2022-05-12T19:40:20-05:00 2021-06-30 470617373 COMMONSPIRIT HEALTH 198 INVERNESS DRIVE WEST ENGLEWOOD CO 80112 990 2020-07-01 760436439 MEMORIAL MEDICAL CENTER - LIVINGSTON MEMO 9366348111 PO BOX 1447 LUFKIN TX 75902 SHELLI BROOKS VP OF FINANCE, CFO 9366348111 2022-05-12 1 SHELLI BROOKS 999009999 ANGELA NOEL P01051055 3032989100 2 AAL1 IAL1 2020 2022-09-23 18:48:47Z CHI ST LUKE'S HEALTH MEMORIAL LIVINGSTON MONTE BOSTWICK PO BOX 1447 LUFKIN TX 75902 50027349 0 X HTTPS://WWW.STLUKESHEALTH.ORG/ X 1994 TX THE ORGANIZATION OPERATES A GENERAL ACUTE CARE HOSPITAL WITH 66 LICENSED BEDS AND PROVIDES SERVICES TO PATIENTS IN POLK AND SURROUNDING COUNTIES. 18 15 346 44 0 0 2500208 159385 47631184 49784092 24355 13941 88545 69931 50244292 50027349 1660663 17054 0 0 19801657 19028116 0 0 0 25690177 33077937 47152497 52123107 3091795 -2095758 52141729 53695503 26818374 28177554 25323355 25517949 AS AN AFFILIATE OF COMMONSPIRIT HEALTH, WE MAKE THE HEALING PRESENCE OF GOD KNOWN IN OUR WORLD BY IMPROVING THE HEALTH OF THE PEOPLE WE SERVE, ESPECIALLY THOSE WHO ARE VULNERABLE, WHILE WE ADVANCE SOCIAL JUSTICE FOR ALL. 0 0 49734784 17054 49784368 SEE SCHEDULE H 49734784 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 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 X 0 0 346 1 0 0 0 0 0 0 0 0 0 0 0 0 X 18 15 1 0 0 0 1 1 1 1 1 0 0 0 1 1 1 1 1 0 0 0 X SHELLI BROOKS 9366397166 1201 W FRANK AVENUE LUFKIN TX 75904 T DOUGLAS LAWSON PHD PRES & CEO CHI ST. LUKE'S HEALTH SYSTEM 1.00 50.00 X 0 2116319 203814 MONTE BOSTWICK MARKET CEO 1.00 40.00 X X 0 459604 67916 ERIC ROBINSON COO 1.00 40.00 X X 0 330062 48354 KRISTINA FROESE CNO 40.00 0.00 X 185490 0 41800 SHELLI BROOKS CFO 1.00 40.00 X 0 162905 19116 TAMANIKA FITE DIRECTOR OF PHARMACY 40.00 0.00 X 160655 0 24609 MIGUEL GARCIA MARKET DIRECTOR IMAGING SERVICES 5.00 35.00 X 22574 134317 24372 DUANE MILLER FORMER CFO 0.00 0.00 X 0 128593 3215 NICHOLAS FONTENOT CLINICAL PHARMACIST I 40.00 0.00 X 123667 0 32308 ROBERT DAVIS MARKET DIRECTOR OF RESPIRATORY 5.00 35.00 X 14964 105161 25182 JANE AINSWORTH DIRECTOR 1.00 2.00 X 0 0 0 MARLO BRAWNER MD DIRECTOR 1.00 2.00 X 0 0 0 KAYWIN CARTER MD DIRECTOR 1.00 2.00 X 0 0 0 KURUVILLA CHERIPARAMBIL MD DIRECTOR 1.00 2.00 X 0 0 0 JUDY COCHRAN DIRECTOR 1.00 2.00 X 0 0 0 TREY DENMAN DIRECTOR 1.00 2.00 X 0 0 0 CORKY EVANS DIRECTOR 1.00 2.00 X 0 0 0 JULE FENLEY CHAIR 1.00 2.00 X X 0 0 0 GEORGE FIDONE MD DIRECTOR 1.00 2.00 X 0 0 0 DEMETRESS HARRELL VICE CHAIR 1.00 2.00 X X 0 0 0 M HUNT HUBER MD DIRECTOR 1.00 2.00 X 0 0 0 PRASHANT KUMAR MD DIRECTOR 1.00 2.00 X 0 0 0 BEN OGLETREE DIRECTOR 1.00 2.00 X 0 0 0 STEPHEN RALEY DIRECTOR 1.00 2.00 X 0 0 0 MICHAEL SIMON DIRECTOR 1.00 2.00 X 0 0 0 507350 3436961 490686 15 1 1 0 TEXAS EM-I MEDICAL SVCS PA 7032 COLLECTION CENTER DRIVE CHICAGO IL 60693 MEDICAL SERVICES 469430 HB ANESTHESIOLOGY GROUP PA 7032 COLLECTION CENTER DRIVE CHICAGO IL 60693 ANESTHESIA SERVICES 324500 WIMBERLY & SONS LLC 2404 US HWY 190 W LIVINGSTON TX 77351 BUILDING & CONSTRUCTION SERVICES 264198 FERRARAS HEATING & AIR CONDITIONING INC 1810 W FRANK AVE LUFKIN TX 75904 HVAC SERVICES 187430 GRACO MECHANICAL INC 5910 SCHUMACHER LANE HOUSTON TX 77057 MECHANICAL SERVICES 158558 7 158385 1000 159385 PATIENT SERVICES 900099 49784092 49784092 0 0 49784092 7666 7666 6275 0 6275 6275 6275 OTHER REVENUE 900099 69655 0 0 69655 MEDICAL RECORDS REVENU 541200 276 276 0 0 69931 50027349 49784368 0 83596 X 17054 17054 14819480 14671285 148195 756140 748578 7562 2272953 2227493 45460 1179543 1167748 11795 75876 75876 971 971 12981018 12313662 667356 6250 6250 423496 283742 139754 1717305 1631440 85865 1050507 1050507 12998 11438 1560 330 314 16 1427555 1356177 71378 3576241 3576241 401944 401944 MEDICAL SUPPLIES 5784444 5784444 0 0 STATE PROVIDER TAX 2873558 2729880 143678 0 MISCELLANEOUS EXPENSES 1562377 615107 947270 0 REPAIRS AND MAINTENANCE 1152754 1129699 23055 0 30313 18031 12282 52123107 49734784 2388323 0 0 124087 126563 0 3836180 7403748 0 0 0 1031290 1548123 3457 9892 63679336 19314423 46772256 44364913 0 0 0 0 374459 242264 52141729 53695503 8292875 8657834 0 2553498 75197 0 0 0 0 0 15972001 19444523 26818374 28177554 X 25323355 25517949 0 25323355 25517949 52141729 53695503 X -2095758 -53642 2343994 X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 1 971 0 0 0 971 0 PART II-B, LINE 1: THE PORTION OF ORGANIZATION DUES THAT ARE RELATED TO LOBBYING ARE AS FOLLOWS: AMERICAN HOSPITAL ASSOCIATION - 971 530000 530000 50815919 10911757 39904162 12156711 8370282 3786429 176706 32384 144322 44364913 DUE TO AFFILIATE 19276536 LEASE LIABILITY 167987 19444523 X PART X, LINE 2: MEMORIAL MEDICAL CENTER - LIVINGSTON'S FINANCIAL INFORMATION IS INCLUDED IN COMMONSPIRIT HEALTH'S CONSOLIDATED AUDITED FINANCIAL STATEMENTS, WHICH INCLUDES THE FOLLOWING DISCLOSURE: COMMONSPIRIT REVIEWS ITS TAX POSITIONS QUARTERLY AND HAS DETERMINED THAT THERE ARE NO MATERIAL UNCERTAIN TAX POSITIONS THAT REQUIRE RECOGNITION IN THE ACCOMPANYING CONSOLIDATED FINANCIAL STATEMENTS. 