2014-05-14T14:28:01-05:00 2013-06-30 861065772 DELOITTE TAX LLP 111 MONUMENT CIRCLE SUITE 2000 INDIANAPOLIS IN 462045108 990 2012-07-01 350869065 ST MARY'S MEDICAL CENTER OF EVANSVILLE INC STMA 8124854178 3700 WASHINGTON AVENUE EVANSVILLE IN 47750 JOHN L ZABROWSKI 8124854178 2014-05-14 1 SHAWNA M JIMENEZ P01222873 3174648600 2014-05-12 2012 2015-11-30 17:44:51Z KEITH JEWELL 3700 WASHINGTON AVENUE EVANSVILLE IN 47750 469242685 0 0928 X WWW.STMARYS.ORG X 1941 IN DEDICATED TO SPIRITUALLY CENTERED CARE, WHICH IMPROVES THE HEALTH OF INDIVIDUALS AND COMMUNITIES. 15 9 3650 477 230955 -365094 2307954 1527361 438394746 438137652 18374856 17885356 11772892 10819915 470850448 468370284 2911410 21016801 0 0 191033245 156616340 0 0 744206 209550523 241877344 403495178 419510485 67355270 48859799 567651870 614660665 221969770 213767120 345682100 400893545 DEDICATED TO SPIRITUALLY CENTERED CARE, WHICH IMPROVES THE HEALTH OF INDIVIDUALS AND COMMUNITIES. 0 0 344211902 21016801 446118919 ST. MARY'S MEDICAL CENTER OF EVANSVILLE, INC. (SMMC) PROVIDES INPATIENT AND OUTPATIENT MEDICAL SERVICES SERVING VANDERBURGH AND CONTIGUOUS COUNTIES AND PROVIDING SERVICES WITHOUT REGARD TO PATIENT RACE, CREED, NATIONAL ORIGIN, ECONOMIC STATUS, OR ABILITY TO PAY. DURING FISCAL YEAR 2013, SMMC TREATED 17,218 INPATIENTS IN THE COMMUNITY FOR A TOTAL OF 83,119 PATIENT DAYS OF SERVICE. SMMC ALSO PROVIDED SERVICES TO 354,550 OUTPATIENTS, INCLUDING 4,630 INPATIENT SURGERY PATIENTS, 54,869 EMERGENCY ROOM VISITS, 42,224 PHYSICIAN OFFICE VISITS, AND 22,722 CLINIC VISITS. SEE SCHEDULE H FOR A NON-EXHAUSTIVE LIST OF COMMUNITY BENEFIT PROGRAMS AND DESCRIPTIONS. 33279840 SMMC PROVIDES A SUBSTANTIAL PORTION OF ITS CORE HEALTH SERVICES TO THE POOR, UNINSURED, OR UNDERINSURED AND HAS PROACTIVELY TAKEN STEPS TO ADDRESS ACCESSIBILITY, AND THE FINANCING, AND DELIVERY OF HEALTHCARE TO THE UNDERSERVED. DURING THE FISCAL YEAR ENDING JUNE 30, 2013, THE UNREIMBURSED COST OF FREE OR DISCOUNTED SERVICES PROVIDED TO PATIENTS WHO ARE DEEMED INDIGENT UNDER STATE, COUNTY, OR HOSPITAL GUIDELINES WAS $33,279,840, WHICH INCLUDED $18,852,448 OF TRADITIONAL FINANCIAL ASSISTANCE AND $14,427,392 IN UNPAID COSTS OF CARE FOR THOSE QUALIFYING FOR MEDICAID OR OTHER PUBLIC PROGRAMS FOR THE POOR. SEE SCHEDULE H FOR A NON-EXHAUSTIVE LIST OF COMMUNITY BENEFIT PROGRAMS AND DESCRIPTIONS. 1452585 IN ADDITION TO CORE MEDICAL SERVICES, SMMC AND COMMUNITY PARTNERS ASSESS COMMUNITY ASSETS AND NEEDS AND WORK TOGETHER TO ADDRESS ISSUES IMPACTING HEALTH AND QUALITY OF LIFE, WITH SPECIAL EMPHASIS ON THE POOR AND VULNERABLE. IN FISCAL YEAR 2013, SMMC PROVIDED $1,452,585 IN UNBILLED SERVICES TO THE POOR AND TO THE BROADER COMMUNITY. (WHEN COMBINED WITH THE COSTS OF FREE OR DISCOUNTED SERVICES FOR THE POOR LISTED IN LINE 4B, SMMC PROVIDED A TOTAL COMMUNITY BENEFIT OF $34,732,425 IN FISCAL YEAR 2013.) SMMC SERVES AND SUPPORTS ITS COMMUNITY THROUGH SUCH PROGRAMS AS SUPPORT GROUPS, PUBLIC HEALTH SCREENINGS, AND NUTRITION COUNSELING. SEE SCHEDULE H FOR A NON-EXHAUSTIVE LIST OF COMMUNITY BENEFIT PROGRAMS AND DESCRIPTIONS. 378944327 1 1 0 1 0 0 0 0 0 0 1 0 0 1 1 0 0 1 0 0 1 0 0 0 0 0 1 1 1 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 1 1 1 0 0 1 275 0 1 3650 1 1 1 0 0 0 0 0 0 0 0 0 X 15 9 0 0 1 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 1 1 IN X JOHN L ZABROWSKI 8124854178 3700 WASHINGTON AVENUE EVANSVILLE IN 47750 SISTER XAVIER BALLANCE 1.00 4.00 X 0 0 0 NADINE COUDRET 1.00 1.00 X 0 0 0 MARIA DEL-RIO MD 55.00 0.00 X 394937 0 72996 DARCY ELLISON 60.00 1.00 X 293768 0 127565 DORON FINN MD 1.00 0.00 X 0 0 0 PRASAD GADE MD 1.00 1.00 X 0 0 0 JOHN GALLAGHER MD 60.00 1.00 X 444042 0 121575 TRICIA HENNING 1.00 2.00 X 0 0 0 MICHAEL HERRELL MD 1.00 5.00 X X 0 0 0 SHARON KAZEE 1.00 1.00 X 0 0 0 SISTER SHARON RICHARDT 1.00 1.00 X 0 0 0 GWEN SANDEFUR 60.00 6.20 X 381454 0 42467 KARL SASH MD 1.00 56.00 X 0 579307 100068 KENNETH SPEAR MD 1.00 2.00 X 0 0 0 JOHN STANLEY 1.00 2.00 X 0 0 0 TIMOTHY FLESCH 55.00 11.20 X 1704596 0 63161 KIMBERLY HODGKINSON 60.00 4.00 X 368829 0 20703 JANICE ERNEST 60.00 2.00 X 226052 0 99254 JOHN GREANEY 60.00 0.00 X 184725 0 24016 KATHY HALL 60.00 0.00 X 183210 0 