2018-04-30T08:36:36-05:00 2017-06-30 410746749 CLIFTONLARSONALLEN LLP 220 SOUTH SIXTH STREET SUITE 300 MINNEAPOLIS MN 55402 990 2016-07-01 810240726 MARCUS DALY MEMORIAL HOSPITAL MARC 4063632211 1200 WESTWOOD DRIVE HAMILTON MT 59840 JOHN M BARTOS CEO, SECRETARY AND TREASURER 4063632211 2018-04-24 1 DARRYN MCGARVEY P00958683 6123764500 67.137.57.251 2018-04-24 13:35:46 CD P 1FBCD4AA4D8DA69ACB92FF11632DDFE988DCF009 96D79D528C2215BE6F492FFEF68EA7E177A44A5C 2016 2021-01-29 14:40:06Z JOHN M BARTOS 1200 WESTWOOD DRIVE HAMILTON MT 59840 68364533 0 X WWW.MDMH.ORG X 1929 MT OUR COMMITMENT TO THE BITTERROOT VALLEY IS QUALITY, ACCESSIBLE, PERSONALIZED HEALTHCARE. 11 7 635 75 0 0 522820 526928 61202601 67415482 57681 -35982 320492 216552 62103594 68122980 89558 58593 0 0 37720263 39960075 0 0 133890 24151964 23233273 61961785 63251941 141809 4871039 57938753 60014136 29679846 27027195 28258907 32986941 X OUR COMMITMENT TO THE BITTERROOT VALLEY IS QUALITY, ACCESSIBLE, PERSONALIZED HEALTHCARE. 0 0 53623429 58593 67415482 MARCUS DALY MEMORIAL HOSPITAL CORPORATION OWNS AND OPERATES A 25 LICENSED BED ACUTE CARE CRITICAL ACCESS HOSPITAL. THE HOSPITAL PROVIDES ACUTE CARE SERVICES TO PATIENTS IN RAVALLI COUNTY. THE SERVICES PROVIDED INCLUDE ACUTE CARE HOSPITAL, RELATED ANCILLARY SERVICES SUCH AS LABORATORY, RADIOLOGY, THERAPY, INPATIENT AND OUTPATIENT SURGERY, EMERGENCY CARE, AMBULANCE, HOME HEALTH, CLINIC, INPATIENT AND OUTPATIENT HOSPICE CARE. THE HOSPITAL PROVIDES EMS SERVICES WITH 3 CREWS PROVIDING 911 SERVICE TO THE COUNTY. THE GOAL IS TO RESPOND WITHIN 20 MINUTES OR LESS TO ANY CALL WITHIN THE COUNTY. THE HOSPITAL IS A PEDIATRIC REHABILITATION PROVIDER OF PHYSICAL THERAPY, OCCUPATIONAL THERAPY AND SPEECH THERAPY USING CERTIFIED THERAPISTS. THE HOSPITAL CLINICS SEE ALL PATIENTS REGARDLESS OF INSURANCE OR ABILITY TO PAY AND ENABLE THE COMMUNITY ACCESS TO PRIMARY CARE. 53623429 1 1 0 0 0 0 0 0 0 1 1 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 1 1 1 0 1 1 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 1 0 0 0 1 79 0 635 1 0 0 0 0 0 0 0 0 0 0 X 11 7 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 0 0 X X DONJA ERDMAN 4063754609 1200 WESTWOOD DRIVE HAMILTON MT 59840 JOHN M BARTOS CEO/SECRETARY/TREASURER 39.00 1.00 X X 334013 0 35834 BILL BEAN CHAIRMAN 2.00 X X 0 0 0 DON LODMELL CHAIRMAN THROUGH APRIL 2017 2.00 X X 0 0 0 LOIS HEDG-PETH VICE CHAIRMAN 2.00 X X 0 0 0 BARBARA ACKERMAN BOARD MEMBER 2.00 X 0 0 0 TOM ANDERSON BOARD MEMBER 2.00 X 0 0 0 SUSANNAH BENJAMIN BOARD MEMBER 2.00 X 0 0 0 JENNIFER FEIGHNER MD BOARD MEMBER/PHYSICIAN 40.00 X 310050 0 25239 LISA GLENN BOARD MEMBER 2.00 X 0 0 0 ALLEN W JONES MD BOARD MEMBER/PHYSICIAN THRU AUGUST 2016 40.00 X 296802 0 45977 BRIAN KELLEHER MD BOARD MEMBER/PHYSICIAN 40.00 X 139463 0 0 JOHN ORMISTON BOARD MEMBER THROUGH SEPTEMBER 2016 2.00 X 0 0 0 JAMES OWINGS CPA BOARD MEMBER THROUGH OCTOBER 2016 2.00 X 0 0 0 ROBERT WHALEN BOARD MEMBER 2.00 X 0 0 0 TIMOTHY WOODS MD BOARD MEMBER/PHYSICIAN 40.00 X 453768 0 55478 DONJA C ERDMAN CFO 39.00 1.00 X 143668 0 32929 JOHN MORELAND MD CHIEF MEDICAL OFFICER 40.00 X 298451 0 39980 TROY HANSON ASSISTANT ADMINISTRATOR 40.00 X 165365 0 19369 KATHRYN PADILLA RN DIRECTOR OF NURSING 40.00 X 110580 0 14656 MARK CALDERWOOD MD PHYSICIAN 40.00 X 345133 0 30728 YVONNE COURCHESNE MD PHYSICIAN 40.00 X 416194 0 36673 RICHARD DAY MD PHYSICIAN 40.00 X 917876 0 43769 MICHAEL DOLECKI MD PHYSICIAN 40.00 X 451396 0 44802 BENJAMIN WATTERS MD PHYSICIAN 40.00 X 