1 1 X 1 X 300.000000000000 1 X 1 1 1 0 1 1 3598 2511770 0 2511770 0.04820 8326264 7476579 849685 0.01630 3598 10838034 7476579 3361455 0.06450 17054 17054 0.00030 17054 17054 0.00030 3598 10855088 7476579 3378509 0.06480 0 11679102 0 8318058 9854669 -1536611 X 1 1 1 1 MMC-LIVINGSTON 1717 HWY 59 BYPASS LIVINGSTON TX 77351 HTTPS://WWW.STLUKESHEALTH.ORG/ 000466 X X MMC-LIVINGSTON 1 0 0 1 X X X X X X X X X 18 1 1 1 1 X SEE PART V, PAGE 8 X X 1 18 1 SEE PART V, PAGE 8 0 1 X 300.000000000000 300.000000000000 X X X X 1 1 X X X 1 X SEE PART V, PAGE 8 X SEE PART V, PAGE 8 X SEE PART V, PAGE 8 X X X X X X 1 X 0 X X X X 1 X 0 0 MMC-LIVINGSTON PART V, SECTION B, LINE 5: OUR CORE COMMUNITY PARTNERS (AS WERE A PART OF THE LATEST CHNA INITIATIVE) INCLUDE: IMPACT LUFKIN, LUFKIN HIGH SCHOOL, SOUTHSIDE BAPTIST CHURCH, ST. PATRICK CHURCH, HOSPICE IN THE PINES, CITY OF LUFKIN, ANGELINA COLLEGE, TLL TEMPLE FOUNDATION, ADAC AND THE ANGELINA COUNTY COALITION. INDIVIDUALS FROM ALL OF THESE AND MANY OTHER INDIVIDUALS (197 IN TOTAL) PARTICIPATED IN COMMUNITY DISCUSSION GROUPS STRUCTURED GROUP INTERVIEWS ACROSS THE REGION. NOTES WERE TAKEN AND DATA ANALYZED FOR COMMON THEMES. AS OUR FACILITY PIVOTED IN ORDER TO BETTER SERVE THE COMMUNITY WITH COVID-19 RELATED NEEDS, WE SIGNIFICANTLY INCREASED COMMUNICATION AND FEEDBACK WITH SHARON SHAW DIRECTOR OF THE ANGELINA COUNTY AND CITIES HEALTH DISTRICT AS WELL AS THE CITY OF LUFKIN INCLUDING A RECENT COLLABORATION WITH THE BROOKSHIRE BROTHERS GROCERY CHAIN TO AID IN COMMUNAL VACCINATIONS. MMC-LIVINGSTON PART V, SECTION B, LINE 6A: CHI ST. LUKE'S HEALTH MEMORIAL - LUFKIN, TXCHI ST. LUKE'S HEALTH - SAN AUGUSTINE, TX MMC-LIVINGSTON PART V, SECTION B, LINE 6B: IMPACT LUFKIN, SOUTHSIDE BAPTIST CHURCH, ST. ANDREW'S CHURCH, ST. PATRICK CHURCH, HOSPICES IN THE PINES, CITY OF LUFKIN, ANGELINA COLLEGE, TLL TEMPLE FOUNDATION, ULTRASOUND/VASCULAR, LUFKIN ISD, ANGELINA COUNTY AND CITIES HEALTH DISTRICT, MINISTERIAL ALLIANCE, ANGELINA COUNTY COALITION, ADAC, AMERICAN CANCER SOCIETY, LOVE INC, TIMBER CREEK CHURCH, CITY CHURCH LUFKIN, ABUNDANT LIFE UNITED METHODIST CHURCH. MMC-LIVINGSTON PART V, SECTION B, LINE 7D: CHI ST LUKE'S HEALTH MEMORIAL ALSO PARTNERS WITH OUR LOCAL NEWSPAPER AS WELL AS BOTH RADIO NETWORKS AND TV STATIONS. DR SID ROBERTS OF OUR TEMPLE CANCER CENTER ALSO WRITES AN ANNUAL REPORT AND UPDATE FOR THE COMMUNITY ON THE CHNA INCLUDING HOW TO GET INVOLVED OR FIND HELP WITH KEY SERVICES AS THEY PERTAIN TO OUR COMMUNITY HEALTH IMPLEMENTATION STRATEGY. MMC-LIVINGSTON PART V, SECTION B, LINE 11: THE LIVINGSTON TEAM OPENED THEIR FIRST COMMUNITY VACCINE CLINIC IN EARLY 2021 AND CONTINUED TO RUN THE OPERATION THROUGH STRATEGIC PARTNERSHIPS WITH THE COUNTY TO HELP CREATE A LARGER VACCINE CLINIC IN THE SPRING OF 2021 IN ORDER TO ACCOMMODATE LARGER GROUPS. THE TEAM ALSO PARTNERED WITH TDEM AND POLK COUNTY EMERGENCY MANAGEMENT TO PROVIDE A MONOCLONAL ANTIBODY INFUSION CLINIC FOR THE COMMUNITY BEGINNING IN SEPTEMBER 2021.THE LIVINGSTON FACILITY HAS CONTINUED TO MAINTAIN A DRIVE-THRU TESTING SERVICE THROUGHOUT ALL OF 2021. THE LIVINGSTON TEAM HELD AN INFORMATIONAL PRESS CONFERENCE AT THE FACILITY IN SEPTEMBER AND PARTNERED WITH NEWS OUTLETS TO STRATEGICALLY SHARE THE SCOPE OF THE SERVICES BUT ALSO THE BENEFITS AS IT RELATES TO COMMUNITY HEALTH IMPROVEMENT.THE LIVINGSTON SENIOR LEADERSHIP ALSO GAVE EDUCATIONAL PRESENTATIONS FOR LOCAL GROUPS SUCH AS THE ROTARY CLUB AS WELL AS FOR LARGER BUSINESSES IN THE AREA AND DISTRIBUTED EDUCATIONAL RESOURCES FOR COVID-19 AND VACCINE INFORMATION. MMC-LIVINGSTON PART V, SECTION B, LINE 13H: THE PATIENT MUST HAVE A MINIMUM ACCOUNT BALANCE OF THIRTY-FIVE DOLLARS ($35.00) WITH THE CHI HOSPITAL ORGANIZATION. MULTIPLE ACCOUNT BALANCES MAY BE COMBINED TO REACH THIS AMOUNT. PATIENTS/GUARANTORS WITH BALANCES BELOW THIRTY-FIVE DOLLARS ($35) MAY CONTACT A FINANCIAL COUNSELOR TO MAKE MONTHLY INSTALLMENT PAYMENT ARRANGEMENTS. THE PATIENT MUST SUBMIT A COMPLETED FINANCIAL ASSISTANCE APPLICATION. PATIENT COOPERATION STANDARDS - A PATIENT MUST EXHAUST ALL OTHER PAYMENT OPTIONS, INCLUDING PRIVATE COVERAGE, FEDERAL, STATE AND LOCAL MEDICAL ASSISTANCE PROGRAMS, AND OTHER FORMS OF ASSISTANCE PROVIDED BY THIRD-PARTIES PRIOR TO BEING APPROVED. AN APPLICANT FOR FINANCIAL ASSISTANCE IS RESPONSIBLE FOR APPLYING TO PUBLIC PROGRAMS FOR AVAILABLE COVERAGE. HE OR SHE IS ALSO EXPECTED TO PURSUE PUBLIC OR PRIVATE HEALTH INSURANCE PAYMENT OPTIONS FOR CARE PROVIDED BY A CHI HOSPITAL ORGANIZATION WITHIN A HOSPITAL FACILITY. A PATIENT'S AND, IF APPLICABLE, ANY GUARANTOR'S COOPERATION IN APPLYING FOR APPLICABLE PROGRAMS AND IDENTIFIABLE FUNDING SOURCES, INCLUDING COBRA COVERAGE (A FEDERAL LAW ALLOWING FOR A TIME-LIMITED EXTENSION OF EMPLOYEE HEALTHCARE BENEFITS), SHALL BE REQUIRED. IF A HOSPITAL FACILITY DETERMINES THAT COBRA COVERAGE IS POTENTIALLY AVAILABLE, AND THAT A PATIENT IS NOT A MEDICARE OR MEDICAID BENEFICIARY, THE PATIENT OR GUARANTOR SHALL PROVIDE THE HOSPITAL FACILITY WITH INFORMATION NECESSARY TO DETERMINE THE MONTHLY COBRA PREMIUM FOR SUCH PATIENT, AND SHALL COOPERATE WITH HOSPITAL FACILITY STAFF TO DETERMINE WHETHER HE OR SHE QUALIFIES FOR HOSPITAL FACILITY COBRA PREMIUM ASSISTANCE, WHICH MAY BE OFFERED FOR A LIMITED TIME TO ASSIST IN SECURING INSURANCE COVERAGE. A HOSPITAL FACILITY SHALL MAKE AFFIRMATIVE EFFORTS TO HELP A PATIENT OR PATIENT'S GUARANTOR APPLY FOR PUBLIC AND PRIVATE PROGRAMS. PART V, LINE 7A, CHNA WEBSITE: HTTPS://WWW.STLUKESHEALTH.ORG/LOCATIONS/MEMORIAL-LIVINGSTON-HOSPITAL/COMMITMENT-COMMUNITY PART V, LINE 10A, IMPLEMENTATION PLAN WEBSITE: HTTPS://WWW.STLUKESHEALTH.ORG/LOCATIONS/MEMORIAL-LIVINGSTON-HOSPITAL/COMMITMENT-COMMUNITY PART V, LINE 16A, FAP WEBSITE: HTTPS://WWW.STLUKESHEALTH.ORG/LOCATIONS/MEMORIAL-LIVINGSTON-HOSPITAL/PATIENTS/BILLING-INSURANCE/FINANCIAL-ASSISTANCE PART V, LINE 16B, FAP