- Patient outcomes depend on in-language care
- The laws governing language access
- Qualified vs. certified medical interpreters
- Paths to interpreter certification
- Why certification alone cannot fill the need
- Where current systems break down
- How healthcare organizations can close the gap
- An evidence-based model for training bilingual staff
- A three-step path toward certification
- A sustainable path toward better outcomes
Patient outcomes depend on in-language care
Research consistently shows that LEP patients experience worse hospital outcomes than their English-proficient counterparts. This includes more readmissions, medication errors, longer lengths of stay, decreased patient satisfaction, more adverse events, and higher mortality. The risk to LEP patients is especially high when interpreter services or bilingual care providers are not used effectively.
Language barriers can affect nearly every part of the patient experience
One study4 of six accredited U.S. hospitals compared variation in adverse event occurrence between LEP and non-LEP patients over the course of seven months. The study found that when adverse events occur in hospitals, LEP patients are almost twice as likely to experience physical harm, up to and including the death of the patient, as a result of that event.
The study concluded that language barriers increase risks to patient safety, and stressed the importance of patients with language barriers having access to competent language services.
Another study5 investigating how language barriers impact healthcare facilities in Pennsylvania found that of 336 reports in the Pennsylvania Patient Safety Reporting System database, an interpretation challenge was identified in 82.4%. Over half of the reports indicated that interpretation was not used because a certified interpreter was not available. The study found that language barriers were associated with patient safety events such as falls, delayed or canceled procedures, and medication errors. The study concluded that despite previous research and existing policies, language barriers continue to pose a risk to patient safety.
The laws governing language access
There are several federal regulations relevant to language access, Title VI of the Civil Rights Act of 1964, Section 1557 of the Affordable Care Act of 2016, Executive Order 13166, and the Americans with Disabilities Act.
Title VI of the Civil Rights Act of 1964 mandates meaningful access to services for individuals with (LEP). While the act doesn’t spell out specific interpreter qualification standards, it obligates entities receiving federal funds to take reasonable steps to ensure meaningful access for LEP individuals (this includes hospitals that receive Medicare and Medicaid reimbursement).
Subsequent guidance documents and court interpretations have added more specific direction: agencies receiving federal funds need to assess and address the language needs of the populations they serve. This includes developing and implementing language access plans, which often include provisions for qualified interpreters. Many states have enacted their own laws and regulations and provide more specific guidance on interpreter qualifications.
Section 1557 of the Affordable Care Act (ACA) went into effect July 18, 2016 and has a direct impact on the laws surrounding medical language services. Under this law, any healthcare provider or health insurance company receiving federal assistance must provide limited English proficiency (LEP) patients with a qualified interpreter. In the past, interpreters who identified themselves as “bilingual” were deemed competent by the Department of Health and Human Services. Section 1557 is the first change to language services since the DHHS regulations of 2003, and enacts stricter guidelines for interpreter training.7
On May 6, 2024, the U.S. Department of Health and Human Services (HHS) Office for Civil Rights (OCR) published a final rule updating regulations implementing Section 1557 of the ACA. In December, HHS shared a letter intended to assist covered entities in understanding their obligations under the provisions of the final rule.8
The rule provided a clear set of requirements to consider an interpreter “qualified:”9
A qualified interpreter must be able to:
- Demonstrate proficiency in English and the other language
- Interpret effectively, accurately, and impartially
- Use necessary specialized terminology
- Avoid additions, omissions, or changes
- Preserve tone, sentiment, and emotional level
- Follow accepted interpreter ethics, including confidentiality
A person who simply speaks both English and the other language would not be considered qualified under Section 1557.
Read the full regulatory text
“Has demonstrated proficiency in speaking and understanding both spoken English and at least one other spoken language (qualified interpreters for relay interpretation must demonstrate proficiency in two non-English spoken languages); [i]s able to interpret effectively, accurately, and impartially to and from such language(s) and English (or between two non-English languages for relay interpretation), using any necessary specialized vocabulary or terms without changes, omissions, or additions and while preserving the tone, sentiment, and emotional level of the original oral statement; and [a]dheres to generally accepted interpreter ethics principles, including client confidentiality”
The letter advises covered entities that it is imperative they provide interpreters that fit the above criteria, as a person who simply speaks both English and the other language would not be considered qualified under Section 1557. It further stresses that an individual’s self-identification as proficient in the foreign language is not sufficient to determine whether they meet the proficiency required by law.
