Department of Health & Human Services 

OFFICE OF 

INSPECTOR GENERAL 

 

GUIDANCE AND STANDARDS ON 

LANGUAGE ACCESS SERVICES: 

MEDICARE PLANS 

 

Daniel R. Levinson 

Inspector General 

July 2010 

OEI-05-10-00051 
 EXECUTIVE SUMMARY 

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 Health’s (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) OCR’s 

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) OMH’s 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 

 O E I - 0 5 - 1 0 - 0 0 0 5 1 GUIDANCE AND S TANDARDS ON L ANGUAGE ACCESS S ERVICES : MEDICARE P LANS i
 

EXECUTIVE SUMMARY 

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 provider’s 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 

people’s lives; and (4) the resources available to the provider and costs 

for offering language access services. 

OMH’s 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. 

 O E I - 0 5 - 1 0 - 0 0 0 5 1 GUIDANCE AND S TANDARDS ON L ANGUAGE ACCESS S ERVICES : MEDICARE PLANS ii 
 

EXECUTIVE SUMMARY 

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. 

 O E I - 0 5 - 1 0 - 0 0 0 5 1 GUIDANCE AND S TANDARDS ON L ANGUAGE ACCESS S ERVICES : MEDICARE PLANS iii 
 

 O E I - 0 5 - 1 0 - 0 0 0 5 1 GUIDANCE AND S TANDARDS ON L ANGUAGE ACCESS S ERVICES : MEDICARE PLANS iv 

EXECUTIVE SUMMARY 

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.
 TABLE OF CONTENTS 

EXECUTIVE SUMMARY .....................................i

INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 

FINDINGS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 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 

RECOMMENDATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 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 

ACKNOWLEDGMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
 

 INTRODUCTION 

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 Health’s (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) OCR’s 

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) OMH’s 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. 

 O E I - 0 5 - 1 0 - 0 0 0 5 1 GUIDANCE AND S TANDARDS ON L ANGUAGE ACCESS S ERVICES : MEDICARE PLANS 1 
 

INTRODUCTION 

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 

2 

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. 

 O E I - 0 5 - 1 0 - 0 0 0 5 1 GUIDANCE AND S TANDARDS ON L ANGUAGE ACCESS S ERVICES : MEDICARE PLANS
 

INTRODUCTION 

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 

3 

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. 

 O E I - 0 5 - 1 0 - 0 0 0 5 1 GUIDANCE AND S TANDARDS ON L ANGUAGE ACCESS S ERVICES : MEDICARE PLANS
 

INTRODUCTION 

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 

4 

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. 

 O E I - 0 5 - 1 0 - 0 0 0 5 1 GUIDANCE AND S TANDARDS ON L ANGUAGE ACCESS S ERVICES : MEDICARE PLANS
 

INTRODUCTION 

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 recipient’s 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 people’s 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 

OMH’s 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

5 

(standards 4–7), and Organizational Supports for Cultural Competence 

OMH divided the standards into three categories: Culturally 

Competent Care (standards 1–3), Language Access Services 

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. 

 O E I - 0 5 - 1 0 - 0 0 0 5 1 GUIDANCE AND S TANDARDS ON L ANGUAGE ACCESS S ERVICES : MEDICARE PLANS
 

INTRODUCTION 

(standards 8–14).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 OMH’s 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 

6 

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. 1013. 

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). 

 O E I - 0 5 - 1 0 - 0 0 0 5 1 GUIDANCE AND S TANDARDS ON L ANGUAGE ACCESS S ERVICES : MEDICARE PLANS
 

INTRODUCTION 

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 CMS’s 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 

plan’s 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 

7 

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. 

 O E I - 0 5 - 1 0 - 0 0 0 5 1 GUIDANCE AND S TANDARDS ON L ANGUAGE ACCESS S ERVICES : MEDICARE PLANS
 

INTRODUCTION 

In 2008, CMS informed plans of concerns that ineffective processes may 

have been preventing LEP persons from receiving the language access 

services covered by CMS’s 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 4–7, 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. 

 O E I - 0 5 - 1 0 - 0 0 0 5 1 GUIDANCE AND S TANDARDS ON L ANGUAGE ACCESS S ERVICES : MEDICARE PLANS 8 
 

INTRODUCTION 

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 Bureau’s 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. 

 O E I - 0 5 - 1 0 - 0 0 0 5 1 GUIDANCE AND S TANDARDS ON L ANGUAGE ACCESS S ERVICES : MEDICARE PLANS 9 
 

INTRODUCTION 

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 CMS’s 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.

