2013-02-28T13:31:36-06:00 2012-06-30 420714325 MCGLADREY LLP 201 N HARRISON STREET SUITE 300 DAVENPORT IA 528011999 990 2011-07-01 363616314 GENESIS HEALTH SYSTEM GENE 5634216508 801 ILLINI DRIVE SILVIS IL 61282 MARK G ROGERS 5634216508 2013-02-26 1 JOHN J ROMANO P00227323 5638884000 2011 2016-03-07 17:11:31Z MARK G ROGERS 801 ILLINI DRIVE SILVIS IL 61282 93424327 0 X GENESISHEALTH.COM X 1988 IL GENESIS HEALTH SYSTEM EXISTS TO PROVIDE COMPASSIONATE, QUALITY HEALTH SERVICES TO ALL THOSE IN NEED. 18 9 950 236 213355 54942 481284 1714995 89584278 88021750 432239 481458 2442666 2385001 92940467 92603204 358481 169854 0 0 34828113 35615517 0 0 0 51473355 52439096 86659949 88224467 6280518 4378737 75846041 79704790 19154268 18733242 56691773 60971548 GENESIS HEALTH SYSTEM EXISTS TO PROVIDE COMPASSIONATE, QUALITY HEALTH SERVICES TO ALL THOSE IN NEED. 0 0 65339697 169854 83842574 ILLINI HOSPITAL-HEALTH CARE DELIVERY AND MANAGEMENT, GENERAL/OTHER: ILLINI HOSPITAL, A NOT-FOR-PROFIT ORGANIZATION, IS LICENSED AS A 149-BED ACUTE CARE HOSPITAL AND PROVIDES RELATED HEALTHCARE INPATIENT, EMERGENCY, AND OUTPATIENT ANCILLARY SERVICES. (15,799 PATIENT DAYS; 108,227 OUTPATIENT VISITS) 7146721 8137834 ILLINI HOSPITAL NURSING HOME: HEALTH CARE FOR A 75-BED LICENSED NURSING FACILITY AND REHABILITATIVE AND PERSONAL CARE FOR A 45-BED FACILITY (34,422 PATIENT DAYS) WITH ASSISTED LIVING SERVICES CONSISTING OF 76 APARTMENTS AND 2 GUESTROOMS FOR THE ELDERLY (578 RESIDENT MONTHS). 72486418 1 1 0 1 0 0 0 0 0 1 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 0 0 0 0 0 0 0 1 0 0 0 0 0 1 1 1 0 0 1 74 0 1 950 1 1 1 0 0 0 0 0 0 0 0 0 X 18 9 0 0 0 0 0 0 0 1 1 0 1 1 1 1 1 1 1 1 1 1 1 1 IL X MARK G ROGERS 5634216508 1227 EAST RUSHOLME STREET DAVENPORT IA 52803 STEVEN C BAHLS 4.00 X 0 0 0 MARK D BAWDEN 4.00 X X 0 0 0 GREGORY J BUSH 4.00 X X 0 0 0 CHRISTOPHER J COX 4.00 X 0 0 0 EDMUND P COYNE JR MD 4.00 X 0 0 0 DOUGLAS P CROPPER 44.00 X X 0 600993 246461 THOMAS A GILDEHAUS 4.00 X 0 0 0 ROGER J HILL 4.00 X X 0 0 0 MARK C KILMER 4.00 X 0 0 0 JAMES W KOEHLER 4.00 X 0 0 0 GEORGE J KONTOS JR MD 40.00 X 0 535471 28016 CHARLENE E MAASKE 4.00 X 0 0 0 EDWIN V MOTTO MD 4.00 X 0 0 0 EDWARD J ROGALSKI PHD 10.00 X X 0 0 0 G CHRISTOPHER WAHLIG 4.00 X X 0 0 0 C DANA WATERMAN III 4.00 X 0 0 0 CAROL A WATSON PHD RN CENP FAAN 4.00 X 0 0 0 DALE D ZUDE 4.00 X 0 0 0 MARK G ROGERS 40.00 X 0 307527 114567 ROBERT W FRIEDEN 40.00 X 0 325094 36395 FLORENCE L SPYROW 40.00 X 141233 165795 103547 KENNETH R CROKEN 40.00 X 0 258194 63998 JAMES A LEHMAN MD 40.00 X 0 344757 85558 JULIE MANAS 40.00 X 0 378736 17946 JUDITH MONDELLO 40.00 X 0 353948 50268 ROBERT C TRAVIS 40.00 X 0 321056 115027 HEIDI S KAHLY-MCMAHON 40.00 X 0 179576 73626 ROBERT M NELSON MD 40.00 X 0 246631 54548 JUDITH K PRANGER 40.00 X 0 352049 70044 MIKE L SHARP 40.00 X 0 225679 72307 141233 4595506 1132308 26 1 1 0 EMERGENCY CARE AND HEALTH ORGANIZATION 15443 SUMMIT AVE SUITE 302 OAKBROOKE IL 60181 PHYSICIAN FEES- MED SERVICES 2670883 CHG MEDICAL STAFFING INC PO BOX 972670 DALLAS TX 75397 PHYSICIAN FEES- MED SERVICES 793665 COGENT HEALTHCARE INC PO BOX 974451 DALLAS TX 75397 PHYSICIAN FEES- MED SERVICES 670886 QUEST DIAGNOSTICS PO BOX 740709 ATLANTA GA 30374 OUTSIDE SERVICES 403439 CASSLING 13808 F STREET OMAHA NE 68137 OUTSIDE MAINTENANCE CONTRACTS - FA 299469 16 27757 1687238 1714995 PROFESSIONAL SERVICES 900099 164402609 164402609 I/P ANCILLARY SERVICES 621500 26259028 26045673 213355 NURSING SERVICES 900099 23983160 23983160 RESIDENT REVENUE 623000 994618 994618 PHYSICAL THERAPY 900099 26224 26224 -127643889 -127643889 88021750 383073 383073 626359 581521 44838 44838 44838 191905 93520 98385 98385 98385 185064 146082 38982 38982 AMBULANCE 621910 1049155 1049155 OTHER SERVICES 900099 712423 712423 NON OPERATING IH, INV 900099 399974 399974 139629 139629 2301181 92603204 90109576 213355 565278 169854 169854 198287 198287 28733115 28524547 208568 1040935 1033379 7556 3554368 3528283 26085 2088812 2073132 15680 5604952 5364407 240545 27105 27105 1592260 1397284 194976 12543 7301 5242 8355784 8278184 77600 3710805 108374 3602431 3497124 3376734 120390 338453 331641 6812 47796 46666 1130 245142 245142 3946293 3946293 811147 244047 567100 CORPORATE OVERHEAD ALLO 8145334 8145334 PROVISION FOR BAD DEBT 6810254 6810254 PATIENT CHARGEABLE SUPP 5499550 5499550 MISCELLANEOUS EXPENSE 3794554 1501346 2293208 88224467 72486418 15738049 0 4620 4141 18659621 17868586 15899596 17555234 2261478 2258554 388788 659801 102828049 63736352 35809581 39091697 663832 1962113 2070420 196412 196357 75846041 79704790 5297435 6402493 8477977 7750000 5378856 4580749 19154268 18733242 X 56288451 60668171 359030 303377 44292 0 56691773 60971548 75846041 79704790 X 4378737 -98962 X X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 1 0 1 0 0 1 2000 1 2008 0 1 25105 29113 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: PART II-B, LINE 1B, PAID STAFF OR MANAGEMENT: GENESIS HEALTH SYSTEM - ILLINOIS HAD TWO STAFF MEMBERS INVOLVED IN LOBBYING ACTIVITIES ON A PART TIME BASIS. THEIR LOBBYING ACTIVITIES ARE FOCUSED ON SENDING LETTERS OR PUBLICATIONS TO GOVERNMENT OFFICIALS OR LEGISLATORS AND MEETING WITH OR CALLING GOVERNMENT OFFICIALS OR LEGISLATORS ON HEALTHCARE RELATED MATTERS. PART II-B, LINE 1D, MAILINGS TO MEMBERS, LEGISLATORS, OR THE PUBLIC: EMPLOYEES OF GENESIS HEALTH SYSTEM - ILLINOIS ARE ENCOURAGED TO PARTICIPATE IN THE ILLINOIS HOSPITAL ASSOCIATION'S "IHA ACTION ALERTS." THE EMPLOYEES PARTICIPATE BY RESPONDING TO E-MAIL ALERTS WHICH ALLOWS THEM TO VOICE THEIR OPINIONS TO THEIR STATE REPRESENTATIVES ON HEALTHCARE RELATED MATTERS (NOT CANDIDATE-SPECIFIC). THERE IS NO DIRECT