Sec. 202. Amendment to the Public Health Service Act

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Congress finds the following: Effective communication is essential to meaningful access to quality physical and mental health care. Research indicates that the lack of appropriate language services creates language barriers that result in increased risk of misdiagnosis, ineffective treatment plans and poor health outcomes for limited-English-proficient individuals and individuals with communication disabilities such as hearing, vision, or print impairments. The number of limited-English-speaking residents in the United States who speak English less than very well and, therefore, cannot effectively communicate with health and social service providers continues to increase significantly.

The responsibility to fund language services in the provision of health care and health-care-related services to limited-English-proficient individuals and individuals with communication disabilities such as hearing, vision, or print impairments is a societal one that cannot fairly be visited solely upon the health care, public health, or social services community. Title VI of the Civil Rights Act of 1964 prohibits discrimination based on the grounds of race, color, or national origin by any entity receiving Federal financial assistance.

In order to avoid discrimination on the grounds of national origin, all programs or activities administered by the Department must take adequate steps to ensure that their policies and procedures do not deny or have the effect of denying limited-English-proficient individuals with equal access to benefits and services for which such persons qualify. Linguistic diversity in the health care and health-care-related-services workforce is important for providing all patients the environment most conducive to positive health outcomes.

All members of the health care and health-care-related-services community should continue to educate their staff and constituents about limited-English-proficient and disability communication issues and help them identify resources to improve access to quality care for limited-English-proficient individuals and individuals with communication disabilities such as hearing, vision, or print impairments. Access to English as a second language and sign language instructions is an important mechanism for ensuring effective communication and eliminating the language barriers that impede access to health care.

Competent language services in health care settings should be available as a matter of course. The Public Health Service Act ( 42 U.S.C. 201 et seq. ) is amended by adding at the end the following: In this title: The term bilingual with respect to an individual means a person who has sufficient degree of proficiency in two languages. The term community health worker includes a community health advocate, a lay health educator, a community health representative, a peer health promoter, a community health outreach worker, and in Spanish, promotores de salud.

The term competent interpreter services means a translanguage rendition of a spoken or signed message in which the interpreter— comprehends the source language and can communicate comprehensively in the target language to convey the meaning intended in the source language; and knows health and health-related terminology and provides accurate interpretations by choosing equivalent expressions that convey the best matching and meaning to the source language and capture, to the greatest possible extent, all nuances intended in the source message.

The term competent translation services means a translanguage rendition of a written document in which the translator— comprehends the source language and can write or sign comprehensively in the target language to convey the meaning intended in the source language; and knows health and health-related terminology and provides accurate translations by choosing equivalent expressions that convey the best matching and meaning to the source language and capture, to the greatest possible extent, all nuances intended in the source document.

The term cultural competence means a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals that enables effective work in cross-cultural situations. In the preceding sentence— the term cultural refers to integrated patterns of human behavior that include the language, thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic, religious, or social groups, including lesbian, gay, bisexual, transgender, and intersex individuals, and individuals with physical and mental disabilities; and the term competence implies having the capacity to function effectively as an individual and an organization within the context of the cultural beliefs, behaviors, and needs presented by consumers and their communities.

The term effective communication means an exchange of information between the provider of health care or health-care-related services and the recipient of such services who is limited in English proficiency, or has a communication impairment such as a hearing, vision, or learning impairment, that enables access, understanding, and benefit from health care or health-care-related services, and full participation in the development of their treatment plan. The term grievance resolution process means all aspects of dispute resolution including filing complaints, grievance and appeal procedures, and court action.

The term health care group means a group of physicians organized, at least in part, for the purposes of providing physicians’ services under the Medicaid, SCHIP, or Medicare programs and may include a hospital and any other individual or entity furnishing services covered under the Medicaid, SCHIP, or Medicare programs that is affiliated with the health care group. The term health care services means services that address physical as well as mental health conditions in all care settings.

The term health-care-related services means human or social services programs or activities that provide access, referrals or links to health care. The term Indian tribe means any Indian tribe, band, nation, or other organized group or community, including any Alaska Native village or group or regional or village corporation as defined in or established pursuant to the Alaska Native Claims Settlement Act (85 Stat. 688) ( 43 U.S.C. 1601 et seq. ), which is recognized as eligible for the special programs and services provided by the United States to Indians because of their status as Indians.

