2020-11-13T07:36:23-06:00 2019-12-31 990 2019-01-01 010646166 INDIANA UNIVERSITY HEALTH BLACKFORD HOSPITAL INC % CRAIG J JONES INDI 3179634842 950 N MERIDIAN STREET Suite 300 INDIANAPOLIS IN 46204 JONATHAN W VANATOR CFO 3179634842 2020-11-09 JENNIFER D RHODERICK P00395735 3176817000 162.1.179.248 35198520203185000005 2020-11-13 P 4CFE63EA556978BED96946D2A2E6D5903275AA84 1FAF8F4A5CE5AF7D4EEB3F68F347C3134530D94A 2019 2021-01-29 14:40:06Z DAVE HYATT 950 N MERIDIAN ST STE 300 INDIANAPOLIS IN 46204 18922084 false X SEE SCHEDULE O X 2002 IN Promote wellness and improve the health status of the people of East Central Indiana and surrounding areas through patient care, health education and medical research. 3 1 132 35 0 0 0 35270 18049392 18624801 93731 147810 79325 114203 18222448 18922084 325 95 0 0 7759200 5625782 0 0 0 12170777 14764123 19930302 20390000 -1707854 -1467916 15158490 12114937 4234272 2658635 10924218 9456302 PROMOTE WELLNESS AND IMPROVE THE HEALTH STATUS OF THE PEOPLE OF EAST CENTRAL INDIANA AND SURROUNDING AREAS THROUGH PATIENT CARE, HEALTH EDUCATION AND MEDICAL RESEARCH. false false 15681961 95 18519287 Indiana University Health Blackford Hospital, Inc. ("IU Health Blackford Hospital"), located in Hartford City, Indiana, is a 15-bed acute-care and 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. IU Health Blackford Hospital also serves the community with an annual health fair which includes free and low-cost screenings. The hospital promotes wellness initiatives such as diabetes education, tobacco cessation, childrens safety, after-school health lifestyle initiatives, seniors programming and outreach to local employers with screenings and health information. 65211 0 77010 IU Health Blackford Hospital 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. 24137 0 28504 IU Health Blackford received revenue from a related 501(c)(3) entity for shared services. 15771309 true true false true false 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 15 0 true 132 true false false false false false false false false false false false false X 3 1 true false true 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 X JEFFREY C BIRD MD DIRECTOR/PRES.(ECR) 10.0 45.0 X X 0 675023 122854 KEVIN W SCHREIBER M PHYSICIAN 5.0 50.0 X 20280 441929 48858 THOMAS M LEE MD PHYSICIAN 2.0 53.0 X 2880 416537 47910 Peter M Voss MD CMO (ECR) 10.0 45.0 X 0 372104 42519 LORI A LUTHER COO 10.0 45.0 X 0 370838 41320 JUDITH COLEMAN FORMER Officer 5.0 50.0 X 0 314630 38369 JONATHAN W VANATOR CFO (ECR) 10.0 45.0 X 0 308658 41978 CHARLES L CARROLL D PHYSICIAN 5.0 50.0 X 15000 301567 18075 MICHELLE R ALTOBELLA SECRETARY 10.0 45.0 X 0 257421 45230 DAVID W HYATT DIRECTOR/PRESIDENT 20.0 35.0 X X 0 252760 46569 CARLA C COX RN VP & CNO (ECR) 10.0 45.0 X 0 250658 36602 Ann M McGuire VP-Human Resources Regional 10.0 45.0 X 0 203736 22805 RODNEY J STEVENS RN Former Key Employee 45.0 10.0 X 199890 0 23538 BETTIE A CALDWELL TREASURER 10.0 45.0 X 0 124209 18151 Jan Blake Blackford COO/CNO 55.0 0.0 X 110098 0 28173 Monica R Gaither Admin-Assoc-Nursing 55.0 0.0 X 111873 0 20632 DANIEL E BORGENHEIMER DIRECTOR 5.0 0.0 X 0 0 0 JOHN K JACKSON CHAIR (Partial Year) 5.0 5.0 X 0 0 0 JOHN D LITTLER CHAIR 5.0 10.0 X 0 0 0 460021 4290070 643583 3 true true false ALLIANCE HEALTHCARE SERVICES 100 BAYVIEW CIRCLE STE 400 NEWPORT BEACH CA 92658 MEDICAL 130875 1 35270 35270 NET PATIENT SERVICE REVENUE 622110 18519287 18519287 0 0 SHARED SERVICES 541900 77010 77010 0 0 RENT FROM RELATED 501(C)(3) ORGS. 532000 28504 28504 0 18624801 107810 0 0 107810 0 0 1200 1200 0 1200 0 0 1200 40000 40000 40000 0 0 40000 0 0 0 0 0 0 0 0 0 CAFETERIA/FOOD SERVICE 721110 59300 0 0 59300 VENDING 900099 1471 0 0 1471 ALL OTHER REVENUE 900099 52232 0 0 52232 113003 18922084 18624801 0 262013 X 95 95 0 0 0 223428 196222 27206 576427 506239 70188 3607614 3168335 439279 150393 132080 18313 749284 658048 91236 318636 279837 38799 0 0 7350 7350 230 230 0 0 9787548 6053264 3734284 0 3881 3881 50881 22490 28391 9282 7232 2050 0 499798 498860 938 8352 3120 5232 0 170 170 0 0 873215 856646 16569 129703 30201 99502 BAD DEBT 1714176 1714176 0 0 DRUGS AND MEDICAL SUPPLIES 1092362 1092362 0 0 INSTITUTIONAL DUES/LICENSES 3826 3826 0 0 HOSPITAL ASSESSMENT FEE 480568 480568 0 0 102781 67538 35243 20390000 15771309 4618691 0 0 0 4774511 344 0 0 2004576 1928080 0 0 0 0 0 0 237532 245169 109628 67664 19991959 12725148 8032243 7266811 0 0 0 0 0 0 0 0 0 2606869 15158490 12114937 1264067 804161 0 0 43509 0 0 0 0 0 0 0 0 0 0 0 2926696 1854474 4234272 2658635 X 10924218 9456302 0 0 10924218 9456302 15158490 12114937 -1467916 X false true X true false X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED false false false false false false false false true 230 230 false Schedule C, Part II-B, Line 1i - Other Activities IU Health Blackford Hospital paid institutional membership dues to Indiana Hospital Association ("IHA") during 2019 in the amount of $3,515. Each membership organization notified IU Health Blackford Hospital that a portion of the dues it paid were used for lobbying purposes. The IHA used 6.53%, or $230 of the 2019 membership dues paid by IU Health Blackford Hospital, for lobbying expenditures. The total membership dues paid to this organization by IU Health Blackford Hospital during 2019 that was attributable to lobbying expenditures was $230. 