2017-02-10T13:34:14-06:00 2016-06-30 390758449 Wipfli LLP PO Box 8010 Wausau WI 544028010 990 2015-07-01 381443361 Aspirus Keweenaw Hospital ASPI 9063376500 205 OSCEOLA LAURIUM MI 49913 Shane Jacques CFO 9063376500 2017-01-19 1 Kathleen J LaBrake CPA P00164006 7158453111 2017-01-19 2015 2017-02-10 21:41:12Z Shane Jacques 205 Osceola Street Laurium MI 49913 53975294 0 X www.aspiruskeweenaw.org X 1939 MI ASPIRUS KEWEENAW HOSPITAL PROVIDES COMPREHENSIVE INPATIENT, OUTPATIENT, EMERGENCY, MEDICAL AND PHYSICIAN CLINIC SERVICES. 12 6 500 87 -181 -181 14668 12000 46217058 52859532 447475 186804 2027675 854245 48706876 53912581 0 0 0 0 25657467 24084104 0 0 0 20300031 27724367 45957498 51808471 2749378 2104110 52703026 51639337 29428946 23672074 23274080 27967263 To provide comprehensive inpatient, outpatient, emergency, medical, and physician clinic services. 0 0 42026333 53356904 ASPIRUS KEWEENAW HOSPITAL PROVIDES COMPREHENSIVE INPATIENT, OUTPATIENT, EMERGENCY, MEDICAL, AND PHYSICIAN CLINIC SERVICES. ASPIRUS KEWEENAW PROVIDES EYE CLINIC SERVICES. ASPIRUS KEWEENAW BUILT A NEW ER, MED/SURGE ROOMS, ICU, OB REMODEL AND OTHER AREAS IN THE HOSPITAL DURING FY 2016 TO MEET THE NEEDS OF THE COMMUNITY. 42026333 1 0 0 1 0 0 0 0 0 0 1 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 85 0 1 500 1 1 1 0 0 0 0 0 0 0 0 0 X 12 6 1 0 1 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 X SHANE JACQUES 9063376500 205 OSCEOLA STREET LAURIUM MI 49913 DANIEL DALQUIST CHAIRMAN 1.00 0.00 X X 0 0 0 EDWARD JENICH VICE CHAIRMAN 1.00 0.00 X X 20800 0 0 DAVID GILBERT MD SECRETARY 1.00 0.00 X X 0 0 0 CHARLES NELSON BOARD MEMBER / REGIONAL UP CEO 20.00 22.00 X X 0 353959 73509 MATTHEW HEYWOOD BOARD MEMBER / CEO OF AI 1.00 50.00 X X 0 884848 132937 JERRY LUOMA MD BOARD MEMBER 1.00 0.00 X 0 0 0 Sara Lusignan Board member/ VP of Finance AI 1.00 41.00 X 0 191644 27099 DARRYL PIERCE BOARD MEMBER 1.00 0.00 X 0 0 0 Dr Feeley Board Member/ Medical Staff Rep 40.00 X 0 0 0 JOHN HEISLER BOARD MEMBER & SR VP/CHIEF AR Officer 1.00 49.00 X 0 336213 63612 JOHN HORAN MD BOARD MEMBER & MEDICAL STAFF - TERMED 40.00 X 506320 0 27998 MICHAEL LUOMA MD BOARD MEMBER 40.00 X 288038 0 28845 ELIZABETH BENYI DO BOARD MEMBER - Termed 10/2015 & CHIEF OF ST 40.00 X 232585 0 16296 DALE R TAHTINEN BOARD MEMBER 1.00 0.00 X 0 0 0 JOEL TUORINIEMI BOARD MEMBER 1.00 0.00 X 0 0 0 SANDRA HUUKI BOARD MEMBER-Termed 10/2015 1.00 1.00 X 0 0 0 DARRELL LENTZ BOARD MEMBER - Termed 10/2015/ President AWH 1.00 43.00 X 0 379962 73870 MICHAEL HAUSWIRTH AKH CEO 28.00 12.00 X 238171 0 21199 SIDNEY C SCZYGELSKI CFO OF AI 1.00 51.00 X 0 580594 89459 SHANE JACQUES REGIONAL CFO 20.00 20.00 X 211045 0 29665 Grace Tousignant Regional CNO 20.00 21.00 X 163844 0 22787 Dean Danner SVP Ambulatory Services, President ACI 1.00 48.00 X 0 333863 69073 Kathyrne McGowan SVP Population Health, Executive Director ANI 1.00 50.00 X 0 288000 61581 Ruth Risley-Grey SVP Nursing, CNO 1.00 49.00 X 0 307360 65088 Rick Nevers SVP Reg Ops System Int Officer 1.00 50.00 X 0 391429 71338 Cari Logemann SVP & General Counsel 1.00 50.00 X 0 324135 70669 Todd Richardson SVP & CIO 1.00 50.00 X 0 334322 77297 Micheal McGrail SVP System CMO 1.00 50.00 X 0 439142 69729 Fredrick Rau Physician 40.00 X 523642 0 34659 Shahar Madjar Physician 40.00 X 443413 0 31099 Bonnie Hafeman Physician 40.00 X 382005 0 29025 Cynthia Jensen Physician 40.00 X 418128 0 8493 Micheal McAllister Physician 40.00 X 363147 0 9547 3791138 5145471 1204874 33 0 1 0 COAST TO COAST HEALTH CARE PO BOX 56346 ATLANTA GA 30343 CONTRACTED PROVIDERS 548600 Thomas K Carlson 1 Aspen Lane Gladstone MI 49837 ContrACTED PROVIDERS 341200 Donald Patton MD 163 E Hagerman lake iron river MI 49935 