1le AffotJable Cate Act 8 Rac|al aoJ ltlo|c lealtl lqo|ty Set|es

Pollcy 8rlef No.±: HeulLh lnsurunce Lxchunges | Muy zo±¸

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How Wi|| Hea|th Insurance Exchanges Reach Our Nation's
Racia||y and Ethnica||y Oiverse Communities?

Source: kalser lamlly loundaLlon, A ltoflle of neoltb losotooce
íxcbooqe íotollees, March 2011.
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Cne of Lhe cenLerpleces of Lhe Affordable Care AcL
of 2010 (ACA) ls Lhe creaLlon of Affordable PealLh
lnsurance Lxchanges-also called ºMarkeLplaces"-
whlch wlll offer access Lo healLh lnsurance for
mllllons of people ln Lhe unlLed SLaLes sLarLlng on
!anuary 1, 2014. 1he exchanges wlll offer a cholce
of easlly comparable lnsurance plans Lo lndlvlduals
and small buslnesses. 1hey wlll also subsldlze
lnsurance premlums for low-lncome lndlvlduals and
famllles who quallfy. 1he exchanges wlll also
educaLe consumers, asslsL Lhem wlLh deLermlnlng
ellglblllLy for publlc and prlvaLe healLh lnsurance,
and provlde an elecLronlc sysLem for enrollmenL.
Cne key Lo Lhe effecLlveness and success of Lhe
exchanges wlll be Lhe ablllLy Lo reach all
consumers-lncludlng Lhose from dlverse raclal and
eLhnlc herlLage-Lo ensure Lhey undersLand and
can navlgaLe Lhe process of chooslng a plan and
becomlng lnsured.
Why Address Language, Cu|ture, and
Oiversity in the Exchanges?
Lack of healLh lnsurance ls a ma[or reason why
many Afrlcan Amerlcan, Plspanlc or LaLlno,
lmmlgranL, and oLher dlverse populaLlons are
unable Lo access care, delay or forgo care, and
ulLlmaLely face poorer healLh-lncludlng hlgher
raLes of dlsease and morLallLy. 8arrlers Lo obLalnlng
coverage for Lhese populaLlons ofLen lnclude
llmlLed Lngllsh proflclency, culLural dlfferences, lack
of LrusL, and low llLeracy, among oLher facLors.
Lnsurlng dlverse lndlvlduals and famllles galn
lnsurance coverage ls crlLlcal Lo lmprovlng noL only
Lhelr overall healLh and well-belng, buL LhaL of Lhe
enLlre naLlon. 1hls prlorlLy ls also crlLlcal Lo
reduclng medlcal errors, lmprovlng quallLy, and
reduclng unnecessary medlcal cosLs.
An esLlmaLed 24 mllllon people wlll be ellglble for
lndlvldual lnsurance Lhrough Lhe exchanges. AbouL
42° (or over 10 mllllon) of Lhese people wlll be
Afrlcan Amerlcan, Plspanlc or LaLlno, or from
anoLher non-WhlLe raclal and eLhnlc group (llgure
1). nearly one ln four wlll speak a language oLher
Lhan Lngllsh aL home.








How Ooes the ACA Address Language
and Cu|tura| Oiversity in the Exchanges?
1he ACA lncludes aL leasL 7 provlslons Lo ensure
LhaL Lhe exchanges, and healLh plans offered
Lhrough Lhem, wlll reach raclally and eLhnlcally
dlverse populaLlons ln markeLlng, educaLlon, and
ouLreach. ln general, Lhese provlslons focus on
ensurlng language access (such as LranslaLlon
servlces, lnLerpreLaLlon, and mulLl-llngual
lnformaLlon), culLurally approprlaLe ouLreach and
educaLlon, and non-dlscrlmlnaLlon. lollowlng ls a
summary of Lhese 7 requlremenLs, lncludlng
lnformaLlon on accompanylng federal rules and
guldance LhaL have been lssued Lo daLe:
S8¼
11¼
2S¼
6¼
WhlLe
8lack or Afrlcan
Amerlcan
Plspanlc or
LaLlno
CLher
Figure ±. Pro|ected Percent of Hea|th Insurance
Exchange Enro||ees by Race and Ethnicity
1le AffotJable Cate Act 8 Rac|al aoJ ltlo|c lealtl lqo|ty Set|es
Pollcy 8rlef No.±: HeulLh lnsurunce Lxchunges | Muy zo±¸