APPLICATION WEBSITE: HTTPS://WWW.STLUKESHEALTH.ORG/LOCATIONS/MEMORIAL-LIVINGSTON-HOSPITAL/PATIENTS/BILLING-INSURANCE/FINANCIAL-ASSISTANCE PART V, LINE 16C, FAP PLAIN LANGUAGE SUMMARY WEBSITE: HTTPS://WWW.STLUKESHEALTH.ORG/LOCATIONS/MEMORIAL-LIVINGSTON-HOSPITAL/PATIENTS/BILLING-INSURANCE/FINANCIAL-ASSISTANCE PART I, LINE 3C: UNLESS ELIGIBLE FOR PRESUMPTIVE FINANCIAL ASSISTANCE, THE FOLLOWING ELIGIBILITY CRITERIA MUST BE MET IN ORDER FOR A PATIENT TO QUALIFY FOR FINANCIAL ASSISTANCE: * THE PATIENT MUST HAVE A MINIMUM ACCOUNT BALANCE OF THIRTY-FIVE DOLLARS ($35.00) WITH THE CHI HOSPITAL ORGANIZATION. MULTIPLE ACCOUNT BALANCES MAY BE COMBINED TO REACH THIS AMOUNT. PATIENTS/GUARANTORS WITH BALANCES BELOW THIRTY-FIVE DOLLARS ($35) MAY CONTACT A FINANCIAL COUNSELOR TO MAKE MONTHLY INSTALLMENT PAYMENT ARRANGEMENTS. * THE PATIENT'S FAMILY INCOME MUST BE AT OR BELOW 300% OF THE FPG. * THE PATIENT MUST COMPLY WITH PATIENT COOPERATION STANDARDS AS DESCRIBED [IN THE FAP]. * THE PATIENT MUST SUBMIT A COMPLETED FINANCIAL ASSISTANCE APPLICATION. FOR PATIENTS AND GUARANTORS WHO ARE UNABLE TO PROVIDE REQUIRED DOCUMENTATION, A HOSPITAL FACILITY MAY GRANT PRESUMPTIVE FINANCIAL ASSISTANCE BASED ON INFORMATION OBTAINED FROM OTHER RESOURCES. IN PARTICULAR, PRESUMPTIVE ELIGIBILITY MAY BE DETERMINED ON THE BASIS OF INDIVIDUAL LIFE CIRCUMSTANCES THAT MAY INCLUDE: * RECIPIENT OF STATE-FUNDED PRESCRIPTION PROGRAMS; * HOMELESS OR ONE WHO RECEIVED CARE FROM A HOMELESS CLINIC; * PARTICIPATION IN WOMEN, INFANTS AND CHILDREN PROGRAMS (WIC); * FOOD STAMP ELIGIBILITY; * SUBSIDIZED SCHOOL LUNCH PROGRAM ELIGIBILITY; * ELIGIBILITY FOR OTHER STATE OR LOCAL ASSISTANCE PROGRAMS (E.G., MEDICAID SPEND-DOWN); * LOW INCOME/SUBSIDIZED HOUSING IS PROVIDED AS A VALID ADDRESS; OR * PATIENT IS DECEASED WITH NO KNOWN ESTATE. PART I, LINE 7: A COST ACCOUNTING SYSTEM WAS NOT USED TO COMPUTE AMOUNTS IN THE TABLE; RATHER COSTS IN THE TABLE WERE COMPUTED USING THE ORGANIZATION'S COST-TO-CHARGE RATIO. THE COST-TO-CHARGE RATIO COVERS ALL PATIENT SEGMENTS.THE COST-TO-CHARGE RATIO FOR THE YEAR ENDED 6/30/2021 WAS COMPUTED USING THE FOLLOWING FORMULA: OPERATING EXPENSES (BEFORE RESTRUCTURING, IMPAIRMENT AND OTHER LOSSES) DIVIDED BY GROSS PATIENT REVENUE.BASED ON THAT FORMULA, $52,106,053/ $317,648,583 RESULTS IN A 16.40% COST-TO-CHARGE RATIO. PART III, LINE 2: COSTING METHODOLOGY FOR AMOUNTS REPORTED ON LINE 2 IS DETERMINED USING THE ORGANIZATION'S COST/CHARGE RATIO OF 16.40%. WHEN DISCOUNTS ARE EXTENDED TO SELF-PAY PATIENTS, THESE PATIENT ACCOUNT DISCOUNTS ARE RECORDED AS A REDUCTION IN REVENUE, NOT AS BAD DEBT EXPENSE. PART III, LINE 3: MEMORIAL MEDICAL CENTER - LIVINGSTON DOES NOT BELIEVE THAT ANY PORTION OF BAD DEBT EXPENSE COULD REASONABLY BE ATTRIBUTED TO PATIENTS WHO QUALIFY FOR FINANCIAL ASSISTANCE SINCE AMOUNTS DUE FROM THOSE INDIVIDUALS' ACCOUNTS WILL BE RECLASSIFIED FROM BAD DEBT EXPENSE TO CHARITY CARE WITHIN 30 DAYS FOLLOWING THE DATE THAT THE PATIENT IS DETERMINED TO QUALIFY FOR CHARITY CARE. PART III, LINE 4: MEMORIAL MEDICAL CENTER - LIVINGSTON DOES NOT ISSUE SEPARATE COMPANY AUDITED FINANCIAL STATEMENTS. HOWEVER, THE ORGANIZATION IS INCLUDED IN THE CONSOLIDATED FINANCIAL STATEMENTS OF COMMONSPIRIT HEALTH. THE CONSOLIDATED FOOTNOTE READS AS FOLLOWS:COMMONSPIRIT RELIES ON THE RESULTS OF DETAILED REVIEWS OF HISTORICAL WRITE-OFFS AND COLLECTIONS IN ESTIMATING THE COLLECTABILITY OF ACCOUNTS RECEIVABLE. UPDATES TO THE HINDSIGHT ANALYSIS IS PERFORMED AT LEAST QUARTERLY USING PRIMARILY A ROLLING EIGHTEEN-MONTH COLLECTION HISTORY AND WRITE-OFF DATA. SUBSEQUENT CHANGES TO ESTIMATES OF THE TRANSACTION PRICE ARE GENERALLY RECORDED AS ADJUSTMENTS TO NET PATIENT REVENUE IN THE PERIOD OF CHANGE. SUBSEQUENT CHANGES THAT ARE DETERMINED TO BE THE RESULT OF AN ADVERSE CHANGE IN A THIRD-PARTY PAYOR'S ABILITY TO PAY ARE RECORDED AS BAD DEBT EXPENSE IN PURCHASED SERVICES AND OTHER IN THE ACCOMPANYING CONSOLIDATED STATEMENTS OF OPERATIONS AND CHANGE IN NET ASSETS. BAD DEBT EXPENSE FOR 2021 AND 2020 WAS NOT SIGNIFICANT. PART III, LINE 8: COMMONSPIRIT HEALTH HOSPITALS PREPARE MEDICARE COST REPORTS IN A MANNER THAT COMPORTS WITH PROVIDER REIMBURSEMENT MANUAL (PRM) 15-1 AND PRM 15-2 CHAPTER 40 (TRANSMITTAL 13). AS SUCH, THE FOLLOWING LANGUAGE PER PRM 15-1 DESCRIBES THE COMPUTATION OF COSTS PER THE MEDICARE COST REPORT: TOTAL ALLOWABLE COSTS OF A PROVIDER ARE APPORTIONED BETWEEN PROGRAM BENEFICIARIES AND OTHER PATIENTS SO THAT THE SHARE BORNE BY THE PROGRAM IS BASED UPON ACTUAL SERVICES RECEIVED BY PROGRAM BENEFICIARIES. THE RATIO OF COVERED BENEFICIARY CHARGES TO TOTAL PATIENT CHARGES FOR THE SERVICES OF EACH ANCILLARY DEPARTMENT IS APPLIED TO THE COST OF THE DEPARTMENT. ADDED TO THIS AMOUNT IS THE COST OF ROUTINE SERVICES FOR PROGRAM BENEFICIARIES, DETERMINED ON THE BASIS OF A SEPARATE AVERAGE COST PER DIEM FOR ALL PATIENTS FOR GENERAL ROUTINE PATIENT CARE AREAS. ANOTHER FACTOR CONSIDERED IS A SEPARATE AVERAGE COST PER DIEM FOR EACH INTENSIVE CARE UNIT, CORONARY CARE UNIT, AND OTHER SPECIAL CARE INPATIENT HOSPITAL UNITS.COMMONSPIRIT HEALTH AND ITS SUBORDINATE CORPORATIONS BELIEVE THAT THE ENTIRE MEDICARE SHORTFALL FOR THE CONSOLIDATED ENTITIES, CONSTITUTES COMMUNITY BENEFIT. THE IRS COMMUNITY BENEFIT STANDARD INCLUDES THE PROVISION OF CARE TO THE ELDERLY AND MEDICARE PATIENTS. MEDICARE SHORTFALLS MUST BE ABSORBED BY COMMONSPIRIT HEALTH HOSPITALS IN ORDER TO CONTINUE TREATING THE ELDERLY