2015-06-04T15:00:07-05:00 2014-06-30 861065772 Deloitte Tax LLP 555 East Wells Street Suite 1400 Milwaukee WI 53202 990 2013-07-01 390808503 Good Samaritan Health Center of Merrill Wisconsin Inc GOOD 7155365511 601 South Center Avenue Merrill WI 54452 Jeffrey Francis Ministry Health Care CAFO 7155365511 2015-06-04 1 Rachel Becker P00966076 4142713000 2013 2016-02-25 16:41:14Z Mary T Krueger 601 South Center Avenue Merrill WI 54452 22620244 0 0928 X www.ministryhealth.org/gshc/home.nws X 1950 WI To improve the health and well-being of all people in the communities we serve. 11 9 182 114 16065 -14058 0 0 16799268 21376088 411501 987223 141563 190951 17352332 22554262 0 0 0 0 11303412 14343249 0 0 2750 6405619 8358878 17709031 22702127 -356699 -147865 37520954 39219077 3549063 1923258 33971891 37295819 Good Samaritan Health Center of Merrill, Wisconsin, Inc.'s mission as a Catholic hospital is to further the healing ministry of Jesus by continually improving the health and well-being of all people, especially the poor. 0 0 17860171 21458732 Good Samaritan Health Center of Merrill, Wisconsin, Inc. provides inpatient, outpatient, emergency room, and ancillary services regardless of an individual's ability to pay or method of payment. The Hospital also provides educational programs and services on health care issues to the community it serves.See Schedule H for further details regarding the community benefits that Good Samaritan Health Center of Merrill, Wisconsin, Inc. provides. 17860171 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 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 40 0 1 182 1 1 1 0 0 0 0 0 0 0 0 0 X 11 9 1 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 0 0 0 WI X Jeffrey Francis 4143593145 222 W College Ave 3rd Floor Appleton WI 54911 X Michael Ravn Chairperson 1.00 0.00 X X 0 0 0 Val Mindak Vice Chairperson 1.00 0.00 X X 0 0 0 Shannon Murray Secretary/Treasurer 1.00 0.00 X X 0 0 0 Jane Deau Board Member 1.00 0.00 X 0 0 0 Barb Haffemann Board Member 1.00 0.00 X 0 0 0 Karen Karow Board Member 1.00 0.00 X 0 0 0 Denis McCarthy Board Member 1.00 0.00 X 0 0 0 Susan Ryman Board Member 1.00 0.00 X 0 0 0 Robyn Schertz MD Board Member 1.00 40.00 X 0 470864 63557 Sister Maria Vinton SSM Board Member 1.00 0.20 X 0 0 0 Mary T Krueger President 13.00 27.80 X X 0 308415 60217 Nicholas Desien Ministry Health Care CEO 1.00 55.30 X 0 2061606 41974 Jeffrey Francis Ministry Health Care CAFO 1.00 64.90 X 0 522252 124025 Larry T Hegland Chief Medical Officer 3.00 17.00 X 0 312816 42803 Jeffrey Martin President at SMH 4.00 36.80 X 0 561639 136782 Kristine McGarigle VP - Patient Care 13.00 27.10 X 0 205206 29210 Kathryn S Horst Clinical Staff Pharmacist 40.00 0.00 X 130974 0 37453 James L Mason Manager, Pharmacy - E 40.00 0.00 X 140877 0 24709 Jeff Badger Former Officer 1.00 51.00 X 0 497813 62987 271851 4940611 623717 2 1 1 0 Ellis Stone Contruction Co Inc PO Box 366 Stevens Point WI 544810366 Construction Services 358575 Marshfield Clinic 1205 ODay Street Merrill WI 544523416 Medical Staff 354941 Shared Medical Services Inc 209 Limestone Pass Cottage Grove WI 53527 MRI Services 266463 Johnson Controls Inc PO Box 905240 Charlotte NC 282905240 Maintenance Services 214157 Marshfield Laboratories 1000 North Oak Avenue Marshfield WI 544495795 Lab Services 108391 5 Net Patient Revenue 622110 21057228 21057228 Medicaid Stimulus 525990 168962 168962 Rent from Exempt Org. 531190 98861 98861 Intercompany Lab 541380 29018 29018 Physical Therapy 900099 22019 22019 21376088 967150 967150 5895 0 5895 5895 5895 86055 65982 20073 20073 20073 Cafeteria 722210 90656 4309 86347 Radiology 900099 15286 14883 403 Housekeeping 900099 11353 11353 67761 67761 185056 22554262 21458732 16065 1079465 11401450 9139703 2261747 366045 365377 668 2026823 1517779 509044 548931 539813 9118 3114 3114 4907 4907 747222 331793 415429 1311739 1090271 221468 70419 70419 761689 645594 116095 30478 23813 6665 96852 26683 70169 1349344 1177194 172150 75226 72777 2449 Purchased Services 