In 1970, Congress enacted Title X of the Public Health (PHS) Act and established the Title X Family Planning Program—the only federal program devoted exclusively to family planning and related preventive healthcare. “It is administered by the Office of Population Affairs (OPA) within the Assistant Secretary for Health (OASH) in the U.S. Department of Health and Human Services (HHS).”[1] Title X providers, with an estimated annual budget of $286.5 million, offer millions of low-income and uninsured Americans with high-quality, client-centered care.
Title X services in 2021
Based on statistics reported in the Title X Family Planning Annual Report 2021 National Summary, Title X-funded services were implemented through 75 grants to 41 state and local health departments and 34 nonprofit family planning and community health agencies. “Title X funds supported a network of 3,284 service sites operated by either grantees or 899 subrecipients in 44 states, the District of Columbia, and eight U.S. Territories and Freely Associated States.”[2] Title X grant recipients and their subrecipients include: Planned Parenthood facilities; federally qualified health centers (FQHCs); school-based health centers; collegiate student health centers; and hospital outpatient departments. To enhance access to services, the OPA hosts an online Family Planning Clinic Locator, which provides links to Title X sites within a 50-mile radius of an address. During 2021, approximately 1.7 million clients received Title X services, which represented an increase of approximately 8% in comparison to 2020.[3]
Title X is designed to provide:
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A broad range of acceptable and effective family planning methods and services, including:
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Natural family planning methods
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Infertility services
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Services for adolescents
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Contraceptive education and counseling
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Breast and cervical cancer screening
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Sexually transmitted infection and HIV testing, referral, and prevention education
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Pregnancy diagnosis and counseling.
Title X funds cannot be used by centers where abortion is considered a method of family planning.
The intersection of Title X and OPA’s program priorities
In the Centers for Disease Control and Prevention’s (CDC) “Notice of Funding Opportunity,” which was used to fund Title X service delivery grants starting on April 1, 2022, for an up to five-year project period, the OPA set forth three program priorities:
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Advance health equity.
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Expand access.
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Deliver high-quality care.
In its Title X Program Handbook, OPA stated, “Title X is and should be the gold standard of high-quality family planning and sexual and reproductive healthcare.”[4] Clinical services must be consistent with nationally recognized standards of care, including those issued by national medical associations, the U.S. Preventive Services Taskforce, the Advisory Committee on Immunization Practices, and the American Cancer Society. To offer additional support to family planning providers, the OPA collaborated with CDC in developing the first federal evidence-informed set of guidelines for family planning services: Providing Quality Family Planning Services: Recommendations from the Centers for Disease Control and Prevention and the U.S. Office of Population Affairs (QFP). Title X recipients and subrecipients must also meet the service delivery requirements identified in Figure 1.
Title X Service Delivery Requirements
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“Client-centered care is respectful of, and responsive to, individual client preferences, needs, and values; client values guide all clinical decisions.
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“Culturally and linguistically appropriate services are respectful of and responsive to the health beliefs, practices and needs of diverse patients.
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“Inclusive is when all people are fully included and can actively participate in and benefit from family planning, including, but not limited to, individuals who belong to underserved communities, such as Black, Latino, and Indigenous and Native American persons, Asian Americans and Pacific Islanders and other persons of color; members of religious minorities; lesbian, gay, bisexual, transgender, and queer (LGBTQ+) persons; persons with disabilities; persons who live in rural areas; and persons otherwise adversely affected by persistent poverty or inequality.
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“Trauma-informed means a program, organization, or system that is trauma-informed realizes the widespread impact of trauma and understands potential paths for recovery; recognizes the signs and symptoms of trauma in clients, families, staff, and others involved with the system; and responds by fully integrating knowledge about trauma into policies, procedures, and practices, and seeks to actively resist re-traumatization.”[5]
Financial eligibility requirements in the Title X program
To help assure that low-income clients can access care, Title X program recipients and subrecipients must offer their services at no charge to people whose family incomes are below 100% of the most recent federal poverty guidelines (FPGs). Title X services must be offered at a discounted rate on a sliding scale for persons whose family incomes are between 101%–250% of the FPGs.[6] All Title X recipients and subrecipients must update their sliding fee scales annually, following the release of updated FPGs by the Secretary of HHS.
