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Benefits

How Do Plans Provide Claims and Appeals Notices in a Culturally and Linguistically Appropriate Manner?

EBIA  

EBIA  

QUESTION: Can you explain the requirement that claims and appeals notices be provided in a “culturally and linguistically appropriate” manner?

ANSWER: Notices sent by group health plans or insurers relating to claims, appeals, and external review, and notices of adverse benefit determination with respect to disability benefits, must be provided in a “culturally and linguistically appropriate manner.” (Similar language requirements apply to the summary of benefits and coverage; see our Checkpoint Question of the Week.)

If 10% or more of the population residing in a county is literate only in the same non-English language (based on U.S. Census data), notices delivered to addresses in that county by a plan or insurer must include a one-sentence statement, in the applicable language, explaining how to access language-assistance services. There are four designated languages for this purpose: Spanish, Chinese, Tagalog, and Navajo. A table listing the U.S. counties meeting the 10% threshold initially appeared in regulations and is updated from time to time and made available on the agencies’ websites. The most recent table identifies 266 counties that satisfy this threshold.

A plan or insurer sending a notice to an address in a county that meets the 10% threshold must—

  • provide oral language services that include answering questions in the applicable non-English language (for example, through a telephone customer-assistance hotline) and providing assistance with filing claims and appeals, including external review, in that language;
  • include a one-sentence statement in the English versions of all notices—prominently displayed in the non-English language—clearly indicating how to access the language services provided by the plan or insurer; and
  • provide a notice in an applicable non-English language upon request.

The agencies have provided sample language for the one-sentence statement in each of the four languages as part of their model adverse benefit determination notices for group health plans posted on the DOL and HHS websites.

For more information, see EBIA’s Health Care Reform manual at Section XV.E (“Providing Notices in a Culturally and Linguistically Appropriate Manner”); see also EBIA’s ERISA Compliance manual at Sections XXXIV.E.8 (“Providing Notices in a Culturally and Linguistically Appropriate Manner”) and XXXV.D.4.k (“Disability Only: Culturally and Linguistically Appropriate Requirement”), and EBIA’s Self-Insured Health Plans manual at Section XXVI.D (“Documentation for Group Health Plan Claims Procedures”). See also EBIA’s Checkpoint sample documents, “Notice of Adverse Benefit Determination” and “Notice of Final Internal Adverse Benefit Determination” (included in the Appendices to both manuals), and “Notice of Benefit Denial—Disability Claim” (included in the Appendix to the ERISA Compliance manual).

Contributing Editors: EBIA Staff.

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