2016-08-09T15:14:21-05:00 2015-09-30 476097913 SEIM JOHNSON LLP 18081 BURT STREET SUITE 200 OMAHA NE 680224722 990 2014-10-01 470375220 MEMORIAL HEALTH CARE SYSTEMS MEMO 4026432971 300 NORTH COLUMBIA AVENUE SEWARD NE 68434 GREG JERGER CHIEF FINANCIAL OFFICER 4026432971 2016-08-09 1 WENDY R COOLEY P01523804 4023302660 2014 2016-12-15 16:53:06Z GREG JERGER 300 NORTH COLUMBIA AVENUE SEWARD NE 68434 31469733 0 X WWW.MHCS.US X 1947 NE WE PROVIDE HOSPITAL ACUTE INPATIENT, SKILLED NURSING, AND OUTPATIENT SERVICES FOR THE RESIDENTS OF OUR COMMUNITY. WE PROVIDE FAMILY PRACTICE PHYSICIAN CLINIC SERVICES TO THE COMMUNITIES IN OUR SERVICE AREA. 7 7 280 34 0 0 586262 77857 27801635 30565258 1002695 611701 281481 210522 29672073 31465338 0 0 0 0 15460327 16618566 0 0 0 10635634 12034946 26095961 28653512 3576112 2811826 55306723 58264162 4882204 5515984 50424519 52748178 X WE ENHANCE THE QUALITY OF LIFE FOR INDIVIDUALS IN OUR COMMUNITIES BY PROVIDING EXCELLENCE IN HEALTH CARE SERVICES IN THE MOST APPROPRIATE SETTINGS. 0 0 11598071 14289618 HOSPITAL OUTPATIENT SERVICES - THE HOSPITAL PROVIDES OUTPATIENT DIAGNOSTIC, THERAPEUTIC, SURGICAL AND EMERGENCY SERVICES TO THE COMMUNITY. THERE WERE APPROXIMATELY 27,697 OUTPATIENT VISITS THIS YEAR. 6112394 6637677 FAMILY PRACTICE PHYSICIAN CLINIC SERVICES - THE ORGANIZATION PROVIDES 10 BOARD CERTIFIED FAMILY PRACTICE PHYSICIANS AND 3 PHYSICIAN ASSISTANTS THAT STAFF THE CLINICS IN SEWARD, MILFORD AND UTICA. THESE CLINICS OFFER THE MAIN SOURCE OF PRIMARY CARE FOR THE COMMUNITY. THERE WERE APPROXIMATELY 32,635 OFFICE VISITS THIS YEAR. 4365385 5378453 HOSPITAL ACUTE INPATIENT, SKILLED NURSING AND ASSISTED LIVING SERVICES - THE HOSPITAL PROVIDES THREE DIFFERENT LEVELS OF INPATIENT SERVICES TO THE COMMUNITY TO MEET THE LEVEL OF CARE NEEDS FOR EACH PATIENT, INCLUDING DELIVERY AND NURSING SERVICES. THERE WERE APPROXIMATELY 5,076 PATIENT DAYS THIS YEAR. 2656559 4325232 FAMILY PHARMACY AND OTHER SERVICES. 2656559 4325232 24732409 1 1 0 1 0 0 0 0 0 1 1 1 0 0 1 1 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 1 0 0 0 1 54 0 1 280 1 0 0 0 0 0 0 0 0 0 0 X 7 7 0 0 0 0 1 1 1 1 0 0 0 0 1 1 1 1 1 1 1 0 X GREG JERGER 4026432971 300 NORTH COLUMBIA AVE SEWARD NE 68434 STEVE KAYTON CHAIRPERSON 6.00 0.00 X X 0 0 0 DONNA HAVENER VICE CHAIR 5.00 0.00 X X 0 0 0 JAMES SWANSON SECRETARY/TREASURER 5.00 0.00 X X 0 0 0 MIKE HECKER DIRECTOR 4.00 0.00 X 0 0 0 MIKE KLINTWORTH DIRECTOR 4.00 0.00 X 0 0 0 MARLIN POZEHL DIRECTOR 4.00 0.00 X 0 0 0 TAMMY WISSING DIRECTOR 4.00 0.00 X 0 0 0 ROGER REAMER CHIEF EXECUTIVE OFFICER 55.00 0.00 X 264002 0 34120 GREG JERGER CHIEF FINANCIAL OFFICER 