ST MARYS-GOOD SAMARITAN INC: Form 990EZ, tax year 2021

View the entire original 990 at ProPublica ↗

Organization
ST MARYS-GOOD SAMARITAN INC (EIN 36-4170833)
Tax period
2021-01-01 to 2021-12-31
Filed
2022-11-15
IRS object ID
202203199349207500
Schema version
2021v4.2
Source
Download XML · Original 990 at ProPublica

Every field in the e-filed return. Faint text is the IRS element name, for citing.

Return header ReturnHeader

FieldValueIRS element (for citing)
Return2022-11-15T13:36:37-06:00ReturnTs
Tax Period End2021-12-31TaxPeriodEndDt
Return Type990EZReturnTypeCd
Tax Period Begin2021-01-01TaxPeriodBeginDt

Filer Filer

FieldValueIRS element (for citing)
EIN364170833EIN

Business Name BusinessName

FieldValueIRS element (for citing)
Business Name Line1St Mary's - Good Samaritan IncBusinessNameLine1Txt
FieldValueIRS element (for citing)
Business Name ControlSTMABusinessNameControlTxt
Phone6184368000PhoneNum

US Address USAddress

FieldValueIRS element (for citing)
Address Line110101 Woodfield LnAddressLine1Txt
CitySt LouisCityNm
State AbbreviationMOStateAbbreviationCd
ZIP63132ZIPCd

Business Officer BusinessOfficerGrp

FieldValueIRS element (for citing)
PersonRandy CombsPersonNm
Person TitleTreasurerPersonTitleTxt
Phone3149947800PhoneNum
Signature2022-11-15SignatureDt

Signing Officer SigningOfficerGrp

Person Full Name PersonFullName

FieldValueIRS element (for citing)
Person FirstBarbaraPersonFirstNm
Person LastPottsPersonLastNm
FieldValueIRS element (for citing)
SSN999009999SSN
FieldValueIRS element (for citing)
Tax2021TaxYr
Build TS2022-09-23 18:48:47ZBuildTS

Form 990-EZ IRS990EZ

FieldValueIRS element (for citing)
Method Of Accounting AccrualYes (X)MethodOfAccountingAccrualInd
Schedule B Not RequiredYes (X)ScheduleBNotRequiredInd
Website Addresswww.ssmhealth.comWebsiteAddressTxt
Organization501c3Yes (X)Organization501c3Ind
Type Of Organization CorpYes (X)TypeOfOrganizationCorpInd
Gross Receipts$41,630GrossReceiptsAmt
Info In Schedule O Part IYes (X)InfoInScheduleOPartIInd
Membership Dues$41,630MembershipDuesAmt
Gain Or Loss From Sale Of Assets$0GainOrLossFromSaleOfAssetsAmt
Special Events Net Income Loss$0SpecialEventsNetIncomeLossAmt
Gross Profit Loss Sls Of Invntry$0GrossProfitLossSlsOfInvntryAmt
Other Revenue Total$0OtherRevenueTotalAmt
Total Revenue$41,630TotalRevenueAmt
Grants And Similar Amounts Paid$0GrantsAndSimilarAmountsPaidAmt
Other Expenses Total$24,203OtherExpensesTotalAmt
Total Expenses$24,203TotalExpensesAmt
Excess Or Deficit For Year$17,427ExcessOrDeficitForYearAmt
Other Changes In Net Assets$0OtherChangesInNetAssetsAmt
Net Assets Or Fund Balances EOY$17,427NetAssetsOrFundBalancesEOYAmt

Other Assets Total Detail OtherAssetsTotalDetail

FieldValueIRS element (for citing)
BOY$0BOYAmt
EOY$0EOYAmt

Form990 Total Assets Form990TotalAssetsGrp

FieldValueIRS element (for citing)
BOY$0BOYAmt
EOY$0EOYAmt

Sum Of Total Liabilities SumOfTotalLiabilitiesGrp

FieldValueIRS element (for citing)
BOY$0BOYAmt
EOY$0EOYAmt

Net Assets Or Fund Balances NetAssetsOrFundBalancesGrp

FieldValueIRS element (for citing)
BOY$0BOYAmt
EOY$0EOYAmt
FieldValueIRS element (for citing)
Info In Schedule O Part IIIYes (X)InfoInScheduleOPartIIIInd
Primary Exempt PurposeTO IMPROVE ACCESS TO HEALTH CARE AND IMPROVE HEALTH IN OUR COMMUNITIES.PrimaryExemptPurposeTxt

