2017-08-14T12:44:32-05:00 2016-09-30 381357951 PLANTE & MORAN PLLC 10 S Riverside Plaza 9th Floor Chicago IL 60606 990 2015-10-01 361564290 NORWEGIAN AMERICAN HOSPITAL INC NORW 7732928200 1044 NORTH FRANCISCO AVENUE CHICAGO IL 60622 GARY KRUGEL CFO 7732928200 2017-08-11 1 David Lowenthal P00378651 3122071040 2017-08-11 2015 2021-01-29 14:40:06Z JOSE R SANCHEZ 1044 NORTH FRANCISCO AVENUE CHICAGO IL 60622 124202896 0 X WWW.NAHOSPITAL.ORG X 1935 IL NORWEGIAN AMERICAN HOSPITAL PROVIDES QUALITY AND COMPASSIONATE HEALTH CARE SERVICES BY PARTNERING WITH PATIENTS AND THEIR FAMILIES, OUR EMPLOYEES, PHYSICIANS AND THE COMMUNITIES WE SERVE. 16 14 1149 59 0 0 517885 593817 119473777 123560563 99665 24729 -51872 -47342 120039455 124131767 0 0 0 0 54165228 56580974 0 0 0 62965889 63838436 117131117 120419410 2908338 3712357 107970510 109229585 74861725 68570047 33108785 40659538 X NORWEGIAN AMERICAN HOSPITAL PROVIDES QUALITY AND COMPASSIONATE HEALTH CARE SERVICES BY PARTNERING WITH PATIENTS AND THEIR FAMILIES, OUR EMPLOYEES, PHYSICIANS AND THE COMMUNITIES WE SERVE. 0 0 77508363 123560563 NORWEGIAN AMERICAN HOSPITAL IS A PREMIER HEALTH CARE PROVIDER WHERE THE PATIENT COMES FIRST. AS AN ORGANIZATION OF CAREGIVERS, NORWEGIAN AMERICAN INSPIRES TO CONSISTENTLY HIGH STANDARDS OF QUALITY, FAMILY-CENTERED HEALTH CARE SERVICES AND COST EFFECTIVENESS. NORWEGIAN AMERICAN HOSPITAL SEEKS TO PROMOTE WELLNESS WITHIN THE FAMILY AND TO BE DYNAMIC PARTNERS IN HEALTH WITH THE COMMUNITIES IT SERVES. FOR THE FISCAL YEAR ENDED SEPTEMBER 30, 2016, NORWEGIAN AMERICAN HOSPITAL ESTIMATES IT PROVIDED $2,781,106 IN CHARITY CARE COST FOR HEALTHCARE SERVICES AND SUPPLIES PROVIDED TO MEMBERS OF THE COMMUNITIES SERVED UNDER ITS CHARITY CARE POLICY. THESE MEMBERS DID NOT HAVE THE ABILITY TO PAY FOR SERVICES RECEIVED. NORWEGIAN AMERICAN ALSO PROVIDED CARE TO PATIENTS WHO ARE BENEFICIARIES OF MEDICARE, MEDICAID, BLUE CROSS AND MANAGED CARE REIMBURSEMENT PROGRAMS. REIMBURSEMENT AMOUNTS FOR THESE PROGRAMS ARE LESS THAN CHARGES AND IN SOME CASES LESS THAN COST. FOR FISCAL YEAR 2016, NORWEGIAN AMERICAN HOSPITAL SERVED 8,357 PATIENTS ADMITTED WHO RECEIVED 40,413 DAYS OF HEALTHCARE SERVICES. 77508363 1 1 0 1 0 0 0 0 0 0 1 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 1 1 1 0 0 1 81 0 1 1149 1 0 0 0 0 0 0 0 0 0 0 X 16 14 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 1 1 IL X GARY KRUGEL CFO 7732928200 1044 NORTH FRANCISCO AVENUE CHICAGO IL 60622 BILLY OCASIO CHAIRMAN 5.00 0.00 X X 0 0 0 WILMI SCHMIDT VICE-CHAIRMAN 4.00 0.00 X X 0 0 0 JOHN MONTEVERDE MD SECRETARY 8.00 0.00 X X 0 0 0 LOUIS MANETTI TREASURER 8.00 0.00 X X 0 0 0 LOUIS TINAJERO TREASURER (THRU 01/2016) 8.00 0.00 X X 0 0 0 AYMAN JABR MD TRUSTEE 2.00 0.00 X 0 0 0 FRANK O APANTAKU MD TRUSTEE 2.00 0.00 X 0 0 0 RICHARD A BLABOLI TRUSTEE 2.00 0.00 X 0 0 0 ADAM BORIS TRUSTEE 2.00 0.90 X 0 0 0 RAFAEL CAMPANINI MD TRUSTEE 2.00 0.00 X 9600 0 0 KEVIN CMUNT TRUSTEE 4.00 0.00 X 0 0 0 DAVID HERNANDEZ trustEE 2.00 0.00 X 0 0 0 CARMEN C HOVANEC TRUSTEE 2.00 0.00 X 0 0 0 MICHAEL E REED TRUSTEE 2.00 0.00 X 0 0 0 OLGA SAAVEDRA MD TRUSTEE 2.00 0.00 X 0 0 0 MIGUEL TOVAR TRUSTEE 4.00 0.00 X 0 0 0 SANDRA VALENZULA TRUSTEE 4.00 0.00 X 0 0 0 MANUEL MARTINEZ MD TRUSTEE (THRU 01/2016) 2.00 0.00 X 0 0 0 JOSE R SANCHEZ PRESIDENT AND CEO (EX-OFFICIO) 40.00 0.00 X 572896 0 161730 ABHA AGRAWAL VP, MEDICAL AFFAIRS/COO 40.00 0.00 X 445432 0 8787 GARY KRUGEL CHIEF FINANCIAL OFFICER 40.00 0.00 X 250192 0 4458 JAMES KOLKA MD CHIEF MEDICAL OFFICER (4/16-6/17) 