55.00 0.00 X 246110 0 35328 LORANCE NEWBURN MEDICAL DOCTOR 55.00 0.00 X 366443 0 35654 JAMES PLASEK MEDICAL DOCTOR 55.00 0.00 X 354194 0 37962 JARED KETNER MEDICAL DOCTOR 55.00 0.00 X 293040 0 35464 JOEL GABRIEL MEDICAL DOCTOR 55.00 0.00 X 282189 0 35769 ROBERT WERGIN MEDICAL DOCTOR 55.00 0.00 X 975219 0 29148 2781197 0 243445 17 0 1 0 SAMPSON CONSTRUCTION COMPANY 3730 SOUTH 14TH STREET LINCOLN NE 68502 CONSTRUCTION SERVICES 709063 DAVIS DESIGN 1221 N STREET SUITE 600 LINCOLN NE 68508 ARCHITECTURAL SERVICES 451950 BRYAN MEDICAL CENTER 1600 S 48TH STREET LINCOLN NE 68506 DIAGNOSTIC TESTING 312251 ACUTE CARE INC 1606 N ANKENY BLVD STE 200 ANKENY IA 50023 PHYSICIAN ER SERVICES 276709 MEDICAL INFORMATION TECHNOLOGY INC MEDITECH CIRCLE WESTWOOD MA 02090 EHR & FINANCIAL SOFTWARE 176873 15 77857 77857 PRIVATE INSURANCE 621400 17069104 17069104 MEDICARE 621400 11096031 11096031 SELF PAY 624100 1297117 1297117 MEDICAID 621400 1005020 1005020 EHR INCENTIVE PAYMENTS 621400 83157 83157 14829 14829 30565258 607501 607501 4200 0 4200 4200 4200 6875 4395 2480 2480 DAY CARE REVENUE 624100 92562 92562 MISCELLANEOUS 624100 74096 65722 8374 DIETARY REVENUE 623990 41384 41384 208042 31465338 30630980 0 756501 579560 579560 75725 75725 12745174 11128171 1617003 427100 375709 51391 1948910 1679531 269379 842097 707731 134366 34640 34640 29450 29450 60513 60513 2639631 2235137 404494 103845 89053 14792 1364943 1128154 236789 5290 5290 441620 441620 591 591 2059032 1719685 339347 261552 218917 42635 MEDICAL SUPPLIES 3975889 3975889 BAD DEBTS 665546 665546 FOOD 160988 160988 TRAINING & EDUCATION 110547 59418 51129 120869 65254 55615 28653512 24732409 3921103 0 350 1877 24160517 21237637 3541024 3205050 17432 623165 668212 280909 251332 39103755 20642689 13086078 18461066 4775117 5487378 8558199 8619037 281364 315141 55306723 58264162 3098854 4160601 1783350 1355383 4882204 5515984 X 40161186 42439099 220408 203741 10042925 10105338 50424519 52748178 55306723 58264162 X 2811826 -549005 60838 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 4581 4581 0 PART II-B, LINE 1: A PORTION OF DUES PAID TO NHA, AHA AND THE CHAMBER OF COMMERCE IS DEDICATED TO LOBBYING ACTIVITIES. 1705134 1575 -16667 1690042 2015554 850 188730 500000 1705134 1779854 15820 219880 2015554 1504413 2945 272496 1779854 1549141 4020 -48748 1504413 0.00000 0.87940 0.12060 0 0 380521 380521 11199140 7087907 4111233 20801317 12847883 7953434 6722777 706899 6015878 18461066 BENEFICIAL INTEREST IN A PERPETUAL TRUST 8619037 F 8619037 ESTIMATED THIRD-PARTY SETTLEMENTS 473101 DEFERRED COMPENSATION LIABILITY 315952 DEFERRED MEDICARE REVENUE 566330 