Department of Health & Human Services 

OFFICE OF 

INSPECTOR GENERAL 

 

GUIDANCE AND STANDARDS ON 

LANGUAGE ACCESS SERVICES: 

MEDICARE PROVIDERS 

 

Daniel R. Levinson 

Inspector General 

July 2010 

OEI-05-10-00050 
 EXECUTIVE SUMMARY 

OBJECTIVES

1. To determine the extent to which Medicare providers conducted the 

four-factor assessment recommended by the Office for Civil Rights’ 

(OCR) guidance when determining what language access services to 

offer. 

2. To determine the extent to which Medicare providers offered 

language access services consistent with the Office of Minority 

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 providers realized 

benefits, including savings, and encountered obstacles to providing 

language access services. 

4. To describe costs of providing language access services. 

BACKGROUND 

The Medicare Improvements for Patients and Providers Act of 2008 

(MIPPA) requires that the Office of Inspector General (OIG) conduct a 

study examining Medicare provider and plan compliance with (1) 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 providers’ voluntary compliance as indicated by the 

extent to which providers conducted the four-factor assessment 

recommended by OCR guidance and offered language access services 

consistent with CLAS standards. A companion report, Guidance and 

Standards on Language Access Services: Medicare Plans

(OEI-05-10-00051), provides the same assessment for Medicare plans. 

OCR guidance and CLAS standards address the provision of language 

access services. OCR guidance recommends a four-factor assessment to 

help determine what language access services to offer. These factors are 

(1) the number or proportion of Limited English Proficient (LEP) 

persons eligible to be served or likely to be encountered in the provider’s 

service population; (2) the frequency with which LEP persons come in 

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

EXECUTIVE SUMMARY 

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 providers become responsive to the 

cultural and linguistic needs of diverse populations. Four of the 

fourteen CLAS standards focus on the provision of language access 

services. These standards are (1) providing language access services 

during all business hours, (2) providing verbal offers and written notices 

of the rights to language access services, (3) assuring the competence of 

language assistance provided by staff, and (4) providing written 

materials and signage translated into appropriate languages. 

Language access services are designed to promote effective 

communication between LEP persons and non-LEP persons. LEP 

persons do not speak English as their primary language and have a 

limited ability to read, write, speak, or understand English. Language 

access services can include oral interpretation; written translation; and 

other provisions that enhance communication, such as translated signs. 

To conduct this review, we administered a survey in 2009 to 

140 randomly selected Medicare providers located in counties with a 

high percentage of LEP persons. 

FINDINGS 

Sixty-nine percent of providers conducted the four-factor 

assessment recommended by OCR guidance when determining 

what language access services to offer. Sixty-nine percent of 

providers conducted all four factors of the recommended assessment. 

Further, most providers reported completing some of the factors; 

84 percent completed at least three of the four factors and 97 percent 

completed at least one of the factors. The percentages of providers that 

completed each factor ranged between 78 percent and 94 percent. The 

factor completed most frequently was assessing available resources. 

Providers that conducted the assessment were more likely to be familiar 

with OCR guidance than providers that did not. 

Only 33 percent of providers offered services consistent with all 

four CLAS standards on language access services. 

Ninety-eight percent of providers reported offering some language 

access services, but only 33 percent offered services consistent with all 

four CLAS standards on language access services. The percentages of 

providers that offered services consistent with each standard ranged 

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

EXECUTIVE SUMMARY 

between 52 percent and 86 percent. Providers were most likely to offer 

language access services consistent with the standard regarding 

assuring the competence of language assistance provided by staff. 

Providers that offered language access services consistent with all four 

CLAS standards were more likely to be familiar with them. 

Seventy-three percent of providers reported benefits to providing 

language access services and half reported obstacles. The four 

most frequently reported benefits were (1) improved communication, 

(2) improved adherence to treatment regimen, (3) improved diagnosis 

and treatment, and (4) fewer complaints. The three most frequently 

reported obstacles were (1) a lack of training resources for staff, (2) costs 

of providing language access services, and (3) the broad range of 

languages spoken in the providers’ communities. 

Few providers reported data on the costs of providing language 

access services and the data provided were not comparable. 

Because of the overall lack of reporting and the inability to compare data, 

we were unable to make any determinations about cost data related to 

providing language access services. Of the 119 providers that responded 

to the survey, only 49 providers responded to the request for cost data. In 

addition, provider comments indicated different approaches to calculating 

costs; therefore, we were unable to compare cost data. 

RECOMMENDATIONS 

The MIPPA requires OIG to make recommendations on improving 

compliance with and enforcement of CLAS standards. However, in 

keeping with our assessment of voluntary compliance, we make 

recommendations to increase the percentage of providers that 

voluntarily offer services consistent with all four CLAS standards on 

language access services. 

Providers that offered language access services consistent with the 

CLAS standards were more likely to be familiar with them. Therefore, 

to improve Medicare providers’ awareness and implementation of CLAS 

standards, we recommend that: 

 OCR inform providers about OMH’s CLAS standards. 

 OMH increase outreach to providers to familiarize them with 

CLAS standards. 

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

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

EXECUTIVE SUMMARY 

In addition, to help Medicare providers offer language access services, 

we recommend that: 

 OMH offer model translated written materials and signs to 

providers. 

AGENCIES’ COMMENTS AND OFFICE OF INSPECTOR 

GENERAL RESPONSE 

OCR and OMH concurred with our recommendations. OMH stated that 

it will take the lead in developing specific marketing strategies to 

inform providers of the CLAS standards. CMS indicated that it did not 

have any substantive comments. However, it did provide technical 

comments that we incorporated as appropriate.
 TABLE OF CONTENTS 

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

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

FINDINGS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 

 Sixty-nine percent of providers conducted the four-factor 

assessment recommended by OCR guidance when 

determining what language access services to offer . . . . . . . . . . . . 14 

 

 Only 33 percent of providers offered services consistent with all 

four CLAS standards on language access services . . . . . . . . . . . . . 18 

Seventy-three percent of providers reported benefits to providing 

language access services and half reported obstacles . . . . . . . . . . . 21 

Few providers reported data on the costs of providing language 

access services and the data provided were not comparable. . . . . . 24 

RECOMMENDATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 

Agencies’ Comments and Office of Inspector General Response . . 27 

APPENDIXES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 

 A: Section 187 of the Medicare Improvements for Patients and 

 Providers Act of 2008 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 

 B: Culturally and Linguistically Appropriate Services in Health 

 Care Standards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 

 C: Categories of Responses to Key Survey Questions. . . . . . . . . . 31 

 D: Estimates and Confidence Intervals. . . . . . . . . . . . . . . . . . . . . 34 

 E: Supplemental Analysis Tables . . . . . . . . . . . . . . . . . . . . . . . . . 40 

 F: Agencies’ Comments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 

ACKNOWLEDGMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
 INTRODUCTION 

OBJECTIVES 

1. To determine the extent to which Medicare providers conducted the 

four-factor assessment recommended by the Office for Civil Rights’ 

(OCR) guidance when determining what language access services to 

offer. 

2. To determine the extent to which Medicare providers offered 

language access services consistent with the Office of Minority 

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 providers realized 

benefits, including savings, and encountered obstacles to providing 

language access services. 

4. To describe costs of providing language access services. 

BACKGROUND 

The Medicare Improvements for Patients and Providers Act of 2008 

(MIPPA) requires that the Office of Inspector General (OIG) conduct a 

study examining Medicare provider and plan compliance with (1) 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 

providers’ voluntary compliance as indicated by the extent to which 

providers conducted the four-factor assessment recommended by OCR 

1 Although the OCR guidance was signed by the then-Director of OCR, it was issued on 

behalf of the Secretary of Health & Human Services (HHS) and applies to all entities 

receiving funds from HHS. 

2 P.L. 110-275 § 187 (July 15, 2008), 42 U.S.C. § 1395cc note. 

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

guidance and offered language access services consistent with CLAS 

standards. 

This report is one of two issued in response to the MIPPA provision. 

This report focuses on Medicare providers, such as hospitals and 

nursing homes, which directly supply heath care services to 

beneficiaries. A companion report, Guidance and Standards on 

Language Access Services: Medicare Plans (OEI-05-10-00051), focuses 

on Medicare plans. Medicare plans are private companies that contract 

with the Centers for Medicare & Medicaid Services (CMS) to provide 

health insurance or prescription drug coverage to Medicare 

beneficiaries. 

Language Access Services for Limited English Proficient Persons 

Language access services are designed to promote effective 

communication between Limited English Proficient (LEP) persons and 

non-LEP persons.3 LEP persons do not speak English as their primary 

language and have a limited ability to read, write, speak, or understand 

English.4 According to the U.S. Census Bureau, approximately 

18 percent of the U.S. population in 2000 spoke languages other than 

English at home. Further, 8 percent of the U.S. population, or 

approximately 21 million people, spoke English less than “very well.”5

Language access services may include oral interpretation; written 

translation; and other provisions that enhance communication, such as 

translated signs.6 In providing oral interpretation, providers may 

choose, for example, to hire bilingual staff, contract with interpreters, or 

use telephone interpreter lines. When providing written translation, 

providers have discretion over which materials are translated. 

However, some materials are more critical than others.7, 8 These 

2 

3 OMH, A Patient-Centered Guide to Implementing Language Access Services in 

Healthcare Organizations, p. 1. Accessed at http://minorityhealth.hhs.gov on 

January 15, 2010. 

4 OCR, Guidance, pt. IV, 68 Fed. Reg. 47311, 47313 (Aug. 8, 2003). Accessed at 

http://www.hhs.gov/ocr on October 21, 2009. 

5 U.S. Census Bureau, Profile of Selected Social Characteristics: 2000. Accessed at 

http://factfinder.census.gov on January 15, 2010. 

