2014-05-12T14:28:21-05:00 2013-06-30 476097913 SEIM JOHNSON LLP 18081 BURT STREET SUITE 200 OMAHA NE 680224722 990 2012-07-01 470533373 COMMUNITY HOSPITAL ASSOCIATION OF MCCOOK COMM 3083442650 1301 EAST H STREET PO BOX 1328 MCCOOK NE 69001 TROY BRUNTZ 3083442650 2014-05-10 1 WENDY R COOLEY P01523804 4023302660 2012 2015-11-30 17:44:51Z TROY BRUNTZ 434 SEMINOLE DRIVE MCCOOK NE 69001 43966533 0 X WWW.CHMCCOOK.ORG X 1974 NE TO PROMOTE PUBLIC HEALTH 9 8 316 14 0 0 621158 3824993 35227672 38782067 103818 -96848 794329 1052539 36746977 43562751 59417 44943 0 0 15739637 17225030 0 0 0 19800061 20746793 35599115 38016766 1147862 5545985 55218772 63463730 29535084 32234057 25683688 31229673 TO EXCEL AT PROVIDING FOR THE HEALTHCARE NEEDS OF OUR REGION THROUGH QUALITY, EFFICIENT AND PATIENT-CENTERED CARE. 0 0 31029298 44943 39419321 CRITICAL ACCESS ACUTE CARE HOSPITAL PROVIDING INPATIENT AND OUTPATIENT CARE, DIAGNOSTIC, REHABILITATION, SURGICAL, NURSERY, VISITING MEDICAL SPECIALISTS, HOME HEALTH AND HOSPICE, TWO RURAL HEALTH CLINICS, AND HEALTH AND EDUCATION PROGRAMS. 31029298 1 1 0 1 0 0 0 0 0 1 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 0 0 0 1 0 0 1 0 0 0 0 0 0 1 1 1 0 0 1 51 0 1 316 1 0 0 0 0 0 0 0 0 0 0 X 9 8 0 0 0 0 1 1 0 1 1 0 0 1 1 1 1 1 1 1 1 1 1 X TROY BRUNTZ 3083448315 1301 EAST H - PO BOX 1328 MCCOOK NE 69001 JAMES O'DEA 1.00 0.00 X X 0 0 0 WAYNE WATKINS DVM 1.00 0.00 X X 0 0 0 MARK EILER 1.00 0.00 X X 0 0 0 BRUCE BAIR 1.00 0.00 X X 0 0 0 MAX ABERCROMBIE 1.00 0.00 X 0 0 0 KRISTI DAUM 1.00 0.00 X 0 0 0 CONNIE OLSON 1.00 0.00 X 0 0 0 DAVE SMITH 1.00 0.00 X 0 0 0 DORIS FRIEHE 1.00 0.00 X 0 0 0 ROSELYN REMINGTON MD 1.00 0.00 X 0 0 0 BRIAN ESCH 1.00 0.00 X 0 0 0 JAMES ULRICH 39.00 1.00 X 196873 0 24821 TROY BRUNTZ 40.00 0.00 X 138263 0 15004 BRIAN SMITH 40.00 0.00 X 282638 0 28341 ANTHONY RODEWALD 40.00 0.00 X 136945 0 20818 BRENDA KOPRIVA 40.00 0.00 X 257430 0 16210 CHASE CRAWFORD 40.00 0.00 X 122411 0 20924 ELIZABETH NEAL 40.00 0.00 X 122054 0 20821 1256614 0 146939 12 0 1 0 MCCOOK CLINIC PC 1401 EAST H STREET MCCOOK NE 69001 MEDICAL PROFESSIONAL - PHYSICIANS 1034818 SOUTHWEST NEBRASKA PHYSICAL THERAPY PC 1301 EAST H STREET MCCOOK NE 69001 PHYSICAL THERAPY SERVICES 942302 PATHOLOGY SERVICES PC BOX 1289 NORTH PLATTE NE 69103 MEDICAL PROFESSIONAL - PATHOLOGY 253832 LAWRENCE FRIESTAD CRNA 901 WEST 7TH MCCOOK NE 69001 MEDICAL PROFESSIONAL - CRNA SERVICES 189150 PLATTE VALLEY MEDICAL GROUP 3219 CENTRAL AVE KEARNEY NE 68848 MOBILE MEDICAL SERVICES 118551 6 841404 16818 2966771 3824993 PATIENT SERVICE REVENUE 621400 22472937 22472937 MEDICARE/MEDICAID PAYMENTS 621400 15479905 15479905 RECOVERY OF ACCOUNTS 621400 562500 562500 MEANINGFUL USE INCENTIVE PAYMENT 621400 266725 266725 38782067 164075 164075 261458 0 261458 261458 261458 142859 403782 -260923 -260923 -260923 CAFETERIA/MEALS 900099 111823 111823 HOUSEKEEPING INCOME 900099 54588 54588 PURCHASE DISCOUNTS 621400 38644 38644 586026 544022 42004 791081 43562751 39419321 0 318437 X 44943 44943 374961 374961 65402 65402 12670357 10126400 2543957 785239 638705 146534 2309302 1834891 474411 1019769 804787 214982 38050 38050 76846 76846 5596194 4267071 1329123 279320 279320 929863 652692 277171 986212 822154 164058 24963 9748 15215 300142 173530 126612 1342374 1182772 159602 4019461 3541565 477896 143580 126509 17071 MEDICAL SUPPLIES 4597782 4597782 PROVISION FOR BAD DEBTS 1405108 