Cultural and Linguistic Requirements in Health Insurance ...€¦ · Exchange Navigator Program...

The Affordable Care Act & Racial and Ethnic Health Equity Series

Cultural and Linguistic Requirements in Health Insurance Exchanges

Presenter:

Nadia J. Siddiqui, MPH

Senior Health Policy Analyst

Texas Health Institute

Blue Cross Blue Shield Health Care Disparities Workgroup

Webinar, April 10, 2013, 11:00 AM CST

Overview

� Background and Context

� Exchange-Specific Provisions and Progress

� Health Plan-Specific Provisions and Progress� Health Plan-Specific Provisions and Progress

� Practices, Resources and Tools for Health Plans

� Challenges that Lie Ahead

� Next Steps

ACA’s Vision and Promise

� Working to eliminate health disparities and advance

health equity is central to the Affordable Care Act

(ACA) of 2010.

Over three dozen provisions directly advance racial � Over three dozen provisions directly advance racial

and ethnic health equity, diversity, and cultural and

linguistic competence.

� Dozens of other general provisions with major

implications for racially and ethnically diverse

populations.

History & Scope of Work

• Joint Center Report: Advancing Health Equity for Racially and Ethnically Diverse Populations

• Joint Center Report: Advancing Health Equity for Racially and Ethnically Diverse Populations

• Obama vs. McCain Health Care Proposal Analysis

• House & Senate Health Reform Bills Analysis

• Federal agency progress on ACA & Equity

• Health Affairs article on ACA & Safety Net

• Federal agency progress on ACA & Equity

• Health Affairs article on ACA & Safety Net

• ACA & Racial and Ethnic Health Equity Series: Comprehensive Tracking of implementation progress, emerging guidance & programs

• ACA & Racial and Ethnic Health Equity Series: Comprehensive Tracking of implementation progress, emerging guidance & programs

The ACA & Health Equity Series

� Utilizing a “health equity lens” to monitor

implementation of 60+ provisions in the ACA

with mention of or implications for racially and

ethnically diverse communities across five areas:ethnically diverse communities across five areas:

� Health Insurance Exchanges

� Health Care Safety Net

� Workforce Support and Diversity

� Data, Research, and Quality

� Public Health and Prevention

Objectives of Health Insurance Exchange Study

� To track progress of ACA’s equity, diversity, and

cultural & linguistic requirements for exchanges and

health plans.

� To identify experiences, lessons, and challenges.� To identify experiences, lessons, and challenges.

� To highlight tools, models, and best practices.

� To provide guidance for implementation.

Methodology

• Federal rules and guidance

• Funding & collaborative opportunities

Federal Policy and Actions

• Progress & Best Practices of 7 leading state-based exchanges:

State Exchange Case Studies

Literature Review state-based exchanges:

CA, CO, CT, MD, NY, OR, WA

State Exchange Case Studies

• Progress & Best Practices of plans leading in equity—e.g., AHIP’s NHPC

Health Plans

• Community-level Best PracticesCommunity Actions & Feedback

Review

Policy Review

Interviews

ACA Provisions Examined

� Establishment of State Exchanges [§ 1311(b)]

� Culturally & Linguistically Appropriate Information in Exchanges [§1311(i)]

� Plain Language Requirement for Health Plans in Exchanges [§1311(e)]� Plain Language Requirement for Health Plans in Exchanges [§1311(e)]

� Culturally & Linguistically Appropriate Summary of Benefits, Uniform Glossary, and Claims Appeals Process [§1001]

� Incentive Payments in Health Plans for Reducing Disparities [§1311(g)]

� Non-Discrimination in Federal Programs and Exchanges [§1557]

� No Cost Sharing for American Indians below 300% FPL [§2901]

ACA Exchange Summary:

Establishment of State Exchanges - §1311(b)

� States required to have exchanges to facilitate the

purchase of qualified health plans for individuals

by January 1, 2014.

Three types of exchanges:� Three types of exchanges:

� State-Based Exchange

� Partnership Exchange

� Federal Exchange


Exchange Navigator Program - §1311(b)

� Exchanges are required to have a Navigator Program to

assist consumers enroll in coverage and provide information

in a culturally and linguistically appropriate

manner, including for those with limited English proficiency.

