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Federal Register / Vol. 86, No. 192 / Thursday, October 7, 2021 / Rules and Regulations provided in-person or via telehealth and had specifically stated in the NPRM that the Department was readopting the 2000 regulations with revisions that will enhance the Title X program and its family planning services, including family planning services provided using telemedicine, for the future. Telehealth has played a critical role for Title X in responding to the COVID19 pandemic.
By utilizing telehealth modalities, Title X grantees were able to continue to provide essential family planning services throughout the pandemic. With the onset of COVID19, the vast majority of Title X grantees transitioned to some form of telehealth service delivery in order to continue providing services while limiting contact between individuals and protecting client safety.
Telehealth was commonly used by Title X grantees for non-urgent visits that did not require a physical exam. Of importance, more than half of the grantees that were able to deliver telehealth during COVID19 reported to OPA in their progress reports that they intended to continue offering telehealth services even after the pandemic ends, due to the advantages for both clients and staff.
Given the comments received, the Department believes that it is important to include language specifically in the regulatory text to clarify that telehealth services also constitute appropriate service delivery. The Department also agrees with the request to use the term telehealth rather than telemedicine to be clear that telehealth services include non-clinical services like counseling and education. While cognizant that synchronous telehealth services may be delivered through different modes of technology and that audio-only modalities may mitigate access barriers, particularly for those with limited internet and/or cellular data, the Department does not agree that the regulatory text needs to be so specific to reference the use of audioonly modalities, especially given how rapidly technology can change. Instead, the Department will provide additional training and technical assistance to grantees on the use of various telehealth modalities to improve access, quality, and equity.
With the revisions noted above, the revised language of 59.5b1 for the 2021 rule is, Provide for medical services related to family planning including consultation by a clinical services provider, examination, prescription, and continuing supervision, laboratory examination, contraceptive supplies, in person or via telehealth, and necessary referral to other medical facilities when medically
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indicated, and provide for the effective usage of contraceptive devices and practices. This revised language for 59.5b1 is adopted as final.

respond to the comment received. In conclusion, the Department adopts the language from the NPRM for 59.5b3
as final without revisions.

59.5b3 Community Education, Participation, and Engagement In the NPRM, the Department proposed revising section 59.5b3 of the 2000 regulations to reflect the desire to engage diverse individuals to make services accessible. Specifically, the NPRM stated, Provide for opportunities for community education, participation, and engagement to: i Achieve community understanding of the objectives of the program; ii Inform the community of the availability of services; and iii Promote continued participation in the project by diverse persons to whom family planning services may be beneficial to ensure access to equitable, affordable, clientcentered, quality family planning services. The revision added language to clarify the intent to engage diverse individuals to ensure access to equitable, affordable, client-centered, quality family planning services.
Comments: The Department received one comment expressing support for 59.5b3, especially emphasizing the importance of the participation and engagement of diverse individuals in making family planning services accessible, equitable, and clientcentered. The Department received one comment asking that the language of 59.5b3 be revised to be clear that the needs of adolescents and young adults are included in community education, participation, and engagement.
Response: The Department appreciates the comments in response to this provision. Community education, participation, and engagement are important for Title X projects because they help ensure that the community is aware of the Title X program and the services available. In addition, community participation and engagement are critical to helping Title X providers better understand and center the needs and experiences of the community and the clients served.
Together, community education, participation, and engagement are foundational for ensuring access, equity, and quality through the provision of Title X services.
In response to the one comment requesting a revision to the provision, the Department believes that the proposed regulatory text is broad and already includes the needs of adolescents and young adults as currently written. The Department does not believe that additional revisions are needed to the regulatory text in order to
59.5b6 Services Under Direction of Clinical Services Provider The NPRM proposed the same regulatory text for this provision as has been included in the 2000 regulations, which read, Provide that family planning medical services will be performed under the direction of a physician with special training or experience in family planning.
Comments: The Department received numerous comments requesting revisions to the regulatory text for this provision. Comments requested that the regulation expand beyond physicianonly directed services. Several comments requested that the text be revised to be consistent with the revisions to 59.5b1, which recognized the importance of a broader range of healthcare providers, in addition to physicians, in providing family planning services. Several comments requested revisions to expand direction of family planning services to very specific types of healthcare providers. One comment asked that the language clarify that nurse practitioners have the authority to direct family planning programs.
Another comment asked that the language be revised from physician to licensed healthcare provider. Still another asked that this section be revised to specifically authorize physician assistants to direct family planning services.
Several other comments were specific to advanced practice registered nurses APRNs and asked that the language specify that APRNs be able to serve as the medical director in states with full practice authority. One commenter pointed out that while state licensure rules vary, many states have granted full practice authority to APRNs, enabling independent practice. Another comment requested that the Department consider whether registered nurses could direct family planning services especially in areas of provider shortage. A final comment asked for the text to be amended to allow services provided under the direction of an advanced practice clinician, if the services offered are within their scope of practice and if allowable under state law.
Response: Given the comments received, the Department agrees that having consistency between 59.5b1
and 59.5b6 is important to more clearly reflect the role of a broader range of healthcare providers in providing
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