2012-03-13T13:36:13-05:00 2011-06-30 SEIM JOHNSON LLP 18081 BURT STREET SUITE 200 OMAHA NE 680224722 990 2010-07-01 470393176 ANTELOPE MEMORIAL HOSPITAL ANTE 4028874151 PO BOX 229 NELIGH NE 68756 JACK W GREEN 4028874151 2012-03-05 1 BARBARA J FAJEN 4023302660 2010 2016-02-24 21:20:13Z JACK W GREEN PO BOX 229 NELIGH NE 68756 13478704 0 X WWW.AMHNE.ORG X 1974 NE TO BUILD, ERECT, MAINTAIN, EXPAND, EQUIP, MANAGE AND OPERATE A HOSPITAL AND AFFILIATED INSTITUTIONS IN THE COUNTY OF ANTELOPE, NEBRASKA FOR THE CARE AND TREATMENT OF SICK AND INFIRM PEOPLE, REGARDLESS OF RACE, CREED, COLOR AND RESIDENCE. 8 8 170 11 0 0 120175 32756 11826962 13346921 98622 66769 61869 32240 12107628 13478686 0 0 0 0 6206295 6613253 0 0 0 5124773 5582401 11331068 12195654 776560 1283032 15120132 16314684 5830885 5724388 9289247 10590296 MAKING A DIFFERENCE IN PEOPLE'S LIVES THROUGH EXCELLENT PATIENT CARE. 0 0 10967686 13346921 ANTELOPE MEMORIAL HOSPITAL IS A 25-BED CRITICAL ACCESS HOSPITAL IN NELIGH, NE. IT PROVIDES QUALITY HEALTH CARE REGARDLESS OF RACE, CREED, COLOR, NATIONAL ORIGIN, AGE, GENDER, HANDICAP, OR ABILITY TO PAY. THE HOSPITAL IS A FAMILY-CENTERED, COMMUNITY-ORIENTED HOSPITAL, OFFERING COMPREHENSIVE MEDICAL SERVICES, INCLUDING A FULL-TIME EMERGENCY ROOM. 10967686 1 1 0 1 0 0 0 0 0 1 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 1 1 0 0 0 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 1 12 0 1 170 1 0 0 0 0 0 0 0 0 0 0 X 8 8 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 0 0 X MARTHA NELSON 4028876282 PO BOX 229 NELIGH NE 68756 JOHN MLNARIK 4.00 X X 0 0 0 JAMES BLACKBURN 4.00 X X 0 0 0 JOE KNIGHT 4.00 X X 0 0 0 JAMES MEURET 2.00 X 0 0 0 DAVID SULLIVAN 2.00 X 0 0 0 PHILIP KLUTHE 2.00 X 0 0 0 GORDON SHRADER 2.00 X 0 0 0 CHRISTOPHER TWIBELL 2.00 X 0 0 0 JACK GREEN 40.00 X 138293 0 10826 MARTHA NELSON 36.00 X 85504 0 8210 223797 0 19036 1 0 0 0 BOYD'S ELECTRICAL SERVICE 51976 HIGHWAY 275 CLEARWATER NE 68726 ELECTRICAL SERVICES 287488 OVERLAND REHAB SERVICES 405 JAMES STREET VERDIGRE NE 68783 PHYSICAL THERAPY SERVICES 270671 NORTH CENTRAL ANESTHESIA SERVICES PO BOX 359 ONEILL NE 68763 ANESTHESIA SERVICES 252516 FAITH REGIONAL HEALTH SERVICES PO BOX 869 NORFOLK NE 68702 PATIENT ECHOS/STRESS TESTS 123669 4 32756 32756 MEDICARE/MEDICAID PAYM 621400 7944431 7944431 OTHER PATIENT SERVICE 621400 5359333 5359333 LIFELINE 621990 30537 30537 LABORATORY 621990 7220 7220 AMBULANCE 621910 5400 5400 13346921 66487 66487 300 18 282 282 282 CAFETERIA 900099 30225 30225 MISCELLANEOUS REVENUE 900099 2015 2015 32240 13478686 13346921 0 99009 257973 257973 41629 41629 5016442 4576429 440013 178496 155060 23436 751451 652787 98664 367262 319041 48221 51299 51299 37016 37016 1730615 1572708 157907 39240 11153 28087 1618357 1566939 51418 200168 200168 35347 31690 3657 7199 6254 945 168057 168057 1015977 1015977 181020 181020 BAD