4A (Expenses $ 170424414 including grants of $ 7570863) (Revenue $ 180060621)
SEE SCHEDULE O

PART V, SECTION A:
PRESENTATION OF HOSPITAL'S COMPLETE WEBSITE ADDRESS:HTTPS://WWW.DIGNITYHEALTH.ORG/SACRAMENTO/LOCATIONS/SIERRA-NEVADA-MEMORIAL-HOSPITAL

SIERRA NEVADA MEMORIAL - MINER'S HOSPITAL
PART V, SECTION B, LINE 5: FOR THE 2022 (TY 2021) CHNA REPORT, QUALITATIVE DATA INCLUDED INTERVIEWS WITH 23 COMMUNITY HEALTH EXPERTS, MEMBERS OF THE COUNTY'S DEPARTMENT OF PUBLIC HEALTH, SOCIAL-SERVICE PROVIDERS THAT REPRESENTED MEDICALLY UNDERSERVED POPULATIONS, AND MEDICAL PERSONNEL IN ONE-ON-ONE AND GROUP INTERVIEWS. NINETEEN ADDITIONAL COMMUNITY SERVICE PROVIDERS GAVE INPUT THROUGH AN ONLINE SURVEY. ALL INTERVIEW PARTICIPANTS WERE GIVEN AN INFORMED CONSENT FORM PRIOR TO THEIR PARTICIPATION, WHICH PROVIDED INFORMATION ABOUT THE PROJECT, ASKED FOR PERMISSION TO RECORD THE INTERVIEW, AND LISTED THE POTENTIAL BENEFITS AND RISKS OF INVOLVEMENT IN THE INTERVIEW. ALL KEY INFORMANTS WERE ASKED TO IDENTIFY VULNERABLE POPULATIONS. KEY INFORMANTS WERE FROM THE HOSPITAL, NEVADA COUNTY DEPARTMENT OF PUBLIC HEALTH, CHAPA-DE INDIAN HEALTH, WESTERN SIERRA MEDICAL CLINIC, SIERRA FAMILY HEALTH CENTER, HOSPITALITY HOUSE, CONNECTING POINT, GRASS VALLEY POLICE DEPARTMENT, HOSPICE OF THE FOOTHILLS, GOLD COUNTRY SENIOR SERVICES AND FREED CENTER FOR INDEPENDENT LIVING. FURTHER, 11 COMMUNITY RESIDENTS PARTICIPATED IN 2 FOCUS GROUPS ACROSS THE COUNTY; FOCUS GROUP PARTICIPANTS CONSISTED OF COMMUNITY RESIDENTS LIVING IN IDENTIFIED COMMUNITIES OF CONCERN OR REPRESENTING COMMUNITIES EXPERIENCING HEALTH DISPARITIES. DUE TO THE COVID-19 PANDEMIC ALL COMMUNITY INPUT FOR THE 2022 CHNA REPORT WAS PROVIDED OVER ZOOM, AND SURVEYS WERE RECEIVED ELECTRONICALLY.

SIERRA NEVADA MEMORIAL - MINER'S HOSPITAL
PART V, SECTION B, LINE 11: SIERRA NEVADA MEMORIAL HOSPITAL IS ADDRESSING OR DEVELOPING PARTNERSHIP INITIATIVES TO FOCUS ON SIGNIFICANT HEALTH ISSUES IDENTIFIED IN THE MOST RECENT COMMUNITY HEALTH NEEDS ASSESSMENT THAT INCLUDE: 1) ACCESS TO BASIC NEEDS, SUCH AS HOUSING, JOBS, AND FOOD; 2) ACCESS TO MENTAL, BEHAVIORAL, AND SUBSTANCE ABUSE SERVICES; 3) ACCESS TO QUALITY PRIMARY CARE HEALTH SERVICES; 4) ACCESS TO SPECIALTY AND EXTENDED CARE; 5) SYSTEM NAVIGATION; 6) INCREASED COMMUNITY CONNECTIONS; 7) INJURY AND DISEASE PREVENTION AND MANAGEMENT; AND 8) SAFE AND VIOLENCE FREE ENVIRONMENT. INITIATIVES THAT ADDRESS THESE PRIORITIES LARGELY TARGET VULNERABLE AND AT-RISK POPULATIONS, WITH EMPHASIS ON COLLABORATION WITH COMMUNITY PARTNERS. THE HOSPITAL IS ADDRESSING THESE NEEDS WITH NUMEROUS DIRECT SERVICE PROGRAMS, GRANT FUNDING TO THE COMMUNITY, PATIENT FINANCIAL ASSISTANCE, AND COMMUNITY PARTNERSHIPS DESCRIBED IN DETAIL IN THE IMPLEMENTATION STRATEGY, AVAILABLE TO THE PUBLIC ONLINE. PROGRAM AND ACTIVITIES TO HELP ADDRESS THESE NEEDS INCLUDE: HOMELESS RECUPERATIVE CARE PROGRAM, RESOURCES FOR LOW-INCOME PATIENTS, RESOURCES FOR HOMELESS PATIENTS, NEVADA COUNTY HEALTH COLLABORATIVE INTEGRATED NETWORK, CRISIS STABILIZATION UNIT, MENTAL HEALTH CRISIS SUPPORT PARTNERSHIP, CARE TRANSITION INTERVENTION PROGRAM, TELE-PSYCHIATRY, PATIENT NAVIGATOR PROGRAM, HEALTH PROFESSION EDUCATION - OTHER, HEALTH PROFESSION EDUCATION - NURSING, ONCOLOGY NURSE NAVIGATOR, HEPATITIS C ERADICATION PROGRAM, TELE-ENDOCRINOLOGY, FALLS PREVENTION PROGRAM, HEALTHIER LIVING PROGRAM, DISEASE-SPECIFIC SUPPORT GROUPS, ALZHEIMER'S OUTREACH PROGRAM, CARDIAC REHABILITATION, COMPLEX DISCHARGE MANAGEMENT ASSISTANCE, COMMUNITY BASED VIOLENCE PREVENTION AND DIGNITY HEALTH COMMUNITY HEALTH IMPROVEMENT GRANTS PROGRAM. AS A RURAL COMMUNITY HOSPITAL, SIERRA NEVADA MEMORIAL DOES NOT HAVE THE CAPACITY OR RESOURCES TO ADDRESS ALL PRIORITY HEALTH ISSUES IDENTIFIED IN NEVADA COUNTY. THE HOSPITAL IS NOT ADDRESSING ACCESS TO FUNCTIONAL NEEDS AND ACTIVE LIVING AND HEALTHY EATING AS THESE PRIORITIES ARE BEYOND THE CAPACITY AND EXPERTISE OF SIERRA NEVADA MEMORIAL. HOWEVER, THE HOSPITAL WILL LOOK FOR OPPORTUNITIES TO COORDINATE AND COLLABORATE WITH OTHER ENTITIES THAT OFFER PROGRAMS THAT ADDRESS THESE NEEDS. MOREOVER, THE HOSPITAL HAS CONTINUOUSLY ENGAGED IN COLLABORATIVE EFFORTS FOCUSING ON DEVELOPMENT OF A BROAD CLINICAL AND SOCIOECONOMIC PLAN WITH MULTI-DISCIPLINARY PARTNERS FROM HEALTH CARE, BUSINESS, SOCIAL SERVICES, GOVERNMENT, COMMUNITY-BASED ORGANIZATIONS AND WIDER SOCIETY.

