Department of Health & Human Services 
OFFICE OF 
   
INSPECTOR GENERAL 
 
 
 
 
 
 
 
 
GUIDAN  CE AND STANDARDS ON 
 
L A S :
ANGUAGE  CCESS  ERVICES   
 
 
M P  
EDICARE  LANS
 
 
 
 
Daniel R. Levinson  
Inspector General 
 
July 2010 
OEI-05-10-00051   
 
 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 plans 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 plans 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 plans 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 plans voluntary compliance as indicated by the 
extent to which Medicare plans 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 Providers 
(OEI-05-10-00050), provides the same assessment for Medicare 
providers.  
The Centers for Medicare & Medicaid Services (CMS) contracts with 
private companies to provide health insurance plans under Medicare 
Advantage, stand-alone prescription drug plans under Part D 
(hereinafter referred to collectively as plans), or both.  Plans typically 
administer benefits by contracting with direct service providers, such as 
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hospitals, nursing homes, and pharmacies.  Thus, most of plans direct 
contact with beneficiaries is through call centers and marketing 
materials. 
OCR guidance and CLAS standards address the provision of language 
access services.  OCR guidance recommends that plans conduct 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 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 plans 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 right 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 and written translation.     
To conduct this review, we administered a survey in 2009 to 
139 randomly selected plans operating in counties with a high 
percentage of LEP persons. 
FINDINGS 
Eighty-eight percent of plans conducted the four-factor assessment 
recommended by OCR guidance when determining what language 
access services to offer.  Eighty-eight percent of plans conducted all 
four factors of the recommended assessment.  The remaining plans 
considered three of the factors.  The percentages of plans that completed 
each of the individual factors ranged between 94 percent and 
100 percent. 
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E X E C U T I V E   S U M M A R Y  
Sixty-seven percent of plans offered services consistent with all 
four CLAS standards on language access services.  Although all 
plans reported offering some language access services, only 67 percent 
of plans offered services consistent with all four CLAS standards on 
language access services.  The percentages of plans that offered services 
consistent with each of the individual standards ranged between 
71 percent and 99 percent.  Plans were least likely to inform LEP 
persons both verbally and in writing of their right to receive language 
access services. 
Only 49 percent of plans reported benefits to providing language 
access services and 57 percent reported obstacles.  The most 
frequently reported benefit was improved communication with LEP 
persons.  The three most frequently reported obstacles included the 
costs of providing language access services, identifying LEP persons, 
and lack of staffing for providing language access services.   
Although 79 percent of plans reported data on the costs of providing 
language access services, these data were not comparable.  Of the 
135 plans that responded to the survey, 106 reported cost data.  
However, plans comments about how they calculated costs indicated 
different approaches to calculating costs.  Because of these differences, 
we were unable to make determinations about costs of language access 
services. 
RECOMMENDATION 
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 a 
recommendation to increase the percentage of plans that voluntarily 
offer services consistent with all four CLAS standards on language 
access services.  
We recommend that: 
  OMH collaborate with CMS to inform plans that they should 
notify LEP persons both verbally and in writing of their right to 
receive language access services. 
 
 
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E X E C U T I V E   S U M M A R Y  
AGENCIES COMMENTS AND OFFICE OF INSPECTOR 
GENERAL RESPONSE 
OMH and CMS both concurred with our recommendation.  OMH stated 
that it will work closely with CMS to inform plans that they should 
inform LEP persons both verbally and in writing of their rights to 
receive language access services.  CMS reiterated its goal to provide 
clear, accurate, and timely information about language access services.
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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 
Eighty-eight percent of plans conducted the four-factor        
assessment recommended by OCR guidance when determining     
what language access services to offer. . . . . . . . . . . . . . . . . . . . . . 14 
Sixty-seven percent of plans offered services consistent with all      
four CLAS standards on language access services . . . . . . . . . . . . 16 
Only 49 percent of plans reported benefits to providing language 
access services and 57 percent reported obstacles. . . . . . . . . . . . . 19 
Although 79 percent of plans reported data on the costs of      
providing language access services, these data were not          
comparable . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 
 
 
R E C O MMEN D A T ION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 
Agencies Comments and Office of Inspector General Response. . 23 
 
 
APPENDIXES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 
A:  Section 187 of the Medicare Improvements for Patients and 
Providers Act of 2008 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 
B:  Culturally and Linguistically Appropriate Services in Health   
Care Standards. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 
  C:  Categories of Responses to Key Survey Questions. . . . . . . . . . 27 
  D:  Estimates and Confidence Intervals. . . . . . . . . . . . . . . . . . . . . 29 
  E:  Supplemental Analysis Table. . . . . . . . . . . . . . . . . . . . . . . . . . 34  
  F:  Agencies Comments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 
 
 
A C K NO WL E D G M E N T S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 
   
   
 I N T R O D U C T I O N  
OBJECTIVES 
1.  To determine the extent to which Medicare plans 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 plans 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 plans 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 plans 
voluntary compliance, as indicated by the extent to which plans 
 
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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conducted the four-factor assessment recommended by OCR guidance 
and offered language access services consistent with CLAS standards. 
This report is one of two reports issued in response to the MIPPA 
provision.  A companion report, Guidance and Standards on Language 
Access Services:  Medicare Providers (OEI-05-10-00050), focuses on 
Medicare providers, such as hospitals and nursing homes, which 
directly supply heath care services to beneficiaries. 
Medicare Plans 
The Centers for Medicare & Medicaid Services (CMS) contracts with 
private companies to provide health insurance plans under Medicare 
Advantage, stand-alone prescription drug plans under Part D 
(hereinafter referred to collectively as plans), or both.  Private 
companies may choose to provide both Medicare Advantage and 
stand-alone prescription drug plans.  As of February 2010, more than 
29 million Medicare beneficiaries were enrolled in Medicare Advantage 
and stand-alone prescription drug plans.3   
Plans receive a monthly prospective payment from CMS to cover their 
estimated costs for providing services to Medicare beneficiaries.  In 
calculating these payments, CMS allows plans to report all of their 
administrative costs to operate plans.4  According to CMS staff, 
administrative costs include such things as translating marketing 
materials and operating call centers.5   
Plans have limited direct contact with beneficiaries.  These plans 
typically administer benefits by contracting with direct service 
providers, such as hospitals, nursing homes, and pharmacies.  Thus, 
most of plans direct contact with beneficiaries is through call centers 
and marketing materials.   
Language Access Services for Limited English Proficient Persons 
Language access services are designed to promote effective 
communication between Limited English Proficient (LEP) persons and 
 
