2015-04-15T16:06:01-05:00 2014-06-30 721396621 CARR RIGGS & INGRAM LLC TWO RIVERWAY FLOOR 15 HOUSTON TX 77056 990 2013-07-01 203069241 WALKER COUNTY HOSPITAL CORPORATION WALK 9362913411 PO BOX 4001 HUNTSVILLE TX 773424001 SHANNON BROWN CEO 9362913411 2015-04-16 1 DAVID DONNELLY P00956426 7136218090 2015-04-11 2013 2016-02-25 16:41:14Z HUNTSVILLE MEMORIAL HOSPITAL SHANNON BROWN 110 MEMORIAL HOSPITAL DRIVE HUNTSVILLE TX 77340 95080234 0 X WWW.HUNTSVILLEMEMORIAL.COM X 2005 TX WE ARE DEVOTED TO THE HEALTH AND WELL-BEING OF OUR REGIONAL COMMUNITIES BY PROVIDING EXCEPTIONAL CARE TO EVERY PATIENT EVERY DAY WITH A SPIRIT OF WARMTH, COMPASSION AND PERSONAL PRIDE. WE ACHIEVE THIS THROUGH ADVANCED AND EFFICIENT MEDICAL CARE WITH STRONG SELF-GOVERNANCE. 14 14 759 67 0 0 63515 30334 88086935 86093571 647282 203100 414122 1671489 89211854 87998494 1073484 1911689 0 0 37317086 37182631 0 0 0 54876864 45352862 93267434 84447182 -4055580 3551312 65047220 74377425 28824182 34191388 36223038 40186037 X WE ARE DEVOTED TO THE HEALTH AND WELL-BEING OF OUR REGIONAL COMMUNITIES BY PROVIDING EXCEPTIONAL CARE TO EVERY PATIENT EVERY DAY WITH A SPIRIT OF WARMTH, COMPASSION AND PERSONAL PRIDE. WE ACHIEVE THIS THROUGH ADVANCED AND EFFICIENT MEDICAL CARE WITH STRONG SELF-GOVERNANCE. 0 0 67945803 1911689 86093571 TO PROVIDE BENEVOLENT AND CHARITABLE SERVICES FOR THE SICK, INFIRM, AND AFFLICTED RESIDENTS OF WALKER COUNTY THROUGH THE ESTABLISHMENT, MAINTENANCE, SUPPORT, AND OPERATION OF A HOSPITAL. 67945803 1 0 0 1 0 0 0 0 0 0 1 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 1 1 1 0 0 1 497 0 1 759 1 0 1 CJ 0 0 0 0 0 0 0 0 X 14 14 0 1 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 X SHANNON L BROWN 9364352230 110 MEMORIAL HOSPITAL DRIVE HUNTSVILLE TX 77340 DANA GIBSON PHD CPA MEMBER 1.00 X 0 0 0 DAVID ALLEN PRIER MD PRESIDENT 1.00 X 0 0 0 NANCY GAERTNER MEMBER 1.00 X 0 0 0 DON JOHNSON MEMBER 1.00 X 0 0 0 ROSA VALLES MEMBER 1.00 X 0 0 0 WAYNE SCOTT MEMBER 1.00 X 0 0 0 MORRIS JOHNSON VICE PRESIDENT 1.00 X 0 0 0 TIMOTHY DEAHL MD SECRETARY 1.00 X 0 0 0 JOHN KNIGHT MD MEMBER 1.00 X 0 0 0 URMIL SHULKA MD MEMBER 1.00 X 0 0 0 SAM BURRIS MEMBER 1.00 X 0 0 0 WILLIAM DURHAM MEMBER 1.00 X 0 0 0 HELEN WATKINS PHD MEMBER 1.00 X 0 0 0 JACK CHOATE MEMBER 1.00 X 0 0 0 SALLY I NELSON CEO 40.00 X 0 0 0 GUY GROS CFO 40.00 X 215390 0 8317 SHANNON BROWN CEO - EX - OFFICIO 40.00 1.00 X 254834 0 231 SHEILA HOGUE ARD CNO 40.00 X 160655 0 19434 DONNA STEWART RN 40.00 X 135980 0 44 ELIZABETH ROGERS RN 40.00 X 151884 0 103 JULIE M PICKENS RN 40.00 X 125398 0 57 LILLIAN M GULLEDGE-WARD RN 40.00 X 124167 0 142 MARIBEL STEELE RN 40.00 X 122666 0 13783 1290974 0 42111 31 0 1 0 JT VAUGHN CONSTRUCTION LLC 10355 WESTPARK DRIVE HOUSTON TX 77042 CONSTRUCTION 1664641 MORRISON MANAGEMENT SPECIALISTS INC 5801 PEACHTREE DUNWOODY ROAD ATLANTA GA 30342 MANAGEMENT 1445806 COMPREHENSIVE PHARMACY SERVICES PO BOX 1000 DEPT 176 MEMPHIS TN 38148 PHARMACY 1020538 MEMORIAL HERMAN HOSPITAL SYSTEM 9301 SOUTHWEST FWY HOUSTON TX 77074 MANAGEMENT 