of the service area of the program or activity;
(9)
shall 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;
(10)
shall ensure that conflict and grievance resolution processes are culturally and linguistically appropriate and capable of identifying, preventing, and resolving cross-cultural conflicts or complaints by patients;
(11)
shall 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
(12)
shall, if requested, regularly make available to the head of each Federal entity from which Federal funds are provided, information about the progress and successful innovations of the program or activity in implementing the standards under this section as required by the head of such entity.
(c)
Comments accepted through notice and comment rulemaking— An agency carrying out a program described in subsection (a)—
(1)
shall ensure that comments with respect to such program that are accepted through notice and comment rulemaking are accepted in all languages;
(2)
may not require such comments to be submitted only in English; and
(3)
shall ensure that any such comments that are not submitted in English are considered, during the agency’s review of such comments, equally as such comments that are submitted in English.

Sec. 204 Culturally and linguistically appropriate health care in the Public Health Service Act

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

“(a) In general—In this title:

“(1) Bilingual—The term bilingual, with respect to an individual, means an individual who has sufficient degree of proficiency in 2 languages.

“(2) Cultural—The term cultural means relating 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, queer, and questioning individuals, and individuals with physical and mental disabilities.

“(3) Culturally and linguistically appropriate—The term culturally and linguistically appropriate means being respectful of and responsive to the cultural and linguistic needs of all individuals.

“(4) 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, speaking, or learning impairment, that enables access to, understanding of, and benefit from health care or health-care-related services, and full participation in the development of their treatment plan.

“(5) Grievance resolution process—The term grievance resolution process means all aspects of dispute resolution including filing complaints, grievance and appeal procedures, and court action.

“(6) Health care group—The term health care group means a group of physicians organized, at least in part, for the purposes of providing physician services under the Medicaid program under title XIX of the Social Security Act, the State Children's Health Insurance Program under title XXI of such Act, or the Medicare program under title XVIII of such Act and may include a hospital and any other individual or entity furnishing services covered under any such program that is affiliated with the health care group.

“(7) Health care services—The term health care services means services that address physical as well as mental health conditions in all care settings.

“(8) 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.

“(9) Health educator—The term health educator includes a professional with a baccalaureate degree who is responsible for designing, implementing, and evaluating individual and population health promotion and chronic disease prevention programs.

“(10) Indian; indian tribe—The terms Indian and Indian Tribe have the meanings given such terms in section 4 of the Indian Self-Determination and Education Assistance Act.

“(11) Individual with a disability—The term individual with a disability means any individual who has a disability as defined for the purpose of section 504 of the Rehabilitation Act of 1973.

“(12) Individual with limited English proficiency—The term individual with limited English proficiency means an individual whose primary language for communication is not English and who has a limited ability to read, write, speak, or understand English.

“(13) 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 disorder, and related disciplines to improve the health outcomes of an individual. Such providers may include hospitals, health, mental health, or substance use disorder clinics and providers, home health agencies, ambulatory surgery centers, skilled nursing facilities, rehabilitation centers, and employed, independent, or contracted physicians.

“(14) 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.

“(15) Language access—The term language access means the provision of language services to an individual with limited English proficiency or an individual with communication disabilities designed to enhance that individual’s access to, understanding of, or benefit from health care services or health-care-related services.

“(16) Language assistance services—The term language assistance services includes—

“(A) oral language assistance, including interpretation in non-English languages provided in-person or remotely by a qualified interpreter for an individual with limited English proficiency, and the use of qualified bilingual or multilingual staff to communicate directly with individuals with limited English proficiency;

“(B) written translation, performed by a qualified translator, of written content in paper or electronic form into languages other than English; and

“(C) taglines.

“(17) 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, members of sexual and gender minority groups, and individuals with a disability.

“(18) Minority group—The term minority group has the meaning given the term racial and ethnic minority group.

“(19) 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 services or health-care-related services and the recipient of such services who is limited in English proficiency or has a communication impairment such as an impairment in hearing, vision, or learning.

“(20) Qualified individual with a disability—The term qualified individual with a disability means, with respect to a health program or activity, an individual with a disability who, with or without reasonable modifications to policies, practices, or procedures, the removal of architectural, communication, or transportation barriers, or the provision of auxiliary aids and services, meets the essential eligibility requirements for the receipt of aids, benefits, or services offered or provided by the health program or activity.

“(21) Qualified interpreter for an individual with a disability—The term qualified interpreter for an individual with a disability, with respect to an individual with a disability—

“(A) means an interpreter for such individual who by means of a remote interpreting service or an onsite appearance;

“(i) adheres to generally accepted interpreter ethics principles, including client confidentiality; and

“(ii) is able to interpret effectively, accurately, and impartially, both receptively and expressively, using any necessary specialized vocabulary, terminology, and phraseology; and

“(B) may include—

“(i) sign language interpreters;

“(ii) oral transliterators, which are individuals who represent or spell in the characters of another alphabet; and

“(iii) cued language transliterators, which are individuals who represent or spell by using a small number of handshapes.

“(22) Qualified interpreter for an individual with limited English proficiency—The term qualified interpreter for an individual with limited English proficiency means an interpreter who by means of a remote interpreting service or an onsite appearance—

“(A) adheres to generally accepted interpreter ethics principles, including client confidentiality;

“(B) has demonstrated proficiency in speaking and understanding both spoken English and one or more other spoken languages; and

“(C) is able to interpret effectively, accurately, and impartially, both receptively and expressly, to and from such languages and English, using any necessary specialized vocabulary, terminology, and phraseology.

