2016-05-16T16:54:26-05:00 2015-06-30 861065772 Deloitte Tax LLP 555 EAST WELLS STREET Suite 1400 Milwaukee WI 53202 990 2014-07-01 390905385 Calumet Medical Center Inc CALU 9208492386 614 Memorial Drive Chilton WI 53014 Brian Regan Interim CFO 2016-05-16 true Rachel Becker P00966076 4142713000 2016-03-28 2014 2016-08-17 19:52:53Z Timothy Richman 614 Memorial Drive Chilton WI 53014 28218072 false X www.affinityhealth.org X 1954 WI To further the healing ministry of Jesus by improving the health and well-being of all people. 10 5 198 61 0 0 169899 1050096 25150223 26685834 241647 154196 162720 242766 25724489 28132892 0 0 0 0 11089732 12024757 0 0 0 10255921 10360917 21345653 22385674 4378836 5747218 35423368 42872071 3162829 5061009 32260539 37811062 The mission of Calumet Medical Center, Inc. is to live out the healing ministry of Christ by providing services that promote the health and well-being of the communities we serve, especially the poor. false false 17792776 26685834 CALUMET MEDICAL CENTER, INC. OPERATES A 25-BED CRITICAL ACCESS HOSPITAL FACILITY PROVIDING MEDICAL, SURGICAL, EMERGENCY, OUTPATIENT, CLINIC, HOSPICE, AND HOME HEALTH SERVICES TO RESIDENTS IN CALUMET COUNTY, REGARDLESS OF ABILITY TO PAY. THE EMERGENCY DEPARTMENT INCLUDES 24 HOURS A DAY/7 DAYS A WEEK EMERGENCY PHYSICIAN COVERAGE. THE EMERGENCY DEPARTMENT ALSO OFFERS WALK-IN CLINIC SERVICES FOR AFTER DOCTOR'S OFFICE HOURS. DURING 2015, THE HOSPITAL COUNTED 2,054 PATIENT DAYS AND 439 TOTAL DISCHARGES AND ITS EMERGENCY DEPARTMENT RECEIVED 4,852 VISITS. SEE SCHEDULE H FOR FURTHER DETAILS REGARDING THE COMMUNITY BENEFITS THAT CALUMET MEDICAL CENTER PROVIDES. 17792776 true true false true false false false false false false true false false true true true false true false false false false false false false false true true false false true false false false false false false false false false false false false false true true true false false true 20 0 true 198 true false false false false false false false false false false X 10 5 true false false false true true true true true false false true true true true true true false false false WI X Craig Aittama 7153465161 5700 Lands End Way 2nd Floor Stevens Point WI 54482 TRAVIS ANDERSON VICE CHAIRMAN (END 8/14) 1.00 26.50 X X 0 344821 13716 JAMES BURNETT TREASURER 0.30 0 X X 0 0 0 MONICA ANN HILT VICE CHAIRMAN 0.20 44.70 X X 0 572461 19954 TIMOTHY RICHMAN PRESIDENT/CEO - CMC 40.00 0 X X 0 244701 17074 ALLAN UTECHT SECRETARY 0.30 0 X X 0 0 0 WAYNE WIETING CHAIRMAN 0.30 0 X X 0 0 0 JANE GEHL BOARD MEMBER 0.30 0 X 0 0 0 PETER JANU MD BOARD MEMBER 0.30 40.00 X 0 557877 21398 MARK KEHRBERG MD BOARD MEMBER 0.30 40.30 X 0 487342 16019 CRAIG OLSEN MD BOARD MEMBER 0.30 0 X 0 0 0 GENE TIPLER MD BOARD MEMBER 0.30 40.00 X 0 252786 20043 NICHOLAS DESIEN MINISTRY HEALTH CARE CEO 1.00 54.60 X 0 2134343 18803 JEFFREY FRANCIS MINISTRY HEALTH CARE CAFO 0.50 54.30 X 0 1021840 19803 DANIEL NEUFELDER SVP, HOSPITAL OPERATIONS & PRESIDENT 0.10 40.00 X 0 1071649 17365 JENNIFER LEIGH MEDIN WEBER MANAGER INPATIENT SRVCS 40.00 0 X 132921 0 16683 JEFF BADGER FORMER OFFICER 0.00 0.00 X 0 659840 13832 132921 7347660 194690 1 true true false BOLDT COMPANY LOCK BOX 285 MILWAUKEE WI 53288 CONTRUCTION (SCH. O) 5324598 REMEDY MEDICAL SERVICES 1320 W CLAIREMONT AVE EAU CLAIRE WI 54701 PROFESSIONAL SERVICES 1370109 BAY CARE CLINIC 2253 W MASON STREET 100 GREEN BAY WI 54303 PROFESSIONAL SERVICES 490722 GOLD CROSS AMBULANCE SERVICES INC 1055 WITTMANN DRIVE MENASHA WI 54952 PROFESSIONAL SERVICES 441857 Shared Medical Services Medical Services 156268 8 X 0 0 0 1039118 10978 0 0 1050096 Net Patient Revenue 621110 26607858 26607858 Clinic Revenue 621110 34352 34352 43624 43624 0 0 26685834 201560 201560 94949 24561 70388 0 70388 70388 13255 60619 0 -47364 -47364 -47364 Nutrition Services 621110 63002 63002 Purchasing Card Rev 621110 12244 12244 Other Non-Operating 900099 8432 8432 88700 0 0 88700 172378 28132892 26685834 0 396962 X 8964270 7036276 1927994 376827 293925 82902 2138254 1667838 470416 545406 425417 119989 1722 1722 3584471 3317661 266810 0 41841 41841 2148953 2025100 123853 565 565 623538 469552 153986 93833 25834 67999 1069276 946093 123183 56284 56284 Purchase Services 1687558 829058 858500 Drugs 579210 576623 2587 Food 85666 72444 13222 Dues 32335 6214 26121 355665 56613 299052 0 22385674 17792776 4592898 0 2218 2529 11091723 13311365 0 0 3961945 3503948 0 0 0 0 0 0 0 31128 27331 20631341 1764329 13155687 18867012 1924793 1929113 0 0 0 0 5255874 5230773 35423368 42872071 2195552 3840592 0 0 97497 35604 0 0 0 0 0 0 0 0 0 869780 1184813 3162829 5061009 32260539 37811062 0 0 0 0 0 0 0 0 0 0 32260539 37811062 35423368 42872071 5747218 -196695 0 0 0 X false true X true true true X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED false false false false false false false false true 1722 1722 false Schedule C, Part II-B, Line 1 DETAILED DESCRIPTION OF THE LOBBYING ACTIVITY Lobbying expenses represent the portion of dues paid to national and state hospital association that is specifically allocated to lobbying. Calumet Medical Center, Inc. Does not participate in or intervene in (including the publishing or distributing of statements) any political campaign on behalf of (or in opposition to) any candidate for public office. 