CONTRACTED PROVIDERS 193369 Locum Tenenscom LLC 2655 Northwinds Pkwy Alpheretta GA 30009 ContrACTED PROVIDERS 179087 Management health systems inc 1580 sawgrass corporate parkway sui sunrise FL 33323 CONTRACTED PROVIDERS 167485 6 9377 2623 12000 Net Patient Service Revenue 621990 49031283 49031283 340B Revenue Drug Program 900099 3689193 3689193 Cafeteria Revenue 624200 130341 130341 Vending revenue 624200 8715 8715 52859532 186804 186804 162928 62713 100215 100215 -181 100396 E.H.R INCENTIVE 900099 636488 636488 Other Revenue 999999 117542 117542 754030 53912581 53356964 -181 543798 1169848 644922 524926 18590432 17420664 1169768 588459 537991 50468 2534096 2324875 209221 1201269 1097173 104096 42165 42165 68563 68563 4246520 3904278 342242 199081 30362 168719 9581998 9388938 193060 155450 118374 37076 638009 638009 248284 167706 80578 664174 664174 2781493 2700541 80952 269833 170314 99519 Corporate Allocations 5817651 5817651 EQUIPMENT RENTAL AND MA 1347838 1175575 172263 Provision for bad debts 990276 990276 DUES AND SUBSCRIPTIONS/ 654894 45454 609440 18138 6707 11431 51808471 42026333 9782138 0 1050658 4723307 9273561 6458511 5876637 4523026 600250 557759 675864 936212 47649989 19619295 24596835 28030694 6012379 360344 1490088 2207602 56567 32324 3070187 3809558 52703026 51639337 6786712 4652043 1259490 1387115 18669750 16804846 664025 2048969 828070 29428946 23672074 X 23274080 27967263 23274080 27967263 52703026 51639337 X 2104110 2589073 X X 0 1 X 1 0 X 0 0 0 0 0 0 0 0 1 6393 6393 0 Part II-B, Line 1: Organization has indirect lobbying activities through the payment of hospital association dues. 874763 874763 23042054 7036703 16005351 1889462 855629 1033833 20954832 11726963 9227869 888878 888878 28030694 Due from Aspirus Keweenaw enterprises 1498078 Due from Aspirus Keweenaw Foundation 4570 Note Receivable 892500 Due from other entities 136096 THIRD PARTY RECEIVABLES 679614 Other 598700 3809558 Long Term Insurance Payable 427853 Asbestos Liability 21448 Medicare Payable 9498 Blue Cross Payable 344579 Other Third Party Payable 24692 828070 X Part X, Line 2: ALL SUBSIDIARIES, EXCEPT FOR ASPIRUS NETWORK, INC. (ANI), ARE TAX-EXEMPT CORPORATIONS AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE (THE "CODE") AND ARE EXEMPT FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 509(A)(2) OF THE CODE. THEY ARE ALSO EXEMPT FROM STATE INCOME TAXES ON RELATED INCOME. ASPIRUS IS ALSO ENGAGED, TO A LIMITED EXTENT, IN CERTAIN ACTIVITIES SUBJECT TO TAXATION AS UNRELATED BUSINESS INCOME (UBI). INCOME TAXES ON UBI ARE NOT SIGNIFICANT. INCOME TAXES FOR ANI, A NOT-FOR-PROFIT TAXABLE CORPORATION, WERE IMMATERIAL FOR THE YEARS ENDED JUNE 30, 2016 AND 2015. 1 1 X 1 X 1 X 1 1 0 1 1 323446 323446 0.00640 9668801 6102759 3566042 0.07020 9992247 6102759 3889488 0.07660 82152 82152 0.00160 5192922 5013060 179862 0.00350 19070 19070 0.00040 5294144 5013060 281084 0.00550 15286391 11115819 4170572 0.08210 1 329237 13077585 13004289 73296 X 1 0 1 1 Aspirus keweenaw hospital 205 Osceola Street Laurium MI 49913 www.aspiruskeweenaw.org 1060000151 X X X X PHYSICIAN CLINIC, HOME MEDICAL EQUIPMENT, & PHARMACY Aspirus Keweenaw Hospital 1 0 0 1 X X X X X X X X X 15 1 1 1 1 X http://www.aspirus.org/Main/Community-Resources.aspx?srcaud=Main X 1 15 1 SEE PART V - SUPPLEMENTAL INFORMATION FOR WEB ADDRESS 1 0 1 X 200.000000000000 300.000000000000 X X X X 1 1 X X X 1 X http://www.aspirus.org/Main/Pay-My-Bill.aspx?srcaud=Main#tab2 X http://www.aspirus.org/Uploads/Public/Documents/Financial-Aid-Application.p X http://www.aspirus.org/Main/Pay-My-Bill.aspx?srcaud=Main#tab2 X X X X X X 1 X 0 X X X X 1 X 0 0 Aspirus Keweenaw Hospital Part V, Section B, Line 5: Survey