302575 0 40511 FREDERICK ILGENFRITZ MD BOARD MEMBER/PHYSICIAN THRU APRIL 2016 40.00 X 272030 0 53176 4957364 0 519121 19 1 1 0 CERNER CORPORATION PO BOX 959156 ST LOUIS MO 63195 EHR PROVIDER 807356 OZ ARCHITECTS 531 NORTH HIGGINS AVE A MISSOULA MT 59802 ARCHITECTUAL SERVICES 785110 HEALTHCARE OUTSOURCING NETWORK 1597 COLE BLVD 150 LAKEWOOD CO 80401 PATIENT PAYMENT ASSISTANCE 478603 WEATHERBY LOCUMS INC PO BOX 972633 DALLAS TX 75397 NURSING LOCUM STAFFING 391515 BECK BUILDERS INC 110 FABERS WAY HAMILTON MT 59840 HOSPITAL CONSTRUCTION 355617 9 433517 93411 526928 NET PATIENT SERVICE REVENUE 621400 63818480 63818480 HOSPITAL UTILZTN. REV. 621400 2938494 2938494 OTHER OPERATING INCOME 621400 658508 658508 67415482 32060 32060 249421 144959 104462 104462 104462 28552 96594 -68042 -68042 -68042 MISCELLANEOUS 900099 86034 86034 EDUCATION 900099 15017 15017 CAFETERIA/VENDING 900099 11039 11039 112090 68122980 67415482 0 180570 56593 56593 2000 2000 2733420 2017785 715635 29452143 25013491 4367566 71086 1150339 980618 166947 2774 4541501 3849054 682127 10320 2082672 1710472 366798 5402 114837 114837 63160 63160 3989496 2181745 1804658 3093 84657 84657 4520195 4237678 281736 781 980474 827866 152608 308942 288565 20377 162869 129371 33498 1019068 924159 75927 18982 4013127 3742882 251593 18652 922886 922886 PROVISION FOR BAD DEBTS 4255620 4255620 PHARMACY/ LAB EXPENSES 1559974 1559974 MAINTENANCE AND REPAIRS 911074 761490 149584 MISCELLANEOUS EXPENSES 269843 32252 234851 2740 57051 44271 12720 60 63251941 53623429 9494622 133890 8250264 8066741 3494400 2336122 8811539 11843760 239166 272638 2009194 2024926 391756 484065 69460163 37401066 33146400 32059097 1181917 1241212 414117 0 1685575 57938753 60014136 6509367 6162363 93744 15534 6155000 9505000 14092451 7878906 847592 334950 1981692 3130442 29679846 27027195 X 26367443 31033258 1193193 1250204 698271 703479 28258907 32986941 57938753 60014136 X 4871039 -143005 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 313190 724 724 313190 313190 984 984 313190 313190 1019 1019 313190 313190 2806 2806 313190 313190 2665 2665 313190 0.00000 1.00000 0.00000 0 0 1897280 1897280 45759138 21541933 24217205 1488385 817383 671002 20022925 15041750 4981175 292435 292435 32059097 THIRD PARTY SETTLEMENT 1890355 BOND ISSUE COSTS -445488 EMPLOYEE BENEFIT OBLIGATION 1685575 3130442 X 63230301 -4255620 -4255620 67485921 637059 637059 68122980 59136412 121061 121061 59015351 4236590 4236590 63251941 PART V, LINE 4: THE ENDOWMENT FUND IS DESIGNATED FOR THE PURPOSE OF BUILDING AND CARRYING ON A HOSPITAL IN HAMILTON, MONTANA. THE EVANS ENDOWMENT IS TO BE USED FOR THE CARE AND TREATMENT OF CRIPPLED CHILDREN. PART X, LINE 2: PER THE AUDITED FINANCIAL STATEMENTS, NOTE 1: THE INTERNAL REVENUE SERVICE (IRS) HAS DETERMINED THAT MARCUS DALY MEMORIAL HOSPITAL IS A TAX-EXEMPT, NOT-FOR-PROFIT CORPORATION UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE (IRC). THE HOSPITAL FOLLOWS THE GUIDANCE IN THE ACCOUNTING STANDARDS REGARDING THE RECOGNITION AND MEASUREMENT OF UNCERTAIN TAX POSITIONS. THE GUIDANCE CLARIFIES THE ACCOUNTING FOR UNCERTAINTY IN INCOME TAXES RECOGNIZED IN AN ENTITY'S FINANCIAL STATEMENTS. THE GUIDANCE FURTHER PRESCRIBES RECOGNITION AND MEASUREMENT OF TAX PROVISIONS TAKEN OR EXPECTED TO BE TAKEN ON A TAX RETURN THAT ARE NOT CERTAIN TO BE REALIZED. THE APPLICATION OF THIS STANDARD HAS NO IMPACT ON THE HOSPITAL'S FINANCIAL STATEMENTS. PART XI, LINE 2D - OTHER ADJUSTMENTS: PROVISION FOR UNCOLLECTIBLE ACCOUNTS -4,255,620. PART XI, LINE 4B - OTHER ADJUSTMENTS: TEMPORARILY RESTRICTED CONTRIBUTIONS 460,231. OTHER OPERATING REVENUES 199,132. RENTAL EXPENSE -121,061. INTEREST REVENUE 32,060. GRANTS AND CONTRIBUTIONS 66,697. PART XII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES 121,061. PART XII, LINE 4B - OTHER ADJUSTMENTS: PROVISION FOR UNCOLLECTIBLE ACCOUNTS 4,255,620. EMPLOYEE BENEFIT PLAN EXPENSES REFUNDED -19,030. 