DEBT 429843 429843 DUES & SUBSCRIPTIONS 33771 33771 LICENSES 20265 3444 16821 MISCELLANEOUS EXPENSES 12554 43 12511 WELLNESS 1673 1673 12195654 10967686 1227968 0 1192756 1235354 3842605 4657818 40302 13370 1410822 1435327 14130 23450 351799 309263 23143 48468 15574533 7514836 7728948 8059697 395916 429275 119711 102662 15120132 16314684 1534770 1397175 3990000 3770000 306115 557213 5830885 5724388 X 9258532 10533546 30715 56750 9289247 10590296 15120132 16314684 X 1283032 18017 X X 0 1 0 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 1203 1203 0 EXPLANATION OF OTHER LOBBYING ACTIVITIES: PART II-B, LINE 1I: PAID NEBRASKA HOPSITAL ASSOCIATION AND AMERICAN HOSPITAL ASSOCIATION DUES GOING TO LOBBYING ACTIVITIES OF $468 AND $735, RESPECTIVELY. 63764 63764 4592627 2309784 2282843 8343562 4730541 3613021 2574580 474511 2100069 8059697 ESTIMATED THIRD PARTY PAYORS 557213 557213 13478686 12195654 1283032 18017 18017 1301049 13496703 18017 18017 13478686 0 13478686 12195654 0 12195654 0 12195654 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: THE HOSPITAL IS A NOT-FOR-PROFIT CORPORATION AS DESCRIBED IN SECTION 501(C)(3) OF THE CODE AND HAS RECEIVED A DETERMINATION LETTER THAT IT IS EXEMPT FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE CODE. THE INTERNAL REVENUE SERVICE HAS ESTABLISHED STANDARDS TO BE MET TO MAINTAIN THE HOSPITALS TAX EXEMPT STATUS. IN GENERAL, SUCH STANDARDS REQUIRE THE HOSPITAL TO MEET A COMMUNITY BENEFITS STANDARD AND COMPLY WITH VARIOUS LAWS AND REGULATIONS. THE HOSPITAL ACCOUNTS FOR UNCERTAINTIES IN ACCOUNTING FOR INCOME TAX ASSETS AND LIABILITIES USING GUIDANCE INCLUDED IN FASB ASC 740, INCOME TAXES. THE HOSPITAL RECOGNIZES THE EFFECT OF INCOME TAX POSITIONS ONLY IF THOSE POSITIONS ARE MORE LIKELY THAN NOT OF BEING SUSTAINED. AT JUNE 30, 2011, THE HOSPITAL HAD NO UNCERTAIN TAX POSITIONS ACCRUED. 1 1 1 X 0 1 1 0 1 1 53400 53400 0.00450 693280 748357 -55077 0.00000 746680 748357 -1677 0.00450 16323 8754 7569 0.00060 4000 0 4000 0.00030 693346 401009 292337 0.02480 1038 0 1038 0.00010 714707 409763 304944 0.02580 1461387 1158120 303267 0.03030 1 292467 0 6341355 6185447 155908 X 1 0 1 1 ANTELOPE MEMORIAL HOSPITAL

102 WEST 9TH STREET NELIGH NE 68756

X X X ANTELOPE MEMORIAL HOSPITAL 1 PART I, LINE 3C: NOT APPLICABLE AS FEDERAL POVERTY GUIDELINES ARE USED TO DETERMINE ELIGIBILITY FOR PROVIDING FREE AND DISCOUNTED CARE TO LOW INCOME INDIVIDUALS. PART I, LINE 6A: ANTELOPE MEMORIAL HOSPITAL'S COMMUNITY BENEFIT REPORT IS NOT PREPARED BY A RELATED ORGANIZATION. PART I, LINE 7: THE COST TO CHARGE RATIO AS FOLLOWS WAS USED TO DETERMINE CHARITY CARE AND MEANS-TESTED GOVERNMENT PROGRAMS AT COST: (TOTAL EXPENSES - BAD DEBT) / GROSS PATIENT SERVICE REVENUE = PERCENTAGE OF COST TO CHARGE. OTHER COMMUNITY BENEFIT EXPENSES ARE STATED AT COST BASED ON ANTELOPE MEMORIAL HOSPITAL'S INTERNAL