Bridges to Success: Keystones of Health for Pennsylvania

Overview, Goals, and Objectives

The Pennsylvania Department of Human Services (Department) is making available for public review and comment the proposed Federal Section 1115 Demonstration application, entitled Bridges to Success: Keystones of Health for Pennsylvania (Keystones of Health), which proposes Medicaid Coverage for Health-Related Social Needs (HRSNs), reentry supports, and multiyear continuous eligibility for young children. 

The purpose of this demonstration is to further the objectives of Medicaid to expand access to care, improve health outcomes, drive innovation, and engage partners and communities through targeted, time-limited interventions to address HRSNs.

The goals of this demonstration are to:

1. Address Pennsylvania's Medicaid beneficiaries' HRSNs, such as food and housing, to improve health outcomes and quality of life with interventions that are both lifesaving and cost saving.
2. Provide HRSN services to support beneficiaries, especially those experiencing life transitions, to reduce avoidable hospitalizations and medical utilization and increase recommended or preventive care.
3. Reduce churn and gaps in coverage for children enrolled in Medicaid.
4. Expand Medicaid coverage to improve services to beneficiaries as they prepare to leave incarceration and provide continued support as beneficiaries transition back into the community.

Under Keystones of Health, services are proposed to be provided in the following areas:

• Reentry from correctional facilities:  Improve transitions to the community for beneficiaries reentering society from correctional facilities. The available services, which will require a legislative amendment, will focus on improving transitions to community-based health care and social services with a particular emphasis on those with significant health care needs such as serious mental illness and substance use disorder. The demonstration will also provide continuous eligibility for 12 months after release.

• Housing supports: Add new Medicaid services to help beneficiaries without stable housing find and keep a place to live. Having stable housing makes it easier to find and use health care. These services will focus on beneficiaries with behavioral health issues and chronic conditions where health outcomes are greatly impacted by improved consistency of care and medication access.

• Food and nutrition supports: Provide food and nutrition services to specific Medicaid populations facing food insecurity, including pregnant beneficiaries and beneficiaries with diet-sensitive conditions. Services would include direct food support such as medically-tailored meals or groceries with a goal of also connecting eligible beneficiaries to long-term food assistance, like the Supplemental Nutrition Assistance Program (SNAP).

• Multi-year continuous coverage for children under 6 years of age:  Provide continuous Medicaid coverage for children from birth or older but under 6 years of age to reduce gaps in coverage that interrupt access to essential health care services, such as preventive care. This proposal provides eligibility from birth, or when a child first receives Medicaid, through the last day of the month in which they turn 6 years of age. This proposal will make it easier for children to get the important early childhood health care they need.

The 1115 Demonstration application is available at dhs.pa.gov/Keystones-of-Health. In addition, copies of the application are available upon written request to: 

Department of Human Services
Office of Medical Assistance Programs
c/o Regulations Coordinator
P.O. Box 2675, Harrisburg, PA 17120

Eligible Beneficiaries and Proposed Services

The services provided under Keystones of Health will be in addition to the services provided through the Medicaid State Plan Most services will be provided through Pennsylvania's managed care programs, collectively known as HealthChoices, which provide physical and behavioral health care, as well as LTSS, through managed care organizations (MCOs). Managed care enrollment is mandatory for most Medicaid populations. Beneficiaries receiving services in the fee-for-service (FFS) delivery system, including those who are in FFS as they transition to managed care, will also be able to access HRSN services.

This demonstration affects all eligibility groups under the State Plan (Table 1) through the provision of additional services.

Table 1: Existing Medicaid eligibility groups affected by the demonstration

The demonstration will not restrict any existing eligibility, rather it will expand the eligibility of justice-involved individuals. This demonstration will provide coverage and limited benefits for incarcerated adults who are preparing for release and meet criteria for being high risk as defined in the table below. Eligibility will be determined through existing State Plan processes and eligibility criteria, and only include those who would be otherwise eligible if not incarcerated.

Table 2: Expansion eligibility groups requested under the demonstration

DHS seeks to provide continuous 12-month enrollment for beneficiaries following reentry from correctional settings, regardless of changes in circumstances that would otherwise cause a loss of eligibility. This continuous 12-month enrollment applies to beneficiaries identified in Table 2 following release. This change will stabilize coverage, increase access to primary and preventive services, and preserve participants' continuity in access to ongoing care during a time of transition. The continuous eligibility period will begin on the release date and expire 12 months later at the end of the month.

DHS also requests the ability to provide continuous enrollment for children from birth through the end of the month in which their sixth birthday falls, regardless of when they first enroll in Medicaid, and regardless of changes in circumstances that would otherwise cause a loss of eligibility. This demonstration request will end churn among young Medicaid-enrolled children and better address their primary and preventive health care needs. Children must meet the existing eligibility criteria when they first enroll.

Under the demonstration, DHS will not impose any new cost sharing requirements for services. DHS is also seeking to waive all existing cost-sharing requirements in the State Plan for incarcerated beneficiaries prior to release.

Medicaid beneficiaries will qualify for services outlined in this demonstration based upon their medical need for services and an identified social need. For reentry supports, incarceration qualifies as the social need. Additional screening during case management will connect the individual to the most appropriate services. For Food and Housing Supports, DHS will develop a new core HRSN assessment tool based on existing assessments in use within Pennsylvania.

Table 3: Proposed populations by reentry service

Proposed populations by Housing service

Table 4: Proposed populations by housing service

Proposed populations by Food and Nutrition service

Table 5: Proposed populations by food and nutrition service

Public Hearing Schedule

The Department will hold three virtual public hearings to receive comments regarding the proposed Demonstration. The Department will also receive comments on the Demonstration application at the Income Maintenance Advisory Council meeting on December 5, 2023, the Medical Assistance Advisory Committee meeting on December 7, 2023, and the Information Sharing and Advisory Committee Hub meeting on December 12, 2023.

