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TITLE: FINANCIAL ASSISTANCE POLICY AND PROCEDURES 

CURRENT EFFECTIVE DATE: 01/01/2019 



GENERAL STATEMENT of PURPOSE: 



Northwell Health strives to improve the health of the communities it serves and is committed to providing 
the highest quality of care for the community regardless of ability to pay. As part of its commitment, 
Northwell Health provides emergency or other medically necessary care at a discount depending upon the 
circumstances. This Financial Assistance Policy (ÒFAPÓ or Òthe PolicyÓ) defines the process that will be 
used to determine whether any Northwell Health patient, whether uninsured or underinsured, is eligible 
for full or partial financial assistance. 



This policy serves the purpose as outlined under Internal Revenue Code Section 501(r) as enacted in 
2016. 



POLICY 



Northwell Health is committed to providing services at a discount, based upon financial need, as a 
community benefit to persons who are uninsured, underinsured, ineligible for government programs or 
other third-party coverage, or otherwise unable to pay for emergency or other medically necessary care. 
Northwell Health is dedicated to assisting and counseling patients in managing the financial aspects of the 
care they receive and to fulfilling our commitment to improve the health of individuals, families and the 
communities it serves. 



This policy is in effect for all Northwell Health tax-exempt hospital facilities and clinics exempt under 
501(c)(3) of the Internal Revenue Code. A listing of the tax-exempt hospital facilities to which this policy 
applies is included in Appendix A on the hospitalÕs website https://www.northwell.edu/billing-and-
insurance/financial-assistance-programs-policies/financial-assistance-policy or available upon request. 



Financial assistance is not considered to be a substitute for personal financial responsibility. Financial 
assistance is available only to persons who are unable to pay for their care and are uninsured or 
underinsured and are ineligible for current enrollment in or additional support from government programs 
or other third-party coverage. Patients are expected to comply with Northwell HealthÕs procedures for 
obtaining financial assistance or other forms of payment and to contribute to the cost of their care based 
on their individual ability to pay. Individuals with the financial capacity to purchase health insurance shall 
be encouraged to do so, as a means of assuring access to health care services for their overall personal 
health and for the protection of their individual assets. 

Financial assistance is available only for services provided directly by a Northwell Health hospital facility 
or by a physician employed by Northwell Health. Northwell Health does not, through this policy, assist 


any patient in paying for services provided by an independent provider or practitioner, even if those 
services are provided in one of Northwell HealthÕs hospitals or other facilities. A listing of independent 
providers or practitioners, who may deliver emergency or medically necessary care, at each 
facility and whose services may not be covered under this policy can be found in Appendix B on 
the following Northwell Health website https://www.northwell.edu/billing-and-
insurance/financial-assistance-programs-policies/financial-assistance-policy. The provider listing 
is reviewed and updated, as necessary, on a routine basis. 

 

SCOPE 

 

This policy applies to all Northwell Health employees, as well as medical staff, volunteers, students, 
trainees, physician office staff, contractors, trustees and other persons performing work for or at 
Northwell Health; faculty and students of the Donald and Barbara Zucker School of Medicine at 
Hofstra/Northwell conducting research on behalf of the Zucker School of Medicine on or at any 
Northwell Health facility; and the faculty and students of the Hofstra Northwell School of Graduate 
Nursing and Physician Assistant Studies. 

 

DEFINITIONS 

 

For the purpose of this policy, the certain terms are defined as follows: 

 

Amount Generally Billed (ÒAGBÓ): The amounts generally billed for emergency or other medically 
necessary care to individuals who have insurance covering such care. 

 

AGB Percentage: The percentage of gross charges that a hospital facility uses to determine the AGB for 
any emergency or other medically necessary care it provides to an individual who is eligible for assistance 
under the Financial Assistance Policy. 

 

Documentation: Consists of a completed financial assistance program application (ÒApplicationÓ). The 
Application (whether submitted in hard copy or electronically via telephone interview) includes wage 
verification for the last thirty (30) days of income. 