2102149 1235825 866324 0 Anesthesia Services 739396 739396 0 0 Pharmaceuticals 595438 592281 3157 0 Food 109043 93472 15571 0 361862 193074 166038 2750 22702127 17860171 4839206 2750 759 685 2848028 644190 0 2876533 3368028 0 0 0 451309 411806 72433 47030 9857099 1407859 8259286 8449240 319911 982709 22692695 25315389 37520954 39219077 2645065 2315873 903998 -392615 3549063 1923258 X 33971891 37273722 22097 0 33971891 37295819 37520954 39219077 X -147865 1607183 1864610 X 0 1 X 1 1 1 X 0 0 0 0 0 0 0 0 1 3114 3114 0 Part II-B, Line 1: Lobbying expenses represent the portion of dues paid to national and state hospital associations that is specifically allocable to lobbying. Good Samaritan Health Center of Merrill, Wisconsin, 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. 1250000 1250000 5451043 820824 4630219 201112 33615 167497 2842029 553420 2288609 112915 112915 8449240 Interest in Investments Held by Ascension Health Alliance 25163453 Other Assets 151936 25315389 Accretion Amortization 177428 Asset Retirement Obligation 149998 Pension Reserve -1067041 Unspecified Reserve 347000 -392615 X Part X, Line 2: From the consolidated audited financial statements of Ministry Health Care, Inc., which includes the activity of Good Samaritan Health Center of Merrill, Wisconsin, 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 tax position taken or expected to be taken in a tax return. 1 1 X 1 X 1 X 1 1 0 1 1 272838 272838 0.01200 3228348 2290524 937824 0.04130 3501186 2290524 1210662 0.05330 20 5423 96386 0 96386 0.00420 8 88 35941 0 35941 0.00160 5 195 35199 17341 17858 0.00080 0 0 0 0 14 1387 85225 0 85225 0.00380 47 7093 252751 17341 235410 0.01040 47 7093 3753937 2307865 1446072 0.06370 1 38 38 0.00000 2 19 14144 14144 0.00060 1 599 599 0.00000 2 233 5264 5264 0.00020 2 3102 700 2402 0.00010 2 47 2388 2388 0.00010 10 299 25535 700 24835 0.00100 0 1568961 9785421 11291608 -1506187 X 1 1 1 1 Good Samaritan Health Center 601 South Center Merrill WI 54452 http://ministryhealth.org/gshc/home.nw 1043 X X X X Good Samaritan Health Center 1 1 X X X X X X X X X 12 1 1 1 X See Narrative X X X X X X X X X 0 0 1 1 200.000000000000 1 300.000000000000 1 X X X X X X 1 1 X X 1 0 X X X X 1 X 0 0 Good Samaritan Health Center Part V, Section B, Line 3: The assessment team comprised of private and public Lincoln County organization members include: hospital nurses and administrators; clinic personnel; public health nurses and educators; behavioral health therapists and leaders; 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 interested community members in the health needs assessment process. Community members received an invitation by mail and follow-up email.Jim Lawrence, Health Educator Consultant, and Angela Nimsgern, Regional Director from the Division of Public Health Northern Region Office, and Art Lersch, Community Resource Development Educator at UW Extension Lincoln County, were consultants.A representative from Ministry Good Samaritan Health of Merrill, Wisconsin, Inc. ("MGSHC") joined the Lincoln County Community Health Improvement Plan Steering Team as a community partner to obtain further data for each of the priorities. This team created the community health survey and MGSHC assisted with data compilation and analysis.Additionally, MGSHC conducted a focus group with physicians and case managers practicing in the facility. Those attending included: Dr. Robyn Schertz (Medical Director of Good Samaritan Emergency Department), Dr. Mark Gaulke (Internal Medicine/Pediatrics, Ministry Medical Group, Inc.), Dr. Robert Sedlacek (Family Practice, Ministry Medical Group, Inc.), Dr. Dionna Pendleton (Family Practice, Ministry Medical Group, Inc.), Dr. Ken Anuligo (Family Practice, Ministry Medical Group, Inc.) and Mark Moser (LSW Case Management, Ministry Good Samaritan Health Center of Merrill, Wisconsin, Inc.). Appendix 2 lists the individuals who participated in the community needs assessment process.Public Health Experts:- Shelley Hersil, Director and Health Officer Lincoln County Health Department Master in Public Health Administration, UW-Lacrosse Certified Health Education Specialist (CHES). Lincoln County Health Officer for seven years and more than 10 years experience with tobacco control and prevention.