3200000 3200000 3139858 736530 2403328 177300 58617 118683 3152125 969182 2182943 10962058 0 10962058 18867012 INTEREST IN INVESTMENTS HEALTH BY ASCENSION HEALTH ALLIANCE 4910971 UNEMPLOYMENT DEPOSIT 169348 OTHER ACCOUNTS RECEIVABLE 110275 DUE FROM RELATED ENTITIES 40179 5230773 Accumulated Accretion 239216 Retirement Obligation 59208 Due to Third Party Payor 886389 1184813 X Schedule D, Part X, Line 2 FIN 48 (ASC 740) footnote From the consolidated audited financial statements of Ministry Health Care, Inc. which includes the activity of Calumet Medical Center, Inc.: The Health Ministry accounts for uncertainty in income tax positions by applying a recognition threshold and measurement attribute for financial statement recognition and measurement of a tax position taken or expected to be taken in a tax return. true true X true X true X true true true false true true 34851 34851 0.0016 284243 284243 0.0126 0 0 0.0 0 0 319094 0 319094 0.0142 9 1230 50678 0 50678 0.0023 2 1 3824 0 3824 0.0002 0 0.0 0 0.0 7 0 34446 10001 24445 0.0011 18 1231 88948 10001 78947 0.0035 18 1231 408042 10001 398041 0.0177 0 0 0 0 0 0.0 0 0 0 0 0 0.0 0 0 0 0 0 0.0 0 0 0 0 0 0.0 0 0 0 0 0 0.0 2 0 1069 0 1069 0.0000 1 130 30455 0 30455 0.0014 0 0 0 0 0 0.0 0 0 0 0 0 0.0 3 130 31524 0 31524 0.0014 false 646920 0 14643839 12120794 2523045 X true true 1 1 Calumet Medical Center Inc 614 Memorial Drive Chilton WI 53014 www.affinityhealth.org 1020 X X X X Calumet Medical Center Inc 1 false false true X X X X X X X X X 12 true true true true X http://www.affinityhealth.org/Affinity-Files/Community-Health-Needs-Assessments/FY2013-CMC-CHNA_FINA X true 12 true http://www.affinityhealth.org/Affinity-Files/Community-Health-Needs-Assessments/FY2013_CMC_Implement false false true X 2.0 4.0 X X X X true true X X X true X HTTP://MINISTRYHEALTH.ORG/MINISTRY_HEALTH_CARE/FINANCIAL_ASSISTANCE_PROGRAM_RC08.PDF X HTTP://MINISTRYHEALTH.ORG/MINISTRY_HEALTH_CARE/MHC_FINANCIALAID_APPLICATION_REV4.PDF X X X X X true X false X X X X true X false false Schedule H, Part V, Section B, Line 5 Facility , 1 Facility , 1 - CALUMET MEDICAL CENTER, INC.. CALUMET MEDICAL CENTER PARTICIPATED IN THE ASSESSMENT PROCESSES THAT GATHERED INPUT FROM PRIVATE AND PUBLIC CALUMET, WINNEBAGO AND OUTAGAMIE COUNTY ORGANIZATION MEMBERS INCLUDING: MEDICAL STAFF, NURSES AND ADMINISTRATORS; CLINIC PERSONNEL; PUBLIC HEALTH NURSES AND EDUCATORS; BEHAVIORAL HEALTH STAFF AND LEADERS; HEALTH INSURANCE-HEALTH MANAGEMENT STAFF, ELEMENTARY, HIGH SCHOOL AND POST HIGH SCHOOL EDUCATORS, NURSES AND ADMINISTRATORS; POLICE AND EMERGENCY PERSONNEL; CHILD, WOMEN'S, FAMILY AND SENIOR SOCIAL SERVICES; AS WELL AS COMMUNITY MEMBERS INTERESTED IN THE HEALTH NEEDS ASSESSMENT PROCESS. SEVERAL AFFINITY REPRESENTATIVES PARTICIPATED AS MEMBERS OF THE FOX VALLEY L.I.F.E. STUDY AND/OR FOX VALLEY REGIONAL COMMUNITY HEALTH COALITION THROUGHOUT THE ASSESSMENT PROCESS. ERNESTO GONZALEZ, CASA HISPANA WAS CONSULTED ABOUT THE LATINO COMMUNITY HEALTH NEEDS. AS PART OF THE FOX CITIES L.I. F.E. STUDY, KRISTENE STACKER, FOX CITIES COMMUNITY HEALTH CLINIC WAS CONSULTED ABOUT THE MEDICALLY UNDERSERVED COMMUNITY HEALTH NEEDS. CALUMET COUNTY PUBLIC HEALTH EXPERTS - BONNIE KOLBE, HEALTH DIVISION MANAGER/HEALTH OFFICER CALUMET COUNTY HEALTH AND HUMAN SERVICES - TWENTY-FIVE YEARS OF EXPERIENCE. CITY OF MENASHA PUBLIC HEALTH EXPERTS - SUE NETT, PUBLIC HEALTH DIRECTOR CITY OF MENASHA HEALTH DEPARTMENT BSN AND MASTER IN PUBLIC ADMINISTRATION - TWENTY-EIGHT YEARS OF EXPERIENCE AS CITY OF MENASHA PUBLIC HEALTH DIRECTOR OVERSEEING THE HEALTH OF THE COMMUNITY - TEN YEARS OF EXPERIENCE CONDUCTING AND OVERSEEING COMMUNITY NEEDS ASSESSMENTS (AS PART OF THE FOX CITIES LIFE STUDY). Schedule H, Part V, Section B, Line 6a Facility , 1 Facility , 1 - CALUMET MEDICAL CENTER, INC.. THE CHNA WAS CONDUCTED WITH ST. ELIZABETH HOSPITAL, MERCY MEDICAL CENTER, THEDACARE AND AURORA HEALTH. Schedule H, Part V, Section B, Line 6b Facility , 1 Facility , 1 - CALUMET MEDICAL CENTER, INC.. THE CHNA WAS CONDUCTED WITH THE HEALTH DEPARTMENTS OF: APPLETON, NEENAH, MENASHA, CALUMET COUNTY, OUTAGAMIE COUNTY & WINNEBAGO COUNTY. Schedule H, Part V, Section B, Line 11 Facility , 1 Facility , 1 - CALUMET MEDICAL CENTER, INC.. HOW THE HOSPITAL IS ADDRESSING THE SIGNIFICANT NEEDS: USING THE CHNA COMPLETED IN FISCAL YEAR 2013, THE HOSPITAL DEVELOPED, ADOPTED, AND WORKED ON EXECUTING A 2014-2016 IMPLEMENTATION STRATEGY TO ADDRESS PRIORITY COMMUNITY HEALTH NEEDS. IN 2014, THE HOSPITAL IMPLEMENTED THE FOLLOWING PLAN TO ADDRESS THE PRIORITY NEEDS: 1.EXCESSIVE ALCOHOL CONSUMPTION: - DECREASE THE PERCENTAGE OF ADULTS AND ADOLESCENSTS WHO BINGE DRINK IN CALUMET COUNTY. - PUBLIC AWARENESS EFFORTS TO INFORM THE COMMUNITY ABOUT THE ISSUES OF EXCESSIVE ALCOHOL CONSUMPTION (PAMPHLETS AND FACEBOOK PAGE). - PREVENTION EDUCATION PROGRAMS FOR PARENTS, YOUTH AND THE GENERAL COMMUNITY (POST-PROM EVENT, NATIONAL NIGHT OUT, PARENTS WHO HOST). 