You may disregard any bills sent by the hospital until a written decision is made.

Dear Patient and/or Responsible Party: Pursuant to Article II(a) of the Bylaws of South Nassau Communities Hospital, the Hospital provides care without regard to source of payment. To this end, the Hospital provides care to uninsured and underinsured patients who meet certain criteria under its charity care policy without charge or at amounts less than it s established Rates. Patient eligibility and the process to apply for this program are explained in this letter. Note: This charity care program does not cover Physicians whose billing is independent of the hospital. Any New York State resident who needs emergency services is eligible for a discount if they meet the income limits. Any patient who lives in Nassau County, Suffolk County and Queens (the Hospital s Primary Service and contiguous areas) is eligible for a discount on non-emergency, medically necessary services if they meet the income limits. Patient eligibility for free care or partial charity care is determined by measuring family income and liquid assets against the Income Poverty Guidelines established by the U.S. Department of Health and Human Services according to the table below: If you think that you may qualify for free care or care at reduced rates and wish to be considered, please complete the attached charity care application and return it to the Financial Assistance Department at the address listed on the application form. Documentation to support the income for all household members residing at the same address must also be submitted. Patient will be given one hundred thirty (130) days from the date of discharge or for recurring outpatients, one hundred thirty (130) days from the end of the month in which service was received, to apply for assistance. A completed application must be submitted to the hospital within thirty days (30) of the request. Upon receipt of a completed charity care application, the hospital shall cease its billing process until a final determination is made. The hospital will utilize your current income and make a written determination of eligibility within thirty days (30) of receiving and reviewing the completed application and the information submitted to support the household income reported. If based on income and family size, it is determined that you may qualify for Medicaid benefits, New York State's Family Health Plus or other similar programs, the hospital may require you to cooperate in applying for such coverage as a condition of receiving financial aid. You may disregard any bills sent by the hospital until a written decision is made. Charity Care is not an insurance coverage. It is a courtesy provided by South Nassau Communities Hospital and it is only valid at South Nassau Communities Hospital 1

Required Documentation for Determination of Charity Care Eligibility The completed, signed application listing all household members must be filled out and returned to the Financial Assistance Department along with the following: 1. Valid Photo Identification along with proof of address. Examples are: Drivers License; passport Current utility bill or property tax bill. 2. Proof of Income for the last 3 months Examples are: pay stubs, Social Security checks, unemployment checks. If you do not have any income information, and another person is supporting you, a letter is required from that party as well as all information listed above. If applicant's salary is paid in cash - A statement from the employer on the Company s letterhead with income information is required. NOTE: Applications submitted without supporting documents will not be considered. You will be notified by mail of the Hospital's decision within thirty days (30). Please return your application to: South Nassau Communities Hospital Financial Assistance Department One Healthy Way Oceanside, New York 11572 (516) 632-4015 COMMENTS: 2

APPLICATION FOR CHARITY CARE Date of Application Patient s Name Hospital Account #_ Applicant s Name_ Address Number and Street City State Zip Code Telephone # Employer Name & Telephone # Income: List combined income for yourself, spouse and other dependents from: Total-last 3 months Wages.. $ Self Employment Earnings....$ Public Assistance...$ Social Security....$ Unemployment/Worker s Comp...$ Alimony..$ Child Support.$ Military Family Allotments...$ Pensions $ Income From Dividends, Interest, Rent$_ As a condition to providing Charity Care, you are required to submit proof of income/resources: (1) income tax returns including W-2 s for the past year, (2) pay stubs, Social Security checks, Unemployment or Compensation papers for the past 3 consecutive months 3) other proof as request. Proof means copies. Family Size: Family members living in your household Name Age Relationship If additional space is needed, please attach another sheet. I hereby request that South Nassau Communities Hospital make a written determination of my eligibility for Charity Care. I understand that the information, which I submit concerning my annual income and family size is subject to verification by the hospital and that Charity Care, is offered at the discretion of the hospital. I also understand that if the information, which I submit is determined to be false, such determination will result in a denial and that I will be liable for charges for services provided. I affirm that the above information is true and correct to the best of my knowledge. Further, I hereby give my permission to South Nassau Communities Hospital to verify any information contained above. Date:_ Signature of Applicant 3

