Common use of Billed by Facility Clause in Contracts

Billed by Facility. (3) Billed direct by Provider or Vendor. (4) Patient/Resident responsible for co-insurance and deductible. (5) Coverage depends on services provided. ADDITIONAL NON-CLINICAL SERVICES THE FOLLOWING ADDITIONAL NON- CLINICAL SERVICES ARE AVAILABLE TO ALL RESIDENTS AND IF REQUESTED BY THE RESIDENT, SPONSOR AND/OR DESIGNATED REPRESENTATIVE, WILL BE CHARGED TO THE RESIDENT: • Telephone • Television/radio for Resident’s personal use • Personal comfort items, notions and novelties, and confections • Cosmetic and grooming items and services, in excess of those for which payment is made under Medicaid, Medicare, or other insurance programs • Personal clothing • Personal reading matter • Gifts purchased on behalf of a Resident • Flowers and plants • Social events, special meals, and entertainment offered off the premises and outside the scope of the Activities program provided by the Facility • Non-covered special care services, such as private duty nurses • Specially prepared or alternative food (other than Kosher food or food required by a therapeutic or modified diet prescribed by a physician) • Private room (except when therapeutically required, such as for isolation for infection control) IF YOU HAVE ANY QUESTIONS REGARDING CHARGES AND BILLING, PLEASE FEEL FREE TO CONTACT THE BUSINESS OFFICE AT (718) 298- 7800. ATTACHMENT “B” SPECIAL RULES REGARDING SELECTED PAYORS PAYMENT FOR IN-PATIENT LONG TERM CARE SERVICES IS AN EXPENSIVE AND COMPLICATED PROCESS. THIS SUMMARY PROVIDES OUR RESIDENTS AND THEIR FAMILIES WITH BASIC INFORMATION WHICH SHOULD SIMPLIFY THE PROCESS. NOTHING HEREIN SHOULD BE CONSIDERED TO BE LEGAL ADVICE. WE URGE YOU TO CONSULT WITH AN INSURANCE AGENT, ATTORNEY AND/OR OTHER KNOWLEDGEABLE PROFESSIONAL(S) IN ORDER TO HELP MAXIMIZE AVAILABLE COVERAGE. FURTHER, AS THE INFORMATION PROVIDED BELOW IS BASED UPON STATUTE AND REGULATIONS, IT IS SUBJECT TO CHANGE WITHOUT NOTICE. MEDICARE PART A PAYMENT Medicare Part A Hospital Insurance Skilled Nursing Facility coverage is generally available to qualified individuals 65 years of age or older, and individuals under age 65 who have been disabled for at least twenty-four months, who meet the following five requirements: 1) The Resident requires daily skilled nursing or rehabilitation services that can be provided only in a skilled nursing facility; 2) The Resident was hospitalized for at least three consecutive days, not counting the day of discharge, before entering the skilled nursing facility; 3) The Resident was admitted to the facility within 30 days after leaving the hospital; 4) The Resident is admitted to the facility to receive treatment for the same condition(s) for which he or she was treated in the hospital; and 5) A medical professional certifies that the Resident requires skilled nursing care on a “daily basis.” A Resident requires skilled nursing or skilled rehabilitation services on a daily basis when services are medically necessary and provided seven (7) days a week. There is an exception if they are only provided by the facility for five (5) days per week, due to staffing levels at the facility. Additionally, there may be a one to two day break if the Residents needs require suspension of the services. Where these five criteria are met, Medicare may provide coverage of up to 100 days of care in a skilled nursing facility (SNF): the first 20 days of covered services are fully paid for; and the next 80 days (days 21 through 100), of the covered services are paid for by Medicare subject to a daily coinsurance amount for which the Resident is responsible. For 2020, the Medicare Part A co-insurance amount is $176.00 per day. Additionally, Medicare Residents requesting a leave of absence from the facility should be aware of the Medicare rules regarding leave of absence and transfer within thirty (30) days. Medicare treats a leave of absence, where a Resident leaves the facility on a particular day and does not return by twelve (12) midnight that day, as an uncovered day. Additionally, the day in which a Resident begins a leave of absence (i.e., hospitalization), where the resident is absent for more than 24 hours, is treated as a day of discharge. Except for specifically excluded services, nursing home services provided to Medicare Part A beneficiaries are covered under the consolidated billing requirements. Residents must consult with the Facility before obtaining any services outside of the Facility. Medicare also has a thirty (30) day transfer requirement. A Resident must be transferred from a hospital or other SNF within thirty (30) days of discharge and meet the skilled care requirements in order to be eligible for SNF coverage. If a Resident meets the eligibility requirements for Skilled Nursing Facility benefits under the Medicare Part A Hospital Insurance Program, Facility will xxxx Medicare directly for all Part A services provided to the Resident. Medicare will reimburse Facility a fixed per diem or daily fee based on the Resident’s classification within the Medicare RUG III guidelines. RUG is an acronym for Resource-based Utilization Groups. These guidelines are a measure of what type of care the Resident requires and what it costs health care providers to provide that care to a Resident. Members of our professional staff will evaluate the Resident’s health condition based on a standardized assessment form (called the MDS 2.0) provided by the Centers for Medicare and Medicaid Services (CMS). Information from the MDS 2.0 form will be used by Medicare to assign the Resident a RUG III category. The Resident will be responsible for the daily co-insurance amount determined by Medicare. This amount is subject to increase each calendar year. With limited exceptions, a Resident who requires more than 100 days of SNF care in a benefit period will be responsible for private payment of all charges beginning with the 101st day. A new benefit period may begin when the Resident has either not been in a facility or has not been receiving a covered level of care in a skilled nursing facility for at least 60 days, returns to the hospital for another three-day stay, and then re-enters the SNF. A SNF may not request private payment until the Resident has received an official initial determination from Medicare that “skilled nursing” benefits are no longer available. While a SNF may make a determination of non-coverage, beneficiaries have a right to request an official Medicare determination of coverage (called a “Demand Xxxx”), which can be appealed. MEDICARE PART B PAYMENT Individuals who pay monthly premiums to enroll in Medicare Part B will be charged according to Facility’s or the service providers’ stated charge schedule for services they receive at Facility. Medicare Part B pays for a wide range of additional services beyond Part A coverage. Part B may cover some of a Residents care regardless of whether they are eligible for Part A benefits. Part B covers eighty (80%) percent of the Medicare approved charge for a specific service and the individual is responsible for the additional twenty (20%) percent. In general, Part B covers medical services and supplies. Part B covers such services as: physical, occupational and speech therapy, physician services, durable medical equipment, ambulance services and certain out-patient and clinical laboratory services. However, Part B benefits have limitations. For example, for 2020, there is a $198.00 deductible applicable to Medicare Part B benefits. Additionally, physical therapy (including speech- language pathology services) and occupational therapy are each subject to an annual limitation. The therapy financial limitations or “caps” are indexed by the Medicare Economic Index (MEI) each year. For 2020, the indexed amounts for physical therapy (including speech-language pathology services) and occupational therapy are $2,080.00 each, including co- insurance. Beneficiaries may be eligible for the Therapy Cap Exception Process. Both therapy limitations are still subject to the 80% - 20% coverage limitation in that the individual will be responsible for the 20 % co-insurance payments. The Resident is responsible for private payment of all therapy charges and any other ancillary charges above the Medicare Part B coverage limitations. The Facility can xxxx and receive payment if the Resident fills out a Medicare assignment of benefits form. If the Resident completes an assignment of benefits form, a health care provider cannot charge the Resident above the Medicare approved charge. In order to determine the Resident’s Part B coverage you should contact the Social Security Administration. In addition, Medicare Advantage programs and other alternatives may increase available Medicare benefits. To receive additional information about Medicare and Medicare Advantage programs, call the Social Security Administration at 800-772- 1213 or the Centers for Medicare and Medicaid Services at 1-800-MEDICARE. MEDICARE PART D - PRESCRIPTION DRUG COVERAGE Individuals eligible for Medicare Part A or enrolled in Medicare Part B and who do not have prescription drug coverage from a privately operated health plan or a Medicare Advantage-PD plan are eligible to enroll in Medicare Part D for prescription drug coverage. Medicare Part D through the selected PDP will provide reimbursement for prescription drugs listed in the PDP’s formulary subject to applicable premiums, deductibles and co-payments. Eligible individuals interested in obtaining prescription drug coverage through Medicare Part D must enroll in a PDP approved in the region. Upon admission to a skilled nursing home, individuals enrolled in a PDP in the community are permitted to continue with, or switch to a different PDP in the region. Dual eligible Medicare/Medicaid beneficiaries are automatically enrolled in, and assigned to an approved benchmark prescription drug plan (“PDP”) in the region. As of January 1, 2006, Medicaid no longer pays for prescription drug cost for dual eligibles. Dual eligibles in nursing homes will receive prescription drug coverage through Medicare Part D for the drugs listed on the selected PDP’s formulary. As long as dual eligibles are enrolled in benchmark plans in their region, they will not be responsible for premiums, deductibles and cost sharing obligations. Please call 000-000-0000 or contact xxx.xxxxxxxx.xxx/xxxxxxx.xxx to obtain enrollment information. MANAGED CARE Residents who are members of a managed care benefit plan that is under a contract with the Facility to provide specified services to plan members will receive those services with full coverage so long as the Resident meets the eligibility requirements of the managed care benefit plan. To the extent the Resident meets the eligibility requirements of the managed care benefit plan, he or she will be financially responsible only for the required deductibles and co-insurance and for those services that are not included in the list of covered services. Residents who have not received a list of covered services and eligibility requirements from their managed care benefit plan are advised to contact their social worker and/or managed care benefit plan. PRIVATE INSURANCE Residents who are covered by a private insurance plan that does not have a contract with the Facility must exhaust all available insurance coverage before seeking Medicare or Medicaid coverage. Where the insurance proceeds under the private plan are insufficient to cover the cost of care, the Resident will be responsible for any difference. The coverage requirements for nursing home care vary depending on the terms of the insurance policy. Questions regarding private insurance coverage should be directed to the social work staff and/or the Resident’s insurance carrier or agent. MEDICAID Medicaid is a publicly-funded program of assistance that covers nursing home Residents who can demonstrate financial need. To qualify for Medicaid, an individual may have only limited assets. For example, in 2020, the individual resource limit is $15,750 (subject to annual increases); plus any funds held in an “irrevocable burial trust” arrangement or up to $1,500 under a revocable burial account. Generally, most of the Resident’s monthly income must be paid to the Facility, except for a $50 monthly “personal needs allowance” and the monthly cost of retaining a private health insurance policy. This monthly income obligation, called the NAMI (Net Available Monthly Income), is determined by the Medicaid agency. If the Resident has a spouse in the community, the spouse might be entitled to a contribution from the Resident’s monthly income. During 2020, the “community spouse” is entitled to a minimum monthly income of $3,216 and resources up to a maximum of $128,640 (these figures are subject to increase each calendar year); increases beyond these amounts are possible, but a Department of Social Services Fair Hearing or Family Court support proceeding may be required. The Resident’s home may be exempt for Medicaid eligibility purposes if the equity value is less than $878,000.00 or if the spouse or disabled or minor child resides there. Upon application, Medicaid looks back at financial transactions or transfers of assets made within a sixty (60) month period of time from the date on which the person was institutionalized and applied for Medicaid coverage. A Resident or spouse who makes a transfer within those periods may create a period of Medicaid ineligibility. Private-pay Residents should apply for Medicaid about three months before their funds are depleted. A Medicaid application must include proof of the Resident’s identity, U.S. citizenship or legal alien status, and past and present financial status. Medicaid recipients are required to recertify eligibility each year in order to retain benefits. Medicaid is a complex program and a knowledgeable professional can advise Residents and their families as to their rights under the Medicaid program. To receive information about Medicaid, individuals can call their local Department of Social Services in the county in which the Resident resides. WORKERS’ COMPENSATION Workers’ Compensation benefits are available for an employee’s work-related injuries. Benefits, including direct payments to a health care provider, are paid by the employer’s insurance carrier. Workers’ Compensation will provide primary coverage of nursing home care, as long as it is established that the nursing home care is necessitated solely by the Workers’ Compensation injury. Claim forms must be submitted to the local Workers’ Compensation Board Office within two years of the date of injury. It is advisable to consult with an attorney practicing in the Workers’ Compensation area when pursuing a claim. For further information, you can contact your local Workers’ Compensation Board office.

Billed by Facility. (3) Billed direct by Provider or Vendor. (4) Patient/Resident responsible for co-insurance and deductible. (5) Coverage depends on services provided. Attachment A (2/15) ii ADDITIONAL NON-CLINICAL SERVICES THE FOLLOWING ADDITIONAL NON- CLINICAL SERVICES ARE AVAILABLE TO ALL RESIDENTS AND IF REQUESTED BY THE RESIDENT, SPONSOR AND/OR DESIGNATED REPRESENTATIVE, WILL BE CHARGED TO THE RESIDENT: • Telephone • Television/radio for Resident’s personal use • Personal comfort items, notions and novelties, and confections • Cosmetic and grooming items and services, in excess of those for which payment is made under Medicaid, Medicare, or other insurance programs • Personal clothing • Personal reading matter • Gifts purchased on behalf of a Resident • Flowers and plants • Social events, special meals, and entertainment offered off the premises and outside the scope of the Activities program provided by the Facility • Non-covered special care services, such as private duty nurses • Specially prepared or alternative food (other than Kosher food or food required by a therapeutic or modified diet prescribed by a physician) • Private room (except when therapeutically required, such as for isolation for infection control) IF YOU HAVE ANY QUESTIONS REGARDING CHARGES AND BILLING, PLEASE FEEL FREE TO CONTACT THE BUSINESS OFFICE AT (718) 298- 7800636- 1000. Attachment A (2/15) iii ATTACHMENT “B” SPECIAL RULES REGARDING SELECTED PAYORS PAYMENT FOR IN-PATIENT LONG TERM CARE SERVICES IS AN EXPENSIVE AND COMPLICATED PROCESS. THIS SUMMARY PROVIDES OUR RESIDENTS AND THEIR FAMILIES WITH BASIC INFORMATION WHICH SHOULD SIMPLIFY THE PROCESS. NOTHING HEREIN SHOULD BE CONSIDERED TO BE LEGAL ADVICE. WE URGE YOU TO CONSULT WITH AN INSURANCE AGENT, ATTORNEY AND/OR OTHER KNOWLEDGEABLE PROFESSIONAL(S) IN ORDER TO HELP MAXIMIZE AVAILABLE COVERAGE. FURTHER, AS THE INFORMATION PROVIDED BELOW IS BASED UPON STATUTE AND REGULATIONS, IT IS SUBJECT TO CHANGE WITHOUT NOTICE. MEDICARE PART A PAYMENT Medicare Part A Hospital Insurance Skilled Nursing Facility coverage is generally available to qualified individuals 65 years of age or older, and individuals under age 65 who have been disabled for at least twenty-four months, who meet the following five requirements: 1) The Resident requires daily skilled nursing or rehabilitation services that can be provided only in a skilled nursing facility; 2) The Resident was hospitalized for at least three consecutive days, not counting the day of discharge, before entering the skilled nursing facility; 3) The Resident was admitted to the facility within 30 days after leaving the hospital; 4) The Resident is admitted to the facility to receive treatment for the same condition(s) for which he or she was treated in the hospital; and 5) A medical professional certifies that the Resident requires skilled nursing care on a “daily basis.” A Resident requires skilled nursing or skilled rehabilitation services on a daily basis when services are medically necessary and provided seven (7) days a week. There is an exception if they are only provided by the facility for five (5) days per week, due to staffing levels at the facility. Additionally, there may be a one to two day break if the Residents needs require suspension of the services. Where these five criteria are met, Medicare may provide coverage of up to 100 days of care in a skilled nursing facility (SNF): the first 20 days of covered services are fully paid for; and the next 80 days (days 21 through 100), of the covered services are paid for by Medicare subject to a daily coinsurance amount for which the Resident is responsible. For 2020, the Medicare Part A co-insurance amount is $176.00 per day. Additionally, Medicare Residents requesting a leave of absence from the facility should be aware of the Medicare rules regarding leave of absence and transfer within thirty (30) days. Medicare treats a leave of absence, where a Resident leaves the facility on a particular day and does not return by twelve (12) midnight that day, as an uncovered day. Additionally, the day in which a Resident begins a leave of absence (i.e., hospitalization), where the resident is absent for more than 24 hours, is treated as a day of discharge. Except for specifically excluded services, nursing home services provided to Medicare Part A beneficiaries are covered under the consolidated billing requirements. Residents must consult with the Facility before obtaining any services outside of the Facility. Medicare also has a thirty (30) day transfer requirement. A Resident must be transferred from a hospital or other SNF within thirty (30) days of discharge and meet the skilled care requirements in order to be eligible for SNF coverage. If a Resident meets the eligibility requirements for Skilled Nursing Facility benefits under the Medicare Part A Hospital Insurance Program, Facility will xxxx Medicare directly for all Part A services provided to the Resident. Medicare will reimburse Facility a fixed per diem or daily fee based on the Resident’s classification within the Medicare RUG III guidelines. RUG is an acronym for Resource-based Utilization Groups. These guidelines are a measure of what type of care the Resident requires and what it costs health care providers to provide that care to a Resident. Members of our professional staff will evaluate the Resident’s health condition based on a standardized assessment form (called the MDS 2.0) provided by the Centers for Medicare and Medicaid Services (CMS). Information from the MDS 2.0 form will be used by Medicare to assign the Resident a RUG III category. The Resident will be responsible for the daily co-insurance amount determined by Medicare. This amount is subject to increase each calendar year. With limited exceptions, a Resident who requires more than 100 days of SNF care in a benefit period will be responsible for private payment of all charges beginning with the 101st day. A new benefit period may begin when the Resident has either not been in a facility or has not been receiving a covered level of care in a skilled nursing facility for at least 60 days, returns to the hospital for another three-day stay, and then re-enters the SNF. A SNF may not request private payment until the Resident has received an official initial determination from Medicare that “skilled nursing” benefits are no longer available. While a SNF may make a determination of non-coverage, beneficiaries have a right to request an official Medicare determination of coverage (called a “Demand Xxxx”), which can be appealed. Attachment B (12/13) i MEDICARE PART B PAYMENT Individuals who pay monthly premiums to enroll in Medicare Part B will be charged according to Facility’s or the service providers’ stated charge schedule for services they receive at Facility. Medicare Part B pays for a wide range of additional services beyond Part A coverage. Part B may cover some of a Residents care regardless of whether they are eligible for Part A benefits. Part B covers eighty (80%) percent of the Medicare approved charge for a specific service and the individual is responsible for the additional twenty (20%) percent. In general, Part B covers medical services and supplies. Part B covers such services as: physical, occupational and speech therapy, physician services, durable medical equipment, ambulance services and certain out-patient and clinical laboratory services. However, Part B benefits have limitations. For example, for 2020, there is a $198.00 deductible applicable to Medicare Part B benefits. Additionally, physical therapy (including speech- language pathology services) and occupational therapy are each subject to an annual limitation. The therapy financial limitations or “caps” are indexed by the Medicare Economic Index (MEI) each year. For 2020, the indexed amounts for physical therapy (including speech-language pathology services) and occupational therapy are $2,080.00 each, including co- insurance. Beneficiaries may be eligible for the Therapy Cap Exception Process. Both therapy limitations are still subject to the 80% - 20% coverage limitation in that the individual will be responsible for the 20 % co-insurance payments. The Resident is responsible for private payment of all therapy charges and any other ancillary charges above the Medicare Part B coverage limitations. The Facility can xxxx and receive payment if the Resident fills out a Medicare assignment of benefits form. If the Resident completes an assignment of benefits form, a health care provider cannot charge the Resident above the Medicare approved charge. In order to determine the Resident’s Part B coverage you should contact the Social Security Administration. In addition, Medicare Advantage programs and other alternatives may increase available Medicare benefits. To receive additional information about Medicare and Medicare Advantage programs, call the Social Security Administration at 800-772- 1213 or the Centers for Medicare and Medicaid Services at 1-800-MEDICARE. MEDICARE PART D - PRESCRIPTION DRUG COVERAGE Individuals eligible for Medicare Part A or enrolled in Medicare Part B and who do not have prescription drug coverage from a privately operated health plan or a Medicare Advantage-PD plan are eligible to enroll in Medicare Part D for prescription drug coverage. Medicare Part D through the selected PDP will provide reimbursement for prescription drugs listed in the PDP’s formulary subject to applicable premiums, deductibles and co-payments. Eligible individuals interested in obtaining prescription drug coverage through Medicare Part D must enroll in a PDP approved in the region. Upon admission to a skilled nursing home, individuals enrolled in a PDP in the community are permitted to continue with, or switch to a different PDP in the region. Dual eligible Medicare/Medicaid beneficiaries are automatically enrolled in, and assigned to an approved benchmark prescription drug plan (“PDP”) in the region. As of January 1, 2006, Medicaid no longer pays for prescription drug cost for dual eligibles. Dual eligibles in nursing homes will receive prescription drug coverage through Medicare Part D for the drugs listed on the selected PDP’s formulary. As long as dual eligibles are enrolled in benchmark plans in their region, they will not be responsible for premiums, deductibles and cost sharing obligations. Please call 000-000-0000 or contact xxx.xxxxxxxx.xxx/xxxxxxx.xxx to obtain enrollment information. MANAGED CARE Residents who are members of a managed care benefit plan that is under a contract with the Facility to provide specified services to plan members will receive those services with full coverage so long as the Resident meets the eligibility requirements of the managed care benefit plan. To the extent the Resident meets the eligibility requirements of the managed care benefit plan, he or she will be financially responsible only for the required deductibles and co-insurance and for those services that are not included in the list of covered services. Residents who have not received a list of covered services and eligibility requirements from their managed care benefit plan are advised to contact their social worker and/or managed care benefit plan. PRIVATE INSURANCE Residents who are covered by a private insurance plan that does not have a contract with the Facility must exhaust all available insurance coverage before seeking Medicare or Medicaid coverage. Where the insurance proceeds under the private plan are insufficient to cover the cost of care, the Resident will be responsible for any difference. The coverage requirements for nursing home care vary depending on the terms of the insurance policy. Questions regarding private insurance coverage should be directed to the social work staff and/or the Resident’s insurance carrier or agent. Attachment B (12/13) ii MEDICAID Medicaid is a publicly-funded program of assistance that covers nursing home Residents who can demonstrate financial need. To qualify for Medicaid, an individual may have only limited assets. For example, in 2020, the individual resource limit is $15,750 (subject to annual increases); plus any funds held in an “irrevocable burial trust” arrangement or up to $1,500 under a revocable burial account. Generally, most of the Resident’s monthly income must be paid to the Facility, except for a $50 monthly “personal needs allowance” and the monthly cost of retaining a private health insurance policy. This monthly income obligation, called the NAMI (Net Available Monthly Income), is determined by the Medicaid agency. If the Resident has a spouse in the community, the spouse might be entitled to a contribution from the Resident’s monthly income. During 2020, the “community spouse” is entitled to a minimum monthly income of $3,216 and resources up to a maximum of $128,640 (these figures are subject to increase each calendar year); increases beyond these amounts are possible, but a Department of Social Services Fair Hearing or Family Court support proceeding may be required. The Resident’s home may be exempt for Medicaid eligibility purposes if the equity value is less than $878,000.00 or if the spouse or disabled or minor child resides there. Upon application, Medicaid looks back at financial transactions or transfers of assets made within a sixty (60) month period of time from the date on which the person was institutionalized and applied for Medicaid coverage. A Resident or spouse who makes a transfer within those periods may create a period of Medicaid ineligibility. Private-pay Residents should apply for Medicaid about three months before their funds are depleted. A Medicaid application must include proof of the Resident’s identity, U.S. citizenship or legal alien status, and past and present financial status. Medicaid recipients are required to recertify eligibility each year in order to retain benefits. Medicaid is a complex program and a knowledgeable professional can advise Residents and their families as to their rights under the Medicaid program. To receive information about Medicaid, individuals can call their local Department of Social Services in the county in which the Resident resides. WORKERS’ COMPENSATION Workers’ Compensation benefits are available for an employee’s work-related injuries. Benefits, including direct payments to a health care provider, are paid by the employer’s insurance carrier. Workers’ Compensation will provide primary coverage of nursing home care, as long as it is established that the nursing home care is necessitated solely by the Workers’ Compensation injury. Claim forms must be submitted to the local Workers’ Compensation Board Office within two years of the date of injury. It is advisable to consult with an attorney practicing in the Workers’ Compensation area when pursuing a claim. For further information, you can contact your local Workers’ Compensation Board office.