6 OMH, Patient-Centered Guide, loc. cit. 

7 OCR, Guidance, pt. VI at 47316. 

8 OMH, National Standards on Culturally and Linguistically Appropriate Services in 

Health Care Final Report, March 2001, p. 78. Accessed at http://minorityhealth.hhs.gov on 

February 12, 2010. 

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

include, but are not limited to, patients’ rights information; medication 

directions; and screening, diagnosis, or treatment explanations.9, 10

The lack of language access services enables language barriers to 

persist between LEP persons and non-LEP persons. The inability to 

communicate with a provider can lead to ineffective care because 

providers are unable to elicit an LEP person’s symptoms, making it 

difficult to render a proper diagnosis and course of treatment.11 

Research indicates that LEP persons are more likely than non-LEP 

persons to report being in fair or poor health, defer medical care, miss 

followup appointments, and experience drug complications.12, 13 LEP 

patients are also more likely than non-LEP patients to experience 

adverse events because of a communication failure.14

Title VI of the Civil Rights Act 

Title VI of the Civil Rights Act of 1964, as amended, provides that no 

person in the United States shall “on the ground of race, color, or 

national origin, be excluded from participation in, be denied the benefits 

of, or be subjected to discrimination under any program or activity 

receiving Federal financial assistance.”15 The Supreme Court has 

interpreted the Title VI implementing regulation to find that conduct 

with a disproportionate effect on LEP persons had a discriminatory 

impact on the basis of national origin.16

OCR Oversight of Title VI Compliance 

3 

OCR is the civil rights law enforcement agency for HHS. As such, it 

ensures that all recipients of Federal financial assistance through HHS 

operate their programs in compliance with Federal civil rights laws. 

9 OCR, Guidance, pt. VI at 47316. 

10 OMH, National Standards, loc. cit. 

11 Leighton Ku and Glenn Flores, “Pay Now Or Pay Later: Providing Interpreter 

Services in Health Care,” Health Affairs. March/April 2005. Vol. 24, No. 2. Accessed at 

http://content.healthaffairs.org on February 26, 2010. 

12 Bradford Kirkman-Liff and Delfi Mondragón, “Language of Interview: Relevance for 

Research on Southwest Hispanics,” American Journal of Public Health. November 1991. 

Vol. 81, No. 11. Accessed at http://ajph.aphapublications.org/ on February 26, 2010. 

13 Glenn Flores et al., “Access Barriers to Health Care for Latino Children,” Archives of 

Pediatrics & Adolescent Medicine. November 1998. Vol. 152. Accessed at 

http://archpedi.ama-assn.org/ on February 26, 2010. 

14 The Joint Commission, Language Proficiency and Adverse Events in U.S. Hospitals: A 

Pilot Study, February 2010. Accessed at http://www.jointcommission.org on 

February 22, 2010. 

15 P.L. 88-352 § 601; 42 USC § 2000d. 

16 Lau v. Nichols. 414 U.S. 563 (1974). 

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

Federal financial assistance includes grants, training, use of equipment, 

donation of surplus property, and other assistance. It does not include 

Medicare Part B payments to physicians.17

OCR conducts civil rights reviews of all new Medicare provider 

applicants that receive Federal financial assistance. OCR also conducts 

these reviews when there is a change of ownership. During these 

reviews, OCR certifies that providers have plans in place to operate 

their programs in accordance with, among other laws, Title VI.18 

According to OCR staff, OCR completed 2,385 civil rights reviews in 

fiscal year (FY) 2009. Alternatively, corporations with multiple 

facilities may enter into corporate agreements with OCR. In these 

cases, OCR conducts reviews of the corporate policies that apply to all 

corporate facilities rather than reviewing each facility. OCR had 

24 corporate agreements in effect in 2009. 

In addition, OCR investigates complaints of discrimination. According 

to OCR staff, of the 17 complaints concerning LEP persons received in 

FY 2009, 6 complaints involved Medicare providers. If OCR 

investigates and determines that discrimination has occurred, a 

provider usually has 60 days to correct the violation or provide OCR 

with a plan of correction.19 OCR staff stated that they strive for 

voluntary compliance and resolution in all cases as required by Title VI. 

Accordingly, complaints are often voluntarily resolved through an 

exchange of letters containing requirements for improvement. 

Further, OCR encourages compliance with Title VI by providing 

technical assistance and training.20 OCR provided technical assistance 

and training to more than 95,000 individuals in FY 2009.21 This 

technical assistance included telephone consultations, written 

correspondence, and in-person presentations at conferences, as well as 

meetings with advocacy groups and organizations receiving HHS 

financial assistance. In addition, OCR collaborates with organizations, 

such as the American Hospital Association and the Joint Commission, 

4 

17 45 CFR § 80, App. A.; 45 CFR § 80.2. 

18 OCR, Nondiscrimination Laws, Regulations, and Standards. Accessed at 

http://www.hhs.gov/ocr/ on February 25, 2010. 

19 OCR, How Does OCR Investigate a Civil Rights Complaint? Accessed at 

http://www.hhs.gov/ocr on February 25, 2010. 

20 OCR, Guidance, pt. VIII at 47321. 

21 OCR, Fiscal Year 2011 Online Performance Appendix. Accessed at 

http://www.hhs.gov/ocr/ on April 12, 2010. 

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

to develop training materials to help providers respond to LEP persons’ 

communication needs. 

OCR Guidance for Determining What Language Access Services To Offer 

In August 2000, OCR, on behalf of the Secretary of HHS, issued 

guidance specifically concerning discrimination affecting LEP persons.22 

The guidance was issued in response to an August 2000 Executive 

Order requiring Federal agencies to clarify and publish guidance on 

Title VI requirements.23 The original guidance was republished in 

February 2002, seeking public comment.24 In 2003, after receiving 

public comments and subsequent guidance from the U.S. Department of 

Justice, OCR issued revised guidance.25

OCR guidance applies to all providers receiving HHS financial 

assistance, including hospitals, nursing homes, and home health 

agencies, among others. It does not apply to physicians solely 

reimbursed for services under Medicare Part B, per Title VI 

regulations.26

OCR guidance is meant to assist recipients of HHS financial assistance 

in ensuring meaningful access for LEP persons to critical services while 

not imposing an undue burden. OCR guidance does not carry the force 

of law and is not mandatory.27

OCR guidance recommends that each recipient of HHS financial 

assistance determine what language access services to offer by 

conducting a four-factor assessment. The four factors are:28

(1) the number or proportion of LEP persons eligible to be served or 

likely to be encountered in the 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 

5 

22 65 Fed. Reg. 52762 (Aug. 30, 2000). 

23 Executive Order 13166, “Improving Access to Services for Persons with Limited 

English Proficiency,” 65 Fed. Reg. 50121 (Aug. 16, 2000). 

24 67 Fed. Reg. 4968 (Feb. 1, 2002). 

25 OCR, Guidance, introduction at 47311. 

26 Ibid., pt. III at 47313. 

27 Ibid., pt. III at 47313, footnote 2. 

28 Ibid., pt. V at 47314. 

 O E I - 0 5 - 1 0 - 0 0 0 5 0 GUIDANCE AND S TANDARDS ON L ANGUAGE ACCESS S ERVICES : MEDICARE P ROVIDERS
O E I - 0 5 - 1 0 - 0 0 0 5 0 GUIDANCE AND S TANDARDS ON L ANGUAGE ACCESS S ERVICES : M EDICARE P ROVIDERS 6 

INTRODUCTION

(4) the resources available to the recipient and costs for offering 

language access services. 

After conducting the four-factor assessment, recipients have discretion 

to determine what language access services to offer. In some cases, 

offering language access services may not be necessary to comply with 

Title VI.29 However, this discretion does not diminish, and should not 

be used to minimize, recipients’ obligation to address the needs of LEP 

persons.30 

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.31 

OMH divided the standards into three categories: Culturally 

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

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

(standards 8–14).32 For a list of all 14 CLAS standards, see Appendix B. 

The four Language Access Services standards are:33 

Standard 4. Health care organizations must offer and provide language 

assistance services, including bilingual staff and 

interpreter services, at no cost to each patient/consumer 

with limited English proficiency at all points of contact, in 

a timely manner during all hours of operation. 

Standard 5. Health care organizations must provide to 

patients/consumers in their preferred language both verbal 

offers and written notices informing them of their right to 

receive language assistance services. 

Standard 6. Health care organizations must assure the competence of 

language assistance provided to limited English proficient 

patients/consumers by interpreters and bilingual staff. 

29 OCR, Guidance, pt. V at 47314.
 

30 Ibid. 

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

mandatory despite language stating that they are Federal requirements and that health 

care organizations “must” provide the services noted in each of the four standards. 

32 OMH, Standards, p. 3. 

33 Ibid., pp. 1013. 
OEI-05-10-00050 GUIDANCE AND S TANDARDS ON L ANGUAGE ACCESS S ERVICES : M EDICARE P ROVIDERS 7 

INTRODUCTION

Family and friends should not be used to provide 

interpretation services (except on request by the 

patient/consumer). 

Standard 7. Health care organizations must make available easily 

understood patient-related materials and post signage in 

the languages of the commonly encountered groups and/or 

groups represented in the service area. 

OMH staff offer training and educational resources related to CLAS 

standards to providers through the Center for Cultural and Linguistic 

Competence in Health Care (the Center).34 Established in FY 1995, 

the Center was 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.35 

Through the Center, OMH offers training and educational resources 

related to the provision of language access services. This includes 

accredited training programs for physicians, nurses, and disaster 

personnel on cultural competency through e-learning programs. OMH 

also publishes A Patient-Centered Guide to Implementing Language 

Access Services in Healthcare Organizations, which was designed to 

help health care administrators and organizations comply with Title VI 

and implement the CLAS standards.36 In addition, OMH distributes an 

e-newsletter that is geared toward all persons interested in cultural 

competency in health care settings. 

