2017-11-07T15:16:46-06:00 2016-12-31 010494526 Baker Newman & Noyes PO Box 507 Portland ME 04112 990 2016-01-01 010212444 York Hospital YORK 2073634321 15 Hospital Drive York ME 03909 Robin LaBonte CFO 2073634321 2017-11-01 1 Nicholas E Porto P01310283 2078792100 2017-11-01 208.105.168.164 2017-11-01 09:32:29 ED P 2CC4C4610C7CE537855CCDE76D04A8640C960E3E 2CC4C4610C7CE537855CCDE76D04A8640C960E3E 2016 2018-03-14 21:41:22Z Jud Knox 15 Hospital Drive York ME 03909 186444173 0 X www.yorkhospital.com X 1904 ME Community Hospital 33 24 1468 202 2945404 -126353 3285593 737994 170199481 173552221 1243984 2370620 121617 128252 174850675 176789087 121804 196513 0 0 93023401 96015394 0 0 157223 78900423 80668236 172045628 176880143 2805047 -91056 120234895 140133572 38477542 59100282 81757353 81033290 Community Hospital 0 0 167378690 196513 170703414 York Hospital is a not-for-profit health care center established to provide health care services to the York county area. It offers both inpatient and outpatient acute services and has 79 licensed acute beds. The Hospital has outpatient satellite services in Wells, Kittery, Berwick, North Berwick, and South Berwick.York Hospital is committed to providing exceptional care to patients and their families. All efforts must be thoughtful, kind, and loving. York Hospital is dedicated to creating and nurturing a fabric of compassionate relationships among physicians, caregivers, patients, and families to offer sensitive, understandable, high-quality medical care experiences. 167378690 1 1 0 1 0 0 0 0 0 1 1 1 0 0 1 1 1 0 0 0 0 0 0 0 1 0 1 1 0 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 73 0 1 1468 1 1 1 0 0 0 0 1 1 0 0 0 0 X 33 24 0 0 0 0 0 0 0 1 1 0 0 0 1 1 1 0 0 1 1 0 X X Robin LaBonte CFO 2073634321 15 Hospital Drive York ME 03909 Todd Adams Trustee (part year)/Physician 40.00 X 239741 0 0 Douglas Bracy Trustee 1.00 X 0 0 0 Meghan Brandt RN Trustee/RN 36.00 X 69629 0 12404 Wendy Cote Trustee 1.00 X 0 0 0 Jennifer Cutts MD Trustee 1.00 X 105064 0 675 Ken Fellows MD Trustee 1.00 X 0 0 0 Robert Foley Trustee 1.00 X 0 0 0 Mark Foster Trustee 1.00 X 0 0 0 James Gilroy MD FACP Trustee/Physician 40.00 X 242388 0 17898 Joan Goodrich Trustee 1.00 X 0 0 0 Connie Hanley PhD Trustee 1.00 X 0 0 0 Madeline Hayes Trustee 1.00 X 0 0 0 Ann Lee Hussey Trustee 1.00 X 0 0 0 John Houlihan Trustee 1.00 X 0 0 0 Connie James Trustee 1.00 X 0 0 0 Chris Kehl Trustee 1.00 X 0 0 0 Jeffrey Lockhart MD Trustee/Anesthesiologist 40.00 X 531964 0 38814 Daniel Morrison Trustee 1.00 X 0 0 0 Michael O'Keefe Trustee 1.00 X 0 0 0 Kelly Parker-Mello MD Trustee/Pediatrician 40.00 X 179708 0 4926 Deborah Pease Trustee 1.00 X 0 0 0 Lawrence Petrovich MD Trustee/Cardiologist 40.00 X 468319 0 42226 Suzi Raeside Trustee 1.00 X 0 0 0 Brett Rankin MD Trustee 1.00 X 0 0 0 Gary Samia Trustee 1.00 X 0 0 0 Frederick Thaler MD Trustee/Physician 40.00 X 146724 0 15823 Donato Tramuto Trustee 1.00 X 0 0 0 Henry F Warner Jr Trustee 1.00 X 0 0 0 Lorraine Boston Trustee/Chair 1.00 X X 0 0 0 Ala Reid Trustee/Vice Chair 1.00 X X 0 0 0 Christopher Crane Trustee/Treasurer 1.00 X X 0 0 0 Jud Knox Trustee/President/Leader 40.00 X X 399769 0 159671 Robin LaBonte CFO/Leader 40.00 X 259476 0 39365 Stephen Pelletier COO/Leader 40.00 X 160553 0 15486 Jonathan Bridges MD FACC Cardiologist 40.00 X 490685 0 19939 Peter Dourdoufis MD Cardiologist 40.00 X 724296 0 34841 Jeffrey Colnes MD Cardiologist 40.00 X 669016 0 35853 David Cunningham MD Cardiologist 40.00 X 489230 0 40839 John Fani Srour MD Cardiologist 40.00 X 532744 0 36734 5709306 0 515494 151 0 1 0 Southcoast Radiology 18 Northwood Drive Kennebunkport ME 04046 Contract Radiologist Services 1650000 Medifis PO Box 5068 New York NY 10087 Locum Tenums Services 940414 Hutter Construction Corp 810 Turnpike Road PO Box 257 Ipswich NH 03071 Construction 860046 Quest Diagnostic 12436 Collection Center Drive Chicago IL 60693 Contract Laboratory Services 740484 Seacoast Pathology Inc PO Box 100519 Atlanta GA 30384 Contract Pathology Services 652547 18 10000 27333 79501 