 O E I - 0 5 - 1 0 - 0 0 0 5 1 GUIDANCE AND S TANDARDS ON L ANGUAGE ACCESS S ERVICES : MEDICARE PLANS 10 
 

INTRODUCTION 

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 

persons eligible to be served or likely to be 

encountered in the recipient’s service 

population 

Which of the following sources of information does your 

plan use to determine the number or proportion of LEP 

persons from each language group represented in its 

geographic service area? 

Factor 2: The frequency with which LEP 

persons come in contact with the recipient 

Which of the following sources of information does your 

plan use to track how often it encounters LEP persons? 

Factor 3: The importance, nature, and 

urgency of the program, activity, or service 

to people’s lives 

When determining whether to communicate to LEP 

persons in their preferred language, does your plan 

consider the importance and urgency of the activity, 

program, or service to people’s lives? 

Factor 4: The resources available to the 

recipient and costs for offering language 

access services 

How does your plan assess whether it has resources 

available to provide language 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 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. See Appendix C 

for the categories of responses to each question. 

 O E I - 0 5 - 1 0 - 0 0 0 5 1 GUIDANCE AND S TANDARDS ON L ANGUAGE ACCESS S ERVICES : MEDICARE PLANS 11 
 

INTRODUCTION 

Table 2: CLAS Standards and Corresponding Survey Questions

CLAS Standards on Language Access Services Corresponding Question in Survey of 

Plans 

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. 

During what percentage of your plan’s 

business hours are language access 

services offered? 

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. 

Does your plan inform LEP persons of their 

right to receive language access services in 

their preferred language in any of the 

following ways? 

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). 

Which of the following training topics does 

your organization require for staff and 

contractors? 

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. 

Which of the following written materials are 

translated into the languages of commonly 

encountered groups? 

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 

 O E I - 0 5 - 1 0 - 0 0 0 5 1 GUIDANCE AND S TANDARDS ON L ANGUAGE ACCESS S ERVICES : MEDICARE PLANS 12 
 

INTRODUCTION 

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. 

 O E I - 0 5 - 1 0 - 0 0 0 5 1 GUIDANCE AND S TANDARDS ON L ANGUAGE ACCESS S ERVICES : MEDICARE PLANS 13 
 

Eighty-eight percent of plans conducted the 

four-factor assessment recommended by OCR 

guidance when determining what language 

access services to offer 

 FINDINGS 

Eighty-eight percent of plans in 

counties with a high percentage of 

LEP persons considered all four 

factors of the recommended 

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

Four Factors in OCR Guidance Percentage 

of Plans 

Factor 1: The number or proportion of LEP persons eligible to be 

served or likely to be encountered in the recipient’s service population 94% 

Factor 2: The frequency with which LEP persons come in contact with 

the recipient 99% 

Factor 3: The importance, nature, and urgency of the program, activity, 

or service to people’s lives 96% 

Factor 4: The resources available to the recipient and costs for offering 

language access services 100% 

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. 

 O E I - 0 5 - 1 0 - 0 0 0 5 1 GUIDANCE AND S TANDARDS ON L ANGUAGE ACCESS S ERVICES : MEDICARE PLANS 14 
 

FINDINGS 

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

15 

40 Choices are not mutually exclusive. 

 O E I - 0 5 - 1 0 - 0 0 0 5 1 GUIDANCE AND S TANDARDS ON L ANGUAGE ACCESS S ERVICES : MEDICARE PLANS
 

FINDINGS 

All plans operating in counties 

with a high percentage of LEP 

persons reported offering some 

language access services by either 

translating documents or providing interpreter services. However, only 

67 percent offered language access services consistent with all four of 

OMH’s 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. 

Sixty-seven percent of plans offered services 

consistent with all four CLAS standards on 

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. 

16 

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. 

 O E I - 0 5 - 1 0 - 0 0 0 5 1 GUIDANCE AND S TANDARDS ON L ANGUAGE ACCESS S ERVICES : MEDICARE PLANS
 

FINDINGS 

Table 4: CLAS Standards and Percentage of Plans Offering 

Services Consistent With Each Standard

CLAS Standards on Language Access Services Percentage of 

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 

during all hours of operation. 

94% 

Standard 5: Provide to patients in their preferred language both verbal offers 

and written notices informing them of their right to receive language 

assistance services. 

71% 

Standard 6: Assure the competence of language assistance provided. 

Family and friends should not be used to provide interpretation services 

(except on request by the patient). 

99% 

Standard 7: Make available easily understood patient-related materials and 

post signage in the languages of the commonly encountered groups 

represented in the service area. 

94% 

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. 