1405108 COLLECTION EXPENSE 157638 157638 849260 577601 271659 38016766 31029298 6987468 0 1475 1575 8851123 13864502 2232751 5105680 5513970 456 159 1354371 1151553 722483 732715 64245652 24753270 37486734 39492382 112222 194470 222863 1501980 139038 55218772 63463730 3480517 2235268 69427 112222 25985140 29395704 0 490863 29535084 32234057 X 25683688 29038813 0 2190860 25683688 31229673 55218772 63463730 5545985 0 X X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 1 0 0 0 0 1 2558 0 1 4878 7436 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: ITEM 1I - A PORTION OF DUES PAID TO THE NEBRASKA CHAMBER OF COMMERCE, AMERICAN HOSPITAL ASSOCIATION AND NEBRASKA HOSPITAL ASSOCIATION ARE USED FOR LOBBYING AND POLITICAL ACTIVITIES. MANAGEMENT IS ACTIVE IN NEBRASKA HOSPITAL ASSOCIATION'S PAC, AHA'S ADVOCACY DAY, AND OTHER INDUSTRY FUNCTIONS. EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: ITEM 1G - JIM ULRICH, CEO, TRAVELED TO DC AND LINCOLN TO ATTEND ADVOCACY EVENTS. 2243200 5955 257537 70128 17532 2419032 2335881 6653 -30823 54809 13702 2243200 2095101 11236 408161 142894 35723 2335881 1545264 441506 165360 45171 11858 2095101 1852460 42818 -288173 47008 14833 1545264 0.36920 0.63080 0 1 1 76468 76468 24548845 12924781 11624064 38589091 11828489 26760602 1031248 1031248 39492382 ESTIMATED THIRD-PARTY PAYOR SETTLEMENTS 490863 490863 X DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: THE ENDOWMENT FUNDS ARE HELD BY THE COMMUNITY HOSPITAL HEALTH FOUNDATION OF MCCOOK (A RELATED PARTY) AND ARE USED IN SUPPORT OF THE HOSPITAL'S PROGRAMS AND PROJECTS, INCLUDING PROPERTY AND EQUIPMENT PURCHASES, SCHOLARSHIPS, HOSPICE PROGRAMS, REHABILITATION SERVICES AND OTHERS. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X, LINE 2: THE HOSPITAL AND FOUNDATION ARE NOT-FOR-PROFIT CORPORATIONS AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE AND ARE EXEMPT FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE CODE. THE INTERNAL REVENUE SERVICE HAS ESTABLISHED STANDARDS TO BE MET TO MAINTAIN TAX-EXEMPT STATUS. IN GENERAL, SUCH STANDARDS REQUIRE THE HOSPITAL AND FOUNDATION TO MEET A COMMUNITY BENEFIT STANDARD AND COMPLY WITH VARIOUS LAWS AND REGULATIONS. RED WILLOW IS A FOR-PROFIT CORPORATION. RED WILLOW HAD $9,778 AND $16,898 OF TAXABLE INCOME; INCURRED AND PAID $1,467 AND $2,535 OF FEDERAL INCOME TAX; AND INCURRED AND PAID $546 AND $943 OF STATE INCOME TAX FOR THE FISCAL YEARS ENDING DECEMBER 31, 2012 AND 2011, RESPECTIVELY. AS OF JUNE 30, 2013, RED WILLOW HAD NO TAX LIABILITY. THE HOSPITAL, FOUNDATION AND RED WILLOW ACCOUNT FOR UNCERTAINTIES IN ACCOUNTING FOR INCOME TAX ASSETS AND LIABILITIES USING GUIDANCE INCLUDED IN FASB ASC 740, INCOME TAXES. THE HOSPITAL, FOUNDATION AND RED WILLOW RECOGNIZE THE EFFECT OF INCOME TAX POSITIONS ONLY IF THOSE POSITIONS ARE MORE LIKELY THAN NOT OF BEING SUSTAINED. AT JUNE 30, 2013 AND 2012, THE HOSPITAL, FOUNDATION AND RED WILLOW HAD NO UNCERTAIN TAX POSITIONS ACCRUED. THESE ENTITIES ARE NO LONGER SUBJECT TO INCOME TAX EXAMINATIONS FOR THE YEARS ENDED PRIOR TO JUNE 30, 2010. 1 1 1 X 150.000000000000 0 1 1 1 0 1 1 898177 0 898177 0.02450 2111303 1966516 144787 0.00400 3009480 1966516 1042964 0.02850 101075 20420 80655 0.00220 2267 2267 0.00010 44943 44943 0.00120 148285 20420 127865 0.00350 3157765 1986936 1170829 0.03200 0 1405108 86199 17473621 17633383 -159762 X 1 1 1 1 COMMUNITY HOSPITAL ASSN OF MCCOOK

