Statement of Purpose

The Mount Sinai Hospitals Group, Inc. ("MSHG"), The Mount Sinai Hospital, Beth Israel Medical Center, The St. Luke’s Roosevelt Hospital Center, and the New York Eye & Ear Infirmary (collectively the "MSHG Member Hospitals") recognize that many of the patients served in the MSHG Member Hospitals may be unable to access quality health care services without financial assistance. This Financial Assistance and Billing and Collections Policy (the "Policy") was developed to ensure that the MSHG and the MSHG Member Hospitals continue to uphold their mission of providing quality health care to the community, while carefully taking into consideration the ability of the patient to pay, as applied in a fair and consistent manner.

Definitions

"MSHG Member Hospitals" means Beth Israel Medical Center ("MSBI"), The St. Luke's-Roosevelt Hospital Center ("MSW", "MSSL"), The New York Eye and Ear Infirmary ("NYEEI"), and The Mount Sinai Hospital ("MSH").

“MSHG Member Hospital Facilities” or “Hospital Facilities” means those facilities that are a part of either MSBI, MSW, MSSL, NYEEI, or MSH, that are licensed by New York State to operate as "Article 28" hospital facilities and that are listed in Section 8 of this Policy.

“Emergency Medical Care” means care provided by the MSHG and or the MSHG Member Hospitals, at any of the MSHG Member Hospital Facilities, for emergency medical conditions.

“Financial Assistance Application Period” means the period ending on the 240th day after the first post-discharge billing statement is provided to a patient.

“ISMMS” means the Icahn School of Medicine at Mount Sinai.

“Medically Necessary Care” means items and services that are reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Policy Administration

The Mount Sinai Department of Patient Financial Services has ownership, control, and responsibility for administration of this Policy. Patients who need assistance with the financial assistance application process should contact:

• Mount Sinai West, Mount Sinai St. Luke’s, Mount Sinai Beth Israel: Patient Financial Services, 1111 Amsterdam Avenue, New York, New York 10025, (212) 523 4674, Attn: Hiram Martinez


• NYEEI: NYEEI Admitting Department, 310 East 14th Street, New York, New York 10003, (212) 979 4115, Attn: Brian Goldstein


• Mount Sinai Hospital, Mount Sinai Queens and REAP: Patient Financial Services, One Gustave L. Levy Place, Box 6000, New York, New York 10029, (212) 731 3100, Attn: Erwin Ramirez

Policy

It is MSHG and MSHG Member Hospital policy that patients who meet the eligibility criteria and apply for financial assistance as set forth herein will receive financial assistance for Emergency Medical Care and other Medically Necessary Care rendered in the MSHG Member Hospital Facilities by the MSHG and the MSHG Member Hospitals themselves (including providers employed by or contracted directly by the MSHG Member Hospitals).

In addition, as set forth in this Policy and in the Appendices to this Policy, patients who meet the eligibility criteria set forth in this Policy and apply for financial assistance as set forth herein may be entitled to receive financial assistance for Emergency Medical Care and other Medically Necessary Care rendered in the MSHG Member Hospital Facilities by providers who are directly employed by or contracted by ISMMS.

Eligibility Criteria for Financial Assistance Under This Policy

Eligibility for Emergency Medical Care: Patients may be eligible for financial assistance for Emergency Medical Care under this Policy if:

• Their primary residence is located in the State of New York; and
• They are uninsured, have exhausted, or will exhaust all available insurance benefits; and
• Their annual income does not exceed 400% of the current Federal Poverty Guidelines; and
• They apply for financial assistance within the Financial Assistance Application Period (i.e. within the period ending on the 240th day after the first post-discharge billing statement is provided to a patient).

Eligibility for non-emergency Medically Necessary Care: Patients may be eligible for financial assistance for non-emergency Medically Necessary Care under this Policy if:

• Their primary residence is located in the City of New York; and
• They are uninsured, have exhausted, or will exhaust all available insurance benefits; and
• Their annual income does not exceed 400% of the current Federal Poverty Guidelines; and
• They apply for financial assistance within the Financial Assistance Application Period (i.e. within the period ending on the 240th day after the first post-discharge billing statement is provided to a patient).

