Schedule A       Calculation of Low-Income Portion of          
            Unreimbursed Costs   
Attach to Form PTAX-300-H
Step 1:  Write the total of unreimbursed costs
   1     Emergency     $_____________________
   2     Trauma     $_____________________
   3     Burn     $_____________________
   4     Neonatal     $_____________________
   5     Psychiatric     $_____________________
   6     Rehabilitation     $_____________________
   7     Medical education     $_____________________
   8     Research     $_____________________
   9     Other (describe)     $_____________________
   10     Other (describe)     $_____________________
   11     Total.  Add Lines 1 through 10.        $_____________________
Step 2:  Calculate the low-income ratio
   12     Charity     $_____________________
   13     Medicaid     $_____________________
   14     Other means-tested programs     $_____________________
   15     Disabled Medicare for people less than 65 years of age     $_____________________
   16     Dual-eligible     $_____________________
   17     Add gross charges for Lines 12 through 16.  This is your numerator.     $_____________________
   18     Total gross charges.  This is your denominator.          $_____________________
   19     Multiply Line 17 by cost to charge ratio     ___________  =    $_____________________
   20     Multiply Line 18 by cost to charge ratio     ___________  =    $_____________________
   21     Divide Line 19 by Line 20.  This is the low-income ratio.        _____________________
Step 3:  Determine the low-income portion of unreimbursed costs
   22     Multiply Line 11 by Line 21.  Write this amount on Form PTAX- 300-H, Line 16.     $_____________________
General Instructions
The portion of unreimbursed costs of the Relevant Hospital Entity   by adding the Relevant Hospital Entity’s costs attributable to charity 
attributable to providing, paying for, or subsidizing goods, activities, or   care, Medicaid, other means-tested government programs, disabled 
services that relieve the burden of government related to health care   Medicare patients under age 65, and dual-eligible Medicare/Medicaid 
for low-income individuals.  Examples of these activities or services   patients and dividing that total by the Relevant Hospital Entity’s total 
are  costs.  Costs for the numerator and denominator shall be determined 
by multiplying gross charges by the cost to charge ratio taken from 
•    providing emergency, trauma, burn, neonatal, psychiatric, reha-
the most recently iled Medicare cost report (CMS 2552-10 Work-
bilitation, or other special services;
sheet C, Part 1).  In the case of emergency services, the ratio shall 
•    providing medical education; and 
be calculated using costs (gross charges by the cost to charge ratio 
•    conducting medical research or training of health care profes-  taken from the most recently iled Medicare cost report (CMS 2552-
sionals.  10 Worksheet C, Part 1)) of patients treated in the Relevant Hospital 
Entity’s emergency department.  
The portion of those unreimbursed costs attributable to beneiting 
low-income individuals shall be determined using the ratio calculated 

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