1301 EAST H STREET - PO BOX 1328 MCCOOK NE 69001

X X X X COMMUNITY HOSPITAL ASSN OF MCCOOK 1 1 X X X X X X X X X 10 1 0 1 X X X X 0 0 1 1 150.000000000000 0 1 X X 1 1 X X X 1 0 X X X 1 X 0 0 5 COMMUNITY HEALTHCARE & HOSPICE

407 WEST 5TH STREET MCCOOK NE 69001

HOME HEALTH AND HOSPICE SERVICES COMMUNITY HOSPITAL SLEEP LAB

801 WEST C STREET SUITE 3B MCCOOK NE 69001

OUTPATIENT SLEEP SERVICES CURTIS MEDICAL CENTER

302 EAST 6TH STREET CURTIS NE 69025

RURAL HEALTH CLINIC-OUTPATIENT SERVICES TRENTON MEDICAL CLINIC

406 EAST 1ST STREET TRENTON NE 69044

RURAL HEALTH CLINIC-OUTPATIENT SERVICES COMMUNITY HOSPITAL - OUTPATIENT SERVICES

104 NORTH 3RD STREET INDIANOLA NE 69034

OUTPATIENT SERVICES PART I, LINE 3C: CHARITY CARE IS GRANTED TO ALL INDIVIDUALS WHOSE HOUSEHOLD INCOME IS BELOW 150% OF THE FEDERAL POVERTY GUIDELINE AT THE 100% WRITE-OFF LEVEL. DISCOUNTING OR 100% WRITE-OFF TO CHARITY CARE IS ALLOWED ABOVE 150% OF THE FEDERAL POVERTY GUIDELINE BASED ON AN ANALYSIS OF INDIVIDUAL NEED AND DETERMINATION OF THE PATIENT BEING MEDICALLY INDIGENT; THIS ANALYSIS INCLUDES FACTORS SUCH AS INCOME, ACCESSIBLE ASSETS, MEDICAL OR/AND OTHER DEBTS, THE LIKELIHOOD OF ONGOING MEDICAL CARE AND THE INDIVIDUAL'S OVERALL ABILITY TO PAY. PART I, LINE 6A: THE COMMUNITY BENEFIT REPORT IS PREPARED BY THE STAFF OF COMMUNITY HOSPITAL ASSOCIATION OF MCCOOK. PART I, LINE 7: THE ORGANIZATION USES A COST-TO-CHARGE RATIO METHODOLOGY DERIVED FROM WORKSHEET #2 OF THE FORM 990 INSTRUCTIONS. PART I, L7 COL(F): THE BAD DEBT EXPENSE INCLUDED IN FORM 990, PART IX, LINE 25 BUT NOT INCLUDED IN SCHEDULE H, PART I, LINE 7, COLUMN (F) IS $1,405,108. PART II: COMMUNITY HOSPITAL SUPPORTS VARIOUS COMMUNITY BUILDING ACTIVITIES, PRIMARILY THROUGH MONETARY SUPPORT. EXAMPLES INCLUDE SUPPORT TO THE ECONOMIC DEVELOPMENT CORPORATION, THE LOCAL COMMUNITY COLLEGE AND INVEST NEBRASKA. THESE PROGRAMS DIRECTLY IMPACT THE HEALTH OF OUR COMMUNITY BY DEVELOPMENT OF EMPLOYMENT OPPORTUNITIES AND A MORE EMPLOYABLE WORKFORCE. MEMBERS OF OUR COMMUNITY WITH GOOD EMPLOYMENT HAVE ACCESS TO HEALTH INSURANCE AND ARE GENERALLY ABLE TO LIVE HEALTHIER LIVES. METHODOLOGY USED BY THE ORGANIZATION TO ESTIMATE BAD DEBT EXPENSE: PART III, LINE 2: IN EVALUATING THE COLLECTABILITY OF PATIENT ACCOUNTS RECEIVABLE, THE HOSPITAL ANALYZES ITS HISTORICAL EXERIENCE 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 ADEQUACY AND APPROPRIATENESS OF THE ALLOWANCE FOR DOUBTFUL ACCOUNTS.FOR RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE THIRD-PARTY COVERAGE, SUCH AS MEDICARE, MEDICAID OR COMMERCIAL INSURANCE, THE HOSPITAL ANALYZES CONTRACTUALLY DUE AMOUNTS AND PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS AND A PROVISION FOR BAD DEBTS FOR EXPECTED UNCOLLECTIBLE DEDUCTIBLES AND COPAYMENTS ON ACCOUNTS FOR WHICH THE THIRD-PARTY PAYOR HAS NOT YET PAID, IN THE PERIOD OF SERVICE.FOR RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO 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 HOSPITAL RECORDS A PROVISION FOR BAD DEBT IN THE PERIOD OF SERVICE ON THE BASIS OF ITS HISTORICAL EXPERIENCE, WHICH INDICATES THAT SOME PATIENTS ARE UNABLE OR UNWILLING TO PAY SOME OR ALL OF THEIR BILL FOR WHICH THEY ARE FINANCIALLY RESPONSIBLE. THE DIFFERENCE BETWEEN THE GROSS CHARGES OR THE NEGOTIATED DISCOUNTED RATES, IF A CONTRACTED PAYOR, AND THE AMOUNTS ACTUALLY COLLECTED AFTER ALL REASONABLE