2011-03-14T14:13:11-05:00 2010-07-31 EIDE BAILLY LLP 3999 PENNSYLVANIA AVE SUITE 100 DUBUQUE IA 52002 990 2009-08-01 370645239 CARLINVILLE AREA HOSPITAL ASSOCIATION CARL 2178543141 20733 NORTH BROAD STREET CARLINVILLE IL 62626 KENNETH REID 2178543141 2011-03-08 1 CARMEN KRANTZ 5635561790 2009 2016-02-24 21:20:13Z X KENNETH REID 20733 NORTH BROAD STREET CARLINVILLE IL 62626 20173028 0 X WWW.CAHCARE.COM X 1947 IL Provide quality acute and preventative health care benefits 7 7 187 7 0 0 1698870 5169276 13796047 14891049 42051 53184 44491 58376 15581459 20171885 250 0 6562306 7201608 0 0 6317455 7051117 12879761 14252975 2701698 5918910 10836622 36167440 5035212 24415448 5801410 11751992 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 0 11458003 250 14891049 During fiscal year 2010, we carried out our exempt purpose in the following ways: 1) Provided quality short term acute care medical services to 478 inpatients, of which 81% 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 158 patients in our swing bed unit, with an average length of stay of 8.2 days. 3) Provided 24 hour a day emergency room services. Our emergency room treated 5,871 patients during fiscal year 2010. 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 residency of 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 18,189 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 5,906 visits to their specialty clinics. These clinics bring specialist from metropolitan areas to Carlinville on a rotating basis. This provides access to specialty services not otherwise offered in the area. 6) The hospital board maintains a charity care policy which provides free or discounted care for all qualified patients. In 2010 the amount of charges foregone totaled $293,511. 7) In treating all patients, regardless of their ability to pay the hospital discounted its services a total of 51%.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 amount of charges foregone were $293,511 for the year ended July 31, 2010. The estimated costs of the charges foregone, based on an overall cost-to-charge ratio calculation was $126,000. 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. 11458003 1 1 0 0 0 0 0 0 1 1 1 1 0 0 0 0 0 0 0 0 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 33 0 1 187 1 0 0 0 0 0 0 0 0 0 7 7 1 1 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 IL X BRIAN ENGELKE 2178543851 20733 NORTH BROAD STREET CARLINVILLE IL 62626 J Richard Schien 1.00 X X 0 0 0 James Salske 1.00 X X 0 0 0 Shirley Boente 1.00 X X 0 0 0 Philip Williams 1.00 X X 0 0 0 Steve Gourley 0.50 X 0 0 0 Ralph March 0.50 X 0 0 0 Richard Walden 0.50 X 0 0 0 Kenneth Reid 40.00 X 180345 0 12624 Greg Ward 40.00 X 122846 0 8599 Jon Andersen MD 40.00 X 272645 0 17611 Curtis Cravens 40.00 X 188639 0 15091 764475 0 53925 4 0 1 1 Acute Care 1609 N Ankeny Blvd Ste 200 Ankeny IA 50021 Emergency room physicians 569869 Illinois Emergency Physicians 4075 Copper Ridge Drive Traverse City MI 496840793 Emergency room physicians 547175 Brim Healthcare Inc PO Box 636426 Cincinnati OH 452636426 Management services 482316 Alberici Constructors 800 Page Avenue St Louis MO 631146106 Construction 163191 CPSI 6600 Wall St Mobile AL 36695 Information technology services 129339 9 5086304 54696 28276 5169276 Net Patient service re 622110 14394802 14394802 Clinic revenue 621110 420866 420866 Other supporting reven 900099 75381 75381 14891049 54327 54327 58376 58376 58376 58376 1143 -1143 -1143 -1143 20171885 14891049 0 111560 250 250 317989 317989 5603135 4604057 999078 182307 149807 32500 692977 569421 123556 405200 332937 72263 307271 307271 22593 22593 56870 56870 2411643 2277688 133955 84111 84111 2242920 1811530 431390 168067 153983 14084 12471 6872 5599 61154 21082 40072 7384 7384 372077 372077 140427 591 139836 Bad Debt Expense 1141666 1141666 Miscellaneous Expense 22463 8658 13805 14252975 11458003 2794972 0 1832074 4769595 1372652 1922228 43168 172535 193250 93485 165548 35437916 7251129 6807814 28186787 80000 348714 434894 581318 10836622 36167440 797696 2001815 4448 129112 3478948 17610145 754120 4674376 5035212 24415448 X 5308572 8551780 2675702 492838 524510 5801410 11751992 10836622 36167440 X 0 1 1 X 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 492838 31672 524510 570417 -77579 492838 0.00000 1.00000 0.00000 1 0 602527 602527 3925398 3484937 440461 4534825 3407711 1127114 26375166 358481 26016685 28186787 Employee health claims 111553 Capitalized lease obligation 179514 Construction accounts payable 4383309 4674376 20171885 14252975 5918910 31672 31672 5950582 15085581 0 15085581 5086304 5086304 20171885 14252975 0 14252975 0 14252975 Part V, Line 4: Description of Intended Use of Endowment Funds: $80,000 is in the possession of the organization for hospice care. $444,510 is a beneficial interest in a trust not in the possession of the organization and represents contributions received, which are permanently restricted. Part X: Description of Uncertain Tax Positions Under FIN 48: The Hospital has adopted the provisions of FASB Accounting Standards Codification Topic ASC 740-10 (previously Financial