COST TO GENESIS HEALTH SYSTEM - ILLINOIS REGARDING THIS ACTIVITY. PART II-B, LINE 1F, GRANTS TO OTHER ORGANIZATIONS FOR LOBBYING PURPOSES: GENESIS HEALTH SYSTEM - ILLINOIS CONTRIBUTED TO ONE ORGANIZATION: 1.) QUAD CITIES CHAMBER - ILLINOIS LEGISLATIVE FORUM, 2012, $2,000. PART II-B, LINE 1G, DIRECT CONTACT WITH LEGISLATORS, THEIR STAFFS, GOVERNMENT OFFICIALS, OR A LEGISLATIVE BODY: GENESIS HEALTH SYSTEM - ILLINOIS HAD TWO STAFF MEMBERS INVOLVED IN LOBBYING ACTIVITIES ON A PART TIME BASIS. THEIR LOBBYING ACTIVITIES ARE FOCUSED ON SENDING LETTERS OR PUBLICATIONS TO GOVERNMENT OFFICIALS OR LEGISLATORS AND MEETING WITH OR CALLING GOVERNMENT OFFICIALS OR LEGISLATORS ON HEALTHCARE RELATED MATTERS. THE DIRECT COSTS INCLUDED: SALARIES - $1,957, AND MILEAGE/TRAVEL EXPENSES - $51. PART II-B, LINE 1I, OTHER LOBBYING ACTIVITIES: LOBBYING EXPENDITURES RELATED TO MEMBERSHIP DUES INCLUDED: 27% OF MEMBERSHIP DUES TO THE ILLINOIS HOSPITAL ASSOCIATION, OR $19,285, AND 25% OF MEMBERSHIP DUES TO THE AMERICAN HOSPITAL ASSOCIATION, OR $5,820. 5519844 2014051 99448 100 7633243 5040857 16614 465988 3616 5519844 5010740 28352 297861 296096 5040857 5224450 30636 -243446 900 5010740 0.49980 0.50020 0 1 1 2355591 2355591 55054368 30445328 24609040 16771 9052 7719 41493730 31725462 9768268 3907589 1556510 2351079 39091697 DUE TO AFFILIATES 2339227 THIRD PARTY PAYOR SETTLEMENTS 1834713 ACCRUED INS TRUST LOSSES 406809 4580749 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: GENESIS HEALTH SERVICES FOUNDATION, A RELATED ORGANIZATION, HOLDS THE ENDOWMENT FUNDS. THE INTENDED USE OF THE FOUNDATION'S ENDOWMENT FUNDS ARE AS FOLLOWS: SCHOLARSHIPS FOR EDUCATION IN THE MEDICAL FIELD, CHARITY CARE FOR THE INDIGENT AND VISITING NURSE, HOSPICE HOUSE, DIABETIC CARE, EMPLOYEE ASSISTANCE, AND PEDIATRIC HOSPICE SERVICES. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: GHS IOWA, GHS ILLINOIS, THE GENESIS HEALTH SERVICES FOUNDATION, THE ILLINI HOSPITAL FOUNDATION AND THE GENESIS HEALTH SYSTEM WORKERS' COMPENSATION PLAN AND TRUST ALL FILE A FORM 990 (RETURN OF ORGANIZATION EXEMPT FROM INCOME TAX) ANNUALLY. WHEN THESE RETURNS ARE FILED, IT IS HIGHLY CERTAIN THAT SOME POSITIONS TAKEN WOULD BE SUSTAINED UPON EXAMINATION BY THE TAXING AUTHORITIES, WHILE OTHERS ARE SUBJECT TO UNCERTAINTY ABOUT THE MERITS OF THE POSITION TAKEN OR THE AMOUNT OF THE POSITION THAT WOULD ULTIMATELY BE SUSTAINED. EXAMPLES OF TAX POSITIONS COMMON TO HEALTH SYSTEMS INCLUDE SUCH MATTERS AS THE FOLLOWING: THE TAX EXEMPT STATUS OF EACH ENTITY, THE NATURE, CHARACTERIZATION AND TAXABILITY OF JOINT VENTURE INCOME AND VARIOUS POSITIONS RELATIVE TO POTENTIAL SOURCES OF UNRELATED BUSINESS TAXABLE INCOME. UNRELATED BUSINESS TAXABLE INCOME IS REPORTED ON FORM 990T, AS APPROPRIATE. THE BENEFIT OF A TAX POSITION IS RECOGNIZED IN THE CONSOLIDATED FINANCIAL STATEMENTS IN THE PERIOD DURING WHICH, BASED ON ALL AVAILABLE EVIDENCE, MANAGEMENT BELIEVES THAT IT IS MORE LIKELY THAN NOT THAT THE POSITION WILL BE SUSTAINED UPON EXAMINATION, INCLUDING THE RESOLUTION OF APPEALS OR LITIGATION PROCESSES, IF ANY. TAX POSITIONS ARE NOT OFFSET OR AGGREGATED WITH OTHER POSITIONS. TAX POSITIONS THAT MEET THE "MORE LIKELY THAN NOT" RECOGNITION THRESHOLD ARE MEASURED AS THE LARGEST AMOUNT OF TAX BENEFIT THAT IS MORE THAN 50% LIKELY TO BE REALIZED ON SETTLEMENT WITH THE APPLICABLE TAXING AUTHORITY. THE PORTION OF THE BENEFITS ASSOCIATED WITH TAX POSITIONS TAKEN THAT EXCEEDS THE AMOUNT MEASURED AS DESCRIBED ABOVE IS REFLECTED AS A LIABILITY FOR UNCERTAIN TAX BENEFITS IN THE ACCOMPANYING CONSOLIDATED BALANCE SHEETS ALONG WITH ANY ASSOCIATED INTEREST AND PENALTIES THAT WOULD BE PAYABLE TO THE TAXING AUTHORITIES UPON EXAMINATION. FORMS 990 AND 990T FILED BY GHS IOWA, GHS ILLINOIS, THE GENESIS HEALTH SERVICES FOUNDATION, THE ILLINI HOSPITAL FOUNDATION AND THE GENESIS HEALTH SYSTEM WORKERS' COMPENSATION PLAN & TRUST ARE SUBJECT TO EXAMINATION BY THE INTERNAL REVENUE SERVICE (IRS) UP TO THREE YEARS FROM THE EXTENDED DUE DATE OF EACH RETURN. FORMS 990 AND 990T FILED BY GHS IOWA, GHS ILLINOIS, THE GENESIS HEALTH SERVICES FOUNDATION, THE ILLINI HOSPITAL FOUNDATION AND THE GENESIS HEALTH SYSTEM WORKERS' COMPENSATION PLAN AND TRUST ARE NO LONGER SUBJECT TO EXAMINATION FOR THE FISCAL YEARS ENDED JUNE 30, 2008 AND PRIOR. GENVENTURES, INC. IS A TAXABLE ORGANIZATION AND CURRENTLY FILES INCOME TAX RETURNS IN THE U.S. FEDERAL JURISDICTION AND VARIOUS STATE JURISDICTIONS. GENVENTURES, INC. IS NO LONGER SUBJECT TO INCOME TAX EXAMINATIONS FOR YEARS JUNE 30, 2008 AND PRIOR. FOR THE YEARS ENDED JUNE 30, 2012 AND 2011, UNCERTAIN TAX POSITIONS HAVE REDUCED INCOME TAX EXPENSE AND HAVE INCREASED EXCESS OF REVENUE OVER EXPENSES BY NONE AND $45,000, RESPECTIVELY. FOR THE YEARS ENDED JUNE 30, 2012 AND 2011, THERE WAS NO INTEREST EXPENSE ASSOCIATED WITH UNCERTAIN TAX POSITIONS. NO AMOUNT HAS BEEN ACCRUED FOR PENALTIES. CENTRAL AMERICA AND THE CARIBBEAN 0 0 INVESTMENTSINVESTMENTS 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 X 1 X 1 X 1 1 0 1 1 2162729 0 2162729 0.02660 15301114 11957802 3343312 0.04110 0 0 17463843 11957802 5506041 0.06770 11749 0 11749 0.00010 0 0 0 0 0 0 71743 0 71743 0.00090 83492 83492 0.00100 17547335 11957802 5589533 0.06870 109 109 0.00000 8937 8937 0.00010 9046 9046 0.00010 1 2452435 0 24761081 25777187 -1016106 X 1 1 1 LARSON CENTER PARTNERSHIP LLC PROPERTY MANAGEMENT 0.75600 0.00000 0.22730 1 1 GENESIS MEDICAL CENTER - ILLINI

801 ILLINI DRIVE SILVIS IL 61282

X X X GENESIS MEDICAL CENTER - ILLINI 1 1 1 200.000000000000 1 200.000000000000 1 X X X X X X X 1 1 X X X X X X 1 0 1 X 0 0 6 ILLINI RESTORATIVE CARE

1455 ILLINI DRIVE SILVIS IL 61282