1015124 HOSPITAL HOUSEKEEPING SYSTEMS LLC 216 EAST 4TH STREET AUSTIN TX 78701 HOUSEKEEPING 794763 73 28325 2009 30334 ROUTINE & ANCILLARY SERVICES 621990 85869590 85869590 EDUCATION NURSING REVENUE 621990 223981 223981 86093571 165871 165871 119101 119101 40320 0 40320 40320 40320 7118969 7074964 6776 44005 -6776 37229 37229 EHR INCENTIVE PROGRAM PAYMENTS 900099 1396729 1396729 OTHER INCOME 900099 53672 53672 MEDICAL RECORDS REVENUE 900099 30173 30173 31494 31494 1512068 87998494 86093571 0 1874589 1910239 1910239 1450 1450 751038 633651 117387 29164693 24606251 4558442 1134897 957513 177384 3993224 3369083 624141 2138779 1804488 334291 591832 11582 580250 137643 137643 6350341 5012886 1337455 471933 191154 280779 455104 124088 331016 1069311 236615 832696 15869 15869 89606 56559 33047 651176 651176 3931571 3931571 470012 470012 MEDICAL SUPPLIES 9889010 9441077 447933 PURCHASES SERVICES 9748173 6097955 3650218 BAD DEBT EXPENSE 7235175 7235175 REPAIR AND MAINTENANCE 2328199 1270051 1058148 1917907 1038546 879361 84447182 67945803 16501379 0 240413 3951287 10433549 4396259 9750692 13321075 -288769 1689539 1908194 587387 818713 70944270 45154625 22235884 25789645 7767108 5000000 10544648 10493524 2086769 8698728 65047220 74377425 13447783 12264092 11549218 16682533 3827181 5244763 28824182 34191388 X 36095940 40056978 127098 129059 36223038 40186037 65047220 74377425 X 3551312 337049 74638 X 0 1 X 1 0 X 2225 0 0 0 0 0 0 0 1 2225 0 0 0 2225 0 PART II-B, LINE 1: AMOUNT REPORTED IN PART II-B, QUESTION 1F REPRESENTS PORTION OF DUES PAID TO TRADE ASSOCIATIONS THAT IS ATTRIBUTABLE TO LOBBYING ACTIVITIES. 699139 699139 19707388 10353814 9353574 2070026 1404314 665712 47600599 33396497 14204102 867118 867118 25789645 ESTIMATED DUE TO THIRD PARTIES 5999855 DUE FROM AFFILIATE 351216 ASSETS LIMITED AS TO USE 2306179 OTHER 41478 8698728 PENSION LIABILITY 5123084 ASSET RETIREMENT OBLIGATION 121679 5244763 81098407 337049 337049 80761358 7237136 7237136 87998494 77212007 0 77212007 7235175 7235175 84447182 PART XI, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT EXPENSE IN AUDIT REVENUE 7,235,175. INVESTMENT INCOME RECORDED TO NET ASSETS 1,961. PART XII, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT EXPENSE IN AUDIT REVENUE 7,235,175. 1 1 X 1 X 1 X 1 1 1 0 1 1 2450582 2450582 0.03170 5635624 2330903 3304721 0.04280 5124 5124 0.00010 8091330 2330903 5760427 0.07460 363784 1000 362784 0.00470 708321 223996 484325 0.00630 1653858 1653858 0.02140 2725963 224996 2500967 0.03240 10817293 2555899 8261394 0.10700 1 7235175 1808794 17504454 19379787 -1875333 X 1 1 1 HUNTSVILLE HEART & VASCULAR CENTER LLC HEART & VASCULAR CENTER 0.51000 1 1 WALKER COUNTY HOSPITAL CORPORATION 110 MEMORIAL HOSPITAL DRIVE HUNTSVILLE TX 77340 X X X WALKER COUNTY HOSPITAL CORPORATION 1 1 X X X X X X X X X 12 1 0 1 X HTTP://WWW.HUNTSVILLEMEMORIAL.COM X X X X X 1 0 1 1 100.000000000000 1 200.000000000000 1 X X X X X X X X 1 1 X X X X 1 0 X X X 1 X 0 0 PART V, SECTION A: WALKER COUNTY HOSPITAL CORPORATION HAS