It is the policy of Adagio Health to ensure all sub-recipient/grantee medical offices provide quality family planning and related reproductive/preventive health services that complies with the 2019 Title X Final Rule “Compliance with Statutory Program Integrity Requirements” as published by the Department of Health and Human Services in March 2019. Adherence to Title X family planning program requirements is a core component of on-site audits and sub-recipient monitoring.
[Source: Federal Register, Vol. 84, No. 42 as published Monday, March 4, 2019, pages 7714 – 7791.]
Compliance with the following standards are required by all subrecipients and any subcontracted agencies and/or employees of subrecipients.
I. Voluntary Participation
Family planning services are to be provided solely on a voluntary basis. Clients cannot be coerced to accept family planning services, nor should they be coerced to use/not to use any particular method of contraception. A client’s acceptance or refusal of family planning services cannot be used as a prerequisite to receipt of any other service or assistance provided through any other program offered by the Title X grantee/sub-recipient. Specific language regarding voluntary services and a client’s acceptance or refusal of services cannot be used as a prerequisite to any other service offered at the clinical site must be included on all consents for services.
No client seeking family planning services may be coerced to undergo an abortion or sterilization procedure. Family planning program staff shall receive annual training and/or notification that attempts to coerce a client to undergo an abortion or sterilization procedure are prohibited and that any employee attempting to coerce may be subject to prosecution, according to Section 205, Public Law 94-63, as set out in 42 CFR 59.5(a)(2) footnote 1.
II. Confidentiality of Care and Services
No agency/office/individual practitioner is permitted to require written consent of parents or guardians for the provision of family planning services to teens. Parents/guardians of minors cannot be notified before or after a minor has requested and/or received Title X family planning services.
All Title X-funded project personnel are to encourage family participation in the decision of minors to seek family planning services. Providers should assist these minor clients in opening lines of communication with his/her parent(s) or guardian(s). Refer to Policy C-2 and Procedure C-2 for additional guidance. A minor client’s request for confidentiality is not justification for ignoring the requirement to encourage family participation in his/her decision to seek family planning services. Such documentation is not required if the provider has documented in the health record (1) that the provider suspects the minor to be the victim of child abuse or incest; and (2) the provider has reported the suspicions to relevant authorities, as consistent with State or local laws.
All Title X-funded project personnel should provide education and counseling to minors seeking family planning services on how to resist attempts to coerce the minor into engaging in sexual activities. Refer to Manual I - Policy C-3 and Procedure C-3 for additional guidance.
When minor clients present with a sexually transmitted disease or positive pregnancy test, providers should conduct a preliminary screening to rule out victimization of the client. All Title X-funded project staff must comply with applicable state laws requiring notification and/or reporting of child abuse, child molestation, sexual abuse, rape, or incest. Refer to Manual I - Policy A-10 and Procedure A-10 for additional guidance.
B. Confidentiality of all Clients
A client’s request for confidentiality of family planning services supersedes organizational policies related to third-party billing of services. This is regardless of the client’s age. In cases where an insured client is seeking confidentiality, the organization cannot bill the insurer for services if there is risk of an Explanation of Benefits being mailed to the client/client’s home, or otherwise violates the client’s request for confidentiality.
No identifying information on a client receiving family planning services may be disclosed without the individual’s documented consent, except where required by law. Information on family planning services may only be disclosed in summary or statistical form in which no individual is identified.
A minor’s request for confidentiality of services cannot be used as justification for ignoring requirements to encourage and discuss family involvement (parent or guardian) in the minor’s decision to seek family planning services.
All Title X-funded family planning organizations/clinical service sites must be in full compliance with Section 1008 of the Title X statute and 42 CFR 59.5(a)5, which prohibit abortion as a method of family planning. No Title X funds will be used to provide, promote, refer for, or support abortion as a method of family planning. Referrals for abortion for emergency care purposes are not prohibited. Permitted referrals under this scenario include one in which a medical emergency is revealed, such as when a woman has a suspected ectopic pregnancy. In cases involving rape and/or incest, it would not be considered a violation of the prohibition on referral for abortion as a method of family planning if a patient is provided a referral to a licensed, qualified, comprehensive health service provider who also provides abortion provided that the Title X provider has complied with any applicable State and/or local laws requiring reporting to, or notification of, law enforcement or other authorities and such reporting or notification is documented in the patient’s record. There must exist a clear financial and physical separation of services and funding between Title X and non-Title X activities, as per the 2019 Title X Final Rule “Compliance with Statutory Program Integrity Requirements” as published by the Department of Health and Human Services in March 2019.
