2023-05-12T13:06:35-05:00 2022-06-30 390758449 WIPFLI LLP 1502 LONDON ROAD SUITE 200 DULUTH MN 55812 990 2021-07-01 390806250 DIVINE SAVIOR HEALTHCARE INC DIVI 6087424131 PO BOX 387 2817 NEW PINERY ROAD PORTAGE WI 53901 SIDNEY C SCZYGELSKI SENIOR VP OF FINANCE & CFO 7158472250 2023-05-12 1 SIDNEY SCZYGELSKI 999009999 MICHAEL J PETERSON CPA P01833529 2187224705 2023-05-12 3 AAL1 IAL1 2021 2023-04-26 12:10:37Z ASPIRUS DIVINE SAVIOR HOSPITAL & CLINICS INC MATTHEW HEYWOOD 2200 WESTWOOD DRIVE WAUSAU WI 54401 97565302 0 X WWW.ASPIRUS.ORG X 1917 WI WE HEAL PEOPLE, PROMOTE HEALTH, AND STRENGTHEN COMMUNITIES. 11 7 774 10 0 0 532314 2483258 93624074 89909017 5247216 1615992 144559 132482 99548163 94140749 0 10000 0 0 56203421 46948082 0 0 0 43709075 51821633 99912496 98779715 -364333 -4638966 146404206 138487582 60304271 48226517 86099935 90261065 X WE HEAL PEOPLE, PROMOTE HEALTH, AND STRENGTHEN COMMUNITIES. 0 0 61999659 10000 67797877 ADS IS AN ACUTE CARE 73-BED HOSPITAL LOCATED IN PORTAGE, WI. INPATIENT SERVICES INCLUDED ADMISSIONS OF ADULTS AND PEDIATRIC PATIENTS WHICH TOTALED 5,146 PATIENT DAYS IN FISCAL YEAR 2022. ADS ALSO OFFERS A WIDE ARRAY OF OUTPATIENT SERVICES TO MEET THE HEALTHCARE NEEDS OF THE COMMUNITY. EMERGENCY ROOM, URGENT CARE, SURGERY, AMBULANCE, RENAL DIALYSIS, AND REHABILITATION SERVICES ARE AMONG MANY OF THE OUTPATIENT SERVICES PROVIDED. KEY OUTPATIENT SERVICE STATISTICS IN FISCAL YEAR 2022 INCLUDED 15,038 EMERGENCY ROOM VISITS, 15,610 X-RAYS AND 4,058 INFUSION THERAPY VISITS WERE AMONG MANY OF THE PATIENT SERVICES AS NOTED. ADS ALSO PROVIDES SPECIALIZED HOME CARE SERVICES TO INDIVIDUALS WHO NEED CARE WITHIN THEIR OWN HOME. THESE PERSONALIZED SERVICES INCLUDE SKILLED NURSING SERVICES, HOME HEALTH AIDES, PHYSICAL THERAPY, OCCUPATIONAL THERAPY, SPEECH THERAPY, IV THERAPY, AND PALLIATIVE CARE FOR TERMINAL ILLNESS.ADS PROMISES TO THE COMMUNITY TO PROVIDE HEALTHCARE SERVICES TO THOSE IN NEED REGARDLESS OF THEIR ABILITY TO PAY AS DEFINED IN THE HOSPITAL'S CHARITY AND COMMUNITY CARE POLICIES AND PROGRAMS. DURING FISCAL YEAR 2022, ADS'S CHARITY CARE PROGRAM AWARDED APPROXIMATELY $1,705,798 IN GROSS CHARGES FOR FINANCIAL ASSISTANCE TO PATIENTS WHO COULD NOT OTHERWISE AFFORD CARE.IN ADDITION TO INPATIENT AND OUTPATIENT HOSPITAL SERVICES, ADS ALSO PROVIDES EDUCATIONAL AND PREVENTATIVE SERVICES AT FREE OR REDUCED COSTS TO COMMUNITY MEMBERS. SOME OF THESE EVENTS OFFERED TO THE PUBLIC INCLUDE:LOW COST EXERCISE CLASSES, FREE BLOOD PRESSURE SCREENINGS, LOW COST CHOLESTEROL SCREENINGS, LOW COST CHILDBIRTH EDUCATION CLASSES, BLOOD DRIVES, FREE BREASTFEEDING WORKSHOPS, SUPPORT GROUPS, AND LOW-COST CPR AND FIRST AID CLASSES.IN FISCAL YEAR 2016, ADS OPENED A MEDICALLY INTEGRATED FITNESS CENTER IN RESPONSE TO THE COMMUNITY NEEDS ASSESSMENT PERFORMED. 18735280 0 15742839 TOTAL CLINIC VISITS FOR FISCAL YEAR 2022 WERE 63,070. THESE CLINICS PROVIDE FAMILY PRACTICE, INTERNAL MEDICINE, PHYSIATRY, OB, ORTHOPEDICS, AND SURGICAL SERVICES, AMONG MANY OTHER CLINICAL SERVICES OFFERED TO PATIENTS IN THE COMMUNITY, AND WORK TOGETHER WITH THE HOSPITAL SERVICES OF ADS IN AN EFFORT TO COORDINATE HOSPITAL AND CLINICAL CARE TO PROVIDE CONVENIENT, COST-EFFECTIVE CARE TO MEMBERS OF THE COMMUNITY. THE RURAL OXFORD CLINIC IS IN A HEALTH SHORTAGE AREA TO BETTER MEET THE RESIDENTS OF THIS COMMUNITY CLOSER TO THEIR HOMES.THE CLINICS SERVICE A LARGE PORTION OF ELDERLY, DISABLED, AND LOW-INCOME PATIENTS WHO ARE COVERED UNDER THE MEDICARE AND WISCONSIN MEDICAL ASSISTANCE PROGRAMS. THE CLINICS ARE OFTEN REIMBURSED FROM THESE PROGRAMS AT RATES WELL BELOW THE COST OF CARING FOR THESE PATIENTS, HOWEVER, IT IS ADS'S MISSION IN THE COMMUNITY TO PROVIDE CARE TO THESE PATIENTS.PATIENTS OF THE ADS CLINICS ARE ALSO ELIGIBLE FOR THE ORGANIZATION'S CHARITY AND COMMUNITY CARE PROGRAMS WHICH PROVIDE FREE OR REDUCED CARE TO INDIVIDUALS AND FAMILIES BASED ON INCOME AND ASSET GUIDELINES. THE FIGURES PRESENTED IN STATEMENT 4A OF THE HOSPITAL PROGRAM SERVICE ACCOMPLISHMENTS INCLUDE CHARITY CARE AMOUNTS PROVIDED TO CLINIC PATIENTS AS WELL. ADDITIONAL INFORMATION ON THE CHARITY CARE POLICIES CAN ALSO BE FOUND IN SCHEDULE H (HOSPITALS) OF THE FORM 990. 9870026 0 6368301 ADS OWNS AND OPERATES AN 83-BED EXTENDED CARE FACILITY AND 40-BED ASSISTED LIVING FACILITY. THE EXTENDED CARE FACILITY OFFERS SKILLED AND INTERMEDIATE CARE NURSING FOR RESIDENTS WHO REQUIRE SHORT-TERM REHABILITATION PROGRAMS OR LONG-TERM CARE. THE FACILITY ALSO OFFERS MEDICATION MANAGEMENT, PHYSICAL THERAPY, OCCUPATIONAL THERAPY, SPEECH THERAPY, IV THERAPY, AND NUTRITION SERVICES, AS WELL AS ACCESS TO OTHER HEALTHCARE AND HOSPITAL SERVICES OFFERED BY ADS'S HOSPITAL PROGRAMS. IN 2022, 16,679 RESIDENT DAYS OF CARE AND 9,791 ASSISTED LIVING DAYS WERE PROVIDED BY THE EXTENDED CARE FACILITY. A MAJORITY OF THE RESIDENTS RECEIVE CARE UNDER THE WISCONSIN MEDICAL ASSISTANCE OR FAMILY CARE PROGRAMS. ADS RECOGNIZES THAT THE COST OF CARING FOR THESE INDIVIDUALS OFTEN EXTENDS BEYOND THE AMOUNT THAT IS PAID TO THE FACILITY BY THE MEDICAL ASSISTANCE PROGRAM. RESIDENTS OF THE EXTENDED CARE FACILITY AT ADS WHO HAVE EXHAUSTED ALL OTHER PROGRAMS SUCH AS MEDICAL ASSISTANCE OR THE WISCONSIN FAMILY CARE PROGRAM ARE ALSO ABLE TO APPLY FOR DISCOUNTED OR FREE CARE FOR HOSPITAL OR CLINICAL SERVICES UNDER THE ORGANIZATION'S CHARITY AND COMMUNITY CARE PROGRAMS AS DESCRIBED EARLIER NOTING THE HOSPITAL AND CLINIC PROGRAM SERVICE ACCOMPLISHMENTS. SINCE MOST EXTENDED CARE CHARGES ARE COVERED UNDER WISCONSIN MEDICAL ASSISTANCE PROGRAMS WHEN INCOME LEVELS ARE BELOW ESTABLISHED GOVERNMENT STANDARDS, THESE PROGRAMS ARE MOST OFTEN UTILIZED AS A SOURCE OF PAYMENTS FOR MANY RESIDENTS. IF THESE MEDICAL ASSISTANCE PROGRAMS ARE NOT AVAILABLE DUE TO A UNIQUE CIRCUMSTANCE, THE RESIDENT'S STAY MAY BE EVALUATED FOR CHARITY OR COMMUNITY CARE ON A CASE BY CASE BASIS BY ADMINISTRATION OF THE ORGANIZATION. 