ASCENSION CALUMET HOSPITAL INC: Form 990, tax year 2015
View the entire original 990 at ProPublica ↗
- Organization
- ASCENSION CALUMET HOSPITAL INC (EIN 39-0905385)
- Tax period
- 2015-07-01 to 2016-06-30
- Filed
- 2017-05-09
- IRS object ID
- 201711299349301891
- Schema version
- 2015v3.0
- Source
- Download XML · Original 990 at ProPublica
Every field in the e-filed return. Faint text is the IRS element name, for citing.
- Return header
- Form 990
- Schedule A
- Schedule B
- Schedule C
- Schedule D
- Schedule H
- Schedule J
- Schedule O
- Schedule R
Return header ReturnHeader
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return | 2017-05-09T17:04:06-05:00 | ReturnTs |
| Tax Period End | 2016-06-30 | TaxPeriodEndDt |
| Return Type | 990 | ReturnTypeCd |
| Tax Period Begin | 2015-07-01 | TaxPeriodBeginDt |
Filer Filer
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 390905385 | EIN |
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Calumet Medical Center Inc | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Control | CALU | BusinessNameControlTxt |
| Phone | 9208492386 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 614 Memorial Drive | AddressLine1Txt |
| City | Chilton | CityNm |
| State Abbreviation | WI | StateAbbreviationCd |
| ZIP | 53014 | ZIPCd |
Business Officer BusinessOfficerGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person | Bill Hinner | PersonNm |
| Person Title | CFO Reg Health System,WI North | PersonTitleTxt |
| Signature | 2017-05-09 | SignatureDt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tax | 2015 | TaxYr |
| Build TS | 2021-01-29 14:40:06Z | BuildTS |
Form 990 IRS990
Principal Ofcr Business Name PrincipalOfcrBusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Timothy Richman | BusinessNameLine1Txt |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 614 Memorial Drive | AddressLine1Txt |
| City | Chilton | CityNm |
| State Abbreviation | WI | StateAbbreviationCd |
| ZIP | 53014 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Receipts | $29,136,370 | GrossReceiptsAmt |
| Group Return For Affiliates | false | GroupReturnForAffiliatesInd |
| Organization501c3 | Yes (X) | Organization501c3Ind |
| Website Address | www.affinityhealth.org | WebsiteAddressTxt |
| Type Of Organization Corp | Yes (X) | TypeOfOrganizationCorpInd |
| Formation | 1954 | FormationYr |
| Legal Domicile State | WI | LegalDomicileStateCd |
| Activity Or Mission | To further the healing ministry of Jesus by improving the health and well-being of all people. | ActivityOrMissionDesc |
| Voting Members Governing Body | 13 | VotingMembersGoverningBodyCnt |
| Voting Members Independent | 8 | VotingMembersIndependentCnt |
| Total Employee | 196 | TotalEmployeeCnt |
| Total Volunteers | 39 | TotalVolunteersCnt |
| Total Gross UBI | $0 | TotalGrossUBIAmt |
| Net Unrelated Bus Txbl Incm | $0 | NetUnrelatedBusTxblIncmAmt |
| PY Contributions Grants | $1,050,096 | PYContributionsGrantsAmt |
| CY Contributions Grants | $1,076,274 | CYContributionsGrantsAmt |
| PY Program Service Revenue | $26,685,834 | PYProgramServiceRevenueAmt |
| CY Program Service Revenue | $27,672,786 | CYProgramServiceRevenueAmt |
| PY Investment Income | $154,196 | PYInvestmentIncomeAmt |
| CY Investment Income | $92,338 | CYInvestmentIncomeAmt |
| PY Other Revenue | $242,766 | PYOtherRevenueAmt |
| CY Other Revenue | $274,465 | CYOtherRevenueAmt |
| PY Total Revenue | $28,132,892 | PYTotalRevenueAmt |
| CY Total Revenue | $29,115,863 | CYTotalRevenueAmt |
| PY Grants And Similar Paid | $0 | PYGrantsAndSimilarPaidAmt |
| CY Grants And Similar Paid | $0 | CYGrantsAndSimilarPaidAmt |
| PY Benefits Paid To Members | $0 | PYBenefitsPaidToMembersAmt |
| CY Benefits Paid To Members | $0 | CYBenefitsPaidToMembersAmt |
| PY Salaries Comp Emp Bnft Paid | $12,024,757 | PYSalariesCompEmpBnftPaidAmt |
| CY Salaries Comp Emp Bnft Paid | $10,697,851 | CYSalariesCompEmpBnftPaidAmt |
| PY Total Prof Fndrsng Expns | $0 | PYTotalProfFndrsngExpnsAmt |
| CY Total Prof Fndrsng Expns | $0 | CYTotalProfFndrsngExpnsAmt |
| CY Total Fundraising Expense | $0 | CYTotalFundraisingExpenseAmt |
| PY Other Expenses | $10,360,917 | PYOtherExpensesAmt |
| CY Other Expenses | $13,050,265 | CYOtherExpensesAmt |
| PY Total Expenses | $22,385,674 | PYTotalExpensesAmt |
| CY Total Expenses | $23,748,116 | CYTotalExpensesAmt |
| PY Revenues Less Expenses | $5,747,218 | PYRevenuesLessExpensesAmt |
| CY Revenues Less Expenses | $5,367,747 | CYRevenuesLessExpensesAmt |
| Total Assets BOY | $42,872,071 | TotalAssetsBOYAmt |
| Total Assets EOY | $47,514,110 | TotalAssetsEOYAmt |
| Total Liabilities BOY | $5,061,009 | TotalLiabilitiesBOYAmt |
| Total Liabilities EOY | $4,497,988 | TotalLiabilitiesEOYAmt |
| Net Assets Or Fund Balances BOY | $37,811,062 | NetAssetsOrFundBalancesBOYAmt |
| Net Assets Or Fund Balances EOY | $43,016,122 | NetAssetsOrFundBalancesEOYAmt |
| Mission | The mission of Calumet Medical Center, Inc. is to live out the healing ministry of Christ by providing services that promote the health and well-being of the communities we serve, especially the poor. | MissionDesc |
| Significant New Program Srvc | false | SignificantNewProgramSrvcInd |
| Significant Change | false | SignificantChangeInd |
| Expense | $17,110,834 | ExpenseAmt |
| Revenue | $27,672,786 | RevenueAmt |
| Desc | CALUMET MEDICAL CENTER, INC. OPERATES A 25-BED CRITICAL ACCESS HOSPITAL FACILITY PROVIDING MEDICAL, SURGICAL, EMERGENCY, OUTPATIENT, CLINIC, HOSPICE, AND HOME HEALTH SERVICES TO RESIDENTS IN CALUMET COUNTY, REGARDLESS OF ABILITY TO PAY. THE EMERGENCY DEPARTMENT INCLUDES 24 HOURS A DAY/7 DAYS A WEEK EMERGENCY PHYSICIAN COVERAGE. THE EMERGENCY DEPARTMENT ALSO OFFERS WALK-IN CLINIC SERVICES FOR AFTER DOCTOR'S OFFICE HOURS. DURING 2016, THE HOSPITAL COUNTED 1,616 PATIENT DAYS AND 415 TOTAL DISCHARGES AND ITS EMERGENCY DEPARTMENT RECEIVED 4,504 VISITS. SEE SCHEDULE H FOR FURTHER DETAILS REGARDING THE COMMUNITY BENEFITS THAT CALUMET MEDICAL CENTER PROVIDES. | Desc |
| Total Program Service Expenses | $17,110,834 | TotalProgramServiceExpensesAmt |
| Described In Section501c3 | Yes (true) | DescribedInSection501c3Ind |
| Schedule B Required | Yes (true) | ScheduleBRequiredInd |
| Political Campaign Acty | false | PoliticalCampaignActyInd |
| Lobbying Activities | Yes (true) | LobbyingActivitiesInd |
| Subject To Proxy Tax | false | SubjectToProxyTaxInd |
| Donor Advised Fund | false | DonorAdvisedFundInd |
| Conservation Easements | false | ConservationEasementsInd |
| Collections Of Art | false | CollectionsOfArtInd |
| Credit Counseling | false | CreditCounselingInd |
| Temp Or Permanent Endowments | false | TempOrPermanentEndowmentsInd |
| Report Land Building Equipment | Yes (true) | ReportLandBuildingEquipmentInd |
| Report Investments Other Sec | false | ReportInvestmentsOtherSecInd |
| Report Program Related Invst | false | ReportProgramRelatedInvstInd |
| Report Other Assets | Yes (true) | ReportOtherAssetsInd |
| Report Other Liabilities | Yes (true) | ReportOtherLiabilitiesInd |
| Include FIN48 Footnote | Yes (true) | IncludeFIN48FootnoteInd |
| Independent Audit Fincl Stmt | false | IndependentAuditFinclStmtInd |
| Consolidated Audit Fincl Stmt | Yes (true) | ConsolidatedAuditFinclStmtInd |
| School Operating | false | SchoolOperatingInd |
| Foreign Office | false | ForeignOfficeInd |
| Foreign Activities | false | ForeignActivitiesInd |
| More Than5000 K To Org | false | MoreThan5000KToOrgInd |
| More Than5000 K To Individuals | false | MoreThan5000KToIndividualsInd |
| Professional Fundraising | false | ProfessionalFundraisingInd |
| Fundraising Activities | false | FundraisingActivitiesInd |
| Gaming Activities | false | GamingActivitiesInd |
| Operate Hospital | Yes (true) | OperateHospitalInd |
| Audited Financial Stmt Att | Yes (true) | AuditedFinancialStmtAttInd |
| Grants To Organizations | false | GrantsToOrganizationsInd |
| Grants To Individuals | false | GrantsToIndividualsInd |
| Schedule J Required | Yes (true) | ScheduleJRequiredInd |
| Tax Exempt Bonds | false | TaxExemptBondsInd |
| Engaged In Excess Benefit Trans | false | EngagedInExcessBenefitTransInd |
| PY Excess Benefit Trans | false | PYExcessBenefitTransInd |
| Loan Outstanding | false | LoanOutstandingInd |
| Grant To Related Person | false | GrantToRelatedPersonInd |
| Business Rln With Org Mem | false | BusinessRlnWithOrgMemInd |
| Business Rln With Fam Mem | false | BusinessRlnWithFamMemInd |
| Business Rln With Officer Ent | false | BusinessRlnWithOfficerEntInd |
| Deductible Non Cash Contri | false | DeductibleNonCashContriInd |
| Deductible Art Contribution | false | DeductibleArtContributionInd |
| Terminate Operations | false | TerminateOperationsInd |
| Partial Liquidation | false | PartialLiquidationInd |
| Disregarded Entity | false | DisregardedEntityInd |
| Related Entity | Yes (true) | RelatedEntityInd |
| Related Organization Ctrl Ent | Yes (true) | RelatedOrganizationCtrlEntInd |
| Transaction With Control Ent | Yes (true) | TransactionWithControlEntInd |
| Trnsfr Exmpt Non Chrtbl Rltd Org | false | TrnsfrExmptNonChrtblRltdOrgInd |
| Activities Conducted Prtshp | false | ActivitiesConductedPrtshpInd |
| Schedule O Required | Yes (true) | ScheduleORequiredInd |
| IRP Document | 20 | IRPDocumentCnt |
| IRP Document W2 G | 0 | IRPDocumentW2GCnt |
| Backup Wthld Compliance | Yes (true) | BackupWthldComplianceInd |
| Employee | 196 | EmployeeCnt |
| Employment Tax Returns Filed | Yes (true) | EmploymentTaxReturnsFiledInd |
| Unrelated Bus Incm Over Limit | false | UnrelatedBusIncmOverLimitInd |
| Foreign Financial Account | false | ForeignFinancialAccountInd |
| Prohibited Tax Shelter Trans | false | ProhibitedTaxShelterTransInd |
| Taxable Party Notification | false | TaxablePartyNotificationInd |
| Nondeductible Contributions | false | NondeductibleContributionsInd |
| Quid Pro Quo Contributions | false | QuidProQuoContributionsInd |
| Form8282 Property Disposed Of | false | Form8282PropertyDisposedOfInd |
| Rcv Fnds To Pay Prsnl Bnft Cntrct | false | RcvFndsToPayPrsnlBnftCntrctInd |
| Pay Premiums Prsnl Bnft Cntrct | false | PayPremiumsPrsnlBnftCntrctInd |
| Indoor Tanning Services | false | IndoorTanningServicesInd |
| Info In Schedule O Part VI | Yes (X) | InfoInScheduleOPartVIInd |
| Governing Body Voting Members | 13 | GoverningBodyVotingMembersCnt |
| Independent Voting Member | 8 | IndependentVotingMemberCnt |
| Family Or Business Rln | false | FamilyOrBusinessRlnInd |
| Delegation Of Mgmt Duties | false | DelegationOfMgmtDutiesInd |
| Change To Org Documents | false | ChangeToOrgDocumentsInd |
| Material Diversion Or Misuse | false | MaterialDiversionOrMisuseInd |
| Members Or Stockholders | Yes (true) | MembersOrStockholdersInd |
| Election Of Board Members | Yes (true) | ElectionOfBoardMembersInd |
| Decisions Subject To Approva | Yes (true) | DecisionsSubjectToApprovaInd |
| Minutes Of Governing Body | Yes (true) | MinutesOfGoverningBodyInd |
| Minutes Of Committees | Yes (true) | MinutesOfCommitteesInd |
| Officer Mailing Address | false | OfficerMailingAddressInd |
| Local Chapters | false | LocalChaptersInd |
| Form990 Provided To Gvrn Body | Yes (true) | Form990ProvidedToGvrnBodyInd |
| Conflict Of Interest Policy | Yes (true) | ConflictOfInterestPolicyInd |
| Annual Disclosure Covered Prsn | Yes (true) | AnnualDisclosureCoveredPrsnInd |
| Regular Monitoring Enfrc | Yes (true) | RegularMonitoringEnfrcInd |
| Whistleblower Policy | Yes (true) | WhistleblowerPolicyInd |
| Document Retention Policy | Yes (true) | DocumentRetentionPolicyInd |
| Compensation Process CEO | false | CompensationProcessCEOInd |
| Compensation Process Other | false | CompensationProcessOtherInd |
| Investment In Joint Venture | false | InvestmentInJointVentureInd |
| States Where Copy Of Return Is Fld | WI | StatesWhereCopyOfReturnIsFldCd |
| Upon Request | Yes (X) | UponRequestInd |
Books In Care Of Detail BooksInCareOfDetail
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Craig Aittama | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Phone | 7153465161 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 5700 Lands End Way 2nd Floor | AddressLine1Txt |
| City | Stevens Point | CityNm |
| State Abbreviation | WI | StateAbbreviationCd |
| ZIP | 54482 | ZIPCd |
Form990 Part VII Section A Form990PartVIISectionAGrp (25 entries)
| TitleTitleTxt | Average Hours Per WeekAverageHoursPerWeekRt | Average Hours Per Week Rltd OrgAverageHoursPerWeekRltdOrgRt | Individual Trustee Or DirectorIndividualTrusteeOrDirectorInd | OfficerOfficerInd | Reportable Comp From OrgReportableCompFromOrgAmt | Reportable Comp From Rltd OrgReportableCompFromRltdOrgAmt | Other CompensationOtherCompensationAmt | Highest Compensated EmployeeHighestCompensatedEmployeeInd |