COLLECTION EFFORTS HAVE BEEN EXHAUSTED IS CHARGES OFF AGAINST THE ALLOWANCE FOR DOUBTFUL ACCOUNTS.PART III, LINE 3:LINE 3 WAS ESTIMATED USING BOTH QUANTITATIVE AND QUALITATIVE SOURCES. THE QUANTITATIVE WAS AN ANALYTICAL ANALYSIS OF THE AMOUNT OF CHARITY CARE GIVEN BY COMMUNITY HOSPITAL COMPARED TO THE LOCAL DEMOGRAPHICS FOR POVERTY BASED ON US CENSUS DATA. ONE OF THE ASSUMPTIONS MADE WAS THAT MOST INDIVIDUALS THAT WOULD HAVE QUALIFIED FOR CHARITY CARE BUT WOULD NOT APPLY ENDED UP AS BAD DEBT WRITE-OFFS OF THE HOSPITAL. THIS ANALYSIS SHOWED THAT APPROXIMATELY 15% OF THE BAD DEBT EXPENSE WAS LIKELY TO HAVE CAME FROM INDIVIDUALS THAT WOULD HAVE QUALIFIED FOR CHARITY CARE HAD THEY APPLIED. THE QUALITATIVE SOURCE WE EMPLOYED WAS TO ASK OUR STAFF THAT ROUTINELY HANDLE CHARITY CARE APPLICATIONS AND BAD DEBT DETERMINATIONS, WHAT PERCENTAGE, IN THEIR PROFESSIONAL OPINION, OF BAD DEBT WAS FROM INDIVIDUALS THAT WOULD HAVE LIKELY QUALIFIED FOR THE CHARITY CARE PROGRAM HAD THE PATIENT APPLIED FOR ASSISTANCE. THE ESTIMATE WE RECEIVED WAS 15% OF ACCOUNTS TURNED OVER AS BAD DEBT, IN THEIR OPINION, LIKELY WOULD HAVE QUALIFIED FOR CHARITY ASSISTANCE HAD THE PATIENT BEEN COOPERATIVE IN THE PROCESS AND APPLIED FOR CHARITY CARE. PART III, LINE 4: THE ORGANIZATION'S FINANCIAL STATEMENTS DO NOT CONTAIN A SPECIFIC FOOTNOTE DESCRIBING BAD DEBT. HOWEVER, THE FOLLOWING IS THE TEXT OF THE FOOTNOTES TITLED "PATIENT RECEIVABLES, NET," "NET PATIENT SERVICE REVENUE," AND "CHARITY CARE."PATIENT RECEIVABLES, NET:THE HOSPITAL 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 HOSPITAL ANALYZES ITS PAST HISTORY AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYER SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND PROVISION FOR BAD DEBTS. MANAGEMENT REGULARLY REVIEWS DATA ABOUT THESE MAJOR PAYER 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 HOSPITAL ANALYZES CONTRACTUALLY DUE AMOUNTS AND PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS AND A PROVISION FOR BAD DEBTS FOR THOSE ACCOUNTS OVER A CERTAIN AGE BASED ON DISCHARGE THAT MAKE THE REALIZATION OF AMOUNTS DUE UNLIKELY. FOR RECEIVABLES ASSOCIATED WITH SELF-PAY PATIENTS (WHICH INCLUDES BOTH PATIENTS WITHOUT INSURANCE AND PATIENTS WITH DEDUCTIBLE AND COPAYMENT BALANCES DUE FOR WHICH THIRD-PARTY COVERAGE EXISTS FOR PART OF THE BILL), THE HOSPITAL 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.NET PATIENT SERVICE REVENUE:THE HOSPITAL HAS AGREEMENTS WITH THIRD-PARTY PAYORS THAT PROVIDE FOR PAYMENTS TO THE HOSPITAL AT AMOUNTS DIFFERENT FROM ITS ESTABLISHED RATES. PAYMENT ARRANGEMENTS INCLUDE PROSPECTIVELY DETERMINED RATES PER DISCHARGE, REIMBURSED COSTS, DISCOUNTED CHARGES AND PER DIEM PAYMENTS. 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.CHARITY CARE:THE HOSPITAL 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 HOSPITAL DOES NOT PURSUE COLLECTION OF AMOUNTS DETERMINED TO QUALIFY AS CHARITY CARE, THEY ARE NOT REPORTED AS REVENUE IN THE CONSOLIDATED STATEMENT OF OPERATIONS. THE HOSPITAL IS DEDICATED TO PROVIDING COMPREHENSIVE HEALTHCARE SERVICES TO ALL SEGMENTS OF SOCIETY, INCLUDING THE AGED AND OTHERWISE ECONOMICALLY DISADVANTAGED. IN ADDITION, THE HOSPITAL PROVIDES A VARIETY OF COMMUNITY HEALTH SERVICES AT OR BELOW COST. PART III, LINE 8: THE SOURCE USED TO DETERMINE THE AMOUNT REPORTED ON LINE 6 WAS THE MEDICARE COST REPORT. NO MEDICARE SHORTFALL IS TREATED AS COMMUNITY