SIERRA NEVADA MEMORIAL - MINER'S HOSPITAL
PART V, SECTION B, LINE 13H: THE PATIENT MUST HAVE A MINIMUM ACCOUNT BALANCE OF TEN DOLLARS ($10.00) WITH THE COMMONSPIRIT HOSPITAL ORGANIZATION. MULTIPLE ACCOUNT BALANCES MAY BE COMBINED TO REACH THIS AMOUNT. IF APPLICABLE, PATIENTS/GUARANTORS WITH BALANCES BELOW TEN DOLLARS ($10.00) MAY CONTACT A FINANCIAL COUNSELOR TO MAKE MONTHLY INSTALLMENT PAYMENT ARRANGEMENTS.THE PATIENT MUST SUBMIT A COMPLETED FINANCIAL ASSISTANCE APPLICATION.PATIENT COOPERATION STANDARDS - A PATIENT MUST COOPERATE WITH THE HOSPITAL FACILITY IN PROVIDING THE INFORMATION AND DOCUMENTATION NECESSARY TO DETERMINE ELIGIBILITY. SUCH COOPERATION INCLUDES COMPLETING ANY REQUIRED APPLICATIONS OR FORMS. THE PATIENT IS RESPONSIBLE FOR NOTIFYING THE HOSPITAL FACILITY OF ANY CHANGE IN FINANCIAL SITUATION THAT WOULD IMPACT THE ASSESSMENT OF ELIGIBILITY. A PATIENT MUST EXHAUST ALL OTHER PAYMENT OPTIONS, INCLUDING PRIVATE COVERAGE, FEDERAL, STATE AND LOCAL MEDICAL ASSISTANCE PROGRAMS, AND OTHER FORMS OF ASSISTANCE PROVIDED BY THIRD PARTIES PRIOR TO BEING APPROVED. AN APPLICANT FOR FINANCIAL ASSISTANCE IS RESPONSIBLE FOR APPLYING TO PUBLIC PROGRAMS FOR AVAILABLE COVERAGE. HE OR SHE IS ALSO EXPECTED TO PURSUE PUBLIC OR PRIVATE HEALTH INSURANCE PAYMENT OPTIONS FOR CARE PROVIDED BY A COMMONSPIRIT HOSPITAL ORGANIZATION WITHIN A HOSPITAL FACILITY. A PATIENT'S AND, IF APPLICABLE, ANY GUARANTOR'S COOPERATION IN APPLYING FOR APPLICABLE PROGRAMS AND IDENTIFIABLE FUNDING SOURCES, INCLUDING COBRA COVERAGE (A FEDERAL LAW ALLOWING FOR A TIME-LIMITED EXTENSION OF EMPLOYEE HEALTHCARE BENEFITS), SHALL BE REQUIRED. IF A HOSPITAL FACILITY DETERMINES THAT COBRA COVERAGE IS POTENTIALLY AVAILABLE, AND THAT A PATIENT IS NOT A MEDICARE OR MEDICAID BENEFICIARY, THE PATIENT OR GUARANTOR SHALL PROVIDE THE HOSPITAL FACILITY WITH INFORMATION NECESSARY TO DETERMINE THE MONTHLY COBRA PREMIUM FOR SUCH PATIENT, AND SHALL COOPERATE WITH HOSPITAL FACILITY STAFF TO DETERMINE WHETHER HE OR SHE QUALIFIES FOR HOSPITAL FACILITY COBRA PREMIUM ASSISTANCE, WHICH MAY BE OFFERED FOR A LIMITED TIME TO ASSIST IN SECURING INSURANCE COVERAGE. A HOSPITAL FACILITY SHALL MAKE AFFIRMATIVE EFFORTS TO HELP A PATIENT OR PATIENT'S GUARANTOR APPLY FOR PUBLIC AND PRIVATE PROGRAMS.THE FOLLOWING REQUIREMENTS FOR ADDITIONAL HARDSHIP DISCOUNTS IS AN ADDENDUM OF THE FINANCIAL ASSISTANCE POLICY THAT APPLY TO PATIENTS RECEIVING SERVICES AT A COMMONSPIRIT HOSPITAL ORGANIZATION IN THE STATE OF CALIFORNIA ONLY.A PATIENT WHO RECEIVES DISCOUNTED CARE, BUT (1) WHOSE LIABILITY STILL EXCEEDS 30% OF THE SUM OF (A) HIS OR HER FAMILY INCOME, AND (B) HIS OR HER MONETARY ASSETS, AND (2) WHO DOES NOT HAVE THE ABILITY TO PAY HIS OR HER BILL, AS DETERMINED BY A REVIEW OF FACTORS SUCH AS PROJECTED FAMILY INCOME FOR THE COMING YEAR AND EXISTING OR ANTICIPATED HEALTH CARE LIABILITIES MAY BE GIVEN AN ADDITIONAL HARDSHIP DISCOUNT. FOR PURPOSES OF THE DETERMINATION OF THIS HARDSHIP DISCOUNT, THE COMMONSPIRIT HOSPITAL ORGANIZATION WILL NOT CONSIDER ASSETS IN RETIREMENT PLANS QUALIFIED UNDER THE INTERNAL REVENUE CODE IN EFFECT AT THE TIME OF THE DETERMINATION OR DEFERRED COMPENSATION PLANS.IF THE PATIENT MEETS ALL ELIGIBILITY CRITERIA, THE PATIENT WILL RECEIVE A HARDSHIP DISCOUNT, WHICH WILL REDUCE THE PATIENT'S REMAINING LIABILITY TO NO MORE THAN 30% OF THE SUM OF HIS OR HER (1) PATIENT FAMILY INCOME, AND (2) MONETARY ASSETS.A PATIENT MAY ALSO RECEIVE DISCOUNTS OR WAIVERS UNDER THIS ADDENDUM IF CONSIDERED HOMELESS OR TRANSIENT OR IF THEY PARTICIPATE IN A FEDERAL, STATE, OR LOCAL MANAGED INDIGENT CARE PROGRAM.