L-T INTERMEDIATE, NSG, & SHELTERED CARE ILLINI LARSON CENTER

855 ILLINI DRIVE SILVIS IL 61284

I/P PHARMACY & O/P LAB CROSSTOWN SQUARE

900 CROSSTOWN SQUARE SILVIS IL 61282

INDEPENDENT LIVING FACILITY ILLINI AMBULANCE SERVICE

730 AVENUE OF THE CITIES EAST MOLINE IL 61244

AMBULANCE SERVICES ILLINI - BUILDING #3

1414 10TH STREET SILVIS IL 61282

OUTPATIENT DIAGNOSTIC CLINIC PHYSICAL THERAPY CLINIC KING PLAZA

3650 AVENUE OF THE CITIES MOLINE IL 61265

OUTPATIENT PHYSICAL THERAPY CLINIC PART I, LINE 3C: NOT APPLICABLE PART I, LINE 6A: NOT APPLICABLE PART I, LINE 7: GENESIS HEALTH SYSTEM UTILIZED WORKSHEET 2 TO CALCULATE ITS COST-TO-CHARGE RATIO. THE CALCULATED COST-TO-CHARGE RATIO WAS USED TO CALCULATE THE COST OF CHARITY CARE AND UNREIMBURSED MEDICAID. THE COST OF SUBSIDIZED HEALTH SERVICES WAS OBTAINED FROM GENESIS HEALTH SYSTEM'S COST ACCOUNTING SYSTEM (I.E., DECISION SUPPORT SYSTEM) THAT CALCULATES THE PER UNIT REIMBURSEMENT AND COST FOR EACH TYPE OF SERVICE AND SUPPLY THAT THE NON-MEDICARE AND NON-MEDICAID PATIENTS CONSUMED IN THE DEPARTMENTS REPORTED. COSTS OF THE "OTHER BENEFITS" (EXCLUDING SUBSIDIZED HEALTH SERVICES) REPORTED IN 7E -7I WERE COMPILED THROUGHOUT THE YEAR IN THE COMMUNITY BENEFIT DATABASE (I.E., CBISA) THAT GENESIS HEALTH SYSTEM UTILIZES. PART I, LINE 7G: NO COSTS ASSOCIATED WITH A PHYSICIAN CLINIC WERE REPORTED IN SUBSIDIZED HEALTH SERVICES. PART I, L7 COL(F): $6,810,255 OF BAD DEBT EXPENSE IS SUBTRACTED FOR PURPOSES OF COMPUTING THE PERCENTAGE IN PART I, LINE 7K, COLUMN F. THE ORGANIZATION'S TOTAL COMMUNITY BENEFIT EXPENSE AS A PERCENTAGE OF TOTAL EXPENSES, LESS BAD DEBT, IS 21.55%, AND THE PERCENTAGE INCREASES TO 53.21% IF MEDICARE ALLOWABLE COSTS ARE INCLUDED IN TOTAL COMMUNITY BENEFIT EXPENSE. PART II: COMMUNITY HEALTH IMPROVEMENT ADVOCACY: GENESIS HEALTH SYSTEM LIVES ITS MISSION BY CONTINUALLY ADVOCATING AT LOCAL-LEVEL EVENTS, PROGRAMS AND FUNCTIONS, FOR THE IMPROVEMENT OF COMMUNITY HEALTH AND POLICY CHANGES TO IMPROVE HEALTHCARE PROGRAMS' EFFECTIVENESS. WORKFORCE DEVELOPMENT: GENESIS HEALTH SYSTEM AND UNITED TOWNSHIP HIGH SCHOOL CO-OPERATE A PROGRAM THAT TEACHES LIFE AND JOB SKILLS TO THE MENTALLY DISABLED. PART III, LINE 4: PATIENT RECEIVABLES DUE DIRECTLY FROM THE PATIENTS ARE CARRIED AT THE ORIGINAL CHARGE FOR THE SERVICE PROVIDED LESS AMOUNTS COVERED BY THIRD-PARTY PAYORS AND LESS AN ESTIMATED ALLOWANCE FOR DOUBTFUL RECEIVABLES BASED ON A REVIEW OF ALL OUTSTANDING AMOUNTS ON A MONTHLY BASIS. RECEIVABLES DUE FROM MEDICAL OFFICE BUILDING TENANTS AND FROM COMMERCIAL LAUNDRY CUSTOMERS ARE CARRIED AT THE ORIGINAL INVOICE AMOUNT LESS AN ESTIMATE MADE FOR DOUBTFUL ACCOUNTS. MANAGEMENT DETERMINES THE ALLOWANCE FOR DOUBTFUL ACCOUNTS BY IDENTIFYING TROUBLED ACCOUNTS, BY HISTORICAL EXPERIENCE APPLIED TO AN AGING OF ACCOUNTS, AND BY CONSIDERING THE PATIENT'S FINANCIAL HISTORY, CREDIT HISTORY AND CURRENT ECONOMIC CONDITIONS. THE SYSTEM DOES NOT CHARGE INTEREST ON PATIENT RECEIVABLES. RECEIVABLES ARE WRITTEN OFF AS BAD DEBTS WHEN DEEMED UNCOLLECTIBLE. RECOVERIES OF RECEIVABLES PREVIOUSLY WRITTEN OFF ARE RECORDED AS A REDUCTION OF BAD DEBT EXPENSE WHEN RECEIVED.THE RATIONALE AND COSTING METHODOLOGY USED TO CALCULATE BAD DEBT EXPENSE AT COST (LINE 2) CONSISTED OF MULTIPLYING THE TOTAL BAD DEBT EXPENSE PER THE INCOME STATEMENT BY THE RATIO OF PATIENT CARE COST TO CHARGES TO ARRIVE AT ESTIMATED COST OF BAD DEBT. PAYMENTS RECEIVED AFTER AN ACCOUNT HAD BEEN WRITTEN OFF TO BAD DEBT WERE CREDITED TO A BAD DEBT RECOVERY ACCOUNT. DISCOUNTS ON PATIENT ACCOUNTS PROVIDED BY THIRD-PARTY PAYERS WERE WRITTEN OFF TO A CONTRACTUAL ALLOWANCE ACCOUNT. GENESIS HEALTH SYSTEM CONTRACTS WITH AVADYNE HEALTH TO PROCESS AGING PATIENT ACCOUNTS. AVADYNE HEALTH'S COLLECTION PROCESS UTILIZES PUBLICLY AVAILABLE INFORMATION TO ENSURE ALL AGING PATIENT ACCOUNTS RECEIVE FINANCIAL ASSISTANCE IN ACCORDANCE TO GENESIS HEALTH SYSTEMS' POLICY BEFORE BEING DEEMED BAD DEBT. GENESIS HEALTH SYSTEM REPORTED ZERO DOLLARS FOR THE ESTIMATED AMOUNT OF THE ORGANIZATION'S BAD DEBT ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S FINANCIAL ASSISTANCE POLICY. PART III, LINE 8: THE MEDICARE COST REPORT WAS USED TO DETERMINE THE AMOUNT REPORTED IN PART III, LINES 5, 6, AND 7 FOR THE HOSPITAL. IN ADDITION, GENESIS HEALTH SYSTEM - ILLINOIS CALCULATED ITS MEDICARE SHORTFALL TWO WAYS FOR SUPPLEMENTAL INFORMATIONAL PURPOSES. THESE CALCULATIONS WERE COMPUTED USING THE GROSS PATIENT REVENUE BY PAYOR MIX AND CONVERTED TO COST USING THE COST TO CHARGE RATIO FROM PART I, WORKSHEET 2. THE PAYMENT RATE WAS CALCULATED BY DIVIDING THE MEDICARE PAYMENTS BY MEDICARE CHARGES USING A 12-MONTH ZERO BALANCE REPORT. THE SHORTFALL IS THE DIFFERENCE BETWEEN THE PAYMENTS AND THE COSTS. A. UTILIZING THE PAYOR MIX AND ZERO BALANCE REPORT FOR GENESIS MEDICAL CENTER (GMC) - ILLINI CAMPUS, COMBINED WITH ITS COST TO CHARGE RATIO OF 36.01%, CALCULATED USING WORKSHEET 2, GMC - ILLINI HOSPITAL'S MEDICARE SHORTFALL IS $4,143,126. -SECTION B. MEDICARE - ILLINI HOSPITAL USING COST TO CHARGE RATIO5. TOTAL REVENUE RECEIVED FROM MEDICARE $30,315,052 6. ALLOWABLE COSTS OF CARE $34,458,1787. SURPLUS (SHORTFALL) ($4,143,126)B. UTILIZING THE PAYOR MIX AND ZERO BALANCE REPORT FOR GMC - ILLINI CAMPUS AND GMC - ILLINI NURSING HOME, ALONG WITH EACH BUSINESS UNIT'S RESPECTIVE COST TO CHARGE RATIO OF 36.01% AND 81.27%, CALCULATED USING WORKSHEET 2, THE GHS-ILLINOIS MEDICARE SHORTFALL IS $5,486,795. -SECTION B. MEDICARE - INDIVIDUAL ADDED - ILLINI HOSPITAL & INH5. TOTAL REVENUE RECEIVED FROM MEDICARE $32,912,926 6. ALLOWABLE COSTS OF CARE $38,399,7217. SURPLUS (SHORTFALL) ($5,486,795)NO MEDICARE SHORTFALLS WERE INCLUDED IN COMMUNITY