1355383 X 30311625 -549005 60838 -488167 30799792 665546 665546 31465338 27987966 0 27987966 665546 665546 28653512 PART V, LINE 4: INCOME FROM THE HOSPITAL ENDOWMENT FUND WILL BE USED FOR MEMORIAL HOSPITAL TO ENHANCE AND IMPROVE THE QUALITY OF HOSPITAL SERVICES PROVIDED TO THE COMMUNITY. THIS COULD TAKE THE FORM OF KEEPING UP WITH CHANGING TECHNOLOGY, ACQUIRING THE BEST EQUIPMENT, OR IMPROVING OUR BUILDING FACILITIES. PART X, LINE 2: THE SYSTEM IS A NOT-FOR-PROFIT CORPORATION AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. THE SYSTEM HAS RECEIVED A DETERMINATION LETTER THAT IT IS EXEMPT FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE INTERNAL REVENUE CODE. THE INTERNAL REVENUE SERVICE HAS ESTABLISHED STANDARDS TO BE MET TO MAINTAIN TAX EXEMPT STATUS. IN GENERAL, SUCH STANDARDS REQUIRE THE SYSTEM TO MEET A COMMUNITY BENEFIT STANDARD AND COMPLY WITH VARIOUS LAWS AND REGULATIONS. THE SYSTEM ACCOUNTS FOR UNCERTAINTIES IN ACCOUNTING FOR INCOME TAX ASSETS AND LIABILITIES USING GUIDANCE INCLUDED IN INCLUDED IN TOPIC 740 OF THE ACCOUNTING STANDARDS CODIFICATION, INCOME TAXES. THE SYSTEM RECOGNIZES THE EFFECT OF INCOME TAX POSITIONS ONLY IF THOSE POSITIONS ARE MORE LIKELY THAN NOT OF BEING SUSTAINED. AT SEPTEMBER 30, 2015 AND 2014, THE SYSTEM HAD NO UNCERTAIN TAX POSITIONS ACCRUED. PART XI, LINE 2D - OTHER ADJUSTMENTS: CHANGE IN INTEREST IN BENEFICIAL TRUST 60,838. PART XI, LINE 4B - OTHER ADJUSTMENTS: PROVISION FOR BAD DEBTS 665,546. PART XII, LINE 4B - OTHER ADJUSTMENTS: PROVISION FOR BAD DEBTS 665,546. 1 1 1 X 1 X 1 1 0 0 64727 0 64727 0.00230 1281334 1013571 267763 0.00960 1346061 1013571 332490 0.01190 1346061 1013571 332490 0.01190 0 665564 0 11082729 11375318 -292589 X 1 1 1 1 MEMORIAL HOSPITAL 300 N COLUMBIA AVE SEWARD NE 68434 WWW.MHCS.US 720001 X X X X MEMORIAL HEALTH CARE SYSTEMS 1 0 0 1 X X X X X X X X X 12 1 0 0 1 X WWW.MHCS.US X 1 12 1 WWW.MHCS.US 0 0 1 X 150.000000000000 250.000000000000 X X 1 1 X X X 1 X X X X 1 X 0 X X X 1 X 0 0 MEMORIAL HEALTH CARE SYSTEMS PART V, SECTION B, LINE 5: THERE WERE A TOTAL OF 51 INDIVIDUALS THAT COLLABORATED ON MEMORIAL HEALTH CARE SYSTEMS' COMMUNITY HEALTH NEEDS ASSESSMENT. THESE INDIVIDUALS REPRESENTED A WIDE VARIETY OF COMMUNITY INTERESTS, INCLUDING HEALTH DEPARTMENTS, PUBLIC SCHOOLS, PHYSICIAN PRACTICES, MENTAL HEALTH, NURSING HOMES AND VARIOUS COMMUNITY REPRESENTATIVES. THIS COMMUNITY TEAM USED A PROCESS DEVELOPED BY THE CENTERS FOR DISEASE CONTROL AND PREVENTION (CDC) AND THE NATIONAL ASSOCIATIONS OF CITY AND COUNTY HEALTH OFFICIALS. THIS PROCESS IS CALLED MOBILIZING FOR ACTION THROUGH PLANNING AND PARTNERSHIPS (MAPP) AND IT WAS USED TO PRIORITIZE PUBLIC HEALTH ISSUES AND IDENTIFY RESOURCES FOR ADDRESSING THEM. MEMORIAL HEALTH CARE SYSTEMS PART V, SECTION B, LINE 11: THERE WERE 9 HEALTH NEEDS IDENTIFIED IN THE NEEDS ASSESSMENT. MEMORIAL HEALTH CARE SYSTEMS (MHCS) DIRECTLY ADDRESSES 6 OF THESE 9 NEEDS AS FOLLOWS. 