|---|---|---|---|---|---|---|---|---|
| TIMOTHY RICHMAN | ||||||||
| PRESIDENT/CEO - CMC | 40.0 | 1.0 | Yes (X) | Yes (X) | $0 | $262,734 | $32,572 | |
| JOHN RUSSO | ||||||||
| CHAIRMAN (START 1/2016) | 0.3 | 1.5 | Yes (X) | Yes (X) | $0 | $0 | $0 | |
| WAYNE WIETING | ||||||||
| CHAIRMAN (END 12/2015) | 0.3 | 0 | Yes (X) | Yes (X) | $0 | $0 | $0 | |
| KATHRYN SIEMAN | ||||||||
| VICE CHAIR (START 1/2016) | 0.3 | 1.5 | Yes (X) | Yes (X) | $0 | $0 | $0 | |
| MONICA ANN HILT | ||||||||
| VICE CHAIRMAN (END 12/2015) | 6.0 | 37.5 | Yes (X) | Yes (X) | $0 | $709,688 | $64,149 | |
| BRIAN WALLACE | ||||||||
| TREASURER (START 1/2016) | 0.3 | 1.5 | Yes (X) | Yes (X) | $0 | $0 | $0 | |
| JAMES BURNETT | ||||||||
| TREASURER (END 12/2015) | 0.3 | 0 | Yes (X) | Yes (X) | $0 | $0 | $0 | |
| WAYNE TREMBLY | ||||||||
| SECRETARY (START 1/2016) | 0.3 | 1.5 | Yes (X) | Yes (X) | $0 | $0 | $0 | |
| ALLAN UTECHT | ||||||||
| SECRETARY (END 12/2015) | 0.3 | 0 | Yes (X) | Yes (X) | $0 | $0 | $0 | |
| LANE EARNS | ||||||||
| BOARD MEMBER (START 1/2016) | 0.3 | 1.5 | Yes (X) | $0 | $0 | $0 | ||
| MARK W FAUSTICH MD | ||||||||
| BOARD MEMBER (START 1/2016) | 0.3 | 41.1 | Yes (X) | $0 | $438,031 | $21,791 | ||
| JANE GEHL | ||||||||
| BOARD MEMBER (END 12/2015) | 0.3 | 0 | Yes (X) | $0 | $0 | $0 | ||
| MARLIN GREENFIELD | ||||||||
| BOARD MEMBER (START 1/2016) | 0.3 | 1.5 | Yes (X) | $0 | $0 | $0 | ||
| PETER JANU MD | ||||||||
| BOARD MEMBER (END 12/2015) | 0.3 | 40.0 | Yes (X) | $0 | $552,160 | $45,990 | ||
| MARK KEHRBERG MD | ||||||||
| BOARD MEMBER | 0.3 | 40.3 | Yes (X) | $0 | $355,616 | $30,314 | ||
| CRAIG OLSEN MD | ||||||||
| BOARD MEMBER (END 12/2015) | 0.3 | 0 | Yes (X) | $0 | $0 | $0 | ||
| KEVIN RALOFSKY | ||||||||
| BOARD MEMBER (START 1/2016) | 0.3 | 1.2 | Yes (X) | $0 | $0 | $0 | ||
| SUDEEP SODHI MD | ||||||||
| BOARD MEMBER (START 1/2016) | 0.3 | 41.1 | Yes (X) | $0 | $882,249 | $47,537 | ||
| GENE TIPLER MD | ||||||||
| BOARD MEMBER (END 12/2015) | 0.3 | 40.0 | Yes (X) | $0 | $239,857 | $43,316 | ||
| MONICA VOMASTIC | ||||||||
| BOARD MEMBER (START 1/2016) | 0.3 | 1.5 | Yes (X) | $0 | $0 | $0 | ||
| WENDY SCHROEDER MD | ||||||||
| BOARD MEMBER (START 1/2016) | 0.3 | 41.5 | Yes (X) | $0 | $258,146 | $48,066 | ||
| NICHOLAS DESIEN | ||||||||
| MINISTRY HEALTH CARE CEO (END 12/31/15) | 1.0 | 54.3 | Yes (X) | $0 | $2,799,737 | $271,786 | ||
| JEFFREY FRANCIS | ||||||||
| MINISTRY HEALTH CARE CAFO (END 9/9/15) | 0.5 | 54.3 | Yes (X) | $0 | $652,678 | $51,385 | ||
| DANIEL NEUFELDER | ||||||||
| SVP, HOSPITAL OPERATIONS & PRESIDENT | 0.1 | 63.8 | Yes (X) | $0 | $2,171,860 | $190,168 | ||
| JENNIFER LEIGH MEDIN WEBER | ||||||||
| MANAGER INPATIENT SRVCS | 40.0 | 0 | $137,319 | $0 | $31,593 | Yes (X) | ||
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Reportable Comp From Org | $137,319 | TotalReportableCompFromOrgAmt |
| Tot Reportable Comp Rltd Org | $9,322,755 | TotReportableCompRltdOrgAmt |
| Total Other Compensation | $878,667 | TotalOtherCompensationAmt |
| Indiv Rcvd Greater Than100 K | 1 | IndivRcvdGreaterThan100KCnt |
| Former Ofcr Employees Listed | false | FormerOfcrEmployeesListedInd |
| Total Comp Greater Than150 K | Yes (true) | TotalCompGreaterThan150KInd |
| Compensation From Other Srcs | false | CompensationFromOtherSrcsInd |
Contractor Compensation ContractorCompensationGrp (2 entries)
| Address Line1ContractorAddress/USAddress/AddressLine1Txt | CityContractorAddress/USAddress/CityNm | State AbbreviationContractorAddress/USAddress/StateAbbreviationCd | ZIPContractorAddress/USAddress/ZIPCd | ServicesServicesDesc | CompensationCompensationAmt | Address Line2ContractorAddress/USAddress/AddressLine2Txt |
|---|---|---|---|---|---|---|
| GOLD CROSS AMBULANCE SERVICE I | ||||||
| 1055 Wittmann Drive | Menasha | WI | 54952 | Professional Services | $439,816 | |
| BOLDT PROCUREMENT LLC | ||||||
| 2525 N Roemer Rd | Appleton | WI | 54912 | Construction Services | $398,062 | PO Box 419 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Cntrct Rcvd Greater Than100 K | 2 | CntrctRcvdGreaterThan100KCnt |
| Info In Schedule O Part VIII | Yes (X) | InfoInScheduleOPartVIIIInd |
| Related Organizations | $1,064,995 | RelatedOrganizationsAmt |
| Government Grants | $11,279 | GovernmentGrantsAmt |
| Total Contributions | $1,076,274 | TotalContributionsAmt |
Program Service Revenue ProgramServiceRevenueGrp (3 entries)
| DescDesc | BusinessBusinessCd | Total Revenue ColumnTotalRevenueColumnAmt | Related Or Exempt Func IncomeRelatedOrExemptFuncIncomeAmt |
|---|---|---|---|
| Net Patient Revenue | 621110 | $22,360,520 | $22,360,520 |
| Clinic Revenue | 621110 | $5,205,491 | $5,205,491 |
| Rent to Affiliates | 531190 | $26,058 | $26,058 |
Total Oth Program Service Rev TotalOthProgramServiceRevGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $80,717 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $80,717 | RelatedOrExemptFuncIncomeAmt |
| Unrelated Business Revenue | $0 | UnrelatedBusinessRevenueAmt |
| Exclusion | $0 | ExclusionAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Revenue | $27,672,786 | TotalProgramServiceRevenueAmt |
Investment Income InvestmentIncomeGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $92,338 | TotalRevenueColumnAmt |
| Exclusion | $92,338 | ExclusionAmt |
Gross Rents GrossRentsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | $52,815 | RealAmt |
Less Rental Expenses LessRentalExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | $20,507 | RealAmt |
Rental Income Or Loss RentalIncomeOrLossGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | $32,308 | RealAmt |
| Personal | $0 | PersonalAmt |
Net Rental Income Or Loss NetRentalIncomeOrLossGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $32,308 | TotalRevenueColumnAmt |
| Exclusion | $32,308 | ExclusionAmt |
Gain Or Loss GainOrLossGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Securities | $0 | SecuritiesAmt |
| Other | $0 | OtherAmt |
Other Revenue Misc OtherRevenueMiscGrp (3 entries)
| DescDesc | BusinessBusinessCd | Total Revenue ColumnTotalRevenueColumnAmt | ExclusionExclusionAmt |
|---|---|---|---|
| Nutrition Services | 621110 | $72,225 | $72,225 |
| Purchasing Card Rev | 621110 | $6,675 | $6,675 |
| Other Non-Operating | 900099 | $58 | $58 |
Miscellaneous Revenue MiscellaneousRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $163,199 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $0 | RelatedOrExemptFuncIncomeAmt |
| Unrelated Business Revenue | $0 | UnrelatedBusinessRevenueAmt |
| Exclusion | $163,199 | ExclusionAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Revenue Total | $242,157 | OtherRevenueTotalAmt |
Total Revenue TotalRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $29,115,863 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $27,672,786 | RelatedOrExemptFuncIncomeAmt |
| Unrelated Business Revenue | $0 | UnrelatedBusinessRevenueAmt |
| Exclusion | $366,803 | ExclusionAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part IX | Yes (X) | InfoInScheduleOPartIXInd |
Other Salaries And Wages OtherSalariesAndWagesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $8,178,255 | TotalAmt |
| Program Services | $6,082,006 | ProgramServicesAmt |
| Management And General | $2,096,249 | ManagementAndGeneralAmt |
Pension Plan Contributions PensionPlanContributionsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $358,962 | TotalAmt |
| Program Services | $266,953 | ProgramServicesAmt |
| Management And General | $92,009 | ManagementAndGeneralAmt |
Other Employee Benefits OtherEmployeeBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,734,904 | TotalAmt |
| Program Services | $1,290,214 | ProgramServicesAmt |
| Management And General | $444,690 | ManagementAndGeneralAmt |
Payroll Taxes PayrollTaxesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $425,730 | TotalAmt |
| Program Services | $316,607 | ProgramServicesAmt |
| Management And General | $109,123 | ManagementAndGeneralAmt |
Fees For Services Legal FeesForServicesLegalGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $18,447 | TotalAmt |
| Management And General | $18,447 | ManagementAndGeneralAmt |
Fees For Services Lobbying FeesForServicesLobbyingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $381 | TotalAmt |
| Management And General | $381 | ManagementAndGeneralAmt |
Fees For Services Other FeesForServicesOtherGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $3,940,413 | TotalAmt |
| Program Services | $3,691,339 | ProgramServicesAmt |
| Management And General | $249,074 | ManagementAndGeneralAmt |
| Fundraising | $0 | FundraisingAmt |
Office Expenses OfficeExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $2,000,696 | TotalAmt |
| Program Services | $1,933,524 | ProgramServicesAmt |
| Management And General | $67,172 | ManagementAndGeneralAmt |
Information Technology InformationTechnologyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $2,141 | TotalAmt |
| Program Services | $2,141 | ProgramServicesAmt |
Occupancy OccupancyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $500,611 | TotalAmt |
| Program Services | $450,028 | ProgramServicesAmt |
| Management And General | $50,583 | ManagementAndGeneralAmt |
Travel TravelGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $93,936 | TotalAmt |
| Program Services | $22,700 | ProgramServicesAmt |
| Management And General | $71,236 | ManagementAndGeneralAmt |
Depreciation Depletion DepreciationDepletionGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,378,442 | TotalAmt |
| Program Services | $1,193,831 | ProgramServicesAmt |
| Management And General | $184,611 | ManagementAndGeneralAmt |
Insurance InsuranceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $48,567 | TotalAmt |
| Management And General | $48,567 | ManagementAndGeneralAmt |
Other Expenses OtherExpensesGrp (4 entries)
| DescDesc | TotalTotalAmt | Program ServicesProgramServicesAmt | Management And GeneralManagementAndGeneralAmt |
|---|---|---|---|
| Purchase Services | $3,279,549 | $1,106,182 | $2,173,367 |
| Drugs | $619,205 | $619,205 | |
| Executive Salaries | $488,645 | $488,645 | |
| Dues | $24,971 | $3,678 | $21,293 |
All Other Expenses AllOtherExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $654,261 | TotalAmt |
| Program Services | $132,426 | ProgramServicesAmt |
| Management And General | $521,835 | ManagementAndGeneralAmt |
| Fundraising | $0 | FundraisingAmt |
Total Functional Expenses TotalFunctionalExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $23,748,116 | TotalAmt |
| Program Services | $17,110,834 | ProgramServicesAmt |
| Management And General | $6,637,282 | ManagementAndGeneralAmt |
| Fundraising | $0 | FundraisingAmt |
Cash Non Interest Bearing CashNonInterestBearingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $2,529 | BOYAmt |
| EOY | $2,358 | EOYAmt |
Savings And Temp Cash Invst SavingsAndTempCashInvstGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $13,311,365 | BOYAmt |
| EOY | $17,223,584 | EOYAmt |
Pledges And Grants Receivable PledgesAndGrantsReceivableGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $0 | BOYAmt |
| EOY | $0 | EOYAmt |
Accounts Receivable AccountsReceivableGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $3,503,948 | BOYAmt |
| EOY | $4,037,926 | EOYAmt |
Receivables From Officers Etc ReceivablesFromOfficersEtcGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| EOY | $0 | EOYAmt |
Rcvbl From Disqualified Prsn RcvblFromDisqualifiedPrsnGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| EOY | $0 | EOYAmt |
Oth Notes Loans Receivable Net OthNotesLoansReceivableNetGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $0 | BOYAmt |
| EOY | $0 | EOYAmt |
Inventories For Sale Or Use InventoriesForSaleOrUseGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $0 | BOYAmt |
| EOY | $130,797 | EOYAmt |
Prepaid Expenses Defrd Charges PrepaidExpensesDefrdChargesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $27,331 | BOYAmt |
| EOY | $39,571 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Land Bldg Equip Cost Or Other Bss | $21,934,482 | LandBldgEquipCostOrOtherBssAmt |
| Land Bldg Equip Accum Deprec | $2,958,160 | LandBldgEquipAccumDeprecAmt |
Land Bldg Equip Basis Net LandBldgEquipBasisNetGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $18,867,012 | BOYAmt |
| EOY | $18,976,322 | EOYAmt |
Investments Pub Traded Sec InvestmentsPubTradedSecGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,929,113 | BOYAmt |
| EOY | $1,932,893 | EOYAmt |
Investments Other Securities InvestmentsOtherSecuritiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $0 | BOYAmt |
Investments Program Related InvestmentsProgramRelatedGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $0 | BOYAmt |
