2022-11-15T15:37:58-06:00 2021-12-31 990 2021-01-01 831869297 Texas Health Hospital Mansfield TEXA 6823415004 2300 Lone Star Road Mansfield TX 76063 Lynn C Addiscott Assistant Secretary 4073572194 2022-11-15 Lynn Addiscott 999009999 3 AAL1 IAL1 2021 2022-09-23 18:48:47Z Kenneth Rose 2300 Lone Star Road Mansfield TX 76063 33017334 0 X www.texashealth.org/texas-health-mansfield X 2018 TX The provision of medical care to the community through the operation of a 59 bed hospital. 12 7 0 7 0 0 0 111254 669226 32604343 727569 301737 0 0 1396795 33017334 95015 31830 0 0 701717 1005438 0 0 0 16566563 63161462 17363295 64198730 -15966500 -31181396 183219510 170784990 18395166 13894079 164824344 156890911 Our mission is to extend the healing ministry of Christ by identifying and meeting the health needs of our community, providing quality, costumer oriented, and cost effective services, and ensuring access to those services. 0 0 60356851 31830 32604343 Operation of a hospital totaling 59 beds with 1,226 patient admissions, 5,368 patient days, and 11,684 outpatient visits in the current year. 60356851 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 1 1 0 0 1 X 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 X 12 7 0 1 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 0 0 0 X Stephanie Nelson 6823415003 2300 Lone Star Road Mansfield TX 76063 X Bacon Kenneth Trustee (Beg. 3/21 - End 12/21) 0.20 0.30 X 0 0 0 Craft Brian Trustee/THR SVP Hospital Fin. Ops. 0.20 50.00 X 0 574902 96841 Haffner PhD Randall Trustee (Beg. 1/21 - End 3/21) 0.20 0.30 X 0 0 0 Jackson David Trustee/THR Chief Acct. Officer 0.20 50.00 X 0 535754 90372 King James Kirk Trustee/THR EVP Zone Ops. 0.20 50.00 X 0 1201569 149837 Randolph Karsten Trustee (Beg. 8/21 - End 12/21) 0.20 0.30 X 0 0 0 Soler Eddie Trustee (Beg. 1/21 - End 8/21) 0.20 0.30 X 0 0 0 Griffith Buddy Hospital Board Member 0.20 0.00 X 0 0 0 Homer MD Kevin Hospital Board Member 4.40 0.00 X 33000 0 0 Schroeder Jennifer Hospital Board Member 0.20 50.00 X 0 459823 50701 Stoecker Jennifer Hospital Board Member 0.20 0.00 X 0 0 0 Sultana MD Nazia Hospital Board Member 0.20 0.00 X 0 0 0 Sanchez Priscilla Hospital Board Member 0.20 0.00 X 0 0 0 Carroll RJ Hospital Board Member 0.20 0.00 X 0 0 0 Nelson Stephanie CFO 50.00 0.20 X 273031 0 51246 Rose Kenneth CEO 50.00 0.20 X 344066 0 97173 Johnson Penny Regional CEO 10.00 30.00 X 520364 1561091 146254 Sutton Kristen CNO 50.00 0.20 X 193441 0 46481 1363902 4333139 728905 4 0 1 1 HC Beck 1601 Elm St Ste 2800 Dallas TX 75201 General Contractor Services 2363437 Northstar Anesthesia II PA PO Box 650252 Dallas TX 752650252 Anesthesia Services 739216 Texas Health Resources 612 E Lamar Blvd Ste 600 Arlington TX 76011 Clinical Services 659024 Sound Physicians of Florida II PO Box 742936 Los Angeles CA 900742936 Physician Services 655308 Comphealth PO Box 972651 Dallas TX 753972651 Physician Services 508685 24 X 111218 36 111254 Net Patient Revenue 622110 31060647 31060647 Medical Office Building 622110 1098672 1098672 TS Allocation 622110 269408 269408 Cafeteria Revenue 622110 175616 175616 32604343 144234 144234 157503 0 157503 157503 157503 33017334 32604343 0 301737 X 31830 31830 1005438 1005438 12335 12335 38984246 37846308 1137938 789282 789282 732249 202340 529909 2569507 2427688 141819 2358518 2358518 62504 2013 60491 32729 32729 60846 60846 9641419 9641419 65556 50257 15299 Medical Supplies 6113589 6113589 Repairs & Maintenance 1593315 1593315 Dues & Memberships 116639 116639 Licenses & Permits 28728 28728 64198730 60356851 3841879 0 X 1399 1400 38616970 3736951 618558 7463835 1316606 1973469 228423 705363 163556384 10239992 140509428 153316392 691252 1370909 1236874 2216671 183219510 170784990 10737090 1809365 7658076 12084714 18395166 13894079 X 164824344 156890911 164824344 156890911 183219510 170784990 X -31181396 112394 23135569 X X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 602 602 0 Part II-B, Line 1: Dues were paid to the American Hospital Association and the Texas Hospital Association. 10064275 10064275 96570320 3041573 93528747 56658229 7198419 49459810 263560 263560 153316392 Due to related 9596239 Credit balances in A/R 30960 Operating Lease Liability 1322173 Other Liabilities 1132697 Accrued interest payable 2645 12084714 X Part X, Line 2: The Consolidated Audited Financial Statements for the twelve-month period ended 12/31/2021 include the filing organization, its member tax-exempt hospital, Texas Health Huguley Hospital (THH or the Company), and two of THH's subsidiaries: Huguley Medical Associates (HMA), a nonprofit, tax-exempt physician group and Texas Health Huguley Surgery Center, an LLC Surgery Center treated as a partnership. These Consolidated audited financial statements contain the following FIN 48 footnote: The Company is exempt from state and federal income taxes. Accordingly, the Company and its tax-exempt affiliates are not subject to federal, state, or local income taxes, except for any net unrelated business taxable income. For the years ended December 31, 2021 and 2020, unrelated business income activities conducted by the Company and its tax-exempt affiliates did not generate a material amount of combined federal, state, or local income tax. 1 1 X 1 X 0 1 1 1 0 1 0 4837213 4837213 0.07530 5328229 1257335 4070894 0.06340 10165442 1257335 8908107 0.13870 10165442 1257335 8908107 0.13870 1 5834836 383092 2770682 6967521 -4196839 X 1 1 1 1 Texas Health Hospital Mansfield 2300 Lone Star Road Mansfield TX 76063 www.texashealth.org/texas-health-mansf 100524 X X X Texas Health Hospital Mansfield 1 1 1 0 0 1 X 200.000000000000 X X X X X 1 1 X 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 Texas Health Hospital Mansfield Part V, Section B, Line 2: The filing organization was created on August 20, 2018 with the intent of constructing a new hospital facility in the North Texas community of Mansfield, Texas. Construcion of the new facility, Texas Health Hospital Mansfield (THHM), was completed during 2020 and began providing services on December 1, 2020. The four-story, nearly 200,000 square foot hospital has a capacity of 59 beds. At a cost of $150 million, THHM's campus also includes an 80,000 square foot medical office building that offers primary care and specialty practices. Texas Health Hospital Mansfield Part V, Section B, Line 13h: Effective March 1, 2020, the filing organization's hospital facility (or facilities) augmented their Financial Assistance Policy with a COVID-19 Financial Grace Addendum. Pursuant to the COVID-19 Financial Grace Addendum, uninsured patients treated for COVID-19 related evaluations are to receive free or discounted care depending on the patient's cooperation in submitting necessary financial assistance information. Insured patients tested for COVID-19 are not expected to have out-of-pocket expenses based on insurance community response to waive patient financial responsibility. If a payer unexpectedly fails to waive patient responsibility for COVID-19 related testing, the filing organization will not balance bill patients for any out-of-pocket expenses related to COVID-19. In addition, patients with existing payment plans are provided opportunities for reducing their monthly payments. Part V, Section B, Line 16a, 16b, and 16c: 16a. FAP website:https://www.texashealthmansfield.org/hospital-and-emergency-rooms/texas-health-hospital-mansfield/billing-and-financial-services16b. FAP Application Website:https://www.texashealthmansfield.org/hospital-and-emergency-rooms/texas-health-hospital-mansfield/billing-and-financial-services16c. Plain Language Summary of FAP Website:https://www.texashealthmansfield.org/hospital-and-emergency-rooms/texas-health-hospital-mansfield/billing-and-financial-services Part V, Section B, Line 22: As discussed in our response to Schedule H, Part B, Section B, Line 2, the filing organization began providing services on December 1, 2020. The filing organization and the filing organization's member, Texas Health Huguley, Inc. (THH) both operate hospitals that share the same service area, Tarrant County. Claims data provided by THH, enabled the filing organization to utilize the look-back method for porposes of determining the maximum amounts that can be charged to FAP-eligible individuals for emergency or other medically necessary care. Part I, Line 6a: The filing organization was a partially owned subsidiary of Adventist Health System Sunbelt Healthcare Corporation (AHSSHC) during its current tax year. During the current year, AHSSHC served as a parent organization to 30 tax-exempt 501(c)(3) hospital organizations and a number of other health care facilities that operated in 10 states within the U.S. The system of organizations under the control and ownership of AHSSHC is known as "AdventHealth".All hospital organizations within AdventHealth collect, calculate, and report the community benefits they provide to the communities they serve. AdventHealth organizations exist solely to improve and enhance the local communities they serve. AdventHealth has a system-wide community benefits accounting policy that provides guidelines for its health care provider organizations to capture and report the costs of services provided to the underprivileged and to the broader community. Each AdventHealth hospital facility reports their community benefits to their Board of