Schedule H (Form 9 Hospitals

SCHEDULE H
(Form 990)

Hospitals
▶

Department of the Treasury
Internal Revenue Service

OMB No. 1545-0047

Complete if the organization answered “Yes” to Form 990, Part IV, question 20.
▶ Attach to Form 990. ▶ See separate instructions.

Name of the organization

Part I

2012

Open to Public
Inspection

Employer identification number

Financial Assistance and Certain Other Community Benefits at Cost
Yes

1a Did the organization have a financial assistance policy during the tax year? If “No,” skip to question 6a . .
b If “Yes,” was it a written policy? . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2
If the organization had multiple hospital facilities, indicate which of the following best describes application of
the financial assistance policy to its various hospital facilities during the tax year.

1a
1b

Applied uniformly to most hospital facilities
Applied uniformly to all hospital facilities
Generally tailored to individual hospital facilities
Answer the following based on the financial assistance eligibility criteria that applied to the largest number of
the organization’s patients during the tax year.
Did the organization use Federal Poverty Guidelines (FPG) as a factor in determining eligibility for providing
free care? If “Yes,” indicate which of the following was the FPG family income limit for eligibility for free care:

3a

100%
150%
200%
Other
%
b Did the organization use FPG as a factor in determining eligibility for providing discounted care? If “Yes,”
indicate which of the following was the family income limit for eligibility for discounted care: . . . . .

3b

3
a

c

200%
250%
300%
350%
400%
Other
%
If the organization used factors other than FPG in determining eligibility, describe in Part VI the income based
criteria for determining eligibility for free or discounted care. Include in the description whether the
organization used an asset test or other threshold, regardless of income, as a factor in determining eligibility
for free or discounted care.
Did the organization’s financial assistance policy that applied to the largest number of its patients during the
tax year provide for free or discounted care to the “medically indigent”? . . . . . . . . . . . .

4

No

5a Did the organization budget amounts for free or discounted care provided under its financial assistance policy during the tax year?
b If “Yes,” did the organization’s financial assistance 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? . . . . . . . . . . .

4
5a
5b

5c
6a Did the organization prepare a community benefit report during the tax year? . . . . . . . . . .
6a
b If “Yes,” did the organization make it available to the public? . . . . . . . . . . . . . . . .
6b
Complete the following table using the worksheets provided in the Schedule H instructions. Do not submit
these worksheets with the Schedule H.
7
Financial Assistance and Certain Other Community Benefits at Cost
(a) Number of
(b) Persons
(c) Total community
(d) Direct offsetting
(e) Net community
(f) Percent
Financial Assistance and
activities or
served
benefit expense
revenue
benefit expense
of total
Means-Tested Government Programs programs
(optional)
(optional)
expense
a

Financial Assistance at cost

(from Worksheet 1)

.

.

.

.

b Medicaid (from Worksheet 3, column a)
c Costs of other means-tested
d

e
f

government programs (from
Worksheet 3, column b) . . . .
Total Financial Assistance and
Means-Tested Government Programs

Other Benefits

Community health improvement
services and community benefit
operations (from Worksheet 4) .
Health professions education
(from Worksheet 5) . . .

.
.

g Subsidized health services (from
Worksheet 6)

h
i
j
k

.

.

Research (from Worksheet 7)
Cash and in-kind contributions
for community benefit (from
Worksheet 8)
. . . . .
Total. Other Benefits . . .
Total. Add lines 7d and 7j .

.

.

.

.

.
.
.
.

For Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 50192T

Schedule H (Form 990) 2012

Page 2

Schedule H (Form 990) 2012

Part II

Community Building Activities Complete this table if the organization conducted any community building
activities during the tax year, and describe in Part VI how its community building activities promoted the
health of the communities it serves.
(a) Number of
activities or
programs
(optional)

1
2
3
4
5

Physical improvements and housing
Economic development
Community support
Environmental improvements
Leadership development and training
for community members

6
7
8
9
10

Coalition building
Community health improvement advocacy
Workforce development
Other
Total

Part III

(b) Persons
served
(optional)

