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Updated June 10, 2021
Title X Family Planning Program: 2019 Final Rule
The Title X Family Planning Program (Title X) is the only
domestic federal program devoted solely to family planning
and related preventive health services. The program
provides grants to public and nonprofit agencies to establish
and maintain family planning projects (Title X projects). A
Title X grantee can undertake a Title X project that has
several participating entities. For example, a state-agency
grantee can have a Title X project that supports the state's
local organizations and clinics.
In the March 4, 2019, Federal Register, the Department of
Health and Human Services (HHS) published a final rule
for the program, https://go.usa.gov/xEdTp. Among other
things, it prohibits Title X projects from referring clients for
abortion as a method of family planning. It also requires
physical separation between Title X projects and certain
abortion-related activities. For a redline document showing
how the rule changed prior regulations, see
https://go.usa.gov/xAFQA.
Status of the Final Rule
HHS required compliance with the final rule starting July
15, 2019, except for the physical separation requirements,
for which compliance was required by March 4, 2020. The
rule was challenged in several lawsuits across the country,
but took effect in all states except Maryland, where it was
enjoined, see https://go.usa.gov/xVX4t.
In the April 15, 2021 Federal Register, HHS published a
proposed rule that would, among other things, reverse
several changes made by the 2019 rule. For example, the
proposed rule would restore a pre-2019 requirement that
projects provide an abortion referral if requested by the
client and would remove the physical separation
requirement, among other changes, see https://go.usa.gov/
xHWMb. HHS has indicated that it expect the notice-and-
comment rulemaking process to be completed by the end of
2021; until a new final rule takes effect, HHS plans to
continue to enforce the 2019 rule, see https://go.usa.gov/
xHeyY.
Overview of the 2019 Final Rule
This section summarizes selected regulatory changes made
by the final rule.
Family Planning Definition
Prior regulation. Family planning was not defined.
2019 rule. The rule introduces a new definition of family
planning, referring to it as the voluntary process of
identifying goals and developing a plan for the number and
spacing of children and the means by which those goals
may be achieved. Family planning can include, among
other things, an array of acceptable and effective choices,
which may range from choosing not to have sex to the use
of other family planning methods and services to limit or
enhance the likelihood of conception (including
contraceptive methods and natural family planning or other
fertility awareness-based methods) and the management of
infertility (including adoption).
Scope of Family Planning Services
Prior regulation. Title X projects were required
to[p]rovide a broad range of acceptable and effective
medically approved family planning methods (including
natural family planning methods) and services (including
infertility services and services for adolescents). If a health
care entity offers only a single method of family planning,
it may participate as part of a project as long as the entire
project offers a broad range of family planning services.
2019 rule. The rule requires Title X projects to [p]rovide a
broad range of acceptable and effective family planning
methods (including contraceptives, natural family planning
or other fertility awareness-based methods) and services
(including infertility services, information about or referrals
for adoption, and services for adolescents). The rule does
not require family planning methods and services to be
medically approved. The rule does not require Title X
projects to provide every acceptable and effective family
planning method or service. The rule states that [a]
participating entity may offer only a single method or a
limited number of methods of family planning as long as
the entire project offers a broad range of such family
planning methods and services.According to the preamble,
the rule allows participation by clinics that, for reasons of
conscience, limit the services they offer.
Physical and Financial Separation
By law, Title X funds may not be used in projects where
abortion is a method of family planning (42 U.S.C. 300a-6).
Prior guidance. Program guidance interpreted the law as
requiring that a grantee's abortion activities be separate
and distinct from its Title X project activities. Under prior
guidance, a grantee's abortion activities and its Title X
project activities could share a common facility, a common
waiting room, common staff, and a common records
system, so long as it is possible to distinguish between the
Title X supported activities and non-Title X abortion-
related activities, for example, through allocating and
prorating costs, see https://go.usa.gov/xEdtA.
2019 rule. The rule requires Title X projects to be
physically and financially separate from prohibited
activities, including providing, referring, encouraging,
promoting, or advocating for abortion. The rule requires,
for example, separate facilities (including exam and waiting
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