Access to Health Care for People with Disabilities under the ADA and other Civil Rights Laws

This pub explains the rights people with disabilities have to get health care. They include equal access to medical facilities and services. The law says, people with disabilities must be treated the same as everyone else.

Introduction

This publication focuses on the rights of people with disabilities when accessing health care. Under Federal Civil Rights laws, people with disabilities have the right to certain accessible facilities, services, and information offered by doctors’ offices, other medical providers, and insurance plans. These rights extend to covered public and private entities. Healthcare providers include hospitals, doctors, clinics, psychologists, dentists, chiropractors, nursing homes, and pharmacies. A covered entity can include a doctor’s office, clinics, dental offices, psychologists, nursing homes, pharmacies, hospitals, health plans, insurance companies, and government programs that pay for healthcare.

For many Californians, medical services are provided either by a public entity, such as a county, or through Managed Care plans, a network of providers managed by an umbrella corporation or agency.1 When providing Medi-Cal services, Managed Care plans are doing so under a contract with the state of California, county government, or both. This publication focuses on an overview of the federal civil rights laws prohibiting discrimination in health care; the requirements for accessibility under these laws; and specific examples of discrimination that can arise in the healthcare setting.

DRC has an additional publication on disability discrimination by public entities and in places of public accommodation generally: https://www.disabilityrightsca.org/publications/disability-discrimination-fact-sheet-government-agencies-and-other-public-entities

The main federal laws that protect a person’s rights are the Americans with Disabilities Act (ADA) and Section 504 of the Rehabilitation Act (Section 504), and Section 1557 of the Affordable Care Act (ACA).2

• Americans with Disabilities Act:3 Title II of the ADA covers medical services and facilities run by government bodies, including public hospitals, clinics, and medical offices because they are public entities.
• Privately owned and operated hospitals or medical offices are covered under Title III of the ADA because they are “public accommodations.”
• Section 504 of the Rehabilitation Act:4Section 504 covers programs or activities that receive federal financial assistance, such as hospitals or healthcare providers that take Medi-Cal payments, as well as federally conducted programs and activities such as the Medicare program.5 There are similar state law provisions as well.6
• Section 1557 of the Affordable Care Act:7 Section 1557 covers programs or activities that receive federal financial assistance such as Medi-Cal or Children’s Health Insurance Program (CHIP), Medicare, and any entity created under Title I of the ACA such as state-based Exchange programs, state partnerships, and the federally facilitated marketplaces.8 In limited circumstances, employers can also be liable for discriminating in health insurance or health coverage under Section 1557.9

In California, the state Medicaid Agency (Department of Health Care Services, or DHCS) is responsible for ensuring that all Medi-Cal services and Medi-Cal Managed Care Plans comply with the ADA, Section 504, and Section 1557. The state is responsible for ensuring that all Managed Care Plans maintain an adequate network of providers that provide physical access for enrollees with disabilities.10 Most Managed Care Plans are not public entities and not directly bound by Title II of the ADA. However, the ADA and Section 504 require all public services to comply with the ADA and Section 504 even if private contractors provide them.11 In addition to a state’s obligations under Title II, private contractors have obligations under Title III because they are places of “public accommodation.”

Under Medi-Cal’s program structure, it can be challenging to figure out what civil rights laws a person’s plan or healthcare provider must follow. As a result, this publication explains some of the responsibilities the Department of Health Care Services, Counties, Medi-Cal Managed Care Plans, and Primary Care Providers have under these laws. However, it is important to note that these civil rights laws prohibit all types of covered entities from discriminating against people with disabilities and require them to provide access in various ways.

General Provisions

Considered together, Title II and III of the ADA, Section 504, and Section 1557 require that covered entities provide individuals with disabilities:

• Full and equal access to their health care services and facilities;
• Reasonable modifications to policies, practices, and procedures when necessary to make health care services accessible; and,
• Effective communication, including auxiliary aids and services, such as the provision of sign language interpreters or written materials in alternative formats.12

However, refusing to provide a person with a disability full and equal physical access or a modification is not a violation under Title II and III of the ADA, Section 504, or Section 1557 if the building or service’s alteration would result in an “undue burden” to the covered entity.13 The covered entity may assess whether the modification needed or requested is reasonable by determining if it would be a fundamental alteration in the program that would result in significant difficulty or expense.

