2013-08-13T09:28:37-05:00 2012-09-30 346565596 Ernst & Young LLP 200 Claredon Street Boston MA 02116 990 2011-10-01 042103575 Baystate Franklin Medical Center BAYS 4137947872 164 High Street Greenfield MA 01301 Dennis W Chalke 4137940000 2013-08-13 1 Jeanne M Schuster P00743154 6172662000 2011 2016-02-24 21:20:13Z Dennis W Chalke 759 Chestnut Street Springfield MA 01199 81285889 0 X www.baystatehealth.org/fmc/ X 1895 MA The mission of the organization is to improve the health of the people in our communities every day, with quality and compassion. 20 14 783 366 0 0 41276 89950 74143198 79504590 326232 227409 1501066 1249841 76011772 81071790 0 0 0 0 42689169 42255014 0 0 0 37027183 38499650 79716352 80754664 -3704580 317126 62064706 69519808 29462557 33077315 32602149 36442493 The mission of Baystate Franklin Medical Center is to improve the health of the people in our communities every day, with quality and compassion. 0 0 32892960 30522074 Inpatient healthcare services - Providing inpatient community-based medicine and tertiary care to the surrounding region. Services are available to individuals regardless of their ability to pay. During FY12, Baystate Franklin Medical Center provided 19,601 patient days of inpatient services, with 4,370 discharges 29780034 33838718 Outpatient healthcare services - Providing outpatient clinical services to the surrounding region. Services are available to individuals regardless of their ability to pay. During FY12, Baystate Franklin Medical Center had 87,089 outpatient visits. 10719944 11918849 Emergency department services - Providing emergency department services to the surrounding region. Services are available to individuals regardless of their ability to pay. During FY12, Baystate Franklin Medical Center had 26,534 emergency department visits. 1747824 4073598 1747824 4073598 75140762 1 1 0 1 0 0 0 0 0 0 1 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1 0 1 0 0 1 72 0 1 783 1 0 0 0 0 0 0 0 0 0 0 X 20 14 1 1 0 0 1 1 0 1 1 0 0 1 1 1 1 1 1 1 1 0 MA X Peter Lyons Baystate Health Inc 4137940000 759 Chestnut Street Springfield MA 01199 X Richard B Steele Jr 1.00 X X 0 0 0 Victor Woolridge 1.00 X X 0 0 0 Allan W Blair 1.00 X 0 0 0 Charles L D'Amour 1.00 X 0 0 0 John H Davis 1.00 X 0 0 0 John A Egelhofer MD 1.00 X 0 0 0 John E Kole 1.00 X 0 0 0 Grace P Makari-Judson MD 1.00 X 320107 0 75990 John F Maybury 1.00 X 0 0 0 Alan D McClelland MD 1.00 X 341414 0 40980 Steven M Mitus 1.00 X 0 0 0 John M O'Brien III 1.00 X 0 0 0 Anne M Paradis 1.00 X 0 0 0 Katherine E Putnam 1.00 X 0 0 0 Timothy S Rice 1.00 X 0 0 0 James P Sadowsky 1.00 X 0 0 0 David C Southworth 1.00 X 0 0 0 Barbara W Stechenberg MD 1.00 X 145851 0 36735 Frances K Stotz CFP 1.00 X 0 0 0 Katherine McG Sullivan 1.00 X 0 0 0 Mark R Tolosky 1.00 X 0 1536640 99365 Howard G Trietsch MD 1.00 X 0 0 0 Steven M Wenner MD 1.00 X 0 0 0 Charles Gijanto 1.00 X 0 329648 112585 Dennis W Chalke 1.00 X 0 672631 92548 Kristin R Delaney 1.00 X 0 94511 47834 Frances C Grabowski 1.00 X 0 55522 17868 Patricia A Sheldon 1.00 X 0 65183 16061 Gerda Maissel MD 50.00 X 332156 0 145433 David M Farrick 50.00 X 151758 0 36721 Deborah A Palmeri 50.00 X 147627 0 57130 Edward G Tessier 50.00 X 127130 0 18546 Brian P Joyce 50.00 X 119314 0 37642 Regina O Campbell 50.00 X 117496 0 41767 Donald McCool 50.00 X 114503 0 34032 Keith C McLean-Shinaman 0.00 X 0 802768 36779 1917356 3556903 948016 13 1 1 1 Baystate Administrative Services Inc 759 Chestnut Street Springfield MA 01199 Management/I.S, Services 7182362 Baystate Medical Practices Inc 759 Chestnut Street Springfield MA 01199 Physician Services/ Lab Services 5017527 Baystate Medical Center Inc 759 Chestnut Street Springfield MA 01199 Lab Services 996376 Angelica Textile SVC 125 Bath Street Ballston Spa NY 120201300 Linen Services 319520 Locumtenenscom PO Box 405547 Atlanta GA 303840001 Physician Services 292168 7 48718 41232 89950 Net Patient Revenue 900099 77584037 77584037 CMS Elec Med Rec Fdg 900099 1383036 1383036 Rental Income From Rel 532000 537517 537517 79504590 261211 261211 134427 179447 -45020 -45020 -45020 850 34652 -33802 -33802 -33802 Net As Rsd from Fnd 900099 427675 427675 Cafeteria Income 900099 412070 412070 Printing In House 900099 182330 182330 272786 272446 340 1294861 81071790 80353239 0 628601 354556 354556 32983874 31736709 1247165 2194194 2106426 87768 4303801 4131649 172152 2418589 2321845 96744 5427551 2103966 3323585 116895 116895 38866 38866 18824 18824 16804 14897 1907 21038182 20455500 582682 3456712 3456712 1533636 1533636 88651 61482 27169 34956 22159 12797 121230 121230 4229837 4225594 4243 180435 180435 Provision for Uncollect 2197071 2197071 80754664 75140762 5613902 0 2474672 10060311 7337412 7652131 1124060 1108680 101031 83592 102454343 69359467 34112886 33094876 327351 566577 16587294 16953641 62064706 69519808 5892430 5925550 7141116 6762950 16429011 20388815 29462557 33077315 X 18933027 21656184 5914519 6463576 7754603 8322733 32602149 36442493 62064706 69519808 X 317126 3523218 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 1 18824 0 18824 0 Part IV, Supplemental Information: Baystate Franklin Medical Center pays membership dues to the Massachusetts Hospital Association (MHA) and the American Hospital Association (AHA). These organizations have advised us that portions of these dues are used for lobbying purposes for various healthcare matters at the state level. The portion of the dues listed as lobbying expenses for the year ending September 30, 2012 is $ 18,824. 261921 261921 61277786 35888362 25389424 36753662 30058836 6694826 4160974 3412269 748705 33094876 Funds Held By Bond Trustee 101872 Benefical Interest in Perpetual Trust BHF 4815662 Due from Affiliated Companies 25478 Estimated Final Settlement Receivable 2039982 Interest- Net assets of BHF 9970647 16953641 Due to Affiliates 1307323 Estimated Final Settlement Payable 4820295 Insurance Liability Loss Reserve 132000 Minimum Pension Liability 14129197 20388815 Part XIV: Baystate Franklin Medical Center did not have a FIN 48 footnote included in the audited financial statements. Additional Information: Part V: Certain endowments are held at Baystate Health Foundation (BHF), an affiliate, and are reported as temporarily restricted and permanently restricted but Part V has not been completed as it is already addressed on BHF's Form 990 (EIN 04-3549011). 1 1 1 X 1 X 1 1 0 1 1 2571610 1392984 1178626 0.01500 14038126 10786856 3251270 0.04140 2443444 2304286 139158 0.00180 19053180 14484126 4569054 0.05820 312971 312971 0.00400 4673497 2698566 1974931 0.02510 2882 2882 0.00000 4989350 2698566 2290784 0.02910 24042530 17182692 6859838 0.08730 1944 1944 0.00000 1944 1944 1 751044 84978 21549474 22030820 -481346 X 1 1 1 1 Baystate Franklin Medical Center

164 High Street Greenfield MA 01301

X X X Baystate Franklin Medical Center 1 1 1 200.000000000000 1 400.000000000000 1 X X X X 1 1 X X X X X 1 0 1 X 0 0 2 Baystate Rehabilitation Care at BFMC

48 Sanderson St Lev 1 Ste 3 Greenfield MA 01301

Rehabilitation Clinic Outpatient Behavioral Health Srvcs

48 Sanderson St 2nd Flr Greenfield MA 01301

Partial Hospitalization Services Part I, Line 7: Line 7a (Financial Assistance at Cost) - Column (e) Net community benefit expense was calculated by applying the ratio of patient care cost to charges, calculated on Worksheet 2,against total charity care gross patient charges from the audited financial statements.Line 7b (Unreimbursed Medicaid) - Column (e) Net community benefit expense was derived using the organization's cost accounting system, which takes into account all hospital inpatients, outpatients and emergency room patients for whom services were provided and covered under Medicaid and Medicaid managed care plans.Line 7c (Other Means-Tested Programs) - Column (e) Net community benefit expense was derived using the organization's cost accounting system, which takes into account all hospital inpatients, outpatients and emergency room patients for whom services were provided and covered under other means-tested government programs.Line 7g (Subsidized Programs) - Column (e) Net community benefit expense was derived using the organization's cost accounting system. The expense relates to the inpatient behavioral health program. Part I, Line 7g: There are no costs attributable to physician clinics reported as subsidized health services in Part I, line 7g. Part I, L7 Col(f): Bad debt expense of $2,197,071 was subtracted from total expenses reported in Part IX, Line 25, column (A) for the purpose of calculating the percentages in Part I, Line 7, column (f). Part II: Specific to Part II Baystate Franklin Medical Center paid dues to the Franklin County Chamber of Commerce in the amount of $1574, to Shelburne Falls Business Association in the amount of $250 and to the Greenfield Business Association in the amount of $120 for FY12. Baystate Franklin Medical Center is a dues paying member of the local Franklin County Chamber of Commerce, and the Shelburne Falls and Greenfield Business Associations. BFMC participates in the Chamber and the local