Intangible Assets IntangibleAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $0 | BOYAmt |
| EOY | $0 | EOYAmt |
Other Assets Total OtherAssetsTotalGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $5,230,773 | BOYAmt |
| EOY | $5,170,659 | EOYAmt |
Total Assets TotalAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $42,872,071 | BOYAmt |
| EOY | $47,514,110 | EOYAmt |
Accounts Payable Accr Expnss AccountsPayableAccrExpnssGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $3,840,592 | BOYAmt |
| EOY | $1,474,188 | EOYAmt |
Grants Payable GrantsPayableGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $0 | BOYAmt |
Deferred Revenue DeferredRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $35,604 | BOYAmt |
| EOY | $67,635 | EOYAmt |
Tax Exempt Bond Liabilities TaxExemptBondLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $0 | BOYAmt |
| EOY | $0 | EOYAmt |
Escrow Account Liability EscrowAccountLiabilityGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $0 | BOYAmt |
| EOY | $0 | EOYAmt |
Mortg Notes Pybl Scrd Invst Prop MortgNotesPyblScrdInvstPropGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $0 | BOYAmt |
Unsecured Notes Loans Payable UnsecuredNotesLoansPayableGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $0 | BOYAmt |
Other Liabilities OtherLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,184,813 | BOYAmt |
| EOY | $2,956,165 | EOYAmt |
Total Liabilities TotalLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $5,061,009 | BOYAmt |
| EOY | $4,497,988 | EOYAmt |
Unrestricted Net Assets UnrestrictedNetAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $37,811,062 | BOYAmt |
| EOY | $43,016,122 | EOYAmt |
Temporarily Rstr Net Assets TemporarilyRstrNetAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $0 | BOYAmt |
| EOY | $0 | EOYAmt |
Permanently Rstr Net Assets PermanentlyRstrNetAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $0 | BOYAmt |
| EOY | $0 | EOYAmt |
Cap Stk Tr Prin Current Funds CapStkTrPrinCurrentFundsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $0 | BOYAmt |
| EOY | $0 | EOYAmt |
Pd In Cap Srpls Land Bldg Eqp Fund PdInCapSrplsLandBldgEqpFundGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $0 | BOYAmt |
| EOY | $0 | EOYAmt |
Rtn Earn Endowment Incm Oth Fnds RtnEarnEndowmentIncmOthFndsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $0 | BOYAmt |
| EOY | $0 | EOYAmt |
Total Net Assets Fund Balance TotalNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $37,811,062 | BOYAmt |
| EOY | $43,016,122 | EOYAmt |
Tot Liab Net Assets Fund Balance TotLiabNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $42,872,071 | BOYAmt |
| EOY | $47,514,110 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part XI | Yes (X) | InfoInScheduleOPartXIInd |
| Reconcilation Revenue Expnss | $5,367,747 | ReconcilationRevenueExpnssAmt |
| Net Unrlzd Gains Losses Invst | -$164,982 | NetUnrlzdGainsLossesInvstAmt |
| Other Changes In Net Assets | $2,295 | OtherChangesInNetAssetsAmt |
| Method Of Accounting Accrual | Yes (X) | MethodOfAccountingAccrualInd |
| Accountant Compile Or Review | false | AccountantCompileOrReviewInd |
| FS Audited | Yes (true) | FSAuditedInd |
FS Audited Basis FSAuditedBasisGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Consolidated Basis Fincl Stmt | Yes (X) | ConsolidatedBasisFinclStmtInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Audit Committee | Yes (true) | AuditCommitteeInd |
| Federal Grant Audit Required | Yes (true) | FederalGrantAuditRequiredInd |
| Federal Grant Audit Performed | Yes (true) | FederalGrantAuditPerformedInd |
Schedule A IRS990ScheduleA
| Field | Value | IRS element (for citing) |
|---|---|---|
| Hospital | Yes (X) | HospitalInd |
Schedule B IRS990ScheduleB
Contributor Information ContributorInformationGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Contributor | RESTRICTED | ContributorNum |
Contributor Business Name ContributorBusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | RESTRICTED | BusinessNameLine1 |
Contributor US Address ContributorUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | RESTRICTED | AddressLine1 |
| Address Line2 | RESTRICTED | AddressLine2 |
| City | RESTRICTED | City |
| State | RESTRICTED | State |
| ZIP Code | RESTRICTED | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Contributions | RESTRICTED | TotalContributionsAmt |
Schedule C IRS990ScheduleC
| Field | Value | IRS element (for citing) |
|---|---|---|
| Volunteers | false | VolunteersInd |
| Paid Staff Or Management | false | PaidStaffOrManagementInd |
| Media Advertisements | false | MediaAdvertisementsInd |
| Mailings Members | false | MailingsMembersInd |
| Publications Or Broadcast | false | PublicationsOrBroadcastInd |
| Grants Other Organizations | false | GrantsOtherOrganizationsInd |
| Direct Contact Legislators | false | DirectContactLegislatorsInd |
| Rallies Demonstrations | false | RalliesDemonstrationsInd |
| Other Activities | Yes (true) | OtherActivitiesInd |
| Other Activities | $381 | OtherActivitiesAmt |
| Total Lobbying Expenditures | $381 | TotalLobbyingExpendituresAmt |
| Not Described Section501c3 | false | NotDescribedSection501c3Ind |
Supplemental Information Detail SupplementalInformationDetail (2 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| Schedule C, Part II-B, Line 1 DETAILED DESCRIPTION OF THE LOBBYING ACTIVITY | Lobbying expenses represent the portion of dues paid to national and state hospital association that is specifically allocated to lobbying. Calumet Medical Center, Inc. Does not participate in or intervene in (including the publishing or distributing of statements) any political campaign on behalf of (or in opposition to) any candidate for public office. |
| Schedule C, Part II-B, Line 1 DETAILED DESCRIPTION OF THE LOBBYING ACTIVITY | Lobbying expenses represent the portion of dues paid to national and state hospital association that is specifically allocated to lobbying. Calumet Medical Center, Inc. Does not participate in or intervene in (including the publishing or distributing of statements) any political campaign on behalf of (or in opposition to) any candidate for public office. |
Schedule D IRS990ScheduleD
Land LandGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $3,200,000 | OtherCostOrOtherBasisAmt |
| Book Value | $3,200,000 | BookValueAmt |
Buildings BuildingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $13,739,216 | OtherCostOrOtherBasisAmt |
| Depreciation | $1,322,339 | DepreciationAmt |
| Book Value | $12,416,877 | BookValueAmt |
Leasehold Improvements LeaseholdImprovementsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $177,300 | OtherCostOrOtherBasisAmt |
| Depreciation | $50,516 | DepreciationAmt |
| Book Value | $126,784 | BookValueAmt |
Equipment EquipmentGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $4,017,128 | OtherCostOrOtherBasisAmt |
| Depreciation | $1,585,305 | DepreciationAmt |
| Book Value | $2,431,823 | BookValueAmt |
Other Land Buildings OtherLandBuildingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $800,838 | OtherCostOrOtherBasisAmt |
| Depreciation | $0 | DepreciationAmt |
| Book Value | $800,838 | BookValueAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Book Value Land Buildings | $18,976,322 | TotalBookValueLandBuildingsAmt |
Other Assets Org OtherAssetsOrgGrp (5 entries)
| DescDesc | Book ValueBookValueAmt |
|---|---|
| INTEREST IN INVESTMENTS HEALTH BY ASCENSION HEALTH ALLIANCE | $4,770,045 |
| UNEMPLOYMENT DEPOSIT | $169,348 |
| OTHER ACCOUNTS RECEIVABLE | $6,925 |
| DUE FROM RELATED ENTITIES | $185,841 |
| ESTIMATED DUE FROM 3RD PARTY PAYORS | $38,500 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Book Value Other Assets | $5,170,659 | TotalBookValueOtherAssetsAmt |
Other Liabilities Org OtherLiabilitiesOrgGrp (5 entries)
| DescDesc | AmtAmt |
|---|---|
| Accumulated Accretion | $318,867 |
| Retirement Obligation | $59,208 |
| Due to Third Party Payor | $860,116 |
| intercompany payables | $1,555,778 |
| other liabilities | $162,196 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Liability | $2,956,165 | TotalLiabilityAmt |
| Footnote Text | Yes (X) | FootnoteTextInd |
Supplemental Information Detail SupplementalInformationDetail
| Field | Value | IRS element (for citing) |
|---|---|---|
| Form And Line Reference | Schedule D, Part X, Line 2 FIN 48 (ASC 740) footnote | FormAndLineReferenceDesc |
| Explanation | THE SYSTEM ACCOUNTS FOR UNCERTAINTY IN INCOME TAX POSITIONS BY APPLYING A RECOGNITION THRESHOLD AND MEASUREMENT ATTRIBUTE FOR FINANCIAL STATEMENT RECOGNITION AND MEASUREMENT OF A TAX POSITION TAKEN OR EXPECTED TO BE TAKEN IN A TAX RETURN. THE SYSTEM HAS DETERMINED THAT NO MATERIAL UNRECOGNIZED TAX BENEFITS OR LIABILITIES EXIST AS OF JUNE 30, 2016. | ExplanationTxt |
Schedule H IRS990ScheduleH
| Field | Value | IRS element (for citing) |
|---|---|---|
| Financial Assistance Policy | Yes (true) | FinancialAssistancePolicyInd |
| Written Policy | Yes (true) | WrittenPolicyInd |
| All Hospitals Policy | Yes (X) | AllHospitalsPolicyInd |
| FPG Reference Free Care | Yes (true) | FPGReferenceFreeCareInd |
Free Care Oth Percentage FreeCareOthPercentageGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | Yes (X) | OtherInd |
| Free Care Other | 250 | FreeCareOtherPct |
| Field | Value | IRS element (for citing) |
|---|---|---|
| FPG Reference Discounted Care | Yes (true) | FPGReferenceDiscountedCareInd |
| Percent400 | Yes (X) | Percent400Ind |
| Free Care Medically Indigent | Yes (true) | FreeCareMedicallyIndigentInd |
| Financial Assistance Budget | Yes (true) | FinancialAssistanceBudgetInd |
| Expenses Exceed Budget | Yes (true) | ExpensesExceedBudgetInd |
| Unable To Provide Care | false | UnableToProvideCareInd |
| Annual Community Bnft Report | Yes (true) | AnnualCommunityBnftReportInd |
| Report Publically Available | Yes (true) | ReportPublicallyAvailableInd |
Financial Assistance At Cost Typ FinancialAssistanceAtCostTyp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $39,790 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $0 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $39,790 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.0017 | TotalExpensePct |
Unreimbursed Medicaid UnreimbursedMedicaidGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $685,214 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $0 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $685,214 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.0289 | TotalExpensePct |
Unreimbursed Costs UnreimbursedCostsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $0 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $0 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $0 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.0 | TotalExpensePct |
Total Financial Assistance Typ TotalFinancialAssistanceTyp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Activities Or Programs | 0 | ActivitiesOrProgramsCnt |
| Persons Served | 0 | PersonsServedCnt |
| Total Community Benefit Expns | $725,004 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $0 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $725,004 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.0305 | TotalExpensePct |
Community Health Services CommunityHealthServicesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Activities Or Programs | 13 | ActivitiesOrProgramsCnt |
| Persons Served | 946 | PersonsServedCnt |
| Total Community Benefit Expns | $90,292 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $0 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $90,292 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.0038 | TotalExpensePct |
Health Professions Education HealthProfessionsEducationGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Activities Or Programs | 4 | ActivitiesOrProgramsCnt |
| Persons Served | 0 | PersonsServedCnt |
| Total Community Benefit Expns | $17,327 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $0 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $17,327 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.0007 | TotalExpensePct |
Subsidized Health Services SubsidizedHealthServicesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Activities Or Programs | 0 | ActivitiesOrProgramsCnt |
| Persons Served | 0 | PersonsServedCnt |
| Total Community Benefit Expns | $0 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $0 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $0 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.0 | TotalExpensePct |
Research ResearchGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Activities Or Programs | 0 | ActivitiesOrProgramsCnt |
| Persons Served | 0 | PersonsServedCnt |
