2015-05-12T14:27:49-05:00 2014-09-30 476097913 SEIM JOHNSON LLP 18081 BURT STREET SUITE 200 OMAHA NE 680224722 990 2013-10-01 470375220 MEMORIAL HEALTH CARE SYSTEMS MEMO 4026432971 300 NORTH COLUMBIA AVENUE SEWARD NE 68434 GREG JERGER CHIEF FINANCIAL OFFICER 4026432971 2015-05-08 1 WENDY R COOLEY P01523804 4023302660 2013 2016-02-25 16:41:14Z GREG JERGER 300 NORTH COLUMBIA AVENUE SEWARD NE 68434 29691519 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 7 277 34 0 0 212699 586262 26900423 27801635 916904 1002695 247547 281481 28277573 29672073 0 0 0 0 15179675 15460327 0 0 0 9874702 10635634 25054377 26095961 3223196 3576112 50463439 55306723 5129738 4882204 45333701 50424519 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 10338869 12889675 HOSPITAL OUTPATIENT SERVICES - THE HOSPITAL PROVIDES OUTPATIENT DIAGNOSTIC, THERAPEUTIC, SURGICAL AND EMERGENCY SERVICES TO THE COMMUNITY. THERE WERE APPROXIMATELY 26,330 OUTPATIENT VISITS THIS YEAR. 5678758 6178253 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 32,759 OFFICE VISITS THIS YEAR. 4316515 5381485 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 5,319 PATIENT DAYS THIS YEAR. 2128553 3486037 FAMILY PHARMACY AND OTHER SERVICES. 2128553 3486037 22462695 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 0 0 0 0 1 49 0 1 277 1 1 1 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 MIKE HECKER CHAIRPERSON 6.00 0.00 X X 0 0 0 LARRY LINDQUIST VICE CHAIR (THRU 12/2013) 5.00 0.00 X X 0 0 0 STEVE KAYTON VICE CHAIR (1/2014 - PRESENT) 4.00 0.00 X X 0 0 0 JAMES SWANSON SECRETARY/TREASURER 5.00 0.00 X X 0 0 0 DONNA HAVENER 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 236785 0 31722 GREG JERGER CHIEF FINANCIAL OFFICER 55.00 0.00 X 228851 0 33669 LORANCE NEWBURN MEDICAL DOCTOR 55.00 0.00 X 389743 0 34081 JAMES PLASEK MEDICAL DOCTOR 55.00 0.00 X 363333 0 36389 JARED KETNER MEDICAL DOCTOR 55.00 0.00 X 291740 0 33891 JOEL GABRIEL MEDICAL DOCTOR 55.00 0.00 X 256370 0 34196 CONNIE NOVAK MEDICAL DOCTOR 55.00 0.00 X 252694 0 36542 2019516 0 240490 17 0 1 0 MEDICAL INFORMATION TECHNOLOGY INC MEDITECH CIRCLE WESTWOOD MA 02090 EHR & FINANCIAL SOFTWARE 1010848 BRYAN MEDICAL CENTER 1600 S 48TH STREET LINCOLN NE 68506 DIAGNOSTIC TESTING 315870 ACUTE CARE INC 1609 N ANKENY BLVD STE 200 ANKENY IA 50023 PHYSICIAN ER SERVICES 231439 SOUTHEAST NEBRASKA MOBILE DIAGNOSTIC SER 245 S 84TH ST STE 111 LINCOLN NE 68510 DIAGNOSTIC TESTING 102875 ALLSCRIPTS HEALTHCARE SOLUTIONS INC 8529 SIX FORKS ROAD RALEIGH NC 27615 EHR & FINANCIAL SOFTWARE 101736 5 586262 586262 PRIVATE INSURANCE 621400 15210733 15210733 MEDICARE 621400 10557125 10557125 SELF PAY 624100 1030262 1030262 MEDICAID 621400 818772 818772 EHR INCENTIVE PAYMENTS 621400 167420 167420 17323 17323 27801635 1018707 1018707 16012 -16012 -16012 -16012 7001 3434 3567 3567 MISCELLANEOUS 624100 138398 133815 4583 DAY CARE REVENUE 624100 99594 99594 DIETARY REVENUE 623990 39922 39922 277914 29672073 27935450 0 1150361 531027 531027 73222 73222 12226302 10668430 1557872 414317 364030 50287 1421534 1235831 185703 793925 668074 125851 23946 23946 28512 28512 66617 66617 2481648 2165924 315724 99501 77236 22265 1443854 1214431 229423 5643 5643 408309 408309 706 706 2063972 1716194 347778 262703 219432 43271 MEDICAL SUPPLIES 3162958 3162958 BAD DEBTS 356799 356799 DUES & SUBSCRIPTIONS 103213 49634 