Billed by Facility. (3) Billed direct by Provider or Vendor. (4) Patient/Resident responsible for co-insurance and deductible. (5) Coverage depends on services provided. Attachment A (2/15) ii ADDITIONAL NON-CLINICAL SERVICES THE FOLLOWING ADDITIONAL NON- CLINICAL SERVICES ARE AVAILABLE TO ALL RESIDENTS AND IF REQUESTED BY THE RESIDENT, SPONSOR AND/OR DESIGNATED REPRESENTATIVE, WILL BE CHARGED TO THE RESIDENT: • Telephone • Television/radio for Resident’s personal use • Personal comfort items, notions and novelties, and confections • Cosmetic and grooming items and services, in excess of those for which payment is made under Medicaid, Medicare, or other insurance programs • Personal clothing • Personal reading matter • Gifts purchased on behalf of a Resident • Flowers and plants • Social events, special meals, and entertainment offered off the premises and outside the scope of the Activities program provided by the Facility • Non-covered special care services, such as private duty nurses • Specially prepared or alternative food (other than Kosher food or food required by a therapeutic or modified diet prescribed by a physician) • Private room (except when therapeutically required, such as for isolation for infection control) IF YOU HAVE ANY QUESTIONS REGARDING CHARGES AND BILLING, PLEASE FEEL FREE TO CONTACT THE BUSINESS OFFICE AT (718516) 298- 7800897- 1110. Attachment A (2/15) iii ATTACHMENT “B” SPECIAL RULES REGARDING SELECTED PAYORS PAYMENT FOR IN-PATIENT LONG TERM CARE SERVICES IS AN EXPENSIVE AND COMPLICATED PROCESS. THIS SUMMARY PROVIDES OUR RESIDENTS AND THEIR FAMILIES WITH BASIC INFORMATION WHICH SHOULD SIMPLIFY THE PROCESS. NOTHING HEREIN SHOULD BE CONSIDERED TO BE LEGAL ADVICE. WE URGE YOU TO CONSULT WITH AN INSURANCE AGENT, ATTORNEY AND/OR OTHER KNOWLEDGEABLE PROFESSIONAL(S) IN ORDER TO HELP MAXIMIZE AVAILABLE COVERAGE. FURTHER, AS THE INFORMATION PROVIDED BELOW IS BASED UPON STATUTE AND REGULATIONS, IT IS SUBJECT TO CHANGE WITHOUT NOTICE. MEDICARE PART A PAYMENT Medicare Part A Hospital Insurance Skilled Nursing Facility coverage is generally available to qualified individuals 65 years of age or older, and individuals under age 65 who have been disabled for at least twenty-four months, who meet the following five requirements: 1) The Resident requires daily skilled nursing or rehabilitation services that can be provided only in a skilled nursing facility; 2) The Resident was hospitalized for at least three consecutive days, not counting the day of discharge, before entering the skilled nursing facility; 3) The Resident was admitted to the facility within 30 days after leaving the hospital; 4) The Resident is admitted to the facility to receive treatment for the same condition(s) for which he or she was treated in the hospital; and 5) A medical professional certifies that the Resident requires skilled nursing care on a “daily basis.” A Resident requires skilled nursing or skilled rehabilitation services on a daily basis when services are medically necessary and provided seven (7) days a week. There is an exception if they are only provided by the facility for five (5) days per week, due to staffing levels at the facility. Additionally, there may be a one to two day break if the Residents needs require suspension of the services. Where these five criteria are met, Medicare may provide coverage of up to 100 days of care in a skilled nursing facility (SNF): the first 20 days of covered services are fully paid for; and the next 80 days (days 21 through 100), of the covered services are paid for by Medicare subject to a daily coinsurance amount for which the Resident is responsible. For 2020, the Medicare Part A co-insurance amount is $176.00 per day. Additionally, Medicare Residents requesting a leave of absence from the facility should be aware of the Medicare rules regarding leave of absence and transfer within thirty (30) days. Medicare treats a leave of absence, where a Resident leaves the facility on a particular day and does not return by twelve (12) midnight that day, as an uncovered day. Additionally, the day in which a Resident begins a leave of absence (i.e., hospitalization), where the resident is absent for more than 24 hours, is treated as a day of discharge. Except for specifically excluded services, nursing home services provided to Medicare Part A beneficiaries are covered under the consolidated billing requirements. Residents must consult with the Facility before obtaining any services outside of the Facility. Medicare also has a thirty (30) day transfer requirement. A Resident must be transferred from a hospital or other SNF within thirty (30) days of discharge and meet the skilled care requirements in order to be eligible for SNF coverage. If a Resident meets the eligibility requirements for Skilled Nursing Facility benefits under the Medicare Part A Hospital Insurance Program, Facility will xxxx Medicare directly for all Part A services provided to the Resident. Medicare will reimburse Facility a fixed per diem or daily fee based on the Resident’s classification within the Medicare RUG III guidelines. RUG is an acronym for Resource-based Utilization Groups. These guidelines are a measure of what type of care the Resident requires and what it costs health care providers to provide that care to a Resident. Members of our professional staff will evaluate the Resident’s health condition based on a standardized assessment form (called the MDS 2.0) provided by the Centers for Medicare and Medicaid Services (CMS). Information from the MDS 2.0 form will be used by Medicare to assign the Resident a RUG III category. The Resident will be responsible for the daily co-insurance amount determined by Medicare. This amount is subject to increase each calendar year. With limited exceptions, a Resident who requires more than 100 days of SNF care in a benefit period will be responsible for private payment of all charges beginning with the 101st day. A new benefit period may begin when the Resident has either not been in a facility or has not been receiving a covered level of care in a skilled nursing facility for at least 60 days, returns to the hospital for another three-day stay, and then re-enters the SNF. A SNF may not request private payment until the Resident has received an official initial determination from Medicare that “skilled nursing” benefits are no longer available. While a SNF may make a determination of non-coverage, beneficiaries have a right to request an official Medicare determination of coverage (called a “Demand Xxxx”), which can be appealed. Attachment B (12/13) i MEDICARE PART B PAYMENT Individuals who pay monthly premiums to enroll in Medicare Part B will be charged according to Facility’s or the service providers’ stated charge schedule for services they receive at Facility. Medicare Part B pays for a wide range of additional services beyond Part A coverage. Part B may cover some of a Residents care regardless of whether they are eligible for Part A benefits. Part B covers eighty (80%) percent of the Medicare approved charge for a specific service and the individual is responsible for the additional twenty (20%) percent. In general, Part B covers medical services and supplies. Part B covers such services as: physical, occupational and speech therapy, physician services, durable medical equipment, ambulance services and certain out-patient and clinical laboratory services. However, Part B benefits have limitations. For example, for 2020, there is a $198.00 deductible applicable to Medicare Part B benefits. Additionally, physical therapy (including speech- language pathology services) and occupational therapy are each subject to an annual limitation. The therapy financial limitations or “caps” are indexed by the Medicare Economic Index (MEI) each year. For 2020, the indexed amounts for physical therapy (including speech-language pathology services) and occupational therapy are $2,080.00 each, including co- insurance. Beneficiaries may be eligible for the Therapy Cap Exception Process. Both therapy limitations are still subject to the 80% - 20% coverage limitation in that the individual will be responsible for the 20 % co-insurance payments. The Resident is responsible for private payment of all therapy charges and any other ancillary charges above the Medicare Part B coverage limitations. The Facility can xxxx and receive payment if the Resident fills out a Medicare assignment of benefits form. If the Resident completes an assignment of benefits form, a health care provider cannot charge the Resident above the Medicare approved charge. In order to determine the Resident’s Part B coverage you should contact the Social Security Administration. In addition, Medicare Advantage programs and other alternatives may increase available Medicare benefits. To receive additional information about Medicare and Medicare Advantage programs, call the Social Security Administration at 800-772- 1213 or the Centers for Medicare and Medicaid Services at 1-800-MEDICARE. MEDICARE PART D - PRESCRIPTION DRUG COVERAGE Individuals eligible for Medicare Part A or enrolled in Medicare Part B and who do not have prescription drug coverage from a privately operated health plan or a Medicare Advantage-PD plan are eligible to enroll in Medicare Part D for prescription drug coverage. Medicare Part D through the selected PDP will provide reimbursement for prescription drugs listed in the PDP’s formulary subject to applicable premiums, deductibles and co-payments. Eligible individuals interested in obtaining prescription drug coverage through Medicare Part D must enroll in a PDP approved in the region. Upon admission to a skilled nursing home, individuals enrolled in a PDP in the community are permitted to continue with, or switch to a different PDP in the region. Dual eligible Medicare/Medicaid beneficiaries are automatically enrolled in, and assigned to an approved benchmark prescription drug plan (“PDP”) in the region. As of January 1, 2006, Medicaid no longer pays for prescription drug cost for dual eligibles. Dual eligibles in nursing homes will receive prescription drug coverage through Medicare Part D for the drugs listed on the selected PDP’s formulary. As long as dual eligibles are enrolled in benchmark plans in their region, they will not be responsible for premiums, deductibles and cost sharing obligations. Please call 000-000-0000 or contact xxx.xxxxxxxx.xxx/xxxxxxx.xxx to obtain enrollment information. MANAGED CARE Residents who are members of a managed care benefit plan that is under a contract with the Facility to provide specified services to plan members will receive those services with full coverage so long as the Resident meets the eligibility requirements of the managed care benefit plan. To the extent the Resident meets the eligibility requirements of the managed care benefit plan, he or she will be financially responsible only for the required deductibles and co-insurance and for those services that are not included in the list of covered services. Residents who have not received a list of covered services and eligibility requirements from their managed care benefit plan are advised to contact their social worker and/or managed care benefit plan. PRIVATE INSURANCE Residents who are covered by a private insurance plan that does not have a contract with the Facility must exhaust all available insurance coverage before seeking Medicare or Medicaid coverage. Where the insurance proceeds under the private plan are insufficient to cover the cost of care, the Resident will be responsible for any difference. The coverage requirements for nursing home care vary depending on the terms of the insurance policy. Questions regarding private insurance coverage should be directed to the social work staff and/or the Resident’s insurance carrier or agent. Attachment B (12/13) ii MEDICAID Medicaid is a publicly-funded program of assistance that covers nursing home Residents who can demonstrate financial need. To qualify for Medicaid, an individual may have only limited assets. For example, in 2020, the individual resource limit is $15,750 (subject to annual increases); plus any funds held in an “irrevocable burial trust” arrangement or up to $1,500 under a revocable burial account. Generally, most of the Resident’s monthly income must be paid to the Facility, except for a $50 monthly “personal needs allowance” and the monthly cost of retaining a private health insurance policy. This monthly income obligation, called the NAMI (Net Available Monthly Income), is determined by the Medicaid agency. If the Resident has a spouse in the community, the spouse might be entitled to a contribution from the Resident’s monthly income. During 2020, the “community spouse” is entitled to a minimum monthly income of $3,216 and resources up to a maximum of $128,640 (these figures are subject to increase each calendar year); increases beyond these amounts are possible, but a Department of Social Services Fair Hearing or Family Court support proceeding may be required. The Resident’s home may be exempt for Medicaid eligibility purposes if the equity value is less than $878,000.00 or if the spouse or disabled or minor child resides there. Upon application, Medicaid looks back at financial transactions or transfers of assets made within a sixty (60) month period of time from the date on which the person was institutionalized and applied for Medicaid coverage. A Resident or spouse who makes a transfer within those periods may create a period of Medicaid ineligibility. Private-pay Residents should apply for Medicaid about three months before their funds are depleted. A Medicaid application must include proof of the Resident’s identity, U.S. citizenship or legal alien status, and past and present financial status. Medicaid recipients are required to recertify eligibility each year in order to retain benefits. Medicaid is a complex program and a knowledgeable professional can advise Residents and their families as to their rights under the Medicaid program. To receive information about Medicaid, individuals can call their local Department of Social Services in the county in which the Resident resides. WORKERS’ COMPENSATION Workers’ Compensation benefits are available for an employee’s work-related injuries. Benefits, including direct payments to a health care provider, are paid by the employer’s insurance carrier. Workers’ Compensation will provide primary coverage of nursing home care, as long as it is established that the nursing home care is necessitated solely by the Workers’ Compensation injury. Claim forms must be submitted to the local Workers’ Compensation Board Office within two years of the date of injury. It is advisable to consult with an attorney practicing in the Workers’ Compensation area when pursuing a claim. For further information, you can contact your local Workers’ Compensation Board office.

Billed by Facility. (3) Billed direct by Provider or Vendor. (4) Patient/Resident responsible for co-insurance and deductible. (5) Coverage depends on services provided. ADDITIONAL NON-CLINICAL SERVICES THE FOLLOWING ADDITIONAL NON- CLINICAL SERVICES ARE AVAILABLE TO ALL RESIDENTS AND IF REQUESTED BY THE RESIDENT, SPONSOR AND/OR DESIGNATED REPRESENTATIVE, WILL BE CHARGED TO THE RESIDENT: • Telephone • Television/radio for Resident’s personal use • Personal comfort items, notions and novelties, and confections • Cosmetic and grooming items and services, in excess of those for which payment is made under Medicaid, Medicare, or other insurance programs • Personal clothing • Personal reading matter • Gifts purchased on behalf of a Resident • Flowers and plants • Social events, special meals, and entertainment offered off the premises and outside the scope of the Activities program provided by the Facility • Non-covered special care services, such as private duty nurses • Specially prepared or alternative food (other than Kosher food or food required by a therapeutic or modified diet prescribed by a physician) • Private room (except when therapeutically required, such as for isolation for infection control) IF YOU HAVE ANY QUESTIONS REGARDING CHARGES AND BILLING, PLEASE FEEL FREE TO CONTACT THE BUSINESS OFFICE AT (718212) 298- 7800337- 9400. ATTACHMENT “B” SPECIAL RULES REGARDING SELECTED PAYORS PAYMENT FOR IN-PATIENT LONG TERM CARE SERVICES IS AN EXPENSIVE AND COMPLICATED PROCESS. THIS SUMMARY PROVIDES OUR RESIDENTS AND THEIR FAMILIES WITH BASIC INFORMATION WHICH SHOULD SIMPLIFY THE PROCESS. NOTHING HEREIN SHOULD BE CONSIDERED TO BE LEGAL ADVICE. WE URGE YOU TO CONSULT WITH AN INSURANCE AGENT, ATTORNEY AND/OR OTHER KNOWLEDGEABLE PROFESSIONAL(S) IN ORDER TO HELP MAXIMIZE AVAILABLE COVERAGE. FURTHER, AS THE INFORMATION PROVIDED BELOW IS BASED UPON STATUTE AND REGULATIONS, IT IS SUBJECT TO CHANGE WITHOUT NOTICE. MEDICARE PART A PAYMENT Medicare Part A Hospital Insurance Skilled Nursing Facility coverage is generally available to qualified individuals 65 years of age or older, and individuals under age 65 who have been disabled for at least twenty-four months, who meet the following five requirements: 1) The Resident requires daily skilled nursing or rehabilitation services that can be provided only in a skilled nursing facility; 2) The Resident was hospitalized for at least three consecutive days, not counting the day of discharge, before entering the skilled nursing facility; 3) The Resident was admitted to the facility within 30 days after leaving the hospital; 4) The Resident is admitted to the facility to receive treatment for the same condition(s) for which he or she was treated in the hospital; and 5) A medical professional certifies that the Resident requires skilled nursing care on a “daily basis.” A Resident requires skilled nursing or skilled rehabilitation services on a daily basis when services are medically necessary and provided seven (7) days a week. There is an exception if they are only provided by the facility for five (5) days per week, due to staffing levels at the facility. Additionally, there may be a one to two day break if the Residents needs require suspension of the services. Where these five criteria are met, Medicare may provide coverage of up to 100 days of care in a skilled nursing facility (SNF): the first 20 days of covered services are fully paid for; and the next 80 days (days 21 through 100), of the covered services are paid for by Medicare subject to a daily coinsurance amount for which the Resident is responsible. For 20202021, the Medicare Part A co-insurance amount is $176.00 185.50 per day. Additionally, Medicare Residents requesting a leave of absence from the facility should be aware of the Medicare rules regarding leave of absence and transfer within thirty (30) days. Medicare treats a leave of absence, where a Resident leaves the facility on a particular day and does not return by twelve (12) midnight that day, as an uncovered day. Additionally, the day in which a Resident begins a leave of absence (i.e., hospitalization), where the resident is absent for more than 24 hours, is treated as a day of discharge. Except for specifically excluded services, nursing home services provided to Medicare Part A beneficiaries are covered under the consolidated billing requirements. Residents must consult with the Facility before obtaining any services outside of the Facility. Medicare also has a thirty (30) day transfer requirement. A Resident must be transferred from a hospital or other SNF within thirty (30) days of discharge and meet the skilled care requirements in order to be eligible for SNF coverage. If a Resident meets the eligibility requirements for Skilled Nursing Facility benefits under the Medicare Part A Hospital Insurance Program, Facility will xxxx Medicare directly for all Part A services provided to the Resident. Medicare will reimburse Facility a fixed per diem or daily fee based on the Resident’s classification within the Medicare RUG III guidelines. RUG is an acronym for Resource-based Utilization Groups. These guidelines are a measure of what type of care the Resident requires and what it costs health care providers to provide that care to a Resident. Members of our professional staff will evaluate the Resident’s health condition based on a standardized assessment form (called the MDS 2.0) provided by the Centers for Medicare and Medicaid Services (CMS). Information from the MDS 2.0 form will be used by Medicare to assign the Resident a RUG III category. The Resident will be responsible for the daily co-insurance amount determined by Medicare. This amount is subject to increase each calendar year. With limited exceptions, a Resident who requires more than 100 days of SNF care in a benefit period will be responsible for private payment of all charges beginning with the 101st day. A new benefit period may begin when the Resident has either not been in a facility or has not been receiving a covered level of care in a skilled nursing facility for at least 60 days, returns to the hospital for another three-day stay, and then re-enters the SNF. A SNF may not request private payment until the Resident has received an official initial determination from Medicare that “skilled nursing” benefits are no longer available. While a SNF may make a determination of non-coverage, beneficiaries have a right to request an official Medicare determination of coverage (called a “Demand Xxxx”), which can be appealed. MEDICARE PART B PAYMENT Individuals who pay monthly premiums to enroll in Medicare Part B will be charged according to Facility’s or the service providers’ stated charge schedule for services they receive at Facility. Medicare Part B pays for a wide range of additional services beyond Part A coverage. Part B may cover some of a Residents care regardless of whether they are eligible for Part A benefits. Part B covers eighty (80%) percent of the Medicare approved charge for a specific service and the individual is responsible for the additional twenty (20%) percent. In general, Part B covers medical services and supplies. Part B covers such services as: physical, occupational and speech therapy, physician services, durable medical equipment, ambulance services and certain out-patient and clinical laboratory services. However, Part B benefits have limitations. For example, for 20202021, there is a $198.00 203.00 deductible applicable to Medicare Part B benefits. Additionally, physical therapy (including speech- language pathology services) and occupational therapy are each subject to an annual limitation. The therapy financial limitations or “caps” are indexed by the Medicare Economic Index (MEI) each year. For 20202021, the indexed amounts for physical therapy (including speech-language pathology services) and occupational therapy are $2,080.00 2,110.00 each, including co- insurance. Beneficiaries may be eligible for the Therapy Cap Exception Process. Both therapy limitations are still subject to the 80% - 20% coverage limitation in that the individual will be responsible for the 20 % co-insurance payments. The Resident is responsible for private payment of all therapy charges and any other ancillary charges above the Medicare Part B coverage limitations. The Facility can xxxx and receive payment if the Resident fills out a Medicare assignment of benefits form. If the Resident completes an assignment of benefits form, a health care provider cannot charge the Resident above the Medicare approved charge. In order to determine the Resident’s Part B coverage you should contact the Social Security Administration. In addition, Medicare Advantage programs and other alternatives may increase available Medicare benefits. To receive additional information about Medicare and Medicare Advantage programs, call the Social Security Administration at 800-772- 1213 or the Centers for Medicare and Medicaid Services at 1-800-MEDICARE. MEDICARE PART D - PRESCRIPTION DRUG COVERAGE Individuals eligible for Medicare Part A or enrolled in Medicare Part B and who do not have prescription drug coverage from a privately operated health plan or a Medicare Advantage-PD plan are eligible to enroll in Medicare Part D for prescription drug coverage. Medicare Part D through the selected PDP will provide reimbursement for prescription drugs listed in the PDP’s formulary subject to applicable premiums, deductibles and co-payments. Eligible individuals interested in obtaining prescription drug coverage through Medicare Part D must enroll in a PDP approved in the region. Upon admission to a skilled nursing home, individuals enrolled in a PDP in the community are permitted to continue with, or switch to a different PDP in the region. Dual eligible Medicare/Medicaid beneficiaries are automatically enrolled in, and assigned to an approved benchmark prescription drug plan (“PDP”) in the region. As of January 1, 2006, Medicaid no longer pays for prescription drug cost for dual eligibles. Dual eligibles in nursing homes will receive prescription drug coverage through Medicare Part D for the drugs listed on the selected PDP’s formulary. As long as dual eligibles are enrolled in benchmark plans in their region, they will not be responsible for premiums, deductibles and cost sharing obligations. Please call 000-000-0000 or contact xxx.xxxxxxxx.xxx/xxxxxxx.xxx to obtain enrollment information. MANAGED CARE Residents who are members of a managed care benefit plan that is under a contract with the Facility to provide specified services to plan members will receive those services with full coverage so long as the Resident meets the eligibility requirements of the managed care benefit plan. To the extent the Resident meets the eligibility requirements of the managed care benefit plan, he or she will be financially responsible only for the required deductibles and co-insurance and for those services that are not included in the list of covered services. Residents who have not received a list of covered services and eligibility requirements from their managed care benefit plan are advised to contact their social worker and/or managed care benefit plan. PRIVATE INSURANCE Residents who are covered by a private insurance plan that does not have a contract with the Facility must exhaust all available insurance coverage before seeking Medicare or Medicaid coverage. Where the insurance proceeds under the private plan are insufficient to cover the cost of care, the Resident will be responsible for any difference. The coverage requirements for nursing home care vary depending on the terms of the insurance policy. Questions regarding private insurance coverage should be directed to the social work staff and/or the Resident’s insurance carrier or agent. MEDICAID Medicaid is a publicly-funded program of assistance that covers nursing home Residents who can demonstrate financial need. To qualify for Medicaid, an individual may have only limited assets. For example, in 20202021, the individual resource limit is $15,750 15,900 (subject to annual increases); plus any funds held in an “irrevocable burial trust” arrangement or up to $1,500 under a revocable burial account. Generally, most of the Resident’s monthly income must be paid to the Facility, except for a $50 monthly “personal needs allowance” and the monthly cost of retaining a private health insurance policy. This monthly income obligation, called the NAMI (Net Available Monthly Income), is determined by the Medicaid agency. If the Resident has a spouse in the community, the spouse might be entitled to a contribution from the Resident’s monthly income. During 20202021, the “community spouse” is entitled to a minimum monthly income of $3,216 3,259.50 and resources up to a maximum of $128,640 130,380 (these figures are subject to increase each calendar year); increases beyond these amounts are possible, but a Department of Social Services Fair Hearing or Family Court support proceeding may be required. The Resident’s home may be exempt for Medicaid eligibility purposes if the equity value is less than $878,000.00 893,000.00 or if the spouse or disabled or minor child resides there. Upon application, Medicaid looks back at financial transactions or transfers of assets made within a sixty (60) month period of time from the date on which the person was institutionalized and applied for Medicaid coverage. A Resident or spouse who makes a transfer within those periods may create a period of Medicaid ineligibility. Private-pay Residents should apply for Medicaid about three months before their funds are depleted. A Medicaid application must include proof of the Resident’s identity, U.S. citizenship or legal alien status, and past and present financial status. Medicaid recipients are required to recertify eligibility each year in order to retain benefits. Medicaid is a complex program and a knowledgeable professional can advise Residents and their families as to their rights under the Medicaid program. To receive information about Medicaid, individuals can call their local Department of Social Services in the county in which the Resident resides. WORKERS’ COMPENSATION Workers’ Compensation benefits are available for an employee’s work-related injuries. Benefits, including direct payments to a health care provider, are paid by the employer’s insurance carrier. Workers’ Compensation will provide primary coverage of nursing home care, as long as it is established that the nursing home care is necessitated solely by the Workers’ Compensation injury. Claim forms must be submitted to the local Workers’ Compensation Board Office within two years of the date of injury. It is advisable to consult with an attorney practicing in the Workers’ Compensation area when pursuing a claim. For further information, you can contact your local Workers’ Compensation Board office.

Billed by Facility. (3) Billed direct by Provider or Vendor. (4) Patient/Resident responsible for co-insurance and deductible. (5) Coverage depends on services provided. Attachment A (2/15) ii ADDITIONAL NON-CLINICAL SERVICES THE FOLLOWING ADDITIONAL NON- CLINICAL SERVICES ARE AVAILABLE TO ALL RESIDENTS AND IF REQUESTED BY THE RESIDENTThe following additional Non- clinical services are available to all residents and if requested by the Resident, SPONSOR AND/OR DESIGNATED REPRESENTATIVESponsor and/or Designated Representative, WILL BE CHARGED TO THE RESIDENTwill be charged to the Resident: • Telephone • Television/radio for Resident’s personal use • Personal comfort items, notions and novelties, and confections • Cosmetic and grooming items and services, in excess of those for which payment is made under Medicaid, Medicare, or other insurance programs • Personal clothing • Personal reading matter • Gifts purchased on behalf of a Resident • Flowers and plants • Social events, special meals, and entertainment offered off the premises and outside the scope of the Activities program provided by the Facility • Non-covered special care services, such as private duty nurses • Specially prepared or alternative food (other than Kosher food or food required by a therapeutic or modified diet prescribed by a physician) • Private room (except when therapeutically required, such as for isolation for infection control) IF YOU HAVE ANY QUESTIONS REGARDING CHARGES AND BILLING, PLEASE FEEL FREE TO CONTACT THE BUSINESS OFFICE AT (718) 298- 7800891- 4400. Attachment A (2/15) iii ATTACHMENT “B” SPECIAL RULES REGARDING SELECTED PAYORS PAYMENT FOR IN-PATIENT LONG TERM CARE SERVICES IS AN EXPENSIVE AND COMPLICATED PROCESS. THIS SUMMARY PROVIDES OUR RESIDENTS AND THEIR FAMILIES WITH BASIC INFORMATION WHICH SHOULD SIMPLIFY THE PROCESS. NOTHING HEREIN SHOULD BE CONSIDERED TO BE LEGAL ADVICE. WE URGE YOU TO CONSULT WITH AN INSURANCE AGENT, ATTORNEY AND/OR OTHER KNOWLEDGEABLE PROFESSIONAL(S) IN ORDER TO HELP MAXIMIZE AVAILABLE COVERAGE. FURTHER, AS THE INFORMATION PROVIDED BELOW IS BASED UPON STATUTE AND REGULATIONS, IT IS SUBJECT TO CHANGE WITHOUT NOTICE. MEDICARE PART A PAYMENT Medicare Part A Hospital Insurance Skilled Nursing Facility coverage is generally available to qualified individuals 65 years of age or older, and individuals under age 65 who have been disabled for at least twenty-four months, who meet the following five requirements: 1) The Resident requires daily skilled nursing or rehabilitation services that can be provided only in a skilled nursing facility; 2) The Resident was hospitalized for at least three consecutive days, not counting the day of discharge, before entering the skilled nursing facility; 3) The Resident was admitted to the facility within 30 days after leaving the hospital; 4) The Resident is admitted to the facility to receive treatment for the same condition(s) for which he or she was treated in the hospital; and 5) A medical professional certifies that the Resident requires skilled nursing care on a “daily basis.” A Resident requires skilled nursing or skilled rehabilitation services on a daily basis when services are medically necessary and provided seven (7) days a week. There is an exception if they are only provided by the facility for five (5) days per week, due to staffing levels at the facility. Additionally, there may be a one to two day break if the Residents needs require suspension of the services. Where these five criteria are met, Medicare may provide coverage of up to 100 days of care in a skilled nursing facility (SNF): the first 20 days of covered services are fully paid for; and the next 80 days (days 21 through 100), of the covered services are paid for by Medicare subject to a daily coinsurance amount for which the Resident is responsible. For 2020, the Medicare Part A co-insurance amount is $176.00 per day. Additionally, Medicare Residents requesting a leave of absence from the facility should be aware of the Medicare rules regarding leave of absence and transfer within thirty (30) days. Medicare treats a leave of absence, where a Resident leaves the facility on a particular day and does not return by twelve (12) midnight that day, as an uncovered day. Additionally, the day in which a Resident begins a leave of absence (i.e., hospitalization), where the resident is absent for more than 24 hours, is treated as a day of discharge. Except for specifically excluded services, nursing home services provided to Medicare Part A beneficiaries are covered under the consolidated billing requirements. Residents must consult with the Facility before obtaining any services outside of the Facility. Medicare also has a thirty (30) day transfer requirement. A Resident must be transferred from a hospital or other SNF within thirty (30) days of discharge and meet the skilled care requirements in order to be eligible for SNF coverage. If a Resident meets the eligibility requirements for Skilled Nursing Facility benefits under the Medicare Part A Hospital Insurance Program, Facility will xxxx bill Medicare directly for all Part A services provided to the Resident. Medicare will reimburse Facility a fixed per diem or daily fee based on the Resident’s classification within the Medicare RUG III guidelines. RUG is an acronym for Resource-based Utilization Groups. These guidelines are a measure of what type of care the Resident requires and what it costs health care providers to provide that care to a Resident. Members of our professional staff will evaluate the Resident’s health condition based on a standardized assessment form (called the MDS 2.0) provided by the Centers for Medicare and Medicaid Services (CMS). Information from the MDS 2.0 form will be used by Medicare to assign the Resident a RUG III category. The Resident will be responsible for the daily co-insurance amount determined by Medicare. This amount is subject to increase each calendar year. With limited exceptions, a Resident who requires more than 100 days of SNF care in a benefit period will be responsible for private payment of all charges beginning with the 101st day. A new benefit period may begin when the Resident has either not been in a facility or has not been receiving a covered level of care in a skilled nursing facility for at least 60 days, returns to the hospital for another three-day stay, and then re-enters the SNF. A SNF may not request private payment until the Resident has received an official initial determination from Medicare that “skilled nursing” benefits are no longer available. While a SNF may make a determination of non-coverage, beneficiaries have a right to request an official Medicare determination of coverage (called a “Demand XxxxBill”), which can be appealed. Attachment B (12/13) i MEDICARE PART B PAYMENT Individuals who pay monthly premiums to enroll in Medicare Part B will be charged according to Facility’s or the service providers’ stated charge schedule for services they receive at Facility. Medicare Part B pays for a wide range of additional services beyond Part A coverage. Part B may cover some of a Residents care regardless of whether they are eligible for Part A benefits. Part B covers eighty (80%) percent of the Medicare approved charge for a specific service and the individual is responsible for the additional twenty (20%) percent. In general, Part B covers medical services and supplies. Part B covers such services as: physical, occupational and speech therapy, physician services, durable medical equipment, ambulance services and certain out-patient and clinical laboratory services. However, Part B benefits have limitations. For example, for 2020, there is a $198.00 deductible applicable to Medicare Part B benefits. Additionally, physical therapy (including speech- language pathology services) and occupational therapy are each subject to an annual limitation. The therapy financial limitations or “caps” are indexed by the Medicare Economic Index (MEI) each year. For 2020, the indexed amounts for physical therapy (including speech-language pathology services) and occupational therapy are $2,080.00 each, including co- insurance. Beneficiaries may be eligible for the Therapy Cap Exception Process. Both therapy limitations are still subject to the 80% - 20% coverage limitation in that the individual will be responsible for the 20 % co-insurance payments. The Resident is responsible for private payment of all therapy charges and any other ancillary charges above the Medicare Part B coverage limitations. The Facility can xxxx bill and receive payment if the Resident fills out a Medicare assignment of benefits form. If the Resident completes an assignment of benefits form, a health care provider cannot charge the Resident above the Medicare approved charge. In order to determine the Resident’s Part B coverage you should contact the Social Security Administration. In addition, Medicare Advantage programs and other alternatives may increase available Medicare benefits. To receive additional information about Medicare and Medicare Advantage programs, call the Social Security Administration at 800-772- 1213 or the Centers for Medicare and Medicaid Services at 1-800-MEDICARE. MEDICARE PART D - PRESCRIPTION DRUG COVERAGE Individuals eligible for Medicare Part A or enrolled in Medicare Part B and who do not have prescription drug coverage from a privately operated health plan or a Medicare Advantage-PD plan are eligible to enroll in Medicare Part D for prescription drug coverage. Medicare Part D through the selected PDP will provide reimbursement for prescription drugs listed in the PDP’s formulary subject to applicable premiums, deductibles and co-payments. Eligible individuals interested in obtaining prescription drug coverage through Medicare Part D must enroll in a PDP approved in the region. Upon admission to a skilled nursing home, individuals enrolled in a PDP in the community are permitted to continue with, or switch to a different PDP in the region. Dual eligible Medicare/Medicaid beneficiaries are automatically enrolled in, and assigned to an approved benchmark prescription drug plan (“PDP”) in the region. As of January 1, 2006, Medicaid no longer pays for prescription drug cost for dual eligibles. Dual eligibles in nursing homes will receive prescription drug coverage through Medicare Part D for the drugs listed on the selected PDP’s formulary. As long as dual eligibles are enrolled in benchmark plans in their region, they will not be responsible for premiums, deductibles and cost sharing obligations. Please call 000-000-0000 or contact xxx.xxxxxxxx.xxx/xxxxxxx.xxx to obtain enrollment information. MANAGED CARE Residents who are members of a managed care benefit plan that is under a contract with the Facility to provide specified services to plan members will receive those services with full coverage so long as the Resident meets the eligibility requirements of the managed care benefit plan. To the extent the Resident meets the eligibility requirements of the managed care benefit plan, he or she will be financially responsible only for the required deductibles and co-insurance and for those services that are not included in the list of covered services. Residents who have not received a list of covered services and eligibility requirements from their managed care benefit plan are advised to contact their social worker and/or managed care benefit plan. PRIVATE INSURANCE Residents who are covered by a private insurance plan that does not have a contract with the Facility must exhaust all available insurance coverage before seeking Medicare or Medicaid coverage. Where the insurance proceeds under the private plan are insufficient to cover the cost of care, the Resident will be responsible for any difference. The coverage requirements for nursing home care vary depending on the terms of the insurance policy. Questions regarding private insurance coverage should be directed to the social work staff and/or the Resident’s insurance carrier or agent. Attachment B (12/13) ii MEDICAID Medicaid is a publicly-funded program of assistance that covers nursing home Residents who can demonstrate financial need. To qualify for Medicaid, an individual may have only limited assets. For example, in 2020, the individual resource limit is $15,750 (subject to annual increases); plus any funds held in an “irrevocable burial trust” arrangement or up to $1,500 under a revocable burial account. Generally, most of the Resident’s monthly income must be paid to the Facility, except for a $50 monthly “personal needs allowance” and the monthly cost of retaining a private health insurance policy. This monthly income obligation, called the NAMI (Net Available Monthly Income), is determined by the Medicaid agency. If the Resident has a spouse in the community, the spouse might be entitled to a contribution from the Resident’s monthly income. During 2020, the “community spouse” is entitled to a minimum monthly income of $3,216 and resources up to a maximum of $128,640 (these figures are subject to increase each calendar year); increases beyond these amounts are possible, but a Department of Social Services Fair Hearing or Family Court support proceeding may be required. The Resident’s home may be exempt for Medicaid eligibility purposes if the equity value is less than $878,000.00 or if the spouse or disabled or minor child resides there. Upon application, Medicaid looks back at financial transactions or transfers of assets made within a sixty (60) month period of time from the date on which the person was institutionalized and applied for Medicaid coverage. A Resident or spouse who makes a transfer within those periods may create a period of Medicaid ineligibility. Private-pay Residents should apply for Medicaid about three months before their funds are depleted. A Medicaid application must include proof of the Resident’s identity, U.S. citizenship or legal alien status, and past and present financial status. Medicaid recipients are required to recertify eligibility each year in order to retain benefits. Medicaid is a complex program and a knowledgeable professional can advise Residents and their families as to their rights under the Medicaid program. To receive information about Medicaid, individuals can call their local Department of Social Services in the county in which the Resident resides. WORKERS’ COMPENSATION Workers’ Compensation benefits are available for an employee’s work-related injuries. Benefits, including direct payments to a health care provider, are paid by the employer’s insurance carrier. Workers’ Compensation will provide primary coverage of nursing home care, as long as it is established that the nursing home care is necessitated solely by the Workers’ Compensation injury. Claim forms must be submitted to the local Workers’ Compensation Board Office within two years of the date of injury. It is advisable to consult with an attorney practicing in the Workers’ Compensation area when pursuing a claim. For further information, you can contact your local Workers’ Compensation Board office.