The term integrated health care delivery system means an interdisciplinary system that brings together providers from the primary health, mental health, substance use and related disciplines to improve the health outcomes of an individual. Providers may include but are not limited to hospitals, health, mental health or substance use clinics and providers, home health agencies, ambulatory surgery centers, skilled nursing facilities, rehabilitation centers, and employed, independent, or contracted physicians.

The terms interpreting and interpretation mean the transmission of a spoken, written, or signed message from one language or format into another, faithfully, accurately, and objectively. The term language access means the provision of language services to an LEP individual or individual with communication disabilities designed to enhance that individual’s access to, understanding of, or benefit from health care or health-care-related services. The term language or language access services means provision of health care services directly in a non-English language, interpretation, translation, signage, video recording, and English or non-English alternative formats.

The term LEP means limited-English-proficient. The terms Medicare , Medicaid , and SCHIP mean the respective programs under titles XVIII, XIX, and XXI of the Social Security Act. The terms minority and minorities refer to individuals from a minority group. The term minority , with respect to populations, refers to racial and ethnic minority groups. The term minority group has the meaning given the term racial and ethnic minority group . The term racial and ethnic minority group means American Indians and Alaska Natives, African-Americans (including Caribbean Blacks, Africans, and other Blacks), Asian-Americans, Hispanics (including Latinos), and Native Hawaiians and other Pacific Islanders.

The term onsite interpretation means a method of interpreting or interpretation for which the interpreter is in the physical presence of the provider of health care or health-care-related services and the recipient of such services who is limited in English proficiency or has a communication impairment such as hearing, vision, or learning. The term Secretary means the Secretary of Health and Human Services. The term sight translation means the transmission of a written message in one language into a spoken or signed message in another language, or an alternative format in English or another language.

The term State means each of the several States, the District of Columbia, the Commonwealth of Puerto Rico, the Indian tribes, the United States Virgin Islands, Guam, American Samoa, and the Commonwealth of the Northern Mariana Islands. The term telephonic interpretation (also known as over the phone interpretation or OPI) means a method of interpreting/interpretation for which the interpreter is not in the physical presence of the provider of health care or related services and the limited-English-proficient recipient of such services but is connected via telephone.

The term translation means the transmission of a written message in one language into a written or signed message in another language, and includes translation into another language or alternative format, such as large print font, Braille, audio recording, or CD. The term video interpretation means a method of interpreting/interpretation for which the interpreter is not in the physical presence of the provider of health care or related services and the limited-English-proficient recipient of such services but is connected via a video hook-up that includes both audio and video transmission.

The term vital document includes but is not limited to applications for government programs that provide health care services, medical or financial consent forms, financial assistance documents, letters containing important information regarding patient instructions (such as prescriptions, referrals to other providers, and discharge plans) and participation in a program (such as a Medicaid managed care program), notices pertaining to the reduction, denial, or termination of services or benefits, notices of the right to appeal such actions, and notices advising limited-English-proficient individuals and individuals with communication disabilities of the availability of free language services, alternative formats, and other outreach materials.

As provided in Executive Order 13166, it is the purpose of this section— to improve Federal agency performance regarding access to federally conducted and federally assisted programs and activities for individuals who are limited in their English proficiency; to require each Federal agency to examine the services it provides and develop and implement a system by which limited-English-proficient individuals can obtain cultural competence and meaningful access to those services consistent with, and without substantially burdening, the fundamental mission of the agency; to require each Federal agency to ensure that recipients of Federal financial assistance provide cultural competence and meaningful access to their limited-English-proficient applicants and beneficiaries; to ensure that recipients of Federal financial assistance take reasonable steps, consistent with the guidelines set forth in the Limited English Proficient Guidance of the Department of Justice (as issued on June 12, 2002), to ensure cultural competence and meaningful access to their programs and activities by limited-English-proficient individuals; and to ensure compliance with title VI of the Civil Rights Act of 1964 and that health care providers and organizations do not discriminate in the provision of services.

