2014-03-11T16:30:34-05:00 2013-07-31 450250958 EIDE BAILLY LLP 3999 PENNSYLVANIA AVE SUITE 100 DUBUQUE IA 52002 990 2012-08-01 370645239 Carlinville Area Hospital Association CARL 2178543141 20733 North Broad Street Carlinville IL 62626 Kenneth Reid 2178543141 2014-03-06 1 Carmen Krantz P00031958 5635561790 2014-03-03 2012 2015-11-30 17:44:51Z Kenneth Reid 20733 North Broad Street Carlinville IL 62626 19944764 0 X www.cahcare.com X 1947 IL Provide quality acute and preventative health care benefits 8 8 213 170 0 0 532394 233382 19008176 19493349 304481 83232 35805 42256 19880856 19852219 0 0 0 0 7822912 8073891 0 0 0 11828293 11556841 19651205 19630732 229651 221487 33763785 33930045 20606842 20511942 13156943 13418103 X To maintain a professional medical community, a primary care hospital and other health care services, in order to provide quality acute and preventative health care for the benefit of those persons living in the service area. 0 1 15787482 19493349 During fiscal year 2013, we carried out our exempt purpose in the following ways: 1) Provided quality short term acute care medical services to 446 inpatients, of which 75% were eligible for Medicare. Without our services these elderly patients would have had to travel over 20 miles to receive similar services. 2) Provided quality short term skilled care to 172 patients in our swing bed unit, with an average length of stay of 9.4 days. 3) Provided 24 hour a day emergency room services. Our emergency room treated 6,370 patients during fiscal year 2013. We treat everyone who presents themselves to our emergency room regardless of their medical condition or ability to pay. We provided 24 hour physician service so the residence in the Carlinville area do not have to travel long distances for emergency medical care. 4) In addition to the inpatient and emergency services we provide, we also had 22,028 visits in our outpatient departments. These services range from preventative care items such as mammograms and lab tests to rehabilitative services such as Physical and Occupational therapy. 5) The hospital also had 5,975 visits to their specialty clinics. These clinics bring specialists from metropolitan areas to Carlinville on a rotating basis. This provides access to specialty services not otherwise offered in the area. The Hospital maintains records to identify and monitor the level of charity care it provides. These records include the amount of charges foregone for services and supplies furnished under its charity care policy. The amounts of charges foregone were $368,000 for the year ended July 31, 2013. The estimated costs of the charges foregone, based upon an overall cost-to-charge ratio calculation, for the year ended July 31, 2013 were $202,000.In addition, the Hospital provides services to other medically indigent patients under certain government-reimbursed public aid programs. Such programs pay providers amounts which are less than established charges for the services provided to the recipients, and for some services the payments are less than the cost of rendering the services provided.The Hospital also commits significant time and resources to endeavors and critical services which meet otherwise unfulfilled community needs. Many of these activities are sponsored with the knowledge that they will not be self-supporting or financially viable. 15787482 1 1 0 0 0 0 0 0 0 0 1 1 0 0 1 1 1 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 0 0 0 1 33 0 1 213 1 0 0 0 0 0 0 0 0 0 0 X 8 8 1 1 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 0 0 0 IL X Michael Brown 2178543857 20733 North Broad Street Carlinville IL 62626 J Richard Schien 1.00 0.30 X X 0 0 0 James Salske 1.00 0.30 X X 0 0 0 Ralph March 1.00 0.60 X X 0 0 0 Dennis Pickrel 1.00 0.60 X X 0 0 0 Steve Gourley 1.00 0.00 X 0 0 0 Tracey Smith 1.00 0.00 X 0 0 0 Richard Walden 1.00 0.80 X 0 0 0 Elizabeth O'Brien MD 1.00 0.00 X 0 0 0 Kenneth Reid 40.00 1.30 X 0 0 0 Greg Ward 40.00 1.30 X 0 0 0 Michael Brown 40.00 1.30 X 0 0 0 Curtis Cravens 40.00 0.00 X 189916 0 19837 Kate Wilkens MD 40.00 0.00 X 190413 0 13068 Kathleen Laboray 40.00 0.00 X 101310 0 9873 Kimberly Spencer 40.00 0.00 X 121002 0 2595 602641 0 45373 4 0 1 0 Illinois Emergency Physicians 4075 Copper Ridge Drive Traverse City MI 496840793 Emergency room physicians 1406462 CPSI 6600 Wall St Mobile AL 36695 Information technology services 477000 HealthTech Management Services Inc PO Box 636426 Cincinnati OH 452636426 Management services 429147 Precise Specialties PO Box 572 Hillsboro IL 62049 Radiology services 146355 G2N 13421 Manchester Road St Louis MO 63131 Coding services 114167 5 178654 32201 22527 233382 Patient service revenue 622110 18683781 18683781 Clinic revenue 621110 464360 464360 EHR Medicare incentive 900099 198497 198497 Supporting revenue 900099 146711 146711 19493349 47725 47725 42256 0 42256 42256 42256 128052 92545 35507 35507 35507 19852219 19493349 0 125488 X 6560102 5406746 1153356 205182 169112 36070 832607 686235 146372 476000 387769 88231 680254 680254 86492 86492 57725 57725 2261948 2155577 106371 109115 109115 1827091 810635 1016456 242961 242961 17891 6445 11446 