Overview, Goals, and Objectives
The Pennsylvania Department of Human Services (Department) is making available for public review and comment the proposed
Federal Section 1115 Demonstration application, entitled Bridges to Success: Keystones of Health for Pennsylvania (Keystones of Health), which proposes Medicaid Coverage for Health-Related Social Needs (HRSNs), reentry supports, and multiyear continuous eligibility for young children.
The purpose of this demonstration is to further the objectives of Medicaid to expand access to care, improve health outcomes, drive innovation, and engage partners and communities through targeted, time-limited interventions to address HRSNs.
The goals of this demonstration are to:
1. Address Pennsylvania's Medicaid beneficiaries' HRSNs, such as food and housing, to improve health outcomes and quality of life with interventions that are both lifesaving and cost saving.
2. Provide HRSN services to support beneficiaries, especially those experiencing life transitions, to reduce avoidable hospitalizations and medical utilization and increase recommended or preventive care.
3. Reduce churn and gaps in coverage for children enrolled in Medicaid.
4. Expand Medicaid coverage to improve services to beneficiaries as they prepare to leave incarceration and provide continued support as beneficiaries transition back into the community.
Under Keystones of Health, services are proposed to be provided in the following areas:
-
Reentry from correctional facilities: Improve transitions to the community for beneficiaries reentering society from correctional facilities. The available services, which will require a legislative amendment, will focus on improving transitions to community-based health care and social services with a particular emphasis on those with significant health care needs such as serious mental illness and substance use disorder. The demonstration will also provide continuous eligibility for 12 months after release.
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Housing supports: Add new Medicaid services to help beneficiaries without stable housing find and keep a place to live. Having stable housing makes it easier to find and use health care. These services will focus on beneficiaries with behavioral health issues and chronic conditions where health outcomes are greatly impacted by improved consistency of care and medication access.
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Food and nutrition supports: Provide food and nutrition services to specific Medicaid populations facing food insecurity, including pregnant beneficiaries and beneficiaries with diet-sensitive conditions. Services would include direct food support such as medically-tailored meals or groceries with a goal of also connecting eligible beneficiaries to long-term food assistance, like the Supplemental Nutrition Assistance Program (SNAP).
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Multi-year continuous coverage for children under 6 years of age: Provide continuous Medicaid coverage for children from birth or older but under 6 years of age to reduce gaps in coverage that interrupt access to essential health care services, such as preventive care. This proposal provides eligibility from birth, or when a child first receives Medicaid, through the last day of the month in which they turn 6 years of age. This proposal will make it easier for children to get the important early childhood health care they need.
The 1115 Demonstration application is available at dhs.pa.gov/Keystones-of-Health. In addition, copies of the application are available upon written request to:
Department of Human Services
Office of Medical Assistance Programs
c/o Regulations Coordinator
P.O. Box 2675, Harrisburg, PA 17120
Eligible Beneficiaries and Proposed Services
The services provided under Keystones of Health will be in addition to the services provided through the Medicaid State Plan Most services will be provided through Pennsylvania's managed care programs, collectively known as HealthChoices, which provide physical and behavioral health care, as well as LTSS, through managed care organizations (MCOs). Managed care enrollment is mandatory for most Medicaid populations. Beneficiaries receiving services in the fee-for-service (FFS) delivery system, including those who are in FFS as they transition to managed care, will also be able to access HRSN services.
This demonstration affects all eligibility groups under the State Plan (Table 1) through the provision of additional services.
Eligibility Group |
Federal Citations |
Income Level (% of FPL) |
Children aged 18 and under | 42 CFR §435.118 | Up to 341% |
Pregnant women | 42 CFR §435.116 | Up to 215% |
Parents and care takers of children under 21 | 42 CFR §435.116 | Up to 133% |
Adults ages 19-64 | 42 CFR §435.119 | Up to 133% |
Individuals who are aged (65 and older), blind, or disabled | 42 CFR §435.121-435.138 | Varies by program |
Medical assistance for workers with disabilities | 1902(a)(10)(A) (ii)(XVI) and 1905(v)(2) | Up to 250% |
Individuals receiving long-term care or home and community based services | 42 CFR §435.725, 435.733, 435.832 | Up to 300% |
Table 1: Existing Medicaid eligibility groups affected by the demonstration
The demonstration will not restrict any existing eligibility, rather it will expand the eligibility of justice-involved individuals. This demonstration will provide coverage and limited benefits for incarcerated adults who are preparing for release and meet criteria for being high risk as defined in the table below. Eligibility will be determined through existing State Plan processes and eligibility criteria, and only include those who would be otherwise eligible if not incarcerated.