BENEFITS. PART III, LINE 9B: COMMUNITY HOSPITAL GRANTS 100% CHARITY CARE FOR PATIENTS KNOWN TO QUALIFY FOR FINANCIAL ASSISTANCE. OUR CHARITY CARE POLICY IS SET AT 150% OF THE FEDERAL POVERTY GUIDELINE BASED FAMILY SIZE. FOR PATIENTS THAT EXCEED THE INCOME THRESHHOLD OF THE CHARITY CARE POLICY, OUR MEDICALLY INDIGENT FINANCIAL ASSISTANCE IS AVAILABLE FOR PATIENTS THAT HAVE INCURRED CATASTROPHIC MEDICAL COSTS OR OTHER OBLIGATIONS (PRESENTLY OR ONGOING) THAT HAVE SUBSTANTIALLY REDUCED THEIR ABILITY TO PAY. IN SUCH CASES, THE INDIVIDUAL OR GUARANTOR MAY BE DETERMINED BY THE HOSPITAL TO BE MEDICALLY INDIGENT AND MAY, AT THE HOSPITAL'S DISCRETION, BE ELIGIBLE FOR FINANCIAL ASSISTANCE IN THE FORM OF FREE OR DISCOUNTED LIABILITIES.CERTAIN CLASSES OF PATIENTS ARE DEEMED TO HAVE QUALIFIED FOR CHARITY CARE WITHOUT AN APPLICATION. ACCOUNTS THAT MAY QUALIFY FOR FINANCIAL ASSISTANCE WITHOUT A COMPLETED APPLICATION INCLUDE:1. MEDICAID SHARE OF COST PORTIONS.2. MEDICAID APPLICATIONS APPROVED FOR SUBSEQUENT CARE (NOT RETROACTIVE TO THE LIABILITY).3. PATIENTS OR GUARANTORS WHO HAVE DECLARED BANKRUPTCY.4. PATIENTS OR GUARANTORS WHO ARE DECEASED WITH NO ESTATE IN PROBATE AND FOR WHOM NO ONE ELSE (SUCH AS A SPOUSE OR LEGAL GUARDIAN) IS LEGALLY RESPONSIBLE FOR THE LIABILITY.5. PATIENTS OR GUARANTORS DETERMINED TO BE HOMELESS. COMMUNITY HOSPITAL ASSN OF MCCOOK PART V, SECTION B, LINE 3: IN CONDUCTING THE CHNA, THE HOSPITAL COLLECTED DATA THROUGH A SURVEY MADE AVAILABLE TO THE PUBLIC, FOCUS GROUPS FOR BOTH COMMUNITY MEMBERS AND THE HEALTHCARE COMMUNITY, ALONG WITH KEY-INFORMANT INTERVIEWS OF COMMUNITY LEADERS. COMMUNITY HOSPITAL ASSN OF MCCOOK PART V, SECTION B, LINE 7: THE HOSPITAL WAS NOT ABLE TO ADDRESS TWO OF THE NEEDS IDENTIFIED IN THE 2010 CHNA; THE MENTAL HEALTH NEEDS OF OUR COMMUNITY AND THE NEED FOR 24 HOUR IN-HOME CARE. WHILE THE HOSPITAL CONTINUES TO WORK IN THE INDUSTRY TO FIND ECONOMICALLY FEASIBLE SOLUTIONS TO THESE COMPLEX NEEDS, WE WERE NOT ABLE TO FURNISH OR COORDINATE ADDITIONAL COMMUNITY RESOURCES TO BETTER MEET THESE NEEDS. COMMUNITY HOSPITAL ASSN OF MCCOOK PART V, SECTION B, LINE 11: OUR MEDICALLY INDIGENT FINANCIAL ASSISTANCE IS AVAILABLE FOR PATIENTS THAT HAVE INCURRED CATASTROPHIC MEDICAL COSTS OR OTHER OBLIGATIONS (PRESENTLY OR ONGOING) THAT HAVE SUBSTANTIALLY REDUCED THEIR ABILITY TO PAY. IN SUCH CASES, THE INDIVIDUAL OR GUARANTOR MAY BE DETERMINED BY THE HOSPITAL TO BE MEDICALLY INDIGENT AND MAY, AT THE HOSPITAL'S DISCRETION, BE ELIGIBLE FOR FINANCIAL ASSISTANCE IN THE FORM OF FREE OR DISCOUNTED LIABILITIES. COMMUNITY HOSPITAL ASSN OF MCCOOK PART V, SECTION B, LINE 14G: THE HOSPITAL PUBLICIZED THE FINANCIAL ASSISTANCE POLICY ON BILLING INVOICES, ON POSTERS IN THE ER AND WAITING ROOMS, AT THE ADMISSIONS DESKS, INCLUDING UPON ADMISSIONS WITH SUMMARY NOTICES OF THE POLICIES. THE COMPLETE POLICY WAS AVAILABLE ON THE HOSPITAL'S WEBSITE AND UPON REQUEST. THE HOSPITAL ALSO PUBLICIZED THE POLICY THROUGH REFERRALS BY CLINICAL, SOCIAL WORKERS, AND OTHER STAFF TO THE HOSPITALS FINANCIAL COUNSELORS. COMMUNITY HOSPITAL ASSN OF MCCOOK PART V, SECTION B, LINE 20D: THE HOSPITAL GRANTED 100% FREE CARE TO FAP ELIGIBLE INDIVIDUALS. PART VI, LINE 2: COMMUNITY HOSPITAL HAS COMPLETED A COMMUNITY HEALTH NEEDS ASSESSMENT. ACTION PLANS ARE IN PLACE TO ADDRESS SEVERAL OF THE IDENTIFIED NEEDS IN THE REPORT. PART VI, LINE 3: IDENTIFICATION OF PATIENTS