110337 31970 78367 1476092 1476092 2072354 2072354 275748 9865 265883 Bad debt expense 1289035 1289035 Medical supplies 889427 889427 Food 142849 142828 21 17522 10431 7091 19630732 15787482 3843250 0 2222083 4213280 3522972 2922000 193910 167114 200160 210385 27897663 6696109 23127345 21201554 1712887 2036790 1420533 1912148 1363895 1266774 33763785 33930045 1354776 1139986 594000 19131361 18707956 120705 70000 20606842 20511942 X 12582755 12804242 574188 613861 13156943 13418103 33763785 33930045 X 221487 39673 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 561322 561322 19884618 4965915 14918703 6024642 1469718 4554924 1427081 260476 1166605 21201554 Beneficial interest in perpetual trust 533861 F Mortgage escrow funds 1378287 F 1912148 Employee health claims 70000 70000 X 18384530 -1289035 -1289035 19673565 178654 178654 19852219 18341697 0 18341697 1289035 1289035 19630732 Description of Uncertain Tax Positions Under FIN 48: Part X, Line 2: The Hospital is organized as an Illinois nonprofit corporation and has been recognized by the Internal Revenue Service (IRS) as exempt from federal income taxes under Internal Revenue Code Section 501(c)(3). The Hospital is annually required to file a Return of Organization Exempt from Income Tax (Form 990) with the IRS. In addition, the Hospital is subject to income tax on net income that is derived from business activities that are unrelated to its exempt purpose. The Hospital believes that it has appropriate support for any tax positions taken affecting its annual filing requirements, and as such, does not have any uncertain tax positions that are material to the financial statements. The Hospital would recognize future accrued interest and penalties related to unrecognized tax benefits and liabilities in income tax expense if such interest and penalties are incurred. Part XI, Line 2d - Other Adjustments: Provision for bad debts included in total expenses for Form 990 -1,289,035. Part XI, Line 4b - Other Adjustments: Transfer from related party included in fund balance for financial statement 178,654. Part XII, Line 4b - Other Adjustments: Provision for bad debts included in total expenses for Form 990 1,289,035. 1 1 X 1 X 125.000000000000 1 X 1 1 0 1 1 202000 202000 0.01100 2111546 1895863 215683 0.01180 2313546 1895863 417683 0.02280 466241 113368 352873 0.01920 466241 113368 352873 0.01920 2779787 2009231 770556 0.04200 0 1289035 14342 9235824 9197360 38464 X 1 1 1 1 Carlinville Area Hospital Association

20733 North Broad Street Carlinville IL 62626

X X X X Provider based rural health clinic Carlinville Area Hospital Association 1 1 X X X X X X X X X 12 1 0 1 X X X X X X X X X 1 0 1 1 125.000000000000 1 300.000000000000 1 X X X X X 1 1 X X 1 0 X X X 1 X 0 1 Part I, Line 6a: The annual community benefit report is mailed to 15,000 residents in our service area. Part I, Line 7: Charity care expense was converted to cost on line 7a based on an overall cost-to-charge ratio addressing all patient segments. Unreimbursed Medicaid on line 7b was calculated using the costing methods to prepare the cost reports. The cost for subsidized health services reported on line 7g was determined using the Medicare Cost Report. Part I, L7 Col(f): The amount of bad debt expense removed from total expenses to determine the percentage was $1,289,035. Part III, Line 4: The bad debt expense is only the uncollected portion of the patient account. Any discounts would be treated as a reduction in revenue. All forms of payment, including self-pay, insurance, contractual allowances, and discounts reduce the patient's account prior to the account being classified as bad debt. A payment received on an account previously written off as bad debt reduces bad debt expense. Bad debt expense reported on line 2 is at charges as reported on the financial statements.The estimated amount of the organization's bad debt expense attributable to patients eligible under the organization's charity care policy is calculated based on an estimate of charges foregone to gross patient charges.The footnote to the Organization's financial statements can be found on pages 8 and 9 of the attached audited financial statements. Part III, Line 8: Both the total revenue received from Medicare and the Medicare allowable costs are reported from the Medicare Cost Report. The Medicare Cost Report is completed based on the rules and regulations set forth by Centers for Medicare and Medicaid Services. Part III, Line 9b: Carlinville Area Hospital Association will give the charity care applicant at least 120 days from the date of service to apply for financial assistance without any collection efforts. If the applicant has applied for health care coverage under Medicaid, Kidcare, or other government sponsored health care programs, Carlinville Area Hospital will await the approval or denial of the application without additional collection efforts.Carlinville Area Hospital Association will not refer a bill to collection without first offering the patient the opportunity to request a reasonable payment plan for the amount personally owed by the patient. Such an opportunity shall be made available