53234 MICHAEL KLUEH 60.00 0.00 X 198159 0 78001 THOMAS LILLY 60.00 1.00 X 233955 0 52181 VERNON MAASMD 60.00 0.00 X 224746 0 40778 MIKE WHITMORE 60.00 0.00 X 211751 0 66277 KATHRYN BRYAN MD 55.00 0.00 X 460866 0 58099 ROBERT CUTRELL MD 55.00 0.00 X 368482 0 69777 MYLES GRANT 55.00 0.00 X 422516 0 94704 CHARLES LACKEY MD 55.00 0.00 X 510134 0 58612 MUREENA TURNQUEST-WELLS MD 55.00 1.00 X 614834 0 109136 7427056 579307 1352604 89 0 1 0 AMBULATORY CARE CENTER LLC 1125 PROFESSIONAL BLVD EVANSVILLE IN 47714 MEDICAL SERVICES 25988358 TRIMEDX PO BOX 636129 CINCINNATI OH 45263 HEALTH CARE EQUIPMENT MANAGEMENT 4194519 AIR METHODS CORPORATION PO BOX 172892 DENVER CO 802172892 AIR TRANSPORT SERVICES 1559206 EMERGENCY PROFESSIONAL SERVICE PO BOX 634850 CINCINNATI OH 45263 MEDICAL SERVICES 1519667 ST MARY'S PERIPHERAL VASCULAR SERVICES 3700 WASHINGTON AVENUE EVANSVILLE IN 47750 MEDICAL SERVICES 1181398 55 1494653 32708 9795 1527361 OUTPATIENT SERVICE REV 621110 219888425 219888425 INPATIENT SERVICE REV 621110 218249227 218249227 438137652 17922403 17922403 631776 522271 109505 109505 109505 313083 350130 -37047 -37047 -37047 APOTHECARY 446110 4619370 4619370 CAFETERIA/MISC. SERV 722320 1835442 108212 1727230 LAB SERVICES 621500 828758 94847 733911 3426840 3398944 27896 10710410 468370284 446118919 230955 20493049 21016801 21016801 6012500 6012500 118467180 108407324 9501410 558446 2647080 2317174 329906 20818340 18160756 2594591 62993 8671240 7556130 1080697 34413 19911102 17429580 2481522 91657 80234 11423 125037 103957 15583 5497 4266270 3667527 531802 66941 19069732 16683051 2376662 10019 8536938 7472979 1063959 418446 361343 52151 4952 199962 174528 24921 513 4712929 4125556 587373 21065232 18439871 2625361 1543290 1350518 192340 432 PURCHASED SERVICES 68662977 60105506 8557471 MEDICAL SUPPLIES 57940960 57940960 PROVIDER TAX EXPENSE 16160221 16160221 COST OF GOODS SOLD 6051858 6051858 13120733 11338453 1782280 419510485 378944327 39821952 744206 4387544 3446252 54931619 54541611 957935 854961 5409364 6068368 2567499 2562612 358326159 273102016 87687421 85224143 48701 55798 450788 279255 411210999 461627665 567651870 614660665 38839540 37975128 183130230 175791992 221969770 213767120 X 345682100 400893545 345682100 400893545 567651870 614660665 X 48859799 11473267 -5121621 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 3199 3199 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: LOBBYING EXPENSES REPRESENT THE PORTION OF DUES PAID TO NATIONAL AND STATE HOSPITAL ASSOCIATIONS THAT IS SPECIFICALLY ALLOCABLE TO LOBBYING. ST. MARY'S MEDICAL CENTER OF EVANSVILLE, INC. DOES NOT PARTICIPATE IN OR INTERVENE IN (INCLUDING THE PUBLISHING OR DISTRIBUTING OR STATEMENTS) ANY POLITICAL CAMPAIGN ON BEHALF OF (OR IN OPPOSITION TO) ANY CANDIDATE FOR PUBLIC OFFICE. 7736792 7736792 92320106 61856222 30463884 21275229 11422404 9852825 236994032 199823390 37170642 85224143 INTERCOMPANY RECEIVABLES 8265929 OTHER RECEIVABLES 4036235 DEFERRED COMPENSATION ASSET 4359995 ESTIMATED SETTLEMENTS FROM THIRD PARTIES 938359 PHYSICIAN GUARANTEES ASSET 19602250 OTHER CURRENT ASSETS 57355 INTEREST IN INVESTMENTS HELD BY ASCENSION HEALTH ALLIANCE 424367542 461627665 PENSION LIABILITY 5602628 DEFERRED COMPENSATION 4359995 SELF INSURANCE LIABILITY 1475372 ESTIMATED SETTLEMENT LIABILITY 3001494 AH SAVINGS LIABILITY 1679957 INTERCOMPANY PAYABLES 222973 VALUATION ALLOWANCE 1950000 DEFERRED RENT PAYABLE 459073 PHYSICIAN GUARANTEE LIABILITY 19602250 INTERCOMPANY DEBT WITH ASCENSION HEALTH ALLIANCE 137438250 175791992 NORTH AMERICA 0 0 PROGRAM SERVICES LICENSES, PERMITS 2712 NORTH AMERICA 0 0 PROGRAM SERVICES MEDICAL SUPPLIES 8137 0 0 0 0 0 0 10849 0 10849 0 0 0 0 0 0 1 1 X 1 X 1 X 1 1 0 1 1 18852448 18852448 0.04830 55601119 41173727 14427392 0.04090 74453567 41173727 33279840 0.08920 892244 1155117 433383 721734 0.00170 289786 289786 0.00070 40010 441065 441065 0.00110 932254 1885968 433383 1452585 0.00350 932254 76339535 41607110 34732425 0.09270 0 4222693 422269 113481329 151333702 -37852373 X 1 1 1 ST MARY'S PERIPHERAL VASCULAR SERVICES MANAGEMENT COMPANY LLC MANAGEMENT 0.75000 0.00000 0.75000 1 1 ST MARY'S MEDICAL CENTER OF EVA INC

