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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A new commission that will oversee decisions about recognition of dental specialties and their certifying boards met for the first time May 9-10 at the American Dental Association headquarters in Chicago.

Among the meeting participants was Dr. Andrew J. Kwasny of Erie, Pennsylvania, who was appointed by the AAO as its representative on the National Commission on Recognition of Dental Specialties and Certifying Boards. The ADA announced that the commission includes nine general dentists, appointed by the ADA Board of Trustees, and one specialist from each of the nine recognized specialties, with a public/consumer member still to be appointed. The commission’s initial meeting included establishment of rules, policies, operating procedures and organizational structure.
View the ADA Announcement

Dr. Kwasny became the ADA Third District trustee in 2013 and served a four-year term on the ADA Board. He had been a delegate to the ADA House since 2003 and was a member of the ADA Council on Government Affairs. He is a past president of the Pennsylvania Dental Association. Dr. Kwasny completed his dental education and orthodontic residency at the University of Pittsburgh, where he also earned an advanced degree in microbiology.

AAO Leaders Helped Spur ADA Policy on the New Commission 
During the 2017 ADA Annual Session last fall, AAO Board members advocated for the resolution that changed the ADA by-laws to allow the creation of the new commission.  Dr. Brent Larson, now AAO president, served on an ADA task force that developed the resolution calling for establishment of the commission.

Dr. Larson and Dr. Christopher A. Roberts, now AAO secretary-treasurer, said at the time that the commission would shift responsibility for specialty and certifying board recognition from the state dental boards to the ADA, which would be the preference of most state boards.
Read More about the AAO’s Role in Advocating for the Commission
May. 31, 2018

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A company seeking interview subjects for a program that it says will air on the FOX Business Channel has initiated a new “pay-to-play” media opportunity campaign targeting orthodontists.
 
As has been the case with past programs of this nature, the salesperson may contact your office and ask to speak to you about a possible interview for a health-related TV show. If you accept the call, the initial dialogue with the company may be lengthy and the representative may pressure you to sign a contract almost immediately. There could be insinuations that the offer must be acted upon quickly or it will be withdrawn and/or offered to a competitor.
 
The caller may not reveal that there are costs involved or may avoid responding with straightforward information about costs when asked to do so.  With these types of situations, costs often range from a few thousand to tens of thousands of dollars.

Legitimate news organizations do not expect people they interview to pay for the interview, its production costs, or air time, nor do they expect those interviewed to sign a contract.

While many AAO members may have no interest in paying the hefty price tag, others may determine that a “pay-to-play” media opportunity is a desirable marketing option for their practice. If you feel this is an option you want to pursue, make sure you know about any financial or legal obligations up front.  You can also ask the representative to provide:

● The name and URL of the media outlet they represent;

● The day(s) and time(s) the interview will air;
 
● The station(s) or websites that will air the interview;
 
● All fees associated with the opportunity.
 
You may also wish to ask if you will be able to use the video for your own purposes if you contract for interview production.  However, if you are interested primarily in video production, it may be less expensive to hire your own video production company.

If you receive a questionable “media” call, you are welcome to refer the caller to the AAO.  You may also contact AAO staff with questions or concerns about “pay to play” media opportunities:

Pam Paladin
Marketing and Member/Consumer Relations Manager
800-424-2841, Ext. 524
ppaladin@aaortho.org
 
 
May. 24, 2018

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The AAO Component Legal Support Fund (CLSF) achieved a victory in recent work with the New Hampshire Association of Orthodontists.

The New Hampshire component applied for funding from the CLSF after the AAO Legal Department’s Sean Murphy discovered that the state legislature was considering amendments to its specialty advertising laws that would have removed the “general dentist” disclaimer from general dentists advertising specialty services. 

Where the law now requires each dentist to indicate in his or her advertisement whether they are a "general dentist" or "specialist" when advertising services, the proposed revisions would have removed the required “general dentist” disclaimer from general dentists’ advertisements in New Hampshire.  The change would have made it possible for a general dentist to advertise orthodontic or other specialty services, without clarifying that he or she is a general dentist.

To put this in perspective, under the old language, a general dentist practicing orthodontics would have to state, "John Doe, general dentist, practicing orthodontics." Given that requirement, consumers knew exactly who they were dealing with - a general dentist.  Under the proposed change, the general dentist disclaimer would not have been required, so the same advertisement could read, "John Doe practicing orthodontics."  As you might imagine, consumers might have concluded (incorrectly) that John Doe is a specialist in orthodontics or maybe even an orthodontist, rather than a general dentist.