2.MENTAL HEALTH: - DECREASE THE RATE OF SUICIDE IN CALUMET COUNTY AND THE FOX VALLEY. - CREATE QPR (QUESTION. PERSUADE. REFER) PORTAL TO PROMOTE QPR TRAINING AND RESOURCES. - EXPAND QPR TRAININGS TO SPANISH SPEAKING POPULATION IN THE AREA. - CREATE A COMMUNITY-WIDE SUICIDE PREVENTION COLLABORATION. 3.OBESITY: - REDUCE OBESITY IN CALUMET COUNTY RESIDENTS. - ORGANIZE A KICK-OFF EVENT FOR WEIGHT OF THE FOX VALLEY ACTION TEAMS. - EXPAND WEIGHT OF THE FOX VALLEY'S WEB AND SOCIAL MEDIA PRESENCE. - ESTABLISH A PROCESS TO SHARE BMI INFORMATION BETWEEN WEIGHT OF THE FOX VALLEY PARTNERS. - PROVIDE HEALTHY LIVING COOKING CLASSES. - PROVIDE A CALUMET MEDICAL CENTER COMMUNITY GARDEN. NEEDS NOT BEING ADDRESSED AND REASONS WHY: FOURTEEN OTHER HEALTH ISSUES WERE IDENTIFIED BY THE COMMUNITY HEALTH NEEDS ASSESSMENT PROCESS. GIVEN THE REASONS INDICATED BELOW, CALUMET MEDICAL CENTER WILL NOT BE FOCUSING ON THESE HEALTH NEEDS AT THIS TIME. - ACCESS TO DENTAL CARE - ALREADY BEING ADDRESSED BY OTHERS IN THE COMMUNITY. - LOW BIRTH WEIGHTS - ISSUE IS NOT A PRIORITY FOR COMMUNITY MEMBERS AND THEREFORE APPROACH IS UNLIKELY TO SUCCEED. - TEEN BIRTH RATE UP - NEED IS NOT AS LIKELY TO BE RESOLVED AS OTHER PROBLEMS. - HIGH COST OF CHILD CARE - HOSPITAL DOES NOT HAVE THE EXPERTISE TO EFFECTIVELY ADDRESS THE NEED. - INCREASED GAPS IN CARE MANAGEMENT FOR PEOPLE WITH DISABILITIES OF ALL AGES - NEED IS NOT AS LIKELY TO BE RESOLVED AS OTHER PROBLEMS. - INCREASE IN LOW INCOME STUDENTS - HOSPITAL DOES NOT HAVE THE EXPERTISE TO EFFECTIVELY ADDRESS THE NEED. - DECREASED WATER QUALITY - HOSPITAL DOES NOT HAVE THE EXPERTISE TO EFFECTIVELY ADDRESS THE NEED. - INCREASED ELDER ABUSE - HOSPITAL DOES NOT HAVE THE EXPERTISE TO EFFECTIVELY ADDRESS THE NEED. - INCREASE IN VIOLENT CRIME ESPECIALLY DRUG-RELATED - HOSPITAL DOES NOT HAVE THE EXPERTISE TO EFFECTIVELY ADDRESS THE NEED. - INCREASED HOMELESSNESS RELATED TO UNEMPLOYMENT (MORE CHILDREN) - HOSPITAL DOES NOT HAVE THE EXPERTISE TO EFFECTIVELY ADDRESS THE NEED. - INCREASED FOODSHARE RECIPIENTS - HOSPITAL DOES NOT HAVE THE EXPERTISE TO EFFECTIVELY ADDRESS THE NEED. - INCREASED FOOD INSECURITY AND HUNGER - HOSPITAL DOES NOT HAVE THE EXPERTISE TO EFFECTIVELY ADDRESS THE NEED. - TRANSPORTATION CHALLENGES - HOSPITAL DOES NOT HAVE THE EXPERTISE TO EFFECTIVELY ADDRESS THE NEED. - AVAILABILITY OF JOBS WITH HEALTH CARE BENEFITS - HOSPITAL DOES NOT HAVE THE EXPERTISE TO EFFECTIVELY ADDRESS THE NEED. 0 Schedule H, Part I, Line 3c Description of Income Based Criteria It is the policy of the Organization to provide medically necessary health care services to people in the communities it serves, regardless of their ability to pay. Affinity Care Financial Assistance is granted based upon the patient's inability to pay and to individuals who are uninsured, underinsured or medically indigent. Affinity Care works in collaboration with other financial (both public and private) assistance programs. This is to ensure holistic wellness of patients by facilitating knowledge of available services and programs for health while practicing good stewardship of funds. Key criteria utilized to determine eligibility for Affinity Care Financial Assistance includes family size, federal poverty income guidelines and available assets. The available asset test includes consideration of the amount of equity in a home, automobiles, and savings accounts which are considered part of total allowable income when assessing against the federal poverty income guidelines. Schedule H, Part I, Line 6a PREPARATION OF COMMUNITY BENEFIT REPORT Calumet Medical Center, Inc. is included in the annual community benefit report which is published by Ministry Health Care, Inc. (EIN: 39-1490371) and available to the public on its website, www.ministryhealth.org. This report includes all of the related entities within the Ministry Health Care network of hospitals, clinics and other health-related organizations. Schedule H, Part I, Line 7 Costing Methodology used to calculate financial assistance Amounts calculated in part I, Line 7 are determined both on a cost accounting system and a cost-to-charge ratio. Other benefits are determined based on the direct and indirect costs (where allocated) associated with a program net of earned revenue. Detail for each program/activity is maintained and determined at the department level. Charity care and means-tested programs are determined based on a cost-to-charge ratio consistent with worksheet 2, ratio of patient care cost to charges. Prior year cost report settlements are excluded from the shortfall calculation in order to get a true fiscal year shortfall amount. Schedule H, Part II Community Building Activities Community building activities include programs that, while