Form Schedule H (F 990) Schedule H (F 990) Hospitals

SCHEDULE H
(Form 990)

OMB No. 1545-0047

Hospitals
䊳 Complete if the organization answered “Yes” to Form 990, Part IV, question 20.
䊳 Attach to Form 990.

Department of the Treasury
Internal Revenue Service

䊳 See separate instructions.

Name of the organization

Part I

2009
Open to Public
Inspection

Employer identification number

Charity Care and Certain Other Community Benefits at Cost
Yes

1a Does the organization have a charity care policy? If “No,” skip to question 6a
b If “Yes,” is it a written policy?
2 If the organization has multiple hospitals, indicate which of the following best describes application of the
charity care policy to the various hospitals.
Applied uniformly to all hospitals
Applied uniformly to most hospitals
Generally tailored to individual hospitals
Answer the following based on the charity care eligibility criteria that applies to the largest number of the
organization’s patients.
a Does the organization use Federal Poverty Guidelines (FPG) to determine eligibility for providing free care to low income
individuals? If “Yes,” indicate which of the following is the family income limit for eligibility for free care:
100%
150%
200%
Other
%
b Does the organization use FPG to determine eligibility for providing discounted care to low income individuals? If “Yes,”
indicate which of the following is the family income limit for eligibility for discounted care:
200%
250%
300%
400%
Other
%
350%

No

1a
1b

3

c If the organization does not use FPG to determine eligibility, describe in Part VI the income based criteria for
determining eligibility for free or discounted care. Include in the description whether the organization uses an
asset test or other threshold, regardless of income, to determine eligibility for free or discounted care.
4 Does the organization’s policy provide free or discounted care to the “medically indigent”?
5a Does the organization budget amounts for free or discounted care provided under its charity care policy?
b If “Yes,” did the organization’s charity care expenses exceed the budgeted amount?
c If “Yes” to line 5b, as a result of budget considerations, was the organization unable to provide free or
discounted care to a patient who was eligible for free or discounted care?
6a Does the organization prepare an annual community benefit report?
b If “Yes,” does the organization make it available to the public?
Complete the following table using the worksheets provided in the Schedule H instructions. Do not submit
these worksheets with the Schedule H.
7 Charity Care and Certain Other Community Benefits at Cost
Charity Care and
Means-Tested Government
Programs

(a) Number of
activities or
programs
(optional)

(b) Persons
served
(optional)

(c) Total community
benefit expense

(d) Direct offsetting
revenue

3a

3b

4
5a
5b
5c
6a
6b

(e) Net community
benefit expense

(f) Percent
of total
expense

a Charity care at cost (from
Worksheets 1 and 2)

b Unreimbursed Medicaid (from
Worksheet 3, column a)

c Unreimbursed costs—other meanstested government programs (from
Worksheet 3, column b)

d Total Charity Care and
Means-Tested Government
Programs

Other Benefits
e Community health improvement
services and community benefit
operations (from Worksheet 4)

f Health

professions
(from Worksheet 5)

education

g Subsidized health services (from
Worksheet 6)

h Research (from Worksheet 7)
i Cash and in-kind contributions to
community groups (from
Worksheet 8)
j Total. Other Benefits
k Total. Add lines 7d and 7j
For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 50192T

Schedule H (Form 990) 2009

Schedule H (Form 990) 2009

Part II

Page

(a) Number of (b) Persons
activities or
served
programs
(optional)
(optional)

1

Physical improvements and housing

2
3

Economic development
Community support

4

Environmental improvements

5

Leadership development and training
for community members

6

Coalition building

7
8

Community health improvement
advocacy
Workforce development

9

Other

10

Total

Part III

(c) Total community
building expense

(d) Direct offsetting
revenue

(e) Net community
building expense

(f) Percent of
total expense

Bad Debt, Medicare, & Collection Practices

Section A. Bad Debt Expense
1
2
3

2

Community Building Activities Complete this table if the organization conducted any community
building activities.

Yes No

Does the organization report bad debt expense in accordance with Healthcare Financial Management
Association Statement No. 15?
2
Enter the amount of the organization’s bad debt expense (at cost)
Enter the estimated amount of the organization’s bad debt expense (at cost) attributable
3
to patients eligible under the organization’s charity care policy

1

4

Provide in Part VI the text of the footnote to the organization’s financial statements that describes bad debt
expense. In addition, describe the costing methodology used in determining the amounts reported on lines
2 and 3, and rationale for including other bad debt amounts in community benefit.
Section B. Medicare
5
5 Enter total revenue received from Medicare (including DSH and IME)
6
6 Enter Medicare allowable costs of care relating to payments on line 5
7
7 Subtract line 6 from line 5. This is the surplus or (shortfall)
8 Describe in Part VI the extent to which any shortfall reported in line 7 should be treated as community
benefit. Also describe in Part VI the costing methodology or source used to determine the amount reported
on line 6. Check the box that describes the method used:
Cost accounting system
Cost to charge ratio
Other
Section C. Collection Practices
9a Does the organization have a written debt collection policy?
b If “Yes,” does the organization’s collection policy contain provisions on the collection practices to be followed
for patients who are known to qualify for charity care or financial assistance? Describe in Part VI

Part IV

9a
9b

Management Companies and Joint Ventures
(a) Name of entity

(b) Description of primary
activity of entity

(c) Organization’s
profit % or stock
ownership %

(d) Officers, directors, (e) Physicians’
trustees, or key
profit % or stock
employees’ profit %
ownership %
or stock ownership %

1
2
3
4
5
6
7
8
9
10
11
12
13
14
Schedule H (Form 990) 2009

Facility Information
Part V
IV

Licensed hospital

General medical & surgical

Children’s hospital

Teaching hospital

Critical access hospital

Research facility

ER–24 hours

ER–other

Other
(Describe)
Name and address

3
Page
Schedule H (Form 990) 2009

Schedule H (Form 990) 2009

Schedule H (Form 990) 2009

Part VI

Page

4

Supplemental Information

Complete this part to provide the following information.
1

Provide the description required for Part I, line 3c; Part I, line 6a; Part I, line 7g; Part I, line 7, column (f); Part I, line 7; Part III,
line 4; Part III, line 8; Part III, line 9b, and Part V. See Instructions.

2

Needs assessment. Describe how the organization assesses the health care needs of the communities it serves.

3

Patient education of eligibility for assistance. Describe how the organization informs and educates patients and persons who
may be billed for patient care about their eligibility for assistance under federal, state, or local government programs or under
the organization’s charity care policy.

4

Community information. Describe the community the organization serves, taking into account the geographic area and
demographic constituents it serves.

5

Community building activities. Describe how the organization’s community building activities, as reported in Part II, promote
the health of the communities the organization serves.

6

Provide any other information important to describing how the organization’s hospitals or other health care facilities further its exempt
purpose by promoting the health of the community (e.g., open medical staff, community board, use of surplus funds, etc.).

7

If the organization is part of an affiliated health care system, describe the respective roles of the organization and its affiliates
in promoting the health of the communities served.
If applicable, identify all states with which the organization, or a related organization, files a community benefit report.

8

Schedule H (Form 990) 2009