2020-11-13T09:40:34-06:00 2019-12-31 ERNST & YOUNG US LLP 111 MONUMENT CIR STE 4000 INDIANAPOLIS IN 46204 990 2019-01-01 351932442 INDIANA UNIVERSITY HEALTH NORTH HOSPITAL INC % CRAIG J JONES INDI 3179634842 950 N MERIDIAN STREET Suite 300 INDIANAPOLIS IN 46204 CARA L BREIDSTER CFO 3179634842 2020-11-08 JENNIFER D RHODERICK P00395735 3176817000 162.1.179.250 35198520203185000013 2020-11-13 P EC0F867CDA2A68A93B900C7968EA20F6D551AC78 6C5B360722C3FFAFCFE5827037413334CAD8ED04 2019 2021-01-29 14:40:06Z KENNETH D PUCKETT 950 N MERIDIAN ST STE 300 INDIANAPOLIS IN 46204 293117483 false X SEE SCHEDULE O X 1994 IN Improve the health of our communities, support the educational commitment of Indiana University Health, Inc., nurture the individual spirit, and celebrate the experiences of life. 12 7 1418 149 31105 0 840 87079 265380249 279590809 6268908 10608057 3468255 2812234 275118252 293098179 0 920 0 0 74079791 74854375 0 0 9898 137002362 146306981 211082153 221162276 64036099 71935903 539270716 612988321 231715962 233518606 307554754 379469715 X IMPROVE THE HEALTH OF OUR COMMUNITIES, SUPPORT THE EDUCATIONAL COMMITMENT/EFFORTS OF INDIANA UNIVERSITY HEALTH, INC. ("IU HEALTH"), NURTURE THE INDIVIDUAL SPIRIT, AND CELEBRATE THE EXPERIENCES OF LIFE. false false 179316733 920 274782012 Indiana University Health North Hospital, Inc. ("IU Health North Hospital") has provided leading family-centered care to Carmel and Hamilton County residents since 2005. As a full-service hospital for adults and children with an attached medical office building, IU Health North Hospital brings together physician offices, 149 inpatient beds, and operating rooms in a state-of-the-art facility where compassionate caregivers provide superior patient treatment without regard to a patient's ability to pay. 2604941 0 3991769 IU Health North Hospital provides services to related tax-exempt organizations. 521754 0 799528 IU Health North Hospital leases physician office and clinic space to related tax-exempt organizations. 11420 17500 Pharmacy 11420 17500 182454848 true true false true false false false false false false true false false false 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 58 0 true 1418 true true true false false false false false false false false false false false X 12 7 false false true false true true true true true false false true true true true true true false true false IN X CRAIG J JONES 3179634842 950 N MERIDIAN STREET SUITE 300 INDIANAPOLIS IN 46204 X X Kristy A Schulhof DIRECTOR/PRESIDENT (PART YEAR) 53.0 2.0 X X 0 1022070 423160 MATTHEW R COOK DIRECTOR 2.0 53.0 X 0 884838 150078 Kenneth D Puckett President - Indy Suburban Reg. 35.0 20.0 X X 0 749896 145910 PAUL M CALKINS MD VP & CMO 55.0 0.0 X 602605 0 31892 KEVIN L SMITH MD DIRECTOR 2.0 53.0 X 0 520724 12547 MEGAN CRITTENDON MD DIRECTOR 2.0 53.0 X 0 374099 11362 ARTHUR VASQUEZ COO - Indy Suburban Region 35.0 20.0 X 0 316788 48361 Cara L Breidster CFO - Indy Suburban Region 35.0 20.0 X 0 321380 41748 MICHAEL L HARLOWE PRESIDENT - TIPTON 0.0 55.0 X 291075 0 35860 DEREK E EMPIE SECRETARY 5.0 50.0 X 0 268310 45345 RUTH A KAIN RN Former Key Employee 0.0 55.0 X 0 264913 41126 LISA A SPARKS RN CNO - Indy Suburban Region 35.0 20.0 X 0 231548 43717 RANDALL C YUST Former Officer 55.0 0.0 X 0 227727 29249 DIANE L HESSON Interim CNO (PART YEAR) 35.0 20.0 X 141699 65495 36484 MARK A MCLEAN DIR OPERATIONS (PART YEAR) 35.0 20.0 X 88973 115837 32933 TAMARAH D BROWNLEE VP-HR - Indy Suburban Region 35.0 20.0 X 0 192896 40664 ATHANASIA S BANICH PRES. North/Coo Saxony (Pt Yr) 55.0 0.0 X 8391 166818 34137 JONATHAN R GOBLE Former Officer 0.0 0.0 X 0 208726 0 JANICE M VADAS Director Allied Services 40.0 0.0 X 182794 0 15145 CHAD A DILLEY ADMIN DIR-CV(PT YR)/COO-SAXONY 40.0 0.0 X 159296 14813 7156 ROBERT E EVARD MD DIRECTOR 12.0 2.0 X 0 79612 0 JAY L HESS MD DIRECTOR 1.0 7.0 X 6500 37500 0 CHARLES E SCHALLIOL CHAIRMAN 2.0 2.0 X X 18750 0 0 CLAUDIA J SOMES MD DIRECTOR 2.0 2.0 X 14375 0 0 MARSHA A STONE DIRECTOR 2.0 2.0 X 0 8000 0 MARK R BENSON DO DIRECTOR 2.0 2.0 X 0 7000 0 MICHELE M KAWIECKI DIRECTOR 2.0 2.0 X 6500 0 0 REV KAREN E DEVAISHE DIRECTOR (Part Year) 2.0 2.0 X 0 3500 0 JOHN D GOLDENBERG M DIRECTOR 2.0 2.0 X 3000 0 0 MICHAEL L KUBACKI DIRECTOR (Part Year) 2.0 0.0 X 0 0 0 1514458 6071990 1226874 54 true true true ARAMARK HEALTHCARE TECHNOLOGIES 10510 TWIN LAKES PARKWAY CHARLOTTE NC 28269 CLINICAL ENGINEERING 1079911 MESSER CONSTRUCTION CO 2445 N MERIDIAN ST INDIANAPOLIS IN 46208 CONSTRUCTION 27965031 SODEXO INC AFFILIATES 4880 PAYSPHERE CIRCLE CHICAGO IL 60674 FACILITIES 775719 TRIMEDX LLC 5451 LAKEVIEW PKWY S DR INDIANAPOLIS IN 46268 CLINICAL ENGINEERING 1422412 SOUTH WESTERN COMMUNICATIONS INC 7031 Mayflower Park Drive ZIONSVILLE IN 46077 CONSULTING 679241 29 87058 21 87079 NET PATIENT SERVICE REVENUE 622110 274782012 274782012 SHARED SERVICES 541990 3991769 3991769 RENT FROM RELATED 501(C)(3) ORGS. 532000 799528 799528 PHARMACY 446110 17500 17500 279590809 10038200 10038200 0 0 102099 18042 84057 0 84057 84057 571119 1262 569857 569857 569857 0 0 0 0 0 0 0 0 0 CAFETERIA/FOOD SERVICE 721110 2565319 31105 2534214 EDUCATION 900099 23359 23359 GIFT SHOP 453220 78822 78822 60677 60677 2728177 293098179 279590809 31105 13389186 X 0 920 920 0 0 507364 445154 62210 0 59484412 52191690 7292722 2176686 1909827 266859 8416884 7384983 1031901 4269029 3745651 523378 5889 5889 0 3750 3750 1257 1257 0 0 49124273 47252638 1871635 0 218808 217692 1116 951853 721972 229881 455429 240459 214970 0 9326082 3296723 6029359 68036 31418 36618 0 29774 18976 10798 12816024 12816024 0 10615380 5693660 4921720 1658646 364592 1294054 DRUGS AND MEDICAL SUPPLIES 32875589 32875589 BAD DEBT 9855480 9855480 HOSPITAL ASSESSMENT FEE 12130306 12130306 INSTITUTIONAL DUES/LICENSES 136399 136399 6034006 3940719 2083389 9898 221162276 182454848 38697530 9898 0 0 357360930 375510963 0 0 37241837 36603411 0 0 0 0 188412 171399 2332371 2597290 1144255 1524064 331901870 135320676 140844785 196581194 0 0 0 0 0 0 0 0 158126 0 539270716 612988321 20914414 31338641 0 0 473581 265779 0 0 0 0 0 0 0 0 0 0 210327967 201914186 231715962 233518606 X 307554754 379469715 0 0 307554754 379469715 539270716 612988321 X 71935903 -20942 X false true X true false X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED false false false false false false false false true 1257 1257 false Schedule C, Part II-B, Line 1i - Other Activities IU Health North Hospital paid institutional membership dues to the Indiana Hospital Association ("IHA") during 2019 in the amount of $19,247. Each membership organization notified IU Health North Hospital that a portion of the dues it paid were used for lobbying purposes. The IHA used 6.53%, or $1,257 of the 2019 membership dues paid by IU Health North Hospital, for lobbying expenditures. The total membership dues paid to this organization by IU Health North Hospital during 2019 that were attributable to lobbying expenditures was $1,257. 166811493 57914732 108896761 1086838 384649 702189 84918580 65471849 19446731 79084959 11549446 67535513 196581194 0 INTERCOMPANY PAYABLES (NET) 198371042 DUE TO THIRD-PARTY PAYERS 1838884 SELF-INSURANCE LIABILITIES 363253 OPERATING LEASE LIABILITIES 1341007 201914186 X Schedule D, Part X, Line 2 - FIN 48 (ASC 740) Footnote IU Health North Hospital 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. 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. 