PART V, SECTION B, LINE 7A
ALL DIGNITY HEALTH HOSPITAL FACILITY COMMUNITY HEALTH NEEDS ASSESSMENT REPORTS CAN BE ACCESSED ATHTTPS://WWW.DIGNITYHEALTH.ORG/ABOUT-US/COMMUNITY-HEALTH/COMMUNITY-HEALTH-PROGRAMS-AND-REPORTS/COMMUNITY-HEALTH-NEEDS-ASSESSMENTSCHNA REPORT WEB SITE LOCATION FOR SNMH IS PROVIDED BELOW.HTTPS://WWW.DIGNITYHEALTH.ORG/SACRAMENTO/ABOUT-US/COMMUNITY-HEALTH-AND-OUTREACH/HEALTH-NEEDS-ASSESSMENTHTTPS://WWW.DIGNITYHEALTH.ORG/CONTENT/DAM/DIGNITY-HEALTH/PDFS/SACRAMENTO/CHNA-SNMH-VOLUME1.PDF

PART V, SECTION B, LINE 10A
DIGNITY HEALTH AFFILIATED HOSPITAL FACILITY IMPLEMENTATION STRATEGY DOCUMENTS CAN BE ACCESSED ATHTTPS://WWW.DIGNITYHEALTH.ORG/ABOUT-US/COMMUNITY-HEALTH/COMMUNITY-HEALTH-PROGRAMS-AND-REPORTS/COMMUNITY-HEALTH-NEEDS-ASSESSMENTSTHE HOSPITAL'S IMPLEMENTATION STRATEGY IS ALSO ON SNMH'S WEB SITE, AT THE SAME LOCATION AS THE CHNA REPORT LISTED IN PART V, SECTION B, LINE 7A ABOVE.

SCHEDULE H, PART V, SECTION B, LINE 16A, 16B AND 16C
HTTPS://WWW.DIGNITYHEALTH.ORG/SACRAMENTO/PATIENTS-AND-VISITORS/FOR-PATIENTS/BILLING-INFORMATION/PAYMENT-ASSISTANCE

PART I, LINE 3C:
UNLESS ELIGIBLE FOR PRESUMPTIVE FINANCIAL ASSISTANCE, THE FOLLOWING ELIGIBILITY CRITERIA MUST BE MET IN ORDER FOR A PATIENT TO QUALIFY FOR FINANCIAL ASSISTANCE: - THE PATIENT MUST HAVE A MINIMUM ACCOUNT BALANCE OF TEN DOLLARS ($10.00) WITH THE COMMONSPIRIT HOSPITAL ORGANIZATION. MULTIPLE ACCOUNT BALANCES MAY BE COMBINED TO REACH THIS AMOUNT. PATIENTS/GUARANTORS WITH BALANCES BELOW TEN DOLLARS ($10.00) MAY CONTACT A FINANCIAL COUNSELOR TO MAKE MONTHLY INSTALLMENT PAYMENT ARRANGEMENTS. - THE PATIENT MUST COMPLY WITH PATIENT COOPERATION STANDARDS AS DESCRIBED IN SCHEDULE H, PART V, SECTION B, LINE 13H, 3RD PARAGRAPH. - THE PATIENT MUST SUBMIT A COMPLETED FINANCIAL ASSISTANCE APPLICATION (FAA).FOR PATIENTS AND GUARANTORS WHO ARE UNABLE TO PROVIDE REQUIRED DOCUMENTATION, A HOSPITAL FACILITY MAY GRANT PRESUMPTIVE FINANCIAL ASSISTANCE BASED ON INFORMATION OBTAINED FROM OTHER RESOURCES. IN PARTICULAR, PRESUMPTIVE ELIGIBILITY MAY BE DETERMINED ON THE BASIS OF INDIVIDUAL LIFE CIRCUMSTANCES THAT MAY INCLUDE: - RECIPIENT OF STATE-FUNDED PRESCRIPTION PROGRAMS; - HOMELESS OR ONE WHO RECEIVED CARE FROM A HOMELESS OR FREE CARE CLINIC; - PARTICIPATION IN WOMEN, INFANTS AND CHILDREN PROGRAMS (WIC); - FOOD STAMP ELIGIBILITY; - ELIGIBILITY OR REFERRALS FOR OTHER STATE OR LOCAL ASSISTANCE PROGRAMS (E.G., MEDICAID); - LOW INCOME/SUBSIDIZED HOUSING IS PROVIDED AS A VALID ADDRESS; OR - PATIENT IS DECEASED WITH NO KNOWN SPOUSE OR KNOWN ESTATE.THE FOLLOWING REQUIREMENTS FOR ADDITIONAL HARDSHIP DISCOUNTS IS AN ADDENDUM OF THE FINANCIAL ASSISTANCE POLICY THAT APPLY TO PATIENTS RECEIVING SERVICES AT A COMMONSPIRIT HOSPITAL ORGANIZATION IN THE STATE OF CALIFORNIA ONLY.A PATIENT WHO RECEIVES DISCOUNTED CARE, BUT (1) WHOSE LIABILITY STILL EXCEEDS 30% OF THE SUM OF (A) HIS OR HER FAMILY INCOME, AND (B) HIS OR HER MONETARY ASSETS, AND (2) WHO DOES NOT HAVE THE ABILITY TO PAY HIS OR HER BILL, AS DETERMINED BY A REVIEW OF FACTORS SUCH AS PROJECTED FAMILY INCOME FOR THE COMING YEAR AND EXISTING OR ANTICIPATED HEALTH CARE LIABILITIES MAY BE GIVEN AN ADDITIONAL HARDSHIP DISCOUNT. FOR PURPOSES OF THE DETERMINATION OF THIS HARDSHIP DISCOUNT, THE COMMONSPIRIT HOSPITAL ORGANIZATION WILL NOT CONSIDER ASSETS IN RETIREMENT PLANS QUALIFIED UNDER THE INTERNAL REVENUE CODE IN EFFECT AT THE TIME OF THE DETERMINATION OR DEFERRED COMPENSATION PLANS.IF THE PATIENT MEETS ALL ELIGIBILITY CRITERIA, THE PATIENT WILL RECEIVE A HARDSHIP DISCOUNT, WHICH WILL REDUCE THE PATIENT'S REMAINING LIABILITY TO NO MORE THAN 30% OF THE SUM OF HIS OR HER (1) PATIENT FAMILY INCOME, AND (2) MONETARY ASSETS.A PATIENT MAY ALSO RECEIVE DISCOUNTS OR WAIVERS UNDER THIS ADDENDUM IF CONSIDERED HOMELESS OR TRANSIENT OR IF THEY PARTICIPATE IN A FEDERAL, STATE, OR LOCAL MANAGED INDIGENT CARE PROGRAM.

