Hospitals. Complete if the organization answered "Yes" to Form 990, Part IV, question 20. Attach to Form 990. See separate instructions.

Transcription

1 SCHEDULE H (Form 990) Department of the Treasury Internal Revenue Service 2 If "Yes," was it a written policy? If the organization had multiple hospital facilities, indicate which of the following est descries application of the financial assistance policy to its various hospital facilities during the tax year. c If the organization used factors other than FPG in determining eligiility, descrie in Part VI the income ased criteria for determining eligiility for free or discounted care. Include in the description whether the organization used an asset test or other threshold, regardless of income, as a factor in determining eligiility for free or discounted care. 4 Did the organization s financial assistance policy that applied to the largest numer of its patients during the tax year provide for free or discounted care to the "medically indigent"? ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 5a Did the organization udget amounts for free or discounted care provided under its financial assistance policy during the tax year? ~~~~ Complete the following tale using the worksheets provided in the Schedule H instructions. Do not sumit these worksheets with the Schedule H. OMB No Financial Assistance and Certain Other Community Benefits at Cost Numer of Persons Total Direct Net Percent of Financial Assistance and (a) () (c) (d) (e) (f) activities or served community offsetting community total expense programs (optional) (optional) enefit expense revenue enefit expense Means-Tested Government Programs d Total Financial Assistance and Means-Tested Government Programs Complete if the organization answered "Yes" to Form 990, Part IV, question 20. Attach to Form 990. See separate instructions. 3 Answer the following ased on the financial assistance eligiility criteria that applied to the largest numer of the organization s patients during the tax year. a Did the organization use Federal Poverty Guidelines (FPG) as a factor in determining eligiility for providing free care? c a c e f g h i j k Applied uniformly to all hospital facilities Generally tailored to individual hospital facilities If "Yes," indicate which of the following was the FPG family income limit for eligiility for free care: ~~~~~~~~~~~~~ 100% 150% 200% Other % Did the organization use FPG as a factor in determining eligiility for providing discounted care? If "Yes," indicate which Other Benefits Total. Other Benefits ~~~~~~ Total. Add lines 7d and 7j Applied uniformly to most hospital facilities of the following was the family income limit for eligiility for discounted care: ~~~~~~~~~~~~~~~~~~~~~~~~ 200% 250% 300% 350% 400% Other % If "Yes," did the organization s financial assistance expenses exceed the udgeted amount? ~~~~~~~~~~~~~~~~ If "Yes" to line 5, as a result of udget considerations, was the organization unale to provide free or discounted care to a patient who was eligile for free or discounted care? ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 6a Did the organization prepare a community enefit report during the tax year? ~~~~~~~~~~~~~~~~~~~~~~~ If "Yes," did the organization make it availale to the pulic? ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Financial Assistance at cost (from Worksheet 1) ~~~~~~~~~~ Medicaid (from Worksheet 3, column a) ~~~~~~~~~~~ Costs of other means-tested government programs (from Worksheet 3, column ) ~~~~~ Community health improvement services and community enefit operations (from Worksheet 4) ~~~~~~~ Health professions education (from Worksheet 5) ~~~~~~~ Susidized health services (from Worksheet 6) ~~~~~~~ Research (from Worksheet 7) ~~ Cash and in-kind contriutions for community enefit (from Worksheet 8) ~~~~~~~~~ Hospitals 2012 Open to Pulic Inspection Name of the organization SUNNYVIEW HOSPITAL & REHABILITATION Employer identification numer CENTER Part I Financial Assistance and Certain Other Community Benefits at Cost Yes No 1a Did the organization have a financial assistance policy during the tax year? If "No," skip to question 6a ~~~~~~~~~~~ 1a 1 672, , , % % % 121, , , % 30, , % 187, , % 338, , , % % LHA For Paperwork Reduction Act Notice, see the Instructions for Form 990. Schedule H (Form 990) a 3 4 5a 5 5c 6a 6

