2015-08-12T08:54:31-05:00 2014-09-30 440160260 BKD LLP 1201 WALNUT SUITE 1700 KANSAS CITY MO 64106 990 2013-10-01 060250773 THE WILLIAM W BACKUS HOSPITAL WILL 8608898331 326 WASHINGTON STREET NORWICH CT 06360 DANIEL E LOHR SENIOR VP/CFO 8608898331 2015-08-12 1 MICHAEL J ENGLE P00482834 8162216300 2013 2016-02-25 16:41:14Z DANIEL E LOHR 326 WASHINGTON STREET NORWICH CT 06360 345215684 0 X WWW.BACKUSHOSPITAL.ORG X 1891 CT BACKUS HOSPITAL DELIVERS AND COORDINATES A CONTINUUM OF HIGH-QUALITY HEALTH CARE THAT IS SENSITIVE TO THE NEEDS OF INDIVIDUALS IN EASTERN CONNECTICUT. 16 9 2061 453 2712206 424011 1225848 2374100 279344487 302711330 6336590 9511371 2501468 2179591 289408393 316776392 130303 145509 0 0 144190562 134279532 0 0 479261 113205414 124191524 257526279 258616565 31882114 58159827 477063817 513864285 151234531 158969385 325829286 354894900 X THE WILLIAM W BACKUS HOSPITAL DELIVERS AND COORDINATES A CONTINUUM OF HIGH QUALITY HEALTH CARE THAT IS SENSITIVE TO THE NEEDS OF INDIVIDUALS IN EASTERN CONNECTICUT. THE HOSPITAL IS COMMITTED TO BEING RESPONSIVE AND ACCOUNTABLE TO THOSE FOR WHOSE BENEFIT IT EXISTS, AND TO IMPROVING THE HEALTH OF ITS COMMUNITIES. 0 0 206360909 145509 303812409 IN FISCAL YEAR 2014, BACKUS HOSPITAL HAD 9,801 ADMISSIONS, 78,481 EMERGENCY DEPARTMENT VISITS, AND 486,854 OUTPATIENT VISITS. THE HOSPITAL DELIVERED 896 BABIES AND 6,363 SAME DAY SURGICAL PROCEDURES. BACKUS PERFORMED 137,707 OUTPATIENT IMAGING EXAMS, 7,293 MRI EXAMINATIONS, 7,985 PSYCHIATRIC CLINICAL VISITS AND 8,093 PSYCHIATRIC PARTIAL HOSPITAL VISITS. 206360909 1 1 0 1 0 0 0 0 0 1 1 0 0 0 1 0 1 1 0 0 0 0 0 0 1 0 1 1 1 1 1 0 0 0 0 0 0 0 1 0 0 0 0 0 1 1 1 0 0 1 202 0 1 2061 1 1 1 0 0 0 0 1 1 0 0 0 0 X 16 9 1 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 1 0 CT X X DANIEL LOHR 8608898331 326 WASHINGTON STREET NORWICH CT 06360 DAVID WHITEHEAD TRUSTEE/PRESIDENT/CEO 40.00 7.00 X X 731171 0 45918 JOHN BILDA TRUSTEE 2.00 1.00 X 0 0 0 STEPHEN BRIGGS TRUSTEE 2.00 1.00 X 0 0 0 ELIZABETH CONWAY TRUSTEE/VICE CHAIRMAN 6.00 1.00 X X 0 0 0 JAMES CARDON MD TRUSTEE 2.00 1.00 X 0 0 0 NANCY GENTES TRUSTEE 2.00 1.00 X 0 0 0 ANTHONY JOYCE TRUSTEE/CHAIRMAN 6.00 1.00 X X 0 0 0 PETER MANERI TRUSTEE 2.00 1.00 X 0 0 0 PAUL MAXFIELD TRUSTEE 2.00 1.00 X 0 0 0 DEBORAH MONAHAN TRUSTEE/SECRETARY 6.00 1.00 X X 0 0 0 LYNNE QUINTAL-HILL TRUSTEE 2.00 1.00 X 0 0 0 ROBERT RAMSDELL TRUSTEE/TREASURER 6.00 1.00 X X 0 0 0 DONNA ROMITO TRUSTEE 2.00 1.00 X 0 0 0 DENNIS SLATER TRUSTEE 2.00 1.00 X 0 0 0 MARK TRAMONTOZZI TRUSTEE 2.00 1.00 X 0 0 0 ELLIOT JOSEPH TRUSTEE 2.00 40.00 X 0 1847535 347786 DANIEL LOHR SENIOR VP/CFO 40.00 9.00 X 481725 0 38685 CAROLYN TRANTALIS VP OPERATIONS EAST REGION 1.00 40.00 X 0 195013 21586 MARY BYLONE VP PATIENT CARE EAST REGION 40.00 X 246598 0 20900 THERESA BUSS VP HUMAN RESOURCES E. REGION 40.00 X 234419 0 20380 PETER SHEA SENIOR VP/MEDICAL DIRECTOR 40.00 X 452908 0 38268 SERGIO CASILLAS PHYSICIAN 40.00 X 552668 0 36254 ROBERT SIDMAN PHYSICIAN 40.00 X 436250 0 37598 MARK TOUSIGNANT PHYSICIAN 40.00 X 440368 0 37598 WILLIAM HORGAN PHYSICIAN 40.00 X 358568 0 37598 RICHARD GOULDING PHYSICIAN 40.00 X 361040 0 37598 4295715 2042548 720169 191 0 1 0 ALLIANCE HEALTHCARE SERVICES PO BOX 96485 CHICAGO IL 60693 MEDICAL SERVICES 3187496 YALE NEW HAVEN HOSPITAL 20 YORK STREET NEW HAVEN CT 06504 MEDICAL SERVICES 2311515 ROPES & GRAY LLP PO BOX 414265 BOSTON MA 02241 LEGAL 1416980 BARTON & ASSOCIATES PO BOX 417844 BOSTON MA 02241 MEDICAL SERVICES 1326206 EXECUTIVE HEALTH RESOURCES PO BOX 822688 PHILADELPHIA PA 19182 CONSULTING 975105 37 82858 1710 556154 1733378 3765 2374100 INPATIENT 900099 123906609 123906609 OUTPATIENT 900099 116551873 116551873 EMERGENCY DEPT 900099 58535862 58535862 LAB COURIER SERVICE 621500 2658878 2658878 EHR REVENUE 900099 1058108 1058108 302711330 3751637 3751637 1177783 1655972 -478189 -478189 -478189 32039843 93500 26093258 280351 5946585 -186851 5759734 5759734 24800 82858 56725 -31925 -31925 499903 352986 146917 146917 CAFETERIA 722320 1250359 1250359 PURCHASE DISCOUNTS 900099 285378 285378 CHILD CARE 624410 191350 191350 815701 762373 53328 2542788 316776392 301100203 2712206 10589883 X 135509 135509 10000 10000 2025125 430003 1595122 110766120 101785251 8848523 132346 3092638 2802653 286356 3629 10453351 9473181 967904 12266 7942298 7197580 735399 9319 604127 604127 596470 596470 64774 64774 213746 213746 28797163 15378807 13418356 142823 119444 23379 4705389 3679610 1023712 2067 3584111 462903 3121208 5558850 517301 5041549 268727 133647 135080 27319 4633 22686 2777042 2777042 15002794 6543596 8459198 1924718 1363097 561621 MEDICAL EXPENSES 37083444 37083444 BAD DEBT 8078005 8035283 42722 MAINT/SERVICE CONTRACTS 5112846 3981740 1131106 LAB EXPENSES 4227272 4227272 5421904 2995955 2129694 296255 258616565 206360909 51776395 479261 1643564 2710787 130996812 184674883 29416 460 31013657 36980052 53821 11760 3778841 3836103 2941851 2589705 303097892 175263190 138743906 127834702 158491234 145614943 12632 12632 9358083 9598258 477063817 513864285 21300221 22981573 62005476 1527930 1463627 66400904 134524185 151234531 158969385 X 314456228 343007454 3305592 3534497 8067466 8352949 325829286 354894900 477063817 513864285 X 58159827 604064 -407865 -29290412 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 1 64774 0 0 0 64774 0 PART II-B, LINE 1: LOBBYING ACTIVITIES ARE PRIMARILY COMPRISED OF THE PORTION OF DUES PAID TO THE CONNECTICUT HOSPITAL ASSOCIATION AND THE AMERICAN HOSPITAL ASSOCIATION THAT THOSE INSTITUTIONS DEEM LOBBYING BASED ON THE MEDICARE DEFINITION. 