IN OUR COMMUNITIES. THE HOSPITALS PROVIDE CARE REGARDLESS OF THIS SHORTFALL AND THEREBY RELIEVE THE FEDERAL GOVERNMENT OF THE BURDEN OF PAYING THE FULL COST FOR MEDICARE BENEFICIARIES. MEMORIAL MEDICAL CENTER-LIVINGSTON'S SHORTFALL, AS REPORTED ON PART III, SECTION B, LINE 7, OF $1,536,611 REPRESENTS THE FILING ORGANIZATION'S MEDICARE COST REPORTS. PART III, LINE 9B: THE ORGANIZATION'S BILLING AND COLLECTIONS POLICY APPLIES TO ALL INDIVIDUALS PRESENTING FOR EMERGENCY OR OTHER MEDICALLY NECESSARY CARE. THE POLICY CONTAINS PROVISIONS FOR COLLECTING AMOUNTS DUE FROM THOSE PATIENTS WHO THE ORGANIZATION KNOWS TO QUALIFY FOR FINANCIAL ASSISTANCE EITHER THROUGH THE TRADITIONAL FINANCIAL ASSISTANCE APPLICATION PROCESS OR THROUGH PRESUMPTIVE ELIGIBILITY PROCESSES. BEFORE ENGAGING IN EXTRAORDINARY COLLECTION ACTIONS (ECAS) TO OBTAIN PAYMENT FOR EMCARE, HOSPITAL FACILITIES MUST MAKE REASONABLE EFFORTS THROUGH ITS BILLING AND COLLECTIONS PROCESSES, PURSUANT TO TREAS. REG. 1.501(R)-6(C), TO DETERMINE WHETHER AN INDIVIDUAL IS ELIGIBLE FOR FINANCIAL ASSISTANCE. IN NO EVENT WILL AN ECA BE INITIATED PRIOR TO 120 DAYS FROM THE DATE THE FACILITY PROVIDES THE FIRST POST-DISCHARGE BILLING STATEMENT (I.E., DURING THE NOTIFICATION PERIOD) UNLESS ALL REASONABLE EFFORTS HAVE BEEN MADE.HOSPITAL FACILITIES WILL NOT REFER ACCOUNTS FOR COLLECTION WHERE THE PATIENT HAS INITIALLY APPLIED FOR FINANCIAL ASSISTANCE, AND THE HOSPITAL FACILITY HAS NOT YET MADE REASONABLE EFFORTS WITH RESPECT TO THE ACCOUNT. FOR PATIENTS AND GUARANTORS WHO ARE UNABLE TO PROVIDE REQUIRED DOCUMENTATION, A HOSPITAL FACILITY MAY GRANT PRESUMPTIVE FINANCIAL ASSISTANCE BASED ON INFORMATION OBTAINED FROM OTHER RESOURCES. PATIENTS WHO QUALIFY FOR MEDICAID ARE PRESUMED TO QUALIFY FOR FULL CHARITY WRITE OFF. ANY CHARGES FOR DAYS OR SERVICES WRITTEN OFF (EXCLUDING MEDICAID DENIALS RELATED TO TIMELINESS OF BILLING, INSUFFICIENT MEDICAL RECORD DOCUMENTATION, MISSING INVOICES, AUTHORIZATION, OR ELIGIBILITY ISSUES) AS A RESULT OF A MEDICAID ARE BOOKED AS CHARITY.SOME MEDICAID PLANS OFFER COVERAGE FOR A LIMITED OR RESTRICTED LIST OF SERVICES. IF A PATIENT IS ELIGIBLE FOR MEDICAID, ANY CHARGES FOR DAYS OR SERVICES NOT COVERED BY THE PATIENT'S COVERAGE MAY BE WRITTEN OFF TO CHARITY WITHOUT A COMPLETED APPLICATION. THIS DOES NOT INCLUDE ANY SHARE OF COST (SOC) OR OTHER PATIENT COST-SHARING AMOUNTS SUCH AS DEDUCTIBLES OR COPAYMENTS, AS SUCH COSTS ARE DETERMINED BY THE STATE TO BE AN AMOUNT THAT THE PATIENT MUST PAY BEFORE THE PATIENT IS ELIGIBLE FOR MEDICAID. HEALTH AND HUMAN SERVICES (HSS) USES THE TERM "SPEND DOWN" INSTEAD OF SHARE OF COST.ALL COLLECTION ACTIVITIES CONDUCTED BY THE FACILITY, A DESIGNATED SUPPLIER, OR ITS THIRD-PARTY COLLECTION AGENTS WILL BE IN CONFORMANCE WITH ALL FEDERAL AND STATE LAWS GOVERNING DEBT COLLECTION PRACTICES. ALL THIRD-PARTY AGREEMENTS GOVERNING COLLECTION AND RECOVERY ACTIVITIES MUST INCLUDE A PROVISION REQUIRING COMPLIANCE WITH THE HOSPITAL FACILITIES' FINANCIAL ASSISTANCE AND BILLING AND COLLECTIONS POLICY AND INDEMNIFICATION FOR FAILURES AS A RESULT OF ITS NONCOMPLIANCE. THIS INCLUDES, BUT IS NOT LIMITED TO, AGREEMENTS BETWEEN THIRD PARTIES WHO SUBSEQUENTLY SELL OR REFER DEBT OF THE HOSPITAL FACILITY. PART VI, LINE 2: OUR FACILITIES HEAVILY LEAN INTO THE SURVEYING PROCESS AS PROVIDED BY THE RESEARCH TEAM OF TEXAS A&M. IN ADDITION, SEVERAL OTHER NON-PROFIT ORGANIZATIONS IN THE AREA ALSO CONDUCT THEIR OWN INDIVIDUAL SURVEYS AND SHARE THEIR FINDINGS WITH OUR HOSPITAL ADMINISTRATORS. PART VI, LINE 3: NOTIFICATION ABOUT THE AVAILABILITY OF FINANCIAL ASSISTANCE FROM CHI HOSPITAL ORGANIZATIONS SHALL BE DISSEMINATED BY VARIOUS MEANS, WHICH MAY INCLUDE, BUT NOT BE LIMITED TO: * CONSPICUOUS PUBLICATION OF NOTICES IN PATIENT BILLS; * NOTICES POSTED IN EMERGENCY ROOMS, URGENT CARE CENTERS, ADMITTING/REGISTRATION DEPARTMENTS, BUSINESS OFFICES, AND AT OTHER PUBLIC PLACES AS A HOSPITAL FACILITY MAY ELECT; AND * PUBLICATION OF A SUMMARY OF THIS POLICY ON THE HOSPITAL FACILITY'S WEBSITE AND AT OTHER PLACES WITHIN THE COMMUNITIES SERVED BY THE HOSPITAL FACILITY AS IT MAY ELECT. SUCH NOTICES AND SUMMARY INFORMATION SHALL INCLUDE A CONTACT NUMBER AND SHALL BE PROVIDED IN ENGLISH, SPANISH, AND OTHER PRIMARY LANGUAGES SPOKEN BY THE POPULATION SERVED BY AN INDIVIDUAL HOSPITAL FACILITY, AS APPLICABLE. REFERRAL OF PATIENTS FOR FINANCIAL ASSISTANCE MAY BE MADE BY ANY MEMBER OF THE CHI HOSPITAL ORGANIZATION NON-MEDICAL OR MEDICAL STAFF, INCLUDING PHYSICIANS, NURSES, FINANCIAL COUNSELORS, SOCIAL WORKERS, CASE MANAGERS, CHAPLAINS, AND RELIGIOUS SPONSORS. A REQUEST FOR ASSISTANCE MAY BE MADE BY THE PATIENT OR A FAMILY MEMBER, CLOSE FRIEND, OR ASSOCIATE OF THE PATIENT, SUBJECT TO APPLICABLE PRIVACY LAWS.IN ADDITION, HOSPITAL REGISTRATION CLERKS ARE TRAINED TO PROVIDE CONSULTATION TO THOSE WHO HAVE NO INSURANCE OR POTENTIALLY INADEQUATE INSURANCE CONCERNING THEIR FINANCIAL OPTIONS INCLUDING APPLICATION FOR MEDICAID AND FOR ASSISTANCE UNDER THE FINANCIAL ASSISTANCE POLICY. COUNSELORS ASSIST MEDICARE ELIGIBLE PATIENTS IN ENROLLMENT BY PROVIDING REFERRALS TO THE APPROPRIATE GOVERNMENT AGENCIES. ONCE IT IS DETERMINED THAT THE PATIENT DOES NOT QUALIFY FOR ANY THIRD PARTY FUNDING, THE PATIENT IS VERBALLY NOTIFIED ABOUT THE EXISTENCE OF FINANCIAL ASSISTANCE APPLICATION AND ADDITIONAL SCREENING TAKES PLACE BY A HOSPITAL EMPLOYEE TO DETERMINE IF THE PATIENT IS ELIGIBLE FOR CHARITY SERVICE