2 Schedule H (Form 990) 2012 CENTER Page 2 Part II Community Building Activities Complete this tale if the organization conducted any community uilding activities during the tax year, and descrie in Part VI how its community uilding activities promoted the health of the communities it serves. (a) Numer of activities or programs (optional) () Persons served (optional) (c) Total community uilding expense (d) Direct offsetting revenue (e) Net community uilding expense (f) Percent of total expense Total Part III Bad Det, Medicare, & Collection Practices Section A. Bad Det Expense Section B. Medicare Physical improvements and housing Economic development Community support Environmental improvements Leadership development and training for community memers Coalition uilding Community health improvement advocacy Workforce development Other Did the organization report ad det expense in accordance with Healthcare Financial Management Association Statement No. 15? ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Enter the amount of the organization s ad det expense. Explain in Part VI the methodology used y the organization to estimate this amount Enter the estimated amount of the organization s ad det expense attriutale to patients eligile under the organization s financial assistance policy. Explain in Part VI the methodology used y the organization to estimate this amount and the rationale, if any, for including this portion of ad det as community enefit ~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~ Provide in Part VI the text of the footnote to the organization s financial statements that descries ad det expense or the page numer on which this footnote is contained in the attached financial statements. Enter total revenue received from Medicare (including DSH and IME) Enter Medicare allowale costs of care relating to payments on line 5 ~~~~~~~~~~~~ ~~~~~~~~~~~~ Sutract line 6 from line 5. This is the surplus (or shortfall) ~~~~~~~~~~~~~~~~~~ Descrie in Part VI the extent to which any shortfall reported in line 7 should e treated as community enefit. Also descrie in Part VI the costing methodology or source used to determine the amount reported on line 6. Check the ox that descries the method used: Cost accounting system Cost to charge ratio Other Section C. Collection Practices 9a Did the organization have a written det collection policy during the tax year? ~~~~~~~~~~~~~~~~~~~~~~~ 9a If "Yes," did the organization s collection policy that applied to the largest numer of its patients during the tax year contain provisions on the collection practices to e followed for patients who are known to qualify for financial assistance? Descrie in Part VI 9 Part IV Management Companies and Joint Ventures (owned 10% or more y officers, directors, trustees, key employees, and physicians - see instructions) , ,349, ,936,250. 3,413,151. (a) Name of entity () Description of primary (c) Organization s (d) Officers, direct- (e) Physicians activity of entity profit % or stock ownership % ors, trustees, or key employees profit % or stock ownership % 1 Yes No profit % or stock ownership % Schedule H (Form 990)

3 Schedule H (Form 990) 2012 CENTER Part V Facility Information Section A. Hospital Facilities (list in order of size, from largest to smallest) How many hospital facilities did the organization operate during the tax year? 1 Name, address, and primary wesite address 1 SUNNYVIEW HOSPITAL & REHAB CTR 1270 BELMONT AVENUE SCHENECTADY, NY Licensed hospital General medical & surgical Children s hospital Teaching hospital Critical access hospital Research facility ER-24 hours ER-other Other (descrie) REHABILITATION HOSPITAL Page 3 Facility reporting group Schedule H (Form 990)

4 Schedule H (Form 990) 2012 CENTER Part V Facility Information (continued) Section B. Facility Policies and Practices (Complete a separate Section B for each of the hospital facilities or facility reporting groups listed in Part V, Section A) Page 4 Name of hospital facility or facility reporting groupsunnyview HOSPITAL & REHAB CTR For single facility filers only: line numer of hospital facility (from Schedule H, Part V, Section A) 1 Community Health Needs Assessment (Lines 1 through 8c are optional for tax years eginning on or efore March 23, 2012) 1 During the tax year or either of the two immediately preceding tax years, did the hospital facility conduct a community health needs assessment (CHNA)? If "No," skip to line 9~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ If "Yes," indicate what the CHNA report descries (check all that apply): a A definition of the community served y the hospital facility Demographics of the community c Existing health care facilities and resources within the community that are availale to respond to the health needs of the community d How data was otained e The health needs of the community f Primary and chronic disease needs and other health issues of uninsured persons, low-income persons, and minority groups g The process for identifying and prioritizing community health needs and services to meet the community health needs h The process for consulting with persons representing the community s interests i Information gaps that limit the hospital facility s aility to assess the community s health needs j Other (descrie in Part VI) 2 Indicate the tax year the hospital facility last conducted a CHNA: 20 3 In conducting its most recent CHNA, did the hospital facility take into account input from representatives of the community served y the hospital facility, including those with special knowledge of or expertise in pulic health? If "Yes," descrie in Part VI how the hospital facility took into account input from persons who represent the community, and identify the persons the hospital facility consulted ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 4 Was the hospital facility s CHNA conducted with one or more other hospital facilities? If "Yes," list the other hospital facilities in Part VI ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 5 Did the hospital facility make its CHNA report widely availale to the pulic? ~~~~~~~~~~~~~~~~~~~~~~~~ If "Yes," indicate how the CHNA report was made widely availale (check all that apply): a Hospital facility s wesite Availale upon request from the hospital facility c Other (descrie in Part VI) 6 If the hospital facility addressed needs identified in its most recently conducted CHNA, indicate how (check all that apply to date): a Adoption of an implementation strategy that addresses each of the community health needs identified through the CHNA Execution of the implementation strategy c Participation in the development of a community-wide plan d Participation in the execution of a community-wide plan e Inclusion of a community enefit section in operational plans f Adoption of a udget for provision of services that address the needs identified in the CHNA g Prioritization of health needs in its community h Prioritization of services that the hospital facility will undertake to meet health needs in its community i Other (descrie in Part VI) 7 Did the hospital facility address all of the needs identified in its most recently conducted CHNA? If "No," explain in Part VI which needs it has not addressed and the reasons why it has not addressed such needs ~~~~~~~~~~~~~ 8a Did the organization incur an excise tax under section 4959 for the hospital facility s failure to conduct a CHNA as required y section 501(r)(3)? ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ If "Yes" to line 8a, did the organization file Form 4720 to report the section 4959 excise tax? ~~~~~~~~~~~~~~~~ c If "Yes" to line 8, what is the total amount of section 4959 excise tax the organization reported on Form 4720 for all of its hospital facilities? $ a 8 Yes No Schedule H (Form 990)