for the 30 days following the date of the initial bill. If the patient requests a reasonable payment plan, but fails to agree to a plan within 30 days of the request the hospital may proceed with collection action against the patient.No collection efforts will be pursued if the uninsured patient has agreed to a reasonable payment plan and the patient keeps to the agreement. If the patient fails to make the payments agreed upon, regular collection efforts will be pursued.Carlinville Area Hospital Association will not pursue legal action for non-payment of a hospital bill against uninsured patients who have clearly demonstrated that they have neither sufficient income nor assets to meet their financial obligations. Carlinville Area Hospital Association Part V, Section B, Line 3: Input from persons who represent the community include a nurse practitioner, the Dean from Lewis and Clark Community College, Ambulance Districts, VNA-TIP, Nursing Homes, a Local Pharmacy, a dentist and an optometrist. Also consulted was the Superintendent of Carlinville Schools, the principal of Carlinville High School, President of Carlinville Chamber of Commerce, Macoupin County sheriff, President of Carlinville National Bank, and Davis-Anderson Funeral Home. A town hall meeting was also held. Carlinville Area Hospital Association Part V, Section B, Line 5c: Carlinville Area Hospital Assocation's community health needs assessment can be accessed on the hospital facility's website at www.cahcare.com. Carlinville Area Hospital Association Part V, Section B, Line 6i: Carlinville Area Hospital has adopted an implementation strategy to address the community health needs identified in its Community Health Needs Assessment. The implementation strategy is posted to the Hospital's website at www.cahcare.com. Carlinville Area Hospital Association Part V, Section B, Line 7: The Community Health Needs Assessment identified needs in physician recruitment and replacement planning, emergency and follow-up mental health care, health education for elderly, including dietary and general health, and risk for alcohol abuse.Macoupin County is a designated health professional shortage area for dental, mental and primary care. We have been aggressive in physician recruitment and have seen success. Additional aggressive efforts are required to meet the health care concerns and needs of the services area as physicians age and retire. We still continue the two recruitment plans that were initiated following the strategic planning and continue the process for recruiting mid-level physicians.The Hospital has worked with other health care providers toward a collaborative resolution regarding emergency and follow-up mental health care. We will collaborate with Blackburn College, Locust Street Resource Center, and Carlinville Winning Community Organization to assist in providing prevention education and information on local area resources.We will continue collaborating with Macoupin County Public Health Department's diabetes workshops and create and/or participate in new wellness activities for seniors to address health education among the elderly. We will create a relationship with the community substance abuse awareness group to address alcohol abuse among all ages. Carlinville Area Hospital Association Part V, Section B, Line 14g: Financial assistance contact information is provided on each bill. A notice about the availability of charity care is posted in the admitting areas, including the ER. The Hospital also employs a full time financial counselor to discuss the availability of various government services and charity care with patients. Carlinville Area Hospital Association Part V, Section B, Line 22: All individuals eligible under the hospital financial assistance policy are provided a discount for emergency and other medically necessary care. The financial assistance policy does not apply to elective procedures. Therefore, FAP-eligible patients without insurance may be charged gross charges on elective procedures. Part VI, Line 2: The Hospital works with physicians, the health department, nursing homes and other health care providers in the community to determine the health care needs. The Hospital also formed a partnership with Illinois Emergency Physicians, LLP. The physicians of the partnership serve in a dual role at Carlinville Area Hospital. They have improved the service in the growing Emergency Department, and act as Hospitalist physicians. This means they can admit and care for patients who do not have a physician that regularly admits patients to the Hospital. Some of the staff physicians at Carlinville Area Hospital may also elect to use the physicians in the partnership to assist in managing the care of their own admitted patients.A formal community health needs assessment was completed in FY 2013 and posted to our website to meet one of the 501r requirements. Part VI, Line 3: Financial assistance contact information is provided on each bill. A notice about the availability of charity care is posted in the admitting areas, including the ER. The Hospital also employs a full time financial counselor to