Updated March 9, 2020
Title X Family Planning Program: 2019 Final Rule
Introduction
contraceptive methods and natural family planning or other
The Title X Family Planning Program (Title X) is the only
fertility awareness-based methods) and the management of
domestic federal program devoted solely to family planning
infertility (including adoption).”
and related preventive health services. The program
provides grants to public and nonprofit agencies to establish
Scope of Family Planning Services
and maintain family planning projects (Title X projects).
A Title X grantee can undertake a Title X project that has
several participating entities, organizations, or clinics. A
On March 4, 2019, the Department of Health and Human
grantee that is a state agency, for example, can have a Title
Services (HHS) published a final rule on the program in the
X project that supports local entities, organizations, and
Federal Register, at https://go.usa.gov/xEdTp. The final
clinics throughout the state.
rule changes, among other things, how Title X projects
provide family planning methods and services to clients. In
Prior regulation. Prior regulations required Title X
2018, the program served 3.9 million clients through 3,954
projects to“[p]rovide a broad range of acceptable and
Title X clinics.
effective medically approved family planning methods
(including natural family planning methods) and services
As of July 15, 2019, HHS has required compliance with the
(including infertility services and services for adolescents).
final rule, except for the physical separation requirements,
If a health care entity offers only a single method of family
for which compliance was required by March 4, 2020,
planning, it may participate as part of a project as long as
https://go.usa.gov/xVX4t. However, on February 14, 2020,
the entire project offers a broad range of family planning
the United States District Court for the District of Maryland
services.”
enjoined the rule’s implementation in Maryland. Future
court rulings could affect the rule’s implementation in that
2019 rule. The rule requires Title X projects to “[p]rovide a
state and in others.
broad range of acceptable and effective family planning
methods (including contraceptives, natural family planning
Change in Title X Providers
or other fertility awareness-based methods) and services
Some Title X providers who oppose the 2019 rule,
(including infertility services, information about or referrals
including Planned Parenthood-affiliated clinics, have
for adoption, and services for adolescents).” The rule does
announced that they are no longer using Title X funds or
not require family planning methods and services to be
have withdrawn from the program because of the new
“medically approved.” The rule does not require Title X
regulatory requirements. (The Kaiser Family Foundation is
projects to provide every acceptable and effective family
tracking program participation at https://www.kff.org/
planning method or service. The rule states that “[a]
interactive/the-status-of-participation-in-the-title-x-federal-
participating entity may offer only a single method or a
family-planning-program.) Previously, Planned Parenthood
limited number of methods of family planning as long as
had served an estimated 40% of Title X clients. HHS
the entire project offers a broad range of such family
redistributed some of the relinquished funds among
planning methods and services.”According to the rule’s
remaining grantees, https://go.usa.gov/xVMPF.
preamble, the rule allows participation by clinics that, “for
reasons of conscience,” limit the services they offer.
Overview of the 2019 Final Rule
This section summarizes selected regulatory changes made
Physical and Financial Separation
by the final rule.
Prior guidance. By law, Title X funds may not be used in
projects where abortion is a method of family planning.
Family Planning Definition
Prior program guidance interpreted the law as requiring that
Prior regulation. Prior regulations did not define “family
a grantee’s abortion activities be “separate and distinct”
planning.”
from its Title X project activities. Under prior guidance, a
grantee’s abortion activities and its Title X project activities
2019 rule. The rule introduces a new definition of family
could share a common facility, a common waiting room,
planning, referring to it as “the voluntary process of
common staff, and a common records system, “so long as it
identifying goals and developing a plan for the number and
is possible to distinguish between the Title X supported
spacing of children and the means by which those goals
activities and non-Title X abortion-related activities,” for
may be achieved.” Family planning can include, among
example, through allocating and prorating costs,
other things, a range of “acceptable and effective choices,
https://go.usa.gov/xEdtA.
which may range from choosing not to have sex to the use
of other family planning methods and services to limit or
2019 rule. The rule requires Title X projects to be
enhance the likelihood of conception (including
“physically and financially separate” from prohibited
https://crsreports.congress.gov