WITH A POTENTIAL NEED FOR FINANCIAL ASSISTANCE WILL BE ACCOMPLISHED BY BOTH AN OPEN AND PUBLICIZED APPLICATION PROCESS AND A VARIETY OF SCREENING OPPORTUNITIES INCLUDING:A. ADMISSIONS/REGISTRATION PERSONNEL BASED UPON INFORMATION RECEIVED DURING THE REGISTRATION PROCESS.B. SOCIAL SERVICES PERSONNEL BASED UPON INFORMATION DURING THE INITIAL VISIT AND DISCHARGE PLANNING.C. NURSING STAFF BASED UPON INFORMATION RECEIVED DURING DISCUSSIONS WITH FAMILY AND/OR PATIENT.D. BUSINESS OFFICE PERSONNEL BASED UPON STATUS OF ACCOUNTS AND DISCUSSIONS WITH RESPONSIBLE PARTY.E. ACCOUNTS RECEIVABLE REPORTS.HOSPITAL STAFF OR THE NOTIFIED PATIENT ADVOCATE WILL EDUCATE THE PATIENT OR GUARANTOR ABOUT THE FINANCIAL ASSISTANCE POLICY AND WILL PROVIDE THEM AN APPLICATION FOR FINANCIAL ASSISTANCE. IF NECESSARY, THE PATIENT FINANCIAL COUNSELOR OR OTHER HOSPITAL STAFF MAY ASSIST THE PATIENT IN COMPLETING THE APPLICATION; HOWEVER, THE COMPLETION OF AN APPLICATION AND PROVIDING ALL NECESSARY SUPPORTING DOCUMENTATION IS THE PATIENT'S RESPONSIBILITY. PATIENTS MAY ALSO REQUEST AN APPLICATION OR ADDITIONAL INFORMATION IN PERSON AT THE ADMISSIONS OFFICE OR BY CALLING OR WRITING THE PATIENT FINANCIAL COUNSELOR AND AN APPLICATION WILL BE MAILED. PART VI, LINE 4: COMMUNITY HOSPITAL SERVES A RURAL POPULATION IN SOUTHWEST NEBRASKA. THE NEXT CLOSEST HOSPITAL FROM THE CITY OF MCCOOK IS 24 MILES AWAY AND THE NEXT LARGER HOSPITAL IS OVER 70 MILES AWAY. ACCORDING TO THE US CENSUS BUREAU, IN 2010 RED WILLOW COUNTY HAD A POPULATION OF 11,055; 18.7% OF WHICH WAS 65 YEARS OF AGE OR OLDER AND 12.3% WHICH LIVE BELOW THE FEDERAL POVERTY LEVEL. MEDIAN HOUSEHOLD INCOME WAS $40,572; 14.5% BELOW THE NEBRASKA MEDIAN OF $47,470 AND MORE THAN 60% OF HOUSEHOLDS LIVING ON LESS THAN $50,000 PER YEAR. PART VI, LINE 5: COMMUNITY HOSPITAL IS THE LARGEST HOSPITAL WITHIN AN HOUR TRAVEL TIME FOR MOST OF THE COMMUNITY SERVED. THE HOSPITAL PROVIDES THE PHYSICIANS OF MCCOOK A HOSPITAL TO PRACTICE MEDICINE. WITHOUT THE HOSPITAL OUR PATIENTS WOULD HAVE EXTREMELY LONG DISTANCES TO TRAVEL FOR EVERYTHING FROM EMERGENCY TO ROUTINE CARE. OUR HOSPITAL IS OVERSEEN BY A NON-COMPENSATED BOARD OF INDEPENDENT COMMUNITY MEMBERS. ANY PROFITS FROM THE OPERATION OF THE HOSPITAL ARE REINVESTED BACK INTO THE FACILITIES, EQUIPMENT AND STAFF TO PROVIDE OUR COMMUNITY WITH CURRENT AND HIGH QUALITY MEDICAL SERVICES CLOSE TO HOME. PART VI, LINE 6: N/A REPORTS FILED WITH STATES PART VI, LINE 7 NE 1 COMMUNITY HOSPITAL HEALTH FOUNDATION 801 WEST C STREET MCCOOK NE 69001 470693261 501(C)(3) 11206 TO SUPPORT THE MISSION OF THE FOUNDATION MCCOOK ECONOMIC DEVELOPMENT CORPORATION 301 NORRIS AVE SUITE 200 - PO BOX 626 MCCOOK NE 69001 470685662 501(C)(4) 12000 TO RECRUIT, STRENGTHEN AND EXPAND THE BUSINESSES THAT ARE THE FOUNDATION TO 1 1 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: GRANTS ARE MADE ONLY TO SELECTED CHARITABLE OR OTHER EXEMPT ORGANIATIONS. COMMUNITY HOSPITAL ASSOCIATION ENTERS INTO AGREEMENTS WITH GRANTEES THAT GRANT FUNDS WILL BE RESTRICTED TO SPECIFIED EXEMPT PURPOSES. X X X X 0 0 0 0 0 0 0 0 0 JAMES ULRICH 196063 0 0 0 810 0 14245 0 10576 0 221694 0 0 0 TROY BRUNTZ 137855 0 0 0 408 0 9838 0 5166 0 153267 0 0 0 BRIAN SMITH 282206 0 0 0 432 0 10401 0 17940 0 310979 0 0 0 ANTHONY RODEWALD 136615 0 0 0 330 0 10046 0 10772 0 157763 0 0 0 BRENDA KOPRIVA 257095 0 0 0 335 0 4038 0 12172 0 273640 0 0 0 TROY BRUNTZ CFO EMPLOYEE COMPUTER PURCHASE X 1908 159 0 1 1 159 MAX ABERCROMBIE SUZANNE ABERCROMB MAX ABERCROMBIE: BOARD OF DIRECTORS - MEMBER, SUZANNE ABERCROMBIE: SPOUSE 28110 MRS. ABERCROMBIE IS EMPLOYED BY THE HOSPITAL. 