2017-05-09T17:04:06-05:00 2016-06-30 990 2015-07-01 390905385 Calumet Medical Center Inc CALU 9208492386 614 Memorial Drive Chilton WI 53014 Bill Hinner CFO Reg Health System,WI North 2017-05-09 2015 2021-01-29 14:40:06Z Timothy Richman 614 Memorial Drive Chilton WI 53014 29136370 false X www.affinityhealth.org X 1954 WI To further the healing ministry of Jesus by improving the health and well-being of all people. 13 8 196 39 0 0 1050096 1076274 26685834 27672786 154196 92338 242766 274465 28132892 29115863 0 0 0 0 12024757 10697851 0 0 0 10360917 13050265 22385674 23748116 5747218 5367747 42872071 47514110 5061009 4497988 37811062 43016122 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. false false 17110834 27672786 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. 17110834 true true false true false false false false false false true false false true true true false true false false false false false false false false true true false false true false false false false false false false false false false false false false true true true false false true 20 0 true 196 true false false false false false false false false false false X 13 8 false false false false true true true true true false false true true true true true true false false false WI X Craig Aittama 7153465161 5700 Lands End Way 2nd Floor Stevens Point WI 54482 TIMOTHY RICHMAN PRESIDENT/CEO - CMC 40.0 1.0 X X 0 262734 32572 JOHN RUSSO CHAIRMAN (START 1/2016) 0.3 1.5 X X 0 0 0 WAYNE WIETING CHAIRMAN (END 12/2015) 0.3 0 X X 0 0 0 KATHRYN SIEMAN VICE CHAIR (START 1/2016) 0.3 1.5 X X 0 0 0 MONICA ANN HILT VICE CHAIRMAN (END 12/2015) 6.0 37.5 X X 0 709688 64149 BRIAN WALLACE TREASURER (START 1/2016) 0.3 1.5 X X 0 0 0 JAMES BURNETT TREASURER (END 12/2015) 0.3 0 X X 0 0 0 WAYNE TREMBLY SECRETARY (START 1/2016) 0.3 1.5 X X 0 0 0 ALLAN UTECHT SECRETARY (END 12/2015) 0.3 0 X X 0 0 0 LANE EARNS BOARD MEMBER (START 1/2016) 0.3 1.5 X 0 0 0 MARK W FAUSTICH MD BOARD MEMBER (START 1/2016) 0.3 41.1 X 0 438031 21791 JANE GEHL BOARD MEMBER (END 12/2015) 0.3 0 X 0 0 0 MARLIN GREENFIELD BOARD MEMBER (START 1/2016) 0.3 1.5 X 0 0 0 PETER JANU MD BOARD MEMBER (END 12/2015) 0.3 40.0 X 0 552160 45990 MARK KEHRBERG MD BOARD MEMBER 0.3 40.3 X 0 355616 30314 CRAIG OLSEN MD BOARD MEMBER (END 12/2015) 0.3 0 X 0 0 0 KEVIN RALOFSKY BOARD MEMBER (START 1/2016) 0.3 1.2 X 0 0 0 SUDEEP SODHI MD BOARD MEMBER (START 1/2016) 0.3 41.1 X 0 882249 47537 GENE TIPLER MD BOARD MEMBER (END 12/2015) 0.3 40.0 X 0 239857 43316 MONICA VOMASTIC BOARD MEMBER (START 1/2016) 0.3 1.5 X 0 0 0 WENDY SCHROEDER MD BOARD MEMBER (START 1/2016) 0.3 41.5 X 0 258146 48066 NICHOLAS DESIEN MINISTRY HEALTH CARE CEO (END 12/31/15) 1.0 54.3 X 0 2799737 271786 JEFFREY FRANCIS MINISTRY HEALTH CARE CAFO (END 9/9/15) 0.5 54.3 X 0 652678 51385 DANIEL NEUFELDER SVP, HOSPITAL OPERATIONS & PRESIDENT 0.1 63.8 X 0 2171860 190168 JENNIFER LEIGH MEDIN WEBER MANAGER INPATIENT SRVCS 40.0 0 X 137319 0 31593 137319 9322755 878667 1 false true false GOLD CROSS AMBULANCE SERVICE I 1055 Wittmann Drive Menasha WI 54952 Professional Services 439816 BOLDT PROCUREMENT LLC 2525 N Roemer Rd PO Box 419 Appleton WI 54912 Construction Services 398062 2 X 1064995 11279 1076274 Net Patient Revenue 621110 22360520 22360520 Clinic Revenue 621110 5205491 5205491 Rent to Affiliates 531190 26058 26058 80717 80717 0 0 27672786 92338 92338 52815 20507 32308 0 32308 32308 0 0 Nutrition Services 621110 72225 72225 Purchasing Card Rev 621110 6675 6675 Other Non-Operating 900099 58 58 163199 0 0 163199 242157 29115863 27672786 0 366803 X 8178255 6082006 2096249 358962 266953 92009 1734904 1290214 444690 425730 316607 109123 18447 18447 381 381 3940413 3691339 249074 0 2000696 1933524 67172 2141 2141 500611 450028 50583 93936 22700 71236 1378442 1193831 184611 48567 48567 Purchase Services 3279549 1106182 2173367 Drugs 619205 619205 Executive Salaries 488645 488645 Dues 24971 3678 21293 654261 132426 521835 0 23748116 17110834 6637282 0 2529 2358 13311365 17223584 0 0 3503948 4037926 0 0 0 0 0 130797 27331 39571 21934482 2958160 18867012 18976322 1929113 1932893 0 0 0 0 5230773 5170659 42872071 47514110 3840592 1474188 0 35604 67635 0 0 0 0 0 0 1184813 2956165 5061009 4497988 37811062 43016122 0 0 0 0 0 0 0 0 0 0 37811062 43016122 42872071 47514110 X 5367747 -164982 2295 X false true X true true true X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED false false false false false false false false true 381 381 false 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. 