PART I, LINE 7:
"FOR PURPOSES OF CALCULATING THE AMOUNTS PROVIDED IN THE TABLE, SNMH USES AN ADJUSTED COST TO CHARGE RATIO (CCR) CALCULATED IN A MANNER CONSISTENT WITH WORKSHEET 2 FOR EACH REPORTING FACILITY, TO DERIVE THE REPORTED COSTS OF FINANCIAL ASSISTANCE, MEDICAID AND OTHER MEANS-TESTED PROGRAMS. WORKSHEET 3 IS USED IN THE COMMUNITY BENEFIT INVENTORY FOR SOCIAL ACCOUNTABILITY (""CBISA"") SOFTWARE TO CALCULATE EXPENSE AND REVENUE, INCLUDING WHERE APPLICABLE MEDICAID PROVIDER FEES AND PAYMENTS FROM UNCOMPENSATED CARE PROGRAMS. ACTUAL OR ESTIMATED COST AND ANY DIRECT OFFSETTING REVENUE IS REPORTED, AND SCHEDULE H WORKSHEETS OR THEIR EQUIVALENTS ARE USED, FOR OTHER COMMUNITY BENEFIT ACTIVITIES SUCH AS COMMUNITY HEALTH IMPROVEMENT SERVICES, COMMUNITY BENEFIT OPERATIONS, HEALTH PROFESSIONS EDUCATION, SUBSIDIZED HEALTH SERVICES, RESEARCH, AND CASH AND IN-KIND DONATIONS.PART I, LINE 7B, COLUMN (F)BEGINNING IN 2009, THE STATE OF CALIFORNIA ESTABLISHED PROVIDER FEE PROGRAMS. THESE PROGRAMS ARE FUNDED BY QUALITY ASSURANCE FEES PAID BY PARTICIPATING HOSPITALS AND MATCHING FEDERAL FUNDS. SIERRA NEVADA MEMORIAL HOSPITAL RECOGNIZED FEE-FOR-SERVICE SUPPLEMENTAL PAYMENTS OF $6.5 MILLION DURING THE YEAR REFLECTED UNDER THE MEDICAID PROGRAM AS DIRECT OFFSETTING REVENUE (PART I, LINE 7B, COLUMN D).PART I, LINE 7I COLUMN CTHE CALIFORNIA HOSPITAL ASSOCIATION CREATED A PRIVATE PROGRAM, THE CALIFORNIA HEALTH FOUNDATION AND TRUST (""CHFT""), ESTABLISHED FOR SEVERAL PURPOSES, INCLUDING AGGREGATING AND DISTRIBUTING FINANCIAL RESOURCES TO SUPPORT CHARITABLE ACTIVITIES AT VARIOUS HOSPITALS AND HEALTH SYSTEMS IN CALIFORNIA. DURING THE YEAR, SIERRA NEVADA MEMORIAL HOSPITAL (SNMH) RECORDED A PLEDGE TO A GRANT FUND ESTABLISHED BY CHFT IN THE AMOUNT $105 THOUSAND. THE GRANT IS REPORTED UNDER OTHER BENEFITS (PART I, LINE 7I, COLUMN C), AS CASH AND IN-KIND CONTRIBUTIONS TO COMMUNITY GROUPS."

PART II, COMMUNITY BUILDING ACTIVITIES:
"THE HOSPITAL'S WORK TO PROMOTE THE HEALTH OF THE COMMUNITIES SERVED EXTENDS BEYOND PROVIDING HEALTH CARE AND COMMUNITY HEALTH IMPROVEMENT SERVICES. THE HOSPITAL TAKES A PROACTIVE APPROACH TO ADDRESSING THE SOCIAL, ECONOMIC AND ENVIRONMENTAL BARRIERS TO GOOD HEALTH, AND SUPPORTS THE WORLD HEALTH ORGANIZATION DEFINITION OF HEALTH AS A STATE OF COMPLETE PHYSICAL, MENTAL AND SOCIAL WELL-BEING, NOT MERELY THE ABSENCE OF DISEASE OR INFIRMITY. IN ADDITION TO THE EXAMPLES BELOW, THE HOSPITAL'S PUBLICLY AVAILABLE ANNUAL COMMUNITY BENEFIT REPORTS DESCRIBE SPECIFIC COMMUNITY BUILDING ACTIVITIES IN A SECTION TITLED ""OTHER PROGRAMS AND NON-QUANTIFIABLE BENEFITS."" MEMBERS OF THE HOSPITAL'S LEADERSHIP AND MANAGEMENT TEAMS VOLUNTEER SIGNIFICANT TIME AND EXPERTISE AS BOARD MEMBERS OF NONPROFIT HEALTH CARE ORGANIZATIONS AND CIVIC AND SERVICE AGENCIES, SUCH AS THE WESTERN SIERRA MEDICAL CLINIC, HOSPITALITY HOUSE, NEVADA COUNTY ECONOMIC RESOURCE COUNCIL, BRIARPATCH COMMUNITY MARKET AND HOSPICE OF THE FOOTHILL. ANNUAL SPONSORSHIPS ALSO SUPPORT MULTIPLE PROGRAMS, SERVICES AND FUND-RAISING EVENTS OF ORGANIZATIONS; AMONG THEM, GRANITE WELLNESS CENTER, NEVADA COUNTY ARTS COUNCIL, NEVADA CITY CHAMBER OF COMMERCE, AMERICAN HEART ASSOCIATION, AND OTHERS."