business associations as we are one of the largest local employers in our service area. The Chamber and its membership coordinate activities toward a common purpose of sustainability and economic growth for the region. The following description is not quantified specifically in Part II of Schedule H. Baystate Franklin Medical Center is committed to creating healthier communities and understands that many state and federally mandated community benefit programs and services are not sufficient to address ethnic, racial and economic health disparities. BFMC extends the traditional definition of "health" to include economic opportunity, affordable housing, education, safe neighborhoods, the arts, and supporting and valuing diversity - all elements that enable families and communities to thrive. In keeping with our commitment to improve health, Baystate Franklin Medical Center provides many valuable services, resources and programs beyond the walls of the hospital and into the communities and homes of the people we serve. Part III, Line 4: The cost of bad debts reported in Part III, line 2 was calculated by applying a ratio of cost to charges (based on the organization's cost accounting system including all hospital inpatients and outpatients) against total patient bad debt net of recoveries as reported in the audited financial statements. The portion of bad debt expense that reasonably could be attributable to patients who may qualify for financial assistance under the hospital's charity care program (reported in Part III line 3) was calculated by applying the percentage of bad debts by zip code (for which the average household income for each zip code is less than 200% of the federal poverty level) to bad debt expense reported in Part III line 2. Since this portion of bad debt is attributable to patients residing in an area where the average income is less than 200% of the Federal poverty level, it is highly likely these patients would have qualified for Baystate Franklin Medical Center's charity care program had they applied. For this reason, we believe the amount should be treated as community benefit expense in Part I. The financial statements do not contain a footnote describing bad debt expense.If a patient is determined eligible for financial assistance, the appropriate adjustment is made to the patient account based on their income level. Once the necessary approvals are obtained, it then flows to the general ledger. Patients applying for a prompt payment discount will have this allowance entered after agreed upon payment is received. Part III, Line 8: Line 6 - included all Medicare allowable costs as calculated in Worksheets D-1 Part II (inpatient) and D Part V (outpatient) of the hospital's 2012 Medicare cost report, based on Medicare costing principles. We believe the shortfall reported on line 20 should be treated as community benefit expense for tax reporting purposes because providing care for the elderly is a key component of our commitment to the community. The unreimbursed expenses should be treated similarly to unreimbursed Medicaid since the majority of the local elderly population is not affluent. Part III, Line 9b: For patients who are known to qualify for Charity Care or Financial Assistance: The patient may have requested assistance up front at time of service with a Financial Counselor or the Patient could have asked for assistance after receiving their bill by contacting our Patient Billing Services Representatives. The Financial Counselor will assist the patient in applying for the appropriate type of assistance based on their income and circumstances. Once approved for a State Medicaid or other program, all billing and collection activity will stop (except for required co-payments or deductibles).For all other patients, our statements contain information regarding how to apply for financial assistance. Notices concerning availability for assistance are also posted at patient care sites. Part VI, Line 2: Baystate Health completed a community health needs assessment in July 2010. During this assessment process information was gathered and reviewed from various community sources across several counties and Baystate Health's three hospitals and their respective service areas including the following: 1. Baystate Medical Center (BMC) and Hampden County; 2. Baystate Franklin Center (BFMC) and Franklin County; 3. Baystate Mary Lane Hospital (BMLH) and Hampshire County and 13 Quaboag Hills communities.Baystate Health used the Association for Community Health Improvement's (ACHI) Community Health Assessment Toolkit to complete a thorough community health planning and needs assessment process. The toolkit included six core process steps and had a particular emphasis on community engagement. The six-step process included: 1. establishing the assessment infrastructure; 2. defining the purpose and scope; 3. collecting and analyzing data; 4. selecting priorities (included community engagement); 5. documenting and communicating results and 6. planning for action and monitoring progress.The FY2010 community needs assessment process gathered information and reviewed data from a number of sources, including the following: 1. Healthy People 2020 (formerly Healthy People 2010) indicators collected by the Massachusetts Department of Public Health and the Centers for Disease Control and Prevention were major sources of data for community health needs assessment and planning information; 2. Massachusetts Department of Public Health, several of its websites, MassCHIP, and key MDPH staff provided county-level and locality-based data for municipal and neighborhood geographic areas; 3. morbidity and mortality data was drawn from Baystate Health's internal hospital discharge data and statewide data sources. This data, which generally includes reasons for hospitalization and length of stay, can contribute to measuring the burden and cost of illness and disability in the community; 4. both by internal and external respondents in the health care, human service and public health field and unaffiliated stakeholders (community residents) participated in focus groups; 5. hospital Community Benefits Advisory Council, hospital advisory board members, and local community coalitions and task forces played a key role in helping the hospital identify community health needs; 6. existing community needs assessment data (United Way, Pioneer Valley Planning Commission, and Community Action Programs) was included in this assessment; 7. surveys of community stakeholders - expert testimony and resident (lay) opinions - were used to identify and prioritize community health needs.Baystate Franklin Medical Center's needs assessment community partners included the Community Development Corporation, DIAL/SELF, Early Childhood Collaborative, Food Bank of Western MA, Franklin County Community Action Program, Franklin County Community Health Center, Franklin County Home Care, Franklin Regional Council of Governments (COG), Greenfield Community College, Interfaith Council, Montague Catholic Ministries, MotherWoman, School Nurses Association, Service Net, Superintendent of Schools, TRIAD - Jail program, United Way, and YMCA of Greenfield.The ranking and prioritization process and development of target populations was based on input from several sources including surveys of community stakeholders, focus groups of key constituents and key internal and external community member interviews. The needs assessment was a balanced and comprehensive community perspective reflecting the values and experiences of both health care providers and experts and resident opinions in ranking and prioritizing community needs.Four broad health priorities were subjected to ranking and prioritization. Polling of key participant organizations and a variety of other discussions resulted in the following health priorities and target populations. Baystate Franklin Medical Center's health priorities include: 1. promoting wellness of vulnerable populations; 2. reducing racial and ethnic health disparities; 3. chronic disease management in disadvantaged populations; and 4. supporting health care reform.Baystate Franklin Medical Center's target populations include: public school students throughout Franklin County; teachers seeking to enhance their science curriculum via hands-on learning in health care applications; homebound seniors at greater risk for medication management challenges and for falls or other injuries; low-income and obese community members at high-risk of developing diabetes; persons dealing with chronic diseases and other health challenges, for whom sharing the experience with peers has been proven beneficial to long-term health outcomes; and access to care issues with a targeted focus on uninsured or underinsured residents of our communities.Baystate Franklin Medical Center joined the Coalition of Western MA Hospitals, a partnership between seven (7) non-profit hospitals in western Massachusetts; Baystate Medical Center, Baystate Franklin Medical Center, Baystate Mary Lane Hospital, Holyoke