Directors and strives to communicate their community benefits to their local communities. Part I, Line 7: The amounts of costs reported in the table in line 7 of Part I of Schedule H were determined by utilizing a cost-to-charge ratio derived from Worksheet 2, Ratio of Patient Care Cost-to-Charges, contained in the Schedule H instructions. Part III, Line 2: The amount of bad debt expense reported on line 2 of Section A of Part III is recorded in accordance with Healthcare Financial Management Association Statement No. 15. Discounts and payments on patient accounts are recorded as adjustments to revenue, not bad debt expense. Part III, Line 3: Methodology for Determining the Estimated Amount of Bad Debt Expense that May Represent Patients who Could Have Qualified under the Filing Organization's Financial Assistance Policy:Self-pay patients may apply for financial assistance by completing a Financial Assistance Application Form (FAA Form). If an individual does not submit a complete FAA Form within 240 days after the first post-discharge billing statement is sent to the individual, an individual may be considered for presumptive eligibility based upon a scoring tool that is designed to classify patients into groups of varying economic means. The scoring tool uses algorithms that incorporate data from credit bureaus, demographic databases, and hospital specific data to infer and classify patients into respective economic means categories. Individuals who earn a certain score on the scoring tool are considered to qualify as eligible for the most generous financial assistance under the filing organization's Financial Assistance Policy. As determined by the filing organization, a nominal amount of such a patient's bill is written off as bad debt expense, while the remaining portion of the patient's bill is considered non-state charity. The amount written off as bad debt expense for those patients who potentially qualify as non-state charity using the scoring tool is the amount shown on line 3 of Section A of Part III. Rationale for Including Certain Bad Debts in Community Benefit:The filing organization is dedicated to the view that medically necessary health care for emergency and non-elective patients should be accessible to all, regardless of age, gender, geographic location, cultural background, physician mobility, or ability to pay. The filing organization treats emergency and non-elective patients regardless of their ability to pay or the availability of third-party coverage. By providing health care to all who require emergency or non-elective care in a non-discriminatory manner, the filing organization is providing health care to the broad community it serves. As a 501(c)(3) hospital organization, the filing organization maintains a 24/7 emergency room providing care to all whom present. When a patient's arrival and/or admission to the facility begins within the Emergency Department, triage and medical screening are always completed prior to registration staff proceeding with the determination of a patient's source of payment. If the patient requires admission and continued non-elective care, the filing organization provides the necessary care regardless of the patient's ability to pay. The filing organization's operation of a 24/7 Emergency Department that accepts all individuals in need of care promotes the health of the community through the provision of care to all whom present. Current Internal Revenue Service guidance that tax-exempt hospitals maintain such emergency rooms was established to ensure that emergency care would be provided to all without discrimination. The treatment of all at the filing organization's Emergency Department is a community benefit. Under the filing organization's Financial Assistance Policy, every effort is made to obtain a patient's necessary financial information to determine eligibility for financial assistance. However, not all patients will cooperate with such efforts and a financial assistance eligibility determination cannot be made based upon information supplied by the individual. In this case, a patient's portion of a bill that remains unpaid for a certain stipulated time period is wholly or partially classified as bad debt. Bad debts associated with patients who have received care through the filing organization's Emergency Department should be considered community benefit as charitable hospitals exist to provide such care in pursuit of their purpose of meeting the need for emergency medical care services available to all in the community. Part III, Line 4: Financial Statement Footnote Related to Accounts Receivable and Allowance for Uncollectible Accounts:The financial information of the filing organization is included in a consolidated audited financial statement for the current year.The applicable footnote from the attached consolidated audited financial statements that addresses accounts receivable, the allowance for uncollectible accounts, and the provision for bad debts can be found on pages 8 through 10. Part III, Line 8: Costing Methodology: Medicare allowable costs were calculated using a cost-to-charge ratio.Rationale for Including a Medicare Shortfall as Community Benefit:As a 501(c)(3) organization, the filing organization provides emergency and non-elective care to all regardless of ability to pay. All hospital services are provided in a non-discriminatory manner to patients who are covered beneficiaries under the Medicare program. As a public insurance program, Medicare provides a pre-established reimbursement rate/amount to health care providers for the services they provide to patients. In some cases, the reimbursement amount provided to a hospital may exceed its costs of providing a particular service or services to a patient. In other cases, the Medicare reimbursement amount may result in the hospital experiencing a shortfall of reimbursement received over costs incurred. In those cases where an overall shortfall is generated for providing services to all Medicare patients, the shortfall amount should be considered as a benefit to the community. Tax-exempt hospitals are required to accept all Medicare patients regardless of the profitability, or lack thereof, with respect to the services they provide to Medicare patients. The population of individuals covered under the Medicare program is sufficiently large so that the provision of services to the population is a benefit to the community and relieves the burdens of government. In those situations where the provision of services to the total Medicare patient population of a tax-exempt hospital during any year results in a shortfall of reimbursement received over the cost of providing care, the tax-exempt hospital has provided a benefit to a class of persons broad enough to be considered a benefit to the community. Despite a financial shortfall, a tax-exempt hospital must and will continue to accept and care for Medicare patients. Typically, tax-exempt hospitals provide health care services based upon an assessment of the health care needs of their community as opposed to their taxable counterparts where profitability often drives decisions about patient care services that are offered. Patient care provided by tax-exempt hospitals that results in Medicare shortfalls should be considered as providing a benefit to the community and relieving the burdens of government. Part III, Line 9b: The hospital filing organization's collection practices are in conformity with the requirements set forth in the 2014 Final Regulations regarding the requirements of Internal Revenue Code Section 501(r)(4) - (r)(6). No extraordinary collection actions (ECA's) are initiated by the hospital filing organization in the 120-day period following the date after the first post-discharge billing statement is sent to the individual (or, if later, the specified deadline given in a written notice of actions that may be taken, as described below). Individuals are provided with at least one written notice (notice of actions that may be taken) and a copy of the filing organization's Plain Language Summary of the Financial Assistance Policy that informs the individual that the hospital filing organization may take actions to report adverse information to credit reporting agencies/bureaus if the individual does not submit a Financial Assistance Application Form (FAA Form) or pay the amount due by a specified deadline. The specified deadline is not earlier than 120 days after the first post-discharge billing statement is sent to the individual and is at least 30 days after the notice is provided. A reasonable attempt is also made to orally notify an individual about the filing organization's Financial Assistance Policy and how the individual may obtain assistance with the Financial Assistance application process. If an individual submits an incomplete FAA Form during the 240-day period following the date on which the first post-discharge billing statement was sent to the individual, the hospital filing organization suspends any reporting to consumer credit reporting agencies/bureaus (or ceases any other ECA's) and provides a written notice to the individual describing what additional information or documentation is needed to complete the FAA Form. This written notice contains contact information including the telephone number and physical