- Jim Lawrence, Health Educator Consultant Wisconsin Division of Public Health - Northern Regional office. More than 20 years of experience in public health consulting.- Art Lersch, Associate Professor, Community Resources Development Educator, UW Extension Lincoln County Master in Public Health Administration, Kent State University. Focus areas are organizational, leadership and business development.- Angela Nimsgern, Regional Director, Wisconsin Division of Public Health-Northern Regional Office Master in Public Health Administration, CHP more than 12 years of experience with community health assessments.- Angela Nimsgern, WI Division of Public Health Northern Region- Brenda Jones, Ministry Good Samaritan Health Center of Merrill, Wisconsin, Inc.- Susan Cronick, Ministry Sacred Heart-St. Mary's Hospitals, Inc.- Bill Zeitz, Lincoln County Board of Health- Bob Odegard, Merrill Fire Department- Bonnie Rudie, UW Extension - Lincoln County- Brigid Flood, Lincoln County Health Department- Carmen A. Viegut, Ministry Sacred Heart-St. Mary's Hospitals, Inc.- Cindy Lezotte, Ministry Good Samaritan Health Center of Merrill, Wisconsin, Inc.- Connie Kuczmarski, Community Care of Central Wisconsin- Dan Wendorf, City of Merrill - Parks & Recreation Department- Debbie Moellendorf, UW Extension - Lincoln County- Debi McGregor, Children's Service Society of Wisconsin- Dee Olsen, Merrill Area United Way- Erin Zastrow, Aging & Disability Resource Center- Evelyn Lee, Anderson Associates- Jane Deau, Merrill Area Community Enrichment- Jesse Borchardt, Community Care of Central Wisconsin- Jessica DeJong, Aspirus Clinics- Jim Lawrence, WI Division of Public Health Northern Region- John Sample, Merrill Area Public Schools- Julie Thompson, Tomahawk Senior Community Center- Kathy Graham, Citizen- Ken Neff, City of Merrill Police Department- Lori Decker, Ministry Medical Group, Inc. - Tomahawk- Pam Melander, Church Mutual Insurance Company- Paula Gebauer, Ministry Sacred Heart-St. Mary's Hospitals, Inc.- Peggy McDowell, Northern WI Tobacco Free Coalition- Robin Lane, Marshfield Clinic - Merrill Center- Sarah Jaeger, Bridge Community Health Clinic- Sharon Anderson, Citizen- Shelley Hersil, Lincoln County Health Department- Stacy Bolder, Tomahawk School District- Tammi Boers, Lincoln County Health Department- Tammy Hansen, UW Extension Lincoln County- William Erickson, COO Ministry Sacred Heart-St. Mary's Hospitals, Inc.- Amanda Kostman, UW Extension Lincoln County. Good Samaritan Health Center Part V, Section B, Line 4: The CHNA was conducted with Ministry Sacred Heart Hospital. Good Samaritan Health Center Part V, Section B, Line 7: Priority Needs Not Being Addressed and the Reasons:Sexual Health:Although sexual health has been identified, MGSHC, being a Catholic health organization, is guided by ethical and religious directives. These directives do not align with public health and the public school programs available in the community.Domestic Violence:MGSHC currently provides Sexual Assault Nurse Examiners (SANE) when an incident occurs. The Health Center works very closely with HAVEN a domestic abuse shelter by providing funding. The Health Center Chaplain serves on the HAVEN Board of Directors.Alcohol and Drug Abuse:The Lincoln County Drug Free Coalition is very active in the Merrill community providing multiple agencies to decrease alcohol and drug use. Good Samaritan Health Center Part V, Section B, Line 14g: A plain language summary of the financial assistance policy is available in the following locations:- The Hospital facilitiy's website- Attachment to billing invoices- Posted to the Hospital facility's emergency rooms and waiting rooms- Posted in the Hospital facility's admission offices- Provided, in writing, to