2021-11-09T13:30:56-06:00 2020-12-31 990 2020-01-01 010646166 Indiana University Health Blackford Hospital Inc INDI 3179634842 950 N MERIDIAN STREET 300 INDIANAPOLIS IN 46204 JONATHAN W VANATOR CFO 2021-11-09 JONATHAN W VANATOR 999009999 2020 2022-09-23 18:48:47Z DAVID HYATT 950 N MERIDIAN STREET 300 INDIANAPOLIS IN 46204 19874944 false X SEE SCHEDULE O X 2002 IN Lead the transformation of healthcare through quality, innovation & education, and make Indiana one of the nation's healthiest states. 3 1 158 11 0 0 35270 13831 18624801 19738983 147810 68498 114203 53632 18922084 19874944 95 0 0 5625782 6203076 0 0 14764123 15079161 20390000 21282237 -1467916 -1407293 12114937 16345493 2658635 8296484 9456302 8049009 X Lead the transformation of healthcare through quality, innovation & education, and make Indiana one of the nation's healthiest states. false false 16804266 0 19369495 IU HEALTH BLACKFORD HOSPITAL IS A 15-BED CRITICAL ACCESS HOSPITAL THAT OFFERS A BROAD RANGE OF SERVICES TO CARE FOR ITS PATIENTS WITHOUT REGARD TO THEIR ABILITY TO PAY. IU HEALTH BLACKFORD HOSPITAL FEATURES ALL PRIVATE ROOMS, A SPECIALTY CLINIC, CARDIAC AND PULMONARY REHABILITATION, OUTPATIENT SURGICAL SERVICES AND DIAGNOSTIC IMAGING. IN ADDITION TO PROVIDING 24 HOUR EMERGENCY SERVICES, THE HOSPITAL HOSTS A PARAMEDIC-LEVEL AMBULANCE SERVICE. 0 0 252904 As of December 31, 2020, Indiana University Health Blackford Hospital, Inc. had received stimulus funds from the Provider Relief Fund under the provisions of the Coronavirus Aid, Relief, and Economic Security Act (CARES Act) and Paycheck Protection Program and Health Care Enhancement Act. Indiana University Health Blackford Hospital recognized $252,904 as other program service revenue. Indiana University Health Blackford Hospital, Inc. will continue to monitor compliance with the terms and conditions of the Provider Relief Fund. 74070 0 85377 INDIANA UNIVERSITY HEALTH BLACKFORD HOSPITAL, INC. RECEIVED REVENUE FROM A RELATED 501(C)(3) ENTITY FOR SHARED SERVICES. 27074 0 31207 INDIANA UNIVERSITY HEALTH BLACKFORD HOSPITAL, INC. LEASES PHYSICIAN AND CLINIC SPACE TO RELATED TAX-EXEMPT ORGANIZATIONS. IU HEALTH BLACKFORD RECEIVES REVENUE FROM A RELATED 501(C)(3) ENTITY FOR SHARED SERVICES. 27074 31207 16905410 true true false true false false false false false true false false true true true false true false false false false false false false false true true false false true false false false false false false false false false false false false false true true true false false true 12 0 true 158 true false false false false false false false false false false false false X 3 1 false false false false true true true true true false false true true true true true true false false false IN X CRAIG J JONES 3179634842 950 N MERIDIAN STREET SUITE 300 INDIANAPOLIS IN 46204 DAVID W HYATT DIRECTOR / PRESIDENT 40.0 14.0 X X 0 288680 48538 JEFFREY C BIRD MD DIRECTOR/REGIONAL PRESIDENT (ECR) 10.0 45.0 X X 0 747116 130370 DANIEL E BORGENHEIMER DIRECTOR 1.0 2.0 X 0 0 0 BETTIE A CALDWELL TREASURER 10.0 45.0 X 0 131594 19317 JOHN D LITTLER CHAIR 1.0 3.0 X 0 0 0 JONATHAN W VANATOR CFO (ECR) 10.0 45.0 X 0 372058 43631 MICHELLE R ALTOBELLA SECRETARY 10.0 45.0 X 0 279960 46434 ANN M MCGUIRE VP-HUMAN RESOURCES REGIONAL (ECR)-PART YEAR 10.0 40.0 X 0 230605 230742 CARLA C COX RN VP & CNO (ECR) 10.0 40.0 X 0 282881 40641 LORI A LUTHER COO (ECR) 10.0 45.0 X 0 408555 44542 PETER M VOSS MD CMO (ECR) 10.0 45.0 X 0 413509 40761 JAN BLAKE VP - CNO - BLACKFORD HOSP 50.0 0 X 156408 0 27175 MONICA R GAITHER ADMIN-ASSOC-NURSING 45.0 5.0 X 114596 11221 31997 THOMAS M LEE MD PHYSICIAN 2.0 49.0 X 15292 445031 50166 CHARLES L CARROLL DO FORMER HIGHEST COMPENSATED EMPLOYEE 0.0 50.0 X 0 255371 9528 JUDITH L COLEMAN FORMER OFFICER 0.0 55.0 X 0 366850 39639 KEVIN W SCHREIBER MD FORMER HIGHEST COMPENSATED EMPLOYEE 0.0 50.0 X 0 402908 47602 286296 4636338 851084 2 true true false ALLIANCE HEALTHCARE SERVICES 100 BAYVIEW CIRCLE STE 400 NEWPORT BEACH CA 92658 MEDICAL 109375 1 13831 13831 NET PATIENT SERVICE REVENUE 622110 19369495 19369495 FEDERAL RECOVERY REVENUE 900099 252904 252904 SHARED SERVICES 541900 85377 85377 RENT FROM RELATED 501(C)(3) ORGS 532000 31207 31207 0 0 0 0 19738983 57498 57498 1100 1100 0 1100 1100 11000 0 11000 11000 11000 CAFETERIA/FOOD SERVICES 721110 50586 50586 VENDING 900099 696 696 1250 0 0 1250 52532 19874944 19738983 0 122130 X 4829244 4472756 356488 167714 155334 12380 842524 780330 62194 363594 336754 26840 1891 1891 10165949 6429468 3736481 0 1944 1944 45697 15340 30357 23293 21631 1662 524253 523973 280 2471 833 1638 746212 728089 18123 121315 121315 BAD DEBT 1623073 1623073 DRUGS AND MEDICAL SUPPLIES 1052668 1052668 INSTITUTIONAL DUES/LICENSES 7596 7596 HOSPITAL ASSESSMENT FEE 708063 708063 54736 49502 5234 0 21282237 16905410 4376827 0 344 0 1928080 2243451 0 0 0 0 245169 307281 67664 50102 19788887 13186253 7266811 6602634 0 0 2606869 7142025 12114937 16345493 804161 6835024 0 0 1854474 1461460 2658635 8296484 X 9456302 8049009 9456302 8049009 12114937 16345493 -1407293 0 X false true X true false X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED false false false false false false false false true 1891 1891 false Schedule C, Part II-B, Line 1 DETAILED DESCRIPTION OF THE LOBBYING ACTIVITY IU Health Blackford Hospital paid institutional membership dues to the American Hospital Association ("AHA") and Indiana Hospital Association ("IHA") during 2020 in the amount of $7,042 and $3,463 respectively. Each membership organization notified IU Health Blackford Hospital that a portion of the dues it paid were used for lobbying purposes. The AHA used 23.32%, or $1,642 of the 2020 membership dues paid by IU Health Blackford Hospital, for lobbying expenditures. The IHA used 7.18%, or $249 of the 2020 membership dues paid by IU Health Blackford Hospital, for lobbying expenditures. 190324 190324 15007745 9772937 5234808 4288990 3127421 1161569 301828 285895 15933 6602634 INTERCOMPANY RECEIVABLES (NET) 7142025 7142025 SELF-INSURANCE LIABILITIES 16556 DUE TO THIRD-PARTY PAYERS 1444904 1461460 X Schedule D, Part X, Line 2 FIN 48 (ASC 740) footnote IU Health Blackford is a subsidiary in Indiana University Health, Inc.'s ("IU Health") Consolidated Audited Financial Statements. The Internal Revenue Service (IRS) has determined that Indiana University Health and certain of its affiliated entities are tax-exempt organizations as defined in Section 501(c)(3) of the Internal Revenue Code (IRC). Indiana University Health and its tax-exempt affiliates are, however, subject to federal and state income taxes on unrelated business income under the provisions of IRC Section 511. Deferred income taxes that, as of December 31, 2020 and 2019, have no net carrying value reflect the net tax effect of temporary differences between the carrying amounts of assets and liabilities for financial reporting and the amounts used for income tax purposes. As of December 31, 2020, and 2019, the Indiana University Health System had gross deferred tax assets of $135,889,000 and $143,157,000, respectively, primarily relating to net operating loss carryovers. Management determined that a full valuation allowance at December 31, 2020 and 2019, was necessary to reduce the deferred tax assets to the amount that would more likely than not be realized. Based on the weight of the evidence, if it is more likely than not that some portion or all of the deferred tax assets will not be realized, a valuation allowance to reduce the deferred tax assets is recorded. The decrease in the valuation allowance for the current year was $7,264,000. At December 31, 2020, the Indiana University Health System has available net operating loss carryforwards of $546,376,000. Net operating losses generated from 2000 through 2017 will expire between 2021 and 2037. Net operating losses generated after 2017 do not expire. true true X true X 300 false true true false true true 837 406930 406930 0.0207 2150 4229960 1458532 2771428 0.1410 0 0.0 0 2987 4636890 1458532 3178358 0.1617 7 367 139355 139355 0.0071 2 11 19467 19467 0.0010 1 652 335703 300208 35495 0.0018 0 0.0 1 10 800 800 0.0000 11 1040 495325 300208 195117 0.0099 11 4027 5132215 1758740 3373475 0.1716 0 0.0 0 0.0 1 3 479 479 0.0000 0 0.0 0 0.0 1 100 160 160 0.0000 0 0.0 0 0.0 0 0.0 2 103 639 0 639 0.0000 true 734765 7901969 7541006 360963 X true true 1 1 IU HEALTH BLACKFORD HOSPITAL 410 PILGRIM BLVD HARTFORD CITY IN 47348 https://iuhealth.org/FIND-LOCATIONS/IU-HEALTH-BLACKFORD-HOSPITAL 20-005101-1 X X X X IU HEALTH BLACKFORD HOSPITAL 1 false false true X X X X X X X X X 18 true false false true X https://iuhealth.org/in-the-community/community-benefit true 19 true https://iuhealth.org/in-the-community/community-benefit false true X 300.0 X X X X X X X true true X X X true X https://iuhealth.org/pay-a-bill/financial-assistance X https://iuhealth.org/pay-a-bill/financial-assistance X https://iuhealth.org/pay-a-bill/financial-assistance X X X X X X X true X false X X X X true X false false Schedule H, Part V, Section B, Line 3E IU Health Blackford Hospital's 2018 Community Health Needs Assessment (CHNA) report includes a prioritized description of significant health needs in the community. The CHNA report identified the following eight needs as priorities for IU Blackford Hospital: - Access to healthcare services - Aging population and needs of seniors - Drug and substance abuse - Maternal and infant health and child wellbeing - Mental health - Obesity and diabetes - Smoking and tobacco usage - Social determinants of health Schedule H, Part V, Section B, Line 5 Facility , 1 Facility , 1 - IU HEALTH BLACKFORD HOSPITAL. IN CONDUCTING ITS MOST RECENT COMMUNITY HEALTH NEEDS ASSESSMENT ("CHNA") IU HEALTH BLACKFORD HOSPITAL TOOK INTO ACCOUNT INPUT FROM PERSONS WHO REPRESENT THE BROAD INTERESTS OF THE COMMUNITIES IT SERVES. PRIMARY DATA WERE GATHERED IN TWO DIFFERENT METHODOLOGIES FOR THIS ASSESSMENT: COMMUNITY MEETINGS AND A COMMUNITY SURVEY. FOR PURPOSES OF THIS CHNA, IU HEALTH BLACKFORD HOSPITAL'S COMMUNITY IS DEFINED AS BLACKFORD COUNTY, INDIANA. THIS COUNTY ACCOUNTED FOR 74.4 PERCENT OF THE HOSPITAL'S INPATIENT CASES IN 2016. COMMUNITY MEETINGS - BLACKFORD COUNTY ON MAY 24, 2018, A MEETING OF COMMUNITY REPRESENTATIVES WAS HELD AT THE CITY HALL BUILDING IN HARFORD CITY, THE COUNTY SEAT OF BLACKFORD COUNTY. THE MEETING WAS ATTENDED BY 24 COMMUNITY MEMBERS INVITED BY IU HEALTH BECAUSE THEY REPRESENT IMPORTANT COMMUNITY ORGANIZATIONS AND SECTORS SUCH AS: LOCAL HEALTH DEPARTMENTS, POLICE/FIRE DEPARTMENTS, NON-PROFIT ORGANIZATIONS, LOCAL BUSINESS, HEALTH CARE PROVIDERS, MAYORS/LOCAL POLICYMAKERS, FAITH-BASED ORGANIZATIONS, PARKS AND RECREATION DEPARTMENTS, AND SCHOOLS. THROUGH THIS MEETING, IU HEALTH SOUGHT A BREADTH OF PERSPECTIVES ON THE COMMUNITY'S HEALTH NEEDS. THE SPECIFIC ORGANIZATIONS REPRESENTED AT THE MEETING ARE LISTED BELOW. - 3M HARTFORD CITY - AMVETS POST 23 - BLACKFORD COMMUNITY FOUNDATION - BLACKFORD COUNTY HEALTH DEPARTMENT - BLACKFORD COUNTY SCHOOLS - BLACKFORD COUNTY SHERIFF'S DEPARTMENT - BLACKFORD ECONOMIC DEVELOPMENT - HARTFORD CITY - HARTFORD CITY KIWANIS CLUB - HESTER HOLLIS CONCERN CENTER - IU HEALTH - IU HEALTH BLACKFORD HOSPITAL - INDIANA STATE GOVERNMENT - LIFESTREAM - MAYOR'S OFFICE, HARTFORD CITY - MERIDIAN HEALTH SERVICES - PLEXUS WORLDWIDE - PURDUE EXTENSION THE MEETING BEGAN WITH A PRESENTATION THAT DISCUSSED THE GOALS AND STATUS OF THE CHNA PROCESS AND THE PURPOSE OF THE COMMUNITY MEETING. THEN, SECONDARY DATA WERE PRESENTED, ALONG WITH A SUMMARY OF THE MOST UNFAVORABLE COMMUNITY HEALTH INDICATORS. FOR THE COMMUNITY SERVED BY IU HEALTH BLACKFORD HOSPITAL, THOSE INDICATORS WERE (IN ALPHABETICAL ORDER): - AIR POLLUTION - CANCER INCIDENCE AND MORTALITY RATES - MATERNAL AND CHILD HEALTH: LOW BIRTHWEIGHT BIRTHS, PRETERM BIRTHS, AND SMOKING DURING PREGNANCY - MENTAL HEALTH AND SUPPLY OF MENTAL HEALTH PROVIDERS - MOTOR VEHICLE ACCIDENTS - OBESITY AND PHYSICAL INACTIVITY - PREVENTABLE HOSPITAL ADMISSIONS - TEEN PREGNANCY MEETING PARTICIPANTS THEN WERE ASKED TO DISCUSS WHETHER THE IDENTIFIED, UNFAVORABLE INDICATORS ACCURATELY IDENTIFIED THE MOST SIGNIFICANT COMMUNITY HEALTH ISSUES AND WERE ENCOURAGED TO ADD ISSUES THAT THEY BELIEVED WERE SIGNIFICANT. SEVERAL ISSUES WERE ADDED, SUCH AS: TRANSPORTATION CHALLENGES, SUBSTANCE ABUSE AND OVERDOSES, AND THE NEEDS OF SENIORS. DURING THE MEETING, A RANGE OF OTHER TOPICS WAS DISCUSSED, INCLUDING: - THE NEED TO ENHANCE SERVICES FOR SENIORS, INCLUDING TRANSPORTATION OPTIONS - THE COMMUNITY'S NEED FOR MORE PRIMARY CARE PHYSICIANS - WHETHER AIR POLLUTION HAS CONTRIBUTED TO COMPARATIVELY HIGH RATES OF LUNG (AND OTHER TYPES OF) CANCER - THE UNDERSUPPLY OF OPTIONS FOR INDOOR EXERCISE AND RECREATION - CONCERNS REGARDING THE PROJECTED POPULATION DECREASE AND THE NEED TO KEEP YOUNG PEOPLE IN THE COMMUNITY - THE NEED FOR A COLLECTIVE IMPACT MODEL TO COLLABORATE AND PROVIDE A CENTRAL RESOURCE FOR ACCESSING INFORMATION ABOUT HEALTH AND SERVICES - THE IMPORTANCE OF LEARNING DIRECTLY FROM COMMUNITY MEMBERS ABOUT THEIR NEEDS, RATHER THAN DEVELOPING SERVICES BASED ON WHAT COULD BE INACCURATE ASSUMPTIONS AFTER DISCUSSING THE NEEDS IDENTIFIED THROUGH SECONDARY DATA AND ADDING OTHERS TO THE LIST, EACH PARTICIPANT WAS ASKED THROUGH A VOTING PROCESS TO IDENTIFY "THREE TO FIVE" THEY CONSIDER TO BE MOST SIGNIFICANT. FROM THIS PROCESS, THE GROUP IDENTIFIED THE FOLLOWING NEEDS AS MOST SIGNIFICANT IN THE COMMUNITY SERVED BY IU HEALTH BLACKFORD HOSPITAL: - SUBSTANCE ABUSE - MENTAL HEALTH, INCLUDING THE SHORTAGE OF MENTAL HEALTH WORKERS AND PSYCHIATRISTS - THE NEED TO PROVIDE HEALTH EDUCATION TO ENHANCE HEALTH LITERACY - THE NEED TO REDUCE OR ELIMINATE BARRIERS TO COLLABORATION AMONG COMMUNITY ORGANIZATIONS, INCLUDING THE LACK OF SHARING INFORMATION ABOUT AVAILABLE RESOURCES TO RESIDENTS AND OTHER ORGANIZATIONS - PARENTAL FACTORS, INCLUDING A LACK OF PARTICIPATION IN AVAILABLE PROGRAMS DESIGNED TO ADDRESS A VARIETY OF SOCIAL AND HEALTH-RELATED ISSUES IN HOUSEHOLDS COMMUNITY SURVEY TO INFORM THE CHNA, A COMMUNITY SURVEY WAS CONDUCTED BY THE INDIANA HOSPITAL COLLABORATIVE. ACROSS INDIANA, 9,161 COMPLETED QUESTIONNAIRES WERE RECEIVED BY ALL PARTICIPATING HOSPITALS IN THE INDIANA HOSPITAL COLLABORATIVE, FOR AN OVERALL RESPONSE RATE OF 11.6 PERCENT; 5,030 QUESTIONNAIRES WERE RECEIVED FROM THE 17 INDIANA COUNTIES SERVED BY ONE OR MORE IU HEALTH HOSPITALS. FOR IU HEALTH BLACKFORD HOSPITAL, SURVEYS WERE RECEIVED FROM 296 COMMUNITY HOUSEHOLDS. ACCORDING TO THE RESPONSES, THESE HOUSEHOLDS INCLUDED 530 ADULTS. THE COMMUNITY SURVEY INDICATES THAT SUBSTANCE USE AND ABUSE, OBESITY, CHRONIC DISEASES, AND POVERTY REPRESENT TOP CONCERNS IN THE COMMUNITY SERVED BY IU HEALTH BLACKFORD HOSPITAL. Schedule H, Part V, Section B, Line 11 Facility , 1 Facility , 1 - IU HEALTH BLACKFORD HOSPITAL. In conjunction with the CHNA, IU Health Blackford Hospital's Board adopted an implementation strategy in April 2019 related to the 2018 CHNA. IU Health Blackford Hospital prioritized and determined which of the community health needs identified in its most recently conducted CHNA were most critical for it to address. IU Health Blackford Hospital will address the following community health needs between 2019 and 2021: - Access to Healthcare Services - Aging Population and Needs of Seniors - Drug and Substance Abuse (including Opioids and Alcohol) - Maternal and Infant Health and Child Wellbeing - Mental Health - Obesity and Diabetes - Smoking and Tobacco Usage - Social Determinants of Health IU Health uses the term "Behavioral Health" to refer to Mental Health and Drug and Substance Abuse (including Opioids and Alcohol). Access to Healthcare Services IU Health Blackford Hospital's implementation strategy to address the identified need of Access to Healthcare includes the following: - Recruit new primary care, obstetric and mental health medical doctors to practice in East Central Indiana. - Utilize IU Health's internal recruitment resources. - Leverage IU Health's Ball Memorial Residency Programs for potential recruits. - Maintain and update facilities' plan and initiatives to support incoming practices. - Provide two family medicine directors and a resident rotation at a subsidized rate to local federally qualified health center (FQHC) Open Door Health Services to expand obstetrics capacity to serve low-income residents. Aging Population and Needs of Seniors IU Health Blackford Hospital's implementation strategy to address the identified need of Aging Population and Needs of Seniors include the following: - Support communication, organization and facilitation of local collaboration to advance new food policy, food waste reduction, and food access. - Facilitate organization recruitment and engagement using the collective impact model around improved nutrition, increased physical activity and tobacco cessation. - Organize workgroups and develop partner tools for audience engagement. - Build and maintain Healthy Community Alliance (HCA) website and other communication tools to support partner engagement. - Engage local partners to recruit low-income families to participate. - Provide opportunities for families to learn about nutrition value of fresh produce, physical activity and tobacco cessation. - Offer IU Health Bucks to participants so they may fully engage in farmers' market experience - Investigate potential partnership levels and investments with community-building activities related to food access, housing, aging population, behavioral health and education. Behavioral Health (includes Drug & Substance Abuse and Mental Health) IU Health Blackford Hospital's implementation strategy to address the identified need of Behavioral Health includes the following: - Provide structured therapeutic recovery program. - Apply for grant funding to expand virtual IOP to serve other East Central Region facilities. - Assist in the establishment of a community network of existing substance use disorders (SUD) related concerns. - Provide access to peer recovery coaches, advanced practice nursing and psychiatry for emergency department (ED) patients who need help with substance use disorders (SUD) related concerns. - Provide prescription medication disposal kiosks at IU Health East Central Region facilities. - Investigate potential partnership levels and investments with community-building activities related to food access, housing, aging population, behavioral health and education. - Provide Perinatal Coordinator to facilitate and collaborate within the hospital and with outside physician offices and community agencies to enhance efforts to decrease infant mortality in the IU Health East Central Region. Maternal and Infant Health and Child Wellbeing IU Health Blackford Hospital's implementation strategy to address the identified need of Maternal and Infant Health and Child Wellbeing include the following: - Provide two family medicine directors and a resident rotation at a subsidized rate to local federally qualified health center (FQHC) Open Door Health Services to expand obstetrics capacity to serve low-income residents. Obesity and Diabetes IU Health Blackford Hospital's implementation strategy to address the identified need of Obesity and Diabetes include the following: - Support communication, organization and facilitation of local collaboration to advance new food policy, food waste reduction, and food access. - Facilitate organization recruitment and engagement using the collective impact model around improved nutrition, increased physical activity and tobacco cessation. - Organize workgroups and develop partner tools for audience engagement. - Build and maintain Healthy Community Alliance (HCA) website and other communication tools to support partner engagement. - Engage local partners to recruit low-income families to participate. - Provide opportunities for families to learn about nutrition value of fresh produce, physical activity and tobacco cessation. - Offer IU Health Bucks to participants so they may fully engage in farmers' market experience Smoking and Tobacco Usage IU Health Blackford Hospital's implementation strategy to address the identified need of Smoking and Tobacco Usage include the following: - Facilitate organization recruitment and engagement using the collective impact model around improved nutrition, increased physical activity and tobacco cessation. - Organize workgroups and develop partner tools for audience engagement. - Build and maintain Healthy Community Alliance (HCA) website and other communication tools to support partner engagement. - Educate staff regarding "Ask, Advise, Refer" process to refer patients and family members to the Indiana Tobacco Quitline. - Provide Perinatal Coordinator to facilitate and collaborate within the hospital and with outside physician offices and community agencies to enhance efforts to decrease infant mortality in the IU Health East Central Region. - Engage local partners to recruit low-income families to participate. - Provide opportunities for families to learn about nutrition value of fresh produce, physical activity and tobacco cessation. - Offer IU Health Bucks to participants so they may fully engage in farmers' market experience Social Determinants of Health IU Health Blackford Hospital's implementation strategy to address the identified need of Social Determinants of Health include the following: - Investigate potential partnership levels and investments with community-building activities related to food access, housing, aging population, behavioral health and education. IU Health Blackford Hospital will address all community health needs based on their 2018 Community Health Needs Assessment. There were no identified needs that will not be addressed. Schedule H, Part V, Section B, Line 13 Facility , 1 Facility , 1 - IU HEALTH BLACKFORD HOSPITAL. IN ADDITION TO FPG, IU HEALTH BLACKFORD HOSPITAL MAY TAKE INTO CONSIDERATION A PATIENT'S INCOME AND/OR ABILITY TO PAY IN CALCULATION OF A FINANCIAL ASSISTANCE AWARD. Schedule H, Part V, Section B, Line 13 Facility , 1 Facility , 1 - IU HEALTH BLACKFORD HOSPITAL. IU Health Blackford Hospital takes into consideration several other factors in determining patient eligibility for financial assistance. These factors include the following: 1. Eligibility for Financial Assistance due to Financial or Personal Hardship In order to be eligible for Financial Assistance due to Financial or Personal Hardship under this Policy, a patient or guarantor must: - Submit a completed Financial Assistance Application with all supporting documentation and be approved in accordance with this Policy; - Be an Indiana Resident as defined in this Policy; and - If Uninsured, consult with a member of IU Health's Individual Solutions department to determine if health care coverage may be obtained from a government insurance or assistance product, the Health Insurance Marketplace, or from any other source of coverage. Financial Assistance due to Financial Hardship is only available for encounters where care was initiated via an eligible facility's emergency department, direct admission from a physician's office, or transfer from another hospital facility. 