5551985 169678 2217 5719446 5396859 159637 4511 5551985 5396859 5226 5226 5396859 5320786 5000 76505 5432 5396859 4841631 358064 505259 378271 5897 5320786 1.00000 0 0 5011878 5011878 10381267 118751476 38393196 90739547 64622232 57266471 7355761 104145346 79603523 24541823 185693 185693 127834702 DUE TO 3RD PARTIES 8036715 EMPLOYEE RELATED OBLIGATIONS 42795856 SELF-INSURED PROF LIABILITY 9181837 CAPITAL LEASE OBLIGATIONS 6848070 OTHER LIABILITIES 4532110 DUE FROM AFFILIATES 2841766 TAX EXEMPT SERIES E BOND PREMIUM 1503488 LT INTERCOMPANY DEBT SERIES E 58784343 134524185 318530621 604064 604064 317926557 596611 -1746776 -1150165 316776392 260250295 1899548 1899548 258350747 188746 77072 265818 258616565 PART V, LINE 4: THE PERMANENTLY RESTRICTED ENDOWMENT FUNDS ARE MEANT TO PROVIDE LONG TERM SUPPORT FOR CAPITAL AND OPERATING PROGRAMS FOR THE HOSPITAL IN ACCORDANCE WITH THE DONOR'S WISHES. PART XI, LINE 4B - OTHER ADJUSTMENTS: AUXILIARY INCOME-152,130 K-1 PASSTHROUGH-642 LOSS ON FIXED ASSETS-(186,851) RENTAL EXPENSES-(1,655,972) GOLF TOURNAMENT EXPENSES-(56,725) PART XII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES-1,655,972 GOLF TOURNAMENT EXPENSES-56,725 LOSS ON FIXED ASSETS-186,851 PART XII, LINE 4B - OTHER ADJUSTMENTS: AUXILIARY EXPENSES-77,072 SCHEDULE D PART X LINE 2 ASC 740-10, UNCERTAIN TAX POSITIONS, PRECRIBES A RECOGNITION THRESHOLD AND MEASUREMENT ATTRIBUTE FOR THE FINANCIAL STATEMENT RECOGNITION AND MEASUREMENT OF A TAX POSITION TAKEN OR EXPECTED TO BE TAKEN IN A TAX RETURN.THIS INTERPRETATION ALSO PROVIDES GUIDANCE ON DERECOGNITION, CLASSIFICATION, INTEREST AND PENALTIES, ACCOUNTING IN INTERIM PERIODS, AND DISCLOSURE REQUIREMENTS FOR UNCERTAIN TAX POSITION.MANAGEMENT HAS EVALUATED THE IMPLICATIONS OF ASC 740-10 AND DETERMINED THAT ITS IMPACT ON THE FINANCIAL STATEMENTS IS NOT SIGNIFICANT. GOLF TOURNAMENT 58110 40510 17600 5100 16910 3485 7768 SEDER GOLF TOURNAMENT 49548 42348 7200 1500 8580 8664 750 3968 107658 82858 24800 6600 25490 12149 750 11736 56725 -31925 1 1 1 X 250.000000000000 1 X 1 1 0 1 1 1788699 1788699 0.00710 59487196 39651920 19835276 0.07920 61275895 39651920 21623975 0.08630 532644 5455 527189 0.00210 221658 221658 0.00090 2194502 2194502 0.00880 11812 11812 0.00000 63564 63564 0.00030 3024180 5455 3018725 0.01210 64300075 39657375 24642700 0.09840 57761 57761 0.00020 3694 3694 0.00000 2702 2702 0.00000 64157 64157 0.00020 0 8035283 617246 73314619 84280637 -10966018 X 1 1 1 1 THE WILLIAM W BACKUS HOSPITAL 326 WASHINGTON STREET NORWICH CT 06360 X X X THE WILLIAM W BACKUS HOSPITAL 1 1 X X X X X X X X X 12 1 0 1 X WWW.BACKUSHOSPITAL.ORG/HEALTHSURVEY X X X X X X X X X X 0 0 1 1 250.000000000000 1 400.000000000000 1 X X X X X X 1 1 X X X X 1 0 X X X X 1 X 0 0 THE WILLIAM W BACKUS HOSPITAL PART V, SECTION B, LINE 3: IN THE MOST RECENT CHNA, WILLIAM W. BACKUS HOSPITAL CONTRACTED WITH HOLLERAN, AN INDEPENDENT RESEARCH AND CONSULTING FIRM LOCATED IN LANCASTER, PENNSYLVANIA. A SAMPLE OF 461 INDIVIDUALS WHO RESIDE WITHIN EASTERN CONNECTICUT WERE INTERVIEWED BY TELEPHONE TO ASSESS THEIR HEALTH BEHAVIORS, PREVENTATIVE PRACTICES, AND ACCESS TO HEALTH CARE. INDIVIDUALS WERE RANDOMLY SELECTED FOR PARTICIPATION BASED ON A STATISTICALLY VALID SAMPLING FRAME DEVELOPED BY HOLLERAN. THE SAMPLING FRAME REPRESENTED 24 ZIP CODES WITHIN THE HOSPITAL'S SERVICE AREA. INTERVIEWS WERE CONDUCTED BY HOLLERAN'S TELE-RESEARCH CENTER BETWEEN THE DATES OF JULY 24, 2012 AND SEPTEMBER 6, 2012. INTERVIEWERS CONTACTED RESPONDENTS VIA LAND-LINE TELEPHONE NUMBERS GENERATED FROM A RANDOM CALL LIST. EACH INTERVIEW LASTED APPROXIMATELY 12 - 15 MINUTES DEPENDING ON THE CRITERIA MET AND WAS COMPLETELY CONFIDENTIAL. ONLY RESPONDENTS WHO WERE AT LEAST 18 YEARS OF AGE AND LIVED IN A PRIVATE RESIDENCE WERE INCLUDED. THE SURVEY WAS ADAPTED FROM THE CENTER FOR DISEASE CONTROL AND PREVENTION'S BEHAVIORAL RISK FACTOR SURVEILLANCE SYSTEM (BRFSS). BRFSS IS THE LARGEST TELEPHONE HEALTH SURVEY IN THE WORLD. IT IS USED NATIONALLY TO IDENTIFY NEW HEALTH PROBLEMS, MONITOR CURRENT PROBLEMS AND GOALS, AND ESTABLISH AND EVALUATE HEALTH PROGRAMS AND POLICIES. THE SURVEY TOOL CONSISTED OF APPROXIMATELY 100 FACTORS SELECTED FROM THE 2010 AND 2011 BRFSS TOOLS. THE FACTORS WERE CHOSEN BY WILLIAM W. BACKUS HOSPITAL, IN CONSULTATION WITH HOLLERAN AND ADDRESSED 27 HEALTH-RELATED TOPICS RANGING FROM GENERAL HEALTH STATUS TO CHILD HUMAN PAPILLOMA VIRUS. IN ADDITION, BRFSS RESULTS FOR CONNECTICUT AND THE UNITED STATES ARE INCLUDED WHEN AVAILABLE TO INDICATE HOW THE HEALTH STATUS OF WILLIAM W. BACKUS HOSPITAL'S SERVICE AREA COMPARES ON A STATE AND NATIONAL LEVEL.THE SUMMARY REPORT IS AVAILABLE AT: HTTP://BACKUSHOSPITAL.ORG/WP-CONTENT/UPLOADS/2013/05/CHNA-FINAL-REPORT.PDF THE WILLIAM W BACKUS HOSPITAL PART