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Vol. 80 Tuesday,No. 173 September 8, 2015

Part V

Department of Health and Human Services

45 CFR Part 92Nondiscrimination in Health Programs and Activities; Proposed Rule

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54172 Federal Register / Vol. 80, No. 173/ Tuesday, September 8, 2015 / Proposed Rules

178 FR 46558 (Aug. 1, 2013).

DEPARTMENT OF HEALTH ANDHUMAN SERVICES

Office of the Secretary

45 CFR Part 92

RIN 0945–AA02

Nondiscrimination in Health Programs

and Activities

AGENCY: Office for Civil Rights (OCR),Office of the Secretary, HHS.

ACTION: Notice of proposed rulemaking.

SUMMARY: The Department of Health andHuman Services (HHS or ‘‘theDepartment’’) is issuing this proposedrule on Section 1557 of the AffordableCare Act (ACA) (Section 1557). Section1557 prohibits discrimination on the

basis of race, color, national origin, sex,age, or disability in certain healthprograms and activities. Section 1557(c)

of the ACA authorizes the Secretary ofthe Department to promulgateregulations to implement thenondiscrimination requirements ofSection 1557. In addition, the Secretaryis authorized to prescribe regulations forthe Department’s governance, conduct,and performance of its business,including, here, how HHS will applythe standards of Section 1557 to HHS-administered health programs andactivities.

DATES: Submit comments on or beforeNovember 9, 2015.

ADDRESSES: You may submit comments,

identified by RIN Number 0945–AA02, by any of the following methods:• Federal eRulemaking Portal: You

may submit electronic comments athttp://www.regulations.gov . Follow theinstructions for submitting electroniccomments. Attachments should be inMicrosoft Word or Excel; however, weprefer Microsoft Word.

• Regular, Express, or Overnight Mail:You may mail written comments (oneoriginal and two copies) to the followingaddress only: U.S. Department of Healthand Human Services, Office for CivilRights, Attention: 1557 NPRM (RIN

0945–AA02), Hubert H. HumphreyBuilding, Room 509F, 200Independence Avenue SW.,Washington, DC 20201. Mailedcomments may be subject to deliverydelays due to security procedures.Please allow sufficient time for mailedcomments to be timely received in theevent of delivery delays.

• Hand Delivery or Courier: If youprefer, you may deliver (by hand orcourier) your written comments (oneoriginal and two copies) to the followingaddress only: Office for Civil Rights,

Attention: 1557 NPRM (RIN 0945–AA02), Hubert H. Humphrey Building,Room 509F, 200 Independence AvenueSW., Washington, DC 20201. (Becauseaccess to the interior of the Hubert H.Humphrey Building is not readilyavailable to persons without Federalgovernment identification, commentersare encouraged to leave their comments

in the mail drop slots located in themain lobby of the building.)

• Inspection of Public Comments: Allcomments received before the close ofthe comment period will be available forpublic inspection, including anypersonally identifiable or confidential

business information that is included ina comment. We will post all commentsreceived before the close of thecomment period at http:// www.regulations.gov .

FOR FURTHER INFORMATION CONTACT:Claudia Adams, at (800) 368–1019 or(800) 537–7697 (TDD).

SUPPLEMENTARY INFORMATION:

I. Background

Section 1557 of the ACA provides thatan individual shall not, on the groundsprohibited under Title VI of the CivilRights Act of 1964 (Title VI), 42 U.S.C.2000d et seq. (race, color, nationalorigin), Title IX of the EducationAmendments of 1972 (Title IX), 20U.S.C. 1681 et seq. (sex), the AgeDiscrimination Act of 1975 (Age Act),42 U.S.C. 6101 et seq. (age), or Section504 of the Rehabilitation Act of 1973(Section 504), 29 U.S.C. 794 (disability),

be excluded from participation in, bedenied the benefits of, or be subjectedto discrimination under any healthprogram or activity, any part of whichis receiving Federal financial assistance,or under any program or activity that isadministered by an Executive Agency orany entity established under Title I ofthe Act or its amendments. Section 1557states that the enforcement mechanismsprovided for and available under TitleVI, Title IX, Section 504, or the Age Actshall apply for purposes of addressingviolations of Section 1557. TheDepartment is responsible for

developing regulations to implementSection 1557.On August 1, 2013, the Office for Civil

Rights of the Department (OCR)published a Request for Information(RFI) in the Federal Register to obtaininformation that would assist OCR indrafting the proposed regulation.1 TheRFI solicited information on issuesarising under Section 1557. OCRreceived 402 comments. Of the totalcomments, one-quarter (99) were from

organizational commenters, with theremainder from individuals. Of theorganizational comments, one-third (33)were from civil rights/advocacy groupswith over half of these (17) coming fromorganizations serving lesbian, gay,

bisexual, or transgender (LGBT)individuals. Six comments werereceived from health care providers

(including two local government healthagencies) and two were from healthinsurance providers or providerorganizations. Of the comments fromindividuals, 239 were personaltestimonies from transgenderindividuals describing their experiencesof discrimination in the health caresetting.

OCR has carefully reviewed allcomments received, and has referencedthem where appropriate and relevant inthis preamble. The proposed rule bothclarifies and codifies existingnondiscrimination requirements, and

also sets forth new standards toimplement Section 1557, particularlywith respect to the prohibition ofdiscrimination on the basis of sex inhealth programs other than thoseprovided by educational institutionsand the prohibition of various forms ofdiscrimination in health programsadministered by the Department andentities established under Title I of theACA. The Department invites commenton this proposed rule by all interestedparties, including comment from Tribeson application of the rule to them.

Subpart A—General Provisions

Purpose and Effective Date (§92.1)

Proposed §92.1 states that thepurpose of this part is to implementSection 1557 of the ACA, whichprohibits discrimination in certainhealth programs and activities on thegrounds prohibited under Title VI, TitleIX, the Age Act, and Section 504, whichtogether prohibit discrimination on the

basis of race, color, national origin, sex,age, or disability.

Section 92.1 also establishes that theeffective date of the Section 1557implementing regulation shall be 60days after the publication of the finalrule in the Federal Register.

Application (§ 92.2)

Section 1557 applies to all healthprograms and activities, any part ofwhich receives Federal financialassistance from any Federal agency. Inaddition, Section 1557 applies to allprograms and activities that areadministered by an Executive Agency orany entity established under Title I ofthe ACA.


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54173Federal Register / Vol. 80, No. 173/ Tuesday, September 8, 2015 / Proposed Rules

2Section 1557 applies to all health programs andactivities, any part of which receives Federalfinancial assistance from any Federal Department.However, this proposed rule would apply only tohealth programs and activities any part of whichreceives Federal financial assistance from HHS.This narrowed application is consistent with HHS’enforcement authority over such health programsand activities, but other Federal agencies areencouraged to adopt the standards set forth in thisproposed rule in their own enforcement of Section1557.

3See 42 U.S.C. 6103(b).

4We are also seeking comment elsewhere in thisPreamble on a number of possible exceptions to theproposed rule, including with regard to what sex- based distinctions, if any, should be permitted inthe context of health programs and activities andthe standards for permitting those distinctions. SeePreamble discussion of § 92.101(c).

5See, e.g., 42 U.S.C. 300a–7; 42 U.S.C. 238n;Consolidated and Continuing Appropriations Act2015, Pub. L. 113–235, 507(d) (Dec. 16, 2014).

642 U.S.C. 2000bb–1.7See, e.g., 42 U.S.C. 18023.8See 45 CFR 147.131.

OCR proposes in §92.2(a) to apply therule, except as otherwise provided inthis part, to: (1) All health programs andactivities, any part of which receivesFederal financial assistanceadministered by HHS;2 (2) healthprograms and activities administered bythe Department, including theFederally-facilitated Marketplaces; and

(3) health programs and activitiesadministered by entities establishedunder Title I of the ACA, including theState-based Marketplaces.

Section 92.2(b) provides limitations tothe application of the proposed rule. Inthis section, addressing limitations inthe statutes referenced in Section 1557,and in Subpart B, which incorporatesexceptions in the regulationsimplementing the statutes referenced inSection 1557, we have adopted theexisting limitations and exceptions thatalready govern the health programs andactivities subject to Section 1557. These

limitations and exceptions are found inthe Age Act and in the regulationsimplementing the Age Act, Section 504,and Title VI, which apply to allprograms and activities that receiveFederal financial assistance.

Thus, §92.2(b)(1) incorporates theexclusions found in the Age Act, suchthat the provisions of this proposed ruledo not apply to any age distinctioncontained in that part of a Federal,State, or local statute or ordinanceadopted by an elected, general purposelegislative body which provides any

benefits or assistance to persons basedon age, establishes criteria for

participation in age-related terms, ordescribes intended beneficiaries totarget groups in age-related terms.3

By contrast, we are requestingcomment on whether the exemptionsfound in Title IX and its implementingregulation should be incorporated intothis proposed rule. Unlike the Age Act,Section 504, and Title VI, which applyto all programs and activities thatreceive Federal financial assistance,Title IX applies only in the context ofeducation programs and not to thehealth programs and activities subject tothis proposed rule. In addition, many of

Title IX’s limitations and exceptions donot readily apply in a context that is

grounded in health care, rather thaneducation. For example, Title IXexempts from its prohibitions on sexdiscrimination certain institutions ofundergraduate higher education,military and merchant marineeducational institutions, andmembership practices of socialfraternities and sororities and voluntary

youth service organizations.In the RFI, OCR specifically inquired

as to what exceptions, if any, shouldapply in the context of sexdiscrimination in health programs andactivities. Nearly all commenters whoprovided a response to this inquiryindicated that Section 1557 includesonly one exception—that the statuteapplies except as otherwise provided inTitle I of the ACA. To this end,commenters argued that nothing in thelanguage or legislative history of Section1557 allows for any other limitations orexceptions regarding its application,

highlighting that exceptions to generalrules like Section 1557’santidiscrimination provision must beread strictly and narrowly.

