2014-11-03T12:57:56-07:00 2013-12-31 202707086 TCA Partners LLP 1111 E Herndon Avenue Suite 211 Fresno CA 93720 990 2013-01-01 860732836 Cobre Valley Regional Medical Center COBR 9284253261 5880 S Hospital Drive Globe AZ 85501 Neal Jensen Chief Executive Officer 9284253261 2014-04-15 1 Jeremy Ware P00642659 5594317708 2014-04-15 2013 2015-11-30 17:44:51Z Neal Jensen 5880 S Hospital Drive Globe AZ 85501 37560530 0 X www.cvrmc.org X 1988 AZ The Organization will provide medical services which will be competitive with those charged for similar services by comparable facilities. The Organization will also allow a portion of its services and facilities to be used for charity patients. 8 8 332 50 0 0 98658 20297 36799904 36553655 271600 659149 351079 327429 37521241 37560530 0 0 18937222 19290073 0 0 16557637 17245304 35494859 36535377 2026382 1025153 43588938 43290880 13839199 12493375 29749739 30797505 The Mission of our Hospital is to develop and maintain a local health care delivery system that serves the region with quality, efficiency and compassion. Our mission is your health. 0 0 30091325 0 37560530 The organization will provide medical services which will be competitive with those charged for similar services by comparable facilities. The organization will also allow a portion of its services and facilities to be used for charity patients. Along with providing acute health care services to the community as a non-profit entity, Cobre Valley Regional Medical Center hosts many educational programs available to the residents in the service area. The hospital and staff host and sponsor an annual health fair working with other area agencies to distribute and disseminate health, wellness, and information. The Hospital also sponsors diabetic workshops, birthing and new baby care classes. The Emergency Department at CVRMC is the base station for the other departments in the service area. CVRMC is also the clinical training site for students attending nursing programs at Gila Community College and Eastern Arizona Community College. 0 0 0 30091325 1 0 0 1 0 0 0 0 0 0 1 0 0 1 1 0 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 252 0 1 332 1 0 0 0 0 0 0 X 8 8 0 1 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 AZ X James Childers 9284021123 5880 S Hospital Drive Globe AZ 85501 Byron Belew Chairperson 1 0 X 0 0 0 Ed Carpenter Director 1 0 X 0 0 0 Fernando Shipley Treasurer 1 0 X 0 0 0 Jim Rasmussen Vice Chairman 1 0 X 0 0 0 Janice Cook Secretary 1 0 X 0 0 0 Jendean Sartain Director 1 0 X 0 0 0 Gary Gustason Director 1 0 X 0 0 0 Brad Werrell Director 1 0 X 0 0 0 Joseph Ring Director 1 0 X 0 0 0 Dana Miller Physician 40 0 X 448174 0 0 Stephens Triplett Physician 40 0 X 351000 0 0 Binoy Chandra Physician 40 0 X 329277 0 0 Phuong Nguyen Physician 40 0 X 306055 0 0 Werner Andrade Ortiz Physician 40 0 X 278693 0 0 1713199 0 0 30 0 1 0 HealthTech Management Services Inc 405 Duke Drive Suite 2012 Franklin TN 37067 Management Services 1046898 Cobre Valley Heart Institute 2055 Highway 60 Globe AZ 85501 Cardiologist 527638 VTR Cobre Valley PO Box 846208 Dallas TX 75284 Rent and associated services 344259 SHC Services PO Box 27124 Salt Lake City UT 84127 Contract Labor 315037 ARUP Laboratories PO Box 27964 Salt Lake City UT 84127 Lab Testing 219223 11 0 0 0 0 0 20297 0 20297 Net Patient Service Revenue 622000 36553655 36553655 0 0 0 0 0 0 36553655 659149 0 0 659149 0 0 0 0 0 0 0 0 113980 0 0 0 113980 0 113980 0 0 113980 0 0 0 213449 213449 0 0 213449 37560530 36767104 0 773129 X 15949473 12962105 2987368 3340600 2505450 835150 6244255 4683191 1561064 288935 216701 72234 585609 439207 146402 387585 290689 96896 2180129 1651083 529046 425318 318989 106329 Medical Supplies 5895216 5895216 0 0 1238257 1128694 109563 36535377 30091325 6444052 0 44159 2772095 18261228 13338734 5569572 6230467 1334398 1308738 316938 422132 44458386 27749748 16124238 16708638 1938405 2510076 43588938 43290880 4511344 3655375 6065000 5745000 2498653 1758907 764202 1334093 13839199 12493375 X 29332361 30338171 417378 459334 0 0 29749739 30797505 43588938 43290880 1025153 22613 0 0 0 0 X 0 1 X 1 0 X 0 0 0 0 0 1 2975 0 0 0 2975 0 Schedule C, Part II-B, Line 1 A portion of the annual dues paid to the Arizona Hospital and Healthcare Association are used for lobbying. 0 904177 904177 0 19783048 0 19783048 0 0 0 0 0 20523894 27749748 -7225854 0 3247267 0 3247267 16708638 Bond Issuance Costs 254543 Other Receivables 1046240 Assets limited as to use 1209293 2510076 0 Estimated third party settlements 498149 Accrued Retiree Health 835944 1334093 37560530 0 0 0 0 0 37560530 0 0 0 37560530 36535377 0 0 0 0 0 36535377 0 0 0 36535377 1 1 X 1 X 1 X 1 1 0 1 1 2788719 9042176 0 14455333 0 0 26286228 0 0 0 26 1302060 844122 5751 0 0 0 0 26 1302060 844122 5751 0 0 26 1302060 27130350 5751 0 0 1 4687644 0 13169075 14066085 -897010 X 1 1 1 1 Cobre Valley Regional Medical Center 5880 South Hospital Drive Globe AZ 85501 www.cvrmc.org X X X X Cobre Valley Regional Medical Center 1 1 X X X X X X X X 13 1 0 1 X cvrmc.org X X X X X X X X 1 0 1 1 100 1 400 1 X X X X X X X X 1 1 X X X 1 0 X X X X 1 X 0 0 Schedule H, Part V, Section B, Line 3-Cobre Valley Regional Medical Center CVRMC uses outpatient surveys, Hospital Consumers Assessment of Healthcare Providers and Systems, and direct feedback to properly assess the needs of the communities it serves. 