PRIOR TO DISCHARGE. UPON REGISTRATION (AND ONCE ALL EMTALA REQUIREMENTS ARE MET), PATIENTS WHO ARE IDENTIFIED AS UNINSURED (AND NOT COVERED BY MEDICARE OR MEDICAID) ARE PROVIDED WITH A PACKET OF INFORMATION THAT ADDRESSES THE FINANCIAL ASSISTANCE POLICY, THE PLAIN LANGUAGE SUMMARY OF THAT POLICY, AND AN APPLICATION FOR ASSISTANCE. HOSPITAL REGISTRATION CLERKS READ THE ORGANIZATION'S MEDICAL ASSISTANCE POLICY TO THOSE WHO APPEAR TO BE INCAPABLE OF READING, AND PROVIDE TRANSLATORS FOR NON-ENGLISH-SPEAKING INDIVIDUALS. PATIENTS THAT HAVE BEEN DISCHARGED PRIOR TO CHARITY SCREENING, SUCH AS EMERGENCY ROOM PATIENTS, RECEIVE A WRITTEN NOTIFICATION OF POSSIBLE ELIGIBILITY FOR SERVICES. IF THE PATIENT IS DETERMINED NOT TO BE ELIGIBLE FOR GOVERNMENT ASSISTANCE, HE/SHE MAY NOTIFY THE HOSPITAL THAT THEY SEEK CHARITY ASSISTANCE. THE APPROPRIATE CHARITY FORM IS SENT TO THE PATIENT/GUARANTOR FOR COMPLETION AND THEN RETURNED TO THE HOSPITAL FOR EVALUATION AND QUALIFICATION. ONCE DETERMINATION OF ELIGIBILITY IS MADE, THE PATIENT IS SENT A NOTICE INFORMING HIM/HER IF THEY QUALIFY FOR FULL, PARTIAL, OR NO CHARITY CARE SERVICES.HOSPITAL FACILITIES MUST MAKE REASONABLE EFFORTS THROUGH ITS BILLING AND COLLECTIONS PROCESSES, PURSUANT TO TREAS. REG. 1.501(R)-6(C), TO DETERMINE WHETHER ANY INDIVIDUAL IS ELIGIBLE FOR FINANCIAL ASSISTANCE. PART VI, LINE 4: THE EAST TEXAS MEMORIAL MARKET IS PRIMARILY A RURAL REGION COMPRISED OF MANY SMALLER TOWNS AND TOWNSHIPS. LUFKIN SERVES AS THE BIGGEST 'HUB' BEFORE HOUSTON. THE POPULATION IS PRIMARILY WHITE BUT THE LATINO POPULATION IS ON THE RISE. LUFKIN IN PARTICULAR HAS BOTH AFRICAN AMERICAN, FILIPINO, AND VIETNAMESE COMMUNITIES AS WELL. THE REGION IS MIDDLE TO LOWER CLASS INCOME WITH A LARGE PERCENTAGE OF CITIZENS AT OR BELOW THE POVERTY LEVEL. WHILE THERE ARE SOME CLINICS IN THE SMALLER TOWNS, LUFKIN, LIVINGSTON, SAN AUGUSTINE AND NACOGDOCHES (NOT A CHI FACILITY) PROVIDE THE MOST EXTENSIVE HEALTH CARE FOR THE REGION. AS DEPICTED IN THE CHNA, ACCESS AND TRANSPORTATION TO THESE HEALTH HUBS HAS BEEN A LONG-STANDING CHALLENGE FOR THE POOR AND VULNERABLE POPULATIONS IN OUR REGION. EAST TEXAS CONTINUALLY RANKS AMONG THE HIGHEST FOR SIGNIFICANT HEALTH DISPARITIES INCLUDING LUNG CANCER, DIABETES, DRUG, AND OPIOID ADDICTION. PART VI, LINE 5: OUR MARKET CONTINUES TO OFFER HEALTH SCREENINGS AND MAINTAIN STRONG COMMUNITY PRESENCE THROUGH PARTNERSHIP OF THE MAJOR NON-PROFIT ORGANIZATIONS IN THE REGION INCLUDING COMMUNAL EVENTS (SUCH AS THE PUBLIC FAIR AND PUBLIC HEALTH FAIR). ALL THREE MARKET LOCATIONS ALSO PARTICIPATED IN COMMUNITY EVENTS INCLUDING BUSINESS-DRIVEN HEALTH FAIRS. A KEY STRATEGY FOR PROMOTING HEALTHY LIVING HAS BEEN TO RELY ON LOCAL MINISTERIAL ALLIANCE FOR REACHING AND MOBILIZING CONGREGATION MEMBERS. PART VI, LINE 6: THE ORGANIZATION IS AFFILIATED WITH COMMONSPIRIT HEALTH. COMMONSPIRIT HEALTH WAS CREATED BY THE ALIGNMENT OF CATHOLIC HEALTH INITIATIVES AND DIGNITY HEALTH IN EARLY 2019. COMMONSPIRIT HEALTH, A NONPROFIT, FAITH-BASED HEALTH SYSTEM IS COMMITTED TO BUILDING HEALTHIER COMMUNITIES, ADVOCATING FOR THOSE WHO ARE POOR AND VULNERABLE, AND INNOVATING HOW AND WHERE HEALING CAN HAPPEN BOTH INSIDE ITS HOSPITALS AND OUT IN THE COMMUNITY. COMMONSPIRIT HEALTH OWNS AND OPERATES HEALTH CARE FACILITIES IN 21 STATES AND IS THE SOLE CORPORATE MEMBER (PARENT CORPORATION) OF OTHER PRIMARILY NONPROFIT CORPORATIONS THAT ARE EXEMPT FROM FEDERAL AND STATE INCOME TAXES. COMMONSPIRIT HEALTH IS COMPRISED OF MORE THAN 1,500 CARE SITES, CONSISTING OF 140 HOSPITALS, INCLUDING ACADEMIC HEALTH CENTERS, MAJOR TEACHING HOSPITALS, AND CRITICAL ACCESS FACILITIES, COMMUNITY HEALTH SERVICES ORGANIZATIONS, ACCREDITED NURSING COLLEGES, HOME HEALTH AGENCIES, LIVING COMMUNITIES, A MEDICAL FOUNDATION AND OTHER AFFILIATED MEDICAL GROUPS, AND OTHER FACILITIES AND SERVICES THAT SPAN THE INPATIENT AND OUTPATIENT CONTINUUM OF CARE. IN FISCAL YEAR 2021, COMMONSPIRIT HEALTH PROVIDED MORE THAN $2.5 BILLION IN FINANCIAL ASSISTANCE AND COMMUNITY BENEFIT FOR PROGRAMS AND SERVICES FOR THE POOR, FREE CLINICS, EDUCATION AND RESEARCH. FINANCIAL ASSISTANCE AND COMMUNITY BENEFIT TOTALED MORE THAN $5.1 BILLION WITH THE INCLUSION OF THE UNPAID COSTS OF MEDICARE. THE HEALTH SYSTEM, WHICH GENERATED OPERATING REVENUES OF $33.25 BILLION IN FISCAL YEAR 2021, HAS TOTAL ASSETS OF APPROXIMATELY $54.87 BILLION.COMMONSPIRIT HEALTH PROVIDES STRATEGIC PLANNING AND MANAGEMENT SERVICES AS WELL AS CENTRALIZED SERVICES FOR ITS DIVISIONS. THE PROVISION OF CENTRALIZED MANAGEMENT AND SHARED SERVICES INCLUDING AREAS SUCH AS ACCOUNTING, HUMAN RESOURCES, PAYROLL AND SUPPLY CHAIN PROVIDES ECONOMIES OF SCALE AND PURCHASING POWER TO THE DIVISIONS. THE COST SAVINGS ACHIEVED THROUGH COMMONSPIRIT HEALTH'S CENTRALIZATION ENABLE DIVISIONS TO DEDICATE ADDITIONAL RESOURCES TO HIGH-QUALITY HEALTH CARE AND COMMUNITY OUTREACH SERVICES TO THE MOST VULNERABLE MEMBERS OF OUR SOCIETY. PART VI, LINE 7, REPORTS FILED WITH STATES TX 1 THE BURKE CENTER 2001 SOUTH MEDFORD DRIVE LUFKIN TX 75901 751442393 501(C)(3) 17054 PROGRAM SUPPORT 1 0 PART I, LINE 2: MOST DISBURSEMENTS IN FURTHERANCE OF THE ORGANIZATION'S EXEMPT PROGRAMS ARE MADE DIRECTLY IN THE ACTIVE CONDUCT OF THE ACTIVITIES CONSTITUTING THE EXEMPT PURPOSE OR FUNCTION OF THE ORGANIZATION. OTHERWISE, DISTRIBUTIONS IN FURTHERANCE OF THE INSTITUTION'S EXEMPT PROGRAMS ARE MADE IN ACCORDANCE WITH PROCEDURES OR SUBJECT TO CONDITIONS ESTABLISHED BY THE INSTITUTION'S GOVERNING BOARD OR MANAGEMENT DESIGNED TO ENSURE THAT RECIPIENTS OF SUCH DISBURSEMENTS FROM THE ORGANIZATION ARE ADEQUATELY INVESTIGATED AND GRANTED TO QUALIFIED RECIPIENTS. 