2013-05-13T11:00:37-05:00 2012-06-30 470617373 CATHOLIC HEALTH INITIATIVES 198 INVERNESS DRIVE WEST ENGLEWOOD CO 80112 990 2011-07-01 420680308 MERCY MEDICAL CENTER - CENTERVILLE MERC 5154373413 1 St Josephs Drive Centerville IA 52544 STEVE KUKLA 2013-05-06 true PAMELA KROHN P01210500 3032989100 2011 2016-02-24 21:20:13Z CLINTON CHRISTIANSON 1 St Josephs Drive Centerville IA 52544 27465415 false 0928 X WWW.MERCYCENTERVILLE.ORG X 1965 IA MERCY MEDICAL CENTER-CENTERVILLE IS A NOT-FOR-PROFIT CATHOLIC HEALTH ORGANIZATION CREATING HEALTHIER COMMUNITIES BY OPERATING A 25-BED ACUTE CARE HOSPITAL AND A 20-BED SKILLED NURSING FACILITY. 14 10 289 11 284 0 916315 1036074 25249567 25953589 545736 326321 120669 149431 26832287 27465415 13846 22693 0 0 12908069 12582954 0 0 0 11439638 12161957 24361553 24767604 2470734 2697811 20619452 22643471 2621621 2233131 17997831 20410340 THE ORGANIZATION'S MISSION IS TO NURTURE THE HEALING MINISTRY OF THE CHURCH BY BRINGING IT NEW LIFE, ENERGY AND VIABILITY IN THE 21ST CENTURY. FIDELITY TO THE GOSPEL URGES US TO EMPHASIZE HUMAN DIGNITY AND SOCIAL JUSTICE AS WE MOVE TOWARD THE CREATION OF HEALTHIER COMMUNITIES. false false 22983590 22693 25953589 SEE SCHEDULE H. 22983590 true true false true false false false false false true true false false true true false true false false false false false false false false true true true false true false false false false false false false false false false false false false true false false false false true 0 0 289 true false false false false false false false false false false X 14 10 false false false false true true true true true false false false true true true true true true true false IA X Randall L Rubin 5156437860 1111 6th Avenue Des Moines IA 50314 X CLINTON CHRISTIANSON 40.00 X X 185897 0 28415 LEANNE DROBNICH 1.00 X X 0 258351 37370 ROBERT PONTIUS 1.00 X X 0 0 0 BILL BUSS 1.00 X 0 0 0 DAVID FRASER 40.00 X 258965 0 33155 DAVID HOWE 1.00 X 0 0 0 DR KATHLEEN LANGE 1.00 X 0 0 0 DR PAUL PONCY 1.00 X 0 0 0 JOSEPH LEVALLEY 1.00 X 0 316058 45582 MADELINE CUMMINS 1.00 X 0 0 0 MARLENE SPROUSE 1.00 X 0 0 0 MIKE CRAVER 1.00 X 0 0 0 SR CAMILLA VERRET RSM 1.00 X 0 0 0 SR JEANNE CHRISTENSEN RSM 1.00 X 0 0 0 LORI RATHBUN 40.00 X 104646 0 26362 ERICA COLLINS 40.00 X 223959 0 27863 JAMES MCCONVILLE 40.00 X 141702 0 16536 JEFFREY WILLIER 40.00 X 107383 0 26270 NANCY BARTON 40.00 X 145654 3364 36070 RICHARD J BURGER 40.00 X 128846 0 8450 1297052 577773 286073 9 false true false EMCARE PHYSICIAN SERVICES 7032 COLLECTION DRIVE CHICAGO IL 60693 PHYSICIAN SERVICES 1314796 NUCLEAR SONICS PO BOX 6 NEW RICHMOND WI 54017 PHYSICIAN SERVICES 159599 ALL ABOUT STAFFING 1000 SAWGRASS CORP PARKWAY SUNRISE FL 33323 MEDICAL SERVICES 149966 3 971819 63755 500 1036074 PATIENT SERVICES 900099 25621173 25621173 PROGRAM SERVICE REVENUE 900099 59216 59216 INCENTIVE PAYMENTS 900099 273200 273200 0 0 0 0 0 25953589 241038 284 240754 0 0 0 0 0 85283 85283 0 85283 85283 0 0 0 CAFETERIA 722100 56178 56178 REIMBURSEMENT OF EXPENSES 900099 66085 66085 MEALS ON WHEELS 624210 14486 14486 12682 0 0 12682 149431 27465415 25953589 284 475468 22693 22693 0 0 0 557002 238706 318296 0 9332795 9140275 192520 530448 504907 25541 1433981 1402661 31320 728728 694574 34154 0 0 0 0 0 0 2675210 2643029 32181 70718 17195 53523 1448512 1352122 96390 0 0 652333 652333 86612 65165 21447 0 5009 837 4172 61182 61182 0 651301 645982 5319 181580 181580 CHI IA MBO ASSESSMENT 882698 882698 MEDICAL SUPPLIES 2524214 2524214 BAD DEBTS 2069781 2069781 REPAIRS AND MAINTENANCE 618623 590909 27714 234184 175445 58739 0 24767604 22983590 1784014 0 0 783 783 1706715 2778796 3104812 4198247 367915 354101 176419 195268 16879397 12325020 4724723 4554377 10538085 10561899 0 0 0 0 20619452 22643471 1250424 1017247 1371197 1215884 2621621 2233131 X 17997831 20410340 17997831 20410340 20619452 22643471 X 2697811 -285302 X false true true X true true X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED false false false false false true 4080 false false false 4080 false Description of the activities reported on Lines 1a through 1i Schedule C, Part II-B, Line 1 $17,817 IN ANNUAL DUES WAS PAID TO THE IOWA HOSPITAL ASSOCIATION AND $4,080 WAS ALLOCATED AS LOBBYING EXPENSES. THE AMOUNT SHOWN IN LINE 1F REPRESENTS THE ENTITY'S SHARE OF ALLOCATED LOBBYING EXPENSES. 160349 160349 10779227 7629276 3149951 0 5617434 4402540 1214894 322387 293204 29183 4554377 0 0 CHI OIP - FIXED INCOME 5335791 CHI OIP - EQUITY SECURITIES 5226108 10561899 0 CHI DEBT PROGRAM 1215884 1215884 FIN 48 (ASC 740) footnote Schedule D, Part X, Line 2 MERCY MEDICAL CENTER - CENTERVILLE'S FINANCIAL INFORMATION IS INCLUDED IN THE CONSOLIDATED AUDITED FINANCIAL STATEMENTS OF CATHOLIC HEALTH INITIATIVES - IOWA, CORP DBA MERCY MEDICAL CENTER - DES MOINES (CHI-IOWA CORP). CHI-IOWA CORP'S FIN 48 (ASC 740) FOOTNOTE FOR THE YEAR ENDED JUNE 30, 2012 READS AS FOLLOWS: "THE CORPORATION AND ALL SUBSIDIARIES, EXCEPT MPA, AND DMMC ARE EXEMPT FROM FEDERAL INCOME TAXES UNDER SECTION 501(C)(3) OF THE CODE. ASC 740, INCOME TAXES, PRESCRIBES CRITERIA FOR THE FINANCIAL STATEMENT RECOGNITION AND MEASUREMENT OF A TAX POSITION TAKEN OR EXPECTED TO BE TAKEN IN A TAX RETURN. ASC 740 ALSO PROVIDES GUIDANCE ON DERECOGNITION, CLASSIFICATION, INTEREST AND PENALTIES, ACCOUNTING IN INTERIM PERIODS, DISCLOSURE, AND TRANSITION. MANAGEMENT HAS DETERMINED THAT THERE ARE NO MATERIAL UNCERTAIN TAX POSITIONS THAT HAVE NOT BEEN REFLECTED IN THE CONSOLIDATED FINANCIAL STATEMENTS. THE CORPORATION'S FEDERAL INCOME TAX RETURNS ARE OPEN TO EXAMINATION FOR THE YEARS ENDED JUNE 30, 2009 THROUGH JUNE 30, 2012." true true X false false true true false true true 0 155972 0 155972 0.00690 0 0 0 0 0.00000 0 0 0 0 0.00000 0 0 155972 0 155972 0.00690 13 7861 41654 0 41654 0.00180 4 222 7256 0 7256 0.00030 1 0 621 0 621 0.00000 0 0 0 0 0 0.00000 5 140 53204 0 53204 0.00230 23 8223 102735 0 102735 0.00440 23 8223 258707 0 258707 0.01130 0 0 0 0 0 0.00000 0 0 0 0 0 0.00000 1 6096 65981 15242 50739 0.00220 0 0 0 0 0 0.00000 0 0 0 0 0 0.00000 3 1861 0 1861 0.00010 0 0 0 0 0 0.00000 0 0 0 0 0 0.00000 1 340 0 340 0.00000 5 6096 68182 15242 52940 0.00230 true 2069781 0 9951675 9756611 195064 X true true 1 1 MERCY MEDICAL CENTER - CENTERVILLE

