2022-05-06T11:23:20-05:00 2021-06-30 205991824 SC&H GROUP INC 910 RIDGEBROOK ROAD SPARKS MD 21152 990 2020-07-01 521638026 LUMINIS HEALTH DOCTORS COMMUNITY MEDICAL CENTER INC DOCT 4434811308 2000 MEDICAL PARKWAY NO 606 ANNAPOLIS MD 21401 KEVIN L SMITH CFO 4434811308 2022-05-04 1 KEVIN SMITH 999009999 LORI S BURGHAUSER P00370694 4104031500 2022-05-04 0 AAL1 IAL1 2020 2022-09-23 18:48:47Z VICTORIA W BAYLESS 2000 MEDICAL PARKWAY NO 606 ANNAPOLIS MD 21401 230338893 0 X WWW.DCHWEB.ORG/ X 1989 MD TO ENHANCE THE COMPREHENSIVE HEALTH CARE WE PROVIDE TO THE LOCAL AND REGIONAL COMMUNITY WE SERVE. 13 11 1818 11 496690 52808 0 17818322 247282842 211274667 349766 385501 69885 860403 247702493 230338893 22500 0 0 0 122058648 98386799 0 0 0 120090484 132629750 242171632 231016549 5530861 -677656 417636246 328661773 313449774 250281975 104186472 78379798 X THE HOSPITAL OFFERS A BROAD RANGE OF INPATIENT AND OUTPATIENT SERVICES, A NUMBER OF SPECIALTY AND SUBSPECIALTY SERVICES, AND A FULL RANGE OF ANCILLARY AND SUPPORT SERVICES. IT PROVIDES HEALTHCARE SERVICES TO THE CITIZENS OF PRINCE GEORGES COUNTY AND THE SURROUNDING COMMUNITY. THE HOSPITAL PROVIDES HEALTHCARE SERVICES TO PATIENTS REGARDLESS OF THE PATIENTS' ABILITY TO PAY. 0 0 161695553 0 210820826 PROVIDING ACCESSIBLE, HIGH QUALITY INPATIENT AND AMBULATORY HEALTHCARE SERVICES TO MEMBERS OF THE COMMUNITY, WHICH INCLUDES MOST OF PRINCE GEORGE'S COUNTY, MARYLAND AND SURROUNDING AREAS. THE HOSPITAL PROVIDES HEALTHCARE SERVICES TO PATIENTS REGARDLESS OF THE PATIENTS' ABILITY TO PAY. 161695553 1 1 0 1 0 0 0 0 0 0 1 0 0 1 1 1 0 1 0 0 1 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 1 0 0 1 194 0 1818 1 1 1 0 0 0 0 0 0 0 0 0 1 0 X 13 11 0 0 0 0 1 1 1 1 1 0 1 1 1 1 1 1 1 1 1 1 1 1 MD X KEVIN L SMITH 4434811308 2000 MEDICAL PARKWAY SUITE 606 ANNAPOLIS MD 21401 VICTORIA BAYLESS BOARD MEMBER/LUMINIS CEO 1.00 40.00 X X 0 1955497 257325 TIMOTHY ADELMAN ESQ SECRETARY/BOARD MEMBER (PART-YEAR) 1.00 40.00 X X 0 508585 54319 DENEEN RICHMOND PRESIDENT/BOARD MEMBER (PART-YEAR) 40.00 1.00 X X 0 431249 35228 REGINA HAMPTON MD MEDICAL DIRECTOR, BREAST CENTER 1.00 40.00 X 241100 0 13861 RENE LAVIGNE CHAIR 1.00 1.00 X X 0 0 0 GARY MICHAEL VICE CHAIR 1.00 1.00 X X 0 0 0 TIMOTHY J ADAMS BOARD MEMBER 1.00 1.00 X 0 0 0 PATRICIA ARZUAGA BOARD MEMBER 1.00 0.00 X 0 0 0 GEORGE L ASKEW BOARD MEMBER 1.00 0.00 X 0 0 0 LAURA CLINE BOARD MEMBER 1.00 0.00 X 0 0 0 CHARLES DUKES BOARD MEMBER (PART-YEAR) 1.00 0.00 X 0 0 0 MONSIGNOR JOHN ENZLER BOARD MEMBER 1.00 0.00 X 0 0 0 P MICHAEL ERRICO BOARD MEMBER 1.00 0.00 X 0 0 0 CARLESA R FINNEY BOARD MEMBER 1.00 1.00 X 0 0 0 JOANNE GOLDSMITH BOARD MEMBER (PART-YEAR) 1.00 0.00 X 0 0 0 RICHARD HAM BOARD MEMBER (PART-YEAR) 1.00 0.00 X 0 0 0 ALAN J HYATT ESQ BOARD MEMBER 1.00 1.00 X 0 0 0 ALICIA WILSON BOARD MEMBER 1.00 0.00 X 0 0 0 CAMILLE BASH RET 8720 CFO/TREASURER (PT YEAR) 40.00 1.00 X 530671 0 1105 KEVIN L SMITH TREASURER/LUMINIS CFO 1.00 40.00 X 0 86542 0 PAUL GRENALDO CHIEF OPERATING OFFICER 40.00 1.00 X 1313110 0 14990 SUNIL MADAN CHIEF MEDICAL OFFICER 40.00 0.00 X 711677 0 27943 JOYCE HANSCOME VP, CHIEF INFORMATION OFFICER 40.00 0.00 X 352178 0 14510 PATRICIA CHRISTENSEN CHIEF NURSING OFFICER 40.00 0.00 X 296609 0 5312 LEONID SELYA PHYSICIAN 40.00 0.00 X 701874 0 21460 HITESH AMIN GENERAL SURGEON 40.00 0.00 X 453331 0 23561 MELISSA YEAGER VP, SYSTEM INTEGRATION 40.00 0.00 X 371154 0 20727 DAVID PRESS INTERNAL MEDICINE PHYSICIAN 40.00 0.00 X 320479 0 13570 JOHN JOLY ORTHOPEDIC SURGEON 40.00 0.00 X 314211 0 14660 PHILIP DOWN FORMER CHIEF EXECUTIVE OFFICER 40.00 1.00 X 1706798 0 0 7313192 2981873 518571 278 1 1 0 ALTEON HEALTH PO BOX 645849 CINCINNATI OH 45264 PHYSICIAN OWNED & LED ACUTE CARE MEDICAL 4335254 AYA HEALTHCARE PO BOX 123519 DALLAS TX 75312 TRAVEL NURSING AGENCY 2555261 MED ONE CAPITAL FUNDING LLC PO BOX 35145 SEATTLE WA 98124 MEDICAL EQIPMENT SERVICES 1750876 INSTAPILL 222 SOUTH MAIN STREET LOS ANGELES CA 90012 MEDICATION DELIVERY 1252520 ACCOUNTS RECEIVABLE CLEARING HOUSE PO BOX 2373 GLEN BURNIE MD 21060 BILLING SERVICES 1239349 48 163071 17617543 37708 17818322 NET PATIENT REVENUE 621110 210799428 210302738 496690 OTHER OPERATING REVENUE 621300 475239 475239 211274667 360689 360689 42849 0 42849 42849 42849 24812 0 24812 24812 24812 CAFETERIA REVENUE 722210 665951 665951 ANSWERING