90604965 1 1 0 1 0 0 0 0 0 0 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 40 0 774 1 0 0 0 0 0 0 0 0 0 0 0 0 X 11 7 1 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 WI X SIDNEY C SCZYGELSKI 7158472250 2200 WESTWOOD DRIVE WAUSAU WI 54401 TRAVIS HAMELE CHAIRPERSON 3.00 X X 0 0 0 JUDY WARMUTH PHD VICE CHAIRPERSON (THRU 09/21) 2.50 X X 0 0 0 PETE WELSH TREASURER (THRU 09/21) 2.50 X X 0 0 0 LYNN VOGT SECRETARY 1.00 1.00 X 0 0 0 ROBERT CRAWFORD BOARD MEMBER 1.00 X 0 0 0 LOUIS HEITKE BOARD MEMBER 2.50 X X 0 0 0 ROBIN KVALO BOARD MEMBER 1.00 X 0 0 0 KRISTEN SKOLARZ BOARD MEMBER (THRU 12/21) 1.00 X 0 0 0 CHAD STEVENSON BOARD MEMBER 1.00 X 0 0 0 ROB WALZ BOARD MEMBER 1.00 X 0 0 0 ERIC ANDERSON BOARD MEMBER/SVP-SERV. & PATIENT EXP. 2.00 50.00 X 0 495034 104300 JESSE TISCHER BOARD MEMBER/SVP & PRES. REG. MKTS. 2.00 50.00 X X 0 644385 101649 SUSAN KRECKMAN BOARD MEMBER/PHYSICIAN 40.00 X 332022 0 40626 JOSHUA POGORELEC BOARD MEMBER/PHYSICIAN 40.00 X 694305 0 42225 CRYSTAL KIRSCHLING INTERIM PRESIDENT 1.00 40.00 X 0 0 0 NANCY ROTH-MALLEK VICE CHAIR/VP-FINANCE SOUTH REGION 2.00 50.00 X 0 263519 46838 MICHAEL HOLZHUETER ASSIST. SEC./SVP-GENERAL COUNSEL 2.00 50.00 X 0 449756 89333 SIDNEY SCZYGELSKI ASSIST. TREASURER/SR. VP OF FIN./CFO 2.00 50.00 X 0 915379 141626 MATTHEW HEYWOOD PRESIDENT & CEO ASPIRUS 2.00 50.00 X 0 2684221 266094 MICHAEL DECKER PRESIDENT & CEO ADS (THRU 05/22) 40.00 X 667269 0 103194 BENJAMIN BARSOTTI VP-CHIEF MEDICAL INFORMATION OFFICER 2.00 50.00 X 0 462446 50766 BRETT DAVIS PRESIDENT-ASPIRUS HEALTH PLAN 2.00 50.00 X 0 394127 62857 JAMES MATHESON SVP-CHIEF STRATEGY OFFICER 2.00 50.00 X 0 452729 89948 JOHN HEISLER BOARD MEM.(THRU 03/21)/CHIEF HR OFF. 2.00 50.00 X 0 751984 56650 RENEE SMITH EXECUTIVE DIRECTOR-ANI 2.00 50.00 X 0 460002 93775 TODD RICHARDSON SVP & CHIEF INFORMATION OFFICER 2.00 50.00 X 0 516494 97286 JENNIFER REDMAN-SCHELL SVP & PRESIDENT-AMG 2.00 50.00 X 0 572454 92664 DOUGLAS ARNOLD PHYSICIAN 40.00 X 635884 0 48825 BRAD ROGOWSKI PHYSICIAN 40.00 X 590973 0 44477 JOSEPH MUELLER PHYSICIAN 40.00 X 602628 0 41971 KATHERINE MURPHY PHYSICIAN 40.00 X 422555 0 10903 JAMES SELF PHYSICIAN 40.00 X 494105 0 43518 MICHAEL MCGRAIL MD FORMER SVP & SYSTEM CMO 0.00 0.00 X 0 449085 0 MICHAEL WALTERS FORMER KE/VP-SEN. SYS. PHYS. EXEC. 2.00 50.00 X 0 604827 43884 4439741 10116442 1713409 46 1 1 0 TOTAL MSP LLC 221 WEST COLLEGE AVE APPLETON WI 54944 STAFFING SERVICE 1545026 FOCUSONE SOLUTIONS LLC PO BOX 3037 OMAHA NE 68103 STAFFING SERVICE 873237 ARCH ELECTRIC INC 1237 PILGRIM RD PLYMOUTH WI 53073 ELECTRIC SERVICES-SOLAR PANELS 656322 CHG COMPANIES PO BOX 972651 DALLAS TX 75397 STAFFING SERVICE 650986 NOVUS WISCONSIN SERVICE CORP PO BOX 12766 PENSACOLA FL 32591 ANESTHESIOLOGY SERVICES 479770 9 2476755 6503 2483258 PATIENT SERVICE REVENUE 621990 66505669 66505669 CLINIC REVENUE 623000 15742839 15742839 EXTENDED CARE FACILITY REVENUE 621110 6368301 6368301 1292208 1292208 89909017 1701964 1701964 47835 0 47835 47835 47835 3334301 4280 3396512 28041 -62211 -23761 -85972 -85972 CAFETERIA REVENUE 722514 84647 84647 84647 94140749 89909017 0 1748474 X 10000 10000 1222300 1222300 36993664 31832462 5161202 1297383 940452 356931 5762173 5015423 746750 1672562 1188037 484525 174241 174241 25819 -178 25997 13822 13822 5971 5971 12157797 11279955 877842 12157 12157 130785 53876 76909 41400 20475 20925 1634078 943 1633135 260318 227837 32481 45679 45532 147 669979 669979 5787953 1944266 3843687 133854 22328 111526 CORPORATE ALLOCATIONS 13338396 25085365 -11746969 MEDICAL SUPPLIES 11757673 11471492 286181 REPAIRS AND MAINTENANCE 2337271 1210624 1126647 BAD DEBT EXPENSE 1274021 1274021 2020419 256076 1764343 98779715 90604965 8174750 0 2645741 961292 9225742 5435352 12178537 13605299 1727368 1398492 530955 614181 143133861 73902681 71693330 69231180 43285229 42105546 5117304 5136240 146404206 138487582 9033497 4867850 1240856 664096 37324876 34914514 12705042 7780057 60304271 48226517 X 86067056 90230825 32879 30240 86099935 90261065 146404206 138487582 X -4638966 -6604814 15404910 X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 13822 13822 0 PART II-B, LINE 1: ADS PAYS ANNUAL ASSOCIATION MEMBERSHIP DUES TO THE WISCONSIN HOSPITAL ASSOCIATION (WHA). THESE DUES ARE PRIMARILY TO ACCESS EDUCATIONAL MATERIALS AND FOR STAFF TRAINING AND MATERIALS. THE WHA HAS NOTIFIED ADS THAT APPROXIMATELY $3,543 OF THE ANNUAL DUES WERE USED IN CONJUNCTION WITH LOBBYING ACTIVITIES WITH THE GOAL OF IMPROVING THE OVERALL HEALTHCARE ENVIRONMENT. ADS IS ALSO A MEMBER OF THE RURAL WISCONSIN HEALTH COOPERATIVE (RWHC). EACH YEAR, ADS PAYS MEMBERSHIP FEES TO THE RWHC. THE RWHC PROVIDES SUPPORT SERVICES FOR A NUMBER OF ITS MEMBER HOSPITALS THROUGHOUT THE STATE OF WISCONSIN. SOME OF THE MANY SERVICES PROVIDED TO MEMBER HOSPITALS INCLUDE PROVIDING ASSISTANCE TO ORGANIZATIONS IN FINDING GRANT FUNDING FOR NEW PROGRAMS, LEGAL SERVICES, REIMBURSEMENT REVIEW SERVICES, ACCOUNTING ASSISTANCE, CONTRACTING FOR THERAPIST AND EMERGENCY ROOM PATIENT CARE COVERAGE, AND ADMINISTRATIVE CONSULTING SERVICES. AS A PART OF THESE SERVICES, THE RWHC ALSO DOES PROVIDE ANALYSIS ON CURRENT HEALTHCARE ISSUES IN AN EFFORT TO PROMOTE AND BETTER HEALTHCARE FOR HOSPITALS IN RURAL COMMUNITIES THROUGHOUT WISCONSIN. ONE OF THESE EFFORTS ALSO INCLUDES SOME LOBBYING ON THE PART OF THE MEMBER ORGANIZATIONS. RWHC DETERMINED THAT APPROXIMATELY $2,066 OF THE FEES PAID BY DIVINE SAVIOR HEALTHCARE IN FISCAL YEAR 2022 RELATED TO LOBBYING ACTIVITIES WITH THE GOAL OF IMPROVING THE HEALTHCARE ENVIRONMENT IN THE STATE OF WISCONSIN. ADS PAID AHA DUES OF $31,027 OF WHICH 26.47% IS FOR LOBBYING OR $8,213. 