BENEFIT. THE MEDICARE SHORTFALL REPRESENTS THE DIFFERENCE BETWEEN THE TOTAL REVENUE RECEIVED FROM MEDICARE BASED ON MEDICARE REIMBURSEMENT RATES AND THE COSTS INCURRED BY GENESIS HEALTH SYSTEM IN PROVIDING HEALTHCARE SERVICES TO THE ELDERLY. IN 2012, THE PERCENT OF PERSONS 65 YEARS AND OVER IN ROCK ISLAND AND SCOTT COUNTIES WAS 18.6%. IN ACCORDANCE WITH GENESIS HEALTH SYSTEM'S MISSION STATEMENT, "TO PROVIDE COMPASSIONATE, QUALITY HEALTH SERVICES TO ALL THOSE IN NEED," THE ELDERLY WERE SERVED DESPITE THE MEDICARE LOSS OF $1,016,106. GENESIS HEALTH SYSTEM HAS A CLEAR MISSION TO SERVE ALL THOSE IN NEED AND TO IMPROVE THE HEALTH OF THE COMMUNITY INCLUDING THE ELDERLY. FURTHERMORE, THERE ARE NO FOR-PROFIT HOSPITALS IN THE COMMUNITY, AND THEREFORE GENESIS HEALTH SYSTEM IS ONE OF TWO TAX-EXEMPT HEALTHCARE ORGANIZATIONS IN THE COMMUNITY WHO PROVIDE ACCESS TO HEALTHCARE FOR MEDICARE PATIENTS. ACCORDINGLY, IT IS GENESIS HEALTH SYSTEM'S POSITION FOR THE REASONS STATED ABOVE THAT THE MEDICARE SHORTFALL OF $1,016,106 REPRESENTS A COMMUNITY BENEFIT. PURSUANT TO THE INSTRUCTIONS TO THE FORM 990, SCHEDULE H, THE MEDICARE SHORTFALL IS NOT INCLUDED IN PART I, LINE 7. IF THE MEDICARE SHORTFALL WAS INCLUDED IN PART I, LINE 7, THEN PART I, LINE 7K, COLUMN F WOULD BE 8.11%. PART III, LINE 9B: EVERY EFFORT IS MADE TO DETERMINE A PATIENT'S ELIGIBILITY FOR FINANCIAL ASSISTANCE. IF ELIGIBLE, PAYMENT PLANS ARE MADE AVAILABLE BASED ON THEIR RESOURCES AND INCOME. ALL BALANCES OWING AFTER FINANCIAL ASSISTANCE ALLOWANCES HAVE BEEN TAKEN ARE PAYABLE IN MONTHLY PAYMENTS IN ACCORDANCE WITH THE ORGANIZATION'S FINANCIAL ASSISTANCE POLICY. PART VI, LINE 2: GENESIS HEALTH SYSTEM UTILIZES THE COMMUNITY HEALTH ASSESSMENTS CREATED BY THE QUAD CITY HEALTH INITIATIVE (QCHI) AND THE COMMUNITY VITALITY TASK FORCE OF UNITED WAY. QCHI WAS FORMED BY GENESIS HEALTH SYSTEM, WHICH IS HEADQUARTERED IN SCOTT COUNTY, IOWA, AND TRINITY REGIONAL HEALTH SYSTEM, WHICH IS HEADQUARTERED IN ROCK ISLAND COUNTY, ILLINOIS. QCHI IS NOW A COMMUNITY PARTNERSHIP OF OVER 100 ORGANIZATIONS CONSISTING OF 500 ACTIVE INDIVIDUALS PURSUING INITIATIVES TO CREATE A HEALTHIER COMMUNITY, SERVING AS A CATALYST FOR IMPROVING THE HEALTH AND OVERALL QUALITY OF LIFE WITHIN THE QUAD CITIES. A COMMUNITY HEALTH ASSESSMENT WAS CONDUCTED BY PROFESSIONAL RESEARCH CONSULTANTS, INC., IN 2012. PART VI, LINE 3: INFORMATION ON THE AVAILABILITY OF FINANCIAL ASSISTANCE IS POSTED IN VISIBLE LOCATIONS IN THE ADMISSION DEPARTMENTS OF THE HOSPITALS. IN ADDITION, THE HOSPITAL REGISTRATION STAFF MAKE AVAILABLE INFORMATIVE BROCHURES FOR PATIENTS IN THE EMERGENCY ROOM REGISTRATION AREA EXPLAINING THEIR ELIGIBILITY FOR ASSISTANCE. GENESIS HEALTH SYSTEM PROVIDES PATIENT FINANCIAL COUNSELORS ON EACH HOSPITAL CAMPUS TO DISCUSS OPTIONS WITH THE PATIENTS. SHARED BUSINESS SERVICES PREPARES AND PROVIDES A LETTER TO EACH PATIENT, EXPLAINING THEIR CURRENT BALANCE AND ADVISING THEM OF THEIR OPTIONS. A PHONE NUMBER IS PROVIDED WITH THE LETTER ENCOURAGING THE PATIENT TO CALL IF NEEDED. IN ADDITION, THE GENESIS HEALTH SYSTEM WEBSITE ALSO LISTS THE OPTIONS FOR PAYMENT, AND ON A MONTHLY BASIS A POWER POINT PRESENTATION IS GIVEN TO INCOMING CANCER PATIENTS INFORMING THEM OF THEIR PAYMENT OPTIONS. THE OUTPATIENT PHYSICIAN CLINICS AND THE HOME HEALTH DIVISION MAKE AVAILABLE THEIR FINANCIAL POLICY BROCHURES ALONG WITH DIRECTING PATIENTS TO GOVERNMENT PROGRAMS SUCH AS SCHIP. PART VI, LINE 4: GENESIS HEALTH SYSTEM'S MISSION IS TO PROVIDE COMPASSIONATE, QUALITY HEALTH SERVICES TO ALL THOSE IN NEED. GENESIS LIVES ITS MISSION EACH AND EVERY DAY BY SERVING A 10-COUNTY REGION OF EASTERN IOWA AND WESTERN ILLINOIS, INCLUDING BOTH URBAN AND RURAL AREAS. THE REGION SERVED BY GENESIS HEALTH SYSTEM HAS A POPULATION OF 379,690. ACCORDING TO THE 2010 CENSUS, WHITES MADE UP 88.4% OF THE POPULATION WITH 8.3% BLACK OR AFRICAN-AMERICAN AND 7.6% HISPANIC OR LATINO ORIGIN.MEDIAN AGE OF THE POPULATION OF THE REGION IS 40.6 YEARS. MORE THAN 30% OF THE POPULATION OF THE REGION IS GREATER THAN 50 YEARS OLD, WHICH WILL CREATE A CONTINUED AND EXPANDED NEED FOR HEALTH CARE SERVICES IN THE NEXT 20 YEARS. THE PERCENT OF PERSONS 65 YEARS AND OVER WAS 18.6% IN ROCK ISLAND AND SCOTT COUNTIES.ACCORDING TO ESTIMATES FROM THE AMERICAN COMMUNITY SURVEY (ACS), 11.9% OF QUAD CITIES AREA RESIDENTS (SCOTT AND ROCK ISLAND COUNTIES) LIVE BELOW THE FEDERAL POVERTY. IN 2012, 2.0% OF QUAD CITIES AREA ADULTS REPORTED THAT THERE WAS A TIME IN THE PAST TWO YEARS WHEN THEY WERE LIVING ON THE STREET, IN A CAR, OR IN A TEMPORARY SHELTER. THE AVERAGE UNEMPLOYMENT RATE IN 2009 WAS 9.2% FOR ROCK ISLAND COUNTY, ILLINOIS AND 6.6% IN SCOTT COUNTY, IOWA.THE PERCENTAGE OF PEOPLE AGES 18-64 WHO DID NOT HAVE ANY HEALTH INSURANCE IN 2012 WAS 9.3% IN ROCK ISLAND COUNTY, ILLINOIS AND 11.4% IN SCOTT COUNTY, IOWA. THE QUAD CITIES AREA PERCENTAGE OF ADULTS WHO CURRENTLY SMOKED IN 2012 WAS 19.4%. THE PERCENTAGE OF ADULTS WHO WERE OBESE IN 2012 WAS 33.4% IN ROCK ISLAND COUNTY, ILLINOIS AND 33.6% IN SCOTT COUNTY, IOWA. PART VI, LINE 5: GENESIS HEALTH SYSTEM'S BOARD OF DIRECTORS IS A DIVERSE REPRESENTATION OF PERSONS WHO RESIDE IN THE PRIMARY SERVICE AREA THAT GENESIS HEALTH SYSTEM SERVES. GENESIS EXECUTIVES AND EMPLOYEES SERVE ON DOZENS OF VOLUNTEER BOARDS THROUGHOUT THE REGION ON IMPORTANT PROJECTS AND INITIATIVES, SUCH AS NEW LIBRARY CONSTRUCTION, HOMELESS SHELTERS, MENTAL HEALTH, DOWNTOWN REDEVELOPMENT AND EVENTS AND FESTIVALS. GENESIS EMPLOYEES SERVE THE COMMUNITIES WHERE THEY LIVE BY SERVING IN ELECTED OFFICES IN CITY AND COUNTY GOVERNMENT.GENESIS HEALTH SYSTEM EXTENDS MEDICAL STAFF PRIVILEGES TO ALL QUALIFIED PHYSICIANS IN ITS COMMUNITIES. GENESIS