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 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 change in the 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 false true true 1630 1884697 1884697 0.00890 4406 33534638 19330103 14204535 0.06720 6036 35419335 19330103 16089232 0.07610 8 9430 986162 25366 960796 0.00450 2 217 537965 537965 0.00250 2 9082 98335 98335 0.00050 12 18729 1622462 25366 1597096 0.00750 12 24765 37041797 19355469 17686328 0.08360 1 359 359 0.00000 1 359 359 0.00000 false 2431347 0 31754867 41638200 -9883333 X true true 1 1 IU HEALTH NORTH HOSPITAL 11700 N MERIDIAN ST CARMEL IN 46032 SEE PART V, SECTION C 20-004171-1 X X X X X IU HEALTH NORTH 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 Primary Website Address https://iuhealth.org/find-locations/iu-health-north-hospital Schedule H, Part V, Section B, Line 3e Prioritized Health Needs IU Health North Hospitals 2018 Community Health Needs Assessment (CHNA) Report includes a prioritized description of significant health needs in the community. The CHNA report identified the following seven needs as priorities for IU Health North: - ACCESS TO HEALTH CARE SERVICES - DRUG AND SUBSTANCE ABUSE - Food Insecurity - HEALTH CARE AND SOCIAL SERVICES FOR SENIORS - MENTAL HEALTH - OBESITY AND DIABETES - 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 North Hospital took into account input from persons who represent the broad interests of the communities it serves. Primary data were gathered in three different methodologies for this assessment: Community Meetings, Key Stakeholder Interviews, and a Community Survey. For purposes of this CHNA, IU Health North Hospitals community is defined as Hamilton and Marion Counties, Indiana. These two counties accounted for 68 percent of the hospitals inpatient cases in 2016. Community Meetings Hamilton County On April 17, 2018, a meeting of community representatives was held at the Hamilton County 4H Fairgrounds in Noblesville, the county seat of Hamilton County. The meeting was attended by 38 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 communitys health needs. The specific organizations represented at the meeting are listed below. - Aspire Indiana - Central Indiana Council on Aging (CICOA) - Chaucies Place - Community Health Network North - Department of Child Services - Fishers City Council - Fishers Fire & Emergency Services - Good Samaritan Network - HAND, Inc. - HOPE Family Care Center - Hamilton County Council on Alcohol and other Drugs - Hamilton County Health Department - Hamilton County Harvest Food Bank - Hamilton County Youth Assistance Program - Hamilton Heights School Corporation - Hamilton Southeastern Schools - IU Health - IU Health Indy Suburban Region/IU Health North Hospital and IU Health Saxony Hospital - Noblesville Chamber of Commerce - Noblesville Town Council - Noblesville Schools - Partnership for a Healthy Hamilton County - Prevail, Inc. - PrimeLife Enrichment, Inc. - Riverview Health - Riverview Health Physicians - Shepherds Center of Hamilton County - St. Francis - St. Vincent Carmel/Fishers - Stones 3 Resources - Trinity Free Clinic - Westfield Washington School 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. Due to the size of the group, participants were then split into three groups. The same list was provided to each group of potential unmet health needs for the individuals to discuss and vote on to indicate what they considered to be the most significant health needs for Hamilton County. Those health needs were: - Transportation - Housing - Employment - Job training - Food insecurity - Nutritional education - Social support - Access to health services - Cost of medication - Insurance coverage/enrollment - Violence/crime - Chronic disease management During the meeting, a range of other topics was discussed, including: - Individuals with a mental health diagnosis - Individuals with a history of substance abuse/misuse - Individuals with chronic conditions - Children and seniors as priority populations - Nutritional education - Employment - Limited supply of health care professionals After discussing the needs identified, each participant was asked through a voting process to identify the two they consider to be most significant. From this process, the groups identified the following needs as most significant for Hamilton County: - Transportation - Housing - Access to health services - Chronic disease management - Cost of medication - Insurance coverage/enrollment - Social support Interviews Hamilton County An interview also was conducted with a representative of the Hamilton County Health Department. The interview was conducted to assure that appropriate and additional input was received from a governmental public health official. The individual that was interviewed participated in the community meeting. Accordingly, the results of the community meeting were discussed and insights were sought regarding significant community health needs, why such needs are present, and how they can be addressed. The interview was guided by a structured protocol that focused on opinions regarding significant community health needs, describing why such needs are present, and seeking ideas for how to address them. According to the interviewee, many in Indiana incorrectly believe that since Hamilton County is affluent, there is little need to focus on improving community health. The county does have needs and has pockets of vulnerable populations that need continued attention. The county also needs more public health funding to provide adequate programs and services. The interviewee confirmed that the three top needs identified by community meeting participants were significant, adding that all three have been chronic issues in the county. These three needs were: - Transportation - Access to Health Services - Housing Mental health and substance abuse services are particularly difficult to access in the county. Only one real treatment center and no inpatient facilities exist, requiring residents to travel long distances to services outside of the county. Primary care also is difficult to access for patients with certain types of insurance coverage. Many providers are not accepting new patients with Medicare or Medicaid. This issue became more problematic a few years ago after a community clinic closed. Regarding populations at risk, individuals with a mental health diagnosis, the uninsured or underinsured, children, and seniors are most at risk. Seniors face issues including a lack of transportation, difficulties accessing mental health services, and isolation. A lack of specialized providers for pain management, physical therapy, and related pain management services is contributing to an over-prescribing of opiates. The need for health education in the community is significant. Health department and other community resources are limited. Education is needed particularly regarding risks associated with substance abuse and sexually-transmitted diseases. Many uninsured are using emergency rooms for primary care since they do not know where else to go. A service that could connect these residents to providers accepting low income and Medicaid patients is needed. Medication assistance for seniors also is an issue. Many seniors are confused by the array of medications they have been prescribed, leading to a lack of medication adherence and compliance. Community Meetings Marion County Between May 7 and 9, 2018, three meetings of community representatives were held in Indianapolis, the county seat of Marion County. In total, the meetings were attended by 42 community members invited by IU Health in partnership with Community Health Network 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 these meetings, IU Health sought a breadth of perspectives on the