Department of Health & Human Services 
OFFICE OF 
 
INSPECTOR GENERAL 
 
 
 
 
 
 
 
 
GUIDAN  CE AND STANDARDS ON 
 
L A S :
ANGUAGE  CCESS  ERVICES   
 
 
M P  
EDICARE  ROVIDERS
 
 
 
 
 
 
 
Daniel R. Levinson  
Inspector General 
 
July 2010 
OEI-05-10-00050 
   
 E X E C U T I V E   S U M M A R Y  
OBJECTIVES
 
1.  To determine the extent to which Medicare providers conducted the 
four-factor assessment recommended by the Office for Civil Rights 
(OCR) guidance when determining what language access services to 
offer. 
2.  To determine the extent to which Medicare providers offered 
language access services consistent with the Office of Minority 
Healths (OMH) Culturally and Linguistically Appropriate Services 
in Health Care (CLAS) standards on language access services. 
3.  To determine the extent to which Medicare providers realized 
benefits, including savings, and encountered obstacles to providing 
language access services. 
4.  To describe costs of providing language access services. 
BACKGROUND 
The Medicare Improvements for Patients and Providers Act of 2008 
(MIPPA) requires that the Office of Inspector General (OIG) conduct a 
study examining Medicare provider and plan compliance with (1) OCRs 
Guidance to Federal Financial Assistance Recipients Regarding Title VI 
Prohibition Against National Origin Discrimination Affecting Limited 
English Proficient Persons (hereinafter referred to as OCR guidance) 
and (2) OMHs CLAS standards.  The MIPPA also requires that OIG 
describe the costs or savings related to the provision of language access 
services.  
Because OCR guidance and CLAS standards are not mandatory, OIG 
assessed Medicare providers voluntary compliance as indicated by the 
extent to which providers conducted the four-factor assessment 
recommended by OCR guidance and offered language access services 
consistent with CLAS standards.  A companion report, Guidance and 
Standards on Language Access Services:  Medicare Plans 
(OEI-05-10-00051), provides the same assessment for Medicare plans. 
OCR guidance and CLAS standards address the provision of language 
access services.  OCR guidance recommends a four-factor assessment to 
help determine what language access services to offer.  These factors are 
(1) the number or proportion of Limited English Proficient (LEP) 
persons eligible to be served or likely to be encountered in the providers 
service population; (2) the frequency with which LEP persons come in 
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contact with the provider; (3) the importance, nature, and urgency of the 
program, activity, or service to peoples lives; and (4) the resources 
available to the provider and costs for offering language access services.   
OMHs CLAS standards can help providers become responsive to the 
cultural and linguistic needs of diverse populations.  Four of the 
fourteen CLAS standards focus on the provision of language access 
services.  These standards are (1) providing language access services 
during all business hours, (2) providing verbal offers and written notices 
of the rights to language access services, (3) assuring the competence of 
language assistance provided by staff, and (4) providing written 
materials and signage translated into appropriate languages. 
Language access services are designed to promote effective 
communication between LEP persons and non-LEP persons.  LEP 
persons do not speak English as their primary language and have a 
limited ability to read, write, speak, or understand English.  Language 
access services can include oral interpretation; written translation; and 
other provisions that enhance communication, such as translated signs. 
To conduct this review, we administered a survey in 2009 to 
140 randomly selected Medicare providers located in counties with a 
high percentage of LEP persons. 
FINDINGS 
Sixty-nine percent of providers conducted the four-factor 
assessment recommended by OCR guidance when determining 
what language access services to offer.  Sixty-nine percent of 
providers conducted all four factors of the recommended assessment.  
Further, most providers reported completing some of the factors; 
84 percent completed at least three of the four factors and 97 percent 
completed at least one of the factors.  The percentages of providers that 
completed each factor ranged between 78 percent and 94 percent.  The 
factor completed most frequently was assessing available resources.   
Providers that conducted the assessment were more likely to be familiar 
with OCR guidance than providers that did not. 
Only 33 percent of providers offered services consistent with all 
four CLAS standards on language access services.  
Ninety-eight percent of providers reported offering some language 
access services, but only 33 percent offered services consistent with all 
four CLAS standards on language access services.  The percentages of 
providers that offered services consistent with each standard ranged 
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between 52 percent and 86 percent.  Providers were most likely to offer 
language access services consistent with the standard regarding 
assuring the competence of language assistance provided by staff.  
Providers that offered language access services consistent with all four 
CLAS standards were more likely to be familiar with them.   
Seventy-three percent of providers reported benefits to providing 
language access services and half reported obstacles.  The four 
most frequently reported benefits were (1) improved communication, 
(2) improved adherence to treatment regimen, (3) improved diagnosis 
and treatment, and (4) fewer complaints.  The three most frequently 
reported obstacles were (1) a lack of training resources for staff, (2) costs 
of providing language access services, and (3) the broad range of 
languages spoken in the providers communities. 
Few providers reported data on the costs of providing language 
access services and the data provided were not comparable.  
Because of the overall lack of reporting and the inability to compare data, 
we were unable to make any determinations about cost data related to 
providing language access services.  Of the 119 providers that responded 
to the survey, only 49 providers responded to the request for cost data.  In 
addition, provider comments indicated different approaches to calculating 
costs; therefore, we were unable to compare cost data. 
RECOMMENDATIONS 
The MIPPA requires OIG to make recommendations on improving 
compliance with and enforcement of CLAS standards.  However, in 
keeping with our assessment of voluntary compliance, we make 
recommendations to increase the percentage of providers that 
voluntarily offer services consistent with all four CLAS standards on 
language access services.  
Providers that offered language access services consistent with the 
CLAS standards were more likely to be familiar with them.  Therefore, 
to improve Medicare providers awareness and implementation of CLAS 
standards, we recommend that: 
  OCR inform providers about OMHs CLAS standards. 
  OMH increase outreach to providers to familiarize them with 
CLAS standards. 
 
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In addition, to help Medicare providers offer language access services, 
we recommend that: 
  OMH offer model translated written materials and signs to 
providers. 
AGENCIES COMMENTS AND OFFICE OF INSPECTOR 
GENERAL RESPONSE 
OCR and OMH concurred with our recommendations.  OMH stated that 
it will take the lead in developing specific marketing strategies to 
inform providers of the CLAS standards.  CMS indicated that it did not 
have any substantive comments.  However, it did provide technical 
comments that we incorporated as appropriate.
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 T A B L E   O F   C O N T E N T S  
EXECUTIVE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . i
 
 
I N T RO DUC T IO N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 
 
 
F I N D IN G S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 
  Sixty-nine percent of providers conducted the four-factor 
assessment recommended by OCR guidance when 
determining what language access services to offer . . . . . . . . . . . . 14 
   
  Only 33 percent of providers offered services consistent with all 
four CLAS standards on language access services . . . . . . . . . . . . . 18 
 
Seventy-three percent of providers reported benefits to providing 
language access services and half reported obstacles. . . . . . . . . . . 21 
Few providers reported data on the costs of providing language 
access services and the data provided were not comparable. . . . . . 24 
 
 
R E C O MMEN D A T ION S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 
Agencies Comments and Office of Inspector General Response. . 27 
 
 
APPENDIXES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 
  A:  Section 187 of the Medicare Improvements for Patients and 
    Providers Act of 2008 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 
  B:  Culturally and Linguistically Appropriate Services in Health 
    Care Standards. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 
 
  C:  Categories of Responses to Key Survey Questions. . . . . . . . . . 31 
  D:  Estimates and Confidence Intervals. . . . . . . . . . . . . . . . . . . . . 34 
  E:  Supplemental Analysis Tables . . . . . . . . . . . . . . . . . . . . . . . . . 40 
  F:  Agencies Comments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 
 
 
A C K NO WL E D G M E N T S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 
   
 I N T R O D U C T I O N  
OBJECTIVES 
1.  To determine the extent to which Medicare providers conducted the 
four-factor assessment recommended by the Office for Civil Rights 
(OCR) guidance when determining what language access services to 
offer. 
2.  To determine the extent to which Medicare providers offered 
language access services consistent with the Office of Minority 
Healths (OMH) Culturally and Linguistically Appropriate Services 
in Health Care (CLAS) standards on language access services. 
3.  To determine the extent to which Medicare providers realized 
benefits, including savings, and encountered obstacles to providing 
language access services. 
4.  To describe costs of providing language access services. 
BACKGROUND 
The Medicare Improvements for Patients and Providers Act of 2008 
(MIPPA) requires that the Office of Inspector General (OIG) conduct a 
study examining Medicare provider and plan compliance with (1) OCRs 
Guidance to Federal Financial Assistance Recipients Regarding Title VI 
Prohibition Against National Origin Discrimination Affecting Limited 
English Proficient Persons (hereinafter referred to as OCR guidance) 
and (2) OMHs CLAS standards.1  The MIPPA also requires that OIG 
describe the costs or savings related to the provision of language access 
services.  Pursuant to the MIPPA, OIG must issue a report that 
provides recommendations for improving compliance with and 
enforcement of CLAS standards.2  For relevant text of the MIPPA, see 
Appendix A. 
Because OCR guidance and CLAS standards are not mandatory, OIG 
could not assess compliance or make recommendations on the 
enforcement of CLAS standards.  Instead, OIG assessed Medicare 
providers voluntary compliance as indicated by the extent to which 
providers conducted the four-factor assessment recommended by OCR 
 
1 Although the OCR guidance was signed by the then-Director of OCR, it was issued on 
behalf of the Secretary of Health & Human Services (HHS) and applies to all entities 
receiving funds from HHS. 
2 P.L. 110-275  187 (July 15, 2008), 42 U.S.C.  1395cc note. 
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guidance and offered language access services consistent with CLAS 
standards.   
This report is one of two issued in response to the MIPPA provision.  
This report focuses on Medicare providers, such as hospitals and 
nursing homes, which directly supply heath care services to 
beneficiaries.  A companion report, Guidance and Standards on 
Language Access Services:  Medicare Plans (OEI-05-10-00051), focuses 
on Medicare plans.  Medicare plans are private companies that contract 
with the Centers for Medicare & Medicaid Services (CMS) to provide 
health insurance or prescription drug coverage to Medicare 
beneficiaries. 
Language Access Services for Limited English Proficient Persons 
Language access services are designed to promote effective 
communication between Limited English Proficient (LEP) persons and 
non-LEP persons.3  LEP persons do not speak English as their primary 
language and have a limited ability to read, write, speak, or understand 
English.4  According to the U.S. Census Bureau, approximately 
18 percent of the U.S. population in 2000 spoke languages other than 
English at home.  Further, 8 percent of the U.S. population, or 
approximately 21 million people, spoke English less than very well.5 
Language access services may include oral interpretation; written 
translation; and other provisions that enhance communication, such as 
translated signs.6  In providing oral interpretation, providers may 
choose, for example, to hire bilingual staff, contract with interpreters, or  
use telephone interpreter lines.  When providing written translation, 
providers have discretion over which materials are translated.  
However, some materials are more critical than others.7, 8  These 
 