Patients are ineligible for financial assistance for Emergency Medical Care or other non-emergency Medically Necessary Care under this Policy if:

• False information was provided by the patient or responsible party; or
• The patient or responsible party refuses to cooperate with any of the terms of this Policy; or
• The patient or responsible party refuses to apply for government insurance programs after it is determined that the patient or responsible party is likely to be eligible for those programs; or
• The patient or responsible party refuses to adhere to their primary insurance requirements.

Services For Which Financial Assistance Is Or May Be Available Under This Policy

Financial assistance is available under this policy for Emergency Medical Care and other Medically Necessary Care rendered in the MSHG Member Hospital Facilities by either: (1) the MSHG; or (2) the MSHG Member Hospitals (including providers employed by or contracted by those hospitals). Appendices A - D to this Policy contain lists that set forth, for each MSHG Member Hospital: (1) the names of all of the providers and entities (as appropriate) that provide Emergency Medical Care and/or Medically Necessary Care in each such MSHG Member Hospital; (2) the affiliation and/or employment status of each such provider; and (3) the extent to which, if at all, financial assistance under this Policy is available for such services provided by those providers. These Appendices can be accessed online at www.hospitalassistance.org, or can be obtained in hard copy upon request to any of the offices listed in Section 3 herein.

Financial assistance may be available under this Policy for certain Emergency Medical Care and other Medically Necessary Care rendered in the MSHG Member Hospital Facilities that is billed to patientsby providers who are either directly employed by or contracted by ISMMS, depending on the nature and scope of the services at issue and the patient’s eligibility for financial assistance. The Appendices to this Policy contain information regarding the extent to which, if at all, financial assistance is available for such services rendered at the MSHG Member Hospital Facilities by ISMMS providers; additional information regarding whether or not financial assistance is available under this Policy for services rendered at the MSHG Member Hospital Facilities by ISMMS providers may be available atwww.hospitalassistance.org.

Services For Which Financial Assistance Is Not Available Under This Policy

Financial assistance is not available under this policy for the following types of care and services:

• Non-medically necessary services (including but not limited to cosmetic surgery, cosmetic contact lenses, and/or sleep study services);
• Discretionary charges (including but not limited to private rooms, private nurses, TV);
• Research related services; and ____________ Notwithstanding the foregoing, financial assistance is not available under this Policy for services provided at the Mount Sinai Downtown Union Square or any other “mixed use” Article 28 facilities that are operated by the MSHG or any of the MSHG Member Hospitals that are not provided under those hospitals’ respective Public Health Law Article 28 Licenses.
• Unless otherwise noted herein or in the Appendices to this Policy, services rendered in the MSHG Member Hospital Facilities by providers who are not employed by or directly contracted by the MSHG or the MSHG Member Hospitals (see the Appendices to this Policy to determine the extent to which, if at all, financial assistance is available under this Policy for services rendered at the MSHG Member Hospital Facilities by your particular provider).

MSHG Member Hospital Facilities To Which This Policy Applies

This Policy and the financial assistance provided under this Policy is available only for Emergency Medical Care and other Medically Necessary Care rendered by qualifying providers at the following hospital facilities (the “MSHG Member Hospital Facilities”):

• Mount Sinai Beth Israel Facilities:
  
  Mount Sinai Beth Israel
  First Avenue at 16th Street
  New York, New York 10003
  
  BIMC Comprehensive Cancer Center – West Campus
  325 West 15th Street
  New York, New York 10011
  
  BIMC Geriatrics Senior Health Center
  275 Eighth Avenue
  New York, New York 10011
  