What if I use a wheelchair, walker, or crutches and cannot get into my doctor’s office?

The ADA Standards for Accessible Design require covered entities to provide:14

• accessible paths of travel, waiting areas, and exam rooms
• elevators
• ramps
• doors that open easily
• reachable light switches
• accessible bathrooms
• accessible parking
• signage used by individuals who are blind or have low vision.15

Newly constructed buildings need to comply with current federal and state laws requiring physical accessibility.16 Complete access requirements are in the law and regulations.17 Older buildings still need to comply with accessibility requirements under Title II and Title III of the ADA, Section 1557, and Section 504.18 A person can contact Disability Rights California if they have access issues at their doctor’s office.

What about physical access to medical equipment and exam rooms?

The ADA authorizes the U.S. Department of Justice to provide technical assistance to individuals and entities who have rights or responsibilities under the Act.19 Under the DOJ guidelines, it is generally not acceptable for a covered entity to deny treatment due to an inaccessible examination table, inaccessible medical equipment, or because of concern that staff might be injured if they assist in transferring a patient with a mobility disability. The DOJ requires covered entities to provide accessible equipment and to use a lift or trained staff as necessary to ensure equal access to medical examinations and tests.20

• Examinations requiring specialized positioning, such as gynecological examinations, must be accessible to a person with a disability. To provide an accessible gynecological examination to a person with a mobility impairment, a covered entity may need a height-accessible exam table with adjustable, padded leg supports instead of standard stirrups.
• A person who uses a wheelchair may require a height-adjustable table for an independent transfer. If that is not available, the covered entity should offer transfer assistance. Failing to offer these modifications and, as a result, examining the person in their chair is not equal access to medical services.

Additionally, Title II and III of the ADA standards outline requirements for patient and resident sleeping rooms in medical care and long-term care facilities. These include, turning space in each room, floor space on each side of the bed, and toilet and bathing room requirements for patient and resident sleeping rooms.21

Under Section 1557, covered Medi-Cal managed care plans, or other covered plans, do not need to ensure that all healthcare providers in the network have accessible medical and diagnostic equipment. However, the plan should ensure that enough providers in its network have accessible medical and diagnostic equipment allowing individuals with disabilities to receive necessary diagnostic exams. A covered plan has additional responsibilities if it cannot meet these requirements. These requirements include taking other steps to provide accessible services, such as making sure a process is available to allow an individual with a disability to go out of network to receive these services at no additional charge.22

Covered entities who are healthcare providers have flexibility in determining how to meet these requirements.23 For example, a covered entity can use different types of accessible medical diagnostic equipment or have enough staff to assist the patient transfer from a wheelchair to an examination table, but only if that approach is effective for an individual with the disability.24 Regardless of how the covered entity chooses to meet these requirements, under Title II and III of the ADA, Section 504, and Section 1557, a person with a disability must receive medical services equal to those received by a person without a disability.25

Can I bring my service animal with me to my appointment?

Yes. The ADA, Section 504, Section 1557, and state law require covered entities, including public and private healthcare providers, to allow a service animal to accompany a person with a disability to areas such as patient waiting rooms, clinics, cafeterias, or examination rooms.26 Covered entities can make limited inquiries about what the animal does but cannot ask about a person’s disability. There are some restrictions on service animals. It may be appropriate to exclude a service animal from operating rooms or burn units where the animal’s presence might compromise a sterile environment.27 The animal must be a dog or a miniature horse.28 The animal must have individual training to do work or perform tasks related to its handler’s disability.

For example, a Deaf person may use a dog to alert him to sounds. Many people who are blind use dogs to assist with orientation. People with mobility impairments might use a dog to retrieve items or pull a wheelchair. A person with epilepsy or a panic-related condition might use a dog to warn about an oncoming episode. Under the ADA, an animal used for comfort, therapy, or emotional support does not meet the service animal definition and would only be allowed as a reasonable modification in limited circumstances.

I have impaired sensory, manual, or speaking skills. How is a covered entity required to communicate with me?

