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Pennsylvania Keystones of Health Section 1115 Demonstration Approval Period: December 26, 2024 through December 31, 2029 Page 33 of 90 The reported data and attestations pertain to HRSN related provider payment increase requirements for the demonstration period of performance DY 1 through DY 5. Category of Service Medicaid Fee-for- Service to Medicare Fee-for- Service ratio Medicaid Managed Care to Medicare Fee-for- Service Ratio Primary Care Services [insert percent, or N/A if state does not make Medicaid fee-for-service payments] [insert percent, or N/A if state does not utilize a Medicaid managed care delivery system for applicable covered service categories] [insert approach, either ratio derived under STC 7.5(a) or STC 7.5(b)] [insert approach, either ratio derived under STC 7.6(a) or STC 7.6(b), insert data source and time period (e.g., applicable 12- month rating period) for each of Medicaid and Medicare to derive the ratio] Obstetric Care Services [insert percent, or N/A if state does not make Medicaid fee-for-service payments] [insert percent, or N/A if state does not utilize a Medicaid managed care delivery system for applicable covered service categories] [insert approach, either ratio derived under STC 7.5(a) or STC 7.5(b)] [insert approach, either ratio derived under STC 7.6(a) or STC 7.6(b) insert data source and time period (e.g., applicable 12- month rating period) for each of Medicaid and