ONE FACILITY THAT INCLUDES THE ACUTE CARE HOSPITAL, I/P REHAB, AMBULATORY SURGERY CENTER, O/P IMAGING CENTER, AND RURAL HEALTH CARE CLINIC.NEEDS ASSESSMENTIN THE PAST, HUNTSVILLE MEMORIAL HOSPITAL HAS CONTRACTED WITH A 3RD PARTY VENDOR TO CONDUCT A COMMUNITY NEEDS ASSESSMENT AND MARKET ANALYSIS. THE COMMUNITY ASSESSMENT IS EVALUATED AND REPORTED EVERY THREE (3) YEARS AND THE MARKET ANALYSIS EVERY 1-2 YEARS AS NEEDED. AFTER DATA IS GATHERED AND FULL ASSESSMENT COMPLETED, THIS INFORMATION IS REPORTED TO THE HOSPITAL LEADERSHIP TEAM AND BOARD OF DIRECTORS. HOSPITAL LEADERS UTILIZE THE INFORMATION GATHERED IN BOTH OF THESE REPORTS TO FORMAT OUR STRATEGIC PLAN FOR THE NEXT FISCAL YEAR, AS WELL AS A FIVE YEAR PLAN. PATIENT EDUCATION OF ELIGIBILITY OF ASSISTANCETHE PATIENT IS ENCOURAGED TO APPLY FOR CHARITY AS EARLY AS POSSIBLE IN THE ACCOUNT MANAGEMENT PROCESS. CHARITY APPLICATION AND QUALIFICATIONS GUIDELINES ARE GIVEN UP FRONT IN REGISTRATION. THE SELF PAY BALANCES ARE SENT TO A MEDICAID ELIGIBILITY COMPANY, WHO SCREENS PATIENTS FROM DAY 1 TO DAY 60. THE SELF PAY BALANCES ARE RETURNED IF THE COMPANY IS UNABLE TO REACH THE PATIENT OR THE PATIENT DOES NOT QUALIFY. SELF PAY BALANCES THAT ARE RETURNED ARE SENT TO AN EARLY OUT COMPANY, WHO HAS OUR CHARITY GUIDELINES, IF THE PATIENT EXPRESSES AN INABILITY TO PAY, THEY ARE REFERRED TO THE HOSPITAL FOR SCREENING. ONCE A COMPLETED APPLICATION IS RECEIVED AND APPROVED, ANY ACCOUNT BALANCES ARE ADJUSTED ACCORDING TO THE LEVEL OF CHARITY THE PATIENT HAS QUALIFIED FOR. IF THE ACCOUNT IS WITH A COLLECTION AGENCY, IT IS RETURNED TO THE HOSPITAL.COMMUNITY INFORMATIONHUNTSVILLE MEMORIAL HOSPITAL IS A JOINT COMMISSION-ACCREDITED, NOT-FOR-PROFIT ACUTE CARE COMMUNITY HOSPITAL. SINCE 1927, WE HAVE PROVIDED CHARITABLE HEALTH CARE SERVICES, DELIVERING QUALITY HEALTHCARE TO THE RESIDENTS OF WALKER COUNTY AND THE SURROUNDING COMMUNITIES. FOUNDED IN 1835, HUNTSVILLE IS ONE OF TEXAS' OLDEST CITIES AND THE HOME OF SAM HOUSTON, THE FIRST AND THIRD PRESIDENT OF THE REPUBLIC OF TEXAS. WE ARE HOME TO SAM HOUSTON STATE UNIVERSITY AND THE TEXAS DEPARTMENT OF CRIMINAL JUSTICE (THE ONLY STATE AGENCY WITH HEADQUARTERS OUTSIDE OF AUSTIN). THE CITY OF HUNTSVILLE IS PART OF WALKER COUNTY IN EAST TEXAS, APPROXIMATELY 70 MILES NORTH OF HOUSTON AND 170 MILES SOUTH OF DALLAS VIA INTERSTATE 45. IT IS ON TEXAS HIGHWAY 30 (WEST TO BRYAN-COLLEGE STATION) AND HIGHWAY 190 (EAST TO LIVINGSTON). OTHER CITIES IN WALKER COUNTY INCLUDE NEW WAVERLY AND RIVERSIDE. HUNTSVILLE COVERS 31 SQUARE MILES, WHILE WALKER COUNTY INCLUDES 790 SQUARE MILES. THE POPULATION OF HUNTSVILLE IS 35,078, NEW WAVERLY IS 950, AND RIVERSIDE IS 425. THE POPULATION IN WALKER COUNTY IS 61,758. WALKER COUNTY IS LOCATED NEAR LAKE LIVINGSTON AND LAKE CONROE AND IS SURROUNDED BY THE SAM HOUSTON NATIONAL FOREST. WALKER COUNTY IS PROUD TO HOST A CULTURALLY DIVERSE COMMUNITY. THE POPULATION DENSITY IS 78 PEOPLE PER SQUARE MILE (30/KM^2). THERE ARE 21,099 HOUSING UNITS AT AN AVERAGE DENSITY OF 27 PER SQUARE MILE (10/KM^2). THE RACIAL MAKEUP OF THE COUNTY IS 67.9% WHITE, 23.88% BLACK OR AFRICAN AMERICAN, 0.35% NATIVE AMERICAN, 0.77% ASIAN, 0.05% PACIFIC ISLANDER, 4.42% FROM OTHER RACES, AND 1.41% FROM TWO OR MORE RACES. 