Reimbursement for Language Access Services 

Limited reimbursement is available for language access services. 

Medicare does not reimburse providers for language access services. On 

the other hand, State Medicaid Programs and Children’s Health 

Insurance Programs can, as an optional benefit, access Federal 

matching funds to reimburse for language access services.37 In 2009, 

34 OMH, About the Center for Cultural and Linguistic Competence in Health Care. 

Accessed at http://minorityhealth.hhs.gov/ on March 8, 2010. 

35 H.R. Rep. No. 103-553, at 54 (1994). 

36 OMH, A Patient-Centered Guide to Implementing Language Access Services in 

Healthcare Organizations. Accessed at http://www.thinkculturalhealth.org on 

February 1, 2010. 

37 42 U.S.C. § 1396b(a)(2)(E); 42 U.S.C. § 1397ee(a)(1)(D). 
OEI-05-10-00050 GUIDANCE AND S TANDARDS ON L ANGUAGE ACCESS S ERVICES : M EDICARE P ROVIDERS 8 

INTRODUCTION

13 States and the District of Columbia used this optional benefit to 

reimburse providers or interpreters.38 In addition, a national survey of 

hospitals in the United States found that only 3 percent of hospitals 

receive reimbursement for providing language access services.39 

Related Work 

In 2007, the Joint Commission found that there was still a gap between 

current practice and the CLAS standards among a purposive sample of 

hospitals selected for their advanced provision of culturally and 

linguistically appropriate care. Ninety percent of sampled hospitals 

cited funding services as a challenge to providing language access 

services.40 

METHODOLOGY 

To conduct this review, we collected information, in 2009, through a 

survey of randomly selected Medicare providers located in counties with a 

high percentage of LEP persons. OCR and OMH staff provided additional 

context through structured interviews. 

Scope 

The MIPPA mandates that OIG report on Medicare providers’ and 

plans’ compliance with OCR guidance and CLAS standards. However, 

because OCR guidance and CLAS standards are not mandatory, HHS 

lacks authority to enforce them. Therefore, we assessed providers’ 

voluntary compliance as indicated by the extent to which they 

conducted the four-factor assessment recommended by OCR guidance 

and offered language access services consistent with CLAS standards. 

This study focused on CLAS Standards 4–7, which OMH designated as 

the Language Access Services standards. 

This study focused on the types of Medicare providers uniformly subject 

to Title VI. For this reason, we excluded Medicare Part B providers. 

We also limited our analysis to providers located in counties with a high 

percentage of LEP persons to increase the likelihood that sampled 

38 Families USA, Improving Language Access: CHIPRA Provides Increased Funding For 

Language Services. Accessed at http://www.familiesusa.org on March 15, 2010. 

39 The Health Research and Educational Trust, Hospital Language Services for Patients 

with Limited English Proficiency: Results from a National Study, October 2006. Accessed 

at http://www.hret.org on February 12, 2010. 

40 The Joint Commission, Hospitals, Language, and Culture: A Snapshot of the Nation, 

2007. Accessed at http://www.jointcommission.org on February 12, 2010. 
O E I - 0 5 - 1 0 - 0 0 0 5 0 GUIDANCE AND S TANDARDS ON L ANGUAGE ACCESS S ERVICES : M EDICARE P ROVIDERS 9 

INTRODUCTIO N 

providers needed to offer language access services. Medicare plans are 

covered in a companion report. 

Finally, we broadened the definition of costs and savings to include 

nonfinancial obstacles and benefits. 

Sample 

Provider sampling frame. We created a sampling frame of providers 

located in counties with a high percentage of LEP persons. To do this, 

we used 2000 decennial Census data and demographic data contained in 

CMS’s Online Survey Certification and Reporting (OSCAR) system as of 

October 2009.41, 42 First, we used the Census data to rank counties by 

the percentage of residents who answered anything other than “very 

well” when asked how well they speak English. We selected the 

10 percent of counties with the highest percentage of these LEP 

persons. Together, the 313 selected counties, representing 37 States, 

contained 72 percent of LEP persons residing in the United States. 

These LEP persons represented between 9 percent and 51 percent of all 

county residents in each of the selected counties. Then, we used the 

OSCAR data to identify Medicare providers located in the selected 

counties. We identified 16,853 providers in the sampling frame. 

Sample selection. After creating the sampling frame of 

16,853 providers, we selected a simple random sample of 

145 providers.43 The sample consisted of 14 provider types, including 

hospitals, skilled nursing facilities, and home health agencies. After 

selecting the sample, we excluded one provider because of an ongoing 

OIG investigation and four additional providers because they were no 

longer in business. The final sample consisted of 140 providers. 

Data Collection 

Survey. We mailed the survey to the sample of 140 providers in 

December 2009. We made at least two followup attempts by telephone 

and one by signature-required certified mail. Data collection lasted 

41 The U.S. Census Bureau’s 2000 decennial Census has the most recent data on all 

counties for the same year. 

42 OSCAR contains survey results from certification and complaint surveys for all 

Medicare providers receiving Federal financial assistance. As such, it contains location 

information on all of these providers. 

43 This sample design enabled us to estimate the percentage of providers with certain 

characteristics with +/- 10-percent precision at the 95-percent confidence level assuming a 

75-percent response rate and assuming that 7 percent would be excluded because of ongoing 

OIG investigations. 
O E I - 0 5 - 1 0 - 0 0 0 5 0 GUIDANCE AND S TANDARDS ON L ANGUAGE ACCESS S ERVICES : M EDICARE P ROVIDERS 10 

INTRODUCTION

through January 2010. Of the 140 providers, 119 responded to the 

survey, for an overall response rate of 85 percent. However, providers 

did not always answer every question; therefore, item response rates 

may be lower. No item response rate was less than 79 percent. 

Structured interviews. In January 2010, we conducted separate 

structured interviews with OCR and OMH staff to obtain background 

information. We interviewed OCR staff about their role and activities 

related to Title VI enforcement, OCR guidance, and the types of 

technical assistance OCR provided for language access services. We 

interviewed OMH staff about their activities related to CLAS standards. 

Data Analysis 

To analyze providers’ survey responses, we calculated response category 

frequencies for the key questions related to whether providers 

conducted the four-factor assessment recommended by OCR guidance 

and whether providers offered language access services consistent with 

all four CLAS standards on language access services. We also analyzed 

the percentage of providers that completed each individual factor of the 

four-factor assessment and offered language access services consistent 

with each of the four standards. 

We considered a provider to have conducted the four-factor assessment 

if the provider indicated at least one activity corresponding with each of 

the four factors. Table 1 lists each of the four factors and the 

corresponding survey question. See Appendix C for the categories of 

responses to each question. 
NTRODUCT o N 

Table 1: OCR Four Factors and Corresponding Survey 

Questions 

Four Factors in OCR Guidance Corresponding Question in Survey of Providers 

Factor 1: The number or proportion of LEP Which of the following sources of information does your 

persons eligible to be served or likely to be organization use to determine the number or proportion 

encountered in the recipient's service of LEP persons from each language group represented 

population in its geographic service area? 

Factor 2: The frequency with which LEP 

persons come into contact with the recipient 

Which of the following sources of information does your 

organization 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 

organization consider the importance and urgency of 

the activity, program, or service to people's lives? 

Factor 4: The resources available to the How does your organization assess whether it has 

recipient and costs for offering language resources available to provide language access 

access services services? 

Source: OCR guidance and OIG survey of providers, 2010. 

Similarly, we considered a provider to have offered language access 

services consistent with CLAS standards if the provider indicated 

activities meeting each ofthe four standards. For Standards 4, 6, and 7, 

we considered a provider to have offered language access services 

consistent with the standard if it indicated at least one activity 

corresponding with each of the survey questions about these standards. 

For Standard 5, providers needed to indicate at least two activities-one 

associated with verbal notification of rights and another associated with 

written notification. Table 2 lists the four CLAS standards on language 

access services and the corresponding survey question(s). See 

Appendix C for the categories of responses to each question. 

OEI·05·10·00050 GUIDANCE AND STANDARDS ON LANGUAGE ACCESS SERVICES: MEDICARE PROVIDERS 11 
NTRODUCT ON 

Table 2: CLAS Standards and Corresponding Survey Questions 

CLAS Standards on Language Access Services Corresponding Questions in Survey of 

Providers 

Standard 4: Health care organizations must offer and 

provide language assistance services, including 

bilingual staff and interpreter services, at no cost to 

each patienUconsumer with limited English proficiency 

at all points of contact, in a timely manner during all 

During what percentage of your 

organization's business hours are 

language access services offered? 

hours of operation. 

Standard 5: Health care organizations must provide to Does your organization inform LEP 

patients/consumers in their preferred language both persons of their right to receive language 

verbal offers and written notices informing them of their access services in their preferred 

right to receive language assistance services. language in any of the following ways? 

Standard 6: Health care organizations must assure 

the competence of language assistance provided to 

limited English proficient patients/consumers by 

interpreters and bilingual staff. Family and friends 

should not be used to provide interpretation services 

Which of the following training topics 

does your organization require for staff, 

contractors, and volunteers? 

(except on request by the patienUconsumer). 

Which of the following written materials 

are translated into the languages of 

Standard 7: Health care organizations must make commonly encountered groups? 

available easily understood patient-related materials 

and post signage in the languages of the commonly 

encountered groups and/or groups represented in the 

service area. Which of the following types of signs are 

posted in the languages of commonly 

encountered groups? 

Source: CLAS standards and OIG survey of providers, 2010. 

The survey had two questions related to CLAS Standard 7 to 

distinguish between patient-related materials and signs. Ten percent of 

providers responded "Not applicable" to the survey question related to 

posting signs. Upon review of the provider types, we concluded that this 

was a reasonable response for specific providers, such as home health 

agencies, and counted these providers as having offered language access 

services consistent with CLAS Standard 7 ifthey indicated only 

activities related to translating written materials. 

