2011-08-15T11:29:28-05:00 2010-09-30 BAKER NEWMAN & NOYES PO BOX 507 PORTLAND ME 04112 990 2009-10-01 010234189 Northern Maine Medical Center NORT 2078343155 194 East Main Street Fort Kent ME 04743 Peter J Sirois 2078343155 2011-08-12 1 Nicholas E Porto 2078792100 2009 2016-02-24 21:20:13Z Peter J Sirois 194 East Main Street Fort Kent ME 04743 44070600 0 X www.nmmc.org X 1948 ME Acute care & long term care hospital and mental health services facility 27 25 605 50 0 0 400725 227660 42992442 43910006 -29681 -187032 616096 -76212 43979582 43874422 0 0 21759673 20965773 0 0 23183686 25855470 44943359 46821243 -963777 -2946821 32557593 29391825 14714196 14493190 17843397 14898635 The mission of Northern Maine Medical Center is to provide, coordinate, or support access to high quality, affordable health care and to positively impact our communities' quality of life by improving health status. 0 0 37874319 43591738 Medical care & ancillary services; nursing home & skilled services; physician services 37874319 1 1 0 1 0 0 0 0 1 1 0 0 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 77 0 605 1 0 0 0 0 0 0 0 0 0 27 25 1 0 0 0 0 0 0 1 1 0 0 0 1 1 1 0 1 1 1 0 X Peter Sirois 2078343155 194 East Main Street Fort Kent ME 04743 Guy Raymond 52.00 X 375265 0 21890 Bob Bellefleur 1.00 X 0 0 0 Rita C Cannan 1.00 X 0 0 0 Richard Cost 1.00 X 0 0 0 Fern Desjardins 1.00 X 0 0 0 Wally Desjardin 1.00 X 0 0 0 John Ezzy 1.00 X 0 0 0 Roy Gardner 1.00 X 0 0 0 Nelson Jandreau 1.00 X 0 0 0 Frances LaBrie 1.00 X 0 0 0 John Martin 1.00 X 0 0 0 Bill Melvin 1.00 X 0 0 0 Dr David Mitchell 1.00 X 0 0 0 Clifford Ouellette 1.00 X 0 0 0 Kim Ouellette 1.00 X 0 0 0 Ronald Paradis 1.00 X 0 0 0 David Parent 1.00 X 0 0 0 James Roy 1.00 X 0 0 0 Kathy Roy 1.00 X 0 0 0 Michael Sullivan MD 47.00 X 385945 0 21890 Joan Sylvain 1.00 X 0 0 0 James Thibodeau 1.00 X 0 0 0 Fred Wetmore 2.00 X X 0 0 0 Dan Vaillancourt 1.00 X X 0 0 0 Glenn Lamarr 1.00 X X 0 0 0 Ronald Daigle 1.00 X X 0 0 0 Norman Fournier 1.00 X X 0 0 0 Martin B Bernstein 50.00 X 198494 0 9533 Roger L Lagasse 50.00 X 135879 0 11538 Peter J Sirois 50.00 X 164448 0 21725 Scott Richards 50.00 X 152768 0 22570 Joanne Fortin 50.00 X 123380 0 9924 David Jones MD 50.00 X 311519 0 7853 1847698 0 126923 8 0 1 0 Quest Diagnostics 12436 Collection Center Drive Chicago IL 60693 Lab Test Services 314497 Brian Gretta MD 63 Merganser Cove Road Orrs Island ME 04066 ER Physician Services 187311 Cary Medical Center 163 Van Buren Road Suite 1 Caribou ME 04736 Lab Test Analysis Services 185786 Roof Systems of Maine PO Box 1134 Bangor ME 04401 Contractor Services 140310 New England Pharmacy Solutions PO Box 771 Brunswick ME 04011 Remote Pharmacy Coverage 126500 8 129204 98456 227660 Patient Service Revenu 623000 43306641 43306641 Miscellaneous Revenue 623000 449787 449787 Cafeteria Revenue 900099 153578 153578 43910006 9146 9146 88478 88478 88478 88478 196178 -196178 -196178 -196178 Insurance Captive 900099 -164690 -164690 -164690 43874422 43591738 0 55024 1160434 782718 377716 16459331 13730156 2729175 5103 4206 897 2047162 1697747 349415 1293743 1066378 227365 117379 74563 42816 63010 40026 22984 134525 85455 49070 9000594 5717494 3283100 1386346 880656 505690 528430 335677 192753 2316549 1471553 844996 879875 558928 320947 Valley Medical Associat 8944829 8944829 Provision for Bad Debts 1327567 1327567 Health Care Provider Ta 1156366 1156366 46821243 37874319 8946924 0 3449017 2446668 1552899 1336455 3999675 5067316 88143 29548 922999 725624 256765 555925 36700115 19346321 17840096 17353794 32759 34953 144936 30430 4270304 1811112 32557593 29391825 4686476 5213239 9706890 8834343 320830 445608 14714196 14493190 X 17440996 14506439 402401 392196 17843397 14898635 32557593 29391825 X 0 0 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 5622 5622 0 Part II-B, Line 1i: Explanation of Other Lobbying Activities: The Organization paid $34,706 in dues to MHA, of which 16.2% was used for lobbying. 402401 95643 5196 111044 392196 719671 81375 3267 401912 402401 0.00000 0.00000 1.00000 0 0 150384 150384 18119422 6160420 11959002 1712354 981989 730365 15927829 11807630 4120199 790126 396282 393844 17353794 Deferred Compensation 445608 Cash Surrender Value of Life Insurance 165235 Construction in Progress 201012 Estimated Third-Party Payor Settlements 43844 Interest in Synernet Reinsurance 955413 1811112 Deferred Compensation 445608 445608 Part V, Line 4: Description of Intended Use of Endowment Funds: To help insure the long-term financial health of the Organization. 1 1 1 X 1 X 1 1 0 1 0 323584 323584 0.00710 10589584 7389808 3199776 0.07030 10913168 7389808 3523360 0.07740 26969 18030 8939 0.00020 18523032 8065192 10457840 0.22990 18550001 8083222 10466779 0.23010 29463169 15473030 13990139 0.30750 4643 0 4643 0.00010 4643 4643 0.00010 0 845886 8170341 7766536 403805 X 1 0 Northern Maine Medical Center

