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Pennsylvania Keystones of Health Section 1115 Demonstration Approval Period: December 26, 2024 through December 31, 2029 Page 32 of 90 a. Comply with the requirements for state directed payments in accordance with 42 CFR 438.6(c), as applicable; and b. Ensure that the entirety of a two-percentage point increase applied to the provider payments rates in the service category whose Medicaid to Medicare average payment rate ratio is below 80 percent is paid to providers, and none of such payment rate increase is retained by managed care plans. 7.9. For the entirety of DY 3 through DY 5, the provider payment rate increase for each service in a service category and delivery system for which the average ratio is less than 80 percent will be an amount necessary so that the Medicaid to Medicare ratio increases by two percentage points over the highest rate for each service in DY 1, and such rate will be in effect on the first day of DY 3. A required payment rate increase shall apply to all services in a service category as defined under STC 7.4. 7.10. If the state uses a managed care delivery system for any of the service categories defined in STC 7.4, for the beginning of the first rating period as defined in 42 CFR 438.2(a) that starts in each demonstration year from DY 3 through DY 5, the managed care plans’ provider payment rate increase for each service in the affected categories will be no lower than the highest rate in DY 1 plus an amount necessary so that the Medicaid to Medicare ratio for that service increases by two percentage points. The payment increase shall apply to all services in a service category as defined under STC 7.4. 7.11. If the state has a biennial legislative session that requires provider payment rate approval and the timing of that session precludes the state from implementing a required payment rate increase by the first day of DY 3 (or, as applicable, the first day of the first rating period that starts in DY 3), the state will provide an alternative effective date and rationale for CMS review and approval. 7.12. Pennsylvania will provide the information to document the payment rate ratio required under STC 7.5 and 7.6, via submission to the Performance Metrics Database and Analytics (PMDA) portal for CMS review and approval. 7.13. For demonstration years following the first year of provider payment rate increases, if any, Pennsylvania will provide an annual attestation within the State’s annual demonstration monitoring report that the provider payment rate increases subject to these STCs were at least sustained from, if not higher than, in the previous year. 7.14. No later than 90 days following the demonstration effective date, the state will provide to CMS the following information and Attestation Table signed by the State Medicaid Director, or by the Director’s Chief Financial Officer (or equivalent position), to PMDA, along with a description of the state’s methodology and the state’s supporting data for establishing ratios for each of the three service categories in accordance with STCs 7.5 and 7.6 for CMS review and approval, at which time the Attestation Table will be appended to the STCs as Attachment J. Table 3. Pennsylvania HRSN-Related Provider Payment Increase Assessment – Attestation Table.