We continue to seek comment onwhether the regulation should includeany specific exemptions for healthproviders, health plans, or other coveredentities with respect to requirements ofthe proposed rule related to sexdiscrimination, including the particularrequirements that are discussed in thisproposed rule.4 For example, HHSwants to ensure that the rule has theproper scope and appropriately protects

sincerely held religious beliefs to theextent that those beliefs conflict withprovisions of the regulation. We notethat certain protections already existwith respect to religious beliefs,particularly with respect to theprovision of certain health-relatedservices; for example, this proposed rulewould not displace the protectionsafforded by provider conscience laws,5 the Religious Freedom Restoration Act,6 provisions in the ACA related toabortion services,7 or regulations issuedunder the ACA related to preventivehealth services.8 We seek comment onthe extent to which these existingprotections would provide sufficient

safeguards for religious concerns in thecontext of the proposed rule.

At the same time, a fundamentalpurpose of the ACA is to ensure thatvital health care services are broadlyand nondiscriminatorily available toindividuals throughout the country. Asa result, we seek comment on any healthcare consequences that would ensue

were the regulation to provideadditional exemptions.

Finally, we seek comment on thescope of additional exemptions, if any,that should be included and theprocesses for claiming them, includingwhether those processes should trackthose used under Title IX, at 45 CFR86.12.

Relationship to Other Laws (§ 92.3)

Proposed §92.3 explains therelationship of this part to existing laws.Paragraph (a) provides that Section 1557is not intended to apply lesser standardsfor the protection of individuals fromdiscrimination than the standards underTitle VI, Title IX, Section 504, the AgeAct, or the regulations issued pursuantto those laws. Consistent with thestatute, paragraph (b) states that nothingin this part shall be interpreted toinvalidate or limit the existing rights,remedies, procedures, or legal standardsavailable to individuals aggrieved underother Federal civil rights laws or tosupersede State or local laws thatprovide greater or equal protectionagainst discrimination on the basis ofrace, color, national origin, sex, age, ordisability. This intent is derived from

Section 1557(b) of the ACA. In additionto the statutory references cited directlyin Section 1557(b), the proposed ruleincludes the Architectural Barriers Actof 1968, 42 U.S.C. 4151–4157 (2012), theAmericans with Disabilities Act of 1990,42 U.S.C. 12101 et seq. (codified asamended by the Americans withDisabilities Amendments Act of 2008,Pub. L. 110–325, 122 Stat. 3553 (2008))(ADA), and Section 508 of theRehabilitation Act of 1973, 29 U.S.C.794d (Section 508). These laws establishadditional Federal civil rightsprotections for individuals with

disabilities, and covered entities must be mindful that the obligations imposed by those laws apply to themindependent of the application ofSection 1557.

Definitions (§ 92.4)

Section 92.4 contains proposeddefinitions. Definitions of particularnote are set out below.

Auxiliary aids and services. Thedefinition of ‘‘auxiliary aids andservices’’ is the same as the definitionof this term in the regulations



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9As noted supra at n.2, this proposed rule wouldapply to recipients of Federal financial assistancefrom HHS only. The term ‘‘covered entity’’ isnonetheless defined broadly so that other FederalDepartments can readily apply the standards of thisrule to their own enforcement of Section 1557.

10See, e.g., 42 U.S.C. 18031(i) (authorizing theNavigator program); 45 CFR 155.210 (c), (e)(identifying eligibility requirements for, andresponsibilities of, receiving a Navigator grant). 11See 45 CFR 86.2(g)(1)(ii).

12See, e.g., Memorandum from Office ofPersonnel Management, ‘‘Guidance Regarding theEmployment of Transgender Individuals in theFederal Workplace’’ (May 27, 2011); ResourceGuide from Office of Personnel Management, theEqual Employment Opportunity Commission, theOffice of Special Counsel, and the Merit SystemsProtection Board, ‘‘Addressing Sexual Orientationand Gender Identity Discrimination in FederalCivilian Employment’’ (June 2015).

13Health Insurance Marketplaces are also knownas ‘‘Marketplaces.’’

implementing the ADA, at 28 CFR35.104, 36.303(b).

Covered entity. The term ‘‘coveredentity’’ means: (1) An entity thatoperates a health program or activity,any part of which receives Federalfinancial assistance; 9 (2) an entityestablished under Title I of the ACA thatadministers a health program or activity;

and (3) the Department.With regard to the Health Insurance

Marketplaces, covered entities include,for example, Navigators that receiveFederal financial assistance as definedin this rule. Navigators are entities thatcarry out the duties identified in theACA and its implementing regulations,such as informing the public about thehealth coverage options availablethrough the Health InsuranceMarketplaces and facilitating enrollmentin health coverage programs.10 State-

based Marketplaces are covered as TitleI entities. The Federally-facilitated

Marketplaces are covered both as TitleI entities and as health programs oractivities of the Department.

Director. Director means the Directorof the Office for Civil Rights in theDepartment.

Disability. The definition of‘‘disability’’ is the same as the definitionof this term in the Rehabilitation Act, at29 U.S.C. 705(9)(B), which incorporatesthe definition of disability in the ADA,as construed by the ADA AmendmentsAct of 2008 (Pub .L. 110–325; 42 U.S.C.12102), as amended. This part uses theterm ‘‘disability’’ in place of the term

‘‘handicap’’ used in some previous civilrights statutes and regulations.Throughout this part, where we cross-reference other regulatory provisions,regulatory language that uses the term‘‘handicap’’ shall mean ‘‘disability.’’This change in terminology does notreflect a change in the substance of thedefinition.

Electronic and informationtechnology. The definition of‘‘electronic and informationtechnology’’ is consistent with 36 CFR1194.4, the regulation implementingSection 508.

Employee health benefit program. Theterm ‘‘employee health benefit program’’means (1) health benefits coverage orhealth insurance provided to employeesand/or their dependents established,

operated, sponsored or administered by,for, or on behalf of one or moreemployers, whether provided oradministered by entities including butnot limited to, a health insurance issuer,group health plan (as defined in theEmployee Retirement Income SecurityAct of 1974 (ERISA, at 29 U.S.C.1191(a)), a third party administrator, or

an employer; (2) an employer-providedor -sponsored wellness program; (3) anemployer-provided health clinic; or (4)long term care coverage or insuranceprovided or administered by anemployer, group health plan, third partyadministrator, or health insuranceissuer.

Federal financial assistance. The term‘‘Federal financial assistance’’ includesthe standard definition of grants, loans,and other types of assistance inaccordance with the definition of‘‘Federal financial assistance’’ in theregulations implementing Section 504

and the Age Act at 45 CFR 84.3(h) and91.4, respectively, and also specificallyincludes subsidies and contracts ofinsurance, in accordance with thestatutory language of Section 1557.

However, consistent with OCR’senforcement of other civil rightsauthorities, the definition of Federalfinancial assistance does not includeMedicare Part B.

An additional clause is added to theproposed regulatory provision, modeledon the definition of ‘‘Federal financialassistance’’ in the regulationimplementing Title IX at 45 CFR 86.2(g).That Title IX regulatory provision

clarifies that Federal financial assistanceincludes wages, loans, grants,scholarships and other monies that aregiven to any entity for payment to or on

behalf of students who are admitted tothat entity or that are given directly tothese students for payment to thatentity.11 This provision was included inthe Title IX regulation to make clear that

both funds paid to the educationalentity on behalf of a student, and fundspaid to the student and then remitted tothe educational entity, are Federalfinancial assistance. In the health carecontext, Federal funds are provided to

or on behalf of eligible individuals forpremium tax credits and advancepayments of premium tax credits andcost sharing reductions to ensure theaffordability of health insurancecoverage purchased through the HealthInsurance Marketplaces. To clarify thatthese funds are Federal financialassistance, we have added language tothis proposed definition stating thatsuch funds are Federal financialassistance when extended to the entity

providing the health insurance coverageor services, whether they are paiddirectly by the Federal government tothat entity or to the individual forremittance to the entity providing healthinsurance coverage or services. Thus, anissuer participating in any HealthInsurance Marketplace is receivingFederal financial assistance when

advance payments of premium taxcredits and/or cost sharing reductionsare provided to any of the issuer’senrollees. A health services providerthat contracts with such an issuer doesnot become a recipient of Federalfinancial assistance by virtue of thecontract, but would be a recipient if theprovider otherwise receives Federalfinancial assistance.

Federally-facilitated Marketplace. Theterm Federally-facilitated Marketplacehas the same meaning as ‘‘Federally-facilitated Exchange’’ defined in 45 CFR155.20.

Gender identity. The term ‘‘genderidentity’’ means an individual’s internalsense of gender, which may be differentfrom an individual’s sex assigned at

birth. The way an individual expressesgender identity is frequently called‘‘gender expression,’’ and may or maynot conform to social stereotypesassociated with a particular gender.Gender may be expressed through, forexample, dress, grooming, mannerisms,speech patterns, and social interactions.For purposes of this part, an individualhas a transgender identity when theindividual’s gender identity is differentfrom the sex assigned to that person at

birth; an individual with a transgenderidentity is referred to in this part as atransgender individual. The approachtaken in this definition is consistentwith the approach taken by the Federalgovernment in similar matters.12

Health Insurance Marketplace. Theterm ‘‘Health Insurance Marketplace’’ 13 means the same as ‘‘Exchange’’ definedin 45 CFR 155.20.