Not later than 120 days after the date of enactment of this title, each Federal agency that carries out health-care-related activities shall prepare a plan to improve access cultural competence to the federally conducted, health-care-related programs and activities of the agency by limited-English-proficient individuals. Not later than one year after the date of enactment of this title, each such Federal agency shall ensure that such plan is fully implemented. Each plan under paragraph

(1)shall include— the steps the agency will take to ensure that limited-English-proficient individuals have access to the agency’s federally conducted health care and health-care-related programs and activities; the policies and procedures for identifying, assessing, and meeting the language needs and cultural competence needs of its limited-English-proficient beneficiaries served by federally conducted programs and activities; the steps the agency will take for its federally conducted programs and activities to improve cultural competence to provide a range of language assistance options, notice to limited-English-proficient individuals of the right to competent language services, periodic training of staff, monitoring and quality assessment of the language services and, in appropriate circumstances, the translation of written materials; the steps the agency will take to ensure that applications, forms, and other relevant documents for its federally conducted programs and activities are competently translated into the primary language of a limited-English-proficient client where such materials are needed to improve access to federally conducted and federally assisted programs and activities for such a limited-English-proficient individual; the resources the agency will provide to improve cultural competence to assist recipients of Federal funds to improve access to health care or health-care-related programs and activities for limited-English-proficient individuals; the resources the agency will provide to ensure that competent language assistance is provided to limited-English-proficient patients by interpreters or trained bilingual staff; and the resources the agency will provide to ensure that family, particularly minor children, and friends are not used to provide interpretation services, except— in the case of a medical emergency where delay directly associated with obtaining a competent interpreter would jeopardize the health of the patient; or on request of the patient, who has been informed in his or her preferred language of the availability of free interpretation services, if the health care services provider has determined that the family or friend can provide competent interpreter services as defined in section 3400. Each agency that is required to prepare a plan under paragraph

(1)shall send a copy of such plan to the Department of Justice, which shall serve as the central repository of such plans. Paragraph (2)(G)(i) shall not be construed to mean that emergency rooms or similar entities that regularly provide health care services in medical emergencies are exempt from legal or regulatory requirements related to competent interpreter services. Not later than 120 days after the date of enactment of this title, each Federal agency providing health-care-related Federal financial assistance shall ensure that the guidance for recipients of Federal financial assistance developed by the agency to ensure compliance with title VI of the Civil Rights Act of 1964 ( 42 U.S.C. 2000d et seq. ) is specifically tailored to the recipients of such assistance. Each agency shall send a copy of such guidance to the Department of Justice which shall serve as the central repository of the agency’s plans. After approval by the Department of Justice, each agency shall publish its guidance document in the Federal Register for public comment. The agency-specific guidance developed under paragraph

(1)shall take into account the types of health care services provided by the recipients, the individuals served by the recipients, and other factors set out in such standards. A Federal agency that has developed a guidance for purposes of title VI of the Civil Rights Act of 1964 shall examine such existing guidance, as well as the programs and activities to which such guidance applies, to determine if modification of such guidance is necessary to comply with this subsection. Each Federal agency shall consult with the Department of Justice in establishing the guidances under this subsection. In carrying out this section, each Federal agency that carriers out health care and health-care-related activities shall ensure that stakeholders, such as limited-English-proficient individuals and their representative organizations, recipients of Federal assistance, and other appropriate individuals or entities, have an adequate opportunity to provide input with respect to the actions of the agency. Each Federal agency described in paragraph

(1)shall evaluate the— particular needs of the limited-English-proficient individuals served by the agency; particular needs of the limited-English-proficient individuals served by the agency’s recipients of Federal financial assistance; and burdens of compliance with the agency guidance and this section for the agency and its recipients. This section applies to any health program or activity, any part of which is receiving Federal financial assistance, including credits, subsidies, or contracts of insurance, or any program or activity that is administered by an executive agency or any entity established under title I of the Patient Protection and Affordable Care Act (or amendments made thereby), as such programs, activities, agencies, and entities are described in section 1557(a) of the Patient Protection and Affordable Care Act. The programs, activities, agencies, and entities described in subsection

