2023-11-15T17:22:44+00:00 2022-12-31 264532849 Purk & Associates PC 1034 S Brentwood Boulevard Suite 20 00 St Louis MO 63117 990 2022-01-01 390807236 Agnesian Healthcare Inc AGNE 9209265519 430 E Division St Fond du Lac WI 54935 Randy Combs Treasurer 3149947800 2023-11-15 true Barbara Potts 999009999 Douglas G Pleus P00013488 3148844022 2022 2023-04-26 12:10:37Z Katherine Vergos 430 E Division St Fond du Lac WI 54935 501485210 false 0928 X https://www.ssmhealth.com/locations/st-agnes-hospital X 1892 WI THE MISSION OF AGNESIAN HEALTHCARE IS TO PROVIDE COMPASSIONATE CARE THAT BRINGS HOPE, HEALTH AND WHOLENESS TO THOSE WE SERVE BY HONORING THE SACREDNESS AND DIGNITY OF ALL PERSONS AT EVERY STAGE OF LIFE. WE ARE ROOTED IN THE HEALING MINISTRY OF THE CATHOLIC CHURCH. 12 11 3891 354 16238025 740026 11552150 1057580 381964458 459604910 29185721 5610312 47064538 8010341 469766867 474283143 456570 444254 0 188698260 196454202 0 98907 233015557 292856999 422170387 489755455 47596480 -15472312 726281113 639250818 173444598 140433680 552836515 498817138 THE MISSION OF AGNESIAN HEALTHCARE IS TO PROVIDE COMPASSIONATE CARE THAT BRINGS HOPE, HEALTH AND WHOLENESS TO THOSE WE SERVE BY HONORING THE SACREDNESS AND DIGNITY OF ALL PERSONS AT EVERY STAGE OF LIFE. WE ARE ROOTED IN THE HEALING MINISTRY OF THE CATHOLIC CHURCH. false false 392896956 444254 450823217 Please see Schedule O for a complete description of program service accomplishments. 392896956 true true false true false false false false true true true false true true true false true false false false false false false false false true true true false true true true false false false false false false false false true false false false false true true true true false false true X 0 0 3891 true true true false false false false false false false false false false false X 12 11 true false false false true true true true true false false false true true true true true false false true true X Jackie Taylor 6082416949 1808 W Beltline Hwy Madison WI 53713 Sue Anderson DIRECTOR,CHAIR,REGIONAL PRESIDENT WI 1.0 42.0 X X 0 721772 397232 Thor H Gilbertson Director, Chairperson 1.0 0 X X 0 0 0 Bret Pasiuk MD Director 1.0 0 X 0 0 0 Dr Doug Fownes Director 1.0 0 X 0 0 0 Jeffrey Strong MD Director 1.0 0 X 0 0 0 Mark Thompson MD Director, Regional President-Medical Groups-Wisconsin 1.0 42.0 X 0 834779 308562 Matt Hanley MD Director, Interim Regional President - Wisconsin 1.0 45.0 X 0 1162974 20472 Sister Donna Innes Director 1.0 1.0 X 0 0 0 Sister Hertha Longo Director 1.0 0 X 0 0 0 Sister Susan Stucki Director 1.0 1.0 X 0 0 0 Stephen M Peterson Director 1.0 0 X 0 0 0 Theodore Miller MD Director 1.0 1.0 X 0 0 0 Thomas Schuessler Director 1.0 0 X 0 0 0 Douglas Long Secretary, General Counsel at SSM Health 1.0 72.2 X 0 1354027 686727 Katherine Vergos President - St. Agnes Hospital 40.0 1.0 X 612331 0 241663 Randy Combs Treasurer, Chief Financial Officer at SSM Health 1.0 69.0 X 0 1879738 971053 Steve Smoot VICE PRESIDENT, COO of SSM Health 1.0 65.0 X 0 1870292 1033999 Michael Drees VP - Operations, Fond du Lac Clinic 40.0 0 X 379517 0 106910 Tami Schattschneider VP - Patient Care Services/CNO 40.0 0 X 286345 0 100442 Tara Rhodes VP - Operations, St. Agnes Hospital 40.0 0 X 239739 0 91236 Kristof Gehrke Physician 40.0 0 X 617797 0 58585 Marcio Shiokawa Physician 40.0 0 X 596018 0 55954 Michael Vander Kooy Radiation Oncologist 40.0 0 X 661943 0 68908 Steven Flurry Anesthesiologist 40.0 0 X 635427 0 62406 Syed Mohiuddin Physician 40.0 0 X 613032 0 57680 Jim Mugan Former Key Employee 0.0 0 X 147804 0 0 Kris Zimmer Former Officer 0.0 0.0 X 0 135402 0 Nancy Birschbach Former Key Employee 0.0 40.0 X 0 451306 162351 4789952 8410290 4424181 309 true true false CD SMITH CONSTRUCTION 125 CAMELOT DRIVE FOND DU LAC WI 54935 CONSTRUCTION SERVICES 7152623 AMN HEALTHCARE INC 12400 HIGH BLUFF DRIVE SAN DIEGO CA 92130 STAFFING SERVICES 6134535 FOND DU LAC REGIONAL CLINIC SC 420 E DIVISION ST FOND DU LAC WI 54935 PHYSICIAN SERVICES 3790328 MEDICAL COLLEGE OF WI 8701 WATERTOWN PLANK RD WAUWATOSA WI 53226 PHYSICIAN SERVICES 3180247 MOREDIRECT INC PO BOX 536464 PITTSBURGH PA 15253 INFORMATION TECHNOLOGY SERVICES 2157268 72 1037580 20000 1057580 Net patient service revenue 622110 423101501 423101501 Pharmacy 9562925 9562925 26940484 26940484 0 0 459604910 5692243 5692243 1305754 1305754 0 1305754 1305754 81931 0 -81931 -81931 -81931 28477798 27120136 1357662 3159190 -1801528 Laboratory 621500 1149421 1149421 Optical sales 456130 799671 781232 18439 Cafeteria 722210 1049783 1049783 2348050 0 2348050 0 5346925 474283143 450823217 16238025 6164321 X 444254 444254 2058184 2000563 57621 147804 143666 4138 151098981 147619453 3479528 7704067 7488384 215683 24745108 24052346 692762 10700058 10400500 299558 247740 247740 26263 26263 117201015 41664494 75535617 904 63060 63060 34120420 32999663 1038396 82361 258240 257840 400 9263596 6610014 2653582 743745 705475 37254 1016 884525 829082 40817 14626 4303037 4303037 19257212 19257212 1606483 1606483 Medical supplies 78524736 78524736 Medicaid Provider Tax 4967396 4967396 Internal management fees 19323708 6956535 12367173 Licenses and taxes 2065823 2065823 0 0 0 0 489755455 392896956 96759592 98907 42211476 7659554 1475100 81286829 48737014 0 0 0 0 5480095 5502193 1299648 1266415 303226329 88458522 231838587 214767807 334323585 302032449 22300391 21702615 6065402 37582771 726281113 639250818 39624654 16914743 237216 58782 0 0 133582728 123460155 173444598 140433680 X 544659986 490640609 8176529 8176529 552836515 498817138 726281113 639250818 X -15472312 -37949289 -597776 X false true X true false X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED false false false false false false false false true 26263 26263 false Schedule C, Part II-B, Line 1 DETAILED DESCRIPTION OF THE LOBBYING ACTIVITY THE ORGANIZATION PAID DUES TO VARIOUS NATIONAL HOSPITAL ASSOCIATIONS AND A PORTION OF THESE DUES WAS ALLOCATED TO LOBBYING ACTIVITIES. 1487797 1075000 2562797 1487797 1487797 1487797 1487797 1487297 500 1487797 1487297 1487297 0.0 1.0 0.0 true false 14685750 14685750 205441281 43583092 161858189 6032571 4196405 1836166 64593446 40638310 23955136 12473281 40715 12432566 214767807 SSM COMPREHENSIVE INVESTMENT PROGRAM 302032449 F 302032449 Due from affiliates 36079133 OPERATING RIGHT-OF-USE ASSETS 1503638 37582771 Third Party Payor 4103164 Capital Lease Obligations 313819 Allocated tax-exempt debt: SSM Health Care Corporation 117430192 Due to affiliates OPERATING LEASE OBLIGATIONS 1505622 Physician Supplemental Benefit Plan 107358 123460155 X Schedule D, Part V, Line 4 Intended uses of endowment funds ENDOWMENTS ARE DESIGNATED FOR MEDICAL CARE FOR THOSE IN FINANCIAL NEED, HEART AND CANCER CARE, AND OTHER HEALTH-RELATED NEEDS. Schedule D, Part X, Line 2 FIN 48 (ASC 740) footnote AGNESIAN HEALTHCARE INC'S FINANCIAL INFORMATION IS INCLUDED IN THE CONSOLIDATED AUDITED FINANCIAL STATEMENTS OF A RELATED ORGANIZATION, SSM HEALTH (SSMH). SSMH EVALUATES ITS UNCERTAIN TAX POSITIONS ON AN ANNUAL BASIS. A TAX BENEFIT FROM AN UNCERTAIN TAX POSITION MAY BE RECOGNIZED WHEN IT IS MORE LIKELY THAN NOT THAT THE POSITION WILL BE SUSTAINED UPON EXAMINATION, INCLUDING RESOLUTIONS OF ANY RELATED APPEALS OR LITIGATION PROCESSES, BASED ON THE TECHNICAL MERITS. THERE HAVE BEEN NO UNCERTAIN TAX POSITIONS RECORDED IN 2022 OR 2021. true true X true X true X true true true false true true 1608151 1608151 0.0033 52299618 17868492 34431126 0.0703 6551687 4422887 2128800 0.0043 0 0 60459456 22291379 38168077 0.0779 553960 553960 0.0011 496186 496186 0.0010 4727259 4332865 394394 0.0008 28036 28036 0.0001 389386 389386 0.0008 0 0 6194827 4332865 1861962 0.0038 0 0 66654283 26624244 40030039 0.0817 0 0.0 0 0.0 0 0.0 5954 5954 0.0000 0 0.0 0 0.0 0 0.0 1891 1891 0.0000 0 0.0 0 0 7845 0 7845 0.0000 true 19887072 34205409 41410658 -7205249 X true true 1 1 St Agnes Hospital 430 E Division Street Fond du lac WI 54935 https://www.ssmhealth.com/locations/st-agnes-hospital 120 X X X A A 1 false false true X X X X X X X X X 21 true false true true X https://www.ssmhealth.com/resources/about/community-health X true 22 true https://www.ssmhealth.com/resources/about/community-health false true X 200.0 400.0 X X X X X true true X X X true X https://www.ssmhealth.com/resources/patients-visitors/pay-my-bill/financial-assistance X https://www.ssmhealth.com/resources/patients-visitors/pay-my-bill/financial-assistance X https://www.ssmhealth.com/resources/patients-visitors/pay-my-bill/financial-assistance X X X X X X true X false X X X true X false false Schedule H, Part V, Section B, Line 3E THE HOSPITAL FACILITIES ANALYZED SEVERAL HEALTH NEEDS OF THE COMMUNITY AND HAVE PRIORITIZED THOSE OF MOST CONCERN. THE PRIORITIZATION OF THE TOP SIGNIFICANT COMMUNITY HEALTH NEEDS IS DESCRIBED IN THE CHNA. Schedule H, Part V, Section B, Line 5 