“(23) Qualified translator—The term qualified translator means a translator who—

“(A) adheres to generally accepted translator ethics principles, including client confidentiality;

“(B) has demonstrated proficiency in writing and understanding both written English and one or more other written non-English languages; and

“(C) is able to translate effectively, accurately, and impartially to and from such languages and English, using any necessary specialized vocabulary, terminology, and phraseology.

“(24) Racial and ethnic minority group—The term racial and ethnic minority group means 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.

“(25) Sexual and gender minority group—The term sexual and gender minority group encompasses lesbian, gay, bisexual, and transgender populations, as well as those whose sexual orientation, gender identity and expression, or reproductive development varies from traditional, societal, cultural, or physiological norms.

“(26) 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.

“(27) State—Notwithstanding section 2, the term State means each of the several States, the District of Columbia, the Commonwealth of Puerto Rico, the United States Virgin Islands, Guam, American Samoa, and the Commonwealth of the Northern Mariana Islands.

“(28) Telephonic interpretation—The term telephonic interpretation (also known as “over the phone interpretation” or “OPI”) means, with respect to interpretation for an individual with limited English proficiency, a method of interpretation in which the interpreter is not in the physical presence of the provider of health care services or health-care-related services and such individual receiving such services, but the interpreter is connected via telephone.

“(29) 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.

“(30) Video remote interpreting services—The term video remote interpreting services means the provision, in health care services or health-care-related services, through a qualified interpreter for an individual with limited English proficiency, of video remote interpreting services that are—

“(A) in real-time, full-motion video, and audio over a dedicated high-speed, wide-bandwidth video connection or wireless connection that delivers high quality video images that do not produce lags, choppy, blurry, or grainy images, or irregular pauses in communication; and

“(B) in a sharply delineated image that is large enough to display.

“(31) Vital document—The term vital document includes 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 individuals with limited English proficiency with communication disabilities of the availability of free language services, alternative formats, and other outreach materials.

“(b) Reference—In any reference in this title to a regulatory provision applicable to a handicapped individual, the term handicapped individual in such provision shall have the same meaning as the term individual with a disability as defined in subsection (a).

“A Resources and innovation for culturally and linguistically appropriate health care

“3401. Robert T. Matsui Center for Culturally and Linguistically Appropriate 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 Culturally and Linguistically Appropriate Health Care (referred to in this section as the Center) to carry out each of 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) Vital documents—The Center shall provide, directly or through contract, vital documents from competent translation services for providers of health care services and health-care-related services at no cost to such providers. Such documents may be submitted by covered entities (as defined in section 92.4 of title 45, Code of Federal Regulations, as in effect on May 18, 2016) for translation into non-English languages or alternative formats at a fifth-grade reading level. Such translation services shall be provided in a timely and reasonable manner. The quality of such translation services shall be monitored and reported publicly.

“(B) Forms—For each form developed or revised by the Secretary that will be used by individuals with limited English proficiency 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 shall be completed within 45 calendar days of the Secretary receiving final approval of the form from the Office of Management and Budget. The Center shall post all translated forms on its website so that other entities may use the same translations.

“(3) Toll-free customer service telephone number—The Center shall provide, through a toll-free number, a customer service line for individuals with limited English proficiency—

“(A) to obtain information about federally conducted or funded health programs, including the Medicare program under title XVIII of the Social Security Act, the Medicaid program under title XIX of such Act, and the State Children's Health Insurance Program under title XXI of such Act, and coverage available through an Exchange established under title I of the Patient Protection and Affordable Care Act, and other sources of free or reduced care including through federally qualified health centers, entities receiving assistance under title X, and public health departments;

“(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 services and health-care-related services to reduce medical errors, improve medical outcomes, improve cultural competence, reduce health care costs caused by miscommunication with individuals with limited English proficiency, and reduce or eliminate the duplication of efforts to translate materials. The clearinghouse shall include the information described in subparagraphs (B) through (F) and make such information available on the internet and in print.

“(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 templates for each of the following:

“(i) Administrative and legal documents, including—

“(I) intake forms;

“(II) forms related to the Medicare program under title XVIII of the Social Security Act, the Medicaid program under title XIX of such Act, and the State Children's Health Insurance Program under title XXI of such Act, including eligibility information for such programs;

“(III) forms informing patients of the compliance and consent requirements pursuant to the regulations under section 264(c) of the Health Insurance Portability and Accountability Act of 1996 (42 U.S.C. 1320–2 note); 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 and linguistically appropriate;

“(ii) allow public review of the documents before dissemination in order to ensure that the documents are understandable and culturally and linguistically 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 individuals with limited English proficiency, including case studies using de-identified patient information, program summaries, and program evaluations.

“(E) Culturally and linguistically appropriate materials—The Center shall provide information relating to culturally and linguistically appropriate 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 appropriate care;

“(ii) culturally and linguistically appropriate self-assessment tools;

“(iii) culturally and linguistically appropriate training tools;

“(iv) strategic plans to increase cultural and linguistic appropriateness in different types of providers of health care services and health-care-related services, including regional collaborations among health care organizations; and

“(v) culturally and linguistically appropriate information for educators, practitioners, and researchers.

“(F) Translation Glossaries—The Center shall—

“(i) develop and publish on its website translation glossaries that provide standardized translations of commonly used terms and phrases utilized in documents translated by the Center; and

“(ii) make these glossaries available—

“(I) free of charge;

“(II) in each language in which the Center translates forms under paragraph (2)(B); and

“(III) in alternative formats in accordance with the Americans with Disabilities Act of 1990 (42 U.S.C. 12101 et seq.).

