CMS-10338.CLAS Bulletin

DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services

200 Independence Avenue SW
Washington, DC 20201

TECHNICAL GUIDANCE- JUNE 22, 2011
DATE:

JUNE 22, 2011

SUBJECT:

Updated Instructions for Calculating County Level Estimates Pertaining to
the Culturally and Linguistically Appropriate Standards Set Forth in the
Internal Claims and Appeals and External Review Processes under the
Affordable Care Act

Background
Public Health Service (PHS) Act section 2719 relating to Internal Claims and Appeals
and External Review processes requires group health plans and health insurance issuers to
provide relevant notices in a culturally and linguistically appropriate manner. The interim final
rules (IFR) implementing section 2719 (as amended) require that group health plans and health
insurance issuers offering both group and individual health insurance coverage provide notices in
a culturally and linguistically appropriate manner (in accordance with the rules in the amended
IFR) when a certain threshold is met. The threshold percentage for the group and individual
markets is that at least 10 percent of the population in the claimant’s county speak a particular
non-English language and speak English less than “very well” as determined by American
Community Survey (ACS) data published by the United States Census Bureau. The amended
IFR provides a chart listing those 255 U.S. counties (78/255 are in Puerto Rico) in which this 10
percent threshold is met. These data are applicable for 2011 and are calculated using 2005-2009
ACS data.
The amended IFR noted that the Department of Health and Human Services (HHS)
would publish guidance as to how county level estimates should be established in order to
calculate the 10 percent threshold. Below are step-by-step instructions to make the calculations
that are included in the amended IFR. These instructions are provided for transparency purposes

and to facilitate plans and issuers making these calculations on their own, if they so choose,
consistent with the requirements of the amended IFR. Plans and issuers do not need to perform
calculations on their own and can rely on the chart in the amended IFR as a safe harbor. HHS
will update this table on an annual basis if there are changes to the list of the counties determined
to meet this 10 percent threshold. It will be posted on the CCIIO website at http://cciio.cms.gov.

Instructions for downloading American Community Survey five-year data
Step-by-step instructions
1: Downloading data
A. Go to www.census.gov (the U.S. Census website).
B. Click on “American Fact Finder,” along the left side of the website. Then click on the
“Legacy American Factfinder” link (factfinder.census.gov) on the right hand side of the website
for data from the American Community Survey.
C. On the left side of the website, click “Download Center.”
D. Under “American Community Survey,” click “2005-2009 American Community Survey 5Year Estimates
E. Select the geography “All Counties.” Under “Select a Download Method,” the option
“Selected Detailed Tables” should be pre-selected. If it is not, select it.
F. Click “Go.”
G. This will take you to the list of variables on the “Select Tables” screen. In the “Show all
tables” tab, scroll down and select B16001: Language Spoken at Home by Ability to speak
English, and click “Add”; then click “Next.”
H. This will take you to a page called “Download Center.” Click “Start Download.”
I. Save the file and unzip it. The files are pipe-delimited .txt files. The pipe is this character: |
Convert the file to a usable form with your chosen program (Excel, etc.). There are 3 files: one

called Readme, one called dc_acs_2009_5yr_g00__data1 and one called
dc_acs_2009_5yr_g00__geo. The Readme lists the variables in the set. The one called
dc_acs_2009_5yr_g00__data1 is the one that contains the data you will use. The last one
contains a list of the geographies in the set.
1. Note for Excel users: After opening the file in Excel, highlight column “A”, convert
text to columns under the “Data” header, click on “Delimited” and then click on
“Other” and enter the |.
J. Below are the names of the columns you will need (Note: Every language variable has a
Margin of Error (MOE) estimate after it. The MOE is not relevant for the purposes of this
calculation, and therefore does not need to be taken into consideration.)
•

B16001_1: Total Population 5 Years and Over (Total Estimate)

•

B16001_5: Total Population 5 Years and Over That Speaks Spanish or Spanish
Creole and speaks English less than “very well” (Estimate)

•

B16001_8: Total Population 5 Years and Over That Speaks French (Incl. Patois,
Cajun) and speaks English less than “very well” (Estimate)

•

B16001_11: Total Population 5 Years and Over That Speaks French Creole and
speaks English less than “very well” (Estimate)

•

B16001_14: Total Population 5 Years and Over That Speaks Italian and speaks
English less than “very well” (Estimate)

•

B16001_17: Total Population 5 Years and Over That Speaks Portuguese or
Portuguese Creole and speaks English less than “very well” (Estimate)

•

B16001_20: Total Population 5 Years and Over That Speaks German and speaks
English less than “very well” (Estimate)

•

B16001_23: Total Population 5 Years and Over That Speaks Yiddish and speaks
English less than “very well” (Estimate)