3200000 3200000 13739216 1322339 12416877 177300 50516 126784 4017128 1585305 2431823 800838 0 800838 18976322 INTEREST IN INVESTMENTS HEALTH BY ASCENSION HEALTH ALLIANCE 4770045 UNEMPLOYMENT DEPOSIT 169348 OTHER ACCOUNTS RECEIVABLE 6925 DUE FROM RELATED ENTITIES 185841 ESTIMATED DUE FROM 3RD PARTY PAYORS 38500 5170659 Accumulated Accretion 318867 Retirement Obligation 59208 Due to Third Party Payor 860116 intercompany payables 1555778 other liabilities 162196 2956165 X Schedule D, Part X, Line 2 FIN 48 (ASC 740) footnote 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. true true X true X 250 true X true true true false true true 39790 0 39790 0.0017 685214 0 685214 0.0289 0 0 0 0.0 0 0 725004 0 725004 0.0305 13 946 90292 0 90292 0.0038 4 0 17327 0 17327 0.0007 0 0 0 0 0 0.0 0 0 0 0 0 0.0 5 0 20597 0 20597 0.0009 22 946 128216 0 128216 0.0054 22 946 853220 0 853220 0.0359 0 0 0 0 0 0.0 0 0 0 0 0 0.0 0 0 0 0 0 0.0 0 0 0 0 0 0.0 0 0 0 0 0 0.0 1 0 1251 0 1251 0.0001 1 150 21952 0 21952 0.0009 1 2 86 0 86 0.0000 0 0 0 0 0 0.0 3 152 23289 0 23289 0.0010 false 600677 0 14079276 12451637 1627639 X true true 1 1 Calumet Medical Center Inc 614 Memorial Drive Chilton WI 53014 www.affinityhealth.org 1020 X X X X Calumet Medical Center Inc 1 false false true X X X X X X X X X 15 true true true true X http://www.affinityhealth.org/Affinity/For-Patients-and-Visitors/Community-Benefit-and-Outreach.htm X true 15 true http://www.affinityhealth.org/Affinity/For-Patients-and-Visitors/Community-Benefit-and-Outreach.htm false false true X 250.0 400.0 X X X X X true true X X X true X http://ministryhealth.org/MinistryHealth/AboutUs/BillingandPayment/FinancialAssistance.nws X http://ministryhealth.org/MinistryHealth/AboutUs/BillingandPayment/FinancialAssistance.nws X http://ministryhealth.org/MinistryHealth/AboutUs/BillingandPayment/FinancialAssistance.nws X X X X X true X false X X X X true X false false 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. 0 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 true true false false false false false false false TIMOTHY RICHMAN PRESIDENT/CEO - CMC 0 189115 0 64344 0 9275 0 9034 0 23538 0 295306 0 0 MONICA ANN HILT VICE CHAIRMAN (END 12/2015) 0 457522 0 238701 0 13465 0 33355 0 30794 0 773837 0 0 MARK W FAUSTICH MD BOARD MEMBER (START 1/2016) 0 412928 0 21608 0 3495 0 17225 0 4566 0 459822 0 0 PETER JANU MD BOARD MEMBER (END 12/2015) 0 550436 0 0 0 1724 0 17225 0 28765 0 598150 0 0 MARK KEHRBERG MD BOARD MEMBER 0 219105 0 129827 0 6684 0 15923 0 14391 0 385930 0 0 SUDEEP SODHI MD BOARD MEMBER (START 1/2016) 0 878922 0 0 0 3327 0 17225 0 30312 0 929786 0 0 GENE TIPLER MD BOARD MEMBER (END 12/2015) 0 234733 0 2578 0 2546 0 13801 0 29515 0 283173 0 0 WENDY SCHROEDER MD BOARD MEMBER (START 1/2016) 0 257093 0 50 0 1003 0 13623 0 34443 0 306212 0 0 NICHOLAS DESIEN MINISTRY HEALTH CARE CEO (END 12/31/15) 0 1298254 0 1454145 0 47338 0 242978 0 28808 0 3071523 0 0 JEFFREY FRANCIS MINISTRY HEALTH CARE CAFO (END 9/9/15) 0 382625 0 40711 0 229342 0 27845 0 23540 0 704063 0 0 DANIEL NEUFELDER SVP, HOSPITAL OPERATIONS & PRESIDENT 0 1009083 0 1146884 0 15893 0 162663 0 27505 0 2362028 0 0 JENNIFER LEIGH MEDIN WEBER MANAGER INPATIENT SRVCS 136473 0 0 0 846 0 5017 0 26576 0 168912 0 0 0 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. 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. 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