Billed by Facility. (3) Billed direct by Provider or Vendor. (4) Patient/Resident responsible for co-insurance and deductible. (5) Coverage depends on services provided. Attachment A (2/15) ii ADDITIONAL NON-CLINICAL SERVICES THE FOLLOWING ADDITIONAL NON- CLINICAL SERVICES ARE AVAILABLE TO ALL RESIDENTS AND IF REQUESTED BY THE RESIDENT, SPONSOR AND/OR DESIGNATED REPRESENTATIVE, WILL BE CHARGED TO THE RESIDENT: • Telephone • Television/radio for Resident’s personal use • Personal comfort items, notions and novelties, and confections • Cosmetic and grooming items and services, in excess of those for which payment is made under Medicaid, Medicare, or other insurance programs • Personal clothing • Personal reading matter • Gifts purchased on behalf of a Resident • Flowers and plants • Social events, special meals, and entertainment offered off the premises and outside the scope of the Activities program provided by the Facility • Non-covered special care services, such as private duty nurses • Specially prepared or alternative food (other than Kosher food or food required by a therapeutic or modified diet prescribed by a physician) • Private room (except when therapeutically required, such as for isolation for infection control) IF YOU HAVE ANY QUESTIONS REGARDING CHARGES AND BILLING, PLEASE FEEL FREE TO CONTACT THE BUSINESS OFFICE AT (718631) 298- 7800271- 5800. Attachment A (2/15) iii ATTACHMENT “B” SPECIAL RULES REGARDING SELECTED PAYORS PAYMENT FOR IN-PATIENT LONG TERM CARE SERVICES IS AN EXPENSIVE AND COMPLICATED PROCESS. THIS SUMMARY PROVIDES OUR RESIDENTS AND THEIR FAMILIES WITH BASIC INFORMATION WHICH SHOULD SIMPLIFY THE PROCESS. NOTHING HEREIN SHOULD BE CONSIDERED TO BE LEGAL ADVICE. WE URGE YOU TO CONSULT WITH AN INSURANCE AGENT, ATTORNEY AND/OR OTHER KNOWLEDGEABLE PROFESSIONAL(S) IN ORDER TO HELP MAXIMIZE AVAILABLE COVERAGE. FURTHER, AS THE INFORMATION PROVIDED BELOW IS BASED UPON STATUTE AND REGULATIONS, IT IS SUBJECT TO CHANGE WITHOUT NOTICE. MEDICARE PART A PAYMENT Medicare Part A Hospital Insurance Skilled Nursing Facility coverage is generally available to qualified individuals 65 years of age or older, and individuals under age 65 who have been disabled for at least twenty-four months, who meet the following five requirements: 1) The Resident requires daily skilled nursing or rehabilitation services that can be provided only in a skilled nursing facility; 2) The Resident was hospitalized for at least three consecutive days, not counting the day of discharge, before entering the skilled nursing facility; 3) The Resident was admitted to the facility within 30 days after leaving the hospital; 4) The Resident is admitted to the facility to receive treatment for the same condition(s) for which he or she was treated in the hospital; and 5) A medical professional certifies that the Resident requires skilled nursing care on a “daily basis.” A Resident requires skilled nursing or skilled rehabilitation services on a daily basis when services are medically necessary and provided seven (7) days a week. There is an exception if they are only provided by the facility for five (5) days per week, due to staffing levels at the facility. Additionally, there may be a one to two day break if the Residents needs require suspension of the services. Where these five criteria are met, Medicare may provide coverage of up to 100 days of care in a skilled nursing facility (SNF): the first 20 days of covered services are fully paid for; and the next 80 days (days 21 through 100), of the covered services are paid for by Medicare subject to a daily coinsurance amount for which the Resident is responsible. For 2020, the Medicare Part A co-insurance amount is $176.00 per day. Additionally, Medicare Residents requesting a leave of absence from the facility should be aware of the Medicare rules regarding leave of absence and transfer within thirty (30) days. Medicare treats a leave of absence, where a Resident leaves the facility on a particular day and does not return by twelve (12) midnight that day, as an uncovered day. Additionally, the day in which a Resident begins a leave of absence (i.e., hospitalization), where the resident is absent for more than 24 hours, is treated as a day of discharge. Except for specifically excluded services, nursing home services provided to Medicare Part A beneficiaries are covered under the consolidated billing requirements. Residents must consult with the Facility before obtaining any services outside of the Facility. Medicare also has a thirty (30) day transfer requirement. A Resident must be transferred from a hospital or other SNF within thirty (30) days of discharge and meet the skilled care requirements in order to be eligible for SNF coverage. If a Resident meets the eligibility requirements for Skilled Nursing Facility benefits under the Medicare Part A Hospital Insurance Program, Facility will xxxx Medicare directly for all Part A services provided to the Resident. Medicare will reimburse Facility a fixed per diem or daily fee based on the Resident’s classification within the Medicare RUG III guidelines. RUG is an acronym for Resource-based Utilization Groups. These guidelines are a measure of what type of care the Resident requires and what it costs health care providers to provide that care to a Resident. Members of our professional staff will evaluate the Resident’s health condition based on a standardized assessment form (called the MDS 2.0) provided by the Centers for Medicare and Medicaid Services (CMS). Information from the MDS 2.0 form will be used by Medicare to assign the Resident a RUG III category. The Resident will be responsible for the daily co-insurance amount determined by Medicare. This amount is subject to increase each calendar year. With limited exceptions, a Resident who requires more than 100 days of SNF care in a benefit period will be responsible for private payment of all charges beginning with the 101st day. A new benefit period may begin when the Resident has either not been in a facility or has not been receiving a covered level of care in a skilled nursing facility for at least 60 days, returns to the hospital for another three-day stay, and then re-enters the SNF. A SNF may not request private payment until the Resident has received an official initial determination from Medicare that “skilled nursing” benefits are no longer available. While a SNF may make a determination of non-coverage, beneficiaries have a right to request an official Medicare determination of coverage (called a “Demand Xxxx”), which can be appealed. Attachment B (12/13) i MEDICARE PART B PAYMENT Individuals who pay monthly premiums to enroll in Medicare Part B will be charged according to Facility’s or the service providers’ stated charge schedule for services they receive at Facility. Medicare Part B pays for a wide range of additional services beyond Part A coverage. Part B may cover some of a Residents care regardless of whether they are eligible for Part A benefits. Part B covers eighty (80%) percent of the Medicare approved charge for a specific service and the individual is responsible for the additional twenty (20%) percent. In general, Part B covers medical services and supplies. Part B covers such services as: physical, occupational and speech therapy, physician services, durable medical equipment, ambulance services and certain out-patient and clinical laboratory services. However, Part B benefits have limitations. For example, for 2020, there is a $198.00 deductible applicable to Medicare Part B benefits. Additionally, physical therapy (including speech- language pathology services) and occupational therapy are each subject to an annual limitation. The therapy financial limitations or “caps” are indexed by the Medicare Economic Index (MEI) each year. For 2020, the indexed amounts for physical therapy (including speech-language pathology services) and occupational therapy are $2,080.00 each, including co- insurance. Beneficiaries may be eligible for the Therapy Cap Exception Process. Both therapy limitations are still subject to the 80% - 20% coverage limitation in that the individual will be responsible for the 20 % co-insurance payments. The Resident is responsible for private payment of all therapy charges and any other ancillary charges above the Medicare Part B coverage limitations. The Facility can xxxx and receive payment if the Resident fills out a Medicare assignment of benefits form. If the Resident completes an assignment of benefits form, a health care provider cannot charge the Resident above the Medicare approved charge. In order to determine the Resident’s Part B coverage you should contact the Social Security Administration. In addition, Medicare Advantage programs and other alternatives may increase available Medicare benefits. To receive additional information about Medicare and Medicare Advantage programs, call the Social Security Administration at 800-772- 1213 or the Centers for Medicare and Medicaid Services at 1-800-MEDICARE. MEDICARE PART D - PRESCRIPTION DRUG COVERAGE Individuals eligible for Medicare Part A or enrolled in Medicare Part B and who do not have prescription drug coverage from a privately operated health plan or a Medicare Advantage-PD plan are eligible to enroll in Medicare Part D for prescription drug coverage. Medicare Part D through the selected PDP will provide reimbursement for prescription drugs listed in the PDP’s formulary subject to applicable premiums, deductibles and co-payments. Eligible individuals interested in obtaining prescription drug coverage through Medicare Part D must enroll in a PDP approved in the region. Upon admission to a skilled nursing home, individuals enrolled in a PDP in the community are permitted to continue with, or switch to a different PDP in the region. Dual eligible Medicare/Medicaid beneficiaries are automatically enrolled in, and assigned to an approved benchmark prescription drug plan (“PDP”) in the region. As of January 1, 2006, Medicaid no longer pays for prescription drug cost for dual eligibles. Dual eligibles in nursing homes will receive prescription drug coverage through Medicare Part D for the drugs listed on the selected PDP’s formulary. As long as dual eligibles are enrolled in benchmark plans in their region, they will not be responsible for premiums, deductibles and cost sharing obligations. Please call 000-000-0000 or contact xxx.xxxxxxxx.xxx/xxxxxxx.xxx to obtain enrollment information. MANAGED CARE Residents who are members of a managed care benefit plan that is under a contract with the Facility to provide specified services to plan members will receive those services with full coverage so long as the Resident meets the eligibility requirements of the managed care benefit plan. To the extent the Resident meets the eligibility requirements of the managed care benefit plan, he or she will be financially responsible only for the required deductibles and co-insurance and for those services that are not included in the list of covered services. Residents who have not received a list of covered services and eligibility requirements from their managed care benefit plan are advised to contact their social worker and/or managed care benefit plan. PRIVATE INSURANCE Residents who are covered by a private insurance plan that does not have a contract with the Facility must exhaust all available insurance coverage before seeking Medicare or Medicaid coverage. Where the insurance proceeds under the private plan are insufficient to cover the cost of care, the Resident will be responsible for any difference. The coverage requirements for nursing home care vary depending on the terms of the insurance policy. Questions regarding private insurance coverage should be directed to the social work staff and/or the Resident’s insurance carrier or agent. Attachment B (12/13) ii MEDICAID Medicaid is a publicly-funded program of assistance that covers nursing home Residents who can demonstrate financial need. To qualify for Medicaid, an individual may have only limited assets. For example, in 2020, the individual resource limit is $15,750 (subject to annual increases); plus any funds held in an “irrevocable burial trust” arrangement or up to $1,500 under a revocable burial account. Generally, most of the Resident’s monthly income must be paid to the Facility, except for a $50 monthly “personal needs allowance” and the monthly cost of retaining a private health insurance policy. This monthly income obligation, called the NAMI (Net Available Monthly Income), is determined by the Medicaid agency. If the Resident has a spouse in the community, the spouse might be entitled to a contribution from the Resident’s monthly income. During 2020, the “community spouse” is entitled to a minimum monthly income of $3,216 and resources up to a maximum of $128,640 (these figures are subject to increase each calendar year); increases beyond these amounts are possible, but a Department of Social Services Fair Hearing or Family Court support proceeding may be required. The Resident’s home may be exempt for Medicaid eligibility purposes if the equity value is less than $878,000.00 or if the spouse or disabled or minor child resides there. Upon application, Medicaid looks back at financial transactions or transfers of assets made within a sixty (60) month period of time from the date on which the person was institutionalized and applied for Medicaid coverage. A Resident or spouse who makes a transfer within those periods may create a period of Medicaid ineligibility. Private-pay Residents should apply for Medicaid about three months before their funds are depleted. A Medicaid application must include proof of the Resident’s identity, U.S. citizenship or legal alien status, and past and present financial status. Medicaid recipients are required to recertify eligibility each year in order to retain benefits. Medicaid is a complex program and a knowledgeable professional can advise Residents and their families as to their rights under the Medicaid program. To receive information about Medicaid, individuals can call their local Department of Social Services in the county in which the Resident resides. WORKERS’ COMPENSATION Workers’ Compensation benefits are available for an employee’s work-related injuries. Benefits, including direct payments to a health care provider, are paid by the employer’s insurance carrier. Workers’ Compensation will provide primary coverage of nursing home care, as long as it is established that the nursing home care is necessitated solely by the Workers’ Compensation injury. Claim forms must be submitted to the local Workers’ Compensation Board Office within two years of the date of injury. It is advisable to consult with an attorney practicing in the Workers’ Compensation area when pursuing a claim. For further information, you can contact your local Workers’ Compensation Board office.

Billed by Facility. (3) Billed direct by Provider or Vendor. (4) Patient/Resident responsible for co-insurance and deductible. (5) Coverage depends on services provided. ADDITIONAL NON-CLINICAL SERVICES THE FOLLOWING ADDITIONAL NON- NON-CLINICAL SERVICES ARE AVAILABLE TO ALL RESIDENTS NOT INCLUDED IN THE DAILY BASIC RATE AND IF REQUESTED ARE NOT PAID FOR BY THE RESIDENT, SPONSOR MEDICARE AND/OR DESIGNATED REPRESENTATIVEMEDICAID OR OTHER INSURANCE. IF REQUESTED, THE CHARGES FOR SUCH ITEMS WILL BE CHARGED TO THE RESPONSIBILITY OF THE RESIDENT: . • Telephone Telephone, including a cellular phone • Television/radio radio, personal computer or other electronic devices for Resident’s personal use • Personal comfort items, notions and novelties, and confections • Cosmetic and grooming items and services, in excess of those for which payment is made under Medicaid, Medicare, or other insurance programs • Beauty shop / xxxxxx services • Personal clothing • Personal Dry cleaning • Newspapers and other personal reading matter • Gifts Items purchased on behalf of a Resident • Flowers and plants • Social events, special meals, and entertainment offered off the premises and outside the scope of the Activities activities program provided by the Facility • Non-covered special care services, such as private duty nurses privately hired nurses, aides, or companions • Specially prepared or alternative food (other than Kosher food or food required by a therapeutic or modified diet prescribed by a physician) • Private room (except when therapeutically required, such as for isolation for infection control) IF YOU HAVE ANY QUESTIONS REGARDING CHARGES AND BILLING, PLEASE FEEL FREE TO CONTACT THE BUSINESS OFFICE AT (718) 298- 7800OFFICE. ATTACHMENT “B” SPECIAL RULES REGARDING SELECTED PAYORS PAYMENT FOR IN-PATIENT LONG TERM CARE SERVICES IS AN EXPENSIVE AND COMPLICATED PROCESS. THIS SUMMARY PROVIDES OUR RESIDENTS AND THEIR FAMILIES WITH BASIC INFORMATION WHICH THAT SHOULD SIMPLIFY THE PROCESS. NOTHING HEREIN SHOULD BE CONSIDERED TO BE LEGAL ADVICE. WE URGE YOU TO CONSULT WITH AN INSURANCE AGENT, ATTORNEY AND/OR OTHER KNOWLEDGEABLE PROFESSIONAL(S) IN ORDER TO HELP MAXIMIZE AVAILABLE COVERAGE. FURTHER, AS THE INFORMATION PROVIDED BELOW IS BASED UPON STATUTE AND REGULATIONS, IT IS SUBJECT TO CHANGE WITHOUT NOTICE. MEDICARE PART A PAYMENT Medicare Part A Hospital Insurance Skilled Nursing Facility (“SNF”) coverage is generally available to qualified individuals 65 years of age or older, and individuals under age 65 who have been disabled for at least twenty-four months, who meet the following five requirements: 1) The Resident requires daily skilled nursing or rehabilitation services that can be provided only in a skilled nursing facility; 2) The Resident was hospitalized for at least three consecutive days, not counting the day of discharge, before entering the skilled nursing facility; 3) The Resident was admitted to the facility within 30 days after leaving the hospital; 4) The Resident is admitted to the facility to receive treatment for the same condition(s) for which he or she was treated in the hospital; and 5) A medical professional certifies that the Resident requires skilled nursing care on a “daily basis.” A Resident requires skilled nursing or skilled rehabilitation services on a daily basis when services are medically necessary and provided seven (7) days a week. There is an exception if they are only provided by the facility for five (5) days per week, due to staffing levels at the facility. Additionally, there may be a one to two day break if the Residents needs require suspension of the services. Where these five criteria are met, Medicare may provide coverage of up to 100 days of care in a skilled nursing facility (SNF): the first 20 days of covered services are fully paid for; and the next 80 days (days 21 through 100), of the covered services are paid for by Medicare subject to a daily coinsurance amount for which the Resident is responsible. For 2020, the Medicare Part A co-insurance amount is $176.00 per day. Additionally, Medicare Residents requesting a leave of absence from the facility should be aware of the Medicare rules regarding leave of absence and transfer within thirty (30) days. Medicare treats a leave of absence, where a Resident leaves the facility on a particular day and does not return by twelve (12) midnight that day, as an uncovered day. Additionally, the day in which a Resident begins a leave of absence (i.e., hospitalization), where the resident is absent for more than 24 hours, is treated as a day of discharge. Except for specifically excluded services, nursing home services provided to Medicare Part A beneficiaries are covered under the consolidated billing requirements. Residents must consult with the Facility before obtaining any services outside of the Facility. Medicare also has a thirty (30) day transfer requirement. A Resident must be transferred from a hospital or other SNF within thirty (30) days of discharge and meet the skilled care requirements in order to be eligible for SNF coverage. If a Resident meets the eligibility requirements for Skilled Nursing Facility benefits under the Medicare Part A Hospital Insurance Program, Facility will xxxx Medicare directly for all Part A services provided to the Resident. Medicare will reimburse Facility a fixed per diem or daily fee based on the Resident’s classification within the Medicare RUG III IV guidelines. RUG is an acronym for Resource-based Utilization Groups. These guidelines are a measure of what type of care the Resident requires and what it costs health care providers to provide that care to a Resident. Members of our professional staff will evaluate the Resident’s Residents health condition based on a standardized assessment form (called the MDS 2.03.0) provided by the Centers for Medicare and Medicaid Services (CMS). Information from the MDS 2.0 form will 3.0 information is be used by Medicare to assign the Resident a RUG III categoryIV category for the Resident. The Resident will be responsible for the daily co-insurance amount determined by Medicare. This amount is subject to increase each calendar year. With limited exceptions, a Resident who requires more than 100 days of SNF care in a benefit period will be responsible for private payment of all charges beginning with the 101st day. A new benefit period may begin when the Resident has either not been in a facility or has not been receiving a covered level of care in a skilled nursing facility for at least 60 days, returns to the hospital for another three-day stay, and then re-enters the SNF. A SNF may not request private payment until the Resident has received an official initial determination from Medicare that “skilled nursing” benefits are no longer available. While a SNF may make a determination of non-coverage, beneficiaries have a right to request an official Medicare determination of coverage (called a “Demand Xxxx”), which can be appealed. MEDICARE PART B PAYMENT Individuals who pay monthly premiums to enroll in Medicare Part B will be charged according to Facility’s or the service providers’ stated charge schedule for services they receive at Facility. Medicare Part B pays for a wide range of additional services beyond Part A coverage. Part B may cover some of a Residents care regardless of whether they are eligible for Part A benefits. Part B covers eighty (80%) percent of the Medicare approved charge for a specific service and the individual is responsible for the additional twenty (20%) percent. In general, Part B covers medical services and supplies. Part B covers such services as: physical, occupational and speech therapy, physician services, durable medical equipment, ambulance services and certain out-patient and clinical laboratory services. However, Part B benefits have limitations. For example, for 2020, there is a $198.00 deductible applicable to Medicare Part B benefits. Additionally, physical therapy (including speech- language pathology services) and occupational therapy are each subject to an annual limitation. The therapy financial limitations or “caps” are indexed by the Medicare Economic Index (MEI) each year. For 2020, the indexed amounts for physical therapy (including speech-language pathology services) and occupational therapy are $2,080.00 each, including co- co-insurance. Beneficiaries may be eligible for the Therapy Cap Exception Process. Both therapy limitations are still subject to the 80% - 20% coverage limitation in that the individual will be responsible for the 20 % co-insurance payments. The Resident is responsible for private payment of all therapy charges and any other ancillary charges above the Medicare Part B coverage limitations. The Facility can xxxx and receive payment if the Resident fills out a Medicare assignment of benefits form. If the Resident completes an assignment of benefits form, a health care provider cannot charge the Resident above the Medicare approved charge. In order to determine the Resident’s Part B coverage you should contact the Social Security Administration. In addition, Medicare Advantage programs and other alternatives may increase available Medicare benefits. To receive additional information about Medicare and Medicare Advantage programs, call the Social Security Administration at 800-772- 1213 or the Centers for Medicare and Medicaid Services at 1-800-MEDICARE. MEDICARE PART D - PRESCRIPTION DRUG COVERAGE Individuals eligible for Medicare Part A or enrolled in Medicare Part B and who do not have prescription drug coverage from a privately operated health plan or a Medicare Advantage-PD plan are eligible to enroll in Medicare Part D for prescription drug coverage. Medicare Part D through the selected PDP will provide reimbursement for prescription drugs listed in the PDP’s formulary subject to applicable premiums, deductibles and co-payments. Eligible individuals interested in obtaining prescription drug coverage through Medicare Part D must enroll in a PDP approved in the region. Upon admission to a skilled nursing home, individuals enrolled in a PDP in the community are permitted to continue with, or switch to a different PDP in the region. Dual eligible Medicare/Medicaid beneficiaries are automatically enrolled in, and assigned to an approved benchmark prescription drug plan (“PDP”) in the region. As of January 1, 2006, Medicaid no longer pays does not pay for prescription drug cost for dual eligibleseligible individuals. Dual eligibles eligible residents in nursing homes will receive prescription drug coverage through Medicare Part D for the drugs listed on the selected PDP’s formulary. As long as dual eligibles eligible residents are enrolled in benchmark plans in their region, they will not be responsible for premiums, deductibles and cost sharing obligations. Please call 000-000-0000 or contact xxx.xxxxxxxx.xxx/xxxxxxx.xxx to obtain enrollment information. MANAGED CARE Residents who are members of a managed care benefit plan that is under a contract with the Facility to provide specified services to plan members will receive those services with full coverage so long as the Resident meets the eligibility requirements of the managed care benefit plan. To the extent the Resident meets the eligibility requirements of the managed care benefit plan, he or she will be financially responsible only for the required deductibles and co-insurance and for those services that are not included in the list of covered services. Residents who have not received a list of covered services and eligibility requirements from their managed care benefit plan are advised to contact their social worker and/or managed care benefit plan. PRIVATE INSURANCE Residents who are covered by a private insurance plan that does not have a contract with the Facility must exhaust all available insurance coverage before seeking Medicare or Medicaid coverage. Where the insurance proceeds under the private plan are insufficient to cover the cost of care, the Resident will be responsible for any difference. The coverage requirements for nursing home care vary depending on the terms of the insurance policy. Questions regarding private insurance coverage should be directed to the social work staff and/or the Resident’s insurance carrier or agent. MEDICAID Medicaid is a publicly-funded program of assistance that covers nursing home Residents who can demonstrate financial need. To qualify for Medicaid, an individual may have only limited assets. For example, in 2020, the individual resource limit is $15,750 (subject to annual increases); plus any funds held in an “irrevocable burial trust” arrangement or up to $1,500 under a revocable burial account. Generally, most of the Resident’s monthly income must be paid to the Facility, except for a $50 monthly “personal needs allowance” and the monthly cost of retaining a private health insurance policy. This monthly income obligation, called the NAMI (Net Available Monthly Income), is determined by the Medicaid agency. If the Resident has a spouse in the community, the spouse might be entitled to a contribution from the Resident’s monthly income. During 2020, the “community spouse” is entitled to a minimum monthly income of $3,216 and resources up to a maximum of $128,640 (these figures are subject to increase each calendar year); increases beyond these amounts are possible, but a Department of Social Services Fair Hearing or Family Court support proceeding may be required. The Resident’s home may be exempt for Medicaid eligibility purposes if the equity value is less than $878,000.00 or if the spouse or disabled or minor child resides there. Upon application, Medicaid looks back at financial transactions or transfers of assets made within a sixty (60) month period of time from the date on which the person was institutionalized and applied for Medicaid coverage. A Resident or spouse who makes a transfer within those periods may create a period of Medicaid ineligibility. Private-pay Residents should apply for Medicaid about three months before their funds are depleted. A Medicaid application must include proof of the Resident’s identity, U.S. citizenship or legal alien status, and past and present financial status. Medicaid recipients are required to recertify eligibility each year in order to retain benefits. Medicaid is a complex program and a knowledgeable professional can advise Residents and their families as to their rights under the Medicaid program. To receive information about Medicaid, individuals can call their local Department of Social Services in the county in which the Resident resides. WORKERS’ COMPENSATION Workers’ Compensation benefits are available for an employee’s work-related injuries. Benefits, including direct payments to a health care provider, are paid by the employer’s insurance carrier. Workers’ Compensation will provide primary coverage of nursing home care, as long as it is established that the nursing home care is necessitated solely by the Workers’ Compensation injury. Claim forms must be submitted to the local Workers’ Compensation Board Office within two years of the date of injury. It is advisable to consult with an attorney practicing in the Workers’ Compensation area when pursuing a claim. For further information, you can contact your local Workers’ Compensation Board office.