5041760 5041760 95583587 45575514 50008073 41305179 28327167 12978012 1203335 1203335 69231180 LONG TERM INSURANCE 192824 MEDICARE ACCELERATED PAYMENTS 6104278 ESTIMATED THIRD-PARTY PAYOR SETTLEMENTS 901539 DEFERRED COMPENSATION 581416 7780057 X PART X, LINE 2: ASPIRUS HAS REVIEWED ITS TAX POSITIONS FOR ALL OPEN YEARS AND CONCLUDED THAT NO MATERIAL LIABILITIES EXIST FOR UNCERTAIN TAX POSITIONS AT JUNE 30, 2022. 1 1 X 1 X 1 X 1 1 1 0 1 1 725222 63240 661982 0.00680 17736828 10351590 7385238 0.07570 18462050 10414830 8047220 0.08250 7 591 27584 27584 0.00030 1 5 14637 14637 0.00020 9681475 1121387 8560088 0.08780 2 119 15873 15873 0.00020 10 715 9739569 1121387 8618182 0.08850 10 715 28201619 11536217 16665402 0.17100 1 17 117 117 0.00000 1 17 117 117 0.00000 541652 0 10867676 14933819 -4066143 X 1 1 1 1 DIVINE SAVIOR HEALTHCARE INC 2817 NEW PINERY ROAD PORTAGE WI 53901 WWW.ASPIRUS.ORG 80 X X X DIVINE SAVIOR HEALTHCARE INC 1 0 0 1 X X X X X X X X X 21 1 0 1 1 X WWW.ASPIRUS.ORG/COMMUNITY-RESOURCES X 1 21 1 WWW.ASPIRUS.ORG/COMMUNITY-RESOURCES 0 1 X 200.000000000000 300.000000000000 X X X X 1 1 X X X 1 X WWW.ASPIRUS.ORG/FINANCIAL-ASSISTANCE X WWW.ASPIRUS.ORG/FINANCIAL-ASSISTANCE X WWW.ASPIRUS.ORG/FINANCIAL-ASSISTANCE X X X X X X 1 X 0 X X X X 1 X 0 0 DIVINE SAVIOR HEALTHCARE, INC. PART V, SECTION B, LINE 5: COLUMBIA COUNTY COMMUNITY MEMBERS PROVIDED FEEDBACK ON COMMUNITY HEALTH NEEDS THROUGH A COMMUNITY SURVEY AND KEY INFORMANT INTERVIEWS. APPROXIMATELY 650 PEOPLE RESPONDED TO THE COMMUNITY SURVEY AND TWENTY-SEVEN KEY INFORMANT INTERVIEWS WERE CONDUCTED. AN INTENTIONAL EFFORT WAS MADE TO ENSURE THAT THE INDIVIDUALS AND ORGANIZATIONS REPRESENTED THE NEEDS AND PERSPECTIVES OF: 1) PUBLIC HEALTH PRACTICE; 2) INDIVIDUALS WHO ARE MEDICALLY UNDERSERVED, LOW INCOME, OR ARE CONSIDERED AMONG THE MINORITY POPULATIONS SERVED BY THE HOSPITAL; AND 3) THE BROADER COMMUNITY AT LARGE AND THOSE WHO REPRESENT THE BROAD INTERESTS AND NEEDS OF THE COMMUNITY SERVED. THE COMMUNITY SURVEY, DEVELOPED AND DISTRIBUTED BY ASPIRUS DIVINE SAVIOR AND COLUMBIA COUNTY HEALTH DEPARTMENT, WAS CONDUCTED IN FALL 2021. THE SURVEY WAS AVAILABLE IN SPANISH AND WAS DISTRIBUTED ELECTRONICALLY AND ON PAPER. NUMEROUS ORGANIZATIONS INCLUDING LIBRARIES, CHAMBERS OF COMMERCE, COLUMBIA COUNTY HEALTH DEPARTMENT, AGING AND DISABILITY RESOURCE CENTER, FOOD PANTRIES, COALITIONS AND MORE DISTRIBUTED THE SURVEY. KEY INFORMANTS PROVIDING INPUT ON THE TOP ISSUES INCLUDED REPRESENTATIVES FROM MULTIPLE SECTORS AND GROUPS: EDUCATION; AGING; SUBSTANCE USE AND RECOVERY; FAITH; RECREATION; HEALTH CARE; YOUTH SERVICES; MEDIA; ELECTED PUBLIC OFFICE; OTHER. DIVINE SAVIOR HEALTHCARE, INC. PART V, SECTION B, LINE 6B: ASPIRUS DIVINE SAVIOR COLLABORATED WITH THE COLUMBIA COUNTY HEALTH DEPARTMENT TO COMPLETE THIS WORK. COLUMBIA COUNTY HEALTH DEPARTMENT CONTRACTED WITH UNIVERSITY OF WISCONSIN-OSHKOSH FOR DATA ANALYSIS AND WISCONSIN COMMUNITY HEALTH ALLIANCE FOR PROCESS FACILITATION. DIVINE SAVIOR HEALTHCARE, INC. PART V, SECTION B, LINE 11: IN FY22, ASPIRUS DIVINE SAVIOR HOSPITAL WORKED TO ADDRESS THE HEALTH ISSUES IDENTIFIED IN ITS PREVIOUS CHNA. ALTHOUGH MANY EFFORTS HAVE BEEN SUCCESSFUL, THE HOSPITAL'S EFFORTS HAVE BEEN HAMPERED BY COVID-19 AND ITS RIPPLE EFFECT ON COMMUNITY OUTREACH AND PUBLIC EVENTS / PROGRAMS AS WELL AS ORGANIZATIONAL CHANGES IN STAFFING AND STRUCTURE.MANAGEMENT OF OBESITY & OTHER CHRONIC CONDITIONS IN THE PREVIOUS CHNA, THE MANAGEMENT OF OBESITY, ITS RELATED HEALTH RISKS, AND OTHER CHRONIC CONDITIONS WAS IDENTIFIED AS AN UNMET HEALTH NEED IN THE COMMUNITY. ASPIRUS DIVINE SAVIOR CONDUCTED THE FOLLOWING ACTIVITIES TO RESPOND TO THIS PRIORITY.INTERNAL EFFORTS ASPIRUS DIVINE SAVIOR PARTICIPATED IN THE SYSTEM WIDE FRUIT AND VEGGIE PRESCRIPTION PROGRAM FOR PATIENTS TO RECEIVE $20 VOUCHERS FOR THE LOCAL FARMER'S MARKET INCREASED PUBLIC ACCESSIBILITY TO PERSONAL WELLNESS SERVICES THROUGH LA VITA, ASPIRUS DIVINE SAVIOR'S MEDICALLY-INTEGRATED FITNESS CENTER THE PAVE THE WEIGH PROGRAM, AND OTHER TRANSITIONAL PROGRAMS, WERE OFFERED AT LAVITA AND INCLUDED FREE MEMBERSHIP FEES A VERTICAL GARDEN WAS STARTED AT ASPIRUS TIVOLI EXTERNAL EFFORTS FREE PRESENTATIONS ON DIABETES PREVENTION AND MANAGEMENT WERE OFFERED FREE BREAST CANCER SUPPORT WAS OFFERED BRAIN INJURY AND STROKE SUPPORT GROUP WAS OFFERED PARTICIPATED ON THE PLANNING COMMITTEE FOR A NEW BOYS AND GIRLS CLUBACCESS TO CARE ACCESSIBILITY TO HEALTH CARE REMAINS A SIGNIFICANT ISSUE IN THE COMMUNITY SERVED. ASPIRUS DIVINE SAVIOR CONTINUED TO PRIORITIZE ACCESS AND RECRUITMENT AS A KEY INITIATIVE OF THE ORGANIZATION AND HAS MADE STRIDES IN COMBATING THIS