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Bridges to Success:
Keystones of Health for Pennsylvania

DHS’ mission is to help all Pennsylvanians live healthy, enriching, and vibrant lives. As part of this work, DHS seeks to use its Medicaid program to offer targeted supports and services to certain Pennsylvanians through Bridges to Success: Keystones of Health for Pennsylvania (Keystones of Health). 

Social determinants of health can be more influential on a person’s health and quality of life than clinical care. DHS hopes to use this program to make health care more accessible, improve quality of care and services, and test new strategies in health care to help people live healthier lives. This program is under development and services and populations are subject to change.

Keystones of Health aims to address the health care needs of Pennsylvanians in four main areas: Reentry Supports, Housing Supports, Food and Nutrition Supports, and Continuous Coverage for Children Under Age Six. 

Submitted Section 1115 demonstration waiver application

The Pennsylvanian Department of Human Services submitted our Section 1115 demonstration waiver application, titled “Bridges to Success: Keystones of Health for Pennsylvania” to the Centers for Medicare & Medicaid Services on January 26, 2024. Below are copies of what was submitted:

Sections on this page:

By improving support in these areas, we can help people to get and stay healthier while reducing health care costs.

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Non-Discrimination and Accessibility Information

DHS complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, creed, religious affiliation, ancestry, gender, gender identity or expression, or sexual orientation.

DHS does not exclude people or treat them differently because of race, color, national origin, age, disability, creed, religious affiliation, ancestry, gender, gender identity or expression, or sexual orientation.

DHS provides free aids and services to people with disabilities to communicate effectively with us, such as: 

    • Qualified sign language interpreters 
    • Written information in other formats (large print, audio, accessible electronic formats, other formats) 

DHS provides free language services to people whose primary language is not English, such as: 

    • Qualified interpreters 
    • Information written in other languages 

If you need these services, contact DHS at: 

  • Telephone: 1-866-872-8969 — choose Option #1 for English, Option #2 for Spanish, Option #3 for Vietnamese, Option #4 for Cambodian, Option #5 for Russian, Option #6 for Mandarin Chinese, or Option #7 for a sign language interpreter and leave a detailed voice mail message.
  • TDD/TTY – PA Relay 711 — give the operator the 1-866-872-8969 phone number to call, choose Option #7 for a sign language interpreter, and leave a detailed voice mail message.
  • E-mail:

Keystones of Health Overview:

DHS’ goal and vision for the waiver is to address Pennsylvania’s Medicaid participants’ health-related social needs with interventions that are both lifesaving and cost saving.

Unmet social needs such as housing instability and homelessness, food insecurity, and lack of social supports create barriers to accessing and utilizing health care services and can directly impact health and the cost of care 1,2. Under Keystones of Health, services are proposed to be provided in the following areas:

Reentry from correctional facilities:

Leaving correctional facilities exposes individuals to a heightened risk of health challenges, including mental health and substance use disorders. Two thirds of incarcerated individuals have a history of substance use disorder and are at 12 times the risk of death immediately following release 3.  Keystones of Health aims to 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.

Housing supports:

Individuals experiencing homelessness are often faced with chronic health conditions, impacting both mental and physical well-being. Stable housing, a recognized cornerstone of good health, can serve as a bridge for homeless adults with chronic illnesses, leading to a nearly 30% reduction in hospital stays 4. Keystones of Health proposes to 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.

Food and nutrition supports:

Addressing social needs such as food insecurity not only enhances the diet of individuals but also has been shown to reduce hospital admissions by half for individuals with chronic conditions 5. Keystones of Health proposes to 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).

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 6. 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.

[1] Taylor LA, Tan AX, Coyle CE, et al. Leveraging the social determinants of health: what works? PLoS One. 2016;11(8):e0160217. doi:10.1371/journal.pone.0160217

[2] Koh KA, Racine M, Gaeta JM, et al. Health care spending and use among people experiencing unstable housing in the era of accountable care organizations. Health Aff (Millwood). 2020;39(2):214-223. doi:10.1377/hlthaff.2019.00687

[3] Binswanger IA, Stern MF, Deyo RA, Heagerty PJ, Cheadle A, Elmore JG, Koepsell TD. Release from prison--a high risk of death for former inmates. N Engl J Med. 2007 Jan 11;356(2):157-65. doi: 10.1056/NEJMsa064115. Erratum in: N Engl J Med. 2007 Feb 1;356(5):536. PMID: 17215533; PMCID: PMC2836121.

