[Federal Register Volume 86, Number 99 (Tuesday, May 25, 2021)]
[Rules and Regulations]
[Pages 27984-27985]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2021-10477]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

45 CFR Parts 86 and 92


Notification of Interpretation and Enforcement of Section 1557 of 
the Affordable Care Act and Title IX of the Education Amendments of 
1972

AGENCY: Office of the Secretary, Department of Health and Human 
Services (HHS).

ACTION: Notification of interpretation and enforcement.

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SUMMARY: This Notification is to inform the public that, consistent 
with the Supreme Court's decision in Bostock and Title IX, beginning 
May 10, 2021, the Department of Health and Human Services (HHS) will 
interpret and enforce section 1557 of the Affordable Care Act 
prohibition on discrimination on the basis of sex to include: 
Discrimination on the basis of sexual orientation; and discrimination 
on the basis of gender identity. This interpretation will guide the 
Office for Civil Rights (OCR) in processing complaints and conducting 
investigations, but does not itself determine the outcome in any 
particular case or set of facts.

DATES: This notification of interpretation became effective May 10, 
2021.

FOR FURTHER INFORMATION CONTACT: Rachel Seeger at (202) 619-0403 or 
(800) 537-7697 (TDD).

SUPPLEMENTARY INFORMATION: HHS is informing the public that, consistent 
with the Supreme Court's decision in Bostock \1\ and Title IX,\2\ 
beginning May 10, 2021, the Department of Health and Human Services 
(HHS) will interpret and enforce Section 1557's \3\ prohibition on 
discrimination on the basis of sex to include: (1) Discrimination on 
the basis of sexual orientation; and (2) discrimination on the basis of 
gender identity.
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    \1\ Bostock v. Clayton County, 140 S. Ct. 1731 (2020). https://www.supremecourt.gov/opinions/19pdf/17-1618_hfci.pdf.
    \2\ Title IX of the Education Amendments of 1972, 20 U.S.C. 1681 
et seq. https://www.govinfo.gov/content/pkg/CFR-2011-title45-vol1/pdf/CFR-2011-title45-vol1-part86.pdf.
    \3\ Section 1557 of the Patient Protection and Affordable Care 
Act. https://www.govinfo.gov/content/pkg/USCODE-2010-title42/pdf/USCODE-2010-title42-chap157-subchapVI-sec18116.pdf.
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I. Background

    The Office for Civil Rights (OCR) at the U.S. Department of Health 
and Human Services (the Department) is responsible for enforcing 
Section 1557 of the Affordable Care Act (Section 1557) and regulations 
issued under Section 1557, protecting the civil rights of individuals 
who access or seek to access covered health programs or activities. 
Section 1557 prohibits discrimination on the bases of race, color, 
national origin, sex, age, and

[[Page 27985]]