not directly related to health care, provide opportunities to address the root causes of health problems, such as poverty, homelessness, and environmental problems. These activities support community assets by offering the expertise and resources of the organization. Costs for these activities include cash, in-kind donations, and expenditures for the development of the variety of community health programs and partnerships. Another example is health career presentations in which professionals from Calumet Medical Center, Inc. go to career classes at area high schools and universities to talk about their professionals (i.e. physical therapy, occupational therapy, speech therapy, cardiac & pulmonary rehab). Schedule H, Part III, Line 2 Bad debt expense - methodology used to estimate amount Accounts are written off to bad debt after all internal collection efforts have been exhausted. Attempts to resolve these outstanding balances can include, but are not limited to, statements being sent, phone calls and letters being sent. Account follow up protocol is based on personal pay balance size owed. Schedule H, Part III, Line 3 Bad Debt Expense Methodology Calumet Medical Center, Inc. has a very robust financial assistance program; therefore, no estimate is made for bad debt attributed to financial assistance eligible patients. Schedule H, Part III, Line 4 Bad debt expense - financial statement footnote From the consolidated audited financial statements of Ministry Health Care, Inc. (which includes the activity of Calumet Medical Center, Inc.): The provision for doubtful accounts is based upon management's assessment of expected net collections considering historical experience, economic conditions, trends in health care coverage, and other collection indicators. Periodically throughout the year, management assesses the adequacy of the allowance for doubtful accounts based upon historical write-off experience by payor category, including those amounts not covered by insurance. The results of this review are then used to make any modifications to the provision for doubtful accounts to establish an appropriate allowance for doubtful accounts. After satisfaction of amounts due from insurance and reasonable efforts to collect from the patient have been exhausted, the Health Ministry follows established guidelines for placing certain past-due patient balances with collection agencies, subject to the terms of certain restrictions on collection efforts as determined by Ascension Health. Accounts receivable are written off after collection efforts have been followed in accordance with the Health Ministry's policies. The methodology for determining the allowance for doubtful accounts and related write-offs on uninsured patient accounts has remained consistent with the prior year. Schedule H, Part III, Line 8 Community benefit & methodology for determining medicare costs Ascension Health and related health ministries follow the Catholic Health Association ("CHA") guidelines for determining community benefit. CHA community benefit reporting guidelines suggest that Medicare shortfall is not treated as community benefit. Schedule H, Part III, Line 9b Collection practices for patients eligible for financial assistance Calumet Medical Center, Inc. has a debt collection policy which sets forth collection practices for patients who are known to qualify or may qualify for financial assistance under the charity care program. Sufficient financial counseling support is made available to patients so they can easily access patient financial service representatives and have their questions answered, and gain an understanding of the reasons why they owe a balance. Accounts are designated as charity care in the business offices so no additional time is spent on collection efforts. Schedule H, Part V, Section B, Line 16a FAP website - Calumet Medical Center, Inc.: Line 16a URL: HTTP://MINISTRYHEALTH.ORG/MINISTRY_HEALTH_CARE/FINANCIAL_ASSISTANCE_PROGRAM_RC08.PDF; Schedule H, Part V, Section B, Line 16b FAP Application website - Calumet Medical Center, Inc.: Line 16b URL: HTTP://MINISTRYHEALTH.ORG/MINISTRY_HEALTH_CARE/MHC_FINANCIALAID_APPLICATION_REV4.PDF; Schedule H, Part VI, Line 2 Needs assessment Calumet Medical Center, Inc. performs community needs assessments as needed. When a need is identified, the Hospital develops a plan to implement a program either through community collaboration or individually. Outcomes from the programs are measured and considered in subsequent community needs assessments. Community benefit plans are presented to senior leadership and board members to ensure the findings are incorporated into the Organization's strategy and policy development. For example, senior leaders are required to provide direct service hours to the poor as part of their performance goals. Schedule H, Part VI, Line 3 Patient education of eligibility for assistance Calumet Medical Center, Inc. goes to great lengths in order to inform and