 O E I - 0 5 - 1 0 - 0 0 0 5 1 GUIDANCE AND S TANDARDS ON L ANGUAGE ACCESS S ERVICES : MEDICARE PLANS 17 
 

FINDINGS 

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. 

18 

43 Choices are not mutually exclusive. 

44 Choices are not mutually exclusive. 

 O E I - 0 5 - 1 0 - 0 0 0 5 1 GUIDANCE AND S TANDARDS ON L ANGUAGE ACCESS S ERVICES : MEDICARE PLANS
 

FINDINGS 

Table 5: Testing Topics for Staff and Contractors 

Testing Topics* Percentage of Plans 

Confidentiality requirements 57% 

Plan’s 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 

providing language access services and 

57 percent reported obstacles 

Although all plans reported 

offering some language access 

services, only 49 percent reported 

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. 

 O E I - 0 5 - 1 0 - 0 0 0 5 1 GUIDANCE AND S TANDARDS ON L ANGUAGE ACCESS S ERVICES : MEDICARE PLANS 19 
 

FINDINGS 

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. 

 O E I - 0 5 - 1 0 - 0 0 0 5 1 GUIDANCE AND S TANDARDS ON L ANGUAGE ACCESS S ERVICES : MEDICARE PLANS 20 
 

FINDINGS 

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 data on the 

costs of providing language access 

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.

 O E I - 0 5 - 1 0 - 0 0 0 5 1 GUIDANCE AND S TANDARDS ON L ANGUAGE ACCESS S ERVICES : MEDICARE PLANS 21 
 

RECOMMENDATIONS RECOMMENDATION 

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 

 O E I - 0 5 - 1 0 - 0 0 0 5 1 GUIDANCE AND S TANDARDS ON L ANGUAGE ACCESS S ERVICES : MEDICARE PLANS 22 
 

RECOMMENDATION 

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.

 O E I - 0 5 - 1 0 - 0 0 0 5 1 GUIDANCE AND S TANDARDS ON L ANGUAGE ACCESS S ERVICES : MEDICARE PLANS 23 
 

 APPENDIX~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 Health’s 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. 

 O E I - 0 5 - 1 0 - 0 0 0 5 1 GUIDANCE AND S TANDARDS ON L ANGUAGE ACCESS S ERVICES : MEDICARE PLANS 24 
 

 APPENDIX ~ 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. 

25 

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. 

 O E I - 0 5 - 1 0 - 0 0 0 5 1 GUIDANCE AND S TANDARDS ON L ANGUAGE ACCESS S ERVICES : MEDICARE PLANS
 

APPENDIX ~ 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 patient’s/consumer’s race, ethnicity, and spoken and written 

language are collected in health records, integrated into the 

organization’s 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. 

 O E I - 0 5 - 1 0 - 0 0 0 5 1 GUIDANCE AND S TANDARDS ON L ANGUAGE ACCESS S ERVICES : MEDICARE PLANS 26 
 

 APPENDIX ~ 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 people’s 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) 

 O E I - 0 5 - 1 0 - 0 0 0 5 1 GUIDANCE AND S TANDARDS ON L ANGUAGE ACCESS S ERVICES : MEDICARE PLANS 27 
 

APPENDIX ~ C 

Culturally and Linguistically Appropriate Services in Health Care (CLAS) Standard 4 Question: 

During what percentage of your plan’s 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) 

 O E I - 0 5 - 1 0 - 0 0 0 5 1 GUIDANCE AND S TANDARDS ON L ANGUAGE ACCESS S ERVICES : MEDICARE PLANS 28 
 

 APPENDIX~D 

 O E I - 0 5 - 1 0 - 0 0 0 5 1 GUIDANCE AND S TANDARDS ON L ANGUAGE ACCESS S ERVICES : MEDICARE PLANS 29 

Estimates and Confidence Intervals 

Table D-1: Estimates of Survey Responses 

Estimate Description Sample 

Size 

Point 

Estimate 

95-Percent

Confidence Interval 

Percentage of plans that conducted the four-factor assessment 

recommended by Office for Civil Rights (OCR) guidance when 

determining what language access services to offer 

135 88.1 82.6%–93.7% 

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 

likely to encounter in their geographic service areas (OCR Factor 1) 

135 94.1 90.0%–98.1% 

Percentage of plans that reported determining the frequency of contact 

with LEP persons (OCR Factor 2) 135 98.5 94.8%–99.8% 

Percentage of plans that reported considering the situation when 

determining what language access services to provide or reported 

offering services in all situations (OCR Factor 3) 

