2013-05-14T09:31:24-05:00 2012-06-30 861065772 DELOITTE TAX LLP 111 MONUMENT CIRCLE SUITE 2000 INDIANAPOLIS IN 46204 990 2011-07-01 351343019 ST MARY'S WARRICK HOSPITAL INC WARR 8124854178 1116 MILLIS AVENUE BOONVILLE IN 47601 KIMBERLY A HODGKINSON 8124854178 2013-05-14 1 SHAWNA M JIMENEZ P01222873 3174648600 2013-05-09 2011 2016-02-24 21:20:13Z TIMOTHY A FLESCH 1116 MILLIS AVENUE BOONVILLE IN 47601 14975015 0 X WWW.STMARYS.ORG X 1971 IN ST. MARY'S WARRICK HOSPITAL, INC. IS A CRITICAL ACCESS HOSPITAL IN RURAL WARRICK COUNTY. THE HOSPITAL PROVIDES ACUTE CARE AND OUTPATIENT SERVICES TO PERSONS REGARDLESS OF ABILITY TO PAY. 9 5 228 5 60763 -17908 0 430 18851815 14679999 20901 10205 237797 284381 19110513 14975015 0 0 0 0 8091856 7944564 0 0 0 10713688 7383193 18805544 15327757 304969 -352742 9406823 9850454 8355363 10137297 1051460 -286843 ST. MARY'S WARRICK HOSPITAL, INC. IS A CRITICAL ACCESS HOSPITAL IN RURAL WARRICK COUNTY. THE HOSPITAL PROVIDES ACUTE CARE AND OUTPATIENT SERVICES TO PERSONS REGARDLESS OF ABILITY TO PAY. 0 0 7981954 14625842 ST. MARY'S WARRICK HOSPITAL, INC. (SMW) IS A NOT-FOR-PROFIT GENERAL SHORT-TERM CRITICAL ACCESS HOSPITAL SERVING WARRICK, POSEY, SPENCER, AND OTHER RURAL POPULATED COUNTIES SURROUNDING THE AREA WITHOUT REGARD TO PATIENT RACE, CREED, NATIONAL ORIGIN, ECONOMIC STATUS, OR ABILITY TO PAY. DURING THE FISCAL YEAR ENDING JUNE 30, 2012, THE HOSPITAL PROVIDED HEALTHCARE TO 969 PATIENTS IN THE COMMUNITY FOR A TOTAL OF 6,577 PATIENT DAYS OF SERVICE. ADDITIONALLY, THE HOSPITAL ALSO PROVIDED SERVICES TO 20,979 OUTPATIENTS, INCLUDING 213 OUTPATIENT SURGERY SERVICES AND 7,890 EMERGENCY ROOM VISITS. SEE SCHEDULE H FOR A NON-EXHAUSTIVE LIST OF COMMUNITY BENEFIT PROGRAMS AND DESCRIPTIONS. 2642188 SMW 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, 2012, THE UNREIMBURSED COST OF FREE OR DISCOUNTED SERVICES PROVIDED TO PATIENTS WHO WERE DEEMED INDIGENT UNDER STATE, COUNTY, OR HOSPITAL GUIDELINES WAS $2,642,188 WHICH INCLUDED $562,719 OF TRADITIONAL FINANCIAL ASSISTANCE AND $2,079,469 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. 83682 IN ADDITION TO CORE MEDICAL SERVICES, SMW 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 2012, SMW PROVIDED $83,682 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, SMW PROVIDED A TOTAL COMMUNITY BENEFIT OF $2,725,870 IN FISCAL YEAR 2012.) SMW SERVES AND SUPPORTS ITS COMMUNITY THROUGH SUCH PROGRAMS AS HEALTH FAIRS AND SCREENINGS, TRANSPORTATION FOR PATIENT AT NO COST TO PATIENT, AS WELL AS VARIOUS COMMUNITY SUPPORT GROUPS. SEE SCHEDULE H FOR A NON-EXHAUSTIVE LIST OF COMMUNITY BENEFIT PROGRAMS AND DESCRIPTIONS. 10707824 1 0 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 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 24 0 1 228 1 1 1 0 0 0 0 0 0 0 0 0 X 9 5 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 IN X KIMBERLY A HODGKINSON 8124854178 3700 WASHINGTON AVENUE EVANSVILLE IN 47750 X TIMOTHY FLESCH 65.00 X X 0 1175690 66599 GWEN SANDEFUR 65.00 X 0 372781 48407 LLOYD MCGINNIS MD 50.00 X 0 127004 26337 LAURENCE STEENBERG 1.00 X X 0 0 0 MICHAEL HERRELL MD 1.00 X X 0 0 0 JUDGE DONALD HENDRICKSON 1.00 X 0 0 0 SALLY RIDEOUT LAMBERT 1.00 X 0 0 0 JERRY L AIGNER 1.00 X 0 0 0 SR JANE BURGER DC 1.00 X 0 0 0 CAROL GODSEY 65.00 X 0 