2. Financial Assistance due to Financial Hardship The FPL income threshold under this section is as follows: - If one or more adults and zero dependents are in the household, the FPL Income Threshold is 200%. - If two or more adults and one or more dependents are in the household, the FPL Income Threshold is 250%. - If one adult and one or more dependents are in the household, the FPL Income Threshold is 300%. In some instances, an adult will also qualify as a dependent. When this occurs, IU Health will treat the adult as a dependent for purposes of the FPL calculation. IU Health will utilize the most recent FPL data available and will apply the FPL data to a patient or guarantor's account balance based upon the calendar date a completed Financial Assistance Application was received, not a patient's date of service. An Uninsured Patient or their guarantor whose household income is less than or equal to the FPL income threshold may be eligible for full Financial Assistance up to 100% of Gross Charges if approved. An Underinsured Patient or their guarantor whose household income is less than or equal to the FPL income threshold may be eligible for full Financial Assistance up to 100% of Patient Responsibility if approved. 3. Financial Assistance due to Personal Hardship An Uninsured or Underinsured patient or their guarantor whose household income is above the FPL income threshold may be eligible for Financial Assistance if the patient's outstanding Patient Responsibility exceeds 20% of the patient's or their guarantor's annual household income. - If approved, the patient's balance will be reduced to 20% of the patient or guarantor's annual household income or the Amounts Generally Billed, whichever is less. - IU Health will work with the patient or guarantor to identify a reasonable payment plan on the remainder of the balance. 4. Eligibility Period If approved for financial assistance by IU Health, the patient will be guaranteed financial assistance for treatment related to the underlying condition, for which the patient was originally screened and approved, through the remainder of the calendar year. As a condition of extending the on-going Financial Assistance, the patient must comply with requests from IU Health to verify that the patient continues to meet the conditions for qualification. 5. Appeals and Assistance Granted By the Financial Assistance Committee The Financial Assistance Committee will review and make determinations on all requests for appeals related to Financial Assistance. If a patient or guarantor seeks to appeal a Financial Assistance Determination, a written request must be submitted, along with the supporting documentation. The Financial Assistance Committee will review requests for and may grant additional Financial Assistance, including but not limited to, the following: - Assistance to patients who are seeking treatment that can only be provided in Indiana by IU Health or who would benefit from continued medical services from IU Health for continuity of care; - Care approved by the IU Health Chief Medical Officer (CMO) or the Chief Executive Officer (CEO) or CMO of an IU Health facility or region, including medically necessary non-elective services for which no payment source can be identified; - Care provided when it is known no payment source exists; - International humanitarian aid; and - Other care identified by the Financial Assistance Committee that fulfills the IU Health Mission. All decisions of the Financial Assistance Committee are final. 6. Presumptive Eligibility No Financial Assistance Application is required to receive Financial Assistance under this Presumptive Eligibility section. IU Health will deem patients or their guarantors presumptively eligible for Financial Assistance if they are found to be eligible for one of the following programs and care was initiated via an eligible facility's emergency department, direct admission from a physician's office, or transfer from another hospital facility: - Medicaid (any state) - Indiana Children's Special Health Care Services - Healthy Indiana Plan - Patients who are awarded Hospital Presumptive Eligibility (HPE) - A state and/or federal program that verifies the patient or guarantor's gross household income meets the FPL income threshold. IU Health will conduct a quarterly review of all accounts placed with a collection agency partner for at least one hundred and twenty (120) days after the account is eligible for an ECA as set forth in this Policy. If the patient or guarantor's individual scoring criteria demonstrates the patient has a low likelihood and/or propensity to pay or no credit, the patient or guarantor may be deemed presumptively eligible for Financial Assistance. Financial Assistance may additionally be granted in the following circumstances: - If the patient or their guarantor is found to have filed a petition for bankruptcy. - If the patient is deceased and found to have no estate. - If the patient is deceased and was under 21 years of age at the time of death. 7. Exhaustion of Alternate Sources of Assistance Patients must exhaust all other state and federal assistance programs prior to receiving Financial Assistance due to Financial or Personal Hardship under this Policy including, but not limited to, Medicaid. Patients who may be eligible for coverage under an applicable health insurance policy must exhaust all insurance benefits. - This includes patients covered under their own policy and those who may be entitled to benefits from a third-party policy. - IU Health may request patients show proof that such a claim was properly submitted to the appropriate insurance provider before awarding Financial Assistance. Eligible patients who receive medical care from an IU Health facility as a result of an injury proximately caused by a third party, and later receive a monetary settlement or award from said third party, may receive Financial Assistance for any outstanding balance not covered by the settlement or award. In the event Financial Assistance has already been granted in the above circumstances, IU Health reserves the right to reverse the Financial Assistance Determination in an amount equal to the amount IU Health would be entitled to receive had no Financial Assistance been awarded. 8. Patient Assets There are situations where a patient or their guarantor may have significant income or assets available to pay for healthcare services such as a legal settlement. The Financial Assistance Committee may evaluate the income or assets in determining Financial Hardship. IU Health may require a list of all property owned by the patient or guarantor and adjust a Financial Assistance Determination as a result. Schedule H, Part V, Section B, Line 16 Facility , 1 Facility , 1 - IU HEALTH BLACKFORD HOSPITAL. IU Health Blackford Hospital takes several other measures to publicize its FAP within the community. These measures include the following: 1. Post this Policy, a Plain Language Summary of this Policy, and the Financial Assistance Application on its website. 2. Provide patients with a Plain Language Summary of this Policy during registration and/or discharge. 3. Post conspicuous displays in appropriate acute care settings such as emergency departments and registration areas describing the available assistance and directing eligible patients to the Financial Assistance Application. 4. Include a conspicuous written notice on all patient post-discharge billing statements notifying the patient about this Policy and the telephone number of the Customer Service Department which can assist patients with questions regarding this Policy. 5. Make available Customer Service representatives via telephone during normal business hours. 6. Mail copies of this Policy, a Plain Language Summary of this Policy, and a Financial Assistance Application to patients or their guarantor free of charge upon request. 7. Broadly communicate this Policy as a part of its general outreach efforts. 8. Educate patient-facing team members on this Policy and the process for referring patients to the program. 