ISSUE. INTERNAL EFFORTS THE CLINIC ADDED NEW PROVIDERS FOR PAIN MANAGEMENT AND CARDIOLOGY PEDIATRIC AND ORTHOPEDIC PRACTITIONERS EXPANDED SERVICES TO OXFORD CLINIC TELEHEALTH AND VIRTUAL CARE VISITS WERE AVAILABLE TRAVEL VOUCHERS WERE PROVIDED TO PATIENTS THE ED2RECOVERY PROGRAM WAS UTILIZED IN THE EMERGENCY DEPARTMENT TO PROVIDE PEER SUPPORT FOR SUBSTANCE USE TWO PHYSICIANS ARE CERTIFIED TO PRESCRIBE SUBOXONE FOR SUBSTANCE ABUSE TREATMENT INTERPRETER/TRANSLATION SERVICES WERE UTILIZED; ADDITIONALLY, A PEDIATRICIAN SPEAKS SPANISH OVER THE NEXT THREE YEARS, AS IDENTIFIED IN ITS NEW CHNA, ASPIRUS DIVINE SAVIOR WILL FORMALLY ADDRESS MENTAL HEALTH AND SUBSTANCE USE. THE THREE NEEDS THAT WERE PRIORITIZED IN THE COMMUNITY STAKEHOLDER MEETING AND WILL NOT BE FORMALLY PURSUED BY THE HOSPITAL IN ITS IMPLEMENTATION STRATEGY ARE: LACK OF COMMUNICATION BETWEEN PARTNERS LACK OF HEALTH CARE PROVIDERS TRANSPORTATION THE HOSPITAL VIEWS COMMUNICATION, HEALTH CARE PROVIDERS AND TRANSPORTATION AS CONTRIBUTORS TO THE ISSUES OF MENTAL HEALTH AND SUBSTANCE USE. WHILE THESE ARE NOT THE HOSPITAL'S FORMAL PRIORITIES, THEY MAY BE PART OF THE STRATEGY TO ADDRESS THE PRIORITY NEEDS AROUND MENTAL HEALTH AND SUBSTANCE USE. DIVINE SAVIOR HEALTHCARE, INC. PART V, SECTION B, LINE 13B: THIRD PARTY SEGMENTATION AND PROPENSITY TO PAY. DIVINE SAVIOR HEALTHCARE, INC. PART V, SECTION B, LINE 13H: THE CHARITABLE CARE POLICY OF DIVINE SAVIOR HEALTHCARE, INC. ALSO ALLOWS FOR AN ADMINISTRATIVE DETERMINATION FOR A PATIENT THAT MAY UNDERGO A CATASTROPHIC EVENT OR UNIQUE CIRCUMSTANCE. THIS ADDITIONAL PROVISION ALLOWS FOR ADMINISTRATION TO MAKE A DETERMINATION THAT MAY ASSIST A PATIENT IN A UNIQUE TIME OF FINANCIAL NEED. 5 1 - ASPIRUS PORTAGE CLINIC 2817 NEW PINERY ROAD PORTAGE WI 53901 PHYSICIAN CLINIC 2 - ASPIRUS DIVINE SAVIOR WELLNESS CENTER 2815 NEW PINERY ROAD PORTAGE WI 53901 WELLNESS CENTER 3 - ASPIRUS TIVOLI COMMUNITY 2805 HUNTERS TRAIL PORTAGE WI 53901 SKILLED NURSING FACILITY, ASSISTED LIVING FACILITY, AND HOME HEALTH PROGRAM 4 - ASPIRUS OXFORD CLINIC N4390 CROSSROADS CLINIC ROAD OXFORD WI 53952 PHYSICIAN CLINIC 5 - ASPIRUS PARDEEVILLE CLINIC 102 GILLETTE STREET PARDEEVILLE WI 53954 PHYSICIAN CLINIC PART I, LINE 3C: THE PATIENT/GUARANTOR, HUSBAND OR WIFE, AND DEPENDENTS MAY NOT HAVE PROPERTY IN EXCESS OF THE FOLLOWING (EXCEPT FOR BALANCES INCURRED AT HOSPITALS THAT PARTICIPATE IN THE NATIONAL HEALTH SERVICE CORPS PROGRAM (NHSC) AND/OR MICHIGAN STATE LOAN REPAYMENT PROGRAM (MSLRP) WHERE THIS CRITERIA DOES NOT APPLY): PRIMARY RESIDENCE IS EXEMPT FOR PATIENTS UNDER 200% FEDERAL POVERTY GUIDELINES. FOR THOSE OVER 200% EQUITY ALLOWANCE IS $75,000 (FINANCIAL STATEMENTS AND TAX BILLS ARE REQUIRED). INCOME PRODUCING LAND (E.G., DAIRY FARM) IS EVALUATED INDIVIDUALLY ON A CASE-BY-CASE BASIS. CASH ASSETS IN EXCESS OF $4,000 AT THE TIME OF APPLICATION. SPECIFICALLY EXCLUDED FROM CONSIDERATION ARE IRA AND PENSION PLANS AND IRREVOCABLE BURIAL TRUST FUNDS. TOTAL NET ASSETS CANNOT EXCEED 800% OF FEDERAL POVERTY GUIDELINES. THIS INCLUDES ALL ASSETS INCLUDING CASH ASSETS ABOVE. PART I, LINE 6A: DIVINE SAVIOR HEALTHCARE, INC. PREPARES A COMMUNITY BENEFIT REPORT ANNUALLY AND FILES IT WITH THE WISCONSIN HOSPITAL ASSOCIATION (WHA). THE REPORT IS AVAILABLE TO THE GENERAL PUBLIC ON WHA'S WEBSITE. PART I, LINE 7: THE COSTING METHODOLOGY USED ON FORM 990 IS BASED ON A COST TO CHARGE RATIO WHICH IS DEVELOPED BASED ON THE ORGANIZATION'S TOTAL OPERATING EXPENSE, EXCLUDING THE PROVISION FOR BAD DEBTS DIVIDED BY GROSS PATIENT SERVICE REVENUES. THIS COST TO CHARGE RATIO IS APPLIED AGAINST THE TOTAL CHARGES THAT ARE WRITTEN OFF DURING THE FISCAL YEAR TO ESTIMATE THE COST OF THE CARE OF PATIENTS THAT HAVE ACCOUNTS THAT ARE DEEMED TO BE BAD DEBTS TO THE ORGANIZATION. THE ORGANIZATION ALSO PROVIDES DISCOUNTS TO ELIGIBLE UNINSURED OR UNDERINSURED PATIENTS UNDER ITS CHARITABLE CARE POLICY. THESE AMOUNTS ARE INCLUDED IN THE CONTRACTUAL ADJUSTMENTS ON THE FINANCIAL STATEMENTS AND ARE NOT INCLUDED IN THE RATIO AS DESCRIBED ABOVE AND APPROVED BY THE IRS FOR USE ON FORM 990. IF CONSIDERED, THESE ADDITIONAL WRITE-OFF AMOUNTS TO UNINSURED OR UNDERINSURED ACCOUNTS WOULD ALSO INCREASE THE ESTIMATED BAD DEBT EXPENSE AMOUNT ASSOCIATED WITH THESE UNCOLLECTIBLE ACCOUNTS TO THE ORGANIZATION. PART I, LINE 7G: THE ABOVE COSTS OF SUBSIDIZED HEALTH SERVICES ARE RELATED TO THE ASPIRUS SKILLED NURSING FACILITIES/EXTENDED CARE UNITS. DIVINE SAVIOR HEALTHCARE, INC. UTILIZED AN INTERNAL DEPARTMENTAL FINANCIAL STATEMENT TO REPORT THE COST AND DIRECT OFFSETTING REVENUE THAT CALCULATES THE COMMUNITY BENEFIT EXPENSE. SKILLED NURSING FACILITIES/EXTENDED CARE UNIT REPORTED COSTS OF $9,681,475 WITH OFFSETTING REVENUE OF $1,121,387. PART I, LN 7 COL(F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 24E, BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGES IN THIS COLUMN IS $1,274,021. PART II, COMMUNITY BUILDING ACTIVITIES: ADS PROVIDES SIGNIFICANT CHARITY CARE AND OTHER COMMUNITY BENEFITS AS DEFINED BY THE IRS AND IN ADDITION, THE ORGANIZATION BELIEVES THAT IT PROVIDES A CRITICALLY IMPORTANT COMMUNITY BENEFIT WHICH IS NOT QUANTIFIED. ADS, LIKE MOST COMMUNITY HOSPITALS, WAS CREATED AND IS MAINTAINED IN ORDER TO PROVIDE CARE LOCALLY WHICH WITHOUT THE HOSPITAL, WOULD NOT BE AVAILABLE LOCALLY. BEYOND INPATIENT HOSPITALIZATIONS, THE HOSPITAL PROVIDES LOCAL ACCESS TO MANY HEALTH