V, SECTION B, LINE 5D: THE CHNA REPORT WAS MADE WIDELY AVAILABLE TO THE PUBLIC. INFORMATION ABOUT THE CHNA AND ITS MAJOR FINDINGS AND IMPLEMENTATION STRATEGY APPEARED IN HEALTHY CONNECTIONS AND THE HOSPITELL. BACKUS HOSPITAL PUBLISHES HEALTHY CONNECTIONS EACH MONTH AS A COMMUNITY SERVICE TO THE RESIDENTS OF EASTERN CONNECTICUT. INFORMATION IN HEALTHY CONNECTIONS COMES FROM A WIDE RANGE OF MEDICAL RESOURCES. THE HOSPITELL IS A WEEKLY NEWSLETTER FOR BACKUS EMPLOYEES, VOLUNTEERS, PATIENTS, AND COMMUNITY MEMBERS. IT KEEPS READERS UPDATED ON HOSPITAL NEWS AND CAN BE FOUND IN PRINTED FORM IN THE HOSPITAL AND ITS OFFSITE LOCATIONS AND IT CAN ALSO BE FOUND ONLINE AT THE HOSPITAL'S WEBSITE. THE ENTIRE NEEDS ASSESSMENT IS MADE AVAILABLE TO THE PUBLIC VIA THE HOSPITALS WEBSITE AND CAN BE FOUND AT WWW.BACKUSHOSPITAL.ORG/HEALTHSURVEY. YOU CAN ALSO ACCESS THE CHNA REPORT ON THE CONNECTICUT OFFICE OF HEALTHCARE ACCESS WEBSITE AT WWW.CT.GOV/DPH/CWP/VIEW.ASP?A=3902&Q=277344 . THE WILLIAM W BACKUS HOSPITAL PART V, SECTION B, LINE 7: BY FOCUSING EFFORTS THE CROSS-CUTTING ISSUES OF ACCESS TO CARE, PREVENTATIVE HEALTH (INCLUDING CHRONIC AND INFECTIOUS DISEASE, RESPIRATORY HEALTH, AND OBESITY), AND MENTAL HEALTH (INCLUDING SUBSTANCE ABUSE), THE BACKUS HEALTH SYSTEM WILL TAKE A COMPREHENSIVE APPROACH TO ADDRESSING EIGHT OF THE NINE MOST URGENT NEEDS IN THE COMMUNITIES IT SERVES. AS WITH ALL BACKUS HEALTH SYSTEM PROGRAMS, IT WILL CONTINUE TO MONITOR COMMUNITY NEEDS AND ADJUST PROGRAMMING AND SERVICES ACCORDINGLY.BACKUS RECOGNIZES THAT THERE ARE NUMEROUS PARTNERS IN THE COMMUNITY THAT CAN HELP TO IMPROVE THE IDENTIFIED HEALTH NEEDS. IN SOME CASES, PARTNERS ARE BETTER SUITED TO LEAD THE INITIATIVE TO IMPACT CERTAIN HEALTH NEEDS. SUCH IS THE CASE WITH THE BUILT ENVIRONMENT. BACKUS HEALTH SYSTEM WILL SUPPORT ONGOING AND NEW EFFORTS TO IMPROVE THE COMMUNITY'S PHYSICAL ENVIRONMENT AND INFRASTRUCTURE TO IMPROVE SAFETY, THE TRANSPORTATION SYSTEM, AND CREATE MORE OPPORTUNITIES FOR PHYSICAL ACTIVITY, BUT SEES ITS PRIMARY ROLE AS ALLOCATING RESOURCES TO ADDRESS DIRECT HEALTH NEEDS FOR THE COMMUNITY. 11 BACKUS OUTPATIENT CARE CENTER 111 SALEM TURNPIKE NORWICH CT 06360 OUTPATIENT SERVICES MEDICAL OFFICE BUILDING 330 WASHINGTON STREET NORWICH CT 06360 RADIATION THERAPY/LAB COLCHESTER BACKUS HEALTH CENTER 163 BROADWAY COLCHESTER CT 06415 RADIOLOGY/LAB/PRIMARY CARE MONTVILLE BACKUS HEALTH CARE 80 NORWICH/NEW LONDON TURNPIKE UNCASVILLE CT 06382 RADIOLOGY/LAB/PRIMARY CARE LEDYARD BACKUS HEALTH CENTER 2 LORENZ PARKWAY LEDYARD CT 06339 LAB/PRIMARY CARE FAMILY HEALTH CENTER AT CROSSROADS 196 PARKWAY SOUTH WATERFORD CT 06385 PRIMARY CARE/REHAB/ORTHOPEDICS INFECTIOUS DISEASE CLINIC 107 LAFAYETTE STREET NORWICH CT 06360 CLINIC NORTH STONINGTON BACKUS HEALTH CENTER 82 NORWICH-WESTERLY ROAD NORTH STONINGTON CT 06359 PRIMARY CARE NORWICHTOWN BACKUS PATIENT SERVICE CTR 55 TOWN STREET NORWICH CT 06360 LAB PLAINFIELD EMERGENCY CENTER 582 NORWICH ROAD PLAINFIELD CT 06374 LAB/RADIOLOGY/EMERGENCY SERVICES JEWETT CITY PATIENT SERVICE CENTER 70 MAIN STREET JEWETT CITY CT 06351 LAB PART I, LINE 7, COLUMN (F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $ 8,078,005. PART III, LINE 4: SEE PAGES 10&19 OF THE AUDITED FINANCIAL STATEMENTS. LINE 3-COST METHODOLOGY EQUALS RCC FROM 2014 OHCA FILING. PORTION OF BAD DEBT CONSIDERED COMMUNITY BENEFIT IS BASED ON THE COST OF THE ACCOUNTS RETURNED FROM THE COLLECTION AGENCY AS UNCOLLECTIBLE. PART III, LINE 8: THE MEDICARE SHORTFALL WAS NOT INCLUDED IN THE COMMUNITY BENEFIT COST. THE COSTING METHODOLOGY CONSISTED OF INFORMATION FROM THE HOSPITAL'S COST ACCOUNTING SYSTEM AS WELL AS COSTS FROM THE MEDICARE COST REPORT PART III, LINE 9B: IN THE SELF-PAY POLICY, SECTION IIB, STATES THAT THE MEDICAL BUREAU OF ECONOMICS (MBE) RECEIVES A WEEKLY LIST OF PATIENTS WHO WERE SENT FINANCIAL ASSISTANCE APPLICATIONS FROM BACKUS STAFF. THIS INFORMATION IS FROM THE PATIENT ACCOUNTS OR FINANCIAL COUNSELING DEPARTMENTS. MBE'S COLLECTION ACTIVITY ON THESE PATIENTS IS HAULTED UNTIL IT HAS BEEN DETERMINED IF THE PATIENT QUALIFIES FOR FINANCIAL ASSISTANCE UNDER THE HOSPITAL'S POLICY,BY THE HOSPITAL FINANCIAL COUNCELING UNIT. COLLECTION ACTION IS ONLY RESUMED ONCE IT IS DETERMINED THE PATIENT DOES NOT QUALIFY FOR FINANCIAL ASSISTANCE. PART VI, LINE 2: IN 2012, THE WILLIAM W. BACKUS HOSPITAL COMMISSIONED A COMPREHENSIVE COMMUNITY HEALTH NEEDS ASSESSMENT CONDUCTED BY HOLLERAN, A PROFESSIONAL RESEARCH FIRM. THE ASSESSMENT CONSISTED OF 461 TELEPHONE INTERVIEWS WHICH WERE CONDUCTED THROUGHOUT THE HOSPITAL'S SERVICE REGION (BOTH NEW LONDON AND WINDHAM COUNTIES). THE ASSESSMENT ALSO INCLUDED A DETAILED ANALYSIS OF SECONDARY DATA SOURCES, AS WELL AS KEY INFORMANT INTERVIEWS AND THREE FOCUS GROUPS. THE NEEDS ASSESSMENT WAS PRESENTED AND DISTRIBUTED, AND CAN BE ACCESSED AT WWW.BACKUSHOSPITAL.ORG/HEATLHSURVEY. THE SUMMARY REPORT IS AVAILABLE AT: HTTP://BACKUSHOSPITAL.ORG/WP-CONTENT/UPLOADS/2013/05/CHNA-FINAL-REPORT.PDF PART VI, LINE 3: NOTIFICATION ABOUT CHARITABLE CARE AND ASSISTANCE PROGRAMS IS AVAILABLE AT ALL REGISTRATION AREAS, ON AND OFF THE MAIN HOSPITAL CAMPUS, IN WAITING AREAS, IN THE PATIENT HANDBOOK, ON OUR