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Pennsylvania Keystones of Health Section 1115 Demonstration Approval Period: December 26, 2024 through December 31, 2029 Page 1 of 90 CENTERS FOR MEDICARE & MEDICAID SERVICES EXPENDITURE AUTHORITY

NUMBER: 11-W-00484/3

TITLE: Keystones of Health

AWARDEE: Pennsylvania Department of Human Services

Under the authority of section 1115(a)(2) of the Social Security Act (the “Act”), expenditures made by the Commonwealth of Pennsylvania for the items identified below, which are not otherwise included as expenditures under section 1903 of the Act shall, for the period from December 26, 2024, through December 31, 2029, unless otherwise specified, be regarded as expenditures under the commonwealth’s title XIX plan.

The following expenditure authorities may only be implemented consistent with the approved Special Terms and Conditions (STCs) and shall enable the Commonwealth of Pennsylvania to operate the above-identified section 1115 demonstration.

1. Expenditures for Pre-Release Services. Expenditures for pre-release services, as described in these STCs, provided to qualifying Medicaid individuals for up to 90-days immediately prior to the expected date of release from a correctional facility that is participating in the Reentry Demonstration Initiative under this demonstration.

2. Expenditures for Pre-Release Administrative Costs. Capped expenditures for payments for allowable administrative costs, services, supports, transitional non-service expenditures, infrastructure and interventions, as is detailed in STC 5.12, which may not be recognized as medical assistance under section 1905(a) and may not otherwise qualify for federal matching funds under section 1903 of the Act, to the extent such activities are authorized as part of the Reentry Demonstration Initiative.

3. Expenditures for Health-Related Social Needs (HRSN) Services. Expenditures for allowable HRSN services not otherwise covered that are furnished to individuals who meet the qualifying criteria as described in Section 6.6. This expenditure authority is contingent upon compliance with Section 6, as well as all other applicable STCs.

4. Expenditures for Health-Related Social Needs Services Infrastructure. Expenditures for allowable HRSN administrative and infrastructure costs not otherwise covered under section 1903 of the Act, as described in Section 6 of the STCs.