2018-04-30T08:17:00-05:00 2017-06-30 410746749 CLIFTONLARSONALLEN LLP 600 WASHINGTON AVENUE SUITE 1800 ST LOUIS MO 63101 990 2016-07-01 237426289 HARRISBURG MEDICAL CENTER HARR 6182537671 100 DR WARREN TUTTLE DRIVE HARRISBURG IL 62946 JUNE HAYES CHIEF FINANCIAL OFFICER 6182537671 2018-04-26 1 JEFF PARKER P00970069 3149254300 67.137.57.251 2018-04-26 12:08:10 CD P 5C592A38642564D958275A63599AC7915113978F 4264D1B680993024C276DC83B894831CF63E241F 2016 2021-01-29 14:40:06Z JUNE HAYES 100 DR WARREN TUTTLE DRIVE HARRISBURG IL 62946 69657888 0 X WWW.HARRISBURGMC.COM X 1975 IL THE MISSION OF HARRISBURG MEDICAL CENTER IS TO MAINTAIN AND IMPROVE THE HEALTH OF THE COMMUNITIES WE SERVE. 12 11 654 12 0 0 150 51927 52393269 61465955 -8300 -58666 0 228263 52385119 61687479 0 8712 0 0 33988212 34489329 0 0 0 22886898 26880697 56875110 61378738 -4489991 308741 41815143 45443478 16512539 19599394 25302604 25844084 THE MISSION OF HARRISBURG MEDICAL CENTER IS TO MAINTAIN AND IMPROVE THE HEALTH OF THE COMMUNITIES WE SERVE. 0 0 54909560 8712 61465955 IN SUPPORT OF ITS MISSION, THE HOSPITAL PROVIDES CARE TO PATIENTS AT LESS THAN ITS ESTABLISHED CHARGES FOR PATIENTS THAT MEET THE HOSPITAL'SFINANCIAL ASSISTANCE CRITERIA. BECAUSE THE HOSPITAL DOES NOT PURSUECOLLECTION OF AMOUNTS DETERMINED TO QUALIFY FOR FINANCIAL ASSISTANCE, THEY ARE NOT REPORTED IN NET PATIENT SERVICE REVENUE. CHARGES EXCLUDED FROM REVENUE UNDER THE HOSPITAL'S FINANCIAL ASSISTANCE POLICY (FAP) WERE APPROXIMATELY $3,294,000 FOR 2017. IN ADDITION, THE HOSPITAL PROVIDES SERVICES TO OTHER MEDICALLY INDIGENT PATIENTS UNDER CERTAIN GOVERNMENT-REIMBURSED PUBLIC AID PROGRAMS. SUCH PROGRAMS PAY PROVIDERS AMOUNTS WHICH ARE LESS THAN ESTABLISHED CHARGES FOR THE SERVICES PROVIDED TO THE RECIPIENTS AND MANY TIMES THE PAYMENTS ARE LESS THAN THE COST OF RENDERING CARE. 54909560 1 1 0 1 0 0 0 0 0 0 1 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 1 0 0 0 0 0 1 0 0 1 0 0 0 0 0 1 1 1 1 0 0 1 55 0 654 1 0 0 0 0 0 0 0 0 0 0 X 12 11 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 IL X X JUNE HAYES 6182537671 100 DR WARREN TUTTLE DR HARRISBURG IL 62946 STEVE LEDBETTER BOARD CHAIR 4.00 X X 0 0 0 DENNIS MURPHY VICE-CHAIR 4.00 X X 0 0 0 TOM DAVIS SECRETARY/TREASURER 2.00 X X 0 0 0 LARRY JONES BOARD MEMBER 2.00 X 0 0 0 HAROLD WILSON BOARD MEMBER 4.00 X 0 0 0 JOAN HARPER BOARD MEMBER 2.00 X 0 0 0 MARY SUE EWING BOARD MEMBER 2.00 X 0 0 0 BENNA DAUGHERTY BOARD MEMBER 2.00 X 0 0 0 DAVID EDMISTER BOARD MEMBER 4.00 X 0 0 0 KOLBY SMITHPETERS BOARD MEMBER 2.00 X 0 0 0 MIKE WILLIAMS BOARD MEMBER 4.00 X 0 0 0 MICHAEL TISON BOARD MEMBER 4.00 X 0 0 0 JIM HAYES PAST BOARD CHAIRPERSON 2.00 X 0 0 0 DAVID DISNEY PAST BOARD CHAIRPERSON 4.00 X 0 0 0 JAMES C HENSON PAST BOARD MEMBER 2.00 X 0 0 0 RODNEY SMITH PRESIDENT/CEO 39.00 1.00 X 290063 0 23831 THERESA JUNE HAYES VICE-PRESIDENT/CFO 40.00 X 178477 0 16087 CINDY FORD VICE-PRESIDENT/CNO 40.00 X 127956 0 5811 DANIEL LAMPLEY VICE-PRESIDENT/COO 40.00 X 180586 0 13203 JAMES ALEXANDER PHYSICIAN 40.00 X 570673 0 14121 THOMAS BUCINSKI PHYSICIAN 36.00 X 331252 0 17078 SAMIR ABDO PHYSICIAN 36.00 X 284730 0 17546 CLAYTON FORD PHYSICIAN 40.00 X 280112 0 16299 KIMBALL EWELL PHYSICIAN 40.00 X 271977 0 17473 2515826 0 141449 31 0 1 0 MORTHLAND COLLEGE HEALTH SERVICES 