communitys health needs. The specific organizations represented at the meetings are listed below. - Adult and Child Health - All Senior Citizens Connect - Central Indiana Council on Aging (CICOA) - City of Indianapolis - Coburn Place - Community Health Network - Gennesaret Free Clinics - Gleaners Food Bank - Health by Design - IU Health Methodist Hospital - IU Health University Hospital - Indiana Youth Institute - Indianapolis Fire Department - Indianapolis Metropolitan Police Department - Indy Hunger Network - Indianapolis Parks and Recreation - Irvington Development Organization - Jump IN for Healthy Kids - Lawrence Community Gardens - Marion County Public Health Department - New Beginnings Church - Paramount Schools of Excellence - Progress House - Purdue Extension - The Polis Center - University of Indianapolis The meeting began with a presentation that discussed the goals and status of the CHNA process and the purpose of the community meetings. Then, secondary data were presented, along with a summary of the most unfavorable community health indicators. For Marion County, those indicators were (in alphabetical order): - Air pollution - Communicable diseases and STDs - Crime - Mental health and supply of mental health providers - Obesity and lack of physical activity - Poverty and high 'Community Need Index' - Smoking and tobacco use 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 by each group, such as: - High school graduation rates - Built environment - Access to prim Schedule H, Part V, Section B, Line 7a CHNA Website A copy of IU Health North 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 North Hospital's CHNA implementation strategy 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 North Hospital's Board adopted an implementation strategy in April 2019 related to the 2018 CHNA. IU Health North 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 North Hospital will address the following community health needs between 2019 and 2021: - Access to Healthcare Services - Drug and Substance Abuse (including Opioids and Alcohol) - Food Insecurity - Healthcare and Social Services for Seniors - Mental Health - Obesity and Diabetes - 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 North Hospital's implementation strategy to address the identified need of Access to Healthcare includes the following: - Provide funding for Trinity Free Clinic to support the medical and dental needs of Hamilton County residents who are uninsured and underinsured. - In 2019, IU Health North provided support to Trinity, which allowed the clinic to expand its mental health screening program, increase hours of acute medical and dental care, expand well-child visits to include fluoride varnish, and provide continued care for hypertension patients who have difficulty accessing primary care. - Encourage IU Health team members to assist in staffing the medical clinic. - Provide funding for the Heart & Soul Clinic's operations in Westfield to support medical and dental needs of Hamilton County residents who are uninsured and underinsured. - In 2019, IU Health North provided support to Heart & Soul, which was used in providing medical and dental care for the 567 patients they served, an increase of 32 percent over 2018. Of the 567 patients, 90 percent were classified as low or very-low income. - Invest in the Partnership for a Healthy Hamilton County (PHHC) to encourage collaboration among area health agencies and organizations. - IU Health North provided support to PHHC in 2019, which was used to assist the Fishers Youth Assistance Summer Meals Program and PHHC's overall operations during its transition to become its own 501c3 organization. - Develop programs and strategies to improve the overall health of Hamilton County residents and employees. - Participate in PHHC committees related to pertinent Community Health Needs Assessment (CHNA) priorities. - Support the Fishers Youth Assistance Summer Meals Program. - Provide an Individual Solutions coordinator to help patients register for health insurance through Healthy Indiana Plan (HIP) 2.0 or other Marketplace insurance. - Create a pilot program that provides in-home visits by a licensed social worker for seniors who need behavioral health services. - Provide physician-led health seminars to seniors at PrimeLife Enrichment, Inc. - Provide free finger-stick health screenings for seniors at PrimeLife Enrichment, Inc. to measure cholesterol, triglycerides, glucose, A1C and blood pressure. - Provide education to encourage positive changes to impact future screening results. - Provide in-hospital training for team members so the hospital is able to create an environment that is welcoming and conducive for those living with dementia. - Provide funding to the Shepherd's Center of Hamilton County in support of its Reaching Resources program, which allows seniors to age as independently and gracefully as possible. - Provide 24/7 peer counseling via telemedicine for patients who present in the emergency department (ED) with substance abuse issues. - Provide telemedicine visits with trained behavioral health clinicians to patients who present in the emergency department (ED) with behavioral health needs. - Provide funding for a Fishers EMS Duty Officer (EDO) to provide follow-up home visits for patients who have been discharged from the hospital with behavioral health-related issues. - Provide funding for Aspire Indiana to address specific behavioral health needs in Hamilton County. - In 2019, IU Health North provided support to Aspire to purchase two new pediatric exam tables for the Noblesville clinic and one for the Carmel clinic, and to provide employment assistance for Aspire clients. - Collaborate with the Max Challenge of Fishers to provide 100 Hamilton County residents with a free 10-week program to improve their overall health through fitness and nutrition. - Provide three health screenings during the 10-week period to measure changes in cholesterol, triglycerides, glucose, A1C, blood pressure, weight and Body Mass Index (BMI). Behavioral Health (includes Drug & Substance Abuse and Mental Health) IU Health North Hospital's implementation strategy to address the identified need of Behavioral Health includes the following: - Invest in the Partnership for a Healthy Hamilton County (PHHC) to encourage collaboration among area health agencies and organizations. - Develop programs and strategies to improve the overall health of Hamilton County residents and employees. - Participate in PHHC committees related to pertinent Community Health Needs Assessment (CHNA) priorities. - Support the Fishers Youth Assistance Summer Meals Program. - Create a pilot program that provides in-home visits by a licensed social worker for seniors who need behavioral health services. - Provide in-hospital training for team members so the hospital is able to create an environment that is welcoming and conducive for those living with dementia. - Provide funding to the Shepherd's Center of Hamilton County in support of its Reaching Resources program, which allows seniors to age as independently and gracefully as possible. - Provide 24/7 peer counseling via telemedicine for patients who present in the emergency department (ED) with substance abuse issues. - In 2019, 91 percent of patients who were offered peer recovery counseling accepted the service and were open to discussing ways to treat their substance abuse disorder. The peer recovery counselors spent 2,004 total minutes coaching patients with substance abuse disorders. - Provide telemedicine visits with trained behavioral health clinicians to patients who present in the emergency department (ED) with behavioral health needs. - In 2019, approximately 60 patients were transferred from the ED to behavioral health services for follow-up services or referral to an inpatient facility. - Provide funding for a Fishers EMS Duty Officer (EDO) to provide follow-up home visits for patients who have been discharged from the hospital with behavioral health-related issues. - In 2019, 366 Hamilton County resident patients and 44 non-Hamilton County resident patients received a follow-up call via the program. 