193220 77099 DAVID VAUGHN 45.00 X 279679 0 38564 THOMAS L MILLER 42.00 X 206028 0 7343 MATTHEW P DATZMAN 45.00 X 276040 0 13962 STEVEN BECKER 40.00 X 177817 0 3043 KENNETH PARKER 45.00 X 228925 0 0 1168489 1868695 281354 6 0 1 0 DANCO CONSTRUCTION 3201 INTERSTATE DRIVE EVANSVILLE IN 47715 CONSTRUCTION SERVICES 584047 CPSI 6600 WALL STREET MOBILE AL 36695 HEALTHCARE INFORMATION MANAGEMENT 578969 EMCARE 7032 COLLECTION CENTER DRIVE CHICAGO IL 60693 MEDICAL SERVICES/CODING 512959 HORIZON HEALTH PO BOX 840839 DALLAS TX 75284 MANAGEMENT SERVICES 420573 KENNETH PARKER MD PO BOX 129 INGLEFIELD IN 47618 MEDICAL SERVICE 207750 9 430 430 430 OUTPATIENT REVENUE 621990 9533647 9533647 INPATIENT REVENUE 621990 5085589 5085589 REFERENCE LAB FEES 541380 60763 60763 14679999 4705 4705 75067 0 75067 75067 75067 5500 0 5500 5500 5500 VENDING MACHINE/CAFETE 900099 36462 36462 EXERCISE PROGRAM/GYM M 713940 29065 29065 HOUSEKEEPING 561700 7370 7370 136417 1106 135311 209314 14975015 14625842 60763 287980 6409624 4666033 1743591 15084 10981 4103 1087432 791621 295811 432424 314793 117631 1301168 947215 353953 23623 17197 6426 600 437 163 427918 311513 116405 32615 23743 8872 182091 182091 799650 799650 41888 41888 PURCHASED SERVICES 1756767 1278879 477888 PROVIDER TAX EXPENSE 1083734 1083734 SUPPLIES 1010988 735972 275016 CONTRACT LABOR 542203 394709 147494 179948 130997 48951 15327757 10707824 4619933 0 930143 240719 2355829 2312039 187784 194086 62716 49870 21073646 14771020 5398024 6302626 192304 106367 280023 644747 9406823 9850454 2957974 4279124 5397389 5858173 8355363 10137297 X 1051460 -286843 1051460 -286843 9406823 9850454 X -352742 -985561 X 0 1 1 X 0 X 0 0 0 0 0 0 0 0 1 559 559 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. 181810 181810 11794182 7296056 4498126 14267 14267 0 8779051 7171664 1607387 304336 289033 15303 6302626 RECEIVABLE FROM 3RD PARTY PROGRAM 323584 INVESTMENT IN UNCONSOLIDATED ENTITIES 9763 AH DEFERRED COMPENSATION 188180 OTHER CURRENT ASSETS 95342 INTERCOMPANY RECEIVABLES 284 INTEREST IN INVESTMENTS HELD BY ASCENSION HEALTH ALLIANCE 27594 644747 INTERCOMPANY DEBT WITH ASCENSION HEALTH ALLIANCE 3730610 PENSION LIABILITY 1136963 INTERCOMPANY TO ST. MARY'S MEDICAL CENTER 802254 DEFERRED COMPENSATION 188180 SELF INSURANCE LIABILITY 166 5858173 1 1 X 1 X 1 X 1 1 0 1 1 562719 562719 0.03670 3365766 1286297 2079469 0.13570 3928485 1286297 2642188 0.17240 424 424 424 0.00000 2867 50367 50367 0.00330 3291 50791 50791 0.00330 3291 3979276 1286297 2692979 0.17570 123 850 850 0.00010 263 941 941 0.00010 221 31100 31100 0.00200 607 32891 32891 0.00220 0 2036394 203639 8815505 9450747 -635242 X 1 1 1 1 ST MARY'S WARRICK HOSPITAL INC

1116 MILLIS AVENUE BOONVILLE IN 47601

X X X X ST MARY'S WARRICK HOSPITAL INC 1 1 1 200.000000000000 1 300.000000000000 1 X X 1 1 X X X 1 0 1 X 0 0 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, WILL BE ELIGIBLE FOR 100% CHARITY CARE WRITE OFF OF CHARGES FOR SERVICES THAT HAVE BEEN PROVIDED TO THEM. ALSO, AT A MINIMUM, PATIENTS WITH INCOMES ABOVE 200% OF THE FPL BUT NOT EXCEEDING 300% OF THE FPL, ARE ELIGIBLE TO 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 AN 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: WHILE MOST OF ST. MARY'S WARRICK HOSPITAL, INC.'S