  BIMC Vascular Access Center
  140 Fourth Avenue
  New York, New York 10003
  
  Beth Israel Med Center # 2
  103 East 125th Street
  New York, New York 10035
  
  Beth Israel Med Center 1-E2-F3-G
  429 2nd Avenue
  New York, New York 10010
  
  Beth Israel Med Center 2-C
  435 2nd Avenue
  New York, New York 10010
  
  Beth Israel Med Center 3-C
  433 2nd Avenue
  New York, New York 10010
  
  Beth Israel Med Center 8 & 8-D
  140 West 125th Street
  New York, New York 10027
  
  Beth Israel Med Center Cooper Square
  26 Avenue A
  New York, New York 10009
  
  Beth Israel Med Center Cumberland
  98 Flatbush Avenue
  Brooklyn, New York 11217
  
  Gouverneur Clinic
  109 Delancey Street
  New York, New York 10002
  
  Harlem Clinics #1 #3 #6 #7
  103 East 125th Street
  New York, New York 10035
  
  Max Meltzer Health & Service Center
  94 East 1st Street
  New York, New York 10009
  
  Mount Sinai Downtown Union Square
  10 Union Square East
  New York, New York 10003
  
  Vincent P. Dole Clinic
  25 12th Street
  Brooklyn, New York 11215
  
  
• Mount Sinai Beth Israel Brooklyn Facilities:
  
  Mount Sinai Beth Israel Brooklyn
  3201 Kings Highway
  Brooklyn, New York 11234
  
  BIMC Comprehensive Cancer Center – West Campus
  325 West 15th Street
  New York, New York 10011
  
  BIMC Geriatrics Senior Health Center
  275 Eighth Avenue
  New York, New York 10011
  
  BIMC Vascular Access Center
  140 Fourth Avenue
  New York, New York 10003
  
  Beth Israel Med Center #2
  103 East 125th Street
  New York, New York 10035
  
  Beth Israel Med Center 1-E2-F3-G
  429 2nd Avenue
  New York, New York 10010
  
  Beth Israel Med Center 2-C
  435 2nd Avenue
  New York, New York 10010
  
  Beth Israel Med Center 3-C
  433 2nd Avenue
  New York, New York 10010
  
  Beth Israel Med Center 8 & 8-D
  140 West 125th Street
  New York, New York 10027
  
  Beth Israel Med Center Cooper Square
  26 Avenue A
  New York, New York 10003
  
  Beth Israel Med Center Cumberland
  98 Flatbush Avenue
  Brooklyn, New York 11217
  
  Gouverneur Clinic
  109 Delancey Street
  New York, New York 10002
  
  Harlem Clinics #1 #3 #6 #7
  103 East 125th Street
  New York, New York 10035
  
  Max Meltzer Health & Service Center
  94 East 1st Street
  New York, New York 10009
  
  Mount Sinai Downtown Union Square
  10 Union Square East
  New York, New York 10003
  
  Vincent P. Dole Clinic
  25 12th Street
  Brooklyn, New York 11215
  
  

• Mount Sinai Hospital Facilities:
  
  Mount Sinai Hospital
  One Gustave L. Levy Place
  New York, New York 10029
  
  Mount Sinai Hospital of Queens
  25-10 30th Avenue
  Long Island City, New York 11102
  
  Ambulatory Care Center
  1200 Fifth Avenue
  New York, New York 10029
  
  Center for Advanced Medicine
  5 East 102nd Street
  New York, New York 10029
  
  Joseph H. Hazan Amb Cardiac Care Center
  5 East 98th Street
  New York, New York 10029
  
  Mount Sinai Comprehensive Health Program – Downtown
  275 7th Avenue
  New York, New York 10001-6708
  
  Mount Sinai Kidney Center
  309 East 94th Street
  New York, New York 10128
  
  Mount Sinai Queens Physician Associates
  27-15 30th Avenue
  Long Island City, New York 11102
  
  Mount Sinai Adolescent Health Center
  320 East 94th Street
  New York, New York 10128
  
  Mount Sinai Sports Therapy Center
  625 Madison Avenue
  New York, New York 10022
  