621160 20806 737994 Patient Services 621400 134577298 134577298 Lab 621500 30230875 30081268 149607 Pharmacy 446110 6320095 3524298 2795797 Miscellaneous Program Services 621400 1522445 1522445 Cafeteria 722210 704326 704326 197182 197182 173552221 393693 393693 96597 0 96597 96597 96597 11509536 75085 9607694 0 1901842 75085 1976927 1976927 68978 27333 47316 21662 21662 10069 76 9993 9993 176789087 170703414 2945404 2402275 196513 196513 3150623 2978967 171656 74194244 71030597 3102049 61598 1769205 1713829 53825 1551 11986394 11477973 498690 9731 4914928 4704569 206427 3932 275855 275855 144931 57972 86959 80905 80905 13983360 11885856 2097504 684718 650482 27389 6847 7019629 6668648 280785 70196 1920 1728 192 5898840 5014014 884826 250530 238004 10021 2505 109815 93343 16472 696182 591755 104427 4439824 3773850 665974 1417713 640891 776822 Medical Supplies/Fees 22095981 22095981 Provision for bad debt 10462890 10462890 Pharmacy Supplies 9489018 9489018 Healthcare provider tax 3529834 3529834 86291 81976 3452 863 176880143 167378690 9344230 157223 826302 4194157 4773099 3713847 485305 292963 22268214 21866724 3622457 3700051 986468 987807 126900057 76737093 46118192 50162964 33780245 36331255 7106892 7449886 267721 11433918 120234895 140133572 11859236 13026661 10893747 9857245 5079157 7594263 10645402 28622113 38477542 59100282 X 70361418 69329947 8193544 8354947 3202391 3348396 81757353 81033290 120234895 140133572 X -91056 262930 -895937 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 1 12326 0 0 0 12326 0 Part II-B, Line 1: Maine Hospital Association dues totaled $52,789, of which $9,502 was available for lobbying. American Hospital Association dues totaled $15,690, of which $2,824 was available for lobbying. 11395935 269308 762506 724406 11703343 11333784 1030609 -113275 855183 11395935 10896475 601780 170465 334936 11333784 9387385 326240 1607261 424411 10896475 8569801 669672 1078525 930613 9387385 0.00000 0.28610 0.71390 0 0 3904522 3904522 62685661 32405328 30280333 3172988 2428203 744785 49757070 41903562 7853508 7379816 7379816 50162964 Other Investments 405951 F Alternative Investments 7043935 F 7449886 Medical Malpractice Insurance Recoveries Receivable 10921908 Other Receivables 512010 11433918 Assets Held on Behalf of 3rd Party 1017125 Pension Obligation 10442828 Estimated 3rd-Party Payor Settlements 5664735 Estimated Professional Liability Losses 11497425 28622113 X 176122567 262930 47392 310322 175812245 80905 895937 976842 176789087 176846630 47392 47392 176799238 80905 80905 176880143 Part V, Line 4: Temporarily Restricted Funds Biewend (12/82)- Principal and income restricted for purchase of new equipment (at Board discretion which must be approved by a family member) and the acquisition of land and buildings other than an addition to the present hospital buildings. Page (1945) - To be used for support and maintenance of district visiting nurses. Palmer/Perkins Nursing Scholarship - See Perm Restricted for description. Baldwin Fund for Nursing Excellence - Financial support for nurses who need to be re-certified and current in their helath care skills, including advanced training or change of focus. Scolarships for support staff, who are interested in entering the field of nursing. Financial assistance to help defray the costs of ongoing orientation, classroom instruction and clinical training of new York Hospital nurses. To help defray the costs associated with the York Hospital's summer intern program for young nursing students who are currently enrolled in a nursing school. Winkler Fund-Funds to be used for Nursing Education. Rose Voignier Education Fund-Funds to be used for staff education. Breast Cancer Living Well Fund-Funds to be used for breast cancer patients. Cancer Living Well Fund-Funds to be used for cancer patients. Permanently Restricted Funds Elizabeth B. Perkins - Principal to remain in perpetuity, the income for the care of patients who are unable to pay for proper treatment. Gerrity - 80% of income is unrestricted. 