0 WAYNE WATKINS JESSICA JOHNSON WAYNE WATKINS: BOARD OF DIRECTORS - VICE CHAIR, JESSICA JOHNSON: DAUGHTER 37292 JESSICA JOHNSON IS EMPLOYED BY THE HOSPITAL. 0 FORM 990, PART VI, SECTION A, LINE 6 THE MEMBERS CONSIST OF ALL PERSONS WHO CONTRIBUTE TO THE BUILDING AND IMPROVEMENT FUND OF THE CORPORATION, AT ANY TIME DURING THE EXISTENCE OF THE CORPORATION, NOT LESS THAN THE SUM OF $100. FORM 990, PART VI, SECTION A, LINE 7A THE MEMBERS ELECT THE BOARD OF DIRECTORS AT THE ANNUAL MEETING EACH YEAR. FORM 990, PART VI, SECTION B, LINE 11 COMMUNITY HOSPITAL'S FORM 990, 990-T AND NEBRASKA INCOME TAX FORMS ARE COMPILED BY THE PUBLIC ACCOUNTING FIRM SEIM JOHNSON. MANAGEMENT RECEIVES DRAFT COPIES OF THE COMPLETED FORMS FOR REVIEW. AFTER HOSPITAL MANAGEMENT HAS REVIEWED THE RETURNS, COMPLETE COPIES ARE DISTRIBUTED TO ALL MEMBERS OF THE BOARD OF DIRECTORS OF THE COMMUNITY HOSPITAL ASSOCIATION AND THE RETURNS ARE APPROVED FOR FILING BY THE BUDGET & FINANCE COMMITTEE OF THE BOARD (A STANDING COMMITTEE WITH RESPONSIBILITY TO OVERSEE FINANCIAL, AUDIT, TAXATION AND BUDGET MATTERS OF THE HOSPITAL). BOARD COMMITTEE APPROVAL IS REQUIRED PRIOR TO SIGNATURE AND SUBMISSION OF THE RETURNS TO THE IRS AND STATE TAXING AUTHORITIES. FORM 990, PART VI, SECTION B, LINE 12C THE COMMUNITY HOSPITAL ASSOCIATION'S CODE OF CONDUCT REQUIRES ALL EMPLOYEES, CONTRACTORS, AND AGENTS TO REPORT ANY CONFLICTS OF INTEREST THAT ARISE. IN ADDITION, THE ASSOCIATION HAS A CONFLICT OF INTEREST POLICY THAT IS APPLICABLE TO DIRECTORS, OFFICERS, MEMBERS OF COMMITTEES AND SUBCOMMITTEES WITH BOARD-DELEGATED POWERS, AND KEY EMPLOYEES THAT REQUIRES, AMONG OTHER THINGS, ALL APPLICABLE PERSONS DISCLOSE ANY RELATIONSHIPS THAT MAY CREATE A CONFLICT OF INTEREST AND ARE REQUIRED TO COMPLETE AN ANNUAL DISCLOSURE OF ALL SUCH RELATIONSHIPS. ALL SUCH RELATIONSHIPS ARE DISCLOSED TO THE ENTIRE BOARD AND SENIOR MANAGEMENT, AND ANY AND ALL CONFLICTS OR POTENTIAL CONFLICTS ARE MONITORED BY SENIOR MANAGEMENT AND THE ASSOCIATION'S COMPLIANCE FUNCTION. FORM 990, PART VI, SECTION B, LINE 15 COMMUNITY HOSPITALS PROCESS FOR DETERMINING THE COMPENSATION OF THE CEO IS AS FOLLOWS: THE EXECUTIVE COMMITTEE OF THE BOARD OF DIRECTORS IS RESPONSIBLE FOR SETTING THE SALARY OF THE CEO. ANNUALLY, THE COMMITTEE CONDUCTS A REVIEW OF THE CEO'S PERFORMANCE, ABILITIES, AND OVERALL EFFECTIVENESS. THE COMMITTEE IS PRESENTED WITH SALARY AND COMPENSATION SURVEY DATA THAT IS COMPILED BY THE CEO AND THE HUMAN RESOURCE DEPARTMENT AND THE ACCURACY OF WHICH IS ATTESTED TO BY THE CFO. MULTIPLE SOURCES OF SURVEY DATA ARE USED, INCLUDING INFORMATION FROM THE NEBRASKA AND IOWA HOSPITAL ASSOCIATIONS, WHICH IS BROKEN DOWN TO SIMILARLY QUALIFIED PERSONS IN COMPARABLE POSITIONS AT SIMILARLY SIZED AND SITUATED ORGANIZATIONS. ALL SOURCE DOCUMENTATION IS GIVEN TO THE COMMITTEE AS WELL AS SUMMARIES PROVIDED FOR EASE OF REFERENCE. THE EXECUTIVE COMMITTEE CONDUCTS THE PERFORMANCE REVIEW WITH THE CEO; THEN MEETS IN PRIVATE CHAMBERS TO DISCUSS THE REVIEW AND TO DELIBERATE ANY AND ALL CHANGES TO THE EMPLOYMENT AGREEMENT, INCLUDING COMPENSATION, AND GOALS FOR THE FOLLOWING YEAR. CONTEMPORANEOUS RECORDS ARE KEPT OF ALL SURVEY AND COMPARABILITY