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Noviqotor Proqrom in £xchonqes. Lxchanges are
requlred Lo have a navlgaLor Þrogram Lo asslsL
consumers enrolllng ln coverage and provlde
culLurally and llngulsLlcally Lallored and approprlaLe
lnformaLlon, lncludlng meeLlng Lhe needs of Lhose
wlLh llmlLed Lngllsh proflclency. Lxchanges musL
develop Lralnlng sLandards Lo assure navlgaLors are
quallfled Lo asslsL underserved populaLlons ln
deLermlnlng ellglblllLy and Lo address language and
culLural needs and preferences ln enrollmenL. 1hese
sLandards also apply Lo ln-person asslsLers, a
caLegory of helpers added by subsequenL federal
guldance.

P/oin Lonquoqe in neo/th P/ons. PealLh plans ln Lhe
exchange musL provlde enrollmenL daLa, flnanclal
dlsclosures, and oLher lnformaLlon ln plaln language
Lo appllcanLs, enrollees, and general publlc,
lncludlng Lhose wlLh llmlLed Lngllsh proflclency.

5ummory of 8enefits ond uniform 6/ossory. lor
plan years beglnnlng on or afLer SepLember 23,
2012, healLh plans musL provlde a sLandard
summary of beneflLs documenL LhaL ls culLurally
and llngulsLlcally approprlaLe and follows Lhe
federal LemplaLe, as well as provlde a sLandard
glossary of lnsurance Lerms, Lo all enrollees,
employers, and oLhers who ask. PealLh plans musL
provlde a summary of beneflLs ln oLher languages
when 10° or more of Lhe populaLlon llvlng ln Lhe
enrollee's counLy are llLeraLe only ln Lhe same non-
Lngllsh language. ln 2012, 233 u.S. counLles meL
Lhls Lhreshold for Spanlsh, Chlnese, 1agalog, and
nava[o.
c/oims 4ppeo/s Process. PealLh plans musL provlde
clalms appeals noLlces Lo enrollees upon requesL ln
languages oLher Lhan Lngllsh lf Lhe address Lo whlch
Lhe noLlce ls senL ls locaLed ln a counLy where 10°
or more of Lhe populaLlon ls llLeraLe only ln Lhe
same non-Lngllsh language. ln such counLles, Lhe
healLh plan musL lnclude Lagllnes ln Lhe non-Lngllsh
language on how Lo access language servlces
provlded by Lhe plan. ln counLles meeLlng Lhe
language Lhreshold, oral language servlces (such as
Lelephone hoLllnes) musL be provlded. 1hese
requlremenLs Look effecL for plan years beglnnlng
on or afLer !anuary 1, 2012.
lncentive Poyments for keducinq uisporities.
PealLh plans may reward quallLy and encourage
acLlvlLles for reduclng dlsparlLles such as language
servlces, communlLy ouLreach, and culLural
compeLency Lralnlng. no federal guldance has been
lssued on Lhls provlslon Lo daLe.
kemove cost-5horinq for 4mericon lndions.
Amerlcan lndlans and Alaska naLlves (Al/Ans) wlll
pay no cosL-sharlng for healLh care obLalned
Lhrough a healLh plan ln Lhe exchange lf Lhey have
lncomes below 300° of Lhe federal poverLy level.
PealLh plans are also requlred Lo provlde monLhly
enrollmenL perlods (as opposed Lo annual) Lo
lncrease Lhelr opporLunlLles Lo enroll. Lxchanges are
requlred Lo consulL sLakeholders represenLlng
Al/Ans, lncludlng lederally 8ecognlzed 1rlbes,
whlch are locaLed wlLhln an exchange's geographlc
area. Members of lndlan Lrlbes are also exempL
from Lhe lndlvldual mandaLe and wlll lncur no
penalLles for noL havlng lnsurance.
Non-uiscriminotion. AnLl-dlscrlmlnaLlon laws ln Lhe
Clvll 8lghLs AcL and oLher acLs are exLended Lo Lhe
exchanges and healLh plans offered wlLhln Lhem.
lndlvlduals are noL Lo be excluded from Lhe
exchanges, denled any beneflLs, or be sub[ecLed Lo
dlscrlmlnaLlon based on race, color, and naLlonal
orlgln among oLher facLors.
What Progress are 5tate-Based
Exchanges Making?