3 IU HEALTH BLACKFORD HOSPITAL RADIOLOGY 410 PILGRIM BLVD HARTFORD CITY IN 47348 DIAGNOSTIC AND OTHER OUTPATIENT IUH BLACKFORD PHYSICAL THERAPY AND REHAB 410 PILGRIM BLVD HARTFORD CITY IN 47350 DIAGNOSTIC AND OTHER OUTPATIENT IU HEALTH BLACKFORD PHARMACY 400 PILGRIM BLVD HARTFORD CITY IN 47349 PHARMACY Schedule H, Part I, Line 6a C.B. REPORT PREPARED BY A RELATED ORG. IU HEALTH BLACKFORD HOSPITAL'S COMMUNITY BENEFIT AND OTHER INVESTMENTS, ENCOMPASSING ITS TOTAL COMMUNITY INVESTMENT, ARE INCLUDED IN THE IU HEALTH COMMUNITY BENEFIT REPORT WHICH IS PREPARED ON BEHALF OF AND INCLUDES IU HEALTH AND ITS RELATED HOSPITAL ENTITIES IN THE STATE OF INDIANA ("IU HEALTH STATEWIDE SYSTEM"). THE IU HEALTH COMMUNITY BENEFIT REPORT IS MADE AVAILABLE TO THE PUBLIC ON IU HEALTH'S WEBSITE AT HTTPS://IUHEALTH.ORG/IN-THE-COMMUNITY/COMMUNITY BENEFIT THE IU HEALTH COMMUNITY BENEFIT REPORT IS ALSO DISTRIBUTED TO NUMEROUS KEY ORGANIZATIONS THROUGHOUT THE STATE OF INDIANA IN ORDER TO BROADLY SHARE THE IU HEALTH STATEWIDE SYSTEM'S COMMUNITY BENEFIT EFFORTS. IT IS ALSO AVAILABLE BY REQUEST THROUGH THE INDIANA STATE DEPARTMENT OF HEALTH OR IU HEALTH. Schedule H, Part I, Line 7f BAD DEBT EXPENSE THE AMOUNT OF BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE OF TOTAL EXPENSE IS $1,623,073. BAD DEBT EXPENSE IS REPORTED AT COST BASED ON THE COST-TO-CHARGE RATIO. DERIVED FROM WORKSHEET 2, RATIO OF PATIENT CARE COST TO-CHARGES. Schedule H, Part I, Line 7 TOTAL COMMUNITY BENEFIT EXPENSE SCHEDULE H, PART I, LINE 7, COLUMN (F), PERCENT OF TOTAL EXPENSE, IS BASED ON COLUMN (E) NET COMMUNITY BENEFIT EXPENSE. THE PERCENT OF TOTAL EXPENSE BASED ON COLUMN (C) TOTAL COMMUNITY BENEFIT EXPENSE, WHICH DOES NOT INCLUDE DIRECT OFFSETTING REVENUE, IS 26.11%. Schedule H, Part II PROMOTION OF HEALTH IN COMMUNITIES SERVED IU Health Blackford Hospital participates in a variety of community-building activities that address the social determinants of health in the communities it serves. IU Health Blackford Hospital and its related hospital entities across the state of Indiana ("IU Health Statewide System") invest in economic development efforts across the state, collaborate with like-minded organizations through coalitions that address key issues, and advocate for improvements in the health status of vulnerable populations. Additionally, through the IU Health Statewide System's team member volunteer program, IU Health Serves, team members across the state positively impact the health of the community and foster a culture of engagement and social responsibility. In 2020, more than 1,400 team members throughout the statewide system dedicated time to support over 49 projects to positively impact the community. Schedule H, Part I, Line 3c Eligibility criteria for free or discounted care IU Health Blackford Hospital uses several factors other than Federal Poverty Guidelines ("FPGs") in determining eligibility for free care under its FAP. These factors include the following: 1. Eligibility for Financial Assistance due to Financial or Personal Hardship In order to be eligible for Financial Assistance due to Financial or Personal Hardship under this Policy, a patient or guarantor must: - Submit a completed Financial Assistance Application with all supporting documentation and be approved in accordance with this Policy; - Be an Indiana Resident as defined in this Policy; and - If Uninsured, consult with a member of IU Health's Individual Solutions department to determine if health care coverage may be obtained from a government insurance or assistance product, the Health Insurance Marketplace, or from any other source of coverage. Financial Assistance due to Financial Hardship is only available for encounters where care was initiated via an eligible facility's emergency department, direct admission from a physician's office, or transfer from another hospital facility. 2. Financial Assistance due to Financial Hardship The FPL income threshold under this section is as follows: - If one or more adults and zero dependents are in the household, the FPL Income Threshold is 200%. - If two or more adults and one or more dependents are in the household, the FPL Income Threshold is 250%. - If one adult and one or more dependents are in the household, the FPL Income Threshold is 300%. In some instances, an adult will also qualify as a dependent. When this occurs, IU Health will treat the adult as a dependent for purposes of the FPL calculation. IU Health will utilize the most recent FPL data available and will apply the FPL data to a patient or guarantor's account balance based upon the calendar date a completed Financial Assistance Application was received, not a patient's date of service. An Uninsured Patient or their guarantor whose household income is less than or equal to the FPL income threshold may be eligible for full Financial Assistance up to 100% of Gross Charges if approved. An Underinsured Patient or their guarantor whose household income is less than or equal to the FPL income threshold may be eligible for full Financial Assistance up to 100% of Patient Responsibility if approved. 3. Financial Assistance due to Personal Hardship An Uninsured or Underinsured patient or their guarantor whose household income is above the FPL income threshold may be eligible for Financial Assistance if the patient's outstanding Patient Responsibility exceeds 20% of the patient's or their guarantor's annual household income. - If approved, the patient's balance will be reduced to 20% of the patient or guarantor's annual household income or the Amounts Generally Billed, whichever is less. - IU Health will work with the patient or guarantor to identify a reasonable payment plan on the remainder of the balance. 4. Eligibility Period If approved for financial assistance by IU Health, the patient will be guaranteed financial assistance for treatment related to the underlying condition, for which the patient was originally screened and approved, through the remainder of the calendar year. As a condition of extending the on-going Financial Assistance, the patient must comply with requests from IU Health to verify that the patient continues to meet the conditions for qualification. 5. Appeals and Assistance Granted By the Financial Assistance Committee The Financial Assistance Committee will review and make determinations on all requests for appeals related to Financial Assistance. If a patient or guarantor seeks to appeal a Financial Assistance Determination, a written request must be submitted, along with the supporting documentation. The Financial Assistance Committee will review requests for and may grant additional Financial Assistance, including but not limited to, the following: - Assistance to patients who are seeking treatment that can only be provided in Indiana by IU Health or who would benefit from continued medical services from IU Health for continuity of care; - Care approved by the IU Health Chief Medical Officer (CMO) or the Chief Executive Officer (CEO) or CMO of an IU Health facility or region, including medically necessary non-elective services for which no payment source can be identified; - Care provided when it is known no payment source exists; - International humanitarian aid; and - Other care identified by the Financial Assistance Committee that fulfills the IU Health Mission. All decisions of the Financial Assistance Committee are final. 6. Presumptive Eligibility No Financial Assistance Application is required to receive Financial Assistance under this Presumptive Eligibility section. IU Health will deem patients or their guarantors presumptively eligible for Financial Assistance if they are found to be eligible for one of the following programs and care was initiated via an eligible facility's emergency department, direct admission from a physician's office, or transfer from another hospital facility: - Medicaid (any state) - Indiana Children's Special Health Care Services - Healthy Indiana Plan - Patients who are awarded Hospital Presumptive Eligibility (HPE) - A state and/or federal program that verifies the patient or guarantor's gross household income meets the FPL income threshold. IU Health will conduct a quarterly review of all accounts placed with a collection agency partner for at least one hundred and twenty (120) days after the account is eligible for an ECA as set forth in this Policy. If the patient or guarantor's individual scoring criteria demonstrates the patient has a low likelihood and/or propensity to pay or no credit, the patient or guarantor may be deemed presumptively eligible for Financial Assistance. Financial Assistance may additionally be granted in the following circumstances: - If the patient or their guarantor is found to have filed a petition for bankruptcy. - If the patient is deceased and found to have no estate. - If the patient is deceased and was under 21 years of age at the time of death. 7. Exhaustion of Alternate Sources of Assistance Patients must exhaust all other state and federal assistance programs prior to receiving Financial Assistance due to Financial or Personal Hardship under this Policy including, but not limited to, Medicaid. Patients who may be eligible for coverage under an applicable health insurance policy must exhaust all insurance benefits. - This includes patients covered under their own policy and those who may be entitled to benefits from a third-party policy. - IU Health may request patients show proof that such a claim was properly submitted to the appropriate insurance provider before awarding Financial Assistance. Eligible patients who receive medical care from an IU Health facility as a result of an injury proximately caused by a third party, and later receive a monetary settlement or award from said third party, may receive Financial Assistance for any outstanding balance not covered by the settlement or award. In the event Financial Assistance has already been granted in the above circumstances, IU Health reserves the right to reverse the Financial Assistance Determination in an amount equal to the amount IU Health would be entitled to receive had no Financial Assistance been awarded. 8. Patient Assets There are situations where a patient or their guarantor may have significant income or assets available to pay for healthcare services such as a legal settlement. The Financial Assistance Committee may evaluate the income or assets in determining Financial Hardship. IU Health may require a list of all property owned by the patient or guarantor and adjust a Financial Assistance Determination as a result. Schedule H, Part I, Line 7g Subsidized Health Services IU HEALTH BLACKFORD HOSPITAL DOES NOT INCLUDE ANY COSTS ASSOCIATED WITH PHYSICIAN CLINICS AS SUBSIDIZED HEALTH SERVICES. Schedule H, Part I, Line 7 Bad Debt Expense excluded from financial assistance calculation 1623073 Schedule H, Part III, Line 2 Bad debt expense - methodology used to estimate amount THE BAD DEBT EXPENSE OF $734,765 REPORTED ON SCHEDULE H, PART III, LINE 2 IS REPORTED AT COST, AS CALCULATED USING THE COST TO CHARGE RATIO METHODOLOGY. Schedule H, Part III, Line 3 Bad Debt Expense Methodology IU Health will deem patients or their guarantors presumptively eligible for Financial Assistance if they are found to be eligible for one of the following programs and care was initiated via an eligible facility's emergency department, direct admission from a physician's office, or transfer from another hospital facility: 1. Medicaid (any state) 2. Indiana Children's Special Health Care Services 3. Healthy Indiana Plan 4. Patients who are awarded Hospital Presumptive Eligibility (HPE) 5. A state and/or federal program that verifies the patient or guarantor's gross household income meets the FPL income threshold. No Financial Assistance Application is required to receive Financial Assistance under this Presumptive Eligibility section. IU Health will conduct a quarterly review of all accounts placed with a collection agency partner for at least one hundred and twenty (120) days after the account is eligible for an ECA as set forth in this Policy. If the patient or guarantor's individual scoring criteria demonstrates the patient has a low likelihood and/or propensity to pay or no credit, the patient or guarantor may be deemed presumptively eligible for Financial Assistance. Financial Assistance may additionally be