•

B16001_26: Total Population 5 Years and Over That Speaks West Germanic
Languages and speaks English less than “very well” (Estimate)

•

B16001_29: Total Population 5 Years and Over That Speaks Scandinavian languages
and speaks English less than “very well” (Estimate)

•

B16001_32: Total Population 5 Years and Over That Speaks Greek and speaks
English less than “very well” (Estimate)

•

B16001_35: Total Population 5 Years and Over That Speaks Russian and speaks
English less than “very well” (Estimate)

•

B16001_38: Total Population 5 Years and Over That Speaks Polish and speaks
English less than “very well” (Estimate)

•

B16001_41: Total Population 5 Years and Over That Speaks Servo-Croatian and
speaks English less than “very well” (Estimate)

•

B16001_44: Total Population 5 Years and Over That Speaks Other Slavic Languages
and speaks English less than “very well” (Estimate)

•

B16001_47: Total Population 5 Years and Over That Speaks Armenian and speaks
English less than “very well” (Estimate)

•

B16001_50: Total Population 5 Years and Over That Speaks Persian and speaks
English less than “very well” (Estimate)

•

B16001_53: Total Population 5 Years and Over That Speaks Gujarati and speaks
English less than “very well” (Estimate)

•

B16001_56: Total Population 5 Years and Over That Speaks Hindi and speaks
English less than “very well” (Estimate)

•

B16001_59: Total Population 5 Years and Over That Speaks Urdu and speaks
English less than “very well” (Estimate)

•

B16001_62: Total Population 5 Years and Over That Speaks Other Indic Languages
and speaks English less than “very well” (Estimate)

•

B16001_65: Total Population 5 Years and Over That Speaks Other Indo-European
languages and speaks English less than “very well” (Estimate)

•

B16001_68: Total Population 5 Years and Over That Speaks Chinese and speaks
English less than “very well” (Estimate)

•

B16001_71: Total Population 5 Years and Over That Speaks Japanese and speaks
English less than “very well” (Estimate)

•

B16001_74: Total Population 5 Years and Over That Speaks Korean and speaks
English less than “very well” (Estimate)

•

B16001_77: Total Population 5 Years and Over That Speaks Mon-Khmer,
Cambodian and speaks English less than “very well” (Estimate)

•

B16001_80: Total Population 5 Years and Over That Speaks Hmong and speaks
English less than “very well” (Estimate)

•

B16001_83: Total Population 5 Years and Over That Speaks Thai and speaks
English less than “very well” (Estimate)

•

B16001_86: Total Population 5 Years and Over That Speaks Laotian and speaks
English less than “very well” (Estimate)

•

B16001_89: Total Population 5 Years and Over That Speaks Vietnamese but speaks
English less than “very well” (Estimate)

•

B16001_92: Total Population 5 Years and Over That Speaks Other Asian Languages
and speaks English less than “very well” (Estimate)

•

B16001_95: Total Population 5 Years and Over That Speaks Tagalog and speaks
English less than “very well” (Estimate)

•

B16001_98: Total Population 5 Years and Over That Speaks Other Pacific Island
Languages and speaks English less than “very well” (Estimate)

•

B16001_101: Total Population 5 Years and Over That Speaks Navajo and speaks
English less than “very well” (Estimate)

•

B16001_104: Total Population 5 Years and Over That Speaks Other Native North
American Languages and speaks English less than “very well” (Estimate)

•

B16001_107: Total Population 5 Years and Over That Speaks Hungarian and speaks
English less than “very well” (Estimate)

•

B16001_110: Total Population 5 Years and Over That Speaks Arabic and speaks
English less than “very well” (Estimate)

•

B16001_113: Total Population 5 Years and Over That Speaks Hebrew and speaks
English less than “very well” (Estimate)

•

B16001_116: Total Population 5 Years and Over That Speaks African languages and
speaks English less than “very well” (Estimate)

2: Calculating whether the 10 percent threshold is met for a particular non-English
language
To determine whether the threshold is met for a particular non-English language in a
particular county in which the issuer is operating, the “Total Population 5 Years and Over” is the
denominator (B16001_1) and the numerator is the “Total Population 5 Years and Over” that
speaks a particular non-English language and speaks English less than “very well.” For every
language for which this percentage is 10 percent or greater, the issuer must meet the
requirements established in the IFR and articulated in this guidance.

For example: in Los Angeles County, California, the estimated total population is 9,056,154
(ACS 2005-2009 data). The estimated Spanish speaking population that speaks English less than
“very well” is 1,755,933. This represents 19.4 percent of the population. Therefore, a group
health plan and health insurance issuer must meet the requirements for culturally and
linguistically appropriate notices for all claimants residing in Los Angeles County.