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Pennsylvania Keystones of Health Section 1115 Demonstration Approval Period: December 26, 2024 through December 31, 2029 Page 34 of 90 Medicare to derive the ratio] Behavioral Health 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] In accordance with STCs 7.1 through 7.12, including that the Medicaid provider payment rates used to establish the ratios do not reflect fee-for-service supplemental payments or Medicaid managed care pass-through payments under 42 CFR 438.6(a) and 438.6(d), I attest that at least a two percentage point payment rate increase will be applied to each of the services in the service category in each delivery system, as applicable to the state’s Medicaid or demonstration service delivery model, if for that delivery system the ratio is both the lowest ratio among the three and below 80 percent. Such provider payment increases for each service will be effective beginning on January 1, 2027, and will not be lower than the highest rate for that service code in DY 1 plus a two-percentage point increase relative to the rate for the same or similar Medicare billing code through at least December 30, 2029.

For the purpose of deriving the Medicaid to Medicare provider payment rate ratio, and to apply the rate increase as may be required under a fee-for-service delivery system or under managed care delivery system, as applicable, the state agrees to define primary care, behavioral health and obstetric care, and to identify applicable service codes and providers types for each of these service categories in a manner consistent with other state and federal Medicaid program requirements, except that inpatient behavioral health services may be excluded from the state’s definition.

The services that comprise each service category to which the rate increase must be applied will include all service codes that fit under the state’s definition of the category, except the behavioral health codes do not have to include inpatient care services.