discuss the availability of various government services and charity care with patients. Part VI, Line 4: Carlinville Area Hospital Association is a 25-bed acute care hospital located in Carlinville, Illinois. The Hospital serves the residents of Macoupin County. Carlinville Area Hospital is the only hospital within a 20 mile radius of Carlinville Illinois, a small rural community in central Illinois. Illinois Route 4 passes through Carlinville. Interstate 55 is also within 12 miles of the city. The community is mostly agricultural.Other hospitals and medical centers near Carlinville are St. Francis Hospital, a Critical Access Hospital in Litchfield, IL, approximately 14 miles away, Community Memorial Hospital, a Critical Access Hospital in Staunton, IL, approximately 20 miles away and Hillsboro Area Hospital, a Critical Access Hospital in Hillsboro, IL, approximately 24 miles away.Carlinville had a population of 5,920 in 2011. Unemployment was 9.3% compared to 8.9% in the state of Illinois. Carlinville residents with income below the poverty level was 23.6% and residents with income below 50% of the poverty level was 3.7%. Part VI, Line 5: Carlinville Area Hospital Association's core purpose is "Excellent healthcare close to home." This is very important to our board as all of our members live in our service area and use our facility. The Hospital extends medical staff privileges to all qualified physicians in the community. Carlinville Area Hospital invests in improvements in the community and continues to minimize long-term debt. The Hospital also provides the following services that would not otherwise be available within the Hospital's service area: Twenty-four hour a day emergency room that treats all patients regardless of ability to pay Specialty Clinic - The Hospital has an arrangement with a physician group out of Springfield, IL that brings specialists to the Carlinville Area that would not otherwise be available.Throughout the year, Carlinville Area Hospital offered CPR training to the community for a special rate of $12 per participant.The Hospital provided free blood pressure checks in Carlinville and Palmyra on a monthly basis.Carlinville Area Hospital's Imaging Department hosted a free community presentation in observance of National Breast Cancer Awareness Month in October. Early detection, benefits of digital mammography, and how the advanced technology aids in early detection were discussed.Approximately 16 churches throughout Macoupin County received first aid supply bags from Carlinville Area Hospital. The bags included a pillow, blanket, stethoscope, blood pressure cuff, gloves, disposable washcloths, ice packs, pocket CPR mask, band aids, various dressings, peroxide, alcohol wipes, and cotton balls. These basic supplies were provided to help the churches during services or activities when church members may become ill or injured.Carlinville Area Hospital participated in the Illinois Cooperative Work Study Program. The program offered opportunities for college students to gain hands-on experience in their field of study. The Hospital also served as a clinical site for students in Radiology from Southwestern Illinois College and Pharmacy from St. Louis College of Pharmacy. Reports Filed With States Part VI, Line 7 IL 0 0 0 0 0 0 0 0 0 Curtis Cravens 188772 0 0 0 1144 0 6647 0 13190 0 209753 0 0 0 Kate Wilkens MD 189678 0 0 0 735 0 6664 0 6404 0 203481 0 0 0 Supplemental Information Part III Part I, Question 3: Carlinville Area Hospital Association does not pay compensation to the CEO directly. The CEO is compensated by an unrelated management company, HealthTech Management Services, Inc. The Hospital Board of Directors uses the processes described in Part I, Question 3 to determine appropriate compensation for the CEO. The Board of Directors also approves the Organization's contract with the Management Company. Changes in Program Services Form 990, Part III, line 3 Carlinville Rural Health Clinic opened on June 16, 2013. This was previously the provider based outpatient specialty clinic. It moved off site and added a mid-level provider to see more patients. Form 990, Part VI, Section A, line 1 The Executive Committee is composed of the elected officers of the Board and includes the Chairman, Vice Chairman, Secretary, and Treasurer of the Association. The Executive Committee has the power and authority to manage and control the business and affairs of the Association as the Board of Directors; however, the Executive Committee is not allowed to exercise those powers prohibited by Illinois law which include: amending the Articles or Bylaws; sell, transfer, or otherwise dispose of substantially all of the Association's assets; or adopt Articles of Merger or Consolidation. Form 990, Part VI, Section A, line 2 J. Richard Schien, Chairman, and Richard Walden, board member have a business relationship. James Salske, Vice Chairman, and Richard Walden, board member have a business relationship. Form 990, Part VI, Section A, line 3 Kenneth Reid, CEO, Greg Ward, CFO until January 2013 and Michael Brown, current CFO who was hired on April 3, 2013, are common law employees