Section 1557: How to Ensure Your Small Practice Doesn't Discriminate Based on Gender or Language (45 CFR Part 92)

Section 1557 of the Affordable Care Act, implemented through 45 CFR Part 92, is the main federal civil rights rule for health care settings that receive federal financial assistance. It prohibits discrimination on the basis of race, color, national origin, sex, age, and disability in covered health programs and activities, which includes most physician practices that bill Medicare, Medicaid, or Marketplace plans. 

Under the 2024 final rule, discrimination “on the basis of sex” explicitly includes discrimination based on sex stereotypes, sex characteristics such as intersex traits, sexual orientation, and gender identity, while discrimination “on the basis of national origin” includes failures to provide meaningful access for people with limited English proficiency.  For a small clinic, that means misgendering patients, denying care because someone is transgender, or failing to arrange interpreter services when needed are not just bad customer service, they are potential federal civil rights violations. 

Understanding how 45 CFR Part 92 works, and how to translate it into a short set of intake scripts, signage, language support processes, and gender-affirming access policies, can keep a small practice out of OCR investigations and align the practice with payer and community expectations.

Small practices feel Section 1557 in very practical moments: at check in, when a staff member hesitates over how to address a patient whose legal ID does not match their presentation; during a visit, when no interpreter is available and a family member is pressed into service; at billing, when a gender diverse person is told that certain services are “not for people like you.” These are exactly the situations 45 CFR Part 92 is designed to address, even when they occur in a three exam room clinic.

Most small practices already have policies for HIPAA and basic nondiscrimination statements. The gap is usually in daily execution. Staff may not know what “meaningful access” for limited English proficiency actually requires under 45 CFR 92.201 or how far equal program access on the basis of sex goes under 45 CFR 92.206, especially after the 2024 rule. 

This article focuses on that operational gap. It explains the legal framework and then offers concrete tools to reduce risk around gender and language for small, resource constrained clinics, without assuming a dedicated civil rights department.

Understanding Legal Framework and Scope Under 45 CFR Part 92

Section 1557 is codified at 42 U.S.C. 18116. It provides that no individual shall, on the ground prohibited under Title VI, Title IX, Section 504, or the Age Discrimination Act, be excluded from participation in, denied benefits of, or subjected to discrimination under any health program or activity receiving federal financial assistance, any program administered by an executive agency, or any entity established under the ACA.  The statute effectively imports the protected classes from those civil rights laws into the health care context.

HHS implemented Section 1557 through 45 CFR Part 92. The purpose section confirms that Part 92 implements Section 1557 and prohibits discrimination in covered health programs or activities on the basis of race, color, national origin, sex, age, and disability.  Section 92.101 then states the core nondiscrimination requirement: individuals must not, on these bases, be excluded from participation in, denied the benefits of, or otherwise subjected to discrimination under any health program or activity of a covered entity. 

The 2024 rule makes clear that discrimination on the basis of sex includes discrimination based on sex stereotypes, sex characteristics including intersex traits, pregnancy or related conditions, sexual orientation, and gender identity, subject to ongoing litigation regarding specific provisions.  For a small practice, this means that policies or habits that misgender patients, deny services because of transgender status, or treat LGBTQ+ patients differently in any clinically unsupported way can be sex discrimination under 45 CFR 92.101 and 92.206.

For language, Section 1557 builds on Title VI of the Civil Rights Act, which treats certain language barriers as a form of national origin discrimination. The regulation at 45 CFR 92.201 requires covered entities to take reasonable steps to provide meaningful access to each individual with limited English proficiency who is eligible to be served or likely to be directly affected by the entity’s health programs and activities.  This includes companions such as parents or caretakers.

Part 92 also contains specific provisions on equal program access on the basis of sex, nondiscrimination in insurance coverage, facilities and telehealth, notices of nondiscrimination, grievance procedures, and enforcement.  States can and sometimes do go further, adopting more protective nondiscrimination standards or language access laws. Clinics must follow whichever rule is more protective of patients, but meeting the federal Part 92 baseline significantly reduces federal risk.

By understanding this framework, a small practice can connect everyday decisions about how patients are addressed, how interpreters are provided, and how services are configured to concrete regulatory citations, which reduces denials of care, civil rights complaints, and administrative friction with payers and regulators.

HHS Office for Civil Rights is the primary enforcement body for Section 1557 and 45 CFR Part 92. OCR investigates complaints, conducts compliance reviews, issues technical assistance, and negotiates corrective action or resolution agreements. Its enforcement mechanisms borrow from Title VI, Title IX, Section 504, and the Age Discrimination Act, including requirements to take remedial action, the possibility of loss of federal financial assistance, and the ability to refer matters to the Department of Justice. 