40.00 0.00 X 0 0 0 JUSTIN BYNUM CHIEF OPERATING OFFICER (5/16-7/16) 40.00 0.00 X 0 0 0 NARAYAN RAVISHANKAR MD ANESTHESIOLOGIST 40.00 0.00 X 363463 0 15303 NATASHA T JENKINS HOSPITALIST, OB/GYN 40.00 0.00 X 315907 0 9997 MAX IZBICKI MD PHYSICIAN, OB/GYN 40.00 0.00 X 304969 0 0 JAMAL QAISER MD CHIEF HOSPITALIST 40.00 0.00 X 257032 0 13649 DAGOBERTO CAMACHO MD HOSPITALIST 40.00 0.00 X 229499 0 6954 2748990 0 220878 71 0 1 0 Quest Diagnostics 12989 Collections Center Drive Chicago IL 60693 Lab service contract 2805969 SODEXO INC & AFFILIATES 4880 PAYSPHERE CIRCLE CHICAGO IL 60674 DIETARY & FACILITIES MANAGEMENT SERVICES 2218157 US BANK CORPORATE TRUST 2501 SW 1ST AVE SUITE 200 PORTLAND OR 97201 SHIFTWISE NURSING STAFFING AGENCY 2064022 TOTAL MSP LLC 10 E COLLEGE AVE 300 APPLETON MI 54911 NURSING STAFFING AGENCY 1206141 CONTINENTAL ANESTHESIA 1301 W 22ND ST 610 OAKBROOK IL 60523 ANESTHESIA SERVICE CONTRACT 1151796 37 593817 593817 MEDICARE/MEDICAID PAYMENTS 621110 72418587 72418587 MEDICAID ASSESSMENT REVENUE 621110 20801391 20801391 NET PATIENT SERVICES 621110 18104647 18104647 ACA Access Payments 621110 8594384 8594384 OPERATING REVENUE 621110 3018642 3018642 622912 622912 123560563 30396 30396 18120 65462 -47342 -47342 -47342 5667 -5667 -5667 -5667 124131767 123560563 0 -22613 X 2188651 1239411 949240 45394537 33891543 11502994 537575 537575 5154039 4650707 503332 3306172 2544630 761542 1370980 428658 942322 49050 49050 102823 102823 8336 8336 14571469 9750899 4820570 173817 115228 58589 1589512 61670 1527842 1253705 178874 1074831 80369 32166 48203 1508632 1508632 5012255 1951957 3060298 2680463 89368 2591095 MEDICAL SUPPLIES 9171561 8787203 384358 PROVISION FOR BAD DEBT 8021062 8021062 IL MEDICAID TAX ASSESSM 7610831 7610831 Non-medical supplies 1517260 1215024 302236 9116311 4549963 4566348 120419410 77508363 42911047 0 8080779 13018638 6492228 7004362 21869359 17835071 970432 1102757 1176713 1311496 133216559 101459017 33139451 31757542 17299833 18007044 18941715 19192675 107970510 109229585 14103129 14792674 129029 0 18567547 18228413 42062020 35548960 74861725 68570047 X 31181939 38799785 1926846 1859753 33108785 40659538 107970510 109229585 X 3712357 698249 3140147 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 1 0 0 0 0 1 190000 0 1 62478 252478 0 Part II-B, Line 1: HOSPITAL REPRESENTATIVES HAVE DIRECT CONTACT WITH LEGISLATORS, THEIR STAFF, AND OFFICIALS WITHIN THE ADMINISTRATION REGARDING ISSUES RELATED TO THE PROVISION OF HEALTHCARE AND HEALTHCARE FINANCING. HOSPITAL REPRESENTATIVES HAVE ENGAGED IN DIRECT MEETINGS WITH LEGISLATORS, LEGISLATIVE STAFF, AND AGENCY STAFF. THEY HAVE ALSO HAD PHONE CONVERSATIONS AND CORRESPONDED BY EMAIL. WRITTEN COMMUNICATION IN THE FORM OF MEMOS AND LETTERS IS ALSO USED. ADDITIONALLY, A PORTION OF MEMBERSHIP DUES PAID TO THE ILLINOIS HOSPITAL ASSOCIATION AND THE METROPOLITAN HEALTHCARE COUNCIL ARE USED FOR LOBBYING PURPOSES. 4529913 4529913 66395658 48590968 17804690 3527432 3182145 345287 58112882 49685904 8426978 650674 650674 31757542 BENEFICIAL INTEREST IN NET ASSETS OF FOUNDATION 1699753 DUE FROM AFFILIATES 159321 INSURANCE RECOVERIES RECEIVABLE 4456545 INVESTMENT IN JOINT VENTURE 8934618 INVESTMENT IN SUBSIDIARY 1036874 OTHER ASSETS 1716118 PROPERTY HELD FOR FUTURE USE 1189446 19192675 ACCRUED MALPRACTICE LIABILITY 18587902 CONDITIONAL ASSET RETIREMENT OBLIGATION 2723894 NET PENSION LIABILITY 12470352 DUE TO THIRD PARTY PROGRAMS 1766812 35548960 1 1 1 X 1 X 600.000000000000 1 1 1 0 1 1 2800792 2800792 0.02490 59242500 63845762 -4603262 0.00000 62043292 63845762 -1802470 0.02490 745383 528666 216717 0.00190 706763 1056063 -349300 0.00000 1452146 1584729 -132583 0.00190 63495438 65430491 -1935053 0.02680 1 8021062 0 22833131 21353859 1479272 X 1 1 1 CENTURY PHO INC TO OBTAIN AND MANAGE CONTRACTS WITH HEALTH MAINTENANCE ORGANIZATIONS. 