Tag Archive for: meaningful use

ACA Non-Discrimination Notice, Statement, and Taglines [updated]

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[ this article was last updated on November 9, 2016 ]

The Department of Health and Human Services (HHS) has issued final regulations prohibiting discrimination (under Section 1557 of the Affordable Care Act or ACA) on the basis of race, color, national origin, sex, age, or disability. The requirements apply to all health programs and activities that receive federal funds or assistance.

Effective Date – Posting a non-discrimination notice or statement, together with non-English taglines in significant publications, physical locations, and on the practice’s website (if applicable) was required by October 17, 2016. Note that this regulation is not part of HIPAA and only applies to covered entities that receive federal funds or assistance (including EHR incentive payments).

There are three elements to meeting requirements for posting non-discrimination information (Notice, Statement, and Non-English Taglines). In addition, practices with 15 or more employees are required to have a civil rights grievance procedure, and an employee designated to coordinate compliance. All employees, regardless of the total number, should receive basic training. Please follow the steps below to comply with these requirements.

Quick steps to Compliance with ACA 1557

  1. Notice – Post the non-discrimination Notice in a conspicuous area of the practice, and on the practice website, if such is maintained. A sample Notice is available in English and in 61 other languages through the following link. Notices in non-English languages may be provided to patients upon request. Covered entities are only required to post the Notice in English. The sample Notices are available at this link.
  2. Taglines – The final rule requires that covered entities post taglines that alert individuals with limited English proficiency to the availability of language assistance services in the top 15 languages spoken in the State in which the entity is located or does business. The posting of taglines shall also be in a conspicuous location, such as the check-in or waiting area of the practice. In addition, small-sized, significant communications such as postcards must include taglines in at least the top 2 non-English languages spoken in the State.
    • Lists of the top 15 languages spoken in each state may be found at this link.
    • You may find the top 15 translated Taglines for your State with this link.
  3. Statement – A statement of non-discrimination must be included in all significant publications or communications of small size (if the material is too small to permit the full Notice to be included). Examples of such items include marketing brochures, bulletins or other announcements. You may use existing supplies of printed materials, and include the Statement as documents are reprinted. A sample Statement may also be found on this web page.
  4. Grievance Procedure – If your practice employs 15 or more people, a grievance procedure must be established. This link will take you to a model grievance procedure.
  5. Civil Rights Coordinator – If your practice employs 15 or more people, an employee must be designated to coordinate compliance with Section 1557 (i.e., to ensure that postings are made, employees are informed of the regulations, publications include required statements and taglines, and grievance procedures are followed).
  6. Employee Training – Have employees read your Notice and Grievance Procedure so that they are familiar with the rights afforded by Section 1557, and inform them of the Civil Rights/Compliance Coordinator designation so that they know to whom questions or complaints should be directed.
  7. Identify an Interpreter Service that you would use on an as-needed basis.  Additionally, you will need a Business Associate Agreement with each interpreter service you select.
  8. Assurance of Compliance – To attest that you have met the requirement, you may use this HHS link to electronically attest.

Meaningful Use and Security Risk Analysis

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Now that the final rule for 2015 meaningful use has been released, we have received some questions as to whether there are changes that will need to be made to our Security Risk Analysis template. The final rule was released on October 16, 2015, and changed the Medicare and Medicaid EHR Incentive Programs reporting period in 2015 to a 90-day period aligned with the calendar year.

The good news is that the final rule did not include any modifications to Security Rule requirements, and therefore does not necessitate any changes to our 2015 Security Risk Analysis template. If you have already completed a Security Risk Analysis during 2015, and used our template, you will NOT need to re-do it, or change anything.

The rule specifies that you may select any 90-day period in the calendar year as a measurement period, and that your Security Risk Analysis must be completed during the same calendar year, and before you submit your attestation. So, even if you conducted your Security Risk Analysis outside of your 90-day measurement period, that is fine, as long as it took place during 2015, and was completed prior to submitting your attestation.

HIPAA Compliance System Subscribers

Security Risk Analysis – The 2015 Security Risk Analysis template is available in the Member Services area of our website. Simply log in to locate the document on the HIPAA Compliance System materials page, and then save the template to your hard drive to enable saving your entries. Explanations, instruction and HIPAA Compliance Manual references are provided for each item to be addressed within the risk analysis.

Risk Analysis Assistance – If you would prefer that Eagle Associates complete your risk analysis with you, you may call to schedule a phone conference with one of our consultants. During the call, our consultant will collect information about the security measures that are in place in your practice, make note of these in the risk analysis document, and identify any corrective actions that are needed to comply with Security Rule requirements. The fee for this service is $350. (Note that an active subscription to the HIPAA Compliance System is required.)