Program Srvc Accomplishment ProgramSrvcAccomplishmentGrp

FieldValueIRS element (for citing)
Description Program Srvc AccomPLEASE SEE SCHEDULE O FOR A COMPLETE DESCRIPTION OF PROGRAM SERVICE ACCOMPLISHMENTS.DescriptionProgramSrvcAccomTxt
Program Service Expenses$24,203ProgramServiceExpensesAmt
FieldValueIRS element (for citing)
Total Program Service Expenses$24,203TotalProgramServiceExpensesAmt

Officer Director Trustee Empl OfficerDirectorTrusteeEmplGrp (17 entries)

TitleTitleTxtAverage Hrs Per Wk Devoted To PosAverageHrsPerWkDevotedToPosRtCompensationCompensationAmtEmployee Benefit ProgramEmployeeBenefitProgramAmtExpense Account Other AllwncExpenseAccountOtherAllwncAmt
Candace Jennings
Pt Yr Director, Pt Yr Chairperson, Pt Yr Regional President-St. Louis/Southern Illinois1.000$0$0$0
Sr M Clarette Stryzewski CSSF
Director, Chairperson1.000$0$0$0
Damon Harbison
Director, Hospital President-SSM Health St. Mary's Hospital0$0$0$0
Patty Williams
Director1.000$0$0$0
Michael Baumgartner
Director, Regional President-Southern Illinois1.000$0$0$0
Sr M Ramona Dombrowski CSSF
Director1.000$0$0$0
Matthew Flanigan
Director1.000$0$0$0
Stacy Tate
Director1.000$0$0$0
Ryan Willis MD
Director1.000$0$0$0
Jeremy Bradford
Director, Hospital President-SSM Health Good Samaritan Hospital1.000$0$0$0
Erica Ibendahl MD
Director, SSM Health Medical Group Physician1.000$0$0$0
Sudeep Nair MD
Director, SSM Health Medical Group Physician1.000$0$0$0
Sajjan K Nemani MD
Director1.000$0$0$0
Douglas Long
Secretary, General Counsel at SSM Health1.000$0$0$0
John Snodsmith
Regional VP, Finance1.000$0$0$0
Randy Combs
Treasurer, Chief Financial Officer at SSM Health1.000$0$0$0
Rachel Hall
Assistant Secretary1.000$0$0$0
FieldValueIRS element (for citing)
Activities Not Previously RptfalseActivitiesNotPreviouslyRptInd
Chg Made To Orgnzng Doc Not RptfalseChgMadeToOrgnzngDocNotRptInd
Organization Had UBIfalseOrganizationHadUBIInd
Subject To Proxy TaxfalseSubjectToProxyTaxInd
Organization Dissolved EtcfalseOrganizationDissolvedEtcInd
Direct Indirect Pltcl Expend$0DirectIndirectPltclExpendAmt
Form1120 Pol FiledfalseForm1120PolFiledInd
Made Loans To From OfficersfalseMadeLoansToFromOfficersInd
Engaged In Excess Benefit TransfalseEngagedInExcessBenefitTransInd
Prohibited Tax Shelter TransfalseProhibitedTaxShelterTransInd

Books In Care Of Detail BooksInCareOfDetail

Business Name BusinessName

FieldValueIRS element (for citing)
Business Name Line1Mark StoverBusinessNameLine1Txt