4 Cobre Valley Surgical Services 5860 South Hospital Drive Globe AZ 85501 Surgical Clinic. Schedule H, Part I, Line 7 The costing methodology is Cost to Charge Ratio. Schedule H, Part III, Section A, Line 4 PATIENT ACCOUNTS RECEIVABLE CONSIST OF AMOUNTS OWED BY VARIOUS GOVERNMENTAL AGENCIES, INSURANCE COMPANIES AND PRIVATE PATIENTS. THE HOSPITAL MANAGES ITS RECEIVABLES BY REGULARLY REVIEWING THE ACCOUNTS, INQUIRING WITH RESPECTIVE PAYORS AS TO COLLECTIBILITY AND PROVIDING FOR ALLOWANCES ON THEIR ACCOUNTING RECORDS FOR ESTIMATED CONTRACTUAL ADJUSTMENTS AND UNCOLLECTIBLE ACCOUNTS. Schedule H, Part III, Section B, Line 8 The annual Medicare cost report is the source for the costing methodology. Schedule H, Part III, Section C, Line 9b CVRMC MANAGEMENT SHALL DEVELOP POLICIES AND PROCEDURES FOR INTERNAL AND EXTERNAL COLLECTION PRACTICES THAT TAKE INTO ACCOUNT THE EXTENT TO WHICH THE PATIENT QUALIFIES FOR FINANCIAL ASSISTANCE, A PATIENT'S GOOD FAITH EFFORT TO APPLY FOR A GOVERNMENTAL PROGRAM OR FOR FINANCIAL ASSISTANCE FROM CVRMC, AND A PATIENT'S GOOD FAITH EFFORT TO COMPLY WITH HIS OR HER PAYMENT AGREEMENTS WITH CVRMC. Schedule H, Part VI, Line 2 QUESTION 2 NEEDS ASSESSMENT: Describe how the organization assesses the health care needs of the communities it serves. Cobre Valley Regional Medical Center (CVRMC) completed our Community Health Needs Assessment in October of 2013. The Cobre Valley Community Health Needs Advisory Board consists of representatives of city government, county government, chambers of commerce, economic development, industry and business, public education, technology education, higher education, physicians, skilled nursing facilities, nursing homes, mental health professionals, county health, religious leaders, and service organizations. The first step in the process was to accumulate information related to the health of the community from sources such as the Environmental Assessment and Market Share Report (HealthTech) and The Gila County Health Department Community Health Improvement Plan. The Cobre Valley Community Health Needs Advisory Board was organized to share ideas, information, and to develop a survey which was used to gather more data for the assessment. From this data and resource information, five key areas of health issues and needs were identified: 1.Urgent Care 2. Access to Care 3. Specialty Services 4. Mental Health 5. Preventative Care The Community Health Needs Implementation Plan is a strategic plan of action to address the identified concerns. Currently, CVRMC utilizes several methods of assessing community health care needs. Evaluating the health needs of the CVRMC service area leads to identifying physicians needed in the area as well as recognizing those illnesses which can be targeted for community education and intervention. Community Feedback CVRMC utilizes many methods of community feedback for needs determination. Our patients, their families, and the greater community enlighten our organization through patient surveys and direct comments. CVRMC strives to give the very best care and in order to accomplish that goal, it is vital that patient and community comments and concerns are addressed. Professional Research Consultants (PRC) conducts outpatient surveys for the Outpatient Surgery, Physical Therapy, Registration, Med/Surg/ICU, Obstetrics, Respiratory Therapy, Emergency, Laboratory, and Radiology Departments on patient satisfaction. PRC also conducts the inpatient Hospital Consumers Assessment of Healthcare Providers and Systems (HCAHPS) survey which measures patient satisfaction in multiple areas including promptness and efficiency of the admission and registration process, length of time waiting, nursing care, physician care, teamwork, discharge instructions, safety, cleanliness of the facility, food service, overall quality of care, and the likelihood of recommending the hospital to relatives and friends. Statistics regarding patient feedback are calculated on a weekly basis and distributed to all department directors with a hard copy, graphs are posted, and e-mails are dispersed to ensure all staff is informed of results. Management is then able to make necessary assessments of weak areas and strategically plan for improvements. Audio of the actual phone surveys are also available to all management. Many changes within CVRMC have been made as a direct result of the feedback obtained in these surveys. Hospital Consumers Assessment of Healthcare Providers and Systems (HCAHPS) is a standardized survey method conducted nationally and is publicly reported regarding the patients opinions and observations regarding their hospital care. This survey is helpful in determining how CVRMC measures against other hospitals across the nation. The public reporting aspect of this survey is a motivation factor for the hospital as a whole to improve quality of care, focusing on the patients needs. These objective and meaningful comparisons of hospitals on topics that are important to the consumer and the public reporting aspect of HCAHPS serves as a transparency tool which drives accountability and improves quality of care. Direct feedback from patients and family members is also a tool utilized for needs assessment. One of the many advantages of a rural hospital is the personal relationships the staff and patients are able to build. Direct phone calls, e-mails, or letters received from patients after their care has been provided is a valuable source of information for determining need. Legislative Actions: Legislative decisions will have a dramatic effect on the direction CVRMC will move regarding community benefit, as well as how healthcare for the region will be financed and delivered. As healthcare reform moves forth, CVRMC will continue to offer community benefit programs within its budgetary means in response to the needs of the region served. With changes to the Arizona Health Care Cost Containment System (AHCCCS), CVRMC will continue to strive for growth, bringing new services to the hospital while focusing on prevention. Schedule H, Part VI, Line 3 QUESTION 3 PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCE: Describe how the organization informs and educates patients and persons who may be billed for patient care about their eligibility for assistance under federal, state or local government programs or under the organizations charity care policy. Education of Financial Assistance to Patients at CVRMC: In public waiting areas of Cobre Valley Regional Medical Center, multi-lingual posters explain to patients in common language that CVRMC is a MedicareAHCCCS (Medicaid) participating facility. In addition, posters and signs in these areas explain to the patient what financial obligations may occur and if additional billing will be submitted by providers. If, at the time of admission or visit, the patient does not have third party insurance coverage, the patient is offered an AHCCCS application