Facility A, 1 Facility A, 1 - St. Agnes Hospital. The Community Health Needs Assessment is comprised of five different data collection methods to include primary, secondary, qualitative, and quantitative data. Once it was collected, it was organized into five health focus areas. COMMUNITY HEALTH SURVEY The Community Health Survey conducted by JKV Research, LLC., provides primary, quantitative data collected from Fond du Lac County residents. The data provides an overview of behavioral and lifestyle habits as well as prevalence of risk factors and disease conditions existing within the Fond du Lac County adult population. The survey was mailed out to a random sample and 674 adults participated. Aggregate data from six school districts in Fond du Lac County is included in the Community Health Survey report to provide student data when available. PUBLIC INPUT SURVEY The Priority Health Issues Survey was conducted to provide an outlet for the community at large to provide additional input and voice their concerns regarding the most pressing county health issues. The survey was available in hard copy at the health department and online on the health department's website. The survey was available to take in English and Spanish. Residents were encouraged to review key findings from the 2020 Community Health Survey beforehand to provide additional feedback. A total of 284 Fond du Lac County residents completed the survey. The health focus areas ranked most consistently in the top five by respondents were: mental health, alcohol and other drug use, social determinants of health, food security and nutrition and infectious disease. KEY INFORMANT INTERVIEWS A total of 37 Key Informant Interviews were conducted to provide further qualitative data regarding community needs. Key informants identified were considered community experts who can provide valuable insight on pressing health issues in the Fond du Lac County community. The top health focus areas ranked most consistently by key informants were: mental health, alcohol and other drug use, social determinants of health, chronic disease, oral health and food security and nutrition. COMMUNITY CONVERSATIONS New for the 2021 Community Health Assessment was data collected from community conversations These conversations were organized by members of the SSM Health Greater Fond du Lac Region, Fond du Lac County Health Department and other entities that served as host locations for these events. The purpose of these community conversations was to further engage the public and provide an opportunity for various populations to voice their input that may otherwise have not been heard. 16 community conversations were held across the county, providing further information regarding the health needs of residents in Fond du Lac County. Top needs identified from community conversations include: access to resources, mental health, transportation, access to care and racism. Highlights and themes from these conversations can be found throughout the report. SECONDARY DATA Secondary data was collected from local, state, and national health sources to supplement the community health survey and other data collection information listed above. This data helped build a community health profile for Fond du Lac County and allowed this report to be comparable to other counties as well as state and national benchmarks. The secondary data collected is included in throughout the health focus area and the definition of community profiles. Schedule H, Part V, Section B, Line 6a Facility A, 1 Facility A, 1 - St. Agnes Hospital. Hospitals included in the CHNA were Agnesian Healthcare (St. Agnes Hospital), Waupun Memorial Hospital, and Ripon Medical Center. Schedule H, Part V, Section B, Line 6b Facility A, 1 Facility A, 1 - St. Agnes Hospital. St. Agnes Hospital partnered with the Fond du Lac County Health Department and Healthy Fond du Lac County. Schedule H, Part V, Section B, Line 11 Facility A, 1 Facility A, 1 - St. Agnes Hospital. The hospital identified various health needs in the 2021 CHNA. In order to make meaningful impact, and to use its finances most effectively and efficiency, the hospital will place primary focus on the following key priorities: - Mental health - Chronic disease - Substance Use Mental health According to the World Health Organization, the definition of health is a "State of complete physical, mental and social well-being, and not merely the absence of disease or infirmity." Mental health is something we all have, and it varies in its degree from time to time. If there is a significant impact on our thinking, feeling and/or behavior, treatment, services or intervention may be required. In general, the sooner one gets treatment, the better the outcome. Having an untreated mental disorder can create serious problems such as increasing the chance of risky behaviors, drug or alcohol addiction, and in extreme cases, death. It also can ruin relationships, cause problems at work, and make it difficult to overcome serious illnesses. Mental Health was identified as the number one priority to address as a result of the 2021 CHNA. Mental health needs in Fond du Lac County may include, but is not limited to challenges, barriers or needs related to provider availability, affordability, transportation, insurance, stigma, substance use, culturally sensitive and diverse providers and services, stress, and suicide. Additionally, statistics show: - 20 deaths by suicide reported in Fond du Lac County in 2020 - 1 in 5 adults reported to have a mental health condition in the past three years - 1 in 5 youth reported they always or nearly always felt sad, blue or depressed - 44% unserved children with mental illness in Fond du Lac County - 79% adults report to have their mental health condition under control (down from 96% in 2017) In order to decrease the number of deaths by suicide in Fond du Lac County, as well as increase access to behavioral health services, the hospital's action plan includes the following initiatives: - Expand trainings for Question, Persuade, Refer (QPR), Mental Health First Aid for Adults (MHFA), Youth Mental Health First Aid (YMHFA). Explore additional trainings and programs for suicide prevention and mental health - Potential new partners and collaborations: Businesses and employers - Increase means for data collection, monitoring and evaluation of mental health needs, with community partners such as DCP, and public safety departments - Research universal and individual screening tools for behavioral and mental health needs across the lifespan and develop a plan to assess and expand SBIRT at the Hospital - increase mental health/behavioral health services and access to them - increase mental health resources and navigation tools - develop more universal approach to safety planning across the country - decrease stigma, campaigns, awareness, TIC, ACEs, build community Chronic disease Chronic diseases are illnesses that last a long time, do not go away on their own, are rarely cured, and often result in disability later in life. Multiple health conditions are classified as chronic diseases such as high blood pressure, high cholesterol, heart disease, obesity, diabetes, asthma and more. Nutrition and physical activity are important to maintain and improve overall health and both play a prominent role in obesity prevention and control. As established in the U.S. Dietary Guidelines, good nutrition includes meeting nutrient recommendations yet keeping calories under control. Physical activity means any bodily activity that enhances or maintains physical fitness and overall health. Obesity is one of the most critical health issues of our time and is a complex health issue resulting from many interacting causes and factors in our society, behavior, and genetics. Obesity is also associated with poorer mental health outcomes and reduces quality of life. The burden of obesity and other diet-related chronic diseases are vast, and rates continue to rise. Changes at the community level, such as policies, systems, and environment, are more likely to be effective, although they may be more difficult to achieve. According to Fond du Lac community members responses throughout the assessment, common barriers and challenges to chronic diseases and related health behaviors included, but not limited to, access and affordability to healthy foods, awareness of nutritious food and cooking healthy meals, access to indoor and outdoor recreation, access and affordability of healthcare services. insurance, stigma, transportation, and cultural competencies. Additionally, statistics show: - Heart diseases is the number one cause of death among adults - 75% (3 in 4) adults were classified as at least overweight - About 1 in 3 youth were classified as at least overweight - 52% of adults reported meeting