122 total individuals did not answer or respond to the follow-up call but there were 237 referrals to services in the community. There were 53 home visit referrals, 17 referrals to financial assistance for medication and other needs, five referrals to transportation services, 55 referrals to social services and 15 referrals to a primary care provider or contact. - Provide annual funding to the Indiana Center for Prevention of Youth Abuse & Suicide. - In 2019, IU Health North provided support to ICPYAS, and approximately 70 schools hosted the Smart Steps program in 2019. - Collaborate with the Indiana Center for Prevention of Youth Abuse & Suicide to provide training for community and IU Health team members on the recognition and prevention of child sexual abuse. - In 2019, 525 adults completed the Stewards of Children training. - Provide funding for Breathe Easy Hamilton County efforts. - Provide senior executive support for the Breathe Easy Hamilton County initiative. - Attend and financially support the annual Breathe Easy Hamilton County luncheon. - Provide funding for Aspire Indiana to address specific behavioral health needs in Hamilton County. Food Insecurity IU Health North Hospital's implementation strategy to address the identified need of Food Insecurity includes the following: - Invest in the Partnership for a Healthy Hamilton County (PHHC) to encourage collaboration among area health agencies and organizations. - Develop programs and strategies to improve the overall health of Hamilton County residents and employees. - Participate in PHHC committees related to pertinent Community Health Needs Assessment (CHNA) priorities. - Support the Fishers Youth Assistance Summer Meals program through investment in the Partnership for a Healthy Hamilton County (PHHC). - With PHHC's assistance, the program increased access to healthy food by providing a total of 46,220 meals in 2019, an average of 514 students served each week. - Collaborate with the Fishers Parks & Recreation to provide 20 garden boxes measuring 10'x10' on the campus. - Provide funding to the Fishers Parks & Recreation to cover the cost of garden plot rental for community members who rent one of the Fishers Parks garden plots Schedule H, Part V, Section B, Line 13b Income Level Other than FPG In addition to FPG, IU Health North Hospital may take into consideration a patients 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 North Hospital takes into consideration several other factors in determining patient eligibility for financial assistance. These factors include the following: 1. IU Healths Individual Solutions Department Prior to seeking Financial Assistance under the FAP, all patients or their guarantors must consult with a member of IU Healths 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 North Hospitals Financial Assistance Program. Patients who may be eligible for coverage under an applicable insurance policy, including, but not limited to, health, automobile, and homeowners, must exhaust all insurance benefits prior to receiving an award from IU Health North Hospitals 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 North Hospital. Eligible patients who receive medical care from IU Health North 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 North Hospital is entitled. In the event a Financial Assistance Award has already been granted in such circumstances, IU Health North Hospital reserves the right to reverse the award in an amount equal to the amount IU Health North Hospital would be entitled to receive had no Financial Assistance been awarded. 3. Alternate Methods of Eligibility Determination IU Health North 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 patients individual scoring criteria. To ensure all patients potentially eligible for Financial Assistance under the FAP may receive Financial Assistance, IU Health North 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 Childrens 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 patients account if said patient is found to have no estate. Additionally, IU Health North 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 North 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 EMTALA and IU Health Policy ADM 1.32, Screening and Transfer of Emergency or Unstable Patients. 7. Amount of Non-Refundable Deposit All Uninsured Patients presenting for services at IU Health North Hospitals 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 North 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 A copy of IU Health North Hospitals FAP is available on the following website: https://iuhealth.org/pay-a-bill/financial-assistance Schedule H, Part V, Section B, Line 16b FAP Application Website A copy of IU Health North Hospitals FAP Application is available on the following website: 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 North 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 North 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 North Hospital will broadly communicate this Policy as part of its general outreach efforts. 5. IU Health North Hospital will educate its patient facing team members of the FAP and the process for referring patients to the Program. 1 Carmel Rehab 2476 East 116th StreetG100 CARMEL IN 46032 rehabilitation services Schedule H, Part I, Line 3c - Other Factors Used in Determining Elig. IU Health North 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 North 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 parents or guardians federal income tax return. 2. IU Healths Individual Solutions Department Prior to seeking Financial Assistance under the FAP, all patients or their guarantors must consult with a member of IU Healths 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 North 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 North Hospitals Financial Assistance Program. Patients who may be eligible for coverage under an applicable insurance policy, including, but not limited to, health, automobile, and homeowners, must exhaust all insurance benefits prior to receiving an award from IU Health North Hospitals 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 North Hospital. Eligible patients who receive medical care from IU Health North 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 North Hospital is entitled. In the event a Financial Assistance Award has already been granted in such circumstances, IU Health North Hospital reserves the right to reverse the award in an amount equal to the amount IU Health North Hospital would be entitled to receive had no Financial Assistance been awarded. 