ACCOUNTING RECORDS. PART I, LINE 7G: THERE ARE NO COSTS ATTRIBUTABLE TO A PHYSICIAN CLINIC INCLUDED ON LINE 7G. PART I, L7 COL(F): THE COST OF BAD DEBT THAT HAS BEEN SUBTRACTED FROM TOTAL EXPENSES TO DETERMINE THE DENOMINATOR IN THE PERCENTAGES FOR COLUMN (F) IS $429,843. PART III, LINE 4: THE HOSPITAL'S FINANCIAL STATMENTS DO NOT CONTAIN A SPECIFIC FOOTNOTE DESCRIBING BAD DEBT. HOWEVER, THE FOLLOWING IS THE TEXT OF THE FOOTNOTE TITLED "PATIENT RECEIVABLES, NET" AND "CHARITY CARE": NET PATIENT RECEIVABLES CONSIST OF UNCOLLATERALIZED PATIENT AND THIRD PARTY OBLIGATIONS REDUCED BY A VALUATION ALLOWANCE FOR DOUBTFUL ACCOUNTS AND CONTRACTUAL ADJUSTMENTS FROM THIRD PARTY PAYORS. THE ALLOWANCES REFLECT MANAGEMENT'S ESTIMATE OF AMOUNTS THAT WILL NOT BE COLLECTED IN THE FUTURE AND ARE BASED ON REVIEWS OF PATIENT BALANCES BY PAYOR CLASSES. PERCENTAGES ARE APPLIED TO EACH PAYOR CLASS BASED ON CONTRACTUAL AGREEMENTS AND HISTORICAL COLLECTION AND RECOVERY INFORMATION TO DETERMINE THE NET REALIZABLE VALUE OF THE PATIENT RECEIVABLES. PAYMENT FOR SERVICES IS EXPECTED WITHIN THIRTY DAYS OF INITIAL BILLING. ACCOUNTS CONSIDERED PAST DUE ARE SENT TO COLLECTION AGENCIES WHEN INTERNAL COLLECTION EFFORTS HAVE BEEN UNSUCCESSFUL. ANY AMOUNTS DEEMED UNCOLLECTIBLE ARE WRITTEN OFF ON A MONTHLY BASIS. THE HOSPITAL DOES NOT CHARGE INTEREST ON OUTSTANDING BALANCES OWED. THE HOSPITAL ALSO MAINTAINS A CHARITY CARE POLICY.THE HOSPITAL PROVIDES CARE TO PATIENTS WHO MEET CERTAIN CRITERIA UNDER ITS CHARITY CARE POLICY WITHOUT CHARGE OR AT AMOUNTS LESS THAN ITS ESTABLISHED RATES. BECAUSE THE HOSPITAL DOES NOT PURSUE COLLECTION OF AMOUNTS DETERMINED TO QUALIFY AS CHARITY CARE, THEY ARE NOT REPORTED AS REVENUE. IN ADDITION, THE HOSPITAL PROVIDES A VARIETY OF COMMUNITY HEALTH SERVICES AT NO OR MINIMAL CHARGE.CHARGES EXCLUDED FROM REVENUE UNDER THE HOSPITAL'S CHARITY CARE POLICY WERE $78,529 AND $25,896 IN 2011 AND 2010, RESPECTIVELY.PART III, SECTION A, LINE 2 WAS CALCULATED AS FOLLOWS:[(OPERATING EXPENSES - BAD DEBT) / (GROSS PATIENT SERVICE REVENUE + OTHER REVENUE)] X BAD DEBT.[(12,195,654 - 429,843) / 17,203,417 + 88,982] X 429,843 = 292,467.ALL INFORMATION IS FROM THE AUDITED FINANCIAL STATEMENTS. PART III, LINE 8: "MEDICARE ALLOWABLE COSTS OF CARE" WAS CALCULATED FROM INFORMATION IN THE MEDICARE COST REPORT D, E, H & M WORKSHEETS, OR PS&R. IT DOES NOT INCLUDE ALL OF THE MEDICARE REVENUES AND COSTS. IF ALL OF THE MEDICARE REVENUES AND COSTS WERE INCLUDED, THE SHORTFALL WOULD BE GREATER THAN THAT SHOWN ON LINE 7. THE SHORTFALL REPRESENTS ACTUAL UNREIMBURSED COSTS INCURRED BY ANTELOPE MEMORIAL HOSPITAL IN PROVIDING SERVICES TO INDIVIDUALS ELIGIBLE FOR MEDICARE. THE COMMUNITY BENEFITS BECAUSE THE HOSPITAL APPLIES OTHER REVENUES TO COVER THE COSTS OF CARING FOR MEDICARE PATIENTS. PART III, LINE 9B: THE COLLECTION POLICY INCLUDES AN EXPLANATION