| Total Community Benefit Expns | $0 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $0 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $0 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.0 | TotalExpensePct |
Cash And In Kind Contributions CashAndInKindContributionsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Activities Or Programs | 5 | ActivitiesOrProgramsCnt |
| Persons Served | 0 | PersonsServedCnt |
| Total Community Benefit Expns | $20,597 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $0 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $20,597 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.0009 | TotalExpensePct |
Total Other Benefits TotalOtherBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Activities Or Programs | 22 | ActivitiesOrProgramsCnt |
| Persons Served | 946 | PersonsServedCnt |
| Total Community Benefit Expns | $128,216 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $0 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $128,216 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.0054 | TotalExpensePct |
Total Community Benefits TotalCommunityBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Activities Or Programs | 22 | ActivitiesOrProgramsCnt |
| Persons Served | 946 | PersonsServedCnt |
| Total Community Benefit Expns | $853,220 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $0 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $853,220 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.0359 | TotalExpensePct |
Physical Imprv And Housing PhysicalImprvAndHousingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Activities Or Programs | 0 | ActivitiesOrProgramsCnt |
| Persons Served | 0 | PersonsServedCnt |
| Total Community Benefit Expns | $0 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $0 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $0 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.0 | TotalExpensePct |
Economic Development EconomicDevelopmentGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Activities Or Programs | 0 | ActivitiesOrProgramsCnt |
| Persons Served | 0 | PersonsServedCnt |
| Total Community Benefit Expns | $0 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $0 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $0 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.0 | TotalExpensePct |
Community Support CommunitySupportGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Activities Or Programs | 0 | ActivitiesOrProgramsCnt |
| Persons Served | 0 | PersonsServedCnt |
| Total Community Benefit Expns | $0 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $0 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $0 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.0 | TotalExpensePct |
Environmental Improvements EnvironmentalImprovementsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Activities Or Programs | 0 | ActivitiesOrProgramsCnt |
| Persons Served | 0 | PersonsServedCnt |
| Total Community Benefit Expns | $0 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $0 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $0 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.0 | TotalExpensePct |
Leadership Development LeadershipDevelopmentGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Activities Or Programs | 0 | ActivitiesOrProgramsCnt |
| Persons Served | 0 | PersonsServedCnt |
| Total Community Benefit Expns | $0 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $0 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $0 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.0 | TotalExpensePct |
Coalition Building CoalitionBuildingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Activities Or Programs | 1 | ActivitiesOrProgramsCnt |
| Persons Served | 0 | PersonsServedCnt |
| Total Community Benefit Expns | $1,251 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $0 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $1,251 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.0001 | TotalExpensePct |
Health Improvement Advocacy HealthImprovementAdvocacyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Activities Or Programs | 1 | ActivitiesOrProgramsCnt |
| Persons Served | 150 | PersonsServedCnt |
| Total Community Benefit Expns | $21,952 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $0 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $21,952 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.0009 | TotalExpensePct |
Workforce Development WorkforceDevelopmentGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Activities Or Programs | 1 | ActivitiesOrProgramsCnt |
| Persons Served | 2 | PersonsServedCnt |
| Total Community Benefit Expns | $86 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $0 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $86 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.0000 | TotalExpensePct |
Other Communtity Building Acty OtherCommuntityBuildingActyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Activities Or Programs | 0 | ActivitiesOrProgramsCnt |
| Persons Served | 0 | PersonsServedCnt |
| Total Community Benefit Expns | $0 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $0 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $0 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.0 | TotalExpensePct |
Total Communtity Building Acty TotalCommuntityBuildingActyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Activities Or Programs | 3 | ActivitiesOrProgramsCnt |
| Persons Served | 152 | PersonsServedCnt |
| Total Community Benefit Expns | $23,289 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $0 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $23,289 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.0010 | TotalExpensePct |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bad Debt Expense Reported | false | BadDebtExpenseReportedInd |
| Bad Debt Expense | $600,677 | BadDebtExpenseAmt |
| Bad Debt Expense Attributable | $0 | BadDebtExpenseAttributableAmt |
| Reimbursed By Medicare | $14,079,276 | ReimbursedByMedicareAmt |
| Cost Of Care Reimbursed By Medcr | $12,451,637 | CostOfCareReimbursedByMedcrAmt |
| Medicare Surplus Or Shortfall | $1,627,639 | MedicareSurplusOrShortfallAmt |
Costing Methodology Used CostingMethodologyUsedGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Cost To Charge Ratio | Yes (X) | CostToChargeRatioInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Written Debt Collection Policy | Yes (true) | WrittenDebtCollectionPolicyInd |
| Financial Assistance Prvsn | Yes (true) | FinancialAssistancePrvsnInd |
| Hospital Facilities | 1 | HospitalFacilitiesCnt |
Hospital Facilities HospitalFacilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | 1 | FacilityNum |
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Calumet Medical Center Inc | BusinessNameLine1Txt |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 614 Memorial Drive | AddressLine1Txt |
| City | Chilton | CityNm |
| State Abbreviation | WI | StateAbbreviationCd |
| ZIP | 53014 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Website Address | www.affinityhealth.org | WebsiteAddressTxt |
| State License | 1020 | StateLicenseNum |
| Licensed Hospital | Yes (X) | LicensedHospitalInd |
| General Medical And Surgical | Yes (X) | GeneralMedicalAndSurgicalInd |
| Critical Access Hospital | Yes (X) | CriticalAccessHospitalInd |
| Emergency Room24 Hrs | Yes (X) | EmergencyRoom24HrsInd |
Hospital Fclty Policies Prctc HospitalFcltyPoliciesPrctcGrp
Hospital Facility Name HospitalFacilityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Calumet Medical Center Inc | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | 1 | FacilityNum |
| First Licensed CY Or PY | false | FirstLicensedCYOrPYInd |
| Tax Exempt Hospital CY Or PY | false | TaxExemptHospitalCYOrPYInd |
| CHNA Conducted | Yes (true) | CHNAConductedInd |
| Community Definition | Yes (X) | CommunityDefinitionInd |
| Community Demographics | Yes (X) | CommunityDemographicsInd |
| Existing Resources | Yes (X) | ExistingResourcesInd |
| How Data Obtained | Yes (X) | HowDataObtainedInd |
| Community Health Needs | Yes (X) | CommunityHealthNeedsInd |
| Other Health Issues | Yes (X) | OtherHealthIssuesInd |
| Community Hlth Needs Id Process | Yes (X) | CommunityHlthNeedsIdProcessInd |
| Consulting Process | Yes (X) | ConsultingProcessInd |
| Information Gaps | Yes (X) | InformationGapsInd |
| CHNA Conducted | 15 | CHNAConductedYr |
| Take Into Account Others Input | Yes (true) | TakeIntoAccountOthersInputInd |
| CHNA Conducted With Other Fclts | Yes (true) | CHNAConductedWithOtherFcltsInd |
| CHNA Conducted With Non Fclts | Yes (true) | CHNAConductedWithNonFcltsInd |
| CHNA Report Widely Available | Yes (true) | CHNAReportWidelyAvailableInd |
| Rpt Available On Own Website | Yes (X) | RptAvailableOnOwnWebsiteInd |
| Own Website URL | http://www.affinityhealth.org/Affinity/For-Patients-and-Visitors/Community-Benefit-and-Outreach.htm | OwnWebsiteURLTxt |
| Paper Copy Public Inspection | Yes (X) | PaperCopyPublicInspectionInd |
| Implementation Strategy Adopt | Yes (true) | ImplementationStrategyAdoptInd |
| Implementation Strategy Adpt | 15 | ImplementationStrategyAdptYr |
| Strategy Posted Website | Yes (true) | StrategyPostedWebsiteInd |
| Strategy Website URL | http://www.affinityhealth.org/Affinity/For-Patients-and-Visitors/Community-Benefit-and-Outreach.htm | StrategyWebsiteURLTxt |
| Strategy Attached | false | StrategyAttachedInd |
| Organization Incur Excise Tax | false | OrganizationIncurExciseTaxInd |
| Elig Criteria Explained | Yes (true) | EligCriteriaExplainedInd |
| FPG Family Incm Lmt Free Dscnt | Yes (X) | FPGFamilyIncmLmtFreeDscntInd |
| FPG Family Incm Lmt Free Care | 250.0 | FPGFamilyIncmLmtFreeCarePct |
| FPG Family Incm Lmt Dscnt Care | 400.0 | FPGFamilyIncmLmtDscntCarePct |
| Asset Level Criteria | Yes (X) | AssetLevelCriteriaInd |
| Medical Indigency Criteria | Yes (X) | MedicalIndigencyCriteriaInd |
| Insurance Status Criteria | Yes (X) | InsuranceStatusCriteriaInd |
| Underinsurance Stat Criteria | Yes (X) | UnderinsuranceStatCriteriaInd |
| Residency Criteria | Yes (X) | ResidencyCriteriaInd |
| Explained Basis | Yes (true) | ExplainedBasisInd |
| App Financial Asst Expln | Yes (true) | AppFinancialAsstExplnInd |
| Described Info | Yes (X) | DescribedInfoInd |
| Described Suprt Doc | Yes (X) | DescribedSuprtDocInd |
| Provided Hospital Contact | Yes (X) | ProvidedHospitalContactInd |
| Includes Publicity Measures | Yes (true) | IncludesPublicityMeasuresInd |
| FAP Available On Website | Yes (X) | FAPAvailableOnWebsiteInd |
| FAP Available On Website URL | http://ministryhealth.org/MinistryHealth/AboutUs/BillingandPayment/FinancialAssistance.nws | FAPAvailableOnWebsiteURLTxt |
| FAP App Available On Website | Yes (X) | FAPAppAvailableOnWebsiteInd |
| FAP App Available On Website URL | http://ministryhealth.org/MinistryHealth/AboutUs/BillingandPayment/FinancialAssistance.nws | FAPAppAvailableOnWebsiteURLTxt |
| FAP Summary On Website | Yes (X) | FAPSummaryOnWebsiteInd |
| FAP Summary On Website URL | http://ministryhealth.org/MinistryHealth/AboutUs/BillingandPayment/FinancialAssistance.nws | FAPSummaryOnWebsiteURLTxt |
| FAP Avlbl On Request No Charge | Yes (X) | FAPAvlblOnRequestNoChargeInd |
| FAP App Avlbl On Request No Chrg | Yes (X) | FAPAppAvlblOnRequestNoChrgInd |
| FAP Sum Avlbl On Request No Chrg | Yes (X) | FAPSumAvlblOnRequestNoChrgInd |
| FAP Notice Displayed | Yes (X) | FAPNoticeDisplayedInd |
| Communtity Notified FAP | Yes (X) | CommuntityNotifiedFAPInd |
| FAP Actions On Nonpayment | Yes (true) | FAPActionsOnNonpaymentInd |
| Permit No Actions | Yes (X) | PermitNoActionsInd |
| Collection Activities | false | CollectionActivitiesInd |
| FAP Notified Upon Admission | Yes (X) | FAPNotifiedUponAdmissionInd |
| FAP Notified Before Discharge | Yes (X) | FAPNotifiedBeforeDischargeInd |
| FAP Notified All Patients | Yes (X) | FAPNotifiedAllPatientsInd |
| Documented Elig Determination | Yes (X) | DocumentedEligDeterminationInd |
| Nondis Emergency Care Policy | Yes (true) | NondisEmergencyCarePolicyInd |
| Medicare Rates | Yes (X) | MedicareRatesInd |
| Amounts Generally Billed | false | AmountsGenerallyBilledInd |
| Gross Charges | false | GrossChargesInd |
