Reasonable modifications required by HIPAA for patients with disabilities

Flexible scheduling, accessible communication formats, and physical accommodations like wheelchair-accessible exam rooms are all necessary adjustments to healthcare facilities that can be defined as reasonable modifications. These adjustments are required by the Americans with Disabilities (ADA) and Section 1557 of the Affordable Care Act but not directly mentioned in the regulations of HIPAA. The role legislation plays is more complementary, with the handling of protected health information (PHI) within these accommodations being governed by HIPAA’s Rules. 

HIPAA has now been updated for 2025 and aims to ease care coordination by creating exceptions to this standard for individual-level care management. This follows the ideas behind coordinated care as echoed in Federal Privacy Protections: Ethical Foundations, Sources of Confusion in Clinical Medicine, and Controversies in Biomedical Research, “HIPAA is often invoked as a frustrating barrier to coordinated delivery of care and appropriate sharing of information (i.e., to promote patient well-being).” 

What are reasonable modifications?

Reasonable modifications in healthcare are the legally required adjustments that allow individuals to access healthcare services without discrimination. Rooted in civil rights law, these modifications span a range of linguistic, physical, and policy-related changes that intersect with privacy rules. 

A study published in the NIHR Journals Library notes, “The implementation of reasonable adjustments requires a range of facilitating factors:

• Hospital structures, systems and policies allow for the need for reasonable adjustments to be identified and acted upon.
• Additional funding and allocation of adequate resources (particularly for adjustments that involve the provision of extra aids or services, or altering physical obstacles and designs).
• Management support for reasonable adjustments (particularly where these adjustments represent a change to the way things are done). It is likely that many reasonable adjustments need to be instigated, encouraged and approved by the ward manager or the consultant, who in turn needs to be supported by senior management.
• Staff understanding of a wide range of potentially complex adjustments that may be needed, and a ward culture where staff are willing to be flexible.”

The ADA and Section 1557 of the Affordable Care Act impose direct obligations on healthcare providers to make adjustments unless doing so would cause what is known as “undue hardship.” The ADA’s Title III goes further by requiring private healthcare facilities to remove barriers to access while Title II applies similar standards to public entities. 

The interactions between ADA Titles II and III with HIPAA 

Under ADA Title II, public healthcare entities (e.g., state-run hospitals) must provide reasonable modifications, such as policy adjustments, auxiliary aids, or physical accessibility changes, unless doing so causes a fundamental alteration to services or imposes an undue financial burden. Title III extends similar obligations to private healthcare providers, requiring accommodations like sign language interpreters, Braille materials, or flexible scheduling to ensure equitable access.

The role of HIPAA as previously mentioned relates to the use of PHI. For example, if a patient with a cognitive disability authorizes a caregiver to receive PHI, HIPAA permits disclosure under the "minimum necessary" standard, limiting shared data to what is necessary for care. Together the legislation creates a dual mandate alongside ADA Titles II/III.  

Section 504 of the Rehabilitation Act and its implications for federally funded healthcare providers

Section 504 of the Rehabilitation Act of 1973 provides equitable access to federally funded healthcare by requiring reasonable modifications, and adaptations to policies, practices, or environments that prevent discrimination against individuals with disabilities. Unlike the ADA, which broadly applies to public and private entities, Section 504 specifically targets programs receiving federal financial assistance, including Medicare/Medicaid providers, hospitals, and clinics.

The 2024 updates to Section 504, proposed by the U.S. Department of Health and Human Services (HHS), reflect a critical shift toward modernizing accessibility standards. These revisions explicitly address digital inequities (e.g., inaccessible websites, telehealth platforms, and medical kiosks) and physical barriers (e.g., non-adaptive medical equipment like exam tables or MRI machines). 

Another tie between Section 504 and reasonable modifications is the balance of integration mandates with specialized needs. The 2024 rule reinforces the requirement to serve patients in the "most integrated setting appropriate," discouraging unnecessary institutionalization. While this promotes autonomy, it may inadvertently strain community-based systems unprepared to handle complex disabilities. Conflicts also arise when modifications intersect with privacy protocols like PHI. 

Examples of reasonable modifications 

Policy adjustments

• Flexible scheduling: Allowing patients with anxiety to have early appointments when the office is less crowded reduces stress and improves their experience.
• Assistance with paperwork: Modifying policies to allow staff to assist patients with cognitive or visual impairments in completing paperwork ensures equal access to services.