3700 WASHINGTON AVENUE EVANSVILLE IN 47750

WWW.STMARYS.ORG/SMLOCATION X X X X X ST MARY'S MEDICAL CENTER OF EVA INC 1 1 X X X X X X X X X 12 1 1 1 X X X X X X X X X X 0 0 1 1 200.000000000000 1 300.000000000000 1 X X 1 1 X X X 1 0 1 X 0 0 18 ST MARY'S SURGICARE

300 CIRCLE FRONT DRIVE EVANSVILLE IN 47715

GENERAL SURGICAL CENTER ST MARY'S SURGICARE

1125 PROFESSIONAL BLVD EVANSVILLE IN 47714

GENERAL SURGICAL CENTER ST MARY'S PRE-PROCEDURE CLINIC

1140 WASHINGTON AVENUE EVANSVILLE IN 47714

PRIMARY CARE FACILITY ST MARY'S MATERNAL-FETAL MEDICINE

3700 WASHINGTON AVENUE SUITE 2100A EVANSVILLE IN 47750

OBSTETRICS/GYNECOLOGY ST MARY'S REHAB

3900 WASHINGTON AVENUE EVANSVILLE IN 47714

INPATIENT REHAB CENTER ST MARY'S OUTPATIENT REHAB

1144 WASHINGTON SQUARE EVANSVILLE IN 47715

OUTPATIENT REHAB CLINIC ST MARY'S FOR CHILDREN

3900 WASHINGTON AVENUE EVANSVILLE IN 47714

CHILDREN'S HEALTH FACILITY ST MARY'S CONVENIENT CARE - WEST

5320 WESTON ROAD EVANSVILLE IN 47712

PRIMARY CARE FACILITY ST MARY'S OCCMED

2330 LYNCH ROAD EVANSVILLE IN 47711

OCCUPATIONAL MEDICINE CLINIC ST MARY'S CONVENIENT CARE EAST

10444 SR 66 FRONTAGE ROAD NORTH NEWBURGH IN 47630

PRIMARY CARE FACILITY ST MARY'S NORTH POINTE REHAB

2300 LYNCH ROAD EVANSVILLE IN 47711

OUTPATIENT REHAB CLINIC ST MARY'S IMAGING AND LAB

1138 WASHINGTON SQUARE EVANSVILLE IN 47715

IMAGING SERVICES/RADIOLOGY ST MARY'S NORTHBROOK

3838 N FIRST AVENUE EVANSVILLE IN 47710

PRIMARY CARE FACILITY ST MARY'S BOONVILLE PHYSICIAN OFFICE

1116 MILLIS AVENUE BOONVILLE IN 47601

PRIMARY CARE FACILITY JOSLIN DIABETES CENTER

3801 BELLEMEADE AVENUE EVANSVILLE IN 47714

DIABETES SERVICE CENTER ST MARY'S HEART INSTITUTE

3700 WASHINGTON AVENUE EVANSVILLE IN 47714

SPECIALITY CARE FACILITY ST MARY'S WEIGHT MANAGEMENT CENTER

950 S KENMORE EVANSVILLE IN 47714

WEIGHT MANAGEMENT FACILITY ST MARY'S WEST SIDE X-RAY

2345 W FRANKLIN STREET EVANSVILLE IN 47712

IMAGING SERVICES/RADIOLOGY PART I, LINE 3C: THE ORGANIZATION PROVIDES MEDICALLY NECESSARY CARE TO ALL PATIENTS, REGARDLESS OF RACE, COLOR, CREED, ETHNIC ORIGIN, GENDER, DISABILITY, OR ECONOMIC STATUS. THE HOSPITAL USES A PERCENTAGE OF FEDERAL POVERTY LEVEL (FPL) TO DETERMINE FREE AND DISCOUNTED CARE. AT A MINIMUM, PATIENTS WITH INCOME LESS THAN OR EQUAL TO 200% OF THE FPL, WHICH MAY BE ADJUSTED FOR COST OF LIVING UTILIZING THE LOCAL WAGE INDEX COMPARED TO THE NATIONAL WAGE INDEX, WILL BE ELIGIBLE FOR 100% CHARITY CARE WRITE OFF OF CHARGES FOR SERVICES THAT HAVE BEEN PROVIDED TO THEM. ALSO, AT A MINUMUM, PATIENTS WITH INCOMES ABOVE 200% OF THE FPL BUT NOT EXCEEDING 300% OF THE FPL, SUBJECT TO ADJUSTMENTS FOR COST OF LIVING UTILIZING THE LOCAL WAGE INDEX COMPARED TO NATIONAL WAGE INDEX, WILL RECEIVE A DISCOUNT ON THE SERVICES PROVIDED TO THEM. PART I, LINE 7: THE COST OF PROVIDING CHARITY CARE, MEANS TESTED GOVERNMENT PROGRAMS, AND COMMUNITY BENEFIT PROGRAMS IS ESTIMATED USING INTERNAL COST DATA, AND IS CALCULATED IN COMPLIANCE WITH CATHOLIC HEALTH ASSOCIATION ("CHA") GUIDELINES. THE ORGANIZATION USES A COST ACCOUNTING SYSTEM THAT ADDRESSES ALL PATIENT SEGMENTS (FOR EXAMPLE, INPATIENT, OUTPATIENT, EMERGENCY ROOM, PRIVATE INSURANCE, MEDICAID, MEDICARE, UNINSURED, OR SELF PAY). THE BEST AVAILABLE DATA WAS USED TO CALCULATE THE AMOUNTS REPORTED IN THE TABLE. FOR THE INFORMATION IN THE TABLE, A COST-TO-CHARGE RATIO WAS CALCULATED AND APPLIED. PART II: ST. MARY'S MEDICAL CENTER OF EVANSVILLE, INC. PROMOTES THE HEALTH OF ITS COMMUNITIIES BY STRIVING TO IMPROVE THE QUALITY OF LIFE WITHIN THE COMMUNITY. RESEARCH HAS ESTABLISHED THAT FACTORS SUCH AS ECONOMIC STATUS, EMPLOYMENT, HOUSING, EDUCATION LEVEL, AND BUILT ENVIRONMENT CAN ALL BE POWERFUL SOCIAL DETERMINANTS OF HEALTH. ADDITIONALLY, HELPING TO CREATE GREATER CAPACITY WITHIN THE COMMUNITY TO ADDRESS A BROAD RANGE OF QUALITY OF LIFE ISSUES ALSO IMPACTS HEALTH. ST. MARY'S MEDICAL CENTER OF EVANSVILLE, INC. MEETS REGULARLY WITH LOCAL ORGANIZATIONS IN THE COMMUNITY TO LEARN WHAT RESOURCES ARE AVAILABLE AND PLAN COMMUNITY HEALTH IMPROVEMENT EFFORTS. PART III, LINE 2: AFTER SATISFACTION OF AMOUNTS DUE FROM INSURANCE AND REASONABLE EFFORTS TO COLLECT FROM THE PATIENT HAVE BEEN EXHAUSTED, THE CORPORATION FOLLOWS ESTABLISHED GUIDELINES FOR PLACING CERTAIN PAST-DUE PATIENT BALANCES WITHIN COLLECTION AGENCIES, SUBJECT TO THE TERMS OF CERTAIN RESTRICTIONS ON COLLECTION EFFORTS AS DETERMINED BY ASCENSION HEALTH. ACCOUNTS RECEIVABLE ARE WRITTEN OFF AFTER COLLECTION EFFORTS HAVE BEEN FOLLOWED, IN ACCORDANCE WITH THE CORPORATION'S POLICIES. AFTER APPLYING THE COST-TO-CHARGE RATIO, THE SHARE OF THE BAD DEBT EXPENSE IN FISCAL YEAR 2013 WAS $14,594,746 AT CHARGES ($4,222,693 AT COST). PART III, LINE 3: THE PROVISION FOR DOUBTFUL ACCOUNTS IS BASED UPON MANAGEMENT'S ASSESSMENT OF EXPECTED NET COLLECTIONS CONSIDERING ECONOMIC CONDITIONS, HISTORICAL EXPERIENCE, TRENDS IN HEALTH CARE COVERAGE, AND OTHER COLLECTION INDICATORS. PERIODICALLY THROUGHOUT THE YEAR, MANAGEMENT ASSESSES THE ADEQUACY OF THE ALLOWANCE FOR DOUBTFUL ACCOUNTS BASED UPON HISTORICAL WRITE-OFF EXPERIENCE BY PAYOR CATEGORY, INCLUDING THOSE AMOUNTS NOT COVERED BY INSURANCE. THE RESULTS OF THIS REVIEW ARE THEN USED TO MAKE ANY MODIFICATIONS TO THE PROVISION FOR DOUBTFUL ACCOUNTS TO ESTABLISH AN APPROPRIATE ALLOWANCE FOR DOUBTFUL ACCOUNTS. PART III, LINE 