2015 FEDERAL POVERTY LEVEL GUIDELINES 500% OF THE FPL HOUSEHOLD Published UP TO GREATER UP TO GREATER UP TO GREATER UP TO GREATER UP TO GREATER UP TO GREATER UP TO SIZE FPL 2015 200% THAN 200% 250% THAN 250% 300% THAN 300% 350% THAN 350% 400% THAN 400% 450% THAN 450% 500% 1 11770 23540 23540 29425 29425 35310 35310 41195 41195 47080 47080 52965 52965 58850 2 15930 31860 31860 39825 39825 47790 47790 55755 55755 63720 63720 71685 71685 79650 3 20090 40180 40180 50225 50225 60270 60270 70315 70315 80360 80360 90405 90405 100450 4 24250 48500 48500 60625 60625 72750 72750 84875 84875 97000 97000 109125 109125 121250 5 28410 56820 56820 71025 71025 85230 85230 99435 99435 113640 113640 127845 127845 142050 6 32570 65140 65140 81425 81425 97710 97710 113995 113995 130280 130280 146565 146565 162850 7 36730 73460 73460 91825 91825 110190 110190 128555 128555 146920 146920 165285 165285 183650 8 40890 81780 81780 102225 102225 122670 122670 143115 143115 163560 163560 184005 184005 204450 EACH ADDITIONAL 4160 8320 8320 10400 10400 12480 12480 14560 14560 16640 16640 18720 18720 20800 Patient Liability: Lesser of Total Chgs or % of Blue Cross Rate FREE CARE 10% 20% 40% 60% 80% 100% Federal Register Wednesday, January 22, 2015

SOUTH NASSAU COMMUNITIES HOSPITAL Healthy Way. Oceanside, NY 11572 POLICY TITLE: Charity Care Policy POLICY NUMBER: OF-FD-160 DEPARTMENT: Finance PURPOSE: Pursuant to Article II (a) of the Bylaws of South Nassau Communities Hospital (the Hospital ), the Hospital provides care without regard to source of payment. To this end, the Hospital provides charity care and financial aid ( charity care ) for medically necessary services to assist those low-income, uninsured and underinsured individual s who do not otherwise have the ability to pay as determined under the Hospital s qualification criteria. DEFINITION: Primary Language- Any language that is either (1) used to communicate, during at least 5% of patient visits in a year, by patients who cannot speak, read, write or understand the English language at the level of proficiency necessary for effective communication with health care providers, or (2) spoken by non-english speaking individuals comprising more than 1% of the population of the Hospital s service area. Self Pay Program- A program to incorporate those uninsured and underinsured patients with substantial health care charges into the charity care program where such patients would otherwise not qualify because their gross income is more than 500% of Federal Poverty Level Guidelines. Recurring Patients- These patients receive three of more visits per week for the following service areas; physical therapy, radiation oncology, dialysis, outpatient mental health and cardiac rehabilitation and four or more visits per month for the Wound Care Center. Calendar Year- Defined as January 01 st through December 31 st of any given year. Foreign Visitors- Anyone entering the United States with the intention of returning back to their country of residence. POLICY STATEMENT: The Hospital posts the availability of charity care in English and Spanish in prominent locations (including the Emergency Room, Billing Office, Admitting, Family Practice Center, Account Services, Mental Health Center, Outpatient Registration, Dialysis Center, Home Care, Cardiac Rehabilitation, Physical Therapy,Wound Care) and other registration areas.