Medical Center, Cooley Dickinson Hospital, Mercy Medical Center (a member of Sisters of Providence Health System) and Wing Memorial Hospital and Medical Centers (a member of UMass Memorial Health Care). The Coalition, formed in early 2012, developed a successful partnership to identify and address the health needs of their communities while sharing limited resources and enhancing the quality of data collection to benefit the Pioneer Valley community as a whole. The Coalition engaged Verit-Healthcare Consulting to begin community health needs assessments that consider multiple data sources, including secondary data (regarding demographics, health status indicators, and measures of health care access), assessments prepared by other organizations in recent years, and primary data derived from a community survey and from interviews with persons who represent the broad interests of the community, including those with expertise in public health. The needs assessment process will culminating with hospital-specific CHNA reports in April 2013 followed by the Coalition hospital's development of their own respective implementation strategies describing how the hospital plans to address or not address priority needs identified in CHNA report. Part VI, Line 3: Baystate Franklin Medical Center (BFMC) is committed to ensuring that patients in its community have access to quality health care services with fairness and respect without regard to the patients' ability to pay. BFMC recognizes that the cost of necessary health care services can impose a significant financial burden on patients who are uninsured or underinsured and acts affirmatively to lessen that burden by offering patients in need the opportunity to apply for free or reduced cost services. BFMC not only offers free and reduced cost care to the financially needy as required by law, but has also voluntarily established discount and financial assistance programs that provide additional free and reduced cost care to more patients residing within the communities served by BFMC.Baystate Franklin Medical Center recognizes that the billing and collection process can be bewildering and burdensome for patients and has implemented procedures to make the process understandable for patients; to inform patients about discount and financial assistance options; and to ensure that patients are not subject to aggressive collection activities. Consistent with its patient commitment BFMC is required to maintain a credit and collection policy that reflects its patient billing and collection procedures and complies with applicable state and federal laws and regulations. Baystate Franklin Medical Center has Financial Counselors available to help patients apply for available financial assistance programs that may cover unpaid hospital bills, including a variety of federal and state programs as well as financial assistance through Baystate Franklin Medical Center. BFMC is committed to ensuring that patients or prospective patients in the community are aware of financial assistance programs. For uninsured or underinsured patients, BFMC will assist in applying for available financial assistance programs. To assist patients the hospital provides all patients with a general notice of the availability of programs in both the initial bill sent to patients as well as in general notices posted throughout the hospital.The goal of these notices is to assist patients in applying for coverage within a financial assistance program. When applicable, BFMC also assists patients in applying for coverage of services as a Medical Hardship based on the patient's documented income and allowable medical expenses. BFMC provides, upon request, specific information about the eligibility process to be a Low Income Patient under either the Massachusetts Health Safety Net Program or additional assistance for patients who are low income through BFMC's own internal financial assistance program. BFMC also notifies patients about available payment plans based on their family size and income. Signs are posted around the hospital to notify patients of the availability of financial assistance programs. Signs are clearly visible in the hospital's service area: they are 8-1/2 x 11 inches and the Header print font is 32 pts. Notice of availability of financial assistance programs are posted in the following locations; inpatient, clinic, emergency department admissions and/or registration areas, central admission/registration area, patient financial counselor areas and business office areas that are open to patients. Our Credit and Collection Policy is posted on the baystatehealth.org website. The goal of posting the Credit and Collection Policy is to ensure that patients or prospective patients in our community are aware of our financial assistance programs. Baystate Franklin Medical Center's Credit and Collection Policy was developed in partnership with Health Care For All, a Massachusetts non-profit organization dedicated to making adequate and affordable health care accessible to everyone, regardless of income, social or economic status. Part VI, Line 4: Baystate Franklin Medical Center (BFMC) is located in Greenfield, Massachusetts, the county seat of rural Franklin County. Its service area also includes parts of rural northwestern Worcester County, referred to as the North Quabbin Region.The BFMC service area encompasses a large rural area of over 880 square miles inhabited by 86,871 people (US Census, America Communities Survey, 2009). The community consists of the Massachusetts Department of Public Health's Community Health Network Area (CHNA 2 Upper Valley Health) and is comprised of the following 30 towns: Ashfield, Athol, Bernardston, Buckland, Charlemont, Colrain, Conway, Deerfield, Erving, Gill, Greenfield, Hawley, Heath, Leverett, Leyden, Monroe, Montague, New Salem, Northfield, Orange, Petersham, Phillipston, Rowe, Royalston, Shelburne, Shutesbury, Sunderland, Warwick, Wendell and Whately. The average family income is very low and the BFMC service area is one of the poorest regions in the state. According to the 2010 Census, the population of Franklin County is 94% white. From 1990 to 2009, the proportion of Latinos in the population of Franklin County grew from 1.2% to 2.8%, a 133% increase. The proportion of Franklin County residents who are Asian doubled between 1990 and 2000, and then stabilized. The Latino members of our community are primarily of Mexican and Puerto Rican origin. The median age for Franklin County is 40, which is slightly higher than the median age for the Commonwealth: approximately 37. Eighty-eight percent of County residents over 25 have a high school degree or higher compared with almost 85% for the Commonwealth. Approximately 29% of the County have a bachelor's degree or higher compared with 33% for the Commonwealth. The poverty rates in the County range from 3% in Whately to almost 22% in Monroe. The American Community Survey from 2006-2008 estimates median household income for Franklin County as $51,102 compared with $64,684 in Massachusetts. In Franklin County, 15.5% of the population aged 0 - 17 were living in poverty compared with 12.6% for Massachusetts and 18.2% for the United States. Almost 40% of the housing in the County was built before 1939, a far higher percentage than the statewide rate of 13%. Of the 30 towns in the BFMC service region, seven have a population of under 1,000, 13 have a population of between 1,000 and 2,000, and two have a population of between 2,000 and 3,000. To summarize, the region has more Caucasian residents, is slightly older, slightly less well-educated, and has older housing than the state as a whole. Because it is a very large, rural region, BFMC has pockets of great poverty and a growing immigrant population that are not apparent from these statistics. The 26-towns of Franklin County cover 727 square miles and have a population of 71,826 people (U.S. Census, American Communities Survey 2009). With a population density of 98.7 people per square mile it is the most rural county in Massachusetts. The towns of Greenfield, Orange and Montague (pop. 13,761, pop. 7,518 and pop. 8,489 respectively) make up nearly 40% of the Franklin County's population. The four Worcester County towns in the North Quabbin area are anchored by the town of Athol (pop. 11,827). In the past, these population centers were the "mill towns" of the region, supported by textiles and light manufacturing and surrounded by small farming communities. In the last thirty years the manufacturing base of the region has dissipated. Over the last three decades, Massachusetts has experienced a technology-based economic boom that completely bypassed the western part of the state. Unfortunately, the residents of the BFMC 30-town communities now suffer an economic downturn that has not bypassed them. Nationwide and in Massachusetts, poverty rates are higher in rural areas than in metropolitan areas. Rural-based adults have less formal schooling, and a greater share derive their livelihood from low-skill, low-wage jobs. The lower