6. Alternate Methods of Eligibility Determination IU Health North 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 patients individual scoring criteria. To ensure all patients potentially eligible for Financial Assistance under the FAP may receive Financial Assistance, IU Health North 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 Childrens 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 patients account if said patient is found to have no estate. Additionally, IU Health North 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 North 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 North 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 North 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 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 North Hospitals 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 North 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 North 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. 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 (c) - 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 excludes direct offsetting revenue, is 17.53%. Schedule H, Part I, Line 7, Column (f) - Percent of Total Expense The amount of bad debt expense subtracted for purposes of calculating the percentage of total expense on Line 7, column (f) is $9,855,480. 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 II - Promotion of Health in Communities Served IU Health North Hospital is part of the IU Health Statewide System. The IU Health Statewide System participates in a variety of community-building activities that address the social determinants of health in the communities it serves through investments in economic development efforts across the state, collaboration with like-minded organizations through coalitions that address key issues and advocacy 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 address issues, such as access to healthcare, community support and economic development. Several examples include IU Health North Hospital's support of the following organizations and initiatives that focus on some of the root causes of health issues, such as lack of education, insufficient access to resources, employment and poverty: - Partnership for a Healthy Hamilton County - Aspire Indiana, Inc. - Trinity Free Clinic - Indiana Center for the Prevention of Youth Abuse and Suicide - Shepherd's Center of Hamilton County 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 - Bad Debt Expense Methodology The amount reported on line 2 as bad debt 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 HEALTH CARE 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 IS 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 AN 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 North Hospital is a subsidiary in the consolidated financial statements of IU Health. IU Health's bad debt expense footnote is 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 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 $96,693,000 and $94,886,000 in 2019 and 2018, respectively. Schedule H, Part III, Line 8 - Medicare Shortfall The amount reported on Schedule H, Part III, Line 6 is calculated, in accordance with the Form 990 instructions, using "allowable costs" from IU Health North Hospitals Medicare Cost Report. "Allowable costs" for Medicare Cost Report purposes, however, are not reflective of all costs associated with IU Health North Hospitals 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 North Hospitals participation in Medicare programs would significantly increase the Medicare shortfall reported on Schedule H, Part III, Line 7. IU Health North Hospital's Medicare shortfall is attributable to reimbursements that are less than the cost of providing patient care and services to Medicare beneficiaries and does not include any amounts that result from inefficiencies or poor management. IU Health North 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. Schedule H, Part III, Line 9b - Written Debt Collection Policy IU Health North Hospitals 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 applications 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 patients physician, family members, legal counsel, community or religious groups, social services or hospital personnel may request a FAP Application to be mailed to a patients primary mailing address free of charge. IU Health 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 patients and/or guarantors 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 North 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 patients Financial Assistance Application and eligibility determination are specific to each individual date(s) of service and related encounters. 3. Extraordinary Collection Actions IU Health North Hospital may refer delinquent patient accounts to a third-party collection agency after utilizing reasonable efforts to determine a patients eligibility for assistance under the FAP. IU Health 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 patients or their guarantors 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 patients or their guarantors 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 patients or their guarantors property, foreclosing on a patients or their guarantors real property attaching or seizing a patients or their guarantors bank account or other personal property, commencing a civil action against a patient or their guarantor, causing a patient or guarantors arrest, causing a patient and/or guarantor to be subject to a writ of body attachment, and garnishing a patient or guarantors wages. When it is necessary to engage in such action, IU Health North 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. IU Health 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 North 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 North 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 North Hospital assesses the health care needs of the communities it serves by conducting a Community Health Needs Assessment (CHNA) for each of its hospital locations. For the 2018 CHNAs, Indiana University Health conducted the community survey data collection in collaboration with Indiana University, University of Evansville and an Indiana Hospital Collaborative, including Community Health Network, Franciscan Alliance, St. Vincent Health and other hospital partners. After completion of the CHNA, IU Health North Hospital reviewed secondary data, findings from other community health assessments of areas 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 communities 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. IU Health believes its CHNA process is comprehensive and additional assessments are not required. Schedule H, Part VI, Line 3 - Patient Education of Eligibility for Assist. IU Health North 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 North Hospital has established a FAP to provide Financial Assistance to Uninsured Patients. IU Health North Hospital is committed to ensuring its patients are compliant with all provisions of the Patient Protection & Affordable Care Act. To that end, IU Health North 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 North 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 North 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 North Hospital will broadly communicate this Policy as part of its general outreach efforts. 