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

Appendix

Summary of Relevant Federal Nondiscrimination Laws

State Medicaid agency program information must be accessible to people with LEP and people with disabilities. States must provide information about Medicaid eligibility requirements, covered services, and applicant/enrollee rights and responsibilities via a website as well as orally and in writing.¹ States also must allow individuals the opportunity to apply for Medicaid without delay.² Individuals must be able to apply online, by telephone, by mail, in person, and through other commonly available electronic means.³ State Medicaid agencies must provide assistance to individuals seeking help with the application or renewal process in person, over the telephone, and online.⁴

Federal law requires state Medicaid agencies to provide meaningful access for people with LEP. As recipients of federal funds, state Medicaid agencies are prohibited from discriminating on the basis of national origin, pursuant to Title VI of the Civil Rights Act of 1964 and Section 1557 of the Affordable Care Act (ACA). Current regulations require state Medicaid agencies to “ensure meaningful access to… programs or activities by limited English proficient individuals.”⁵ People who are LEP may include those who do not speak English as their primary language and who have a limited ability to read, write, speak, or understand English. The current Section 1557 regulations, issued by the Trump Administration, reduced the regulatory standards originally adopted by the Obama Administration. The Biden Administration has issued a proposed rule taking steps to reverse Trump Administration policy and strengthen and reinstate Section 1557 regulatory standards.

The two main types of language assistance services are oral interpreting and written translation. In addition to the requirements of Title VI and Section 1557, federal Medicaid regulations specifically require state Medicaid agencies to provide information about eligibility requirements, covered services, and applicant/enrollee rights and responsibilities as well as application assistance in a timely manner and in a way that is accessible to people with LEP, though the provision of language assistance services at no cost to the individual.⁶ Individuals must be informed about the availability of these language assistance services and how to access them.⁷ At minimum, state Medicaid agencies must provide taglines in non-English languages that indicate the availability of language assistance services.⁸

Federal law requires state Medicaid agencies to make programs and services accessible to people with disabilities. Title II of the Americans with Disabilities Act (ADA) applies to state and local governmental entities, while Section 504 of the Rehabilitation Act and Section 1557 of the ACA apply to recipients of federal funds. All of these laws prohibit state Medicaid agencies from discriminating against people with disabilities. This means that people with disabilities cannot be excluded from participation in or be denied the benefits of the services, programs, or activities offered by a state Medicaid agency.⁹ People with disabilities also must have an equal opportunity and ability to participate in or benefit from the services, programs, and activities of state Medicaid agencies.¹⁰ Additionally, state Medicaid agencies must afford people with disabilities the opportunity to request, and must make, reasonable modifications in policies, practices, or procedures when necessary to avoid disability-based discrimination, unless doing so would result in a fundamental program alteration  or result in an undue burden.¹¹ The definition of disability is to be construed broadly in favor of expansive coverage to the maximum extent permitted.¹²

State Medicaid agencies must take appropriate steps to ensure that communication with applicants, participants, and members of the public with disabilities is as effective as communication with those without disabilities.¹³ State Medicaid agencies also must timely furnish appropriate auxiliary aids & services where necessary to afford people with disabilities an equal opportunity to participate in and enjoy the benefits of a program or activity.¹⁴ The type of auxiliary aid or service to be provided varies based on the individual’s communication method; the nature, length and complexity of the communication; and the context. Governmental entities like state Medicaid agencies must give primary consideration to the individual’s requested type of auxiliary aid or service. Auxiliary aids and services may include qualified onsite or video remote interpreters. A teletypewriter (TTY) or equally effective telecommunication system must be used when an agency communicates with applicants or enrollees by phone, and agencies must respond to relay calls in the same manner as other phone calls.¹⁵ Any automated attendant system (voicemail or interactive voice response system) to receive or direct incoming calls must provide effective real time communication.¹⁶

In addition to the requirements of the ADA, Section 504, and Section 1557, federal Medicaid regulations specifically require state Medicaid agencies to provide information about eligibility requirements, covered services, and applicant/enrollee rights and responsibilities as well as application assistance in plain language, in a timely manner, and in a way that is accessible to people with disabilities, though the provision of auxiliary aids and services at no cost to the individual.¹⁷ Individuals must be informed about the availability of accessible information and how to obtain it.¹⁸