Updated May 18, 2021
Title X Family Planning Program
Introduction
adoption, and services for adolescents).” The 2019 rule also
The Title X Family Planning Program (Title X) was
states that family planning methods and services include,
enacted in 1970 as Title X of the Public Health Service Act
for example, choosing not to have sex, preconception
(PHS Act). Title X provides grants to public and nonprofit
counseling, general reproductive and fertility health care,
agencies for family planning services, research, and
and “the prevention, diagnosis, and treatment of infections
training. The Office of Population Affairs (OPA) within the
and diseases which may threaten childbearing capability or
Department of Health and Human Services (HHS)
the health of the individual, sexual partners, and potential
administers Title X, which is the only domestic federal
future children.” Title X does not fund prenatal care
program dedicated solely to family planning and related
directly, but the 2019 rule requires Title X projects to
preventive health services.
provide prenatal care referrals for all pregnant clients.
Overview of Title X
Does Title X Fund Abortions? Since the program’s
What Is the Federal Funding Level? The Consolidated
establishment in 1970, the PHS Act has prohibited using
Appropriations Act, 2021 (P.L. 116-260) provides $286.5
Title X funds in projects where abortion is a method of
million in FY2021 discretionary funding for Title X. The
family planning (42 U.S.C. §300a-6). The 2019 rule
American Rescue Plan Act (P.L. 117-2) also provides the
requires “physical and financial separation” between Title
program with $50 million in mandatory funding for
X projects and prohibited activities, replacing the prior
FY2021, with funds to remain available until expended.
requirement that they be “separate and distinct” from each
This provision increases the funds available for Title X in
other. Prohibited activities include abortion, referral for
FY2021 by 17%, the first increased funding level for the
abortion as a method of family planning, and activities that
program since FY2014. The President’s discretionary
encourage, promote, or advocate for abortion.
budget request proposes $340 million for Title X in
FY2022 (see https://go.usa.gov/xHW6s).
Physicians and advanced practice providers may, however,
provide nondirective abortion counseling. The 2019 rule’s
What Is the Status of the 2019 Final Rule? In March
preamble provides guidance that nondirective counseling
2019, HHS published in the Federal Register a final rule
involves presenting options “in a factual, objective, and
that, among other things, prohibits Title X projects from
unbiased manner.” Title X projects may also refer patients
referring clients for abortion as a method of family
to abortion providers for emergency care and in certain
planning. It also requires physical and financial separation
cases of rape and incest.
between Title X projects and certain abortion-related
activities. (CRS In Focus IF11142, Title X Family Planning
What Do Clients Pay? Persons with income at or below
Program: 2019 Final Rule.) The rule has been challenged
100% of the federal poverty guidelines do not pay for care.
in several lawsuits across the country, but is currently in
Clients with income higher than 100% and up to 250% of
effect in all states except Maryland, where it has been
the poverty guidelines are charged on a sliding scale based
enjoined (see https://go.usa.gov/xVX4t).
on their ability to pay. Clients with income higher than
250% of the poverty guidelines are charged fees designed
In the April 15, 2021, Federal Register, HHS published a
to recover the reasonable cost of providing services. (In
proposed rule that would, among other things, reverse many
2021, the poverty guidelines for an individual in the 48
of the changes made by the 2019 final rule. For example, it
contiguous states and the District of Columbia is an annual
would require Title X projects to provide an abortion
income of $12,880; for families of two or more persons,
referral if requested by the client and would remove the
$4,540 is added to the annual income figure for each
physical separation requirement (see https://go.usa.gov/
additional person.)
xHWMb). HHS has indicated that it expects the notice-and-
comment rulemaking process to be completed by the end of
For unemancipated minors who request confidential
2021; until a new final rule takes effect, HHS plans to
services, eligibility for discounts is based on the minor’s
continue to enforce the 2019 rule (see https://go.usa.gov/
own income. The 2019 rule also allows Title X project
xHeyY).
directors to offer discounted or free contraceptive services
to certain clients who cannot get job-based contraception
What Clinical Services Are Provided? Title X clinical
coverage due to their employer’s religious or moral
guidelines are at https://go.usa.gov/xEdm6. The 2019 rule
objection.
requires Title X projects to provide “a broad range of
acceptable and effective family planning methods
Are There Special Requirements for Services to
(including contraceptives, natural family planning, or other
Minors? All Title X services are confidential, including
fertility awareness-based methods) and services (including
services to minors. Title X projects do not require parental
infertility services, information about or referrals for
notification or parental consent. However, Title X statute
https://crsreports.congress.gov
link to page 2 
Title X Family Planning Program
requires grantees, “[t]o the extent practical,” to encourage
Grantees must certify that they encourage family
family participation. By law, Title X providers must also
participation when minors seek services.
