2011-05-27T10:26:01-05:00 2010-09-30 LarsonAllen LLP 600 Washington Avenue Suite 1800 St Louis MO 63101 990 2009-10-01 430662495 Hannibal Regional Hospital HANN 5732481300 6000 HOSPITAL DRIVE PO BOX 551 HANNIBAL MO 63401 Roger DIx 5732481300 2011-05-27 1 3149254300 2009 2016-02-24 21:20:13Z JOHN GROSSMEIeR 6000 HOSPITAL DRIVE PO BOX 551 HANNIBAL MO 63401 137140254 0 X WWW.HRHONLINE.ORG X 1987 MO HOSPITAL OPERATES A FULL SERVICE ACUTE CARE FACILITY 8 7 1141 250 0 0 638746 683092 102644525 109199153 -3620109 366209 1785614 1630332 101448776 111878786 0 0 58599844 63354257 0 376695 41647761 41741375 100247605 105095632 1201171 6783154 105970314 116939024 48861436 50791935 57108878 66147089 Healthier residents of our region. 0 0 86214563 110096538 The system operates a full service 105 bed acute care hospital facility in Hannibal, Missouri as its primary service activity. 24,095 total inpatient days were provided during the course of the year. The hospital provides services to patients that meet the hospital's charity care policy as well as services to other medically indigent patients under certain government-reimbursed public aid programs. The total cost of uncompensated care was, Charity Care - $4,010,948 and State Medicaid and other public aid programs - $4,849,918. 86214563 1 1 0 1 1 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 1 0 0 1 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1 1 0 0 0 1 124 0 1 1141 1 0 0 0 0 0 0 0 0 0 0 0 8 7 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 1 1 X Roger Dix 5732481300 6000 Hospital Drive Hannibal MO 63401 Gene Scholes Jr 1.00 X X 0 0 0 Robert Gilstrap 1.00 X X 0 0 0 B Stevens Plowman 1.00 X X 0 0 0 Jerry Trower 1.00 X X 0 0 0 Darren Smith 1.00 X X 0 0 0 Tom Lennon 1.00 X X 0 0 0 Gordon Spilker 1.00 X X 0 0 0 Jim Humphreys 1.00 X X 0 0 0 Timothy A Reuschel 1.00 X 0 0 0 Carolyn Shaw 1.00 X 0 0 0 Jennifer Valuck MD 1.00 X 0 0 0 Jack Whitaker 1.00 X 0 0 0 Roderick Bartlett MD 1.00 X 0 0 0 Pranav Parikh MD 1.00 X 0 0 0 Robert Chriscinske 1.00 X 0 0 0 William Craigmiles 1.00 X 0 0 0 Jill Janes PhD 1.00 X 0 0 0 Jeffry Evans MD 1.00 X 0 0 0 John Grossmeier 40.00 X 547005 0 30625 Roger Dix 40.00 X 292091 0 9770 C Todd Ahrens 40.00 X 213964 0 9747 David Hevel 40.00 X 142429 0 9936 Julie Leverenz 40.00 X 137176 0 4854 Sharon Nunley 40.00 X 206562 0 13418 Sarah Bradshaw 40.00 X 133020 0 17028 G Doug Ruble 40.00 X 116765 0 9996 Jeffrey Evans 40.00 X 81166 0 2444 Scott Siemer 40.00 X 0 0 0 Suzanne Koehler 40.00 X 0 0 0 Richard Draper 40.00 X 515762 0 11025 Dean Akerson 40.00 X 202491 0 9030 Mark Shima 40.00 X 774472 0 11025 Pervez Alvi 40.00 X 565155 0 0 Richard Valuck 40.00 X 560619 0 11025 Luvell Glanton 40.00 X 544050 0 11025 Anne Delonais-Turner 40.00 X 443704 0 11025 5476431 0 171973 53 0 1 0 Healthlink Inc PO BOX 66971 St Louis MO 63166 Insurance Provider 470663 Heimer Construction Company 6811 County Road 344 Taylor MO 63471 ConstRuction 439871 CellDox PO BOX 916 Hannibal MO 63401 Pathology Services 420762 Emercon Emergency Medical 8021 Cornell Ave St Louis MO 63130 Locum Physicians 381994 SCC Soft Computer 5400 Tech Data Drive Clearwater FL 33760 Computer Services 290423 25 683092 683092 NET PATIENT SERVICE RE 621110 109199153 109199153 109199153 611456 611456 247569 30298 217271 217271 217271 24945323 40600 25167928 63242 -222605 -22642 -245247 -22642 -222605 CHILDREN'S DEVELOPMENT 624410 615462 615462 CAFETERIA 722210 534009 534009 CONTRACTED SERVICES 621110 214201 214201 49389 90364 -40975 1413061 111878786 110096538 0 1099156 2706306 