for health-care coverage through public programs. In addition, staff members in the ER are trained to run searches to determine if a patient has existing coverage. Below is a description of the Patient Education Policy followed by a copy of the Patient Financial Assistance and Discount Program. When neither existing insurance coverage nor AHCCCS eligibility is available, the Patient Account Services department talks to the patient about the Cobre Valley Regional Medical Centers Charity Care program. The patient is offered an AHCCCS application, and a financial contract. The patient is advised he/she must complete the AHCCCS application, appointment, etc. If the patient is denied by AHCCCS, he/she are to present the denial to the Patient Accounting Department. When the patient is offered the financial assistance application, demonstrable proof of income, living expenses, size of household and proof of AHCCCS denial are required for completion of the application. Included in the income computation are earnings from employment and other income such as child support, alimony, social security and any other sources. When requesting proof of living expenses, patients are asked to provide documentation of expenses associated with housing, utilities, transportation, insurance, food, other medical bills, and all other living expenses. After all information is obtained and reviewed, the Federal Poverty Income Guidelines and Discount Table is now being used to calculate the total discount that can be offered to the patient. Once this is compiled, Patient Account Services (PAS) signs off on the Financial Assistance Form which is forwarded to the Director, CFO, and CEO for approval, as appropriate. (CVRMC is highly dependent on payment rates set by Medicare and Medicaid, both of which generally do not cover costs. At CVRMC, about 67% of patient revenue comes from these government payors. In July of 2011, the Arizona Health Care Cost Containment System (AHCCCS) reduced payments by over 10% to help reduce the rising deficits which have impacted the State of Arizona. These changes, along with the changes at the federal level (the Patient Protection and Affordable Care Act) will continue to change how CVRMC informs and educates patients and families regarding their eligibility for assistance. POLICY OVERVIEW: Cobre Valley Regional Medical Center (CVRMC) is committed to providing financial assistance to persons who have health care needs and are uninsured. Consistent with its mission to deliver quality healthcare in a safe, respectful, and efficient manner, CVRMC strives to ensure that the financial capacity of people who need health care services does not prevent them from seeking or receiving care. PURPOSE This Policy provides a fair and comprehensive system of distributing free or discounted medical care to uninsured patients within the available resources of Cobre Valley Regional Medical Center (the Hospital and/or Clinics). The Policy addresses: Eligibility criteria for financial assistance; The extent to which financial assistance includes free or discounted care; The basis for calculating amounts charged to individuals who are eligible for assistance under this policy; The method for applying for assistance; Measures to widely publicize the Policy RESPONSIBILITY It is the responsibility of the Hospital Board of Directors to ensure that this Policy is being administered and carried out in a consistent manner and within the guidelines set forth in controlling laws and regulations. SCOPE This Policy applies to all emergency and medically necessary inpatient and outpatient hospital services provided to Uninsured individuals who qualify for assistance in accordance with the terms and conditions herein. It also applies to CVRMC employed physician services, clinic services, or other services that may be offered by the Hospital. Any services deemed non-medically necessary or cosmetic in nature are not eligible for financial assistance. DEFINITIONS: The following definitions shall apply to this Policy: AGB discount percentage is determined by dividing the sum of all claims Medically Necessary services provided at Cobre Valley Regional Medical Center paid during the Relevant Period by Medicare fee-for-service and all private health insurers as primary payors, together with any associated portions of these claims paid by Medicare beneficiaries or insured individuals in the form of co-pays, co-insurance or deductibles. Application Period: The period during which the Hospital must accept and process an application for assistance under this Policy in order to have made reasonable efforts to determine whether the patient is an individual who is eligible for assistance under this Policy. The Application Period ends on the 240th day the Hospital provides the individual with the first statement for care provided. Extraordinary Collection Action or ECA: Actions taken by the Hospital against a patient or any other individual who has accepted or is required to accept responsibility for the patients bills that involve a legal or judicial process; selling an individuals debt to a third party; or reporting adverse information about the individual to a consumer credit agency or credit bureau. Gross Charges: The Hospitals full, established price for medical care that it consistently and uniformly charges all patients before applying any contractual allowances, discounts, or deductions. Household Income: The total income of all members living in the individuals household. Individuals who are eligible for assistance under this Policy: An individual who is uninsured and is eligible for financial assistance under this Policy. Individuals who qualify for financial assistance: Individuals who are eligible for assistance under this Policy and who have submitted a completed financial assistance application within required time periods as set forth herein and have been approved for financial assistance according to the processes set forth herein. Medically Indigent: Individuals who do not have health insurance and who are not eligible for other health care coverage, such as Medicare, Medicaid, or private