3 CMS, Medicare Advantage, Cost, PACE, Demo, and Prescription Drug Medicare Plan 
Contract Report - Monthly Summary Report, March 2010.  Accessed at 
http://www.cms.hhs.gov on March 31, 2010.  
4 CMS, Instructions for Completing the Medicare Advantage Bid Pricing Tool and the 
Medical Savings Account Bid Pricing Tool for Contract Year 2010, Pub. No. 10142.  
Accessed at http://www.cms.hhs.gov on February 17, 2010. 
5 Medicare plans must operate call centers that Medicare beneficiaries can contact to 
speak with a customer service representative to answer questions concerning, for example, 
enrollment, benefits, costs, or coverage. 
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non-LEP persons.6  LEP persons do not speak English as their primary 
language and have a limited ability to read, write, speak, or understand 
English.7  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.8  
Language access services may include oral interpretation; written 
translation; and other provisions that enhance communication, such as 
translated signage.9  In providing oral interpretation plans may choose, 
for example, to hire bilingual staff, to contract with interpreters, or to 
use telephone interpreter lines.  When providing written translation, for 
example, plans may translate marketing materials or benefit 
explanation materials.  
The lack of language access services enables language barriers to 
persist between LEP persons and non-LEP staff at plans, which can 
lead to problems for LEP persons.  Congressional testimony suggests 
that LEP beneficiaries have had problems with plan call centers 
resulting from language barriers.10  Problems included failure to 
connect LEP persons to interpreters or interpreters who were not 
knowledgeable or able to answer questions.11 
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.12  The Supreme Court has 
 
6 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. 
7 OCR, Guidance, pt. IV, 68 Fed. Reg. 47311, 47313 (Aug. 8, 2003).  Accessed at 
http://www.hhs.gov/ocr on October 21, 2009. 
8 U.S. Census Bureau, Profile of Selected Social Characteristics:  2000.  Accessed at 
http://factfinder.census.gov on January 15, 2010. 
9 OMH, Patient-Centered Guide, loc. cit.  
10 California Health Advocates, Medicare Part D:  Implementation of the New Drug 
Benefit, written testimony before the U.S. House of Representatives, Committee on Energy 
and Commerce, Hearing by the Subcommittee on Health, March 1, 2006.  Accessed at 
http://www.cahealthadvocates.org on March 2, 2010. 
11 Ibid. 
12 P.L. 88-352  601; 42 U.S.C.  2000d. 
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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.13  
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, 
including plans, operate their programs in compliance with Federal civil 
rights laws.  Federal financial assistance includes grants, training, use 
of equipment, donation of surplus property, and other assistance.14 
OCR enforces compliance with Title VI by investigating complaints of 
discrimination.   According to OCR staff, of the 17 complaints 
concerning LEP persons received in fiscal year (FY) 2009, 1 complaint 
involved plans.  If OCR investigates and determines that discrimination 
has occurred, a plan usually has 60 days to correct the violation or 
provide OCR with a plan of correction.15  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.   
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.16  
The guidance was issued in response to an August 2000 Executive 
Order requiring Federal agencies to clarify and publish guidance on 
Title VI requirements.17  The original guidance was republished in 
February 2002, seeking public comment.18  In 2003, after receiving 
public comments and subsequent guidance from the U.S. Department of 
Justice, OCR issued revised guidance.19   
 
13 Lau v. Nichols.  414 U.S. 563 (1974). 
14 45 CFR  80, App. A.; 45 CFR  80.2. 
15 OCR, How Does OCR Investigate a Civil Rights Complaint?  Accessed at 
http://www.hhs.gov/ocr on February 25, 2010. 
16 65 Fed. Reg. 52762 (Aug. 30, 2000). 
17 Executive Order 13166, Improving Access to Services for Persons with Limited English 
Proficiency, 65 Fed. Reg. 50121 (Aug. 16, 2000). 
18 67 Fed. Reg. 4968 (Feb. 1, 2002). 
19 OCR, Guidance, introduction at 47311. 
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I N T R O D U C T I O N  
OCR guidance is meant to assist recipients of HHS financial assistance, 
including plans, 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.20   
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:21 
(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 
(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 acccess services may not be necessary to comply with 
Title VI.22  However, this discretion does not diminish, and should not 
be used to minimize, recipients obligation to address the needs of LEP 
persons.23   
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.24 
OMH divided the standards into three categories:  Culturally 
Competent Care (standards 13), Language Access Services 
(standards 47), and Organizational Supports for Cultural Competence 
 
20OCR, Guidance, pt. III at 47313, footnote 2. 
21 Ibid., pt. V at 47314. 
22 Ibid.  
23 Ibid. 
24 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. 
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(standards 814).25  For a list of all 14 CLAS standards, see Appendix 
B. 
The four Language Access Services standards are:26 
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. 
OMH staff offer training and educational resources related to CLAS 
standards to plans through its Center for Cultural and Linguistic 
Competence in Health Care (the Center).27  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.28   
 
25 OMH, National Standards for Culturally and Linguistically Appropriate Services in 
Health Care:  Final Report, p. 3.  Accessed at http://minorityhealth.hhs.gov on 
January 15, 2010. 
26 Ibid., pp. 1013. 
27 OMH, About the Center for Cultural and Linguistic Competence in Health Care.  
Accessed at http://minorityhealth.hhs.gov/ on March 8, 2010. 
28 H.R. Rep. No. 103-553 at 54 (1994). 
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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.29  In addition, OMH distributes an 
e-newsletter that is geared toward all persons interested in cultural 
competency in health care settings. 
CMS Guidance Supporting Language Access Services 
CMS has published marketing guidelines establishing that plans must 
provide interpretation and translation services to LEP persons.30  
Although OCR guidance allows discretion when determining what 
language access services to offer, CMS requires plans to offer at least 
some language access services. 
Three of CMSs marketing guidelines correspond closely to CLAS 
Standards 4 and 7 and partially to CLAS Standard 5.  Specifically, CMS 
guidelines state that plans call centers must accommodate LEP persons 
and provide service to LEP persons during business hours.31, 32  CMS 
guidelines also state that plans should make marketing materials, such 
as promotional, enrollment, and benefit materials, available in any 
language that is the primary language of more than 10 percent of a 
plans service area.33  In 2009, CMS began making LEP population 
information available for plans when a particular LEP population 
exceeded the 10-percent threshold.34  Finally, CMS guidelines state that 
plans must disclose on all required explanatory marketing materials 
that the document is available in alternative languages.35   
 