PART VI, LINE 6:
AFFILIATES OF SNMH PROMOTE THE HEALTH OF ADDITIONAL COMMUNITIES IN BAKERSFIELD, SAN BERNARDINO, SAN FRANCISCO, SAN ANDREAS, CALIFORNIA, PHOENIX, CHANDLER AND GILBERT, ARIZONA, LAS VEGAS AND HENDERSON, NEVADA AND IN 18 ADDITIONAL STATES THROUGH THE ALLIANCE WITHIN COMMONSPIRIT HEALTH SYSTEM. THESE AFFILIATES FOLLOW PRACTICES SIMILAR TO THOSE NOTED ABOVE IN DETERMINING THE UNMET HEALTHCARE NEEDS OF THEIR COMMUNITIES. TOTAL UNSPONSORED COMMUNITY BENEFIT EXPENSE NET OF OFFSETTING REVENUE FOR COMMONSPIRIT HEALTH AND ITS AFFILIATED CORPORATIONS, WHICH INCLUDES SNMH, FOR THE YEAR JUNE 30, 2022, IS $3.2 BILLION. A SUMMARY OF COMMONSPIRIT'S COMMUNITY BENEFITS CAN BE VIEWED IN THE ATTACHED COMMONSPIRIT HEALTH CONSOLIDATED FINANCIAL STATEMENTS ON PAGE 44.

PART VI, LINE 7, REPORTS FILED WITH STATES
CA

PART III, LINE 2:
THE AMOUNT OF THE ORGANIZATION'S BAD DEBT AT COST IS DETERMINED BY APPLYING THE CCR (SEE PART I, LINE 7 DISCLOSURE) TO PATIENT CHARGES THAT ARE DEEMED TO BE UNCOLLECTIBLE. THIS AMOUNT REPRESENTS THE COST OF SERVICES PROVIDED TO PATIENTS WHO ARE UNABLE OR REFUSE TO PAY THEIR BILLS AND DO NOT QUALIFY FOR FREE OR DISCOUNTED CARE, GOVERNMENT SPONSORED PROGRAMS OR OTHER PAYMENT ASSISTANCE, AND ARE OTHERWISE UNINSURED.AS NOTED IN PART I, LINE 3B, SNMH PROVIDES FREE OR DISCOUNTED CARE TO UNINSURED OR UNDER-INSURED INDIVIDUALS THAT FALL INTO THREE CATEGORIES; UNDER 250%, 251%-350% OR 351%-500% OF THE FEDERAL POVERTY LEVEL. SNMH ALSO PROVIDES PATIENTS OPTIONS FOR UNINSURED PATIENT DISCOUNT AND SELF-PAY DISCOUNTS. IN CALIFORNIA, PATIENTS WHO ARE UNINSURED OR WITH HIGH MEDICAL COSTS ARE ELIGIBLE TO RECEIVE DISCOUNTED CARE IN ADDITION TO AN INTEREST-FREE EXTENDED PAYMENT PLAN THAT WILL ALLOW PAYMENT OF THE DISCOUNTED AMOUNT OVER TIME. DISCOUNTS ARE ACCOUNTED FOR AS DEDUCTIONS FROM REVENUE, NOT AS BAD DEBT EXPENSE.

PART III, LINE 3:
THE DIGNITY HEALTH FINANCIAL ASSISTANCE POLICY WAS UPDATED AND RENAMED AS COMMONSPIRIT HEALTH FINANCIAL ASSISTANCE POLICY. SNMH FOLLOWS THIS POLICY.SNMH MAKES EVERY EFFORT TO DETERMINE IF A PATIENT QUALIFIES FOR FINANCIAL ASSISTANCE UPON ADMISSION. COMMONSPIRIT HEALTH'S FINANCIAL ASSISTANCE POLICY IS COMMUNICATED TO PATIENTS UPON ADMISSION AND IS AVAILABLE IN THE LANGUAGES PRIMARILY SPOKEN IN THE COMMUNITY. IT IS ALSO POSTED IN VARIOUS COMMON AREAS OF THE HOSPITAL, SUCH AS EMERGENCY ROOMS, URGENT CARE CENTERS, ADMITTING AND REGISTRATION DEPARTMENTS, HOSPITAL BUSINESS OFFICES LOCATED ON FACILITY CAMPUSES, AND OTHER PUBLIC PLACES, AND IS PROVIDED UPON BILLING IF ELIGIBILITY IS NOT PREVIOUSLY DETERMINED. ELIGIBILITY IS REEVALUATED AS NEEDED AND AMOUNTS ARE CLASSIFIED AS CHARITY AS SOON AS ELIGIBILITY IS KNOWN. COMMONSPIRIT HEALTH ALSO UTILIZES A PAYMENT ASSISTANCE RANK ORDERING (PARO) SCORING SYSTEM TO ASSIST IN DETERMINING IF AN UNINSURED PATIENT MAY QUALIFY FOR PAYMENT ASSISTANCE EVEN THOUGH THEY HAVE NOT APPLIED FOR IT. PARO IS A METHODOLOGY THAT APPLIES CONSISTENT SCREENING AND APPLICATION STANDARDS TO ALL UNINSURED PATIENTS UTILIZING HISTORICAL DATA TO DEVELOP A PREDICTIVE MODEL FOR HEALTHCARE PAYMENT ASSISTANCE. IN ITS DEVELOPMENT, SPECIAL ATTENTION WAS PAID TO THOSE SOCIOECONOMIC FACTORS THAT MIGHT ADVERSELY AFFECT THOSE PATIENTS DESERVING THE MOST ATTENTION. OTHER CRITERIA ARE ALSO UTILIZED TO ENSURE THAT SERVICES THAT HAVE QUALIFIED AS FINANCIAL ASSISTANCE ARE NOT REPORTED AS BAD DEBT. AS SUCH, DIGNITY COMMUNITY CARE DOES NOT BELIEVE THAT ANY AMOUNTS INCLUDED IN PART III, LINE 2, ARE ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S PAYMENT ASSISTANCE POLICY, AND THEREFORE, NO PORTION OF BAD DEBT EXPENSE IS INCLUDED AS COMMUNITY BENEFIT EXPENSE.