1he 1exas PealLh lnsLlLuLe revlewed a number of
leadlng sLaLe-based exchanges or markeLplaces Lo
ldenLlfy promlslng pracLlces sLaLes are adopLlng Lo
ensure effecLlve ouLreach and enrollmenL across
dlverse communlLles. Among sLaLes lncluded ln lLs
revlew were Callfornla (CA), Colorado (CC),
ConnecLlcuL (C1), Maryland (Mu), new ?ork (n?),
Cregon (C8), and WashlngLon (WA). lollowlng are
ways ln whlch Lhese sLaLes are addresslng culLure,
language, and dlverslLy.
£xchonqe P/onninq ond ueve/opment. ln exchange
plannlng and developmenL, Lhese 7 sLaLes are
addresslng dlverslLy and equlLy beyond whaL ls
requlred by Lhe ACA. lor example, Lhey are:
1le AffotJable Cate Act 8 Rac|al aoJ ltlo|c lealtl lqo|ty Set|es
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 8equlrlng raclal and eLhnlc represenLaLlon on
Lhe 8oard of ulrecLors (CA, CC, Mu, and C8).
 Lnsurlng dlverslLy and equlLy ob[ecLlves are
expllclLly a parL of Lhe exchange vlslon and
mlsslon (CA, C1, C8, and WA).
 8equlrlng advlsory groups Lo lnclude raclal
and eLhnlc represenLaLlon (CA, Mu, and C8).
 Lngaglng raclal and eLhnlc communlLy
members, advocaLes, and oLher
represenLaLlves Lo provlde lnpuL on varlous
aspecLs of plannlng (all 7 sLaLes).
 AdopLlng a Lrlbal consulLaLlon pollcy and
consulLlng federally recognlzed Lrlbes (all
sLaLes excepL Mu, whlch has no federally
recognlzed Lrlbes).
Outreoch, £ducotion, ond £nro//ment. As requlred
by Lhe ACA, Lhese sLaLes are developlng programs
Lo ensure ouLreach, educaLlon, and enrollmenL
processes are Lallored for raclally and eLhnlcally
dlverse consumers. lor example, Lhey are:
 1argeLlng Lhelr ouLreach and educaLlon for
people wlLh llmlLed Lngllsh proflclency, and
oLher dlverse consumer groups (all 7 sLaLes).
 Lnsurlng Lhelr navlgaLor or AsslsLer Þrogram
asslsLs lndlvlduals from dlverse raclal, eLhnlc,
and language backgrounds (all 7 sLaLes).
 ueveloplng navlgaLor or AsslsLer Lralnlng
maLerlals on culLural and llngulsLlc
compeLency (Mu and n? are leadlng, wlLh CA,
CC, C1, C8, and WA maklng some progress).
Other 4ctivities. 1hese 7 sLaLes are also progresslng
ln ensurlng oLher aspecLs of Lhelr exchange
plannlng, developmenL, and operaLlon address
raclal and eLhnlc dlverslLy, such as:
 Þlannlng for Lhelr exchange Web porLals Lo
lnclude LranslaLed maLerlals or Lagllnes wlLh
access Lo language maLerlals or servlces (all 7
sLaLes).
 Þlannlng Lo Lake culLural compeLency
measures lnLo accounL ln selecLlng quallfled
healLh plans for Lhe exchange (CA).
 Þlannlng Lo measure dlsparlLles and dlverslLy
efforLs for fuLure lmprovemenL (CA ls leadlng,
wlLh CC and Mu maklng some progress).
What Cha||enges Lie Ahead for
Exchanges?
uemandlng deadllnes, LlghL budgeLs, llmlLed
resources, and lncompleLe guldance on
lmplemenLaLlon are among Lhe broad challenges
LhaL many exchanges may conLlnue Lo face. lor
example, whlle Lhe ACA requlres Lhe esLabllshmenL
of a navlgaLor program, lL does noL allow Lhe
program Lo be funded Lhrough federal funds from
sLaLe-based exchange esLabllshmenL granLs. SLaLes
