Section 1115 Waiver


Bridges to Success: Keystones of Health for PA

PA Department of Human Services submitted a Section 1115 Demonstration Waiver entitled Bridges to Success: Keystones of Health for Pennsylvania to the Centers for Medicare and Medicaid Services (CMS) on January 26, 2024. Keystones of Health focuses on health-related social needs, such as homelessness and food insecurity, that jeopardize the health of Pennsylvanians and lead to costly, but avoidable, health care use. Now that the federal comment period has ended, DHS will enter into a negotiation process with CMS. This process may result in revisions to services and populations. After negotiations, and should DHS receive approval, DHS will follow the regular budgetary process and collaborate with stakeholders to determine how initiatives can be implemented.  

Keystones of Health Overview

Under Keystones of Health, services are proposed to be provided in the following areas (from the PA DHS website):

Reentry from correctional facilities
Leaving correctional facilities exposes individuals to a heightened risk of health challenges, including mental health and substance use disorders. Two thirds of incarcerated individuals have a history of substance use disorder and are at 12 times the risk of death immediately following release 3. Keystones of Health aims to 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.

Housing Supports
Individuals experiencing homelessness are often faced with chronic health conditions, impacting both mental and physical well-being. Stable housing, a recognized cornerstone of good health, can serve as a bridge for homeless adults with chronic illnesses, leading to a nearly 30% reduction in hospital stays 4. Keystones of Health proposes to add new Medicaid services to help beneficiaries without stable housing find and keep a place to live. 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
Addressing social needs such as food insecurity not only enhances the diet of individuals but also has been shown to reduce hospital admissions by half for individuals with chronic conditions 5. Keystones of Health proposes to 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 
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 6. 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.

Section 1115 Waiver Q+As

Keystones of Health is an 1115 demonstration. These allow states to develop programs in coordination with the Federal Centers for Medicare and Medicaid Services (CMS) that provide services and benefits not normally allowed in state Medicaid plans. States use these to design and evaluate new and creative ways to make health care better. DHS’ goal for Keystones of Health is to improve health and quality of life for Pennsylvania’s Medicaid beneficiaries by helping with health-related social needs, which can improve a person’s quality of life and offset the need for more costly, intensive acute care. It will also improve access to care through improved reentry supports following release from correctional facilities and multi-year continuous coverage for children under 6 years of age.

Health-related social needs are things that affect people’s health and well-being that are not purely medical. These include different social, economic, and environmental factors such as having healthy food to eat or a safe place to live. Health-related social needs are often external to the health care system but play a crucial role in shaping an individual’s health status and quality of life.

Bridges to Success: Keystones of Health for Pennsylvania focuses on individuals who need help with their health-related social needs who also have related health conditions. For example:

  • Beneficiaries who are leaving or recently released from correctional facilities with substance use disorder and serious mental illness;
  • Beneficiaries experiencing homelessness
  • Beneficiaries with diet sensitive chronic conditions;
  • Pregnant and post-partum beneficiaries; and,
  • Provide continuous Medicaid coverage for children under six years of age.

The application and topic overviews include more details on populations and eligibility. DHS will update the Keystones of Health application based on public comments and feedback from the Centers for Medicare & Medicaid Services. This means populations and scope may change.