JULY 2023 Issue Brief by Beccah Rothschild, MPA, principal, Health Engagement Strategies Plain and Clear: Making the Medi-Cal Rights and Responsibilities Document Easier to Understand for Enrollees M Process edi-Cal, California's Medicaid program, pro- vides health coverage to Californians with From summer 2020 through winter 2022, Health low incomes, including families with children, Engagement Strategies (HES) led the following adults, seniors, people with disabilities, pregnant process: people, and many more. But, due to low adult literacy rates in California and complex program rules, many $ Key informant interviews and baseline user test- adults that Medi-Cal serves may not be able to read ing. HES conducted key informant interviews to or understand the forms and documents they receive understand how the document is used, known from the program. This includes the What You Need barriers to understanding it, and suggestions for to Know When You Apply for and Enroll in Medi-Cal improvement. Informants included advocates, (PDF) document that the California Department of attorneys, experts in cultural and linguistic compe- Health Care Services (DHCS) and county offices pro- tency, clinic-based Medi-Cal enrollment assisters, vide to all Medi-Cal applicants and over six million and subject matter experts from DHCS. HES also households yearly.1 (DHCS is the state agency that conducted baseline user testing with demographi- oversees and administers Medi-Cal.) This document cally diverse Medi-Cal enrollees (see Appendix is important, as it is the primary written notice that A) in English to solicit their insights on the docu- explains Medi-Cal rights and responsibilities to appli- ment. Based on those findings and best practices cants and enrollees. in health literacy and plain language, HES rewrote the document. To improve the readability and understandability of What You Need to Know (also known as MC 219), a $ More review and revisions. DHCS staff circulated project assessed, reviewed, and revised it based on the initial revision of What You Need to Know to best health literacy practices and on findings from user staff in a dozen units to solicit their input.3 DHCS testing in English, Spanish, Vietnamese, and Mandarin. also circulated it to the County Welfare Directors This report, intended for Medi-Cal staff and adminis- Association of California, Covered California, and the trators, advocates, and stakeholders across California, California Department of Social Services. HES used focuses on that process, the resulting outcomes, and the submitted input to significantly revise the docu- recommendations to consider when modifying or cre- ment. DHCS staff then circulated it once again to all ating future communications for Medi-Cal enrollees. stakeholder groups mentioned in Step 1 (above) for It also builds on the lessons and recommendations of feedback; HES then made more revisions. Plain and Clear: Making Medi-Cal Communications $ More user testing and revisions in English. HES Easy to Understand, a report documenting an earlier tested the revised document with English-speaking phase of this project in which four Medi-Cal enrollee– Medi-Cal enrollees to determine what was clear facing communications were assessed and revised.2 and understandable and what needed further revi- Key Findings and sion. (See Appendix B for demographic details.) HES then revised and finalized the document. Recommendations Like the earlier Plain and Clear report, Medi-Cal $ User testing and revisions in more languages. A enrollees pointed to five main readability and usability vetted, independent, third-party translation orga- themes that prevented them from easily and accu- nization translated the document into Spanish, rately understanding What You Need to Know. While Vietnamese, and simplified Chinese. Community- some themes overlap from the previous report, they based organizations then conducted one-on-one bear repeating here with new examples that surfaced user interviews with Medi-Cal enrollees in each in this project - many of which could affect future of the additional languages. (See Appendix C for communication materials. demographic details.) As a final step, HES collabo- rated with DHCS and the translation organization to These themes, presented below as key findings, make final edits in each language. are important because until they are improved, Californians may delay applying for, obtaining, keep- ing, and effectively using their Medi-Cal benefits. In fact, when reviewing the original What You Need to Know document, one Medi-Cal enrollee (a man in his mid-50s, with a disability, living in southern California) said: "It's good to know what your rights are. . . . But, when you see all this, you're going to get turned off. . . . You're given reasons to think you might be denied and that just turns people off to even apply. It's negativity and red flags. Instead, you want to cap- ture their undivided attention. You want to give them encouraging words to apply. You want to invite them in. And it needs to be more clearly written." Plain and Clear: Making the Medi-Cal Rights and Responsibilities Document Easier to Understand 2 1 There was an