Under Section 1557, covered entities, regardless of the number of people they employ, must provide appropriate auxiliary aids and services to individuals with impaired sensory, manual, or speaking skills if needed to have an equal opportunity to benefit from the service.29 Interpreters can include:

• Sign language interpreters.
• Oral translators (individuals who represent or spell in the characters of another alphabet).
• Cued-language translators (individuals who represent or spell by using a small number of handshapes).

Under Section 1557, American Sign Language interpreters are not the only type of interpreters available to a person with a disability. The covered entity should give priority to the choice of aid or service requested by the individual with a disability.

I am Deaf. How is a covered entity required to communicate with me?

Under the ADA and Section 1557 of the ACA, covered entities must provide effective communication for patients, family members, and visitors who are Deaf or hard of hearing using auxiliary aids and services. Auxiliary aids and services include equipment or services such as qualified sign-language interpreters, assistive listening devices, note-takers, written materials, television decoders, closed caption decoders, and real-time captioning.30 Moreover, Section 1557 provides additional examples of auxiliary aids and services.31 Since people who are Deaf or hard of hearing use various ways to communicate, the method provided will vary depending on the abilities of the individual, their preferences for communication, and the complexity and nature of the communications required.32 The covered entity should prioritize the communication method requested by the person with a disability.

For example, effective communication might be:

• Exchanging notes or pointing to items in the hospital gift shop or responding to a visitor’s inquiry about a patient’s room number. However, notes may not be effective for a patient when the communication is between a healthcare provider and a patient;
• Written forms or information sheets in situations where there may not be a need for much interaction, such as billing or insurance information or medical history forms;
• Provision of a qualified sign language interpreter or other interpreters for discussion of symptoms or treatment information between a patient and their doctor or a minor patient’s parents/guardian and the minor’s doctor, or for group therapy; and
• Providing information about self-care after a procedure in sign-language on a DVD or streaming video format.

A covered entity cannot charge a person for providing sign language interpreter services.33 It is inappropriate to ask a family member or other companion to interpret for a Deaf or hard of hearing patient because the situation might be private, too emotional, or the family member might not have the appropriate communication skills for the situation. Under Section 1557, an interpreter must adhere to generally accepted interpreter ethics principles.34 Additionally, being able to call a provider on the phone is important. Covered entities should provide telephone access through TTY or video, or another relay service. There may be additional requirements to provide visual alarms and public phone access in specific settings.35

In some circumstances, Medi-Cal covers sign language interpreters. In other circumstances, this is covered directly by the healthcare provider. Under Medi-Cal regulations, sign language interpreter services are reimbursable only to providers or provider groups employing fewer than 15 people. Additionally, Medi-Cal regulations have a health facility limitation. Medi-Cal does not cover sign language interpreter services for recipients receiving these services in a health facility required by law to provide sign language interpreter services.36 Regardless, covered entities cannot charge the patient for providing sign language interpreter services, and interpretation services are provided.37

I am blind or visually impaired. How can I get information from a covered entity?

Under the ADA and Section 1557, covered entities must offer auxiliary aids and services to provide effective communication for patients, family members, and visitors who are blind or have low vision. These services may include readers, taped texts, Braille materials, buying or modifying equipment, or other effective means of conveying the information.38 Section 1557 provides additional examples of auxiliary aids and services.39 A covered entity must effectively communicate all information that it makes available in print, including general health guidance, side effect information, billing invoices, and appointment reminders. Other examples of auxiliary aids and services are:

• Assistance with reading and completing admission and consent forms, or reading discharge information, medication names and dosages;
• Providing text materials in an accessible, electronic format;
• Providing documents in Braille or audio;
• Providing a Braille-output TTY to a patient who is Deaf and blind; or,
• Making healthcare plan websites accessible.40

Note: a covered entity cannot require a person who is blind to bring someone with them to interpret or facilitate communication and cannot rely on a companion to interpret or facilitate communication.41

How are covered entities required to make health programs and activities provided through electronic and information technology accessible?

Under Section 1557, covered entities must ensure that their health programs and activities provided through information and communication technology are accessible to people with disabilities in the same way they are accessible to people without disabilities.