1. ACCESS TO MEDICAL CARE - MHCS CONTINUES TO PROVIDE READILY ACCESSIBLE HIGH QUALITY PRIMARY, OBSTETRICAL, MEDICAL, SURGICAL, AND PEDIATRIC HEALTH CARE PROGRAMS AND SERVICES TO MEET THIS NEED. 2. CANCER - MHCS STAFF IS TRAINED TO ADMINISTER INFUSION THERAPY AND PROVIDE CARE TO PATIENTS RECEIVING CHEMOTHERAPY AND RELATED CANCER TREATMENTS. 3. HEALTHY LIFESTYLE, OBESITY - MHCS PROVIDES EFFORTS TO COMBAT CHILDHOOD OBESITY THROUGH ITS "BLAST OFF FOR HEALTHY KIDS" PROGRAM. MONTHLY COMMUNITY WELLNESS TALKS ARE HELD TO ADDRESS A HEALTHY LIFESTYLE. 4. DOMESTIC VIOLENCE - MHCS WILL PROVIDE EMERGENCY TREATMENT TO INDIVIDUALS AFFECTED AS NEEDED. REFERRALS WILL BE MADE TO THE APPROPRIATE RESOURCES. 5. HEALTHY HEART - MHCS OFFERS CARDIAC REHABILITATION SERVICES TO PATIENTS AFFECTED BY HEART DISEASE. 6. DIABETES - MHCS PROVIDES TREATMENT FOR PATIENTS WITH DIABETES. MHCS ALSO OFFERS DIABETIC EDUCATION AND SUPPORT GROUPS.THERE WERE 9 HEALTH NEEDS IDENTIFIED IN THE NEEDS ASSESSMENT. MEMORIAL HEALTH CARE SYSTEMS (MHCS) DIRECTLY ADDRESSES 6 OF THESE BUT WAS UNABLE TO ADDRESS 3 OF THEM AS FOLLOWS. 1. SUBSTANCE ABUSE - MHCS DOES NOT HAVE THE RESOURCES FOR FACILITIES AND STAFF TRAINED IN SUBSTANCE ABUSE TREATMENT. MHCS WILL KEEP ITSELF INFORMED OF SUBSTANCE ABUSE RESOURCES OUTSIDE OF THE COUNTY AND MAKE REFERRALS AS NEEDED. 2. BEHAVIORAL HEALTH - MHCS DOES NOT HAVE THE RESOURCES FOR FACILITIES AND STAFF TRAINED IN BEHAVIORAL HEALTH. MHCS WILL KEEP ITSELF INFORMED OF BEHAVIORAL HEALTH RESOURCES OUTSIDE OF THE COUNTY AND MAKE REFERRALS AS NEEDED. 3. MOTOR VEHICLE DEATHS - MHCS DOES NOT HAVE THE RESOURCES TO PROVIDE COMMUNITY ASSISTANCE RELATED TO MOTOR VEHICLE DEATHS. MHCS WILL REFER TO APPROPRIATE SOURCES AS NEEDED. MEMORIAL HEALTH CARE SYSTEMS PART V, SECTION B, LINE 16I: PATIENTS ARE NOTIFIED OF THE AVAILABILITY OF FINANCIAL ASSISTANCE FOR HOSPITAL SERVICES IF THEY MEET THE CHARITY CARE POLICY CRITERIA THROUGH A WIDE RANGE OF SOURCES. NOTICES OF THE AVAILABILITY OF FINANCIAL ASSISTANCE ARE POSTED IN THE EMERGENCY DEPARTMENT AND IN ALL HOSPITAL ADMISSION AREAS. PATIENTS ARE NOTIFIED OF THE AVAILABILITY OF FINANCIAL ASSISTANCE UPON ADMISSION. NOTICES OF THE AVAILABILITY OF FINANCIAL ASSISTANCE ARE ALSO INCLUDED ON ALL STATEMENTS SENT TO PATIENTS OR THE RESPONSIBLE BILLING PARTY. A SIMILAR NOTICE IS POSTED