aerobic physical activity guidelines - 23% of adults reported eating the recommended servings of fruit per day - 17% of youth reported eating the recommended servings of fruit per day - 4,920 (6%) households reported they went hungry because they couldn't afford enough food In order to improve residents' weight, physical activity, nutrition, and increase breastfeeding, the hospital has implemented the following action items: - Research and identify chronic disease prevention and self-management classes - increase trail usage, enhance bike and pedestrian master plans - implement a physical activity campaign - increase schools participating in safe routes to school - identify existing efforts and assess impact - increase SNAP usage - increase access to and affordability of fruits and vegetables - assess current food forests or community/shared gardens and increase value/impact - increase health promotion programs offered to low-income housing residents - Increase number of childcare centers and business centers who have adopted the Ten Steps to Breastfeeding-Friendly Toolkit (Promote support for breastfeeding mothers in the workplace, early childhood education settings, and throughout the community Substance use Alcohol and other drug use means any use of a substance that result in negative consequences. This includes a broad array of mood-altering substances such as alcohol, tobacco, prescription substances, and illegal substances like methamphetamine and heroin. Negative consequences or unhealthy uses include but are not limited to, operating a motor vehicle while intoxicated, drinking while pregnant, alcohol dependence, fetal alcohol spectrum disorder, alcohol-related hospitalizations, and more. Substance use was identified as the number three priority to address in the 2022-2024 CHIP. Substance use needs in Fond du Lac County may include, but is not limited to barriers, challenges and needs related tobacco, vaping, drugs (narcotics, marijuana, etc.), prescription medications, and alcohol use, mental health and access to care. Throughout the Community Health Needs Assessment, substance use was consistently ranked as a top priority. Additionally, statistics show: - 25 opioid related deaths in Fond du Lac County in 2020, over double the deaths from 2019 - 74% of adults reported drinking alcohol in the past month - 22% of youth reported drinking alcohol in the past month - 37% of adults reported binge drinking alcohol in the past month - 37% of adults reported binge drinking alcohol in the past month The hospital's action plan includes the following initiatives to decrease underage drinking and binge drinking, and decrease misuse of opioids/prescription medication: - Increase festivals evaluated annually using the Community Events Best Practices Toolkit - Increase number of law enforcement agencies completing annual compliance checks - Decrease Alcohol Outlet density - Awareness and education campaign - Increase number of Narcan trainings and kits distributed - Syringe services program - Prescription medication prescribing practices and pain management - Prescription medication disposal The hospital has no plans to discontinue other community benefit efforts addressing the remaining CHNA-identified needs. 4 Fond du Lac Regional Clinic 420 E Division Street Fond du lac WI 54935 Outpatient clinic Consultants Lab of Wisconsin LLC 430 E Division Street Fond du lac WI 54935 Laboratory and testing Agnesian Healthcare Enterprises LLC 430 E Division Street Fond du lac WI 54935 Pharmaceuticals, home health, and medical supplies SSM Health Eye Care 421 Camelot Drive Fond du Lac WI 54935 Outpatient clinic Schedule H, Part I, Line 3c Discounted Care Exceptions Patients whose family income exceeds 400% of the FPL may be eligible to receive discounted rates on a case-by-case basis based on their specific circumstances, such as catastrophic illness or medical indigence, at the discretion of the hospital; however the discounted rates shall not be greater than the amounts generally billed to commercially insured [or Medicare] patients. In such cases, other factors may be considered in determining their eligibility for discounted or free services, including: * Bank accounts, investments and other assets * Employment status and earning capacity * Amount and frequency of bills for health care services * Other financial obligations and expenses * Generally, financial responsibility will be no more than 25% of gross family income. The hospital may utilize predictive analytical software or other criteria to assist in making a determination of financial assistance eligibility in situations where the patient qualifies for financial assistance but has not provided the necessary documentation to make a determination. This process is called "presumptive eligibility." Schedule H, Part I, Line 6a Community benefit report prepared by related organization SSM Health Care Corporation, 46-6029223 Schedule H, Part I, Line 7 Costing Methodology used to calculate financial assistance The amounts reported on Form 990, Schedule H, Part I, Line 7a, 7b, and 7c were determined using the cost to charge ratio derived from worksheet 2 in the schedule h instructions. Form 990, schedule h, part I, Lines 7e, 7f, 7g, 7h, and 7i are reported at cost as reported in the organization's financial statements. The calculation of Schedule H, Part I, Line 7, Column F utilizes 990, Part IX, Line 25, Column A, which does not include Bad Debt Expense. Schedule H, Part II Community Building Activities AGNESIAN HEALTHCARE INC PARTICIPATES IN A WIDE ARRAY OF COMMUNITY AND CIVIC ORGANIZATIONS IN THE PROMOTION OF HEALTH CARE AND COMMUNITY BUILDING ACTIVITIES. SPECIFIC ACTIVITIES REPORTED IN PART II OF SCHEDULE H INCLUDE THE FOLLOWING: ENVIRONMENTAL IMPROVEMENTS: SAFE SHARPS DISPOSAL; LEADERSHIP DEVELOPMENT AND TRAINING FOR COMMUNITY MEMBERS: SUPPORT TO HELP PROGRAMMING AND TUITION FOR VULNERABLE STUDENTS AT MARIAN UNIVERSITY; WORKFORCE DEVELOPMENT: YOUTH APPRENTICESHIP AND JOB SHADOWING; SUPPORT FOR THE FOND DU LAC WORKS PROGRAM AND ECONOMIC FORECAST BREAKFAST. Schedule H, Part III, Line 2 Bad debt expense - methodology used to estimate amount AS A RESULT OF NEW ACCOUNTING GUIDANCE, BAD DEBT IS NO LONGER AN EXPENSE, BUT IS INCLUDED AS A REDUCTION IN NET PATIENT REVENUE. Schedule H, Part III, Line 3 Bad Debt Expense Methodology FOR FINANCIAL STATEMENT PURPOSES, SSM Health HAS ADOPTED ACCOUNTING STANDARDS UPDATE NO. 2014-09 (TOPIC 606). IMPLICIT PRICE CONCESSIONS INCLUDES BAD DEBTS. THEREFORE, BAD DEBTS ARE INCLUDED IN NET PATIENT REVENUE IN ACCORDANCE WITH HEALTHCARE FINANCIAL MANAGEMENT ASSOCIATION STATEMENT NO. 15 AND BAD DEBT EXPENSE IS NOT SEPARATELY REPORTED AS AN EXPENSE. THE AMOUNT REPORTED ON PART III, LINE 3 IS THE ESTIMATED COST OF BAD DEBT ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER NORTON HOSPITAL'S FINANCIAL ASSISTANCE POLICY ON A GROSS BASIS. Schedule H, Part III, Line 4 Bad debt expense - financial statement footnote Agnesian Healthcare Inc is part of the SSM Health consolidated audit. The footnote that references the treatment of uncollectible accounts and implicit price concessions in the December 31, 2022 consolidated audit is contained on page 13, 14 and 15 of the attached financial statements. Schedule H, Part III, Line 8 Community benefit & methodology for determining medicare costs THE COSTING METHODOLOGY USED TO DETERMINE THE MEDICARE ALLOWABLE COST WAS BASED ON THE MEDICARE PRINCIPLES USED IN COMPLETING THE MEDICARE COST REPORT. ALL COST REPORTED CAME FROM THE MEDICARE COST REPORT. SSM HEALTH ACCEPTS ALL MEDICARE PATIENTS WITH THE KNOWLEDGE THAT THERE MAY BE SHORTFALLS AND OPERATES TO PROMOTE THE HEALTH OF THE COMMUNITY. SSM HEALTH BELIEVES THAT ANY MEDICARE SHORTFALL SHOULD BE TREATED AS A COMMUNITY BENEFIT BECAUSE MEDICARE DOES NOT FULLY COMPENSATE HOSPITALS FOR THE COST OF PROVIDING HOSPITAL CARE TO MEDICARE BENEFICIARIES, AS MEDICARE ALLOWED COST IS LESS THAN ACTUAL COST. Schedule H, Part III, Line 9b Collection practices for patients eligible for financial assistance Agnesian Healthcare Inc has established a written credit and collection policy and procedures. The billing and collection policies and practices reflect the mission and values of SSM Health, including our special concern for people who are poor and vulnerable. Agnesian Healthcare Inc embraces its responsibility to serve the communities in which it participates by establishing sound business practices. Agnesian Healthcare Inc's billing and collection practices will be fairly and consistently applied. All staff and vendors are expected to treat all patients consistently and fairly regardless of their ability to pay. They respond to patients in a prompt and courteous manner regarding any questions about their bills and provide notification of the availability of financial assistance. All uninsured patients will be provided a standard discount for medically necessary inpatient and outpatient services, including services provided at off-campus outpatient sites. The hospital determined the amount of the discount based on the local managed care market, applicable statutory requirements and other relevant local circumstances. The rate must be no less than the lowest effective discount rate and no greater than the highest effective discount rate for the current managed care contracts of the hospital. Uninsured patients may also qualify for an additional discount based upon financial need under the system financial assistance policy. All accounts due from the patient will receive a statement after discharge or after final adjudication from patient's insurance. Generally the patient will receive 4 months (120 days) of in-house collection efforts (including early out vendors) and 12 months of bad debt collection efforts. The hospital will make Reasonable Efforts to determine FAP eligibility including: 1. The financial assistance summary will be included with each billing statement 2. Extraordinary Collection Activity (ECAs) may not occur until bad debt placement and only after 120 days. 3. ECAs must be suspended if a guarantor submits a FAP application during the application period. 