Existing law establishes the Medi-Cal program, administered by the State Department of Health Care Services, under which health care services are provided to qualified, low-income persons. The Medi-Cal program is, in part, governed and funded by federal Medicaid Program provisions. Existing law requires the department to notify Medi-Cal beneficiaries, prospective beneficiaries, and members of the public about the program, including the availability of language assistance services and the availability of the grievance procedure.

This bill would require the department to ensure that all written health education and informing materials, as defined, in English and those translated into threshold languages by managed care plans or their subcontractors are at or below the equivalent of 6th-grade reading level. The bill would require the department to require managed care plans, as defined, or their subcontractors to conduct, by January 1, 2020, a one-time, targeted community review of informing materials in threshold languages for which a 6th-grade reading level cannot be determined, in order for members to ensure the cultural and linguistic appropriateness of materials in community-based settings, as specified. The bill would exempt material translated by either the department or its contractors, excluding managed care plans, from the targeted-community review. The bill would require the managed care plans to adopt additional readability and suitability standards developed by the community review process, and would require the managed care plans to apply the adopted standards to health education and informing materials developed on or after July 1, 2020. The bill would require managed care plans to report the findings of the community review process, and would require the department to publish those findings and develop recommendations for additional readability and suitability standards based on the findings, as described. The bill would include a statement of legislative findings and declarations.

Existing law establishes the Medi-Cal program, administered by the State Department of Health Care Services, under which health care services are provided to qualified, low-income persons. The Medi-Cal program is, in part, governed and funded by federal Medicaid Program provisions. Existing law requires the department to notify Medi-Cal beneficiaries, prospective beneficiaries, and members of the public about the program, including the availability of language assistance services and the availability of the grievance procedure.

This bill would require the department to ensure that all written health education and informing materials, as defined, in English and those translated into threshold languages by managed care plans or their subcontractors are at or below the equivalent of 6th grade reading level. The bill would require the department to require managed care plans, as defined, or other contractors their subcontractors to conduct, by January 1, 2020, a one-time, targeted community review of health education and informing materials in English and each threshold language, languages for which a 6th-grade reading level cannot be determined, in order for members to ensure the cultural and linguistic appropriateness of materials in community-based settings, as specified. The bill would exempt material translated by either the department or its contractors, excluding managed care plans, from the targeted-community review. The bill would require the managed care plans to adopt additional readability and suitability standards developed by the community-review process by process, and would require the managed care plans to apply the adopted standards to health education and informing materials developed on or after July 1, 2020. The bill would require managed care plans to report the findings of the community review process, and would require the department to publish those findings and develop recommendations for additional readability and suitability standards based on the findings, as described. The bill would include a statement of legislative findings and declarations.

Existing law establishes the Medi-Cal program, administered by the State Department of Health Care Services, under which health care services are provided to qualified, low-income persons. The Medi-Cal program is, in part, governed and funded by federal Medicaid Program provisions. Existing law requires the department to notify Medi-Cal beneficiaries, prospective beneficiaries, and members of the public about the program, including the availability of language assistance services and the availability of the grievance procedure.

This bill would require the department to ensure that all written health education and informing materials, as defined, in English and those translated into threshold languages by managed care plans are at or below the equivalent of 6th grade reading level. The bill would require the department to require managed care plans plans, as defined, or other contractors to conduct, by January 1, 2020, a one-time, targeted community review of health education and informing materials in English and each threshold language, in order for members to ensure the cultural and linguistic appropriateness of materials in community-based settings, as specified. The bill would require the managed care plans to adopt additional readability and suitability standards developed by the community-review process by July 1, 2020. The bill would require managed care plans to report the findings of the community review process, and would require the department to publish those findings and develop recommendations for additional readability and suitability standards based on the findings, as described. The bill would include a statement of legislative findings and declarations.

Existing law establishes the Medi-Cal program, administered by the State Department of Health Care Services, under which health care services are provided to qualified, low-income persons. The Medi-Cal program is, in part, governed and funded by federal Medicaid Program provisions. Existing law requires the department to notify Medi-Cal beneficiaries, prospective beneficiaries, and members of the public about the program, including the availability of language assistance services and the availability of the grievance procedure.

This bill would require the department to ensure that all written health education and informing materials, as defined, in English and those translated into threshold languages by managed care plans are at or below the equivalent of 6th grade reading level. The bill would require the department to require managed care plans or other contractors to conduct, by January 1, 2020, a one-time, targeted community review of health education and informing materials in English and each threshold language, in order for members to ensure the cultural and linguistic appropriateness of materials in community-based settings. settings, as specified. The bill would require the managed care plans to adopt additional readability and suitability standards developed by the community-review process by July 1, 2020. The bill would require managed care plans to report the findings of the community review process, and would require the department to publish those findings and develop recommendations for additional readability and suitability standards based on the findings. findings, as described. The bill would include a statement of legislative findings and declarations.

Existing law establishes the Medi-Cal program, administered by the State Department of Health Care Services, under which health care services are provided to qualified, low-income persons. The Medi-Cal program is, in part, governed and funded by federal Medicaid Program provisions. Existing law requires the department to notify Medi-Cal beneficiaries, prospective beneficiaries, and members of the public about the program, including the availability of language assistance services and the availability of the grievance procedure.

This bill would require the department to ensure that all written health education and informing materials, as defined, in English and those translated into threshold languages by managed care plans are at or below the equivalent of 6th grade reading level. The bill would require the department to require managed care plans or other contractors to conduct conduct, by January 1, 2020, a one-time, targeted community review of health education and informing materials in English and each threshold language, in order for members to ensure the cultural and linguistic appropriateness of materials in community-based settings. The bill would require the managed care plans to adopt additional readability and suitability standards developed by the community-review process by July 1, 2020. The bill would require managed care plans to report the findings of the community review process, and would require the department to publish those findings and develop recommendations for additional readability and suitability standards based on the findings. The bill would include a statement of legislative findings and declarations.

Existing law establishes the Medi-Cal program, administered by the State Department of Health Care Services, under which health care services are provided to qualified, low-income persons. The Medi-Cal program is, in part, governed and funded by federal Medicaid Program provisions. Existing law requires the department to notify Medi-Cal beneficiaries, prospective beneficiaries, and members of the public about the program, including the availability of language assistance services and the availability of the grievance procedure.

This bill would require the department to ensure that all written health education and informing materials, as defined, in English and those translated into threshold languages by managed care plans are at or below the equivalent of 6th grade reading level. The bill would require the department to require managed care plans or other contractors to conduct a one-time, targeted community review of health education and informing materials in English and each threshold language, in order for members to ensure the cultural and linguistic appropriateness of materials in community-based settings. The bill would require the managed care plans to report the findings of the community review process, and would require the department to publish those findings and develop recommendations for additional readability and suitability standards based on the findings. The bill would include a statement of legislative findings and declarations.

Existing law establishes the Medi-Cal program, administered by the State Department of Health Care Services, under which health care services are provided to qualified, low-income persons. The Medi-Cal program is, in part, governed and funded by federal Medicaid program Program provisions. Existing law requires the department to notify Medi-Cal beneficiaries, prospective beneficiaries, and members of the public about the program, including the availability of language assistance services and the availability of the grievance procedure.

This bill would require the department to ensure that all written health education and informing materials, as defined, developed and in English and those translated into threshold languages by managed care plans are at or below the equivalent of 6th grade reading level in English. level. The bill would require the department to require managed care plans or other contractors to conduct a one-time, targeted community review of health education and informing materials in English and each threshold language, in order for members to ensure the cultural and linguistic appropriateness of materials in community-based settings. The bill would require the managed care plans to report the findings of the community review process, and would require the department to publish those findings and develop recommendations for additional readability and suitability standards based on the findings. The bill would include a statement of legislative findings and declarations.

Existing law establishes the Medi-Cal program, administered by the State Department of Health Care Services, under which health care services are provided to qualified, low-income persons. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions. Existing law requires the department to notify Medi-Cal beneficiaries, prospective beneficiaries, and members of the public about the program, including the availability of language assistance services and the availability of the grievance procedure.

This bill would require the department to ensure that all written health education and informing materials, as defined, developed and translated into threshold languages by managed care plans are at or below the equivalent of 6th grade reading level in English. The bill would require the department to require managed care plans or other contractors to conduct a one-time, targeted community review of health education and informing materials in English and each threshold language, in order for members to ensure the cultural and linguistic appropriateness of materials in community-based settings. The bill would require the managed care plans to report the findings of the community review process, and would require the department to publish those findings and develop recommendations for additional readability and suitability standards based on the findings. The bill would include a statement of legislative findings and declarations.

GOVERNOR'S VETO

GV Bill Id:AB 2299

Author:(Chu)

As Enrolled Ver:September 5, 2018

2/3 vote

Original Committee Reference: HEALTH

SUMMARY: Requires the Department of Health Care Services (DHCS) to ensure that all written health education and informing materials developed by Medi-Cal managed care (MCMC) plans in English or translated into threshold languages are at or below the equivalent of sixth grade reading level, except as specified. Requires DHCS to require MCMC plans or their subcontractors to conduct a one-time, targeted community review of health education and informing materials in English and each threshold language, in order for members to ensure the cultural and linguistic appropriateness of materials in community-based settings. Establishes requirements for the structure of the community review, and requires it to be completed by January 1, 2020. Requires MCMC plans or other contractors to conduct a targeted community review when new informing materials are created. Exempts specified documents from the community review requirement.

The Senate amendments:

1. Require MCMC plans to apply adopted standards to health education and informing materials developed by the MCMC plans on or after July 1, 2020.
2. Clarify to apply the provisions of this bill to MCMC plans or their subcontractors.
3. Revise the one-time, targeted community review of informing materials in threshold languages for which a sixth grade reading level cannot be determined, instead of in English and each threshold language.
4. Delete language that specified that the use of software shall not be used in lieu of a native speaker to evaluate consumer facing materials and that exempt health education materials from the community review requirements.
5. Add language that exempts from the community review requirements, any material translated by either DHCS or its contractors, excluding MCMC plans. Also exempt any informing material related to a requested service or grievance, as specified, from the community review requirements and the field test standards.
6. Require MCMC plans to ensure that any informing material, as described, be reviewed pursuant to the one time, targeted community review, and field test.
7. Require DHCS publication to also identify any differences between current English readability and suitability standards and the checklists established by DHCS, as specified.
8. Defines native speaker as an individual whose primary language is a threshold language subject to the community review process, as described.
9. Defines plans as any individual, organization, or entity that enters into a contract with DHCS to provide services to enrolled Medi-Cal beneficiaries, as specified.
10. Make technical changes.