135 95.6 92.0%–99.1% 

Percentage of plans that reported assessing the available resources for 

offering language access services (OCR Factor 4) 135 100.0 97.3%–100%* 

Percentage of plans that reported they used Census data to determine 

the number or proportion of LEP persons represented in their 

geographic service areas 

135 80.7 74.0%–87.5% 

Percentage of plans that reported the collected data from plan members 

to determine the number or proportion of LEP persons represented in 

their geographic service areas 

135 64.4 56.3%–72.6% 

Percentage of plans that reported using data collected from call centers 

to determine the frequency of contact with LEP persons 135 78.5 71.5%–85.5% 

Percentage of plans that reported using data collected from plan 

member databases to determine the frequency of contact with LEP 

persons 

135 65.9 57.8%–74.0% 

*Confidence interval calculated with an exact method based on the binomial distribution. 

continued on next page 
 

APPENDIX ~ D 

Table D-1: Estimates of Survey Responses, continued

Estimate Description Sample 

Size 

Point 

Estimate 

95-Percent

Confidence Interval 

Percentage of plans that reported using data both from call centers and 

from plan member databases when determining the frequency of 

contact with LEP persons 

135 48.9 40.3%–57.4% 

Percentage of plans that reported assessing the importance of their 

program activities and services 135 17.8 11.2%–24.3% 

Percentage of plans that reported offering language access services in 

all types of situations regardless of importance and urgency 135 77.8 70.7%–84.9% 

Percentage of plans that reported assessing the availability of bilingual 

staff for providing language access services 135 94.1 90.0%–98.1% 

Percentage of plans that reported assessing the availability of 

technology for providing language access services 135 78.5 71.5%–85.5% 

Percentage of plans that reported assessing the financial resources 

available to them when determining whether to provide language access 

services 

135 47.4 38.9%–55.9% 

Percentage of plans that offered language access services consistent 

with the four selected Culturally and Linguistically Appropriate Services 

in Health Care (CLAS) standards 

135 66.7 58.6%–74.7% 

Percentage of plans that reported offering some language access 

services 135 100.0 97.3%–100%* 

Percentage of plans that reported offering language access services 

and financial assistance to providers 135 79.3 72.3%–86.2% 

Percentage of plans that reported requiring providers to offer language 

services to their patients 135 48.1 39.6%–56.7% 

Percentage of plans that reported offering language access services 

during all business hours (CLAS Standard 4) 135 94.1 90.0%–98.1% 

Percentage of plans that reported informing LEP persons both verbally 

and in writing of their right to receive language access services (CLAS 

Standard 5) 

135 71.1 63.4%–78.9% 

*Confidence interval calculated with an exact method based on the binomial distribution. 

continued on next page 

 O E I - 0 5 - 1 0 - 0 0 0 5 1 GUIDANCE AND S TANDARDS ON L ANGUAGE ACCESS S ERVICES : MEDICARE PLANS 30 
 

APPENDIX ~ D 

Table D-1: Estimates of Survey Responses, continued

Estimate Description Sample 

Size 

Point 

Estimate 

95-Percent

Confidence Interval 

Percentage of plans that reported requiring training for staff and 

contractors on language access services (CLAS Standard 6) 135 99.3 95.9%–99.9%* 

Percentage of plans that reported translating materials in the languages 

of commonly encountered groups (CLAS Standard 7) 135 94.1 90.0%–98.1% 

Percentage of plans that reported offering language access services 

during more than half of their business hours 135 5.9 1.9%–10.0% 

Percentage of plans that reported informing LEP persons of their right to 

receive language access services in enrollment materials 135 96.3 93.1%–99.5% 

Percentage of plans that reported informing LEP persons of their right to 

receive language access services in plan benefit materials 135 95.6 92.0%–99.1% 

Percentage of plans that reported informing LEP persons of their right to 

receive language access services in other marketing materials 135 85.9 80.0%–91.9% 

Percentage of plans that reported informing LEP persons of their right to 

receive language access services verbally during the enrollment 

process 

135 71.1 63.4%–78.9% 

Percentage of plans that reported training staff or contractors on 

responding to LEP persons 135 96.3 93.1%–99.5% 

Percentage of plans that reported training staff or contractors on 

language access policies and procedures 135 89.6 84.4%–94.8% 

Percentage of plans that reported training staff or contractors on cultural 

competency 135 72.6 65.0%–80.2% 

Percentage of plans that reported training staff or contractors on 

language skills 135 55.6 47.1%–64.0% 

Percentage of plans that reported formally testing the skills and 

competency of staff and contractors in providing language access 

services 

135 57.0 48.6%–65.5% 

Percentage of plans that reported testing staff and contractors on their 

ability to interpret effectively 135 41.5 33.1%–49.9% 

*Confidence interval calculated with an exact method based on the binomial distribution. 