WEBSITE, AND ON PROMINENTLY PLACED SIGNS (IN ENGLISH AND IN SPANISH). ADDITIONALLY, CARE MANAGEMENT STAFF MEET WITH PARENTS, FAMILY, CLERGY, AND OTHERS AS APPROPRIATE TO DISCUSS ASSISTANCE PROGRAMS AND SERVICES THAT MAY BE AVAILABLE. IN ADDITION TO THE COMPLETE FINANCIAL ASSISTANCE POLICY AND APPLICATION FOR FINANCIAL ASSISTANCE, HERE IS THE INFORMATION INCLUDED ON THE HOSPITAL WEBSITE:FINANCIAL ASSISTANCEBACKUS HOSPITAL PROVIDES FINANCIAL ASSISTANCE PROGRAMS FOR CERTAIN QUALIFIED PATIENTS WHO ARE UNABLE TO PAY ALL OR PART OF THEIR BILL FOR INPATIENT, OUTPATIENT AND EMERGENCY SERVICES RENDERED AT THE HOSPITAL.IF YOU ARE COPING WITH A FINANCIAL HARDSHIP, AND ARE FACING DEBTS OWED TO BACKUS HOSPITAL, FINANCIAL ASSISTANCE MAY BE AVAILABLE TO YOU.INCOME VERIFICATIONBACKUS REQUESTS INCOME INFORMATION FROM THE APPLICANT. VERIFICATION OF REPORTED INCOME SHOULD BE INCLUDED WITHIN THE APPLICATION PACKAGE.APPROPRIATE VERIFICATION SOURCES INCLUDE:" MOST RECENT FEDERAL TAX RETURN AND W-2" MOST RECENT 3 PAYROLL CHECKS" COPIES OF UNEMPLOYMENT CHECKS" COPIES OF ANY PENSION, ALIMONY, CHILD SUPPORT OR OTHER SOURCES OF INCOME" COPIES OF SOCIAL SECURITY EARNINGS, IF ANY" ANY OTHER PERTINENT INFORMATIONIF THE APPLICANT HAS NO INCOME A STATEMENT DETAILING THE CURRENT METHOD OF SUPPORT WILL BE ACCEPTED. PROOF OF INCOME OR EARNINGS IS REQUIRED WITH APPLICATION OR THE APPLICATION WILL NOT BE CONSIDERED.FINANCIAL ASSISTANCE OPTIONSTHE LEVEL OF FINANCIAL ASSISTANCE THAT YOU MAY BE ELIGIBLE TO RECEIVE WILL BE BASED UPON THE CRITERIA DEFINED IN THE FINANCIAL ASSISTANCE POLICY.THE WILLIAM W. BACKUS HOSPITAL CONSIDERS FINANCIAL ASSISTANCE AWARDS ON A CASE-BY-CASE BASIS. PLEASE CONTACT US IF YOU HAVE QUESTIONS REGARDING ELIGIBILITY.FINANCIALLY INDIGENTFINANCIALLY INDIGENT IS DEFINED AS AN INDIVIDUAL WHOSE TOTAL GROSS ANNUAL INCOME IS LESS THAN OR EQUAL TO 250% OF THE FEDERAL POVERTY GUIDELINES (FPG).PATIENTS AT OR BELOW 250% FPG ARE ELIGIBLE FOR A 100% DISCOUNT OFF OF THEIR OUTSTANDING BALANCES. INDIVIDUALS ABOVE 250% UP TO 400% FPG ARE ELIGIBLE FOR A DISCOUNT BASED ON THEIR TOTAL GROSS ANNUAL INCOME.MEDICALLY INDIGENTBACKUS HOSPITAL CONSIDERS AN INDIVIDUAL TO BE MEDICALLY INDIGENT IF THEIR TOTAL ANNUAL GROSS INCOME IS ABOVE 400% FPG AND THEIR OUTSTANDING MEDICAL OBLIGATIONS ARE GREATER THAN 50% OF THEIR TOTAL ANNUAL GROSS INCOME.THESE INDIVIDUALS MAY BE ELIGIBLE FOR A DISCOUNT SEPARATE FROM TRADITIONAL FINANCIAL ASSISTANCE. PLEASE REFER TO THE FINANCIAL ASSISTANCE POLICY FOR DETAILS REGARDING ELIGIBILITY AND THE DISCOUNT SCHEDULE.MEDICALLY INDIGENT IS DEFINED BY THE IRS AS: "PERSONS WHOM THE ORGANIZATION HAS DETERMINED ARE UNABLE TO PAY SOME OR ALL OF THEIR MEDICAL BILLS BECAUSE THEIR MEDICAL BILLS EXCEED A CERTAIN PERCENTAGE OF THEIR FAMILY OR HOUSEHOLD INCOME OR ASSETS (FOR EXAMPLE, DUE TO CATASTROPHIC COSTS OR CONDITIONS), EVEN THOUGH THEY HAVE INCOME OR ASSETS THAT OTHERWISE EXCEED THE GENERALLY APPLICABLE ELIGIBILITY REQUIREMENTS FOR FREE OR DISCOUNTED CARE UNDER THE ORGANIZATION'S FINANCIAL ASSISTANCE POLICY."BACKUS HOSPITAL TREATS EACH APPLICATION INDIVIDUALLY. IF YOU HAVE ANY QUESTIONS ABOUT YOUR SPECIFIC SITUATION, PLEASE CONTACT OUR CUSTOMER SERVICE REPRESENTATIVES AT 860-889-8331, EXT. 2917, MONDAY THROUGH FRIDAY FROM 7:30 AM TO 4 PM.FINANCIAL ASSISTANCE LETTERTHE WILLIAM W. BACKUS HOSPITAL PROVIDES FINANCIAL ASSISTANCE FOR CERTAIN QUALIFIED PATIENTS WHO ARE UNABLE TO PAY ALL OR PART OF THEIR BILL FOR INPATIENT, OUTPATIENT AND EMERGENCY SERVICES RENDERED AT THE HOSPITAL.IF YOU ARE COPING WITH A FINANCIAL HARDSHIP AND ARE FACING DEBTS OWED TO THE WILLIAM W. BACKUS HOSPITAL, FINANCIAL ASSISTANCE SUCH AS FREE CARE OR A SLIDING SCALE DISCOUNT MAY BE AVAILABLE TO YOU. THE FINANCIAL COUNSELING PROCESS WILL INDICATE WHAT OPTIONS EXIST TO ASSIST YOU WITH YOUR OUTSTANDING BALANCE.FINANCIAL ASSISTANCE APPLIES TO BACKUS HOSPITAL BILLS ONLY. IT DOES NOT APPLY TO RADIOLOGISTS, PATHOLOGISTS, ANESTHESIOLOGISTS OR OTHER PROFESSIONAL SERVICES INVOLVED IN YOUR CARE THAT ARE BILLED SEPARATELY.FREQUENTLY ASKED QUESTIONS 1. DOES THE HOSPITAL HAVE A FINANCIAL ASSISTANCE POLICY?THE WILLIAM W. BACKUS HOSPITAL DOES HAVE A WRITTEN FINANCIAL ASSISTANCE POLICY THAT DEFINES THE DISCOUNT STRUCTURE AND PROGRAMS AVAILABLE TO QUALIFYING PATIENTS.THE WILLIAM W. BACKUS HOSPITAL BASES ALL FINANCIAL ASSISTANCE ON THE MOST CURRENT FEDERAL POVERTY GUIDELINES (FPG), WHICH ARE BASED ON THE GROSS INCOME AND HOUSEHOLD SIZE.BACKUS GRANTS 100% CHARITY CARE TO THOSE APPLICANTS WHOSE GROSS HOUSEHOLD INCOME IS AT OR BELOW 250% FPG. A SLIDING DISCOUNT IS AVAILABLE TO THOSE PATIENTS WHO HAVE GROSS INCOME UP TO 400% FPG.CURRENTLY, THE FEDERAL GOVERNMENT DEFINES 100% OF POVERTY AS AN INDIVIDUAL EARNING A GROSS INCOME OF $11,670 PER YEAR. THE WILLIAM W. BACKUS HOSPITAL FINANCIAL ASSISTANCE POLICY GRANTS 100% CHARITY CARE TO A FAMILY OF ONE EARNING UP TO $29,175 PER YEAR, OR 250% FPG. INCOME THRESHOLDS INCREASE RELATIVE TO HOUSEHOLD SIZE. A DISCOUNT IS AVAILABLE FOR APPLICANTS EARNING UP TO 400% FPG.2. WHAT SERVICES DOES THE FINANCIAL ASSISTANCE POLICY COVER?THE WILLIAM W. BACKUS HOSPITAL'S FINANCIAL ASSISTANCE POLICY COVERS SERVICES RENDERED