Services Must Be Culturally and Linguistically Appropriate and Physically and Programmatically Accessible

Dual eligibles in integrated models have a right to receive services, including notices, in a culturally appropriate manner, accounting for their race, ethnicity, language, sex, disability, sexual orientation and gender identity. Integration models must ensure that the services are accessible to all enrollees, whether supplied directly or through contractor networks. Entities must also be held responsible for collecting data on the race, ethnicity, and language of its enrollees.

Language Access:

Integrated models must comply with Title VI of the Civil Rights Act and other federal and state laws providing language access services to dual eligibles. Where state and federal laws impose different translation or interpretation requirements on health care providers and plans, the stricter standard should apply to the model.

Pursuant to these laws, models should be required to set out a language access plan. They should incorporate specific language access requirements for both their internal procedures and their provider networks that could include: specific training or certification requirements for interpreters; availability of “I speak” cards in provider offices; training for providers in language access procedures and in cultural competency; procedures to ensure that limited English proficient (LEP) callers to customer service phone lines get needed interpreter services; and identification of specific documents and correspondence subject to translation requirements.

Physical and Programmatic Disability Access:

Physical Accessibility. Providers in the integrated model must be accessible to the significant numbers of dual eligibles with physical disabilities. Facilities must be physically accessible. Full physical access includes at least the following: accessible entry doors, accessible parking and entry pathways, clear floor space and turning space in exam rooms, positioning and transferring space in exam rooms, accessible exam tables, patient lifts, staff assistance with transfers, accessible medical equipment, and accessible health information technology.

In addition, providers in the models’ network must provide programmatic accessibility. Policies, procedures and practices must include modifications designed to meet the unique needs of persons with disabilities. This means having accessible equipment in the office and staff that is trained in how to use it. Another example is appointment policies that recognize that people with disabilities rely on para-transit services that can be unpredictable and delayed.

Disability Communication Access. Integrated models must have in place systems for effective communication with individuals who are deaf or hard of hearing. These may include: qualified interpreters, note-takers, computer aided transcription services, written materials, telephone handset amplifiers, assistive listening systems, telephones compatible with hearing aids, closed caption decoders, open and closed captioning, Text Telephone (TTY), videotext displays, and exchange of written notes.

For effective communication with persons who are visually impaired, entities should be required to use systems which may include qualified readers, taped texts, audio recordings, Braille materials, large print materials, and assistance in locating items. Systems for effective communication with persons with speech impairments should also be required, which may include TTY, computer terminals, speech synthesizers, and communication boards.

The Disability Rights Education and Defense Fund has a variety or resources on physical and programmatic accessibility. These include:

– a brief on what programmatic access is.

– a brief on disability healthcare access generally.

– a brief on accessibility related network readiness review criteria in dual eligible demonstration projects

– A slide presentation by Prof. Nancy Mudrick at Syracuse University reporting on research on the physical access surveys conducted by health plans on over 2,300 provider offices. The survey, a joint effort with DREDF, involved physical access and equipment (exam tables and weight scales). One highlight is that only 8.4% and 3.6% of offices had accessible tables and scales, respectively…

The current MOUs include a standard provision that requires physical and programmatic access to services and requires compliance with the Americans with Disabilities Act and the Civil Rights Act of 1964. See MOUs at Sec. E.6. The challenge will be to put those requirements into practice.

The Special Terms and Conditions for a CMS-approved 1115 demonstration waiver for CaIifornia covering non-dual seniors and persons with disabilities, as well as implementing state legislation, also contained some specific language addressing accessibility:

Under General Program Requirements for the entire waiver at p. 3: “Compliance with Federal Non-Discrimination Statutes. The State must comply with all applicable Federal statutes relating to non-discrimination. These include, but are not limited to, the Americans with Disabilities Act of 1990, title VI of the Civil Rights Act of 1964, section 504 of the Rehabilitation Act of 1973, and the Age Discrimination Act of 1975.”

Under “Plan Readiness – Initial and Ongoing” at p. 37, relating specifically to the SPD portion of the waiver: “The State shall consult with CMS to determine the final procedures for establishing and monitoring initial and ongoing network adequacy to serve the mandatorily enrolled SPDs that ensures compliance with 42 CFR 438 and the Knox Keene Act [existing CA law regulating managed care plans]. The final methodology will be developed in consultation with CMS and will include such items as specialist to beneficiary ratios based on data from the COHS, geo-mapping of FFS providers versus network providers, minimum standards regarding access to specialty providers and their capacity to serve individuals, physical and programmatic accessibility of the plan (including completion of facility site reviews before readiness) or other strategies to ensure adequate network resources to meet the needs of the individuals to be served. December 1, 2010.

Under “Items Necessary for plan readiness” at p. 39: “Physical Accessibility – The State will ensure, using the facility site review tool, that each plan has physically accessible accommodations or contingency plans to meet the array of needs of all individuals who require accessible offices, examination or diagnostic equipment and other accommodations as a result of their disability or condition, and that they are advised of their obligations under the Americans with Disabilities Act and other applicable Federal statutes and rules regarding accessibility.”

Under “Contract Requirements” at p. 40: “Each plan shall be required to submit service encounter data, for individuals enrolled, as determined by the State and as required by 42 CFR 438 and 1903 of the Act as amended by the Affordable Care Act [s. 4302 of the ACA requires info re disability status].. The State will develop specific data requirements and require contractual provisions to impose financial penalties if accurate data are not submitted in a timely fashion by January 2012.”