29 OMH, A Patient-Centered Guide to Implementing Language Access Services in 
Healthcare Organizations.  Accessed at http://www.thinkculturalhealth.org on 
February 1, 2010. 
30 CMS, Medicare Manual, Pub. 100-16, ch. 3, interpreting 42 CFR  422.2264(e), 
423.2264(e), and 423.128(d)(1). 
31 Ibid.,  30.7.  
32 Ibid.,  80.1. 
33 Ibid.,  30.7. 
34 CMS, New Marketing Material Language Lookup Functionality in HPMS, 
September 28, 2009.  Accessed at http://www.cms.hhs.gov on March 1, 2010. 
35  CMS allows an exception to this disclosure for identification cards.  CMS, Medicare 
Managed Care Manual, Pub. 100-16, ch. 3,  50.5.8. 
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In 2008, CMS informed plans of concerns that ineffective processes may 
have been preventing LEP persons from receiving the language access 
services covered by CMSs marketing guidelines.36  CMS distributed a 
memorandum to all plans listing best practices that plans could 
implement to better serve LEP persons.  For example, CMS 
recommended that if plans use an interactive voice response system, 
they should ensure that callers who do not choose an option by pressing 
a number or speaking a word will automatically be connected with a 
person who can access interpretation services.  In this memorandum, 
CMS cited OCR guidance as a useful tool for developing language access 
services for LEP persons.37   
METHODOLOGY 
To conduct this review, we collected information through a survey of 
randomly selected plans operating in 2009 in counties with a high 
percentage of LEP persons.  OCR, OMH, and CMS staff provided 
additional context through structured interviews. 
Scope 
The MIPPA mandates that OIG report on plans and providers 
compliance with OCR guidance and CLAS standards.  However, because 
CLAS standards are not mandatory, HHS lacks authority to enforce 
them.  Therefore, we assessed plans 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 plans that were located in counties with a high 
percentage of LEP persons to increase the likelihood that sampled plans 
needed to offer language access services.  Medicare providers are 
covered in a companion report.   
Finally, we broadened the definition of costs and savings to include 
nonfinancial obstacles and benefits. 
 
36 CMS, Best practices for addressing the needs of non-English speaking and limited 
English proficient (LEP) beneficiaries, January 2, 2008.  Accessed at 
http://www.cms.hhs.gov on February 17, 2010.   
37 Ibid.    
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Sample 
Plan sampling frame.  We created a sampling frame of plans operating in 
counties with a high percentage of LEP persons.  To do this, we used 
2000 decennial Census data and 2009 enrollment data from CMS.38  
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 residents in each of 
the selected counties.  Then, we used the CMS enrollment data to 
identify the plans offered in the selected counties.  We identified 
5,611 plans in the sampling frame. 
Sample selection.  After creating the sampling frame of 5,611 plans, we 
selected a simple random sample of 145 plans.39  After selecting the 
sample, we excluded five plans because of ongoing OIG investigations 
and one additional plan because we discovered that it did not operate in 
2009.  The final sample consisted of 139 plans.   
Data Collection 
Survey.  We emailed the survey to the sample of 139 plans in 
December 2009.  We made three followup attempts by telephone.  Data 
collection lasted through January 2010.  Of the 139 plans, 
135 responded to the survey, for an overall response rate of 97 percent.  
However, plans did not always answer every question; therefore, item 
response rates may be lower.  No item response rate was less than 
88 percent. 
In the cases in which a health care organization operated multiple plans 
in the sample and offered the same language access services, we allowed 
the health care organization to submit one survey for all of its plans.  
Then, we recorded the responses individually for each associated plan.  
Twenty-four health care organizations, representing 107 of the sampled 
 
38 The U.S. Census Bureaus 2000 decennial Census has the most recent data on all 
counties for the same year. 
39 This sample design enabled us to estimate the percentage of plans 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. 
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plans, submitted surveys in this manner.  An additional 28 plans 
responded individually. 
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.   
In addition, to obtain background information about CMSs guidelines 
for plans related to the provision of language access services, we 
interviewed CMS staff.  We interviewed CMS staff in January 2010. 
Data Analysis 
To analyze plans survey responses, we calculated response category 
frequencies for the key questions related to whether plans conducted 
the four-factor assessment recommended by OCR guidance and whether 
plans offered language access services consistent with all four CLAS 
standards on language access services.  We also analyzed the 
percentage of plans that completed each individual factor of the 
four-factor assessment and offered language access services consistent 
with each of the four CLAS standards.   
We considered a plan to have conducted the four-factor assessment if 
the plan indicated at least one activity corresponding to 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.
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I N T R O D U C T I O N  
Table 1:  OCR Four Factors and Corresponding Survey 
Questions 
Four Factors in OCR Guidance  Corresponding Question in Survey of Plans 
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  plan use to determine the number or proportion of LEP 
encountered in the recipients service  persons from each language group represented in its 
population  geographic service area? 
Factor 2:  The frequency with which LEP  Which of the following sources of information does your 
persons come in contact with the recipient  plan use to track how often it encounters LEP persons? 
When determining whether to communicate to LEP 
Factor 3:  The importance, nature, and 
persons in their preferred language, does your plan 
urgency of the program, activity, or service 
consider the importance and urgency of the activity, 
to peoples lives 
program, or service to peoples lives? 
Factor 4:  The resources available to the 
How does your plan assess whether it has resources 
recipient and costs for offering language 
available to provide language access services? 
access services 
Source:  OCR guidance and OIG survey of plans, 2010. 
Similarly, we considered a plan to have offered language access services 
consistent with CLAS standards if it indicated activities meeting each of 
the four standards.  For Standards 4, 6, and 7, we considered a plan to 
have offered language access services consistent with the standards if it 
indicated at least one activity corresponding to the standards.  For 
Standard 5, plans needed to indicate at least two activitiesone 
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.  See Appendix C 
for the categories of responses to each question. 
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I N T R O D U C T I O N  
Table 2:  CLAS Standards and Corresponding Survey Questions  
Corresponding Question in Survey of 
CLAS Standards on Language Access Services 
Plans 
Standard 4:  Health care organizations must offer and 
provide language assistance services, including bilingual 
During what percentage of your plans 
staff and interpreter services, at no cost to each 
business hours are language access 
patient/consumer with limited English proficiency at all 
services offered? 
points of contact, in a timely manner during all hours of 
operation. 
Standard 5:  Health care organizations must provide to  Does your plan inform LEP persons of their 
patients/consumers in their preferred language both  right to receive language access services in 
verbal offers and written notices informing them of their  their preferred language in any of the 
right to receive language assistance services.  following ways? 
Standard 6:  Health care organizations must assure the 
competence of language assistance provided to limited 
Which of the following training topics does 
English proficient patients/consumers by interpreters 
your organization require for staff and 
and bilingual staff.  Family and friends should not be 
contractors? 
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  Which of the following written materials are 
post signage in the languages of the commonly  translated into the languages of commonly 
encountered groups and/or groups represented in the  encountered groups? 
service area. 
Source:  CLAS standards and OIG survey of plans, 2010. 
We did not ask plans about posting signs in languages of the commonly 
encountered groups for Standard 7, as we determined that signs were 
not applicable to plans. 
We used the results of the response category frequencies for the CLAS 
standards to determine whether any standards were 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 of 0.01. 
Where possible, we calculated frequencies and ranges on the key 
questions related to costs, savings, nonfinancial obstacles, and benefits.  
We also reviewed plans comments about how they calculated cost data 
to determine the extent to which reported costs were comparable. 
Unless noted, we projected survey statistics to all 5,611 plans operating 
in the 313 counties with a high percentage of LEP persons.  See 
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I N T R O D U C T I O N  
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 plans 
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 of the Inspectors General on 
Integrity and Efficiency. 
 
