2016-02-08T13:35:39-06:00 2015-06-30 390758449 WIPFLI LLP PO BOX 8010 WAUSAU WI 544028010 990 2014-07-01 381443361 ASPIRUS KEWEENAW HOSPITAL ASPI 9063376500 205 OSCEOLA LAURIUM MI 49913 SHANE JACQUES CFO 9063376500 2016-01-23 1 KATHLEEN J LABRAKE CPA P00164006 7158453111 2016-01-23 2014 2016-04-25 22:37:26Z SHANE JACQUES 205 OSCEOLA STREET LAURIUM MI 49913 51298175 0 X WWW.ASPIRUSKEWEENAW.ORG X 1939 MI ASPIRUS KEWEENAW HOSPITAL PROVIDES COMPREHENSIVE INPATIENT, OUTPATIENT, EMERGENCY, MEDICAL AND PHYSICIAN CLINIC SERVICES. 14 6 481 96 -4596 -4386 37883 14668 37698743 46217058 528184 447475 2575013 2027675 40839823 48706876 0 0 0 0 24282960 25657467 0 0 0 15862376 20300031 40145336 45957498 694487 2749378 32573455 52703026 11664523 29428946 20908932 23274080 TO PROVIDE COMPREHENSIVE INPATIENT, OUTPATIENT, EMERGENCY, MEDICAL, AND PHYSICIAN CLINIC SERVICES. 0 0 38617747 47648880 ASPIRUS KEWEENAW HOSPITAL PROVIDES COMPREHENSIVE INPATIENT, OUTPATIENT, EMERGENCY, MEDICAL, AND PHYSICIAN CLINIC SERVICES. ASPIRUS KEWEENAW BEGAN EYE CLINIC SERVICES IN FY2015. THIS IS A NEW SERVICE FOR AKH. ASPIRUS KEWEENAW BUILT A NEW CLINIC IN HOUGHTON IN FY2015 PROVIDING BREAST CARE AND IMAGING, CANCER CARE, CHILDREN'S HEALTH, DIABETES CARE, FAMILY MEDICINE, HOME MEDICAL EQUIPMENT, IMAGING (RADIOLOGY), LABORATORY SERVICES, NUTRITION COUNSELING, ORTHOPEDICS, PEDIATRICS, SENIOR HEALTH, WALK-IN CARE, WEIGHT LOSS PROGRAM, AND WOMEN'S HEALTH. 38617747 1 0 0 1 0 0 0 0 0 0 1 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 101 0 1 481 1 1 1 0 0 0 0 0 0 0 0 0 X 14 6 1 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 X SHANE JACQUES 9063376500 205 OSCEOLA STREET LAURIUM MI 49913 DANIEL DALQUIST CHAIRMAN 0.50 1.00 X X 0 0 0 EDWARD JENICH VICE CHAIRMAN 0.50 1.00 X X 16800 0 0 DAVID GILBERT MD SECRETARY 0.50 1.00 X X 0 0 0 MATTHEW HEYWOOD BOARD MEMBER / CEO OF AI 1.00 51.00 X 0 875945 124428 CHARLES NELSON BOARD MEMBER / REGIONAL CEO UP 24.00 17.00 X X 0 318458 74308 SANDRA HUUKI BOARD MEMBER 0.50 1.00 X 0 0 0 DARRELL LENTZ BOARD MEMBER / PRESIDENT AWH 0.50 39.50 X 0 315572 68176 JERRY LUOMA MD BOARD MEMBER 20.00 1.00 X 58037 0 11393 MARIANA PERINOT MD BOARD MEMBER & MEDICAL STAFF TERMED 1/1/2015 40.00 X 219787 0 7327 DARRYL PIERCE BOARD MEMBER 0.50 1.00 X 0 0 0 DALE R TAHTINEN BOARD MEMBER 0.50 1.00 X 0 0 0 JOEL TUORINIEMI BOARD MEMBER 0.50 1.00 X 0 0 0 ELIZABETH BENYI DO BOARD MEMBER & CHIEF OF STAFF 40.00 X 258277 0 16656 JOHN HEISLER BOARD MEMBER & SR VP/CHIEF HR OFFICER 1.00 40.00 X 0 287789 44598 JOHN HORAN MD BOARD MEMBER & MEDICAL STAFF REP 1.00 40.00 X 419894 0 10275 MICHAEL LUOMA MD BOARD MEMBER TERMED 1/1/2015 40.00 X 216621 0 27995 RICK NEVERS BOARD MEMBER TERM ENDED 7/22/2014 1.00 40.00 X 0 331104 71838 SIDNEY C SCZYGELSKI CFO OF AI 1.00 51.00 X 0 445401 99296 MICHAEL HAUSWIRTH COO 40.00 X 217448 0 28914 SHANE JACQUES CFO 40.00 X 180771 0 22933 GRACE TOUSIGNANT CNO 40.00 X 150566 0 23024 FREDERICK RAU ORTHOPEDIC SURGEON 40.00 X 495508 0 28291 SHAHAR MADJAR PHYSICIAN 40.00 X 312183 0 9265 BONNIE HAFEMAN PHYSICIAN 40.00 X 340095 0 22521 JOHN NOVOSAD ANESTHESIOLOGIST 40.00 X 298746 0 18004 JAMES BLACK ED PHYSICIAN 40.00 X 320272 0 32491 DUANE ERWIN FORMER CEO OF AI 0.00 0.00 X 0 576532 28814 3505005 3150801 770547 32 1 1 0 COAST TO COAST HEALTH CARE PO BOX 56346 ATLANTA GA 30343 CONTRACTED PROVIDERS 562800 WEATHERBY LOCUMS INC PO BOX 972633 DALLAS TX 75397 CONTRACTED PROVIDERS 539296 CHG COMPANIES INC PO BOX 972651 DALLAS TX 75397 CONTRACTED PROVIDERS 287741 THOMAS K CARLSON 1 ASPEN LANE GLADSTONE MI 49837 CONTRACTED PROVIDERS 274400 LOCUM TENENSCOM LLC 2655 NORTHWINDS PKWY ALPHERETTA GA 30009 CONTRACTED PROVIDERS 238259 9 12016 2652 14668 NET PATIENT SERVICE REVENUE 