by mail and participation in regional health assessments with other hospitals and agencies. Aspirus Keweenaw Hospital Part V, Section B, Line 6a: Aspirus Grand View, Aspirus Ontonagon, Baraga County Memorial Hospital, U.P. Health System - Portage. Aspirus Keweenaw Hospital Part V, Section B, Line 6b: Western Upper Peninsula Health Department and Copper County Memorial Health Services Aspirus Keweenaw Hospital Part V, Section B, Line 11: Four major priority areas were selected by the steering committee on a regional scale with a goal of the member organizations to continue to work together, add members, pool resources, leadership, and expertise to develop initiatives with an even greater impact on a region basis than an individual organization might be able to undertake, especially with limited resources.The 1st of the four priority areas and overarching theme of all four priorities is The Importance of Prevention. Aspirus Keweenaw will target root causes of heart disease, cancer, stroke, and diabetes. The strategies and goals are:1. Focus human resource and local public relations resources on healthy eating and nutrition community outreach.2. Expand attendance of fitness classes or personal training sessions and facility usage by 5% annually at Laurium Fitness Center. Target 50 percent of that expansion to aging population.3. Continue to support the diabetes education program through offering a variety of avenues for education to the community. Grow patient encounters by 5 percent annually over 3 years.4. Identify patient population who have diabetes and also use tobacco products and provide cessation education to 20 percent of the identified population5. Reach 50 percent of Houghton and Keweenaw County population annually with "how-to" information regarding positive disease prevention behaviors and access to services. Aspirus Keweenaw Hospital Part V, Section B, Line 16i: BILLING INVOICES CONTAIN CONTACT INFORMATION FOR MORE INFORMATION ABOUT THE THE FINANCIAL ASSISTANCE POLICY. A POSTING OF HOW TO OBTAIN MORE INFORMATION ON THE FINANCIAL ASSISTANCE POLICY IS LOCATED IN THE EMERGENCY AND WAITING ROOMS. Aspirus Keweenaw Hospital Part V, Section B, Line 22d: Aspirus Keweenaw Hospital uses the Lookback method to determine the amounts charged to FAP eligible individuals are based on FPL level. This is discounted using average past amounts paid by commercially insured and medicare patients to the hospital. PART V, SECTION B, LINE 5A HOSPTIAL WEB ADDRESS TO LOCATE CHNA: http://aspirus.org/Main/Community-Resources.aspx 5 1 - ASPIRUS HOUGHTON CLINIC 1000 CEDAR STREET HOUGHton MI 49931 CLINIC & Outpatient Therapy 2 - Aspirus Keweenaw Outpatient Therapies 342 Hecla Street Laurium MI 49913 Outpatient Therapy 3 - Aspirus Keweenaw Laurium Wellness 300 Hecla Street Laurium MI 49913 Clinic 4 - Aspirus Eye Clinic 404 East Sharon Avenue Houghton MI 49931 Clinic 5 - Aspirus Keweenaw Lake Linden Clinic 110 Calumet StREET Lake Linden MI 49945 Clinic Part I, Line 3c: The patient/guarantor, husband or wife, and dependents may not have property in excess of:Primary residence is exempt for patients under 200% federal poverty guidelines. For those over 200% equity allowance is $75,000 (financial statements and tax bills are required). Income producing land (e.g., dairy farm) is evaluated individually on a case-by-case basis. Cash assets in excess of $4,000 at the time of application. Specifically excluded from consideration are IRA and Pension Plans and Irrevocable Burial Trust Funds.Total net assets cannot exceed 800% of federal poverty guidelines. This includes all assets including cash assets above. Part I, Line 7: The cost method that is used on