abundance of acronyms, needed and allotted benefits, and knew how to seek jargon, and words that were help. However, when faced with words, phrases, and intimidating or confusing to Medi-Cal acronyms they did not understand or were intimidated enrollees. by, they stated that they skipped over that informa- When understanding their rights and responsibilities tion, guessed at what it meant, or gave up altogether. as Medi-Cal enrollees, participants stressed the impor- tance of understanding everything to ensure they RECOMMENDATION 1A. Use phrasing that does not did not lose their coverage, could take advantage of intimidate Medi-Cal applicants and enrollees. Table 1. Examples of Intimidating Phrasing, Related Quotes from Medi-Cal Enrollees, and Suggested New Words/Phrases ORIGINAL PHRASE FROM MEDI-CAL'S SELECTED QUOTE WHAT YOU NEED TO KNOW FROM MEDI-CAL ENROLLEE SUGGESTED PHRASE "After your death, the State must seek "O h, wow. OK. I have not heard this "After someone dies (in limited situa- reimbursement from your estate." before. This is totally new. It's kind of tions), the Medi-Cal program must shocking. It caught me off guard. If I try to get paid back from certain die, I'm dead. . . . Maybe make it clear Medi-Cal beneficiaries' estates." right away that it's only in very specific circumstances, so we don't panic as much." -Black woman (mid-40s), Medi-Cal enrollee, Central California, completed some college, has a disability "Information shared with DHS * cannot "How is fraud defined? What does that "Your personal information cannot be be used for immigration enforcement even mean? That's what I'd ask. It's a used for immigration enforcement unless you are committing fraud." red flag, and you don't want to call up unless you are being investigated for and say, `What constitutes fraud?' They fraud related to Medi-Cal or other should have more details. Like, `Do I public benefits." have to be convicted of something?' Or `What if I'm just accused of fraud but it never went anywhere?'" -Latina/x woman (early 30s), Medi-Cal enrollee, Southern California, completed some college Source: Author analysis of interviews with Medi-Cal enrollees between 2020 and 2022 about MC 219. * DHS is Department of Homeland Security. Plain and Clear: Making the Medi-Cal Rights and Responsibilities Document Easier to Understand 3 RECOMMENDATION 1B. Continually test Medi-Cal and health care–related wording and phrasing to ensure it resonates with commonly used wording and phrasing that applicants and enrollees use. Table 2. Examples of Confusing Words, Phrases, and Acronyms; Related Quotes from Medi-Cal Enrollees; and Suggested New Words/Phrases SELECTED QUOTE ORIGINAL WORD, PHRASE, OR ACRONYM FROM MEDI-CAL ENROLLEE SUGGESTED WORD/PHRASE "Local county office" "I've never heard of 'local county office.' "Local office" or "welfare office" Just say 'welfare office' or 'local office.'" -White woman (mid-40s), Medi-Cal enrollee, Central California, completed vocational college "County worker" "We say, 'call your worker.' That's it. We "Worker" or "caseworker" don't say 'county worker.'" -Black woman (early 60s), Medi-Cal enrollee, Central California, completed 10th grade, has a disability "Regular Medi-Cal and FFS "'Straight Medi-Cal' is what people say. "Straight Medi-Cal (also known as (fee-for-service) Medi-Cal" I've never heard of 'Regular Medi-Cal' Fee-for-Service Medi-Cal)" or 'free-for-service.'"* -Black woman (early 60s), Medi-Cal enrollee, Central California, completed 10th grade, has a disability "End-Stage Renal Disease (ESRD)" "'Kidney failure' is a common term. But "Kidney failure" or "kidney disease" 'renal disease'? Most people don't know that medical term." -White woman (mid-40s), Medi-Cal enrollee, Central California, completed vocational college "DHCS" "What is 'DHCS'? I've never heard of that." "The California Department of Health -Black woman (mid-70s), Care Services (DHCS) is the California Medi-Cal enrollee, Central California, state agency that oversees and completed high school, has a disability administers Medi-Cal." "If you . . . obtained money from a "That's confusing. I kept seeing "You must tell us if Medi-Cal paid for legal settlement for injuries, includ- 'Medi-Cal' and 'medical,' and they health care you received from an ing medical expenses that Medi-Cal looked the same to me. It made me accident or injury that someone else paid for, Medi-Cal is entitled to be pause and think about that those were caused." reimbursed from the medical expense two different words. I lost my train of portion of the settlement." thought. Couldn't you use a different word so that it doesn't look so similar?" -Biracial woman (late 70s), Medi-Cal enrollee, Southern California, has associate's degree, has a disability Source: Author analysis of interviews with Medi-Cal enrollees between 2020 and 2022 about MC 219. *It was common for Medi-Cal enrollees to misread "Fee-for-Service Medi-Cal" as "Free-for-Service Medi-Cal." Plain and Clear: Making the Medi-Cal Rights and Responsibilities Document Easier to Understand 4 2 There was no useful "road map" to RECOMMENDATION 2E. Downplay the prominence of help enrollees know where or how fax numbers when