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Pennsylvania Keystones of Health Section 1115 Demonstration Approval Period: December 26, 2024 through December 31, 2029 Page 23 of 90 DY1 DY2 DY3 DY4 DY5 Total Total Computable Expenditures

$18,200,000

$31,850,000

$31,850,000

$9,100,000

$0

$91,000,000

c. Infrastructure expenditures will receive the FFP match for applicable administrative costs for the expenditure. d. This infrastructure funding is separate and distinct from payments for delivery of HRSN services. The state must ensure that HRSN infrastructure expenditures described in STC 6.5 are not included in HRSN service payments (including capitation payments, as applicable) and that there is no duplication of payments to entities providing or administering HRSN service benefits. e. The state may not claim any FFP in HRSN infrastructure expenditures until Attachment F (HRSN Assessment of Beneficiary Eligibility and Needs, Infrastructure Planning, and Provider Qualifications for HRSN Services Protocol) is approved, as described in STC 6.9. Once approved, the state can claim FFP in HRSN infrastructure expenditures retrospectively to the beginning of when the demonstration expenditure authority for HRSN infrastructure was approved. f. To the extent the state requests any additional infrastructure funding, or changes to its scope as described within this STC, it must submit an amendment to the demonstration for CMS’s consideration. 6.6. Covered Populations. Expenditures for HRSN services may be made for the populations of focus specified in Attachment F, consistent with this STC. To qualify to receive coverage for HRSN services, individuals must be Medicaid (or Medicaid demonstration)-eligible and have a documented medical/clinical need for the services and the services must be determined medically/clinically appropriate, as described STC 6.1, to address the documented need. Medical appropriateness must be based on clinical and health-related social risk factors. This determination must be documented in the beneficiary’s care plan or medical record. Additional detail, including the clinical and other health related-social needs criteria, is outlined in Attachment F. Attachment G, the HRSN Service Matrix, describes the full list of clinical and social risk factors the state anticipates incorporating into Attachment F over the course of the demonstration at the time of the demonstration approval of the expenditure authority for HRSN services. While Attachment G reflects the full list of clinical and social risk factors the state is authorized to implement, the state is not required to implement all of the clinical and social risk factors outlined in Attachment G. Additionally, the state can later include additional clinical and social risk factors in compliance with STC 6.7 and 6.8. 6.7. Protocol for Assessment of Beneficiary Eligibility and Needs, and Provider Qualifications for HRSN Services. The state must submit, for CMS approval, a Protocol for Assessment of Beneficiary Eligibility and Needs, Infrastructure Planning, and Provider Qualifications to CMS no later than 90 days after approval of the HRSN expenditure authority. The protocol must include, as appropriate, a list of the HRSN services and service descriptions, the criteria for