The Secretary of HHS is required to update the FPGs at least annually, adjusting them based on the preceding year’s increase in prices as measured by the Consumer Price Index for All Urban Consumers (CPI–U).[7] FPGs are based on the number of persons in the family’s household. For households with more than eight persons, a dollar amount is established for each additional person. Three jurisdictions are designated by HHS, each with a separate set of FPGs.
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The 48 contiguous states and the District of Columbia (see Table 1)
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Alaska (see Table 2)
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Hawaii (see Table 3)
The tables display FPGs set at 100% poverty, based on the number of persons living in the household.
|
Persons in Family/Household |
Poverty Guideline |
|---|---|
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1 |
$14,580 |
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2 |
$19,720 |
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3 |
$24,860 |
|
4 |
$30,000 |
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5 |
$35,140 |
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6 |
$40,280 |
|
7 |
$45,420 |
|
8 |
$50,560 |
For households with more than eight persons, add $5,140 for each additional person to establish the household’s income, which would equal 100% of the federal poverty level. For example, if there are 10 persons in a household, 100% of federal poverty would be $50,560 + ($5,140 X 2) = $60,840.
|
Persons in Family/Household |
Poverty Guideline |
|---|---|
|
1 |
$18,210 |
|
2 |
$24,640 |
|
3 |
$31,070 |
|
4 |
$37,500 |
|
5 |
$43,930 |
|
6 |
$50,360 |
|
7 |
$56,790 |
|
8 |
$63,220 |
For families/households in Alaska with more than eight persons, add $6,430 for each additional person. For example, if there are 10 persons in an Alaskan household, then 100% of federal poverty would be calculated as $63,220 + ($6,430 X 2) = $75,900.
|
Persons in Family/Household |
Poverty Guideline |
|---|---|
|
1 |
$16,770 |
|
2 |
$22,680 |
|
3 |
$28,590 |
|
4 |
$34,500 |
|
5 |
$40,410 |
|
6 |
$46,320 |
|
7 |
$52,230 |
|
8 |
$58,140 |
For families/households in Hawaii with more than eight persons, add $5,910 for each additional person. For example, if there are 10 persons in a Hawaiian household, then 100% of federal poverty would be calculated as $58,140 + ($5,910 X 2) = $69,960.
An important caveat about determining Title X clients’ household income
There is an important requirement that pertains to income calculations, which Title X program recipients and subrecipients must meet. This requirement helps promote the provision of adolescent-friendly health services; it protects the privacy of unemancipated adolescents who do not choose to engage their parent or guardian in deciding whether to receive Title X services.
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To fully meet this requirement, when an unemancipated minor requests confidential services, a Title X recipient or subrecipient should classify this client as having a household of one.
Sliding fee scale requirements for Title X
The OPA’s sliding fee scale requirements for Title X recipients and subrecipients differ from the sliding fee discount scale requirements that are established by the Health Resources and Services Administration (HRSA) for the Health Center Program. Requirements for health centers’ sliding fee discount program are outlined in Chapter 9 of the Health Center Program Compliance Manual.[11] HRSA’s requirements for sliding fee discount scales for FQHCs that receive funding under Section 330 of the Public Health Service Act, as well as for FQHC “look-alikes” (LALs), which meet Section 330 requirements but do not receive Section 330 grant funds, may not exceed 200% of FPG. However, OPA has established Title X’s sliding fee scale with an upper threshold of up to 250% of federal poverty.
Another difference between Title X and HRSA’s Health Center Program pertains to collecting a nominal fee (or “nominal charge”). In the Health Center Program, each health center must decide whether to charge a nominal fee to patients whose income is at or below 100% of FPG. Based on the Health Center Program Compliance Manual, nominal fees are not “minimum fees,” “minimum charges,” or “co-pays.” The development of a health center’s nominal fee would be a specified dollar amount based on patients’ perspectives. The nominal fee “would not reflect the actual cost of the service being provided.”[12]
Because some FQHCs and LALs participate in Title X either as a grant recipient or subrecipient, these organizations must have dual discount fee schedules. On November 22, 2016, OPA released a Program Policy Notice to clarify how Title X recipients and subrecipients may remain in compliance with the OPA’s requirements when integrating services with FQHCs and LALs. The purpose of “OPA Program Policy Notice: 2016-11 – Integrating with Primary Care Providers” was to “address three issues commonly faced by integrated Title X and HRSA health center providers:
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“How to bill clients receiving Title X family planning services in compliance with Title X and Health Center Program Sliding Fee Discount Schedules and billing guidelines;
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“How to report data to the Family Planning Annual Report (FPAR) and to the Uniform Data System (UDS) appropriately; and
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“How to preserve Title X client confidentiality when billing for services provided.”[13]
Issue 1: Nominal charge and Sliding Fee Discount Schedules (SFDS)
The OPA has provided the following guidance in “OPA Program Policy Notice: 2016-11 – Integrating with Primary Care Providers” when Title X clients only receive Title X family planning services that are directly related to preventing or achieving pregnancy:
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“Clients receiving only Title X family planning services with family incomes at or below 100% of the [federal poverty level] FPL must not be charged for services received. In order to comply with Title X regulations, any nominal fee typically collected by a HRSA health center program grantee or look-alike would not be charged to the client who only receives Title X family planning services.”