190324 190324 15007745 9594663 5413082 0 4504982 3105104 1399878 288908 25381 263527 7266811 INTERCOMPANY RECEIVABLES (NET) 2606869 2606869 0 INTERCOMPANY PAYABLES (NET) 0 SELF-INSURANCE LIABILITIES 18774 DUE TO THIRD-PARTY PAYERS 1835700 1854474 X Schedule D, Part X, Line 2 - FIN 48 (ASC 740) Footnote IU Health Blackford is a subsidiary in IU Health's Consolidated Audited Financial Statements. The Internal Revenue Service (IRS) has determined that IU Health and certain of its affiliated entities are tax-exempt organizations as defined in Section 501(c)(3) of the Internal Revenue Code (IRC). IU Health and its tax-exempt affiliates are, however, subject to federal and state income taxes on unrelated business income under the provision of IRC Section 511. The Tax Cuts and Jobs Act (TCJA) was enacted on December 22, 2017. For tax-exempt entities, TCJA requires organizations to pay an excise tax on compensation above certain thresholds and record income or losses for tax determination purposes from unrelated business activities on an activity-by-activity basis, among other provisions. Proposed regulations and interim guidance, necessary for implementation, have been issued on most aspects of TCJA. It is expected that proposed regulations will be issued as final regulations by the IRS in 2020. As of and for the year ended December 31, 2019, Indiana University Health has made reasonable estimates of the provision for income taxes, the compensation excise tax, and the effects, if any, on existing deferred tax balances based on accounting guidance included in Accounting Standards Codification (ASC) 740, Income Taxes. Indiana University Health will continue to refine its calculations in future periods, as additional regulations and guidance are issued by the IRS. Deferred income taxes that, as of December 31, 2019 and 2018, 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, 2019 and 2018, the Indiana University Health System had gross deferred tax assets of $143,157,000 and $119,965,000, respectively, primarily relating to net operating loss carryovers. Management determined that a full valuation allowance at December 31, 2019 and 2018 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 same portion or all of the deferred tax assets will not be realized, a valuation allowance to reduce the deferred tax assets is recorded. The change in valuation allowance for the current year is $23,192,000. At December 31, 2019, the Indiana University Health System has available net operating loss carryforwards of $575,596,000. Net operating losses generated from 1999 through 2017 will expire between 2020 and 2037. Net operating losses generated after 2017 do not expire. Certain subsidiaries of Indiana University Health are taxable entities. The tax expense and liabilities of these subsidiaries are not material to the consolidated financial statements. true true X true X false true true true false true true 780 631262 631262 0.03380 1348 3861655 1257623 2604032 0.13940 2128 4492917 1257623 3235294 0.17320 11 6473 205083 2828 202255 0.01080 2 78 45884 45884 0.00250 1 36 1379 1379 0.00010 14 6587 252346 2828 249518 0.01340 14 8715 4745263 1260451 3484812 0.18660 1 12 2225 2225 0.00010 1 419 1390 1390 0.00010 1 22 2067 2067 0.00010 3 453 5682 5682 0.00030 false 751323 8538611 8139900 398711 X true true 1 1 IU HEALTH BLACKFORD HOSPITAL 410 PILGRIM BLVD HARTFORD CITY IN 47348 SEE PART V, SECTION C 19-005101-1 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 SEE PART V, SECTION C true 19 true SEE PART V, SECTION C false true X 200. 0. X X X X X X true true X X X true X SEE PART V, SECTION C X SEE PART V, SECTION C X SEE PART V, SECTION C X X X X X X X true X false X X X X true X false false Schedule H, Part V, Section A, Line 1 - Website address IU Health Blackford Hospital's website address is: https://iuhealth.org/find-locations/iu-health-blackford-hospital Schedule H, Part V, Section B, Line 3e - Prioritized Health Needs 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 - Input from Community 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 7a - CHNA Website A copy of IU Health Blackford Hospital's CHNA is available on its website at the following URL: https://iuhealth.org/in-the-community/community-benefit Schedule H, Part V, Section B, Line 10a - Implementation Strategy Website A copy of IU Health Blackford Hospital's CHNA is available on its website at the following URL: https://iuhealth.org/in-the-community/community-benefit Schedule H, Part V, Section B, Line 11 - Addressing Identified Needs 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 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 13b - Income Level Other than FPG 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 13h Other FAP Factors IU Health Blackford Hospital takes into consideration several other factors in determining patient eligibility for financial assistance. These factors include the following: 1. IU Health Blackford Hospital's Individual Solutions Department Prior to seeking Financial Assistance under the FAP, all patients or their guarantors must consult with a member of IU Health's Individual Solutions department to determine if healthcare coverage may be obtained from a government insurance/assistance product or from the Health Insurance Exchange Marketplace. 2. Alternate Sources of Assistance When technically feasible, a patient will exhaust all other state and federal assistance programs prior to receiving an award from IU Health Blackford Hospital's Financial Assistance Program. Patients who may be eligible for coverage under an applicable insurance policy, including, but not limited to, health, automobile, and homeowner's, must exhaust all insurance benefits prior to receiving an award from IU Health Blackford Hospital's Financial Assistance Program. This includes patients covered under their own policy and those who may be entitled to benefits from a third-party policy. Patients may be asked to show proof that such a claim was properly submitted to the proper insurance provider at the request of IU Health Blackford Hospital. Eligible patients who receive medical care from IU Health Blackford Hospital 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 to which IU Health Blackford Hospital is entitled. In the event a Financial Assistance Award has already been granted in such circumstances, IU Health Blackford Hospital reserves the right to reverse the award in an amount equal to the amount IU Health Blackford Hospital would be entitled to receive had no Financial Assistance been awarded. 