5 Schedule H (Form 990) 2012 CENTER Page 5 Part V Facility Information (continued) SUNNYVIEW HOSPITAL & REHAB CTR Financial Assistance Policy Yes No c d e f g h c d e f g Billing and Collections a c d e a c d e Did the hospital facility have in place during the tax year a written financial assistance policy that: Explained eligiility criteria for financial assistance, and whether such assistance includes free or discounted care? ~~~~~ Used federal poverty guidelines (FPG) to determine eligiility for providing free care? ~~~~~~~~~~~~~~~~~~~~ If "Yes," indicate the FPG family income limit for eligiility for free care: 100 % If "No," explain in Part VI the criteria the hospital facility used. Used FPG to determine eligiility for providing discounted care? ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ If "Yes," indicate the FPG family income limit for eligiility for discounted care: 300 % If "No," explain in Part VI the criteria the hospital facility used. Explained the asis for calculating amounts charged to patients? ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ If "Yes," indicate the factors used in determining such amounts (check all that apply): a Income level Asset level Medical indigency Insurance status Uninsured discount Medicaid/Medicare State regulation Other (descrie in Part VI) Explained the method for applying for financial assistance? ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Included measures to pulicize the policy within the community served y the hospital facility? ~~~~~~~~~~~~~~~ If "Yes," indicate how the hospital facility pulicized the policy (check all that apply): a The policy was posted on the hospital facility s wesite The policy was attached to illing invoices The policy was posted in the hospital facility s emergency rooms or waiting rooms The policy was posted in the hospital facility s admissions offices The policy was provided, in writing, to patients on admission to the hospital facility The policy was availale on request Other (descrie in Part VI) Did the hospital facility have in place during the tax year a separate illing and collections policy, or a written financial assistance policy (FAP) that explained actions the hospital facility may take upon non-payment? Check all of the following actions against an individual that were permitted under the hospital facility s policies during the tax year efore making reasonale efforts to determine patient s eligiility under the facility s FAP: Reporting to credit agency Lawsuits Liens on residences Body attachments Other similar actions (descrie in Part VI) ~~~~~~~~~~~~~~ Did the hospital facility or an authorized third party perform any of the following actions during the tax year efore making reasonale efforts to determine the patient s eligiility under the facility s FAP? ~~~~~~~~~~~~~~~~~~~~~~~ If "Yes," check all actions in which the hospital facility or a third party engaged: Reporting to credit agency Lawsuits Liens on residences Body attachments Other similar actions (descrie in Part VI) Schedule H (Form 990)

6 Schedule H (Form 990) 2012 CENTER Part V Facility Information (continued) SUNNYVIEW HOSPITAL & REHAB CTR 18 Indicate which efforts the hospital facility made efore initiating any of the actions listed in line 17 (check all that 19 apply): ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ a Notified individuals of the financial assistance policy on admission Notified individuals of the financial assistance policy prior to discharge c d e Notified individuals of the financial assistance policy in communications with the patients regarding the patients ills Documented its determination of whether patients were eligile for financial assistance under the hospital facility s financial assistance policy Other (descrie in Part VI) Policy Relating to Emergency Medical Care Did the hospital facility have in place during the tax year a written policy relating to emergency medical care that requires the hospital facility to provide, without discrimination, care for emergency medical conditions to individuals regardless of their eligiility under the hospital facility s financial assistance policy? ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 19 Yes Page 6 No a c d If "No," indicate why: The hospital facility did not provide care for any emergency medical conditions The hospital facility s policy was not in writing The hospital facility limited who was eligile to receive care for emergency medical conditions (descrie in Part VI) Other (descrie in Part VI) Charges to Individuals Eligile for Assistance under the FAP (FAP-Eligile Individuals) 20 Indicate how the hospital facility determined, during the tax year, the maximum amounts that can e charged to FAP-eligile individuals for emergency or other medically necessary care. a The hospital facility used its lowest negotiated commercial insurance rate when calculating the maximum amounts that can e charged The hospital facility used the average of its three lowest negotiated commercial insurance rates when calculating the maximum amounts that can e charged c The hospital facility used the Medicare rates when calculating the maximum amounts that can e charged d Other (descrie in Part VI) 21 During the tax year, did the hospital facility charge any of its FAP-eligile individuals, to whom the hospital facility provided emergency or other medically necessary services, more than the amounts generally illed to individuals who had insurance covering such care? ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 21 If "Yes," explain in Part VI. 22 During the tax year, did the hospital facility charge any FAP-eligile individuals an amount equal to the gross charge for any service provided to that individual? ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 22 If "Yes," explain in Part VI. Schedule H (Form 990)