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 F I N D I N G S  
Eighty-eight percent of plans conducted the  Eighty-eight percent of plans in 
four-factor assessment recommended by OCR  counties with a high percentage of 
LEP persons considered all four 
guidance when determining what language 
factors of the recommended 
access services to offer 
assessment.  The remaining 
12 percent of plans considered three of the four factors.  As noted 
previously, OCR guidance is not mandatory.  Rather, it is guidance that 
plans may use to ensure meaningful access for LEP persons to critical 
services.   
Table 3 lists the four factors and the percentage of plans that reported 
considering each factor. 
Table 3:  OCR Four Factors and Percentage of Plans 
Considering Each Factor 
Percentage 
Four Factors in OCR Guidance 
of Plans 
Factor 1:  The number or proportion of LEP persons eligible to be 
94% 
served or likely to be encountered in the recipients service population 
Factor 2:  The frequency with which LEP persons come in contact with 
99% 
the recipient 
Factor 3:  The importance, nature, and urgency of the program, activity, 
96% 
or service to peoples lives 
Factor 4:  The resources available to the recipient and costs for offering 
100% 
language access services 
Source:  OCR guidance and OIG analysis of plan survey responses, 2010. 
Ninety-four percent of plans reported determining the number or proportion 
of LEP persons in their service areas 
Corresponding to the first factor in OCR guidance, 94 percent of plans 
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. 
Plans determined the number or proportion of LEP persons represented 
in their geographic service areas primarily from two sources.  
Eighty-one percent of plans reported that they used Census data and 
64 percent reported that they collected data from plan members.   
 
 
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F I N D I N G S  
Ninety-nine percent of plans reported determining the frequency of contact 
with LEP persons 
Corresponding to the second factor in OCR guidance, 99 percent of plans 
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.   
Plans reported collecting data on encounters with LEP persons 
primarily from two sources.  Seventy-nine percent of plans reported 
using data collected from their call centers and 66 percent reported 
using data collected from plan member databases.  Forty-nine percent of 
plans reported that they used both sources. 
Ninety-six percent of plans reported considering the situation when 
determining what language access services to provide or reported offering 
services in all situations 
Ninety-six percent of plans reported activities that correspond to the 
third factor in OCR guidance for determining the importance of 
language access services.  This factor recommends that plans 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, 18 percent of plans reported assessing the 
importance and urgency of their programs, activities, and services.  An 
additional 78 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.   
All plans reported assessing the available resources 
Corresponding to the fourth factor in OCR guidance, all plans reported 
assessing available financial, material, and staff resources when 
determining what language access services to offer.  Plans may use 
information about available resources to help them balance costs and 
benefits when deciding what language access services to offer.  
Specifically, 94 percent of plans reported assessing the availability of 
bilingual staff, 79 percent reported assessing the availability of 
technology for providing language access services, and 47 percent 
reported assessing the financial resources available to them.40 
 
40 Choices are not mutually exclusive. 
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F I N D I N G S  
Sixty-seven percent of plans offered services  All plans operating in counties 
consistent with all four CLAS standards on  with a high percentage of LEP 
persons reported offering some 
language access services 
language access services by either 
translating documents or providing interpreter services.  However, only 
67 percent offered language access 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 plans can use when developing their language access 
services. 
In addition to offering language access services directly, 79 percent of 
plans reported offering language access services or financial assistance 
to their contracted providers.  Further, 48 percent of plans reported 
requiring their contracted providers to offer language access services to 
their patients.  See Table E-1 in Appendix E for a list of the assistance 
that plans reported offering to their contracted providers. 
Plans were least likely to offer language access services consistent with 
CLAS Standard 5, which recommends that patients be informed of their 
rights both verbally and in writing.41  See Table 4 for the four CLAS 
standards on language access services and the percentage of plans that 
reported offering services consistent with each standard. 
 
41 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 4:  CLAS Standards and Percentage of Plans Offering 
Services Consistent With Each Standard 
Percentage of 
CLAS Standards on Language Access Services 
Plans 
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  94% 
during 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  71% 
assistance services. 
Standard 6:  Assure the competence of language assistance provided.  
Family and friends should not be used to provide interpretation services  99% 
(except on request by the patient). 
Standard 7:  Make available easily understood patient-related materials and 
post signage in the languages of the commonly encountered groups  94% 
represented in the service area. 
Source:  CLAS standards and OIG analysis of plan survey responses, 2010. 
Ninety-four percent of plans reported offering language access services 
during all business hours 
Consistent with CLAS Standard 4, 94 percent of plans reported offering 
some type of language access services during all hours of operation.  The 
6 percent of plans that did not offer language access services during all 
hours of operation reported offering language access services during 
more than half of their business hours.  
However, there is evidence that beneficiaries have difficulty accessing 
the language access services that plans provide through call centers.  
For example, one study found that only 69 percent of LEP persons 
calling plans could reach someone who spoke their primary language 
and were often unable to access translated documents from the plans.42  
This indicates that while plans may have language access services 
available, they may not be providing these services to all of the 
beneficiaries who need them. 
 