0.50000 0.00000 0.50000 1 1 NORWEGIAN AMERICAN HOSPITAL INC 1044 N FRANCISCO CHICAGO IL 60660 WWW.NAHOSPITAL.ORG X X NORWEGIAN AMERICAN HOSPITAL INC 0 0 1 X X X X X X X X X 14 1 0 0 1 X SEE PART V, SECTION C 1 14 1 SEE PART V, SECTION C 0 0 1 X 200.000000000000 600.000000000000 X X X X 1 1 X X 1 X SEE PART V, SECTION C X SEE PART V, SECTION C X SEE PART V, SECTION C X X X 1 X 0 X X X X 1 X 0 0 PART V, SECTION B, LINE 7A, CHNA WEBSITE: https://www.nahospital.org/wp-content/uploads/2016/01/Community-Health-Needs-Assessment-2014.pdf PART V, SECTION B, LINE 10A IMPLEMENTATION STRATEGY WEBSITE: https://www.nahospital.org/wp-content/uploads/2016/01/Community-Health-Needs-Assessment-2014.pdf PART V, SECTION B, LINE 16A, FAP WEBSITE: https://www.nahospital.org/wp-content/uploads/2015/11/Financial.pdf PART V, SECTION B, LINE 16B, FAP APPLICATION WEBSITE: https://nahospital.org/wp-content/uploads/2015/11/Financial-Assistance-Application.pdf PART V, SECTION B, LINE 16C, PLAIN LANGUAGE SUMMARY OF FAP WEBSITE: https://nahospital.org/wp-content/uploads/2015/11/Norwegian-American-Hospital-Summary-of-Assistance-Policy.pdf PART V, SECTION B, LINE 16I: PATIENTS WILL BE INFORMED OF FINANCIAL ASSISTANCE THROUGH VARIOUS METHODS. NOTICES INFORMING PATIENTS OF FINANCIAL ASSISTANCE WILL BE POSTED IN ADMISSION AND REGISTRATION AREAS. IT WILL ALSO BE PROVIDED TO PATIENTS, OR GUARANTORS, IN THEIR ADMISSION PACKET AND IN BILLING STATEMENTS. THIS INFORMATION, AND THE NOTICE POSTED IN HOSPITAL LOCATIONS, WILL BE IN ENGLISH, AND IN ANY OTHER LANGUAGE THAT IS THE PRIMARY LANGUAGE SPOKEN BY AT LEAST 5% OF THE RESIDENTS IN THE SERVICE AREA. TRANSLATIONS IN SPANISH AND POLISH CAN BE OBTAINED BY CALLING THE HOSPITAL'S PATIENT FINANCIAL SERVICES AND ARE CURRENTLY AVAILABLE ON THE HOSPITAL'S WEBSITE: HTTPS://WWW.NAHOSPITAL.ORG/PATIENTS-AND-VISITORS/FINANCIAL-ASSISTANCE/ PART V, SECTION B, LINE 22D: THE HOSPITAL DETERMINES THE MAXIMUM AMOUNT THAT CAN BE CHARGED TO THE FAP-ELIGIBLE INDIVIDUALS BY CALCULATING THE UNINSURED PATIENT DISCOUNT AMOUNT AND APPLYING IT TO PATIENT ACCOUNT. THE DISCOUNT AMOUNT IS CALCULATED BY SUBTRACTING FROM 100% THE PRODUCT OF THE HOSPITAL'S COST TO CHARGE RATIO (FROM WORKSHEET C PART 1 FROM THE MEDICARE COST REPORT) AND 135% (MEDICARE COST ALLOWED TO CHARGE TO UNINSURED PATIENTS). NORWEGIAN AMERICAN HOSPITAL'S UNINSURED DISCOUNT FOR FY 2016 IS 61% AS ROUNDED UP FROM THE CALCULATION AS SHOWN BELOW. 2016 COST TO CHARGE RATIO = 28.93%28.93% X 135% = 39.06%100% - 39.06% = 60.94% Part I, Line 3c: NORWEGIAN AMERICAN HOSPITAL USES THE FPG TO DETERMINE FREE AND DISCOUNTED CARE. PATIENTS WITH ELIGIBLE ASSETS AND INCOME ABOVE THE 200%, BUT NOT EXCEEDING 600% OF FPG, ADJUSTED FOR FAMILY SIZE, WILL RECEIVE A DISCOUNT ON MEDICALLY NECESSARY SERVICES PROVIDED TO THEM, BASED UPON A SLIDING SCALE ESTABLISHED BY HOSPITAL POLICY. Part I, Line 7: THE COSTING METHODOLOGY USED TO CALCULATE THE AMOUNTS REPORTED ON LINES 7A AND 7B IS THE COST-TO-CHARGE RATIO DERIVED FROM THE IRS'S SCHEDULE H, WORKSHEET 2 INSTRUCTIONS. NORWEGIAN AMERICAN HOSPITAL USED ITS INTERNAL ACCOUNTING RECORDS TO CALCULATE THE AMOUNTS REPORTED IN LINES 7E AND 