of HealthTech Management Services, Inc., an unrelated management company. The CEO has the responsibility of supervising the management, administration and operation of the Organization. The CFO has the responsibility for managing the Organization's finances. Kenneth Reid was compensated $188,007 for services to Carlinville Area Hospital Association. Greg Ward was compensated $142,106 for services to Carlinville Area Hospital Association. Form 990, Part VI, Section A, line 6 The Organization's sole member is Middle Macoupin Health Care Systems. Form 990, Part VI, Section A, line 7a The Member has the exclusive right and power to designate three of its Directors to serve as a member of the Board of Directors, and by resolution to appoint all such Directors or to remove them from the Board of Directors. Form 990, Part VI, Section A, line 7b The Member has the exclusive right and power to approve or reject the following actions prior to the Board of Directors taking any action: 1. the annual operating budget, capital budget, long-range plan and any action which will result in a substantial change in the expenditures or revenue forecast; 2. the undertaking of or substantive amendments to a contractual obligation in excess of $50,000, or the guaranteeing of any obligation in excess of $50,000; 3. the purchase, lease, transfer, mortgage or sale of any asset or property with a value in excess of $50,000, except with respect to transactions specified and previously approved within the capital budget; 4. any plan of construction or remodeling involving an expenditure in excess of $50,000, except with respect to transactions specified and previously approved within the capital budget; 5. any borrowing; 6. any application for a government grant; 7. any general plan for the solicitation of charitable contributions or the solicitation or acceptance as a gift of any real property or any interest; 8. any proposal to adopt Articles of Dissolution, Merger, or Consolidation; 9. any selection, removal or change in the compensation or other terms of employment of the operating officers; 10. any substantial change in employee fringe benefits or personnel policies; and 11. any other matters as may be required by law to be submitted to the Member or as to which the Member determines, by resolution, that submission is advisable. Form 990, Part VI, Section B, line 11 The Form 990 is distributed to the governing body before it is filed. The CEO and CFO review the Form 990. Form 990, Part VI, Section B, line 12c Any duality of interest or possible conflict of interest on the part of any Board member should be disclosed to the other members of the Board and made a matter of record through an annual procedure and also when the interest becomes a matter of Board action. Any Board member having a duality of interest or possible conflict of interest on any matter should not vote or use his or her personal influence on the matter. The minutes of the meeting must reflect the disclosure, the abstention from voting, and the quorum situation. Any new member of the Board will be advised of this policy upon entering on the duties of office. The governing Board, CEO, and CFO complete and sign the conflict of interest form yearly. The forms are reviewed by the CEO of the Organization and if a potential conflict is identified the CEO follows up. The CEO and CFO are compensated through HealthTech Management Services, Inc., an unrelated management company. They are considered common law employees of HealthTech Management Services, Inc. HealthTech Management Services, Inc. gives the Board of Directors a recommended salary range for the CEO and CFO and the Board sets the compensation within this range after review of performance evaluations and comparability data. The process is documented and is completed on an annual basis. The last completion was in FY 2013. Form 990, Part VI, Section C, line 19 The Organization's governing documents, conflict of interest policy, and financial statements are not available to the public. Financial information is available through the public disclosure copy of the 990. Other Fees Form 990, Part IX, line 11g Repairs and maintenance: Program service expenses 63,890. Management and general expenses 1,694. Fundraising expenses 0. Total expenses 65,584. Purchased services and contract labor: Program service expenses 1,487,323. Management and general expenses 49,762. Fundraising expenses 0. Total expenses 1,537,085. Professional fees: Program service expenses 604,364. Management and general expenses 54,915. Fundraising expenses 0. Total expenses 659,279. Changes in Net Assets or Fund Balances: Form 990, Part XI, line 9: Change in beneficial interest in perpetual trust 39,673. Carlinville Area Hospital Foundation 20733 North Broad Street Carlinville IL 62626 371193348 Support Carlinville Area Hospital Association IL 501(c)(3) Line 1 Middle Macoupin Healthcare Systems 0 Middle Macoupin Healthcare Systems 20733 North Broad Street Carlinville IL 62626 371193396 Provide support and benefit Carlinville Area Hospital Association IL 501(c)(3) Line 11a, I N/A 0 0 0 1 0 0 0 0 0 0 0 0 0 1 1 1 0 1 0 0