(a)shall— implement strategies to recruit, retain, and promote individuals at all levels to maintain a diverse staff and leadership that can provide culturally and linguistically appropriate health care to patient populations of the service area of the programs, activities, agencies, and entities; educate and train governance, leadership, and workforce at all levels and across all disciplines of the programs, activities, agencies, and entities in culturally and linguistically appropriate policies and practices on an ongoing basis; offer and provide language assistance, including trained bilingual staff and interpreter services, to individuals who have limited-English proficiency or other communication needs, at no cost to them at all points of contact, and during all hours of operation, to facilitate timely access to all health care and services; notify patients, in a culturally appropriate manner, of their right to receive language assistance services in their primary language, verbally and in writing; ensure the competence of language assistance provided to limited-English-proficient patients by interpreters and bilingual staff, and ensure that family, particularly minor children, and friends are not used to provide interpretation services— except in case of emergency; or except on request of the patient, who has been informed in his or her preferred language of the availability of free interpretation services if the health care services provider has determined that the family or friend can provide competent interpreter services as defined in section 3400; for each eligible LEP language group that constitutes 5 percent or 500 individuals, whichever is less, of the population of persons eligible to be served or likely to be affected or encountered in the service area of the organization, make available— easily understood patient-related materials, including print and multimedia materials; information or notices about termination of benefits; and signage; develop and implement clear goals, policies, operational plans, and management, accountability, and oversight mechanisms to provide culturally and linguistically appropriate services and infuse them throughout the organization’s planning and operations; conduct initial and ongoing organizational assessments of culturally and linguistically appropriate services-related activities and integrate valid linguistic, competence-related National Standards for Culturally and Linguistically Appropriate Services