granted in the following circumstances: a) If the patient or their guarantor is found to have filed a petition for bankruptcy. b) If the patient is deceased and found to have no estate. c) If the patient is deceased and was under 21 years of age at the time of death. Due to this comprehensive methodology, IU Health does not believe any amount of bad debt is attributable to patients who may be eligible under the financial assistance policy and no portion of bad debt is included as community benefit. Schedule H, Part III, Line 4 Bad debt expense - financial statement footnote IU Health's consolidated financial statements, Footnote 4, addresses bad debt expense as follows: The Indiana University Health System does not require collateral or other security from its patients, substantially all of whom are residents of the State, for the delivery of health care services. However, consistent with industry practice, the Indiana University Health System routinely obtains assignment of (or is otherwise entitled to receive) patients' benefits payable under their health insurance programs, plans, or policies (e.g., Medicare, Medicaid, managed care payers, and commercial insurance policies). The Indiana University Health System uses a portfolio approach to account for categories of patient contracts as a collective group, rather than recognizing revenue on an individual contract basis. The portfolios consist of major payer classes for inpatient revenue and outpatient revenue. Based on the historical collection trends and other analysis, the Indiana University Health System believes that revenue recognized by utilizing the portfolio approach approximates the revenue that would have been recognized if an individual contract approach were used. In support of its mission, the Indiana University Health System provides care to uninsured and underinsured patients. The Indiana University Health System provides charity care to patients who lack financial resources and are deemed to be medically indigent. Financial assistance is available to qualifying uninsured and underinsured patients receiving care at an Indiana University Health System hospital location. Under its financial assistance policy, the Indiana University Health System provides medically necessary care to uninsured patients. Financial assistance up to the full amount of patient financial responsibility is available for uninsured and underinsured patients receiving care via the emergency department, direct admission from a physician's office, or transfer from another hospital. The federal poverty level (FPL) thresholds for this type of financial assistance are based on household makeup. Households without dependents are eligible for assistance if household income is less than or equal to 200% FPL, two adults and at least one dependent are eligible if household income is less than or equal to 250% FPL, and households with one adult and at least one dependent are eligible if household income is less than or equal to 300% FPL. Individuals with medical bills totaling more than 20% of annual household income, regardless of FPL, qualify for catastrophic assistance and are eligible for a reduction in patient financial responsibility to 20% of annual household income. Since the Indiana University Health System does not pursue collection of these amounts, the discounted amounts are not reported as patient service revenue. The Indiana University Health System uses presumptive eligibility screening procedures for some forms of financial assistance and recognizes net patient service revenue on services provided to self-pay patients at the discounted rate at the time services are rendered. The estimated cost of charity care, using the consolidated cost to charge ratio, was $90,358,000 and $96,693,000 in 2020 and 2019, respectively. Schedule H, Part III, Line 8 Community benefit & methodology for determining medicare costs IU Health Blackford Hospital did not have a Medicare shortfall for 2020. IU Health Blackford Hospital's Medicare reimbursements, however, are normally less than the cost of providing patient care and services to Medicare beneficiaries and do not include any amounts that result from inefficiencies or poor management. IU Health Blackford Hospital accepts all Medicare patients knowing that there may be shortfalls; therefore it has taken the position that any shortfall should be counted as part of its community benefit. Additionally, it is implied in Internal Revenue Service Revenue Ruling 69-545 that treating Medicare patients is a community benefit. Revenue Ruling 69-545, which established the community benefit standard for nonprofit hospitals, states that if a hospital serves patients with governmental health benefits, including Medicare, then this is an indication that the hospital operates to promote the health of the community. The amount reported on Schedule H, Part III, Line 6 is calculated, in accordance with the Form 990 instructions, using "allowable costs" from the IU Health Medicare Cost Report. "Allowable costs" for Medicare Cost Report purposes, however, are not reflective of all costs associated with IU Health's participation in Medicare programs. For example, the Medicare Cost Report excludes certain costs such as billed physician services, the costs of Medicare Parts C and D, fee schedule reimbursed services, and durable medical equipment services. Inclusion of all costs associated with IU Health Blackford Hospital's participation in Medicare programs would significantly reduce the Medicare surplus reported on Schedule H, Part III, Line 7. Schedule H, Part III, Line 9b Collection practices for patients eligible for financial assistance IU Health Blackford Hospital's FAP and Written Debt Collection Policy describe the collection practices applicable to patients, including those who may qualify for financial assistance. 1. Financial Assistance Application Financial Assistance Applications must include the following documentation: - All sources of Income for the last three (3) months. - Most recent three (3) months of pay stubs or Supplemental Security Income via Social Security. - Most recent three (3) statements from checking and savings accounts, certificates of deposit, stocks, bonds and money market accounts. - Most recent state and Federal Income Tax forms including Schedules C, D, E, and F. In the event the patient or guarantor's income does not warrant the filing of a federal tax statement, the individual may submit a notarized affidavit attesting to the foregoing. - Most recent W-2 statement. - For patients or members of the Household who are currently unemployed, Wage Inquiry from WorkOne. - If applicable, divorce/dissolution decrees and child custody order. Patients or their guarantors wishing to apply for Financial Assistance due to Financial Hardship are encouraged to submit an Application within ninety (90) days of discharge. Patients or their guarantors may submit an Application up to two-hundred and forty (240) days from the date of their initial post-discharge billing statement from IU Health, however, accounts may be subject to Extraordinary Collection Actions (ECA) as soon as one-hundred and twenty (120) days after receipt of the initial post-discharge billing statement. Patients or their guarantors submitting an incomplete Financial Assistance Application will receive written notification of the Application's deficiency upon discovery by IU Health. The Application will be pended for a period of forty-five (45) days from the date the notification is mailed. IU Health will suspend any ECA until the Application is complete or the expiration of the forty-five (45) day period. Patients with limited English proficiency may request a copy of this Policy, a Financial Assistance Application, and a Plain Language Summary in one of the below languages: - Arabic; - Burmese; - Burmese - Falam; - Burmese - Hakha Chin; - Mandarin/Chinese; or - Spanish The patient, and/or their representative, such as the patient's physician, family members, legal counsel, community or religious groups, social services or hospital personnel may request a Financial Assistance Application be mailed to a patient's primary mailing address free of charge. IU Health maintains the confidentiality of all Financial Assistance Applications and supporting documentation. IU Health will deny or revoke Financial Assistance for any patient or guarantor who falsifies any portion of a Financial Assistance Application. 2. Financial Assistance Determinations IU Health will inform patients or guarantors of the results of their Application by providing the patient or guarantor with a Financial Assistance Determination within ninety (90) days of receiving a completed Application and all requested documentation. A patient's Financial Assistance Application and Financial Assistance Determination are specific to each date(s) of service and approved related encounters. If a patient or guarantor is granted less than full charity assistance and the patient or guarantor provides additional information for reconsideration, Revenue Cycle Services may amend a prior Financial Assistance Determination. 3. Extraordinary Collection Actions IU Health may refer delinquent patient accounts to a third-party collection agency after utilizing reasonable efforts to determine a patient's eligibility for assistance under this Policy. Reasonable efforts include the following: - IU Health will notify the patient of this Policy at least thirty (30) days prior to initiating an ECA. - IU Health will not initiate an ECA for at least one-hundred and twenty (120) days after the patient's initial post-discharge billing statement. - IU Health will review all Financial Assistance Applications received up to and including two-hundred and forty (240) days after the patient's initial post-discharge billing statement. IU Health will cease any ECAs it has initiated upon receipt of a Financial Assistance Application until a Financial Assistance Determination is made under this policy. - If an Application is Approved, IU Health will issue a revised statement, issue refunds, and make reasonable efforts to reverse ECAs as necessary. IU Health and its third-party collection agencies may initiate an ECA against a patient or their guarantor in accordance with this Policy and 26 C.F.R. § 1.501(r). ECAs may include the following: - Selling a patient or their guarantor's outstanding financial responsibility to a third party. - Reporting adverse information about the patient or their guarantor to consumer credit reporting agencies or credit bureaus. - Deferring or denying, or requiring a payment before providing, medically necessary care because of a patient or their guarantor's nonpayment of one or more bills for previously provided care covered under this Policy. - Actions requiring a legal or judicial process, including but not limited to placing a lien on a patient's or their guarantor's property, foreclosing on a patient's or their guarantor's real property, attaching or seizing a patient's or their guarantor's bank account or other personal property, commencing a civil action against a patient or their guarantor, causing a patient or guarantor's arrest, causing a patient and/or guarantor to be subject to a writ of body attachment, and garnishing a patient or guarantor's wages When it is necessary to engage in such action, IU Health and its third party collection agencies, will engage in fair, respectful and transparent collections activities. 