SERVICES INCLUDING: BIRTHING CENTER, DIAGNOSTICS, EMERGENCY SERVICES, URGENT CARE, HOME CARE, RENAL DIALYSIS, INFUSION SERVICES, SWING BED SERVICES, NURSING HOME SERVICES, ASSISTED LIVING SERVICES, CLINICAL SERVICES, LABORATORY SERVICES, OCCUPATIONAL HEALTH, REHABILITATION SERVICES, SPECIALTY MEDICINE, SLEEP CENTER, SPEECH PATHOLOGY, SURGICAL SERVICES, WOMEN'S SERVICES, AND AMBULANCE SERVICES, TO NAME SOME OF THE MAJOR SERVICES PROVIDED. PART III, LINE 2: THE PROVISION FOR BAD DEBTS IS BASED ON MANAGEMENT'S ASSESSMENT OF HISTORICAL AND EXPECTED NET COLLECTION CONSIDERING BUSINESS AND ECONOMIC CONDITIONS, TRENDS IN HEALTHCARE COVERAGE, AND OTHER COLLECTION INDICATORS. THROUGHOUT THE YEAR, MANAGEMENT ASSESSES THE ADEQUACY OF THE ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS BASED UPON THESE TRENDS. THE RESULTS OF THIS REVIEW ARE THEN USED TO MAKE ANY MODIFICATIONS TO THE PROVISION FOR BAD DEBTS TO ESTABLISH AN ESTIMATED ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS. ACCOUNTS RECEIVABLES ARE WRITTEN OFF AFTER ALL COLLECTION EFFORTS HAVE BEEN FOLLOWED IN ACCORDANCE WITH ASPIRUS' POLICIES. THE COSTING METHODOLOGY USED WAS THE PATIENT CARE COST TO CHARGE RATIO WHICH WAS DERIVED FROM THE CALCULATION ON IRS WORKSHEET 2. PART III, LINE 3: THE ORGANIZATION HAS A VERY ROBUST FINANCIAL ASSISTANCE PROGRAM; THEREFORE, NO ESTIMATE IS MADE FOR BAD DEBT ATTRIBUTED TO FINANCIAL ASSISTANCE ELIGIBLE PATIENTS. PART III, LINE 4: THE PROVISION FOR BAD DEBTS IS BASED ON MANAGEMENT'S ASSESSMENT OF HISTORICAL AND EXPECTED NET COLLECTION CONSIDERING BUSINESS AND ECONOMIC CONDITIONS, TRENDS IN HEALTHCARE COVERAGE, AND OTHER COLLECTION INDICATORS. THROUGHOUT THE YEAR, MANAGEMENT ASSESSES THE ADEQUACY OF THE ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS BASED UPON THESE TRENDS. THE RESULTS OF THIS REVIEW ARE THEN USED TO MAKE ANY MODIFICATIONS TO THE PROVISION FOR BAD DEBTS TO ESTABLISH AN ESTIMATED ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS. ACCOUNTS RECEIVABLES ARE WRITTEN OFF AFTER ALL COLLECTION EFFORTS HAVE BEEN FOLLOWED IN ACCORDANCE WITH ASPIRUS' POLICIES.BAD DEBT POLICY AND PROCEDURE:POLICY: I. ASPIRUS' FINANCIAL POLICY REQUIRES SETTLEMENT OF A PATIENT SELF-PAY BILL OR ACCOUNT WILL BE REFERRED FOR OUTSIDE COLLECTION. II. FAILURE TO MEET THESE REQUIREMENTS IN ASPIRUS POLICY WILL RESULT IN THE ACCOUNT BEING CONSIDERED FOR BAD DEBT ONCE ALL COLLECTION EFFORTS HAVE BEEN EXHAUSTED. THE ACCOUNT WILL BE REMOVED FROM ACCOUNTS RECEIVABLE AND TURNED OVER TO AN OUTSIDE AGENCY OR LAW FIRM FOR COLLECTION. PRIOR TO THIS HAPPENING, THE FOLLOWING CRITERIA MUST BE MET: A. PATIENT FINANCIAL SERVICES STAFF WILL MAKE REASONABLE COLLECTION EFFORTS BY WAY OF: 1. MONTHLY STATEMENTS 2. COLLECTION LETTERS 3. COLLECTION PHONE CALLS III. ALL COLLECTION ACTIVITY AND PATIENT CONTACTS WILL BE DOCUMENTED ON THE INDIVIDUAL ACCOUNTS. IV. ALL COLLECTION ACCOUNTS ARE TO BE TREATED THE SAME REGARDLESS OF PAYOR TYPE: SELF-PAY, GENERAL INSURANCE, MEDICARE, OR MEDICAL ASSISTANCE. V. PATIENT FINANCIAL SERVICES STAFF WILL USE SOUND BUSINESS JUDGMENT WHEN WORKING WITH THE ACCOUNT. AT THE DISCRETION OF THE FINANCIAL COUNSELOR, CREDIT REPORTS WILL BE REQUESTED FROM THE CREDIT BUREAU AND PROPERTY VERIFICATION OBTAINED THROUGH THE COUNTY TREASURER'S OFFICE. PROCEDURE: VI. THE FINAL STEP IS TO SUBMIT THE ACCOUNT TO A COLLECTION AGENCY OR LAW FIRM. EACH ACCOUNT IS REVIEWED TO DETERMINE IF THE ACCOUNT HAS MET THE BAD DEBT CRITERIA. ONCE IT HAS BEEN DETERMINED THAT ALL REQUIREMENTS HAVE BEEN MET, THE ACCOUNT IS TRANSFERRED FROM ACCOUNTS RECEIVABLE TO BAD DEBT BY THE FINANCIAL COUNSELOR. SPECIFIC PROCEDURES PERTAINING TO THE DETAILED PROCEDURAL STEPS FOR TRANSFERRING TO THE AGENCY CAN BE FOUND IN THE INTERNAL POLICY. A. ADDITIONAL INFORMATION REGARDING MEDICARE BAD DEBTS: 1. THE DEBT MUST BE RELATED TO COVERED SERVICES AND DERIVED FROM DEDUCTIBLE AND COINSURANCE AMOUNTS. 2. THE HOSPITAL MUST PROVIDE REASONABLE COLLECTION EFFORTS. 3. THE DEBT IS NOT COLLECTABLE (AT LEAST 120 DAYS OUTSTANDING FROM THE DATE OF THE FIRST BILLING TO THE PATIENT.) 4. SOUND BUSINESS JUDGMENT ESTABLISHES THAT THERE WAS NO LIKELIHOOD OF RECOVERY AT ANY TIME IN THE FUTURE. II. BAD DEBT RECOVERIES A. PAYMENTS ON MONTHLY REMITTANCE ADVICES FROM OUTSIDE COLLECTION AGENCIES WILL BE POSTED TO EACH INDIVIDUAL ACCOUNT. B. PAYMENTS MADE DIRECTLY TO ASPIRUS BUT INTENDED FOR COLLECTION ACCOUNTS WILL BE POSTED TO THE APPROPRIATE ACCOUNT AND REPORTED DAILY/WEEKLY TO COLLECTION AGENCIES FOR RECONCILIATION OF THEIR RECORDS. C. INVOICES FOR COMMISSIONS DUE TO COLLECTION AGENCIES WILL BE PROCESSED MONTHLY. INVOICE AND REMITTANCE ADVICE WILL BE REVIEWED BY THE FINANCIAL COUNSELOR TEAM LEAD AND APPROVED BY THE MANAGER/DIRECTOR, THEN SUBMITTED TO FISCAL SERVICES FOR CHECK PROCESSING AND PAYMENT TO AGENCIES FOR COMMISSIONS DUE. PART III, LINE 8: THE TOTAL MEDICARE REVENUE SHOWN IN SCHEDULE H TO THE FORM 990 IS BASED ON THE IRS 990 INSTRUCTIONS AND INCLUDES ONLY A PORTION OF THE GROSS MEDICARE REVENUE OF THE HOSPITAL AND ALSO DOES NOT CONSIDER CONTRACTUAL ADJUSTMENTS FOR THE REIMBURSEMENT THAT IS ACTUALLY RECEIVED FROM THE MEDICARE PROGRAM. AMOUNTS LISTED FOR MEDICARE REVENUES DO NOT INCLUDE SIGNIFICANT PORTIONS OF LABORATORY, RADIOLOGY, AMBULANCE, AND REHABILITATION SERVICES PROVIDED TO MEDICARE BENEFICIARIES AS WELL AS PHYSICIAN SERVICES FOR THE COVERAGE OF THE