Eligibility Group |
Program or Policy Change |
Incarcerated individuals who are preparing for release and meet one or more of the following criteria for high risk: - Have one or more substance use disorders
- Have serious mental illness
- Eligible for Medicaid funded 1915(c) home and community based services administered by the Office of Long Term Living or Office of Developmental Programs upon release
- With one or more chronic health conditions
- Are pregnant or in the 12-month post-partum period
| Coverage and limited benefits 90 calendar days prior to release |
Individuals following release from correctional settings and meet one or more of the following criteria for high risk: - Have one or more substance use disorders
- Have serious mental illness
- Eligible for Medicaid funded 1915(c) home and community based services administered by the Office of Long Term Living or Office of Developmental Programs
- With one or more chronic health conditions
- Are pregnant or in the 12-month post-partum period
| Continued reentry supports following release as described in Table 3 |
Table 2: Expansion eligibility groups requested under the demonstration
DHS seeks to provide continuous 12-month enrollment for beneficiaries following reentry from correctional settings, regardless of changes in circumstances that would otherwise cause a loss of eligibility. This continuous 12-month enrollment applies to beneficiaries identified in Table 2 following release. This change will stabilize coverage, increase access to primary and preventive services, and preserve participants' continuity in access to ongoing care during a time of transition. The continuous eligibility period will begin on the release date and expire 12 months later at the end of the month.
DHS also requests the ability to provide continuous enrollment for children from birth through the end of the month in which their sixth birthday falls, regardless of when they first enroll in Medicaid, and regardless of changes in circumstances that would otherwise cause a loss of eligibility. This demonstration request will end churn among young Medicaid-enrolled children and better address their primary and preventive health care needs. Children must meet the existing eligibility criteria when they first enroll.
Under the demonstration, DHS will not impose any new cost sharing requirements for services. DHS is also seeking to waive all existing cost-sharing requirements in the State Plan for incarcerated beneficiaries prior to release.
Medicaid beneficiaries will qualify for services outlined in this demonstration based upon their medical need for services and an identified social need. For reentry supports, incarceration qualifies as the social need. Additional screening during case management will connect the individual to the most appropriate services. For Food and Housing Supports, DHS will develop a new core HRSN assessment tool based on existing assessments in use within Pennsylvania.
Population |
Services |
Incarcerated individuals who are preparing for release and have one or more substance use disorders | - Case management
- Medication Assisted Treatment (MAT)
- 30-day supply of all prescription medications on release
- Housing and tenancy supports
Benefit does not include: -
Routine medical care provided while in custody
-
Full State Plan benefit package while in custody
|
Individuals following release from correctional settings who have one or more substance use disorders | - Case management
- Housing and tenancy supports
- Note: MAT will be provided under the State Plan, not the demonstration authority
- Other HRSN supports as indicated in the following tables for beneficiaries with substance use disorders
|
Incarcerated individuals who are preparing for release and have serious mental illness | - Case management
- 30-day supply of all prescription medications on release
- Housing and tenancy supports
Benefit does not include: -
Routine medical care provided while in custody
-
Full State Plan benefit package while in custody
|
Individuals following release from correctional settings who have serious mental illness | - Case management
- 30-day supply of all prescription medications on release
- Housing and tenancy supports
- Other HRSN supports as indicated in the following tables for beneficiaries with serious mental illness
|
Incarcerated individuals who are preparing for release and will be eligible for Medicaid funded 1915(c) home and community based services administered by the Office of Long Term Living or Office of Developmental Programs upon release | - Case management
- 30-day supply of all prescription medications on release
- Housing and tenancy supports
Benefit does not include: -
Routine medical care provided while in custody
-
Full State Plan benefit package while in custody
|
Individuals following release from correctional settings who are eligible for home and community based services | - Case management
- 30-day supply of all prescription medications on release
- Housing and tenancy supports
|
