An independent news publication of
United Way of Lancaster County


Pennsylvania pursuing waiver to expand social services for at-risk Medicaid patients

Pa. Human Services Secretary Dr. Valerie Arkoosh speaks at the Homes Within Reach Conference in Hershey on Friday, Dec. 8, 2023. (Photo: Tim Stuhldreher)

(Editor’s note: This article is part of One United Lancaster’s coverage of the Housing Alliance of Pennsylvania’s 2023 Homes Within Reach conference.)

If Pennsylvania is approved for a federal waiver expanding the services it can provide to certain categories of high-need Medicaid patients, the results could be transformative, officials told attendees at the Housing Association of Pennsylvania’s Homes Within Reach conference.

Dr. David Grande

It offers the chance “to bring the disciplines of social work and medicine together” and dismantle some of “the structural and policy barriers that stand in the way for so many individuals facing significant challenges,” said Dr. David Grande, special advisor to the Department of Human Services.

The state’s Department of Human Services is seeking what is known as a “Section 1115” waiver. It allows states to set up Medicaid-funded pilot projects. Projects must advance Medicaid’s overall goal of improving health, but can include services the program would not ordinarily reimburse.

The initiative that Pennsylvania would implement has been dubbed “Keystones of Health.” It would provide targeted support to Medicaid patients in four areas:

• Reentry: Individuals reentering the community after incarceration would receive additional help in accessing health care and social services. Services would include case management, housing support and Medication Assisted Treatment for those with substance abuse disorders.

Housing: Homeless individuals who have an eligible health condition would receive case management and housing support, potentially including moving costs, furnishings and short-term rental subsidies. Eligible conditions include a chronic physical or mental illness, substance abuse disorder or pregnancy (including a post-partum period).

Food: Food-insecure individuals who have a “diet-sensitive condition” such as diabetes or who are pregnant (including a post-partum period) would be eligible for nutrition counseling, and up to six months of grocery deliveries.

Child health insurance: Continuous Medicaid coverage for children from birth through the month of their 6th birthday, with the goal of ensuring uninterrupted access to health care in the period most crucial for their development.

Make your voice heard

Pennsylvania is nearing the end of a public comment period for its proposed Section 115 waiver application.

Information on the state’s proposed initiative, Keystones of Health, is available here. Comments can be provided via this online form or by mail at this address:

Department of Human Services

Office of Medical Assistance Programs

c/o Regulations Coordinator

P.O. Box 2675, Harrisburg, PA 17120

Comments are being accepted through Tuesday, Jan. 2.

‘Upstream’ investment

Human Services Secretary Dr. Valerie Arkoosh said her clinical work as a physician early in her career made her acutely aware of the importance of “social determinants of health,” leading her to obtain a master’s degree in public health and become involved in government and public policy.

The Keystones of Health initiatives are “exactly the kind of upstream work I’ve been hoping to expand,” she said.

To move forward, Pennsylvania must receive approval from the Centers for Medicare & Medicaid Services. The state developed Keystones of Health based on Section 1115 waiver initiatives approved in other states, so it is as confident as it can be that it will get the nod, Grande said.

As of March, according to Health Affairs, CMS had approved waivers for 18 states that included programs related to social determinants of health, while another 11 were pending.

Stephanie Meyer

Keystones of Health will operate mostly through Pennsylvania’s managed care organizations, said Stephanie Meyer, the department’s special assistant to Secretary Arkoosh. They are the same entities that administer HealthChoices, an existing program that provides physical and mental health care and social services to vulnerable populations covered by Medicaid.

Section 1115 demonstration programs run for five years. If Keystones of Health is approved, it will most likely begin in 2025 and run through 2029. Realistically, program development will take up much of the first year, so most services probably won’t roll out until 2026, Dr. Grande said.

A pro forma published by the Human Services Department shows the annual cost for Keystones of Health rising from $220 million in 2025 to $754.5 million in 2029, for a five-year total of a little over $3 billion. The child health insurance expansion accounts for just under 60% of that.

In general, Section 1115 waiver programs cannot result in the federal government spending more on Medicaid than it would otherwise. Pennsylvania says Keystones of Health will lower health care costs as well as yield healthier outcomes: For example, a diabetes patient who eats appropriately is less likely to suffer complications that would lead to a hospital admission, and children who get good healthcare early in life are less likely to develop chronic conditions.

Annual spending on Medicaid in Pennsylvania is around $37 billion, with the majority reimbursed by the federal government, according to the health think tank KFF.