the Form 990 is based on a cost to charge ratio which is developed based on the hospital's total operating expenses less the provision for bad debts. This is then divided by gross patient services revenue. Part I, Line 7g: The cost of subsidized heatlh services are related to the Laurium Clinic. Aspirus Keweenaw Hospital utilized an internal departmental financial statement to report the cost and direct offsetting revenue that calculates the community benefit expense. Part I, Ln 7 Col(f): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 24C, BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGES IN THIS COLUMN IS $990,276. Part II, Community Building Activities: While there is growing agreement in the United States about what constitutes a non-profits hospital's community benefit and charity care, these efforts continue to be a work in progress. Aspirus Keweenaw Hospital, Inc., in addition to providing significant charity care and other community benefits as defined by the IRS, the organization believes that it provides a critically important benefit which is not quantified. Aspirus Keweenaw Hospital, like most community hospitals, was created and is maintained in order to provide care locally which without the hospital would not be available locally. In addition to inpatient hospitalizations, the organization provides local access to many services including: Emergency services, respiratory therapy, occupational therapy, physical therapy, family practice clinics, and laboratory and pathology services. Part III, Line 4: In evaluating the collectability of accounts receivable, the Organization analyzes past results and identifies trends for each of its major payor sources of revenue to estimate the appropriate allowance for doubtful accounts and the 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. Specifically, for receivables relating to services provided to patients having third-party coverage, the Organization analyzes contractually due amounts and provides an allowance for doubtful accounts and a provision for bad debts 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 Organization 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: Allowable Medicare costs were obtained from the Organization's filed Medicare Cost Report. As such they only include the amounts allowed in the form 990 instructions. Therefore, they only include a portion of the gross Medicare revenue of the organization and do not consider all of the contractual adjustments for services reimbursed by the Medicare program. The Medicare revenues amounts listed do not include physician services for the coverage of the emergency department at the hospital as well as anesthesia professional services, revenues for any patients covered under Medicare advantage plan programs, physical therapy services provided to nursing home residents, and a significant portion of lab services provided to area clinic patients. Part III, Line 9b: Upon a patients approval for financial assistance, this is loaded as an insurance coverage to the patients account with an effective and termination date to assure capturing all charges for the patient for adjustment in a workqueue prior to any remaining balance being moved to patient liability and therefore preventing undiscounted services from being billed to a patient. Part VI, Line 2: The organization meets with a local federally qualified health center to consult and determine how to meet the health care needs in the organization's geographical area. In addition, the organization itself evaluates its' own services offered in their service area and evaluates other services that could be provided to benefit the community