3. Alternate Methods of Eligibility Determination IU Health Blackford Hospital will conduct a quarterly review of all accounts placed with a collection agency partner for a period of no less than one hundred and twenty (120) days after the account is eligible for an Extraordinary Collection Action ("ECA"). Said accounts may be eligible for assistance under the FAP based on the patient's individual scoring criteria. To ensure all patients potentially eligible for Financial Assistance under the FAP may receive Financial Assistance, IU Health Blackford Hospital will deem patients/guarantors to be presumptively eligible for Financial Assistance if they are found to be eligible for one of the following programs, received emergency or direct admit care, and satisfied his/her required co-pay/deductible: - Indiana Children's Special Health Care Services - Medicaid - Healthy Indiana Plan - Patients who are awarded Hospital Presumptive Eligibility (HPE) - Enrolled in a state and/or federal program that verifies the patient's gross household income is less than or equal to 200% of the Federal Poverty Level 4. Additional Considerations Financial Assistance may be granted to a deceased patient's account if said patient is found to have no estate. Additionally, IU Health Blackford Hospital will deny or revoke Financial Assistance for any patient or guarantor who falsifies any portion of a Financial Assistance application. 5. Non-Emergent Services Down Payment Uninsured Patients presenting for scheduled or other non-emergent services will not be charged more than the Amounts Generally Billed ("AGB") for their services. Patients will receive an estimated AGB cost of their care prior to IU Health Blackford Hospital rendering the services and will be asked to pay a down-payment percentage of the AGB adjusted cost prior to receiving services. In the event a patient is unable to fulfill the down-payment, their service may be rescheduled for a later date as medically prudent and in accordance with all applicable federal and state laws and/or regulations. 6. Emergency Services Non-Refundable Deposit This section will be implemented with a strict adherence to Emergency Medical Treatment and Active Labor Act ("EMTALA") and IU Health Policy ADM 1.32, Screening and Transfer of Emergency or Unstable Patients. Amount of Non-Refundable Deposit All Uninsured Patients presenting for services at IU Health Blackford Hospital's Emergency Department, via transfer from another hospital facility, or direct admission, will be responsible for a one-hundred dollar ($100.00) non-refundable deposit for services rendered. Patients/guarantors will be responsible for any copays and/or deductibles required by their plan prior to full Financial Assistance being applied. Uninsured Patients wishing to make an application for Financial Assistance greater than the AGB must fulfill their non-refundable deposit prior to IU Health Blackford Hospital processing said application. Uninsured Patients making payments toward their outstanding non-refundable deposit balance will have said payments applied to their oldest application on file, if applicable. Schedule H, Part V, Section B, Line 16a - FAP Website address IU Health Blackford Hospital's FAP is available at the following URL: https://iuhealth.org/pay-a-bill/financial-assistance Schedule H, Part V, Section B, Line 16b - FAP Application Website IU Health Blackford Hospital's FAP is available at the following URL: https://iuhealth.org/pay-a-bill/financial-assistance Schedule H, Part V, Section B, Line 16c - FAP PLS Website A plain language summary of the FAP, including translated copies, is available on the following website: https://iuhealth.org/pay-a-bill/financial-assistance Schedule H, Part V, Section B, Line 16j - Other Measures to Publicize IU Health Blackford Hospital takes several other measures to publicize its FAP within the community.These measures include the following: 1. Conspicuous public displays will be posted in appropriate acute care settings such as the emergency department and registration areas describing the available assistance and directing eligible patients to the Financial Assistance Application. 2. IU Health Blackford Hospital will include a conspicuous written notice on all patient billing statements that notifies the patient about the availability of this Policy, and the telephone number of its Customer Service Department which can assist patients with any questions they may have regarding this Policy. 3. IU Health Blackford Hospital Customer Service representatives will be available via telephone Monday through Friday, excluding major holidays, from 8:00 a.m. to 7:00 p.m. Eastern Time to address questions related to this Policy. 4. IU Health Blackford Hospital will broadly communicate this Policy as part of its general outreach efforts. 5. IU Health Blackford Hospital will educate its patient facing team members of the FAP and the process for referring patients to the Program. 3 IU Health Blackford Hospital Radiology 410 Pligrim Blvd Hartford City IN 47348 Diagnostic and Other Outpatient IUH Blackford Physical Therapy and Rehab 410 Pligrim Blvd Hartford City IN 47350 Diagnostic and Other Outpatient IU Health Blackford Pharmacy 400 Pligrim Blvd Hartford City IN 47349 Pharmacy Schedule H, Part I, Line 3c - Other Factors Used in Determining Elig. 