Billed by Facility. (3) Billed direct by Provider or Vendor. (4) Patient/Resident responsible for co-insurance and deductible. (5) Coverage depends on services provided. ADDITIONAL NON-CLINICAL SERVICES THE FOLLOWING ADDITIONAL NON- CLINICAL SERVICES ARE AVAILABLE TO ALL RESIDENTS AND IF REQUESTED BY THE RESIDENT, SPONSOR AND/OR DESIGNATED REPRESENTATIVE, WILL BE CHARGED TO THE RESIDENT: • Telephone • Television/radio for Resident’s personal use • Personal comfort items, notions and novelties, and confections • Cosmetic and grooming items and services, in excess of those for which payment is made under Medicaid, Medicare, or other insurance programs • Personal clothing • Personal reading matter • Gifts purchased on behalf of a Resident • Flowers and plants • Social events, special meals, and entertainment offered off the premises and outside the scope of the Activities program provided by the Facility • Non-covered special care services, such as private duty nurses • Specially prepared or alternative food (other than Kosher food or food required by a therapeutic or modified diet prescribed by a physician) • Private room (except when therapeutically required, such as for isolation for infection control) • Deluxe private room • Luxury amenities (e.g. plush bathrobe, luxury toiletries, luxury linens, etc.) IF YOU HAVE ANY QUESTIONS REGARDING CHARGES AND BILLING, PLEASE FEEL FREE TO CONTACT THE BUSINESS OFFICE AT (718212) 298- 7800879- 1600. Attachment A (12/13) iii ATTACHMENT “B” SPECIAL RULES REGARDING SELECTED PAYORS PAYMENT FOR IN-PATIENT LONG TERM CARE SERVICES IS AN EXPENSIVE AND COMPLICATED PROCESS. THIS SUMMARY PROVIDES OUR RESIDENTS AND THEIR FAMILIES WITH BASIC INFORMATION WHICH SHOULD SIMPLIFY THE PROCESS. NOTHING HEREIN SHOULD BE CONSIDERED TO BE LEGAL ADVICE. WE URGE YOU TO CONSULT WITH AN INSURANCE AGENT, ATTORNEY AND/OR OTHER KNOWLEDGEABLE PROFESSIONAL(S) IN ORDER TO HELP MAXIMIZE AVAILABLE COVERAGE. FURTHER, AS THE INFORMATION PROVIDED BELOW IS BASED UPON STATUTE AND REGULATIONS, IT IS SUBJECT TO CHANGE WITHOUT NOTICE. MEDICARE PART A PAYMENT Medicare Part A Hospital Insurance Skilled Nursing Facility coverage is generally available to qualified individuals 65 years of age or older, and individuals under age 65 who have been disabled for at least twenty-four months, who meet the following five requirements: 1) The Resident requires daily skilled nursing or rehabilitation services that can be provided only in a skilled nursing facility; 2) The Resident was hospitalized for at least three consecutive days, not counting the day of discharge, before entering the skilled nursing facility; 3) The Resident was admitted to the facility within 30 days after leaving the hospital; 4) The Resident is admitted to the facility to receive treatment for the same condition(s) for which he or she was treated in the hospital; and 5) A medical professional certifies that the Resident requires skilled nursing care on a “daily basis.” A Resident requires skilled nursing or skilled rehabilitation services on a daily basis when services are medically necessary and provided seven (7) days a week. There is an exception if they are only provided by the facility for five (5) days per week, due to staffing levels at the facility. Additionally, there may be a one to two day break if the Residents needs require suspension of the services. Where these five criteria are met, Medicare may provide coverage of up to 100 days of care in a skilled nursing facility (SNF): the first 20 days of covered services are fully paid for; and the next 80 days (days 21 through 100), of the covered services are paid for by Medicare subject to a daily coinsurance amount for which the Resident is responsible. For 2020, the Medicare Part A co-insurance amount is $176.00 per day. Additionally, Medicare Residents requesting a leave of absence from the facility should be aware of the Medicare rules regarding leave of absence and transfer within thirty (30) days. Medicare treats a leave of absence, where a Resident leaves the facility on a particular day and does not return by twelve (12) midnight that day, as an uncovered day. Additionally, the day in which a Resident begins a leave of absence (i.e., hospitalization), where the resident is absent for more than 24 hours, is treated as a day of discharge. Except for specifically excluded services, nursing home services provided to Medicare Part A beneficiaries are covered under the consolidated billing requirements. Residents must consult with the Facility before obtaining any services outside of the Facility. Medicare also has a thirty (30) day transfer requirement. A Resident must be transferred from a hospital or other SNF within thirty (30) days of discharge and meet the skilled care requirements in order to be eligible for SNF coverage. If a Resident meets the eligibility requirements for Skilled Nursing Facility benefits under the Medicare Part A Hospital Insurance Program, Facility will xxxx Medicare directly for all Part A services provided to the Resident. Medicare will reimburse Facility a fixed per diem or daily fee based on the Resident’s classification within the Medicare RUG III guidelines. RUG is an acronym for Resource-based Utilization Groups. These guidelines are a measure of what type of care the Resident requires and what it costs health care providers to provide that care to a Resident. Members of our professional staff will evaluate the Resident’s health condition based on a standardized assessment form (called the MDS 2.0) provided by the Centers for Medicare and Medicaid Services (CMS). Information from the MDS 2.0 form will be used by Medicare to assign the Resident a RUG III category. The Resident will be responsible for the daily co-insurance amount determined by Medicare. This amount is subject to increase each calendar year. With limited exceptions, a Resident who requires more than 100 days of SNF care in a benefit period will be responsible for private payment of all charges beginning with the 101st day. A new benefit period may begin when the Resident has either not been in a facility or has not been receiving a covered level of care in a skilled nursing facility for at least 60 days, returns to the hospital for another three-day stay, and then re-enters the SNF. A SNF may not request private payment until the Resident has received an official initial determination from Medicare that “skilled nursing” benefits are no longer available. While a SNF may make a determination of non-coverage, beneficiaries have a right to request an official Medicare determination of coverage (called a “Demand Xxxx”), which can be appealed. MEDICARE PART B PAYMENT Individuals who pay monthly premiums to enroll in Medicare Part B will be charged according to Facility’s or the service providers’ stated charge schedule for services they receive at Facility. Medicare Part B pays for a wide range of additional services beyond Part A coverage. Part B may cover some of a Residents care regardless of whether they are eligible for Part A benefits. Part B covers eighty (80%) percent of the Medicare approved charge for a specific service and the individual is responsible for the additional twenty (20%) percent. In general, Part B covers medical services and supplies. Part B covers such services as: physical, occupational and speech therapy, physician services, durable medical equipment, ambulance services and certain out-patient and clinical laboratory services. However, Part B benefits have limitations. For example, for 2020, there is a $198.00 deductible applicable to Medicare Part B benefits. Additionally, physical therapy (including speech- language pathology services) and occupational therapy are each subject to an annual limitation. The therapy financial limitations or “caps” are indexed by the Medicare Economic Index (MEI) each year. For 2020, the indexed amounts for physical therapy (including speech-language pathology services) and occupational therapy are $2,080.00 each, including co- insurance. Beneficiaries may be eligible for the Therapy Cap Exception Process. Both therapy limitations are still subject to the 80% - 20% coverage limitation in that the individual will be responsible for the 20 % co-insurance payments. The Resident is responsible for private payment of all therapy charges and any other ancillary charges above the Medicare Part B coverage limitations. The Facility can xxxx and receive payment if the Resident fills out a Medicare assignment of benefits form. If the Resident completes an assignment of benefits form, a health care provider cannot charge the Resident above the Medicare approved charge. In order to determine the Resident’s Part B coverage you should contact the Social Security Administration. In addition, Medicare Advantage programs and other alternatives may increase available Medicare benefits. To receive additional information about Medicare and Medicare Advantage programs, call the Social Security Administration at 800-772- 1213 or the Centers for Medicare and Medicaid Services at 1-800-MEDICARE. MEDICARE PART D - PRESCRIPTION DRUG COVERAGE Individuals eligible for Medicare Part A or enrolled in Medicare Part B and who do not have prescription drug coverage from a privately operated health plan or a Medicare Advantage-PD plan are eligible to enroll in Medicare Part D for prescription drug coverage. Medicare Part D through the selected PDP will provide reimbursement for prescription drugs listed in the PDP’s formulary subject to applicable premiums, deductibles and co-payments. Eligible individuals interested in obtaining prescription drug coverage through Medicare Part D must enroll in a PDP approved in the region. Upon admission to a skilled nursing home, individuals enrolled in a PDP in the community are permitted to continue with, or switch to a different PDP in the region. Dual eligible Medicare/Medicaid beneficiaries are automatically enrolled in, and assigned to an approved benchmark prescription drug plan (“PDP”) in the region. As of January 1, 2006, Medicaid no longer pays for prescription drug cost for dual eligibles. Dual eligibles in nursing homes will receive prescription drug coverage through Medicare Part D for the drugs listed on the selected PDP’s formulary. As long as dual eligibles are enrolled in benchmark plans in their region, they will not be responsible for premiums, deductibles and cost sharing obligations. Please call 000-000-0000 or contact xxx.xxxxxxxx.xxx/xxxxxxx.xxx to obtain enrollment information. MANAGED CARE Residents who are members of a managed care benefit plan that is under a contract with the Facility to provide specified services to plan members will receive those services with full coverage so long as the Resident meets the eligibility requirements of the managed care benefit plan. To the extent the Resident meets the eligibility requirements of the managed care benefit plan, he or she will be financially responsible only for the required deductibles and co-insurance and for those services that are not included in the list of covered services. Residents who have not received a list of covered services and eligibility requirements from their managed care benefit plan are advised to contact their social worker and/or managed care benefit plan. PRIVATE INSURANCE Residents who are covered by a private insurance plan that does not have a contract with the Facility must exhaust all available insurance coverage before seeking Medicare or Medicaid coverage. Where the insurance proceeds under the private plan are insufficient to cover the cost of care, the Resident will be responsible for any difference. The coverage requirements for nursing home care vary depending on the terms of the insurance policy. Questions regarding private insurance coverage should be directed to the social work staff and/or the Resident’s insurance carrier or agent. MEDICAID Medicaid is a publicly-funded program of assistance that covers nursing home Residents who can demonstrate financial need. To qualify for Medicaid, an individual may have only limited assets. For example, in 2020, the individual resource limit is $15,750 (subject to annual increases); plus any funds held in an “irrevocable burial trust” arrangement or up to $1,500 under a revocable burial account. Generally, most of the Resident’s monthly income must be paid to the Facility, except for a $50 monthly “personal needs allowance” and the monthly cost of retaining a private health insurance policy. This monthly income obligation, called the NAMI (Net Available Monthly Income), is determined by the Medicaid agency. If the Resident has a spouse in the community, the spouse might be entitled to a contribution from the Resident’s monthly income. During 2020, the “community spouse” is entitled to a minimum monthly income of $3,216 and resources up to a maximum of $128,640 (these figures are subject to increase each calendar year); increases beyond these amounts are possible, but a Department of Social Services Fair Hearing or Family Court support proceeding may be required. The Resident’s home may be exempt for Medicaid eligibility purposes if the equity value is less than $878,000.00 or if the spouse or disabled or minor child resides there. Upon application, Medicaid looks back at financial transactions or transfers of assets made within a sixty (60) month period of time from the date on which the person was institutionalized and applied for Medicaid coverage. A Resident or spouse who makes a transfer within those periods may create a period of Medicaid ineligibility. Private-pay Residents should apply for Medicaid about three months before their funds are depleted. A Medicaid application must include proof of the Resident’s identity, U.S. citizenship or legal alien status, and past and present financial status. Medicaid recipients are required to recertify eligibility each year in order to retain benefits. Medicaid is a complex program and a knowledgeable professional can advise Residents and their families as to their rights under the Medicaid program. To receive information about Medicaid, individuals can call their local Department of Social Services in the county in which the Resident resides. WORKERS’ COMPENSATION Workers’ Compensation benefits are available for an employee’s work-related injuries. Benefits, including direct payments to a health care provider, are paid by the employer’s insurance carrier. Workers’ Compensation will provide primary coverage of nursing home care, as long as it is established that the nursing home care is necessitated solely by the Workers’ Compensation injury. Claim forms must be submitted to the local Workers’ Compensation Board Office within two years of the date of injury. It is advisable to consult with an attorney practicing in the Workers’ Compensation area when pursuing a claim. For further information, you can contact your local Workers’ Compensation Board office.

Billed by Facility. (3) Billed direct by Provider or Vendor. (4) Patient/Resident responsible for co-insurance and deductible. (5) Coverage depends on services provided. ADDITIONAL NON-CLINICAL SERVICES THE FOLLOWING ADDITIONAL NON- CLINICAL SERVICES ARE AVAILABLE TO ALL RESIDENTS AND IF REQUESTED BY THE RESIDENT, SPONSOR AND/OR DESIGNATED REPRESENTATIVE, WILL BE CHARGED TO THE RESIDENT: • Telephone • Television/radio for Resident’s personal use • Personal comfort items, notions and novelties, and confections • Cosmetic and grooming items and services, in excess of those for which payment is made under Medicaid, Medicare, or other insurance programs • Personal clothing • Personal reading matter • Gifts purchased on behalf of a Resident • Flowers and plants • Social events, special meals, and entertainment offered off the premises and outside the scope of the Activities program provided by the Facility • Non-covered special care services, such as private duty nurses • Specially prepared or alternative food (other than Kosher food or food required by a therapeutic or modified diet prescribed by a physician) • Private room (except when therapeutically required, such as for isolation for infection control) IF YOU HAVE ANY QUESTIONS REGARDING CHARGES AND BILLING, PLEASE FEEL FREE TO CONTACT THE BUSINESS OFFICE AT (718) 298- 7800372- 4500. ATTACHMENT “B” SPECIAL RULES REGARDING SELECTED PAYORS PAYMENT FOR IN-PATIENT LONG TERM CARE SERVICES IS AN EXPENSIVE AND COMPLICATED PROCESS. THIS SUMMARY PROVIDES OUR RESIDENTS AND THEIR FAMILIES WITH BASIC INFORMATION WHICH SHOULD SIMPLIFY THE PROCESS. NOTHING HEREIN SHOULD BE CONSIDERED TO BE LEGAL ADVICE. WE URGE YOU TO CONSULT WITH AN INSURANCE AGENT, ATTORNEY AND/OR OTHER KNOWLEDGEABLE PROFESSIONAL(S) IN ORDER TO HELP MAXIMIZE AVAILABLE COVERAGE. FURTHER, AS THE INFORMATION PROVIDED BELOW IS BASED UPON STATUTE AND REGULATIONS, IT IS SUBJECT TO CHANGE WITHOUT NOTICE. MEDICARE PART A PAYMENT Medicare Part A Hospital Insurance Skilled Nursing Facility coverage is generally available to qualified individuals 65 years of age or older, and individuals under age 65 who have been disabled for at least twenty-four months, who meet the following five requirements: 1) The Resident requires daily skilled nursing or rehabilitation services that can be provided only in a skilled nursing facility; 2) The Resident was hospitalized for at least three consecutive days, not counting the day of discharge, before entering the skilled nursing facility; 3) The Resident was admitted to the facility within 30 days after leaving the hospital; 4) The Resident is admitted to the facility to receive treatment for the same condition(s) for which he or she was treated in the hospital; and 5) A medical professional certifies that the Resident requires skilled nursing care on a “daily basis.” A Resident requires skilled nursing or skilled rehabilitation services on a daily basis when services are medically necessary and provided seven (7) days a week. There is an exception if they are only provided by the facility for five (5) days per week, due to staffing levels at the facility. Additionally, there may be a one to two day break if the Residents needs require suspension of the services. Where these five criteria are met, Medicare may provide coverage of up to 100 days of care in a skilled nursing facility (SNF): the first 20 days of covered services are fully paid for; and the next 80 days (days 21 through 100), of the covered services are paid for by Medicare subject to a daily coinsurance amount for which the Resident is responsible. For 2020, the Medicare Part A co-insurance amount is $176.00 per day. Additionally, Medicare Residents requesting a leave of absence from the facility should be aware of the Medicare rules regarding leave of absence and transfer within thirty (30) days. Medicare treats a leave of absence, where a Resident leaves the facility on a particular day and does not return by twelve (12) midnight that day, as an uncovered day. Additionally, the day in which a Resident begins a leave of absence (i.e., hospitalization), where the resident is absent for more than 24 hours, is treated as a day of discharge. Except for specifically excluded services, nursing home services provided to Medicare Part A beneficiaries are covered under the consolidated billing requirements. Residents must consult with the Facility before obtaining any services outside of the Facility. Medicare also has a thirty (30) day transfer requirement. A Resident must be transferred from a hospital or other SNF within thirty (30) days of discharge and meet the skilled care requirements in order to be eligible for SNF coverage. If a Resident meets the eligibility requirements for Skilled Nursing Facility benefits under the Medicare Part A Hospital Insurance Program, Facility will xxxx Medicare directly for all Part A services provided to the Resident. Medicare will reimburse Facility a fixed per diem or daily fee based on the Resident’s classification within the Medicare RUG III guidelines. RUG is an acronym for Resource-based Utilization Groups. These guidelines are a measure of what type of care the Resident requires and what it costs health care providers to provide that care to a Resident. Members of our professional staff will evaluate the Resident’s health condition based on a standardized assessment form (called the MDS 2.0) provided by the Centers for Medicare and Medicaid Services (CMS). Information from the MDS 2.0 form will be used by Medicare to assign the Resident a RUG III category. The Resident will be responsible for the daily co-insurance amount determined by Medicare. This amount is subject to increase each calendar year. With limited exceptions, a Resident who requires more than 100 days of SNF care in a benefit period will be responsible for private payment of all charges beginning with the 101st day. A new benefit period may begin when the Resident has either not been in a facility or has not been receiving a covered level of care in a skilled nursing facility for at least 60 days, returns to the hospital for another three-day stay, and then re-enters the SNF. A SNF may not request private payment until the Resident has received an official initial determination from Medicare that “skilled nursing” benefits are no longer available. While a SNF may make a determination of non-coverage, beneficiaries have a right to request an official Medicare determination of coverage (called a “Demand Xxxx”), which can be appealed. MEDICARE PART B PAYMENT Individuals who pay monthly premiums to enroll in Medicare Part B will be charged according to Facility’s or the service providers’ stated charge schedule for services they receive at Facility. Medicare Part B pays for a wide range of additional services beyond Part A coverage. Part B may cover some of a Residents care regardless of whether they are eligible for Part A benefits. Part B covers eighty (80%) percent of the Medicare approved charge for a specific service and the individual is responsible for the additional twenty (20%) percent. In general, Part B covers medical services and supplies. Part B covers such services as: physical, occupational and speech therapy, physician services, durable medical equipment, ambulance services and certain out-patient and clinical laboratory services. However, Part B benefits have limitations. For example, for 2020, there is a $198.00 deductible applicable to Medicare Part B benefits. Additionally, physical therapy (including speech- language pathology services) and occupational therapy are each subject to an annual limitation. The therapy financial limitations or “caps” are indexed by the Medicare Economic Index (MEI) each year. For 2020, the indexed amounts for physical therapy (including speech-language pathology services) and occupational therapy are $2,080.00 each, including co- insurance. Beneficiaries may be eligible for the Therapy Cap Exception Process. Both therapy limitations are still subject to the 80% - 20% coverage limitation in that the individual will be responsible for the 20 % co-insurance payments. The Resident is responsible for private payment of all therapy charges and any other ancillary charges above the Medicare Part B coverage limitations. The Facility can xxxx and receive payment if the Resident fills out a Medicare assignment of benefits form. If the Resident completes an assignment of benefits form, a health care provider cannot charge the Resident above the Medicare approved charge. In order to determine the Resident’s Part B coverage you should contact the Social Security Administration. In addition, Medicare Advantage programs and other alternatives may increase available Medicare benefits. To receive additional information about Medicare and Medicare Advantage programs, call the Social Security Administration at 800-772- 1213 or the Centers for Medicare and Medicaid Services at 1-800-MEDICARE. MEDICARE PART D - PRESCRIPTION DRUG COVERAGE Individuals eligible for Medicare Part A or enrolled in Medicare Part B and who do not have prescription drug coverage from a privately operated health plan or a Medicare Advantage-PD plan are eligible to enroll in Medicare Part D for prescription drug coverage. Medicare Part D through the selected PDP will provide reimbursement for prescription drugs listed in the PDP’s formulary subject to applicable premiums, deductibles and co-payments. Eligible individuals interested in obtaining prescription drug coverage through Medicare Part D must enroll in a PDP approved in the region. Upon admission to a skilled nursing home, individuals enrolled in a PDP in the community are permitted to continue with, or switch to a different PDP in the region. Dual eligible Medicare/Medicaid beneficiaries are automatically enrolled in, and assigned to an approved benchmark prescription drug plan (“PDP”) in the region. As of January 1, 2006, Medicaid no longer pays for prescription drug cost for dual eligibles. Dual eligibles in nursing homes will receive prescription drug coverage through Medicare Part D for the drugs listed on the selected PDP’s formulary. As long as dual eligibles are enrolled in benchmark plans in their region, they will not be responsible for premiums, deductibles and cost sharing obligations. Please call 000-000-0000 or contact xxx.xxxxxxxx.xxx/xxxxxxx.xxx to obtain enrollment information. MANAGED CARE Residents who are members of a managed care benefit plan that is under a contract with the Facility to provide specified services to plan members will receive those services with full coverage so long as the Resident meets the eligibility requirements of the managed care benefit plan. To the extent the Resident meets the eligibility requirements of the managed care benefit plan, he or she will be financially responsible only for the required deductibles and co-insurance and for those services that are not included in the list of covered services. Residents who have not received a list of covered services and eligibility requirements from their managed care benefit plan are advised to contact their social worker and/or managed care benefit plan. PRIVATE INSURANCE Residents who are covered by a private insurance plan that does not have a contract with the Facility must exhaust all available insurance coverage before seeking Medicare or Medicaid coverage. Where the insurance proceeds under the private plan are insufficient to cover the cost of care, the Resident will be responsible for any difference. The coverage requirements for nursing home care vary depending on the terms of the insurance policy. Questions regarding private insurance coverage should be directed to the social work staff and/or the Resident’s insurance carrier or agent. MEDICAID Medicaid is a publicly-funded program of assistance that covers nursing home Residents who can demonstrate financial need. To qualify for Medicaid, an individual may have only limited assets. For example, in 2020, the individual resource limit is $15,750 (subject to annual increases); plus any funds held in an “irrevocable burial trust” arrangement or up to $1,500 under a revocable burial account. Generally, most of the Resident’s monthly income must be paid to the Facility, except for a $50 monthly “personal needs allowance” and the monthly cost of retaining a private health insurance policy. This monthly income obligation, called the NAMI (Net Available Monthly Income), is determined by the Medicaid agency. If the Resident has a spouse in the community, the spouse might be entitled to a contribution from the Resident’s monthly income. During 2020, the “community spouse” is entitled to a minimum monthly income of $3,216 and resources up to a maximum of $128,640 (these figures are subject to increase each calendar year); increases beyond these amounts are possible, but a Department of Social Services Fair Hearing or Family Court support proceeding may be required. The Resident’s home may be exempt for Medicaid eligibility purposes if the equity value is less than $878,000.00 or if the spouse or disabled or minor child resides there. Upon application, Medicaid looks back at financial transactions or transfers of assets made within a sixty (60) month period of time from the date on which the person was institutionalized and applied for Medicaid coverage. A Resident or spouse who makes a transfer within those periods may create a period of Medicaid ineligibility. Private-pay Residents should apply for Medicaid about three months before their funds are depleted. A Medicaid application must include proof of the Resident’s identity, U.S. citizenship or legal alien status, and past and present financial status. Medicaid recipients are required to recertify eligibility each year in order to retain benefits. Medicaid is a complex program and a knowledgeable professional can advise Residents and their families as to their rights under the Medicaid program. To receive information about Medicaid, individuals can call their local Department of Social Services in the county in which the Resident resides. WORKERS’ COMPENSATION Workers’ Compensation benefits are available for an employee’s work-related injuries. Benefits, including direct payments to a health care provider, are paid by the employer’s insurance carrier. Workers’ Compensation will provide primary coverage of nursing home care, as long as it is established that the nursing home care is necessitated solely by the Workers’ Compensation injury. Claim forms must be submitted to the local Workers’ Compensation Board Office within two years of the date of injury. It is advisable to consult with an attorney practicing in the Workers’ Compensation area when pursuing a claim. For further information, you can contact your local Workers’ Compensation Board office.