OF ANTELOPE MEMORIAL HOSPITAL'S CHARITY CARE PROGRAM. THE PROGRAM IS CONSIDERED A "LAST RESORT FOR PATIENTS MAKING A GENUINE EFFORT TO PAY THEIR BILLS. ALL OTHER AVENUES FOR PAYMENT MUST BE EXHAUSTED (SUCH AS MEDICAID, DISABILITY, KID'S CONNECTION) BEFORE THIS PROGRAM APPLIES." REGULAR COLLECTION EFFORTS WILL BE FOLLOWED UNTIL A DETERMINATION IS MADE FROM A COMPLETED ASSISTANCE APPLICATION THAT A PATIENT QUALIFIES FOR FINANCIAL ASSISTANCE. PART V, SECTION A: ANTELOPE MEMORIAL HOSPITAL OPERATES A 25-BED CRITICAL ACCESS HOSPITAL. THE HOSPITAL ALSO OFFERS PHYSICIAN CLINICS, CARDIAC REHAB, AND HOME HEALTH. PART VI, LINE 7: NEBRASKA DOES NOT REQUIRE THE FILING OF A COMMUNITY BENEFIT REPORT WITH THE STATE. A COMMUNITY BENEFIT REPORT IS FILED ANNUALLY WITH THE NEBRASKA HOSPITAL ASSOCIATION. ALSO, A MEDICARE COST REPORT IS FILED ANNUALLY WITH NEBRASKA. PART VI, LINE 2: CURRENTLY, ANTELOPE MEMORIAL HOSPITAL DOES NOT PERFORM ANY PROCEDURES TO ASSESS THE HEALTH NEEDS OF THE COMMUNITY IT SERVES. PART VI, LINE 3: ANTELOPE MEMORIAL HOSPITAL INCLUDES ITS PAYMENT POLICY WITH ALL STATEMENTS SENT TO PATIENTS. THIS POLICY EXPLAINS OUR CHARITY CARE PROGRAM AND GIVES INSTRUCTIONS FOR THE APPLICATION PROCESS. PART VI, LINE 4: ANTELOPE MEMORIAL HOSPITAL IS THE LARGEST ACUTE CARE FACILITY SERVING THE ANTELOPE COUNTY AREA. CURRENTLY THERE ARE TWO HOSPITALS PROVIDING ACUTE CARE SERVICES WITHIN ANTELOPE COUNTY. THE HOSPITAL ALSO PROVIDES SERVICE TO THE FOLLOWING FIVE NEBRASKA COUNTIES: BOONE, HOLT, KNOX, MADISON, AND PIERCE. PART VI, LINE 6: NOT APPLICABLE. PART VI, LINE 7: ANTELOPE MEMORIAL HEALTH SYSTEM IS NOT PART OF AN AFFILIATED HEALTH CARE ORGANIZATION. X X X 0 0 0 1 0 0 0 0 0 PART I, LINE 5 PROFESSIONAL EMPLOYMENT AGREEMENTS ENTERED INTO BETWEEN THE HOSPITAL AND PHYSICIANS PROVIDES FOR AN ANNUAL INCENTIVE PAY IN WHICH THE RESPECTIVE PHYSICIAN RECEIVES A PERCENTAGE OF THE COLLECTIVE GROSS RECEIPTS FOR SERVICES PERSONALLY PERFORMED BY THAT PHYSICIAN AS LONG AS THE COLLECTIVE GROSS FEES EXCEED A SPECIFIED AMOUNT. HOSPITAL AUTH NO 1 OF ANTELOPE CTY NE 900198231 03665RBB5 2010-12-21 3770000 REFUND PRIOR ISSUE (7/1/2004) 0 0 0 3770777 363787 3770000 2006 1 0 1 1 0 0 1 0 1 0.02910 0.00000 0.02910 1 0 0 0 0 0 1 PEGGY GREEN FAMILY MEMBER OF JACK GREEN, CEO FOR ANTELOPE MEMORIAL HOSPITAL. 41629 COMPENSATION WAS PAID TO PEGGY GREEN FOR HER SERVICES AS AN EMPLOYEE OF ANTELOPE MEMORIAL HOSPTIAL. 0 FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 IS PREPARED BY A CERTIFIED PUBLIC ACCOUNTANT AND DELIVERED TO THE CHIEF FINANCIAL OFFICER. THE CFO REVIEWS FORM 990 AND PRESENTS IT AT A MONTHLY BOARD MEETING, PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C ALL OFFICERS, DIRECTORS, COMMITTEE MEMBERS, AND KEY EMPLOYEES SHALL REVIEW THE CONFLICT OF INTEREST POLICY AND COMPLETE A CONFLICT OF INTEREST QUESTIONNAIRE AND CERTIFICATION