SERVICE REV. 812900 151603 151603 817554 230338893 210820826 496690 1203055 X 5325749 5325749 77567738 63765588 13802150 519296 410531 108765 7530494 5850204 1680290 7443522 5731512 1712010 141188 141188 249000 249000 85645 85645 64881197 34137725 30743472 53820 41441 12379 3369912 2649646 720266 376635 290009 86626 4465317 3438294 1027023 2920 2248 672 4512479 3474609 1037870 12589708 9694075 2895633 1838138 1415366 422772 SUPPLIES 37759577 29074874 8684703 ENERGY COSTS 2233027 1719431 513596 UBIT 71187 71187 231016549 161695553 69320996 0 24000 9242 94720621 138332760 35092434 36572475 2639606 0 5587114 10202440 1519747 2195079 131577130 19110725 113015730 112466405 18179843 19062409 4241920 656185 106264086 -24820453 4000000 4100000 32351145 29885231 417636246 328661773 165661699 53968492 49208926 122765997 118842965 25022078 28261592 313449774 250281975 X 104092476 78285574 93996 94224 104186472 78379798 417636246 328661773 X -677656 681000 -28468815 2658797 X X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 1 38436 0 1 47209 85645 0 PART II-B, LINE 1: THE ORGANIZATION PAID ITS LOBBYIST PERCY PUBLIC AFFAIRS TO DIRECTLY CONTACT LEGISLATORS ON MATTERS AFFECTING HEALTH CARE. THE ORGANIZATION PAYS DUES TO THE MARYLAND HOSPITAL ASSOCIATION. A PORTION OF THESE DUES WERE USED FOR LOBBYING ACTIVITIES. 7922374 7922374 84946557 7872651 77073906 3765412 982057 2783355 31402728 10193750 21208978 3540059 62267 3477792 112466405 RIGHT OF USE ASSET 3949445 LIFE INSURANCE 8664315 DEPOSITS 352355 OTHER RECEIVABLES 11495761 LEASE INCENTIVE AND DEFERRED RENT 820076 OTHER LONG-TERM ASSETS 4603279 29885231 OPERATING LEASE 4830441 DEFERRED COMPENSATION AND IBNRS 8675315 PENSION OBLIGATION 2200977 CAPITAL LEASES 5085283 INTERCOMPANY 7469576 28261592 X PART X, LINE 2: UNDER THE REQUIREMENTS OF ASC 740, INCOME TAXES, TAX-EXEMPT ORGANIZATIONS COULD BE REQUIRED TO RECORD AN OBLIGATION AS THE RESULT OF A TAX POSITION THEY HAVE HISTORICALLY TAKEN ON VARIOUS TAX EXPOSURE ITEMS. THE GROUP HAS DETERMINED THAT IT DOES NOT HAVE ANY UNCERTAIN TAX POSITIONS THROUGH JUNE 30, 2021. CENTRAL AMERICA AND THE CARIBBEAN 0 0 REINSURANCE EXPENSES 8416203 CENTRAL AMERICA AND THE CARIBBEAN - ANTIGUA & BARBUDA, ARUBA, BAHAMAS, 0 0 INVESTMENT 20000 0 0 0 0 0 0 8436203 0 8436203 1 0 1 0 0 0 PART III ACCOUNTING METHOD: 1 1 1 X 1 X 330.000000000000 1 1 1 0 1 1 819043 0 819043 0.00350 819043 819043 0.00350 1372864 1372864 0.00590 1624770 1624770 0.00700 8466747 8466747 0.03660 638346 638346 0.00280 12102727 12102727 0.05230 12921770 12921770 0.05580 29759 29759 0.00010 565818 565818 0.00250 595577 595577 0.00260 1 5175876 76951777 81314304 -4362527 X 1 1 1 1 LUMINIS HEALTH DOCTORS COMMUNITY MEDICAL CENTER INC 8118 GOOD LUCK ROAD LANHAM MD 20706 HTTPS://WWW.DCHWEB.ORG/ 16022 X X X LUMINIS HEALTH DOCTORS COMMUNITY MEDICAL 1 0 0 1 X X X X X X X X X 18 1 1 1 1 X SEE PART V, SECTION C X SEE PART V, SECTION C X 1 18 1 SEE PART V, SECTION C 0 1 X 200.000000000000 330.000000000000 1 1 X X X X 1 X SEE PART V, SECTION C X SEE PART V, SECTION C X SEE PART V, SECTION C X X X X X X 1 X 0 X X X X 1 X 0 0 LUMINIS HEALTH DOCTORS COMMUNITY MEDICAL CENTER PART V, SECTION B, LINE 5: LUMINIS HEALTH DOCTORS COMMUNITY MEDICAL CENTER (DCMC) TOOK INTO ACCOUNT INPUT FROM REPRESENTATIVES OF DCMC'S COMMUNITY, INCLUDING FROM THOSE WITH SPECIALIZED KNOWLEDGE OF OR EXPERTISE IN PUBLIC HEALTH, COMMUNITY LEADERS, AND LEADERS OR REPRESENTATIVES OF LOW INCOME OR UNDERSERVED GROUPS SERVED IN THE COMMUNITY. FROM DECEMBER 2015 TO APRIL 2016 AND AGAIN IN DECEMBER 2018 TO APRIL 2019, A SURVEY PREPARED BY THE PRINCE GEORGES COUNTY HEALTH DEPARTMENT AND OTHER PRINCE GEORGES COUNTY HOSPITALS WAS DISTRIBUTED AMONG COMMUNITY MEMBERS, FAITH-BASED ORGANIZATIONS, BUSINESS LEADERS, AND TO CURRENT PATIENTS AND THEIR FAMILIES. AS PART OF THE SURVEY, RESPONDENTS SELECTED THEIR TOP FOUR HEALTHCARE CONCERNS. LUMINIS HEALTH DOCTORS COMMUNITY MEDICAL CENTER PART V, SECTION B, LINE 6A: THE CHNA WAS A JOINT UNDERTAKING WITH THE PRINCE GEORGES HEALTH DEPARTMENT, LUMINIS HEALTH DOCTORS COMMUNITY MEDICAL CENTER (DCMC), FORT WASHINGTON MEDICAL CENTER, MEDSTAR SOUTHERN MARYLAND HOSPITAL CENTER AND UNIVERSITY OF MARYLAND PRINCE GEORGE'S HOSPITAL CENTER. LUMINIS HEALTH DOCTORS COMMUNITY MEDICAL CENTER PART V, SECTION B, LINE 6B: - PRINCE GEORGE'S