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GAO-09-752R:
United States Government Accountability Office:
Washington, DC 20548:
July 30, 2009:
The Honorable Nydia M. Velázquez:
Chairwoman:
Committee on Small Business:
House of Representatives:
Subject: Centers for Medicare & Medicaid Services: CMS Should Develop
an Agencywide Policy for Translating Medicare Documents into Languages
Other Than English:
Dear Chairwoman Velázquez:
The Department of Health and Human Services' (HHS) Centers for Medicare
& Medicaid Services (CMS) is the federal agency responsible for
administering the Medicare program for nearly 45 million beneficiaries,
including beneficiaries with limited English proficiency (LEP)--
meaning they may not be proficient or are limited in their ability to
communicate in the English language. Medicare beneficiaries face a
complex set of health care choices that require them to obtain
information about the comparative benefits, costs, and quality of
available options. CMS is responsible for providing clear, accurate,
and timely information about this program and making the information
accessible to beneficiaries.
Under section 601 of Title VI of the Civil Rights Act of 1964, entities
that receive federal financial assistance are prohibited from
discriminating against or otherwise excluding individuals from their
programs or activities on the basis of race, color, or national origin.
[Footnote 1] In 1964, as directed under section 602 of Title VI, HHS
first published regulations applying these prohibitions to entities
receiving federal financial assistance from HHS, including health care
organizations.[Footnote 2] In 2000, Executive Order 13166 was
published, requiring federal agencies to take certain steps to clarify
Title VI requirements.[Footnote 3] Specifically, this order required
federal agencies to publish guidance addressing how their recipients of
federal financial assistance can provide LEP individuals meaningful
access to programs and activities that recipients normally provide in
English, and thus do not discriminate on the basis of national origin
in violation of Title VI and implementing regulations. As a result, HHS
published guidance, which clarified these responsibilities for all
recipients of federal financial assistance from HHS.[Footnote 4] This
guidance provides a method of analysis for providers to use in
determining the extent to which oral and written language assistance
services for LEP individuals is needed, if any, in order to comply with
Title VI and the implementing regulations.[Footnote 5]
Executive Order 13166 also required federal departments and agencies,
including HHS, to examine the services they provide and prepare a plan
identifying the steps they will take to provide LEP individuals with
meaningful access to the agencies' programs and activities.
Accordingly, HHS developed an LEP strategic plan that identified the
steps the department and its agencies, including CMS, intended to take
to help ensure timely access to language assistance services by
eligible LEP beneficiaries to their programs and activities.[Footnote
6] For example, the plan includes elements related to providing oral
language assistance and written translations of vital program documents
in languages other than English where there are significant numbers of
LEP beneficiaries. The plan also indicates that HHS agencies will
strive to implement written policies and procedures related to plan
elements, including written translations of program documents.
As immigration patterns have changed and more languages are spoken in
the United States, some providers have reported that the cost burden
for providing language services to LEP beneficiaries--such as
translating documents into additional languages and providing
interpreters--has increased as well. While recognizing that health care
providers receiving federal financial assistance have certain
responsibilities under Title VI and implementing regulations, some
organizations representing them and organizations interested in LEP
issues have requested CMS to do more to ease the burden providers face
in communicating with beneficiaries with LEP, such as translating
Medicare documents into additional languages.
You asked us to review CMS's language access policies, efforts to
translate Medicare documents, and the challenges health care providers
face in communicating with LEP beneficiaries. In this correspondence,
we (1) examine the extent to which CMS translates Medicare documents
into languages other than English and (2) describe the challenges
health care providers may face in communicating with LEP beneficiaries,
including translating Medicare and other documents.
Scope and Methodology:
To determine the extent that CMS translates Medicare documents into
languages other than English, we first reviewed Executive Order 13166
and the LEP Strategic Plan developed by HHS, and interviewed staff from
the HHS Office for Civil Rights. To identify CMS's specific language
access policies, we interviewed officials from various components
within CMS, including the Office of External Affairs--in particular the
Creative Services Group and the Partner Relations Group--and the Center
for Drug and Health Plan Choice. To identify Medicare documents that
are directed to beneficiaries and include key program information, we
interviewed officials from CMS and provider organizations; reviewed
available lists of Medicare documents compiled by CMS, the American
Hospital Association (AHA), and the National Health Law Program
(NHeLP); and reviewed documents available on CMS's Web sites, including
[hyperlink, http://www.cms.hhs.gov] and [hyperlink,
http://www.medicare.gov], between January 2009 and April 2009. Using
these sources, we identified 134 Medicare documents. The 134 documents
we identified only include documents such as forms, notices, and
publications that CMS created and may be used by beneficiaries. We
specifically did not include documents that CMS considers model
notices, which are produced by CMS and contain CMS-approved language
that may be modified and used by providers or other entities. To
determine the extent to which these documents were translated into
languages other than English, we first identified the CMS components
responsible for each of the 134 documents. We then interviewed each
component to determine which documents it translated into other
languages and the rationale for the translation decisions.
To confirm that documents identified were translated and to assess the
availability of those documents, we conducted an Internet search of
CMS's Web sites between September 2008 and June 2009.
To identify current language access policies or practices employed by
health care providers and the challenges these providers encountered in
communicating with LEP individuals, including translating Medicare and
other documents, we reviewed reports, surveys, and letters, and
interviewed officials of health care provider organizations--AHA, the
American Medical Association (AMA), the National Association of
Community Health Centers (NACHC), and the National Association of
Public Hospitals and Health Systems. Further, we interviewed officials
at the Joint Commission about their ongoing revision to the hospital
accreditation standards to include standards for culturally competent
patient-centered care. Similarly, we reviewed reports and surveys and
interviewed officials of organizations interested in LEP issues,
including NHeLP and the National Senior Citizens Law Center (NSCLC). We
also interviewed representatives from the Asian American Pacific Island
Health Forum (AAPIHF), the AARP Public Policy Institute, the National
Federation of Independent Businesses, and the National Academy of
Social Insurance. In addition, we convened a focus group, which was
facilitated by an organization called "Out of Many, One" to discuss
challenges providers face in communicating with LEP beneficiaries. The
focus group was comprised of representatives of several additional
organizations, including New York Lawyers for the Public Interest,
National Partnership for Women and Families, Summit Health Institute
for Research and Education, La Fe Policy Research and Education Center,
Office of the Governor of Puerto Rico, Southeast Asia Resource Action
Center, California Pan-Ethnic Health Network, National Council of La
Raza, National Association of State Offices of Minority Health, and
Brookings. To provide examples of the challenges health care providers
experience, we also interviewed four officials representing different
types of health care providers. We interviewed the chief executive
officers of an oncology practice and a community health center and
spoke with officials representing two health care systems. To further
understand the complexities involved with translating Medicare
documents into languages other than English, we consulted with a number
of translators who were certified by the American Translators
Association (ATA) and had experience in translating medical documents.
Further, we interviewed organizations representing providers and groups
interested in LEP issues to understand the extent to which these groups
were involved in the development of CMS's language access policies.
We undertook this performance audit from September 2008 to July 2009 in
accordance with generally accepted government auditing standards. Those
standards require that we plan and perform the audit to obtain
sufficient, appropriate evidence to provide a reasonable basis for our
findings and conclusions based on our audit objectives. We believe that
the evidence obtained provides a reasonable basis for our findings and
conclusions based on our audit objectives.
Results in Brief:
In summary, CMS components translated 87 percent of the 134 Medicare
documents we identified into Spanish and, to a limited extent, other
languages, including Chinese, Korean, and Vietnamese. The translated
documents provide information about the Medicare program, specific
health care conditions, and information specific to an individual
beneficiary's Medicare coverage. For example, CMS translated into
Spanish Medicare & You, a handbook that is sent to all Medicare
beneficiaries every year, which summarizes program benefits and
beneficiaries' rights and protections, and answers the most frequently
asked questions about the program. CMS officials we interviewed were
unaware of any agencywide translation policy related to Medicare
documents, echoing findings from a prior GAO report that identified
shortcomings in CMS's implementation of HHS's LEP plan.[Footnote 7]
Because of the absence of an agencywide translation policy, the extent
to which Medicare documents were translated depended entirely on
decisions made by individual CMS components. For example, the Office of
External Affairs and the Center for Drug and Health Plan Choice--the
two CMS components that translated the majority of the documents into
Spanish--did so because it is the most common language spoken by LEP
Medicare beneficiaries. The roughly 13 percent of documents that were
not translated by CMS varied in terms of their content. Some were
templated forms or notices that require health care providers to add
beneficiary-specific information, including information related to
benefit exclusions or changes to the beneficiary's portion of costs. In
addition, some documents that were not translated contain information
about how to manage certain health conditions or the Medicare program-
-information similar to what is included in other documents that CMS
translated into Spanish. In response to our recommendation in the 1-
800-MEDICARE report, CMS recently appointed an individual in its Office
of Equal Opportunity and Civil Rights (OEOCR) to develop an LEP plan,
but this plan is still in development, and agency officials have not
informed us how their LEP plan will address the translation of written
materials. Without an agencywide policy, there is no guarantee that CMS
can ensure that Medicare documents containing vital beneficiary
information will consistently be translated in the future for the
various groups of beneficiaries that have limited English proficiency.