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. Indiana Residency Requirement Financial Assistance will only be made available to residents of the State of Indiana and those eligible for assistance under 42 U.S.C.A. 1396b(v). IU Health Blackford Hospital will employ the same residency test as set forth in Indiana Code 6-3-1-12 to define an Indiana resident. The term Resident includes any individual who was domiciled in Indiana during the taxable year, or any individual who maintains a permanent place of residence in Indiana and spends more than one hundred eight-three (183) days of the taxable year in Indiana. Patients residing in the state of Indiana while attending an institution of higher education may be eligible for assistance under the FAP if they meet the aforementioned residency test and are not claimed as a dependent on a parent's or guardians' federal income tax return. 2. IU Health Blackford Hospital's Individual Solutions Department Prior to seeking Financial Assistance under the FAP, all patients or their guarantors must consult with a member of IU Health Blackford Hospital's Individual Solutions department to determine if healthcare coverage may be obtained from a government insurance/assistance product or from the Health Insurance Exchange Marketplace. 3. Uninsured Patients All Uninsured Patients presenting for services at IU Health Blackford Hospital eligible under the FAP will not be charged more than the AGB as described in the FAP. 4. Services Rendered by Individual Providers The FAP does not cover services rendered by individual providers. A full listing of providers and services not covered by the FAP is available at https://iuhealth.org/pay-a-bill/financial-assistance and is updated on a quarterly basis. 5. Alternate Sources of Assistance When technically feasible, a patient will exhaust all other state and federal assistance programs prior to receiving an award from IU Health Blackford Hospital's Financial Assistance Program. Patients who may be eligible for coverage under an applicable insurance policy, including, but not limited to, health, automobile, and homeowner's, must exhaust all insurance benefits prior to receiving an award from IU Health Blackford Hospital's Financial Assistance Program. This includes patients covered under their own policy and those who may be entitled to benefits from a third-party policy. Patients may be asked to show proof that such a claim was properly submitted to the proper insurance provider at the request of IU Health Blackford Hospital. Eligible patients who receive medical care from IU Health Blackford Hospital 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 to which IU Health Blackford Hospital is entitled. In the event a Financial Assistance Award has already been granted in such circumstances, IU Health Blackford Hospital reserves the right to reverse the award in an amount equal to the amount IU Health Blackford Hospital would be entitled to receive had no Financial Assistance been awarded. 6. Alternate Methods of Eligibility Determination IU Health Blackford Hospital will conduct a quarterly review of all accounts placed with a collection agency partner for a period of no less than one hundred and twenty (120) days after the account is eligible for an ECA. Said accounts may be eligible for assistance under the FAP based on the patient's individual scoring criteria. To ensure all patients potentially eligible for Financial Assistance under the FAP may receive Financial Assistance, IU Health Blackford Hospital will deem patients/guarantors to be presumptively eligible for Financial Assistance if they are found to be eligible for one of the following programs, received emergency or direct admit care, and satisfied his/her required co-pay/deductible: - Indiana Children's Special Health Care Services - Medicaid - Healthy Indiana Plan - Patients who are awarded Hospital Presumptive Eligibility (HPE) - Enrolled in a state and/or federal program that verifies the patient's gross household income is less than or equal to 200% of the Federal Poverty Level 7. Additional Considerations Financial Assistance may be granted to a deceased patient's account if said patient is found to have no estate. Additionally, IU Health Blackford Hospital will deny or revoke Financial Assistance for any patient or guarantor who falsifies any portion of a Financial Assistance application. 8. Patient Assets IU Health Blackford Hospital may consider patient/guarantor Assets in the calculation of a patient's true financial burden. A patient's/guarantor's primary residence and one (1) motor vehicle will be exempted from consideration in most cases. A patient's primary residence is defined as the patient's principal place of residence and will be excluded from a patient's extraordinary asset calculation so long as the patient's equity is less than five-hundred thousand dollars ($500,000) and the home is occupied by the patient/guarantor, patient's/guarantor's spouse or child under twenty-one (21) years of age. One (1) motor vehicle may be excluded as long as the patient's equity in the vehicle is less than fifty-thousand dollars ($50,000). IU Health Blackford Hospital reserves the right to request a list of all property owned by the patient/guarantor and adjust a patient's award of Financial Assistance if the patient demonstrates a claim or clear title to any extraordinary Asset not excluded from consideration under the above guidance. 9. Non-Emergent Services Down Payment Uninsured Patients presenting for scheduled or other non-emergent services will not be charged more than the AGB for their services. Patients will receive an estimated AGB cost of their care prior to IU Health Blackford Hospital rendering the services and will be asked to pay a down-payment percentage of the AGB adjusted cost prior to receiving services. In the event a patient is unable to fulfill the down-payment, their service may be rescheduled for a later date as medically prudent and in accordance with all applicable federal and state laws and/or regulations. 