(CLAS)measures into the internal audits, performance improvement programs, patient satisfaction assessments, continuous quality improvement activities, and outcomes-based evaluations of the organization and develop ways to standardize the assessments; ensure that, consistent with the privacy protections provided for under the regulations promulgated under section 264(c) of the Health Insurance Portability and Accountability Act of 1996, data on an individual required to be collected pursuant to section 3101, including the individual’s alternative format preferences and policy modification needs, are— collected in health records; integrated into the organization’s management information systems; and periodically updated; maintain a current demographic, cultural, and epidemiological profile of the community, conduct regular assessments of community health assets and needs, and use the results to accurately plan for and implement services that respond to the cultural and linguistic characteristics of the service area of the organization; develop participatory, collaborative partnerships with communities and utilize a variety of formal and informal mechanisms to facilitate community and patient involvement in designing, implementing, and evaluating policies and practices to ensure culturally and linguistically appropriate service-related activities; 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; regularly make available to the public information about their progress and successful innovations in implementing the standards under this section and provide public notice in their communities about the availability of this information; and if requested, regularly make available to the head of each Federal entity from which Federal funds are received, information about their progress and successful innovations in implementing the standards under this section as required by the head of such entity. The Secretary, acting through the Director of the Agency for Healthcare Research and Quality, shall establish and support a center to be known as the Robert T. Matsui Center for Cultural and Linguistic Competence in Health Care (referred to in this section as the Center ) to carry out the following activities: The Center shall provide resources via the Internet to identify and link health care providers to competent interpreter and translation services. The Center shall provide, directly or through contract, vital documents from competent translation services for providers of health care and health-care-related services at no cost to such providers. Materials may be submitted for translation into non-English languages. Translation services shall be provided in a timely and reasonable manner. The quality of such translation services shall be monitored and reported publicly. For each form developed or revised by the Secretary that will be used by LEP individuals in health care or health-care-related settings, the Center shall translate the form, at a minimum, into the top 15 non-English languages in the United States according to the most recent data from the American Community Survey or its replacement. The translation must be completed within 45 days of the Secretary receiving final approval of the form from the Office of Management and Budget. The Center shall provide, through a toll-free number, a customer service line for LEP individuals— to obtain information about federally conducted or funded health programs, including Medicare, Medicaid, and SCHIP; to obtain assistance with applying for or accessing these programs and understanding Federal notices written in English; and to learn how to access language services. The Center shall develop and maintain an information clearinghouse to facilitate the provision of language services by providers of health care and health-care-related services to reduce medical errors, improve medical outcomes, to improve cultural competence, reduce health care costs caused by miscommunication with individuals with limited-English proficiency, and reduce or eliminate the duplication of effort to translate materials. The clearinghouse shall make such information available on the Internet and in print. Such information shall include the information described in the succeeding provisions of this paragraph. The Center shall collect and evaluate for accuracy, develop, and make available templates for standard documents that are necessary for patients and consumers to access and make educated decisions about their health care, including the following: Administrative and legal documents, including— intake forms; Medicare, Medicaid, and SCHIP forms, including eligibility information; forms informing patient of HIPAA compliance and consent; and documents concerning informed consent, advanced directives, and waivers of rights. Clinical information, such as how to take medications, how to prevent transmission of a contagious disease, and other prevention and treatment instructions. Public health, patient education, and outreach materials, such as immunization notices, health warnings, or screening notices. Additional health or health-care-related materials as determined appropriate by the Director of the Center. In operating the clearinghouse, the Center shall— ensure that the documents posted in English and non-English languages are culturally appropriate; allow public review of the documents before dissemination in order to ensure that the documents are understandable and culturally appropriate for the target populations; allow health care providers to customize the documents for their use; facilitate access to these documents; provide technical assistance with respect to the access and use of such information; and carry out any other activities the Secretary determines to be useful to fulfill the purposes of the clearinghouse. The Center shall provide for the collection and dissemination of information on current examples of language assistance programs and strategies to improve language services for LEP individuals, including case studies using de-identified patient information, program summaries, and program evaluations. The Center shall provide information relating to culturally and linguistically competent health care for minority populations residing in the United States to all health care providers and health-care-related services at no cost. Such information shall include— tenets of culturally and linguistically competent care; cultural and linguistic competence self-assessment tools; cultural and linguistic competence training tools; strategic plans to increase cultural and linguistic competence in different types of providers of health care and health-care-related services, including regional collaborations among health care organizations; and cultural and linguistic competence information for educators, practitioners, and researchers. The Center shall regularly collect and make publicly available information about the progress of entities receiving grants under section 3404 regarding successful innovations in implementing the obligations under this subsection and provide public notice in the entities’ communities about the availability of this information. The Center shall be headed by a Director who shall be appointed by, and who shall report to, the Director of the Agency for Healthcare Research and Quality. The Director shall collaborate with the Deputy Assistant Secretary for Minority Health, the Administrator of the Centers for Medicare & Medicaid Services, and the Administrator of the Health Resources and Services Administration to notify health care providers and health care organizations about the availability of language access services by the Center. The Secretary, directly or through contract, shall undertake a national education campaign to inform providers, LEP individuals, health professionals, graduate schools, and community health centers about— Federal and State laws and guidelines governing access to language services; the value of using trained interpreters and the risks associated with using family members, friends, minors, and untrained bilingual staff; funding sources for developing and implementing language services; and promising practices to effectively provide language services. In addition to the amounts authorized under subsection (e)(8)(F), there are authorized to be appropriated to carry out this section such sums as may be necessary for each of fiscal years 2015 through 2019. The Secretary, acting through the Director of the Agency for Healthcare Research and Quality, shall award grants to eligible entities to enable such entities to design, implement, and evaluate innovative, cost-effective programs to improve cultural competence and language access in health care for individuals with limited-English proficiency. The Director of the Agency for Healthcare Research and Quality shall coordinate with, and ensure the participation of, other agencies including the Health Resources and Services Administration, the Center on Minority Health and Health Disparities at the National Institutes of Health, and the Office of Minority Health, regarding the design and evaluation of the grants program. To be eligible to receive a grant under subsection