AT THE WILLIAM W. BACKUS HOSPITAL, INCLUDING INPATIENT, EMERGENCY, AND OUTPATIENT PROCEDURES.FINANCIAL ASSISTANCE MAY NOT BE GRANTED FOR SOME PROCEDURES, SUCH AS ELECTIVE PROCEDURES OR SOME SPECIAL SITUATIONS, SUCH AS THAT OF AN INDIVIDUAL WHO IS ELIGIBLE FOR INSURANCE BUT HAS REFUSED TO APPLY OR FUNDS ARE AVAILABLE THROUGH ANOTHER SOURCE FOR PAYMENT (I.E. SETTLEMENTS, STATE FUNDED PROGRAMS).FINANCIAL ASSISTANCE APPLIES TO BACKUS HOSPITAL BILLS ONLY. IT DOES NOT APPLY TO RADIOLOGISTS, PATHOLOGISTS, ANESTHESIOLOGISTS OR OTHER PROFESSIONAL SERVICES INVOLVED IN YOUR CARE THAT ARE BILLED SEPARATELY.3. DOES THE HOSPITAL PROVIDE PERSONNEL TO HELP WITH APPLICATIONS AND TO ANSWER QUESTIONS?THE WILLIAM W. BACKUS HOSPITAL EMPLOYS FINANCIAL COUNSELORS TO HELP PATIENTS APPLY FOR FINANCIAL ASSISTANCE, MEDICAID, AND OTHER STATE HEALTH PROGRAMS.THE HOSPITAL ALSO HAS RESOURCES TO HELP WITH APPLICATIONS FOR STATE NUTRITIONAL ASSISTANCE PROGRAMS (SNAP) AND PHARMACY ASSISTANCE PROGRAMS. FINANCIAL COUNSELORS CAN HELP TO DETERMINE APPROPRIATE REFERRALS TO THESE RESOURCES.THE WILLIAM W. BACKUS HOSPITAL PROVIDES LANGUAGE TRANSLATION VIA CYRACOM AND MARTTI LANGUAGE LINES.4. DOES THE HOSPITAL COMMUNICATE THE AVAILABILITY OF FINANCIAL ASSISTANCE TO THE COMMUNITY?THE WILLIAM W. BACKUS HOSPITAL BELIEVES IT IS IMPORTANT TO COMMUNICATE THE AVAILABILITY OF FINANCIAL ASSISTANCE TO THE COMMUNITIES IT SERVES. THEREFORE, A NOTICE OF THE AVAILABILITY OF FINANCIAL ASSISTANCE IS INCLUDED WITH THE PAPER BILL SENT TO THE PATIENT'S HOME, IS POSTED IN ALL MAIN REGISTRATION AREAS, IS AVAILABLE ON THE HOSPITAL'S WEBSITE, AND UPON REQUEST OF HOSPITAL STAFF OR REPRESENTATIVES.5. DOES THE HOSPITAL EVER DENY CARE BASED ON INABILITY TO PAY?THE WILLIAM W. BACKUS HOSPITAL WILL NEVER DELAY OR DENY EMERGENCY CARE OR NECESSARY SERVICES DUE TO AN INABILITY TO PAY.6. DOES THE HOSPITAL HAVE A PROGRAM FOR PATIENTS WHO DON'T QUALIFY FOR TRADITIONAL FINANCIAL ASSISTANCE BUT INCUR CATASTROPHIC MEDICAL DEBTS?THE HOSPITAL HAS A WRITTEN POLICY THAT COVERS CATASTROPHIC FINANCIAL ASSISTANCE FOR THE MEDICALLY INDIGENT. THE POLICY IS INCLUDED IN THE FINANCIAL ASSISTANCE POLICY, IS AVAILABLE ON THE WEBSITE, AND UPON REQUEST. PART VI, LINE 4: THE WILLIAM W. BACKUS HOSPITAL IS LOCATED IN NORWICH, 45 MINUTES SOUTHEAST OF HARTFORD, IN THE PAST DECADE, THE REGION HAS UNDERGONE MAJOR ECONOMIC CHANGES, DUE TO THE OPERATION OF TWO NATIVE-AMERICAN OWNED ENTERTAINMENT VENUES BRINGING THOUSANDS OF VISITORS INTO THE REGION EACH DAY. THE CASINOS ARE THE LARGEST EMPLOYERS, AND ARE EXPERIENCING FINANCIAL DIFFICULTIES AS THE ECONOMY DECLINES. THE HOSPITAL'S SERVICE AREA HAS AN ESTIMATED POPULATION OF ABOUT 243,000. THE SERVICE AREA CONSISTS OF LARGER COMMUNITIES, SUCH AS NEW LONDON AND GROTON, AND SMALLER LOWER-DENSITY RURAL COMMUNITIES. THE SERVICE AREAS CONTAIN MUNICIPALITIES IN THE NEW LONDON AND WINDHAM COUNTIES. PART VI, LINE 5: A) THE HOSPITAL IS GOVERNED BY A VOLUNTEER COMMUNITY BOARD OF DIRECTORS/TRUSTEES. THESE INDIVIDUALS REPRESENT AN ARRAY OF PROFESSIONS AND BACKGROUNDS. B) THE HOSPITAL HAS 125 CORPORATORS - VOLUNTEER MEMBERS CHOSEN FROM ALL THE COMMUNITIES IN OUR PRIMARY AND SECONDARY SERVICE AREAS. IN ADDITION TO THEIR OFFICIAL CAPACITY AS NOMINATORS OF BOARD MEMBERS, THE CORPORATORS SERVE AS THE HOSPITAL'S EYES AND EARS THROUGHOUT ITS SERVICE AREA. C) THE HOSPITAL OWNS AND OPERATES A MOBILE HEALTH RESOURCE CENTER- A 40-FOOT VAN AND A SMALLER "CAREVAN" THAT TRAVELS TO VARIOUS LOCATIONS IN EASTERN CONNECTICUT OFFERING HEALTH EDUCATION, COUNSELING, AND SCREENINGS. THE VANS MAKE REGULARLY SCHEDULED STOPS AT SENIOR CITIZEN CENTERS, SOUP KITCHENS, ELDERLY HOUSING COMPLEXES, AND HOMELESS SHELTERS. NOT-FOR PROFIT GROUPS ARE ENCOURAGED TO REQUEST THE VANS AND THEIR SERVICES AT THEIR FUNCTIONS OR OFFICES. D) THE HOSPITAL PROVIDES INDIVIDUALS WHO DO NOT IDENTIFY AS HAVING A PRIMARY MEDICAL HOME WITH A FOLLOW UP VISIT POST DISCHARGE TO LINK THESE INDIVIDUALS WITH A PRIMARY CARE PHYSICIAN IN THE COMMUNITY. THIS IS FACILITATED THROUGH THE "MY HEALTH DIRECT" PROGRAM, A WEB-BASED TOOL THAT ALLOWS HOSPITAL STAFF TO ACCESS BLOCKED APPOINTMENTS FOR PHYSICIANS IN THE COMMUNITY. FROM 10/1/13 TO 9/30/14 THE HOSPITAL LINKED 1,171 INDIVIDUALS WITH PRIMARY AND PREVENTIVE CARE. E) THE HOSPITAL PROVIDES FREE COMMUNITY PROSTATE SCREENINGS, DIABETES EDUCATION, BACKPACK SAFETY, HIV EDUCATION/TESTING, BLOOD PRESSURE TESTS, SKIN CANCER SCREENINGS, NUTRITION EDUCATION, AND MANY OTHER SERVICES. F) THE HOSPITAL PROVIDES A COMPREHENSIVE MEDICAL LIBRARY, WHICH IS OPEN TO ALL STAFF. THE LIBRARY HAS SUBSCRIPTIONS TO HUNDREDS OF MAJOR SCIENTIFIC AND CLINICAL JOURNALS, AS WELL AS AN ON-STAFF LIBRARIAN TO HELP WITH SPECIFIC REQUESTS. G) THE HOSPITAL PROVIDES FREE MEDICATION CARDS TO HELP PATIENTS KEEP TRACK OF THEIR CURRENT MEDICATIONS, AND ITS PHARMACISTS OFFER FREE REGULAR EDUCATION REVIEWS TO CHECK FOR POSSIBLE INTERACTIONS AND EXPIRED MEDICATION. H) THE HOSPITAL OFFERS FREE WIRELESS INTERNET (WI-FI) USE THROUGHOUT THE CAMPUS, AND PROVIDES FREE COMPUTER USE TO VISITORS. I) THE HOSPITAL PUBLISHES A BI-MONTHLY HEALTH MAGAZINE. THE PUBLICATION CONTAINS INFORMATION ABOUT HEALTH ISSUES AND TRENDS, A CALENDAR OF FREE HEALTHCARE EDUCATION AND SCREENINGS, AND CONTACT INFORMATION FOR HEALTHCARE PROVIDERS. 