2017-04-05T14:18:34-05:00 2016-06-30 410746749 CLIFTONLARSONALLEN LLP 220 SOUTH SIXTH STREET SUITE 300 MINNEAPOLIS MN 55402 990 2015-07-01 810240726 MARCUS DALY MEMORIAL HOSPITAL MARC 4063632211 1200 WESTWOOD DRIVE HAMILTON MT 59840 JOHN M BARTOS CEO, SECRETARY AND TREASURER 4063632211 2017-03-31 1 DARRYN MCGARVEY P00958683 6123764500 2015 2021-01-29 14:40:06Z JOHN M BARTOS 1200 WESTWOOD DRIVE HAMILTON MT 59840 62451641 0 X WWW.MDMH.ORG X 1929 MT OUR COMMITMENT TO THE BITTERROOT VALLEY IS QUALITY, ACCESSIBLE, PERSONALIZED HEALTHCARE. 11 7 622 75 0 0 1609705 522820 57609506 61202601 38637 57681 813728 320492 60071576 62103594 72240 89558 0 0 34802931 37720263 0 0 160810 23133990 24151964 58009161 61961785 2062415 141809 60236732 57938753 31861353 29679846 28375379 28258907 X OUR COMMITMENT TO THE BITTERROOT VALLEY IS QUALITY, ACCESSIBLE, PERSONALIZED HEALTHCARE. 0 0 52432380 89558 61201809 MARCUS DALY MEMORIAL HOSPITAL CORPORATION OWNS AND OPERATES A 25 LICENSED BED ACUTE CARE CRITICAL ACCESS HOSPITAL. THE HOSPITAL PROVIDES ACUTE CARE SERVICES TO PATIENTS IN RAVALLI COUNTY. THE SERVICES PROVIDED INCLUDE ACUTE CARE HOSPITAL, RELATED ANCILLARY SERVICES SUCH AS LABORATORY, RADIOLOGY, THERAPY, INPATIENT AND OUTPATIENT SURGERY, EMERGENCY CARE, AMBULANCE, HOME HEALTH, CLINIC, INPATIENT AND OUTPATIENT HOSPICE CARE. THE HOSPITAL PROVIDES EMS SERVICES WITH 3 CREWS PROVIDING 911 SERVICE TO THE COUNTY. THE GOAL IS TO RESPOND WITHIN 20 MINUTES OR LESS TO ANY CALL WITHIN THE COUNTY. THE HOSPITAL IS A PEDIATRIC REHABILITATION PROVIDER OF PHYSICAL THERAPY, OCCUPATIONAL THERAPY AND SPEECH THERAPY USING CERTIFIED THERAPISTS. THE HOSPITAL CLINICS SEE ALL PATIENTS REGARDLESS OF INSURANCE OR ABILITY TO PAY AND ENABLE THE COMMUNITY ACCESS TO PRIMARY CARE. 52432380 1 1 0 0 0 0 0 0 0 1 1 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 1 1 1 0 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 1 0 0 0 1 76 0 622 1 0 0 0 0 0 0 0 0 0 0 X 11 7 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 0 0 X X DONJA ERDMAN 4063754609 1200 WESTWOOD DRIVE HAMILTON MT 59840 DON LODMELL PHD CHAIRMAN 2.00 X X 0 0 0 BILL BEAN VICE CHAIR 2.00 X X 0 0 0 BARBARA ACKERMAN BOARD MEMBER 2.00 X 0 0 0 TOM ANDERSON BOARD MEMBER 2.00 X 0 0 0 SUSAN BENJAMIN BOARD MEMBER 2.00 X 0 0 0 LOIS HEDG-PETH BOARD MEMBER 2.00 X 0 0 0 FREDERICK ILGENFRITZ MD BOARD MEMBER/PHYSICIAN THRU APRIL 2016 40.00 X 302453 0 63996 ALLEN W JONES MD BOARD MEMBER/PHYSICIAN 40.00 X 303114 0 44730 BRIAN KELLEHER MD BOARD MEMBER/PHYSICIAN 40.00 X 176744 0 0 JOHN ORMISTON BOARD MEMBER 2.00 X 0 0 0 JAMES OWINGS CPA BOARD MEMBER 2.00 X 0 0 0 TIMOTHY WOODS MD BOARD MEMBER/PHYSICIAN 40.00 X 525649 0 54333 JOHN M BARTOS CEO/SECRETARY/TREASURER 39.00 1.00 X 322741 0 33374 DONJA C ERDMAN CFO 39.00 1.00 X 138037 0 30809 JOHN MORELAND MD CHIEF MEDICAL OFFICER 40.00 X 299881 0 39544 TROY HANSON ASSISTANT ADMINISTRATOR 40.00 X 164564 0 14599 SUSAN HILL RN DIRECTOR OF NURSING THRU APRIL 2016 40.00 X 127109 0 5849 KATHRYN PADILLA RN DIRECTOR OF NURSING 40.00 X 108739 0 14189 MARY CAMDEN MD PHYSICIAN 40.00 X 318726 0 16938 RICHARD DAY MD PHYSICIAN 40.00 X 923146 0 43049 JEREMIAH CLINTON MD PHYSICIAN 40.00 X 397244 0 39767 JENNIFER FEIGHNER MD PHYSICIAN 40.00 X 296448 0 21464 MARK CALDERWOOD MD PHYSICIAN 