Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1696592724524.pdf (United States)
HRSA Technical Assistance Resource: Family Planning and Related Services in Health Centers December 27, 2022 Purpose This technical assistance resource (TAR) provides information related to the delivery of voluntary family planning and related services, which is a required primary health service under section 330(b)(1)(A) of the Public Health Service Act, for Health Resources and Services Administration (HRSA)-supported health centers.1 This resource: • Outlines related health center scope of project requirements and other Health Center Program requirements, and • Provides evidence-based recommendations and resources to support health centers to provide high quality family planning services, including how to address potential barriers to providing the full-range of family planning services.
Background HRSA supports health centers in their provision of comprehensive, culturally competent, and high- quality primary and preventive health services to underserved communities and populations through the Health Center Program, including voluntary family planning services.2 Quality family planning services are an important part of reproductive health care for women and families.
Family planning services include patient-centered counseling, contraceptive services, pregnancy testing and counseling, assisting patients who want to conceive, basic infertility services, preventive services to improve overall health, and screening and treatment for sexually transmitted diseases.

Ensuring access to family planning services, including access to the full range of Food and Drug Administration (FDA)-approved contraceptive methods, is an important strategy to help reduce unplanned pregnancy.
In 2017, the Centers for Disease Control and Prevention (CDC) and the Office of Population Affairs (OPA) updated the evidence-based recommendations for providing quality family planning services.

Quality family planning services assist women and their partners in achieving the number and spacing of children they desire and increase the likelihood that those children are born healthy.
1 For the purposes of this document, the term “health center” refers to entities that apply for or receive a federal award under section 330 of the PHS Act (including section 330 (e), (g), (h) and (i)), section 330 subrecipients, and organizations designated as look-alikes (sections 1861(aa)(4)(B) and 1905(l)(2)(B)(iii) of the Social Security Act).

2 For information on health center impact and performance data, visit Health Center Program Uniform Data System (UDS) Data.
HRSA Technical Assistance Resource: Family Planning and Related Services in Health Centers Health Center Scope of Project Health centers are required by the Health Center Program statute and implementing regulations to provide a set of primary and preventive health services, including supportive services such as health education, translation, care coordination, and transportation.
Health centers may provide additional health services as appropriate to meet the health needs of the population served by the health center, including certain specialty services.3 directly or through contracts or cooperative arrangements, also known as formal written referral arrangements.
They must make services available to all residents of the health center’s service area, regardless of patients’ ability to pay, and charge for services on a sliding fee scale.4 and level of these services will vary across health centers based on a number of factors that could include the specific needs of the population served, general unmet need in the community, and/or licensing requirements.
Health centers may provide required and additional health services The specific amount As described in the Form 5A: Service Descriptors, obstetrics, gynecology, and voluntary family planning services are among the primary and preventive health services health centers are required to provide.
The general elements of what comprise these required primary services are described in more detail below: • Voluntary family planning services: Delivery of voluntary family planning and related services is a required primary health service under section 330(b)(1)(A) of the Public Health Service Act for HRSA-supported health centers.
Voluntary family planning services are preventive health services that include: counseling on family planning options; contraceptive services, such as the full range of FDA-approved, -granted, or -cleared contraceptives; effective family planning practices; sterilization procedures that are determined by an individual and the individual’s medical provider to be medically appropriate; and management of patient care related to such services.
• Obstetrical services: Obstetrical services include the clinical assessment, management/treatment, and coordination of services and referrals to care for people planning pregnancy, during their pregnancy, during labor and delivery, and after they give birth.

Such services can be divided into three components: 1) prenatal; 2) intrapartum (labor and delivery); and 3) postpartum.

These services should be consistent with the individual health center provider's licensure, credentials, and privileging.
◦ Prenatal care includes regular screening (including labs and basic ultrasounds), ongoing monitoring of uterine and fetal growth, risk assessment, and counseling.

◦ Intrapartum care includes birthing care and care for the newborn during labor and birth and ongoing assessment and potential transfer to an appropriate delivery and/or postnatal care setting.

◦ Postpartum care includes postpartum checkup(s), along with appropriate follow-up treatment and education, for up to a year.
3 Review section 330(b)(1) for the list of Required Primary Care Services and (2) of the PHS Act (42 U.S.C.