PART III, LINE 4:
THE FOLLOWING IS AN EXCERPT FROM COMMONSPIRIT'S CONSOLIDATED ANNUAL AUDITED FINANCIAL STATEMENTS FOR THE YEAR ENDED JUNE 30, 2022, RELATED TO PATIENT ACCOUNTS RECEIVABLE AND NET PATIENT REVENUE. THE ENTIRE FOOTNOTE CAN BE VIEWED IN THE ATTACHED COMMONSPIRIT HEALTH CONSOLIDATED FINANCIAL STATEMENTS ON PAGES 12-13.PATIENT SERVICE REVENUE IS REPORTED AT THE AMOUNTS THAT REFLECT THE CONSIDERATION COMMONSPIRIT EXPECTS TO BE PAID IN EXCHANGE FOR PROVIDING PATIENT CARE. THESE AMOUNTS ARE DUE FROM PATIENTS, THIRD-PARTY PAYORS (INCLUDING HEALTH INSURERS AND GOVERNMENT PROGRAMS), AND OTHERS, AND INCLUDE CONSIDERATION FOR RETROACTIVE REVENUE ADJUSTMENTS DUE TO SETTLEMENT OF AUDITS AND REVIEWS. GENERALLY, PERFORMANCE OBLIGATIONS FOR PATIENTS RECEIVING INPATIENT ACUTE CARE SERVICES AND OUTPATIENT SERVICES ARE RECOGNIZED OVER TIME AS SERVICES ARE PROVIDED. NET PATIENT REVENUE IS PRIMARILY COMPRISED OF HOSPITAL AND PHYSICIAN SERVICES.

PART III, LINE 8:
COMMONSPIRIT HEALTH HOSPITALS PREPARE MEDICARE COST REPORTS IN A MANNER THAT COMPORTS WITH PROVIDER REIMBURSEMENT MANUAL (PRM) 15-1, 2150FF AND PRM 15-2, 1000FF. AS SUCH, THE FOLLOWING LANGUAGE PER THE PRM 15-1 DESCRIBES THE COMPUTATION OF COSTS PER THE MEDICARE COST REPORT:TOTAL ALLOWABLE COSTS OF A PROVIDER ARE APPORTIONED BETWEEN PROGRAM BENEFICIARIES AND OTHER PATIENTS SO THAT THE SHARE BORNE BY THE PROGRAM IS BASED UPON ACTUAL SERVICES RECEIVED BY PROGRAM BENEFICIARIES. THE RATIO OF COVERED BENEFICIARY CHARGES TO TOTAL PATIENT CHARGES FOR THE SERVICES OF EACH ANCILLARY DEPARTMENT IS APPLIED TO THE COST OF THE DEPARTMENT. ADDED TO THIS AMOUNT IS THE COST OF ROUTINE SERVICES FOR PROGRAM BENEFICIARIES, DETERMINED ON THE BASIS OF A SEPARATE AVERAGE COST PER DIEM FOR ALL PATIENTS FOR GENERAL ROUTINE PATIENT CARE AREAS. ANOTHER FACTOR TO BE CONSIDERED IS A SEPARATE AVERAGE COST PER DIEM FOR EACH INTENSIVE CARE UNIT, CORONARY CARE UNIT, AND OTHER SPECIAL CARE INPATIENT HOSPITAL UNITS.COMMONSPIRIT HEALTH AND ITS SUBORDINATE CORPORATIONS BELIEVE THAT THE ENTIRE MEDICARE SHORTFALL FOR THE CONSOLIDATED ENTITIES CONSTITUTES COMMUNITY BENEFIT. THE IRS COMMUNITY BENEFIT STANDARD INCLUDES THE PROVISION OF CARE TO THE ELDERLY AND MEDICARE PATIENTS. MEDICARE SHORTFALLS MUST BE ABSORBED BY COMMONSPIRIT HEALTH HOSPITALS IN ORDER TO CONTINUE TREATING THE ELDERLY IN OUR COMMUNITIES. THE HOSPITALS PROVIDE CARE REGARDLESS OF THIS SHORTFALL AND THEREBY RELIEVE THE FEDERAL GOVERNMENT OF THE BURDEN OF PAYING THE FULL COST FOR MEDICARE BENEFICIARIES. SNMH'S SHORTFALL INCLUDES $21.9 MILLION REPORTED ON PART III, SECTION B, LINE 7.