educate patients/persons who may be billed for patient care about their eligibility for assistance under federal, state or local government programs and under the Organization's financial assistance policy. The financial assistance policy and application is posted on the organization's website. Admissions and other key areas contain summary information of the financial assistance policy. As part of the intake/discharge process, patients are provided with a copy of the brochure and other information for financial assistance. If during the course of the patient registration process, care encounter, treatment, or upon discharge it becomes evident that a patient may need financial assistance; the patient shall be referred to Calumet Medical Center, Inc.'s financial assistance program. Patients may be identified as needing financial assistance at any time during the course of an encounter. A referral for consideration of financial assistance can be initiated by any member of the Hospital's workforce, including medical staff members, who become aware of the patients potential need for financial assistance. The financial assistance policy was also translated into dialects prevalent in the community in order to reach out to those that may speak another language (Spanish and Hmong). Patient registration staff and financial counselors are provided with scripts to follow when interacting with patients. As part of the financial assistance process, patients must register with the county public assistance to see if they may qualify under any other federal or state programs. Schedule H, Part VI, Line 4 Community information While there is growing agreement in the United States about what constitutes a non-profit hospital's "Community Benefit" this is a work in progress. The Organization provided significant charity care and other community benefits as defined by the IRS. But in addition, we believe that we provide a critically important community benefit, which is not quantified. Calumet Medical Center, Inc., like most community hospitals, was created and is maintained in order to provide care locally - care that without our hospital, may not be available locally. Certain specialized services available include: I/P rehabilitation services, I/P sub-acute (snf) services. The Town of Chilton is located in Calumet County. According to the 2010 census, there were 3,933 people living in Chilton, consisting of 1,687 households and 1,027 families. The population density of Chilton was 990.7 people per square mile. The population consisted of 95.8% White, 1.1% Hispanic, 0.2% African American, 0.4% Native American, 0.5% Asian, and 2% Other. Of the 1,687 households in Chilton, 29.4% of those had children under the age of 18, living at home. The 1,687 households are categorized as 48.0% married couples living together, 4.7% had a male head of household with no wife present, 8.2% had a female head of household with no husband present, and 39.1% were non-families. 34.7% of the households consisted of individuals and 16.7% had someone 65 and older living alone. The age population is widely spread. 24% were under 18, 6.3% were 19-24, 26.3% were 25-44, 25.9% were 45-64, and 17.5% were 65+. The median income for a household was $51,106 and the median income for a family was $63,038. The per capita income for the city was $24,842. The largest industry in Chilton is manufacturing (32.4%). Educational, health and social services (20.3%) and retail trade (10.6%) are the next largest industries in Chilton. Roughly 11.4% of families and 14.5% of the population were below the poverty line. That includes 25.9% of those under 18 years old and 4.9% of those 65 and older. The unadjusted seasonal unemployment rate for Calumet County was 3.7%, compared to a state unemployment rate of 5.1% and a national unemployment rate of 7.9%. Schedule H, Part VI, Line 5 Promotion of community health Calumet Medical Center, Inc.'s governing board consists primarily of persons who reside within the primary service area who are not employees of the organization. The Organization strives to further its exempt purposes by the following: - Calumet Medical Center, Inc. participates in government-sponsored health programs (Medicare, Medicaid, Champus, general relief, and specialized county programs). - Calumet Medical Center, Inc. donates food to area shelters. They also donate medical supplies and medications to clinics in third world countries. Calumet Medical Center, Inc. donated funds to support area organizations that provide services to the following sectors of our population: low-income, homeless, physically and mentally challenged and chronically ill. - Calumet Medical Center, Inc. operates the only paramedic-level ambulance service in Calumet County. This service operates at a loss and is subsidized by the Hospital. - Calumet Medical Center, Inc. provides community health improvement services through health education lectures, health fairs and support