COMMUNITY BENEFIT ACTIVITIES DIRECTLY IMPACT THE HEALTH OF ITS COMMUNITIES, ST. MARY'S WARRICK HOSPITAL, INC. ALSO INVESTS IN COMMUNITY BUILDING ACTIVITIES THAT INDIRECTLY IMPROVE HEALTH BY IMPROVING 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. ADDITIONALY, HELPING TO CREATE GREATER CAPACITY WITHIN THE COMMUNITY TO ADDRESS A BROAD RANGE OF QUALITY OF LIFE ISSUES ALSO IMPACTS HEALTH. IN FISCAL YEAR 2012, ST. MARY'S WARRICK HOSPITAL, INC.'S COMMUNITY BUILDING ACTIVITIES INCLUDED: UNITED WAY DAY OF CARING, PARTNERING WITH THE WARRICK CO. HEALTH COALITION, AND EMBRACING PROJECT SEARCH STUDENTS WITHIN THE HOSPITAL. PART III, LINE 4: THE ORGANIZATION IS A PART OF THE ST. MARY'S HEALTH SYSTEM OF AMERICA, INC. CONSOLIDATED AUDIT. THE PROVISION FOR BAD DEBT EXPENSE 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 UNCOLLECTIBLE 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 BAD DEBT EXPENSE TO ESTABLISH AN APPROPRIATE ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS. 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 WITH 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. THE SHARE OF THE BAD DEBT EXPENSE IN FISCAL YEAR 2012 WAS $5,866,879 AT CHARGES ($2,036,394 AT COST). PART III, LINE 8: 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 SURPLUS (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. ST. MARY'S WARRICK HOSPITAL, INC. PART V, SECTION B, LINE 19D: 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. ST. MARY'S WARRICK HOSPITAL, INC. PART V, SECTION B, LINE 20: 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). 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 13. 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 TRANSALATIONS 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 11). ST. MARY'S WARRICK HOSPITAL, INC. 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 HOSPITAL'S FINANCIAL ASSISTANCE POLICY (FAP) AS NOTED IN QUESTION 13. 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 TRANSALATIONS 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 11). PART V, SECTION B, LINE 15: ST. MARY'S WARRICK HOSPITAL, INC.: THE FOLLOWING STEPS WERE FOLLOWED AND CONSIDERED REASONABLE EFFORTS FOR PURPOSES OF QUESTION 15:- 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 AS NOTED IN QUESTION 13. 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 11). PART V, SECTION B, LINE 16: ST. MARY'S WARRICK HOSPITAL, INC.: THE FOLLOWING STEPS WERE FOLLOWED AND CONSIDERED REASONABLE EFFORTS FOR PURPOSES OF QUESTION 16:- 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 13. THIS INCLUDES, BUT IS NOT LIMITED TO, THE FOLLOWING:- A 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 TRANSALATIONS 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 11). PART VI, LINE 2: COMMUNITIES ARE DYNAMIC 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 WARRICK HOSPITAL, INC. IS TO WORK WITH ITS COMMUNITY TO CONDUCT AN ASSESSMENT AT LEAST EVERY THREE YEARS IN PARTNERSHIP WITH ST. MARY'S MEDICAL CENTER OF EVANSVILLE, INC. ASSESSMENTS MAY INCLUDE PRIMARY SURVEY DATA, SECONDARY SURVEY 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 WARRICK HOSPITAL, 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 WARRICK HOSPITAL, 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 