� Exchanges must develop training standards to ensure

navigators are qualified to assist underserved populations

determine eligibility and enroll in a culturally and

linguistically appropriate manner.


Non-Discrimination in Exchanges - §1557

� Protections of previous anti-discrimination laws

extended to federally funded health programs in

ACA, including exchanges.

� Exchanges and states are not to discriminate “based � Exchanges and states are not to discriminate “based

on race, color, national origin, disability,

age, sex, gender identify, or sexual orientation”

� Non-discrimination requirement likely applies to

qualified health plans in an exchange too since they

will receive federal funds (premium subsidies).


State Exchange Decisions as of Feb. 15, 2013


Projected Enrollees by Race & Ethnicity

25%

6% White

Black or African

Percent of Health Insurance Exchange Enrollees

Projected by Race and Ethnicity for 2019

58%11%

25% Black or African

American

Hispanic or Latino

Other

� About 42% (or over 12 million) of people enrolling through the

Exchanges will belong to a Non-White racial and ethnic group.

� Nearly one in four will speak a language other than English at home.

Source: Kaiser Family Foundation, A Profile of Health Insurance Exchange Enrollees, March 2011.


How are Exchanges Integrating Diversity & Equity into their Planning?

� Requiring racial and ethnic representation on the Board of

Directors.

� Ensuring diversity and equity objectives are explicitly a part of

the exchange vision and mission.

� Requiring stakeholder advisory groups to include racial and � Requiring stakeholder advisory groups to include racial and

ethnic representation.

� Engaging racial and ethnic community members, advocates, and

other representatives to provide input on various aspects of

planning.

� Adopting a tribal consultation policy and consulting federally

recognized tribes.

Note: Findings are Based on Case Studies of 7 State-Based Exchanges

(California, Colorado, Connecticut, Maryland, New York, Oregon, and Washington).


How are Exchanges Targeting Outreach & Education to Diverse Communities?

� Developing culturally and linguistically tailored outreach through

multiple mediums (e.g., translated print & online

information, multilingual hotlines, in-person programs).

� Ensuring the Navigator and Assister Programs are reflective of

diverse communities and have the capacity to inform and enroll diverse communities and have the capacity to inform and enroll

diverse individuals (e.g., bilingual, trusted, community-based).

� Developing training materials on cultural and linguistic

competency for Navigators and Assisters.

� Monitoring outcomes of culturally and linguistically tailored

outreach and education on enrollment, satisfaction, and other

measures.Note: Findings are Based on Case Studies of 7 State-Based Exchanges

(California, Colorado, Connecticut, Maryland, New York, Oregon, and Washington).


Special Provisions for American Indians*

� American Indians/Alaska Natives (AI/AN) will pay no cost-sharing for health care obtained through a plan in an exchange if they have incomes below 300% FPL

� AI/ANs enrolled through the exchange will also not pay cost-sharing for services received from Indian Health Service and tribal organizations.

Monthly enrollment periods for AI/ANs� Monthly enrollment periods for AI/ANs

� Exchanges required to consult stakeholders representing AI/ANs including “Federally-recognized Tribes”

� Need to consult “Tribal Governments” in development of navigator program.

� Future guidance forthcoming on AI/AN provisions

� AI/ANs exempt from individual mandate & thus will not face penalties

*See the following sections for details: §2901, §1402, §1311.

ACA Health Plan Summary:

Plain Language in Health Plans- §1311(e)

� Overview: Health plans must provide plan data, such as enrollment data, financial disclosures, and other information in plain language, including for individuals with limited English skills.

� Progress: Overall positive progress, especially as several health plans have addressed plain language & health literacy well before the ACA.

� Emerging Practices: � Emerging Practices:

� Hiring contractors to develop outreach documents with plain language

� Using internal or commercial software to evaluate plain language—e.g., UnitedHealthcare’s software called “DocScrub”

� Training staff on plain language & health literacy awareness—e.g., Aetna & WellPoint

� Health Literacy Ambassadors Program – BCBS of Minnesota

� Resources:

� www.plainlanguage.gov

� Harvard Pilgrim Health Care’s guide on health literacy & cultural competence

� Center for Plain Language

� Enroll America’s Best Practices Institute


Summary of Benefits and Uniform Glossary - §1001

� Overview: Plan years as of Sept.23, 2012 must provide: (1) a standard summary

of benefits and coverage (SBC) that is culturally/linguistically appropriate and

follows federal template; and (2) a standard glossary of insurance terms. Health

plans must provide SBC in other languages when 10% or more of population

living in enrollee’s county are literate only in the same non-English language (in

2012, Spanish, Chinese, Tagalog, and Navajo).