3 OMH, A Patient-Centered Guide to Implementing Language Access Services in 
Healthcare Organizations, p. 1.  Accessed at http://minorityhealth.hhs.gov on 
January 15, 2010. 
4 OCR, Guidance, pt. IV, 68 Fed. Reg. 47311, 47313 (Aug. 8, 2003).  Accessed at 
http://www.hhs.gov/ocr on October 21, 2009. 
5 U.S. Census Bureau, Profile of Selected Social Characteristics:  2000.  Accessed at 
http://factfinder.census.gov on January 15, 2010. 
6 OMH, Patient-Centered Guide, loc. cit. 
7 OCR, Guidance, pt. VI at 47316. 
8 OMH, National Standards on Culturally and Linguistically Appropriate Services in 
Health Care Final Report, March 2001, p. 78.  Accessed at http://minorityhealth.hhs.gov on 
February 12, 2010. 
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include, but are not limited to, patients rights information; medication 
directions; and screening, diagnosis, or treatment explanations.9, 10 
The lack of language access services enables language barriers to 
persist between LEP persons and non-LEP persons.  The inability to 
communicate with a provider can lead to ineffective care because 
providers are unable to elicit an LEP persons symptoms, making it 
difficult to render a proper diagnosis and course of treatment.11  
Research indicates that LEP persons are more likely than non-LEP 
persons to report being in fair or poor health, defer medical care, miss 
followup appointments, and experience drug complications.12, 13  LEP 
patients are also more likely than non-LEP patients to experience 
adverse events because of a communication failure.14 
Title VI of the Civil Rights Act 
Title VI of the Civil Rights Act of 1964, as amended, provides that no 
person in the United States 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.15  The Supreme Court has 
interpreted the Title VI implementing regulation to find that conduct 
with a disproportionate effect on LEP persons had a discriminatory 
impact on the basis of national origin.16 
OCR Oversight of Title VI Compliance 
OCR is the civil rights law enforcement agency for HHS.  As such, it 
ensures that all recipients of Federal financial assistance through HHS 
operate their programs in compliance with Federal civil rights laws.  
 
9 OCR, Guidance, pt. VI at 47316. 
10 OMH, National Standards, loc. cit. 
11 Leighton Ku and Glenn Flores, Pay Now Or Pay Later:  Providing Interpreter 
Services in Health Care, Health Affairs.  March/April 2005.  Vol. 24, No. 2.  Accessed at 
http://content.healthaffairs.org on February 26, 2010. 
12 Bradford Kirkman-Liff and Delfi Mondragon, Language of Interview:  Relevance for 
Research on Southwest Hispanics, American Journal of Public Health.  November 1991.  
Vol. 81, No. 11.  Accessed at http://ajph.aphapublications.org/ on February 26, 2010. 
13 Glenn Flores et al., Access Barriers to Health Care for Latino Children, Archives of 
Pediatrics & Adolescent Medicine.  November 1998.  Vol. 152.  Accessed at 
http://archpedi.ama-assn.org/ on February 26, 2010. 
14 The Joint Commission, Language Proficiency and Adverse Events in U.S. Hospitals:  A 
Pilot Study, February 2010.  Accessed at http://www.jointcommission.org on 
February 22, 2010. 
15 P.L. 88-352  601; 42 USC  2000d. 
16 Lau v. Nichols. 414 U.S. 563 (1974). 
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Federal financial assistance includes grants, training, use of equipment, 
donation of surplus property, and other assistance.  It does not include 
Medicare Part B payments to physicians.17 
OCR conducts civil rights reviews of all new Medicare provider 
applicants that receive Federal financial assistance.  OCR also conducts 
these reviews when there is a change of ownership.  During these 
reviews, OCR certifies that providers have plans in place to operate 
their programs in accordance with, among other laws, Title VI.18  
According to OCR staff, OCR completed 2,385 civil rights reviews in 
fiscal year (FY) 2009.  Alternatively, corporations with multiple 
facilities may enter into corporate agreements with OCR.  In these 
cases, OCR conducts reviews of the corporate policies that apply to all 
corporate facilities rather than reviewing each facility.  OCR had 
24 corporate agreements in effect in 2009. 
In addition, OCR investigates complaints of discrimination.  According 
to OCR staff, of the 17 complaints concerning LEP persons received in 
FY 2009, 6 complaints involved Medicare providers.  If OCR 
investigates and determines that discrimination has occurred, a 
provider usually has 60 days to correct the violation or provide OCR 
with a plan of correction.19  OCR staff stated that they strive for 
voluntary compliance and resolution in all cases as required by Title VI.  
Accordingly, complaints are often voluntarily resolved through an 
exchange of letters containing requirements for improvement. 
Further, OCR encourages compliance with Title VI by providing 
technical assistance and training.20  OCR provided technical assistance 
and training to more than 95,000 individuals in FY 2009.21  This 
technical assistance included telephone consultations, written 
correspondence, and in-person presentations at conferences, as well as 
meetings with advocacy groups and organizations receiving HHS 
financial assistance.  In addition, OCR collaborates with organizations, 
such as the American Hospital Association and the Joint Commission, 
 
17 45 CFR  80, App. A.; 45 CFR  80.2. 
18 OCR, Nondiscrimination Laws, Regulations, and Standards.  Accessed at 
http://www.hhs.gov/ocr/ on February 25, 2010. 
19 OCR, How Does OCR Investigate a Civil Rights Complaint?  Accessed at 
http://www.hhs.gov/ocr on February 25, 2010. 
20 OCR, Guidance, pt. VIII at 47321. 
21 OCR, Fiscal Year 2011 Online Performance Appendix.  Accessed at 
http://www.hhs.gov/ocr/ on April 12, 2010. 
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to develop training materials to help providers respond to LEP persons 
communication needs. 
OCR Guidance for Determining What Language Access Services To Offer 
In August 2000, OCR, on behalf of the Secretary of HHS, issued 
guidance specifically concerning discrimination affecting LEP persons.22  
The guidance was issued in response to an August 2000 Executive 
Order requiring Federal agencies to clarify and publish guidance on 
Title VI requirements.23  The original guidance was republished in 
February 2002, seeking public comment.24  In 2003, after receiving 
public comments and subsequent guidance from the U.S. Department of 
Justice, OCR issued revised guidance.25 
OCR guidance applies to all providers receiving HHS financial 
assistance, including hospitals, nursing homes, and home health 
agencies, among others.  It does not apply to physicians solely 
reimbursed for services under Medicare Part B, per Title VI 
regulations.26 
OCR guidance is meant to assist recipients of HHS financial assistance 
in ensuring meaningful access for LEP persons to critical services while 
not imposing an undue burden.  OCR guidance does not carry the force 
of law and is not mandatory.27 
OCR guidance recommends that each recipient of HHS financial 
assistance determine what language access services to offer by 
conducting a four-factor assessment.  The four factors are:28 
(1) the number or proportion of LEP persons eligible to be served or 
likely to be encountered in the recipients service population; 
(2) the frequency with which LEP persons come in contact with the 
recipient; 
(3) the importance, nature, and urgency of the program, activity, or 
service to peoples lives; and 
 
22 65 Fed. Reg. 52762 (Aug. 30, 2000). 
23 Executive Order 13166, Improving Access to Services for Persons with Limited 
English Proficiency, 65 Fed. Reg. 50121 (Aug. 16, 2000). 
24 67 Fed. Reg. 4968 (Feb. 1, 2002). 
25 OCR, Guidance, introduction at 47311. 
26 Ibid., pt. III at 47313. 
27 Ibid., pt. III at 47313, footnote 2. 
28 Ibid., pt. V at 47314. 
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(4)  the resources available to the recipient and costs for offering 
language access services. 
After conducting the four-factor assessment, recipients have discretion 
to determine what language access services to offer.  In some cases,  
offering language access services may not be necessary to comply with 
Title VI.29  However, this discretion does not diminish, and should not 
be used to minimize, recipients obligation to address the needs of LEP 
persons.30  
OMHs CLAS  Standards  
In 2001, OMH created the CLAS standards to provide consistent and 
comprehensive guidance to promote cultural and linguistic competence  
in health care.  As is OCR guidance, the CLAS standards are not 
mandatory.31    
OMH divided the standards into three categories:  Culturally 
Competent Care (standards 13), Language Access Services 
(standards 47), and Organizational Supports for Cultural Competence 
(standards 814).32  For a list of all 14 CLAS standards, see Appendix B. 
The four Language Access Services standards are:33  
Standard 4.  	Health care organizations must offer and provide language 
assistance services, including bilingual staff and 
interpreter services, at no cost to each patient/consumer 
with limited English proficiency at all points of contact, in 
a timely manner during  all hours of operation.  
Standard 5.  	Health care organizations must provide to 
patients/consumers in their preferred language both verbal 
offers and written notices informing  them of their right to  
receive language assistance services. 
Standard 6.  	Health care organizations must assure the competence of 
language assistance provided to limited English proficient 
patients/consumers by interpreters and bilingual staff.  
 
29 OCR, Guidance, pt. V at 47314.
  
30 Ibid. 

31 According to OMH officials, the four Language Access Services standards are not 

mandatory despite language stating that they are Federal requirements and that health 
care organizations must provide the services noted in each of  the four standards. 
32 OMH, Standards, p. 3. 
33  Ibid., pp. 1013. 
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Family and friends should not be used to provide 
interpretation services (except on request by the 
patient/consumer). 
Standard 7.  	Health care organizations must make available easily 
understood patient-related materials and post signage in 
the languages of the commonly encountered groups and/or 
groups represented in the service area. 
OMH staff offer training and educational resources related to CLAS 
standards to providers through the Center for Cultural and Linguistic 
Competence in Health Care (the Center).34  Established in FY 1995, 
the Center was OMHs response to the Disadvantaged Minority 
Health Improvement Act of 1990 and encouragement from Congress 
to establish a center to develop and evaluate models, conduct 
research, and provide technical assistance to providers on removing 
language barriers to health care services.35    
Through the Center, OMH offers training and educational resources 
related to the provision of language access services.  This includes 
accredited training programs for physicians, nurses, and disaster 
personnel on cultural competency  through e-learning programs.  OMH 
also publishes A Patient-Centered Guide to Implementing Language 
Access Services in Healthcare Organizations, which was designed to 
help health care administrators and organizations comply with Title VI 
and implement the CLAS standards.36  In addition, OMH distributes an 
e-newsletter that is geared toward all persons interested in cultural 
competency in health care settings. 
Reimbursement for Language Access Services 
Limited reimbursement is available for language access services.  
Medicare does not reimburse providers for language access services. On 
the other hand, State Medicaid Programs and Childrens Health 
Insurance Programs can, as an optional benefit, access Federal 
matching funds to reimburse for language access services.37  In 2009, 
 