Section 92.301 and related provisions describe how OCR enforces Part 92, including investigations, compliance reviews, and coordination with other agencies.  Individuals can also bring private lawsuits for Section 1557 violations, which may lead to compensatory damages in appropriate cases. 

Common triggers for review in the gender and language space include:

• Complaints from patients who are misgendered, denied gender-affirming services available to others, or assigned rooms or facilities inconsistent with their gender identity, potentially violating 45 CFR 92.206.

• Complaints from patients or companions with limited English proficiency who were not offered timely, free language assistance and instead had to rely on children or family members as interpreters in situations where that is inappropriate under 45 CFR 92.201.

• Patterns noted by state Medicaid agencies, Marketplace entities, or payers showing that certain groups, such as LGBTQ+ patients or speakers of particular languages, experience higher cancellation rates, denials, or delays.

For a small clinic, the most realistic path into OCR’s line of sight is a single patient complaint about disrespectful treatment or lack of language support. If the clinic can show that it has a working notice, basic policies, training, and documentation that reflect 45 CFR Part 92, OCR is more likely to resolve the matter through corrective action rather than escalate to sanctions.

To keep operational guidance focused and efficient, small practices can weave Section 1557 into their existing HIPAA and quality activities instead of building a separate bureaucracy. The following controls are designed for low cost and direct alignment with 45 CFR Part 92.

First, standardize intake questions for gender and language across all front doors. Section 92.101 and 92.206 prohibit discrimination based on sex, including gender identity, and 92.201 requires meaningful access for individuals with limited English proficiency. 

• Implementation: Add two mandatory fields or questions to your intake script and forms: “What name and pronouns do you want us to use?” and “What language do you prefer for health care conversations and written information?” Include a simple checkbox for “Interpreter needed” when the preferred language is not English. Tie these questions into both your EHR and your scheduling system.

• Evidence: Maintain screenshots or configuration records showing these fields in your systems, along with sample completed intakes that demonstrate consistent use. Retain updated policies that reference these exact questions as part of your nondiscrimination approach.

• Low cost: Modify existing templates in your EHR and practice management system instead of buying a new platform, and use brief staff scripts rather than printed brochures for initial implementation.

Second, build a short, realistic Language Access Plan that fits your clinic’s size. Under 45 CFR 92.201, you must take reasonable steps to provide meaningful access for individuals with limited English proficiency; the 2024 guidance emphasizes timely, accurate interpretation and translated materials where appropriate. 

• Implementation: Identify the top one to three non-English languages in your patient panel using existing demographic reports. Contract with a reputable telephonic interpreter service and designate which staff can initiate calls. Pre-select a small set of vital documents, such as consent forms and financial agreements, that will be translated into these priority languages. Document in your plan when in person interpreters will be used, for example in complex cases.

• Evidence: Keep the Language Access Plan in your policy manual, along with interpreter service contracts, usage logs, invoices showing actual use of interpreters, and sample translated documents.

• Low cost: Choose telephonic or video remote interpretation over building an in house interpreter team and leverage free or low cost translated templates from federal agencies where they align with your forms.

Third, adopt a concise gender identity and sex discrimination policy that staff can actually apply at the point of care. Section 92.206 requires equal program access on the basis of sex and prohibits policies or practices that prevent individuals from participating in a health program consistent with their gender identity. 

• Implementation: Create a policy that commits the clinic to using patients’ self identified names and pronouns, permitting access to restrooms and exam areas consistent with gender identity, and applying clinical protocols and eligibility criteria in a gender-neutral way unless a sex specific standard is clinically justified. Align this policy with EHR workflows so that staff can see and update a “name to use” field without overriding legal identity fields required for billing.

• Evidence: Maintain the written policy, training sign in sheets, and periodic chart review notes showing that pronouns and names used in documentation and communication match the patient’s stated preferences. If you apply sex specific clinical criteria, record the medical evidence that supports them.

• Low cost: Use existing staff meetings to review scenarios rather than separate trainings, and rely on low cost legal updates from associations to keep the policy current.

Fourth, create a simple combined grievance pathway for gender and language concerns. Section 92.10 requires a notice of nondiscrimination and, for many covered entities, a grievance procedure with a Section 1557 coordinator. 

• Implementation: Designate a current manager or privacy officer as your Section 1557 coordinator and document this role. Develop a one-page grievance form that patients can submit on paper, online, or through the portal to report concerns about discrimination, misgendering, or language access. Include contact information for the coordinator in your Notice of Nondiscrimination and post the notice prominently in reception and on your website.