40.00 X 396557 0 30818 4801152 0 453459 50 0 1 0 JACKSON CONTRACTOR GROUP INC PO BOX 967 MISSOULA MT 59806 GENERAL CONTRACTOR 1163728 CERNER CORPORATION PO BOX 959156 ST LOUIS MO 63195 EHR SERVICES 763776 BECK BUILDERS INC 231 BLODGETT WAY HAMILTON MT 59840 CONSTRUCTION SERVICES 443291 HEALHCARE OUTSOURCING NETWORK 617 17TH ST 1800 DENVER CO 80293 BILLING SERVICES 399077 OZ ARCHITECTS 531 NORTH HIGGINS AVE A MISSOULA MT 59802 ARCHITECTUAL FEES 250542 14 333914 188906 522820 NET PATIENT SERVICE REVENUE 621400 59744165 59744165 OTHER OPERATING INCOME 621400 785125 785125 HOSPITAL UTILZTN. REV. 621400 673311 673311 61202601 22835 22835 1910 1910 235842 128057 107785 107785 107785 50770 17834 32936 32936 32936 111125 202156 -91031 -91031 CONSTRUCTION SETTLEMENT 900099 180726 180726 MISCELLANEOUS 900099 106326 106326 EDUCATION 900099 8838 8838 7848 7848 303738 62103594 61202601 0 378173 89558 89558 2666629 1955270 711359 28217923 23688725 4449116 80082 1054559 890245 161327 2987 3940698 3288547 641710 10441 1840454 1552905 282565 4984 122905 122905 62373 62373 3443727 1705797 1734609 3321 81007 81007 548709 224837 323239 633 958725 851468 107257 295654 277071 18583 193146 157389 35757 1166899 996929 135976 33994 4175104 3953502 202558 19044 963080 963080 PROVISION FOR BAD DEBTS 5813595 5813595 MEDICAL EXPENSES 3736200 3736200 PHARMACY/ LAB EXPENSES 1230899 1230899 MAINTENANCE AND REPAIRS 909107 765852 143255 450834 209504 236006 5324 61961785 52432380 9368595 160810 6796587 8250264 3076859 3494400 9534975 8811539 25000 239166 2151464 2009194 430819 391756 67208920 34062520 36325571 33146400 1444609 1181917 450848 414117 60236732 57938753 8163771 6509367 269181 93744 6675000 6155000 14158822 14092451 287758 847592 2306821 1981692 31861353 29679846 X 26296467 26367443 1385095 1193193 693817 698271 28375379 28258907 60236732 57938753 X 141809 -258281 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 313190 984 984 313190 313190 1019 1019 313190 313190 2806 2806 313190 313190 2665 2665 313190 313190 1997 1997 313190 1.00000 0 0 1637827 1637827 45697357 19371320 26326037 1090651 686293 404358 18629811 14004907 4624904 153274 153274 33146400 THIRD PARTY SETTLEMENT 1981692 1981692 X 55626761 -5813595 -5813595 61440356 663238 663238 62103594 56289002 106568 106568 56182434 5779351 5779351 61961785 PART V, LINE 4: THE ENDOWMENT FUND IS DESIGNATED FOR THE PURPOSE OF BUILDING AND CARRYING ON A HOSPITAL IN HAMILTON, MONTANA. THE EVANS ENDOWMENT IS TO BE USED FOR THE CARE AND TREATMENT OF CRIPPLED CHILDREN. PART X, LINE 2: PER THE AUDITED FINANCIAL STATEMENTS, NOTE 1: THE INTERNAL REVENUE SERVICE (IRS) HAS DETERMINED THAT MARCUS DALY MEMORIAL HOSPITAL IS A TAX-EXEMPT, NOT-FOR-PROFIT CORPORATION UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE (IRC). THE HOSPITAL FOLLOWS THE GUIDANCE IN THE ACCOUNTING STANDARDS REGARDING THE RECOGNITION AND MEASUREMENT OF UNCERTAIN TAX POSITIONS. THE GUIDANCE CLARIFIES THE ACCOUNTING FOR UNCERTAINTY IN INCOME TAXES RECOGNIZED IN AN ENTITY'S FINANCIAL STATEMENTS. THE GUIDANCE FURTHER PRESCRIBES RECOGNITION AND MEASUREMENT OF TAX PROVISIONS TAKEN OR EXPECTED TO BE TAKEN ON A TAX RETURN THAT ARE NOT CERTAIN TO BE REALIZED. THE APPLICATION OF THIS STANDARD HAS NO IMPACT ON THE HOSPITAL'S