20% is to be reinvested as Principle Cowey - Income and gains to be used for pediatrics (corpus only to be kept in tact). Forristall - To be used for SNF (corpus only to be kept in tact). Mason - To be used for free work provided to patients who cannot afford to pay (corpus only to be kept in tact). Brewster - Income and gains to be used for any form of diabetes research and care (corpus only to be kept in tact). Palmer/Perkins Endowment - Principal to be kept in tact and the income to be used for nursing education for the staff. Sidelinger - (6/88) Principal to be kept in tact and the income to be used for general purposes of the support, upkeep and maintenance of the hospital as determined by the Board. Oncology Fund-Income to be used for support programs for patients, their families and caregivers. Part X, Line 2: The Hospital is a not-for-profit corporation and is tax-exempt under Section 501(c)(3) of the Internal Revenue Code. Tax-exempt organizations could be required to record an obligation for income taxes as the result of a tax position they have historically taken on various tax exposure items including unrelated business income or tax status. Under guidance issued by the Financial Accounting Standards Board, assets and liabilities are established for uncertain tax positions taken or positions expected to be taken in income tax returns when such positions are judged to not meet the "more-likely-than-not" threshold, based upon the technical merits of the position. Estimated interest and penalties, if applicable, related to uncertain tax positions are included as a component of income tax expense. The Hospital has evaluated the position taken on its filed tax returns. The Hospital has concluded no uncertain income tax positions exist at December 31, 2016. The Hospital's tax years from 2013 through 2016 are open and subject to examination. Part XI, Line 2d - Other Adjustments: Special events expenses 47,392. Part XI, Line 4b - Other Adjustments: Adjustment to Long-Term Pension Obligations 895,937. Part XII, Line 2d - Other Adjustments: Special events expenses 47,392. Hancock Gala 2016 30175 12545 17630 0 2066 957 11407 1400 3309 Road Race Event 20205 11350 8855 2000 1711 1178 716 955 4586 4 45931 3438 42493 2860 213 0 906 2164 10888 96311 27333 68978 4860 3990 2135 13029 4519 18783 47316 21662 1 1 1 X 0 1 1 0 0 1 999 2776231 2776231 0.01670 1 5069 11956140 9825102 2131038 0.01280 2 6068 14732371 9825102 4907269 0.02950 350083 16883 333200 0.00200 54277907 23896915 30380992 0.18260 54627990 23913798 30714192 0.18460 2 6068 69360361 33738900 35621461 0.21410 1 4591372 0 28819544 38581154 -9761610 X 1 1 1 1 York Hospital 15 Hospital Drive York ME 03909 38066 X X X York Hospital 1 0 0 1 X X X X X X X X X 15 1 0 1 1 X Please see Part V X Please see Part V X 1 15 1 Please see Part V 1 0 1 X 200.000000000000 X 1 1 X X X X 1 X Please see Part V X Please see Part V X Please see Part V X X X X X X 1 X 0 X X X X 1 0 0 York Hospital Part V, Section B, Line 3j: A shared vision of a healthy Southern York County; socio-economic characteristics by town, and a community themes and strengths assessment. York Hospital Part V, Section B, Line 5: Between October and December 2015, York Hospital undertook a community health needs assessment (CHNA) to identify the health needs of those living in the Hospital's entire service area. The assessment updated the one completed in June 2013. The Hospital partnered with the Choose to be Healthy Coalition (CTBH), a comprehensive community health coalition. CTBH has a membership purposefully comprised of those representing diverse community sectors such as education, law enforcement, behavioral health care, social service agencies, municipalities, and business. The advisory board provided guidance within its regular monthly meeting. Members included representation from:Faith CommunityHigh School Nurse (York)Parent (York) with degree in Community HealthMiddle & High School Parent (SAD 60)Behavioral Health CounselorHigh School Nurse (Wells) & ParentOut-patient Clinical Care