98,000 COPIES ARE DISTRIBUTED BI-MONTHLY. PART VI, LINE 6: HARTFORD HEALTHCARE CORPORATION (HHC) IS ORGANIZED AS A SUPPORT ORGANIZATION TO GOVERN, MANAGE AND PROVIDE SUPPORT SERVICES TO ITS AFFILIATES. HHC, THROUGH ITS AFFILIATES INCLUDING HARTFORD HOSPITAL, STRIVES TO IMPROVE HEALTH USING THE "TRIPLE AIM" MODEL: IMPROVING QUALITY AND EXPERIENCE OF CARE; IMPROVING HEALTH OF THE POPULATION (POPULATION HEALTH) AND REDUCING COSTS. THE STRATEGIC PLANNING AND COMMUNITY BENEFIT COMMITTEE OF THE HHC BOARD OF DIRECTORS ENSURES THE OVERSIGHT FOR THESE SERVICES BY EACH HOSPITAL COMMUNITY. IN ADDITION, HHC CONTINUES TO TAKE IMPORTANT STEPS TOWARD ACHIEVING ITS VISION OF BEING "NATIONALLY RESPECTED FOR EXCELLENCE IN PATIENT CARE AND MOST TRUSTED FOR PERSONALIZED, COORDINATED CARE". HHC AFFILIATION CREATES A STRONG, INTEGRATED HEALTH CARE DELIVERY SYSTEM WITH A FULL CONTINUUM OF CARE ACROSS A BROADER GEOGRAPHIC AREA. THIS ALLOWS THE SMALL COMMUNITIES EASY AND EXPEDIENT ACCESS TO THE MORE EXTENSIVE AND SPECIALIZED SERVICES THE LARGER HOSPITALS ARE ABLE TO OFFER. THIS INCLUDES CONTINUING EDUCATION OF HEALTH CARE PROFESSIONALS AT ALL THE AFFILIATED INSTITUTIONS THROUGH THE CENTER OF EDUCATION, SIMULATION AND INNOVATION LOCATED AT HARTFORD HOSPITAL, THE LARGEST OF THE SYSTEM HOSPITALS. THE AFFILIATION FURTHER ENHANCES THE HOSPITALS' ABILITIES TO SUPPORT THEIR MISSIONS, IDENTITY, AND RESPECTIVE COMMUNITY ROLES. THIS IS ACHIEVED THROUGH INTEGRATED PLANNING AND COMMUNICATION TO MEET THE CHANGING NEEDS OF THE REGION. THIS INCLUDES RESPONSIBLE DECISION MAKING AND APPROPRIATE SHARING OF SERVICES, RESOURCES AND TECHNOLOGIES, AS WELL AS CONTAINMENT STRATEGIES. ADDITIONALLY, THE HOSPITAL IS AFFILIATED WITH SEVERAL OTHER NON HOSPITAL CHARITABLE ORGANIZATIONS. THESE ORGANIZATIONS PROVIDE SIGNIFICANT BENEFITS TO THE COMMUNITY. THESE BENEFITS ARE NOT REPORTED IN THE COMMUNITY BENEFIT DATA PROVIDED BY THE HOSPITAL. PART VI, LINE 7, REPORTS FILED WITH STATES CT 1 CHAMBER OF COMMERCE OF SE CT 914 HARTFORD TPKE WATERFORD CT 06385 060475490 501C6 11000 SPONSORSHIPSPONSORSHIP DR MARTIN LUTHER KING SCHOLARSHIP TRUST FUND PO BOX 1308 NEW LONDON CT 06320 066107846 501C3 10000 SPONSORSHIP CENTER FOR HOSPICE CARE 227 DURHAM STREET NORWICH CT 06360 222667260 501C3 8500 SPONSORSHIP UNITED WAY OF SE CT PO BOX 375 GALES FERRY CT 06335 060771393 501C3 8000 SPONSORSHIP BROADWAY KIDS 12 PENNSYLVANIA AVE NIANTIC CT 06357 15000 SPONSORSHIP LEE MEMORIAL CHURCH 294 WASHINGTON STREET NORWICH CT 06360 222512537 10000 SPONSORSHIP THREE RIVERS COLLEGE FOUNDATION 574 NEW LONDON TRNPKE NORWICH CT 06360 237303151 501C3 72000 NURSING SCHOOL/SPONSORSHIP 4 3 SCHOLARSHIP 4 10000 PART I, LINE 2: DONATIONS MADE FOR LOCAL EVENTS, SUCH AS SPONSORSHIPS ARE TYPICALLY ATTENDED BY HOSPITAL EMPLOYEES. FOUR SCHOLARSHIPS IN THE AMOUNT OF $2500 EACH ARE AWARDED TO STUDENTS WHO WILL ATTEND SCHOOL EITHER FOR NURSING OR IN THE MEDICAL FIELD. THE APPLICANTS ARE REVIEWED BY THE SCHOLARSHIP COMMITTEE OF THE AUXILIARY AND WINNERS ARE BASED ON ACADEMICS AS WELL AS COMMUNITY SERVICE. X X X X 0 1 0 0 0 0 0 1 0 DAVID WHITEHEAD TRUSTEE/PRESIDENT/CEO 708316 0 0 0 22855 0 21420 0 24498 0 777089 0 0 0 ELLIOT JOSEPH TRUSTEE 0 1133866 0 365065 0 348604 0 307338 0 40448 0 2195321 0 0 DANIEL LOHR SENIOR VP/CFO 454802 0 0 0 26923 0 21420 0 17265 0 520410 0 0 0 CAROLYN TRANTALIS VP OPERATIONS EAST REGION 0 194197 0 0 0 816 0 11709 0 9877 0 216599 0 0 MARY BYLONE VP PATIENT CARE EAST REGION 244552 0 0 0 2046 0 12321 0 8579 0 267498 0 0 0 THERESA BUSS VP HUMAN RESOURCES E. REGION 232220 0 0 0 2199 0 11754 0 8626 0 254799 0 0 0 PETER SHEA SENIOR VP/MEDICAL DIRECTOR 450316 0 0 0 2592 0 13770 0 24498 0 491176 0 0 0 SERGIO CASILLAS PHYSICIAN 499498 0 52771 0 399 0 13770 0 22484 0 588922 0 0 0 ROBERT SIDMAN PHYSICIAN 330562 0 105418 0 270 0 13770 0 23828 0 473848 0 0 0 MARK TOUSIGNANT PHYSICIAN 440100 0 0 0 268 0 13770 0 23828 0 477966 0 0 0 WILLIAM HORGAN PHYSICIAN 273322 0 85066 0 180 0 13770 0 23828 0 396166 0 0 0 RICHARD GOULDING PHYSICIAN 279085 0 81775 0 180 0 13770 0 23828 0 398638 0 0 0 PART I, LINE 4B DAVID WHITEHEAD, DANIEL LOHR AND PETER SHEA PARTICIPATE IN A SUPPLEMENTAL NONQUALIFIED RETIREMENT PLAN. THERE WERE NO ACCRUALS OR CONTRIBUTIONS THAT WERE MADE TO THE PLAN DURING THE REPORTING PERIOD.THEY DID RECEIVE DISBURSEMENTS OF $3800, $500 AND $0, RESPECTIVELY. PART I, LINE 7 THE INDEPENDENT EXECUTIVE COMPENSATION COMMITTEE (COMMITTEE) OF THE BOARD OF DIRECTORS OF HARTFORD HEALTHCARE ON BEHALF OF BACKUS HOSPITAL HIRES AN OUTSIDE CONSULTANT, INTEGRATED HEALTHCARE STRATEGIES, TO DETERMINE BEST PRACTICES IN GOVERNING EXECUTIVE COMPENSATION. THE FOLLOWING STEPS WERE TAKEN: - INDEPENDENT EXECUTIVE COMPENSATION COMMITTEE (COMMITTEE) OF THE BOARD OF DIRECTORS OF HARTFORD HEALTHCARE, ON BEHALF OF BACKUS HOSPITAL, ESTABLISHED AND REGULARLY REVIEWS EXECUTIVE COMPENSATION PHILOSOPHY - COMMITTEE REGULARLY REVIEWS SCOPE AND DEPTH OF POSITIONS TAKING INTO ACCOUNT COMPLEXITY AND THE FINANCIAL IMPACT AND ACCOUNTABILITY OF ALL "DISQUALIFIED PERSONS" - NATIONAL