served. Part VI, Line 3: All patient statements provide information regarding the Aspirus Finacial Aid Program. This includes a telephone number to request in-person assistance, information about the program as well as to request an application. The statement also provides the web address which directs patients to our financial aid policy as well as the application and plain language summary. Letters from Central Billing Office staff inform patients that Aspirus has a FAP. The FAP is offered at the time of registration annually to all patients. Financial Counselors offer FAP to patients during collection calls. Aspirus has Certified Application Counselors that are available to assist with Marketplace enrollment at well as Medical Assistance applications. Cardon Outreach is used to review all patients that are inpatient or present to the ED to assist with Medical Assistance applications. Part VI, Line 4: The organization provides services primarily to the elderly and frail of Northern Houghton and Keweenaw counties. The largest cities in these regions include Houghton, Hancock, Laurium and Calumet. As a percentage of total revenue, Medicare and Medicaid comprise of 47% and 20%, respectively for the organization. Part VI, Line 5: The board of director's is comprised of independent community members. The organization provides, free of charge to the local school, an athletic trainer. Part VI, Line 6: ASPIRUS KEWEENAW IS AN AFFILIATED HEALTH SYSTEM WHICH SERVES THE COMMUNITY SURROUNDING LAURIUM, MICHIGAN. AFFILIATES OF ASPIRUS KEWEENAW PROMOTE THE HEALTH OF THE COMMUNITY BY FULFILLING THEIR INDIVIDUAL MISSIONS. ASPIRUS KEWEENAW PROVIDES PHYSICIAN SERVICES IN OUTPATIENT CLINICS. Part VI, Line 7, Reports Filed With States MI X X 1 1 X X X X X 0 1 0 0 0 0 0 0 0 CHARLES NELSON BOARD MEMBER / REGIONAL UP CEO 0 248933 0 62538 0 42488 0 17371 0 56138 0 427468 0 0 MATTHEW HEYWOOD BOARD MEMBER / CEO OF AI 0 649912 0 232922 0 2014 0 13360 0 119577 0 1017785 0 0 Sara Lusignan Board member/ VP of Finance AI 0 169081 0 10000 0 12563 0 0 0 27099 0 218743 0 0 JOHN HEISLER BOARD MEMBER & SR VP/CHIEF AR Office 0 256725 0 70436 0 9052 0 12179 0 51433 0 399825 0 0 JOHN HORAN MD BOARD MEMBER & MEDICAL STAFF - TERME 505713 0 0 0 607 0 5085 0 22913 0 534318 0 0 0 MICHAEL LUOMA MD BOARD MEMBER 274855 0 8000 0 5183 0 7040 0 21805 0 316883 0 0 0 ELIZABETH BENYI DO BOARD MEMBER - Termed 10/2015 & CHIE 231048 0 75 0 1462 0 9306 0 6990 0 248881 0 0 0 DARRELL LENTZ BOARD MEMBER - Termed 10/2015/ Presi 0 253833 0 67811 0 58318 0 18258 0 55612 0 453832 0 0 MICHAEL HAUSWIRTH AKH CEO 199710 0 34111 0 4350 0 8116 0 13083 0 259370 0 0 0 SIDNEY C SCZYGELSKI CFO OF AI 0 376534 0 157197 0 46863 0 18660 0 70799 0 670053 0 0 SHANE JACQUES REGIONAL CFO 172833 0 31462 0 6750 0 7417 0 22248 0 240710 0 0 0 Grace Tousignant Regional CNO 138628 0 23939 0 1277 0 5725 0 17062 0 186631 0 0 0 Dean Danner SVP Ambulatory Services, President A 0 232445 0 63986 0 37432 0 17028 0 52045 0 402936 0 0 Kathyrne McGowan SVP Population Health, Executive Dir 0 245256 0 41541 0 1203 0 4662 0 56919 0 349581 0 0 Ruth Risley-Grey SVP Nursing, CNO 0 237122 0 67504 0 2734 0 14872 0 50216 0 372448 0 0 Rick Nevers SVP Reg Ops System Int Officer 0 291780 0 68268 0 31381 0 18145 0 53193 0 462767 0 0 Cari Logemann SVP & General Counsel 0 253718 0 69397 0 1020 0 15593 0 55076 0 394804 0 0 Todd Richardson SVP & CIO 0 261084 0 71992 0 1246 0 18113 0 59184 0 411619 0 0 Micheal McGrail SVP System CMO 0 370677 0 58414 0 10051 0 3750 0 65979 0 508871 0 0 Fredrick Rau Physician 518774 0 0 0 4868 0 10600 0 24059 0 558301 0 0 0 Shahar Madjar Physician 442033 0 0 0 1380 0 9000 0 22099 0 474512 0 0 0 Bonnie Hafeman Physician 