counsel minors on how to resist attempted coercion into
Grantees must certify that they counsel minors on how
sexual activity. Under the 2019 rule, Title X projects must
to resist attempted coercion into sexual activity.
conduct a preliminary screening of any minor who presents
with a sexually transmitted disease, pregnancy, or any
Family planning providers are not exempt from state
suspicion of abuse in order to rule out victimization. The
notification and reporting laws on child abuse, child
2019 rule also has new documentation requirements (e.g.,
molestation, sexual abuse, rape, or incest.
certain minors’ medical records should indicate their sexual
partners’ ages).
These requirements are in addition to statutory mandates in
Title X of the PHS Act, which, among other things, require
Who Are Title X Clients? In 2019, Title X served 3.1
family planning participation to be voluntary and prohibit
million clients, 21% fewer than in 2018. Of those clients,
the use of Title X funds in programs in which abortion is a
87% were female, 13% were male, 64% had incomes at or
method of family planning.
below the federal poverty guidelines, and 84% had incomes
Other Family Planning Programs
at or below 200% of the federal poverty guidelines. The
Guttmacher Institute found that in 2016, 60% of clients said
Do Other Federal Programs Fund Family Planning?
their Title X clinic was their only source of broader health
Although Title X is the only federal domestic program
care over the past year. In 2019, 41% of Title X clients
primarily focused on family planning, other programs also
were uninsured. Figure 1 provides demographic data.
finance family planning, among their other services. These
programs include Medicaid, the Health Center Program
Figure 1. Title X Clients by Age and by Race
under Section 330 of the PHS Act, Maternal and Child
Health Block Grants, Social Services Block Grants, and
Temporary Assistance for Needy Families. In FY2015,
Medicaid accounted for 75% of U.S. public family planning
expenditures (including federal, state, and local government
spending), whereas Title X accounted for 10% (see
https://www.guttmacher.org/report/public-funding-family-
planning-abortion-services-fy-1980-2015).
Are Private Health Plans Required to Cover Family
Planning Services? Federal law generally requires health
insurance issuers and employment-based health plans to
cover FDA-approved contraceptives for women (see
https://go.usa.gov/x7xg2). Regulations issued in 2018
exempt employers that have religious or moral objections to
providing contraceptive coverage. See CRS Report R45928,
The Federal Contraceptive Coverage Requirement: Past
and Pending Legal Challenges. In 2020, following legal
challenges by a number of states, the Supreme Court upheld
the 2018 rules as authorized by the Affordable Care Act
(Little Sisters of the Poor Saints Peter & Paul Home v.
Pennsylvania, 140 S. Ct. 2367 (2020)). However, litigation
continues in the lower courts on other grounds.
Source: CRS using data from HHS, Title X Family Planning Annual
Report: 2019 National Summary, pp. 12, 15, http://go.usa.gov/xGQXE.
COVID-19
Notes: 33% of clients (al races) identified as Latino/Hispanic.
How Has the COVID-19 Pandemic Affected Title X?
Percentages may not sum to 100% due to rounding.
Title X clinics have continued to provide services during
the COVID-19 pandemic. The Centers for Disease Control
Legislative Mandates
and Prevention released guidance on “Ensuring access to
What Title X Provisions Are in the Most Recent
family planning services during COVID-19”; for example,
Appropriations Law? The Consolidated Appropriations
through telehealth, curbside pickup, and by providing a
Act, 2021 (P.L. 116-260) included requirements on the use
one-year supply of oral contraceptives (see
of Title X funds that are similar to provisions included in
https://go.usa.gov/xGQXH). According to John Snow, Inc.,
previous years’ appropriations laws:
in a May 2020 survey, 87% of Title X providers reported
that they were providing telehealth services, compared to
Title X funds cannot be spent on abortions.
11% about a year earlier. HHS’s preliminary estimate is
All pregnancy counseling must be nondirective.
that Title X served 1.5 million clients in 2020, compared to
3.1 million in 2019 and 3.9 million in 2018 (see
Funds cannot be spent on “any activity (including the
https://go.usa.gov/xHWMs). It is not clear how much of the
publication or distribution of literature) that in any way
decrease was due to the pandemic versus other factors, such
tends to promote public support or opposition to any
as providers leaving the program due to the 2019 final rule.
legislative proposal or candidate for public office.”
https://crsreports.congress.gov
Title X Family Planning Program
IF10051
Angela Napili, Senior Research Librarian
Disclaimer
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https://crsreports.congress.gov | IF10051 · VERSION 21 · UPDATED