 

Emergency Medical Conditions: as defined by section 1867 of the Social Security Act (42 U.S.C. 
1395dd), also known as the Emergency Medical Treatment and Active Labor Act (ÒEMTALAÓ). 
EMTALA defines an emergency medical condition as a medical condition manifesting itself by acute 
symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be 
expected to result in: (i) placing the health of the individual in serious jeopardy; (ii) serious impairment to 
bodily functions; or (iii) serious dysfunction of any bodily organ part. EMTALA also defines an 
emergency medical condition to include a pregnant woman who is having contractions. 

 

Extraordinary Collection Action (ÒECAÓ): Pursuant to Internal Revenue Service Code Section 
501(r)(6) ECAs may include any one of the following actions taken by a hospital facility against an 
individual related to obtaining payment of a bill for care: (1) actions that require a legal or judicial 
process, (2) reporting of adverse information to consumer credit reporting agencies or credit bureaus, (3) 
placing of a lien and/or foreclosing on real property, (4) attaching or seizing a bank account or 
garnishment of wages, and (5) deferring, denying or requiring payment prior to providing non-emergency 
medical care due to nonpayment of debt for previously provided care covered under the Financial 
Assistance Policy. 

 


Family: Using the Census Bureau definition, a group of two or more people who reside together and who 
are related by birth, marriage (including legal common law spouse), or adoption. According to Internal 
Revenue Service rules, if the patient claims someone as a dependent on their income tax return, they may 
be considered a dependent for purposes of the provision of financial assistance. Northwell Health reserves 
the right to validate the financial responsibility for any listed family member. 

 

Family Income: Family Income includes wages, salaries, unemployment compensation, workersÕ 
compensation, Social Security, Supplemental Security Income, public assistance, veteransÕ payments, 
survivor benefits, pension or retirement income, rents from property, profits and fees from their own 
business, interest, dividends, rents, royalties, income from estates, trusts, alimony, child support and other 
miscellaneous sources. Family Income is determined on a before-tax basis and excludes capital gains or 
losses. If a person lives with a family, income of all members may be considered. (Unrelated house-hold 
members do not count). Noncash benefits, such as food stamps and housing subsidies, are not considered 
income. 

 

Gross Charges: The total charge for providing patient care and other services at a Northwell entity based 
upon established rates before any deductions from the total charge is applied. 

 

Medically Necessary Services: Health care services that a physician, exercising prudent clinical 
judgment, would provide to a patient for the purpose of evaluating, diagnosing or treating an illness, 
injury, disease or its symptoms, and that are: (a) in accordance with the generally accepted standards of 
medical practice; (b) clinically appropriate; and (c) not primarily for the convenience of the patient. 

 

Plain Language Summary of the Policy (ÒPLSÓ): A written statement that notifies an individual that 
the hospital facility offers financial assistance and provides the following information in language that is 
clear, concise, and easy to understand: 

 

1. A brief description of the eligibility requirements and assistance offered under the Financial 
Assistance Policy; 


 

2. A brief summary of how to apply for assistance under the Financial Assistance Policy; 


 

3. The direct Web site address (or URL) and physical locations where the individual can obtain 
copies of the FAP and the Application form; 


 

4. Instructions on how the individual can obtain a free copy of the Financial Assistance Policy and 
the Application by mail; 


 

5. The contact information, including telephone number and physical location, of the hospital 
facility office or department that can provide information about the Financial Assistance Policy 
and assistance with the application process; 


 

6. A statement of the availability of translations of the Financial Assistance Policy, Application and 
Plain Language Summary in other languages, if applicable; 


 

7. A statement that an individual eligible for financial assistance may not be charged more than 
AGB for emergency or other medically necessary care. 


 

Primary Languages: Languages that are spoken by individuals with Limited English Proficiency 
(ÒLEPÓ) who comprise more than five (5) percent or 1,000 residents, whichever is less, of the community 
served by Northwell Health or the population likely to be affected or encountered by the hospital facility. 


 

Underinsured: The patient has some level of health insurance or third-party assistance but may have out-
of-pocket expenses that exceed a patientÕs ability to pay. 

 

Uninsured: The patient has no level of health insurance or third party assistance to assist with meeting 
his/her health care related payment obligations. 