4. Refunds Patients eligible for Financial Assistance under this Policy who remitted payment to IU Health in excess of their Patient Responsibility will be alerted to the overpayment as promptly after discovery as is reasonable given the nature of the overpayment. Patients with an outstanding account balance due on a separate account will have their refund applied to the outstanding balance. Patients without an outstanding account balance described above will be issued a refund check for their overpayment as soon as technically feasible. Schedule H, Part V, Section B, Line 16a FAP website - IU HEALTH BLACKFORD HOSPITAL: Line 16a URL: https://iuhealth.org/pay-a-bill/financial-assistance; Schedule H, Part V, Section B, Line 16b FAP Application website - IU HEALTH BLACKFORD HOSPITAL: Line 16b URL: https://iuhealth.org/pay-a-bill/financial-assistance; Schedule H, Part V, Section B, Line 16c FAP plain language summary website - IU HEALTH BLACKFORD HOSPITAL: Line 16c URL: https://iuhealth.org/pay-a-bill/financial-assistance; Schedule H, Part VI, Line 2 Needs assessment Communities are multifaceted and so are their health needs. IU Health Blackford Hospital understands that the health of individuals and communities are shaped by various social and environmental factors, along with health behaviors and additional influences. IU Health Blackford Hospital assesses the health care needs of the communities it serves by conducting a community health needs assessment (CHNA). For the 2018 CHNA, IU Health Blackford Hospital conducted the community survey data collection in collaboration with Indiana University, University of Evansville and the Indiana Hospital Collaborative, including Community Health Network, Franciscan Alliance, St. Vincent Health and other hospital partners. After completion of the CHNA, IU Health Blackford Hospital reviewed secondary data, findings from other community health assessments of area served by the hospital, input obtained from individuals who participated in community meetings, input obtained from key stakeholders, and a community survey to identify and analyze the needs identified by each source. The top health needs of the IU Health Blackford Hospital community are those that are supported by multiple data sources. Additionally, the effectiveness of an intervention for each need and IU Health's ability to impact positive change was evaluated. Schedule H, Part VI, Line 3 Patient education of eligibility for assistance IU Health Blackford Hospital is committed to serving the healthcare needs of all of its patients regardless of their ability to pay for such services. To assist in meeting those needs, IU Health Blackford Hospital has established a FAP to provide Financial Assistance to Uninsured Patients. IU Health Blackford Hospital is committed to ensuring its patients are compliant with all provisions of the Patient Protection & Affordable Care Act. To that end, IU Health Blackford Hospital will make a good faith effort to locate and obtain health insurance coverage for patients prior to considering patients for coverage under the FAP. IU Health Blackford Hospital takes several measures to inform its patients of the FAP and FAP-eligibility. These measures include the following: 1. Post this Policy, a Plain Language Summary of this Policy, and the Financial Assistance Application on its website. 2. Provide patients with a Plain Language Summary of this Policy during registration and/or discharge. 3. Post conspicuous displays in appropriate acute care settings such as emergency departments and registration areas describing the available assistance and directing eligible patients to the Financial Assistance Application. 4. Include a conspicuous written notice on all patient post-discharge billing statements notifying the patient about this Policy and the telephone number of the Customer Service Department which can assist patients with questions regarding this Policy. 5. Make available Customer Service representatives via telephone during normal business hours. 6. Mail copies of this Policy, a Plain Language Summary of this Policy, and a Financial Assistance Application to patients or their guarantor free of charge upon request. 7. Broadly communicate this Policy as a part of its general outreach efforts. 8. Educate patient-facing team members on this Policy and the process for referring patients to the program. Schedule H, Part VI, Line 4 Community information IU Health Blackford Hospital is located in Blackford County, Indiana, a county located in east-central Indiana. Its service areas include Blackford, Grant, Delaware, Jay, and Wells counties. Blackford County includes ZIP codes within the towns of Hartford City and Montpelier. Based on the most recent Census Bureau (2020) statistics, Blackford County's population is 12,112 persons with approximately 51% being female and 49% male. The county's population estimates by race are 95.2% White, 1.8% Hispanic or Latino, 0.8% Black, 0.6% Asian, 0.3% American Indian or Alaska Native, and 1.6% persons reporting two or more races. Blackford County has relatively low levels of educational attainment. The level of education most of the population has achieved is a high school degree (84.7%). As of 2020, 13.5% of the population had a bachelor's degree or higher. Schedule H, Part VI, Line 5 Promotion of community health During 2019, IU Health Blackford Hospital's promotion of community health included the following highlights: IU Health Blackford Hospital hosted their annual community health fair on Saturday, October 12, 2019 at IU Health Blackford Hospital in Hartford City. Residents of Blackford County and the surrounding areas came out to visit with local medical professionals, receive health and wellness screenings, see activity demonstrations and enjoy family entertainment. The one-day event, sponsored by IU Health Blackford Hospital, focused on specific health needs, including cardiac services, cancer, and diabetes, heart failure and stroke screenings were offered to visitors, along with free or reduced-cost lab work. IU Health Blackford Hospital participates as a supporting partner in a three-county health coalition focused on obesity prevention and tobacco cessation as a means to reduce the impact of chronic disease including cancer and heart disease. More than 150 organizations are partners in the "Healthy Community Alliance of East Central Indiana" coalition and each pledges to influence audiences to make positive choices regarding improved nutrition, increased physical activity or tobacco cessation. Coalition partners report a collective total audience size of more than 50,000 people. As an additional obesity prevention initiative, IU Health Blackford Hospital partners with the Hartford City Growers and Makers Market and other community partners to offer "families at the farmers market." This program consists of three monthly Saturday workshops that offer a wellness-based presentation on utilizing tasty natural herbs, ideal healthy recipes for children, or a diabetes component, grocery shopping tips are often a part of the educational lectures, including a better understanding of nutritional labels and food storage. Participating families also receive free "IU Health Bucks" to shop for produce in the farmers market. In 2019, 7 families participated in the program. Schedule H, Part VI, Line 6 Affiliated health care system IU Health Blackford Hospital is part of the IU Health Statewide System ("the system"), which is Indiana's most comprehensive healthcare system. A unique partnership with the Indiana University School of Medicine ("IU School of Medicine"), one of the nation's leading medical schools, gives patients access to innovative treatments and therapies. The system is comprised of hospitals, physicians and allied services dedicated to providing preeminent care throughout Indiana and beyond. National Recognition - Eight hospitals designated as Magnet by the American Nurses Credentialing Center recognizing excellence in nursing care. - U.S. News & World Report - Annual Rankings - IU Health Medical Center is nationally ranked for the 23rd year in a row. IU Health Medical Center is nationally ranked in 3 adult specialties and 10 pediatric specialties and rated high performing in 5 adult specialties and 6 procedures and conditions. - IU Health has five hospitals that are considered high performing in certain procedures and conditions: IU Health Ball, IU Health Arnett, IU Health North, IU Health West, and IU Health Bloomington hospitals. - Riley Hospital for Children at IU Health is nationally ranked in 10 pediatric specialties. IU Health Statewide System Hospitals in the system include the following: - IU Health Inc. (i.e., the IU Health Academic Health Center consists of IU Health Methodist Hospital, IU Health University Hospital, Riley Hospital for Children at IU Health, and IU Health Saxony Hospital) - IU Health Arnett - IU Health Ball - IU Health Bedford Hospital - IU Health Blackford - IU Health Bloomington Hospital - IU Health Frankfort - IU Health Jay - IU Health North Hospital - IU Health Paoli Hospital - IU Health Tipton Hospital - IU Health West Hospital - IU Health White Memorial Hospital The system is divided into five regions that serve communities in Northwest, Northeast, Central, and Southern Indiana. IU Health Inc. has significant statewide reach as a: 1) teaching hospital, 2) research activities with the IU School of Medicine and other national collaborations, 3) Riley's network of locations throughout the state due to its pediatric expertise, and 4) Riley's trauma department is the only Level I Pediatric Trauma Center in Indiana. Although each hospital in the system conducts and adopts its own CHNA and implementation strategy, the system considers the sum of these plans part of a system wide goal of making Indiana one of the healthiest states in the nation. The hospitals are guided by a system wide mission to improve the health of our patients and community through innovation, and excellence in care, education, research, and service. The system is keenly aware of the positive impact it can have on improving the health of communities throughout the state of Indiana by aligning resources in a system-level and strategic way. Education and Research The system includes the Academic