WHAT IS THE FINAL RULE IMPLEMENTING SECTION 1557 OF THE PATIENT PROTECTION AND AFFORDABLE CARE ACT?


Section 1557 is the nondiscrimination provision of the Affordable Care Act (ACA).[1]  The final rule implementing Section 1557 prohibits discrimination on the basis of race, color, national origin[2], sex, age, or disability in health programs or activities that receive Federal financial assistance or are administered by an Executive agency or any entity established under Title I of the ACA.[3]  The Section 1557 final rule makes it unlawful for any health care provider that receives federal funding to refuse to treat an individual – or to otherwise discriminate against the individual – based on race, color, national origin, sex, age or disability.[4]  Sex discrimination includes, but is not limited to, discrimination on the basis of sex; pregnancy, childbirth and related medical conditions; gender identity[5]; or sex stereotyping.[6],[7]  The Section 1557 final rule also enhances language assistance for people with limited English proficiency and helps to ensure effective communication for individuals with disabilities.[8]

The U.S. Department of Health and Human Services (HHS), Office for Civil Rights (OCR) enforces Section 1557.[9]  When OCR finds violations, a health care provider will need to take corrective actions, which may include revising policies and procedures, and/or implementing training and monitoring programs.[10]  Health care providers may also be required to pay monetary damages.[11]  Section 1557 also allows individuals to sue health care providers in court for discrimination.[12]

To learn more about Section 1557, please feel free to visit the Office of Civil Rights’ (OCR’s) website at http://www.hhs.gov/civil-rights/for-individuals/section-1557 or call the Office of Civil Rights at 1-800-368-1019.  The full text of the final rule implementing Section 1557 is available by clicking here.  In addition, answers to frequently asked questions about the final rule for Section 1557 can be found at http://www.hhs.gov/sites/default/files/2016-05-13-section-1557-final-rule-external-faqs-508.pdf.

 

If you DO NOT receive any federal funding (i.e. Medicaid, CHIP, grants, property, Medicare Parts A, C and D Payments, tax credits, cost-sharing subsidies under Title I of the ACA, etc, then Section 1557 final rule does not apply to you and you can stop reading.    [13]

  1. Educate yourself and your staff about Section 1557.
    1. A Presenter’s Guide on Section 1557 can be found on the OCR’s site at: http://www.hhs.gov/sites/default/files/section1557-presenters-guide.pdf
    2. A Staff slideshow about Section 1557 can be found on the OCR’s site at:
      http://www.hhs.gov/sites/default/files/section1557-training-slides.pdf
  2. You are required to post Notices and Taglines [COMPLIANCE DATE – 10/16/16].  The following must be posted in your office, on your website, and in any office publications or communications:
  1. You may not exclude, deny or limit treatment or services based on an individual’s age (e.g. you cannot deny a 62-year-old patient treatment, stating you only treat patients under 60).[18]
 
  1. You cannot ask for a guardian’s/family member’s/companion’s citizenship or immigration status when he or she applies for your health services for an eligible patient.[19]
 
  1. You cannot deny treatment based on an individual’s sex, including their gender identity or sex stereotyping.[20]  For instance, you must treat individuals consistent with their gender identities, including with respect to access to facilities, such as bathrooms and patient rooms.[21]   For more information on this requirement, visit http://www.hhs.gov/sites/default/files/1557-fs-sex-discrimination-508.pdf.
 
  1. You must make reasonable changes to policies, procedures, and practices where necessary to provide equal access for individuals with disabilities, unless doing so would impose an undue financial burden on you or fundamentally alter your program.[22]  For example an office must modify its “no pets” policy to permit an individual with a disability to be accompanied by a service animal.[23]  Additionally, an office must allow an individual with an anxiety disorder to wait for an appointment in a separate, quiet room if the individual is unable to wait in a patient waiting area because of anxiety.[24]  For more information on this requirement, visit http://www.hhs.gov/sites/default/files/1557-fs-disability-discrimination-508.pdf.
 