OEI·05·10·00050 GUIDANCE AND STANDARDS ON LANGUAGE ACCESS SERVICES: MEDICARE PROVIDERS 12 
INTRODUCTION 

We used the results of the response category frequencies for the CLAS 

standards to determine whether one standard was completed more or 

less frequently than any other standard. We used the Bonferroni 

method of multiple comparisons to determine whether any noted 

differences were statistically significant. A difference was statistically 

significant if the confidence interval of the difference did not contain 

zero using an alpha ofO.O!. 

Where possible, we calculated frequencies and ranges on the key 

questions related to costs, savings, nonfinancial obstacles, and benefits. 

We also reviewed providers' comments about how they calculated cost 

data to determine the extent to which the reported costs were 

comparable. 

Unless noted, we projected survey statistics to all 16,853 Medicare 

providers located in the 313 counties with a high percentage ofLEP 

persons. See Appendix D for a list of 95"percent confidence intervals for 

all statistical projections. 

Data Limitations 

This report relies on self"reported data. We did not verify providers' 

responses. 

Because populations may shift, the 2000 decennial Census data may not 

exactly reflect the counties with the highest percentage of LEP persons 

in 2009, when the sample was selected. However, they were the most 

recent data available for all counties in the same year. 

Standards 

This study was conducted in accordance with the Quality Standards for 

Inspections approved by the Council ofthe Inspectors General on 

Integrity and Efficiency. 

OEI·05·10·00050 GUIDANCE AND STANDARDS ON LANGUAGE ACCESS SERVICES: MEDICARE PROVIDERS 13 
Sixty-nine percent of providers conducted the 

four-factor assessment recommended by OCR 

guidance when determining what language 

access services to offer 

 FINDINGS 

Sixty-nine percent of Medicare 

providers in counties with a high 

percentage of LEP persons 

considered all four factors of the 

recommended assessment. As 

noted previously, OCR guidance is not mandatory. Rather, it is 

guidance that providers may use to ensure meaningful access for LEP 

persons to critical services while not imposing an undue burden on 

small providers. 

Providers that conducted the recommended four-factor assessment were 

more likely to be familiar with the OCR guidance.44 Specifically, 

85 percent of providers that conducted the assessment reported being 

familiar with the guidance. In contrast, only 40 percent of providers 

that did not conduct the assessment reported being familiar with the 

guidance. 

Even though 31 percent of providers did not consider all four factors, 

almost all providers considered some of these factors. Eighty-four 

percent of providers considered at least three of the four factors and 

97 percent considered at least one of the factors. Chart 1 illustrates the 

extent to which providers considered the four factors. 

14 

44 The difference is statistically significant at the 95-percent confidence level. 

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

Completed all four 

factors, 

69%

Completed no 

factors, 3%

Completed two 

factors, 9%

Completed one 

factor, 4%

Completed three 

factors, 15%

Chart 1: Number 

of Factors 

Completed, by 

Percentage of 

Providers 

Source: OIG analysis of provider survey responses, 2010.

When the factors are reviewed individually, the factor completed most 

frequently was Factor 4, assessing available resources. Table 3 lists the 

four factors and the percentage of providers that reported completing 

each factor. 

Table 3: OCR Four Factors and Percentage of Providers 

Completing Each Factor

Four Factors in OCR Guidance Percentage of Providers 

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

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

population

78% 

Factor 2: The frequency with which LEP persons come in 

contact with the recipient 80% 

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

activity, or service to people’s lives 92% 

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

offering language access services 94% 

Source: OCR guidance and OIG analysis of provider survey responses, 2010. 

 O E I - 0 5 - 1 0 - 0 0 0 5 0 GUIDANCE AND S TANDARDS ON L ANGUAGE ACCESS S ERVICES : MEDICARE P ROVIDERS 15 
FINDINGS 

Seventy-eight percent of providers reported determining the number or 

proportion of LEP persons in their service areas 

Corresponding to the first factor in OCR guidance, 78 percent of 

providers reported determining the number or proportion of LEP 

persons represented in their geographic service areas. The greater the 

number or proportion of LEP persons, the greater the likelihood that 

language access services are needed. 

Providers reported determining the number or proportion of LEP 

persons represented in their service areas using a variety of information 

sources, as listed in Table 4. 

Table 4: Sources Providers Reported Using To Determine 

Number of LEP Persons 

Sources* Percentage of Providers 

Patient utilization data 61% 

Census data 45% 

Community assessments conducted by their organizations 31% 

Medicare data 30% 

County or State health status reports 24% 

Community assessments conducted by community organizations 15% 

School enrollment data 7% 

*Choices are not mutually exclusive. 

Source: OIG analysis of provider survey responses, 2010. 

OCR guidance states that providers should first rely on their data from 

prior experiences with LEP encounters to determine the number of LEP 

persons in their geographic service areas. It also recommends that 

providers refine this assessment using other data sources. Seventy-one 

percent of providers that reported determining the number of LEP 

persons used multiple data sources. Providers relied primarily on 

patient utilization data, supplemented with other sources, to determine 

the number of LEP persons in their service areas. Only 17 percent of 

providers reported using patient utilization data as their only source. 

Although 78 percent of providers reported determining the number of 

LEP persons in their service areas, only 46 percent reported that they 

monitor changes in the LEP population. Even though OCR guidance 

does not recommend that providers monitor demographic changes, it 

does note that a recipient’s LEP plan may require annual reevaluation 

 O E I - 0 5 - 1 0 - 0 0 0 5 0 GUIDANCE AND S TANDARDS ON L ANGUAGE ACCESS S ERVICES : MEDICARE P ROVIDERS 16 
FINDINGS 

of changes in demographics. Assessing data for shifts in the LEP 

population can help ensure that providers remain up-to-date on 

language needs in their service areas. Only 34 percent of providers 

reported monitoring changes in the LEP population annually. An 

additional 10 percent reported monitoring changes every 5 years and 2 

percent reported monitoring changes every 10 years. 

Eighty percent of providers reported determining the frequency of contact 

with LEP persons 

Corresponding to the second factor in OCR guidance, 80 percent of 

providers reported determining the frequency with which they 

encountered LEP persons. The more frequent the contact with a 

particular language group, the more likely that language access services 

in that language are needed. 

Providers reported collecting data on encounters with LEP persons 

primarily from two sources. Sixty-four percent of providers reported 

using data from patient databases and 62 percent reported using data 

from patient medical records. Forty-nine percent used both sources. 

Ninety-two percent of providers reported considering the situation when 

determining what language access services to provide or reported offering 

services in all situations 

Ninety-two percent of providers reported activities that correspond to 

the third factor in OCR guidance for determining the importance of 

language access services. This factor recommends that providers 

determine whether denial or delay of services or information because of 

a lack of language access services could have serious implications for 

LEP persons. To that end, 15 percent of providers reported assessing 

the importance and urgency of their programs, activities, and services. 

An additional 77 percent reported offering language access services in 

all types of situations regardless of importance and urgency, in which 

case determining the importance and urgency is no longer necessary. 

Ninety-four percent of providers reported assessing the available resources 

Almost all providers reported assessing available financial, material, 

and staff resources when determining what language access services to 

offer; such an assessment corresponds to the fourth factor in OCR 

guidance. Providers may use information about available resources to 

help them balance costs and benefits when deciding what language 

access services to offer. See Table E-1 in Appendix E for a list of the 

available resources that providers reported assessing. 

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

Only 33 percent of providers offered services 

consistent with all four CLAS standards on 

language access services 

Ninety-eight percent of providers 

in counties with a high percentage 

of LEP persons reported offering 

some language access services, but 

only 33 percent offered 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 

providers can use when developing their language access services. 

Providers that offered language access services consistent with all four 

CLAS standards were more likely to be familiar with these standards.45 

Specifically, 82 percent of providers that offered language access 

services consistent with all four standards reported being familiar with 

the standards. In contrast, only 55 percent of providers that offered 

language access services that were not consistent with all four CLAS 

standards reported being familiar with the standards. 

When the standards are reviewed individually, providers were most 

likely to offer language access services consistent with the standard 

about assuring the competence of language assistance provided by staff 

as opposed to the standards stating that services must be available 

during all business hours, that patients must be informed of their rights 

both verbally and in writing, and that written materials and signage 

should be translated into appropriate languages.46 See Table 5 for each 

of the four CLAS standards on language access services and the 

percentage of providers that reported offering services consistent with 

each standard. 

18 

45 The difference is statistically significant at the 95-percent confidence level. 

46 The difference is statistically different from other standards at the 95-percent 

confidence level in a multiple comparison test using a Bonferroni threshold of 0.01. 

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

Table 5: CLAS Standards and Percentage of Providers Offering 

Services Consistent With Each Standard 

CLAS Standards on Language Access Services Percentage of 

Providers 

Standard 4: Provide language assistance services at no cost to each patient 

with limited English proficiency at all points of contact, in a timely manner during 

all hours of operation.

64% 

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.

52% 

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).

86% 

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

post signage in the languages of the commonly encountered groups in the 

service area.

71% 

Source: CLAS standards and OIG analysis of provider survey responses, 2010. 

Sixty-four percent of providers reported offering language access services 

during all business hours 

Consistent with CLAS Standard 4, 64 percent of providers reported 

offering some type of language access services during all hours of 

operation. Further, 15 percent of providers offered language access 

services during more than half but less than all of their business hours. 

Fifty-two percent of providers reported informing LEP persons both verbally 

and in writing of their right to receive language access services 

Consistent with CLAS Standard 5, 52 percent of providers reported 

informing LEP persons verbally and in writing of their right to receive 

language access services. However, 23 percent of providers reported 

notifying LEP persons only verbally at check-in. Fifteen percent of 

providers reported notifying LEP persons only in writing of their right 

to receive language access services. Providers informed LEP persons in 

writing either through translated handouts or signs. 