representativeYork Hospital Community Health Patient-Centered Medical Home DevelopmentPhD in Public HealthDirector of York Community Action Services & Town of York General Assistance ProgramYork Hospital RepresentativeEliot community member York Hospital Part V, Section B, Line 6b: York Hospital's CHNA was conducted with Choose To Be Healthy (CTBH), a community health coalition with a membership purposefully comprised of those representing diverse community sectors, such as education, health care, business, municipalities, law enforcement, etc. York Hospital Part V, Section B, Line 11: Please see the attached Community Health Needs Assessment Action Plan for details on how York Hospital is addressing the significant needs identified in its most recently conducted CHNA. York Hospital Part V, Section B, Line 13b: In addition to providing free care to patients with household income at or below 200% of the FPG, during 2016 York Hospital also offered a 25% discount to self-pay patients and a HELP Financial Assistance Program offered to patients that had no insurance or were underinsured. Reduction of their hospital bills was based on household income and the amount owed. York Hospital Part V, Section B, Line 16j: The patients' billing statement lists the phone number and website address to use for more information regarding the Financial Assistance Program. Schedule H, Part V-B, Line 7a York Hospital's Community Health Needs Assessment can be found on its website at:http://www.yorkhospital.com/uploads/York_Hospital_CHNA_Report_2015.pdf Schedule H, Part V-B, Line 7b: Other websites where York Hospital's Community Health Needs Assessment can be found:http://ctbh.org/public-health-in-york-county-and-maine/ Schedule H, Part V-B, Line 16a: York Hospital's Financial Assistance Policy is available on their website at: http://www.yorkhospital.com/uploads/FAP%20Final%202017.pdf Schedule H, Part V-B, Line 16b: York Hospital's FAP Application is available on their website at: http://www.yorkhospital.com/uploads/FAP%20Application%202017%20NEW.pdf Schedule H, Part V-B, Line 16c: York Hospital's FAP Plain Language Summary is available on their website at: http://www.yorkhospital.com/patients-and-families/billing-and-insurance/need-help-paying-your-bill.aspx Schedule H, Part V-B, Line 10: The Hospital's Implementation Plan is included on pages 34-37 of the 2015 CHNA, available here: http://www.yorkhospital.com/uploads/York_Hospital_CHNA_Report_2015.pdfSchedule H, Part V-B, Line 10b has been answered yes, even though the Hospital's most recently enacted Implementation Plan is posted on its website. To provide information to answer Schedule H, Part V-B, Line 11 the Hospital has attached its CHNA and Implementation Plan to this return. In order to qualify for electronic filing in this scenario, Line 10b has also been answered yes. Schedule H, Part V-B, Line 16i: 501(r) Regulations require that hospitals translate their financial assistance policy (FAP) into primary languages spoken by limited English proficient (LEP) populations in their hospital service area. Should a LEP population demographic exceed 5% of the community residents or 1,000 individuals, whichever is less, a hospital must make available translated copies of its FAP. According to the most recent Census information, no single LEP population in York County is large enough to reach the 501(r) thresholds. Therefore, Schedule H, Part V, Section B, Line 16i is not applicable to York Hospital and has been left blank. Schedule H, Part V-B, Line 22: Individuals who qualify under the Hospital's financial assistance policy receive a 100% write off of charges. Accordingly, no box has been checked to indicate how the Hospital determines the maximum amount that may be charged to FAP-eligible patients. 