10. Emergency Services Non-Refundable Deposit This section will be implemented with a strict adherence to EMTALA and IU Health Blackford Hospital Policy ADM 1.32, Screening and Transfer of Emergency or Unstable Patients. Amount of Non-Refundable Deposit All Uninsured Patients presenting for services at IU Health Blackford Hospital's Emergency Department, via transfer from another hospital facility, or direct admission, will be responsible for a one-hundred dollar ($100.00) non-refundable deposit for services rendered. Patients/guarantors will be responsible for any copays and/or deductibles required by their plan prior to full Financial Assistance being applied. Uninsured Patients wishing to make an application for Financial Assistance greater than the AGB must fulfill their non-refundable deposit prior to IU Health Blackford Hospital processing said application. Uninsured Patients making payments toward their outstanding non-refundable deposit balance will have said payments applied to their oldest application on file, if applicable. 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 7, Column (f) - 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 $1,714,176. 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 25.41%. Schedule H, Part II - Promotion of Health in Communities Served IU Health Blackford Hospital is a subsidiary of IU Health. IU Health participates in a variety of community-building activities that address the social determinants of health in the communities it serves. IU Health 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. This includes making contributions to community-building activities by providing investments and resources to local community initiatives that addressed economic development, community support and workforce development, several examples include IU Health's support of the following organizations and initiatives that focus on some of the root causes of the health issues, such as lack of education, employment and poverty: - Healthy Community Alliance of East Central Indiana - Community and Family Services - Hartford City Growers and Makers Market - Blackford Community Schools - Purdue Extension - United Way - Blackford County 4H - Blackford County Chamber of Commerce Additionally, through the IU Health Statewide System's team member community benefit service program, "IU Health Serves," team members across the state make a difference in the lives of thousands of Hoosiers every year. Schedule H, Part III, Line 2 - Methodology Used to Est. Bad Debt Exp. The bad debt expense of $751,323 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 - Est. Bad Debt Attr. to Patients Under FAP An uninsured patient and/or guarantor who was admitted through an eligible facility's emergency department via a direct admission from a physician's office, or transfer from another hospital facility, and whose household income is less than or equal to 200% of the federal poverty level may be eligible for full charity assistance after the successful completion of the financial assistance application and satisfaction of his/her non-refundable deposit. To capture all patients who are potentially eligible for financial assistance under the IU Health Financial Assistance Policy, IU Health will deem patients/guarantors to be presumptively eligible for financial assistance if they are found to be eligible for one of the following programs, received emergency or direct admit care, and satisfied the required co-pay/deductible: 1. Indiana Children's Special Healthcare Services 2. Medicaid 3. Healthy Indiana Plan 4. Patients who are awarded hospital presumptive eligibility 5. Enrolled in a state and/or federal program that verifies the patient's gross household income in less than or equal to 200% of the federal poverty level (FPL). IU Health also conducts a quarterly review of all accounts placed with a collection agency partner for a period of no less than one hundred and twenty (120) days after the account is eligible for extraordinary collection actions. Said accounts may be eligible for assistance under the financial assistance policy based on the patient's individual scoring criteria and are not included in bad debt, 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 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. Under its financial assistance policy, the Indiana University Health System provides medically necessary care to uninsured patients with inadequate financial resources at charitable discounts equivalent to the amounts generally billed, and it provides eligibility for full charity for emergent encounters for uninsured patients who earn less than 200% of the federal poverty level and who meet application criteria. Patients whose liability is deemed catastrophic relative to their annual household income are also eligible for reduced charges. 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 free care and recognizes net patient service revenue on services provided for self-pay patients at the discounted rate at the time of service are rendered. The estimated cost of charity care, using the consolidated cost to charge ratio, was $96,693,000 and $94,886,000 in 2019 and 2018. Schedule H, Part III, Line 8 - Medicare Shortfall IU Health Blackford Hospital did not have a Medicare shortfall for 2019. 