Health program or activity. The term‘‘health program or activity’’ is definedto include the provision oradministration of health-related servicesor health-related insurance coverage and

the provision of assistance in obtaininghealth-related services or health-relatedinsurance coverage. Similar to the



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14102 Stat. 28, Pub. Law 100–259 (1988).15Employee health benefits programs are

discussed elsewhere in this proposed rule. See infradiscussion of proposed § 92.208.

16A health program or activity also includes allof the operations of a State Medicaid program.Where a State Medicaid program resides in anagency that is principally engaged in providinghealth services or health insurance coverage, or is

primarily engaged in providing assistance inobtaining health services or health coverage, all ofthe operations of the agency will be a healthprogram or activity. Where a State Medicaidprogram is operated by a State agency that operatesmany other programs that provide services otherthan health-related services, health relatedinsurance coverage, or assistance in obtaininghealth-related services or health-related coverage,the agency as a whole may not be principallyengaged in providing health services, healthinsurance coverage, or assistance in obtaininghealth services or health coverage; in such cases,only the agency’s Medicaid program and otherhealth-related programs will meet the definition ofhealth program and activity. The same is true forlocal Medicaid agencies.

17Guidance to Federal Financial AssistanceRecipients Regarding Title VI Prohibition AgainstNational Origin Discrimination Affecting LimitedEnglish Proficient Persons, 68 FR 47311, 47313(Aug. 8, 2003) (hereinafter HHS LEP Guidance).

approach of the Civil Rights RestorationAct 14 and except as specifically setforth otherwise in this part,15 the termfurther includes all of the operations ofan entity principally engaged inproviding or administering healthservices or health insurance coverage,such as a hospital, health clinic,community health center, group health

plan, health insurance issuer,physician’s practice, nursing facility, orresidential or community-basedtreatment facility.16 OCR intends tointerpret ‘‘principally engaged’’ in amanner consistent with civil rights lawsthat use this term.

OCR intends the plural ‘‘healthprograms or activities’’ used in thisproposed part to have the same meaningas the term ‘‘health program or activity’’in the singular. Similarly, this proposedpart’s use of ‘‘health programs andactivities,’’ a variation of ‘‘healthprogram or activity,’’ does not reflect a

change in the substance of the definitionof ‘‘health program or activity.’’Commenters responding to the

request in the RFI for examples ofprograms and activities that should beconsidered ‘‘health programs oractivities’’ generally supported a broadinterpretation of the term. We proposeto interpret ‘‘health programs andactivities’’ to include programs such ashealth education and health researchprograms. However, OCR recognizesthat health research is conducted toanswer scientific questions and advancehealth through the advancement ofknowledge; it is not designed to result

in direct health benefits to participants,though individuals may in fact receivehealth benefits from participation. Inaddition, and consistent with basicnondiscrimination principles applied inother contexts, OCR notes thatindividuals have a right to

nondiscriminatory consideration forinclusion in a research project but arenot entitled to be selected to participate.

Because Federal civil rights lawsalready prohibit discrimination on the

basis of race, color, national origin,disability, or age in all health researchprograms and activities that receiveFederal financial assistance and prohibit

discrimination on the basis of sex in allhealth research programs conducted bycolleges and universities, application ofSection 1557 to health research shouldimpose limited additional burden oncovered entities. But including healthresearch under Section 1557 wouldextend the prohibition againstdiscrimination on the basis of sex toFederally assisted health researchprograms and activities in non-educational institutions, complementingexisting initiatives to increase diversityand inclusion in health research.Moreover, applying the requirements of

Section 1557 to Department-conductedhealth programs and activities,including health research, would holdHHS components to the same standardsas recipients of Federal financialassistance, prohibiting discriminationon all bases covered by Section 1557.

OCR also recognizes that researchprojects are often limited in scope formany reasons, such as the principalinvestigator’s scientific interest, fundinglimitations, recruitment requirements,and other nondiscriminatoryconsiderations. Thus, criteria inresearch protocols that target or excludecertain populations are warranted where

nondiscriminatory justificationsestablish that such criteria areappropriate with respect to the health orsafety of the subjects, the scientificstudy design, or the purpose of theresearch. OCR does not intend forinclusion of health research within thedefinition of health program or activityto alter the fundamental manner inwhich research projects are designed,conducted, or funded; nor is OCRproposing to systematically reviewhealth research protocols. For example,a medical research institution that is acovered entity may exclude individuals

who are a deaf from a clinical trial toinvestigate a new brain imagingtechnology for assessing cognitivefunctioning that relies on auditorystimulation as the test stimulus. Thisresearch design would not bediscriminatory on the basis of disability

because there is a nondiscriminatoryjustification for excluding individualswho are deaf.

OCR continues to seek comment onprograms and activities that should beconsidered health programs oractivities.

Individual with a disability. Theproposed definition of ‘‘individual witha disability’’ is the same as thedefinition of this term used for thepurpose of Section 504 of theRehabilitation Act, found at 29 U.S.C.705(20)(B)–(F), as amended. TheRehabilitation Act, at 29 U.S.C.705(20)(B)–(F), incorporates the

definition of ‘‘individual with adisability’’ from the ADA. This part usesthe person-first term ‘‘individual with adisability’’ in place of the outdatedterms ‘‘handicapped person’’ and‘‘individual with handicaps’’ which arefound in earlier civil rights laws andregulations. Throughout this part, wherewe cross-reference Section 504,regulatory language that uses‘‘handicapped person’’ and ‘‘individualwith handicaps’’ shall mean ‘‘individualwith a disability.’’ This change interminology does not reflect a change inthe substance of the definition.

Individual with limited English proficiency. The term ‘‘individual withlimited English proficiency’’ codifiesthe Department’s long-standingdefinition reflected in guidanceinterpreting Title VI’s prohibition ofnational origin discrimination, entitledGuidance to Federal FinancialAssistance Recipients Regarding Title VIProhibition Against National OriginDiscrimination Affecting LimitedEnglish Proficient Persons 17 (HHS LEPGuidance). Under this definition, anindividual whose primary language forcommunication is not English is anindividual with limited English

proficiency under this part as long asthe individual has a limited ability tocommunicate in one of the followingways: Reading, speaking, writing, orunderstanding. Consequently, anindividual whose primary language forcommunication is not English and whohas some ability to speak English is anindividual with limited Englishproficiency under this part if theindividual has a limited ability to read,write, or understand English.

Language assistance services. Theterm ‘‘language assistance services’’identifies types of well-established

methods or services used tocommunicate with individuals withlimited English proficiency, includingoral language assistance, writtentranslation, and taglines. A coveredentity has flexibility to provide languageassistance services in-house or throughcommercially available options. Tomaximize covered entities’ flexibilities



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18We use the terms ‘‘oral interpretation’’ and‘‘written translation’’ for clarity but we note that theterm ‘‘interpretation’’ used without the preceding

descriptor of ‘‘oral’’ refers to the communication ofinformation orally and the term ‘‘translation’’ usedwithout the preceding descriptor of ‘‘written’’ refersto the communication of information in writing.See, e.g., U.S Dep’t of Justice, Commonly AskedQuestions and Answers Regarding Limited EnglishProficient (LEP) Individuals and Translators,available at http://www.lep.gov/faqs/042511 _Q&A _EO _13166.pdf (differentiating between interpretersand translators in FAQ 11); Interpreters andTranslators, U.S. Department of Labor, Bureau ofLabor Statistics, Occupational Outlook Handbook,2014–15, available at http://www.bls.gov/ooh/ media-and-communication/interpreters-and-translators.htm (explaining that interpreters convertinformation in a spoken language and translatorsconvert information in written language).

19See Letter from Leon Rodriguez, Director, U.S.Department of Health & Human Services, Office forCivil Rights, to Maya Rupert, Federal PolicyDirector, National Center for Lesbian Rights (Jul. 12,2012).

20See regulations issued by the Office ofPersonnel Management, clarifying that the

discrimination on the basis of sex includesdiscrimination on the basis of gender identity, 79FR 43919 (Jul. 29, 2014); Directive 2014–02, U.S.Department Of Labor, Office of Federal ContractCompliance Programs (Aug. 19, 2014), available athttp://www.dol.gov/ofccp/regs/compliance/ directives/dir2014 _02.html ; Statement of Interest ofthe United States, Jamal v. SAKS & Co., No. 4:14–CV–2782 (S.D. Tex. 2015); Statement of Interest ofthe United States, Tooley v. Van Buren PublicSchools, No. 2:14–cv–13466–AC–DRG (E.D. Mich.)(Feb. 24, 2015), Mediated Settlement Order, UnitedStates v. Toone, No. 6:13–CV–744 (E.D. Tex. 2014);Memo from Eric Holder, Att’y Gen., to U.S. Att’ys& Heads of Dep’t Components (Dec. 15, 2014); U.S.Dep’t of Educ., Questions and Answers on Title IXand Sexual Violence at B–2 (http://www2.ed.gov/ about/offices/list/ocr/docs/qa-201404-title-ix.pdf ) Resolution Agreement Between Arcadia UnifiedSch. Dist., U.S. Dep’t of Educ., Office for CivilRights, & the U.S. Dep’t of Justice, Civil Rights Div.,OCR Case No. 09–12–1020, DOJ Case No. 169–12C–70, at 1 (Jul. 24, 2013); Macy v. Holder, EEOCAppeal No. 0120120821, Agency No. ATF–2011–00751 (Apr. 20, 2012) 2012 WL 1435995, at *11.