IV. Charges / Billing / Collections
Clients must not be denied family planning services or be subject to any variation in quality of care because of their inability to pay. Fees must be waived for clients whose incomes fall above 100% of the Federal Poverty Level and are unable, as determined by the family planning site manager/director, to pay for their family planning services.
Waiver of charges can be made for good cause. All family planning provider organizations are required to have in place a policy and procedure for handling requests from clients seeking a waiver of charges due to inability to pay for services.
For clients whose income exceeds 250% of Federal Poverty Level, charges for services must be made in accordance with a schedule of fees designed to recover the reasonable cost of services.
No Title X-funded agency/office/clinical provider is permitted to have a general policy of no fee or flat fees for the provision of services to any particular population type, e.g., college students.
Title X-funded projects must bill all third-party payers authorized or legally obligated to pay for services unless the client is specifically requesting confidentiality of services.
Reasonable efforts to collect charges may be made as long as they do not jeopardize client confidentiality.
A site may consider a woman, whose employer’s insurance does not cover birth control methods due to strongly held religious beliefs, to be low-income (at/below 100% FPL), or in determining her annual income for the sliding fee scale, may reduce her annual income by an estimated $600 (the average annual out-of-pocket expenses for contraceptive services).
V. Schedule of Discounts
All Title X-funded sub-recipients must have in place an approved Schedule of Discounts, with incremental discounts ranging from 101% to 250% Federal Poverty Level (FPL), to be applied to all clients seeking family planning services. Assessment and update of an approved Schedule of Discounts must be conducted on an annual basis that considers the cost of providing family planning services and client ability to pay. The Schedule of Discounts will be designed to recover the reasonable cost of providing services. Reasonable costs for service provision must be used to determine charges to clients whose income is above 250% FPL. Adagio Health releases an approved schedule of discounts every February when new Federal Poverty Guidelines are published. Subrecipient agencies have the option to use their own Schedule of Discounts that adhere to items A, B, and C – below. Selection of the Schedule of Discounts to be used must be indicated in Contract Agency Addendums, specifically located in ADDENDUM B: Sub Recipient Schedule of Discounts. All variances from the Adagio Health approved Schedule of Discounts must be submitted in writing to the Adagio Health Title X Project Director for approval and review by the US Dept. of Health & Human Services, Region III staff.
A. Clients with documented income at/below 100% of the FPL must not be charged for their services, including no co-pays.
B. Fees must be appropriately slid, according to client’s income and household size based on the current schedule of discounts, for clients whose income is between 101% and 250% of the FPL. Fees must be waived for clients who are unable to pay for their family planning services.
C. Clients whose income is above 250% of the FPL must be charged at a rate to recover the reasonable cost of providing services.
D. Eligibility for discounts for unemancipated minor clients seeking confidential family planning services must be based on the income of the minor with no consideration given to the minor’s family/household income.
Where there is legal obligation or authorization for third party reimbursement (public and private), all reasonable efforts must be made to obtain this payment without application of any discounts. With regard to insured clients whose income are at/below 250% FPL, clients should not pay more (in copayments or additional fees, such as deductibles) than what they would otherwise pay when the schedule of discounts is applied.
VI. Project Services
All family planning projects must provide family planning services as defined in the Quality Family Planning Services guidelines published by the Centers for Disease Control and Prevention and the U.S. Office of Population Affairs (April 2014). Comprehensive medical, informational, educational, social, and referral services related to family planning must be provided to all clients requesting such services. At a minimum, family planning services include the following:
1. Providing contraception to help women and men plan and space births, prevent unintended pregnancies, and reduce the number of abortions. Contraception services must include natural family planning and/or fertility awareness-based methods;
2. Offer pregnancy testing, counseling, and referrals for prenatal care;
3. Help clients wishing to conceive;
4. Provide basic infertility services;
5. Provide preconception health services to improve infant and maternal outcomes and improve women’s and men’s health; and
6. Provide sexually transmitted disease screening and treatment services to prevent tubal infertility and improve the health of women, men, and infants.
For specific clinical policies and procedures, see Adagio Health Policy & Standards, Part II: Clinical Policies and Procedures for Family Planning and Related Reproductive Health Services.
