Page 49

Pennsylvania Keystones of Health Section 1115 Demonstration Approval Period: December 26, 2024 through December 31, 2029 Page 36 of 90 Pennsylvania further agrees not to decrease provider payment rates for other Medicaid- or demonstration-covered services to make state funds available to finance provider rate increases required under this STC Section 7. I, [insert name of SMD or CFO (or equivalent position)] [insert title], attest that the above information is complete and accurate. [Provide signature]____________________________ [Provide date] [Provide printed name of signatory] 8. Cost Sharing 8.1. The demonstration will not include cost-sharing for any demonstration services. The demonstration will make no changes to other Health Insurance Premium Payment Program (HIPP) benefits and cost sharing. 9. Delivery System 9.1. The services provided under Keystones of Health will be in addition to the services provided through the Medicaid state plan. All demonstration beneficiaries will continue to receive services through the same delivery system arrangements as currently authorized in the state. Services approved through this demonstration will be delivered through the FFS delivery system. 10. Monitoring and Reporting Requirements 10.1. Deferral for failure to Submit Timely Demonstration Deliverables. CMS may issue deferrals in the amount of $5,000,000 (federal share) when items required by these STCs (e.g., required data elements, analyses, reports, design documents, presentations, and other items specified in these STCs (hereafter singly or collectively referred to as “deliverable(s)”)) are not submitted timely to CMS or found to not be consistent with the requirements approved by CMS. A deferral shall not exceed the value of the federal amount for the demonstration period. The state does not relinquish its rights provided under 42 CFR part 430 subpart C to challenge any CMS finding that the state materially failed to comply with the terms of this agreement. The following process will be used: 1) 30-days after the deliverable was due if the state has not submitted a written request to CMS for approval of an extension as described in subsection 10.1.b. below; or 2) 30-days after CMS has notified the state in writing that the deliverable was not accepted for being inconsistent with the requirements of this agreement and the information needed to bring the deliverable into alignment with CMS requirements. a. CMS will issue a written notification to the state providing advance notification of a pending deferral for late or non-compliant submission of required deliverable(s). b. For each deliverable, the state may submit to CMS a written request for any extension to submit the required deliverable that includes a supporting rationale for the cause(s) of the delay and the state’s anticipated date of submission. Should CMS agree to the state’s request, a corresponding extension of the deferral process will be provided. CMS may agree to a corrective action plan submitted by the state as an