PEER GROUPS ARE SELECTED FOR COMPARATIVE PURPOSES BASED ON ORGANIZATIONAL SIZE, OPERATING REVENUE, GEOGRAPHY AND OTHER RELEVANT FACTORS - ANALYSIS OF CURRENT TOTAL COMPENSATION VERSUS MARKET PERFORMED BY INDEPENDENT THIRD PARTY COMPENSATION CONSULTING FIRM, REVIEWED BY THE COMMITTEE - RECOMMENDATIONS MADE BASED ON DATA ANALYSIS TO ENSURE APPROPRIATE COMPETITIVE POSITIONING WITHIN PARAMETERS OF COMPENSATION PHILOSOPHY - CEO COMPENSATION REVIEWED BY COMMITTEE BASED ON COMPARATIVE MARKET INFORMATION AND ORGANIZATIONAL PERFORMANCE - ALL CHANGES REVIEWED AND APPROVED BY EXECUTIVE COMPENSATION COMMITTEE THE CEO COMPENSATION DETERMINATION PROCESS IS REVIEWED ON AN ANNUAL BASIS. ALL OTHER EXECUTIVE COMPENSATION IS REGULARLY REVIEWED FOR SCOPE AND DEPTH OF POSITIONS TAKING INTO ACCOUNT COMPLEXITY AND THE FINANCIAL IMPACT AND ACCOUNTABILITY DAVID WHITEHEAD DANIEL LOHR AND PE OFFICERS OF BOTH WWBH AND CONNCARE INC 12031362 REIMBURSEMENTS PAID BY CONNCARE TO WWBH, $773,607 LEASED PROPERTY 0 DAVID WHITEHEAD AND DANIEL LOHR OFFICERS OF BOTH WWBH AND OMNI HOME HEALTH 137208 MANAGEMENT FEES PAID BY OMNI TO WWBH 0 DAVID WHITEHEAD AND DANIEL LOHR OFFICERS OF BOTH WWBH AND WWB INC 7623267 REIMBURSEMENTS PAID BY WWB TO WWBH 0 FORM 990, PART VI, SECTION A, LINE 2 DAVID WHITEHEAD AND DANIEL LOHR HAVE A BUSINESS RELATIONSHIP WITH EACH OTHER. THEY SERVE AS AN OFFICER OR DIRECTOR FOR CONNCARE INC, WWB CORPORATION, AND BACKUS HOME HEALTH WHICH ARE RELATED FOR PROFIT COMPANIES. FORM 990, PART VI, SECTION A, LINE 6 BACKUS CORPORATION, A NOT-FOR-PROFIT 501(C)(3) ORGANIZATION, IS THE SOLE MEMBER OF THE WILLIAM W BACKUS HOSPITAL. FORM 990, PART VI, SECTION A, LINE 7A BACKUS CORPORATION, BEING THE SOLE MEMBER OF THE WILLIAM W BACKUS HOSPITAL, HAS THE RIGHT TO ELECT ALL THE BOARD OF TRUSTEES. FORM 990, PART VI, SECTION A, LINE 7B IN ADDITION TO ANY OTHER RIGHTS AND POWERS WHICH THE MEMBER MAY HAVE UNDER LAW, THE MEMBER SHALL HAVE THE RIGHT AND POWER TO (A)APPROVE THE STRATEGIC PLAN AND THE CONSOLIDATION OR CLOSURE OF SIGNIFICANT LINES OF BUSINESS, PROGRAMS OR SERVICES (B)TO EFFECTUATE THE TRANSFER OF FUNDS TO ANOTHER AFFILIATED CORPORATION (C)TO EFFECTUATE THE HOSPITALS PAYMENT TO OR RECEIPT OF PAYMENT FROM THE CORPORATION (D)TO APPROVE THE ACQUISITION OR LEASE OF ANY EQUIPMENT AND ANY PROJECT OR CONSTRUCTION CONTRACT THAT ENTAILS AN EXPENDITURE BY THE HOSPITAL IN EXCESS OF, OR WITH A VALUE OVER, $400,000 IN ANY FISCAL YEAR AND THAT IS NOT ALREADY INCORPORATED IN AN APPROVED BUDGET (E) TO APPROVE ANY PROJECTS THAT WOULD REQUIRE A CERTIFICATE OF NEED (CON) OR FOR WHICH A CON DETERMINATION WILL BE SUBMITTED TO THE OFFICE OF HEALTH CARE ACCESS (F)TO APPROVE THE REORGANIZATION, MERGER, CONSOLIDATION OR DISSOLUTION OF THE HOSPITAL OR THE AFFILIATION OF THE HOSPITAL WITH ANOTHER HOSPITAL OR HEALTH DELIVERY SYSTEM, OR THE CREATION OR ACQUISITION OF ANY SUBSIDIARY OR AFFILIATE OF THE HOSPITAL (G)TO APPROVE THE HOSPITALS ANNUAL OPERATING BUDGET (H)TO APPROVE PLANS FOR THE BORROWING OF ANY SUM IN EXCESS OF $400,000 WHICH HAS A STATED TERM GREATER THAN ONE YEAR OR WHICH IS SECURED BY A MORTGAGE OF ALL OR ANY PORTION OF THE HOSPITALS REAL PROPERTY OR BY A SECURITY INTEREST IN THE HOSPITALS ASSETS OR REVENUES (I)TO APPROVE AMENDMENTS TO THE CERTIFICATE OF INCORPORATION OR BYLAWS FORM 990, PART VI, SECTION B, LINE 11 THE 990 IS PREPARED BY THE ACCOUNTING STAFF AND THEN REVIEWED BY AN INDEPENDENT ACCOUNTING FIRM. THE 990 IS THEN REVIEWED BY THE CFO AND ANY QUESTIONS ADDRESSED. THE FINAL 990 IS THEN PROVIDED TO THE BOARD. FORM 990, PART VI, SECTION B, LINE 12C THE HOSPITAL'S BOARD HAS ADOPTED THE POLICY OF THE MEMBER, HARTFORD HEALTHCARE CORPORATION (HHC). HHC'S CONFLICT OF INTEREST POLICY (POLICY) REQUIRES ALL COVERED INDIVIDUALS, INCLUDING BOARD MEMBERS AND OFFICERS, TO PROVIDE A DISCLOSURE OF RELATIONSHIPS THAT CREATE OR HAVE THE APPEARANCE OF CREATING A CONFLICT OF INTEREST OR COMMITMENT. THE POLICY REQUIRES UPDATES IF CHANGES IN CIRCUMSTANCES ARISE DURING THE YEAR THAT EITHER (A) CREATE A NEW POTENTIAL CONFLICT OF INTEREST OR COMMITMENT OR (B) CHANGE OR ELIMINATE A CONFLICT OF INTEREST OR COMMITMENT PREVIOUSLY DISCLOSED. CONFLICT OF INTEREST DISCLOSURE STATEMENTS ARE MAINTAINED BY THE HHC OFFICE OF COMPLIANCE, AUDIT & PRIVACY (OCAP). ALL EMPLOYEE DISCLOSURES ARE REVIEWED BY OCAP TO DETERMINE IF THERE IS A POTENTIAL CONFLICT. LEGAL COUNSEL REVIEWS ALL CASES WHERE THE INDIVIDUAL HAS A SIGNIFICANT FINANCIAL INTEREST AND THESE CASES ARE FORWARDED TO THE SYSTEM EXECUTIVE COMPLIANCE STEERING COMMITTEE. THE SYSTEM EXECUTIVE COMPLIANCE STEERING COMMITTEE ASSESS AND MAY RECOMMEND WHETHER 1) THE CONFLICT BE ELIMINATED, 2) THE PROPOSED ACTIVITY BE PROHIBITED, OR 3) A CONFLICT OF INTEREST MANAGEMENT PLAN BE IMPLEMENTED. RESULTS OF THE SURVEY OF BOARD MEMBERS ARE REPORTED TO THE HHC NOMINATING AND GOVERNANCE COMMITTEE FOR DETERMINATIONS OF CONFLICTS AND THE MANAGEMENT OF THEM, WHERE APPLICABLE. FORM 990, PART VI, SECTION B, LINE 15 THE INDEPENDENT EXECUTIVE COMPENSATION COMMITTEE (COMMITTEE) OF THE BOARD OF DIRECTORS OF HARTFORD HEALTHCARE ON BEHALF OF BACKUS HOSPITAL HIRES AN OUTSIDE CONSULTANT, INTEGRATED HEALTHCARE