1 1 X 1 X 1 X 1 1 0 1 1 162371 162371 0.00260 10720642 6338644 4381998 0.06930 10883013 6338644 4544369 0.07190 279637 279637 0.00440 43881 43881 0.00070 6519146 5279255 1239891 0.01960 50954 50954 0.00080 6893618 5279255 1614363 0.02550 17776631 11617899 6158732 0.09740 976 976 0.00000 63684 63684 0.00100 64660 64660 0.00100 1 4255620 11297176 17739710 -6442534 X 1 1 1 1 MARCUS DALY MEMORIAL HOSPITAL 1200 WESTWOOD DRIVE HAMILTON MT 59840 WWW.MDMH.ORG 12911 X X X X MARCUS DALY MEMORIAL HOSPITAL 1 0 0 1 X X X X X X X X X 15 1 0 0 1 X HTTPS://WWW.MDMH.ORG/DOCUMENTS/BLOG/2015_COMMUNITY_HEALTH_NEEDS_ASSESSMENT_ X 1 15 1 HTTPS://WWW.MDMH.ORG/DOCUMENTS/BLOG/2015_COMMUNITY_HEALTH_NEEDS_ASSESSMENT_ 0 1 X 100.000000000000 200.000000000000 X X X X X X 1 1 X X X 1 X HTTPS://WWW.MDMH.ORG/DOCUMENTS/PDF/CHARITY_CARE_POLICY_REVISED_061617.PDF X HTTPS://WWW.MDMH.ORG/DOCUMENTS/PDF/FINANCIAL_ASSISTANCE_APPLICATION_8.1.16. X HTTPS://WWW.MDMH.ORG/DOCUMENTS/PLAIN_LANGUAGE_SUMMARY_OF_FINANCIAL_ASSISTAN X X X X X 1 X 0 X X X 1 X 0 0 MARCUS DALY MEMORIAL HOSPITAL PART V, SECTION B, LINE 3J: PART V, SECTION B, LINE 3F:THIS BOX WAS LEFT UNCHECKED BECAUSE MDMH'S CHNA DIDN'T DIRECTLY INCLUDE A STATEMENT ADDRESSING THE PRIMARY AND CHRONIC DISEASE NEEDS AND OTHER HEALTH ISSUES OF UNINSURED PERSONS, LOW INCOME PERSONS, AND MINORITY GROUPS, HOWEVER, THE HOSPITAL IS TAKING STEPS TO ADDRESS THESE ISSUES. MDMH HAS RECENTLY JOINED TOGETHER WITH 10 OTHER HOSPITALS FROM RURAL MONTANA, IDAHO, AND WYOMING TO FORM THE MOUNTAIN WEST ACCOUNTABLE CARE ORGANIZATION (ACO). ONE OF THE MAIN OBJECTIVES OF THE ACO IS TO IMPROVE OVERALL COMMUNITY HEALTH BY FOCUSING ON THOSE WITH CHRONIC HEALTH NEEDS. AS PART OF THE ACO PROGRAM, MDMH HAS SPECIFICALLY HIRED A SECOND CLINIC RN TO HELP MANAGE THOSE PATIENTS IDENTIFIED WITH CHRONIC HEALTH CONDITIONS AND CONCERNS. MARCUS DALY MEMORIAL HOSPITAL PART V, SECTION B, LINE 5: MR. VETO J. "SONNY" LASALLE SERVED AS THE 2015 COMMUNITY HEALTH NEEDS ASSESSMENT (CHNA) PROGRAM COORDINATOR. ALMOST 70 ORGANIZATIONS WERE IDENTIFIED WITH IN THE COUNTY , INCLUDING BUT NOT LIMITED TO COUNTY AND CITY ELECTED OFFICERS, SCHOOL BOARDS, SCHOOL STAFF, SERVICE CLUBS, RETIREMENT HOMES, POLITICAL GROUPS, FEDERAL AND STATE OFFICES, AND OTHERS. MR. LASALLE WOULD MEET WITH THE GROUP AT A SCHEDULED MEETING PRESENT THE PURPOSE OF THE CHNA, ANSWER QUESTIONS AND DISTRIBUTE SURVEYS. NOTICE OF THE SURVEY WAS ALSO MADE BY NEWSPAPER, TELEVISION, AND THE HOSPITAL NEWSLETTER, HEALTHLINES, WHICH IS MAILED TO COUNTY RESIDENTS. THIS SURVEY WAS ALSO POSTED ON THE HOSPITAL'S WEBSITE. MARCUS DALY MEMORIAL HOSPITAL PART V, SECTION B, LINE 11: THE HIGHEST PRIORITY HEALTH NEEDS AS SUGGESTED BY THE COMMUNITY SERVED BY MDMH BASED UPON THE RESULT OF THE 2015 SURVEY ARE:1. EXPAND SERVICES TO INCLUDE A HEALTH CARE CINIC IN DARBY AND EXPANDED CHEMOTHERAPY SERVICES. 2. EXPAND PHYSICIAN SERVICES TO INCLUDE A PEDIATRITION, UROLOGIST, EAR, NOSE, AND THROAT SPECIALIST, PULMONOLOGY AND DERMATOLOGY. THE HOSPITAL BOARD OF DIRECTORS HAS DECIDED NOT TO PURSUE A PEDIATRICIAN AT THIS TIME. 3. EXPAND EDUCATIONAL OPPORTUNITIES ESPECIALLY RELATED TO DIABETES, NUTRITION, OBESITY AND DEMENTIA. 