2017-11-15T07:39:35-06:00 2016-12-31 ERNST & YOUNG US LLP 111 MONUMENT CIRCLE SUITE 4000 INDIANAPOLIS IN 46204 990 2016-01-01 273532963 INDIANA UNIVERSITY HEALTH WHITE MEMORIAL HOSPITAL INC % SEAN M BARR INDI 3179624112 950 N MERIDIAN STREET SUITE 300 INDIANAPOLIS IN 46204 CARA L BREIDSTER CFO 3179624112 2017-11-14 JENNIFER D RHODERICK P00395735 3176817000 162.1.129.128 35668520173195000011 2017-11-15 P 49A42BAE7DB19B68098C55D96BB751E89F2C86F0 49A42BAE7DB19B68098C55D96BB751E89F2C86F0 2016 2017-02-10 21:41:12Z X MARY E MINIER 950 N MERIDIAN ST STE 300 INDIANAPOLIS IN 46204 30378615 false X HTTP://IUHEALTH.ORG/WHITE-MEMORIAL/ X 2010 IN Improve the health of our patients and community through innovation and excellence in care, education, research and service. 11 6 205 30 0 310707 272937 31141173 29160342 -118 -17207 366410 291884 31818172 29707956 22500 9500 0 0 8751378 9053050 0 0 0 14621118 16839823 23394996 25902373 8423176 3805583 54515350 54412367 30133887 26183394 24381463 28228973 X IMPROVE THE HEALTH OF OUR PATIENTS AND COMMUNITY THROUGH INNOVATION AND EXCELLENCE IN CARE, EDUCATION, RESEARCH AND SERVICE. false false 18723035 9500 29160342 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 18723035 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 false true false false false false false false false false false false false false false true true true false false true 19 0 true 205 true false false false false false false false false false false X 11 6 false false false false true true true true false false false true true true true true true false false false IN X SEAN M BARR 3179624112 950 N MERIDIAN ST STE 800 INDIANAPOLIS IN 46204 X VICTOR L LECHTENBERG CHAIRMAN (WCR) 2.0 5.0 X X 0 9000 0 CHRISTOPHER A MANSFIELD MD VICE CHAIR (WCR) 2.0 60.0 X X 0 427445 41519 ROGER G BANGS MD DIRECTOR (WCR) 2.0 60.0 X 0 647104 35264 P RON ELLIS DIRECTOR (WCR) 2.0 5.0 X 0 7500 0 DANIEL F EVANS JR DIRECTOR (WCR) 2.0 60.0 X 0 1523416 274557 GARY D HENRIOTT DIRECTOR (WCR) 2.0 5.0 X 0 9804 0 KENNETH E MARNOCHA MD DIRECTOR (WCR) 2.0 60.0 X 0 621811 13250 RANDALL R MITCHELL DIRECTOR (WCR) 2.0 5.0 X 3600 9750 0 RUBAN NIRMALAN MD DIRECTOR (WCR) 2.0 60.0 X 0 680180 35685 RANDY PRICE DIRECTOR (WCR) 2.0 5.0 X 0 3000 0 REV KATE L WALKER DIRECTOR (WCR) 2.0 5.0 X 0 14250 0 JEFFREY C ZEH PRES & CEO/COO(WCR-PART YEAR) 0.0 55.0 X 0 264161 13772 JEROME P KELLY SECRETARY (PARTIAL YEAR) 0.0 55.0 X 0 196412 20834 DEREK E EMPIE SECRETARY 0.0 55.0 X 0 173787 37304 CARA L BREIDSTER CFO (WCR) 0.0 55.0 X 0 304151 33901 DONALD E CLAYTON MD PRESIDENT & CEO (WCR) 55.0 55.0 X 0 509156 97816 JEFFREY P BROWN MD CMO (WCR) 0.0 55.0 X 0 301757 39906 ADEL M KHDOUR MD CMO (PARTIAL YEAR) 0.0 55.0 X 0 361249 39971 JANA M SEARS CLINICAL PHARMACIST 50.0 0.0 X 114778 0 29471 MARY E MINIER COO 50.0 0.0 X 109530 20503 14843 BRIAN T SHOCKNEY FORMER INTERIM CEO 0.0 55.0 X 0 284213 34974 ANDREW K EDWARDS MD FORMER VICE CHAIR 0.0 55.0 X 0 445959 36162 227908 6814608 799229 2 true true false MONTICELLO EMERGENCY CARE LLC 720 S SIXTH STREET MONTICELLO IN 46960 MEDICAL 785592 TRIMEDX LLC 5451 LAKEVIEW PKWY S DR INDIANAPOLIS IN 46268 CLINICAL ENGINEERING 400316 2 23926 249011 272937 NET PATIENT SERVICE REVENUE 621110 28897685 28897685 RENT FROM RELATED 501(C)(3) ORGS. 532000 258528 258528 SHARED SERVICES 541900 4129 4129 29160342 35966 35966 0 0 166555 166555 0 166555 166555 617486 622755 47904 -5269 -47904 -53173 -53173 0 0 0 0 0 0 0 0 0 CAFETERIA/FOOD SERVICE 721210 83727 83727 EDUCATION 900099 8390 8390 ALL OTHER REVENUE 900099 33212 33212 125329 29707956 29160342 274677 X 9500 9500 0 0 0 3600 2682 918 0 7182354 5351492 1830862 297319 217748 79571 1054954 823529 231425 514823 411026 103797 0 0 3903 3903 2372 2372 0 1302 1302 6765249 2861728 3903521 0 0 134876 67186 67690 17341 17028 313 0 814127 296423 517704 19996 9746 10250 0 2000 1925 75 1116074 1116035 39 0 1796452 1752204 44248 172111 136057 36054 DRUGS AND MEDICAL SUPPLIES 2694450 2694450 BAD DEBT 2245432 2245432 INSTITUTIONAL DUES/LICENSES 24832 24832 HOSPITAL ASSESSMENT FEE 594543 594543 434763 89469 345294 25902373 18723035 7179338 0 930 930 18440210 19465910 0 0 2838753 3587076 0 0 0 0 0 0 278446 274032 103443 118848 38962192 8312465 31482902 30649727 1069079 0 0 0 0 0 0 0 301587 315844 54515350 54412367 1517488 1340371 0 0 0 0 0 0 0 0 0 0 1644 0 0 0 28614755 24843023 30133887 26183394 X 24069574 27890026 71010 125452 240879 213495 24381463 28228973 54515350 54412367 X 3805583 14869 27058 X false true X true false X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED false false false false false false false false true 2372 2372 false Schedule C, Part II-B, Line 1i - Other Activities IU Health White Memorial Hospital paid institutional membership dues to the American Hospital Association ("AHA") and Indiana Hospital Association ("IHA") during 2016 in the amount of $9,327 and $2,860, respectively. Each membership organization notified IU Health White Memorial Hospital that a portion of the dues it paid were used for lobbying purposes. The AHA used 23.65%, or $2,206 of 2016 membership dues paid by IU Health White Memorial Hospital, for lobbying expenditures. The IHA used 5.80%, or $166 of the 2016 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 2016 that were attributable to lobbying expenditures was $2,372. 311889 54442 27384 338947 293053 18836 311889 277877 15176 293053 143329 134496 52 277877 133831 15823 6325 143329 0.00000 0.62990 0.37010 true true true 0 972779 972779 0 30187561 4110224 26077337 0 7331711 4124185 3207526 0 470141 78056 392085 30649727 0 INTERCOMPANY PAYABLES (NET) 22814417 DUE TO THIRD-PARTY PAYORS 1999506 SELF-INSURANCE LIABILITIES 29100 24843023 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 IU Health's Consolidated Audited Financial Statements. The Internal Revenue Service (IRS) has determined that IU Health and certain of its affiliated entities are tax-exempt organizations as defined in Section 501(c)(3) of the Internal Revenue Code (IRC). IU Health and its tax-exempt affiliates are, however, subject to federal and state income taxes on unrelated business income under the provision of IRC Section 511. Deferred income taxes, which as of December 31, 2016 and 2015, 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 amount used for income tax purposes. As