HEALTH SYSTEM HAS ENDEAVORED TO IMPROVE ACCESS TO HEALTH CARE FOR THE COMMUNITIES IT SERVES BY PARTICIPATING IN APPROPRIATE JOINT VENTURES THAT OFFER NEEDED HEALTH CARE SERVICES TO UNDER-SERVED AREAS. GENESIS HEALTH SYSTEM SCHEDULES DOZENS OF HEALTH SCREENINGS AND IMMUNIZATIONS THROUGHOUT THE YEAR AT A REDUCED COST. THESE INCLUDE SCREENINGS FOR DIABETES, STROKE AND HEART DISEASE AND PUBLIC FLU IMMUNIZATION CLINICS.GENESIS HAS DONATED FUNDING FOR OUTDOOR EXERCISE COURSES CALLED GENESIS HEALTHBEAT IN DAVENPORT, IA., MOLINE, IL., AND DEWITT, IA. GENESIS SPONSORS GENESIS ADVENTURES IN NURSING (GAIN), A CAMP FOR CHILDREN INTERESTED IN HEALTH CARE CAREERS. GENESIS EMPLOYEES SERVE AS MENTORS AND INSTRUCTORS DURING CAMP WEEK.GENESIS EMPLOYEES MAKE MEDICAL MISSION TRIPS EACH YEAR TO AREAS OF NEED ALL OVER THE WORLD. GENESIS EMPLOYEES, WITH THE SUPPORT OF THE HEALTH SYSTEM, HAVE PROVIDED RELIEF TO HAITI AFTER THE EARTHQUAKE AND DURING THE CHOLERA OUTBREAK AND TO TRADITIONALLY IMPOVERISHED COUNTRIES, INCLUDING PERU, ECUADOR, THE DOMINICAN REPUBLIC, HAITI AND TO AFRICAN NATIONS.GENESIS EMPLOYEES SUPPORT COMMUNITY OUTREACH PROGRAMS THROUGH A PROGRAM CALLED "TAKIN IT TO THE STREETS." PROJECTS HAVE INCLUDED PRIMARY SPONSORSHIP OF A HABITAT FOR HUMANITY HOUSE (280 VOLUNTEERS); COLLECTION OF 18,000 ITEMS FOR DOMESTIC VIOLENCE SHELTERS AND HUMILITY OF MARY HOMELESS SHELTER; X-STREAM CLEANUP (85 VOLUNTEERS), A CLEANUP PROJECT OF RIVERS AND STREAMS. EMPLOYEES HAVE USED THEIR COLLECTIVE IMPACT TO SECURE DONATIONS FOR FOOD PANTRIES. GENESIS HAS REDUCED ITS ENVIRONMENTAL FOOTPRINT ON THE COMMUNITIES IT SERVES BY IMPLEMENTING BULK WASTE RECYCLING, POLYSTYRENE RECYCLING, REDUCING SHARPS DISPOSAL, AND IMPLEMENTING WATER RUNOFF MEASURES. IN 2012, GENESIS WILL BEGIN BUILDING A MEDICAL OFFICE PARK IN MOLINE, IL ON LAND THAT WAS REMEDIATED BY GENESIS FROM A LANDFILL SITE. GREEN FEATURES WILL BE INTEGRATED INTO THE SITE AND THE DESIGN OF THE BUILDING.GENESIS SPONSORS AND HOSTS A VERY POPULAR ANNUAL BOY SCOUT MERIT BADGE DAY TO ASSIST SCOUTS IN WORKING TOWARD FIRST AID AND MEDICINE MERIT BADGES. PROFESSIONAL HEALTH CARE STAFF VOLUNTEER TO INSTRUCT THE SCOUTS FOR THE DAY.GENESIS MAINTAINS AN ACTIVE EFFORT TO ADVOCATE FOR ACCESS TO HEALTH CARE IN IOWA AND ILLINOIS STATE GOVERNMENT AND IN WASHINGTON D.C. GENESIS EMPLOYEES PARTICIPATE IN A VOTER VOICE INITIATIVE TO ALSO ADVOCATE ON IMPORTANT HEALTH ISSUES WITH CITY, COUNTY, STATE AND NATIONAL ELECTED OFFICIALS. SURPLUS FUNDS RESULTING FROM EFFICIENT OPERATIONS AND COST-CONTAINMENT MEASURES ARE RE-INVESTED IN THE HEALTHCARE OPERATIONS OF GENESIS HEALTH SYSTEM TO IMPROVE THE HEALTHCARE SERVICES THAT GENESIS PROVIDES. ADVANCES IN MEDICAL EQUIPMENT AND TECHNOLOGY, STAFF EDUCATION, AND NEW MEDICAL SERVICES ARE EXAMPLES OF OPERATIONAL INVESTMENTS THAT ULTIMATELY IMPROVE THE HEALTH OF THE COMMUNITIES THAT GENESIS SERVES. PART VI, LINE 6: GENESIS HEALTH SYSTEM (TAX ID #42-1418847), AN IOWA NONPROFIT CORPORATION, AND GENESIS HEALTH SYSTEM (TAX ID #36-3616314), AN ILLINOIS NOT-FOR-PROFIT CORPORATION, HAVE IDENTICAL GOVERNING BOARDS, MANAGEMENT AND BYLAWS AND CAN ACT JOINTLY.GENESIS HEALTH SYSTEM (TAX ID #42-1418847) IS ALSO THE SOLE MEMBER OF GENESIS HEALTH SERVICES FOUNDATION AND GENESIS HEALTH SYSTEM WORKERS' COMPENSATION PLAN AND TRUST, THE SOLE STOCKHOLDER OF GENVENTURES, INC., A MEMBER OF MISERICORDIA ASSURANCE COMPANY, LTD. AND A PARTNER IN GENGASTRO, LLC. GENESIS HEALTH SYSTEM (TAX ID #36-3616314) IS A PARTNER IN THE LARSON CENTER PARTNERSHIP.GENESIS HEALTH SYSTEM (TAX ID #42-1418847) OPERATES THE FOLLOWING BUSINESS UNITS TO PROMOTE THE HEALTH OF THE COMMUNITIES IT SERVES:GENESIS HEALTH SYSTEM PROVIDES ADMINISTRATIVE, MANAGEMENT, INFORMATION TECHNOLOGY AND OTHER SUPPORT SERVICES TO ITS AFFILIATES. GENESIS CLINICAL SERVICES: GHS OWNS AND OPERATES PHYSICIAN MEDICAL PRACTICES, CONVENIENT CARE PRACTICES, OPERATES AN OCCUPATIONAL MEDICINE CLINIC AND PROVIDES BEHAVIORAL HEALTH SERVICES TO THE RESIDENTS OF EASTERN IOWA AND WESTERN ILLINOIS. GENESIS MEDICAL CENTER - DAVENPORT (GMC - DAVENPORT) IS LICENSED AS A 502-BED ACUTE CARE HOSPITAL WHICH PROVIDES SERVICES FROM TWO HOSPITAL FACILITIES LOCATED IN DAVENPORT, IOWA. GENESIS FAMILY MEDICAL CENTER (GFMC) IS A FAMILY PRACTICE RESIDENCY TRAINING PROGRAM THAT OPERATES CLINICS IN DAVENPORT AND BLUE GRASS, IOWA TO PROVIDE A CLINICAL SETTING FOR THE RESIDENTS TO TREAT PATIENTS. GENESIS MEDICAL CENTER - DEWITT (GMC - DEWITT) IS CERTIFIED AS A CRITICAL ACCESS HOSPITAL, WHICH HAS 13-ACUTE CARE AND SWING BEDS, AND HAS A 77-BED LONG-TERM CARE FACILITY, WHICH PROVIDES SERVICES FROM ITS FACILITY IN DEWITT, IOWA. GENESIS ILLINOIS PROPERTIES (GIP) OWNS LAND LOCATED IN MOLINE, ILLINOIS. DURING THE YEAR ENDED JUNE 30, 2012, GIP SOLD ITS LAND TO GENESIS MEDICAL CENTER - ILLINI AND GIP WAS DISCONTINUED AS A BUSINESS UNIT. GENESIS VISITING NURSE ASSOCIATION AND HOSPICE (VNA) PROVIDES HOME HEALTH CARE, COMMUNITY NURSING SERVICES AND HOSPICE SERVICES TO PATIENTS IN EASTERN IOWA AND WESTERN ILLINOIS. GENESIS MEDICAL CENTER - ILLINI (GMC - ILLINI) IS LICENSED AS A 149-BED ACUTE CARE HOSPITAL WHICH PROVIDES SERVICES FROM ITS FACILITY IN SILVIS, ILLINOIS.ILLINI HOSPITAL NURSING HOME (INH) OPERATES ILLINI RESTORATIVE CARE CENTER AND CROSSTOWN SQUARE. ILLINI RESTORATIVE CARE CENTER IS A 120-BED LICENSED NURSING FACILITY, CONSISTING OF 75 SKILLED CARE BEDS AND 45 SHELTERED CARE BEDS. TWENTY-TWO OF THE SKILLED CARE BEDS ARE DESIGNATED AS HOSPITAL-BASED MEDICARE CERTIFIED BEDS. THE SHELTERED CARE UNIT PROVIDES REHABILITATIVE AND PERSONAL CARE IN A FAMILY-ORIENTED SETTING. CROSSTOWN SQUARE IS AN INDEPENDENT LIVING FACILITY CONTAINING 