2020-11-13T10:46:20-06:00 2019-12-31 990 2019-01-01 273532963 INDIANA UNIVERSITY HEALTH WHITE MEMORIAL HOSPITAL INC % CRAIG J JONES INDI 3179634842 950 N MERIDIAN STREET Suite 300 INDIANAPOLIS IN 46204 TODD A WILLIAMS CFO 3179634842 2020-11-06 JENNIFER D RHODERICK P00395735 3176817000 162.1.179.250 35198520203185000020 2020-11-13 P EC0F867CDA2A68A93B900C7968EA20F6D551AC78 6C5B360722C3FFAFCFE5827037413334CAD8ED04 2019 2021-01-29 14:40:06Z MARY E MINIER 950 N MERIDIAN ST STE 300 INDIANAPOLIS IN 46204 34080049 false X SEE SCHEDULE O X 2010 IN Improve the health of our patients and community through innovation and excellence in care, education, research and service. 13 8 223 80 0 0 251005 468616 30388378 32729806 451679 653840 288083 163514 31379145 34015776 15000 15000 0 0 9639216 10199767 0 0 0 21395570 22640031 31049786 32854798 329359 1160978 59106976 58533779 31000300 29273049 28106676 29260730 IMPROVE THE HEALTH OF OUR PATIENTS AND COMMUNITY THROUGH INNOVATION AND EXCELLENCE IN CARE, EDUCATION, RESEARCH AND SERVICE. false false 23931070 15000 32440754 Indiana University Health White Memorial Hospital, Inc. ("IU Health White Memorial Hospital"), located in Monticello, Indiana, is a 25-bed acute-care and critical access hospital that offers a comprehensive range of services to care for its patients without regard to their ability to pay. All patient rooms are private and boast warm colors and natural light to enhance comfort and healing. A family-friendly environment offers pullout beds for overnight stays and wireless internet access. As part of its commitment to the community, the hospital offers several programs to benefit residents in the Monticello area, such as the following: - Walking Groups - Car Seat Safety Inspections - Strong Schools - Health and Safety Fair - Farmers Market at 4H Fair - CPR and Safe Sitter classes - Day of Service - Kindergarten Countdown Camps 213229 0 289052 IU Health White Memorial Hospital leases physician office and clinic space to related tax-exempt organizations. 24144299 true true false true false false false false false true true false false false true true false true false false false false false false false false true true false true true false false false false false false false false false false false false false true true true false false true 13 0 true 223 true false false false false false false false false false false false false X 13 8 false false true false true true true true true false false true true true true true true true true false IN X CRAIG J JONES 3179634842 950 N MERIDIAN STREET SUITE 300 INDIANAPOLIS IN 46204 X RUBAN NIRMALAN MD DIRECTOR 2.0 53.0 X 0 793692 41752 DANIEL E Neufelder REGIONAL PRESIDENT 10.0 45.0 X 0 653485 137797 BRIAN T SHOCKNEY FORMER OFFICER 0.0 55.0 X 0 662735 125994 ROGER G BANGS MD DIRECTOR 2.0 53.0 X 0 754478 29102 CHRISTOPHER A MANSFIE Director/ Vice Chair 2.0 53.0 X X 0 490434 48014 WILLIAM Y LI MD Director (PART YEAR) 2.0 53.0 X 0 449760 47651 MICHELE S SAYSANA M Director (PART YEAR) 2.0 53.0 X 0 463278 9426 JAMES P BIEN MD CMO - VP Quality & Safety 10.0 45.0 X 0 414510 45939 ANDREW K EDWARDS MD FORMER OFFICER 0.0 55.0 X 0 403118 42151 Adel M Khdour MD FORMER KEY EMPLOYEE 0.0 55.0 X 0 319517 47475 CARA L BREIDSTER FORMER OFFICER 0.0 55.0 X 0 321381 41748 JEFFREY C ZEH COO 10.0 45.0 X 0 324863 18711 TODD A WILLIAMS CFO/TREASURER 10.0 45.0 X 0 293058 40463 DEREK E EMPIE SECRETARY 2.0 53.0 X 0 268309 45346 Brian M Weirich CNO 10.0 45.0 X 0 246496 40004 KENNETH E MARNOCHA M DIRECTOR (PART YEAR) 2.0 53.0 X 0 250801 25348 MARY C DREWES Assoc Chief Nurse Exec Sys Ops 40.0 0.0 X 101753 125505 17300 KOREEN C KYHNELL VP - HUMAN RESOURCES 10.0 45.0 X 0 197647 40279 MARY E MINIER PRESIDENT - WHITE MEMORIAL 55.0 0.0 X 207132 0 22147 DONALD E CLAYTON MD FORMER OFFICER 0.0 55.0 X 0 186972 34117 Elsie Thoma Mgr, Pharmacy 40.0 0.0 X 160485 0 10527 JULIA B CHOI PHARMACIST 40.0 0.0 X 100700 0 29073 Sara P Phelps Supervisor, Rehabilitation Svs 40.0 0.0 X 104514 0 15849 DALE C LINOWSKI Physical Therapist 40.0 0.0 X 101092 0 18365 RANDALL R MITCHELL DIRECTOR 2.0 7.0 X 0 13500 0 REV KATE L WALKER DIRECTOR 2.0 7.0 X 0 13500 0 SHAN SHERIDAN DIRECTOR 2.0 7.0 X 0 9000 0 GARY D HENRIOTT DIRECTOR 2.0 7.0 X 0 7500 0 RANDY PRICE DIRECTOR 2.0 7.0 X 0 4500 0 VICTOR L LECHTENBERG Director/ Chairman 2.0 7.0 X X 0 3750 0 DAVID HUMMELS Director (PART YEAR) 2.0 7.0 X 0 2250 0 AMANDA WHITLOCK Director (PART YEAR) 2.0 7.0 X 0 750 0 775676 7633539 974578 6 true true false MONTICELLO EMERGENCY CARE LLC 720 S SIXTH STREET MONTICELLO IN 46960 MEDICAL 1153886 TRIMEDX LLC 5451 LAKEVIEW PKWY S DR INDIANAPOLIS IN 46268 CLINICAL ENGINEERING 8720120 WURSTER CONSTRUCTION CO INC 8463 Castlewood Dr 100 INDIANAPOLIS IN 46250 CONSTRUCTION 196079 3 152756 314460 1400 468616 NET PATIENT SERVICE REVENUE 622110 32440754 32440754 RENT FROM RELATED 501(C)(3) ORGS. 532000 289052 289052 32729806 653840 653840 0 0 128682 64273 64409 0 64409 64409 0 0 0 0 0 0 0 0 0 0 CAFETERIA/FOOD SERVICE 721210 59877 59877 EDUCATION 900099 3140 3140 ALL OTHER REVENUE 900099 36088 36088 99105 34015776 32729806 817354 X 7000 7000 8000 8000 0 0 229279 184047 45232 0 7832072 6283903 1548169 302447 246148 56299 1241594 1001014 240580 594375 470330 124045 0 0 6997 6997 230 230 0 0 9070522 3807972 5262550 0 2244 2244 127800 67296 60504 40883 36400 4483 0 956819 399774 557045 13658 7832 5826 0 4457 1885 2572 1029475 1029475 0 1672852 1440758 232094 196055 47648 148407 DRUGS AND MEDICAL SUPPLIES 4305150 4305150 BAD DEBT 2882042 2882042 INSTITUTIONAL DUES/LICENSES 21806 21806 HOSPITAL ASSESSMENT FEE 1781337 1781337 527704 114482 413222 32854798 24144299 8710499 0 0 0 25582115 26318590 0 119139 3357683 2831380 0 0 0 0 0 0 256445 232295 73630 252273 41928880 13307581 29667577 28621299 0 0 0 0 0 0 0 0 169526 158803 59106976 58533779 3574231 2432388 0 0 0 0 0 0 0 0 0 0 0 0 0 0 27426069 26840661 31000300 29273049 X 27864754 29023696 241922 237034 28106676 29260730 59106976 58533779 X 1160978 -6924 X false true X true false X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED false false false false false false false false true 230 230 false Schedule C, Part II-B, Line 1i - Other Activities IU Health White Memorial Hospital paid institutional membership dues to the Indiana Hospital Association ("IHA") during 2019 in the amount of $3,515 respectively. Each membership organization notified IU Health White Memorial Hospital that a portion of the dues it paid were used for lobbying purposes. The IHA used 6.53%, or $230 of the 2019 membership dues paid by IU Health White Memorial Hospital, for lobbying expenditures. The total membership dues paid to these organizations by IU Health White Memorial Hospital during 2019 that were attributable to lobbying expenditures was $3,515. 241922 7833 12721 237034 75520 178268 11866 241922 338947 93540 356967 75520 311889 54442 27384 338947 293053 18836 311889 0.00000 0.00000 1.00000 false true true 972779 972779 30277094 6659791 23617303 9168877 6533030 2635847 1510130 114760 1395370 28621299 0 INTERCOMPANY PAYABLES (NET) 21869270 DUE TO THIRD-PARTY PAYERS 4921253 SELF-INSURANCE LIABILITIES 32071 OPERATING LEASE LIABILITIES 18067 26840661 X Schedule D, Part V, Line 4 - Intended Use of the Org.'s Endowment Funds The net income from restricted net assets is generally used for equipment, improvements, and maintenance of the hospital's facilities. Schedule D, Part X, Line 2 - FIN 48 (ASC 740) Footnote IU Health White Memorial Hospital is a subsidiary in Indiana University Health, Inc.'s ("IU Health") Consolidated Audited Financial Statements. The Internal Revenue Service (IRS) has determined that Indiana University Health and certain of its affiliated entities are tax-exempt organizations as defined in Section 501(c)(3) of the Internal Revenue Code (IRC). Indiana University Health and its tax-exempt affiliates are, however, subject to federal and state income taxes on unrelated business income under the provisions of IRC Section 511. The Tax Cuts and Jobs Act (TCJA) was enacted on December 22, 2017. For tax-exempt entities, TCJA requires organizations to pay an excise tax on compensation above certain thresholds and record income or losses for tax determination purposes from unrelated business activities on an activity-by-activity basis, among other provisions. Proposed regulations and interim guidance, necessary for implementation, have been issued on most aspects of TCJA. It is expected that proposed regulations will be issued as final regulations by the IRS in 2020. As of and for the year ended December 31, 2019, Indiana University Health has made reasonable estimates of the provision for income taxes, the compensation excise tax, and the effects, if any, on existing deferred tax balances. Indiana University Health will continue to refine its calculations in future periods, as additional regulations and guidance are issued by the IRS. Deferred income taxes that, as of December 31, 2019 and 2018, have no net carrying value reflect the net tax effect of temporary differences between the carrying amounts of assets and liabilities for financial reporting and the amounts used for income tax purposes. As of December 31, 2019 and 2018, the Indiana University Health System had gross deferred tax assets of $143,157,000 and $119,965,000 respectively, primarily relating to net operating loss carryovers. Management determined that a full valuation allowance at December 31, 2019 and 2018, was necessary to reduce the deferred tax assets to the amount that would more likely than not be realized. Based on the weight of the evidence, if it is more likely than not that some portion or all of the deferred tax assets will not be realized, a valuation allowance to reduce the deferred tax assets is recorded. The change in the valuation allowance for the current year is $23,192,000. At December 31, 2019, the Indiana University Health System has available net operating loss carryforwards of $575,596,000. Net operating losses generated from 1999 through 2017 will expire between 2020 and 2037. Net operating losses generated after 2017 do not expire. Certain subsidiaries of Indiana University Health are taxable entities. The tax expense and liabilities of these subsidiaries are not material to the consolidated financial statements. true true X true X false true true true false true true 1305 950707 0 950707 0.03170 1858 6018467 2891561 3126906 0.10410 0 0 0 0 0.00000 3163 6969174 2891561 4077613 0.13580 7 1068 175926 175926 0.00590 1 30 476 476 0.00000 3 3683 19975 1867 18108 0.00060 11 4781 196377 1867 194510 0.00650 11 7944 7165551 2893428 4272123 0.14230 1 160 6569 6569 0.00020 1 45 7322 7322 0.00020 1 19 5107 5107 0.00020 3 224 18998 18998 0.00060 false 899197 12773255 12739444 33811 X true true 1 1 IU HEALTH WHITE MEMORIAL HOSPITAL 720 SOUTH SIXTH STREET MONTICELLO IN 47960 SEE PART V, SECTION C X X X X IU HEALTH WHITE MEMORIAL HOSPITAL 1 false false true X X X X X X X X X 18 true false false true X SEE PART V, SECTION C true 19 true SEE PART V, SECTION C false true X 200. 