NEWS

A 50-State Review of Access to State Medicaid Program Information for People with Limited English Proficiency and/or Disabilities Ahead of the PHE Unwinding

Govt Abstract

State Medicaid web sites are a key supply of knowledge and an avenue for enrollment in or renewal of protection for a lot of candidates and current enrollees. Medicaid households embrace a disproportionate share of nonelderly adults with restricted English proficiency (LEP), and three in ten nonelderly Medicaid adults report having a incapacity. When the continual enrollment requirement associated to the COVID-19 public well being emergency (PHE) ends and states resume frequently scheduled redeterminations and renewals, people with LEP and/or disabilities could also be at elevated danger of shedding protection, regardless of remaining eligible, on account of boundaries in accessing eligibility and renewal info. A number of federal legal guidelines require state Medicaid businesses to supply info in a approach that’s accessible to folks with LEP and other people with disabilities (Appendix).

This problem transient critiques accessibility of knowledge for folks with LEP and other people with disabilities offered via state Medicaid web sites and name heart automated telephone timber as of June 16, 2022. The evaluation reveals that whereas states have taken some steps to help entry to info and functions for folks with LEP and other people with disabilities, gaps in accessibility stay. Given the potential challenges folks with LEP and other people with disabilities could face sustaining protection as soon as Medicaid renewal and redeterminations resume following the tip of the general public well being emergency, particular steps to attenuate boundaries and guarantee quick access to info, functions, and help may assist forestall protection losses amongst those that stay eligible.

Most states have taken steps to help entry to info and functions for folks with LEP and other people with disabilities.  Such steps embrace the next:

  • Most states (43) present info on their homepage and/or have their PDF Medicaid functions translated into languages aside from English. About two-thirds of states (33) present info on their homepage in a language aside from English. The variety of languages aside from English vary from one to over 100 in states utilizing automated translation programs reminiscent of Google Translate, though as famous under, there could also be high quality points related to mechanically translated info. The languages mostly accessible embrace Spanish, Chinese language, Vietnamese, and Tagalog. Most states with on-line PDF functions (34 of 41) provide the applying in languages aside from English, though normally the one different language accessible is Spanish.
  • A complete of 34 states have multilingual tagline notices about find out how to acquire language help companies on their homepages or inside one click on of their homepage and/or on their PDF software. In these states, taglines are offered in between 1 and 55 languages aside from English, with most of those states together with taglines in not less than 15 languages along with English. All states with taglines embrace taglines in Spanish. Along with Spanish, the most typical different languages during which taglines are provided are Chinese language and Vietnamese.
  • Forty states present common details about the provision of affordable modifications (also referred to as affordable lodging) for folks with disabilities on their homepage or inside one click on from their homepage or on their on-line PDF software. Examples of different codecs and companies to extend entry for folks with disabilities embrace teletypewriter (TTY) name heart numbers to help people who find themselves deaf, hard-of-hearing, or have a extreme speech impairment (32 states), giant print or Braille supplies and/or PDF functions (16 states), and details about find out how to request an American Signal Language interpreter or different applicable interpreter (22 states).
  • State Medicaid homepages and on-line software touchdown pages on common have fewer accessibility errors for people who find themselves blind or have low imaginative and prescient in comparison with webpages normally. State homepages and on-line software touchdown pages have been evaluated utilizing WAVE, a collection of automated net accessibility measurement instruments that features 110 parts that assess potential accessibility errors for people who find themselves blind or have low imaginative and prescient. WAVE detected a mean of 11.4 errors per web page throughout the 101 webpages assessed, in comparison with the typical of fifty.8 errors per web page discovered on the highest a million net homepages typically. About half of the assessed webpages confirmed 5 or fewer detectible errors, and 11 pages confirmed no detectible errors. These findings counsel that states have given notable consideration to making sure accessibility on these pages total.

Whereas states have taken steps to help entry to info and functions for folks with LEP and other people with disabilities, persevering with gaps in accessibility stay. A few of these gaps embrace:

  • Multilingual info is usually accessible in a restricted variety of different languages. In 5 states, Spanish is the one language aside from English during which translated info is offered on Medicaid homepages. Most states with on-line PDF functions accessible in non-English languages (23 of 31) provide the functions solely in Spanish and English. Of the 40 states that provide language choices via name heart automated menus, 31 states provide choices solely in English and Spanish. Whereas Spanish is the most typical language spoken amongst nonelderly adults in Medicaid households who’ve LEP, Chinese language and Vietnamese are every spoken by 3% of those adults, and there are a various set of languages spoken total by this group.
  • Translated info on Medicaid homepages could also be much less dependable than the knowledge accessible on English variations of homepages. A complete of twenty-two states use automated translations via Google Translate, which can result in high quality points related to the translations. Google has indicated that it’s not meant to exchange human translators or for use in public well being contexts with out having translations verified. Two states embrace disclaimers that the English model of the homepage is probably the most dependable. In three states, some content material within the headers, footers, and/or menus of the translated variations of the homepage stays in English and in 9 states, clicking hyperlinks in translated variations of the homepage results in English content material.
  • Most states don’t make info and functions accessible in a number of codecs to enhance accessibility for folks with disabilities. Solely two states put up a big print PDF software type on-line, whereas one other 14 states included info on their homepage about find out how to acquire supplies in giant print or Braille. The remaining 35 states don’t point out different codecs on their homepage or inside one click on from their homepage. Making info and functions accessible in a number of codecs is a vital means of accelerating entry for folks with disabilities. Folks with disabilities could entry info in numerous methods, relying on their kind of incapacity and kind of assistive expertise they use.
  • Many of the webpages (in 47 states) assessed via WAVE confirmed not less than one incidence of low distinction textual content, which is tough for folks with shade blindness or low imaginative and prescient to learn. Connecticut is the one state that permits customers to vary the homepage to a “excessive distinction” mode to enhance readability for customers. Different generally detected accessibility points included lacking labels to explain the assorted fields of content material in a type (24 states) and pictures lacking different textual content (23 states).
  • Practically all state name facilities (49 states) reply with an automatic telephone tree, which may enhance accessibility challenges for folks with LEP and/or mental, developmental, or psychological well being disabilities. In 12 states with automated telephone timber, the primary set of menu choices embrace the choice to talk to a dwell individual. As of the time of our information assortment, the decision heart wait time to talk with a dwell individual was lower than quarter-hour in 34 states, whereas in 8 states the wait time was greater than quarter-hour, and within the remaining 7 states, we couldn’t attain a dwell individual. Entry to a dwell individual can enhance accessibility for folks with LEP and/or mental or developmental disabilities and other people with psychological well being disabilities.
  • States hardly ever addressed the intersection of LEP and incapacity. Solely two states present TTY numbers in Spanish on their homepages. 

Introduction

State Medicaid web sites are a key supply of knowledge and an avenue for enrollment in or renewal of protection for a lot of candidates and current enrollees. Medicaid households embrace a disproportionate share of nonelderly adults with restricted English proficiency (LEP), and three in ten nonelderly Medicaid adults report having a incapacity. Whereas Spanish is the most typical language spoken amongst nonelderly adults in Medicaid households who’ve LEP, Chinese language and Vietnamese are every spoken by 3% of those adults, and there are a various set of languages spoken total by this group. Medicaid enrollees have quite a lot of disabilities, together with blindness or low imaginative and prescient; deafness or exhausting of listening to; mental and developmental disabilities reminiscent of autism or Down’s syndrome; traumatic mind or spinal twine accidents; and psychological sickness. Some folks could have each LEP and a incapacity.

When the continual enrollment requirement associated to the COVID-19 public well being emergency (PHE) ends, and states resume frequently scheduled redeterminations and renewals, people with LEP and/or disabilities could also be at elevated danger of shedding protection, regardless of remaining eligible, on account of boundaries in accessing eligibility and enrollment info. The Facilities for Medicare & Medicaid Companies (CMS) steering concerning the PHE unwinding reminds states about these obligations and prompts states to overview their communications with folks with LEP and other people with disabilities as a technique to mitigate inappropriate protection loss. A number of federal legal guidelines require state Medicaid businesses to supply info in a approach that’s accessible to folks with LEP and other people with disabilities. The Appendix gives background info on these legal guidelines.

This problem transient critiques accessibility of knowledge for folks with LEP and other people with disabilities offered via state Medicaid web sites in addition to name heart automated telephone timber and data on software help, as of June 16, 2022. We assessed homepages and name heart automated menu choices in all 50 states and DC and PDF functions within the 41 states that present them on-line (Appendix Desk 1). We had restricted capacity to evaluate on-line functions as a result of, whereas all states besides Alaska present a web-based software, people should create an account to view the web software in all however three states (IN, MS, UT) (Appendix Desk 1).  We recognized sixteen states that present details about find out how to acquire one on one help with finishing an software on their homepage or software. See the Strategies field for extra element.