76 RENTABLE APARTMENTS AND TWO GUEST ROOMS THAT OFFERS SERVICES DESIGNED TO MEET THE NEEDS OF SENIOR ADULTS. GHS IOWA AND GHS ILLINOIS HAVE A CONTROLLING OWNERSHIP INTEREST OR MEMBERSHIP IN THE FOLLOWING ORGANIZATIONS: GENESIS HEALTH SERVICES FOUNDATION (GENESIS FOUNDATION) IS AN ORGANIZATION WHOSE MISSION IS TO DEVELOP, MANAGE AND GRANT CHARITABLE SUPPORT TO MEET THE HEALTH-RELATED NEEDS OF THE COMMUNITIES SERVED BY GENESIS HEALTH SYSTEM. THE GENESIS FOUNDATION IS REFERRED TO AS THE FOUNDATION. ILLINI HOSPITAL FOUNDATION (ILLINI FOUNDATION) SUPPORTS GMC - ILLINI BY PROVIDING FINANCIAL AND FUNDRAISING ASSISTANCE. THE MISSION OF THE ILLINI FOUNDATION IS TO ASSIST GMC - ILLINI IN PROVIDING QUALITY, COMPASSIONATE CARE FOR ALL THOSE IN NEED BY RAISING, MANAGING AND GRANTING CHARITABLE FUNDS. DURING THE YEAR ENDED JUNE 30, 2012, ILLINI FOUNDATION MERGED WITH GENESIS FOUNDATION AND ILLINI FOUNDATION WAS DISSOLVED. THE LARSON CENTER PARTNERSHIP (LCP) IS A FOR-PROFIT REAL ESTATE PARTNERSHIP WHICH OWNS A MEDICAL OFFICE BUILDING ADJACENT TO GMC - ILLINI AND LEASES SPACE FOR CLINICS, LABORATORY, PHARMACY AND OFFICES TO GMC - ILLINI AND OTHER THIRD-PARTY ORGANIZATIONS. GHS ILLINOIS IS A GENERAL PARTNER AND OWNS APPROXIMATELY 75.6% OF LCP.GENVENTURES, INC. (GENVENTURES) IS A WHOLLY-OWNED FOR-PROFIT CORPORATION WHICH OPERATES THE FOLLOWING DIVISIONS, PRIMARILY IN THE QUAD CITIES:GENESIS AT HOME, CONTINUING CARE SELLS AND LEASES HOME MEDICAL EQUIPMENT; PROVIDES INTRAVENOUS THERAPY SERVICES, INCLUDING SALES OF RELATED SOLUTIONS AND SUPPLIES TO PATIENTS; AND PROVIDES RETAIL PHARMACEUTICAL AND OVER-THE-COUNTER PRODUCTS TO PATIENTS AND EMPLOYEES OF THE SYSTEM.GENPROPERTIES OWNS, LEASES AND/OR MANAGES OFFICE SPACE IN 14 MEDICAL OFFICE BUILDINGS LOCATED IN DAVENPORT, ELDRIDGE, LECLAIRE, MUSCATINE AND BETTENDORF, IOWA.CRESCENT LAUNDRY PROVIDES COMMERCIAL LAUNDRY SERVICES TO HEALTH CARE FACILITIES IN EASTERN IOWA AND IN NORTH-CENTRAL ILLINOIS.GENESIS HEALTH SYSTEM WORKERS' COMPENSATION PLAN AND TRUST (WORKERS' COMPENSATION TRUST) PROVIDES A FUND WHICH CAN BE USED TO PAY WORKERS' COMPENSATION CLAIMS AND COSTS FOR THE BENEFIT OF GENESIS HEALTH SYSTEM.MISERICORDIA ASSURANCE COMPANY, LTD. (MISERICORDIA) IS A WHOLLY-OWNED CAYMAN BASED CAPTIVE INSURANCE COMPANY WHICH UNDERWRITES THE GENERAL AND PROFESSIONAL LIABILITY RISKS OF GENESIS HEALTH SYSTEM AND AFFILIATES.GENGASTRO, LLC (D/B/A THE CENTER FOR DIGESTIVE HEALTH) IS A LIMITED LIABILITY COMPANY, WHICH WAS FORMED IN 2003, A SINGLE-SPECIALTY GASTROENTEROLOGY AMBULATORY SURGERY CENTER LOCATED IN BETTENDORF, IOWA. IN DECEMBER 2010, GENESIS HEALTH SYSTEM ACQUIRED AN ADDITIONAL 16.67% INTEREST IN GENGASTRO AND MAINTAINED A 66.67% OWNERSHIP INTEREST AS OF JUNE 30, 2011. UPON OBTAINING A CONTROLLING INTEREST, THE SYSTEM CONSOLIDATED THE ACCOUNTS OF GENGASTRO, LLC IN ITS CONSOLIDATED FINANCIAL STATEMENTS IN JANUARY 2011. DURING THE YEAR ENDED JUNE 30, 2012, GENESIS HEALTH SYSTEM ACQUIRED AN ADDITIONAL 8.33% INTEREST IN GENGASTRO, LLC FROM NONCONTROLLING INTERESTS AND MAINTAINS A 75% OWNERSHIP INTEREST AS OF JUNE 30, 2012.DAVENPORT SRS LEASING, LLC (SRS) IS A LIMITED LIABILITY COMPANY, WHICH WAS FORMED IN 2008, WHICH LEASES MEDICAL EQUIPMENT. GENESIS HEALTH SYSTEM MAINTAINED A 93.75% OWNERSHIP INTEREST AS OF JUNE 30, 2011. DURING THE YEAR ENDED JUNE 30, 2012, GMC - DAVENPORT ACQUIRED THE REMAINING INTEREST OF SRS, TO OBTAIN 100% OWNERSHIP. UPON OBTAINING 100% OWNERSHIP, THE ASSETS, LIABILITIES AND OPERATIONS OF SRS WERE TRANSFERRED TO GMC - DAVENPORT AND SRS WAS DISSOLVED.GENESIS ACCOUNTABLE CARE ORGANIZATION, LLC (GENESIS ACO): THE GENESIS ACO IS AN IOWA LIMITED LIABILITY COMPANY FORMED IN DECEMBER 2011. ITS PURPOSE IS TO ENGAGE IN ANY LAWFUL BUSINESS AND ANY BUSINESS RELATED TO CREATION AND ORGANIZATION OF A "PHYSICIAN-DRIVEN" NETWORK TO ACT AS, AND/OR PARTICIPATE IN, AN ACCOUNTABLE CARE ORGANIZATION WITHIN THE MEANING OF THE FEDERAL PATIENT PROTECTION AND AFFORDABLE CARE ACT. THE COMPANY IS ALSO ORGANIZED TO DEVELOP A CLINICALLY INTEGRATED NETWORK OF PROVIDERS INCLUDING PHYSICIANS, HEALTH PROFESSIONALS, HOSPITALS AND ANCILLARY PROVIDERS WORKING TOGETHER TO PROMOTE HIGH QUALITY, COORDINATED AND EFFICIENT CARE TO PATIENTS INCLUDING MEMBERS OF VARIOUS MANAGED CARE PAYORS AND THE COMMUNITY AT LARGE. THE GENESIS ACO HAD NO FINANCIAL ACTIVITY DURING THE YEAR ENDED JUNE 30, 2012. REPORTS FILED WITH STATES PART VI, LINE 7 IL,IA 1 GENESIS HEALTH SYSTEM WORKERS' COMPENSATION PLAN & TRUST 1227 EAST RUSHOLME STREET DAVENPORT IA 52803 391905171 501(C)(3) 155549 CLAIM PAYMENTS GENESIS HEALTH SYSTEM - IOWA 1227 EAST RUSHOLME STREET DAVENPORT IA 52803 421418847 501(C)(3) 7860 DEDUCTIONS BY MEDICAL STAFF, DIRECTED TOWARDS MEDICAL EDUCATION PURPOSES AND THE PERLMUTTER LIBRARY AT THE GMC, ILLINOIS CAMPUS. GENESIS HEALTH SERVICES FOUNDATION 1227 EAST RUSHOLME STREET DAVENPORT IA 52803 421421670 501(C)(3) 5100 UNRESTRICTED DONATIONS BY THE MEDICAL STAFF TO SUPPORT THE MISSION OF THE GENESIS HEALTH SERVICES FOUNDATION. 