population density in our rural community makes it much more difficult to have all support services -- public transportation, education and job training, child care, emergency services, and health and mental health care -- available and easily accessible. Much of BFMC service area has Medically Underserved Area or Population (MUA/P) designation from the Health Resources and Services Administration (HRSA) while the major towns have Health Professional Shortage Area (HPSA) designation. Perinatal and child indicators in the BFMC service area are similar to state-wide indicators. Infectious disease indicators in the BFMC service area indicate that pertussis is a public health issue that needs to be addressed. Chronic disease indicators in the BFMC service area indicate that persons die of cancer and cardiovascular disease prematurely in the community at a higher rate than rest of the state. In the BFMC service area there is a higher rate of discharges for bacterial pneumonia in comparison to the rest of the state, while the community fares better than the state in the area of asthma and angina. The BFMC service area is similar to the rest of the state in meeting Healthy People 2010 Chronic Disease Objectives and fares considerably better in meeting objectives related to reducing asthma hospitalizations. The BFMC service area is similar to the rest of the state in meeting Healthy People 2010 Maternal Child Health Objectives. Part VI, Line 5: Baystate Franklin Medical Center has a responsibility to respond to health care needs unsupported by government programs. In exchange for this responsibility, BFMC qualifies for tax-exempt status under 501(c)(3). However, providing hospital care alone is not enough to qualify for tax-exempt status. Hospitals also must operate in the public interest and provide programs that benefit the community. Baystate Franklin Medical Center is fully committed to its role in the community and serves with pride and compassion for people in need.The charitable mission of Baystate Franklin Medical Center, a member hospital of Baystate Health (BH), is to improve the health of the people in our communities every day, with quality and compassion. Baystate Franklin Medical Center's Community Benefits Mission is to reduce health disparities, promote community wellness and improve access to care for vulnerable populations. BFMC is committed to meeting the identified health and wellness needs of constituencies and communities served through the combined efforts of Baystate Health's member organizations, affiliated providers, and community partners.Baystate Franklin Medical Center provides high quality inpatient and outpatient services to residents of rural Franklin and Hampshire counties and Southern Vermont. The Birthplace, Cardiopulmonary Services, a Dialysis Unit, outpatient surgical services, rehabilitation and sports medicine services, and orthopedics are some of the specialized programs available at this acute care facility. In addition, Baystate Franklin Medical Center meets all of the factors required of medical facilities in order to maintain tax exemption, as first described in Revenue Ruling 69-545. In support of patient care and the medical needs of the communities served by Baystate Franklin Medical Center, medical staff membership and privileges are extended to all qualified physicians and practitioners in western Massachusetts who meet the requirements for credentialing and clinical privileges, whether employed by a related Baystate entity or community-based. Baystate Franklin Medical Center's emergency department is open to all in need of care and services; no one requiring emergency care is denied treatment. Additionally, surplus funds from operations are generally applied, as permitted, to the following; improvements in patient care, expansion and renovation of existing facilities, purchase and replacement of equipment, debt service, expenses associated with training of physicians and other health care professionals, professional development of medical and other clinical staff, and the support of scientific, translational, and clinical research.Baystate Health's volunteer Board of Trustees, the governing body of the organization and its affiliates, is comprised of the President and Chief Executive Officer of Baystate Health and up to twenty-two (22) other elected Trustees who are representative of the broad range of interests which exist in the communities served by Baystate Health and its affiliates. The Governance Committee oversees the nomination of Trustees and submits recommendations to the Board of Trustees for membership on the various Board committees. In considering nominations or recommendations for trustees, directors, committee members or officers the Governance Committee selects nominees who are representative of the various and diverse constituencies served by Baystate Health and its affiliates. In particular the Committee nominates persons who are representative of the community consumer interests of the various neighborhoods and localities which are served by Baystate Health and its affiliates in the carrying out of and pursuant to the charitable mission of the Baystate Health and its affiliates.Baystate Franklin Medical Center's Patient and Family Advisory Council facilitates patients and families to share information and advise the hospital regarding policies and programs. Information from the Council provides hospital leadership with an enhanced understanding of how to improve quality, program development, service excellence, communications, patient safety, facility design, patient and family education, patient and family satisfaction, and loyalty.Please refer to the section above in line 2 for additional examples of Baystate Franklin Medical Center's responsiveness to the community and opportunities for community involvement; including the Board of Trustees' Governance Committee, Community Benefits Advisory Council, and Community Health Needs Assessment.In addition to Tufts University School of Medicine Baystate Health's other education affiliations & accreditations include Accreditation Council for Graduate Medical Education (ACGME), American College of Nurse-Midwives, Accreditation Commission for Midwifery Education, Midwifery Institute of Philadelphia University, American International College, Elms College, Fitchburg State College, Greenfield Community College, Holyoke Community College, Springfield Technical Community College, University of Massachusetts Amherst, American Society of Health System Pharmacists, Massachusetts College of Pharmacy and Health Sciences-Worcester, Accreditation Council for Continuing Medical Education, Massachusetts Association of Registered Nurses, Inc. (an accredited approver by the American Nursing Credentialing Center's (ANCC) Commission on Accreditation), American Psychological Association, American Heart Association, Global Health Education Consortium, Medical Library Association.Baystate Health encourages all of its affiliates, hospital and non-hospital to align their charity care and collections standards with Baystate Health's Credit and Collection Policy. While some of the rules and regulations are hospital specific, the guidelines stated in the Baystate Health Credit and Collection Policy concern all affiliates. Many of Baystate Health's physicians, researchers, and leaders also serve in leadership roles with our affiliates, which include the following organizations; Tufts Clinical and Translational Science Institute; University of Massachusetts Amherst; Eastern Cooperative Oncology Group (ECOG); Childrens Oncology Group (COG); Gynecologic Oncology Group (GOG); Radiation Therapy Oncology Group (RTOG); Massachusetts Society for Medical Research; American Association for Laboratory Animal Science; Massachusetts Technology Collaborative (MTC); Regional Technology Corporation (RTC); Western Massachusetts Economic Development Council; The Association of University Technology Managers; Massachusetts Association of Technology Transfer Offices (MATTO). Part VI, Line 6: Baystate Health, Inc. is the parent entity of a multi-institutional integrated delivery system composed of three hospitals and other 501(c)(3) organizations. The three hospitals are Baystate Medical Center, Baystate Franklin Medical Center, and Baystate Mary Lane Hospital and other 501(c)(3) organizations include Baystate Medical Practices, Visiting Nurse Association and Hospice of Western New England, Inc., and Baystate Health Foundation. In addition to its nearly 10,000 employees, Baystate Health and its affiliates has 1,689 medical staff, 2,536 nurses and 2,185 new residents and fellows, medical students, nursing students, allied health students being educated for the future. Additionally, 1,107 volunteers and auxiliary members donated 112,602 hours to Baystate Medical Center, Baystate Franklin Medical Center, Baystate Mary Lane Hospital and Baystate Visiting Nurse Association & Hospice.Baystate Medical Center (BMC), the flagship 773-bed hospital (including Baystate Children's Hospital) based in