Accessibility of Data for Folks with LEP

Translation of Web site Data and Purposes

Total, about two-thirds of states (33) present info on their Medicaid program homepage in a language aside from English (Appendix Desk 2 and Determine 1). The variety of languages aside from English vary from 1 to over 100 in 17 states utilizing automated translation programs reminiscent of Google Translate. 5 states (GA, KY, LA, MA and NE) additionally use Google Translate to supply translations in a extra restricted variety of languages. Within the remaining 11 states with translated info, the variety of languages accessible aside from English ranges from 1 to 22. All 33 states that provide translation on their homepages provide info in Spanish, and, in 5 states, Spanish is the one language aside from English that’s accessible. The opposite languages mostly accessible embrace Chinese language, Vietnamese, and Tagalog. There could also be potential high quality points with translations in states utilizing automated translations, reminiscent of Google Translate. Google has indicated that it’s not meant to exchange human translators or for use in public well being contexts with out having translations verified and different analysis has discovered Google Translate to be unreliable in medical contexts., Two states (MD and GA) embrace disclaimers that the English model of the homepage is probably the most dependable. In three states (FL, MS, and KY), some content material within the headers, footers, and/or menus of the translated variations of the homepage stays in English. In 9 states, clicking hyperlinks in translated variations of the homepage results in English content material. Ten state homepages included automated chatbots to handle easy questions. In seven of those states, the chatbots can deal with questions in Spanish, together with Florida, which additionally interprets into Haitian Creole, and Rhode Island, which makes use of Google Translate to supply over 100 languages.

Determine 2: Google Translate Translation Menu from California’s Medicaid Homepage

Most states with on-line PDF functions (34 of 41 states) provide the applying in languages aside from English (Appendix Desk 2 and Determine 1). In 23 of those states, Spanish is the one different language during which the PDF software is offered. Within the remaining 11 states, PDF functions are provided in extra languages, together with in over 10 languages in California, New York, Oregon and Washington. The commonest different languages accessible are Vietnamese (6 states), Chinese language (5 states) and Korean (5 states). Most PDF functions (37 of 41) ask concerning the applicant’s most well-liked spoken language, which can facilitate entry to linguistically accessible communications sooner or later. Seven states had cellular system functions via which people may entry functions and eligibility info and submit paperwork, and in three of those states (CO, MD, and MI), these functions might be accessed in languages aside from English, primarily Spanish.

Entry to Language Help and Interpretation Companies

Seventeen states embrace multilingual taglines on their homepages or inside one click on of their homepages with info on find out how to entry language help companies (Appendix Desk 2). Eleven of those states present taglines in not less than 15 languages aside from English. All 17 states embrace taglines in Spanish, and the opposite commonest languages are Chinese language (13 states) and Vietnamese (12 states).

Most states with PDF functions (29 of 41 states) embrace multilingual tagline notices relating to the provision of language help companies on the PDF software (Appendix Desk 2). These taglines are typically current on the primary or second web page of the applying or as a footer operating throughout each web page. In 11 of those states, taglines are solely offered in Spanish and English, and, within the remaining 18 states, they’re offered in between 5 and 19 languages aside from English. Along with Spanish, the most typical different languages during which taglines are provided are Chinese language (13 states) and Vietnamese (13 states)

9990 - Figure 3

Determine 3: Spanish Tagline from Iowa’s Medicaid Web site

In 49 states, name facilities answered with automated telephone timber, and 40 of those states provided menu choices in languages aside from English. Nonetheless, in 31 of those states the one different language provided via the menu is Spanish (Appendix Desk 2 and Determine 1). Within the remaining states, telephone tree menus provide between two and 6 languages aside from English. In some states, different language choices are solely provided after the applicant listens to an extended set of choices in English.

Accessibility of Data for Folks with Disabilities

Availability of Cheap Modifications

Roughly half of states (25) present common details about the provision of affordable modifications (also referred to as affordable lodging) for folks with disabilities on their homepage or inside one click on from their homepage, whereas 32 states present this info on their on-line PDF software (Appendix Desk 4 and Determine 4). States typically present details about affordable modifications for folks with disabilities on a separate webpage titled “Nondiscrimination coverage” or “Accessibility” fairly than straight on their homepage. Customers can normally discover these separate webpages by clicking on a “Nondiscrimination coverage” hyperlink on the backside of the homepage. States typically use these separate webpages to stipulate their common dedication “to serving the wants of individuals with disabilities” (CT). Most of those separate webpages embrace details about free “auxiliary aids and companies essential to afford a person with a incapacity an equal alternative to take part in all companies, applications and actions” (KY). Moreover, states typically embrace details about affordable lodging reminiscent of different codecs together with Braille or giant print supplies, teletypewriter (TTY) numbers, and find out how to request certified American Signal Language (ASL) interpreters on these separate webpages. The provision of knowledge in plain language additionally is a vital technique of offering entry for folks with cognitive disabilities, although our web site overview didn’t assess content material for plain language.