groups. - Calumet Medical Center, Inc. conducts cardiac rehabilitation and diabetic education sessions. This service is provided at a cost to the patient that is far below the cost to offer the service. - Discounted care is provided to low income families up to 662% of federal poverty guidelines. - Calumet Medical Center, Inc. serves as a sponsor site for clinical training of college students in various health care programs. - Calumet Medical Center, Inc. offers athletic training services to local high schools that would otherwise not have this service available to their students. The service is offered at a cost to the schools that is far below the cost to offer the service. Schedule H, Part VI, Line 6 Affiliated health care system Ministry Health Care, Inc. (Ministry or the Health Ministry) is a member of Ascension Health. In December 2011, Ascension Health Alliance, doing business as Ascension, became the sole corporate member and parent organization of Ascension Health, a Catholic national health system consisting primarily of nonprofit corporations that own and operate local health care facilities, or Health Ministries, located in 23 states and the District of Columbia. In addition to serving as the sole corporate member of Ascension Health, Ascension serves as the member or shareholder of various other subsidiaries. Ascension, its subsidiaries, and the Health Ministries are referred to collectively from time to time hereafter as the System. Ascension is sponsored by Ascension Sponsor, a Public Juridic Person. The Participating Entities of Ascension Sponsor are the Daughters of Charity of St. Vincent de Paul, St. Louise Province, the Congregation of St. Joseph, the Congregation of the Sisters of St. Joseph of Carondelet, the Congregation of Alexian Brothers of the Immaculate Conception Province, Inc. - American Province, and the Sisters of the Sorrowful Mother of the Third Order of St. Francis of Assisi - US/Caribbean Province. The Health Ministry is a Wisconsin non-stock, tax-exempt corporation that manages, promotes, and supports health care and related ministries in Wisconsin and Minnesota. The Health Ministry provides inpatient, outpatient, and emergency care services for the residents of Wisconsin and Minnesota. Admitting physicians are primarily practitioners in the local area. The Health Ministry is related to Ascension Health's other sponsored organizations through common control. Substantially all expenses of the Health Ministry are related to providing health care services. Effective November 1, 2014, the Health Ministry sold 50% of its ownership in Network Health, Inc. to an unrelated health system (see Note 3). On February 1, 2015, the Health Ministry transferred its ownership in Ministry Home Care, Inc. to Ascension Health. The consolidated financial statements include the following affiliates located primarily in Wisconsin, in which Ministry has a controlling interest and/or is the sole sponsor. Affinity Health System, Inc. (Affinity): - Calumet Medical Center, Inc. (CMC): - Affinity Medical Group (AMG) - Twin Med, LLC - Mercy Medical Center, Inc. - Mercy Health Foundation - St. Elizabeth Hospital Catalpa Health: - St. Elizabeth Foundation Agape Community Center of Milwaukee, Inc. Door County Memorial Hospital (Door County) Good Samaritan Health Center of Merrill Good Samaritan Health Center Foundation Howard Young Health Care, Inc. (Howard Young): - Dr. Kate Newcomb Convalescent Center - Howard Young Medical Center, Inc. - Dr. Howard Young Foundation - Eagle River Memorial Hospital, Inc. Ministry Medical Group, Inc. Ministry Holdings, Inc. (through November 1, 2014): - Network Health (NH) (through November 1, 2014) Network Health Insurance Corporation (NHIC) (through November 1, 2014) Our Lady of Victory Hospital Sacred Heart Hospital-St. Mary's Hospital, Inc. St. Clare's Hospital of Weston, Inc. Foundation of St. Clare's Hospital of Weston, Inc. St. Elizabeth's Hospital of Wabasha, Inc. St. Joseph's Hospital of Marshfield, Inc. Foundation of St. Joseph's Hospital of Marshfield, Inc. St. Michael's Hospital of Stevens Point, Inc. St. Michael's Foundation of Stevens Point, Inc. Mission The System directs its governance and management activities toward strong, vibrant, Catholic Health Ministries united in service and healing and dedicates its resources to spiritually centered care that sustains and improves the health of the individuals and communities it serves. In accordance with the System's mission of service to those persons living in poverty and to other vulnerable persons, each Health Ministry accepts patients regardless of their ability to pay. The System uses four categories to identify the resources utilized for the care of persons living in poverty and for community benefit programs: - Traditional charity care includes the cost of services provided to persons who cannot afford health care because of inadequate resources and/or who are uninsured or underinsured. - Unpaid cost of public