194 East Main Street Fort Kent ME 04743

X X X Part I, Line 3c: Northern Maine Medical Center uses the Federal Poverty Guidelines to determine eligibility. Part I, Line 6a: Northern Maine Medical Center prepares a community benefit report through its annual report process. The annual report is available three months after fiscal year end. Within the annual report the Hospital describes community benefit in financial terms and a summary of services provided. This includes the losses from subsidized physician practices, subsidized community health and wellness programs, the cost of patients who cannot afford to pay, Medicaid and Medicare shortfalls, and patients who do not pay. Part I, Line 7: In the IRS Form 990, Schedule H instructions/guidance a template (Worksheet 2) was provided as a way to determine the overall cost-to-charge ratio that could be applied throughout the IRS Form 990, Schedule H. Where applicable, the Hospital has utilized the Worksheet 2 template calculation. The only areas we did not utilize this template calculation was on the following areas:A. IRS Form 990, Schedule H, Worksheet 6, Subsidized Health Services (which is the supporting schedule for Part I, Line 7g), we did not utilize the Worksheet 2 percentage when we were determining the profit/loss of each of our hospital clinical services and hospital-owned physician practices, SNF, RHCs, ER, and Pscyh. In addition, when we were compiling the subsidized services and practices listed in 1c above, we utilized the actual estimated costs on the modified Medicare cost report we prepared instead of applying the Worksheet 2 cost-to-charge percentage.B. IRS Form 990, Schedule H, Worksheet 3, Unreimbursed Medicaid and Other Means Tested Government Programs (which is the supporting schedule for Part 1, Lines 7b and 7c), and Worksheet 6, Medicaid allowable costs for the subsidized health services listed on line 1c above (which is part of the line 7g costs), we did not use the Worksheet 2 percentage when calculating the Medicaid allowable costs. Instead, we utilized the actual Medicaid filed cost report for the allowable costs. In addition, for any prior year settlements that were received during the current year, we have netted the settlement against what was filed. Part I, Line 7g: Northern Maine Medical Center has several provider-based physician practices, a skilled nursing facility (SNF), rural health centers (RHCs), an emergency Room (ER), and an inpatient psychiatric unit (Psych). Per the instructions for IRS Form 990, Schedule H, Worksheet 6, we are allowed to include any applicable physician practice, SNF, RHCs, ER and Psych that the Hospital subsidizes (i.e., operates at a loss). As such, we have included the following provider-based physician practices, SNF, RHCs and Psych units that operate at a loss (i.e., subsidized by the hospital) and the associated costs of these practices: a. Forest Hill Manor - Skilled Nursing Facility b. Northern Maine Medical Center - Inpatient Psych Unit c. Northern Maine Medical Center - Emergency Room d. Valley Medical Associates RHCs i. Fort Kent ii. Acadia Family Health iii. Station Hill iv. Valley Medical Associates e. Endoscopy f. Valley Medical Associates - Orthopedics/Prosthetics g. Diabetes (includes Dietary Consultation) h. Valley Medical Associates - Oncology i. Ophthalmology j. Ear, Nose, and Throat k. Neurology l. Cardiac Rehab m. CPR/EMT Services n. Wellness o. Valley Medical Associates - Several individual physician practices p. Valley Medical Associates - Anesthesiology q. Valley Medical Associates - Clinic at University of Fort Kent r. Valley