 

PROCEDURE/GUIDELINES 

 

In order to manage our resources responsibly and to allow Northwell Health to provide the appropriate 
level of financial assistance to persons in need, the following guidelines are established for the provision 
of financial assistance. Accordingly, the policy includes the following information regarding financial 
assistance; 

 

1. Description of the basis for calculating amounts charged to patients eligible for financial 
assistance under this policy; 


 

2. Description of the method by which patients may apply for financial assistance; 


 

3. Description of the information obtained from external or internal data sources, other than the 
information received directly from the individual seeking financial assistance, that may be used, 
and under which circumstances a previous determination of a patientÕs eligibility for financial 
assistance may be used to presumptively determine that the individual is eligible for financial 
assistance; 


 

4. Description of how the Northwell Health facilities will widely publicize the Policy within the 
communities served; and 


 

5. Description of the limits on the amounts that a hospital will charge for emergency or other 
medically necessary care provided to individuals eligible for financial assistance to the lesser of 
(1) amounts generally billed or (2) any discount available in accordance with the sliding scale 
included in item (F) of the Procedures section of this policy. 


 

 

A. Eligibility for Financial Assistance 


 

Eligibility for financial assistance will be considered for patients in the New York Tri State Region who 
are uninsured, underinsured, ineligible for government programs that would pay for services, or otherwise 
unable to pay for their care/or have exhausted their benefits for covered services. 

 

The granting of financial assistance will be based on an individualized determination of financial need in 
accordance with this policy, and shall not take into account age, gender, race, color, national origin, 
religion, social or immigrant status, sexual orientation, gender identity, spousal affiliation, physical 
handicap, or mental handicap. 

 

Participation in the FAP (a) may be contingent upon a patientÕs willingness to apply for Medicaid or such 
other public insurance programs that the patient may be eligible for based upon Northwell Health 
assessment, and (b) requires the patient to fully cooperate with Northwell HealthÕs Application 
requirements, including the disclosure of personal, financial or other information necessary for 
determination of financial need. 

 

 


When considering FAP applications, Northwell Health reserves the right to: 

 

1. Consider eligibility for financial assistance at any point before or after service(s) are rendered 
and/or any time during the billing and collection cycle; 

 

2. Request application for eligibility for financial assistance for each medical visit or admission to 
a Northwell facility; 

 

3. Make hardship modifications to any aspect of the Financial Assistance Policy; 

 

4. Apply the terms of this policy to patients that reside outside of the primary service area of each 
hospital facility as defined by the NYSDOH; and 

 

5. Utilize externally obtained income information from available resources for use in family size 
and income verification. 

 

Eligibility for the program is based on current Family Income and is available to individuals with 
household incomes that are less than those shown below: 

 

Household / Family Size 

Maximum Household Income 
(500% of 2020 Federal Poverty 
Guidelines) 

1 

$63,800 

2 

$86,200 

3 

$108,600 

4 

$131,000 

5 

$153,400 

6 

$175,800 

For each additional person, add 

$22,400 

* 2020 shown for illustrative purpose. Amounts updated annually as necessary. 



 

B. Services Eligible under Northwell HealthÕs Financial Assistance Policy 


 

For purposes of this policy, Òfinancial assistanceÓ refers to health care services provided by Northwell 
Health at discounted amounts to qualifying patients. (Pediatric and prenatal medical services may not 
require payment from qualifying patients.) The following health care services are eligible for financial 
assistance: 

 

1. Emergency medical services for any individual in the Northwell Health service area, including 
patients who present at any Northwell Health Emergency Department (including transfers under 
the Emergency Medical Treatment and Active Labor Act ÒEMTALAÓ), provided in an 
emergency room setting; 


 

2. Services for a condition which, if not promptly treated, would lead to an adverse change in the 
health status of an individual; 


 

3. Non-elective services provided in response to life-threatening circumstances in a non-emergency 
room setting; and 


 


4. Medically necessary non-emergency medical care services. 


 

Determinations regarding medical necessity are the responsibility of the health care professional 
providing the care, without regard to the ability to pay by the patient. Northwell Health will not engage in 
any actions that discourage individuals from seeking emergency medical care. 