(a)an entity shall— be— a city, county, Indian tribe, State, territory, or subdivision thereof; an organization described in section 501(c)(3) of the Internal Revenue Code of 1986 and exempt from tax under section 501(a) of such Code; a community health, mental health, or substance use center or clinic; a solo or group physician practice; an integrated health care delivery system; a public hospital; a health care group, university, or college; or other entity designated by the Secretary; and prepare and submit to the Secretary an application, at such time, in such manner, and accompanied by such additional information as the Secretary may require. An entity shall use funds received under a grant under this section to— develop, implement, and evaluate models of providing competent interpretation services through onsite interpretation, telephonic interpretation, or video interpretation; implement strategies to recruit, retain, and promote individuals at all levels of the organization to maintain a diverse staff and leadership that can promote and provide language services to patient populations of the service area of the organization; develop and maintain a needs assessment that identifies the current demographic, cultural, and epidemiological profile of the community to accurately plan for and implement language services needed in service area of the organization; develop a strategic plan to implement language services; develop participatory, collaborative partnerships with communities encompassing the LEP patient populations being served to gain input in designing and implementing language services; develop and implement grievance resolution processes that are culturally and linguistically sensitive and capable of identifying, preventing, and resolving complaints by LEP individuals; or develop short-term medical mental health interpretation training courses and incentives for bilingual health care staff who are asked to interpret in the workplace; develop formal training programs, including continued professional development and education programs as well as supervision, for individuals interested in becoming dedicated health care interpreters and culturally competent providers; provide staff language training instruction, which shall include information on the practical limitations of such instruction for non-native speakers; develop policies that address compensation in salary for staff who receive training to become either a staff interpreter or bilingual provider; develop other language assistance services as determined appropriate by the Secretary; develop, implement, and evaluate models of improving cultural competence; and ensure that, consistent with the privacy protections provided for under the regulations promulgated under section 264(c) of the Health Insurance Portability and Accountability Act of 1996 ( 42 U.S.C. 1320d–2 note) and any applicable State privacy laws, data on the individual patient or recipient’s race, ethnicity, and primary language are collected (and periodically updated) in health records and integrated into the organization’s information management systems or any similar system used to store and retrieve data. In awarding grants under this section, the Secretary shall give priority to entities that primarily engage in providing direct care and that have developed partnerships with community organizations or with agencies with experience in improving language access. An entity that receives a grant under this section shall submit to the Secretary an evaluation that describes, in the manner and to the extent required by the Secretary, the activities carried out with funds received under the grant, and how such activities improved access to health and health-care-related services and the quality of health care for individuals with limited-English proficiency. Such evaluation shall be collected and disseminated through the Robert T. Matsui Center for Cultural and Linguistic Competence in Health Care established under section 3403. The Director of the Agency for Healthcare Research and Quality shall notify grantees of the availability of technical assistance for the evaluation and provide such assistance upon request. The Director of the Agency for Healthcare Research and Quality shall evaluate or arrange with other individuals or organizations to evaluate projects funded under this section. There is authorized to be appropriated to carry out this section, $5,000,000 for each of fiscal years 2015 through 2019. The Secretary, acting through the Director of the Agency for Healthcare Research and Quality, shall expand research concerning language access in the provision of health care. The Director of the Agency for Healthcare Research and Quality may conduct the research described in subsection

(a)or enter into contracts with other individuals or organizations to do so. Research under this section shall be designed to do one or more of the following: To identify the barriers to mental and behavioral services that are faced by LEP individuals. To identify health care providers’ and health administrators’ attitudes, knowledge, and awareness of the barriers to quality health care services that are faced by LEP individuals. To identify optimal approaches for delivering language access. To identify best practices for data collection, including— the collection by providers of health care and health-care-related services of data on the race, ethnicity, and primary language of recipients of such services, taking into account existing research conducted by the Government or private sector; the development and implementation of data collection and reporting systems; and effective privacy safeguards for collected data. To develop a minimum data collection set for primary language. To evaluate the most effective ways in which the Department can create or coordinate, and then subsidize or otherwise fund telephonic interpretation providers for health care providers, taking into consideration, among other factors, the flexibility necessary for such a system to accommodate variations in— provider type; languages needed and their frequency of use; type of encounter; time of encounter, including regular business hours and after hours; and location of encounter. There are authorized to be appropriated to carry out this section such sums as may be necessary for each of fiscal years 2015 through 2019. .

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