4. Reasonable measures must be taken to reverse ECAs if the application is approved which may include refunding any payments made in excess of amounts owed as an FAP-eligible individual. 5. Bad Debt vendors will gain written approval from SSM prior to engaging in ECAs. SSM will review the accounts and verify satisfactory completion of reasonable efforts during the notification and application period. A waiver is not considered reasonable efforts. Obtaining a signed waiver that an individual does not wish to apply for FAP assistance or receive FAP application information will not meet the requirement to make "reasonable efforts" to determine whether the individual is FAP-eligible before engaging in ECAs. All outside collection agencies must comply with state and federal laws, comply with the association of credit and collection professional's code of ethics and professional responsibility and comply with Agnesian Healthcare Inc's collection and financial assistance policies. Schedule H, Part V, Section B, Line 16a FAP website A - St. Agnes Hospital: Line 16a URL: https://www.ssmhealth.com/resources/patients-visitors/pay-my-bill/financial-assistance; Schedule H, Part V, Section B, Line 16b FAP Application website A - St. Agnes Hospital: Line 16b URL: https://www.ssmhealth.com/resources/patients-visitors/pay-my-bill/financial-assistance; Schedule H, Part V, Section B, Line 16c FAP plain language summary website A - St. Agnes Hospital: Line 16c URL: https://www.ssmhealth.com/resources/patients-visitors/pay-my-bill/financial-assistance; Schedule H, Part VI, Line 2 Needs assessment SSM Health (SSMH) participates in Community Benefit according to our vision. Through our participation in the healing ministry of Jesus Christ, communities, especially those that are economically, physically, and socially marginalized, will experience improved health in mind, body, spirit and environment. In the tradition of our founders, the Franciscan Sisters of Mary, caring for those in greatest need remains our organizational priority. Today our System Board monitors Community Benefit efforts, and views achievement of our vision as a primary responsibility. The purpose of SSM's Community Benefit program is to assess and address community health needs. Making our communities healthier in measurable ways is always our goal. To fulfill this commitment, SSM's Community Benefit is divided into two parts: 1) Community Health Needs Assessment (CHNA), and 2) Community Benefit Inventory for Social Accountability (CBISA). The CHNA is an assessment and prioritization of community health needs and the adoption and implementation of strategies to address those needs. A CHNA is conducted every three years by each hospital according to the following steps: * Assess and prioritize community health needs: Gather CHNA data from secondary sources; obtain input from stakeholders representing the broad interests of the community through interviews and focus groups; use data to select top health priorities; and complete written CHNA. * Develop, adopt, and implement strategies to address top-health priorities: Establish strategies to address priorities; complete Strategic Implementation Plan; obtain Regional/Divisional Board approval; and integrate strategies into operational plan. * Make CHNA widely available to the public: Publish CHNA and summary document on hospital's website. * Monitor, track, and report progress on top health priorities: Collect data and evaluate progress; report to Regional/Divisional Board every six months and System Board every year; share findings with community stakeholders; and send results to finance for submission to the Internal Revenue Service (IRS). System Office staff and leaders oversee and monitor SSMH's Community Benefit Program, and ensure reporting is in compliance with IRS regulations. In collaboration with community stakeholders and partner organizations, SSM Health Care Corporation also identifies needs based on assessments and research, and SSMH facilities also involve case managers and care team staff to pinpoint critical health issues in the community. All hospital CHNAs are completed, approved, and integrated into the organization's strategic plan. We continue to monitor and assess the progress of our local efforts in the spirit of caring for others and improving community health. Schedule H, Part VI, Line 3 Patient education of eligibility for assistance Each entity providing medical service shall provide information to the public regarding its charity care policies and the qualification requirements for each of its facilities. When standard system notices and communication regarding charity care are available, these must be used. Modifications to the standard may be made to comply with state and local laws, as well as reflect culturally sensitive terminology for the policy. All notices are easy to understand by the general public, culturally appropriate and available in those languages that are prevalent in the community. They provide information about: * The patient's responsibility for payment, * The availability of financial assistance from public programs and entity charity care and payment arrangements, * The entity's charity policy and application process, and * Who to contact to get additional information or financial counseling. The following types of notices to the public are provided: * Signs in the emergency department, outpatient and inpatient registration and public waiting areas. * Brochures or fliers provided at time of registration and available in the financial counseling areas. * Notices sent with or on patient bills or communications sent to patients and guarantors related to medical services. * Applications provided to uninsured patients at the time of registration. The application for charity care, together with any instructions, must clearly state the policies regarding charity care, including excluded services, eligibility criteria and documentation requirements. Information about the entity's charity policies is also provided to public agencies. Schedule H, Part VI, Line 4 Community information St. Agnes Hospital defines its community as Fond du Lac County and the surrounding portions of adjacent Dodge and Green Lake Counties within the hospital's primary service area. The hospital's secondary service areas also include a small portion of Sheboygan and Calumet Counties. St. Agnes Hospital is located in Fond du Lac, Wisconsin, which had an estimated population of 43,263 according to the U.S. Census. The county as a whole was estimated at 103,403 adults. When compared to Wisconsin, Fond du Lac County's population is slightly older and less diverse. The population in Fond cu Lac County and the Greater Fond du Lac Market is predominantly white with 90.8 percent and 91.6percent white population, respectively. Additional races and ethnicities that make up the population in Fond du Lac County include 3.3 percent Black/African American, 5.3 percent Hispanic/Latino, and 1.9 percent Asian. Fond du Lac County has a greater percent of the population with a high school and some college education and has a larger percent of population age 65 and older, compared to Wisconsin. The percent of population in Fond du Lac County with a household income of $50,000-$75,000 is greater compared to Wisconsin, and the percent of individuals living in poverty in Fond du Lac County is less compared to Wisconsin. Additionally, according to the Asset Limited, Income Constrained, Employed (ALICE) 24 percent of