� Progress: Generally, plans are already complying with this requirement.

� Emerging Practices:

� Some plans providing their own SBC and glossaries, in addition to federal template.

� Some plans providing SBC in more than 5 languages or using lower thresholds.

� Resources:

� Center for Consumer Information and Insurance Oversight (CCIIO)

http://cciio.cms.gov/resources/other/index.html#sbcug


Claims Appeals Process - §1001

� Overview: Plans (as of Jan 1., 2012) must provide claims appeals notices to enrollees upon request in other languages if the address where notice is sent is located in a county where 10% or more of the population is literate only in the same non-English language. In such counties, must include taglines in Non-English language on how to access language services provided by plan. In counties meeting language threshold, oral language services (such as telephone hotlines) must be provided.

� Progress: While not many plans did this before ACA, plans are generally now in compliance.

� Emerging Practices:� Internal teams to examine & evaluate language gaps in appeals processes

� Hiring external vendors for translation and interpretation services

� Accommodating languages beyond the 10% threshold

� Resources:� Cigna’s “Let’s Be Clear: Insurance Speak Guide”


Incentives for Reducing Disparities - §1311(g)

� Overview: HHS Secretary will consult experts and stakeholders and

develop guidelines on implementing market-based incentives in health

plans that carry out activities for reducing disparities such as language

services, community outreach, and cultural competency training.

� Progress: No federal guidance has been issued on this provision to date.� Progress: No federal guidance has been issued on this provision to date.

� Emerging Practices:

� Some health plans, such as Harvard Pilgrim, already reward provision of

culturally and linguistically appropriate services

� Some plans have provider incentives built into quality initiatives

Other Promising Health Plan Activities:

Tailoring Websites to Diverse Consumers

� Offering translated pages

or portions of website.� e.g., Highmark Inc.’s website is

offered in English, Spanish, Italian, Russian, Vietnamese, and Chineseand Chinese

� Creating separate

websites targeting

various ethnic groups.

� e.g., UnitedHealthcare has

different websites targeting

Asians, Hispanics, and

African Americans.


Transcreation

� Transcreation =

adapting a concept or

message from one

language or culture to

another, while

MenuMenuMenuMenuToday’s SpecialToday’s SpecialToday’s SpecialToday’s Special

Our wines leave you nothing to hope for.

- Swiss restaurant menu

Literal translations

gone wrong!

another, while

maintaining its intent.

� Not literal translations.

� Adaptation of ideas and

concepts.

� Take into account

cultural nuances.

Salad a firm’s own make; lipid red beet

soup with cheesy dumpling in the form of

a finger; roasted duck let loose; beef

rashers beaten up in the country

people’s fashion.

- Polish hotel menu

For your convenience, we recommend

courteous efficient self-service.

- Hong King supermarket


How are plans “transcreating” information?

� Hiring outside vendors to transcreate documents

� Testing accuracy of information and transcreation with focus groups

� Creating internal committees for review with employees from different ethnic backgrounds and proficient in Creating internal committees for review with employees from different ethnic backgrounds and proficient in different languages

� Example:� Aetna formed an external advisory committee of diverse

medical experts to review and evaluate racial and ethnic materials and data & provide feedback to target specific outreach initiatives.


Health Literacy & Equity Efforts

� Health reform office or department within health plans to deliver updates, information, and education to consumers

� Some have programs dedicated to reducing health care disparities, promoting equity, and increasing health literacy. � e.g., In 2010, 83% of health plans with health literacy program� e.g., In 2010, 83% of health plans with health literacy program

� Some leading in adopting measures or standards addressing or advancing multicultural health

� National Quality Forum’s Multicultural Award

� National Committee for Quality Assurance’s (NCQA) Distinction in Multicultural Health Care

� NCQA’s Recognizing Innovation in Multicultural Health Care Award

Models, Tools, and Resources

National Health Plan Collaborative

� 2004-2008: Funded by AHRQ & RWJF, in collaboration with Center for Health Care Strategies coordinated the Collaborative to understand, measure, and share strategies to reduce racial/ethnic disparities.