381674 0 0 0 331 0 7735 0 21290 0 411030 0 0 0 Cynthia Jensen Physician 416544 0 0 0 1584 0 0 0 8493 0 426621 0 0 0 Micheal McAllister Physician 362859 0 0 0 288 0 0 0 9547 0 372694 0 0 0 Part I, Line 1a TRAVEL FOR COMPANIONS, AND HOUSING ALLOWANCES, WHEN APPLICABLE, WERE ADDED TO THE INDIVIDUAL'S COMPENSATION AT FAIR VALUE. TRAVEL FOR COMPANIONS: C.NELSON $160, D. LENZ $209, J. HEISLER $184, M. HEYWOOD $174, S. LUSIGNAN $132; D. DANNER $105; K. MCGOWAN $120; R. RISLEY-GREY $175; R. NEVERS $202; T. RICHARDSON $105; S. SCZYGELSKI $166 - INCLUDED IN INCOME. HOUSING ALLOWANCE OR RESIDENCE FOR PERSONAL USE: S. LUSIGNAN $3,600; M. MCGRAIL $1,200 - INCLUDED IN INCOME. Part I, Line 3 FOR THE PURPOSE OF DETERMINING COMPENSATION, ASPIRUS KEWEENAW HOSPITAL RELIED ON RELATED ORGANIZATIONS TO ESTABLISH COMPENSATION OF THE CEO, OTHER OFFICERS AND KEY EMPLOYEES. THE RELATED ORGANIZATIONS USED THE FOLLOWING PRACTICIES FOR ESTABLISHING COMPENSATION FOR SUCH INDIVIDUAL: COMPENSATION COMMITTEE, INDEPENDENT COMPENSATION CONSULTANT, WRITTEN EMPLOYMENT CONTRACT, COMPENSATION SURVEY OR STUDY, AND APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE. Part I, Line 4b Schedule J, Part I, Line 4b - Supplemental nonqualified retirment 457 (f) Distribution: KEY EMPLOYEES OF THE ORGANIZATION OR A PARTICIPATING AFFILIATE ARE ELIGIBLE TO PARTICIPATE IN THE PLAN. THE PLAN YEAR IS JANUARY 1 TO DECEMBER 31ST. EMPLOYER CONTRIBUTIONS: THE CONTRIBUTION MADE BY THE EMPLOYER IS A THREE-TIERED STRUCTURE DEPENDING UPON THE EXECUTIVE'S POSITION, WHICH ARE AS FOLLOWS: 9% FOR VICE PRESIDENT, 13% FOR SENIOR LEADERSHIP COUNCIL, AND 15% FOR THE CEO. IF A PARTICIPANT TERMINATES DURING THE YEAR, THE PARTICIPANT'S EXECUTIVE ALLOWANCE IS PRORATED BASED ON THE NUMBER OF FULL CALENDAR MONTHS FROM THE BEGINNING OF THE PLAN YEAR TO THE BEGINNING OF THE CALENDAR YEAR MONTH CLOSEST TO THE CHANGE OR TERIMINATION OF EMPLOYMENT. DISTRIBUTIONS: CONTINUATION OF EMPLOYMENT THROUGH THE DEFERRED VESTING DATE; THE DATE ON WHICH THE PARTICIPANT'S EMPLOYMENT IS TERMINATED AS A RESULT OF A DEATH OR DISABILITY; THE DATE ON WHICH THE PARTICIANT INCURS AN INVOLUNTARY SEPARATION FROM SERVICE WITHOUT REASONABLE CASUSE; OR THE DATE THAT IS 24 MONTHS FOLLOWING THE PARTICIPANT'S SEPARATION FROM SERVICE, BUT ONLY IF THE PARTICIPANT'S INTEREST HAS NOT BEEN FORFEITED FROM COMPETITION DURING SUCH 24 MONTH PERIOD AND THE PARTICIPANT HAS NOT ENGAGED IN COMPETITION AFTER HIS OR HER SEPARATION FROM SERVICE AND PRIOR TO HIS OR HER DEATH, THE PARTICIPANT SHALL BE VESTED AT HIS OR HER DATE OF DEATH. C. NELSON $35,744 D. LENZ $54,129 S. SCZYGELSKI $40,323 D. DANNER $31,730 R. NEVERS $29,240 A WISCONSIN HEALTH AND EDUCATIONAL FACILITIES AUTHORITY 391337855 97712DMG9 2015-05-07 16997543 NEW CONSTRUCTION 0 0 0 A 16997543 16112065 893854 0 0 0 1 A 0 0 1 0 0 0.00500 0.00500 1 0 1 A 0 1 0 0 0 0 0 0 1 A 1 SCHEDULE K, PART VI The proceeds of the Wisconsin Health and Educational Facilities Authority Revenue Bonds, Series 2015 (Aspirus, Inc. Obligated Group) were borrowed by the following organizations: Aspirus Riverview Hospital & Clinics, Inc. (EIN 39-0868982); Aspirus Iron River Hospital & Clinics, Inc. (EIN 38-3236977); and Aspirus Keweenaw Hospital (EIN 38-1443361). Information regarding the Series 2015 Bonds is reported in the Schedule K for each organization. [The information reported in Part I, Part II and Part III relates only to the portion of the Series 2015 Bonds loaned to the Organization. The information reported in Part IV relates to the entire issue of the Series 2015 Bonds.] SCHEDULE K, PART III - LINE 3A AND 3B ASPIRUS, INC., THE PARENT ORGANIZATION OF ASPIRUS KEWEENAW HOSPITAL, HAS POLICIES AND PROCEDURES