Under Title VI and implementing regulations, health care providers that
receive federal financial assistance must take reasonable steps to
ensure that eligible LEP individuals have meaningful access to their
services. While our review focused primarily on the challenges of
translating Medicare documents, provider organizations, other groups
interested in LEP issues, and health care providers we interviewed told
us that they face additional challenges in communicating with LEP
beneficiaries--such as the high cost of providing translation and
interpretation services and difficulty identifying qualified
translators and interpreters. Health care providers and organizations
representing them told us that translating Medicare documents into
languages other than English and Spanish is challenging. These
providers also indicated that most of the documents they translate are
documents they have developed for their patients, such as consent forms
or discharge information, rather than Medicare documents CMS has
created. In lieu of translating Medicare documents, three providers we
spoke to told us that they sometimes use bilingual staff or hire
interpreters to perform "sight" translations--reading the Medicare
document to the beneficiary in their primary language--or use a
variation, where the provider reads the document and an interpreter
orally interprets what has been said. Although CMS has translated the
majority of Medicare documents into Spanish, organizations representing
health care providers and the LEP population told us it would be
helpful if CMS were to translate Medicare documents into additional
languages. This would prevent multiple providers from translating the
same documents and reduce the need for "sight" translations. However,
this would not alleviate the need to have interpreters or bilingual
staff available during visits with LEP patients. Some health care
provider organizations and other organizations told us they approached
CMS about translating Medicare documents into other languages but
typically received little or no response from the agency. However, CMS
officials told us that they have developed partnerships with several
external stakeholder groups to obtain their input. CMS also recently
appointed an individual whose responsibility is to develop an LEP plan
specific to CMS, and this official has begun meeting with external LEP
organizations to address their concerns with the plan.
To improve the consistency and transparency of CMS's translation
decisions, we recommend that CMS develop a written, agencywide policy
that includes criteria for the translation of written documents as part
of its LEP plan. In commenting on a draft of this correspondence, CMS
generally agreed with our recommendation and said that it has developed
a draft LEP plan that will include an agencywide strategic policy with
criteria to ensure CMS-produced Medicare documents with vital
beneficiary information are consistently translated. CMS and HHS also
provided technical comments, which we incorporated as appropriate.
Background:
CMS administers Medicare, a federal health insurance program that
provides a variety of health care services to individuals who are 65 or
older, have end-stage renal disease, or are disabled. Medicare includes
four separate "parts" under which different types of services are
covered. Individuals eligible for Medicare are entitled to hospital
insurance, known as Part A, which helps pay for services such as
inpatient hospital care and skilled nursing facility services following
a hospital stay. Medicare beneficiaries may opt to enroll in
supplemental medical insurance, known as Part B, which helps pay for
services, such as physician and outpatient hospital services.
Traditionally, Medicare has reimbursed providers for Part A and B
services on a fee-for-service basis. In contrast, Medicare
beneficiaries may choose to obtain this coverage from the Medicare
Advantage program, known as Part C, where private health insurance plan
sponsors offer Medicare Advantage plans (MA-plans) that cover Part A
and B services for enrollees. Medicare beneficiaries may also choose to
obtain coverage for outpatient prescription drugs through the
prescription drug benefit, known as Part D. Under Part D, plan sponsors
may offer MA-plans with prescription drug coverage, referred to as MA-
PD plans, or stand-alone prescription drug plans.
Medicare providers generally are required to take reasonable steps to
ensure meaningful access to their services for LEP beneficiaries.
Section 601 of Title VI provides that no person shall "on the ground of
race, color, or national origin, be excluded from participation in, be
denied the benefits of, or be subjected to discrimination under any
program or activity receiving Federal financial assistance."[Footnote
8] Section 602 of Title VI directs federal agencies to implement
section 601 by issuing rules, regulations, or orders.[Footnote 9]
Accordingly, in 1964, HHS first published implementing regulations for
entities receiving federal financial assistance from HHS, including
health care organizations.[Footnote 10]
On August 11, 2000, Executive Order 13166 was published, requiring
federal agencies to take certain steps to clarify Title VI
requirements.[Footnote 11] Specifically, this order required federal
agencies to publish Title VI guidance for their recipients of federal
financial assistance that is consistent with guidance provided by the
Department of Justice (DOJ). The order further provided that to assist
other federal agencies, DOJ published general guidance which set forth
compliance standards that federal financial assistance recipients must
follow to ensure programs and activities normally provided by
recipients in English are accessible to LEP persons, and thus do not
discriminate on the basis of national origin in violation of Title VI
and implementing regulations.[Footnote 12] In 2002, DOJ also published
guidance addressing the Title VI obligations of its recipients to take
reasonable steps to ensure access to programs and activities by LEP
persons.[Footnote 13] In DOJ's guidance, DOJ clarified that Title VI
and implementing regulations required recipients of federal financial
assistance from DOJ to take reasonable steps to provide meaningful
access to LEP individuals based on an assessment that balances the
following factors: (1) number or proportion of LEP individuals, (2)
frequency of contact with the program and LEP individuals, (3) nature
and importance of the program, and (4) resources available to the
recipients and the costs of language assistance services.
Consistent with Executive Order 13166 and the DOJ guidance, HHS
initially published guidance for federal financial assistance
recipients, including Medicare providers, on August 30, 2000,[Footnote
14] and later revised this guidance in August 2003.[Footnote 15] HHS's
guidance describes four factors that providers should consider in
determining what language assistance services, if any, are necessary:
(1) the number or proportion of LEP individuals served or encountered;
(2) the frequency of these encounters (less frequent encounters with a
language group may require a different approach than what would be
required for daily encounters); (3) the importance of the program or
service being offered and whether the denial or delay of service or
information could have serious or even life-threatening implications
for the LEP individual;[Footnote 16] and (4) the resources available to
the recipient, and costs.[Footnote 17] According to HHS's guidance,
these factors are designed to provide flexibility to health care
providers, such as allowing providers to make an individualized
assessment using these four factors to determine what language services
the provider plans to offer. The guidance provides options for oral
interpretation services for LEP individuals, such as hiring staff
interpreters, contracting interpreters, or using telephone interpreter
lines. The guidance also identifies criteria for written translations,
such as how to determine what documents under its purview are
considered "vital" and to translate these documents into the languages
most frequently encountered.[Footnote 18],[Footnote 19]
Executive Order 13166 also required federal departments and agencies,
including HHS, to examine the services they provide and prepare a plan
identifying the steps they will take to provide LEP individuals with
meaningful access to the agencies' programs and activities.[Footnote
20] As required by the order, HHS developed a plan that identified the
steps the department and its agencies would take to provide eligible
LEP persons with meaningful access to the department's programs and
activities, which would include CMS's administration of the Medicare
program. The HHS LEP Strategic Plan, issued in December 2000,
identified seven elements designed to meet HHS's goal of providing
"access to timely, quality language assistance services to LEP
persons." According to the plan, HHS addresses what its programs will
do in terms of providing language assistance to beneficiaries with whom
it directly interacts. HHS also explains that it will strive to
implement each element of the plan, establishing priorities that best
meet the needs of LEP individuals in the context of resource
constraints. Table 1 shows that the plan includes elements related to
assessing the language assistance needs and capacity at each HHS
component; provisions for oral language assistance services and written
translation of vital documents; written policies and procedures related
to each plan element, as well as staff responsible for implementing
them; and training of front-line managerial staff at the component and
program levels.[Footnote 21]
Table 1: Elements of HHS's LEP Strategic Plan:
Element: Assessment: needs and capacity;
Element description: "Each agency, program, and activity of HHS will
have in place mechanisms to assess, on a regular and consistent basis,
the LEP status and language assistance needs of current and potential
customers, as well as mechanisms to assess the agency's capacity to
meet these needs according to the elements of this plan."
Element: Oral language assistance services;
Element description: "Each agency, program, and activity of HHS will
arrange for the provision of oral language assistance in response to
the needs of LEP customers, in both face-to-face and by telephone
encounters."