(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
Did the organization report bad debt expense in accordance with Healthcare Financial Management Association Statement No. 15?
Enter the amount of the organization’s bad debt expense. Explain in Part VI the
2
methodology used by the organization to estimate this amount . . . . . . . . .
2
Enter the estimated amount of the organization’s bad debt expense attributable to
3
patients eligible under the organization’s financial assistance policy. Explain in Part VI the
methodology used by the organization to estimate this amount and the rationale, if any,
for including this portion of bad debt as community benefit. . . . . . . . . . .
3
4
Provide in Part VI the text of the footnote to the organization’s financial statements that describes bad debt
expense or the page number on which this footnote is contained in the attached financial statements.

Yes No
1

Section B. Medicare
5
Enter total revenue received from Medicare (including DSH and IME) . . . . . . .
5
6
Enter Medicare allowable costs of care relating to payments on line 5 . . . . . . .
6
7
Subtract line 6 from line 5. This is the surplus (or shortfall) . . . . . . . . . . .
7
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 Did the organization have a written debt collection policy during the tax year? . . . . . . . . . .
b If “Yes,” did the organization’s collection policy that applied to the largest number of its patients during the tax year contain provisions
on the collection practices to be followed for patients who are known to qualify for financial assistance? Describe in Part VI . . .

Part IV

9a
9b

Management Companies and Joint Ventures (owned 10% or more by officers, directors, trustees, key employees, and physicians—see instructions)
(a) Name of entity

(b) Description of primary
activity of entity

(c) Organization’s (d) Officers, directors,
profit % or stock
trustees, or key
ownership %
employees’ profit %
or stock ownership %

(e) Physicians’
profit % or stock
ownership %

1
2
3
4
5
6
7
8
9
10
11
12
13
Schedule H (Form 990) 2012

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Schedule H (Form 990) 2012

Part V

Facility Information
ER–other

ER–24 hours

Research facility

Critical access hospital

Teaching hospital

Name, address, and primary website address
1

Children’s hospital

How many hospital facilities did the organization operate
during the tax year?

General medical & surgical

(list in order of size, from largest to smallest—see instructions)

Licensed hospital

Section A. Hospital Facilities

Other (describe)

Facility
reporting
group

2

3

4

5

6

7

8

9

10

11

12

Schedule H (Form 990) 2012

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Schedule H (Form 990) 2012

Part V

Facility Information (continued)

Section B. Facility Policies and Practices
(Complete a separate Section B for each of the hospital facilities or facility reporting groups listed in Part V, Section A)

Name of hospital facility or facility reporting group
For single facility filers only: line number of hospital facility (from Schedule H, Part V, Section A)
Yes

Community Health Needs Assessment (Lines 1 through 8c are optional for tax years beginning on or before March 23, 2012)
1
During the tax year or either of the two immediately preceding tax years, did the hospital facility conduct a
community health needs assessment (CHNA)? If “No,” skip to line 9. . . . . . . . . . . . . .
If “Yes,” indicate what the CHNA report describes (check all that apply):
a
A definition of the community served by the hospital facility
b
Demographics of the community
Existing health care facilities and resources within the community that are available to respond to the
c
health needs of the community
d
How data was obtained
e
The health needs of the community
f
Primary and chronic disease needs and other health issues of uninsured persons, low-income persons,
and minority groups
g
The process for identifying and prioritizing community health needs and services to meet the
community health needs
h
The process for consulting with persons representing the community's interests
i
Information gaps that limit the hospital facility's ability to assess the community's health needs
j
Other (describe in Part VI)
Indicate the tax year the hospital facility last conducted a CHNA:
2
20
3
In conducting its most recent CHNA, did the hospital facility take into account input from representatives of
the community served by the hospital facility, including those with special knowledge of or expertise in public
health? If “Yes,” describe in Part VI how the hospital facility took into account input from persons who
represent the community, and identify the persons the hospital facility consulted . . . . . . . . .
Was the hospital facility's CHNA conducted with one or more other hospital facilities? If "Yes," list the other
4
hospital facilities in Part VI . . . . . . . . . . . . . . . . . . . . . . . . . . .
5
Did the hospital facility make its CHNA report widely available to the public?
. . . . . . . . . .
If “Yes,” indicate how the CHNA report was made widely available (check all that apply):
a
Hospital facility's website
b
Available upon request from the hospital facility
Other (describe in Part VI)
c
If the hospital facility addressed needs identified in its most recently conducted CHNA, indicate how (check
6
all that apply to date):
Adoption of an implementation strategy that addresses each of the community health needs identified
a
through the CHNA
b
Execution of the implementation strategy
c
Participation in the development of a community-wide plan
d
Participation in the execution of a community-wide plan
Inclusion of a community benefit section in operational plans
e
f
Adoption of a budget for provision of services that address the needs identified in the CHNA
g
Prioritization of health needs in its community
h
Prioritization of services that the hospital facility will undertake to meet health needs in its community
i
Other (describe in Part VI)
7
Did the hospital facility address all of the needs identified in its most recently conducted CHNA? If “No,”
explain in Part VI which needs it has not addressed and the reasons why it has not addressed such needs .
8 a Did the organization incur an excise tax under section 4959 for the hospital facility's failure to conduct a
CHNA as required by section 501(r)(3)? . . . . . . . . . . . . . . . . . . . . . . .
b If “Yes” to line 8a, did the organization file Form 4720 to report the section 4959 excise tax? . . . . .
c If “Yes” to line 8b, what is the total amount of section 4959 excise tax the organization reported on Form
4720 for all of its hospital facilities? $