Recent executive orders have added confusion to an already complex group of regulations. Executive orders cannot overturn existing laws, unless Congress passes a new law to do so. Thus, despite the new executive order and rescission of EO 13166, both Title VI of the Civil Rights Act of 1964 and Section 1557 of the Affordable Care Act remain the law, prohibiting discrimination on the basis of “national origin,” which the Supreme Court and the Department of Health and Human Services have interpreted as including language.
Together, Title VI and Section 1557 apply to all health programs and activities funded by the federal government, operated by a federal agency, and created under Title I of the Affordable Care Act (including marketplaces and qualified health plans). Other HHS regulations also require language access (Medicaid, Medicare and marketplace regulations).10
Title VI of the Civil Rights Act. Mandates meaningful access to services for individuals with LEP among entities receiving federal funds.
Federal language-access direction. Rescinded by a recent executive order; the underlying statutory duties remain.
Section 1557 of the Affordable Care Act. Requires a qualified interpreter and enacts stricter guidelines for interpreter training.7
HHS Section 1557 Final Rule. Published May 6, 2024; updates the regulations implementing Section 1557.8
Recent executive orders have added confusion. Executive orders cannot overturn existing laws; Title VI and Section 1557 remain the law.
What is the difference between a qualified and a certified medical interpreter?
Interpreting is a professional skill that must be formally developed in an individual who fluently speaks two languages. Medical interpreters need training in listening and delivery skills, memory and note-taking strategies, accurate terminology, cultural competence, and interpreter ethics and standards. While specific requirements will vary between states, most require at least 40 hours of medical interpreter training.
To gain the title of “certified,” an interpreter must have passed a standardized examination and met specific criteria set by a certifying body, indicating a higher level of training and competence. “Qualification,” as defined by the rule listed above, is consistent with the prerequisites on a path to certification, while certification provides greater assurance of an interpreter’s training, skills and knowledge.
| Qualified interpreter | Certified medical interpreter |
|---|---|
| Meets defined language and interpreting competency requirements | Has also passed standardized certification requirements |
| Demonstrates appropriate language proficiency | Demonstrates proficiency plus formal certification |
| Requires professional interpreting skills | Provides a higher level of external assurance |
| May serve as a step toward certification | Credential granted by a recognized certification body |
Bilingual ≠ Qualified ≠ Certified
Exact requirements can vary by state, credential, language, and context.
Even a truly bilingual individual’s language skills do not equate to the ability to interpret in a medical setting, as medical interpretation is a learned skill.
Paths to certification
There are two national certifying bodies in the US, both with a 40-hour training minimum to qualify for their certification exam: Certification Commission for Healthcare Interpreters (CCHI) and NBCMI (National Board of Certification for Medical Interpreters). For both, certification includes two parts: a written exam and an oral exam. Both require continuing education to maintain certification. Some healthcare providers prefer one credential over the other, but both demonstrate appropriate evidence of professional medical interpreter training.
The NBCMI currently offers two pathways to certification: the Hub-CMI is a credential available to all interpreters, regardless of target language. It is a less rigorous certification than the CMI, and is not intended as a replacement for a CMI if one is available in the language. The CMI is available in Spanish, Cantonese, Mandarin, Russian, Korean, and Vietnamese.
HUB-CMI is an entry-level interpreting credential, indicating that an interpreter has passed a written examination in English only. Once this credential is achieved, individuals have two years to pass the oral and interpreting components in their language to achieve the full certification of CMI granted by the NBCMI. No language designation is added to the HUB-CMI title, while the full CMI credential includes the language (CMI-Spanish).
CCHI’s certification is the CHI, or Certified Healthcare Interpreter. It offers a credential similar to the HUB-CMI, called the CoreCHI, which requires a written examination covering foundational knowledge of medical interpretation and is applicable to interpreters of any language. The CHI credential is based on an oral exam and available in Spanish, Arabic, and Mandarin. CCHI also offers an oral exam-based version of the Core credential, called CoreCHI-P.
CCHI’s CoreCHI, CoreCHI-P, and CHI-Spanish credentials are accredited by the National Commission for Certifying Agencies (NCCA), while NBCMI does not currently have NCCA accreditation.