9 1 - Wells Medical Services 112-114 Sanford Road Wells ME 04090 General Medical & Surgical 2 - Kittery Medical Services 35 Walker Street Kittery ME 03904 General Medical & Surgical 3 - South Berwick Medical Services 57 Portland Street South Berwick ME 03908 General Medical & Surgical 4 - York Hospital at Long Sands 127 Long Sands Road York ME 03909 General Medical & Surgical 5 - York Outpatient Physical Therapy 16 Long Sands Road York ME 03909 General Medical & Surgical 6 - Berwick Medical Services 4 Dana Drive Berwick ME 03901 General Medical & Surgical 7 - Kittery Medical Services 75 US Route 1 Kittery ME 03904 General Medical & Surgical 8 - York Hospital Medical Services-Rte 1 343 US Route 1 York ME 03901 general Medical & Surgical 9 - North Berwick Medical Services 23 Wells Street North Berwick ME 03906 General Medical & Surgical Part I, Line 3c: In addition to its financial assistance program, during 2016 York Hospital offered a 25% discount to self-pay patients and a HELP Financial Assistance Program offered to patients that had no insurance or were underinsured. Reduction of their hospital bills was based on household income and the amount owed. Part I, Line 7: York Hospital has several hospital clinical services and hospital-owned physician practices. Per instructions for IRS Form 990, Schedule H, Worksheet 6, organizations may include any applicable physician practice that the Hospital subsidizes (i.e., operates at a loss) in the completing of Schedule H. Therefore, the Hospital has included the following hospital clinical services and hospital-owned physician practices that operate at a loss (i.e., are subsidized by the Hospital) and the associated costs of these practices:a. Diabetes Education (combined with Endocrinology in July 2016)b. Berwick Walk-In Clinicc. Kittery Family Practice d. Emergency Room (the Hospital has ER facilities located at the main hospital campus and also in Wells)e. Home Health Agencyf. Chemical Dependency Clinic g. OB/GYN Practice h. Wells Walk-Ini. Rheumatology Practicej. Neurology Practicek. Psychiatry Practicel. Urology Practicem. Physical Therapy Practicen. Pulmonary Practiceo. Great Works Family Practicep. Wells Primary Careq. York Family Practicer. Webhannet Internal Medicine Practices. Pediatric Practicet. York Walk-Inu. Surgical Associatesv. North Berwick Family Practicew. Cardiology Practicex. Kittery Walk-InThe above-listed hospital clinical services and hospital-owned physician practices have a community benefit (i.e. aggregate loss or subsidy from the Hospital) of approximately $30.38 million. In addition, the community benefit does not take into account bad debts, charity care, or contractual adjustments. Thus, this community benefit of approximately $30.38 million is a conservative figure that reconciles to the community benefit reported on IRS Form 990, Schedule H, Part I, Line 7g, Column e.Form 990, Schedule H instructions/guidance contains a template (Worksheet 2) that may be used to determine the overall cost to charge ratio that could be applied throughout Schedule H in order to convert charges to cost. Where applicable, the Hospital has utilized Worksheet 2 for various calculations. The only areas where Worksheet 2 was not utilized for Part 1, Line 7 were the following:a. Schedule H Worksheet 6, Subsidized Health Services (the supporting worksheet for Part I, Line 7g), the Hospital did not utilize Worksheet 2 when calculating the percentage used when determining the profit/loss of each hospital clinical service and hospital-owned physician practice. Instead, when compiling the subsidized hospital clinical services and hospital-owned physician practices listed in 1c above, the Hospital utilized the actual estimated costs on the modified Medicare cost report instead of applying the Worksheet 2 cost to charge percentage. b. Schedule H Worksheet 3, Unreimbursed Medicaid and Other Means Tested Government Programs (the supporting schedule for Part I, Lines 7b and 7c), and Worksheet 6, Medicaid Allowable Costs for Subsidized Health Services, listed in line 1c above (which is part of the line 7g costs). The Hospital did not utilize the Worksheet 2 percentage when calculating the Medicaid allowable cost. Instead, the Hospital utilized the actual Medicaid filed cost report for the allowable