402865 2058217 245224 45351440 36330080 9006720 14640 3455338 2754500 682878 17960 8771792 6992630 1733568 45594 3069381 2445956 606386 17039 286193 286193 75000 75000 8018 6381 1637 284676 284676 11404772 9075981 2328791 1441875 1147452 294423 551941 439238 112703 64673 51467 13206 1251413 995881 255532 7650100 7650100 650690 517823 132867 Bad Debt Expense 4382214 4382214 Healthcare Purchased Se 3400198 3400198 Pharmacy Drugs 3044624 3044624 equipment rental 2535973 2018141 517832 Professional Fees 1777232 1777232 2931783 2497124 398421 36238 105095632 86214563 18504374 376695 3118750 8050601 12115408 14060513 227000 1234335 1395375 2121135 2301765 395276 549085 121200616 63527806 60241809 57672810 22590544 27374246 4153057 5307629 105970314 116939024 10048854 11248266 28293739 26918499 3725456 5136796 6793387 7488374 48861436 50791935 X 55096493 63376049 2012385 2771040 57108878 66147089 105970314 116939024 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 1 8018 0 0 0 8018 0 Part II-B, Line 1i: Explanation of Other Lobbying Activities: Lobbying activity provided through membership in the Missouri Hospital Association 1 2131 26536 51892 0 0 2172770 2172770 68457338 28908769 39548569 50259749 34619037 15640712 310759 310759 57672810 CASH 43162 F US GOVERNMENT SECURITIES 4880188 F US Coporate bonds 161102 F MUTUAL FUNDS - EQUITY SECURITIES 15028771 F MUTUAL FUNDS - FIXED INCOME 3151316 F MUTUAL FUNDS - REAL ESTATE 1096222 F ACCRUED INVESTMENT INCOME 38919 F HELD BY TRUSTEE UNDER INDENTURE AGREEMENT 2903128 F RESTRICTED BY DONOR 51892 F Held by trustee accrued investment income 19546 F 27374246 Minimum Pension Liability 5501701 Supplemental Employer Retirement Plan Liability 1986673 7488374 111878786 105095632 6783154 1954116 300941 2255057 9038211 111195694 0 111195694 683092 683092 111878786 105095632 0 105095632 0 105095632 Part X: Description of Uncertain Tax Positions Under FIN 48: The Hospital has been recognized as exempt from income taxes under Section 501 of the Internal Revenue Code and a similar provision of state law. However, the Hospital is subject to federal income tax on any unrelated business taxable income. The Hospital applies the income tax standard for uncertain tax positions. This standard clarifies the accounting for uncertainty in income taxes recognized in an organization's financial statements in accordance with the income tax standard. This standard prescribes recognition and measurement of tax positions taken or expected to be taken on a tax return that are not certain to be realized. The Hospital's income tax returns are subject to review and examination by federal, state, and local authorities. The Hospital is not aware of any activities that would jeopardize its tax-exempt status. The Hospital is not aware of any activities that are subject to tax on unrelated business income or excise or other taxes. The tax returns for the fiscal years 2008 to 2010 are open to examination by federal, local, and state authorities. Part XI, Line 8 - Other Adjustments: Change in Minimum Pension Liability: -457714. pearl lowrie fund net activity: -24405. temp. Restricted Net Assets released for Capital expenditures: -683092. Net Contribution Revenue from Foundation: 1466152. Part XII, Line 4b - Other Adjustments: NET ASSETS RELEASED FROM RESTRICTION FOR PROPERTY AND EQUIPMENT ADDITIONS: 683092. 1 1 0 0 1 1 1 0 0 4010948 4010948 0.03980 13975764 9125846 4849918 0.04820 17986712 9125846 8860866 0.08800 2365049 803706 1561343 0.01550 399048 399048 0.00400 18907 18907 0.00020 2783004 803706 1979298 0.01970 20769716 9929552 10840164 0.10770 2 920 2094634 746094 1348540 0.01340 87757 87757 0.00090 2 920 2182391 746094 1436297 0.01430 1898953 949477 34553072 45430180 -10877108 X 1 0 Hannibal Medical Supply DME Company 0.33000 0.33000 Hannibal Mobile Diagnostics Mobile imaging/radiology services 0.50000 0.50000 Hannibal Regional Hospital