ONE ST JOSEPHS DRIVE CENTERVILLE IA 52544

X X X 1 MERCY CENTERVILLE LONGTERM CARE FACILITY

ONE ST JOSEPHS DRIVE CENTERVILLE IA 52544

NURSING HOME Eligibility criteria for free or discounted care Schedule H, Part I, Line 3c WHEN CATHOLIC HEALTH INITIATIVES (THE ULTIMATE PARENT ORGANIZATION TO MERCY MEDICAL CENTER - CENTERVILLE ESTABLISHED ITS FINANCIAL ASSISTANCE POLICY IT WAS DETERMINED THAT ESTABLISHING A HOUSEHOLD INCOME SCALE BASED ON THE HUD VERY LOW INCOME GUIDELINES MORE ACCURATELY REFLECTS THE SOCIOECONOMIC DISPERSIONS AMONG THE 69 URBAN AND RURAL COMMUNITIES IN 19 STATES SERVED BY CHI HOSPITALS AND HEALTH CARE FACILITIES. IN COMPARING HUD GUIDELINES TO THE FEDERAL POVERTY GUIDELINES ("FPG"), WE FIND THAT ON AVERAGE HUD GUIDELINES COMPUTE TO APPROXIMATELY 200% TO 250% (AND SOMETIMES 300%) OF FPG. MERCY MEDICAL CENTER - CENTERVILLE BASES ITS FINANCIAL ASSISTANCE ELIGIBILITY ON HUD'S 130% OF VERY LOW INCOME GUIDELINES BASED ON GEOGRAPHY, AND AFFORDS THE UNINSURED AND UNDERINSURED THE ABILITY TO OBTAIN FINANCIAL ASSISTANCE WRITE-OFFS, BASED ON A SLIDING SCALE, RANGING FROM 25%-100% OF CHARGES. AN INDIVIDUAL'S INCOME UNDER THE HUD GUIDELINES IS A SIGNIFICANT FACTOR IN DETERMINING ELIGIBILITY FOR FINANCIAL ASSISTANCE. HOWEVER, IN DETERMINING WHETHER TO EXTEND DISCOUNTED OR FREE CARE TO A PATIENT, THE PATIENT'S ASSETS MAY ALSO BE TAKEN INTO CONSIDERATION. FOR EXAMPLE, A PATIENT SUFFERING A CATASTROPHIC ILLNESS MAY HAVE A REASONABLE LEVEL OF INCOME, BUT A LOW LEVEL OF LIQUID ASSETS SUCH THAT THE PAYMENT OF MEDICAL BILLS WOULD BE SERIOUSLY DETRIMENTAL TO THE PATIENT'S BASIC FINANCIAL (AND ULTIMATELY PHYSICAL) WELL-BEING AND SURVIVAL. SUCH A PATIENT MAY BE EXTENDED DISCOUNTED OR FREE CARE BASED UPON THE FACTS AND CIRCUMSTANCES. Costing Methodology used to calculate financial assistance Schedule H, Part I, Line 7 PROVIDE AN EXPLANATION OF THE COSTING METHODOLOGY USED TO CALCULATE THE AMOUNTS REPORTED IN THE TABLE. IF A COST ACCOUNTING SYSTEM WAS USED, INDICATE WHETHER THE COST ACCOUNTING SYSTEM ADDRESSES ALL PATIENT SEGMENTS (FOR EXAMPLE, INPATIENT, OUTPATIENT, EMERGENCY ROOM, PRIVATE INSURANCE, MEDICAID, MEDICARE, UNINSURED OR SELF PAY). A COST ACCOUNTING SYSTEM WAS NOT USED TO COMPUTE AMOUNTS IN THE TABLE; RATHER COSTS IN THE TABLE WERE COMPUTED USING THE ORGANIZATION'S COST-TO-CHARGE RATIO. THE COST-TO-CHARGE RATIO COVERS ALL PATIENT SEGMENTS. ALSO INDICATE WHETHER A COST-TO-CHARGE RATIO WAS USED FOR ANY OF THE FIGURES REPORTED IN THE TABLE. DESCRIBE WHETHER THIS COST-TO-CHARGE RATIO WAS DERIVED FROM WORKSHEET 2, AND, IF NOT, WHAT KIND OF COST-TO-CHARGE RATIO WAS USED AND HOW IT WAS DERIVED. IF SOME OTHER COSTING METHODOLOGY WAS USED BESIDES A COST ACCOUNTING SYSTEM, COST-TO-CHARGE RATIO, OR A COMBINATION OF THE TWO, DESCRIBE THE METHOD USED. THE COST-TO-CHARGE RATIO FOR THE YEAR ENDED 6/30/12 WAS COMPUTED USING THE FOLLOWING FORMULA: OPERATING EXPENSE (BEFORE RESTRUCTURING, IMPAIRMENT AND OTHER LOSSES) DIVIDED BY GROSS PATIENT REVENUE. BASED ON THAT FORMULA, A 43.17% COST-TO-CHARGE RATIO RESULTS. WORKSHEET 2 WAS NOT USED TO DERIVE THE COST-TO-CHARGE RATIO. Bad Debt Expense excluded from financial assistance calculation Schedule H, Part I, Line 7, column(f) 2,069,781 Bad debt expense - financial statement footnote Schedule H, Part III, Line 4 THE COSTING METHODOLOGY FOR AMOUNTS REPORTED ON LINE 2 IS BASED ON THE SAME METHODOLOGY USED TO REPORT BAD DEBT EXPENSE IN THE ORGANIZATION'S CONSOLIDATED AUDITED FINANCIAL STATEMENTS. MERCY MEDICAL CENTER - CENTERVILLE DOES NOT BELIEVE THAT ANY PORTION OF BAD DEBT EXPENSE COULD REASONABLY BE ATTRIBUTED TO PATIENTS WHO QUALIFY FOR FINANCIAL ASSISTANCE SINCE AMOUNTS DUE FROM THOSE INDIVIDUALS' ACCOUNTS WILL BE RECLASSIFIED FROM BAD DEBT EXPENSE TO CHARITY CARE WITHIN 30 DAYS FOLLOWING THE DATE THAT THE PATIENT IS DETERMINED TO QUALIFY FOR CHARITY CARE. "THE PROVISION FOR BAD DEBTS IS BASED UPON MANAGEMENT'S ASSESSMENT OF HISTORICAL AND EXPECTED NET COLLECTIONS CONSIDERING HISTORICAL BUSINESS AND ECONOMIC CONDITIONS, TRENDS IN HEALTH CARE COVERAGE, AND OTHER COLLECTION INDICATORS. MANAGEMENT ROUTINELY ASSESSES THE ADEQUACY OF THE ALLOWANCES FOR UNCOLLECTIBLE ACCOUNTS BASED UPON HISTORICAL WRITE-OFF EXPERIENCE BY PAYOR CATEGORY. THE RESULTS OF THESE REVIEWS ARE USED TO MODIFY, AS NECESSARY, THE PROVISION FOR BAD DEBTS AND TO ESTABLISH APPROPRIATE ALLOWANCES FOR UNCOLLECTIBLE NET PATIENT ACCOUNTS RECEIVABLE. AFTER SATISFACTION OF AMOUNTS DUE FROM INSURANCE, THE CORPORATION FOLLOWS ESTABLISHED GUIDELINES FOR PLACING CERTAIN PATIENT BALANCES WITH COLLECTION AGENCIES, SUBJECT TO THE TERMS OF CERTAIN RESTRICTIONS ON COLLECTION EFFORTS AS DETERMINED BY THE CORPORATION." Community benefit & methodology for determining medicare costs Schedule H, Part III, Line 8 MERCY MEDICAL CENTER - CENTERVILLE IS DESIGNATED AS A CRITICAL ACCESS HOSPITAL ("CAH"). CAHS ARE RURAL COMMUNITY HOSPITALS THAT ARE CERTIFIED TO RECEIVE COST-BASED REIMBURSEMENT FROM MEDICARE. THE REIMBURSEMENT THAT CAHS RECEIVE IS INTENDED TO IMPROVE THEIR FINANCIAL PERFORMANCE AND THEREBY REDUCE HOSPITAL CLOSURES. CAHS