Supplemental Information SupplementalInformationGrp (4 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| Schedule H, Part V, Section B, Line 5 Facility , 1 | Facility , 1 - calumet medical center, inc.. Calumet Medical Center's CHNA process included three specific efforts to seek input from community members, including members of medically underserved, low-income and minority populations and from organizations that serve those populations. First, a telephone survey of Calumet County residents was conducted in early calendar year 2015. The survey resulted in the Calumet County Behavioral Risk Factor Surveillance System (BRFSS) Study: 2015 Report, and included questions health practices and health-related risk behaviors. Second, in August and September 2015, key informant interviews were conducted with stakeholders in the community, including with leaders of organizations that serve the medically underserved, low-income and minority populations. Participants were asked about the most important health issues for the region as well as existing strategies, resources and barriers in addressing them. (See below for list of key informants' organizations.) Finally, in September and October 2015, a survey was distributed electronically to a variety of community partners and agencies that serve vulnerable populations, including the Women, Infants and Children (WIC) clinics, senior centers, food pantries, community clinics and others. The survey was available in Spanish for those organizations and agencies that serve Spanish-speaking individuals. The survey asked about the most important health issues for the region. Key informant interviews were conducted with representatives of the agencies listed below. These agencies serve Calumet County exclusively. * Calumet County Public Health Division *, **, *** * Wisconsin Public Service * Calumet Medical Center ** * Delta Publications * Calumet County * Healthiest Calumet County Steering Committee * Heritage Orchard * Calumet County Health and Human Services *, **, *** * The Boldt Company * St. Vincent de Paul * * Calumet County Veteran Services * Chilton Furniture, Inc. * School District of Chilton * Miller Manufacturing, Inc. * Bellin College of Nursing * Fox Valley Technical College * Calumet County Women, Infants, and Children (WIC) Program * * Moehn Grain Farms, LLC * Hilbert School District Key informant interviews were also conducted with representatives of the agencies listed below. These agencies serve the Fox Valley Region. (Note: Some agencies are listed multiple times, reflecting interviews with multiple representatives from that organization.) * University of Wisconsin- Oshkosh Head Start *, ** * Samaritan Counseling Center *, **, *** * YMCA of the Fox Cities *, **, *** * City of Appleton Health Department *, **, *** * University of Wisconsin-Oshkosh Head Start *, ** * N. E. W. Mental Health Connection *, **, *** * Heart of the Valley Chamber of Commerce * Wisconsin DNR; Menasha Health Department * Goodwill Industries of North Central WI *, **, *** * *Affinity Health System *, **, *** * Casa Hispana *, *** * Common Ground *, *** * ESTHER *, *** * University of Wisconsin- Oshkosh Head Start *, ** * J.J. Keller Foundation *, ** * ThedaCare Trauma * St. Therese Church *, *** * INCLUDE *, **, *** * Appleton Health Department *, **, *** * Hope Clinic/Alliance *, **, *** * United Way Fox Cities *, **, *** * Appleton Health Department * Catalpa Health *, **, *** * ThedaCare at Work; Well City Fox Cities * East Central Wisconsin Regional Planning Commission * Appleton Health Department ** ** Affinity Health System *, **, *** * Outagamie County * Appleton Health Department * ThedaCare * Children's Hospital of Wisconsin- Fox Valley *, **, *** * Homeless Connections * * Children's Hospital of Wisconsin- Fox Valley *, **, *** * Child Care Resource & Referral *, *** * Children's Hospital of Wisconsin- Fox Valley * City of Appleton Health Department * African Heritage, Inc. *** * Hispanic Chamber of Commerce of WI *, *** * Weight of the Fox Valley/ United Way * *Affinity Health System *, **, *** * *St. Elizabeth Hospital, Affinity Health System *, **, *** * Harbor House *, **, *** * Wisconsin Safe and Healthy Schools Center *, *** * Children's Hospital of Wisconsin- Fox Valley *, **, *** * Partnership Community Health Ctr. *, **, *** * Parent Connection of Family Services * City of Appleton Police * ThedaCare Trauma * U.S. Venture, Inc. * * Partnership Community Health Ctr. *, **, *** * ThedaCare *, **, *** * University of Wisconsin- Oshkosh Head Start *, ** * Big Brothers Big Sisters of the Fox Valley * * Evolve *, **, *** * Denotes that the organization and/or the key informant's position represents low-income populations ** Denotes that the organization and/or the key informant's position represents medically undeserved populations *** Denotes that the organization and/or the key informant's position represents minority populations * Affinity Health System is part of Ministry Health Care |
| Schedule H, Part V, Section B, Line 6a Facility , 1 | Facility , 1 - calumet medical center, inc.. THE CHNA WAS CONDUCTED WITH THE FOLLOWING HOSPITAL FACILITY(S): St. Elizabeth Hospital Mercy Medical Center Children's Hospital of Wisconsin -- Fox Valley Aurora Medical Center Oshkosh ThedaCare Regional Medical Center - Appleton (formerly Appleton Medical Center) ThedaCare Regional Medical Center - Neenah (formerly ThedaClark) |
| Schedule H, Part V, Section B, Line 6b Facility , 1 | Facility , 1 - calumet medical center, inc.. THE CHNA WAS CONDUCTED WITH THE FOLLOWING NON-HOSPITAL FACILITY(S): Calumet Public Health Department Outagamie County Public Health Department Winnebago County Public Health Department City of Appleton Public Health Department City of Menasha Public Health Department |
| Schedule H, Part V, Section B, Line 11 Facility , 1 | Facility , 1 - Calumet Medical Center, Inc.. Using the CHNA completed in June 2013, the hospital developed, adopted, and worked on executing a three-year Implementation Strategy to address priority community health needs. In Fiscal Year 2016 (Tax Year 2015), the hospital implemented the following plan to address the priority needs: 1. Mental Health: Decrease the rate of suicide in Calumet County and the Fox Valley. * Supported local Question, Persuade, Refer (QPR) suicide prevention training. * Contributed to the development of a mental health resource directory. * Actively participated in Zero Suicide Coalition. 2. Excessive Alcohol Consumption: Decrease the percentage of adults and adolescents who binge drink in Calumet County. * Worked to implement local social host policy changes. 3. Obesity: Reduce obesity rates in Calumet County. * Obtained local communities' endorsement of Weight of the Fox Valley's resolution that supports a variety of efforts to address obesity. * Continued work with area business to create healthier choices for catering and restaurant options. * Conducted Healthy Living Cooking event. * Expanded the number of plots in the Calumet Medical Center Community Garden. Using the CHNA completed in June 2016, the hospital developed and adopted FY17-FY19 (tax years 2016-2018) Implementation Strategy. The following summarizes the strategies the hospital will implement during that time period to address the priority needs. AODA * Parents Who Host Lose the Most - Parents Who Host, Lose the Most is a public awareness program educating communities and parents about the health and safety risks of serving alcohol at teen parties. The program encourages parents and the entire community to send a unified message that teen alcohol consumption is unhealthy, unsafe and unacceptable. * The Real Happy Hour - Research shows that family connectedness and parent-child bonding has positive effects including a reduction of substance abuse among adolescents, increased academic performance and more. The purpose of the Real Happy Hour is to increase family time and family connectedness across the tri-county area of the Fox Valley (Calumet, Outagamie and Winnebago). * Medication Disposal Drop Boxes - Calumet County has increased the number of drop box locations throughout the county to get unused or expired medications dropped off at a number of safe locations to avoid contamination of our water supply and the chance of an overdose/death if not disposed of properly. Along with a local coalition, CMC will distribute brochures and communication about the drop boxes. Mental Health * QPR - QPR stands for Question, Persuade, and Refer, a nationally recognized "best practice" method for suicide prevention and education. Trainings are organized for community members. * Test Your Mood Online Survey - This anonymous online mood survey allows respondents to choose from six different screening surveys (anxiety, PTSD, eating disorders, depression, alcohol use and bipolar disorder). The survey also provides respondents with a list of local resources they can access for further assistance. * Zero Suicide - The Zero Suicide Initiative is a commitment to suicide prevention in health and behavioral health care systems and includes a specific set of strategies and tools. The initiative uses a methodical approach to system-wide quality improvement to reduce the chances of suicidal individuals falling through the cracks in a healthcare system. Nutrition and Physical Activity * Community garden - Community members can obtain garden space to grow fresh fruits and vegetables. * Healthy Living Cooking - Healthy Living Cooking is an annual event that includes a cooking demonstration from local chefs, a sit-down dinner to taste the demonstrated meal and local food vendors. * Weight of the Fox Valley - Weight of the Fox Valley (WOTFV) is a three-county initiative with a shared vision of working together to achieve and maintain a healthy weight at every age. Using a collective impact model, WOTFV strives to support mutually reinforcing activities conducted by a variety of community-based organizations committed to obesity prevention. The description below includes the needs not being addressed as well as the reason why the needs are not being addressed. In addition to the three health issues selected as top priority, stakeholders identified several other significant health issues in Calumet County. These issues will be addressed by other organizations in the community. While these issues will not be addressed by CMC as priority health needs, we will provide support to those community efforts whenever possible. Chronic Disease Prevention: The stakeholders identified chronic diseases as an important health issue to be addressed in the community. Discussions with community leaders, public health organizations and CMC leaders, revealed that by tackling the nutrition and physical activity needs of the community, often seen as proxy for obesity prevention, chronic diseases would also be positively affected. Many stated that many of the chronic diseases that need attention such as, diabetes, hypertension, high cholesterol, etc. can be positively influenced by working on obesity prevention efforts. Healthy Growth and Development: Many stakeholders identified healthy growth and development, especially early childhood growth and development, as a health need. Many community members there saw a need to support the development of healthy, well-rounded individuals. At the same time, respondents stated there are many existing organizations and programs in the community that address these issues, including the Fox Valley Early Childhood Coalition, Parent Connection, Community Early Learning Center, Birth To 3 Program, The Boys and Girls Club, Head Start, as well as school-based and YMCA- based programs. Given the variety of existing efforts in the community, CMC will continue to support the public health departments and community organizations already in existence to address healthy growth and development issues whenever possible. |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | 0 | FacilityNum |
Supplemental Information Detail SupplementalInformationDetail (18 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| Schedule H, Part I, Line 3c Description of Income Based Criteria | It is the policy of the Organization to provide medically necessary health care services to people in the communities it serves, regardless of their ability to pay. Affinity Care Financial Assistance is granted based upon the patient's inability to pay and to individuals who are uninsured, underinsured or medically indigent. Affinity Care works in collaboration with other financial (both public and private) assistance programs. This is to ensure holistic wellness of patients by facilitating knowledge of available services and programs for health while practicing good stewardship of funds. Key criteria utilized to determine eligibility for Affinity Care Financial Assistance includes family size, federal poverty income guidelines and available assets. The available asset test includes consideration of the amount of equity in a home, automobiles, and savings accounts which are considered part of total allowable income when assessing against the federal poverty income guidelines. |