 
 
42 National Senior Citizen Law Center, Please Hold Medicare plans leave limited 
English proficient beneficiaries waiting for access, December 2008.  Accessed at 
http://www.nsclc.org on February 17, 2010. 
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F I N D I N G S  
Seventy-one percent of plans reported informing LEP persons both verbally 
and in writing of their right to receive language access services 
Consistent with CLAS Standard 5, 71 percent of plans reported 
informing LEP persons verbally and in writing of their right to receive 
language access services.  Plans reported informing beneficiaries of 
language access services mostly in writing during the enrollment 
process.  Specifically, 96 percent of plans reported informing LEP 
persons through enrollment materials or plan benefit materials, and 
86 percent reported informing LEP persons through other marketing 
materials.  However, only 71 percent of plans reported verbally 
informing LEP persons during the enrollment process.43  In addition, 
the enrollment process typically occurs annually, which means LEP 
persons may not be informed of their right to receive language access 
services at each encounter with plans. 
Ninety-nine percent of plans reported requiring training for staff and 
contractors on language access services 
Consistent with CLAS Standard 6, 99 percent of plans reported 
requiring training for staff and contractors on language access services.  
Specifically, 96 percent of plans reported requiring training for staff or 
contractors on responding to LEP persons, 90 percent on language 
access policies and procedures, 73 percent on cultural competency, and 
56 percent on language skills.44 
Although most plans reported requiring training for staff and 
contractors about language access services, only 57 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.  Only 41 percent of plans reported either testing staff or 
contractors on their ability to interpret effectively or testing them on 
their language proficiency.  See Table 5 for a list of the topics plans 
reported covering on formal tests. 
 
 
 
 
43 Choices are not mutually exclusive. 
44 Choices are not mutually exclusive. 
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F I N D I N G S  
Table 5:  Testing Topics for Staff and Contractors 
Testing Topics*  Percentage of Plans 
Confidentiality requirements  57% 
Plans policies and procedures  55% 
Medical terminology  42% 
Ability to interpret effectively  41% 
Proficiency in English and non-English languages  41% 
*Choices are not mutually exclusive.    
Source:  OIG analysis of plan survey responses, 2010.   
Ninety-four percent of plans reported translating materials into the 
languages of commonly encountered groups 
Consistent with CLAS Standard 7, 94 percent of plans reported 
translating written materials into the languages of commonly 
encountered groups.  Plans reported translating a variety of materials.  
Eighty-seven percent of plans reported translating enrollment 
applications, 83 percent reported translating marketing materials, and 
78 percent reported translating plan benefit materials.45 
 
Only 49 percent of plans reported benefits to  Although all plans reported 
offering some language access 
providing language access services and 
services, only 49 percent reported 
57 percent reported obstacles 
that providing language access 
services resulted in any benefits.  The two most frequently reported 
benefits were related to communication.46  Specifically, 46 percent of 
plans reported improvements in communication with beneficiaries and 
10 percent reported improvements in communication between providers 
and their patients.   
Only 1 percent of plans reported saving money by offering language 
access services.  Twenty-eight percent of plans reported that they did 
not save money by providing language access services and 70 percent 
reported that they did not know whether they saved money.47 
 
 
45 Choices are not mutually exclusive. 
46 Choices are not mutually exclusive. 
47 Percentages do not add to 100 percent because of rounding. 
  OEI-05-10-00051  GUIDANCE AND STANDARDS ON LANGUAGE ACCESS SERVICES:  MEDICARE PLANS  19   
   
F I N D I N G S  
Fifty-seven percent of plans reported obstacles to providing language 
access services  
Fifty-seven percent of plans reported obstacles to providing language 
access services, including the costs of providing language access 
services, difficulties in identifying LEP persons, and a lack of staffing.  
See Table 6 for a list of obstacles that plans reported. 
Table 6:  Obstacles Reported by Plans 
Obstacles*  Percentage of Plans 
Costs  41% 
Lack of means for staff to identify LEP persons  22% 
Lack of staffing  20% 
Broad range of languages spoken in the community   19% 
Staff discomfort in providing language services  19% 
Lack of training resources for staff  11% 
Liability concerns  10% 
*Choices are not mutually exclusive.    
Source:  OIG analysis of plan survey responses, 2010.   
The cost of providing language access services was the most frequently 
reported obstacle, cited by 41 percent of plans.  In addition, 30 percent 
of plans reporting obstacles reported costs as the only obstacle.  As 
previously noted, plans may include the costs of providing language 
access services in their administrative expenses that are subsidized by 
CMS. 
A majority of plans indicated that they would like help in overcoming 
obstacles to providing language access services.  In fact, 52 percent of 
plans reported that it would be useful to have additional assistance in 
implementing these services.  In responding to the survey, these plans 
suggested specific areas for assistance.  There were three general 
requests:  that HHS (1) translate model documents to ensure the 
accuracy of documents and reduce costs for plans; (2) offer staff training 
and testing assistance, which would include providing materials and 
covering plan responsibilities, information on the LEP populations, and 
best practices; and (3) provide financial assistance for language access 
services, for both training staff and direct interpretation and translation 
services. 
 