households are considered an ALICE Household, compared to 23 percent in Wisconsin. An ALICE household describes families who work, earn above the federal poverty level, but do not enough to afford a basic household budget, driving families to make tough choices to support their families, survive and thrive in the community. The highest rates of ALICE are among adults 65 years and older. Additional demographic and statistical data on Fond du Lac County's residents and their health can be found throughout the 2021 CHNA. Schedule H, Part VI, Line 5 Promotion of community health Agnesian Healthcare Inc participates in a wide array of community programs throughout the area to further its exempt purpose of promoting the health of the community. The community initiatives build on the strengths of our communities and systems to improve the quality of life and to create a sense of hope. Community Benefit initiatives build community capacity and individual empowerment through community organizing, leadership development, partnerships, and coalition building. Our Community Health programs provide compassionate and competent care while they promote health improvement by reaching directly into the community to ensure that low-income and under-served persons can access health care services. In response to the global coronavirus pandemic, Agnesian Healthcare Inc worked relentlessly to respond to community needs by developing and implementing strategies to address social needs of those served, providing screening & testing services, personal protective equipment and education throughout the community, as well as treatment for those who presented with COVID-19. Agnesian Healthcare Inc promotes grassroots advocacy and engages persons of influence to affect social and public policy change in order to promote community health. Agnesian Healthcare Inc also furthers its exempt purpose with the following activities: * Operates an emergency room that is open to all persons regardless of ability to pay, * Has an open medical staff with privileges available to all qualified physicians in the area, * Engages in the training and education of health care professionals, * Participates in Medicaid, Medicare, Champus, Tricare, and/or other government-sponsored health care programs * All surplus funds generated by SSMH entities are reinvested in improving our patient care delivery system. Schedule H, Part VI, Line 6 Affiliated health care system Agnesian Healthcare Inc is a 501(c)(3) organization and is a member of the integrated health care system know as SSM Health. SSM Health (SSMH) is a centrally managed, fully integrated health care delivery system with its headquarters based in St. Louis, Missouri. SSM Health Care Corporation (SSMHCC) (doing business as SSMH) is the principal not-for-profit corporation and has been established as the parent corporation. SSMH owns and operates 22 adult hospitals, one pediatric hospital, thirteen post-acute care facilities, a national pharmacy benefit management company (PBM), an extensive network of physician practice operations, and other health care businesses. SSMH's hospital operations are located primarily in Missouri, Wisconsin, Oklahoma and Illinois, and its related businesses provide health related services in 50 states. SSMH's mission statement is as follows: Through our exceptional health care services, we reveal the healing presence of God. SSMHCC and most of its affiliated subsidiary corporations have been granted exemption from federal income tax as charitable organizations under Section 501(c)(3) of the Internal Revenue Code (IRC). Certain subsidiaries of SSMH are for-profit entities that are taxable under the IRC. SSMH is sponsored by SSM Health Ministries, an independent nine-member body composed of two Franciscan Sisters of Mary, one Sister of St. Agnes, one Jesuit priest, and five lay persons who collectively hold certain reserved powers over SSMH. Schedule H, Part VI, Line 7 State filing of community benefit report WI true SOCIETY OF ST VINCENT DE PAUL FOND DU LAC COUNTY 330 N PETERS AVENUE FOND DU LAC WI 54935 999999999 501(C )(3) 80000 SUPPORT FOR THE CEDARHURST CENTER FOR THE ARTS BOYS & GIRLS CLUB OF FOND DU LAC INC 6 WEST 2ND STREET FOND DU LAC WI 54936 391896496 501(C )(3) 60000 GENERAL SUPPORT FOND DU LAC FAMILY YMCA 90 W SECOND ST FOND DU LAC WI 54935 390806436 501(C )(3) 53000 GENERAL SUPPORT TYPENEX MEDICAL LLC DBA ARC MEDICAL INC 303 E WACKER DR STE 1030 Chicago IL 60601 200495579 LLC PARTNERSHIP 29000 General Support FOND DU LAC COUNTY UNITED WAY 74 S MAIN ST SUITE 201 FOND DU LAC WI 54935 390806194 501(C )(3) 25000 GENERAL SUPPORT FOND DU LAC SCHOOL DISTRICT 72 W 9TH ST FOND DU LAC WI 54935 391411371 501(C )(3) 22500 General Support FONDY FOOD PANTRY INC PO BOX 492 FOND DU LAC WI 54936 510156435 501(C )(3) 15000 General Support SOLUTIONS CENTER INC 39 N SOPHIA STREET FOND DU LAC WI 54935 391452956 501(C )(3) 15000 General Support FOND DU LAC BASEBALL CLUB PO BOX 2152 FOND DU LAC WI 54936 813327957 LLC PARTNERSHIP 10000 General Support PIER PTO 259 OLD PIONEER RD FOND DU LAC WI 54935 391440939 501(C )(3) 10000 General Support BLUE LINE HOCKEY CLUB INCORPORATED 550 FOND DU LAC AVE FOND DU LAC WI 54935 237182059 501(C )(3) 10000 General Support FOND DU LAC SOCCER ASSOCIATION PO BOX 1292 FOND DU LAC WI 54936 391369383 501(C )(3) 10000 General Support FOND DU LAC AREA ASSOCIATION OF COMMERCE FOUNDATION 1020 S MAIN ST SUITE E FOND DU LAC WI 54935 510181570 501(C )(3) 8000 GENERAL SUPPORT FOND DU LAC LITERACY SVCS INC 32 SHEBOYGAN ST FOND DU LAC WI 54935 391901303 501(C )(3) 7500 General Support MAHALA'S HOPE INC N4590 HWY 45 Eden WI 53019 841680693 501(C )(3) 6000 General Support BLANDINE HOUSE INC 25 N PARK AVE FOND DU LAC WI 54935 237025601 501(C )(3) 6000 General Support 14 2 Schedule I, Part I, Line 2 Procedures for monitoring use of grant funds. THE PROCEDURES USED TO MONITOR THE USE OF GRANT FUNDING VARIES BASED ON THE GRANT RECIPIENT. GRANTS TO RELATED ENTITIES ARE MONITORED DIRECTLY BY THE ORGANIZATION WHEREBY THE RECIPIENT REPORTS ON THE SPECIFIC USE OF THE FUNDING. FOR GRANTS TO UNRELATED ENTITIES, THE ORGANIZATION UTILIZES THE COMMUNITY BENEFIT INVENTORY FOR SOCIAL ACCOUNTABILITY (CBISA) TO TRACK, STORE AND REPORT A WIDE RANGE OF INFORMATION RELATED TO GRANTS AND OVERALL COMMUNITY IMPACT. X true true false true false false false false false false false Sue Anderson DIRECTOR,CHAIR,REGIONAL PRESIDENT WI 0 619602 0 75000 0 27170 0 382472 0 14760 0 1119004 0 0 Matt Hanley MD Director, Interim Regional President - Wisconsin 0 207940 0 954328 0 706 0 11163 0 9308 0 1183446 0 522328 Mark Thompson MD Director, Regional President-Medical Groups-Wisconsin 0 594071 0 183917 0 56791 0 265834 0 42728 0 1143341 0 183917 Kris Zimmer Former Officer 0 0 0 0 0 135402 0 0 0 0 0 135402 0 372 Douglas Long Secretary, General Counsel at SSM Health 0 724576 0 460492 0 168959 0 664054 0 22673 0 2040753 0 460492 Randy Combs Treasurer, Chief Financial Officer at SSM Health 0 1144254 0 475226 0 260259 0 938234 0 32819 0 2850792 0 475226 Katherine Vergos President - St. Agnes Hospital 443295 0 130707 0 38329 0 204618 0 37046 0 853994 0 130707 0 Steve Smoot VICE PRESIDENT, COO of SSM Health 0 1084584 0 672081 0 113627 0 995370 0 38629 0 2904291 0 672081 Nancy Birschbach Former Key Employee 0 337366 0 84466 0 29474 0 136928 0 25423 0 613657 0 84466 Jim Mugan Former Key Employee 0 0 0 0 147804 0 0 0 0 0 147804 0 0 0 Michael Drees VP - Operations, Fond du Lac Clinic 297921 0 51225 0 30371 0 77282 0 29628 0 486427 0 51225 0 Tara Rhodes VP - Operations, St. Agnes Hospital 205998 0 33059 0 681 0 53932 0 37303 0 330975 0 33059 0 Tami Schattschneider VP - Patient Care Services/CNO 245190 0 40324 0 831 0 62873 0 37569 0 386787 0 40324 0 Michael Vander Kooy Radiation Oncologist 656963 0 0 0 4980 0 17850 0 51058 0 730851 0 0 0 Steven Flurry Anesthesiologist 632727 0 0 0 2700 0 27658 0 34748 0 697833 0 0 0 Syed Mohiuddin Physician 610635 0 0 0 2397 0 15738 0 41942 0 670712 0 0 0 Marcio Shiokawa Physician 594848 0 0 0 1170 0 13627 0 42327 0 651972 0 0 0 Kristof Gehrke Physician 616100 0 0 0 1697 0 16310 0 42275 0 676382 0 0 0 Schedule J, Part I, Line 1a Tax indemnification and gross-up payments An individual listed on Part VII, Section A received a tax indemnification/grossup payment in 2022. The payment was included in taxable compensation. Schedule J, Part I, Line 3 Arrangement used to establish the top management official's compensation The organization's top management official, president, is compensated by a related organization that utilized the following to determine compensation: (1) independent compensation consultant; (2) compensation survey or study; (3) approval by the board or compensation committee. Schedule J, Part I, Line 4b Supplemental nonqualified retirement plan Pension Restoration Plan: SSM