Research

The language rules a health program has to follow

Where these rules apply, interpretation is free, a family member is not an acceptable interpreter, and machine translation of anything important has to be checked by a person. Whether they apply at all turns on one definition.

By Nora Castellan, Standards EditorUpdated September 2026

Start with who is bound, because it is not everyone

These rules are strong, and they are also scoped. Reading the scope first prevents the most common mistake about them.

The duties fall on a covered entity, and the definition is short. A covered entity means "A recipient of Federal financial assistance", the department itself, or an entity established under one title of the health reform law.

The part applies to every health program or activity, any part of which receives that assistance directly or indirectly, and to programs the department administers.

Federal financial assistance is defined broadly, reaching grants, loans, credits, subsidies and contracts, including a contract of insurance, though not an ordinary procurement contract.

That leaves a real question for a cash-pay service. Whether any particular seller is a recipient depends on facts about its funding and its participation in federal programs, and this article did not check that for anyone.

They are worth knowing regardless. They set out what good practice looks like, and many clinical partners behind a consumer-facing brand are covered even where the brand is not.

The core duty, and three words that do a lot of work

The central obligation is one sentence. A covered entity "must 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 its programs.

That reaches companions as well as patients, which matters where a relative is the one asking the questions.

The services themselves are then constrained. They must "be provided free of charge, be accurate and timely, and protect the privacy and the independent decision-making ability" of the person.

Free of charge is the first of those, and it is absolute in the text rather than qualified by cost.

Independent decision-making is the least obvious and arguably the most important. It rules out arrangements where someone else effectively makes the decision because they are the only one who understood the conversation.

Who is not allowed to interpret

The section devotes a whole paragraph to people who may not be used, and the list describes what actually happens in clinics.

A covered entity must not "Require an individual with limited English proficiency to provide their own interpreter, or to pay the cost of their own interpreter".

It must not rely on an unqualified adult, with two narrow exceptions. A temporary emergency measure where there is an imminent threat and no qualified interpreter immediately available, with the qualified interpreter confirming or supplementing the initial communication when they arrive.

Or where the person specifically requests it, in private, with a qualified interpreter present and the accompanying adult absent, the adult agrees, the request and agreement are documented, and reliance is appropriate in the circumstances.

It must not "Rely on a minor child to interpret or facilitate communication", except as the same temporary emergency measure.

And it must not "Rely on staff other than qualified interpreters, qualified translators, or qualified bilingual/multilingual staff" to communicate with people with limited English proficiency.

The last of those is the one that quietly rules out the common practice of asking whoever in the office speaks the language.

What qualified means, spelled out

The word qualified is not left to the entity to define. The definitions section sets three tests for an interpreter.

Demonstrated proficiency in speaking and understanding English and at least one other spoken language.

The ability to interpret effectively, accurately and impartially, using any necessary specialized vocabulary, "without changes, omissions, or additions and while preserving the tone, sentiment, and emotional level of the original oral statement".

And adherence to generally accepted interpreter ethics principles, including client confidentiality.

The second of those is a higher bar than bilingualism. Preserving tone and emotional level is a skill, and it is written into the definition rather than treated as a nicety.

Parallel definitions exist for a qualified translator and a qualified reader.

The machine translation rule

One paragraph addresses automated translation directly, and it is the most modern thing in the part.

Machine translation is not banned. It is conditioned.

Three triggers apply. Where a covered entity uses machine translation and the underlying text is critical to a person's rights, benefits or meaningful access. Where accuracy is essential. Or where the source contains complex, non-literal or technical language. In any of those, "the translation must be reviewed by a qualified human translator."

Read against a medical intake form or a consent document, all three triggers tend to fire at once.

Remote interpreting has its own specifications too. Video remote interpreting requires real-time full-motion video and audio over a dedicated high-speed connection, images without lags or blurring, a sharply delineated image large enough to show both faces, clear audio, and trained users.

Audio remote interpreting requires real-time audio without lags or irregular pauses, clear transmission of voices, and the same training requirement.

The notice, and where it has to appear

Two separate notices are required, and their placement rules are unusually concrete.

A notice of availability of language assistance services and auxiliary aids must state that those services are provided free of charge when necessary.

It must be provided in English and in "at least the 15 languages most commonly spoken by individuals with limited English proficiency of the relevant State or States" where the entity operates. It must also come in alternate formats for people who need them.

It goes out annually, on request, and "At a conspicuous location on the covered entity's health program or activity website, if it has one".

In physical locations it must appear "in no smaller than 20-point sans serif font" where people seeking service can reasonably be expected to read or hear it.

It also has to accompany a named list of documents. That list includes "Application and intake forms", privacy notices, and denial and termination notices. It also includes consent forms and instructions related to medical procedures, discharge papers, and billing and collections materials including good faith estimates.

A separate notice of nondiscrimination carries its own contents. Those include how to obtain the modifications, aids and language services, contact details for the entity's coordinator where applicable, the grievance procedure, and how to file a complaint with the department.