health insurance. Notification Period: Begins on the first date care is provided and ends on the 120th day after the Hospital provides the individual with the first bill for care. Uninsured: A patient (or his or her financially responsible individual) has no insurance or medical coverage under governmental programs and is not eligible for any other third party payment. Schedule H, Part VI, Line 4 QUESTION 4: Describe the community the organization serves, taking into account the geographic area and demographic constituents it serves. Cobre Valley Regional Medical Center (CVRMC) is located in Globe, Arizona and serves a population of 45,000 within a radius of 65 miles in a full-service acute care facility. This population includes both the primary and secondary service areas. CVRMC is located in the heart of the copper belt of Arizona and serves many rural copper communities within the region including its neighboring towns of Miami, Superior to the west, Kearny, Hayden, and Winkelman to the south. The Apache San Carlos Apache Nation borders Globe to the east and Roosevelt, Pleasant Valley/Young are located to the north. CVRMC serves as an acute medical/surgical and obstetric provider for all the residents of these communities, with the clinic and hospital located on the San Carlos Apache Nation referring many patients to CVRMC. The CVRMC primary and secondary service area communities are located in two counties, Gila and Pinal. Based on the 2010 U. S. Census, approximately 23% of the total population in Gila County was over the age of 65 while in neighboring Pinal County it was 15%, compared to 14% for Arizona and 13 % for the United States. The five leading causes of death among adults age 65 and older in Gila and Pinal Counties are heart disease, cancer, chronic lower respiratory diseases, cerebrovascular disease, and diabetes. Total reported number of people with disabilities within Gila County is 22,453 and 63,082 for Pinal County. Globe and Miami, Arizona Primary Service Area (62.7% Inpatient Patient Origin) Globe, Miami and the unincorporated areas nearby (including Inspiration, Claypool, Central Heights, and Midland City) are commonly called Globe-Miami. The towns are located on the northeastern slope of the Pinal Mountains, and are surrounded (except to the east) by the Tonto National Forest. Globe-Miami is located on U.S. Routes 60 and 70, and is served industrially by the Arizona Eastern Railway. Globe-Miami are located in Gila County with a total population of 18,134. Globes economy remains heavily dependent on the mining industry, but as the county seat, county as well as city government employment are the highest numbers of jobs within the city. Tourism and retirees are also among the most important in Globes economy. Miami borders Globe to the west and copper mining accounts for the largest number of jobs in Miami according to the 2002 annual report of the Arizona State Mine Inspector. Freeport MacMoRan currently employs more than 1,000 at its Miami operations; Quadra Mining employs nearly 200 at its Carlota facility; and BHP Billiton employs nearly 400 employees between its Pinto Valley and Miami operations. As of 2012, Miami was home to one of the last 4 copper smelters in the United States. Following is the housing status and demographic information for the population of Globe-Miami and the unincorporated areas: Housing Status for Globe-Miami, U.S. Census 2010 (in housing units unless noted ) Total: 9,090; Occupied: 7,253; Owner-occupied: 5,324; Population in owner-occupied (number of individuals): 12,727; Renter-occupied: 1,929; Population in renter-occupied (number of individuals): 4,827; Households with individuals under 18 2,099 Vacant 1,837 Vacant: for rent 319 Vacant: for sale 142 Male 9,102 Female 9,032 Under 18 4,195 18 & over 13,939 20 - 24 989 25 - 34 1,787 35 - 49 3,146 50 - 64 4,104 65 & over 3,486 Population by Ethnicity Hispanic or Latino 6,175 Non Hispanic or Latino 11,959 Population by Race White 14,862 African American 130 Asian 129 American Indian and Alaska Native 692 Native Hawaiian and Pacific Islander 15 Other 1,784 Identified by two or more 522 Roosevelt, Arizona Primary Service Area (2.5% Inpatient Patient Origin) Roosevelt is located 20 miles north of CVRMC and is a major center for fishing, boating, camping, water skiing, and other recreational water sports. The community of Roosevelt was developed after the construction of a masonry dam on the Salt River in 1911, making it the oldest artificial reservoir in Arizona and the largest within the boundaries of the state. The population of Roosevelt is estimated at 120 with many visitors moving in and out of the area depending on the season. San Carlos Apache Nation San Carlos, Ft. Apache, and Peridot, Arizona Secondary Service Area (20.8% Inpatient Patient Origin) The San Carlos Apache Indian Reservation is located 4 miles east of Globe and is located in Gila, Graham, and Pinal Counties. The San Carlos Reservation is home to a number of Apache tribes relocated from traditional Apache homelands from Arizona and New Mexico in 1871. The San Carlos Reservation is one of the poorest Native American communities in the United States, with the median annual household income being approximately $13,000. About 60% of the people live under the poverty level, and one-fourth of the active labor force is unemployed. The population of the San Carlos Reservation is just over 10,000 residents with its largest communities being San Carlos, Ft. Thomas, and Peridot, Arizona. The Apache Gold Casino employs 300 people while hunting, fishing, boating, camping, and gaming are attractions to tourists visiting the area.AZ - San Carlos CCD, Gila County, US Census 2010 Population Total Population 4,780 Housing Status ( in housing units unless noted ) Total 1,171 Occupied 1,059 Owner-occupied 769 Population in owner-occupied ( number of individuals ) 3,295 Renter-occupied 290 Population in renter-occupied ( number of individuals ) 1,474 Households with individuals under 18 706 Vacant 112 Vacant: for rent 13 Vacant: for sale 0 Population by Sex/Age Male 2,296 Female 2,484 Under 18 1,889 18 & over 2,891 