309 WEST ST LOUIS STREET SUITE B WEST FRANKFORT IL 62896 HOSPITALISTS AND ER PHYSICIANS 2349676 MORTHLAND COLLEGE SPECIALTY PHYSICIANS 11057 COUNTRY CLUB ROAD WEST FRANKFORT IL 62896 SPECIALTY PHYSICIANS 527543 HORIZON MENTAL HEALTH MANAGEMENT PO BOX 840839 DALLAS TX 752840839 MANAGEMENT COMPANY FOR BEHAVIORAL HEALTH 344229 SELECT PSYCHIATRIC MGMT GROUP 112 AIRWAY DRIVE MARION IL 62959 MEDICAL DIRECTORSHIP/CALL COVERAGE PSYCH 307365 BARTON ASSOCIATES 300 JUBILEE DRIVE PEABODY MA 01960 MEDICAL STAFFING 302269 9 50000 1927 51927 PATIENT SERVICE REVENUE 624110 61337152 61337152 RENT REVENUE 624100 128803 128803 61465955 45159 45159 7866584 7937906 32503 -71322 -32503 -103825 -103825 CAFETERIA REVENUE 624110 112547 112547 OTHER MISCELLANEOUS 624100 105645 105645 COIN MACHINES & TV 624100 5196 5196 4875 4875 228263 61687479 61465955 0 169597 X 8712 8712 886661 886661 24811161 23175459 1635702 747027 673703 73324 6290918 5673435 617483 1753562 1581442 172120 49750 49750 7741837 6939344 802493 354710 460 354250 4269913 3506101 763812 672137 665358 6779 166960 142038 24922 35058 24158 10900 454814 453014 1800 2643257 2643257 888375 888375 MEDICAL SUPPLIES 3115124 3115124 0 BAD DEBT EXPENSE 2763200 2763200 0 PHARMACY SUPPLIES 2756250 2756250 0 FOOD & DIETARY 335029 329454 5575 634283 459051 175232 61378738 54909560 6469178 0 3076858 49361 501387 1307852 8838076 13066859 14572 59351 362116 261523 1212919 1434511 932545 897410 50064602 24363738 22672998 25700864 3984064 2619843 122625 96983 45904 41815143 45443478 6420240 5869551 12455120 10092299 1274723 16512539 19599394 X 25302604 25844084 25302604 25844084 41815143 45443478 308741 232739 0 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 18791 18791 0 PART II-B, LINE 1: THE HOSPITAL PAYS MEMBERSHIP DUES TO THE ILLINOIS HEALTH AND HOSPITAL ASSOCIATION (IHA) AND THE AMERICAN HOSPITAL ASSOCIATION (AHA), A PERCENTAGE OF THESE DUES IS SPENT ON LOBBYING ACTIVITIES BY THESE ASSOCIATIONS. 810438 810438 27222357 12962502 14259855 882870 533431 349439 16042650 10867805 5174845 5106287 5106287 25700864 X PART X, LINE 2: THE ORGANIZATION APPLIES THE INCOME TAX STANDARD FOR UNCERTAIN TAX POSITIONS. THIS STANDARD CLARIFIES THE ACCOUNTING FOR UNCERTAINTY IN INCOME TAXES RECOGNIZED IN AN ORGANIZATION'S FINANCIAL STATEMENTS IN ACCORDANCE WITH THE INCOME TAX STANDARD. THIS STANDARD PRESCRIBES RECOGNITION AND MEASUREMENT OF TAX POSITIONS TAKEN OR EXPECTED TO BE TAKEN ON A TAX RETURN THAT ARE NOT CERTAIN TO BE REALIZED. THE ORGANIZATION DOES NOT CURRENTLY INCLUDE AN INCOME TAX PROVISION IN THE CONSOLIDATED FINANCIAL STATEMENTS. MANAGEMENT MONITORS THE REPORTING OF UNCERTAIN TAX POSITIONS, WHICH COULD RESULT IN RECORDING OF AN INCOME TAX PROVISION IN THE FUTURE. 1 1 X 1 X 1 X 1 1 0 0 1123582 1123582 0.01830 19068412 9488591 9579821 0.15610 20191994 9488591 10703403 0.17440 20191994 9488591 10703403 0.17440 1 2763200 921067 12732806 20503705 -7770899 X 1 1 1 1 HARRISBURG MEDICAL CENTER 100 DR WARREN TUTTLE DRIVE HARRISBURG IL 62946 WWW.HARRISBURGMC.COM 521 X X X HARRISBURG MEDICAL CENTER 1 0 0 1 X X X X X X X X X 15 1 0 0 1 X SEE PART V, PAGE 8 X 1 16 1 SEE PART V, PAGE 8 0 1 X 200.000000000000 300.000000000000 X X X X 1 1 X X X X 1 X SEE FOLLOWING NOTE FOR FULL URL FOR FINANCIAL ASSISTANCE