The proposed revision eliminating the general dentist disclaimer was included in legislation designed to update regulations applicable to dentists and dental hygienists by the New Hampshire Board of Dental Examiners.
 
The New Hampshire Dental Society responded positively to the AAO’s outreach on this issue. Society leaders subsequently indicated to the bill’s sponsors that the organization would not object to removing the language eliminating the general dentist disclaimer law from the pending legislation.

Working with Dr. Dennis Hiller, an AAO member from Jackson, New Hampshire, the AAO Legal Department prepared a letter outlining concerns about the bill. After it was approved and signed by Dr. Hiller and by Dr. Phil Mansour of Goffstown, New Hampshire, (Northeastern Society of Orthodontists’ representative to the AAO Political Action Committee), the letter was sent to all New Hampshire state legislators.
View the Letter to the New Hampshire Legislators
 
In the end, the language that would have removed the general dentist disclaimer was stricken from the bill.  General dentists’ advertising specialty services in NH must continue to inform consumers that they are “general dentists.” 
 
 
May. 24, 2018

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The 2018 AAO House of Delegates met May 4 and May 7 in Washington, D.C., acting on numerous items impacting the association and the specialty.
 
The HOD directed that the AAO president create a Big Data task force consisting of AAO members, nonmembers and/or consultants who have an expertise and/or interest in data analytics. The task force will assess how the AAO might develop a data analytics program to better position the association and/or the specialty in propelling the AAO’s mission and strategic plan forward in new and/or more effective ways than would be possible without the data. A detailed explanation of the importance of Big Data to the future of the specialty recently appeared in the AAO Tech Talk blog.

Additional HOD actions included:

Newly Approved Strategy Map, Policies Reflect Goal of Diversity in Leadership, Governance 
▪  The HOD approved a new AAO Strategy Map developed by the Global Strategic Planning Committee (GSPC), a group of diverse and representative AAO stakeholders. The Global Strategic Planning Committee includes delegates, councils, constituents, vendors, manufacturers, industry consultants and new and younger members. The proposed new strategy map emphasizes inclusiveness as a core value of the AAO. In addition, it focuses on promotion and defense of the specialty and leadership in innovation and transformation in the specialty that will help drive member success.

▪ The HOD encouraged constituents to assemble House delegations that reflect the diversity of members in their geographic region. In addition, each year the breakdown of delegates by race and gender, by constituent, is to be reported to the HOD by the AAO staff, who are also directed to investigate the best method of assessing the racial and gender make-up of the AAO membership and leadership.
 
▪ The HOD also called for the Council on New and Younger Members (CONYM) to select one of its members to attend each of the quarterly regularly scheduled meetings of the AAO Board of Trustees.

▪ An AAO task force will research issues specific to female orthodontists and specific ways that women may be better served as association members.

Dues, Consumer Awareness Program Fees Set for 2018-19 
Dues for U.S. Active Members will be $793.00 for 2018-19 (unchanged since 2013). 

▪ U.S. and Canadian active and affiliate members (active academic members excluded) will also be assessed $600 for Fiscal Year 2018-19 to fund the AAO Consumer Awareness Program (CAP),* keeping the assessment the same as that of 2017-18. The CAP assessment for 2019-20, 2020-21 and 2021-22 will be $800 per year. The objective of the CAP is to increase the public’s awareness of the value of having orthodontic treatment rendered by orthodontic specialists by exposing consumers to accurate information. The CAP’s all-digital approach for 2017-18 garnered a 6,100 percent increase in monthly visits to the consumer website, aaoinfo.org. A recent Google study (March 2018) showed that consumers who had seen a CAP ad were 615 percent more likely to search for the AAO or an AAO orthodontist than those who had not.
Learn More about the Consumer Awareness Program
 
Component Legal Support Fund Augmented to $1 Million
The Component Legal Support Fund (CLSF) balance will be increased to $1 million. 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 at the state level. Recent initiatives funded by the CLSF have addressed issues in Rhode Island, Georgia, Iowa, and New Hampshire.

AAO Faculty Fellowships to be Reinstated 
The AAO Faculty Fellowship Award Program will be reinstated for 2019, 2020, and 2021 with three, two-year funded Fellowships per year for orthodontic educators, and an outcomes assessment to follow. The fellowships are designed to help address an anticipated shortage of orthodontic faculty, data from the American Dental Education Association having revealed high numbers of experienced full-time and part-time dental faculty members are currently age 50+, with a significant number age 60+. AAO Full-time Faculty and Faculty First Fellowships were first awarded from 2007-09, with a total of $1.5 million being distributed among recipients in exchange for specific commitments to orthodontic education. The AAO has tracked recipients’ careers and of the 20 former Fellows, all but one has remained in academics.
 