Medical Associates - UrologyThe above listed hospital clinical services and hospital-owned physician practices have a community benefit (i.e., aggregate loss or subsidy from the Hospital) of approximately $10.4 million. In addition, the community benefit also does not take into account bad debts, charity care, and contractual adjustments. Thus, this community benefit of approximately $10.4 million is a conservative figure that reconciles to the community benefit reported on IRS Form 990, Schedule H, Part I, Line 7g, Column e. Part I, Line 7f: As part of the Hospital's total expenses, there is $1,327,567 worth of bad debts. This amount has been removed from the Part I, Line 7, Column f calculation per the IRS instructions. Part III, Line 4: Northern Maine Medical Center classifies bad debts as an operating expense. The Hospital follows the Medicare guidelines for allowable bad debts. It uses the following criteria: a. Reasonable collection efforts were made b. The accounts were uncollectible c. There is no likelihood of recovery at any time in the futureThe bad debt expense at cost was the total write-offs reduced by the ratio of patient care cost to charges. Part III, Line 8: The IRS Form 990, Schedule H instructions/guidance provided a template (Worksheet 2 template) as a way to determine the overall cost-to-charge ratio that could be applied throughout the IRS Form 990, Schedule H form in order to convert charges to cost. Where applicable, we have utilized the Worksheet 2 template calculation. We did not utilize this template calculation on IRS Form 990, Schedule H, Worksheet B, Lines 2 & 6, Medicare Allowable Costs and Payments Related to the Subsidized Health Services, where we utilized the Medicare cost report estimated cost and payment for these services.The Hospital believes that the clinics and units listed in 1c above should be, and are considered, a community benefit due to the fact that without the Hospital subsidizing and offering the services that these clinics and units offer the community at large would have to travel at least 45 minutes to the nearest like-hospital and that hospital's service offerings. Additionally, in order to receive inpatient psych services, patients would have to travel at least 4 hours to the nearest inpatient psych unit. As such, Northern Maine believes that by offering, and thus subsidizing, these clinics and units within its community - and thus benefiting the community members by having easy access and commute for these services - it benefits the community at large. Part III, Line 9b: When a patient is referred out to collections but then applies for free or discounted care, the account is pulled back from collections when it is determined they qualify for one of the programs. If the collection agency suspects that someone may need to apply for one of the programs, it sends out an application and notifies us. We make every effort to screen as many people as possible before we send them to collections. Part V: See Form 990, Schedule H, Part V Part VI, Line 2: A community needs assessment is conducted by the Power of Prevention office located at an NMMC location. Input is acquired by organizations, executive board sessions, and other groups. The Power of Prevention is a grant-funded entity that is shared between the Hospital and Cary Medical Center located in Caribou, ME. The project director of this grant-funded organization operates from the NMMC Wellness Center in Fort Kent. Part VI, Line 3: We notify patients and customers about access to assistance in various ways. The simplest way is the signage, pamphlets, and educational material located around the Organization and in various offices. In every patient access/patient financial services area is a sign explaining the availability of free/discounted care and the Federal Poverty Guidelines. There are also pamphlets located in the outpatient areas explaining free/discounted care and providing information on MaineCare. For inpatients, there is a book in each room which provides all the information on all programs available.Through the patient accounting department, we provide information about these statements. We also counsel patients on the phone about all the programs available