  1. You must make all health programs and activities provided electronically (e.g., through online appointment systems, electronic billing, etc.) accessible to individuals with disabilities, unless doing so would impose an undue financial burden on you or fundamentally alter your program.[25]  For example, a doctor’s office that requires patients to make appointments only online must modify its procedures so that a person with a disability who cannot use the required method can still make an appointment.[26]  For more information on this requirement, visit http://www.hhs.gov/sites/default/files/1557-fs-disability-discrimination-508.pdf.
 
  1. You should ensure newly constructed and altered facilities are physically accessible to individuals with disabilities, using the standards for physical accessibility set forth in the 2010 Americans with Disabilities Act, “Standards for Accessible Design.”[27]  For more information on this requirement, visit http://www.hhs.gov/sites/default/files/1557-fs-disability-discrimination-508.pdf.
 
  1. You must provide effective means of communication to individuals with disabilities, including both patients and their companions.[28]  You must provide auxiliary aids and services (free of charge and in a timely manner) when necessary to individuals with disabilities to ensure those individuals have equal opportunity to participate and benefit from your health programs or activities.[29]  Auxiliary aids  and services include such things as:  (i) qualified sign language interpreters, (ii) large print materials, (iii) text telephones (TTYs), (iv) captioning, (v) screen reader software, (vi) video remote interpreting services.[30]  You may not:
    • Require an individual to provide his or her own interpreter.
    • Rely on a minor child to interpret, except in a life threatening emergency where there is no qualified interpreter immediately available. 
    • Rely on interpreters that the individual prefers when there are competency, confidentiality, or other concerns.
    • Rely on unqualified staff interpreters.
    • Use low-quality video remote interpreting services.[31]
 
  1. For individuals with limited English proficiency,[32] you are required to offer (free of charge and in a timely manner) a qualified interpreter when oral interpretation is a reasonable step to provide an individual with meaningful access to your health programs and activities.[33]  You must adhere to certain quality standards in delivering language assistance services. [34]  For instance, if a patient prefers and requests to have a family member or friend interpret for them, that is allowed as long as the companion agrees to interpret, your reliance on the companion is appropriate under the circumstances, and there are no competency or confidentiality concerns.[35]  In addition, you may not:
    • Require an individual to provide his or her own interpreter
    • Rely on a minor child to interpret, except in a life threatening emergency where there is no qualified interpreter immediately available
    • Rely on interpreters that the individual prefers when there are competency, confidentiality, or other concerns
    • Rely on unqualified bilingual or multilingual staff
    • Use low-quality video remote interpreting services.[36]

      For more information on this requirement, visit http://www.hhs.gov/sites/default/files/1557-fs-lep-508.pdf.
 
  1. Section 1557 also prohibits discrimination in your practice’s employee health benefit programs.[37]
 
  1. Do you have 15 or more employees?
    1. NO:  you can stop reading
    2. YES:  in addition to the requirements above, you must have a civil rights grievance procedure and designate an employee as a compliance coordinator.[38]  A model grievance procedure can be found in Appendix C of the following:  https://www.federalregister.gov/articles/2016/05/18/2016-11458/nondiscrimination-in-health-programs-and-activities?utm_campaign=subscription+mailing+list&utm_medium=email&utm_source=federalregister.gov#h-141.
 
[2] “The term ‘national origin’ includes, but is not limited to, an individual’s, or his or her ancestor’s, place of origin (such as a country), or physical, cultural, or linguistic characteristics of a national origin group.”  See http://www.hhs.gov/sites/default/files/section1557-presenters-guide.pdf, at p. 12.
 
[5] “Gender identity means and individual’s internal sense of gender, which may be male, female, neither, or a combination of male and female.”  See http://www.hhs.gov/sites/default/files/section1557-presenters-guide.pdf, at p. 8.  “An individual need not have sought medical treatment or have undergone specific processes to be transgender.”  Id.
 
[6] “Sex stereotypes mean stereotypical notions of masculinity or femininity.”  See http://www.hhs.gov/sites/default/files/section1557-presenters-guide.pdf, at p. 8.
 