WARRICK HOSPITAL, 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 CONTRACTS 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. PART VI, LINE 4: ST. MARY'S WARRICK HOSPITAL, INC. IS A CRITICAL ACCESS HOSPITAL LOCATED IN BOONVILLE, INDIANA SERVING WARRICK, POSEY, SPENCER, AND OTHER RURAL POPULATED COUNTIES SURROUNDING THE AREA. ACCORDING TO THE 2012 COUNTY AND HEALTH RANKINGS, WARRICK COUNTY HAS A POPULATION OF 58,521 AND 10% OF THE CHILDREN IN WARRICK COUNTY ARE DEEMED TO LIVE IN HOUSEHOLDS BELOW THE POVERTY GUIDELINES. IN ADDITION, 15% OF THOSE LIVING IN WARRICK COUNTY UNDER THE AGE OF 65 DO NOT HAVE HEALTH INSURANCE. CHILD AND ADULT OBESITY CONTINUES TO BE ONE OF THE HIGHEST COMMUNITY ISSUES FOR WARRICK COUNTY WITH 32% OF ADULTS WITH A BODY MASS GREATER THAN 30. OTHER COMMUNITY ISSUES INCLUDE:- FAMILIES' UNDERSTANDING OF FINANCES, BUDGETING, AND TAX CREDITS;- UNDERSTANDING THE CYCLE OF POVERTY THAT OCCURS IN SUCCESSIVE GENERATIONS;- COST OF PRESCRIPTION MEDICINE; AND- AFFORDABLE AND ACCESSIBLE HEALTH CARE FOR LOW- TO MODERATE-INCOME INDIVIDUALS 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 WARRICK HOSPITAL, INC.:- DELIVERS PATIENT SERVICES, INCLUDING EMERGENCY DEPARTMENT SERVICES 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 FACILTIES.- PARTICIPATES IN GOVERNMENT-SPONSORED PROGRAMS SUCH AS MEDICAID AND MEDICARE TO THE POOR AND ELDERLY.- HOLDS MEMBERSHIP ON OTHER PUBLIC AGENCY BOARDS TO ENHANCE WELL BEING OF THE COMMUNITY IN PARTNERSHIP PROGRAMS. PART VI, LINE 6: AS A PART OF ST. MARY'S HEALTH SYSTEM, ST. MARY'S WARRICK HOSPITAL, INC. IS DEDICATED TO IMPROVING THE HEALTH STATUS AND QUALITY OF LIFE FOR THE COMMUNITIES IT SERVES. WHILE DESIGNATED ASSOCIATES AT ST. MARY'S WARRICK HOSPITAL, INC. DEVOTE SIGNIFICANT PORTIONS OF 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 WARRICK HOSPITAL, INC. PARTICIPATES. REPORTS FILED WITH STATES PART VI, LINE 7 IN 0 1 0 0 0 0 0 0 0 TIMOTHY FLESCH 0 482010 0 631246 0 62434 0 39114 0 27485 0 1242289 0 0 GWEN SANDEFUR 0 318830 0 48877 0 5074 0 19559 0 28848 0 421188 0 0 LLOYD MCGINNIS MD 0 109219 0 7500 0 10285 0 22274 0 4063 0 153341 0 0 CAROL GODSEY 0 127441 0 25014 0 40765 0 65147 0 11952 0 270319 0 0 DAVID VAUGHN 262834 0 0 0 16845 0 33708 0 4856 0 318243 0 0 0 THOMAS L MILLER 200420 0 0 0 5608 0 1462 0 5881 0 213371 0 0 0 MATTHEW P DATZMAN 242164 0 0 0 33876 0 5775 0 8187 0 290002 0 0 0 STEVEN BECKER 177817 0 0 0 0 0 0 0 3043 0 180860 0 0 0 KENNETH PARKER 228925 0 0 0 0 0 0 0 0 0 228925 0 0 0 SUPPLEMENTAL INFORMATION PART III PART I, LINE 3: ST. MARY'S HEALTH SYSTEM OF AMERICA, INC., A RELATED ORGANIZATION OF ST. MARY'S WARRICK HOSPITAL, INC., USES THE FOLLOWING TO ESTABLISH THE COMPENSATION OF THE ORGANIZATION'S CEO/EXECUTIVE DIRECTOR: COMPENSATION COMMITTEE COMPENSATION SURVEY OR STUDY APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE SUPPLEMENTAL INFORMATION PART III 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. NO PAYMENTS WERE MADE TO LISTED PERSONS IN PART VII UNDER THE VARIOUS NON-QUALIFIED DEFERRED COMPENSATION PLANS DURING THE YEAR. FORM 990, PART VI, SECTION A, LINE 6 ST. MARY'S WARRICK HOSPITAL, INC. HAS A SINGLE CORPORATE MEMBER, ST. MARY'S HEALTH SYSTEM OF AMERICA, INC. FORM 990, PART VI, SECTION A, LINE 7A