Under Section 1557, accessibility requirements apply to:

• Accessing online appointment systems
• Accessing electronic billing and statements
• Accessing find-a-doctor search tools
• Information about specific plan and benefits provided
• Comparison of health plans offered on the federally facilitated health insurance marketplace

However, if providing this information in an electronic format would result in undue financial and administrative burdens or a fundamental alteration in the nature of the program, the covered entity may provide the information in another format. The alternative format must also ensure that individuals with disabilities receive the benefits or services of the health program or activity provided through information and communication technology to the maximum extent possible.42

What if I have mental health or other disabilities? Can I ask for other modifications to help me access my health care?

Yes. The ADA, Section 504, and Section 1557 prohibit discrimination against people with all types of disabilities, including people with physical, cognitive, communication, and mental health disabilities. Titles II and III of the ADA, Section 504, and Section 1557 equally protect from disability discrimination individuals who have physical disabilities and individuals with mental health or other disabilities.43 These protections can also extend to disabilities that are episodic or in remission.44

For example, under Title III of the ADA, covered entities must make “reasonable modifications in policies, practices and procedures” when necessary to avoid discrimination based on disability, unless the covered entity can demonstrate that making the modification would “fundamentally alter the nature of the service, program or activity.” An entity must make changes to the way it does business (i.e., to provide modifications) to people with disabilities in many types of situations, including:

• Taking extra time to explain a procedure to a patient who has a cognitive disability and might have difficulty understanding;
• Modifying policies to schedule an appointment at a specific time for a patient with an anxiety disorder who has difficulty waiting in a crowded waiting room; or
• Providing assistance to help a patient who is blind choose food in the cafeteria line at the clinic.

The ADA, Section 504, and Section 1557 ensure full and equal access to health care services and facilities. This includes the reasonable modifications necessary to make healthcare services accessible, including services that a person may not consider inherent to healthcare. Still, a covered entity provides such as a hospital’s cafeteria or the televisions in hospital rooms. These modifications extend to all types of disabilities. These federal laws protect access to healthcare for people with disabilities.

The federal civil rights laws prohibit discrimination based on mental health disability. However, in understanding access to care, it is also necessary to understand Mental Health Parity. The ACA and the Mental Health Parity and Addiction Equity Act (MHPAEA) incorporate the concept of Mental Health parity into law. Mental Health parity requires most insurance plans to equally cover mental health conditions and substance use disorders as they cover physical and acute care needs. For example, Section 1302 of the ACA requires a qualified health plan to provide an essential health benefits package that includes traditional medical and surgical services and mental health and substance use disorder services, including behavioral health treatments.45

Mental Health Parity and civil rights laws are distinct. When a plan has parity, if it offers unlimited appointments for a chronic condition like diabetes, it must also provide unlimited appointments for a mental health condition such as depression.46 Mental health parity is a comparison between types of services covered in an insurance plan. In contrast, civil rights laws exist to ensure that people with disabilities receive medical services equal to those that do not have a disability. As a result, whether federal parity law covers a plan depends on the type of plan a person is enrolled in. Even if a plan is not subject to the MHPAEA, it can still be subject to civil rights laws.

What are some examples of disability-related discrimination that might violate the ADA, Section 504, or Section 1557?

Examples of discrimination might include:

• Requiring a person to wait longer for an examination because there is only one accessible examination room;
• Requiring a person to bring an attendant or companion to a provider’s office to assist with lifting, understanding, or interpreting (unless this is their own choice);
• Refusing to serve a person because the exam may take longer due to their disability;
• Charging an extra fee to provide sign language interpretation when needed for effective communication;
• Providing limited appointment dates or times due to an individual’s disability;
• Refusing to provide effective communication assistance such as a person’s files in an alternate format or a sign-language interpreter when appealing a health plan’s refusal to authorize treatment or when filing a grievance or complaint with a health plan; or
• Refusing to provide any information or assistance to plan members who indicate a need for a sign language interpreter in their appointments or a network provider with accessible examination equipment.
• Refusing to provide a requested treatment based on subjective quality-of-life assumptions.47 For example, a doctor refusing to provide cancer treatment for a child with a severe intellectual disability based on their personal belief that the child has a low quality of life.
• Pressure to consent to a do not resuscitate (DNR) order or withdrawal of life-sustaining treatment based on the assumption that persons with certain disabilities should not seek to unduly extend their life.48

What do I do if I am having difficulties accessing my health care provider or health care plan due to my disability?