| Schedule H, Part I, Line 6a PREPARATION OF COMMUNITY BENEFIT REPORT | Calumet Medical Center, Inc. is included in the annual community benefit report which is published by Ministry Health Care, Inc. (EIN: 39-1490371) and available to the public on its website, www.ministryhealth.org. This report includes all of the related entities within the Ministry Health Care network of hospitals, clinics and other health-related organizations. |
| Schedule H, Part I, Line 7 Costing Methodology used to calculate financial assistance | Amounts calculated in part I, Line 7 are determined both on a cost accounting system and a cost-to-charge ratio. Other benefits are determined based on the direct and indirect costs (where allocated) associated with a program net of earned revenue. Detail for each program/activity is maintained and determined at the department level. Charity care and means-tested programs are determined based on a cost-to-charge ratio consistent with worksheet 2, ratio of patient care cost to charges. Prior year cost report settlements are excluded from the shortfall calculation in order to get a true fiscal year shortfall amount. |
| Schedule H, Part II Community Building Activities | Calumet Medical Center participates in several community coalitions and other collaborative efforts with the community whose purpose is to improve the health of the community. These include UCAN, Healthiest Calumet County Steering Committee, REACH, Weight of the Fox Valley Strategic Planning and Fox Valley Community Health Improvement Coalition. By working together with other organizations in the community , we expect to have a greater impact on health. According to the County Health Rankings site, with a shared vision and commitment to improved health, working together can yield better results than working alone. In addition, Calument Medical Center provides job shadowing experiences for area youth. According to the County Health Rankings, employment provides income and, often, benefits that can support healthy lifestyle choices. Unemployment and under employment limit these choices, and negatively affect both quality of life and health overall. |
| Schedule H, Part III, Line 2 Bad debt expense - methodology used to estimate amount | Accounts are written off to bad debt after all internal collection efforts have been exhausted. Attempts to resolve these outstanding balances can include, but are not limited to, statements being sent, phone calls and letters being sent. Account follow up protocol is based on personal pay balance size owed. |
| Schedule H, Part III, Line 3 Bad Debt Expense Methodology | Calumet Medical Center, Inc. has a very robust financial assistance program; therefore, no estimate is made for bad debt attributed to financial assistance eligible patients. |
| Schedule H, Part III, Line 4 Bad debt expense - financial statement footnote | From the consolidated audited financial statements of Ministry Health Care, Inc. (which includes the activity of Calumet Medical Center, Inc.): The provision for doubtful accounts is based upon management's assessment of expected net collections considering historical experience, economic conditions, trends in health care coverage, and other collection indicators. Periodically throughout the year, management assesses the adequacy of the allowance for doubtful accounts based upon historical write-off experience by payor category, including those amounts not covered by insurance. The results of this review are then used to make any modifications to the provision for doubtful accounts to establish an appropriate allowance for doubtful accounts. After satisfaction of amounts due from insurance and reasonable efforts to collect from the patient have been exhausted, the Health Ministry follows established guidelines for placing certain past-due patient balances with collection agencies, subject to the terms of certain restrictions on collection efforts as determined by Ascension Health. Accounts receivable are written off after collection efforts have been followed in accordance with the Health Ministry's policies. The methodology for determining the allowance for doubtful accounts and related write-offs on uninsured patient accounts has remained consistent with the prior year. |
| Schedule H, Part III, Line 8 Community benefit & methodology for determining medicare costs | Ascension Health and related health ministries follow the Catholic Health Association ("CHA") guidelines for determining community benefit. CHA community benefit reporting guidelines suggest that Medicare shortfall is not treated as community benefit. |
| Schedule H, Part III, Line 9b Collection practices for patients eligible for financial assistance | Calumet Medical Center, Inc. has a debt collection policy which sets forth collection practices for patients who are known to qualify or may qualify for financial assistance under the charity care program. Sufficient financial counseling support is made available to patients so they can easily access patient financial service representatives and have their questions answered, and gain an understanding of the reasons why they owe a balance. Accounts are designated as charity care in the business offices so no additional time is spent on collection efforts. |
| Schedule H, Part V, Section B, Line 16a FAP website | - Calumet Medical Center, Inc.: Line 16a URL: http://ministryhealth.org/MinistryHealth/AboutUs/BillingandPayment/FinancialAssistance.nws; |
| Schedule H, Part V, Section B, Line 16b FAP Application website | - Calumet Medical Center, Inc.: Line 16b URL: http://ministryhealth.org/MinistryHealth/AboutUs/BillingandPayment/FinancialAssistance.nws; |
| Schedule H, Part V, Section B, Line 16c FAP plain language summary website | - Calumet Medical Center, Inc.: Line 16c URL: http://ministryhealth.org/MinistryHealth/AboutUs/BillingandPayment/FinancialAssistance.nws; |
| Schedule H, Part VI, Line 2 Needs assessment | Calumet Medical Center, Inc. performs community needs assessments as needed. When a need is identified, the Hospital develops a plan to implement a program either through community collaboration or individually. Outcomes from the programs are measured and considered in subsequent community needs assessments. Community benefit plans are presented to senior leadership and board members to ensure the findings are incorporated into the Organization's strategy and policy development. For example, senior leaders are required to provide direct service hours to the poor as part of their performance goals. |
| Schedule H, Part VI, Line 3 Patient education of eligibility for assistance | Calumet Medical Center, Inc. goes to great lengths in order to inform and educate patients/persons who may be billed for patient care about their eligibility for assistance under federal, state or local government programs and under the Organization's financial assistance policy. The financial assistance policy and application is posted on the organization's website. Admissions and other key areas contain summary information of the financial assistance policy. As part of the intake/discharge process, patients are provided with a copy of the brochure and other information for financial assistance. If during the course of the patient registration process, care encounter, treatment, or upon discharge it becomes evident that a patient may need financial assistance; the patient shall be referred to Calumet Medical Center, Inc.'s financial assistance program. Patients may be identified as needing financial assistance at any time during the course of an encounter. A referral for consideration of financial assistance can be initiated by any member of the Hospital's workforce, including medical staff members, who become aware of the patients potential need for financial assistance. The financial assistance policy was also translated into dialects prevalent in the community in order to reach out to those that may speak another language (Spanish and Hmong). Patient registration staff and financial counselors are provided with scripts to follow when interacting with patients. As part of the financial assistance process, patients must register with the county public assistance to see if they may qualify under any other federal or state programs. |
| Schedule H, Part VI, Line 4 Community information | While there is growing agreement in the United States about what constitutes a non-profit hospital's "Community Benefit" this is a work in progress. The Organization provided significant charity care and other community benefits as defined by the IRS. But in addition, we believe that we provide a critically important community benefit, which is not quantified. Calumet Medical Center, Inc., like most community hospitals, was created and is maintained in order to provide care locally - care that without our hospital, may not be available locally. Certain specialized services available include: I/P rehabilitation services, I/P sub-acute (snf) services. The Town of Chilton is located in Calumet County. According to the 2010 census, there were 3,933 people living in Chilton, consisting of 1,687 households and 1,027 families. The population density of Chilton was 990.7 people per square mile. The population consisted of 95.8% White, 1.1% Hispanic, 0.2% African American, 0.4% Native American, 0.5% Asian, and 2% Other. Of the 1,687 households in Chilton, 29.4% of those had children under the age of 18, living at home. The 1,687 households are categorized as 48.0% married couples living together, 4.7% had a male head of household with no wife present, 8.2% had a female head of household with no husband present, and 39.1% were non-families. 34.7% of the households consisted of individuals and 16.7% had someone 65 and older living alone. The age population is widely spread. 24% were under 18, 6.3% were 19-24, 26.3% were 25-44, 25.9% were 45-64, and 17.5% were 65+. The median income for a household was $51,106 and the median income for a family was $63,038. The per capita income for the city was $24,842. The largest industry in Chilton is manufacturing (32.4%). Educational, health and social services (20.3%) and retail trade (10.6%) are the next largest industries in Chilton. Roughly 11.4% of families and 14.5% of the population were below the poverty line. That includes 25.9% of those under 18 years old and 4.9% of those 65 and older. The unadjusted seasonal unemployment rate for Calumet County was 3.7%, compared to a state unemployment rate of 5.1% and a national unemployment rate of 7.9%. |
| Schedule H, Part VI, Line 5 Promotion of community health | Calumet Medical Center, Inc.'s governing board consists primarily of persons who reside within the primary service area who are not employees of the organization. The Organization strives to further its exempt purposes by the following: - Calumet Medical Center, Inc. participates in government-sponsored health programs (Medicare, Medicaid, Champus, general relief, and specialized county programs). - Calumet Medical Center, Inc. donates food to area shelters. They also donate medical supplies and medications to clinics in third world countries. Calumet Medical Center, Inc. donated funds to support area organizations that provide services to the following sectors of our population: low-income, homeless, physically and mentally challenged and chronically ill. - Calumet Medical Center, Inc. operates the only paramedic-level ambulance service in Calumet County. This service operates at a loss and is subsidized by the Hospital. - Calumet Medical Center, Inc. provides community health improvement services through health education lectures, health fairs and support groups. - Calumet Medical Center, Inc. conducts cardiac rehabilitation and diabetic education sessions. This service is provided at a cost to the patient that is far below the cost to offer the service. - Discounted care is provided to low income families up to 662% of federal poverty guidelines. - Calumet Medical Center, Inc. serves as a sponsor site for clinical training of college students in various health care programs. - Calumet Medical Center, Inc. offers athletic training services to local high schools that would otherwise not have this service available to their students. The service is offered at a cost to the schools that is far below the cost to offer the service. |