Northwell Health does not require emergency department patients to pay before receiving 
treatment for emergency medical conditions nor does Northwell Health permit debt collection 
activities in the emergency department or other areas where such activities could interfere with 
the provision of emergency care on a non-discriminatory basis. 

 

C. Method for Applying for Financial Assistance 

 

1. Patients are encouraged to apply for financial assistance within ninety (90) days from the date 
noted on the first Òpost-dischargeÓ billing statement; however patients are permitted a minimum 
of two hundred and forty (240) days to apply and submit a completed application. As per 
Internal Revenue Service guidelines, a billing statement for care is considered Òpost-
dischargeÓ if it is provided to an individual after the patient received care, whether 
inpatient or outpatient. 


 

2. Patients may apply for financial assistance by submitting an application or through an interactive 
process with a financial counselor. In order for Northwell Health to make a determination of 
eligibility for financial assistance, patients must complete the application and provide all required 
documentation. Applications may be obtained in the following ways: 


 

a) On-line at Northwell Health web address: www.northwell.edu/manage-your-
care/financial-aid-programs/financial-assistance-program; 


 

b) By calling a customer service representative using the phone number listed below in 
item (J) of the Procedures section of this policy below; or 

 

c) By contacting a financial counselor at the respective facility listed below in in item (J) 
of the Procedures section of this policy below. 

 

3. Applicants for financial assistance will be requested to fully cooperate in applying for any public 
insurance program (e.g., Medicaid, Child Health Plus, etc.) that Northwell Health believes the 
applicant may be eligible for. 


 

4. Please mail completed applications to respective addresses listed below. 


 

5. Once the completed application is submitted using one of the methods noted above, the patient 
may disregard any bills/statement until a written notification regarding the status of the financial 
assistance application. The notification of eligibility for financial assistance should be received by 
the patient in writing within thirty (30) days of submission of a completed application. 


 

Upon receipt of a complete financial assistance application, any and all ECAs that are in process 
related to the patient will be suspended. 

 

If a patient is deemed eligible for financial assistance, an updated billing statement will be 
provided which will indicate the amount owed, how the amount was determined, and the 


applicable AGB percentage. Any amounts paid in excess of the amount determined to be owed by 
a patient will be refunded accordingly. 

 

All decisions on financial assistance eligibility will be made in writing. The notification of denial 
of financial assistance will explain the reason for the denial, an overview of the appeals process, 
and instructions for submitting an appeal. 

 

Appeals can be filed within thirty (30) days of the denial notice. A determination regarding the 
appeal will be made within thirty (30) days of receiving an appeal. Patients will be notified in 
writing of the outcome of their appeal. 

 

If an incomplete application is received, the patient will receive written notice that describes the 
additional information or documentation required to make an eligibility determination for 
financial assistance. The additional information or documentation is expected to be provided 
within 30 days of notification. The patient should expect to receive the routine follow up notices 
for any unpaid bills, however in accordance with Internal Revenue Service Code Section 
501(r)(6) any ECAs which had been initiated will be suspended until a determination of eligibility 
for financial assistance is made. 

 

D. Required Documentation and Determination of Financial Assistance 

 

The financial assistance office as detailed in Procedures Section (J) of this policy will determine financial 
assistance on an individual basis. 

 

Documentation requested during the application submission process may require the patient or the 
patientÕs guarantor to supply personal, financial, and other information or documentation relevant to 
verifying Family Income. In making the determination of financial assistance, some or all of the 
following items may need to be provided: 

 

a. A completed application; 

 

b. Prior yearÕs tax return(s); 

 

c. Minimum of two most recent pay stubs; 

 

d. Minimum of three most recent bank statements for savings and checking accounts; and 

 

e. Other proof of income as defined by ÔFamily IncomeÕ listed in the Definitions section of this 
policy. 

 

If an applicant does not have any of the listed documents to prove household income, the applicant may 
call the hospital facilityÕs financial assistance office noted in item (J) of the Procedures section of this 
policy below and discuss other evidence that may be provided to demonstrate eligibility. 

