The Nondiscrimination Requirement: Why Your Practice Must Have an Accessibility Notice (45 CFR § 92.8)

Section 1557 of the Affordable Care Act and its implementing regulation at 45 CFR Part 92 prohibit discrimination in health programs and activities that receive federal financial assistance, including most small outpatient practices. The updated 2024 rule requires covered entities to implement written civil rights policies and procedures under 45 CFR 92.8 and to provide clear public notices of nondiscrimination and of the availability of language assistance and auxiliary aids and services under 45 CFR 92.10 and 92.11.

For a small practice, this “accessibility notice” is the visible tip of an entire compliance iceberg: it signals to patients, regulators, and payers that the practice understands and honors its nondiscrimination duties. A missing or outdated notice is one of the easiest findings OCR can make in a complaint-driven investigation and a strong indicator that policies, procedures, and training are also weak.

By aligning your written nondiscrimination policy, grievance procedures, language access plan, and effective communication processes with a simple, well-placed accessibility notice, you can reduce the risk of civil rights complaints, avoid costly corrective action plans, and improve patient trust at the same time.

Most small practices assume they “do not discriminate” because staff treat patients politely and clinicians strive to provide good care. Section 1557, however, requires more than good intentions. It requires written policies, defined processes, and clear public communication, so that patients with limited English proficiency or disabilities actually know how to obtain equal access to your services and how to escalate concerns if something goes wrong.

The 2024 Section 1557 rule sets deadlines for covered entities to implement civil rights policies and related training within one year of July 5, 2024, and to provide specific nondiscrimination and language access notices to patients and the public. For a small clinic that already struggles with staffing and billing demands, the fastest way to operationalize these requirements is to design one accessibility notice that reflects the core nondiscrimination commitments required by 45 CFR 92.8 and the content elements listed in 45 CFR 92.10 and 92.11.

This article explains how Section 1557’s nondiscrimination requirement works, what your accessibility notice must communicate, where and how it should be posted, and how to back it up with lean policies, procedures, and training that will stand up to OCR scrutiny.

Understanding Legal Framework & Scope Under 45 CFR 92.8

Section 1557 of the ACA, codified at 42 U.S.C. 18116, prohibits discrimination on the basis of race, color, national origin, sex, age, or disability in certain health programs and activities that receive federal financial assistance or are administered by HHS or ACA-created entities. 45 CFR Part 92 implements this statute and incorporates standards from Title VI, Title IX, Section 504, and the Age Discrimination Act, with the requirement that Section 1557 never be interpreted to apply a weaker civil rights standard than those laws.

Under the 2024 rule, 45 CFR 92.8 requires covered entities to implement written policies and procedures “designed to comply with the requirements of this part,” taking into account the size, complexity, and type of health programs or activities. These policies must have an effective date and must at minimum include a nondiscrimination policy, grievance procedures for entities with 15 or more employees, language access procedures, effective communication procedures for individuals with disabilities, and reasonable modification procedures.

Separate but closely linked provisions require clear public-facing notices. 45 CFR 92.10 requires a notice of nondiscrimination that describes the entity’s commitment not to discriminate, the availability of reasonable modifications, auxiliary aids and services, and language assistance, plus contact information for the Section 1557 Coordinator, grievance procedures, and OCR complaint instructions. This notice must appear annually to participants and applicants, in conspicuous physical locations in at least 20-point sans serif font, and prominently on the entity’s website. 45 CFR 92.11 then requires a specific notice of availability of language assistance services and auxiliary aids and services.

For small practices, understanding this framework helps translate a dense regulation into three practical questions:

• Do we have dated, written civil rights policies that match the content of 45 CFR 92.8?

• Do our public accessibility notices accurately reflect those policies and include all required elements from 45 CFR 92.10 and 92.11?

• Can we show OCR how these policies and notices actually work in day-to-day operations if a complaint arises?

Getting these elements right reduces the risk of denials of care, communication breakdowns, and OCR enforcement, and it also reduces administrative friction when patients, payers, or advocates ask how your practice handles disability and language access.