21See, e.g., Rumble v. Fairview Heath Services,2015 WL 1197415 (D. Minn. 2015) (order denyingmotion to dismiss); Barnes v. City of Cincinnati, 401F.3d 729 (6th Cir.), cert. denied, 546 U.S. 1003(2005); Smith v. City of Salem, Ohio, 378 F.3d 566(6th Cir. 2004); Schroer v. Billington, 577 F.Supp.2d 293 (D.D.C. 2008). But see Johnston v.University of Pittsburgh, Civ. Action No. 3:13–213(W.D.Pa. Mar. 31, 2015) (interpreting Title IX,among other authorities).

22See, e.g,, Kiley v. Am. Soc’y for Prevention ofCruelty to Animals, 296 Fed. App’x 107, 109 (2dCir. 2008); Vickers v. Fairfield Med. Ctr., 453 F.3d757, 759 (6th Cir. 2006); Bibby v. Philadelphia CocaCola Bottling Co., 260 F.3d 257, 260 (3d Cir. 2001);but cf. Latta v. Otter, 771 F.3d 456 (9th Cir. 2014)(Berzon, J., concurring) (in striking down State law

prohibition on same sex marriage, observing that‘‘the same sex marriage laws treat the subgroup ofmen who wish to marry men less favorably than theotherwise similarly situated subgroup of womenwho want to marry men’’ and therefore constitutesex discrimination); see also Muhammad v.Caterpillar, 767 F.3d 694 (7th Cir. 2014), 2014 WL4418649 (7th Cir. Sept. 9, 2014, as Amended onDenial of Rehearing, Oct. 16, 2014) (removingstatements from previously issued panel decisionthat relied on outdated precedents about coverageof sexual orientation discrimination under Title VIIas requested in EEOC Amicus Brief).

23Baldwin v. Foxx, EEOC Appeal No.0120133080, Agency No. 2012–24738–FAA–03, at5–6 (July 15, 2015) (finding that sexual orientationis inseparable from and inescapably linked to sexand thus that an allegation of discrimination basedon sexual orientation is necessarily an allegation ofsex discrimination).

24See e.g. Centola v. Potter, 183 F. Supp. 2d 403,410 (D. Mass. 2002); Heller v. Columbia EdgewaterCountry Club, 195 F. Supp. 2d at 1212 (D. Or. 2002);Koren v. Ohio Bell, 894 F. Supp. 2d 1032, 1038(N.D. Ohio 2012); Terveer v. Billington, 34 F. Supp.3d 100, 116, 2014 WL 1280301 (D.D.C. 2014);Boutillier v. Hartford Public Schools, 2014 WL4794527 (D. Conn. 2014); Deneffe v. SkyWest, Inc.,2015 WL 2265373, at *6 (D. Colo. May 11, 2015).

25For example, in 1996, the Supreme Courtstruck down an amendment to the Coloradoconstitution that prohibited the State governmentfrom providing any legal protections to gay, lesbian,and bisexual individuals. Seven years later, in 2003,the Supreme Court invalidated a Texas law thatcriminalized same-sex sodomy. And just this year,

and to account for the likelihood offuture innovations, we decline to offeran exhaustive list of available methods.However, given the range of methodsavailable specifically for oral languageassistance, proposed paragraph (1)identifies the following as availablemethods to communicate orally withindividuals with limited English

proficiency: Oral interpretation (in-person or remotely) 18 and directcommunication through the use of

bilingual and multilingual staffcompetent to communicate directly, innon-English languages using anynecessary specialized vocabulary, withindividuals with limited Englishproficiency.

On the basis of sex. The term ‘‘on the basis of sex’’ is defined to include, butis not limited to, discrimination on the

basis of pregnancy, false pregnancy,termination of pregnancy, or recoverytherefrom, childbirth or related medical

conditions, sex stereotyping, or genderidentity.Section 1557 extends the grounds for

discrimination found innondiscrimination laws (i.e., race, color,national origin, sex, age, or disability) tocertain health programs and activities.The HHS Title IX regulation explicitlyincludes discrimination on the basis ofpregnancy as a form of discriminationon the basis of sex, and the definitionin this section mirrors that regulation.See 45 CFR 86.40(b) (prohibitingdiscrimination on the basis of‘‘pregnancy, childbirth, false pregnancy,termination of pregnancy or recovery

therefrom’’).The proposed inclusion of sex

stereotyping reflects the SupremeCourt’s holding in Price Waterhouse v.Hopkins, 490 U.S. 228, 250–51 (1989),that discrimination based onstereotypical notions of appropriate

behavior, appearance or mannerisms foreach gender constitutes sexdiscrimination.

We propose that discrimination onthe basis of sex further includes

discrimination on the basis of genderidentity. OCR has previously interpretedsex discrimination to includediscrimination on the basis of genderidentity.19 Other Federal agencies havesimilarly interpreted the meaning of sexdiscrimination.20 In addition, courts,including in the context of Section1557, have recognized that sexdiscrimination includes discrimination

based on gender identity.21 We thuspropose to formally adopt this well-accepted interpretation ofdiscrimination ‘‘on the basis of sex.’’

As a matter of policy, we support banning discrimination in healthprograms and activities not only on the

bases identified previously, but also onthe basis of sexual orientation. Currentlaw is mixed on whether existingFederal nondiscrimination laws prohibitdiscrimination on the basis of sexualorientation as a part of their

prohibitions of sex discrimination. Todate, no Federal appellate court hasconcluded that Title IX’s prohibition ofdiscrimination ‘‘on the basis of sex’’—orFederal laws prohibiting sexdiscrimination more generally—prohibits sexual orientationdiscrimination, and some appellate

courts previously reached the oppositeconclusion.22

However, a recent EEOC decisionconcluded that Title VII’s prohibition ofdiscrimination ‘‘on the basis of sex’’precludes sexual orientationdiscrimination because discriminationon the basis of sexual orientationnecessarily involves sex-based

considerations. The EEOC relied onseveral theories to reach thisconclusion: A plain interpretation of theterm ‘‘sex’’ in the statutory language, anassociational theory of discrimination

based on ‘‘sex,’’ and the gender-stereotype theory announced in PriceWaterhouse.23 The EEOC’s decisioncited several district court decisions thatsimilarly concluded that sexdiscrimination included sexualorientation discrimination, using thesetheories.24 The EEOC also analyzed andcalled into question the appellatedecisions that have concluded that

sexual orientation discrimination is notcovered under Title VII. The EEOCdecision applies to workplaceconditions, as well as hiring, firing, andpromotion decisions, and is one ofseveral recent developments in the lawthat have resulted in additionalprotections for lesbian and gayindividuals against discrimination.25


http://www.lep.gov/faqs/042511_Q&A_EO_13166.pdfhttp://www.lep.gov/faqs/042511_Q&A_EO_13166.pdfhttp://www.lep.gov/faqs/042511_Q&A_EO_13166.pdfhttp://www.lep.gov/faqs/042511_Q&A_EO_13166.pdfhttp://www.lep.gov/faqs/042511_Q&A_EO_13166.pdfhttp://www.lep.gov/faqs/042511_Q&A_EO_13166.pdfhttp://www.lep.gov/faqs/042511_Q&A_EO_13166.pdfhttp://www.bls.gov/ooh/media-and-communication/interpreters-and-translators.htmhttp://www.bls.gov/ooh/media-and-communication/interpreters-and-translators.htmhttp://www.bls.gov/ooh/media-and-communication/interpreters-and-translators.htmhttp://www.dol.gov/ofccp/regs/compliance/directives/dir2014_02.htmlhttp://www.dol.gov/ofccp/regs/compliance/directives/dir2014_02.htmlhttp://www.dol.gov/ofccp/regs/compliance/directives/dir2014_02.htmlhttp://www.dol.gov/ofccp/regs/compliance/directives/dir2014_02.htmlhttp://www.dol.gov/ofccp/regs/compliance/directives/dir2014_02.htmlhttp://www2.ed.gov/about/offices/list/ocr/docs/qa-201404-title-ix.pdfhttp://www2.ed.gov/about/offices/list/ocr/docs/qa-201404-title-ix.pdfhttp://www2.ed.gov/about/offices/list/ocr/docs/qa-201404-title-ix.pdfhttp://www.lep.gov/faqs/042511_Q&A_EO_13166.pdfhttp://www.lep.gov/faqs/042511_Q&A_EO_13166.pdfhttp://www.dol.gov/ofccp/regs/compliance/directives/dir2014_02.htmlhttp://www.dol.gov/ofccp/regs/compliance/directives/dir2014_02.htmlhttp://www2.ed.gov/about/offices/list/ocr/docs/qa-201404-title-ix.pdfhttp://www2.ed.gov/about/offices/list/ocr/docs/qa-201404-title-ix.pdfhttp://www.bls.gov/ooh/media-and-communication/interpreters-and-translators.htmhttp://www.bls.gov/ooh/media-and-communication/interpreters-and-translators.htmhttp://www.bls.gov/ooh/media-and-communication/interpreters-and-translators.htm


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the Supreme Court ruled that States may notprohibit same-sex couples from marrying and mustrecognize the validity of same-sex couples’marriages.

