# H.R. 3200/Division B/Title II/Subtitle B
## SUBTITLE B — REDUCING HEALTH DISPARITIES
### Sec. 1221. Ensuring Effective Communication in Medicare.

    (a) Ensuring Effective Communication by the Centers for Medicare & Medicaid Services.—
          (1) Study on Medicare Payments for Language Services.—
             The Secretary of Health and Human Services shall conduct a study that examines the extent to which Medicare service providers utilize, offer, or make available language services for beneficiaries who are limited English proficient and ways that Medicare should develop payment systems for language services.
          (2) Analyses.—
             The study shall include an analysis of each of the following:
                (A) How to develop and structure appropriate payment systems for language services for all Medicare service providers.
                (B) The feasibility of adopting a payment methodology for on-site interpreters, including interpreters who work as independent contractors and interpreters who work for agencies that provide on-site interpretation, pursuant to which such interpreters could directly bill Medicare for services provided in support of physician office services for an LEP Medicare patient.
                (C) The feasibility of Medicare contracting directly with agencies that provide off-site interpretation including telephonic and video interpretation pursuant to which such contractors could directly bill Medicare for the services provided in support of physician office services for an LEP Medicare patient.
                (D) The feasibility of modifying the existing Medicare resource-based relative value scale (RBRVS) by using adjustments (such as multipliers or add-ons) when a patient is LEP.
                (E) How each of options described in a previous paragraph would be funded and how such funding would affect physician payments, a physician’s practice, and beneficiary cost-sharing.
                (F) The extent to which providers under parts A and B of title XVIII of the Social Security Act, MA organizations offering Medicare Advantage plans under part C of such title and PDP sponsors of a prescription drug plan under part D of such title utilize, offer, or make available language services for beneficiaries with limited English proficiency.
                (G) The nature and type of language services provided by States under title XIX of the Social Security Act and the extent to which such services could be utilized by beneficiaries and providers under title XVIII of such Act.
          (3) Variation in Payment System Described.—
             The payment systems described in paragraph (2)(A) may allow variations based upon types of service providers, available delivery methods, and costs for providing language services including such factors as—
                (A) the type of language services provided (such as provision of health care or health care related services directly in a non-English language by a bilingual provider or use of an interpreter);
                (B) type of interpretation services provided (such as in-person, telephonic, video interpretation);
                (C) the methods and costs of providing language services (including the costs of providing language services with internal staff or through contract with external independent contractors or agencies, or both);
                (D) providing services for languages not frequently encountered in the United States; and
                (E) providing services in rural areas.
          (4) Report.—
             The Secretary shall submit a report on the study conducted under subsection (a) to appropriate committees of Congress not later than 12 months after the date of the enactment of this Act.
          (5) Exemption from Paperwork Reduction Act.—
             Chapter 35 of title 44, United States Code (commonly known as the ``Paperwork Reduction Act´´), shall not apply for purposes of carrying out this subsection.
          (6) Authorization of Appropriations.—
             There is authorized to be appropriated to carry out this subsection such sums as are necessary.
    (b) Health Plans.—
       Section 1857(g)(1) of the Social Security Act (42 U.S.C. 1395w–27(g)(1)) is amended—
          (1) by striking ``or´´ at the end of subparagraph (F);
          (2) by adding ``or´´ at the end of subparagraph (G); and
          (3) by inserting after subparagraph (G) the following new subparagraph:
                ``(H) fails substantially to provide language services to limited English proficient beneficiaries enrolled in the plan that are required under law;´´.

### Sec. 1222. Demonstration to Promote Access for Medicare Beneficiaries with Limited English Proficiency by Providing Reimbursement for Culturally and Linguistically Appropriate Services.