of December 31, 2016 and 2015, the Indiana University Health System had gross deferred tax assets of $116,490,000 and $79,469,000, respectively, primarily relating to net operating loss carryovers. Management determined that a full valuation allowance at both December 31, 2016 and 2015 was necessary to reduce the deferred tax assets to the amount that would more likely than not be realized. ASC Topic 740-10-50-3, Income Taxes: Disclosure, requires a valuation allowance to reduce the deferred tax assets reported if, based on the weight of the evidence, it is more likely than not that some portion or all of the deferred tax assets will not be realized. The change in valuation allowance for the current year is $37,021,000. At December 31, 2016, the Indiana University Health System has available net operating loss carryforwards of $291,226,000. These net operating losses will expire between 2018 and 2036. Certain subsidiaries of IU 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 false true true 1049 722744 722744 0.03060 3410 4389602 2788689 1600913 0.06770 4459 5112346 2788689 2323657 0.09830 9 9801 111355 111355 0.00470 1 49 275937 275937 0.01170 1 12 1432 1432 0.00010 3 10808 115904 435 115469 0.00490 14 20670 504628 435 504193 0.02140 14 25129 5616974 2789124 2827850 0.11970 1 50 5659 5659 0.00020 1 6872 6872 0.00030 1 1425 23208 23208 0.00100 1 34 52060 52060 0.00220 4 1509 87799 87799 0.00370 false 705154 10855005 10274532 580473 X true true 1 1 IU HEALTH WHITE MEMORIAL HOSPITAL 720 SOUTH SIXTH STREET MONTICELLO IN 47960 HTTP://IUHEALTH.ORG/WHITE-MEMORIAL/ 16-005034-1 X X X X IU HEALTH WHITE MEMORIAL HOSPITAL 1 false false true X X X X X X X X X 15 true false false true X SEE PART V, SECTION C X true 15 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 B, Line 5 - Input from Community IU Health White Memorial Hospital's approach to gathering qualitative data for its CHNA consisted of a multi-component approach to identify and verify community health needs for the IU Health White Memorial Hospital service area. This included the following components: 1. Hosting a two-hour community conversation focus group with public health officials and community leaders in attendance to discuss healthcare needs of the service area and what role IU Health White Memorial Hospital could play in addressing the identified needs. 2. Surveying the community at large through the hospital's website and paper surveys, with special attention to gathering input from low income, uninsured or minority groups. Local leaders with a stake in the community's health were invited to attend focus group sessions held at IU Health White Memorial Hospital. Attendees from organizations, such as the White Oak Health Campus, Twin Lakes School Corporation, Monticello-Union Township Public Library, City of Monticello Parks and Recreation, and City of Monticello, Mayor among others participated in the focus group. To obtain a more complete picture of the factors that play into the White County communitys health, input from local health leaders was gathered through one focus group session. The focus group was a two hour live group session at IU Health White Memorial Hospital. IU Health White Memorial Hospital facilitators mailed letters and made follow-up telephone calls inviting public health officials and community leaders to attend the focus group discussion, paying special attention to including organizations that represent the interest of low-income, minority and uninsured individuals. The goal of soliciting these leaders feedback was to gather insights into data findings from the secondary statistical sources and from the survey. Upon arrival to the focus group, participants were asked to list their believed five prioritized health needs for the IU Health White Memorial community. These responses were collected and aggregated into a comprehensive list of identified needs to be further discussed later in the session and ranked for severity of need within the community. IU Health facilitators then provided participants with a presentation featuring IU Healths mission, current outreach priorities and local health data, including demographics, insurance information, poverty rates, county health rankings, causes of death, physical activity levels, chronic conditions, preventive behaviors and community needs index. Upon completion of its data presentation, IU Health White Memorial Hospital facilitated a discussion on the comprehensive list of identified needs from earlier in the session. The objective of this method was intended to inspire candid discussions prior to a second identification of five prioritized health needs by each participant. The votes on the five prioritized health needs were tallied and final input from the group was encouraged during this process in order to validate the previously identified needs. Following additional discussion, participants were also asked to address what they thought IU Health White Memorials role could be in meeting the local health needs. IU Health White Memorial Hospital solicited responses from the general public regarding the health of the IU Health White Memorial Hospital community through an online survey as well as paper versions of the survey. The survey consisted of approximately 20 multiple choice and open-ended questions that assessed the community members feedback regarding healthcare issues and barriers to access. From December 2014 through June 2015, a link was made available on the hospital's website via an electronic survey tool and a paper version was distributed to local community centers, health clinics and community health fairs and events, as well as within some hospital patient waiting areas. Additionally, survey links or paper surveys were e-mailed, direct-mailed, or sent via newsletter. In addition to disseminating directly to the community, the survey was also sent via e-mail to participants in the needs assessment focus group to provide an opportunity for these community leaders to pass the survey along to their constituents and allies. Schedule H, Part V, Section B, Line 7a - CHNA Website A copy of IU Health White Memorial Hospitals CHNA is available on its website at the following URL: http://iuhealth.org/about-iu-health/in-the-community/ Schedule H, Part