COUNTY HEALTH DEPARTMENT - PRINCE GEORGE'S HEALTHCARE ACTION COALITION LUMINIS HEALTH DOCTORS COMMUNITY MEDICAL CENTER PART V, SECTION B, LINE 11: THE CHNA IDENTIFIED NUMEROUS COMMUNITY HEALTH NEEDS. THE FOUR MAIN PRIORITY AREAS IDENTIFIED IN THE FISCAL YEAR 2016 CHNA CONTINUE TO BE THE FOUR PRIORITY AREAS FOR THE CURRENT CHNA (1) SOCIAL DETERMINANTS OF HEALTH, (2) BEHAVIORAL HEALTH, (3) OBESITY AND METABOLIC SYNDROME AND (4) CANCER. DCMC WILL FOCUS ON:(1) METABOLIC SYNDROME PREVENTION - EXPAND DIABETES PREVENTION PROGRAMS VIA CDC PARTNERSHIP; INCREASE PARTNER PARTICIPATION, DEVELOP HEALTH EDUCATION MATERIALS; CONTINUE/EXPAND SCREENINGS AND SERVICES PROVIDED BY THE WELLMOBILE CLINIC TO PROVIDE FREE SCREENING TO VULNERABLE RESIDENTS.(2) CANCER - CONTINUE TO PROVIDE AND EXPAND FREE EDUCATION, SCREENINGS AND SUPPORT PROGRAMS FOR BREAST, CERVICAL AND COLORECTAL CANCERS, PROGRAMS TARGETED TO UNINSURED AND UNDER-INSURED MEN AND WOMEN. INITIATE TOBACCO CESSATION PROGRAM.(3) BEHAVIORAL HEALTH - IN COLLABORATION WITH PRINCE GEORGE'S GOVERNMENT, INITIATE PLANNING FOR BEHAVIORAL HEALTH PROGRAMS TO PROVIDE ENHANCED SERVICES THAT ADDRESS NEEDS THROUGH THE DCMC EMERGENCY DEPARTMENT AND THE COMMUNITY. DEVELOP AND IMPLEMENT IN-PATIENT, OUT-PATIENT, AND URGENT CARE PROGRAMS. - UNMET HEALTH NEEDS ILLITERACY-ILLITERACY WAS IDENTIFIED IN THE CHNA. THE HOSPITAL DOES NOT HAVE THE SPECIALIZED RESOURCES CAPABILITIES NEEDED TO PROVIDE THIS TYPE OF PROGRAM. THE HOSPITAL WILL CONTINUE TO WORK WITH THE PRINCE GEORGE'S COUNTY OFFICIALS TO SEE HOW WE CAN ASSIST. LUMINIS HEALTH DOCTORS COMMUNITY MEDICAL CENTER, INC. PART V, SECTION A, FACILITY INFORMATION:HTTPS://WWW.DCHWEB.ORGPART V, SECTION B, LINE 7A, CHNA WEBSITE:HTTPS://WWW.DCHWEB.ORG/SITES/DOCTORS-COMMUNITY-HOSPITAL/FILES/COMMUNITY_HEALTH_ASSESSEMENT2019.PDFPART V, SECTION B, LINE 7B, OTHER URL:HTTPS://WWW.DCHWEB.ORG/WELLNESS/COMMUNITY-HEALTH-NEED-ASSESSMENTPART V, SECTION B, LINE 10A, IMPLEMENTATION STRATEGY:HTTPS://WWW.DCHWEB.ORG/SITES/DOCTORS-COMMUNITY-HOSPITAL/FILES/DOCUMENTS/DCMC-CHNA-IP.PDFPART V, LINE 16A, FAP WEBSITE:HTTPS://WWW.DCHWEB.ORG/PATIENTS-VISITORS/FINANCIAL-ASSISTANCE-PROGRAMLUMINIS HEALTH DOCTORS COMMUNITY MEDICAL CENTER, INC.PART V, LINE 16B, FAP APPLICATION WEBSITE:HTTPS://WWW.DCHWEB.ORG/SITES/DOCTORS-COMMUNITY-HOSPITAL/FILES/DCH_FORM_FIN-SCRN_2018-04-23.PDFLUMINIS HEALTH DOCTORS COMMUNITY MEDICAL CENTER, INC.PART V, LINE 16C, FAP PLAIN LANGUAGE SUMMARY WEBSITE:HTTPS://WWW.DCHWEB.ORG/PATIENTS-VISITORS/FINANCIAL-ASSISTANCE-PROGRAM 5 1 - DOCTORS REGIONAL CANCER CENTER 8116 GOOD LUCK ROAD LANHAM MD 20706 CANCER TREATMENT CENTER 2 - CAPITAL ORTHOPEDICS SPECIALISTS LLC 8116 GOOD LUCK ROAD LANHAM MD 20706 ORTHOPEDICS PHYSICIAN PRACTICE 3 - CAPITAL ORTHOPEDICS SPECIALISTS LLC 4000 MITCHELLVILLE ROAD B116 LANHAM MD 20706 ORTHOPEDIC PHYSICIAN PRACTICE 4 - CAPITAL ORTHOPEDICS SPECIALISTS LLC 7501 SURRATS ROAD STE 110 AND 301 CLINTON MD 20735 ORTHOPEDIC PHYSICIAN PRACTICE 5 - UNIVERSITY CENTER FOR AMBULATORY SURGICAL 6052 KENILWORTH AVENUE RIVERDALE MD 20737 AMBULATORY SURGICAL CENTER PART I, LINE 7: CHARITY CARE REPORTED IN LINE 7A WAS CALCULATED USING A COST TO CHARGE RATIO DERIVED USING THE RATIO OF PATIENT CARE COST TO CHARGES AND THE HOSPITAL'S AUDITED FINANCIAL STATEMENTS. OTHER COST AMOUNTS INCLUDED IN LINE 7 RELATING TO COMMUNITY BENEFITS AND COMMUNITY BUILDING ACTIVITIES WERE OBTAINED FROM THE ORGANIZATION'S COMMUNITY BENEFIT REPORT FILING WITH THE HSCRC IN THE STATE OF MARYLAND. THESE COSTS WERE DETERMINED USING A VARIETY OF SOURCES, INCLUDING PAYROLL INFORMATION (FOR DIRECT LABOR COSTS) AND THE ORGANIZATION'S GENERAL LEDGER SYSTEM DETAIL (FOR OTHER DIRECT COSTS E.G. SUPPLIES). INDIRECT COSTS IN THESE AREAS OF BENEFIT WERE DETERMINED BY APPLYING AN INDIRECT COST RATIO TO THE DIRECT COST AMOUNTS OBTAINED. THIS RATIO IS CALCULATED USING SCHEDULE M OF THE HOSPITAL'S ANNUAL COST REPORT FILING WITH THE HSCRC IN THE STATE OF MARYLAND.PART I, LINE 7A, COLUMN (D) AND LINE 7F, COLUMNS (C) AND (D): MARYLAND'S REGULATORY SYSTEM CREATES A UNIQUE PROCESS FOR HOSPITAL PAYMENT THAT DIFFERS FROM THE REST OF THE NATION. THE HEALTH SERVICES COST REVIEW COMMISSION, (HSCRC) DETERMINES PAYMENT THROUGH A RATE SETTING PROCESS AND ALL PAYORS, INCLUDING GOVERNMENTAL PAYORS, PAY THE SAME AMOUNT FOR THE SAME SERVICES DELIVERED