34 OMH, About the Center for Cultural and Linguistic Competence in Health Care. 
Accessed at http://minorityhealth.hhs.gov/ on March 8, 2010. 
35 H.R. Rep. No. 103-553, at 54 (1994). 
36 OMH, A Patient-Centered Guide to Implementing Language Access Services in 
Healthcare Organizations. Accessed at http://www.thinkculturalhealth.org on  
February 1, 2010. 
37 42 U.S.C.  1396b(a)(2)(E); 42 U.S.C.  1397ee(a)(1)(D). 
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13 States and the District of Columbia used this optional benefit to 
reimburse providers or interpreters.38  In addition, a national survey of 
hospitals in the United  States found that only 3 percent of hospitals 
receive reimbursement for providing language access services.39  
Related Work 
In 2007, the Joint Commission found that there was still a gap between 
current practice and the  CLAS standards among a purposive sample of 
hospitals selected for their advanced provision of culturally and 
linguistically appropriate care.  Ninety percent of sampled hospitals 
cited funding services as a challenge to providing language access 
services.40  
METHODOLOGY 
To conduct this review, we collected information, in 2009, through a 
survey of randomly selected Medicare providers located  in counties with a 
high percentage of LEP  persons.  OCR and OMH staff provided additional 
context through structured interviews. 
Scope 
The MIPPA  mandates that OIG report on Medicare providers and  
plans compliance with OCR guidance and CLAS standards.  However, 
because OCR guidance and CLAS standards are not mandatory, HHS 
lacks authority to enforce them.  Therefore, we assessed providers 
voluntary compliance as indicated by the extent to which they 
conducted the four-factor assessment recommended by OCR guidance  
and offered language access services  consistent with CLAS standards.  
This study focused on CLAS Standards 47, which OMH designated as 
the Language Access Services standards. 
This study focused on the types of Medicare providers uniformly subject 
to Title VI.  For this reason, we  excluded Medicare Part B providers.   
We also limited our analysis to providers located in counties with a high 
percentage of LEP persons to increase the likelihood that sampled 
 
38 Families USA, Improving Language Access:  CHIPRA Provides Increased Funding For 
Language Services. Accessed at http://www.familiesusa.org on March 15, 2010.  
39 The Health Research and Educational Trust, Hospital Language Services for Patients  
with Limited English Proficiency:  Results from a National Study, October 2006. Accessed 
at http://www.hret.org on February 12, 2010. 
40 The Joint Commission, Hospitals, Language, and Culture:  A Snapshot of the Nation, 
2007. Accessed at http://www.jointcommission.org on February 12, 2010. 
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providers needed to offer language access services.  Medicare  plans are 
covered in a  companion report. 
Finally, we  broadened the definition of costs and savings to include 
nonfinancial obstacles and benefits. 
Sample 
Provider sampling frame. We  created a sampling frame of providers 
located in counties with a high percentage of LEP persons.  To do this, 
we used 2000 decennial Census data  and demographic data contained in 
CMSs Online Survey Certification and Reporting (OSCAR) system as of  
October 2009.41, 42  First, we used the Census data to rank counties by 
the percentage of residents who answered anything other than very  
well when asked how well they speak English.  We selected the 
10 percent of counties with the highest percentage of these LEP 
persons. Together, the 313 selected  counties, representing 37 States, 
contained 72 percent of LEP persons residing in the United States.  
These LEP persons represented between 9 percent and 51 percent of all 
county residents in each of the selected counties.  Then, we used the 
OSCAR data to identify Medicare providers located in the selected  
counties. We identified 16,853 providers in the sampling frame. 
Sample selection.  After creating the sampling frame of  
16,853 providers, we selected a simple random sample of 
145 providers.43  The sample consisted  of 14 provider types, including 
hospitals, skilled nursing facilities, and home health agencies. After 
selecting the sample, we excluded one provider  because of an ongoing 
OIG investigation and four additional providers because they were no  
longer in business.  The final sample consisted of 140 providers. 
Data Collection 
Survey.  We  mailed the survey to the sample of 140 providers in 
December 2009. We made at least two followup attempts by telephone 
and one by signature-required certified mail.  Data collection lasted 
 
41 The U.S. Census Bureaus 2000  decennial Census has the most recent data on all  
counties for the same year. 
42 OSCAR contains survey results from certification and complaint surveys for all 
Medicare providers receiving Federal financial assistance.  As such, it contains location 
information on  all of these providers. 
43 This sample design enabled  us  to estimate the percentage of  providers with  certain  
characteristics with +/- 10-percent precision at the 95-percent confidence level assuming a 
75-percent response rate and assuming that 7 percent would be excluded because of ongoing  
OIG investigations. 
  OEI-05-10-00050   GUIDANCE AND  STANDARDS ON  LANGUAGE ACCESS  SERVICES:   MEDICARE  PROVIDERS   9   
I N T R O D U C T I O N   
through January 2010. Of the 140 providers, 119 responded to the 
survey, for an overall response rate of 85 percent.  However, providers 
did not always answer every question; therefore, item response rates  
may be lower.  No item response rate was less than 79 percent. 
Structured interviews. In January 2010, we conducted separate  
structured interviews with OCR and OMH staff to obtain background  
information. We interviewed OCR staff about their role and activities 
related to Title VI enforcement, OCR guidance, and the types of 
technical assistance OCR provided for language access services.  We  
interviewed OMH staff about their activities related to CLAS standards. 
Data Analysis 
To analyze providers survey responses, we calculated response category 
frequencies for the key questions related to whether providers 
conducted the four-factor assessment recommended by OCR guidance  
and whether providers  offered language access services consistent with 
all four CLAS standards on language access services.  We also analyzed 
the percentage of providers that completed each individual factor of the 
four-factor assessment and offered language access services consistent 
with each of the four standards. 
We considered a provider to have conducted the four-factor assessment 
if the provider indicated  at least one  activity corresponding with each of 
the four factors.  Table 1 lists each of the four factors and the  
corresponding survey question.  See Appendix C for the categories of 
responses to each question. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  OEI-05-10-00050   GUIDANCE AND  STANDARDS ON  LANGUAGE ACCESS  SERVICES:   MEDICARE  PROVIDERS   10  NTRODUCT  o  N 
Table 1:  OCR Four Factors and Corresponding Survey 
Questions 
Four Factors in OCR Guidance  Corresponding Question in Survey of Providers 
Factor 1: The number or proportion of LEP  Which of the following sources of information does your 
persons eligible to be served or likely to be  organization use to determine the number or proportion 
encountered in the recipient's service  of LEP persons from each language group represented 
population  in its geographic service area? 
Which of the following sources of information does your 
Factor 2:  The frequency with which LEP 
organization use to track how often it encounters LEP 
persons come into contact with the recipient 
persons? 
When determining whether to communicate to LEP 
Factor 3:  The importance, nature, and 
persons in their preferred language, does your 
urgency of the program, activity, or service to 
organization consider the importance and urgency of 
people's lives 
the activity, program, or service to people's lives? 
Factor 4:  The resources available to the  How does your organization assess whether it has 
recipient and costs for offering language  resources available to provide language access 
access services  services? 
Source: OCR guidance and OIG survey of providers, 2010. 
Similarly, we considered a provider to have offered language access 
services consistent with CLAS standards if the provider indicated 
activities meeting each ofthe four standards.  For Standards 4, 6, and 7, 
we considered a provider to have offered language access services 
consistent with the standard if it indicated at least one activity 
corresponding with each of the survey questions about these standards. 
For Standard 5, providers needed to indicate at least two activities-one 
associated with verbal notification of rights and another associated with 
written notification.  Table 2 lists the four CLAS standards on language 
access services and the corresponding survey question(s).  See 
Appendix C for the categories of responses to each question. 
OEI051000050  GUIDANCE AND STANDARDS ON LANGUAGE ACCESS SERVICES:  MEDICARE PROVIDERS  11  NTRODUCT  ON 
Table 2:  CLAS Standards and Corresponding Survey Questions 
Corresponding Questions in Survey of 
CLAS Standards on Language Access Services 
Providers 
Standard 4:  Health care organizations must offer and 
provide language assistance services, including 
During what percentage of your 
bilingual staff and interpreter services, at no cost to 
organization's business hours are 
each patienUconsumer with limited English proficiency 
language access services offered? 
at all points of contact, in a timely manner during all 
hours of operation. 
Standard 5:  Health care organizations must provide to  Does your organization inform LEP 
patients/consumers in their preferred language both  persons of their right to receive language 
verbal offers and written notices informing them of their  access services in their preferred 
right to receive language assistance services.  language in any of the following ways? 
Standard 6:  Health care organizations must assure 
the competence of language assistance provided to 
Which of the following training topics 
limited English proficient patients/consumers by 
does your organization require for staff, 
interpreters and bilingual staff.  Family and friends 
contractors, and volunteers? 
should not be used to provide interpretation services 
(except on request by the patienUconsumer). 
Which of the following written materials 
are translated into the languages of 
Standard 7:  Health care organizations must make  commonly encountered groups? 
available easily understood patient-related materials 
and post signage in the languages of the commonly 
encountered groups and/or groups represented in the 
service area.  Which of the following types of signs are 
posted in the languages of commonly 
encountered groups? 
Source: CLAS standards and OIG survey of providers, 2010. 
The survey had two questions related to CLAS Standard 7 to 
distinguish between patient-related materials and signs.  Ten percent of 
providers responded "Not applicable" to the survey question related to 
posting signs.  Upon review of the provider types, we concluded that this 
was a reasonable response for specific providers, such as home health 
agencies, and counted these providers as having offered language access 
services consistent with CLAS Standard 7 ifthey indicated only 
activities related to translating written materials. 
OEI051000050  GUIDANCE AND STANDARDS ON LANGUAGE ACCESS SERVICES:  MEDICARE PROVIDERS  12  INTRODUCTION 
We used the results of the response category frequencies for the CLAS 
standards to determine whether one standard was completed more or 
less frequently than any other standard.  We used the Bonferroni 
method of multiple comparisons to determine whether any noted 
differences were statistically significant.  A difference was statistically 
significant if the confidence interval of the difference did not contain 
zero using an alpha ofO.O!. 
Where possible, we calculated frequencies and ranges on the key 
questions related to costs, savings, nonfinancial obstacles, and benefits. 
We also reviewed providers' comments about how they calculated cost 
data to determine the extent to which the reported costs were 
comparable. 
Unless noted, we projected survey statistics to all 16,853 Medicare 
providers located in the 313 counties with a high percentage ofLEP 
persons.  See Appendix D for a list of 95"percent confidence intervals for 
all statistical projections. 
Data Limitations 
This report relies on self"reported data.  We did not verify providers' 
responses. 
Because populations may shift, the 2000 decennial Census data may not 
exactly reflect the counties with the highest percentage of LEP persons 
in 2009, when the sample was selected.  However, they were the most 
recent data available for all counties in the same year. 
Standards 
This study was conducted in accordance with the Quality Standards for 
Inspections approved by the Council ofthe Inspectors General on 
Integrity and Efficiency. 
OEI051000050  GUIDANCE AND STANDARDS ON LANGUAGE ACCESS SERVICES:  MEDICARE PROVIDERS  13   
 FF II NN DD II NN GG SS   
Sixty-nine percent of providers conducted the  Sixty-nine percent of Medicare 
four-factor assessment recommended by OCR  providers in counties with a high 
percentage of LEP persons 
guidance when determining what language 
considered all four factors of the 
access services to offer  
recommended assessment.  As 
noted previously, OCR guidance is not mandatory.  Rather, it is 
guidance that providers may use to ensure meaningful access for LEP 
persons to critical services while not imposing an undue burden on 
small providers.   
Providers that conducted the recommended four-factor assessment were 
more likely to be familiar with the OCR guidance.44  Specifically, 
85 percent of providers that conducted the assessment reported being 
familiar with the guidance.  In contrast, only 40 percent of providers 
that did not conduct the assessment reported being familiar with the 
guidance.   
Even though 31 percent of providers did not consider all four factors, 
almost all providers considered some of these factors.  Eighty-four 
percent of providers considered at least three of the four factors and 
97 percent considered at least one of the factors.  Chart 1 illustrates the 
extent to which providers considered the four factors. 
 
