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Page 1 of 7P-FC-016POLK MEDICAL CENTERPOLICY AND PROCEDURE MANUALPATIENT FINANCIAL SERVICESTITLE: Financial Assistance Policy(FAP)Policy No.: P-FC-016Purpose: To set forth the eligibility criteria andprocess relating to Polk Medical Center’sprovision of financial assistance to qualifyingpatients for emergency and other medicallynecessary care.Developed Date: 03/25/2013Review Date: 03/17/2021Revised Date: 11/10/2017, 4/6/2018, 7/30/19,4/2020, 03/17/2021Review Responsibility: Revenue CycleReference Standards: IRC § 501(r)Policy:Polk Medical Center will provide to qualifying patients free or discounted emergency andother medically necessary care in accordance with the eligibility criteria and determinationprocesses set forth in this Policy. In addition, following a determination of a patient’seligibility for financial assistance, Polk Medical Center will not charge the patient more foremergency or other medically necessary care than the amounts generally billed toindividuals who have insurance covering such care, as determined in accordance with thisPolicy.As further described below, this Financial Assistance Policy:1.Includes the eligibility criteria for financial assistance and sets forth thecircumstances in which a patient will qualify for free or discounted care.2.Describes the basis for calculating amounts charged to patients eligible forfinancial assistance under this Policy, as well as the amounts to whichdiscounts will be applied.3.Limits the amounts that Polk Medical Center will charge for emergency orother medically necessary care provided to patients eligible for financialassistance to no more than the amount generally billed to individuals whohave insurance covering such care.4.Describes the method by which Polk Medical Center determines theAmounts Generally Billed to individuals who have insurance.5.Describes the method by which patients may apply for financial assistance.6.States that the actions Polk Medical Center may take in the event ofnonpayment are described in a separate Billing and Collection Policy andexplains how an individual may readily obtain a free copy of the Billing andCollection Policy.

Page 2 of 7FC-0167.States that Polk Medical Center maintains as a separate document a listspecifying which providers (other than Polk Medical Center itself) deliveringemergency or other medically necessary care in the hospital are covered bythis Policy and which are not and explains how an individual may readilyobtain a free copy of the list.Please note that financial assistance provided under this Policy applies only to chargesof Polk Medical Center. Polk Medical Center cannot offer financial assistance for thecharges of any private physician practices, including those offering services at PolkMedical Center, and patients will need to make payment arrangements directly with thesephysician practices.As required by the Emergency Medical Treatment and Active Labor Act (EMTALA), PolkMedical Center provides emergency care to all patients, regardless of ability to pay.DEFINITIONSAmounts Generally BilledPolk Medical Center will apply the “look-back method” for determining Amounts GenerallyBilled (AGB). In particular, Polk Medical Center will determine the Amounts GenerallyBilled for emergency or other medically necessary care by multiplying the Gross Chargesfor that care by the AGB Percentage.AGB PercentagePolk Medical Center will calculate the AGB Percentage at least annually by dividing thesum of all claims that have been allowed for emergency and other medically necessarycare by Medicare fee-for-service and all private health insurers together during a priortwelve (12)-month period by the sum of the associated Gross Charges for those claims.For these purposes, Polk Medical Center will include in the amount “allowed” both theamount to be reimbursed by Medicare or the private insurer and the amount (if any) theMedicare beneficiary or insured individual is personally responsible for paying (in the formof co-insurance, copayments or deductibles), regardless of whether and when theindividual actually pays all or any of his or her portion, and disregarding any discountsapplied to the individual’s portion (under this Policy or otherwise).Federal Poverty GuidelinesThe current Federal Poverty Income Guidelines as published in the Federal Register fromtime to time by the U.S. Department of Health and Human Services.Financial AssistanceFree or discounted emergency or other medically necessary services provided by PolkMedical Center to patients who satisfy Polk Medical Center’s criteria for financialassistance and who are unable to pay for all or a portion of the services.Gross ChargesPolk Medical Center’s full established rates for the provision of healthcare items andservices.