location of the hospital facility's office or department that can provide information about the Financial Assistance Policy, as well as contact information of the hospital facility's office or department that can provide assistance with the financial assistance application process or, alternatively, a nonprofit organization or governmental agency that can provide assistance with the financial assistance application process if the hospital facility is unable to do so. If an individual submits a complete FAA Form within a reasonable time-period as set forth in the notice described above, the hospital filing organization will suspend any adverse reporting to consumer credit reporting agencies/bureaus until a financial assistance policy eligibility determination can be made. Schedule H, Part III, Section B: Supplemental Schedule to Schedule H, Part III, Section B, Line 8Reconciliation of Schedule H Reported Medicare Surplus/(Shortfall) to Unreimbursed Medicare Costs Associated with the Provision of ServicesTo All Medicare Beneficiaries:The Medicare revenue and allowable costs of care reported in Section B of Part III of Schedule H are based upon the amounts reported in the filing organization's Medicare cost report in accordance with the IRS instructions for Schedule H. On an annual basis, the filing organization also determines its total unreimbursed costs associated with providing services to all Medicare patients. Unreimbursed costs are considered a community benefit to the elderly and are combined into an annual Community Benefit Statement prepared by AdventHealth. The primary reconciling items between the Medicare surplus/(shortfall) shown on line 7 of Section B of Part III of Schedule H and the filing organization's unreimbursed costs of services provided to Medicare patients as reported in the AHS Community Benefit Report are as follows:- Medicare surplus/(shortfall) shown on line 7 of Section B of Schedule H: $ (4,196,839) - Difference in costing methodology: 121,068- Unreimbursed costs incurred for services provided to Medicare patients that are not included in the organization's Medicare cost report: (11,201,430) ------------Total Unreimbursed Costs of serving all Medicare patients per the filing organization's community benefit reporting: $ (15,277,201)As indicated above, the primary differences between the Medicare surplus/(shortfall) reported on Schedule H, Part III, Section B, line 7 and the filing organization's portion of the Company's annual community benefit statement is due to a difference in the costing methodology and differences in the population of Medicare patients within the calculation. The cost methodology utilized in calculating any Medicare surplus/(shortfall) for purposes of the annual community benefit reporting is based upon the cost-to-charge ratio outlined in Worksheet 2 of the Schedule H instructions. The same cost-to-charge ratio is used to determine the costs associated with services provided to charity care patients and Medicaid patients as reported in Schedule H, Part I, line 7. In addition, the Medicare cost report excludes services provided to Medicare patients for physician services, services provided to patients enrolled in Medicare HMOs, and certain services provided by outpatient departments of the filing organization that are reimbursed on a fee schedule. The Company's own community benefit statement captures the unreimbursed cost of providing services to all Medicare beneficiaries throughout the organization. Part VI, Line 2: A variety of practices and processes are in place to ensure that the filing organization is responsive to the health needs of its community.Such practices and processes involve the following:1. A hospital operating/community board composed of individuals broadly representative of the community, community leaders, and those with specialized medical training and expertise;2. Post-discharge patient follow-up related to the on-going care and treatment of patients who suffer from chronic diseases; 3. Sponsorship and participation in community health and wellness activities that reach a broad spectrum of the filing organization's community; and 4. Collaboration with other local community groups to address the health care needs of the filing organization's community. Part VI, Line 3: The Financial Assistance Policy (FAP), Financial Assistance Application Form (FAA Form), and the Plain Language Summary of the Financial Assistance Policy (PLS) of the filing organization's hospital facility are transparent and available to all individuals served at any point in the care continuum. The FAP, FAA Form, PLS, and contact information for the hospital facility's financial counselors are prominently and conspicuously posted on the filing organization's hospital facility's website. The website indicates that a copy of the FAP, FAA Form, and PLS is available and how to obtain such copies in the primary languages of any populations with limited proficiency in English that constitute the lesser of 1,000 individuals or 5% of the members of the community served by the hospital facility (referred to below as LEP defined populations). Signage is displayed in public locations of the filing organization's hospital facility, including at all points of admission and registration and the Emergency Department. The signage contains the hospital facility's website address where the FAP, FAA Form, and PLS can be accessed and the telephone number and physical location that individuals can call or visit to obtain copies of the FAP, FAA Form and PLS or to obtain more information about the hospital facility's FAP, FAA Form and PLS. Paper copies of the hospital facility's FAP, FAA Form and PLS are available upon request and without charge, both in public locations in the hospital facility and by mail. Paper copies are made available in English and in the primary languages of any LEP defined populations. The filing organization's hospital facility's financial counselors seek to provide personal financial counseling to all individuals admitted to the hospital facility who are classified as self-pay during the course of their hospital stay or at time of discharge to explain the FAP and FAA Form and to provide information concerning other sources of assistance that may be available, such as Medicaid. A paper copy of the hospital facility's PLS will be offered to every patient as a part of the intake or discharge process. A conspicuous written notice is included on all billing statements sent to patients that notifies and informs recipients about the availability of financial assistance under the filing organization's financial assistance policy, including the following: 1) the telephone number of the hospital facility's office or department that can provide information about the FAP and the FAA Form; and 2) the website address where copies of the FAP, FAA Form and PLS may be obtained. Reasonable attempts are made to inform individuals about the hospital facility's FAP in all oral communications regarding the amount due for the individual's care. Copies of the PLS are distributed to members of the community in a manner reasonably calculated to reach those members of the community who are most likely to require financial assistance. Part VI, Line 4: The filing organization currently operates Texas Health Hospital Mansfield (THHM) a 59-bed hospital in Mansfield, Texas that opened on December 1, 2020. THHM serves the communities of Tarrant County, Johnson County, and the surrounding areas. This is one of the fastest growing areas in North Texas with a growing need for available healthcare. The hospital offers comprehensive services, including 24-hour emergency care, general surgery, women's care, orthopedics, and interventional cardiology. During 2021, the Hospital's patient percentage population was made up of self-pay patients and patients covered under commercial insurance. In 2021, about 75.0% of the Hospital's in-patients were admitted through the Hospital's Emergency Department. The demographic makeup of the Hospital's community is as follows: - Population (approximately) 250,000 - Poverty (Below 100% FPL) 6.6% - Unemployment Rate 4.0% - Pop. Age 25+ with No High School Diploma 9.4% - Uninsured Adults 26.9% - Uninsured Children 11.73% - Food Insecurity Rate 14.4% - Pop. with Low Food Access 71.96% Part VI, Line 5: The provision of community benefit is central to Texas Health Hospital Mansfield's mission of service and compassion. Restoring and promoting the health and quality of life of those in the communities served by the Hospital is a function of "extending the healing ministry of Christ and embodies the Hospital's commitment to its values and principles. The Hospital commits substantial resources to provide a broad range of services to both the underprivileged as well as the broader community. In addition to the community benefit and community building information provided in Parts I, II and III of this Schedule H, the Hospital captures and reports the benefits provided to its community through faith-based care. Examples of such benefits include the cost associated with chaplaincy care programs and mission peer reviews and mission conferences. During the current year, the Hospital provided $132,047 of benefit with respect to the faith-based and spiritual needs of the community in conjunction