5. IU Health North 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 North Hospital is located in Hamilton County, Indiana, a county located in central Indiana. Its service area counties include Marion, Hamilton, Boone, Hendricks, Hancock, Madison and Tipton counties. Hamilton County includes ZIP codes within the towns of Arcadia, Atlanta, Carmel, Cicero, Fishers, Noblesville, Sheridan, and Westfield. Based on the most recent Census Bureau (2019) statistics, Hamilton County's population is 338,011 persons with approximately 51% being female and 49% male. The county's population estimates by race are 82.8% White, 4.5% Black, 4.3% Hispanic or Latino, 6.5%% Asian, 0.2% American Indian or Alaska Native, and 2.1% persons reporting two or more races. Hamilton County has relatively high levels of educational attainment. Among residents ages 25 and up, 96.4% completed their education with a high school diploma or equivalent. Among resident ages 25 and up, 57.8% earned a bachelor's degree or higher. Schedule H, Part VI, Line 5 - Promotion of Community Health IU Health North Hospital is a subsidiary of Indiana University Health, Inc., a tax-exempt healthcare organization, whose Board of Directors is composed of members of which substantially all are independent community members. During 2019, IU Health North Hospital's promotion of community health included the following highlights: In 2019, IU Health North Hospital maintained a strong presence across the northern Indianapolis suburbs in Hamilton County and supported numerous not-for-profit agencies including local parks departments, medical and dental clinics that provide care to the un- and under-insured, behavioral health agencies, and organizations that provide health and social services to seniors who are in need. As part of these efforts, IU Health North Hospital also continued its participation in the Partnership for a Healthy Hamilton County in conjunction with Community Health Network, Riverview Health, Ascension St. Vincent Carmel and several other health-related agencies in the county. This group seeks to transform communities by influencing and leading health innovation through community collaborations. IU Health North Hospital provided a 10-week fitness and nutrition program, Fresh & Fit, to 100 Hamilton County residents helping them to improve their overall health by lowering cholesterol, blood pressure, blood sugar, A1C and weight. Participants in Fresh & Fit also report additional benefits of the program including increased energy, improved mental well-being, reduced pain and a reduction in medications. IU Health North Hospital is a subsidiary of IU Health. IU Health and its related hospital entities across the state of Indiana extend medical privileges to all physicians who meet the credentialing qualifications necessary for appointment to its medical staff. IU Health does not deny appointment on the basis of gender, race, creed or national origin. IU Health, in conjunction with the IU School of Medicine, trains the next generation of physicians in an exceptional environment. Blending breakthrough research and treatments with the highest quality of patient care. Schedule H, Part VI, Line 6 - Affiliated Health Care System IU Health North Hospital is part of the IU Health Statewide System. The IU Health Statewide system 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. IU Health 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. - 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 - high performing - Geriatrics - 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 (#5), IU Health Arnett (#8) and IU Health Bloomington (#8) hospitals. 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 $50 million over six 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 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: - 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 (NCI) 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 benefit plan relative to the local community, the IU Health Statewide System considers the sum of these plans part of a statewide 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 more than $738 million 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 health need. 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 educational 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 Indiana University Health Foundation, were awarded to the following: 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 specific focus on implementing strategies that create healthy places, healthy neighborhoods, and healthy communities in Marion County. - Playworks (https://www.playworks.org/indiana/), a national non-profit organization that partners with Indianapolis schools and youth organizations to help them leverage play for positive outcomes, received a $23,000 grant. - Additional grant winners: - Indianapolis Parks Foundation (https://www.indyparksfoundation.org/) Social Determinants of Health - A $100,250 grant was awarded to Gleaners Food Bank's (https://www.gleaners.org/) Ho Schedule H, Part VI, Line 7 - State Filing of Community Benefit Report IN true true false false false false false true false JONATHAN R GOBLE Former Officer 0 0 0 0 0 208726 0 0 0 0 0 208726 0 208726 MATTHEW R COOK DIRECTOR 0 581502 0 248092 0 55244 0 126007 0 24071 0 1034916 0 0 KEVIN L SMITH MD DIRECTOR 0 426132 0 94052 0 540 0 11200 0 1347 0 533271 0 0 DEREK E EMPIE SECRETARY 0 231195 0 36357 0 758 0 14966 0 30379 0 313655 0 0 RANDALL C YUST Former Officer 0 107866 0 62817 0 57044 0 14926 0 14323 0 256976 0 0 PAUL M CALKINS MD VP & CMO 483673 0 55818 0 63114 0 15337 0 16555 0 634497 0 0 0 RUTH A KAIN RN Former Key Employee 0 196146 0 37691 0 31076 0 15998 0 25128 0 306039 0 0 MARK A MCLEAN DIR OPERATIONS (PART YEAR) 77359 100716 8992 11708 2622 3413 5723 7450 8584 11176 103280 134463 0 0 DIANE L HESSON Interim CNO (PART YEAR) 101023 46694 36512 16876 4164 1925 7559 3494 17392 8039 166650 77028 0 0 MICHAEL L HARLOWE PRESIDENT - TIPTON 256500 0 32253 0 2322 0 11657 0 24203 0 326935 0 0 0 JANICE M VADAS Director Allied Services 173502 0 8740 0 552 0 11523 0 3622 0 197939 0 0 0 Kristy A Schulhof DIRECTOR/PRESIDENT (PART YEAR) 0 302984 0 148510 0 570576 0 392112 0 31048 0 1445230 0 60777 Cara L Breidster CFO - Indy Suburban Region 0 268019 0 40264 0 13097 0 18008 0 23740 0 363128 0 0 Kenneth D Puckett President - Indy Suburban Reg. 0 462981 0 211080 0 75835 0 116713 0 29197 0 895806 0 0 MEGAN CRITTENDON MD DIRECTOR 0 365105 0 6684 0 2310 0 11362 0 0 0 385461 0 0 ATHANASIA S BANICH PRES. North/Coo Saxony (Pt Yr) 7801 155087 575 11429 15 302 245 4871 1390 27631 10026 199320 0 0 LISA A SPARKS RN CNO - Indy Suburban Region 0 195530 0 35029 0 989 0 14942 0 28775 0 275265 0 0 ARTHUR VASQUEZ COO - Indy Suburban Region 0 269606 0 46696 0 486 0 18075 0 30286 0 365149 0 0 TAMARAH D BROWNLEE VP-HR - Indy Suburban Region 0 163933 0 28597 0 366 0 8259 0 32405 0 233560 0 0 CHAD A DILLEY ADMIN DIR-CV(PT YR)/COO-SAXONY 131520 12230 23762 2210 4014 373 6348 590 199 19 165843 15422 0 0 Schedule J, Part I, Line 3 - Comp. of the Org.'s CEO/Executive Director IU Health North Hospital's Regional President is employed by IU Health. IU Health North Hospital's President is also employed by IU Health, Inc. IU Health, IU Health North Hospital, and other related entities have a process in place to determine the compensation for the other 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. Please see schedule O for additional details.. SCHEDULE J, PART I, LINE 4A - SEVERANCE Jonathan R. Goble entered into a severance agreement with IU Health during 2018. Severance of $208,726 that was received during 2019 is included in column B(III), other reportable compensation. Deferred severance of $231,294 was disclosed in 2018 in column C, retirement and other deferred compensation. Kristy A. Schulhof entered into a severance agreement with IU Health during 2019. Severance of $55,348 that was received during 2019 is included in column B(III), other reportable compensation. Deferred severance of $374,645 is included in column C, retirement and other deferred compensation. Schedule J, Part I, Line 4b - Supplemental Nonqualified Retirement Plan Matthew R. Cook, Kristy