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F I N D I N G S  
Although 79 percent of plans reported data on  Of the 135 plans that responded to 
the costs of providing language access  the survey, 106 reported data on the 
costs of providing language access 
services, these data were not comparable 
services.  For example, a small 
regional plan reported $407 in language access services expenditures in 
FY 2008, at $0.29 per LEP enrollee.  On the other hand, a large national 
plan reported $3.7 million in language access services expenditures in 
FY 2008, at $52.78 per LEP enrollee.   
Plans comments about how they calculated cost 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.  
Some health care organizations that offer several plans indicated that 
they could report cost data only at the organizational level and not at 
the plan level.  Others could report only on the total cost of a contract 
with a vendor and not the parts of the contract specific to language 
access services, and some plans could only estimate costs.  Because of 
these differences in reporting, we were unable to make any 
determinations about costs of language access services.
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R E C O M M E N D A T I O N S  
 R E C O M M E N D A T I O N  
Eighty-eight percent of plans 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 67 percent of plans offered services consistent with all 
four CLAS standards on language access services, largely because many 
did not inform LEP persons verbally of their right to language access 
services.  
OMH created the CLAS standards to guide plans 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 plans 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 a 
recommendation to increase the percentage of plans that voluntarily 
offer services consistent with all four CLAS standards on language 
access services.   
We recommend that: 
OMH collaborate with CMS to inform plans that they should notify LEP 
persons both verbally and in writing of their right to receive language 
access services 
More than one in four plans reported that they do not verbally inform 
LEP persons of their right to receive language access services.  OMH 
should collaborate with CMS, as well as work with professional 
associations, to inform plans that they should notify LEP persons of 
their rights in writing and verbally.  CMS has an established 
infrastructure for communicating with plans.  OMH and CMS could use 
this infrastructure to encourage plans to inform LEP persons of their 
rights to language access services not only in writing during enrollment, 
but verbally every time LEP persons contact plans. 
This joint effort could suggest ways in which plans could increase verbal 
notification of language access services at call centers.  To help ensure 
that language access services are provided to those who need them, 
OMH and CMS could suggest that plans ensure that (1) call center staff 
are trained to identify LEP persons; (2) LEP persons are transferred 
from call centers to interpreter services; and (3) callers are 
automatically transferred to interpreter services in cases in which an 
  OEI-05-10-00051  GUIDANCE AND STANDARDS ON LANGUAGE ACCESS SERVICES:  MEDICARE PLANS  22   
   
R E C O M M E N D A T I O N  
automated response is required and none is selected, as this may 
indicate that callers do not understand the automatic prompts. 
AGENCIES COMMENTS AND OFFICE OF INSPECTOR 
GENERAL RESPONSE 
OMH and CMS both concurred with our recommendation.  OMH stated 
that it will work closely with CMS to inform plans that they should 
inform LEP persons both verbally and in writing of their rights to 
receive language access services.  CMS reiterated its goal to provide 
clear, accurate, and timely information about language access services. 
For the full text of the agencies comments, see Appendix F.
  OEI-05-10-00051  GUIDANCE AND STANDARDS ON LANGUAGE ACCESS SERVICES:  MEDICARE PLANS  23   
   
 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-05-10-00051  GUIDANCE AND STANDARDS ON LANGUAGE ACCESS SERVICES:  MEDICARE PLANS  24   
   
 A P P E N D I X   ~   B  
Culturally and Linguistically Appropriate Services in Health Care 
Standards48 
 
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.   
 
48 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. 
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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-05-10-00051  GUIDANCE AND STANDARDS ON LANGUAGE ACCESS SERVICES:  MEDICARE PLANS  26   
   
 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 plan 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)  Collection of language data from plan members 
c)  Community assessment conducted by a community organization 
d)  Community assessment conducted by your organization 
e)  County or State health status reports 
f)  Medicare data 
g)  Other (please specify) 
 
OCR Factor 2 Question:  Which of the following sources of information does your plan use to 
track how often it encounters LEP persons? 
a)  Call center data 
b)  Claims records 
c)  Plan member database 
d)  Other (please specify) 
 
OCR Factor 3 Question:  When determining whether to communicate with LEP persons in their 
preferred language, does your plan 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-05-10-00051  GUIDANCE AND STANDARDS ON LANGUAGE ACCESS SERVICES:  MEDICARE PLANS  27   
   
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 plans 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)  Plan 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)  In enrollment materials 
c)  In marketing materials 
d)  In plan benefit materials 
e)  Told verbally during application process 
f)  Other (please specify) 
 
CLAS Standard 6 Question:  Which of the following training topics does your plan require for 
staff and contractors? 
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 
 
CLAS Standard 7 Question:  Which of the following written materials are translated into the 
languages of commonly encountered groups?  
a)  Application materials 
b)  Educational materials 
c)  Marketing materials 
d)  Notice of language access services 
e)  Plan benefit materials 
f)  Promotional materials 
g)  Wellness materials 
h)  Other (please specify) 
  OEI-05-10-00051  GUIDANCE AND STANDARDS ON LANGUAGE ACCESS SERVICES:  MEDICARE PLANS  28   
   
 A P P E N D I X ~ D  
Estimates and Confidence Intervals 
Table D-1:  Estimates of Survey Responses 
Sample  Point  95-Percent
Estimate Description 
Size  Estimate  Confidence Interval 
Percentage of plans that conducted the four-factor assessment 
recommended by Office for Civil Rights (OCR) guidance when  135  88.1  82.6%93.7% 
determining what language access services to offer 
Percentage of plans that completed three of the four OCR factors  135  11.9  6.3%17.4% 
Percentage of plans that reported determining the number or proportion 
of Limited English Proficient (LEP) persons they are eligible to serve or  135  94.1  90.0%98.1% 
likely to encounter in their geographic service areas (OCR Factor 1) 
Percentage of plans that reported determining the frequency of contact 
135  98.5  94.8%99.8% 
with LEP persons (OCR Factor 2) 
Percentage of plans that reported considering the situation when 
determining what language access services to provide or reported  135  95.6  92.0%99.1% 
offering services in all situations (OCR Factor 3) 
Percentage of plans that reported assessing the available resources for 
135  100.0  97.3%100%* 
offering language access services (OCR Factor 4) 
Percentage of plans that reported they used Census data to determine 
the number or proportion of LEP persons represented in their  135  80.7  74.0%87.5% 
geographic service areas 
Percentage of plans that reported the collected data from plan members 
to determine the number or proportion of LEP persons represented in  135  64.4  56.3%72.6% 
their geographic service areas 
Percentage of plans that reported using data collected from call centers 
135  78.5  71.5%85.5% 
to determine the frequency of contact with LEP persons 
Percentage of plans that reported using data collected from plan 
member databases to determine the frequency of contact with LEP  135  65.9  57.8%74.0% 
persons 
*Confidence interval calculated with an exact method based on the binomial distribution. 
   
continued on next page 
  OEI-05-10-00051  GUIDANCE AND STANDARDS ON LANGUAGE ACCESS SERVICES:  MEDICARE PLANS  29   
   