3 0 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: THE GENESIS HEALTH SYSTEM - ILLINOIS STAFF REQUIRES RECEIPTS AND OTHER DOCUMENTATION PRIOR TO RELEASING FUNDS FOR PROJECTS AND SERVICES WITHIN THE SCOPE OF THE ORGANIZATION'S MISSION. PROPER AUTHORIZATION OF GRANT REQUESTS IS ALSO REQUIRED. STAFF FOLLOWS THE ORGANIZATION'S FUNDING ADMINISTRATIVE POLICY TO ENSURE THAT GRANTS ARE BEING APPROVED AND UTILIZED CORRECTLY. X X 1 1 0 1 0 0 0 0 0 0 0 DOUGLAS P CROPPER 0 560169 0 0 0 40824 0 222056 0 24405 0 847454 0 0 GEORGE J KONTOS JR MD 0 494699 0 0 0 40772 0 9800 0 18216 0 563487 0 0 MARK G ROGERS 0 254279 0 0 0 53248 0 101521 0 13046 0 422094 0 0 ROBERT W FRIEDEN 0 230219 0 0 0 94875 0 15894 0 20501 0 361489 0 0 FLORENCE L SPYROW 130146 152780 0 0 11087 13015 46588 54690 1044 1225 188865 221710 0 0 KENNETH R CROKEN 0 197200 0 0 0 60994 0 45123 0 18875 0 322192 0 0 JAMES A LEHMAN MD 0 254253 0 0 0 90504 0 71404 0 14154 0 430315 0 0 JULIE MANAS 0 190053 0 0 0 188683 0 7157 0 10789 0 396682 0 0 JUDITH MONDELLO 0 213448 0 0 0 140500 0 41565 0 8703 0 404216 0 0 ROBERT C TRAVIS 0 215755 0 0 0 105301 0 98911 0 16116 0 436083 0 0 HEIDI S KAHLY-MCMAHON 0 161960 0 0 0 17616 0 55206 0 18420 0 253202 0 0 ROBERT M NELSON MD 0 178775 0 0 0 67856 0 38686 0 15862 0 301179 0 0 JUDITH K PRANGER 0 183585 0 0 0 168464 0 57689 0 12355 0 422093 0 89919 MIKE L SHARP 0 143246 0 0 0 82433 0 57390 0 14917 0 297986 0 39942 PART I, LINE 1A GENESIS HEALTH SYSTEM PROVIDES THE FOLLOWING TO INDIVIDUALS REPORTED IN PART VII, SECTION A, LINE 1A: TRAVEL FOR COMPANIONS: THIS BENEFIT IS OFFERED TO ALL EMPLOYEES. THE ORGANIZATION REQUIRES REIMBURSEMENT OF THESE EXPENSES DIRECTLY TO THE ORGANIZATION. GROSS-UP PAYMENTS: THIS BENEFIT IS OFFERED TO QUALIFYING EXECUTIVES WHO HAD CONTRIBUTIONS MADE ON THEIR BEHALF IN THE SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN. CONTRIBUTIONS TO THE PLAN ARE INCLUDED WITH REPORTABLE COMPENSATION FOR INDIVIDUALS WITH VESTED CONTRIBUTIONS. PART I, LINE 4B THE FOLLOWING INDIVIDUALS PARTICIPATED IN A SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN IN 2011 SPONSORED BY GENESIS HEALTH SYSTEM - IOWA, A RELATED ORGANIZATION: ROBERT C. TRAVIS - $64,692, AND JAMES A. LEHMAN, M.D. - $50,324. THE DOLLAR AMOUNT REPRESENTS THE CURRENT YEAR CONTRIBUTION MADE BY GENESIS HEALTH SYSTEM - IOWA ON BEHALF OF THE INDIVIDUALS TO THE PLAN IN 2011 AND THE GROSS-UP PAYMENT TO COVER TAX. THIS INFORMATION IS INCLUDED IN REPORTABLE COMPENSATION ON THE FORM 990, PART VII AND SCHEDULE J, PART II. THE FOLLOWING INDIVIDUALS PARTICIPATED IN A SUPPLEMENTAL EXECUTIVE RETIREMENT SAVING BENEFIT PLAN IN 2011 SPONSORED BY GENESIS HEALTH SYSTEM - IOWA, A RELATED ORGANIZATION: KENNETH R. CROKEN - $28,908, ROBERT W. FRIEDEN - $80,498, JUDITH MONDELLO - $100,291, ROBERT M. NELSON, M.D. - $26,086, JUDITH K. PRANGER - $142,899, MIKE L. SHARP - $60,684. THE DOLLAR AMOUNT REPRESENTS THE CURRENT YEAR CONTRIBUTION MADE BY GENESIS HEALTH SYSTEM - IOWA ON BEHALF OF THE INDIVIDUALS TO THE PLAN IN 2011. THIS INFORMATION IS INCLUDED IN REPORTABLE COMPENSATION ON THE FORM 990, PART VII AND SCHEDULE J, PART II. THE FOLLOWING INDIVIDUALS ALSO PARTICIPATED IN A SUPPLEMENTAL EXECUTIVE RETIREMENT SAVINGS BENEFIT PLAN IN 2011 SPONSORED BY GENESIS HEALTH SYSTEM - IOWA: KENNETH R. CROKEN - $28,908, DOUGLAS P. CROPPER - $212,256, HEIDI S. KAHLY-MCMAHON - $44,290, JUDITH MONDELLO - $31,765, ROBERT M. NELSON, M.D. - $26,086, MARK G. ROGERS - $88,100, MIKE L. SHARP - $19,093, AND FLORENCE L. SPYROW - $91,478. THE DOLLAR AMOUNT REPRESENTS THE CURRENT YEAR CONTRIBUTION MADE BY GENESIS HEALTH SYSTEM - IOWA ON BEHALF OF THE INDIVIDUALS TO THE PLAN IN 2011. THIS INFORMATION IS INCLUDED IN DEFERRED COMPENSATION ON THE FORM 990, PART VII AND SCHEDULE J PART II. SUPPLEMENTAL INFORMATION PART III PART I, LINE 3: GENESIS HEALTH SYSTEM - ILLINOIS RELIES ON GENESIS HEALTH SYSTEM - IOWA TO DETERMINE THE COMPENSATION OF THE ORGANIZATION'S TOP MANAGEMENT OFFICIALS, OFFICERS, DIRECTORS, AND KEY EMPLOYEES. GENESIS HEALTH SYSTEM - IOWA UTILIZES A COMPENSATION COMMITTEE, AN INDEPENDENT COMPENSATION CONSULTANT, A WRITTEN EMPLOYMENT CONTRACT, A COMPENSATION SURVEY OR STUDY, AND APPROVAL BY THE COMPENSATION COMMITTEE TO DETERMINE SUCH COMPENSATION. PART II, COLUMN F: THE FOLLOWING INDIVIDUAL ALSO PARTICIPATED IN A SUPPLEMENTAL EXECUTIVE RETIREMENT SAVINGS BENEFIT PLAN IN 2009, 2010, AND 2011 SPONSORED BY GENESIS HEALTH SYSTEM - IOWA, A RELATED ENTITY: JUDITH K. PRANGER - $89,919 AND MIKE L. SHARP - $39,942. THE DOLLAR AMOUNT REPRESENTS PRIOR YEAR CONTRIBUTIONS MADE BY GENESIS HEALTH SYSTEM - IOWA ON BEHALF OF THE INDIVIDUALS TO THE PLAN IN 2009 AND 2010. THIS INFORMATION WAS INCLUDED IN DEFERRED COMPENSATION ON THE PRIOR YEARS' FORM 990, PART VII AND SCHEDULE J, PART II. THESE INDIVIDUALS REACHED A SPECIFIED LEVEL OF VESTING IN 2011, SO THE DOLLAR AMOUNT IS NOW INCLUDED IN REPORTABLE COMPENSATION ON THE CURRENT YEAR FORM 990, PART VII AND SCHEDULE J, PART II. THE DOLLAR AMOUNT IS ALSO LISTED AS COMPENSATION REPORTED IN A PRIOR FORM 990 ON THE CURRENT YEAR FORM 990, SCHEDULE J, PART II. WELLMARK HEALTH PLAN OF IOWA INC SEE BELOW IN PART V 3920719 GENESIS HEALTH SYSTEM (GHS) OBTAINS EMPLOYEE HEALTH INSURANCE COVERAGE AND ISSUES REFUNDS FOR OVERPAYMENTS TO WELLMARK HEALTH PLAN OF IOWA, INC. 0 WELLMARK HEALTH PLAN OF IOWA INC SEE BELOW IN PART V 1599258 GHS HAS A PROVIDER SERVICE AGREEMENT FOR PATIENT MEDICAL SERVICES WITH WELLMARK HEALTH PLAN OF IOWA, INC. 0 LARSON CENTER PARTNERSHIP SEE BELOW IN PART V 702514 FACILITY LEASE PAYMENTS 0 GENVENTURES INC SEE BELOW IN PART V 617602 GHS PAID GENVENTURES, INC. FOR MEDICAL SUPPLIES AND LAUNDRY SERVICES. 