53579 TRAINING & EDUCATION 96119 49413 46706 31134 26429 4705 26095961 22462695 3633266 0 350 350 19228885 24160517 5334301 3541024 564787 623165 393472 280909 32084401 18998323 13290826 13086078 3435028 4775117 7217664 8558199 998126 281364 50463439 55306723 2814036 3098854 2315702 1783350 5129738 4882204 X 36100483 40161186 531678 220408 8701540 10042925 45333701 50424519 50463439 55306723 X 3576112 174171 1340535 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 4408 4408 0 PART II-B, LINE 1: A PORTION OF DUES PAID TO NHA, AHA AND THE CHAMBER OF COMMERCE IS DEDICATED TO LOBBYING ACTIVITIES. 2015554 850 188730 500000 1705134 1779854 15820 219880 2015554 1504413 2945 272496 1779854 1549141 4020 -48748 1504413 655664 823751 69726 1549141 0.00000 0.87070 0.12930 0 0 334557 334557 9896400 6705629 3190771 19703288 11625287 8078001 2150156 667407 1482749 13086078 BENEFICIAL INTEREST IN A PERPETUAL TRUST 8558199 F 8558199 ESTIMATED THIRD PARTY SETTLEMENTS 714218 DEFERRED COMPENSATION LIABILITY 282245 DEFERRED MEDICARE REVENUE 786887 1783350 X 30829980 174171 1340535 1514706 29315274 356799 356799 29672073 25739162 0 25739162 356799 356799 26095961 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 FASB ASC TOPIC 740, 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, 2014, THE SYSTEM HAD NO UNCERTAIN TAX POSITIONS ACCRUED. WITH FEW EXCEPTIONS, THE SYSTEM IS NO LONGER SUBJECT TO INCOME TAX EXAMINATIONS FOR THE YEARS ENDED PRIOR TO 2011. PART XI, LINE 2D - OTHER ADJUSTMENTS: CHANGE IN INTEREST IN BENEFICIAL TRUST 1,340,535. PART XI, LINE 4B - OTHER ADJUSTMENTS: PROVISION FOR BAD DEBTS 356,799. PART XII, LINE 4B - OTHER ADJUSTMENTS: PROVISION FOR BAD DEBTS 356,799. 1 1 1 X 1 X 1 1 0 0 134813 0 134813 0.00520 1047856 808314 239542 0.00930 1182669 808314 374355 0.01450 1182669 808314 374355 0.01450 0 356799 0 10277211 10558404 -281193 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 1 X X X X X X X X X 12 1 0 1 X WWW.MHCS.US X X X X X X X X X 1 0 1 1 150.000000000000 1 250.000000000000 1 X X X 1 1 X X X 1 0 X 1 X 0 0 MEMORIAL HEALTH CARE SYSTEMS PART V, SECTION B, LINE 3: 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, PHYSICIANS 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 14G: THE PATIENT RECEIVES SEVERAL NOTICES THAT CHARITY CARE IS AVAILABLE AT THE HOSPITAL IF THEY MEET THE CHARITY CARE POLICY CRITERIA. THESE NOTICES BEGIN WITH THE ADMISSION PROCESS AND ARE ON ALL BILLING STATEMENTS. PATIENT BILLING STAFF ARE TRAINED TO OFFER CHARITY CARE APPLICATIONS TO ANYONE WHO MAY BE ELIGIBLE. MEMORIAL HEALTH CARE SYSTEMS PART V, SECTION B, LINE 18E: THE HOSPITAL MADE NO SUCH EFFORTS. 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 $356,799. 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: THERE IS NO FOOTNOTE IN THE ORGANIZATION'S FINANCIAL STATEMENTS THAT DESCRIBES BAD DEBT EXPENSE. HOWEVER, THE FOLLOWING IS THE TEXT OF THE FOOTNOTE TITLED "PATIENT ACCOUNTS RECEIVABLE, NET":THE SYSTEM REPORTS PATIENT ACCOUNTS RECEIVABLE FOR SERVICES RENDERED AT NET REALIZABLE AMOUNTS FROM THIRD-PARTY PAYERS, PATIENTS AND OTHERS. ACCOUNTS RECEIVABLE ARE REDUCED BY AN ALLOWANCE FOR DOUBTFUL ACCOUNTS. 