 

Northwell Health may request additional documentation related to assets for patients with household 
incomes under 150% of the Federal Poverty Guidelines (ÒFPGÓ). 

 

Northwell Health may also: 

 

a. Request the patient participate in joint efforts to apply for alternative sources of payment for 
the health care services provided and possibly obtain health care coverage from public and private 
payment programs; 


 

b. Take into account the patientÕs available assets exceeding $10,000 (excluding primary 
residence and a vehicle used for daily transport to school or work). Northwell Health will only 
consider 25% of the total Òunencumbered valueÓ of available assets, which will be added to 
Family Income amounts to determine eligibility; 

 

c. Take into account other resources available to the patient; and 

 

d. Include a review of the patientÕs outstanding bill(s) for prior services rendered and the patientÕs 
payment history. 

 

Northwell Health will not deny financial assistance for failure to provide documentation not identified in 
this policy. 

 

Non-emergent services may be scheduled prior to making a request for financial assistance; however, a 
determination on the financial assistance application is generally required prior to obtaining services. The 
financial assistance application will be kept on file for three months and may be used to determine 
eligibility for subsequent services. The need for financial assistance may be re-evaluated at any time 
additional information relevant to the eligibility of the patient for financial assistance becomes known. 

 

Financial assistance will be applied at approved levels to any outstanding unpaid account the patient may 
have without respect to date of service. 

 

E. Presumptive Financial Assistance Eligibility & Information Obtained from other Sources 

 

There are instances when a patient may receive financial assistance discounts without a written / formal 
financial assistance application on file. Often there is adequate information provided by the patient or 
obtained by Northwell Health through other sources, which could provide sufficient evidence to provide 
the patient with financial assistance. 

 

In such cases, Northwell Health may use outside agencies to estimate gross income in order to determine 
eligibility or may make a determination based on a patientÕs enrollment in other assistance programs not 
related to Northwell Health. Once determined by the financial counselor, due to the inherent nature of the 
presumptive circumstances, the patient may be eligible for discount on the account balance. If a patient is 
presumptively determined to be eligible for less than the maximum assistance available under this policy, 
Northwell Health will notify the patient, in writing, regarding the basis for the presumptive financial 
assistance eligibility determination, and how to apply for more additional assistance. A copy of the PLS 
will also be provided to the patient. Other sources of data used to make a presumptive eligibility decision 
may include the patientÕs participation in certain programs or the availability of externally obtained 
information such as: 

 

1. State-funded prescription programs; 
2. Homeless or received care from a homeless clinic; 
3. Participation in Women, Infants and Children programs (WIC); 
4. Food stamp eligibility; 
5. Subsidized school lunch program eligibility; 
6. Eligibility for other state or local assistance programs that are unfunded (i.e. Medicaid spend-
down); 
7. Low income/subsidized housing is provided as a valid address; 
8. Patient is deceased with no known estate; 



9. Patients enrolled in limited service Medicaid programs that use a defined family income at or 
below 100% of the Federal Poverty Guidelines, specifically, Medicaid for Pregnant Women-
Pregnancy Related Services Only or Family Planning Services and EMSA; 
10. Patients with non-participating out-of-state Medicaid insurance plans; 
11. Patients identified as having income below 100% of the Federal Poverty Guidelines through 
access to external sources of information after services have been rendered; and 
12. The use of publically available data sources (i.e. credit reporting agency) that provide information 
on a patientÕs or a patientÕs guarantorÕs ability to pay (such as credit scoring). 


 

 

To facilitate the compilation of documentation for FAP Application processing and/or the financial 
screening process, Northwell Health may utilize soft credit inquiries that are not visible / transparent to 
creditors (only visible to the patient or responsible party), and have no impact on the patientÕs credit status 
or ability to obtain future credit (i.e. FICO score). 

 

Such inquiries may be used to: 

 

1. Reduce the patientÕs administrative burden (re: compiling documents); and/or 

 

2. Determine presumptive eligibility for patients, guarantorÕs and/or the patientÕs legal 
representative that do not establish contact with Northwell Health during the billing and 
collection cycle despite the usual and customary efforts of Northwell Health. 