� 2008: America’s Health Insurance Plans led coordination.� 2008: America’s Health Insurance Plans led coordination.

� Currently, 17 member plans.

� Accomplishments:� REaL data collection and standardization

� Language access services

� Creation of toolkit on resources to address disparities


NHPC Toolkit: Tips on Language Access

� Step 1: Assess plan’s language needs & resources

� Identify number of limited English proficiency individuals served

� Frequency of contact & type of contact

� Step 2: Create written policy with an approach for

addressing the language needs of membersaddressing the language needs of members

� Outline how to identify members needing language services, their

points of contact, types of services needed, and how to notify them

� Assess how understandable consumer education materials are

� Establish a process for maintaining, evaluating, and improving

language services


Office of Minority Health

� Health Care Language Services Implementation

Guide

� National Standards for Culturally and

Linguistically Appropriate ServicesLinguistically Appropriate Services


Other State & Health Plan Efforts

� Health Industry Collaboration Effort (ICE) in California –assisted in transfer of knowledge and experience in addressing language in Medicaid to commercial health plans

� Kaiser Permanente’s Qualified Bilingual Program to educate and qualify employees to be trained interpreters

� Kaiser Permanente’s Qualified Bilingual Program to educate and qualify employees to be trained interpreters with varying skills (language liaison, language facilitator, and designated interpreter). Includes 9 languages.

� LA Care provides a database of linguist-approved translated terms for translation and interpretation vendors.

Summary of Health Plan Progress

� Health plans we reviewed & interviewed—particularly those that are a part of AHIP’s National Health Plan Collaborative—are generally making good progress in implementing plain language and cultural/linguistic measures.

However, other plans not as familiar with or far along � However, other plans not as familiar with or far along with equity objectives, may be slower to progress.

� Many plans we reviewed started relevant activities pre-ACA due to Medicaid rules, diverse customer base, or for quality purposes. These plans serve, in many cases, as models and offer best practices or lessons that other health plans can draw on.

Questions & Challenges Moving Forward

� Short timelines, incomplete federal guidance

� Most health plans have experience in marketing to employers, but if in an exchange they will need to market to and reach individuals directly

� Some plans may be less familiar with the new client base – which will be largely racially and ethnically diverse. How will plans reach individuals: largely racially and ethnically diverse. How will plans reach individuals:

� Not familiar with the concept of health insurance?

� Linguistically isolated, particularly smaller groups of non-English speaking populations that do not meet federal threshold requirements?

� Belonging to mixed-citizenship families?

� Do not trust Government and federal programs?

� Face a combination of the above factors?

� Evolving decisions around active purchasing in exchanges, and implications for health plans

Guidance Moving Forward

� Fully integrate diversity and equity objectives in exchanges & health plans from the get-go (it should not be an afterthought).

� Work with trusted advocates and representatives who are reflective of diverse communities and are culturally and linguistically competent to develop and provide appropriate and targeted outreach, education, and enrollment in the exchanges.enrollment in the exchanges.

� Ensure culturally and linguistically appropriate information, resources, and communication are vetted and provided through exchanges and plans.

� Actively share and disseminate information on experiences, promising practices, and lessons learned in addressing diversity and equity across exchanges and health plans.

� Use active purchasing to ensure good value and high quality in health plans sold through the exchange and a reasonable number of choices at each benefit level.

Report Authors

Dennis P. Andrulis, PhD, MPHSenior Research Scientist, Texas Health Institute

Associate Professor, University of Texas School of Public Health

Lauren R. Jahnke, MPAffConsultant, LRJ Research & Consulting

Nadia J. Siddiqui, MPHSenior Health Policy Analyst, Texas Health Institute

Maria Rascati Cooper, MAHealth Policy Analyst, Texas Health Institute

For questions, feedback, or to be added to our mailing list, please e-mail:

[email protected].

Website: http://www.texashealthinstitute.org/health-care-reform.html

Cultural and Linguistic Requirements in Health Insurance ...€¦ · Exchange Navigator Program...

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