“(G) Information about progress—The Center shall regularly collect and make publicly available information about the progress of entities receiving grants under section 3402 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, individuals with limited English proficiency, individuals with hearing or vision impairments, 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 and competent 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—There are authorized to be appropriated to carry out this section $5,000,000 for each of fiscal years 2021 through 2025.

“3402. Innovations in culturally and linguistically appropriate health care grants

“(a) In general

“(1) Grants—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 culturally and linguistically appropriate access to health care services for individuals with limited English proficiency.

“(2) Coordination—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 National Institute 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, 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 disorder 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) any other entity designated by the Secretary; and

“(2) prepare and submit to the Secretary an application, at such time, in such manner, and containing such additional information as the Secretary may reasonably require.

“(c) Use of funds—An entity shall use funds received through a grant under this section to—

“(1) develop, implement, and evaluate models of providing competent interpretation services through onsite interpretation, telephonic interpretation, or video remote interpreting services;

“(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 entity;

“(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 the service area of the entity;

“(4) develop a strategic plan to implement language services;

“(5) develop participatory, collaborative partnerships with communities encompassing the patient populations of individuals with limited English proficiency served by the grant to gain input in designing and implementing language services;

“(6) develop and implement grievance resolution processes that are culturally and linguistically appropriate and capable of identifying, preventing, and resolving complaints by individuals with limited English proficiency;

“(7) develop short-term medical and mental health interpretation training courses and incentives for bilingual health care staff who are asked to provide interpretation services 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 and linguistically appropriate providers;

“(9) provide staff language training instruction, which shall include information on the practical limitations of such instruction for nonnative 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, including cultural competence programs for community health workers; 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 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 care services 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 Culturally and Linguistically Appropriate Health Care established under section 3401. 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 2021 through 2025.

“3403. 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 services.

“(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 conduct such research.

“(c) Use of funds—Research conducted 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 individuals with limited English proficiency.

“(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 individuals with limited English proficiency.

“(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 services 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 Secretary can create or coordinate, and subsidize or otherwise fund, telephonic interpretation services 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 $5,000,000 for each of fiscal years 2021 through 2025.”

Sec. 205 Pilot program for improvement and development of State medical interpreting services

(a)
Grants authorized— The Secretary of Health and Human Services shall award 1 grant in accordance with this section to each of 3 States (to be selected by the Secretary) to assist each such State in designing, implementing, and evaluating a statewide program to provide onsite interpreter services under the State Medicaid plan.
(b)
Grant period— A grant awarded under this section is authorized for the period of 3 fiscal years beginning on October 1, 2021, and ending on September 30, 2024.
(c)
Preference— In awarding a grant under this section, the Secretary shall give preference to a State—
(1)
that has a high proportion of qualified LEP enrollees, as determined by the Secretary;
(2)
that has a large number of qualified LEP enrollees, as determined by the Secretary;
(3)
that has a high growth rate of the population of individuals with limited English proficiency, as determined by the Secretary; and
(4)
that has a population of qualified LEP enrollees that is linguistically diverse, requiring interpreter services in at least 200 non-English languages.
(d)
Use of funds— A State receiving a grant under this section shall use the grant funds to—
(1)
ensure that all health care providers in the State participating in the State Medicaid plan 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;
(2)
establish, expand, procure, or contract for—
(A)
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 Medicaid plan; and
(B)
an entity to administer such system, the duties of which shall include—
(i)
procuring and scheduling interpreter services for qualified LEP enrollees;
(ii)
procuring and scheduling interpreter services for individuals with limited English proficiency seeking to enroll in the State Medicaid plan;
(iii)
ensuring that interpreters receive payment for interpreter services rendered under the system; and
(iv)
consulting regularly with organizations representing consumers, interpreters, and health care providers; and
(3)
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.
(e)
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:
(1)
A description of the language access needs of individuals in the State enrolled in the State Medicaid plan.
(2)
A description of the extent to which the program will—
(A)
use the grant funds for the purposes described in subsection (d);
(B)
meet the health care needs of rural populations of the State; and
(C)
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 Medicaid plan.
(3)
A description of how the program will be evaluated, including a proposal for collaboration with organizations representing interpreters, consumers, and individuals with limited English proficiency.
(f)
Definitions— In this section:
(1)
Qualified LEP enrollee— The term qualified LEP enrollee means an individual—
(A)
who is limited English proficient; and
(B)
who is enrolled in a State Medicaid plan.
(2)
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 (42 U.S.C. 1396 et seq.).
(3)
State Medicaid plan— The term State Medicaid plan means a State plan under title XIX of the Social Security Act (42 U.S.C. 1396 et seq.) or a waiver of such a plan.
(4)
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 (42 U.S.C. 1396 et seq.).
(g)
Continuation past demonstration— Any State receiving a grant under this section must agree to directly pay for language services in Medicaid for all Medicaid providers by the end of the grant period.
(h)
Funding—
(1)
Authorization of appropriations— There is authorized to be appropriated $5,000,000 to carry out this section.
(2)
Availability of funds— Amounts appropriated pursuant to the authorization in paragraph (1) are authorized to remain available without fiscal year limitation.
(3)
Increased Federal financial participation— Section 1903(a)(2)(E) of the Social Security Act (42 U.S.C. 1396b(a)(2)(E)) is amended by inserting “(or, in the case of a State that was awarded a grant under section 205 of the Health Equity and Accountability Act of 2020, 100 percent for each quarter occurring during the grant period specified in subsection (b) of such section)” after “75 percent”.
(i)
Limitation— No Federal funds awarded under this section may be used to provide interpreter services from a location outside the United States.