costs. Part I, Line 7, Column (f): The Bad Debt expense included on Form 990, Part IX, Line 25, Column (A), but subtracted for purposes of calculating the percentage in this column is $ 10,462,890. Part II, Community Building Activities: Not Applicable Part III, Line 2: The Hospital utilized Worksheet 2 from the IRS Schedule H instructions/guidance to determine the ratio of patient care cost to charge (43.88% for fiscal year 2016) and multiplied this ratio by the Hospital's total bad debt expense of $10,462,890 to determine the Part II, Line 2 bad debt expense of $4,591,372. Part III, Line 3: Patients who qualify for financial assistance have 100% of their liability written off, so no portion of it is included in the Hospital's bad debt expense. Part III, Line 4: See Footnote 2 on page 9 of the attached audited financial statements. Part III, Line 8: Form 990, Schedule H instructions/guidance contains a template (Worksheet 2) that may be used to determine the overall cost to charge ratio that could be applied throughout Schedule H in order to convert charges to cost. Where applicable, the Hospital has utilized Worksheet 2 for various calculations. The only areas where Worksheet 2 was not utilized for Part III, Line 8 was Schedule H, Worksheet B, Line 2 & 6, Medicare Allowable Costs and Payments Related to Subsidized Health Services. The Hospital utilized the Medicare cost report estimated cost and payment for these services. The Hospital believes that its hospital clinical services, hospital-owned physician practices, emergency room, and home health agency listed above should be considered a community benefit, as community members benefit by having easy access to these services, facilities, and programs which are both offered and subsidized. These facilities and programs are offered and thus subsidized through the Hospital. Part III, Line 9b: Accounts with self-pay balances that show no evidence of patient payments or eligibility for financial assistance that have completed a patient dunning cycle (120 days approximately) may be transferred to a collection agency. Any patient account that has applied for any of York Hospital's financial assistance programs and supplied all required documentation will be held in a pending status until a determination is made. Part VI, Line 2: York Hospital has focused on three goals identified in its Community Health Needs Assessment: lowering the % of overweight and obese community members in the service area by the end of 2018, decrease the number of opiate poisoning (ED Visits) per 100,000 population by 25% by December 2019, and reduce the number of York Hospital Primary Care Practice patients who are current smokers by 5% by December 2019.Obesity Goal:- Continue to offer a healthy weight management program at least 5 times per year (ongoing January 2016-December 2017). - Develop an evaluation plan that tracks participants at 6 months, one year after participation (January 2017).- Support the expansion of the Eastern Trail through towns of Wells, North Berwick, South Berwick, Eliot, and Kittery (ongoing January 2016-December 2018). - Sponsor a series of six "Walk with the Doc" community walks with York Hospital Family Practice physicians, on local land trust properties (June and September 2016, 2017, 2018). Opiate Poisoning Goal- Expand outpatient addiction treatment services to include Medication Assisted Treatment including buprenorphine and naltrexone (December 2016).- Expand obstetrical services to include Medication Assisted Treatment (buprenorphine) for pregnant women who abuse opiates (June 2017).- Enact a responsible opioid prescribing policy throughout the York Hospital system including physician practices, emergency department, and impatient care (June 2016).- Continue to implement Student Intervention and Reintegration (SIRP) in partnership with area high schools and Sweetser, Inc. at least quarterly (December 2016, 2017, 2018).