 
 
 
 
 
 
 
 
 
 
 
 
44 The difference is statistically significant at the 95-percent confidence level. 
  OEI-05-10-00050  GUIDANCE AND STANDARDS ON LANGUAGE ACCESS SERVICES:  MEDICARE PROVIDERS  14   
F I N D I N G S  
 
 
Chart 1:  Number 
of Factors  Completed no 
Completed one  factors, 3%
Completed, by  factor, 4%
Percentage of 
Providers  Completed two 
  factors, 9%
Completed three 
factors, 15%
Completed all four 
factors, 
69%
  Source:  OIG analysis of provider survey responses, 2010. 
 
When the factors are reviewed individually, the factor completed most 
frequently was Factor 4, assessing available resources.  Table 3 lists the 
four factors and the percentage of providers that reported completing 
each factor. 
 
Table 3:  OCR Four Factors and Percentage of Providers 
Completing Each Factor 
Four Factors in OCR Guidance  Percentage of Providers 
Factor 1:  The number or proportion of LEP persons eligible to 
be served or likely to be encountered in the recipients service  78% 
population 
Factor 2:  The frequency with which LEP persons come in 
80% 
contact with the recipient 
Factor 3:  The importance, nature, and urgency of the program, 
92% 
activity, or service to peoples lives 
Factor 4:  The resources available to the recipient and costs for 
94% 
offering language access services 
Source:  OCR guidance and OIG analysis of provider survey responses, 2010. 
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Seventy-eight percent of providers reported determining the number or 
proportion of LEP persons in their service areas 
Corresponding to the first factor in OCR guidance, 78 percent of 
providers reported determining the number or proportion of LEP 
persons represented in their geographic service areas.  The greater the 
number or proportion of LEP persons, the greater the likelihood that 
language access services are needed.   
Providers reported determining the number or proportion of LEP 
persons represented in their service areas using a variety of information 
sources, as listed in Table 4. 
Table 4:  Sources Providers Reported Using To Determine 
Number of LEP Persons 
Sources*  Percentage of Providers 
Patient utilization data  61% 
Census data  45% 
Community assessments conducted by their organizations  31% 
Medicare data  30% 
County or State health status reports  24% 
Community assessments conducted by community organizations  15% 
School enrollment data  7% 
*Choices are not mutually exclusive. 
Source:  OIG analysis of provider survey responses, 2010. 
 
OCR guidance states that providers should first rely on their data from 
prior experiences with LEP encounters to determine the number of LEP 
persons in their geographic service areas.  It also recommends that 
providers refine this assessment using other data sources.  Seventy-one 
percent of providers that reported determining the number of LEP 
persons used multiple data sources.  Providers relied primarily on 
patient utilization data, supplemented with other sources, to determine 
the number of LEP persons in their service areas.  Only 17 percent of 
providers reported using patient utilization data as their only source. 
Although 78 percent of providers reported determining the number of 
LEP persons in their service areas, only 46 percent reported that they 
monitor changes in the LEP population.  Even though OCR guidance 
does not recommend that providers monitor demographic changes, it 
does note that a recipients LEP plan may require annual reevaluation 
  OEI-05-10-00050  GUIDANCE AND STANDARDS ON LANGUAGE ACCESS SERVICES:  MEDICARE PROVIDERS  16   
F I N D I N G S  
of changes in demographics.  Assessing data for shifts in the LEP 
population can help ensure that providers remain up-to-date on 
language needs in their service areas.  Only 34 percent of providers 
reported monitoring changes in the LEP population annually.  An 
additional 10 percent reported monitoring changes every 5 years and 2 
percent reported monitoring changes every 10 years. 
Eighty percent of providers reported determining the frequency of contact 
with LEP persons 
Corresponding to the second factor in OCR guidance, 80 percent of 
providers reported determining the frequency with which they 
encountered LEP persons.  The more frequent the contact with a 
particular language group, the more likely that language access services 
in that language are needed.   
Providers reported collecting data on encounters with LEP persons 
primarily from two sources.  Sixty-four percent of providers reported 
using data from patient databases and 62 percent reported using data 
from patient medical records.  Forty-nine percent used both sources. 
Ninety-two percent of providers reported considering the situation when 
determining what language access services to provide or reported offering 
services in all situations 
Ninety-two percent of providers reported activities that correspond to 
the third factor in OCR guidance for determining the importance of 
language access services.  This factor recommends that providers 
determine whether denial or delay of services or information because of 
a lack of language access services could have serious implications for 
LEP persons.  To that end, 15 percent of providers reported assessing 
the importance and urgency of their programs, activities, and services.  
An additional 77 percent reported offering language access services in 
all types of situations regardless of importance and urgency, in which 
case determining the importance and urgency is no longer necessary. 
Ninety-four percent of providers reported assessing the available resources 
Almost all providers reported assessing available financial, material, 
and staff resources when determining what language access services to 
offer; such an assessment corresponds to the fourth factor in OCR 
guidance.  Providers may use information about available resources to 
help them balance costs and benefits when deciding what language 
access services to offer.  See Table E-1 in Appendix E for a list of the 
available resources that providers reported assessing. 
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F I N D I N G S  
Ninety-eight percent of providers 
Only 33 percent of providers offered services 
in counties with a high percentage 
consistent with all four CLAS standards on 
of LEP persons reported offering 
language access services  
some language access services, but 
only 33 percent offered services consistent with all four of OMHs CLAS 
standards on language access services.  As noted previously, CLAS 
standards are not mandatory.  Rather, they are a resource that 
providers can use when developing their language access services. 
Providers that offered language access services consistent with all four 
CLAS standards were more likely to be familiar with these standards.45  
Specifically, 82 percent of providers that offered language access 
services consistent with all four standards reported being familiar with 
the standards.  In contrast, only 55 percent of providers that offered 
language access services that were not consistent with all four CLAS 
standards reported being familiar with the standards. 
When the standards are reviewed individually, providers were most 
likely to offer language access services consistent with the standard 
about assuring the competence of language assistance provided by staff 
as opposed to the standards stating that services must be available 
during all business hours, that patients must be informed of their rights 
both verbally and in writing, and that written materials and signage 
should be translated into appropriate languages.46  See Table 5 for each 
of the four CLAS standards on language access services and the 
percentage of providers that reported offering services consistent with 
each standard. 
 
 
 
 
 
 
 
 
45 The difference is statistically significant at the 95-percent confidence level. 
46 The difference is statistically different from other standards at the 95-percent 
confidence level in a multiple comparison test using a Bonferroni threshold of 0.01. 
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F I N D I N G S  
Table 5:  CLAS Standards and Percentage of Providers Offering 
Services Consistent With Each Standard 
Percentage of 
CLAS Standards on Language Access Services 
Providers 
Standard 4:  Provide language assistance services at no cost to each patient 
with limited English proficiency at all points of contact, in a timely manner during  64% 
all hours of operation. 
Standard 5:  Provide to patients in their preferred language both verbal offers 
and written notices informing them of their right to receive language assistance  52% 
services. 
Standard 6:  Assure the competence of language assistance provided.  Family 
and friends should not be used to provide interpretation services (except on  86% 
request by the patient). 
Standard 7:  Make available easily understood patient-related materials and 
post signage in the languages of the commonly encountered groups in the  71% 
service area. 
Source:  CLAS standards and OIG analysis of provider survey responses, 2010. 
 
Sixty-four percent of providers reported offering language access services 
during all business hours 
Consistent with CLAS Standard 4, 64 percent of providers reported 
offering some type of language access services during all hours of 
operation.  Further, 15 percent of providers offered language access 
services during more than half but less than all of their business hours. 
Fifty-two percent of providers reported informing LEP persons both verbally 
and in writing of their right to receive language access services 
Consistent with CLAS Standard 5, 52 percent of providers reported 
informing LEP persons verbally and in writing of their right to receive 
language access services.  However, 23 percent of providers reported 
notifying LEP persons only verbally at check-in.  Fifteen percent of 
providers reported notifying LEP persons only in writing of their right 
to receive language access services.  Providers informed LEP persons in 
writing either through translated handouts or signs. 
 
 
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F I N D I N G S  
Eighty-six percent of providers reported requiring training for staff, 
contractors, and volunteers on language access services 
Consistent with CLAS Standard 6, 86 percent of providers reported 
requiring training for staff, contractors, and volunteers on language 
access services.  See Table E-2 in Appendix E for a list of the training 
topics that providers reported requiring for staff, contractors, and 
volunteers. 
This standard also recommends that family and friends not be used as 
interpreters except when requested by the patient.  Further, this 
standard states that minor children should never be used as 
interpreters or be allowed to interpret for their parents when they are 
the patients.  Seventy percent of providers required training for staff, 
contractors, and volunteers on the use of family and friends as 
interpreters.  In particular, 28 percent of providers required training on 
the use of minor children as interpreters.47 
Although most providers reported requiring training for staff, 
contractors, and volunteers on language access services, only 39 percent 
reported formally testing them on their skills and competencies in 
providing language access services.  CLAS Standard 6 mentions formal 
testing as a way to assure the competence of language assistance 
provided by staff.  See Table E-3 in Appendix E for a list of the topics 
providers reported covering on formal tests. 
Seventy-one percent of providers reported translating materials and posting 
signs in the languages of commonly encountered groups 
Consistent with CLAS Standard 7, 71 percent of providers reported 
translating written materials and posting signs in the languages of 
commonly encountered groups. 
Materials.  Eighty-nine percent of providers reported translating at least 
one type of patient-related written material into the languages of 
commonly encountered groups.  Further, 88 percent of providers 
reported translating at least one critical document as outlined by OCR 
guidance and CLAS standards as documents that are particularly 
important to translate.  These documents include, but are not limited to, 
patients rights information; medication directions; and screening, 
diagnosis, and treatment explanations.  However, only 8 percent of 
providers translated all critical documents.  See Table E-4 in 
 
47 Choices are not mutually exclusive. 
  OEI-05-10-00050  GUIDANCE AND STANDARDS ON LANGUAGE ACCESS SERVICES:  MEDICARE PROVIDERS  20   
F I N D I N G S  
Appendix E for a complete list of materials that providers reported 
translating. 
Signs.  Seventy-nine percent of providers either reported posting 
translated signs or reported that posting signs was not applicable to 
their organizations.  Signs should provide notices of patient rights, the 
conflict and grievance process, and directions to facility services.  
Specifically, 68 percent of providers reported posting signs in the 
languages of commonly encountered groups.  An additional 10 percent of 
providers reported that posting signs was not applicable to their 
organizations.48  See Table E-5 in Appendix E for a list of signs that 
providers reported posting in commonly encountered languages. 
 