POLICY X SEE FOLLOWING NOTE FOR FULL URL FOR FAP APPLICATION X SEE FOLLOWING NOTE FOR FULL URL FOR FAP PLAIN LANGUAGE SUMMARY X X X X X 1 X 0 X X X X 1 X 0 0 HARRISBURG MEDICAL CENTER PART V, SECTION B, LINE 5: A SURVEY OF COMMUNITY MEMBERS WAS DEVELOPED THAT ASKED SEVERAL QUESTIONS RELATED TO INDIVIDUAL HEALTH AND ACCESS TO CARE, HEALTH SERVICES CHALLENGES AND RISK FACTORS. THE ORGANIZATION ASKED AREA PHYSICIANS ABOUT THEIR THOUGHTS, CONCERNS AND IDEAS ABOUT THE HEALTH OF THE COMMUNITY AND THEIR PATIENTS VIA HARD COPY SURVEY. HMC ALSO FACILITATED A FOCUS GROUP MEETING WITH KEY COMMUNITY MEMBERS REPRESENTING BROAD INTERESTS OF THE COMMUNITY. INVITATION WAS BASED ON THE INDIVIDUAL'S KNOWLEDGE OF AND INTEREST IN COMMUNITY HEALTH ISSUES AFFECTING THE ORGANIZATION'S PRIMARY SERVICE AREA. HMC ALSO ANALYZED DATA FROM OTHER AREA AGENCIES' COMMUNITY ASSESSMENTS. HARRISBURG MEDICAL CENTER PART V, SECTION B, LINE 11: THE TOP THREE PRIORITY HEALTH NEEDS IDENTIFIED FOR HARRISBURG MEDICAL CENTER THAT ARE ADDRESSED IN THE IMPLEMENTATION PLAN ARE:1) MENTAL HEALTH:FOCUS ON ACCESS TO AND TREATMENT OF INDIVIDUALS HAVING MENTAL HEALTH ISSUES OTHER THAN THE EMERGENCY ROOM.2) CHRONIC DISEASES:ENCOURAGE HEALTHY LIFESTYLES AND PROVIDE EDUCATIONAL ACTIVITIES TO ELEMENTARY SCHOOL AGE CHILDREN TO HELP PREVENT CONGESTIVE HEART FAILURE (CHF) AND CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD), DIABETES, AND OBESITY IN LATER LIFE.3) SUBSTANCE ABUSE: FOCUS ON THE DEVELOPMENT OF A HOSPITAL PROVIDED INPATIENT MEDICAL STABILIZATION RELATED WITHDRAWAL FROM SUBSTANCE ABUSE/ADDICTION AND A STRONG OUTPATIENT NETWORK OF PROGRAMS AND PROVIDERS FOR TREATMENT OF PATIENTS WITH SUBSTANCE ABUSE/ADDICTION RELATED TO DRUGS AND ALCOHOL. HARRISBURG MEDICAL CENTER PART V, SECTION B, LINE 13H: IF A PATIENT MEETS THE PRESUMPTIVE ELIGIBILITY CATEGORIES LISTED BELOW, THE PATIENT SHALL NOT BE REQUIRED TO COMPLETE THE FINANCIAL ASSISTANCE APPLICATION AND SHALL BE DEEMED TO RECEIVE A 100% ALLOWANCE. PRESUMPTIVE ELIGIBILITY CATEGORIES:1. HOMELESSNESS-WHICH IS DEFINED AS AN INDIVIDUAL WITHOUT PERMANENT HOUSING WHO MAY LIVE ON THE STREETS, STAY IN A SHELTER, MISSION, SINGLE ROOM OCCUPANCY FACILITIES, ABANDONED BUILDING OR VEHICLE, OR IN ANY OTHER UNSTABLE OR NON-PERMANENT SITUATION.2. DECEASED WITH NO ESTATE.3. MENTAL INCAPACITATION WITH NO REPRESENTATIVE.4. MEDICAID ELIGIBLE BUT NOT ON DATE OF SERVICE.5. MEDICAID ELIGIBLE ON DATE OF SERVICE, BUT THE SERVICE IS NON-COVERED (I.E. HOSPITAL INPATIENT CO-PAYS, NONCOVERED DAYS, NON-COVERED CHARGES AND SPENDDOWN AMOUNTS. NOTE: THIS DOES NOT INCLUDE OFFICE CO-PAY AMOUNTS).6. INCARCERATION IN A PENAL INSTITUTION. SCHEDULE H, PART V, SECTION B, LINE 16A THE FAP WAS WIDELY AVAILABLE AT:HTTP://WWW.HARRISBURGMC.COM/WP-CONTENT/UPLOADS/2018/02/FINANCIAL-ASSISTANCE-POLICY-AND-GUIDELINES.PDF SCHEDULE H, PART V, SECTION B, LINE 16B THE FAP APPLICATION WAS WIDELY AVAILABLE AT:HTTP://WWW.HARRISBURGMC.COM/WP-CONTENT/UPLOADS/2017/05/FAP-SUMMARY_APP-4-1-17.PDF SCHEDULE H, PART V, SECTION B, LINE 16C THE FAP PLAIN LANGUAGE SUMMARY WAS WIDELY AVAILABLE AT:HTTP://WWW.HARRISBURGMC.COM/WP-CONTENT/UPLOADS/2017/05/FAP-SUMMARY_APP-4-1-17.PDF SCHEDULE H, PART V, SECTION B, LINE 7A THE ORGANIZATION'S MOST RECENT CHNA REPORT CAN BE FOUND