FISCAL EFFECT: According to the Senate Appropriations Committee, DHCS provides the following:

1. $4.5 million ($2.2 million General Fund (GF)) in 2019-20 for up to 32 positions and contract costs to review, monitor, and approve written health education and informational materials. These costs would decrease to $1.3 million ($643,000 GF) in 2020-21 for eight positions and contract costs, and $1.2 million ($584,000 GF) in 2021-22 and ongoing for seven positions and contract costs. The Senate Appropriations Committee notes the number of positions would significantly decrease in the out-years, as this bill's provisions appear necessitate a more upfront staff to prepare for the specified 2020 requirements for DHCS to MCMC plans.
2. Indeterminate contract costs for DHCS and MCMC plans (likely to be significant, GF, federal fund) to ensure readability and suitability standards related to threshold versions. The magnitude of the number of documents that would necessitate review are unknown at this time.

COMMENTS: According to the author, language barriers could prevent individuals from accessing crucial services and health education information. For better health outcomes, we need to do better in providing information in English and other languages that is clear, easy to understand, and culturally appropriate. This bill will ensure that important documents in English and all the most commonly spoken languages are also readable and easy to comprehend for those receiving the documents.

Medi-Cal population and threshold languages. In a May 2014 Medi-Cal statistical brief on the frequency of threshold language speakers in the Medi-Cal population by county for December 2013, DHCS indicated the following:

1. Forty percent of Medi-Cal beneficiaries statewide reported a language other than English as their primary language and met the statutory criteria for a threshold language population;
2. Forty-nine of California's 58 counties include the minimum number of Medi-Cal beneficiaries for meeting the threshold language definition (49 counties include English and Spanish);
3. Thirteen distinct languages qualified as threshold languages (Spanish, Vietnamese, Cantonese, Armenian, Russian, Mandarin, Tagalog, Korean, Arabic, Hmong, Farsi, Cambodian, and other Chinese);
4. Spanish was the most frequently occurring, threshold language (34.5%) and was represented in the greatest number of counties (49), followed by Vietnamese (7 counties, 1.6%), Cantonese (five counties, 1.1%), Mandarin (four counties, 0.4%), and Tagalog (four counties, 0.3%); and,
5. Los Angeles had the greatest number of threshold languages (12) of any county.

Translated materials must be provided in threshold languages, which are determined by population groups under existing law within the plan service area as determined by DHCS, as follows:

1. A population group of mandatory Medi-Cal beneficiaries residing in the Service Area who indicate their primary language as other than English, and that meet a numeric threshold of 3,000; or,
2. A population group of mandatory Medi-Cal beneficiaries residing in the Service Area who indicate their primary language as other than English and who meet the concentration standards of 1,000 in a single zip code or 1,500 in two contiguous zip codes.

Existing Medi-Cal readability and translation requirements. Federal Medicaid managed care regulations establish broad general requirements for readability (for example, requiring specific documents to be provided in a manner and format "that may be easily understood and is readily accessible") and require written materials that are "critical to obtaining services, including, at a minimum, provider directories, enrollee handbooks, appeal and grievance notices, and denial and termination notices," available in the prevalent non-English languages in its particular service area.

This bill is jointly sponsored by Western Center on Law & Poverty and the Women's Foundation of California – Women's Policy Institute (WFC-WPI) to codify Medi-Cal readability standards for health education and informing materials in English for managed care plans, as well as establish a transparent and accountable process for determining readability in all threshold languages, including an initial community review of all consumer-facing materials. WFC-WPI writes, as health advocates, they work closely with diverse cultural and linguistic communities in cities such as Los Angeles, Santa Ana, Long Beach, and Oakland, and time and time again, they have encountered Medi-Cal beneficiaries that have trouble understanding their health plan materials and unaware of very crucial services, such as language assistance services and filing an appeal. It is critical to place the readability requirements into law, and apply these standards to both informing and health education material.

The California Association of Health Plans (CAHP) and the Local Health Plans of California (LHCP) write in opposition that this bill includes unnecessary, repetitive, and costly steps for documents already translated by health plans. CAHP and LHPC argue Medi-Cal managed care plans are currently required to provide health plan materials in a readability format which means the documents are written at or below sixth grade reading level.

GOVERNOR'S VETO MESSAGE:

This bill would require the Department of Health Care Services to ensure all written health education and informational materials provided by Medi-Cal managed care plans to their beneficiaries are translated at or below the sixth grade reading level.

I signed legislation last year to codify the Affordable Care Act's language access provisions into state law. Furthermore, the department requires its plans to provide written materials in an easily understood and readily accessible format. Current law and contractual practice are sufficient to compel plans to make these important health care documents understandable for Medi-Cal beneficiaries.

Analysis Prepared by: Kristene Mapile / HEALTH / (916) 319-2097 FN: 0005303

CONCURRENCE IN SENATE AMENDMENTS

CSA1 Bill Id:AB 2299

Author:(Chu)

As Amended Ver:August 6, 2018

Majority vote

Original Committee Reference: HEALTH

SUMMARY: Requires the Department of Health Care Services (DHCS) to ensure that all written health education and informing materials developed by Medi-Cal managed care (MCMC) plans in English or translated into threshold languages are at or below the equivalent of sixth grade reading level, except as specified. Requires DHCS to require MCMC plans or their subcontractors to conduct a one-time, targeted community review of health education and informing materials in English and each threshold language, in order for members to ensure the cultural and linguistic appropriateness of materials in community-based settings. Establishes requirements for the structure of the community review, and requires it to be completed by January 1, 2020. Requires MCMC plans or other contractors to conduct a targeted community review when new informing materials are created. Exempts specified documents from the community review requirement.

The Senate amendments:

1. Require MCMC plans to apply adopted standards to health education and informing materials developed by the MCMC plans on or after July 1, 2020.
2. Clarify to apply the provisions of this bill to MCMC plans or their subcontractors.
3. Revise the one-time, targeted community review of informing materials in threshold languages for which a sixth grade reading level cannot be determined, instead of in English and each threshold language.
4. Delete language that specified that the use of software shall not be used in lieu of a native speaker to evaluate consumer facing materials and that exempt health education materials from the community review requirements.
5. Add language that exempts from the community review requirements, any material translated by either DHCS or its contractors, excluding MCMC plans. Also exempt any informing material related to a requested service or grievance, as specified, from the community review requirements and the field test standards.
6. Require MCMC plans to ensure that any informing material, as described, be reviewed pursuant to the one time, targeted community review, and field test.
7. Require DHCS publication to also identify any differences between current English readability and suitability standards and the checklists established by DHCS, as specified.
8. Defines native speaker as an individual whose primary language is a threshold language subject to the community review process, as described.
9. Defines plans as any individual, organization, or entity that enters into a contract with DHCS to provide services to enrolled Medi-Cal beneficiaries, as specified.
10. Make technical changes.

FISCAL EFFECT: According to the Senate Appropriations Committee, DHCS provides the following:

1. $4.5 million ($2.2 million General Fund (GF)) in 2019-20 for up to 32 positions and contract costs to review, monitor, and approve written health education and informational materials. These costs would decrease to $1.3 million ($643,000 GF) in 2020-21 for eight positions and contract costs, and $1.2 million ($584,000 GF) in 2021-22 and ongoing for seven positions and contract costs. The Senate Appropriations Committee notes the number of positions would significantly decrease in the out-years, as this bill's provisions appear necessitate a more upfront staff to prepare for the specified 2020 requirements for DHCS to MCMC plans.
2. Indeterminate contract costs for DHCS and MCMC plans (likely to be significant, GF, federal fund) to ensure readability and suitability standards related to threshold versions. The magnitude of the number of documents that would necessitate review are unknown at this time.

COMMENTS: According to the author, language barriers could prevent individuals from accessing crucial services and health education information. For better health outcomes, we need to do better in providing information in English and other languages that is clear, easy to understand, and culturally appropriate. This bill will ensure that important documents in English and all the most commonly spoken languages are also readable and easy to comprehend for those receiving the documents.

Medi-Cal population and threshold languages. In a May 2014 Medi-Cal statistical brief on the frequency of threshold language speakers in the Medi-Cal population by county for December 2013, DHCS indicated the following:

1. Forty percent of Medi-Cal beneficiaries statewide reported a language other than English as their primary language and met the statutory criteria for a threshold language population;
2. Forty-nine of California's 58 counties include the minimum number of Medi-Cal beneficiaries for meeting the threshold language definition (49 counties include English and Spanish);
3. Thirteen distinct languages qualified as threshold languages (Spanish, Vietnamese, Cantonese, Armenian, Russian, Mandarin, Tagalog, Korean, Arabic, Hmong, Farsi, Cambodian, and other Chinese);
4. Spanish was the most frequently occurring, threshold language (34.5%) and was represented in the greatest number of counties (49), followed by Vietnamese (7 counties, 1.6%), Cantonese (five counties, 1.1%), Mandarin (four counties, 0.4%), and Tagalog (four counties, 0.3%); and,
5. Los Angeles had the greatest number of threshold languages (12) of any county.

Translated materials must be provided in threshold languages, which are determined by population groups under existing law within the plan service area as determined by DHCS, as follows:

1. A population group of mandatory Medi-Cal beneficiaries residing in the Service Area who indicate their primary language as other than English, and that meet a numeric threshold of 3,000; or,
2. A population group of mandatory Medi-Cal beneficiaries residing in the Service Area who indicate their primary language as other than English and who meet the concentration standards of 1,000 in a single zip code or 1,500 in two contiguous zip codes.

Existing Medi-Cal readability and translation requirements. Federal Medicaid managed care regulations establish broad general requirements for readability (for example, requiring specific documents to be provided in a manner and format "that may be easily understood and is readily accessible") and require written materials that are "critical to obtaining services, including, at a minimum, provider directories, enrollee handbooks, appeal and grievance notices, and denial and termination notices," available in the prevalent non-English languages in its particular service area.

This bill is jointly sponsored by Western Center on Law & Poverty and the Women's Foundation of California – Women's Policy Institute (WFC-WPI) to codify Medi-Cal readability standards for health education and informing materials in English for managed care plans, as well as establish a transparent and accountable process for determining readability in all threshold languages, including an initial community review of all consumer-facing materials. WFC-WPI writes, as health advocates, they work closely with diverse cultural and linguistic communities in cities such as Los Angeles, Santa Ana, Long Beach, and Oakland, and time and time again, they have encountered Medi-Cal beneficiaries that have trouble understanding their health plan materials and unaware of very crucial services, such as language assistance services and filing an appeal. It is critical to place the readability requirements into law, and apply these standards to both informing and health education material.

The California Association of Health Plans (CAHP) and the Local Health Plans of California (LHCP) write in opposition that this bill includes unnecessary, repetitive, and costly steps for documents already translated by health plans. CAHP and LHPC argue Medi-Cal managed care plans are currently required to provide health plan materials in a readability format which means the documents are written at or below sixth grade reading level.