0 GENVENTURES INC SEE BELOW IN PART V 20530 PAYMENT FROM GENVENTURES, INC. FOR MEDICAL SUPPLIES 0 FORM 990, SCHEDULE L, PART IV, COLUMN B DESCRIPTION OF RELATIONSHIP - WELLMARK HEALTH PLAN OF IOWA, INC. DOUGLAS P. CROPPER IS THE BOARD PRESIDENT/CEO OF GHS AND A DIRECTOR ON THE BOARD OF WELLMARK HEALTH PLAN OF IOWA, INC. FORM 990, SCHEDULE L, PART IV, COLUMN B DESCRIPTION OF RELATIONSHIP - LARSON CENTER PARTNERSHIP FLORENCE L. SPYROW IS A KEY EMPLOYEE OF GHS-IL AND THE VOTING REPRESENTATIVE IN THE LARSON CENTER PARTNERSHIP, OF WHICH GHS-IL IS A PARTNER. FORM 990, SCHEDULE L, PART IV, COLUMN B DESCRIPTION OF RELATIONSHIP - GENVENTURES, INC. MARK G. ROGERS AND ROGER A. HILL ARE OFFICERS, FLORENCE L. SPYROW IS A KEY EMPLOYEE, JAMES W. KOEHLER IS A DIRECTOR, AND MIKE L. SHARP IS A FORMER KEY EMPLOYEE OF GHS AND ARE REPORTED ON THE FORM 990, PART VII. DURING THE TAX YEAR, MARK G. ROGERS, ROGER A. HILL, JAMES W. KOEHLER, AND MIKE L. SHARP WERE OFFICERS OF GENVENTURES, INC., AND FLORENCE L. SPYROW WAS A DIRECTOR OF GENVENTURES, INC. FORM 990, PART VI, SECTION B, LINE 11 INTERNAL MANAGEMENT REVIEW IS COMPLETED OF THE COMPILED INFORMATION PRIOR TO PREPARATION AND REVIEW BY MCGLADREY LLP. FOLLOWING MCGLADREY LLP'S PREPARATION AND REVIEW OF THE FORM 990, IT IS REVIEWED WITH THE ORGANIZATION'S VICE PRESIDENT, FINANCE/CFO; VICE PRESIDENT, LEGAL AFFAIRS; AND VICE PRESIDENT, HUMAN RESOURCES. THE FORM 990 IS THEN REVIEWED AT A JOINT MEETING OF THE ORGANIZATION'S FINANCE COMMITTEE AND AUDIT & COMPLIANCE COMMITTEE. PRIOR TO SUBMITTING THE FORM 990 TO THE IRS, IT IS E-MAILED TO THE ORGANIZATION'S BOARD OF DIRECTORS ONE WEEK IN ADVANCE OF A SCHEDULED MEETING. AT THE BOARD OF DIRECTORS MEETING, INTERNAL MANAGEMENT REVIEWS THE FORM 990 WITH THE BOARD OF DIRECTORS. SUGGESTED CHANGES FROM ALL OF THESE REVIEWS ARE CONSIDERED FOR INCLUSION IN THE FINAL FORM 990 SUBMITTED TO THE IRS. FORM 990, PART VI, SECTION B, LINE 12C ANY COVERED PERSON, DEFINED AS ANY DIRECTOR, OFFICER, OR MEMBER OF A BOARD OR BOARD COMMITTEE OF GENESIS HEALTH SYSTEM (GHS) OR AN AFFILIATE, SHOULD DISCLOSE AN INTEREST OR POTENTIAL INTEREST AS SOON AS THEY BECOME AWARE OF A POTENTIAL TRANSACTION THAT WILL BE CONSIDERED BY MANAGEMENT, THE BOARD, OR A COMMITTEE OF THE BOARD. COVERED PERSONS ARE REQUIRED ANNUALLY TO DISCLOSE ANY POSSIBLE PERSONAL, FAMILY, OR BUSINESS RELATIONSHIPS THAT REASONABLY COULD GIVE RISE TO AN INTEREST OR CONFLICT INVOLVING GHS, OR AN AFFILIATE, OR WITH RESPECT TO DESIGNATED FACILITIES AND ACTIVITIES, AND ACKNOWLEDGE BY HIS OR HER SIGNATURE THAT HE OR SHE IS FAMILIAR WITH AND IS IN COMPLIANCE WITH THE LETTER AND SPIRIT OF THIS POLICY. ANY COVERED PERSON FOUND TO HAVE A CONFLICT OF INTEREST MAY MAKE A PRESENTATION AT THE BOARD OR COMMITTEE MEETING TO PRESENT INFORMATION AND ADDRESS ANY QUESTIONS RAISED BY OTHER DIRECTORS OR COMMITTEE MEMBERS. SAID PERSON SHALL NOT BE ALLOWED TO ACTIVELY AND AGGRESSIVELY ADVOCATE IN HIS OR HER OWN BEHALF NOR SHALL SUCH PERSON ADVOCATE HIS OR HER POSITION INFORMALLY THROUGH PRIVATE CONTACT, COMMUNICATION AND DISCUSSION WITH ANOTHER DIRECTOR. AFTER SUCH PRESENTATION, THE PERSON SHALL LEAVE THE MEETING DURING THE DISCUSSION OF, AND THE VOTE ON, THE APPLICABLE TRANSACTION OR ARRANGEMENT. FORM 990, PART VI, SECTION B, LINE 15 EACH EXECUTIVE POSITION IS EVALUATED USING A FORMAL EVALUATION PLAN THAT IS ESTABLISHED BY AN OUTSIDE CONSULTANT. AT THE PRESENT TIME, THE CONSULTANT USES A POINT SYSTEM FOR JOB EVALUATION. THE POINT VALUES ARE BASED ON "KNOW HOW", "PROBLEM SOLVING", "ACCOUNTABILITY", AND OTHER JOB ATTRIBUTES SPECIFIC TO THE POSITION. ONCE THE POINT VALUE IS SET FOR A POSITION, MARKET COMPARISONS FOR JOBS WITH THE SAME ORGANIZATIONAL IMPACT CAN BE COMPARED FOR SALARY PURPOSES AND ESTABLISH PAY RANGES. THE DESIGN OF THE PAY RANGES FOR EXECUTIVES IS BASED ON MARKET DATA. THE MIDPOINT OF EACH PAY RANGE IS ESTABLISHED AT THE 50TH PERCENTILE OF THE MARKET COMPARISONS. A MINIMUM GUIDELINE IS ESTABLISHED AT THE 25TH PERCENTILE, AND A MAXIMUM GUIDELINE IS SET AT THE 75TH PERCENTILE. SPECIFIC PAY RATES FOR EXECUTIVES ARE SUBJECT TO CEO AND COMPENSATION COMMITTEE AND THE GHS BOARD OF DIRECTORS APPROVAL. PAY RANGES ARE REVIEWED EACH YEAR TO DETERMINE THE NEED FOR REVISION. WHEN MARKET CONDITIONS SUGGEST AN ADJUSTMENT TO PAY RANGES, DATA WILL BE PRESENTED TO THE COMPENSATION COMMITTEE FOR ITS REVIEW. THE SPECIFIC PAY RANGES ARE SUBJECT TO CEO, COMPENSATION COMMITTEE, AND GENESIS HEALTH SYSTEM (GHS) BOARD OF DIRECTOR APPROVAL. THE PRESIDENT AND CEO HAS THE AUTHORITY AND RESPONSIBILITY TO ESTABLISH AND ADJUST, WITHIN THE RANGE APPROVED BY THE COMPENSATION COMMITTEE AND THE GHS BOARD OF DIRECTORS, THE BASE COMPENSATION OF EACH EXECUTIVE EMPLOYED BY GHS, AT APPROPRIATE TIMES. THE GHS BOARD OF DIRECTORS SHALL ESTABLISH AND ADJUST, WITHIN THE RANGE APPROVED BY THE COMPENSATION COMMITTEE, THE BASE COMPENSATION FOR THE CEO OF GHS, AT APPROPRIATE TIMES. THE LAST TIME THIS PROCESS WAS FORMALLY UNDERTAKEN WAS NOVEMBER 2012. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE NOT MADE AVAILABLE TO THE PUBLIC. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED GAINS ON INVESTMENTS: 983. CHANGE IN NET ASSETS OF THE FOUNDATION -99,945. TOTAL TO FORM 990, PART XI, LINE 5: -98,962. FORM 990, PART XII, LINE 2C THE OVERSIGHT AND SELECTION PROCESS HAS NOT CHANGED FROM THE PRIOR TAX YEAR. FORM 990, PART VII, LINE 1A GENESIS HEALTH SYSTEM, EIN 42-1418847, AND GENESIS HEALTH SYSTEM, EIN 36-3616314 HAVE IDENTICAL GOVERNING BOARDS AND AN IDENTICAL EXECUTIVE MANAGEMENT TEAM. THE HOURS REPORTED ON FORM 990, PART VII, SECTION A, COLUMN (B) REPRESENTS THE NUMBER OF HOURS THESE INDIVIDUALS DEVOTE TO BOTH ORGANIZATIONS. FURTHERMORE, THE AMOUNTS REPORTED AS REPORTABLE COMPENSATION FOR THE OFFICERS, KEY EMPLOYEES, AND HIGHLY COMPENSATED EMPLOYEES, UNLESS OTHERWISE NOTED ELSEWHERE IN PART VII, ARE FOR SERVICES RENDERED ON BEHALF OF BOTH ORGANIZATIONS. IT WOULD BE ADMINISTRATIVELY IMPRACTICABLE FOR MEMBERS OF THE GOVERNING BOARD AND THE EXECUTIVE TEAM TO BREAKOUT THEIR HOURS DEVOTED AS WELL AS THEIR REPORTABLE COMPENSATION BETWEEN EACH ORGANIZATION. ALL REPORTABLE COMPENSATION, UNLESS OTHERWISE NOTED IN PART VII, IS PAID BY GENESIS HEALTH SYSTEM, EIN 42-1418847. 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