with its operation of a community hospital. The Hospital also provides benefits to its community's infrastructure by investing in capital improvements to ensure that facilities and technology provide the best possible care to the community. During the current year, the Hospital expended $22,727,788 in new capital improvements. As a faith-based mission-driven community hospital, the Hospital is continually involved in monitoring its community, identifying unmet health care needs and developing solutions and programs to address those needs. In accordance with its conservative approach to fiscal responsibility, surplus funds of the Hospital are continually being invested in resources that improve the availability and quality of delivery of health care services and programs to its community. Part VI, Line 6: As explained in our response to Form 990, Part VI, Section A, line 6, Texas Health Hospital Mansfield (THHM or the Hospital) has one member. The sole member of THHM is Texas Health Huguley, Inc. (THH). The members of THH are Texas Health Resources and Adventist Health System/Sunbelt, Inc. (AHSSI). AHSSI is a wholly-owned subsidiary of Adventist Health System Sunbelt Healthcare Corporation. THHM is able to draw upon the expertise and leadership of both of THH's health system members in its effort to create excellent patient experiences and offer a broad spectrum of health services needed in its community.During its current tax year, THHM was managed by Adventist Health System Sunbelt Healthcare Corporation (AHSSHC). AHSSHC is an organization exempt from federal income tax under IRC Section 501(c)(3). AHSSHC and its subsidiary organizations operate 48 hospitals throughout the U.S., primarily in the Southeastern portion of the U.S. AHSSHC and its subsidiaries also operate 10 nursing home facilities and other ancillary health care provider facilities, such as ambulatory surgery centers and diagnostic imaging centers. Pursuant to a management services agreement, AHSSHC provides management and certain consulting services to Texas Health Hospital Mansfield. Management and consulting services include personnel administration, procurement, health information management, maintenance and security, contracts, financial accounting systems and budget development.The reader of this Form 990 should keep in mind that this reporting entity may differ in certain areas from that of a stand-alone hospital organization due to its inclusion in a larger system of healthcare organizations. As a part of a system of hospital and other health care organizations, the filing organization benefits from reduced costs due to system efficiencies, such as large group purchasing discounts, and the availability of internal resources such as internal legal counsel. Each AdventHealth subsidiary pays a management fee to AHSSHC for the internal services provided by AHSSHC. As a result, management fee expense reported by an AdventHealth subsidiary organization may appear greater in relation to management fee expense that may be reported by a single stand-alone hospital. The single stand-alone hospital would likely report costs associated with management and other professional services on various expense line items in its statement of revenue and expense as opposed to reporting such costs in one overall management fee expense. As the reporting of the Form 990 is done on an entity by entity basis, there is no single Form 990 that captures the programs and operations of AdventHealth as a whole. The reader is directed to visit the web-site of AdventHealth at www.adventhealth.com to learn more about the mission and operations of AdventHealth. 1 Mansfield ISD Education Foundation 609 E Broad Street Mansfield TX 76063 752765533 501(c)(3) 10000 0 General Support Mansfield Mission Center Inc 901 W Broad St Mansfield TX 76063 364753862 501(c)(3) 5300 0 General Support 2 0 Part I, Line 2: Grants are generally made only to related organizations that are exempt from Federal Income Tax under 501(c)(3), other 501(c)(3) organizations that are a part of the group exemption ruling issued to the General Conference of Seventh-Day Adventists, or to other 501(c)(3) community organizations involved in health-related causes. Accordingly, the filing organization has not established specific procedures for monitoring the use of grant funds in the United States as the filing organization does not have a grant making program that would necessitate such procedures. X X X X X X 1 1 0 1 0 0 0 0 0 0 0 Johnson Penny Regional CEO 131392 394177 55127 165380 333845 1001534 25742 77227 10821 32464 556927 1670782 16005 48015 King James Kirk Trustee/THR EVP Zone Ops. 0 656358 0 307624 0 237587 0 101868 0 47969 0 1351406 0 48503 Craft Brian Trustee/THR SVP Hospital Fin. Ops. 0 345243 0 124202 0 105457 0 48567 0 48274 0 671743 0 13982 Jackson David Trustee/THR Chief Acct. Officer 0 325186 0 111884 0 98684 0 53076 0 37296 0 626126 0 11705 Schroeder Jennifer Hospital Board Member 0 281886 0 80550 0 97387 0 21750 0 28951 0 510524 0 0 Rose Kenneth CEO 276671 0 55738 0 11657 0 56890 0 40283 0 441239 0 0 0 Nelson Stephanie CFO 213566 0 37719 0 21746 0 13778 0 37468 0 324277 0 0 0 Sutton Kristen CNO 157690 0 26142 0 9609 0 9104 0 37377 0 239922 0 0 0 Part I, Line 1a As disclosed in our response to Form 990, Part VI, Section A, Line 3, individuals who serve as officers of the filing organization in the roles of Regional CEO, CEO, CFO, and CNO are compensated by and on the payroll of Adventist Health System Sunbelt Healthcare Corporation (AHSSHC), the parent organization of the healthcare system known as AdventHealth. AHSSHC is exempt from federal income tax under IRC Section 501(c)(3). The filing organization reimburses AHSSHC for the salary and benefit cost of those executives on the payroll of AHSSHC. At the direction of AHSSHC, and in accordance with the reserved powers in the filing organization's governing documents, the executive team listed on Part VII provides services to the filing organization. First-class or charter travel: Pursuant to the AdventHealth system-wide general policy regarding business travel, no reimbursement will be provided for any additional cost incurred with respect to first-class or charter air travel beyond the cost of a regular coach airfare. As a means of providing additional business travel reimbursement for those members of the AHSSHC senior executive management team that travel frequently on behalf of AdventHealth, a special annual travel allowance is provided for those executives. As AdventHealth operates 48 hospitals in 9 states, the senior leadership of AHSSHC travel extensively and often visit multiple hospital locations in different states as a part of a single business trip. The special travel allowance can provide reimbursements to the executive for such items as the purchase of air travel upgrade coupons, to cover the cost differential between coach and first-class travel, or to cover the cost of a charter flight. The special travel allowance benefit was originally authorized by and codified into a policy by the AHSSHC Board Compensation Committee (the Committee), an independent body of the AHSSHC Board of Directors, who also approves the annual cap on the amount of the allowance. The special travel allowance has an annual cap of $24,000 for members of the Leadership Executive Team (AdventHealth Cabinet - 13 members) and $15,000 for AdventHealth Corporate Office Senior Vice Presidents, Regional CEO's, and Division Chief Officers (generally 20-35 individual executives). Two individuals who served in 2021 as Regional CEOs for AdventHealth are members of the Board of Directors of the filing organization. The Regional CEOs are considered common law employees and are on the payroll of AHSSHC. While the special travel allowance benefit is an AHSSHC compensation policy and practice, the cost of providing this benefit is allocated to and either wholly or partially reimbursed by the filing organization. Accordingly, the filing organization has checked the box in Schedule J, Part I, line 1a for first-class or charter travel since it has wholly or partially paid for the cost of providing this benefit. Those executives who receive the special travel allowance are responsible for tracking the expenses reimbursable under the special travel allowance and must submit such expenses on their accountable plan expense report. Any taxable reimbursements made to executives under the special travel allowance arrangement are treated as taxable compensation to the executive. Travel for companions: AHSSHC has a Corporate Executive Policy that provides a benefit to allow for a traveling AHSSHC executive to have his or her spouse accompany the executive on certain business trips each year. Typically, reimbursement is only provided to certain executive leaders and is usually limited to one business trip per year beyond the annual AdventHealth President's Council business meeting and other meetings where the spouse is specifically invited. The AHSSHC Corporate Executive Spousal Travel Policy was originally approved and reviewed by the AHSSHC Board Compensation Committee, an independent body of the AHSSHC Board of Directors. All spousal travel costs reimbursed to the executive are considered taxable compensation to the executive. Tax Indemnification and gross-up payments: AdventHealth has