Release Date: November 22, 2016
OPA Program Policy Notice: 2016 – 11
The purpose of this Program Policy Notice (PPN) is to clarify how Title X grantees may remain in compliance with Program Requirements for Title X Funded Family Planning Projects when integrating services with Health Resources & Services Administration (HRSA) Health Center Program grantees and look-alikes (i.e., health centers that receive funding under Section 330 of the Public Health Service Act, which authorizes the Health Center Program, as well as those that have been determined to meet Section 330 requirements but do not receive grant funding under that program). This PPN applies only to integrated settings, and not to settings in which only Health Center Program services are provided. We address three issues commonly faced by integrated Title X and HRSA-funded health center providers:
- 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;
- How to report data to the Family Planning Annual Report (FPAR) and to the Uniform Data System (UDS) appropriately; and
- How to preserve Title X client confidentiality when billing for services provided.
In 2014, the Office of Population Affairs (OPA) released new Title X program guidelines consisting of two parts:
- Program Requirements for Title X Funded Family Planning Projects; and
- Providing Quality Family Planning Services: Recommendations of CDC and the U.S. Office of Population Affairs (QFP).
Title X Program Requirements align closely with the Title X statute and family planning services project implementing regulations (42 CFR part 59, subpart A), as well as other applicable federal statutes, regulations, and policies. This PPN is intended to help Title X grantees address integrated care settings with regard to Title X Program Requirements.
This section provides clarification for some of the most common issues facing Title X Family Planning (FP) providers when integrating with primary care organizations, and suggests sample strategies to overcome these issues. Endnotes are provided for reference to the applicable section(s) of the Title X and HRSA Health Center Program Requirements aligned with each strategy.
Issue 1: Nominal Charge and Sliding Fee Discount Schedules (SFDS)
The HRSA Health Center Program and the OPA Title X Program have unique Sliding Fee Discount Schedule (SFDS) program requirements, which include having differing upper limits. HRSA’s policies, currently contained in Policy Information Notice (PIN) 2014-02, allow health centers to accommodate the further discounting of services as required by Title X regulations. Title X agencies (or providers) that are integrated with or receive funding from the HRSA Health Center Program may have dual fee discount schedules: one schedule that ranges from 101% to 200% of the Federal Poverty Level (FPL) for all health center services, and one schedule that ranges from 101% to 250% FPL for clients receiving only Title X family planning services directly related to preventing or achieving pregnancy, and as defined in their approved Title X project.
Title X agencies and providers may consult with the health center if they have additional questions regarding implementing discounting schedules that comply with Title X and Health Center Program requirements, which may result in the health center needing to consult their HRSA Health Center Program Project Officer.
To decide which SFDS to use, the health center should determine whether a client is receiving only Title X family planning services (Title X family planning services are defined by the service contract between the Title X grantee and health center) or health center services in addition to Title X family planning services within the same visit.
The following guidance applies specifically to clients who receive only Title X family planning services that are directly related to preventing or achieving pregnancy:
- Clients receiving only Title X family planning services with family incomes at or below 100% of the 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 receiving only Title X family planning services.i
- Clients receiving only Title X family planning services with family incomes that are between 101% FPL and 250% FPL must be charged in accordance with 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 discounting schedule could be allocated to Title X grant funds. This allocation is aligned with the guidance provided in HRSA’s PIN 2014-02, as discussed above. This PIN states that program grantees, “may receive or have access to other funding sources (e.g., Federal, State, local, or private funds) that contain terms and conditions for reducing patient costs for specific services. These terms and conditions may apply to patients over 200 percent of the FPG [Federal Poverty Guidelines]. In such cases, it is permissible for a health center to allocate a portion (or all) of this patient’s charge to this grant or subsidy funding source.”ii
- Note that unemancipated minors who receive confidential Title X family planning services must be billed according to the income of the minor.iii
The following guidance applies specifically to clients who receive health center services in addition to Title X family planning services within the same visit:
- For clients receiving health center services in addition to Title X family planning services, as defined above, within the same visit, the health center or look-alike may utilize its health center discounting schedule (which ranges from 101% to 200% FPL) including collecting one nominal fee for health center services provided to clients with family incomes at or below 100% FPL.