programs, excluding Medicare, represents the unpaid cost of services provided to persons covered by public programs for persons living in poverty and for other vulnerable persons. - Cost of other programs for persons living in poverty and for other vulnerable persons includes unreimbursed costs of programs intentionally designed to serve the persons living in poverty and the other vulnerable persons of the community, including substance abusers, the homeless, victims of child abuse, and persons with acquired immune deficiency syndrome. - Community benefit consists of the unreimbursed costs of community benefit programs and services for the general community, not solely for the persons living in poverty, including health promotion and education, health clinics and screenings, and medical research. Discounts are provided to all uninsured patients, including those with the means to pay. Discounts provided to those patients who did not qualify for assistance under charity care guidelines are not included in the cost of providing care to persons living in poverty or in the cost of other community benefit programs. The cost of providing care to persons living in poverty and of other community benefit programs is estimated using internal cost data and is estimated by reducing charges forgone by a factor derived from the ratio of total operating expenses to billed charges for patient care. The amount of traditional charity care provided, determined on the basis of cost, was approximately $12,600 and $18,400 for the years ended June 30, 2015 and 2014, respectively. The amount of unpaid cost of public programs, cost of other programs for persons living in poverty and for other vulnerable persons, and cost of community benefit programs are reported in the accompanying supplementary information. false true false false false false false false false TRAVIS ANDERSON VICE CHAIRMAN (END 8/14) 0 176807 0 136945 0 31068 0 0 0 13716 0 358537 0 0 MONICA ANN HILT VICE CHAIRMAN 0 331953 0 118639 0 121869 0 0 0 19954 0 592415 0 0 TIMOTHY RICHMAN PRESIDENT/CEO - CMC 0 174029 0 54851 0 15821 0 0 0 17074 0 261775 0 0 PETER JANU MD BOARD MEMBER 0 543360 0 0 0 14517 0 0 0 21398 0 579275 0 0 MARK KEHRBERG MD BOARD MEMBER 0 113129 0 344147 0 30066 0 0 0 16019 0 503361 0 0 GENE TIPLER MD BOARD MEMBER 0 218817 0 0 0 33969 0 0 0 20043 0 272829 0 0 JEFF BADGER FORMER OFFICER 0 264031 0 374899 0 20910 0 0 0 13832 0 673672 0 0 NICHOLAS DESIEN MINISTRY HEALTH CARE CEO 0 1009502 0 1079643 0 45198 0 0 0 18803 0 2153146 0 0 JEFFREY FRANCIS MINISTRY HEALTH CARE CAFO 0 438327 0 141768 0 441745 0 0 0 19803 0 1041644 0 0 DANIEL NEUFELDER SVP, HOSPITAL OPERATIONS & PRESIDENT 0 791344 0 259379 0 20926 0 0 0 17365 0 1089014 0 0 Schedule J, Part I, Line 3 EXPLANATION MINISTRY HEALTH CARE, INC., A RELATED ORGANIZATION OF CALUMET MEDICAL CENTER, INC., USES THE FOLLOWING TO ESTABLISH THE COMPENSATION OF THE ORGANIZATION'S CEO: - COMPENSATION COMMITTEE - INDEPENDENT COMPENSATION CONSULTANT - COMPENSATION SURVEY OR STUDY, AND - APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE Schedule J, Part I, Line 4b Supplemental nonqualified retirement plan Eligible executives participate in a program that provides for supplemental retirement benefits. The payment of benefits under the program, if any, is entirely dependent upon the facts and circumstances under which the executive terminates employment with the organization. Benefits under the program are unfunded and non-vested. Due to the substantial risk of forfeiture provision, there is no guarantee that these executives will ever receive any benefit under the program. Any amount ultimately paid under the program to the executive is reported as compensation on Form 990, Schedule J, Part II, Column B in the year paid. THE FOLLOWING INDIVIDUALS RECEIVED DISTRIBUTIONS OF: JEFFREY FRANCIS $260,079 MONICA HILT $52,618 Form 990, Part VI, Line 15 COMPENSATION OF OFFICERS IN DETERMINING COMPENSATION OF THE ORGANIZATION'S CEO, THE PROCESS, PERFORMED BY MINISTRY HEALTH CARE, INC., A RELATED ORGANIZATION OF CALUMET MEDICAL CENTER, INC., INCLUDED A REVIEW AND APPROVAL BY INDEPENDENT PERSONS, COMPARABILITY DATA, AND CONTEMPORANEOUS SUBSTANTIATION OF THE DELIBERATION AND DECISION. THE COMPENSATION COMMITTEE REVIEWED AND APPROVED THE COMPENSATION. IN THE REVIEW OF THE COMPENSATION, THE CEO WAS COMPARED TO INDIVIDUALS AT OTHER ORGANIZATIONS IN THE AREA WHO HOLD THE SAME TITLE. DURING THE REVIEW AND APPROVAL OF THE COMPENSATION, DOCUMENTATION OF THE DECISION WAS RECORDED IN THE BOARD MINUTES. THE INDIVIDUAL WAS NOT PRESENT WHEN HIS COMPENSATION WAS DETERMINED. IN DETERMINING COMPENSATION OF OTHER OFFICERS AND KEY EMPLOYEES OF THE ORGANIZATION, THE PROCESS, PERFORMED BY MINISTRY HEALTH CARE, INC., A RELATED ORGANIZATION OF CALUMET MEDICAL CENTER, INC., INCLUDED A REVIEW AND APPROVAL BY INDEPENDENT PERSONS, COMPARABILITY DATA, AND CONTEMPORANEOUS SUBSTANTIATION OF THE DELIBERATION AND DECISION. THE COMPENSATION COMMITTEE REVIEWED