AT:WWW.HARRISBURGMC.COM/WP-CONTENT/UPLOADS/2016/11/COMMUNITY-HEALTH-NEEDS-ASSESSMENT.PDF SCHEDULE H, PART V, SECTION B, LINE 10A THE ORGANIZATION'S MOST RECENTLY ADOPTED IMPLEMENTATION STRATEGY CAN BE FOUND WITH ITS CHNA REPORT AT:WWW.HARRISBURGMC.COM/WP-CONTENT/UPLOADS/2016/11/COMMUNITY-HEALTH-NEEDS-ASSESSMENT.PDF 9 1 - HMC CLINIC AT HARRISBURG 901 S COMMERCIAL HARRISBURG IL 62946 PRIMARY CARE CLINIC 2 - ELDORADO PRIMARY CARE 1007 US HIGHWAY 45 ELDORADO IL 62930 PROVIDER BASED RURAL HEALTH CLINIC 3 - EQUALITY FAMILY PRACTICE 183 WEST LANE EQUALITY IL 62934 PROVIDER BASED RURAL HEALTH CLINIC 4 - HMC CLINIC AT MARION 3106 OUTER DRIVE MARION IL 62959 PRIMARY CARE CLINIC 5 - GALATIA PRIMARY CARE 124 EAST MAIN GALATIA IL 62935 PROVIDER BASED RURAL HEALTH CLINIC 6 - MACH MINE CLINIC 16468 LIBERTY SCHOOL ROAD MARION IL 62959 PRIMARY CARE CLINIC 7 - VIKING MINE CLINIC 13643 NORTH THOMPSONVILLE ROAD MACEDONIA IL 62860 PRIMARY CARE CLINIC 8 - HMC SPECIALTY CLINIC 20 DR WARREN TUTTLE DRIVE HARRISBURG IL 62946 SPECIALTY MEDICINE CLINIC 9 - HMC ORTHOPAEDIC CLINIC 50 DR WARREN TUTTLE DRIVE HARRISBURG IL 62946 ORTHOPAEDIC MEDICINE CLINIC PART I, LINE 3C: HOMELESSNESS, DECEASED WITH NO ESTATE, MENTAL INCAPACITATION WITH NO REPRESENTATIVE, MEDICAID ELIGIBLE BUT NOT ON DATE OF SERVICE, MEDICAID ELIGIBLE ON DATE OF SERVICE, BUT SERVICE IS NON-COVERED, AND INCARCERATION IN A PENAL INSTITUTION QUALIFY A PATIENT UNDER THE PRESUMPTIVE ELIGIBILITY RULES FOR FINANCIAL ASSISTANCE. PART I, LINE 7: THE ORGANIZATION USED A COST-TO-CHARGE RATIO AS CALCULATED UTILIZING DATA FROM INTERNAL ACCOUNTING RECORDS AND USING A METHODOLOGY CONSISTENT WITH SCHEDULE H INSTRUCTIONS TO DETERMINE AMOUNTS ON LINES 7A AND 7B OF PART I SCHEDULE H. PART I, LINE 7, COLUMN (F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $ 2,763,200. PART III, LINE 2: THE HOSPITAL CALCULATED BAD DEBT EXPENSE AT COST USING THE COST-TO-CHARGE RATIO, AS CALCULATED USING WORKSHEET 2 OF THE SCHEDULE H INSTRUCTIONS. PATIENT ACCOUNTS ARE WRITTEN OFF TO BAD DEBT ONLY AFTER ALL COLLECTION PROCEDURES HAVE BEEN EXHAUSTED AND AFTER ALL DISCOUNTS AND PAYMENTS HAVE BEEN APPLIED. PART III, LINE 3: BASED ON THE HOSPITAL'S EXPERIENCE WITH ALL ITS PATIENTS, THE ORGANIZATION ESTIMATES THAT IT IS LIKELY THAT UP TO ONE-THIRD OF ACCOUNTS WRITTEN OFF TO BAD DEBT MAY HAVE QUALIFIED FOR FINANCIAL ASSISTANCE, BUT THE PATIENT CHOSE NOT TO APPLY. THEREFORE, 33.333% OF THE BAD DEBT ADJUSTMENTS ARE INCLUDED ON PART III, LINE 3 AT COST. PART III, LINE 4: THE ORGANIZATION'S BAD DEBT EXPENSE IS EXPLAINED IN NOTE 1 OF ITS AUDITED FINANCIAL STATEMENTS:--PATIENT ACCOUNTS RECEIVABLE--THE HOSPITAL PROVIDES AN ALLOWANCE FOR BAD DEBTS BASED UPON A REVIEW OF OUTSTANDING RECEIVABLES, HISTORICAL COLLECTION INFORMATION AND EXISTING ECONOMIC CONDITIONS. PATIENT SERVICES ARE PROVIDED ON AN UNSECURED BASIS. PAYMENT IS REQUIRED UPON RECEIPT OF THE INVOICE. THE HOSPITAL BILLS THIRD-PARTY PAYERS DIRECTLY AND BILLS THE PATIENT WHEN THE PATIENT'S LIABILITY IS DETERMINED. ACCOUNTS ARE CONSIDERED DELINQUENT AND SUBSEQUENTLY WRITTEN OFF AS BAD DEBTS BASED ON INDIVIDUAL CREDIT EVALUATION AND SPECIFIC CIRCUMSTANCES OF THE ACCOUNT. AN ESTIMATED ALLOWANCE OF APPROXIMATELY $5,314,000 AND $3,893,000 WAS RECORDED AT JUNE 30, 2017 AND 