14.11% OF THE POPULATION ARE HISPANIC OR LATINO OF ANY RACE.PROMOTION OF COMMUNITY HEALTHHUNTSVILLE MEMORIAL HOSPITAL'S COMMITMENT TO CHARITABLE CARE GOES BACK TO THE 1927 HOSPITAL CHARTER PROMISING "BENEVOLENT AND CHARITABLE" SERVICES FOR THE "SICK AND INFIRM." OUR GOAL IS TO EDUCATE AND BUILD AWARENESS, PROMOTING HEALTHY LIFESTYLES IN WALKER COUNTY. WE BELIEVE IN GIVING BACK TO THE COMMUNITY THROUGH A NUMBER OF VALUABLE HEALTH RESOURCES SUCH AS EDUCATIONAL MATERIALS, HANDS-ON CLASSES AND INFORMATIVE EVENTS. ON A MONTHLY BASIS, THE HOSPITAL HOLDS FREE COMMUNITY EDUCATION SESSIONS THAT ARE OPEN TO THE PUBLIC. THESE FORUMS PROVIDE CITIZENS A CHANCE TO DETECT A HEALTH THREAT AT ITS EARLIEST, MOST TREATABLE STAGE OR A WAY TO LEARN MORE ABOUT A LOVED ONE'S ILLNESS. EACH SESSION FEATURES A LOCAL PHYSICIAN AS THE KEY SPEAKER AND IS ALSO ASSOCIATED WITH A MEDICAL SCREENING. NOT ONLY DO WE PROVIDE ADVANCED CARE WITH A FRIENDLY TOUCH, WE ALSO FOCUS ON GIVING BACK TO THE GREAT COMMUNITY OF WALKER COUNTY EACH AND EVERY YEAR. WE PROVIDE REDUCED- OR NO-COST CARE FOR THOSE WITH FINANCIAL CHALLENGES. WE EDUCATE AND PRODUCE TOP-NOTCH NURSES THROUGH OUR ACCREDITED JOE G. DAVIS SCHOOL OF VOCATIONAL NURSING. WE RECRUIT EXPERT PHYSICIANS INTO OUR OPEN MEDICAL STAFF. UNDER THE LEADERSHIP OF OUR BOARD OF DIRECTORS, AND THROUGH THE DEDICATION OF OUR PROFESSIONAL HEALTH CARE STAFF, HUNTSVILLE MEMORIAL HOSPITAL IS SETTING THE STANDARD IN QUALITY HEALTH CARE TODAY. HUNTSVILLE MEMORIAL HOSPITAL IS ALSO ABLE TO GAIN VALUABLE INSIGHT FROM LOCAL COMMUNITY LEADERS WHO SERVE ON OUR FOUNDATION BOARD AND COMMUNITY ADVISORY BOARD.THE HUNTSVILLE MEMORIAL HOSPITAL MEDICAL CLINIC WAS ESTABLISHED IN 1992 TO MEET THE PRIMARY HEALTH CARE NEEDS OF THE RESIDENTS OF WALKER COUNTY. IT IS AN AMBULATORY ACUTE CARE CLINIC THAT PROVIDES CARE FOR PATIENTS OF ALL AGES. SERVICES INCLUDE PEDIATRIC CARE, ADOLESCENT MEDICINE AND ADULT MEDICINE. WALKER COUNTY HOSPITAL CORPORATION PART V, SECTION B, LINE 3: THE ORGANIZATION GATHERED INPUT FROM PERSONS WHO REPRESENT THE COMMUNITY BY TELEPHONE INTERVIEWS WITH KEY ORGANIZATIONS AND INSTITUTIONS WITHIN THE COMMUNITY. GATHERED DATA WAS REVIEWED TO IDENTIFY HEALTH NEEDS OF THE COMMUNITY. WALKER COUNTY HOSPITAL CORPORATION PART V, SECTION B, LINE 20D: THE MAXIMUM AMOUNTS THAT CAN BE CHARGED TO FAP-ELIGIBLE INDIVIDUALS FOR EMERGENCY OR OTHER MEDICALLY NECESSARY CARE ARE CALCULATED USING A SLIDING SCALE BASED UPON FEDERAL POVERTY GUIDELINES. IN ALL CASES, AMOUNTS CHARGED TO PATIENTS WILL BE BELOW THE LOWEST NEGOTIATED COMMERCIAL INSURANCE RATE, THE AVERAGE LOWEST NEGOTIATED COMMERCIAL INSURANCE RATE, AND MEDICARE RATES. SCHEDULE H, PART V, LINE 16, 17, & 18 NEITHER HUNTSVILLE MEMORIAL HOSPITAL, NOR THIRD PARTIES AUTHORIZED BY HMH, TAKE ANY ACTIONS UPON NON-PAYMENT FROM A PATIENT BEFORE