AT THE SAME HOSPITAL. MARYLAND'S UNIQUE ALL PAYOR SYSTEM INCLUDES A METHOD FOR CONSIDERING UNCOMPENSATED CARE IN EACH PAYORS' RATES, AND THEREFORE MARYLAND HOSPITALS ARE UNABLE TO BREAKOUT ANY OFFSETTING REVENUE RELATED TO UNCOMPENSATED CARE. COMMUNITY BENEFIT EXPENSES ARE EQUAL TO MEDICAID REVENUES IN MARYLAND, AS SUCH, THE NET EFFECT IS ZERO. THE EXCEPTION TO THIS IS THE IMPACT ON THE HOSPITAL OF ITS SHARE OF THE MEDICAID ASSESSMENT. IN RECENT YEARS, THE STATE OF MARYLAND HAS CLOSED FISCAL GAPS IN THE STATE MEDICAID BUDGET BY ASSESSING HOSPITALS THROUGH THE RATE SETTING SYSTEM. PART I, LINE 7G: PHYSICIAN CLINIC COSTS ARE INCLUDED AS SUBSIDIZED HEALTH SERVICES BECAUSE THEY WOULD NOT OTHERWISE BE AVAILABLE TO MEET PATIENT DEMAND. PART I, LN 7 COL(F): LUMINIS HEALTH DOCTORS COMMUNITY MEDICAL CENTER (DCMC) PROMOTES ACCESS TO ALL MEDICALLY NECESSARY SERVICES REGARDLESS OF AN INDIVIDUAL'S ABILITY TO PAY. DCMC WILL PROVIDE FINANCIAL ASSISTANCE BASED ON INDIGENCE OR HIGH MEDICAL EXPENSES FOR PATIENTS WHO MEET SPECIFIED FINANCIAL CRITERIA AND REQUEST SUCH ASSISTANCE. A PATIENT WHO IS ELIGIBLE FOR FINANCIAL ASSISTANCE WILL NOT BE CHARGED MORE THAN THE AMOUNT GENERALLY BILLED TO OTHER PAYERS. PART II, COMMUNITY BUILDING ACTIVITIES: THE ENVIRONMENTAL IMPROVEMENTS AND LEADERSHIP DEVELOPMENT AND TRAINING FOR COMMUNITY MEMBERS ARE DESIGNED TO PROMOTE THE HEALTH OF THE COMMUNITY RESIDENTS AND THE COMMUNITY AS A WHOLE. THE HOSPITAL ATTENDS MANY HEALTH FAIRS THROUGHOUT THE COMMUNITY AND FOCUSES ON DIABETIC SCREENING, A COUNTY DEPARTMENT HEALTH INITIATIVE. PART III, LINE 2: SEE PART III, LINE 3 FOR EXPLANATION OF METHODOLOGY USED. PART III, LINE 3: THE HOSPITAL HAS ADOPTED HEALTHCARE FINANCIAL MANAGEMENT ASSOCIATION STATEMENT #15. THE HOSPITAL'S POLICY IS TO WRITE OFF ALL PATIENT ACCOUNTS THAT HAVE BEEN IDENTIFIED AS UNCOLLECTIBLE. AN ALLOWANCE FOR DOUBTFUL ACCOUNTS IS RECORDED FOR ACCOUNTS NOT YET WRITTEN OFF THAT ARE ANTICIPATED TO BECOME UNCOLLECTIBLE IN FUTURE PERIODS. INSURANCE COVERAGE AND CREDIT INFORMATION ARE OBTAINED FROM PATIENTS WHEN AVAILABLE. NO COLLATERAL IS OBTAINED FOR ACCOUNTS RECEIVABLE. BAD DEBT EXPENSE AT COST WAS DETERMINED BY USING A COST TO CHARGE RATIO. THE BAD DEBT EXPENSE ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S CHARITY CARE POLICY WAS DETERMINED BY SPECIFIC IDENTIFICATION REVIEWING BAD DEBT RECORDS AND DETERMINING WHO WOULD HAVE BECOME ELIGIBLE FOR CHARITY CARE IF ALL INFORMATION HAD BEEN OBTAINED FROM THE PATIENTS. PART III, LINE 4: SEE FOOTNOTE #2 OF AUDITED FINANCIAL STATEMENTS - PAGES 19-21 PART III, LINE 8: COMMUNITY BENEFIT QUESTION IS NOT APPLICABLE IN MARYLAND AS MARYLAND HOSPITALS ARE REIMBURSED UNDER THE HSCRC WAIVER PROGRAM WHEREIN NET REVENUE (REIMBURSEMENT) IS BASED ON A PERCENTAGE OF REGULATED CHARGES. COSTING METHODOLOGY BASED ON TRIAL BALANCE EXPENSES ADJUSTED TO ALLOWABLE EXPENSE IN ACCORDANCE WITH MEDICARE COST REPORTING RULES AND REGULATIONS. COST NUMBERS REPORTED ARE CONSISTENT WITH DCMC'S MEDICARE COST REPORT FILING. PART III, LINE 9B: EACH DMCC PATIENT BILL INCLUDES CONTACT INFORMATION FOR FINANCIAL ASSISTANCE AND STATES WHERE TO CALL TO REQUEST A PAYMENT PLAN. SHORT AND LONG TERM INTEREST FREE PAYMENT PLANS ARE AVAILABLE. THE HOSPITAL TAKES INTO ACCOUNT THE BALANCE OF THE BILL AND THE PATIENTS FINANCIAL CIRCUMSTANCES IN DETERMINING THE APPROPRIATE AGREEMENT. SHOULD THE PATIENT CONTACT PATIENT FINANCIAL SERVICES CUSTOMER SERVICE UNIT REGARDING INABILITY TO PAY, FINANCIAL ASSISTANCE IS OFFERED, THE AMOUNT OF WHICH IS BASED ON THE FINANCIAL ASSISTANCE SCREENING PROCESS. IF THERE IS NO INDICATION FROM THE PATIENT OR A REPRESENTATIVE THAT THEY CANNOT PAY AND NO ATTEMPT AT PAYMENT OR REASONABLE PAYMENT ARRANGEMENTS ARE MADE, THE ACCOUNT IS REFERRED TO A COLLECTION AGENCY. THE COLLECTION AGENCY IS EDUCATED ON HOW TO MAKE REFERRALS TO THE FINANCIAL COUNSELING DEPARTMENT FOR INDIVIDUALS INDICATING THEY HAVE AN INABILITY TO PAY. THE HOSPITAL COLLECTION POLICY ALLOWS THE HOSPITAL TO TAKE INTO ACCOUNT PATIENT CIRCUMSTANCES SUCH AS THE AMOUNT OF THE BILL AND AMOUNTS OWED TO OTHER PROVIDERS IN DETERMINATION OF ULTIMATE AMOUNT TO BE PAID. PART VI, LINE 2: DCMC USES A VARIETY OF STATE AND COUNTY REPORTS FOR HEALTH STATISTICS. THEY ARE AS FOLLOWS: HTTPS://WWW.PRINCEGEORGESCOUNTYMD.GOV/2561/DATA-REPORTS MARYLAND