 

F. Patient Financial Assistance Guidelines 

 

Northwell Health uses the Federal Poverty Guidelines (ÒFPGÓ); in effect at the time the application is 
reviewed, to determine eligibility for financial assistance level. Northwell Health will update the FPG, 
which is published annually by the US Department of Health and Human Services, effective each year as 
of March 1 or thirty (30) days from the date of publication, whichever is later. 

 

Subject to the availability of other assets, 

 

1. Patients whose family income is at or below 100% of the FPG are eligible to receive emergency 
or medically necessary services at no charge or at the nominal payment level defined by the 
NYSDOH; and 


 

2. Patients whose family income is above 100% but not more than 500% of the FPG are eligible to 
receive a discount for emergency or medically necessary services as outlined in the table below. 


 

All uninsured patients will automatically receive a reduction from total charges to the hospitalÕs 
commercial rate regardless of their FPG %. In addition if hardship is claimed, under-insured patients may 
receive additional financial assistance. 

 

Amounts charged to patients who are eligible for financial assistance are outlined in the table below: 

 

Gross Wages and Assets as 
% of FPG 

Patient Responsibility 

(% of AGB) 

100% or less 

$0 - $150 

101% to 125% 

10% 

126% to 150% 

15% 

151% to 200% 

20% 




201% to 250% 

25% 

251% to 300% 

35% 

301% to 500% 

100% 



 

 

AGB is calculated by Northwell Health utilizing Medicaid rates on a ÒLook-BackÓ basis, as defined by 
the Internal Revenue Code Section 501(r)(5), for all of its tax-exempt hospital facilities with the 
exception of Huntington Hospital Association, Northern Westchester Hospital Association, Phelps 
Memorial Hospital Association, Northwell Health Physician Partners (formerly known as the North 
Shore LIJ Medical Group), and Staten Island University Hospital which utilize Medicare rates on a 
ÒLook-BackÓ basis for their AGB calculations. 

 

G. Communication of the Financial Assistance Program to Patients and the Public 

 

Northwell Health provides public notice regarding the availability of financial assistance by various 
means, including notices in patient bills, emergency rooms, urgent care centers, admitting and registration 
departments, hospital business offices, clinics, and patient financial services offices that are located on 
Northwell Health hospital facility campuses. Information is also included on Northwell Health hospital 
facility websites. Additionally, Northwell Health provides summaries of the financial assistance program 
to local public agencies and non-profit organizations who serve the health needs of the communityÕs low 
income populations. 

 

Referral of patients for financial assistance may be made by any member of the Northwell HealthÕs staff 
or medical staff, including physicians, nurses, financial counselors, social workers, case managers, 
chaplains, and religious sponsors. A request for financial assistance may be made by the patient or a 
family member, close friend, or associate of the patient, subject to applicable privacy laws. Northwell 
Health will endeavor to contact uninsured patients, while they are in the hospital, prior to discharge from 
a Northwell Health hospital facility in order to provide financial counseling, including information about 
payment programs and financial assistance. 

 

Northwell HealthÕs Financial Assistance Policy Application and Plain Language Summary of the Policy 
are available in English and the primary language of populations with Limited English Proficiency. 

 

Patients will be notified regarding the availability of financial assistance during the intake, registration 
and financial counseling process. The PLS will be offered to all patients as part of the intake process. 
Translation services for those non-English speaking patients that donÕt meet the criteria to constitute 
Primary Language may be available upon request. 

 

 

H. Billing and Collection Policies 

 

Northwell Health has policies and procedures for internal and external collection practices (including 
actions the hospital may take in the event of non-payment, including collections action and reporting to 
credit agencies) that take into account the extent to which the patient qualifies for financial assistance, a 
patientÕs good faith effort to apply for a governmental program or for financial assistance from Northwell 
Health, and a patientÕs good faith effort to comply with his or her payment agreements with Northwell 
Health. For patients who qualify for financial assistance and who are cooperating in good faith to resolve 
their discounted hospital bill, Northwell Health may offer extended payment plans, and will not impose 


wage garnishments or liens on primary residences, and will cease all collection efforts, unless the 
payment agreement is broken or the patient ceases to cooperate with Northwell Health to resolve his/her 
account. 

