Updated May 20, 2019
Title X Family Planning Program: 2019 Final Rule
Introduction
effective medically approved family planning methods
The Family Planning Services and Population Research Act
(including natural family planning methods) and services
of 1970 (P.L. 91-572, as amended) established the Title X
(including infertility services and services for adolescents).
Family Planning Program (Title X) under Title X of the
If a health care entity offers only a single method of family
Public Health Service Act. Administered by HHS, Title X
planning, it may participate as part of a project as long as
provides grants to public and nonprofit agencies to establish
the entire project offers a broad range of family planning
and maintain family planning projects (Title X projects).
services.”
Title X is the only domestic federal program devoted solely
to family planning and related preventive health services. In
2019 rule. The rule does not require family planning
2017, the program served 4 million clients through 3,858
methods and services to be “medically approved.” The rule
Title X clinics. Congress appropriated $286.5 million to the
also does not require Title X projects to provide every
program for FY2019.
acceptable and effective family planning method or service.
It states that “[a] participating entity may offer only a single
On March 4, 2019, the Department of Health and Human
method or a limited number of methods of family planning
Services (HHS) published a final rule on Title X in the
as long as the entire project offers a broad range of such
Federal Register, at https://go.usa.gov/xEdTp. The rule
family planning methods and services.”According to the
changes, among other things, how Title X projects provide
rule’s preamble, the rule allows participation by clinics that,
family planning methods and services to clients.
“for reasons of conscience,” limit the services they offer.
Courts have preliminarily enjoined the final rule from being
Physical and Financial Separation
implemented (see https://go.usa.gov/xmNRh and
Prior guidance. By law, Title X funds may not be used for
https://go.usa.gov/xmNn3). Future court rulings may
abortion. Prior program guidance interpreted the law as
determine whether and when the rule is implemented.
requiring that a grantee’s abortion activities be “separate
and distinct” from its Title X project activities. Under prior
Overview of the 2019 Final Rule
guidance, a grantee’s abortion activities and its Title X
This section summarizes selected regulatory changes made
project activities could share a common facility, a common
by the final rule.
waiting room, common staff, and a common records
system, “so long as it is possible to distinguish between the
Family Planning Definition
Title X supported activities and non-Title X abortion-
Prior regulation. Prior regulations did not define “family
related activities,” for example, through allocating and
planning.”
prorating costs (see https://go.usa.gov/xEdtA).
2019 rule. The rule introduces a new definition of family
2019 rule. The rule requires Title X projects to be
planning, referring to it as “the voluntary process of
“physically and financially separate” from prohibited
identifying goals and developing a plan for the number and
activities, including providing, referring, encouraging,
spacing of children and the means by which those goals
promoting, or advocating for abortion. The rule requires,
may be achieved.” Family planning can include, among
for example, separate facilities (including exam and waiting
other things, a range of “acceptable and effective choices,
rooms, entrances and exits, and websites), separate staff,
which may range from choosing not to have sex to the use
separate accounting and medical records, and separate
of other family planning methods and services to limit or
workstations. Title X funds cannot be used to build
enhance the likelihood of conception (including
infrastructure for prohibited abortion-related activities.
contraceptive methods and natural family planning or other
fertility awareness-based methods) and the management of
The preamble to the rule states that abortion-providing
infertility (including adoption).”
organizations may still apply for and receive Title X grants,
provided they comply with the physical and financial
Scope of Family Planning Services
separation requirements, and other Title X requirements.
A Title X grantee can undertake a Title X project that has
several participating entities, organizations, and/or clinics.
Referrals to Primary Care
A grantee that is a state agency, for example, can have a
Prior regulation. Prior regulations required Title X
Title X project that supports local entities, organizations,
projects to “provide for coordination and use of referral
and clinics throughout the state.
arrangements” with other health care providers.
Prior regulation. Prior regulations required Title X
2019 rule. The rule encourages Title X projects to “offer
projects to“[p]rovide a broad range of acceptable and
either comprehensive primary health services onsite or have
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Title X Family Planning Program: 2019 Final Rule
a robust referral linkage with primary health providers who
participation or (2) the specific reason why such family
are in close physical proximity, to the Title X site.”
participation was not encouraged.