Analysis Prepared by: Kristene Mapile / HEALTH / (916) 319-2097 FN: 0004270

 THIRD READING  

Bill No: AB 2299

Author:

Amended: 8/6/18 in Senate

Vote:

SENATE HEALTH COMMITTEE: 8-1, 6/27/18

AYES: Pan, Nguyen, Beall, Hernandez, Leyva, Mitchell, Monning, Roth

NOES: Nielsen

SENATE APPROPRIATIONS COMMITTEE: 5-2, 8/16/18

AYES: Portantino, Beall, Bradford, Hill, Wiener

NOES: Bates, Nielsen

ASSEMBLY FLOOR: 53-23, 5/29/18 - See last page for vote

SUBJECT:

SOURCE: Western Center on Law and Poverty

Women’s Foundation of California - Women’s Policy Institute

DIGEST:

This bill (1) requires the Department of Health Care Services (DHCS) to ensure that all written health education and informing materials developed pursuant to Medi-Cal managed care plan contracts in English or translated into threshold languages are at or below the equivalent of sixth grade reading level, except as specified; (2) requires DHCS to require Medi-Cal managed care plans or their subcontractors to conduct a one-time, targeted community review of informing materials in threshold languages for which a sixth-grade reading level cannot be determined, in order for members to ensure the cultural and linguistic appropriateness of materials in community-based settings; (3) establishes requirements for the structure of the community review, and requires it to be completed by January 1, 2020; (4) requires Medi-Cal managed care plans or other contractors to conduct a targeted community review when new informing materials are created; and (5) exempts specified documents from the community review requirement.

ANALYSIS:

Existing law:

1. Establishes the Medi-Cal program, which is administered by the Department of Health Care Services (DHCS), under which qualified low-income individuals receive health care services. [WIC §14000, et seq.]
2. Requires, pursuant to federal regulation, each state, enrollment broker, and managed care plan entities to provide specified information to enrollees and potential enrollees in a manner and format that may be easily understood and is readily accessible by such enrollees and potential enrollees. [42 CFR §438.210]
3. Requires, pursuant to federal regulation, each to state to require each Medicaid managed care plan to make its written materials that are critical to obtaining services, including, at a minimum, provider directories, enrollee handbooks, appeal and grievance notices, and denial and termination notices, available in the prevalent non-English languages in its particular service area. [42 CFR §438.210]

This bill:

Reading level and suitability for written health education and informing documents in English

1. Requires DHCS to ensure that all written health education and informing materials developed pursuant to Medi-Cal managed care plan contracts are at or below the equivalent of sixth grade reading level in English.
2. Requires written health education in English to meet the readability and suitability checklists established by DHCS by means of all-county letters, plan letters, including All Plan Letter (APL) 11-018, plan or provider bulletins, or similar instructions.
3. Requires written informing materials in English to meet the readability and suitability checklists established through DHCS contracts with Medi-Cal managed care plans.
4. Requires Medi-Cal managed care plans to adopt any additional readability and suitability standards developed by the community review process required by this bill and recommended by DHCS under this bill.
5. Requires Medi-Cal managed care plans to apply the adopted standards to health education and informing materials developed by the plans on or after July 1, 2020.

Reading level and suitability for written health education and informing documents in threshold languages

1. Requires DHCS to ensure that all written health education and informing materials translated into threshold languages by Medi-Cal managed care plans or their subcontractors are at or below the equivalent of sixth grade reading level, except as specified in 7) below.

One-time targeted community review of informing materials

1. Requires DHCS to require Medi-Cal managed care plans or their subcontractors to conduct a one-time, targeted community review of informing materials in threshold languages, in order for members to ensure the cultural and linguistic appropriateness of materials in community-based settings.
2. Requires, for each threshold language for which an equivalent sixth grade reading level cannot be determined, DHCS to require managed care plans or their subcontractors to establish a process for Medi-Cal beneficiaries, advocates, and stakeholders to review existing and new informing materials through the one-time community review, with sufficient time to provide meaningful feedback.
3. Requires this review to be completed by January 1, 2020, and requires Medi-Cal managed care plans to adopt any additional readability and suitability standards developed by the community review process described in this bill and recommended by DHCS under this bill by July 1, 2020.

Targeted community review for new informing materials

1. Requires Medi-Cal managed care plans or their subcontractors to conduct a targeted community review when new informing materials are created.
2. Permits Medi-Cal managed care plans or their subcontractors to aggregate community reviews by threshold language, so as to not require separate reviews for each county served.

Requirements for community review process

1. Requires Medi-Cal managed care plans or their subcontractors to structure the community review process. Requires, when determining who participates in the community review process, the Medi-Cal managed care plans or other contractors to do all of the following:
2. Provide background information on plan members, including the ratio of threshold language speakers, and a summary of the plan’s current community review process;
3. Include current Medi-Cal beneficiaries and community-based organizations that work directly with Medi-Cal beneficiaries to identify and recruit beneficiaries; and,
4. Identify and include native speakers of a specific threshold language to review translated materials in their threshold language.
5. Requires outreach methods for participants in the community review process to include, but not be limited to, email, mail, and telephone calls.
6. Requires, when conducting the community review process, Medi-Cal managed care plans or other contractors to do all of the following:
7. Incorporate both quantitative and qualitative approaches, including focus groups and surveys with a minimum of four participants;
8. Allow 45 days for participants to provide feedback;
9. Have a native speaker of the threshold language assess, conduct, and evaluate the community review process and provide feedback; and,
10. Allow community feedback in both written and oral formats.

Exemptions from community review

1. Exempts informing materials produced by a Medi-Cal managed care plan prior to January 1, 2019, which are field tested by a minimum of four native speakers and meet the additional readability and suitability standards developed under this bill from the one-time community review. Requires any material that fails to meet subsequently adopted readability and suitability standards to be updated accordingly and reviewed under this bill.
2. Exempts any material translated by either DHCS or its contractors (excluding Medi-Cal managed care plans) from the community review requirements.
3. Exempts any informing material related to a requested service or grievance, including but not limited to, documents that explain the reason for denial of a requested service, that is produced for an individual beneficiary from the community review requirement and the field test standards in this bill. Requires plans to ensure that any informing materials related to a requested service or grievance, including but not limited to, a denial or service, to include, as may be relevant, language that has been reviewed in accordance with the one-time targeted community review under this bill, or field tested pursuant to this bill.
4. Exempts from the provisions of this bill statements that are specifically required by law to be included in written materials.

Reporting requirement for plans and for DHCS to publish findings and make recommendations

1. Requires Medi-Cal managed care plans to report the findings of the community review process, and requires DHCS to publish the findings of the community reviews and develop recommendations for additional readability and suitability standards based on the findings for each threshold language. Requires DHCS to also identify any differences between current English readability and suitability standards and the checklists established by DHCS under this bill.

Comments

1. Author’s statement. According to the author, language barriers could prevent individuals from accessing crucial services and health education information. For better health outcomes, we need to do better in providing information in English and other languages that is clear, easy to understand, and culturally appropriate. This bill will ensure that important documents in English and all the most commonly spoken languages are also readable and easy to comprehend for those receiving the documents.
2. Existing Medi-Cal readability and translation requirements. Federal Medicaid managed care regulations establish broad general requirements for readability (for example, requiring specific documents to be provided in a manner and format “that may be easily understood and is readily accessible”) and require written materials that are “critical to obtaining services, including, at a minimum, provider directories, enrollee handbooks, appeal and grievance notices, and denial and termination notices,” available in the prevalent non-English languages in its particular service area. This bill applies to two different types of documents: health education materials and informing materials and their reading level, suitability and translation. The existing specific provisions on translation, readability and suitability are currently in contractual language between DHCS and the plans, and in APLs or similar guidance issued by DHCS. This bill places into state law some of the existing provisions from contracts and letters (such as the definitions of health education and informing materials and the use of a 6th grade level for documents in English). In addition, this bill establishes new requirements, such as requiring the use of a checklist for informing materials (currently allowed for health education materials via all plan letter) and by placing into law a new one-time and on-going community review process (with exceptions), with specific detail on the review process, selection of individuals for the process, and timeframes for feedback.

FISCAL EFFECT: Appropriation: Fiscal Com.: Local:

According to the Senate Appropriations Committee, DHCS indicates costs as follows:

• $4.5 million ($2.2 million General Fund) in 2019-20 for up to 32 positions and contract costs to review, monitor, and approve written health education and informational materials. These costs would decrease to $1.3 million ($643,000 General Fund) in 2020-21 for eight positions and contract costs, and $1.2 million ($584,000 General Fund) in 2021-22 and ongoing for seven positions and contract costs. Staff notes the number of positions would significantly decrease in the out-years, as this bill’s provisions appear necessitate a more upfront staff to prepare for the specified 2020 requirements for DHCS to managed care plans.
• Indeterminate contract costs for DHCS and Medi-Cal managed care plans (likely to be significant, GF, federal fund) to ensure readability and suitability standards related to threshold versions. The magnitude of the number of documents that would necessitate review are unknown at this time.

SUPPORT: (Verified 8/15/18)

Western Center on Law and Poverty (co-source)

Women’s Foundation of California - Women’s Policy Institute (co-source)

Asian Americans Advancing Justice – California

Asian Law Alliance

California Immigrant Policy Center

California Pan-Ethnic Health Network

Children Now

Children’s Defense Fund-California

Children’s Partnership

County Welfare Directors Association of California

Disability Rights California

Disability Rights Education and Defense Fund

Having Our Say Coalition

Health Access California

Justice in Aging

National Association of Social Workers

National Health Law Program

Public Health Justice Collective

San Francisco Senior & Disability Action

Santa Ana Building Healthy Communities

OPPOSITION: (Verified 8/15/18)

California Association of Health Plans

Department of Finance

Department of Health Care Services

Health Net

Local Health Plans of California

ARGUMENTS IN SUPPORT: This bill is jointly sponsored by Western Center on Law & Poverty and the Women’s Foundation of California – Women’s Policy Institute (WFC-WPI) to codify Medi-Cal readability standards for health education and informing materials in English for managed care plans, as well as establish a transparent and accountable process for determining readability in all threshold languages, including an initial community review of all consumer-facing materials. WFC-WPI writes, they have encountered Medi-Cal beneficiaries that have trouble understanding their health plan materials and unaware of very crucial services, such as language assistance services and filing an appeal. It is critical to place the readability requirements into law, and apply these standards to both informing and health education material. By expanding upon the reading level mandate and codifying the readability requirements for both sets of materials, this bill will ensure all consumer-facing materials are able to be easily digested. Without the ability to thoroughly understand their health care documents, consumers are less equipped to properly navigate the health care system, which can lead to lower quality health care and poor health outcomes.

In addition, the WFC-WPI writes that the establishment of a community review process for English and all other threshold languages is a crucial first step to evaluate the current state of consumer-facing materials. A targeted community review is the most effective process to engage consumers and have them provide direct feedback on the readability and cultural relevance of translated materials.

ARGUMENTS IN OPPOSITION: The California Association of Health Plans (CAHP) and the Local Health Plans of California (LHCP) write in opposition that this bill includes unnecessary, repetitive, and costly steps for documents already translated by health plans. CAHP and LHPC argue Medi-Cal managed care plans are currently required to provide health plan materials in a readability format which means the documents are written at or below sixth grade reading level. These requirements are contained in an APL and in the contracts between health plans and DHCS. In the new “boilerplate” contract with DHCS, both health education materials and informing materials are to be at or below a sixth grade reading level. The APL also already requires field testing of health educational materials. Codifying these requirements in statute will make it difficult to change and update the requirements if necessary.