V, Section B, Line 10a - Implementation Strategy Website A copy of IU Health White Memorial Hospitals CHNA implementation strategy is available on its website at the following URL: http://iuhealth.org/about-iu-health/in-the-community/ Schedule H, Part V, Section B, Line 11 - Addressing Identified Needs 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 by using the Hanlon Method of prioritization. This method prioritizes identified needs based upon the prevalence and severity of the need and the effectiveness of interventions available to address the needs. Based upon the Hanlon Method of prioritization, IU Health White Memorial Hospital selected the following three needs to be addressed: - Access to Healthcare - Obesity Prevention, Nutrition and Active Living - Mental Health, Substance Abuse and Behavioral Health Access to Healthcare IU Health White Memorial Hospital's implementation strategy to address the identified need of access to healthcare includes the following: - Expand hours of walk-in-clinic - Provide better and more coordinated care through Certified Patient Centered Medical home - Provide financial assistance and information on prescription/healthcare insurance assistance to those in need - Provide support groups for community members to discuss health concerns Obesity Prevention, Nutrition and Active Living IU Health White Memorial Hospital's implementation strategy to address the identified need of obesity prevention, nutrition and active living includes the following: - Community Walking Programs - Nutrition education at Farmer's Markets - Health & Safety Fair - Educational programs at local senior residences Mental Health, Substance Abuse and Behavioral Health IU Health White Memorial Hospital's implementation strategy to address the identified need of mental health, substance abuse and behavioral health includes the following: - Identify patients who need intervention for drug/alcohol abuse - Screening, Brief Intervention and Referral to Treatment ("SBIRT") Training - Offer a teen texting program so high school kids/teachers can get help in crisis situations - Tobacco Cessation/ 1-800-QUIT-NOW - Mental Health America Question Persuade Refer Training - National Alliance on Mental Illness ("NAMI") Training - Provide outpatient access to community members requiring behavioral health services - Work in collaboration with Sycamore Springs, River Bend Hospital and NAMI to serve community members in need of inpatient behavioral health services Also, based upon the Hanlon Method of prioritization, the following identified community health needs were not chosen as one of the needs to be addressed: - Prenatal Health - Injury Prevention - Chronic Disease Management After completing a gap analysis, IU Health White Memorial Hospital determined that the severity of and lack of resources available to address the three needs chosen to be addressed outweighed the severity of and resources available to address the three needs not chosen. 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 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. 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 Hospitals Financial Assistance Program. Patients who may be eligible for coverage under an applicable insurance policy, including, but not limited to, health, automobile, and homeowners, must exhaust all insurance benefits prior to receiving an award from IU Health White Memorial Hospitals 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 patients 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 Childrens 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 patients 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 will 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 Hospitals 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 Hospitals FAP is available on the following website: http://iuhealth.org/patients/my-iu-health/pay-a-bill/financial-assistance/ Schedule H, Part V, Section B, Line 16b - FAP Application Website A copy of IU Health White Memorial Hospitals plain language summary of the FAP is available on the following website: http://iuhealth.org/patients/my-iu-health/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: http://iuhealth.org/patients/my-iu-health/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. 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 parents 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 www.iuhealth.org/financialassistance 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 Hospitals Financial Assistance Program. Patients who may be eligible for coverage under an applicable insurance policy, including, but not limited to, health, automobile, and homeowners, must exhaust all insurance benefits prior to receiving an award from IU Health White Memorial Hospitals 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 patients 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 Childrens 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 patients 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/guarantor's 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 will 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 Hospitals 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 Hospitals 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 Healths website at http://iuhealth.org/communitybenefit/. 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 Systems 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) - Bad Debt 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 $2,245,432. 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 23.74%. Schedule H, Part I, Line 7g - Subsidized Health Services IU Health White Memorial Hospital does not include any costs associated with physician clinics as subsidized health services. 