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Pennsylvania Keystones of Health Section 1115 Demonstration Approval Period: December 26, 2024 through December 31, 2029 Page 25 of 90 e. A plan to avoid duplication/displacement of existing food assistance/nutrition services, including how the state will prioritize and wrap around Supplemental Nutrition Assistance Program (SNAP) and/or Women Infants and Children (WIC) enrollment, appropriately adjust HRSN demonstration initiative benefits for individuals also receiving SNAP and/or WIC services, and ensure eligible beneficiaries are enrolled to receive SNAP and/or WIC services. f. An affirmation that the state agrees to meet the enhanced monitoring and evaluation requirements stipulated in STCs 10.5.b and 11.6, which require the state to monitor and evaluate how the renewals of recurring nutrition services under STC 6.3.b affect care utilization and beneficiary physical and mental health outcomes, as well as the cost of providing such services. As required in STCs 10.5.b and 11.6, the Monitoring Protocol and Evaluation Design are subject to CMS approval. 6.8. Updates to the Protocol for Assessment of Beneficiary Eligibility and Needs and Provider Qualifications for HRSN Services: a. The state may choose to cover a subset of the HRSN services and/or beneficiary qualifying criteria specified in Attachments F and G. Certain changes to the state’s service offerings and qualifying criteria, within what CMS has approved in Attachment G, do not require additional CMS approval. The state must follow the following process to notify CMS of any such HRSN service or qualifying criteria change in Attachment F by the following process: i. The state must follow the same beneficiary notification procedures as apply in the case of changes to coverage and/or beneficiary service qualification criteria for state plan services, including with respect to beneficiaries who currently qualify for and/or are receiving services who may receive a lesser amount, duration, or scope of coverage as a result of the changes. ii. The state must provide public notice. iii. The state must submit a letter to CMS no less than 30 days prior to implementation describing the changes, which will be incorporated in the demonstration’s administrative record. b. In addition to the requirements in STC 6.8.a. above, if the state seeks to implement additional clinical and/or social risk factors than what are included in approved Attachment G, the state must follow the process below to update the protocol: i. The state must provide a budget neutrality analysis demonstrating the state’s expected cost for the additional population(s). The state may only add additional clinical and/or social risk factors through the protocol process described in this STC if CMS determines the criteria are allowable and doing so would not require an increase to the amount of the state’s HRSN expenditure authority in Table 8. ii. The state must receive CMS approval for the updated protocol prior to implementation of changes under this STC 6.8.b.