Sec. 206 Training tomorrow’s doctors for culturally and linguistically appropriate care: graduate medical education

(a)
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 and linguistically appropriate 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 culturally and linguistically appropriate service delivery, which shall include all diverse populations including people with disabilities and the Lesbian, gay, bisexual, transgender, queer, questioning, questioning and intersex (LGBTQIA) community, shall be counted toward the determination of full-time equivalency.”

(b)
Indirect medical education— Section 1886(d)(5)(B) of the Social Security Act (42 U.S.C. 1395ww(d)(5)(B)) is amended—
(1)
by redesignating the clause (x) added by section 5505(b) of the Patient Protection and Affordable Care Act as clause (xi) and moving the left margin of such clause and each subclause and item therein 2 ems to the left; and
(2)
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.”

(c)
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. 207 Federal reimbursement for culturally and linguistically appropriate services under the Medicare, Medicaid, and State Children’s Health Insurance Programs

(a)
Language Access grants for Medicare Providers—
(1)
Establishment—
(A)
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 (as referred to in section 1115A of the Social Security Act (42 U.S.C. 1315a)), shall establish a demonstration program under which the Secretary shall award grants to eligible Medicare service providers to improve communication between such providers and Medicare beneficiaries who are limited English proficient, including beneficiaries who live in diverse and underserved communities.
(B)
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).
(C)
Number of grants— To the extent practicable, the Secretary shall award not less than 24 grants under this subsection.
(D)
Grant period— Except as provided under paragraph (2)(D), each grant awarded under this subsection shall be for a 3-year period.
(2)
Eligibility requirements— To be eligible for a grant under this subsection, an entity must meet the following requirements:
(A)
Medicare provider— The entity must be—
(i)
a provider of services under part A of title XVIII of the Social Security Act (42 U.S.C. 1395c et seq.);
(ii)
a provider of services under part B of such title (42 U.S.C. 1395j et seq.);
(iii)
a Medicare Advantage organization offering a Medicare Advantage plan under part C of such title (42 U.S.C. 1395w–21 et seq.); or
(iv)
a PDP sponsor offering a prescription drug plan under part D of such title (42 U.S.C. 1395w–101 et seq.).
(B)
Underserved communities— The entity must serve a community that, with respect to necessary language services for improving access and utilization of health care among English learners, is disproportionally underserved.
(C)
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.
(D)
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.
(3)
Distribution— To the extent feasible, the Secretary shall award—
(A)
at least 6 grants to providers of services described in paragraph (2)(A)(i);
(B)
at least 6 grants to service providers described in paragraph (2)(A)(ii);
(C)
at least 6 grants to organizations described in paragraph (2)(A)(iii); and
(D)
at least 6 grants to sponsors described in paragraph (2)(A)(iv).
(4)
Considerations in awarding grants—
(A)
Variation in grantees— In awarding grants under this subsection, the Secretary shall select grantees to ensure the following:
(i)
The grantees provide many different types of language services.
(ii)
The grantees serve Medicare beneficiaries who speak different languages, and who, as a population, have differing needs for language services.
(iii)
The grantees serve Medicare beneficiaries in both urban and rural settings.
(iv)
The grantees serve Medicare beneficiaries in at least two geographic regions, as defined by the Secretary.
(v)
The grantees serve Medicare beneficiaries in at least two large metropolitan statistical areas with racial, ethnic, sexual, gender, disability, and economically diverse populations.
(B)
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—
(i)
a community organization; or
(ii)
a consortia of community organizations, State agencies, and local agencies,
(5)
Use of funds for competent language services—
(A)
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 English learners.
(B)
Competent language services defined— For purposes of this subsection, the term competent language services means—
(i)
interpreter and translation services that—
(I)
subject to the exceptions under subparagraph (C)—
(aa)
if the grantee operates in a State that has statewide health care interpreter standards, meet the State standards currently in effect; or
(bb)
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 comply with the requirements of section 1557 of the Patient Protection and Affordable Care Act (42 U.S.C. 18116) as published in the Federal Register on May 18, 2016; and
(II)
that, in the case of interpreter services, are provided through—
(aa)
onsite interpretation;
(bb)
telephonic interpretation; or
(cc)
video interpretation; and
(ii)
the direct provision of health care or health-care-related services by a competent bilingual health care provider.
(C)
Exceptions— The requirements of subparagraph (B)(i)(I) do not apply, with respect to interpreter and translation services and a grantee—
(i)
in the case of a Medicare beneficiary who is an English learner if—
(I)
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
(II)
the grantee documents such request in the beneficiary’s medical record; or
(ii)
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.
(D)
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 (42 U.S.C. 1395w–21 et seq.) or a PDP sponsor offering a prescription drug plan under part D of such title (42 U.S.C. 1395w–101 et seq.), 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 English learners.
(E)
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).
(6)
Determination of amount of grant payments—
(A)
In general— Payments to grantees under this subsection shall be calculated based on the estimated numbers of Medicare beneficiaries who are English learners in a grantee’s service area utilizing—
(i)
data on the numbers of English learners 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
(ii)
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 English learners than would be estimated using the data under clause (i).
(B)
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.
(C)
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).
(7)
Assurances— Grantees under this subsection shall, as a condition of receiving a grant under this subsection—
(A)
ensure that clinical and support staff receive appropriate ongoing education and training in linguistically appropriate service delivery;
(B)
ensure the linguistic competence of bilingual providers;
(C)
offer and provide appropriate language services at no additional charge to each patient who is an English learner for all points of contact between the patient and the grantee, in a timely manner during all hours of operation;
(D)
notify Medicare beneficiaries of their right to receive language services in their primary language;
(E)
post signage in the primary languages commonly used by the patient population in the service area of the organization; and
(F)
ensure that—
(i)
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
(ii)
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.
(8)
No Cost Sharing— Medicare beneficiaries who are English learners shall not have to pay cost sharing or co-payments for competent language services provided under this demonstration program.
(9)
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:
(A)
The number of Medicare beneficiaries to whom competent language services are provided.
(B)
The primary languages of those Medicare beneficiaries.
(C)
The types of language services provided to such beneficiaries.
(D)
Whether such language services were provided by employees of the grantee or through a contract with external contractors or agencies.
(E)
The types of interpretation services provided to such beneficiaries, and the approximate length of time such service is provided to such beneficiaries.
(F)
The costs of providing competent language services.
(G)
An account of the training or accreditation of bilingual staff, interpreters, and translators providing services funded by the grant under this subsection.
(10)
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:
(A)
An analysis of the patient outcomes and the costs of furnishing care to the Medicare beneficiaries who are English learners participating in the project as compared to such outcomes and costs for such Medicare beneficiaries not participating, based on the data provided under paragraph (9) and any other information available to the Secretary.
(B)
The effect of delivering language services on—
(i)
Medicare beneficiary access to care and utilization of services;
(ii)
the efficiency and cost effectiveness of health care delivery;
(iii)
patient satisfaction;
(iv)
health outcomes; and
(v)
the provision of culturally appropriate services provided to such beneficiaries.
(C)
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 section 1115A(c) of the Social Security Act (42 U.S.C. 1315a(c)).
(D)
Recommendations, if any, regarding the extension of such project to the entire Medicare Program, subject to the provisions of such section 1115A(c).
(11)
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.
(12)
English learner defined— In this subsection, the term English learner has the meaning given such term in section 8101(20) of the Elementary and Secondary Education Act of 1965, except that subparagraphs (A), (B), and (D) of such section shall not apply.
(b)
Language assistance services under the Medicare program—
(1)
Inclusion as rural health clinic services— Section 1861 of the Social Security Act (42 U.S.C. 1395x) is amended—
(A)
in subsection (aa)(1)—
(i)
in subparagraph (B), by striking “and” at the end;
(ii)
by adding “and” at the end of subparagraph (C); and
(iii)
by inserting after subparagraph (C) the following new subparagraph:

“(D) language assistance services as defined in subsection (kkk)(1),”

(B)
by adding at the end the following new subsection:

“(kkk) Language assistance services and related terms

“(1) The term language assistance services means language access or language assistance services (as those terms are defined in section 3400 of the Public Health Service Act) furnished by a qualified interpreter for an individual with limited English proficiency or a qualified translator (as those terms are defined in such section 3400) to an individual with limited English proficiency (as defined in such section 3400) or an “English learner” (as defined in paragraph (2)).

“(2) The term English learner has the meaning given that term in section 8101(20) of the Elementary and Secondary Education Act of 1965, except that subparagraphs (A), (B), and (D) of such section shall not apply.”

(2)
Coverage— Section 1832(a)(2) of the Social Security Act (42 U.S.C. 1395k(a)(2)) is amended—
(A)
by striking “and” at the end of subparagraph (I);
(B)
by striking the period at the end of subparagraph (J) and inserting “; and”; and
(C)
by adding at the end the following new subparagraph:

“(K) language assistance services (as defined in section 1861(kkk)(1)).”

(3)
Payment— Section 1833(a) of the Social Security Act (42 U.S.C. 1395l(a)) is amended—
(A)
by striking “and” at the end of paragraph (8);
(B)
by striking the period at the end of paragraph (9) and inserting “; and”; and
(C)
by inserting after paragraph (9) the following new paragraph:

“(10) in the case of language assistance services (as defined in section 1861(kkk)(1)), 100 percent of the reasonable charges for such services, as determined in consultation with the Medicare Payment Advisory Commission.”

(4)
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 assistance services (as defined in section 1861(kkk)(1) of such Act).
(c)
Medicare parts C and D—
(1)
In general— Medicare Advantage plans under part C of title XVIII of the Social Security Act (42 U.S.C. 1395w–21 et seq.) and prescription drug plans under part D of such title (42 U.S.C. 1395q–101) shall comply with title VI of the Civil Rights Act of 1964 (42 U.S.C. 2000d et seq.) and section 1557 of the Patient Protection and Affordable Care Act (42 U.S.C. 18116) to provide effective language services to enrollees of such plans.
(2)
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:

“(6) 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 internal policies and procedures of the organization (or sponsor) 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 2020, 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 language services programs and services offered by the organization (or sponsor) with respect to the 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 enrollee population.

“(E) The periodic provision of educational information to plan enrollees on the language services and programs offered by the organization (or sponsor).”