20 - 24 454 25 - 34 617 35 - 49 732 50 - 64 610 65 & over 237 Population by Ethnicity Hispanic or Latino 152 Non Hispanic or Latino 4,628 Population by Race White 28 African American 1 Asian 0 American Indian and Alaska Native 4,727 Native Hawaiian and Pacific Islander 1 Other 2 Identified by two or more 21 AZ - San Carlos CCD, Graham County, US Census 2010 Population Total Population 5,288 Housing Status ( in housing units unless noted ) Total 1,455 Occupied 1,261 Owner-occupied 950 Population in owner-occupied ( number of individuals ) 3,992 Renter-occupied 311 Population in renter-occupied ( number of individuals ) 1,296 Households with individuals under 18 758 Vacant 194 Vacant: for rent 12 Vacant: for sale 1 Population by Sex/Age Male 2,607 Female 2,681 Under 18 1,965 18 & over 3,323 20 - 24 450 25 - 34 658 35 - 49 918 50 - 64 748 65 & over 353 Population by Ethnicity Hispanic or Latino 205 Non Hispanic or Latino 5,083 Population by Race White 112 African American 5 Asian 1 American Indian and Alaska Native 5,108 Native Hawaiian and Pacific Islander 0 Other 14 Identified by two or more 48 X X X 0 0 0 0 0 0 0 0 0 Dana Miller Physician 448174 0 0 0 0 0 0 0 0 0 448174 0 0 0 Stephens Triplett Physician 351000 0 0 0 0 0 0 0 0 0 351000 0 0 0 Binoy Chandra Physician 329277 0 0 0 0 0 0 0 0 0 329277 0 0 0 Phuong Nguyen Physician 306055 0 0 0 0 0 0 0 0 0 306055 0 0 0 Werner Andrade Ortiz Physician 278693 0 0 0 0 0 0 0 0 0 278693 0 0 0 Form 990, Part IV, Line 20a Schedule H Part VI, Line 2, continued. The Payor Mix: By identifying customers, CVRMC is able to determine to whom services are provided. This information is invaluable for the strategic planning and management of the hospital in regards to new services and/or the addition of new providers. The payor mix also provides valuable information regarding the mix of services needed, education programs, new outreach programs, and future demands. The payor mix is also a very good indicator of the socioeconomic structure of the community, allowing CVRMC to tailor programs to better meet the community needs. Medical Staff Development Plan: The approach used to project physician need for Cobre Valley Regional Medical Centers service area included the following: Defining the CVRMC service area and market share by service area and service line; Projecting the service areas population growth and characteristics for the next five years; Taking into account competition and other local circumstances such as in-migration and out-migration; Developing a profile of the current medical staff including number, FTE, specialty, age, activity; and, Identifying an appropriate demand model from among the available physician need estimation tools. Utilizing the above information, estimates are developed projecting the number of physicians by specialty required to serve the CVRMC service region. Methods used to project physician need include: demographics and population The source for the population is the Claritas Update Demographics (CUD) product. Estimates are data prepared for the current year and projections are prepared for dates five years in the future. The CUD is brought up to date each year for many geographic levels including national, state, county, town, census tract and block group. Data is also available for commonly used areas as metropolitan areas, ZIP Codes, and other media areas. Because it is produced for small areas, the update can be easily aggregated to custom geographic areas specified by the user. Provider Supply: Provider supply is provided by CVRMC management. Much of the physician information is obtained by medical staff rosters and the survey responses. The information gathered for the provider supply is the provider name, specialty, town in which they practice, office days and times, birth date, and any information about their practice. The office days and times are used to calculate a provider full-time equivalent (FTE). Provider Demand The two models used to determine provider demand and community need are: Population Based Model which is obtained by multiplying Thomson Reuters physician to population ratios by the population of the service area and Productivity Based Model which provides data on current and projected physician resources required within a defined market.Service Area Definition: A service area definition takes into consideration multiple factors including patient origin, market share, population and geography. The service area is defined as the geographic area from which a health care facility draws at least 75% of its patients and in which it maintains a considerable share of the health care market. The first step in defining CVRMCs service area is identification of the communities from which the hospital draws 75% of patients, and to assess the hospitals market share in each of these communities. The service area was then divided into two service areas: Primary and Secondary. Three ZIP Codes have been identified as CVRMCs primary service area and five Zip Codes comprise the secondary service area. Out Migration Data: CVRMC is located 85 miles southeast of the largest metropolitan area in Arizona. The cities of Phoenix, Mesa, and Tempe are the out migration areas patients of the CVRMC service area sometimes choose for health care services. Out migration data is provided by the HealthTech Strategic Planning department in the Environmental Assessment and Market Share Report. Two data sources are used: 1. Population trends are another determination for needs assessment. Population trends by ZIP Code are provided for the primary and secondary service areas of CVRMC as well as population trends by age. As the population trends increase or decrease and healthcare needs change with age, it is definitely something to consider when strategically planning for future needs. 