PART III, LINE 9B:
SNMH ENSURES THAT PATIENT ACCOUNTS ARE PROCESSED FAIRLY AND CONSISTENTLY. SNMH ALSO FOLLOWS COMMONSPIRIT HEALTH'S COLLECTION POLICY. THE HOSPITAL'S BILLING AND COLLECTION POLICY CONTAINS PROVISIONS THAT PROHIBIT THE COLLECTION OF AMOUNTS DUE FROM PATIENTS WHO THE ORGANIZATION KNOWS QUALIFY FOR FINANCIAL ASSISTANCE. ACCOUNTS WITH INCORRECT OR INCOMPLETE DEMOGRAPHIC INFORMATION ARE ASSIGNED TO A COLLECTION AGENCY IF SNMH OR BILLING COMPANY RETAINED BY COMMONSPIRIT HEALTH IS UNABLE TO OBTAIN AN UPDATED ADDRESS THROUGH SKIP TRACING OR OTHER MEANS. FOR PATIENTS WHO HAVE AN APPLICATION PENDING FOR EITHER GOVERNMENT-SPONSORED FINANCIAL ASSISTANCE OR FOR ASSISTANCE UNDER SNMH'S FINANCIAL ASSISTANCE POLICY, OR WHERE THE PATIENT IS ATTEMPTING IN GOOD FAITH TO SETTLE AN OUTSTANDING BILL WITH THE FACILITY VIA PAYMENT PLANS, SNMH WILL NOT KNOWINGLY SEND THAT PATIENT'S BILL TO AN OUTSIDE COLLECTION AGENCY. LEGAL ACTION WILL NOT BE PURSUED TO COLLECT DEBTS FROM PATIENTS WHO HAVE QUALIFIED FOR CHARITY OR ARE COOPERATING IN GOOD FAITH TO RESOLVE THEIR DEBT. ON SELF-PAY ACCOUNTS THAT DO NOT MEET THE CRITERIA NOTED ABOVE, THE INITIAL DETERMINATION OF ASSIGNMENT TO A COLLECTION AGENCY WILL VARY DEPENDING ON THE NATURE OF THE ACCOUNT WITH THE FINAL DECISION BEING AT THE DISCRETION OF THE HOSPITAL PATIENT FINANCIAL ASSISTANCE DEPARTMENT. UPON ASSIGNMENT OF SUCH A PATIENT ACCOUNT TO A COLLECTION AGENCY, SNMH REQUIRES THE AGENCY TO COMPLY WITH THE FAIR DEBT COLLECTION PRACTICES ACT.

PART VI, LINE 2:
IN ADDITION TO THE HOSPITAL CONDUCTING A COMMUNITY HEALTH NEEDS ASSESSMENT AT LEAST EVERY THREE YEARS, THE HOSPITAL ASSESSES THE HEALTH NEEDS OF THE COMMUNITY IT SERVES BY WORKING COLLABORATIVELY WITH LOCAL FEDERALLY QUALIFIED HEALTH CENTERS, OTHER NON-PROFIT CLINICS, PUBLIC HEALTH DEPARTMENTS, AND OTHER HEALTH, SOCIAL SERVICE AND COMMUNITY ORGANIZATIONS TO IDENTIFY AND SERVE THE NEEDS OF VULNERABLE POPULATIONS. THE HOSPITAL OBTAINS AND MAINTAINS KNOWLEDGE OF HEALTH NEEDS IN PART THROUGH REFERRAL RELATIONSHIPS, SERVICE PLANNING ACTIVITIES, COMMUNITY HEALTH PARTNERSHIPS, COMMUNITY GRANTS PROGRAM, AND LOCAL ADVOCACY CONDUCTED IN CONJUNCTION WITH COMMUNITY PARTNERS. THE HOSPITALS UTILIZE DATABASES AND PLANNING TOOLS TO EVALUATE CHANGES IN CURRENT AND PROJECTED COMMUNITY NEED FOR HEALTH CARE SERVICES, INCLUDING PHYSICIANS.THE HOSPITAL CREATES AND MAKES AVAILABLE TO THE PUBLIC AN ANNUAL COMMUNITY BENEFIT REPORT THAT SUMMARIZES IDENTIFIED HEALTH NEEDS, UPDATES COMMUNITY DEMOGRAPHIC INFORMATION, AND REPORTS ON RECENT AND PLANNED COMMUNITY HEALTH PROGRAMS, INCLUDING GOALS, OBJECTIVES AND MEASURABLE RESULTS.

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COMMUNICATION OF THE FINANCIAL ASSISTANCE PROGRAM TO PATIENTS AND THE PUBLIC: INFORMATION ABOUT THE ORGANIZATION'S FINANCIAL ASSISTANCE PROGRAM AND A CONTACT NUMBER ARE MADE AVAILABLE TO PATIENTS AND THE PUBLIC. PATIENTS ARE INFORMED OF THE FACILITY'S FINANCIAL ASSISTANCE PROGRAM VIA SIGNAGE IN ALL ADMITTING AREAS AND IN VARIOUS COMMON AREAS OF THE HOSPITAL. FINANCIAL ASSISTANCE PROGRAM INFORMATION NOTICES ARE POSTED IN THE EMERGENCY AND ADMITTING DEPARTMENTS AND AT OTHER PUBLIC PLACES AS THE HOSPITAL FACILITY MAY ELECT. SUCH INFORMATION IS PROVIDED IN THE PRIMARY LANGUAGES SPOKEN IN THE COMMUNITIES SNMH SERVES. THE SIGNAGE INCLUDES NOTIFICATION THAT FURTHER DISCOUNTS MAY BE PROVIDED UPON THE COMPLETION AND SUBMISSION OF A FINANCIAL ASSISTANCE APPLICATION AND HOW TO REACH STAFF THAT CAN ASSIST WITH ANSWERING QUESTIONS AND GUIDE PATIENTS THROUGH THE APPLICATION PROCESS. INFORMATION CAN ALSO BE FOUND ON THE FACILITY WEBSITE.IF FINANCIAL ASSISTANCE ELIGIBILITY IS NOT DETERMINED PRIOR TO BILLING, INITIAL BILLING STATEMENTS TO PATIENTS INCLUDE A REQUEST TO THE PATIENT TO PROVIDE ANY INSURANCE INFORMATION THAT WAS VALID FOR THE DATES OF SERVICE BILLED, A STATEMENT INFORMING PATIENTS HOW TO CONTACT US REGARDING FINANCIAL ASSISTANCE. ADDITIONALLY, CONTRACT TERMS WITH COLLECTION VENDORS WORKING ON BEHALF OF COMMONSPIRIT HEALTH REQUIRES THEY FOLLOW COMMONSPIRIT HEALTH FINANCIAL ASSISTANCE POLICY. ALSO, REFERRAL OF PATIENTS FOR FINANCIAL ASSISTANCE MAY BE MADE BY ANY MEMBER OF SNMH NON MEDICAL OR MEDICAL STAFF, INCLUDING PHYSICIANS, NURSES, FINANCIAL COUNSELORS, SOCIAL WORKS, CASE MANAGERS, CHAPLAINS, AND RELIGIOUS SPONSORS. A REQUEST FOR ASSISTANCE MAY BE MADE BY THE PATIENT OR A FAMILY MEMBER, CLOSE FRIEND OR ASSOCIATE OF THE PATIENT, SUBJECT TO APPLICABLE PRIVACY LAWS.