DHCS writes that it already requires its managed care plans to provide materials to beneficiaries and members in an easily understood and readily accessible format. DHCS also requires its managed care plans to provide the delivery of services in a culturally competent manner, which includes the provision of documents at a sixth grade reading level and the use of readability and suitability checklists when reviewing English versions of health education materials. Though DHCS is supportive of the intent of AB 2299, given the existing efforts and requirements, it is not clear that AB 2299 is necessary. In addition, AB 2299 could prove to be extremely problematic, for reasons ranging from a lack of consensus on what is considered the appropriate reading level across languages and cultures, to how difficult it would be to attempt to hold a community-based process to review the tens of thousands of documents utilized by each managed care plan.

ASSEMBLY FLOOR: 53-23, 5/29/18

AYES: Aguiar-Curry, Arambula, Berman, Bloom, Bonta, Burke, Caballero, Calderon, Carrillo, Cervantes, Chau, Chiu, Chu, Cooley, Cooper, Daly, Eggman, Frazier, Friedman, Cristina Garcia, Eduardo Garcia, Gipson, Gloria, Gonzalez Fletcher, Gray, Grayson, Holden, Irwin, Jones-Sawyer, Kalra, Kamlager-Dove, Levine, Limón, Low, Maienschein, McCarty, Medina, Mullin, Muratsuchi, Nazarian, O'Donnell, Quirk, Quirk-Silva, Reyes, Rodriguez, Salas, Santiago, Mark Stone, Thurmond, Ting, Weber, Wood, Rendon

NOES: Acosta, Travis Allen, Baker, Bigelow, Brough, Chávez, Chen, Cunningham, Dahle, Flora, Fong, Gallagher, Harper, Kiley, Lackey, Mathis, Mayes, Melendez, Obernolte, Patterson, Steinorth, Voepel, Waldron

NO VOTE RECORDED: Choi, Rubio

Prepared by:

8/18/18 13:41:51

**** END ****

SENATE COMMITTEE ON APPROPRIATIONS

Senator Anthony Portantino, Chair

2017 - 2018 Regular Session

AB 2299 (Chu) - Medi-Cal: managed care plans: informational materials

This bill meets the criteria for referral to the Suspense File.

Bill Summary:

Requires the Department of Health Care Services (DHCS) to ensure that all written health education and informing materials developed by Medi-Cal managed care plans in English or translated into threshold languages are at or below the equivalent of sixth grade reading level, except as specified. Requires DHCS to require Medi-Cal managed care plans or other contractors to conduct a one-time, targeted community review of health education and informing materials in English and each threshold language, in order for members to ensure the cultural and linguistic appropriateness of materials in community-based settings. Establishes requirements for the structure of the community review, and requires it to be completed by January 1, 2020. Requires Medi-Cal managed care plans or other contractors to conduct a targeted community review when new informing materials are created. Exempts specified documents from the community review requirement.

Fiscal Impact:

According to the Department of Health Care Services:

• $4.5 million ($2.2 million General Fund) in 2019-20 for up to 32 positions and contract costs to review, monitor, and approve written health education and informational materials. These costs would decrease to $1.3 million ($643,000 General Fund) in 2020-21 for 8 positions and contract costs, and $1.2 million ($584,000 General Fund) in 2021-22 and ongoing for 7 positions and contract costs. Staff notes the number of positions would significantly decrease in the out-years, as the bill’s provisions appear necessitate a more upfront staff to prepare for the specified 2020 requirements for DHCS to managed care plans. For more detail, please see Staff Comments.
• Indeterminate contract costs for DHCS and Medi-Cal managed care plans (likely to be significant, GF, federal fund) to ensure readability and suitability standards related to threshold versions. The magnitude of the number of documents that would necessitate review are unknown at this time.

Background:

Federal Medicaid managed care regulations establish broad general requirements for readability (for example, requiring specific documents to be provided in a manner and format “that may be easily understood and is readily accessible”) and require written materials that are “critical to obtaining services, including, at a minimum, provider directories, enrollee handbooks, appeal and grievance notices, and denial and termination notices,” available in the prevalent non-English languages in its particular service area. The Department of Health Care Services (DHCS), which administers the Medi-Cal program, requires all managed care plans that contract with DHCS to provide language assistance services to limited-English proficient Medi-Cal beneficiaries who are mandatorily enrolled in managed care. In addition, current law requires a mental health plan to notify beneficiaries, prospective beneficiaries, and the public about language assistance service availability, including oral interpretation services to be provided by an interpreter that meets specified qualifications.

A May 2014 Medi-Cal statistical brief on the frequency of threshold language speakers in the Medi-Cal population, by county, for December 2013, identified:

• • 40% of Medi-Cal beneficiaries statewide reported a language other than English as their primary language and met the statutory criteria for a threshold language population;
  • Forty-nine of California’s 58 counties include the minimum number of Medi-Cal beneficiaries for meeting the threshold language definition (49 counties include English and Spanish);
  • Thirteen distinct languages qualified as threshold languages (Spanish, Vietnamese, Cantonese, Armenian, Russian, Mandarin, Tagalog, Korean, Arabic, Hmong, Farsi, Cambodian and other Chinese);
  • Spanish was the most frequently occurring, threshold language (34.5%) and was represented in the greatest number of counties (49), followed by Vietnamese (7 counties, 1.6%), Cantonese (five counties, 1.1%), Mandarin (four counties, 0.4%) and Tagalog (four counties, 0.3%); and,
  • Los Angeles had the greatest number of threshold languages (12) of any county.

Translated materials must be provided in threshold languages, which are determined by population groups under existing law within the plan service area as determined by DHCS, as follows:

• A population group of mandatory Medi-Cal beneficiaries residing in the Service Area who indicate their primary language as other than English, and that meet a numeric threshold of 3,000; or,
• A population group of mandatory Medi-Cal beneficiaries residing in the Service Area who indicate their primary language as other than English and who meet the concentration standards of 1,000 in a single zip code or 1,500 in two contiguous zip codes.

Proposed Law:

Assembly Bill 2299 includes the following provisions, among others:

• Requires DHCS to ensure that all written health education and informing materials developed pursuant to managed care plan contracts are at or below the equivalent of sixth-grade reading level in English.
  • Requires written health education in English to meet the readability and suitability checklists established by the department by means of all-county letters, plan letters, including All Plan Letter 11-018, plan or provider bulletins, or similar instructions.
  • Requires written informing materials in English to meet the readability and suitability checklists established through the department’s contracts with managed care plans.
  • Requires managed care plans to adopt any additional readability and suitability standards developed by the community review process.
  • Requires managed care plans to apply the adopted standards to health education and informing materials developed by the managed care plans on or after July 1, 2020.
• Requires DHCS to ensure that all written health education and informing materials translated into threshold languages by managed care plans or their subcontractors are at or below the equivalent of sixth-grade reading level.
  • For each threshold language for which an equivalent sixth grade reading level cannot be determined, the department must require managed care plans or their subcontractors to establish a process for Medi-Cal beneficiaries, advocates, and stakeholders to review existing and new informing materials through a one-time community review, and complete the review by January 1, 2020.
  • Requires managed care plans to adopt any additional readability and suitability standards developed by the community review process and recommended by the department pursuant to subdivision (e) by July 1, 2020.
• Requires DHCS to require managed care plans or their subcontractors to conduct a one-time, targeted community review of informing materials in threshold languages for which a sixth-grade reading level cannot be determined, in order for members to ensure the cultural and linguistic appropriateness of materials in community-based settings.
• Specifies the process by which managed care plans or their subcontractors must structure the community review process,
• Exempts informing materials produced by the managed care plan prior to January 1, 2019, which are field tested by a minimum of four native speakers and meet the additional readability and suitability standards from the one-time community review
• Requires the managed care plans to report the findings of the community review process, and for DHCS to publish the findings of the community reviews and to develop recommendations for additional readability and suitability standards for each threshold language based on the findings.
• Defines terms, such as field tested, health education materials, informing materials, native speaker, and plans.
• Exempts the bill’s provisions from statements that are specifically required by law to be included in written materials.

Related Legislation:

• SB 1423 (Hernandez) modifies the minimum qualifications that an interpreter is required to possess to provide oral interpretation services to a limited English proficient beneficiary enrolled in either a managed care plan or a mental health plan. SB 1423 is pending consideration in the Assembly Appropriations Committee.
• SB 223 (Atkins, Chapter 771, Statutes of 2017) requires health plans, including Medi-Cal managed care plans and health insurers to include information about the availability of language assistance services, including oral interpretation services in the top 15 languages as determined by DHCS. Requires interpreters to meet specified requirements, requires specified disclosures to the public and Medi-Cal beneficiaries and applies these and existing Medi-Cal provisions on language assistance to Medi-Cal mental health plans.

Staff Comments: Proposition 30 of 2012 provides that any legislation enacted after September 30, 2012 that has an overall effect of increasing the costs already borne by a local agency for realigned services applies to local agencies only to the extent that the State provides annual funding for the cost increase. Local agencies are not be obligated to provide programs or levels of service required by legislation above the level for which funding has been provided.

To the extent that the requirements of this bill could increase county mental health service costs, the state could be obligated under Proposition 30 to reimburse those costs. Neither the state constitution or statute create a process for adjudicating issues where the state has increased county costs relating to a realigned program. To date, there is no case law on this issue. Therefore, it is not yet clear how this issue will be adjudicated, with respect to this bill or other bills that increase county costs.

According to the DHCS, the following positions would be needed to implement the bill’s provisions:

         2.0 permanent, full-time Health Education Consultants (HEC) III to oversee the review of all health education materials and need a strong background in the National Standards for Culturally and Linguistically Appropriate Services.

        1.0 full-time Health Program Specialist (HPS) II to manage managed care plan community review and public the findings of the community review process.

        4.0 permanent full-time Associate Governmental Program Analysts (AGPAs) for Dental Managed Care and mental health plans.

        3.0 one-year limited term Staff Services Manager I

        1.0 full-time, two-year limited term AGPA

        21.0 one-year limited term AGPAs. Staff notes hiring for one-year limited term positions are historically challenging and difficult to fill, if at all.

-- END --

SENATE COMMITTEE ON HEALTH

Senator Dr. Richard Pan, O.D., Chair

BILL NO: AB 2299

SUBJECT: Medi-Cal: managed care plans: informational materials.

SUMMARY:

Requires the Department of Health Care Services (DHCS) to ensure that all written health education and informing materials developed by Medi-Cal managed care plans in English or translated into threshold languages are at or below the equivalent of sixth grade reading level, except as specified. Requires DHCS to require Medi-Cal managed care plans or other contractors to conduct a one-time, targeted community review of health education and informing materials in English and each threshold language, in order for members to ensure the cultural and linguistic appropriateness of materials in community-based settings. Establishes requirements for the structure of the community review, and requires it to be completed by January 1, 2020. Requires Medi-Cal managed care plans or other contractors to conduct a targeted community review when new informing materials are created. Exempts specified documents from the community review requirement.