Page 3 of 7FC-016Household AssetsThe combined assets (other than Household Income) of the patient, all account guarantorsand members of the patient’s household, as adjusted in accordance with this Policy.Household Assets include, without limitation, monies held in bank accounts andinvestment accounts, bonds, certificates of deposit, non-homeplace real property, andtrust assets. Excluded from Household Assets are: pension plan assets (including 401(k)plans) provided by an employer if the individual is still employed under the plan and iftermination of employment is required in order to receive benefits or a penalty would beimposed for early withdrawal; property (including vehicles) used to produce income; onevehicle per household member of driving age; assets jointly owned by the patient and anindividual who is not a member of the household, but only if the patient’s access to theasset is solely for the benefit of the non-household member. Applicants for financialassistance may be required to provide documentation regarding the value of HouseholdAssets.Household IncomeThe combined amount, before taxes, for all account guarantors and members of thepatient’s household from earnings, unemployment compensation, workers’ compensation,Social Security, Supplemental Security Income, public assistance, veterans’ payments,survivor benefits, pension or retirement income, interest, dividends, rents, royalties,income from estates, trusts, educational assistance, alimony, child support, assistancefrom outside the household, and other miscellaneous sources.Emergency and Medically NecessaryEmergency care is defined as medical services required for the immediate diagnosis andtreatment of medical conditions which, if not immediately diagnosed and treated, couldlead to serious physical or mental disability or death. Medically Necessary service asdefined by Medicare (i.e., services or items reasonable and necessary for the diagnosisor treatment of illness or injury). Any dispute as to the status of Emergency or MedicallyNecessary services will reviewed by the Senior Vice President and Chief Medical Officerto make a final determination.GuarantorAn individual other than the patient who is responsible for payment of the patient’s bill.ELIGIBILITY CRITERIA FOR FINANCIAL ASSISTANCEA patient is not eligible for financial assistance if Household Assets of the patient and anyguarantor are valued at 25,000 or more, regardless of the patient’s or the guarantor’sincome.A patient may qualify under this Policy for free emergency or other medically necessarycare when the aggregate Household Income of the patient and any guarantor are equalto or less than 125% of the current Federal Poverty Guidelines and the aggregateHousehold Assets of the patient and all guarantors are valued at less than 25,000.An uninsured patient is defined as a patient with no health insurance or other third partypayor coverage and may qualify under this Policy for discounted emergency or othermedically necessary care when both (i) the aggregate Household Assets of the patientand any guarantor are valued at less than 25,000 and (ii) the aggregate Household

Page 4 of 7FC-016Income of the patient and any guarantor is in excess of 125% but equal to or lower than400% of the Federal Poverty Guidelines.An insured patient may qualify under this Policy for discounted emergency or othermedically necessary care when both (i) the aggregate Household Assets of the patientand any guarantor are valued at less than 25,000 and (ii) the aggregate HouseholdIncome of the patient and any guarantor is in excess of 125% but equal to or lower than400% of the Federal Poverty Guidelines.Financial Assistance is not applicable to an insurance company’s or benefit plan’s paymentresponsibility under a health benefits plan or any third party payor responsibility for themedical services, regardless of whether the insurance company or plan has madepayment to the patient or to Polk Medical Center.In addition to meeting the Household Income and Available Household Assets criteria setforth above, in order to be eligible for Financial Assistance under this Policy, a patient alsomust: Complete the Financial Assistance Application provided by Polk Medical Center; Supply all documentation requested by Polk Medical Center in accordance withthis Policy and the Financial Assistance Application form; Apply for all public assistance programs requested by Polk Medical Centerincluding, for example, Medicaid, Social Security, disability, Victims of Crime, etc.;and Cooperate with Polk Medical Center in determining whether or not the patient iseligible for Financial Assistance under this Policy.Polk Medical Center will provide reasonable assistance to patients in pursuit of publicbenefits for which they may qualify (such as, for example, Georgia Medicaid, SocialSecurity, Victims of Crime, etc.) and any third party payor coverage (such as, for example,worker’s compensation or auto/personal liability insurance). Polk Medical Center mayuse the services of outside vendors to assist patients in seeking these benefits. It isimperative that patients or patients’ guarantors comply with the application process for anypublic benefits or assistance in obtaining any third party payor responsible for the bill.Those who do not cooperate will be denied Floyd financial assistanceInsured Patients with Copayment and Deductible qualify for Charity:Patients whom are underinsured or cannot pay the patient portion of the bill (copayment anddeductible) and they qualify for financial assistance, may have that portion of the bill writtenoff to Charity. The manager of patient financial services will run a quarterly report to identifythe co-insurance and deductible amounts that were adjusted to Charity.Non-Covered Medicaid Charges:Medicaid non-covered charges will be included as Charity Care Charges for patients whomqualify for financial assistance. Medicaid patients are indigent by definition. On a quarterly