  PT Program at Asphalt Center
  York Avenue at 92nd Street
  New York, New York 10128
  
  Primary Care Center
  31-60 21st Street
  Astoria, New York 11102
  
  Psychiatric Out-Patient Clinic
  1160 Fifth Avenue
  New York, New York 10029
  
  The Primary Care Building
  101st and Madison Avenue
  New York, New York 10029
  
  Bayard Rustin Education Complex (BREC)
  West 18th Street
  New York, New York 10011
  
  JHS 117 (Alternative Education Complex)
  240 East 109th Street
  New York, New York 10029
  
  Julia Richman High School
  317 East 67th Street
  New York, New York 10021
  
  Manhattan Center for Math & Science
  FDR Drive & East 116th Street
  New York, New York 10029
  
  PS 108
  1615 Madison Avenue
  New York, New York 10029
  
  PS 38
  232 East 103rd Street
  New York, New York 10029
  
  PS 83 Mendoza School
  219 East 109th Street
  New York, New York 10029
  
  

• Mount Sinai St. Luke’s Roosevelt Facilities:
  
  Mount Sinai St. Luke’s
  1111 Amsterdam Avenue
  New York, New York 10025
  
  Mount Sinai Roosevelt
  1000 Tenth Avenue
  New York, New York 10019
  
  Ambulatory Psychiatric Center
  411 West 114th Street
  New York, New York 10025
  
  Center for Comprehensive Care, West Village Division
  230 West 17th Street
  New York, New York 10011
  
  SLR Community Care at 59th Street
  425 West 59th Street
  New York, New York 10019
  
  Louis Brandeis High School
  145 West 84th Street
  New York, New York 10024
  
  Martin Luther King Jr. High School
  122 Amsterdam Avenue
  New York, New York 10024
  
  Philip Randolph Campus High School
  135th Street at Convent Avenue
  New York, New York 10031
  
  

• New York Eye and Ear Infirmary of Mount Sinai Facilities:
  
  New York Eye & Ear Infirmary of Mount Sinai
  310 East 14th Street
  New York, New York 10003
  
  New York Eye & Ear Infirmary Ext Clinic
  380 Second Avenue
  New York, New York 10010
  
  New York Eye & Ear Outpatient Center
  230 Second Avenue
  New York, New York 10003
  
  

Specific Financial Assistance Available Under This Policy

A patient who is determined to be entitled to financial assistance for Emergency Medical Care or other Medically Necessary Care under this Policy is entitled to a discount in accordance with the Sliding Fee Scale Discount Table attached as Appendix E (the “Discount Table”).

A patient who is determined to be entitled to financial assistance for Emergency Medical Care or other Medically Necessary Care under this Policy will not be charged more for hospital services than the amount generally billed by the applicable MSHG Member Hospital for such Emergency Medical Care or other Medically Necessary Care Consistent with federal regulations, the MSHG Member Hospitals set the amount generally billed at the total amount the Medicare fee-for-service program would allow for the care (i.e., the amount Medicare and the Medicare beneficiary together would pay for the care).

All uninsured patients are presumptively eligible for the lowest level of discount available under the Discount Table for Emergency Medical Care and other Medically Necessary Care provided by the MSHG Member Hospitals themselves (including providers who are employed by or contracted directly by the MSHG Member Hospitals). The MSHG Member Hospitals will notify such patients that they may apply for additional assistance available under this Policy.

Uninsured patients are not presumptively eligible for financial assistance for bills for Emergency Medical Care and other Medically Necessary Care rendered in the MSHG Member Hospital Facilities by providers who are directly employed by or contracted by ISMMS. In order to receive financial assistance for bills for Emergency Medical Care and other Medically Necessary Care rendered in the MSHG Member Hospital Facilities by providers who are directly employed by or contracted by ISMMS, patients must apply for financial assistance (as set forth in Section 12 herein) and be determined to be entitled to such financial assistance by the appropriate MSHG Member Hospital.