patients on admission to the Hospital facility. Part V, Section B, Line 5a: The Hospital facility's CHNA can be found at the following website:http://ministryhealth.org/GoodSamaritan/Ministry_Good_Samaritan_Health_ Center_CHNA_2013_2_13FINAL3.pdf Part I, Line 6a: Good Samaritan Health Center of Merrill, Wisconsin, 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, Inc. network of hospitals, clinics and other health-related organizations. Part I, Line 7: Amounts calculated in Part 1, 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. Part II, Community Building Activities: Community building activities include activities 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 a variety of community health programs and partnerships. The Organization provides various community health education programs. They include health promotion and wellness, school health education programs, child safety programs, advanced health directive education programs and various support groups. The Organization also provides various clinical services to the community. They include diabetes education, prostate and various other screenings, and school and athletic exams. The Organization also provided job shadowing and mentoring opportunities for the community. Part III, Line 2: 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. Part III, Line 3: Good Samaritan Health Center of Merrill, Wisconsin, Inc. has a very robust financial assistance program; therefore, no estimate is made for bad debt attributed to financial assistance eligible patients. Part III, Line 4: From the footnote of the consolidated financial statements of Ministry Health Care, Inc., which includes the activity of Good Samaritan Health Center of Merrill, Wisconsin, Inc.:The provision for doubtful accounts is based upon management's assessment of expected net collections considering economic conditions, historical experience, 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. The Health Ministry has not experienced material changes in write-off trends and has not materially changed its charity care policy in the current year. Part III, Line 8: 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. Part III, Line 9b: The Organization 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. Part VI, Line 2: The Organization performs Community Health Needs Assessments as needed. Planning workgroups consisting of community partners are formed to define the community and its needs through review of healthy people initiatives, census documents, and local government health and welfare agencies. Considering other community resources/assets, data collection methods are used to identify particular problems or subgroups and areas known to have high poverty rates and to be underserved. The data is analyzed and priorities are set based on trending information which may target a specific need. 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 Health 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 to the poor in their communities, and the hours are included as part of their performance goals. Part VI, Line 3: Ministry Health Care, Inc. ("MHC") has financial counselors located at every hospital. If a patient indicates they are unable to pay their bill at any point during pre-service, admission, discharge or billing process, the financial counselors will assist the patient in either securing a funding source (grants, COBRA coverage, disability benefits, Medicaid, VA, etc.) if eligible or assist them in completing a financial assistance application. Part VI, Line 4: The city of Merrill is located in Southern Lincoln County located in the Northern portion of Wisconsin. Merrill serves as the county seat and is the largest city in the county. The 2013 population of Merrill is 9,475. According to the 2010 census data the population of Merrill was 9,661. The racial make-up consisted of 96.3% White, 2.00% Hispanic, 0.50% African American, 0.40% Native American, 0.60% Asian, and 0.20% other. 