ARE CERTIFIED UNDER A DIFFERENT SET OF MEDICARE CONDITIONS OF PARTICIPATION (COP). SHORTFALLS ARE CREATED WHEN A FACILITY RECEIVES PAYMENTS THAT ARE LESS THAN THE COSTS OF CARING FOR PROGRAM BENEFICIARIES. BECAUSE SHORTFALLS ARE BASED ON COSTS, NOT CHARGES, MERCY MEDICAL CENTER - CENTERVILLE, DUE TO THEIR DESIGNATION AS A CAH, RECEIVED COST-BASED REIMBURSEMENT FOR MEDICARE PURPOSES, MERCY MEDICAL CENTER - CENTERVILLE WILL NOT EXPERIENCE MEDICARE RELATED SHORTFALLS. ALTHOUGH NOT PRESENTED ON THE MEDICARE COST REPORT, IN ORDER TO FACILITATE A MORE ACCURATE UNDERSTANDING OF THE "TRUE" COST OF SERVICES (FOR "SHORTFALL" PURPOSES) THE CHI WORKBOOK ALLOWS A HEALTH CARE FACILITY NOT TO OFFSET COSTS THAT MEDICARE CONSIDERS TO BE NON-ALLOWABLE, BUT FOR WHICH THE FACILITY CAN LEGITIMATELY ARGUE ARE RELATED TO THE CARE OF THE FACILITY'S PATIENTS. IN ADDITION, ALTHOUGH NOT REPORTABLE ON THE MEDICARE COST REPORT, THE CHI WORKBOOK INCLUDES THE COST OF SERVICES THAT ARE PAID VIA A SET FEE-SCHEDULE RATHER THAN BEING REIMBURSED BASED ON COSTS (E.G. OUTPATIENT CLINICAL LABORATORY). FINALLY, THE CHI WORKBOOK ALLOWS A FACILITY TO INCLUDE OTHER HEALTH CARE SERVICES PERFORMED BY A SEPARATE FACILITY (SUCH AS A PHYSICIAN PRACTICE) THAT ARE MAINTAINED ON SEPARATE BOOKS AND RECORDS (AS OPPOSED TO THE MAIN FACILITY'S BOOKS AND RECORDS WHICH HAS ITS COSTS OF SERVICE INCLUDED WITHIN A COST REPORT). TRUE COSTS OF MEDICARE COMPUTED USING THIS METHODOLOGY: TOTAL MEDICARE REVENUE: $9,968,897 TOTAL MEDICARE COSTS: $9,789,834 SURPLUS: $179,063 MERCY MEDICAL CENTER - CENTERVILLE BELIEVES THAT EXCLUDING MEDICARE LOSSES FROM COMMUNITY BENEFIT MAKES THE OVERALL COMMUNITY BENEFIT REPORT MORE CREDIBLE FOR THESE REASONS: UNLIKE SUBSIDIZED AREAS SUCH AS BURN UNITS OR BEHAVIORAL-HEALTH SERVICES, MEDICARE IS NOT A DIFFERENTIATING FEATURE OF TAX-EXEMPT HEALTH CARE ORGANIZATIONS. IN FACT, FOR-PROFIT HOSPITALS FOCUS ON ATTRACTING PATIENTS WITH MEDICARE COVERAGE, ESPECIALLY IN THE CASE OF WELL-PAID SERVICES THAT INCLUDE CARDIAC AND ORTHOPEDICS. SIGNIFICANT EFFORT AND RESOURCES ARE DEVOTED TO ENSURING THAT HOSPITALS ARE REIMBURSED APPROPRIATELY BY THE MEDICARE PROGRAM. THE MEDICARE PAYMENT ADVISORY COMMISSION (MEDPAC), AN INDEPENDENT CONGRESSIONAL AGENCY, CAREFULLY STUDIES MEDICARE PAYMENT AND THE ACCESS TO CARE THAT MEDICARE BENEFICIARIES RECEIVE. THE COMMISSION RECOMMENDS PAYMENT ADJUSTMENTS TO CONGRESS ACCORDINGLY. THOUGH MEDICARE LOSSES ARE NOT INCLUDED BY CATHOLIC HOSPITALS AS COMMUNITY BENEFIT, THE CATHOLIC HEALTH ASSOCIATION GUIDELINES ALLOW HOSPITALS TO COUNT AS COMMUNITY BENEFIT SOME PROGRAMS THAT SPECIFICALLY SERVE THE MEDICARE POPULATION. FOR INSTANCE, IF HOSPITALS OPERATE PROGRAMS FOR PATIENTS WITH MEDICARE BENEFITS THAT RESPOND TO IDENTIFIED COMMUNITY NEEDS, GENERATE LOSSES FOR THE HOSPITAL, AND MEET OTHER CRITERIA, THESE PROGRAMS CAN BE INCLUDED IN THE CHA FRAMEWORK IN CATEGORY C AS "SUBSIDIZED HEALTH SERVICES." MEDICARE LOSSES ARE DIFFERENT FROM MEDICAID LOSSES, WHICH ARE COUNTED IN THE CHA COMMUNITY BENEFIT FRAMEWORK, BECAUSE MEDICAID REIMBURSEMENTS GENERALLY DO NOT RECEIVE THE LEVEL OF ATTENTION PAID TO MEDICARE REIMBURSEMENT. MEDICAID PAYMENT IS LARGELY DRIVEN BY WHAT STATES CAN AFFORD TO PAY, AND IS TYPICALLY SUBSTANTIALLY LESS THAN WHAT MEDICARE PAYS. Collection practices for patients eligible for financial assistance Schedule H, Part III, Line 9b MERCY MEDICAL CENTER - CENTERVILLE ALONG WITH ITS AFFILIATED OUTPATIENT FACILITIES ARE PART OF CATHOLIC HEALTH INITIATIVES "CHI". CHI HAS A WRITTEN POLICY (STEWARDSHIP POLICY NO. 16) GOVERNING THE PROCEDURES FOR COLLECTIONS OF PAST DUE ACCOUNTS. ALL HOSPITAL FACILITIES INCLUDED IN THE FILING ORGANIZATION HAVE ADOPTED THIS POLICY AND FOLLOW THESE PRACTICES WITH REGARDS TO COLLECTIONS: PROCEDURES CHI ENTITIES WILL FOLLOW STANDARD PROCEDURES IN COLLECTING SELF-PAY BALANCES AS FOLLOWS: PERMISSIBLE COLLECTIONS ACTIVITY EACH FACILITY MUST ADHERE TO THE FOLLOWING REQUIREMENTS IN RELATION TO THE PURSUIT OF SELF-PAY BALANCES: * FAIR PURSUIT. EACH FACILITY SHALL ENSURE THAT ALL PATIENT AND PATIENT GUARANTOR ACCOUNTS ARE PURSUED FAIRLY. * ETHICS AND INTEGRITY. EACH FACILITY SHALL ENSURE THAT ALL COLLECTION ACTIVITIES CONSISTENTLY REFLECT THE HIGHEST STANDARDS OF ETHICS AND INTEGRITY. * REASONABLE PAYMENT TERMS. EACH FACILITY SHALL OFFER REASONABLE PAYMENT SCHEDULES AND TERMS TO EACH PATIENT AND PATIENT GUARANTOR WITH SELF-PAY BALANCES. ALL COLLECTION ACTIVITIES CONDUCTED BY THE FACILITY OR ITS THIRD-PARTY COLLECTION AGENTS WILL BE IN CONFORMANCE WITH ALL FEDERAL AND STATE LAWS GOVERNING DEBT COLLECTION PRACTICES. COLLECTION ACTIVITY MAY BE IN THE FORM OF LETTERS, EMAILS, PHONE CALLS, AND/OR CREDIT REPORTING AND MAY ALSO INCLUDE WAGE GARNISHMENTS, PLACING OF LIENS ON BUILDINGS OR RESIDENCES OTHER THAN PERSONAL RESIDENCES, INITIATION OF LAWSUIT, AND/OR OTHER ACTIONS AS REQUIRED, EXCEPT AS PROHIBITED BY IMPERMISSIBLE COLLECTIONS ACTIONS BELOW. PRE-COLLECTIONS ACTIVITY * TIMING. GENERALLY, ACCOUNTS WILL NOT BE REFERRED TO COLLECTIONS UNTIL THEY ARE 120 DAYS OLD. HOWEVER, IN CIRCUMSTANCES WHERE INVOICES TO NON-MEDICARE PATIENTS ARE RETURNED UNDELIVERED WITH NO KNOWN ADDRESS, THOSE SELF-PAY BALANCES MAY BE REFERRED TO COLLECTIONS PRIOR TO EXPIRATION OF 120 DAYS. * LIMITATIONS - FINANCIAL ASSISTANCE ELIGIBILITY. THE FACILITY SHALL PERFORM A REASONABLE REVIEW OF EACH PATIENT ACCOUNT PRIOR TO TURNING AN ACCOUNT OVER TO A THIRD-PARTY COLLECTION AGENT AND PRIOR TO INSTITUTING ANY LEGAL ACTION FOR NON-PAYMENT (INCLUDING, BUT NOT LIMITED TO, REPORTING THE ACCOUNT TO A COLLECTION AGENCY) TO ENSURE THAT THE PATIENT AND PATIENT GUARANTOR ARE NOT ELIGIBLE FOR ANY ASSISTANCE PROGRAM (E.G., MEDICAID) AND DO NOT QUALIFY FOR COVERAGE THROUGH THE FACILITY'S FINANCIAL ASSISTANCE POLICY. THAT REASONABLE REVIEW WILL INCLUDE ONE OR MORE OF THE FOLLOWING: * NOTIFICATION TO PATIENT OF THE AVAILABILITY OF FINANCIAL ASSISTANCE ON ADMISSION, PRIOR TO DISCHARGE, AND/OR IN THE BILLING PROCESS; * REVIEW OF FINANCIAL ASSISTANCE APPLICATION SUBMITTED BY OR ON BEHALF OF THE PATIENT; OR * REVIEW OF THE PATIENT'S ELIGIBILITY USING PATIENT ACCOUNT STATISTICAL SCORING SOFTWARE. * COOPERATING EFFORTS. NO FACILITY SHALL SEND ANY UNPAID SELF-PAY ACCOUNT TO A THIRD-PARTY COLLECTION AGENT AS LONG AS THE PATIENT AND PATIENT GUARANTOR ARE COOPERATING WITH THE FACILITY IN EFFORTS TO SETTLE THE ACCOUNT BALANCE WITHIN A REASONABLE TIME FRAME (GENERALLY 18 MONTHS). * SUBSEQUENT ASSESSMENT. AFTER HAVING BEEN TURNED OVER TO A THIRD-PARTY COLLECTION AGENT, ANY ACCOUNT THAT SUBSEQUENTLY IS DETERMINED TO QUALIFY FOR FINANCIAL ASSISTANCE SHALL BE RETURNED IMMEDIATELY BY THE THIRD-PARTY COLLECTION AGENT TO THE FACILITY FOR APPROPRIATE FOLLOW-UP. CHI SHALL DIRECT ITS STAFF AND THIRD-PARTY COLLECTION AGENTS TO CONTINUALLY ASSESS EACH PATIENT AND PATIENT GUARANTOR'S ABILITY TO PAY OR TO BE DETERMINED ELIGIBLE FOR FINANCIAL ASSISTANCE. COLLECTIONS THE FACILITY MAY USE A THIRD-PARTY COLLECTION AGENT AS A REPRESENTATIVE, ACTING IN THE NAME OF THE FACILITY AND ENGAGED ON A CONTRACTUAL BASIS, FOR THE EXPRESS PURPOSES OF FOLLOWING-UP ON AND POTENTIALLY COLLECTING ANY PATIENT ACCOUNTS RECEIVABLE BALANCES. THE FACILITY SHALL CONTRACTUALLY DEFINE THE STANDARDS AND SCOPE OF PRACTICES TO BE USED BY THIRD-PARTY COLLECTION AGENTS. THOSE STANDARDS AND SCOPE OF PRACTICES SHALL BE CONSISTENT WITH THIS POLICY AND SHALL, AT A MINIMUM, INCLUDE THE FOLLOWING: * STATEMENT MESSAGE. THE FACILITY SHALL REQUIRE ITS THIRD-PARTY COLLECTION AGENTS TO INCLUDE A MESSAGE ON ALL STATEMENTS INDICATING THAT IF A PATIENT OR PATIENT GUARANTOR MEETS CERTAIN STIPULATED INCOME REQUIREMENTS, THE PATIENT OR PATIENT GUARANTOR MAY BE ELIGIBLE FOR FACILITY OR OTHER FINANCIAL ASSISTANCE PROGRAMS. * ADVANCE SETTLEMENT APPROVALS. THE FACILITY SHALL INSTRUCT ITS THIRD-PARTY COLLECTION AGENTS TO SEEK APPROVAL FROM THE AUTHORIZED AND DESIGNATED FACILITY STAFF MEMBER BEFORE ANY SETTLEMENT, AS A RESULT OF BANKRUPTCY PROCEEDINGS, SHALL BE ACCEPTED. * STANDARDS OF CONDUCT. THE FACILITY SHALL REQUIRE THAT THE THIRD-PARTY COLLECTION AGENTS CONDUCT THEMSELVES IN COMPLIANCE WITH THE HIGHEST STANDARDS OF BUSINESS ETHICS AND INTEGRITY AND APPLICABLE LEGAL REQUIREMENTS, AS REFLECTED IN THE CHI STANDARDS OF CONDUCT, AS MAY BE AMENDED BY CHI, AVAILABLE AT THE FOLLOWING WEBSITE: HTTP://WWW.CATHOLICHEALTHINITIATIVES.ORG/CORPORATERESPONSIBILITY. * PROHIBITED COLLECTIONS ACTIONS. THE FACILITY SHALL PROHIBIT THE THIRD-PARTY COLLECTION AGENTS FROM ENGAGING IN PROHIBITED COLLECTIONS ACTIONS AS DEFINED IN IMPERMISSIBLE COLLECTIONS ACTIONS BELOW. * ANNUAL ADHERENCE AUDIT. THE FACILITY OR ITS DESIGNEE SHALL BE PERMITTED TO AUDIT ITS THIRD-PARTY COLLECTION AGENTS AT LEAST ANNUALLY FOR ADHERENCE TO THESE STANDARDS. IMPERMISSIBLE COLLECTIONS ACTIONS CHI ENTITIES SHALL DIRECT THEIR STAFF AND THIRD-PARTY COLLECTION AGENTS THAT THE FOLLOWING ACTIONS ARE ALWAYS PROHIBITED IN RELATION TO THE PURSUIT OF SELF-PAY BALANCES. * UNEMPLOYED WITHOUT SIGNIFICANT INCOME/ASSETS. NO FACILITY SHALL PURSUE ANY LEGAL ACTION FOR NON-PAYMENT OF ANY BILLS AGAINST ANY PATIENT OR PATIENT GUARANTOR WHO IS KNOWN TO BE UNEMPLOYED AND WHO HAS BEEN DETERMINED IN ACCORDANCE WITH CHI STEWARDSHIP POLICY NO. 15, HOSPITAL FINANCIAL ASSISTANCE, ON THE BASIS OF A COMPLETED FINANCIAL ASSISTANCE APPLICATION, TO BE WITHOUT SIGNIFICANT INCOME OR ASSETS. * PRINCIPAL RESIDENCE. NO FACILITY SHALL PURSUE ANY LEGAL ACTION AGAINST ANY PATIENT OR PATIENT GUARANTOR BY SEEKING A REMEDY THAT WOULD INVOLVE FORECLOSING UPON THE PRINCIPLE RESIDENCE OF A PATIENT OR PATIENT GUARANTOR, PLACING A LIEN ON THE PRINCIPAL RESIDENCE, TAKING ANY OTHER ACTION THAT COULD RESULT IN THE INVOLUNTARY SALE OR TRANSFER OF SUCH RESIDENCE, OR INFORMING ANY PATIENT OR PATIENT GUARANTOR THAT HE/SHE MAY BE SUBJECT TO ANY SUCH ACTION. * OTHER IMPERMISSIBLE COLLECTION TACTICS. O NO FACILITY SHALL CHARGE INTEREST ON OUTSTANDING BALANCES; O NO FACILITY SHALL REQUIRE PATIENTS OR PATIENT GUARANTORS TO INCUR DEBT OR LOANS WITH RECOURSE TO THE PATIENT'S OR GUARANTOR'S PERSONAL OR REAL PROPERTY ASSETS ("RECOURSE INDEBTEDNESS"); AND O NO FACILITY SHALL INVOKE SO-CALLED "BODY ATTACHMENTS" (I.E., THE ARREST OR JAILING OF PATIENTS IN DEFAULT ON THEIR ACCOUNTS, SUCH AS FOR MISSED COURT APPEARANCES). IN ADDITION TO THE WRITTEN POLICY ALL OF CATHOLIC HEALTH INITIATIVES' HOSPITALS' CONTRACTS WITH THIRD PARTY COLLECTION AGENCIES INCLUDE THE FOLLOWING STANDARDS: * NEITHER CHI HOSPITALS NOR THEIR COLLECTION AGENCIES WILL REQUEST BENCH OR ARREST WARRANTS AS A RESULT OF NON-PAYMENT; * NEITHER CHI HOSPITALS NOR THEIR COLLECTION AGENCIES WILL SEEK LIENS THAT WOULD REQUIRE THE SALE OR FORECLOSURE OF A PRIMARY RESIDENCE; AND * NO CATHOLIC HEALTH INITIATIVES' COLLECTION AGENCY MAY SEEK COURT ACTION WITHOUT HOSPITAL APPROVAL. FINALLY, COLLECTION AGENCIES ARE TRAINED ON THE CATHOLIC HEALTH INITIATIVES MISSION, CORE VALUES AND STANDARD OF CONDUCT TO MAKE SURE ALL PATIENTS ARE TREATED WITH DIGNITY AND RESPECT. Used federal poverty guidelines (FPG) to determine eligibility Schedule H, Part V Section B, Line 9 (1) MERCY MEDICAL CENTER - CENTERVILLE - HUD LOW INCOME GUIDELINES USED; Used FPG to determine eligibility for providing discounted care criteria Schedule H, Part V Section B, Line 10 (1) MERCY MEDICAL CENTER - CENTERVILLE - HUD LOW INCOME GUIDELINES USED; Means used to