Not enough nationally certified interpreters to fill the need
Starting from the principle that LEP patients should have similar access to healthcare they can understand as the general population, we can perform the following rough calculation using the state of California as an example case:
- California has between 2.7M and 6.8M LEP adults, depending on how this population is defined.11
- According to the NBCMI registry, there are 660 registered CMIs for Spanish in California,12 so about 1 Spanish CMI for 4,091 LEP adults, if we use the lower number for the population estimate.
- There are 124,383 active physicians in California,13 for a total population of about 39,345,844,14 a ratio of about 1 physician for every 316 people.
- Considering that the total population statistic includes children so the ratio comparison is inexact, to achieve coverage for Spanish-speaking LEPs similar to physician ratios for English proficient patients, California would need around 8,000 Spanish CMIs.
Regulations that don’t work
An article recently published in Slator15 highlighted chronic credential misrepresentation and misuse of the pre-certification HUB-CMI badge in California. A group of certified medical interpreters (CMIs) and administrators within the Northern California Translators Association (NCTA) report a widespread trend of non-certified interpreters accepting assignments explicitly reserved for certified medical interpreters. These assignments are high-stakes medical-legal evaluations and as such are required to go to CMIs per state regulations.
The article highlights a surge in demand for interpretation in high-stakes medical-legal environments connected to a rise in trauma claims within industries that employ high concentrations of LEP individuals. To uphold due process based on the requirements of the Department of Workers’ Compensation, interpreter presence is mandated at all medical treatment appointments, legal depositions, and hearings. In one of dozens of documented incidents, a HUB-CMI was identified at Qualified Medical Evaluation assignments 12 times from 2024-25. In a situation like this, sometimes the doctor defers to an attorney, while in other cases the HUB-CMI interpreter interprets during the entire medical-legal exam. Unfortunately, the parties with the most at stake typically do not have the ability to judge the quality of the interpretation. Most are not aware of the distinction between HUB-CMI and the full CMI credential, and assume the interpreter is doing an adequate job, leading to a false sense of security.
Earning the CMI certification can take years of training and resources. CMIs express frustration that when HUB holders misrepresent credentials and there is no legal relief, it sends a message that the standards behind the certification don’t matter. Credential misrepresentation results in devaluation of certification and a potential risk to the quality of care for LEP injured workers. An inaccurate interpretation can lead to a misdiagnosis or an undervalued settlement.
NBCMI has emphasized that as a certification body it does not have the power to oversee the types of assignments that an interpreter takes. The burden of keeping track of regulations and credentials falls to organizations, which in turn often rely on individual interpreters’ self-representation. In many cases, staff are left in a legal gray area if an unqualified interpreter arrives. Often, the examination is allowed to proceed, though the legal validity of the evaluation is jeopardized.
Credential confusion or misrepresentation
Organization accepts interpreter
Stakeholders cannot independently judge quality
High-stakes evaluation proceeds
Potential clinical or legal consequences
Organizations can be the solution
If providers and organizations shoulder the responsibility for testing bilingual staff and certifying staff interpreters, the risk of unqualified interpreters taking assignments is eliminated. This powerful step addresses grave disparities in health outcomes, protects the organization, and follows the law. Using nationally certified interpreters ensures the health, well-being, and dignity of patients.
Healthcare organizations routinely invest in the professional development of nurses, technicians, and other clinical staff whose credentials support patient safety and regulatory compliance. Credentialing for language concordant care and training medical interpreters should be viewed through the same lens. Rather than relying on a limited external labor pool, hospitals can develop internal talent by identifying bilingual employees, providing interpreter training, and requiring certification within a defined period. Bilingual care providers and other clinical staff, once their language skills have been verified by an objective third party, are also a valuable supplement. This approach creates a sustainable workforce pipeline while maintaining quality standards for patient care.
An affordable, evidence-based model for training medical interpreters
While the problem may seem daunting, a team of doctors and researchers at WACO Family Medicine recently completed a study that models an easy, affordable process built to address the language gap between providers and LEP patients by leveraging heritage speakers already on staff. This is the first comprehensive study16 analyzing the results of testing and training heritage-speaking employees as qualified medical interpreters.
Published in the Annals of Family Medicine17, the study used ALTA’s Breaking Boundaries in Healthcare medical interpreter training course and Interpreter Skills Assessment to train and assess a cohort of staff at a community health center. The 137 participants were heritage Spanish speakers who self-reported their language proficiency, took an oral proficiency test in Spanish, underwent a pre-assessment for interpreter skills, and completed ALTA’s 40-hour online medical interpreter course, followed by a post-training interpretation assessment.