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 - Written Debt Collection Policy 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 Patients or their guarantors wishing to apply for Financial Assistance are encouraged to submit a Financial Assistance Application within ninety (90) days of their discharge. Patients or their guarantors may submit an application up to two-hundred and forty (240) days from the date of their first billing statement from IU Health, however, accounts may be subject to ECA as soon as one hundred and twenty (120) days after having received their first billing statement. Patients or their guarantors submitting an incomplete 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 patient fails to cure any deficiencies in their application in the allotted period. Patients with limited English proficiency may request to have a copy of the FAP, a FAP Application, and FAP Plain Language Summary in one of the below languages: - Arabic - Burmese - Burmese-Falam - Burmese-Hakha Chin - Mandarin/Chinese - 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 FAP Application to be mailed to a patient's primary mailing address free of charge. IU Health Blackford Hospital keeps all applications and supporting documentation confidential. Patients applying for assistance under the FAP will be required to complete a Financial Assistance Application. Patients must include the following documentation with their Financial Assistance Application: - 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 a patient's and/or guarantor's income does not warrant the filing of a federal tax return, the patient 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; and - If applicable, divorce/dissolution decrees and child custody order 2. Eligibility Determination IU Health Blackford Hospital 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. If a patient or guarantor is granted less than full charity assistance and the patient or guarantor provides additional information for reconsideration, IU Health Revenue Cycle Services may amend a prior Financial Assistance Determination. If a patient or guarantor seeks to appeal the Financial Assistance Determination further, a written request must be submitted, along with the supporting documentation, to the Financial Assistance Committee for additional review/reconsideration. All decisions of the Financial Assistance Committee are final. A patient's Financial Assistance Application and eligibility determination are specific to each individual date(s) of service and related encounters. 3. Extraordinary Collection Actions IU Health Blackford Hospital may refer delinquent patient accounts to a third-party collection agency after utilizing reasonable efforts to determine a patient's eligibility for assistance under the FAP. IU Health Blackford Hospital and its third-party collection agencies may initiate ECA against a patient or their guarantor in accordance with this Policy and 26 C.F.R. 1.501(r). Said ECA may include the following: - Selling a patient's 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's or their guarantor's nonpayment of one or more bills for previously provided care covered under the FAP. - Actions requiring a legal or judicial process, including but not limited to placing a lien on 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 Blackford Hospital and its third party collection agencies, will engage in fair, respectful and transparent collections activities. Patients or guarantors currently subject to an ECA who have not previously applied for Financial Assistance may apply for assistance up to two-hundred and forty (240) days of the date of their first billing statement from IU Health Blackford Hospital. IU Health Blackford Hospital and their third-party collection agencies will suspend any ECA engaged on a patient or their guarantor while an Application is being processed and considered. 4. Refunds Patients eligible for assistance under the FAP who remitted payment to IU Health Blackford Hospital 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 on a separate account not eligible for assistance under the FAP 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 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 Assist. 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. Conspicuous public displays will be posted in appropriate acute care settings such as the emergency department and registration areas describing the available assistance and directing eligible patients to the Financial Assistance Application. 2. IU Health Blackford Hospital will include a conspicuous written notice on all patient billing statements that notifies the patient about the availability of this Policy, and the telephone number of its Customer Service Department which can assist patients with any questions they may have regarding this Policy. 3. IU Health Customer Service representatives will be available via telephone Monday through Friday, excluding major holidays, from 8:00 a.m. to 7:00 p.m. Eastern Time to address questions related to this Policy. 4. IU Health Blackford Hospital will broadly communicate this Policy as part of its general outreach efforts. 5. IU Health Blackford Hospital will educate its patient facing team members of the FAP 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 (2019) statistics, Blackford County's population is 11,758 persons with approximately 50.6% being female and 49.4% male. The county's population estimates by race are 95.4% White, 1.8% Hispanic or Latino, 0.8% Black, 0.4% 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 (89.4%). As of 2019, 13.6% 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 IU Health Statewide system is Indiana's most comprehensive healthcare system. With hospitals, physician offices and allied services, IU Health provides access to a full range of specialty and primary care services for adults and children. A unique partnership with Indiana University School of Medicine - one of the nation's leading medical schools - gives patients access to groundbreaking research and innovative treatments to complement high-quality care. National Recognition - Eight hospitals designated as Magnet by the American Nurses Credentialing Center recognizing excellence in nursing care. - IU Health Medical Center is honored to be nationally ranked by U.S. News & World Report for the 22nd year in a row. According to the U.S. News rankings, IU Health Medical Center is the No. 1 ranked hospital in Indiana and Indianapolis and the only nationally ranked adult hospital in the state. For 2019-2020, IU Health Medical Center was rated as high performing nationally in five specialties, with a sixth specialty achieving a top 50 national ranking: - Cancer - high performing - Gastroenterology - ranked 45th in nation - Nephrology - high performing - Neurology & Neurosurgery - high performing - Urology - high performing Besides IU Health Medical Center, IU Health has three other hospitals among the 10 top ranked hospitals in Indiana: . IU Health Ball Memorial Hospital - 5th . IU Health Arnett Hospital - 8th . IU Health Bloomington Hospital - 8th The annual rankings, now in their 30th year, are designed to assist patients and their doctors in making informed decisions about where to receive care for challenging health conditions or for common elective procedures. Education and Research As an academic health center, IU Health 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 $150 million over five years in the Strategic Research Initiative, 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 our 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: - Cancer: One of the initiative's primary goals is to enable the IU Health Melvin and Bren Simon Cancer Center to attain the National Cancer Institute's top status of "comprehensive," which would recognize it as one of the top-tier cancer centers in the nation. 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. - Neuroscience: The neurosciences research program tackles a broad range of brain injuries, neurodegenerative disorders and neurodevelopmental disorders. - Cardiovascular: The cardiovascular research initiative develops a comprehensive program for the study and treatment of heart failure, from newborns to older adults. A top priority is developing a cardiovascular genetics program. The Strategic Research Initiative provides patients with access to internationally renowned physicians and to new therapies developed through translational research and clinical trials, and will make use of the latest genetic tools to develop personalized therapies that are more effective for individuals and efficient for healthcare providers. IU Health Statewide System IU Health is a part of the IU Health Statewide System which continues to broaden its reach and positive impact throughout the state of Indiana. IU Health is Indiana's most comprehensive academic health center and consists of IU Health Methodist Hospital, IU Health University Hospital, Riley Hospital for Children at IU Health, and IU Health Saxony Hospital. Other hospitals in the IU Health Statewide System include the following: - IU Health Arnett Hospital - IU Health Ball Memorial Hospital - IU Health Bedford Hospital - IU Health Blackford Hospital - IU Health Bloomington Hospital - IU Health Frankfort Hospital - IU Health Jay Hospital - IU Health North Hospital - IU Health Paoli Hospital - IU Health Tipton Hospital - IU Health West Hospital - IU Health White Memorial Hospital Although each hospital in the IU Health Statewide System prepares and submits its own community benefits plan relative to the local community, the IU Health Statewide System considers its community benefit plan as part of an overall vision for strengthening Indiana's overall health. A comprehensive community outreach strategy and community benefit plan is in place that encompasses the academic medical center downtown Indianapolis, suburban Indianapolis and statewide entities around priority areas that focus on health improvement efforts statewide. IU Health is keenly aware of the positive impact it can have on the communities of need in the state of Indiana by focusing on the most pressing needs in a systematic and strategic way. In 2019, IU Health provided over $700 million of dollars in total community benefit and served more than one million individuals. Some ways we address our community health priorities as a system include: IU Health Day of Service The annual IU Health Days of Service is a high-impact event aimed at engaging IU Health team members in activities that address an identified community priority. Each year, more than 2,000 IU Health team members volunteer during the Days of Service. Community Health Initiatives With investments in high-quality and impactful initiatives to address community health needs statewide, IU Health is helping Indiana residents improve their health and their quality of life. In 2019, IU Health impacted many people statewide through presentations, health risk screenings, health education programs, and additional health educational opportunities made available to the community, especially to our community members in the greatest need of such services. Twenty-four local organizations are benefitting from grants awarded by IU Health. In 2019, IU Health Community Outreach and Engagement awarded more than $900,000 to community organizations and institutions which-like IU Health-are addressing the health needs of the community. These needs include access to affordable healthcare, behavioral health and substance abuse, healthy weight and nutrition and social determinants of health. The grants, administered by the IU Health Foundation, were awarded to the following: Access to Affordable Healthcare - Covering Kids and Families (https://www.ckfindiana.org/) received $25,000 to assist in increasing health insurance enrollment and retention. - LifeSmart Youth (https://lifesmartyouth.org/) received $50,000 toward a new initiative called Tween Education & Access to Community Health (TEACH), which aims to help advance racial health equity and access to care by providing culturally-relevant, medically-accurate reproductive health education to 4,000 Black and Latin youth ages 8 - 12 (grades 4 - 7) in Marion County schools and summer camps. Behavioral Health and Substance Abuse: - Volunteers of America Ohio & Indiana's (https://www.voaohin.org/) (VOAOHIN) Fresh Start Recovery Center received a $75,000 grant to provide residential addiction treatment to pregnant women and mothers. It also allows up to two children ages 5 and under to live with their mother while they