2016, RESPECTIVELY. THE HOSPITAL'S ALLOWANCE FOR DOUBTFUL ACCOUNTS FOR SELF-PAY PATIENTS WAS AN AVERAGE OF 70% AND 78% OF SELF-PAY ACCOUNTS RECEIVABLE AT JUNE 30, 2017 AND 2016, RESPECTIVELY. DURING THE YEARS ENDING JUNE 30, 2017 AND 2016, THE HOSPITAL WROTE OFF APPROXIMATELY $2,763,000 AND $3,090,000, RESPECTIVELY. PART III, LINE 8: UNPAID COST OF MEDICARE REPRESENTS THE COST (DETERMINED USING THE OVERALL COST TO CHARGE RATIO) OF PROVIDING SERVICES TO PRIMARILY ELDERLY BENEFICIARIES OF THE MEDICARE PROGRAM, IN EXCESS OF PAYMENTS FOR THOSE SERVICES. IRS REVENUE RULING 69-545, WHICH ESTABLISHED THE COMMUNITY BENEFIT STANDARD FOR NONPROFIT HOSPITALS, STATES THAT IF A HOSPITAL SERVES PATIENTS WITH GOVERNMENT HEALTH BENEFITS, INCLUDING MEDICARE, THEN THIS IS AN INDICATION THAT THE HOSPITAL OPERATES TO PROMOTE THE HEALTH OF THE COMMUNITY. THIS IMPLIES THAT TREATING MEDICARE PATIENTS IS A COMMUNITY BENEFIT. PART III, LINE 9B: THE ORGANIZATION APPLIES ITS COLLECTION PRACTICES EQUALLY TO ALL PATIENTS, BOTH FAP-ELIGIBLE AND FAP NON-ELIGIBLE PATIENTS. THE PROCEDURES FOR COLLECTION ON PATIENT ACCOUNTS ARE AS FOLLOWS:A.SELF-PAY PATIENTS RECEIVE THEIR FIRST STATEMENT WITHIN TEN DAYS OF DISCHARGE. TWO WEEKS AFTER THE FIRST STATEMENT, A FOLLOW-UP TELEPHONE CALL WILL BE MADE AND THE PATIENT WILL RECEIVE STATEMENTS AND LETTERS. ANY BALANCE REMAINING ON AN ACCOUNT AFTER INSURANCE HAS PAID IS HANDLED IN THE SAME WAY.B.FOLLOW UP TELEPHONE CALLS WILL BE MADE ONCE PER MONTH.C.IF A PAYMENT PLAN IS ESTABLISHED PER THE PAYMENT PLAN POLICY, THEN THE ACCOUNT WILL BE MONITORED ACCORDING TO THE TERMS OF THE PAYMENT PLAN.D.THE HOSPITAL OFFERS PATIENTS SEVERAL PAYMENT ALTERNATIVES:1.CASH/CHECK FOR THE FULL PAYMENT2.MASTERCARD, VISA, AMERICAN EXPRESS AND DISCOVER CREDIT CARDS3.FINANCIAL ASSISTANCE - HOSPITAL PERSONNEL ARE AVAILABLE TO ANSWER QUESTIONS AND ASSIST PATIENTS WITH GATHERING INFORMATION AND DOCUMENTATION TO QUALIFY FOR THE HOSPITAL'S FINANCIAL ASSISTANCE POLICY.4.HOSPITAL SHORT TERM FINANCING - THE HOSPITAL WILL ACCEPT MONTHLY PAYMENT ARRANGEMENTS IN THOSE CIRCUMSTANCES WHERE FINANCIAL NEED IS VERIFIED BY THE BUSINESS OFFICE STAFF. THE MINIMUM MONTHLY PAYMENT AMOUNT FOR HOSPITAL ACCOUNTS IS $100 OR 1/25THOF THE ACCOUNT BALANCE, WHICHEVER IS GREATER. THE MINIMUM MONTHLY PAYMENT AMOUNT FOR CLINIC ACCOUNTS IS $25 OR 1/12TH OF THE ACCOUNT BALANCE, WHICHEVER IS GREATER. ANY VARIATIONS FROM THIS POLICY MUST BE APPROVED BY THE DIRECTOR OF PATIENT FINANCIAL SERVICES.E.AN ACCOUNT IS CONSIDERED DELINQUENT WHEN:1.NO PERSONAL PAYMENT OR REASONABLE PAYMENT ARRANGEMENTS ARE RECEIVED WITHIN 30 DAYS OF SERVICE OR 30 DAYS OF FINAL INSURANCE PAYMENT.2.THERE IS A FAILURE TO RESPOND TO PHONE CALLS AND/OR CORRESPONDENCE FOR 30 DAYS OR MORE.3.FAILURE TO COMPLY WITH THE TERMS OF A REASONABLE PAYMENT PLAN.4.STATEMENTS ARE RETURNED VIA US MAIL AND BUSINESS OFFICE IS UNABLE TO OBTAIN NEW ADDRESS INFORMATION.F.ONCE AN ACCOUNT HAS BEEN DETERMINED DELINQUENT:1.A FINAL NOTICE IS SENT TO THE PATIENT VIA US MAIL AND THE PATIENT HAS 14 DAYS TO RESPOND.2.IN THOSE CASES WHERE THE PATIENT FINANCIAL SERVICES STAFF HAS EXHAUSTED ALL REASONABLE EFFORTS TO COLLECT THE BALANCES DUE TO THE HOSPITAL, THE ACCOUNT(S) WILL BE REFERRED TO A LICENSED COLLECTION AGENCY FOR ADJUDICATION.FOR