7F.MANAGEMENT DOES NOT CONCUR WITH WORKSHEET 3 INSTRUCTIONS IN REGARDS TO INCLUDING THE PROVIDER TAX EXPENSES IN WITH COLUMN (C) TOTAL COMMUNITY BENEFIT EXPENSE, AS WELL AS INCLUDING THE PROVIDER TAX REVENUE IN COLUMN (D) DIRECT OFFSETTING REVENUE. IF THESE WERE REMOVED FROM THE WORKSHEET 3 CALCULATION, NET COMMUNITY BENEFIT EXPENSE ON LINE 7B, COLUMN (E) WOULD HAVE BEEN $8,587,298 OR 7.67 PERCENT OF TOTAL EXPENSE. THIS WOULD HAVE INCREASED THE TOTAL NET COMMUNITY BENEFIT EXPENSE ON LINE 7K, COLUMN (E) FROM ($1,935,053) TO $11,255,601 OR 10.05 PERCENT OF TOTAL EXPENSE. Part I, Line 7g: NORWEGIAN AMERICAN HOSPITAL DID NOT INCLUDE ANY COSTS ATTRIBUTABLE TO A PHYSICIAN CLINIC AS SUBSIDIZED HEALTH SERVICES. PART I, LINE 7, COLUMN (G):THERE WAS A TOTAL OF BAD DEBT EXPENSE OF $8,021,062 SUBTRACTED FROM TOTAL EXPENSES. Part III, Line 2: THE BAD DEBT EXPENSE REPORTED ON PART III, LINE 2, IS THE BAD DEBT EXPENSE REPORTED ON FORM 990, PART IX. Part III, Line 3: ALL OF THE HOSPITAL'S PATIENTS AUTOMATICALLY QUALIFY FOR FINANCIAL ASSISTANCE IF THEY DO NOT HAVE INSURANCE (THEY ARE CONSIDERED "SELF-PAY AND GIVEN 65% DISCOUNT). ONCE THE HOSPITAL DETERMINES THAT A PATIENT HAS NO INSURANCE, THEY AUTOMATICALLY DISCOUNT THE BILL BY 65%. SO THERE ARE NO INDIVIDUALS THAT MAY HAVE BEEN ELIGIBLE FOR FINANCIAL ASSISTANCE AND DID NOT RECEIVE ANY. BAD DEBT EXPENSE IS ATTRIBUTABLE TO PATIENTS WITH INSURANCE THAT MAY NOT HAVE PAID THEIR SHARE/CO-PAY OF THE BILL OR ATTRIBUTABLE TO PATIENTS THAT RECEIVED FINANCIAL ASSISTANCE (65% DISCOUNT) BUT DID NOT PAY THEIR 40%. THEREFORE, ZERO HAS BEEN REPORTED IN PART III, LINE 3. Part III, Line 4: AUDITED FINANCIAL STATEMENTS FOOTNOTE REGARDING BAD DEBT EXPENSE: ACCOUNTS RECEIVABLE FOR PATIENTS, INSURANCE COMPANIES, AND GOVERNMENTAL AGENCIES ARE BASED ON GROSS CHARGES. AN ALLOWANCE FOR CONTRACTUAL ADJUSTMENTS AND INTERIM PAYMENT ADVANCES IS BASED ON EXPECTED PAYMENT RATES FROM PAYORS BASED ON CURRENT REIMBURSEMENT METHODOLOGIES. THIS AMOUNT ALSO INCLUDES AMOUNTS RECEIVED AS INTERIM PAYMENTS AGAINST UNPAID CLAIMS BY CERTAIN PAYORS. IN EVALUATING THE COLLECTIBILITY OF ACCOUNTS RECEIVABLE, THE HOSPITAL ANALYZES ITS PAST HISTORY AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYOR SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND PROVISION FOR BAD DEBTS. MANAGEMENT REGULARLY REVIEWS DATA ABOUT THESE MAJOR PAYOR SOURCES OF REVENUE IN EVALUATING THE SUFFICIENCY OF THE ALLOWANCE FOR DOUBTFUL ACCOUNTS.FOR RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE THIRD-PARTY COVERAGE, THE HOSPITAL ANALYZES CONTRACTUALLY DUE AMOUNTS AND PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS AND A PROVISION FOR BAD DEBTS, IF NECESSARY (FOR EXAMPLE, FOR EXPECTED UNCOLLECTIBLE DEDUCTIBLES AND COPAYMENTS ON ACCOUNTS FOR WHICH THE THIRD PARTY PAYOR HAS NOT YET PAID, OR FOR PAYORS WHO ARE KNOWN TO BE HAVING FINANCIAL DIFFICULTIES THAT MAKE THE REALIZATION OF AMOUNTS DUE UNLIKELY).FOR RECEIVABLES ASSOCIATED WITH SELF-PAY PATIENTS (WHICH INCLUDES BOTH PATIENTS WITHOUT INSURANCE AND PATIENTS WITH DEDUCTIBLE AND COPAYMENT BALANCES DUE FOR WHICH THIRD PARTY COVERAGE EXISTS FOR PART OF THE BILL), THE HOSPITAL RECORDS A SIGNIFICANT PROVISION FOR BAD DEBTS IN THE PERIOD OF SERVICE ON THE BASIS OF ITS PAST EXPERIENCE, WHICH INDICATES THAT MANY PATIENTS ARE UNABLE OR UNWILLING TO PAY THE PORTION OF THEIR BILL FOR WHICH THEY ARE FINANCIALLY RESPONSIBLE. THE DIFFERENCE BETWEEN THE STANDARD RATES (OR THE DISCOUNTED RATES IF NEGOTIATED) AND THE AMOUNTS ACTUALLY