Any patient can request an application for charity care from the above registration areas, Billing Office and Account Services during regular business hours and via telephone. Patients will be notified of this policy as part of the admission package for inpatients and when registering for outpatient services. Hospital staff that interact with patients or have responsibility for billing and collection will be trained in the implementation of this policy. The Hospital will implement a mechanism to measure its compliance with this policy. Applications for charity care will be printed in English and Spanish. Any New York State Resident who needs emergency services is eligible for a discount if they meet the income limits. Any patient who lives in Nassau County, Suffolk County and Queens (the Hospital s Primary Service and contiguous areas) is eligible for a discount on non-emergency, medically necessary services at South Nassau Communities Hospital if they meet the income limits. They cannot be denied medically necessary care because they need financial assistance. Verification of residency is a requirement for eligibility purposes. Anyone may apply for charity care regardless of their immigration status except as indicated below for Foreign Visitors. The Hospital will presume that patients whose income is equal to or less than 500% of the Federal Poverty Level Guidelines are eligible for charity care. Upon receipt of a completed charity care application for a patient whose income is equal to or less than 500% of the Federal Poverty Level Guidelines, the Hospital will suspend billing such patients and all collection notices will be suspended until a final determination is made on the application. Upon request, a patient will be given the opportunity to satisfy his/her liability through a payment plan. The monthly payment plan will not exceed 10% of the gross monthly income of the patient. The rate of interest shall not exceed the rate for a ninety-day security issued by the U.S. Department of Treasury, plus 0.5%. No payment plan will include an acceleration or similar clause under which a higher rate of interest is triggered upon a missed payment. Please contact the Finance Department for the current rate. Deposits received for non-emergent, medically necessary care shall be included as part of any financial aid consideration.

Patients will be given one hundred thirty (130) days from the date of discharge or for recurring patients, one hundred thirty (130) days from the end of the month in which service was received, to apply for assistance. The Hospital may waive the 130 day period if the patient can show good cause for the late filing. All late filings will require the approval of the Director of Patient Accounts. Patients will be given thirty (30) days to submit a completed application. The Hospital shall issue a written denial/approval, including its appeal process, to the patient within thirty days (30) of receipt of a completed application. The Hospital will not refer an account to collection unless 30 days or more notice is provided to the patient. No account will be referred to collection if the patient was eligible for Medicaid at the time services were rendered. Hospital staff will telephone the patient regarding the bill prior to referring the account to a collection agency, except where no telephone information is on file for the patient. The Hospital will require all collection agencies to obtain the Hospital s prior consent before commencing legal action. All collection agencies must follow the Hospital s charity care policy and provide information to patients on how to apply for charity care. Consideration will be given in providing charity care on a case-by-case basis to those patients who have exhausted their insurance benefits and/or who have exceeded their financial eligibility criteria but face extraordinary medical costs including deductibles, coinsurance and co-payments. Special consideration will be given to recurring patients. Foreign visitors who need emergency services are eligible for a discount if they meet the income limits. Foreign visitors who need non-emergency medically necessary services are not eligible for charity care, but may qualify for a discount and/or payment schedule under the Self Pay Program. Hospital charity care is not a substitute for employer-sponsored, public, or individually purchased insurance. Patients eligible for Medicaid/Child Health Plus (CHP) or Family Health Plus (FHP) must present proof that an application was filed for such benefit prior to being considered for charity care. Proof of filing must be within 90 days of applying for Charity Care.