FINANCIAL STATEMENTS. PART XI, LINE 2D - OTHER ADJUSTMENTS: PROVISION FOR UNCOLLECTIBLE ACCOUNTS -5,813,595. PART XI, LINE 4B - OTHER ADJUSTMENTS: TEMPORARILY RESTRICTED CONTRIBUTIONS 488,054. OTHER OPERATING REVENUES 222,241. RENTAL EXPENSE -106,568. INTEREST REVENUE 24,745. GRANTS AND CONTRIBUTIONS 34,766. PART XII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES 106,568. PART XII, LINE 4B - OTHER ADJUSTMENTS: PROVISION FOR UNCOLLECTIBLE ACCOUNTS 5,813,595. EMPLOYEE BENEFIT PLAN EXPENSES REFUNDED -34,244. 1 1 X 1 X 1 X 1 1 0 1 1 150 434561 0 434561 0.00700 7560297 5722727 1837570 0.02970 150 7994858 5722727 2272131 0.03670 354686 0 354686 0.00570 93830 0 93830 0.00150 7225930 4994946 2230984 0.03600 95437 0 95437 0.00150 7769883 4994946 2774937 0.04470 150 15764741 10717673 5047068 0.08140 1319 1319 0.00000 853 853 0.00000 68731 68731 0.00110 70903 70903 0.00110 1 5813595 0 16303620 16671355 -367735 X 1 1 1 1 MARCUS DALY MEMORIAL HOSPITAL 1200 WESTWOOD DRIVE HAMILTON MT 59840 WWW.MDMH.ORG 12911 X X X X MARCUS DALY MEMORIAL HOSPITAL 1 0 0 1 X X X X X X X X X 15 1 0 0 1 X HTTP://WWW.MDMH.ORG/DOCS/2015_COMMUNITY_HEALTH_NEEDS_ASSESSMENT_REVISED_5.2 X 1 15 1 HTTP://WWW.MDMH.ORG/DOCS/2015_COMMUNITY_HEALTH_NEEDS_ASSESSMENT_REVISED_5.2 0 0 1 X 100.000000000000 200.000000000000 X X X X X X 1 1 X X X 1 X HTTP://WWW.MDMH.ORG/DOCS/CHARITY_CARE_POLICY_REVISED_062816FINAL.PDF X HTTP://WWW.MDMH.ORG/DOCS/FINANCIAL_ASSISTANCE_APPLICATION_8.1.16.PDF X HTTP://WWW.MDMH.ORG/DOCS/PATIENT_FINANCIAL_ASSISTANCE_PLAIN_LANGUAGE_SUMMAR X X X X X 1 X 0 X X 1 X 0 0 MARCUS DALY MEMORIAL HOSPITAL PART V, SECTION B, LINE 3J: PART V, SECTION B, LINE 3F:THIS BOX WAS LEFT UNCHECKED BECAUSE MDMH'S CHNA DIDN'T DIRECTLY INCLUDE A STATEMENT ADDRESSING THE PRIMARY AND CHRONIC DISEASE NEEDS AND OTHER HEALTH ISSUES OF UNINSURED PERSONS, LOW INCOME PERSONS, AND MINORITY GROUPS, HOWEVER, THE HOSPITAL IS TAKING STEPS TO ADDRESS THESE ISSUES. MDMH HAS RECENTLY JOINED TOGETHER WITH 10 OTHER HOSPITALS FROM RURAL MONTANA, IDAHO, AND WYOMING TO FORM THE MOUNTAIN WEST ACCOUNTABLE CARE ORGANIZATION (ACO). ONE OF THE MAIN OBJECTIVES OF THE ACO IS TO IMPROVE OVERALL COMMUNITY HEALTH BY FOCUSING ON THOSE WITH CHRONIC HEALTH NEEDS. AS PART OF THE ACO PROGRAM, MDMH HAS SPECIFICALLY HIRED A SECOND CLINIC RN TO HELP MANAGE THOSE PATIENTS IDENTIFIED WITH CHRONIC HEALTH CONDITIONS AND CONCERNS. MARCUS DALY MEMORIAL HOSPITAL PART V, SECTION B, LINE 5: MR. VETO J. "SONNY" LASALLE SERVED AS THE 2015 COMMUNITY HEALTH NEEDS ASSESSMENT (CHNA) PROGRAM COORDINATOR. ALMOST 70 ORGANIZATIONS WERE IDENTIFIED WITH IN THE COUNTY , INCLUDING BUT NOT LIMITED TO COUNTY AND CITY ELECTED OFFICERS, SCHOOL BOARDS, SCHOOL STAFF, SERVICE CLUBS, RETIREMENT HOMES, POLITICAL GROUPS, FEDERAL AND STATE OFFICES, AND OTHERS. MR. LASALLE WOULD MEET WITH THE GROUP AT A SCHEDULED MEETING PRESENT THE PURPOSE OF THE CHNA, ANSWER QUESTIONS AND DISTRIBUTE SURVEYS. NOTICE OF THE SURVEY WAS ALSO MADE BY NEWSPAPER, TELEVISION, AND THE HOSPITAL NEWSLETTER, HEALTHLINES, WHICH IS MAILED TO COUNTY RESIDENTS. THIS SURVEY WAS ALSO POSTED ON THE HOSPITAL'S WEBSITE. MARCUS DALY MEMORIAL HOSPITAL PART V, SECTION B, LINE 11: THE HIGHEST PRIORITY HEALTH NEEDS AS SUGGESTED BY THE COMMUNITY SERVED BY MDMH BASED UPON THE RESULT OF THE 2015 SURVEY ARE:1. EXPAND SERVICES TO INCLUDE A HEALTH CARE CINIC IN DARBY AND EXPANDED CHEMOTHERAPY SERVICES. 