US Address USAddress

FieldValueIRS element (for citing)
Address Line1400 N PleasantAddressLine1Txt
CityCentraliaCityNm
State AbbreviationILStateAbbreviationCd
ZIP62801ZIPCd
FieldValueIRS element (for citing)
Phone6184367545PhoneNum
FieldValueIRS element (for citing)
Foreign Financial AccountfalseForeignFinancialAccountInd
Foreign OfficefalseForeignOfficeInd
Donor Advised FndsfalseDonorAdvisedFndsInd
Operate HospitalfalseOperateHospitalInd
Tanning Services ProvidedfalseTanningServicesProvidedInd
Related Organization Ctrl EntfalseRelatedOrganizationCtrlEntInd
Transaction With Control EntfalseTransactionWithControlEntInd
Political Campaign ActyfalsePoliticalCampaignActyInd
Lobbying ActivitiesfalseLobbyingActivitiesInd
School OperatingfalseSchoolOperatingInd
Trnsfr Exmpt Non Chrtbl Rltd OrgfalseTrnsfrExmptNonChrtblRltdOrgInd
Filed Schedule AYes (true)FiledScheduleAInd

Schedule A IRS990ScheduleA

FieldValueIRS element (for citing)
Supporting Organization509a3Yes (X)SupportingOrganization509a3Ind
Supporting Org Type1Yes (X)SupportingOrgType1Ind
Supported Organizations3SupportedOrganizationsCnt

Supported Org Information SupportedOrgInformationGrp (3 entries)

EINEINOrganization TypeOrganizationTypeCdGoverning Document ListedGoverningDocumentListedIndSupportSupportAmtOther SupportOtherSupportAmt
ST MARY'S HOSPITAL CENTRALIA ILLINOIS
3706625803Yes (true)$0$0
GOOD SAMARITAN REGIONAL HEALTH CENTER
4306535873Yes (true)$0$0
CENTRALIA MEDICAL SERVICES BUILDING ASSOCIATION
2374080259Yes (true)$0$0
FieldValueIRS element (for citing)
Supported Organizations Total3SupportedOrganizationsTotalCnt
Support Sum$0SupportSumAmt
Other Support Sum$0OtherSupportSumAmt

Form990 Sch A Supporting Org Form990SchASupportingOrgGrp

FieldValueIRS element (for citing)
Listed By Name Governing DocYes (true)ListedByNameGoverningDocInd
Suprt Org No IRS DeterminationYes (true)SuprtOrgNoIRSDeterminationInd
Supported Org Section C456falseSupportedOrgSectionC456Ind
Supported Org Not Organized USfalseSupportedOrgNotOrganizedUSInd
Organization Change Suprt OrgfalseOrganizationChangeSuprtOrgInd
Support Non Supported OrgfalseSupportNonSupportedOrgInd
Payment Substantial ContribtrfalsePaymentSubstantialContribtrInd
Loan Disqualified PersonfalseLoanDisqualifiedPersonInd
Controlled Disqualified PrsnfalseControlledDisqualifiedPrsnInd
Disqualified Prsn Controll IntfalseDisqualifiedPrsnControllIntInd
Disqualified Prsn Ownr IntfalseDisqualifiedPrsnOwnrIntInd
Excess Business Holdings RulesfalseExcessBusinessHoldingsRulesInd
Contribution ControllerfalseContributionControllerInd
Contribution FamilyfalseContributionFamilyInd
Contribution35 ControlledfalseContribution35ControlledInd

Form990 Sch A Type1 Suprt Org Form990SchAType1SuprtOrgGrp

FieldValueIRS element (for citing)
Power Appoint Majority Dir TrstYes (true)PowerAppointMajorityDirTrstInd
Operate Benefit Non Suprt OrgfalseOperateBenefitNonSuprtOrgInd

Form990 Schedule A Part VI Form990ScheduleAPartVIGrp (2 entries)