disability in covered health programs or activities. 42 U.S.C. 
18116(a).
    On June 15, 2020, the U.S. Supreme Court held that Title VII of the 
Civil Rights Act of 1964 (Pub. L. 88-352) (Title VII)'s \4\ prohibition 
on employment discrimination based on sex encompasses discrimination 
based on sexual orientation and gender identity. Bostock v. Clayton 
County, GA, 140 S. Ct. 1731 (2020). The Bostock majority concluded that 
the plain meaning of ``because of sex'' in Title VII necessarily 
included discrimination because of sexual orientation and gender 
identity. Id. at 1753-54.
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    \4\ Title VII of the Civil Rights Act of 1964 (Pub. L. 88-352) 
(41 CFR part 60-20). https://www.govinfo.gov/content/pkg/FR-2015-01-30/pdf/2015-01422.pdf.
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    Since Bostock, two federal circuits have concluded that the plain 
language of Title IX of the Education Amendments of 1972's (Title IX) 
prohibition on sex discrimination must be read similarly. See Grimm v. 
Gloucester Cnty. Sch. Bd., 972 F.3d 586, 616 (4th Cir. 2020), as 
amended (Aug. 28, 2020),\5\ reh'g en banc denied, 976 F.3d 399 (4th 
Cir. 2020), petition for cert. filed, No. 20-1163 (Feb. 24, 2021); 
Adams v. Sch. Bd. of St. Johns Cnty., 968 F.3d 1286, 1305 (11th Cir. 
2020), petition for reh'g en banc pending, No. 18-13592 (Aug. 28, 
2020).\6\ In addition, on March 26, 2021, the Civil Rights Division of 
the U.S. Department of Justice issued a memorandum to Federal Agency 
Civil Rights Directors and General Counsel \7\ concluding that the 
Supreme Court's reasoning in Bostock applies to Title IX of the 
Education Amendments of 1972. As made clear by the Affordable Care Act, 
Section 1557 prohibits discrimination ``on the grounds prohibited under 
. . . Title IX.'' 42 U.S.C. 18116(a).
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    \5\ Grimm v. Gloucester Cnty. Sch. Bd., 972 F.3d 586, 616 (4th 
Cir. 2020). https://www.ca4.uscourts.gov/opinions/191952.P.pdf.
    \6\ Adams v. Sch. Bd. of St. Johns Cnty., 968 F.3d 1286, 1305 
(11th Cir. 2020). https://media.ca11.uscourts.gov/opinions/pub/files/201813592.pdf.
    \7\ March 26, 2021, the Civil Rights Division of the U.S. 
Department of Justice memorandum to Federal Agency Civil Rights 
Directors and General Counsel re: Application of Bostock v. Clayton 
County to Title IX of the Education Amendments of 1972. https://www.justice.gov/crt/page/file/1383026/download.
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    Consistent with the Supreme Court's decision in Bostock and Title 
IX, beginning today, OCR will interpret and enforce Section 1557's 
prohibition on discrimination on the basis of sex to include: (1) 
Discrimination on the basis of sexual orientation; and (2) 
discrimination on the basis of gender identity. This interpretation 
will guide OCR in processing complaints and conducting investigations, 
but does not itself determine the outcome in any particular case or set 
of facts.
    In enforcing Section 1557, as stated above, OCR will comply with 
the Religious Freedom Restoration Act, 42 U.S.C. 2000bb et seq.,\8\ and 
all other legal requirements. Additionally, OCR will comply with any 
applicable court orders that have been issued in litigation involving 
the Section 1557 regulations, including Franciscan Alliance, Inc. v. 
Azar, 414 F. Supp. 3d 928 (N.D. Tex. 2019); \9\ Whitman-Walker Clinic, 
Inc. v. U.S. Dep't of Health & Hum. Servs., 485 F. Supp. 3d 1 (D.D.C. 
2020); \10\ Asapansa-Johnson Walker v. Azar, No. 20-CV-2834, 2020 WL 
6363970 (E.D.N.Y. Oct. 29, 2020); \11\ and Religious Sisters of Mercy 
v. Azar, No. 3:16-CV-00386, 2021 WL 191009 (D.N.D. Jan. 19, 2021).\12\
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    \8\ Religious Freedom Restoration Act, 42 U.S.C. 2000bb et seq. 
https://www.govinfo.gov/content/pkg/USCODE-2010-title42/pdf/USCODE-2010-title42-chap21B-sec2000bb-1.pdf.
    \9\ Franciscan Alliance, Inc. v. Azar, 414 F. Supp. 3d 928 (N.D. 
Tex. 2019). https://www.govinfo.gov/content/pkg/USCOURTS-nyed-1_20-cv-02834/pdf/USCOURTS-nyed-1_20-cv-02834-0.pdf.
    \10\ Whitman-Walker Clinic, Inc. v. U.S. Dep't of Health & Hum. 
Servs., 485 F. Supp. 3d 1 (D.D.C. 2020). http://www.ca5.uscourts.gov/opinions/unpub/20/20-10093.0.pdf.
    \11\ Asapansa-Johnson Walker v. Azar, No. 20-CV-2834, 2020 WL 
6363970 (E.D.N.Y. Oct. 29, 2020). https://www.govinfo.gov/content/pkg/USCOURTS-nyed-1_20-cv-02834/pdf/USCOURTS-nyed-1_20-cv-02834-0.pdf.
    \12\ Religious Sisters of Mercy v. Azar, No. 3:16-CV-00386, 2021 
WL 191009 (D.N.D. Jan. 19, 2021). https://www.hhs.gov/sites/default/files/document-124-memorandum-opinion-and-order.pdf.
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    OCR applies the enforcement mechanisms provided for and available 
under Title IX when enforcing Section 1557's prohibition on sex 
discrimination. 45 CFR 92.5(a). Title IX's enforcement procedures can 
be found at 45 CFR 86.71 (adopting the procedures at 45 CFR 80.6 
through 80.11 and 45 CFR part 81).
    If you believe that a covered entity violated your civil rights, 
you may file a complaint at https://www/hhs.gov/ocr/complaints.

    Dated: May 13, 2021.
Xavier Becerra,
Secretary, Department of Health and Human Services.
[FR Doc. 2021-10477 Filed 5-24-21; 8:45 am]
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