2. EXPAND PHYSICIAN SERVICES TO INCLUDE A PEDIATRITION, UROLOGIST, EAR, NOSE, AND THROAT SPECIALIST, PULMONOLOGY AND DERMATOLOGY. THE HOSPITAL BOARD OF DIRECTORS HAS DECIDED NOT TO PURSUE A PEDIATRICIAN AT THIS TIME. 3. EXPAND EDUCATIONAL OPPORTUNITIES ESPECIALLY RELATED TO DIABETES, NUTRITION, OBESITY AND DEMENTIA. 4. EXPANDED MENTAL HEALTH COVERAGE WAS ALSO REQUESTED. MDMH RECOGNIZES THAT THIS IS A STATE AND NATIONAL CONCERN BUT UNFORTUNATELY AT THIS TIME MDMH IS NOT STAFFED TO DEAL WITH MENTAL HEALTH PATIENTS OUTSIDE OF THE EMERGENCY DEPARTMENT. MARCUS DALY MEMORIAL HOSPITAL PART V, SECTION B, LINE 13B: ELIGIBILITY FOR PATIENT ASSISTANCE SHALL BE MADE REGARDLESS OF RACE, GENDER, AGE, SEXUAL ORIENTATION, RELIGIOUS AFFILIATION, AND SOCIAL OR IMMIGRANT STATUS. MAJOR AREAS OF CONSIDERATIONS 1) RELATIONSHIP TO FEDERAL INCOME POVERTY GUIDELINES ADJUSTED FOR FAMILY SIZE 2) FAMILY NET ASSETS 3) DEMONSTRATION OF INABILITY TO WORK 4) COMPLETED APPLICATION AND 5) RESIDENT OF RAVALLI COUNTY MONTANA WITH EXCEPTIONS. MARCUS DALY MEMORIAL HOSPITAL PART V, SECTION B, LINE 22D: FOR FIRST SIX MONTHS OF FY16, MDMH DETERMINED AMOUNTS GENERALLY BILLED ("AGB") BASED ON COMMERCIAL PAYOR PERCENTAGE FROM LARGEST COMMERCIAL PAYOR DISCOUNT OF 19% AS OF YEAR ENDED JUNE 30, 2015. FOR THE SECOND SIX MONTHS, MDMH IMPLETMENTED THE NEW 501R GUIDELINES AND DETERMINED AMOUNTS GENERALLY BILLED ("AGB") BASED ON MEDICAID, MEDICARE FEE-FOR-SERVICE, AND ALL PRIVATE HEALTH INSURERS. THE AVERAGE PAYOR DISCOUNT WAS 47.66% FOR THE TWELVE MONTHS ENDED JUNE 30, 2015. 2 1 - CORVALLIS FAMILY MEDICINE CLINIC 1037 MAIN STREET CORVALLIS MT 59828 FAMILY PRACTICE CLINIC 2 - BITTERROOT VALLEY EYE ASSOCIATES 300 N 10TH STREET HAMILTON MT 59840 OPTICAL SPECIALTY CLINIC PART I, LINE 3C: ELIGIBILITY FOR FINANCIAL ASSISTANCE IS BASED ON MULTIPLE FACTORS, INCLUDING THE NATURE OF THE CONDITION AND CARE REQUIRED, INSURANCE COVERAGE OR OTHER SOURCES OF PAYMENT, INCOME (FEDERAL POVERTY LEVEL GUIDELINES ARE USED TO DETERMINE THE AMOUNT OF FINANCIAL ASSISTANCE OFFERED), FAMILY SIZE, ASSETS, AND RESIDENCY IN RAVALLI COUNTY UNLESS SERVICES WERE FOR EMERGENCY CARE.FULL FINANCIAL ASSISTANCE WILL BE GRANTED BASED ON INCOME EQUAL TO OR LESS THAN 100% OF FEDERAL POVERTY LEVEL GUIDELINES. PARTIAL ASSISTANCE MAY BE GRANTED BASED ON INCOME BETWEEN 100% AND 200% OF FEDERAL POVERTY LEVEL GUIDELINES. VALUE OF ASSETS MAY BE CONSIDERED IN DETERMINING THE LEVEL OF ASSISTANCE. PART I, LINE 7: EXPLANATION OF COSTING METHOD:FINANCIAL ASSISTANCE AT COST AND MEDICAID AMOUNTS REPORTED IN PART I, LINE 7 ARE COMPUTED USING THE COST TO CHARGE RATIO DERIVED FROM WORKSHEET 2 OF THE IRS INSTRUCTIONS. COMMUNITY HEALTH IMPROVEMENTS SERVICES, COMMUNITY BENEFIT OPERATIONS, HEALTH PROFESSIONAL EDUCATION, AND CASH AND IN-KIND CONTRIBUTIONS TO COMMUNITY GROUPS ARE REPORTED AT COST. GENERAL SUBSIDIZED SERVICES ARE COMPUTED USING THE IRS GUIDELINES OF COST ADJUSTED NET PAYMENTS RECEIVED. THE MEDICARE COST REPORT WAS USED TO DETERMINE THE TOTAL SUBSIDY FOR THE HOME HEALTH / HOSPICE DEPARTMENTS. PART I, LINE 7G: INCLUDED IN THE SUBSIDIZED HEALTH SERVICES ARE THE FOLLOWING DEPARTMENTS: HOME