7 Schedule H (Form 990) 2012 CENTER Part V Facility Information (continued) Section C. Other Health Care Facilities That Are Not Licensed, Registered, or Similarly Recognized as a Hospital Facility Page 7 (list in order of size, from largest to smallest) How many non-hospital health care facilities did the organization operate during the tax year? 2 Name and address Type of Facility (descrie) 1 SUNNYVIEW HOSPITAL & REHAB CTR 3757 CARMAN ROAD PT,OT & SPEECH OUTPATIENT SCHENECTADY, NY CLINIC 2 SUNNYVIEW HOSPITAL & REHAB CTR 427 GUY PARK AVENUE SPEECH AND HEARING OUTPATIENT AMSTERDAM, NY CLINIC Schedule H (Form 990)

8 Schedule H (Form 990) 2012 CENTER Complete this part to provide the following information Required descriptions. Provide the descriptions required for Part I, lines 3c, 6a, and 7; Part II; Part III, lines 4, 8, and 9; Part V, Section A; and Part V, Section B, lines 1j, 3, 4, 5c, 6i, 7, 10, 11, 12h, 14g, 16e, 17e, 18e, 19c, 19d, 20d, 21, and 22. Needs assessment. Descrie how the organization assesses the health care needs of the communities it serves, in addition to any needs assessments reported in Part V, Section B. Patient education of eligiility for assistance. Descrie how the organization informs and educates patients and persons who may e illed for patient care aout their eligiility for assistance under federal, state, or local government programs or under the organization s financial assistance policy. Community information. Descrie the community the organization serves, taking into account the geographic area and demographic constituents it serves. Promotion of community health. Provide any other information important to descriing how the organization s hospital facilities or other health care facilities further its exempt purpose y promoting the health of the community (e.g., open medical staff, community oard, use of surplus funds, etc.). Affiliated health care system. If the organization is part of an affiliated health care system, descrie the respective roles of the organization and its affiliates in promoting the health of the communities served. State filing of community enefit report. If applicale, identify all states with which the organization, or a related organization, files a community enefit report. Facility reporting group(s). If applicale, for each hospital facility in a facility reporting group provide the descriptions required for Part V, Section B, lines 1j, 3, 4, 5c, 6i, 7, 10, 11, 12h, 14g, 16e, 17e, 18e, 19c, 19d, 20d, 21, and 22. PART I, LINE 3C: SUNNYVIEW HOSPITAL AND REHABILITATION CENTER S FINANCIAL ASSISTANCE POLICY USES THE FEDERAL POVERTY GUIDELINES TO DETERMINE ELIGIBILITY, AND DOES NOT USE AN ASSET TEST. PART I, LINE 6A: THE COMMUNITY BENEFIT REPORT, IN THE FORM OF A DOCUMENT ENTITLED "COMMUNITY SERVICE PLAN - COMPREHENSIVE THREE-YEAR PLAN," WAS PREPARED BY NORTHEAST HEALTH, INC., A RELATED ORGANIZATION THAT CONTROLS SUNNYVIEW HOSPITAL AND REHABILITATION CENTER. PART I, LN 7 COL(F): THE COSTING METHOLOGY USED TO CALCULATE THE AMOUNTS REPORTED IN THE TABLE WAS A COST-TO-CHARGE RATIO DERIVED FROM SUNNYVIEW HOSPITAL AND REHABILITATION CENTER S 2012 YEAR-END CMS-2552 REPORT. PART III, LINE 2: THE COSTING METHODOLOGY USED IN PART III, LINES 2 IS THE COST-TO-CHARGE RATIO Schedule H (Form 990)