determine amounts billed Schedule H, Part V Section B, Line 19d (1) MERCY MEDICAL CENTER - CENTERVILLE - THE HOSPITAL FACILITY USED THE AVERAGE OF THE NEGOTIATED COMMERCIAL INSURANCE RATES FOR THOSE SERVICES AT THE HOSPITAL FACILITY.; Charges for Medical Care Schedule H, Part V Section B, Line 20 (1) MERCY MEDICAL CENTER - CENTERVILLE - BECAUSE THE HOSPITAL FACILITY GIVES THE AVERAGE DISCOUNTED RATE, SOME PATIENTS PAY LOWER OR HIGHER RATES THAN THE INDIVIDUAL COMMERCIAL INSURANCE RATES.; Gross Charges for Medical Care Schedule H, Part V Section B, Line 21 (1) MERCY MEDICAL CENTER - CENTERVILLE - WE INITIALLY CHARGE PATIENTS THE FULL CHARGE FOR CARE AND THEN IF THEY FILL OUT AN APPLICATION WE DETERMINE WHETHER PATIENT QUALIFIES FOR CHARITY CARE, SELF PAY, OR A COMBINATION OF BOTH. AT A MINIMUM, WE WRITE OFF THE AMOUNT OF CHARGES DOWN TO THE LEVEL OF THE AVERAGE INSURANCE ALLOWED AMOUNT.; LINES 2, 4, 5 - NEEDS ASSESSMENT AND COMMUNITY INFORMATION SCHEDULE H, PART VI ORGANIZATION'S MISSION, VISION, AND TAX-EXEMPT PURPOSE: MERCY MEDICAL CENTER-CENTERVILLE IS A 25-BED CRITICAL ACCESS NOT-FOR-PROFIT CATHOLIC HOSPITAL LOCATED IN CENTERVILLE, IA. THE HOSPITAL IS INCLUDED IN THE OFFICIAL CATHOLIC DIRECTORY AS A TAX-EXEMPT HOSPITAL. THE MISSION OF THE HOSPITAL IS TO NURTURE THE HEALING MINISTRY OF THE CHURCH BY BRINGING IT NEW LIFE, ENERGY, AND VIABILITY IN THE 21ST CENTURY. THE MEDICAL FRATERNITY IN CENTERVILLE FOUNDED THE HOSPITAL AS THE CENTERVILLE HOSPITAL IN 1902. AT THE COMMUNITY'S REQUEST, MANAGEMENT AND OPERATIONS OF THE HOSPITAL WERE TAKEN OVER BY THE SISTERS OF MERCY IN 1910. SINCE THAT TIME, MERCY HAS CONTINUED TO REACH OUT TO PROVIDE EDUCATION, HEALTH CARE AND SERVICES IN OUR COMMUNITY. GUIDED BY OUR VALUES OF REVERENCE, INTEGRITY, COMPASSION, AND EXCELLENCE, WE HOLD OURSELVES TO A HIGH STANDARD OF GIVING TO THE POOR AND BROADER COMMUNITY. MERCY CENTERVILLE EMPLOYS 230 PEOPLE WITH A MEDICAL STAFF OF 9 FAMILY PRACTICE PHYSICIANS, 2 GENERAL SURGEONS, 1 OB-GYN, 1 INTERNAL MEDICINE, AND 1 PEDIATRICIAN. CONSULTING SPECIALTY CLINICS AT THE HOSPITAL ARE ALSO AVAILABLE IN THE AREAS OF PATHOLOGY, ALLERGY, UROLOGY, ORTHOPEDICS, NEUROLOGY, OTOLARYNGOLOGY, CARDIOLOGY, ONCOLOGY, PODIATRY, OPHTHALMOLOGY, VASCULAR SURGERY, PLASTIC SURGERY, DERMATOLOGY, NEPHROLOGY AND ORTHOPEDICS. JUST LIKE FIRE AND POLICE PROTECTION, THE HOSPITAL PROVIDES 24-HOUR EMERGENCY ROOM PHYSICIANS AND THE COUNTY'S ONLY AMBULANCE SERVICE. DIAGNOSTIC CAPABILITY INCLUDES X-RAY, ULTRASOUND, VASCULAR ULTRASOUND, CT SCAN, PET-CT SCAN, NUCLEAR MEDICINE, MRI, DIGITAL MAMMOGRAPHY AND BONE DENSITOMETRY. OTHER SERVICES INCLUDE PHYSICAL & OCCUPATIONAL THERAPY, RESPIRATORY THERAPY, OBSTETRICS, SURGERY, HOME CARE, HOSPICE, AMBULANCE, CARDIAC REHABILITATION, AND SOCIAL AND PASTORAL CARE PROGRAMS. THE HOSPITAL ALSO OPERATES A 20-BED LONG-TERM CARE FACILITY, DIALYSIS CENTER AND SLEEP LAB. THE HOSPITAL'S SERVICES ARE PROVIDED TO THE COMMUNITY ON A NON-DISCRIMINATORY BASIS AND INCLUDE AN EMERGENCY ROOM STAFFED 24/7 WITH EMERGENCY ROOM PHYSICIANS THAT IS OPEN TO ALL PERSONS REGARDLESS OF ABILITY TO PAY. THE HOSPITAL IS GOVERNED BY A BOARD IN WHICH INDEPENDENT PERSONS REPRESENTATIVE OF THE COMMUNITY COMPRISE THE MAJORITY. THE HOSPITAL PARTICIPATES IN GOVERNMENT-SPONSORED HEALTH CARE PROGRAMS LIKE MEDICAID AND MEDICARE. COMMUNITY BENEFIT APPROACH: MERCY MEDICAL CENTER HAS PROVIDED CENTERVILLE AND THE PEOPLE OF APPANOOSE COUNTY WITH MANY ONGOING COMMUNITY BENEFITS SINCE ITS BEGINNING. FOREMOST, AS A PRIVATE HOSPITAL, IT HAS SAVED THE COMMUNITY NEARLY ONE MILLION DOLLARS ANNUALLY IN PROPERTY TAXES COMPARED TO SURROUNDING COUNTIES WHO SUPPORT PUBLIC HOSPITALS. TRUE TO ITS MISSION, MERCY-CENTERVILLE HAS MADE A COMMITMENT TO IMPROVING THE HEALTH OF THE COMMUNITY BEFORE THEY BECOME ILL. THE HOSPITAL HAS FINANCIAL ASSISTANCE POLICIES AND PROGRAMS FOR LOW-INCOME PERSONS LIKE THE UNINSURED/UNDERINSURED PATIENT DISCOUNT POLICY AND THE SELF-PAY AND THIRD-PARTY DISCOUNTS POLICY. LINES 2, 4, 5 - NEEDS ASSESSMENT AND COMMUNITY INFORMATION (CONTINUED) SCHEDULE H, PART VI (CONTINUED) QUALITATIVE DESCRIPTION OF COMMUNITY BENEFIT: I. COMMUNITY OUTREACH FOR THE POOR SENIOR TRANSPORTATION: THE HOSPITAL SPONSORS A COMMUNITY BUS WHICH PROVIDES TRANSPORTATION TO MEDICAL APPOINTMENTS FOR THE ELDERLY AND THOSE WITH LOW INCOME WHO ARE UNABLE TO DRIVE OR HAVE NO ONE TO TRANSPORT THEM. THE BUS SERVED 880 RIDERS LAST YEAR. MEALS ON WHEELS: THE HOSPITAL PROVIDES MEAL PREPARATION AND DIETICIAN CONSULTANT SERVICE FOR THE COUNTY MEALS OF WHEELS PROGRAM. THIS PROGRAM SERVED 6,096 MEALS ON WHEELS TO THE POOR AND ELDERLY IN THE COMMUNITY. II. COMMUNITY OUTREACH FOR THE BROADER COMMUNITY DIABETES EDUCATION & SUPPORT GROUP: MERCY OFFERS A CERTIFIED DIABETES EDUCATION AND SUPPORT GROUP FROM PATIENTS WITH DIABETES AND THEIR SPOUSES. THIS PROGRAM OFFERS BOTH PRESENTATIONS FROM VARIOUS DISCIPLINES INVOLVED IN MANAGING DIABETES AS WELL AS DISCUSSION. 33 INDIVIDUALS TOOK PART IN THIS EDUCATION TO ASSIST THEM IN MANAGING THEIR DIABETES. DIABETES SCREENING: MERCY OFFERS DIABETES SCREENINGS TO THE COMMUNITY IN AN EFFORT TO IDENTIFY POTENTIAL DIABETICS OR THOSE WITH THE DISEASE WHO ARE UNAWARE THEY HAVE THE DISEASE TO PROVIDE INTERVENTIONS WITH THEIR PHYSICIAN. 57 PEOPLE WERE ASSISTED THROUGH THIS EFFORT. ALZHEIMER'S SUPPORT GROUP: MERCY HOLDS A MONTHLY ALZHEIMER'S SUPPORT GROUP TO MEET THE GROWING NEEDS OF THE ELDERLY FACING ALZHEIMER'S AND THOSE WHO ARE PROVIDING CARE TO THEM IN THE HOME. THE GROUP HAS BOTH A MORNING AND EVENING SESSION FOR THE CONVENIENCE OF CAREGIVERS. 