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SIERRA NEVADA MEMORIAL HOSPITAL IS LOCATED WEST OF LAKE TAHOE IN THE SIERRA NEVADA MOUNTAINS. THE HOSPITAL'S SERVICE AREA ENCOMPASSES FOUR ZIP CODES IN THE COMMUNITIES OF GRASS VALLEY, PENN VALLEY, AND NEVADA CITY (95945, 95946, 95949, 95959). PORTIONS OF THE SERVICE AREA ARE DESIGNATED HEALTH PROFESSIONAL SHORTAGE AREAS (HPSAS) FOR PRIMARY CARE. IT IS ESTIMATED THAT OVER ONE-THIRD OF THE COUNTY POPULATION LIVES IN UNINCORPORATED COMMUNITIES, AND WHILE HEALTH RESOURCES ARE MORE AVAILABLE IN POPULATED COMMUNITIES, NEVADA COUNTY'S RURAL ENVIRONMENT CONTRIBUTES TO BARRIERS IN ACCESSING HEALTH CARE AND HEALTH-RELATED SERVICES. RESIDENTS OF NEVADA COUNTY ARE PRIMARILY WHITE AND A HIGH PROPORTION OF ADULTS ARE OVER THE AGE OF 65 (28.5%).TOTAL POPULATION: 76,537HISPANIC OR LATINO: 8.9%WHITE - NON-HISPANIC: 80.3%BLACK/AFRICAN AMERICAN: 0.5%ASIAN/PACIFIC ISLANDER: 1.3%ALL OTHERS: 9.0%% BELOW POVERTY: 5.4%UNEMPLOYMENT: 2.6%NO HIGH SCHOOL DIPLOMA: 4.8%MEDICAID: 23.5%UNINSURED: 4.7%OTHER AREA HOSPITALS: 1

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FINANCIAL ASSISTANCE: IT IS THE POLICY OF COMMONSPIRIT HEALTH TO PROVIDE, WITHOUT DISCRIMINATION, EMERGENCY MEDICAL CARE AND MEDICALLY NECESSARY CARE IN COMMONSPIRIT HOSPITAL FACILITIES TO ALL PATIENTS, WITHOUT REGARD TO A PATIENT'S FINANCIAL ABILITY TO PAY. THIS HOSPITAL HAS A FINANCIAL ASSISTANCE POLICY THAT DESCRIBES THE ASSISTANCE PROVIDED TO PATIENTS FOR WHOM IT WOULD BE A FINANCIAL HARDSHIP TO FULLY PAY THE EXPECTED OUT-OF-POCKET EXPENSES FOR SUCH CARE, AND WHO MEET THE ELIGIBILITY CRITERIA FOR SUCH ASSISTANCE. THE FINANCIAL ASSISTANCE POLICY, A PLAIN LANGUAGE SUMMARY AND RELATED MATERIALS ARE AVAILABLE IN MULTIPLE LANGUAGES ON THE HOSPITAL'S WEBSITE.USE OF SURPLUS FUNDS: AS A NOT-FOR-PROFIT HOSPITAL ORGANIZATION DEDICATED TO IMPROVING THE QUALITY OF LIFE, THE HOSPITAL REINVESTS ALL OF ITS SURPLUS FUNDS FROM OPERATING AND INVESTMENT ACTIVITIES TO IMPROVE THE QUALITY OF PATIENT CARE, EXPAND AND REPLACE EXISTING FACILITIES AND EQUIPMENT, INVEST IN TECHNOLOGICAL ADVANCEMENTS, SUPPORT COMMUNITY HEALTH PROGRAMS, AND ADVANCE MEDICAL TRAINING, EDUCATION, AND RESEARCH. THIS ACTIVE REINVESTMENT OF FUNDS MAKES IT POSSIBLE FOR THE HOSPITAL TO DELIVER ON ITS MISSION, INCLUDING HELPING TO ENSURE THAT EVERYONE IN THE COMMUNITIES SERVED HAS ACCESS TO HEALTH CARE.OPEN MEDICAL STAFF: MEDICAL STAFF PRIVILEGES ARE OPEN TO PHYSICIANS WHOSE EXPERIENCE AND TRAINING ARE VERIFIED THROUGH A CREDENTIALING PROCESS. THE PROCESS INCLUDES GATHERING AND VERIFYING CREDENTIALS, ALLOWING THE MEDICAL STAFF TO EVALUATE AN APPLICANT'S QUALIFICATIONS, PREVIOUS EXPERIENCE, AND COMPETENCE, AND ULTIMATELY MAKING A DECISION TO GRANT OR DENY MEDICAL STAFF MEMBERSHIP AND CLINICAL PRIVILEGES ON THE BASIS OF AUTHENTIC AND VALID CREDENTIALS.ROLE OF THE BOARD: THE COMMONSPIRIT HEALTH BOARD AND SPECIFIC COMMITTEES HAVE ORGANIZATIONAL, POLICY-BASED ROLES TO OVERSEE COMMUNITY BENEFIT AND COMMUNITY HEALTH PROGRAMS, AND THEY RECEIVE REGULAR REPORTS ON ACTIVITIES AND PERFORMANCE. HOSPITAL COMMUNITY BOARDS (OR THEIR DESIGNATED COMMUNITY HEALTH OR COMMUNITY BENEFIT COMMITTEES) ARE RESPONSIBLE FOR ENSURING THAT THE HOSPITALS CONDUCT AND ADOPT COMMUNITY HEALTH NEEDS ASSESSMENTS AND IMPLEMENTATION STRATEGIES, TAKE ACTIONS TO HELP ADDRESS IDENTIFIED SIGNIFICANT HEALTH NEEDS WITH AN EMPHASIS ON POOR AND VULNERABLE POPULATIONS AND HEALTH EQUITY, AND MONITORING ACTIONS AND PROGRESS TOWARD IDENTIFIED GOALS.