| Schedule H, Part VI, Line 6 Affiliated health care system | Ministry Health Care, Inc. (Ministry or the Health Ministry) is a member of Ascension Health. In December 2011, Ascension Health Alliance, doing business as Ascension, became the sole corporate member and parent organization of Ascension Health, a Catholic national health system consisting primarily of nonprofit corporations that own and operate local health care facilities, or Health Ministries, located in 23 states and the District of Columbia. In addition to serving as the sole corporate member of Ascension Health, Ascension serves as the member or shareholder of various other subsidiaries. Ascension, its subsidiaries, and the Health Ministries are referred to collectively from time to time hereafter as the System. Ascension is sponsored by Ascension Sponsor, a Public Juridic Person. The Participating Entities of Ascension Sponsor are the Daughters of Charity of St. Vincent de Paul, St. Louise Province, the Congregation of St. Joseph, the Congregation of the Sisters of St. Joseph of Carondelet, the Congregation of Alexian Brothers of the Immaculate Conception Province, Inc. - American Province, and the Sisters of the Sorrowful Mother of the Third Order of St. Francis of Assisi - US/Caribbean Province. The Health Ministry is a Wisconsin non-stock, tax-exempt corporation that manages, promotes, and supports health care and related ministries in Wisconsin and Minnesota. The Health Ministry provides inpatient, outpatient, and emergency care services for the residents of Wisconsin and Minnesota. Admitting physicians are primarily practitioners in the local area. The Health Ministry is related to Ascension Health's other sponsored organizations through common control. Substantially all expenses of the Health Ministry are related to providing health care services. Effective November 1, 2014, the Health Ministry sold 50% of its ownership in Network Health, Inc. to an unrelated health system (see Note 3). On February 1, 2015, the Health Ministry transferred its ownership in Ministry Home Care, Inc. to Ascension Health. The consolidated financial statements include the following affiliates located primarily in Wisconsin, in which Ministry has a controlling interest and/or is the sole sponsor. Affinity Health System, Inc. (Affinity) Calumet Medical Center, Inc. (CMC) Affinity Medical Group (AMG) Twin Med, LLC Mercy Medical Center, Inc. Mercy Health Foundation St. Elizabeth Hospital Catalpa Health St. Elizabeth Foundation Agape Community Center of Milwaukee, Inc. Door County Memorial Hospital (Door County) Good Samaritan Health Center of Merrill Good Samaritan Health Center Foundation Howard Young Health Care, Inc. (Howard Young) Dr. Kate Newcomb Convalescent Center Howard Young Medical Center, Inc. Dr. Howard Young Foundation Eagle River Memorial Hospital, Inc. Ministry Medical Group, Inc. Our Lady of Victory Hospital Sacred Heart Hospital-St. Mary's Hospital, Inc. St. Clare's Hospital of Weston, Inc. Foundation of St. Clare's Hospital of Weston, Inc. St. Elizabeth's Hospital of Wabasha, Inc. St. Joseph's Hospital of Marshfield, Inc. Foundation of St. Joseph's Hospital of Marshfield, Inc. St. Michael's Hospital of Stevens Point, Inc. St. Michael's Foundation of Stevens Point, Inc. Mission The System directs its governance and management activities toward strong, vibrant, Catholic Health Ministries united in service and healing and dedicates its resources to spiritually centered care that sustains and improves the health of the individuals and communities it serves. In accordance with the System's mission of service to those persons living in poverty and to other vulnerable persons, each Health Ministry accepts patients regardless of their ability to pay. The System uses four categories to identify the resources utilized for the care of persons living in poverty and for community benefit programs: - Traditional charity care includes the cost of services provided to persons who cannot afford health care because of inadequate resources and/or who are uninsured or underinsured. - Unpaid cost of public programs, excluding Medicare, represents the unpaid cost of services provided to persons covered by public programs for persons living in poverty and for other vulnerable persons. - Cost of other programs for persons living in poverty and for other vulnerable persons includes unreimbursed costs of programs intentionally designed to serve the persons living in poverty and the other vulnerable persons of the community, including substance abusers, the homeless, victims of child abuse, and persons with acquired immune deficiency syndrome. - Community benefit consists of the unreimbursed costs of community benefit programs and services for the general community, not solely for the persons living in poverty, including health promotion and education, health clinics and screenings, and medical research. Discounts are provided to all uninsured patients, including those with the means to pay. Discounts provided to those patients who did not qualify for assistance under charity care guidelines are not included in the cost of providing care to persons living in poverty or in the cost of other community benefit programs. The cost of providing care to persons living in poverty and of other community benefit programs is estimated using internal cost data and is estimated by reducing charges forgone by a factor derived from the ratio of total operating expenses to billed charges for patient care. The amount of traditional charity care provided, determined on the basis of cost, was approximately $495,863 and $500,067 for the years ended June 30, 2016 and 2015, respectively. The amount of unpaid cost of public programs, cost of other programs for persons living in poverty and for other vulnerable persons, and cost of community benefit programs are reported in the accompanying supplementary information. |
| Schedule H, Part VI, Line 7 State filing of community benefit report | WI |
Schedule J IRS990ScheduleJ
| Field | Value | IRS element (for citing) |
|---|---|---|
| Severance Payment | Yes (true) | SeverancePaymentInd |
| Supplemental Nonqual Rtr Plan | Yes (true) | SupplementalNonqualRtrPlanInd |
| Equity Based Comp Arrngm | false | EquityBasedCompArrngmInd |
| Comp Based On Revenue Of Flng Org | false | CompBasedOnRevenueOfFlngOrgInd |
| Comp Bsd On Rev Related Orgs | false | CompBsdOnRevRelatedOrgsInd |
| Comp Bsd Net Earns Flng Org | false | CompBsdNetEarnsFlngOrgInd |
| Comp Bsd Net Earns Rltd Orgs | false | CompBsdNetEarnsRltdOrgsInd |
| Any Non Fixed Payments | false | AnyNonFixedPaymentsInd |
| Initial Contract Exception | false | InitialContractExceptionInd |
Rltd Org Officer Trst Key Empl RltdOrgOfficerTrstKeyEmplGrp (12 entries)
| TitleTitleTxt | Base Compensation Filing OrgBaseCompensationFilingOrgAmt | Compensation Based On Rltd OrgsCompensationBasedOnRltdOrgsAmt | Bonus Filing OrganizationBonusFilingOrganizationAmount | Bonus Related OrganizationsBonusRelatedOrganizationsAmt | Other Compensation Filing OrgOtherCompensationFilingOrgAmt | Other Compensation Rltd OrgsOtherCompensationRltdOrgsAmt | Deferred Compensation Flng OrgDeferredCompensationFlngOrgAmt | Deferred Comp Rltd OrgsDeferredCompRltdOrgsAmt | Nontaxable Benefits Filing OrgNontaxableBenefitsFilingOrgAmt | Nontaxable Benefits Rltd OrgsNontaxableBenefitsRltdOrgsAmt | Total Compensation Filing OrgTotalCompensationFilingOrgAmt | Total Compensation Rltd OrgsTotalCompensationRltdOrgsAmt | Comp Report Prior990 Filing OrgCompReportPrior990FilingOrgAmt | Comp Report Prior990 Rltd OrgsCompReportPrior990RltdOrgsAmt |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| TIMOTHY RICHMAN | ||||||||||||||
| PRESIDENT/CEO - CMC | $0 | $189,115 | $0 | $64,344 | $0 | $9,275 | $0 | $9,034 | $0 | $23,538 | $0 | $295,306 | $0 | $0 |
| MONICA ANN HILT | ||||||||||||||
| VICE CHAIRMAN (END 12/2015) | $0 | $457,522 | $0 | $238,701 | $0 | $13,465 | $0 | $33,355 | $0 | $30,794 | $0 | $773,837 | $0 | $0 |
| MARK W FAUSTICH MD | ||||||||||||||
| BOARD MEMBER (START 1/2016) | $0 | $412,928 | $0 | $21,608 | $0 | $3,495 | $0 | $17,225 | $0 | $4,566 | $0 | $459,822 | $0 | $0 |
| PETER JANU MD | ||||||||||||||
| BOARD MEMBER (END 12/2015) | $0 | $550,436 | $0 | $0 | $0 | $1,724 | $0 | $17,225 | $0 | $28,765 | $0 | $598,150 | $0 | $0 |
| MARK KEHRBERG MD | ||||||||||||||
| BOARD MEMBER | $0 | $219,105 | $0 | $129,827 | $0 | $6,684 | $0 | $15,923 | $0 | $14,391 | $0 | $385,930 | $0 | $0 |
| SUDEEP SODHI MD | ||||||||||||||
| BOARD MEMBER (START 1/2016) | $0 | $878,922 | $0 | $0 | $0 | $3,327 | $0 | $17,225 | $0 | $30,312 | $0 | $929,786 | $0 | $0 |
| GENE TIPLER MD | ||||||||||||||
| BOARD MEMBER (END 12/2015) | $0 | $234,733 | $0 | $2,578 | $0 | $2,546 | $0 | $13,801 | $0 | $29,515 | $0 | $283,173 | $0 | $0 |
| WENDY SCHROEDER MD | ||||||||||||||
| BOARD MEMBER (START 1/2016) | $0 | $257,093 | $0 | $50 | $0 | $1,003 | $0 | $13,623 | $0 | $34,443 | $0 | $306,212 | $0 | $0 |
| NICHOLAS DESIEN | ||||||||||||||
| MINISTRY HEALTH CARE CEO (END 12/31/15) | $0 | $1,298,254 | $0 | $1,454,145 | $0 | $47,338 | $0 | $242,978 | $0 | $28,808 | $0 | $3,071,523 | $0 | $0 |
| JEFFREY FRANCIS | ||||||||||||||
| MINISTRY HEALTH CARE CAFO (END 9/9/15) | $0 | $382,625 | $0 | $40,711 | $0 | $229,342 | $0 | $27,845 | $0 | $23,540 | $0 | $704,063 | $0 | $0 |
| DANIEL NEUFELDER | ||||||||||||||
| SVP, HOSPITAL OPERATIONS & PRESIDENT | $0 | $1,009,083 | $0 | $1,146,884 | $0 | $15,893 | $0 | $162,663 | $0 | $27,505 | $0 | $2,362,028 | $0 | $0 |
| JENNIFER LEIGH MEDIN WEBER | ||||||||||||||
| MANAGER INPATIENT SRVCS | $136,473 | $0 | $0 | $0 | $846 | $0 | $5,017 | $0 | $26,576 | $0 | $168,912 | $0 | $0 | $0 |
Supplemental Information Detail SupplementalInformationDetail (3 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| Schedule J, Part I, Line 3 EXPLANATION | MINISTRY HEALTH CARE, INC., A RELATED ORGANIZATION OF CALUMET MEDICAL CENTER, INC., USES THE FOLLOWING TO ESTABLISH THE COMPENSATION OF THE ORGANIZATION'S CEO: - COMPENSATION COMMITTEE - INDEPENDENT COMPENSATION CONSULTANT - COMPENSATION SURVEY OR STUDY, AND - APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE |
| Schedule J, Part I, Line 4a Severance or change-of-control payment | The following individual(s) received severance payments from the organization or a related organization: Jeffrey Francis $225,000 |
| Schedule J, Part I, Line 4b Supplemental nonqualified retirement plan | Eligible executives participate in a program that provides for supplemental retirement benefits. The payment of benefits under the program, if any, is entirely dependent upon the facts and circumstances under which the executive terminates employment with the organization. Benefits under the program are unfunded and non-vested. Due to the substantial risk of forfeiture provision, there is no guarantee that these executives will ever receive any benefit under the program. Any amount ultimately paid under the program to the executive is reported as compensation on Form 990, Schedule J, Part II, Column B in the year paid. |
Schedule O IRS990ScheduleO
Supplemental Information Detail SupplementalInformationDetail (12 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| Form 990, Part VI, Line 15 COMPENSATION OF OFFICERS | IN DETERMINING COMPENSATION OF THE ORGANIZATION'S CEO, THE PROCESS, PERFORMED BY MINISTRY HEALTH CARE, INC., A RELATED ORGANIZATION OF CALUMET MEDICAL CENTER, INC., INCLUDED A REVIEW AND APPROVAL BY INDEPENDENT PERSONS, COMPARABILITY DATA, AND CONTEMPORANEOUS SUBSTANTIATION OF THE DELIBERATION AND DECISION. THE COMPENSATION COMMITTEE REVIEWED AND APPROVED THE COMPENSATION. IN THE REVIEW OF THE COMPENSATION, THE CEO WAS COMPARED TO INDIVIDUALS AT OTHER ORGANIZATIONS IN THE AREA WHO HOLD THE SAME TITLE. DURING THE REVIEW AND APPROVAL OF THE COMPENSATION, DOCUMENTATION OF THE DECISION WAS RECORDED IN THE BOARD MINUTES. THE INDIVIDUAL WAS NOT PRESENT WHEN HIS COMPENSATION WAS DETERMINED. IN DETERMINING COMPENSATION OF OTHER OFFICERS AND KEY EMPLOYEES OF THE ORGANIZATION, THE PROCESS, PERFORMED BY MINISTRY HEALTH CARE, INC., A RELATED ORGANIZATION OF CALUMET MEDICAL CENTER, INC., INCLUDED A REVIEW AND APPROVAL BY INDEPENDENT PERSONS, COMPARABILITY DATA, AND CONTEMPORANEOUS SUBSTANTIATION OF THE DELIBERATION AND DECISION. THE COMPENSATION COMMITTEE REVIEWED AND APPROVED THE COMPENSATION. IN THE REVIEW OF THE COMPENSATION, THE OTHER OFFICERS AND KEY EMPLOYEES OF THE ORGANIZATION WERE COMPARED TO INDIVIDUALS AT OTHER ORGANIZATIONS IN THE AREA WHO HOLD THE SAME TITLE. DURING THE REVIEW AND APPROVAL OF THE COMPENSATION, DOCUMENTATION OF THE DECISION WAS RECORDED IN THE BOARD MINUTES. |
| Form 990, Part VI, Line 6 Classes of members or stockholders | Calumet Medical Center, Inc. has two corporate members, Affinity Health System and Calumet Area Community Health Foundation, Inc. |
| Form 990, Part VI, Line 7a Members or stockholders electing members of governing body | One of Calumet Medical Center, Inc.'s members, Affinity Health System, has the ability to elect members to the governing board of Calumet Medical Center, Inc. |