• Evidence: Keep copies of grievances received, responses issued, any corrective actions taken, and logs summarizing themes and resolutions. These records demonstrate that the clinic takes Section 1557 duties seriously and responds promptly.

• Low cost: Reuse elements from your existing complaint or HIPAA privacy forms and do not create a separate administrative layer; the focus is on a clear pathway, not complexity.

Fifth, align telehealth processes with gender and language protections. The 2024 rule includes provisions stating that covered entities must not discriminate in the delivery of health programs through telehealth and decision support tools. 

• Implementation: Ensure your telehealth platform allows display of chosen names and pronouns and does not default to legal name only in patient facing interfaces. Integrate interpreter services into telehealth workflows by creating a standard step for adding an interpreter to video or audio visits when “Interpreter needed” is flagged.

• Evidence: Maintain workflow diagrams, training materials, and platform settings that show how gender identity and language needs are handled in telehealth encounters. Periodically review a small sample of telehealth visits involving LEP patients or gender diverse patients to confirm that processes are working.

• Low cost: Use your existing telehealth platform’s configuration options and your current interpreter vendor, rather than purchasing specialized software, and build simple checklists into scheduling scripts.

Taken together, these controls help a small clinic embed 45 CFR Part 92 into existing HIPAA and quality structures, turning abstract nondiscrimination rules into visible, documented steps that can withstand OCR or payer scrutiny.

Case Study

A small internal medicine clinic in a suburban area serves a diverse population, including many immigrants and several transgender patients. One afternoon, a patient whose legal documentation still reflects their sex assigned at birth presents for hormone management. The front desk uses the legal first name loudly in the waiting room, and the nurse repeatedly uses incorrect pronouns during vitals. Later the same day, a patient whose preferred language is Vietnamese arrives for a diabetes follow up. No interpreter is arranged, and the clinician relies on the patient’s teenage child to interpret complex instructions.

Both patients eventually file complaints. The transgender patient submits a grievance to the clinic and then an OCR complaint, stating that they felt humiliated and unsafe returning for care. The LEP patient’s community advocate helps file an OCR complaint alleging that the clinic failed to provide meaningful language access. OCR opens an investigation under Section 1557 and 45 CFR Part 92.

OCR reviews the clinic’s policies. There is a generic nondiscrimination statement, but no specific policy on gender identity or language access. Intake forms do not ask for pronouns or preferred language; interpreter use is undocumented; and there is no Notice of Nondiscrimination or grievance procedure posted in the waiting room. The clinic’s reliance on the teenager to interpret appears inconsistent with the obligation to take reasonable steps to provide meaningful access under 45 CFR 92.201. The treatment of the transgender patient suggests a failure to provide equal program access on the basis of sex under 45 CFR 92.206. 

OCR negotiates a resolution agreement. The clinic must designate a Section 1557 coordinator, implement a written Language Access Plan, adopt a gender identity policy that ensures patients can access services consistent with their gender identity, train all staff, and report back to OCR on grievances received for two years. The clinic also spends unplanned funds on legal counsel and experiences reputational damage in the community.

If the clinic had implemented the operational playbook described earlier, the outcome would have looked different. Intake scripts would have captured chosen name, pronouns, and preferred language. The front desk would have used the chosen name in the waiting room, and the nurse would have had the correct pronouns visible in the EHR. The scheduling team would have flagged the need for a Vietnamese interpreter, and the clinician would have used a professional interpreter to discuss diabetes management. When the transgender patient still raised a concern, the clinic’s grievance process would have allowed quick acknowledgment and internal correction, possibly resolving the issue before an OCR complaint.

The following table translates Section 1557 and 45 CFR Part 92 into self-audit tasks that a small practice can complete annually or semi-annually.

Using this table as a recurring tool helps the clinic detect gaps in notice, intake processes, language services, and training before they become the basis of an OCR finding.

Common Audit Pitfalls to Avoid Under 45 CFR Part 92

Auditors and OCR investigators repeatedly see certain patterns that signal poor Section 1557 compliance, especially around gender and language. Each of the following pitfalls carries real legal and operational consequences.

• Assuming that a brief ability to converse in English eliminates any obligation to provide language assistance, contrary to 45 CFR 92.201, which requires reasonable steps to ensure meaningful access for individuals with limited English proficiency; this can lead to misdiagnosis, medication errors, and findings of national origin discrimination.

• Relying routinely on minor children to interpret in clinical encounters instead of professional interpreters, which undermines confidentiality and accuracy and is inconsistent with OCR language access guidance under Section 1557.

• Treating transgender or nonbinary patients according to sex assigned at birth for rooming, restroom access, or eligibility for services without a clinically sound and documented reason, risking violations of equal program access on the basis of sex under 45 CFR 92.206.