Incarcerated individuals who are preparing for release with one or more chronic health conditions | - Case management
- 30-day supply of all prescription medications on release
- Housing and tenancy supports
Benefit does not include: -
Routine medical care provided while in custody
-
Full State Plan benefit package while in custody
|
Individuals following release from correctional settings who have one or more chronic health conditions | - Case management
- 30-day supply of all prescription medications on release
- Housing and tenancy supports
- Other HRSN supports as indicated in the following tables Table 4, Table 5 for beneficiaries with
|
Incarcerated individuals who are preparing for release who are pregnant or in the 12-month post-partum period | - Case management
- 30-day supply of all prescription medications on release
- Housing and tenancy supports
Benefit does not include: -
Routine medical care provided while in custody
-
Full State Plan benefit package while in custody
|
Individuals following release from correctional settings who are pregnant or in the 12-month post-partum period | - Case management
- 30-day supply of all prescription medications on release
- Housing and tenancy supports
- Other HRSN supports as indicated in tables Table 4, Table 5 for pregnant and post-partum beneficiaries
|
Table 3: Proposed populations by reentry service
Proposed populations by Housing service
Population |
Services |
Individuals experiencing homelessness who also have serious mental illness or substance use disorder | - Pre-tenancy and transition navigation and case management, including connection to housing specialists
- One-time transition start-up services (moving costs, initial furnishings)
- Rental subsidies for up to six months
- Tenancy sustaining services
|
Individuals experiencing homelessness who also have a chronic health condition | - Pre-tenancy and transition navigation and case management, including connection to housing specialists
- One-time transition start-up services (moving costs, initial furnishings)
- Rental subsidies for up to six months
- Tenancy sustaining services
|
Individuals experiencing homelessness who are pregnant or in the post-partum period | - Pre-tenancy and transition navigation and case management, including connection to housing specialists
- One-time transition start-up services (moving costs, initial furnishings)
- Rental subsidies for up to six months
- Tenancy sustaining services
|
Individuals transitioning from corrections facilities who are homeless or at risk of homelessness | - Pre-tenancy and transition navigation and case management, including connection to housing specialists
- One-time transition start-up services (moving costs, initial furnishings)
- Rental subsidies for up to six months
- Tenancy sustaining services
|
Table 4: Proposed populations by housing service
Proposed populations by Food and Nutrition service
Population |
Services |
Individuals experiencing food insecurity or with a history of food insecurity who are pregnant or in the post-partum period (and their household) | - Grocery delivery/food boxes for pregnant beneficiaries for six months (includes their children under age 18 who reside in the same household)
- Ongoing nutrition assistance navigation and application support
|
Individuals experiencing food insecurity or with a history of food insecurity who have a diet-sensitive condition | - Medically tailored meals and/or groceries for adults with diet sensitive conditions for six months
- Ongoing nutrition assistance navigation and application support
|
Table 5: Proposed populations by food and nutrition service
Public Hearing Schedule
The Department will hold three virtual public hearings to receive comments regarding the proposed Demonstration. The Department will also receive comments on the Demonstration application at the Income Maintenance Advisory Council meeting on December 5, 2023, the Medical Assistance Advisory Committee meeting on December 7, 2023, and the Information Sharing and Advisory Committee Hub meeting on December 12, 2023.
The public hearings will be held as follows:
December 11, 2023, from 12:00 p.m. to 1:00 p.m.
This meeting has already occurred.
December 12, 2023, from 6:00 p.m. to 7:00 p.m.
This meeting has already occurred.
December 15, 2023, from 9:00 a.m. to 10:00 a.m.
This meeting has already occurred.
Please register to participate virtually. When you register, there will be an option to add the Public Forum to your calendar. Registration is not necessary to join by phone. Closed captioning will be provided during each public forum.
DHS is also consulting existing DHS advisory groups and meeting with additional stakeholders in the public comment period:
Medical Assistance Advisory (MAAC) Managed Care Subcommittee
December 4, 2023, from 11:00 a.m. to 10:00 a.m.
This meeting has already occurred.
Income Maintenance Advisory Committee (IMAC)
December, 5, 2023, from 1:00 p.m. to 4:30 p.m.
This meeting has already occurred.
MAAC Consumer Subcommittee
December 6, 2023, from 1:00 p.m. to 3:00 p.m.
This meeting has already occurred.