621990 41562794 41562794 340B REVENUE DRUG PROGRAM 900099 4523046 4523046 CAFETERIA REVENUE 624200 120763 120763 VENDING REVENUE 624200 10455 10455 46217058 61308 61308 164689 67841 96848 96848 -4596 101444 2871258 38367 2430435 93023 440823 -54656 386167 386167 E.H.R INCENTIVE 900099 1563040 1563040 OTHER REVENUE 999999 367787 367787 1930827 48706876 47648880 -4596 1047924 1175013 802101 372912 19647666 17663862 1983804 557549 501277 56272 2955937 2657604 298333 1321302 1172415 148887 31505 31505 62450 62450 12877 12877 4118470 2889390 1229080 203904 8354 195550 7597653 7512426 85227 184120 106936 77184 494352 481533 12819 216665 160902 55763 86154 86154 1702916 1606377 96539 187951 86585 101366 EQUIPMENT RENTAL AND MA 1691825 1484848 206977 CORPORATE ALLOCATIONS 1623635 1623635 PROVISION FOR BAD DEBTS 1169916 1169916 DUES AND SUBSCRIPTIONS/ 719371 81769 637602 196267 145298 50969 45957498 38617747 7339751 0 218165 1050658 7002868 9273561 4285153 5876637 392746 600250 926915 675864 42036125 17439290 12913207 24596835 2317190 6012379 1505234 1490088 56567 3011977 3070187 32573455 52703026 4955498 6786712 1259490 2058425 18669750 4279229 664025 371371 2048969 11664523 29428946 X 20908932 23274080 20908932 23274080 32573455 52703026 2749378 -384230 0 X X 0 1 X 1 0 X 0 0 0 0 0 0 0 0 1 10463 10463 0 PART II-B, LINE 1: ORGANIZATION HAS INDIRECT LOBBYING ACTIVITIES THROUGH THE PAYMENT OF HOSPITAL ASSOCIATION DUES. 871587 871587 18390381 11365864 7024517 10313226 6073426 4239800 12460931 12460931 24596835 DUE FROM ASPIRUS KEWEENAW ENTERPRISES 1833272 DUE FROM ASPIRUS KEWEENAW FOUNDATION 4290 NOTE RECEIVABLE 892500 DUE FROM OTHER ENTITIES 72824 THIRD PARTY RECEIVABLES 267301 3070187 LONG TERM INSURANCE PAYABLE 225630 ASBESTOS LIABILITY 61471 MEDICARE PAYABLE 775083 BLUE CROSS PAYABLE 921922 OTHER THIRD PARTY PAYABLE 64863 2048969 X PART X, LINE 2: THE HOSPITAL IS A NONPROFIT CORPORATION AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE (THE "CODE") AND IS EXEMPT FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE CODE. THE HOSPITAL IS ALSO EXEMPT FROM STATE INCOME TAXES ON RELATED INCOME. THE COMPANY IS A TAXABLE CORPORATION. ANY INCOME TAX PROVISION, IF REQUIRED, IS NOT CONSIDERED MATERIAL TO THE CONSOLIDATED FINANCIAL STATEMENTS. 1 1 1 X 1 X 1 1 0 1 1 151218 151218 0.00340 8665230 6323045 2342185 0.05230 8816448 6323045 2493403 0.05570 79917 79917 0.00180 5579493 4911622 667871 0.01490 24949 24949 0.00060 5684359 4911622 772737 0.01730 14500807 11234667 3266140 0.07300 1 688708 11798373 11693957 104416 X 1 1 1 1 ASPIRUS KEWEENAW HOSPITAL 205 OSCEOLA STREET LAURIUM MI 49913 WWW.ASPIRUSKEWEENAW.ORG 1060000151 X X X X PHYSICIAN CLINIC, HOME MEDICAL EQUIPMENT, & PHARMACY ASPIRUS KEWEENAW HOSPITAL 1 0 0 1 X X X X X X X X X 12 1 1 1 1 X HTTP://WWW.ASPIRUS.ORG/MAIN/COMMUNITY-RESOURCES.ASPX?SRCAUD=MAIN X 1 12 1 SEE PART V - SUPPLEMENTAL INFORMATION FOR WEB ADDRESS 1 0 1 X 150.000000000000 300.000000000000 X X X X 1 1 X X X 1 X HTTP://WWW.ASPIRUS.ORG/MAIN/PAY-MY-BILL.ASPX?SRCAUD=MAIN#TAB2 X HTTP://WWW.ASPIRUS.ORG/UPLOADS/PUBLIC/DOCUMENTS/FINANCIAL-AID-APPLICATION.P X HTTP://WWW.ASPIRUS.ORG/MAIN/PAY-MY-BILL.ASPX?SRCAUD=MAIN#TAB2 X X X X X X 1 X 0 X X X 1 X 0 0 ASPIRUS KEWEENAW HOSPITAL PART V, SECTION B, LINE 5: SURVEY BY MAIL AND PARTICIPATION IN REGIONAL HEALTH ASSESSMENTS WITH OTHER HOSPITALS AND AGENCIES. ASPIRUS KEWEENAW HOSPITAL PART V, SECTION B, LINE 6A: ASPIRUS GRAND VIEW, ASPIRUS ONTONAGON, BARAGA COUNTY MEMORIAL HOSPITAL, PORTAGE HEALTH. ASPIRUS KEWEENAW HOSPITAL PART V, SECTION B, LINE 11: THE HOSPITAL HAS SUCCESSFULLY ADDRESS ALL ITEMS IDENTIFIED IN THE CHNA EXCEPT ONE. THIS IS MAINTAINING A ONE-ON-ONE HYPERTENSION CLINIC. THE NURSE PRACTITIONER