[32] “An individual with [limited English proficiency] is an individual whose primary language is not English and who has a limited ability to read, speak, or understand English often because they are not originally from the United States.”  See http://www.hhs.gov/sites/default/files/section1557-presenters-guide.pdf, p. 12.
 
 
Jan. 16, 2017

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The 2017-18 ABO Board announced the testing change in the March 2018 AJO-DO. Pictured, from left, front row: Drs. Valmy Pangrazio-Kulbersh, Chun-His Chung, Larry Tadlock, Nicholas Barone. Back row: Drs. Steven Dugoni, Jae Hyun Park, Timothy Trulove, Patrick Foley, David Sabott.
 
 
Following its May 2018 meeting in Washington, D.C., the AAO Board of Trustees announced its support for the American Board of Orthodontics’ new, scenario-based testing format.

“The AAO supports the ABO scenario-based exam,” said Dr. Brent Larson, AAO president. “We encourage board certification for all AAO members.”

“There have been many changes in the ABO exam since its inception,” said Dr. Gary Inman, AAO president-elect and chair of the AAO/ABO Communications Committee. “This is simply another way to promote and encourage Board Certification without the ethical dilemma that presenting cases poses. The scenario-based exam will be a true test of orthodontic knowledge as well as problem solving. The key objective of the change is to encourage all eligible AAO orthodontists to become Board certified.”

The ABO Board announced the change in testing format in a March 2018 editorial in the AJO-DO. The editorial noted the ABO written examination will remain the same and the exam as a whole will “not be easier.” The ABO Board cited a lengthy process of evaluation that led to the conclusion that the requirement for presenting treated cases was proving to be a barrier to Board certification for many in today’s orthodontic work environment.

The editorial noted, “The clinical examinations of 4 of the American Dental Association’s recognized dental specialty boards are completely scenario-based (American Board of Oral and Maxillofacial Pathology, American Board of Oral and Maxillofacial Surgery, American Board of Pediatric Dentistry, and American Board of Periodontology). Also, the orthodontics oral examination of the Royal College of Dentists of Canada is entirely scenario-based. The majority of the American Board of Medical Specialties’ member boards also offer scenario-based certification.”
Additional information about the ABO’s planned implementation of the scenario-based testing system may be found in the March 2018 AJO-DO editorial, including an explanation of how the tools previously used by the ABO to assess case outcomes will be used within the scenario-based exam system.

In addition, Dr. Larry Tadlock, then ABO president-elect, was interviewed about the change to scenario-based testing in an AAO podcast that was made available via the eBulletin. The podcast featuring Dr. Tadlock’s interview remains available at The Business of Orthodontics Podcast.  Additional information may also be found at americanboardortho.com.
 
Jul. 12, 2018

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The 2017-18 ABO Board announced the testing change in the March 2018 AJO-DO. Pictured, from left, front row: Drs. Valmy Pangrazio-Kulbersh, Chun-His Chung, Larry Tadlock, Nicholas Barone. Back row: Drs. Steven Dugoni, Jae Hyun Park, Timothy Trulove, Patrick Foley, David Sabott.
 
 
Following its May 2018 meeting in Washington, D.C., the AAO Board of Trustees announced its support for the American Board of Orthodontics’ new, scenario-based testing format.

“The AAO supports the ABO scenario-based exam,” said Dr. Brent Larson, AAO president. “We encourage board certification for all AAO members.”

“There have been many changes in the ABO exam since its inception,” said Dr. Gary Inman, AAO president-elect and chair of the AAO/ABO Communications Committee. “This is simply another way to promote and encourage Board Certification without the ethical dilemma that presenting cases poses. The scenario-based exam will be a true test of orthodontic knowledge as well as problem solving. The key objective of the change is to encourage all eligible AAO orthodontists to become Board certified.”