a system-wide policy addressing gross-up payments provided in connection with employer-provided benefits/other taxable items. Under the policy, certain taxable business-related reimbursements (i.e. taxable business-related moving expenses, taxable items provided in connection with employment) provided to any employee may be grossed-up at a 25% rate upon approval by the filing organization's CEO and CFO. Additionally, employees at the Director level and above are eligible for gross-up payments on gifts received for board of director services. Discretionary spending account: Occasional discretionary spending amounts are periodically provided to eligible executives who attend annual business meetings such as the AdventHealth President's Council, CFO Conference or the CMO/CNO business meeting. Payments provided to each executive are considered taxable compensation to the executive. Housing allowance or residence for personal use: AHSSHC has a Corporate Executive Policy that addresses assistance to executives who have been relocated by the company during the year. Relocation assistance provided to executives may include relocation allowances to assist with duplicate housing expenses. Relocation assistance is administered per AHSSHC policy by an external relocation company. All taxable reimbursements made to executives in connection with relocation assistance are treated as wages to the executive and are subject to all payroll withholding and reporting requirements. Health or social club dues or initiation fees: AHSSHC has a Corporate Executive Policy that addresses business development expenditures. Under this policy, to encourage executives to establish and cultivate strong working relationships with the medical community and other leaders in the community and industry, certain AdventHealth executives may be reimbursed for member dues and usage charges for a country club or other social club upon authorization. Club memberships must be approved by the AdventHealth President/CEO initially as well as on an annual basis. Each AdventHealth executive who is approved for a club membership must submit an annual report describing how they used the membership to benefit their organization during the preceding year so that the AdventHealth President/CEO can make a determination if continuance of the club membership furthers the business interests of AdventHealth. In the current year, for this filing organization, one executive listed in Part VII received reimbursement for club fees. While the club dues membership is an AHSSHC compensation policy and practice, the cost of providing this benefit is allocated to and reimbursed in whole or in part by the filing organization. Accordingly, the filing organization has checked the box in Schedule J, Part I, line 1a for health or social club dues since it has wholly or partially paid for the cost of providing this benefit. Part I, Line 3 The individual who serves as the CEO of the filing organization is compensated by Adventist Health System Sunbelt Healthcare Corporation (AHSSHC), an unrelated entity as disclosed in our response to Form 990, Part VI, Section A, Line 3, for that individual's role in serving as the CEO pursuant to the management Services agreement between the filing organization and AHSSHC. Compensation and benefits provided to this individual are determined pursuant to policies, procedures, and processes of AHSSHC that are designed to ensure compliance with the intermediate sanctions laws as set forth in IRC Section 4958. AHSSHC has taken steps to ensure that processes are in place to satisfy the rebuttable presumption of reasonableness standard as set forth in Treasury Regulation 53.4958-6 with respect to its active executive-level positions. The AHSSHC Board Compensation Committee (the Committee) serves as the governing body for all executive compensation matters. The Committee is composed of certain members of the Board of Directors (the Board) of AHSSHC. Voting members of the Committee include only individuals who serve on the Board as independent representatives, who hold no employment positions with AHSSHC and who do not have relationships with any of the individuals whose compensation is under their review that impacts their best independent judgment as fiduciaries of AHSSHC. The Committee's role is to review and approve all components of the executive compensation plan of AHSSHC. As an independent governing body with respect to executive compensation, it should be noted that the Committee will often confer in executive sessions on matters of compensation policy and policy changes. In such executive sessions, no members of management of AHSSHC are present, other than the Chief People Officer, who remains at the request of the Chairman/committee to provide assistance/information as needed. The Committee is advised by an independent third-party compensation advisor. This advisor prepares all the benchmark studies for the Committee. Compensation levels are benchmarked with a national peer group of other not-for-profit healthcare systems and hospitals of similar size and complexity to AdventHealth and each of its affiliated entities. The following principles guide the establishment of individual executive compensation: - The salary of the President/CEO of AdventHealth will not exceed the 50th percentile of comparable salaries paid by similarly situated organizations; and - Other executive salaries shall be established using market medians. The compensation philosophy, policies, and practices of AHSSHC are consistent with the organization's faith-based mission and conform to applicable laws, regulations, and business practices. As a faith-based organization sponsored by the Seventh-day Adventist Church (the Church), AHSSHC's philosophy and principles with respect to its executive compensation practices reflect the conservative approach of the Church's mission of service and were developed in counsel with the Church's leadership. Part I, Line 4b Sch J, Part I, Line 4b Nonqualified Retirement Plan: Nonqualified Retirement Plan - Texas Health Resources Certain members of the Board of Trustees are compensated by Texas Health Resources (THR), a related entity to the filing organization, and are covered by a nonqualified retirement plan. Participation in the plan is made available to a select group of management and highly compensated employees as determined by the THR Board of Trustees, who are providing service in key position of management and responsibility. For the active restoration account (Account balances after 12/31/2009) SERP benefits vest while the participant is employed if the participant: - Reaches age 65 - Becomes disabled or dies, - Reaches the following years of service: 2 Years 25%; 3 Years 50%; 4 Years 75% and 5 or more years 100% Participants must be employed on Dec 1 to qualify for the current year's SERP Benefit unless separation is due to death, disability, retirement (Age 65) or early retirement (separation from service at or after age 55 with 75 years of combined age and continuous service with the system.) SERP benefits are calculated each Dec 1. Vested balances are taxed to the employee and the net balances begin accruing earnings. Vested balances are paid in cash lump sum within a 90-day period commencing on the earlier of death, disability, or separation from service. The deferred portion is included in Schedule J, Part II, column C. In frozen restoration accounts (account balances prior to 1/1/2010), the participant or beneficiary shall be taxed on his or her vested SERP benefits upon the earliest of: - Continued employment in THR until age 68 - Termination of employment for disability or death - Involuntary termination of employment without reasonable cause; or - Satisfying a 24 month non-compete period following his/her termination of employment. Payment follow the before mentioned events, except in the case of involuntary separation when the participant must wait 24 months to receive the previously taxed benefit. Payouts to the following employees were made during the year. The amounts below are included in the amount reported on Schedule J, Part II, Column B(III) and Column (F): King, James Kirk - 48,503 Craft, Brian - 13,982 Jackson, David - 11,705 NONQUALIFIED RETIREMENT PLAN - ADVENTIST HEALTH SYSTEM SUNBELT HEALTHCARE CORPORATION Penny Johnson, Kenneth Rose, Stephanie Nelson, and Kristen Sutton received compensation from Adventist Health System Sunbelt Healthcare Corporation (AHSSHC), the top-tier parent of the the 49% owner of the filing organization and the parent organization of the healthcare system known as AdventHealth. In recognition of the contribution that each executive makes to the success of AdventHealth, AdventHealth provides supplemental executive benefit plans to eligible executives. In 2020, AdventHealth restructured its executive supplemental retirement and benefit plans to reduce complexity, to increase predictability of benefits and to consolidate multiple supplemental executive benefit plans into one plan. Effective 1/1/2020, a new supplemental executive retirement plan (SERP III) was adopted, reviewed and approved by the AHSSHC Board Compensation Committee, an independent body of the AHSSHC Board of Directors. SERP III Plan (Effective 1/1/2020): To recognize the contribution each executive makes to the success of