SUPPORTING THE EFFORT IS NO LONGER WITH THE ORGANIZATION. THE CLINIC MANAGERS HAVE BEEN IN THE PROCESS OF WORKING WITH OTHER STAFF TO FILL GAPS AND ADDRESS THE NEEDS OF THE HYPERTENSION CLINIC. THE HOSPITAL EXPECTS SOLUTIONS AND SUPPORT OF THE CLINIC IN FALL OF 2015. ASPIRUS KEWEENAW HOSPITAL PART V, SECTION B, LINE 16I: BILLING INVOICES CONTAIN CONTACT INFORMATION FOR MORE INFORMATION ABOUT THE THE FINANCIAL ASSISTANCE POLICY. A POSTING OF HOW TO OBTAIN MORE INFORMATION ON THE FINANCIAL ASSISTANCE POLICY IS LOCATED IN THE EMERGENCY AND WAITING ROOMS. ASPIRUS KEWEENAW HOSPITAL PART V, SECTION B, LINE 22D: ASPIRUS KEWEENAW HOSPITAL USES THE LOOKBACK METHOD TO DETERMINE THE AMOUNTS CHARGED TO FAP ELIGIBLE INDIVIDUALS ARE BASED ON FPL LEVEL. THIS IS DISCOUNTED USING AVERAGE PAST AMOUNTS PAID BY COMMERCIALLY INSURED AND MEDICARE PATIENTS TO THE HOSPITAL. PART V, SECTION B, LINE 5A HOSPTIAL WEB ADDRESS TO LOCATE CHNA: HTTP://ASPIRUS.ORG/MAIN/COMMUNITY-RESOURCES.ASPX PART V, SECTION B, LINE 10A HOSPITALS MOST RECENT ADOPTED IMPLEMENTATION STRATEGY CAN BE FOLLOWED AT HTTP://WWW.ASPIRUS.ORG/MAIN/COMMUNITY-RESOURCES.ASPX PART V, SECTION B, LINE 16 FINANCIAL ASSISTANCE POLICY WEBSITE AVAILABILITY ASPIRUS KEWEENAW HOSPITAL PART V, SECTION B, LINE 16A WEBSITE: HTTP://WWW.ASPIRUS.ORG/MAIN/PAY-MY-BILL.ASPX?SRCAUD=MAIN#TAB2 ASPIRUS KEWEENAW HOSPITAL PART V, SECTION B, LINE 16B WEBSITE: HTTP://WWW.ASPIRUS.ORG/UPLOADS/PUBLIC/DOCUMENTS/FINANCIAL-AID-APPLICATION.P ASPIRUS KEWEENAW HOSPITAL PART V, SECTION B, LINE 16C WEBSITE: HTTP://WWW.ASPIRUS.ORG/MAIN/PAY-MY-BILL.ASPX?SRCAUD=MAIN#TAB2 6 ASPIRUS HOUGHTON CLINIC 1000 CEDAR STREET HOUGHTON MI 49931 CLINIC & OUTPATIENT THERAPY ASPIRUS KEWEENAW OUTPATIENT THERAPIES 342 HECLA STREET LAURIUM MI 49913 OUTPATIENT THERAPY ASPIRUS KEWEENAW LAURIUM WELLNESS 300 HECLA STREET LAURIUM MI 49913 CLINIC ASPIRUS EYE CLINIC 404 EAST SHARON AVENUE HOUGHTON MI 49931 CLINIC ASPIRUS KEWEENAW LAKE LINDEN CLINIC 110 CALUMET STREET LAKE LINDEN MI 49945 CLINIC ASPIRUS KEWEENAW FASTCARE 9900 MEMORIAL ROAD HOUGHTON MI 49931 CLINIC PART I, LINE 7: THE COST METHOD THAT IS USED ON THE FORM 990 IS BASED ON A COST TO CHARGE RATIO WHICH IS DEVELOPED BASED ON THE HOSPITAL'S TOTAL OPERATING EXPENSES LESS THE PROVISION FOR BAD DEBTS. THIS IS THEN DIVIDED BY GROSS PATIENT SERVICES REVENUE. PART I, LINE 7G: THE COST OF SUBSIDIZED HEATLH SERVICES ARE RELATED TO THE LAURIUM CLINIC. ASPIRUS KEWEENAW HOSPITAL UTILIZED AN INTERNAL DEPARTMENTAL FINANCIAL STATEMENT TO REPORT THE COST AND DIRECT OFFSETTING REVENUE THAT CALCULATES THE COMMUNITY BENEFIT EXPENSE. PART I, LN 7 COL(F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 24C, BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGES IN THIS COLUMN IS $1,169,916. PART II, COMMUNITY BUILDING ACTIVITIES: WHILE THERE IS GROWING AGREEMENT IN THE UNITED STATES ABOUT WHAT CONSTITUTES A NON-PROFITS HOSPITAL'S COMMUNITY BENEFIT AND CHARITY CARE, THESE EFFORTS CONTINUE TO BE A WORK IN PROGRESS. ASPIRUS KEWEENAW HOSPITAL, INC., IN ADDITION TO PROVIDING SIGNIFICANT CHARITY CARE AND OTHER COMMUNITY BENEFITS AS DEFINED BY THE IRS, THE ORGANIZATION BELIEVES THAT IT PROVIDES A CRITICALLY IMPORTANT BENEFIT WHICH IS NOT QUANTIFIED. ASPIRUS KEWEENAW HOSPITAL, LIKE MOST COMMUNITY HOSPITALS, WAS CREATED AND IS MAINTAINED IN ORDER TO PROVIDE CARE LOCALLY WHICH WITHOUT THE HOSPITAL WOULD NOT BE AVAILABLE LOCALLY. IN ADDITION TO INPATIENT HOSPITALIZATIONS, THE ORGANIZATION PROVIDES LOCAL ACCESS TO MANY SERVICES INCLUDING: EMERGENCY SERVICES, RESPIRATORY THERAPY, OCCUPATIONAL THERAPY, PHYSICAL THERAPY, FAMILY PRACTICE CLINICS, AND LABORATORY AND PATHOLOGY SERVICES. PART III, LINE 4: IN EVALUATING THE COLLECTABILITY OF ACCOUNTS