The ABO Board announced the change in testing format in a March 2018 editorial in the AJO-DO. The editorial noted the ABO written examination will remain the same and the exam as a whole will “not be easier.” The ABO Board cited a lengthy process of evaluation that led to the conclusion that the requirement for presenting treated cases was proving to be a barrier to Board certification for many in today’s orthodontic work environment.1

The editorial noted, “The clinical examinations of 4 of the American Dental Association’s recognized dental specialty boards are completely scenario-based (American Board of Oral and Maxillofacial Pathology, American Board of Oral and Maxillofacial Surgery, American Board of Pediatric Dentistry, and American Board of Periodontology). Also, the orthodontics oral examination of the Royal College of Dentists of Canada is entirely scenario-based. The majority of the American Board of Medical Specialties’ member boards also offer scenario-based certification.”2
Additional information about the ABO’s planned implementation of the scenario-based testing system may be found in the March 2018 AJO-DO editorial, including an explanation of how the tools previously used by the ABO to assess case outcomes will be used within the scenario-based exam system.

In addition, Dr. Larry Tadlock, then ABO president-elect, was interviewed about the change to scenario-based testing in an AAO podcast that was made available via the eBulletin. The podcast featuring Dr. Tadlock’s interview remains available at The Business of Orthodontics Podcast.  Additional information may also be found at americanboardortho.com.
 
Jul. 12, 2018

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Determining your ultimate career path in orthodontics starts with understanding your options. And whether your plans are already intact or you don’t know where to begin, the AAO has developed multiple resources to educate you on the various orthodontic practice modalities and help plan your journey ahead. Go here to learn more: http://pm.aaoinfo.org/practice-modalities/ 
 
Join your colleagues for an intensive examination of the many complex issues related to obstructive sleep apnea and orthodontic treatment. Make plans to join the AAO January 25-27 in Marco Island, Florida for the 2019 Winter Conference, “Sleep Apnea and Orthodontics: Consensus and Guidance.”
 
Attendees will receive a wealth of information about diagnosis and management of sleep-disordered breathing issues, especially pediatric and adult obstructive sleep apnea (OSA), pediatric airway development, and OSA relative to orthodontic practice. Experts representing multiple disciplines will engage attendees with in-depth
presentations on aspects of the conference topic, with the intimate conference format making possible detailed discussion with lecturers.

The conference speakers’ list includes:
 
Medical Specialists

(Keynote Speaker) Anita Shelgikar, MD, FAASM, of the Department of Neurology Sleep Clinic at the University of Michigan. Dr. Shelgikar is the program director of the UM Sleep Medicine Fellowship.
 
(Keynote Speaker) Christian Guilleminault, MD, professor, Department of Psychiatry and Behavior Sciences and Stanford Center for Sleep Sciences and Medicine, Stanford University.  Dr. Guilleminault is known for having established
sleep medicine as a medical field.
 
(Keynote Speaker) Ron B. Mitchell, MD, William Beckner Distinguished Chair in Otolaryngology, The University of Texas Southwestern, Dallas, Texas. Dr. Mitchell is a practicing physician at Children’s Health Specialty Center and is a national leader in ENT management of OSA. 
 
Douglas Kirsch, MD, FAAN, FAASM, associate professor, University of North Carolina School of Medicine; Medical Director, CHS Sleep Medicine, Carolinas  Healthcare System, Charlotte, NC. 

Vishesh Kapur, MD, MPH, FAASM, professor of medicine; Director of Sleep Medicine, Division of Pulmonary and Critical Care Medicine, The University of Washington.
 
Timothy F. Hoban, MD, FAASM, Departments of Pediatrics and Neurology; Director of Pediatric Sleep Medicine and Clinical Neurophysiology, The University of Michigan. 

 
Dental Specialists
 
R. Scott Conley, DDS, chair, Department of Orthodontics, the University of Buffalo. 
 
Carlos Flores-Mir, DDS, MSc, PhD, head, Orthodontics Division and director, Orthodontic Graduate Program, University of Alberta.

Benjamin Pliska, DDS, MS, FRCD(C), assistant professor, Division of Orthodontics, University of British Columbia; private practice of orthodontics, Vancouver, BC. 