Billed by Facility. (3) Billed direct by Provider or Vendor. (4) Patient/Resident responsible for co-insurance and deductible. (5) Coverage depends on services provided. ADDITIONAL NON-CLINICAL SERVICES THE FOLLOWING ADDITIONAL NON- CLINICAL SERVICES ARE AVAILABLE TO ALL RESIDENTS AND IF REQUESTED BY THE RESIDENT, SPONSOR AND/OR DESIGNATED REPRESENTATIVE, WILL BE CHARGED TO THE RESIDENT: • Telephone • Television/radio for Resident’s personal use • Personal comfort items, notions and novelties, and confections • Cosmetic and grooming items and services, in excess of those for which payment is made under Medicaid, Medicare, or other insurance programs • Personal clothing • Personal reading matter • Gifts purchased on behalf of a Resident • Flowers and plants • Social events, special meals, and entertainment offered off the premises and outside the scope of the Activities program provided by the Facility • Non-covered special care services, such as private duty nurses • Specially prepared or alternative food (other than Kosher food or food required by a therapeutic or modified diet prescribed by a physician) • Private room (except when therapeutically required, such as for isolation for infection control) IF YOU HAVE ANY QUESTIONS REGARDING CHARGES AND BILLING, PLEASE FEEL FREE TO CONTACT THE BUSINESS OFFICE AT (718) 298- 7800379- 8100. ATTACHMENT “B” SPECIAL RULES REGARDING SELECTED PAYORS PAYMENT FOR IN-PATIENT LONG TERM CARE SERVICES IS AN EXPENSIVE AND COMPLICATED PROCESS. THIS SUMMARY PROVIDES OUR RESIDENTS AND THEIR FAMILIES WITH BASIC INFORMATION WHICH SHOULD SIMPLIFY THE PROCESS. NOTHING HEREIN SHOULD BE CONSIDERED TO BE LEGAL ADVICE. WE URGE YOU TO CONSULT WITH AN INSURANCE AGENT, ATTORNEY AND/OR OTHER KNOWLEDGEABLE PROFESSIONAL(S) IN ORDER TO HELP MAXIMIZE AVAILABLE COVERAGE. FURTHER, AS THE INFORMATION PROVIDED BELOW IS BASED UPON STATUTE AND REGULATIONS, IT IS SUBJECT TO CHANGE WITHOUT NOTICE. MEDICARE PART A PAYMENT Medicare Part A Hospital Insurance Skilled Nursing Facility coverage is generally available to qualified individuals 65 years of age or older, and individuals under age 65 who have been disabled for at least twenty-four months, who meet the following five requirements: 1) The Resident requires daily skilled nursing or rehabilitation services that can be provided only in a skilled nursing facility; 2) The Resident was hospitalized for at least three consecutive days, not counting the day of discharge, before entering the skilled nursing facility; 3) The Resident was admitted to the facility within 30 days after leaving the hospital; 4) The Resident is admitted to the facility to receive treatment for the same condition(s) for which he or she was treated in the hospital; and 5) A medical professional certifies that the Resident requires skilled nursing care on a “daily basis.” A Resident requires skilled nursing or skilled rehabilitation services on a daily basis when services are medically necessary and provided seven (7) days a week. There is an exception if they are only provided by the facility for five (5) days per week, due to staffing levels at the facility. Additionally, there may be a one to two day break if the Residents needs require suspension of the services. Where these five criteria are met, Medicare may provide coverage of up to 100 days of care in a skilled nursing facility (SNF): the first 20 days of covered services are fully paid for; and the next 80 days (days 21 through 100), of the covered services are paid for by Medicare subject to a daily coinsurance amount for which the Resident is responsible. For 2020, the Medicare Part A co-insurance amount is $176.00 per day. Additionally, Medicare Residents requesting a leave of absence from the facility should be aware of the Medicare rules regarding leave of absence and transfer within thirty (30) days. Medicare treats a leave of absence, where a Resident leaves the facility on a particular day and does not return by twelve (12) midnight that day, as an uncovered day. Additionally, the day in which a Resident begins a leave of absence (i.e., hospitalization), where the resident is absent for more than 24 hours, is treated as a day of discharge. Except for specifically excluded services, nursing home services provided to Medicare Part A beneficiaries are covered under the consolidated billing requirements. Residents must consult with the Facility before obtaining any services outside of the Facility. Medicare also has a thirty (30) day transfer requirement. A Resident must be transferred from a hospital or other SNF within thirty (30) days of discharge and meet the skilled care requirements in order to be eligible for SNF coverage. If a Resident meets the eligibility requirements for Skilled Nursing Facility benefits under the Medicare Part A Hospital Insurance Program, Facility will xxxx Medicare directly for all Part A services provided to the Resident. Medicare will reimburse Facility a fixed per diem or daily fee based on the Resident’s classification within the Medicare RUG III guidelines. RUG is an acronym for Resource-based Utilization Groups. These guidelines are a measure of what type of care the Resident requires and what it costs health care providers to provide that care to a Resident. Members of our professional staff will evaluate the Resident’s health condition based on a standardized assessment form (called the MDS 2.0) provided by the Centers for Medicare and Medicaid Services (CMS). Information from the MDS 2.0 form will be used by Medicare to assign the Resident a RUG III category. The Resident will be responsible for the daily co-insurance amount determined by Medicare. This amount is subject to increase each calendar year. With limited exceptions, a Resident who requires more than 100 days of SNF care in a benefit period will be responsible for private payment of all charges beginning with the 101st day. A new benefit period may begin when the Resident has either not been in a facility or has not been receiving a covered level of care in a skilled nursing facility for at least 60 days, returns to the hospital for another three-day stay, and then re-enters the SNF. A SNF may not request private payment until the Resident has received an official initial determination from Medicare that “skilled nursing” benefits are no longer available. While a SNF may make a determination of non-coverage, beneficiaries have a right to request an official Medicare determination of coverage (called a “Demand Xxxx”), which can be appealed. MEDICARE PART B PAYMENT Individuals who pay monthly premiums to enroll in Medicare Part B will be charged according to Facility’s or the service providers’ stated charge schedule for services they receive at Facility. Medicare Part B pays for a wide range of additional services beyond Part A coverage. Part B may cover some of a Residents care regardless of whether they are eligible for Part A benefits. Part B covers eighty (80%) percent of the Medicare approved charge for a specific service and the individual is responsible for the additional twenty (20%) percent. In general, Part B covers medical services and supplies. Part B covers such services as: physical, occupational and speech therapy, physician services, durable medical equipment, ambulance services and certain out-patient and clinical laboratory services. However, Part B benefits have limitations. For example, for 2020, there is a $198.00 deductible applicable to Medicare Part B benefits. Additionally, physical therapy (including speech- language pathology services) and occupational therapy are each subject to an annual limitation. The therapy financial limitations or “caps” are indexed by the Medicare Economic Index (MEI) each year. For 2020, the indexed amounts for physical therapy (including speech-language pathology services) and occupational therapy are $2,080.00 each, including co- insurance. Beneficiaries may be eligible for the Therapy Cap Exception Process. Both therapy limitations are still subject to the 80% - 20% coverage limitation in that the individual will be responsible for the 20 % co-insurance payments. The Resident is responsible for private payment of all therapy charges and any other ancillary charges above the Medicare Part B coverage limitations. The Facility can xxxx and receive payment if the Resident fills out a Medicare assignment of benefits form. If the Resident completes an assignment of benefits form, a health care provider cannot charge the Resident above the Medicare approved charge. In order to determine the Resident’s Part B coverage you should contact the Social Security Administration. In addition, Medicare Advantage programs and other alternatives may increase available Medicare benefits. To receive additional information about Medicare and Medicare Advantage programs, call the Social Security Administration at 800-772- 1213 or the Centers for Medicare and Medicaid Services at 1-800-MEDICARE. MEDICARE PART D - PRESCRIPTION DRUG COVERAGE Individuals eligible for Medicare Part A or enrolled in Medicare Part B and who do not have prescription drug coverage from a privately operated health plan or a Medicare Advantage-PD plan are eligible to enroll in Medicare Part D for prescription drug coverage. Medicare Part D through the selected PDP will provide reimbursement for prescription drugs listed in the PDP’s formulary subject to applicable premiums, deductibles and co-payments. Eligible individuals interested in obtaining prescription drug coverage through Medicare Part D must enroll in a PDP approved in the region. Upon admission to a skilled nursing home, individuals enrolled in a PDP in the community are permitted to continue with, or switch to a different PDP in the region. Dual eligible Medicare/Medicaid beneficiaries are automatically enrolled in, and assigned to an approved benchmark prescription drug plan (“PDP”) in the region. As of January 1, 2006, Medicaid no longer pays for prescription drug cost for dual eligibles. Dual eligibles in nursing homes will receive prescription drug coverage through Medicare Part D for the drugs listed on the selected PDP’s formulary. As long as dual eligibles are enrolled in benchmark plans in their region, they will not be responsible for premiums, deductibles and cost sharing obligations. Please call 000-000-0000 or contact xxx.xxxxxxxx.xxx/xxxxxxx.xxx to obtain enrollment information. MANAGED CARE Residents who are members of a managed care benefit plan that is under a contract with the Facility to provide specified services to plan members will receive those services with full coverage so long as the Resident meets the eligibility requirements of the managed care benefit plan. To the extent the Resident meets the eligibility requirements of the managed care benefit plan, he or she will be financially responsible only for the required deductibles and co-insurance and for those services that are not included in the list of covered services. Residents who have not received a list of covered services and eligibility requirements from their managed care benefit plan are advised to contact their social worker and/or managed care benefit plan. PRIVATE INSURANCE Residents who are covered by a private insurance plan that does not have a contract with the Facility must exhaust all available insurance coverage before seeking Medicare or Medicaid coverage. Where the insurance proceeds under the private plan are insufficient to cover the cost of care, the Resident will be responsible for any difference. The coverage requirements for nursing home care vary depending on the terms of the insurance policy. Questions regarding private insurance coverage should be directed to the social work staff and/or the Resident’s insurance carrier or agent. MEDICAID Medicaid is a publicly-funded program of assistance that covers nursing home Residents who can demonstrate financial need. To qualify for Medicaid, an individual may have only limited assets. For example, in 2020, the individual resource limit is $15,750 (subject to annual increases); plus any funds held in an “irrevocable burial trust” arrangement or up to $1,500 under a revocable burial account. Generally, most of the Resident’s monthly income must be paid to the Facility, except for a $50 monthly “personal needs allowance” and the monthly cost of retaining a private health insurance policy. This monthly income obligation, called the NAMI (Net Available Monthly Income), is determined by the Medicaid agency. If the Resident has a spouse in the community, the spouse might be entitled to a contribution from the Resident’s monthly income. During 2020, the “community spouse” is entitled to a minimum monthly income of $3,216 and resources up to a maximum of $128,640 (these figures are subject to increase each calendar year); increases beyond these amounts are possible, but a Department of Social Services Fair Hearing or Family Court support proceeding may be required. The Resident’s home may be exempt for Medicaid eligibility purposes if the equity value is less than $878,000.00 or if the spouse or disabled or minor child resides there. Upon application, Medicaid looks back at financial transactions or transfers of assets made within a sixty (60) month period of time from the date on which the person was institutionalized and applied for Medicaid coverage. A Resident or spouse who makes a transfer within those periods may create a period of Medicaid ineligibility. Private-pay Residents should apply for Medicaid about three months before their funds are depleted. A Medicaid application must include proof of the Resident’s identity, U.S. citizenship or legal alien status, and past and present financial status. Medicaid recipients are required to recertify eligibility each year in order to retain benefits. Medicaid is a complex program and a knowledgeable professional can advise Residents and their families as to their rights under the Medicaid program. To receive information about Medicaid, individuals can call their local Department of Social Services in the county in which the Resident resides. WORKERS’ COMPENSATION Workers’ Compensation benefits are available for an employee’s work-related injuries. Benefits, including direct payments to a health care provider, are paid by the employer’s insurance carrier. Workers’ Compensation will provide primary coverage of nursing home care, as long as it is established that the nursing home care is necessitated solely by the Workers’ Compensation injury. Claim forms must be submitted to the local Workers’ Compensation Board Office within two years of the date of injury. It is advisable to consult with an attorney practicing in the Workers’ Compensation area when pursuing a claim. For further information, you can contact your local Workers’ Compensation Board office.

Billed by Facility. (3) Billed direct by Provider or Vendor. (4) Patient/Resident responsible for co-insurance and deductible. (5) Coverage depends on services provided. ADDITIONAL NON-CLINICAL SERVICES THE FOLLOWING ADDITIONAL NON- CLINICAL SERVICES ARE AVAILABLE TO ALL RESIDENTS AND IF REQUESTED BY THE RESIDENT, SPONSOR AND/OR DESIGNATED REPRESENTATIVE, WILL BE CHARGED TO THE RESIDENT: • Telephone • Television/radio for Resident’s personal use • Personal comfort items, notions and novelties, and confections • Cosmetic and grooming items and services, in excess of those for which payment is made under Medicaid, Medicare, or other insurance programs • Personal clothing • Personal reading matter • Gifts purchased on behalf of a Resident • Flowers and plants • Social events, special meals, and entertainment offered off the premises and outside the scope of the Activities program provided by the Facility • Non-covered special care services, such as private duty nurses • Specially prepared or alternative food (other than Kosher food or food required by a therapeutic or modified diet prescribed by a physician) • Private room (except when therapeutically required, such as for isolation for infection control) IF YOU HAVE ANY QUESTIONS REGARDING CHARGES AND BILLING, PLEASE FEEL FREE TO CONTACT THE BUSINESS OFFICE AT (718) 298- 7800734- 2000. ATTACHMENT “B” SPECIAL RULES REGARDING SELECTED PAYORS PAYMENT FOR IN-PATIENT LONG TERM CARE SERVICES IS AN EXPENSIVE AND COMPLICATED PROCESS. THIS SUMMARY PROVIDES OUR RESIDENTS AND THEIR FAMILIES WITH BASIC INFORMATION WHICH SHOULD SIMPLIFY THE PROCESS. NOTHING HEREIN SHOULD BE CONSIDERED TO BE LEGAL ADVICE. WE URGE YOU TO CONSULT WITH AN INSURANCE AGENT, ATTORNEY AND/OR OTHER KNOWLEDGEABLE PROFESSIONAL(S) IN ORDER TO HELP MAXIMIZE AVAILABLE COVERAGE. FURTHER, AS THE INFORMATION PROVIDED BELOW IS BASED UPON STATUTE AND REGULATIONS, IT IS SUBJECT TO CHANGE WITHOUT NOTICE. MEDICARE PART A PAYMENT Medicare Part A Hospital Insurance Skilled Nursing Facility coverage is generally available to qualified individuals 65 years of age or older, and individuals under age 65 who have been disabled for at least twenty-four months, who meet the following five requirements: 1) The Resident requires daily skilled nursing or rehabilitation services that can be provided only in a skilled nursing facility; 2) The Resident was hospitalized for at least three consecutive days, not counting the day of discharge, before entering the skilled nursing facility; 3) The Resident was admitted to the facility within 30 days after leaving the hospital; 4) The Resident is admitted to the facility to receive treatment for the same condition(s) for which he or she was treated in the hospital; and 5) A medical professional certifies that the Resident requires skilled nursing care on a “daily basis.” A Resident requires skilled nursing or skilled rehabilitation services on a daily basis when services are medically necessary and provided seven (7) days a week. There is an exception if they are only provided by the facility for five (5) days per week, due to staffing levels at the facility. Additionally, there may be a one to two day break if the Residents needs require suspension of the services. Where these five criteria are met, Medicare may provide coverage of up to 100 days of care in a skilled nursing facility (SNF): the first 20 days of covered services are fully paid for; and the next 80 days (days 21 through 100), of the covered services are paid for by Medicare subject to a daily coinsurance amount for which the Resident is responsible. For 2020, the Medicare Part A co-insurance amount is $176.00 per day. Additionally, Medicare Residents requesting a leave of absence from the facility should be aware of the Medicare rules regarding leave of absence and transfer within thirty (30) days. Medicare treats a leave of absence, where a Resident leaves the facility on a particular day and does not return by twelve (12) midnight that day, as an uncovered day. Additionally, the day in which a Resident begins a leave of absence (i.e., hospitalization), where the resident is absent for more than 24 hours, is treated as a day of discharge. Except for specifically excluded services, nursing home services provided to Medicare Part A beneficiaries are covered under the consolidated billing requirements. Residents must consult with the Facility before obtaining any services outside of the Facility. Medicare also has a thirty (30) day transfer requirement. A Resident must be transferred from a hospital or other SNF within thirty (30) days of discharge and meet the skilled care requirements in order to be eligible for SNF coverage. If a Resident meets the eligibility requirements for Skilled Nursing Facility benefits under the Medicare Part A Hospital Insurance Program, Facility will xxxx Medicare directly for all Part A services provided to the Resident. Medicare will reimburse Facility a fixed per diem or daily fee based on the Resident’s classification within the Medicare RUG III guidelines. RUG is an acronym for Resource-based Utilization Groups. These guidelines are a measure of what type of care the Resident requires and what it costs health care providers to provide that care to a Resident. Members of our professional staff will evaluate the Resident’s health condition based on a standardized assessment form (called the MDS 2.0) provided by the Centers for Medicare and Medicaid Services (CMS). Information from the MDS 2.0 form will be used by Medicare to assign the Resident a RUG III category. The Resident will be responsible for the daily co-insurance amount determined by Medicare. This amount is subject to increase each calendar year. With limited exceptions, a Resident who requires more than 100 days of SNF care in a benefit period will be responsible for private payment of all charges beginning with the 101st day. A new benefit period may begin when the Resident has either not been in a facility or has not been receiving a covered level of care in a skilled nursing facility for at least 60 days, returns to the hospital for another three-day stay, and then re-enters the SNF. A SNF may not request private payment until the Resident has received an official initial determination from Medicare that “skilled nursing” benefits are no longer available. While a SNF may make a determination of non-coverage, beneficiaries have a right to request an official Medicare determination of coverage (called a “Demand Xxxx”), which can be appealed. MEDICARE PART B PAYMENT Individuals who pay monthly premiums to enroll in Medicare Part B will be charged according to Facility’s or the service providers’ stated charge schedule for services they receive at Facility. Medicare Part B pays for a wide range of additional services beyond Part A coverage. Part B may cover some of a Residents care regardless of whether they are eligible for Part A benefits. Part B covers eighty (80%) percent of the Medicare approved charge for a specific service and the individual is responsible for the additional twenty (20%) percent. In general, Part B covers medical services and supplies. Part B covers such services as: physical, occupational and speech therapy, physician services, durable medical equipment, ambulance services and certain out-patient and clinical laboratory services. However, Part B benefits have limitations. For example, for 2020, there is a $198.00 deductible applicable to Medicare Part B benefits. Additionally, physical therapy (including speech- language pathology services) and occupational therapy are each subject to an annual limitation. The therapy financial limitations or “caps” are indexed by the Medicare Economic Index (MEI) each year. For 2020, the indexed amounts for physical therapy (including speech-language pathology services) and occupational therapy are $2,080.00 each, including co- insurance. Beneficiaries may be eligible for the Therapy Cap Exception Process. Both therapy limitations are still subject to the 80% - 20% coverage limitation in that the individual will be responsible for the 20 % co-insurance payments. The Resident is responsible for private payment of all therapy charges and any other ancillary charges above the Medicare Part B coverage limitations. The Facility can xxxx and receive payment if the Resident fills out a Medicare assignment of benefits form. If the Resident completes an assignment of benefits form, a health care provider cannot charge the Resident above the Medicare approved charge. In order to determine the Resident’s Part B coverage you should contact the Social Security Administration. In addition, Medicare Advantage programs and other alternatives may increase available Medicare benefits. To receive additional information about Medicare and Medicare Advantage programs, call the Social Security Administration at 800-772- 1213 or the Centers for Medicare and Medicaid Services at 1-800-MEDICARE. MEDICARE PART D - PRESCRIPTION DRUG COVERAGE Individuals eligible for Medicare Part A or enrolled in Medicare Part B and who do not have prescription drug coverage from a privately operated health plan or a Medicare Advantage-PD plan are eligible to enroll in Medicare Part D for prescription drug coverage. Medicare Part D through the selected PDP will provide reimbursement for prescription drugs listed in the PDP’s formulary subject to applicable premiums, deductibles and co-payments. Eligible individuals interested in obtaining prescription drug coverage through Medicare Part D must enroll in a PDP approved in the region. Upon admission to a skilled nursing home, individuals enrolled in a PDP in the community are permitted to continue with, or switch to a different PDP in the region. Dual eligible Medicare/Medicaid beneficiaries are automatically enrolled in, and assigned to an approved benchmark prescription drug plan (“PDP”) in the region. As of January 1, 2006, Medicaid no longer pays for prescription drug cost for dual eligibles. Dual eligibles in nursing homes will receive prescription drug coverage through Medicare Part D for the drugs listed on the selected PDP’s formulary. As long as dual eligibles are enrolled in benchmark plans in their region, they will not be responsible for premiums, deductibles and cost sharing obligations. Please call 000-000-0000 or contact xxx.xxxxxxxx.xxx/xxxxxxx.xxx to obtain enrollment information. MANAGED CARE Residents who are members of a managed care benefit plan that is under a contract with the Facility to provide specified services to plan members will receive those services with full coverage so long as the Resident meets the eligibility requirements of the managed care benefit plan. To the extent the Resident meets the eligibility requirements of the managed care benefit plan, he or she will be financially responsible only for the required deductibles and co-insurance and for those services that are not included in the list of covered services. Residents who have not received a list of covered services and eligibility requirements from their managed care benefit plan are advised to contact their social worker and/or managed care benefit plan. PRIVATE INSURANCE Residents who are covered by a private insurance plan that does not have a contract with the Facility must exhaust all available insurance coverage before seeking Medicare or Medicaid coverage. Where the insurance proceeds under the private plan are insufficient to cover the cost of care, the Resident will be responsible for any difference. The coverage requirements for nursing home care vary depending on the terms of the insurance policy. Questions regarding private insurance coverage should be directed to the social work staff and/or the Resident’s insurance carrier or agent. MEDICAID Medicaid is a publicly-funded program of assistance that covers nursing home Residents who can demonstrate financial need. To qualify for Medicaid, an individual may have only limited assets. For example, in 2020, the individual resource limit is $15,750 (subject to annual increases); plus any funds held in an “irrevocable burial trust” arrangement or up to $1,500 under a revocable burial account. Generally, most of the Resident’s monthly income must be paid to the Facility, except for a $50 monthly “personal needs allowance” and the monthly cost of retaining a private health insurance policy. This monthly income obligation, called the NAMI (Net Available Monthly Income), is determined by the Medicaid agency. If the Resident has a spouse in the community, the spouse might be entitled to a contribution from the Resident’s monthly income. During 2020, the “community spouse” is entitled to a minimum monthly income of $3,216 and resources up to a maximum of $128,640 (these figures are subject to increase each calendar year); increases beyond these amounts are possible, but a Department of Social Services Fair Hearing or Family Court support proceeding may be required. The Resident’s home may be exempt for Medicaid eligibility purposes if the equity value is less than $878,000.00 or if the spouse or disabled or minor child resides there. Upon application, Medicaid looks back at financial transactions or transfers of assets made within a sixty (60) month period of time from the date on which the person was institutionalized and applied for Medicaid coverage. A Resident or spouse who makes a transfer within those periods may create a period of Medicaid ineligibility. Private-pay Residents should apply for Medicaid about three months before their funds are depleted. A Medicaid application must include proof of the Resident’s identity, U.S. citizenship or legal alien status, and past and present financial status. Medicaid recipients are required to recertify eligibility each year in order to retain benefits. Medicaid is a complex program and a knowledgeable professional can advise Residents and their families as to their rights under the Medicaid program. To receive information about Medicaid, individuals can call their local Department of Social Services in the county in which the Resident resides. WORKERS’ COMPENSATION Workers’ Compensation benefits are available for an employee’s work-related injuries. Benefits, including direct payments to a health care provider, are paid by the employer’s insurance carrier. Workers’ Compensation will provide primary coverage of nursing home care, as long as it is established that the nursing home care is necessitated solely by the Workers’ Compensation injury. Claim forms must be submitted to the local Workers’ Compensation Board Office within two years of the date of injury. It is advisable to consult with an attorney practicing in the Workers’ Compensation area when pursuing a claim. For further information, you can contact your local Workers’ Compensation Board office.