- Partner with Choose to Be Healthy Coalition to support youth substance abuse prevention activities. This will include in-kind support for the Drug Free Communities grant such as rent, bookkeeping, and HR department support, etc. (ongoing).Tobacco Usage Goal:- Work with the Center for Tobacco Independence to allow for electronic referrals of patients who smoke directly to CTI from our EMRs (June 2016).- Implement EMR changes to help support the use of brief interventions and referrals for tobacco users (December 2016).- Promote resources on Choose To Be Healthy Coalition and hospital websites (continuous).- Promote tobacco addiction treatment resources on Choose To Be Healthy Coalition and hospital websites (continuous).- Make Tobacco Helpline materials available in all York Hospital physician offices (continuous). Part VI, Line 3: The patients' billing statement lists the phone number and website address to use for more information regarding the Financial Assistance Program. The York Hospital financial assistance guidelines are posted at patient registration areas. Additionally, information regarding financial assistance is available on the Hospital's website. Part VI, Line 4: York Hospital's primary service area includes the following communities in Southern York County Maine: Berwick, Eliot, Kittery, North Berwick, Ogunquit, South Berwick, Wells, and York. The Hospital's secondary service area includes: Kennebunk, Sanford and Lebanon, Maine, and Portsmouth, Dover, Rollinsford, and Somersworth, New Hampshire. Approximately 6% of York Hospital patients utilize Medicaid and approximately 50% of York Hospital patients utilize Medicare. According to the United States Census Bureau, in 2016, 8.3% of York County Residents lived in poverty (http://www.census.gov/). Part VI, Line 5: The board of trustees is made up of members from all communities served by York Hospital. All medical staff are eligible to participate if they meet privileging criteria. All hospital profits are reinvested in the facilities, equipment and services for the communities. Part VI, Line 6: Not Applicable 1 Continuing Education/Seminars and Workshops 104 98017 New Graduate Nursing Orientation 3 42000 Medical Assistant Program 6 4750 Health Stream Online Learning Library 900 51746 Part I, Line 2: The scholarship funds are monitored by the Education Committee, which manages the funds in accordance with the donor's wishes. The committee does this by determining what the spending policy is at the beginning of the year by fund category. Some funds are restricted to nursing education, others to non-nursing education. The funds can be used for those who want to attend workshops or seminars or to further their education through a post-secondary accredited school. Funds are also used for orientation programs. Requests for funding must be made through a formal process. Each person requesting funds must prepare an application which must be approved by a director or leader. The form is then submitted to the Education Committee for review and approval. All amounts are also tracked and reviewed in accounting to ensure that the monies are used in accordance with the donor's wishes. Annually, the Director of Development reports fund activity directly to donors that request it. X 0 1 X X X 0 1 0 0 0 0 0 1 0 Todd Adams Trustee (part year)/Physician 219758 0 0 0 19983 0 0 0 0 0 239741 0 0 0 James Gilroy MD FACP Trustee/Physician 231025 0 11363 0 0 0 11014 0 6884 0 260286 0 0 0 Jeffrey Lockhart MD Trustee/Anesthesiologist 531964 0 0 0 0 0 29814 0 9000 0 570778 0 0 0 Kelly Parker-Mello MD Trustee/Pediatrician 172242 0 7466 0 0 0 1705 0 3221 0 184634 0 0 0 Lawrence Petrovich MD Trustee/Cardiologist 445698 0 22621 0 0 0 4245 0 37981 0 510545 0 0 0 Frederick Thaler MD Trustee/Physician 131384 0 15340 0 0 0 4299 0 11524 0 162547 0 0 0 Jud Knox Trustee/President/Leader 399769 0 0 0 0 0 129000 0 30671 0 559440 0 0 0 Robin LaBonte CFO/Leader 259476 0 0 0 0 0 9000 0 30365 0 298841 0 0 0 Stephen Pelletier COO/Leader 160553 0 0 0 0 0 3201 0 12285 0 176039 0 0 0 Jonathan Bridges MD FACC Cardiologist 402667 0 88018 0 0 0 4500 0 15439 0 510624 0 0 0 Peter Dourdoufis