96 PEOPLE BENEFITED FROM THE SERVICES OF THIS PROGRAM LAST YEAR. FALL ASSESSMENT SCREENING: THE PHYSICAL THERAPY DEPARTMENT OFFERED FREE FALL ASSESSMENTS FOR SENIOR CITIZENS. THE PURPOSE IS TO HELP COMMUNITY MEMBERS IDENTIFY THEIR RISK FOR FALLING AND TO PROVIDE THE RESOURCES AND EDUCATION TO HELP PREVENT FALLS/INJURIES. 25 PEOPLE PARTICIPATED IN THE ASSESSMENT. BLOOD PRESSURE CLINICS & HEALTH PROMOTION EDUCATION: THE HOSPITAL PROVIDED BLOOD PRESSURE AND GLUCOSE SCREENINGS TO THE COMMUNITY THROUGHOUT THE YEAR AND PROVIDED COMMUNITY EDUCATION ON HEART DISEASE AND DIABETES. 451 PEOPLE BENEFITTED FROM THESE HEALTH/WELLNESS PROGRAMS. INFECTION CONTROL TRAINING FOR COMMUNITY: THE HOSPITAL PROVIDED INFECTION CONTROL TRAINING FOR AREA BUSINESSES. THE UPDATE INCLUDED BASIC BLOODBORNE PATHOGENS AND EXPOSURE REPORTING FOR COMMUNITY BUSINESSES. PARTICIPANTS WERE ENGAGED TO UNDERSTAND HOW BLOOD BORNE PATHOGENS RELATE TO THEIR DUTIES IN EMERGENCIES THEY MAY ENCOUNTER. 81 PEOPLE PARTICIPATED IN THIS PROGRAM. INFECTION PREVENTION: THE HOSPITAL PROVIDED EDUCATION FOR ELEMENTARY STUDENTS ABOUT PREVENTING THE SPREAD OF GERMS. 75 CHILDREN BENEFITTED FROM THIS ACTIVITY. NARCOTICS ANONYMOUS: THE HOSPITAL PROVIDES FACILITIES ONCE A WEEK THROUGHOUT THE YEAR TO NARCOTICS ANONYMOUS, ALLOWING THE GROUP A SAFE AND CONFIDENTIAL ENVIRONMENT TO ASSIST AND SUPPORT THEIR RECOVERY. Patient education of eligibility for assistance. Schedule H, Part VI, Line 3 MERCY MEDICAL CENTER - CENTERVILLE INCLUDES INFORMATION CONCERNING ITS FINANCIAL ASSISTANCE POLICY ON ITS WEBSITE. IN ADDITION, MERCY MEDICAL CENTER - CENTERVILLE PROMINENTLY DISPLAYS ITS FINANCIAL ASSISTANCE POLICY IN BOTH ENGLISH AND SPANISH IN OBVIOUS LOCATIONS THROUGHOUT THE HOSPITALS, INCLUDING THE EMERGENCY ROOMS AND OTHER PATIENT INTAKE AREAS, AS WELL AS IN MERCY MEDICAL CENTER - CENTERVILLE OUTPATIENT FACILITIES. IN ADDITION, MERCY MEDICAL CENTER - CENTERVILLE REGISTRATION CLERKS ARE TRAINED TO PROVIDE CONSULTATION TO THOSE WHO HAVE NO INSURANCE OR POTENTIALLY INADEQUATE INSURANCE CONCERNING THEIR FINANCIAL OPTIONS INCLUDING APPLICATION FOR MEDICAID AND FOR FINANCIAL ASSISTANCE UNDER MERCY MEDICAL CENTER - CENTERVILLE'S FINANCIAL ASSISTANCE POLICY. UPON REGISTRATION (AND ONCE ALL EMTALA REQUIREMENTS ARE MET), PATIENTS WHO ARE IDENTIFIED AS UNINSURED (AND NOT COVERED BY MEDICARE OR MEDICAID) ARE PROVIDED WITH A PACKET OF INFORMATION THAT ADDRESSES THE FINANCIAL ASSISTANCE POLICY AND PROCEDURES INCLUDING AN APPLICATION FOR ASSISTANCE.MERCY MEDICAL CENTER - CENTERVILLE REGISTRATION CLERKS READ THE ORGANIZATION'S MEDICAL ASSISTANCE POLICY TO THOSE WHO APPEAR TO BE INCAPABLE OF READING, AND PROVIDE TRANSLATORS FOR NON ENGLISH-SPEAKING INDIVIDUALS. MERCY MEDICAL CENTER - CENTERVILLE'S STAFF WILL ALSO ASSIST THE PATIENT/GUARANTOR WITH APPLYING FOR OTHER AVAILABLE COVERAGE (SUCH AS MEDICAID), IF NECESSARY. COUNSELORS ASSIST MEDICARE ELIGIBLE PATIENTS IN ENROLLMENT BY PROVIDING REFERRALS TO THE APPROPRIATE GOVERNMENT AGENCIES. Affiliated health care system Schedule H, Part VI, Line 6 MERCY MEDICAL CENTER - CENTERVILLE, ALONG WITH ITS AFFILIATED OUTPATIENT FACILITIES ARE PART OF CATHOLIC HEALTH INITIATIVES. CATHOLIC HEALTH INITIATIVES (CHI) IS A NATIONAL FAITH-BASED NONPROFIT HEALTH CARE ORGANIZATION WITH HEADQUARTERS IN ENGLEWOOD, COLORADO. CHI'S EXEMPT PURPOSE IS TO SERVE AS AN INTEGRAL PART OF ITS NATIONAL SYSTEM OF HOSPITALS AND OTHER CHARITABLE ENTITIES, WHICH ARE DESCRIBED AS MARKET-BASED ORGANIZATIONS, OR MBOS. AN MBO IS A DIRECT PROVIDER OF CARE OR SERVICES WITHIN A DEFINED MARKET AREA THAT MAY BE AN INTEGRATED HEALTH SYSTEM AND/OR A STAND-ALONE HOSPITAL OR OTHER FACILITY OR SERVICE PROVIDER. CHI SERVES AS THE PARENT CORPORATION OF ITS MBOS WHICH ARE COMPRISED OF 73 HOSPITALS; 40 LONG-TERM CARE, ASSISTED- AND RESIDENTIAL-LIVING FACILITIES; TWO COMMUNITY HEALTH-SERVICES ORGANIZATIONS; TWO ACCREDITED NURSING COLLEGES; AND HOME HEALTH AGENCIES. TOGETHER, THESE FACILITIES PROVIDED $612 MILLION IN CHARITY CARE AND COMMUNITY BENEFIT IN THE 2011 FISCAL YEAR, INCLUDING SERVICES FOR THE POOR, FREE CLINICS, EDUCATION AND RESEARCH. CHI PROVIDES STRATEGIC PLANNING AND MANAGEMENT SERVICES AS WELL AS CENTRALIZED "SHARED SERVICES" FOR THE MBOS. THE PROVISION OF CENTRALIZED MANAGEMENT AND SHARED SERVICES - INCLUDING AREAS SUCH AS ACCOUNTING, HUMAN RESOURCES, PAYROLL AND SUPPLY CHAIN -- PROVIDES ECONOMIES OF SCALE AND PURCHASING POWER TO THE MBOS. THE COST SAVINGS ACHIEVED THROUGH CHI'S CENTRALIZATION ENABLE MBOS TO DEDICATE ADDITIONAL RESOURCES TO HIGH-QUALITY HEALTH CARE AND COMMUNITY OUTREACH SERVICES TO THE MOST VULNERABLE MEMBERS OF OUR SOCIETY. MERCY MEDICAL CENTER - CENTERVILLE OPERATES TO SERVE THE HEALTH CARE NEEDS OF THE CENTERVILLE, IA AND SURROUNDING APPANOOSE COUNTY COMMUNITIES. State filing of community benefit report Schedule H, Part VI, Line 7 IA true RATHBUN LAKE AREA YMCA 708 S MAIN ST CENTERVILLE IA 52544 262927214 501(C)(3) 10500 COMMUNITY SUPPORT 1 0 Procedures for monitoring use of grant funds Schedule I, Part I, Line 2 ALL OF OUR GRANTS ARE MADE TO 501(C)(3) ORGANIZATIONS TO ENSURE THE GRANTS ARE USED FOR CHARITABLE PURPOSES. X X X X false false false false false false false true false CLINTON CHRISTIANSON 166116 0 0 0 19781 0 16015 0 12400 0 214312 0 0 0 DAVID FRASER 229899 0 26921 0 2145 0 20228 0 12927 0 292120 0 0 0 ERICA COLLINS 222802 0 50 0 1107 0 20483 0 7380 0 251822 0 0 0 JAMES MCCONVILLE 135258 0 4535 0 1909 0 9836 0 6700 0 158238 0 0 0 JOSEPH LEVALLEY 0 284349 0 0 0 31709 0 25128 0 20454 0 361640 0 0 LEANNE DROBNICH 0 226215 0 0 0 32136 0 29990 0 7380 0 295721 0 0 NANCY BARTON 138616 0 3381 1939 3657 1425 17487 0 18583 0 181724 3364 0 0 SEVERANCE PAYMENTS SCHEDULE J, PART I, LINE 4A POST-TERMINATION PAYMENTS ARE ADDRESSED IN EXECUTIVE