ON THE HOSPITAL'S WEBSITE. PATIENT BILLING STAFF ARE TRAINED TO OFFER CHARITY CARE APPLICATIONS TO ANYONE WHO MAY BE ELIGIBLE. PART V, SECTION B, LINE 10A: THE IMPLEMENTATION STRATEGY IS REPORTED ON PAGE 11 AND 12 OF THE COMMUNITY HEALTH NEEDS ASSESSMENT THAT IS POSTED ON THE WEBSITE AT WWW.MHCS.US. 4 SEWARD FAMILY MEDICAL CENTER 250 N COLUMBIA AVE SEWARD NE 68434 RURAL HEALTH CLINIC SEWARD FAMILY PHARMACY 250 N COLUMBIA AVE SEWARD NE 68434 PHARMACY - CONVENIENCE OF PATIENT/EMPLOYEE MILFORD FAMILY MEDICAL CENTER 119 S C ST MILFORD NE 68405 RURAL HEALTH CLINIC UTICA FAMILY MEDICAL CENTER 100 4TH ST UTICA NE 68456 RURAL HEALTH CLINIC PART I, LINE 3C: NOT APPLICABLE PART I, LINE 7: THE ORGANIZATION USED THE COST-TO-CHARGE RATIO FROM WORKSHEET 2, RATIO OF PATIENT CARE COST-TO-CHARGES, PROVIDED BY THE IRS IN THE INSTRUCTIONS OF FORM 990, SCHEDULE H. PART I, LINE 7G: THERE ARE NO COSTS REPORTED ON LINE 7G. THEREFORE, THERE WOULD BE NO COSTS ATTRIBUTABLE TO A PHYSICIAN CLINIC INCLUDED ON LINE 7G. PART I, LN 7 COL(F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 24, COLUMN (A) BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $665,546. PART II, COMMUNITY BUILDING ACTIVITIES: THERE ARE NO COMMUNITY BUILDING ACTIVITIES TO REPORT. PART III, LINE 2: IN EVALUATING THE COLLECTIBILITY OF ACCOUNTS RECEIVABLE, THE SYSTEM ANALYZES ITS PAST HISTORY AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYOR SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND 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. FOR RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE THIRD-PARTY COVERAGE, THE SYSTEM ANALYZES CONTRACTUALLY DUE AMOUNTS AND ESTIMATES A PERCENTAGE OF THOSE ACCOUNTS THAT WILL TRANSITION TO SELF-PAY PATIENTS BASED ON HISTORICAL ANALYSIS. THE ESTIMATED PERCENTAGE OF THOSE TRANSITION ACCOUNTS ARE ADDED TO 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 SYSTEM 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 4: THE HOSPITAL'S FINANCIAL STATMENTS DO NOT CONTAIN A SPECIFIC FOOTNOTE DESCRIBING BAD DEBT. HOWEVER, PAGES 8 AND 10 OF THE ATTACHED AUDITED FINANCIAL STATEMENTS INCLUDE FOOTNOTES TITLED "PATIENT RECEIVABLES, NET", "NET PATIENT SERVICE REVENUE AND "CHARITY CARE". PART III, LINE 8: THE ORGANIZATION USED VARIOUS WORKSHEETS FROM THE MEDICARE COST REPORT FOR THE YEAR ENDED SEPTEMBER 30, 2015 TO CALCULATE PART III, LINES 5 AND 6. MEDICARE CURRENTLY PAYS CRITICAL ACCESS HOSPITALS (CAH) 101% OF ALLOWABLE COSTS. MEDICARE PAYS THE ORGANIZATION'S RURAL HEALTH CLINICS (RHC) AT COST SUBJECT TO CERTAIN LIMITS. THERE IS GENERALLY NO MEDICARE SHORTFALL ON CAH SERVICES. THE