wlll need Lo flnd oLher sources Lo seL up and susLaln
Lhese programs. ln reachlng dlverse communlLles,
many sLaLes clLe Lhelr challenges on how Lo
effecLlvely markeL Lo and educaLe lndlvlduals and
famllles who may noL be famlllar wlLh healLh
lnsurance, lncludlng non-Lngllsh speakers,
lmmlgranLs from counLrles wlLh llLLle concepL of
healLh lnsurance, and culLurally and llngulsLlcally
lsolaLed famllles ln rural areas. llnally, ln many
sLaLes, lnformaLlon Lechnology ls drlvlng Lhe
exchange lmplemenLaLlon process more Lhan
consumer needs. SLaLes wlll need Lo make a
concerLed efforL Lo ensure LhaL flnanclal resources
are puL Loward ensurlng Lhe exchange experlence ls
accesslble Lo and Lallored for raclally, eLhnlcally, and
dlverse communlLles.
What Progress Are Hea|th P|ans Making?
Many healLh plans have Laken sLeps Lo ensure
lnformaLlon, resources, and servlces Lhey provlde
are culLurally and llngulsLlcally approprlaLe. Whlle
some healLh plans-such as Lhose ln Lhe naLlonal
PealLh Þlan CollaboraLlve of Amerlca's PealLh
lnsurance Þlans (APlÞ)-were addresslng dlverslLy
and equlLy well before Lhe ACA, oLhers are only
geLLlng sLarLed. Cenerally, glven Lhe need Lo ensure
regulaLory compllance, healLh plans have been swlfL
Lo respond Lo Lhe culLural, llngulsLlc, and plaln
language requlremenLs for summary of beneflLs
documenLs, unlform glossarles, and clalms appeals
processes. lacLors whlch have faclllLaLed Lhls
process among leadlng healLh plans are: (1)
leadershlp-or a champlon-LhaL recognlzes Lhe
lmporLance of addresslng dlsparlLles and can
shepherd relaLed prlorlLles Lo lmplemenLaLlon, (2)
1le AffotJable Cate Act 8 Rac|al aoJ ltlo|c lealtl lqo|ty Set|es
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Lhe recognlLlon and lnLegraLlon of raclal and eLhnlc
healLh equlLy prlorlLles early ln plannlng, and (3)
prlor experlence wlLh culLurally and llngulsLlcally
Lallored ouLreach and enrollmenL ln Medlcald.
What Cha||enges Lie Ahead for Hea|th
P|ans?
Many healLh plans are sLruggllng Lo meeL federal
requlremenLs puL forLh by Lhe ACA glven LlghL
deadllnes and lncompleLe guldellnes. Some are also
concerned abouL markeLlng Lo lndlvldual consumers
ln such a shorL Llmeframe as Lhey are more
accusLomed Lo markeLlng Lo employers. And as
healLh plans seek Lo advance Lhelr cllenL base ln
Lhese new markeLplaces, many worry abouL how
besL Lo reach and enroll a large proporLlon of low-
lncome, raclal and eLhnlc non-WhlLe lndlvlduals and
famllles. ln addlLlon, meeLlng language needs
beyond whaL ls requlred by Lhe ACA may be more
daunLlng Lhan meeLs Lhe eye. lor example, healLh
plans wlll need Lo declde wheLher and how Lo reach
slzeable non-Lngllsh speaklng communlLles LhaL
may noL meeL Lhe 10° Lhreshold requlremenL. And
how wlll Lhey reach lndlvlduals who cannoL read ln
Lhe language Lhey speak, or use reglonal dlalecLs?
llnally, ln some communlLles, healLh plans wlll also
need Lo overcome barrlers Lo lnsurance relaLed Lo
LrusL-someLlmes ln comblnaLlon wlLh language.