A. Schulhof, and Kenneth D. Puckett participate in an IU Health supplemental executive retirement plan, provisions of which are designed to retain these critical employees. The plan provides for an additional retirement benefit for service through normal retirement or other key dates. If the executive leaves prior to retirement or other key dates, that benefit may be forfeited or reduced. Each of these executives listed above, with the exception of Kristy A. Schulhof have an amount included in column c, deferred compensation, representing the current year unvested contributions made under the supplemental retirement plan. These amounts were not paid to these executives during the year. The following executives have an amount included in column B (III), other reportable compensation, representing the current year vested amounts received under the supplemental executive retirement plan: - Kristy A. Schulhof ($461,442) 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 a 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 VII, Section A, Line 5 / Schedule J, Part II -- Compensation paid for services rendered by Paul Calkins Paul Calkins was employed as the VP & Chief Medical Officer, by IU Health North Hospital from January 2019 through August 2019. Paul Calkins ceased employment with IU Health North effective 8/16/2019. After this date, IU Health North contracted and paid Anesthesia Consultants, Inc. for Paul Calkins' services as the VP & Chief Medical Officer of IU Health North. During 2019, compensation paid by IU Health North to Anesthesia Consultants, Inc. for his services to IU Health North was $186,285. This amount is reflected in compensation paid by IU Health North on Schedule J, Part II, in column (B)(i), base compensation paid by IU Health North. Page 1, Line J Web Site: https://iuhealth.org/find-locations/iu-health-north-hospital Part VI, Section A - Governing Body and Management Line 4 - Significant Changes to Organizational Documents Indiana University Health North Hospital, Inc. ("IU Health North Hospital") filed Amended Articles of Incorporation with the Indiana Secretary of State's Office effective March 1, 2019. IU Health North Hospital also executed amended and restated bylaws effective March 1, 2019 in order to reflect its change in operation following the boards merger with IU Health West Hospital. A summary of the updated bylaws are shown on Schedule O, lines 7a and 7b. A summary of the Amended Articles of Incorporation are included below. Article II, Which defines the purposes of the legal entity was amended to specifically address: - Increasing community access to quality health care services to the indigent, poor, and underserved; - Providing health services to the community through ownership and operation of a hospital in Hendricks County, Indiana; - Engaging in and supporting health education, training and research activities, including programs for nurses, health professionals and clergy; - Engaging in any lawful activities within the purposes for which a corporation may be organized under the Act, which are in furtherance of, supportive of, allied with or incidental to the purposes of the corporation; - Engage in all of the above mentioned activities on an interdenominational, public benefit basis while adhering to and assuring the preservation of the corporations values. Part VI, Section A, Line 1b Independent Voting Members IU Health North Hospital is part of a multi-entity hospital system controlled by IU Health, a 501(c)(3) tax-exempt organization whose board is comprised of voting members, of which substantially all are independent community members. Part VI, Section A, Lines 6, 7a and 7b Members or Stockholders Line 6: The sole member of IU Health North Hospital is IU Health, a 501(c)(3) tax-exempt organization. Line 7A: The Board of Directors of the IU Health North Hospital shall consist of up to fifteen (15) voting members all appointed by IU Health, who shall include representatives from the Medical staffs of IU Health North Hospital and IU Health West Hospital, and the President of the Indianapolis Suburban Region, who shall be an ex-officio, voting director of the Board. At all times, the IU Health North Hospital directors shall consist of the same individuals appointed by IU Health to serve as directors of IU Health West Hospital. Line 7B: The Board of Directors shall not, without the prior approval of the IU Health: - Any proposed amendment to the Corporation's Articles of Incorporation or these Bylaws; - Adoption of the Corporation's annual capital and operating budgets; - Approval of any unbudgeted operating or capital budget items or deviations, including any issuance or guarantee of any unbudgeted debt; - Approval of any strategic plan for the Corporation, including any amendments to a strategic plan; - Approval of any encumbrance, sale or conveyance of assets; - Any merger, consolidation, joint venture or affiliation involving the Corporation or any of its affiliates and any other entity; - Appointment and removal of the Corporation's President and other officers; - Construction, acquisition or lease of Hospital buildings; - Approve any management agreement for the management of all or substantial part of IU Health West Hospital's operations; - Projects or contracts that require Member approval in accordance with the Member's resolution and policy governing system-wide Contract Execution Authority and Payment Approval Limits; and - The dissolution of the Corporation or any of its affiliates. Part VI, Section A, Line 11b Review of Form 990 The Indianapolis Suburban Chief Financial Officer and Finance Committee reviewed and approved the Form 990. Following their review and approval, 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 North Hospital is part of the IU Health system. As the sole member and controlling parent of IU Health North 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 North 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. Part VI, Section B, Line 12c Conflict of Interest Policy IU Health North 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 Compen. IU Health North Hospital's Regional President is employed by IU Health, Inc. IU Health North Hospital's President is also employed by IU Health, Inc. 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 North Hospital and other related entities have a process in place to determine the compensation for the other 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 North Hospital's Articles of Incorporation are available to the public through the Indiana Secretary of State's web-site. IU Health North Hospital's conflict of interest policy is described on Form 990, Schedule O. IU Health North 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 as well as IU Health North's Form 990. Part VII, Section B, Attach 2 Comp of the Five Highest Pd Ind. Contractors The amounts paid to Messer Construction Co. totaling $27,965,031 include both goods and services associated with the construction of IU Health Joe & Shelly Schwarz Cancer Center located on the IU Health North Hospital campus. The amounts for goods vs. services were not easily separated for reporting on the 990, Part VII, Section B, Independent contractors. Part XI, Line 9 Other Changes in Net Assets or Fund Balances IU Health North Hospital recorded the following other changes in net assets or fund balances in 2019: EQUITY TRANSFER (SETTLEMENT OF DEBT): (20,942) FORM 990 PART IX LINE 11G DESCRIPTION:SHARED SERVICES/PROF. FEES TOTAL FEES:49124273 Clarian Transplant Institute Inc 950 N Meridian St Ste 800 Indianapolis