The following highlights are important for hospitals to consider when building a strategy to address linguistic equity:
0%
Heritage speakers had limited ability to predict their language proficiency (32% of participants self-estimated their general language proficiency as native, but none tested at the native proficiency level).17
Hospitals cannot rely on staff to accurately self-report their language or interpretation proficiency, medical language proficiency for interpreting must be formally assessed as required by federal regulations.
72%
Online interpreter training programs increase heritage speakers’ ability to effectively interpret in a clinical setting. 72% of participants who completed training achieved the qualifications necessary to interpret in the health center.17
$1.50/hr
Implementing an online interpreter training program for existing bilingual staff constitutes a massive cost reduction in comparison to hiring outside interpreters. The participants who scored at or above the community health center’s established threshold for interpreter qualification received a $1.50/hour pay raise. The costs for remote interpretation average $2-3.50 per minute and for in-person can be $150 – $210 per hour.17
Heritage speakers are valuable assets for bridging the language gap between providers and patients, perfectly positioned for targeted training to step into medical interpreter roles in ambulatory care settings. The WACO case study provides evidence that an affordable, asynchronous online interpreter training program like ALTA’s Breaking Boundaries in Healthcare is an effective preparation for heritage speakers to become qualified interpreters.
Breaking Boundaries in Healthcare
ALTA’s 40-hour medical interpreter course, Breaking Boundaries in Healthcare, is an asynchronous online course that covers the content required to begin working as a professional medical interpreter, while also providing remote live coaching by seasoned industry professionals, and optional interpretation practice modules.
The path toward national certification we recommend for hospitals
Step 1: Assess
Assess medical providers’ and heritage speakers’ language abilities with professional language tests.
- Develop a relationship with a reliable testing and training agency to help guide test selection and overall process.
- Verify that tests to establish the language proficiency of bilingual staff such as doctors, nurses, PAs, and non-clinical staff are role-based and include research-backed qualifying thresholds (cut scores), since the language skills required to perform roles as different as administrative intake and explaining a complex medical procedure are different.
- Set a minimum language proficiency benchmark required to begin the interpreter training process. Establishing a qualifying proficiency score allows the organization to focus its resources on candidates with the highest chance of succeeding.
Step 2: Train
Implement an interpreter training program to immediately address language gaps and leverage existing staff skills.
This course requires demonstration of interpretation skills, and, in addition to a code of ethics test in English, also includes a consecutive English/target language interpretation skills test (unlike the HUB CMI). An excellent first step toward certification, ALTA’s course stands out by preparing students through the active demonstration of skills, a step beyond simply talking about the skills needed to be a medical interpreter.
Step 3: Credential
Provide funding for credentialing.
While risk elimination, ethical principles, and protecting the integrity of credentialing are worth the cost, reimbursement may be a factor in the feasibility of deploying a fully funded credentialing program.
What about reimbursement?
14 states + D.C.
As of 2024, only 14 states and the District of Columbia had Medicaid policies that directly reimburse providers for qualified interpretation.18
The ability to bill for interpreter services is driven almost entirely by the patient’s insurance coverage and the specific Medicaid policy in your state. Federal law requires that hospitals provide access, but payment depends on the payer.
Even if reimbursement is not always an option, providing effective and consistent language access for LEP patients helps hospitals avoid the high costs associated with language barriers.
A sustainable path toward better outcomes
The mission of medical organizations is providing quality care that enables patients to live their healthiest lives. Ensuring language equity for all patient populations is a critical component of this mission. When an organization takes responsibility for the quality of their medical interpreters, the positive impact for the patients and for the organization itself is enormous. While cost may be a significant factor in the process, implementing a credentialed medical interpreter training program for existing staff is a simple, scalable solution on the path to addressing this issue.
Better language access starts with a system
Assess bilingual ability
Train interpreting skills
Verify competency
Support certification
Maintain quality over time
Healthcare systems already have a model for this process, routinely investing in continuing education and certifications for nurses, technicians, and other credentialed professionals to improve quality of care and reduce risks. Why not do the same for interpreters?
If organizations invest in developing the next generation of certified medical interpreters, the burden of keeping track of credentials, relying on self-reporting of interpretation skills, and the massive risk of inadequate interpretation skills is lifted. Requiring certification within a reasonable timeframe while supporting employees through training and testing creates a sustainable path toward both compliance and better patient outcomes.