SHORTFALL IS MAINLY GENERATED BY NON-RHC PHYSICIAN SERVICES THAT ARE PAID UNDER THE MEDICARE FEE SCHEDULE. MEDICARE SHORTFALLS IN PAYMENT SHOULD BE CONSIDERED A COMMUNITY BENEFIT AS IT IS PART OF THE ORGANIZATION'S MISSION TO PROVIDE THESE SERVICES EVEN IF MEDICARE REIMBURSEMENT IS BELOW COST. PART III, LINE 9B: PATIENTS THAT ARE KNOWN TO QUALIFY FOR CHARITY CARE EITHER RECEIVE FREE EMERGENCY AND URGENT CARE IN THE HOSPITAL IF THEY ARE AT OR BELOW 150% OF POVERTY, OR A SLIDING DISCOUNT IF THEY ARE AT OR BELOW 250% OF POVERTY. SHOULD THESE PATIENTS OWE A PORTION OF THEIR BILL, THE ORGANIZATION FOLLOWS THE SAME COLLECTION POLICY AS IT DOES FOR PATIENTS WHO DO NOT QUALIFY FOR CHARITY CARE. PART VI, LINE 2: THE ORGANIZATION IS GOVERNED BY A VOLUNTEER BOARD OF DIRECTORS WHICH HAS 7 MEMBERS FROM THE COMMUNITY. THE BOARD OF DIRECTORS ASSISTS HOSPITAL ADMINISTRATION IN IDENTIFYING SERVICES NEEDED BY THE COMMUNITIES SERVED. PART VI, LINE 3: THE BUSINESS OFFICE IS EDUCATED ON HOW TO INFORM PATIENTS ABOUT THE PROCESS OF APPLYING FOR MEDICAID COVERAGE. THE OPPORTUNITY FOR FINANCIAL ASSISTANCE THROUGH OUR CHARITY CARE POLICY IS LISTED ON THE ORGANIZATION'S WEB-SITE, AND A STATEMENT ABOUT THIS IS INCLUDED WITH THE FINANCIAL AGREEMENT EACH PATIENT SIGNS AND IS ALSO INCLUDED WITH BILLINGS STATEMENTS SENT TO THE PATIENT. PART VI, LINE 4: THE ORGANIZATION'S PRIMARY SERVICE AREA IS SEWARD COUNTY, NEBRASKA, WHICH HAS A POPULATION OF AROUND 17,000. IT MAINLY PROVIDES PRIMARY CARE SERVICES WITH SOME SPECIALTY CARE OFFERED BY VISITING SPECIALISTS THAT PRACTICE HERE MAINLY OUT OF LINCOLN, NEBRASKA. PART VI, LINE 5: THE ORGANIZATION OFFERS EXTENSIVE HEALTHCARE AND WELLNESS EDUCATION TO THE COMMUNITY ON AN ON-GOING BASIS. THE COSTS FOR THESE SERVICES ARE NOT SEPARATELY IDENTIFIED AS "COMMUNITY BENEFIT" EXPENSES ELSEWHERE IN THIS RETURN. IT IS LIKELY THESE COSTS EXCEED $100,000 PER YEAR, AND THERE IS NO OFFSETTING REVENUE. THE HOSPITAL MAINTAINS AN OPEN MEDICAL STAFF AND HAS A GOVERNING BOARD OF DIRECTORS WHICH ARE ALL MEMBERS OF THE COMMUNITY SERVED. ALL SURPLUS FUNDS ARE USED TO FURTHER THE MISSION OF PROVIDING EXCELLENT HEALTHCARE SERVICES TO THE MEMBERS OF THE COMMUNITIES SERVED. PART VI, LINE 6: N/A X 1 1 X X X 0 1 0 1 0 0 0 0 0 ROGER REAMER CHIEF EXECUTIVE OFFICER 226244 0 37758 0 0 0 10276 0 23844 0 298122 0 0 0 GREG JERGER CHIEF FINANCIAL OFFICER 209639 0 36471 0 0 0 9684 0 25644 0 281438 0 0 0 LORANCE NEWBURN MEDICAL DOCTOR 170643 0 195710 0 90 0 10400 0 25254 0 402097 0 0 0 JAMES PLASEK MEDICAL DOCTOR 170643 0 183491 0 60 0 10400 0 27562 0 392156 0 0 0 JARED KETNER MEDICAL DOCTOR 170643 0 122307 