Ensuring equal access to healthcare isn’t just a legal requirement—it’s a fundamental responsibility. Every patient, regardless of background, deserves fair and equitable care. Compliance of Section 1557 of the Affordable Care Act (ACA) reinforces this by prohibiting discrimination and holding healthcare providers accountable for fostering an inclusive environment.
But here’s the question: Is your organization truly prepared for the upcoming changes?
With July 5, 2025, fast approaching, healthcare organizations must act now to ensure compliance. Failure to do so could not only jeopardize patient trust and safety but also put federal funding and your organization’s reputation at risk. Now is the time to assess policies, train staff, and implement the necessary changes to build a stronger, more inclusive healthcare system.
Section 1557 Compliance: What Healthcare Providers Must Do by July 5, 2025
Who Needs to Comply?
Section 1557 compliance applies to a broad spectrum of healthcare entities, including:
- Hospitals and Clinics: Facilities offering medical services to the public.
- Health Insurance Providers: Companies providing health coverage plans.
- Medicare and Medicaid Participants: Entities receiving payments through these federal programs.
- Any Organization Receiving HHS Funding: This encompasses a wide range of healthcare-related services and programs.
It’s noteworthy that the 2024 Final Rule expanded the definition of covered entities to include providers receiving Medicare Part B payments, marking a significant shift from previous interpretations.
Key Deadlines and Requirements
To ensure compliance with Section 1557, healthcare providers must adhere to several critical deadlines:
Designation of a Section 1557 Coordinator (By November 2, 2024)
Entities with 15 or more employees are required to appoint a Section 1557 Coordinator. This individual’s responsibilities include overseeing compliance efforts, addressing grievances related to discrimination, and serving as a resource for staff and patients.
2. Notice of Nondiscrimination (By November 2, 2024)
All covered entities must provide a Notice of Nondiscrimination to participants, beneficiaries, enrollees, and applicants. This notice should clearly state the entity’s commitment to nondiscrimination and inform individuals of their rights under Section 1557. The notice must be:
- Accessible: Posted prominently on the entity’s website and in physical locations.
- Clear: Written in plain language to ensure understanding.
- Inclusive: Available in multiple languages and formats to cater to diverse populations.
3. Development and Implementation of Policies and Procedures (By July 5, 2025)
Covered entities must establish comprehensive policies and procedures that promote compliance with Section 1557. These should encompass:
- Nondiscrimination Policies: Affirming the entity’s commitment to equitable treatment.
- Grievance Procedures: Outlining steps for individuals to report discrimination and seek resolution.
- Language Access Procedures: Ensuring services are accessible to individuals with limited English proficiency (LEP).
- Auxiliary Aids and Services Procedures: Providing necessary support for individuals with disabilities.
- Reasonable Modifications: Adjusting policies and practices to accommodate individuals with disabilities
4. Staff Training (By May 1, 2025)
It’s imperative that all relevant staff members are trained on the newly developed policies and procedures. This training should:
- Be Timely: Conducted within 30 days of implementing the policies, but no later than May 1, 2025.
- Be Comprehensive: Cover all aspects of the policies to ensure staff can effectively uphold them.
- Be Documented: Maintain records of training sessions for accountability and future reference.
5. Broader Interpretations of Discrimination
The Final Rule has expanded the understanding of discrimination, particularly concerning sex. Under the new regulations, discrimination based on sex includes:
- Gender Identity: Protecting individuals whose gender identity differs from their sex assigned at birth.
- Sexual Orientation: Ensuring equitable treatment regardless of whom an individual is attracted to.
- Sex Characteristics: Including intersex traits and other physical attributes.
- Pregnancy or Related Conditions: Protecting individuals from discrimination related to pregnancy, childbirth, or related medical conditions.
This broader interpretation underscores the importance of creating an inclusive environment that respects and acknowledges diverse identities and experiences.
Steps to Ensure Compliance
To align with Section 1557 by the impending deadlines, healthcare providers should consider the following actions:
Assess Current Practices
Conduct a thorough review of existing policies, procedures, and practices to identify areas that may require adjustments to meet the new standards.
Develop Comprehensive Policies
Create or update policies that reflect the nondiscrimination mandates of Section 1557. Ensure these policies are easily accessible to both staff and patients.
Appoint a Qualified Coordinator
Designate an individual or team responsible for overseeing compliance efforts. This compliance coordinator should have a clear understanding of Section 1557 requirements and the authority to implement necessary changes.
Implement Training Programs
Develop training modules that educate staff on the importance of nondiscrimination, effective communication with individuals with LEP or disabilities, and procedures for addressing grievances.
Enhance Accessibility
Ensure that all services, both physical and digital, are accessible to individuals with disabilities. This includes providing auxiliary aids, accessible facilities, and compliant digital platforms.
Establish Grievance Mechanisms
Create clear, confidential, and efficient processes for individuals to report discrimination. Ensure that grievances are addressed promptly and equitably.
Monitor and Evaluate
Regularly assess the effectiveness of implemented policies and procedures. Seek feedback from patients and staff to identify areas for improvement and ensure ongoing compliance.
The Importance of Compliance
Section 1557 compliance is not merely a legal obligation but a moral imperative. By fostering an environment free from discrimination, healthcare providers can:
- Improve Patient Outcomes: When patients feel respected and understood, they are more likely to engage in their care and adhere to treatment plans.
- Enhance Reputation: Organizations known for equitable treatment attract a diverse patient base and are viewed favorably in the community.
- Mitigate Legal Risks: Compliance reduces the risk of legal actions, financial penalties, and reputational harm associated with discrimination claims.
Conclusion
As July 5, 2025, approaches, healthcare providers must take proactive steps to ensure compliance with Section 1557 of the ACA. By understanding the requirements, meeting critical deadlines, and fostering an inclusive environment, providers not only adhere to legal standards but also affirm their commitment to equitable and compassionate care for all individuals.
Ensuring compliance isn’t just about avoiding penalties—it’s about boosting efficiency and fostering trust with patients and staff. A well-implemented compliance strategy streamlines operations, enhances patient satisfaction, and strengthens your organization’s reputation as a leader in equitable care.
Take action now to make compliance seamless and stress-free. Enroll your large team in our customized, free course development program today and ensure your healthcare organization is fully prepared for the upcoming ACA requirements! Click here.