COLLECTED AFTER ALL REASONABLE COLLECTION EFFORTS HAVE BEEN EXHAUSTED IS CHARGED OFF AGAINST THE ALLOWANCE FOR DOUBTFUL ACCOUNTS IN THE PERIOD THEY ARE DETERMINED TO BE UNCOLLECTIBLE.PART III, LINE 6: MANAGEMENT DOES NOT CONCUR WITH PART III, SECTION B MEDICARE, LINE 6 REPORTING INSTRUCTIONS REGARDING UTILIZING ALLOWABLE COSTS FROM MEDICARE WORKSHEET B. IF MANAGEMENT USED THE ACTUAL AMOUNT OF COSTS TO CARE FOR MEDICARE PATIENTS, ALLOWABLE COSTS WOULD HAVE BEEN REPORTED AS $32,864,010 AND THE AMOUNT OF (SHORTFALL) WOULD HAVE BEEN ($10,030,879). Part III, Line 8: COSTING METHODOLOGY USED IS THE MEDICARE COST REPORT WHICH UTILIZES A STEP-DOWN METHOD OF COST ALLOCATION. THIS ORDER OF ALLOCATION FOR OVERHEADS HAS BEEN PREDETERMINED BY MEDICARE AND IS PRINTED OUT ON THE COST REPORT. THE MOST COMMON OVERHEAD IS ALLOCATED FIRST TO ALL OTHER OVERHEADS AND THE PATIENT CARE COST CENTERS. THEN THAT COST CENTER IS CLOSED AND THE NEXT MOST COMMON OVERHEAD IS ALLOCATED. THIS IS CONTINUED UNTIL ALL THE OVERHEADS ARE ALLOCATED OUT. THE SEPTEMBER 30, 2016 COST REPORT DID NOT SHOW A SHORTFALL. Part III, Line 9b: THE COLLECTION POLICIES CONTAIN PROVISIONS ON THE COLLECTIONS PRACTICES TO BE FOLLOWED FOR PATIENTS THAT QUALIFY FOR FINANCIAL ASSISTANCE. SUCH PRACTICES ARE: CHARITY - UPON APPROVAL OF PATIENT'S CHARITY APPLICATION THE COLLECTIONS ARE STOPPED, PATIENT'S BALANCE IS WRITTEN OFF ACCORDINGLY AND PATIENT IS NOTIFIED IN WRITING; UNINSURED PATIENT - UPON DETERMINATION THAT PATIENT HAS NO INSURANCE, 65% DISCOUNT IS APPLIED TO PATIENT ACCOUNT AND PATIENT IS NOTIFIED IN WRITING FOR THE OUTSTANDING BALANCE. Part VI, Line 2: NORWEGIAN AMERICAN HOSPITAL'S COMMUNITY BENEFIT PLAN WAS DEVELOPED TO ESTABLISH STRATEGIES FOR IMPROVING ACCESS TO CARE AND POSITIVELY AFFECTING THE HEALTH OF THE COMMUNITIES THAT IT SERVES. ADDITIONALLY, THE PLAN SETS THE COURSE FOR STRENGTHENING EXISTING PARTNERSHIPS AND BUILDING NEW ONES WITH INDIVIDUALS AND ORGANIZATIONS WITHIN NORWEGIAN AMERICAN HOSPITAL'S PRIMARY SERVICE AREAS IN ORDER TO LEVERAGE AND MAXIMIZE THE IMPACT OF ITS PROGRAMS. DEVELOPMENT OF THE PLAN IS DERIVED THROUGH THE STRATEGIC PLANNING OF NORWEGIAN AMERICAN HOSPITAL'S BOARD OF TRUSTEES AND THROUGH ORGANIZATIONAL INVOLVEMENT IN COMMUNITY PARTNERSHIPS. THE GOALS DEVELOPED FOR PLANNING COMMUNITY SERVICES INVOLVED MEETING WITH PHYSICIANS AND COMMUNITY PARTNERS TO DETERMINE WHERE THE GAPS OF CARE AND SERVICES COULD BE FILLED THROUGH NORWEGIAN AMERICAN HOSPITAL INVOLVEMENT. IN DEVELOPING ITS COMMUNITY BENEFITS PLAN, NORWEGIAN AMERICAN HOSPITAL SET THE FOLLOWING GOALS:1) SERVE AS A CATALYST/CONVENER FOR THE OBESITY AND DIABETES INITIATIVES IN HUMBOLDT PARK.2) HOST COMMUNITY-BASED EDUCATION EVENTS SUCH AS ESL, LIFE SKILLSTRAINING, JOB SEEKING SKILLS, ETC.3) PROMOTE INITIATIVES THAT ENHANCE ACCESS TO HEALTH CARE FOR THE UNINSURED AND UNDERINSURED.4) NORWEGIAN AMERICAN HOSPITAL LEADERSHIP TO ASSUME AN ACTIVE ROLE IN COMMUNITY BASED ORGANIZATIONS BOARDS, TASK FORCES AND COMMUNITY EVENTS. Part VI, Line 3: NORWEGIAN AMERICAN HOSPITAL INFORMS AND EDUCATES PATIENTS AND PERSONS, WHO MAY BE BILLED FOR PATIENT CARE, ABOUT THEIR ELIGIBILITY FOR ASSISTANCE UNDER FEDERAL, STATE OR LOCAL GOVERNMENT PROGRAMS OR UNDER THE ORGANIZATION'S CHARITY CARE POLICY ON ITS INTRANET AND THROUGH FLYERS. PATIENTS ARE PROVIDED THESE POLICIES AT THE TIME OF REGISTRATION AND ARE ALSO AVAILABLE UPON REQUEST Part VI, Line 4: NORWEGIAN AMERICAN HOSPITAL SERVES A PRIMARY COMMUNITY AREA AND A SECONDARY COMMUNITY