Page 5 of 7FC-016basis, the manager of patient financial services will request a Summary Hospital StatisticalReport from Medicaid. A journal entry will made with a reclassification of Medicaidcontractual to Medicaid non-covered charity account on the general ledger.Bankruptcy:Patients whom file for bankruptcy are too be considered indigent. The write-off of all patientbalances or a commercial insurance balance related to the Hospital service should be takenas a charity transaction code. The documentation for Chapter 7 or Chapter 11 will beobtained from the Bankruptcy Court that is applicable to the situation.BASIS FOR CALCULATING AMOUNTS CHARGED TO PATIENTSPolk Medical Center will not charge patients eligible for Financial Assistance under thisPolicy for emergency or other medically necessary care more than the Amounts GenerallyBilled to individuals who have insurance covering such care (i.e., Polk Medical Center willnot charge patients eligible for Financial Assistance under this Policy for emergency orother medically necessary care more than the Gross Charges for such care multiplied bythe AGB Percentage.) Individuals may request the AGB Percentage in effect at anyparticular time by contacting the Financial Counseling Department or the Billing Office atthe addresses and phone numbers listed below.In addition, Polk Medical Center will provide free or discounted emergency or othermedically necessary care to patients eligible for Financial Assistance under this Policy inaccordance with the chart attached to this Policy as Exhibit A. The discount percentagesshown on Exhibit A shall be applied to the Gross Charges for such care multiplied by theAGB Percentage. For insured patients, the discounted Gross Charges will be used tocalculate only the patient’s financial responsibility under the applicable health benefitsplan. The health plan’s financial responsibility will be based on the plan’s terms and PolkMedical Center’s agreed rates without further adjustment, regardless of whether the healthplan has made payment to the patient or to Polk Medical Center. The dollar amounts onExhibit A will be updated from time to time as necessary to reflect the then- currentFederal Poverty Guidelines amounts.Polk Medical Center will charge patients eligible for financial assistance under this Policyless than Gross Charges for services other than emergency or other medically necessarycare.METHOD BY WHICH PATIENTS MAY APPLY FOR FINANCIAL ASSISTANCETo apply for Financial Assistance, patients or their guarantors must complete the FinancialAssistance Application provided by Polk Medical Center and provide all documentationrequested by Polk Medical Center in accordance with this Policy.In particular, allapplicants for Financial Assistance must provide proof of Household Income andHousehold Assets by providing copies of all of the following that are applicable: Paycheck stubs for at least the last four weeks or a statement from employerverifying gross wagesIRS Form W -2 issued during the past year

Page 6 of 7 FC-016Most recent IRS Form 1040Most recent two months of bank statements for each checking, savings,money market or other bank or investment accountWritten statements for the most recent two months for all other income (e.g.,unemployment compensation, disability, retirement, student loans, etc.)Unemployment compensation denial letterDocumentation of asset values, including, without limitation, property taxstatementsContribution statements from individuals who contribute income or in-kindassistance to the patientIf an applicant does not have any of the listed documents to demonstrate HouseholdIncome or Household Assets, the applicant may call the Financial CounselingDepartment or the Billing Office at the phone numbers listed below and discuss otherevidence that may be provided to demonstrate eligibility.Polk Medical Center generally will render a decision in writing regarding whether anindividual qualifies for Financial Assistance within five business days after its receipt of acomplete Financial Assistance Application. The written notice will include how the patientmay receive a more generous discount through prompt payment guidelines described inthe Payment Arrangements Policy PFS-030.Incomplete applications and those lacking supporting data will be returned to the applicantalong with a written description of the additional information and/or documentation requiredin order for the individual to complete the application.Polk Medical Center will make financial counselors reasonably available to provideassistance with the Financial Assistance Application.Approval of Financial Assistance in the form of free care or discounts, as applicable, willapply only to the episode of care for which the patient has submitted a complete FinancialAssistance Application and Polk Medical Center has found the patient to be eligible.ACTIONS POLK MEDICAL CENTER MAY TAKE IN THE EVENT OF NON-PAYMENTThe actions that Polk Medical Center may take in the event of non-payment are describedin Polk Medical Center’s Billing and Collections Policy. Individuals may obtain a copy ofthe Billing and Collections Policy on Polk Medical Center’s website at www.polkhospital.org,in both English and Spanish.WHERE TO FIND FURTHER INFORMATION REGARDING POLK MEDICALCENTER’S FINANCIAL ASSISTANCEPolk Medical Center makes this Financial Assistance Policy, the Financial AssistancePolicy Application form and a plain language summary of this Financial Assistance Policywidely available on its website at www.polkhospital.org, in both English and Spanish. Inaddition, Polk Medical Center makes paper copies of this Financial Assistance Policy, theFinancial Assistance Application, list of covered and non-covered providers (Exhibit B),List of Covered and Non-covered services (Exhibit C), and a plain language summary ofthis Financial Assistance Policy available, upon request and without charge, in Admissionsand Registration areas and, during normal business hours, at the following locations:

Page 7 of 7FC-016Financial Counseling DepartmentPolk Medical Center2360 Rockmart HighwayCedartown, Georgia 30125770-749-4284Billing OfficeFloyd Medical Center Corporate Support420 E. Second AvenueSuite 102Rome, Georgia 30161706-509-6000Individuals may also receive a copy of these documents by mail by contacting theFinancial Counseling Department and Billing Office listed above.

POLK INSURED DISCOUNT SCALE 2021DiscountAnnual PayPercent of Federal Poverty Guidelines 2021 AnnualHH %57%400%57%1 12,880 16,100 19,320 22,540 23,828 25,760 28,980 30,268 32,200 35,420 38,640 41,860 45,080 48,300 51,5202 17,420 21,775 26,130 30,485 32,227 34,840 39,195 40,937 43,550 47,905 52,260 56,615 60,970 65,325 69,6803 21,960 27,450 32,940 38,430 40,626 43,920 49,410 51,606 54,900 60,390 65,880 71,370 76,860 82,350 87,8404 26,500 33,125 39,750 46,375 49,025 53,000 59,625 62,275 66,250 72,875 79,500 86,125 92,750 99,375 106,0005 31,040 38,800 46,560 54,320 57,424 62,080 69,840 72,944 77,600 85,360 93,120 100,880 108,640 116,400 124,1606 35,580 44,475 53,370 62,265 65,823 71,160 80,055 83,613 88,950 97,845 106,740 115,635 124,530 133,425 142,3207 40,120 50,150 60,180 70,210 74,222 80,240 90,270 94,282 100,300 110,330 120,360 130,390 140,420 150,450 160,4808 44,660 55,825 66,990 78,155 82,621 89,320 100,485 104,951 111,650 122,815 133,980 145,145 156,310 167,475 178,640* 4,540 5,675 6,810 7,945 8,399 9,080 10,215 10,669 11,350 12,485 13,620 14,755 15,890 17,025 18,160325%350%375%400%57%57%57%* add for each additional family member.HH SizeDiscountPOLK UNINSURED DISCOUNT SCALE 2021Percent of Federal Poverty Guidelines 2021 0%85%80%75%70%250%65%275%60%300%57%57%1 12,880 16,100 19,320 22,540 23,828 25,760 28,980 30,268 32,200 35,420 38,640 41,860 45,080 48,300 51,5202 17,420 21,775 26,130 30,485 32,227 34,840 39,195 40,937 43,550 47,905 52,260 56,615 60,970 65,325 69,6803 21,960 27,450 32,940 38,430 40,626 43,920 49,410 51,606 54,900 60,390 65,880 71,370 76,860 82,350 87,8404 26,500 33,125 39,750 46,375 49,025 53,000 59,625 62,275 66,250 72,875 79,500 86,125 92,750 99,375 106,0005 31,040 38,800 46,560 54,320 57,424 62,080 69,840 72,944 77,600 85,360 93,120 100,880 108,640 116,400 124,1606 35,580 44,475 53,370 62,265 65,823 71,160 80,055 83,613 88,950 97,845 106,740 115,635 124,530 133,425 142,3207 40,120 50,150 60,180 70,210 74,222 80,240 90,270 94,282 100,300 110,330 120,360 130,390 140,420 150,450 160,4808 44,660 55,825 66,990 78,155 82,621 89,320 100,485 104,951 111,650 122,815 133,980 145,145 156,310 167,475 178,640* 4,540 5,675 6,810 7,945 8,399 9,080 10,215 10,669 11,350 12,485 13,620 14,755 15,890 17,025 18,160* add for each additional family member.Effective 08-31-2021