EMPLOYMENT AGREEMENTS FOR CATHOLIC HEALTH INITIATIVES ("CHI") AND RELATED ORGANIZATIONS' EMPLOYEES AT THE LEVEL OF VICE PRESIDENT AND ABOVE, INCLUDING THE MBO CEOS. THESE EMPLOYMENT AGREEMENTS REQUIRE THAT IN ORDER FOR THE EXECUTIVE TO RECEIVE POST-TERMINATION PAYMENTS, THESE INDIVIDUALS MUST EXECUTE A GENERAL RELEASE AND SETTLEMENT AGREEMENT. POST-TERMINATION PAYMENT ARRANGEMENTS ARE PERIODICALLY REVIEWED FOR OVERALL REASONABLENESS IN LIGHT OF THE EXECUTIVE'S OVERALL COMPENSATION PACKAGE. NO REPORTABLE INDIVIDUALS RECEIVED SEVERANCE PAYMENTS DURING THE 2011 CALENDAR YEAR. SUPPLEMENTAL NON-QUALIFIED RETIREMENT PLAN SCHEDULE J, PART I, LINE 4B DURING THE 2011 CALENDAR YEAR CATHOLIC HEALTH INITIATIVES ("CHI"), A RELATED ORGANIZATION, MAINTAINED A SUPPLEMENTAL NON-QUALIFIED DEFERRED COMPENSATION PLAN FOR MBO CEOS AND OTHER CHI EMPLOYEES AT THE LEVEL OF SENIOR VICE PRESIDENT AND ABOVE. NO INDIVIDUALS WERE ELGIBLE TO PARTICIPATE FOR 2011. Non-fixed payments Schedule J, Part I, Line 7 THE ORGANIZATION MAINTAINS A VARIABLE PAY PROGRAM FOR CERTAIN ELIGIBLE EMPLOYEES THAT PUTS A PORTION OF COMPENSATION AT RISK. AWARDS OF INCENTIVE COMPENSATION ARE MADE BASED UPON THE ACHIEVEMENT OF ORGANIZATIONAL OBJECTIVES. Delegate broad authority to a committee Form 990, Part VI, Section A, Line 1a THE EXECUTIVE COMMITTEE CONSISTS ONLY OF DIRECTORS OF THE ORGANIZATION AND IS COMPOSED OF THE CHAIRPERSON OF THE BOARD, THE VICE CHAIRPERSON OF THE BOARD, AND THE PRESIDENT AND CHIEF EXECUTIVE OFFICER, EACH OF WHOM SERVE AS EX OFFICIO VOTING MEMBERS OF THE EXECUTIVE COMMITTEE, AND ANY ADDITIONAL VOTING MEMBERS APPOINTED BY THE BOARD OF DIRECTORS. THE EXECUTIVE COMMITTEE HAS THE POWER TO TRANSACT THE ROUTINE BUSINESS OF THE CORPORATION IN THE INTERIM PERIODS BETWEEN REGULARLY SCHEDULED MEETINGS OF THE BOARD OF DIRECTORS, PROVIDED THAT THEIR ACTIONS ARE CONSISTENT WITH ANY ACTIONS OR POLICIES OF THE BOARD OR THE CORPORATE MEMBER. ALL ACTIONS TAKEN ARE CONTEMPORANEOUSLY DOCUMENTED AND REPORTED TO THE BOARD AT THE EARLIEST MEETING. Classes of members or stockholders Form 990, Part VI, Section A, Line 6 THE ENTITY'S SOLE CORPORATE MEMBER IS CATHOLIC HEALTH INITIATIVES - IOWA, CORP D/B/A MERCY MEDICAL CENTER - DES MOINES, AN IOWA NONPROFIT CORPORATION. Members or stockholders electing members of governing body Form 990, Part VI, Section A, Line 7a THE SOLE CORPORATE MEMBER HAS THE RIGHT TO APPROVE AND REMOVE WITH OR WITHOUT CAUSE THE MEMBERS OF THE GOVERNING BOARD. Decisions requiring approval by members or stockholders Form 990, Part VI, Section A, Line 7b THE ORGANIZATION'S CORPORATE MEMBER IS CATHOLIC HEALTH INITIATIVES - IOWA, CORP D/B/A MERCY MEDICAL CENTER - DES MOINES, AN IOWA NONPROFIT CORPORATION. PURSUANT TO SECTION 5.4 OF THE ORGANIZATION'S BYLAWS, BOTH CATHOLIC HEALTH INITIATIVES - IOWA, CORP AND CATHOLIC HEALTH INITIATIVES ("CHI") (CATHOLIC HEALTH INITIATIVES - IOWA, CORP'S SOLE CORPORATE MEMBER) HAVE RESERVED POWERS AS OUTLINED IN THE CHI GOVERNANCE MATRIX. PURSUANT TO THE GOVERNANCE MATRIX THE FOLLOWING RIGHTS ARE HELD BY CATHOLIC HEALTH INITIATIVES - IOWA, CORP: *APPROVE MEMBERS OF THE MERCY MEDICAL CENTER - CENTERVILLE BOARD; *AMENDMENT OF THE CORPORATE DOCUMENTS OF MERCY MEDICAL CENTER - CENTERVILLE; *APPROVE REMOVAL OF A MEMBER OF THE GOVERNING BODY OF MERCY MEDICAL CENTER - CENTERVILLE; *ADOPTION OF LONG RANGE AND STRATEGIC PLANS FOR MERCY MEDICAL CENTER - CENTERVILLE; THE FOLLOWING RIGHTS ARE RESERVED TO THE CHI BOARD DIRECTLY OR THROUGH POWERS DELEGATED TO THE CHI CHIEF EXECUTIVE OFFICER: *SUBSTANTIAL CHANGE IN THE MISSION OR PHILOSOPHY OF MERCY MEDICAL CENTER - CENTERVILLE; *REMOVAL OF A MEMBER OF THE GOVERNING BODY OF MERCY MEDICAL CENTER - CENTERVILLE; *APPROVAL OF ISSUANCE OF DEBT BY MERCY MEDICAL CENTER - CENTERVILLE; *APPROVAL OF PARTICIPATION OF MERCY MEDICAL CENTER - CENTERVILLE IN A JOINT VENTURE; *APPROVAL OF FORMATION OF A NEW CORPORATION BY MERCY MEDICAL CENTER - CENTERVILLE; *APPROVAL OF A MERGER INVOLVING MERCY MEDICAL CENTER - CENTERVILLE; *APPROVAL OF THE SALE OF ALL OR SUBSTANTIALLY ALL OF THE ASSETS OF MERCY MEDICAL CENTER - CENTERVILLE; *TO REQUIRE THE TRANSFER OF ASSETS BY MERCY MEDICAL CENTER - CENTERVILLE TO CHI TO ACCOMPLISH CHI'S GOALS AND OBJECTIVES, AND TO SATISFY CHI DEBTS. PURSUANT TO SECTION 5.5 OF THE ORGANIZATION'S BYLAWS, CATHOLIC HEALTH INITIATIVES - IOWA, CORP OR CHI MAY, IN EXERCISE OF THEIR APPROVAL POWERS, GRANT OR WITHHOLD APPROVAL IN WHOLE OR IN PART, OR MAY, IN ITS COMPLETE DISCRETION, AFTER CONSULTATION WITH THE BOARD AND ITS PRESIDENT AND THE CHIEF EXECUTIVE OFFICER OF THE ORGANIZATION, RECOMMEND SUCH OTHER OR DIFFERENT ACTIONS AS IT DEEMS APPROPRIATE. Review of form 990 by governing body Form 990, Part VI, Section B, Line 11b THE ORGANIZATION'S ACCOUNTING PERSONNEL WORK WITH THE CHI TAX DEPARTMENT PERSONNEL TO PREPARE THE FORM 990. WHEN AVAILABLE, THE CFO REVIEWS THE RETURN AND ANY NECESSARY REVISIONS ARE INCLUDED IN THE FINAL VERSION WHICH IS APPROVED FOR FILING WITH THE IRS. SUBSEQUENT TO REVIEW BY THE CHIEF FINANCIAL OFFICER, THE TAX DEPARTMENT FILES THE RETURN WITH THE APPROPRIATE FEDERAL AND STATE AGENCIES, MAKING ANY NON-SUBSTANTIVE CHANGES NECESSARY TO EFFECT E-FILING. SUBSEQUENT TO E-FILING, THE FINAL E-FILED FORM 990 IS PRESENTED TO THE BOARD AT A REGULARLY SCHEDULED BOARD MEETING. Conflict of interest policy Form 990, Part VI, Section B, Line 12c ALL BOARD MEMBERS ARE REQUIRED TO COMPLETE AN ANNUAL CONFLICT OF INTEREST DISCLOSURE STATEMENT. IN ADDITION, ANY BOARD MEMBER WITH A CONFLICT IS REQUIRED TO DECLARE THE CONFLICT BEFORE THE BEGINNING OF EACH BOARD OR COMMITTEE MEETING. THE ENTIRE BOARD OR COMMITTEE DETERMINES WHETHER THE