Element: Written translations;
Element description: "Each agency, program, and activity of HHS will
provide vital documents in languages other than English where a
significant number or percentage of the customers served or eligible to
be served has LEP. These written materials may include paper and
electronic documents such as publications, notices, correspondence, web
sites and signs."
Element: Policies and procedures;
Element description: "Each agency, program, and activity of HHS will
have in place specific written policies and procedures related to each
of the plan elements and designated staff who will be responsible for
implementing activities related to these policies."
Element: Notification of the availability of free language services;
Element description: "Each agency, program, and activity of HHS will
proactively inform LEP customers of the availability of free language
assistance services through both oral and written notice, in his or her
primary language."
Element: Staff training;
Element description: "Each agency, program, and activity of HHS will
train front-line and managerial staff on the policies and procedures of
its language assistance activities."
Element: Assessing accessibility and quality;
Element description: "Each agency, program, and activity of HHS will
institute procedures to assess the accessibility and quality of
language assistance activities for LEP customers."
Source: HHS LEP Strategic Plan.
[End of table]
In our December 2008 report on 1-800-MEDICARE, we reported that HHS
officials said the language assistance plan provides a "road map" for
addressing HHS's goals, while allowing individual operating divisions
and agencies, including CMS, some flexibility in implementing the
plan's requirements.[Footnote 22] We also reported on shortcomings in
CMS's implementation of HHS's language access plan, primarily the lack
of a specific division or point person within the agency to manage the
plan. Consequently, we recommended that CMS designate an official or
office with responsibility for the LEP plan to ensure its offices are
aware of, and take steps consistent with, HHS's Plan when considering
the needs of people with LEP. In response to our recommendation, CMS
appointed an individual in OEOCR and gave this person responsibility
for developing an LEP plan specific to CMS.
CMS Translates Most Medicare Documents into Spanish, but Lacks an
Agencywide Translation Policy:
CMS components translated 117 (87 percent) of the 134 Medicare
documents we identified into Spanish, including general educational
materials and forms and notices specific to individual beneficiaries'
coverage. In addition, one CMS component--the Office of External
Affairs (OEA)--which supports all the components of the agency in their
efforts to communicate with beneficiaries and the public about Medicare
and other CMS-administered programs--translated a limited number of
these documents into other languages, such as Chinese, Korean, and
Vietnamese. The remaining 17 documents we identified were only
available in English. Responsibility for creating and translating most
of these documents fell primarily under the purview of two CMS
components, the OEA and the Center for Drug and Health Plan Choice
(CPC) which oversees the MA-plans and the prescription drug benefit
program. Table 2 provides information about the components responsible
for the Medicare documents we identified and the number of translated
documents. (Enclosure I provides additional information on these
documents and their availability in languages other than English.)
Table 2: Translation of Medicare Documents by CMS Component:
Medicare documents by component: Office of External Affairs' Creative
Services Group;
Number of translated documents: 88;
1.
Medicare documents by component: Center for Drug and Health Plan
Choice;
Number of translated documents: 21;
Number of documents available only in English: 4.
Medicare documents by component: Other;
Number of translated documents: 8;
Number of documents available only in English: 12.
Medicare documents by component: Total;
Number of translated documents: 117;
Number of documents available only in English: 17.
Source: GAO analysis of Medicare documents.
[End of table]
These translation efforts were undertaken despite the absence of an
agencywide translation policy and lack of awareness internally of HHS's
LEP plan. This plan indicates that HHS agencies, including CMS, will
strive to implement specific written policies and procedures related to
written translations for LEP individuals and designate staff who are
responsible for activities related to these policies. As in the prior
GAO report, which identified shortcomings in CMS's implementation of
HHS's LEP plan, CMS officials we interviewed were unaware of any
agencywide translation policies related to Medicare documents. Although
CMS, in response to our recommendation, appointed an OEOCR official to
develop an LEP plan specific to CMS, the plan is still under
development and is not expected to be completed until fall 2009,
according to a CMS official.[Footnote 23]
Because CMS does not have an agencywide translation policy and only
recently appointed an official responsible for developing a CMS-
specific LEP plan, the extent to which Medicare documents were
translated depended entirely on decisions made by individual CMS
components. For example, the Creative Services Group (CSG), within
CMS's OEA, was responsible for 89 of the 134 documents we identified
and translated all but one of the documents (99 percent) it created
into Spanish because it determined that it is the most common language
spoken by LEP Medicare beneficiaries.[Footnote 24],[Footnote 25] CSG
also translated 7 of these 89 documents into additional languages based
on available resources, such as funding and qualified translators. CSG
develops publications to educate beneficiaries about various aspects of
the Medicare program and about specific health care issues.[Footnote
26] For example, CSG develops Medicare & You, a handbook that is sent
to all Medicare beneficiaries, which summarizes program benefits and
beneficiaries' rights and protections and answers the most frequently
asked questions about the program. Numerous other CSG publications,
such as Women and Heart Disease and Medicare Coverage of Diabetes and
Supplies, provide disease-specific health information or explain
related Medicare coverage. CSG's documents are typically accessed via
one of two CMS Web sites--[hyperlink, http://www.cms.hhs.gov] or
[hyperlink, http://www.medicare.gov]--or by calling 1-800-
MEDICARE.[Footnote 27]
In addition, the Medicare Enrollment and Appeals Group (MEAG), as well
as other groups within CMS's CPC, created 25 of the 134 documents we
identified and translated 21 of these documents (84 percent) into
Spanish. Similar to CSG, the CPC translates most materials it creates
into Spanish because most Medicare LEP beneficiaries speak Spanish;
however, the CPC does not always translate templated documents that
require the addition of beneficiary-specific information. The CPC
primarily creates these documents to help CMS, or the participating
plans, communicate with beneficiaries about their specific drug or MA-
plan's coverage. For example, the center's Notice of Denial of Medical
Coverage informs beneficiaries that coverage of certain medical
services has been denied, provides the reason for the denial, and
describes the appeal process. Another form, Loss of Deemed Status,
informs beneficiaries who previously were eligible for a subsidy to
help pay for their Part D premiums that they no longer automatically
qualify for this assistance. In addition to CSG and the CPC, four other
CMS components translated an additional eight documents into Spanish,
which provided a range of information to Medicare beneficiaries,
including payment notices, consent forms for home visits, and general
Medicare information; however, CMS officials we interviewed were
generally not aware of the reasons for the decision to translate these
documents into Spanish.
When compared to the documents that CMS translated, the 17 documents we
identified that were not translated varied in terms of their content
and how they were disseminated. For example, 4 of these documents are
templated forms that require health care providers to add specific
information about a beneficiary's coverage, including 2 documents
related to benefit exclusions or changes to a beneficiary's portion of
costs and 2 documents that provide a beneficiary the opportunity to
request information about their coverage.[Footnote 28] These documents
are typically provided directly to beneficiaries by their health care
provider.[Footnote 29],[Footnote 30] Further, according to CMS
officials, the CSG did not translate one publication into Spanish
because the publication was targeted to the Native American population,
which made translating the publication into Spanish unnecessary. CMS
officials we interviewed were unaware of why the remaining 12 documents
were not translated and provided several possible reasons why the
documents may not have been translated, including not being able to
identify the CMS component that originated the document. The majority
of the remaining documents contain information about how to manage
certain health conditions or the Medicare program--information similar
to what is included in other documents that CMS translated into
Spanish. Although the agency currently translates approximately 87
percent of the Medicare documents we identified into Spanish, without
an agencywide policy, there is no guarantee that the agency can ensure
that Medicare documents containing vital beneficiary information will
consistently be translated in the future for various LEP beneficiaries.
Health Care Providers Face Challenges Communicating with LEP
Beneficiaries, Including Translating Medicare and Other Documents:
Under Title VI and implementing regulations, health care providers that
receive federal financial assistance must take reasonable steps to
ensure meaningful access by eligible LEP individuals to their services.
In some circumstances a recipient may need to provide language
assistance services, such as translating written documents or providing
oral language interpreters, to comply with Title VI and its
implementing regulations. However, some provider organizations and four
health care providers that we spoke to report that they have
encountered challenges to overcoming language barriers and translating
necessary documents. The majority of documents providers translate for
their LEP patients are documents they have developed specifically for
their patients--such as consent forms, discharge information documents,
and patient education material--but health care providers and provider
organizations also cite some challenges specific to translating
Medicare documents created by CMS into languages other than English and
Spanish. Although CMS has translated 117 of the 134 Medicare documents
we identified into Spanish, three providers that we spoke with told us
that they have needed to translate some Medicare documents into
additional languages. For example, one provider--whose primary patient
population is Native American and who encounters five Native American
dialects--told us they translated some Part D benefit information and
Advance Beneficiary Notifications. Another provider told us that rather
than translate Medicare materials word for word, they created their own
documents describing Medicare's drug benefit program to give to
patients. In lieu of translating these documents, three health care
providers we spoke to use bilingual staff or an interpreter to perform
"sight translations"--reading the Medicare document to the beneficiary
in their primary language--or use a variation, where the provider reads
the document and an interpreter orally interprets what has been said.