0. X X X X X X true true X X X true X SEE PART V, SECTION C X SEE PART V, SECTION C X SEE PART V, SECTION C X X X X X X X true X false X X X X true X false false Schedule H, Part V, Section A, Line 1 Primary Website Address https://iuhealth.org/find-locations/iu-health-white-memorial-hospital Schedule H, Part V, Section B, Line 3e Prioritized Health Needs IU HEALTH WHITE MEMORIAL HOSPITAL'S 2018 COMMUNITY HEALTH NEEDS ASSESSMENT (CHNA) REPORT INCLUDES A PRIORITIZED DESCRIPTION OF SIGNIFICANT HEALTH NEEDS IN THE COMMUNITY. THE CHNA REPORT IDENTIFIED THE FOLLOWING NEEDS AS PRIORITIES FOR IU HEALTH WHITE MEMORIAL HOSPITAL: - Access to Health Care Services - Drug and Substance Abuse - Health Care and Social Services for Seniors - Maternal and Child Health - Mental Health - Obesity and Diabetes - Smoking - Social Determinants of Health Schedule H, Part V, Section B, Line 5 - Input from Community In conducting its most recent Community Health Needs Assessment ("CHNA") IU Health White Memorial Hospital took into account input from persons who represent the broad interests of the communities it serves. Primary data were gathered in three ways: Community Meetings, Key Stakeholder Interviews, and a Community Survey. For purposes of this CHNA, IU Health White Memorial Hospital's community is defined as White County, Indiana. This county accounted for over 89 percent of the hospital's inpatient cases in 2016. Community Meetings - White County On April 23, 2018, a meeting of community representatives was held at IU Health White Memorial Hospital in Monticello, the county seat of White County. The meeting was attended by 32 community members invited by IU Health because they represent important community organizations and sectors such as: non-profit organizations, local business, health care providers, local policymakers, and schools. Through this meeting, IU Health sought a breadth of perspectives on the community's health needs. The specific organizations represented at the meeting are listed below. - Adkev, Inc. - Ball Corporation - Boys & Girls Club of White County - Carroll White REMC - Greater Monticello Chamber of Commerce - City of Monticello - Community Foundation of White County - Family Health Clinics Monon and Wolcott - Frontier School Corporation - Girtz Industries, Inc. - IU Health White Memorial Hospital - IU White Foundation - Monticello Healthcare - Monticello Spring Corporation - Monticello - Union Township Public Library - North White School Corporation - Premier Advertising - Purdue Extension - Purdue University Nutrition Education Program - Twin Lakes High School - White County Council - White County Council on Aging/Public Transit - White County Economic Development - White County Area Plan - White County United Way - ViaQuest Hospice The meeting began with a presentation that discussed the goals and status of the CHNA process and the purpose of the community meeting. Then, secondary data were presented, along with a summary of the most unfavorable community health indicators. For the community served by IU Health White Memorial Hospital, those indicators were (in alphabetical order): - Cancer incidence and mortality - Education attainment levels - Low birth weight and teen births - Motor vehicle accidents, injuries and resulting mortality - Obesity, physical inactivity and access to exercise opportunities - Physical environment and air pollution - Preventable hospitalizations Meeting participants then were asked to discuss whether the identified, unfavorable indicators accurately identified the most significant community health issues and were encouraged to add issues that they believed were significant. Several issues were added, such as: mental health, drugs, occupational medicine, Spanish-speaking services, and nutrition. During the meeting, a range of other topics was discussed, including: - Growing interest in identifying places children can go that are safe to get help - Distance individuals need to travel to obtain services and lack of transportation options - Significant Spanish-speaking population for which translation services are needed - Concerns about extent of available data for maternal and child health After discussing the needs identified through secondary data and adding others to the list, each participant was asked through a voting process to identify "three to five" they consider to be most significant. From this process, the group identified the following needs as most significant for the community served by IU Health White Memorial Hospital: - Mental health, including education of the need for these services and lack of access - Obesity, physical inactivity, and access to exercise opportunities - Drugs, including methamphetamine and opioids and lack of resources - Occupational medicine, lack of local access to these services - Nutrition, quality of food available and lack of knowledge about how to prepare healthy food Interviews - White County An interview also was conducted with a representative of the White County Health Department. The interview was conducted to assure that appropriate and additional input was received from a governmental public health official. The individual that was interviewed did not participate in the community meeting. Accordingly, the results of the community meeting were discussed and insights were sought regarding significant community health needs, why such needs are present, and how they can be addressed. The interview was guided by a structured protocol that focused on opinions regarding significant community health needs, describing why such needs are present, and seeking ideas for how to address them. The interviewee confirmed that the needs identified by the community meeting group were significant. These needs were: - Mental health - Drugs - Obesity, physical inactivity, and access to exercise opportunities Mental health and the supply of mental health providers is a need, as the county often sends people elsewhere for mental health and substance abuse treatment, especially for inpatient care. Drug overdoses have increased greatly overall, and overdoses in high school students are more noticeable. Overdoses are coming in cycles from bad batches of opioids, particularly with fentanyl or methamphetamine. Many children are being taken from homes due to positive drug tests among parents. The need for more bike trails, walking areas, and established exercise space is significant, and getting residents to use existing equipment is also challenging. Obesity, including childhood obesity, is an issue. Fast food is readily available and cheap, making healthy choices difficult. While grocery stores are present, the number of fast food options greatly outnumbers healthy options. A lack of primary care providers is a significant issue, with many family practice doctors retiring or moving away in old age. Many residents go elsewhere in the state for medical care. Many residents go to the emergency room for primary care purposes, as Medicaid patients think they may get seen quicker there than waiting elsewhere. There is one urgent care clinic, but it is very busy. There are few providers for OB care and the local hospital does not have a maternity ward. Recruitment of physicians needs to be stronger or more effective to bring providers to White County. More resources are needed for people who struggle in their family situation, for child protection, and for support in the court system for those going through addiction. Basic needs assistance programs need to be expanded to aid those in poverty, although collaboration in fixing this issue is strong presently. Parents often do not know where to go for child immunizations and leads to underutilization of these services. Communicable diseases and STDs are becoming more prominent, and more screens and education are needed to combat the issue. Community Survey To inform the CHNA, a community survey was conducted by the Indiana Hospital Collaborative. Across Indiana, 9,161 completed questionnaires were received by all participating hospitals in the Indiana Hospital Collaborative, for an overall response rate of 11.6 percent; 5,030 questionnaires were received from the 17 Indiana counties served by one or more IU Health hospitals. For IU Health White Memorial Hospital, surveys were received from 284 community households. According to the responses, these households included 514 adults. The community survey indicates that substance abuse, obesity, aging and older adult needs, alcohol use and abuse, and chronic disease represent top concerns in the community served by IU Health White Memorial Hospital. Schedule H, Part V, Section B, Line 7a - CHNA Website A copy of IU Health White Memorial Hospital's CHNA is available on its website at the following URL: https://iuhealth.org/in-the-community/community-benefit Schedule H, Part V, Section B, Line 10a - Implementation Strategy Website A copy of IU Health White Memorial Hospital's CHNA implementation strategy is available on its website at the following URL: https://iuhealth.org/in-the-community/community-benefit Schedule H, Part V, Section B, Line 11 - Addressing Identified Needs In conjunction with the CHNA, IU Health White Memorial Hospital's Board adopted an implementation strategy in April 2019 related to the 2018 CHNA. IU Health White Memorial Hospital prioritized and determined which of the community health needs identified in its most recently conducted CHNA were most critical for it to address. IU Health White Memorial Hospital will address the following community health needs between 2019 and 2021: - Access to Healthcare Services - Drug and Substance Abuse (including Opioids, Alcohol and Tobacco) - Healthcare and Social Services for Seniors - Mental Health IU Health uses the term "Behavioral Health" to refer to Mental Health and Drug and Substance Abuse (including Opioids and Alcohol). Access to Healthcare IU Health White Memorial Hospital's implementation strategy to address the identified need of Access to Healthcare includes the following: - Support telemedicine virtual visits with primary care physicians and behavioral health specialists. - Expand virtual peer recovery coaches. - Continue/expand quick response team (QRT)/paramedicine model. - In September 2019, the North Central Indiana Quick Response Team began serving White County. IU Health White Memorial's emergency department is a source for QRT referrals. - Provide recovery coach and certified recovery specialist training. - In 2019, IU Health White Memorial Hospital hosted 13 peer recovery coaches in their training and certification. - Support youth career events and organizations. - IU Health team members painted playgrounds at local schools to help increase physical activity and reduce mental strain. - Execute IU Health's five-year recruitment plan. - Explore the option to become a National Health Service Corps Site. - Still exploring the eligibility of IU Health White Memorial Hospital. - Provide windshield tours for physician recruits. - None needed. - Provide internships and onsite/offsite learning opportunities for future professionals. Behavioral Health (includes Drug & Substance Abuse and Mental Health) IU Health White Memorial Hospital's implementation strategy to address the identified need of Behavioral Health includes the following: - Create support groups for parents, families and those struggling with behavioral health issues. - IU Health White Memorial partnered with White Oak Health Campus to host support groups. Turnout was minimal, so the support groups were canceled and other avenues explored. - Support the Mental Health America Crisis Center. - IU Health White Memorial Hospital promoted the Crisis Center with local schools, providing informational magnets and marketing materials to students 5th-12th grades. - Support local schools on North Central Health Services Youth Resilience grant project. - Roosevelt Middle School received a $2,500 grant from the hospital to host a RMS Day (Resilient, Mindful, Stress-free), where all 600 students participated in several stations designed to teach them resilient coping skills. - Provide health insurance navigation. - Provide behavioral health navigation services. - Collaborate on behavioral health community initiatives. - IU Health team members participate in the White County HEALTH 4 All Coalition, leading the mental health work team. Team members also participate in the United Council on Opioids, with representatives on the Prevention, Treatment and Recovery task forces. - Increase number of behavioral health screenings. - IU Health received a grant from the IU Health Foundation to increase mental health screenings. However, the pilot project in Clinton County lasted all of 2019, with the project expected to launch in White County in 2020. - Provide trainings to hospital staff and community members (Question, Persuade, Refer (QPR) training, Mental Health First Aid, Applied Suicide Intervention Skills Training (ASIST), etc.). - Create/support awareness campaigns or events. - IU Health supported local events and campaigns, including those launched by the United Council on Opioids. Team members participated in the creation of campaign messages and themes. - Increase youth education programs to prevent substance use. - As part of the Prevention Task Force of the United Council on Opioids, children from the White County Boys and Girls Club practiced and performed an original play regarding substance use in youth. - Reduce written prescriptions of opioids. - Encourage proper storage and safe disposal of prescription medication through participation in drug take-back activities. - IU Health White Memorial Hospital received a grant from the IU Health Foundation to purchase and install a permanent medication disposal box onsite. - Expand Q-Source program. - Support opportunities for physician training and continuing education on substance use disorders (SUD). - Support community naloxone training. - IU Health served as the host site for Naloxone training in White County. - Increase the number of trained peer recovery coaches and certified recovery specialists. - In 2019, IU Health hosted 13 peer recovery coaches in their training sessions for PRC certification. - Support existing and research expansion of Quick Response Team (QRT)/community paramedicine programs. - In September 2019, the North Central Indiana Quick Response Team began serving White County. - Refer patients to local treatment facilities. - Accept primary care provider patients from local treatment facilities. - Increase health insurance navigation. - Create/support local support groups. - IU Health White Memorial partnered with White Oak Health Campus to host support groups. Turnout was minimal, so the support groups were canceled and other avenues explored. - Fund the printing of "Resource Guide: Road Map to Recovery." - At the end of 2019, IU Health White Memorial Hospital was granted $47,470 from the Indiana State Department of Health for the INCAREs ECHO grant. The work of this grant will take place in 2020 and include the creation and distribution of a local resource guide. - Support tobacco cessation program. - In 2019, IU Health White Memorial Hospital opened a cardiopulmonary rehabilitation unit, including tobacco cessation programs. - Support recovery housing options. - Collaborate with local initiatives. - IU Health team members participate in the White County HEALTH 4 All Coalition, which encompasses several community health needs, as well as the United Council on Opioids, which focuses on substance use. Healthcare and Social Services for Seniors IU Health White Memorial Hospital's implementation strategy to address the identified need of Healthcare and Social Services for Seniors include the following: - Expand the medication assistance program. - Due to team member illness, the medication assistance program was discontinued in 2019. - Provide insurance navigation for seniors. - Support organizations that provide programming or services to seniors. - Volunteer with Senior Programs. - Support the "Stepping On" classes (fall prevention). - In 2019, the IU Health Trauma Services staff provided fall risk outreach education to 365 seniors in the region. IU Health White Memorial Hospital is unable to address those community health needs that do not relate directly to the Hospital's mission to deliver healthcare. These are needs that other governmental agencies and/or community organizations have the most appropriate expertise and resources to address. IU Health White Memorial Hospital is unable to address the following community health needs identified in the 2018 Community Health Needs Assessment: Maternal and Child Health As a critical access hospital, IU Health White Memorial Hospital does not provide maternity services in their facility. However, there are support services available to pregnant women and young mothers in each community. The Nurse Family Partnership provides in-home services to qualifying families. IU Health Arnett Hospital provides maternity services in the region, as well as post-partum and breastfeeding support groups for new mothers. As a system, IU Health is addressing maternal and child health by focusing on infant mortality, creating a system-wide collaborative to focus on this issue. Obesity and Diabetes IU Health White Memorial Hospital focused on obesity prevention as one of the priority health needs from 2015-2018. The hospital supported many activities in each community. However, during the 2018 community health needs assessment, other needs arose as more severe and necessary to address. There are other community resources that continue to address obesity and diabetes. There are coalitions in each community that address healthy eating and active living. The hospitals provide diabetes education programs. Purdue Extension is another community resource to address obesity and diabetes. IU Health staff will continue to participate in the White County HEALTH Coalition, which addresses healthy eating and active living. Social Determinants of Health Many of the strategies will indirectly Schedule H, Part V, Section B, Line 13b - Income Level Other than FPG In addition to FPG, IU Health White Memorial Hospital may take into consideration a patient's income and/or ability to pay in calculation of a financial assistance award. Schedule H, Part V, Section B, Line 13h - Other FAP Factors IU Health White Memorial Hospital takes into consideration several other factors in determining patient eligibility for financial assistance. These factors include the following: 1. IU Health's Individual Solutions Department Prior to seeking Financial Assistance under the FAP, all patients or their guarantors must consult with a member of IU Health's Individual Solutions department to determine if healthcare coverage may be obtained from a government insurance/assistance product or from the Health Insurance Exchange Marketplace. 2. Alternate Sources of Assistance When technically feasible, a patient will exhaust all other state and federal assistance programs prior to receiving an award from IU Health White Memorial Hospital's Financial Assistance Program. Patients who may be eligible for coverage under an applicable insurance policy, including, but not limited to, health, automobile, and homeowner's, must exhaust all insurance benefits prior to receiving an award from IU Health White Memorial Hospital's Financial Assistance Program. This includes patients covered under their own policy and those who may be entitled to benefits from a third-party policy. Patients may be asked to show proof that such a claim was properly submitted to the proper insurance provider at the request of IU Health White Memorial Hospital. Eligible patients who receive medical care from IU Health White Memorial Hospital as a result of an injury proximately caused by a third party, and later receive a monetary settlement or award from said third party, may receive Financial Assistance for any outstanding balance not covered by the settlement or award to which IU Health White Memorial Hospital is entitled. In the event a Financial Assistance Award has already been granted in such circumstances, IU Health White Memorial Hospital reserves the right to reverse the award in an amount equal to the amount IU Health White Memorial Hospital would be entitled to receive had no Financial Assistance been awarded. 3. Alternate Methods of Eligibility Determination IU Health White Memorial Hospital will conduct a quarterly review of all accounts placed with a collection agency partner for a period of no less than one hundred and twenty (120) days after the account is eligible for an Extraordinary Collection Action ("ECA"). Said accounts may be eligible for assistance under the FAP based on the patient's individual scoring criteria. To ensure all patients potentially eligible for Financial Assistance under the FAP may receive Financial Assistance, IU Health White Memorial Hospital will deem patients/guarantors to be presumptively eligible for Financial Assistance if they are found to be eligible for one of the following programs, received emergency or direct admit care, and satisfied his/her required co-pay/deductible: - Indiana Children's Special Health Care Services - Medicaid - Health Indiana Plan - Patients who are awarded Hospital Presumptive Eligibility (HPE) - Enrolled in a state and/or federal program that verifies the patient's gross household income is less than or equal to 200% of the Federal Poverty Level 4. Additional Considerations Financial Assistance may be granted to a deceased patient's account if said patient is found to have no estate. Additionally, IU Health White Memorial Hospital will deny or revoke Financial Assistance for any patient or guarantor who falsifies any portion of a Financial Assistance application. 5. Non-Emergent Services Down Payment Uninsured Patients presenting for scheduled or other non-emergent services will not be charged more than the AGB for their services. Patients will receive an estimated AGB cost of their care prior to IU Health White Memorial Hospital rendering the services and will be asked to pay a down-payment percentage of the AGB adjusted cost prior to receiving services. In the event a patient is unable to fulfill the down-payment, their service may be rescheduled for a later date as medically prudent and in accordance with all applicable federal and state laws and/or regulations. 6. Emergency Services Non-Refundable Deposit This section will be implemented with a strict adherence to EMTALA and IU Health Policy ADM 1.32, Screening and Transfer of Emergency or Unstable Patients. Amount of Non-Refundable Deposit All Uninsured Patients presenting for services at IU Health White Memorial Hospital's Emergency Department, via transfer from another hospital facility, or direct admission, will be responsible for a one-hundred dollar ($100.00) non-refundable deposit for services rendered. Patients/guarantors will be responsible for any copays and/or deductibles required by their plan prior to full Financial Assistance being applied. Uninsured Patients wishing to make an application for Financial Assistance greater than the AGB must fulfill their non-refundable deposit prior to IU Health White Memorial Hospital processing said application. Uninsured Patients making payments toward their outstanding non-refundable deposit balance will have said payments applied to their oldest application on file, if applicable. Schedule H, Part V, Section B, Line 16a - FAP Website A copy of IU Health White Memorial Hospital's FAP is available on the following website: https://iuhealth.org/pay-a-bill/financial-assistance Schedule H, Part V, Section B, Line 16b - FAP Application Website A copy of IU Health White Memorial Hospital's FAP application is available on the following website: https://iuhealth.org/pay-a-bill/financial-assistance Schedule H, Part V, Section B, Line 16c - FAP PLS Website A plain language summary of the FAP, including translated copies, is available on the following website: https://iuhealth.org/pay-a-bill/financial-assistance Schedule H, Part V, Section B, Line 16j - Other Measures to Publicize IU Health White Memorial Hospital takes several other measures to publicize its FAP within the community. These measures include the following: 1. Conspicuous public displays will be posted in appropriate acute care settings such as the emergency department and registration areas describing the available assistance and directing eligible patients to the Financial Assistance Application. 2. IU Health White Memorial Hospital will include a conspicuous written notice on all patient billing statements that notifies the patient about the availability of this Policy, and the telephone number of its Customer Service Department which can assist patients with any questions they may have regarding this Policy. 