254b(b)(1) and (2)) and 42 CFR 51c.102(h) and (j) for information on Additional Services.

4 More information on current Health Center Program Scope of Project policy, including service descriptors, is available at Scope of Project.
Page 2 of 6 HRSA Technical Assistance Resource: Family Planning and Related Services in Health Centers • Gynecological services: Gynecological services include pelvic and breast exams, cervical cancer screening, and the review of menstrual and reproductive history, gynecological symptoms, and basic gynecological ultrasounds.

Such services may also include common gynecological procedures required to ensure continuity of care for health center patients (e.g., colposcopy, hysterectomy, and fibroid removal).
Advanced gynecological services, such as gynecologic oncology, urogynecology, reproductive endocrinology, and infertility, are considered specialty services.

Health centers that wish to offer specialty services must seek HRSA approval to amend their scope of project by submitting a request to HRSA.
Pursuant to existing law and consistent with Executive Order 13535 (75 FR 15599), health centers are prohibited from using federal funds to provide abortions, except in cases of rape or incest or if the patient’s life is in danger.

Health Center Program Requirements Health centers must comply with all Health Center Program statutory and regulatory requirements, as well as all applicable federal, state, and local laws and regulations.
This includes protecting from disclosure patients’ personal health information regarding family planning services and related care pursuant to the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule.
Once a service is included in a health center’s scope of project, all Health Center Program requirements also apply,5 including ensuring that no patient is denied service based on inability to pay; providing sliding fee discounts consistent with the health center’s Sliding Fee Discount Program; and ensuring that all providers are properly credentialed and privileged to perform any services, activities, and procedures on behalf of the health center.
operations, including developing and implementing its own operating procedures, in compliance with all Health Center Program requirements and all other applicable federal, state, and local laws and regulations.6 Each health center is responsible for maintaining its It is the responsibility of the health center’s patient-majority governing board to approve the overall plan and budget for the health center, the hours of operation for the health center sites, as well as the selection of the services provided by the health center.
More information about health center requirements for services provided is available at Scope of Project.

Available Resources to Support Quality Family Planning Services There are numerous evidence-based recommendations, training, and other resources7 to support The following resources may assist health centers in health center provision of family planning services.
providing high quality family planning services, including providing access to contraceptive services and the full range of FDA-approved, -granted, or -cleared contraceptives, effective family planning practices, and sterilization procedures.

5 For further information on Health Center Program requirements, visit the Health Center Program Compliance Manual.

6 42 CFR 51c.304(d)(3)(v).


7 The information provided in this TAR includes hypertext links to information created and maintained by other public and private organizations.

Page 3 of 6 HRSA Technical Assistance Resource: Family Planning and Related Services in Health Centers Resources • HRSA supports the development and dissemination of preventive services guidelines for adolescents, young adults, and women through its Bright Futures Program and the Women's Preventive Services Initiative (WPSI).
HRSA's Bright Futures Program and WPSI aim to improve health outcomes for adolescents, young adults, and women by increasing the quality of primary and preventive care through the development, updating, and widespread use of age-specific, evidence-driven clinical guidelines.
Bright Futures recommends that pediatricians ask age-appropriate questions on patients’ sexual history, assess sexually transmitted infection and pregnancy risk, and provide appropriate screening, counseling, and, if needed, contraceptives to adolescents and young adults.
WPSI recommends adolescent and adult women have access to the full range of FDA- approved, -granted, or -cleared contraceptives, effective family planning practices, and sterilization procedures to prevent unintended pregnancies and improve birth outcomes.
WPSI recommendations include that contraceptive care should include contraceptive counseling, initiation of contraceptive use, and follow-up care (e.g., management, and evaluation as well as changes to and removal or discontinuation of the contraceptive method).

Most group health plans and health insurance issuers are required to cover the preventive services described in the HRSA-supported guidelines without cost sharing.8 For more information, see HRSA's WPSI Guidelines and Bright Futures Guidelines.
• HHS’ Know Your Rights: Reproductive Health Care resource provides information for individuals on their right to access care and where to find information.
• • CDC and OPA jointly published Providing Quality Family Planning Services (2017), a comprehensive resource with evidence-based recommendations regarding what services should be offered as part of comprehensive family planning, how to provide services with a patient-centered approach, and ways to leverage the family planning visit to address other primary and preventive health needs.

