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Federal Register / Vol. 86, No. 192 / Thursday, October 7, 2021 / Rules and Regulations
99022 will be made in accordance with a schedule of fees designed to recover the reasonable cost of providing services. i Family income should be assessed before determining whether copayments or additional fees are charged. ii With regard to insured clients, clients whose family income is at or below 250 percent FPL should not pay more in copayments or additional fees than what they would otherwise pay when the schedule of discounts is applied.
Comments: The Department received several comments on this provision specifically seeking closer alignment of HRSAs Health Resources & Service Administration Health Center Program authorized by Section 330 of the PHS
Act and OPAs Title X Program to minimize administrative burden for dually funded grantees. Specifically, one comment suggested modifying the proposed language in 59.5a8ii to include additional language about sliding fee discounts from the Health Center Program Compliance Manual that states that sliding fee discounts are subject to potential legal and contractual restrictions. Another comment lauded 59.5a8ii for ensuring that clients with family income at or below 250 percent FPL do not pay more than what they would otherwise pay under the schedule of discounts;
however, the comment expressed that this requirement violates insurance contracts and contradicts the guidance of other funders e.g., HRSA. Yet another comment expressed the need for additional guidance specific to Title X
grantees and subrecipients operating under the Health Center Program, to assist with alignment of billing practices.
Response: The Department fully supports minimizing administrative burden for grantees funded under both the Title X program and HRSAs Section 330 Health Center Program, recognizing that providers that dually participate in the two programs have been one of the fastest growing segments of the Title X
provider network. Similar to the Health Center Programs statutory requirement that health centers must operate in a manner such that no patient shall be denied service due to an individuals inability to pay, the Department also believes, and the Title X statute requires, that an individuals economic status shall not be a deterrent to participation in Title X program services. See PHS Act sec. 1006c. The Department does not believe that adding to this rule the commenters suggested language with respect to the Health Center Program Compliance Manual is warranted as it is taken out of context
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and does not state the statutory requirement. The Department believes that adding language requested in the comments could hinder Title X clients who qualify for sliding fee discounts from receiving the discounts, which is contrary to Title Xs mandate of prioritizing services to low-income clients. Further, OPA clarifies how Title X grantees may remain in compliance with Title X Program requirements when integrating services with HRSAs Health Center Program grantees and look-alikes in OPA Program Policy Notice: 201611: Integrating with Primary Care Providers.
Rather than revising the regulation and risk Title X clients not receiving all discounts for which they qualify, OPA
will continue to work closely with HRSA to ease administrative burden for grantees funded under both programs.
The Department will provide additional guidance and technical assistance to dually funded grantees aimed at reducing administrative burden. In conclusion, the Department adopts the language from the NPRM for 59.5a8
as final without revisions.
59.5a9. Reasonable Measures To Verify Client Income In the NPRM, the Department proposed adding a new section 59.5a9 to include one requirement from the 2014 Title X Program Requirements that grantees take reasonable measures to verify client income, and a new requirement that grantees use client self-reported income if the income cannot be verified after reasonable attempts. The Department believes that these proposed revisions will greatly improve accessibility and affordability of services for low-income clients consistently across all Title X
grantees.
The NPRM text reads, Take reasonable measures to verify client income, without burdening clients from low-income families. Recipients that have lawful access to other valid means of income verification because of the clients participation in another program may use those data rather than re-verify income or rely solely on clients selfreport. If a clients income cannot be verified after reasonable attempts to do so, charges are to be based on the clients self-reported income.
Comments: The Department received several comments supporting the use of self-reported income. Comments received from members of the House of Representatives stated, We support the Departments stance that patients be allowed to self-report their income, removing an unnecessary potential barrier to care. Other comments
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expressed support that cost should not be a barrier to receiving services. Still other reaffirmed support that allowing use of self-reported income will greatly improve accessibility and affordability for low-income and uninsured patients seeking care from Title X program grantees. One comment felt that the provision did not go far enough and asked that the language explicitly state that a clients self-reported income is sufficient, and that providers do not need to verify client income.
The Department also received several comments on this provision specifically seeking closer alignment between Title X and HRSAs Health Center Program authorized by Section 330 of the PHS
Act to minimize administrative burden for dually funded grantees. Several comments felt that allowing a clients self-reported income in cases where a clients income cannot be verified despite reasonable attempts is inconsistent with the Health Center Program guidance. Comments reported that health centers have broad discretion to determine the appropriate means to assess patient income and family size. While allowing selfdeclaration is typical in the health center program, some health centers have opted to adopt a policy establishing that self-declaration, without supporting documentation, is not an acceptable means to verify income for every patient.
Response: The Department appreciates the supportive comments and agrees that the requirements in this provision will greatly improve accessibility and affordability of services for low-income clients consistently across all Title X grantees.
The elimination of barriers to Title X
services for low-income clients is important to the Title X program. The Department disagrees that the requirements in 59.5a9 are not compatible with HRSAs guidance.
HRSA requires health centers to operate in a manner such that no patient shall be denied service due to an individuals inability to pay; further, HRSA Health Center Program grantees are required to establish systems for sliding fee scale eligibility that comply with statutory requirements under section 330 of the PHS Act and regulatory requirements under 42 CFR 51c.303f and 56.303f, which do not preclude self-declaration of income and family size. The Department believes that the HRSA
Health Center Program requirements are fully consistent with the language in 59.5a9. A strict standard of income verification at a particular health center is a choice that does not warrant weakening a standard in Title X that the
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