providing contact information.4 to get help, find forms, and submit important documentation. "Nobody uses faxes anymore, do they? Where Medi-Cal enrollees were eager to complete and sub- mit their required paperwork on time. However, they do you find a fax machine? I wouldn't know were often frustrated by unusable, antiquated, incon- where to find one, and it makes it seem like sistent, and confusing communication channels. the people in charge of Medi-Cal are really not RECOMMENDATION 2A. Ensure that all websites with the times." referenced in Medi-Cal enrollee communications -Latina/x woman (mid-60s), Medi-Cal enrollee, Southern California, are specifically for applicants and enrollees rather completed college, has a disability than for providers. RECOMMENDATION 2B. Provide contact information RECOMMENDATION 2F. Create vanity URLs that are in a consistent and recognizable pattern. short and easy to remember and type. "It's good how you put all the phone numbers "Those websites are just too long to type. How listed together in one place in this new version. would we even remember them?" -Black woman (mid-40s), Otherwise, we didn't know what we were Medi-Cal enrollee, Central California, completed some college, has a disability looking for. This is good now because it tells you what it's for, who to call, and where to RECOMMENDATION 2G. Specify when contact write to." information is available for specific languages.5 -Black woman (mid-40s), Medi-Cal enrollee, Central California, completed some college, has a disability "When it says you can make a complaint by calling . . . could there be any kind of reference RECOMMENDATION 2C. Ensure that mailing for Spanish-speakers or an extension? Make addresses are complete and current. some sort of reference there to language." RECOMMENDATION 2D. Ensure that TTY numbers -Latina/x woman (mid-60s), Medi-Cal enrollee, Southern California, are consistently and accurately provided. completed college, has a disability Plain and Clear: Making the Medi-Cal Rights and Responsibilities Document Easier to Understand 5 3 Trust is key and bidirectional. paperwork that DHCS and the Medi-Cal program Medi-Cal enrollees were grateful and appre- should make the same commitment to them. ciative to receive health care for free or at a very low cost. They understood implicitly that if they RECOMMENDATION 3A. Phrase information in knowingly provided false information, there would transparent ways so that Medi-Cal applicants and be ramifications. However, they also felt that if they enrollees do not feel that DHCS and the Medi-Cal committed to providing honest information in their program are "out to get them." Table 3. Examples of Nontransparent Phrases, Related Quotes from Medi-Cal Enrollees, and Suggested New Phrases SELECTED QUOTE ORIGINAL PHRASE FROM MEDI-CAL ENROLLEE SUGGESTED PHRASE "You have the right to reduce your "This is interesting, but are they trying to "For information on how much property to meet the Medi-Cal get me to scam Medi-Cal? I'd like more property you can have and still be property limit. . . . The county social information, but I'd be embarrassed to eligible for Medi-Cal, ask your case services worker can tell you more." call and ask. Maybe say to ask about worker." exactly what we can have instead of how to illegally get rid of what little we do have." -Latina/x woman (early 30s), Medi-Cal enrollee, Southern California, completed some college "The personal information gathered "This means they're sharing my informa- "W hen you apply for and renew your about you may be used in the follow- tion with someone else? I thought they Medi-Cal, we need to collect personal ing ways [list of seven major ways it is were keeping my information within information about you and the shared, plus a list and companies and Medi-Cal. But it turns out they told a people living in your household. This organizations it's shared with, including lie. And they're sharing it with a lot of is to determine if you are eligible for DHS to verify immigration status]. . . . organizations. So that's plural. That's Medi-Cal and other public benefits. You have a right to have all the infor- more than one. . . . Could they say It's also to confirm the information mation you give to the county social these partners and companies are at you gave us on your application. services office or to Covered California least vetted?" To do this, we use computers to kept confidential." -Black woman (mid-50s), share specific information with our Medi-Cal enrollee, Northern California, vetted partners, which may include completed 10th grade, has a disability other government departments and agencies, other organizations, and other companies. They are all required to keep your information confidential." Source: Author analysis of interviews with Medi-Cal enrollees between 2020 and 2022 about MC 219. Plain and Clear: Making the Medi-Cal Rights and Responsibilities Document Easier to Understand 6 4 Information is vague, lacks important benefits are available to them, and understand how details, and at times, seems outdated. specific laws may or may not apply to them. Medi-Cal enrollees are often confused, stressed, and frustrated by the