According to some translators we spoke to who had experience
translating medical documents, translating any government document can
be difficult because of words and terms specific to government and the
frequent use of acronyms. Further, translators and one organization
interested in LEP issues explained that words specific to the medical
profession made translation difficult because some languages do not
contain words that reflect the meaning of those terms.
Although CMS translated the majority of Medicare documents we
identified into Spanish, provider organizations and advocates
representing the LEP population told us it would be helpful for CMS to
have more Medicare documents translated into additional languages. This
would prevent multiple providers from translating the same documents,
as well as reduce the need for bilingual staff or interpreters to do
sight translations. Some health care provider organizations and
organizations interested in LEP issues told us they approached CMS
about translating Medicare documents into other languages but typically
received little or no response from the agency. However, CMS officials
told us that they had developed partnerships with several external
stakeholder groups and, in collaboration with these groups, have
translated documents into additional languages. For example, this
collaboration resulted in CMS translating seven products into Asian
languages--Chinese, Korean, and Vietnamese. In addition, CMS's new LEP
official has met with external LEP organizations and heard a wide range
of concerns about LEP issues, which the official is working to address
in the development of CMS's LEP plan.
Although our review focused on the translation of Medicare documents,
providers, provider organizations, and advocacy groups told us that
health care providers face multiple challenges to communicating with
LEP patients, such as the high cost of providing translation or
interpretation services, keeping staff trained and apprised of policies
for communicating with LEP patients, and difficulty identifying
qualified translators and interpreters. In addition, some providers,
provider organizations, and other groups we spoke to told us the costs
associated with establishing a language program is one of the biggest
challenges that providers face in serving LEP patients. According to
two provider organizations and one advocacy organization, this
challenge may be particularly acute for smaller providers with more
limited resources. However, when we asked the providers we spoke to
what their total translation costs were, none were able to give us
costs for translation services because they do not differentiate
between the costs for translation and interpretation services or do not
track these costs at all.[Footnote 31] All four providers that we spoke
to told us that they have bilingual staff that may translate documents
or have an internal translation department. These translation costs may
be absorbed into the salaries of employees. Some translators told us
that translation costs are generally charged on a per-word basis and
may range between 8 cents per word to 30 cents per word, but may vary
based on various factors, such as a document's complexity, dialects,
use of jargon and acronyms, and the time frame to complete the project.
Further, one provider organization and some providers and other groups
told us that communication between providers and LEP patients does not
occur solely through translated forms. For example, providers must be
able to communicate verbally with LEP patients, including Medicare
beneficiaries, to discuss symptoms, explain instructions and tests, and
describe diagnoses. To do this, providers have hired bilingual or
multilingual staff, contracted with interpreters, or established
language help lines.
Conclusions:
While CMS has translated 87 percent of its Medicare documents into
Spanish, the agency does not have an agencywide policy related to the
translation of documents. We previously reported that CMS has not taken
steps to ensure that officials throughout the agency are fully aware of
the HHS LEP Plan and therefore lacks a key internal control measure--a
clearly defined area of responsibility that has been communicated
agencywide--by not identifying an official point of contact responsible
for implementing HHS's LEP plan for CMS. CMS has since appointed an
individual who has begun to develop an agencywide LEP plan and told us
that it plans to address who will have responsibility for managing this
plan. Although CMS told us that it plans to address translation in its
LEP plan, this plan is still in development, and agency officials have
not informed us of how their plan will address the translation of
written materials at this time. CMS should have an agencywide policy
that includes criteria for translating documents into languages other
than English that is coordinated across its components to ensure
translation decisions are made consistently. For example, such criteria
should include assessing the language needs of current and potential
beneficiaries. Without such a policy, CMS cannot ensure that Medicare
documents containing vital information for beneficiaries will be
consistently translated in the future for the various groups of LEP
beneficiaries.
Recommendation for Executive Action:
To improve the consistency and transparency of CMS's decisions to
translate its documents into other languages, we recommend that the
Administrator of the Centers for Medicare & Medicaid Services direct
the appropriate CMS offices or LEP plan manager to include a written,
agencywide policy for translation of written documents as part of its
LEP plan. Such a policy should include criteria for translating
documents, including assessing the language needs of current and
potential beneficiaries, and a process for ensuring that the CMS office
or individual responsible for managing the LEP plan has complete and
accurate information about CMS's efforts to translate documents.
Agency Comments:
We provided the Centers for Medicare & Medicaid Services a draft of
this report for review and comment. In response to our draft report,
CMS said that it has developed a draft LEP plan that will include an
agencywide strategic policy that provides criteria to ensure Medicare
documents produced by CMS with vital beneficiary information are
consistently translated. However, agency officials declined to provide
a copy to us, stating that it was still in development. CMS also noted
that the agency ensures marketing materials used by MA organizations
and PDP sponsors are translated for LEP Medicare beneficiaries by
requiring, under its Marketing Guidelines, that these materials are
provided by sponsors in alternative formats, including foreign
languages. They also said that beneficiaries can request that their
health plan send materials to them in a specific translated format.
Further, CMS updated its Health Plan Management System, which collects
and tracks Medicare health plan marketing materials. The updates will
permit CMS to better track the marketing materials by allowing health
plans to submit individually translated documents to the management
system any time during the year, beginning in contract year 2010. CMS's
written comments are reprinted in enclosure II. CMS and HHS also
provided technical comments which we incorporated as appropriate.
We are sending copies of this report to the Administrator of the
Centers for Medicare & Medicaid Services, interested congressional
committees, and other parties. In addition, the report will be
available at no charge on GAO's Web site at [hyperlink,
http://www.gao.gov].
If you or your staffs have any questions about this report, please
contact Kathleen M. King at (202) 512-7114 or kingk@gao.gov, or William
B. Shear at (202) 512-8678 or shearw@gao.gov. Contact points for our
Offices of Congressional Relations and Public Affairs may be found on
the last page of this report. Major contributors to this report were
Susan Anthony, Assistant Director; Kay Kuhlman, Assistant Director;
Tania Calhoun; Drew Long; Michaela M. Monaghan; Rhonda Rose; Sari B.
Shuman; and Hemi Tewarson.
Sincerely yours,
Signed by:
Kathleen M. King:
Director, Health Care:
Signed by:
William B. Shear:
Director, Financial Markets and Community Investment:
Enclosures (2):
[End of section]
Enclosure I: Availability of Medicare Documents:
Table 3: Availability of Medicare Documents Translated into Spanish:
Documents containing general health or Medicare information:
1;
Title: 2009 Choosing a Medigap Policy: A Guide to Health Insurance for
People with Medicare;
Document number, when available: 2110;
Web site[A]: Medicare.
2;
Title: 4 Ways to Help Lower Your Medicare Prescription Drug Costs;
Document number, when available: 11417;
Web site[A]: Medicare.
3;
Title: A Healthier US Starts Here;
Document number, when available: 11308;
Web site[A]: Medicare.
4;
Title: Are You Having Trouble Paying for Prescription Drugs?[B];
Document number, when available: 11318;
Web site[A]: Medicare.
5;
Title: Are You Paying the Right Amount for Your Prescriptions?;
Document number, when available: 11324;
Web site[A]: Medicare.
6;
Title: Billing for Certain Injectable and Infused Medicare Part B
Drugs;
Document number, when available: 11148;
Web site[A]: Medicare.
7;
Title: Bridging the Coverage Gap;
Document number, when available: 11213;
Web site[A]: Medicare.
8;
Title: Colorectal Cancer Basic Facts on Screening;
Document number, when available: 11011;
Web site[A]: Medicare.
9;
Title: Dialysis Facility Compare Tool at [hyperlink,
http://www.medicare.gov];
Document number, when available: 10208;
Web site[A]: Medicare.
10;
Title: Enrolling in Medicare[C];
Document number, when available: 11036;
Web site[A]: N/A.
11;
Title: e-prescribing: Connecting to Better Healthcare;
Document number, when available: 11382;
Web site[A]: Medicare.
12;
Title: Get Your Medicare Questions Answered with 1-800-MEDICARE;
Document number, when available: 11386;
Web site[A]: Medicare.