AREA.THE PRIMARY COMMUNITY AREA CONSISTS OF THE FOLLOWING AREAS, ZIP CODES AND POPULATION:- AUSTIN- BELMONT-CRAGIN- HERMOSA- HUMBOLDT PARK- LOGAN SQUARE- WEST TOWN- IRVING PARK- NORTH CENTER- EAST GARFIELD PARK- WEST GARFIELD PARK- NORTH LAWNDALE WHITE HISPANIC AFRICAN-AMERICANPRIMARY ZIP CODES POPULATION - PERCENTAGE 60618 46,754 51% 42,771 46% 2,559 3%60622 33,399 64% 15,289 29% 3,860 7%60624 958 3% 1,160 3% 35,987 94%60639 8,056 9% 68,639 76% 13,712 15%60647 34,357 39% 47,697 55% 5,237 6%60651 2,538 4% 21,756 34% 39,973 62%THE SECONDARY AREA CONSISTS OF THE FOLLOWING AREAS, ZIP CODES AND POPULATION:- ARCHER HEIGHTS- BRIGHTON PARK- CAGE PARK- GARFIELD RIDGE- WEST ELSDON- SOUTH LAWNDALE- PORTAGE PARK- PULLMAN WHITE HISPANIC AFRICAN-AMERICANPRIMARY ZIP CODES POPULATION - PERCENTAGE 60612 8,738 26% 4,319 13% 20,412 61%60623 2,301 2% 59,438 65% 30,369 33%60625 47,050 60% 28,304 36% 3,297 4%60632 12,939 14% 76,902 84% 1,485 2%60641 32,054 45% 38,057 53% 1,552 2%60644 1,506 3% 1,583 3% 45,559 94%60640 44,239 67% 9,923 15% 11,628 18%NORWEGIAN AMERICAN HOSPITAL'S AGE FOR THE FISCAL YEAR WAS AS FOLLOWS:AGE PERCENTAGE0-14 2%15-44 44%45-64 37%65-74 9%75+ 8%NORWEGIAN AMERICAN HOSPITAL'S RACE AND ETHNICITY FOR THE FISCAL YEAR WAS AS FOLLOWS:RACE PERCENTAGEASIAN 1%AMERICAN INDIAN OR NATIVE ALASKAN 0%BLACK OR AFRICAN-AMERICAN 43%WHITE 13%OTHER 43%ETHNICITY PERCENTAGEHISPANIC 41%NON-HISPANIC 59% Part VI, Line 5: IN ADDITION TO PROVIDING QUALITY INPATIENT AND OUTPATIENT SERVICES, NORWEGIAN AMERICAN HOSPITAL REACHES BEYOND ITS WALLS AND INTO COMMUNITIES THROUGH AN ARRAY OF ACTIVITIES AND PROGRAMS DESIGNED AND DELIVERED TO BENEFIT THE COMMUNITIES IT SERVES. THESE COMMUNITY BENEFITS INCLUDE: - CARE THAT IS PROVIDED FREE, SUBSIDIZED OR WITHOUT FULL REIMBURSEMENT FROM MEDICARE, MEDICAID OR OTHER GOVERNMENT INSURANCE PROGRAMS.-SERVICES RESPONDING TO UNIQUE COMMUNITY NEEDS, SUCH AS DIABETES SERVICES, EMERGENCY CARE, BEHAVIORAL HEALTH SERVICES, SUBSTANCE ABUSE, PEDIATRIC CARE-A-VAN; AS WELL AS HEALTH SCREENINGS, IMMUNIZATION PROGRAMS, SCHOOL-BASED HEALTH CARE AND OTHER COMMUNITY OUTREACH PROGRAMS.-EDUCATION TO TRAIN PHYSICIANS, NURSES, RADIOLOGY TECHNICIANS, AND OTHER HIGHLY SKILLED HEALTH CARE PROFESSIONALS.-VOLUNTEER SERVICES PROVIDED BY HOSPITAL EMPLOYEES WHO VOLUNTEER IN THEIR COMMUNITIES AND COMMUNITY MEMBERS WHO VOLUNTEER AT THE HOSPITAL.-LANGUAGE-ASSISTANCE SERVICES, SUCH AS TRANSLATORS, SIGNAGE, FORMS, BROCHURES, PATIENT EDUCATION MATERIALS AND OTHER INFORMATION IN LANGUAGES OTHER THAN ENGLISH.-DONATIONS BY NORWEGIAN AMERICAN HOSPITAL OF MEETING AND CLINIC SPACE, AS WELL AS OTHER ASSISTANCE TO COMMUNITY GROUPS. Part VI, Line 6: NOT AFFILIATED Part VI, Line 7, Reports Filed With States IL X 1 1 X X 0 1 0 0 0 0 0 1 0 JOSE R SANCHEZ PRESIDENT AND CEO (EX-OFFICIO) 556096 0 0 0 16800 0 155250 0 6480 0 734626 0 0 0 ABHA AGRAWAL VP, MEDICAL AFFAIRS/COO 445432 0 0 0 0 0 0 0 8787 0 454219 0 0 0 GARY KRUGEL CHIEF FINANCIAL OFFICER 250192 0 0 0 0 0 0 0 4458 0 254650 0 0 0 NARAYAN RAVISHANKAR MD ANESTHESIOLOGIST 363463 0 0 0 0 0 0 0 15303 0 378766 0 0 0 NATASHA T JENKINS HOSPITALIST, OB/GYN 315907 0 0 0 0 0 0 0 9997 0 325904 0 0 0 MAX IZBICKI MD PHYSICIAN, OB/GYN 304969 0 0 0 0 0 0 0 0 0 304969 0 0 0 JAMAL QAISER MD CHIEF HOSPITALIST 257032 0 0 0 0 0 0 0 13649 0 270681 0 0 0 DAGOBERTO CAMACHO MD HOSPITALIST 229499 0 0 0 0 0 0 0 6954 0 236453 0 0 0 Part I, Line 1a NAH PAYS MEMBERSHIP DUES ON BEHALF OF JOSE R. SANCHEZ, PRESIDENT AND CEO, TO A SOCIAL CLUB. THE MEMBERSHIP IS