Springfield, Massachusetts is Western New England's only tertiary care referral medical center, Level 1 trauma center and neonatal and pediatric intensive care units. BMC serves as a regional resource for specialty medical care and research, while providing comprehensive primary medical services to the community. In FY 2012 Baystate Medical Center provided $17.0 million in financial assistance and means-tested government programs, $35.6 million in health professions education, $6.1 in subsidized health services, $18.7 million in research and $3.4 million in community health improvement services. BMC's community benefit efforts included providing assessment, treatment and crisis support to child abuse victims and their non-offending caretakers affected by child abuse and domestic violence in western Massachusetts, offering enrichment and career development programs for disadvantaged Springfield students, ensuring cohesive health care for school-aged children and the broader community, prevention of accidental childhood injuries and death through public awareness, safety education and distribution of safety devices, coordination of health education focus groups, community health forums and fairs, supporting transgender individuals, their allies and anyone from the broader community who identifies as LGBT through a peer lead and psychosocial support group, providing TB diagnosis and treatment to patients throughout western Massachusetts, assisting low-income patients access free prescription medications and providing financial counseling services to inpatient and outpatient individuals who have concerns about how to pay for care.Baystate Franklin Medical Center (BFMC), a 90-bed facility located in Greenfield, Massachusetts (40 miles north of Springfield near the Vermont border) provides high quality inpatient and outpatient services to residents of rural Franklin and Hampshire counties and Southern Vermont. The Birthplace, Cardiopulmonary Services, a Dialysis Unit, outpatient surgical services, rehabilitation and sports medicine services, and orthopedics are some of the specialized programs available at this acute care facility. In FY2012 Baystate Franklin Medical Center provided $4.6 million in financial assistance and means-tested government programs, $2.0 in subsidized health services and $312,971 in community health improvement services. BFMCs community benefit efforts included the ongoing support group through the Franklin County Postpartum Partnership - a partnership initiated by BFMC nurses; expanded senior outreach program to focus on persons most at-risk for hospital readmission due to issues with medication management; and continued the regionally recognized Blood & Guts program for youth, including an annual hospital-based event for high school students and three school-based events for elementary school students and their families. In addition, BFMC HealthBeat TV, a monthly 30-minute cable access talk show produced, directed and hosted by Baystate Franklin employees, engages the hospital's physicians, employees, patients and community leaders in discussions of interest to residents of Franklin County. Topics range from heart health, emergency response to senior outreach. The program runs more than 60 times a month on stations throughout the county.Baystate Mary Lane Hospital (BMLH), a 25-bed facility located in rural Ware, Massachusetts (20 miles east of Springfield) provides quality patient care services to more than twelve Central Massachusetts communities. In addition to offering a wide spectrum of services from women's health, OB/GYN and pediatrics to surgical, intensive care and emergency care. In FY2012 Baystate Mary Lane Hospital provided $1.3 million in financial assistance and means-tested programs and $291,088 in community health improvement services. BMLH's community benefit efforts included a continued partnership with Quality EMT Educators of Worcester to offer Basic EMT Training to community members. To date over 90 community members (22 community members in FY 2012) have taken the EMT Basic Course. In December 2010 Baystate Mary Lane Hospital sponsored the first Paramedic Training program. A total of 25 EMT Basic candidates enrolled in this new class held at the hospital two nights a week. Through 2012 BMLH physicians shared their expertise beyond the walls of the hospital by offering high quality training and continuing education programs at no cost to EMS providers in our communities. The close working relationship between Emergency Physicians and EMS providers is essential to ensuring that patients receive the highest quality care in the field. BMLH provided critical support and resources to the community at large through our Support Groups including; Alcoholic Anonymous, Caregivers Support Group, Quilting Support Group for those touched by Cancer, Diabetes Support Group, Grieving Support Group, Hepatitis C Support Group & WIC Sponsored Breast Feeding Support Group. In addition, BMLH and its staff offered over 100 outreach programs providing a variety of education and wellness seminars to the community at large at no cost. These programs were presented by physicians, nurses and staff that work at the hospital and addressed ways to live healthier by offering a variety of educational opportunities and health screening. Lectures and screenings were offered at the hospital and in community settings including area schools and senior centers, and promoted disease prevention, behavior change, and healthier lifestyles for community members of all ages. In addition, BMLH HealthBeat TV, a monthly 30-minute cable access talk show produced, directed and hosted by Baystate Mary Lane Hospital employees, engages the hospital's physicians, employees, patients and community leaders in discussions of interest to residents of the 15-town Quaboag Hills region. Topics range from winter health safety, cancer, Lyme's disease to stroke awareness. The program runs more than 60 times a month.Baystate Medical Practices (BMP) is a tax-exempt, not-for-profit corporation organized to support and assist Baystate Health and its affiliate hospitals, including BMC, BFMC and BMLH, each of which is a Massachusetts not-for-profit corporation, in achieving the fulfillment of their clinical, teaching, research, and other missions related to health care. BMP, Inc. provides physician services, medical education and research programs to people in the community within its geographic location. BMP's policy is to provide care to any patient in need of medical care, regardless of the patient's ability to pay for such care. Dependent upon the patient's financial capability to pay, BMP may provide such care free of charge or at amounts below its normal charges. In FY 2012 BMP provided $4,115,241 in financial assistance. In addition to the charity care provided to patients, BMP's physicians participate in many and varied ongoing community outreach initiatives in the areas of education, employment, safety and health. BMP has also taken a leadership role in strengthening the health of disadvantaged citizens in surrounding communities including specific focus on AIDS and HIV and by providing physician staffing for three community-based health centers through Baystate Medical Center.Visiting Nurse Association and Hospice of Western New England, Inc. (VNAH) based in Springfield, Massachusetts is a tax-exempt, not-for-profit corporation organized to support and assist Baystate Health and its affiliate hospitals, including BMC and BMLH, each of which is a Massachusetts not-for-profit corporation, in achieving the fulfillment of their clinical, teaching, research, and other missions related to health care. VNAH is a comprehensive home health care agency committed to providing the highest quality care to patients and families, primarily in the home setting. (Continued) Form 990, Schedule H, Part VI, Line 6 VNAH has the expertise to meet individual needs by bringing experienced nurses, rehabilitation therapists, social workers and home care aides to patients' homes.The Home Care Program of Baystate's VNAH serves over 6,000 patients annually of which approximately 950 are on service daily. The services, aimed at allowing patients to recuperate while remaining in the comfort of their homes, includes skilled nursing, rehabilitation therapy, medical social work and homecare aides. The Hospice and Palliative Care Program of Baystate's VNAH provides end of life care for patients in the community, assisted living facilities and skilled nursing facilities. The Hospice and Palliative Care program coordinates care for an average daily census of about 140 to 180 patients of all ages. In FY 2012 a total of 128,605 home visits were made by Baystate Visiting Nurse Association & Hospice nurses. Additionally, the VNAH provided $30.2 million in financial assistance for FY 2012. Hospice has an interdisciplinary approach using nursing, social work, chaplains, hospice aides and volunteers to allow patients to meet goals related to comfort and symptom management. Baystate Health Foundation raised $1 