(d)
Improving language services in Medicaid and CHIP—
(1)
Payments to States— Section 1903(a)(2)(E) of the Social Security Act (42 U.S.C. 1396b(a)(2)(E)), as amended by section 205(h)(3), is further amended by—
(A)
striking “75” and inserting “95”;
(B)
striking “translation or interpretation services” and inserting “language assistance services”; and
(C)
striking “children of families” and inserting “individuals”.
(2)
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 (29)” and inserting “(29), and (30)”.
(3)
Definition of medical assistance— Section 1905(a) of the Social Security Act (42 U.S.C. 1396d(a)) is amended—
(A)
in paragraph (29), by striking “and” at the end;
(B)
by redesignating paragraph (30) as paragraph (31); and
(C)
by inserting after paragraph (29) the following new paragraph:

“(30) language assistance services, as such term is defined in section 1861(kkk)(1), provided in a timely manner to individuals with limited English proficiency as defined in section 3400 of the Public Health Service Act; and”

(4)
Use of deductions and cost sharing— Section 1916(a)(2) of the Social Security Act (42 U.S.C. 1396o(a)(2)) is amended—
(A)
by striking “or” at the end of subparagraph (F);
(B)
by striking “; and” at the end of subparagraph (G) and inserting “, or”; and
(C)
by adding at the end the following new subparagraph:

“(H) language assistance services described in section 1905(a)(30); and”

(5)
CHIP coverage requirements— Section 2103 of the Social Security Act (42 U.S.C. 1397cc) is amended—
(A)
in subsection (a), in the matter before paragraph (1), by striking “(7) and (8)” and inserting “(7), (10), and (11)”;
(B)
in subsection (c), by adding at the end the following new paragraph:

“(11) Language assistance services—The child health assistance provided to a targeted low-income child shall include coverage of language assistance services, as such term is defined in section 1861(kkk)(1), provided in a timely manner to individuals with limited English proficiency (as defined in section 3400 of the Public Health Service Act).”

(C)
in subsection (e)(2)—
(i)
in the heading, by striking “preventive” and inserting “certain”; and
(ii)
by inserting “language assistance services described in subsection (c)(11),” before “visits described in”.
(6)
Definition of child health assistance— Section 2110(a)(27) of the Social Security Act (42 U.S.C. 1397jj(a)(27)) is amended by striking “translation” and inserting “language assistance services as described in section 2103(c)(11)”.
(7)
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—
(A)
the primary language of individuals receiving child health assistance under title XXI of the Social Security Act (42 U.S.C. 1397aa et seq.); and
(B)
in the case of such individuals who are minors or incapacitated, the primary language of the individual’s parent or guardian.
(8)
CHIP payments to States— Section 2105 of the Social Security Act (42 U.S.C. 1397ee) is amended—
(A)
in subsection (a)(1)—
(i)
in the matter preceding subparagraph (A), by striking “75” and inserting “95”; and
(ii)
in subparagraph (D)(iv), by striking “translation or interpretation services” and inserting “language assistance services”; and
(B)
in subsection (c)(2)(A), by inserting before the period at the end the following: “, except that expenditures pursuant to clause (iv) of subparagraph (D) of such paragraph shall not count towards this total”.
(e)
Funding language assistance services furnished by providers of health care and health-Care-Related services that serve high rates of uninsured LEP individuals—
(1)
Payment of costs—
(A)
In general— Subject to subparagraph (B), the Secretary of Health and Human Services (referred to in this subsection as the Secretary) shall make payments (on a quarterly basis) directly to eligible entities to support the provision of language assistance services to English learners in an amount equal to an eligible entity’s eligible costs for providing such services for the quarter.
(B)
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 2021 through 2025.
(C)
Relation to Medicaid DSH— Payments under this subsection shall not offset or reduce payments under section 1923 of the Social Security Act (42 U.S.C. 1396r–4), nor shall payments under such section be considered when determining uncompensated costs associated with the provision of language assistance services for the purposes of this section.
(2)
Methodology for payment of claims—
(A)
In general— The Secretary shall establish a methodology to determine the average per person cost of language assistance services.
(B)
Different entities— In establishing such methodology, the Secretary may establish different methodologies for different types of eligible entities.
(C)
No individual claims— The Secretary may not require eligible entities to submit individual claims for language assistance services for individual patients as a requirement for payment under this subsection.
(3)
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.
(4)
Guidelines— Not later than 6 months after the date of enactment of this Act, the Secretary shall establish and distribute guidelines concerning the implementation of this subsection.
(5)
Reporting requirements—
(A)
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.
(B)
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.
(6)
Definitions— In this subsection:
(A)
Eligible costs— The term eligible costs means, with respect to an eligible entity that provides language assistance services to English learners, the product of—
(i)
the average per person cost of language assistance services, determined according to the methodology devised under paragraph (2); and
(ii)
the number of English learners who are provided language assistance services by the entity and for whom no reimbursement is available for such services under the amendments made by subsection (a), (b), (c), or (d) or by private health insurance.
(B)
Eligible entity— The term eligible entity means an entity that—
(i)
is a Medicaid provider that is—
(I)
a physician;
(II)
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
(III)
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)));
(ii)
not later than 6 months after the date of the enactment of this Act, provides language assistance services to not less than 8 percent of the entity’s total number of patients; and
(iii)
prepares and submits 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.
(C)
English learner— The term English learner has the meaning given such term in section 8101(20) of the Elementary and Secondary Education Act of 1965 (20 U.S.C. 7801(20)), except that subparagraphs (A), (B), and (D) of such section shall not apply.
(D)
Language assistance services— The term language assistance services has the meaning given such term in section 1861(kkk)(1) of the Social Security Act, as added by subsection (b).
(f)
Application of Civil Rights Act of 1964, section 1557 of the Affordable Care Act, 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. 2000d et seq.), section 1557 of the Affordable Care Act, or other laws that protect the civil rights of individuals.
(g)
Effective date—
(1)
In general— Except as otherwise provided and subject to paragraph (2), the amendments made by this section shall take effect on January 1, 2021.
(2)
Exception if State legislation required— In the case of a State plan for medical assistance under title XIX of the Social Security Act (42 U.S.C. 1396 et seq.) or a State plan for child health assistance under title XXI of such Act (42 U.S.C. 1397aa et seq.) 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, such 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. 208 Increasing understanding of and improving health literacy