    (a) In General.—
       Not later than 6 months after the date of the completion of the study described in section 1221(a), the Secretary, acting through the Centers for Medicare & Medicaid Services, shall carry out a demonstration program under which the Secretary shall award not fewer than 24 3-year grants to eligible Medicare service providers (as described in subsection (b)(1)) to improve effective communication between such providers and Medicare beneficiaries who are living in communities where racial and ethnic minorities, including populations that face language barriers, are underserved with respect to such services. In designing and carrying out the demonstration the Secretary shall take into consideration the results of the study conducted under section 1221(a) and adjust, as appropriate, the distribution of grants so as to better target Medicare beneficiaries who are in the greatest need of language services. The Secretary shall not authorize a grant larger than $500,000 over three years for any grantee.
    (b) Eligibility; Priority.—
          (1) Eligibility.—
             To be eligible to receive a grant under subsection (a) an entity shall—
                (A) be—
                      (i) a provider of services under part A of title XVIII of the Social Security Act;
                      (ii) a service provider under part B of such title;
                      (iii) a part C organization offering a Medicare part C plan under part C of such title; or
                      (iv) a PDP sponsor of a prescription drug plan under part D of such title; and
                (B) prepare and submit to the Secretary an application, at such time, in such manner, and accompanied by such additional information as the Secretary may require.
          (2) Priority.—
                (A) Distribution.—
                   To the extent feasible, in awarding grants under this section, the Secretary shall award—
                      (i) at least 6 grants to providers of services described in paragraph (1)(A)(i);
                      (ii) at least 6 grants to service providers described in paragraph (1)(A)(ii);
                      (iii) at least 6 grants to organizations described in paragraph (1)(A)(iii); and
                      (iv) at least 6 grants to sponsors described in paragraph (1)(A)(iv).
                (B) For Community Organizations.—
                   The Secretary shall give priority to applicants that have developed partnerships with community organizations or with agencies with experience in language access.
                (C) Variation in Grantees.—
                   The Secretary shall also ensure that the grantees under this section represent, among other factors, variations in—
                      (i) different types of language services provided and of service providers and organizations under parts A through D of title XVIII of the Social Security Act;
                      (ii) languages needed and their frequency of use;
                      (iii) urban and rural settings;
                      (iv) at least two geographic regions, as defined by the Secretary; and
                      (v) at least two large metropolitan statistical areas with diverse populations.
    (c) Use of Funds.—
          (1) In General.—
             A grantee shall use grant funds received under this section to pay for the provision of competent language services to Medicare beneficiaries who are limited English proficient. Competent interpreter services may be provided through on-site interpretation, telephonic interpretation, or video interpretation or direct provision of health care or health care related services by a bilingual health care provider. A grantee may use bilingual providers, staff, or contract interpreters. A grantee may use grant funds to pay for competent translation services. A grantee may use up to 10 percent of the grant funds to pay for administrative costs associated with the provision of competent language services and for reporting required under subsection (e).
          (2) Organizations.—
             Grantees that are part C organizations or PDP sponsors must ensure that their network providers receive at least 50 percent of the grant funds to pay for the provision of competent language services to Medicare beneficiaries who are limited English proficient, including physicians and pharmacies.
          (3) Determination of Payments for Language Services.—
             Payments to grantees shall be calculated based on the estimated numbers of limited English proficient Medicare beneficiaries in a grantee’s service area utilizing—
                (A) data on the numbers of limited English proficient individuals who speak English less than ``very well´´ from the most recently available data from the Bureau of the Census or other State-based study the Secretary determines likely to yield accurate data regarding the number of such individuals served by the grantee; or
                (B) the grantee’s own data if the grantee routinely collects data on Medicare beneficiaries’ primary language in a manner determined by the Secretary to yield accurate data and such data shows greater numbers of limited English proficient individuals than the data listed in subparagraph (A).
          (4) Limitations.—
                (A) Reporting.—
                   Payments shall only be provided under this section to grantees that report their costs of providing language services as required under subsection (e) and may be modified annually at the discretion of the Secretary. If a grantee fails to provide the reports under such section for the first year of a grant, the Secretary may terminate the grant and solicit applications from new grantees to participate in the subsequent two years of the demonstration program.
                (B) Type of services.—
                      (i) In General.—
                         Subject to clause (ii), payments shall be provided under this section only to grantees that utilize competent bilingual staff or competent interpreter or translation services which—
                            (I) if the grantee operates in a State that has statewide health care interpreter standards, meet the State standards currently in effect; or
                            (II) if the grantee operates in a State that does not have statewide health care interpreter standards, utilizes competent interpreters who follow the National Council on Interpreting in Health Care’s Code of Ethics and Standards of Practice.
                      (ii) Exemptions.—
                         The requirements of clause (i) shall not apply—
                            (I) in the case of a Medicare beneficiary who is limited English proficient (who has been informed in the beneficiary’s primary language of the availability of free interpreter and translation services) and who requests the use of family, friends, or other persons untrained in interpretation or translation and the grantee documents the request in the beneficiary’s record; and
                            (II) in the case of a medical emergency where the delay directly associated with obtaining a competent interpreter or translation services would jeopardize the health of the patient.
                         Nothing in clause (ii)(II) shall be construed to exempt emergency rooms or similar entities that regularly provide health care services in medical emergencies from having in place systems to provide competent interpreter and translation services without undue delay.
    (d) Assurances.—
       Grantees under this section shall—
          (1) ensure that appropriate clinical and support staff receive ongoing education and training in linguistically appropriate service delivery;
          (2) ensure the linguistic competence of bilingual providers;
          (3) offer and provide appropriate language services at no additional charge to each patient with limited English proficiency at all points of contact, in a timely manner during all hours of operation;
          (4) notify Medicare beneficiaries of their right to receive language services in their primary language;
          (5) post signage in the languages of the commonly encountered group or groups present in the service area of the organization; and
          (6) ensure that—
                (A) primary language data are collected for recipients of language services; and
                (B) consistent with the privacy protections provided under the regulations promulgated pursuant to section 264(c) of the Health Insurance Portability and Accountability Act of 1996 (42 U.S.C. 1320d–2 note), if the recipient of language services is a minor or is incapacitated, the primary language of the parent or legal guardian is collected and utilized.
    (e) Reporting Requirements.—
       Grantees under this section shall provide the Secretary with reports at the conclusion of the each year of a grant under this section. Each report shall include at least the following information:
          (1) The number of Medicare beneficiaries to whom language services are provided.
          (2) The languages of those Medicare beneficiaries.
          (3) The types of language services provided (such as provision of services directly in non-English language by a bilingual health care provider or use of an interpreter).
          (4) Type of interpretation (such as in-person, telephonic, or video interpretation).
          (5) The methods of providing language services (such as staff or contract with external independent contractors or agencies).
          (6) The length of time for each interpretation encounter.
          (7) The costs of providing language services (which may be actual or estimated, as determined by the Secretary).
    (f) No Cost Sharing.—
       Limited English proficient Medicare beneficiaries shall not have to pay cost-sharing or co-pays for language services provided through this demonstration program.
    (g) Evaluation and Report.—
       The Secretary shall conduct an evaluation of the demonstration program under this section and shall submit to the appropriate committees of Congress a report not later than 1 year after the completion of the program. The report shall include the following:
          (1) An analysis of the patient outcomes and costs of furnishing care to the limited English proficient Medicare beneficiaries participating in the project as compared to such outcomes and costs for limited English proficient Medicare beneficiaries not participating.
          (2) The effect of delivering culturally and linguistically appropriate services on beneficiary access to care, utilization of services, efficiency and cost-effectiveness of health care delivery, patient satisfaction, and select health outcomes.
          (3) Recommendations, if any, regarding the extension of such project to the entire Medicare program.
    (h) General Provisions.—
       Nothing in this section shall be construed to limit otherwise existing obligations of recipients of Federal financial assistance under title VI of the Civil Rights Act of 1964 (42 U.S.C. 2000(d) et seq.) or any other statute.
    (i) Authorization of Appropriations.—
       There are authorized to be appropriated to carry out this section $16,000,000 for each fiscal year of the demonstration program.