4: THE ORGANIZATION IS A PART OF THE ST.VINCENT HEALTH SYSTEM'S CONSOLIDATED AUDIT IN WHICH THE FOOTNOTE THAT DISCUSSES THE BAD DEBT EXPENSE IS LOCATED ON PAGE 22. PART III, LINE 8: A COST TO CHARGE RATIO IS APPLIED TO THE ORGANIZATION'S MEDICARE EXPENSE TO DETERMINE THE MEDICARE ALLOWABLE COSTS REPORTED IN THE ORGANIZATION'S MEDICARE COST REPORT. ASCENSION HEALTH AND RELATED HEALTH MINISTRIES FOLLOW THE CATHOLIC HEALTH ASSOCIATION ("CHA") GUIDELINES FOR DETERMINING COMMUNITY BENEFIT. CHA COMMUNITY BENEFIT REPORTING GUIDELINES SUGGEST THAT MEDICARE SHORTFALL IS NOT TREATED AS A COMMUNITY BENEFIT. PART III, LINE 9B: THE ORGANIZATION HAS A WRITTEN DEBT COLLECTION POLICY THAT ALSO INCLUDES A PROVISION ON THE COLLECTION PRACTICES TO BE FOLLOWED FOR PATIENTS WHO ARE KNOWN TO QUALIFY FOR CHARITY CARE OR FINANCIAL ASSISTANCE. IF A PATIENT QUALIFIES FOR CHARITY OR FINANCIAL ASSISTANCE CERTAIN COLLECTION PRACTICES DO NOT APPLY AND THE FINANCIAL ASSISTANCE PROGRAM IS FOLLOWED. PART V, SECTION B, LINE 3: IN CONDUCTING ITS CHNA, THE HOSPITAL FACILITY TOOK INTO ACCOUNT INPUT FROM PERSONS WHO REPRESENT THE BROAD INTERESTS OF THE COMMUNITY SERVED BY THE HOSPITAL FACILITY AS WELL AS PROFESSIONAL RESEARCH CONSULTANTS, INC., A CONSULTING COMPANY THAT HAS SPECIAL KNOWLEDGE AND EXPERTISE IN PUBLIC HEALTH.THE HOSPITAL FACILITY CONSULTED WITH THESE PERSONS THROUGH MEETINGS AND FOCUS GROUPS.ADDITIONALLY, THE HOSPITAL CONSULTED WITH THE FOLLOWING ORGANIZATIONS AND GROUPS IN CONDUCTING ITS MOST RECENT CHNA: ECHO, UNITED WAY, WELBORN BAPTIST FOUNDATION, SMOKE FREE COMMUNITIES, YMCA, DIEHL CONSULTING, THE CITY OF EVANSVILLE'S MAYOR'S OFFICE, SOUTHWEST MENTAL HEALTH, BRENTWOOD MEADOWS, CROSSPOINTE, EVANSVILLE-VANDERBURGH DRUG TASK FORCE, WARRICK CO. SHERIFF DEPARTMENT, VANDERBURGH CO. SHERIFF DEPARTMENT, YOUTH FIRST, EVANSVILLE STATE HOSPITAL, LAMPION CENTER, WARRICK PSYCHIATRIC CARE AND THE CHILDREN'S PSYCHIATRIC HOSPITAL. PART V, SECTION B, LINE 4: THE OTHER HOSPITAL FACILITIES WITH WHICH THE REPORTING HOSPITAL FACILITY CONDUCTED ITS CHNA INCLUDES ST. MARY'S WARRICK HOSPITAL, INC., DEACONESS HOSPITAL, DEACONESS GATEWAY, DEACONESS CROSSPOINTE, AND THE WOMEN'S HOSPITAL. PART V, SECTION B, LINE 5: THE COMMUNITY HEALTH NEEDS ASSESSMENT ("CHNA") OF THE HOSPITAL FACILITY CAN BE LOCATED AT THE FOLLOWING WEB ADDRESS: HTTP://WWW.STMARYS.ORG/CHNA. PART V, SECTION B, LINE 5C: THE HOSPITAL FACILITY PRESENTED ITS CHNA TO THE COMMUNITY AT A LOCAL FINANCIAL INSTITUTION. PART V, SECTION B, LINE 7: THE HOSPITAL FACILITY'S COMMUNITY NEEDS HEALTH ASSESSMENT IDENTIFIED ACCESS TO CARE, ORAL HEALTH, AND EDUCATION TRAINING AS NEEDS OF THE COMMUNITY. THE HOSPITAL FACILITY DID NOT TAKE ACTION TO ADDRESS THESE NEEDS AS IT HAS LIMITED FINANCIAL AND OTHER RESOURCES. PART V, SECTION B, LINE 16: THE FOLLOWING STEPS WERE FOLLOWED AND CONSIDERED REASONABLE EFFORTS FOR PURPOSES OF QUESTION 16:- NOTIFIED EACH INDIVIDUAL OF THE FACILITY'S FINANCIAL ASSISTANCE POLICY (FAP). THIS NOTIFICATION BEGAN ON THE DATE CARE WAS PROVIDED AND ENDED ON THE 120TH DAY AFTER THE FIRST BILLING STATEMENT WAS PROVIDED TO THE INDIVIDUAL.- INDIVIDUALS WERE NOTIFIED OF THE FAP BY METHODS AS NOTED IN QUESTION 14. THIS INCLUDES, BUT IS NOT LIMITED TO, PROVIDING THE FOLLOWING:- A BRIEF DESCRIPTION OF ELIGIBILITY REQUIREMENTS AND ASSISTANCE PROVIDED- DIRECTIONS ON HOW TO ACCESS THE FAP AND APPLICATION ON OUR WEBSITE AND PHYSICAL LOCATION OF APPLICATION FORMS- INSTRUCTIONS TO OBTAIN FREE COPY OF FAP AND APPLICATION BY MAIL- CONTACT INFORMATION FOR AN INDIVIDUAL/NONPROFIT ORGANIZATION TO ASSIST IF THE INDIVIDUAL HAS QUESTIONS- STATEMENT OF TRANSLATIONS OF FAP AS WELL AS PLAIN LANGUAGE SUMMARIES- STATEMENT THAT NO FAP-ELIGIBLE INDIVIDUAL WILL BE CHARGED MORE FOR EMERGENCY/MEDICALLY NECESSARY CARE THAN AGB- FOR INDIVIDUALS WHO SUBMITTED AN INCOMPLETE FAP, WE PROVIDED THAT INDIVIDUAL WITH INFORMATION RELEVANT TO ASSIST THEM WITH COMPLETION OF THE FAP.- FOR INDIVIDUALS WHO SUBMITTED A COMPLETE FAP, WE MADE AND DOCUMENTED A DETERMINATION AS TO WHETHER THAT PERSON WAS ELIGIBLE UNDER THE FACILITY'S FAP.- WE DETERMINED ELIGIBILITY BASED ON OTHER MEANS SUCH AS ESTABLISHING THAT THE INDIVIDUAL IS ELIGIBLE UNDER ONE OR MORE MEANS TESTED PROGRAMS (AS NOTED IN QUESTION 12). PART V, SECTION B, LINE 17: THE FOLLOWING STEPS WERE FOLLOWED AND CONSIDERED REASONABLE EFFORTS FOR PURPOSES OF QUESTION 17:- NOTIFIED EACH INDIVIDUAL OF THE HOSPITAL'S FINANCIAL ASSISTANCE POLICY (FAP). THIS NOTIFICATION BEGAN ON THE DATE CARE WAS PROVIDED AND ENDED ON THE 120TH DAY AFTER THE FIRST BILLING STATEMENT WAS PROVIDED TO THE INDIVIDUAL.- INDIVIDUALS WERE NOTIFIED OF THE FAP AS NOTED IN QUESTION 14. THIS INCLUDES, BUT IS NOT LIMITED TO, THE FOLLOWING:- BRIEF DESCRIPTION OF ELIGIBILITY REQUIREMENTS AND ASSISTANCE PROVIDED- DIRECT INDIVIDUALS TO OUR WEBSITE AND PHYSICAL LOCATION OF APPLICATION FORMS- PROVIDED INSTRUCTIONS TO OBTAIN FREE COPY OF FAP AND APPLICATION BY MAIL- PROVIDED CONTACT INFORMATION FOR AN INDIVIDUAL/NONPROFIT ORGANIZATION TO ASSIST IF THE INDIVIDUAL HAS QUESTIONS- PROVIDED STATEMENT OF TRANSLATIONS OF FAP AS WELL AS PLAIN LANGUAGE SUMMARIES- PROVIDED STATEMENT THAT NO FAP-ELIGIBLE INDIVIDUAL WILL BE CHARGED MORE FOR EMERGENCY/MEDICALLY NECESSARY CARE THAN AGB- FOR INDIVIDUALS WHO SUBMITTED AN INCOMPLETE FAP, WE PROVIDED THAT INDIVIDUAL WITH INFORMATION RELEVANT TO ASSIST THEM WITH COMPLETION OF THE FAP.