Various Written Codecs for Folks with Disabilities

Two states (CA, CO) put up a big print PDF software type on-line, whereas one other 15 states embrace info on their homepage about find out how to acquire supplies in giant print or Braille (Appendix Desk 4 and Determine 4). For instance, Wyoming’s homepage signifies that a big print PDF software is offered upon request. Like Wyoming, most different states typically listing a telephone quantity (and/or a TTY quantity) for people to name to request supplies in different codecs or advise customers to contact their native workplace. The remaining 35 states don’t point out different codecs on their homepage or inside one click on from their homepage. Ten state homepages (CT, DE, HI, KS, LA, MS, NH, NY, TN, and VA) permit customers to extend or lower the font measurement of textual content on the webpage. Connecticut and Louisiana are the one two states that permits customers to vary the homepage to a “excessive distinction” mode to enhance readability for customers. Making info and functions accessible in a number of codecs is a vital means of accelerating entry for folks with disabilities. Folks with disabilities could entry info in numerous methods, relying on their kind of incapacity and kind of assistive expertise they use.

Web site Accessibility for Folks Who’re Blind or Have Low Imaginative and prescient

State homepages and on-line software touchdown pages have been evaluated utilizing WAVE, a collection of automated net accessibility measurement instruments that features 110 parts that assess potential accessibility errors for people who find themselves blind or have low imaginative and prescient. WAVE is developed and made accessible as a free group service by WebAIM (Net Accessibility in Thoughts) at Utah State College. WAVE assesses net accessibility, together with compatibility with display screen reader software program, which can be utilized by people who find themselves blind to transform net content material to synthesized speech, and display screen magnifiers or zoom, which can be utilized by folks with low imaginative and prescient. As a result of WAVE is automated, it doesn’t assess all features of accessibility that could be encountered by web site customers. Nonetheless, WAVE does determine the accessibility errors which are most steadily encountered and that are inclined to have the best influence on customers who’re blind or have low imaginative and prescient. Moreover, errors recognized by WAVE have been discovered to correlate with the existence of different accessibility points that WAVE doesn’t detect however which may be encountered by an internet site consumer. The WAVE evaluation was utilized to a complete of 101 webpages, together with the homepages for all 50 states and DC and the web software touchdown pages for 49 states and DC.

The commonest accessibility problem detected by WAVE may be very low distinction textual content, with 67% of the assessed webpages (in 47 states) exhibiting not less than one incidence of this error (Appendix Desk 3 and Determine 5). Total, WAVE detected a mean of seven situations of very low distinction textual content errors per web page throughout the 101 webpages assessed. Low distinction textual content refers back to the distinction in brightness between textual content or a graphic and its background colours and is tough for folks with shade blindness or low imaginative and prescient to learn. Different generally detected accessibility points embrace lacking labels to explain the assorted fields of content material in a type (27% of pages, 24 states) and pictures lacking different textual content (25% of pages, 23 states) (Appendix Desk 3). Various textual content is used to explain the content material of a picture. Photographs that lack different textual content and kinds with out textual content labels can’t be correctly recognized by display screen readers, making this content material very tough to entry for individuals who depend on that expertise.

The typical variety of accessibility errors detected by WAVE throughout the 101 assessed state homepages and on-line software touchdown pages is considerably decrease than the typical variety of errors discovered on webpages normally. Particularly, WAVE detected a mean of 11.4 errors per web page throughout the 101 webpages assessed, in comparison with the typical of fifty.8 errors per web page discovered on the highest a million net homepages typically. The variety of net accessibility errors detected on the assessed webpages varies broadly throughout states (Appendix Desk 3). Over half of the states have 15 or fewer errors throughout their homepages and on-line software pages and in seven states, there are lower than 5 errors (Determine 5). These findings counsel that states have given notable consideration to making sure accessibility on these pages total, though some pages could have errors that might pose issue for customers with disabilities.

Efficient Communication for Folks with Disabilities

Thirty-two states listing a TTY name heart quantity straight on their homepage or inside one click on from the homepage (Appendix Desk 4 and Determine 6). Eight of those states require customers to click on on a “contact us” tab to discover a TTY quantity, whereas 13 states require customers to click on on a unique hyperlink to a “nondiscrimination” or “entry for customers with particular wants” webpage to discover a TTY quantity. TTY numbers permit people who’re deaf or exhausting of listening to to speak by sending typed messages over the telephone line. If states talk with candidates or the general public by telephone, additionally they should deal with calls by way of TTY or comparable expertise. North Carolina is the one state to listing a Spanish language TTY (Relay Service) on its homepage. Equally, Utah is the one state to listing a Spanish Relay quantity for people with speech and/or listening to impairment on their PDF software.