No

1

3
4
5

7
8a
8b

Schedule H (Form 990) 2012

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Schedule H (Form 990) 2012

Part V

Facility Information (continued)

Financial Assistance Policy
Did the hospital facility have in place during the tax year a written financial assistance policy that:
9
Explained eligibility criteria for financial assistance, and whether such assistance includes free or discounted
care? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
10

Used federal poverty guidelines (FPG) to determine eligibility for providing free care? . . . . . . . .
If “Yes,” indicate the FPG family income limit for eligibility for free care:
%
If “No,” explain in Part VI the criteria the hospital facility used.
11
Used FPG to determine eligibility for providing discounted care?
. . . . . . . . . . . . . .
%
If “Yes,” indicate the FPG family income limit for eligibility for discounted care:
If “No,” explain in Part VI the criteria the hospital facility used.
12
Explained the basis for calculating amounts charged to patients? . . . . . . . . . . . . . .
If “Yes,” indicate the factors used in determining such amounts (check all that apply):
a
Income level
b
Asset level
c
Medical indigency
d
Insurance status
e
Uninsured discount
f
Medicaid/Medicare
g
State regulation
h
Other (describe in Part VI)
13
Explained the method for applying for financial assistance? . . . . . . . . . . . . . . . .
14
Included measures to publicize the policy within the community served by the hospital facility? . . . .
If “Yes,” indicate how the hospital facility publicized the policy (check all that apply):
a
The policy was posted on the hospital facility's website
b
The policy was attached to billing invoices
c
The policy was posted in the hospital facility's emergency rooms or waiting rooms
The policy was posted in the hospital facility's admissions offices
d
e
The policy was provided, in writing, to patients on admission to the hospital facility
f
The policy was available on request
g
Other (describe in Part VI)
Billing and Collections
Did the hospital facility have in place during the tax year a separate billing and collections policy, or a written
15
financial assistance policy (FAP) that explained actions the hospital facility may take upon non-payment? .
16
Check all of the following actions against an individual that were permitted under the hospital facility's
policies during the tax year before making reasonable efforts to determine the patient's eligibility under the
facility's FAP:
a
b
c
d
e
17

Reporting to credit agency
Lawsuits
Liens on residences
Body attachments
Other similar actions (describe in Part VI)
Did the hospital facility or an authorized third party perform any of the following actions during the tax year
before making reasonable efforts to determine the patient's eligibility under the facility's FAP? . . . . .