AdventHealth and to recognize the limitations available to executives in qualified retirement plans due to compensation limits set on such plans, AdventHealth adopted a new supplemental executive retirement plan (SERP III) in 2020. The SERP III plan effectively replaces the prior SERP II plan, the Executive Flex Benefit Program Plan, and the Senior Executive Death Benefit Plan for qualified executives except for certain grandfathered executive employees. The SERP III plan provides eligible executives a percentage of their base pay, which is credited to a deferred compensation account. The plan also provides for compensation deferral and selection of life insurance coverage and long-term care insurance. To be eligible to participate in the SERP III plan, executives must be on the AHSSHC corporate payroll and be either a CEO of an AdventHealth entity, an AHSSHC Vice President (VP) or VP of an AdventHealth entity with a base salary of at least $290,000 in 2021 (adjusted annually by the same percentage as IRC Section 401(a)(17) limit increases), or other leader specifically approved by the AdventHealth President. Eligible executives do not include grandfathered executives, meaning those executives who would satisfy all the eligibility requirements of the SERP II plan prior to Dec 31, 2027, had the plan not been amended and restated as of Jan. 1, 2020. Contribution credits will be established and maintained by class year accounts for each participant using tiered contribution credit percentages of annual base compensation. Contribution credit percentages range between 15% and 19% of base compensation. Contribution credits will be made each quarter in 25% increments. SERP III provides for a class year vesting and payment schedule (7 years for each class year) with respect to amounts accumulated in the executive's deferred compensation account. Upon attainment of a normal retirement age (age 62), or upon certain other circumstances as defined in the SERP III plan document, all deferred amounts are paid immediately to the participant. For any executives working beyond the normal retirement age, future employer contributions will be made quarterly from SERP III directly to the participant as a taxable cash bonus. SERP II Plan (Amended and Restated in 2020): In 2020, the SERP II plan was amended and restated to provide that eligible employees are restricted to those executives who, as of January 1, 2020, satisfied, or if employment continues, will satisfy the eligibility requirements of SERP II prior to December 31, 2027. The SERP II plan is a defined benefit, non-tax-qualified deferred compensation plan for certain executives who have provided lengthy service to AdventHealth and/or to other Seventh-day Adventist Church hospitals or health care institutions. Under the provisions of the SERP II plan, benefits are provided to qualifying executive participants on a pro-rata schedule beginning with 20 years of service as an employee of AdventHealth and/or another hospital or health care institution controlled by the Seventh-day Adventist Church and who satisfy certain other qualifying criteria. This supplemental executive retirement plan (SERP II) was designed to provide eligible executives with the economic equivalent of an annual income beginning at normal retirement age equal to 60% of the average of the participant's three, five or seven highest years of base salary from AdventHealth active employment inclusive of income from all other Seventh-day Adventist Church healthcare employer-financed retirement income sources and investment income earned on those contributions through social security normal retirement age as defined in the plan. The number of years included in highest average compensation is determined by the individual's year of entry to SERP II and by the individual's year of entry to the AdventHealth Executive FLEX Benefit Program. FLEX Plan (Amended and Restated in 2020): In 2020, the Flex Plan was amended and restated to exclude employed executives who are hired or promoted after a certain date from being eligible to participate in the Flex Plan except for certain insurance coverage features of the plan. Additionally, a provision was added to place a maximum limit on the amount of a participant's annual Flex allowance to not be greater than a maximum dollar amount or percentage of compensation as established by the AdventHealth Benefits Administration Committee. Part I, Line 4b (Continued): The Flex Plan was originally designed to provide eligible executives an opportunity to select from among a variety of supplemental benefits, including a split dollar life insurance policy and long-term care insurance, to individually tailor a benefits program appropriate to each executive's needs. The Flex Plan provides eligible participants a pre-determined benefits allowance credit that is equal to a percentage of the executive's base pay from which the cost of mandatory and elective employee benefits is deducted. The benefits allowance credit percentage is determined by the AdventHealth Benefits Administration Committee. For grandfathered eligible employees, the annual pre-determined Flex allowance is contributed and any funds that remain after the cost of mandatory and elective benefits are subtracted are, at the employee's option, contributed to either an IRC 457(f) deferred compensation account or to an IRC 457(b) eligible deferred compensation plan. Upon attainment of age 65, all previous 457(f) deferred amounts are paid immediately to the participant and any future employer contributions are made quarterly from the Plan directly to the participant. The Plan provides for a class year vesting schedule (2 years for each class year) with respect to amounts accumulated in the executive's 457(f) deferred compensation account. Distributions could also be made from the executive's 457(f) deferred compensation account upon attainment of age 65 or upon an involuntary separation. The account will be forfeited by the executive upon a voluntary separation. With respect to grandfathered participants, the Flex Plan documents define eligible employees to include the Chief Executive Officers of AdventHealth entities and Vice Presidents of all AdventHealth entities whose base salary was at least equal to the Internal Revenue Code Section 401(a)(17) compensation limit each year. Senior Executive Death Benefit Plan (SEDB) (Amended and Restated in 2020): The SEDB plan was originally designed to provide a benefit in an amount equal to the amount the executive's benefit would have been under the SERP II Plan assuming that, on the date of the executive's death (and not before), the executive satisfied the last of the eligibility requirements of the SERP II Plan with present value recognizing an early benefit commencement. In conjunction with the amendment and restatement of the SERP II Plan, the SEDB was similarly amended in 2020 to limit eligible employees to only those who either satisfy the eligibility requirements of SERP II as of January 1 2020, or remain in active employment and will satisfy those requirements prior to December 31, 2027. An eligible executive becomes a participant in the SEDB Plan if the executive dies prior to termination of employment, provided the executive has not satisfied all the eligibility requirements of SERP II as of the executive's date of death but would have satisfied all those requirements within five (5) years following death had the executive lived and continued employment. The SEDB Plan will terminate automatically after December 31, 2027. FLEX Plan FLEX Plan SERP II SERP III Contr. Distr.* Contr./Distr. Contr. Johnson, Penny $ 0 $ 90,531 $ 77,160 $1,239,962 Rose, Kenneth $ 0 $ 0 $ 0 $ 41,427 Form 990, Part VII, Section A, Line 5: The Regional CEO, Penny Johnson, CEO, Kenneth Rose, CFO, Stephanie Nelson, and CNO, Kristen Sutton were compensated by AHSSHC, an unrelated IRC Section 501(c)(3) entity, during 2021 for services provided to the filing organization and its affiliates. Please see our response to Form 990, Part VI, Section A, Line 3 for a discussion concerning the filing organization's affiliation with AHSSHC. Compensation for Penny Johnson, Kenneth Rose, Stephanie Nelson and Kristen Sutton pertaining to the filing organization and its related affiliates, is disclosed in Schedule J, Part II. Compensation for Penny Johnson reflects compensation for services provided to the filing organization and related entities. This executive also provides services to AHHSSHC affiliates, which are unrelated, and are not reflected in this return. Form 990, Part V, Line 1a: The sole member of the filing organization is Texas Health Huguley, Inc. (THH). THH is 49% owned by Adventist Health System/Sunbelt, Inc. (AHSSI). The parent corporation and sole top-tier member of AHSSI is Adventist Health System Sunbelt Healthcare Corporation (AHSSHC). AHSSHC is a Florida, not-for-profit corporation that is exempt from federal income tax under Internal Revenue Code (IRC) Section 501(c)(3). AHSSHC has established a shared service center to centralize the Accounts Payable (A/P) function for all AHSSHC subsidiary organizations. The filing organization has entered "0" in Part V, Line 1a because the filing organization does not issue Form 1099 returns, rather, all such returns are filed by and under the name and EIN of AHSSHC as