million in 2012 for the Hospital of the Future and an additional $5.7 million through system wide annual fundraising efforts. Along with the Campaign for Baystate Medical Center's Hospital of the Future capital expansion project, the Foundation actively engaged in annual fund, major gift, and event fundraising to ensure ongoing annual support for education, research, programs and capital needs throughout the health system that impact patient care throughout western Massachusetts.In addition to the brief descriptions of the affiliated entities above, this further information speaks to activities of Baystate Health and its affiliates other activities regarding promotion of community health.In FY 2012 Baystate Health interpreters provided over 142,471 sessions in 49 languages to help deliver a positive patient care experience and 4,601 pages of documents were translated for providers. Interpreter sessions included in person, telephonic and video interpreting. Languages interpreted include Spanish, Russian, Vietnamese, Ukrainian, Mandarin (Chinese), American Sign Language, Arabic and Portuguese. Interpreters also translated the newest language to come into the area, Tigrinya, a language spoken in Ethiopia and Eritrea.Baystate Medical Center is recognized as a leading academic medical center. As the Western Campus of Tufts University School of Medicine since 1974, BMC offers clinical training and undergraduate and graduate medical student education across all specialties. In addition to BMC,Medical Residents and Fellows rotate through the Baystate Franklin Medical Center and Baystate Mary Lane Hospital.Baystate Health is a nationally accredited provider of continuing education for health care professionals on staff and in the community. Our mission is to provide high-quality, evidence based continuing education to maintain and enhance the knowledge, expertise, and performance of health care professionals, to improve the health of the people in our communities every day, with quality and compassion. In 2012, Baystate Health ran 65 courses for a total of 1,143 hours of continuing education activities. A total of 14,173 health care professionals attended these live activities. All courses and sessions were attended by both employees and non employees. Our educational activities are a service to the community.Baystate Health's Midwifery Education Program is offered in collaboration with the Midwifery Institute of Philadelphia University. Through our affiliation with the Massachusetts College of Pharmacy and Health Science, we offer a one-year pharmacy residency. Baystate Health's educational partnerships allow us to offer allied health programs such as emergency medical technician (EMT), pharmacy technician and surgical technologist. For nursing we offer clinical practicums for baccalaureate, masters, or doctoral-level nursing students in affiliation with the University of Massachusetts, University of Connecticut, Yale University, and other schools of nursing. Baystate Medical Center's high quality nursing care earned re-designation as a Magnet Hospital for Nursing Excellence by the American Nurses Credentialing Center (ANCC) - one of 170 in the nation and only five in Massachusetts.As an academic teaching hospital and the Western Campus of Tufts University School of Medicine, Baystate Medical Center is a center for research. Strong partnerships with other research organizations allow us BMC to further its institutional commitment to the Advancement of Knowledge. Collaborations enable Baystate Health to better support the innovative research of our investigators and to improve the lives of the people in the communities we serve. Baystate Medical Center is an active participant in the research communities of Massachusetts and a member institution of the state and regional organizations that also promote the goals of biomedical research. Its faculty and research staff are engaged in basic, clinical and biomedical research across a broad spectrum of medical and surgical specialties, with nationally-recognized research programs in quality of care and diabetes and metabolism. Baystate Medical Center serves as a regional resource for specialty medical care while providing comprehensive primary medical services to its community.Baystate Medical Center is also a research partner with University of Massachusetts through the Pioneer Valley Life Sciences Institute. Formed in 2003, PVLSI is a research institution which applies its translational research efforts in the areas of cancer, diabetes, obesity, and wound healing. Its scientists and technicians are committed to improving human health and reducing suffering from disease through creative strategies for early detection and preventiveinterventions. Baystate Administrative Services, Inc. the management company of the 3 hospitals is a dues paying member of the Economic Development Council of Western Massachusetts (EDC) and the Affiliated Chambers of Commerce of Greater Springfield (ACCGS). BMC participates in the EDC and ACCGS as we are the largest local employer in the region. The Chamber and its membership coordinate activites toward a common purpose of sustainability and economic growth for the region. The amount paid in dues for FY 2012 was $57,952.Other Baystate Health affiliations include Council of Teaching Hospitals and Health Systems (COTH) of the Association of American Medical Colleges (AAMC), Alliance of Independent Academic Medical Centers (AIAMC), and Group on Regional Medical Campuses (GRMC) of the Association of American Medical Colleges (AAMC), Joint Commission and Medical Library Association (MLA). Baystate Health and its affiliates are committed to creating healthier communities and continue to partner with members of the community to ensure we are meeting the diverse needs of the community. Baystate Health extends the traditional definition of "health" to include economic opportunity, affordable housing, education, safe neighborhoods, the arts, and supporting and valuing diversity - all elements that enable families and communities to thrive. In keeping with this commitment to improve health, Baystate Health and its various entities provide many valuable services, resources, programs and financial support - beyond the walls of the hospitals and into the communities and homes of the people we serve.Baystate Health and its affiliates are committed to providing the communities they serve throughout western Massachusetts with the resources necessary to stay informed and healthy by providing both basic and extensive educational opportunities; including smoking cessation programs, parent education classes and babysitting academy. Some classes are free while others are offered at a reasonable fee. No one is turned away due to inability to pay. In addition, Baystate Health has libraries and resource centers at Baystate Medical Center and Baystate Franklin Medical Center staffed by professionals who help patients, families and the general public access reliable health information.The Mini-Medical School program is an eight-part health education series offered at Baystate Medical Center featuring a different aspect of medicine each week. Designed for an adult audience, each course is taught by an energetic faculty member who will explain the science of medicine without resorting to complex terms. Mini-Medical School gives Baystate Health the opportunity to open our doors to the public and share our knowledge of medicine in a comfortable and friendly environment. (Continued) Form 990, Schedule H, Part VI,Line 6 Many of the students participate due to a general interest and later find that many of the things they learned over the semester are relevant to their own lives. The goal of this program is to help members of the public make more informed decisions about all aspects of their health care while receiving insight on what it's like to be a medical student. Tuition is $95 per person, $80 for Senior Class and Spirit of Women members. Baystate Health offers 50+ free programs to seniors and women. Baystate Health Senior Class is a loyalty program dedicated to health and wellness for men and women ages 55 and over. The 23,000 Senior Class members receive a quarterly newsletter with valuable health information, benefits and invitations to special events designed with their interests in mind. Baystate Spirit of Women Loyalty Program offers its 15,000 members 50+ monthly seminars with direct access to physicians, nurses and other medical professionals and the latest women's health information. The program is designed to increase knowledge of women's health issues so they are well prepared to make the best decisions regarding their health.The Baystate Neighbors Program, which began in 1999, was established to help employee first-time homebuyers purchase a home and to promote homeownership in neighborhoods around Baystate Medical Center, Baystate Franklin Medical Center, and Baystate Mary Lane Hospital. Employees were granted forgivable loans, which increased from $5,000 to $7,500 in 2006, that may be used towards a down payment or closing costs. In the past 13 years, the Baystate Neighbors Program has awarded 116 loans, a total of $785,973, to help employees become homeowners in communities served by Baystate Health hospitals, helping to stabilize housing in those communities. Specific to FY 2012, 15 neighbor loans were awarded, for a total of $112,500Since 1994, Rays of Hope - A Walk & Run Toward the Cure of Breast Cancer has been committed to improving the breast health of people in our communities with quality and compassion. Through the Baystate Health Foundation, the Walk has grown from 500 participants to over 22,000. Now in its 20th year, Rays of Hope has raised over $11.08 million - all of which has been awarded locally throughout western Massachusetts. 