26See HHS LEP Guidance, supra n. 17, 68 FR at47316 (explaining that an individual’s proficiencyin another language, knowledge of specializedterminology, and adherence to interpreter ethics areconsiderations in determining competency tointerpret); id. at 47317–18 and 47323 (discussingwhy family members, friends, and ad hoc

interpreters may not be competent to interpret); seealso, e.g., Voluntary Resolution Agreement betweenU.S. Dep’t of Health & Human Servs., Office forCivil Rights and Mee Memorial Hosp., OCRTransaction Nos. 12–143846, 13–1551016, & 13–153378, pt. II.J. (2014), available at http:// www.hhs.gov/ocr/civilrights/activities/agreements/ mee.html (defining qualified interpreter); VoluntaryResolution Agreement between U.S. Dep’t of Health& Human Servs., Office for Civil Rights andMontgomery County Dep’t of Soc. Servs., OCRTransaction No. 08–79992, pts. II.E (definingqualifications of an ‘‘interpreter’’ under theagreement), IV.H (requiring timely, competentlanguage assistance); & IV.L (identifying interpreterstandards), available at http://www.hhs.gov/ocr/ civilrights/activities/examples/LEP/mcdssra.html .

27See supra n. 2.28See Brief of the U.S. Equal Employment

Opportunity Commission as Amicus Curiae inSupport of Rehearing, Muhammad v. CaterpillarInc., No. 12–1723 at 4 (7th Cir. filed Oct. 9, 2014).

29The HHS LEP Guidance, supra n. 17, describesthe practice of tagging non-English statements in‘‘brochures, booklets, and in outreach andrecruitment information’’ informing individuals

with limited English proficiency of the availabilityof language assistance services. See id. at 47,320(explaining how statements in non-Englishlanguages ‘‘could be ‘tagged’ onto the front ofcommon documents.’’).

The final rule should reflect thecurrent state of nondiscrimination law,including with respect to prohibited

bases of discrimination. We seekcomment on the best way of ensuringthat this rule includes the most robustset of protections supported by thecourts on an ongoing basis.

Qualified individual with a disability.The definition of ‘‘qualified individualwith a disability’’ is the same aslanguage in the ADA and the regulationimplementing Title II of the ADA, at 42U.S.C. 12131(2) and 28 CFR 35.104,respectively, except that the definitionhas been modified to apply in thecontext of a health program or activity.

Qualified interpreter. The term‘‘qualified interpreter’’ means anindividual who has the characteristicsand skills necessary to interpret for anindividual with a disability, for anindividual with limited English

proficiency, or for both. The language inparagraph (1) applicable for interpretingfor an individual with a disability is thesame as language in the regulationsimplementing the ADA, at 28 CFR35.104, 36.104. The language inparagraph (2) applicable for interpretingfor an individual with limited Englishproficiency reflects a synthesis of theattributes, described in the Department’sLEP Guidance, that are necessary for anindividual to interpret competently andeffectively under the circumstances andthus to provide the effective orallanguage assistance services required

under the law.26

The fact that anindividual has above average familiaritywith speaking or understanding alanguage other than English does notsuffice to make that individual a

qualified interpreter for an individualwith limited English proficiency.

The definition of ‘‘qualifiedinterpreter’’ includes criteria regardinginterpreter ethics, including clientconfidentiality. Because the definitionof a qualified interpreter includesadherence to generally acceptedinterpreter ethics principles, bilingual

or multilingual staff who are competentto communicate directly withindividuals with limited Englishproficiency nonetheless may not satisfya requirement to adhere to suchprinciples. For instance, a bilingualnurse who is competent to communicatein Spanish directly with Spanish-speaking individuals with limitedEnglish proficiency may not be a‘‘qualified interpreter’’ if serving as aninterpreter would pose a conflict ofinterest with the nurse’s treatment of thepatient.

Recipient. The term ‘‘recipient’’ is the

same as language in the regulationimplementing Title IX at 45 CFR86.2(h), except that it has been modifiedto apply in the context of a healthprogram or activity.27

Sex stereotypes. The term ‘‘sexstereotypes’’ refers to stereotypicalnotions of masculinity or femininity,including expectations of howindividuals represent or communicatetheir gender to others, such as behavior,clothing, hairstyles, activities, voice,mannerisms, or body characteristics.These stereotypes can includeexpectations that gender can only beconstructed within two distinctopposite and disconnected forms(masculinity and femininity), and thatgender cannot be constructed outside ofthis gender construct (individuals whoidentify as neither, both, or acombination of male and female). Thisdefinition is consistent with theapproach taken by the Federalgovernment in similar matters.28

State-based Marketplace. The term‘‘State-based Marketplace’’ means anExchange operated by a State with theapproval of the Department pursuant to45 CFR 155.105.

Taglines. Taglines are short

statements written in non-Englishlanguages to alert individuals withlimited English proficiency to theavailability of language assistanceservices free of charge.29 For instance, a

tagline in Tagalog appearing on anEnglish language document serves tonotify Tagalog-speaking individualswith limited English proficiency thatlanguage assistance services, such asoral interpretation services through aqualified interpreter, are available andhow they can be obtained.

Title I Entity. Title I of the ACA

established Health InsuranceMarketplaces, including the State-basedMarketplaces and Federally-facilitatedMarketplaces. The Federally-facilitatedMarketplaces are also a health programor activity operated by the Department.

Assurances Required (§92.5)

Section 92.5 proposes that each entityapplying for Federal financialassistance, each issuer seekingcertification to participate in a HealthInsurance Marketplace, and each Stateseeking approval to operate a State-

based Marketplace be required to submitan assurance that its health programsand activities will be operated incompliance with Section 1557 and thispart. The regulations implementingTitle VI, Title IX, Section 504, and theAge Act all require similar assurances.We modeled the assurance, duration ofobligation, and covenants language onthe Section 504 regulation, at 45 CFR84.5. To reduce burden on coveredentities, OCR is revising the Assuranceof Compliance HHS–690 Form toinclude all civil rights laws, includingSection 1557, with which coveredentities must comply.

Remedial Action and Voluntary Action(§ 92.6)

Section 92.6 proposes provisionsaddressing remedial action andvoluntary action by covered entities.Paragraph (a) proposes that a recipientor State-based Marketplace that has

been found to have discriminated onany of the bases prohibited by Section1557 be required to take remedial actionas required by the Director to overcomethe effects of that discrimination. TheDepartment, including the Federally-facilitated Marketplaces, like recipientsand State-based Marketplaces, is alsoobligated to address discrimination, butis subject to a different remedial processthan recipients and State-basedMarketplaces. See proposed § 92.303.

Proposed paragraph (b) permits, butdoes not require, all covered entities totake voluntary action in the absence ofa finding of discrimination to overcomethe effects of conditions that result or


http://www.hhs.gov/ocr/civilrights/activities/agreements/mee.htmlhttp://www.hhs.gov/ocr/civilrights/activities/agreements/mee.htmlhttp://www.hhs.gov/ocr/civilrights/activities/agreements/mee.htmlhttp://www.hhs.gov/ocr/civilrights/activities/examples/LEP/mcdssra.htmlhttp://www.hhs.gov/ocr/civilrights/activities/examples/LEP/mcdssra.htmlhttp://www.hhs.gov/ocr/civilrights/activities/examples/LEP/mcdssra.htmlhttp://www.hhs.gov/ocr/civilrights/activities/agreements/mee.htmlhttp://www.hhs.gov/ocr/civilrights/activities/agreements/mee.htmlhttp://www.hhs.gov/ocr/civilrights/activities/agreements/mee.htmlhttp://www.hhs.gov/ocr/civilrights/activities/examples/LEP/mcdssra.htmlhttp://www.hhs.gov/ocr/civilrights/activities/examples/LEP/mcdssra.html


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resulted in limited participation bypersons based on race, color, nationalorigin, sex, age, or disability. Theprovisions at §92.6(a) and (b) aremodeled after the Title VI, Title IX,Section 504, and Age Act regulations.

Designation of Responsible Employeeand Adoption of Grievance Procedures

(§ 92.7)Proposed §92.7 outlines the

requirement for covered entities thatemploy 15 or more persons to designatea responsible employee and adoptgrievance procedures. Theimplementing regulations for Section504 and Title IX contain suchrequirements. Moreover, through itscase investigative experience, OCR hasobserved that the presence of acoordinator and a grievance procedurehelp to bring concerns to promptresolution within the entity, leading tolower compliance costs and moreefficient outcomes. We thus propose inthis provision to apply theserequirements to all bases of prohibiteddiscrimination.

Paragraph (a) proposes that coveredentities that employ 15 or more personsdesignate at least one employee tocoordinate compliance with therequirements of the rule. A coveredentity that has already designated aresponsible employee pursuant to theregulations implementing Section 504or Title IX may use that individual tocoordinate its efforts to comply withSection 1557 or this part, provided thatthe scope of the individual’s

responsibilities is modified to includeall prohibited bases of discriminationincluded in Section 1557 and otherduties as required by Section 1557 orthis part. For the Department, includingFederally-facilitated Marketplaces, OCRwill be deemed the responsibleemployee.

Paragraph (b) proposes that coveredentities that employ 15 or more persons

be required to adopt grievanceprocedures and appropriate due processstandards that would allow for theprompt and equitable resolution ofcomplaints concerning actions

prohibited by Section 1557 and thispart. Covered entities that already havea grievance procedure in place pursuantto the regulation implementing Section504 may use that procedure to addressclaims under Section 1557 or this part,provided that the existing proceduremeets the standards established underthe Section 504 regulation. In addition,covered entities may use that procedureto address all other Section 1557 claims,provided that that procedure meets thestandards under the Section 504regulation and that the procedure is

modified to apply to race, color,national origin, sex, and agediscrimination claims. For theDepartment, including Federally-facilitated Marketplaces, the proceduresfor addressing complaints ofdiscrimination on the grounds coveredunder Section 1557 will be deemedgrievance procedures.