The Hospital will not require a denial from Medicaid/CHP/FHP prior to accepting and processing an application for charity care. Patients with gross income at or below 200% of the Federal Poverty Level Guidelines will receive free care, subject to other provisions in this policy. Patients with gross income between 200% and 250% of the Federal Poverty Level Guidelines will be responsible for the lower of the Hospital s full charges or 10% of the Blue Cross rate. Patients with gross income between 250% and 300% of the Federal Poverty Level Guidelines will be responsible for the lower of the Hospital s full charges or 20% of the Blue Cross rate. Patients with gross income between 300% and 350% of the Federal Poverty Level Guidelines will be responsible for the lower of the Hospital s full charges or 40% of the Blue Cross rate for that service. Patient with gross income between 350% and 400% of the Federal Poverty Level Guidelines will be responsible for the lower of the Hospital s full charges or 60% of the Blue Cross rate. Patients with gross income between 400% and 450% of the Federal Poverty Level Guidelines will be responsible for the lower of the Hospital s full charges or 80% of the Blue Cross rate. Patient with gross income between 450% and 500% of the Federal Poverty Level Guidelines will be responsible for the lower of the Hospital s full charges or 100% of the Blue Cross rate. A patient who is not eligible for Medicaid, CHP/FHP and/or a discount under the Hospital s charity care policy may be entitled to charity care in the form of a discount and/or payment schedule through the Self Pay Program. The Hospital shall make available, in summary form, its policy and procedures including gross income level used to determine eligibility and a description of its service areas. This policy does not cover bills for physicians services unless such professional services are included in the Hospital s bill for its services. PROCEDURE: All completed applications must be submitted and processed by the Financial Assistance Counselors in Accounts Service, the Family Practice Center or the Mental Health Counseling Center. Patient eligibility for charity care is determined by: current (last three months) family gross income, based on the Federal Poverty Level Guidelines issued by the U.S. Department of Health and Human Services.

The Hospital may utilize credit scoring software as a primary or secondary source of determining a patient s eligibility for charity care, but will not require the provision of social security numbers. Such credit scoring may not negatively impact the patient s FICO. Credit scoring software will not be used to deny an application for financial aid. The charity care application will not reference credit scoring. A patient s Medicaid spend-down, if applicable, is not considered a Hospital expense, but rather is the responsibility of the patient. If based upon income and family size, it appears that the patient may qualify for Medicaid, FHP or CHP, the Hospital may request the patient to apply for such benefits prior to making a charity care determination, but the patient may submit a request for charity care while the application for Medicaid/CHP/FHP is pending. All completed requests with supporting documents will be reviewed by the Financial Counselors or those individuals identified in Family Practice and Mental Health. The patient will be notified in writing of the determination as early as possible, but not later than thirty days (30) from the receipt of the completed application. Once a completed application, including required documentation or other information needed to make a determination on the request for charity care, has been submitted, the patient should be advised to disregard any bill that has been sent until the Hospital has rendered a decision on the application. If the patient is not satisfied with the determination, he/she can submit a written or verbal request for appeal to the Sr. Director of Patient Financial Services. The Chief Financial Office, Vice President of Finance or the Sr. Director of Patient Financial Services must approve all determinations. Each patient s eligibility for charity care will be re-evaluated at the beginning of each calendar year. The patient is responsible for initiating the re-evaluation. Charity care applications will be mailed out in September of each year to all then current charity care eligible patients for completion and return for processing. A patient s application will be re-evaluated if the Hospital becomes aware of additional or new information which may affect the application. Prior to approving a charity care application, the Financial Assistance personnel will confirm that the patient has no other insurance coverage, is not currently a Medicaid, CHP or FHP member and must document in the hospital financial system why the patient will not qualify for Medicaid, CHP or FHP. Charity Care applications for balances greater than $5,000.00 will require the approval of Financial Assistance Supervisor or the Manager/Director of Patient Access

Once an applicant has been approved for charity care, Patient Financial Services (PFS) will be notified. The PFS staff will review all related accounts, including accounts in bad debt, for possible insurance coverage. All charity care approval with a balance greater than $5,000 will require the approval of an assistant supervisor/supervisor prior to being allowanced. All charity care approval must be allowances by the last business day of each month and will be validated by the Managers of PFS and Patient Access. REPLACES: Hill-Burton Charity Care Obligation, Charity Care Application 06/2003; Charity Care Policy 5/25/04; 1/07; (Reviewed without revision 1/09); 3/10 (Reviewed without revisions 3/12) APPROVALS: Oversight Committee 7/12