Existing law:

1. Establishes the Medi-Cal program, which is administered by the Department of Health Care Services (DHCS), under which qualified low-income individuals receive health care services. [WIC §14000, et seq.]
   
2. Requires, pursuant to federal regulation, each state, enrollment broker, and managed care plan entities to provide specified information to enrollees and potential enrollees in a manner and format that may be easily understood and is readily accessible by such enrollees and potential enrollees. [42 CFR §438.210]
   
3. Requires, pursuant to federal regulation, each to state to require each Medicaid managed care plan to make its written materials that are critical to obtaining services, including, at a minimum, provider directories, enrollee handbooks, appeal and grievance notices, and denial and termination notices, available in the prevalent non-English languages in its particular service area. [42 CFR §438.210]
   
4. Requires, pursuant to federal regulation, written materials to also be made available in alternative formats upon request of the potential enrollee or enrollee at no cost, and requires auxiliary aids and services to also be made available upon request of the potential enrollee or enrollee at no cost. [42 CFR §438.210]
   
5. Requires written materials to include taglines in the prevalent non-English languages in the state, as well as large print, explaining the availability of written translation or oral interpretation to understand the information provided and the toll-free and TTY/TDY telephone number of the Medicaid managed care plan’s member/customer service unit. Large print means printed in a font size no smaller than 18 point. [42 CFR §438.210]
   

This bill:
Reading level and suitability for written health education and informing documents in English

1. Requires DHCS to ensure that all written health education and informing materials developed by Medi-Cal managed care plans are at or below the equivalent of sixth grade reading level in English.
   
2. Requires written health education in English to meet the readability and suitability checklists established by DHCS by means of all-county letters, plan letters, including All Plan Letter (APL) 11-018, plan or provider bulletins, or similar instructions.
   
3. Requires written informing materials in English to meet the readability and suitability checklists established through DHCS contracts with Medi-Cal managed care plans.
   
4. Requires Medi-Cal managed care plans to adopt any additional readability and suitability standards developed by the community review process required by this bill and recommended by DHCS under this bill.

Reading level and suitability for written health education and informing documents in threshold languages

1. Requires DHCS to ensure that all written health education and informing materials translated into threshold languages by Medi-Cal managed care plans are at or below the equivalent of sixth grade reading level, except as specified in 7) below.

One-time targeted community review of health education and informing materials

1. Requires DHCS to require Medi-Cal managed care plans or other contractors to conduct a one-time, targeted community review of health education and informing materials in English and each threshold language, in order for members to ensure the cultural and linguistic appropriateness of materials in community-based settings.
   
2. Requires, for each threshold language for which an equivalent sixth grade reading level cannot be determined, DHCS to require managed care plans to establish a process for Medi-Cal beneficiaries, advocates, and stakeholders to review existing and new materials through the one-time community review, with sufficient time to provide meaningful feedback.
   
3. Requires this review to be completed by January 1, 2020, and requires Medi-Cal managed care plans to adopt any additional readability and suitability standards developed by the community review process described in this bill and recommended by DHCS under this bill by July 1, 2020.

Targeted community review for new informing materials

1. Requires Medi-Cal managed care plans or other contractors to conduct a targeted community review when new informing materials are created.
   
2. Permits Medi-Cal managed care plans to aggregate community reviews by threshold language, so as to not require separate reviews for each county served.

Requirements for community review process

1. Requires Medi-Cal managed care plans or other contractors to structure the community review process. Requires, when determining who participates in the community review process, the Medi-Cal managed care plans or other contractors to do all of the following:
   
2. Provide background information on plan members, including the ratio of threshold language speakers, and a summary of the plan’s current community review process;
3. Include current Medi-Cal beneficiaries and community-based organizations that work directly with Medi-Cal beneficiaries to identify and recruit beneficiaries; and,
4. Identify and include native speakers of a specific threshold language to review translated materials in their threshold language.
   
5. Requires outreach methods for participants in the community review process to include, but not be limited to, email, mail, and telephone calls.
   
6. Requires, when conducting the community review process, Medi-Cal managed care plans or other contractors to do all of the following:
   
7. Incorporate both quantitative and qualitative approaches, including focus groups and surveys with a minimum of four participants;
8. Allow 45 days for participants to provide feedback;
9. Have a native speaker of the threshold language assess, conduct, and evaluate the community review process and provide feedback; and,
10. Allow community feedback in both written and oral formats.

Exemptions from community review

1. Exempts health education materials produced by a third-party vendor, which have been field tested by a minimum of four native speakers and meet the additional readability and suitability standards developed under this bill from the community review requirements in this bill.
   
2. Exempts health education and informing materials produced by a Medi-Cal managed care plan prior to January 1, 2019, which are field tested by a minimum of four native speakers and meet the additional readability and suitability standards developed under this bill from the one-time community review. Requires any material that fails to meet subsequently adopted readability and suitability standards to be updated accordingly and reviewed under this bill.
   
3. Exempts health education and informing materials translated by DHCS from the community review requirement in this bill.
   
4. Exempts any informing material related to a requested service or grievance, including but not limited to, documents that explain the reason for denial of a requested service, that is produced for an individual beneficiary from the community review requirement and the field test standards in this bill. Requires plans to ensure that any informing materials related to a requested service or grievance, including but not limited to, a denial or service, to include, as may be relevant, language that has been reviewed in accordance with the one-time targeted community review under this bill, or field tested pursuant to this bill.
   
5. Exempts from the provisions of this bill statements that are specifically required by law to be included in written materials.

Reporting requirement for plans and for DHCS to publish findings and make recommendations

1. Requires Medi-Cal managed care plans to report the findings of the community review process, and requires DHCS to publish the findings of the community reviews and develop recommendations for additional readability and suitability standards based on the findings for each threshold language. Requires DHCS to also identify any differences between current English readability and suitability standards and the checklists established by DHCS under this bill.

Definitions under this bill

1. Defines, pursuant to this bill, health education materials, informing materials, native speaker and plan, as follows:
2. “Health education materials” as documents that are designed to assist members to modify personal health behaviors, achieve and maintain healthy lifestyles, and promote positive health outcomes, including updates on current health conditions, self-care, and management of health conditions, as detailed in the APL 11-018, or subsequently published letters, bulletins, or similar instructions. Health education materials include, but are not limited to, topics about preventive care, health promotion, screenings, disease management, healthy living, and health communications; and,
3. “Informing materials” as vital documents that provide members with essential information about access to and usage of plan services, as detailed in the APL 11-018, or subsequently published letters, bulletins, or similar instructions. Informing materials include, but are not limited to, all of the following:
   
   • 1. Enrollment and disenrollment forms and information;
     2. Evidence of coverage (EOC) booklets;
     3. Facility directories;
     4. Form letters;
     5. Information regarding members’ rights and grievance procedures;
     6. Insurance plan documents;
     7. New member welcome packets; and,
     8. Notices of action.
        
4. “Native speaker” as someone whose primary language is the language under review; and,
5. “Plan” as Medi-Cal managed care plans.

Legislative findings and declarations
21) Makes legislative finding and declarations that:

1. Low health literacy and low reading literacy are barriers to meaningful access and equal opportunity to fully participate in one’s health care services;
2. A significant number of Medi-Cal managed care plan members speak a language other than English as their primary language. In comparison to their English-speaking counterparts, limited-English-proficient (LEP) individuals are more likely to have low literacy levels or low health literacy, which leads to lower quality health care and poorer health care outcomes;
3. Informing materials provide essential information to members regarding their health care rights, plan benefits, and access to services. Using plain and simple language will increase the readability of materials, improving access for members with varying health literacy levels;
4. By applying reading level, readability, and suitability requirements to informing materials, DHCS can empower and help safeguard the health care rights of its most vulnerable members; and,
5. The individuals for whom plan documents are designed are best equipped to assess the cultural and linguistic suitability of the materials, and targeted community review is the most effective process to engage these consumers of particular cultural and linguistic groups.

FISCAL EFFECT:

According to the Assembly Appropriations Committee analysis:

1. Unknown, likely minor administrative cost pressure on Medi-Cal managed care plans (General Fund [GF]/federal).
2. Minor ongoing administrative costs to DHCS to verify plan compliance with the requirements and to publish findings of community reviews (GF/federal).

PRIOR VOTES:

COMMENTS:

1. Author’s statement. According to the author, language barriers could prevent individuals from accessing crucial services and health education information. For better health outcomes, we need to do better in providing information in English and other languages that is clear, easy to understand, and culturally appropriate. This bill will ensure that important documents in English and all the most commonly spoken languages are also readable and easy to comprehend for those receiving the documents.
   
2. Medi-Cal population and threshold languages. In a May 2014 Medi-Cal statistical brief on the frequency of threshold language speakers in the Medi-Cal population by county for December 2013, DHCS indicated the following:
   
   1. 40% of Medi-Cal beneficiaries statewide reported a language other than English as their primary language and met the statutory criteria for a threshold language population;
   2. Forty-nine of California’s 58 counties include the minimum number of Medi-Cal beneficiaries for meeting the threshold language definition (49 counties include English and Spanish);
   3. Thirteen distinct languages qualified as threshold languages (Spanish, Vietnamese, Cantonese, Armenian, Russian, Mandarin, Tagalog, Korean, Arabic, Hmong, Farsi, Cambodian and other Chinese);
   4. Spanish was the most frequently occurring, threshold language (34.5%) and was represented in the greatest number of counties (49), followed by Vietnamese (7 counties, 1.6%), Cantonese (five counties, 1.1%), Mandarin (four counties, 0.4%) and Tagalog (four counties, 0.3%); and,
   5. Los Angeles had the greatest number of threshold languages (12) of any county.

Translated materials must be provided in threshold languages, which are determined by population groups under existing law within the plan service area as determined by DHCS, as follows:

1. A population group of mandatory Medi-Cal beneficiaries residing in the Service Area who indicate their primary language as other than English, and that meet a numeric threshold of 3,000; or,
2. A population group of mandatory Medi-Cal beneficiaries residing in the Service Area who indicate their primary language as other than English and who meet the concentration standards of 1,000 in a single zip code or 1,500 in two contiguous zip codes.
3. Existing Medi-Cal readability and translation requirements. Federal Medicaid managed care regulations establish broad general requirements for readability (for example, requiring specific documents to be provided in a manner and format “that may be easily understood and is readily accessible”) and require written materials that are “critical to obtaining services, including, at a minimum, provider directories, enrollee handbooks, appeal and grievance notices, and denial and termination notices,” available in the prevalent non-English languages in its particular service area.
   
   This bill applies to two different types of documents: health education materials and informing materials and their reading level, suitability and translation. The existing specific provisions on translation, readability and suitability are currently in contractual language between DHCS and the plans, and in APLs or similar guidance issued by DHCS.
   