OCR is considering requiring that allcovered entities, not just those thatemploy 15 or more persons, designate aresponsible employee and establishgrievance procedures. While Section504 limits these requirements torecipients with 15 or more employees,Title IX applies them to all recipientsthat operate educational programs oractivities, regardless of the size of therecipient. Following the approach ofTitle IX would lead to a broaderapplication under Section 1557 thatwould benefit more individuals byreaching more covered entities and

allowing covered entities to address anypotential compliance issues at an earlierstage and in a less formal manner thanan OCR investigation. We invitecomment on this proposal, includingany associated costs and benefits.

Notice Requirement (§92.8)

Section 92.8 proposes that eachcovered entity take initial andcontinuing steps to notify beneficiaries,enrollees, applicants, or members of thepublic of certain important information.We modeled this section generally afterthe notice requirements found inregulations implementing Title VI, Title

IX, Section 504, and the Age Act, whichrequire covered entities to have a noticein place.

Paragraphs (a)(1)–(7) of §92.8 proposethe components of the notice that eachcovered entity is required by § 92.8(b)and (f) to post.

Paragraph (a)(1) proposes that thenotice include that the covered entitydoes not discriminate on the basis ofrace, color, national origin, sex, age, ordisability.

Paragraphs (a)(2) and (a)(3) proposethat the notice include a statement thatthe covered entity provides auxiliary

aids and services, free of charge, in atimely manner, to individuals withdisabilities, when such aids andservices are necessary to provide anindividual with a disability an equalopportunity to benefit from the entity’shealth programs or activities; andlanguage assistance services, free ofcharge, in a timely manner, toindividuals with limited Englishproficiency, when those services arenecessary to provide an individual withlimited English proficiency meaningfulaccess to a covered entity’s health

programs or activities. These provisionsare necessary to ensure that individualsare aware of their rights under the law,and are grounded in OCR’s experiencethat failures of communication based onthe absence of auxiliary aids andservices and language assistanceservices raise particularly significantcompliance concerns. In addition, such

failures of communication often are aprimary contributor to limitations inaccess to health programs and activitiesfor individuals with disabilities andindividuals with limited Englishproficiency. Apprising individuals ofthe availability of communicationassistance under Section 1557 willpromote both compliance with the lawand better health outcomes.

Paragraph (a)(4) proposes that thenotice include information on how anindividual can access the aids andservices referenced in (a)(2) and (a)(3).

Paragraph (a)(5) proposes that thenotice provide contact information forthe responsible employee, where such aresponsible employee is required by§ 92.7(a).

Paragraph (a)(6) proposes that thenotice include the availability of thegrievance procedure, where such agrievance procedure is required by§ 92.7(b), and information on how to filea grievance.

Paragraph (a)(7) proposes that thenotice provide information on how tofile a complaint with OCR. Inclusion ofthis requirement ensures that coveredentities inform individuals about theenforcement mechanisms outside of the

covered entity’s internal process.Paragraph (b) provides that within 90

days of the effective date of this part,each covered entity shall post thenotice, consistent with paragraph (f) ofthis section, that conveys theinformation in English in paragraph(a)(1) through (7) of this section.

Paragraph (c) provides that theDirector shall make available anelectronic sample notice in English thatcontains the content listed in, and meetsthe requirements of, paragraphs (a)(1)through (7). Covered entities may usethis sample notice or may develop their

own notices that meet the requirementsof paragraphs (a)(1) through (7). Werequest comment on the sample noticeincluded in Appendix A to thisproposed rule.

OCR also invites comment on whetherthis proposed rule should permitcovered entities to combine the contentof the notice required under theproposed rule with the content of othernotices that covered entities may berequired to disseminate or post underFederal laws and, if so, what stepscovered entities may or should take to



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30See U.S. Dep’t of Commerce, U.S. CensusBureau, American FactFinder, Language Spoken atHome by Ability to Speak English for thePopulation 5 Years and Older, 3-Year AmericanCommunity Survey (ACS), Estimates (2011–2013),http://factfinder.census.gov/faces/tableservices/jsf/ pages/productview.xhtml?pid=ACS _13 _3YR _

B16001&prodType=table (last visited Mar. 27,2015). The most recent ACS data available are the2013 estimates. OCR chose the three-year data set(as opposed to the one-year or five-year data) because it best balances the currency and stabilityof the data. The top 15 languages in which OCRplans to translate the notice excludes bundledlanguage groups, such as ‘‘other Indo-Europeanlanguages’’ and ‘‘other Pacific Islander languages.’’The top 15 foreign languages, ordered from high tolow estimates of number of individuals speakingEnglish less than ‘‘very well,’’ are Spanish (orSpanish Creole), Chinese, Vietnamese, Korean,Tagalog, Russian, Arabic, French Creole, French(including Patois and Cajun), Portuguese (orPortuguese Creole), Polish, Japanese, Italian,German, and Persian (Farsi).

31See, e.g., HHS LEP Guidance, supra n. 17 at 68FR at 47320 (discussing ways to identify theprimary languages in which individuals withlimited English proficiency communicate andconsiderations for notifying individuals withlimited English proficiency of language assistanceservices).

32See HHS LEP Guidance, id at 68 FR at 47320.

ensure that the content of the noticerequired by the proposed rule issufficiently conspicuous and visible to

beneficiaries, enrollees, applicants, ormembers of the public that they are ableto become aware of the content of thenotice. In addition, OCR invitescomment on whether this proposed ruleshould allow the notice to be modified

to be appropriate for publications andother communication vehicles that maynot have sufficient space toaccommodate the full notice, e.g.,postcards, trifold brochures, and socialmedia platforms and, if so, whatinformation such a modified noticeshould include.

Paragraph (c) also proposes that theDirector shall translate the samplenotice into the top 15 languages 30 spoken by individuals with limitedEnglish proficiency nationally and makethe translated notices available tocovered entities electronically and in

any other manner the Directordetermines appropriate. Assigning toOCR the responsibility to translate thesample notice maximizes efficiency andeconomies of scale. This approachmeans covered entities will receive the

benefits of having multi-languagenotices available without incurring theassociated translation costs. We expectthat making the sample notice availablein non-English languages willsubstantially increase the value andutility of the notice required inparagraphs (a) and (b) of § 92.8.

Under our proposed approach,covered entities are encouraged, but notrequired, to post one or more of thetranslated notices, particularly in themost prevalent languages spoken byindividuals with limited Englishproficiency in the covered entities’geographic service areas, as determined

by the covered entities. Covered entitiesalso may make the notice available in

non-English languages other than thetop 15 languages for which translatednotices are provided by the Director. Weencourage covered entities to make thecontent of the notice available inadditional non-English languages toinform national origin groups withincovered entities’ geographic serviceareas of their rights under Section 1557

and this proposed rule.In lieu of this approach, OCR

considered requiring, rather than merelyencouraging, covered entities to postone or more of the notices in the mostprevalent non-English languagesfrequently encountered by coveredentities in their geographic serviceareas, such as Spanish. This optionwould leverage the OCR-translatednotices and improve, for certainnational origin populations, access tothe information in the notice in alanguage that those individuals withlimited English proficiency could

understand. The main disadvantage ofthis option is the burden of usingphysical wall space to post notices andusing information technology staff/resources for web posting of notices andprinting of notices. For the purposes ofthis proposed rule, we believe theavailability of the taglines that §92.8(d)of this proposed rule requires coveredentities to post strikes an appropriate

balance. We seek comment on thealternate approach.

With regard to the proposal that theDirector provide translations of thesample notice, we selected the top 15languages spoken by individuals with

limited English proficiency nationallyas a data driven policy. This scopereaches nearly 90 percent of individualswith limited English proficiency in theUnited States based on the U.S. CensusBureau’s 2011 to 2013 data—the mostrecent three-year data available—thatestimates the prevalence of foreign-language speakers who speak Englishless than ‘‘very well.’’ We will reviewU.S. Census Bureau data more recentthan 2011 to 2013, as the data becomesavailable, to determine if and when thetop 15 languages spoken nationally byindividuals with limited English

proficiency change, warranting theDirector to make available noticestranslated in additional non-Englishlanguages.

Paragraph (d) proposes that within 90days of the effective date of this part,each covered entity shall post,consistent with paragraph (f) of thissection, taglines in the top 15 languagesspoken nationally by individuals withlimited English proficiency.