Billed by Facility. (3) Billed direct by Provider or Vendor. (4) Patient/Resident responsible for co-insurance and deductible. (5) Coverage depends on services provided. ADDITIONAL NON-CLINICAL SERVICES THE FOLLOWING ADDITIONAL NON- CLINICAL SERVICES ARE AVAILABLE TO ALL RESIDENTS AND IF REQUESTED BY THE RESIDENTThe following additional Non- clinical services are available to all residents and if requested by the Resident, SPONSOR AND/OR DESIGNATED REPRESENTATIVESponsor and/or Designated Representative, WILL BE CHARGED TO THE RESIDENTwill be charged to the Resident: •  Telephone •  Television/radio for Resident’s personal use •  Personal comfort items, notions and novelties, and confections •  Cosmetic and grooming items and services, in excess of those for which payment is made under Medicaid, Medicare, or other insurance programs •  Personal clothing •  Personal reading matter •  Gifts purchased on behalf of a Resident •  Flowers and plants •  Social events, special meals, and entertainment offered off the premises and outside the scope of the Activities program provided by the Facility •  Non-covered special care services, such as private duty nurses •  Specially prepared or alternative food (other than Kosher food or food required by a therapeutic or modified diet prescribed by a physician) •  Private room (except when therapeutically required, such as for isolation for infection control) IF YOU HAVE ANY QUESTIONS REGARDING CHARGES AND BILLING, PLEASE FEEL FREE TO CONTACT THE BUSINESS OFFICE AT (718) 298- 7800636- 1000. ATTACHMENT “B” SPECIAL RULES REGARDING SELECTED PAYORS PAYMENT FOR IN-PATIENT LONG TERM CARE SERVICES IS AN EXPENSIVE AND COMPLICATED PROCESS. THIS SUMMARY PROVIDES OUR RESIDENTS AND THEIR FAMILIES WITH BASIC INFORMATION WHICH SHOULD SIMPLIFY THE PROCESS. NOTHING HEREIN SHOULD BE CONSIDERED TO BE LEGAL ADVICE. WE URGE YOU TO CONSULT WITH AN INSURANCE AGENT, ATTORNEY AND/OR OTHER KNOWLEDGEABLE PROFESSIONAL(S) IN ORDER TO HELP MAXIMIZE AVAILABLE COVERAGE. FURTHER, AS THE INFORMATION PROVIDED BELOW IS BASED UPON STATUTE AND REGULATIONS, IT IS SUBJECT TO CHANGE WITHOUT NOTICE. MEDICARE PART A PAYMENT Medicare Part A Hospital Insurance Skilled Nursing Facility coverage is generally available to qualified individuals 65 years of age or older, and individuals under age 65 who have been disabled for at least twenty-four months, who meet the following five requirements: 1) The Resident requires daily skilled nursing or rehabilitation services that can be provided only in a skilled nursing facility; 2) The Resident was hospitalized for at least three consecutive days, not counting the day of discharge, before entering the skilled nursing facility; 3) The Resident was admitted to the facility within 30 days after leaving the hospital; 4) The Resident is admitted to the facility to receive treatment for the same condition(s) for which he or she was treated in the hospital; and 5) A medical professional certifies that the Resident requires skilled nursing care on a “daily basis.” A Resident requires skilled nursing or skilled rehabilitation services on a daily basis when services are medically necessary and provided seven (7) days a week. There is an exception if they are only provided by the facility for five (5) days per week, due to staffing levels at the facility. Additionally, there may be a one to two day break if the Residents needs require suspension of the services. Where these five criteria are met, Medicare may provide coverage of up to 100 days of care in a skilled nursing facility (SNF): the first 20 days of covered services are fully paid for; and the next 80 days (days 21 through 100), of the covered services are paid for by Medicare subject to a daily coinsurance amount for which the Resident is responsible. For 20202024, the Medicare Part A co-insurance amount is $176.00 204.00 per day. Additionally, Medicare Residents requesting a leave of absence from the facility should be aware of the Medicare rules regarding leave of absence and transfer within thirty (30) days. Medicare treats a leave of absence, where a Resident leaves the facility on a particular day and does not return by twelve (12) midnight that day, as an uncovered day. Additionally, the day in which a Resident begins a leave of absence (i.e., hospitalization), where the resident is absent for more than 24 hours, is treated as a day of discharge. Except for specifically excluded services, nursing home services provided to Medicare Part A beneficiaries are covered under the consolidated billing requirements. Residents must consult with the Facility before obtaining any services outside of the Facility. Medicare also has a thirty (30) day transfer requirement. A Resident must be transferred from a hospital or other SNF within thirty (30) days of discharge and meet the skilled care requirements in order to be eligible for SNF coverage. If a Resident meets the eligibility requirements for Skilled Nursing Facility benefits under the Medicare Part A Hospital Insurance Program, Facility will xxxx bill Medicare directly for all Part A services provided to the Resident. Medicare will reimburse Facility a fixed per diem or daily fee based on the Resident’s classification within the Medicare RUG III guidelines. RUG is an acronym for Resource-based Utilization Groups. These guidelines are a measure of what type of care the Resident requires and what it costs health care providers to provide that care to a Resident. Members of our professional staff will evaluate the Resident’s health condition based on a standardized assessment form (called the MDS 2.0) provided by the Centers for Medicare and Medicaid Services (CMS). Information from the MDS 2.0 form will be used by Medicare to assign the Resident a RUG III category. The Resident will be responsible for the daily co-insurance amount determined by Medicare. This amount is subject to increase each calendar year. With limited exceptions, a Resident who requires more than 100 days of SNF care in a benefit period will be responsible for private payment of all charges beginning with the 101st day. A new benefit period may begin when the Resident has either not been in a facility or has not been receiving a covered level of care in a skilled nursing facility for at least 60 days, returns to the hospital for another three-day stay, and then re-enters the SNF. A SNF may not request private payment until the Resident has received an official initial determination from Medicare that “skilled nursing” benefits are no longer available. While a SNF may make a determination of non-coverage, beneficiaries have a right to request an official Medicare determination of coverage (called a “Demand XxxxBill”), which can be appealed. MEDICARE PART B PAYMENT Individuals who pay monthly premiums to enroll in Medicare Part B will be charged according to Facility’s or the service providers’ stated charge schedule for services they receive at Facility. Medicare Part B pays for a wide range of additional services beyond Part A coverage. Part B may cover some of a Residents care regardless of whether they are eligible for Part A benefits. Part B covers eighty (80%) percent of the Medicare approved charge for a specific service and the individual is responsible for the additional twenty (20%) percent. In general, Part B covers medical services and supplies. Part B covers such services as: physical, occupational and speech therapy, physician services, durable medical equipment, ambulance services and certain out-patient and clinical laboratory services. However, Part B benefits have limitations. For example, for 20202024, there is a $198.00 240.00 deductible applicable to Medicare Part B benefits. Additionally, physical therapy (including speech- language pathology services) and occupational therapy are each subject to an annual limitation. The therapy financial limitations or “caps” are indexed by the Medicare Economic Index (MEI) each year. For 20202024, the indexed amounts for physical therapy (including speech-language pathology services) and occupational therapy are $2,080.00 2330.00 each, including co- insurance. Beneficiaries may be eligible for the Therapy Cap Exception Process. Both therapy limitations are still subject to the 80% - 20% coverage limitation in that the individual will be responsible for the 20 % co-insurance payments. The Resident is responsible for private payment of all therapy charges and any other ancillary charges above the Medicare Part B coverage limitations. The Facility can xxxx bill and receive payment if the Resident fills out a Medicare assignment of benefits form. If the Resident completes an assignment of benefits form, a health care provider cannot charge the Resident above the Medicare approved charge. In order to determine the Resident’s Part B coverage you should contact the Social Security Administration. In addition, Medicare Advantage programs and other alternatives may increase available Medicare benefits. To receive additional information about Medicare and Medicare Advantage programs, call the Social Security Administration at 800-772- 1213 or the Centers for Medicare and Medicaid Services at 1-800-MEDICARE. MEDICARE PART D - PRESCRIPTION DRUG COVERAGE Individuals eligible for Medicare Part A or enrolled in Medicare Part B and who do not have prescription drug coverage from a privately operated health plan or a Medicare Advantage-PD plan are eligible to enroll in Medicare Part D for prescription drug coverage. Medicare Part D through the selected PDP will provide reimbursement for prescription drugs listed in the PDP’s formulary subject to applicable premiums, deductibles and co-payments. Eligible individuals interested in obtaining prescription drug coverage through Medicare Part D must enroll in a PDP approved in the region. Upon admission to a skilled nursing home, individuals enrolled in a PDP in the community are permitted to continue with, or switch to a different PDP in the region. Dual eligible Medicare/Medicaid beneficiaries are automatically enrolled in, and assigned to an approved benchmark prescription drug plan (“PDP”) in the region. As of January 1, 2006, Medicaid no longer pays for prescription drug cost for dual eligibles. Dual eligibles in nursing homes will receive prescription drug coverage through Medicare Part D for the drugs listed on the selected PDP’s formulary. As long as dual eligibles are enrolled in benchmark plans in their region, they will not be responsible for premiums, deductibles and cost sharing obligations. Please call 000-000-0000 or contact xxx.xxxxxxxx.xxx/xxxxxxx.xxx to obtain enrollment information. MANAGED CARE Residents who are members of a managed care benefit plan that is under a contract with the Facility to provide specified services to plan members will receive those services with full coverage so long as the Resident meets the eligibility requirements of the managed care benefit plan. To the extent the Resident meets the eligibility requirements of the managed care benefit plan, he or she will be financially responsible only for the required deductibles and co-insurance and for those services that are not included in the list of covered services. Residents who have not received a list of covered services and eligibility requirements from their managed care benefit plan are advised to contact their social worker and/or managed care benefit plan. PRIVATE INSURANCE Residents who are covered by a private insurance plan that does not have a contract with the Facility must exhaust all available insurance coverage before seeking Medicare or Medicaid coverage. Where the insurance proceeds under the private plan are insufficient to cover the cost of care, the Resident will be responsible for any difference. The coverage requirements for nursing home care vary depending on the terms of the insurance policy. Questions regarding private insurance coverage should be directed to the social work staff and/or the Resident’s insurance carrier or agent. MEDICAID Medicaid is a publicly-funded program of assistance that covers nursing home Residents who can demonstrate financial need. To qualify for Medicaid, an individual may have only limited assets. For example, in 20202024, the individual resource limit is $15,750 30,182 (subject to annual increases); plus any funds held in an “irrevocable burial trust” arrangement or up to $1,500 under a revocable burial account. Generally, most of the Resident’s monthly income must be paid to the Facility, except for a $50 monthly “personal needs allowance” and the monthly cost of retaining a private health insurance policy. This monthly income obligation, called the NAMI (Net Available Monthly Income), is determined by the Medicaid agency. If the Resident has a spouse in the community, the spouse might be entitled to a contribution from the Resident’s monthly income. During 20202024, the “community spouse” is entitled to a minimum monthly income of $3,216 3,853.50 and resources up to a maximum of $128,640 154,140 (these figures are subject to increase each calendar year); increases beyond these amounts are possible, but a Department of Social Services Fair Hearing or Family Court support proceeding may be required. The Resident’s home may be exempt for Medicaid eligibility purposes if the equity value is less than $878,000.00 1,071,000.00 or if the spouse or disabled or minor child resides there. Upon application, Medicaid looks back at financial transactions or transfers of assets made within a sixty (60) month period of time from the date on which the person was institutionalized and applied for Medicaid coverage. A Resident or spouse who makes a transfer within those periods may create a period of Medicaid ineligibility. Private-pay Residents should apply for Medicaid about three months before their funds are depleted. A Medicaid application must include proof of the Resident’s identity, U.S. citizenship or legal alien status, and past and present financial status. Medicaid recipients are required to recertify eligibility each year in order to retain benefits. Medicaid is a complex program and a knowledgeable professional can advise Residents and their families as to their rights under the Medicaid program. To receive information about Medicaid, individuals can call their local Department of Social Services in the county in which the Resident resides. WORKERS’ COMPENSATION Workers’ Compensation benefits are available for an employee’s work-related injuries. Benefits, including direct payments to a health care provider, are paid by the employer’s insurance carrier. Workers’ Compensation will provide primary coverage of nursing home care, as long as it is established that the nursing home care is necessitated solely by the Workers’ Compensation injury. Claim forms must be submitted to the local Workers’ Compensation Board Office within two years of the date of injury. It is advisable to consult with an attorney practicing in the Workers’ Compensation area when pursuing a claim. For further information, you can contact your local Workers’ Compensation Board office.

Billed by Facility. (3) Billed direct by Provider or Vendor. (4) Patient/Resident responsible for co-insurance and deductible. (5) Coverage depends on services provided. ADDITIONAL NON-CLINICAL SERVICES THE FOLLOWING ADDITIONAL NON- CLINICAL SERVICES ARE AVAILABLE TO ALL RESIDENTS AND IF REQUESTED BY THE RESIDENTThe following additional Non- clinical services are available to all residents and if requested by the Resident, SPONSOR AND/OR DESIGNATED REPRESENTATIVESponsor and/or Designated Representative, WILL BE CHARGED TO THE RESIDENTwill be charged to the Resident: • Telephone • Television/radio for Resident’s personal use • Personal comfort items, notions and novelties, and confections • Cosmetic and grooming items and services, in excess of those for which payment is made under Medicaid, Medicare, or other insurance programs • Personal clothing • Personal reading matter • Gifts purchased on behalf of a Resident • Flowers and plants • Social events, special meals, and entertainment offered off the premises and outside the scope of the Activities program provided by the Facility • Non-covered special care services, such as private duty nurses • Specially prepared or alternative food (other than Kosher food or food required by a therapeutic or modified diet prescribed by a physician) • Private room (except when therapeutically required, such as for isolation for infection control) IF YOU HAVE ANY QUESTIONS REGARDING CHARGES AND BILLING, PLEASE FEEL FREE TO CONTACT THE BUSINESS OFFICE AT (718) 298- 7800. ATTACHMENT “B” SPECIAL RULES REGARDING SELECTED PAYORS PAYMENT FOR IN-PATIENT LONG TERM CARE SERVICES IS AN EXPENSIVE AND COMPLICATED PROCESS. THIS SUMMARY PROVIDES OUR RESIDENTS AND THEIR FAMILIES WITH BASIC INFORMATION WHICH SHOULD SIMPLIFY THE PROCESS. NOTHING HEREIN SHOULD BE CONSIDERED TO BE LEGAL ADVICE. WE URGE YOU TO CONSULT WITH AN INSURANCE AGENT, ATTORNEY AND/OR OTHER KNOWLEDGEABLE PROFESSIONAL(S) IN ORDER TO HELP MAXIMIZE AVAILABLE COVERAGE. FURTHER, AS THE INFORMATION PROVIDED BELOW IS BASED UPON STATUTE AND REGULATIONS, IT IS SUBJECT TO CHANGE WITHOUT NOTICE. MEDICARE PART A PAYMENT Medicare Part A Hospital Insurance Skilled Nursing Facility coverage is generally available to qualified individuals 65 years of age or older, and individuals under age 65 who have been disabled for at least twenty-four months, who meet the following five requirements: 1) The Resident requires daily skilled nursing or rehabilitation services that can be provided only in a skilled nursing facility; 2) The Resident was hospitalized for at least three consecutive days, not counting the day of discharge, before entering the skilled nursing facility; 3) The Resident was admitted to the facility within 30 days after leaving the hospital; 4) The Resident is admitted to the facility to receive treatment for the same condition(s) for which he or she was treated in the hospital; and 5) A medical professional certifies that the Resident requires skilled nursing care on a “daily basis.” A Resident requires skilled nursing or skilled rehabilitation services on a daily basis when services are medically necessary and provided seven (7) days a week. There is an exception if they are only provided by the facility for five (5) days per week, due to staffing levels at the facility. Additionally, there may be a one to two day break if the Residents needs require suspension of the services. Where these five criteria are met, Medicare may provide coverage of up to 100 days of care in a skilled nursing facility (SNF): the first 20 days of covered services are fully paid for; and the next 80 days (days 21 through 100), of the covered services are paid for by Medicare subject to a daily coinsurance amount for which the Resident is responsible. For 2020, the Medicare Part A co-insurance amount is $176.00 per day. Additionally, Medicare Residents requesting a leave of absence from the facility should be aware of the Medicare rules regarding leave of absence and transfer within thirty (30) days. Medicare treats a leave of absence, where a Resident leaves the facility on a particular day and does not return by twelve (12) midnight that day, as an uncovered day. Additionally, the day in which a Resident begins a leave of absence (i.e., hospitalization), where the resident is absent for more than 24 hours, is treated as a day of discharge. Except for specifically excluded services, nursing home services provided to Medicare Part A beneficiaries are covered under the consolidated billing requirements. Residents must consult with the Facility before obtaining any services outside of the Facility. Medicare also has a thirty (30) day transfer requirement. A Resident must be transferred from a hospital or other SNF within thirty (30) days of discharge and meet the skilled care requirements in order to be eligible for SNF coverage. If a Resident meets the eligibility requirements for Skilled Nursing Facility benefits under the Medicare Part A Hospital Insurance Program, Facility will xxxx bill Medicare directly for all Part A services provided to the Resident. Medicare will reimburse Facility a fixed per diem or daily fee based on the Resident’s classification within the Medicare RUG III guidelines. RUG is an acronym for Resource-based Utilization Groups. These guidelines are a measure of what type of care the Resident requires and what it costs health care providers to provide that care to a Resident. Members of our professional staff will evaluate the Resident’s health condition based on a standardized assessment form (called the MDS 2.0) provided by the Centers for Medicare and Medicaid Services (CMS). Information from the MDS 2.0 form will be used by Medicare to assign the Resident a RUG III category. The Resident will be responsible for the daily co-insurance amount determined by Medicare. This amount is subject to increase each calendar year. With limited exceptions, a Resident who requires more than 100 days of SNF care in a benefit period will be responsible for private payment of all charges beginning with the 101st day. A new benefit period may begin when the Resident has either not been in a facility or has not been receiving a covered level of care in a skilled nursing facility for at least 60 days, returns to the hospital for another three-day stay, and then re-enters the SNF. A SNF may not request private payment until the Resident has received an official initial determination from Medicare that “skilled nursing” benefits are no longer available. While a SNF may make a determination of non-coverage, beneficiaries have a right to request an official Medicare determination of coverage (called a “Demand XxxxBill”), which can be appealed. MEDICARE PART B PAYMENT Individuals who pay monthly premiums to enroll in Medicare Part B will be charged according to Facility’s or the service providers’ stated charge schedule for services they receive at Facility. Medicare Part B pays for a wide range of additional services beyond Part A coverage. Part B may cover some of a Residents care regardless of whether they are eligible for Part A benefits. Part B covers eighty (80%) percent of the Medicare approved charge for a specific service and the individual is responsible for the additional twenty (20%) percent. In general, Part B covers medical services and supplies. Part B covers such services as: physical, occupational and speech therapy, physician services, durable medical equipment, ambulance services and certain out-patient and clinical laboratory services. However, Part B benefits have limitations. For example, for 2020, there is a $198.00 deductible applicable to Medicare Part B benefits. Additionally, physical therapy (including speech- language pathology services) and occupational therapy are each subject to an annual limitation. The therapy financial limitations or “caps” are indexed by the Medicare Economic Index (MEI) each year. For 2020, the indexed amounts for physical therapy (including speech-language pathology services) and occupational therapy are $2,080.00 each, including co- insurance. Beneficiaries may be eligible for the Therapy Cap Exception Process. Both therapy limitations are still subject to the 80% - 20% coverage limitation in that the individual will be responsible for the 20 % co-insurance payments. The Resident is responsible for private payment of all therapy charges and any other ancillary charges above the Medicare Part B coverage limitations. The Facility can xxxx bill and receive payment if the Resident fills out a Medicare assignment of benefits form. If the Resident completes an assignment of benefits form, a health care provider cannot charge the Resident above the Medicare approved charge. In order to determine the Resident’s Part B coverage you should contact the Social Security Administration. In addition, Medicare Advantage programs and other alternatives may increase available Medicare benefits. To receive additional information about Medicare and Medicare Advantage programs, call the Social Security Administration at 800-772- 1213 or the Centers for Medicare and Medicaid Services at 1-800-MEDICARE. MEDICARE PART D - PRESCRIPTION DRUG COVERAGE Individuals eligible for Medicare Part A or enrolled in Medicare Part B and who do not have prescription drug coverage from a privately operated health plan or a Medicare Advantage-PD plan are eligible to enroll in Medicare Part D for prescription drug coverage. Medicare Part D through the selected PDP will provide reimbursement for prescription drugs listed in the PDP’s formulary subject to applicable premiums, deductibles and co-payments. Eligible individuals interested in obtaining prescription drug coverage through Medicare Part D must enroll in a PDP approved in the region. Upon admission to a skilled nursing home, individuals enrolled in a PDP in the community are permitted to continue with, or switch to a different PDP in the region. Dual eligible Medicare/Medicaid beneficiaries are automatically enrolled in, and assigned to an approved benchmark prescription drug plan (“PDP”) in the region. As of January 1, 2006, Medicaid no longer pays for prescription drug cost for dual eligibles. Dual eligibles in nursing homes will receive prescription drug coverage through Medicare Part D for the drugs listed on the selected PDP’s formulary. As long as dual eligibles are enrolled in benchmark plans in their region, they will not be responsible for premiums, deductibles and cost sharing obligations. Please call 000-000-0000 or contact xxx.xxxxxxxx.xxx/xxxxxxx.xxx to obtain enrollment information. MANAGED CARE Residents who are members of a managed care benefit plan that is under a contract with the Facility to provide specified services to plan members will receive those services with full coverage so long as the Resident meets the eligibility requirements of the managed care benefit plan. To the extent the Resident meets the eligibility requirements of the managed care benefit plan, he or she will be financially responsible only for the required deductibles and co-insurance and for those services that are not included in the list of covered services. Residents who have not received a list of covered services and eligibility requirements from their managed care benefit plan are advised to contact their social worker and/or managed care benefit plan. PRIVATE INSURANCE Residents who are covered by a private insurance plan that does not have a contract with the Facility must exhaust all available insurance coverage before seeking Medicare or Medicaid coverage. Where the insurance proceeds under the private plan are insufficient to cover the cost of care, the Resident will be responsible for any difference. The coverage requirements for nursing home care vary depending on the terms of the insurance policy. Questions regarding private insurance coverage should be directed to the social work staff and/or the Resident’s insurance carrier or agent. MEDICAID Medicaid is a publicly-funded program of assistance that covers nursing home Residents who can demonstrate financial need. To qualify for Medicaid, an individual may have only limited assets. For example, in 2020, the individual resource limit is $15,750 (subject to annual increases); plus any funds held in an “irrevocable burial trust” arrangement or up to $1,500 under a revocable burial account. Generally, most of the Resident’s monthly income must be paid to the Facility, except for a $50 monthly “personal needs allowance” and the monthly cost of retaining a private health insurance policy. This monthly income obligation, called the NAMI (Net Available Monthly Income), is determined by the Medicaid agency. If the Resident has a spouse in the community, the spouse might be entitled to a contribution from the Resident’s monthly income. During 2020, the “community spouse” is entitled to a minimum monthly income of $3,216 and resources up to a maximum of $128,640 (these figures are subject to increase each calendar year); increases beyond these amounts are possible, but a Department of Social Services Fair Hearing or Family Court support proceeding may be required. The Resident’s home may be exempt for Medicaid eligibility purposes if the equity value is less than $878,000.00 or if the spouse or disabled or minor child resides there. Upon application, Medicaid looks back at financial transactions or transfers of assets made within a sixty (60) month period of time from the date on which the person was institutionalized and applied for Medicaid coverage. A Resident or spouse who makes a transfer within those periods may create a period of Medicaid ineligibility. Private-pay Residents should apply for Medicaid about three months before their funds are depleted. A Medicaid application must include proof of the Resident’s identity, U.S. citizenship or legal alien status, and past and present financial status. Medicaid recipients are required to recertify eligibility each year in order to retain benefits. Medicaid is a complex program and a knowledgeable professional can advise Residents and their families as to their rights under the Medicaid program. To receive information about Medicaid, individuals can call their local Department of Social Services in the county in which the Resident resides. WORKERS’ COMPENSATION Workers’ Compensation benefits are available for an employee’s work-related injuries. Benefits, including direct payments to a health care provider, are paid by the employer’s insurance carrier. Workers’ Compensation will provide primary coverage of nursing home care, as long as it is established that the nursing home care is necessitated solely by the Workers’ Compensation injury. Claim forms must be submitted to the local Workers’ Compensation Board Office within two years of the date of injury. It is advisable to consult with an attorney practicing in the Workers’ Compensation area when pursuing a claim. For further information, you can contact your local Workers’ Compensation Board office.

