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Pennsylvania Keystones of Health Section 1115 Demonstration Approval Period: December 26, 2024 through December 31, 2029 Page 4 of 90 CENTERS FOR MEDICARE & MEDICAID SERVICES SPECIAL TERMS AND CONITIONS

NUMBER: 11-W-00484/3

TITLE: Keystones of Health

AWARDEE: Pennsylvania Department of Human Services 1. PREFACE The following are the Special Terms and Conditions (STCs) for the “Keystones of Health” section 1115(a) Medicaid demonstration (hereinafter “demonstration”), to enable the Commonwealth of Pennsylvania (hereinafter “state”) to operate this demonstration. The Centers for Medicare & Medicaid (CMS) has granted a waiver of certain requirements under section 1902(a) of the Social Security Act (Act) and expenditure authorities authorizing federal matching of demonstration costs not otherwise matchable, which are separately enumerated. These STCs set forth conditions and limitations on those waiver and expenditure authorities, and describe in detail the nature, character, an extent of federal involvement in the demonstration and the state’s obligations to CMS related to the demonstration. These STCs neither grant additional waivers or expenditure authorities, nor expand upon those separately granted.

The STCs related to the programs for those populations affected by the demonstration are effective from December 26, 2024, through December 31, 2029, unless otherwise specified.

The STCs have been arranged into the following subject areas:

1. Preface 2. Program Description and Objectives 3. General Program Requirements 4. Eligibility and Enrollment 5. Reentry Demonstration Initiative Program 6. Health-Related Social Needs Program 7. Provider Rate Requirements 8. Cost Sharing 9. Delivery System 10. Monitoring and Reporting Requirements 11. Evaluation of the Demonstration 12. General Financial Requirements 13. Monitoring Budget Neutrality for the Demonstration 14. Schedule of Deliverables for the Demonstration Extension Period