USED EXCLUSIVELY FOR BUSINESS PURPOSES. Part I, Line 4b JOSE R. SANCHEZ, PRESIDENT AND CEO, PARTICIPATED IN A SUPPLEMENTAL NONQUALIFIED RETIREMENT PLAN. $155,250 WAS CREDITED TO HIS ACCOUNT IN THE FISCAL YEAR 2016. Part I, Line 7 THE PRESIDENT RECEIVED A BONUS BASED ON PERFORMANCE AND THE FINANCIAL RESULTS OF THE ORGANIZATION. THIS BONUS WAS APPROVED BY THE EXECUTIVE COMMITTEE OF THE BOARD. THE BONUS FOR FISCAL YEAR 2016 WAS PAID OUT AFTER THE CALENDAR YEAR ENDING DECEMBER 31, 2015 AND WAS NOT INCLUDED IN THE 2015 W-2. AS A RESULT, THE BONUS FOR FISCAL YEAR 2016 IS NOT REPORTED ON SCHEDULE J, PART II. A ILLINOIS FINANCE AUTHORITY REVENUE BONDS SERIES 2008 861091967 45200FMS5 2008-08-15 5000000 SEE PART VI 0 0 0 B ILLINOIS FINANCE AUTHORITY REVENUE BONDS SERIES 2008 861091967 45200FMT3 2008-08-15 14450000 SEE PART VI 0 0 0 A 259673 5000000 798334 1159612 157619 2884435 2008 1 0 1 1 B 390000 14450000 798333 1159612 157620 12334436 2008 1 0 1 1 A 0 0 0 0 0 0 1 B 0 0 0 0 0 0 1 A 0 0 0 0 0 0 THE ARBITRAGE GROUP 0 0 0 0 0 B 0 0 0 0 0 0 THE ARBITRAGE GROUP 0 0 0 0 0 A 0 B 0 Schedule K Supplental Information THE SERIES 2008 BOND PROCEEDS, TOGETHER WITH OTHER AVAILABLE FUNDS, WERE USED TO REFUND THE OUTSTANDING PRINCIPAL AMOUNTS OF CERTAIN BONDS IN THE AMOUNT OF $3,467,000, TO PAY OR REIMBURSE THE HOSPITAL FOR THE PAYMENT OF THE COST OF ACQUIRING, CONSTRUCTING AND EQUIPPING CERTAIN OF THE HOSPITAL'S HEALTH CARE FACILITIES, TO FUND A DEBT SERVICE RESERVE FUND FOR THE BENEFIT OF THE SERIES 2008 BONDS, AND TO PAY CERTAIN EXPENSES INCURRED IN CONNECTION WITH THE ISSUANCE OF THE SERIES 2008 BONDS. JOHN MONTEVERDE MD Trustee 204999 THE HOSPITAL PAID ST. JOHN HEART CLINIC S.C. FOR MEDICAL SERVICES. TRUSTEE JOHN MONTEVERDE OWNS 100% OF ST. JOHN HEART CLINIC. 0 Form 990, Part VI, Section B, line 11 THE BOARD RETAINS THE SERVICES OF AN INDEPENDENT CPA FIRM TO PREPARE THE ORGANIZATION'S FORM 990. MEMBERS OF THE FISCAL SERVICES DEPARTMENT, THE CHIEF FINANCIAL OFFICER AND THE CHIEF EXECUTIVE OFFICER REVIEW THE COMPLETED FORM 990 AND PROVIDE A FULL COPY TO ALL MEMBERS OF THE FINANCE & AUDIT COMMITTEE. AFTER FORM 990 IS REVIEWED AND ACCEPTED BY THE FINANCE & AUDIT COMMITTEE, A COPY IS MADE AVAILABLE TO ALL VOTING MEMBERS OF THE GOVERNING BODY PRIOR TO FILING. THE GOVERNING BODY IS PROVIDED A REASONABLE AMOUNT OF TIME TO REVIEW THE RETURN AND ASK ANY QUESTIONS DIRECTLY TO ORGANIZATION MANAGEMENT OR THE CONTACT AT THE INDEPENDENT CPA FIRM PRIOR TO FILING. Form 990, Part VI, Section B, line 12c ALL TRUSTEES, OFFICERS, AND KEY EMPLOYEES AND KEY PHYSICIANS (AS DEFINED IN THE BOARD'S CONFLICT OF INTEREST POLICY) OF THE CORPORATION ARE SUBJECT TO THE CONFLICT OF INTEREST POLICY. IN ADDITION, ALL INDEPENDENT CONTRACTORS WHO PROVIDE SERVICES AND/OR MATERIALS TO THE CORPORATION IN EXCHANGE FOR $20,000 OR MORE IN PAYMENT DURING ANY FISCAL YEAR SHALL BE SUBJECT TO THESE PROVISIONS. ALL PERSONS SUBJECT HERETO SHALL BE HEREINAFTER REFERRED TO AS "COVERED PERSONS." THE CHIEF EXECUTIVE OFFICER OF THE CORPORATION IS RESPONSIBLE FOR PUBLICIZING THE PROVISIONS OF THIS ARTICLE TO THE PERSONS AFFECTED THEREBY. NO PERSON SHALL BECOME A TRUSTEE, OFFICER, OR EMPLOYEE OR MEDICAL DEPARTMENT DIRECTOR OF THE CORPORATION WITHOUT FIRST ACKNOWLEDGING IN WRITING TO THE CORPORATION THAT HE OR SHE HAS REVIEWED, FULLY UNDERSTANDS AND IS IN COMPLIANCE WITH THE PROVISIONS OF THE CONFLICT OF INTEREST POLICY. ALL COVERED PERSONS SHALL PROMPTLY DISCLOSE TO THE BOARD OF TRUSTEES OF THE CORPORATION ALL