3. IU Health White Memorial Hospital Customer Service representatives will be available via telephone Monday through Friday, excluding major holidays, from 8:00 a.m. to 7:00 p.m. Eastern Time to address questions related to this Policy. 4. IU Health White Memorial Hospital will broadly communicate this Policy as part of its general outreach efforts. 5. IU Health White Memorial Hospital will educate its patient facing team members of the FAP and the process for referring patients to the Program. 4 IUH WHITE MEM HOS OCCUPATIONAL THERAPY 720 S 6TH ST MONTICELLO IN 47960 DIAGNOSTIC AND OTHER OUTPATIENT IU HEALTH WHITE MEMORIAL HOS RADIOLOGY 720 S 6TH ST MONTICELLO IN 47960 DIAGNOSTIC AND OTHER OUTPATIENT IUH WHITE MEMORIAL HOS REHABILITATION 720 S 6TH ST MONTICELLO IN 47960 REHABILITATION SERVICES IUH WHITE MEM HOS SPEECH & LG Pathology 720 S 6TH ST MONTICELLO IN 47960 DIAGNOSTIC AND OTHER OUTPATIENT Schedule H, Part I, Line 3c - Other Factors Used in Determining Elig. IU Health White Memorial Hospital uses several factors other than Federal Poverty Guidelines ("FPGs") in determining eligibility for free care under its FAP. These factors include the following: 1. Indiana Residency Requirement Financial Assistance will only be made available to residents of the State of Indiana and those eligible for assistance under 42 U.S.C.A. 1396b (v). IU Health White Memorial Hospital will employ the same residency test as set forth in Indiana Code 6-3-1-12 to define an Indiana resident. The term Resident includes any individual who was domiciled in Indiana during the taxable year, or any individual who maintains a permanent place of residence in Indiana and spends more than one hundred eight-three (183) days of the taxable year in Indiana. Patients residing in the state of Indiana while attending an institution of higher education may be eligible for assistance under the FAP if they meet the aforementioned residency test and are not claimed as a dependent on a parent's or guardians' federal income tax return. 2. IU Health White Memorial Hospital's Individual Solutions Department Prior to seeking Financial Assistance under the FAP, all patients or their guarantors must consult with a member of IU Health White Memorial Hospital's Individual Solutions department to determine if healthcare coverage may be obtained from a government insurance/assistance product or from the Health Insurance Exchange Marketplace. 3. Uninsured Patients All Uninsured Patients presenting for services at IU health White Memorial Hospital eligible under the FAP will not be charged more than the AGB as described in the FAP. 4. Services Rendered by Individual Providers The FAP does not cover services rendered by individual providers. A full listing of providers and services not covered by the FAP is available at https://iuhealth.org/pay-a-bill/financial-assistance and is updated on a quarterly basis. 5. Alternate Sources of Assistance When technically feasible, a patient will exhaust all other state and federal assistance programs prior to receiving an award from IU Health White Memorial Hospital's Financial Assistance Program. Patients who may be eligible for coverage under an applicable insurance policy, including, but not limited to, health, automobile, and homeowner's, must exhaust all insurance benefits prior to receiving an award from IU Health White Memorial Hospital's Financial Assistance Program. This includes patients covered under their own policy and those who may be entitled to benefits from a third-party policy. Patients may be asked to show proof that such a claim was properly submitted to the proper insurance provider at the request of IU Health White Memorial Hospital. Eligible patients who receive medical care from IU Health White Memorial Hospital as a result of an injury proximately caused by a third party, and later receive a monetary settlement or award from said third party, may receive Financial Assistance for any outstanding balance not covered by the settlement or award to which IU Health White Memorial Hospital is entitled. In the event a Financial Assistance Award has already been granted in such circumstances, IU Health White Memorial Hospital reserves the right to reverse the award in an amount equal to the amount IU Health White Memorial Hospital would be entitled to receive had no Financial Assistance been awarded. 6. Alternate Methods of Eligibility Determination IU Health White Memorial Hospital will conduct a quarterly review of all accounts placed with a collection agency partner for a period of no less than one hundred and twenty (120) days after the account is eligible for an ECA. Said accounts may be eligible for assistance under the FAP based on the patient's individual scoring criteria. To ensure all patients potentially eligible for Financial Assistance under the FAP may receive Financial Assistance, IU Health White Memorial Hospital will deem patients/guarantors to be presumptively eligible for Financial Assistance if they are found to be eligible for one of the following programs, received emergency or direct admit care, and satisfied his/her required co-pay/deductible: - Indiana Children's Special Health Care Services - Medicaid - Health Indiana Plan - Patients who are awarded Hospital Presumptive Eligibility (HPE) - Enrolled in a state and/or federal program that verifies the patient's gross household income is less than or equal to 200% of the Federal Poverty Level 7. Additional Considerations Financial Assistance may be granted to a deceased patient's account if said patient is found to have no estate. Additionally, IU Health White Memorial Hospital will deny or revoke Financial Assistance for any patient or guarantor who falsifies any portion of a Financial Assistance application. 8. Patient Assets IU Health White Memorial Hospital may consider patient/guarantor Assets in the calculation of a patient's true financial burden. A patient's/guarantors primary residence and one (1) motor vehicle will be exempted from consideration in most cases. A patient's primary residence is defined as the patient's principal place of residence and will be excluded from a patient's extraordinary asset calculation so long as the patient's equity is less than five-hundred thousand dollars ($500,000) and the home is occupied by the patient/guarantor, patient's/guarantor's spouse or child under twenty-one (21) years of age. One (1) motor vehicle may be excluded as long as the patient's equity in the vehicle is less than fifty-thousand dollars ($50,000). IU Health White Memorial Hospital reserves the right to request a list of all property owned by the patient/guarantor and adjust a patient's award of Financial Assistance if the patient demonstrates a claim or clear title to any extraordinary Asset not excluded from consideration under the above guidance. 9. Non-Emergent Services Down Payment Uninsured Patients presenting for scheduled or other non-emergent services will not be charged more than the AGB for their services. Patients will receive an estimated AGB cost of their care prior to IU Health White Memorial Hospital rendering the services and will be asked to pay a down-payment percentage of the AGB adjusted cost prior to receiving services. In the event a patient is unable to fulfill the down-payment, their service may be rescheduled for a later date as medically prudent and in accordance with all applicable federal and state laws and/or regulations. 10. Emergency Services Non-Refundable Deposit This section will be implemented with a strict adherence to EMTALA and IU Health Policy ADM 1.32, Screening and Transfer of Emergency or Unstable Patients. Amount of Non-Refundable Deposit All Uninsured Patients presenting for services at IU Health White Memorial Hospital's Emergency Department, via transfer from another hospital facility, or direct admission, will be responsible for a one-hundred dollar ($100.00) non-refundable deposit for services rendered. Patients/guarantors will be responsible for any copays and/or deductibles required by their plan prior to full Financial Assistance being applied. Uninsured Patients wishing to make an application for Financial Assistance greater than the AGB must fulfill their non-refundable deposit prior to IU Health White Memorial Hospital processing said application. Uninsured Patients making payments toward their outstanding non-refundable deposit balance will have said payments applied to their oldest application on file, if applicable. Schedule H, Part I, Line 6a - C.B. Report Prepared by a Related Org. IU Health White Memorial Hospital's community benefit and other investments, encompassing its total community investment, are included in the IU Health Community Benefit Report which is prepared on behalf of and includes IU Health and its related hospital entities in the State of Indiana ("IU Health Statewide System"). The IU Health Community Benefit Report is made available to the public on IU Health's website at https://iuhealth.org/in-the-community/community-benefit. The IU Health Community Benefit Report is also distributed to numerous key organizations throughout the State of Indiana in order to broadly share the IU Health Statewide System's community benefit efforts. It is also available by request through the Indiana State Department of Health or IU Health. Schedule H, Part I, Line 7, Column (f) - Percent of total expense The amount of bad debt expense included on Form 990, Part IX, Line 25, column (A), but subtracted for purposes of calculating the percentage of total expense is $2,882,042. BAD DEBT EXPENSE IS REPORTED AT COST BASED ON THE COST-TO-CHARGE RATIO DERIVED FROM WORKSHEET 2, RATIO OF PATIENT CARE COST-TO-CHARGES. Schedule H, Part I, Line 7 - Total community benefit expense Schedule H, Part I, Line 7, Column (f), Percent of Total Expense, is based on column (e) Net Community Benefit Expense. The percent of total expense based on column (c) Total Community Benefit Expense, which includes direct offsetting revenue, is 23.86%. Schedule H, Part II - Promotion of Health in Communities Served IU Health White Memorial Hospital participates in a variety of community-building activities that address the social determinants of health in the communities it serves. IU Health and its related hospital entities across the State of Indiana ("IU Health Statewide System") participate in a variety of community-building activities that address the health and wellness of residents in the communities it serves through investments in workforce development efforts across the state, collaboration with like-minded organizations through coalitions that address key issues, and advocacy for improvements in the health status of vulnerable populations. IU Health makes contributions to community-building activities by providing investments and resources to local partners in the community. Several examples include IU Health's support of the following organizations and initiatives that focus on community health needs, as well as the conditions and barriers that impact health, including access to healthcare, behavioral health and substance abuse, social determinants of health and nutrition and healthy weight: - Covering Kids and Families - LifeSmart Youth - Volunteers of America Ohio & Indiana - Goodwill Foundation of Central and Southern Indiana - Reach for Youth - Lutheran Foundation - Indy Public Safety Foundation - United Way of Central Indiana - Playworks - Indianapolis Parks Foundation - Gleaner's Food Bank - Indiana Legal Services - Brandywine Creek Farms - Lawrence Community Garden - Greater Indy Habitat for Humanity - Groundwork Indy - Junior Achievement of Central Indiana - Marion County Public Health Department To take volunteer service outside the walls of our facilities, Indiana University Health created IU Health Serves, a team member volunteer program, to positively impact the health of the community and foster a culture of engagement and social responsibility. In 2019, more than 3,800 IU Health team members dedicated more than 29,000 volunteer hours in their communities. IU Health also sponsors and promotes IU Health Days of Service, which are high-impact events aimed at engaging IU Health team members in activities that address identified community outreach priorities. Each year, more than 2,000 IU Health team members volunteer during Days of Service. Schedule H, Part III, Line 2 - Methodology Used to Est. Bad Debt Exp. The amount reported on line 2 as bad debt is reported at cost, as calculated using the cost to charge ratio methodology. Schedule H, Part III, Line 3 - bad debt attributable to patients eligible under the Financial Assistance Policy an uninsured patient and/or guarantor who was admitted through an eligible facility's emergency department via a direct admission from a physician's office, or transfer from another hospital facility, and whose household income is less than or equal to 200% of the federal poverty level may be eligible for full charity assistance after the successful completion of the financial assistance application and satisfaction of his/her non-refundable deposit. To capture all patients who are potentially eligible for financial assistance under the IU Health Financial Assistance Policy, IU Health will deem patients/guarantors to be presumptively eligible for financial assistance if they are found to be eligible for one of the following programs, received emergency or direct admit care, and satisfied the required co-pay/deductible. 