dards of compliance expected under public programs and public health care accommodations.

The need for such guidance ranges from a clear explanation regarding the meaning of the broad federal rules within health care facilities to an explanation of the types of health benefit administration practices that could be considered discriminatory. While the Access Board sets standards for the modification and construction of facilities, these standards do not speak to internal equipment and operations that play an equal role in access, nor is there language guidance for health services providers in an ADA context that is comparable to the guidance that applies to persons with limited English proficiency. Robust ADA guidance regarding public and private insurance and employee health plan administration is also lacking. At what point do certain practices become discriminatory methods of administration? When would medical necessity decision making, for example, lose its “design” characteristics and become the arbitrary denial of coverage to persons with disabilities? When might the refusal to pay a claim cease being a limitation on coverage and be transformed into the discriminatory withholding of covered benefits because of the patient’s disability? The cases—as well as the complexity of health care itself—suggest a need for carefully developed guidelines that help health care corporations understand the meaning of the ADA in both health care and coverage decision making and payment.

The author thanks Nancy Lopez for research assistance.