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Notice of Nondiscrimination and Taglines Posting Requirements Now in Effect

The Final Rule implementing Section 1557 of the Affordable Care Act went in to effect on October 16, 2016. Section 1557 prohibits discrimination on the basis of race, color, national origin, sex, age, or disability in certain health programs and activities.

The 1557 Regulations require a covered entity to take appropriate initial and continuing steps to notify patients and members of the public that the covered entity does not discriminate based on race, color, national origin, sex, age, or disability in its health activities. "Covered entities" include entities that provide or administer health related services. One of the steps a healthcare entity must take to fulfill its obligations under the 1557 Regulations is to post Notices in its facilities which demonstrate the facility's compliance with the nondiscrimination mandate. The Notices must include "taglines" (written in a conspicuously visible font size) translated into the 15 most common languages spoken by individuals with limited English proficiency in the state that the healthcare entity is located in, which describe how the covered entity will provide language assistance services to those in need.

Samples of the required Notice and Taglines translated into a host of different languages can be found on the CMS website at:

http://www.hhs.gov/civil-rights/for-individuals/section-1557/translated-resources

A list of the 15 most common languages in your state can also be found on the CMS Website at:

https://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/Appendix-A-Top-15.pdf

The 1557 Regulation further requires that the same notice and taglines be included in all "Significant Publications" and "Significant Communications" targeted to patients and members of the public, except for Significant Publications or Significant Communications that are small sized such as postcards or tri-fold brochures. Those "smaller" publications only need to contain a Statement of Nondiscrimination and Taglines in the two most common languages spoken by individuals with limited English proficiency in the state where the healthcare entity is located. The required "Statement of Nondiscrimination" can be found at the links above.

While the1557 Regulation does not specifically define "Significant Publications" or "Significant Communications," it does provide some guidance as to which documents would be considered "Significant" by CMS. Latsha, Davis & McKenna recommends adding Notices and Taglines to at least the following documents:

• non-discrimination statements provided to residents or patients

• admissions agreements and admission documents

• resident handbooks

• invoices

• documents communicating changes in practices or policies

• consent and complaint forms

• any other documents requiring a response from a resident regarding care or billing

• marketing materials

Many of the resources needed to be compliant with the Notice and Tagline requirements can be accessed at the CMS websites above.

If you would like to discuss these requirements and their implementation at your organization, please do not hesitate to contact Kimber L. Latsha or David Marshall at 717-620-2424.

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