- FOR INDIVIDUALS WHO SUBMITTED A COMPLETE FAP, WE MADE AND DOCUMENTED A DETERMINATION AS TO WHETHER THAT PERSON WAS ELIGIBLE UNDER THE FACILITY'S FAP.- WE DETERMINED ELIGIBILITY BASED ON OTHER MEANS SUCH AS ESTABLISHING THAT THE INDIVIDUAL IS ELIGIBLE UNDER ONE OR MORE MEANS TESTED PROGRAMS (AS NOTED IN QUESTION 12). PART V, SECTION B, LINE 18: QUESTION 18 IS MORE APPROPRIATELY ANSWERED AS NOT APPLICABLE AS THE BILLING AND COLLECTIONS POLICY OF ST. MARY'S MEDICAL CENTER OF EVANSVILLE, INC. DOES NOT ALLOW A HOSPITAL TO ENGAGE IN EXTRAORDINARY COLLECTION ACTIONS BEFORE THE ORGANIZATION MADE REASONABLE EFFORTS TO DETERMINE WHETHER THE INDIVIDUAL IS ELIGIBLE FOR ASSISTANCE UNDER THE FINANCIAL ASSISTANCE POLICY. REASONABLE EFFORTS TAKEN INCLUDE BUT ARE NOT LIMITED TO:- NOTIFYING INDIVIDUALS OF THE FINANCIAL ASSISTANCE POLICY ON ADMISSION- NOTIFYING INDIVIDUALS OF THE FINANCIAL ASSISTANCE POLICY PRIOR TO DISCHARGE- NOTIFYING INDIVIDUALS OF THE FINANCIAL ASSISTANCE POLICY IN COMMUNICATIONS WITH THE PATIENTS REGARDING THE PATIENTS' BILLS- DOCUMENTING ITS DETERMINATION OF WHETHER PATIENTS WERE ELIGIBLE FOR FINANCIAL ASSISTANCE UNDER THE HOSPITAL FACILITY'S FINANCIAL ASSISTANCE POLICY PART V, SECTION B, LINE 20D: THE DISCOUNT WAS DETERMINED BY REVIEWING THE LOWEST DISCOUNT PROVIDED TO MANAGED CARE PAYERS THAT COMPRISE AT LEAST 3% OF OUR VOLUME WITH AN ADDED PROMPT PAY DISCOUNT TO THE HIGHEST PAID DISCOUNT PROVIDED TO OUR MANAGED CARE PAYERS. PART V, SECTION B, LINE 21: THE FOLLOWING STEPS WERE FOLLOWED AND CONSIDERED REASONABLE EFFORTS FOLLOWED FOR PURPOSES OF IDENTIFYING PATIENTS ELIGIBLE FOR ASSISTANCE UNDER THE FACILITY'S FAP:- NOTIFIED EACH INDIVIDUAL OF THE HOSPITALS'S FINANCIAL ASSISTANCE POLICY (FAP). THIS NOTIFICATION BEGAN ON THE DATE CARE WAS PROVIDED AND ENDED ON THE 120TH DAY AFTER THE FIRST BILLING STATEMENT WAS PROVIDED TO THE INDIVIDUAL.- INDIVIDUALS WERE NOTIFIED OF THE FAP AS NOTED IN QUESTION 14. THIS INCLUDES, BUT IS NOT LIMITED TO, THE FOLLOWING:- BRIEF DESCRIPTION OF ELIGIBILITY REQUIREMENTS AND ASSISTANCE PROVIDED- DIRECT INDIVIDUALS TO OUR WEBSITE AND PHYSICAL LOCATION OF APPLICATION FORMS- PROVIDED INSTRUCTIONS TO OBTAIN FREE COPY OF FAP AND APPLICATION BY MAIL- PROVIDED CONTACT INFORMATION FOR AN INDIVIDUAL/NONPROFIT ORGANIZATION TO ASSIST IF THE INDIVIDUAL HAS QUESTIONS- PROVIDED STATEMENT OF TRANSLATIONS OF FAP AS WELL AS PLAIN LANGUAGE SUMMARIES- PROVIDED STATEMENT THAT NO FAP-ELIGIBLE INDIVIDUAL WILL BE CHARGED MORE FOR EMERGENCY/MEDICALLY NECESSARY CARE THAN AGB- FOR INDIVIDUALS WHO SUBMITTED AN INCOMPLETE FAP, WE PROVIDED THAT INDIVIDUAL WITH INFORMATION RELEVANT TO ASSIST THEM WITH COMPLETION OF THE FAP.- FOR INDIVIDUALS WHO SUBMITTED A COMPLETE FAP, WE MADE AND DOCUMENTED A DETERMINATION AS TO WHETHER THAT PERSON WAS ELIGIBLE UNDER THE FACILITY'S FAP.- WE DETERMINED ELIGIBILITY BASED ON OTHER MEANS SUCH AS ESTABLISHING THAT THE INDIVIDUAL IS ELIGIBLE UNDER ONE OR MORE MEANS TESTED PROGRAMS (AS NOTED IN QUESTION 12). PART V, SECTION B, LINE 22: THE FOLLOWING STEPS WERE FOLLOWED AND CONSIDERED REASONABLE EFFORTS FOLLOWED FOR PURPOSES OF IDENTIFYING PATIENTS ELIGIBLE FOR ASSISTANCE UNDER THE FACILITY'S FAP:- NOTIFIED EACH INDIVIDUAL OF THE HOSPITAL'S FINANCIAL ASSISTANCE POLICY (FAP) AS NOTED IN QUESTION 14. THIS INCLUDES, BUT IS NOT LIMITED TO, THE FOLLOWING:- BRIEF DESCRIPTION OF ELIGIBILITY REQUIREMENTS AND ASSISTANCE PROVIDED- DIRECT INDIVIDUALS TO OUR WEBSITE AND PHYSICAL LOCATION OF APPLICATION FORMS- PROVIDED INSTRUCTIONS TO OBTAIN FREE COPY OF FAP AND APPLICATION BY MAIL- PROVIDED CONTACT INFORMATION FOR AN INDIVIDUAL/NONPROFIT ORGANIZATION TO ASSIST IF THE INDIVIDUAL HAS QUESTIONS- PROVIDED STATEMENT OF TRANSLATIONS OF FAP AS WELL AS PLAIN LANGUAGE SUMMARIES- PROVIDED STATEMENT THAT NO FAP-ELIGIBLE INDIVIDUAL WILL BE CHARGED MORE FOR EMERGENCY/MEDICALLY NECESSARY CARE THAN AGB- THIS NOTIFICATION BEGAN ON THE DATE CARE WAS PROVIDED AND ENDED ON THE 120TH DAY AFTER THE FIRST BILLING STATEMENT WAS PROVIDED TO THE INDIVIDUAL.- FOR INDIVIDUALS WHO SUBMITTED AN INCOMPLETE FAP, WE PROVIDED THAT INDIVIDUAL WITH INFORMATION RELEVANT TO ASSIST THEM WITH COMPLETION OF THE FAP.- FOR INDIVIDUALS WHO SUBMITTED A COMPLETE FAP, WE MADE AND DOCUMENTED A DETERMINATION AS TO WHETHER THAT PERSON WAS ELIGIBLE UNDER THE FACILITY'S FAP.- WE DETERMINED ELIGIBILITY BASED ON OTHER MEANS SUCH AS ESTABLISHING THAT THE INDIVIDUAL IS ELIGIBLE UNDER ONE OR MORE MEANS TESTED PROGRAMS (AS NOTED IN QUESTION 12). PART VI, LINE 2: COMMUNITIES ARE DYNAMIC SYSTEMS IN WHICH MULTIPLE FACTORS INTERACT TO IMPACT QUALITY OF LIFE AND HEALTH STATUS. AS PART OF THE ST. MARY'S HEALTH SYSTEM, THE GOAL OF ST. MARY'S MEDICAL CENTER OF EVANSVILLE, INC. IS TO WORK WITH ITS COMMUNITY TO CONDUCT AN ASSESSMENT AT LEAST EVERY THREE YEARS. ASSESSMENTS MAY INCLUDE PRIMARY SURVEY DATA, SECONDARY DATA, FOCUS GROUP INPUT, COMMUNITY LEADERS' SURVEY AND OTHER DATA. RESULTS ARE MADE AVAILABLE TO ORGANIZATIONS AND INDIVIDUALS THROUGHOUT THE COMMUNITY. THESE NEEDS ASSESSMENTS ARE ALSO UTILIZED IN CREATING THE HOSPITAL'S INTEGRATED STRATEGIC FINANCIAL AND OPERATIONAL PLAN. TO THAT END, ST. MARY'S MEDICAL CENTER OF EVANSVILLE, INC. HAS BROUGHT TOGETHER A COMMUNITY ROUNDTABLE WITH