EMERGENCY DEPARTMENT, ANESTHESIA PROFESSIONAL SERVICES, CLINICAL PHYSICIAN PROFESSIONAL SERVICES, SURGICAL PHYSICIAN PROFESSIONAL SERVICES, HOSPITALIST PHYSICIAN PROFESSIONAL SERVICES, AND REVENUES FOR ANY PATIENTS COVERED UNDER MEDICARE ADVANTAGE PLAN PROGRAMS. PHYSICIAN SERVICES ARE REIMBURSED PRIMARILY ON FEE SCHEDULE REIMBURSEMENT AT RATES THAT ARE OFTEN BELOW THE COSTS OF CARING FOR PATIENTS. EMERGENCY, SURGICAL, AND CLINICAL SERVICES PROVIDED TO MEDICARE PATIENTS ARE VITAL TO THE WELL-BEING OF THE COMMUNITY AND AS SUCH THESE COSTS AND SHORTFALLS SHOULD ALSO BE CONSIDERED AS AN ADDITIONAL BENEFIT THAT DIVINE SAVIOR HEALTHCARE, INC. PROVIDES TO THE COMMUNITY AND SURROUNDING AREAS. THE COSTING METHOD USED ABOVE FOR IRS 990 COMPLIANCE REPORTING IS ALSO BASED ON THE FILED MEDICARE COST REPORT FOR THE YEAR ENDED JUNE 30, 2022 AND DOES NOT CONSIDER MEDICARE NON-ALLOWABLE EXPENSES AS IT IS BASED ON TOTAL HOSPITAL PATIENT SERVICE REVENUES (IGNORING CONTRACTUAL ADJUSTMENTS ON FEE SCHEDULE REIMBURSED ITEMS AND NON-ALLOWABLE MEDICARE EXPENSES AS NOTED ABOVE).WHETHER THERE IS A SHORTFALL OR SURPLUS ON SERVICES PROVIDED TO MEDICARE BENEFICIARIES, THESE PEOPLE, WHICH ARE TYPICALLY ELDERLY OR DISABLED MEMBERS OF THE COMMUNITY, ARE AN UNDERSERVED POPULATION WHO EXPERIENCE ISSUES WITH ACCESS TO HEALTHCARE SERVICES. WITHOUT TAX-EXEMPT HOSPITALS PROVIDING MEDICARE PATIENT SERVICES, THE CENTERS FOR MEDICARE AND MEDICAID (CMS) WOULD BEAR THE BURDEN OF DIRECTLY PROVIDING SERVICES TO THE ELDERLY AND DISABLED MEMBERS OF THE COMMUNITY. PART III, LINE 9B: UPON A PATIENT'S APPROVAL FOR FINANCIAL ASSISTANCE, THIS IS LOADED AS AN INSURANCE COVERAGE TO THE PATIENT'S ACCOUNT WITH AN EFFECTIVE AND TERMINATION DATE TO ASSURE CAPTURING ALL CHARGES FOR THE PATIENT FOR ADJUSTMENT IN A WORK QUEUE PRIOR TO ANY REMAINING BALANCE BEING MOVED TO PATIENT LIABILITY AND THEREFORE PREVENTING UNDISCOUNTED SERVICES FROM BEING BILLED TO A PATIENT. PART VI, LINE 2: DIVINE SAVIOR HEALTHCARE USES HEALTH AND SOCIAL DATA AND TRENDS FOR THE SAME TO DETERMINE POSSIBLE UNMET NEEDS WITH THE COMMUNITY IT SERVES. IT ALSO USES ITS TEAM MEMBERS' INVOLVEMENT IN COMMUNITY EVENTS TO USE AS A THERMOMETER FOR WHAT IS NEEDED. PART VI, LINE 3: ALL PATIENT STATEMENTS PROVIDE INFORMATION REGARDING THE ASPIRUS FINANCIAL AID PROGRAM. THIS INCLUDES A TELEPHONE NUMBER TO REQUEST IN-PERSON ASSISTANCE, INFORMATION ABOUT THE PROGRAM AS WELL AS TO REQUEST AN APPLICATION. THE STATEMENT ALSO PROVIDES THE WEB ADDRESS WHICH DIRECTS PATIENTS TO OUR FINANCIAL AID POLICY AS WELL AS THE APPLICATION AND PLAIN LANGUAGE SUMMARY. LETTERS FROM CENTRAL BILLING OFFICE STAFF INFORM PATIENTS THAT ASPIRUS HAS A FAP. THE FAP IS OFFERED AT THE TIME OF REGISTRATION ANNUALLY TO ALL PATIENTS. FINANCIAL COUNSELORS OFFER FAP TO PATIENTS DURING COLLECTION CALLS. ASPIRUS HAS CERTIFIED APPLICATION COUNSELORS THAT ARE AVAILABLE TO ASSIST WITH MARKETPLACE ENROLLMENT AS WELL AS MEDICAL ASSISTANCE APPLICATIONS. CARDON OUTREACH IS USED TO REVIEW ALL PATIENTS THAT ARE INPATIENT OR PRESENT TO THE ED TO ASSIST WITH MEDICAL ASSISTANCE APPLICATIONS. UNINSURED AND UNDER INSURED PATIENTS ARE ASKED TO MEET WITH ONE OF THE ORGANIZATION'S FINANCIAL COUNSELORS EITHER AT THE TIME SERVICE IS PROVIDED OR WHEN THE PATIENT'S BILL IS GENERATED. THE FINANCIAL COUNSELOR EXPLAINS THE VARIOUS PAYMENT OPTIONS AVAILABLE TO THE PATIENT AS WELL AS THE HOSPITAL'S CHARITY AND COMMUNITY CARE PROGRAM AND OFFERS THE CHARITY CARE APPLICATION WHEN APPROPRIATE. IF OTHER PROGRAMS ARE AVAILABLE TO THE PATIENT, SUCH AS THE WISCONSIN MEDICAL ASSISTANCE OR BADGERCARE PROGRAMS, THESE PATIENTS ARE REFERRED TO THE APPROPRIATE GOVERNMENT AGENCY FOR FURTHER ASSISTANCE. PART VI, LINE 4: THE PRIMARY SERVICE AREA FOR ADS ENCOMPASSES ALL PERSONS LIVING WITHIN A 20 TO 30-MILE RADIUS OF THE HOSPITAL. SOME OF THE COMMUNITIES INCLUDED IN THIS AREA ARE PORTAGE, PARDEEVILLE, WISCONSIN DELLS, LAKE DELTON, BRIGGSVILLE, WYOCENA, POYNETTE, AND ARLINGTON, WISCONSIN, AMONG MANY OTHERS. THE HOSPITAL PROVIDES A SIGNIFICANT PORTION OF ITS PATIENT CARE SERVICES TO BENEFICIARIES OF THE MEDICARE AND MEDICAID PROGRAMS ESPECIALLY THOSE BENEFICIARIES WHO RESIDE IN THE ORGANIZATION'S EXTENDED AND LONG-TERM CARE FACILITIES OR PATIENTS WHO RECEIVE HOME HEALTH SERVICES FROM THE ORGANIZATION. PART VI, LINE 5: DIVINE SAVIOR HEALTHCARE, INC. PROVIDES SERVICES AND EDUCATIONAL OPPORTUNITIES EITHER FREE OF CHARGE OR AT A NOMINAL FEE IN AN ATTEMPT TO PROVIDE THESE OPPORTUNITIES TO THOSE MEMBERS OF THE COMMUNITIES WHO OTHERWISE MAY NOT BE ABLE TO AFFORD OR HAVE ACCESS TO THESE PROGRAMS. THESE EFFORTS ARE PROVIDED THROUGH A VARIETY OF EDUCATIONAL SPEAKER FORUMS, SUPPORT GROUPS, HEALTH SCREENINGS, HEALTH EDUCATION FORUMS, AND OTHER EDUCATIONAL OPPORTUNITIES FOR STUDENTS. PART VI, LINE 6: DIVINE SAVIOR HEALTHCARE IS A PART OF THE ASPIRUS, INC. SYSTEM WITH THE MAIN BASE IN WAUSAU WI. TOGETHER WE PROMOTE THE MISSION AND WORK COLLABORATIVELY TO SHARE THE PASSION FOR EXCELLENCE AND COMPASSION FOR PEOPLE. THE COMBINED EFFORTS ARE ABLE TO PROVIDE THE SMALLER COMMUNITIES WITH THE ACCESS TO CARE THAT THEY MAY NOT OTHERWISE BE ABLE TO HAVE. ALSO, AS PART OF THIS SYSTEM ARE 3 OTHER UPPER PENINSULA OF MI HOSPITALS AND 11 OTHER HOSPITAL SYSTEMS IN WI ALONG WITH POST-ACUTE CARE PROGRAMS, MANY PROVIDER CLINICS, AMBULANCE SERVICE AND LONG-TERM CARE. PART VI, LINE 7, REPORTS FILED WITH STATES WI 1 BOYS & GIRLS CLUB OF WEST CENTRAL WI 105 WEST MILWAUKEE STREET TOMAH WI 54660 391962065 501(C)(3) 10000 0 BUILD A PORTAGE CLUB DONATION 1 0 PART I, LINE 2: SCHOLARSHIPS/LOANS ARE AWARDED BY THE DIVINE SAVIOR HEALTHCARE, INC. SCHOLARSHIP COMMITTEE. APPLICANTS WILL GENERALLY BE GRADUATING HIGH SCHOOL SENIORS, THOUGH OTHERS MAY BE ELIGIBLE, AS APPROVED BY THE COMMITTEE. THE COMMITTEE WILL INTERVIEW APPLICANTS, AND THE DECISION WILL BE BASED UPON INTERVIEW RESULTS, CHOICE OF PROGRAM, GRADE POINT AVERAGE, AND FINANCIAL NEED. 0 1 0 0 0 0 0 0 0 MATTHEW HEYWOOD PRESIDENT & CEO ASPIRUS 0 1051076 0 1629342 0 3803 0 17346 0 248748 0 2950315 0 0 SIDNEY SCZYGELSKI ASSIST. TREASURER/SR. VP OF FIN./CFO 0 610115 0 177495 0 127769 0 20196 0 121430 0 1057005 0 112143 JOHN HEISLER BOARD MEM.