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") invest in economic development efforts across the state, collaborate with like-minded organizations through coalitions that address key issues, and advocate for improvements in the health status of vulnerable populations. This includes making contributions to community-building activities by providing investments and resources to local community initiatives that addressed economic development, community support and workforce development. Several examples include IU Healths support of the following organizations and initiatives that focus on some of the root causes of health issues, such as lack of education, employment and poverty: - Twin Lakes High School - Starfish Initiative - Teach for America - United Way Additionally, through the IU Health Statewide Systems team member community benefit service program, "Strength That Cares", team members across the state make a difference in the lives of thousands of Hoosiers every year. Schedule H, Part III, Line 2 - Methodology Used to Est. Bad Debt Exp. The bad debt expense of $705,154 reported on Schedule H, Part III, Line 2 is reported at cost, as calculated using the cost to charge ratio methodology. 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 Healths bad debt expense footnote is as follows: The Indiana University Health System does not require collateral or other security for the delivery of health care services from its patients, substantially all of whom are residents of the state of Indiana. However, assignment of benefit payments payable under patients health insurance programs and plans (e.g., Medicare, Medicaid, health maintenance organizations, and commercial insurance policies) is routinely obtained, consistent with industry practice. The provision for uncollectible accounts, for all payers, is recognized when services are provided based upon managements assessment of historical and expected net collections, taking into consideration business and economic conditions, changes and trends in health care coverage, and other collection indicators. Periodically, management assesses the adequacy of the allowance for uncollectible accounts based upon accounts receivable payer composition and aging, the significance of individual payers to outstanding accounts receivable balances, and historical write-off experience by payer category, as adjusted for collection indicators. The results of this review are then used to make any modifications to the provision for uncollectible accounts and the allowance for uncollectible accounts. In addition, the Indiana University Health System follows established guidelines for placing certain past-due patient balances with collection agencies. Patient accounts that are uncollected, including those placed with collection agencies, are initially charged against the allowance for uncollectible accounts in accordance with collection policies of the Indiana University Health System and, in certain cases, are reclassified to charity care if deemed to otherwise meet financial assistance policies of the Indiana University Health System. Schedule H, Part III, Line 8 - Medicare Shortfall IU Health White Memorial Hospital did not have a Medicare shortfall for 2016. 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 Hospitals 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 applications 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 patients physician, family members, legal counsel, community or religious groups, social services or hospital personnel may request a FAP Application to be mailed to a patients primary mailing address free of charge. IU Health White Memorial Hospital 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 patients and/or guarantors 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 patients 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 patients 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 patients or their guarantors 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 patients or their guarantors 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 patients or their guarantors property, foreclosing on a patients or their guarantors real property attaching or seizing a patients or their guarantors bank account or other personal property, commencing a civil action against a patient or their guarantor, causing a patient or guarantors arrest, causing a patient and/or guarantor to be subject to a writ of body attachment, and garnishing a patient or guarantors 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 utilizing the detailed community needs assessment undertaken by organizations such as the White County Health Department, The Indiana State Department of Health, The Centers for Disease Control and Prevention and the United Way of Central Indiana. After completion of the CHNA, IU Health White Memorial Hospital reviewed the information gathered from community leader focus groups, community input surveys and statistical data. The needs identified were analyzed and ranked using the Hanlon method of prioritization to determine the prevalence and severity of community health needs and which ones were most critical. Additionally, the effectiveness of an intervention for each need and IU Healths 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 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. 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 (2016) statistics, White Countys population is 24,643. The countys population estimates by race are 93.3% white, 4.5% Hispanic, 0.5% Asian, and 1.3% Black, or 0.4% American Indian. White county has modest levels of educational attainment. Roughly 10% finished their education before obtaining a high school degree. About 43% ended their education with a high school degree. An additional 31% had some college, including an associate's degree with 15% of the population having 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 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 education and the community, IU Health White Memorial Hospital offers a job shadow class to Twin Lakes High School students in Health Occupation class. Each year, high school students learn about the various departments in the hospital and spend 10 hours a week during the spring semester shadowing IU Health White Memorial employees. The hospital is dedicated to helping local high school students expand their career options through job shadowing and learning about careers in the medical field. The Health & Safety Fair focuses on providing education to children and their families about their health and well-being. Dozens of community organizations provide educational booths including blood pressure and cholesterol screenings, balance screenings, free bike helmets provided by IU Health White Memorial Foundation, hands-on CPR and AED training for families and free car seat safety checks. A Teddy Bear Clinic allows children to bring in their stuffed animals for a check-up. IU Health White Memorial hosts a booth at the White County 4H Fair. We set up a farmers market that offers fresh vegetables, healthy recipe tips and samples to encourage participants to eat healthier. Educational materials on Eat This, Walk That helps educate people on how far they must walk to burn the calories of different fair foods. 