STATE HEALTH IMPROVEMENT PROCESS (SHIP) MEASURES HTTPS://POPHEALTH.HEALTH.MARYLAND.GOV/PAGES/SHIP-LITE-HOME.ASPX MD VITAL STATISTICS ADMINISTRATIONHTTP://DHMH.MARYLAND.GOV/VSA/PAGES/HOME.ASPX ROBERT WOOD JOHNSON FOUNDATION - COUNTY HEALTH RANKINGS HTTPS://WWW.COUNTYHEALTHRANKINGS.ORG/ DCMC USES A VARIETY OF OTHER SOURCES: CRISP AND DISCHARGE INFORMATION ARE ALSO USED TO IDENTIFY TARGET POPULATION AT RISK FOR READMISSION. US CENSUS DATA.THE CHNA CAN BE ACCESSED ONLINE VIA HTTPS://WWW.DCHWEB.ORG/SITES/DOCTORS-COMMUNITY-HOSPITAL/FILES/COMMUNITY_HEALTH_ASSESSEMENT2019.PDF PART VI, LINE 3: PUBLIC NOTICE AND INFORMATION REGARDING THE LUMINIS HEALTH DOCTORS COMMUNITY MEDICAL CENTER'S CHARITY CARE POLICY INCLUDES THE FOLLOWING:A) ANNUAL NOTICE THAT CHARITY CARE IS PROVIDED, AND THE CRITERIA IS PROVIDED AND PUBLISHED IN THE LOCAL NEWSPAPER, THE CAPITAL.B) THE NOTICE PROVIDED BY THE UNITED STATES DEPARTMENT OF HEALTH AND HUMAN SERVICES REGARDING MEDICAL CARE FOR THOSE WHO CANNOT AFFORD TO PAY IS POSTED AT THE POINT OF ADMISSION, THE BUSINESS OFFICE, CASHIER, AND EMERGENCY ROOM.C) INDIVIDUAL NOTICE IS PROVIDED TO EACH PERSON SEEKING SERVICE AT THE TIME OF ADMISSION OR PRE-ADMISSION TESTING.D) INFORMATION ON HOW TO OBTAIN FINANCIAL ASSISTANCE IS INCLUDED ON EVERY PATIENT LETTER AND STATEMENT.E) THE MEDICAL CENTER'S CALL CENTER REPRESENTATIVES AND COLLECTORS INFORM PATIENTS OF FINANCIAL ASSISTANCE AVAILABILITY IF THE PATIENT INDICATES THEY ARE UNABLE TO PAY THEIR BILL.F) FINANCIAL ASSISTANCE APPLICATION FORMS, IN ENGLISH AND SPANISH, ARE AVAILABLE ON THE MEDICAL CENTER'S WEBSITE.G) THE MEDICAL CENTER'S FINANCIAL ASSISTANCE POLICY, IN ENGLISH AND SPANISH, IS AVAILABLE ON THE MEDICAL CENTER'S WEBSITE.H) PAMPHLETS EXPLAINING FINANCIAL ASSISTANCE ARE AVAILABLE AT THE INFORMATION DESK AS WELL AS REGISTRATION STATIONS, INCLUDING THE EMERGENCY ROOM THROUGHOUT THE MEDICAL CENTER. PART VI, LINE 4: THE HOSPITAL SERVES PRINCE GEORGE'S COUNTY OF MARYLAND. PRINCE GEORGE'S COUNTY IS THE SECOND LARGEST JURISDICTION IN MARYLAND WITH 912,756 RESIDENTS AS REPORTED IN 2017, WHICH REPRESENTS AN INCREASE OF 110,000 SINCE 2000. THE RACE AND ETHNICITY COMPOSITION OF THE COMMUNITY IS 62.0% BLACK, NON-HISPANIC, 18.5% HISPANIC, 12.6% WHITE, NON-HISPANIC, 4.0% ASIAN, NON-HISPANIC AND 2.0% OTHER, NON-HISPANIC. THE MEDIAN HOUSEHOLD INCOME IS 81,240. THE POVERTY RATE IS 8.4%. THE HIGH SCHOOL GRADUATE PERCENTAGE FOR INDIVIDUALS 25 AND OVER IS 26.9% WITH 18.1% HOLDING A BACHELOR'S DEGREE.OUR COMMUNITY REPRESENTS A DIVERSE POPULATION. GOOD HEALTH IS NOT ATTAINABLE FOR MOST RESIDENTS. PART VI, LINE 5: DOCTORS COMMUNITY HOSPITAL IS GOVERNED BY A BOARD OF DIRECTORS THAT IS COMPRISED ALMOST ENTIRELY OF INDEPENDENT PERSONS WHO RESIDE WITHIN THE DOCTORS COMMUNITY HOSPITAL'S COMMUNITY. THE HOSPITAL EXTENDS MEDICAL STAFF PRIVILEGES TO ALL QUALIFIED PHYSICIANS FOR ALL OF ITS DEPARTMENTS. ALL FINANCIAL SURPLUSES THAT ARE GENERATED ARE USED EXCLUSIVELY TO FURTHER THE EXEMPT PURPOSES OF THE HOSPITAL AND PROMOTE THE HEALTH OF THE COMMUNITY. PART VI, LINE 6: LUMINIS HEALTH DOCTORS COMMUNITY MEDICAL CENTER OFFERS A BROAD RANGE OF INPATIENT AND OUTPATIENT SERVICES, A NUMBER OF SPECIALTY AND SUB-SPECIALTY SERVICES TO MOST OF PRINCE GEORGE'S COUNTY, MARYLAND AND SURROUNDING AREAS. THE HOSPITAL PROVIDES HEALTHCARE SERVICES TO PATIENTS REGARDLESS OF THE PATIENTS' ABILITY TO PAY. DURING FISCAL YEAR 2021 DCMC, PARTICIPATED IN SEVERAL INITIALS THAT FOCUSED ON HELPING THE COMMUNITY.CANCER:NUMEROUS CANCER INITIATIVES INCLUDED REDUCING THE MORTALITY OF BREAST, CERVICAL AND COLORECTAL CANCERS IN UNDERSERVED COMMUNITIES BY INCREASING THE NUMBER OF SCREENINGS.COVID-19 MOBILE VACCINE CLINICS:THERE WAS THE EXPANSION INTO THE HYATTSVILLE, DISTRICT HEIGHTS, AND CAPITAL HEIGHTS AREA AS THE RESULT OF HSCRC FUNDING FOR COVID-19 MOBILE VACCINE CLINICS. THESE PARTICULAR AREAS WERE UNDERSERVED AND UNDER VACCINATED.DIABETES:DIABETES EDUCATION PREVENTION INITIATIVE FOCUSED ON IMPLEMENTING DIABETES PREVENTION PROGRAMS, AS A RESULT TWO NEW COHORTS WERE STARTED DURING FY2021.MENTAL HEALTH:WORKED WITH THE COUNTY TO DEVELOP AND IMPLEMENT AN INPATIENT AND OUTPATIENT BEHAVIORAL HEALTH PROGRAM THAT'S SCHEDULED TO OPEN IN APRIL 2022.HEALTH CARE DISPARITIES:LUMINIS HEALTH HAS RELEASED A BOLD PLAN TO BECOME A NATIONAL MODEL FOR