Twenty-two states present details about find out how to request an ASL interpreter on their web site (Appendix Desk 4 and Determine 6). Considered one of these states (WA) straight lists this info on their homepage, whereas the opposite 21 states require customers to click on on one other hyperlink reminiscent of a “nondiscrimination” webpage to seek out details about find out how to request an ASL interpreter. Each TTY numbers and ASL interpreters can assist promote efficient communication for people who find themselves deaf or exhausting of listening to that might be important for somebody to know find out how to enroll in or retain Medicaid protection.

The big majority (49 of 51) of name facilities reply with an automatic telephone tree and solely 12 of the automated telephone timber embrace an choice to talk to a dwell individual within the first set of menu choices (Appendix Desk 4 and Determine 6). Two name facilities (DC, SD) reply with a dwell individual as an alternative of an automatic telephone tree. Entry to a dwell individual can enhance accessibility for folks with LEP and/or mental or developmental disabilities and other people with psychological well being disabilities. As of the time of our information assortment, the decision heart wait time to talk with a dwell individual was lower than quarter-hour in 34 states, whereas in six states, the wait time was greater than quarter-hour. Within the remaining seven states, we have been unable to succeed in a dwell individual. The tip of the COVID-19 PHE could enhance these wait instances, as states resume processing redeterminations and renewals.

Wanting Forward

Because the COVID-19 PHE ends and states resume frequently scheduled Medicaid redeterminations and renewals, folks with LEP and/or disabilities could face elevated challenges to sustaining protection regardless of remaining eligible on account of boundaries in accessing eligibility and enrollment info. Below Title VI of the Civil Rights Act, Part 1557 of the Inexpensive Care Act, and the Rehabilitation Act, state Medicaid company program info should be accessible to folks with LEP and other people with disabilities. The Biden Administration has issued a proposed rule revising implementing regulation for Part 1557, taking steps to reverse Trump Administration coverage and laws that considerably narrowed the implementation and administrative enforcement of the laws. The proposed rule reinstates the requirement that Medicaid businesses present discover of the provision of language help companies and auxiliary aids and companies in each bodily areas and on their web sites. Moreover, the rule, for the primary time, requires state Medicaid businesses to present employees clear steering and coaching on the supply of language help companies, and efficient communication and affordable modifications to insurance policies and procedures for folks with disabilities, with a view to enhance compliance. Whatever the standing of the laws, the underlying statutory protections of Part 1557, which require significant entry to federal applications for folks with LEP and/or disabilities, stay in addition to protections underneath different federal legal guidelines and federal Medicaid laws that require public applications be accessible to folks with LEP and/or disabilities.

As states put together to renew Medicaid redeterminations and renewals, they’ll take steps to stop and reduce potential administrative boundaries to sustaining protection, notably for individuals who have LEP and/or disabilities. CMS steering outlines particular steps states can take, together with guaranteeing accessibility of kinds and notices for folks with LEP and other people with disabilities and reviewing communications methods to make sure accessibility of knowledge. Growing entry to a dwell individual via name facilities and/or offering a devoted name heart line for folks with LEP might also assist enhance accessibility for folks with LEP and other people with disabilities. Guaranteeing accessibility of knowledge, kinds, and help shall be key for stopping protection losses and gaps amongst these people.

Homepage information was obtained from Healthcare.gov’s listing of state Medicaid web sites. In circumstances the place the Healthcare.gov hyperlink was damaged or led to the wrong web site, hyperlinks from the Nationwide Affiliation of Medicaid Administrators’ listing of state web sites have been used or when wanted, researchers looked for, “[LOCATION] Medicaid” and used the primary outcome. An abbreviated listing of indicators used to find out the accessibility and lodging info discovered on state Medicaid web sites is reproduced in Appendix 1 via 4. Name heart information was obtained by looking out the Medicaid state homepage for the shopper help name heart quantity. Calls have been made to those numbers (listed in Appendix desk 1) from June 2 via June 16, 2022, between 9 AM and 5 PM EST.

KFF appreciates the help of Jared Smith, program supervisor at Utah State College Institute for Incapacity Analysis, Coverage and Apply, with analyzing and decoding the WAVE outcomes.

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