Sean Edwards, DDS, MD, associate professor, Department of Oral and Maxillofacial Surgery, the University of Michigan; in practice at the Michigan Medicine Oral Surgery Clinic with emphasis on craniomaxillofacial deformity and pediatric obstructive sleep apnea. 
 
Stacy Quo, DDS, MS, clinical professor of orthodontics at the University of California, San Francisco; adjunct assistant clinical professor, Stanford Sleep Disorders Clinic; and co- director of the UCSF Continuing Dental Education Series on Dental Sleep Medicine.
 
Mark Hans, DDS, MSD, professor and chair of the Department of Orthodontics at Case Western Reserve University.
 
Juan-Carlos Quintero, DDS, MS, private practice of orthodontics, Miami, Florida; faculty member, The L.D. Pankey Institute; attending professor, Department of Pediatric Dentistry, Miami Children's Hospital; Board of Directors, Baptist Hospital Foundation. 

Sean Carlson, DDS, MS, private practice of orthodontics, Mill Valley, CA; associate professor of Orthodontics, Dugoni School of Dentistry, The University of the Pacific; Senior Investigator in the Craniofacial Research and Instrumentation Laboratory at UOP. Dr. Carlson has been at the forefront of diagnosis with 3-D (Cone Beam CT) imaging technology. 
 
Rose D. Sheats, DMD, MPH, Graduate Orthodontic Program Director (retired), The University of North Carolina; Board of Directors, American Academy of Dental Sleep Medicine; associate editor, Journal of Dental Sleep Medicine.
 
Mitchell Levine, DMD, MS, private practice of orthodontics, Jacksonville, Florida; Diplomate of the American Board of Orthodontics; Diplomate of the American Board of Dental Sleep Medicine.
 
J. Martin Palomo, DDS, MSD, professor of orthodontics, director of the Orthodontic Program, director of the Craniofacial Imaging Center, School of Dentistry, Case Western Reserve University.  
 
Ki Beom Kim, DDS, MS, PhD, associate professor and director of the Graduate Orthodontic Program, Saint Louis University, Saint Louis University; Diplomate of the American Board of Orthodontics; Diplomate of the American Board of Orofacial Pain. Dr. Kim recently published a book, Comprehensive Management of Obstructive Sleep Apnea: Evidence-based Guidelines, with other medical and dental experts.
 
Spyros N. Papageorgiou, DDS, PhD, senior teaching and research assistant at the Clinic of Orthodontics and Pediatric Dentistry, Center of Dental Medicine, University of Zurich in Switzerland.
 
The conference will conclude on Sunday, January 27 with a presentation by Dr. Rolf G.  Behrents, editor-in-chief of the AJO-DO and professor emeritus, Graduate Orthodontic Program, Saint Louis University.  Dr. Behrents, who is the chair of the AAO Task Force on Obstructive Sleep Apnea and Orthodontics, will present, “Evidence-Based Recommendations for the Treatment of Children or Adults with Obstructive Sleep Apnea.”
 
Watch your in-box in August for an announcement that registration for the 2019 Winter Conference is open.
 
 
Jul. 6, 2018

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Missouri was the fifth state to receive advocacy assistance via the AAO Component Legal Support Fund (CLSF). In January, the Missouri Society of Orthodontists applied for CLSF funding and in April, the state dental board rescinded the state’s dental advertising rules. *
 
Dr. Michael LaFerla of Joplin, president of the Missouri Society of Orthodontists, recently reported to the component’s membership:

“The AAO’s Component Legal Support Fund (CLSF) enabled Associate General Counsel Sean Murphy the ability to work with the Missouri Dental Association and the Missouri Dental Board to draft a legislative amendment that strengthens Missouri’s advertising laws and as a result, protects the public. It all moved very quickly, but the coalition was still able to amend the language into HB 1719, which passed within the final hours of Missouri’s legislative session this year.”

Click here to view the language, which is underlined on pages 98-100. 