JUSTICE, EQUITY, DIVERSITY AND INCLUSION (JEDI). THE GROUNDWORK FOR THE PLAN BEGAN IN 2020 WITH THE FORMATION OF THE HEALTH SYSTEM'S HEALTH EQUITY AND ANTI-RACISM TASK (HEART) FORCE, A MULTIDISCIPLINARY GROUP CONSISTING OF MEMBERS OF THE BOARDS OF TRUSTEES, SENIOR LEADERS, MEDICAL STAFF, COMMUNITY PARTNERS AND STAKEHOLDERS. THE EVENTS OF THE YEAR 2020 PROMPTED LUMINIS HEALTH TO ASSESS DATA AND INFORMATION TO IDENTIFY GREATER OPPORTUNITY TO AFFECT CHANGE IN CONFRONTING RACISM, ADDRESSING THE EFFECTS OF SYSTEMIC INEQUITY, AND DISMANTLING STRUCTURAL INJUSTICE. THE RECOMMENDATIONS ARE STRUCTURED BY THREE MAJOR CATEGORIES:-LEAD AS AN ANTI-RACIST ORGANIZATION AND CONFRONT RACISM AND ERADICATE INEQUITIES IN HEALTH CARE.-ENHANCE CULTURALLY INFORMED COMMUNICATIONS AND COMMUNITY COLLABORATION.-MEASURE AND INTEGRATE ACCOUNTABILITY.WHILE LUMINIS HEALTH/ DCMC TRACKS UTILIZATION PATTERNS BY RACE AND ETHNICITY, THERE ARE ADDITIONAL PLANS TO MEASURE EFFORTS TO REDUCE DISPARITY. THE NEXT YEAR WILL STRUCTURE THE PROCESS TO TRACK AND REDUCE DISPARITIES IN THE COMMUNITIES WE SERVE.DOCTOR'S REGIONAL CANCER CENTER:DOCTORS REGIONAL CANCER CENTER WAS FORMED IN 2006. WITH TWO MODERN FACILITIES LOCATED IN BOWIE AND LANHAM, MARYLAND, WE PROVIDE RADIATION THERAPY SERVICES TO THE COMMUNITIES OF PRINCE GEORGE'S, ARUNDEL AND MONTGOMERY COUNTIES.OUR MISSION IS TO IMPROVE THE QUALITY OF LIFE FOR CANCER PATIENTS THROUGH THE SAFE AND PROFESSIONAL DELIVERY OF RADIATION THERAPY USING THE MOST ADVANCED TREATMENT PLANNING AND TECHNOLOGY. WE ARE DEDICATED TO UTILIZING STATE-OF-THE-ART EQUIPMENT, CLINICAL RESOURCES AND PROFESSIONAL PERSONNEL TO TREAT CANCER PATIENTS WITH DIGNITY AND RESPECT.WE ARE COMMITTED TO PROVIDING STATE-OF-THE-ART RADIATION THERAPY FOR PATIENTS WITH DIFFERENT TYPES OF CANCER. WE OFFER 4-D IGRT AND 3-D VOLUMETRIC IMAGING AT OUR LANHAM AND BOWIE LOCATIONS.OUR RADIATION ONCOLOGY SERVICES INCLUDE:ADVANCED CT SIMULATION IS A PROCESS USED TO PRECISELY IDENTIFY AND DEFINE THE TARGET TREATMENT AREA AND DELIVER AN EFFECTIVE RADIATION DOSE WHILE PROTECTING THE SURROUNDING NORMAL TISSUE. THIS IS A VERY IMPORTANT FIRST STEP FOR EVERY PATIENT RECEIVING RADIATION.THREE-DIMENSIONAL (3-D) TREATMENT PLANNING SUPPORTS SAFE AND ACCURATE TREATMENT DELIVERY. SPECIAL COMPUTER PROGRAMS USE CT IMAGES TO DESIGN RADIATION BEAMS THAT CONFORM TO THE SHAPE OF THE TUMOR. DAILY IGRT IMAGES (DESCRIBED BELOW) MONITOR THE ACCURACY OF THE TREATMENT.HIGH DOSE RATE (HDR) BRACHYTHERAPY DELIVERS RADIATION WITHIN THE CONFINES OF THE TUMOR AND IS AVAILABLE AT OUR LANHAM LOCATION. IT IS USED FOR BREAST AND PROSTATE CANCER TREATMENT AND ALLOWS PATIENTS WHO MEET THE CAREFULLY DEFINED CRITERIA TO COMPLETE TREATMENT WITHIN FIVE DAYS. IT IS ALSO USED TO TREAT GYNECOLOGICAL, ESOPHAGEAL AND THORACIC MALIGNANCIES.IMAGE GUIDED RADIATION THERAPY (IGRT) INVOLVES IMAGING THE TUMOR AREA ON A DAILY BASIS WHILE THE PATIENT IS IN THE TREATMENT POSITION. SHOULD THE IMAGE SHOW A CHANGE IS NEEDED TO ACCURATELY MATCH THE TREATMENT FIELD TO THE TUMOR, THE RADIATION ONCOLOGIST IS ABLE TO MAKE THAT MODIFICATION BEFORE THE TREATMENT IS DELIVERED.INTENSITY-MODULATED RADIATION THERAPY (IMRT) USES RADIATION BEAMS OF VARYING INTENSITIES TO DELIVER DIFFERENT DOSES OF RADIATION TO SMALL AREAS OF TISSUE AT THE SAME TIME. THIS TREATMENT ALLOWS ESCALATION OF THE DOSE OF RADIATION TO THE TUMOR WITHOUT EXCESSIVE DAMAGE TO NORMAL TISSUES. IN SELECT SITUATIONS, IMRT ALLOWS RE-TREATMENT FOR RECURRENT DISEASE.TRANS PERINEAL INTERSTITIAL BRACHYTHERAPY (PROSTATE SEED IMPLANTATION) IS PERFORMED BY A RADIATION ONCOLOGIST AND A UROLOGIST FOR TREATMENT OF PROSTATE CANCER. IT CAN BE USED ALONE OR IN CONJUNCTION WITH EXTERNAL BEAM RADIATION, WITH OR WITHOUT HORMONE TREATMENT. PART VI, LINE 7, REPORTS FILED WITH STATES MD X 1 0 X X X X X 1 1 0 0 0 0 0 0 0 VICTORIA BAYLESS BOARD MEMBER/LUMINIS CEO 0 1102812 0 440003 0 412682 0 257325 0 0 0 2212822 0 362240 PHILIP DOWN FORMER CHIEF EXECUTIVE OFFICER 0 0 388885 0 1317913 0 0 0 0 0 1706798 0 0 0 PAUL GRENALDO CHIEF OPERATING OFFICER 564323 0 634152 0 114635 0 0 0 14990 0 1328100 0 0 0 SUNIL MADAN CHIEF MEDICAL OFFICER 631945 0 63324 0 16408 0 0 0 27943 0 739620 0 0 0 LEONID SELYA PHYSICIAN 541057 0 157776 0 3041 0 0 0 21460 0 723334 0 0 0 TIMOTHY ADELMAN ESQ SECRETARY/BOARD MEMBER (PART-YEAR) 0 376850 0 111627 0 20108 