Billed by Facility. (3) Billed direct by Provider or Vendor. (4) Patient/Resident responsible for co-insurance and deductible. (5) Coverage depends on services provided. ADDITIONAL NON-CLINICAL SERVICES THE FOLLOWING ADDITIONAL NON- CLINICAL SERVICES ARE AVAILABLE TO ALL RESIDENTS AND IF REQUESTED BY THE RESIDENT, SPONSOR AND/OR DESIGNATED REPRESENTATIVE, WILL BE CHARGED TO THE RESIDENT: • Telephone • Television/radio for Resident’s personal use • Personal comfort items, notions and novelties, and confections • Cosmetic and grooming items and services, in excess of those for which payment is made under Medicaid, Medicare, or other insurance programs • Personal clothing • Personal reading matter • Gifts purchased on behalf of a Resident • Flowers and plants • Social events, special meals, and entertainment offered off the premises and outside the scope of the Activities program provided by the Facility • Non-covered special care services, such as private duty nurses • Specially prepared or alternative food (other than Kosher food or food required by a therapeutic or modified diet prescribed by a physician) • Private room (except when therapeutically required, such as for isolation for infection control) IF YOU HAVE ANY QUESTIONS REGARDING CHARGES AND BILLING, PLEASE FEEL FREE TO CONTACT THE BUSINESS OFFICE AT (718) 298- 7800409- 8200. ATTACHMENT “B” SPECIAL RULES REGARDING SELECTED PAYORS PAYMENT FOR IN-PATIENT LONG TERM CARE SERVICES IS AN EXPENSIVE AND COMPLICATED PROCESS. THIS SUMMARY PROVIDES OUR RESIDENTS AND THEIR FAMILIES WITH BASIC INFORMATION WHICH SHOULD SIMPLIFY THE PROCESS. NOTHING HEREIN SHOULD BE CONSIDERED TO BE LEGAL ADVICE. WE URGE YOU TO CONSULT WITH AN INSURANCE AGENT, ATTORNEY AND/OR OTHER KNOWLEDGEABLE PROFESSIONAL(S) IN ORDER TO HELP MAXIMIZE AVAILABLE COVERAGE. FURTHER, AS THE INFORMATION PROVIDED BELOW IS BASED UPON STATUTE AND REGULATIONS, IT IS SUBJECT TO CHANGE WITHOUT NOTICE. MEDICARE PART A PAYMENT Medicare Part A Hospital Insurance Skilled Nursing Facility coverage is generally available to qualified individuals 65 years of age or older, and individuals under age 65 who have been disabled for at least twenty-four months, who meet the following five requirements: 1) The Resident requires daily skilled nursing or rehabilitation services that can be provided only in a skilled nursing facility; 2) The Resident was hospitalized for at least three consecutive days, not counting the day of discharge, before entering the skilled nursing facility; 3) The Resident was admitted to the facility within 30 days after leaving the hospital; 4) The Resident is admitted to the facility to receive treatment for the same condition(s) for which he or she was treated in the hospital; and 5) A medical professional certifies that the Resident requires skilled nursing care on a “daily basis.” A Resident requires skilled nursing or skilled rehabilitation services on a daily basis when services are medically necessary and provided seven (7) days a week. There is an exception if they are only provided by the facility for five (5) days per week, due to staffing levels at the facility. Additionally, there may be a one to two day break if the Residents needs require suspension of the services. Where these five criteria are met, Medicare may provide coverage of up to 100 days of care in a skilled nursing facility (SNF): the first 20 days of covered services are fully paid for; and the next 80 days (days 21 through 100), of the covered services are paid for by Medicare subject to a daily coinsurance amount for which the Resident is responsible. For 2020, the Medicare Part A co-insurance amount is $176.00 per day. Additionally, Medicare Residents requesting a leave of absence from the facility should be aware of the Medicare rules regarding leave of absence and transfer within thirty (30) days. Medicare treats a leave of absence, where a Resident leaves the facility on a particular day and does not return by twelve (12) midnight that day, as an uncovered day. Additionally, the day in which a Resident begins a leave of absence (i.e., hospitalization), where the resident is absent for more than 24 hours, is treated as a day of discharge. Except for specifically excluded services, nursing home services provided to Medicare Part A beneficiaries are covered under the consolidated billing requirements. Residents must consult with the Facility before obtaining any services outside of the Facility. Medicare also has a thirty (30) day transfer requirement. A Resident must be transferred from a hospital or other SNF within thirty (30) days of discharge and meet the skilled care requirements in order to be eligible for SNF coverage. If a Resident meets the eligibility requirements for Skilled Nursing Facility benefits under the Medicare Part A Hospital Insurance Program, Facility will xxxx Medicare directly for all Part A services provided to the Resident. Medicare will reimburse Facility a fixed per diem or daily fee based on the Resident’s classification within the Medicare RUG III guidelines. RUG is an acronym for Resource-based Utilization Groups. These guidelines are a measure of what type of care the Resident requires and what it costs health care providers to provide that care to a Resident. Members of our professional staff will evaluate the Resident’s health condition based on a standardized assessment form (called the MDS 2.0) provided by the Centers for Medicare and Medicaid Services (CMS). Information from the MDS 2.0 form will be used by Medicare to assign the Resident a RUG III category. The Resident will be responsible for the daily co-insurance amount determined by Medicare. This amount is subject to increase each calendar year. With limited exceptions, a Resident who requires more than 100 days of SNF care in a benefit period will be responsible for private payment of all charges beginning with the 101st day. A new benefit period may begin when the Resident has either not been in a facility or has not been receiving a covered level of care in a skilled nursing facility for at least 60 days, returns to the hospital for another three-day stay, and then re-enters the SNF. A SNF may not request private payment until the Resident has received an official initial determination from Medicare that “skilled nursing” benefits are no longer available. While a SNF may make a determination of non-coverage, beneficiaries have a right to request an official Medicare determination of coverage (called a “Demand Xxxx”), which can be appealed. MEDICARE PART B PAYMENT Individuals who pay monthly premiums to enroll in Medicare Part B will be charged according to Facility’s or the service providers’ stated charge schedule for services they receive at Facility. Medicare Part B pays for a wide range of additional services beyond Part A coverage. Part B may cover some of a Residents care regardless of whether they are eligible for Part A benefits. Part B covers eighty (80%) percent of the Medicare approved charge for a specific service and the individual is responsible for the additional twenty (20%) percent. In general, Part B covers medical services and supplies. Part B covers such services as: physical, occupational and speech therapy, physician services, durable medical equipment, ambulance services and certain out-patient and clinical laboratory services. However, Part B benefits have limitations. For example, for 2020, there is a $198.00 deductible applicable to Medicare Part B benefits. Additionally, physical therapy (including speech- language pathology services) and occupational therapy are each subject to an annual limitation. The therapy financial limitations or “caps” are indexed by the Medicare Economic Index (MEI) each year. For 2020, the indexed amounts for physical therapy (including speech-language pathology services) and occupational therapy are $2,080.00 each, including co- insurance. Beneficiaries may be eligible for the Therapy Cap Exception Process. Both therapy limitations are still subject to the 80% - 20% coverage limitation in that the individual will be responsible for the 20 % co-insurance payments. The Resident is responsible for private payment of all therapy charges and any other ancillary charges above the Medicare Part B coverage limitations. The Facility can xxxx and receive payment if the Resident fills out a Medicare assignment of benefits form. If the Resident completes an assignment of benefits form, a health care provider cannot charge the Resident above the Medicare approved charge. In order to determine the Resident’s Part B coverage you should contact the Social Security Administration. In addition, Medicare Advantage programs and other alternatives may increase available Medicare benefits. To receive additional information about Medicare and Medicare Advantage programs, call the Social Security Administration at 800-772- 1213 or the Centers for Medicare and Medicaid Services at 1-800-MEDICARE. MEDICARE PART D - PRESCRIPTION DRUG COVERAGE Individuals eligible for Medicare Part A or enrolled in Medicare Part B and who do not have prescription drug coverage from a privately operated health plan or a Medicare Advantage-PD plan are eligible to enroll in Medicare Part D for prescription drug coverage. Medicare Part D through the selected PDP will provide reimbursement for prescription drugs listed in the PDP’s formulary subject to applicable premiums, deductibles and co-payments. Eligible individuals interested in obtaining prescription drug coverage through Medicare Part D must enroll in a PDP approved in the region. Upon admission to a skilled nursing home, individuals enrolled in a PDP in the community are permitted to continue with, or switch to a different PDP in the region. Dual eligible Medicare/Medicaid beneficiaries are automatically enrolled in, and assigned to an approved benchmark prescription drug plan (“PDP”) in the region. As of January 1, 2006, Medicaid no longer pays for prescription drug cost for dual eligibles. Dual eligibles in nursing homes will receive prescription drug coverage through Medicare Part D for the drugs listed on the selected PDP’s formulary. As long as dual eligibles are enrolled in benchmark plans in their region, they will not be responsible for premiums, deductibles and cost sharing obligations. Please call 000-000-0000 or contact xxx.xxxxxxxx.xxx/xxxxxxx.xxx to obtain enrollment information. MANAGED CARE Residents who are members of a managed care benefit plan that is under a contract with the Facility to provide specified services to plan members will receive those services with full coverage so long as the Resident meets the eligibility requirements of the managed care benefit plan. To the extent the Resident meets the eligibility requirements of the managed care benefit plan, he or she will be financially responsible only for the required deductibles and co-insurance and for those services that are not included in the list of covered services. Residents who have not received a list of covered services and eligibility requirements from their managed care benefit plan are advised to contact their social worker and/or managed care benefit plan. PRIVATE INSURANCE Residents who are covered by a private insurance plan that does not have a contract with the Facility must exhaust all available insurance coverage before seeking Medicare or Medicaid coverage. Where the insurance proceeds under the private plan are insufficient to cover the cost of care, the Resident will be responsible for any difference. The coverage requirements for nursing home care vary depending on the terms of the insurance policy. Questions regarding private insurance coverage should be directed to the social work staff and/or the Resident’s insurance carrier or agent. MEDICAID Medicaid is a publicly-funded program of assistance that covers nursing home Residents who can demonstrate financial need. To qualify for Medicaid, an individual may have only limited assets. For example, in 2020, the individual resource limit is $15,750 (subject to annual increases); plus any funds held in an “irrevocable burial trust” arrangement or up to $1,500 under a revocable burial account. Generally, most of the Resident’s monthly income must be paid to the Facility, except for a $50 monthly “personal needs allowance” and the monthly cost of retaining a private health insurance policy. This monthly income obligation, called the NAMI (Net Available Monthly Income), is determined by the Medicaid agency. If the Resident has a spouse in the community, the spouse might be entitled to a contribution from the Resident’s monthly income. During 2020, the “community spouse” is entitled to a minimum monthly income of $3,216 and resources up to a maximum of $128,640 (these figures are subject to increase each calendar year); increases beyond these amounts are possible, but a Department of Social Services Fair Hearing or Family Court support proceeding may be required. The Resident’s home may be exempt for Medicaid eligibility purposes if the equity value is less than $878,000.00 or if the spouse or disabled or minor child resides there. Upon application, Medicaid looks back at financial transactions or transfers of assets made within a sixty (60) month period of time from the date on which the person was institutionalized and applied for Medicaid coverage. A Resident or spouse who makes a transfer within those periods may create a period of Medicaid ineligibility. Private-pay Residents should apply for Medicaid about three months before their funds are depleted. A Medicaid application must include proof of the Resident’s identity, U.S. citizenship or legal alien status, and past and present financial status. Medicaid recipients are required to recertify eligibility each year in order to retain benefits. Medicaid is a complex program and a knowledgeable professional can advise Residents and their families as to their rights under the Medicaid program. To receive information about Medicaid, individuals can call their local Department of Social Services in the county in which the Resident resides. WORKERS’ COMPENSATION Workers’ Compensation benefits are available for an employee’s work-related injuries. Benefits, including direct payments to a health care provider, are paid by the employer’s insurance carrier. Workers’ Compensation will provide primary coverage of nursing home care, as long as it is established that the nursing home care is necessitated solely by the Workers’ Compensation injury. Claim forms must be submitted to the local Workers’ Compensation Board Office within two years of the date of injury. It is advisable to consult with an attorney practicing in the Workers’ Compensation area when pursuing a claim. For further information, you can contact your local Workers’ Compensation Board office.

Billed by Facility. (3) Billed direct by Provider or Vendor. (4) Patient/Resident responsible for co-insurance and deductible. (5) Coverage depends on services provided. ADDITIONAL NON-CLINICAL SERVICES THE FOLLOWING ADDITIONAL NON- CLINICAL SERVICES ARE AVAILABLE TO ALL RESIDENTS AND IF REQUESTED BY THE RESIDENTThe following additional Non- clinical services are available to all residents and if requested by the Resident, SPONSOR AND/OR DESIGNATED REPRESENTATIVESponsor and/or Designated Representative, WILL BE CHARGED TO THE RESIDENTwill be charged to the Resident: •  Telephone •  Television/radio for Resident’s personal use •  Personal comfort items, notions and novelties, and confections •  Cosmetic and grooming items and services, in excess of those for which payment is made under Medicaid, Medicare, or other insurance programs •  Personal clothing •  Personal reading matter •  Gifts purchased on behalf of a Resident •  Flowers and plants •  Social events, special meals, and entertainment offered off the premises and outside the scope of the Activities program provided by the Facility •  Non-covered special care services, such as private duty nurses •  Specially prepared or alternative food (other than Kosher food or food required by a therapeutic or modified diet prescribed by a physician) •  Private room (except when therapeutically required, such as for isolation for infection control) IF YOU HAVE ANY QUESTIONS REGARDING CHARGES AND BILLING, PLEASE FEEL FREE TO CONTACT THE BUSINESS OFFICE AT (718631) 298- 7800422- 4800. ATTACHMENT “B” SPECIAL RULES REGARDING SELECTED PAYORS PAYMENT FOR IN-PATIENT LONG TERM CARE SERVICES IS AN EXPENSIVE AND COMPLICATED PROCESS. THIS SUMMARY PROVIDES OUR RESIDENTS AND THEIR FAMILIES WITH BASIC INFORMATION WHICH SHOULD SIMPLIFY THE PROCESS. NOTHING HEREIN SHOULD BE CONSIDERED TO BE LEGAL ADVICE. WE URGE YOU TO CONSULT WITH AN INSURANCE AGENT, ATTORNEY AND/OR OTHER KNOWLEDGEABLE PROFESSIONAL(S) IN ORDER TO HELP MAXIMIZE AVAILABLE COVERAGE. FURTHER, AS THE INFORMATION PROVIDED BELOW IS BASED UPON STATUTE AND REGULATIONS, IT IS SUBJECT TO CHANGE WITHOUT NOTICE. MEDICARE PART A PAYMENT Medicare Part A Hospital Insurance Skilled Nursing Facility coverage is generally available to qualified individuals 65 years of age or older, and individuals under age 65 who have been disabled for at least twenty-four months, who meet the following five requirements: 1) The Resident requires daily skilled nursing or rehabilitation services that can be provided only in a skilled nursing facility; 2) The Resident was hospitalized for at least three consecutive days, not counting the day of discharge, before entering the skilled nursing facility; 3) The Resident was admitted to the facility within 30 days after leaving the hospital; 4) The Resident is admitted to the facility to receive treatment for the same condition(s) for which he or she was treated in the hospital; and 5) A medical professional certifies that the Resident requires skilled nursing care on a “daily basis.” A Resident requires skilled nursing or skilled rehabilitation services on a daily basis when services are medically necessary and provided seven (7) days a week. There is an exception if they are only provided by the facility for five (5) days per week, due to staffing levels at the facility. Additionally, there may be a one to two day break if the Residents needs require suspension of the services. Where these five criteria are met, Medicare may provide coverage of up to 100 days of care in a skilled nursing facility (SNF): the first 20 days of covered services are fully paid for; and the next 80 days (days 21 through 100), of the covered services are paid for by Medicare subject to a daily coinsurance amount for which the Resident is responsible. For 20202024, the Medicare Part A co-insurance amount is $176.00 204.00 per day. Additionally, Medicare Residents requesting a leave of absence from the facility should be aware of the Medicare rules regarding leave of absence and transfer within thirty (30) days. Medicare treats a leave of absence, where a Resident leaves the facility on a particular day and does not return by twelve (12) midnight that day, as an uncovered day. Additionally, the day in which a Resident begins a leave of absence (i.e., hospitalization), where the resident is absent for more than 24 hours, is treated as a day of discharge. Except for specifically excluded services, nursing home services provided to Medicare Part A beneficiaries are covered under the consolidated billing requirements. Residents must consult with the Facility before obtaining any services outside of the Facility. Medicare also has a thirty (30) day transfer requirement. A Resident must be transferred from a hospital or other SNF within thirty (30) days of discharge and meet the skilled care requirements in order to be eligible for SNF coverage. If a Resident meets the eligibility requirements for Skilled Nursing Facility benefits under the Medicare Part A Hospital Insurance Program, Facility will xxxx bill Medicare directly for all Part A services provided to the Resident. Medicare will reimburse Facility a fixed per diem or daily fee based on the Resident’s classification within the Medicare RUG III guidelines. RUG is an acronym for Resource-based Utilization Groups. These guidelines are a measure of what type of care the Resident requires and what it costs health care providers to provide that care to a Resident. Members of our professional staff will evaluate the Resident’s health condition based on a standardized assessment form (called the MDS 2.0) provided by the Centers for Medicare and Medicaid Services (CMS). Information from the MDS 2.0 form will be used by Medicare to assign the Resident a RUG III category. The Resident will be responsible for the daily co-insurance amount determined by Medicare. This amount is subject to increase each calendar year. With limited exceptions, a Resident who requires more than 100 days of SNF care in a benefit period will be responsible for private payment of all charges beginning with the 101st day. A new benefit period may begin when the Resident has either not been in a facility or has not been receiving a covered level of care in a skilled nursing facility for at least 60 days, returns to the hospital for another three-day stay, and then re-enters the SNF. A SNF may not request private payment until the Resident has received an official initial determination from Medicare that “skilled nursing” benefits are no longer available. While a SNF may make a determination of non-coverage, beneficiaries have a right to request an official Medicare determination of coverage (called a “Demand XxxxBill”), which can be appealed. MEDICARE PART B PAYMENT Individuals who pay monthly premiums to enroll in Medicare Part B will be charged according to Facility’s or the service providers’ stated charge schedule for services they receive at Facility. Medicare Part B pays for a wide range of additional services beyond Part A coverage. Part B may cover some of a Residents care regardless of whether they are eligible for Part A benefits. Part B covers eighty (80%) percent of the Medicare approved charge for a specific service and the individual is responsible for the additional twenty (20%) percent. In general, Part B covers medical services and supplies. Part B covers such services as: physical, occupational and speech therapy, physician services, durable medical equipment, ambulance services and certain out-patient and clinical laboratory services. However, Part B benefits have limitations. For example, for 20202024, there is a $198.00 240.00 deductible applicable to Medicare Part B benefits. Additionally, physical therapy (including speech- language pathology services) and occupational therapy are each subject to an annual limitation. The therapy financial limitations or “caps” are indexed by the Medicare Economic Index (MEI) each year. For 20202024, the indexed amounts for physical therapy (including speech-language pathology services) and occupational therapy are $2,080.00 2330.00 each, including co- insurance. Beneficiaries may be eligible for the Therapy Cap Exception Process. Both therapy limitations are still subject to the 80% - 20% coverage limitation in that the individual will be responsible for the 20 % co-insurance payments. The Resident is responsible for private payment of all therapy charges and any other ancillary charges above the Medicare Part B coverage limitations. The Facility can xxxx bill and receive payment if the Resident fills out a Medicare assignment of benefits form. If the Resident completes an assignment of benefits form, a health care provider cannot charge the Resident above the Medicare approved charge. In order to determine the Resident’s Part B coverage you should contact the Social Security Administration. In addition, Medicare Advantage programs and other alternatives may increase available Medicare benefits. To receive additional information about Medicare and Medicare Advantage programs, call the Social Security Administration at 800-772- 1213 or the Centers for Medicare and Medicaid Services at 1-800-MEDICARE. MEDICARE PART D - PRESCRIPTION DRUG COVERAGE Individuals eligible for Medicare Part A or enrolled in Medicare Part B and who do not have prescription drug coverage from a privately operated health plan or a Medicare Advantage-PD plan are eligible to enroll in Medicare Part D for prescription drug coverage. Medicare Part D through the selected PDP will provide reimbursement for prescription drugs listed in the PDP’s formulary subject to applicable premiums, deductibles and co-payments. Eligible individuals interested in obtaining prescription drug coverage through Medicare Part D must enroll in a PDP approved in the region. Upon admission to a skilled nursing home, individuals enrolled in a PDP in the community are permitted to continue with, or switch to a different PDP in the region. Dual eligible Medicare/Medicaid beneficiaries are automatically enrolled in, and assigned to an approved benchmark prescription drug plan (“PDP”) in the region. As of January 1, 2006, Medicaid no longer pays for prescription drug cost for dual eligibles. Dual eligibles in nursing homes will receive prescription drug coverage through Medicare Part D for the drugs listed on the selected PDP’s formulary. As long as dual eligibles are enrolled in benchmark plans in their region, they will not be responsible for premiums, deductibles and cost sharing obligations. Please call 000-000-0000 or contact xxx.xxxxxxxx.xxx/xxxxxxx.xxx to obtain enrollment information. MANAGED CARE Residents who are members of a managed care benefit plan that is under a contract with the Facility to provide specified services to plan members will receive those services with full coverage so long as the Resident meets the eligibility requirements of the managed care benefit plan. To the extent the Resident meets the eligibility requirements of the managed care benefit plan, he or she will be financially responsible only for the required deductibles and co-insurance and for those services that are not included in the list of covered services. Residents who have not received a list of covered services and eligibility requirements from their managed care benefit plan are advised to contact their social worker and/or managed care benefit plan. PRIVATE INSURANCE Residents who are covered by a private insurance plan that does not have a contract with the Facility must exhaust all available insurance coverage before seeking Medicare or Medicaid coverage. Where the insurance proceeds under the private plan are insufficient to cover the cost of care, the Resident will be responsible for any difference. The coverage requirements for nursing home care vary depending on the terms of the insurance policy. Questions regarding private insurance coverage should be directed to the social work staff and/or the Resident’s insurance carrier or agent. MEDICAID Medicaid is a publicly-funded program of assistance that covers nursing home Residents who can demonstrate financial need. To qualify for Medicaid, an individual may have only limited assets. For example, in 20202024, the individual resource limit is $15,750 30,182 (subject to annual increases); plus any funds held in an “irrevocable burial trust” arrangement or up to $1,500 under a revocable burial account. Generally, most of the Resident’s monthly income must be paid to the Facility, except for a $50 monthly “personal needs allowance” and the monthly cost of retaining a private health insurance policy. This monthly income obligation, called the NAMI (Net Available Monthly Income), is determined by the Medicaid agency. If the Resident has a spouse in the community, the spouse might be entitled to a contribution from the Resident’s monthly income. During 20202024, the “community spouse” is entitled to a minimum monthly income of $3,216 3853.50 and resources up to a maximum of $128,640 154,140 (these figures are subject to increase each calendar year); increases beyond these amounts are possible, but a Department of Social Services Fair Hearing or Family Court support proceeding may be required. The Resident’s home may be exempt for Medicaid eligibility purposes if the equity value is less than $878,000.00 1,071,000.00 or if the spouse or disabled or minor child resides there. Upon application, Medicaid looks back at financial transactions or transfers of assets made within a sixty (60) month period of time from the date on which the person was institutionalized and applied for Medicaid coverage. A Resident or spouse who makes a transfer within those periods may create a period of Medicaid ineligibility. Private-pay Residents should apply for Medicaid about three months before their funds are depleted. A Medicaid application must include proof of the Resident’s identity, U.S. citizenship or legal alien status, and past and present financial status. Medicaid recipients are required to recertify eligibility each year in order to retain benefits. Medicaid is a complex program and a knowledgeable professional can advise Residents and their families as to their rights under the Medicaid program. To receive information about Medicaid, individuals can call their local Department of Social Services in the county in which the Resident resides. WORKERS’ COMPENSATION Workers’ Compensation benefits are available for an employee’s work-related injuries. Benefits, including direct payments to a health care provider, are paid by the employer’s insurance carrier. Workers’ Compensation will provide primary coverage of nursing home care, as long as it is established that the nursing home care is necessitated solely by the Workers’ Compensation injury. Claim forms must be submitted to the local Workers’ Compensation Board Office within two years of the date of injury. It is advisable to consult with an attorney practicing in the Workers’ Compensation area when pursuing a claim. For further information, you can contact your local Workers’ Compensation Board office.

Billed by Facility. (3) Billed direct by Provider or Vendor. (4) Patient/Resident responsible for co-insurance and deductible. (5) Coverage depends on services provided. ADDITIONAL NON-CLINICAL SERVICES THE FOLLOWING ADDITIONAL NON- CLINICAL SERVICES ARE AVAILABLE TO ALL RESIDENTS AND IF REQUESTED BY THE RESIDENTThe following additional Non- clinical services are available to all residents and if requested by the Resident, SPONSOR AND/OR DESIGNATED REPRESENTATIVESponsor and/or Designated Representative, WILL BE CHARGED TO THE RESIDENTwill be charged to the Resident: • Telephone • Television/radio for Resident’s personal use • Personal comfort items, notions and novelties, and confections • Cosmetic and grooming items and services, in excess of those for which payment is made under Medicaid, Medicare, or other insurance programs • Personal clothing • Personal reading matter • Gifts purchased on behalf of a Resident • Flowers and plants • Social events, special meals, and entertainment offered off the premises and outside the scope of the Activities program provided by the Facility • Non-covered special care services, such as private duty nurses • Specially prepared or alternative food (other than Kosher food or food required by a therapeutic or modified diet prescribed by a physician) • Private room (except when therapeutically required, such as for isolation for infection control) IF YOU HAVE ANY QUESTIONS REGARDING CHARGES AND BILLING, PLEASE FEEL FREE TO CONTACT THE BUSINESS OFFICE AT (718) 298- 7800379- 8100. ATTACHMENT “B” SPECIAL RULES REGARDING SELECTED PAYORS PAYMENT FOR IN-PATIENT LONG TERM CARE SERVICES IS AN EXPENSIVE AND COMPLICATED PROCESS. THIS SUMMARY PROVIDES OUR RESIDENTS AND THEIR FAMILIES WITH BASIC INFORMATION WHICH SHOULD SIMPLIFY THE PROCESS. NOTHING HEREIN SHOULD BE CONSIDERED TO BE LEGAL ADVICE. WE URGE YOU TO CONSULT WITH AN INSURANCE AGENT, ATTORNEY AND/OR OTHER KNOWLEDGEABLE PROFESSIONAL(S) IN ORDER TO HELP MAXIMIZE AVAILABLE COVERAGE. FURTHER, AS THE INFORMATION PROVIDED BELOW IS BASED UPON STATUTE AND REGULATIONS, IT IS SUBJECT TO CHANGE WITHOUT NOTICE. MEDICARE PART A PAYMENT Medicare Part A Hospital Insurance Skilled Nursing Facility coverage is generally available to qualified individuals 65 years of age or older, and individuals under age 65 who have been disabled for at least twenty-four months, who meet the following five requirements: 1) The Resident requires daily skilled nursing or rehabilitation services that can be provided only in a skilled nursing facility; 2) The Resident was hospitalized for at least three consecutive days, not counting the day of discharge, before entering the skilled nursing facility; 3) The Resident was admitted to the facility within 30 days after leaving the hospital; 4) The Resident is admitted to the facility to receive treatment for the same condition(s) for which he or she was treated in the hospital; and 5) A medical professional certifies that the Resident requires skilled nursing care on a “daily basis.” A Resident requires skilled nursing or skilled rehabilitation services on a daily basis when services are medically necessary and provided seven (7) days a week. There is an exception if they are only provided by the facility for five (5) days per week, due to staffing levels at the facility. Additionally, there may be a one to two day break if the Residents needs require suspension of the services. Where these five criteria are met, Medicare may provide coverage of up to 100 days of care in a skilled nursing facility (SNF): the first 20 days of covered services are fully paid for; and the next 80 days (days 21 through 100), of the covered services are paid for by Medicare subject to a daily coinsurance amount for which the Resident is responsible. For 2020, the Medicare Part A co-insurance amount is $176.00 per day. Additionally, Medicare Residents requesting a leave of absence from the facility should be aware of the Medicare rules regarding leave of absence and transfer within thirty (30) days. Medicare treats a leave of absence, where a Resident leaves the facility on a particular day and does not return by twelve (12) midnight that day, as an uncovered day. Additionally, the day in which a Resident begins a leave of absence (i.e., hospitalization), where the resident is absent for more than 24 hours, is treated as a day of discharge. Except for specifically excluded services, nursing home services provided to Medicare Part A beneficiaries are covered under the consolidated billing requirements. Residents must consult with the Facility before obtaining any services outside of the Facility. Medicare also has a thirty (30) day transfer requirement. A Resident must be transferred from a hospital or other SNF within thirty (30) days of discharge and meet the skilled care requirements in order to be eligible for SNF coverage. If a Resident meets the eligibility requirements for Skilled Nursing Facility benefits under the Medicare Part A Hospital Insurance Program, Facility will xxxx bill Medicare directly for all Part A services provided to the Resident. Medicare will reimburse Facility a fixed per diem or daily fee based on the Resident’s classification within the Medicare RUG III guidelines. RUG is an acronym for Resource-based Utilization Groups. These guidelines are a measure of what type of care the Resident requires and what it costs health care providers to provide that care to a Resident. Members of our professional staff will evaluate the Resident’s health condition based on a standardized assessment form (called the MDS 2.0) provided by the Centers for Medicare and Medicaid Services (CMS). Information from the MDS 2.0 form will be used by Medicare to assign the Resident a RUG III category. The Resident will be responsible for the daily co-insurance amount determined by Medicare. This amount is subject to increase each calendar year. With limited exceptions, a Resident who requires more than 100 days of SNF care in a benefit period will be responsible for private payment of all charges beginning with the 101st day. A new benefit period may begin when the Resident has either not been in a facility or has not been receiving a covered level of care in a skilled nursing facility for at least 60 days, returns to the hospital for another three-day stay, and then re-enters the SNF. A SNF may not request private payment until the Resident has received an official initial determination from Medicare that “skilled nursing” benefits are no longer available. While a SNF may make a determination of non-coverage, beneficiaries have a right to request an official Medicare determination of coverage (called a “Demand XxxxBill”), which can be appealed. MEDICARE PART B PAYMENT Individuals who pay monthly premiums to enroll in Medicare Part B will be charged according to Facility’s or the service providers’ stated charge schedule for services they receive at Facility. Medicare Part B pays for a wide range of additional services beyond Part A coverage. Part B may cover some of a Residents care regardless of whether they are eligible for Part A benefits. Part B covers eighty (80%) percent of the Medicare approved charge for a specific service and the individual is responsible for the additional twenty (20%) percent. In general, Part B covers medical services and supplies. Part B covers such services as: physical, occupational and speech therapy, physician services, durable medical equipment, ambulance services and certain out-patient and clinical laboratory services. However, Part B benefits have limitations. For example, for 2020, there is a $198.00 deductible applicable to Medicare Part B benefits. Additionally, physical therapy (including speech- language pathology services) and occupational therapy are each subject to an annual limitation. The therapy financial limitations or “caps” are indexed by the Medicare Economic Index (MEI) each year. For 2020, the indexed amounts for physical therapy (including speech-language pathology services) and occupational therapy are $2,080.00 each, including co- insurance. Beneficiaries may be eligible for the Therapy Cap Exception Process. Both therapy limitations are still subject to the 80% - 20% coverage limitation in that the individual will be responsible for the 20 % co-insurance payments. The Resident is responsible for private payment of all therapy charges and any other ancillary charges above the Medicare Part B coverage limitations. The Facility can xxxx bill and receive payment if the Resident fills out a Medicare assignment of benefits form. If the Resident completes an assignment of benefits form, a health care provider cannot charge the Resident above the Medicare approved charge. In order to determine the Resident’s Part B coverage you should contact the Social Security Administration. In addition, Medicare Advantage programs and other alternatives may increase available Medicare benefits. To receive additional information about Medicare and Medicare Advantage programs, call the Social Security Administration at 800-772- 1213 or the Centers for Medicare and Medicaid Services at 1-800-MEDICARE. MEDICARE PART D - PRESCRIPTION DRUG COVERAGE Individuals eligible for Medicare Part A or enrolled in Medicare Part B and who do not have prescription drug coverage from a privately operated health plan or a Medicare Advantage-PD plan are eligible to enroll in Medicare Part D for prescription drug coverage. Medicare Part D through the selected PDP will provide reimbursement for prescription drugs listed in the PDP’s formulary subject to applicable premiums, deductibles and co-payments. Eligible individuals interested in obtaining prescription drug coverage through Medicare Part D must enroll in a PDP approved in the region. Upon admission to a skilled nursing home, individuals enrolled in a PDP in the community are permitted to continue with, or switch to a different PDP in the region. Dual eligible Medicare/Medicaid beneficiaries are automatically enrolled in, and assigned to an approved benchmark prescription drug plan (“PDP”) in the region. As of January 1, 2006, Medicaid no longer pays for prescription drug cost for dual eligibles. Dual eligibles in nursing homes will receive prescription drug coverage through Medicare Part D for the drugs listed on the selected PDP’s formulary. As long as dual eligibles are enrolled in benchmark plans in their region, they will not be responsible for premiums, deductibles and cost sharing obligations. Please call 000-000-0000 or contact xxx.xxxxxxxx.xxx/xxxxxxx.xxx to obtain enrollment information. MANAGED CARE Residents who are members of a managed care benefit plan that is under a contract with the Facility to provide specified services to plan members will receive those services with full coverage so long as the Resident meets the eligibility requirements of the managed care benefit plan. To the extent the Resident meets the eligibility requirements of the managed care benefit plan, he or she will be financially responsible only for the required deductibles and co-insurance and for those services that are not included in the list of covered services. Residents who have not received a list of covered services and eligibility requirements from their managed care benefit plan are advised to contact their social worker and/or managed care benefit plan. PRIVATE INSURANCE Residents who are covered by a private insurance plan that does not have a contract with the Facility must exhaust all available insurance coverage before seeking Medicare or Medicaid coverage. Where the insurance proceeds under the private plan are insufficient to cover the cost of care, the Resident will be responsible for any difference. The coverage requirements for nursing home care vary depending on the terms of the insurance policy. Questions regarding private insurance coverage should be directed to the social work staff and/or the Resident’s insurance carrier or agent. MEDICAID Medicaid is a publicly-funded program of assistance that covers nursing home Residents who can demonstrate financial need. To qualify for Medicaid, an individual may have only limited assets. For example, in 2020, the individual resource limit is $15,750 (subject to annual increases); plus any funds held in an “irrevocable burial trust” arrangement or up to $1,500 under a revocable burial account. Generally, most of the Resident’s monthly income must be paid to the Facility, except for a $50 monthly “personal needs allowance” and the monthly cost of retaining a private health insurance policy. This monthly income obligation, called the NAMI (Net Available Monthly Income), is determined by the Medicaid agency. If the Resident has a spouse in the community, the spouse might be entitled to a contribution from the Resident’s monthly income. During 2020, the “community spouse” is entitled to a minimum monthly income of $3,216 and resources up to a maximum of $128,640 (these figures are subject to increase each calendar year); increases beyond these amounts are possible, but a Department of Social Services Fair Hearing or Family Court support proceeding may be required. The Resident’s home may be exempt for Medicaid eligibility purposes if the equity value is less than $878,000.00 or if the spouse or disabled or minor child resides there. Upon application, Medicaid looks back at financial transactions or transfers of assets made within a sixty (60) month period of time from the date on which the person was institutionalized and applied for Medicaid coverage. A Resident or spouse who makes a transfer within those periods may create a period of Medicaid ineligibility. Private-pay Residents should apply for Medicaid about three months before their funds are depleted. A Medicaid application must include proof of the Resident’s identity, U.S. citizenship or legal alien status, and past and present financial status. Medicaid recipients are required to recertify eligibility each year in order to retain benefits. Medicaid is a complex program and a knowledgeable professional can advise Residents and their families as to their rights under the Medicaid program. To receive information about Medicaid, individuals can call their local Department of Social Services in the county in which the Resident resides. WORKERS’ COMPENSATION Workers’ Compensation benefits are available for an employee’s work-related injuries. Benefits, including direct payments to a health care provider, are paid by the employer’s insurance carrier. Workers’ Compensation will provide primary coverage of nursing home care, as long as it is established that the nursing home care is necessitated solely by the Workers’ Compensation injury. Claim forms must be submitted to the local Workers’ Compensation Board Office within two years of the date of injury. It is advisable to consult with an attorney practicing in the Workers’ Compensation area when pursuing a claim. For further information, you can contact your local Workers’ Compensation Board office.