2. Demographic snapshots are also provided by the report for each of the service areas that reflect various characteristics, including education, household income, and ethnicity. These are important factors to consider when establishing marketing and public relations messages. Those in CVRMCs primary and secondary service areas are primarily White and Hispanic; have a lower percentage than the U.S. with a high school degree, and a higher percentage than the U.S. with lower incomes. Diagnosis-Related Groups Groups of patients tend to have common demographic, diagnostic, and therapeutic attributes that determine their health care needs. Diagnosis-Related Groups (DRG) form a manageable, clinically coherent set of patient classes relating CVRMCs case mix to the resource demands and the associated costs experienced by the hospital. Database of Admissions Queries of the CVRMC Admissions database are a quick analytical source for determining the major health issues of the region. From this information education, prevention, and intervention can be determined and implemented in community benefit programs or released to other regional health organizations for tracking and trending the impact of their programs within the region. Case Management, Discharge Planning, and Social Work: Through case management, discharge planning, and social work provided by CVRMC, data is generated by specific diagnosis related groups. Form 990, Part IV, Line 20b Schedule H, Part VI, Line 3 continued. ELIGIBILITY FOR FINANCIAL ASSISTANCE: 1 Uninsured - Status to be verified through state websites or other third party eligibility systems 2 Citizenship- Individuals must be U.S. citizens 2a. Patients who are not legal U.S. citizens are not eligible for Financial Assistance. However, they are encouraged to inquire about emergency health care services through the Federal Emergency Services Program (FESP) provided by AHCCCS. Patients who do not meet the qualifications of this program will be able to receive the Self-Pay discount. 3 Federal Poverty Level - The applicants household income must be at or below 400% of the Federal Poverty Guidelines (http://aspe.hhs.gov/poverty/14poverty.cfm) 4 Homeless - Individuals without a payment source may be classified as eligible for Financial Assistance if it is determined that they do not have a job, mailing address, residence, or insurance. Consideration must also be given to classifying emergency room patients who do not provide adequate information as to their financial status. In many instances, these patients are homeless and have few resources to cover the cost of their care. 5 Bankruptcy - Individuals who are in bankruptcy or recently completed bankruptcy may be eligible for Financial Assistance. 6 Special circumstances - In rare occasions, a patients individual circumstances may be such that while they do not meet the regular Financial Assistance criteria in this policy, they do not have the ability to pay his/her Hospital bill. In these situations, with the approval of the CVRMC CEO/CFO, part or all of their cost of care may be written off. There must be complete documentation of why the decision was made to do so and why the patient did not meet the regular criteria. 7 Deceased patients without an estate or third party coverage will be eligible for financial assistance. DETERMINATION OF FINANCIAL ASSISTANCE ELIGIBILITY Financial assistance will be determined through an individual assessment of financial need, including an application process in which the patient or the patients guarantor is required to cooperate and submit all documentation necessary to make the determination of financial need; a reasonable effort by the CVRMC to explore and assist patients in applying for appropriate alternative sources of payment and coverage from public and private payment programs; and will take into account the patients assets and other financial resources. It is preferred but not required that a request for financial assistance and a determination of financial need occur prior to rendering of medically necessary services. The need for financial assistance shall be re-evaluated at each subsequent rendering of medically necessary services, if the last financial evaluation was completed more than one hundred eighty days prior, and at any time additional information relevant to the eligibility of the patient for financial assistance becomes known. The granting of financial assistance shall be based on an individualized determination of financial need, and shall not take into account age, gender, race, socioeconomic, sexual orientation or religious affiliation. In determining whether each individual qualifies for Financial Assistance, only those patient billings not covered by other county or governmental assistance programs should also be considered. Many applicants are not aware that they may be eligible for assistance such as AHCCCS or other government or private funded programs. Persons eligible for programs such as AHCCCS but whose eligibility status is not established for the period during which the medical services were rendered may be granted Financial Assistance for those services. CVRMC may make the granting of Financial Assistance contingent upon applying for governmental program assistance. This may be prudent, especially if the patient requires ongoing services. EXCLUSIONS 1. This policy and the Financial Assistance Program do not apply to the portion of charges an insured patient is personally responsible for, i.e., co-pays, co-insurance, and deductibles, and does not apply to elective procedures except as may be determined in the sole discretion of CVRMC on a case-by-case basis. METHOD FOR APPLYING FOR FINANCIAL ASSISTANCE 1. A copy of this Policy and Financial Assistance applications will be made available at the Hospital or by contacting Patient Accounts/Billing Office at 928-425-3261. 2. Individuals who feel that they qualify for financial assistance under this Policy, or have requested that financial assistance be provided, are required to submit an application on the Hospital provided form during the Application Period. It is the applicants responsibility to provide proof of household income and/or any other information provided on the application as requested by the Hospital. 