OCR enforces Federal protections against discrimination based on conscience and religion in specific programs funded by HHS federal financial assistance.
Conscience protections apply to certain health care providers, patients, and other participants in specific federal programs who refuse on religious or moral grounds to participate in certain health care services.
Laws that prohibit discrimination based on religion protect individuals from discrimination on the basis of the individual’s faith in certain contexts. These statutes protect individuals who profess as well as those who do not profess a faith.
The Final Rule
On January 9, 2024, the U.S. Department of Health and Human Services’ (HHS) Office for Civil Rights (OCR) announced a Final Rule entitled Safeguarding the Rights of Conscience as Protected by Federal Statutes.
The Final Rule clarifies the process for enforcing federal conscience laws and strengthens protections against conscience and religious discrimination. This important Final Rule is a part of HHS’ actions in furtherance of Executive Order 13985, entitled Advancing Racial Equity and Support for Underserved Communities Through the Federal Government.
- Read the Final Rule (89 FR 2078).
- Read the press release on the Final Rule (January 9, 2024).
- Read the fact sheet: Safeguarding the Rights of Conscience as Protected by Federal Statutes.
- Watch the webinar: OCR Informational Webinar – Conscience Rule (January 10, 2024).
Your Conscience Rights
Federal statutes protect health care conscience rights, including by prohibiting recipients of certain federal funds from requiring certain individual providers to participate in actions they find religiously or morally objectionable. Some providers for example, object for religious or moral reasons to providing or referring for abortions or assisted suicide, among other procedures. These statutes also provide protections against discrimination based on individuals’ religious or moral beliefs about certain health care services.
Several provisions also protect the conscience rights of certain federally funded health care entities to not participate in actions they find religiously or morally objectionable.
Regarding patients, other provisions clarify that certain programs related to mental health treatment, hearing screening programs, occupational illness testing, and compulsory health care services generally are not to be construed to require patients to receive certain health care services to which they object based on religious or moral beliefs.
More information about the various Federal Health Care Conscience Protection Statutes can be found below and in the Statutory Background section of the Final Rule.
Federal Health Care Conscience Protection Statutes
The Final Rule clarifies existing authorities and processes for handling complaints related to federal health care conscience protection statutes. OCR receives complaints under the federal conscience statutes, and a short summary of those statutes is below.
For a more detailed summary of conscience statutes, read the Statutory Background section of the Final Rule.
The Church Amendments
The conscience provisions contained in 42 U.S.C. 300a-7, et seq. - PDF, collectively known as the Church Amendments, were enacted in the 1970s to protect the rights of individuals and entities to object to performing or assisting in the performance of certain procedures because of their religious beliefs or moral convictions. These provisions:
- Prohibit public officials and authorities from requiring recipients of certain federal financial assistance to provide or make their facilities available for abortion or sterilization when the recipient has a religious or moral objection to sterilization or abortion.
- Prohibit entities that receive certain federal financial assistance from discriminating against physicians and health care personnel:
- because they performed a lawful sterilization, abortion, or other lawful health service or research activity,
- because they refused to perform a lawful sterilization, abortion, or other lawful health service or research activity, or
- because of their religious beliefs or moral convictions about sterilization, abortion, or any other lawful health services or research activities.
- Protect individuals who object because of their religious or moral beliefs to performing or assisting in the performance of any part of a federally funded health service program or research activity.
- Prohibit entities that receive certain federal financial assistance from discriminating against applicants for training or study because the applicant is reluctant or willing to participate in abortions or sterilizations due to their religious or moral beliefs.