If you have problems with access, the provision of modifications, or securing auxiliary aids and services (or any other form of discrimination), you should start by talking directly to your provider and/or health care plan. Under Section 1557, if you are a member of a Medi-Cal managed care plan and either the plan or its contractors engaged in prohibited conduct, file the complaint directly with the plan itself. Section 1557 requires all covered entities to adopt appropriate grievance procedures for handling complaints.49

Also, covered entities, such as public health care providers and large private facilities and plans, should have an ADA or Section 504 coordinator responsible for ensuring compliance with the law and dealing with consumers’ complaints. If a person cannot work it out with the provider or health care plan, they can call or file a complaint with the entity’s ADA coordinator. A plan’s website, plan materials, or a plan’s member services department provides information on who to contact and how to file a complaint.

Where can I file a complaint if I cannot work it out with my healthcare provider or health care plan?

If a person is unable to resolve the problem directly with the covered entity or the Section 504 or ADA compliance officer for the covered entity, they can file a complaint with any number of state and federal agencies that are responsible for enforcing the ADA, Section 504, Section 1557, and/or state civil rights laws. These are:

U.S. Department of Health and Human Services
Office for Civil Rights (OCR)
90 - 7th Street, Suite 4-100
San Francisco, CA 94103
Telephone: (415) 437-8310
TDD: (415) 437-8311
Fax: (415) 437-8329
www.hhs.gov/ocr/civilrights/complaints

United States Department of Justice (DOJ)
950 Pennsylvania Avenue, NW
Washington, DC 20530
Disability Rights Section: (202)514-4713
ADA Information Line: (800)514-0301
TTY: ADA Information Line: (800)514-0383
E-mail: www.askDOJ@usdoj.gov
https://www.ada.gov/filing_complaint.htm

California Department of Health Care Services
Office of Civil Rights
PO Box 997413, MS 0009,
Sacramento, CA 95899-7413
Telephone: (916)440-7370
E-mail: CivilRights@dhcs.ca.gov
https://www.dhcs.ca.gov/discrimination-grievance-procedures

California Department of Social Services (CDSS)
Civil Rights Bureau (CRB)
744 P Street, M.S. 8-16-70
Sacramento, CA. 95814
Telephone: (916)654-2107
Toll Free: (866)741-6241
Call Collect: (800)688-4486
TDD: (800)735-2929
E-mail: crb@dss.ca.gov
https://www.cdss.ca.gov/reporting/file-a-complaint/discrimination-complaints

In addition, the California Department of Managed Care is responsible for regulating managed care plans. If a person has a complaint about services or care, they can file a complaint, ask for an Independent Medical Review (IMR) or file for a fair hearing (if about Medi-Cal). For more information about rights and filing complaints, visit:

California Department of Managed Care
http://www.dmhc.ca.gov/.

A person may only have 180 days from the date of discrimination to file a complaint with the appropriate state or federal agency. A person may also be able to file a lawsuit against the covered entity; however, they should consult an attorney for more information.50

Where can I get more information or assistance if I need help accessing health care?

Disability Rights Education & Defense Fund
www.dredf.org
510-644-2555

Disability Rights California is funded by a variety of sources, for a complete list of funders, go to http://www.disabilityrightsca.org/Documents/ListofGrantsAndContracts.html.