23.9% were under 18 and 19.40% were over 65.The median income for a household in Lincoln County over the last five years is $49,021 and 11.1% of the population was below the poverty line. Part VI, Line 5: The Organization strives to further its exempt purposes by the following:- The Organization's governing board consists primarily of persons who reside within the primary service area who are not employees of the Organization.- As mentioned, the Organization provides several services which are nototherwise available being in a rural setting.- Based on the Organization's mission, emergency rooms are made availableto all patients regardless of the ability to pay.- The Organization also participates in the education and training ofhealthcare professional through internship programs.The Hospital participates in government-sponsored health programs(Medicare, Medicaid, Champus, Tricare).The Hospital offers volunteer opportunities to the community. There are 359 volunteers that serve the Hospital as needed.Various financial programs are available to patients of Good Samaritan Health Center of Merrill, Wisconsin, Inc. They include discounted and/or free care depending on individual circumstances. The facility also offers payment plans for those self pay patients.Good Samaritan Health Center of Merrill, Wisconsin, Inc. is a critical access hospital that has inpatient and swing beds. They also provide emergency and walk-in services. As a critical access hospital, the Organization serves as a critical point in stabilizing patients for transport to other facilities. Part VI, Line 6: Ministry Health Care, Inc. ("Ministry" or "the Health Ministry") is a member of Ascension Health. Ascension Health Alliance, d/b/a Ascension (Ascension), is a Missouri nonprofit corporation formed on September 13, 2011. Ascension is 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 healthcare facilities, or Health Ministries, located in 23 of the United States and the District of Columbia. Ascension and its member organizations are hereafter referred to collectively 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; theCongregation 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. As more fully described in the Organizational Changes note, Marian Health System, which was previously sponsored by the Sisters of the Sorrowful Mother of the Third Order of St. Francis of Assisi US/Caribbean Province, became part of Ascension Health on April 1, 2013.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.The consolidated financial statements include the following affiliates in which Ministry has a controlling interest or is the sole sponsor.Affiliate Organization - LocationAffinity Health System (Affinity)Calumet Medical Center, Inc. (CMC) - Chilton, WINetwork Health System, Inc. (NHS)Affinity Medical Group (AMG) - Fox Valley of WisconsinTwin Med, LLC - Fox Valley of WisconsinMercy Medical Center of Oshkosh, Inc. - Oskosh, WIMercy Health Foundation, Inc. - Oshkosh, WISt. Elizabeth Hospital, Inc. - Appleton, WICatalpa Health, Inc. - Appleton, WISt. Elizabeth Hospital Foundation, Inc. - Appleton, WIAgape Community Center of Milwaukee, Inc. - Milwaukee, WIDoor County Memorial Hospital (Door County) - Sturgeon Bay, WIGood Samaritan Health Center of Merrill, Wisconsin, Inc. - Merrill, WIGood Samaritan Health Center Foundation of Merrill, Wisconsin, Inc. - Merrill, WIHoward Young Health Care, Inc. (Howard Young)Dr. Kate Newcomb Convalescent Center, Inc. - Woodruff, WIThe Howard Young Medical Center, Inc. - Woodruff, WIHoward Young Foundation, Inc. - Woodruff, WIEagle River Memorial Hospital, Incorporated - Eagle River, WIMinistry Holdings, Inc.Network Health (NH) - Fox Valley of WisconsinNetwork Health Insurance Corporation (NHIC) - Fox Valley of WisconsinMinistry Home Care, Inc.Ministry Home Care Services - Various in WisconsinMinistry Medical Group, Inc.Our Lady of Victory Hospital, Inc. - Stanley, WISacred Heart-St. Mary's Hospitals, Inc. - Tomahawk, WI/Rhinelander, WISaint Clare's Hospital of Weston, Inc. - Weston, WIFoundation