Many Californians are not able to apply for or effectively use Medi-Cal because they cannot read or understand the forms and documents created specifically for them. Many of these documents are written at between the 10th and 16th grade levels, a much higher level than the ideal 6th to 8th grade level at which they should be written.

This project conducted expert review of selected Medi-Cal print communications for English-speaking enrollees and assessed their usability, made actionable recommendations to improve them, and put steps in place for long-term change at the California Department of Health Care Services (DHCS). This report discusses the process for doing so, key findings, recommended action steps, and recommended policy changes.

Key Findings and Proposed Action Steps

Below are just a couple examples of the paper’s key findings, corresponding action steps with concrete examples, and direct quotes taken from focus groups with Medi-Cal members. Read the full report for the complete list of findings and action steps.

Finding #1

The documents contained acronyms, jargon, phrasing, and vague wording that enrollees did not understand.

They say ‘medically indigent, medically needy, and programs for people with disabilities.’ Okay, I’m confused by this whole thing right here. What is ‘medically indigent’? What is that? . . . That’s confusion. Big confusion right there. . . . I’m not understanding none of that.

Recommendation: Avoid unnecessary jargon. If it must be used, explain it — for example:

• Original text. We used your information, as well as state and federal data, to see what health coverage you and each member of your family can get, including: MAGI Medi-Cal (Modified Adjusted Gross Income) which is the new Medi-Cal program based on tax rules; Other Medi-Cal programs, such as Medically Indigent, Medically Needed, and programs for people with disabilities; and Covered California private health insurance.
• Suggested revision. We used the information you gave us to see which type of health coverage you and your family members can get. We also used information from state and federal agencies to confirm your income and tax statements.

Finding #2

The documents contained contradictory information often presented in nonlinear ways, causing enrollees to feel frustrated, confused, and stressed.

They say, ‘You are not eligible for MAGI Medi-Cal.’ But then it says, ‘You have not lost your Medi-Cal benefits at this time.’ So what are they saying? I don’t understand. . . . I don’t understand that at all. . . . It’s sending two different messages. Am I going to get it or am I not going to get it?

Recommendation: Provide consistent messaging that minimizes confusion, stress, and panic about the potential of losing Medi-Cal benefits — for example:

• Original text. We are sending you this letter because you or someone in your family is not eligible for MAGI Medi-Cal. You may be eligible for other Medi-Cal programs. . . . To keep health benefits without a break in coverage, you must complete the last page of this form. . . . You are not eligible for MAGI Medi-Cal. You have not lost your Medi-Cal benefits at this time.
• Suggested revision. We are checking to see if you are or will continue to be eligible for certain Medi-Cal programs. To help us do that, please answer the questions on the next pages for everyone who is part of your household.

Policy and Process Implications and Recommendations

Ten recommendations emerged for DHCS to consider as additional mechanisms to further improve print communication materials for Medi-Cal applicants and enrollees:

• Create a style guide that adheres to best plain language and health literacy practices, focusing on phrasing, vocabulary, and design.
• Establish and enforce a consistent policy for creating and revising user-friendly documents for applicants and enrollees.
• Conduct an audit of all written applicant and enrollee communications to determine where duplication and redundancy exists and can be eliminated.
• Acknowledge that rewriting certain documents may lead to needed changes on related documents and materials.
• Acknowledge that enrollee testing will uncover programmatic and policy deficiencies and highlight potential improvements.
• Ensure that staff and consultants working to improve communication materials have policy expertise and/or access to subject matter experts — and designate one staff member with the authority to make final decisions.
• Include stakeholders regularly and throughout the entire process, including in the very early stages, and ensure that comprehensive methods are in place to incorporate their suggestions.
• Use this process as an opportunity to align with state laws, federal laws, and/or temporary protective regulations by adding, editing, or omitting specific information.
• Request the minimum amount of information and “proofs” from applicants and enrollees.
• Use phrasing that is not intimidating to applicants and enrollees.

About the Author

Beccah Rothschild, MPA, is the principal of Health Engagement Strategies, a consultancy that aims to improve health outcomes by influencing health behaviors, systems, and cultures. She has more than 20 years of experience working on making health information clear and understandable.