RECEIVABLE, THE ORGANIZATION ANALYZES PAST RESULTS AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYOR SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND THE PROVISION FOR BAD DEBTS. MANAGEMENT REGULARLY REVIEWS DATA ABOUT THESE MAJOR PAYOR SOURCES OF REVENUE IN EVALUATING THE SUFFICIENCY OF THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. SPECIFICALLY, FOR RECEIVABLES RELATING TO SERVICES PROVIDED TO PATIENTS HAVING THIRD-PARTY COVERAGE, THE ORGANIZATION ANALYZES CONTRACTUALLY DUE AMOUNTS AND PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS AND A PROVISION FOR BAD DEBTS FOR EXPECTED UNCOLLECTIBLE DEDUCTIBLES AND COPAYMENTS ON ACCOUNTS FOR WHICH THE THIRD-PARTY PAYOR HAS NOT YET PAID, OR FOR PAYORS WHO ARE KNOWN TO BE HAVING FINANCIAL DIFFICULTIES THAT MAKE THE REALIZATION OF AMOUNTS DUE UNLIKELY. FOR RECEIVABLES ASSOCIATED WITH SELF-PAY PATIENTS (WHICH INCLUDES BOTH PATIENTS WITHOUT INSURANCE AND PATIENTS WITH DEDUCTIBLE AND COPAYMENT BALANCES DUE FOR WHICH THIRD-PARTY COVERAGE EXISTS FOR PART OF THE BILL), THE ORGANIZATION RECORDS A SIGNIFICANT PROVISION FOR BAD DEBTS IN THE PERIOD OF SERVICE ON THE BASIS OF ITS PAST EXPERIENCE, WHICH INDICATES THAT MANY PATIENTS ARE UNABLE OR UNWILLING TO PAY THE PORTION OF THEIR BILL FOR WHICH THEY ARE FINANCIALLY RESPONSIBLE. THE DIFFERENCE BETWEEN THE STANDARD RATES (OR THE DISCOUNTED RATES IF NEGOTIATED) AND THE AMOUNTS ACTUALLY COLLECTED AFTER ALL REASONABLE COLLECTION EFFORTS HAVE BEEN EXHAUSTED IS CHARGED OFF AGAINST THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. PART III, LINE 8: ALLOWABLE MEDICARE COSTS WERE OBTAINED FROM THE ORGANIZATION'S FILED MEDICARE COST REPORT. AS SUCH THEY ONLY INCLUDE THE AMOUNTS ALLOWED IN THE FORM 990 INSTRUCTIONS. THEREFORE, THEY ONLY INCLUDE A PORTION OF THE GROSS MEDICARE REVENUE OF THE ORGANIZATION AND DO NOT CONSIDER ALL OF THE CONTRACTUAL ADJUSTMENTS FOR SERVICES REIMBURSED BY THE MEDICARE PROGRAM. THE MEDICARE REVENUES AMOUNTS LISTED DO NOT INCLUDE PHYSICIAN SERVICES FOR THE COVERAGE OF THE EMERGENCY DEPARTMENT AT THE HOSPITAL AS WELL AS ANESTHESIA PROFESSIONAL SERVICES, REVENUES FOR ANY PATIENTS COVERED UNDER MEDICARE ADVANTAGE PLAN PROGRAMS, PHYSICAL THERAPY SERVICES PROVIDED TO NURSING HOME RESIDENTS, AND A SIGNIFICANT PORTION OF LAB SERVICES PROVIDED TO AREA CLINIC PATIENTS. PART III, LINE 9B: UNDER THE ORGANIZATION'S COLLECTION AND CHARITY CARE POLICIES, ASPIRUS KEWEENAW HOSPITAL MAKES EVERY ATTEMPT TO IDENTIFY AND PROMOTE CHARITY CARE TO PATIENTS. INCLUDED IN THE ORGANIZATION'S CHARITY CARE POLICY IT IS NOTED THAT PATIENTS MAY QUALIFY FOR CHARITY CARE EITHER PRIOR TO ADMISSION OR FOLLOWING DISCHARGE.ASPIRUS KEWEENAW HOSPITAL WILL PROVIDE MEDICALLY ACUTE SERVICES TO PATIENTS WHO MEET THE CRITERIA OF THE PATIENT FINANCIAL ASSISTANCE PROGRAM WITHOUT CHARGE OR AT AMOUNTS LESS THAN ESTABLISHED RATES FOR QUALIFYING PATIENTS. THIS PROGRAM IS PROVIDED FOR PATIENTS WHO ARE UNINSURED, UNDERINSURED, AND/OR MEDICALLY INDIGENT. PATIENTS AND THEIR FAMILIES HAVE A RESPONSIBILITY TO HELP THE HOSPITAL QUALIFY THEM FOR THE APPROPRIATE LEVEL OR TYPE OF FINANCIAL ASSISTANCE GIVEN THEIR CIRCUMSTANCES.DURING THE PATIENT ACCOUNT COLLECTION PROCESS, SELF-PAY PATIENTS ARE ALSO INFORMED OF THE HOSPITAL'S COLLECTION POLICIES AS WELL AS THE CARITY CARE PROGRAM TO ALLOW PATIENTS THE OPPORTUNITY TO COMPLETE THE APPROPRIATE FORMS AND QUALIFY UNDER THE PROGRAM.RELATIONSHIP TO COLLECTION POLICIESASPIRUS MANAGMENT SHALL DEVELOP POLICIES AND PROCEDURES FOR INTERNAL AND EXTERNAL COLLECTION PRACTICES (INCLUDING ACTIONS THE HOSPITAL MAY TAKE IN THE EVENT OF NON-PAYMENT, INCLUDING COLLECTION ACTION AND REPORTING TO CREDIT AGENCIES) THAT TAKE INTO ACCOUNT THE EXTENT TO WHICH