AMOUNTS GENERALLY BILLED

Under Northwell Health Inc. and affiliated subsidiaries’ Financial Assistance Policy, all hospitals use the look back method as prescribed under   501(r)(5) of the Internal Revenue Code, to ensure that all not-for-profit hospitals limit the amount generally billed (AGB) for emergency or other medically necessary care provided to individuals who are eligible for financial assistance under Northwell Health Inc.’s Financial Assistance Policy (FAP). The AGB composite percentage used for Peconic Bay Medical Center (the Hospital) is 19.93%. The patient’s actual rate will vary depending upon what kind of inpatient/outpatient health services are performed.

The Hospital’s AGB percentages are based on the total allowable payments during a prior twelve month period from Medicare for each different category of care divided by the total gross charges associated with those claims.

The resulting AGB percentage is applied to the Hospital’s total gross charges for the care provided to the FAP eligible individual to ensure that individual is not charged more that the amount allowed. The final amount charged may further be discounted based on the individual’s family income and size in relation to the Federal Poverty Guidelines (FPG). In addition to adherence to the Internal Revenue Code, the Hospital’s FAP is in full compliance with New York State Public Health Law Section 2807-k (9-a).

The AGB is recalculated annually and is adjusted in accordance with updates to the FPG and/or in accordance with changes to the Public Health Law.

Effective date: 1/1/2022