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Pennsylvania Keystones of Health Section 1115 Demonstration Approval Period: December 26, 2024 through December 31, 2029 Page 83 of 90 Pennsylvania 1115 HRSN Services Matrix: Nutrition

Service Population Social Risk Factor Clinical Criteria for the pop

Home Delivered Meals 1) Pregnant or Postpartum Meet USDA Definition of Low or Very Low Food Security 1) Pregnant or up to 8 weeks after the end of pregnancy. Nutrition interventions with food Medically Tailored Meals 1) Acute Cancer with Active Chemotherapy, 2) High-Risk Pregnancy, or 3) Diet-sensitive chronic health condition Meet USDA Definition of Low or Very Low Food Security 1) Acute Cancer with active chemotherapy 2) Gestational Diabetes 3) At least one inpatient visit with primary, secondary or tertiary diagnosis of: •Congestive Heart Failure; or •End Stage Renal Disease; or •Poorly Controlled Diabetes.