(a)
In general— The Secretary of Health and Human Services, acting through the Director of the Agency for Healthcare Research and Quality with respect to grants under subsection (c)(1) and through the Administrator of the Health Resources and Services Administration with respect to grants under subsection (c)(2), in consultation with the Director of the National Institute on Minority Health and Health Disparities and the Deputy Assistant Secretary for Minority Health, shall award grants to eligible entities to improve health care for patient populations that have low functional health literacy.
(b)
Eligibility— To be eligible to receive a grant under subsection (a), an entity shall—
(1)
be a hospital, health center or clinic, health plan, or other health entity (including a nonprofit minority health organization or association); and
(2)
prepare and submit to the Secretary an application at such time, in such manner, and containing such information as the Secretary may reasonably require.
(c)
Use of funds—
(1)
Agency for healthcare research and quality— A grant awarded under subsection (a) through the Director of the Agency for Healthcare Research and Quality shall be used—
(A)
to define and increase the understanding of health literacy;
(B)
to investigate the correlation between low health literacy and health and health care;
(C)
to clarify which aspects of health literacy have an effect on health outcomes; and
(D)
for any other activity determined appropriate by the Director.
(2)
Health resources and services administration— A grant awarded under subsection (a) through the Administrator of the Health Resources and Services Administration shall be used to conduct demonstration projects for interventions for patients with low health literacy that may include—
(A)
the development of new disease management programs for patients with low health literacy;
(B)
the tailoring of disease management programs addressing mental, physical, oral, and behavioral health conditions for patients with low health literacy;
(C)
the translation of written health materials for patients with low health literacy;
(D)
the identification, implementation, and testing of low health literacy screening tools;
(E)
the conduct of educational campaigns for patients and providers about low health literacy;
(F)
the conduct of educational campaigns concerning health directed specifically at patients with mental disabilities, including those with cognitive and intellectual disabilities, designed to reduce the incidence of low health literacy among these populations, which shall have instructional materials in the plain language standards promulgated under the Plain Writing Act of 2010 (5 U.S.C. 301 note) for Federal agencies; and
(G)
other activities determined appropriate by the Administrator.
(d)
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.
(e)
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 2021 through 2025.

Sec. 209 Requirements for health programs or activities receiving Federal funds

(a)
Covered entity; covered program or activity— In this section—
(1)
the term covered entity has the meaning given such term in section 92.4 of title 45, Code of Federal Regulations, as in effect on May 18, 2016 (81 Fed. Reg. 31466 (May 18, 2016)); and
(2)
the term health program or activity has the meaning given such term in section 92.4 of title 45, Code of Federal Regulations, as in effect on May 18, 2016 (81 Fed. Reg. 31466 (May 18, 2016)).
(b)
Requirements— A covered entity, in order to ensure the right of individuals with limited English proficiency to receive access to high-quality health care through the covered program or activity, shall—
(1)
ensure that appropriate clinical and support staff receive ongoing education and training in culturally and linguistically appropriate service delivery;
(2)
offer and provide appropriate language assistance services at no additional charge to each patient that is an individual with limited English proficiency at all points of contact, in a timely manner during all hours of operation;
(3)
notify patients of their right to receive language services in their primary language; and
(4)
utilize only qualified interpreters for an individual with limited English proficiency or qualified translators, except as provided in subsection (c).
(c)
Exemptions— The requirements of subsection (b)(4) shall not apply as follows:
(1)
When a patient requests the use of family, friends, or other persons untrained in interpretation or translation if each of the following conditions are met:
(A)
The interpreter requested by the patient is over the age of 18.
(B)
The covered entity informs the patient in the primary language of the patient that he or she has the option of having the entity provide to the patient an interpreter and translation services without charge.
(C)
The covered entity informs the patient that the entity may not require an individual with a limited English proficiency to use a family member or friend as an interpreter.
(D)
The covered entity evaluates whether the person the patient wishes to use as an interpreter is competent. If the covered entity has reason to believe that such person is not competent as an interpreter, the entity provides its own interpreter to protect the covered entity from liability if the patient’s interpreter is later found not competent.
(E)
If the covered entity has reason to believe that there is a conflict of interest between the interpreter and patient, the covered entity may not use the patient’s interpreter.
(F)
The covered entity 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 primary language.
(2)
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.
(d)
Rule of construction— Subsection (c)(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. 210 Report on Federal efforts to provide culturally and linguistically appropriate health care services

(a)
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 National Academy 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 to health care services and health-care-related services that are culturally and linguistically appropriate. Such report shall include—
(1)
a description and evaluation of the activities carried out under this Act;
(2)
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;
(3)
recommendations on the development and implementation of policies and practices by providers of health care services and health-care-related services for individuals with limited English proficiency, including people with cognitive, hearing, vision, or print impairments;
(4)
recommend guidelines or standards for health literacy and plain language, informed consent, discharge instructions, and written communications, and for improvement of health care access;
(5)
a description of the effect of providing language services on quality of health care and access to care; and
(6)
a description of the costs associated with or savings related to the provision of language services.
(b)
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 2021 through 2025.