Interpretation No. 48, Accounting for the Uncertainty in Income Taxes) on August 1, 2009. The implementation of this standard had no impact on the financial statements. As of both the date of adoption, and as of July 31, 2010, the unrecognized tax benefit accrual was zero. The Hospital will recognize future accrued interest and penalties related to unrecognized tax benefits in income tax expense if incurred. The Hospital is no longer subject to Federal or state tax examinations by tax authorities for years before 2006. Part XI, Line 8 - Other Adjustments: Change in beneficial interest in perpetual trust: 31672. Part XII, Line 4b - Other Adjustments: Foundation transfer recorded in fund balance per financial statements: 2675702. Foundation transfer recorded as contribution on Form 990: 2410602. 1 1 X 1 X 1 X 1 1 1 0 1 1 126000 126000 0.00960 1539332 1220188 319144 0.02430 1665332 1220188 445144 0.03390 4 87 1000 1000 0.00010 2321378 2048955 272423 0.02080 250 250 0.00000 4 87 2322628 2048955 273673 0.02090 4 87 3987960 3269143 718817 0.05480 2 150 138 138 0.00000 1 13458 13458 0.00100 3 150 13596 13596 0.00100 0 439253 4305 6213019 6148751 64268 X 1 1 Carlinville Area Hospital Association

20733 North Broad Street Carlinville IL 62626

X X X X Part I, Line 7: Charity care expense was reported at cost on line 7a based on an overall cost-to-charge ratio which addresses all patient segments. Unreimbursed Medicaid on line 7b was calculated using the costing methods to prepare the cost reports. Community health improvement services and cash and in-kind contributions to community groups, lines 7e and 7i, are reported based on actual expenses recorded in the organization's general ledger. The cost for subsidized health services on line 7g was determined using the Medicare cost report.Total community benefit expense as a percentage of total expenses is 28%. Part I, Line 7g: The organization did not include any costs attributable to a physician clinic in subsidized health services. Part I, Line 7f: The amount of bad debt expense removed from total expenses to determine the percentage was $1,141,666. Part III, Line 4: The organization's bad debt expense was converted to cost using the cost-to-charge ratio derived from Worksheet 2. The bad debt expense does not include charity care write offs. Patients that are eligible for charity care are written off as a reduction in revenue. 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. Carlinville Community Hospital does not refuse services to patients that generate bad debt.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 charity care to gross charges.Financial Statement Footnote: The carrying amount of patient receivables is reduced by a valuation allowance that reflects management's estimate of amounts that will not be collected from patients and third-party payors. Management reviews patient receivables by payor class and applies percentages to determine estimated amounts that will not be collected from third parties under contractual agreements and amounts that will not be collected from patients due to bad debts. Management considers historical write off and recovery information in determining the estimated bad debt provision. Management also reviews accounts to determine if classification as charity care is appropriate. Part III, Line 8: Carlinville Area Hospital Association did not have a Medicare shortfall in FY 2010. In years where there is a shortfall this would be treated as a community benefit. The organization provides services to Medicare patients understanding there will be write-offs and knowing the organization will not recover all the costs of the services provided. Providing these services is essential to these patients and the community and increases their access to healthcare services, which is a community benefit.Total revenue received from Medicare is the gross reimbursement plus settlement. The costing methodology used is the cost accounting system. Part III, Line 9b: Carlinville Area Hospital Association will give the charity care applicant at least 60 days from the date of service to apply for financial assistance. 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. Part V: The organization also has the following types of facilities other than those required to be licensed as healthcare facilities in the state of Illinois:1 Outpatient physical therapy1 Sleep lab clinic 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. Carlinville is considered a healthcare shortage area so the hospital added a Family Practice physician. 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. Part VI, Line 3: The full charity care policy is posted on the Hospital's web site. 