What Are Action 5teps for Advancing
Hea|th Equity through the Exchanges?
SLaLes, healLh plans, communlLy organlzaLlons, and
oLhers lnvolved ln exchange plannlng and operaLlon
musL ensure equlLy ls a cenLral prlorlLy Lo effecLlvely
educaLe, reach, and enroll all ellglble populaLlons,
lncludlng Lhose from dlverse raclal and eLhnlc
herlLage. 1he Notloool 5tooJotJs oo coltotolly ooJ
lloqolstlcolly Apptoptlote 5etvlces (clA5), lssued ln
2000 by Lhe federal Cfflce of MlnorlLy PealLh, and
enhanced ln 2013, have been used by many healLh
plans and can serve as a crlLlcal resource ln broadly
provldlng guldance on plaln language, use of
lnLerpreLers, Lralnlng and educaLlon, dlverslLy
among navlgaLors, and meLrlcs Lo conslder ln
measuremenL and evaluaLlon, among oLher acLlons
necessary for reachlng dlverse communlLles.
urawlng on and complemenLlng Lhese sLandards
are speclflc acLlons LhaL exchanges can Lake Lo
advance raclal and eLhnlc healLh equlLy:

£xchonqe P/onninq & ueve/opment:
 lnLegraLe equlLy and dlverslLy ln mlsslon,
ob[ecLlves, and plannlng.
 Lnsure lncluslon, represenLaLlon, and regular
feedback from dlverse communlLles.
 lncorporaLe feedback ln developmenL of Web
porLal, markeLlng, and ouLreach sLraLegles.

Outreoch, £ducotion, & £nro//ment:
 lnvolve LrusLed represenLaLlves who are
reflecLlve of or from wlLhln Lhe communlLy.
 Make avallable LranslaLlon and lnLerpreLer
servlces when aL leasL 3° of Lhe populaLlon ln
a geographlc area speaks Lhe same non-
Lngllsh language.
 Assure LhaL lndlvlduals provldlng ouLreach
recelve Lralnlng ln culLural compeLence.
 Assure communlcaLlon and LranslaLlons are
culLurally-approprlaLe.
 CommunlcaLe Lhrough a range of medlums-
onllne, ln-person, prlnL, and eLhnlc medla.

£xchonqe Monitorinq & £vo/uotion:
 Learn whaL oLher leadlng sLaLes and healLh
plans are dolng Lo address healLh equlLy.
 MonlLor progress ln reachlng and enrolllng
dlverse communlLles.
 Share your own lessons, challenges, and
promlslng pracLlces for advanclng equlLy.

1hese acLlons can help sLaLes, healLh plans, and
oLhers assure LhaL hlsLorlcally marglnallzed, dlverse
lndlvlduals do, ln facL, obLaln healLh care coverage.
Acknow|egements: 1he 1exas PealLh lnsLlLuLe would llke Lo
Lhank 1he Callfornla LndowmenL, W.k. kellogg loundaLlon, and
kalser ÞermanenLe CommunlLy 8eneflL naLlonal Þrogram Cfflce
for Lhelr generous granL supporL. AuLhors for Lhls pollcy brlef
are uennls Andrulls, Þhu, MÞP, nadla Slddlqul, MÞP, Lauren
!ahnke, MÞAff, and Marla Cooper, MA.
Source: lnformaLlon lncluded ln Lhls Þollcy 8rlef ls drawn from
1Pl's reporL enLlLled lmplemeotloq coltotol ooJ lloqolstlc
kepoltemeots lo neoltb losotooce íxcbooqes. 1o access Lhe full
reporL, vlslL: hLLp://www.LexashealLhlnsLlLuLe.org/healLh-care-
reform.hLml.