1 1 0 0 0 0 0 0 0 T DOUGLAS LAWSON PHD PRES & CEO CHI ST. LUKE'S HEALTH SYS 0 958843 0 1006996 0 150480 0 182377 0 21437 0 2320133 0 117000 MONTE BOSTWICK MARKET CEO 0 391555 0 43229 0 24820 0 36938 0 30978 0 527520 0 18692 ERIC ROBINSON COO 0 272450 0 56545 0 1067 0 16924 0 31430 0 378416 0 0 KRISTINA FROESE CNO 177669 0 7242 0 579 0 11047 0 30753 0 227290 0 0 0 SHELLI BROOKS CFO 0 146716 0 3227 0 12962 0 8545 0 10571 0 182021 0 0 TAMANIKA FITE DIRECTOR OF PHARMACY 158484 0 1969 0 202 0 6254 0 18355 0 185264 0 0 0 MIGUEL GARCIA MARKET DIRECTOR IMAGING SERVICES 22574 128540 0 5590 0 187 0 9267 360 14745 22934 158329 0 0 DUANE MILLER FORMER CFO 0 0 0 0 0 128593 0 3215 0 0 0 131808 0 0 NICHOLAS FONTENOT CLINICAL PHARMACIST I 122937 0 625 0 105 0 6996 0 25312 0 155975 0 0 0 PART I, LINE 3 DURING THE CALENDAR YEAR 2020, COMPENSATION FOR THE TOP MANAGEMENT OFFICIAL WAS ESTABLISHED AND PAID BY COMMONSPIRIT HEALTH, A RELATED ORGANIZATION. COMMONSPIRIT HEALTH USED THE FOLLOWING TO ESTABLISH THE TOP MANAGEMENT OFFICIAL'S COMPENSATION: (1) COMPENSATION COMMITTEE; (2) INDEPENDENT COMPENSATION CONSULTANT; (3) COMPENSATION SURVEY OR STUDY; (4) APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE. PART I, LINE 4A: FOR REPORTABLE INDIVIDUALS EMPLOYED PRIOR TO 2019, POST-TERMINATION PAYMENTS ARE ADDRESSED IN EXECUTIVE EMPLOYMENT AGREEMENTS FOR EMPLOYEES AT THE LEVEL OF VICE PRESIDENT AND ABOVE. THESE EMPLOYMENT AGREEMENTS REQUIRE THAT IN ORDER FOR THE EXECUTIVE TO RECEIVE POST-TERMINATION PAYMENTS, THESE INDIVIDUALS MUST EXECUTE A GENERAL RELEASE AND SETTLEMENT AGREEMENT. POST-TERMINATION PAYMENT ARRANGEMENTS ARE PERIODICALLY REVIEWED FOR OVERALL REASONABLENESS IN LIGHT OF THE EXECUTIVE'S OVERALL COMPENSATION PACKAGE. OFFICERS, KEY EMPLOYEES AND CERTAIN HIGHLY COMPENSATED EMPLOYEES WHO BEGAN EMPLOYMENT AFTER NOVEMBER 1ST OF 2019 ARE COVERED BY THE COMMONSPIRIT HEALTH EXECUTIVE SEVERANCE POLICY. THIS POLICY PROVIDES FOR SEVERANCE PAY WHICH VARIES BASED UPON THE EXECUTIVE'S POSITION LEVEL, IN THE EVENT OF A POSITION ELIMINATION OR OTHER QUALIFYING EVENT, IN ACCORDANCE WITH THE GUIDELINES OF THE EXECUTIVE SEVERANCE POLICY. AN EXECUTIVE'S WRITTEN EMPLOYMENT OR SEVERANCE AGREEMENT SHALL CONTROL WHERE THE SEVERANCE PAY AMOUNTS IN THE POLICY CONFLICT WITH THE EXECUTIVE'S WRITTEN EMPLOYMENT OR SEVERANCE AGREEMENT. IN ORDER FOR THE EXECUTIVE TO RECEIVE POST-TERMINATION PAYMENTS, THESE INDIVIDUALS MUST EXECUTE A GENERAL RELEASE AND SETTLEMENT OF CLAIMS. POST-TERMINATION PAYMENT ARRANGEMENTS ARE PERIODICALLY REVIEWED FOR OVERALL REASONABLENESS IN LIGHT OF THE EXECUTIVE'S OVERALL COMPENSATION PACKAGE. THE FOLLOWING REPORTABLE INDIVIDUALS RECEIVED SEVERANCE PAYMENTS FROM COMMONSPIRIT HEALTH (A RELATED ORGANIZATION) DURING THE 2020 CALENDAR YEAR, AND THESE SEVERANCE PAYMENTS WERE INCLUDED IN THE INDIVIDUALS' W-2 INCOME AND REPORTABLE COMPENSATION ON PART VII AND SCHEDULE J, PART II, COLUMN (B)(III): DUANE MILLER, $128,593. PART I, LINE 4B: DURING THE 2020 CALENDAR YEAR, COMMONSPIRIT HEALTH ("COMMONSPIRIT") MAINTAINED A SUPPLEMENTAL NON-QUALIFIED DEFERRED COMPENSATION PLAN FOR DIVISION CEOS/PRESIDENTS AND OTHER DESIGNATED COMMONSPIRIT EXECUTIVES AT THE LEVEL OF SENIOR VICE PRESIDENT AND ABOVE. DURING 2020 THE FOLLOWING DISTRIBUTIONS WERE MADE BY COMMONSPIRIT FROM THE DEFERRED COMPENSATION PLAN: MONTE BOSTWICK, $21,470 AND T. DOUGLAS LAWSON, $136,636. DUE TO THE "SUPER" VESTING RULES UNDER COMMONSPIRIT'S DEFERRED COMPENSATION PLAN, PARTICIPANTS WHO HAVE MET CERTAIN REQUIREMENTS SUCH AS INVOLUNTARY TERMINATION WITHOUT CAUSE, AGE, AGE AND YEARS OF SERVICE, OR MORE THAN 5 YEARS OF PLAN PARTICIPATION ARE ELIGIBLE TO RECEIVE THEIR 2020 CONTRIBUTIONS IN CASH. THESE CASH PAYOUTS ARE INCLUDED IN THE PARTICIPANT'S REPORTABLE COMPENSATION IN COLUMN (III) OTHER REPORTABLE COMPENSATION ON SCHEDULE J PART II. FORM 990, PART V, LINE 1A: PAYMENTS TO VENDORS FOR ENTITIES THAT ARE PART OF COMMONSPIRIT HEALTH (CSH) ARE MADE BY CSH. CSH FILES THE FORM 1099S AND COMPLIES WITH THE BACKUP WITHHOLDING RULES FOR REPORTABLE PAYMENTS TO VENDORS AND GAMING WINNINGS. THE 1099'S ISSUED BY CSH ON BEHALF OF MEMORIAL MEDICAL CENTER - LIVINGSTON ARE REPORTED TO THE IRS. FORM 990, PART VI, SECTION A, LINE 2 CORKY EVANS AND JUDY COCHRAN - BUSINESS RELATIONSHIP TREY DENMAN AND STEPHEN RALEY - BUSINESS AND FAMILY RELATIONSHIP FORM 990, PART VI, SECTION A, LINE 6 MEMORIAL HEALTH SYSTEM OF EAST TEXAS IS THE SOLE CORPORATE MEMBER. FORM 990, PART VI, SECTION A, LINE 7A THE BOARD OF DIRECTORS OF THE SOLE MEMBER (MEMORIAL HEALTH SYSTEM OF EAST TEXAS) ALSO SERVE AS MEMBERS OF THE BOARD OF DIRECTORS OF MMC- LIVINGSON . THE MANAGEMENT OF MHSET PROVIDES OVERSIGHT OF FINANCIAL AND CLINICAL OPERATIONS. FORM 990, PART VI, SECTION A, LINE 7B THE MEMBER (MEMORIAL HEALTH SYSTEM OF EAST TEXAS) APPROVES THE INDIVIDUALS SELECTED TO THE BOARD OF DIRECTORS OF MMC-LIVINGSTON AND HAS FINAL APPROVAL OF ALL ACTIONS OF THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION B, LINE 11B THE BOARD OF DIRECTORS, BY RESOLUTION, APPOINTS A SPECIAL COMMITTEE TO REVIEW FORM 990. ONCE THE RETURN IS COMPLETED, IT IS PROVIDED TO THIS COMMITTEE FOR THEIR REVIEW AND APPROVAL FOR FILING. EMPLOYEES OF THE CORPORATION