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Pennsylvania Keystones of Health Section 1115 Demonstration Approval Period: December 26, 2024 through December 31, 2029 Page 84 of 90 Pennsylvania 1115 HRSN Services Matrix: Clinical Criteria Detail Clinical Risk Factor Clinical Criteria Detail Serious Mental Illness 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. Substance Use Disorder 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. Pregnant or Postpartum Pregnant or up to 12 months after the end of pregnancy. Acute Cancer with active chemotherapy Acute Cancer with active chemotherapy High-Risk Pregnancy Gestational Diabetes Diet-sensitive chronic health condition At least one hospitalization with diagnosis of: •Congestive Heart Failure; or •End Stage Renal Disease; or •Poorly Controlled Diabetes. High-Risk Chronic health condition Chronic Health condition with treatment plan: • 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. Autism Spectrum Disorder Diagnosis of Autism Spectrum Disorder