   This bill would place into state law some of the existing provisions from contracts and letters (such as the definitions of health education and informing materials and the use of a 6^th grade level for documents in English). In addition, this bill would establish new requirements, such as requiring the use of a checklist for informing materials (currently allowed for health education materials via all plan letter) and by placing into law a new one-time and on-going community review process (with exceptions), with specific detail on the review process, selection of individuals for the process, and timeframes for feedback.
   
4. Related legislation. SB 1423 (Hernandez) modifies the minimum qualifications that an interpreter is required to possess to provide oral interpretation services to a limited English proficient beneficiary enrolled in either a managed care plan or a mental health plan. SB 1423 is pending hearing in the Assembly Appropriations Committee.
   
5. Prior legislation. SB 223 (Atkins, Chapter 771, Statutes of 2017) requires health plans, including Medi-Cal managed care plans and health insurers to include information about the availability of language assistance services, including oral interpretation services in the top 15 languages as determined by DHCS. Requires interpreters to meet specified requirements, requires specified disclosures to the public and Medi-Cal beneficiaries and applies these and existing Medi-Cal provisions on language assistance to Medi-Cal mental health plans.
   
6. Support. This bill is jointly sponsored by Western Center on Law & Poverty and the Women’s Foundation of California – Women’s Policy Institute (WFC-WPI) to codify Medi-Cal readability standards for health education and informing materials in English for managed care plans, as well as establish a transparent and accountable process for determining readability in all threshold languages, including an initial community review of all consumer-facing materials. WFC-WPI writes, as health advocates, they work closely with diverse cultural and linguistic communities in cities such as Los Angeles, Santa Ana, Long Beach, and Oakland, and time and time again, they have encountered Medi-Cal beneficiaries that have trouble understanding their health plan materials and unaware of very crucial services, such as language assistance services and filing an appeal. It is critical to place the readability requirements into law, and apply these standards to both informing and health education material. By expanding upon the reading level mandate and codifying the readability requirements for both sets of materials, this bill will ensure all consumer-facing materials are able to be easily digested. Without the ability to thoroughly understand their health care documents, consumers are less equipped to properly navigate the health care system, which can lead to lower quality health care and poor health outcomes.
   
   In addition, the WFC-WPI writes that the establishment of a community review process for English and all other threshold languages is a crucial first step to evaluate the current state of consumer-facing materials. WFC-WPI states Medi-Cal managed care plans do not apply the same reading level and readability requirements to any consumer-facing materials after they are translated into threshold languages. For English materials, there is a readability and suitability checklist that is used to measure its effectiveness. However, it is difficult to standardize readability and suitability for all other threshold languages because there is such rich diversity in each of these languages. Therefore, a targeted community review is the most effective process to engage consumers and have them provide direct feedback on the readability and cultural relevance of translated materials. The establishment of a one-time community review is an essential next step in determining the best action and next steps for DHCS to take. It would establish an evidence base by which DHCS can adequately determine the cultural and linguistic appropriateness of existing health education and informing materials and is the ideal format for conducting the evaluation, as it enables consumers for whom the materials are designed to guide the process, and provide direct feedback and examples of the effectiveness of these materials.
   
7. Opposition. The California Association of Health Plans (CAHP) and the Local Health Plans of California (LHCP) write in opposition that this bill includes unnecessary, repetitive, and costly steps for documents already translated by health plans. CAHP and LHPC argue Medi-Cal managed care plans are currently required to provide health plan materials in a readability format which means the documents are written at or below sixth grade reading level. These requirements are contained in an APL and in the contracts between health plans and DHCS. In the new “boilerplate” contract with DHCS, both health education materials and informing materials are to be at or below a sixth grade reading level. The APL also already requires field testing of health educational materials. Codifying these requirements in statute will make it difficult to change and update the requirements if necessary.
   

CAHP and LHPC argue the bill’s requirement for plans to conduct a one-time, targeted “community review” of health education and informing materials in English and each language is extensive. This community review of existing health education and informing materials in English and threshold languages will require a significant expenditure of time and resources for materials that have already been translated appropriately. Opponents argue one of the unintended consequences of this bill would seriously impair the ability to deploy new materials to plan enrollees when outbreaks or disasters occur and a plan needs to convey new information in a timely manner to all of their enrollees because the plan informing materials would be required to go through the targeted community review prior to distribution. Additionally, CAHP and LHPC states the purpose of plan reporting on the community review process is unclear. CAHP and LHPC conclude this bill adds additional costs, will require additional state and plan resources, and offers no assurance that the community reviewed materials would be more effective for Medi-Cal members than the materials currently produced.

DHCS writes in opposition that it recognizes the importance of developing materials that inform beneficiaries about their health choices in such a way that those with low health and reading literacy are able to understand them. Because of this, DHCS writes that it already requires its managed care plans to provide materials to beneficiaries and members in an easily understood and readily accessible format. DHCS also requires its managed care plans to provide the delivery of services in a culturally competent manner, which includes the provision of documents at a sixth grade reading level and the use of readability and suitability checklists when reviewing English versions of health education materials. Furthermore, both existing federal and state law require DHCS to take reasonable steps to provide meaningful access to individuals with limited English proficiency, which includes providing language assistance services, including translated documents and oral interpretation, free of charge and in a timely manner. Though DHCS is supportive of the intent of AB 2299, given the existing efforts and requirements, it is not clear that AB 2299 is necessary. In addition, AB 2299 could prove to be extremely problematic, for reasons ranging from a lack of consensus on what is considered the appropriate reading level across languages and cultures, to how difficult it would be to attempt to hold a community-based process to review the tens of thousands of documents utilized by each managed care plan by January 1, 2019.

1. Definition of Medi-Cal managed care needed. Staff recommends an amendment to better define “plans” to make clear whether this bill is intended to apply to Denti-Cal managed care plans and county specialty mental health plans.

SUPPORT AND OPPOSITION:

Support: The Women’s Foundation of California - Women’s Policy Institute (co-sponsor)

Western Center on Law and Poverty (co-sponsor)

Asian Americans Advancing Justice – California

Asian Law Alliance

California Immigrant Policy Center

California Pan-Ethnic Health Network

Children Now

Children’s Defense Fund-California

Children’s Partnership

Disability Rights California

Disability Rights Education and Defense Fund

Having Our Say Coalition

Justice in Aging

National Health Law Program

Public Health Justice Collective

Santa Ana Building Healthy Communities

Oppose: California Association of Health Plans

Department of Health Care Services

Health Net

Local Health Plans of California

-- END --

ASSEMBLY THIRD READING

ATR Bill Id:AB 2299

Author:(Chu)

As Amended Ver:May 21, 2018

Majority vote

SUMMARY: Requires the Department of Health Care Services (DHCS) to ensure that all written health education and informing materials, as defined, in English and those translated into threshold languages by Medi-Cal managed care (MCMC) plans are at or below the equivalent of 6th grade reading level in English. Authorizes DHCS to require MCMC plans to establish a process, by January 1, 2020, for Medi-Cal beneficiaries, advocates, and stakeholders to review existing and new materials through a one-time community review, for each threshold language for which an equivalent sixth grade reading level cannot be determined, with sufficient time to provide meaningful feedback. Requires MCMC plans to report findings of the community review process to DHCS. Requires DHCS to publish the findings of the community reviews and to develop recommendations for additional readability and sustainability standards based on these findings. Requires MCMC plans to adopt any additional readability and suitability standards, as developed by the community review process, and recommended by the Department of Health Care Services, as described, by July 1, 2020. Exempts certain health education and information materials, which are field tested, as specified, from the community review requirements.

FISCAL EFFECT: According to the Assembly Appropriations Committee,

1. Unknown, likely minor administrative cost pressure on MCMC plans (General Fund (GF)/federal).
2. Minor ongoing administrative costs to DHCS to verify plan compliance with the requirements and to publish findings of community reviews (GF/federal).

COMMENTS: According to the author, language barriers could prevent individuals from accessing essential healthcare services and health education information. In order to improve healthcare outcomes among Medi-Cal members that are non-native English speakers, we need to strengthen existing requirements for both health education and informing materials in English and threshold languages. Often times, professionally translated materials are not culturally sensitive to ethnically and linguistically diverse Medi-Cal populations. The community review is the ideal format for conducting the evaluation, enabling consumers for whom the materials are designed to guide the process. This bill will ensure that Medi-Cal members have access to important documents in English and in their preferred language that is clear, easy to understand, and culturally appropriate.

According to a 2016 DHCS Medi-Cal Statistical Brief, more than one-in-three MCMC plan members self-identify as a non-native English speaker. Additionally a study published by the Journal of Health Education states that individuals with both limited English proficiency (LEP) and low health literacy are at high risk for poor health. LEP may carry greater health risk than those with low health literacy, though important racial/ethnic variations exist. The study found that low health literacy was prevalent among Californians with LEP, although prevalence varied widely by racial/ethnic group. Individuals with both LEP and low health literacy comprise a particularly vulnerable group, with high prevalence of poor health status. Although the relationship of low health literacy and LEP to health status varied by racial/ethnic group, it appears that having LEP alone may carry a greater health risk than low health literacy alone.

While there are existing California requirements that mirror federal standards on readability for health educational materials in English and other threshold languages, Medi-Cal Managed Care Divisions All Plan Letter (APL) 11-018 standards do not apply to informing documents. This bill codifies the provisions of the APL as described below, applies these provisions to informing documents, and requires a community review of health education and informing materials in English and each threshold language.

1. Existing DHCS practice. According to DHCS, MCMC plan contracts already require that all written materials (both member informing and health education) be provided to Medi-Cal members at a sixth grade reading level.

Currently, MCMC plans are required to assess the reading level of all English versions of member informing and health education materials, and after the material is approved in English, it is translated into other threshold languages. MCMC plans use many methods to review translations; focusing on making sure the material is culturally and linguistically appropriate and easily understood by members. MCMC plans use readability software to determine the grade level of each health education material. Currently this type of software is only readily available for English, although at least one company now has software for Spanish language materials. There are additional software tools that assist with improving the readability of documents but they are not accepted as the standard for the industry.

1. DHCS APL 11-018. A 2011 APL provided information to MCMC plans regarding requirements for the readability and suitability of health education materials. DHCS contracts with MCMC plans require plans to submit all written member information materials for approval. The APL, instead, allows MCMC plans to use written member health education materials without DHCS approval, so long as the provisions in the APL are met. The APL only applies to written health education materials for MCMC plans and does not apply to informing materials. The APL notes that Health education materials are designed to assist members to modify personal health behaviors, achieve and maintain healthy lifestyles, and promote positive health outcomes, including updates on current health conditions, self-care, and management of health conditions. Topics may include messages about preventive care, health promotion, screenings, disease management, healthy living, and health communications. Informing materials are vital documents that provide members with essential information about access to and usage of plan services. Evidence of coverage booklets, enrollment, and disenrollment forms/information, member rights and grievance information, new member welcome packets, provider directories, and facility directories are examples of informing materials.

Western Center on Law and Poverty, a cosponsor of this bill, states that all Medi-Cal beneficiaries, whether speakers of English or another language should be able to understand the materials that are sent to them.