(THRU 03/21)/CHIEF HR OFF. 0 289961 0 426149 0 35874 0 13626 0 43024 0 808634 0 25179 MICHAEL DECKER PRESIDENT & CEO ADS (THRU 05/22) 470862 0 106791 0 89616 0 9832 0 93362 0 770463 0 86828 0 JESSE TISCHER BOARD MEMBER/SVP & PRES. REG. MKTS. 0 501025 0 142821 0 539 0 11714 0 89935 0 746034 0 0 JOSHUA POGORELEC BOARD MEMBER/PHYSICIAN 660337 0 20600 0 13368 0 8700 0 33525 0 736530 0 0 0 DOUGLAS ARNOLD PHYSICIAN 607020 0 10600 0 18264 0 8700 0 40125 0 684709 0 0 0 JENNIFER REDMAN-SCHELL SVP & PRESIDENT-AMG 0 405520 0 113119 0 53815 0 17346 0 75318 0 665118 0 51368 MICHAEL WALTERS FORMER KE/VP-SEN. SYS. PHYS. EXEC. 0 452168 0 151458 0 1201 0 8700 0 35184 0 648711 0 0 JOSEPH MUELLER PHYSICIAN 565527 0 20600 0 16501 0 8700 0 33271 0 644599 0 0 0 BRAD ROGOWSKI PHYSICIAN 557880 0 20600 0 12493 0 8700 0 35777 0 635450 0 0 0 TODD RICHARDSON SVP & CHIEF INFORMATION OFFICER 0 357568 0 105424 0 53502 0 17346 0 79940 0 613780 0 50634 ERIC ANDERSON BOARD MEMBER/SVP-SERV. & PATIENT EXP 0 382299 0 111001 0 1734 0 17346 0 86954 0 599334 0 0 RENEE SMITH EXECUTIVE DIRECTOR-ANI 0 315463 0 89914 0 54625 0 17346 0 76429 0 553777 0 53547 JAMES MATHESON SVP-CHIEF STRATEGY OFFICER 0 322706 0 94649 0 35374 0 16347 0 73601 0 542677 0 26065 MICHAEL HOLZHUETER ASSIST. SEC./SVP-GENERAL COUNSEL 0 399152 0 25600 0 25004 0 8700 0 80633 0 539089 0 0 JAMES SELF PHYSICIAN 480142 0 600 0 13363 0 7243 0 36275 0 537623 0 0 0 BENJAMIN BARSOTTI VP-CHIEF MEDICAL INFORMATION OFFICER 0 367202 0 65298 0 29946 0 17346 0 33420 0 513212 0 23406 BRETT DAVIS PRESIDENT-ASPIRUS HEALTH PLAN 0 260587 0 127333 0 6207 0 16557 0 46300 0 456984 0 0 MICHAEL MCGRAIL MD FORMER SVP & SYSTEM CMO 0 0 0 0 0 449085 0 0 0 0 0 449085 0 449085 KATHERINE MURPHY PHYSICIAN 406269 0 600 0 15686 0 8700 0 2203 0 433458 0 0 0 SUSAN KRECKMAN BOARD MEMBER/PHYSICIAN 320187 0 600 0 11235 0 7441 0 33185 0 372648 0 0 0 NANCY ROTH-MALLEK VICE CHAIR/VP-FINANCE SOUTH REGION 0 223367 0 38193 0 1959 0 12914 0 33924 0 310357 0 0 PART I, LINE 3 FOR THE PURPOSES OF DETERMINING COMPENSATION, THE FILING ORGANIZATION RELIED ON THE RELATED ORGANIZATIONS TO ESTABLISH COMPENSATION OF THE CEO, OTHER OFFICERS, AND KEY EMPLOYEES. THE RELATED ORGANIZATIONS USED THE FOLLOWING PRACTICES FOR ESTABLISHING COMPENSATION FOR SUCH INDIVIDUALS: COMPENSATION COMMITTEE, INDEPENDENT COMPENSATION CONSULTANT, WRITTEN EMPLOYMENT CONTRACT, COMPENSATION SURVEY OR STUDY, AND APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE. PART I, LINE 4B THE FOLLOWING OFFICERS AND KEY EMPLOYEES PARTICIPATED IN A NON-QUALIFIED 457(F) RETIREMENT PLAN AND REPORTED THE FOLLOWING INCREASE IN THEIR RESPECTIVE PLANS: MIKE DECKER $86,828 SCHEDULE J, PART I, LINE 4B RELATED PARTY INFORMATION - SUPPLEMENTAL NONQUALIFIED RETIREMENT 457(F) DISTRIBUTION: S. SCZYGELSKI $112,143 W. CARROLL $23,743 B. BARSOTTI $23,406 J. MATHESON $26,065 J. HEISLER $25,179 J. HARDESTY $21,288 L. ROWE-PEPLINSKI $22,695 M. BREWER $24,855 M. MCGRAIL $449,085 R. SMITH $53,547 R. RISLEY-GRAY $19,718 T. RICHARDSON $50,634 J. REDMAN-SCHELL $51,368 KEY EMPLOYEES OF THE ORGANIZATION OR A PARTICIPATING AFFILIATE ARE ELIGIBLE TO PARTICIPATE IN THE PLAN. THE PLAN YEAR IS JANUARY 1 TO DECEMBER 31ST. EMPLOYER CONTRIBUTIONS: THE CONTRIBUTION MADE BY THE EMPLOYER IS A THREE-TIERED STRUCTURE DEPENDING UPON THE EXECUTIVE'S POSITION, WHICH ARE AS FOLLOWS: 13% FOR SENIOR VICE PRESIDENT OR PRESIDENT, 15% FOR SVP & CHIEF FINANCIAL OFFICER, AND 20% FOR THE PRESIDENT & CHIEF EXECUTIVE OFFICER. IF A PARTICIPANT TERMINATES DURING THE YEAR, THE PARTICIPANT'S EXECUTIVE ALLOWANCE IS PRORATED BASED ON THE NUMBER OF FULL CALENDAR MONTHS FROM THE BEGINNING OF THE PLAN YEAR TO THE BEGINNING OF THE CALENDAR YEAR MONTH CLOSEST TO THE CHANGE OR TERMINATION OF EMPLOYMENT. DISTRIBUTIONS: CONTINUATION OF EMPLOYMENT THROUGH THE DEFERRED VESTING DATE; THE DATE ON WHICH THE PARTICIPANT'S EMPLOYMENT IS TERMINATED AS A RESULT OF DEATH OR DISABILITY; 24 MONTHS FROM THE DATE ON WHICH THE PARTICIPANT INCURS AN INVOLUNTARY SEPARATION FROM SERVICE WITHOUT REASONABLE CAUSE OR THE DATE THAT IS 24 MONTHS FOLLOWING THE PARTICIPANT'S SEPARATION FROM SERVICE, BUT ONLY IF THE PARTICIPANT'S INTEREST HAS NOT BEEN FORFEITED FOR COMPETITION DURING SUCH 24 MONTH PERIOD AND THE PARTICIPANT HAS NOT ENGAGED IN COMPETITION AFTER HIS OR HER SEPARATION FROM SERVICE AND PRIOR TO HIS OR HER DEATH, THE PARTICIPANT SHALL BE VESTED AT HIS OR HER DATE OF DEATH. A WISCONSIN HEALTH AND EDUCATIONAL FACILITIES AUTHORITY 391337855 2020-06-29 39808745 REFINANCE OF 2006, 2009, 2012, 2014, 2016, 2019 REVENUE BONDS 0 0 0 A 2420460 