THE PATIENT QUALIFIED FOR FINANCIAL ASSISTANCE, A PATIENT'S GOOD FAITH EFFORT TO APPLY FOR A GOVERNMENTAL PROGRAM OR FOR FINANCIAL ASSISTANCE FROM ASPIRUS, AND A PATIENT'S GOOD FAITH EFFORT TO COMPLY WITH HIS OR HER PAYMENT AGREEMENTS WITH ASPIRUS. PATIENTS WHO DO NOT SATISFY THEIR FINANCIAL OBLIGATIONS WILL BE PROCESSED OUT TO THE ASPIRUS KEWEENAW CONTRACTED COLLECTION AGENCY. FOR PATIENTS WHO QUALIFY FOR CHARITY AND WHO ARE COOPERATING IN GOOD FAITH TO RESOLVE THEIR DISCOUNTED HOSPITAL BILLS, ASPIRUS MAY OFFER EXTENDED PAYMENT PLANS, WILL NOT SEND UNPAID BILLS TO OUTSIDE COLLECTION AGENCIES, AND WILL CEASE ALL COLLECTION EFFORTS TO ELIGIBLE PATIENTS. EXTRAORDINARY COLLECTION ACTIONS1. ASPIRUS WILL NOT IMPOSE EXTRAORDINARY COLLECTIONS ACTIONS SUCH AS WAGE GARNISHMENTS, LIENS ON PRIMARY RESIDENCES, OR OTHER LEGAL ACTIONS, WILL NOT SEND UPAID BILLS TO OUTSIDE COLLECTION AGENCIES AND WILL CEASE ALL COLLECTION EFFORTS FOR ANY PATIENT WITHOUT FIRST MAKING RESONABLE EFFORTS TO DETERMINE WHEATHER THAT PATIENT IS ELIGIBLE FOR CHARITY CARE UNDER THIS FINANCIAL ASSISTANCE POLICY. REASONABLE EFFORTS SHALL INCLUDE:2. VALIDATING THAT THE PATIENT OWES THE UNPAID BILLS AND THAT ALL SOURCES OF THIRD-PARTY PAYMENT HAVE BEEN IDENTIFIED AND BILLED BY THE HOSPITAL;3. DOCUMENTATION THAT ASPIRUS HAS OR HAS ATTEMPTED TO OFFER THE PATIENT THE OPPORTUNITY TO APPLY FOR FINANCIAL ASSISTANCE PROGRAM PURSUANT TO THIS POLICY AND THAT THE PATIENT HAS NOT COMPLIED WITH ASPIRUS APPLICATION REQUIREMENTS;4. DOCUMENTATION THAT THE PATIENT DOES NOT QUALIFY FOR FINANCIAL ASSISTANCE ON A PRESUMPTIVE BASIS;5. DOCUMENTATION THAT THE PATIENT HAS BEEN OFFERED A PAYMENT PLAN BUT HAS NOT HONORED THE TERMS OF THAT PLAN. PART VI, LINE 2: THE ORGANIZATION MEETS WITH A LOCAL FEDERALLY QUALIFIED HEALTH CENTER TO CONSULT AND DETERMINE HOW TO MEET THE HEALTH CARE NEEDS IN THE ORGANIZATION'S GEOGRAPHICAL AREA. IN ADDITION, THE ORGANIZATION ITSELF EVALUATES ITS' OWN SERVICES OFFERED IN THEIR SERVICE AREA AND EVALUATES OTHER SERVICES THAT COULD BE PROVIDED TO BENEFIT THE COMMUNITY SERVED. PART VI, LINE 3: ASPIRUS KEWEENAW HOSPITAL WILL PROVIDE MEDICALLY ACUTE SERVICES TO PATIENTS WHO MEET THE CRITERIA OF THE PATIENT FINANCIAL ASSISTANCE PROGRAM (PFAP) WITHOUT CHARGE OR AT AMOUNTS LESS THAN ESTABLISHED RATES FOR QUALIFYING PATIENTS. THIS PROGRAM IS PROVIDED FOR PATIENTS WHO ARE UNINSURED, UNDERINSURED, AND/OR MEDICALLY INDIGENT. PATIENTS AND THEIR FAMILIES HAVE A RESPONSIBILITY TO HELP THE HOSPITAL QUALIFY THEM FOR THE APPROPRIATE LEVEL OR TYPE OF FINANCIAL ASSISTANCE GIVEN THEIR CIRCUMSTANCE.A PFAP BROCHURE IS GIVEN TO EACH INPATIENT. THE BROCHURE INFORMS PATIENTS OF OUR PATIENT FINANCIAL ASSISTANCE PROGRAM AND HOW TO APPLY. WE HAVE SIGNS POSTED IN ALL ASPIRUS KEWEENAW HOSPITAL AND CLINIC LOCATIONS THAT LET THE PATIENT KNOW ABOUT OUR PFAP PROGRAM. PFAP BROCHURES ARE DISPLAYED IN PATIENT AREAS OF OUR CLINICS AND HOSPITAL. SIGNS ARE POSTED THROUGHOUT AKH TO INFORM THE PATIENT THAT WE PARTICIPATE IN THE MEDICAID PROGRAM. A NOTICE REGARDING OUR SLIDING FEE SCALE AND HOW TO APPLY FOR IT, IS POSTED AT ALL PHYSICIAN RECEPTION AREAS. ALL BILLERS AND FRONT LINE STAFF DIRECT PATIENT INQUIRIES REGARDING PAYMENT, MEDICAID, AND FINANCIAL ASSISTANCE TO A FINANCIAL COUNSELOR. SELF PAY PATIENTS ARE INFORMED OF THE COST OF HIGH DOLLAR PROCEDURES AND OFFERED OPTIONS FOR PAYMENT AND ASSISTANCE PROGRAMS PRIOR TO SCHEDULING THE PROCEDURE. AN ASPIRUS KEWEENAW SOCIAL WORKER COUNSELS PATIENTS AND MAKES THEM AWARE OF ALL AVAILABLE COMMUNITY RESOURCES, INCLUDING MEDICAID AND OUR AKH PATIENT FINANCIAL ASSISTANCE PROGRAM. SHE ASSISTS THEM IN COMPLETING THE MEDICAID APPLICATION. A FINANCIAL COUNSELOR WILL VISIT THE PATIENT IF