Eligibility/Entitlement Determinations

Determinations of patient eligibility/entitlement to financial assistance under this Policy will be made by the appropriate MSHG Member Hospitals as listed in Section 12 herein.

The MSHG Member Hospitals will determine if a patient has third party coverage. If no third party coverage exists, the MSHG Member Hospitals will determine if the patient is eligible for government insurance programs such as Medicare or Medicaid. If the patient is eligible for Medicaid under the “Emergency Services Only” coverage, or if the patient is eligible for Medicaid but the patient’s Emergency Medical Care or other Medically Necessary Care is not covered by Medicaid, the patient will automatically be deemed eligible for the highest level of financial assistance available under this Policy or, if the patient is employed, will be given the applicable discount under the Discount Table. No further documentation will be required other than confirmation from the State of New York of the patient’s Medicaid status. If a patient is not eligible for government insurance programs and meets the requirements set forth in Section 5 of this Policy, the patient will be eligible to apply for financial assistance under this Policy.

Eligibility Period

If a patient is approved for financial assistance under this Policy, such eligibility shall not exceed one year commencing on the first day of the month in which services were first delivered or up to the last day of the month of the next “open enrollment period” as established under the Affordable Care Act, whichever comes first. If the patient requires an ambulatory surgery procedure or inpatient hospitalization, the MSHG Member Hospitals may require the patient to recertify the patient’s eligibility for financial assistance under this Policy.

How to Apply for Financial Assistance Under This Policy

Patients may apply for financial assistance under this Policy by completing and submitting a Financial Aid Application form to the MSHG Member Hospital at which the services were rendered, at the following addresses:

• Mount Sinai Beth Israel (Petrie Campus): Department of Patient Financial Counseling, 307 First Avenue, New York, NY 10003, (212) 844-1914 (p), (212) 505-6910 (f)


• Mount Sinai Downtown Union Square:: Department of Patient Financial Services, 10 Union Square East, Room 2030, New York, New York 10003, (212) 844-6041 (p), (212) 844-8401 (f)


• Mount Sinai Beth Israel Brooklyn: 3201 Kings Highway, Room 116, Brooklyn NY 11234, (718) 951-2751 (p), (718) 951-2822 (f)


• Mount Sinai Hospital (New York): Department of Financial Counseling, 5 East 102nd Street, Room D1-228, New York, New York 10029, (212) 824-7274 (p), (212) 876-7775 (f); Department of Financial Counseling, 1468 Madison Avenue, Room 210, New York, New York 10029, (212) 241-4851 (p), (212) 426-1094 (f); REAP 1405-05 Madison Ave, New York, NY 10029 (212) 423-2800 (p), (212) 534-5721 (F)


• Mount Sinai Queens: Crescent Condo, Suite 1D, 23-22 30th Road, Long Island City, New York 11102, (718) 267-4369 (p), (718) 726-2967 (f)


• New York Eye and Ear Infirmary of Mount Sinai: First Floor, 310 East 14th Street, New York, New York 10003, (212) 979-4183 (p), (212) 353-5738 (f)


• Mount Sinai West (formerly Roosevelt Hospital): Department of Patient Financial Counseling, 1000 Tenth Avenue, Room 2H, New York, New York 10019, (212) 523-7816 (p), (212) 523-8143 (f)


• Mount Sinai West (HEAL Center): 1000 Tenth Avenue, Room 1M, New York, New York 10019, (212) 523-3900 (p), (212) 636-3806 (f)


• Mount Sinai St. Luke’s: Department of Patient Financial Counseling, 1111 Amsterdam Avenue at 114th Street, New York, New York 10025, (212) 523-2552 (p), (212) 523-5620 (f)


• Mount Sinai St. Luke’s (HEAL Center): 1111 Amsterdam Avenue, Clark Building, Room 108, New York, New York 10025, (212) 523-3900 (p), (212) 523-3955 (f)


• Mount Sinai Hospital, Mount Sinai Queens and REAP: Patient Financial Services, One Gustave L. Levy Place, Box 6000, New York, New York 10029, (212) 731 3100, Attn: Erwin Ramirez