---

Title X Family Planning Program: 2019 Final Rule
activities, including providing, referring, encouraging,
grantees, “[t]o the extent practical,” to encourage family
promoting, or advocating for abortion. The rule requires,
participation. Appropriations law requires Title X projects
for example, separate facilities (including exam and waiting
to counsel minors on how to resist attempted coercion into
rooms, entrances and exits, and websites), separate staff,
sexual activity, and to comply with all state and local laws
separate accounting and medical records, and separate
on notification or reporting of child abuse, child
workstations. Title X funds cannot be used to build
molestation, sexual abuse, rape, and incest.
infrastructure for prohibited abortion-related activities. The
preamble to the rule states that abortion-providing
2019 rule. The rule does not change the law, but it adds a
organizations may still apply for and receive Title X grants,
new regulation that Title X projects must conduct a
provided they comply with the physical and financial
preliminary screening of any minor client with a sexually
separation requirements, and other Title X requirements.
transmitted disease, pregnancy, or any suspicion of abuse,
in order to rule out victimization. The rule also has new
Primary Care Referrals
documentation requirements. For example, certain minors’
Prior regulation. Prior regulations required Title X
medical records must indicate their sexual partners’ ages.
projects to “provide for coordination and use of referral
Title X projects must also document, for each minor client,
arrangements” with other health care providers.
either (1) the specific actions taken to encourage family
participation or (2) the specific reason why such family
2019 rule. The rule encourages Title X projects to “offer
participation was not encouraged.
either comprehensive primary health services onsite or have
a robust referral linkage with primary health providers who
Free or Discounted Care Eligibility
are in close physical proximity, to the Title X site.”
Prior regulations. Clients are eligible for free, discounted,
or full-cost services, depending on their income. Clients
Services for Pregnant Clients
who the Title X project director determines are unable, “for
Prior regulation. Prior regulations required Title X
good reasons,” to pay for family planning are also eligible
projects to offer pregnant clients information and
for free or discounted services. For example, for
nondirective pregnancy counseling on each of these
unemancipated minors who request confidential services,
options: prenatal care and delivery; infant care, foster care,
discounts are based on the minor’s own income.
or adoption; and abortion. Projects were also required to
provide referrals upon client request, including abortion
2019 rule. The rule allows, but does not require, Title X
referrals.
project directors to use the “good reasons” exception to
offer free or discounted contraceptive services to certain
2019 rule. The rule removes the requirements described
clients who cannot get job-based contraception coverage
above. It adds a new requirement that Title X projects must
due to their employer’s religious or moral objection. In such
refer pregnant clients “to a health care provider for
cases, the director would also consider the client’s total
medically necessary prenatal health care.” The preamble to
income and the out-of-pocket costs of contraception.
the rule states that prenatal care is medically necessary for
all pregnant clients.
Congressional Activity
On June 19, 2019, the House Energy and Commerce
The rule allows Title X projects to refer pregnant clients to
Subcommittee on Oversight and Investigations held a
social services and adoption agencies, to provide pregnancy
hearing on Title X final rule, https://go.usa.gov/xdbVG.
health information, and to provide a list of comprehensive
During the hearing, some Members of Congress contended
primary health care providers including prenatal care
that the final rule helps ensure that Title X funds are not
providers. The rule permits, but does not require, the
improperly used for abortion as a method of family
abovementioned list to include some primary care providers
planning. Other Members contended that the rule is not
who also perform abortion. The list and project staff may
justified by any evidence that Title X funds have been
not identify which providers on the list perform abortion.
misapplied for abortion. On that same day, the House
The rule generally prohibits Title X projects from referring
passed the Labor, Health and Human Services, Education,
patients for abortion as a method of family planning.
Defense, State, Foreign Operations, and Energy and Water
However, the preamble to the rule states that abortion
Development Appropriations Act, 2020 (H.R. 2740) that
referrals are permitted in certain circumstances, including in
would, among other things, require the HHS Secretary to
emergencies and in cases of rape and incest. The rule
administer Title X under regulations put in place on January
permits, but does not require, physicians and advanced
18, 2017, which would prohibit the final rule’s
practice providers to give nondirective pregnancy
implementation in FY2020. H.R. 2740 has not become law.
counseling, which may include nondirective counseling on
On December 20, 2019, the President signed into law the
abortion. The preamble states that nondirective counseling
FY2020 Further Consolidated Appropriations Act (P.L.
involves presenting options “in a factual, objective, and
116-94), which does not include the provision.
unbiased manner.”
Angela Napili, Senior Research Librarian
Services for Minors
Victoria L. Elliott, Analyst in Health Policy
Current law and guidance. All Title X services are
confidential, including services to minors. Title X projects
IF11142
may not require parental notification or parental consent for
services to minors. However, Title X statutorily requires
https://crsreports.congress.gov

---

Title X Family Planning Program: 2019 Final Rule


Disclaimer
This document was prepared by the Congressional Research Service (CRS). CRS serves as nonpartisan shared staff to
congressional committees and Members of Congress. It operates solely at the behest of and under the direction of Congress.
Information in a CRS Report should not be relied upon for purposes other than public understanding of information that has
been provided by CRS to Members of Congress in connection with CRS’s institutional role. CRS Reports, as a work of the
United States Government, are not subject to copyright protection in the United States. Any CRS Report may be
reproduced and distributed in its entirety without permission from CRS. However, as a CRS Report may include
copyrighted images or material from a third party, you may need to obtain the permission of the copyright holder if you
wish to copy or otherwise use copyrighted material.

https://crsreports.congress.gov | IF11142 · VERSION 6 · UPDATED

---