Updated November 16, 2021
Title X Family Planning Program
Introduction
family planning (42 U.S.C. §300a-6). In addition, annual
The Title X Family Planning Program (Title X) was
appropriations laws state that Title X funds “shall not be
enacted in 1970 as Title X of the Public Health Service Act
expended for abortions.”
(PHS Act). Title X provides grants to public and nonprofit
agencies for family planning services, research, and
According to the 2021 final rule’s preamble, the program is
training. The Office of Population Affairs (OPA) within the
reinstating guidance published in the July 3, 2000 Federal
Department of Health and Human Services (HHS)
Register (see https://go.usa.gov/xMfP5). This guidance
administers Title X, which is the only domestic federal
requires that a grantee’s Title X project activities and its
program dedicated solely to family planning and related
non-Title X abortion activities be “separate and distinct”;
preventive health services.
they may share a common facility, a common waiting
room, common staff, and a common records system, “so
In the March 4, 2019 Federal Register, HHS published a
long as it is possible to distinguish between the Title X
final rule that, among other things, prohibited Title X
supported activities and non-Title X abortion-related
projects from referring clients for abortion as a method of
activities,” for example, through allocating and prorating
family planning. It also required physical separation
costs.
between Title X projects and certain abortion-related
activities. (CRS In Focus IF11142, Title X Family Planning
Must Title X projects provide abortion referrals upon
Program: 2019 Final Rule.) The 2019 final rule took effect
client request? The 2021 rule restores pre-2019
in all states except Maryland, where it was enjoined.
requirements that Title X projects offer pregnant clients
information and nondirective counseling on each of these
In the October 7, 2021 Federal Register, HHS published a
options: prenatal care and delivery; infant care, foster care,
final rule that, among other things, revokes the 2019 final
or adoption; and abortion (unless a client indicates that they
rule in its entirety. For example, it requires Title X projects
do not want information or counseling about particular
to provide an abortion referral if requested by the client and
options). Projects would also be required to provide
removes the physical separation requirement (see
referrals upon client request, including abortion referrals.
https://go.usa.gov/xMfQy). The 2021 rule took effect
November 8, 2021.
Program guidance states that abortion referrals may include
providing relevant factual information (such as the abortion
Overview of Title X
provider’s phone number, address, and charges), but “the
What Is the Federal Funding Level? The Consolidated
project may not take further affirmative action (such as
Appropriations Act, 2021 (P.L. 116-260) provided $286.5
negotiating a fee reduction, making an appointment,
million in FY2021 discretionary funding for Title X. The
providing transportation) to secure abortion services for the
Extending Government Funding and Delivering Emergency
patient” (see https://go.usa.gov/xMGgv).
Assistance Act (P.L. 117-43) continues funding for most
discretionary HHS programs, including Title X, through
The 2021 rule’s preamble states that “objecting individuals
December 3, 2021 (or until full-year funding is
and grantees will not be required to counsel or refer for
appropriated), at the same rate, and under the same
abortions in the Title X program in accordance with
authority and conditions, as P.L. 116-260. Additionally, the
applicable federal law.” A footnote in the final rule notes
American Rescue Plan Act (P.L. 117-2) provided Title X
that “[p]roviders may separately be covered by federal
with $50 million in mandatory funding for FY2021, with
statutes protecting conscience.”
funds to remain available until expended.
What Do Clients Pay? Persons with income at or below
What Clinical Services Are Provided? The 2021 rule
100% of the federal poverty guidelines (FPL) do not pay for
requires Title X projects to provide “a broad range of
care. Clients with income higher than 100% and up to
acceptable and effective medically approved family
250% FPL are charged on a sliding scale based on their
planning methods (including natural family planning
ability to pay. Clients with income higher than 250% FPL
methods) and services (including pregnancy testing and
are charged fees designed to recover the reasonable cost of
counseling, assistance to achieve pregnancy, basic
providing services. (In 2021, in the 48 contiguous states and
infertility services, STI services, preconception health
the District of Columbia, the poverty guidelines for an
services, and adolescent-friendly health services).” Title X
individual is an annual income of $12,880; for families of
clinical guidelines are at https://go.usa.gov/xEdm6.
two or more persons, $4,540 is added to the annual income
figure for each additional person.)