HEALTH, HOSPICE CENTER AND HOSPICE OUTPATIENT, BITTERROOT GENERAL VASCULAR SURGERY CENTER, BITTERROOT VALLEY EYE ASSOCIATES, BITTERROOT ORTHOPEDIC & SPORTS MEDICINE, HAMILTON GENERAL SURGERY CENTER, HAMILTON OB/GYN, AND ROCKY MOUNTAIN NEUROSURGERY. PART I, LN 7 COL(F): THE AMOUNT OF BAD DEBT EXPENSES THAT WAS EXCLUDED FROM THE CALCULATION TO DETERMINE THE NET COMMUNITY BENEFIT EXPENSES AS A PERCENT OF TOTAL EXPENSES WAS $5,813,595. PART II, COMMUNITY BUILDING ACTIVITIES: THE HOSPITAL PROMOTES THE HEALTH OF THE COMMUNITY BY PARTICIPATION IN BOTH ECONOMIC AND COALITION BUILDING EVENTS. THE HOSPITAL PARTNERS WITH LOCAL HIGH SCHOOLS WITH A "JOB SHADOW" PROGRAM. THE GOAL IS TO EXPOSE AND PROMOTE THE HEALTH CARE PROFESSION TO AREA YOUTH. THE HOSPITAL IS ALSO ACTIVELY INVOLVED IN NUMEROUS COMMUNITY SUPPORT ORGANIZATIONS. PART III, LINE 2: BAD DEBT EXPENSE IS CALCULATED BY REVIEWING PAYMENT ARRANGEMENTS WHICH INCLUDE PROSPECTIVELY DETERMINED RATES PER DISCHARGE, REIMBURSED COSTS, DISCOUNTED CHARGES AND PER DIEM PAYMENTS. NET PATIENT SERVICE REVENUE IS REPORTED AT THE ESTIMATED NET REALIZABLE AMOUNTS FROM PATIENTS, THIRD-PARTY PAYORS, AND OTHERS FOR SERVICES RENDERED, INCLUDING ESTIMATED RETROACTIVE ADJUSTMENTS UNDER REIMBURSEMENT AGREEMENTS WITH THIRD-PARTY PAYORS. PART III, LINE 4: THE FOLLOWING IS FROM THE "PATIENT ACCOUNTS RECEIVABLE" PARAGRAPH IN NOTE 1 TO THE HOSPITAL'S FINANCIAL STATEMENTS:"PATIENT AND RESIDENT ACCOUNTS RECEIVABLE ARE REDUCED BY AN ALLOWANCE FOR DOUBTFUL ACCOUNTS. IN EVALUATING THE COLLECTIBILITY OF PATIENT AND RESIDENT 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." PART III, LINE 8: MDMH HAS A MEDICARE SHORTFALL IN EXCESS OF APPROXIMATELY $367,735. THE HOSPITAL HAS CRITICAL ACCESS HOSPITAL STATUS AND IS REIMBURSED BY MEDICARE FOR INPATIENT AND OUTPATIENT SERVICES ON A COST BASIS AS DEFINED AND LIMITED BY THE MEDICARE PROGRAM. MDMH PROVIDES A SIGNIFICANT RURAL LINK FOR BOTH THE HEALTH AND WELL-BEING OF RAVALLI COUNTY RESIDENTS. WE ARE COMMITTED TO LOCAL HEALTHCARE CLOSE TO HOME AND WORK HARD TO EARN AND KEEP THE TRUST OF THE LOCAL COMMUNITY. TO ENSURE THAT A VARIETY OF CLINIC, HOSPITAL AND EMERGENCY SERVICES ARE OPEN AND AVAILABLE TO ALL THOSE WITHIN OUR SERVICE AREA WE STRIVE TO OPERATE AT THE HIGHEST LEVEL OF FISCAL RESPONSIBILITY AND TO BE A GOOD STEWARD OF OUR RESOURCES. THE MEDICARE ALLOWABLE COSTS INCLUDED IN PART III, LINE 6 WAS DERIVED USING THE 2016 FILED MEDICARE COST REPORT. PART III, LINE 9B: IF A PATIENT IS PRESUMED TO BE FINANCIALLY INDIGENT, THE PATIENT REPRESENTATIVE WILL OFFER A PERSONAL FINANCIAL STATEMENT (PFS) TO BE FILLED OUT. THE PFS WILL BE FORWARDED TO THE PATIENT FINANCIAL ASSISTANCE COMMITTEE FOR REVIEW AND DETERMINATION OF PATIENT FINANCIAL ASSISTANCE STATUS. A PATIENT MAY REQUEST A MONTHLY PAYMENT ARRANGMENT. A MINIMUM PAYMENT OF $50 MUST BE PAID MONTHLY, WITH THE GOAL OF THE BALANCE PAID IN FULL WITHIN 5 YEARS. ACCOUNTS THAT CANNOT BE COLLECTED AFTER NORMAL IN-HOUSE COLLECTION PROCEDURES MAY BE REFERRED TO A COLLECTION AGENCY, MAGISTRATE OR ATTORNEY FOR FURTHER COLLECTION ACTION. PART VI, LINE 2: IN ADDITION TO CONDUCTING A COMMUNITY HEALTH NEEDS ASSESSMENT EVERY THREE YEARS, MDMH ASSESSES THE HEALTH NEEDS OF THE COMMUNITY BY LISTENING TO OUR PATIENTS, FRIENDS, FAMILY AND