Patients will be required to provide the following documentation with the Financial Aid Application form (documentation must meet the standards of proof applied by Medicaid to Medicaid application documentation):

• Proof of address;
• Proof of Identity;
• Current financial management as evidenced by income verification (wages, disability benefits, compensation benefits, etc. by providing (as necessary):
  • 30 days of the most recent payroll stubs; or
  • Employer letter; or
  • New York State Self-attestation form (see below); or
  • Most current Federal Tax returns with all schedules; AND/OR
  • Letter from the Social Security Administration or the New York State Department of Labor regarding unemployment benefits; AND/OR
  • Letter of support from individuals providing for patient’s basic living needs
• Proof of dependents (if claimed); and
• Proof of child support, alimony (if claimed).
• As allowed in Medicaid documentation standards, the New York State Self-attestation form (Currently Form MAP 2050a or any other acceptable form in use at the time of application) may be accepted if the above is not obtainable.

The MSHG and the MSHG Member Hospitals will not deny a patient financial assistance under this Policy based on the patient’s failure to provide any information unless the information is specifically requested in this Policy or on the Financial Aid Application form.

Deposits

Any deposit paid by a patient as part of the financial assistance program will be included in the overall discount package.

Payment Determination

When patient has been determined eligible for financial assistance, an appropriate discount will be determined based on the current Discount Table. The patient or responsible party will be notified in writing of eligibility and if eligible and if applicable, asked to sign a payment agreement. A New York State surcharge will be added to all amounts determined to be the patient’s responsibility, as appropriate under the Health Care Reform Act. Payment terms shall be compliant with the existing New York State Financial Assistance Law. Payment terms shall not exceed the limits as set forth under the New York State Financial Assistance Law and shall not include interest (all installment plans are interest free). Installment plans (if any) shall not exceed 10% of the head of household gross monthly income in accordance with the New York State Financial Assistance Law for persons who qualify under this policy.

Appeals of Eligibility Determinations

A patient has the right to appeal decisions regarding financial assistance within 30 days of notification of non-eligibility. Appeals can only be submitted based on the following:

• Incorrect information was provided; OR
• A change in the patient’s financial status occurred; OR
• Due to extenuating circumstances.

The Departments of Patient Financial Services (as appropriate depending on where the subject services were rendered (see lists below)) will decide appeals in cases as specified above.
Appeals should be made in writing (or in person, by appointment) to the following:

• BIMC and SLR: Patient Financial Services, 1111 Amsterdam Avenue, New York, New York 10025, (212) 523 4674, Attn: Hiram Martinez


• NYEEI: NYEEI Admitting Department, 310 East 14th Street, New York, New York 10003, (212) 979 4115, Attn: Debra Hallgren


• MSH and REAP: Patient Financial Services, One Gustave L. Levy Place, Box 6000, New York, New York 10029, (212) 731 3100, Attn: Erwin Ramirez


• Mount Sinai Queens: Patient Financial Services, Crescent Condo, Suite 1D, 23-22 30 Road, Long Island City, New York, 11102, (212) 256 2956, Attn: Thomas Weingarten

Appeals decisions will be issued within 10 business days of receipt of a patient appeal (i.e., after receipt of letter or an in-person appeal). The DFC, at its discretion, may request that an application or additional appeal be filed for government sponsored benefits as part of the financial aid appeal process.

Follow-Up Information

Patients are responsible for promptly reporting changes in financial status and/or contact information to the appropriate MSHG Member Hospital. If a patient or responsible party is unable to comply with a signed payment agreement they must contact the appropriate MSHG Member Hospital. If a patient or responsible party defaults on a payment agreement with the appropriate MSHG Member Hospital, the account in question will be considered delinquent and the MSHG Member Hospital reserves its right to refer the patient’s account to an outside collection service, where appropriate, consistent with guidelines set forth in section 16 of this Policy and with applicable law.