THE PURPOSE OF DETERMINING THE RESOURCES AND NEEDS, PRIORITIZING ACTION AND WORKING IN PARTNERSHIP TO ADDRESS IDENTIFIED CHALLENGES WITHIN A DESIGNATED AREA SURROUNDING THE HOSPITAL. ST. MARY'S MEDICAL CENTER OF EVANSVILLE, INC. ALSO IDENTIFIES COMMUNITY HEALTH NEEDS BY EMPLOYING OTHER PUBLIC AGENCY NEEDS ASSESSMENTS SUCH AS WELBORN BAPTIST FOUNDATION AND THE UNITED WAY. PART VI, LINE 3: ST. MARY'S MEDICAL CENTER OF EVANSVILLE, INC. COMMUNICATES WITH PATIENTS IN MULTIPLE WAYS TO ENSURE THAT THOSE WHO ARE BILLED FOR SERVICES ARE AWARE OF THE HOSPITAL'S CHARITY CARE PROGRAM AS WELL AS THEIR POTENTIAL ELIGIBILITY FOR LOCAL, STATE OR FEDERAL PROGRAMS. SIGNS ARE PROMINENTLY POSTED IN EACH SERVICE AREA. IN ADDITION, THE HOSPITAL EMPLOYS FINANCIAL COUNSELORS, HEALTH ACCESS WORKERS, AND ENROLLMENT SPECIALISTS WHO CONSULT WITH PATIENTS ABOUT THEIR ELIGIBILITY FOR FINANCIAL ASSISTANCE PROGRAMS AND HELP PATIENTS IN APPLYING FOR ANY PUBLIC PROGRAMS FOR WHICH THEY MAY QUALIFY. ALL SELF-PAY PATIENTS RECEIVE A 15% DISCOUNT OFF THE TOP ON ALL CHARGES BEFORE STATEMENTS ARE MAILED. PART VI, LINE 4: ST. MARY'S MEDICAL CENTER OF EVANSVILLE, INC. IS LOCATED IN EVANSVILLE, INDIANA AND SERVES VANDERBURGH AND CONTINGUOUS COUNTIES IN SOUTHERN INDIANA AND NORTH-CENTRAL KENTUCKY. THE PRIMARY SERVICE AREA IS DEFINED AS VANDERBURGH, WARRICK AND POSEY COUNTIES. THE POPULATION FOR THE PRIMARY SERVICE AREA WAS 287,261 IN 2013. ALSO THE MEDIAN INCOME FOR THE PRIMARY SERVICE AREA WAS $54,016 FOR 2013 WITH 17% OF CHILDREN BELOW POVERTY LEVEL. PART VI, LINE 5: TO PROVIDE THE HIGHEST QUALITY HEALTHCARE TO ALL PERSONS IN THE COMMUNITY, AND IN KEEPING WITH ITS NOT-FOR-PROFIT STATUS, ST. MARY'S MEDICAL CENTER OF EVANSVILLE, INC.:- DELIVERS PATIENT SERVICES, INCLUDING EMERGENCY DEPARTMENT SERVICES AND URGENT CARE SITES, TO ALL INDIVIDUALS REQUIRING HEALTHCARE, WITHOUT REGARD TO PATIENT RACE, ETHNICITY, ECONOMIC STATUS, INSURANCE STATUS OR ABILITY TO PAY.- MAINTAINS AN OPEN MEDICAL STAFF THAT ALLOWS CREDENTIALED PHYSICIANS TO PRACTICE AT ITS FACILITIES.- TRAINS AND EDUCATES HEALTH CARE PROFESSIONALS- PARTICIPATES IN GOVERNMENT-SPONSORED PROGRAMS SUCH AS MEDICAID AND MEDICARE TO PROVIDE TO THE POOR AND ELDERLY. APPLICATION EVENTS ARE HELD AS WELL AS FOLLOW UP ASSISTANCE FOR INSURANCE.- HEALTH ACCESS ADVOCATES ("HAA") ARE COMMUNITY BASED STAFF WHOSE PRIMARY ROLE IS TO SIGN CHILDREN UP FOR HOOSIER HEALTHCARE INSURANCE. THEY CAN DO THIS BY ASSISTING FAMILIES IN APPLYING FOR HOOSIER HEALTHCARE INSURANCE HERE IN THE OFFICE, IN THE COMMUNITY, OR AT THE PATIENT'S HOME. DURING THIS PROCESS, THEY CAN ALSO ASSIST FAMILIES WITH BASIC NEEDS SUCH AS FOOD, SHELTER AND CLOTHING. THE ADVOCATES CAN ALSO ASSIST ADULTS WITH APPLYING FOR MEDICAID, HEALTHY INDIANA PLAN, AND OTHER RESOURCES SUCH AS PHARMACEUTICAL APPLICATIONS FOR THOSE WHO QUALIFY. HAA WILL AT TIMES TRANSPORT PATIENTS TO NECESSARY APPOINTMENTS. ADDITIONALLY, HAA PROVIDES ASSISTANCE TO THE LATINO POPULATION BY PROVIDING A BI-LINGUAL ASSOCIATE. THIS ASSOCIATE SPEARHEADS A CERTIFIED MEDICAL INTERPRETER TRAINING PROGRAM THROUGH THE BRIDGING THE GAP PROGRAM. - IS GOVERNED BY A BOARD IN WHICH INDEPENDENT COMMUNITY MEMBERS COMPRISE A MAJORITY- CONDUCTS COMMUNITY HEALTH NEEDS ASSESSMENTS AND HOLDS MEMBERSHIP ON OTHER PUBLIC AGENCY BOARDS TO ENHANCE WELL BEING OF THE COMMUNITY IN PARTNERSHIP PROGRAMS- PROVIDES DENTAL SERVICES FOR PRIMARY SERVICE AREA WITH MOBILE DENTAL FOR KIDS CLINIC- NUTRITION COUNSELING IS PROVIDED TO THE COMMUNITY AND SPECIFICALLY AREA SCHOOLS AND YOUTH GROUPS, SUCH AS FOOD PYRAMID PROGRAMS, STAFF HEALTH FAIR, ETC- COMPLIMENTARY THERAPIES INCLUDING MASSAGES, YOGA CLASSES, STRESS REDUCTION CLASSES AT HOPE RESOURCE CENTER FOR CANCER PATIENTS AND SURVIVORS.- MALL WALKING PROGRAMS AND MONTHLY BLOOD PRESSURE SCREENINGS AT LOCAL MALL- CHRISTMAS PROGRAMS FOR THE POOR: GREAT EXPECTATIONS. AREA FAMILIES ARE IDENTIFIED FROM LOCAL GROUPS SUCH AS UNITED WAY, CHURCHES, AND THE SCHOOL SYSTEMS, AS NEEDING ASSISTANCE WITH CHRISTMAS. ASSOCIATES OF ST. MARY'S GIVE MONIES, FOOD, CLOTHING, TOYS, ETC. TO FAMILIES IN NEED EACH YEAR. - AUTISM VISIT WITH SANTA- WNIN KIDS DAY - MOBILE DENTAL KARE LAB- CPR CLASSES GIVEN AT LOCAL DAYCARES AND SCHOOLS- JOSLIN AND DIABETIC FOOT CLINIC - LECTURES, CLASSES, EXERCISE INSERVICES.- SAFESITTERS EDUCATION FOR TEENAGERS PREPARING TO TAKE CARE OF YOUNG CHILDREN, TODDLERS, AND INFANTS- ST. MARY'S NIGHTS AT CHILDREN'S MUSEUM OF EVANSVILLE.- YOUTH FIRST RETREATS- AMERICAN RED CROSS BLOOD DRIVES- AMBULANCE, REHAB, AND MISC. BILLINGS PAID FOR PATIENTS- PATIENT CARE FOR NON-PROFIT ECHO CLINIC- TRANSPORTATION SERVICES FOR PATIENTS AND FAMILIES - MEAL TICKETS FOR PATIENT FAMILIES PART VI, LINE 6: AS A PART OF ST. MARY'S HEALTH, INC., ST. MARY'S MEDICAL CENTER OF EVANSVILLE, INC. IS DEDICATED TO IMPROVING THE HEALTH STATUS AND QUALITY OF LIFE FOR THE COMMUNITIES IT SERVES. WHILE DESIGNATED ASSOCIATES AT ST. MARY'S MEDICAL CENTER OF EVANSVILLE, INC. DEVOTE ALL OR SIGNIFICANT PORTIONS OF THEIR TIME TO LEADING AND ADMINISTERING LOCAL COMMUNITY-BASED PROGRAMS AND PARTNERSHIPS, ASSOCIATES THROUGHOUT THE ORGANIZATION ARE ACTIVE PARTICIPANTS IN COMMUNITY OUTREACH. THEY ARE ASSISTED AND SUPPORTED BY DESIGNATED ST. MARY'S HEALTH COMMUNITY DEVELOPMENT AND SERVICE STAFF WHO WORK WITH EACH OF ITS HEALTHCARE FACILITIES