NEIGHBORS AS WE INTERACT WITH THEM DAILY WE HEAR THEIR CARES AND CONCERNS. WE ALWAYS ARE LOOKING FOR NEW WAY TO RESPOND TO, AND PROVIDE BETTER CARE FOR THE LOCAL COMMUNITY. PART VI, LINE 3: AS OF JANUARY 1, 2014, THE HOSPITAL'S FINANCIAL ASSISTANCE PROGRAM IS POSTED ON THEIR WEBSITE AT HTTP://WWW.MDMH.ORG/GETPAGE.PHP?NAME=FINANCIAL_ASSISTANCE_POLICY_SUMMARY. IN ADDITION THE HOSPITAL INFORMS PATIENTS UNABLE TO PAY THEIR BILLS ABOUT THEIR FINANCIAL ASSISTANCE WHILE TALKING TO THEM OVER THE PHONE AND SENDS THEM A FINANCIAL ASSISTANCE PACKET. PART VI, LINE 4: THE HOSPITAL SERVES A RURAL POPULATION WHERE THE AVERAGE ANNUAL WAGE IS $40,065. THE PAYER MIX IS 53% MEDICARE, 14% MEDICAID, 6% SELF PAY, NO INSURANCE, WITH THE BALANCE AT OTHER COMMERCIAL PAYORS. THE UNEMPLOYMENT RATE IN RAVALLI COUNTY IS CURRENTLY AT 4.1% ACCORDING TO THE MONTANTA DEPARTMENT OF LABOR AND INDUSTRY. PART VI, LINE 5: THE HOSPITAL IS PROUD OF ITS EFFORTS TO PROMOTE COMMUNITY HEALTH AND WELLNESS. "SPRINKLE PINK" PROGRAM IS A COMMUNITY WIDE PROGRAM THAT PROMOTES MAMMOGRAPHY SCREENING AND RAISES FUNDS TO PROVIDE NO-COST MAMMOGRAMS TO QUALIFIED LOW INCOME AREA RESIDENTS. THE HOSPITAL COORDINATES AND SPONSORS THE ANNUAL SPORTS PHYSICAL CLINIC TO SUPPORT AND ENCOURAGE AREA YOUTH TO PARTICIPATE IN PHYSICIAL ACTIVITIES. OTHER COMMUNITY CLINICS OR SCREENINGS INCLUDED BLOOD PRESSURE TESTING AT AREA SENIOR CENTERS, AND LIPID PROFILES AND CHOLESTEROL TESTS PROVIDED TO THE COMMUNITY FREE OF CHARGE. A VARIETY OF HEALTH EDUCATION CLASSES ARE OFFERED TO THE COMMUNITY FREE OF CHARGE THROUGH OUT THE YEAR. PART VI, LINE 6: THE ORGANIZATION IS NOT PART OF AN AFFILIATED HEALTH CARE SYSTEM. PART VI, LINE 7, REPORTS FILED WITH STATES MT 1 HAMILTON SCHOOL DISTRICT 217 DALY AVENUE HAMILTON MT 59840 816000830 GOVERNMENTAL 9525 SUPPORT FOR SCHOOL RN PROGRAM AND STUDENT ATHLETICS. CORVALLIS SCHOOL DISTRICT PO BOX 700 1045 MAIN STREET CORVALLIS MT 59828 816000828 GOVERNMENTAL 9450 SUPPORT FOR SCHOOL RN PROGRAM AND STUDENT ATHLETICS. STEVENSVILLE SCHOOL DISTRICT 300 PARK STREET STEVENSVILLE MT 59870 816000829 GOVERNMENTAL 6625 SUPPORT FOR SCHOOL RN PROGRAM AND STUDENT ATHLETICS DARBY SCHOOL DISTRICT 209 SCHOOL DRIVE DARBY MT 59829 816000834 GOVERNMENTAL 7250 SUPPORT FOR SCHOOL RN PROGRAM AND STUDENT ATHLETICS. 4 0 PART I, LINE 2: THE HOSPITAL IS COMMITTED TO SUPPORT THE HEALTH AND WELL-BEING OF AREA SCHOOL AGED CHILDREN BY PROVIDING FUNDING GRANTS RESTRICTED TO THE DISTRICT'S SCHOOL NURSE PROGRAM. THE HOSPITAL HAS ALSO COMMITTED TO SUPPORT STUDENT ATHLETICS BY PROVIDING A VOLUNTEER BASED, LOW-COST SPORTS PHYSICAL CLINIC DURING THE SUMMER. THE PROCEEDS ARE GIVEN TO THE PARTICIPATING STUDENTS' HOME DISTRICT TO SUPPORT THE DISTRICT'S ATHLETIC PROGRAMS. OTHER COMMUNITY ORGANIZATIONS MAY SUBMIT A GRANT PROPOSAL DIRECTLY TO THE HOSPITAL CEO FOR CONSIDERATION. THE REQUESTS ARE EVALUATED BASED UPON BROAD BASED COMMUNITY SUPPORT AND THE URGENCY OF NEED. X X 1 0 X X X X 0 0 0 0 0 0 0 0 0 FREDERICK ILGENFRITZ MD BOARD MEMBER/PHYSICIAN THRU APRIL 20 298976 0 3477 0 0 0 54000 0 9996 0 366449 0 0 0 ALLEN W JONES MD BOARD MEMBER/PHYSICIAN 213456 0 89658 0 0 0 36000 0 8730 0 347844 0 0 0 BRIAN KELLEHER MD BOARD MEMBER/PHYSICIAN 176744 0 0 0 0 0 0 0 0 0 176744 0 0 0 TIMOTHY WOODS MD BOARD