1. Indiana Children's Special Health Care Services 2. Medicaid 3. Healthy Indiana Plan 4. Patients who are awarded hospital presumptive eligibility 5. Enrolled in a state and/or federal program that verifies the patient's gross household income is less than or equal to 200% of the federal poverty level (FPL). IU Health also conducts a quarterly review of all accounts placed with a collection agency partner for a period of no less than one hundred and twenty (120) days after the account is eligible for an extraordinary collection actions. Said accounts may be eligible for assistance under the financial assistance policy based on the patient's individual scoring criteria and are not included in bad debt. Due to this comprehensive methodology. IU Health does not believe any amount of bad debt is attributable to patients who may be eligible under the financial assistance policy and no portion of bad debt is included as community benefit. Schedule H, Part III, Line 4 - Bad Debt Expense IU Health White Memorial Hospital is a subsidiary in the consolidated financial statements of IU Health. IU Health's bad debt expense footnote is as follows: The Indiana University Health System does not require collateral or other security from its patients, substantially all of whom are residents of the State, for the delivery of health care services. However, consistent with industry practice, the Indiana University Health System routinely obtains assignment of (or is otherwise entitled to receive) patients' benefits payable under their health insurance programs, plans or policies (e.g., Medicare, Medicaid, managed care payers, and commercial insurance policies. The Indiana University Health System uses a portfolio approach to account for categories of patient contracts as a collective group, rather than recognizing revenue on an individual contract basis. The portfolios consist of major payer classes for inpatient revenue and outpatient revenue. Based on the historical collection trends and other analysis, the Indiana University Health System believes that revenue recognized by utilizing the portfolio approach approximates the revenue that would have been recognized if an individual contract approach were used. In support of its mission, the Indiana University Health System provides care to uninsured and underinsured patients. The Indiana University Health System provides charity care to patients who lack financial resources and are deemed to be medically indigent. Under its financial assistance policy, the Indiana University Health System provides medically necessary care to uninsured patients with inadequate financial resources at charitable discounts equivalent to the amounts generally billed, and it provides eligibility for full charity for emergent encounters for uninsured patients who earn less than 200% of the federal poverty level and who meet application criteria. Patients whose liability is deemed catastrophic relative to their annual household income are also eligible for reduced charges. Since the Indiana University Health System does not pursue collection of these amounts, the discounted amounts are not reported as patient service revenue. The Indiana University Health System uses presumptive eligibility screening procedures for free care and recognizes net patient service revenue on services provided to self-pay patients at the discounted rate at the time services are rendered. The estimated cost of charity care, using the consolidated cost to charge ratio, was $96,693,000 and $94,886,000 in 2019 and 2018, respectively. Schedule H, Part III, Line 8 - Medicare Shortfall IU HEALTH WHITE MEMORIAL HOSPITAL DID NOT HAVE A MEDICARE SHORTFALL FOR 2019. IU HEALTH WHITE MEMORIAL HOSPITAL'S MEDICARE REIMBURSEMENTS, HOWEVER, ARE NORMALLY LESS THAN THE COST OF PROVIDING PATIENT CARE AND SERVICES TO MEDICARE BENEFICIARIES AND DO NOT INCLUDE ANY AMOUNTS THAT RESULT FROM INEFFICIENCIES OR POOR MANAGEMENT. IU HEALTH WHITE MEMORIAL HOSPITAL ACCEPTS ALL MEDICARE PATIENTS KNOWING THAT THERE MAY BE SHORTFALLS; THEREFORE IT HAS TAKEN THE POSITION THAT ANY SHORTFALL SHOULD BE COUNTED AS PART OF ITS COMMUNITY BENEFIT. ADDITIONALLY, IT IS IMPLIED IN INTERNAL REVENUE SERVICE REVENUE RULING 69-545 THAT TREATING MEDICARE PATIENTS IS A COMMUNITY BENEFIT. REVENUE RULING 69-545, WHICH ESTABLISHED THE COMMUNITY BENEFIT STANDARD FOR NONPROFIT HOSPITALS, STATES THAT IF A HOSPITAL SERVES PATIENTS WITH GOVERNMENTAL HEALTH BENEFITS, INCLUDING MEDICARE, THEN THIS IS AN INDICATION THAT THE HOSPITAL OPERATES TO PROMOTE THE HEALTH OF THE COMMUNITY. THE AMOUNT REPORTED ON SCHEDULE H, PART III, LINE 6 IS CALCULATED, IN ACCORDANCE WITH THE FORM 990 INSTRUCTIONS, USING "ALLOWABLE COSTS" FROM THE IU HEALTH WHITE MEMORIAL HOSPITAL MEDICARE COST REPORT. "ALLOWABLE COSTS" FOR MEDICARE COST REPORT PURPOSES, HOWEVER, ARE NOT REFLECTIVE OF ALL COSTS ASSOCIATED WITH IU HEALTH WHITE MEMORIAL HOSPITAL'S PARTICIPATION IN MEDICARE PROGRAMS. FOR EXAMPLE, THE MEDICARE COST REPORT EXCLUDES CERTAIN COSTS SUCH AS BILLED PHYSICIAN SERVICES, THE COSTS OF MEDICARE PARTS C AND D, FEE SCHEDULE REIMBURSED SERVICES, AND DURABLE MEDICAL EQUIPMENT SERVICES. INCLUSION OF ALL COSTS ASSOCIATED WITH IU HEALTH WHITE MEMORIAL HOSPITAL'S PARTICIPATION IN MEDICARE PROGRAMS WOULD SIGNIFICANTLY REDUCE THE MEDICARE SURPLUS REPORTED ON SCHEDULE H, PART III, LINE 7. Schedule H, Part III, Line 9b - Written Debt Collection Policy IU Health White Memorial Hospital's FAP and Written Debt Collection Policy describe the collection practices applicable to patients, including those who may qualify for financial assistance. 1. Financial Assistance Application Patients or their guarantors wishing to apply for Financial Assistance are encouraged to submit a Financial Assistance Application within ninety (90) days of their discharge. Patients or their guarantors may submit an application up to two-hundred and forty (240) days from the date of their first billing statement from IU Health, however, accounts may be subject to ECA as soon as one hundred and twenty (120) days after having received their first billing statement. Patients or their guarantors submitting an incomplete application will receive written notification of the application's deficiency upon discovery by IU health. The application will be pended for a period of forty-five (45) days from the date the notification is mailed. IU Health will suspend any ECA until the application is complete, or the patient fails to cure any deficiencies in their application in the allotted period. Patients with limited English proficiency may request to have a copy of the FAP, a FAP Application, and FAP Plain Language Summary in one of the below languages: - Arabic - Burmese - Burmese-Falam - Burmese-Hakha Chin - Mandarin/Chinese - Spanish The patient, and/or their representative, such as the patient's physician, family members, legal counsel, community or religious groups, social services or hospital personnel may request a FAP Application to be mailed to a patient's primary mailing address free of charge. IU Health White Memorial Hosptial keeps all applications and supporting documentation confidential. Patients applying for assistance under the FAP will be required to complete a Financial Assistance Application. Patients must include the following documentation with their Financial Assistance Application: - All sources of Income for the last three (3) months; - Most recent three (3) months of pay stubs or Supplemental Security Income via Social Security; - Most recent three (3) statements from checking and savings accounts, certificates of deposit, stocks, bonds and money market accounts; - Most recent state and Federal Income Tax forms including schedules C, D, E, and F. In the event a patient's and/or guarantor's income does not warrant the filing of a federal tax return, the patient may submit a notarized affidavit attesting to the foregoing; - Most recent W-2 statement; - For patients or members of the Household who are currently unemployed, Wage Inquiry from WorkOne; and - If applicable, divorce/dissolution decrees and child custody order 2. Eligibility Determination IU Health White Memorial Hospital will inform patients or guarantors of the results of their application by providing the patient or guarantor with a Financial Assistance Determination within ninety (90) days of receiving a completed Application and all requested documentation. If a patient or guarantor is granted less than full charity assistance and the patient or guarantor provides additional information for reconsideration, IU Health Revenue Cycle Services may amend a prior Financial Assistance Determination. If a patient or guarantor seeks to appeal the Financial Assistance Determination further, a written request must be submitted, along with the supporting documentation, to the Financial Assistance Committee for additional review/reconsideration. All decisions of the Financial Assistance Committee are final. A patient's Financial Assistance Application and eligibility determination are specific to each individual date(s) of service and related encounters. 3. Extraordinary Collection Actions IU Health White Memorial Hospital may refer delinquent patient accounts to a third-party collection agency after utilizing reasonable efforts to determine a patient's eligibility for assistance under the FAP. IU Health White Memorial Hospital and its third-party collection agencies may initiate ECA against a patient or their guarantor in accordance with this Policy and 26 C.F.R. 1.501(r). Said ECA may include the following: - Selling a patient's or their guarantor's outstanding financial responsibility to a third party. - Reporting adverse information about the patient or their guarantor to consumer credit reporting agencies or credit bureaus. - Deferring or denying, or requiring a payment before providing, medically necessary care because of a patient's or their guarantor's nonpayment of one or more bills for previously provided care covered under the FAP. - Actions requiring a legal or judicial process, including but not limited to placing a lien on patient's or their guarantor's property, foreclosing on a patient's or their guarantor's real property attaching or seizing a patient's or their guarantor's bank account or other personal property, commencing a civil action against a patient or their guarantor, causing a patient or guarantor's arrest, causing a patient and/or guarantor to be subject to a writ of body attachment, and garnishing a patient or guarantor's wages. When it is necessary to engage in such action, IU Health White Memorial Hospital and its third party collection agencies, will engage in fair, respectful and transparent collections activities. Patients or guarantors currently subject to an ECA who have not previously applied for Financial Assistance may apply for assistance up to two-hundred and forty (240) days of the date of their first billing statement from IU Health. IU Health and their third-party collection agencies will suspend any ECA engaged on a patient or their guarantor while an Application is being processed and considered. 