PATIENTS SPECIFICALLY SEEKING FINANCIAL ASSISTANCE THE PROCEDURES ARE AS FOLLOWS: DURING THE APPLICATION PERIOD (PRIOR TO SERVICE THOUGH THE 240TH DAY AFTER THE BILLING STATEMENT IS PROVIDED) ALL COLLECTIONS EFFORTS ARE SUSPENDED AND DOCUMENTED IN THE PATIENT'S ACCOUNT, PENDING DETERMINATION OF ELIGIBILITY. IF THE ACCOUNT HAS BEEN PLACED WITH AN OUTSIDE COLLECTION AGENCY, THE AGENCY IS NOTIFIED BY THE FINANCIAL COUNSELOR TO SUSPEND COLLECTION EFFORTS UNTIL A DETERMINATION IS MADE. THE NOTIFICATION IS ALSO DOCUMENTED IN THE PATIENT'S ACCOUNT. ALL EXTRAORDINARY COLLECTION ACTIONS ARE ALSO SUSPENDED, INCLUDING REPORTING TO CREDIT AGENCIES, SELLING THE DEBT TO A THIRD PARTY, AND COMMENCING CIVIL ACTION AGAINST THE INDIVIDUAL. PART VI, LINE 2: HOSPITAL ASSESSES HEALTHCARE NEEDS OF COMMUNITY AND HOW THE HOSPITAL MIGHTADDRESS THOSE NEEDS BY PARTICIPATING IN STRATEGIC PLANNING SESSIONS THAT INCLUDES COMMUNITY BOARD MEMBERS, PHYSICIANS AND STAFF. CEO ALSO PARTICIPATES IN STRATEGIC PLANNING SESSIONS WITH NEARBY REGIONAL HOSPITAL.CEO MEETS WITH LOCAL PROVIDERS AND ADMINISTRATORS FROM NURSING HOMES ANDOTHER LOCAL HOSPITALS TO DETERMINE HOW STRATEGIC ALLIANCES CAN BEST SERVICE OUR REGION'S PATIENTS. HOSPITAL DATA IS REVIEWED TO DETERMINE NEEDS OF PATIENTS BY ANALYZING TOP DIAGNOSES AS WELL AS RE-ADMISSION RATES AND RELATED DIAGNOSES. ALONG WITH STAFF FROM THE EMERGENCY MANAGEMENT AGENCY AND PERSONNEL FROM THE COUNTY HEALTH, LAW ENFORCEMENT, AND FIRE DEPARTMENTS, HOSPITAL STAFF PARTICIPATES IN ANNUAL REGIONAL HAZARD VULNERABILITY ASSESSMENTS TO ASSESS COMMUNITY READINESS FOR DISASTERS SUCH AS MINING ACCIDENTS, EARTHQUAKES AND TORNADOS. PART VI, LINE 3: ALL PATIENTS THAT ARE WITHOUT THIRD PARTY COVERAGE, I.E. "SELF PAY", RECEIVE A HANDOUT DURING REGISTRATION THAT DETAILS THE FINANCIAL ASSISTANCE PROGRAM. ALL PATIENT BILLING STATEMENTS FOR THE HOSPITAL INCLUDE A STATEMENT REGARDING HOW A PATIENT MAY APPLY FOR CONSIDERATION UNDER THE HOSPITAL'S FINANCIAL ASSISTANCE POLICY. SIGNAGE IS DISPLAYED IN REGISTRATION, PATIENT CARE AND BUSINESS OFFICE AREAS THAT ANNOUNCES FINANCIAL HELP WITH PATIENT BILLS FOR THOSE WHO QUALIFY. IF A PATIENT CONTACTS THE BUSINESS OFFICE WITH AN INABILITY TO MAKE PAYMENT ISSUE, HOSPITAL PERSONNEL INFORM THE PATIENT OF THE FINANCIAL ASSISTANCE PROGRAM. ONE FULL-TIME EMPLOYEE SERVES AS A FINANCIAL COUNSELOR TO HELP THE ORGANIZATION'S PATIENTS APPLY FOR GOVERNMENT FUNDED MEDICAL COVERAGE OR FOR THE HOSPITAL'S OWN FINANCIAL ASSISTANCE PROGRAM. PART VI, LINE 4: THE COMMUNITIES SERVED BY HARRISBURG MEDICAL CENTER ARE SALINE, GALLATIN, HARDIN, POPE AND WHITE COUNTIES. IN THE FIVE COUNTIES, THERE IS A TOTAL POPULATION OF ROUGHLY 52,000, WITH ABOUT 20% OF THE TOTAL OVER THE AGE OF 65. THIS AREA HAS EXPERIENCED DECLINING POPULATION BETWEEN 2014 AND 2016. THE RESIDENTS IN THE COUNTIES SERVED ARE PREDOMINANTLY WHITE AND THE MEDIAN INCOME RANGES FROM $39,243 IN POPE COUNTY TO A HIGH OF $43,678 IN WHITE COUNTY. AROUND 20% OF THE POPULATION LIVES IN POVERTY. UNEMPLOYMENT RATES RANGE FROM 4.4% TO 6.4%, HIGHER THAN THE NATIONAL AVERAGE OF 3.9%. THE MOST COMMON EMPLOYMENT SECTORS FOR THOSE WHO LIVE IN SALINE COUNTY ARE HEALTHCARE AND SOCIAL ASSISTANCE, RETAIL TRADE AND EDUCATIONAL SERVICES. HARRISBURG MEDICAL CENTER'S ENTIRE SERVICE