39808745 139675 39669070 2020 0 1 1 1 A 0 0 0 0 0 0 1 A 0 1 0 0 0 0 0 0 1 A 1 PART VI: THE PROCEEDS OF THE WISCONSIN HEALTH AND EDUCATION FACILITIES AUTHORITY REVENUE BONDS, SERIES 2020 BONDS (ASPIRUS, INC. OBLIGATED GROUP) WERE BORROWED BY DIVINE SAVIOR HEALTHCARE, INC. (EIN 39-0806250). THE PROCEEDS OF THE SERIES 2020 BONDS WERE USED TO REFINANCE THE DIVINE SAVIOR HEALTHCARE, INC., SERIES 2016 BONDS (REFINANCING OF SERIES 2006 BONDS) AND SERIES 2019 BONDS (REFINANCING OF SERIES 2009, 2012, 2014 BONDS). INFORMATION REGARDING THE SERIES 2020 BONDS IS REPORTED IN SCHEDULE K FOR THAT ORGANIZATION. FOR THE ENTITY THAT BORROWED FUNDS, THE INFORMATION REPORTED IN PART I, PART II AND PART III OF SCHEDULE K RELATES ONLY TO THE PORTION OF THE SERIES 2020 BONDS LOANED TO THE ORGANIZATION. FOR THE ENTITY THAT BORROWED FUNDS, THE INFORMATION REPORTED IN PART IV OF SCHEDULE K RELATES TO THE ENTIRE ISSUE OF THE SERIES 2020 BONDS. PART III, LINES 2, 3A, AND 3B: ASPIRUS, INC., THE PARENT ORGANIZATION OF DIVINE SAVIOR HEALTHCARE, INC., HAS POLICIES AND PROCEDURES IN PLACE TO REVIEW LEASE AGREEMENTS, MANAGEMENT, AND SERVICE CONTRACTS TO IDENTIFY AGREEMENTS THAT MAY RESULT IN PRIVATE BUSINESS USE OF BOND-FINANCED PROPERTY. ON A CONTRACT BY CONTRACT BASIS, ASPIRUS, INC. WILL SEEK HELP FROM BOND COUNSEL AS MANAGEMENT DEEMS NECESSARY. PART III, LINE 9: SUPPLEMENTAL INFORMATION ON TAX EXEMPT BONDS: POLICY STATES WE WILL SEEK BOND COUNSEL OPINION ON ALL REMEDIAL ACTIONS. FORM 990, PART VI, SECTION A, LINE 2 BOARD MEMBERS TRAVIS HAMELE AND CHAD STEVENSON HAVE A FAMILY RELATIONSHIP. FORM 990, PART VI, SECTION A, LINE 6 THE PARENT ORGANIZATION, ASPIRUS, INC., IS THE SOLE CORPORATE MEMBER OF THE ORGANIZATION. FORM 990, PART VI, SECTION A, LINE 7A THERE SHALL BE A MINIMUM OF 11 VOTING DIRECTORS ALLOCATED AS FOLLOW. THERE SHALL BE FOUR CLASSES OF VOTING DIRECTORS: THE COMMUNITY CLASS, ASPIRUS CLASS, PROVIDER CLASS, AND SISTERS OF DIVINE SAVIOR (SDS) CLASS. NO LESS THAN SIX INDEPENDENT COMMUNITY CLASS DIRECTORS (APPROVED BY MEMBER), TWO ASPIRUS CLASS DIRECTORS NOMINATED AND ELECTED BY ASPIRUS, INC., TWO PROVIDER CLASS DIRECTOR NOMINATED BY THE CORPORATION'S BOARD AND ELECTED BY ASPIRUS, INC. AND ONE SDS CLASS DIRECTOR NOMINATED AND ELECTED BY SDS. FORM 990, PART VI, SECTION A, LINE 7B THE FOLLOWING ACTIONS MUST BE APPROVED BY THE SOLE MEMBER OF THE ORGANIZATION, ASPIRUS, INC.: 1) CHANGE OR AMEND THE ARTICLES OF INCORPORATION OR BYLAWS; 2) CHANGE THE MISSION, PURPOSE, OR SCOPE OF THE CORPORATION; 3) RATIFICATION OR REMOVAL OF DIRECTORS OR OFFICER; 4) CHANGE THE FORMULA OR METHODOLOGY FOR DETERMINING PHYSICIAN COMPENSATION; 5) APPROVAL OF ANNUAL OPERATING AND CAPITAL EXPENDITURE BUDGETS, STRATEGIC AND LONG-RANGE PLANS. FORM 990, PART VI, SECTION B, LINE 11B THE ACCOUNTING DEPARTMENT ACCUMULATES ALL 990 INFORMATION. THESE DOCUMENTS ARE REVIEWED BY THE CFO. THE 990 IS REVIEWED BY OTHER SENIOR MANAGEMENT PRIOR TO SUBMISSION TO THE INTERNAL REVENUE SERVICE AND IS MADE AVAILABLE TO THE BOARD OF DIRECTORS THROUGH DIRECTOR'S DESK OR OTHER MEANS OF ELECTRONIC RETRIEVAL. FORM 990, PART VI, SECTION B, LINE 12C BOARD MEMBERS AND KEY EMPLOYEES ARE REQUIRED TO SIGN ANNUAL CONFLICT OF INTEREST STATEMENTS AND ALL MANAGERS ARE REQUIRED TO SIGN BIANNUAL CONFLICT OF INTEREST STATEMENTS. THE ORGANIZATION'S CEO AND BOARD CHAIR REVIEW THE STATEMENTS AND HIGHLIGHT POTENTIAL CONFLICTS. THE BOARD DETERMINES ON A CASE BY CASE BASIS ANY ACTIONS REQUIRED. INDIVIDUALS ARE NOT PERMITTED TO VOTE ON ANY TRANSACTION WHERE A CONFLICT HAS BEEN DETERMINED TO EXIST. ALL CONFLICTS AND PROCEEDINGS ARE NOTED IN THE MEETING MINUTES. FORM 990, PART VI, SECTION B, LINE 15 FOR PURPOSES OF DETERMINING COMPENSATION, DIVINE SAVIOR HEALTHCARE, INC. RELIES ON RELATED ORGANIZATIONS TO ESTABLISH THE COMPENSATION OF THE CEO, OTHER OFFICERS, AND KEY EMPLOYEES. THE RELATED ORGANIZATIONS USED THE FOLLOWING PRACTICES FOR ESTABLISHING COMPENSATION FOR SUCH INDIVIDUALS: COMPENSATION COMMITTEE, INDEPENDENT COMPENSATION CONSULTANT, WRITTEN EMPLOYMENT CONTRACT, COMPENSATION SURVEY OR STUDY, AND APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE. FORM 990, PART VI, SECTION C, LINE 19 THE AUDITED FINANCIAL STATEMENTS, GOVERNING DOCUMENTS, AND THE CONFLICT OF INTEREST POLICY ARE AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART IX, LINE 11G LAB FEES: PROGRAM SERVICE EXPENSES 1,451,124. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,451,124. CONTRACT NURSING AND OTHER LABOR FEES: PROGRAM SERVICE EXPENSES 9,403,625. MANAGEMENT AND GENERAL EXPENSES 46,548. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 9,450,173. OTHER PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 425,206. MANAGEMENT AND GENERAL EXPENSES 831,294. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,256,500. FORM 990, PART XI, LINE 9: INTERCOMPANY TRANSFERS - AWH 644,306. INTERCOMPANY TRANSFERS - AI 13,831,806. INTERCOMPANY TRANSFERS - ACI 906,924. INTERCOMPANY TRANSFERS - AOH -20. INTERCOMPANY TRANSFERS - VNA 307. INTERCOMPANY TRANSFERS - AIW 972. INTERCOMPANY TRANSFERS - AIR -240. INTERCOMPANY TRANSFERS - ARH 21,069. INTERCOMPANY TRANSFERS - AKH -210. INTERCOMPANY TRANSFERS - ASP 105. INTERCOMPANY TRANSFERS - ASH -54. INTERCOMPANY TRANSFERS - AMR 202. INTERCOMPANY TRANSFERS - ARN -279. INTERCOMPANY TRANSFERS - HYMC 22. 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