[4] Sadowski LS, Kee RA, VanderWeele TJ, Buchanan D. Effect of a housing and case management program on emergency department visits and hospitalizations among chronically ill homeless adults: a randomized trial. JAMA. 2009 May 6;301(17):1771-8. doi: 10.1001/jama.2009.561. PMID: 19417194.

[5] Berkowitz S, Terranova J, Randall L, et al. Association Between Receipt of a Medically Tailored Meal Program and Health Care Use. JAMA Intern Med. 2019;179(6):786-793. doi:10.1001/jamainternmed.2019.0198.

[6] Brantley E, Ku L. Continuous Eligibility for Medicaid Associated With Improved Child Health Outcomes. Medical Care Research and Review. 2022;79(3):404-413. doi:10.1177/10775587211021172

What is an 1115 Demonstration?

Keystones of Health is an 1115 demonstration. These allow states to develop programs in coordination with the federal Centers for Medicare and Medicaid Services (CMS) that provide services and benefits not normally allowed in state Medicaid plans. States use these to design and evaluate new and creative ways to make health care better. DHS' goal for Keystones of Health is to improve health and quality of life for Pennsylvania's Medicaid beneficiaries by helping with health-related social needs, which can improve a person's quality of life and offset the need for more costly, intensive acute care. It will also improve access to care through improved reentry supports following release from correctional facilities and multi-year continuous coverage for children under 6 years of age.

What are Health-Related Social Needs?

Health-related social needs are things that affect people's health and well-being that are not purely medical. These include different social, economic, and environmental factors such as having healthy food to eat or a safe place to live. Health-related social needs are often external to the health care system but play a crucial role in shaping an individual's health status and quality of life.

Who will be part of Keystones of Health?

Bridges to Success: Keystones of Health for Pennsylvania focuses on individuals who need help with their health-related social needs who also have related health conditions. For example:

  • Beneficiaries who are leaving or recently released from correctional facilities with substance use disorder and serious mental illness;
  • Beneficiaries experiencing homelessness
  • Beneficiaries with diet sensitive chronic conditions;
  • Pregnant and post-partum beneficiaries; and,
  • Provide continuous Medicaid coverage for children under six years of age.

The application and topic overviews include more details on populations and eligibility. DHS will update the Keystones of Health application based on public comments and feedback from the Centers for Medicare & Medicaid Services. This means populations and scope may change.

Provide Feedback

DHS' public comment period on the Keystones of Health draft application opened on December 2, 2023 and closed January 2, 2024. During this time, DHS accepted written and verbal comments on the Keystones of Health application. These comments will inform the final application. Full details of how DHS will seek input are available on the Public Input Process page.

The public comment period opened on 12/2/2023 and closed as of 1/2/2024.

Join a public event:

DHS is offering the public the opportunity to come to virtual forums to learn more about the Keystones of Health 1115 demonstration and the proposed services. During the forums, the public will be able to ask questions and provide comments. If you are interested in joining the public forums, the information is below:

Public Forum 1

  • Date: Monday, December 11, 2023 - This meeting has already occurred.
  • Time: 12:00-1:00pm
  • This meeting has already occurred.

Public Forum 2

  • Date: Tuesday, December 12, 2023
  • Time: 6:00-7:00pm
  • This meeting has already occurred.

Public Forum 3

  • Date: Friday, December 15, 2023 - This meeting has already occurred.
  • Time: 9:00-10:00am
  • 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 only. Closed captioning will be provided during each public forum. See the Public Input Process for a list of additional meetings including a Keystones of Health presentation and brief comment opportunity.

Resources and Additional Information

Interested in learning more about Bridges to Success: Keystones of Health for Pennsylvania? Consider downloading these resources or subscribing to email updates.

Other Useful Links:

Public Notice

Proposed Federal Section 1115 Demonstration for Medicaid Coverage of Health-Related Social Needs and Continuous Eligibility for Young Children


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