9 Schedule H (Form 990) CENTER PART III, LINE 4: THE COMBINED FINANCIAL STATEMENTS FOR NORTHEAST HEALTH, INC. AND AFFILIATES (WHICH INCLUDES SUNNYVIEW HOSPITAL AND REHABILITATION CENTER), CONTAIN THE FOLLOWING NOTE REGARDING BAD DEBT EPENSE THE AFFILIATES GRANT CREDIT WITHOUT COLLATERAL TO PATIENTS, MOST OF WHOM ARE LOCAL RESIDENTS AND ARE INSURED UNDER THIRD-PARTY AGREEMENTS. ADDITIONS TO THE ALLOWANCE FOR ESTIMATED UNCOLLECTIBLE ACCOUNTS ARE MADE BY MEANS OF THE PROVISION FOR BAD DEBTS. ACCOUNTS WRITTEN OFF AS UNCOLLECTIBLE ARE DEDUCTED FROM THE ALLOWANCE AND SUBSEQUENT RECOVERIES ARE ADDED. THE AMOUNT OF THE PROVISION FOR BAD DEBTS IS BASED UPON MANAGEMENT S ASSESSMENT OF HISTORICAL AND EPECTED NET COLLECTIONS, BUSINESS AND ECONOMIC CONDITIONS, TRENDS IN FEDERAL AND STATE GOVERNMENTAL HEALTH CARE COVERAGE AND OTHER COLLECTION INDICATORS. SERVICES RENDERED TO INDIVIDUALS WHEN PAYMENT IS EPECTED AND ULTIMATELY NOT RECEIVED ARE WRITTEN OFF TO THE ALLOWANCE FOR ESTIMATED UNCOLLECTIBLE ACCOUNTS. PART III, LINE 8: MEDICARE ALLOWABLE COSTS WERE DERIVED BY TAKING THE INPATIENT ALLOWABLE COST FROM THE 2012 CMS-2552, WORKSHEET D-1, PART II FOR THE HOSPITAL AND THE REHABILITATION CENTER (IRF) PLUS THE TOTAL OF ALL OUTPATIENT CHARGES FROM THE PS & R (DATED 04/01/13) MULTIPLIED BY THE RCC TAKEN FROM THE 2012 CMS-2552, WORKSHEET S-10, LINE 1. PART III, LINE 9B: IF A PATIENT QUALIFIES FOR FINANCIAL ASSISTANCE, THEIR ACCOUNT WILL NOT BE SUBJECT TO THE USUAL COLLECTION PRACTICES DURING THIS PROCESS. IF THE PATIENT DOES NOT SUBMIT THE NECESSARY DOCUMENTATION WITHIN 90 DAYS, THEN THEIR ACCOUNT COULD BE FORWARDED TO COLLECTIONS Schedule H (Form 990) 37

10 Schedule H (Form 990) CENTER SUNNYVIEW HOSPITAL & REHAB CTR: PART V, SECTION B, LINE 20D: THE HOSPITAL USED ITS NEGOTIATED COMMERCIAL INSURANCE RATE NEGOTIATED WITH ITS HIGHEST VOLUME COMMERCIAL PAYER. PART VI, LINE 2: THE ORGANIZATION AS A COMPONENT OF THE NORTHEAST HEALTH SYSTEM, HAS BEEN A PARTICIPANT IN THE HEALTHY CAPITAL DISTRICT INITIATIVE ("HCDI") SINCE OTHER PARTICIPANTS INCLUDE ALL HOSPITALS, COUNTY HEALTHY DEPARTMENTS AND PAYERS IN THE ALBANY, RENSSELAER AND SCHENECTADY COUNTIES. RECENTLY, HCDI UNDERTOOK A THREE-PRONGED INITIATIVE TO ENGAGE THE PUBLIC AND ASSESS COMMUNITY NEEDS. THE THREE EFFORTS CONSISTED OF: 1. THE COLLECTION AND ANALYSIS OF DATA IN THE COMMUNITY HEALTH PROFILE. 2. THE PRODUCTION OF A COMMUNITY HEALTH FORUM BROADCASTED BY THE LOCAL PBS AFFILIATE AND 3. THE COLLECTION OF DATA USING AN ONLINE COMMUNITY HEALTH SURVEY TO ASSESS RESPONDENTS OPINIONS ON THE HEALTH OF THE CAPITAL DISTRICT. THROUGH THE HCDI PROCESS, CONSIDERATION OF THE NEW YORK STATE COMMISSIONER OF HEALTH S TEN PUBLIC HEALTH PRIORITIES AND THROUGH OTHER LOCAL EFFORTS TO OBTAIN ADDITIONAL COMMUNITY INPUT, NORTHEAST HEALTH DEVELOPED HEALTH SERVICES PRIORITIES CONTAINED IN ITS COMMUNITY SERVICE PLAN. PART VI, LINE 3: FINANCIAL ASSISTANCE FOR LOW INCOME, UNINSURED OR UNDER INSURED INDIVIDUALS WITH THEIR HOSPITAL CLAIMS FOR SERVICES PROVIDED, WHICH ARE DEEMED TO BE MEDICALLY NECESSARY IS AVAILABLE TO ALL WHO QUALIFY. THIS INFORMATION IS PROVIDED UPON ADMISSION IN THE PATIENT S INFORMATION PACKAGE, IS POSTED IN THE ADMITTING & THE OUTPATIENT Schedule H (Form 990) 38