MAKING A REASONABLE EFFORT TO DETERMINE IF THE PATIENT IS ELIGIBLE FOR THE FACILITY'S FINANCIAL ASSISTANCE POLICY. PART V, SECTION B, LINE 6A THE IMPLEMENTATION STRATEGY IS INCLUDED IN THE COMMUNITY HEALTH NEEDS ASSESSMENT REPORT AND IS POSTED ONLINE AT THE FOLLOWING WEBSITE ADDRESS:HTTP://WWW.HUNTSVILLEMEMORIAL.COM/RES/FILES/12/HMH%20FY2014%20COMMUNITY%20BENEFIT%20PLAN.PDF 4 HUNTSVILLE HEART & VASCULAR CENTER LLC 110 MEMORIAL HOSPITAL DRIVE HUNTSVILLE TX 77340 HEART & VASCULAR CENTER HUNTSVILLE MEMORIAL AUXILIARY 110 MEMORIAL HOSPITAL DRIVE HUNTSVILLE TX 77340 AUXILIARY HMH PHYSICIAN ORGANIZATION 129 MEDICAL PARK LANE HUNTSVILLE TX 77340 ORTHOPEDIC PHYSICIAN OFFICE PHYSICIAN OFFICES-DRBRUCE &DRWARRIER 125 MEDICAL PARK LANE SUITE D HUNTSVILLE TX 77340 PHYSICIAN OFFICES PART I, LINE 3C: GRADUATED SCALE UP TO 200% OF FPG TO DETERMINE DISCOUNT. PART I, LINE 6A: HUNTSVILLE MEMORIAL HOSPITAL AND THE MATTHEWS GROUP WORK TOGETHER TO PREPARE THE ANNUAL COMMUNITY BENEFIT REPORT. HUNTSVILLE MEMORIAL HOSPITAL'S COMMITMENT TO CHARITABLE CARE GOES BACK TO OUR 1927 HOSPITAL CHARTER PROMISING "BENEVOLENT AND CHARITABLE" SERVICES FOR THE "SICK, INFIRM AND AFFLICTED." WE KEPT THIS PROMISE EVERY YEAR BY HELPING OUR COMMUNITY THROUGH EDUCATIONAL PROGRAMS AND SUPPORT GROUPS. IN ADDITION,HMH INCURRED COSTS EXCEEDING $3 MILLION FROM ITS CHARITY CARE PROGRAMS AND OVER $5 MILLION IN UNREIMBURSED COSTS FROM MEDICARE AND STATE MEDICAID CARE. ALL INFORMATION REGARDING HUNTSVILLE MEMORIAL HOSPITAL'S COMMUNITY BENEFIT REPORT CAN BE LOCATED ON THE EXTERNAL WEBSITE. PART I, LN 7 COL(F): BAD DEBT EXPENSE OF $7,235,175 WAS INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT WAS SUBTRACTED FROM TOTAL EXPENSE FOR THE CALCULATION OF "PERCENT OF TOTAL EXPENSE" IN THIS COLUMN.IN ADDITION TO CHARITY CARE PROVIDED BY THE HOSPITAL TO RESIDENTS OF WALKER COUNTY, THE WALKER COUNTY HOSPITAL DISTRICT HAS A SPECIFIC INDIGENT CARE PROGRAM FOR WALKER COUNTY RESIDENTS THAT PROVIDES ADDITIONAL CHARITY CARE RESOURCES TO THE COMMUNITY OUTSIDE HOSPITAL CARE. THE HOSPITAL PROVIDES CARE TO PATIENTS QUALIFYING UNDER THE COUNTY'S INDIGENT CARE PROGRAM. IF PATIENTS DO NOT QUALIFY FOR THE COUNTY'S PROGRAM, THEY ARE THEN ABLE TO APPLY TO THE HOSPITAL'S CHARITY CARE PROGRAM. THE COUNTY'S INDIGENT CARE PROGRAM PROVIDES ADDITIONAL CHARITY CARE RESOURCES TO THE COMMUNITY FOR NON-HOSPITAL RELATED HEALTHCARE SERVICES REDUCING THE OVERALL COMMUNITY BENEFIT PERCENTAGE OF THE HOSPITAL FOR SERVICES IT WOULD HAVE PROVIDED WERE THE PROGRAM NOT IN PLACE. THE ORGANIZATION BELIEVES THE COMMUNITY BENEFIT AS A PERCENTAGE OF EXPENSES REPORTED IN SCHEDULE H, PART I, LINE 7 IS REASONABLE GIVEN THE ADDITIONAL CHARITY CARE RESOURCES TO THE COMMUNITY PROVIDED BY THE WALKER COUNTY HOSPITAL DISTRICT. PART III, LINE 4: ACCOUNTS RECEIVABLE ARE REDUCED BY AN ALLOWANCE FOR DOUBTFUL ACCOUNTS. IN EVALUATING THE COLLECTIBILITY OF ACCOUNTS RECEIVABLE, THE HOSPITAL ANALYZES ITS PAST HISTORY AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYER SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND PROVISION FOR UNCOLLECTIBLE ACCOUNTS. MANAGEMENT REGULARLY REVIEWS DATA ABOUT THESE MAJOR PAYER SOURCES OF REVENUE IN EVALUATING THE SUFFICIENCY OF THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. PART III, LINE 8: THE MEDICARE SHORTFALL WAS COMPUTED USING THE ANNUAL MEDICARE COST REPORT FOR THE PERIOD 11/01/12 THRU 10/31/13. THE MEDICAL CENTER USES COST REPORT METHODOLOGY, WHICH APPORTIONS ROUTINE COSTS BASED ON MEDICARE OR MEDICAID DAYS TO TOTAL DAYS AND APPORTIONS ANCILLARY COSTS BASED ON PROGRAM CHARGES TO TOTAL CHARGES. THE SHORTFALL BENEFITS THE COMMUNITY BY LESSENING THE BURDEN OF GOVERNMENT. IN ADDITION, THE STATE OF TEXAS TREATS MEDICARE SHORTFALL AS COMMUNITY BENEFIT FOR MEETING STATUTORY REQUIREMENTS FOR CHARITY CARE AND COMMUNITY BENEFIT. PART III, LINE 9B: THE HOSPITAL SHALL CONTRIBUTE APPROPRIATE RESOURCES, ADVOCACY AND COMMUNITY SUPPORT TO PROMOTE THE HEALTH STATUS OF THE COMMUNITY, WHICH IT SERVES, WITHIN ITS ECONOMIC ABILITY TO DO SO. CHARITY CARE WILL BE PROVIDED TO PATIENTS WITH A DEMONSTRATED INABILITY TO PAY. THE PURPOSE OF THIS POLICY IS TO ESTABLISH CRITERIA FOR DETERMINING IF A PATIENT'S ACCOUNT QUALIFIES FOR A CHARITY CARE DISCOUNT. THE AMOUNT OF CHARITY CARE TO BE MADE AVAILABLE, AS WELL AS ANY OTHER CHANGES TO THIS POLICY SHALL BE ASSESSED AND DETERMINED BY THE HOSPITAL'S CHIEF EXECUTIVE OFFICER ON AN ANNUAL BASIS, AND WILL ADHERE TO STATE GUIDELINES FOR NON-PROFIT FACILITIES, IF APPLICABLE. THE AMOUNT OF CHARITY CARE AS WELL AS THE OTHER TERMS OF THIS POLICY MAY BE CHANGED BY THE HOSPITAL'S CHIEF EXECUTIVE OFFICER. PART III, LINE 2: EXPLANATION: THE AMOUNT REPORTED ON LINE 2 IS BASED ON BAD DEBTS PER THE AUDITED FINANCIAL STATEMENTS.THE HOSPITAL'S ALLOWANCE FOR DOUBTFUL ACCOUNTS FOR SELF-PAY PATIENTS INCREASED FROM APPROXIMATELY 98 PERCENT OF SELF-PAY ACCOUNTS RECEIVABLE AT JUNE 30, 2013 TO 100 PERCENT OF SELF-PAY ACCOUNTS RECEIVABLE AT JUNE 30, 2014. THE HOSPITAL'S WRITE-OFFS DECREASED FROM APPROXIMATELY $21,442,000 FOR THE YEAR ENDED JUNE 30, 2013 TO APPROXIMATELY $7,235,000 FOR THE YEAR ENDED JUNE 30, 2014. THE DECREASE IN WRITE-OFFS RESULTED FROM A SUBSTANTIAL INCREASE IN DISCOUNTS ON UNINSURED CHARGES IN FISCAL YEAR 2014, WHICH REDUCED SELF-PAY RECEIVABLES, AND THE TIMING AND AMOUNT OF RECEIVABLES BEING WORKED, DUE TO A CHANGE IN THIRD-PARTY BUSINESS OFFICE ADMINISTRATORS. PART III, LINE 3: EXPLANATION: AMOUNTS REPORTED ON LINE 3 ARE THE ORGANIZATION'S ESTIMATE OF THE AMOUNT OF BAD DEBT ATTRIBUTABLE TO CHARITY CARE PATIENTS, ESTIMATED AT 25%. 