0 24756 0 29563 0 562904 0 0 CAMILLE BASH RET 8720 CFO/TREASURER (PT YEAR) 530298 0 0 0 373 0 0 0 1105 0 531776 0 0 0 HITESH AMIN GENERAL SURGEON 343999 0 108989 0 343 0 0 0 23561 0 476892 0 0 0 DENEEN RICHMOND PRESIDENT/BOARD MEMBER (PART-YEAR) 0 313671 0 96002 0 21576 0 16465 0 18763 0 466477 0 0 MELISSA YEAGER VP, SYSTEM INTEGRATION 334252 0 36575 0 327 0 0 0 20727 0 391881 0 0 0 JOYCE HANSCOME VP, CHIEF INFORMATION OFFICER 317147 0 33596 0 1435 0 0 0 14510 0 366688 0 0 0 DAVID PRESS INTERNAL MEDICINE PHYSICIAN 301660 0 18360 0 459 0 0 0 13570 0 334049 0 0 0 JOHN JOLY ORTHOPEDIC SURGEON 189120 0 122548 0 2543 0 0 0 14660 0 328871 0 0 0 PATRICIA CHRISTENSEN CHIEF NURSING OFFICER 296254 0 0 0 355 0 0 0 5312 0 301921 0 0 0 REGINA HAMPTON MD MEDICAL DIRECTOR, BREAST CENTER 170613 0 70097 0 390 0 13861 0 0 0 254961 0 0 0 PART I, LINE 1B LUMINIS HEALTH DOCTOR'S COMMUNITY MEDICAL CENTER INC., FORMERLY DOCTOR'S COMMUNITY MEDICAL CENTER INC.'S APPROVED A COMPENSATION ARRANGEMENT WITH PHILIP DOWN IN 2014. UNDER THIS ARRANGEMENT, AN ANNUAL PAYMENT IS MADE FOR CERTAIN INCOME TAXES ON THE INCOME IMPUTED TO HIM ANNUALLY UNDER A LIFE INSURANCE ARRANGEMENT ADOPTED IN THE EARLY 1990S. MR. DOWN PARTICIPATES IN A SPLIT DOLLAR PLAN UNDER WHICH DOCTORS COMMUNITY ADVANCED PREMIUMS INTO LIFE INSURANCE POLICIES OWNED BY MR. DOWN. THESE PAYMENTS ARE INCLUDED IN MR. DOWN'S TAXABLE WAGES. PART I, LINES 4A-B THE FOLLOWING PARTICIPATED IN THE ORGANIZATION'S 457(F) PLAN: VICTORIA BAYLESS $ 244,500 TIMOTHY ADELMAN $ 18,231 DENEEN RICHMOND $ 11,664 DURING THE YEAR, THE FOLLOWING RECEIVED PAYMENTS AS PART OF THEIR PARTICIPATION IN THE ORGANIZATION'S 457(F) PLAN: VICTORIA BAYLESS $ 362,240 AS PART OF MR. DOWN'S TRANSITION FROM CEO, MR. DOWN IS RECEIVING SEVERANCE PAYMENTS. THESE PAYMENTS TOTALED $1,215,150 IN THE CURRENT YEAR. A MAYLAND HEALTH AND HIGHER EDUCATION 2016A 520936091 574218Y98 2016-06-29 31945000 REFINANCE 2007A AND PARTIAL 2010 0 0 0 B MAYLAND HEALTH AND HIGHER EDUCATION 2017A 520936091 574218Y98 2017-02-23 64165000 REFINANCE BOND 2010 0 0 0 C MAYLAND HEALTH AND HIGHER EDUCATION 2016B 520936091 5742158L6 2017-03-07 41500000 REFINANCE BOND 2010 0 0 0 A 385000 31945000 398892 31945000 0 1 0 1 B 64165000 1163332 64165000 0 1 0 1 C 21855000 41500000 561722 41500000 1 0 0 1 A 0 0 1 1 0 0 0 0 B 0 0 1 1 0 0 0 0 C 0 0 1 1 1 0 0 0 0 A 0 0 0 1 0 0 0 0 1 B 0 1 0 0 0 0 0 0 0 C 0 1 0 0 0 0 0 0 0 DATE REBATE COMPUTATION PERFORMED ISSUER NAME: MAYLAND HEALTH AND HIGHER EDUCATION 2016A DATE THE REBATE COMPUTATION WAS PERFORMED: 06/30/2021 FORM 990, PART VI, SECTION A, LINE 6 THE SOLE MEMBER OF THE ORGANIZATION IS LUMINIS HEALTH, INC., A SECTION 501(C)(3) ENTITY THAT SERVES AS THE PARENT CORPORATION OF THE INTEGRATED HEALTH SYSTEM. FORM 990, PART VI, SECTION A, LINE 7A THE SOLE MEMBER OF THE ORGANIZATION IS LUMINIS HEALTH, INC., A SECTION 501(C)(3) ENTITY THAT SERVES AS THE PARENT CORPORATION OF THE INTEGRATED HEALTH SYSTEM. LUMINIS HEALTH, INC. HAS THE EXPRESS POWER AND RESPONSIBILITY TO ELECT AND REMOVE THE BOARD OF DIRECTORS AND OFFICERS OF THE CORPORATION. FORM 990, PART VI, SECTION A, LINE 7B THE SOLE MEMBER OF THE ORGANIZATION IS LUMINIS HEALTH, INC., A SECTION 501(C)(3) ENTITY THAT SERVES AS THE PARENT CORPORATION OF THE INTEGRATED HEALTH SYSTEM. LUMINIS HEALTH, INC. HAS THE EXPRESS POWER AND RESPONSIBILITY TO APPROVE DECISIONS OF THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION B, LINE 11B RESPONSIBILITY FOR THE DETAILED REVIEW OF THE FORM 990 HAS BEEN ASSIGNED TO THE AUDIT AND COMPLIANCE COMMITTEE OF LUMINIS HEALTH, INC. THE AUDIT AND COMPLIANCE COMMITTEE REVIEWS THE FORM 990 AND PROVIDES SUMMARY INFORMATION TO THE FULL BOARD. THE FORM 990 IS MADE AVAILABLE TO THE FULL BOARD FOR REVIEW PRIOR TO ITS FILING. FORM 990, PART VI, SECTION B, LINE 12C THE ORGANIZATION REQUIRES THAT SENIOR EXECUTIVE LEADERS AND EACH MEMBER OF THE BOARD REVIEW THE ORGANIZATION'S CONFLICT OF INTEREST POLICY ON AN ANNUAL BASIS AND RETURN AN ACKNOWLEDGEMENT OF RECEIPT AND DISCLOSURE OF ANY POTENTIAL CONFLICTS OF INTEREST. SUBSEQUENT TO THE COMPLETION OF THE ANNUAL CONFLICT OF INTEREST QUESTIONNAIRE, IF A COVERED INDIVIDUAL BECOMES AWARE OF AN ACTUAL OR POTENTIAL CONFLICT OF INTEREST, THE COVERED INDIVIDUAL SHALL PROMPTLY DISCLOSE IT TO THE PRESIDENT OF LUMINIS HEALTH, INC. IF LUMINIS