Form And Line ReferenceFormAndLineReferenceDescExplanationExplanationTxt
30 FINANCIAL SUPPORTST. MARY'S - GOOD SAMARITAN, INC. IS A TYPE I SUPPORTING ORGANIZATION THAT IS OPERATED EXCLUSIVELY TO SUPPORT THE OPERATIONS OF ST. MARY'S HOSPITAL, GOOD SAMARITAN REGIONAL HEALTH CENTER, AND CENTRALIA MEDICAL SERVICES BUILDING ASSOCIATION, RELATED TAX-EXEMPT ORGANIZATIONS. THE AMOUNTS OF SUPPORT PROVIDED TO THESE ORGANIZATIONS ON SCHEDULE A, PART I, LINE 11(H)(V) AND LINE 11(H)(VI) DO NOT INCLUDE EXPENSES PAID ON BEHALF OF BUT NOT DIRECTLY TO THESE ORGANIZATIONS.
Schedule A, Part IV, Section A, Line 2 Supported Org. Without IRS Status 509(a)1 or (2)ST. MARY'S - GOOD SAMARITAN, INC. IS A SUPPORTING ORGANIZATION THAT PROVIDES SUPPORT TO ST. MARY'S HOSPITAL CENTRALIA, ILLINOIS AND GOOD SAMARITAN REGIONAL HEALTH CENTER, BOTH TAX EXEMPT HOSPITALS. THROUGH ITS SUPPORT OF THESE TWO HOSPITALS, ST. MARY'S - GOOD SAMARITAN, INC. ALSO PROVIDES SUPPORT TO CENTRALIA MEDICAL SERVICES BUILDING ASSOCIATION, A SUPPORTING ORGANIZATION OF TO ST. MARY'S HOSPITAL CENTRALIA, ILLINOIS. CENTRALIA MEDICAL SERVICES BUILDING ASSOCIATION PROVIDES OFFICE SPACE TO PHYSICIANS, AN MRI SUITE, AND A CONVENIENT CARE LOCATION TO INCREASE THE AVAILABILITY OF DOCTORS FOR MEDICAL EMERGENCIES AND PROVIDE ADDITIONAL PATIENT ACCESSIBILITY.

Schedule O IRS990ScheduleO

Supplemental Information Detail SupplementalInformationDetail (4 entries)