3. The applicant is required to submit all information required on the financial assistance application form including, but not limited to, the following information: Copy of AHCCCS denial letter (May be waived on a case by case basis) Copies of pay stubs for the last 2 pay periods; Number of dependents claimed on tax return Copies of bills showing expenses 4. Failure to provide this information will result in an incomplete application, which may result in the individual being denied assistance under this Policy. 5. Completed applications shall be returned to the Patient Accounts Billing Department within the Application Period. All eligible applications will be processed within 30 calendar days. PUBLICATION OF POLICY 1 This Policy, an application, a plain language summary of the Policy, and any notices or publications regarding the Policy will be made available on the Hospitals website in pdf form. 2 The Policy, applications, and plain language summaries shall be available upon request, without charge at the Patient Accounts/Billing Department and by mail, upon request. 3 A plain language summary shall be conspicuously displayed in Hospital patient waiting areas and in the Patient Accounts/Billing Department in a manner that is reasonably calculated to attract visitors attention. 4 A plain language summary of this Policy and a copy of the financial assistance application will be provided to all patients upon admission or registration at the Hospital or Clinics. ACTIONS THAT MAY BE TAKEN IN EVENT OF NONPAYMENT OR INSUFFICIENT PAYMENT 1. Accounts for hospital services for patients who are able, but unwilling, to pay are considered uncollectible bad debts and will be referred to outside agencies for collections. REGULATORY REQUIREMENTS 1. In implementing this policy, CVRMC management and CVRMC facilities shall comply with all federal, state and local laws, rules and regulations that may apply to activities conducted pursuant to this policy. ACCOUNTING FOR FINANCIAL ASSISTANCE 1. CVRMC will track and monitor Financial Assistance care being granted and will account for the write-offs as a separate Deduction from the Revenue general ledger account. RECORDKEEPING 1. Records relating to potential Financial Assistance applicants must be readily available. CVRMC will maintain a spreadsheet of all applicants and final disposition. 2. Notes relating to the Financial Assistance application and approval or denial should be entered on the patients account. APPLICATION OF POLICY 1. This policy does not create an obligation to discount for any charges or services not included in the Hospital bill at the time of service. This policy does not apply to services provided within the Hospital by physicians or other medical providers including Emergency Physicians, Anesthesiologists, Radiologists, Pathologist, etc. Form 990, Part IV, Line 38 Schedule H, Part VI, Line 4 continued. Pleasant Valley Young, Arizona Secondary Service Area Surrounded by the Tonto National Forest, Pleasant Valley-Young is a community in Gila County situated in the beautiful pines of the mountains. There are two main dirt roads in and out of Young, one from the north and one from the south, but no fully paved road to a connecting highway. Globe is 65 miles to the south of Young. According to the 2010 U. S. Census, Pleasant Valley-Young had a population of 376 people, 320 households, and 132 families living in the Pleasant Valley-Young area. The racial makeup was 100% White. The 320 households are comprised of 15.3% with children under the age of 18 living with them, 50.9% were married couples living together, 4.7% had a female householder with no husband present, and 39.7% were non-families. Individuals made up 33.4% of all households and 10.3% had someone living alone who was 65 years of age or older. The average household size was 2.08 and the average family size was 2.65. The median age was 51.5. Several small businesses exist in Pleasant Valley-Young. A gas station, convenience store, auto parts store, motel, thrift shore, library, and refuse service are among the businesses and Cobre Valley Regional Medical Center services the primary medical needs of the area with a medical clinic. The median income for a household in the Pleasant Valley-Young area was $26,250, and the median income for a family was $24,886. Males had a median income of $21,000 versus $26,458 for females. The per capita income for the area was $16,943. Kearny, Arizona Secondary Service Area (.8% Inpatient Patient Origin) Kearny is located in Pinal County and was built by the Kennecott Mining Company in 1958 as a planned community to accommodate the populations of nearby Ray, Sonora and Barcelona, which were eventually swallowed by Kennecotts expanding open-pit copper mine. The town sits near the Gila River in the Copper Basin area along with its sister cities of Hayden and Winkelman. The economic base of Kearny is the Ray mine and the Hayden Smelter, both owned and operated by ASARCO. Total 2010 Census Population for KEARNY, AZ 1,950 HOUSEHOLDS BY TYPE Total households for KEARNY, AZ 756 Family households (families) [7] 534 With own children under 18 years 191 Husband-wife family 401 With own children under 18 years 127 Male householder, no wife present 37 With own children under 18 years 17 Female householder, no husband present 96 With own children under 18 years 47 Nonfamily households [7] 222 Householder living alone 197 Male 98 65 years and over 36 Female 99 65 years and over 67 Households with individuals under 18 years 239 Households with individuals 65 years and over 282 Average household size of KEARNY, AZ 2.58 Average family size for KEARNY, AZ [7] 3.09 POPULATION BY RACE FOR KEARNY, AZ What is the Population of KEARNY, AZ 1,950 One Race 1,883 White 1,623 Black or African American 9 American Indian and Alaska Native 15 Asian 8 Asian Indian 0 Chinese 2 Filipino 3 Japanese 2 Korean 0 Vietnamese 0 Other Asian [1] 1 Native Hawaiian and Other Pacific Islander 1 Native Hawaiian 0 Guamanian or Chamorro 1 Samoan 0 Other Pacific Islander [2] 0 Some Other Race 227 Two or More Races 67 White; American Indian and Alaska Native [3] 10 White; Asian [3] 1 White; Black or African American [3] 4 White; Some Other Race [3] 45 Hayden, Arizona Secondary Service Area Hayden is located in both Gila and Pinal counties with the economic base