The Women's Foundation of California – Women's Policy Institute, a cosponsor of this bill, states in support that to ensure cultural and linguistic readability for Medi-Cal members is to increase members' health access and agency, and provide accountability for the processes that individuals receive.

The California Association of Health Plans (CAHP) writes in opposition and contends that this bill is unnecessary, repetitive and costly for documents already translated by health plans. CAHP states that an unintended consequence of this bill could impair the ability to deploy new materials to enrollees when outbreaks or disasters occur.

Analysis Prepared by: Kristene Mapile / HEALTH / (916) 319-2097 FN: 0002985

ASSEMBLY THIRD READING

ATR Bill Id:AB 2299

Author:(Chu)

As Amended Ver:April 23, 2018

Majority vote

SUMMARY: Requires the Department of Health Care Services (DHCS) to ensure that all written health education and informing materials, as defined, in English and those translated into threshold languages by Medi-Cal managed care (MCMC) plans are at or below the equivalent of 6th grade reading level in English. Authorizes DHCS to require MCMC plans to establish a process for Medi-Cal beneficiaries, advocates, and stakeholders to review existing and new materials through a one-time community review, for each threshold language for which an equivalent sixth grade reading level cannot be determined, with sufficient time to provide meaningful feedback. Requires MCMC plans to report findings of the community review process to DHCS. Requires DHCS to publish the findings of the community reviews and to develop recommendations for additional readability and sustainability standards based on these findings.

FISCAL EFFECT: According to the Assembly Appropriations Committee,

1. Unknown, likely minor administrative cost pressure on MCMC plans (General Fund (GF)/federal).
2. Minor ongoing administrative costs to DHCS to verify plan compliance with the requirements and to publish findings of community reviews (GF/federal).

COMMENTS: According to the author, language barriers could prevent individuals from accessing essential healthcare services and health education information. In order to improve healthcare outcomes among Medi-Cal members that are non-native English speakers, we need to strengthen existing requirements for both health education and informing materials in English and threshold languages. Often times, professionally translated materials are not culturally sensitive to ethnically and linguistically diverse Medi-Cal populations. The community review is the ideal format for conducting the evaluation, enabling consumers for whom the materials are designed to guide the process. This bill will ensure that Medi-Cal members have access to important documents in English and in their preferred language that is clear, easy to understand, and culturally appropriate.

According to a 2016 DHCS Medi-Cal Statistical Brief, more than one-in-three MCMC plan members self-identify as a non-native English speaker. Additionally a study published by the Journal of Health Education states that individuals with both limited English proficiency (LEP) and low health literacy are at high risk for poor health. LEP may carry greater health risk than those with low health literacy, though important racial/ethnic variations exist. The study found that low health literacy was prevalent among Californians with LEP, although prevalence varied widely by racial/ethnic group. Individuals with both LEP and low health literacy comprise a particularly vulnerable group, with high prevalence of poor health status. Although the relationship of low health literacy and LEP to health status varied by racial/ethnic group, it appears that having LEP alone may carry a greater health risk than low health literacy alone.

While there are existing California requirements that mirror federal standards on readability for health educational materials in English and other threshold languages, Medi-Cal Managed Care Divisions All Plan Letter (APL) 11-018 standards do not apply to informing documents. This bill codifies the provisions of the APL as described below, applies these provisions to informing documents, and requires a community review of health education and informing materials in English and each threshold language.

1. Existing DHCS practice. According to DHCS, MCMC plan contracts already require that all written materials (both member informing and health education) be provided to Medi-Cal members at a sixth grade reading level.

Currently, MCMC plans are required to assess the reading level of all English versions of member informing and health education materials, and after the material is approved in English, it is translated into other threshold languages. MCMC plans use many methods to review translations; focusing on making sure the material is culturally and linguistically appropriate and easily understood by members. MCMC plans use readability software to determine the grade level of each health education material. Currently this type of software is only readily available for English, although at least one company now has software for Spanish language materials. There are additional software tools that assist with improving the readability of documents but they are not accepted as the standard for the industry.

1. DHCS APL 11-018. A 2011 APL provided information to MCMC plans regarding requirements for the readability and suitability of health education materials. DHCS contracts with MCMC plans require plans to submit all written member information materials for approval. The APL, instead, allows MCMC plans to use written member health education materials without DHCS approval, so long as the provisions in the APL are met. The APL only applies to written health education materials for MCMC plans and does not apply to informing materials. The APL notes that Health education materials are designed to assist members to modify personal health behaviors, achieve and maintain healthy lifestyles, and promote positive health outcomes, including updates on current health conditions, self-care, and management of health conditions. Topics may include messages about preventive care, health promotion, screenings, disease management, healthy living, and health communications. Informing materials are vital documents that provide members with essential information about access to and usage of plan services. Evidence of coverage booklets, enrollment, and disenrollment forms/information, member rights and grievance information, new member welcome packets, provider directories, and facility directories are examples of informing materials.

Western Center on Law and Poverty, a cosponsor of this bill, states that all Medi-Cal beneficiaries, whether speakers of English or another language should be able to understand the materials that are sent to them.

The Women's Foundation of California – Women's Policy Institute, a cosponsor of this bill, states in support that to ensure cultural and linguistic readability for Medi-Cal members is to increase members’ health access and agency, and provide accountability for the processes that individuals receive.

The California Association of Health Plans (CAHP) writes in opposition and contends that this bill is unnecessary, repetitive and costly for documents already translated by health plans. CAHP states that an unintended consequence of this bill could impair the ability to deploy new materials to enrollees when outbreaks or disasters occur.

Analysis Prepared by: Kristene Mapile / HEALTH / (916) 319-2097 FN: 0002977

Date of Hearing: May 16, 2018

ASSEMBLY COMMITTEE ON APPROPRIATIONS

Lorena Gonzalez Fletcher, Chair

ABPCA Bill Id:AB 2299

Author:(Chu) – As Amended Ver:April 23, 2018

Urgency: No State Mandated Local Program: No Reimbursable: No

SUMMARY:

This bill establishes linguistic and readability standards for written materials developed by Medi-Cal managed care plans. Specifically, this bill:

1. Requires the Department of Health Care Services (DHCS) to ensure all written health education and informing materials developed by managed care plans are at or below a 6^th grade reading level and measured and available in all threshold languages.
2. Requires plans to conduct a one-time community review of all health education and informing materials, and specifies standards for the review.
3. Requires plans to report the findings of the community review process to DHCS. Requires DHCS to publish findings and recommend additional readability and suitability standards based on the findings.

FISCAL EFFECT:

1. Unknown, likely minor administrative cost pressure on Medi-Cal managed care health plans (GF/federal).
2. Minor ongoing administrative costs to DHCS to verify plan compliance with the requirements and to publish findings of community reviews (GF/federal).

COMMENTS:

1. Purpose. According to the author, language barriers prevent individuals from accessing essential healthcare services and health education information. In order to improve healthcare outcomes among Medi-Cal members that are non-native English speakers, this bill seeks to strengthen existing requirements for both health education and informing materials in English and threshold languages.
2. Background. According to DHCS, persons with limited English proficiency and non-English speakers encounter a myriad of linguistic challenges that may increase difficulty accessing care. More than a third of Medi-Cal managed care enrollees self-identify as a non-native English speaker. Current law requires Medi-Cal documents to be translated into "threshold languages"— a language identified as the primary language of 3,000 beneficiaries or five % of the beneficiary population, whichever is lower, in an identified geographic area.

Managed care contracts already require all written materials (both informing and health education) be provided to Medi-Cal members at or below a 6th grade reading level. This bill codifies provisions of current guidance and regulations, applies these provisions to informing documents, and requires a community review of health education and informing materials in English and each threshold language.

1. Staff Comment. This bill could be clarified to specify how plans offered in multiple counties must comply with the bill—for instance, it could be clarified whether a community review is required in each county when the same threshold language is used in multiple counties.

Analysis Prepared by: Lisa Murawski / APPR. / (916) 319-2081

Date of Hearing: April 17, 2018

ASSEMBLY COMMITTEE ON HEALTH

Jim Wood, Chair

ABPCA Bill Id:AB 2299

Author:(Chu) – As Amended Ver:April 10, 2018

SUBJECT: Medi-Cal: managed care plans: informational materials.

SUMMARY: Requires the Department of Health Care Services (DHCS) to ensure that all written health education and informing materials, as defined, in English and those translated into threshold languages by Medi-Cal managed care (MCMC) plans are at or below the equivalent of 6th grade reading level in English. Specifically, this bill:

1. Requires DHCS to ensure that all written health education and informing materials developed by MCMC plans are at or below the equivalent of a sixth grade reading level in English.
2. Requires written health education in English to meet the readability and suitability checklists established by Medi-Cal Managed Care Divisions All Plan Letter 11-018 (APL 11-018).
3. Requires written informing materials in English to meet the readability and suitability checklists established through the DHCS’ contracts with MCMC plans.
4. Requires MCMC plans to adopt any additional readability and suitability standards developed in English by the community review process described in 8) below and recommended by DHCS in 9) below.
5. Requires DHCS to ensure that all written health education and informing materials in English and those translated into threshold languages by MCMC plans are at or below the equivalent of a sixth grade reading level.
6. Authorizes DHCS to require MCMC plans to establish a process for Medi-Cal beneficiaries, advocates, and stakeholders to review existing and new materials through a one-time community review described in 9) below, for each threshold languages for which an equivalent sixth grade reading level cannot be determined, with sufficient time to provide meaningful feedback.
7. Requires MCMC plans to adopt any additional readability and suitability standards developed for translated threshold languages by the community review process described in 8) below and recommended by DHCS in 9) below.
8. Authorizes DHCS to require MCMC plans or other contractors to conduct a one-time, targeted community review of health education and informing materials in English and each threshold language, in order for members to ensure the cultural and linguistic appropriateness of materials in community-based settings. Requires MCMC plans or other contractors to structure the community review process, as follows:
   1. Requires the MCMC plans or other contractors to do all of the following when determining who shall participate in the community review process:
      1. Provide background information on plan members, as specified;
      2. Include current Medi-Cal beneficiaries and/or community based organizations, as specified; and,
      3. Identify and include native speakers of the specific threshold language to review, as specified, and prohibits software from being used in lieu of a native speaker to evaluate consumer-facing materials.
   2. Requires outreach methods to include, but are not limited to, e-mail, mail, and telephone calls;
   3. Requires MCMC plans or other contractors to do all of the following when conducting the community review process:
      1. Incorporate both quantitative and qualitative approaches, as specified;
      2. Allow 60 days for participant feedback;
      3. Have a native speaker of the threshold language assess, conduct, and evaluate the community review process and provide feedback; and,
      4. Allow community feedback in both written and oral formats.
   4. Requires MCMC plans or other contractors to conduct a targeted community review when new informing materials are created.
9. Requires MCMC plans to report findings of the community review process to DHCS. Requires DHCS to publish the findings of the community reviews and to develop recommendations for additional readability and sustainability standards based on these findings.
10. Defines health education materials as documents that are designed to assist members, as specified and as detailed in APL 11-018, and includes, but is not limited to, topics about preventive care, health promotion, screenings, disease management, healthy living, and health communications.
11. Defines informing materials as vital documents that provide members with essential information about access to and usage of plan services, as detailed in APL 11-018, and includes, but is not limited to, all of the following:
    1. Enrollment and disenrollment forms and information;
    2. Evidence of coverage booklets;
    3. Facility directories;
    4. Form letters;
    5. Information regarding members’ rights and grievance procedures;
    6. Insurance plan documents;
    7. New member welcome packets; and
    8. Notices of action.
12. Provides that the requirements of this bill do not apply to statements that are specifically required by law to be included in written materials.
13. Makes the following findings and declarations:
    1. Low health literacy and low reading literacy are barriers to meaningful access and equal opportunity to fully participate in one’s health care services.
    2. A significant number of MCMC plan members speak a language other than English as their primary language and in comparison to their English-speaking counterparts.
    3. Informing materials provide essential information to members regarding their health care rights, plan benefits, and access to services.
    4. By applying reading level, readability, and suitability requirements to informing materials, DHCS can empower and help safeguard the health care rights of its most vulnerable members.
    5. The individuals for whom plan documents are designed are best equipped to assess the cultural and linguistic suitability of the materials. Targeted community review is the most effective process to engage these consumers of particular cultural and linguistic groups.