MAAC
December 7, 2023, from 10:00 a.m. to 12:00 p.m.
This meeting has already occurred.
Information Sharing and Advisory Committee (ISAC)
December 12, 2023, from 10:30 a.m. to 11:00 a.m.
Full details of how DHS will seek input are available on the
Public Input Process page.
Public Comment
The Department seeks public input on the proposed 1115 Demonstration application for Medicaid coverage of HRSNs, reentry supports, and multiyear continuous eligibility for young children. The 30-day public comment period will take place from December 2, 2023, through January 2, 2024.
Individuals may submit written comments through:
https://tinyurl.com/KeystonesofHealthComments
by email to: RA-PWMAProgComments@pa.gov
by mail to:
Department of Human Services
Office of Medical Assistance Programs
c/o Regulations Coordinator
P.O. Box 2675, Harrisburg, PA 17120
Persons with a disability who require an auxiliary aid or service may submit comments using the AT&T Relay Service at 1-800-654-5984 (TDD users) or 1-800-654-5988 (voice users).
The Department will consider all comments received by January 2, 2024, in developing the final Demonstration application.
1115 Waiver Estimates of Proposed Annual Enrollment and Annual Aggregate Expenditures and Financial Analysis of Proposed Initiatives.
A summary of annual and aggregate projected demonstration enrollment and expenditure data is provided in the tables below. Note that not all Medicaid expenditures are captured in these tables. For example, Commonwealth administrative expenditures and expenditures for populations or services excluded from the 1115 waiver are not included. The expenditure data for these estimates is limited to expenditures that will be considered as part of the 1115 waiver budget neutrality and projected new expenditures where data and estimates are currently available. Demonstration projections are approximations based on assumptions used for the purpose of the waiver planning. Demonstration estimates, including financing and budget neutrality assumptions, will continue to evolve throughout the course of the waiver application process and as new budget data becomes available. The impact of the ending of the PHE may impact these projections.
|
DY1 CY 2025 |
DY2 CY 2026 |
DY3 CY 2027 |
DY4 CY 2028 |
DY5 CY 2029 |
Five Year Total |
CE 0-6 Expenditures | $189M | $372.5M | $416.5M | $431.5M | $446.5M | $1,856M |
Members Impacted | 340,000 | 415,000 | 450,000 | 450,000 | 450,000 | 450,000 by DY 5 |
CE Reentry Expenditures | $0 | $13.5M | $51M | $56.5M | $62.5M | $183.5M |
Members Impacted | 0 | 7,250 | 27,700 | 27,700 | 27,700 | 27,700 by DY 5 |
Reentry Services | $0 | $47.9M | $142.8M | $144.7M | $146.7M | $482.1M |
Members Impacted | 0 | 7,250 | 27,750 | 27,750 | 27,750 | 90,500 |
HRSN Food and Nutrition Supports | $0 | $45.1M | $72.8M | $60.4M | $42.2M | $220.5M |
Members Impacted | 0 | 15,100 | 23,900 | 19,500 | 13,700 | 72,200 |
HRSN Housing Supports | $0 | $30.1M | $54M | $61.9M | $56.6M | $202.6M |
Members Impacted | 0 | 1,000 | 1,800 | 2,100 | 1,800 | 6,700 |
HRSN Food, Nutrition and Housing Supports Infrastructure Investments* | $12.8 | $12.8M | $12.8M | $12.8M | $0 | $51.2M |
Reentry Supports Infrastructure Investments* | $18.1M | $18.1M | $18.1M | $18.1M | $0 | $72.4M |
Total Expenditures | $219.9M | $540.0M | $768.0M | $785.9M | $754.5M | $3068.3M |
Table 6 Projected Expenditures and Enrollment for Demonstration Proposals
* Infrastructure support funding by year will be refined based on planning and implementation.
Evaluation and Hypotheses
DHS will test the following research hypotheses through the section 1115 demonstration:
- Addressing unmet HRSN within the Medicaid-eligible population will improve health outcomes and reduce the cost of care.
- A focus on health equity improvements for specific populations that have experienced disproportionately poor health outcomes will result in improved health outcomes, increased access to care, and a reduction in the gap between outcomes for populations of focus and those that have historically experienced favorable health outcomes.