A P P E N D I X   ~   D  
Table D-1:  Estimates of Survey Responses, continued 
Sample  Point  95-Percent
Estimate Description 
Size  Estimate  Confidence Interval 
Percentage of plans that reported using data both from call centers and 
from plan member databases when determining the frequency of  135  48.9  40.3%57.4% 
contact with LEP persons 
Percentage of plans that reported assessing the importance of their 
135  17.8  11.2%24.3% 
program activities and services 
Percentage of plans that reported offering language access services in 
135  77.8  70.7%84.9% 
all types of situations regardless of importance and urgency 
Percentage of plans that reported assessing the availability of bilingual 
135  94.1  90.0%98.1% 
staff for providing language access services  
Percentage of plans that reported assessing the availability of 
135  78.5  71.5%85.5% 
technology for providing language access services  
Percentage of plans that reported assessing the financial resources 
available to them when determining whether to provide language access  135  47.4  38.9%55.9% 
services 
Percentage of plans that offered language access services consistent 
with the four selected Culturally and Linguistically Appropriate Services  135  66.7  58.6%74.7% 
in Health Care (CLAS) standards  
Percentage of plans that reported offering some language access 
135  100.0  97.3%100%* 
services 
Percentage of plans that reported offering language access services 
135  79.3  72.3%86.2% 
and financial assistance to providers 
Percentage of plans that reported requiring providers to offer language 
135  48.1  39.6%56.7% 
services to their patients 
Percentage of plans that reported offering language access services 
135  94.1  90.0%98.1% 
during all business hours (CLAS Standard 4) 
Percentage of plans that reported informing LEP persons both verbally 
and in writing of their right to receive language access services (CLAS  135  71.1  63.4%78.9% 
Standard 5) 
*Confidence interval calculated with an exact method based on the binomial distribution. 
continued on next page 
 
  OEI-05-10-00051  GUIDANCE AND STANDARDS ON LANGUAGE ACCESS SERVICES:  MEDICARE PLANS  30   
   
A P P E N D I X   ~   D  
Table D-1:  Estimates of Survey Responses, continued 
Sample  Point  95-Percent
Estimate Description 
Size  Estimate  Confidence Interval 
Percentage of plans that reported requiring training for staff and 
135  99.3  95.9%99.9%* 
contractors on language access services (CLAS Standard 6) 
Percentage of plans that reported translating materials in the languages 
135  94.1  90.0%98.1% 
of commonly encountered groups (CLAS Standard 7) 
Percentage of plans that reported offering language access services 
135  5.9  1.9%10.0% 
during more than half of their business hours 
Percentage of plans that reported informing LEP persons of their right to 
135  96.3  93.1%99.5% 
receive language access services in enrollment materials 
Percentage of plans that reported informing LEP persons of their right to 
135  95.6  92.0%99.1% 
receive language access services in plan benefit materials 
Percentage of plans that reported informing LEP persons of their right to 
135  85.9  80.0%91.9% 
receive language access services in other marketing materials 
Percentage of plans that reported informing LEP persons of their right to 
receive language access services verbally during the enrollment  135  71.1  63.4%78.9% 
process 
Percentage of plans that reported training staff or contractors on 
135  96.3  93.1%99.5% 
responding to LEP persons 
Percentage of plans that reported training staff or contractors on 
135  89.6  84.4%94.8% 
language access policies and procedures  
Percentage of plans that reported training staff or contractors on cultural 
135  72.6  65.0%80.2% 
competency 
Percentage of plans that reported training staff or contractors on 
135  55.6  47.1%64.0% 
language skills 
Percentage of plans that reported formally testing the skills and 
competency of staff and contractors in providing language access  135  57.0  48.6%65.5% 
services 
Percentage of plans that reported testing staff and contractors on their 
135  41.5  33.1%49.9% 
ability to interpret effectively  
*Confidence interval calculated with an exact method based on the binomial distribution. 
continued on next page 
 
  OEI-05-10-00051  GUIDANCE AND STANDARDS ON LANGUAGE ACCESS SERVICES:  MEDICARE PLANS  31   
   
A P P E N D I X   ~   D  
Table D-1:  Estimates of Survey Responses, continued 
Sample  Point  95-Percent
Estimate Description 
Size  Estimate  Confidence Interval 
Percentage of plans that reported testing staff and contractors on their 
135  40.7  32.3%49.1% 
proficiency in English and non-English languages 
Percentage of plans that reported testing staff and contractors on 
135  57.0  48.6%65.5% 
knowledge of confidentiality requirements  
Percentage of plans that reported testing staff and contractors on 
135  54.8  46.3%63.3% 
knowledge of plans policies and procedures  
Percentage of plans that reported testing staff and contractors on 
135  42.2  33.8%50.7% 
knowledge of medical terminology  
Percentage of plans that reported translating enrollment applications 
135  86.7  80.9%92.5% 
into the languages of commonly encountered groups 
Percentage of plans that reported translating marketing materials  135  83.0  76.5%89.4% 
Percentage of plans that reported translating plan benefit materials  135  77.8  70.7%84.9% 
Percentage of plans that reported benefits to providing language access 
135  48.9  40.3%57.4% 
services  
Percentage of plans that reported obstacles to providing language 
123  56.9  48.0%65.8% 
access services 
Percentage of plans that reported improved communication with 
135  45.9  37.4%54.4% 
Medicare beneficiaries by offering language access services 
Percentage of plans that reported improved communication between 
135  10.4  5.2%15.6% 
providers and their patients by offering language access services 
Percentage of plans that reported saving money by providing language 
135  1.5  0.18%5.3%* 
access services 
Percentage of plans that reported that they did not save money by 
135  28.1  20.5%35.8% 
providing language access services 
Percentage of plans that reported that they did not know whether they 
135  69.6  61.8%77.5% 
saved money by providing language access services 
*Confidence interval calculated with an exact method based on the binomial distribution. 
continued on next page 
 
  OEI-05-10-00051  GUIDANCE AND STANDARDS ON LANGUAGE ACCESS SERVICES:  MEDICARE PLANS  32   
   
A P P E N D I X   ~   D  
Table D-1:  Estimates of Survey Responses, continued 
Sample  Point  95-Percent
Estimate Description 
Size  Estimate  Confidence Interval 
Percentage of plans that reported cost as an obstacle to providing 
123  41.5  32.6%50.3% 
language access services 
Percentage of plans that reported a lack of means for staff to identify 
123  22.0  14.5%29.4% 
LEP persons as an obstacle  
Percentage of plans that reported being understaffed as an obstacle   123  20.3  13.1%27.5% 
Percentage of plans that reported the broad range of languages spoken 
123  18.7  11.7%25.7% 
in the community as an obstacle 
Percentage of plans that reported staff discomfort in providing language 
123  18.7  11.7%25.7% 
access services as an obstacle  
Percentage of plans that reported a lack of training resources for staff as 
123  10.6  5.1%16.1% 
an obstacle 
Percentage of plans that reported liability concerns as an obstacle  123  9.8  4.4%15.1% 
Percentage of plans that reported cost as their only obstacle  70  30.0  19.0%41.0% 
Percentage of plans that indicated that it would be useful to have 
128  52.3  43.6%61.1% 
additional assistance in implementing language access services 
Percentage of plans that reported financial data on language access 
135  78.5  71.5%85.5% 
services 
Source:  Office of Inspector General analysis of plan survey responses, 2010. 
 