whether it is Medicaid or a hospital program. Part VI, Line 4: Northern Maine Medical Center is a 94 staffed bed (29 A&P beds, 6 ICU beds, 14 Psych beds, and 45 SNF beds) full-service, acute-care, not-for profit hospital located in Fort Kent, Maine (Aroostook County). The Hospital is accredited by the joint commission and its mission is to serve its communities with excellence in health care. Its services include: acute inpatient, psych inpatient, SNF, 24-hour emergency center, diagnostic, and surgical services. Along with these hospital services, the Hospital employs/contracts with the majority of primary and specialty care physicians in the area.Aroostook County is considered rural by the State of Maine and the United States Census Bureau, under the guidelines set forth by the Office of Management and Budget (OMB). The hospital service area (HSA) as defined by the Maine Health Data Organization (MHDO) uses the statistical method where the greatest proportion of residents received their inpatient care. The following towns make up the Northern Maine Medical Center HSA as defined by the MHDO: Allagash, Eagle Lake, Fort Kent, Frenchville, Grand Isle, Madawaska, New Canada, St. Agatha, St. Francis, St. John Pit, Wallagrass, Winterville Pit, Big Twenty TWP, T9 R7 & R8, T10 R6-8, T11 R7-17, T12 R7-17, T13, R5 & R7-16, T14 R5-16, T15 R5-6 & R8-15, T16 R4-6 & R8-9 & R12-14, T17 R3-5 & R12-14, T18 R10-13, and T19 R11-12.Approximately 17% of Northern Maine Medical Center patients utilize Medicaid and 55% of Northern Maine Medical Center patients utilize Medicare. The population of Fort Kent with income below the Federal Poverty Guidelines is 14.5%, including 13.5% of children under the age of 18 and 18.2% of those over the age of 65. Part VI, Line 5: N/A Part VI, Line 6: Northern Maine Medical Center is a local, not-for-profit hospital that serves its local communities and people regardless of their ability to pay. Northern Maine provides financial assistance and sliding scale discounts to self-pay and low-income patients. Also the Hospital participates in government-sponsored health care programs including Medicare, Medicaid, CHAMPUS, and Tricare. The volunteer board of trustees sets the strategic direction for the Hospital and is comprised of community members from the Hospital's service area. This group is made up of local business owners, professionals, and retirees. Northern Maine's non-profit status allows the Hospital to reinvest any excess of revenues over expense back into the Hospital to continuously improve the medical care it delivers. The Hospital allows access to healthcare that would otherwise be difficult. The Hospital is the main employer for the local physicians, including specialty physicians that would otherwise have to be accessed out of the area. X X 0 0 0 0 0 0 0 0 0 Guy Raymond 375265 0 0 0 0 0 0 0 21890 0 397155 0 0 0 Michael Sullivan MD 385945 0 0 0 0 0 0 0 21890 0 407835 0 0 0 Martin B Bernstein 198494 0 0 0 0 0 0 0 9533 0 208027 0 0 0 Peter J Sirois 164448 0 0 0 0 0 0 0 21725 0 186173 0 0 0 Scott Richards 152768 0 0 0 0 0 0 0 22570 0 175338 0 0 0 David Jones MD 311519 0 0 0 0 0 0 0 7853 0 319372 0 0 0 Form 990, Part VI, Section A, line 2 Peter Sirois and Glenn Lamarr have a family relationship. Form 990, Part VI, Section B, line 11 The Form 990 is prepared by the Organization's independent public accounting firm and thoroughly reviewed by the CFO and controller. Form 990, Part VI, Section B, line 12c The enforcement of the conflict of interest policy is achieved through annual reporting and ongoing monitoring. Form 990, Part VI, Section B, line 15 The executive committee of the board of directors determines the compensation of the CEO using compensation studies and comparability data. The CEO determines tehe compensation of other officers and key employees in a similar manner. Form 990, Part VI, Section C, line 19 The Organization makes its governing documents, conflict of interest policy, and financial statements available to the public upon request. Valley Medical Association 194 East Main Street Fort Kent ME 04743 223245434 Medical Physician Practice ME 501(C)(3) 3 N/A 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 Valley Medical Association Q 8944829