The public hearings will be held as follows:

• December 11, 2023, from 12:00 p.m. to 1:00 p.m.
  This meeting has already occurred.
• December 12, 2023, from 6:00 p.m. to 7:00 p.m.
  This meeting has already occurred.
• December 15, 2023, from 9:00 a.m. to 10:00 a.m.
  This meeting has already occurred.

Please register to participate virtually. When you register, there will be an option to add the Public Forum to your calendar. Registration is not necessary to join by phone. Closed captioning will be provided during each public forum.

DHS is also consulting existing DHS advisory groups and meeting with additional stakeholders in the public comment period:

Medical Assistance Advisory (MAAC) Managed Care Subcommittee
December 4, 2023, from 11:00 a.m. to 10:00 a.m.
This meeting has already occurred.

Income Maintenance Advisory Committee (IMAC)
December, 5, 2023, from 1:00 p.m. to 4:30 p.m.
 This meeting has already occurred.

MAAC Consumer Subcommittee
December 6, 2023, from 1:00 p.m. to 3:00 p.m.
 This meeting has already occurred.

MAAC
December 7, 2023, from 10:00 a.m. to 12:00 p.m.
 This meeting has already occurred.

Information Sharing and Advisory Committee (ISAC)
December 12, 2023, from 10:30 a.m. to 11:00 a.m.

Full details of how DHS will seek input are available on the Public Input Process page.

Public Comment

The Department seeks public input on the proposed 1115 Demonstration application for Medicaid coverage of HRSNs, reentry supports, and multiyear continuous eligibility for young children. The 30-day public comment period will take place from December 2, 2023, through January 2, 2024.

Individuals may submit written comments through:
https://tinyurl.com/KeystonesofHealthComments
by email to: RA-PWMAProgComments@pa.gov
by mail to:
Department of Human Services
Office of Medical Assistance Programs
c/o Regulations Coordinator
P.O. Box 2675, Harrisburg, PA 17120

Persons with a disability who require an auxiliary aid or service may submit comments using the AT&T Relay Service at 1-800-654-5984 (TDD users) or 1-800-654-5988 (voice users).

The Department will consider all comments received by January 2, 2024, in developing the final Demonstration application.

1115 Waiver Estimates of Proposed Annual Enrollment and Annual Aggregate Expenditures and Financial Analysis of Proposed Initiatives.

 
A summary of annual and aggregate projected demonstration enrollment and expenditure data is provided in the tables below. Note that not all Medicaid expenditures are captured in these tables. For example, Commonwealth administrative expenditures and expenditures for populations or services excluded from the 1115 waiver are not included. The expenditure data for these estimates is limited to expenditures that will be considered as part of the 1115 waiver budget neutrality and projected new expenditures where data and estimates are currently available. Demonstration projections are approximations based on assumptions used for the purpose of the waiver planning. Demonstration estimates, including financing and budget neutrality assumptions, will continue to evolve throughout the course of the waiver application process and as new budget data becomes available. The impact of the ending of the PHE may impact these projections.

Table 6 Projected Expenditures and Enrollment for Demonstration Proposals
* Infrastructure support funding by year will be refined based on planning and implementation.

Evaluation and Hypotheses
DHS will test the following research hypotheses through the section 1115 demonstration:

1. Addressing unmet HRSN within the Medicaid-eligible population will improve health outcomes and reduce the cost of care.
2. A focus on health equity improvements for specific populations that have experienced disproportionately poor health outcomes will result in improved health outcomes, increased access to care, and a reduction in the gap between outcomes for populations of focus and those that have historically experienced favorable health outcomes.
3. HRSN services designed to support individuals experiencing life transitions will result in a reduction in avoidable hospitalizations and medical utilization (e.g., lower emergency department (ED) use, lower avoidable ED visits) and an increase in recommended or preventive care.
4. Access to pre-release services will result in increased use of recommended and/or preventive care, resulting in positive impacts on health outcomes.
5. Implementation of pre-release services will result in increased collaboration between stakeholders, identification of medical needs and HRSN prior to release, gradual expansion of access to pre-release services for justice-involved individuals, and improved insights into healthcare delivery for this population.
6. Expanded housing supports will reduce homelessness, homeless recidivism, and housing instability of individuals.
7. Improvements in housing stability will improve access to recommended and/or preventive care.
8. Implementation of nutrition supports will result in increased collaboration between stakeholders, gradual expansion of access to nutrition services for participating individuals, and improved infrastructure for the provision of nutrition support services.
9. Nutrition support services will result in reductions in food insecurity and improved disease management for participating individuals.
10. Continuous coverage will reduce churn and gaps in coverage for children enrolled in Medicaid, including for racial and ethnic minority populations that experience disproportionately high rates of churn.
11. Continuous coverage will reduce the quantity of redeterminations, resulting in lower administrative burden for eligibility workers and associated costs.
12. Continuous coverage will increase utilization of preventive care services including vaccinations and reduce potentially avoidable services, such as inpatient hospitalizations and non-emergency use of emergency departments.

Waiver authorities

Under the authority of Section 1115(a)(1) of the Act, the following waivers shall enable Pennsylvania to implement this Section 1115 demonstration for five years following approval.

Table 7: Pennsylvania waiver authorities for the demonstration
 

Expenditure authorities

The table below lists the expenditure authorities the Commonwealth is seeking to support the demonstration policies.

Table 8: Pennsylvania expenditure authorities for the demonstration