Sec. 211 English for speakers of other languages

(a)
Grants authorized— The Secretary of Education is authorized to provide grants to eligible entities for the provision of English as a second language (in this section referred to ESL) instruction and shall determine, after consultation with appropriate stakeholders, the mechanism for administering and distributing such grants.
(b)
Eligible entity defined— In this section, the term eligible entity means a State or community-based organization that employs and serves minority populations.
(c)
Application— An eligible entity may apply for a grant under this section by submitting such information as the Secretary of Education may require and in such form and manner as the Secretary may require.
(d)
Use of grant— As a condition of receiving a grant under this section, an eligible entity shall—
(1)
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 individuals to access and regularly negotiate the system effectively;
(2)
develop a plan, including, where appropriate, public-private partnerships, for making ESL instruction progressively available to all individuals seeking instruction; and
(3)
maintain current ESL instruction efforts by using funds available under this section to supplement rather than supplant any funds expended for ESL instruction in the State as of January 1, 2020.
(e)
Additional duties of the secretary— The Secretary of Education shall—
(1)
collect and publicize annual data on how much Federal, State, and local governments spend on ESL instruction;
(2)
collect data from State and local governments to identify the unmet needs of English language learners for appropriate ESL instruction, including—
(A)
the preferred written and spoken language of such English language learners;
(B)
the extent of waiting lists for ESL instruction, including how many programs maintain waiting lists and, for programs that do not have waiting lists, the reasons why not;
(C)
the availability of programs to geographically isolated communities;
(D)
the impact of course enrollment policies, including open enrollment, on the availability of ESL instruction;
(E)
the number of individuals in the State and each participating locality;
(F)
the effectiveness of the instruction in meeting the needs of individuals receiving instruction and individuals needing instruction;
(G)
an assessment of the need for programs that integrate job training and ESL instruction, to assist individuals to obtain better jobs; and
(H)
the availability of ESL slots by State and locality;
(3)
determine the cost and most appropriate methods of making ESL instruction available to all English language learners seeking instruction; and
(4)
not later than 1 year after 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.
(f)
Authorization of Appropriations— There are authorized to be appropriated to the Secretary of Education $250,000,000 for each of fiscal years 2021 through 2024 to carry out this section.

Sec. 212 Implementation

(a)
General provisions—
(1)
Immunity— A State shall not be immune under the 11th Amendment to the Constitution of the United States from suit in Federal court for a violation of this title (including an amendment made by this title).
(2)
Remedies— In a suit against a State for a violation of this title (including an amendment made by this title), remedies (including remedies 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 a suit against any public or private entity other than a State.
(b)
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. 2000d et seq.) or any other Federal statute.

Sec. 213 Language access services

(a)
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.”

(b)
Employer-Sponsored minimum essential coverage—
(1)
In general— Section 36B(c)(2)(C) of the Internal Revenue Code of 1986 is amended by redesignating clauses (iii) and (iv) as clauses (iv) and (v), respectively, and by inserting after clause (ii) the following new clause:

“(iii) Coverage must include language access and services—Except as provided in clause (iv), 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.”

(2)
Conforming amendments—
(A)
Section 36B(c)(2)(C) of such Code is amended by striking “clause (iii)” each place it appears in clauses (i) and (ii) and inserting “clause (iv)”.
(B)
Section 36B(c)(2)(C)(iv) of such Code, as redesignated by this subsection, is amended by striking “(i) and (ii)” and inserting “(i), (ii), and (iii)”.
(c)
Quality Reporting— Section 2717(a)(1) of the Public Health Service Act (42 U.S.C. 300gg–17(a)(1)) is amended—
(1)
by striking “and” at the end of subparagraph (C);
(2)
by striking the period at the end of subparagraph (D) and inserting “; and”; and
(3)
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.”

(d)
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 54.9815–2719(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 (or a successor regulation), respectively, to require group health plans and health insurance issuers offering group or individual health insurance coverage to which such sections apply—
(1)
to provide oral interpretation services without any threshold requirements;
(2)
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
(3)
with respect to the requirements for providing relevant notices in a culturally and linguistically appropriate manner in the applicable non-English languages, to apply a threshold that 5 percent of the population, or not less than 500 individuals, in the county is literate only in the same non-English language in order for the language to be considered an applicable non-English language.
(e)
Data collection and reporting— The Secretary of Health and Human Services shall—
(1)
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 such Act (42 U.S.C. 18001 et seq.);
(2)
require navigators, certified application counselors, and other individuals assisting with enrollment to collect and report requests for language assistance; and
(3)
require the toll-free telephone hotlines 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 hotline, and any entity contracting with the Secretary to provide language services, have taken to actively address some of the consumer complaints.
(f)
Effective date— The amendments made by this section shall not apply to plans beginning prior to the date of the enactment of this Act.

Sec. 214 Medically underserved populations

Section 330(b)(3)(A) of the Public Health Service Act (42 U.S.C. 254b(b)(3)(A)) is amended to read as follows:

“(A) In general—The term medically underserved, with respect to a population, means—

“(i) the population of an urban or rural area designated by the Secretary as—

“(I) an area with a shortage of personal health services; or

“(II) a population group having a shortage of such services; or

“(ii) a population of individuals, not confined to a particular urban or rural area, who are designated by the Secretary as having a shortage of personal health services due to a specific demographic trait.”