Health (SSMH) provides this supplemental defined benefit nonqualified retirement plan to any employee who is a participant in the SSMH qualified defined benefit plan who earns over the Internal Revenue Service compensation limit. The plan "restores" the benefits to these employees that would have been provided under the SSMH qualified plan if the regulations did not impose compensation limits. An individual can take a distribution from the plan at (1) age 65 or older if the individual is still employed by SSMH or (2) age 55 or older if the individual is no longer employed by SSMH. No individuals listed on Part VII of Form 990 received distributions from the plan in 2022. Capital Accumulation Plan: SSMH provides this supplemental nonqualified retirement plan to executive level employees. The organization contributed a percentage of the employee's base salary into their choice of a select list of investments. The deposits and earnings of the plan are owned by SSMH and are tax-deferred until a distribution is made to the employee. In addition, the plan has special safeguards in place to protect the funds from contingencies, other than insolvency. For contributions made to the plan in 2014 or after, the distribution will occur after the completion of four plan years for all executives that are still actively employed on the distribution date. Any active participant 65 years or older will receive the contribution in the current year. THE FOLLOWING INDIVIDUALS LISTED ON PART VII OF THE FORM 990 RECEIVED DEFERRALS FROM THIS PLAN IN 2022: Randy Combs $251,115 Douglas Long $159,815 Katherine Vergos $46,356 Michael Drees $14,421 Tara Rhodes $10,086 Tami Schattschneider $12,031 STeven Flurry $9,808 Nancy Birschbach $32,852 The following individuals listed on Part VII of the Form 990 received distributions from this plan in 2022. All distributions received from the plan in the current year were included in the individual's taxable compensation. Katherine Vergos $36,795 Michael Drees $11,465 Nancy Birschbach $27,695 Jim Mugan $147,804 A Wisconsin Health and Educational Facilities Authority 391337855 97712DXT8 2017-08-10 62792652 (1) Finance capital improvements and (2) refund 2010 and 2012 bonds false false false A 6685000 63094342 656999 23301620 39135724 2020 true true true true A false false false false 0.0 0.0 0.0 false false true A false true false false false false false true true A true Schedule K, Part II, Line 3 Total proceeds from issue are not equal to issue price due to investment earnings earned during the project period. Schedule K, Part IV, Line 6 Bond proceeds were invested in a yield-restricted escrow fund beyond the 30-day temporary period. FOND DU LAC REGIONAL CLINIC SC DIRECTORS ARE EMPLOYEE-OWNERS OF INTERESTED PERSON 3790328 Physician services false HOLIDAY AUTO ENTITY OWNED BY THOR H GILBERTSON, DIRECTOR/OFFICER 99300 SALES AND SERVICE TO VEHICLES false Schedule L, Part IV, Column (b) FOND DU LAC REGIONAL CLINIC SC OWNERS THE FOLLOWING DIRECTORS LISTED ON FORM 990, PART VII, ARE EMPLOYEE-OWNERS OF THE FOND DU LAC REGIONAL CLINIC: DR BRET PATSIUK, DR JEFFERY STRONG, AND DR TED MILLER. Form 990, Part III, Line 4a Program Service Accomplishments Briefly describe the organization's mission: Since it was founded in 1872 by Catholic sisters, SSM Health (SSMH) has existed to meet the health needs of the communities it serves. SSMH is a Catholic, not-for-profit health system serving the comprehensive health needs of communities across the Midwest through one of the largest integrated delivery systems in the nation. With care delivery sites in Illinois, Missouri, Oklahoma, and Wisconsin, SSMH includes 23 acute care hospitals, one children's hospital, more than 300 physician offices and other outpatient and virtual care services, 10 post-acute facilities, comprehensive home care and hospice services, a pharmacy benefit company, a health insurance company, and an Accountable Care Organization. The health system employs nearly 40,000 people and is affiliated with 11,000 physicians making it one of the largest employers in every community it serves. In the tradition of its founding sisters, SSMH strives to fulfill its mission by providing exceptional health care to everyone who comes to its hospitals, regardless of their ability to pay. About Agnesian Healthcare Inc: Agnesian Healthcare Inc, operating as St. Agnes Hospital, has been providing healing care for almost 125 years. The hospital has grown into both an inpatient and outpatient facility providing innovative community and regional healthcare services to the greater Fond du Lac area. As a nonprofit Catholic institution, St. Agnes Hospital serves people of all faiths and beliefs. It is a leader in providing quality state-of-the-art healthcare services, whether it is cancer treatment; comprehensive heart care through the Dale Michels Center for Heart Care, including angioplasty and open-heart surgery; home or hospice care; maternity services; laser surgery; sports medicine; behavioral health services; women's health services; occupational health services; rehabilitation services and 24-hour emergency care. In 2018, St. Agnes Hospital received the American Heart Association's Get With The Guidelines - Heart Failure Silver Plus Quality Achievement Award. The award recognizes the hospital's commitment to ensuring heart failure patients receive the most appropriate treatment according to nationally recognized, research-based guidelines founded in the latest scientific evidence. St. Agnes Hospital earned the award by meeting specific quality achievement measures for the diagnosis and treatment of heart failure patients at a set level for a designated period. St. Agnes also earned The Joint Commission's Gold Seal of Approval and the American Heart Association/American Stroke Association's Heart-Check mark for advanced certification and quality for primary stroke centers. The hospital was also one of the 250 recipients of Healthgrades' 2018 Distinguished Hospital Award for Clinical Excellence. Agnesian Healthcare Inc also furthers its exempt purpose with the following activities: * Operates an emergency room that is open to all persons regardless of ability to pay * Has an open medical staff with privileges available to all qualified physicians in the area * Engages in the training and education of health care professionals, * Participates in Medicaid, Medicare, Champus, Tricare, and/or other government-sponsored health care programs * All surplus funds generated by SSMH entities are reinvested in improving our patient care delivery system Quantifiable Uncompensated Care: This section includes a list of the types of programs and services that could be quantified as uncompensated care: Traditional Charity Care $ 1,608,151 Unpaid Cost of Medicaid $ 34,431,126 Unpaid Cost of Other Government Programs $ 2,128,800 Unpaid Cost of Medicare $ 7,205,249 Total Quantifiable Uncompensated Care $ 45,373,326 Form 990, Part V, Line 1a ALL APPLICABLE 1099 AND 1096 IRS TAX FORMS ARE REPORTED AND FILED BY A RELATED ORGANIZATION, SSM HEALTH CARE CORPORATION, EIN 46-6029223. Form 990, Part VI, Line 15a Process for determining compensation A related organization utilized the following to determine compensation: (1) independent compensation consultant; (2) compensation survey or study; (3) approval by the board or compensation committee. Form 990, Part VI, Line 15b Process for determining compensation A related organization utilized the following to determine compensation: (1) independent compensation consultant; (2) compensation survey or study; (3) approval by the board or compensation committee. Form 990, Part VI, Line 2 Family/business relationships amongst interested persons DR JEFFERY STRONG, DR BRET PASIUK, AND DR TED MILLER - Business relationship Form 990, Part VI, Line 6 Classes of members or stockholders The sole member of the corporation is SSM Health Care of Wisconsin, Inc. SSM Health Care of Wisconsin, Inc, is a nonprofit 501(C)(3) organization. Both Agnesian Healthcare Inc and SSM Health Care of Wisconsin, Inc. are part of the integrated health care system known as SSM Health. Form 990, Part VI, Line 7a Members or stockholders electing members of governing body The member has the power to appoint additional, successor or replacement members and to appoint and remove the appointed directors and the ex officio directors. Form 990, Part VI, Line 7b Decisions requiring approval by members or stockholders The member has the following powers: A. to establish and change the mission, philosophy and values of the Corporation; B. to appoint additional, successor or replacement Members; C. to appoint and remove the Directors; D. to appoint and remove the President of the Corporation and the chief executive officer of any operating division of the Corporation; E. to approve