continued on next page 

 O E I - 0 5 - 1 0 - 0 0 0 5 1 GUIDANCE AND S TANDARDS ON L ANGUAGE ACCESS S ERVICES : MEDICARE PLANS 31 
 

APPENDIX ~ D 

Table D-1: Estimates of Survey Responses, continued

Estimate Description Sample 

Size 

Point 

Estimate 

95-Percent

Confidence Interval 

Percentage of plans that reported testing staff and contractors on their 

proficiency in English and non-English languages 135 40.7 32.3%–49.1% 

Percentage of plans that reported testing staff and contractors on 

knowledge of confidentiality requirements 135 57.0 48.6%–65.5% 

Percentage of plans that reported testing staff and contractors on 

knowledge of plans’ policies and procedures 135 54.8 46.3%–63.3% 

Percentage of plans that reported testing staff and contractors on 

knowledge of medical terminology 135 42.2 33.8%–50.7% 

Percentage of plans that reported translating enrollment applications 

into the languages of commonly encountered groups 135 86.7 80.9%–92.5% 

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 

services 135 48.9 40.3%–57.4% 

Percentage of plans that reported obstacles to providing language 

access services 123 56.9 48.0%–65.8% 

Percentage of plans that reported improved communication with 

Medicare beneficiaries by offering language access services 135 45.9 37.4%–54.4% 

Percentage of plans that reported improved communication between 

providers and their patients by offering language access services 135 10.4 5.2%–15.6% 

Percentage of plans that reported saving money by providing language 

access services 135 1.5 0.18%–5.3%* 

Percentage of plans that reported that they did not save money by 

providing language access services 135 28.1 20.5%–35.8% 

Percentage of plans that reported that they did not know whether they 

saved money by providing language access services 135 69.6 61.8%–77.5% 

*Confidence interval calculated with an exact method based on the binomial distribution. 

continued on next page 

 O E I - 0 5 - 1 0 - 0 0 0 5 1 GUIDANCE AND S TANDARDS ON L ANGUAGE ACCESS S ERVICES : MEDICARE PLANS 32 
 

APPENDIX ~ D 

Table D-1: Estimates of Survey Responses, continued

Estimate Description Sample 

Size 

Point 

Estimate 

95-Percent

Confidence Interval 

Percentage of plans that reported cost as an obstacle to providing 

language access services 123 41.5 32.6%–50.3% 

Percentage of plans that reported a lack of means for staff to identify 

LEP persons as an obstacle 123 22.0 14.5%–29.4% 

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 

in the community as an obstacle 123 18.7 11.7%–25.7% 

Percentage of plans that reported staff discomfort in providing language 

access services as an obstacle 123 18.7 11.7%–25.7% 

Percentage of plans that reported a lack of training resources for staff as 

an obstacle 123 10.6 5.1%–16.1% 

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 

additional assistance in implementing language access services 128 52.3 43.6%–61.1% 

Percentage of plans that reported financial data on language access 

services 135 78.5 71.5%–85.5% 

Source: Office of Inspector General analysis of plan survey responses, 2010. 

 O E I - 0 5 - 1 0 - 0 0 0 5 1 GUIDANCE AND S TANDARDS ON L ANGUAGE ACCESS S ERVICES : MEDICARE PLANS 33 
 

 APPENDIX~E 

Supplemental Analysis Table 

Table E-1: Assistance Plans Reported Offering to Providers 

Ways Plans Reported Giving Assistance to Providers* Sample 

Size 

Percentage of 

Plans 

95-Percent

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. 

 O E I - 0 5 - 1 0 - 0 0 0 5 1 GUIDANCE AND S TANDARDS ON L ANGUAGE ACCESS S ERVICES : MEDICARE PLANS 34 
A P PEN D x 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 

.. .. 

OEI·05·10·00051 GUIDANCE AND STANDARDS ON LANGUAGE ACCESS SERVICES: MEDICARE PLANS 35 
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" 

(OEI·OS·IO-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. 

OEI·05·10·00051 GUIDANCE AND STANDARDS ON LANGUAGE ACCESS SERVICES: MEDICARE PLANS 36 

A P PEN D x F 
 

 O E I - 0 5 - 1 0 - 0 0 0 5 1 GUIDANCE AND S TANDARDS ON L ANGUAGE ACCESS S ERVICES : MEDICARE PLANS 37 

 ACKNOWLEDGMENTS 

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. 
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 OIG’s 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.