STRATEGIES, TO DETERMINE BEST PRACTICES IN GOVERNING EXECUTIVE COMPENSATION. THE FOLLOWING STEPS WERE TAKEN: - INDEPENDENT EXECUTIVE COMPENSATION COMMITTEE (COMMITTEE) OF THE BOARD OF DIRECTORS OF HARTFORD HEALTHCARE, ON BEHALF OF BACKUS HOSPITAL, ESTABLISHED AND REGULARLY REVIEWS EXECUTIVE COMPENSATION PHILOSOPHY - COMMITTEE REGULARLY REVIEWS SCOPE AND DEPTH OF POSITIONS TAKING INTO ACCOUNT COMPLEXITY AND THE FINANCIAL IMPACT AND ACCOUNTABILITY OF ALL "DISQUALIFIED PERSONS" - NATIONAL PEER GROUPS ARE SELECTED FOR COMPARATIVE PURPOSES BASED ON ORGANIZATIONAL SIZE, OPERATING REVENUE, GEOGRAPHY AND OTHER RELEVANT FACTORS - ANALYSIS OF CURRENT TOTAL COMPENSATION VERSUS MARKET PERFORMED BY INDEPENDENT THIRD PARTY COMPENSATION CONSULTING FIRM, REVIEWED BY THE COMMITTEE - RECOMMENDATIONS MADE BASED ON DATA ANALYSIS TO ENSURE APPROPRIATE COMPETITIVE POSITIONING WITHIN PARAMETERS OF COMPENSATION PHILOSOPHY - CEO COMPENSATION REVIEWED BY COMMITTEE BASED ON COMPARATIVE MARKET INFORMATION AND ORGANIZATIONAL PERFORMANCE - ALL CHANGES REVIEWED AND APPROVED BY EXECUTIVE COMPENSATION COMMITTEE THE CEO COMPENSATION DETERMINATION PROCESS IS REVIEWED ON AN ANNUAL BASIS. ALL OTHER EXECUTIVE COMPENSATION IS REGULARLY REVIEWED FOR SCOPE AND DEPTH OF POSITIONS TAKING INTO ACCOUNT COMPLEXITY AND THE FINANCIAL IMPACT AND ACCOUNTABILITY. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATIONS FINANCIAL STATEMENTS, GOVERNING DOCUMENTS AND THE CONFLICT OF INTEREST POLICY ARE AVAILABLE FOR INSPECTION UPON REQUEST AT THE ORGANIZATIONS ADDRESS. FORM 990, PART IX, LINE 11G OUTSIDE SERVICES: PROGRAM SERVICE EXPENSES 15,378,807. MANAGEMENT AND GENERAL EXPENSES 13,418,356. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 28,797,163. PART IX LINE 11 G PURCHASED SERVICE 11,614,306 PURCHASED SERVICE-LABOR 9,515,242 SYSTEM FEES 4,686,168 CONSULTING 2,473,558 COURIER SERVICE 386,019 GROUNDS 83,371 WASTE REMOVAL 34,202 OTHER 4,297 TOTAL 28,797,163 FORM 990, PART XI, LINE 9: K-1 PASSTHROUGH -642. TRANSFER TO AFFILIATES -2,553,495. INCREASE IN ASSETS HELD IN TRUST 118,022. CHANGE IN PENSION FUNDING -26,854,297. FORM 990 PART XII LINE 2C THE PROCESS HAS NOT CHANGED FROM PRIOR YEAR BACKUS HEALTH CARE INC 326 WASHINGTON STREET NORWICH CT 06360 222481794 SUPPORT CT 501C3 11A BACKUS CORP 1 BACKUS CORPORATION 326 WASHINGTON STREET NORWICH CT 06360 222757608 SUPPORT CT 501C3 11B HARTFORD HEALTHCARE CORPORATION 1 HARTFORD HOSPITAL 80 SEYMOUR STREET HARTFORD CT 06102 060646668 HEALTHCARE SERVICES CT 501C3 3 HARTFORD HEALTHCARE CORPORATION 1 WINDHAM COMMUNITY MEMORIAL HOSPITAL 112 MANSFIELD AVE WILLIMANTIC CT 06226 060646966 HEALTHCARE SERVICES CT 501C3 3 HARTFORD HEALTHCARE CORPORATION 1 MIDSTATE MEDICAL CENTER 435 LEWIS AVENUE MERIDAN CT 06451 060646715 HEALTHCARE SERVICES CT 501C3 3 HARTFORD HEALTHCARE CORPORATION 1 WINDHAM HOSPITAL FOUNDATION INC 112 MANSFIELD AVE WILLIMANTIC CT 06226 562546632 SUPPORTING ORGANIZATION CT 501C3 11A WINDHAM COMMUNITY MEMORIAL HOSPITAL 1 HARTFORD HOSPITAL AUXILIARY CO HARTFORD HOSPITAL 80 SEYMOUR STREET HARTFORD CT 06115 066040747 FUNDRAISING CT 501C3 11C HARTFORD HOSPITAL 1 CONNECTICUT HEALTH SYSTEM INC 80 SEYMOUR STREET HARTFORD CT 06102 222779421 COORDINATION OF HEALTH DELIVERY CT 501C3 11C HARTFORD HEALTHCARE CORPORATION 1 HARTFORD HEALTHCARE CORPORATION 80 SEYMOUR STREET HARTFORD CT 06102 222672834 SUPPORT & MANAGEMENT SVCS TO HHC & AFFILIATES CT 501C3 11C 1 INSTITUTE OF LIVING 200 RETREAT AVENUE HARTFORD CT 06106 060646683 SUPPORTING ORGANIZATION TO HARTFORD HOSPITAL CT 501C3 11C HARTFORD HOSPITAL 1 NATCHAUG HOSPITAL INC 189 STORRS ROAD MANSFIELD CENTER CT 06226 060966963 BEHAVIORAL HEALTH CT 501C3 3 HARTFORD HEALTHCARE CORPORATION 1 CARING FOR COLLEAGUES EMPLOYEE CRISIS FUND 100 GRAND STREET NEW BRITAIN CT 06052 264469178 EMPLOYEE FUND CT 501C3 7 HARTFORD HEALTHCARE CORPORATION 1 VNA HEALTH RESOURCES INC 103 WOODLAND STREET HARTFORD CT 06105 061161422 HOME HEALTHCARE CT 501C3 9 HARTFORD HEALTHCARE AT HOME 1 RUSHFORD CENTER INC 883 PADDOCK AVENUE MERIDAN CT 06450 060932875 SUBSTANCE ABUSE HEALTHCARE SERVICES CT 501C3 7 HARTFORD HEALTHCARE CORPORATION 1 THE HATCH HOSPITAL CORP 112 MANSFIELD AVE WILLIMANTIC CT 06226 066076412 HEALTHCARE SERVICES CT 501C3 3 WINDHAM COMMUNITY MEMORIAL HOSPITAL 1 WCMH WOMEN'S AUXILIARY INC 112 MANSFIELD AVE WILLIMANTIC CT 06226 060677728 FUNDRAISING CT 501C3 11A WINDHAM COMMUNITY MEMORIAL HOSPITAL 1 THE HOSPITAL OF CENTRAL CT & BRADLEY MEMORIAL 110 GRAND STREET NEW BRITAIN CT 06050 060646768 HEALTHCARE SERVICES CT 501C3 3 HARTFORD HEALTHCARE CORPORATION 1 CENTRAL CT SENIOR HEALTH DBA SOUTHING CARE CENTER 45 MERIDEN AVENUE SOUTHINGTON CT 06489 222635676 SUB-ACUTE & LONG TERM CARE CT 501C3 9 HARTFORD HEALTHCARE CORPORATION 1 BRADLEY HEALTH SERVICES 100 GRAND STREET NEW BRITAIN CT 06050 061367014 HEALTHCARE SERVICES CT 501C3 9 HARTFORD HEALTHCARE CORPORATION 1 CENTRAL CT HEALTH ALLIANCE 100 GRAND STREET NEW BRITAIN CT 06050 222785033 SUPPORT & MANAGEMENT SVCS TO THOCC & AFFILIATES SHELL CT 501C3 11B HARTFORD HEALTHCARE CORPORATION 1 EVA STEARNS FAULKNER FOUNDATION 435 LEWIS AVENUE MERIDAN CT 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