13;
Title: Getting a Second Opinion Before Surgery;
Document number, when available: 2173;
Web site[A]: Medicare.
14;
Title: Getting Medical Care and Prescription Drugs in a Disaster or
Emergency Area;
Document number, when available: 11377;
Web site[A]: Medicare.
15;
Title: Getting Medicare before you get your Full Social Security
Retirement Benefits;
Document number, when available: 11038;
Web site[A]: Medicare.
16;
Title: Guide to Choosing a Nursing Home;
Document number, when available: 2174;
Web site[A]: Medicare.
17;
Title: Have You Done Your Yearly Medicare Enrollment Review?[B];
Document number, when available: 11220;
Web site[A]: Medicare.
18;
Title: How Can Recovery Audit Contractors Help Me;
Document number, when available: 11349;
Web site[A]: Medicare.
19;
Title: How Medicare Covers Self Administered Drugs Given in Hospital
Outpatient Settings;
Document number, when available: 11333;
Web site[A]: Medicare.
20;
Title: How Medicare Drug Plans Use Pharmacies, Formularies and Common
Coverage Rules;
Document number, when available: 11136;
Web site[A]: Medicare.
21;
Title: How the Medicare Beneficiary Ombudsman Works For You;
Document number, when available: 11173;
Web site[A]: Medicare.
22;
Title: How to File a Medicare Part A or Part B Appeal in the Original
Medicare Plan;
Document number, when available: 11316;
Web site[A]: Medicare.
23;
Title: Looking for a Doctor?;
Document number, when available: 11383;
Web site[A]: Medicare.
24;
Title: Marketing Rules for Medicare Private Fee-For-Service plans;
Document number, when available: 11327;
Web site[A]: Medicare.
25;
Title: Medicare and Your Mental Health Benefits;
Document number, when available: 10184;
Web site[A]: Medicare.
26;
Title: Medicare & You 2009;
Document number, when available: 10050;
Web site[A]: Medicare.
27;
Title: Medicare Advantage Plans and Medicare Cost Plans: How to File a
Complaint (Grievance or Appeal);
Document number, when available: 11312;
Web site[A]: Medicare.
28;
Title: Medicare and Ambulance Services;
Document number, when available: 11398;
Web site[A]: Medicare.
29;
Title: Medicare and Clinical Research Studies;
Document number, when available: 2226;
Web site[A]: Medicare.
30;
Title: Medicare and Home Health Care;
Document number, when available: 10969;
Web site[A]: Medicare.
31;
Title: Medicare and Hospice Benefits: Getting Started;
Document number, when available: 11361;
Web site[A]: Medicare.
32;
Title: Medicare and Other Health Benefits: Your Guide to Who Pays
First;
Document number, when available: 2179;
Web site[A]: Medicare.
33;
Title: Medicare and Skilled Nursing Facility Care Benefits: Getting
Started;
Document number, when available: 11359;
Web site[A]: Medicare.
34;
Title: Medicare and Your Mental Health Benefits: Getting Started;
Document number, when available: 11358;
Web site[A]: Medicare.
35;
Title: Medicare at a Glance[B];
Document number, when available: 11082;
Web site[A]: Medicare.
36;
Title: Medicare Basics: A Guide for Families and Friends of People with
Medicare;
Document number, when available: 11034;
Web site[A]: Medicare.
37;
Title: Medicare Coverage of Ambulance Services;
Document number, when available: 11021;
Web site[A]: Medicare.
38;
Title: Medicare Coverage of Diabetes Supplies & Services;
Document number, when available: 11022;
Web site[A]: Medicare.
39;
Title: Medicare Coverage of Durable Medical Equipment and Other
Devices;
Document number, when available: 11045;
Web site[A]: Medicare.
40;
Title: Medicare Coverage of Kidney Dialysis and Kidney Transplant
Services;
Document number, when available: 10128;
Web site[A]: Medicare.
41;
Title: Medicare Coverage of Skilled Nursing Facility Care;
Document number, when available: 10153;
Web site[A]: Medicare.
42;
Title: Medicare Coverage Outside of the United States;
Document number, when available: 11037;
Web site[A]: Medicare.
43;
Title: Medicare Hospice Benefits;
Document number, when available: 2154;
Web site[A]: Medicare.
44;
Title: Medicare Limits on Therapy Services;
Document number, when available: 10988;
Web site[A]: Medicare.
45;
Title: Medicare Physician Quality Reporting Initiative (PQRI) Letter;
Document number, when available: 11317;
Web site[A]: Medicare.
46;
Title: Medicare Prescription Drug Coverage: How to File a Grievance,
Request a Coverage Determination, or File an Appeal[B];
Document number, when available: 11112;
Web site[A]: Medicare.
47;
Title: Medicare Prescription Drug Coverage: How to Join a Medicare Drug
Plan;
Document number, when available: 11111;
Web site[A]: Medicare.
48;
Title: Medicare Savings Programs;
Document number, when available: 10126;
Web site[A]: Medicare.
49;
Title: Medicare: Getting Started;
Document number, when available: 11389;
Web site[A]: Medicare.
50;
Title: Medicare's Coverage of Dialysis and Kidney Transplant Benefits:
Getting Started;
Document number, when available: 11360;
Web site[A]: Medicare.
51;
Title: Medicare's Home Health Benefit: Getting Started;
Document number, when available: 11357;
Web site[A]: Medicare.
52;
Title: Medicare's Hospital Compare;
Document number, when available: 11342;
Web site[A]: Medicare.
53;
Title: Medicare's Nursing Home Compare;
Document number, when available: 11385;
Web site[A]: Medicare.
54;
Title: Medicare's Wheelchair and Scooter Benefit;
Document number, when available: 11046;
Web site[A]: Medicare.
55;
Title: My Medicines;
Document number, when available: 11085;
Web site[A]: Medicare.
56;
Title: MyMedicare.gov;
Document number, when available: 11297;
Web site[A]: Medicare.
57;
Title: New Rules for How Medicare Pays Suppliers for Oxygen Equipment;
Document number, when available: 11405;
Web site[A]: Medicare.
58;
Title: Personal Health Records;
Document number, when available: 11397;
Web site[A]: Medicare.
59;
Title: Planning for Your Discharge: A Checklist for Patients and
Caregivers Preparing to Leave a Hospital, Nursing Home, or Other Health
Care Setting;
Document number, when available: 11376;
Web site[A]: Medicare.
60;
Title: Preparing for Emergencies: A Guide for People on Dialysis;
Document number, when available: 10150;
Web site[A]: Medicare.
61;
Title: Protecting Medicare and You from Fraud;
Document number, when available: 10111;
Web site[A]: Medicare.
62;
Title: Protecting Your Health Insurance Coverage;
Document number, when available: 10199;
Web site[A]: Medicare.
63;
Title: Quick Facts about Medicare Prescription Drug Coverage and How to
Protect Your Personal Information;
Document number, when available: 11147;
Web site[A]: Medicare.
64;
Title: Quick Facts about Medicare's Coverage for Prescription Drugs;
Document number, when available: 11102;
Web site[A]: Medicare.
65;
Title: Quick Facts about Medicare's Coverage for Prescription Drugs for
People Who Have Prescription Coverage from an Employer or Union;
Document number, when available: 11107;
Web site[A]: Medicare.
66;
Title: Quick Facts about Medicare's Prescription Drug Coverage for
People in a Medicare Advantage Plan or Medicare Cost Plan with
Prescription Drug Coverage;
Document number, when available: 11135;
Web site[A]: Medicare.
67;
Title: Quick Facts About Paying for Outpatient Services for People with
Medicare Part B;
Document number, when available: 2118;
Web site[A]: Medicare.
68;
Title: Quick Facts about Programs of All Inclusive Care for the Elderly
(PACE);
Document number, when available: 11341;
Web site[A]: Medicare.
69;
Title: Quick Tips for People with Medicare: Using Your New Medicare
Drug Coverage;
Document number, when available: 11343;
Web site[A]: Medicare.
70;
Title: Staying Healthy--Medicare's Preventive Services[B];
Document number, when available: 11100;
Web site[A]: Medicare.
71;
Title: Things to Think About When You Compare Medicare Drug Coverage;
Document number, when available: 11163;
Web site[A]: Medicare.
72;
Title: Use Information About Quality on Medicare.gov: Compare Plans and
Providers;
Document number, when available: 11266;
Web site[A]: Medicare.
73;
Title: Welcome To Medicare[D];
Document number, when available: 11095;
Web site[A]: N/A.
74;
Title: What are Long-Term Care Hospitals?;
Document number, when available: 11347;
Web site[A]: Medicare.