receive services. - Goodwill Foundation of Central and Southern Indiana (https://www.goodwillindy.org/foundation/) received $75,000 to help Goodwill Education Initiatives (GEI) Resilience Initiative support resilience work across 15 Excel Center locations by leveraging groundbreaking research on neuroplasticity-the ability of the brain to reorganize itself-and to train staff and students on enhancing their resilience and mitigating the effects of trauma. - Additional grant winners: - Reach for Youth (https://www.reachforyouth.org/) - Lutheran Foundation (https://thelutheranfoundation) - Indy Public Safety Foundation (https://indypsf.org/) Healthy Weight and Nutrition - United Way of Central Indiana, Inc.'s (https://uwci.org/) initiative Jump IN for Healthy Kids received a $50,000 grant to address the epidemic of childhood obesity with a s false true false false false false false true false MICHELLE R ALTOBELLA SECRETARY 0 209945 0 46778 0 698 0 17244 0 27986 0 302651 0 0 JEFFREY C BIRD MD DIRECTOR/PRES.(ECR) 0 470693 0 176646 0 27684 0 100293 0 22561 0 797877 0 0 LORI A LUTHER COO 0 306078 0 42196 0 22564 0 18075 0 23245 0 412158 0 0 JONATHAN W VANATOR CFO (ECR) 0 270283 0 37835 0 540 0 18075 0 23903 0 350636 0 0 CARLA C COX RN VP & CNO (ECR) 0 218913 0 28577 0 3168 0 16465 0 20137 0 287260 0 0 CHARLES L CARROLL DO PHYSICIAN 14976 301091 24 476 0 0 856 17219 0 0 15856 318786 0 0 KEVIN W SCHREIBER MD PHYSICIAN 19401 422768 22 478 857 18683 960 20910 1184 25804 22424 488643 0 0 RODNEY J STEVENS RN Former Key Employee 150671 0 18078 0 31141 0 11346 0 12192 0 223428 0 0 0 THOMAS M LEE MD PHYSICIAN 2091 302463 742 107263 47 6811 124 17950 205 29631 3209 464118 0 0 JUDITH COLEMAN FORMER Officer 0 259644 0 43864 0 11122 0 18075 0 20294 0 352999 0 0 DAVID W HYATT DIRECTOR/PRESIDENT 0 220323 0 29686 0 2751 0 16500 0 30069 0 299329 0 0 Peter M Voss MD CMO (ECR) 0 308299 0 42483 0 21322 0 18075 0 24444 0 414623 0 0 Ann M McGuire VP-Human Resources Regional 0 163445 0 21801 0 18490 0 13245 0 9560 0 226541 0 0 Schedule J, Part I, Line 3 - Comp. of the Org.'s President 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 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, Page 1, Item J - Website address IU Health Blackford Hospital's website address is: https://iuhealth.org/find-locations/iu-health-blackford-hospital Part VI, Section A, Line 2 - Family or Business Relationships Certain officers, directors or key employees of Indiana University Health, Inc. (IU Health) may also serve on the boards or as officers of other related or unrelated organizations. As noted below, no additional compensation was provided to these individuals for their service to related organizations. Related for-profit organization: Cardinal Health Ventures, Inc. Type of Relationship: Business Director or Officer: Peter M. Voss, M.D., Jeffrey C. Bird, M.D., and John D. Littler Jeffrey C. Bird, M.D. also served as an Officer. Part VI, Section A, Line 4 - Changes to the Governing Documents On May 16, 2019, Article IV, Section 4.9, Board Member Attendance of Indiana University Health Blackford's by-laws were amended to include the ability to grant excused absence. Part VI, Section A, Lines 6, 7a and 7b - Members or Stockholders Line 6: 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. Line 7a: 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. Line 7b: 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. Part VI, Section B, Line 11b - Review of Form 990 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. Part VI, Section B, Lines 12, 13, 14, and 16b - Policies IU Health Blackford Hospital is part of the IU Health system. As the sole member and controlling parent of IU Health Ball Memorial Hospital, Inc., the sole member and controlling parent of IU Health Blackford Hospital, IU Health and its Board of Directors have mandated that certain policies be followed to ensure greater standardization throughout the system. Thus, IU Health Blackford Hospitals Board of Directors was not required to separately adopt a conflict of interest, whistleblower, document retention and destruction and joint venture policies because IU Healths Board of Directors had already adopted and required these policies to be followed by its subsidiaries. Part VI, Section B, 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. Part VI, Section B, Line 15A & 15B - Process for Determining Comp The Regional President are 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 Ball, IU Health Blackford, 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. Part VI, Section C, Line 19 - Public Disclosure 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 VII - ACRONYM DESCRIPTION The acronym for the East Central Region, (ECR), is used throughout Form 990, most notably in Part VII and in Schedule J. FORM 990 PART IX LINE 11G DESCRIPTION:PROF. FEES/SHARED SERVICES TOTAL FEES:9787548 Clarian Transplant Institute Inc 950 N Meridian St Ste 800 Indianapolis IN 46204 134350599 Healthcare IN 501(c)(3) 10 IUH true Indiana Health Info Exchange Inc 846 N Senate Ave Indianapolis IN 46202 364550324 Healthcare IN 501(c)(3) 12 I NA false Indiana University Health Inc 950 N Meridian St Ste 300 Indianapolis IN 46204 351955872 Healthcare IN 501(c)(3) 3 NA false IU Health Arnett Inc 950 N Meridian St Ste 300 Indianapolis IN 46204 263162145 Healthcare IN 501(c)(3) 3 IUH true IU Health Ball Memorial Hospital Inc 950 N Meridian St Ste 300 Indianapolis IN 46204 350867958 Healthcare IN 501(c)(3) 3 IUH true IU Health Ball Memorial Physicians Inc 950 N Meridian St Ste 300 Indianapolis IN 46204 351925641 Healthcare IN 501(c)(3) 10 IUHBMH false IU Health Bedford Inc 950 N Meridian St Ste 300 Indianapolis IN 46204 237042323 Healthcare IN 501(c)(3) 3 IUH true IU Health Bloomington Inc 950 N Meridian St Ste 300 Indianapolis IN 46204 351720796 Healthcare 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