Does Title X Fund Abortions? Since Title X’s
establishment in 1970, the PHS Act has prohibited using
Title X funds in programs where abortion is a method of
https://crsreports.congress.gov
link to page 2 
Title X Family Planning Program
For unemancipated minors who request confidential
Title X funds cannot be spent on abortions.
services, eligibility for discounts is based on the minor’s
All pregnancy counseling must be nondirective.
own income.
Funds cannot be spent on “any activity (including the
Are There Special Requirements for Services to
publication or distribution of literature) that in any way
Minors? Title X statute requires grantees, “[t]o the extent
tends to promote public support or opposition to any
practical,” to encourage family participation. However, all
legislative proposal or candidate for public office.”
Title X services are confidential, including services to
Grantees must certify that they encourage family
minors. The 2021 final rule states that Title X projects may
participation when minors seek services.
not require parental consent and may not notify a parent or
Grantees must certify that they counsel minors on how
guardian that a minor has requested or received Title X
to resist attempted coercion into sexual activity.
family planning services.
Family planning providers are not exempt from state
Annual appropriations laws state that Title X providers are
notification and reporting laws on child abuse, child
not exempt from state notification and reporting laws on
molestation, sexual abuse, rape, or incest.
child abuse, child molestation, sexual abuse, rape, or incest.
These requirements are in addition to statutory mandates in
Title X providers must counsel minors on how to resist
Title X of the PHS Act, which, among other things, require
attempted coercion into sexual activity.
family planning participation to be voluntary and prohibit
the use of Title X funds in programs where abortion is a
Who Are Title X Clients? In 2020, Title X served 1.5
method of family planning.
million clients (50% fewer than in 2019 and 61% fewer
than in 2018). Of those clients, 86% were female, 66% had
Other Family Planning Programs
incomes at or below FPL, 84% had incomes at or below
Do Other Federal Programs Fund Family Planning?
200% FPL, and 39% were uninsured. The Guttmacher
Although Title X is the only federal domestic program
Institute found that in 2015-2019, 60% of contraceptive
primarily focused on family planning, other programs also
clients said their Title X clinic was their usual source of
finance family planning, among their other services. These
broader health care over the past year. Figure 1 provides
programs include Medicaid, the Health Center Program
demographic data.
under Section 330 of the PHS Act, Maternal and Child
Figure 1. Title X Clients by Age and by Race
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.
COVID-19
Source: CRS using data from HHS, Title X Family Planning Annual Report:
How Has the COVID-19 Pandemic Affected Title X?
2020 National Summary, pp. 14, 17, https://go.usa.gov/xMNPJ.
Title X clinics continue to operate during the pandemic,
Notes: 35% of clients (al races) identified as Latino/Hispanic.
incorporating strategies such as telehealth, curbside
Percentages may not sum to 100% due to rounding.
services, and providing a one-year supply of oral
Legislative Mandates
contraceptives. According to the Family Planning Annual
Report (FPAR), Title X served 1.5 million clients in 2020,
What Title X Provisions Are in the Most Recent
compared to 3.1 million in 2019 and 3.9 million in 2018.
Appropriations Law? The Consolidated Appropriations
FPAR estimated that 37% of the decrease since 2018 was
Act, 2021 (P.L. 116-260) included requirements on the use
due to the pandemic, whereas 63% was due to providers
of Title X funds that are similar to provisions included in
leaving the program after the 2019 rule’s implementation.
previous years’ appropriations laws:
https://crsreports.congress.gov
Title X Family Planning Program
IF10051
Angela Napili, Senior Research Librarian
Disclaimer
This document was prepared by the Congressional Research Service (CRS). CRS serves as nonpartisan shared staff to
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https://crsreports.congress.gov | IF10051 · VERSION 22 · UPDATED