2009 marked the first year the event expanded into Franklin County. Funding benefits the Baystate Regional Cancer Program's Comprehensive Breast Center, breast health programs at Baystate Medical Center in Springfield, Baystate Franklin Medical Center in Greenfield, Baystate Mary Lane Hospital in Ware, local breast cancer research, outreach and education, and various community support projects and organizations. In 2011 $1.5 million was awarded over five years to form the Rays of Hope Center for Breast Cancer Research at the Pioneer Valley Life Sciences Institute, collaboration between clinicians at Baystate Health and scientists at UMass-Amherst, to continue locally based breast cancer research on a broader scale.The United Way develops and supports programs that directly improve the lives of people in our communities, a mission proudly shared by Baystate Health. Baystate Health is a strong supporter of the United Way, and a major contributor to the organization with three workforcecampaigns and thousands of employee donors and volunteers. Baystate Health's contributions help the United Way serve our families, friends, colleagues and others who seek help in different ways and at different times in their lives. Three community campaigns are held annually: Springfield workplace to support the United Way of Pioneer Valley, Greenfield workplace to support the United Way of Franklin County and Ware workplace to support the United Way of Hampshire County. Employees can direct their donations to one or all of the United Way's action areas: Education, Income and Health or designate to a qualified agency with a minimum contribution. Baystate employees also support the United Way by volunteering on work time to participate in a variety of community-based projects for the United Way Day of Caring. Baystate Health employees once again donated generously to the United Way of the Pioneer Valley in 2012, raising a total of $400,000. Baystate Mary Lane Hospital employees raised $11,754 for the United Way of Hampshire County.See also additional information regarding Baystate Health, Inc. and itsaffiliates promotion of community health above in Line 5.Baystate Franklin Medical Center intends to be in compliance with 501(r) regulations when they become final. Reports Filed With States Part VI, Line 7 MA X X X X X 1 1 1 0 0 0 0 0 0 Grace P Makari-Judson MD 277385 0 20725 0 21997 0 49408 0 26582 0 396097 0 0 0 Alan D McClelland MD 285231 0 53312 0 2871 0 24132 0 16848 0 382394 0 0 0 Barbara W Stechenberg MD 131190 0 13968 0 693 0 22132 0 14603 0 182586 0 0 0 Mark R Tolosky 0 696553 0 315856 0 524231 0 58633 0 40732 0 1636005 0 0 Charles Gijanto 0 280176 0 37638 0 11834 0 88631 0 23954 0 442233 0 0 Dennis W Chalke 0 363180 0 131625 0 177826 0 58000 0 34548 0 765179 0 0 Gerda Maissel MD 277948 0 34094 0 20114 0 128453 0 16980 0 477589 0 0 0 David M Farrick 141189 0 10119 0 450 0 14145 0 22576 0 188479 0 0 0 Deborah A Palmeri 136363 0 10007 0 1257 0 30512 0 26618 0 204757 0 0 0 Brian P Joyce 119110 0 0 0 204 0 19568 0 18074 0 156956 0 0 0 Regina O Campbell 109462 0 6216 0 1818 0 18170 0 23597 0 159263 0 0 0 Keith C McLean-Shinaman 0 276485 0 137200 0 389083 0 0 0 36779 0 839547 0 0 Part I, Line 3 The board of the filing organization has appointed the compensation committee of Baystate Health, Inc., a related organization and the parent organization of the health care system to which the filing organization belongs, as the compensation committee of the filing organization. The compensation committee consists entirely of individuals serving on the board of the filing organization. The compensation committee uses an independent compensation consultant and appropriate comparability data to establish the compensation of its key officers, directors, and employees, which includes the filing organization's top management officials, and approves the compensation of those individuals. Part I, Lines 4a-c Part I, Lines 4a-c: Line 4a: Keith McLean-Shinaman terminated employment effective 9/30/2011. The compensation numbers include various one time termination payments. Line 4b: Dennis W. Chalke - Supplemental Retirement of $145,066 is included in column E. This amount was earned in 2011. Charles Gijanto - Supplemental Retirement of $72,706 is included in column E. This amount was earned in 2011. Gerda Maissel, MD- Supplemental Retirement of $6,949 is included in column E. This amount was earned in 2011. Grace Makari-Judson, MD- Supplemental Retirement of $7,354 is included in column E. This amount was earned in 2011. Allan McClelland, MD- Supplemental Retirement of $4,532 is included in column E. This amount was earned in 2011. Keith C. McLean Shinaman - Supplemental Retirement of $41,190 is included in column E. This amount was earned in 2011. Mark R. Tolosky - Supplemental Retirement of $332,054 is included in column E. This amount was earned in 2011. Line 4c The supplemental retirement plan offered to Mr. Tolosky from 1997-2002 provided the right to purchase mutual fund shares at a specified price, with the rights expiring at the end of the 10 years. The 2011 compensation of $130,991 was based on the difference between the fair market value at the date of exercise and the exercise price. MA Health and Education Facilities Authority 042546011 2005-02-11 9100000 MHEFA Series M-4; See Section V 0 0 0 2337050 9766531 67668 45500 8963500 23332 2007 0 0 1 1 0 0 1 1 0 0.00730 0.00000 0.00730 1 0 1 0 0 0 0 X Part I, Column (f) Description of Purpose (continued): A - MHEFA Capital Asset Program Series M-4 Per the Official Statement, the purpose of the bond are three projects ("The Project") all to be owned and operated by Franklin Medical Center, to be located at 164 High Street, Greenfield, Massachusetts, consisting of: (a) the renovation and expansion of the radiology department(including a CAT scan suite, three mammography rooms and one ultrasound room) and the emergency department; (b) acquisition of equipment for the radiology department (including one CAT scan and one mammography unit) and for the emergency department; and (c) the renovation of approximately 28,400 square feet of inpatient units. The HEFA indebtedness listed is a pool loan therefore the questions are being answered with respect to Baystate Franklin Medical Center's pool loan alone rather than with respect to proceeds loaned to other conduit borrowers. There is no CUSIP associated with this loan. Part II, Line 7, The organization follows management practices and procedures to ensure the post-issuance compliance of its tax exempt bond liabilities and is currently in the process of reviewing and modifying these practices. Part IV, Line 1, Column A: A rebate calculation was performed and no amounts were owed, therefore, no Form 8038-T was required to be filed. American Excess Insurance Board Overlap 29232 See Part V - Mark Tolosky, President of the filing organization is also Chairman of the Board of Directors of AEIX. The filing organization purchases general & professional liability insurance from AEIX. 0 Baycare Health Partners Inc (BHP) Common Board Members or Officers 35000 See Part V - The filing organization made payments to BHP for annual support fees. BHP is an affiliate corporation of the filing organization. 0 Baycare Health Partners Inc (BHP) Common Board Members or Officers 135962 See Part V - The filing organization received payments from BHP for patient care services for which BHP is the intermediary between the filing organization. BHP is an affiliate corporation of the filing organization. 0 Health New England Inc (HNE) Common Board Members or Officers 10859895 See Part V - The filing organization received payments from HNE related to medical claims. HNE is an affiliate corporation of the filing organization. 0 Franklin MRI Center LLC (FMRI) Common Board Members or Officers 128805 See Part V - Dennis W. Chalke, Treasurer of the filing organization is also on the board of directors of Franklin MRI Center, LLC. (FMRI). The filing organization paid FMRI for patient care services. FMRI is an affiliate entity of the filing organization. 0 Franklin MRI Center LLC (FMRI) Common Board Members or Officers 253900 See Part V - Dennis W. Chalke, Treasurer of the filing organization is also on the board of directors of Franklin MRI Center, LLC. (FMRI). The filing organization received $200,000 in investment income, $53900 for rental of medical and office space. 