 

All billing statements sent by Northwell Health includes a conspicuous notice regarding the availability of 
financial assistance, along with a telephone number which a patient can call to receive information about 
the FAP and assistance with the application process. The billing statements will also include the website 
address where copies of the FAP, Application, and PLS can be obtained. 

 

Northwell Health, or its agents, will not undertake ECAs until 120 days after the hospital provides a 
patient with the first post-discharge billing statement. Patients will also be provided a minimum of thirty 
(30) days advance notice of the initiation of any ECA. Northwell Health reserves the right to take such 
actions against anyone who has accepted responsibility or is required to accept responsibility for a 
patientÕs hospital bill. This notice will inform patients regarding the availability of financial assistance, 
and of any ECAs that Northwell Health may initiate or resume if a patient has not paid an outstanding 
balance or initiated the financial assistance process. A copy of the PLS will also be included with the 30-
day notice. 

 

I. Regulatory Requirements 

 

Northwell Health will comply with all federal, state, and local laws, rules, and regulations that may apply 
to activities conducted pursuant to this policy. 

 

J. Northwell Health Financial Counseling Offices 

 

Northwell Health Financial Assistance Unit noted below provides counseling services for the 
following facilities: North Shore University Hospital, Long Island Jewish Medical Center, Long Island 
Jewish Forest Hills, Long Island Jewish Valley Stream, Cohen ChildrenÕs Medical Center, The Zucker 
Hillside Hospital, Orzac Center for Rehabilitation, Huntington Hospital Association, Lenox Hill Hospital, 
Manhattan Eye, Ear and Throat Hospital, Staten Island University Hospital, Glen Cove Hospital, 
Plainview Hospital, Southside Hospital and Syosset Hospital. 

 

Northwell Health 

Financial Assistance Unit 

35 Pinelawn Road 

Melville, NY 11747-9001 

Phone: 1.800.995.5727 

 

 

 

Mailing address: 

Northwell Health 

Financial Assistance Unit 

PO Box 9001 

Melville, NY 11747-9001 

Web address: 

www.northwell.edu/manage-your-care/financial-aid-programs/financial-assistance-program 

 

 

 


Northern Westchester Hospital 

Financial Assistance Unit 

400 East Main Street 

Mount Kisco, NY 10549-1096 

Phone: 914.666.1512 

Web address: www.nwhc.net/for-patients-and-visitors/financial-assistance 



Phelps Memorial Hospital Center 

Financial Counseling 

701 North Broadway 

Sleepy Hollow, NY 10591-1096 

Phone: 914.366.3133 

Email - billing@pmhc.us 

Web address: www.phelpshospital.org/patient-visitor-info/billing/ 



Peconic Bay Medical Center 

Financial Assistance Coordinator 

1300 Roanoke Avenue 

Riverhead, NY 11901 

Phone: 631.548.6099 

Web address: www.pbmchealth.org/medical-centers-and-services/peconic-bay-medical-center/billing/ 



REFERENCES to REGULATIONS and/or OTHER RELATED POLICIES 

.New York State Public Health Law 2807-k (9-a)

.Internal Revenue Code Section 501(r)



CLINICAL REFERENCES 

N/A 



ATTACHMENTS 

N/A 



FORMS 

N/A 




 

 

AMOUNTS GENERALLY BILLED 

Under Northwell Health Inc. and affiliated subsidiariesÕ 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.Õs Financial Assistance Policy (FAP). The AGB composite percentage used 
for Peconic Bay Medical Center (the Hospital) is 19.89%. The patientÕs actual rate will vary 
depending upon what kind of inpatient/outpatient health services are performed. 

The HospitalÕs 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 HospitalÕs 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 individualÕs family 
income and size in relation to the Federal Poverty Guidelines (FPG). In addition to adherence to 
the Internal Revenue Code, the HospitalÕs 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.