the payor subject to the information reporting requirements of Section 6041. The facts and circumstances support a position that AHSSHC, as a payor on behalf of its subsidiary organizations in a shared service environment, will have sufficient management and oversight in connection with the subsidiary organizations' payments to meet the standard set forth in Treas. Reg. Section 1.6041-1(e). AHSSHC will not merely be making payments at the direction of its subsidiary organizations. Accordingly, AHSSHC is considered the payor subject to the information reporting requirements of Section 6041. Form 990, Part VI, Section A, line 1a The members of the Board of Trustees listed on Part VII of this Form 990 include the filing organization's Governing Board and members of the filing organization's Hospital Board. The Board of Trustees is primarily responsible for the overall management of the filing organization. The Hospital Board is primarily responsible for matters of the hospital including the following: - Oversight of Medical Staff (including the review and approval of Medical Staff Bylaws and approval of appointments to the Medical Staff), care of patients, quality assessment and improvement programs implemented at the hospital, and risk management functions; - Participation in the development and review of the filing organization's short and long-term plans (including strategic plans, capital plans, and annual budgets); and - Monitoring of compliance with regulatory requirements. Form 990, Part VI, Section A, line 3 Effective January 1, 2012, Texas Health Huguley (THH), the sole member of Texas Health Hospital Mansfield (the filing organization) entered into a Management Services Agreement with Adventist Health System Sunbelt Healthcare Corporation (AHSSHC). AHSSHC is the parent organization of a system of tax-exempt hospitals and other health care provider organizations that operate 48 hospitals throughout the U.S., primarily in the Southeastern portion of the U.S. AHSSHC is exempt from federal income tax under Internal Revenue Code Section 501(c)(3). Under the Management Services Agreement (the Agreement), AHSSHC must follow the policies of the filing organization's Board of Directors. Managerial services provided by AHSSHC during 2020 include oversight and day to day management of the filing organization, including the following functions: a) Personnel administration, including recruitment, hiring, training, promoting, directing and terminating personnel; b) Procurement, including the acquisition of food and beverage items, supplies, devices, furniture, and medical equipment; c) Health Information Management; d) Maintenance and Security; e) Contracting for services and consulting services; f) Financial accounting systems; g) Development of operational and capital budgets; h) Billing and collection of receivables and remittances of payables; i) Patient safety and quality systems; j) Marketing; k) Regulatory compliance; l) Administration - Policies and Procedures, including appointment of the CFO, COO, and CNO. The individuals who served as officers of the filing organization in the role of CEO, CFO, and CNO during 2021 are listed in Part VII, Section A. In 2021 these individuals were compensated by and on the payroll of AHSSHC for services rendered to the filing organization and its affiliate. Form 990, Part VI, Section A, line 6 Texas Health Hospital Mansfield (THHM) has one member. The sole member of THHM is Texas Health Huguley, Inc. (THH). THH is a hospital exempt from federal income tax under IRC Section 501(c)(3). There are no other classes of membership in the filing organization. Form 990, Part VI, Section A, line 7a The sole member of the filing organization is THH. Trustees of the filing organization are appointed by the two members of THH, Texas Health Resources (THR) and Adventist Health System/Sunbelt, Inc. (AHSSI). THR has the right to designate and maintain at all times three (3) trustees, and AHSSI has the right to designate and maintain at all times two (2) trustees. Form 990, Part VI, Section A, line 7b Notwithstanding anything to the contrary contained in the Certificate of Formation or the Bylaws, the authority to undertake, or cause the filing organization to undertake, certain matters (Member Reserved Matters) is expressly and exclusively reserved to THH, the sole member. In undertaking any of the listed actions, THH shall consult with AHSSI and THR as required by THH's certificate of formation and bylaws and includes the following matters: (a) any fundamental change in the purposes of the filing organization as set forth in Article Five of the Certificate of Formation; (b) any fundamental change in the philosphy, mission, or vision of the filing organization; (c) any amendment, restatement, or repeal of the Certificate of Formation or the Bylaws; (d) any entry into or consummation of any merger, consolidation, dissolution, sale, or other transfer of all or substantially all of the assets of the filing organization or any material subsidiary or entity controlled by the filing organization, or other change in corporate form, that in case of any of the foregoing would constitute or otherwise result in a fundamental reorganization of the filing organization or any material subsidiary or entity controlled by the filing organization; (e) any admission of any additional members to the filing organization; (f) the incurrence or issuance of any debt that would require the guaranty of the member; (g) any change to the name of the filing organization; (h) the creation of affiliates or subsidiaries of the filing organization or the entry by the filing organization into any joint venture; (i) the confession of a judgment against the filing organization or any agreement to compromise or settle claims above $100,000; (j) the approval of a decision for the filing organization to file a voluntary petition for bankruptcy; (k) the discontinuation of the operations of a licensed health care facility controlled by the filing organization; (l) the approval of any capital expenditure in excess of $1,000,000; (m) the incurrence or issuance of any non-guaranteed debt in excess of $200,000; (n) the voluntary prepayment or extension of debt in excess of $200,000; (o) the renewal, extension, or termination for cause of any management services agreement related to the operations of the hospital and related facilities; and (p) the approval of any managed care contract that is materially inconsistent with managed care contracts executed by THR on behalf of its other non-wholly owned or controlled acute care health facilities. In addition to the Member Reserved Matters, certain matters are reserved exclusively for AHSSI or exclusively for THR. Both are described in the following three paragraphs. Notwithstanding anything to the contrary contained in the Certificate of Formation or Bylaws, AHSSI shall have the authority to prevent the filing organization from undertaking: i) any changes to operational policies, plans, procedures that are specifically related to the Corporation's religious affiliation with the Seventh-day Adventist Church; ii) any activities of the filing organization that are determined by AHSSI in good faith to be inconsistent with the compliance by AHSSI with the requirements of AHSSI's tax-exempt status including those activities the filing organization is required to perform under Section 501(r); and iii) any activities of the filing organization that are determined by AHSSI in good faith to be inconsistent with the compliance of Sunbelt with the requirements of covenants associated with any outstanding AHSSI indebtedness. Notwithstanding anything to the contrary contained in the Certificate of Formation or Bylaws, THR shall have the authority to prevent the filing organization from undertaking: i) any activities of the filing organization that are determined by THR in good faith to be inconsistent with the compliance by THR with the requirements of THR's tax-exempt status including those activities the filing organization is required to perform under Section 501(r); ii) any activities of the filing organization that are determined by THR in good faith to be inconsistent with the compliance by THR with the requirements of covenants associated with any outstanding THR indebtedness; and iii) any change in the name of any hospital or health care facility owned by the Corporation. Notwithstanding anything to the contrary contained in the Certificate of Formation or Bylaws, THR shall have the authority to approve: i) the filing organization's contracts with insurance and other payers for payments for services provided by the filing organization subject to the requirements outlined in (p) above. Form 990, Part VI, Section B, line 11b The filing organization's current year Form 990 was reviewed by the Board Chairman, Board Finance Committee Chairman, CEO, and CFO prior to its filing with the IRS. The review conducted by the Board Chairman, Board Finance Committee Chairman, CEO, and CFO did not include the review of any supporting workpapers that were used in preparation of the current year Form 990, but did include a review of the entire Form 990 and all supporting schedules. Form 990, Part VI, Section B, line 12c The Conflict of Interest Policy of the filing organization applies to members of its Board of Trustees