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 Indianas most comprehensive healthcare system. A unique partnership with the Indiana University School of Medicine, one of the nations leading medical schools, gives patients access to innovative treatments and therapies. IU Health is comprised of hospitals, physicians and allied services dedicated to providing preeminent care throughout Indiana and beyond. National Recognition - Six hospitals designated as Magnet by the American Nurses Credentialing Center recognizing excellence in nursing care - Ten clinical programs ranked among the top 50 national programs in U.S. News & World Reports 2015-16 edition of Americas Best Hospitals - Ten out of ten specialty programs at Riley Hospital for Children at IU Health ranked among the top 50 childrens hospitals in the nation 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 2012, IU Health and the IU School of Medicine announced that they will invest $150 million over five years in the Strategic Research Initiative, a new research collaboration that will enhance the institutions joint capabilities in fundamental scientific investigation, translational research and clinical trials. The initial focus will be on projects in the fields of neuroscience, cancer and cardiovascular disease with the goal to fund transformative proposals that will fundamentally change our 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 top status of "comprehensive," which would recognize it as one of the top-tier cancer centers in the national - Neuroscience: The neurosciences research program will tackle a broad range of brain injuries, neurodegenerative disorders and neurodevelopmental disorders - Cardiovascular: The cardiovascular research initiative will develop 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 will provide patients with access to internationally renowned physicians and to new therapies developed through translational research and critical 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 Indianas 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 Goshen Hospital - IUHLP Liquidation, Inc. f/k/a IU Health La Porte Hospital - IU Health North Hospital - IU Health Paoli Hospital - IUHLP-SH, LLC f/k/a IU Health Starke 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 benefits plan relative to the local community, the IU Health Statewide System considers its community benefit plan as part of an overall vision for strengthening Indianas 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. Some ways we address our community health priorities as a system include: IU Health Day of Service The annual IU Health Day of Service is a high-impact event aimed at engaging IU Health team members in activities that address an identified community priority. Each year, more than 20,000 IU Health team member volunteer during the Day 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 2016, IU Health impacted many people statewide through 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. Examples of the types of programming and investment we make in community outreach areas include: Access to Healthcare IU Health is committed to providing quality and complete healthcare for Hoosiers. Access to healthcare was a leading community health need identified in all communities served by IU Health across the state. IU Health is focusing on the needs of the underserved to create initiatives and support efforts that: - Educate community members to understand and navigate the healthcare system - Increase the availability of low-cost services and provide financial assistance. IU Health provides free or reduced-cost care and supports a number of clinics to provide free or reduced-cost care to individuals without access to insurance or the ability to pull the full cost of their healthcare. These clinics include: - IU Student Outreach Clinic - Hope Healthcare Services - Gennesaret Free Clinics - Trinity Free Clinic Healthy Weight & Nutrition Like most of the nation, Hoosiers see the alarming rise of obesity in their communities as a leading concern. Nationally, Indiana has the 15th highest adult obesity rate in the nation (The State of Obesity: Better Policies for a Healthier America, 2016). Obesity prevention was a critical community health need identified in IU Health communities across the state. IU Health is committed to launching innovative efforts aimed at preventing and reversing obesity in our communities to help community members get active, get health and get strong. IU Health is working to create initiatives and support efforts to: - Improve access to healthy foods - Create healthier school environments - Increase access to safe places for community members to be physically active IU Health initiatives aimed at preventing and reversing obesity in our communities include: - Strong Schools - Change the Play - My Healthy Habits App - Youth Diabetes Prevention Clinic Healthy Food Access Grant The Healthy Food Access Grant is an extension of the work started in 2011 with the Garden on the Go program to address obesity in the Indianapolis community. According to the USDA, between 25 and 30 million (9%) Americans are currently living in communities that do not provide adequate access to healthy food within a mile of their home. In Indianapolis, it is estimated that over 300,000 (36%) residents live in food deserts and have limited access to healthy and affordable food options. Indianapolis is reported as having the highest incidence of food deserts in the country (USDA, 2014). The lack of consumption and lack of access to healthy affordable food, particularly fresh produce, contributes to a poor diet and often can lead to higher rates of obesity and other diet-related diseases, such as diabetes