• Refusing to schedule or provide gender-affirming care that the clinic otherwise provides to other patients, solely because of gender identity or sexual orientation, which may be sex discrimination under 45 CFR 92.101 and 92.206 as interpreted in the 2024 final rule.

• Failing to post any Notice of Nondiscrimination or to identify a Section 1557 coordinator, leaving patients without clear information about their rights or how to complain, and signaling to OCR that civil rights obligations have been overlooked.

• Maintaining policies that look neutral but are applied in ways that disproportionately burden people with certain gender identities or language needs, such as closing off interpreter access during busy times or limiting same day appointments in a way that impacts certain groups, which can support a finding of discriminatory effect or pretext.

Addressing these pitfalls by strengthening policies, training, and documentation lowers the chance that routine operations will be misaligned with 45 CFR Part 92 and reduces the likelihood that an OCR audit or review will result in a finding of discrimination.

Sustainable compliance with Section 1557 is less about thick manuals and more about daily habits. For small practices, the culture and governance structure can be light but intentional.

Leadership should formally assign responsibility for Section 1557 compliance, usually to an existing compliance officer, practice administrator, or privacy officer who becomes the Section 1557 coordinator. This person is responsible for keeping track of regulatory updates, maintaining the Notice of Nondiscrimination, and ensuring that language and gender policies are current. 

Training should follow a simple cadence. New hires who interact with patients get a short orientation on Section 1557 basics, including the importance of pronouns, name usage, and interpreter offers. Once a year, the clinic reviews one or two real cases or near misses from its own experience to reinforce learning. Short, practical scenarios are more effective than long lectures.

Monitoring can focus on a few metrics: number of interpreter encounters per month, number of grievances involving discrimination or disrespect, and any incidents of misgendering reported by staff or patients. Reviewing these metrics quarterly in a brief leadership meeting allows the clinic to adjust its Language Access Plan, scripts, or training emphasis.

Most importantly, leaders should model the expectation that civil rights compliance is part of quality care. When staff raise questions about how to handle a situation involving gender or language, leaders can respond by asking which part of 45 CFR Part 92 applies and deciding together how to align with it, reinforcing that this is core to the clinic’s mission, not a box checking exercise.

Section 1557 and 45 CFR Part 92 place concrete obligations on even the smallest practices that receive federal financial assistance, particularly around equal treatment based on gender and meaningful access for individuals with limited English proficiency. The 2024 final rule and related guidance clarify that sex discrimination includes gender identity, sexual orientation, and sex stereotypes, and that language barriers can constitute national origin discrimination when clinics do not take reasonable steps to ensure meaningful access. 

For a small clinic, the goal is not to memorize every subsection but to embed a few high impact practices that align with 45 CFR Part 92 and are easy to show to OCR or payers: clear notices, structured intake questions, basic language services, gender-affirming policies, and a working grievance pathway.

Immediate next actions that a small practice can take include:

• Update intake forms and scripts so that every patient is asked for their preferred name, pronouns, and language for care, and ensure this information is visible in the EHR and scheduling systems.

• Draft or revise a short Language Access Plan that identifies priority languages, interpreter vendors, and which documents will be translated, and train staff on when and how to use interpreters.

• Adopt a written gender identity policy that guarantees access to services, facilities, and records consistent with patients’ gender identity, except where clinically justified sex based distinctions are documented.

• Post an updated Notice of Nondiscrimination in visible locations in the clinic and on the practice website, and designate a Section 1557 coordinator with clear contact information for grievances.

• Schedule a short, focused training session for all staff that walks through two gender scenarios and two language access scenarios from the clinic’s own experience and ties each resolution back to 45 CFR Part 92.

Recommended compliance tool: 

A concise Section 1557 policy and procedure template that integrates gender identity, language access, notices, and grievances into one document keyed to 45 CFR Part 92.

Advice: 

Before the end of this month, run a quick walk through of your waiting room, website, and intake forms; if patients cannot easily see their rights, their language options, and how to report discrimination, treat that as your top Section 1557 fix.

• 45 CFR Part 92 – Nondiscrimination in Health Programs or Activities 

• 45 CFR 92.101 – Discrimination Prohibited

• 45 CFR 92.201 – Meaningful Access for Individuals With Limited English Proficiency

• 45 CFR 92.206 – Equal Program Access on the Basis of Sex

• 42 U.S.C. 18116 – Nondiscrimination (Section 1557 of the Affordable Care Act)

• HHS OCR – Section 1557: Prohibiting Sex Discrimination in Health Care

• HHS OCR – Section 1557 Language Access Dear Colleague Letter

• Questions and Answers on the 2024 Final Rule Addressing Section 1557