4. EXPANDED MENTAL HEALTH COVERAGE WAS ALSO REQUESTED. MDMH RECOGNIZES THAT THIS IS A STATE AND NATIONAL CONCERN BUT UNFORTUNATELY AT THIS TIME MDMH IS NOT STAFFED TO DEAL WITH MENTAL HEALTH PATIENTS OUTSIDE OF THE EMERGENCY DEPARTMENT.HOWEVER, THE HOSPITAL IS TAKING STEPS TO ADDRESS ALL OF THESE ISSUES. IN 2016, THE HOSPITAL OPENED A CLINIC IN DARBY TO SERVE THE SOUTH END OF THE VALLEY POPULATION THAT WAS PREVIOUSLY UNDERSERVED. MARCUS DALY MEMORIAL HOSPITAL PART V, SECTION B, LINE 13B: ELIGIBILITY FOR PATIENT ASSISTANCE SHALL BE MADE REGARDLESS OF RACE, GENDER, AGE, SEXUAL ORIENTATION, RELIGIOUS AFFILIATION, AND SOCIAL OR IMMIGRANT STATUS. MAJOR AREAS OF CONSIDERATIONS 1) RELATIONSHIP TO FEDERAL INCOME POVERTY GUIDELINES ADJUSTED FOR FAMILY SIZE 2) FAMILY NET ASSETS 3) DEMONSTRATION OF INABILITY TO WORK 4) COMPLETED APPLICATION AND 5) RESIDENT OF RAVALLI COUNTY MONTANA WITH EXCEPTIONS. 5 1 - CORVALLIS FAMILY MEDICINE CLINIC 1037 MAIN STREET CORVALLIS MT 59828 FAMILY PRACTICE CLINIC 2 - BITTERROOT VALLEY EYE ASSOCIATES 300 N 10TH STREET HAMILTON MT 59840 OPTICAL SPECIALTY CLINIC 3 - BITTERROOT PHYSICIAN CLINIC SOUTH 3334 DVN LANE DARBY MT 59829 FAMILY PRACTICE CLINIC 4 - BITTERROOT PHYSICIAN CLINIC NORTH 2386 HIGHWAY 93 NORTH VICTOR MT 59875 FAMILY PRACTICE CLINIC 5 - RAVALLI UROLOGY 1224 WEST MAIN STREET HAMILTON MT 59840 UROLOGY SERVICES PART I, LINE 3C: ELIGIBILITY FOR FINANCIAL ASSISTANCE IS BASED ON MULTIPLE FACTORS, INCLUDING THE NATURE OF THE CONDITION AND CARE REQUIRED, INSURANCE COVERAGE OR OTHER SOURCES OF PAYMENT, INCOME (FEDERAL POVERTY LEVEL GUIDELINES ARE USED TO DETERMINE THE AMOUNT OF FINANCIAL ASSISTANCE OFFERED), FAMILY SIZE, ASSETS, AND RESIDENCY IN RAVALLI COUNTY UNLESS SERVICES WERE FOR EMERGENCY CARE.FULL FINANCIAL ASSISTANCE WILL BE GRANTED BASED ON INCOME EQUAL TO OR LESS THAN 100% OF FEDERAL POVERTY LEVEL GUIDELINES. PARTIAL ASSISTANCE MAY BE GRANTED BASED ON INCOME BETWEEN 100% AND 200% OF FEDERAL POVERTY LEVEL GUIDELINES. VALUE OF ASSETS MAY BE CONSIDERED IN DETERMINING THE LEVEL OF ASSISTANCE. PART I, LINE 7: EXPLANATION OF COSTING METHOD:FINANCIAL ASSISTANCE AT COST AND MEDICAID AMOUNTS REPORTED IN PART I, LINE 7 ARE COMPUTED USING THE COST TO CHARGE RATIO DERIVED FROM WORKSHEET 2 OF THE IRS INSTRUCTIONS. COMMUNITY HEALTH IMPROVEMENTS SERVICES, COMMUNITY BENEFIT OPERATIONS, HEALTH PROFESSIONAL EDUCATION, AND CASH AND IN-KIND CONTRIBUTIONS TO COMMUNITY GROUPS ARE REPORTED AT COST. GENERAL SUBSIDIZED SERVICES ARE COMPUTED USING THE IRS GUIDELINES OF COST ADJUSTED NET PAYMENTS RECEIVED. THE MEDICARE COST REPORT WAS USED TO DETERMINE THE TOTAL SUBSIDY FOR THE HOME HEALTH / HOSPICE DEPARTMENTS. PART I, LINE 7G: INCLUDED IN THE SUBSIDIZED HEALTH SERVICES ARE THE FOLLOWING DEPARTMENTS: BITTERROOT PHYSICIAN CLINIC SOUTH, BITTERROOT PHYSICIAN CLINIC NORTH, RAVALLI UROLOGY, BITTERROOT GENERAL SURGERY, HAMILTON GENERAL SURGERY, HAMILTON OBGYN, BITTERROOT ORTHOPEDICS & SPORT, HOME HEALTH, HOSPICE IP/OP. PART I, LN 7 COL(F): THE AMOUNT OF BAD DEBT EXPENSES THAT WAS EXCLUDED FROM THE CALCULATION TO DETERMINE THE NET COMMUNITY BENEFIT EXPENSES AS A PERCENT OF TOTAL EXPENSES WAS $4,255,620. PART II, COMMUNITY BUILDING ACTIVITIES: THE HOSPITAL PROMOTES THE HEALTH OF THE COMMUNITY BY PARTICIPATION IN BOTH ECONOMIC AND COALITION BUILDING EVENTS. THE HOSPITAL PARTNERS WITH LOCAL