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

Eighty-six percent of providers reported requiring training for staff, 

contractors, and volunteers on language access services 

Consistent with CLAS Standard 6, 86 percent of providers reported 

requiring training for staff, contractors, and volunteers on language 

access services. See Table E-2 in Appendix E for a list of the training 

topics that providers reported requiring for staff, contractors, and 

volunteers. 

This standard also recommends that family and friends not be used as 

interpreters except when requested by the patient. Further, this 

standard states that minor children should never be used as 

interpreters or be allowed to interpret for their parents when they are 

the patients. Seventy percent of providers required training for staff, 

contractors, and volunteers on the use of family and friends as 

interpreters. In particular, 28 percent of providers required training on 

the use of minor children as interpreters.47

Although most providers reported requiring training for staff, 

contractors, and volunteers on language access services, only 39 percent 

reported formally testing them on their skills and competencies in 

providing language access services. CLAS Standard 6 mentions formal 

testing as a way to assure the competence of language assistance 

provided by staff. See Table E-3 in Appendix E for a list of the topics 

providers reported covering on formal tests. 

Seventy-one percent of providers reported translating materials and posting 

signs in the languages of commonly encountered groups 

Consistent with CLAS Standard 7, 71 percent of providers reported 

translating written materials and posting signs in the languages of 

commonly encountered groups. 

Materials. Eighty-nine percent of providers reported translating at least 

one type of patient-related written material into the languages of 

commonly encountered groups. Further, 88 percent of providers 

reported translating at least one critical document as outlined by OCR 

guidance and CLAS standards as documents that are particularly 

important to translate. These documents include, but are not limited to, 

patients’ rights information; medication directions; and screening, 

diagnosis, and treatment explanations. However, only 8 percent of 

providers translated all critical documents. See Table E-4 in 

47 Choices are not mutually exclusive. 

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

Appendix E for a complete list of materials that providers reported 

translating. 

Signs. Seventy-nine percent of providers either reported posting 

translated signs or reported that posting signs was not applicable to 

their organizations. Signs should provide notices of patient rights, the 

conflict and grievance process, and directions to facility services. 

Specifically, 68 percent of providers reported posting signs in the 

languages of commonly encountered groups. An additional 10 percent of 

providers reported that posting signs was not applicable to their 

organizations.48 See Table E-5 in Appendix E for a list of signs that 

providers reported posting in commonly encountered languages. 

Seventy-three percent of providers reported 

benefits to providing language access services 

and half reported obstacles 

Seventy-three percent of providers 

reported benefits to providing 

language access services. The 

four most frequently reported 

benefits were (1) improved communication, (2) improved adherence to 

treatment regimen, (3) improved diagnosis and treatment, and (4) fewer 

complaints. See Table 6 for a list of benefits that providers reported. 

48 Percentages do not add to 79 percent because of rounding. 

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

Table 6: Benefits Reported by Providers

Benefits* Percentage of Providers 

Improved communication 66% 

Improved adherence to treatment regimen 58% 

Improved diagnosis and treatment 51% 

Fewer complaints 51% 

Fewer adverse events and medical errors 45% 

Fewer emergency visits 26% 

Reduced length of patient visits 22% 

Improved billing and collections 20% 

Fewer facility readmissions 17% 

Reduced length of facility stays 12% 

Financial savings 2% 

*Choices are not mutually exclusive. 

Source: OIG analysis of provider survey responses, 2010. 

Very few providers reported financial savings from providing language 

access services. In fact, only 2 percent of providers reported that they 

saved money by providing language access services. Fifty-three percent 

of providers reported that they did not know whether they saved any 

money. One provider explained that savings because of a reduction in 

unnecessary tests, visits, and emergency room usage are difficult to 

measure while direct costs, such as those for interpreters, are 

measurable. 

Fifty-four percent of providers reported obstacles to providing language 

access services 

Fifty-four percent of providers reported obstacles to providing language 

access services, including such things as (1) a lack of training resources 

for staff, (2) costs of providing language access services, and 

(3) the broad range of languages spoken in the providers’ communities. 

See Table 7 for a list of obstacles reported. 

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

Table 7: Obstacles Reported by Providers 

Obstacles* Percentage of Providers 

Lack of training resources for staff 32% 

Cost of providing language access services 27% 

Broad range of languages spoken in community 26% 

Liability concerns 21% 

Lack of staffing 18% 

Staff discomfort in providing language access services 14% 

Lack of means for staff to identify LEP persons 6% 

*Choices are not mutually exclusive. 

Source: OIG analysis of provider survey responses, 2010. 

Twenty-seven percent of providers reported cost as an obstacle. 

Providers may perceive costs to be an obstacle because they may not see 

savings that would offset their investment in providing language access 

services. Most providers bear the full cost of providing language access 

services. Only 3 percent reported receiving direct reimbursement for 

providing these services. Providers reported that these reimbursements 

were received from Medicaid and State or local governments. 

Forty-five percent of providers reported that it would be useful to have 

additional assistance in overcoming obstacles and implementing 

language access services. In responding to the survey, these providers 

wrote in specific requests for assistance. These requests were, in 

general, for additional information, training, and financial assistance 

for providing language access services. 

Specifically, information requests included such things as 

already-translated documents or the names of organizations that 

provide cost-effective translation and interpretation. Providers were 

interested particularly in resources within their communities. Another 

suggestion providers made was that models of language service 

provision be made available. 

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

Few providers reported data on the costs of 

providing language access services and the 

data provided were not comparable

Because of the overall lack of 

reporting and the inability to 

compare data, we were unable to 

make any determinations about cost 

data related to language access services. 

Of the 119 providers that responded to the survey, only 49 providers 

responded to the request for cost data. These providers reported data 

for at least one of the following requests: (1) annual expenditures on 

language access services, (2) expenditures by type of language access 

service, (3) expenditures by LEP person, or (4) expenditures on staff 

training for language assistance. Only three of these providers reported 

all requested cost data. 

The cost data reported by the 49 providers ranged widely. For example, 

FY 2008 expenditures by one provider on interpreter services 

totaled $50. On the other hand, another provider indicated its total FY 

2008 costs for interpreter services were $779,494. Data for cost per LEP 

person for interpreter services mirrored this wide range with one 

provider reporting spending $0.33 per LEP person and another provider 

reporting $1,500 per LEP person. 

Providers’ comments about how they calculated the data indicated that 

the wide range of costs might be the result of different approaches to 

calculating costs rather than a reflection of varying levels of service. 

For example, some providers reported capturing cost data at the 

organizational level rather than at the facility level and were unable to 

break out the data by facility. In addition, some providers indicated 

that they were unable to exclude salary costs (e.g., for bilingual 

employees) from cost data on language access services. 

 O E I - 0 5 - 1 0 - 0 0 0 5 0 GUIDANCE AND S TANDARDS ON L ANGUAGE ACCESS S ERVICES : MEDICARE P ROVIDERS 24 
 RECOMMENDATIONS 

Sixty-nine percent of Medicare providers in counties with a high 

percentage of LEP persons conducted the four-factor assessment 

recommended by OCR guidance when determining what language 

access services to offer. However, only 33 percent of providers offered 

services consistent with all four CLAS standards on language access 

services. 

OMH created the CLAS standards to guide providers to become more 

responsive to the cultural and linguistic needs of diverse populations. 

Providing language access services is crucial to ensuring access to 

high-quality health care for LEP persons. Clear communication 

between LEP persons and providers can lead to better health outcomes 

for LEP persons. 

The MIPPA requires OIG to make recommendations on improving 

compliance with and enforcement of CLAS standards. However, in 

keeping with our assessment of voluntary compliance, we make 

recommendations to increase the percentage of providers that 

voluntarily offer services consistent with all four CLAS standards on 

language access services. 

Providers that offered language access services consistent with the 

CLAS standards were more likely to be familiar with them. This 

indicates that educating providers on the standards may lead to an 

increase in the percentage of providers offering language access services 

consistent with CLAS standards. 

To improve Medicare providers’ awareness and implementation of CLAS 

standards, we recommend that: 

OCR should inform providers about OMH’s CLAS standards 

OCR should assist providers that receive Federal financial assistance in 

offering high-quality language access services by informing them of 

OMH’s CLAS standards. OCR could also inform providers about 

associated OMH resources, such as the Health Care Languages Services 

Implementation Guide. This could be done during civil rights reviews of 

new Medicare providers, technical assistance interactions, and 

complaint investigations involving LEP persons. During the civil rights 

review process, OCR, unlike OMH, has direct contact with almost all 

new Medicare providers that receive Federal financial assistance, such 

as hospitals, nursing homes, and home health agencies. Therefore, OCR 

has unique opportunities for education. OCR staff indicated that a 

collaborative relationship with OMH already exists, and we encourage 

 O E I - 0 5 - 1 0 - 0 0 0 5 0 GUIDANCE AND S TANDARDS ON L ANGUAGE ACCESS S ERVICES : MEDICARE P ROVIDERS 25 
RECOMMENDATIONS 

the two offices to continue sharing resource information to assist 

providers with serving LEP persons. 

OMH should increase outreach to providers to familiarize them with CLAS 

standards 

OMH should increase provider awareness of the CLAS standards by 

proactively educating them about this resource. OMH should be more 

proactive in its outreach because providers that are seeking out OMH’s 

online resources are likely already aware of the need to be culturally 

and linguistically accessible. To be more proactive, OMH could lead an 

effort to increase awareness among providers about CLAS standards. 

OMH could collaborate with other HHS operating divisions that focus 

on health care, including CMS, as well as work with provider 

associations to disseminate the CLAS standards to providers. 