and heart disease. Approximately 31% of Marion County residents are considered obese, up nearly 7% from 2010. When controlling for obesity, weight-related health problems, and health of environment, the Indianapolis area ranks among the worst metropolitan areas in the United States in terms of health. In sum, obesity is on the rise while increasingly more Indianapolis residents have less access to healthy and affordable food, which can contribute to lower consumption rates of fresh fruits and vegetables and higher rates of diet-related diseases. To address this important community and populatio Schedule H, Part VI - Other Disclosure in Accordance with Revenue Procedure 2015-21: In accordance with Revenue Procedure 2015-21, IU Health White Memorial Hospital discloses the following information with respect to Section 501(r) issues that were discovered during the 2016 tax year and how they have been corrected, to satisfy Section 501(r)(1) and 501(r)(2)(B) requirements. For all items: The cause was a good-faith effort by IU Health White Memorial Hospital to implement the requirements of the Section 501(r) regulations. IU Health White Memorial Hospital obtained information about the requirements and implemented them, though there were some gaps due to the detailed nature of the regulations. The issues were discovered in December 2016 when IU Health's System FAP, as applicable to IU Health White Memorial Hospital, was reviewed by the IRS as part of a courtesy review in conjunction with an audit of a tax-exempt organization related to IU Health White Memorial Hospital. The corrections were completed, in conjunction with the IRS courtesy review, in January 2017. The IRS confirmed in January 2017 that it believed IU Health's System FAP, effective January 2017, was in compliance with Section 501(r) and the Final Regulations. IU Health White Memorial Hospital has not identified any persons directly affected by these issues because the discrepancies related primarily to the specificity of information contained in the FAP. All individuals would have been in the same position. Specific Issues and Corrections: 1. Requirement: Inclusion of a Provider List Pursuant to Treas. Reg. 1.501(r)-4(b)(1)(iii)(F), a hospital facility's FAP is required to include a list of providers, other than the hospital facility itself, who are delivering emergency or other medically necessary care in the hospital facility and to be specific about which providers are covered by the hospital facility's FAP (and which are not). Pursuant to 5 of Notice 2015-46, a hospital facility's provider list is required to be updated "at least quarterly" in order for a hospital organization to be considered as having taken reasonable steps to ensure that its list is accurate. Condition: V.B.4.a of IU Health White Memorial Hospital's FAP, effective January 2016, stated that it "does not cover services rendered by individual providersthat a "full listing of providers and services not covered by this policy is available at www.iuhealth.org/financialassistance and is updated on a quarterly basis." During 2016, the IU Health White Memorial Hospital's Financial Assistance webpage contained a paragraph stating that a "complete list of all IU Health White Memorial Hospital providers not covered under IU Health White Memorial Hospital's FAP is available via the Find A Doctor page or as a PDF file." The "Find A Doctor page" allowed a search by first or last name of the provider. The result was a listing showing providers' pictures, specialties, and Hospitals & Affiliations. None of the information provided specifically identified whether a provider's services were or were not covered by IU Health White Memorial Hospital's FAP. The PDF file, entitled "Find A Doctor Printable Directory", did not specifically identify whose services were covered by IU Health White Memorial Hospital's FAP and whose were not. In addition, the listing was dated December 23, 2015 (almost one year old). These omissions led to the conclusion that IU Health White Memorial Hospital's FAP, effective January 2016, was not compliant with Treas. Reg. 1.501(r)-4(b)(1)(iii)(F) or Notice 2015-46. Corrective Action: IU Health White Memorial Hospital's Financial Assistance website at http://iuhealth.org/patients/my-iu-health/pay-a-bill/financial-assistance/ was updated in January 2017 to include the following information: "IU Health White Memorial Hospital's FAP does not cover individual physician charges. A listing of all providers who render services at an IU Health White Memorial Hospital facility and whose individual professional charges are not covered by this FAP, along with a list of any services that are not covered by this FAP, are available "herewas updated on December 31, 2016." By clicking "here" on the website, an individual was able to view a PDF file listing all individual physicians providing medical services at IU Health White Memorial Hospital with the specification that their services are not covered under IU Health White Memorial Hospital's FAP. Furthermore, IU Health White Memorial Hospital now updates the list no less frequently than quarterly. 2. Requirement: Description of Process and Time Frames Regarding FAP-eligibility and ECAs Pursuant to Treas. Reg. 1.501(r)-6(c), a hospital facility's FAP (or a separate written billing & collections policy) must describe the process and time frames that each hospital facility uses with respect to the reasonable efforts it will make to determine whether an individual is FAP eligible before engaging in any ECAs. Treas. Reg. 1.501(r)-6(c) defines two methods that will constitute reasonable efforts under paragraphs (c)(2) and (c)(3) as follows: - (c)(2): Presumptive FAP-eligibility determinations; and - (c)(3): Various, other efforts based on notification and processing of applications Condition: VI.D.1 of IU Health White Memorial Hospital's FAP, effective January 2016, provided that 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. VI.D.2 stated that IU Health White Memorial Hospital and its third-party collection agencies may initiate ECAs against a patient in accordance with the FAP and 26 CFR 1.501(r). The problem with this wording is that IU Health White Memorial Hospital did not describe the process and time frames that are involved