HIGH SCHOOLS WITH A "JOB SHADOW" PROGRAM. THE GOAL IS TO EXPOSE AND PROMOTE THE HEALTH CARE PROFESSION TO AREA YOUTH. WE HAVE ADDED RESIDENCY TRAINING OPPORTUNITIES TO THOSE NEW PHYSICIANS WHO ARE INTERESTED IN EXPERIENCING MEDICAL PRACTICE IN A RURAL SETTING. THE HOSPITAL CONTINUES TO RECRUIT NEW PHYSICIANS TO THE AREA TO PROVIDE BASIC AND EXPANDED SERVICES TO BETTER SERVE THE NEED OF THE LOCAL COMMUNITY. PART III, LINE 2: BAD DEBT EXPENSE IS CALCULATED BY REVIEWING PAYMENT ARRANGEMENTS WHICH INCLUDE PROSPECTIVELY DETERMINED RATES PER DISCHARGE, REIMBURSED COSTS, DISCOUNTED CHARGES AND PER DIEM PAYMENTS. NET PATIENT SERVICE REVENUE IS REPORTED AT THE ESTIMATED NET REALIZABLE AMOUNTS FROM PATIENTS, THIRD-PARTY PAYORS, AND OTHERS FOR SERVICES RENDERED, INCLUDING ESTIMATED RETROACTIVE ADJUSTMENTS UNDER REIMBURSEMENT AGREEMENTS WITH THIRD-PARTY PAYORS. PART III, LINE 4: THE FOLLOWING IS FROM THE "PATIENT ACCOUNTS RECEIVABLE" PARAGRAPH IN NOTE 1 TO THE HOSPITAL'S FINANCIAL STATEMENTS:"PATIENT AND RESIDENT ACCOUNTS RECEIVABLE ARE REDUCED BY AN ALLOWANCE FOR DOUBTFUL ACCOUNTS. IN EVALUATING THE COLLECTIBILITY OF PATIENT AND RESIDENT ACCOUNTS RECEIVABLE, THE HOSPITAL ANALYZES ITS PAST HISTORY AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYOR SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND PROVISION FOR BAD DEBTS. MANAGEMENT REGULARLY REVIEWS DATA ABOUT THESE MAJOR PAYOR SOURCES OF REVENUE IN EVALUATING THE SUFFICIENCY OF THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. FOR RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE THIRD-PARTY COVERAGE, THE HOSPITAL ANALYZES CONTRACTUALLY DUE AMOUNTS AND PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS AND A PROVISION FOR BAD DEBTS, IF NECESSARY (FOR EXAMPLE, FOR EXPECTED UNCOLLECTIBLE DEDUCTIBLES AND COPAYMENTS ON ACCOUNTS FOR WHICH THE THIRD-PARTY PAYOR HAS NOT YET PAID, OR FOR PAYORS WHO ARE KNOWN TO BE HAVING FINANCIAL DIFFICULTIES THAT MAKE THE REALIZATION OF AMOUNTS DUE UNLIKELY). FOR RECEIVABLES ASSOCIATED WITH SELF-PAY PATIENTS (WHICH INCLUDES BOTH PATIENTS WITHOUT INSURANCE AND PATIENTS WITH DEDUCTIBLE AND COPAYMENT BALANCES DUE FOR WHICH THIRD-PARTY COVERAGE EXISTS FOR PART OF THE BILL), THE HOSPITAL RECORDS A SIGNIFICANT PROVISION FOR BAD DEBTS IN THE PERIOD OF SERVICE ON THE BASIS OF ITS PAST EXPERIENCE, WHICH INDICATES THAT MANY PATIENTS ARE UNABLE OR UNWILLING TO PAY THE PORTION OF THEIR BILL FOR WHICH THEY ARE FINANCIALLY RESPONSIBLE. THE DIFFERENCE BETWEEN THE STANDARD RATES (OR THE DISCOUNTED RATES IF NEGOTIATED) AND THE AMOUNTS ACTUALLY COLLECTED AFTER ALL REASONABLE COLLECTION EFFORTS HAVE BEEN EXHAUSTED IS CHARGED OFF AGAINST THE ALLOWANCE FOR DOUBTFUL ACCOUNTS." PART III, LINE 8: MDMH HAS A MEDICARE SHORTFALL IN EXCESS OF APPROXIMATELY $6,442,534. THE HOSPITAL HAS CRITICAL ACCESS HOSPITAL STATUS AND IS REIMBURSED BY MEDICARE FOR INPATIENT AND OUTPATIENT SERVICES ON A COST BASIS AS DEFINED AND LIMITED BY THE MEDICARE PROGRAM. MDMH PROVIDES A SIGNIFICANT RURAL LINK FOR BOTH THE HEALTH AND WELL-BEING OF RAVALLI COUNTY RESIDENTS. WE ARE COMMITTED TO LOCAL HEALTHCARE CLOSE TO HOME AND WORK HARD TO EARN AND KEEP THE TRUST OF THE LOCAL COMMUNITY. TO ENSURE THAT A VARIETY OF CLINIC, HOSPITAL AND EMERGENCY SERVICES ARE OPEN AND AVAILABLE TO ALL THOSE WITHIN OUR SERVICE AREA WE STRIVE TO OPERATE AT THE HIGHEST LEVEL OF FISCAL RESPONSIBILITY AND TO BE A GOOD STEWARD OF OUR RESOURCES. THE MEDICARE ALLOWABLE COSTS INCLUDED IN PART III, LINE 6 