4. Refunds Patients eligible for assistance under the FAP who remitted payment to IU Health White Memorial Hospital in excess of their patient responsibility will be alerted to the overpayment as promptly after discovery as is reasonable given the nature of the overpayment. Patients with an outstanding account balance on a separate account not eligible for assistance under the FAP will have their refund applied to the outstanding balance. Patients without an outstanding account balance described above will be issued a refund check for their overpayment as soon as technically feasible. Schedule H, Part VI, Line 2 - Needs Assessment Communities are multifaceted and so are their health needs. IU Health White Memorial Hospital understands that the health of individuals and communities are shaped by various social and environmental factors, along with health behaviors and additional influences. IU Health White Memorial Hospital assesses the health care needs of the communities it serves by conducting a community health needs assessment (CHNA). For the 2018 CHNA, IU Health White Memorial Conducted the community survey data collection in collaboration with Indiana University, University of Evansville and an Indiana hospital collaborative, including Community Health Network, Franciscan Alliance, St. Vincent Health and other hospital partners. After completion of the CHNA, IU Health White Memorial Hospital reviewed secondary data, findings from other community health assessments of areas served by the hospital, input obtained from individuals who participated in community meetings, input obtained from key stakeholders, and a community survey to identify and analyze the needs identified by each source. The top health needs of the IU Health White Memorial Community are those that are supported by multiple data sources. Additionally, the effectiveness of an intervention for each need and IU Health's ability to impact positive change was evaluated. Schedule H, Part VI, Line 3 - Patient Education of Eligibility for Assit. IU Health White Memorial Hospital is committed to serving the healthcare needs of all of its patients regardless of their ability to pay for such services. To assist in meeting those needs, IU Health White Memorial Hospital has established a FAP to provide Financial Assistance to Uninsured Patients. IU Health White Memorial Hospital is committed to ensuring its patients are compliant with all provisions of the Patient Protection & Affordable Care Act. To that end, IU Health White Memorial Hospital will make a good faith effort to locate and obtain health insurance coverage for patients prior to considering patients for coverage under the FAP. IU Health White Memorial Hospital takes several measures to inform its patients of the FAP and FAP-eligibility. These measures include the following: 1. Conspicuous public displays will be posted in appropriate acute care settings such as the emergency department and registration areas describing the available assistance and directing eligible patients to the Financial Assistance Application. 2. IU Health White Memorial Hospital will include a conspicuous written notice on all patient billing statements that notifies the patient about the availability of this Policy, and the telephone number of its Customer Service Department which can assist patients with any questions they may have regarding this Policy. 3. IU Health Customer Service representatives will be available via telephone Monday through Friday, excluding major holidays, from 8:00 a.m. to 7:00 p.m. Eastern Time to address questions related to this Policy. 4. IU Health White Memorial Hospital will broadly communicate this Policy as part of its general outreach efforts. 5. IU Health White Memorial Hospital will educate its patient facing team members of the FAP and the process for referring patients to the Program. Schedule H, Part VI, Line 4 - Community Information IU Health White Memorial Hospital is located in White County, Indiana, a county located in central northwest Indiana. White County includes ZIP codes within the towns of Brookston, Burnettsville, Chalmers, Monon, Monticello, Reynolds, and Wolcott. Based on the most recent Census Bureau (2019) statistics, White County's population is 24,102. The county's population estimates by race are 88.8% white, 8.8% Hispanic or Latino, 0.9% Black, or 0.7% American Indian or Alaska Native, 0.6% Asian, and 1.3% persons reporting two or more races. White county has modest levels of educational attainment. Among residents ages 25 and up, 88.6% ended their formal education with a high school diploma or equivalent. Among residents ages 25 and up, 16.8% earned a bachelor's degree or higher. Schedule H, Part VI, Line 5 - Promotion of Community Health IU Health White Memorial Hospital is a subsidiary of IU Health, a tax-exempt healthcare organization, whose Board of Directors is composed of members, of which the majority is independent community members. In 2018, IU Health White Memorial Hospital hosted a community meeting to solicit feedback for the community health needs assessment. This process identified four priority health needs and areas in which IU Health should focus its community benefit investment. In addressing the identified community priorities, IU Health White Memorial Hospital has partnered with a number of high quality engaged community organizations and initiatives to help make health and wellness improvement a reality. As part of its commitment to community health improvement, IU Health team members participated on the White County HEALTH 4 All Coalition, creating a mental health work team for the community. They also actively participated in the United Council on Opioids, with representation on the Prevention, Treatment and Recovery Task Forces. During the annual Day of Service, IU Health White Memorial team members painted buddy benches for north white elementary school and painted the playground at Meadowlawn Elementary School and North White Elementary School. The team members painted four square boards, basketball courts, hopscotch, yoga poses, twister and other fun games on the blacktop for students to enjoy during recess. This increases opportunities for students to be physically active while in the school setting. IU Health White Memorial Hospital is a subsidiary of IU Health. IU Health and its related hospital entities across the state of Indiana extend medical privileges to all physicians who meet the credentialing qualifications necessary for appointment to its medical staff. IU Health does not deny appointment on the basis of gender, race, creed, or national origin. IU Health, in conjunction with the IU School of Medicine, trains the next generation of physicians in an exceptional environment, blending breakthrough research and treatments with the highest quality of patient care. vision is to make Indiana one of the healthiest states in the nation by providing the best care, designed for our patients, and the five year strategy was designed to help IU Health realize this vision. Schedule H, Part VI, Line 6 - Affiliated Health Care System IU Health White Memorial Hospital is part of the IU Health Statewide System. The IU Health Statewide system is Indiana's most comprehensive healthcare system. With hospitals, physician offices and allied services, IU Health provides access to a full range of specialty and primary care services for adults and children. A unique partnership with Indiana University School of Medicine - one of the nation's leading medical schools - gives patients access to groundbreaking research and innovative treatments to complement high-quality care. National Recognition - Eight hospitals designated as Magnet by the American Nurses Credentialing Center recognizing excellence in nursing care. - IU Health Medical Center is honored to be nationally ranked by U.S. News & World Report for the 22nd year in a row. According to the U.S. News rankings, IU Health Medical Center is the No. 1 ranked hospital in Indiana and Indianapolis and the only nationally ranked adult hospital in the state. For 2019-2020, IU Health Medical Center was rated as high performing nationally in five specialties, with a sixth specialty achieving a top 50 national ranking: - Cancer - high performing - Gastroenterology - high performing - Geriatrics - ranked 45th in nation - Nephrology - high performing - Neurology & Neurosurgery - high performing - Urology - high performing Besides IU Health Medical Center, IU Health has three other hospitals among the 10 top ranked hospitals in Indiana: IU Health Ball Memorial (#5), IU Health Arnett (#8) and IU Health Bloomington (#8) hospitals. The annual rankings, now in their 30th year, are designed to assist patients and their doctors in making informed decisions about where to receive care for challenging health conditions or for common elective procedures. Education and Research As an academic health center, IU Health works in partnership with the IU School of Medicine to train physicians, blending breakthrough research and treatments with the highest quality of patient care. Each year, more than 1,000 residents and fellows receive training in IU Health hospitals. Research conducted by IU School of Medicine faculty gives IU Health physicians and patients access to the most leading-edge and comprehensive treatment options. In 2017, IU Health and the IU School of Medicine announced that they would invest $50 million over six years in the Strategic Research Initiative, a new research collaboration that has enhanced the institutions' joint capabilities in fundamental scientific investigation, translational research and clinical trials. The initial focus is on projects in the fields of neuroscience, cancer and cardiovascular disease with the goal to fund transformative proposals that will fundamentally change the understanding of these diseases and lead to important new therapies for patients. The three target research areas represent research strengths at IU School of Medicine, key strategic service lines for IU Health, and important medical needs in a time of an aging population and rising healthcare costs: - Cancer: One of the initiative's primary goals is to enable the IU Health Melvin and Bren Simon Cancer Center to attain the National Cancer Institute's (NCI) top status of "comprehensive," which would recognize it as one of the top-tier cancer centers in the nation. This designation was achieved in August 2019 making the center the only NCI-designated Comprehensive Cancer Center in Indiana and one of just 51 in the nation. - Neuroscience: The neurosciences research program tackles a broad range of brain injuries, neurodegenerative disorders and neurodevelopmental disorders. - Cardiovascular: The cardiovascular research initiative develops a comprehensive program for the study and treatment of heart failure, from newborns to older adults. A top priority is developing a cardiovascular genetics program. The Strategic Research Initiative provides patients with access to internationally renowned physicians and to new therapies developed through translational research and clinical trials, and will make use of the latest genetic tools to develop personalized therapies that are