75;
Title: What is Medicare? What is Medicaid?[B];
Document number, when available: 11306;
Web site[A]: Medicare.
76;
Title: What to Do If You No Longer Automatically Qualify for Extra Help
with Medicare Prescription Drug Costs;
Document number, when available: 11215;
Web site[A]: Medicare.
77;
Title: What You Need to Know about Medicare Prescription Drug Coverage
if You Have a Medigap Policy;
Document number, when available: 11113;
Web site[A]: Medicare.
78;
Title: Where to Get Your Medicare Questions Answered;
Document number, when available: 2246;
Web site[A]: Medicare.
79;
Title: Withholding Medicare Prescription Drug Premiums From Your 2009
Social Security Payment;
Document number, when available: 11400;
Web site[A]: Medicare.
80;
Title: Withholding Premiums From Your Social Security Payment;
Document number, when available: 11200;
Web site[A]: Medicare.
81;
Title: Women and Heart Disease: Things You Need to Know;
Document number, when available: 11294;
Web site[A]: Medicare.
82;
Title: Women with Medicare: Visiting Your Doctor for a Pap Test, Pelvic
Exam, and Clinical Breast Exam;
Document number, when available: 2248;
Web site[A]: Medicare.
83;
Title: [hyperlink, http://www.medicare.gov][B];
Document number, when available: 10108;
Web site[A]: Medicare.
84;
Title: You Can Live: Your Guide for Living with Kidney Failure;
Document number, when available: 2119;
Web site[A]: Medicare.
85;
Title: Your Guide to Medicare Medical Savings Account Plans;
Document number, when available: 11206;
Web site[A]: Medicare.
86;
Title: Your Guide to Medicare Prescription Drug Coverage;
Document number, when available: 11109;
Web site[A]: Medicare.
87;
Title: Your Guide to Medicare Private Fee-for-Service Plans;
Document number, when available: 10144;
Web site[A]: Medicare.
88;
Title: Your Guide to Medicare Special Needs Plans (SNPs);
Document number, when available: 11302;
Web site[A]: Medicare.
89;
Title: Your Guide to Medicare's Preferred Provider Organization (PPO)
plans;
Document number, when available: 11152;
Web site[A]: Medicare.
90;
Title: Your Guide to Medicare's Preventive Services;
Document number, when available: 10110;
Web site[A]: Medicare.
91;
Title: Your Medicare Benefits;
Document number, when available: 10116;
Web site[A]: Medicare.
92;
Title: Your Medicare Rights and Protections[C];
Document number, when available: 10112;
Web site[A]: N/A.
Documents containing information about Medicare Parts A and B:
93;
Title: Advanced Beneficiary Notice of Noncoverage (ABN);
Document number, when available: CMS-R-131;
Web site[A]: CMS.
94;
Title: Consent for Home Visit;
Document number, when available: CMS-36;
Web site[A]: CMS.
95;
Title: Consent for Home Visit for PACE Services Evaluations;
Document number, when available: CMS-36 P;
Web site[A]: CMS.
96;
Title: Detailed Explanation of Non-Coverage;
Document number, when available: CMS-10124;
Web site[A]: CMS.
97;
Title: Home Health Advance Beneficiary Notice;
Document number, when available: CMS-R-296;
Web site[A]: CMS.
98;
Title: Notice of Medicare Provider Non-Coverage;
Document number, when available: CMS-10123;
Web site[A]: CMS.
99;
Title: Transfer (Assignment) of Appeal Rights[C];
Document number, when available: CMS-20031;
Web site[A]: CMS.
Documents containing information about Medicare Part C or Part D:
100;
Title: Detailed Explanation of Non-Coverage;
Document number, when available: CMS-10095 (DENC);
Web site[A]: CMS.
101;
Title: Medicare Prescription Drug Coverage & Your Rights;
Document number, when available: CMS-10147;
Web site[A]: CMS.
102;
Title: Notice of Denial of Medical Coverage;
Document number, when available: CMS-10003;
Web site[A]: CMS.
103;
Title: Notice of Denial of Medicare Prescription Drug Coverage;
Document number, when available: CMS-10146;
Web site[A]: CMS.
104;
Title: Notice of Denial of Payment;
Document number, when available: CMS-10003-NDP;
Web site[A]: CMS.
105;
Title: Notice of Medicare Non-Coverage;
Document number, when available: CMS-10095 (NOMNC);
Web site[A]: CMS.
Documents containing information about Medicare Parts A, B, C, or D:
106;
Title: An Important Message From Medicare About Your Rights;
Document number, when available: CMS-R-193;
Web site[A]: CMS.
107;
Title: Appointment of Representative;
Document number, when available: CMS-1696;
Web site[A]: CMS.
108;
Title: Detailed Notice of Discharge;
Document number, when available: CMS-10066;
Web site[A]: CMS.
Documents containing information about Medicare's low-income subsidy:
109;
Title: Auto-Enrollment Notice;
Document number, when available: 11154;
Web site[A]: CMS.
110;
Title: Change in Extra Help Co-payment letter;
Document number, when available: 11199;
Web site[A]: CMS.
111;
Title: Facilitated Enrollment Notice: Full Subsidy Version;
Document number, when available: 11186;
Web site[A]: CMS.
112;
Title: Loss of Deemed (Extra Help) Status Notice;
Document number, when available: 11198;
Web site[A]: CMS.
113;
Title: Monthly Deemed Notice;
Document number, when available: 11166;
Web site[A]: CMS.
114;
Title: Re-assignment Notice: Plan Termination Version;
Document number, when available: 11208;
Web site[A]: CMS.
Documents containing other Medicare information:
115;
Title: 1-800-MEDICARE Authorization to Disclose Personal Health
Information[E];
Document number, when available: CMS-10106;
Web site[A]: N/A.
116;
Title: Notice of Medicare Premium Payment Due[E];
Document number, when available: CMS-500;
Web site[A]: N/A.
117;
Title: Patient's Request for Medicare Payment;
Document number, when available: CMS-1490S;
Web site[A]: CMS.
Source: GAO analysis of Medicare documents.
[A] Medicare's Web site is [hyperlink, http://www.medicare.gov]; CMS's
Web site is [hyperlink, http://www.cms.hhs.gov].
[B] This publication is also available in Chinese, Korean, and
Vietnamese.
[C] This document is translated into Spanish but is awaiting agency
approval and cannot currently be located on the CMS or Medicare Web
sites.
[D] CMS does not translate this document but provides an equivalent
document in Spanish to beneficiaries in Puerto Rico.
[E] This form can only be found by contacting CMS or the Social
Security Administration directly.
[End of table]
Table 4: Availability of English-Only Medicare Documents:
Documents containing general health or Medicare information:
1;
Title: 1-800-MEDICARE Billing Questions Fact Sheet;
Document number, when available: 11365.
2;
Title: Bringing Better Health Care to Indian Communities;
Document number, when available: 11368-N.
3;
Title: CRC (Colorectal Cancer) Screening Saves Lives;
Document number, when available: 11010.
4;
Title: Filing a Complaint Concerning Dialysis or Kidney Transplant
Care;
Document number, when available: 11314.
5;
Title: Mammograms & Breast Health: An Information Guide for Women;
Document number, when available: 11117.
6;
Title: Medicare Health and Safety Standards: How to File a Complaint;
Document number, when available: 11313.
7;
Title: Medicare's Incentive Reward Program for Fraud and Abuse;
Document number, when available: 99913.
8;
Title: Pap Tests for Older Women;
Document number, when available: 10149.
9;
Title: Prostate Cancer Screening: A Decision Guide for Men with
Medicare;
Document number, when available: 11042.
10;
Title: Quality of Care Concerns;
Document number, when available: 11362.
11;
Title: What to Do If You Have a Concern Regarding Care You Received
While on Medicare;
Document number, when available: 11348.
Documents containing information about Medicare Parts A or B:
12;
Title: Notice of Exclusions From Medicare Benefits - Skilled Nursing
Facility (NEMB-SNF);
Document number, when available: CMS-20014.
13;
Title: FFS Skilled Nursing Facility Advance Beneficiary Notice;
Document number, when available: CMS-10055.
14;
Title: Medicare Reconsideration Request Form;
Document number, when available: CMS-20033.
15;
Title: Medicare Redetermination Request;
Document number, when available: CMS-20027.
Documents containing other Medicare information:
16;
Title: ESRD Beneficiary Selection Form;
Document number, when available: CMS-382.
17;
Title: Financial Statement of Debtor;
Document number, when available: CMS-379.
Source: GAO analysis of Medicare documents.