Health Center that works in partnership with the IU School of Medicine to train physicians, blending breakthrough research and treatments with the highest quality of patient care. Each year, more than 1,000 residents and fellows receive training in IU Health hospitals. Research conducted by IU School of Medicine faculty gives IU Health physicians and patients access to the most leading-edge and comprehensive treatment options. In 2017, IU Health and the IU School of Medicine announced that they would invest $50 million over six years in the Strategic Research Initiative (SRI), a new research collaboration that has enhanced the institutions' joint capabilities in fundamental scientific investigation, translational research and clinical trials. The initial focus is on projects in the fields of neuroscience, cancer and cardiovascular disease with the goal to fund transformative proposals that will fundamentally change the understanding of these diseases and lead to important new therapies for patients. The three target research areas represent research strengths at IU School of Medicine, key strategic service lines for IU Health, and important medical needs in a time of an aging population and rising healthcare costs. One of the most significant outcomes of this initiative includes the Indiana University Melvin and Bren Simon Cancer Center receiving the National Cancer Institute's (NCI)-designated status of "comprehensive." This designation was achieved in August 2019 making the center the only NCI-designated Comprehensive Cancer Center in Indiana and one of just 51 in the nation. Community Health To further promote the health of the communities served by the system, the system-level Community Health team builds the capabilities and competencies to impact team members, risk lives, and patients throughout the system. Additionally, the team partners with state and local community-based organizations, community coalitions, and governmental agencies to pursue a system-level advocacy/collaboration strategy that seeks to improve the health of communities. All hospitals in the system identify and address significant health needs unique to the community it serves. However, because some of these health needs are common in communities served by multiple hospitals in the system, they warrant a system level strategy. Community Health plans and provides technical assistance for system-level strategies that address these common health needs including health equity, tobacco treatment, behavioral health access, and social needs. Each hospital works collaboratively with the Community Health team to operationalize system-level strategies through the implementation of specific activities that align and activate local resources. This benefits the community each hospital serves and works towards a statewide impact (system-level) on health outcomes. IU Health Serves IU Health Serves, a system-level team member volunteer program, seeks to positively impact the health of communities the IU Health Statewide System serves and fosters a culture of engagement and social responsibility. IU Health Blackford coordinates the different initiatives of the program, including Days of Service. This is the largest volunteer event of the year, consisting of projects designed to engage IU Health Blackford team members in activities that address local, identified community health priorities. Community Impact Investment (CII) Fund The CII Fund is a $100 million board designated fund to be managed and overseen by the IU Health Foundation to financially support high impact community investing designed to address social determinants of health in communities IU Health serves. Each IU Health hospital has a significant impact on and are deeply invested in their local communities. Through the grants provided by this CII Fund, IU Health can strategically and intentionally address the social, economic and environmental factors that impact the health of our surrounding communities. Each IU Health hospital and its team members are eligible for this grant opportunity. Schedule H, Part VI, Line 7 State filing of community benefit report IN true true false false false false false true false JEFFREY C BIRD MD DIRECTOR/REGIONAL PRESIDENT (ECR) 0 511071 0 223027 0 13018 0 106852 0 23518 0 877486 0 0 DAVID W HYATT DIRECTOR / PRESIDENT 0 227666 0 31563 0 29451 0 16895 0 31643 0 337218 0 0 JUDITH L COLEMAN FORMER OFFICER 0 267902 0 52568 0 46380 0 18400 0 21239 0 406489 0 0 JONATHAN W VANATOR CFO (ECR) 0 298417 0 35959 0 37682 0 18234 0 25397 0 415688 0 0 MICHELLE R ALTOBELLA SECRETARY 0 216883 0 35925 0 27152 0 17143 0 29292 0 326394 0 0 BETTIE A CALDWELL TREASURER 0 118500 0 12101 0 993 0 8710 0 10607 0 150911 0 0 CARLA C COX RN VP & CNO (ECR) 0 222265 0 30380 0 30236 0 16820 0 23821 0 323521 0 0 LORI A LUTHER COO (ECR) 0 313590 0 44822 0 50144 0 18400 0 26142 0 453098 0 0 ANN M MCGUIRE VP-HUMAN RESOURCES REGIONAL (ECR)-PART YEAR 0 170715 0 23351 0 36539 0 219125 0 11617 0 461347 0 0 PETER M VOSS MD CMO (ECR) 0 315972 0 46038 0 51500 0 18400 0 22361 0 454270 0 0 KEVIN W SCHREIBER MD FORMER HIGHEST COMPENSATED EMPLOYEE 0 381348 0 1250 0 20310 0 18400 0 29202 0 450510 0 0 CHARLES L CARROLL DO FORMER HIGHEST COMPENSATED EMPLOYEE 0 254771 0 600 0 0 0 9508 0 20 0 264899 0 0 THOMAS M LEE MD PHYSICIAN 10718 311902 4347 126498 228 6630 611 17789 1055 30711 16959 493530 0 0 JAN BLAKE VP - CNO - BLACKFORD HOSP 122371 0 16869 0 17168 0 8649 0 18526 0 183583 0 0 0 MONICA R GAITHER ADMIN-ASSOC-NURSING 108859 10659 2496 244 3241 317 7301 715 21842 2139 143739 14075 0 0 Schedule J, Part I, Line 3 Arrangement used to establish the top management official's compensation IU HEALTH BLACKFORD'S REGIONAL PRESIDENT IS EMPLOYED BY IU HEALTH, INC. IU HEALTH BLACKFORD'S PRESIDENT IS EMPLOYED BY IU HEALTH BALL MEMORIAL HOSPITAL. IU HEALTH, IU HEALTH BALL AND OTHER RELATED ORGANIZATIONS HAVE A PROCESS IN PLACE FOR DETERMINING THE COMPENSATION FOR THE OFFICERS AND KEY EMPLOYEES. IU HEALTH HUMAN RESOURCES USES MARKET DATA FROM MULTIPLE COMPENSATION EXPERTS/VENDORS WHO UTILIZE A VARIETY OF METHODS AND PROCEDURES TO OBTAIN COMPENSATION RANGES FOR COMPARABLE OFFICERS AND EMPLOYEE POSITONS. THIS MARKET DATA AND MULTIPLE OTHER FACTORS (INCLUDE MARKET PAY BENCHMARKS, INTERNAL EQUITY, CANDIDATE/EMPLOYEE QUALIFICATIONS AND PERFORMANCE, AND OTHER BUSINESS NEEDS) ARE USED TO RECOMMEND COMPENSATION RANGES FOR ITS OFFICERS AND OTHER EMPLOYEES, WHICH ARE THEN USED AS A GUIDE FOR SETTING REASONABLE COMPENSATION BY MANAGEMENT. PLEASE SEE SCHEDULE O FOR ADDITIONAL DETAILS. Schedule J, Part I, Line 4a Severance or change-of-control payment ANN MCGUIRE ENTERED INTO A SEVERANCE AGREEMENT WITH IU HEALTH INC. DURING 2020. NO SEVERANCE WAS RECEIVED DURING 2020. DEFERRED SEVERANCE OF $205,618 IS INCLUDED IN COLUMN C, RETIREMENT AND OTHER DEFERRED COMPENSATION. Schedule J, Part I, Line 4b Supplemental nonqualified retirement plan JEFFREY C. BIRD M.D. PARTICIPATES IN AN IU HEALTH SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN, PROVISIONS OF WHICH ARE DESIGNED TO RETAIN ITS CRITICAL EMPLOYEES. THE PLAN PROVIDES FOR AN ADDITIONAL RETIREMENT BENEFIT FOR SERVICES THROUGH NORMAL RETIREMENT OR OTHER KEY DATES IF THE EXECUTIVE LEAVES PRIOR TO RETIREMENT OR OTHER KEY DATES, THE BENEFIT MAY BE FORFEITED OR REDUCED. JEFFREY C. BIRD M.D. HAS AN AMOUNT INCLUDED IN COLUMN C, DEFERRED COMPENSATION, REPRESENTING THE CURRENT YEAR UNVESTED CONTRIBUTIONS MADE UNDER THE SUPPLEMENTAL RETIREMENT PLAN. NO AMOUNT WAS ACTUALLY PAID TO JEFFREY C. BIRD M.D. DURING THE YEAR. Schedule J, Part I, Line 7 Non-fixed payments AMOUNTS DISCLOSED IN COLUMN B (II) INCLUDE A LONG-TERM AND SHORT-TERM INCENTIVE FOR CERTAIN EXECUTIVES AND SHORT-TERM INCENTIVE FOR OTHER EMPLOYEES ALTHOUGH THESE PLANS ARE BASED ON FIXED FORMULA THAT HAS BEEN APPROVED BY THE BOARD OF DIRECTORS BASED UPON CERTAIN QUALITATIVE AND QUANTITATIVE FACTORS AND GOALS. ALL DISCRETIONARY INCENTIVE PLANS MUST BE APPROVED BY THE BOARD OF DIRECTORS PRIOR TO ANY INCENTIVE PAYOUT. Form 990, Part III, Line 4d Description of other program services (Expenses $ 27,074 including grants of $ 0)(Revenue $ 31,207) INDIANA UNIVERSITY HEALTH BLACKFORD HOSPITAL, INC. LEASES PHYSICIAN AND CLINIC SPACE TO RELATED TAX-EXEMPT ORGANIZATIONS. IU HEALTH BLACKFORD RECEIVES REVENUE FROM A RELATED 501(C)(3) ENTITY FOR SHARED SERVICES. Form 990, Part VI, Line 13 SECTION B, LINES 12, 13, 14, AND 16B - POLICIES IU HEALTH BLACKFORD HOSPITAL IS PART OF THE IU HEALTH SYSTEM. IU HEALTH BLACKFORD HOSPITAL'S SOLE MEMBER IS IU HEALTH BALL MEMORIAL HOSPITAL. IU HEALTH BALL MEMORIAL HOSPITAL'S SOLE MEMBER IS IU HEALTH, INC. IU HEALTH, INC. AND ITS BOARD OF DIRECTORS HAVE MANDATED THAT CERTAIN POLICIES BE FOLLOWED TO ENSURE GREATER STANDARDIZATION THROUGHOUT THE SYSTEM. THUS, IU HEALTH BLACKFORD HOSPITAL'S BOARD OF DIRECTORS WAS NOT REQUIRED TO SEPARATELY ADOPT A CONFLICT OF INTEREST, WHISTLEBLOWER, DOCUMENT RETENTION AND DESTRUCTION AND JOINT VENTURE POLICIES BECAUSE IU HEALTH'S BOARD OF DIRECTORS HAD ALREADY ADOPTED AND REQUIRED THESE POLICIES TO BE FOLLOWED BY ITS SUBSIDIARIES. Form 990, Part VI, Line 1b INDEPENDENT VOTING MEMBERS IU HEALTH BLACKFORD HOSPITAL IS PART OF A MULTI-ENTITY HOSPITAL SYSTEM, ULTIMATELY CONTROLLED BY IU HEALTH, INC., A 501(C)(3) TAX-EXEMPT ORGANIZATION WHOSE BOARD IS COMPRISED OF VOTING MEMBERS, OF WHICH SUBSTANTIALLY ALL ARE INDEPENDENT COMMUNITY MEMBERS. Form 990, Part VI, Line 15 PROCESS FOR DETERMINING COMPENSATION The Regional President is employed by IU Health. IU Health's process for determining compensation is as follows: (1) The Board of Directors ("Board") has established a Talent Management and Executive Compensation Committee ("TMECC"), the purpose of which includes reviewing and making recommendations regarding executive (Senior Vice Presidents and above) pay and benefits (collectively referred to as "compensation") on an annual basis. The TMECC is made up of members of the Board that are neither physicians nor employees and do not otherwise have a conflict of interest regarding any of IU Health's compensation arrangements. The TMECC reviews an executive's entire compensation package including base salary, short-term and long-term incentives, health and welfare benefits, qualified and nonqualified retirement plans, as well as any additional fringe benefits. As deemed appropriate, the Committee on Finance, which is also made up of members of the Board, may also review executive compensation and benefits. (2) The TMECC engages an independent compensation consulting firm on an annual basis to conduct a compensation analysis for its executive group, which consists of employees at the level of senior vice president and above. The current compensation advisor is SullivanCotter. SullivanCotter performs its analysis in the form of a compensation survey ("survey") that includes relevant comparability data for compensation