Yes

No

9
10

11

12

13
14

15

17

If “Yes,” check all actions in which the hospital facility or a third party engaged:
a
Reporting to credit agency
b
Lawsuits
Liens on residences
c
Body attachments
d
Other similar actions (describe in Part VI)
e
Schedule H (Form 990) 2012

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Schedule H (Form 990) 2012

Part V
18
a
b
c
d

Facility Information (continued)

Indicate which efforts the hospital facility made before initiating any of the actions listed in line 17 (check all that apply):
Notified individuals of the financial assistance policy on admission
Notified individuals of the financial assistance policy prior to discharge
Notified individuals of the financial assistance policy in communications with the patients regarding the patients' bills
Documented its determination of whether patients were eligible for financial assistance under the hospital facility's
financial assistance policy

e
Other (describe in Part VI)
Policy Relating to Emergency Medical Care
Yes

Did the hospital facility have in place during the tax year a written policy relating to emergency medical care
that requires the hospital facility to provide, without discrimination, care for emergency medical conditions to
individuals regardless of their eligibility under the hospital facility's financial assistance policy?
. . . .

19

No

19

If “No,” indicate why:
a
The hospital facility did not provide care for any emergency medical conditions
The hospital facility's policy was not in writing
b
The hospital facility limited who was eligible to receive care for emergency medical conditions (describe
c
in Part VI)
d
Other (describe in Part VI)
Charges to Individuals Eligible for Assistance under the FAP (FAP-Eligible Individuals)
Indicate how the hospital facility determined, during the tax year, the maximum amounts that can be charged
20
to FAP-eligible individuals for emergency or other medically necessary care.
The hospital facility used its lowest negotiated commercial insurance rate when calculating the
a
maximum amounts that can be charged
The hospital facility used the average of its three lowest negotiated commercial insurance rates when
b
calculating the maximum amounts that can be charged
The hospital facility used the Medicare rates when calculating the maximum amounts that can be
c
charged
d
21

22

Other (describe in Part VI)
During the tax year, did the hospital facility charge any of its FAP-eligible individuals, to whom the hospital
facility provided emergency or other medically necessary services, more than the amounts generally billed to
individuals who had insurance covering such care? . . . . . . . . . . . . . . . . . . .

21

If “Yes,” explain in Part VI.
During the tax year, did the hospital facility charge any FAP-eligible individuals an amount equal to the gross
charge for any service provided to that individual? . . . . . . . . . . . . . . . . . . .

22

If “Yes,” explain in Part VI.
Schedule H (Form 990) 2012

Page 7
Part V
Facility Information (continued)
Section C. Other Health Care Facilities That Are Not Licensed, Registered, or Similarly Recognized as a Hospital
Facility

Schedule H (Form 990) 2012

(list in order of size, from largest to smallest)
How many non-hospital health care facilities did the organization operate during the tax year?

Name and address

Type of Facility (describe)

1

2

3

4

5

6

7

8

9

10

Schedule H (Form 990) 2012

Schedule H (Form 990) 2012

Part VI

Page 8

Supplemental Information

Complete this part to provide the following information.
1
2
3

4
5
6
7
8

Required descriptions. Provide the descriptions required for Part I, lines 3c, 6a, and 7; Part II; Part III, lines 4, 8, and 9b; Part
V, Section A; and Part V, Section B, lines 1j, 3, 4, 5c, 6i, 7, 10, 11, 12h, 14g, 16e, 17e, 18e, 19c, 19d, 20d, 21, and 22.
Needs assessment. Describe how the organization assesses the health care needs of the communities it serves, in addition to
any needs assessments reported in Part V, Section B.
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 financial assistance policy.
Community information. Describe the community the organization serves, taking into account the geographic area and
demographic constituents it serves.
Promotion of community health. Provide any other information important to describing how the organization’s hospital facilities 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.).
Affiliated health care system. 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.
State filing of community benefit report. If applicable, identify all states with which the organization, or a related
organization, files a community benefit report.
Facility reporting group(s). If applicable, for each hospital facility in a facility reporting group provide the descriptions required
for Part V, Section B, lines 1j, 3, 4, 5c, 6i, 7, 10, 11, 12h, 14g, 16e, 17e, 18e, 19c, 19d, 20d, 21, and 22.

Schedule H (Form 990) 2012