Form And Line ReferenceFormAndLineReferenceDescExplanationExplanationTxt
Form 990-EZ, Part I, Line 16 Other ExpensesSUPPLIES - 329; PROFESSIONAL LIABILITY INSURANCE - 23874;
Form 990-EZ, Part III, Exempt Purpose PRIMARY EXEMPT PURPOSETO IMPROVE ACCESS TO HEALTH CARE AND IMPROVE HEALTH IN OUR COMMUNITIES.
Form 990-EZ, Part III, Program Services DetailsSINCE 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. ST. MARY'S - GOOD SAMARITAN, INC. IS COMMITTED TO THE PURPOSE OF ENABLING ITS ENTITIES, SSM HEALTH ST MARY'S HOSPITAL - CENTRALIA AND SSM HEALTH GOOD SAMARITAN HOSPITAL - MT. VERNON TO PROVIDE ACCESS TO QUALITY HEALTH CARE SERVICES TO ALL PERSONS ON THE SOUTHERN ILLINOIS REGION REGARDLESS OF THEIR ABILITY TO PAY. THROUGH ITS GOVERNANCE, OPERATION AND ADMINISTRATION, ST MARY'S - GOOD SAMARITAN, INC. HELPS TO MEET THE COMMUNITY NEEDS IDENTIFIED BY EACH HOSPITAL IN AN ECONOMIC AND EFFICIENT MANNER. THE LEADERS OF ST. MARY'S - GOOD SAMARITAN, INC. PARTICIPATE IN COMMUNITY ORGANIZATIONS WHICH ENABLE THEM TO IDENTIFY COMMUNITY NEEDS. ALL SSMH FACILITIES WILL STRIVE TO PROVIDE EXCEPTIONAL HEALTH CARE SERVICES TO ALL PERSONS IN NEED REGARDLESS OF THEIR ABILITY TO PAY. ALL BILLING AND COLLECTION POLICIES AND PRACTICES WILL REFLECT THE MISSION AND VALUES OF SSMH, INCLUDING OUR SPECIAL CONCERN FOR PEOPLE WHO ARE POOR AND VULNERABLE. SSMH FACILITIES OFFER DISCOUNTS FOR HOSPITAL SERVICES TO ALL UNINSURED PERSONS. SELF-PAY DISCOUNTS APPLY TO EVERYONE WHO DOES NOT HAVE HEALTH INSURANCE, NO MATTER THEIR ABILITY TO PAY. SSMH WILL APPLY ITS CHARITY CARE POLICIES FAIRLY AND CONSISTENTLY. EACH PERSON WILL BE TREATED AS AN INDIVIDUAL WITH SPECIFIC NEEDS FOR ASSISTANCE WITHOUT REGARD TO PAYMENT. SSMH EMBRACES ITS RESPONSIBILITY TO SERVE THE COMMUNITIES IN WHICH WE PARTICIPATE BY ESTABLISHING SOUND BUSINESS PRACTICES. CHARITY CARE IS PROVIDED TO PATIENTS BASED ON A SLIDING SCALE FOR HOUSEHOLD INCOMES UP TO FOUR TIMES THE FEDERAL POVERTY LEVEL. PATIENTS WHOSE HOUSEHOLD INCOME IS NO MORE THAN TWO TIMES THE FEDERAL POVERTY LEVEL ARE ELIGIBLE FOR FREE HOSPITAL SERVICES. IN ADDITION, AN EXCEPTION TO THE SLIDING SCALE IS PROVIDED FOR A PATIENT'S BALANCE DUE IF THE AMOUNTIS TOO LARGE TO BE REASONABLY PAID THROUGH AN INSTALLMENT PLAN OVER FOUR YEARS GIVEN THE FAMILY INCOME AND EXPENSES. EACH ENTITY PROVIDING MEDICAL SERVICES 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 COMMUNICATIONS 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 WILL BE EASY TO UNDERSTAND BY THE GENERAL PUBLIC, CULTURALLY APPROPRIATE AND AVAILABLE IN THOSE LANGUAGES THAT ARE PREVALENT IN THE COMMUNITY. THEY WILL 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 WHOM TO CONTACT TO GET ADDITIONAL INFORMATION OR FINANCIAL COUNSELING. THE FOLLOWING TYPES OF NOTICES TO THE PUBLIC SHALL BE PROVIDED: SIGNS IN THE EMERGENCY DEPARTMENT, OUTPATIENT AND INPATIENT REGISTRATION AND PUBLIC WAITING AREAS, BROCHURES OR FLIERS 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 AND 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 WILL ALSO BE PROVIDED TO PUBLIC AGENCIES. ST MARY'S - GOOD SAMARITAN, INC. SUPPORTS TWO SSMH HOSPITALS THAT: EACH OPERATE AN EMERGENCY ROOM THAT IS OPEN TO ALL PERSONS REGARDLESS OF ABILITY TO PAY, HAVE AN OPEN MEDICAL STAFF WITH PRIVILEGES AVAILABLE TO ALL QUALIFIED PHYSICIANS IN THE AREA, HAVE A GOVERNING BODY IN WHICH INDEPENDENT PERSONS REPRESENTATIVE OF THE COMMUNITY COMPRISE A MAJORITY, ENGAGE IN THE TRAINING AND EDUCATION OF HEALTH CARE PROFESSIONALS, AND PARTICIPATE IN MEDICAID, MEDICARE, CHAMPUS, TRICARE, AND/OR OTHER GOVERNMENT-SPONSORED HEALTH CARE PROGRAMS. ADDITIONAL INFORMATION REGARDING SSMH'S 2021 COMMUNITY BENEFIT REPORT CAN BE FOUND AT WWW.SSMHEALTH.COM.
30 FINANCIAL SUPPORTST. MARY'S - GOOD SAMARITAN, INC. IS A TYPE I SUPPORTING ORGANIZATION THAT IS OPERATED EXCLUSIVELY TO SUPPORT THE OPERATIONS OF ST. MARY'S HOSPITAL AND GOOD SAMARITAN REGIONAL HEALTH CENTER, RELATED TAX-EXEMPT ORGANIZATIONS. THE AMOUNTS OF SUPPORT PROVIDED TO ST MARY'S HOSPITAL AND GOOD SAMARITAN REGIONAL HEALTH CENTER ON SCHEDULE A, PART I, LINE 11(H)(VII) DO NOT INCLUDE EXPENSES PAID ON BEHALF OF BUT NOT DIRECTLY TO ST MARY'S HOSPITAL AND GOOD SAMARITAN REGIONAL HEALTH CENTER.

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