more effective for individuals and efficient for healthcare providers. IU Health Statewide System IU Health is a part of the IU Health Statewide System which continues to broaden its reach and positive impact throughout the state of Indiana. IU Health is Indiana's most comprehensive academic health center and consists of IU Health Methodist Hospital, IU Health University Hospital, Riley Hospital for Children at IU Health, and IU Health Saxony Hospital. Other hospitals in the IU Health Statewide System include the following: - IU Health Arnett Hospital - IU Health Ball Memorial Hospital - IU Health Bedford Hospital - IU Health Blackford Hospital - IU Health Bloomington Hospital - IU Health Frankfort Hospital - IU Health Jay Hospital - IU Health North Hospital - IU Health Paoli Hospital - IU Health Tipton Hospital - IU Health West Hospital - IU Health White Memorial Hospital Although each hospital in the IU Health Statewide System prepares and submits its own community benefit plan relative to the local community, the IU Health Statewide System considers the sum of these plans part of a statewide vision for strengthening Indiana's overall health. A comprehensive community outreach strategy and community benefit plan is in place that encompasses the academic medical center downtown Indianapolis, suburban Indianapolis and statewide entities around priority areas that focus on health improvement efforts statewide. IU Health is keenly aware of the positive impact it can have on the communities of need in the state of Indiana by focusing on the most pressing needs in a systematic and strategic way. In 2019, IU Health provided more than $738 million in total community benefit and served more than one million individuals. Some ways we address our community health priorities as a system include: IU Health Day of Service The annual IU Health Days of Service is a high-impact event aimed at engaging IU Health team members in activities that address an identified community priority health need. Each year, more than 2,000 IU Health team members volunteer during the Days of Service. Community Health Initiatives With investments in high-quality and impactful initiatives to address community health needs statewide, IU Health is helping Indiana residents improve their health and their quality of life. In 2019, IU Health impacted many people statewide through educational presentations, health risk screenings, health education programs, and additional health educational opportunities made available to the community, especially to our community members in the greatest need of such services. Twenty-four local organizations are benefitting from grants awarded by IU Health. In 2019, IU Health Community Outreach and Engagement awarded more than $900,000 to community organizations and institutions which - like IU Health - are addressing the health needs of the community. These needs include access to affordable healthcare, behavioral health and substance abuse, healthy weight and nutrition and social determinants of health. The grants, administered by the Indiana University Health Foundation, were awarded to the following: Behavioral Health and Substance Abuse - Volunteers of America Ohio & Indiana's (https://www.voaohin.org/) (VOAOHIN) Fresh Start Recovery Center received a $75,000 grant to provide residential addiction treatment to pregnant women and mothers. It also allows up to two children ages 5 and under to live with their mother while they receive services. - Goodwill Foundation of Central and Southern Indiana(https://www.goodwillindy.org/foundation/) received $75,000 to help Goodwill Education Initiatives (GEI) Resilience Initiative support resilience work across 15 Excel Center locations by leveraging groundbreaking research on neuroplasticity - the ability of the brain to reorganize itself - and to train staff and students on enhancing their resilience and mitigating the effects of trauma. - Additional grant winners: - Reach for Youth (https://www.reachforyouth.org/) - Lutheran Foundation (https://thelutheranfoundation) - Indy Public Safety Foundation (https://indypsf.org/) Healthy Weight and Nutrition - United Way of Central Indiana, Inc.'s (https://uwci.org/) initiative Jump IN for Healthy Kids received a $50,000 grant to address the epidemic of childhood obesity with a specific focus on implementing strategies that create healthy places, healthy neighborhoods, and healthy communities in Marion County. - Playworks (https://www.playworks.org/indiana/), a national non-profit organization that partners with Indianapolis schools and youth organizations to help them leverage play for positive outcomes, received a $23,000 grant. - Additional grant winners: - Indianapolis Parks Foundation (https://www.indyparksfoundation.org/) Social Determinants of Health - A $100,250 grant was awarded to G Schedule H, Part VI, Line 7 - State Filing of Community Benefit Report IN true Scholarships 8 8000 Schedule I, Part I, Line 2 - Org.'s Proc. for Mon. the Use of Grant Funds Although IU Health White Memorial Hospital, Inc. does not monitor the use of grant funds once distributed, through due diligence the organization has reasonably confirmed that the entities OR INDIVIDUALS TO WHICH THE CONTRIBUTIONS ARE MADE MEET SPECIFIED QUALIFICATIONS, AND IN THE CASE OF ENTITIES, ARE HIGHLY REPUTABLE IN THE COMMUNITY AND USE THE FUNDS FOR THE PURPOSES INTENDED. SCHEDULE I, PART III, LINE 1 - GRANTS AND OTHER ASSISTANCE TO INDIVIDUALS THE AMOUNT REPORTED ON SCHEDULE I, PART III, LINE 1 REPRESENTS SCHOLARSHIPS PAID DIRECTLY TO EDUCATIONAL INSTITUTIONS FOR INDIVIDUAL STUDENTS ENROLLED IN MEDICAL EDUCATION PROGRAMS. false true false false false false false true false CHRISTOPHER A MANSFIELD MD Director/ Vice Chair 0 463635 0 8259 0 18540 0 18075 0 29939 0 538448 0 0 ROGER G BANGS MD DIRECTOR 0 722483 0 10431 0 21564 0 18075 0 11027 0 783580 0 0 KENNETH E MARNOCHA MD DIRECTOR (PART YEAR) 0 226725 0 4888 0 19188 0 16168 0 9180 0 276149 0 0 RUBAN NIRMALAN MD DIRECTOR 0 773652 0 500 0 19540 0 16832 0 24920 0 835444 0 0 MARY E MINIER PRESIDENT - WHITE MEMORIAL 182774 0 24358 0 0 0 13100 0 9047 0 229279 0 0 0 DEREK E EMPIE SECRETARY 0 231195 0 36357 0 757 0 14967 0 30379 0 313655 0 0 CARA L BREIDSTER FORMER OFFICER 0 268020 0 40264 0 13097 0 18008 0 23740 0 363129 0 0 DONALD E CLAYTON MD FORMER OFFICER 0 177893 0 500 0 8579 0 17481 0 16636 0 221089 0 0 KOREEN C KYHNELL VP - HUMAN RESOURCES 0 172712 0 21815 0 3120 0 13298 0 26981 0 237926 0 0 BRIAN T SHOCKNEY FORMER OFFICER 0 468991 0 159543 0 34201 0 99076 0 26918 0 788729 0 0 ANDREW K EDWARDS MD FORMER OFFICER 0 383808 0 500 0 18810 0 17047 0 25104 0 445269 0 0 JEFFREY C ZEH COO 0 286519 0 37102 0 1242 0 18484 0 227 0 343574 0 0 TODD A WILLIAMS CFO/TREASURER 0 263340 0 9890 0 19828 0 11200 0 29263 0 333521 0 0 DANIEL E Neufelder REGIONAL PRESIDENT 0 509494 0 121427 0 22564 0 112923 0 24874 0 791282 0 0 JAMES P BIEN MD CMO - VP Quality & Safety 0 344644 0 48634 0 21232 0 18075 0 27864 0 460449 0 0 Elsie Thoma Mgr, Pharmacy 152218 0 6977 0 1290 0 10527 0 0 0 171012 0 0 0 Adel M Khdour MD FORMER KEY EMPLOYEE 0 300207 0 500 0 18810 0 16139 0 31336 0 366992 0 0 MARY C DREWES Assoc Chief Nurse Exec Sys Ops 55953 69014 224 276 45576 56215 2275 2806 5471 6748 109499 135059 0 0 WILLIAM Y LI MD Director (PART YEAR) 0 430018 0 500 0 19242 0 18075 0 29576 0 497411 0 0 MICHELE S SAYSANA MD Director (PART YEAR) 0 365503 0 97197 0 578 0 9426 0 0 0 472704 0 0 Brian M Weirich CNO 0 217167 0 28950 0 379 0 15816 0 24188 0 286500 0 0 Schedule J, Part I, Line 3 - Comp. Or the Org's CEO/Executive Director IU Health White Memorial Hospital's Regional President is employed by IU Health, Inc. IU HEALTH WHITE MEMORIAL HOSPITAL'S PRESIDENT IS EMPLOYED BY IU HEALTH WHITE MEMORIAL HOSPITAL, INC. IU Health, Inc., IU Health White Memorial Hospital, and other related entities have a process in place to determine the compensation for the other officers and key employees. IU Health Human Resources uses market data from multiple compensation experts/vendors who utilize a variety of methods and procedures to obtain compensation ranges for comparable officer and employee positions. This market data and multiple other factors (including market pay benchmarks, internal equity, candidate/employee qualifications & performance, and business needs) are used to recommend compensation ranges for its officers and other employees, which are then used as a guide for setting reasonable compensation by management. Please see schedule O for additional details. Schedule J, Part I, Line 4b - Supplemental Nonqualified Retirement Plan Daniel E. Neufelder and Brian T. Shockney participate in a supplemental executive retirement plan, provisions of which are designed to retain these critical employees. The plan provides for an additional retirement benefit for service through normal retirement or other key dates. If the executive leaves prior to retirement or other key dates, the benefit may be forfeited or reduced. Daniel E. Neufelder and Brian T. Shockney have an amount included in column c, deferred compensation, representing the current year unvested contributions made under the supplemental executive retirement plan. These amounts were not paid to the executives during the year. SCHEDULE J, PART I, LINE 7 - NON-FIXED PAYMENTS Amounts disclosed in Column B(ii) include a long-term and short-term incentive for certain executives and short-term incentive for other employees. Although these plans are based on a fixed formula that has been approved by the Board of Directors based upon certain qualitative and quantitative factors and goals, all discretionary incentive plans must be approved by the Talent Management and Executive Compensation Committee and Board of Directors prior to any incentive payout. Page 1, Line J Web Site: https://iuhealth.org/find-locations/iu-health-white-memorial-hospital Part VI, Section A - Governing Body and Management Line 4 - Significant Changes to Organizational Documents Indiana University Health White Memorial Hospital, Inc. filed Amended and Restated Bylaws in order to reflect its change in operations following the boards merger with IU Health Arnett and IU Health Frankfort. A detail summary of the updated changes to Section 4.2 Appointment and Section 4.4 Member Approval Required are shown on Schedule O, lines 7a and 7b. New Section 4.2 Duties of the Board of Directors highlights the board's annual duties. Summary of this change is as follows: Board's duties shall include, but are not limited to, the following: - To acquire by purchase or lease materials, serv1ces, equipment and supplies for use by the Hospital; - To contract for serv1ces of professionals or firms when considered necessary by the Hospital; - To require that accounting records be kept in the manner prescribed by generally accepted accounting principles; - To provide for institutional planning to meet the health needs of the community; - To require the Medical Staff to develop, adopt and periodically review Medical Staff Bylaws (as described in Section 9 .1 ), rules and regulations that are consistent with Hospital policies, these Bylaws and applicable legal or other requirements, including the applicable accreditation requirements, Indiana State Department of Health regulations and Medicare and Medicaid conditions of participation; - To hold the Medical Staff responsible for making recommendations concerning initial Medical Staff appointments, reappointments, termination of appointments, delineation of clinical privileges and the curtailment of clinical privileges; - To require the Medical Staff to establish mechanisms designed to assure the achievement and maintenance of a standard of medical practice and patient care that is consistent with generally accepted medical standards; and - To be responsible for oversight of the adequacy of the Hospital's physical plant. Part VI, Section A, Lines 6, 7a and 7b - Members or Stockholders Line 6: The sole