Training

The MSHG and the MSHG Member Hospitals will assure that all staff responsible for engaging or otherwise assisting on the application for services covered by this Policy are trained on this Policy.

Actions That May Be Taken In The Event of Non-Payment

The MSHG and the MSHG Member Hospitals (or other authorized party) may take the following actions in the event that a patient does not pay a bill for medical care:

• Refer the patient to a collection agency, subject to the provisions of Section 20.
• Take legal action against the patient, subject to the provisions of Section 19 of this Policy. Legal action means any action that requires a legal or judicial process, including but not limited to placing a lien on an individual’s property (other than a lien that the MSHG or an MSHG Member Hospital is entitled to assert under state law on the proceeds of a judgment, settlement or compromise owed to a patient or the patient’s representative as a result of personal injuries for which the MSHG Member Hospital provided care); foreclosing on an individual’s real property; attaching or seizing an individual’s bank account or any other personal property; commencing a civil action against an individual; causing an individual’s arrest; causing an individual to be subject to a writ of body attachment; and garnishing an individual’s wages. The filing of a claim in any bankruptcy proceeding is not a legal action for purposes of this Policy.

The MSHG and the MSHG Member Hospitals will not take any of the following actions against a patient who does not pay for Emergency Medical Care or other Medically Necessary Care:

• Selling a patient’s debt to another party.
• Reporting adverse information about the patient to consumer credit reporting agencies or credit bureaus.
• Deferring or denying, or requiring a payment before providing, Emergency Medical Care or other Medically Necessary Care because of a patient’s nonpayment of one or more bills for previously provided care covered under this Policy.

Limitations on Legal Actions

The MSHG and the MSHG Member Hospitals will not initiate any legal action for payment for Emergency Medical Care or other Medically Necessary Care provided to a patient until at least 120 days from the date of the first post-discharge billing statement to the patient for the care. Prior to taking any legal action against a patient or against any other individual who has accepted or is required to accept responsibility for the patient’s hospital bill, the MSHG and/or the MSHG Member Hospitals will make reasonable efforts to determine whether the patient is eligible for financial assistance under this Policy, as follows:

• Providing the patient with written notice that indicates financial assistance is available for eligible patients, identifies the legal action that the MSHG or MSHG Member Hospital (or other authorized party) intends to initiate to obtain payment for the care, and states a deadline after which such legal action may be initiated that is no earlier than 30 days after the written notice is provided;


• Including with the written notice referenced above a plain-language summary of this Policy;


• Making a reasonable effort to orally notify the patient about this Policy and about how the patient may obtain assistance with the financial aid application process;


• If a patient submits an incomplete application during the Financial Assistance Application Period, providing the patient with a written notice that describes the additional information and/or documentation required, together with the telephone number and physical location of the hospital office that can provide information about this Policy and assistance with the application process; and


• If a patient submits a complete application during the Financial Assistance Application Period, making a determination as to whether the patient is eligible for financial assistance, and notifying the patient of this determination (including, if applicable, the assistance for which the patient is eligible) and the basis for this determination.

The Mount Sinai Patient Financial Services Department will have final responsibility for determining that the MSHG or the applicable MSHG Member Hospital has made reasonable efforts to determine whether a patient is eligible for financial assistance under this Policy and may therefore engage in legal action against the patient.

If, after the MSHG or the applicable MSHG Member Hospital makes reasonable efforts to determine whether a patient is eligible for financial assistance, the MSHG or the applicable MSHG Member Hospital begins a legal action against the patient, and the patient then submits a financial assistance application before the end of the Financial Assistance Application Period, the MSHG and/or the applicable MSHG Member Hospital will suspend the legal action, determine whether the patient is eligible for financial assistance, and notify the patient of this determination (including any assistance for which the patient is eligible) and the basis for the determination. If the patient is determined to be eligible for assistance, the MSHG or the applicable MSHG Member Hospital will:

• Provide the patient with a billing statement that states what the patient owes for the care, how that amount was determined and how the patient can get information regarding the amount generally billed for the care;
• Refund any amount the patient has paid for the care that exceeds that amount owed, unless the excess is less than $5; and
• Terminate the legal action.

