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lotter on DSK11XQN23PROD with RULES3

Federal Register / Vol. 86, No. 192 / Thursday, October 7, 2021 / Rules and Regulations dignity of the individual; and ensures equitable and quality service delivery consistent with nationally recognized standards of care. These revisions were aimed at increasing access and ensuring equity in all services provided, which the Department believes is especially important for the Title X program with a statutory priority on serving lowincome clients. In addition, the Department believes that the revisions will result in improved services for clients.
Comments: The Department received numerous comments in support of this revised provision. Many comments expressed full support for the provision and urged the Department to adopt it as quickly as possible. Others expressed specific support for the requirement that services be client-centered: We support that the proposed rule names the importance of using client-centered models of care. Still others expressed specific support for the inclusion of QFP within the 2021 rule and the requirement that Title X services be consistent with nationally recognized standards of care. One comment said, The Proposed Rule will again base the standards of care for the Title X
program on the QFP guidelines and require that Title X clients receive highquality, client-centered care that includes comprehensive, medically accurate counseling and information, and referrals for any other services sought.
The Department received a few comments opposed to this provision.
One comment felt that requiring services to be client-centered, inclusive, and trauma-informed would create additional burden on applicants and providers to ensure equity within their programs. Another comment argued with the definition of client-centered care and believed that it violated conscience protections. Still another expressed concern that the requirement for equity in conjunction with the requirement for inclusivity would violate civil rights laws and the Constitution by giving certain classes of people preferential treatment.
Response: The Department appreciates the comments in support of this provision and agrees that providing services in a manner required by this provision will advance equity, increase access, improve outcomes for Title X
clients, and reinforce the longstanding requirement that services must be provided in a manner which protects the dignity of the individual. The Department disagrees that the requirements of this provision will result in additional burden for applicants or providers, rather the
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requirements of this provision simply ensure that all Title X services are of the highest quality and align with nationally recognized standards of care.
The Department also disagrees that the requirements of this provision violate conscience protections and provides a specific response to comments concerning conscience earlier in Section II. D. Application of Conscience Statutes in Title X. Finally, the requirements of this provision do not give preferential treatment to any clients, but rather aim to ensure that all people can actively participate in and benefit from family planning services. In conclusion, the Department adopts the language from the NPRM for 59.5a3 as final without revisions.
59.5a4. Services Do Not Discriminate Against any Client Based on Religion, Race, Color, National Origin, Disability, Age, Sex, Sexual Orientation, Gender Identity, Sex Characteristics, Number of Pregnancies, or Marital Status The NPRM proposed the same regulatory text for this provision as has been included in the 2000 regulations, which read Provide services without regard of religion, race, color, national origin, disability, age, sex, number of pregnancies, or marital status.
Comments: The Department received several comments regarding this provision and specifically expressing concerns with the phrase without regard of. Several comments expressed concern with the specific phrase and stated that if Title X providers are intended, as stated in the proposed rule, to work towards advancing health equity, it is imperative that care is delivered in a way that intentionally centers and considers the identity and needs of the patient. Several comments requested that the Department revise the provision to instead say provide services in a manner that does not discriminate against any patient based on religion, race, color, national origin, disability, age, sex, number of pregnancies, or marital status which they felt better supports health equity.
Response: The Department agrees with the comments and believes that revising the language as requested more clearly meets the intent of this provision, which is to prevent discrimination in the provision of services.
In addition, the Department is updating sex in 59.5a4 to include sexual orientation, gender identity, and sex characteristics consistent with the section 1557 of the Affordable Care Act, case law, Executive Order 13988 86 FR
7023, Jan. 25, 2021, and Departmental
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policy https www.hhs.gov/about/
news/2021/05/10/hhs-announcesprohibition-sex-discrimination-includesdiscrimination-basis-sexual-orientationgender-identity.html. In Bostock v.
Clayton County, 140 S. Ct. 1731 2020, the U.S. Supreme Court held that Title VII of the Civil Rights Act of 1964
prohibition on employment discrimination based on sex encompasses discrimination based on sexual orientation and gender identity.
Courts have now begun consistently interpreting similar languagebecause of sex in other statutes to encompass these protections. See Grimm v.
Gloucester Cty. Sch. Bd., 972 F.3d 586, 616617 4th Cir 2020 relying on Bostock to interpret Title IX as prohibiting policy prohibiting transgender student from using bathroom consistent with his gender identity. Moreover, as the Department of Justice has recently emphasized Discrimination against intersex individuals is similarly motivated by perceived differences between an individuals specific sex characteristics and their sex category either as identified at birth or some subsequent time . . . it is impossible to discuss intersex status without also referring to sex. Title IX justice.gov. As a result of the case law and Administration policy, the Department adds sexual orientation, gender identity, and sex characteristics to 59.5a4.11 The revised language for the 2021 rule for 59.5a4 is Provide services in a manner that does not discriminate against any client based on religion, race, color, national origin, disability, age, sex, sexual orientation, gender identity, sex characteristics, number of pregnancies, or marital status. This revised language is adopted as final.
59.5a8. Charges for Services With a Schedule of Discounts In the NPRM, the Department proposed revising section 59.5a8 of the 2000 regulations by including widely accepted billing practices from the 2014 Title X Program Requirements.
The NPRM text reads, Provide that charges will be made for services to clients other than those from lowincome families in accordance with a schedule of discounts based on ability to pay, except that charges to persons from families whose annual income exceeds 250 percent of the levels set forth in the most recent Poverty Guidelines issued pursuant to 42 U.S.C.
11 This language reflects requirements on Title X
projects principally engaged in healthcare activities under 42 CFR part 59. If grants for the production of informational materials were again to be made under PHSA 1005, this definition might not apply.

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