IN 46204 134350599 Healthcare IN 501(c)(3) 10 IUH true 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 true IU Health Bedford Inc 950 N Meridian St Ste 300 Indianapolis IN 46204 237042323 Healthcare IN 501(c)(3) 3 IUH true IU Health Blackford Hospital Inc 950 N Meridian St Ste 300 Indianapolis IN 46204 010646166 Healthcare IN 501(c)(3) 3 IUHBMH true IU Health Bloomington Inc 950 N Meridian St Ste 300 Indianapolis IN 46204 351720796 Healthcare IN 501(c)(3) 3 IUH true IU Health BMH Foundation Inc 950 N Meridian St Ste 800 Indianapolis IN 46204 311111784 Fundraising IN 501(c)(3) 12 I IUHBMH true IU Health Care Associates Inc 950 N Meridian St Ste 300 Indianapolis IN 46204 351747218 Healthcare IN 501(c)(3) 10 IUH true IU Health Frankfort Inc 950 N Meridian St Ste 300 Indianapolis IN 46204 815174295 Healthcare IN 501(c)(3) 3 IUH true IU Health Jay Inc 950 N Meridian St Ste 300 Indianapolis IN 46204 822736786 Healthcare IN 501(c)(3) 3 IUH true IU Health Morgan Inc 950 N Meridian St Ste 800 Indianapolis IN 46204 273533027 Healthcare IN 501(c)(3) 10 IUH true IU Health Paoli Inc 950 N Meridian St Ste 300 Indianapolis IN 46204 352090919 Healthcare IN 501(c)(3) 3 IUH true IU Health Plans NFP Inc 950 N Meridian St Ste 800 Indianapolis IN 46204 463803873 Insurance IN 501(c)(4) N/A IUH true IU Health Tipton Hospital Inc 950 N Meridian St Ste 300 Indianapolis IN 46204 262772226 Healthcare IN 501(c)(3) 3 IUH true IU Health West Hospital Inc 950 N Meridian St Ste 300 Indianapolis IN 46204 351814660 Healthcare IN 501(c)(3) 3 IUH true IU Health White Memorial Hospital Inc 950 N Meridian St Ste 300 Indianapolis IN 46204 273532963 Healthcare IN 501(c)(3) 3 IUH true IUHLP Liquidation Inc 950 N Meridian St Ste 800 Indianapolis IN 46204 351125434 Healthcare IN 501(c)(3) 10 IUH true IUHLP-P Liquidation Inc 950 N Meridian St Ste 800 Indianapolis IN 46204 311070868 Healthcare IN 501(c)(3) 10 IUHLP true MDwise Marketplace Inc 950 N Meridian St Ste 800 Indianapolis IN 46204 465270582 Insurance IN 501(c)(4) N/A IUH true MDwise Network Inc 950 N Meridian St Ste 800 Indianapolis IN 46204 472619552 Insurance IN 501(c)(4) N/A IUH true IU Health Foundation Inc 1633 N Capitol Ave Ste 1200 Indianapolis IN 46202 356043086 Fundraising IN 501(c)(3) 12 I IUH true Methodist Health Group Inc 950 N Meridian St Ste 800 Indianapolis IN 46204 350876390 Healthcare IN 501(c)(3) 12 III-FI NA false Methodist Occup Health Centers Inc 950 N Meridian St Ste 300 Indianapolis IN 46204 351844176 Healthcare IN 501(c)(3) 3 IUH true Riley Cheer Guild Inc 705 Riley Hospital Dr Indianapolis IN 46202 356018517 Fundraising IN 501(c)(3) 12 III-FI NA false University Family Physicians Inc 950 N Meridian St Ste 800 Indianapolis IN 46204 237427350 Healthcare IN 501(c)(3) 10 IUHCA true Indiana Health Info Exchange Inc 846 N Senate Ave Indianapolis IN 46202 364550324 Healthcare IN 501(c)(3) 12 I NA false IU Medical Group Foundation Inc 340 W 10th St No FS5100 Indianapolis IN 46202 201093251 Fundraising IN 501(c)(3) 12 II NA false Ball Outpatient Sur Ctr LLC 569 Brookwood Village Ste 901 Birmingham AL 35244 270275794 Healthcare IN NA Beltway Surgery Centers LLC 569 Brookwood Village Ste 901 Birmingham AL 35244 352072586 Healthcare IN NA BOSC Holdings LLC 950 N Meridian St Ste 800 Indianapolis IN 46204 454147343 Healthcare IN NA BSC Holdings LLC 950 N Meridian St Ste 800 Indianapolis IN 46204 452314634 Healthcare IN NA CHV Fund I LLC 950 N Meridian St Ste 800 Indianapolis IN 46204 262523206 Venture Capit IN NA CHV Fund II Management LLC 950 N Meridian St Ste 800 Indianapolis IN 46204 371717823 Venture Capit IN NA CHV Fund II LLC 950 N Meridian St Ste 800 Indianapolis IN 46204 800902337 Venture Capit IN NA CHV Fund Management LLC 950 N Meridian St Ste 800 Indianapolis IN 46204 262523151 Venture Capit IN NA Health Venture Management LLC 950 N Meridian St Ste 800 Indianapolis IN 46204 205740218 Management IN NA IEC Holdings LLC 950 N Meridian St Ste 800 Indianapolis IN 46204 454148032 Healthcare IN NA Indiana Endoscopy Centers LLC 569 Brookwood Village Ste 901 Birmingham AL 35244 208398421 Healthcare IN NA ROC Surgery LLC 569 Brookwood Village Ste 901 Birmingham AL 35244 271497960 Healthcare IN NA ROCS Holdings LLC 950 N Meridian St Ste 800 Indianapolis IN 46204 454148369 Healthcare IN NA Senate St Surgery Center LLC 569 Brookwood Village Ste 901 Birmingham AL 35244 421709357 Healthcare IN NA SSSC Holdings LLC 950 N Meridian St Ste 800 Indianapolis IN 46204 454148167 Healthcare IN NA SSC Holdings LLC 950 N Meridian St Ste 800 INDIANPAOLIS IN 46204 464472887 Healthcare IN NA Eagle High Surg Center LLC 569 Brookwood Village Ste 901 Birmingham AL 35244 352259204 Healthcare IN NA EHSC Holdings LLC 950 N Meridian St Ste 800 Indianapolis IN 46204 454147879 Healthcare IN NA EWASC Holdings LLC 950 N Meridian St Ste 800 Indianapolis IN 46204 473087761 Healthcare IN NA IUH EWA Surgery Ctr LLC 569 Brookwood Village Ste 901 Birmingham AL 35244 473102482 Healthcare IN NA IUH Saxony Surgery Ctr LLC 569 Brookwood Village Ste 901 Birmingham AL 35244 275271091 Healthcare IN NA IU HEALTH FORT WAYNE LLC 950 N Meridian St Ste 800 INDIANAPOLIS IN 46204 831224627 HEALTHCARE IN NA CHV Capital Inc 950 N Meridian St Ste 800 Indianapolis IN 46204 260752507 Venture Capit IN NA C true IU Health 457(B) Plan 1100 N Market St Wilmington DE 19890 476948347 Investments DE NA T true IU Health ACO Inc 950 N Meridian St Ste 800 Indianapolis IN 46204 454421020 Healthcare IN NA C true IU Health Board Designated Trust 400 Howard St San Francisco CA 94105 306309021 Investments CA NA T true IU Health NTGI S&P500 Fund CF PO Box 804358 Chicago IL 60680 306298263 Investments IL NA T true IU Health Plans Holding Company Inc 950 N Meridian St Ste 800 Indianapolis IN 46204 463794815 Insurance IN NA C true IU Health Plans Insurance Company 950 N Meridian St Ste 800 Indianapolis IN 46204 811097215 Insurance IN NA C true IU Health Plans Inc 950 N Meridian St Ste 800 Indianapolis IN 46204 262127080 HMO IN NA C true IU Health Risk Purchasing Group Inc 151 Meeting St Ste 301 Charleston SC 29401 260202446 Insurance IN NA C true IU Health Risk Retention Group Inc 151 Meeting St Ste 301 Charleston SC 29401 201107674 Insurance SC NA C true IUH Assurance SPC Ltd PO BOX 69 94 SOLARIS AVE CAMANA BAY GRAND CAYMAN CJ 980395429 Insurance CJ NA C true Proteuo Fund LP PO BOX 31106 89 NEXUS WAY CAMANA BAY GRAND CAYMAN CJ 981075227 Investments CJ NA C true SCANS Inc 950 N MERIDIAN ST STE 800 INDIANAPOLIS IN 46204 453080392 Healthcare IN NA C true BMH Medical Pavilion Association Inc 2525 W University Ave Muncie IN 47303 351858408 Condo Management IN NA C true Cardinal Health Ventures Inc 950 N Meridian St Ste 800 Indianapolis IN 46204 351611424 Management IN NA C true IU Health Southern IN Physicians Inc 950 N Meridian St Ste 300 Indianapolis IN 46204 351913875 Healthcare IN NA C true Cerberus Residential Opport Inst Ltd 190 Elgin Avenue George Town George Town Grand Cayman CJ 000000000 Investments CJ NA C true false false true false true false false false false true true true true false true false false true false IU Health Care Associates Inc J 427555 FMV IU Health Care Asscociates Inc L 362225 FMV IU Health Care Asscociates Inc M 11019468 FMV Methodist Occupational Health Centers Inc M 133680 FMV IU Health Care Asscociates Inc O 100953 FMV IU Health Tipton Hospital Inc O 1137449 FMV IU HEALTH WEST HOSPITAL INC O 101743 FMV IUH ASSURANCE SPC LTD R 513079 FMV IU Health Risk Retention Group Inc R 797135 FMV IU HEALTH FOUNDATION INC C 87058 FMV IU HEALTH WHITE MEMORIAL HOSPITAL INC E 1712285 FMV IU HEALTH ARNETT INC E 1546637 FMV