 
  OEI-05-10-00051  GUIDANCE AND STANDARDS ON LANGUAGE ACCESS SERVICES:  MEDICARE PLANS  33   
   
   A P P E N D I X ~ E  
Supplemental Analysis Table 
Table E-1:  Assistance Plans Reported Offering to Providers 
Sample  Percentage of  95-Percent
Ways Plans Reported Giving Assistance to Providers* 
Size  Plans  Confidence Interval 
Provide access to interpreters  135  58.5  50.1%66.9% 
Provide education materials  135  45.2  36.7%53.7% 
Translate materials for distribution to patients  135  37.8  29.5%46.1% 
Train providers and their staffs on communicating with LEP persons  135  17.8  11.2%24.3% 
Provide financial assistance for language access services  135  8.9  4.0%13.8% 
*Choices are not mutually exclusive.          
Source: Office of Inspector General analysis of plan survey responses, 2010. 
 
  OEI-05-10-00051  GUIDANCE AND STANDARDS ON LANGUAGE ACCESS SERVICES:  MEDICARE PLANS  34  x 
A  P  PEN  D  F 
Agencies' Comments 
(J 
""A
DEPARTMENT OF REALTII AND HUMAN SERVICES  Office of the Secretary 
Office of Public Health and Science 
Office of Minority Health 
Washington, D.C. 20201 
DATE:  May 26, 2010 
TO:  Dan iel R. Levinson 
Inspector General 
FROM: 	 Gal(lh N. Grahaln, M.D., M.P.H. 
Deputy Assistant Secretary for Minority Health 
Office of Minority Health 
Office of the Secretary 
SUBJECT: 	 OIG Draft RepOlis: Guidance and Standards on 
Language Access Services: Medicare Plans, OEI-OS-1 0-00051 
Thank you for the opportunity to revicw and respond to the OIG draft report. We appreciate 
OIG's efforts to examine the extent Medicare Plans 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) OMB's CLAS standards. 
Based on our review of the report, our responses will only focus on those areas that apply to the 
CLAS Standards. 
OIG Recommendation: Medicare Plans: OEl-OS-10-00051 
 	 OMH should inform Medicare plans that they should notify LEP persons both 
verbally and in writing of their right to receive language access services. 
OMH should collaborate with CMS, as well as work with professional 
associations, to inform Medicare plans that they should notify LEP persons of 
their rights in writing and verbally. CMS has an established infrastructure for 
communicating with Medicare plans. OMH and CMS .could use this 
infrastructure to encourage Medicare plans to inform LEI' persons of their rights 
to language access services not only in writing during enrollment, but verbally 
every time LEP persons contact Medicare plans. 
Th is joint effort could suggest ways in which Medicare plans could increase 
verbal notification of language access services at call centers. To help ensure that 
lrulguage access services are provided to those who need them, OMH and CMS 
could suggest that Medicare plans ensure that (I) call center staff are trained to 
identify LEP persons; (2) LEP persons are transferred from call centers to 
interpreter services; and (3) callers are automatically transferred to an interpreter 
service in cases in which an automated response is required and none is selected, 
as this may indicate that the caller does not understand the automatic prompts. 
OMH concurs with OIG's recommendations. The OMH will work closely with eMS to 
implement the specific recommendations as outlined in the OIG draft repmi to inform LEP 
persons both verbally and in writing oftheir rights to receive language access services. 
U.S. Public Health Service 
..  .. 
OEI051000051  GUIDANCE AND STANDARDS ON LANGUAGE ACCESS SERVICES:  MEDICARE PLANS  35  x 
A  P  PEN  D  F 
DEPARTMENT OF HEALTH & HUMAN SERVICES  Centers for Medicare & Medicaid Services 
Office of the Administrator' 
Washington. DC 20201 
DATE: 	 MAY  2 0 2010 
TO: 	 Daniel R. Levinson 
Inspector General 
FROM: 	 Marilyn Tavenner 
Acting Administrator and Chief Operating Officer 
SUBJECT: 	 Office ofInspector Gerieral (01G) Draft Report: "Guidance.and Standards on 
Language Access Services: Medicare Plans" (OEI-05-10-000Sl) 
Thank you for the opportunity to review and comment on the Office ofinspector General (OIG) 
draft report entitled: "Guidance and Standards on Language Access Services: Medicare Plans" 
(OEIOSIO-00051) 
In this draft correspondence, the GIG (1) determined the extent to which Medicare plans 
conducted the four factor assessment recommended by the Office for Civil Rights' (OCR) 
guidance when determining what language access services to offer; (2) determined the extent to 
which Medicare plans offered language access services consistent with the Office ofMinority 
Health's (OMH) Culturally and Linguistically Appropriate Services in Health Care (CLAS) 
standards on language access services; (3) determined the extent to which Medicare plans 
encountered benefits. including savings. and obstacles to providing language access services and 
(4) described costs associated with providing language access services. 
It is our goal at the Centers for Medicare & Medicaid Services (CMS) to provide clear, accurate, 
and timely information regarding Title VI prohibition against National Origin Discrimination 
affecting Limited English Proficient persons. The CMS concurs with the recommendation stated 
in the report. 
Thank you for the opportunity to review the report and provide feedback on this OIG report. 
OEI051000051  GUIDANCE AND STANDARDS ON LANGUAGE ACCESS SERVICES:  MEDICARE PLANS  36   
   
 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.   
Mark Stiglitz 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, Nicole Hrycyk, 
Ericka Kilburn, and Margarita Rodriguez; central office staff who 
contributed include Heather Barton and Kevin Farber.  
 
  OEI-05-10-00051  GUIDANCE AND STANDARDS ON LANGUAGE ACCESS SERVICES:  MEDICARE PLANS  37   
 
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.