SUBSTANTIVE POTENTIAL CONFLICTS OF INTEREST WHICH SUCH PERSON DISCOVERS OR WHICH IS BROUGHT TO HIS OR HER ATTENTION. SUCH DISCLOSURE SHALL INCLUDE SUBMISSION TO THE BOARD OF A WRITTEN STATEMENT OF THE FACTS SURROUNDING THE CONFLICT OF INTEREST AND AN OPPORTUNITY TO MAKE A BRIEF ORAL STATEMENT TO THE BOARD WITH RESPECT TO THE MATTER IN QUESTION. AN ANNUAL DISCLOSURE STATEMENT SHALL BE CIRCULATED TO ALL COVERED PERSONS TO ASSIST THEM IN CONSIDERING SUCH DISCLOSURES. IN ADDITION, THE POLICY IS MONITORED PERIODICALLY THROUGHOUT THE YEAR FOR ANY CONFLICTS OF INTEREST. PROMPT DISCLOSURE NOTICES OF CONFLICT SHALL BE FILED WITH THE PRESIDENT OF THE CORPORATION OR ANY OTHER PERSON DESIGNATED BY HIM FROM TIME TO TIME TO RECEIVE SUCH NOTIFICATIONS. ALL DISCLOSURE NOTICES RECEIVED HEREUNDER SHALL BE NOTED FOR RECORD IN THE MINUTES OF A MEETING OF THE BOARD OF TRUSTEES. THE PRESENCE OF THE TRUSTEE WHO IS DIRECTLY OR INDIRECTLY A PARTY TO THE TRANSACTION IN QUESTION OR A TRUSTEE WHO IS OTHERWISE NOT DISINTERESTED MAY BE COUNTED IN DETERMINING WHETHER A QUORUM IS PRESENT FOR THE PURPOSE OF THE MEETING, BUT SHALL NOT BE PRESENT OR HAVE A VOTE WHEN THE BOARD OF TRUSTEES OR A COMMITTEE OF THE BOARD DISCUSSES AND TAKES ACTION ON THE TRANSACTION. Form 990, Part VI, Section B, line 15 THE COMPENSATION OF THE CHIEF EXECUTIVE OFFICER, CHIEF OPERATING OFFICER/VICE PRESIDENT MEDICAL AFFAIRS AND CHIEF FINANCIAL OFFICER WERE REVIEWED BY AN EXTERNAL ORGANIZATION SPECIALIZING IN COMPENSATION MANAGEMENT. THE RESULTS OF THAT REVIEW WERE PROVIDED TO THE EXECUTIVE COMMITTEE OF THE BOARD OF TRUSTEES. Form 990, Part VI, Section C, line 19 NORWEGIAN AMERICAN HOSPITAL INC. MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. Form 990, Part IX, line 11g PROFESSIONAL FEES NONMEDICAL: Program service expenses 1,400,697. Management and general expenses 1,244,227. Fundraising expenses 0. Total expenses 2,644,924. OUTSOURCED SERVICES: Program service expenses 34,959. Management and general expenses 523,139. Fundraising expenses 0. Total expenses 558,098. temp agency: Program service expenses 2,479,507. Management and general expenses 367,484. Fundraising expenses 0. Total expenses 2,846,991. physician fees: Program service expenses 5,745,425. Management and general expenses 402,483. Fundraising expenses 0. Total expenses 6,147,908. Consulting fees: Program service expenses 50,060. Management and general expenses 2,283,237. Fundraising expenses 0. Total expenses 2,333,297. LAB SERVICES FOR CLINICS: Program service expenses 40,251. Management and general expenses 0. Fundraising expenses 0. Total expenses 40,251. Form 990, Part XI, line 9: INCOME (LOSS) FROM NORWEGIAN AMERICAN HOSPITAL FOUNDATION -10,933. INCOME (LOSS) FROM INVESTMENTS IN JOINT VENTURES 315,580. DISTRIBUTION FROM INVESTMENTS IN JOINT VENTURES 500,000. PENSION RELATED CHANGES, OTHER THAN NET PERIOD PENSION COST 2,391,567. NET ASSETS RELEASED FROM RESTRICTION -56,067. NORWEGIAN AMERICAN HOSPITAL FOUNDATION 1044 NORTH FRANCISCO AVENUE CHICAGO IL 60622 363257131 SUPPORTING FOUNDATION IL 501(c)(3) Line 11a, I NORWEGIAN AMERICAN HOSPITAL INC 1 CENTENNIAL MEDICAL MANAGEMENT CORPORATION 1044 NORTH FRANCISCO AVENUE CHICAGO IL 60622 363394548 OUTPATIENT PHARMACY IL NORWEGIAN AMERICAN HOSPITAL INC C 1285382 1089824 1.00000 1 1 0 1 0 0 0 0 0 0 1 0 0 0 1 1 0 0 0 0 CENTENNIAL MEDICAL MANAGEMENT CORPORATION A 9772 BOOK VALUE NORWEGIAN AMERICAN HOSPITAL FOUNDATION A 4800 BOOK VALUE NORWEGIAN AMERICAN HOSPITAL FOUNDATION C 593817 BOOK VALUE