For more information, visit Quality Family Planning.

CDC provides contraceptive guidance for health care providers.
This includes guidance on what methods are safe for individuals with specific medical conditions and other characteristics (The United States Medical Eligibility Criteria for Contraceptive Use, 2016) and how to address common issues related to initiation and use of contraceptive methods (U.S.

Selected Practice Recommendations for Contraceptive Use, 2016).

For more information, visit CDC Contraceptive Guidance for Health Care Providers.
• OPA supports two training centers that provide training and technical assistance to family planning providers: ◦ The Reproductive Health National Training Center provides training, continuing education opportunities, and resources to support the delivery of high-quality reproductive health services.

8 Section 2713 of the Public Health Service Act, as added by the Patient Protection and Affordable Care Act (42 U.S.C.

300gg-13), available at: Affordable Care Act Implementation FAQs (Set 5).
Page 4 of 6 HRSA Technical Assistance Resource: Family Planning and Related Services in Health Centers ◦ The National Clinical Training Center for Family Planning delivers sexual and reproductive health training, technical assistance, and resources to Title X and other community-based providers to improve clinical skills and care delivery.
• The American College of Obstetricians and Gynecologists (ACOG) publishes recommendations on access to contraceptive services, including expanding access to Long-Acting Reversible Contraception (LARC) methods.

The resources include ACOG’s current clinical guidelines, patient education materials, and educational and training materials for health care professionals.

For more information, visit Long-Acting Reversible Contraception (LARC).
• The HHS Office of Minority Health has developed Culturally and Linguistically Appropriate Services (CLAS) in Maternal Health Care.

National CLAS standards are designed to improve the quality of services provided to all individuals.

The maternal health e-learning program is designed for providers and students seeking knowledge and skills related to cultural competency, cultural humility, person-centered care, and combating implicit bias across the continuum of maternal health care.
For more information, visit Home - Think Cultural Health.

Medicaid Family Planning Resources In addition, the Centers for Medicare and Medicaid Services (CMS) published the following guidance documents to clarify existing policy related to quality family planning services: • A State Health Official (SHO) Letter on Family Planning, released on June 14, 2016, regarding the delivery of family planning services.
The guidance clarifies policies that apply in both fee- for-service (FFS) and Medicaid managed care regarding contraceptive coverage, including the use of all FDA-approved methods of contraception, examples of utilization management methods, and guidance on family planning methods, including LARCs.

For more information, review SHO 16-008.


• An Informational Bulletin, released on April 8, 2016, describing emerging payment approaches several state Medicaid agencies have used to optimize access and use of LARC methods as part of the Center for Medicaid and CHIP Services (CMCS) Maternal and Infant Health Initiative.

For more information, visit CMSC Informational Bulletin: State Medicaid Payment Approaches to Improve Access to Long-Acting Reversible Contraception.
• The Medicaid Managed Care Final Rule, released on April 25, 2016, includes clarifications about family planning policies applicable to Medicaid managed care, including: the ability to receive services from a family planning provider without a referral; free choice of family planning method, including the prohibition of utilization management methods that restrict a beneficiary’s free choice of family planning method; and demonstration of a sufficient number of family planning providers within a Managed Care Organization to ensure timely access.
For more information, review Medicaid and CHIP Managed Care Final Rules.

• A letter to state governors, released August 26, 2022, to invite states to apply for Medicaid waivers to increase access to high quality reproductive health care and to remind governors of health providers’ obligation to comply with federal laws protecting access to emergency health care.
Page 5 of 6 HRSA Technical Assistance Resource: Family Planning and Related Services in Health Centers Other Resources HRSA also encourages health centers to seek training and technical assistance related to expanding and enhancing access to quality family planning services among their patient populations from HRSA-funded technical assistance partners.

These partners include: • National Training and Technical Assistance Partners • Primary Care Associations • Health Center Controlled Networks Page 6 of 6