vagueness of communi- RECOMMENDATION 4A. Provide specific information cations they receive. They want to know how to follow so enrollees feel reassured and know what to through with required action items, know exactly what realistically expect. Table 4. Examples of Nonspecific Phrases, Related Quotes from Medi-Cal Enrollees, and Suggested New Phrases SELECTED QUOTE ORIGINAL PHRASE FROM MEDI-CAL ENROLLEE SUGGESTED WORD/PHRASE "If you received health services in the "You gotta list a time frame for doing "Medi-Cal may pay you back for bills three months before the month of your this. The first thing we're gonna ask is, you already paid. You must submit application, you have a right to be 'What's the time frame?' People will be your claim for a refund: evaluated to see if you are eligible for looking for that." $ Up to one year after you received Medi-Cal to pay for those services. . . . -Black woman (early 60s), your health care services, or Contact your county social services Medi-Cal enrollee, Central California, office to find out more or ask for retro- completed 10th grade, has a disability $ Up to 90 days after you get your active eligibility." Medi-Cal card. Depending on your type of bill, use the contact information below to get more details." "You have a right to information about "I can get all these services that you "You have the right to learn about these programs and help getting these listed in the new paper that you wrote? and get help applying for these services: This is good to describe them like you programs: $ Special Supplemental Food Program did. . . . It's important because when $ WIC, which provides help buying for Women, Infants, and Children I was reading them, I couldn't get the healthy groceries, breastfeeding, name of them all and asked myself, and more for pregnant people, $ Personal Care Services Program 'What's that? What's that mean?' And new parents, and caretakers raising $ Family Planning Access Care and then I started reading it more, and I children under age 5.* Treatment Program" said, 'Okay, so that's what it is. That's what this program will do for me.' By $ Personal Care Services Program, to adding those details, you answered my help you stay at home safely instead question right there before I even could of going to a nursing home or long- finish asking it. I like that it's added in term care facility. there what the program is - keep that $ Family planning services, to help right there!" with birth control and more." -Black woman (early 60s), Medi-Cal enrollee, Central California, completed 10th grade, has a disability Source: Author analysis of interviews with Medi-Cal enrollees between 2020 and 2022 about MC 219. * Key finding 1 stated that acronyms can be confusing and overwhelming. However, when an acronym is commonly known by the target audience, such as WIC in this instance, it is recommended to use the acronym instead of spelling it out. Additional examples of this are COVID, HMO, and HIV/AIDS. Plain and Clear: Making the Medi-Cal Rights and Responsibilities Document Easier to Understand 7 RECOMMENDATION 4B. Ensure information is inclusive and aligned with the current era. Table 5. Example of Noninclusive Phrasing, Related Quote from Medi-Cal Enrollee, and Suggested New Phrasing SELECTED QUOTE ORIGINAL PHRASE FROM MEDI-CAL ENROLLEE SUGGESTED PHRASE "You must cooperate with the State "If you're married, you don't have to "You must cooperate with the state or county to establish paternity and worry about this.* But what if you had or county to get any health cover- identify any possible medical coverage a baby out of a one-night stand? Or age that you or your family may be that you or your family may be entitled me. I'm gay. It's messed up to say it's entitled to." to." excluding same-sex partners." -White woman (mid-40s), Medi-Cal enrollee, Central California, completed vocational college Source: Author analysis of interviews with Medi-Cal enrollees between 2020 and 2022 about MC 219. *Even though the original phrasing did not mention marriage, all Medi-Cal enrollees who were interviewed about this section interpreted it to refer to marriage. 5 Linguistic translations are complex. RECOMMENDATION 5B. Acknowledge and take They need to be user tested and concrete steps to remedy the fact that applicants should be conceptually and culturally and enrollees who do not read English may be appropriate, not simply word-for-word unaware of important Medi-Cal information translations. (because they may not have previously received The results of Spanish, Vietnamese, and Mandarin user materials in their preferred language, materials interviews provided examples of words and phrases historically may not have been translated to revise for improved comprehension. The interviews accurately, and past translations may not have also highlighted the complexity of the translation pro- been adapted for cultural nuances). This includes providing more background information in cess, the importance of consistently conducting user translated documents so enrollees who do not interviews in threshold languages, and the need to read English will have important contextual details make sure opportunities exist