REQUESTED DURING THE SOCIAL WORKER INTERVIEW WITH THE PATIENT. FINANCIAL COUNSELORS SUGGEST OUR PFAP TO ELIGIBLE PATIENTS WHILE MAKING PAYMENT ARRANGEMENTS. PART VI, LINE 4: THE ORGANIZATION PROVIDES SERVICES PRIMARILY TO THE ELDERLY AND FRAIL OF NORTHERN HOUGHTON AND KEWEENAW COUNTIES. THE LARGEST CITIES IN THESE REGIONS INCLUDE HOUGHTON, HANCOCK, LAURIUM AND CALUMET. AS A PERCENTAGE OF TOTAL REVENUE, MEDICARE AND MEDICAID COMPRISE OF 47% AND 20%, RESPECTIVELY FOR THE ORGANIZATION. PART VI, LINE 5: THE BOARD OF DIRECTOR'S IS COMPRISED OF INDEPENDENT COMMUNITY MEMBERS. THE ORGANIZATION PROVIDES, FREE OF CHARGE TO THE LOCAL SCHOOL, AN ATHLETIC TRAINER. PART VI, LINE 6: ASPIRUS KEWEENAW IS AN AFFILIATED HEALTH SYSTEM WHICH SERVES THE COMMUNITY SURROUNDING LAURIUM, MICHIGAN. AFFILIATES OF ASPIRUS KEWEENAW PROMOTE THE HEALTH OF THE COMMUNITY BY FULFILLING THEIR INDIVIDUAL MISSIONS. ASPIRUS KEWEENAW PROVIDES PHYSICIAN SERVICES IN OUTPATIENT CLINICS. ASPIRUS KEWEENAW IS ALSO AN AFFILIATE OF ASPIRUS, INC. ASPIRUS IS AN INTERGRATED, COMMUNITY-GOVERNED HEALTH CARE SYSTEM, WHICH LEADS BY ADVANCING INITIATIVES DEDICATED TO IMPROVING THE HEALTH OF ALL WE SERVE. WE WORK COLLABORATIVELY WITH OTHERS WHO SHARE OUR PASSION FOR EXCELLENCE AND COMPASSION FOR PEOPLE. PART VI, LINE 7, REPORTS FILED WITH STATES MI X X 0 0 X X X 1 1 0 0 0 0 0 0 0 MATTHEW HEYWOOD BOARD MEMBER / CEO OF AI 0 572243 0 233564 0 70138 0 10300 0 114128 0 1000373 0 0 CHARLES NELSON BOARD MEMBER / REGIONAL CEO UP 0 237702 0 74736 0 6020 0 13996 0 60312 0 392766 0 0 DARRELL LENTZ BOARD MEMBER / PRESIDENT AWH 0 246521 0 64793 0 4258 0 8993 0 59183 0 383748 0 0 MARIANA PERINOT MD BOARD MEMBER & MEDICAL STAFF TERMED 219623 0 0 0 164 0 0 0 7327 0 227114 0 0 0 ELIZABETH BENYI DO BOARD MEMBER & CHIEF OF STAFF 257254 0 0 0 1023 0 10340 0 6316 0 274933 0 0 0 JOHN HEISLER BOARD MEMBER & SR VP/CHIEF HR OFFICE 0 239916 0 36511 0 11362 0 0 0 44598 0 332387 0 0 JOHN HORAN MD BOARD MEMBER & MEDICAL STAFF REP 369614 0 50000 0 280 0 0 0 10275 0 430169 0 0 0 MICHAEL LUOMA MD BOARD MEMBER TERMED 1/1/2015 211380 0 0 0 5241 0 6346 0 21649 0 244616 0 0 0 RICK NEVERS BOARD MEMBER TERM ENDED 7/22/2014 0 236472 0 74420 0 20212 0 14127 0 57711 0 402942 0 0 SIDNEY C SCZYGELSKI CFO OF AI 0 335544 0 103558 0 6299 0 15500 0 83796 0 544697 0 0 MICHAEL HAUSWIRTH COO 182688 0 30107 0 4653 0 7520 0 21394 0 246362 0 0 0 SHANE JACQUES CFO 163126 0 17544 0 101 0 6694 0 16239 0 203704 0 0 0 GRACE TOUSIGNANT CNO 134338 0 15322 0 906 0 5558 0 17466 0 173590 0 0 0 FREDERICK RAU ORTHOPEDIC SURGEON 490936 0 0 0 4572 0 6028 0 22263 0 523799 0 0 0 SHAHAR MADJAR PHYSICIAN 281695 0 30000 0 488 0 0 0 9265 0 321448 0 0 0 BONNIE HAFEMAN PHYSICIAN 339764 0 0 0 331 0 7577 0 14944 0 362616 0 0 0 JOHN NOVOSAD ANESTHESIOLOGIST 297714 0 0 0 1032 0 10400 0 7604 0 316750 0 0 0 JAMES BLACK ED PHYSICIAN 318926 0 0 0 1346 0 10400 0 22091 0 352763 0 0 0 DUANE ERWIN FORMER CEO OF AI 0 0 0 0 0 576532 0 5100 0 23714 0 605346 0 0 PART I, LINE 1A TRAVEL FOR COMPANIONS, TAX INDEMNIFICATION AND GROSS-UP PAYMENTS, AND HEALTH OR SOCIAL CLUB DUES OR INITIATION FEES, WHEN APPLICABLE, WERE ADDED TO THE INDIVIDUAL'S COMPENSATION AT FAIR VALUE. TRAVEL FOR COMPANIONS: S. SCZYGELSKI $453; M. HEYWOOD $410; C. NELSON $385; J. HEISLER $410; D. LENTZ $390; R. NEVERS $510 - INCLUDED IN INCOME HOUSING ALLOWANCE OR RESIDENCE FOR PERSONAL USE - M. HEYWOOD $65,048; J. HEISLER $3,600 - INCLUDED IN INCOME. PART I, LINE 3 FOR THE PURPOSE OF DETERMINING COMPENSATION, ASPIRUS KEWEENAW HOSPITAL RELIED ON RELATED ORGANIZATIONS TO ESTABLISH COMPENSATION OF THE CEO, OTHER OFFICERS AND KEY EMPLOYEES. THE RELATED ORGANIZATIONS USED THE FOLLOWING PRACTICIES FOR ESTABLISHING COMPENSATION FOR SUCH