The collaborative effort to inform providers about CLAS standards could 

focus on educating providers on the specific Language Access Services 

standards that providers were less likely to have implemented. To that 

end, the effort could stress that the CLAS standards encourage 

providers to (1) offer language access services during all hours of 

operation; (2) inform LEP persons both verbally and in writing of their 

right to receive language access services; (3) translate and post signs, 

particularly directions to facility services; and (4) translate critical 

materials. 

In addition, we make the following recommendation to help Medicare 

providers offer affordable and accurate language access services: 

OMH should offer model translated written materials and signs to providers 

One suggestion offered by providers was that information about how to 

obtain already-translated materials be made available. To that end, 

OMH should provide model standard language for some frequently used 

written materials and signs in the languages of commonly encountered 

groups. OMH could take the lead in collaborating with other HHS 

operating divisions to develop model language for these materials. In 

particular, OMH could focus on providing translated language for 

critical documents. For example, OMH could provide language 

explaining patients’ rights to language access services. After 

development, OMH could make the model language available online 

through its Center. 

A number of benefits could be realized if OMH assisted providers with 

model translated written materials and signs. OMH could reduce the 

financial burden on providers, which in turn could help increase the 

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

percentage of providers that offer translated materials. In addition, 

OMH would be ensuring the accuracy of critical patient-related 

documents offered to LEP persons. 

AGENCIES’ COMMENTS AND OFFICE OF INSPECTOR 

GENERAL RESPONSE 

OCR and OMH concurred with our recommendations. OMH stated that 

it will take the lead in developing specific marketing strategies to 

inform providers of the CLAS standards. CMS indicated that it did not 

have any substantive comments. However, it did provide technical 

comments that we incorporated as appropriate. 

For the full text of the agencies’ comments, see Appendix F.

 O E I - 0 5 - 1 0 - 0 0 0 5 0 GUIDANCE AND S TANDARDS ON L ANGUAGE ACCESS S ERVICES : MEDICARE P ROVIDERS 27 
 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 0 GUIDANCE AND S TANDARDS ON L ANGUAGE ACCESS S ERVICES : MEDICARE P ROVIDERS 28 
 APPENDIX ~ B 

Culturally and Linguistically Appropriate Services in Health Care 

Standards49

Standard 1. Health care organizations should ensure that 

patients/consumers receive from all staff members effective, 

understandable, and respectful care that is provided in a manner 

compatible with their cultural health beliefs and practices and preferred 

language. 

Standard 2. Health care organizations should implement strategies to 

recruit, retain, and promote at all levels of the organization a diverse 

staff and leadership that are representative of the demographic 

characteristics of the service area. 

Standard 3. Health care organizations should ensure that staff at all 

levels and across all disciplines receive ongoing education and training 

in culturally and linguistically appropriate service delivery. 

Standard 4. Health care organizations must offer and provide language 

assistance services, including bilingual staff and interpreter services, at 

no cost to each patient/consumer with limited English proficiency at all 

points of contact, in a timely manner during all hours of operation. 

Standard 5. Health care organizations must provide to 

patients/consumers in their preferred language both verbal offers and 

written notices informing them of their right to receive language 

assistance services.

Standard 6. Health care organizations must assure the competence of 

language assistance provided to limited English proficient 

patients/consumers by interpreters and bilingual staff. Family and 

friends should not be used to provide interpretation services (except on 

request by the patient/consumer). 

Standard 7. Health care organizations must make available easily 

understood patient-related materials and post signage in the languages 

of the commonly encountered groups and/or groups represented in the 

service area. 

29 

49 Office of Minority Health, National Standards on Culturally and Linguistically 

Appropriate Services in Health Care (CLAS), March 2001. Accessed at 

http://minorityhealth.hhs.gov on February 12, 2010. 

 O E I - 0 5 - 1 0 - 0 0 0 5 0 GUIDANCE AND S TANDARDS ON L ANGUAGE ACCESS S ERVICES : MEDICARE P ROVIDERS
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 0 GUIDANCE AND S TANDARDS ON L ANGUAGE ACCESS S ERVICES : MEDICARE P ROVIDERS 30 
 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 organization use to determine the number or proportion of Limited English Proficient 

(LEP) persons from each language group represented in its geographic service area? 

a) Census data 

b) Community assessment conducted by a community organization 

c) Community assessment conducted by your organization 

d) County or State health status reports 

e) Medicare data 

f) Patient utilization data 

g) School enrollment profiles 

h) Other (please specify) 

OCR Factor 2 Question: Which of the following sources of information does your organization 

use to track how often it encounters LEP persons? 

a) Patient database 

b) Patient medical records 

c) Other (please specify) 

OCR Factor 3 Question: When determining whether to communicate with LEP persons in their 

preferred language, does your organization consider the importance and urgency of the activity, 

program, or service to 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 0 GUIDANCE AND S TANDARDS ON L ANGUAGE ACCESS S ERVICES : MEDICARE P ROVIDERS 31 
APPENDIX ~ C 

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

During what percentage of your organization’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) Organization does not offer language access services 

CLAS Standard 5 Question: Does your organization inform LEP persons of their right to receive 

language access services in their preferred language in any of the following ways? 

a) Given copies of language access rights materials in their preferred language 

b) Referred to posted and translated signs about language access services 

c) Told verbally during check-in process 

d) Other (please specify) 

CLAS Standard 6 Question: Which of the following training topics does your organization 

require for staff, contractors, and volunteers? 

a) Cultural competence 

b) Demographic data of communities served 

c) How to collect data on primary language from LEP persons 

d) How to respond to people who do not speak English 

e) Information related to written policies and procedures regarding language access 

services 

f) Language skills 

g) Use of “I Speak” cards or other communication aids 

h) Use of family members or friends as interpreters 

i) Use of minor children as interpreters 

j) Other (please specify) 

 O E I - 0 5 - 1 0 - 0 0 0 5 0 GUIDANCE AND S TANDARDS ON L ANGUAGE ACCESS S ERVICES : MEDICARE P ROVIDERS 32 
APPENDIX ~ C 

CLAS Standard 7 Question 1: Which of the following written materials are translated into the 

languages of commonly encountered groups? 

a) Advance directives 

b) Applications to receive services 

c) Community resources 

d) Complaint forms 

e) Discharge instructions 

f) Explanations of screening, diagnosis, or treatment options 

g) Facility menus 

h) Financial assistance forms 

i) Illness-related education 

j) Informed consent documents 

k) Intake forms 

l) “I Speak” cards or other communication aids 

m) Medication management and prescription directions 

n) Notice of language access services 

o) Patients’ rights information 

p) Wellness-related education 

q) Other (please specify) 

CLAS Standard 7 Question 2: Which of the following types of signs are posted in the languages 

of commonly encountered groups? 

a) Available services 

b) Business hours 

c) Conflict and grievance procedures 

d) Directions to facility services (such as admissions, pediatrics, emergency room, etc.) 

e) Explanation of right to language access 

f) Patients’ rights information 

g) Other (please specify) 

 O E I - 0 5 - 1 0 - 0 0 0 5 0 GUIDANCE AND S TANDARDS ON L ANGUAGE ACCESS S ERVICES : MEDICARE P ROVIDERS 33 
Estimates and Confidence Intervals 

Table D-1: Estimates of Survey Responses 

Estimate Description Sample Size Point 

Estimate 

95-Percent

Confidence Interval 

Percentage of providers that conducted the four-factor assessment 

recommended by Office for Civil Rights (OCR) guidance when 

determining whether to offer language access services 

119 68.9 60.5%–77.3% 

Percentage of providers that conducted the assessment recommended 

by OCR guidance that reported being familiar with it 82 85.4 77.6%–93.1% 

Percentage of providers that did not conduct the four-factor assessment 

recommended by OCR guidance but reported being familiar with it 35 40.0 23.5%–56.5% 

Percentage of providers that did not complete all four OCR factors 119 31.1 22.7%–39.5% 

Percentage of providers that completed at least three of the four OCR 

factors 119 84.0 77.4%–90.7% 

Percentage of providers that completed at least one of the four OCR 

factors 119 97.5 92.8%–99.5%* 

Percentage of providers that completed three OCR factors 119 15.1 8.6%–21.7% 

Percentage of providers that completed two OCR factors 119 9.2 4.0%–14.5% 

Percentage of providers that completed one OCR factor 119 4.2 0.5%–7.9% 

Percentage of providers that completed no OCR factors 119 2.5 0.5%–7.2%* 

Percentage of providers that reported determining the number or 

proportion of Limited English Proficient (LEP) persons they were eligible 

to serve or likely to encounter in their geographic service areas (OCR 

Factor 1) 

119 78.2 70.6%–85.7% 

Percentage of providers that reported determining the frequency of 

contact with LEP persons (OCR Factor 2) 119 79.8 72.5%–87.1% 

Percentage of providers that reported considering the situation when 

determining what language access services to provide or reported 

offering services in all situations (OCR Factor 3) 

119 91.6 86.5%–96.7% 

Percentage of providers that reported assessing available resources for 

offering language access services (OCR Factor 4) 119 94.1 89.8%–98.4% 

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

continued on next page 

 APPENDIX ~ D 

 O E I - 0 5 - 1 0 - 0 0 0 5 0 GUIDANCE AND S TANDARDS ON L ANGUAGE ACCESS S ERVICES : MEDICARE P ROVIDERS 34 
APPENDIX ~ D 