0 90 0 10400 0 25064 0 328504 0 0 0 JOEL GABRIEL MEDICAL DOCTOR 170643 0 111498 0 48 0 10400 0 25369 0 317958 0 0 0 ROBERT WERGIN MEDICAL DOCTOR 98423 0 72444 0 804352 0 18400 0 10748 0 1004367 0 803956 0 PART I, LINE 1A THE ORGANIZATION PROVIDES A SECTION 162 BONUS PLAN IN WHICH THE CHIEF EXECUTIVE OFFICER AND CHIEF FINANCIAL OFFICER RECEIVE TAXABLE COMPENSATION ON AN ANNUAL BASIS TO PURCHASE LIFE INSURANCE AND/OR DISABILITY INSURANCE. THE BONUS PLAN AND AMOUNT WERE ESTABLISHED BY THE BOARD OF DIRECTORS AND ARE GROSSED-UP PER THE PLAN DESIGN IN ORDER TO PROVIDE A FIXED AMOUNT AFTER TAXES THAT IS AVAILABLE FOR INSURANCE PREMIUMS. THE FULL TAXABLE AMOUNT IS INCLUDED IN BOX 5 OF THE W-2 AND HAS BEEN INCLUDED IN PART II OF THIS SCHEDULE J UNDER COLUMN B(II). PART I, LINE 4B DR. WERGIN RECEIVED THE ENTIRE BALANCE FROM HIS 457(F) PLAN AS TAXABLE COMPENSATION IN 2014. THE 457(F) PLAN REQUIRED THAT HE CONTINUE EMPLOYMENT WITH MEMORIAL HEALTH CARE SYSTEMS UNTIL HE REACHED AGE 60. HE TURNED 60 IN 2014 AND THE RETIREMENT PLAN WAS CASHED OUT. OVER THE LIFE OF THE PLAN, HE DEFERRED A TOTAL OF $654,600 (FROM 5/1996 TO 4/2004). THE EMPLOYEE DEFERRALS OCCURED PRIOR TO THE FORM 990 REVISIONS IN 2008 AND WERE NOT REQUIRED TO BE REPORTED ON PREVIOUSLY FILED FORMS 990. THE AMOUNT OF TAXABLE COMPENSATION INCLUDED ON HIS 2014 FORM W-2 WAS $803,956, WHICH ALSO INCLUDED THE INVESTMENT EARNINGS. PART I, LINE 5 PHYSICIANS RECEIVE BONUSES BASED ON THEIR INDIVIDUAL PROFESSIONAL CHARGES. CYNTHIA WINTER EMPLOYEE OF ORGANIZATION & DAUGHTER OF BYRON WINTER, FORMER BOARD MEMBER 75725 EMPLOYEES W-2 WAGES 0 FORM 990, PART VI, SECTION A, LINE 6 MEMORIAL HEALTH CARE SYSTEMS IS A CORPORATION THAT HAS MEMBERS. ANYONE DONATING $100 TO MEMORIAL HEALTH CARE SYSTEMS CAN FILL OUT AN APPLICATION AND BECOME A MEMBER. MEMORIAL HEALTH CARE SYSTEMS CURRENTLY HAS ABOUT 694 CORPORATE MEMBERS. FORM 990, PART VI, SECTION A, LINE 7A THE MEMBERS OF MEMORIAL HEALTH CARE SYSTEMS (AS DESCRIBED ON FORM 990, PART VI, SECTION A, LINE 6) ELECT THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION A, LINE 7B THE MEMBERS OF MEMORIAL HEALTH CARE SYSTEMS (AS DESCRIBED ON FORM 990, PART VI, SECTION A, LINE 6) APPROVE ANY CHANGES IN THE ARTICLES OF INCORPORATION AND ANY CHANGES TO THE BYLAWS THAT EFFECT THE ELECTION OF THE BOARD OF DIRECTORS (VOTING RIGHTS). THE MEMBERS WOULD ALSO APPROVE ANY SIGNIFICANT DECISIONS, SUCH AS THE SALE OR MERGER OF THE CORPORATION OR A SALE OF ALL OF THE ASSETS OF THE CORPORATION. FORM 990, PART VI, SECTION A, LINE 8B THERE ARE NO COMMITTEES WITH THE AUTHORITY TO ACT ON BEHALF OF THE BOARD. ANY COMMITTEE WHICH