First established by a vote of the 2015 House of Delegates, the CLSF provides grants to component organizations that enable the AAO to assist with legal and advocacy work on proposed legislation or regulatory changes that would impact orthodontic practices and patients at the state level.

Learn about other recent state-based advocacy initiatives:

- New Hampshire
- Iowa
- Georgia
- Rhode Island
 
* An additional 10 states have now qualified for assistance via the CLSF.
 
Jun. 29, 2018

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The 2017-18 AAO webinar series is now available as part of AAO Online Lectures, with the recent webcasts having joined hundreds of other online programs addressing key orthodontic clinical and practice management topics.
Visit Online Lectures to access lectures in the categories you prefer, including:

Business of Orthodontics lectures (free to all members).  Explore recent topics such as:
▪ Speak Their Language! Utilizing Technology to Communicate with the Modern Orthodontic Patient, by Dr. Daniel Bills
▪ New in Practice? Critical Financial Strategies for Success, by Brad A. Kucharo, CPA, CFP®
▪ Let Data Drive Your Strategy, by Mary Beth Kirkpatrick
▪ Building an Elite Office with Facebook Marketing, by Dr. Neal D. Kravitz
▪ Why Your Digital Marketing Isn’t Working, by Dr. Leon Klempner
▪ Measuring Orthodontic Marketing Effectiveness, by Andrew Tucker, JD, CPA, CFP®

Doctors Lectures:  Presentations are accessible with a $100 per year Online Lectures subscription or at $30 pay-per-view. Recent additions include:
▪ Facial Esthetics Oriented Treatment Planning with VTO and TADs Dr. Sercan Akyalcin
▪ Pragmatic and Peculiar Practice Pearls, by Dr. Kelton Stewart 
▪ Realistic Treatment of Patients Missing Maxillary Lateral Incisor by Dr. José A. Bósio
▪ The Doctor’s Role in Case Acceptance:  Key Components of a High-Value Consultation, by Landy Chase, MBA, CSP

Orthodontic Staff Lectures:  Lectures are accessible as a benefit of membership in the Orthodontic Staff Club ($50 per practice, per year, for all staff) or at $30 pay-per-view. Recent additions include:
▪ Clinical Photography: What is Your Doctor Looking For?, by Dr. Douglas Depew
▪ OSHA Safety Rocks – for Ortho Teams, by Jackie Dorst, RDH, BS
▪ Best Practices for Infection Control in Orthodontic Practices, by Jackie Dorst, RDH, BS

ADA CERP Recognition
The American Association of Orthodontists is an ADA CERP Recognized Provider.  ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry.

American Association of Orthodontists designates for all CE activities, 0.25 credit hours will be awarded for each 15 minutes of activity time unless otherwise noted. Concerns or complaints about a CE provider may be directed to the provider or to the Commission for Continuing Education Provider Recognition at www.ada.org/cerp.





 
Jun. 29, 2018

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Dentist and U.S. Rep. Brian Babin (R-Texas) has introduced the Resident Education Deferred Interest Act (REDI) Act in the House of Representatives. The bill, HR 5734, would halt interest accrual while loans are in forbearance or deferment for those who qualify for the internship/residency category of either of these payment delay options.

The AAO supports this bill in addition to H.R. 4001, introduced last year by Congressman John Garamendi, and for which the AAO has advocated extensively. The Babin bill includes language similar to that of the Garamendi bill, but the latter also includes other provisions such as student loan interest rate refinancing and eliminating origination fees on student loans – both of which may be quite costly. The Babin bill focuses exclusively on interest rate deferral and so offers an additional legislative opportunity to address this high-priority issue.

During 2017, AAO leaders and legislative counsel led dental organizations that worked closely with Rep. Garamendi on his bill. The legislator introduced the Student Loan Refinancing and Recalculating Act with Rep. Brian Fitzpatrick of Pennsylvania. Congressman Garamendi is a Democrat and Congressman Fitzpatrick is a Republican, so the bill had immediate bi-partisan support.
Jun. 29, 2018

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Questions? Call 800-424-2841 or e-mail aaomembers@aaoinfo.org