MEMBER/PHYSICIAN 457906 0 67743 0 0 0 42000 0 12333 0 579982 0 0 0 JOHN M BARTOS CEO/SECRETARY/TREASURER 253806 0 68935 0 0 0 24000 0 9374 0 356115 0 0 0 DONJA C ERDMAN CFO 137256 0 781 0 0 0 28600 0 2209 0 168846 0 0 0 JOHN MORELAND MD CHIEF MEDICAL OFFICER 228854 0 71027 0 0 0 39012 0 532 0 339425 0 0 0 TROY HANSON ASSISTANT ADMINISTRATOR 157276 0 7288 0 0 0 2025 0 12574 0 179163 0 0 0 MARY CAMDEN MD PHYSICIAN 311040 0 7686 0 0 0 7200 0 9738 0 335664 0 0 0 RICHARD DAY MD PHYSICIAN 824551 0 98595 0 0 0 42000 0 1049 0 966195 0 0 0 JEREMIAH CLINTON MD PHYSICIAN 392146 0 5098 0 0 0 31500 0 8267 0 437011 0 0 0 JENNIFER FEIGHNER MD PHYSICIAN 270747 0 25701 0 0 0 7898 0 13566 0 317912 0 0 0 MARK CALDERWOOD MD PHYSICIAN 292029 0 104528 0 0 0 24000 0 6818 0 427375 0 0 0 PART I, LINE 1A DR RICHARD DAY RECEIVES A HOUSING ALLOWANCE OF $7,200 THAT IS NOT INCLUDED IN HIS TAXABLE INCOME. THE HOUSE IS PROVIDED TO DR DAY AS A CONVENIENCE TO MARCUS DALY MEMORIAL HOSPITAL. PART I, LINE 1B THE CEO HAS BEEN APPROVED BY THE BOARD OF DIRECTORS TO RECEIVE A MONTHLY $400 VEHICLE ALLOWANCE. A MT HEALTH FACILITY AUTHORITY 810302406 612043ED7 2007-01-31 7068924 CONSTRUCTION OF A NEW EMERGENCY DEPARTMENT 0 0 0 A 2230000 7135000 534379 155264 5973474 2008 0 0 1 1 A 0 0 0 0 0 0 0 A 0 0 0 1 0 0 0 0 0 A 1 DATE REBATE COMPUTATION PERFORMED ISSUER NAME: MT HEALTH FACILITY AUTHORITY DATE THE REBATE COMPUTATION WAS PERFORMED: 08/01/2014 PART II, LINE 3, PROCEEDS OF ISSUE THE ISSUE PRICE OF $7,068,924 (PART I, COLUMN E) DOES NOT EQUAL THE TOTAL PROCEEDS OF ISSUE OF $7,135,000 (PART II, LINE 3) BECAUSE OF A $66,076 ORIGINAL ISSUE DISCOUNT. KATHLEEN OWINGS SPOUSE OF BOARD MEMBER 148651 EMPLOYMENT 0 FORM 990, PART VI, SECTION B, LINE 11 A REPRESENTATIVE FROM CLIFTONLARSONALLEN WILL BE RESPONSIBLE TO PRESENT THE FORM 990 TO THE HOSPITAL FINANCE COMMITTEE. UPON APPROVAL THE FORM 990 WILL BE PRESENTED TO THE BOARD OF DIRECTORS FOR ACCEPTANCE AND APPROVAL. FORM 990, PART VI, SECTION B, LINE 12C ANY DIRECTOR, CORPORATE OFFICER, SENIOR MANAGER, TRUSTEE OR MEMBER OF A COMMITTEE WITH GOVERNING BOARD DELEGATED POWERS, WHO HAS A DIRECT OR INDIRECT FINANCIAL INTEREST, IS AN INTERESTED PERSON. IF A PERSON IS AN INTERESTED PERSON WITH RESPECT TO ANY ENTITY IN THE HEALTH CARE SYSTEM OF WHICH THE HOSPITAL IS A PART, HE OR SHE IS AN INTERESTED PERSON WITH RESPECT TO ALL ENTITIES IN THE HEALTH CARE SYSTEM. UPON APPOINTMENT, HIRE OR TRANSFER AND ANNUALLY THEREAFTER, EACH INTERESTED PERSON SHALL EXECUTE AND SUBMIT TO THE HOSPITAL'S CEO A STATEMENT WHICH AFFIRMS SUCH PERSON: A. HAS RECEIVED A COPY OF THE CONFLICT OF INTEREST POLICY; B. HAS READ AND UNDERSTANDS THE POLICY; C. HAS AGREED TO COMPLY WITH THE POLICY; AND D. UNDERSTANDS THAT THE HOSPITAL IS A CHARITABLE ORGANIZATION AND IN ORDER TO MAINTAIN ITS FEDERAL AND STATE TAX EXEMPTIONS IT MUST ENGAGE PRIMARILY IN ACTIVITIES WHICH ACCOMPLISH ONE OR MORE OF ITS TAX-EXEMPT PURPOSES. IN CONNECTION WITH ANY ACTUAL OR POSSIBLE CONFLICT OF INTEREST, AN INTERESTED PERSON MUST DISCLOSE THE EXISTENCE OF THE CONFLICTING FINANCIAL INTEREST AND MUST BE GIVEN THE OPPORTUNITY TO DISCLOSE ALL MATERIAL FACTS TO THE DIRECTORS AND MEMBERS OF COMMITTEES WITH GOVERNING BOARD DELEGATED POWERS CONSIDERING THE PROPOSED TRANSACTION OR ARRANGEMENT. ANY