REPORTS TO THE BOARD HAS ITS REPORT DOCUMENTED IN THE MINUTES OF THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION B, LINE 11 THE CHIEF FINANCIAL OFFICER IS RESPONSIBLE FOR THE TIMELY FILING OF THE FORM 990. THE ACTUAL FORM 990 IS PREPARED BY AN INDEPENDENT ACCOUNTING FIRM. ALL INFORMATION IS PROVIDED BY THE ORGANIZATION TO THE ACCOUNTING FIRM WHO THEN PREPARES THE FORM 990 FOR SUBMITTAL TO THE IRS. PRIOR TO SUBMISSION TO THE IRS, THE CFO OF THE ORGANIZATION REVIEWS THE FORM 990 AND APPROVES IT FOR SUBMITTAL. THE FORM 990 IS GENERALLY NOT AVAILABLE TO DISTRIBUTE TO THE BOARD PRIOR TO FILING DUE TO THE FILING DEADLINE. A COPY OF THE FORM 990 IS MADE AVAILABLE TO THE BOARD OF DIRECTORS AFTER THE FORM 990 IS FILED. FORM 990, PART VI, SECTION B, LINE 12C EACH MEMBER OF THE BOARD OF DIRECTORS AND ALL SENIOR MANAGEMENT OFFICIALS OF THE ORGANIZATION FILE AN ANNUAL CONFLICT OF INTEREST FORM IN WHICH THEY ARE REQUIRED TO LIST ALL CONFLICTS OF INTEREST. ADMINISTRATION REVIEWS THE ANNUAL CONFLICT OF INTEREST STATEMENTS AND ALL CONFLICTS ARE REPORTED TO THE BOARD CHAIRPERSON. FORM 990, PART VI, SECTION B, LINE 15 THE BOARD OF DIRECTORS PERFORMS AN ANALYSIS OF THE FAIR MARKET VALUE OF COMPENSATION FOR BOTH THE CHIEF EXECUTIVE OFFICER AND CHIEF FINANCIAL OFFICER. LONGEVITY, QUALITY OF THE HEALTHCARE SERVICES PROVIDED, COMMUNITY PERCEPTION, AND FINANCIAL PERFORMANCE ARE ALL FACTORED INTO THE ANALYSIS. THE BOARD OF DIRECTORS THEN APPROVES THE COMPENSATION PACKAGES. THE LAST FULL REVIEW AND ANALYSIS WAS DONE IN AUGUST 2013 AND ANNUAL COMPENSATION WAS SET UNDER THE CEO CONTRACT FOR A 5 YEAR PERIOD OF 2014 THROUGH 2018. THE CFO COMPENSATION WAS REVIEWED BY THE BOARD OF DIRECTORS AT THE SAME TIME AND THE CEO WAS DELEGATED THE AUTHORITY TO ADJUST AND MONITOR CFO COMPENSATION WITHIN THE PARAMETERS SET BY THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION DOES NOT MAKE ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, OR ITS FINANCIAL STATEMENTS AVAILABLE TO THE GENERAL PUBLIC. HOWEVER, THE CORPORATE MEMBERSHIP OF THE ORGANIZATION CONSISTS OF OVER 690 MEMBERS OF THE COMMUNITY SERVED. THE CORPORATE MEMBERSHIP APPROVES THE ARTICLES OF INCORPORATION. FORM 990, PART XI, LINE 9: CHANGE IN INTEREST IN BENEFICIAL TRUST 60,838. FORM 990, PART XI, LINE 2C: THE FINANCE COMMITTEE OF THE BOARD OF DIRECTORS ASSUMES RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT OF ITS FINANCIAL STATEMENTS AND SELECTION OF THE INDEPENDENT ACCOUNTANT. THIS PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. CHARITABLE TRUST TRUST NE N/A T 0.65000 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1