Services for Pregnant Clients
Eligibility for Free or Discounted Care
Prior regulation. Prior regulations required Title X
Prior regulations. Clients are eligible for free, discounted,
projects to offer pregnant clients information and
or full-cost services, depending on their income. Clients
nondirective counseling on each of these options: prenatal
who the Title X project director determines are unable, “for
care and delivery; infant care, foster care, or adoption; and
good reasons,” to pay for family planning are also eligible
abortion. Projects were also required to provide referrals
for free or discounted services. For example, for
upon client request, including referral for abortion.
unemancipated minors who request confidential services,
eligibility for discounts must be based on the minor’s own
2019 rule. The rule removes the above requirements. It
income.
adds a new requirement that Title X projects refer pregnant
clients “to a health care provider for medically necessary
2019 rule. The rule allows, but does not require, Title X
prenatal health care.” The preamble to the rule states that
project directors to use the “good reasons” exception to
prenatal care is medically necessary for all pregnant clients.
offer free or discounted contraceptive services to certain
clients who cannot get job-based contraception coverage
The rule allows Title X projects to refer pregnant clients to
due to their employer’s religious or moral objection. In such
social services and adoption agencies, to provide pregnancy
cases, the director would also consider the client’s total
health information, and to provide a list of comprehensive
income and the out-of-pocket costs of contraception.
primary health care providers including prenatal care
providers. The rule permits, but does not require, the
Supporting and Opposing Views
abovementioned list to include some primary care providers
Some stakeholders and Members of the 116th Congress
who also perform abortion. The list and project staff may
have released statements applauding the rule, while others
not identify which providers on the list perform abortion.
have expressed concerns. Some supporters contended, for
The rule permits, but does not require, physicians and
example, that the rule
advanced practice providers to give nondirective pregnancy
counseling, which may include nondirective counseling on
better ensures compliance with the Title X statute on
abortion. The preamble states that nondirective counseling
abortion,
involves presenting options “in a factual, objective, and
improves conscience protections for providers
unbiased manner.”
participating in the program,
The rule prohibits Title X projects from referring patients
encourages a broader and more diverse set of providers
for abortion as a means of family planning. The preamble to
to apply for and to participate in the program, and
the rule states that abortion referrals for emergency care
reasons are permitted. According to a footnote in the
better protects vulnerable clients, such as minors.
preamble, referral to an abortion provider may also be
Some of the rule’s critics contend
permitted in certain cases of rape or incest.
ed, for example, that
Services for Minors
HHS did not provide evidence of current projects’
Current law and guidance. All Title X services are
noncompliance,
confidential, including services to minors. Title X projects
the rule is a “gag rule” that can keep providers from
may not require parental notification or parental consent for
disclosing all relevant information to clients,
services to minors. However, Title X statutorily requires
grantees, “[t]o the extent practical,” to
encourage family
the rule may make it difficult for some specialized
participation.
family planning clinics (including some Planned
Parenthood clinics) to continue in the program, and
Appropriations law requires Title X projects to counsel
the rule might deter some minors from seeking services
minors on how to resist attempted coercion into sexual
from or disclosing information to Title X providers.
activity, and to comply with all state and local laws on
notification or reporting of child abuse, child molestation,
The abovementioned views are discussed in the preamble to
sexual abuse, rape, and incest.
the rule, at https://go.usa.gov/xEdTp.
2019 rule. The rule does not change the law, but it adds a
Compliance Dates
new regulation that Title X projects must conduct a
The compliance date for the rule’s physical separation
preliminary screening of any minor client with a sexually
requirements is March 4, 2020. Compliance for the rule’s
transmitted disease, pregnancy, or any suspicion of abuse,
other provisions was May 3, 2019, or is July 2, 2019,
in order to rule out victimization. The rule also has new
depending on the provision. As noted above, courts have
documentation requirements. For example, certain minors’
preliminarily enjoined the rule from being implemented.
medical records must indicate their sexual partners’ ages.
Future court rulings may determine whether and when the
Title X projects must also document, for each minor client,
rule is implemented.
either (1) the specific actions taken to encourage family
Angela Napili, Senior Research Librarian
https://crsreports.congress.gov
Title X Family Planning Program: 2019 Final Rule
IF11142
Victoria L. Elliott, Analyst in Health Policy
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