COVID-19 Resource Information

• 1. Medi-Cal Managed Care Health Plans, Disability Rights California, 2018, https://www.disabilityrightsca.org/system/files/file-attachments/549501_0.pdf.
• 2. For additional info see DRC’s publication on disability discrimination: https://www.disabilityrightsca.org/publications/disability-discrimination-fact-sheet-government-agencies-and-other-public-entities.
• 3. 28 C.F.R. § 35 and § 36.
• 4. 29 U.S. Code § 794.
• 5. 29 U.S. Code § 794.
• 6. Cal. Civ. Code § 51 (West).
• 7. 45 C.F.R. § 92.1.
• 8. 85 Fed. Reg. at 37160. https://www.govinfo.gov/content/pkg/FR-2020-06-19/pdf/2020-11758.pdf.
• 9. Section 1557: Frequently Asked Questions. Under what circumstances are employers liable for discriminating in health insurance or health coverage under Section 1557? See https://www.hhs.gov/civil-rights/for-individuals/section-1557/1557faqs/index.html.
• 10. 42 CFR § 438.206. See also, Increasing the Physical Accessibility of Health Care Facilities, Centers for Medicare & Medicaid Services, 2017. See also, 81 Fed. Reg. at 27498. See also, 85 Fed. Reg. at 72754. See also, Medicaid and CHIP Managed Care Final Rules | Medicaid, https://www.medicaid.gov/medicaid/managed-care/guidance/medicaid-and-chip-managed-care-final-rules/index.html.
• 11. Q & A: Medicaid Managed Care and Disability Protections, National Health Law Program, 2013, https://healthlaw.org/resource/q-a-medicaid-managed-care-and-disability-protections/.
• 12. 28 C.F.R. § 35.160(2) & 35.104.
• 13. 28 C.F.R. § 35.150(a)(3) for Title II. See 28 C.F.R. § 36.104 for Title III. See also 28 C.F.R. § 41.53 for Section 504. Each civil rights law will have a different standard for what will constitute an “undue burden” and “fundamental alteration.”
• 14. The ADA, Structural Accessibility, and Existing Buildings, Mid-Atlantic ADA Center, 2017, https://www.adainfo.org/content/ada-structural-accessibility-and-existing-buildings. Title II facilities must follow requirements of the 2010 Standards, including both Title II regulations at 28 C.F.R. 35.151; and the 2004 ADAAG at 36 C.F.R. part 1191, appendices B and D. Title III facilities must follow regulations at 28 C.F.R. part 36, subpart D; and the 2004 ADAAG at 36 C.F.R. part 1191, appendices B and D.
• 15. 2010 ADA Standards for Accessible Design, ADA, http://www.ada.gov/2010ADAstandards_index.htm.
• 16. In California, covered entities under Title II must also comply with California’s Building Code (Title 24). See Cal. Code Regs., Title 24, https://codes.iccsafe.org/content/CBC2019P2/chapter-11b-accessibility-to-public-buildings-public-accommodations-commercial-buildings-and-public-housing.
• 17. 28 C.F.R. § 35.151 (Title II); 28 C.F.R. Part 36, Subpart D (Title III). Regulations available at: https://www.ada.gov/regs2010/titleII_2010/titleII_2010_regulations.pdf and https://www.ada.gov/regs2010/titleIII_2010/titleIII_2010_regulations.htm; Cal. Gov’t. Code §§ 4450 et seq.
• 18. 45 C.F.R. §92.103 (all facilities must comply with the 2010 standards. Allowing departures from the technical and scoping requirements in the 2010 standards only where the same or greater access to and usability of the facility is provided). Section 504 has provisions for physical accessibility for new and existing buildings. See 28 C.F.R. § 42.521 and 28 C.F.R. § 42.522 (covered entities can use any method to ensure its program or activity is accessible in the most integrated setting. Including alternate accessible sites, altering existing facilities, or assignments of aid to patients). See also 28 C.F.R. § 42.521(c) (when an entity has fewer than fifteen employees and cannot provide accessibility without making a significant alteration in its existing facilities, the entity can refer the individual to other providers of those services who can ensure accessibility).