AND APPROVED THE COMPENSATION. IN THE REVIEW OF THE COMPENSATION, THE OTHER OFFICERS AND KEY EMPLOYEES OF THE ORGANIZATION WERE COMPARED TO INDIVIDUALS AT OTHER ORGANIZATIONS IN THE AREA WHO HOLD THE SAME TITLE. DURING THE REVIEW AND APPROVAL OF THE COMPENSATION, DOCUMENTATION OF THE DECISION WAS RECORDED IN THE BOARD MINUTES. Form 990, Part VI, Line 2 FAMILY/BUSINESS RELATIONSHIPS AMONGST INTERESETD PERSONS MANY OF THE PERSONS LISTED ON PART VII HAVE A "BUSINESS RELATIONSHIP" WITH EACH OTHER BY VIRTUE OF EMPLOYMENT BY RELATED MINISTRY HEALTH CARE, INC. RELATED ENTITIES. Form 990, Part VI, Line 6 Classes of members or stockholders Calumet Medical Center, Inc. has two corporate members, Affinity Health System and Calumet Area Community Health Foundation, Inc. Form 990, Part VI, Line 7a Members or stockholders electing members of governing body One of Calumet Medical Center, Inc.'s members, Affinity Health System, has the ability to elect members to the governing board of Calumet Medical Center, Inc. Form 990, Part VI, Line 7b Decisions requiring approval by members or stockholders Affinity Health System and Calumet Area Community Health Foundation, Inc. have the authority to approve any changes to the Articles of Incorporation, and all modifications to the purposes, Board of Directors and member provisions of the Bylaws of Calumet Medical Center, Inc., as well as to approve the dissolution, consolidation or merger of Calumet Medical Center, Inc. All decisions that have a material impact to Calumet Medical Center, Inc's financial information or corporation as a whole are subject to approval by Affinity Health System, the managing member of Calumet Medical Center, Inc. Form 990, Part VI, Line 11b Review of form 990 by governing body Management, including certain officers, works diligently to complete the Form 990 and attached schedules in a thorough manner. Prior to filing the return, all Board Members are provided the Form 990 and management team members are available to answer any Board Members' questions. Form 990, Part VI, Line 12c Conflict of interest policy The organization regularly and consistently monitors and enforces compliance with the Conflict of Interest Policy in that any director, principal officer, or member of a committee with governing board delegated powers, who has a direct or indirect financial interest, must disclose the existence of the financial interest and be given the opportunity to disclose all material facts to the directors and members of the committees with governing board delegated powers considering the proposed transaction or arrangement. The remaining individuals on the governing board or committee meeting will decide if conflicts of interest exist. Each director, principal officer and member of a committee with governing board delegated powers annually signs a statement which affirms such person has received a copy of the Conflict of Interest Policy, has read and understands the policy, has agreed to comply with the policy, and understands that the organization is charitable and in order to maintain its federal tax exemption it must engage primarily in activities which accomplish its tax-exempt purpose. Form 990, Part VI, Line 19 Required documents available to the public The Ministry web page is available to the public for inspection with a good deal of information regarding who Ministry Health Care is and the entities included along with our mission. The Articles of Incorporation, Bylaws, Conflict of Interest Policy and financial statements are not included on any web page. However, if any inquiry is made for any documents they are shared as appropriate. Form 990, Part VII, Section A Compensation The compensation paid to Peter Janu, M.D., Mark Kehrberg, M.D., and Gene Tipler, M.D.is for their services as physicians for Network Health System, Inc., and not for their role as board members for Calumet Medical Center. Form 990, Part VIII, Line 2f Other Program Service Revenue OTHER REV - Total Revenue: 43624, Related or Exempt Function Revenue: 43624, Unrelated Business Revenue: , Revenue Excluded from Tax Under Sections 512, 513, or 514: ; Form 990, Part VIII, Line 11d Other Miscellaneous Revenue Admin meaningful use Medicaid/MISC OTHER OPER REV - Total Revenue: 88700, Related or Exempt Function Revenue: , Unrelated Business Revenue: , Revenue Excluded from Tax Under Sections 512, 513, or 514: 88700; Form 990, Part IX, Line 11g Other Fees Physician Medical Services - Total Expense: 3394741, Program Service Expense: 3157109, Management and General Expenses: 237632, Fundraising Expenses: ; Non Physician Medical Services - Total Expense: 189730, Program Service Expense: 160552, Management and General Expenses: 29178, Fundraising Expenses: ; Form 990, Part VII, Section B Compensation paid to Boldt Company Payments made to Boldt Company constitute payments for both materials and services. These amounts cannot be separated. 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