THE TORCH: CONTENTS By Laiba Waqas & Ben D’Avanzo 

August 9, 2023

In March 2023, after a three-year pause, states resumed terminating the eligibility of Medicaid recipients. These terminations signaled the restart of eligibility redeterminations, which had been halted during the COVID-19 pandemic. Enrollees who face the termination of their eligibility are already up against significant administrative barriers, but people with limited English proficiency (LEP) are more likely to lose Medicaid coverage during this unwinding process even if they remain eligible for Medicaid due to language barriers and ineffective communication. States have an opportunity to remove these barriers and avoid worsening access to in-language explanations and applications so that everyone, regardless of how much money they have, where they were born, or what language they speak, can access the health care they need to thrive.

Under federal civil rights laws, including Title VI of the Civil Rights Act of 1964 and Section 1557 of the Affordable Care Act states have obligations to ensure that individuals have meaningful access to their federally funded programs, including Medicaid. A recent letter from Department of Health and Human Services Office of Civil Rights (HHS OCR), emphasized that states must abide by language access requirements during the unwinding to prevent individuals with LEP from losing coverage. The Centers for Medicare and Medicaid Services has reminded states that regulations require state Medicaid programs to provide in-language oral interpretation and written translations to people with LEP Given that 89 percent of people with LEP are people of color, failure to provide these protections will exacerbate racial health disparities. To identify trends of how states provide information for obtaining language assistance through call centers and on state Medicaid home pages, we analyzed how people with LEP may try to initiate their Medicaid redetermination. Our analysis of call centers and Medicaid websites across all 50 states uncovered some concerning trends. 

Medicaid Call Centers

We looked at whether state Medicaid call centers provide immediate access to in-language assistance upon connection, and, if so, in which languages. For example, to ensure a call line is accessible, a phone menu should start by asking for the caller’s language preference and may ask them to press a number to indicate a specific language. However, nine states: Arizona, Hawaii, Michigan, Mississippi, Montana, North Carolina, Pennsylvania, Rhode Island, and Virginia failed to offer immediate language options and instead began with long English prompts, making their systems potentially unusable by someone with LEP.

Nineteen states’ phone menus provided prompts for people who speak only English and Spanish, not even offering an “other” option. For the 38 percent in the U.S. with LEP who don’t speak those languages, this obstacle makes it unclear how they are supposed to obtain assistance with their Medicaid renewals.

Only 13 states, plus the District of Columbia, had specific language options on their phone menu beyond English, Spanish and a general “other language” option. However, in some states, these language options were stated in English rather than using the identifying word in the language itself. (“Spanish” instead of “Español”)

State Medicaid Websites

Because people with LEP may first go to their state’s Medicaid website for information on renewals, we looked to see if there was any information on how to access in-language information from those homepages.

Alabama, Alaksa and Idaho all failed to provide any information on how to access language services on their Medicaid home pages or application page. Most other states had an option to translate the website, including the renewal application, into Spanish; however, in 18 states, other languages were only accessible through Google Translate, which is often riddled with grammar and syntax errors that reduce the accuracy of information.

Thirteen states, and DC, had translated resources and informational flyers regarding Medicaid application and free translation services on their website; these translations were available in anywhere from two to fifteen languages. Most states had drop-down menus, identified only in English, from which language services could be accessed if available. Notably, only nine states and DC had taglines or footers that either linked to a translated version of the entire website or opened additional resources and information in that language. While some states may have additional information in-language on portions of their website, they were not clearly accessible from the home page.

Many states have failed to abide by the best practices that HHS OCR has communicated, putting themselves at risk of failing to comply with civil rights and Medicaid enrollment requirements. States must ensure people with LEP can access language assistance to mitigate Medicaid coverage gaps and losses.

Recommended Best Practices for States

From the findings above, many states have a long way to go to ensure that people with LEP can access the tools and information they need to renew Medicaid. Our analysis uncovered some important steps that states can take to improve language access:

Call centers should:

• Provide unique phone numbers for speakers of different languages, bypassing the challenges of complex phone trees, as California does in 12 languages.
• Immediately ask callers for their language preferences, using the in-language terminology for the offered languages, as Oregon does for 6 languages.
• Remove lengthy English prompts prior to asking a customer’s language, as consumers must navigate in Arizona, Hawaii, and Montana.

Websites should:

• Provide language access options that use professional translation services. The proposed revisions to Section 1557 regulations note that unreviewed machine translations do not count as meaningful access.
• Place language translation options in a conspicuous location on the website rather than buried within an English drop-down menu. For example, Washington state offers Spanish at the top of the page and taglines in 15 languages at the bottom of the website.

States should:

• Utilize the language preference data that all Medicaid applications collect to identify and regularly publish demographic trends during the unwinding, as Washington and Oregon do. Without data, we cannot truly know how big the coverage loss disparities will be for people with LEP.

States must provide meaningful language access to ensure that no one else loses their health care because of ineffective and inaccessible communications. CMS and OCR should provide oversight and consider pausing renewals in states that do not. No one should be denied access to health care coverage because of the language they speak.

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Laiba Waqas is a NILC Summer 2023 Legal Intern.