to implement cultural they previously may not have had access to. and linguistic recommendations into the final docu- ments. To do this, prioritize and plan for translations early in any communications revisions and conduct "There were some programs listed [in your user testing of translated language. revised document] that enrollees didn't know they could get from Medi-Cal, so that was RECOMMENDATION 5A. DHCS should conduct in-language user testing in all 19 threshold amazing for them to learn about." languages on all Medi-Cal forms, notices, and -Vietnamese-language interviewer documents.6 "This [revised document] is knowledge, and the enrollees would like to know more. They are so excited. And because they'll get full-scope Medi-Cal soon because of the new law, this helped them to learn even more." -Mandarin-language interviewer Plain and Clear: Making the Medi-Cal Rights and Responsibilities Document Easier to Understand 8 RECOMMENDATION 5C. Have a plan to make in the project to ensure it is not duplicative to other in-language edits globally across Medi-Cal efforts being undertaken, (2) create a project timeline communications rather than just the one being feasible for everyone involved, and (3) create open tested. communication channels for soliciting and incorporat- Example: Enrollees understood the individual words ing feedback. used in Spanish and simplified Chinese for "Medi-Cal 2 managed care" and "share of cost," but they were not Consider the timing of when new laws phrases the enrollees would use in daily life. These will go into effect and when existing phrases are used on many other documents and web- legislation will change. sites, so to change them only on the What You Need It takes significant time to do a thorough review and to Know document introduced the potential of using revision of an eight-page document such as What different phrases in different documents - possibly You Need to Know. The process for the English- leading to more confusion.7 language version took 16 months; an additional two months were needed for the additional languages. This does not include time to format the final docu- Policy and Process Implications ment for Americans with Disabilities Act purposes, and Recommendations translate it into threshold languages, upload it into The first goal of this project was to improve the read- the Statewide Automated Welfare System, prepare it ability and usability of the What You Need to Know for large-scale printing, publish it to the DHCS web- document. However, due to legal and departmen- site, and more. Therefore, when starting a revision tal policy decisions, limitations, and/or regulations, process such as this, look ahead and conduct the DHCS did not accept and incorporate some recom- writing process based on any relevant laws that will mendations. With that in mind, the second goal of this go into effect or change before publishing and dis- project - to recommend long-term and sustainable tributing the document.8 change to Medi-Cal documents and the way they 3 are created and reviewed - becomes even more Commit to thinking of Medi-Cal important. communications as living documents that can be changed regularly. The 10 policy and process recommendations listed Before this project, the What You Need to Know below are in addition to the 10 previously provided document had not been changed for seven years. in Plain and Clear. DHCS has already begun to adopt Determine a regular schedule for how to make needed some of these. changes more often and how to test or retest certain sections as needed - especially as new laws go into 1 Determine which units, agencies, effect and existing legislation changes (per item 2, and organizations use, have an above). For example, during the final review process influence on, or will be affected by the for What You Need to Know, DHCS requested to communication - and involve them from add a section about Medi-Cal Matching Plans. Since the start. this happened after all user testing in English had Some Medi-Cal communications have messaging that needs insight and input from multiple units, agen- been completed, there was no opportunity to test it. cies, and organizations. To ensure this is done in a However, if documents are regularly reviewed, there consistent and strategic way, create a project map to could be a scheduled opportunity to seek user insight (1) identify and involve subject-matter experts early and make any suggested changes. Plain and Clear: Making the Medi-Cal Rights and Responsibilities Document Easier to Understand 9 4 Provide specific deadlines, contact not relate it to Medi-Cal or know the meaning of the information, and details on relevant acronym. Consider creating a more modern logo in rules. which "DHCS" is spelled out and the phrase "Medi- A straightforward way to help Medi-Cal applicants and Cal" is included. Also, consider creating a short yet enrollees apply for, maintain, and properly use their understandable tagline, translatable into all thresh- benefits is to provide specific details. Shying away old languages, that makes it clear that DHCS is the from specificity stoked fear, confusion, and stress. government agency in