0 Baystate Health System Ambulance Common Board Members or Officers 23310 See Part V - The filing organization made payments to BHSA for patient transport services. BHSA is an affiliate corporation of the filing organization. 0 Form 990, Part VI, Section A, line 1 The filing organization has a standing executive committee, which is entitled to act between meetings of the Board, on all matters as to which the Board is entitled to act and permitted by law to delegate to a committee. The members of the executive committee are the same individuals serving on the executive committee of Baystate Health, Inc. Form 990, Part VI, Section A, line 2 Allan W. Blair, Dennis W. Chalke, Charles L. D'Amour, John H. Davis, Kristin R. Delaney, John A. Egelhofer, MD, Charles Gijanto, Frances C. Grabowski, John E. Kole, Grace P. Makari-Judson, MD, John E. Maybury, Steven M. Mitus, John M. O'Brien, III, Ann M. Paradis, Katherine E. Putnam, Timothy S. Rice, James P. Sadowsky, Patricia A. Sheldon, David C. Southworth, Barbara W. Stechenberg, MD, Richard B. Steele, Jr., Frances K. Stotz, CFP, Katherine M. Sullivan, Mark R. Tolosky, David W. Townsend, Howard G. Trietsch, MD, Steven M. Wenner, MD and Victor Woolridge are also officers or trustees of its affiliated entities. The following trustees, officers, or key employees serve on a common board of a non-affiliated entity: (1) Katherine E. Putnam and David Southworth; (2) Steven M. Mitus, Timothy S. Rice and Richard B. Steele, Jr.; (3) Allan W. Blair, Charles D'Amour, David C. Southworth, and Mark R. Tolosky; (4) Allan W. Blair and Victor Woolridge; (5) John E. Kole and Steven M. Wenner; (6) John M. O'Brien and Victor Woolridge;(7) Steven M. Mitus and Victor Woolridge. Form 990, Part VI, Section A, line 3 Baystate Franklin Medical Center is affiliated with Baystate Administrative Services, Inc. (BAS) which is a 501(c) (3) organization. Various management and support functions are delegated to BAS. Form 990, Part VI, Section A, line 6 The filing organization has one member, Baystate Health, Inc. (BH). Form 990, Part VI, Section A, line 7a The Board of Trustees of the filing organization are the same individuals serving as members of the Board of Trustees of BH with the addition of the president of the medical staff of the filing organization. The Board of Trustees of BH are elected annually by the Board of Trustees of BH at their annual meeting. Form 990, Part VI, Section B, line 11 Prior to the filing of this return appropriate parts of this Form 990 were reviewed by representatives from the Tax, Finance, and Human Resources Departments of Baystate Health, Inc. (the parent organization of the health care system to which the filing organization belongs), some of whom are officers or trustees of the filing organization and by outside legal counsel. The entire return was reviewed by a tax expert from an outside accounting firm. The entire return was also reviewed prior to filing by the Audit and Compliance Committee of Baystate Health, Inc., which also includes some of the officers and trustees of the filing organization. Form 990, Part VI, Section B, line 12c Baystate Health, Inc. (BH) has a comprehensive conflict of interest policy which has been adopted by the filing organization. All directors, trustees, officers, key employees, and highest compensated employees of BH and its affiliates are asked to complete an annual conflict of interest form. We utilize an electronic database to receive and manage all conflict of interest submissions. This information is reviewed by the BH Chief Compliance Officer, the BH Chief Executive Officer, the Chair of the BH Board of Trustees, and the Chair of the Audit & Compliance Committee of BH. A summary of the conflict of interest disclosures is provided to the Baystate Health Board of Trustees and the Tax Department and reviewed by outside counsel. Potential conflict of interest transactions are reviewed as appropriate under the policy, which provides for recusal from discussion and deliberation by any party with a potential conflict of interest. Form 990, Part VI, Section B, line 15 The compensation of the President, and all key officers and employees is reviewed and determined annually by the compensation committee of Baystate Health, Inc. (the parent organization of the health care system to which the filing organization belongs), which has been appointed as the compensation committee of the filing organization and consists entirely of individuals serving on the board of the filing organization. Form 990, Part VI, Section B, Line 16b: Baystate Health, Inc. has a joint venture policy that covers affiliated tax exempt entities including Baystate Franklin Medical Center. Form 990, Part VI, Section C, line 19 The organization makes its conflict of interest policy and financial statements available to the public at www.baystatehealth.org. Articles of organization and bylaws are generally available at the Commonwealth of Massachusetts website. Average hours per week: Form 990, Part VII, Section A, Line 1a, Column (B) Individuals with reported compensation who have 10 or less average hours per week listed in Part VII, worked between 40 - 60 hours among all related entities. Form 990, Part VII, Section A, Line 5 Certain officers or trustees of the filing organization are paid by an entity, Baystate Medical Practices, Inc. (BMP) EIN 04-2888373, who is part of the health care system to which the filing organization belongs but one that does not meet the technical requirements as a "Related Organization" per Schedule R. Compensation from BMP to the officers and trustees of the filing organization therefore, is reported as paid from an unrelated organization in Line 5 and according to the instructions reported as though paid by the filing organization. Changes in Net Assets or Fund Balances: Form 990, Part XI, line 5: Net unrealized gains on investments: 439,226. Transfer for the cost of Land, Bldg. and Equip from affiliated companies 141,042. Minimum Pension Liability adjustment -2,429,237. Change in value of benefical interest net assets BHF temporarily restricted 549,057. Change in value of benefical interest net assets BHF permanently restricted 568,130. Transfer from Affiliated Companies 4,255,000. Total to Form 990, Part XI, Line 5: 3,523,218. Baystate Administrative Services Inc 759 Chestnut Street Springfield MA 01199 222747685 Administrative services MA 501 (c ) (3) 11c, IIIc Baystate Health Inc 0 Baystate Health Foundation Inc 759 Chestnut Street Springfield MA 01199 043549011 Fundraising MA 501 (c ) (3) 7 Baystate Health Inc 0 Baystate Health Systems Inc Health & Welfare Benefits Plan 759 Chestnut Street Springfield MA 01199 222531644 Voluntary Employees' Benefit Association MA 501 (c ) (9) Baystate Health Inc 0 Baystate Health Inc 759 Chestnut Street Springfield MA 01199 042105941 Healthcare System Parent MA 501 (c ) (3) 7 Baystate Health Inc 0 Baystate Mary Lane Hospital Corporation 85 South Street Ware MA 01082 042103584 Hospital MA 501 (c ) (3) 3 Baystate Health Inc 0 Baystate Medical Center Inc 759 Chestnut Street Springfield MA 01199 042790311 Acute Care Teaching Hospital MA 501 (c ) (3) 3 Baystate Health Inc 0 Baystate Total Home Care Inc 50 Maple Street Springfield MA 01199 203260764 Real Estate and Other MA 501 (c ) (3) 11b, II Baystate Health Inc 0 BH Insurance Company Ltd North Church Street Georgetown CJ 980421413 Offshore captive Insurance CJ Baystate Health Inc 0 Visiting Nurse Assn and Hospice of Western New England Inc 50 Maple Street Springfield MA 01199 042105803 Homehealth and Hospice care MA 501 (c ) (3) 9 Baystate Health Inc 0 Franklin MRI Center LLC Year Ended 123108 164 High Street Greenfield MA 01301 161766731 Management of Radiology Services MA 481696 833957 0 0 Health New England Inc Monarch Place Suite 1500 Springfield MA 011441500 042864973 HMO/Insurance MA Baystate Health Inc C HNE Advisory Services Monarch Place Suite 1500 Springfield MA 011441500 043012347 Administrative Svs MA Health New England Inc C Health New England Insurance Monarch Place Suite 1500 Springfield MA 011441500 043183019 Ancilliary Insurance MA Health New England Inc C Health New England of Connecticut Monarch Place Suite 1500 Springfield MA 011441500 061398662 Dormant MA Health New England Inc C Ingraham Corporation 759 Chestnut Street Springfield MA 01199 043016257 Health care and other business activities MA Baystate Health Inc C Baystate Health System Ambulance Inc 759 Chestnut Street Springfield MA 01199 043018550 Ambulance Svs MA Ingraham Corporation C Tr UW John H Sanderson 100 Federal Street Boston MA 02110 046028223 Trust MA T 1.00000 Ada B Darling UW 100 Federal Street Boston MA 02110 046017199 Trust MA T 1.00000 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 1 Baystate Medical Center L 996376 Baystate Administrative Services L 7182362 Health New England Inc P 10859895 Baystate Health Foundation R 870480 Baystate Health Foundation L 101000 Baystate Health Inc R 4254999