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Clients with family incomes between 101%–250% who are only receiving Title X family planning services must be charged according to a specific Title X SFDS based on the client’s ability to pay. Any differences between charges based on applying the Title X SFDS and the health center’s discount schedule could be allocated to Title X grant funds.
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“Note that unemancipated minors who receive confidential Title X family planning services must be billed according to the income of the minor.”[14]
For Title X “clients who receive health center services in addition to Title X family planning services within the same visit:
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“For clients receiving health center services in addition to Title X family planning services . . . within the same visit, the health center or look-alike may utilize its health center discounting schedule (which ranges from 101% to 200% FPL) . . .”
Issue 2: Fulfilling data reporting requirements
“To comply with mandatory reporting requirements for both the Title X and HRSA Health Center program, health centers that are integrated with Title X funded agencies must provide data on services provided that are relevant to either or both through FPAR and UDS, as appropriate. In cases where a data element applies to both FPAR and UDS, reporting such data” should be reported in each system. The “OPA Program Policy Notice: 2016-11 – Integrating with Primary Care Providers” states that reporting the data to “both Title X and HRSA receive accurate information on services provided during the given reporting period.”
Issue 3: Sliding fee discount schedule eligibility for individuals seeking confidential services
For individuals who request confidential family planning services, including those who do not want their information disclosed for third-party billing, “the provider should ensure that appropriate measures are in place to protect the client’s information . . . Providers may not bill third-party payers for services in such cases where confidentiality cannot be assured.” Examples of potential breaches of confidentiality include:
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When a third-party payer will not suppress generating an explanation of benefits
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When the family planning service cannot be removed from the client’s claims history
“Providers may request payment from clients at the time of the visit for any confidential services provided that cannot be disclosed to third-party payers, as long as the provider uses the appropriate SFDS.” Title X and FQHC providers may bill third-party payers for family planning services the client identified as nonconfidential.
Conclusion
The Title X Family Planning Program assures that low-income clients have access to family planning and associated preventive healthcare services. Recipients and subrecipients must offer their services at no charge to people whose family incomes are below 100% of the most recent FPGs and provide at a discounted rate on a sliding scale for persons whose family incomes are between 101%–250% of the FPGs. Per HHS secretary, sliding fee scales must be updated annually after updated FPGs are released.
Title X’s sliding fee scale requirements differ from the threshold established for the Health Center Program administered by HRSA. Because FQHCs and FQHC LALs participate in Title X either as grant recipients or subrecipients, these organizations must have dual discount fee schedules. FQHCs and LALs participating in Title X should refer to the guidance outlined in “OPA Program Policy Notice: 2016–11 – Integrating with Primary Care Providers” to ensure compliance with HRSA and Title X requirements.
Takeaways
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The Title X Family Planning Program is administered by the Office of Population Affairs under the U.S. Department of Health & Human Services (HHS).
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Title X provides care to 1.7 million clients annually in grant-funded facilities, including Planned Parenthood sites, federally qualified health centers, school-based health centers, and hospital outpatient departments.
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Title X services must be provided without charge to anyone with an income below 100% of the current federal poverty guidelines.
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Title X’s sliding fee discount scale differs from the Health Center Program’s scale, which the Health Resources & Services Administration administers.
Federal poverty guidelines are updated annually by HHS. Separate federal poverty levels are produced for the 48 contiguous states and Washington, DC; Alaska; and Hawaii.