INDIVIDUAL: COMPENSATION COMMITTEE, INDEPENDENT COMPENSATION CONSULTANT, WRITTEN EMPLOYMENT CONTRACT, COMPENSATION SURVEY OR STUDY, AND APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE. PART I, LINES 4A-B SCHEDULE J, PART I, LINE 4A - SEVERANCE PAYMENT: D. ERWIN $585,957 SCHEDULE J, PART I, LINE 4B - SUPPLEMENTAL NONQUALIFIED RETIREMENT 457(F) DISTRIBUTION: R. NEVERS $17,763 KEY EMPLOYEES OF THE ORGANIZATION OR A PARTICIPATING AFFILIATE ARE ELIGIBLE TO PARTICIPATE IN THE PLAN. THE PLAN YEAR IS JANUARY 1 TO DECEMBER 31ST. EMPLOYER CONTRIBUTIONS: THE CONTRIBUTION MADE BY THE EMPLOYER IS A THREE-TIERED STRUCTURE DEPENDING UPON THE EXECUTIVE'S POSITION, WHICH ARE AS FOLLOWS: 9% FOR VICE PRESIDENT, 13% FOR SENIOR LEADERSHIP COUNCIL, AND 15% FOR THE CEO. IF A PARTICIPANT TERMINATES DURING THE YEAR, THE PARTICIPANT'S EXECUTIVE ALLOWANCE IS PRORATED BASED ON THE NUMBER OF FULL CALENDAR MONTHS FROM THE BEGINNING OF THE PLAN YEAR TO THE BEGINNING OF THE CALENDAR YEAR MONTH CLOSEST TO THE CHANGE OR TERMINATION OF EMPLOYMENT. DISTRIBUTIONS: CONTINUATION OF EMPLOYMENT THROUGH THE DEFERRED VESTING DATE; THE DATE ON WHICH THE PARTICIPANT'S EMPLOYMENT IS TERMINATED AS A RESULT OF DEATH OR DISABILITY; THE DATE ON WHICH THE PARTICIPANT INCURS AN INVOLUNTARY SEPARATION FROM SERVICE WITHOUT REASONABLE CAUSE; OR THE DATE THAT IS 24 MONTHS FOLLOWING THE PARTICIPANT'S SEPARATION FROM SERVICE, BUT ONLY IF THE PARTICIPANT'S INTEREST HAS NOT BEEN FORFEITED FOR COMPETITION DURING SUCH 24 MONTH PERIOD AND THE PARTICIPANT HAS NOT ENGAGED IN COMPETITION AFTER HIS OR HER SEPARATION FROM SERVICE AND PRIOR TO HIS OR HER DEATH, THE PARTICIPANT SHALL BE VESTED AT HIS OR HER DATE OF DEATH. A VILLAGE OF LAURIUM FINANCE AUTHORITY 386007184 2004-03-05 3546723 REFUNDING BOND SERIES 1997 0 0 0 B WISCONSIN HEALTH AND EDUCATIONAL FACILITIES AUTHORITY 391337855 97712DMG9 2015-05-07 16997543 NEW CONSTRUCTION 0 0 0 A 1649034 3546723 3546723 1998 1 0 1 1 B 16997543 230937 7562942 3422222 6012379 0 0 0 1 A 0 0 0 0 0.01000 0.01000 1 0 1 B 0 1 0 0 0.00500 0.00500 1 0 1 A 0 1 0 0 1 0 0 0 0 B 0 1 0 0 0 0 0 0 1 A 1 B 1 SCHEDULE K, PART IV, LINE 7 WE ARE ANALYZING AND EVALUATING POLICIES AND PROCEDURES RELATED TO OUR TAX-EXEMPT BONDS AND WILL UPDATE AS APPROPRIATE. FORM 990, PART VI, SECTION A, LINE 2 JERRY LUOMA AND MICHAEL LUOMA HAVE A FAMILY RELATIONSHIP. FORM 990, PART VI, SECTION A, LINE 6 ASPIRUS, INC. AND KEWEENAW HEALTH FOUNDATION ARE VOTING MEMBERS. FORM 990, PART VI, SECTION A, LINE 7A THE BOARD OF DIRECTORS IS COMPRISED OF 3 MEMBERS FROM ASPIRUS, INC. AND 11 MEMBERS FROM KEWEENAW HEALTH FOUNDATION. FORM 990, PART VI, SECTION A, LINE 7B MAJOR OPERATING DECISION ITEMS UPON APPROVAL BY THE BOARD OF ASPIRUS KEWEENAW HOSPITAL REQUIRE APPROVAL BY THE ASPIRUS, INC. BOARD OF DIRECTORS. FORM 990, PART VI, SECTION B, LINE 11 THE BOARD OF DIRECTORS HAS DELEGATED THE REVIEW PROCESS OF THE FORM 990 TO THE CFO. THE FORM 990 IS MADE AVAILABLE TO ALL BOARD MEMBERS ELECTRONICALLY PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C ANNUALLY, BOARD MEMBERS ARE REQUIRED TO DISCLOSE CONFLICTS TO THE BOARD. AN INTERESTED PERSON MUST DISCLOSE THE EXISTENCE AND NATURE OF HIS OR HER FINANCIAL INTEREST TO THE DIRECTORS AND MEMBERS OF COMMITTEES WITH BOARD DELEGATED POWERS. AN INTERESTED PERSON IS AN DIRECTOR, PRINCIPAL, OFFICER, OR MEMBER OF A COMMITTE WITH BOARD DELEGATED POWERS WHO HAS A DIRECT OR INDIRECT FINANCIAL INTEREST. AFTER DISCLOSURE, THE INTERESTED PERSON SHALL LEAVE THE BOARD OR COMMITTEE MEETING WHILE THE FINANCIAL INTEREST IS DISCUSSED AND VOTED UPON. THE REMAINING MEMBERS SHALL DECIDE IF A CONFLICT EXISTS. THE MEMBER WILL ABSTAIN FROM VOTING ON THIS ISSUE IF A CONFLICT OF INTEREST IS DISCOVERED. FORM 