Seventy-three percent of providers reported  Seventy-three percent of providers 
benefits to providing language access services  reported benefits to providing 
language access services.  The 
and half reported obstacles 
four most frequently reported 
benefits were (1) improved communication, (2) improved adherence to 
treatment regimen, (3) improved diagnosis and treatment, and (4) fewer 
complaints.  See Table 6 for a list of benefits that providers reported. 
 
 
 
 
 
 
 
 
 
 
 
 
 
48 Percentages do not add to 79 percent because of rounding. 
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F I N D I N G S  
Table 6:  Benefits Reported by Providers 
Benefits*  Percentage of Providers 
Improved communication  66% 
Improved adherence to treatment regimen  58% 
Improved diagnosis and treatment  51% 
Fewer complaints  51% 
Fewer adverse events and medical errors  45% 
Fewer emergency visits  26% 
Reduced length of patient visits  22% 
Improved billing and collections  20% 
Fewer facility readmissions  17% 
Reduced length of facility stays  12% 
Financial savings  2% 
*Choices are not mutually exclusive.    
Source:  OIG analysis of provider survey responses, 2010. 
 
Very few providers reported financial savings from providing language 
access services.  In fact, only 2 percent of providers reported that they 
saved money by providing language access services.  Fifty-three percent 
of providers reported that they did not know whether they saved any 
money.  One provider explained that savings because of a reduction in 
unnecessary tests, visits, and emergency room usage are difficult to 
measure while direct costs, such as those for interpreters, are 
measurable. 
Fifty-four percent of providers reported obstacles to providing language 
access services 
Fifty-four percent of providers reported obstacles to providing language 
access services, including such things as (1) a lack of training resources 
for staff, (2) costs of providing language access services, and 
(3) the broad range of languages spoken in the providers communities.  
See Table 7 for a list of obstacles reported. 
 
 
 
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F I N D I N G S  
Table 7:  Obstacles Reported by Providers  
Obstacles*  Percentage of Providers 
Lack of training resources for staff  32% 
Cost of providing language access services  27% 
Broad range of languages spoken in community  26% 
Liability concerns  21% 
Lack of staffing  18% 
Staff discomfort in providing language access services  14% 
Lack of means for staff to identify LEP persons  6% 
*Choices are not mutually exclusive.    
Source:  OIG analysis of provider survey responses, 2010.   
 
Twenty-seven percent of providers reported cost as an obstacle.  
Providers may perceive costs to be an obstacle because they may not see 
savings that would offset their investment in providing language access 
services.  Most providers bear the full cost of providing language access 
services.  Only 3 percent reported receiving direct reimbursement for 
providing these services.  Providers reported that these reimbursements 
were received from Medicaid and State or local governments. 
Forty-five percent of providers reported that it would be useful to have 
additional assistance in overcoming obstacles and implementing 
language access services.  In responding to the survey, these providers 
wrote in specific requests for assistance.  These requests were, in 
general, for additional information, training, and financial assistance 
for providing language access services. 
Specifically, information requests included such things as 
already-translated documents or the names of organizations that 
provide cost-effective translation and interpretation.  Providers were 
interested particularly in resources within their communities.  Another 
suggestion providers made was that models of language service 
provision be made available. 
 
 
 
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F I N D I N G S  
 
Because of the overall lack of 
Few providers reported data on the costs of 
reporting and the inability to 
providing language access services and the 
compare data, we were unable to 
data provided were not comparable
make any determinations about cost 
data related to language access services.   
Of the 119 providers that responded to the survey, only 49 providers 
responded to the request for cost data.  These providers reported data 
for at least one of the following requests:  (1) annual expenditures on 
language access services, (2) expenditures by type of language access 
service, (3) expenditures by LEP person, or (4) expenditures on staff 
training for language assistance.  Only three of these providers reported 
all requested cost data. 
The cost data reported by the 49 providers ranged widely.  For example, 
FY 2008 expenditures by one provider on interpreter services 
totaled $50.  On the other hand, another provider indicated its total FY 
2008 costs for interpreter services were $779,494.  Data for cost per LEP 
person for interpreter services mirrored this wide range with one 
provider reporting spending $0.33 per LEP person and another provider 
reporting $1,500 per LEP person.   
Providers comments about how they calculated the data indicated that 
the wide range of costs might be the result of different approaches to 
calculating costs rather than a reflection of varying levels of service.  
For example, some providers reported capturing cost data at the 
organizational level rather than at the facility level and were unable to 
break out the data by facility.  In addition, some providers indicated 
that they were unable to exclude salary costs (e.g., for bilingual 
employees) from cost data on language access services. 
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 R E C O M M E N D A T I O N S  
Sixty-nine percent of Medicare providers in counties with a high 
percentage of LEP persons conducted the four-factor assessment 
recommended by OCR guidance when determining what language 
access services to offer.  However, only 33 percent of providers offered 
services consistent with all four CLAS standards on language access 
services. 
OMH created the CLAS standards to guide providers to become more 
responsive to the cultural and linguistic needs of diverse populations.  
Providing language access services is crucial to ensuring access to 
high-quality health care for LEP persons.  Clear communication 
between LEP persons and providers can lead to better health outcomes 
for LEP persons. 
The MIPPA requires OIG to make recommendations on improving 
compliance with and enforcement of CLAS standards.  However, in 
keeping with our assessment of voluntary compliance, we make 
recommendations to increase the percentage of providers that 
voluntarily offer services consistent with all four CLAS standards on 
language access services.  
Providers that offered language access services consistent with the 
CLAS standards were more likely to be familiar with them.  This 
indicates that educating providers on the standards may lead to an 
increase in the percentage of providers offering language access services 
consistent with CLAS standards.   
To improve Medicare providers awareness and implementation of CLAS 
standards, we recommend that: 
OCR should inform providers about OMHs CLAS standards 
OCR should assist providers that receive Federal financial assistance in 
offering high-quality language access services by informing them of 
OMHs CLAS standards.  OCR could also inform providers about 
associated OMH resources, such as the Health Care Languages Services 
Implementation Guide.  This could be done during civil rights reviews of 
new Medicare providers, technical assistance interactions, and 
complaint investigations involving LEP persons.  During the civil rights 
review process, OCR, unlike OMH, has direct contact with almost all 
new Medicare providers that receive Federal financial assistance, such 
as hospitals, nursing homes, and home health agencies.  Therefore, OCR 
has unique opportunities for education.  OCR staff indicated that a 
collaborative relationship with OMH already exists, and we encourage 
  OEI-05-10-00050  GUIDANCE AND STANDARDS ON LANGUAGE ACCESS SERVICES:  MEDICARE PROVIDERS  25   
R E C O M M E N D A T I O N S  
the two offices to continue sharing resource information to assist 
providers with serving LEP persons. 
OMH should increase outreach to providers to familiarize them with CLAS 
standards 
OMH should increase provider awareness of the CLAS standards by 
proactively educating them about this resource.  OMH should be more 
proactive in its outreach because providers that are seeking out OMHs 
online resources are likely already aware of the need to be culturally 
and linguistically accessible.  To be more proactive, OMH could lead an 
effort to increase awareness among providers about CLAS standards.  
OMH could collaborate with other HHS operating divisions that focus 
on health care, including CMS, as well as work with provider 
associations to disseminate the CLAS standards to providers.   
The collaborative effort to inform providers about CLAS standards could 
focus on educating providers on the specific Language Access Services 
standards that providers were less likely to have implemented.  To that 
end, the effort could stress that the CLAS standards encourage 
providers to (1) offer language access services during all hours of 
operation; (2) inform LEP persons both verbally and in writing of their 
right to receive language access services; (3) translate and post signs, 
particularly directions to facility services; and (4) translate critical 
materials. 
In addition, we make the following recommendation to help Medicare 
providers offer affordable and accurate language access services: 
OMH should offer model translated written materials and signs to providers 
One suggestion offered by providers was that information about how to 
obtain already-translated materials be made available.  To that end, 
OMH should provide model standard language for some frequently used 
written materials and signs in the languages of commonly encountered 
groups.  OMH could take the lead in collaborating with other HHS 
operating divisions to develop model language for these materials.  In 
particular, OMH could focus on providing translated language for 
critical documents.  For example, OMH could provide language 
explaining patients rights to language access services.  After 
development, OMH could make the model language available online 
through its Center. 
A number of benefits could be realized if OMH assisted providers with 
model translated written materials and signs.  OMH could reduce the 
financial burden on providers, which in turn could help increase the 
  OEI-05-10-00050  GUIDANCE AND STANDARDS ON LANGUAGE ACCESS SERVICES:  MEDICARE PROVIDERS  26   
R E C O M M E N D A T I O N S  
percentage of providers that offer translated materials.  In addition, 
OMH would be ensuring the accuracy of critical patient-related 
documents offered to LEP persons. 
AGENCIES COMMENTS AND OFFICE OF INSPECTOR 
GENERAL RESPONSE 
OCR and OMH concurred with our recommendations.  OMH stated that 
it will take the lead in developing specific marketing strategies to 
inform providers of the CLAS standards.  CMS indicated that it did not 
have any substantive comments.  However, it did provide technical 
comments that we incorporated as appropriate. 
For the full text of the agencies comments, see Appendix F.
  OEI-05-10-00050  GUIDANCE AND STANDARDS ON LANGUAGE ACCESS SERVICES:  MEDICARE PROVIDERS  27   
 A P P E N D I X   ~   A  
Section 187 of the Medicare Improvements for Patients and 
Providers Act of 2008 
 
SEC. 187. OFFICE OF THE INSPECTOR GENERAL REPORT ON 
COMPLIANCE WITH AND ENFORCEMENT OF NATIONAL 
STANDARDS ON CULTURALLY AND LINGUISTICALLY 
APPROPRIATE SERVICES (CLAS) IN MEDICARE. 
(a)  REPORT.Not later than two years after the date of the enactment 
of this Act, the Inspector General of the Department of Health and 
Human Services shall prepare and publish a report on  
(1) the extent to which Medicare providers and plans are complying 
with the Office for Civil Rights Guidance to Federal Financial 
Assistance Recipients Regarding Title VI Prohibition Against 
National Origin Discrimination Affecting Limited English Proficient 
Persons and the Office of Minority Healths Culturally and 
Linguistically Appropriate Services Standards in health care; and  
(2) a description of the costs associated with or savings related to the 
provision of language services.  Such report shall include 
recommendations on improving compliance with CLAS Standards 
and recommendations on improving enforcement of CLAS Standards. 
(b)  IMPLEMENTATION.Not later than one year after the date of 
publication of the report under subsection (a), the Department of Health 
and Human Services shall implement changes responsive to any 
deficiencies identified in the report. 
  OEI-05-10-00050  GUIDANCE AND STANDARDS ON LANGUAGE ACCESS SERVICES:  MEDICARE PROVIDERS  28   
 A P P E N D I X   ~   B  
Culturally and Linguistically Appropriate Services in Health Care 
Standards49 
 
