Title X Family Planning Program



Updated October 28, 2020
Title X Family Planning Program
Introduction
requires Title X projects to provide “a broad range of
The Title X Family Planning Program (Title X) was
acceptable and effective family planning methods
enacted in 1970 as Title X of the Public Health Service Act
(including contraceptives, natural family planning, or other
(PHS Act). Title X provides grants to public and nonprofit
fertility awareness-based methods) and services (including
agencies for family planning services, research, and
infertility services, information about or referrals for
training. The Office of Population Affairs (OPA) within the
adoption, and services for adolescents).” The 2019 rule also
Department of Health and Human Services (HHS)
states that family planning methods and services include,
administers Title X, which is the only domestic federal
for example, choosing not to have sex, preconception
program devoted solely to family planning and related
counseling, general reproductive and fertility health care,
preventive health services. This In Focus answers questions
and “the prevention, diagnosis, and treatment of infections
on Title X, legislative mandates, and other family planning
and diseases which may threaten childbearing capability or
programs, and it identifies resources for Title X projects
the health of the individual, sexual partners, and potential
during the Coronavirus Disease 2019 (COVID-19)
future children.” Title X does not fund prenatal care
pandemic.
directly, but the 2019 rule requires Title X projects to
provide prenatal care referrals for all pregnant clients.
Overview of Title X
What Is the Federal Funding Level?
FY2020 funding
Does Title X Fund Abortions? Since the program’s
was $286.5 million, the same as FY2019. Continuing
establishment in 1970, the PHS Act has prohibited using
resolution P.L. 116-159 continues funding for most
Title X funds in projects where abortion is a method of
discretionary HHS programs, including Title X, through
family planning (42 U.S.C. §300a-6). The 2019 rule
December 11, 2020 (or until full-year funding is
requires “physical and financial separation” between Title
appropriated), at the rate they were funded in P.L. 116-94,
X projects and prohibited activities, replacing the prior
Further Consolidated Appropriations Act, 2020. The
requirement that they be “separate and distinct” from each
temporary funding is subject to the same authority and
other. Prohibited activities include abortion, referral for
conditions as in FY2020.
abortion as a method of family planning, and activities that
encourage, promote, or advocate for abortion.
What Is the Status of the 2019 Final Rule? In March
2019, HHS published in the Federal Register a final rule
Physicians and advanced practice providers may, however,
that, among other things, prohibits Title X projects from
provide nondirective abortion counseling. The 2019 rule’s
referring clients for abortion as a method of family
preamble provides guidance that nondirective counseling
planning. It also requires physical and financial separation
involves presenting options “in a factual, objective, and
between Title X projects and certain abortion-related
unbiased manner.” Title X projects may also refer patients
activities. (CRS In Focus IF11142, Title X Family Planning
to abortion providers for emergency care and in certain
Program: 2019 Final Rule.) The rule has been challenged
cases of rape and incest.
in several lawsuits across the country, but is currently in
effect in all states except Maryland, where it has been
What Do Clients Pay? Persons with income at or below
enjoined. Future court rulings could affect the rule’s further
100% of the federal poverty guidelines do not pay for care.
implementation (https://go.usa.gov/xVX4t).
Clients with income higher than 100% and up to 250% of
the poverty guidelines are charged on a sliding scale based
According to the 2019 Family Planning Annual Report, the
on their ability to pay. Clients with income higher than
final rule has affected participation in the Title X program:
250% of the poverty guidelines are charged fees designed
“As a result of the Final Rule, 18 agencies representing 19
to recover the reasonable cost of providing services. (In
grants and 231 subrecipients discontinued participation in
2020, the poverty guidelines for an individual in the 48
the Title X program; the number of Title X service sites
contiguous states and the District of Columbia is an annual
was reduced by 945 sites” (https://go.usa.gov/xGQXE).
income of $12,760; for families of two or more persons,
HHS redistributed some of the relinquished funds among
$4,480 is added to the annual income figure for each
remaining grantees (https://go.usa.gov/xVMPF). In
additional person.)
September 2020, HHS awarded new grants for unserved
and underserved areas (https://go.usa.gov/xGQNN). The
For unemancipated minors who request confidential
September 2020 Family Planning Directory lists no Title X
services, eligibility for discounts is based on the minor’s
sites in Hawaii, Maine, Oregon, Vermont, or Washington
own income. The 2019 rule also allows Title X project
(https://go.usa.gov/x7qrT).
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.
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link to page 2
Title X Family Planning Program
Are There Special Requirements for Services to
 Funds cannot be spent on “any activity (including the
Minors? All Title X services are confidential, including
publication or distribution of literature) that in any way
services to minors. Title X projects do not require parental
tends to promote public support or opposition to any
notification or parental consent. However, Title X statute
legislative proposal or candidate for public office.”
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

sexual activity. Under the 2019 rule, Title X projects must
Grantees must certify that they counsel minors on how
conduct a preliminary screening of any minor who presents
to resist attempted coercion into sexual activity.
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
at or below 200% of the federal poverty guidelines. The
Other Family Planning Programs
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%
(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
(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
COVID-19
Report: 2019 National Summary, pp. 12, 14, http://go.usa.gov/xGQXE
What Resources Are Available for Title X Projects? The
Notes: 33% of clients (al races) identified as Latino/Hispanic.
Centers for Disease Control and Prevention released
Percentages may not sum to 100% due to rounding.
guidance on “Ensuring access to family planning services
during COVID-19” (https://go.usa.gov/xGQXH), and the
Legislative Mandates
Title X-funded Family Planning National Training Center
What Title X Provisions are in the Most Recent
released several resources on COVID-19
Appropriations Law? The Further Consolidated
(https://www.fpntc.org/search?keys=covid). OPA’s grantee
Appropriations Act, 2020 (P.L. 116-94) included
profiles also have examples of grantees’ COVID-19
requirements on the use of Title X funds that are similar to
responses (https://go.usa.gov/x7TJE).
provisions included in previous years’ appropriations laws:

Angela Napili, Senior Research Librarian
Title X funds cannot be spent on abortions.

IF10051
All pregnancy counseling must be nondirective.
https://crsreports.congress.gov

Title X Family Planning Program


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https://crsreports.congress.gov | IF10051 · VERSION 18 · UPDATED