In mid-October 2016, CMS requirements under Section 1557 Final Rule began. Healthcare Compliance Pros has answered several questions regarding Section 1557. The following list includes answers to the top frequently asked questions we have received so far. Following the questions and answers, we have included links to our Section 1557 Webinar and Section 1557 Whitepaper.
- Question: Are you required to post the non-discriminatory notice in your office in all 15 languages?
Answer: You are not required to post nondiscrimination postings in each of the top 15 languages; rather, the nondiscrimination notice can be posted in English, as long as you post taglines of the top 15 languages in your state. You have some flexibility when providing language assistance; however, OCR specifically identified oral language assistance; written translation, performed by a qualified translator; and taglines in the final rule. These services must be provided free of charge, in a timely manner; however, the individual is not required to accept language assistance services (as long as they aren’t coerced not to).
- Question: Are you required to have your office forms printed in each of these languages as well (i.e. registration form, privacy notice, etc.)?
With regard to forms, the patient has a right to request language assistance for completing the forms – you would not need to have all your forms translated in each individual language. Instead, a translator could potentially be necessary to translate for the patient to ensure the correct information is entered on your current forms.
- Question: Can you clarify what is considered significant publications and significant communications?
Answer: There is a lot of room for interpretation based off OCR’s explanation of what makes up “significant communications or publications.” For example, an e-newsletter and a tri-fold practice brochure could potentially be considered significant communications or publications. Therefore, we would recommend including a statement of nondiscrimination and taglines of the top two languages in your state on these types of communications or publications.
For the time being, as long as you have posted the nondiscrimination notice and taglines in your facility and on your website and you have a plan to determine what forms/publications require a statement and the top 2 taglines – then, just include the statement/top 2 taglines on future “significant communications or publications” (after others that have already been printed have all been distributed) – you will be compliant with OCR’s requirements.
- Question: What if we have less than 15 employees? Does Section 1557 Requirements still apply to us?
Answer: Section 1557 requirements still apply to your practice. Covered entities, including healthcare providers, who receive “Federal financial assistance” are required to post a notice of nondiscrimination and taglines of the top 15 languages spoken by individuals with LEP in your State. This is a requirement for practices with less than or greater than 15 employees. There is an additional requirement for covered entities with 15 or more employees; that is to have a civil rights grievance procedure and an employee designated to coordinate compliance.
- Question: What is the recommendation for the number listed on the taglines? Is it reasonable to list the main phone number of your practice on the taglines? Should you list the tagline without a number? Or, is listing a phone number required?
Answer: It’s important to note that you can use your contact number (e.g. practice phone number) and you are not required to list a phone number for an actual language interpretation company. In other words, the contact information should be thought of as who the individual would call to request services. We would recommend making sure whoever answers the phone understands your process for handling language assistance services requests.
Additionally, you are not required to provide a TTY number, unless you have one. If you do not have one, you can just remove the TTY from the taglines and include just the contact number from your practice. For example, HCP’s tagline for Spanish would look like:
ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-(855) 427-0427.
- Question: How does our office complete the Assurance of Compliance?
Answer: Once you complete the following you may simply login to the OCR Attestation page and complete the Assurance of Compliance:
- Do your due diligence in posting a Notice of Nondiscrimination and the taglines of the top 15 languages in your facility and on your website;
- Designate a “Section 1557” Compliance Officer to handle grievances;
- Ensure thatyour employees understand who to contact to file a grievance and the process for doing so.
- You do not need to have your publications updated in order to attest; you have plenty of time to worry about updating them.
To access the OCR Attestation page, click: https://ocrportal.hhs.gov/ocr/aoc/instruction.jsf.
Additional Section 1557 Resources
HCP has included all of the required information, trainings and forms in our Corporate Compliance program. Corporate Plus also includes additional support resources. Please reach out to HCP if you need any additional information or assistance, or to inquire about adding these services to your HCP program.