ST. MARY'S WARRICK HOSPITAL, INC. HAS A SINGLE CORPORATE MEMBER, ST. MARY'S HEALTH SYSTEM OF AMERICA, INC., WHO HAS THE ABILITY TO ELECT MEMBERS TO THE GOVERNING BODY OF THE ST. MARY'S WARRICK HOSPITAL, INC. BOARD. FORM 990, PART VI, SECTION A, LINE 7B ALL DECISIONS THAT HAVE A MATERIAL IMPACT TO ST. MARY'S WARRICK HOSPITAL, INC.'S FINANCIAL INFORMATION OR CORPORATION AS A WHOLE ARE SUBJECT TO APPROVAL BY ITS SOLE CORPORATE MEMBER, ST. MARY'S HEALTH SYSTEM OF AMERICA, INC. FORM 990, PART VI, SECTION B, LINE 11 ST. MARY'S HEALTH SYSTEM OF AMERICA, 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 RECEIVE THE FORM 990 VIA EMAIL FOR REVIEW ELECTRONICALLY AND WILL SEND ANY QUESTIONS REGARDING THE FORM 990 VIA EMAIL. RESPONSES TO ANY QUESTIONS RECEIVED WILL BE PROVIDED ELECTRONICALLY TO THE BOARD MEMBERS 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 WARRICK HOSPITAL, INC.'S CEO, EXECUTIVE DIRECTOR, OR TOP MANAGEMENT OFFICIAL ARE MADE BY A COMPENSATION COMMITTEE OF ST. MARY'S WARRICK HOSPITAL, INC. AND/OR ST. MARY'S HEALTH SYSTEM OF AMERICA, 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 OF AMERICA, INC. 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 WARRICK HOSPITAL, INC.'S OTHER OFFICERS OR KEY EMPLOYEES ARE MADE BY A COMPENSATION COMMITTEE OF ST. MARY'S WARRICK HOSPITAL, INC. AND/OR ST. MARY'S HEALTH SYSTEM OF AMERICA, 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 OF AMERICA, INC. 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 C, LINE 19 THE ORGANIZATION WILL PROVIDE ANY DOCUMENTS OPEN TO PUBLIC INSPECTION UPON REQUEST. FORM 990, PART VII, LINE 1A, COLUMN B: OFFICERS, DIRECTORS, AND KEY EMPLOYEES OF ST. MARY'S WARRICK HOSPITAL, INC. PROVIDE SERVICES TO ST. MARY'S HEALTH SYSTEM OF AMERICA, INC. AND AFFILIATES. HOURS WORKED ARE NOT TRACKED SEPARATELY FOR EACH ENTITY. THEREFORE, HOURS FOR ALL INDIVIDUALS REPORTED ON FORM 990, PART VII, COMPENSATION OF OFFICERS, DIRECTORS, TRUSTEES, KEY EMPLOYEES, HIGHEST COMPENSATED EMPLOYEES, AND INDEPENDENT CONTRACTORS REPRESENT AGGREGATE HOURS WORKED PER WEEK FOR ALL ENTITIES. FORM 990, PART VII, LINE 1A, COLUMNS D, E, AND F: OFFICERS OF ST. MARY'S WARRICK HOSPITAL, INC. PROVIDE SERVICES TO ST. MARY'S HEALTH SYSTEM OF AMERICA, INC. AND ITS AFFILIATES. COMPENSATION IS NOT REPORTED SEPARATELY BY ENTITY. THEREFORE, COMPENSATION AMOUNTS REPORTED ON FORM 990, PART VII, COMPENSATION OF OFFICERS, DIRECTORS, TRUSTEES, AND KEY EMPLOYEES REPRESENT COMPENSATION PAID FOR MANAGING ST. MARY'S HEALTH SYSTEM OF AMERICA, INC. AND ALL RELATED ENTITIES. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED LOSSES ON INVESTMENTS: -3,194. FAS 158 PENSION LIABILITY -982,367. TOTAL TO FORM 990, PART XI, LINE 5: -985,561. FORM 990, PART I, LINE 6: THE TOTAL NUMBER OF VOLUNTEERS FOR THE ORGANIZATION IS 5. THIS CONSISTS OF VOLUNTEERS PARTICIPATING ON THE BOARD OF DIRECTORS. FORM 990, PART IV, LINE 24A: ST. MARY'S WARRICK HOSPITAL, INC. IS A HEALTH FACILITY THAT IS PART OF THE ASCENSION HEALTH SYSTEM. ASCENSION HEALTH SYSTEM IS THE HOLDER OF THE TAX EXEMPT HOSPITAL REVENUE BONDS. ST. MARY'S WARRICK HOSPITAL, INC. HOLDS AN INTERCOMPANY NOTE PAYABLE WITH ASCENSION HEALTH AND THIS INFORMATION IS REPORTED ON THE BALANCE SHEET. 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