Paragraph (e) proposes that theDirector shall make available taglines inthe top 15 languages spoken nationally

by individuals with limited Englishproficiency for use by covered entities.Taglines have a high utility as a gatewayto language assistance services: They arewritten in non-English languages thatindividuals with limited Englishproficiency can understand, informthose individuals how to accesslanguage assistance services, and

encourage those individuals to identifythemselves and the languages in whichthey communicate.31 The Department’sLEP Guidance describes the practice oftagging non-English statements inpublications and informationalmaterials.32

We request comment on the contentof the sample tagline included inAppendix B to this proposed rule. Aswith our approach to making availabletranslated notices, assigning to OCR theresponsibility to provide translatedtaglines maximizes efficiency andeconomies of scale. This approach

means that covered entities will receivethe benefits of having multi-languagetaglines available without incurring theassociated translation costs. For thisreason, we anticipate covered entitieswill use the translated taglines that theDirector makes available. Coveredentities are not limited to postingtaglines in the 15 languages madeavailable by the Director; coveredentities may provide taglines in as manyother non-English languages asappropriate to alert national origingroups in the covered entity’sgeographic service area of languageassistance services that may be

available.Paragraph (f) of this section prescribes

the location for posting both notices andtaglines. Specifically, the proposed rulerequires that covered entities post theEnglish-language notice required by§ 92.8(a) and (b) and the taglinesrequired by §92.8(d) in aconspicuously-visible font size in:Significant publications or significantcommunications targeted to

beneficiaries, enrollees, applicants, ormembers of the public, which mayinclude patient handbooks, outreachpublications, or written notices

pertaining to rights or benefits orrequiring a response from an individual;in conspicuous physical locations; andin a conspicuous location on the homepage of a covered entity’s Web site.Section 92.8(f) specifically states that a


http://factfinder.census.gov/faces/tableservices/jsf/pages/productview.xhtml?pid=ACS_13_3YR_B16001&prodType=tablehttp://factfinder.census.gov/faces/tableservices/jsf/pages/productview.xhtml?pid=ACS_13_3YR_B16001&prodType=tablehttp://factfinder.census.gov/faces/tableservices/jsf/pages/productview.xhtml?pid=ACS_13_3YR_B16001&prodType=tablehttp://factfinder.census.gov/faces/tableservices/jsf/pages/productview.xhtml?pid=ACS_13_3YR_B16001&prodType=tablehttp://factfinder.census.gov/faces/tableservices/jsf/pages/productview.xhtml?pid=ACS_13_3YR_B16001&prodType=tablehttp://factfinder.census.gov/faces/tableservices/jsf/pages/productview.xhtml?pid=ACS_13_3YR_B16001&prodType=tablehttp://factfinder.census.gov/faces/tableservices/jsf/pages/productview.xhtml?pid=ACS_13_3YR_B16001&prodType=tablehttp://factfinder.census.gov/faces/tableservices/jsf/pages/productview.xhtml?pid=ACS_13_3YR_B16001&prodType=tablehttp://factfinder.census.gov/faces/tableservices/jsf/pages/productview.xhtml?pid=ACS_13_3YR_B16001&prodType=tablehttp://factfinder.census.gov/faces/tableservices/jsf/pages/productview.xhtml?pid=ACS_13_3YR_B16001&prodType=tablehttp://factfinder.census.gov/faces/tableservices/jsf/pages/productview.xhtml?pid=ACS_13_3YR_B16001&prodType=table


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33Qualified health plan means the same as‘‘Qualified health plan’’ defined in 45 CFR 155.20.

34See 45 CFR 155.205(c)(2)(iii)(A) through (C).

3542 U.S.C. 2000e et seq.3629 U.S.C. 621 et seq.37This approach is consistent with the coverage

of the Age Act and Title VI, which explicitlyexclude discrimination in employment, subject, inthe case of Title VI, to certain exceptions notapplicable here. See 45 CFR 91.3(b)(2) (excludingemployment from application of the regulationimplementing the Age Act); 80.2(d) (excludingemployment from application of the regulationimplementing Title VI); 80.3(c), (d)(3) (exceptions tothe exclusion of employment discrimination underthe regulation implementing Title VI). Moreover,while Section 504 and Title IX, which are silent onthe question, have been interpreted to bar

discrimination in employment, thoseinterpretations were based on analyses of thepurposes underlying the Rehabilitation Act and onextensive discussion of employment in thelegislative history of Title IX. Consolidated RailCorp. v. Darrone, 465 U.S. 624, 626 (1984)(promoting and expanding employmentopportunities for handicapped individuals is astated purpose of the Rehabilitation Act, 29 U.S.C.701(8), and legislative history demonstrates thatCongressional intent to bar employmentdiscrimination was a focus of the Act); North HavenBd. of Ed. V. Bell, 456 U.S. 512, 522–530 (1982)(statutory language favors inclusion of employmentdiscrimination and legislative history corroboratesCongressional intent to prohibit sex discriminationin employment in Title IX). Our approach in the

covered entity may post the notice andtaglines in additional publications andcommunications beyond those listed inparagraphs (f)(1) through (3) of § 92.8.We seek comments on additional waysto define the scope of the significantpublications and significantcommunications.

We propose to require the notice and

taglines on a covered entity’s Web siteto be located conspicuously on thehome page so that individuals,generally, are aware of their rights, andindividuals with limited Englishproficiency do not have to navigateEnglish-only text to find information inthe individual’s language. Coveredentities may satisfy the requirement topost the notice on the covered entity’sWeb site by including a link in aconspicuous location on the coveredentity’s home page that immediatelydirects the individual to the content ofthe notice on the covered entity’s Web

site. Covered entities may satisfy therequirement to post taglines on thecovered entity’s Web site by includingweb links conspicuously on the homepage that identify each of the 15 non-English languages, written ‘‘inlanguage,’’ and that direct theindividual to the full text of the taglineindicating how the individual mayobtain language assistance services. Forinstance, a tagline web link directing aSpanish-speaking individual with LEPto a Spanish-language tagline shouldappear as ‘‘Espan ˜ ol’’ rather than‘‘Spanish.’’ Similarly, a tagline directingan individual to a Web site with the full

text of a tagline written in HaitianCreole should appear as ‘‘KreyòlAyisien’’ rather than ‘‘Haitian Creole.’’Providing tagline web links and the textof taglines in their respective non-English languages is of particularimportance for languages that do not usea Latin script.

Covered entities that distributegeneral or major publications targeted to

beneficiaries, enrollees, applicants, ormembers of the public will need toupdate these publications to include thenew notice. However, we proposeallowing entities to exhaust their

current stock of hard copy publications,rather than requiring a special printingof the publications to include the newnotice. When covered entities restocktheir printed materials, they will beexpected to include in those printedmaterials the notice that we arepromulgating with the final rule.

Because the top 15 languages spoken by individuals with limited Englishproficiency nationally may be over-inclusive or under-inclusive of thelanguages spoken by individuals withlimited English proficiency within the

areas served by covered entities’ healthprograms and activities, OCRconsidered a State-based methodologyfor identifying the languages in whichcovered entities would be required topost taglines. For instance, weconsidered proposing a requirement forentities to make available taglines in thetop 15 languages spoken statewide,

rather than nationwide, by individualswith limited English proficiency.Identifying a State-based thresholdaligns with Federal regulationsgoverning the Health InsuranceMarketplaces and qualified healthplan 33 issuers.34 Under this approach,OCR would make available to coveredentities translated taglines for the non-English languages constituting the top15 languages spoken statewide byindividuals with limited Englishproficiency. We seek comment on thisalternate methodology, specificallyregarding the geographic areas or service

areas that should apply for determininga threshold number of languages inwhich the Director should translate andmake available, or for which coveredentities should post, taglines.

To reduce the burden on coveredentities, proposed subsection (g) of thissection states that a covered entity’scompliance with §92.8 satisfies thenotice requirements under HHS’ TitleVI, Section 504, Title IX, and Age Actregulations. We request comment onOCR’s proposal to treat compliance with§ 92.8 as satisfying the noticerequirements under the regulations

implementing Title VI, Section 504,Title IX, and the Age Act.

Subpart B—NondiscriminationProvisions

Subpart B of the proposed ruleincorporates regulatory provisionsimplementing the civil rights statutesreferenced in Section 1557(a): Title VI,Title IX, the Age Act, and Section 504.

Discrimination Prohibited (§92.101)

Proposed §92.101 of subpart Bprohibits discrimination on the basis ofrace, color, national origin, sex, age, ordisability under any health program or

activity to which Section 1557 or thispart applies. Paragraphs (a) and (b) of§ 92.101 follow the structure of theimplementing regulations for Title VI,Section 504, Title IX, and the Age Act

by including a generalnondiscrimination provision inparagraph (a) followed by a provisionidentifying specific discriminationprohibited in paragraph (b). Exceptions

to discrimination prohibited under theTitle VI, Section 504, and Age Actregulations are addressed in paragraph(c). Paragraph (d) effectuates technicalchanges in terminology to apply theprovisions incorporated from otherregulations to the covered entitiesobligated to comply with this proposedrule.

General Discriminatory ActionsProhibited § 92.101(a)

In paragraph (a)(1) of §92.101, werestate the core objective of Section1557(a), which prohibits discriminationon the grounds prohibited under TitleVI (race, color, or national origin), TitleIX (sex), the Age Act (age), or Section504 (disability) in any health program oractivity to which this part applies.

In paragraph (a)(2), we propose tolimit the ways in which the proposedrule applies to employment. Except asprovided in §92.208, which addressesemployee health benefit programs, thisproposed rule does not apply todiscrimination by a covered entityagainst its own employees. Thus, thisproposed rule would not extend tohiring, firing, promotions, or terms andconditions of employment outside ofthose identified in §92.208; such claimswould continue to be brought underother laws, including Title VII of theCivil Rights Act of 1964,35 Title IX,Section 504, the ADA and the AgeDiscrimination in Employment Act,36 asappropriate. We believe that thisapproach is consistent with the purposeof the ACA and with Section 1557’s

focus on discrimination in healthprograms and activities.37 We invite



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proposed rule is not intended to alter the scope ofeither Section 504 or Title IX in this regard.

3845 CFR 147.102(a)(1)(iii). This is also consistentwith language in the Section 1557 provision, whichstates that a person is protected from discrimination‘‘[e]xcept as otherwise provided for in this title.’’

comment on our proposal to excludethese forms of employmentdiscrimination from the scope of thisproposed rule.