Table D-1: Estimates of Survey Responses, continued 

Estimate Description Sample Size Point 

Estimate 

95-Percent

Confidence Interval 

Percentage of providers that reported using patient utilization data to 

determine the number of LEP persons represented in their geographic 

service areas 

118 61.0 52.1%–69.9% 

Percentage of providers that reported using Census data to determine 

the number of LEP persons represented in their geographic service 

areas 

118 44.9 35.8%–54.0% 

Percentage of providers that reported using community assessments 

conducted by their organizations to determine the number of LEP 

persons represented in their geographic service areas 

118 30.5 22.1%–38.9% 

Percentage of providers that reported using Medicare data to determine 

the number of LEP persons represented in their geographic service 

areas 

118 29.7 21.3%–38.0% 

Percentage of providers that reported using county or State health 

status reports to determine the number of LEP persons represented in 

their geographic service areas 

118 23.7 15.9%–31.5% 

Percentage of providers that reported using community assessments 

conducted by community organizations to determine the number of LEP 

persons represented in their geographic service areas 

118 15.3 8.7%–21.8% 

Percentage of providers that reported using school enrollment data to 

determine the number of LEP persons represented in their geographic 

service areas 

118 6.8 2.2%–11.4% 

Percentage of providers that reported using multiple sources to 

determine the number of LEP persons represented in their geographic 

service areas 

93 71.0 61.6%–80.4% 

Percentage of providers that reported using patient utilization data as 

their only information source to determine the number of LEP persons 

represented in their geographic service areas 

93 17.2 9.4%–25.0% 

Percentage of providers that reported monitoring changes in the LEP 

population represented in their geographic service areas 114 45.6 36.3%–54.9% 

Percentage of providers that reported annually monitoring changes in 

the LEP population represented in their geographic service areas 114 34.2 25.4%–43.1% 

continued on next page 

 O E I - 0 5 - 1 0 - 0 0 0 5 0 GUIDANCE AND S TANDARDS ON L ANGUAGE ACCESS S ERVICES : MEDICARE P ROVIDERS 35 
APPENDIX ~ D 

Table D-1: Estimates of Survey Responses, continued

Estimate Description Sample Size Point 

Estimate 

95-Percent

Confidence Interval 

Percentage of providers that reported monitoring changes in the LEP 

population represented in their geographic service areas every 5 years 114 9.6 4.1%–15.2% 

Percentage of providers that reported monitoring changes in the LEP 

population represented in their geographic service areas every 10 years 114 1.8 0.2%–6.2%* 

Percentage of providers that reported using data collected from patient 

databases when determining the frequency of contact with LEP persons 118 63.6 54.7%–72.4% 

Percentage of providers that reported using data from patient medical 

records when determining the frequency of contact with LEP persons 118 61.9 53.0%–70.8% 

Percentage of providers that reported using data from both patient 

databases and patient medical records when determining the frequency 

of contact with LEP persons 

118 49.2 40.0%–58.3% 

Percentage of providers that reported assessing the importance and 

urgency of their programs, activities, and services 118 15.3 8.7%–21.8% 

Percentage of providers that reported offering language access services 

in all types of situations regardless of importance and urgency 118 77.1 69.4%–84.8% 

Percentage of providers that offered language access services 

consistent with all four Culturally and Linguistically Appropriate Services 

in Health Care (CLAS) standards on language access services 

119 32.8 24.2%–41.3% 

Percentage of providers that offered some language access services 119 98.3 94.1%–99.8%* 

Percentage of providers that offered language access services 

consistent with the CLAS standards that reported being familiar with 

them 

39 82.1 69.8%–94.3% 

Percentage of providers that offered language access services that 

were not consistent with CLAS standards that reported being familiar 

with them 

78 55.1 43.9%–66.3% 

Percentage of providers that reported offering language access services 

during all business hours (CLAS Standard 4) 119 63.9 55.1%–72.6% 

*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 0 GUIDANCE AND S TANDARDS ON L ANGUAGE ACCESS S ERVICES : MEDICARE P ROVIDERS 36 
APPENDIX ~ D 

Table D-1: Estimates of Survey Responses, continued

Estimate Description Sample Size Point 

Estimate 

95-Percent

Confidence Interval 

Percentage of providers that reported informing LEP persons verbally 

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

Standard 5) 

119 52.1 43.0%–61.2% 

Percentage of providers that reported requiring training for staff, 

contractors, and volunteers on language access services (CLAS 

Standard 6) 

119 85.7 79.3%–92.1% 

Percentage of providers that reported translating materials and posting 

signs in the languages of commonly encountered groups (CLAS 

Standard 7) 

119 71.4 63.2%–79.7% 

Percentage of providers that reported offering language access services 

during more than half of their business hours 116 14.7 8.1%–21.2% 

Percentage of providers that reported notifying LEP persons only 

verbally at check-in of their right to receive language access services 104 23.1 14.8%–31.3% 

Percentage of providers that reported notifying LEP persons only in 

writing of their right to receive language access services 104 15.4 8.3%–22.4% 

Percentage of providers that reported requiring training for staff, 

contractors, and volunteers on the use of family members or friends as 

interpreters 

119 69.7 61.4%–78.1% 

Percentage of providers that reported requiring training for staff, 

contractors, and volunteers on the use of minor children as interpreters 119 27.7 19.6%–35.9% 

Percentage of providers that reported formally testing the skills and 

competencies of staff, contractors, and volunteers in providing language 

access services 

119 38.7 29.8%–47.5% 

Percentage of providers that reported translating at least one type of 

patient-related written materials into the languages of commonly 

encountered groups 

119 89.1 83.4%–94.8% 

Percentage of providers that reported translating at least one critical 

document into the languages of commonly encountered groups 119 88.2 82.4%–94.1% 

Percentage of providers that reported translating all critical documents 

into the languages of commonly encountered groups 119 8.4 3.3%–13.5% 

*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 0 GUIDANCE AND S TANDARDS ON L ANGUAGE ACCESS S ERVICES : MEDICARE P ROVIDERS 37 
APPENDIX ~ D 

Table D-1: Estimates of Survey Responses, continued

Estimate Description Sample Size Point 

Estimate 

95-Percent

Confidence Interval 

Percentage of providers that reported that they either posted translated 

signs or that posting signs was not applicable to their organization 117 78.6 71.1%–86.2% 

Percentage of providers that reported posting signs in the languages of 

commonly encountered groups 117 68.4 59.8%–76.9% 

Percentage of providers that reported that posting signs was not 

applicable to their organizations 117 10.3 4.7%–15.8% 

Percentage of providers that reported benefits to providing language 

access services 119 73.1 65.0%–81.2% 

Percentage of providers that reported improved communication as a 

benefit 119 65.5 56.9%–74.2% 

Percentage of providers that reported improved adherence to treatment 

regimen as a benefit 119 58.0 49.0%–67.0% 

Percentage of providers that reported improved diagnosis and treatment 

as a benefit 119 51.3 42.1%–60.4% 

Percentage of providers that reported fewer complaints as a benefit 119 51.3 42.1%–60.4% 

Percentage of providers that reported fewer adverse events and medical 

errors as a benefit 119 45.4 36.3%–54.5% 

Percentage of providers that reported fewer emergency visits as a 

benefit 119 26.1 18.0%–34.1% 

Percentage of providers that reported reduced length of patient visits as 

a benefit 119 21.8 14.3%–29.4% 

Percentage of providers that reported improved billing and collections as 

a benefit 119 20.2 12.9%–27.5% 

Percentage of providers that reported fewer facility readmissions as a 

benefit 119 16.8 10.0%–23.6% 

Percentage of providers that reported reduced length of facility stays as 

a benefit 119 11.8 5.9%–17.6% 

continued on next page 

 O E I - 0 5 - 1 0 - 0 0 0 5 0 GUIDANCE AND S TANDARDS ON L ANGUAGE ACCESS S ERVICES : MEDICARE P ROVIDERS 38 
APPENDIX ~ D 

Table D-1: Estimates of Survey Responses, continued

Estimate Description Sample Size Point 

Estimate 

95-Percent

Confidence Interval 

Percentage of providers that reported saving money by providing 

language access services 119 1.7 0.2%–5.9%* 

Percentage of providers that reported that they did not know whether 

they saved money by providing language access services 119 52.9 43.8%–62.0% 

Percentage of providers that reported obstacles to providing language 

access services 111 54.1 44.6%–63.5% 

Percentage of providers that reported a lack of training resources for 

staff as an obstacle 111 32.4 23.6%–41.3% 

Percentage of providers that reported the cost of providing language 

access services as an obstacle 111 27.0 18.6%–35.4% 

Percentage of providers that reported the broad range of languages 

spoken in the community as an obstacle 111 26.1 17.8%–34.4% 

Percentage of providers that reported liability concerns as an obstacle 111 20.7 13.1%–28.4% 

Percentage of providers that reported being understaffed as an obstacle 111 18.0 10.8%–25.3% 

Percentage of providers that reported staff discomfort in providing 

language access services as an obstacle 111 14.4 7.8%–21.1% 

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

LEP persons as an obstacle 111 6.3 1.7%–10.9% 

Percentage of providers that reported receiving reimbursement for 

providing language access services 119 2.5 0.5%–7.2%* 

Percentage of providers that reported that it would be useful to have 

additional assistance in implementing language access services 111 45.0 35.6%–54.4% 

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

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

 O E I - 0 5 - 1 0 - 0 0 0 5 0 GUIDANCE AND S TANDARDS ON L ANGUAGE ACCESS S ERVICES : MEDICARE P ROVIDERS 39 
APPENDIX ~ E APPENDIX ~ E 

Supplemental Analysis Tables 

Table E-1: Available Resources That Providers Reported Assessing 

Available Resources* Sample Size Percentage of 

Providers 

95-Percent

Confidence Interval 

Bilingual staff 119 89.1% 83.4%–94.8% 

Technology 119 63.0% 54.2%–71.8% 

Community resources 119 63.0% 54.2%–71.8% 

Operating funds to determine whether money is available 119 33.6% 25.0%–42.2% 

Outside funding 119 22.7% 15.1%–30.3% 

*Choices are not mutually exclusive. 

Source: Office of Inspector General (OIG) analysis of provider survey responses, 2010. 