UPON INITIAL AFFILIATION WITH THE CORPORATION AND ON AN ANNUAL BASIS THEREAFTER. FORM 990, PART VI, SECTION B, LINE 15A SALARY COMPARISON DATA FROM THE NEBRASKA HOSPITAL ASSOCIATION IS USED TO COMPARE ADMINISTRATOR SALARY WITH THAT OF OTHER NEBRASKA CRITICAL ACCESS HOSPITALS. THE CHIEF EXECUTIVE OFFICER AND CHIEF FINANCIAL OFFICER SALARIES ARE DETERMINED USING THE NEBRASKA HOSPITAL ASSOCIATION SALARY SURVEYS AND ARE THEN SET BY THE BOARD OF DIRECTORS. THE BOARD MINUTES DOCUMENT THE DELIBERATIONS AND SALARY DECISIONS. FORM 990, PART VI, SECTION C, LINE 19 THE EXEMPT ORGANIZATION DOES NOT MAKE THESE DOCUMENTS AVAILABLE TO THE PUBLIC. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED GAINS ON INVESTMENTS: 18,017. OVERSIGHT OF AUDIT FORM 990, PART XI, LINE 2C THE FULL BOARD OF DIRECTORS OVERSEES SELECTION OF AN INDEPENDENT ACCOUNTANT AND THE AUDIT OF THE ANTELOPE MEMORIAL HOSPITAL'S FINANCIAL STATEMENTS. MANAGEMENT OR SERVICE CONTRACTS SCHEDULE K, PART III, #3A DURING THE APPLICABLE TAX YEAR, THE ORGANIZATION WAS PARTY TO AN AGREEMENT (THE AGREEMENT) WITH A GROUP OF ANESTHESIOLOGISTS (THE PHYSICIAN GROUP). THE AGREEMENT PERMITS MEMBERS OF THE PHYSICIAN GROUP TO UTILIZE CERTAIN PORTIONS OF THE SURGERY AREA OF THE ORGANIZATION'S HOSPITAL FACILITIES, WHICH, IN WHOLE OR IN PART, WERE FINANCED WITH THE PROCEEDS OF TAX-EXEMPT BONDS. ALTHOUGH THE TERMS OF THE AGREEMENT MAY BE SUBJECT TO MULTIPLE INTERPRETATIONS, THE AGREEMENT DID NOT FALL CLEARLY WITHIN THE SAFE HARBORS PROVIDED UNDER REVENUE PROCEDURE 97-13. ASSUMING THAT THE AGREEMENT IS A MANAGEMENT CONTRACT THAT GIVES RISE TO PRIVATE BUSINESS USE OF BOND-FINANCED FACILITIES, THE ORGANIZATION BELIEVES THAT THE AGREEMENT DID NOT GIVE RISE TO AN IMPERMISSIBLE LEVEL OF PRIVATE USE, IN THAT THE AGREEMENT (1) ONLY RELATES TO THE USE OF APPROXIMATELY 750 SQUARE FEET OF BOND-FINANCED PROPERTY OUT OF A TOTAL OF MORE THAN 25,800 SQUARE FEET (RESULTING IN USE OF LESS THAN THREE PERCENT OF THE BOND FINANCED FACILITY), (2) WAS ONLY IN EFFECT FOR A PORTION OF THE TIME THAT THE REFERENCED BONDS WERE OUTSTANDING, AND (3) USE BY THE PHYSICIAN GROUP IS NOT EXCLUSIVE AND IS IN COMMON WITH THE ORGANIZATION'S EMPLOYEES AND OTHER USERS. IN ADDITION, IT SHOULD BE NOTED THAT THE AGREEMENT EXPIRED AT THE END OF CALENDAR 2010 AND HAS SINCE BEEN REPLACED WITH A CONTRACT THE TERMS OF WHICH ARE BELIEVED BY THE ORGANIZATION TO FALL WITHIN AN APPLICABLE SAFE HARBOR OF REVENUE PROCEDURE 97-13. MANAGEMENT PRACTICES AND PROCEDURES SCHEDULE K, PART III, #7 DURING THE APPLICABLE TAX YEAR, THE ORGANIZATION CONSIDERED ITS TRANSCRIPT DOCUMENTATION (INCLUDING THE APPLICABLE TAX REGULATORY AGREEMENT) AS ITS MANAGEMENT PRACTICES AND PROCEDURES RELATING TO POST-ISSUANCE COMPLIANCE. NEW POLICIES AND PROCEDURES HAVE BEEN PREPARED AND ARE EXPECTED TO BE ADOPTED BY THE BOARD DURING THE NEXT FISCAL YEAR.