| Form 990, Part VI, Line 7b Decisions requiring approval by members or stockholders | Affinity Health System and Calumet Area Community Health Foundation, Inc. have the authority to approve any changes to the Articles of Incorporation, and all modifications to the purposes, Board of Directors and member provisions of the Bylaws of Calumet Medical Center, Inc., as well as to approve the dissolution, consolidation or merger of Calumet Medical Center, Inc. All decisions that have a material impact to Calumet Medical Center, Inc's financial information or corporation as a whole are subject to approval by Affinity Health System, the managing member of Calumet Medical Center, Inc. |
| Form 990, Part VI, Line 11b Review of form 990 by governing body | Management, including certain officers, works diligently to complete the Form 990 and attached schedules in a thorough manner. Prior to filing the return, all Board Members are provided the Form 990 and management team members are available to answer any Board Members' questions. |
| Form 990, Part VI, Line 12c Conflict of interest policy | The organization regularly and consistently monitors and enforces compliance with the Conflict of Interest Policy in that any director, principal officer, or member of a committee with governing board delegated powers, who has a direct or indirect financial interest, must disclose the existence of the financial interest and be given the opportunity to disclose all material facts to the directors and members of the committees with governing board delegated powers considering the proposed transaction or arrangement. The remaining individuals on the governing board or committee meeting will decide if conflicts of interest exist. Each director, principal officer and member of a committee with governing board delegated powers annually signs a statement which affirms such person has received a copy of the Conflict of Interest Policy, has read and understands the policy, has agreed to comply with the policy, and understands that the organization is charitable and in order to maintain its federal tax exemption it must engage primarily in activities which accomplish its tax-exempt purpose. |
| Form 990, Part VI, Line 19 Required documents available to the public | The Ministry web page is available to the public for inspection with a good deal of information regarding who Ministry Health Care is and the entities included along with our mission. The Articles of Incorporation, Bylaws, Conflict of Interest Policy and financial statements are not included on any web page. However, if any inquiry is made for any documents they are shared as appropriate. |
| Form 990, Part VIII, Line 2f Other Program Service Revenue | OTHER REV - Total Revenue: 80717, Related or Exempt Function Revenue: 80717, Unrelated Business Revenue: , Revenue Excluded from Tax Under Sections 512, 513, or 514: ; |
| Form 990, Part VIII, Line 11d Other Miscellaneous Revenue | EHR Meaningful Use - Total Revenue: -1358, Related or Exempt Function Revenue: , Unrelated Business Revenue: , Revenue Excluded from Tax Under Sections 512, 513, or 514: -1358; All Other Revenue - Total Revenue: 164557, Related or Exempt Function Revenue: , Unrelated Business Revenue: , Revenue Excluded from Tax Under Sections 512, 513, or 514: 164557; |
| Form 990, Part IX, Line 11g Other Fees | Physician Medical Services - Total Expense: 3275537, Program Service Expense: 3275537, Management and General Expenses: , Fundraising Expenses: ; Non Physician Medical Services - Total Expense: 65403, Program Service Expense: 4903, Management and General Expenses: 60500, Fundraising Expenses: ; Non-Med Professional Fees - Total Expense: 599473, Program Service Expense: 410899, Management and General Expenses: 188574, Fundraising Expenses: ; |
| Form 990, Part XI, Line 9 Other changes in net assets or fund balances | Transfers with Affiliates - 2295; |
| Form 990, Part VII, Section B Compensation paid to Boldt Company | Payments made to Boldt Company constitute payments for both materials and services. These amounts cannot be separated. |
Schedule R IRS990ScheduleR
Id Related Tax Exempt Org IdRelatedTaxExemptOrgGrp (29 entries)
| Address Line1USAddress/AddressLine1Txt | CityUSAddress/CityNm | State AbbreviationUSAddress/StateAbbreviationCd | ZIPUSAddress/ZIPCd | EINEIN | Primary ActivitiesPrimaryActivitiesTxt | Legal Domicile StateLegalDomicileStateCd | Exempt Code SectionExemptCodeSectionTxt | Public Charity StatusPublicCharityStatusTxt | Business Name Line1DirectControllingEntityName/BusinessNameLine1Txt | Controlled OrganizationControlledOrganizationInd |
|---|---|---|---|---|---|---|---|---|---|---|
| ASCENSION HEALTH ALLIANCE | ||||||||||
| PO BOX 45998 | ST LOUIS | MO | 63145 | 453358926 | NATIONAL HEALTH SYSTEM | MO | 501(c)(3 | Type I | NA | false |
| ASCENSION HEALTH | ||||||||||
| PO BOX 45998 | ST LOUIS | MO | 63145 | 311662309 | NATIONAL HEALTH SYSTEM | MO | 501(c)(3 | Type I | ASCENSION HEALTH ALLIANCE | false |
| AFFINITY HEALTH SYSTEM | ||||||||||
| 1570 MIDWAY PLACE | MENASHA | WI | 54952 | 391568866 | SUPPORT RELATED HEALTHCARE ORGANIZATIONS | IL | 501(c)(3 | Type I | MINISTRY HEALTH CARE INC | false |
| AGAPE COMMUNITY CENTER OF MILWAUKEE INC | ||||||||||
| 6100 NORTH 42ND STREET | MILWAUKEE | WI | 53209 | 391461846 | COMMUNITY CENTER | WI | 501(c)(3 | 7 | MINISTRY HEALTH CARE INC | false |
| CATALPA HEALTH INC | ||||||||||
| N4642 COUNTY N | APPLETON | WI | 54914 | 454681563 | MENTAL HEALTH FACILITY | WI | 501(c)(3 | 3 | ST ELIZABETH HOSPITAL INC | false |
| SAINT MICHAEL'S FOUNDATION OF STEVENS POINT INC | ||||||||||
| 900 ILLINOIS AVENUE | STEVENS POINT | WI | 54481 | 391657410 | CHARITABLE FOUNDATION | WI | 501(c)(3 | SAINT MICHAEL'S HOSPITAL OF STEVENS POINT | false | |
| DOOR COUNTY MEMORIAL HOSPITAL | ||||||||||
| 323 SOUTH 18TH AVENUE | STURGEON BAY | WI | 54235 | 390806324 | HOSPITAL | WI | 501(c)(3 | 3 | MINISTRY HEALTH CAREINC | false |
| DR KATE NEWCOMB CONVALESCENT CENTER INC | ||||||||||
| PO BOX 829 | WOODRUFF | WI | 54568 | 391357365 | NURSING/ASSISTED LIVING SERVICES | WI | 501(c)(3 | 9 | HOWARD YOUNG HEALTH CARE INC | false |
| EAGLE RIVER MEMORIAL HOSPITAL INCORPORATED | ||||||||||
| 201 HOSPITAL ROAD | EAGLE RIVER | WI | 54521 | 390985690 | HOSPITAL | WI | 501(c)(3 | 3 | THE HOWARD YOUNG MEDICAL CENTER INC | false |
| FOUNDATION OF SAINT CLARE'S HOSPITAL OF WESTON INC | ||||||||||
| 3400 MINISTRY PARKWAY | WESTON | WI | 54476 | 753193633 | CHARITABLE FOUNDATION | WI | 501(c)(3 | MINISTRY HEALTH CARE INC | false | |
| FOUNDATION OF SAINT JOSEPH'S HOSPITAL OF MARSHFIELD | ||||||||||
| 611 SAINT JOSEPH AVENUE | MARSHFIELD | WI | 54449 | 391684957 | CHARITABLE FOUNDATION | WI | 501(c)(3 | SAINT JOSEPH'S HOSPITAL OF MARSHFIELD INC | false | |
| GOOD SAMARITAN HEALTH CENTER OF MERRILL WISCONSIN INC | ||||||||||
| 601 SOUTH CENTER AVENUE | MERRILL | WI | 54452 | 390808503 | HOSPITAL | WI | 501(c)(3 | 3 | MINISTRY HEALTH CARE INC | false |
| GOOD SAMARITAN HEALTH CENTER FOUNDATION OF MERRILL WISCONSIN INC | ||||||||||
| 601 SOUTH CENTER AVENUE | MERRILL | WI | 54452 | 391627755 | CHARITABLE FOUNDATION | WI | 501(c)(3 | GOOD SAMARITAN HEALTH CENTER OF MERRILL | false | |
| HOWARD YOUNG FOUNDATION INC | ||||||||||
| 240 MAPLE STREET | WOODRUFF | WI | 54568 | 391521169 | CHARITABLE FOUNDATION | WI | 501(c)(3 | 7 | HOWARD YOUNG HEALTH CARE INC | false |
| HOWARD YOUNG HEALTH CARE INC | ||||||||||
| 240 MAPLE STREET | WOODRUFF | WI | 54568 | 391499115 | HOME OFFICE | WI | 501(c)(3 | Type I | MINISTRY HEALTH CARE INC | false |
| THE HOWARD YOUNG MEDICAL CENTER INC | ||||||||||
| 240 MAPLE STREET | WOODRUFF | WI | 54568 | 390873606 | HOSPITAL | WI | 501(c)(3 | 3 | HOWARD YOUNG HEALTH CARE INC | false |
| MERCY HEALTH FOUNDATION INC | ||||||||||
| PO BOX 3370 | OSHKOSH | WI | 54903 | 237140261 | CHARITABLE FOUNDATION | WI | 501(c)(3 | 9 | AFFINITY HEALTH SYSTEM | Yes (true) |
| MERCY MEDICAL CENTER OF OSHKOSH INC | ||||||||||
| 500 S OAKWOOD ROAD | OSHKOSH | WI | 54904 | 390806268 | HOSPITAL | WI | 501(c)(3 | 3 | MINISTRY HEALTH CARE INC | false |
| MINISTRY MEDICAL GROUP INC | ||||||||||
| 824 ILLINOIS AVENUE | STEVENS POINT | WI | 54481 | 391965593 | CLINICS | WI | 501(c)(3 | Type II | MINISTRY HEALTH CARE INC | false |
| MINISTRY WEIGHT MANAGEMENT INC | ||||||||||
| 2251 NORTH SHORE DRIVE | RHINELANDER | WI | 54501 | 391829015 | HEALTH SERVICES | WI | 501(c)(3 | 3 | SACRED HEART - ST MARY'S HOSPITALS INC | false |
| OUR LADY OF VICTORY HOSPITAL | ||||||||||
| 1120 PINE STREET | STANLEY | WI | 54768 | 390807065 | HOSPITAL | WI | 501(c)(3 | 3 | MINISTRY HEALTH CARE INC | false |
| SACRED HEART-STMARY'S HOSPITALS INC | ||||||||||
| PO BOX 347 | STEVENS POINT | WI | 54481 | 391390638 | HOSPITAL | WI | 501(c)(3 | 3 | MINISTRY HEALTH CARE INC | false |
| SAINT CLARE'S HOSPITAL OF WESTON INC | ||||||||||
| 3400 MINISTRY PARKWAY | WESTON | WI | 54476 | 721531917 | HOSPITAL | WI | 501(c)(3 | 3 | MINISTRY HEALTH CARE INC | false |
| SAINT ELIZABETH'S HOSPITAL OF WABASHA INC | ||||||||||
| 1200 GRANT BLVD WEST | WABASHA | MN | 55981 | 410693877 | HOSPITAL | MN | 501(c)(3 | 3 | MINISTRY HEALTH CARE INC | false |
| ST ELIZABETH HOSPITAL FOUNDATION INC | ||||||||||
| 1506 S ONEIDA STREET | APPLETON | WI | 54915 | 391256677 | CHARITABLE FOUNDATION | WI | 501(c)(3 | 7 | AFFINITY HEALTH SYSTEM | Yes (true) |
| ST ELIZABETH HOSPITAL INC | ||||||||||
| 1506 S ONEIDA STREET | APPLETON | WI | 54915 | 390816818 | HOSPITAL | WI | 501(c)(3 | 3 | MINISTRY HEALTH CARE INC | false |
| SAINT JOSEPH'S HOSPITAL OF MARSHFIELD INC | ||||||||||
| 611 SAINT JOSEPH AVENUE | MARSHFIELD | WI | 54449 | 391847631 | HOSPITAL | WI | 501(c)(3 | 3 | MINISTRY HEALTH CARE INC | false |
| SAINT MICHAEL'S HOSPTIAL OF STEVENS POINT INC | ||||||||||
| 900 ILLINOIS AVENUE | STEVENS POINT | WI | 54481 | 390808443 | HOSPITAL | WI | 501(c)(3 | 3 | MINISTRY HEALTH CARE INC | false |
| NETWORK HEALTH SYSTEM INC | ||||||||||
| 1570 APPLETON RD | MENASHA | WI | 54952 | 391127163 | CLINICAL HEALTHCARE SERVICES | WI | 501(c)(3 | 3 | AFFINITY HEALTH SYSTEM | Yes (true) |
Id Related Org Txbl Partnership IdRelatedOrgTxblPartnershipGrp
Related Organization Name RelatedOrganizationName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | TWIN MED LLP | BusinessNameLine1Txt |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | PO BOX 8005 | AddressLine1Txt |
| City | MENASHA | CityNm |
| State Abbreviation | WI | StateAbbreviationCd |
| ZIP | 54952 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 391180341 | EIN |
| Primary Activities | RENTAL PROPERTY | PrimaryActivitiesTxt |
| Legal Domicile State | WI | LegalDomicileStateCd |
Direct Controlling Entity Name DirectControllingEntityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | NA | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Predominant Income Type | N/A | PredominantIncomeTypeTxt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Receipt Of Int Annts Rnts Rylts | false | ReceiptOfIntAnntsRntsRyltsInd |
| Gift Grnt Or Cap Contri To Oth Org | false | GiftGrntOrCapContriToOthOrgInd |
| Gift Grnt Cap Contri From Oth Org | Yes (true) | GiftGrntCapContriFromOthOrgInd |
| Loans Or Guarantees To Other Org | false | LoansOrGuaranteesToOtherOrgInd |
| Loans Or Guarantees From Oth Org | false | LoansOrGuaranteesFromOthOrgInd |
| Div Related Organization | false | DivRelatedOrganizationInd |
| Asset Sale To Other Org | false | AssetSaleToOtherOrgInd |
| Asset Purchase From Other Org | Yes (true) | AssetPurchaseFromOtherOrgInd |
| Asset Exchange | false | AssetExchangeInd |
| Rental Of Facilities To Oth Org | Yes (true) | RentalOfFacilitiesToOthOrgInd |
| Rental Of Fclts From Oth Org | Yes (true) | RentalOfFcltsFromOthOrgInd |
| Perform Of Services For Oth Org | false | PerformOfServicesForOthOrgInd |
| Perform Of Services By Other Org | Yes (true) | PerformOfServicesByOtherOrgInd |
| Sharing Of Facilities | false | SharingOfFacilitiesInd |
| Paid Employees Sharing | Yes (true) | PaidEmployeesSharingInd |
| Reimbursement Paid To Other Org | Yes (true) | ReimbursementPaidToOtherOrgInd |
| Reimbursement Paid By Other Org | false | ReimbursementPaidByOtherOrgInd |
| Transfer To Other Org | false | TransferToOtherOrgInd |
| Transfer From Other Org | false | TransferFromOtherOrgInd |
Transactions Related Org TransactionsRelatedOrgGrp (7 entries)
| Transaction TypeTransactionTypeTxt | InvolvedInvolvedAmt | Method Of Amount DeterminationMethodOfAmountDeterminationTxt |
|---|---|---|
| ST ELIZABETH HOSPITAL FOUNDATION INC | ||
| C | $1,025,390 | FMV |
| MINISTRY HEALTH CARE INC | ||
| P | $4,922,296 | FMV |
| ST ELIZABETH HOSPITAL INC | ||
| O | $147,606 | FMV |
| AFFINITY MEDICAL GROUP | ||
| M | $1,310,395 | FMV |
| AFFINITY MEDICAL GROUP | ||
| K | $136,750 | FMV |
| AFFINITY MEDICAL GROUP | ||
| J | $129,364 | FMV |
| SAINT JOSEPH'S HOSPITAL OF MARSHFIELD INC | ||
| H | $94,606 | FMV |
Comments