of Saint Clare's Hospital of Weston, Inc. - Weston, WISaint Elizabeth's Hospital of Wabasha, Inc. - Wabasha, MNSaint Joseph's Hospital of Marshfield, Inc. - Marshfield, WIFoundation of Saint Joseph's Hospital of Marshfield, Inc. - Marshfield, WISaint Michael's Hospital of Stevens Point, Inc. - Stevens Point, WISaint Michael's Foundation of Stevens Point, Inc. - Stevens Point, WIMission: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 which 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 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 community benefit programs:- Traditional charity care includes the cost of services provided to persons who cannot afford healthcare 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 other vulnerable persons.- Cost of other programs for persons living in poverty and other vulnerable persons includes unreimbursed costs of programs intentionally designed to serve the persons living in poverty and 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 of persons living in poverty and other community benefit programs. The cost of providing care to persons living in poverty and other community benefit programs is estimated by reducing charges forgone by a factor derived from the ratio of each entity's total operating expenses to the entity's billed charges for patient care. The amount of traditional charity care provided, determined on the basis of cost, was approximately $18,380,000 for the year ended June 30, 2014. The amount of unpaid cost of public programs, cost of other programs for persons living in poverty and other vulnerable persons, and community benefit cost are reported in the accompanying supplementary information. Part VI, Line 7, List of States Receiving Community Benefit Report: WI 1 1 0 0 0 0 0 0 0 Robyn Schertz MD Board Member 0 440810 0 0 0 30054 0 22600 0 40957 0 534421 0 0 Mary T Krueger President 0 242465 0 38261 0 27689 0 43259 0 16958 0 368632 0 0 Nicholas Desien Ministry Health Care CEO 0 1004953 0 329299 0 727354 0 15000 0 26974 0 2103580 0 0 Jeffrey Francis Ministry Health Care CAFO 0 427032 0 63804 0 31416 0 101523 0 22502 0 646277 0 0 Larry T Hegland Chief Medical Officer 0 265895 0 24091 0 22830 0 29175 0 13628 0 355619 0 0 Jeffrey Martin President at SMH 0 428700 0 69766 0 63173 0 113532 0 23250 0 698421 0 0 Kristine McGarigle VP - Patient Care 0 155427 0 13643 0 36136 0 11029 0 18181 0 234416 0 0 Kathryn S Horst Clinical Staff Pharmacist 102818 0 0 0 28156 0 25130 0 12323 0 168427 0 0 0 James L Mason Manager, Pharmacy - E 103234 0 10573 0 27070 0 3822 0 20887 0 165586 0 0 0 Jeff Badger Former Officer 0 405962 0 56934 0 34917 0 44888 0 18099 0 560800 0 0 Part I, Line 3 Ministry Health Care, Inc., a related organization of Good Samaritan Health Center of Merrill, Wisconsin, 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 Part I, Line 4a: The following highest compensated employee received severance payments from the organization or a related organization during the calendar year 2013: James L. Mason $20,870 Part I, Line 4b: 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 individual received current year distributions of: Kristina McGarigle $18,080 Form 990, Part VI, Section A, line 2 Many of the persons listed on Part VII have a "business relationship" with each other by virtue of employment by Ministry Health Care, Inc. related entities. Form 990, Part VI, Section A, line 6 Good Samaritan Health Center of Merrill, Wisconsin, Inc. has a single corporate member, Ministry Health Care, Inc. Form 990, Part VI, Section A, line 7a Good Samaritan Health Center of Merrill, Wisconsin, Inc. has a single corporate member, Ministry Health Care, Inc., who has the ability to elect members to the governing body of Good Samaritan Health Center of Merrill, Wisconsin, Inc. Form 990, Part VI, Section A, line 7b All decisions that have a material impact to Good Samaritan Health Center of Merrill, Wisconsin, Inc. financial information or corporation as a whole are subject