Public Health Service Act § 245 (The Coats-Snowe Amendment)
Enacted in 1996, section 245 of the Public Health Service Act, contained in 42 U.S.C. 238n - PDF, also known as the Coats-Snowe Amendment, prohibits the federal government and any state or local government receiving federal financial assistance from discriminating against any health care entity on the basis that the entity:
- Refuses to undergo training in the performance of abortions;
- Refuses to require or provide abortion training;
- Refuses to perform abortions, or to provide referrals for abortion training or for abortions;
- Refuses to make arrangements for any of the above activities related to abortion; or
- Attends (or attended) a post-graduate physician training program, or any other program of training in the health professions, that does not (or did not) perform induced abortions or require, provide, or refer for training in the performance of induced abortions, or make arrangements for the provision of such training.
The Weldon Amendment
The Weldon Amendment - PDF was originally passed as part of the HHS appropriations act for 2005, and has been readopted (or incorporated by reference) in each subsequent HHS appropriations act since then. It provides that none of the funds made available in those HHS appropriations acts may be made available to a Federal agency or program, or to a state or local government, if the agency, program, or government discriminates against any institutional or individual health care entity on the basis that the health care entity does not provide, pay for, provide coverage of, or refer for abortions. It defines “health care entity” to include “an individual physician or other health care professional, a hospital, a provider-sponsored organization, a health maintenance organization, a health insurance plan, or any other kind of health care facility, organization, or plan.”
The Affordable Care Act
Passed in 2010, the Patient Protection and Affordable Care Act (ACA), Public Law 111–148, as amended by Pub. L. No. 111-152 - PDF, (codified at 42 U.S.C. 18001, et seq.), includes certain conscience provisions in sections 1553, 1303(b)(1)(A), (b)(4), and (c)(2)(A), and 1411(b)(5)(A).
Section 1553 of the Affordable Care Act (42 U.S.C. 18113) - PDF (ACA) includes conscience protections regarding assisted suicide. The provision prohibits the Federal Government, and any State or local government or health care provider that receives Federal financial assistance under the ACA, or any health plan created under the ACA from discriminating against an individual or health care entity on the basis that the individual or entity does not provide any health care item or service for assisted suicide, euthanasia, or mercy killing.
Section 1303(b)(1)(A) (42 U.S.C. 18023(b)(1)(A)(ii)) allows a qualified health plan to determine whether or not to provide coverage of abortion services. Section 1303(b)(4) (42 U.S.C. 18023(b)(4)) prohibits a qualified health plan offered through an Exchange from discriminating against “any individual health care provider or health care facility because of its unwillingness to provide, pay for, provide coverage of, or refer for abortions.” Section 1303(c)(2)(A) (42 U.S.C. 18023(c)(2)(A)) notes that nothing in the Affordable Care Act affects Federal laws regarding conscience protection and discrimination on the basis of the willingness or refusal to provide, pay for, cover, or refer for abortion, or to provide or participate in training to provide abortion.
Section 1411(b)(5)(A) (42 U.S.C. 18081(b)(5)(A)) - PDF addresses exemptions to the ACA’s “individual responsibility requirement.” Under this section, the Department may grant exemptions based on hardship (which the Department has stated includes an individual's inability to secure affordable coverage that does not provide for abortions (84 FR 23172), membership in a particular religious organization, or membership in a “health care sharing ministry”).
Other HHS Authorities
OCR also accepts complaints alleging violations of a number of conscience protections in the Medicare and Medicaid programs, as well as various other programs across the Department.
Under Medicare and Medicaid programs, these include provisions related to:
- providing, reimbursing, or covering, certain counseling or referral servicesi
- conscience provisions related to the performance of advanced directivesii
- provisions related to Religious Nonmedical Health Care Institutions and their patientsiii
- compulsory health care services under Medicaidiv
Under other Department programs, these include provisions related to:
- certain programs administered by the HHS Office on Child Abuse and Neglectv
- the HHS Strengthening Early Hearing Detection and Intervention (EHDI) Programvi
- National Institute for Occupational Safety and Health (NIOSH) requirements for occupational illness testingvii
- the HHS Vaccines for Children Programviii
- the HHS Center for Mental Health Services Garrett Lee Smith (GLS) Suicide Prevention Programix
- provisions prohibiting coercion for abortion or sterilizationx and protecting conscience and prohibiting discriminationxi tied to HHS programs under the President's Emergency Plan for AIDS Relief (PEPFAR).