EXISTING LAW:

1. Establishes the Medi-Cal program, administered by DHCS, under which qualified low-income individuals receive health care services.
2. Prohibits, pursuant to the federal Patient Protection and Affordable Care Act (ACA), discrimination on the basis of race, color, national origin, sex, age, or disability in certain health programs and activities. Prohibits an individual from being excluded from participating in any federally funded or administered health program or activity except as permitted under the health insurance reforms of the ACA.
3. Prohibits discrimination based on ancestry, age, color, disability, genetic information, gender, gender identity and gender expression, marital status, medical condition, national origin (includes language use restrictions), race, religion, sex, or sexual orientation in any program or activity operated or administered by a state agency.
4. Provides increased federal matching funding for translation and interpretation services provided in connection with the enrollment, retention, and use of services under Medicaid (Medi-Cal in California).
5. Requires MCMC plans to provide language assistance services to limited English-proficient (LEP) Medi-Cal beneficiaries. Requires, in federal law, recipients of Federal financial assistance to take reasonable steps to make their programs, services, and activities by eligible persons with limited English proficiency.
6. Establishes the Department of Managed Health Care (DMHC) to regulate health plans and the California Department of Insurance (CDI) to regulate health insurers.
7. Requires health plans and insurers to have notices advising LEP individuals of the availability of free language assistance and other outreach materials that are provided to enrollees and insureds.
8. Requires health plans to assess their members language preference and provide interpretation and translation services in threshold languages.
9. Requires DMHC to develop and adopt regulations to ensure that enrollees have access to health care services in a timely manner and consider the following as indicators of timeliness of access to care:
   1. Waiting times for appointments with physicians, including primary care and specialty physicians;
   2. Timeliness of care in an episode of illness, including the timeliness of referrals and obtaining other services, if needed; and,
   3. Waiting time to speak to a physician, registered nurse, or other qualified health professional acting within his or her scope of practice who is trained to screen or triage an enrollee who may need care.
10. Requires DMHC, in developing these timely access standards, to consider clinical appropriateness, the nature of the specialty, the urgency of care, and the requirements of other provisions of law, including provisions governing utilization review that may affect timeliness of access.
11. Requires DMHC to develop and adopt regulations establishing standards and requirements to provide health plan enrollees with appropriate access to language assistance in obtaining health care services, including that health plans have notices advising LEP persons of the availability of free language assistance and other outreach materials that are provided to enrollees. Requires, pursuant to regulations, the health plan to describe the process of including the notice with all vital documents, all enrollment materials and all correspondence, if any, from the plan confirming a new or renewed enrollment, and the process of including statements, in English and in threshold languages, about the availability of free language assistance services and how to access them, in or with brochures, newsletters, outreach and marketing materials, and other materials that are routinely disseminated to the plan’s enrollees.
12. Requires CDI to promulgate regulations to ensure that insureds have the opportunity to access needed health care services in a timely manner and ensure adequacy of the number and locations of facilities and providers and consider the regulations adopted by DMHC.
13. Requires CDI to promulgate regulations applicable to all individual and group policies of health insurance establishing standards and requirements to provide insureds with appropriate access to translated materials and language assistance in obtaining covered benefits, including notices advising LEP persons of the availability of free language assistance and other outreach materials that are provided to insureds. Specifies, pursuant to CDI regulations, the notice to be included in all welcome and renewal packets, letters, correspondence, brochures, newsletters, outreach and marketing materials, and any other materials sent to insureds.

FISCAL EFFECT: This bill has not yet been analyzed by a fiscal committee.

COMMENTS:

1. PURPOSE OF THIS BILL. According to the author, language barriers could prevent individuals from accessing essential healthcare services and health education information. In order to improve healthcare outcomes among Medi-Cal members that are non-native English speakers, we need to strengthen existing requirements for both health education and informing materials in English and threshold languages. Often times, professionally translated materials are not culturally sensitive to ethnically and linguistically diverse Medi-Cal populations. The community review is the ideal format for conducting the evaluation, enabling consumers for whom the materials are designed for to guide the process. This bill will ensure that Medi-Cal members have access to important documents in English and in their preferred language that is clear, easy to understand, and culturally appropriate.
2. BACKGROUND. According to a 2016 DHCS Medi-Cal Statistical Brief, more than one-in-three MCMC plan members self-identify as a non-native English speaker. Additionally a study published by the Journal of Health Education states that individuals with both LEP and low health literacy are at high risk for poor health. LEP may carry greater health risk than those with low health literacy, though important racial/ethnic variations exist. The study found that low health literacy was prevalent among Californians with LEP, although prevalence varied widely by racial/ethnic group. Individuals with both LEP and low health literacy comprise a particularly vulnerable group, with high prevalence of poor health status. Although the relationship of low health literacy and LEP to health status varied by racial/ethnic group, it appears that having LEP alone may carry a greater health risk than low health literacy alone.

While there are existing California requirements that mirror federal standards on readability for health educational materials in English and other threshold languages, APL 11-018 standards do not apply to informing documents. This bill codifies the provisions of the APL as described below, applies these provisions to informing documents, and requires a community review of health education and informing materials in English and each threshold language.

• 1. Existing DHCS practice. According to DHCS, MCMC plan contracts already requires that all written materials (both member informing and health education) be provided to Medi-Cal members at a sixth grade reading level.

Currently, MCMC plans are required to assess the reading level of all English versions of member informing and health education materials, and after the material is approved in English, it is translated into other threshold languages. MCMC plans use many methods to review translations; focusing on making sure the material is culturally and linguistically appropriate and easily understood by members. MCMC plans use readability software to determine the grade level of each health education material. Currently this type of software is only readily available for English, although at least one company now has software for Spanish language materials. There are additional software tools that assist with improving the readability of documents but they are not accepted as the standard for the industry. 

• 1. DHCS APL 11-018. A 2011 APL provided information to MCMC plans regarding requirements for the readability and suitability of health education materials. DHCS contracts with MCMC plans require plans to submit all written member information materials for approval. The APL, instead, allows MCMC plans to use written member health education materials without DHCS approval, so long as the provisions in the APL are met. The APL only applies to written health education materials for MCMC plans and does not apply to informing materials. The APL notes that Health education materials are designed to assist members to modify personal health behaviors, achieve and maintain healthy lifestyles, and promote positive health outcomes, including updates on current health conditions, self-care, and management of health conditions. Topics may include messages about preventive care, health promotion, screenings, disease management, healthy living, and health communications. Informing materials are vital documents that provide members with essential information about access to and usage of plan services. Evidence of coverage booklets, enrollment, and disenrollment forms/information, member rights and grievance information, new member welcome packets, provider directories, and facility directories are examples of informing materials.

1. SUPPORT. Western Center on Law and Poverty, a cosponsor of this bill, states that all Medi-Cal beneficiaries, whether speakers of English or another language should be able to understand the materials that are sent to them.

The Women’s Foundation of California - Women’s Policy Institute states in support that to ensure cultural and linguistic readability for Medi-Cal members is to increase members’ health access and agency, and provide accountability for the processes that individuals receive.

1. OPPOSITION. The California Association of Health Plans (CAHP) writes In opposition and contends that this bill is unnecessary, repetitive and costly steps for documents already translated by health plans. CAHP states that an unintended consequence of this bill could impair the ability to deploy new materials to enrollees when outbreaks or disasters occur.
2. RELATED LEGISLATION. SB 1423 (Hernandez) modifies the minimum qualifications that an interpreter is required to possess to provide oral interpretation services to an LEP beneficiary enrolled in either a managed care plan or a mental health plan. SB 1423 is pending with Senate Rules Committee.
3. PREVIOUS LEGISLATION. SB 223 (Atkins), Chapter 771, Statutes of 2017, requires health plans, including MCMC plans and health insurers to include information about the availability of language assistance services, including oral interpretation services in the top 15 languages as determined by DHCS. Requires interpreters to meet specified requirements, requires specified disclosures to the public and Medi-Cal beneficiaries and applies these and existing Medi-Cal provisions on language assistance to Medi-Cal mental health plans.
4. POLICY COMMENTS.
   1. This bill’s provisions regarding a community based review appears to apply to all health education and informing materials in English and each threshold language, as specified. As this bill moves forward, the author may wish to consider addressing standardized documents and whether or not every MCMC plan needs to include these documents as part of its review.
   2. This bill also requires a one-time community review of existing and new materials. The author may wish to consider how the MCMC plan will address materials that are developed after the one-time community review.
   3. This bill also requires DHCS to ensure that all written health education and informing materials, as defined, translated into threshold languages by MCMC plans, are at or below the equivalent of 6th grade reading level in English. As this bill moves forward, the author may wish to include as part of the community base review, feedback from participants regarding the appropriateness of this reading level.
5. SUGGESTED AMENDMENTS. This bill currently references APL 11-018 in statutes, the author may wish to amend to allow for subsequent APLs on this issue.

REGISTERED SUPPORT / OPPOSITION:

Support

Western Center on Law and Poverty (cosponsor)

The Women’s Foundation of California - Women’s Policy Institute (cosponsor)

Asian Americans Advancing Justice – California

California Pan-Ethnic Health Network

Consumers Union

Dayle McIntosh Center

Having Our Say Coalition

Health Access California

International Rescue Committee

Justice in Aging

Mi Familia Vota

National Association of Social Workers, California Chapter

National Health Law Program

Native Interpreting

Partnership for the Advancement of New Americans

Santa Ana Building Healthy Communities

San Francisco Senior & Disability Action

Services, Immigrant Rights, and Education Network

Opposition

California Association of Health Plans

Analysis Prepared by: Kristene Mapile / HEALTH / (916) 319-2097