11 Schedule H (Form 990) CENTER REGISTRATION OFFICE AND CAN BE MAILED UPON REQUEST OR AN INDIVIDUAL CAN COME INTO THE FACILITY AND WORK WITH A SOCIAL WORKER TO FILL OUT THE APPLICATION. PRIOR TO APPROVAL FOR FINANCIAL ASSISTANCE, PATIENTS MAY BE ASKED TO APPLY FOR MEDICAID OR OTHER PUBLICLY SPONSORED INSURANCE PROGRAMS. PART VI, LINE 4: GENERAL DESCRIPTION: FOUNDED IN 1928, SUNNYVIEW REHABILITATION HOSPITAL IS A 115-BED HOSPITAL SPECIALIZING IN PHYSICAL REHABILITATION, AND IS PART OF THE NORTHEAST HEALTH NETWORK, A REGIONAL, COMPREHENSIVE, NOT-FOR-PROFIT PROVIDER OF HEALTH CARE AND COMMUNITY SERVICES. NORTHEAST HEALTH WAS FORMED IN 1995 BY THE MERGER OF SAMARITAN HOSPITAL AND THE EDDY, JOINED BY ALBANY MEMORIAL HOSPITAL IN 1997 AND SUNNYVIEW REHABILITATION HOSPITAL IN THE COMPONENTS OF NORTHEAST HEALTH ARE DEEPLY ROOTED IN THEIR COMMUNITIES, EACH WITH A LONG TRADITION OF PROVIDING HIGH QUALITY CARE AND SERVICES. SERVING 22 COUNTIES IN THE GREATER CAPITAL REGION OF UPSTATE NEW YORK, NORTHEAST HEALTH CARES FOR APPROIMATELY 175,000 PEOPLE EACH YEAR AND PROVIDES A VAST ARRAY OF SENIOR CARE, HOSPITAL SERVICES, REHABILITATION, SPECIALTY SERVICES AND RETIREMENT LIVING OPTIONS. COMMUNITIES SERVED: SUNNYVIEW SERVES A REGIONAL CONSTITUENCY, WITH ITS LOCAL COMPONENT MADE UP PRIMARILY OF RESIDENTS FROM SCHENECTADY AND SARATOGA COUNTIES. THESE CONTIGUOUS COUNTIES (SEPARATED PARTIALLY BY THE MOHAWK RIVER) CONTAIN 367,330 PERSONS. THEIR POPULATIONS ARE CONCENTRATED IN THE CITIES OF SCHENECTADY AND SARATOGA SPRINGS, WHICH ACCOUNT FOR ABOUT 25% OF THE POPULATION. THE BALANCE OF THE POPULATION IS DISPERSED AMONG SMALLER Schedule H (Form 990) 39

12 Schedule H (Form 990) CENTER VILLAGES, SUBURBS AND RURAL AREAS. SARATOGA AND SCHENECTADY COUNTIES HAVE A FAIRLY DIVERSE DEMOGRAPHIC PROFILE BASED ON INCOME, POVERTY AND HEALTH INSURANCE MEASURES AS ILLUSTRATED BELOW. DEMOGRAPHIC SARATOGA SCHENECTADY 2010 POPULATION 219, , POPULATION 233, ,694 % CHANGE 6.5% 0.5% 2010 HOUSEHOLDS 88,221 61, HOUSEHOLDS 96,103 62,581 % CHANGE 8.9% 2.0% 2009 MEDIAN HOUSEHOLD INCOME $62,536 $54,066 PERSONS BELOW POVERTY LEVEL (2007 ESTIMATE) 14,556 (6.9%) 16,264 (11.1%) NUMBER OF MEDICAID ENROLLEES ,925 (8.2%) 21,115 (14.3%) NUMBER OF UNINSURED (2007 ESTIMATE) 25,119 (11.4%) 16,294 (11.0%) SARATOGA S PROFILE ABOVE REFLECTS A WEALTHIER PROFILE WITH SUBSTANTIALLY HIGHER MEDIAN INCOME AND MUCH HIGHER GROWTH PROJECTED THAN SCHENECTADY COUNTY. SARATOGA COUNTY HAS MUCH LOWER PERCENTAGES OF PERSONS IN POVERTY Schedule H (Form 990) 40