Position on Medically Necessary Treatment of Craniofacial Anomalies Clarified 
For the purpose of third party reimbursement, the AAO considers serial reconstructive, orthodontic, and restorative therapies to be medically necessary treatment for craniofacial anomalies (CFA) to ensure a reasonable quality of life for affected individuals. Coverage should extend throughout the patient’s lifetime. The AAO supports legislation stipulating that insurers recognize the sequential nature of reconstructive, orthodontic, and restorative therapy for CFA, which requires ongoing coverage for all aspects of the treatment plan.

Additions to Code of Ethics and Professional Conduct Address Harassment, Inapproriate Interpersonal Relationships 
The HOD directed that the Principles of Ethics, Code of Professional Conduct and Advisory Opinions of the American Association of Orthodontists be amended to include:

“Members shall provide a workplace environment devoid of harassment or inappropriate behavior and a workplace that upholds respectful and cooperative relationships for all employees and patients”; and

“Members shall refrain from inappropriate interpersonal relationships or behavior within the orthodontic workplace and shall promote mutual respect, professional communication and cooperative efforts of all team members to enhance excellence in orthodontic care and assure safe and professional relationships with and between employees and patients.” 

Leadership Development Conference to Be Held Every Year
The AAO Leadership Development Conference for constituent and component leaders (formerly the biennial President-Elects Conference) will take place very year. The Leadership Development Conference will now also be open by application to emerging leaders who have not previously held leadership positions, with content of the meeting to be augmented to address this group’s needs. Of participants in the 2018 Leadership Development Conference, 97 percent said that they learned about new practical tools or information that will make a difference in their roles as volunteer leaders and 100 percent would recommend the Conference to colleagues.
 
Component CAP Matching Grant Program to Accept Applications through May 31, 2018 
Components may apply for funding from the Component CAP Matching Grant program through May 31, 2018, with all approved funds to be spent by May 31, 2019. Funds not awarded will be transferred to the Consumer Awareness Program budget for 2018-19. Since the national matching grant fund started in 2015 the media landscape has changed significantly and the national CAP digital program is now reaching all states more effectively than in the past.
 
View the Complete Chart of 2018 HOD Adopted and Referred Resolutions
 


* Life Active members pay 50 percent of the CAP assessment for active members in their country. Full-time faculty members are exempt from paying the assessment. Recent graduates within the 1st year after graduation receive a 90 percent assessment discount; within the 2nd year a 75 percent discount; within the 3rd year a 50 percent discount; and within the 4th year a 25 percent discount.


 
 
May. 24, 2018

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The Space Channel show, “InnerSpace” recently filmed a segment at the “Star Trek”-themed office of Dr. David Hirsch in Aurora, Ontario.  Aurora Borealis Orthodontics is filled with authentic, screen-used props from the original 1960s science fiction television series about the starship USS Enterprise (NCC-1701) and its crew; the five spin-off TV series; and the movie franchise. Dr. Hirsch, an avid Star Trek fan and memorabilia collector, believes that his office is the only orthodontic practice with a Star Trek theme. It has been featured on Canadian television and in numerous publications including Oral Health Magazine, Canada's most widely read dental magazine.

The InnerSpace segment includes a tour of the office led by Dr. Hirsch, with video showing highlights of his memorabilia collection.
View the InnerSpace Segment
 
In addition, Dr. Hirsch’s office was #7 in Off-the-Cusp magazine’s 2017 list of “12 Coolest Dental Offices in the Country.” (The U.S.-based publication made an exception for Dr. Hirsch’s office even though it is not in the United States.)

Two other AAO member practices also made the Off-the-Cusp list. The #2 practice on the list - the Larkspur, California office of Drs. Jasmine Gorton and Bill Schmohl – is a Certified Green Business with a soothing nature theme and a unique design including a living plant wall. 

The office of Dr. Michael Hilgers and his wife, pediatric dentist Dr. Kelly Hilgers, in the Estella Mountain Ranch community of Goodyear, Arizona, is #12 on the Off-the-Cusp list. The Hilgers converted a former gas station into a Route 66-themed office with retro décor and automotive memorabilia. They also have another themed office, featuring a Mardi Gras theme, in the nearby Palm Valley community of Goodyear.
View the Off-the-Cusp Feature, “12 Coolest Dental Offices in the Country.”
 
May. 8, 2018

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