DATA USED, AND THE RESULTS AND DECISIONS OF THE EXECUTIVE COMMITTEES MEETING ON COMPENSATION. COMPENSATION OF EMPLOYEES BELOW THE ROLE OF CEO ARE DETERMINED THROUGH THE USE OF SURVEY INFORMATION OF SIMILARLY QUALIFIED PERSONS IN COMPARABLE POSITIONS AT SIMILARLY SIZED AND SITUATED ORGANIZATIONS. THE CEO SETS THE COMPENSATION OF SENIOR MANAGEMENT BASED ON THOSE SURVEYS, TAKING IN CONSIDERATION PERFORMANCE AND EXPERIENCE OF EACH INDIVIDUAL. COMPENSATION RANGES OF EMPLOYEES BELOW SENIOR MANAGEMENT ARE SET BY HUMAN RESOURCES BASED ON MARKET WAGE RATES FOR SIMILARLY QUALIFIED PERSONS IN COMPARABLE POSITIONS AT SIMILARLY SIZED AND SITUATED ORGANIZATIONS. ALL EMPLOYEES HAVE AN ANNUAL REVIEW BY THEIR SUPERVISOR, WHICH DETERMINE WHERE IN THE SALARY RANGE AN EMPLOYEE WILL FALL. ALL SALARY RANGES, INCLUDING THOSE OF SENIOR MANAGEMENT, ARE ULTIMATELY APPROVED BY THE BOARD OF DIRECTORS DURING THE APPROVAL OF THE ANNUAL OPERATING BUDGET. FORM 990, PART VI, SECTION C, LINE 19 COMMUNITY HOSPITAL MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, FORM 990 & 990-T (CURRENT AND PAST YEARS AS REQUIRED BY LAW) AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. ANY INDIVIDUAL WHO WOULD LIKE A COPY OF ANY OF THE ABOVE MENTIONED DOCUMENTS CAN INSPECT THOSE DOCUMENTS IN PERSON AT THE HOSPITAL DURING NORMAL BUSINESS HOURS, OR REQUEST A COPY OF ANY OF THE ABOVE INFORMATION IN PERSON, BY PHONE, OR BY MAIL, AND WE WILL PROVIDE A COPY FREE OF CHARGE. OTHER FEES FORM 990, PART IX, LINE 11G MISCELLANEOUS FEES FOR SERVICE: PROGRAM SERVICE EXPENSES 1,956,454. MANAGEMENT AND GENERAL EXPENSES 720,536. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,676,990. PHYSICIAN FEES: PROGRAM SERVICE EXPENSES 1,054,770. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,054,770. LAB PATHOLOGIST FEES: PROGRAM SERVICE EXPENSES 304,472. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 304,472. PT MAINTENANCE AGREEMENT: PROGRAM SERVICE EXPENSES 951,375. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 951,375. IS MAINTENANCE AGREEMENT: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 608,587. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 608,587. FORM 990, PART XII, LINE 2C COMMUNITY HOSPITAL HAS A STANDING BOARD COMMITTEE, THE BUDGET AND FINANCE COMMITTEE, WHICH HAS THE AUTHORITY AND ASSUMES THE RESPONSIBILITY FOR THE SELECTION OF THE INDEPENDENT ACCOUNTING FIRM AND ALL RELATED OVERSIGHT, COMMUNICATION, AND REPORTING. THIS COMMITTEE APPROVES ALL ENGAGEMENT LETTERS AND RECEIVES ALL BOARD DIRECTED COMMUNICATION FROM THE INDEPENDENT ACCOUNTING FIRM. COPIES OF RECEIVED LETTERS/COMMUNICATIONS AND REPORTS ARE DISTRIBUTED TO ALL MEMBERS OF THE BOARD OF DIRECTORS IN ADDITION TO THE COMMITTEE MEMBERS. WHILE THE MEMBERS OF THE COMMITTEE HAVE CHANGED, THE PROCESS DESCRIBED HAS NOT CHANGED FROM THE PREVIOUS YEAR. COMMUNITY HOSPITAL HEALTH FOUNDATION 801 WEST C STREET PO BOX 1328 MCCOOK NE 69001 470693261 SUPPORTING ORGANIZATION PROVIDES FUNDRAISING FOR THE HOSPITAL NE 501(C)(3) LINE 11C, III-FI COMMUNITY HOSPITAL ASSOCIATION OF MCCOOK 1 RED WILLOW HOLDING COMPANY PO BOX 1328 MCCOOK NE 69001 470628195 RENTAL REAL ESTATE - CLINIC BUILDING NE COMMUNITY HOSPITAL ASSOCIATION OF MCCOOK C 50316 145593 1.00000 0 0 0 1 0 0 0 0 0 0 0 1 0 1 1 1 1 1 0 0 RED WILLOW MEDICAL HOLDING K 50261 CASH PAYMENTS=FMV COMMUNITY HOSPITAL HEALTH FOUNDATION C 841404 CASH RECEIVED=FMV