Standard 1.  Health care organizations should ensure that 
patients/consumers receive from all staff members effective, 
understandable, and respectful care that is provided in a manner 
compatible with their cultural health beliefs and practices and preferred 
language.  
Standard 2.  Health care organizations should implement strategies to 
recruit, retain, and promote at all levels of the organization a diverse 
staff and leadership that are representative of the demographic 
characteristics of the service area.   
Standard 3.  Health care organizations should ensure that staff at all 
levels and across all disciplines receive ongoing education and training 
in culturally and linguistically appropriate service delivery.   
Standard 4.  Health care organizations must offer and provide language 
assistance services, including bilingual staff and interpreter services, at 
no cost to each patient/consumer with limited English proficiency at all 
points of contact, in a timely manner during all hours of operation.  
Standard 5.  Health care organizations must provide to 
patients/consumers in their preferred language both verbal offers and 
written notices informing them of their right to receive language 
assistance services. 
Standard 6.  Health care organizations must assure the competence of 
language assistance provided to limited English proficient 
patients/consumers by interpreters and bilingual staff.  Family and 
friends should not be used to provide interpretation services (except on 
request by the patient/consumer).  
Standard 7.  Health care organizations must make available easily 
understood patient-related materials and post signage in the languages 
of the commonly encountered groups and/or groups represented in the 
service area.   
 
49 Office of Minority Health, National Standards on Culturally and Linguistically 
Appropriate Services in Health Care (CLAS), March 2001.  Accessed at 
http://minorityhealth.hhs.gov on February 12, 2010. 
  OEI-05-10-00050  GUIDANCE AND STANDARDS ON LANGUAGE ACCESS SERVICES:  MEDICARE PROVIDERS  29   
A P P E N D I X   ~   B  
 
Standard 8.  Health care organizations should develop, implement, and 
promote a written strategic plan that outlines clear goals, policies, 
operational plans, and management accountability/oversight 
mechanisms to provide culturally and linguistically appropriate 
services.  
Standard 9.  Health care organizations should conduct initial and 
ongoing organizational self-assessments of CLAS-related activities and 
are encouraged to integrate cultural and linguistic competence-related 
measures into their internal audits, performance improvement 
programs, patient satisfaction assessments, and outcomes-based 
evaluations.   
Standard 10.  Health care organizations should ensure that data on the 
individual patients/consumers race, ethnicity, and spoken and written 
language are collected in health records, integrated into the 
organizations management information systems, and periodically 
updated.   
Standard 11.  Health care organizations should maintain a current 
demographic, cultural, and epidemiological profile of the community as 
well as a needs assessment to accurately plan for and implement 
services that respond to the cultural and linguistic characteristics of the 
service area.   
Standard 12.  Health care organizations should develop participatory, 
collaborative partnerships with communities and utilize a variety of 
formal and informal mechanisms to facilitate community and 
patient/consumer involvement in designing and implementing 
CLAS-related activities.   
Standard 13.  Health care organizations should ensure that conflict and 
grievance resolution processes are culturally and linguistically sensitive 
and capable of identifying, preventing, and resolving cross-cultural 
conflicts or complaints by patients/consumers.  
Standard 14.  Health care organizations are encouraged to regularly 
make available to the public information about their progress and 
successful innovations in implementing the CLAS standards and to 
provide public notice in their communities about the availability of this 
information. 
  OEI-05-10-00050  GUIDANCE AND STANDARDS ON LANGUAGE ACCESS SERVICES:  MEDICARE PROVIDERS  30   
 A P P E N D I X   ~   C  
Categories of Responses to Key Survey Questions 
Office for Civil Rights (OCR) Factor 1 Question:  Which of the following sources of information 
does your organization use to determine the number or proportion of Limited English Proficient 
(LEP) persons from each language group represented in its geographic service area? 
a) Census data 
b) Community assessment conducted by a community organization 
c) Community assessment conducted by your organization 
d) County or State health status reports 
e) Medicare data 
f) Patient utilization data 
g) School enrollment profiles 
h) Other (please specify) 
 
OCR Factor 2 Question:  Which of the following sources of information does your organization 
use to track how often it encounters LEP persons? 
a) Patient database 
b) Patient medical records 
c) Other (please specify) 
 
OCR Factor 3 Question:  When determining whether to communicate with LEP persons in their 
preferred language, does your organization consider the importance and urgency of the activity, 
program, or service to peoples lives? 
a) We provide language access services in all situations. 
b) We consider the importance and urgency of the situation when determining what 
language access services to provide. 
 
OCR Factor 4 Question:  How does your organization assess whether it has resources available 
to provide language access services? 
a) Assess availability of bilingual staff 
b) Assess available technology 
c) Determine whether outside funding is available 
d) Examine operating funds to determine whether money is available 
e) Review available community resources 
f) Other (please specify) 
  OEI-05-10-00050  GUIDANCE AND STANDARDS ON LANGUAGE ACCESS SERVICES:  MEDICARE PROVIDERS  31   
A P P E N D I X   ~   C  
Culturally and Linguistically Appropriate Services in Health Care (CLAS) Standard 4 Question:  
During what percentage of your organizations business hours are language access services 
offered? 
a) All (100%) 
b) More than 50% but less than 100% 
c) Less than or equal to 50% 
d) Organization does not offer language access services 
 
CLAS Standard 5 Question:  Does your organization inform LEP persons of their right to receive 
language access services in their preferred language in any of the following ways? 
a) Given copies of language access rights materials in their preferred language 
b) Referred to posted and translated signs about language access services 
c) Told verbally during check-in process 
d) Other (please specify) 
 
CLAS Standard 6 Question:  Which of the following training topics does your organization 
require for staff, contractors, and volunteers? 
a) Cultural competence 
b) Demographic data of communities served 
c) How to collect data on primary language from LEP persons 
d) How to respond to people who do not speak English 
e) Information related to written policies and procedures regarding language access 
services 
f) Language skills 
g) Use of I Speak cards or other communication aids 
h) Use of family members or friends as interpreters 
i) Use of minor children as interpreters 
j) Other (please specify) 
  OEI-05-10-00050  GUIDANCE AND STANDARDS ON LANGUAGE ACCESS SERVICES:  MEDICARE PROVIDERS  32   
A P P E N D I X   ~   C  
CLAS Standard 7 Question 1:  Which of the following written materials are translated into the 
languages of commonly encountered groups?  
a) Advance directives 
b) Applications to receive services 
c) Community resources 
d) Complaint forms 
e) Discharge instructions 
f) Explanations of screening, diagnosis, or treatment options 
g) Facility menus 
h) Financial assistance forms 
i) Illness-related education 
j) Informed consent documents 
k) Intake forms 
l) I Speak cards or other communication aids 
m) Medication management and prescription directions 
n) Notice of language access services 
o) Patients rights information 
p) Wellness-related education 
q) Other (please specify) 
 
CLAS Standard 7 Question 2:  Which of the following types of signs are posted in the languages 
of commonly encountered groups? 
a) Available services 
b) Business hours 
c) Conflict and grievance procedures 
d) Directions to facility services (such as admissions, pediatrics, emergency room, etc.) 
e) Explanation of right to language access 
f) Patients rights information 
g) Other (please specify) 
  OEI-05-10-00050  GUIDANCE AND STANDARDS ON LANGUAGE ACCESS SERVICES:  MEDICARE PROVIDERS  33   
 A P P E N D I X   ~   D  
Estimates and Confidence Intervals 
Table D-1:  Estimates of Survey Responses 
Point  95-Percent
Estimate Description  Sample Size 
Estimate  Confidence Interval 
Percentage of providers that conducted the four-factor assessment 
recommended by Office for Civil Rights (OCR) guidance when  119  68.9  60.5%77.3% 
determining whether to offer language access services 
Percentage of providers that conducted the assessment recommended 
82  85.4  77.6%93.1% 
by OCR guidance that reported being familiar with it 
Percentage of providers that did not conduct the four-factor assessment 
35  40.0  23.5%56.5% 
recommended by OCR guidance but reported being familiar with it 
Percentage of providers that did not complete all four OCR factors  119  31.1  22.7%39.5% 
Percentage of providers that completed at least three of the four OCR 
119  84.0  77.4%90.7% 
factors 
Percentage of providers that completed at least one of the four OCR 
119  97.5  92.8%99.5%* 
factors 
Percentage of providers that completed three OCR factors  119  15.1  8.6%21.7% 
Percentage of providers that completed two OCR factors  119  9.2  4.0%14.5% 
Percentage of providers that completed one OCR factor  119  4.2  0.5%7.9% 
Percentage of providers that completed no OCR factors  119  2.5  0.5%7.2%* 
Percentage of providers that reported determining the number or 
proportion of Limited English Proficient (LEP) persons they were eligible 
119  78.2  70.6%85.7% 
to serve or likely to encounter in their geographic service areas (OCR 
Factor 1) 
Percentage of providers that reported determining the frequency of 
119  79.8  72.5%87.1% 
contact with LEP persons (OCR Factor 2) 
Percentage of providers that reported considering the situation when 
determining what language access services to provide or reported  119  91.6  86.5%96.7% 
offering services in all situations (OCR Factor 3) 
Percentage of providers that reported assessing available resources for 
119  94.1  89.8%98.4% 
offering language access services (OCR Factor 4) 
*Confidence interval calculated with an exact method based on the binomial distribution. 
   