Telehealth is named, in one sentence

The part contains a section about telehealth specifically, and it is a single line.

A covered entity "must not, in delivery of its health programs and activities through telehealth services, discriminate" on the basis of race, color, national origin, sex, age or disability.

Its brevity is the point. There is no separate, lighter standard for a service delivered through a screen.

Since national origin includes limited English proficiency and primary language elsewhere in the part, the language duties travel with the service rather than stopping at the clinic door.

For a remote intake, that means the same expectations about free, accurate, timely interpretation and about who may not interpret.

What a reader can do with this

Three practical points come out of the text.

If a service is covered, an interpreter is free and you cannot be asked to bring one or pay for one. If you are told otherwise, that is a statement worth testing rather than accepting.

A relative or a child is not an acceptable interpreter outside the narrow exceptions, and one of those exceptions requires your own private, documented request with a qualified interpreter already present.

And you are never obliged to accept the help. The section ends by saying that "Nothing in this section shall be construed to require an individual with limited English proficiency to accept language assistance services."

Two limits belong here. Only part 92 was read, and only the language access provisions within it were read closely. Whether any particular seller or clinic is a covered entity was not checked, and nothing here says that any company is or is not bound by these rules.

Key takeaways

Frequently asked questions

Who has to follow these language rules?

A covered entity, defined as a recipient of Federal financial assistance, the department itself, or an entity established under one title of the health reform law. The part applies to every health program or activity, any part of which receives that assistance directly or indirectly. Federal financial assistance is defined broadly and includes contracts of insurance, though not ordinary procurement contracts. Whether a particular cash-pay service is a recipient is a factual question, and it was not checked here.

Do I have to pay for an interpreter?

Not where these rules apply. Language assistance services must be provided free of charge, be accurate and timely, and protect the privacy and independent decision-making ability of the person. A covered entity must not require someone with limited English proficiency to provide their own interpreter or to pay the cost of one.

Can my family member interpret for me?

Only in narrow circumstances. A covered entity must not rely on an unqualified adult, with two exceptions. One is a temporary emergency measure, where there is an imminent threat and no qualified interpreter is immediately available. The other is where the person specifically requests it in private, with a qualified interpreter present and the accompanying adult absent, the adult agrees, and the request and agreement are documented. A minor child may be relied on only as the temporary emergency measure.

What makes an interpreter qualified?

Three things in the definition. Demonstrated proficiency in speaking and understanding English and at least one other spoken language. The ability to interpret effectively, accurately and impartially using necessary specialized vocabulary without changes, omissions or additions, while preserving the tone, sentiment and emotional level of the original statement. And adherence to generally accepted interpreter ethics principles, including client confidentiality.

Can a health program use machine translation?

Yes, with a condition. Three triggers require human review. Where the underlying text is critical to a person's rights, benefits or meaningful access, where accuracy is essential, or where the source contains complex, non-literal or technical language. In any of those the translation must be reviewed by a qualified human translator. Intake forms and consent documents tend to satisfy more than one of those triggers at once.

Where should the notice appear?

Annually to participants and applicants, on request, at a conspicuous location on the entity's website if it has one, and in clear and prominent physical locations in no smaller than twenty point sans serif font. It must also accompany a named list of documents, including application and intake forms, privacy notices, denial and termination notices, consent forms and instructions for medical procedures, discharge papers, and billing and collections materials. It must be in English and at least the fifteen languages most commonly spoken by people with limited English proficiency in the relevant states.

Do the rules apply to a telehealth visit?

The part addresses it in one sentence. A covered entity must not, in delivering its health programs and activities through telehealth services, discriminate on the basis of race, color, national origin, sex, age or disability. Since national origin includes limited English proficiency and primary language elsewhere in the part, the language duties travel with the service rather than applying only in person.

Sources

Each document below is named as it names itself, with the date printed on that document rather than the day it was read.

  1. Title 45 Code of Federal Regulations section 92.201, Meaningful access for individuals with limited English proficiency, read in full — Electronic Code of Federal Regulations, Office of the Federal Register, May 2024
  2. Title 45 Code of Federal Regulations section 92.4, Definitions, read for covered entity, Federal financial assistance and qualified interpreter — Electronic Code of Federal Regulations, Office of the Federal Register, May 2024
  3. Title 45 Code of Federal Regulations section 92.11, Notice of availability of language assistance services and auxiliary aids and services, read in full — Electronic Code of Federal Regulations, Office of the Federal Register, May 2024
  4. Title 45 Code of Federal Regulations section 92.10, Notice of nondiscrimination, read for the required contents and placement — Electronic Code of Federal Regulations, Office of the Federal Register, May 2024
  5. Title 45 Code of Federal Regulations section 92.211, Nondiscrimination in the delivery of health programs and activities through telehealth services, read in full — Electronic Code of Federal Regulations, Office of the Federal Register, May 2024
  6. Title 45 Code of Federal Regulations section 92.2, Application, read in full — Electronic Code of Federal Regulations, Office of the Federal Register, May 2024