1 HMH PHYSICIANS ORGANIZATION 110 MEMORIAL HOSPITAL DRIVE HUNTSVILLE TX 77342 760500960 501(C)(3) 1889475 GENERAL SUPPORT 1 PART I, LINE 2: THE ORGANIZATION EVALUATES AND MONITORS DONEES BASED ON PUBLIC AND PRIVATE DATA. X X X X 0 0 0 0 0 1 1 0 0 GUY GROS CFO 182390 0 33000 0 0 0 0 0 8317 0 223707 0 0 0 SHANNON BROWN CEO - EX - OFFICIO 194834 0 60000 0 0 0 0 0 231 0 255065 0 0 0 SHEILA HOGUE ARD CNO 150655 0 10000 0 0 0 0 0 19434 0 180089 0 0 0 ELIZABETH ROGERS RN 151612 0 272 0 0 0 0 0 103 0 151987 0 0 0 PART I, LINE 3 MEMORIAL HERMANN HOSPITAL SYSTEM (MHHS), ALSO A TEXAS NONPROFIT CORPORATION, MANAGED THE OPERATIONS OF THE HOSPITAL THROUGH AN OPERATING AGREEMENT. UNDER THE OPERATING AGREEMENT, MHHS PROVIDED DAY-TO-DAY OPERATIONS MANAGEMENT OF THE HOSPITAL. THE MANAGEMENT AGREEMENT BETWEEN MHHS AND THE HOSPITAL EXPIRED ON APRIL 30, 2013. MANAGEMENT FEES, EXPENSE REIMBURSEMENTS, AND OTHER AMOUNTS PAID PURSUANT TO THIS AGREEMENT FOR THE YEARS ENDED JUNE 30, 2014 AND 2013, WAS APPROXIMATELY $704,494 AND $1,401,000, RESPECTIVELY. THE FOLLOWING INDIVIDUALS WERE REPORTED IN FORM 990, PART VII BUT SHOWN WITH NO COMPENSATION PER IRS GUIDANCE. THEIR COMPENSATION UNDER THEIR EMPLOYMENT WITH MHHS, AN UNRELATED ENTITY, FOR SERVICES TO THE HOSPITAL ARE AS FOLLOWS: SALLY I NELSON, CEO $195,225 SHANNON BROWN, CEO $ 93,820 DAVID FICKLEN, MD, CMO $ 85,948 PART I, LINE 6 THE INCENTIVE COMPENSATION PROGRAM WAS BASED ON THE CONSOLIDATED EBITDA OF WCHC. JUDY BURRIS WIFE OF MEMBER 1242 EMPLOYMENT 0 FORM 990, PART VI, SECTION A, LINE 3 MEMORIAL HERMANN HOSPITAL SYSTEM (MHHS), ALSO A TEXAS NONPROFIT CORPORATION, MANAGED THE OPERATIONS OF THE HOSPITAL THROUGH AN OPERATING AGREEMENT. UNDER THE OPERATING AGREEMENT, MHHS PROVIDED DAY-TO-DAY OPERATIONS MANAGEMENT OF THE HOSPITAL. THE MANAGEMENT AGREEMENT BETWEEN MHHS AND THE HOSPITAL EXPIRED ON APRIL 30, 2013. MANAGEMENT FEES, EXPENSE REIMBURSEMENTS, AND OTHER AMOUNTS PAID PURSUANT TO THIS AGREEMENT FOR THE YEARS ENDED JUNE 30, 2014 AND 2013, WAS APPROXIMATELY $704,494 AND $1,401,000, RESPECTIVELY. THE FOLLOWING INDIVIDUALS WERE REPORTED IN FORM 990, PART VII BUT SHOWN WITH NO COMPENSATION PER IRS GUIDANCE. THEIR COMPENSATION UNDER THEIR EMPLOYMENT WITH MHHS, AN UNRELATED ENTITY, FOR SERVICES TO THE HOSPITAL ARE AS FOLLOWS: SALLY I NELSON, CEO $195,225 SHANNON BROWN, CEO $ 93,820 DAVID FICKLEN, MD, CMO $ 85,948 FORM 990, PART VI, SECTION B, LINE 11 THE DETAILED REVIEW OF THE FORM 990 IS CONDUCTED BY THE CFO FOLLOWING THE PREPARATION AND REVIEW OF THE RETURN BY THE ORGANIZATION'S PAID PREPARER. AN ELECTRONIC COPY OF THE FINAL FORM 990 IS EMAILED TO EACH BOARD MEMBER PRIOR TO FILING WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C THE ORGANIZATION FOLLOWS A CONFLICT OF INTEREST DISCLOSURE PROCESS WHICH REQUIRES ALL OFFICERS, DIRECTORS, KEY EMPLOYEES, HIGHLY COMPENSATED EMPLOYEES AND OTHER MANAGEMENT OFFICIALS ("COVERED PERSONS") TO DISCLOSE POTENTIAL CONFLICTS. PURSUANT TO THE POLICY, A DISCLOSURE STATEMENT IS CIRCULATED ANNUALLY TO COVERED PERSONS IN WHICH THE INDIVIDUAL MUST DISCLOSE TRANSACTIONS THAT MAY RESULT IN A CONFLICT. COVERED PERSONS ARE ALSO ENCOURAGED TO NOTIFY THE BOARD, APPROPRIATE MANAGEMENT PERSONNEL, CHIEF COMPLIANCE OFFICE, GENERAL COUNSEL, OR THE AUDIT AND COMPLIANCE COMMITTEE OF THE GOVERNING BODY AS NECESSARY. WHEN NECESSARY, THE BOARD CHAIR OR APPROPRIATE BOARD COMMITTEE MAY APPOINT A DISINTERESTED PERSON(S) OR COMMITTEE TO INVESTIGATE THE POTENTIAL CONFLICT OF