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.PAYMENT FOR SERVICES IS EXPECTED WITHIN THIRTY DAYS OF RECEIPT OF THE BILLING. ACCOUNTS CONSIDERED PAST DUE ARE SENT TO COLLECTION AGENCIES WHEN EXTERNAL COLLECTION EFFORTS HAVE BEEN UNSUCCESSFUL. ANY AMOUNTS DEEMED UNCOLLECTIBLE ARE WRITTEN OFF ON A MONTHLY BASIS. THE SYSTEM DOES NOT CHARGE INTEREST ON OUTSTANDING BALANCES OWED.THE FOLLOWING IS THE TEXT OF THE FOOTNOTE TITLED "NET PATIENT SERVICE REVENUE":NET PATIENT SERVICE REVENUE IS REPORTED AT THE ESTIMATED NET REALIZABLE AMOUNTS FROM PATIENTS, THIRD-PARTY PAYORS, AND OTHERS FOR SERVICES RENDERED, INCLUDING ESTIMATED RETROACTIVE ADJUSTMENTS UNDER REIMBURSEMENT AGREEMENTS WITH THIRD-PARTY PAYORS. RETROACTIVE ADJUSTMENTS ARE ACCRUED ON AN ESTIMATED BASIS IN THE PERIOD THE RELATED SERVICES ARE RENDERED AND ADJUSTED IN FUTURE PERIODS AS FINAL SETTLEMENTS ARE DETERMINED.THE FOLLOWING IS THE TEXT OF THE FOOTNOTE TITLED "CHARITY CARE":THE SYSTEM PROVIDES CARE TO PATIENTS WHO MEET CERTAIN CRITERIA UNDER ITS CHARITY CARE POLICY WITHOUT CHARGE OR AT AMOUNTS LESS THAN ITS ESTABLISHED RATES. BECAUSE THE SYSTEM DOES NOT PURSUE COLLECTION OF AMOUNTS DETERMINED TO QUALIFY AS CHARITY CARE, THEY ARE NOT REPORTED IN THE STATEMENTS OF OPERATIONS.THE SYSTEM IS DEDICATED TO PROVIDING COMPREHENSIVE HEALTHCARE SERVICES TO ALL SEGMENTS OF SOCIETY, INCLUDING THE AGED AND OTHERWISE ECONOMICALLY DISADVANTAGED. IN ADDITION, THE SYSTEM PROVIDES A VARIETY OF COMMUNITY HEALTH SERVICES AT OR BELOW COST.THERE IS LIKELY A PORTION OF THE BAD DEBT THAT SHOULD BE CONSIDERED COMMUNITY BENEFITS AS SOME OF THOSE PEOPLE LIKELY WOULD HAVE QUALIFIED FOR CHARITY CARE. HOWEVER, THE ORGANIZATION IS UNABLE TO DETERMINE AN ESTIMATED AMOUNT FOR THIS AND HAVE NOT INCLUDED ANY OF THE COST OF BAD DEBTS ON PART III, LINE 3. PART III, LINE 8: THE ORGANIZATION USED VARIOUS WORKSHEETS FROM THE MEDICARE COST REPORT FOR THE YEAR ENDED SEPTEMBER 30, 2014 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 0 0 1 0 0 0 0 0 ROGER REAMER CHIEF EXECUTIVE OFFICER 201213 0 35572 0 0 0 9251 0 22471 0 268507 0 0 0 GREG JERGER CHIEF FINANCIAL OFFICER 193741 0 35110 0 0 0 9038 0 24631 0 262520 0 0 0 LORANCE NEWBURN MEDICAL DOCTOR 165673 0 223980 0 90 0 10200 0 23881 0 423824 0 0 0 JAMES PLASEK MEDICAL DOCTOR 165673 0 197600 0 60 0 10200 0 26189 0 399722 0 0 0 JARED KETNER MEDICAL DOCTOR 165673 0 125977 0 90 0 10200 0 23691 0 325631 0 0 0 JOEL GABRIEL MEDICAL DOCTOR 165673 0 90649 0 48 0 10200 0 23996 0 290566 0 0 0 CONNIE NOVAK MEDICAL DOCTOR 165673 0 86961 0 60 0 10200 0 26342 0 289236 0 0 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 5 PHYSICIANS RECEIVE BONUSES BASED ON THEIR INDIVIDUAL PROFESSIONAL CHARGES. CYNTHIA WINTER CYNTHIA WINTER IS THE DAUGHTER OF BYRON WINTER, FORMER BOARD MEMBER 73222 CYNTHIA WINTER IS EMPLOYED BY THE HOSPITAL. 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 684 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 AND ENSURING COMPLIANCE WITH ALL RELATED RULES AND REGULATIONS. 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 WILL REVIEW THE FORM 990 AND APPROVE IT FOR SUBMITTAL. A COPY OF THE FORM 990 WILL BE 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 680 MEMBERS OF THE COMMUNITY SERVED. THE CORPORATE MEMBERSHIP APPROVES THE ARTICLES OF INCORPORATION AND THEY RECEIVE AN ANNUAL REPORT OF OPERATIONS CONTAINING SUMMARY FINANCIAL STATEMENTS. FORM 990, PART XI, LINE 9: CHANGE IN INTEREST IN BENEFICIAL TRUST 1,340,535. 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.