Collection Agency Policy

The MSHG and the MSHG Member Hospitals instruct all collection agencies that they must follow the principles outlined in this Policy. Any legal actions will be subject to the provisions of Section 19 of this Policy, and will only be approved in cases where the MSHG and/or the MSHG Member Hospitals determine that a patient has the means to pay outstanding balances. For all legal actions, the collection agency must present documentation to the MSHG or the applicable MSHG Member Hospital supporting such action.

• At no time will the MSHG and/or the MSHG Member Hospitals force the sale of a primary residence in order to settle a debt.
• No account will be placed with a collection agency to collect on a debt so long as the application for financial assistance is in process.
• Unless otherwise prohibited, no account will be referred to a collection agency without 30 days written notice.
• All persons granted financial assistance will have 30 days after the final notice under this policy to either pay or dispute the debt before it can be turned over to a collection agency.
• Except as otherwise permitted under the New York State Hospital Financial Assistance Law, any patient that is eligible for Medicaid shall not be referred to a collection agency for collections.
• Collection agencies shall provide information on how to apply for financial assistance when appropriate.

Policy Administration and Maintenance

The MSHG and the MSHG Member Hospitals will centralize the reporting of the data for decisions rendered under this Policy and document such in the Mount Sinai Department of Patient Financial Services accounting system. Such centralization will be limited only to decisions rendered under the terms of this Policy for the purposes of compliance with the New York State Hospital Financial Assistance Law and Internal Revenue Code Section 501(r). The MSHG and the MSHG Member Hospitals will collect and distribute information to the MSHG and the MSHG Member Hospitals’ management teams and Boards of Trustees regarding this Policy. This Policy and the activities described herein are subject to internal audits.

Availability of this Policy

The MSHG and the MSHG Member Hospitals will widely publicize this Policy by:

• Making this Policy, the financial aid application, and a plain language summary of this Policy widely available at www.hospitalassistance.org


• Offering a paper copy of the plain language summary of this Policy to patients as part of the intake or discharge process;


• Setting up conspicuous public displays (or other measures reasonably designed to attract patients’ attention) that notify and inform patients about this Policy in public locations in the MSHG Member Hospital Facilities, including at a minimum in emergency departments and admissions areas, and making paper copies of this Policy, the financial aid application, and a plain language summary of this Policy available, upon request and without charge, in public locations in the MSHG Member Hospitals Facilities, including in the emergency department and admissions area;


• Making paper copies of this Policy, the financial aid application and a plain language summary of this Policy available, upon request and without charge, by mail;


• Notifying members of the community served by the MSHG Member Hospitals in a manner reasonably calculated to reach those members who are most likely to require financial assistance from the MSHG Member Hospitals that the hospitals offer financial assistance under this Policy, and informing them how or where to obtain more information about this Policy, the financial aid application process, and how to obtain copies of this Policy, the Financial Aid Application and the plain language summary of this Policy.


• Including a conspicuous written notice on billing statements that notifies and informs recipients about the availability of financial assistance under this Policy and includes the telephone number of the office that can provide information about this Policy and the direct website address where copies of this Policy, the financial aid application and the plain language summary of this Policy can be obtained;

List of Appendices to this Policy

Appendix A: List of Providers providing Emergency Care or other Medically Necessary Care at BIMC Hospital Facilities

Appendix B: List of Providers providing Emergency Care or other Medically Necessary Care at SLR Hospital Facilities

Appendix C: List of Providers providing Emergency Care or other Medically Necessary Care at NYEEI Hospital Facilities

Appendix D: List of Providers providing Emergency Care or other Medically Necessary Care at MSH Hospital Facilities

Appendix E: Discount Table

These Appendices can be accessed online at www.hospitalassistance.org, or can be obtained in hardcopy upon request to any of the department of patient financial services offices listed herein.