Table E-2: Training Topics for Staff, Contractors, and Volunteers 

Training Topics* Sample Size Percentage of 

Providers 

95-Percent

Confidence Interval 

Use of family members or friends as interpreters 119 69.7% 61.4%–78.1% 

How to respond to people who do not speak English 119 68.9% 60.5%–77.3% 

Written policies and procedures regarding language access services 119 59.7% 50.7%–68.6% 

Cultural competence 119 58.0% 49.0%–67.0% 

How to collect data on primary language from Limited English Proficient 

persons 

119 37.8% 29.0%–46.7% 

Language skills 119 36.1% 27.4%–44.9% 

Use of "I-Speak" cards or other communication aids 119 28.6% 20.3%–36.8% 

Demographic data of communities served 119 27.7% 19.6%–35.9% 

Use of minor children as interpreters 119 27.7% 19.6%–35.9% 

*Choices are not mutually exclusive. 

Source: OIG analysis of provider survey responses, 2010. 

 O E I - 0 5 - 1 0 - 0 0 0 5 0 GUIDANCE AND S TANDARDS ON L ANGUAGE ACCESS S ERVICES : MEDICARE P ROVIDERS 40 
APPENDIX ~ E 

Table E-3: Testing Topics Providers Reported Covering

Testing Topics* Sample Size Percentage of 

Providers 

95-Percent

Confidence Interval 

Confidentiality requirements 119 33.6% 25.0%–42.2% 

Medical terminology 119 33.6% 25.0%–42.2% 

Policies and procedures 119 30.3% 21.9%–38.6% 

Ability to interpret effectively 119 27.7% 19.6%–35.9% 

Proficiency in English and non-English languages 119 26.9% 18.8%–35.0% 

*Choices are not mutually exclusive. 

Source: OIG analysis of provider survey responses, 2010. 

 O E I - 0 5 - 1 0 - 0 0 0 5 0 GUIDANCE AND S TANDARDS ON L ANGUAGE ACCESS S ERVICES : MEDICARE P ROVIDERS 41 
APPENDIX ~ E 

Table E-4: Materials That Providers Reported Translating

Material 

Type Translated Material* Sample Size Percentage of Providers 

95-Percent

Confidence Interval 

Patients' rights information 119 75.6% 67.8%–83.5% 

Advance directives 119 65.5% 56.9%–74.2% 

Informed consent documents 119 58.8% 49.9%–67.8% 

Complaint forms 119 52.9% 43.8%–62.0% 

Illness-related education 119 52.9% 43.8%–62.0% 

Notice of language access services 119 52.1% 43.0%–61.2% 

Medication management and prescription 

directions 119 50.4% 41.3%–59.5% 

Discharge instructions 119 47.9% 38.8%–57.0% 

Applications to receive services 119 43.7% 34.7%–52.7% 

Explanations of screening, diagnosis, or 

treatment options 119 42.0% 33.0%–51.0% 

Financial assistance forms 119 37.8% 29.0%–46.7% 

Critical 

Intake forms 119 36.1% 27.4%–44.9% 

Community resources 119 47.9% 38.8%–57.0% 

Wellness-related education 119 44.5% 35.5%–53.6% 

"I-Speak" cards or other communication aids 119 33.6% 25.0%–42.2% 

Noncritical 

Facility menus 119 24.4% 16.5%–32.2% 

*Choices are not mutually exclusive. 

Source: OIG analysis of provider survey responses, 2010. 

 O E I - 0 5 - 1 0 - 0 0 0 5 0 GUIDANCE AND S TANDARDS ON L ANGUAGE ACCESS S ERVICES : MEDICARE P ROVIDERS 42 
APPENDIX ~ E 

Table E-5: Signs That Providers Reported Posting in Commonly Encountered 

Languages 

Types of Signs* Sample Size Percentage of 

Providers 

95-Percent

Confidence Interval 

Patients' rights information 117 61.5% 52.6%–70.5% 

Conflict and grievance procedures 117 44.4% 35.3%–53.6% 

Available services 117 37.6% 28.7%–46.5% 

Explanation of right to language access services 117 38.5% 29.5%–47.4% 

Business hours 117 36.8% 27.9%–45.6% 

Directions to facility services 117 21.4% 13.8%–28.9% 

*Choices are not mutually exclusive. 

Source: OIG analysis of provider survey responses, 2010. 

 O E I - 0 5 - 1 0 - 0 0 0 5 0 GUIDANCE AND S TANDARDS ON L ANGUAGE ACCESS S ERVICES : MEDICARE P ROVIDERS 43 
A P PEN 0 x F 

Agencies' Comments 

~~"J.YIC&l.V~ 

( ~ DEPARTMENT OF HEALTH &. HUMAN SERVICES Office of the Secretary 

"'....:~-

DATE: 

TO: 

FROM: 

SUBJECT: 

Director 

Office for Ctvit Rights 

Weshington, DC 20201 

May 27, 2010 

Daniel R. Levinson 

Inspector General 

Georgina C. Verdugo 

Director 

Office ofInspector General (orG) Draft Reports: "Guidance and 

Standards on Language Access Services: Medicare Providers" 

(OEI-05-10-00050) 

Thank you for the opportunity to review and respond to the orG Draft Report: Guidance 

and Standards on Language Access Services: Medicare Providers (OEI-05-10-00050). 

The Office for Civil Rights (OCR) at the U.S. Department ofHealth and Human Services 

(HHS) appreciate orG's efforts to determine the extent to which Medicare providers 

utilize the HHS Guidance to Federal Financial Assistance Recipients Regarding Title VI 

Prohibition Against National Origin Discrimination Affecting Limited English Projicient 

Persons and Office of Minority Health's Culturally and Linguistically Appropriate 

Services (CLAS) standards. OCR also commends the OIG inspection team for both their 

thoroughness and professionalism during the review, 

OCR concurs with the report's findings and recommendations and offers no comment. 

Georgina C. Verdugo 

Director 

OEI·05·10·00050 GUIDANCE AND STANDARDS ON LANGUAGE ACCESS SERVICES: MEDICARE PROVIDERS 44 
A P PEN D F 

DEPARTMENT OF HEALTH AND HUMAN SERVICES 	 Office of the Secretary 

Office of Public Health and Science ------------------------------------------1l1li 

Office of Minority Health 

Washington. D.C. 20201 

DATE: 	 May 26, 2010 

TO: 	 Daniel R. Levinson 

Inspector General 

FROM: 	 Ga'tth N. Grhham, M.D., M.P,H. 

Deputy Assistant Secretary for Minority Health 

Office of Minority Health 

Office ofthe Secretary 

SUBJECT: 	 OIG Draft Reports: Guidance and Standards on Language Access Services: 

Medicare Providers, OEI-05-10-00050 

Thank you for the opportunity to review and respond to the OIG draft report. We appreciate 

OIG's efforts to examine the extent Medicare Providers are fulfilling the requirements of 

(I) OCR's Guidance to federal Financial Assistance Recipients Regarding Title VI Prohibition 

Against National Origin Discrimination Affecting Limited English Proficient Persons (OCR 

guidance) and (2) OMH's CLAS standards. 

Based on Ollr review of the report, our responses will only focus on those areas that apply to the 

CLAS Standards. 

OIG Recommendation: Medicare Providers: OEI-OS-1 0-00050 

• 	 OMH should increase outreach to providers to familiarize them with CLAS 


standards. 


OMH could collaborate with other HHS operating divisions that foclls on health 

carc, including CMS, as well as work with provider associations to disseminate 

the CLAS standards to providers. 

• 	 OMH should offer model translated written materials and signs to providers 


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


develop model language for these materials. 


OMH conCllrs with OIG's recommendations. The OMH will take the lead in devcloping specific 

marketing strategies to inform providers ofthe CLAS standards. Additionally, OMH will 

facilitate the development of spccific translated materials and signage for providers in 

collaboration with other JIBS operating divisions. 

U.S. Public Health Service 

OEI·05·10·00050 GUIDANCE AND STANDARDS ON LANGUAGE ACCESS SERVICES: MEDICARE PROVIDERS 45 

x 
A P PEN D x F 

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 

Office of the Administrator 

Washington. DC 20201 

DATE: 	 MAY 20 2010 

TO: 	 Dariel R. Levinson 

Inspecto.r.DeneraJ 

FROM: 	 Maril..y~ 'l\avenner 

Acting ~ministrator and Chief Operating Officer 

SUBJECT: 	 Office oflnspector General (OlG) Draft Report: "Guidance and Standards on 

Language Access Services: Medicare Providers" (OEI-05-10-00050) 

Thank you for the opportunity to review and comment on the OlG draft report entitled, 

"Guidance and Standards on Language Access Services: Medicare Providers" (OEl-05-l 0­

00050). This is to notify you that the Centers for Medicare & Medicaid Services has reviewed 

the subject draft report, and we have no substantive comments. We are attaching technical 

comments for your consideration. 

We appreciate the effort that went into this report and look forward to working with the OIG on 

this and other issues related to language access services. 

Attachment 

OEI·05·10·00050 GUtDANCE AND STANDARDS ON LANGUAGE ACCESS SERVICES: MEDICARE PROVIDERS 46 
 O E I - 0 5 - 1 0 - 0 0 0 5 0 GUIDANCE AND S TANDARDS ON L ANGUAGE ACCESS S ERVICES : MEDICARE P ROVIDERS 47 

 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. 

Nicole Hrycyk served as the team leader for this study and Meghan 

Kearns served as the project lead. Other principal Office of Evaluation 

and Inspections staff from the Chicago regional office who contributed 

to the report include Melissa Baker, Benjamin Dieterich, Ericka 

Kilburn, Margo Rodriguez, and Mark Stiglitz; central office staff who 

contributed include Heather Barton and Kevin Farber. 
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.