13 Schedule H (Form 990) CENTER AND PERSONS RECEIVING MEDICAID. SCHENECTADY PRESENTS A DIFFERENT PROFILE, CONSISTENT WITH A MORE URBAN COMMUNITY, WITH MINIMAL GROWTH AND HIGHER PORTION OF PERSONS IN POVERTY. ITS PERCENTAGE OF PERSONS ON MEDICAID IS THE HIGHEST IN THE REGION. OTHER HOSPITALS: THERE ARE FOUR OTHER HOSPITALS IN THE TWO COUNTY AREA. ELLIS MEDICINE IS THE PARENT ENTITY FOR THREE HOSPITALS IN SCHENECTADY COUNTY. ELLIS HOSPITAL HAS 368 BEDS AND IS A TERTIARY CARE PROVIDER. THE FORMER ST. CLARE S HOSPITAL IS NOW OPERATED AS A DIVISION OF ELLIS. IT HAS APPROIMATELY 100 BEDS. ALSO OPERATING AS A DIVISION OF ELLIS IS BELLEVUE WOMEN S HOSPITAL IN THE TOWN OF NISKAYUNA, WITH 40 MATERNITY AND 15 NEONATAL INTENSIVE CARE BEDS. IN SARATOGA COUNTY, SARATOGA HOSPITAL IN THE CITY OF SARATOGA SPRINGS OPERATES AN ACUTE GENERAL HOSPITAL WITH 171 BEDS. MEDICALLY UNDERSERVED AREAS/POPULATIONS: SCHENECTADY COUNTY IS DESIGNATED IN ITS ENTIRETY AS A MEDICALLY UNDERSERVED POPULATION (MUP) BASED ON ACCESS TO MEDICAL CARE AT HOME. PART VI, LINE 5: IN ADDITION TO ITS ACTIVITIES IN DELIVERING HEALTH CARE SERVICES TO THE COMMUNITY AS DESCRIBED ELSEWHERE IN THIS FILING, SUNNYVIEW HOSPITAL AND REHABILITATION CENTER FURTHERS ITS EEMPT PURPOSES THROUGH THE FOLLOWING MEANS: 1. SUNNYVIEW HOSPITAL AND REHABILITATION CENTER IS MANAGED BY A COMMUNITY BOARD OF DIRECTORS, ON WHICH THE SUBSTANTIAL MAJORITY OF DIRECTORS ARE Schedule H (Form 990) 41

14 Schedule H (Form 990) CENTER RESIDENTS OF THE HOSPITAL S PRIMARY OR SECONDARY SERVICE AREA AND WHO ARE NEITHER EMPLOYEES NOR CONTRACTORS OF THE HOSPITAL; 2. SUNNYVIEW HOSPITAL AND REHABILITATION CENTER MAINTAINS AN OPEN MEDICAL STAFF THAT ETENDS PRIVILEGES TO ALL QUALIFIED PHYSICIAN APPLICANTS; AND 3. THE ORGANIZATION GENERALLY APPLIES ALL SURPLUS FUNDS TO ENSURING FINANCIALLY PRUDENT AVAILABILITY OF FUNDS, CAPITAL MAINTENANCE AND IMPROVEMENTS, AND THE ADDITION OF SERVICES THAT BENEFIT THE COMMUNITY. IN 2010 NORTHEAST HEALTH, THE HEALTH SYSTEM TO WHICH SUNNYVIEW HOSPITAL AND REHABILITATION CENTER BELONGS, ENTERED INTO AN AFFILIATION AGREEMENT WITH ST. PETER S HEALTH CARE SERVICES, PRINCIPALLY LOCATED IN ALBANY, AND SETON HEALTH SYSTEM, PRINCIPALLY LOCATED IN TROY, UNDER WHICH THE PARTIES FORMED A NEW NOT-FOR-PROFIT ENTITY THAT BECAME THE PARENT OF THE CONSTITUENT SYSTEMS. THE PARTIES CONSUMMATED THE AFFILIATION TRANSACTION ON OCTOBER 31, THE AFFILIATION PARTIES BELIEVE THAT BY COMBINING THEIR COMPLEMENTARY STRENGTHS, THEY WILL SIGNIFICANTLY IMPROVE THEIR ABILITY TO MEET THE HEALTHCARE NEEDS OF THE REGION THROUGH MORE COORDINATION, IMPROVED EFFICIENCY, REDUCED FRAGMENTATION OF CARE, AND IMPROVED ACCESS FOR THE POOR AND UNDERSERVED PEOPLE IN THE CAPITAL REGION AND BEYOND. THE AFFILIATION WILL BETTER POSITION THE PARTIES TO ADDRESS CHALLENGES FACING HEALTH CARE DELIVERY AND TO MEET THE NEEDS OF THE COMMUNITY. PART VI, LINE 6: SUNNYVIEW HOSPITAL AND REHABILITATION CENTER IS AFFILIATED WITH NORTHEAST HEALTH, A NETWORK OF HEALTHCARE, SUPPORTIVE HOUSING AND COMMUNITY SERVICES. THE AFFILIATION FURTHERS SUNNYVIEW Schedule H (Form 990) 42