990, PART VI, SECTION B, LINE 15 COMPENSATION IS DETERMINED BY USE OF STATE HOSPITAL ASSOCIATION SURVEY AND SYSTEM SURVEY. THE COMPENSATION OF THE CEO IS DETERMINED BY AN EXECUTIVE COMPENSATION COMMITTEE OF THE BOARD OF DIRECTORS. WAGE DETERMINATION FOR OTHER EXECUTIVE POSITIONS, AN ANNUAL WAGE ANALYSIS IS COMPLETED. THE ORGANIZATION USES SALARY SURVEYS AND SALARY AGENCIES TO DETERMINE THE WAGE SCALE. CONSULTATION ON THE SETTING OF PAY IS PROVIDED TO THE ORGANIZATION BY ASPIRUS, INC. HUMAN RESOURCES. ALL EXECUTIVES ARE ELIGIBLE FOR THE INCENTIVE PLAN ESTABLISHED AND APPROVED BY ASPIRUS, INC. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION HAS DEEMED THAT ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE THE PROPERTY OF THE ORGANIZATION AND ARE NOT AVAILABLE FOR PUBLIC INSPECTION. FORM 990, PART XII, LINE 2C THIS PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. ASPIRUS WAUSAU HOSPITAL INC 333 PINE RIDGE BLVD WAUSAU WI 54401 391138241 HOSPITAL WI 501(C)(3) LINE 3 ASPIRUS INC 1 ASPIRUS BUILDINGS INC 333 PINE RIDGE BLVD WAUSAU WI 54401 391406537 PROPERTY LEASING WI 501(C)(3) LINE 9 ASPIRUS INC 1 ASPIRUS SPECIALISTS INC 425 PINE RIDGE BLVD WAUSAU WI 54401 391945080 MEDICAL SPECIALIST SERVICES WI 501(C)(3) LINE 9 ASPIRUS INC 1 ASPIRUS EXTENDED SERVICES INC 425 PINE RIDGE BLVD WAUSAU WI 54401 390782130 NURSING HOME SERVICES WI 501(C)(3) LINE 9 ASPIRUS INC 1 ASPIRUS CLINICS INC 425 PINE RIDGE BLVD WAUSAU WI 54401 391670223 MEDICAL SERVICES WI 501(C)(3) LINE 9 ASPIRUS INC 1 ASPIRUS ONTONAGON HOSPITAL INC 601 SEVENTH STREET ONTONAGON MI 49953 260806447 HOSPITAL MI 501(C)(3) LINE 3 ASPIRUS INC 1 ASPIRUS VNA HOME HEALTH INC 520 N 32ND AVENUE WAUSAU WI 54401 390808511 HOME HEALTHCARE SERVICES WI 501(C)(3) LINE 9 ASPIRUS INC 1 ASPIRUS VNA EXTENDED CARE INC 520 N 32ND AVENUE WAUSAU WI 54401 391597350 PERSONAL CARE SERVICES WI 501(C)(3) LINE 9 ASPIRUS VNA HOME HEALTH INC 1 ASPIRUS HEALTH FOUNDATION INC 425 PINE RIDGE BLVD WAUSAU WI 54401 391256656 CHARITABLE FOUNDATION WI 501(C)(3) LINE 7 ASPIRUS INC 1 ASPIRUS GRAND VIEW N 10561 GRAND VIEW LANE IRONWOOD MI 49938 382908586 HOSPITAL MI 501(C)(3) LINE 3 ASPIRUS INC 1 GRAND VIEW HOSPITAL AUXILIARY N 10561 GRAND VIEW LANE IRONWOOD MI 49938 237178363 SUPPORTING ORGANIZATION TO HOSPITAL AND LIFELINE EMERGENCY CENTER MI 501(C)(3) LINE 9 ASPIRUS GRAND VIEW 1 ASPIRUS GRAND VIEW SERVICE CORPORATION N 10561 GRAND VIEW LANE IRONWOOD MI 49938 383005582 PHYSICIAN SERVICES MI 501(C)(3) LINE 3 ASPIRUS GRAND VIEW 1 ASPIRUS INC 333 PINE RIDGE BLVD WAUSAU WI 54401 391328331 HEALTH CARE MANAGEMENT SYSTEM WI 501(C)(3) LINE 11B, II N/A 0 ASPIRUS IRON RIVER HOSPITAL & CLINICS INC 1400 W ICE LAKE ROAD IRON RIVER MI 49935 383236977 HOSPITAL MI 501(C)(3) LINE 3 ASPIRUS INC 0 ASPIRUS RIVERVIEW HOSPITAL & CLINICS 410 DEWEY STREET WISCONSIN RAPIDS WI 54494 390868982 HOSPITAL WI 501(C)(3) LINE 3 ASPIRUS INC 1 GREATER IRON COUNTY EMS INC 1400 W ICE LAKE ROAD IRON RIVER MI 49935 383491283 EMERGENCY MEDICAL CARE AND TRANSPORTATION MI 501(C)(3) LINE 11A, I ASPIRUS IRON RIVER HOSPITAL & CLINICS INC 1 ASPIRUS KEWEENAW ENTERPRISES 205 OSCOLA ST LAURIUM MI 49913 383390273 PHARMACY MI ASPIRUS KEWEENAW HOSPITAL C -153358 2229071 1.00000 1 ASPIRUS NETWORK INC 3000 WESTHILL DRIVE 202 WAUSAU WI 54401 391931678 HEALTH CARE SERVICES WI N/A C 1 ASPIRUS GRAND VIEW CARING CAREGIVERS N 10561 GRAND VIEW LANE IRONWOOD MI 49938 382902754 PERSONAL NEEDS SERVICES MI N/A C 1 1 0 0 0 1 0 0 0 0 1 1 1 1 1 1 1 1 0 0 ASPIRUS KEWEENAW ENTERPRISES A 107508 ACTUAL ASPIRUS INC M 2397000 ACTUAL ASPIRUS ONTONAGON HOSPITAL INC L 548000 ACTUAL ASPIRUS GRANDVIEW L 175000 ACTUAL ASPIRUS WAUSAU HOSPITAL INC M 113000 ACTUAL KEWEENAW HEALTH FOUNDATION P 96000 ACTUAL