WAS DERIVED USING THE 2017 FILED MEDICARE COST REPORT. PART III, LINE 9B: IF A PATIENT IS PRESUMED TO BE FINANCIALLY INDIGENT, THE PATIENT REPRESENTATIVE WILL OFFER A PERSONAL FINANCIAL STATEMENT (PFS) TO BE FILLED OUT. THE PFS WILL BE FORWARDED TO THE PATIENT FINANCIAL ASSISTANCE COMMITTEE FOR REVIEW AND DETERMINATION OF PATIENT FINANCIAL ASSISTANCE STATUS. A PATIENT MAY REQUEST A MONTHLY PAYMENT ARRANGMENT. A MINIMUM PAYMENT OF $50 MUST BE PAID MONTHLY, WITH THE GOAL OF THE BALANCE PAID IN FULL WITHIN 5 YEARS. ACCOUNTS THAT CANNOT BE COLLECTED AFTER NORMAL IN-HOUSE COLLECTION PROCEDURES MAY BE REFERRED TO A COLLECTION AGENCY, MAGISTRATE OR ATTORNEY FOR FURTHER COLLECTION ACTION. PART VI, LINE 2: IN ADDITION TO CONDUCTING A COMMUNITY HEALTH NEEDS ASSESSMENT EVERY THREE YEARS, MDMH ASSESSES THE HEALTH NEEDS OF THE COMMUNITY BY LISTENING TO OUR PATIENTS, FRIENDS, FAMILY AND NEIGHBORS AS WE INTERACT WITH THEM DAILY WE HEAR THEIR CARES AND CONCERNS. WE ALWAYS ARE LOOKING FOR NEW WAY TO RESPOND TO, AND PROVIDE BETTER CARE FOR THE LOCAL COMMUNITY. PART VI, LINE 3: AS OF JANUARY 1, 2014, THE HOSPITAL'S FINANCIAL ASSISTANCE PROGRAM IS POSTED ON THEIR WEBSITE AT HTTPS://WWW.MDMH.ORG/PATIENTS-VISITORS/PATIENT-FINANCIAL-ASSISTANCE.ASPX IN ADDITION THE HOSPITAL INFORMS PATIENTS UNABLE TO PAY THEIR BILLS ABOUT THEIR FINANCIAL ASSISTANCE WHILE TALKING TO THEM OVER THE PHONE AND SENDS THEM A FINANCIAL ASSISTANCE PACKET. PART VI, LINE 4: THE HOSPITAL SERVES A RURAL POPULATION WHERE THE AVERAGE ANNUAL WAGE IS $40,065. THE PAYER MIX IS 53% MEDICARE, 19% MEDICAID, 4% SELF PAY, NO INSURANCE, WITH THE BALANCE AT OTHER COMMERCIAL PAYORS. THE UNEMPLOYMENT RATE IN RAVALLI COUNTY IS CURRENTLY AT 4% ACCORDING TO THE MONTANTA DEPARTMENT OF LABOR AND INDUSTRY. PART VI, LINE 5: THE HOSPITAL IS PROUD OF ITS EFFORTS TO PROMOTE COMMUNITY HEALTH AND WELLNESS. "SPRINKLE PINK" PROGRAM IS A COMMUNITY WIDE PROGRAM THAT PROMOTES MAMMOGRAPHY SCREENING AND RAISES FUNDS TO PROVIDE NO-COST MAMMOGRAMS TO QUALIFIED LOW INCOME AREA RESIDENTS. THE HOSPITAL COORDINATES AND SPONSORS THE ANNUAL SPORTS PHYSICAL CLINIC TO SUPPORT AND ENCOURAGE AREA YOUTH TO PARTICIPATE IN PHYSICIAL ACTIVITIES. A VARIETY OF HEALTH EDUCATION CLASSES ARE OFFERED TO THE COMMUNITY FREE OF CHARGE THROUGH OUT THE YEAR. PART VI, LINE 6: THE ORGANIZATION IS NOT PART OF AN AFFILIATED HEALTH CARE SYSTEM. PART VI, LINE 7, REPORTS FILED WITH STATES MT 1 HAMILTON SCHOOL DISTRICT 217 DALY AVENUE HAMILTON MT 59840 816000830 GOVERNMENTAL 9275 SUPPORT FOR SCHOOL RN PROGRAM AND STUDENT ATHLETICS. CORVALLIS SCHOOL DISTRICT PO BOX 700 1045 MAIN STREET CORVALLIS MT 59828 816000828 GOVERNMENTAL 9725 SUPPORT FOR SCHOOL RN PROGRAM AND STUDENT ATHLETICS. STEVENSVILLE SCHOOL DISTRICT 300 PARK STREET STEVENSVILLE MT 59870 816000829 GOVERNMENTAL 6550 SUPPORT FOR SCHOOL RN PROGRAM AND STUDENT ATHLETICS DARBY SCHOOL DISTRICT 209 SCHOOL DRIVE DARBY MT 59829 816000834 GOVERNMENTAL 7050 SUPPORT FOR SCHOOL RN PROGRAM AND STUDENT ATHLETICS. 