TO ADVOCATE FOR AND PROVIDE TECHNICAL ASSISTANCE FOR COMMUNITY OUTREACH, NEEDS ASSESSMENTS AND PARTNERSHIPS AS WELL AS TO SUPPORT REGIONAL AND STATE-WIDE PROGRAMS, COMMUNITY PROGRAMS SPONSORED BY ST. MARY'S HEALTH IN WHICH ST. MARY'S MEDICAL CENTER OF EVANSVILLE, INC. PARTICIPATES. REPORTS FILED WITH STATES PART VI, LINE 7 IN THE STATE OF INDIANA NO LONGER REQUIRES A SEPARATE COMMUNITY BENEFIT REPORT, BUT WILL REFERENCE THE FORM 990. ST. MARY'S MEDICAL CENTER OF EVANSVILLE, INC. AND ITS RELATED ST. MARY'S HEALTH, INC. AFFILIATES PUBLISH A COMMUNITY BENEFIT REPORT WHICH IS AVAILABLE TO THE PUBLIC. A COPY OF THE FULL REPORT IS AVAILABLE AT HTTP://WWW.STMARYS.ORG/CHNA. 1 ST MARY'S OHIO VALLEY HEARTCARE LLC 3700 WASHINGTON AVENUE EVANSVILLE IN 47750 273474697 501(C)(3) 4605000 OPERATING GRANT ST MARY'S PHYSICIAN NETWORK LLC 3700 WASHINGTON AVENUE EVANSVILLE IN 47750 205023387 501(C)(3) 6890000 OPERATING GRANT ST MARY'S PHYSICIANS' HEALTH GROUP LLC 3700 WASHINGTON AVENUE EVANSVILLE IN 47750 261356310 501(C)(3) 2644408 OPERATING GRANT PRIMARY PHYSICIAN NETWORK LLC 3700 WASHINGTON AVENUE EVANSVILLE IN 47750 208775914 501(C)(3) 2615000 OPERATING GRANT ASCENSION HEALTH PO BOX 45998 ST LOUIS MO 63145 311662309 501(C)(3) 4262393 OPERATING GRANT 5 0 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: ONE PERSON OF ST. MARY'S MEDICAL CENTER OF EVANSVILLE, INC., IS RESPONSIBLE FOR RESEARCHING AND COORDINATING GRANT PROPOSALS. THIS PERSON IS ALSO RESPONSIBLE FOR ENSURING THAT TIMELY REPORTS ARE SENT TO THE GRANTOR. THE CHIEF EXECUTIVE OF THE ENTITY OPERATIONS REVIEWS AND APPROVES ALL THE EXPENDITURES FROM THE GRANT FUNDS, ENSURING THEY ARE WITHIN THE GUIDELINES OF THE GRANT. X X X 0 1 0 0 0 0 0 0 0 MARIA DEL-RIO MD 296699 0 93874 0 4364 0 61775 0 11221 0 467933 0 0 0 DARCY ELLISON 253347 0 36611 0 3810 0 109928 0 17637 0 421333 0 0 0 JOHN GALLAGHER MD 272023 0 85461 0 86558 0 101040 0 20535 0 565617 0 64792 0 GWEN SANDEFUR 336657 0 43368 0 1429 0 21708 0 20759 0 423921 0 0 0 KARL SASH MD 0 371349 0 206481 0 1477 0 69649 0 30419 0 679375 0 0 TIMOTHY FLESCH 519605 0 1157134 0 27857 0 37143 0 26018 0 1767757 0 0 0 KIMBERLY HODGKINSON 310911 0 40177 0 17741 0 5000 0 15703 0 389532 0 0 0 JANICE ERNEST 196275 0 25756 0 4021 0 80214 0 19040 0 325306 0 0 0 JOHN GREANEY 171930 0 12523 0 272 0 5000 0 19016 0 208741 0 0 0 KATHY HALL 170469 0 11962 0 779 0 31054 0 22180 0 236444 0 0 0 MICHAEL KLUEH 173063 0 23408 0 1688 0 53414 0 24587 0 276160 0 0 0 THOMAS LILLY 200213 0 26166 0 7576 0 32989 0 19192 0 286136 0 0 0 VERNON MAASMD 213933 0 0 0 10813 0 19611 0 21167 0 265524 0 0 0 MIKE WHITMORE 185607 0 24523 0 1621 0 44408 0 21869 0 278028 0 0 0 KATHRYN BRYAN MD 416905 0 0 0 43961 0 40626 0 17473 0 518965 0 12722 0 ROBERT CUTRELL MD 337927 0 6158 0 24397 0 47672 0 22105 0 438259 0 23815 0 MYLES GRANT 302498 0 93874 0 26144 0 78585 0 16119 0 517220 0 0 0 CHARLES LACKEY MD 452495 0 0 0 57639 0 42499 0 16113 0 568746 0 39499 0 MUREENA TURNQUEST-WELLS MD 546504 0 48058 0 20272 0 83230 0 25906 0 723970 0 0 0 PART I, LINE 4B PART I, LINE 4B: ALL EMPLOYEES AND AMOUNTS LISTED ARE VOLUNTARY DEFERRALS OR COMPANY CONTRIBUTIONS TO VARIOUS NON-QUALIFIED DEFERRED COMPENSATION PLANS ORGANIZED UNDER CODE SECTION 457(F). THE EXACT PURPOSE OF EACH PLAN VARIES BUT THEY INCLUDE: COMPENSATION LIMITATION MAKE-UP PLANS, VOLUNTARY DEFERRAL PLANS, DEFERRAL OF A PORTION OF INCENTIVE BONUS TYPE PLANS, ETC. JOHN T GALLAGHER, MD $64,792 CHARLES W. LACKEY $39,499 KATHRYN BRYAN, MD $12,722 ROBERT CUTRELL, MD $23,815 CLAUDIA RICHARDT - SEE PART V - 74136 SEE PART V 0 CAROL ACKERMAN - SEE PART V - 43582 SEE PART V 0 SCHEDULE L, PART IV: BUSINESS TRANSACTIONS INVOLVING INTERESTED PERSONS (A) NAME OF PERSON: CLAUDIA RICHARDT(B) RELATIONSHIP BETWEEN INTERESTED PERSON AND ORGANIZATION: SISTER-IN-LAW OF SISTER SHARON RICHARDT(C) AMOUNT OF TRANSACTION: $74,136(D) DESCRIPTION OF TRANSACTION: CLAUDIA RICHARDT IS AN EMPLOYEE OF ST. MARY'S MEDICAL CENTER OF EVANSVILLE, INC. AND RECEIVES COMPENSATION FROM THE ORGANIZATION.(E) SHARING OF ORGANIZATION REVENUES: NO SCHEDULE L, PART IV: BUSINESS TRANSACTIONS INVOLVING INTERESTED PERSONS (A) NAME OF PERSON: CAROL ACKERMAN(B) RELATIONSHIP BETWEEN INTERESTED PERSON AND ORGANIZATION: SISTER-IN-LAW OF DARCY ELLISON(C) AMOUNT OF TRANSACTION: $43,582(D) DESCRIPTION OF TRANSACTION: CAROL ACKERMAN IS AN EMPLOYEE OF ST. MARY'S MEDICAL CENTER OF EVANSVILLE, INC. AND RECEIVES COMPENSATION FROM THE ORGANIZATION.(E) SHARING OF ORGANIZATION REVENUES: NO FORM 990, PART IV, LINE 24A: ST. MARY'S MEDICAL CENTER OF EVANSVILLE, INC. IS A HEALTH FACILITY THAT IS PART OF THE ASCENSION HEALTH SYSTEM. ASCENSION HEALTH IS THE BORROWER FOR TAX-EXEMPT HOSPITAL REVENUE BONDS. ST. MARY'S MEDICAL CENTER OF EVANSVILLE, INC. HOLDS AN INTERCOMPANY NOTE PAYABLE WITH ASCENSION HEALTH, AND THIS INFORMATION IS REPORTED ON THE BALANCE SHEET. FORM 990, PART VI, SECTION A, LINE 4 EFFECTIVE JULY 1, 2012, ST. MARY'S HEALTH SERVICES, INC. REPLACED ST. MARY'S HEALTH, INC. AS THE SOLE MEMBER OF ST. MARY'S MEDICAL CENTER OF EVANSVILLE, INC. FORM 990, PART VI, SECTION A, LINE 6 ST. MARY'S MEDICAL CENTER OF EVANSVILLE, INC. HAS A SINGLE CORPORATE MEMBER, ST. MARY'S HEALTH SERVICES, INC. FORM 990, PART VI, SECTION A, LINE 7A ST. MARY'S MEDICAL CENTER OF EVANSVILLE, INC. HAS A SINGLE CORPORATE