amendments to the Articles of Incorporation of the Corporation as provided therein; F. to approve amendments to the Bylaws of the Corporation; G. to approve the merger, consolidation or dissolution of the Corporation; H. to approve the formation of a Controlled Subsidiary or a Remotely Controlled Subsidiary; I. to approve the sale of all or substantially all of the assets of the Corporation; J. to approve the acquisition or disposition by the Corporation of another legal entity or an interest in another legal entity; K. to authorize or approve the acquisition or disposition by the Corporation of real property or any interest in real property; L. to establish centralized employee benefit, insurance, investment, financing, corporate responsibility, performance assessment and improvement and other operational and support programs; to require the participation of the Corporation in such programs; and to authorize the opening and closing of bank accounts and investment accounts in the name of the Corporation in connection with such programs; M. to approve the strategic, financial and human resources plan of the Corporation; N. to appoint the auditor and corporate counsel for the Corporation; O. to authorize and approve borrowing money and entering into financial guaranties by the Corporation, including actions relating to the formation, joining, operation, withdrawal from and termination of a credit group or an obligated group and the granting of security interests in the property of the Corporation; P. to require the Corporation to transfer assets, including but not limited to cash, to SSMHCC or to any other entity exempt from federal income tax as an organization described in §501(c)(3) of the Internal Revenue Code of 1986, as amended, or the corresponding provision of any future United States Internal Revenue Law, which is controlled by SSMHCC, to the extent necessary to accomplish the mission, goals and objectives of SSMHCC as determined by SSMHCC; Q. to approve the transfer of assets by the Corporation to any entity other than SSMHCC, other than transfers made in the ordinary course of operations of the Corporation which will not require Member approval; and R. to determine the extent to which and the manner in which the powers described in this section which are reserved to SSMHCC with respect to the Corporation are to be included in the governing documents of any Controlled Subsidiary, Remotely Controlled Subsidiary or Non-Controlled Subsidiary and exercised with respect to any Controlled Subsidiary, any Remotely Controlled Subsidiary or any Non-Controlled Subsidiary. Form 990, Part VI, Line 11b Review of form 990 by governing body The Form 990 is prepared by the Tax Department of the parent organization, SSM Health Care Corporation (SSM). The Form 990 is reviewed by certain members of Senior Management. Any questions are addressed to the Tax Director of SSM prior to filing the Form 990 with the Internal Revenue Service. A copy of the Form 990 is provided to the Board of Directors at the next regularly scheduled board meeting. Form 990, Part VI, Line 12c Conflict of interest policy A written conflict of interest and insider transaction policy exists which requires each director, principal officer, trustee or committee member to disclose on a annual basis to the designated authority a conflict of interest disclosure statement. The designated authority ensures that all statements are completed, reviews them for conflicts, and submits to the board for review any conflict of interest disclosure statements that disclose actual or potential conflicts. Form 990, Part VI, Line 19 Required documents available to the public A written conflict of interest and insider transaction policy exists which requires each director, principal officer, trustee or committee member to disclose on a annual basis to the designated authority a conflict of interest disclosure statement. The designated authority ensures that all statements are completed, reviews them for conflicts, and submits to the board for review any conflict of interest disclosure statements that disclose actual or potential conflicts. Form 990, Part VIII, Line 2f Other Program Service Revenue All other program service revenue - Total Revenue: 26940484, Related or Exempt Function Revenue: 26940484, Unrelated Business Revenue: , Revenue Excluded from Tax Under Sections 512, 513, or 514: ; Form 990, Part VIII, Line 11d Other Miscellaneous Revenue dme - Total Revenue: 2348050, Related or Exempt Function Revenue: , Unrelated Business Revenue: 2348050, Revenue Excluded from Tax Under Sections 512, 513, or 514: ; Form 990, Part IX, Line 11g Other Fees Medical and other professional services - Total Expense: XXX-XX-XXXX, Program Service Expense: 41664494, Management and General Expenses: 75535617, Fundraising Expenses: 904; Form 990, Part XI, Line 9 Other changes in net assets or fund balances Change in beneficial interest in foundation - -597776; Consultants Laboratory of Wisconsin LLC 430 E Division Street Fond du lac WI 54935 391528550 Lab services WI 13693754 3388868 Agnesian Healthcare Inc Agnesian Healthcare Enterprises LLC 430 E Division Street Fond du lac WI 54935 392038757 Retail pharmacy WI -1329558 5473361 Agnesian Healthcare Inc SSM Health Care Corporation 10101 Woodfield Lane St Louis MO 63132 466029223 Health Care MO 501(c)(3) Type I SSM Health Ministries false SSMHC Liability Trust I 10101 Woodfield Lane St Louis MO 63132 436331003 Insurance MO 501(c)(3) Type I SSM Health Care Corporation false SSM Consolidated Health Services 10101 Woodfield Lane St Louis MO 63132 431473657 Health Care MO 501(c)(3) 10 SSM Health Care Corporation false SSM Policy Institute 10101 Woodfield Lane St Louis MO 63132 431788151 Health Care MO 501(c)(4) SSM Health Care Corporation false SSM Health Care Portfolio Management Co 10101 Woodfield Lane St Louis MO 63132 431825256 Management MO 501(c)(3) Type I SSM Health Care Corporation false SSM Cardinal Glennon Children's Hospital 10101 Woodfield Lane St Louis MO 63132 430738490 Health Care MO 501(c)(3) 3 SSM Health Care St Louis false Cardinal Glennon Children's Foundation 10101 Woodfield Lane St Louis MO 63132 431754347 Fundraising MO 501(c)(3) 7 SSM Cardinal Glennon Children's Hospital false SSM Health Foundation - St Louis 10101 Woodfield Lane St Louis MO 63132 431552945 Fundraising MO 501(c)(3) 7 SSM Health Care St Louis false SSM Health Care of Oklahoma Inc 10101 Woodfield Lane St Louis MO 63132 730657693 Health Care OK 501(c)(3) 3 SSM Health Care Corporation false The St Anthony Hospital Foundation Inc 10101 Woodfield Lane St Louis MO 63132 736104300 Fundraising OK 501(c)(3) 7 SSM Health Care of Oklahoma false SSM Health Care of Wisconsin Inc 10101 Woodfield Lane St Louis MO 63132 430688874 Health Care WI 501(c)(3) 3 SSM Health Care Corporation false Dells Medical Building Inc 10101 Woodfield Lane St Louis MO 63132 391613292 MOB WI 501(c)(2) SSM Health Care of Wisconsin false St Mary's Foundation Inc 10101 Woodfield Lane St Louis MO 63132 431940686 Fundraising WI 501(c)(3) 7 SSM Health Care of Wisconsin false St Clare Health Care Foundation Inc 10101 Woodfield Lane St Louis MO 63132 431940683 Fundraising WI 501(c)(3) 7 SSM Health Care of Wisconsin false Home Health United Inc 2802 Walton Commons Lane Madison WI 53718 391539827 Health Care WI 501(c)(3) 10 SSM Health Care of Wisconsin false Home Care United Inc 2802 Walton Commons Lane Madison WI 53718 391776340 Health Care WI 501(c)(3) 10 SSM Health Care of Wisconsin false HHU Xtra Care Inc 2802 Walton Commons Lane Madison WI 53718 391705111 Health Care WI 501(c)(3) 10 SSM Health Care of Wisconsin false SSM Health at Home Foundation of Wisconsin Inc 2802 Walton Commons Lane Madison WI 53718 391839309 Fundraising WI 501(c)(3) Type I Home Health United Inc false SSM Regional Health Services 10101 Woodfield Lane St Louis MO 63132 440579850 Health Care MO 501(c)(3) 3 SSM Health Care Corporation false St Mary's Health Center Jefferson City Missouri Foundation 10101 Woodfield Lane St Louis MO 63132 431575307 Fundraising MO 501(c)(3) Type I SSM Regional Health Services false Good Samaritan Regional Health Center 10101 Woodfield Lane St Louis MO 63132 430653587 Health Care IL 501(c)(3) 3 SSM Regional Health Services false St Mary's Hospital Centralia Illinois 10101 Woodfield Lane St Louis MO 63132 370662580 Health Care IL 501(c)(3) 3 SSM Regional Health Services false St Mary's - Good Samaritan Inc 10101 Woodfield Lane St Louis MO 63132 364170833 Health Care IL 501(c)(3) Type I SSM Regional Health Services false Good Samaritan Regional Health Center Foundation 10101 Woodfield Lane St Louis MO 63132 262884795 Fundraising IL 501(c)(3) 7 St Mary's-Good Samaritan Inc false St Mary's Hospital Foundation 10101 Woodfield Lane St Louis MO 63132 364636691 Fundraising IL 501(c)(3) 7 St Mary's-Good