with its "reasonable efforts". This omission led to the conclusion that IU Health White Memorial Hospital's FAP, effective January 2016, was not compliant with IRC 501(r)(4). Corrective Action: IU Health White Memorial Hospital added language to VI.D.1 and VI.D.2 of its FAP, effective January 2017, to fully describe the process and time frames that are involved with its reasonable efforts to determine a patient's eligibility for assistance under the FAP. 3. Requirement: Description of ECAs and Final Authority in Making Determinations Regarding FAP-eligibility and ECAs IRC 501(r)(4)(A)(iv) requires that a hospital facility's FAP address the actions that the organization may take in event of nonpayment. Treas. Rag 1.501(r)-(4)(b)(4)(C) requires that a hospital facility's FAP must describe the office, department, committee, or other body with the final authority or responsibility for determining that the hospital facility has made reasonable efforts to determine whether an individual is FAP-eligible and may engage in ECAs against the individual. Condition: IU Health White Memorial Hospital's FAP, effective January 2016, did not contain the required wording described above. This omission led to the conclusion that IU Health White Memorial Hospital's FAP, effective January 2016, was not compliant with IRC 501(r)(4). Corrective Action: IU Health White Memorial Hospital added language to VI.D.2 through VI.D.4 of its FAP, effective January 2017, to fully describe the actions it may take in the event of nonpayment. Furthermore, IU Health White Memorial Hospital's Financial Assistance Committee is identified in IV of the FAP as the body responsible for the effectuation of the FAP including making final determinations if IU Health White Memorial Hospital had made reasonable efforts to determine a patient's eligibility for assistance under the FAP. 4. Requirement: Inclusion of a Facilities List Treas. Reg. 1.501(r)-4(d)(3) states that a hospital organization may establish a FAP (and B&CP and EMCP) that is shared with multiple hospital facilities provided that any joint policy clearly identifies each facility to which it applies. Condition: In II, "Scope," IU Health White Memorial Hospital's FAP, effective January 2016, stated that it "applies to all Uninsured Patients receiving care rendered at all non-profit IU Health White Memorial Hospital facilities, including those receiving emergent and/or medical necessary services." This language did not clearly identify each hospital facility, by name, to which it applied. Lacking this required language resulted in the conclusion that IU Health White Memorial Hospital's FAP, effective January 2016, was not compliant with IRC 501(r)(4). Corrective Action: IU Health White Memorial Hospital added language to VI.B.3 of its FAP, effective January 2017, to clearly identify each hospital facility, by name, to which it applied. false true false false false false false false false CHRISTOPHER A MANSFIELD MD VICE CHAIR (WCR) 0 408959 0 0 0 18486 0 13250 0 28269 0 468964 0 0 ROGER G BANGS MD DIRECTOR (WCR) 0 620828 0 5954 0 20322 0 13250 0 22014 0 682368 0 0 DANIEL F EVANS JR DIRECTOR (WCR) 0 1158577 0 302286 0 62553 0 260986 0 13571 0 1797973 0 0 KENNETH E MARNOCHA MD DIRECTOR (WCR) 0 593032 0 7215 0 21564 0 13250 0 0 0 635061 0 0 RUBAN NIRMALAN MD DIRECTOR (WCR) 0 661640 0 0 0 18540 0 13250 0 22435 0 715865 0 0 JEFFREY C ZEH PRES & CEO/COO(WCR-PART YEAR) 0 238584 0 24822 0 755 0 12532 0 1240 0 277933 0 0 JEROME P KELLY SECRETARY (PARTIAL YEAR) 0 124553 0 35064 0 36795 0 6966 0 13868 0 217246 0 0 DEREK E EMPIE SECRETARY 0 172175 0 1312 0 300 0 9135 0 28169 0 211091 0 0 CARA L BREIDSTER CFO (WCR) 0 257519 0 43697 0 2935 0 12573 0 21328 0 338052 0 0 DONALD E CLAYTON MD PRESIDENT & CEO (WCR) 0 448240 0 31493 0 29423 0 81084 0 16732 0 606972 0 0 JEFFREY P BROWN MD CMO (WCR) 0 257136 0 22727 0 21894 0 12489 0 27417 0 341663 0 0 ADEL M KHDOUR MD CMO (PARTIAL YEAR) 0 342439 0 0 0 18810 0 13249 0 26722 0 401220 0 0 BRIAN T SHOCKNEY FORMER INTERIM CEO 0 249386 0 28265 0 6562 0 13109 0 21865 0 319187 0 0 ANDREW K EDWARDS MD FORMER VICE CHAIR 0 427419 0 0 0 18540 0 13250 0 22912 0 482121 0 0 Schedule J, Part I, Line 3 - Comp. Or the Org's CEO/Executive Director IU Health White Memorial Hospitals President & CEO is employed by IU Health Arnett, Inc. IU Health Arnett's process for determining compensation includes the use of a compensation survey/study conducted by an independent compensation consultant with review and approval by the Committee on Personnel and Compensation and the Board of Directors. Please see Schedule O for additional details. Schedule J, Part I, Line 4b - Supplemental Nonqualified Retirement Plan Daniel F. Evans, Jr. and Donald E. Clayton, M.D. participate in an IU Health supplemental executive retirement plan, provisions of which are designed to retain its 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. Each of these executives have amounts included in column c, deferred compensation, representing the current year unvested contributions made under the supplemental retirement plan. No amounts were actually paid to these executives during the year. 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 twelve (12) voting members appointed by IU Health. At least two (2) directors must reside in White County. Line 7b: The following are subject to IU Healths approval: - Any proposed amendment to the Corporations Articles of Incorporation of Bylaws; - Approval of the Corporations 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, greater than the budgeted amount by (i) $250,000 per fiscal year per budget line item and (ii) $750,000 per fiscal year in the aggregate; provided, however, the foregoing limit shall be subject to change in the event certain performance standards are not met; - Approval of any strategic plan for the Corporation, including any amendments to a strategic plan; - Approval of any encumbrance, sale or conveyance of assets in excess of five percent (5%), on a cumulative basis, of the Corporations Net Book Value, during any fiscal year; - Any merger, consolidation, joint venture or affiliation involving the Corporation or any of its affiliates and any other entity; - Appointment and removal of the Corporations Chief Executive Officer, upon a