RESPONSIBLE FOR THE PREPARATION AND REVIEW OF THE RETURN ARE AVAILABLE TO RESPOND TO QUESTIONS OR PROVIDE BACKGROUND AS NEEDED. ONCE THE DIRECTORS RESPONSIBLE FOR REVIEWING THE RETURN ARE SATISFIED IT IS COMPLETE, THE RETURN IS APPROVED TO BE FILED. SUBSEQUENT TO PRESENTATION TO THE BOARD'S COMMITTEE, THE TAX DEPARTMENT FILES THE RETURN WITH THE IRS, MAKING ANY NON-SUBSTANTIVE CHANGES NECESSARY TO EFFECT E-FILING. ANY SUCH CHANGES ARE NOT RE-SUBMITTED TO THE COMMITTEE. AFTER FILING, THE RETURN IS MADE AVAILABLE TO ALL DIRECTORS FOR THEIR REVIEW. FORM 990, PART VI, SECTION B, LINE 12C THE ORGANIZATION HAS A CONFLICTS OF INTEREST ("COI") POLICY (THE "POLICY") IN PLACE TO PROTECT THE INTERESTS OF COMMONSPIRIT HEALTH ("COMMONSPIRIT") IN CIRCUMSTANCES THAT MAY RESULT IN A CONFLICT BETWEEN PERSONAL INTERESTS OF A PERSON AND THE INTERESTS OF THE ORGANIZATION AND THOSE IT SERVES. THE POLICY WAS LAST UPDATED DURING THE TAX YEAR ENDED 6/30/2021. COMMONSPIRIT'S COI POLICY APPLIES TO COMMONSPIRIT, ITS DIRECT AFFILIATES AND SUBSIDIARIES AND ANY RELATED ENTITY THE GOVERNING DOCUMENTS OF WHICH REQUIRE THE ENTITY TO COMPLY WITH COMMONSPIRIT POLICY (COLLECTIVELY THE "SYSTEM ENTITIES"). THE FOLLOWING PERSONS ARE REQUIRED TO DISCLOSE ACTUAL OR POTENTIAL CONFLICTS OF INTEREST AT LEAST ANNUALLY (VIA A FORMAL SYSTEM-ADMINISTERED SURVEY) IF THE PERSON'S AFFILIATION WITH COMMONSPIRIT CONTINUES: - MEMBERS OF CORPORATE AND COMMUNITY BOARDS OF SYSTEM ENTITIES - MEMBERS OF COMMITTEES OF CORPORATE AND COMMUNITY BOARDS OF SYSTEM ENTITIES - MEMBERS OF THE EXECUTIVE LEADERSHIP TEAM ("ELT") OF COMMONSPIRIT - CORPORATE OFFICERS OF SYSTEM ENTITIES - EMPLOYEES OF SYSTEM ENTITIES AT THE VICE PRESIDENT LEVEL AND ABOVE - ALL INDIVIDUALS ENGAGED IN RESEARCH AT INSTITUTIONS OWNED OR OPERATED BY A SYSTEM ENTITY. - SELECT EMPLOYEES AS DETERMINED FROM TIME TO TIME BY LEADERSHIP (WHICH INCLUDES KEY EMPLOYEES AND HIGHEST COMPENSATED EMPLOYEES AS SPECIFIED BY THE INTERNAL REVENUE SERVICE FOR FORM 990 PURPOSES WHO ARE NOT OTHERWISE INCLUDED IN THE CATEGORIES ABOVE). DISCLOSURE, REVIEW, AND MANAGEMENT OF PERCEIVED, POTENTIAL, OR ACTUAL CONFLICTS OF INTEREST ARE ACCOMPLISHED THROUGH A DEFINED COI DISCLOSURE REVIEW PROCESS. EACH PERSON IS REQUIRED TO PROMPTLY AND FULLY DISCLOSE ANY SITUATION OR CIRCUMSTANCE THAT MAY CREATE A CONFLICT OF INTEREST AS SOON AS SHE/HE BECOMES AWARE OF IT. IN ADDITION, AT THE INCEPTION OF AN INDIVIDUAL'S RELATIONSHIP WITH COMMONSPIRIT (E.G. HIRING, BOARD APPOINTMENT), AND FOR CERTAIN POSITIONS, ANNUALLY THEREAFTER, WRITTEN CONFLICT OF INTEREST DISCLOSURE FORMS MUST BE COMPLETED. A FAILURE TO DISCLOSE MAY RESULT IN DISCIPLINARY OR CORRECTIVE ACTIONS. REPORTED POTENTIAL OR ACTUAL CONFLICTS OF INTEREST ARE INITIALLY REVIEWED BY LEGAL, CORPORATE RESPONSIBILITY OR RESEARCH INTEGRITY STAFF. IF NECESSARY, A CONFLICT OF INTEREST MANAGEMENT PLAN IS DEVELOPED, WHICH PLAN SHALL BE SUBJECT TO ACCEPTANCE BY THE APPROPRIATE DIRECT MANAGER, SUPERVISOR, MEDICAL STAFF OFFICE, BOARD OR BOARD COMMITTEE (FOR BOARD, BOARD COMMITTEE, ELT OR CORPORATE OFFICER CONFLICTS), OR OTHER APPROPRIATE INDIVIDUAL OR BODY. ONCE ACCEPTED, THE CONFLICT OF INTEREST MANAGEMENT PLAN IS COMMUNICATED TO THE PERSON WITH THE ACTUAL OR POTENTIAL CONFLICT AND THE INDIVIDUAL MUST CONDUCT THEMSELVES IN CONFORMITY WITH THE PLAN. IN THE EVENT THAT A TRANSACTIONAL CONFLICT INTEREST ARISES IN CONNECTION WITH A SYSTEM ENTITY BOARD MEETING, THE CONFLICTED INDIVIDUAL MUST DISCLOSE THAT CONFLICT PRIOR TO OR AT THE BEGINNING OF THE MEETING IN WHICH THE MATTER IS TO BE CONSIDERED. THE CONFLICTED INDIVIDUAL IS EXCLUDED FROM VOTING ON THE TRANSACTION AND IS PROHIBITED FROM USING PERSONAL INFLUENCE WITH RESPECT TO THE MATTER, BUT IS NOT PROHIBITED FROM PROVIDING INPUT IF REQUESTED TO DO SO. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S FINANCIAL STATEMENTS, CONFLICT OF INTEREST POLICY AND GOVERNING DOCUMENTS ARE AVAILABLE TO THE PUBLIC UPON REQUEST. THE ORGANIZATION'S FINANCIAL STATEMENTS ARE INCLUDED IN COMMONSPIRIT HEALTH'S CONSOLIDATED AUDITED FINANCIAL STATEMENTS THAT ARE AVAILABLE AT WWW.COMMONSPIRIT.ORG. FORM 990, PART VI, SECTION B, LINE 15A: DURING THE TAX YEAR ENDED 6/30/2021, NO OFFICERS, DIRECTORS OR TRUSTEES RECEIVED COMPENSATION FROM THE ORGANIZATION. ANY EXECUTIVE COMPENSATION PAID TO OFFICERS, DIRECTORS OR TRUSTEES BY RELATED ORGANIZATIONS WAS SET BY THE RELATED ORGANIZATION'S COMPENSATION COMMITTEE UTILIZING BOTH AN INDEPENDENT CONSULTANT AND COMPARABILITY STUDIES TO DETERMINE COMPENSATION. THEREFORE, THESE QUESTIONS ARE MORE APPROPRIATELY ANSWERED AS N/A. FORM 990, PART IX, LINE 11G OTHER FEES FOR SERVICES: PROGRAM SERVICE EXPENSES 2,621,852. MANAGEMENT AND GENERAL EXPENSES 137,992. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,759,844. CONSULTING: PROGRAM SERVICE EXPENSES 9,500. MANAGEMENT AND GENERAL EXPENSES 500. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 10,000. CONTRACT SERVICES: PROGRAM SERVICE EXPENSES 329,485. MANAGEMENT AND GENERAL EXPENSES 36,609. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 366,094. CONTRACT LABOR: PROGRAM SERVICE EXPENSES 5,151,154. MANAGEMENT AND GENERAL EXPENSES 271,113. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 5,422,267. PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 4,201,671. MANAGEMENT AND GENERAL EXPENSES 221,142. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 4,422,813. FORM 990, PART XI, LINE 9: REALLOCATION OF CARES ACT REVENUE 2,343,994. FORM 990, PART XI, LINE 8 PRIOR PERIOD ADJUSTMENT: CENTRALIZED TRANSACTIONS: TRANSFERS FOR JOURNAL ENTRIES RECORDED CENTRALLY AT COMMONSPIRIT TO STANDARDIZE CONTRACTUAL ALLOWANCE METHODOLOGY ACROSS ALL COMMONSPIRIT AFFILIATES AND SUBSIDIARIES. RECORDED CENTRALLY AT YEAR END AND TRANSFERRED TO FACILITIES IN THE FOLLOWING YEAR. ALEGENT CREIGHTON CLINIC 12809 W DODGE RD OMAHA NE 68154 470765154 HOSPITAL NE 501(C)(3) LINE 3 ACH 0 ALEGENT CREIGHTON HEALTH 12809 W DODGE RD OMAHA NE 68154 470757164 HOSPITAL NE 501(C)(3) LINE 3 CHI NEBRASKA 0 ALEGENT HEALTH - BERGAN MERCY HEALTH SYSTEM 7500 MERCY RD OMAHA NE 68124 470484764 HOSPITAL NE 501(C)(3) LINE 3 CHI NEBRASKA 0 ALEGENT HEALTH - COMM MEM HOSP OF MO VALLEYIA 631 N 8TH ST MISSOURI VALLEY IA 51555 420776568 HOSPITAL IA 501(C)(3) LINE 3 CHI NEBRASKA 0 ALEGENT HEALTH - IMMANUEL MEDICAL CENTER 6901 N 72ND ST OMAHA NE 68122 470376615 HOSPITAL NE 501(C)(3) LINE 3 CHI NEBRASKA 0 ALEGENT HEALTH - MEMORIAL HOSPITAL SCHUYLER 104 W 17TH ST SCHUYLER NE 68661 470399853 HOSPITAL NE 501(C)(3) LINE 3 CHI NEBRASKA 0 ALEGENT HEALTH - MERCY HOSPITAL CORNING IOWA PO BOX 368 CORNING IA 50841 420782518 HOSPITAL IA 501(C)(3) LINE 3 CHI NEBRASKA 0 ALVERNA APARTMENTS 300 SE 8TH AVE LITTLE FALLS MN 56345 411351177 LTERM CARE MN 501(C)(3) LINE 10 CSH 0 APPLETREE COURT 601 OAK ST BRECKENRIDGE MN 56520 411850500 SENIOR LIVING MN 501(C)(3) LINE 10 SFH 0 ARROYO GRANDE COMMUNITY HOSPITAL FOUNDATION 345 S HALCYON RD ARROYO GRANDE CA 93420 203256066 FUNDRAISING FOUNDATION CA 501(C)(3) LINE 12A, I DH 0 BAKERSFIELD MEMORIAL HOSPITAL 420 34TH STREET BAKERSFIELD CA 93301 951802779 HOSPITAL CA 501(C)(3) LINE 3 DCC 0 BARROW NEUROLOGICAL FOUNDATION 350 WEST THOMAS ROAD PHOENIX AZ 85013 860174371 FUNDRAISING FOUNDATION AZ 501(C)(3) LINE 7 DH 0 BAYLOR ST LUKE'S HEALTH VENTURES 17200 ST LUKES WAY STE 170 THE WOODLANDS TX 77384 274499340 PHYSICIANS TX 501(C)(3) LINE 12A, I SLHS 0 BAYLOR ST LUKE'S MEDICAL GROUP 6624 FANNIN ST STE 1100 HOUSTON TX 77030 760458535 PHYSICIANS TX 501(C)(3) LINE 3 BSLHV 0 BORNEMANN HEALTHCARE CORPORATION 198 INVERNESS DRIVE WEST ENGLEWOOD CO 80112 232187242 INACTIVE PA 501(C)(3) LINE 12A, I CSH 0 BRAZOSPORT HEALTH FOUNDATION INC 1 WEST WAY CT LAKE JACKSON TX 77566 760080110 FUNDRAISING FOUNDATION TX 501(C)(3) LINE 12A, I TCHB 0 BRAZOSPORT REGIONAL PHYSICIAN SERVICES 100 MEDICAL DRIVE LAKE JACKSON TX 77566 800240261 PHYSICIANS TX 501(C)(3) LINE 3 TCHB 0 BURLESON ST JOSEPH HEALTH CENTER 2801 FRANCISCAN DRIVE BRYAN TX 77802 742759890 HOSPITAL TX 501(C)(3) LINE 3 SJSC 0 BURLESON ST JOSEPH MANOR 2801 FRANCISCAN DRIVE BRYAN TX 77802 742913931 REHABILITATION TX 501(C)(3) LINE 10 SJSC 0 CALIFORNIA HOSPITAL MEDICAL CENTER FOUNDATION 1401 SOUTH GRAND AVENUE LOS ANGELES CA 90015 954000909 FUNDRAISING FOUNDATION CA 501(C)(3) LINE 12A, I DCC 0 CARRINGTON HEALTH CENTER 800 N 4TH ST CARRINGTON ND 58421 450227311 HOSPITAL ND 501(C)(3) LINE 3 CSH 0 CATHOLIC HEALTH INITIATIVES - COLORADO 9100 EAST MINERAL CIRCLE CENTENNIAL CO 80112 840405257 HOSPITAL CO 501(C)(3) LINE 3 CSH 0 CATHOLIC HEALTH INITIATIVES - IOWA CORP 1111 6TH AVE DES MOINES IA 50314 420680448 HOSPITAL IA 501(C)(3) LINE 3 CSH 0 CATHOLIC HEALTH INITIATIVES COLORADO FOUNDATION 9100 EAST MINERAL CIRCLE CENTENNIAL CO 80112 840902211 FUNDRAISING FOUNDATION CO 501(C)(3) LINE 7 CHIC 0 CATHOLIC HEALTH INITIATIVES NATIONAL FOUNDATION 1150 KELLY JOHNSON BLVD 204 COLORADO SPRINGS CO 80920 270930004 FUNDRAISING FOUNDATION CO 501(C)(3) LINE 12A, I CSH 0 CATHOLIC HEALTH INITIATIVES VIRTUAL HEALTH SERVICES 198 INVERNESS DRIVE WEST ENGLEWOOD CO 80112 460992796 TELEHEALTH CO 501(C)(3) LINE 12A, I CHI NS 0 CENTENNIAL MEDICAL GROUP INC 2700 STEWART PKWY ROSEBURG OR 97471 263946191 SURGERY CENTER OR 501(C)(3) LINE 10 MMC - ROSEBURG 0 CENTRAL CALIFORNIA HEALTH CENTERS 300 OLD RIVER ROAD STE 200 BAKERSFIELD CA 93311 844171789 CLINIC CA 501(C)(3) LINE 3 DCC 0 CENTRAL KANSAS MEDICAL CENTER 3515 BROADWAY GREAT BEND KS 67530 480543724 INACTIVE KS 501(C)(3) LINE 3 CSH 0 CHI HEALTH CONNECT AT HOME - FARGO 4816 AMBER VALLEY PKWY S FARGO ND 58104 271966847 SENIOR LIVING MN 501(C)(3) LINE 10 CSH 0 CHI HEALTH FOUNDATION 12809 W DODGE RD OMAHA NE 68154 470648586 FUNDRAISING FOUNDATION NE 501(C)(3) LINE 7 ACH 0 CHI KENTUCKY INC 3900 OLYMPIC BLVD STE 400 ERLANGER KY 41018 202741651 INVESTMENTS KY 501(C)(3) LINE 12A, I CSH 0 CHI LIVING COMMUNITIES 5942 RENAISSANCE PLACE STE A TOLEDO OH 43623 341892096 SENIOR LIVING OH 501(C)(3) LINE 12A, I SFH-OH 0 CHI MEMORIAL HOSPITAL - GEORGIA 100 GROSS CRESCENT CIRCLE FORT OGLETHORPE GA 30742 822748395 HOSPITAL GA 501(C)(3) LINE 3 MHCS 0 CHI NATIONAL HOME CARE 198 INVERNESS DRIVE WEST ENGLEWOOD CO 80112 451261716 HOME HEALTH CO 501(C)(3) LINE 10 CHI NS 0 CHI NATIONAL SERVICES 198 INVERNESS DRIVE WEST ENGLEWOOD CO 80112 452532084 HOLDING CO CO 501(C)(3) LINE 12A, I CSH 0 CHI NEBRASKA 12809 WEST DODGE ROAD OMAHA NE 68510 363233121 HOLDING CO NE 501(C)(3) LINE 12A, I CSH 0 CHI ST JOSEPH CHILDREN'S HEALTH 1929 LINCOLN HWY E STE 150 LANCASTER PA 17602 232342997 HEALTHCARE PA 501(C)(3) LINE 12A, I CSH 0 CHI ST JOSEPH'S CHILDREN 1516 5TH ST NW ALBUQUERQUE NM 87102 710897107 COMMUNITY NM 501(C)(3) LINE 12A, I CSH 0 CHI ST VINCENT HOSPITAL HOT SPRINGS 300 WERNER ST HOT SPRINGS AR 71913 710236913 HOSPITAL AR 501(C)(3) LINE 3 CHISVHS 0 CHI ST 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