INTEREST AND RECOMMEND ALTERNATIVES TO THE APPLICABLE TRANSACTION OR ARRANGEMENT OR OTHERWISE DETERMINE IF THE CONFLICT CAN BE RESOLVED. IF A MORE ADVANTAGEOUS TRANSACTION OR ARRANGEMENT IS NOT REASONABLY POSSIBLY UNDER THE CIRCUMSTANCES NOT PRODUCING A CONFLICT OF INTEREST, THE GOVERNING BOARD OR COMMITTEE SHALL DETERMINE BY A MAJORITY VOTE OF THE DISINTERESTED DIRECTORS WHETHER THE TRANSACTION OR ARRANGEMENT IS IN THE BEST INTEREST OF THE ORGANIZATION, AND WHETHER IT IS REASONABLE. THE GOVERNING BOARD OR COMMITTEE MAKES THE DECISION AS TO WHETHER TO ENTER INTO THE TRANSACTION OR ARRANGEMENT. ANY MEMBER OF THE BOARD OPERATING UNDER A CONFLICT IS NOT PERMITTED TO BE PRESENT OR OTHERWISE PARTICIPATE IN THE VOTE ON ANY MATTER TO WHICH THE CONFLICT RELATES. IF THE GOVERNING BOARD OR COMMITTEE OF THE ORGANIZATION HAS REASONABLE CAUSE TO BELIEVE THAT A COVERED PERSON HAS FAILED TO DISCLOSE AN ACTUAL OR POSSIBLE CONFLICT OF INTEREST AND AFTER INVESTIGATION THE BOARD OR COMMITTEE DETERMINES THAT THE COVERED PERSON FAILED TO DISCLOSE A CONFLICT OF INTEREST, THE ORGANIZATION TAKES APPROPRIATE DISCIPLINARY OR CORRECTIVE ACTION, WHICH MAY INCLUDE, TERMINATION OF THE INDIVIDUAL'S MEMBERSHIP, EMPLOYMENT, OR CONTRACT. FORM 990, PART VI, SECTION B, LINE 15 THE ORGANIZATION USED AON HEWITT TO DEVELOP THE COMPENSATION PLAN AND AON HEWITT UTILIZED NUMEROUS MARKET SURVEYS TO ESTABLISH THE PLAN. THE PLAN WAS DEVELOPED BY AN INDEPENDENT PERSON AND APPROVED BY THE FINANCE COMMITTEE AND BOARD. HMH ALSO UTILIZES SALARY REVIEWS AND SURVEYS FOR COMPARISON WHEN DETERMINING COMPENSATION OF HIGHLY COMPENSATED EMPLOYEES. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, FINANCIAL STATEMENTS, AND CONFLICT OF INTERET POLICY AVAILABLE AT ITS BUSINESS OFFICE UPON REQUEST. FORM 990, PART XI, LINE 9: CHANGE IN PENSION LIABILITY 74,636. ROUNDING ADJUSTMENTS 2. FORM 990, PART V, LINE 3A THE TAXPAYER HAS DETERMINED IN GOOD FAITH THAT THE TAXPAYER DOES NOT HAVE ANY ACTIVITIES GENERATING UNRELATED BUSINESS TAXABLE INCOME ( AS DEFINED IN IRC SECTION 152 (A)) IN THE CURRENT YEAR. THEREFORE, THE TAXPAYER IS NOT REQUIRED TO FILE ANY RETURN OTHER THAN FORM 990. SCHEDULE J PART I PURSUANT TO THE MANAGEMENT AGREEMENT BETWEEN WALKER COUNTY HOSPITAL CORPORATION D/B/A HUNTSVILLE MEMORIAL HOSPITAL ("HMH") AND MEMORIAL HERMANN HOSPITAL SERVICES ("MHHS"), THE SALARIES OF SALLY I. NELSON, SHANNON L. BROWN, DAVID R. FICKLEN AND SUSAN WHITE ARE PAID BY MHHS. HMH PAYS MHHS A MANAGEMENT FEE TO COVER THE SALARIES OF THESE INDIVIDUALS FOR SERVING AS OFFICERS OF HMH. HMH PHYSICIAN ORGANIZATION 110 MEMORIAL HOSPITAL DRIVE HUNTSVILLE TX 77340 760500960 HOSPITAL TX 501(C)(3) 3 HMH 1 HUNSTVILLE MEMORIAL HOSPITAL AUXILIARY 110 MEMORIAL HOSPITAL DRIVE HUNTSVILLE TX 77340 741508450 SUPPORT ORG TX 501(C)(3) 9 0 HUNTSVILLE MEMORIAL HOSPITAL FOUNDATION 110 MEMORIAL HOSPITAL DRIVE HUNTSVILLE TX 77340 273311765 SUPPORT ORG TX 501(C)(3) 11A 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 HMH PHYSICIAN ORGANIZATION INC B 1889475 BOOK BASIS