Past Actions
- February 17, 2023, Closure Letter Regarding Illinois Weldon Investigation - PDF
- January 5, 2023, Notice of Proposed Rulemaking, Safeguarding the Rights of Conscience as Protected by Federal Statutes (88 FR 820)
- September 17, 2021, Guidance on Nondiscrimination Protections under the Church Amendments for Health Care Personnel
- August 13, 2021, Letter Withdrawing January 24, 2020, Notice of Violation Issued to the State of California
- July 30, 2021, University of Vermont Medical Center Letter
- December 16, 2020, HHS to Disallow $200M in California Medicaid Funds Due to Unlawful Abortion Insurance Mandate; Refers Vermont Medical Center to DOJ for Lawsuit Over Conscience Violations
- January 24, 2020, HHS Issues Notice of Violation to California for its Abortion Coverage Mandate
- May 21, 2019, Final Conscience Rule, Protecting Statutory Conscience Rights in Health Care; Delegations of Authority (84 FR 23170)
- March 22, 2019, Notice of Resolution to the State of Hawaii After Hawaii Takes Action in Safeguarding Conscience Protections for Pregnancy Care Centers
- January 18, 2019, State of California FACT Act Notice of Violation
- June 21, 2016, Closure Letter Regarding California Weldon Investigation
- February 23, 2011, Final Conscience Rule, Regulation for the Enforcement of Federal Health Care Provider Conscience Protection Laws (76 FR 9968)
- December 19, 2008, Final Conscience Rule, Ensuring That Department of Health and Human Services Funds Do Not Support Coercive or Discriminatory Policies or Practices in Violation of Federal Law (73 FR 78072)
Endnotes
i 42 U.S.C. 1395w–22(j)(3)(B) - PDF and 1396u–2(b)(3)(B) - PDF
ii 42 U.S.C. 1395cc(f) - PDF, 1396a(w)(3) - PDF, and 14406(2) - PDF
iii 42 U.S.C. 1320a–1(h) - PDF, 1320c–11 - PDF, 1395i–5 - PDF, 1395x(e), 1395x(y)(1), 1396a(a) - PDF and 1397j–1(b) - PDF
viii 42 U.S.C. 1396s(c)(2)(B)(ii) - PDF
Laws Prohibiting Discrimination Based on Religion
OCR enforces a variety of laws and regulations as they apply to recipients of HHS federal financial assistance.
CMS Visitation Regulations
CMS Visitation Regulations at 42 C.F.R. Sections 482.13 - PDF(h), 483.10 - PDF(f)(4), and 485.614 - PDF(h)(3) require hospitals and long term care facilities participating in Medicare and Medicaid to have visitation policies that are clinically necessary or reasonable, publicly available, and in writing. In addition, visitation privileges cannot be restricted in a way that discriminates against religion, among other bases.
During the COVID-19 Pandemic, OCR received numerous complaints alleging religious discrimination in visitation at hospitals and long term care facilities. In January, 2024, OCR released FAQs on Patient Visitation at Certain Federally Funded Entities and Facilities to assist the public with understanding these CMS Visitation Regulations.
Block and Formula Grants
Certain religious nondiscrimination provisions enforced by OCR apply to recipients of specific block or formula grant funds. Block and formula grants are funds administered by the Department directly to eligible States, the District of Columbia, Puerto Rico, the U.S. Virgin Islands, and participating Tribes, generally using a set formula. Recipients use the funds to administer programs either directly or through subrecipients. These laws include:
- Section 508 of the Social Security Act prohibits discrimination on the basis of age, race, color, national origin, disability, sex, or religion in the Maternal and Child Health Services Block Grant (42 U.S.C. 708 - PDF).