[End of table]
[End of section]
Enclosure II: Comments from the Centers for Medicare & Medicaid
Services:
Department Of Health And Human Services:
Office Of The Secretary:
Assistant Secretary for Legislation:
Washington, DC 20201:
July 21, 2009:
Kathleen M. King:
Director, Health Care:
U.S. Government Accountability Office:
441 G Street, NW:
Washington, DC 20548:
William B. Shear:
Director, Financial Markets and Community Investment:
U.S. Government Accountability Office:
441 G Street, NW:
Washington, DC 20548:
Dear Ms. King and Mr. Shear:
Please find enclosed the comments of the U.S. Department of Health and
Human Services, including the Office for Civil Rights and the Centers
for Medicare & Medicaid Services, on the Government Accountability
Office's (GAO) draft report entitled, "CMS Should Develop an Agency-
wide Policy for Translating Medicare Documents into Languages Other
Than English" (GAO-09-752R).
The Department appreciates the opportunity to review and comment before
its publication.
Sincerely,
Signed by:
Barbara Pisaro Clark:
Acting Assistant Secretary for Legislation:
Enclosure:
[End of letter]
Department Of Health & Human Services:
Centers For Medicare & Medicaid Services:
Administrator:
Washington, Dc 20201:
Date: July 16, 2009:
To: Barbara Pisaro Clark:
Assistant Secretary for Legislation:
From: [Signed by] Charlene M. Frizzera:
Acting Administrator:
Subject: Government Accountability Office (GAO) Draft Correspondence:
"CMS Should Develop an Agency-wide Policy for Translating Medicare
Documents into Languages other Than English" (GAO-09-752R):
Thank you for the opportunity to review and comment on the GAO Draft
correspondence "CMS Should Develop an Agency-wide Policy for
Translating Medicare Documents into Languages other Than English" (GAO-
09-752R). In this draft correspondence, the GAO (1) examined the extent
to which the Centers for Medicare & Medicaid Services (CMS) translates
Medicare documents into languages other than English, and (2) describes
the challenges health care providers may face in, communicating with
beneficiaries with limited English proficiency (LEP), including
translating Medicare and other documents.
We appreciate the time and effort GAO put into reviewing our processes.
We are pleased that GAO has acknowledged our efforts to develop an
agency-wide translation policy. It is our goal to provide clear,
accurate, and timely information about this program and to make the
information accessible to beneficiaries and caregivers.
Below is our response to the draft GAO recommendation as well as
additional comments.
GAO Recommendation:
To improve the consistency and transparency of CMS' decisions to
translate its documents into other languages, GAO recommends that CMS
develop a written agency-wide policy for translation of written
documents as part of its development of a LEP plan. Such a policy
should include criteria for translating documents, including assessing
the language needs of current and potential beneficiaries, and a
process for ensuring that the CMS office or individual responsible for
managing the LEP plan has complete and accurate information about CMS'
efforts to translate documents.
CMS Response:
The CMS has prepared a draft "Strategic Language Access Plan (LAP) to
improve access to CMS programs and activities by Limited English
Proficient (LEP) Persons. " The plan will implement the agency-wide
strategic policy that determines the criteria to use to ensure that
Medicare documents produced by CMS that contain vital beneficiary
information are consistently translated.
The CMS also ensures that marketing materials used by Medicare
Advantage (MA) organizations and Prescription Drug Plan (PDP) sponsors
are translated for beneficiaries with LEP by providing specific
alternative format requirements in our Marketing Guidelines (e.g.
foreign languages, as well as Braille, audio tapes, large print).
Furthermore, beneficiaries can call their health plan at any time
during the contract year and request their material be sent to them in
a specific translated format. In addition, CMS has updated its Health
Plan Management System (HPMS), which collects and tracks Medicare
health plan marketing materials. For contract year (CY) 2010 HPMS will
be able to better track translated marketing materials by allowing
plans the ability to submit different individual translated materials
at any time during the year.
The CMS will refine its Marketing Guidelines and the system for
tracking plans' marketing materials as necessary to comply with the LAP
which is currently under development.
Other Comments:
1. Page 3: There is a reference to the Office of External Affairs'
(OEA) "Advanced Services Group" - there is no such group. We believe
GAO is referring to OEA's Partner Relations Group.
2. Pages 5 & 13: CMS is concerned that when the author discusses the 1-
800-MEDICARE study published in December 2008 (GAO-09-104), the author
references shortcomings in CMS' LEP plan specific to 1-800-MEDICARE
("...a prior GAO report that identified shortcomings in CMS's
implementation of HHS's LEP plan specific to 1-800 MEDICARE"). This
reference is made on page 5 and page 13. This is misleading. The prior
report did not identify shortcomings with 1-800-MEDICARE specific to
LEP but rather to responsibility within CMS for the HHS LEP Plan. If
the author is going to reference the report, the complete title should
be used to eliminate confusion between 1-800-MEDICARE and the GAO
report that has 1-800-MEDICARE in its title.
3. Page 6: The GAO report states that OEA and CPC the two CMS
components that translated the majority of the documents into Spanish--
did so because it is the most common language spoken by LEP Medicare
beneficiaries. The roughly 13 percent of documents that were not
translated by CMS varied in terms of their content. Some were templates
of forms and notices, which required MA plans or Part D PDPs to add
beneficiary-specific information, including information related to
benefit exclusions or changes to the beneficiary's portion of costs.
CMS has marketing guidelines available at [hyperlink,
http://www.cms.hhs.gov/ManagedCareMarketing/03_FinalPartCMarketingGuidel
ines.asp#TopOfPage] that require organizations offering MA plans and
PDPs to make marketing materials available to beneficiaries in any
language that is the primary language of more than 10 percent of the
population of the geographic area.
4. Page 12: GAO reported that "CMS components translated 119 (about 87
percent) of the 137 Medicare documents we identified into Spanish,
including general educational materials and forms and notices specific
to individual beneficiaries' coverage ... The remaining 18 documents we
identified were only available in English. Responsibility for creating
and translating most of these documents fell primarily under the
purview of two CMS components, the OEA, and the Center for Drug and
Health Plan Choice (CPC), which oversees the Medicare Advantage program
and the prescription drug benefit program. To ensure that beneficiaries
enrolled in MA plans and PDPs have access to beneficiary education
materials in alternative formats (e.g., Braille, foreign languages,
audio tapes, large print), our Marketing Guidelines require
organizations to provide a disclosure on preenrollment materials and
the post-enrollment Evidence of Coverage (EOC), indicating the document
is available in alternative formats.
5. Page 13: The author notes that OEA/Creative Services Group (CSG) was
responsible for 89 out of 137 documents identified, and translated all
but one. We suggest including the percentage translated (99%) in
addition to the number, as is done with CPC on page 14. We would also
like to note that the single document under OEA's responsibility that
isn't translated into Spanish is one that is written specifically for a
target audience of Native American beneficiaries, and requestors
indicated that a Spanish version was not needed for this target
audience in this case.
6. Page 14: Footnote 25 contains a reference to the State Children's
Health Insurance Program. Drop "State" to indicate the current and
accurate legal name for this program.
7. Page 21, Table 2: The following items listed in Table 2 of Enclosure
1 currently include a
footnote indicating that they are awaiting Spanish translation and CMS
approval:
a. Item 100--Detailed Explanation of Non-Coverage (CMS-10095 (DENC))
[hyperlink, http://www.cms.hhs.govBNI/09_MAEDNotices.asp#TopOfPage]
b. Item 104--Notice of Denial of Medical Coverage (CMS-10003)
[hyperlink, http://www.cms.hhs.govBNI/07_MADenialNotices.asp#TopOfPage]
c. Item 106--Notice of Denial of Payment (CMS-10003-NDP)
d. Item 107--Notice of Medicare Non-Coverage (CMS-100095 (NOMNC))
[hyperlink, http://www.cms.hhs.gov/BNU09_MAEDNotices.asp#TopOfPage]
The Spanish translations for these notices have been completed and the
notices are available on our Web pages. We recommend updating Table 2
by removing the footnote from these four notices and indicating that
the Spanish translations are available on [hyperlink,
http://www.ems.hhs.gov].
Once again, we appreciate the efforts of the GAO and the
professionalism exhibited by the staff responsible for this study. We
are committed to improving our service wherever possible and will
continue to work in partnership to keep you apprised as we implement
the Report's recommendation.
[End of section]
Footnotes:
[1] Pub. L. No. 88-352, Tit. VI, § 601, 78 Stat. 241, 252 (1964)
(codified, as amended, at 42 U.S.C. § 2000d). In this report, we refer
to Title VI of the Civil Rights Act of 1964, as amended, as Title VI.