POLK INSURED DISCOUNT SCALE 2021DiscountMonthly PayPercent of Federal Poverty Guidelines 2021 MonthlyHH 7%57%57%57%1 1,073 1,342 1,610 1,878 1,986 2,147 2,415 2,522 2,683 2,952 3,220 3,488 3,757 4,025 4,2932 1,452 1,815 2,178 2,540 2,686 2,903 3,266 3,411 3,629 3,992 4,355 4,718 5,081 5,444 5,8073 1,830 2,288 2,745 3,203 3,386 3,660 4,118 4,301 4,575 5,033 5,490 5,948 6,405 6,863 7,3204 2,208 2,760 3,313 3,865 4,085 4,417 4,969 5,190 5,521 6,073 6,625 7,177 7,729 8,281 8,8335 2,587 3,233 3,880 4,527 4,785 5,173 5,820 6,079 6,467 7,113 7,760 8,407 9,053 9,700 10,3476 2,965 3,706 4,448 5,189 5,485 5,930 6,671 6,968 7,413 8,154 8,895 9,636 10,378 11,119 11,8607 3,343 4,179 5,015 5,851 6,185 6,687 7,523 7,857 8,358 9,194 10,030 10,866 11,702 12,538 13,3738 3,722 4,652 5,583 6,513 6,885 7,443 8,374 8,746 9,304 10,235 11,165 12,095 13,026 13,956 14,887* 378 473 568 662 700 757 851 889 946 1,040 1,135 1,230 1,324 1,419 1,513* add for each additional family member.POLK UNINSURED DISCOUNT SCALE 2021HH SizeDiscountPercent of Federal Poverty Guidelines 2021 0%57%57%57%57%1 1,073 1,342 1,610 1,878 1,986 2,147 2,415 2,522 2,683 2,952 3,220 3,488 3,757 4,025 4,2932 1,452 1,815 2,178 2,540 2,686 2,903 3,266 3,411 3,629 3,992 4,355 4,718 5,081 5,444 5,8073 1,830 2,288 2,745 3,203 3,386 3,660 4,118 4,301 4,575 5,033 5,490 5,948 6,405 6,863 7,3204 2,208 2,760 3,313 3,865 4,085 4,417 4,969 5,190 5,521 6,073 6,625 7,177 7,729 8,281 8,8335 2,587 3,233 3,880 4,527 4,785 5,173 5,820 6,079 6,467 7,113 7,760 8,407 9,053 9,700 10,3476 2,965 3,706 4,448 5,189 5,485 5,930 6,671 6,968 7,413 8,154 8,895 9,636 10,378 11,119 11,8607 3,343 4,179 5,015 5,851 6,185 6,687 7,523 7,857 8,358 9,194 10,030 10,866 11,702 12,538 13,3738 3,722 4,652 5,583 6,513 6,885 7,443 8,374 8,746 9,304 10,235 11,165 12,095 13,026 13,956 14,887* 378 473 568 662 700 757 851 889 946 1,040 1,135 1,230 1,324 1,419 1,513* add for each additional family member.Effective 08-31-2021

Exhibit BCovered and Non-Covered ProvidersEmergency and medically necessary care provided by Polk Medical Center and Polk Medical Centeremployed providers will be covered by this Policy. Services provided by other entities, such as notedbelow are not covered by this policy.CoveredPolk Medical CenterFloyd EMS (Emergency Services)The Brest Center at FloydNon-CoveredThe Harbin ClinicThe Harbin Clinic PhysiciansApollo AnesthesiaIn Compass Health, Inc.Heyman Hospice CareRome RadiologyFloyd EMS (Non-Emergent Transportations)Floyd Primary CareFloyd Urgent CareSoutheastern PathologyNursing HomesEtowah Emergency Physicians

Exhibit CCovered and Non-Covered ServicesCovered ServicesAnesthesiaCardiology/Cath EchoDiabetes EducationECCEMSPharmacyMobile MammographyLaboratoryFloyd BehavioralOut Patient ServicesWound CarePhysical TherapyInpatient ServicesImaging and RadiologyNon Covered ServicesPhysician Professional ServicesHospiceNon-emergency Transport ServicesPrimary Care OfficesUrgent Care FacilitiesNursing Home Services

Polk Medical Center will calculate the AGB Percentage at least annually by dividing the sum of all claims that have been allowed for emergency and other medically necessary care by Medicare fee-for-service and all private health insurers together during a prior twelve (12)-month period by