- Section 533 of the Public Health Service Act prohibits discrimination on the basis of age, race, color, national origin, disability, sex, or religion in Projects for Assistance in Transition from Homelessness (PATH) (42 U.S.C. 290cc-33 - PDF).
- Section 1908 of the Public Health Service Act prohibits discrimination on the basis of age, race, color, national origin, disability, sex, or religion in programs, services, and activities funded by Preventive Health and Health Services Block Grants (42 U.S.C. 300w-7 - PDF).
- Section 1947 of the Public Health Service Act prohibits discrimination on the basis of age, race, color, national origin, disability, sex, or religion in programs, services, and activities funded by Community Mental Health Services Block Grant and Substance Use Prevention, Treatment, and Recovery Block Grant (42 U.S.C. 300x-57 - PDF).
- The Family Violence Prevention and Services Act prohibits discrimination on the basis of race, color, national origin, disability, sex, or religion in the Family Violence Prevention and Services Act Program (42 U.S.C. 10406 - PDF).
- The Child Care and Development Block Grant Act of 1990 prohibits discrimination on the basis of religion, both against beneficiaries and in employment (with some exceptions), and protects parental choice rights in activities funded by the Childcare and Development Block Grant (42 U.S.C. 9858l - PDF and 9858n - PDF(2), and regulations at 45 C.F.R. 98.48 - PDF, 98.49 - PDF, 98.2 - PDF, and 98.30 - PDF(c)(4) through (5)).
Charitable Choice Provisions
OCR also enforces certain provisions that are designed to allow religious entities to participate in government funded programs on the same basis as nonreligious entities. Many of these provisions also contain explicit protections against discrimination on the basis of religion for beneficiaries of services received by religious entities funded by HHS. Religious organizations nonetheless retain applicable Title VII exemptions regarding employment practices (42 U.S.C. 2000e-1 - PDF).
Many of these provisions also include protections so that religious organizations retain control over their religious character and beliefs, certain prohibitions on the use of funds for sectarian purposes, and obligations on the appropriate Federal, State, or local governmental entity to provide timely and equivalent services to individuals who object to the religious character of a provider.
OCR enforces the following Charitable Choice provisions:
- Provisions at 42 U.S.C. 9920 - PDF, and regulations at 45 C.F.R. Part 1050, that apply to The Community Services Block Grant.
- Provisions at 42 U.S.C. 604a - PDF, and regulations at 45 C.F.R. 260.34 - PDF, that apply to Temporary Assistance for Needy Families (TANF) Funding.
- Provisions at 42 U.S.C. 300x-65 - PDF, and regulations at 42 C.F.R. Parts 54 and 54a, that apply to Substance Use and Mental Health Block Grants administered by the Substance Abuse and Mental Health Services Administration (SAMHSA).
- Provisions at 42 U.S.C. 290kk through 290kk-3 - PDF that apply to discretionary and formula grant programs administered by the Substance Abuse and Mental Health Services Administration (SAMHSA), which make awards of financial assistance to public or private entities for the purpose of carrying out activities to prevent or treat substance use. Visit the SAMHSA Grants webpage for more information on the grants they administer.
- Regulations at 42 C.F.R. 51d.8 that apply to grants administered by the Substance Abuse and Mental Health Services Administration (SAMHSA), which enable public entities to respond to needs in local communities created by mental health or substance use emergencies, as authorized under section 501(o)i of the Public Health Service Act (42 U.S.C. 290aa (o)). Visit the SAMHSA Grants webpage for more information on the grants they administer.
- The provision at 42 U.S.C. 629i - PDF that applies to the Mentoring Children of Prisoners Grant - PDF, administered by the Family and Youth Services Bureau Office of the Administration for Children and Families (ACF).