MD Cardiologist 435988 0 288308 0 0 0 0 0 34841 0 759137 0 0 0 Jeffrey Colnes MD Cardiologist 443706 0 225310 0 0 0 4500 0 31353 0 704869 0 0 0 David Cunningham MD Cardiologist 366643 0 122587 0 0 0 4375 0 36464 0 530069 0 0 0 John Fani Srour MD Cardiologist 415716 0 117028 0 0 0 0 0 36734 0 569478 0 0 0 Part I, Line 1a Minimal rotary dues for president Part I, Line 4b Jud Knox, President, has a SERP Defined Benefit plan. The increase in actuarial value during 2016 was $120,000. Part I, Line 7 Performance-based variable compensation which is subject to review annually. A MHHEFA 010314384 560425UT5 2004-12-09 42196950 CT scanner, nuclear me, radiology, MAMMO unit 0 0 0 B MHHEFA 010314384 560425G20 2006-09-07 91723676 CT scanner, digital MAMMO equip, PAC's equipment 0 0 0 C MHHEFA 010314384 560425L40 2007-07-18 97716087 Refinance 1999B ER project & 2000C Wells Regional 0 0 0 D MHHEFA 010314384 560525Z78 2008-06-19 48451841 Imaging equipment 0 0 0 A 1410000 1941005 135325 31950 1773730 2005 0 0 1 1 B 2025000 2318380 291200 37906 1989274 2006 0 0 1 1 C 2110000 7437938 547568 7368244 97896 2007 1 1 1 1 D 865000 1707209 162330 42816 1474018 28044 2008 0 0 1 1 A 0 0 0 0 0 0 0 B 0 0 0 0 0 0 0 C 0 0 0 0 0 0 0 D 0 0 0 0 0 0 0 A 0 1 0 0 0 0 1 FSA 24.000000000000 1 0 0 B 0 1 0 0 0 0 1 FSA 26.000000000000 1 0 0 C 0 1 0 0 0 0 1 TRANS AMERICA 20.000000000000 1 0 0 D 0 0 0 1 0 0 1 GEFCM 28.000000000000 1 0 0 A 0 B 0 C 0 D 0 Date Rebate Computation Performed Issuer Name: MHHEFA Date the Rebate Computation was Performed: 06/19/2013 Form 990, Schedule K, Part III, Line 9, IV, Line 7, and Part V: Although formal policies are not in place to ensure that violations are timely identified and corrected, the bonds issuer, Maine Health & Higher Educational Facilities Authority (MHHEFA), monitors Section 148 requirements for York Hospital until funds are spent down enough to ensure none of the Hospital's tax exempt bonds become arbitrage bonds. Bond proceeds are placed in low yield investments and no funds are released to York Hospital until expenses have been incurred and receipts are provided to MHHEFA. Furthermore, the Hospital works closely with MHHEFA to ensure that safeguards are in place to take appropriate and timely remedial action should any violations of federal tax requirements occur. A MHHEFA 010314384 5604253L2 2008-12-03 41658395 Surgery center addition 0 0 0 B MHHEFA 010314384 560427GE0 2009-12-10 93040181 New CT and other equipment 0 0 0 C MHHEFA 010314384 560427JA5 2010-06-24 113477369 Refinance 1993, 1998, 1999A & 2001D 0 0 0 A 685000 2788576 341545 46861 2400170 2010 0 0 1 1 B 905000 1827960 194925 29377 1603658 2010 0 0 0 1 C 1985000 4001877 607056 5418358 51237 2010 1 1 1 1 A 0 0 0 0 0 0 0 B 0 0 0 0 0 0 0 C 0 0 0 0 0 0 0 A 0 1 0 0 0 0 0 0 0 B 0 1 0 0 0 0 0 0 0 C 0 1 0 0 0 0 0 0 0 A 0 B 0 C 0 Form 990, Part VI, Section B, line 11b The Hospital's Form 990 is prepared with the assistance of an independent public accounting firm and thoroughly reviewed by the Hospital's finance staff before it is filed. The 990 is distributed to the Board of Trustees for their review after it is filed. Form 990, Part VI, Section B, line 12c Annually the Board of Trustees and the officers sign a conflict of interest form. Form 990, Part VI, Section B, line 15 The executive committee of the Board of Trustees utilizes an outside firm's database of CEO salaries to determine the CEO's compensation. The CEO determines the compensation of other officers or key employees using an outside firm's data to make sure the compensation is market based. Form 990, Part VI, Section C, line 19 The Hospital's governing documents, conflict of interest policy, and financial statements are available upon request. Form 990, Part XI, line 9: Adjustment to Long Term Pension Obligations -895,937. Form 990, Part XII, Line 2c: The audit process has not changed from the prior year. York Health Services 15 Hospital Drive York ME 03909 020469065 Heart health ME 501(c)(3) Line 10 N/A 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0