15 Schedule H (Form 990) CENTER HOSPITAL AND REHABILITATION CENTER S ABILITY TO PROMOTE HEALTH CARE IN MANY WAYS. NORTHEAST HEALTH AFFILIATION HELPS ENSURE SUNNYVIEW HOSPITAL AND REHABILITATION CENTER S FINANCIAL STABILITY THROUGH REDUCED ADMINISTRATIVE OVERHEAD COSTS, ACCESS TO CAPITAL AND SUPPLY CHAIN MANAGEMENT, AMONG OTHER THINGS. SUNNYVIEW HOSPITAL AND REHABILITATION CENTER S AFFILIATION WITH NORTHEAST HEALTH ALSO ENABLES GREATER COLLABORATION WITH AFFILIATED HOSPITALS AND OTHER PROVIDERS OF SERVICES. IN ADDITION TO SHARING POLICIES AND PROCEDURES AND IDEAS FOR BEST OPERATIONAL AND MANAGEMENT PRACTICES, SYSTEM AFFILIATES PARTICIPATE JOINTLY IN QUALITY IMPROVEMENT ACTIVITIES. THE NORTHEAST HEALTH BOARD QUALITY COMMITTEE OVERSEES QUALITY IMPROVEMENT ACTIVITIES IN THE SYSTEM S ACUTE CARE HOSPITALS, REHABILITATION HOSPITAL, SKILLED NURSING FACILITIES, PRIMARY CARE NETWORK, VISITING NURSE AND COMMUNITY SERVICE PROGRAMS, ADULT HOUSING AND PROGRAM FOR ALL-INCLUSIVE CARE FOR THE ELDERLY ("PACE" PROGRAM). THROUGH THIS COMMITTEE AND OTHER JOINT ACTIVITIES, THE SYSTEM SEEKS TO ENSURE COLLABORATION ON QUALITY INITIATIVES AMONG VARIED PROVIDER TYPES. FOR EAMPLE, SEVERAL QUALITY INITIATIVES COMMENCED IN 2010 THAT ARE INTENDED TO LEAD TO MEASURABLE IMPROVEMENTS IN PATIENT CARE TRANSITIONS BETWEEN HOSPITALS, NURSING HOMES, HOME HEALTH AND SUPPORTIVE HOUSING. NORTHEAST HEALTH HAS ALSO SUCCESSFULLY DEPLOYED THE LEAN THINKING AND TOOLS DEVELOPED BY THE TOYOTA PRODUCTION SYSTEM IN ITS INTEGRATED HEALTH CARE DELIVERY SYSTEM. LEAN IS AN INTEGRATED APPROACH TO DESIGNING AND IMPROVING WORK TOWARD AN "IDEAL STATE," WHICH IS CUSTOMER FOCUSED AND Schedule H (Form 990) 43

16 Schedule H (Form 990) CENTER INVOLVES PEOPLE AT ALL LEVELS USING COMMON PRACTICES AND PRINCIPLES. LEAN SYSTEMS GIVE PEOPLE AT ALL LEVELS OF AN ORGANIZATION THE SKILLS AND A SHARED WAY OF THINKING TO SYSTEMATICALLY DRIVE OUT WASTE THROUGH DESIGNING AND IMPROVING WORK OF ACTIVITIES, CONNECTIONS, AND FLOWS. SUNNYVIEW HOSPITAL AND REHABILITATION CENTER S AFFILIATION WITH NORTHEAST HEALTH HAS ENABLED IT TO ADOPT LEAN THINKING AND TOOLS WITH A DEGREE OF SUCCESS UNLIKELY TO HAVE BEEN ATTAINED BUT FOR THE AFFILIATION. LEAN HAS ENABLED SUNNYVIEW HOSPITAL AND REHABILITATION CENTER TO PROVIDE BETTER CARE AND SERVICES TO THE COMMUNITY. PART VI, LINE 7, LIST OF STATES RECEIVING COMMUNITY BENEFIT REPORT: NY Schedule H (Form 990) 44