AFFECTED BOARD MEMBER SHOULD BE EXCLUDED FROM THE MEETING DUE TO THE DISCLOSED CONFLICT. Process used to establish compensation of top management official Form 990, Part VI, Section B, Line 15a THE ORGANIZATION USES A THIRD-PARTY CONSULTANT TO SURVEY COMPENSATION TRENDS ANNUALLY AND TO RECOMMEND A COMPENSATION RANGE FOR THE CEO. THIS RECOMMENDATION IS PRESENTED TO THE BOARD FOR FINAL DETERMINATION AND APPROVAL. THE SALARIES ARE COMPARED TO INDUSTRY STANDARDS AND GUIDELINES FOR APPROPRIATENESS. THIS PROCESS WAS LAST UNDERTAKEN IN THE FISCAL YEAR ENDED JUNE 30, 2012. Process used to establish compensation of other officers/key employees Form 990, Part VI, Section B, Line 15b THE ORGANIZATION USES A THIRD-PARTY CONSULTANT TO SURVEY COMPENSATION TRENDS ANNUALLY AND TO RECOMMEND COMPENSATION RANGES FOR THE OTHER OFFICERS AND KEY EMPLOYEES. THESE RECOMMENDATIONS ARE PRESENTED TO THE BOARD FOR FINAL DETERMINATION AND APPROVAL. THE SALARIES ARE COMPARED TO INDUSTRY STANDARDS AND GUIDELINES FOR APPROPRIATENESS. THIS PROCESS WAS LAST UNDERTAKEN IN THE FISCAL YEAR ENDED JUNE 30, 2012. Governing documents, conflict of interest policy and financial statements available to the public Form 990, Part VI, Section C, Line 19 THE ORGANIZATION'S FINANCIAL STATEMENTS ARE INCLUDED IN CATHOLIC HEALTH INITIATIVES CONSOLIDATED AUDITED FINANCIAL STATEMENTS THAT ARE AVAILABLE AT WWW.CATHOLICHEALTHINIT.ORG OR AT WWW.DACBOND.COM. THE ORGANIZATION'S GOVERNING DOCUMENTS ARE AVAILABLE ON THE IOWA SECRETARY OF STATE'S WEBSITE. THE CONFLICT OF INTEREST POLICY IS NOT PUBLICLY AVAILABLE. HOURS DEVOTED TO RELATED ORGANIZATIONS FORM 990, PART VII, SECTION A COMPENSATION REPORTED ON FORM 990, PART VII WAS PAID TO THESE INDIVIDUALS BY RELATED ORGANIZATIONS IN EXCHANGE FOR THE FULFILLMENT OF THEIR DUTIES AS FULL-TIME, 40 HOUR-PER-WEEK EMPLOYEES. Other changes in net assets or fund balances Form 990, Part XI, Line 5 NET UNREALIZED GAINS (LOSSES) ON INVESTMENTS - -285302; ALEGENT HEALTH - BERGAN MERCY HEALTH SYS 7500 MERCY ROAD OMAHA NE 68124 470484764 HEALTHCARE NE 501(C)(3) 3 CHI true ALEGENT HEALTH - MERCY HOSPITAL CORNING IOWA PO BOX 368 CORNING IA 50841 420782518 HEALTHCARE IA 501(C)(3) 3 AHBMHS true ALVERNA APARTMENTS 300 SE 8TH AVENUE LITTLE FALLS MN 56345 411351177 LTERM CARE MN 501(C)(3) 9 CHI true APPLETREE COURT 601 OAK STREET BRECKENRIDGE MN 56520 411850500 SENIOR HOMES MN 501(C)(3) 9 SFH true BISHOP DRUMM RETIREMENT CENTER 1111 6TH AVENUE DES MOINES IA 50314 420725196 LTERM CARE IA 501(C)(3) 9 CHI-IA CORP true BORNEMANN HEALTHCARE CORPORATION 2500 BERNVILLE RD PO BOX 316 READING PA 19603 232187242 HEALTHCARE PA 501(C)(3) 11 - Type I CHI true CARRINGTON HEALTH CENTER 800 NORTH 4TH STREET CARRINGTON ND 58421 450227311 HEALTHCARE ND 501(C)(3) 3 CHI true CATHOLIC HEALTH INITIATIVES 198 INVERNESS DRIVE WEST ENGLEWOOD CO 80112 470617373 HEALTHCARE CO 501(C)(3) 9 NA true CATHOLIC HEALTH INITIATIVES COLORADO FOUNDATION 6385 CORPORATE DRIVE COLORADO SPRINGS CO 80919 840902211 FUNDRAISING CO 501(C)(3) 7 CHIC true CATHOLIC HEALTH INITIATIVES INSTITUTE FOR RESEARCH AND INNOVATION 198 INVERNESS DRIVE WEST ENGLEWOOD CO 80112 271050565 HEALTHCARE CO 501(C)(3) 11 - Type I CHI true CATHOLIC HEALTH INITIATIVES NATIONAL FOUNDATION 6385 CORPORATE DRIVE COLORADO SPRINGS CO 80919 270930004 FUNDRAISING CO 501(C)(3) 9 CHI true CATHOLIC HEALTH INITIATIVES-COLORADO 188 INVERNESS DRIVE WEST ENGLEWOOD CO 80112 840405257 HEALTHCARE CO 501(C)(3) 3 CHI true CENTENNIAL MEDICAL GROUP INC 2700 STEWART PARKWAY ROSEBURG OR 97470 263946191 PHYSICIANS OR 501(C)(3) 9 MMC true CENTRAL KANSAS MEDICAL CENTER 3515 BROADWAY GREAT BEND KS 67530 480543724 SURGERY CNTR KS 501(C)(3) 3 CHI true CHI HEALTH CONNECT AT HOME - FARGO 4816 AMBER VALLEY PARKWAY FARGO ND 58104 271966847 HEALTHCARE ND 501(C)(3) 3 CHI true CHI KENTUCKY INC 3900 OLYMPIC BLVD SUITE 400 ERLANGER KY 41018 202741651 HEALTHCARE KY 501(C)(3) 11 - Type I CHI true CHI NATIONAL HOME CARE 198 INVERNESS DRIVE WEST ENGLEWOOD CO 80112 451261716 HEALTHCARE CO 501(C)(3) 11 - Type I CHI NS true CHI NATIONAL SERVICES 198 INVERNESS DRIVE WEST ENGLEWOOD CO 80112 452532084 HEALTHCARE CO 501(C)(3) 9 CHI true CHI NEBRASKA 6940 O STREET SUITE 200 LINCOLN NE 68510 363233121 HEALTHCARE NE 501(C)(3) 11 - Type I CHI true CONTINUING CARE HOSPITAL 150 NORTH EAGLE CREEK DRIVE LEXINGTON KY 40509 611400619 LTACH KY 501(C)(3) 3 SJHS true COVENANT HOME CARE 1223 POTTSVILLE PIKE SHOEMAKERSVILLE PA 19555 232018429 HOME HEALTH PA 501(C)(3) 11 - Type II NA true ENUMCLAW REGIONAL HOSPITAL ASSOCIATION 1450 BATTERSBY AVENUE ENUMCLAW WA 98022 910715805 HEALTHCARE WA 501(C)(3) 3 FHS true FLAGET HEALTHCARE DBA FLAGET MEMORIAL HOSPITAL 4305 NEW SHEPHERDSVILLE ROAD BARDSTOWN KY 40004 611345363 HEALTHCARE KY 501(C)(3) 3 KOH true FLAGET MEMORIAL HOSPITAL FOUNDATION INC 4305 NEW SHEPHERDSVILLE ROAD BARDSTOWN KY 40004 562351341 FUNDRAISING KY 501(C)(3) 11 - Type I FH true FRANCISCAN FOUNDATION 1717 SOUTH J STREET TACOMA WA 98405 911145592 FUNDRAISING WA 501(C)(3) 9 FHS true FRANCISCAN HEALTH SYSTEM FKA FRANCISCAN HEALTH SYSTEM WEST 1717 SOUTH J STREET TACOMA WA 98405 910564491 HEALTHCARE WA 501(C)(3) 3 CHI true FRANCISCAN MEDICAL GROUP 1708 SOUTH YAKIMA AVENUE TACOMA WA 98405 911939739 HEALTHCARE WA 501(C)(3) 9 FHS true FRANCISCAN VILLA OF SOUTH MILWAUKEE INC 3601 SOUTH CHICAGO AVENUE SOUTH MILWAUKEE WI 53172 391093829 HEALTHCARE WI 501(C)(3) 9 CHI true GETTYSBURG MEDICAL CENTER 606 EAST GARFIELD AVENUE GETTYSBURG SD 57442 460234354 HEALTHCARE SD 501(C)(3) 3 SMHC true GLOBAL HEALTH INITIATIVES 198 INVERNESS DRIVE WEST ENGLEWOOD CO 80112 201536108 MINISTRIES CO 501(C)(3) 11 - 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