member of IU Health White Memorial Hospital, Inc. is Indiana University Health, Inc. ("IU Health"), a 501(c)(3) tax-exempt organization. Line 7a: The Board of Directors of the IU Health White Memorial Hospital shall consist of up to fourteen (14) voting members all appointed by IU Health, who shall include up to two (2) directors who reside in White County and four (4) physician representatives from the West Central Region. The Physician Directors will be identified through a nomination process developed by the West Central Region and submitted to IU Health for consideration and approval. Line 7b: The following are subject to IU Health's approval: - Any proposed amendment to the Corporation's Articles of Incorporation or Bylaws; - Adoption of the Corporation's annual capital and operating budgets; - Approval of any unbudgeted operating or capital budget items or deviations, including any issuance or guarantee of any unbudgeted debt; - Approval of any strategic plan for the Corporation, including any amendments to a strategic plan; - Approval of any encumbrance, sale or conveyance of assets; - Any merger, consolidation, joint venture or affiliation involving the Corporation or any of its affiliates and any other entity; - Appointment and removal of the Corporation's President and other officers; - Construction, acquisition or lease of Hospital buildings; - Projects or contracts that require Member approval in accordance with the Member's resolution and policy governing system-wide Contract Execution Authority and Payment Approval Limits; and - The dissolution of the Corporation or any of its affiliates. Part VI, Section B, Line 11b - Review of Form 990 The CFO reviewed and approved the Form 990. Following the CFO's review and approval, a complete copy of the Form 990 was made available to each board member prior to its filing. Each member was also informed of the availability of IU Health's Tax Department to answer any questions. Part VI, Section B, Lines 12, 13, 14, and 16b - Policies IU Health White Memorial Hospital is part of the IU Health system. As the sole member and controlling parent of IU Health White Memorial Hospital, IU Health and its board of directors have mandated that certain policies be followed to ensure greater standardization throughout the system. Thus, IU Health White Memorial Hospital's Board of Directors was not required to separately adopt a conflict of interest, whistleblower, document retention and destruction and joint venture policies because IU Health's Board of Directors had already adopted and required these policies to be followed by its subsidiaries. Part VI, Section B, Line 12c - Conflict of Interst Policy IU Health Arnett follows IU Health's Conflict of Interest Policy. IU Health's Conflict of Interest Policy includes the following provisions: All IU Health employees, associates, colleagues and contracted personnel, including employed physicians and paid medical directors ("IU Health Representatives") are covered by and subject to its Conflict of Interest Policy. IU Health regularly and consistently monitors and enforces compliance with the policy through the following procedures: (a) On an annual basis, each IU Health Representative at the level of Manager or above, together with every other person designated by the Corporate Compliance Department ("Department"), must complete, sign and submit a Conflict of Interest Questionnaire ("Questionnaire") to the Department. Governing board members, committee members, corporate officers, medical staff and researchers must comply with the administrative requirements noted in the respective policies and procedures relative to those areas. (b) An IU Health Representative must supplement a Questionnaire in writing, if after completion of the original Questionnaire, a situation arises, or may reasonably be expected to arise, that would change any answer or information on the original Questionnaire if the situation had existed or been anticipated at the time of completion of the original Questionnaire. (c) If a fully and properly completed Questionnaire reveals facts or other information that might reasonably indicate a Conflict of Interest or violation of the policy, the IU Health Representative completing the questionnaire must secure approval by his/her supervisor, evidenced in writing. (d) The Department will review each Questionnaire and determine whether a Conflict of Interest exists and, if so, whether and how it should or may be eliminated, avoided or managed in order to comply with the spirit of the policy and with the best interests of IU Health and its patients. In making the determination, the Corporate Compliance Department may consult with the IU Health Representative's supervisor and other appropriate individuals and groups. (e) The scope of the policy is not limited to those who are required to complete Questionnaires. If an IU Health Representative is involved in a situation or relationship that would constitute a violation of the policy in the absence of disclosure and approval as described above, then the IU Health Representative must disclose the matter to his/her supervisor, secure his/her supervisor's approval in writing, and disclose the matter to the Department. Otherwise, the IU Health Representative is in violation of the policy and subject to corrective action, up to and including termination. (f) The Chief Compliance Officer, in consultation with onsite Compliance personnel, may from time to time appoint standing or ad hoc committees to assist in resolving issues that arise under provisions of the policy. Part VI, Section B, Line 15a & 15b Process for Determining Compen. IU Health White Memorial Hospital's Regional President is employed by IU Health, Inc. IU HEALTH WHITE MEMORIAL HOSPITAL'S PRESIDENT IS EMPLOYED BY IU HEALTH WHITE MEMORIAL HOSPITAL, INC. IU Health's process for determining compensation is as follows: (1) The Board of Directors ("Board") has established a Talent Management and Executive Compensation Committee ("TMECC"), the purpose of which includes reviewing and making recommendations regarding executive (Senior Vice Presidents and above) pay and benefits (collectively referred to as "compensation") on an annual basis. The TMECC is made up of members of the Board that are neither physicians nor employees and do not otherwise have a conflict of interest regarding any of IU Health's compensation arrangements. The TMECC reviews an executive's entire compensation package including base salary, short-term and long-term incentives, health and welfare benefits, qualified and nonqualified retirement plans, as well as any additional fringe benefits. As deemed appropriate, the Committee on Finance, which is also made up of members of the Board, may also review executive compensation and benefits. (2) The TMECC engages an independent compensation consulting firm on an annual basis to conduct a compensation analysis for its executive group, which consists of employees at the level of senior vice president and above. The current compensation advisor is SullivanCotter. SullivanCotter performs its analysis in the form of a compensation survey ("survey") that includes relevant comparability data for compensation levels paid by similarly situated organizations (both governmental and tax exempt) for functionally comparable positions as well as the availability of similar services in the geographic area. SullivanCotter then prepares a survey report and provides recommendations to the TMECC, if deemed appropriate, on changes in executive compensation. A separate analysis using the same methodology is done for the President and Chief Executive Officer. (3) The TMECC then reviews SullivanCotter's report and recommendations and, if appropriate, votes on whether to recommend any changes in executive compensation to the Board. The TMECC will only recommend changes to the Board if they are consistent with the Board's philosophy on compensation matters and are deemed reasonable based upon the independent analysis provided by SullivanCotter. The TMECC's review, discussion and vote are documented in the minutes for the meeting. There are no executives present during the final discussion and approval. (4) The Board then reviews the report prepared by SullivanCotter as well as the recommendations of the TMECC as to any changes in executive compensation. As deemed appropriate, the Committee on Finance may also provide its review of the TMECC's recommendations on any changes in executive compensation. This review and discussion are documented in the minutes. (5) The Board then votes on whether to accept the TMECC's recommendations on any changes in executive compensation. Changes in executive compensation are made if approved by the TMECC and Board on an annual basis, or as necessary throughout the year. The discussion and approval are documented in the minutes of the meeting. There are no executives present during the final discussion and approval. IU Health's General Counsel also prepares a formal written opinion reviewing the executive compensation approval process, comparing it to the Intermediate Sanctions Test of IRC Section 4958. If warranted, IU Health's General Counsel may also provide comments regarding the executive compensation approval process as it relates to meeting the requirements for a rebuttable presumption of reasonableness as provided in the Intermediate Sanctions Test. (6) After the end of each year, the TMECC and Board also review the achievements of the executive group as it relates to the long-term and short-term shared and individual goals developed by the executives and the Board. These achievements may also be reviewed with the Committee on Finance. The Board, at its discretion, may approve bonus payments based upon the achievement of the goals. The discussion and vote of the TMECC and Board is documented in the minutes for each such meeting. The bonuses are not paid until approval is made by the Board. (7) The TMECC and Audit Committee also review Form 990 disclosures related to executive compensation as well as the organization's practices and approval processes prior to the filing of the Form 990 return with the Internal Revenue Service. IU Health White Memorial Hospital and other related entities have a process in place to determine the compensation for the other officers and key employees. IU Health Human Resources uses market data from multiple compensation experts/vendors who utilize a variety of methods and procedures to obtain compensation ranges for comparable officer and employee positions. This market data and multiple other factors (including market pay benchmarks, internal equity, candidate/employee qualifications & performance, and business needs) are used to recommend compensation ranges for its officers and other employees, which are then used as a guide for setting reasonable compensation by management. Part VI, Section C, Line 19 - Public Disclosure IU Health White Memorial Hospital Articles of Incorporation are available for public inspection through the Indiana Secretary of State's website. IU Health White Memorial Hospital conflict of interest procedures are disclosed on the Form 990, Schedule O. IU Health White Memorial Hospital is a subsidiary in IU Health's Consolidated Audited Financial Statements. IU Health's Consolidated Audited Financial Statements are available for public inspection through its bond filings and as an attachment to IU Health's Form 990 as well as IU Health White Memorial Hospital's Form 990. Part XI, Line 9 - Other Changes in Net Assets or Fund Balances During 2019, IU Health White Memorial Hospital, Inc. recorded the following changes in interest in net assets or fund balances: Change in Interest in Net Assets of Foundations: ($4,888) EQUITY TRANSFER (SETTLEMENT OF DEBT): ($2,036) TOTAL OTHER CHANGES IN NET ASSETS: ($6,924) FORM 990 PART IX LINE 11G DESCRIPTION:SHARED SERVICES/PROF. 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