- Regulations at 45 C.F.R. Part 87- Equal Treatment For Faith-Based Organizations and the application of that part to the Uniform Administrative Requirements, Cost Principles, and Audit Requirements for HHS Awards (45 C.F.R. 75.218) and HHS Regulations on the administration of Block Grants (45 C.F.R. 96.18).
Other Laws Prohibiting Discrimination Based on Religion Enforced by OCR
OCR also enforces numerous other provisions that prohibit discrimination on the basis of religion in specific programs funded by HHS:
- The Head Start Act prohibits discrimination on the basis of race, creed, color, national origin, sex, political affiliation, or beliefs in Head Start Programs (42 U.S.C. 9849 - PDF).
- Robert T. Stafford Disaster Relief and Emergency Assistance Act prohibits discrimination on the basis of race, color, religion, nationality, sex, age, disability, English proficiency, or economic status in disaster relief activities (42 U.S.C. 5151 - PDF, and regulations at 44 C.F.R. 206.11 - PDF). Regulations at 42 C.F.R. 38.6 - PDFii implement this prohibition in the context of the Crisis Counseling Assistance and Training Program, administered by SAMHSA’s Disaster Technical Assistance Center. In addition, the Office of Human Services Emergency Preparedness and Response within the Administration for Children and Families implements the Immediate Disaster Case Management (IDCM) Program in accordance with Section 426 of the Stafford Act and in partnership with FEMA. Other HHS offices may be involved in the administration of disaster relief funds and activities after a major disaster declaration by the President under the Stafford Act.
- The Refugee Act of 1980 prohibits discrimination on the basis of race, religion, nationality, sex, or political opinion in the provisions of assistance and services to refugees (8 U.S.C. 1522 - PDF(a)(5)). The Office of Refugee Resettlement within the Administration for Children and Families administers the programs authorized under the Refugee Act.
- The Community Schools Youth Services and Supervision Grant Program Act of 1994 prohibits discrimination on the basis of race, color, religion, sex, national origin, or disability in the selection of children in the Community Schools Youth Services and Supervision Grant (34 U.S.C. 12161(g)(3) and (i)).
- The ADAMHA Reorganization Act prohibits discrimination on the basis of race, religion, national origin, sex, disability, or age in services provided through the Comprehensive Community Mental Health Services for Children and their Families Program (also known as the Children’s Mental Health Initiative or CMHI) (42 U.S.C. 290ff-1 - PDF(e)(2)(C)). The program is administered by the Center for Mental Health Services at the Substance Abuse and Mental Health Services Administration (SAMHSA). Visit the SAMHSA Grants webpage for more information on the grants they administer.
- Regulations under 42 C.F.R. Part 460 - Programs of All-Inclusive Care for the Elderly (PACE) prohibit discrimination on the basis of race, ethnicity, national origin, religion, sex, age, sexual orientation, mental or physical disability, or source of payment in the delivery of required Programs for All-Inclusive Care for the Elderly (PACE) Services (42 C.F.R. 460.112 - PDF).
- The Hill Burton Act’s Community Service Assurance under Title VI of the Public Health Service Act, and regulations 42 C.F.R. 124.603(a)(1), require recipients of Hill-Burton funds - PDF to make non-emergency services, which are provided by the facility, available to any person residing in the Hill-Burton facility’s service area without regard to race, color, national origin, creed or any ground other than the ability to pay or the ability of the facility to provide the needed services.iii
- Regulations implementing the Health Centers Consolidation Act of 1996 prohibit discrimination on the basis of race, color, national origin, age, sex, creed, marital status, or disability in the Health Center Program (42 C.F.R. 56.110,iv 42 C.F.R. 51c.109). The Health Center Program is administered by the Bureau of Primary Health Care (BPHC) in the Health Resources and Services Administration (HRSA).