A. Priority Populations
Priority for Title X-funded family planning services is to persons from low-income families, with an emphasis on clients whose income and family size place them at or below 100% of the Federal Poverty Level.
B. Nondiscriminatory Provision of Services
Family planning services must be provided without regard to religion, race, color, limited English proficiency, national origin, disability, age, sex, number of pregnancies, gender identity, gender expression, sexual orientation, or marital status.
C. Approved Clinical Protocols
All Title X-funded project sites must provide family planning services within written clinical protocols that are in accordance with nationally recognized standards of care. Title X sub-recipients may use their own clinical protocols with prior approval from Adagio Health’s Medical Director.
D. Family Planning Methods and Services
All family planning providers are expected to offer a broad range of acceptable and effective medically approved family planning methods and services either on-site or by written and approved referral agreements with another local provider.
Acceptable family planning methods should include natural family planning methods and/or fertility awareness-based methods.
Acceptable family planning services should include infertility services, preconception health care, and specialized services for adolescents.
Abortion is not an approved method of family planning and no funds from Title X project grants shall be used to provide, or refer for, abortion services, except in cases of rape, incest, or where the life of the mother is endangered unless an abortion is performed.
Pregnancy testing/diagnosis and nondirective counseling must be provided to all clients in need of this service. For positive pregnancy tests, clients must be provided their test results and that she has three options: Prenatal care and delivery; infant care, foster care, or adoption; and pregnancy termination.
All clients with a positive pregnancy test should be provided a prenatal resource guide. All prenatal resource guides must be approved by the Title X Project Director prior to use.
If the client is seeking prenatal care, she can be provided an immediate referral for services to a provider for early prenatal care. If the client has any additional questions, she must be seen by a licensed clinical provider (Physician or Advance Practice Provider). The licensed provider may answer any medical/clinical questions the client may have. A pregnant client must be given a referral for prenatal care because it is medically necessary for all pregnant women. Only in medical emergencies or in cases involving rape and/or incest is it permissible to provide a referral for abortion as long as that referral is to a licensed, qualified comprehensive health service provider who also provides abortion. See Policy & Standards Manual II: Clinical, Policy & Procedure M-5 Pregnancy Diagnosis and Counseling.
Nondirective options counseling should be provided in a neutral, factual, and nondirective manner. There should be in place policies to include conscience protections for personnel not wishing to provide any or all components of nondirective pregnancy options counseling.
Family planning clients may not be coerced to use contraception, nor should they be coerced to use any particular method of contraception or service.
E. Protection from Victimization
All clients receiving services in a Title X-funded clinical site must be screened for child abuse, child molestation, sexual abuse, rape, incest, intimate partner violence, and human trafficking.
All Title X project staff must comply with reporting requirements under appropriate state and local laws. Refer to Manual I - Policy and Procedure A-10 (Mandatory Reporting Requirements, Policy & Standards Manual Section I – Pennsylvania and West Virginia).
F. Referrals for Conditions Deemed Medically Necessary
Title X funds are intended for family planning and preconception health care. Once a client is medically verified as pregnant, she should be referred to a health care provider for medically necessary prenatal health care. The Title X provider may also choose to provide the following:
1. Nondirective pregnancy options counseling;
2. A list of licensed, qualified, comprehensive primary health care providers that provide prenatal care;
3. Referral to social services or adoption agencies;
4. Information about maintaining the health of mother and unborn child.
In cases in which emergency care is required, the client should be referred immediately to an appropriate provider of medical services needed to address the emergency.
VII. Human Subjects Clearance and Research
Any research involving Title X projects may be subject to Department of Health and Human Services regulations regarding the protection of human subjects.
Any requests for research involving Title X family planning clients must be sent to the Adagio Health Title X Project Director, in writing, prior to commencing any such research project. Refer to Manual I - Policy F-1 External Research and Procedure F-1 Protocol for Outside Agency Research Requests for additional instructions related to external research within the family planning network.
VIII. Concerns and Grievances
All clients seeking family planning services have the right, and must be given the opportunity, to present concerns and grievances related to any aspect of their receipt of services.
All family planning subrecipients must have in place a procedure for handling client grievances. See Manual I - Policy E-1 Concerns and Grievances, Procedure E-1 (a) Concerns and Grievances, and Procedure E-1 (b) POSTER for Client Concerns and Grievances. Subrecipient agencies must display some type of poster instructing clients how they can file a grievance.
7/2014; Revised July 2021