IN PLACE TO REVIEW MANAGEMENT AND SERVICE CONTRACTS TO IDENTIFY AGREEMENTS THAT MAY RESULT IN PRIVATE BUSINESS USE OF BOND-FINANCED PROPERY. ON A CONTRACT BY CONTRACT BASIS, ASPIRUS, INC. WILL SEEK HELP FROM BOND COUNSEL AS MANAGEMENT DEEMS NECESSARY. Form 990, Part VI, Section A, line 2 Jerry Luoma and Michael Luoma have a family relationship. Form 990, Part VI, Section A, line 4 The by-laws were updated to reflect effective december 1, 2015 aspirus, inc. became the sole corporate member of aspirus keweenaw hospital. Form 990, Part VI, Section A, line 6 Prior to December 1, 2015, Aspirus, Inc. and Keweenaw Health Foundation were voting members. Effective December 1, 2015 Aspirus, Inc. became the sole corporate and voting member of Aspirus Keweenaw Hospital. Form 990, Part VI, Section A, line 7a THE BOARD OF DIRECTORS IS COMPRISED OF 7 MEMBERS FROM ASPIRUS, INC. AND 3 MEMBERS FROM KEWEENAW HEALTH FOUNDATION. THERE SHALL BE THREE CLASSES OF VOTING DIRECTORS: THE ASPIRUS CLASS, COMMUNITY CLASS, AND THE PROVIDER CLASS. NO LESS THAN SIX INDEPENDENT COMMUNITY CLASS DIRECTORS, CONSISTING OF THREE NOMINATED BY THE FOUNDATION BOARD OF TRUSTEES AND THREE NOMINATED BY ASPIRUS, INC. WITH CONSIDERATION TO INPUT FROM THE CORPORATION'S BOARD, AND ELECTED BY ASPIRUS, INC., TWO ASPIRUS CLASS DIRECTORS NOMINATED AND ELECTED BY ASPIRUS, INC., TWO PROVIDER CLASS DIRECTORS CONSISTING OF PHYSICIANS IN THE ACTIVE CATEGORY OF THE MEDICAL STAFF AT THE HOSPITAL, NOMINATED BY THE CORPORATION'S BOARD AND ELECTED BY ASPIRUS, INC. Form 990, Part VI, Section A, line 7b The following actions must be approved by the members of the organization: 1) Change or amend the articles of incorporation or bylaws; 2) change the mission, purpose, or scope of the corporation; 3) ratification or removal of directors or officer; 4) change the formula or methodology for determining physician compensation; 5) approval of annual operating and capital expenditure budgets, strategic and long-range plans. Form 990, Part VI, Section B, line 11 the accounting department accumulated all 990 and 990-t information, including the ubi calculations. these documents are reviewed by the cfo. the 990 and the 990-t are reviewed by other senior management prior to submission to the internal revenue service and are made available to the board of directors through director's desk or other means of electronic retrieval. Form 990, Part VI, Section B, line 12c Annually, board members are required to disclose conflicts to the board. An interested person must disclose the existence and nature of his or her financial interest to the directors and members of committees with board delegated powers. An interested person is an director, principal, officer, or member of a committe with board delegated powers who has a direct or indirect financial interest. After disclosure, the interested person shall leave the board or committee meeting while the financial interest is discussed and voted upon. The remaining members shall decide if a conflict exists. The member will abstain from voting on this issue if a conflict of interest is discovered. Form 990, Part VI, Section B, line 15 For purposes of determining compensation, Aspirus Keewenaw Hospital relied on related organizations to establish the compensation of the ceo, other officers, and key employees. the related organizations used the following practices for establishing compensation for such individuals: compensation committe, independent compensation consultant, written employment contract, compensation survery or study, and approval by the board or compensation committee. Form 990, Part VI, Section C, line 19 The organization has deemed that its governing