Samaritan Inc false St Mary's Hospital Auxiliary 400 N Pleasant Centralia IL 62801 237126345 Fundraising IL 501(c)(3) 10 St Mary's Hospital Foundation false SSM Health Businesses 10101 Woodfield Lane St Louis MO 63132 431333488 Health Care MO 501(c)(3) 10 SSM Health Care Corporation false SSM Health Care St Louis 10101 Woodfield Lane St Louis MO 63132 431343281 Health Care MO 501(c)(3) 3 SSM Health Care Corporation false Centralia Medical Services Bldg Assoc 10101 Woodfield Lane St Louis MO 63132 237408025 MOB IL 501(c)(3) Type I SSM Regional Health Services false St Mary's Janesville Foundation Inc 10101 Woodfield Lane St Louis MO 63132 273439133 Fundraising WI 501(c)(3) 7 SSM Health Care of Wisconsin false SSM Health Ministries 3221 McKelvey Road Suite 107 Bridgeton MO 63044 431012492 Religious Organization MO 501(c)(3) 1 NA false Lee Dewey Corporation 10101 Woodfield Lane St Louis MO 63132 731279603 MOB OK 501(c)(3) Type I SSM Health Care of Oklahoma false St Mary's Hospital Auxiliary 100 St Marys Medical Plaza Jefferson City MO 65101 436049878 Fundraising MO 501(c)(3) Type II NA false Good Samaritan Hospital Auxiliary 1 Good Samaritan Way Mount Vernon IL 62864 237049599 Fundraising IL 501(c)(3) Type III-FI NA false St Anthony Shawnee Hospital Inc 1000 N Lee Ave Oklahoma City OK 73102 455055149 Health Care OK 501(c)(3) 3 SSM Health Care of Oklahoma false SSM Audrain Health Care Inc 10101 Woodfield Lane St Louis MO 63132 431550298 Health Care MO 501(c)(3) 3 SSM Regional Health Services false SSM-SLUH Inc 10101 Woodfield Lane St Louis MO 63132 474196634 Health Care MO 501(c)(3) 3 SSM Health Care St Louis false Agnesian Healthcare Inc 430 E Division St Fond du Lac WI 54935 390807236 Health Care WI 501(c)(3) 3 SSM Health Care of Wisconsin false Ripon Medical Center Inc 845 Parkside Street Ripon WI 54971 391101287 Health Care WI 501(c)(3) 3 Agnesian Healthcare Inc true Waupun Memorial Hospital Inc 620 West Brown Street Waupun WI 53963 390806265 Health Care WI 501(c)(3) 3 Agnesian Healthcare Inc true St Francis Home of Fond du Lac Wisconsin Inc 33 Everett Street Fond du Lac WI 54935 391029998 Health Care WI 501(c)(3) 10 Agnesian Healthcare Inc true Sister Servants of Christ the King Villa Loretto N8114 County WW Mount Calvary WI 53057 391022770 Health Care WI 501(c)(3) 10 Agnesian Healthcare Inc true Villa Rosa Inc N8120 County WW Mount Calvary WI 53057 421670962 Health Care WI 501(c)(3) 10 Agnesian Healthcare Inc true The Christian Home and Rehabilitation Center Incorporated 331 Bly Street Waupun WI 53963 390884514 Health Care WI 501(c)(3) 10 Agnesian Healthcare Inc true The Monroe Clinic Inc 515 22nd Avenue Monroe WI 53566 390808509 Health Care WI 501(c)(3) 3 SSM Health Care of Wisconsin false Monroe Clinic and Hospital Foundation Inc 515 22nd Avenue Monroe WI 53566 205769038 Fundraising WI 501(c)(3) 7 SSM Health Care of Wisconsin false Agnesian Healthcare Foundation Inc 430 E Division St Fond du Lac WI 54935 391684956 Fundraising WI 501(c)(3) Type I SSM Health Care of Wisconsin false Shared Magnetic Resonance Imaging Facility Inc 1104 John Nolen Drive Madison WI 53713 391534744 Health Care WI 501(c)(3) Type I SSM Health Care of Wisconsin false SSM Health Cardinal Glennon Transport 10101 Woodfield Lane St Louis MO 63132 863519607 Health Care MO 501(c)(3) Type I SSM Cardinal Glennon Children's Hospital false SSM Health Foundation 10101 Woodfield Lane St Louis MO 63132 874109859 Fundraising MO 501(c)(3) Type I SSM Health Care Corporation false SSM Health Care Group 10101 Woodfield Lane St Louis MO 63132 880988603 Health Care MO 501(c)(3) 10 SSM Health Care St Louis false The Sarah Community 10101 Woodfield Lane St Louis MO 63132 431784657 Health Care MO 501(c)(3) 10 SSM Health Businesses false SSM St Joseph Endoscopy Center LLC 10101 Woodfield Lane St Louis MO 63132 270046559 Surgery Services MO NA N/A St Clare Imaging Services LLC 707 14th Street Suite A Baraboo WI 53913 200122365 Diag. Services WI NA N/A Mt Vernon Radiation Therapy Center LLC 10101 Woodfield Lane St Louis MO 63132 201382620 Radiation Therapy IL NA N/A Sleep & Neurology Center of Southern Illinois LLC 10101 Woodfield Lane St Louis MO 63132 208468195 Diag. Services IL NA N/A CHOWSMGSI Office Building LLC 10101 Woodfield Lane St Louis MO 63132 371383861 MOB IL NA N/A Oza Cancer Center LLC 10101 Woodfield Lane St Louis MO 63132 201382727 MOB IL NA N/A Shawnee Real Estate Holdings LLC 1000 N Lee Ave Oklahoma City OK 73102 455458304 MOB OK NA N/A Dean Clinic & St Mary's Hospital Accountable Care Organization LLC 1808 West Beltline Highway Madison WI 53713 452995500 Accountable Care Organization WI NA N/A Wisconsin Integrated Information Technology and Telemedicine Systems LLC 1808 West Beltline Highway Madison WI 53713 392016715 Information Technology Services WI NA N/A Wingra Building Group 1808 West Beltline Highway Madison WI 53713 390237060 MOB WI NA N/A Janesville Riverview Clinic Building Partnership 1808 West Beltline Highway Madison WI 53713 396220698 MOB WI NA N/A 1110 N Classen Blvd LLC 1110 N Classen Boulevard Oklahoma City OK 73106 731158158 MOB OK NA N/A SSM St Clare Surgical Center LLC 10101 Woodfield Lane St Louis MO 63132 261439695 Surgery Services MO NA N/A Windmill LLP 50 Village View Lane Chesterfield MO 63017 431804651 Investments MO NA N/A Navitus Health Solutions LLC 361 Integrity Drive Madison WI 53717 043608530 Pharmacy Benefits WI NA N/A SSM Select Rehab St Louis LLC 4714 Gettysburg Road Mechanicsburg PA 17055 263694972 Health Care DE NA N/A Epiphany Rx LLC 361 Integrity Drive Madison WI 53717 364855405 Pharmacy Benefits DE NA N/A Bain Capital Global Direct Lending 2021 (L Offshore) LP 200 Clarendon Street FL 41 Boston MA 021165016 981506451 Investments DE NA N/A Bloom Tree Long-Only Fund QP LP fka Bloom Tree Ponderosa Funds QP LP 101 Park Avenue 33rd FL New York NY 10178 823704522 Investments DE NA N/A Carlyle Property Investors LP 1001 Pennsylvania Ave NW STE 220 Washington DC 20004 371789359 Investments DE NA N/A NECICF II AIV2-B LP 300 Delaware Ave STE 210 Wilmington DE 19801 845058167 Investments DE NA N/A SSM Managed Care Organization LLC 10101 Woodfield Lane St Louis MO 63132 431708511 Health Promotion MO NA C Corporation false FPP INC & Subs 10101 Woodfield Lane St Louis MO 63132 431465174 Health Care MO NA C Corporation false Diversified Health Services Corp 10101 Woodfield Lane St Louis MO 63132 431369305 Medical Equipment MO NA C Corporation false SSM Properties Inc 10101 Woodfield Lane St Louis MO 63132 431462486 Property Services MO NA C Corporation false HealthFirst Physician Management Services 10101 Woodfield Lane St Louis MO 63132 731534336 Medical Services OK NA C Corporation false SSMHC Liability Trust II 10101 Woodfield Lane St Louis MO 63132 816128118 Insurance MO NA C Corporation false SSM Medical Group Inc 10101 Woodfield Lane St Louis MO 63132 431664107 Physician Offices MO NA C Corporation false SSMHC Insurance Company PO Box 1051 GT Grand Cayman CJ KY11102 030310431 Insurance CJ NA C Corporation false Physicians Services Corp of Southern Illinois Inc 10101 Woodfield Lane St Louis MO 63132 364161526 Health Care IL NA C Corporation false Dean Health Systems Inc 1808 West Beltline Highway Madison WI 53713 391128616 Physician Offices WI NA C Corporation false Dean Health Insurance Inc PO Box 56099 Madison WI 53705 391830837 Insurance WI NA C Corporation false Dean Retail Services Inc 1808 West Beltline Highway Madison WI 53713 391717636 Property Services WI NA C Corporation false Oza Oncology Inc 4117 Veterans Memorial Drive Mt Vernon IL 62804 371343746 Physician Offices IL NA S Corporation false SSM Health Janesville Campus Condominium Association Inc 1808 West Beltline Highway Madison WI 53713 832038674 Condo association WI NA C Corporation false SSM Health Pharmacy LLC 10101 Woodfield Lane St Louis MO 63132 264031708 Pharmacy MO NA C Corporation false Navitus Holdings LLC 1808 West Beltline Highway Madison WI 53713 800968174 Pharmacy WI NA C Corporation false MS Community JV LLC 401 Carlson Parkway CP330 Minnetonka MN 55305 873240022 Insurance DE NA C Corporation false Quality Drug Corporation 239 Broadway Laguna Beach CA 92651 330644268 Pharmacy benefits CA NA C Corporation false St Mary's Hospital Campus Condominium Owners Association Inc 707 South Mills Street Madison WI 53715 000000000 Condo association WI NA C Corporation false Partners Group PMC Private Credit LP c/o Maples Corporate Services LTD George Town CJ KY11104 981439264 Investment CJ NA C Corporation false false false true false false false false false false true true false true true true true false false false ST FRANCIS HOME OF FOND DU LAC M 305873 cash THE CHRISTIAN HOME AND REHABILITATION CENTER INC M 241915 CASH RIPON MEDICAL CENTER M 16237 cash WAUPUN MEMORIAL HOSPITAL M 3496 cash AGNESIAN HEALTHCARE FOUNDATION INC C 1037580 BOOK