[2] The Department of Health, Education, and Welfare, the predecessor
of HHS, published these regulations. See Non-Discrimination in
Federally-Assisted Programs of the Department of Health, Education, and
Welfare--Effectuation of Title VI of the Civil Rights Act of 1964. 29
Fed. Reg. 16,298-16,305 (Dec. 4, 1964) (codified, as amended, at 45
C.F.R. Part 80).
[3] Executive Order 13166, Improving Access to Services for Persons
with Limited English Proficiency, 65 Fed. Reg. 50,121-22 (Aug. 16,
2000).
[4] HHS, Guidance to Federal Financial Assistance Recipients Regarding
Title VI Prohibition Against National Origin Discrimination Affecting
Limited English Proficient Persons, 68 Fed. Reg. 47,311 (Aug. 8, 2003).
[5] Recipients of federal financial assistance from HHS do not include
certain providers, such as physicians, who only receive Medicare Part B
payments. However, if these providers receive federal financial
assistance from HHS in other forms such, as through Medicaid, then they
are covered by Title VI and implementing regulations.
[6] HHS, Strategic Plan for Improving Access to HHS Programs and
Activities by Limited English Proficient (LEP) Persons (Washington,
D.C.: Dec. 15, 2000).
[7] See GAO, Medicare: Callers Can Access 1-800-MEDICARE Services, but
Responsibility within CMS for Limited English Proficiency Plan Unclear,
GAO-09-104 (Washington, D.C.: Dec. 29, 2008).
[8] Pub. L. No. 88-352, § 601, 78 Stat. 241, 252 (1964) (codified, as
amended, at 42 U.S.C. § 2000d).
[9] Pub. L. No. 88-352, § 602, 78 Stat. 241, 252 (1964) (codified, as
amended, at 42 U.S.C. § 2000d-1).
[10] 29 Fed, Reg. 16,298-16,505 (Dec. 4, 1964) (codified, as amended,
at 45 C.F.R. Part 80).
[11] Executive Order 13166, Improving Access to Services for Persons
with Limited English Proficiency, 65 Fed. Reg. 50,121-22 (Aug. 16,
2000).
[12] Enforcement of Title VI of the Civil Rights Act of 1964 - National
Origin Discrimination Against Persons with Limited English Proficiency;
Policy Guidance, 65 Fed. Reg. 50,123 (Aug. 16, 2000).
[13] Guidance to Federal Financial Assistance Recipients Regarding
Title VI Prohibition Against National Origin Discrimination Affecting
Limited English Proficient Persons, 67 Fed. Reg. 41,455 (June 18,
2002).
[14] Title VI of the Civil Rights Act of 1964; Policy Guidance on the
Prohibition Against National Origin Discrimination As It Affects
Persons with Limited English Proficiency, 65 Fed. Reg. 52,762 (Aug. 30,
2000).
[15] Guidance to Financial Assistance Recipients Regarding Title VI
Prohibition Against National Origin Discrimination Affecting Limited
English Proficient Persons, 68 Fed. Reg. 47,311 (Aug. 8, 2003). HHS
modified this guidance, in part, in response to the Title VI guidance
for recipients of federal financial assistance published by DOJ in
2002. This guidance clarifies that entities receiving federal financial
assistance from HHS do not include certain providers, such as
physicians, who only receive Medicare Part B payments. However, if
these providers receive federal financial assistance from HHS in other
forms, such as through Medicaid, then they are covered by Title VI and
implementing regulations. In this report, we focus our discussion of
the guidance on its application to Medicare providers.
[16] According to HHS's guidance, an example of an urgent and important
service relates to communication of information concerning emergency
surgery and obtaining informed consent prior to such surgery, thus
requiring the need for immediate language assistance. Alternatively, if
the activity is important, but not urgent--such as the communication of
information about, and obtaining informed consent for, elective
surgery, where delay will not have any adverse impact on the patient's
health--language services are needed but may be delayed for a
reasonable time without life-threatening implications.
[17] HHS's guidance states that smaller recipients with more limited
budgets are not expected to provide the same level of language services
as larger recipients with larger budgets. The guidance states that
reasonable steps may cease to be "reasonable" when the costs imposed
substantially exceed the benefits.
[18] HHS's guidance states that vital written materials could include
consent and complaint forms; intake forms with the potential for
important consequences; and written notices of eligibility criteria,
rights, denial, loss, or decreases in benefits or services.
[19] The HHS guidance describes safe harbors to help recipients
determine whether certain documents should be translated. The guidance
states that if the recipient provides written translations of vital
documents for each eligible language group that constitutes 5 percent
or 1000, whichever is less of the population eligible to be served,
except where the 5 percent is less than 50 persons, then such action
will be considered strong evidence of compliance with the recipient's
written translation obligations. These safe harbors are to be used as a
starting point for recipients to consider when making decisions about
whether to provide written translations in frequently encountered
languages other than English.
[20] 65 Fed. Reg. 50,121.
[21] It was beyond the scope of our work to conduct an exhaustive
review of all CMS activities that may relate to elements of the plan.
Our review focused on the written translation of documents.
[22] [hyperlink, http://www.gao.gov/products/GAO-09-104].
[23] Since our report in December 2008, the OEOCR official responsible
for developing the LEP plan has drafted a version of this plan using
the HHS LEP plan as a model, consulted with the CMS component
responsible for 1-800-MEDICARE about how they serve LEP beneficiaries,
and spoken to external stakeholders to gain input on CMS's current
approach to address LEP issues.
[24] CMS officials estimate that approximately 6 percent of Medicare
beneficiaries speak Spanish as their primary language.
[25] According to CMS officials, CSG did not translate the publication--
Bringing Better Health Care to Indian Communities--into Spanish because
it was targeted to the Native American population, which made
translating the publication into Spanish unnecessary.
[26] Although beyond the scope of our work, an OEA official indicated
that the group also creates and translates press releases and other
related information into Spanish, Chinese, Korean, and Vietnamese to
better serve LEP Medicare beneficiaries.
[27] These documents can be found by accessing two of CMS's Web sites--
[hyperlink, http://www.medicare.gov] or [hyperlink,
http://www.cms.hhs.gov]. The www.medicare.gov Web site is designed to
provide a variety of program information to Medicare beneficiaries,
whereas www.cms.hhs.gov is a Web site that targets information to a
broader audience, including health professionals and consumers, about
the Medicare program, as well as other CMS programs such as Medicaid
and the State Children's Health Insurance Program (CHIP).
[28] For two of these documents, Medicare Redetermination Request and
Medicare Reconsideration Request, beneficiaries can submit the related
CMS form or a written request that must include certain information,
such as the beneficiary's name, specific services and items for which
the request is being made, and the date the services were rendered or
items were received.
[29] During the course of our work, we also identified 16 model
notices, which are documents CMS provides to MA-plans, PDPs, MA-PD
plans, and health care providers with CMS-approved language. Model
notices are sent to beneficiaries and may contain information about
benefit exclusions or changes to a beneficiary's portion of costs. CMS
considers these documents to be plan marketing materials, and
therefore, CPC, which created the documents, typically does not
translate them. If MA-plans, PDPs, MA-PD plans, or health care
providers use the model notices provided by CMS, the material undergoes
an expedited review process to determine if the marketing materials
meet CMS's guidelines. MA-plans, PDPs, MA-PD plans, and health care
providers can change CMS's suggested language and format if they
include certain CMS-required elements.
[30] In some cases, sponsors of MA-plans, PDPs, and MA-PD plans may
need to translate these documents for LEP beneficiaries to comply with
Title VI and the implementing regulations. Independent of Title VI and
the implementing regulations, sponsors of MA-plans, PDPs, and MA-PD
plans should provide translation services to their LEP enrollees in
accordance with Part C and D regulations and guidelines. For example,
in areas with a significant non-English speaking population, sponsors
of these plans should provide marketing materials in the language of
these individuals. 42 C.F.R. §§ 422.112(a)(8), 423.2264(e). In
addition, in accordance with CMS's Medicare Marketing Guidelines, MA
plans, PDPs, and MA-PD plans should make marketing materials for
beneficiaries available in any language that is the primary language of
more than 10 percent of the population in the plan's service area.
[31] One health care provider we spoke to was able to provide aggregate
costs for their language program, which includes bilingual staff and
physicians, agency interpreters, telephonic language lines, and
translation, but could not break out the costs for interpretation and
translation. This provider told us that for fiscal year 2009, their
total language costs were estimated to be $1.3 million of their total
projected expenses of about $1 billion.
[End of section]
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