California that administers Provide specific details on deadlines and time allot- Medi-Cal. ted to submit paperwork or to request help. Provide 7 contact information in multiple channels (e.g., a phone Test new names of programs before number with minimal wait time for English and other changing and publicizing them. Medi-Cal threshold languages, staffed by a live per- During this project, DHCS began changing son; an email address; and a link to a website that the name of one Medi-Cal eligibility pathway from contains easy-to-understand information in all thresh- the Child Health and Disability Prevention Program to old languages) so applicants and enrollees can seek Children's Presumptive Eligibility.10 Though enrollees help and submit information before deadlines. were happy to learn about the associated benefits dur- ing user interviews, none of them could pronounce, 5 Set realistic expectations, encourage recognize, or understand the word "presumptive." trust, and provide consistent Enrollees were in consensus that if they could not pro- messaging. nounce the name of a program, they would not be As mentioned, enrollees were grateful to receive free comfortable asking about it, understanding if they had or low-cost health coverage. But they often felt anx- access to it, or even talking to friends and family about ious and upset when reading the What You Need to it. They viewed it as a barrier to access and care. In Know document. For example, when enrollees read the future, name changes such as this should undergo they had the "right to have their application pro- user testing in all threshold languages before being cessed faster" if they had a health care emergency, adopted. they felt they were being set up to face unrealistic 8 expectations, given such noncommittal wording. In Stay current. Review and update addition, they lost trust when reading information materials with an eye to the modern that was perceived as encouragement to "scam the era. system." Ensure communications set realistic expec- Enrollees pointed out several ways the What You tations and do not have instructions that could be Need to Know document seemed outdated. And, if interpreted as encouraging applicants or enrollees to such communications were outdated, it led to con- lie or commit fraud - even if those instructions are cern that the quality of health care being provided intended to help enrollees maximize their benefits. may also be outdated. Examples of this are the inclu- Also, to establish and maintain trust, review all docu- sion of fax numbers, the requirement to establish ments carefully to ensure they have consistent - and paternity for a child, and the lack of texting options.11 not contradictory - messaging. Conversely, enrollees were thrilled to learn about and be provided with contact information for the Medi- 6 Refresh the DHCS logo and brand to Cal Office of Civil Rights and the Covered California increase name recognition and trust.9 Civil Rights Coordinator: This felt very current and Enrollees recognized the DHCS logo from modern - and reassuring. having seen it on other documents, but they did Plain and Clear: Making the Medi-Cal Rights and Responsibilities Document Easier to Understand 10 9 10 Translate all communications, test Create and maintain a publicly them, and implement recommended available glossary, for each changes.12 threshold language with The baseline for providing Medi-Cal access to those recommended Medi-Cal and health care– who do not speak or read English as a first language is to related words and phrases. translate materials using third-party, certified translators Base the glossary on insights from applicants and and editors, and conduct user testing in each language. enrollees. Incorporate words and phrases common It is critical to conduct user testing in each language to Medi-Cal and health care. Make sure the glossary to ensure concepts and context are understandable, is a "living document" that can be easily updated as actionable, and culturally appropriate. Allot time and words, phrases, and cultures adapt and evolve. Make budget to implement recommended changes. the glossary publicly available so that DHCS staff, con- tractors, consultants, and others have easy access to it. This will help with consistency and comprehension across all documents. Plain and Clear: Making the Medi-Cal Rights and Responsibilities Document Easier to Understand 11 Best Practices When Based on valuable lessons from the first phase of this project, guided by best practices in health literacy and Implementing Projects plain language, and with valuable inputs during all to Improve the Usability phases of this project, the What You Need to Know document was significantly rewritten and redesigned. of Medi-Cal Enrollee As a result, during the final user interviews, one Communications enrollee (a Black woman in her mid-40s, with a disabil- Like the first phase of this project, the review and revi- ity, living in central California) said, "It's good to read sions of What You Need to Know succeeded because this. Some things stuck out at me because I hadn't specific project management best practices, unique known them before, and other