being the Hayden Smelter, one of four smelters in the United States. Total 2010 Census Population for HAYDEN, AZ 662 HOUSEHOLDS BY TYPE Total households for HAYDEN, AZ 236 Family households (families) [7] 163 With own children under 18 years 50 Husband-wife family 98 With own children under 18 years 25 Male householder, no wife present 15 With own children under 18 years 9 Female householder, no husband present 50 With own children under 18 years 16 Nonfamily households [7] 73 Householder living alone 61 Male 30 65 years and over 10 Female 31 65 years and over 24 Households with individuals under 18 years 74 Households with individuals 65 years and over 93 Average household size of HAYDEN, AZ 2.81 Average family size for HAYDEN, AZ [7] 3.39 POPULATION BY RACE FOR HAYDEN, AZ What is the Population of HAYDEN, AZ 662 One Race 651 White 423 Black or African American 0 American Indian and Alaska Native 1 Asian 2 Asian Indian 1 Chinese 0 Filipino 1 Japanese 0 Korean 0 Vietnamese 0 Other Asian [1] 0 Native Hawaiian and Other Pacific Islander 0 Native Hawaiian 0 Guamanian or Chamorro 0 Samoan 0 Other Pacific Islander [2] 0 Some Other Race 225 Two or More Races 11 White; American Indian and Alaska Native [3] 2 White; Asian [3] 7 White; Black or African American [3] 0 White; Some Other Race [3] 1 Winkelman, Arizona Secondary Service Area (1.8% Inpatient Patient Origin) Winkelman is located in Gila and Pinal counties with over 95% of the population living within Gila County. The major employment is the copper industry of the ASARCO Mine. HOUSEHOLDS BY TYPE Total households for WINKELMAN, AZ 136 Family households (families) [7] 86 With own children under 18 years 22 Husband-wife family 54 With own children under 18 years 10 Male householder, no wife present 13 With own children under 18 years 4 Female householder, no husband present 19 With own children under 18 years 8 Nonfamily households [7] 50 Householder living alone 39 Male 14 65 years and over 8 Female 25 65 years and over 16 Households with individuals under 18 years 34 Households with individuals 65 years and over 66 Average household size of WINKELMAN, AZ 2.6 Average family size for WINKELMAN, AZ [7] 3.28 POPULATION BY RACE FOR WINKELMAN, AZ What is the Population of WINKELMAN, AZ 353 One Race 342 White 214 Black or African American 2 American Indian and Alaska Native 13 Asian 2 Asian Indian 0 Chinese 0 Filipino 0 Japanese 2 Korean 0 Vietnamese 0 Other Asian [1] 0 Native Hawaiian and Other Pacific Islander 0 Native Hawaiian 0 Guamanian or Chamorro 0 Samoan 0 Other Pacific Islander [2] 0 Some Other Race 111 Two or More Races 11 White; American Indian and Alaska Native [3] 1 White; Asian [3] 1 White; Black or African American [3] 0 White; Some Other Race [3] 8 Superior, Arizona Secondary Service Area (1.4% Inpatient Patient Origin) Superior is located in Pinal County 25 miles west of Globe. The town has survived many ups and downs of the copper mining industry throughout the years but during the most recent years is capitalizing on its unique and picturesque location. The town is in a rebuilding phase in its economy and is looking to the areas of tourism and the opportunity for a new underground mine, Resolution Copper, to open in the next 5 years. HOUSEHOLDS BY TYPE Total households for SUPERIOR, AZ 1,103 Family households (families) [7] 709 With own children under 18 years 236 Husband-wife family 477 With own children under 18 years 132 Male householder, no wife present 70 With own children under 18 years 28 Female householder, no husband present 162 With own children under 18 years 76 Nonfamily households [7] 394 Householder living alone 333 Male 175 65 years and over 61 Female 158 65 years and over 95 Households with individuals under 18 years 321 Households with individuals 65 years and over 409 Average household size of SUPERIOR, AZ 2.57 Average family size for SUPERIOR, AZ [7] 3.2 POPULATION BY RACE FOR SUPERIOR, AZ What is the Population of SUPERIOR, AZ 2,837 One Race 2,729 White 2,000 Black or African American 17 American Indian and Alaska Native 56 Asian 18 Asian Indian 1 Chinese 4 Filipino 4 Japanese 8 Korean 0 Vietnamese 0 Other Asian [1] 1 Native Hawaiian and Other Pacific Islander 0 Native Hawaiian 0 Guamanian or Chamorro 0 Samoan 0 Other Pacific Islander [2] 0 Some Other Race 638 Two or More Races 108 White; American Indian and Alaska Native [3] 23 White; Asian [3] 3 White; Black or African American [3] 15 White; Some Other Race [3] 49 Sources: HealthTech Healthcare, April 2012; Thomson Reuters/Market Expert; 2010 U.S. Census Data Form 990, Part VI, Section A, Line 3 The CEO and CFO duties are carried out by employees of HealthTech Management Services, Inc. and unrelated management company. Neal Jensen and James Childers are employees of HealthTech and serve as the top management and financial officials of Cobre Valley Regional Medical Center. Compensation is included in the management fee paid to HealthTech Management Services. Form 990, Part VI, Section B, Line 11b A CPA firm prepares and reviews the Form 990. The return is then provided to the CFO for review and approval. Any questions or concerns the CFO has are addressed and any corrections or clarifications are made. The final form 990, with all required schedules, is made available to the full board prior to filing with the IRS. Form 990, Part VI, Section B, Line 12c Board members and officers are covered by the organization's conflict of interest policy and are required to annually complete a questionnaire disclosing any and all possible conflicts of interest. Form 990, Part VI, Section B, Line 15 The Officer's compensation is determined by a review conducted by Healthtech management services, Inc. using data provided by a nationally recognized management consulting firm, along with Form 990 data from comparable organizations and other hospitals managed by Healthtech. Once this information has been compiled and reviewed, a meeting is held with the board and a decision is made on the Officers' compensation. Form 990, Part VI, Section C, Line 19 Available upon written request. Form 990, Part IX, Line 11g Professional Fees and Purchased Services.