The HHS Office for Civil Rights (OCR) enforces Section 1557 and the regulations at 45 CFR Part 92, including 92.8, 92.10, and 92.11. OCR has authority to investigate individual complaints, conduct compliance reviews, and coordinate enforcement with other components of HHS and with state agencies when systemic problems appear. Enforcement mechanisms under 45 CFR 92.301 mirror those used under Title VI and Section 504, ranging from voluntary corrective action plans to suspension or termination of federal financial assistance in extreme cases.

Common triggers for OCR review related to accessibility notices and nondiscrimination policies include:

• Complaints that a patient with limited English proficiency was never informed of free language access services and was asked to bring a family member to interpret.

• Complaints from individuals with disabilities who could not obtain auxiliary aids (such as sign language interpreters or alternate format materials) and saw no public notice explaining their rights.

• Evidence in broader investigations that a covered entity has not designated a Section 1557 Coordinator, lacks written policies under 45 CFR 92.8, or still uses outdated notices that no longer match the current rule.

Because accessibility notices must be posted in obvious physical and digital locations, they are one of the first artifacts OCR will check. Their presence, content, and alignment with underlying policies strongly influence how deeply OCR believes it must dig into your operations. For a small practice, well-designed notices and matching policies are a low-cost way to demonstrate good faith and reduce the scope and duration of any investigation.

Although this section of the regulation sits under Section 1557 rather than HIPAA, OCR often reviews civil rights compliance alongside HIPAA privacy and security in the same encounter. The following controls help a small practice survive both kinds of audits by aligning written policies, accessibility notices, and daily workflows with 45 CFR 92.8, 92.10, and 92.11.

1. Build a one-page nondiscrimination and accessibility policy aligned with 45 CFR 92.8(b) and 92.10

• How to implement: Draft a concise policy that states your practice does not discriminate on the basis of race, color, national origin (including limited English proficiency), sex, age, or disability; that you provide language assistance services and auxiliary aids free of charge when required; and that you will make reasonable modifications for individuals with disabilities. Include the name and contact information of your Section 1557 Coordinator.

• Evidence to retain: Final signed policy with effective date; board or owner approval notes; version history; and a copy placed in your policy manual and compliance binder.

• Low-cost implementation: Use a short template adapted from OCR examples and store it in a shared folder so every manager and front desk lead can access the current version.

2. Map and post your accessibility notice in every required physical and digital location

• How to implement: Using your policy as the source, draft a patient-friendly accessibility notice that includes the nondiscrimination statement, information about free language assistance services and auxiliary aids, Section 1557 Coordinator contact details, grievance availability, and directions for filing complaints with OCR. Post it in large font at check-in, check-out, and any other waiting areas and place it prominently on your website.

• Evidence to retain: Photos of posted notices with timestamps; copies of the notice as printed; screenshots of the notice location on your website and patient portal.

• Low-cost implementation: Print in-house on letter-sized paper in large, clear font; add a single banner link or footer item on your website that points directly to the notice page.

3. Create a simple grievance procedure under 45 CFR 92.8(c)

• How to implement: For entities with 15 or more employees, establish a short, written grievance procedure that explains how individuals can submit a discrimination concern, who reviews it, investigation timelines, resolution steps, and non-retaliation commitments. Map each step to the Section 1557 Coordinator’s role.

• Evidence to retain: Grievance procedure document; a log of grievances and outcomes maintained for at least three years; copies of any written responses to complainants.

• Low-cost implementation: Use an existing HIPAA or general complaint form and add Section 1557 fields for basis of discrimination and civil rights routing.

4. Document language access procedures that connect to your notice

• How to implement: Write a brief language access procedure that identifies how staff determine a patient’s primary language, how they request a qualified interpreter or translation, and when use of ad hoc interpreters is prohibited. Link these procedures to your language assistance statements in the accessibility notice and to the requirements at 45 CFR 92.201 and 92.8(d).

• Evidence to retain: Vendor contracts or access codes for interpreter services; internal quick-reference cards for staff; logs or EHR fields showing interpreter use.

• Low-cost implementation: Contract with a telephone or video interpretation service that charges per minute and train front desk and clinical staff on how to access it.

5. Establish effective communication and auxiliary aids procedures for individuals with disabilities

• How to implement: Develop written procedures that explain how patients request auxiliary aids (such as sign language interpreters, large-print materials, or alternate formats), who approves them, and the timeframes for arranging them, in line with 45 CFR 92.202 and 92.8(e).