4 0 PART I, LINE 2: THE HOSPITAL IS COMMITTED TO SUPPORT THE HEALTH AND WELL-BEING OF AREA SCHOOL AGED CHILDREN BY PROVIDING FUNDING GRANTS RESTRICTED TO THE DISTRICT'S SCHOOL NURSE PROGRAM. THE HOSPITAL HAS ALSO COMMITTED TO SUPPORT STUDENT ATHLETICS BY PROVIDING A VOLUNTEER BASED, LOW-COST SPORTS PHYSICAL CLINIC DURING THE SUMMER. THE PROCEEDS ARE GIVEN TO THE PARTICIPATING STUDENTS' HOME DISTRICT TO SUPPORT THE DISTRICT'S ATHLETIC PROGRAMS. OTHER COMMUNITY ORGANIZATIONS MAY SUBMIT A GRANT PROPOSAL DIRECTLY TO THE HOSPITAL CEO FOR CONSIDERATION. THE REQUESTS ARE EVALUATED BASED UPON BROAD BASED COMMUNITY SUPPORT AND THE URGENCY OF NEED. X X 0 0 X X X X 0 0 0 0 0 0 0 0 0 JOHN M BARTOS CEO/SECRETARY/TREASURER 322016 0 0 0 11997 0 24000 0 11834 0 369847 0 0 0 JENNIFER FEIGHNER MD BOARD MEMBER/PHYSICIAN 284267 0 24083 0 1700 0 12896 0 12343 0 335289 0 0 0 ALLEN W JONES MD BOARD MEMBER/PHYSICIAN THRU AUGUST 2 240506 0 54744 0 1552 0 36000 0 9977 0 342779 0 0 0 TIMOTHY WOODS MD BOARD MEMBER/PHYSICIAN 445907 0 6000 0 1861 0 42000 0 13478 0 509246 0 0 0 DONJA C ERDMAN CFO 137440 0 0 0 6228 0 30000 0 2929 0 176597 0 0 0 JOHN MORELAND MD CHIEF MEDICAL OFFICER 281018 0 15756 0 1677 0 39012 0 968 0 338431 0 0 0 TROY HANSON ASSISTANT ADMINISTRATOR 157514 0 0 0 7851 0 5400 0 13969 0 184734 0 0 0 MARK CALDERWOOD MD PHYSICIAN 343242 0 0 0 1891 0 24000 0 6728 0 375861 0 0 0 YVONNE COURCHESNE MD PHYSICIAN 240808 0 173910 0 1476 0 35000 0 1673 0 452867 0 0 0 RICHARD DAY MD PHYSICIAN 836241 0 79774 0 1861 0 42000 0 1769 0 961645 0 0 0 MICHAEL DOLECKI MD PHYSICIAN 449535 0 0 0 1861 0 42000 0 2802 0 496198 0 0 0 BENJAMIN WATTERS MD PHYSICIAN 299385 0 1553 0 1637 0 28000 0 12511 0 343086 0 0 0 FREDERICK ILGENFRITZ MD BOARD MEMBER/PHYSICIAN THRU APRIL 20 268375 0 2000 0 1655 0 41550 0 11626 0 325206 0 0 0 PART I, LINE 1A DR RICHARD DAY RECEIVES A NON-PAID HOUSING ALLOWANCE. THE HOUSE IS OWNED BY THE HOSPITAL AND PROVIDED TO DR DAY AS A CONVENIENCE TO MARCUS DALY MEMORIAL HOSPITAL. PART I, LINE 1B THE CEO HAS BEEN APPROVED BY THE BOARD OF DIRECTORS TO RECEIVE A MONTHLY $400 VEHICLE ALLOWANCE. A MT FACILITY FINANCE AUTHORITY 364615155 2017-06-22 9505000 REFINANCE SERIES 2000A AND SERIES 2007A BONDS AND REFINANCE EXISTING LOANS 0 0 0 A 9505000 190100 9314900 2017 1 0 1 1 A 0 1 0 0 0.02830 0.00000 0.02830 0 0 1 A 0 1 0 0 0 0 0 0 1 A 1 KATHLEEN OWINGS SPOUSE OF BOARD MEMBER 135553 WAGES 0 DR JOHN MORELAND CMO/EMPLOYED PHSYICIAN 230702 RETIREMENT OF DEBT 0 DR WALKER ASHCRAFT FORMER BOARD MEMBER/EMPLOYED PHYSICIAN 230702 RETIREMENT OF DEBT 0 FORM 990, PART VI, SECTION B, LINE 11B A REPRESENTATIVE FROM CLIFTONLARSONALLEN WILL BE RESPONSIBLE TO PRESENT THE FORM 990 TO THE HOSPITAL FINANCE COMMITTEE. UPON APPROVAL THE FORM 990 WILL BE PRESENTED TO THE BOARD OF DIRECTORS FOR ACCEPTANCE AND APPROVAL. FORM 990, PART VI, SECTION B, LINE 12C ANY DIRECTOR, CORPORATE OFFICER, SENIOR MANAGER, TRUSTEE OR MEMBER OF A COMMITTEE WITH GOVERNING BOARD DELEGATED POWERS, WHO HAS A DIRECT OR INDIRECT FINANCIAL INTEREST, IS AN INTERESTED PERSON. IF A PERSON IS AN INTERESTED PERSON WITH RESPECT TO ANY ENTITY IN THE HEALTH CARE SYSTEM OF WHICH THE HOSPITAL IS A PART, HE OR SHE IS AN INTERESTED PERSON WITH RESPECT TO ALL ENTITIES IN THE HEALTH CARE SYSTEM. UPON APPOINTMENT, HIRE OR TRANSFER AND ANNUALLY THEREAFTER, EACH INTERESTED PERSON SHALL EXECUTE AND SUBMIT TO THE HOSPITAL'S CEO A STATEMENT WHICH AFFIRMS SUCH PERSON: A. HAS RECEIVED A COPY OF THE CONFLICT OF INTEREST POLICY; B. HAS READ AND UNDERSTANDS THE POLICY; C. HAS AGREED TO COMPLY WITH THE POLICY; AND D. UNDERSTANDS THAT THE HOSPITAL IS A CHARITABLE ORGANIZATION AND IN ORDER TO MAINTAIN ITS FEDERAL AND STATE TAX EXEMPTIONS IT MUST ENGAGE PRIMARILY IN ACTIVITIES WHICH ACCOMPLISH ONE OR MORE OF ITS TAX-EXEMPT PURPOSES. IN CONNECTION WITH ANY ACTUAL OR POSSIBLE CONFLICT OF INTEREST, AN INTERESTED PERSON MUST DISCLOSE THE EXISTENCE OF THE CONFLICTING FINANCIAL INTEREST AND MUST BE GIVEN THE