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 tries to determine if a patient qualifies for financial assistance at the time of registration. The hospital also employees a full time financial counselor to discuss the availability of various government services with patients. The financial counselor meets with all uninsured patients upon discharge. Part VI, Line 4: Carlinville Area 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.Carlinville had a population of 5,912 in July 2009 with an estimated median household income of $42,489. Carlinville residents with income below the poverty level in 2009 was 12.5% and residents with income below 50% of the poverty level was 3.1%. Part VI, Line 5: Carlinville Area Hospital presented two presentations on the new healthcare facility. Much of the discussion focused on the new equipment and improved access to healthcare for members of the community.The Hospital's Hazmat team oversees the Hospital's plans and policies for attending to patients exposed to hazardous materials. All members of the HazMat team complete many hours of specialized training and attend regularly scheduled meetings and drills. Using their specialized skills and knowledge, members of the team work together to be prepared for an emergency situation involving hazardous materials. The team along with other Hospital personnel worked with the local Public Health Department to coordinate a drill for a flu pandemic. The drill involved utilizing the Hospital's Alternate Care Site for patients in need of physician care when the Hospital reached maximum capacity.Carlinville Area Hospital is considered a healthcare shortage area, therefore the organization hired a Family Practice Physician. The costs of $13,458 are for recruitment of this physician. Part VI, Line 6: 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. During this fiscal year Carlinville Area Hospital finished construction of new hospital. The new facility replaces a structure that was built in the 1950s and was no longer meeting health safety codes. 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.Carlinville Area Hospital's nursing department received recognition from Hospira for being the first hospital in the nation to order and use a new type of IV line device, which assists in the prevention of IV site and blood stream infections.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. IL X X X X 0 0 0 0 0 0 0 0 0 Kenneth Reid 180345 0 0 0 0 0 7214 0 5410 0 192969 0 0 0 Jon Andersen MD 272645 0 0 0 0 0 8179 0 11971 0 292795 0 0 0 Curtis Cravens 188639 0 0 0 0 0 5659 0 11103 0 205401 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. The Hospital board of directors uses the processes described in Part I, Question 3 to help determine appropriate compensation for the CEO. The board of directors also approves the organization's contract with the Management Company. Supplemental Information Part III Part II: Kenneth G. Reid, CEO and Greg Ward, CFO are compensated by Brim Healthcare Inc., an unrelated management company, for services provided to Carlinville Area Hospital Association. 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 The organization's CEO and CFO are employees of Brim Healthcare Inc., an unrelated management company. 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, CFO and Director of Finance 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. Form 990, Part VI, Section B, line 15 The CEO and CFO are compensated through Brim Healthcare Inc., an unrelated management company. Brim Healthcare 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 2010. 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. Form 990, Part VI, Section A, Line 1a: The Executive Committee is composed of the elected officers of the Board and includes: the Chairman, Vice Chairman, President, Secretary and Treasurer of the organization. The Executive Committee has power and authority to manage and control the business affairs of the organization as the Board of Directors determines. In no event should the Executive Committee exercise powers to amend the organization's Articles of Incorporation or Bylaws, sell, transfer or otherwise dispose of substantially all of the organization's assets, or to adopt Articles of Merger or Consolidation. Form 990, Part VII, Section A The organization's CEO and CFO were employees of Brim Healthcare Inc. during fiscal year 2009. The reportable compensation and benefits reported on Form 990, Part VII and Schedule J includes salary and benefits paid to Brim Healthcare Inc. for services provided to the organization. Form 990, Part VII, Section A The following individuals devoted time providing services to the following related organizations. Carlinville Area Hospital Foundation Kenneth Reid, CEO 1 hour per week Greg Ward, CFO 1 hour per week Richard Walden .5 hours per week Ralph March .3 hours per week Middle Macoupin Healthcare Systems Kenneth Reid .25 hours per week Greg Ward .25 hours per week Richard Walden .25 hours per week J. Richard Schien .25 hours per week James Salske .25 hours per week Shirley Boente .25 hours per week Philip Williams .25 hours per week Mid-Mac Foundation dba Carlinville Area Hospital Foundation 20733 North Broad Street Carlinville IL 62626 371193348 Support Carlinville Area Hospital Association IL 501(c)(3) 11a N/A Middle Macoupin Healthcare Systems 20733 North Broad Street Carlinville IL 62626 371193396 Provide support and benefit Carlinville Area Hospital Association IL 501(c)(3) 11a N/A 0 0 1 0 0 0 0 0 0 0 0 1 1 1 0 0 0 0