Specific Discriminatory ActionsProhibited § 92.101(b)

Proposed paragraph (b) incorporatesinto this proposed regulation the

specific discriminatory actionsprohibited by each civil rights statutewhich Section 1557 references. Weconsidered harmonizing each of thespecific discriminatory actionsprohibited across each civil rights lawaddressed by Section 1557. Althoughharmonization could reduceredundancy in the specificdiscriminatory actions incorporated thatare similar to one another,harmonization would likely lead toconfusion and unintended differencesin interpretation that are subtle yetsignificant. For example, with respect to

the separate or different treatmentprohibited under the Title VI regulation,such as at 45 CFR 80.3(b)(1)(iii) and (vi),the Section 504 regulation at 45 CFR84.4(b)(1)(iv), 85.21(b)(1)(iv) requiresseparate or different treatment in someinstances where it is necessary toprovide persons with disabilities withaids, benefits or services that are aseffective as those provided to others. Toavoid confusion and unintendeddifferences in interpretation, therefore,paragraphs (b)(1)–(4) incorporate intothis proposed regulation the specificdiscriminatory actions prohibited undereach civil rights law on which Section1557 is grounded. Thus, for example,the specific discriminatory actionslisted under Title VI are incorporatedhere to govern the obligations of coveredentities not to discriminate based onrace, color, or national origin. We seekcomments on this proposed approach.

Proposed paragraph (b)(1) of § 92.101adopts the specific discriminatoryactions prohibited by the Title VIimplementing regulation, which appearin 45 CFR 80.3(b)(1) through (6).

Proposed paragraph (b)(2)(i) of§ 92.101 addresses the specificprohibition of discrimination on the

basis of disability with which recipientsand State-based Marketplaces mustcomply. This paragraph adopts relevantprovisions in the Section 504implementing regulation for Federallyassisted programs and activities at 45CFR part 84. The provisionsincorporated are the specificdiscriminatory actions prohibited at

§ 84.4(b); the program accessibilityprovisions at §§84.21 through 84.23(b);and the provisions governing education,health, welfare, and social services at§§ 84.31, 84.34, 84.37, 84.38, and 84.41–84.55. We do not propose adopting theprogram accessibility provision at§ 84.23(c), addressing conformance withthe Uniform Federal Accessibility

Standards for the construction andalteration of facilities, because thesestandards are outdated. Section 92.203of this proposed rule requirescompliance with more contemporarystandards.

Paragraph (b)(2)(ii) of §92.101addresses the specific prohibitions ofdiscrimination on the basis of disabilitywith which the Department, includingthe Federally-facilitated Marketplaces,must comply. This paragraph adoptsrelevant provisions in the Section 504implementing regulation for Federallyadministered programs and activities at

45 CFR part 85. The provisions adoptedare the specific discriminatory actionsprohibited at §85.21(b) and the programaccessibility provisions at §§85.41through 85.42 and 84.44 through 84.51.

Paragraph (b)(3) of §92.101 adopts thespecific discriminatory actionsprohibited by the Title IX implementingregulation, which appear at 45 CFR86.3(b)(1) through (8).

Paragraph (b)(4) of §92.101 adopts thespecific discriminatory actionsprohibited by the Age Act implementingregulation, which appear at 45 CFR91.11(b).

Paragraph (b)(5) of §92.101 states thatthe specific discriminatory actionsprohibited in §92.101(b)(1) through (4)do not limit the general prohibition ofdiscrimination in § 92.101(a). Thisstatement is consistent with regulatoryprovisions in the implementingregulations for Title VI at 45 CFR80.3(b)(5) and the Age Act at 45 CFR91.11(c).

Paragraph (c) of § 92.101 incorporatesthe exceptions to the general prohibitionof discrimination that appear in theimplementing regulations for Title VI,Section 504, and the Age Act, as theseexceptions have applied to health

programs and activities for nearly 40years. Generally, the exceptions in theTitle VI, Section 504, and Age Actimplementing regulations provide that itis not discriminatory to exclude aperson from the benefits of a programthat Federal law or executive orderlimits to a protected class. For instance,we incorporate the exceptions in theAge Act implementing regulation whichaddress, among other things, agedistinctions in Departmental

regulations, and actions based on agewhere age is a factor necessary to thenormal operation or achievement of astatutory objective of a program oractivity. This would include allowableage rating under the ACA where issuersmay vary premium rates based on agewithin a 3:1 ratio.38

Paragraph (c) of §92.101 does not

address the sex-based distinctionsauthorized in Title IX and itsimplementing regulation in the contextof education programs or activities. Asdiscussed previously, given Title IX’slimitation to education programs andactivities, these distinctions do notnecessarily apply in the health carecontext.

Title IX and its implementingregulation allow some single-sexeducation programs (e.g., separate toilet,locker room, and shower facilities ineducation programs and activities;contact sports in physical education

classes; classes on human sexuality; andchoruses) when certain requirements aremet. Thirty organizations that filedcomments in response to the RFIindicated that, to the extent single-sexprograms are permitted under Section1557 or this part, they should benarrowly tailored and necessary toaccomplish an essential health purpose.Some commenters also indicated thatsingle-sex programs should bepermissible when they are necessary toserve the disadvantaged sex or tocomply with constitutionally protectedrights to privacy. Nearly 20

organizational commenters urged that,in the very narrow circumstances wheresingle-sex programs or activities arepermitted, Section 1557 should requireequal access for all individuals in amanner consistent with their self-identified gender.

HHS does not propose to prohibitseparate toilet, locker room, and showerfacilities where comparable facilities areprovided to individuals, regardless ofsex. However, we continue to seekcomment on what other sex-baseddistinctions, if any, should be permittedin the context of health programs and

activities and the standards forpermitting the distinctions (see also theprevious discussion of § 92.2 regardingthe application of this proposed rule).Examples of sex-based distinctionsinclude a women’s health clinic or acounseling program limited to malevictims of domestic violence.



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39U.S. Dep’t of Commerce, U.S. Census Bureau,American FactFinder, Language Spoken at Home byAbility to Speak English for the Population 5 Yearsand Older, supra n. 30 (serving as data source tocalculate that 25 million of the 294 millionindividuals in the United States speak English lessthan ‘‘very well’’). OCR chose the three-year ACS,data (as opposed to the one-year or five-year data) because it best balances the currency and stabilityof the data.

40Dep’t of Justice, Enforcement of Title VI of theCivil Rights Act of 1964—National OriginDiscrimination Against Persons with LimitedEnglish Proficiency; Policy Guidance, 65 FR 50123,50124 (Aug. 16, 2000) [hereinafter DOJ PolicyGuidance, 2000].

41See, e.g., 29 CFR 1606.1 (defining anindividual’s national origin in Equal EmploymentOpportunity Commission regulations as his or her

ancestor’s place of origin and an individual’s‘‘physical, cultural or linguistic characteristics’’).42DOJ Policy Guidance 2000, 65 FR at 50124 &

n.8 (citing Hernandez v. New York, 500 U.S. 352,370 (1991) (plurality opinion)). See also 29 CFR1606.1 (Equal Employment OpportunityCommission’s definition of national origin, whichincludes an individual’s linguistic characteristics);Garcia v. Gloor, 618 F.2d 264, 269 (‘‘To a personwho speaks only one tongue or to a person who hasdifficulty using another language when spoken inhis home, language might well be an immutablecharacteristic. . . .’’).

43See, e.g., HHS LEP Guidance, supra n. 17 at 68FR at 47313 (‘‘[T]he failure of a recipient of[F]ederal financial assistance from HHS to takereasonable steps to provide LEP persons with [a]meaningful opportunity to participate in HHS-funded programs may constitute a violation of Title

VI and HHS’s implementing regulations’’); PolicyGuidance, Title VI Prohibition against NationalOrigin Discrimination As It Affects Persons withLimited English Proficiency, 65 FR 52762, 52765(August 30, 2000) (explaining the requirement totake reasonable steps to provide meaningful accessand to provide the ‘‘language assistance servicesnecessary to ensure such access. . . .’’). See alsoE.O. 13166, Improving Access to Services forPersons with Limited English Proficiency, (Aug. 11,2000) (requiring each Federal Department toimprove access to Federally assisted programs andactivities by persons with limited Englishproficiency and to implement a system by whichindividuals with limited English proficiency canmeaningfully access the Departments’ Federallyconducted programs and activities).

44Lau v. Nichols, 414 U.S. 563, 566 (1974)(requiring a school district with students withlimited English proficiency of Chinese origin to takereasonable steps to provide the students with ameaningful opportunity to participate in Federallyfunded educational programs).

45The Department’s LEP Guidance provides anin-depth explanation of Title VI’s prohibitionagainst national origin discrimination as it affectslimited English proficient populations and howrecipients can determine what steps are reasonableto provide all individuals with limited Englishproficiency meaningful access. HHS LEP Guidance,supra n. 17 at 68 FR 47311.

Finally, paragraph (d) of §92.101effectuates technical changes to applythe provisions incorporated in§ 92.101(b) and (c) to covered entitiesobligated to comply with this proposedrule by, among other things, replacingreferences to ‘‘recipient’’ in theincorporated provisions with ‘‘coveredentity.’’

Subpart C—Specific Applications toHealth Programs and Activities

Section 1557 is unique among Federalciv

ACA Section 1557 Proposed Rule.pdf

Documents

Transcript of ACA Section 1557 Proposed Rule.pdf