Issue 2: Fulfilling Data Reporting Requirements
To comply with mandatory program 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 is applicable to both FPAR and UDS, reporting such data to each report does not result in “double” credit for services provided; rather, it ensures that both Title X and HRSA receive accurate information on services provided to clients during the given reporting period.
Further instructions on how a family planning “user” is defined can be found in the FPAR Forms & Instructions guidance document.
Issue 3: Sliding Fee Discount Schedule eligibility for individuals seeking confidential services
For individuals requesting that Title X family planning services provided to them are confidential (i.e., they do not want their information disclosed in any way, including for third-party billing), the provider should ensure that appropriate measures are in place to protect the client’s information, beyond HIPAA privacy assurances.iv Providers may not bill third-party payers for services in such cases where confidentiality cannot be assured (e.g., a payer does not suppress Explanation of Benefits documents and does not remove such information from claims history and other documents accessible to the policy holder). 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. Inability to pay, however, cannot be a barrier to services.v Providers may bill third-party payers for services that the client identifies as non-confidential.
i Section 8.4 of the Title X Program Requirements contains information related to charges, billing, and collections. The program requirements in section 8.4 most relevant to charging clients at or below 100% of the FPL, between 101% and 250% of the FPL, and above 250% of the FPL, are as follows:
Title X Program Requirement 8.4.1. Clients whose documented income is at or below 100% of the Federal Poverty Level (FPL) must not be charged, although projects must bill all third parties authorized or legally obligated to pay for services (Section 1006(c)(2), PHS Act; 42 CFR 59.5(a)(7)).
Within the parameters set out by the Title X statute and program requirements, Title X grantees have a large measure of discretion in determining the extent of income verification activity that they believe is appropriate for their client population. Although not required to do so, grantees that have lawful access to other valid means of income verification because of the client’s participation in another program may use those data rather than re-verify income or rely solely on clients self-report.
Title X Program Requirement 8.4.2. A schedule of discounts, based on ability to pay, is required for individuals with family incomes between 101% and 250% of the FPL (42 CFR 59.5(a)(8)).
Title X Program Requirement 8.4.3. Fees must be waived for individuals with family incomes above 100% of the FPL who, as determined by the service site project director, are unable, for good cause, to pay for family planning services (42 CFR 59.2).
Title X Program Requirement 8.4.4. For persons from families whose income exceeds 250% of the FPL, charges must be made in accordance with a schedule of fees designed to recover the reasonable cost of providing services. (42 CFR 59.5(a)(8)).
ii HRSA Policy Information Notice PIN 2014-02, “Sliding Fee Discount and Related Billing and Collections Program Requirements.” Individuals and families with annual incomes above 200 percent of the FPG are not eligible for sliding fee discounts. However, health centers may receive or have access to other funding sources (e.g., Federal, State, local, or private funds) that contain terms or conditions for reducing patient costs for specific services. These terms and conditions may apply to patients over 200 percent of the FPG. In such cases, it is permissible for a health center to allocate a portion (or all) of this patient’s charge to this grant or subsidy funding source.
iii Title X Program Requirement 8.4.5. Eligibility for discounts for unemancipated minors who receive confidential services must be based on the income of the minor (42 CFR 59.2).
iv Title X Program Requirement 8.4.8. Reasonable efforts to collect charges without jeopardizing client confidentiality must be made.
HRSA PIN 2014-02. Patient privacy and confidentiality must be protected throughout the (SFDS eligibility determination) process. The act of billing and collecting from patients should be conducted in an efficient, respectful and culturally appropriate manner, assuring that procedures do not present a barrier to care and patient privacy and confidentiality are protected throughout the process.
v Title X Program Requirement 8.4.3, repeated. Fees must be waived for individuals with family incomes above 100% of the FPL who, as determined by the service site project director, are unable, for good cause, to pay for family planning services (42 CFR 59.2).