• 19. Accessible Medical Diagnostic Equipment, ADA National Network. In 2010, Section 4203 of the Affordable Care Act, directed the Access Board to develop standards for accessible medical equipment used in health care settings. The Access Board complied and proposed the new rules. In 2018 the Department of Justice (DOJ) chose to formally withdraw the advanced notice for the Rule. Regardless, the DOJ and DHHS has published guidance documents for healthcare providers regarding their responsibilities to make services and facilities accessible to individuals with disabilities. The ADA and Section 504 of the Rehabilitation Act require healthcare providers to provide individuals with disabilities full and equal access to their healthcare services and facilities.
• 20. ADA Access to Medical Care for Individual with Mobility Disabilities (July 2010), DOJ, http://www.ada.gov/medcare_mobility_ta/medcare_ta.htm.  
• 21. 2010 ADA Standards for Accessible Design, Department of Justice, at section 223, 81 and section 805, 209. https://www.ada.gov/regs2010/2010ADAStandards/2010ADAStandards.pdf.
• 22. Section 1557: Frequently Asked Questions, Department of Health and Humans Services, https://www.hhs.gov/civil-rights/for-individuals/section-1557/1557faqs/index.html.
• 23. Id.
• 24. Id.
• 25. Supra, Endnote 22.
• 26. Cal. Civ. Code § 54-55.32 (West). See 28 C.F.R. Part 35.104 for Title II. See C.F.R. §36.104 for Title III.
• 27. Service Animals: ADA Requirements, U.S. DOJ, 2010, https://www.ada.gov/service_animals_2010.htm. 
• 28.https://adata.org/faq/i-heard-miniature-horses-are-considered-be-service-animals-ada-true.
• 29. 45 C.F.R. 92.102(b) for Section 1557. See C.F.R. § 35.104 for Title II. See C.F.R. § 36.303 for Title III.
• 30. Id.
• 31. 45 CFR § 92.102(b)(1)(i).
• 32. ADA Business Brief: Communicating with People Who are Deaf or Hard of Hearing in Hospital Settings (October 2003), DOJ, http://www.ada.gov/hospcombr.htm.
• 33. 45 C.F.R. § 92.102(2) for Section 1557. See 28 C.F.R. § 35.160 for Title II. See 28 C.F.R. § 36.301(c) for Title III. See also, Questions and Answers for Health Care Providers, National Association of the Deaf, http://www.nad.org/issues/health-care/providers/questions-and-answers.
• 34. 45 C.F.R. § 92.102.
• 35. Supra, Endnote 33.
• 36. Medi-Cal Provider Guidelines: Sign Language Interpretation, August 2020, https://files.medi-cal.ca.gov/pubsdoco/publications/masters-mtp/part2/sign.pdf.
• 37. Id.
• 38. ADA Checklist: Health Care Facilities and Service Providers: Ensuring Access to Services and Facilities by Patients who are Blind, Deaf-Blind, or Visually Impaired, American Foundation for the Blind, http://www.afb.org/section.aspx?FolderID=3&SectionID=3&TopicID=32&DocumentID=529.
• 39. 45 CFR § 92.102(b)(1)(ii).
• 40. Supra, Endnote 14.
• 41. Supra, Endnote 4 at 37213. Under Title II and III of the ADA, discrimination against an individual based on their association with another individual with a disability is prohibited. The final Rule of Section 1557 eliminates the prohibition against discrimination based on an individual’s association or relationship with someone else based on that other person’s race, color, national origin, sex, age, or disability. For example, a hearing parent required by a hospital to interpret for her deaf child would no longer be able to pursue her own discrimination claim based on association under the Section 1557 regulations. Regardless, the right is still recognized under Title II and III of the ADA.
• 42. 45 CFR § 92.104.
• 43. 42 U.S. Code § 12102. See also, 29 U.S.C. 705(20). Incorporating ADA definition of disability into Section 504; 42 U.S. Code 12102(1)–(3); 28 C.F.R. 35.108(d)(2)(iii)(J).
• 44. 42 U.S. Code § 12102(4)(E)(ii). Exception, mitigating effects of ordinary eyeglasses or contact lenses.
• 45. 42 U.S. Code § 18022.
• 46. What is Mental Health Parity?, National Alliance on Mental Illness, https://www.nami.org/Your-Journey/Individuals-with-Mental-Illness/Understanding-Health-Insurance/What-is-Mental-Health-Parity. 
• 47.https://www.ncd.gov/sites/default/files/NCD_Medical_Futility_Report_508.pdf.
• 48. Id.
• 49. Section 1557: Strengthening Civil Rights Protections in Health Care, Justice in Aging, 2017, https://www.justiceinaging.org/wp-content/uploads/2017/01/Section-1557_Strengthening-Civil-Rights-Protections-in-Health-Care.pdf.
• 50. Id. Under Section 1557 there is no requirement to file with the OCR before going directly to federal court.