### Sec. 1223. IOM Report on Impact of Language Access Services.

    (a) In General.—
       The Secretary of Health and Human Services shall enter into an arrangement with the Institute of Medicine under which the Institute will prepare and publish, not later than 3 years after the date of the enactment of this Act, a report on the impact of language access services on the health and health care of limited English proficient populations.
    (b) Contents.—
       Such report shall include—
          (1) recommendations on the development and implementation of policies and practices by health care organizations and providers for limited English proficient patient populations;
          (2) a description of the effect of providing language access services on quality of health care and access to care and reduced medical error; and
          (3) a description of the costs associated with or savings related to provision of language access services.

### Sec. 1224. Definitions.

    In this subtitle:
          (1) Bilingual.—
             The term ``bilingual´´ with respect to an individual means a person who has sufficient degree of proficiency in two languages and can ensure effective communication can occur in both languages.
          (2) Competent Interpreter Services.—
             The term ``competent interpreter services´´ means a trans-language rendition of a spoken message in which the interpreter comprehends the source language and can speak comprehensively in the target language to convey the meaning intended in the source language. The interpreter knows health and health-related terminology and provides accurate interpretations by choosing equivalent expressions that convey the best matching and meaning to the source language and captures, to the greatest possible extent, all nuances intended in the source message.
          (3) Competent Translation Services.—
             The term ``competent translation services´´ means a trans-language rendition of a written document in which the translator comprehends the source language and can write comprehensively in the target language to convey the meaning intended in the source language. The translator knows health and health-related terminology and provides accurate translations by choosing equivalent expressions that convey the best matching and meaning to the source language and captures, to the greatest possible extent, all nuances intended in the source document.
          (4) Effective Communication.—
             The term ``effective communication´´ means an exchange of information between the provider of health care or health care-related services and the limited English proficient recipient of such services that enables limited English proficient individuals to access, understand, and benefit from health care or health care-related services.
          (5) Interpreting/Interpretation.—
             The terms ``interpreting´´ and ``interpretation´´ mean the transmission of a spoken message from one language into another, faithfully, accurately, and objectively.
          (6) Health Care Services.—
             The term ``health care services´´ means services that address physical as well as mental health conditions in all care settings.
          (7) Health Care-Related Services.—
             The term ``health care-related services´´ means human or social services programs or activities that provide access, referrals or links to health care.
          (8) Language Access.—
             The term ``language access´´ means the provision of language services to an LEP individual designed to enhance that individual’s access to, understanding of or benefit from health care or health care-related services.
          (9) Language Services.—
             The term ``language services´´ means provision of health care services directly in a non-English language, interpretation, translation, and non-English signage.
          (10) Limited English Proficient.—
             The term ``limited English proficient´´ or ``LEP´´ with respect to an individual means an individual who speaks a primary language other than English and who cannot speak, read, write or understand the English language at a level that permits the individual to effectively communicate with clinical or nonclinical staff at an entity providing health care or health care related services.
          (11) Medicare Beneficiary.—
             The term ``Medicare beneficiary´´ means an individual entitled to benefits under part A of title XVIII of the Social Security Act or enrolled under part B of such title.
          (12) Medicare Program.—
             The term ``Medicare program´´ means the programs under parts A through D of title XVIII of the Social Security Act.
          (13) Service Provider.—
             The term ``service provider´´ includes all suppliers, providers of services, or entities under contract to provide coverage, items or services under any part of title XVIII of the Social Security Act.