- HRSN services designed to support individuals experiencing life transitions will result in a reduction in avoidable hospitalizations and medical utilization (e.g., lower emergency department (ED) use, lower avoidable ED visits) and an increase in recommended or preventive care.
- Access to pre-release services will result in increased use of recommended and/or preventive care, resulting in positive impacts on health outcomes.
- Implementation of pre-release services will result in increased collaboration between stakeholders, identification of medical needs and HRSN prior to release, gradual expansion of access to pre-release services for justice-involved individuals, and improved insights into healthcare delivery for this population.
- Expanded housing supports will reduce homelessness, homeless recidivism, and housing instability of individuals.
- Improvements in housing stability will improve access to recommended and/or preventive care.
- Implementation of nutrition supports will result in increased collaboration between stakeholders, gradual expansion of access to nutrition services for participating individuals, and improved infrastructure for the provision of nutrition support services.
- Nutrition support services will result in reductions in food insecurity and improved disease management for participating individuals.
- Continuous coverage will reduce churn and gaps in coverage for children enrolled in Medicaid, including for racial and ethnic minority populations that experience disproportionately high rates of churn.
- Continuous coverage will reduce the quantity of redeterminations, resulting in lower administrative burden for eligibility workers and associated costs.
- Continuous coverage will increase utilization of preventive care services including vaccinations and reduce potentially avoidable services, such as inpatient hospitalizations and non-emergency use of emergency departments.
Waiver authorities
Under the authority of Section 1115(a)(1) of the Act, the following waivers shall enable Pennsylvania to implement this Section 1115 demonstration for five years following approval.
Waiver Authority |
Use for Waiver |
1902(a)(1) Statewideness | To enable the state to limit reentry services to state prisons and qualified county correctional facilities. To allow managed care plans or types of managed care plans only in certain geographic areas. |
1902(a)(8) Reasonable Promptness | To allow the state to create service caps and the potential use of waiting lists for Housing and Food and Nutrition services. |
1902(a)(10)(B) 1902(a)(17) Amount, Duration, and Scope and Comparability | To enable the state to provide a varying amount, duration, and scope of HRSN services to a subset of beneficiaries depending on need, which are not otherwise available to all beneficiaries in the same eligibility group.
To the extent necessary to enable the state to limit housing services and supports under the demonstration to certain targeted groups of participants. |
1902(a)(14)
1916 and 1916A Premiums and Cost Sharing | To enable the state to waive existing cost-sharing requirements in the State Plan for incarcerated beneficiaries prior to release. To enable the state to waive copays on prescription medications in the 30-day supply of medications provided on release. |
Table 7: Pennsylvania waiver authorities for the demonstration
Expenditure authorities
The table below lists the expenditure authorities the Commonwealth is seeking to support the demonstration policies.
Policy |
Use for Expenditure Authority |
Expenditures related to the continuous enrollment of children | Provide continuous State Plan enrollment for children until the end of the month of their sixth birthday (under six years of age) without regard to whether their income or assets exceed eligibility limits as described in Section II. |
Expenditures related to the continuous enrollment of individuals following incarceration | Provide continuous State Plan enrollment for formerly incarcerated beneficiaries for 12-months following release from the correctional setting without regard to whether their income exceeds eligibility limits as described in Section II. |
Expenditures Related to Waiver Implementation | Expenditure authority to support demonstration implementation capacity at the community level, including payments to qualified entities for infrastructure and capacity building, as well as for interventions and services that will enable implementation of the demonstration benefits and complement the array of benefits and services authorized through the State Plan and other related authorities. |
Expenditures Related to Reentry Supports | Expenditures for certain services rendered to incarcerated beneficiaries 90 calendar days prior to their release, including case management, as appropriate; and community based physical and behavioral health clinical consultation services provided via telehealth or, optionally, in-person as needed. In addition, services will include a 30-day supply of medication for use post-release into the community. |
Expenditures Related to Food and Nutrition Services | Expenditures for food and nutrition services not otherwise covered provided to beneficiaries who meet the qualifying criteria as described in Changes to benefits by population in Section III. |
Expenditures Related to Housing Services | Expenditures for housing services not otherwise covered provided to beneficiaries who meet the qualifying criteria as described in Changes to benefits by population in Section III. |
Table 8: Pennsylvania expenditure authorities for the demonstration