documents, conflict of interest policy, and financial statements are the property of the organization and are not available for public inspection. Form 990, Part XI, line 9: FMV PPE Asset write-up due to acquisition 3,189,073. Equity Transfer Aspirius, Inc. -600,000. FORM 990, PART XII, LINE 2C THE AUDIT COMMITTE OF THE BOARD OF DIRECTORS OF ASPIRUS, INC. THE PARENT ORGANIZATION, ASSUMES THE RESPONSIBILITY FOR THE OVERSIGHT OF THE CONSOLIDATED AUDIT OF THE FINANCIAL STATEMENTS AND SELECTION OF THE INDEPENDENT ACCOUNTANT. THERE WAS NO CHANGE IN THIS PROCESS IN THE PAST YEAR. Aspirus Wausau Hospital Inc 333 Pine Ridge Blvd Wausau WI 54401 391138241 Hospital WI 501(c)(3) Line 3 Aspirus Inc 1 Aspirus Buildings Inc 333 Pine Ridge Blvd Wausau WI 54401 391406537 Property Leasing WI 501(c)(3) Line 9 Aspirus Inc 1 Aspirus Extended Services Inc 425 Pine Ridge Blvd Wausau WI 54401 390782130 Nursing Home Services WI 501(c)(3) Line 9 Aspirus Inc 1 Aspirus Clinics Inc 425 Pine Ridge Blvd Wausau WI 54401 391670223 Medical Services WI 501(c)(3) Line 9 Aspirus Inc 1 Aspirus Ontonagon Hospital Inc 601 Seventh Street Ontonagon MI 49953 260806447 Hospital MI 501(c)(3) Line 3 Aspirus Inc 1 Aspirus VNA Home Health Inc 520 N 32nd Avenue Wausau WI 54401 390808511 Home Healthcare Services WI 501(c)(3) Line 9 Aspirus Inc 1 Aspirus VNA Extended Care Inc 520 N 32nd Avenue Wausau WI 54401 391597350 Personal Care Services WI 501(c)(3) Line 9 Aspirus VNA Home Health Inc 1 Aspirus Health Foundation Inc 425 Pine Ridge Blvd Wausau WI 54401 391256656 Charitable Foundation WI 501(c)(3) Line 7 Aspirus Inc 1 Aspirus Grand View N 10561 Grand View Lane Ironwood MI 49938 382908586 Hospital MI 501(c)(3) Line 3 Aspirus Inc 1 Grand View Hospital Auxiliary N 10561 Grand View Lane Ironwood MI 49938 237178363 Supporting Organization to Hospital and Lifeline Emergency Center MI 501(c)(3) Line 9 Aspirus Grand View 1 Aspirus Grand View Service Corporation N 10561 Grand View Lane Ironwood MI 49938 383005582 Physician Services MI 501(c)(3) Line 3 Aspirus Grand View 1 Aspirus Inc 333 Pine Ridge Blvd wausau WI 54401 391328331 health care management system WI 501(c)(3) Line 11b, II N/A 0 ASPIRUS IRON RIVER HOSPITAL & CLINICS INC 1400 W ICE LAKE ROAD IRON RIVER MI 49935 383236977 HOSPITAL MI 501(c)(3) Line 3 ASPIRUS INC 1 Aspirus riverview hospital & clinics inc 410 dewey street wisconsin rapids WI 54494 390868982 HOSPITAL WI 501(c)(3) Line 3 ASPIRUS INC 1 Greater iron county emc 1400 w ICE LAKE ROAD irON RIVER MI 49935 383491283 emergency medical care and transportation MI 501(c)(3) Line 11a, I aspirus iron river hospital & clinics inc 1 Western Upper Michigan Eye Care LLC 131 W Genesee Street Iron River MI 44935 272324957 Eye Care Services MI N/A Aspirus Keweenaw Enterprises Inc 205 Osceola Street Laurium MI 49913 383390273 Pharmacy MI aspirus keweenaw hospital C 1895709 1759491 1.00000 1 Aspirus Network Inc 3000 Westhill Drive 202 Wausau WI 54401 391931678 Health care services WI N/A C 1 Aspirus Grand View Caring Caregivers N 10561 Grand View Lane Ironwood MI 49938 382902754 Personal Needs Services MI N/A C 1 1 1 0 0 1 0 0 0 0 1 1 1 1 1 1 1 1 0 0 Aspirus inc M 5848481 cost aspirus inc O 287954 cost aspirus inc P 801155 cost aspirus inc B 600000 cash aspirus ontonagon hospital inc L 66424 cost aspirus grand view O 295094 cost aspirus wausau hospital inc M 317478 cost Aspirus clinic inc O 125190 cost aspirus wausau hospital inc J 51865 cost aspirus wausau hospital inc O 2916023 cost aspirus wausau hospital inc P 89415 cost aspirus ontonagon hospital inc O 622029 cost aspirus ontonagon hospital inc Q 377572 cost aspirus vna home health inc B 662986 cash aspirus grand view Q 162847 cost