Billed by Facility. (3) Billed direct by Provider or Vendor. (4) Patient/Resident responsible for co-insurance and deductible. (5) Coverage depends on services provided. Attachment A (2/15) ii ADDITIONAL NON-CLINICAL SERVICES THE FOLLOWING ADDITIONAL NON- CLINICAL SERVICES ARE AVAILABLE TO ALL RESIDENTS AND IF REQUESTED BY THE RESIDENT, SPONSOR AND/OR DESIGNATED REPRESENTATIVE, WILL BE CHARGED TO THE RESIDENT: • Telephone • Television/radio for Resident’s personal use • Personal comfort items, notions and novelties, and confections • Cosmetic and grooming items and services, in excess of those for which payment is made under Medicaid, Medicare, or other insurance programs • Personal clothing • Personal reading matter • Gifts purchased on behalf of a Resident • Flowers and plants • Social events, special meals, and entertainment offered off the premises and outside the scope of the Activities program provided by the Facility • Non-covered special care services, such as private duty nurses • Specially prepared or alternative food (other than Kosher food or food required by a therapeutic or modified diet prescribed by a physician) • Private room (except when therapeutically required, such as for isolation for infection control) IF YOU HAVE ANY QUESTIONS REGARDING CHARGES AND BILLING, PLEASE FEEL FREE TO CONTACT THE BUSINESS OFFICE AT (718) 298- 7800891- 4400. Attachment A (2/15) iii ATTACHMENT “B” SPECIAL RULES REGARDING SELECTED PAYORS PAYMENT FOR IN-PATIENT LONG TERM CARE SERVICES IS AN EXPENSIVE AND COMPLICATED PROCESS. THIS SUMMARY PROVIDES OUR RESIDENTS AND THEIR FAMILIES WITH BASIC INFORMATION WHICH SHOULD SIMPLIFY THE PROCESS. NOTHING HEREIN SHOULD BE CONSIDERED TO BE LEGAL ADVICE. WE URGE YOU TO CONSULT WITH AN INSURANCE AGENT, ATTORNEY AND/OR OTHER KNOWLEDGEABLE PROFESSIONAL(S) IN ORDER TO HELP MAXIMIZE AVAILABLE COVERAGE. FURTHER, AS THE INFORMATION PROVIDED BELOW IS BASED UPON STATUTE AND REGULATIONS, IT IS SUBJECT TO CHANGE WITHOUT NOTICE. MEDICARE PART A PAYMENT Medicare Part A Hospital Insurance Skilled Nursing Facility coverage is generally available to qualified individuals 65 years of age or older, and individuals under age 65 who have been disabled for at least twenty-four months, who meet the following five requirements: 1) The Resident requires daily skilled nursing or rehabilitation services that can be provided only in a skilled nursing facility; 2) The Resident was hospitalized for at least three consecutive days, not counting the day of discharge, before entering the skilled nursing facility; 3) The Resident was admitted to the facility within 30 days after leaving the hospital; 4) The Resident is admitted to the facility to receive treatment for the same condition(s) for which he or she was treated in the hospital; and 5) A medical professional certifies that the Resident requires skilled nursing care on a “daily basis.” A Resident requires skilled nursing or skilled rehabilitation services on a daily basis when services are medically necessary and provided seven (7) days a week. There is an exception if they are only provided by the facility for five (5) days per week, due to staffing levels at the facility. Additionally, there may be a one to two day break if the Residents needs require suspension of the services. Where these five criteria are met, Medicare may provide coverage of up to 100 days of care in a skilled nursing facility (SNF): the first 20 days of covered services are fully paid for; and the next 80 days (days 21 through 100), of the covered services are paid for by Medicare subject to a daily coinsurance amount for which the Resident is responsible. For 2020, the Medicare Part A co-insurance amount is $176.00 per day. Additionally, Medicare Residents requesting a leave of absence from the facility should be aware of the Medicare rules regarding leave of absence and transfer within thirty (30) days. Medicare treats a leave of absence, where a Resident leaves the facility on a particular day and does not return by twelve (12) midnight that day, as an uncovered day. Additionally, the day in which a Resident begins a leave of absence (i.e., hospitalization), where the resident is absent for more than 24 hours, is treated as a day of discharge. Except for specifically excluded services, nursing home services provided to Medicare Part A beneficiaries are covered under the consolidated billing requirements. Residents must consult with the Facility before obtaining any services outside of the Facility. Medicare also has a thirty (30) day transfer requirement. A Resident must be transferred from a hospital or other SNF within thirty (30) days of discharge and meet the skilled care requirements in order to be eligible for SNF coverage. If a Resident meets the eligibility requirements for Skilled Nursing Facility benefits under the Medicare Part A Hospital Insurance Program, Facility will xxxx Medicare directly for all Part A services provided to the Resident. Medicare will reimburse Facility a fixed per diem or daily fee based on the Resident’s classification within the Medicare RUG III guidelines. RUG is an acronym for Resource-based Utilization Groups. These guidelines are a measure of what type of care the Resident requires and what it costs health care providers to provide that care to a Resident. Members of our professional staff will evaluate the Resident’s health condition based on a standardized assessment form (called the MDS 2.0) provided by the Centers for Medicare and Medicaid Services (CMS). Information from the MDS 2.0 form will be used by Medicare to assign the Resident a RUG III category. The Resident will be responsible for the daily co-insurance amount determined by Medicare. This amount is subject to increase each calendar year. With limited exceptions, a Resident who requires more than 100 days of SNF care in a benefit period will be responsible for private payment of all charges beginning with the 101st day. A new benefit period may begin when the Resident has either not been in a facility or has not been receiving a covered level of care in a skilled nursing facility for at least 60 days, returns to the hospital for another three-day stay, and then re-enters the SNF. A SNF may not request private payment until the Resident has received an official initial determination from Medicare that “skilled nursing” benefits are no longer available. While a SNF may make a determination of non-coverage, beneficiaries have a right to request an official Medicare determination of coverage (called a “Demand Xxxx”), which can be appealed. Attachment B (12/13) i MEDICARE PART B PAYMENT Individuals who pay monthly premiums to enroll in Medicare Part B will be charged according to Facility’s or the service providers’ stated charge schedule for services they receive at Facility. Medicare Part B pays for a wide range of additional services beyond Part A coverage. Part B may cover some of a Residents care regardless of whether they are eligible for Part A benefits. Part B covers eighty (80%) percent of the Medicare approved charge for a specific service and the individual is responsible for the additional twenty (20%) percent. In general, Part B covers medical services and supplies. Part B covers such services as: physical, occupational and speech therapy, physician services, durable medical equipment, ambulance services and certain out-patient and clinical laboratory services. However, Part B benefits have limitations. For example, for 2020, there is a $198.00 deductible applicable to Medicare Part B benefits. Additionally, physical therapy (including speech- language pathology services) and occupational therapy are each subject to an annual limitation. The therapy financial limitations or “caps” are indexed by the Medicare Economic Index (MEI) each year. For 2020, the indexed amounts for physical therapy (including speech-language pathology services) and occupational therapy are $2,080.00 each, including co- insurance. Beneficiaries may be eligible for the Therapy Cap Exception Process. Both therapy limitations are still subject to the 80% - 20% coverage limitation in that the individual will be responsible for the 20 % co-insurance payments. The Resident is responsible for private payment of all therapy charges and any other ancillary charges above the Medicare Part B coverage limitations. The Facility can xxxx and receive payment if the Resident fills out a Medicare assignment of benefits form. If the Resident completes an assignment of benefits form, a health care provider cannot charge the Resident above the Medicare approved charge. In order to determine the Resident’s Part B coverage you should contact the Social Security Administration. In addition, Medicare Advantage programs and other alternatives may increase available Medicare benefits. To receive additional information about Medicare and Medicare Advantage programs, call the Social Security Administration at 800-772- 1213 or the Centers for Medicare and Medicaid Services at 1-800-MEDICARE. MEDICARE PART D - PRESCRIPTION DRUG COVERAGE Individuals eligible for Medicare Part A or enrolled in Medicare Part B and who do not have prescription drug coverage from a privately operated health plan or a Medicare Advantage-PD plan are eligible to enroll in Medicare Part D for prescription drug coverage. Medicare Part D through the selected PDP will provide reimbursement for prescription drugs listed in the PDP’s formulary subject to applicable premiums, deductibles and co-payments. Eligible individuals interested in obtaining prescription drug coverage through Medicare Part D must enroll in a PDP approved in the region. Upon admission to a skilled nursing home, individuals enrolled in a PDP in the community are permitted to continue with, or switch to a different PDP in the region. Dual eligible Medicare/Medicaid beneficiaries are automatically enrolled in, and assigned to an approved benchmark prescription drug plan (“PDP”) in the region. As of January 1, 2006, Medicaid no longer pays for prescription drug cost for dual eligibles. Dual eligibles in nursing homes will receive prescription drug coverage through Medicare Part D for the drugs listed on the selected PDP’s formulary. As long as dual eligibles are enrolled in benchmark plans in their region, they will not be responsible for premiums, deductibles and cost sharing obligations. Please call 000-000-0000 or contact xxx.xxxxxxxx.xxx/xxxxxxx.xxx to obtain enrollment information. MANAGED CARE Residents who are members of a managed care benefit plan that is under a contract with the Facility to provide specified services to plan members will receive those services with full coverage so long as the Resident meets the eligibility requirements of the managed care benefit plan. To the extent the Resident meets the eligibility requirements of the managed care benefit plan, he or she will be financially responsible only for the required deductibles and co-insurance and for those services that are not included in the list of covered services. Residents who have not received a list of covered services and eligibility requirements from their managed care benefit plan are advised to contact their social worker and/or managed care benefit plan. PRIVATE INSURANCE Residents who are covered by a private insurance plan that does not have a contract with the Facility must exhaust all available insurance coverage before seeking Medicare or Medicaid coverage. Where the insurance proceeds under the private plan are insufficient to cover the cost of care, the Resident will be responsible for any difference. The coverage requirements for nursing home care vary depending on the terms of the insurance policy. Questions regarding private insurance coverage should be directed to the social work staff and/or the Resident’s insurance carrier or agent. Attachment B (12/13) ii MEDICAID Medicaid is a publicly-funded program of assistance that covers nursing home Residents who can demonstrate financial need. To qualify for Medicaid, an individual may have only limited assets. For example, in 2020, the individual resource limit is $15,750 (subject to annual increases); plus any funds held in an “irrevocable burial trust” arrangement or up to $1,500 under a revocable burial account. Generally, most of the Resident’s monthly income must be paid to the Facility, except for a $50 monthly “personal needs allowance” and the monthly cost of retaining a private health insurance policy. This monthly income obligation, called the NAMI (Net Available Monthly Income), is determined by the Medicaid agency. If the Resident has a spouse in the community, the spouse might be entitled to a contribution from the Resident’s monthly income. During 2020, the “community spouse” is entitled to a minimum monthly income of $3,216 and resources up to a maximum of $128,640 (these figures are subject to increase each calendar year); increases beyond these amounts are possible, but a Department of Social Services Fair Hearing or Family Court support proceeding may be required. The Resident’s home may be exempt for Medicaid eligibility purposes if the equity value is less than $878,000.00 or if the spouse or disabled or minor child resides there. Upon application, Medicaid looks back at financial transactions or transfers of assets made within a sixty (60) month period of time from the date on which the person was institutionalized and applied for Medicaid coverage. A Resident or spouse who makes a transfer within those periods may create a period of Medicaid ineligibility. Private-pay Residents should apply for Medicaid about three months before their funds are depleted. A Medicaid application must include proof of the Resident’s identity, U.S. citizenship or legal alien status, and past and present financial status. Medicaid recipients are required to recertify eligibility each year in order to retain benefits. Medicaid is a complex program and a knowledgeable professional can advise Residents and their families as to their rights under the Medicaid program. To receive information about Medicaid, individuals can call their local Department of Social Services in the county in which the Resident resides. WORKERS’ COMPENSATION Workers’ Compensation benefits are available for an employee’s work-related injuries. Benefits, including direct payments to a health care provider, are paid by the employer’s insurance carrier. Workers’ Compensation will provide primary coverage of nursing home care, as long as it is established that the nursing home care is necessitated solely by the Workers’ Compensation injury. Claim forms must be submitted to the local Workers’ Compensation Board Office within two years of the date of injury. It is advisable to consult with an attorney practicing in the Workers’ Compensation area when pursuing a claim. For further information, you can contact your local Workers’ Compensation Board office.

Billed by Facility. (3) Billed direct by Provider or Vendor. (4) Patient/Resident responsible for co-insurance and deductible. (5) Coverage depends on services provided. ADDITIONAL NON-CLINICAL SERVICES THE FOLLOWING ADDITIONAL NON- CLINICAL SERVICES ARE AVAILABLE TO ALL RESIDENTS AND IF REQUESTED BY THE RESIDENT, SPONSOR AND/OR DESIGNATED REPRESENTATIVE, WILL BE CHARGED TO THE RESIDENT: • Telephone • Television/radio for Resident’s personal use • Personal comfort items, notions and novelties, and confections • Cosmetic and grooming items and services, in excess of those for which payment is made under Medicaid, Medicare, or other insurance programs • Personal clothing • Personal reading matter • Gifts purchased on behalf of a Resident • Flowers and plants • Social events, special meals, and entertainment offered off the premises and outside the scope of the Activities program provided by the Facility • Non-covered special care services, such as private duty nurses • Specially prepared or alternative food (other than Kosher food or food required by a therapeutic or modified diet prescribed by a physician) • Private room (except when therapeutically required, such as for isolation for infection control) IF YOU HAVE ANY QUESTIONS REGARDING CHARGES AND BILLING, PLEASE FEEL FREE TO CONTACT THE BUSINESS OFFICE AT (718631) 298- 7800422- 4800. ATTACHMENT “B” SPECIAL RULES REGARDING SELECTED PAYORS PAYMENT FOR IN-PATIENT LONG TERM CARE SERVICES IS AN EXPENSIVE AND COMPLICATED PROCESS. THIS SUMMARY PROVIDES OUR RESIDENTS AND THEIR FAMILIES WITH BASIC INFORMATION WHICH SHOULD SIMPLIFY THE PROCESS. NOTHING HEREIN SHOULD BE CONSIDERED TO BE LEGAL ADVICE. WE URGE YOU TO CONSULT WITH AN INSURANCE AGENT, ATTORNEY AND/OR OTHER KNOWLEDGEABLE PROFESSIONAL(S) IN ORDER TO HELP MAXIMIZE AVAILABLE COVERAGE. FURTHER, AS THE INFORMATION PROVIDED BELOW IS BASED UPON STATUTE AND REGULATIONS, IT IS SUBJECT TO CHANGE WITHOUT NOTICE. MEDICARE PART A PAYMENT Medicare Part A Hospital Insurance Skilled Nursing Facility coverage is generally available to qualified individuals 65 years of age or older, and individuals under age 65 who have been disabled for at least twenty-four months, who meet the following five requirements: 1) The Resident requires daily skilled nursing or rehabilitation services that can be provided only in a skilled nursing facility; 2) The Resident was hospitalized for at least three consecutive days, not counting the day of discharge, before entering the skilled nursing facility; 3) The Resident was admitted to the facility within 30 days after leaving the hospital; 4) The Resident is admitted to the facility to receive treatment for the same condition(s) for which he or she was treated in the hospital; and 5) A medical professional certifies that the Resident requires skilled nursing care on a “daily basis.” A Resident requires skilled nursing or skilled rehabilitation services on a daily basis when services are medically necessary and provided seven (7) days a week. There is an exception if they are only provided by the facility for five (5) days per week, due to staffing levels at the facility. Additionally, there may be a one to two day break if the Residents needs require suspension of the services. Where these five criteria are met, Medicare may provide coverage of up to 100 days of care in a skilled nursing facility (SNF): the first 20 days of covered services are fully paid for; and the next 80 days (days 21 through 100), of the covered services are paid for by Medicare subject to a daily coinsurance amount for which the Resident is responsible. For 2020, the Medicare Part A co-insurance amount is $176.00 per day. Additionally, Medicare Residents requesting a leave of absence from the facility should be aware of the Medicare rules regarding leave of absence and transfer within thirty (30) days. Medicare treats a leave of absence, where a Resident leaves the facility on a particular day and does not return by twelve (12) midnight that day, as an uncovered day. Additionally, the day in which a Resident begins a leave of absence (i.e., hospitalization), where the resident is absent for more than 24 hours, is treated as a day of discharge. Except for specifically excluded services, nursing home services provided to Medicare Part A beneficiaries are covered under the consolidated billing requirements. Residents must consult with the Facility before obtaining any services outside of the Facility. Medicare also has a thirty (30) day transfer requirement. A Resident must be transferred from a hospital or other SNF within thirty (30) days of discharge and meet the skilled care requirements in order to be eligible for SNF coverage. If a Resident meets the eligibility requirements for Skilled Nursing Facility benefits under the Medicare Part A Hospital Insurance Program, Facility will xxxx Medicare directly for all Part A services provided to the Resident. Medicare will reimburse Facility a fixed per diem or daily fee based on the Resident’s classification within the Medicare RUG III guidelines. RUG is an acronym for Resource-based Utilization Groups. These guidelines are a measure of what type of care the Resident requires and what it costs health care providers to provide that care to a Resident. Members of our professional staff will evaluate the Resident’s health condition based on a standardized assessment form (called the MDS 2.0) provided by the Centers for Medicare and Medicaid Services (CMS). Information from the MDS 2.0 form will be used by Medicare to assign the Resident a RUG III category. The Resident will be responsible for the daily co-insurance amount determined by Medicare. This amount is subject to increase each calendar year. With limited exceptions, a Resident who requires more than 100 days of SNF care in a benefit period will be responsible for private payment of all charges beginning with the 101st day. A new benefit period may begin when the Resident has either not been in a facility or has not been receiving a covered level of care in a skilled nursing facility for at least 60 days, returns to the hospital for another three-day stay, and then re-enters the SNF. A SNF may not request private payment until the Resident has received an official initial determination from Medicare that “skilled nursing” benefits are no longer available. While a SNF may make a determination of non-coverage, beneficiaries have a right to request an official Medicare determination of coverage (called a “Demand Xxxx”), which can be appealed. MEDICARE PART B PAYMENT Individuals who pay monthly premiums to enroll in Medicare Part B will be charged according to Facility’s or the service providers’ stated charge schedule for services they receive at Facility. Medicare Part B pays for a wide range of additional services beyond Part A coverage. Part B may cover some of a Residents care regardless of whether they are eligible for Part A benefits. Part B covers eighty (80%) percent of the Medicare approved charge for a specific service and the individual is responsible for the additional twenty (20%) percent. In general, Part B covers medical services and supplies. Part B covers such services as: physical, occupational and speech therapy, physician services, durable medical equipment, ambulance services and certain out-patient and clinical laboratory services. However, Part B benefits have limitations. For example, for 2020, there is a $198.00 deductible applicable to Medicare Part B benefits. Additionally, physical therapy (including speech- language pathology services) and occupational therapy are each subject to an annual limitation. The therapy financial limitations or “caps” are indexed by the Medicare Economic Index (MEI) each year. For 2020, the indexed amounts for physical therapy (including speech-language pathology services) and occupational therapy are $2,080.00 each, including co- insurance. Beneficiaries may be eligible for the Therapy Cap Exception Process. Both therapy limitations are still subject to the 80% - 20% coverage limitation in that the individual will be responsible for the 20 % co-insurance payments. The Resident is responsible for private payment of all therapy charges and any other ancillary charges above the Medicare Part B coverage limitations. The Facility can xxxx and receive payment if the Resident fills out a Medicare assignment of benefits form. If the Resident completes an assignment of benefits form, a health care provider cannot charge the Resident above the Medicare approved charge. In order to determine the Resident’s Part B coverage you should contact the Social Security Administration. In addition, Medicare Advantage programs and other alternatives may increase available Medicare benefits. To receive additional information about Medicare and Medicare Advantage programs, call the Social Security Administration at 800-772- 1213 or the Centers for Medicare and Medicaid Services at 1-800-MEDICARE. MEDICARE PART D - PRESCRIPTION DRUG COVERAGE Individuals eligible for Medicare Part A or enrolled in Medicare Part B and who do not have prescription drug coverage from a privately operated health plan or a Medicare Advantage-PD plan are eligible to enroll in Medicare Part D for prescription drug coverage. Medicare Part D through the selected PDP will provide reimbursement for prescription drugs listed in the PDP’s formulary subject to applicable premiums, deductibles and co-payments. Eligible individuals interested in obtaining prescription drug coverage through Medicare Part D must enroll in a PDP approved in the region. Upon admission to a skilled nursing home, individuals enrolled in a PDP in the community are permitted to continue with, or switch to a different PDP in the region. Dual eligible Medicare/Medicaid beneficiaries are automatically enrolled in, and assigned to an approved benchmark prescription drug plan (“PDP”) in the region. As of January 1, 2006, Medicaid no longer pays for prescription drug cost for dual eligibles. Dual eligibles in nursing homes will receive prescription drug coverage through Medicare Part D for the drugs listed on the selected PDP’s formulary. As long as dual eligibles are enrolled in benchmark plans in their region, they will not be responsible for premiums, deductibles and cost sharing obligations. Please call 000-000-0000 or contact xxx.xxxxxxxx.xxx/xxxxxxx.xxx to obtain enrollment information. MANAGED CARE Residents who are members of a managed care benefit plan that is under a contract with the Facility to provide specified services to plan members will receive those services with full coverage so long as the Resident meets the eligibility requirements of the managed care benefit plan. To the extent the Resident meets the eligibility requirements of the managed care benefit plan, he or she will be financially responsible only for the required deductibles and co-insurance and for those services that are not included in the list of covered services. Residents who have not received a list of covered services and eligibility requirements from their managed care benefit plan are advised to contact their social worker and/or managed care benefit plan. PRIVATE INSURANCE Residents who are covered by a private insurance plan that does not have a contract with the Facility must exhaust all available insurance coverage before seeking Medicare or Medicaid coverage. Where the insurance proceeds under the private plan are insufficient to cover the cost of care, the Resident will be responsible for any difference. The coverage requirements for nursing home care vary depending on the terms of the insurance policy. Questions regarding private insurance coverage should be directed to the social work staff and/or the Resident’s insurance carrier or agent. MEDICAID Medicaid is a publicly-funded program of assistance that covers nursing home Residents who can demonstrate financial need. To qualify for Medicaid, an individual may have only limited assets. For example, in 2020, the individual resource limit is $15,750 (subject to annual increases); plus any funds held in an “irrevocable burial trust” arrangement or up to $1,500 under a revocable burial account. Generally, most of the Resident’s monthly income must be paid to the Facility, except for a $50 monthly “personal needs allowance” and the monthly cost of retaining a private health insurance policy. This monthly income obligation, called the NAMI (Net Available Monthly Income), is determined by the Medicaid agency. If the Resident has a spouse in the community, the spouse might be entitled to a contribution from the Resident’s monthly income. During 2020, the “community spouse” is entitled to a minimum monthly income of $3,216 and resources up to a maximum of $128,640 (these figures are subject to increase each calendar year); increases beyond these amounts are possible, but a Department of Social Services Fair Hearing or Family Court support proceeding may be required. The Resident’s home may be exempt for Medicaid eligibility purposes if the equity value is less than $878,000.00 or if the spouse or disabled or minor child resides there. Upon application, Medicaid looks back at financial transactions or transfers of assets made within a sixty (60) month period of time from the date on which the person was institutionalized and applied for Medicaid coverage. A Resident or spouse who makes a transfer within those periods may create a period of Medicaid ineligibility. Private-pay Residents should apply for Medicaid about three months before their funds are depleted. A Medicaid application must include proof of the Resident’s identity, U.S. citizenship or legal alien status, and past and present financial status. Medicaid recipients are required to recertify eligibility each year in order to retain benefits. Medicaid is a complex program and a knowledgeable professional can advise Residents and their families as to their rights under the Medicaid program. To receive information about Medicaid, individuals can call their local Department of Social Services in the county in which the Resident resides. WORKERS’ COMPENSATION Workers’ Compensation benefits are available for an employee’s work-related injuries. Benefits, including direct payments to a health care provider, are paid by the employer’s insurance carrier. Workers’ Compensation will provide primary coverage of nursing home care, as long as it is established that the nursing home care is necessitated solely by the Workers’ Compensation injury. Claim forms must be submitted to the local Workers’ Compensation Board Office within two years of the date of injury. It is advisable to consult with an attorney practicing in the Workers’ Compensation area when pursuing a claim. For further information, you can contact your local Workers’ Compensation Board office.