• Evidence to retain: Requests and responses logged; purchase or service records for aids; documentation of how telehealth platforms meet accessibility standards.

• Low-cost implementation: Maintain a short list of commonly requested aids and local or remote vendors; pre-build an email template to request an interpreter from a contracted agency.

6. Define a reasonable modification process under 45 CFR 92.8(f)

• How to implement: Write a short procedure for evaluating requests from individuals with disabilities for changes, exceptions, or adjustments to policies or services, including how to determine whether a requested change would fundamentally alter your program and how to propose an alternative.

• Evidence to retain: Documentation of each request, analysis of feasibility, final decision, and any alternative modifications provided.

• Low-cost implementation: Use a one-page form that clinicians and managers can complete when they receive a request, then store it with other Section 1557 documentation.

7. Tie training and documentation back to 45 CFR 92.8 and your notice

• How to implement: Train relevant employees on your civil rights policies and accessibility notice within 30 days of implementation and for new staff within a reasonable time after hire, as required in 45 CFR 92.9.

• Evidence to retain: Training agenda, materials, attendance lists, and electronic confirmation of completion, retained for at least three years.

• Low-cost implementation: Integrate Section 1557 and accessibility notice training into existing HIPAA or onboarding sessions and use free OCR materials as training aids.

Together, these controls give a small practice a compact, defensible system: written policies under 45 CFR 92.8, visible notices under 45 CFR 92.10 and 92.11, and documented training and grievances that show the system actually works in practice.

Case Study

A small multi-physician primary care clinic participates in Medicare and Medicaid and therefore qualifies as a covered entity under Section 1557 and 45 CFR Part 92. The practice has a generic “we treat everyone equally” statement on its website but no formal civil rights policy, no designated Section 1557 Coordinator, and no posted notice describing free language assistance or auxiliary aids.

A patient with limited English proficiency presents for a complex visit. The front desk staff, unsure how to obtain an interpreter, ask the patient’s teenager to interpret. During the visit, key details about medication history and prior hospitalizations are lost, leading to a serious medication error and an avoidable emergency department visit. The patient later files a complaint with OCR, explaining that they were never told about free interpreter services and could not find any information in the clinic about language assistance or disability accommodations.

OCR opens an investigation and quickly confirms that the clinic has no written policies under 45 CFR 92.8, no notice of nondiscrimination that meets 45 CFR 92.10, and no notice of the availability of language assistance services or auxiliary aids required by 45 CFR 92.11. OCR concludes that the clinic failed to take reasonable steps to provide meaningful access to an individual with limited English proficiency and failed to implement the civil rights policies and notices required by the 2024 Section 1557 rule.

Financially, the clinic is required to enter into a multi-year voluntary resolution agreement that includes development and implementation of new policies and procedures, posting of compliant accessibility notices in all locations, training of all staff, and periodic reporting to OCR. Reputationally, the agreement is posted publicly, and local advocates begin asking other patients whether they have experienced language access barriers at the clinic. Administratively, the clinic’s leadership spends significant time responding to OCR data requests and building documentation it could have prepared in advance at far lower cost.

Had the clinic implemented the controls described in the previous section, it would have had a dated nondiscrimination policy, an accessibility notice at check-in and on its website, a defined process for obtaining interpreters, and training logs showing staff knew how to use those processes. OCR might still have investigated the individual incident, but the presence of a robust 45 CFR 92.8 framework would have made it easier to demonstrate that the error was an outlier rather than a systemic failure.

Use this table to test whether your small practice’s accessibility notices and related policies match the requirements of 45 CFR 92.8 and the linked notice provisions at 45 CFR 92.10 and 92.11.

Regularly reviewing this checklist helps confirm that your accessibility notice is backed by real policies and processes, which in turn reduces enforcement risk under 45 CFR 92.8 and related provisions.

Common Audit Pitfalls to Avoid Under 45 CFR 92.8

Even well-intentioned small practices make predictable mistakes when implementing nondiscrimination and accessibility notices. The following pitfalls are common in OCR findings and can often be prevented with modest adjustments.

• Relying on outdated Section 1557 notices that no longer reflect the 2024 regulation structure, including the current scope of sex discrimination and notice content requirements, which can signal noncompliance with 45 CFR 92.8 and 92.10 and invite corrective action.