continued on next page 
  OEI-05-10-00050  GUIDANCE AND STANDARDS ON LANGUAGE ACCESS SERVICES:  MEDICARE PROVIDERS  34   
A P P E N D I X   ~   D  
Table D-1:  Estimates of Survey Responses, continued 
Point  95-Percent
Estimate Description  Sample Size 
Estimate  Confidence Interval 
Percentage of providers that reported using patient utilization data to 
determine the number of LEP persons represented in their geographic  118  61.0  52.1%69.9% 
service areas 
Percentage of providers that reported using Census data to determine 
the number of LEP persons represented in their geographic service  118  44.9  35.8%54.0% 
areas 
Percentage of providers that reported using community assessments 
conducted by their organizations to determine the number of LEP  118  30.5  22.1%38.9% 
persons represented in their geographic service areas 
Percentage of providers that reported using Medicare data to determine 
the number of LEP persons represented in their geographic service  118  29.7  21.3%38.0% 
areas 
Percentage of providers that reported using county or State health 
status reports to determine the number of LEP persons represented in  118  23.7  15.9%31.5% 
their geographic service areas 
Percentage of providers that reported using community assessments 
conducted by community organizations to determine the number of LEP  118  15.3  8.7%21.8% 
persons represented in their geographic service areas 
Percentage of providers that reported using school enrollment data to 
determine the number of LEP persons represented in their geographic  118  6.8  2.2%11.4% 
service areas 
Percentage of providers that reported using multiple sources to 
determine the number of LEP persons represented in their geographic  93  71.0  61.6%80.4% 
service areas 
Percentage of providers that reported using patient utilization data as 
their only information source to determine the number of LEP persons  93  17.2  9.4%25.0% 
represented in their geographic service areas 
Percentage of providers that reported monitoring changes in the LEP 
114  45.6  36.3%54.9% 
population represented in their geographic service areas 
Percentage of providers that reported annually monitoring changes in 
114  34.2  25.4%43.1% 
the LEP population represented in their geographic service areas 
continued on next page 
  OEI-05-10-00050  GUIDANCE AND STANDARDS ON LANGUAGE ACCESS SERVICES:  MEDICARE PROVIDERS  35   
A P P E N D I X   ~   D  
Table D-1:  Estimates of Survey Responses, continued 
Point  95-Percent
Estimate Description  Sample Size 
Estimate  Confidence Interval 
Percentage of providers that reported monitoring changes in the LEP 
114  9.6  4.1%15.2% 
population represented in their geographic service areas every 5 years 
Percentage of providers that reported monitoring changes in the LEP 
114  1.8  0.2%6.2%* 
population represented in their geographic service areas every 10 years 
Percentage of providers that reported using data collected from patient 
118  63.6  54.7%72.4% 
databases when determining the frequency of contact with LEP persons 
Percentage of providers that reported using data from patient medical 
118  61.9  53.0%70.8% 
records when determining the frequency of contact with LEP persons  
Percentage of providers that reported using data from both patient 
databases and patient medical records when determining the frequency  118  49.2  40.0%58.3% 
of contact with LEP persons 
Percentage of providers that reported assessing the importance and 
118  15.3  8.7%21.8% 
urgency of their programs, activities, and services 
Percentage of providers that reported offering language access services 
118  77.1  69.4%84.8% 
in all types of situations regardless of importance and urgency 
Percentage of providers that offered language access services 
consistent with all four Culturally and Linguistically Appropriate Services  119  32.8  24.2%41.3% 
in Health Care (CLAS) standards on language access services 
Percentage of providers that offered some language access services  119  98.3  94.1%99.8%* 
Percentage of providers that offered language access services 
consistent with the CLAS standards that reported being familiar with  39  82.1  69.8%94.3% 
them 
Percentage of providers that offered language access services that 
were not consistent with CLAS standards that reported being familiar  78  55.1  43.9%66.3% 
with them 
Percentage of providers that reported offering language access services 
119  63.9  55.1%72.6% 
during all business hours (CLAS Standard 4) 
*Confidence interval calculated with an exact method based on the binomial distribution. 
continued on next page 
 
 
  OEI-05-10-00050  GUIDANCE AND STANDARDS ON LANGUAGE ACCESS SERVICES:  MEDICARE PROVIDERS  36   
A P P E N D I X   ~   D  
Table D-1:  Estimates of Survey Responses, continued 
Point  95-Percent
Estimate Description  Sample Size 
Estimate  Confidence Interval 
Percentage of providers that reported informing LEP persons verbally 
and in writing of their right to receive language access services (CLAS  119  52.1  43.0%61.2% 
Standard 5) 
Percentage of providers that reported requiring training for staff, 
contractors, and volunteers on language access services (CLAS  119  85.7  79.3%92.1% 
Standard 6) 
Percentage of providers that reported translating materials and posting 
signs in the languages of commonly encountered groups (CLAS  119  71.4  63.2%79.7% 
Standard 7) 
Percentage of providers that reported offering language access services 
116  14.7  8.1%21.2% 
during more than half of their business hours 
Percentage of providers that reported notifying LEP persons only 
104  23.1  14.8%31.3% 
verbally at check-in of their right to receive language access services 
Percentage of providers that reported notifying LEP persons only in 
104  15.4  8.3%22.4% 
writing of their right to receive language access services 
Percentage of providers that reported requiring training for staff, 
contractors, and volunteers on the use of family members or friends as  119  69.7  61.4%78.1% 
interpreters 
Percentage of providers that reported requiring training for staff, 
119  27.7  19.6%35.9% 
contractors, and volunteers on the use of minor children as interpreters 
Percentage of providers that reported formally testing the skills and 
competencies of staff, contractors, and volunteers in providing language  119  38.7  29.8%47.5% 
access services 
Percentage of providers that reported translating at least one type of 
patient-related written materials into the languages of commonly  119  89.1  83.4%94.8% 
encountered groups 
Percentage of providers that reported translating at least one critical 
119  88.2  82.4%94.1% 
document into the languages of commonly encountered groups 
Percentage of providers that reported translating all critical documents 
119  8.4  3.3%13.5% 
into the languages of commonly encountered groups 
*Confidence interval calculated with an exact method based on the binomial distribution. 
continued on next page 
  OEI-05-10-00050  GUIDANCE AND STANDARDS ON LANGUAGE ACCESS SERVICES:  MEDICARE PROVIDERS  37   
A P P E N D I X   ~   D  
Table D-1:  Estimates of Survey Responses, continued 
Point  95-Percent
Estimate Description  Sample Size 
Estimate  Confidence Interval 
Percentage of providers that reported that they either posted translated 
117  78.6  71.1%86.2% 
signs or that posting signs was not applicable to their organization 
Percentage of providers that reported posting signs in the languages of 
117  68.4  59.8%76.9% 
commonly encountered groups 
Percentage of providers that reported that posting signs was not 
117  10.3  4.7%15.8% 
applicable to their organizations 
Percentage of providers that reported benefits to providing language 
119  73.1  65.0%81.2% 
access services 
Percentage of providers that reported improved communication as a 
119  65.5  56.9%74.2% 
benefit 
Percentage of providers that reported improved adherence to treatment 
119  58.0  49.0%67.0% 
regimen as a benefit  
Percentage of providers that reported improved diagnosis and treatment 
119  51.3  42.1%60.4% 
as a benefit  
Percentage of providers that reported fewer complaints as a benefit  119  51.3  42.1%60.4% 
Percentage of providers that reported fewer adverse events and medical 
119  45.4  36.3%54.5% 
errors as a benefit 
Percentage of providers that reported fewer emergency visits as a 
119  26.1  18.0%34.1% 
benefit 
Percentage of providers that reported reduced length of patient visits as 
119  21.8  14.3%29.4% 
a benefit 
Percentage of providers that reported improved billing and collections as 
119  20.2  12.9%27.5% 
a benefit 
Percentage of providers that reported fewer facility readmissions as a 
119  16.8  10.0%23.6% 
benefit 
Percentage of providers that reported reduced length of facility stays as 
119  11.8  5.9%17.6% 
a benefit 
continued on next page 
 
 
  OEI-05-10-00050  GUIDANCE AND STANDARDS ON LANGUAGE ACCESS SERVICES:  MEDICARE PROVIDERS  38   
A P P E N D I X   ~   D  
Table D-1:  Estimates of Survey Responses, continued 
Point  95-Percent
Estimate Description  Sample Size 
Estimate  Confidence Interval 
Percentage of providers that reported saving money by providing 
119  1.7  0.2%5.9%* 
language access services 
Percentage of providers that reported that they did not know whether 
119  52.9  43.8%62.0% 
they saved money by providing language access services  
Percentage of providers that reported obstacles to providing language 
111  54.1  44.6%63.5% 
access services  
Percentage of providers that reported a lack of training resources for 
111  32.4  23.6%41.3% 
staff as an obstacle  
Percentage of providers that reported the cost of providing language 
111  27.0  18.6%35.4% 
access services as an obstacle  
Percentage of providers that reported the broad range of languages 
111  26.1  17.8%34.4% 
spoken in the community as an obstacle  
Percentage of providers that reported liability concerns as an obstacle   111  20.7  13.1%28.4% 
Percentage of providers that reported being understaffed as an obstacle  111  18.0  10.8%25.3% 
Percentage of providers that reported staff discomfort in providing 
111  14.4  7.8%21.1% 
language access services as an obstacle  
Percentage of providers that reported a lack of means for staff to identify 
111  6.3  1.7%10.9% 
LEP persons as an obstacle  
Percentage of providers that reported receiving reimbursement for 
119  2.5  0.5%7.2%* 
providing language access services 
Percentage of providers that reported that it would be useful to have 
111  45.0  35.6%54.4% 
additional assistance in implementing language access services 
*Confidence interval calculated with an exact method based on the binomial distribution. 
Source:  Office of Inspector General analysis of provider survey responses, 2010. 
 
 
  OEI-05-10-00050  GUIDANCE AND STANDARDS ON LANGUAGE ACCESS SERVICES:  MEDICARE PROVIDERS  39   
A P P E N D I X   ~   E  
 A P P E N D I X   ~   E  
Supplemental Analysis Tables 
Table E-1:  Available Resources That Providers Reported Assessing  
Percentage of  95-Percent
Available Resources*  Sample Size 
Providers  Confidence Interval 
Bilingual staff  119  89.1%  83.4%94.8% 
Technology  119  63.0%  54.2%71.8% 
Community resources  119  63.0%  54.2%71.8% 
Operating funds to determine whether money is available   119  33.6%  25.0%42.2% 
Outside funding  119  22.7%  15.1%30.3% 
*Choices are not mutually exclusive.          
Source:  Office of Inspector General (OIG) analysis of provider survey responses, 2010. 
 
Table E-2:  Training Topics for Staff, Contractors, and Volunteers 
Percentage of  95-Percent
Training Topics*  Sample Size 
Providers  Confidence Interval 
Use of family members or friends as interpreters  119  69.7%  61.4%78.1% 
How to respond to people who do not speak English  119  68.9%  60.5%77.3% 
Written policies and procedures regarding language access services  119  59.7%  50.7%68.6% 
Cultural competence  119  58.0%  49.0%67.0% 
How to collect data on primary language from Limited English Proficient 
119  37.8%  29.0%46.7% 
persons 
Language skills  119  36.1%  27.4%44.9% 
Use of "I-Speak" cards or other communication aids  119  28.6%  20.3%36.8% 
Demographic data of communities served   119  27.7%  19.6%35.9% 
Use of minor children as interpreters  119  27.7%  19.6%35.9% 
*Choices are not mutually exclusive.          
Source:  OIG analysis of provider survey responses, 2010. 
 