and its principal officers (to be known as Interested Persons). In connection with any actual or possible conflicts of interest, any member of the Board of Trustees of the filing organization or any principal officer of the filing organization (i.e. Interested Persons) must disclose the existence of any financial interest with the filing organization and must be given the opportunity to disclose all material facts concerning the financial interest/arrangement to the Board of Trustees of the filing organization or to any members of a committee with board delegated powers that is considering the proposed transaction or arrangement. Subsequent to any disclosure of any financial interest/arrangement and all material facts, and after any discussion with the relevant Board member or principal officer, the remaining members of the Board of Trustees or committee with board delegated powers shall discuss, analyze, and vote upon the potential financial interest/arrangement to determine if a conflict of interest exists. According to the filing organization's Conflict of Interest Policy, an Interested Person may make a presentation to the Board of Trustees (or committee with board delegated powers), but after such presentation, shall leave the meeting during the discussion of, and the vote on, the transaction or arrangement that results in a conflict of interest. Each Interested Person, as defined under the filing organization's Conflict of Interest Policy, shall annually sign a statement which affirms that such person has received a copy of the Conflict of Interest policy, has read and understands the policy, has agreed to comply with the policy, and understands that the filing organization is a charitable organization that must primarily engage in activities which accomplish one or more of its exempt purposes. The filing organization's Conflict of Interest Policy also requires that periodic reviews shall be conducted to ensure that the filing organization operates in a manner consistent with its charitable purposes. Form 990, Part VI, Section B, line 15 The filing organization's CEO is not compensated by the filing organization. This individual was compensated by Adventist Health System Sunbelt Healthare Corporation (AHSSHC), an unrelated entity disclosed in our response to Form 990, Part VI, Section A, Line 3. Please see the discussion concerning the process followed by AHSSHC in determining executive compensation in our response to Schedule J, Line 3. Form 990, Part VI, Section C, line 19 The financial statements of the filing organization, its governing documents, and its Conflict of Interest Policy are not generally made available to the public as a whole. Part VII, Section A, Column (B): For those Board of Trustee members and officers who devote less than full-time to the filing organization (based upon the average number of hours per week shown in column (B) on page 7 of the return) the compensation amounts shown in columns (E) and (F) on page 7 were provided in conjunction with that person's responsibilities and roles in serving in an executive leadership position within Texas Health Huguley, Inc. (sole member) and Texas Health Resources, Inc. (majority member of THH). Additionally, compensation for Penny Johnson does not reflect services provided to affiliates of AHSSHC, which are not related to the filing organization. Part VIII, Lines 7a, b and c: The amount shown in Part VIII, Line 7c(i) of the Form 990 represents an allocated share of capital gain/(loss) from a system wide, corporate administered, investment program. Form 990, Part IX, line 11g Payments to Healthcare Professional: Program service expenses 5,211,160. Management and general expenses 0. Fundraising expenses 0. Total expenses 5,211,160. Professional Fees: Program service expenses 1,148,770. Management and general expenses 0. Fundraising expenses 0. Total expenses 1,148,770. Purchased Medical Services: Program service expenses 463,342. Management and general expenses 0. Fundraising expenses 0. Total expenses 463,342. Environmental Services: Program service expenses 115,217. Management and general expenses 0. Fundraising expenses 0. Total expenses 115,217. Transcription Services: Program service expenses 8,812. Management and general expenses 0. Fundraising expenses 0. Total expenses 8,812. Recruiting: Program service expenses 219,012. Management and general expenses 0. Fundraising expenses 0. Total expenses 219,012. Leased Personnel: Program service expenses 30,156,837. Management and general expenses 0. Fundraising expenses 0. Total expenses 30,156,837. Other Purchased Services: Program service expenses 523,158. Management and general expenses 0. Fundraising expenses 0. Total expenses 523,158. AdventHealth Management Fees: Program service expenses 0. Management and general expenses 572,697. Fundraising expenses 0. Total expenses 572,697. Billing & Collection Services: Program service expenses 0. Management and general expenses 43,152. Fundraising expenses 0. Total expenses 43,152. AdventHealth Shared Services Fees: Program service expenses 0. Management and general expenses 522,089. Fundraising expenses 0. Total expenses 522,089. Form 990, Part X, Line 2: The amount shown on line 2 of Part X of this return includes the filing organization's interest in a central investment pool maintained by Adventist Health System Sunbelt Healthcare Corporation, the filing organization's top-tier parent. The investments in the central investment pool are recorded at market value. Form 990, Part XI, line 9: Capital Contributions from tax-exempt owners of the filing 29,665,776. Transfer to Texas Health Huguley, Inc. -6,530,207. Form 990, Part XII, Line 3b: The taxpayer is part of a controlled group of organizations that comprise a consolidated financial statement audit. The controlled group's sole member is Texas Health Huguley, Inc. (THHI). For the year ended December 31, 2021, THHI will file a consolidated Single Audit which will include all entities that are part of the controlled group. Accordingly, the taxpayer has checked yes to the questions on Part XII, line 3a and 3b. Huguley Medical Associates 11801 South Freeway Burleson TX 76028 752547668 Phys. Clinic TX 501(c)(3) Line 3 TH Huguley 1 North Texas Healthy Communities 612 E Lamar Blvd Arlington TX 76011 464513182 Comm Support TX 501(c)(3) Line 7 TH Resources 0 Southwestern Health Resources JOC 5323 Harry Hines Blvd Dallas TX 75390 811575989 Management Org. TX 501(c)(3) Line 12b TH Resources 0 Texas Health Arlington Memorial Hospital 800 West Randol Mill Rd Arlington TX 76012 750972805 Hospital TX 501(c)(3) Line 3 TH Resources 0 Texas Health Back Care 9250 Amberton Pkwy Dallas TX 75243 474724257 Phys. Clinic TX 501(c)(3) Line 10 TH Phys Group 0 Texas Health Harris Methodist Hospital Alliance 10864 Texas Health Trail Fort Worth TX 76244 451502252 Hospital TX 501(c)(3) Line 3 TH Resources 0 Texas Health Harris Methodist Hospital Azle 108 Denver Trail Azle TX 76020 751748586 Hospital TX 501(c)(3) Line 3 TH Resources 0 Texas Health Harris Methodist Hospital Cleburne 201 Walls Dr Cleburne TX 76033 751977850 Hospital TX 501(c)(3) Line 3 TH Resources 0 Texas Health Harris Methodist Hospital Fort Worth 1301 Pennsylvania Ave Fort Worth TX 76104 756001743 Hospital TX 501(c)(3) Line 3 TH Resources 0 Texas Health Harris Methodist Hospital Hurst-Euless-Bedford 1600 Hospital Parkway Bedford TX 76022 751438726 Hospital TX 501(c)(3) Line 3 TH Resources 0 Texas Health Harris Methodist Hospital Southwest Fort Worth 6100 Harris Parkway Fort Worth TX 76132 752678857 Hospital TX 501(c)(3) Line 3 TH Resources 0 Texas Health Harris Methodist Hospital Stephenville 411 Belknap Street Stephenville TX 76401 751752253 Hospital TX 501(c)(3) Line 3 TH Resources 0 Texas Health Hospital Frisco 12400 Dallas Pkwy Frisco TX 75033 831954982 Hospital TX 501(c)(3) Line 3 TH Resources 0 Texas Health Hospital Mansfield 2300 Lone Star Rd Mansfield TX 76063 831869297 Hospital TX 501(c)(3) Line 3 TH Huguley 1 Texas Health Huguley Inc 11801 S Freeway Burleson TX 76028 452694620 Hospital FL 501(c)(3) Line 3 TH Resources 0 Texas Health Medical Support 612 E Lamar Blvd Arlington TX 76011 812833150 Spec Drugs TX 501(c)(3) Line 10 TH Resources 0 Texas Health Physicians Group 9250 Amberton Pkwy Dallas TX 75243 752613493 Phys. Clinic TX 501(c)(3) Line 10 TH Resources 0 Texas Health Presbyterian Hospital Allen 1105 Central Expressway N Allen TX 75013 752890358 Hospital TX 501(c)(3) Line 3 TH Resources 0 Texas Health Presbyterian Hospital Dallas 8200 Walnut Hill Ln Dallas TX 75231 751047527 Hospital TX 501(c)(3) Line 3 TH Resources 0 Texas Health Presbyterian Hospital Denton 3000 North Interstate 35 Denton TX 76201 432008974 Hospital TX 501(c)(3) Line 3 TH Resources 0 Texas Health Presbyterian Hospital Kaufman 850 Ed Hall Drive Kaufman TX 75142 752771437 Hospital TX 501(c)(3) Line 3 TH Resources 0 Texas Health Presbyterian Hospital Plano 6200 W Parker Rd Plano TX 75093 752770738 Hospital TX 501(c)(3) Line 3 TH Resources 0 Texas Health Recovery and Wellness Center 240 Miller Road Mansfield TX 76063 812813227 Resd Trmt Ctr TX 501(c)(3) Line 3 TH Resources 0 Texas Health Research & Education Institute 612 E Lamar Blvd Arlington TX 76011 752562191 Educ & Research TX 501(c)(3) Line 4 TH Resources 0 Texas Health 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