things just caught my to this type of project, were set in place early on with interest." Another enrollee (a Black woman in her early a mindset of creating long-term change. It was also 60s, with a disability, living in central California) said, successful due to the commitment and dedication of "This looks like something that won't mess with my DHCS staff. brain. It's not overwhelming." And one final enrollee (a man in his mid-50s, with a disability, living in southern These best practices are described on page 11 of Plain California) told us that "from a blind point of view, it's and Clear. Each holds true for the What You Need to easy to read. It's straightforward . . . and I could easily Know project and will aid DHCS, other departments, be clear on what was being said. That was helpful." and other states working on similar projects to improve the usability of Medi-Cal or Medicaid communications. DHCS is on a path toward improving the readability and usability of its documents. During this project, it launched several initiatives aimed at improving com- Conclusion munications to Medi-Cal enrollees. It has also begun Medi-Cal enrollees were overwhelmed by the origi- to embrace user testing, including when renaming nal What You Need to Know document. They felt it the EPSDT (Early and Periodic Screening, Diagnostic, may have important information, but as one enrollee and Treatment) program to "Medi-Cal for Kids and (a Latina/x woman in her mid-60s, with a disability, Teens," when creating a corresponding brochure and living in Southern California) said in a baseline user "Know Your Rights" document for it, and when refin- interview, "That is a lot to read! These government ing enrollee messages about the upcoming return programs give you a book to read. No one's going to regular eligibility redetermination processes with to read that. . . . People don't read that well anyways, the end of the federal Medicaid continuous cover- so they need to just simplify it." When asked how the age requirement.13 DHCS has also begun providing original document could be improved, one enrollee more public-facing web pages and eliminating jargon (a Black woman in her mid-70s, with a disability, liv- such as "share of cost" and "Benefits Identification ing in Southern California) said, "The whole thing Card/BIC" from some enrollee-facing communica- felt a little overwhelming. I would not use acronyms. tions. Initiatives such as these, coupled with following I'd spell everything out. And I would make shorter the action steps and policy recommendations in this paragraphs." report, will help many more Californians enroll in and retain Medi-Cal and access the health care they need. Plain and Clear: Making the Medi-Cal Rights and Responsibilities Document Easier to Understand 12 Appendix A. Demographics of English-Speaking Medi-Cal Enrollees Who Participated in Baseline Interviews GENDER EDUCATIONAL YEARS WITH AGE IDENTITY ATTAINMENT COUNTY RACIAL IDENTITY DISABILITY? MEDI-CAL 1 60 Female 10th grade Sacramento Black Yes Unsure (physical) 2 35 Female Some college Alameda Indigenous No 2 years 3 27 Female Community college Riverside Latina/x No 6 years 4 45 Female Vocational college Sacramento White Yes 27 years (physical) 5 30 Female Some college San Bernardino Latina/x No Unsure 6 62 Female Some college Los Angeles White Yes New (caretaker for disabled husband) 7 49 Female Some college Alameda White Yes 49 years (blind) 8 72 Female Some college Los Angeles Black Yes 19 years (mental and physical) 9 64 Female Bachelor's degree Los Angeles Latina/x Yes 44 years (physical) 10 77 Female Associate's degree Los Angeles Biracial Yes 15 years (Black/White) (mental) 11 56 Male Master's degree Los Angeles Declined to Yes 32 years state (blind) 12 44 Female Some college Sacramento Black Yes 26 years (declined to provide details) 13 71 Male Bachelor's degree Los Angeles White Yes "Since blind people became eligible" Plain and Clear: Making the Medi-Cal Rights and Responsibilities Document Easier to Understand 13 Appendix B. Demographics of English-Speaking Medi-Cal Enrollees Who Participated in Final User Interviews GENDER EDUCATIONAL YEARS W/ AGE IDENTITY ATTAINMENT COUNTY RACIAL IDENTITY DISABILITY? MEDI-CAL 1 56 Male Master's degree Los Angeles (Declined to Yes 33 years state) (blind) 2 61 Female 10th grade Sacramento Black Yes Unsure (physical) 3 46 Female Vocational college Sacramento White Yes 28 years (physical) 4 45 Female Some college Sacramento Black Yes 27 years (declined to provide details) 5 30 Female Some college San Bernardino Latina/x No Unsure 6 74 Female High school Merced Black Yes 3 years (mental) 7 60 Female 9th grade Alameda Black/Mixed Yes 15 years (physical and mental) 8 54 Female 10th grade Alameda Black Yes 15 years (physical and mental) Plain and Clear: Making the Medi-Cal Rights and Responsibilities Document Easier to Understand 14 Appendix C. Demographics of Spanish-, Mandarin-, and Vietnamese-Speaking Medi- Cal Enrollees Who Participated in User Interviews GENDER EDUCATIONAL RACIAL YEARS W/ PRIMARY AGE IDENTITY ATTAINMENT COUNTY IDENTITY DISABILITY? MEDI-CAL LANGUAGE 9 67 Female - Los Angeles Latina/x / - - Spanish Mixed 10 63 Male - Los Angeles Latino/x - - Spanish 11 38 Female - Los Angeles Latina/x - - Spanish 12 38 Female - Los Angeles Latina/x - - Spanish 13 46 Female 9th grade Sacramento Chinese No 6 years Mandarin 14 43 Female High school Sacramento Chinese Unsure 9 years Mandarin 15 48 Male University Sacramento Chinese No 7 years Mandarin 16 36 Female High school Sacramento Chinese No 7 years Mandarin 17 54 Female 6th grade Sacramento Vietnamese No 18 years Vietnamese 18 49 Female 11th grade Sacramento Vietnamese No 10 years Vietnamese 19 40 Female High school Sacramento Vietnamese No 2 years Vietnamese 20 41 Female 4th grade Sacramento Vietnamese No 5 years Vietnamese Note: "-" indicates that data were not collected for this demographic question. Plain and Clear: Making the Medi-Cal Rights and Responsibilities Document Easier to Understand 15 Endnotes 1. What You Need to Know When You Apply for and Enroll 8. During the review and revision process for this project, there in Medi-Cal (PDF), California Dept. of Health Care Services were many instances in which the DHCS team did indeed think (DHCS), November 2015. ahead to future legislation and made suggestions based on this document's anticipated publication and circulation date. 2. Beccah Rothschild, Plain and Clear: Making Medi-Cal Communications Easy to Understand, California Health Care 9. Research for this project was completed before DHCS Foundation, January 21, 2022. announced its new brand and logo campaign in February 2023. 3. DHCS Medi-Cal units providing review included applications, civil rights, eligibility and enrollment, former foster care, 10. Children's Presumptive Eligibility, formerly the Child Health and immigration, legal services, managed care, policy operations, Disability Prevention Program, is a process that allows likely privacy, program development, social service hearings, and eligible children to be enrolled in immediate temporary Medi- third-party liability and recovery. Cal coverage by qualified health care providers. It is designed to help ensure children can access needed care immediately and 4. Although the Medi-Cal enrollees who were interviewed for also acts as an on-ramp to ongoing Medi-Cal. this project felt strongly about removing fax numbers from documents, including them is a federal requirement. 11. As previously stated, although the Medi-Cal enrollees who were interviewed for this project felt strongly about removing 5. This was a concern brought up by native English speakers who fax numbers from documents, including them is a federal may not have known about the existence of language-assistance requirement. taglines for those who do not speak English as a first language. 12. Per the amended California 2021 budget, funds have been 6. Per the amended California 2021 budget, funds have been appropriated for "translation of forms into all Medi-Cal threshold appropriated "to support field testing of translated Medi- languages." (See Sec. 173., Provision 4.) Per DHCS's All-Plan Cal materials to ensure they are understood by the intended Letter 21-004 dated May 3, 2022 (PDF), Medi-Cal managed audience." (See Sec. 146, Provision 26; and Sec 147, Provision 7.) care health plans must translate member-facing materials into 7. The decision was ultimately made not to change these phrases threshold languages. in the What You Need to Know document but to conduct 13. Megan Fitzgerald et al., "California's Strategy to Promote additional user testing in the future and determine if global and Improve Understanding of Medi-Cal for Kids & Teens," changes should be made. Manatt Health, April 10, 2023. Plain and Clear: Making the Medi-Cal Rights and Responsibilities Document Easier to Understand 16 About the Author Acknowledgments Beccah Rothschild, MPA, is the principal of Health The author acknowledges these people and organiza- Engagement Strategies, a consultancy that aims to tions for their collaboration on this project: David Kane improve health outcomes by influencing health behav- at Western Center on Law & Poverty, Cary Sanders at iors, systems, and cultures. She has more than 25 years California Pan-Ethnic Health Network, staff in the Medi- of experience working on making health information Cal Eligibility Division of the California Department of clear and understandable. Health Care Services, and all the Medi-Cal enrollees and key informants who were interviewed. About the Foundation The California Health Care Foundation (CHCF) is an independent, nonprofit philanthropy that works to improve the health care system so that all Californians have the care they need. We focus especially on mak- ing sure the system works for Californians with low incomes and for communities who have traditionally faced the greatest barriers to care. We partner with leaders across the health care safety net to ensure they have the data and resources to make care more just and to drive improvement in a complex system. CHCF informs policymakers and industry leaders, invests in ideas and innovations, and connects with changemakers to create a more responsive, patient- centered health care system. Plain and Clear: Making the Medi-Cal Rights and Responsibilities Document Easier to Understand 17