to approval by its sole corporate member, Ministry Health Care, Inc. Form 990, Part VI, Section B, line 11 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, Section B, line 12c 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 will decide if conflicts of interest exist. Each director, principal officer and member of a committee with governing board delegated powers annually signs statement which affirms such person has received a copy of the Conflicts 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, Section B, line 15 In determining compensation of the organization's CEO, the process performed by Ministry Health Care, Inc., a related organization of Good Samaritan Health Center of Merrill, Wisconsin, Inc., included a review and approval by independent persons, comparability data, and contemporaneous substantiation of the deliberation and decision. The Compensation Committee, which is assisted by an independent consulting firm, 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 decided. In determining compensation of other officers and key employees of the organization, the process performed by Ministry Health Care, Inc., a related organization of Good Samaritan Health Center of Merrill, Wisconsin, Inc., included a review and approval by independent persons, comparability data, and contemporaneous substantiation of the deliberation and decision. The Compensation Committee, assisted by an independent consulting firm, 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, Section C, line 19 The Ministry web page is available to the public for inspection with a good deal of information regarding who Ministry Health Care, Inc. is and the entities included along with our mission. The Articles of Incorporation, Bylaws, Conflicts 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 B: Amounts paid to Ellis Stone Construction Co., Inc. represent payments for both services and goods. These amounts cannot be separated. Form 990, Part XI, line 9: Equity Transfer - EHR 701,466. Ascension Pension FMV Adjustment 1,135,641. Intercompany Transfer 5,400. Interentity Transfer 6. Intercompany Fund Balance - Funds Held for Foundation 22,097. Ascension Health Alliance PO BOX 45998 St Louis MO 631455998 453358926 National Health System MO Section 501(c)(3) Schedule A, Line 11a N/A 0 Ascension Health PO Box 45998 St Louis MO 631453806 311662309 National Health System MO Section 501(c)(3) Schedule A, Line 11a Ascension Health Alliance 0 Ministry Health Care Inc 10925 W Lake Park Dr Ste 100 Milwaukee WI 53224 391490371 Parent Corporation WI Section 501(c)(3) Schedule A, Line 11b Ascension Health 0 Agape Community Center of Milwaukee Inc 6100 North 42nd Street Milwaukee WI 532093560 391461846 Community Center WI Section 501(c)(3) Schedule A, Line 7 Ministry Health Care Inc 1 Calumet Medical Center Inc 614 Memorial Drive Chilton WI 53014 390905385 Hospital WI Section 501(c)(3) Schedule A, Line 3 Affinity Health System 1 Catalpa Health Inc N4642 County N Appleton WI 54914 454681563 Mental Health Facility WI Section 501(c)(3) Schedule A, Line 3 St Elizabeth Hospital Inc 1 Saint Michael's Foundation of Stevens Point Inc 900 Illinois Avenue Stevens Point WI 54481 391657410 Charitable Foundation WI Section 501(c)(3) Schedule A, Line 11a Saint Michael's Hospital of Stevens Point Inc 1 Door County Memorial Hospital 323 South 18th Avenue Sturgeon Bay WI 54235 390806324 Hospital WI Section 501(c)(3) Schedule A, Line 3 Ministry Health Care Inc 1 Dr Kate Newcomb Convalescent Center Inc PO Box 829 Woodruff WI 54568 391357365 LTC Facility WI Section 501(c)(3) Schedule A, Line 9 Howard Young Health Care Inc 1 Eagle River Memorial Hospital Incorporated 201 Hospital Road Eagle River WI 54521 390985690 Hospital WI Section 501(c)(3) Schedule A, Line 3 The Howard Young Medical Center Inc 1 Foundation of Saint Clare's Hospital of Weston Inc 3400 Ministry Parkway Weston WI 54476 753193633 Charitable Foundation WI Section 501(c)(3) Schedule A, Line 11a Ministry Health Care Inc 1 