Communication adjustments

• Sign language interpreters: Providing interpreters for patients who are deaf or hard of hearing ensures effective communication during medical consultations.
• Plain language materials: Offering health information in plain English or easy-read formats helps patients with intellectual disabilities understand their care plans.

Physical accessibility

• Wheelchair-accessible facilities: Ensuring that exam rooms, waiting areas, and restrooms are accessible to patients with mobility impairments is crucial for equal access.
• Adaptive medical equipment: Procuring and using medical equipment that can accommodate patients with disabilities (e.g., adjustable exam tables) is essential for providing quality care.

Caregiver involvement

• Allowing companions: Permitting caregivers or companions to assist patients during procedures or appointments supports patients with cognitive or mobility disabilities.

How reasonable modifications support patients 

Studies have shown that reasonable modifications lead to higher patient satisfaction rates among individuals with disabilities. For instance, a study titled Perspectives of Patients with Diverse Disabilities Regarding Healthcare Accommodations to Promote Healthcare Equity: a Qualitative Study notes, “patients identified...adapt communication during interactions, such as speaking slower or using terms that patients can easily understand.” This improved communication, which in turn improved patients' relationships with their doctors. 

Furthermore, a study from the Journal of Advanced Nursing notes, "Reasonable adjustments at the system-level within acute hospitals would promote person-centred care and help address the inequities and health."  Individual-level adjustments, such as pre-admission visits and modified appointment times, help accommodate people with intellectual disabilities. This shows that healthcare accommodations can assist patients with diverse disabilities to receive high-quality and equitable care. 

The practical challenges of reasonable modifications 

1. There is often limited implementation or awareness about necessary accommodations in healthcare. The aforementioned Journal of Advanced Nursing study provides, “Parents described limited or no experiences of reasonable adjustments when accessing or utilizing acute healthcare services for their children.”
2. Modifying physical environments to ensure accessibility can be resource-intensive. A Journal of General Internal Medicine study, “Allowance for accommodations to the environment, including adapting physical space, physical structures, and scheduling and rooming processes”

The HIPAA compliance updates impacting patients with disabilities 

There are proposed updates to the HIPAA Privacy Rule that were part of ongoing discussions and rulemaking processes initiated in previous years. The HHS has been working to modernize HIPAA to better fit contemporary healthcare needs, with significant changes anticipated in 2025. 

The main changes impacting reasonable accommodations include: 

1. Reducing the time limit for responding to patient requests for access to their PHI, allowing easier identity verification, and creating exceptions to the minimum necessary standard for care coordination, particularly for patients with substance use disorders, serious mental illnesses, and emergencies. For patients with disabilities, these updates improve their ability to engage actively in their healthcare by ensuring quicker access to their medical records. 
2. The updates permit disclosures of PHI to relay services for patients who are deaf, hard of hearing, or have speech disabilities, directly addressing accessibility barriers. This change aligns with ADA requirements.

How to securely share reasonable accommodation requests 

Reasonable accommodation requests are formal or informal communications made by individuals with disabilities to request adjustments or modifications that enable them to access services, perform tasks, or participate equally in work or healthcare environments. These requests can be made verbally, in writing, or through representatives, and they do not need to explicitly reference the ADA or use the term "reasonable accommodation" as long as the need is tied to a medical condition. 

These requests should be sent securely because they often involve sensitive personal and medical information protected under HIPAA. Sharing such information improperly could lead to privacy breaches, identity theft, or unauthorized access to PHI. Email is often considered one of the best ways to securely share reasonable accommodation requests when proper safeguards are in place. Specifically HIPAA compliant email platforms like Paubox can protect sensitive information during transmission through encryption so that only authorized recipients can access the data.

Related: HIPAA Compliant Email: The Definitive Guide

FAQs

How are reasonable accommodations requested in healthcare?

Patients or their caregivers can request accommodations by contacting the healthcare provider. Documentation from a healthcare provider may be required to support the request.

What types of accommodations are commonly provided?

Common accommodations include sign language interpreters, Braille materials, flexible scheduling, and wheelchair-accessible facilities.

Can healthcare providers deny requests for accommodations?

Yes, if providing the accommodation would cause an undue hardship or pose a direct threat to health or safety.