In recent policy guidance, the U.S. Department of Health and Human Services’ Health Resources and Services Administration (HRSA) has included “civil legal aid services” as an example of eligibility assistance and additional enabling/supportive services that community health centers may provide to meet the primary care needs of the population and communities they serve.

Section 330 of the Public Health Service Act (the authorizing legislation of the health center program) requires community health centers to provide not only primary care services, but also certain non-medical services, including eligibility assistance services.  Guidance that accompanies HRSA’s Form 5A Services Provided (Services Descriptors for Form 5A: Services Provided) explains that eligibility assistance services are intended to provide “support to health center patients to establish eligibility for and gain access to appropriate federal, state and local programs that provide or financially support the provision of medical, social, educational, housing, or other related services (e.g., Medicaid, Veteran’s benefits, [SNAP, and] Legal Aid.)”[1]

This guidance goes on to state that “legal services/legal aid” are also included in the description of the optional “additional enabling/supportive services” that health centers may (but are not required to) provide, using grant funds provided under Section 330.  Such services are not clinical in nature, but “multiple studies show better access to primary and preventive care among health center patients relative to their non-health center counterparts, with enabling services highlighted as a significant contributor to that difference.”[2]  They “support a health center patient’s access to social, educational, or other related services (e.g., child care, food banks/meals, employment and education counseling, legal services/legal aid).”[3]

You may wonder how civil legal aid services can improve, or enable, patient health.  Imagine a child who struggles with chronic asthma.  Despite the provider’s best efforts to control the asthma through the use of long-term control medications, emergency inhalers, and allergy medication, the child continues to suffer with asthma attacks multiple times a week, and often during the night, which affects his schoolwork due to interrupted sleep.  The provider knows that the child lives in a run-down apartment building and suspects that there may be environmental factors contributing to the child’s asthma, but is not sure what, if anything, she can do about it.

Enter medical-legal partnerships (MLPs).  MLPs pair health care providers with legal professionals to improve the health of health center patients.  In the example provided above, the health care provider can refer her patient to the health center’s legal partner, so that the legal partner can pressure the patient’s landlord to clean out the apartment’s mold, which will improve the health of the asthmatic child living in the apartment.  Other examples of civil legal aid services include legal aid professionals working with a child’s school to develop supports to help that child with his educational goals or contesting utility shut-off in order to keep patients warm and their medications refrigerated.

Given HRSA’s guidance as to what activities qualify as eligibility assistance and enabling services, community health centers may now have an opportunity to use Section 330 grant funds to support the development of MLPs.  Health centers are in an excellent position to work with civil legal aid agencies given the overlap of the missions of and communities served by each partner.  In addition, health centers seeking to strengthen their patient centered medical home efforts would likely benefit from including a legal expert familiar with the social determinants of health on the medical home care team.  At least 72 HRSA-funded health centers across the country already participate in MLPs, as do 135 hospitals and 55 community clinics.

To cultivate and support community health center participation in MLPs, HRSA has awarded the National Center for Medical-Legal Partnership (NCMLP) a three-year National Cooperative Agreement.  Of course, as is the case with any affiliation, health centers should consult with qualified legal counsel to consider the complex legal issues involved in establishing an MLP, such as creating Memorandums of Understanding between the partners, how to properly share medical and legal information, and how to ensure compliance with Section 330 requirements and other federal legal considerations, including potential exposure under the civil monetary penalty laws related to beneficiary inducements enforced by the Office of Inspector General (OIG).[4]  As health centers explore the possibility of forming MLPs, they should bear in mind that the civil legal aid language is currently found only in the Form 5A service descriptors guidance, not in statute or regulation.  Thus, while it appears that HRSA has determined that the use of Section 330 grant funds to support MLPs may be acceptable (provided that legal services/legal aid have been approved by HRSA and included in the health center’s scope of project as additional enabling services), it is unclear at this time as to whether other regulatory agencies, such as the OIG, would be bound by HRSA’s interpretation and approval.

[1] HRSA’s Form 5A Services Provided (Services Descriptors for Form 5A: Services Provided), page 16.

[2] Association of Asian Pacific Community Health Organizations (AAPCHO) & National Association of Community Health Centers (NACHC), Highlighting the Role of Enabling Services at Community Health Centers: Collecting Data to Support Service Expansion & Enhanced Funding, 2010(5), available at http://www.nachc.com/client/Enabling_Services.pdf.

[3] HRSA’s Form 5A Services Provided (Services Descriptors for Form 5A: Services Provided), page 23.

[4] 42 U.S.C. § 1320a-7a.