AREA IS CONSIDERED A FEDERALLY DESIGNATED MEDICALLY UNDERSERVED AREA. PART VI, LINE 5: HARRISBURG MEDICAL CENTER REGULARY PROVIDES FREE OR LOW-COST HEALTH SCREENINGS AND HEALTH EDUCATION PROGRAMS TO THE GENERAL PUBLIC ON A VARIETY OF TOPICS, INCLUDING ARTHRITIS, MENTAL HEALTH, CANCER AND NUTRITION. HMC PROVIDES OTHER SERVICES AT NO COST TO PROMOTE THE HEALTH OF OUR COMMUNITY , SUCH AS CAREGIVER SUPPORT GROUPS, EARLY CHILDHOOLD NUTRITION COUNSELING, TEDDY BEAR FAIRS FOR CHILDREN, AND SUPPORT GROUPS FOR PATIENTS WITH CONGESTIVE HEART FAILURE AND DIABETES. 1 ILLINOIS HOSPITAL RESEARCH & EDUCATIONAL FOUNDATION 1151 E WARRENVILLE RD PO BOX 3015 NAPERVILLE IL 60566 237421930 501(C)(3) 8712 GENERAL ASSISTANCE 1 PART I, LINE 2: THE ORGANIZATION CURRENTLY PROVIDES GRANTS TO A SINGLE RECEIPIENT, THE ILLINOIS HOSPITAL RESEARCH & EDUCATIONAL FOUNDATION (IHREF). PER ITS PUBLICLY DISCLOSED FORM 990 ON GUIDESTAR.ORG, IHREF'S MISSION IS TO PROMOTE THE CONTINUING EDUCATION OF HOSPITAL AND AND OTHER HEALTHCARE PERSONNEL, TO PROVIDE SCHOLARSHIPS TO PERSONS PURSUING HEALTHCARE CAREERS, AND TO PROVIDE GRANTS TO HOSPITALS WHICH WILL ASSIST IN THE IMPROVEMENT OF HEALTHCARE. X X X X X 0 1 0 0 0 0 0 0 0 RODNEY SMITH PRESIDENT/CEO 253161 0 11702 0 25200 0 10600 0 13231 0 313894 0 0 0 THERESA JUNE HAYES VICE-PRESIDENT/CFO 162554 0 0 0 15923 0 7127 0 8960 0 194564 0 0 0 DANIEL LAMPLEY VICE-PRESIDENT/COO 162586 0 0 0 18000 0 6810 0 6393 0 193789 0 0 0 JAMES ALEXANDER PHYSICIAN 304673 0 248000 0 18000 0 12414 0 1707 0 584794 0 0 0 THOMAS BUCINSKI PHYSICIAN 289919 0 23333 0 18000 0 13960 0 3118 0 348330 0 0 0 SAMIR ABDO PHYSICIAN 284730 0 0 0 0 0 14728 0 2818 0 302276 0 0 0 CLAYTON FORD PHYSICIAN 179633 0 100479 0 0 0 14490 0 1809 0 296411 0 0 0 KIMBALL EWELL PHYSICIAN 199285 0 72692 0 0 0 13960 0 3513 0 289450 0 0 0 PART I, LINE 4B RODNEY SMITH, NON-QUALIFIED RETIREMENT PLAN PAYMENTS: $14,197 THE NON-QUALIFIED RETIREMENT PLAN ARRANGEMENT USES A SPECIALLY DESIGNED LIFE INSURANCE CONTRACT AS THE FUNDING VEHICLE. WHILE THE CONTRACT IS JOINTLY OWNED BY BOTH RODNEY SMITH AND HARRISBURG MEDICAL CENTER, THE ARRANGEMENT IS TREATED AS A HARRISBURG MEDICAL CENTER LOAN TO RODNEY SMITH FOR TAX PURPOSES. HARRISBURG MEDICAL CENTER PAID POLICY PREMIUM CONSTITUTES THE "LOAN" UPON WHICH RODNEY SMITH MUST REPORT THE INTEREST AS INCOME. THIS INTEREST PLUS RODNEY SMITH "EQUITY TRANSFER", IF ANY, OF THE LOAN PREMIUM IS GENERALLY PAID BY HIM/HER VIA COMPENSATION BONUS. HARRISBURG MEDICAL CENTER'S NET LOAN REMAINS AN ASSET ON ITS BALANCE SHEET. THE PLAN VALUES OWNED BY RODNEY SMITH ARE MINIMAL IN THE EARLY PLAN YEARS. HOWEVER, AS RODNEY SMITH APPROACHES RETIREMENT, HARRISBURG MEDICAL CENTER GENERALLY BEGINS A SERIES OF SECONDARY COMPENSATION BONUSES THAT ENABLE RODNEY SMITH TO REDUCE THE BALANCE OF THE OUTSTANDING LOAN THROUGH EQUITY TRANSFER. THROUGH THIS PROCESS, RODNEY SMITH CAN RETIRE WITH FULL AND UNENCUMBERED OWNERSHIP OF THE POLICY. IF RODNEY SMITH LEAVES PRIOR TO RETIREMENT, HARRISBURG MEDICAL CENTER MAINTAINS A FINANCIAL INTEREST IN THE PLAN TO THE EXTENT OF THE LOAN NOT YET RELEASED TO RODNEY SMITH. A ILLINOIS FINANCE AUTHORITY 861091967 45204ETA6 2017-03-14 19500000 REFUND MORTGAGE NOTE AND FUND EXPANSION PROJECT 0 0 0 A 19500000 382353 3394967 9056277 