- The Communications Act of 1934 prohibits discrimination on the basis of age, race, color, religion, national origin, or sex by federally-funded public telecommunication entities (47 U.S.C. 398 - PDF). This prohibition covers the Corporation for Public Broadcasting (CPS) , which is funded through HHS.v
- The American Indian Religious Freedom Act, as amended, states that bona fide traditional ceremonial use of peyote is lawful and shall not be prohibited by the United States or any State (42 U.S.C. 1996a - PDF(b)(1)). OCR enforces this provision as it applies the HHS programs and activities.
Past Actions
- March 5, 2024, HHS Office for Civil Rights Works with Hospital to Improve Access to Kosher Electronic Devices Used for Virtual Patient Visitation
- November 18, 2021, State Letter to Michigan Withdrawing Exception from Non-Discrimination Requirements
- November 18, 2021, State Letter to Texas Withdrawing Exception from Non-Discrimination Requirements
- October 20, 2020, OCR Resolves Religious Discrimination Complaints after Maryland and Virginia Hospitals Ensure Patients Can Receive Safe Religious Visitations During COVID-19
- July 21, 2020, OCR Resolves Complaint After Hospital Accommodates Medical Student’s Religious Needs During COVID-19
- July 21, 2020, OCR Resolves Religious Discrimination Complaint after Maryland Hospital System Ensures Patients Can Receive Religious Visitations During COVID-19
Endnotes
i Section 501(o) was originally codified as Section 501(m) at 42 U.S.C. 290aa(m). The 21st Century Cures Act changed the citation to Section 501(o) at 42 U.S.C. 290aa(o). PL 114-255, December 13, 2016, 130 Stat 1033, 1207. The relevant regulatory provision, 42 C.F.R. 51d.1, has not been updated to reflect this citation change.
ii The regulation at 42 C.F.R. 38.6 states that, “Attention is called to the requirements of 24 C.F.R. 2205.13 relating to nondiscrimination on the grounds of race, religion, sex, color, age, economic status, or national origin in the provision of disaster assistance.” The nondiscrimination provision at 24 C.F.R. 2205.13 was promulgated as part of regulations from the Department of Housing and Urban Development at Part 2205—Federal Disaster Assistance, 40 FR 23253, 23256 (May 28, 1975). Shortly after, President Carter signed Executive Order 12127, effective April 1, 1979, establishing the Federal Emergency Management Agency (FEMA). The federal government’s disaster assistance activities were then transferred to FEMA and in that transfer, the provisions at 24 C.F.R. Part 2205 were relocated to 44 C.F.R. Part 205. See Federal Register, Code of Federal Regulations, List of Sections Affected 111 (Sep. 1979). FEMA subsequently moved the regulations at Part 205 to revised regulations in Part 206. See 44 C.F.R. 206.1(b); Disaster Assistance; Robert T. Stafford Disaster Relief and Emergency Assistance Act; Implementation, Etc., 54 FR 22162, (May 22, 1989). These transfers resulted in the nondiscrimination provisions originally located at 24 C.F.R. 2205.13 being eventually relocated to 44 C.F.R. § 206.11, with some revisions.
iii For more information about the obligations of Hill Burton facilities, visit OCR’s website at https://www.hhs.gov/civil-rights/for-individuals/hill-burton/index.html.
iv The regulation cites Secs. 215 and 319 of the Public Health Service Act (42 U.S.C. 216 and 247d) as its authority for the Grants for Migrant Health Services. Under Health Centers Consolidation Act of 1996, PL 104-299, October 11, 1996, 110 Stat. 3626, the provisions at Sec. 319 of the Public Health Service Act (42 U.S.C. 247d) have been moved to 42 U.S.C. 254b and consolidated with the Health Center Program.
v 47 U.S.C. 398; 47 U.S.C. 397(15).
Filing a Complaint
You can file a complaint online or via mail, fax, or e-mail. Learn more about how to file a complaint with OCR.
For information about receiving an Assurance of Exemption under Applicable Federal Religious Freedom and Conscience Protections under OCR’s Regulation implementing Section 1557 of the ACA, visit www.hhs.gov/1557