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Limited English Proficient Patient Requirements

Sep 23, 2016

Another requirement that hospitals/health care entities must now be in compliance with begins next month. 

As per the Affordable Care Act (Sec. 1557), beginning October 17, 2016, all “covered entities” must “take steps to provide meaningful access” to Limited English Proficient patients (“LEP”). Covered entities include hospitals, health clinics and nursing homes. 

The entities must post notices of both nondiscrimination and the availability of qualified interpreter services for patients. 

These notices must be posted in 15 languages and must communicate that the hospital, in concordance with said provision, prohibits discrimination based on race, color, national origin, sex, age or disability. These notices must also clearly communicate that the hospital has and will supply language assistance services/ translation services, free of charge, to limited English proficient patients. 

The 15 languages that these notices must be posted in are the top 15 languages spoken in the respective state where the entity is located. The Office for Civil Rights (“OCR”) has already provided 64 translations on its respective website. An example or “tagline” the entity must post reads: “If you speak [insert language], language assistance services, free of charge, are available to you. Call 1-xxx-xxx-xxxx (TTY:1-xxx-xxx-xxxx).” A statement and notice of nondiscrimination must also be posted in those same respective 15 languages. 

These notices/taglines must be posted in physical locations visible to the patients/public, as well as be posted on the entity’s respective website.  

Once posted, the regulations state that the entity, if it is an entity 15 or more employees, must then ensure compliance with these regulations. Ensuring compliance includes the adoption, provision and adherence to grievance procedures.  

Hospitals are also obligated to comply and supply interpreter/translation services as per the Joint Commission’s Effective Communication Standards. These standards simply state that hospitals must be able to communicate with patients “in a manner that meets the patient’s oral and written communication needs.”  

Also, the entities/providers are required “to translate vital medical documents” so that both the patients and the medical staff “can be heard and understood.”  

To assist the health care entities in deciding which languages they should post their notices in as well as translate vital medical documents into, the HHS has provided a formula: “vital medical documents should be translated into any language spoken by 5% of the people served by the facility or 1,000 of them — whichever is less.” 

Given the abundance of documents utilized by health care entities, the Joint Commission also suggests considering whether written documents have “clinical, legal or other important consequences.” Another resource for identifying which documents should be translated is HHS’s Translated Resources for Covered Entities.

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Steven Bisciello

Steven Bisciello is a Health Care Services Group, Partner experienced in revenue enhancement programs, health care litigation, compliance and physician practice management.

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