HEALTH HAS REASONABLE CAUSE TO BELIEVE THAT A COVERED INDIVIDUAL HAS FAILED TO DISCLOSE A POTENTIAL CONFLICT OF INTEREST, IT SHALL INFORM THE COVERED INDIVIDUAL OF THE BASIS FOR SUCH BELIEF AND PROVIDE THE COVERED INDIVIDUAL AN OPPORTUNITY TO EXPLAIN THE ALLEGED FAILURE TO DISCLOSE. AFTER DISCLOSURE OF AN ACTUAL OR POTENTIAL CONFLICT OF INTEREST BY A MEMBER OF THE BOARD OF TRUSTEES OR AN OFFICER OR SENIOR EXECUTIVE, THE EXECUTIVE COMMITTEE OF THE LUMINIS HEALTH BOARD SHALL DECIDE IF A CONFLICT OF INTEREST EXISTS. IF THE INTERESTED PERSON IS A MEMBER OF THE EXECUTIVE COMMITTEE, AFTER ANY DISCUSSION WITH THE INTERESTED MEMBER SUCH MEMBER SHALL LEAVE THE EXECUTIVE COMMITTEE MEETING WHILE THE DETERMINATION OF A CONFLICT OF INTEREST IS DISCUSSED AND VOTED UPON. THE EXECUTIVE COMMITTEE MAY REQUEST THAT LEGAL COUNSEL OR OTHER ADVISORS ASSIST AND ADVISE THE COMMITTEE IN CONNECTION WITH THE INVESTIGATION AND DETERMINATION OF ANY CONFLICT OF INTEREST ISSUE. IF A CONFLICT OR POTENTIAL CONFLICT IS DEEMED TO EXIST, THE MEMBER MUST REMOVE HIMSELF OR HERSELF FROM THE ROOM DURING ANY DISCUSSION OF THE MATTER, REFRAIN FROM PARTICIPATING IN DISCUSSION AND VOTING UPON OR OTHER DECISION MAKING IN REGARD TO THE MATTER, AVOID USING HIS OR HER PERSONAL INFLUENCE, AVOID MAKING AN ADMINISTRATIVE DECISION ON THE MATTER, AND, IN THE CASE OF A DIRECTOR, MUST NOT BE COUNTED IN DETERMINING THE QUORUM FOR ACTION ON THE MATTER, EVEN WHERE PERMITTED BY THE BY-LAWS. IF A MORE ADVANTAGEOUS TRANSACTION OR ARRANGEMENT IS NOT REASONABLY ATTAINABLE UNDER CIRCUMSTANCES THAT WOULD NOT GIVE RISE TO A CONFLICT OF INTEREST, THE EXECUTIVE COMMITTEE SHALL DETERMINE BY A MAJORITY VOTE WHETHER THE TRANSACTION OR ARRANGEMENT IS IN THE ORGANIZATION'S BEST INTEREST AND FOR ITS OWN BENEFIT AND WHETHER THE TRANSACTION IS FAIR AND REASONABLE TO THE ORGANIZATION AND SHALL MAKE ITS DECISIONS AS TO WHETHER TO ENTER INTO THE TRANSACTION OR ARRANGEMENT IN CONFORMITY WITH SUCH DETERMINATION. IF THE EXECUTIVE COMMITTEE DETERMINES THAT THE TRANSACTION IS IN THE BEST INTEREST OF LUMINIS HEALTH, THE COMMITTEE MAY IMPOSE SUCH CONDITIONS OR REQUIREMENTS ON THE COVERED INDIVIDUAL INCLUDING, BUT NOT LIMITED TO REQUIRING THAT THE COVERED INDIVIDUAL RECUSE HER/HIMSELF FROM DELIBERATIONS AND DECISIONS RELATING TO THOSE MATTERS WHERE THE INDIVIDUAL HAS A PERSONAL INTEREST WHICH COULD CONFLICT, OR APPEAR TO CONFLICT, WITH HER/HIS DUTY OF LOYALTY TO THE BEST INTERESTS OF THE ORGANIZATION AND LUMINIS HEALTH. FORM 990, PART VI, SECTION B, LINE 15 THE ORGANIZATION'S BOARD HAS ADOPTED A COMPENSATION POLICY FOR COVERED INDIVIDUALS. PURSUANT TO THE POLICY, A COMPENSATION COMMITTEE OF INDEPENDENT DIRECTORS WAS ESTABLISHED TO REVIEW THE COMPENSATION OF ALL EMPLOYEES SPECIFIED AS HAVING A SUBSTANTIAL INFLUENCE OVER THE ORGANIZATION AND WHO RECEIVE REMUNERATION FROM THE ORGANIZATION. THE COMPENSATION COMMITTEE IS ADVISED BY AN INDEPENDENT COMPENSATION CONSULTANT, WHO OPINES TO THE COMPENSATION COMMITTEE THAT THE LEVEL OF COMPENSATION PAID AND THE PROCESS BY WHICH COMPENSATION PAID MEET THE IRC SECTION 4958 REBUTTABLE PRESUMPTION TEST. FORM 990, PART VI, SECTION C, LINE 18 THE FORM 990 IS AVAILABLE BY REQUEST TO THE FINANCIAL SERVICES OFFICE OR CAN BE OBTAINED ONLINE VIA WWW.GUIDESTAR.ORG. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS ARE RETAINED IN THE FINANCE OFFICE AND ARE AVAILABLE FOR PUBLIC INSPECTION UPON REQUEST. FORM 990, PART IX, LINE 11G SHARED SERVICES ALLOCATION: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 22,012,352. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 22,012,352. PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 17,887,672. MANAGEMENT AND GENERAL EXPENSES 5,295,862. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 23,183,534. CONTRACT SERVICES: PROGRAM SERVICE EXPENSES 11,500,648. MANAGEMENT AND GENERAL EXPENSES 3,435,258. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 14,935,906. MEDICAL PROFESSIONAL FEES: PROGRAM SERVICE EXPENSES 4,749,405. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 4,749,405. FORM 990, PART XI, LINE 9: PENSION ADJUSTMENT 3,625,290. LOSS IN SUBSIDIARIES -1,055,146. OTHER CHANGES 88,653. FORM 990, PAGE 12, PART XII, LINE 2C THIS PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. 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