  OEI-05-10-00050  GUIDANCE AND STANDARDS ON LANGUAGE ACCESS SERVICES:  MEDICARE PROVIDERS  40   
A P P E N D I X   ~   E  
Table E-3:  Testing Topics Providers Reported Covering 
Percentage of  95-Percent
Testing Topics*  Sample Size 
Providers  Confidence Interval 
Confidentiality requirements  119  33.6%  25.0%42.2% 
Medical terminology  119  33.6%  25.0%42.2% 
Policies and procedures  119  30.3%  21.9%38.6% 
Ability to interpret effectively  119  27.7%  19.6%35.9% 
Proficiency in English and non-English languages   119  26.9%  18.8%35.0% 
*Choices are not mutually exclusive.          
Source:  OIG analysis of provider survey responses, 2010. 
 
  OEI-05-10-00050  GUIDANCE AND STANDARDS ON LANGUAGE ACCESS SERVICES:  MEDICARE PROVIDERS  41   
A P P E N D I X   ~   E  
Table E-4:  Materials That Providers Reported Translating 
Material  Percentage of  95-Percent
Translated Material*  Sample Size 
Type  Providers  Confidence Interval 
Patients' rights information  119  75.6%  67.8%83.5% 
Advance directives  119  65.5%  56.9%74.2% 
Informed consent documents  119  58.8%  49.9%67.8% 
Complaint forms  119  52.9%  43.8%62.0% 
Illness-related education  119  52.9%  43.8%62.0% 
Notice of language access services  119  52.1%  43.0%61.2% 
Critical  Medication management and prescription 
119  50.4%  41.3%59.5% 
directions 
Discharge instructions  119  47.9%  38.8%57.0% 
Applications to receive services  119  43.7%  34.7%52.7% 
Explanations of screening, diagnosis, or 
119  42.0%  33.0%51.0% 
treatment options 
Financial assistance forms  119  37.8%  29.0%46.7% 
Intake forms  119  36.1%  27.4%44.9% 
Community resources  119  47.9%  38.8%57.0% 
Wellness-related education  119  44.5%  35.5%53.6% 
Noncritical 
"I-Speak" cards or other communication aids  119  33.6%  25.0%42.2% 
Facility menus   119  24.4%  16.5%32.2% 
*Choices are not mutually exclusive. 
Source:  OIG analysis of provider survey responses, 2010. 
 
  OEI-05-10-00050  GUIDANCE AND STANDARDS ON LANGUAGE ACCESS SERVICES:  MEDICARE PROVIDERS  42   
A P P E N D I X   ~   E  
Table E-5:  Signs That Providers Reported Posting in Commonly Encountered 
Languages 
Percentage of  95-Percent
Types of Signs*  Sample Size 
Providers  Confidence Interval 
Patients' rights information  117  61.5%  52.6%70.5% 
Conflict and grievance procedures   117  44.4%  35.3%53.6% 
Available services   117  37.6%  28.7%46.5% 
Explanation of right to language access services   117  38.5%  29.5%47.4% 
Business hours  117  36.8%  27.9%45.6% 
Directions to facility services   117  21.4%  13.8%28.9% 
*Choices are not mutually exclusive.          
Source:  OIG analysis of provider survey responses, 2010. 
 
  OEI-05-10-00050  GUIDANCE AND STANDARDS ON LANGUAGE ACCESS SERVICES:  MEDICARE PROVIDERS  43  x 
A  P  PEN  0  F 
Agencies' Comments 
~~"J.YIC&l.V~ 
~ 
(  DEPARTMENT OF HEALTH &. HUMAN SERVICES  Office of the Secretary 
"'....:~-
Director 
Office for Ctvit Rights 
Weshington, DC 20201 
DATE:  May 27, 2010 
TO:  Daniel R. Levinson 
Inspector General 
FROM:  Georgina C. Verdugo 
Director 
SUBJECT:  Office ofInspector General (orG) Draft Reports: "Guidance and 
Standards on Language Access Services: Medicare Providers" 
(OEI-05-10-00050) 
Thank you for the opportunity to review and respond to the orG Draft Report: Guidance 
and Standards on Language Access Services: Medicare Providers (OEI-05-10-00050). 
The Office for Civil Rights (OCR) at the U.S. Department ofHealth and Human Services 
(HHS) appreciate orG's efforts to determine the extent to which Medicare providers 
utilize the HHS Guidance to Federal Financial Assistance Recipients Regarding Title VI 
Prohibition Against National Origin Discrimination Affecting Limited English Projicient 
Persons and Office of Minority Health's Culturally and Linguistically Appropriate 
Services (CLAS) standards. OCR also commends the OIG inspection team for both their 
thoroughness and professionalism during the review, 
OCR concurs with the report's findings and recommendations and offers no comment. 
Georgina C. Verdugo 
Director 
OEI051000050  GUIDANCE AND STANDARDS ON LANGUAGE ACCESS SERVICES:  MEDICARE PROVIDERS  44  x 
A  P  PEN  D  F 
DEPARTMENT OF HEALTH AND HUMAN SERVICES 	 Office of the Secretary 
---------------------------------Of-fice- o-f P-ubl-ic H-e-alth- a-nd 1Scielnc1e  li 
Office of Minority Health 
Washington. D.C. 20201 
DATE: 	 May 26, 2010 
TO: 	 Daniel R. Levinson 
Inspector General 
FROM: 	 Ga'tth N. Grhham, M.D., M.P,H. 
Deputy Assistant Secretary for Minority Health 
Office of Minority Health 
Office ofthe Secretary 
SUBJECT: 	 OIG Draft Reports: Guidance and Standards on Language Access Services: 
Medicare Providers, OEI-05-10-00050 
Thank you for the opportunity to review and respond to the OIG draft report.  We appreciate 
OIG's efforts to examine the extent Medicare Providers are fulfilling the requirements of 
(I) OCR's Guidance to federal Financial Assistance Recipients Regarding Title VI Prohibition 
Against National Origin Discrimination Affecting Limited English Proficient Persons (OCR 
guidance) and (2) OMH's CLAS standards. 
Based on Ollr review of the report, our responses will only focus on those areas that apply to the 
CLAS Standards. 
OIG Recommendation: Medicare Providers: OEI-OS-1 0-00050 
 	 OMH should increase outreach to providers to familiarize them with CLAS 

standards. 

OMH could collaborate with other HHS operating divisions that foclls on health 
carc, including CMS, as well as work with provider associations to disseminate 
the CLAS standards to providers. 
 	 OMH should offer model translated written materials and signs to providers 

OMH could take the lead in collaborating with other HHS operating divisions to 

develop model language for these materials. 

OMH conCllrs with OIG's recommendations. The OMH will take the lead in devcloping specific 
marketing strategies to inform providers ofthe CLAS standards. Additionally, OMH will 
facilitate the development of spccific translated materials and signage for providers in 
collaboration with other JIBS operating divisions. 
U.S. Public Health Service 
OEI051000050  GUIDANCE AND STANDARDS ON LANGUAGE ACCESS SERVICES:  MEDICARE PROVIDERS  45  A  P  PEN  D  x  F 
DEPARTMENT OF HEALTH & HUMAN SERVICES  Centers for Medicare & Medicaid Services 
Office of the Administrator 
Washington. DC 20201 
DATE: 	 MAY 20 2010 
TO: 	 Dariel R. Levinson 
Inspecto.r.DeneraJ 
FROM: 	 Maril.y.~ 'l\avenner 
Acting ~ministrator and Chief Operating Officer 
SUBJECT: 	 Office oflnspector General (OlG) Draft Report: "Guidance and Standards on 
Language Access Services: Medicare Providers" (OEI-05-10-00050) 
Thank you for the opportunity to review and comment on the OlG draft report entitled, 
"Guidance and Standards on Language Access Services: Medicare Providers" (OEl-05-l 0
00050). This is to notify you that the Centers for Medicare & Medicaid Services has reviewed 
the subject draft report, and we have no substantive comments. We are attaching technical 
comments for your consideration. 
We appreciate the effort that went into this report and look forward to working with the OIG on 
this and other issues related to language access services. 
Attachment 
OEI051000050  GUtDANCE AND STANDARDS ON LANGUAGE ACCESS SERVICES:  MEDICARE PROVIDERS  46   
 A C K N O W L E D G M E N T S  
This report was prepared under the direction of Ann Maxwell, Regional 
Inspector General for Evaluation and Inspections in the Chicago 
regional office, and Thomas F. Komaniecki, Deputy Regional Inspector 
General.   
Nicole Hrycyk served as the team leader for this study and Meghan 
Kearns served as the project lead.  Other principal Office of Evaluation 
and Inspections staff from the Chicago regional office who contributed 
to the report include Melissa Baker, Benjamin Dieterich, Ericka 
Kilburn, Margo Rodriguez, and Mark Stiglitz; central office staff who 
contributed include Heather Barton and Kevin Farber.  
 
  OEI-05-10-00050  GUIDANCE AND STANDARDS ON LANGUAGE ACCESS SERVICES:  MEDICARE PROVIDERS  47   
Office of Inspector General 
http://oig.hhs.gov 
 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as 
amended, is to protect the integrity of the Department of Health & Human Services (HHS) 
programs, as well as the health and welfare of beneficiaries served by those programs.  This 
statutory mission is carried out through a nationwide network of audits, investigations, and 
inspections conducted by the following operating components: 
Office of Audit Services 
The Office of Audit Services (OAS) provides auditing services for HHS, either by conducting 
audits with its own audit resources or by overseeing audit work done by others.  Audits 
examine the performance of HHS programs and/or its grantees and contractors in carrying 
out their respective responsibilities and are intended to provide independent assessments of 
HHS programs and operations.  These assessments help reduce waste, abuse, and 
mismanagement and promote economy and efficiency throughout HHS. 
Office of Evaluation and Inspections 
The Office of Evaluation and Inspections (OEI) conducts national evaluations to provide 
HHS, Congress, and the public with timely, useful, and reliable information on significant 
issues.  These evaluations focus on preventing fraud, waste, or abuse and promoting 
economy, efficiency, and effectiveness of departmental programs.  To promote impact, OEI 
reports also present practical recommendations for improving program operations.  
Office of Investigations 
The Office of Investigations (OI) conducts criminal, civil, and administrative investigations 
of fraud and misconduct related to HHS programs, operations, and beneficiaries.  With 
investigators working in all 50 States and the District of Columbia, OI utilizes its resources 
by actively coordinating with the Department of Justice and other Federal, State, and local 
law enforcement authorities.  The investigative efforts of OI often lead to criminal 
convictions, administrative sanctions, and/or civil monetary penalties. 
Office of Counsel to the Inspector General 
The Office of Counsel to the Inspector General (OCIG) provides general legal services to 
OIG, rendering advice and opinions on HHS programs and operations and providing all 
legal support for OIGs internal operations.  OCIG represents OIG in all civil and 
administrative fraud and abuse cases involving HHS programs, including False Claims Act, 
program exclusion, and civil monetary penalty cases.  In connection with these cases, OCIG 
also negotiates and monitors corporate integrity agreements.  OCIG renders advisory 
opinions, issues compliance program guidance, publishes fraud alerts, and provides other 
guidance to the health care industry concerning the anti-kickback statute and other OIG 
enforcement authorities.