levels paid by similarly situated organizations (both governmental and tax exempt) for functionally comparable positions as well as the availability of similar services in the geographic area. SullivanCotter then prepares a survey report and provides recommendations to the TMECC, if deemed appropriate, on changes in executive compensation. A separate analysis using the same methodology is done for the President and Chief Executive Officer. (3) The TMECC then reviews SullivanCotter's report and recommendations and, if appropriate, votes on whether to recommend any changes in executive compensation to the Board. The TMECC will only recommend changes to the Board if they are consistent with the Board's philosophy on compensation matters and are deemed reasonable based upon the independent analysis provided by SullivanCotter. The TMECC's review, discussion and vote are documented in the minutes for the meeting. There are no executives present during the final discussion and approval. (4) The Board then reviews the report prepared by SullivanCotter as well as the recommendations of the TMECC as to any changes in executive compensation. As deemed appropriate, the Committee on Finance may also provide its review of the TMECC's recommendations on any changes in executive compensation. This review and discussion are documented in the minutes (5) The Board then votes on whether to accept the TMECC's recommendations on any changes in executive compensation. Changes in executive compensation are made if approved by the TMECC and Board on an annual basis, or as necessary throughout the year. The discussion and approval are documented in the minutes of the meeting. There are no executives present during the final discussion and approval. IU Health's General Counsel also prepares a formal written opinion reviewing the executive compensation approval process, comparing it to the Intermediate Sanctions Test of IRC Section 4958. If warranted, IU Health's General Counsel may also provide comments regarding the executive compensation approval process as it relates to meeting the requirements for a rebuttable presumption of reasonableness as provided in the Intermediate Sanctions Test. (6) After the end of each year, the TMECC and Board also review the achievements of the executive group as it relates to the long-term and short-term shared and individual goals developed by the executives and the Board. These achievements may also be reviewed with the Committee on Finance. The Board, at its discretion, may approve bonus payments based upon the achievement of the goals. The discussion and vote of the TMECC and Board is documented in the minutes for each such meeting. The bonuses are not paid until approval is made by the Board. (7) The TMECC and Audit Committee also review Form 990 disclosures related to executive compensation as well as the organization's practices and approval processes prior to the filing of the Form 990 return with the Internal Revenue Service. IU Health Blackford Hospital's President is an employee of IU Health Ball Memorial Hospital. IU Health, Inc. and IU Health Ball Memorial Hospital, and other related entities have a process in place to determine the compensation for its officers and key employees. IU Health Human Resources uses market data from multiple compensation experts/vendors who utilize a variety of methods and procedures to obtain compensation ranges for comparable officer and employee positions. This market data and multiple other factors (including market pay benchmarks, internal equity, candidate/employee qualifications & performance, and business needs) are used to recommend compensation ranges for its officers and other employees, which are then used as a guide for setting reasonable compensation by management. Form 990, Part VI, Line 6 Classes of members or stockholders IU HEALTH BLACKFORD HOSPITAL HAS ONE CLASS OF MEMBERSHIP AND THE SOLE MEMBER IS IU HEALTH BALL MEMORIAL HOSPITAL, A WHOLLY OWNED SUBSIDIARY OF IU HEALTH. Form 990, Part VI, Line 7a Members or stockholders electing members of governing body THE BOARD OF DIRECTORS SHALL CONSIST OF SUCH NUMBER OF MEMBERS NOT FEWER THAN THREE (3) NOR MORE THAN FIVE (5) IN NUMBER. COMPOSITION OF THE BOARD OF DIRECTORS SHALL BE CONSISTENT WITH THE FOLLOWING CRITERIA: TWO (2) MEMBERS APPOINTED BY IU HEALTH BALL MEMORIAL HOSPITAL SHALL BE REPRESENTATIVES OF THE LOCAL COMMUNITY AND ONE (1) TO THREE (3) MEMBERS APPOINTED BY IU HEALTH BALL MEMORIAL HOSPITAL SHALL BE AT-LARGE REPRESENTATIVES. Form 990, Part VI, Line 7b Decisions requiring approval by members or stockholders Notwithstanding any other provisions of the Articles of Incorporation, the following matters require the approval of IU Health Ball Memorial Hospital prior to implementation: - Approve the Governing Documents of the Hospital. - Appoint, upon the recommendation of the Board of the Hospital, or remove, with or without cause, the members of the Board of Directors of the Hospital. Removal does not require a recommendation of the Hospital's Board. - Approve the incurrence of debt of the Hospital within limits delegated to the Board of Directors from time to time by IU Health Ball Memorial Hospital - Approve and recommend the formation of legal entities, the sale, transfer or substantial change in use of all or substantially all of the assets of the Hospital or the divestiture, dissolution, closure, merger, consolidation or change in the Corporate Member of the Hospital. - Approve the transfer or encumbrance of the assets of the Hospital, except in the ordinary course of business. - Subject to approval by IU Health, approve the capital and operating budgets for Hospital. - Approve the mission and vision statements for the Hospital. Form 990, Part VI, Line 11b Review of form 990 by governing body THE CFO REVIEWED AND APPROVED THE FORM 990. A COMPLETE COPY OF THE FORM 990 WAS MADE AVAILABLE TO EACH BOARD MEMBER PRIOR TO ITS FILING. EACH MEMBER WAS ALSO INFORMED OF THE AVAILABILITY OF IU HEALTH'S TAX DEPARTMENT TO ANSWER ANY QUESTIONS. Form 990, Part VI, Line 12c Conflict of interest policy IU Health Blackford Hospital follows IU Health's Conflict of Interest Policy. IU Health's Conflict of Interest Policy includes the following provisions: All IU Health employees, associates, colleagues and contracted personnel, including employed physicians and paid medical directors ("IU Health Representatives") are covered by and subject to its Conflict of Interest Policy. IU Health regularly and consistently monitors and enforces compliance with the policy through the following procedures: (a) On an annual basis, each IU Health Representative at the level of Manager or above, together with every other person designated by the Corporate Compliance Department ("Department"), must complete, sign and submit a Conflict of Interest Questionnaire ("Questionnaire") to the Department. Governing board members, committee members, corporate officers, medical staff and researchers must comply with the administrative requirements noted in the respective policies and procedures relative to those areas. (b) An IU Health Representative must supplement a Questionnaire in writing, if after completion of the original Questionnaire, a situation arises, or may reasonably be expected to arise, that would change any answer or information on the original Questionnaire if the situation had existed or been anticipated at the time of completion of the original Questionnaire. (c) If a fully and properly completed Questionnaire reveals facts or other information that might reasonably indicate a Conflict of Interest or violation of the policy, the IU Health Representative completing the questionnaire must secure approval by his/her supervisor, evidenced in writing. (d) The Department will review each Questionnaire and determine whether a Conflict of Interest exists and, if so, whether and how it should or may be eliminated, avoided or managed in order to comply with the spirit of the policy and with the best interests of IU Health and its patients. In making the determination, the Corporate Compliance Department may consult with the IU Health Representative's supervisor and other appropriate individuals and groups. (e) The scope of the policy is not limited to those who are required to complete Questionnaires. If an IU Health Representative is involved in a situation or relationship that would constitute a violation of the policy in the absence of disclosure and approval as described above, then the IU Health Representative must disclose the matter to his/her supervisor, secure his/her supervisor's approval in writing, and disclose the matter to the Department. Otherwise, the IU Health Representative is in violation of the policy and subject to corrective action, up to and including termination. (f) The Chief Compliance Officer, in consultation with onsite Compliance personnel, may from time to time appoint standing or ad hoc committees to assist in resolving issues that arise under provisions of the policy. Form 990, Part VI, Line 19 Required documents available to the public IU Health Blackford Hospital's Articles of Incorporation are available for public inspection through the Indiana Secretary of State's web-site. IU Health Blackford Hospital's conflict of interest procedures are disclosed on the Form 990, Schedule O. IU Health Blackford Hospital is a subsidiary in IU Health's Consolidated Audited Financial Statements. IU Health's Consolidated Audited Financial Statements are available for public inspection through its bond filings and as an attachment to IU Health's Form 990. Form 990, Part VIII, Line 11d Other Miscellaneous Revenue OTHER - Total Revenue: 1250, Related or Exempt Function Revenue: , Unrelated Business Revenue: , Revenue Excluded from Tax Under Sections 512, 513, or 514: 1250; Form 990, Part IX, Line 11g Other Fees PROF. FEES/SHARED SERVICES - Total Expense: 10165949, Program Service Expense: 6429468, Management and General Expenses: 3736481, Fundraising Expenses: ; INDIANA HEALTH INFO EXCHANGE INC 846 N SENATE AVE INDIANAPOLIS IN 46202 364550324 HEALTHCARE IN 501(c)(3) Type I NA false INDIANA UNIVERSITY HEALTH INC 950 N MERIDIAN STREET Suite 300 INDIANAPOLIS IN 46204 351955872 HEALTHCARE IN 501(c)(3) 3 NA false IU HEALTH ARNETT INC 950 N MERIDIAN STREET Suite 300 INDIANAPOLIS IN 46204 263162145 HEALTHCARE IN 501(c)(3) 3 IUH true IU HEALTH BMH FOUNDATION INC 950 N MERIDIAN STREET Suite 800 INDIANAPOLIS IN 46204 311111784 FUNDRAISING IN 501(c)(3) Type I IUHBMH true IU HEALTH BALL MEMORIAL HOSPITAL INC 950 N MERIDIAN STREET Suite 300 INDIANAPOLIS IN 46204 350867958 HEALTHCARE IN 501(c)(3) 3 IUH true IU HEALTH JAY INC 950 N MERIDIAN STREET Suite 300 INDIANAPOLIS IN 46204 822736786 HEALTHCARE IN 501(c)(3) 3 IUH true IU HEALTH BEDFORD INC 950 N MERIDIAN STREET Suite 300 INDIANAPOLIS IN 46204 237042323 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