OPPORTUNITY TO DISCLOSE ALL MATERIAL FACTS TO THE DIRECTORS AND MEMBERS OF COMMITTEES WITH GOVERNING BOARD DELEGATED POWERS CONSIDERING THE PROPOSED TRANSACTION OR ARRANGEMENT. ANY OTHER MEMBER OF THE BOARD OR COMMITTEE MAY RAISE THE QUESTION OF WHETHER A CONFLICT EXISTS, DISCLOSE FACTS RELATING TO THE CONFLICT AND REQUEST THE INTERESTED PERSON TO PROVIDE FURTHER DETAILS. THE BOARD CHAIR (OR VICE CHAIR ACTING IN THE PLACE OF THE CHAIR) OR THE HOSPITAL'S LEGAL COUNSEL MAY, BASED ON THEIR INFORMATION ABOUT THE CONFLICT, DISCLOSE THE CONFLICT AND REQUEST THE INTERESTED PERSON TO WITHDRAW FROM DISCUSSION OF THE TRANSACTION AND/OR NOT VOTE. THE INTERESTED PERSON SHALL LEAVE THE MEETING OR REQUEST A DETERMINATION BY THE BOARD OR COMMITTEE OF WHETHER A CONFLICT OF INTEREST EXISTS. AFTER DISCLOSURE OF THE CONFLICTING INTEREST AND ALL MATERIAL FACTS, AND AFTER ANY DISCUSSION WITH THE INTERESTED PERSON, HE/SHE SHALL LEAVE THE GOVERNING BOARD OR COMMITTEE MEETING WHILE THE DETERMINATION OF A CONFLICT OF INTEREST IS DISCUSSED AND VOTED UPON. THE REMAINING, DISINTERESTED BOARD OR COMMITTEE MEMBERS SHALL DECIDE IF A CONFLICT OF INTEREST EXISTS BEFORE CONSIDERING OR ACTING UPON ANY OTHER BUSINESS. AFTER EXERCISING DUE DILIGENCE, THE GOVERNING BOARD OR COMMITTEE SHALL DETERMINE WHETHER THE HOSPITAL CAN OBTAIN WITH REASONABLE EFFORTS A MORE ADVANTAGEOUS TRANSACTION OR ARRANGEMENT WITH REASONABLE EFFORTS FROM A PERSON OR ENTITY THAT WOULD NOT GIVE RISE TO A CONFLICT OF INTEREST. IF A MORE ADVANTAGEOUS TRANSACTION OR ARRANGEMENT IS NOT REASONABLY ATTAINABLE UNDER CIRCUMSTANCES NOT PRODUCING A CONFLICT OF INTEREST, THE GOVERNING BOARD OR COMMITTEE SHALL DETERMINE BY A MAJORITY VOTE OF THE DISINTERESTED DIRECTORS WHETHER THE TRANSACTION OR ARRANGEMENT IS IN THE HOSPITAL'S BEST INTEREST, FOR ITS OWN BENEFIT, AND WHETHER IT IS FAIR AND REASONABLE. IN CONFORMITY WITH THE ABOVE DETERMINATION, THE GOVERNING BOARD OR COMMITTEE SHALL MAKE ITS DECISION AS TO WHETHER TO ENTER INTO THE TRANSACTION OR ARRANGEMENT. FORM 990, PART VI, SECTION B, LINE 15A ON AN ANNUAL BASIS, THE NON-CONFLICTED HOSPITAL BOARD MEMBERS (COMPENSATION COMMITTEE) RECEIVES THE ANNUAL COMPENSATION AND BENEFIT SURVEY PREPARED BY THE MONTANA HOSPITAL ASSOCIATION (MHA). THE COMMITTEE ALSO RECEIVES A REPORT FROM THE HOSPITAL THAT INCLUDES RESEARCH OF ALL CRITICAL ACCESS HOSPITALS IN THE STATES OF MONTANA, IDAHO, AND WYOMING. USING THIS INFORMATION THE COMPENSATION COMMITTEE THEN PROVIDES A RECOMMENDATION FOR CEO COMPENSATION TO THE FULL HOSPITAL BOARD. THE CEO HAS THE AUTHORITY TO SET THE COMPENSATION OF OTHER OFFICERS AND KEY EMPLOYEES OF THE HOSPITAL. FOR PHYSICIAN COMPENSATION, THE HOSPITAL USES A THIRD PARTY CPA FIRM TO GATHER COMPENSATION DATA FROM MGMA AND NON-PHYSICAN COMPENSATION INFORMATION IS FROM THE MHA COMPENSATION SURVEY. FORM 990, PART VI, SECTION C, LINE 18 IN ADDITION TO BEING AVAILABLE UPON REQUEST, A COPY OF THE FORM 990 IS ALSO AVAILABLE AT WWW.GUIDESTAR.ORG. FORM 990, PART VI, SECTION C, LINE 19 GOVERNING DOCUMENTS AND CONFLICT OF INTEREST POLICY ARE NOT MADE AVAILABLE TO THE PUBLIC. FINANCIAL STATEMENTS ARE MADE AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART XI, LINE 9: CHANGE IN BENEFICIAL INTEREST IN NET ASSETS OF DALY HOSPITAL FOUNDATION 59,295. AUXILIARY 19,199. LOSS ON DEBT REFINANCE -221,499. DALY HOSPITAL FOUNDATIONINC 1200 WESTWOOD DRIVE HAMILTON MT 59840 363766000 CHARITABLE SERVICES MT 501(C)(3) LINE 7 N/A 0 0 0 1 0 0 0 0 0 0 0 0 1 1 1 1 1 1 0 0