Foundation of Saint Joseph's Hospital of Marshfield Inc 611 Saint Joseph Avenue Marshfield WI 54449 391684957 Charitable Foundation WI Section 501(c)(3) Schedule A, Line 11a Saint Joseph's Hospital of Marshfield Inc 1 Good Samaritan Health Center Foundation of Merrill Wisconsin Inc 601 South Center Avenue Merrill WI 54452 391627755 Charitable Foundation WI Section 501(c)(3) Schedule A, Line 11a Good Samaritan Health Center of Merrill Wisconsin Inc 1 Howard Young Foundation Inc 240 Maple Street Woodruff WI 54568 391521169 Charitable Foundation WI Section 501(c)(3) Schedule A, Line 7 Howard Young Health Care Inc 1 Howard Young Health Care Inc 240 Maple Street Woodruff WI 54568 391499115 Home Office WI Section 501(c)(3) Schedule A, Line 11b Ministry Health Care Inc 1 The Howard Young Medical Center Inc 240 Maple Street Woodruff WI 54568 390873606 Hospital WI Section 501(c)(3) Schedule A, Line 3 Howard Young Health Care Inc 1 Mercy Health Foundation Inc PO Box 3370 Oshkosh WI 54903 237140261 Charitable Foundation WI Section 501(c)(3) Schedule A, Line 9 Affinity Health System 1 Mercy Medical Center of Oshkosh Inc 500 S Oakwood Road Oshkosh WI 54904 390806268 Hospital WI Section 501(c)(3) Schedule A, Line 3 Ministry Health Care Inc 1 Ministry Home Care Inc 611 St Joseph Avenue 4S Marshfield WI 54449 391936201 Home Care/Hospice WI Section 501(c)(3) Schedule A, Line 9 Ministry Health Care Inc 1 Ministry Medical Group Inc 824 Illinois Avenue Stevens Point WI 54481 391965593 Clinics WI Section 501(c)(3) Schedule A, Line 11c Ministry Health Care Inc 1 Ministry Weight Management Inc 2251 North Shore Drive Rhinelander WI 54501 391829015 Health Services WI Section 501(c)(3) Schedule A, Line 3 Sacred Heart-St Mary's Hospitals Inc 1 Network Health System Inc 1570 Appleton Rd Menasha WI 54952 391127163 Clinical Healthcare Services WI Section 501(c)(3) Schedule A, Line 3 Affinity Health System 1 Our Lady of Victory Hospital Inc 1120 Pine Street Stanley WI 54768 390807065 Hospital WI Section 501(c)(3) Schedule A, Line 3 Ministry Health Care Inc 1 Sacred Heart-St Mary's Hospitals Inc PO Box 347 Stevens Point WI 54481 391390638 Hospital WI Section 501(c)(3) Schedule A, Line 3 Ministry Health Care Inc 1 Saint Clare's Hospital of Weston Inc 3400 Ministry Parkway Weston WI 54476 721531917 Hospital WI Section 501(c)(3) Schedule A, Line 3 Ministry Health Care Inc 1 Saint Elizabeth's Hospital of Wabasha Inc 1200 Grant Blvd West Wabasha MN 55981 410693877 Hospital MN Section 501(c)(3) Schedule A, Line 3 Ministry Health Care Inc 1 St Elizabeth Hospital Foundation Inc 1506 S Oneida Street Appleton WI 54915 391256677 Charitable Foundation WI Section 501(c)(3) Schedule A, Line 7 Affinity Health System 1 St Elizabeth Hospital Inc 1506 S Oneida Street Appleton WI 54915 390816818 Hospital WI Section 501(c)(3) Schedule A, Line 3 Ministry Health Care Inc 1 Saint Joseph's Hospital of Marshfield Inc 611 Saint Joseph Avenue Marshfield WI 54449 390847631 Hospital WI Section 501(c)(3) Schedule A, Line 3 Ministry Health Care Inc 1 Saint Michael's Hospital of Stevens Point Inc 900 Illinois Avenue Stevens Point WI 54481 390808443 Hospital WI Section 501(c)(3) Schedule A, Line 3 Ministry Health Care Inc 1 Affinity Health System 1570 Midway Place Menasha WI 54952 391568866 Support Related Healthcare Organziations IL Section 501(c)(3) Schedule A, Line 11b Ministry Health Care Inc 1 Twin Med LLP PO Box 8005 Menasha WI 54952 391180341 Rental Property WI N/A Network Health Plan Inc 1570 Midway Place Menasha WI 54952 391442058 Insurance WI N/A C 0 Network Health Insurance Corporation 1570 Midway Place Menasha WI 54952 392020474 Insurance WI N/A C 0 Ministry Holdings Inc 1570 Midway Place Menasha WI 54952 422966177 Insurance Holding Company WI N/A C 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 1 0 Ministry Health Care Inc O 2816845 FMV Saint Clare's Hospital of Weston Inc O 280722 FMV Ministry Medical Group Inc O 3641868 FMV Ministry Medical Group Inc R 739396 FMV Ministry Health Care Inc P 4009473 FMV