Page 94

Pennsylvania Keystones of Health Section 1115 Demonstration Approval Period: December 26, 2024 through December 31, 2029 Page 81 of 90 Pennsylvania 1115 HRSN Services Matrix: Housing

Service Population Social Risk Factor Clinical Criteria for the pop Housing/Home Environment interventions without room and board Case management for housing 1) SMI 2) SUD 3) Pregnant or Postpartum 4) Acute Cancer with active chemotherapy 5) High-Risk Chronic Health Condition, or 6) Autism Spectrum Disorder Homeless or At Risk of Homelessness 1) Meets the criteria for the Adult Priority Group for adults with serious mental illness (SMI) set forth in bulletin OMHSAS-19-03, “Serious Mental Illness: Adult Priority Group,” issued August 6, 2019 or most current version. 2) Substance use disorders (as defined by the Pennsylvania adopted version of the ASAM Criteria) in addition to a diagnosis identified on the Department approved SUD ICD 10 codes list. 3) Pregnant or up to 12 months after the end of pregnancy. 4) Acute Cancer with active chemotherapy (incarcerated population only) 5) Chronic Health condition with treatment plan (incarcerated population only): • End-stage renal disease with active dialysis • Chronic pulmonary disease requiring oxygen • Type 1 diabetes • Type 2 diabetes requiring at least one injectable insulin/day. 6) Diagnosis of Autism Spectrum Disorder (incarcerated population only) Housing navigation and tenancy support* 1) SMI 2) SUD 3) Pregnant or Postpartum 4) Acute Cancer with active chemotherapy 5) High-Risk Chronic Health Condition, or 6) Autism Spectrum Disorder Homeless or At Risk of Homelessness 1) Meets the criteria for the Adult Priority Group for adults with serious mental illness (SMI) set forth in bulletin OMHSAS-19-03, “Serious Mental Illness: Adult Priority Group,” issued August 6, 2019 or most current version. 2) Substance use disorders (as defined by the Pennsylvania adopted version of the ASAM Criteria) in addition to a diagnosis identified on the Department approved SUD ICD 10 codes list. 3) Pregnant or up to 12 months after the end of pregnancy. 4) Acute Cancer with active chemotherapy (incarcerated population only) 5) Chronic Health condition with treatment plan (incarcerated population only): • End-stage renal disease with active dialysis • Chronic pulmonary disease requiring oxygen • Type 1 diabetes • Type 2 diabetes requiring at least one injectable insulin/day. 6) Diagnosis of Autism Spectrum Disorder (incarcerated population only) One-time transition and moving costs other than rent 1) SMI 2) SUD 3) Pregnant or Postpartum 4) Acute Cancer with active chemotherapy 5) High-Risk Chronic Health Condition, or 6) Autism Spectrum Disorder Homeless or At Risk of Homelessness 1) Meets the criteria for the Adult Priority Group for adults with serious mental illness (SMI) set forth in bulletin OMHSAS-19-03, “Serious Mental Illness: Adult Priority Group,” issued August 6, 2019 or most current version. 2) Substance use disorders (as defined by the Pennsylvania adopted version of the ASAM Criteria) in addition to a diagnosis identified on the Department approved SUD ICD 10 codes list. 3) Pregnant or up to 12 months after the end of pregnancy. 4) Acute Cancer with active chemotherapy (incarcerated population only) 5) Chronic Health condition with treatment plan (incarcerated population only): • End-stage renal disease with active dialysis • Chronic pulmonary disease requiring oxygen • Type 1 diabetes • Type 2 diabetes requiring at least one injectable insulin/day. 6) Diagnosis of Autism Spectrum Disorder (incarcerated population only)