MEMBER, ST. MARY'S HEALTH SERVICES, INC. WHO HAS THE ABILITY TO ELECT MEMBERS TO THE GOVERNING BODY OF ST. MARY'S MEDICAL CENTER OF EVANSVILLE, INC. FORM 990, PART VI, SECTION A, LINE 7B ALL DECISIONS THAT HAVE A MATERIAL IMPACT TO ST. MARY'S MEDICAL CENTER OF EVANSVILLE, INC.'S FINANCIAL INFORMATION OR CORPORATION AS A WHOLE ARE SUBJECT TO APPROVAL BY ITS SOLE CORPORATE MEMBER, ST. MARY'S HEALTH SERVICES, INC. FORM 990, PART VI, SECTION B, LINE 11 ST. MARY'S HEALTH, INC.'S FINANCE COMMITTEE REVIEWS THE FORM 990 IN MARCH UPON RECEIVING DIRECTION FROM ITS TAX PREPARER. THE FORM 990 IS THEN SENT TO THE GOVERNING BODY IN APRIL TO ALLOW FOR A THOROUGH REVIEW BY THE GOVERNING BODY PRIOR TO THE FILING DATE OF MAY 15TH. THE GOVERNING BODY WILL REVIEW THE FORM 990 VIA A SECURE WEB-BASED PORTAL AND ASK ANY QUESTIONS REGARDING THE FORM 990. ANY QUESTIONS AND RESPONSES WILL BE POSTED TO THE WEB-BASED PORTAL BEFORE THE RETURN IS FILED. ALL QUESTIONS AND RESPONSES WILL BE REVIEWED AND DISCLOSED IN THE MEETING MINUTES OF THE NEXT BOARD MEETING FOLLOWING THE REVIEW OF THE FORM 990. FORM 990, PART VI, SECTION B, LINE 12C THE ORGANIZATION REGULARLY AND CONSISTENTLY MONITORS AND ENFORCES COMPLIANCE WITH THE CONFLICT OF INTEREST POLICY IN THAT ANY DIRECTOR, PRINCIPAL OFFICER, OR MEMBER OF A COMMITTEE WITH GOVERNING BOARD DELEGATED POWERS, WHO HAS A DIRECT OR INDIRECT FINANCIAL INTEREST, MUST DISCLOSE THE EXISTENCE OF THE FINANCIAL INTEREST AND BE GIVEN THE OPPORTUNITY TO DISCLOSE ALL MATERIAL FACTS TO THE DIRECTORS AND MEMBERS OF THE COMMITTEES WITH GOVERNING BOARD DELEGATED POWERS CONSIDERING THE PROPOSED TRANSACTION OR ARRANGEMENT. THE REMAINING INDIVIDUALS ON THE GOVERNING BOARD OR COMMITTEE MEETING WILL DECIDE IF CONFLICTS OF INTEREST EXIST. EACH DIRECTOR, PRINCIPAL OFFICER AND MEMBER OF A COMMITTEE WITH GOVERNING BOARD DELEGATED POWERS ANNUALLY SIGNS A STATEMENT WHICH AFFIRMS SUCH PERSON HAS RECEIVED A COPY OF THE CONFLICTS OF INTEREST POLICY, HAS READ AND UNDERSTANDS THE POLICY, HAS AGREED TO COMPLY WITH THE POLICY, AND UNDERSTANDS THAT THE ORGANIZATION IS CHARITABLE AND IN ORDER TO MAINTAIN ITS FEDERAL TAX EXEMPTION IT MUST ENGAGE PRIMARILY IN ACTIVITIES WHICH ACCOMPLISH ITS TAX-EXEMPT PURPOSE. FORM 990, PART VI, SECTION B, LINE 15 COMPENSATION DETERMINATIONS OF ST. MARY'S MEDICAL CENTER OF EVANSVILLE, INC.'S CEO, EXECUTIVE DIRECTOR, OR TOP MANAGEMENT OFFICIAL ARE MADE BY A COMPENSATION COMMITTEE OF ST. MARY'S MEDICAL CENTER OF EVANSVILLE, INC. AND/OR ST. MARY'S HEALTH, INC. IN DETERMINING COMPENSATION OF THE ORGANIZATION'S CEO, EXECUTIVE DIRECTOR, OR TOP MANAGEMENT OFFICIAL, THE PROCESS INCLUDED A REVIEW AND APPROVAL BY INDEPENDENT PERSONS, COMPARABILITY DATA, AND CONTEMPORANEOUS SUBSTANTIATION OF THE DELIBERATION AND DECISION. THE EXECUTIVE COMMITTEE OF THE ST. MARY'S HEALTH SYSTEM BOARD REVIEWED AND APPROVED THE COMPENSATION. IN THE REVIEW OF THE COMPENSATION, THE CEO, EXECUTIVE DIRECTOR, AND TOP MANAGEMENT WERE COMPARED TO OTHER HOSPITALS IN THE AREA THAT HOLD THE SAME POSITION. DURING THE REVIEW AND APPROVAL OF THE COMPENSATION, DOCUMENTATION OF THE DECISION WAS RECORDED IN THE BOARD MINUTES. INDIVIDUALS WERE NOT PRESENT WHEN THEIR COMPENSATION WAS DECIDED. COMPENSATION DETERMINATIONS OF ST. MARY'S MEDICAL CENTER OF EVANSVILLE, INC.'S OTHER OFFICERS OR KEY EMPLOYEES ARE MADE BY A COMPENSATION COMMITTEE OF ST. MARY'S MEDICAL CENTER OF EVANSVILLE, INC. AND/OR ST. MARY'S HEALTH, INC. IN DETERMINING COMPENSATION OF OTHER OFFICERS OR KEY EMPLOYEES OF THE ORGANIZATION, THE PROCESS INCLUDED A REVIEW AND APPROVAL BY INDEPENDENT PERSONS, COMPARABILITY DATA, AND CONTEMPORANEOUS SUBSTANTIATION OF THE DELIBERATION AND DECISION. THE EXECUTIVE COMMITTEE OF THE ST. MARY'S HEALTH SYSTEM BOARD REVIEWED AND APPROVED THE COMPENSATION. IN THE REVIEW OF THE COMPENSATION, THE OTHER OFFICERS OR KEY EMPLOYEES OF THE ORGANIZATION WERE COMPARED TO OTHER HOSPITALS' EMPLOYEES IN THE AREA THAT HOLD THE SAME POSITION. DURING THE REVIEW AND APPROVAL OF THE COMPENSATION, DOCUMENTATION OF THE DECISION WAS RECORDED IN THE BOARD MINUTES. FORM 990, PART VI, SECTION B, LINE 16B: ST. MARY'S HEALTH, INC. AND SUBSIDIARES (ST. MARY'S) JOINT VENTURE OPERATING AGREEMENTS ARE NEGOTIATED WITH OTHER MEMBERS OF THE JOINT VENTURE TO ENSURE THAT ADEQUATE SAFEGUARDS ARE IN PLACE TO PROTECT ST. MARY'S EXEMPT STATUS. EACH AGREEMENT CONTAINS SPECIFIC LANGUAGE RELATED TO THE PROVISION OF HEALTH CARE SERVICES WITH A FOCUS ON COMMUNITY HEALTH BENEFIT AND MUST FOLLOW A FORMAL REVIEW PROCESS PRIOR TO CONTRACT EXECUTION. ST. MARY'S CONTINUALLY ENSURES THAT ITS EXEMPT STATUS IS PROTECTED BY ACTIVELY PARTICIPATING IN THE GOVERNANCE OF ALL ST. MARY'S JOINT VENTURES. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION WILL PROVIDE ANY DOCUMENTS OPEN TO PUBLIC INSPECTION UPON REQUEST. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 9: FAS 158 PENSION 940,396. NY DEBT OBLIGATION -410,000. PROJECT SYMPHONY -6,814,833. ASSET TRANSFER FROM ST. MARY'S PHYSICIAN NETWORK, LLC 242,751. ASSET TRANSFER FROM ST. MARY'S OHIO VALLEY HEARTCARE, LLC 24,193. ASSET TRANSFER TO ST. MARY'S BUILDING CORPORATION -2,218,530. ASSET TRANSFER TO ST. MARY'S PHYSICIANS' HEALTH GROUP, LLC 3,170,281. REDEMPTION PREMIUM AMOUNT - 2002 BOND REFINANCING -55,879. 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