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Pennsylvania Keystones of Health Section 1115 Demonstration Approval Period: December 26, 2024 through December 31, 2029 Page 3 of 90 CENTERS FOR MEDICARE & MEDICAID SERVICES WAIVER AUTHORITY

NUMBER: 11-W-00484/3

TITLE: Keystones of Health

AWARDEE: Pennsylvania Department of Human Services

Under the authority of the section 1115(a)(1) of the Social Security Act (the “Act”), the following waivers are granted to enable the Commonwealth of Pennsylvania (referred to herein as the “state”) to operate the Keystones of Health demonstration. These waivers are effective beginning December 26, 2024, and are limited to the extent necessary to achieve the objectives below. These waivers may only be implemented consistent with the approved Special Terms and Conditions (STCs) set forth in the accompanying document.

As discussed in the Centers for Medicare & Medicaid Services’ (CMS) approval letter, the Secretary of Health and Human Services has determined that the Keystones of Health, including the granting of the waivers described below, is likely to assist in promoting the objectives of the title XIX of the Act.

Except as provided below with respect to expenditure authority, all requirements of the Medicaid program expressed in law, regulation and policy statement, not expressly waived in this list, shall apply to the demonstration project for the period beginning December 26, 2024, through December 31, 2029.

1. Coverage of Certain Screening, Diagnostic, Release and Targeted Case Management Services for Eligible Juveniles in the 90-days Prior to Release Section 1902(a)(84)(D)

To enable the state not to provide coverage of the screening, diagnostic, and targeted case management services identified in section 1902(a)(84)(D) of the Act for eligible juveniles described in section 1902(nn)(2) of the Act as a state plan benefit in the 90 days prior to the release of such eligible juveniles from a public institution, to the extent and for the period that the state instead provides such coverage to such eligible juveniles under the approved expenditure authorities under this demonstration. The state will provide coverage to eligible juveniles described in section 1902(nn)(2) in alignment with section 1902(a)(84)(D) of the Act at a level equal to or greater than would be required under the state plan.