6666403 2018 1 0 0 0 A 0 0 0 0 0.00000 0.00000 0.00000 0 0 1 A 0 1 0 0 1 0 0 0 1 A 1 SCHEDULE K, PAGE 1, PART II LINE 17 ONCE THE ORGANIZATION MAKES A FINAL ALLOCATION OF PROCEEDS, THEY WILL HAVE BOOKS AND RECORDS TO SUPPORT SUCH AN ALLOCATION. DR JAMES ALEXANDER EMPLOYEE PRACTICE WINDUP X 55259 15423 1 0 1 RODNEY SMITH EMPLOYEE LIFECOMP DOLLARFLEX PLAN X 43928 43928 0 1 1 59351 KRISTIN WILSON EMPLOYEE 25807 WAGES 0 SCHEDULE L, PART IV, LINE 1 HMC EMPLOYEE KRISTIN WILSON IS A FAMILY MEMBER OF BOARD MEMBER HAROLD WILSON. FORM 990, PART VI, SECTION B, LINE 11B DRAFT COPIES OF THE RETURN WILL BE DISTRIBUTED TO ALL BOARD MEMBERS WITH ADEQUATE TIME TO REVIEW. SPECIFIC ITEMS AND QUESTIONS WILL BE ADDRESSED FIRST WITH THE FINANCE COMMITTEE DURING A FINANCE COMMITTEE MEETING AND AGAIN WITH THE FULL BOARD AT A MONTHLY BOARD MEETING. REVISIONS WILL BE MADE AS REQUESTED AND FINAL COPY WILL BE APPROVED BY THE FULL BOARD AFTER FINANCE COMMITTEE REVIEW. FORM 990, PART VI, SECTION B, LINE 12C A CONFLICT OF INTEREST FORM IS COMPLETED AND REVIEWED ANNUALLY TO DISCLOSE ANY POSSIBLE CONFLICTS OF INTEREST. FORM 990, PART VI, SECTION B, LINE 15 THE BOARD OF DIRECTORS, WITH ASSISTANCE FROM THE DIRECTOR OF HUMAN RESOURCES, REVIEWS THE ILLINOIS HOSPITAL ASSOCIATION (IHA) EXECUTIVE COMPENSATION SURVEY, ALONG WITH THE TOP DATA PAY AND BENEFIT SURVEY TO DETERMINE THE SALARY OF CEO. THE SURVEYS ARE USED EACH YEAR TO ENSURE THAT ANNUAL INCREASES HOLD THE CEO'S COMPENSATION WITHIN THE SALARY RANGE OF CEOS OF SIMILAR SIZED HOSPITALS. THIS PROCESS OF DELIBERATION AND DECISION WAS DOCUMENTED IN BOARD MEETING MINUTES AND WAS MOST RECENTLY COMPLETED IN 2017. THE CHIEF EXECUTIVE OFFICE DETERMINES THE PROPOSED COMPENSATION OF THE CHIEF FINANCIAL OFFICER, CHIEF NURSING OFFICER, AND CHIEF EXECUTIVE OFFICER BY REVIEWING THE IHA EXECUTIVE SALARY SURVEY. COMPARISONS ARE MADE BETWEEN HMC AND HOSPITAL OF SIMILAR SIZE, REVENUE AND NUMBER OF EMPLOYEES. THE PROPOSED COMPENSATIONS ARE REVIEWED AND APPROVED BY THE BOARD OF DIRECTORS. THE SURVEY IS REVIEWED EACH YEAR TO ENSURE THAT ANNUAL INCREASES HOLD THE COMPENSATION WITHIN THE SALARY RANGE OF OFFICERS OF SIMILAR SIZED HOSPITALS. THIS PROCESS OF DELIBERATION AND DECISION WAS DOCUMENTED IN BOARD MEETING MINUTES AND WAS MOST RECENTLY COMPLETED IN 2017. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART IX, LINE 11G PURCHASED MEDICAL SERVICES: PROGRAM SERVICE EXPENSES 6,939,344. MANAGEMENT AND GENERAL EXPENSES 709,633. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 7,648,977. PROFESSIONAL FEES: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 91,897. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 91,897. OTHER MISCELLANEOUS FEES: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 963. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 963. FORM 990, PART XII, LINE 2C THE ORGANIZATION DID NOT CHANGE ITS OVERSIGHT AND SELECTION PROCESSES DURING THE YEAR. HARRISBURG MEDICAL CENTER CLINIC SERVICES LLC 100 DR WARREN TUTTLE DRIVE HARRISBURG IL 62946 452945162 HEALTHCARE IL 2586540 2847321 HARRISBURG MEDICAL CENTER HARRISBURG MEDICAL CENTER FOUNDATION 6 EAST CLARK STREET HARRISBURG IL 62946 371411984 FUNDRAISING IL 501(C)(3) LINE 12A, I HARRISBURG MEDICAL CENTER 1 0 0 1 1 0 0 0 0 0 0 0 0 0 1 1 0 1 0 0