OTHER MEMBER OF THE BOARD OR COMMITTEE MAY RAISE THE QUESTION OF WHETHER A CONFLICT EXISTS, DISCLOSE FACTS RELATING TO THE CONFLICT AND REQUEST THE INTERESTED PERSON TO PROVIDE FURTHER DETAILS. THE BOARD CHAIR (OR VICE CHAIR ACTING IN THE PLACE OF THE CHAIR) OR THE HOSPITAL'S LEGAL COUNSEL MAY, BASED ON THEIR INFORMATION ABOUT THE CONFLICT, DISCLOSE THE CONFLICT AND REQUEST THE INTERESTED PERSON TO WITHDRAW FROM DISCUSSION OF THE TRANSACTION AND/OR NOT VOTE. THE INTERESTED PERSON SHALL LEAVE THE MEETING OR REQUEST A DETERMINATION BY THE BOARD OR COMMITTEE OF WHETHER A CONFLICT OF INTEREST EXISTS. AFTER DISCLOSURE OF THE CONFLICTING INTEREST AND ALL MATERIAL FACTS, AND AFTER ANY DISCUSSION WITH THE INTERESTED PERSON, HE/SHE SHALL LEAVE THE GOVERNING BOARD OR COMMITTEE MEETING WHILE THE DETERMINATION OF A CONFLICT OF INTEREST IS DISCUSSED AND VOTED UPON. THE REMAINING, DISINTERESTED BOARD OR COMMITTEE MEMBERS SHALL DECIDE IF A CONFLICT OF INTEREST EXISTS BEFORE CONSIDERING OR ACTING UPON ANY OTHER BUSINESS. AFTER EXERCISING DUE DILIGENCE, THE GOVERNING BOARD OR COMMITTEE SHALL DETERMINE WHETHER THE HOSPITAL CAN OBTAIN WITH REASONABLE EFFORTS A MORE ADVANTAGEOUS TRANSACTION OR ARRANGEMENT WITH REASONABLE EFFORTS FROM A PERSON OR ENTITY THAT WOULD NOT GIVE RISE TO A CONFLICT OF INTEREST. IF A MORE ADVANTAGEOUS TRANSACTION OR ARRANGEMENT IS NOT REASONABLY ATTAINABLE UNDER CIRCUMSTANCES NOT PRODUCING A CONFLICT OF INTEREST, THE GOVERNING BOARD OR COMMITTEE SHALL DETERMINE BY A MAJORITY VOTE OF THE DISINTERESTED DIRECTORS WHETHER THE TRANSACTION OR ARRANGEMENT IS IN THE HOSPITAL'S BEST INTEREST, FOR ITS OWN BENEFIT, AND WHETHER IT IS FAIR AND REASONABLE. IN CONFORMITY WITH THE ABOVE DETERMINATION, THE GOVERNING BOARD OR COMMITTEE SHALL MAKE ITS DECISION AS TO WHETHER TO ENTER INTO THE TRANSACTION OR ARRANGEMENT. FORM 990, PART VI, SECTION B, LINE 15A ON AN ANNUAL BASIS, THE NON-CONFLICTED HOSPITAL BOARD MEMBERS (COMPENSATION COMMITTEE) RECEIVES THE ANNUAL COMPENSATION AND BENEFIT SURVEY PREPARED BY THE MONTANA HOSPITAL ASSOCIATION (MHA). THE COMMITTEE ALSO RECEIVES A REPORT FROM THE HOSPITAL THAT INCLUDES RESEARCH OF ALL CRITICAL ACCESS HOSPITALS IN THE STATES OF MONTANA, IDAHO, AND WYOMING. USING THIS INFORMATION THE COMPENSATION COMMITTEE THEN PROVIDES A RECOMMENDATION FOR CEO COMPENSATION TO THE FULL HOSPITAL BOARD. THE CEO HAS THE AUTHORITY TO SET THE COMPENSATION OF OTHER OFFICERS AND KEY EMPLOYEES OF THE HOSPITAL. FOR PHYSICIAN COMPENSATION, THE HOSPITAL USES A THIRD PARTY CPA FIRM TO GATHER COMPENSATION DATA FROM MGMA AND NON-PHYSICAN COMPENSATION INFORMATION IS FROM THE MHA COMPENSATION SURVEY. FORM 990, PART VI, SECTION C, LINE 18 IN ADDITION TO BEING AVAILABLE UPON REQUEST, A COPY OF THE FORM 990 IS ALSO AVAILABLE AT WWW.GUIDESTAR.ORG. FORM 990, PART VI, SECTION C, LINE 19 GOVERNING DOCUMENTS AND CONFLICT OF INTEREST POLICY ARE NOT MADE AVAILABLE TO THE PUBLIC. FINANCIAL STATEMENTS ARE MADE AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART XI, LINE 9: CHANGE IN BENEFICIAL INTEREST IN NET ASSETS OF DALY HOSPITAL FOUNDATION -262,692. AUXILIARY 4,411. DALY HOSPITAL FOUNDATIONINC 1200 WESTWOOD DRIVE HAMILTON MT 59840 363766000 CHARITABLE SERVICES MT 501(C)(3) LINE 7 N/A 0 0 0 1 0 0 0 0 0 0 0 0 1 1 1 1 0 0 0 0