recommendation of the Board; and - The dissolution of the Corporation or any of its affiliates. Part VI, Section A, Line 8b - Documentation of Meetings IU Health White Memorial Hospital, Inc.s Board of Directors does not have any committees with the authority to act on behalf of the Board of Directors. Part VI, Section B, Line 11b - Review of Form 990 The CFO and IU Health Arnetts Audit Committee reviewed and approved the Form 990. Following their 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 Healths 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 Hospitals Board of Directors was not required to separately adopt a conflict of interest, whistleblower, document retention and destruction and joint venture policies because IU Healths 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 White Memorial Hospital follows IU Healths Conflict of Interest Policy. IU Healths 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 Representatives 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 supervisors 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 15 - Process for Determining Comp. IU Health White Memorial Hospital's CEO is employed by IU Health Arnett. IU Health Arnett utilizes IU Health's process for determining compensation as follows: (1) The Board of Directors has established a Committee on Personnel and Compensation. The individuals on this Committee are made up of individuals who are on the Board and who do not have a conflict of interest with IU Health. There are no physicians or employees on this Committee. This Committee develops and reviews annually the executive compensation philosophy, market analysis as to comparability and reasonableness. One of the purposes of this Committee is to review, approve and make recommendations regarding executive compensation and benefits to the IU Health Board. As deemed appropriate, this Committee also reviews the same detail with the Committee on Finance. The Committee on Finance is represented by certain members of the Board as well. (2) Each year the Committee on Personnel and Compensation engages an outside compensation consulting firm to conduct a compensation and benefits study for all senior vice presidents and above. The current compensation advisor is the Hay Group. Hay Group performs an independent compensation survey. The relevant comparability data includes: compensation and benefit 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. The Committee reviews the entire compensation package including: base compensation, short term and long term incentive plans, basic health and welfare benefits, qualified and nonqualified plans as well as any additional fringe benefits. Further, Hay Group will provide recommendations based upon the reasonable compensation information as it relates to salary increases, bonuses and benefits that are consistent with the compensation philosophy of the Committee. A separate analysis using the same methodology is done for the Chief Executive Officer. (3) The Committee reviews the salary survey and, if appropriate, makes recommendations on increases in salary and any changes in bonuses or benefits. The Committee's goal is to ensure that the total compensation and benefits package is reasonable based upon the independent data provided by Hay Group. The Committee votes on any changes in compensation or benefits. This review, discussion and vote are documented in the minutes for the meeting. There are no executives present during the final discussion and approval of compensation. (4) The Board reviews the report prepared by the Hay Group as well as the recommendations of the Committee on Personnel and Compensation as to changes in compensation approved by the Committee. As requested, the Committee on Finance also provides its review of recommendations on changes in executive compensation and benefits. This review, discussion and vote are documented in the minutes. (5) The Board then reviews the recommendations provided by the Committee on Personnel and Compensation and votes on the changes as well. No additional compensation or benefits are paid to the executives until the changes have been approved by the Committee and the Board. The discussion and approval are documented in the minutes of the meeting. There are no executives present during the final discussion and approval of compensation. The General Counsel prepares a formal written opinion reviewing the compensation and benefits approval process, comparing that process to the Intermediate Sanctions Test of IRC Section 4958 and, if the facts warrant, provides comments regarding the compensation and benefits approval process as this 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 Committee and Board also reviews the achievements of the executive group as it relates to the long-term and short-term shared and individual goals developed by the executive 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 and the compensation survey. The discussion and vote of the Committee 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 Committee on Personnel and Compensation and Audit Committee also review the required Form 990 disclosures related to executive compensation and benefits as well as compensation practices and approval processes prior to the filing of the Form 990 return with the Internal Revenue Service. Part VI, Section C, Line 19 - Public Disclosure IU Health White Memorial Hospital, Inc.'s Articles of Incorporation are available to the public through the Indiana Secretary of State's web-site. IU Health White Memorial Hospitals conflict of interest policy is described on Form 990, Schedule O. IU Health White Memorial Hospital is a consolidated subsidiary in the consolidated financial statements for Indiana University Health, Inc. ("IU Health"). The consolidated financial statements for IU Health are available to the public through its bond filings and attached to this filed Form 990. Part XI, Line 9 - Other Changes in Net Assets or Fund Balances During 2016, IU Health White Memorial Hospital, Inc. recorded the following changes in interest in net assets or fund balances: Change in Interest in Restricted Net Assets of Foundations: 27,058 FORM 990 PART IX LINE 11G DESCRIPTION:SHARED SERVICES/PROF. 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