• Posting a generic “we do not discriminate” sign without mentioning the availability of free language assistance services or auxiliary aids, leaving the notice incomplete under 45 CFR 92.10 and undermining meaningful access for patients.

• Failing to list current Section 1557 Coordinator contact details in either the written nondiscrimination policy or the public notice, making it harder for patients and staff to route grievances and for OCR to see a coherent compliance structure under 45 CFR 92.7 and 92.8.

• Not posting the notice prominently on the practice website or patient portal, despite 45 CFR 92.10’s requirement to place the notice in a conspicuous location online, which can be a straightforward finding for OCR in a desk review.

• Treating telehealth platforms as outside the scope of accessibility obligations, even though 45 CFR Part 92 extends nondiscrimination protections to telehealth and requires accessible information and communication technology, leading to barriers for individuals with disabilities.

• Keeping no records of grievances, or mixing civil rights grievances with general service complaints without capturing basis of discrimination, which fails the specific recordkeeping expectations in 45 CFR 92.8(c)(2) and weakens your ability to show prompt and equitable resolution.

Addressing these pitfalls by refreshing notices, clarifying coordinator roles, and documenting processes strengthens your practice’s ability to demonstrate compliance under 45 CFR 92.8 and reduces the likelihood that a single complaint will escalate into a broad civil rights investigation.

Accessibility notices are most effective when they express a genuine culture of nondiscrimination rather than simply fulfilling a posting rule. For small practices, this culture begins with leadership explicitly adopting Section 1557 obligations as part of the organization’s mission, then assigning clear ownership and simple monitoring routines.

Designate a Section 1557 Coordinator with real authority to maintain civil rights policies, oversee accessibility notices, manage grievances, and coordinate staff training and vendor relationships tied to language assistance and auxiliary aids. At least annually, leadership should review the nondiscrimination policy and accessibility notice, confirm that postings are current, and evaluate any trends in grievances or informal complaints.

A small set of metrics can keep the program on track without consuming significant resources: for example, percentage of staff who have completed Section 1557 training in the last year, number and outcome of civil rights grievances, and time from request to fulfillment for interpreter services or auxiliary aids. Periodically sharing these metrics with clinicians and office staff reinforces the idea that nondiscrimination and accessibility are core quality indicators, not peripheral legal chores.

For small practices, Section 1557’s nondiscrimination requirement and the related accessibility notice obligations under 45 CFR 92.8, 92.10, and 92.11 can feel technical, but they boil down to a simple principle: every patient should be able to understand and participate in their care, regardless of language, disability, or protected characteristic.

By implementing written civil rights policies tailored to your size and services, posting clear and accurate accessibility notices, and giving staff practical tools to respond to requests for language assistance and auxiliary aids, your practice can reduce legal risk, avoid costly corrective action, and build trust in your community.

Three to five immediate next steps for your clinic:

1. Identify your Section 1557 Coordinator and schedule a short meeting this month to review 45 CFR 92.8, 92.10, and 92.11 requirements and assign tasks.

2. Draft or update your written nondiscrimination policy and create a one-page accessibility notice that includes all required elements and matches your actual processes.

3. Walk through your clinic and website to confirm where the notice is posted and document any gaps; fix the highest impact locations first, such as the main waiting room and homepage.

4. Implement or refresh language access and auxiliary aids procedures, ensuring that front desk, billing, and clinical staff know how to act on the commitments in your notice.

5. Add Section 1557 and accessibility notice training to your regular compliance training cycle and start keeping simple, consistent records of attendance and completion.

Recommended compliance tool: 

Store your Section 1557 nondiscrimination policy, accessibility notice, grievance log, and training records in one labeled “Civil Rights – Section 1557” folder that OCR can review quickly if needed.

Advice: Before making any new flyer, web page, or patient form public, add a quick check that asks, “Does this point clearly to our accessibility notice and match what we promise there?”

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

• 45 CFR § 92.8 – Policies and procedures
  

• 45 CFR § 92 – Nondiscrimination on the Basis of Race, Color, National Origin, Sex, Age, or Disability in Health Programs or Activities Receiving Federal Financial Assistance