6000 hospital drive hannibal MO 63401

X X X Part I, Line 3c: The criteria utilized to determine eligibility for charity care is based on the ability to pay. A person is eigible for charity care if they meet any of the following criteria : Their insurance is inadequate, if they are uninsured, if they have an income that is at or below 200% of the Federal Poverty Guideline, if their spendable income is less than 5% of the balance owed on a month-to-month basis, if their total demonstrable assets are less than $2,000 or if they are unable to borrow funds. Part I, Line 6a: Part I, Line 6a: The Missouri Hospital Association has included Hannibal Regional Hospital in their annual Community Benefit Report. Part III, Line 9b: When Charity consideration is requested all collection efforts are halted until a determination on eligibility is made. Collection efforts are resumed only if the individual does not meet one of the Charity criteria. Part VI, Line 2: The organization receives annual updates on the health status of its population from the State that include mortality and disease status. The organization also monitors national data on trends and disease status. Part VI, Line 3: The organization maintains educational programs to keep staff apprised of all potential programs that might assist patients in paying their hospital claim. Staff members are encouraged to utilize this knowledge to reconcile all outstanding balances. Part VI, Line 4: Hannibal, Marion County are rural communites of approximately 30,000 population. Also served are seven other rural counties in northeast Missouri. X X 0 1 X X X X 0 1 0 0 0 1 0 0 0 John Grossmeier 397152 0 0 0 149853 0 0 0 30625 0 577630 0 0 0 Roger Dix 219092 0 20131 0 52868 0 0 0 9770 0 301861 0 0 0 C Todd Ahrens 213964 0 0 0 0 0 0 0 9747 0 223711 0 0 0 David Hevel 116672 0 0 0 25757 0 0 0 9936 0 152365 0 0 0 Sharon Nunley 153922 0 0 0 52640 0 0 0 13418 0 219980 0 0 0 Sarah Bradshaw 133020 0 0 0 0 0 0 0 17028 0 150048 0 0 0 Richard Draper 510762 0 5000 0 0 0 0 0 11025 0 526787 0 0 0 Dean Akerson 202491 0 0 0 0 0 0 0 9030 0 211521 0 0 0 Mark Shima 774472 0 0 0 0 0 0 0 11025 0 785497 0 0 0 Pervez Alvi 565155 0 0 0 0 0 0 0 0 0 565155 0 0 0 Richard Valuck 560619 0 0 0 0 0 0 0 11025 0 571644 0 0 0 Luvell Glanton 427619 0 116431 0 0 0 0 0 11025 0 555075 0 0 0 Anne Delonais-Turner 443704 0 0 0 0 0 0 0 11025 0 454729 0 0 0 Part I, Line 1a John Grossmeier - Spouse Travel $1,284 not in taxable compensation; Gordon Spilker - Spouse Travel $540.79 no 1099; Roderick Bartlett - Spouse Travel $577.00 no 1099; Jerry Trower - Spouse Travel $743.00 sent 1099; Jeffrey Evans - Charter travel $1,227.54 not in taxable compensation; Richard Draper - Charter Travel $1,227.54 not in taxable compensation Part I, Line 1b All expenses were approved through the normal check request and expense report process which requires two signatures. CEO expenses are approved by a board member and validated by the Controller, all board member expenses are approved by the CEO and validated by the Controller, and all officer and key employee expenses are approved by the CEO and validated by the Controller or another officer. Part I, Line 4a John Grossmeier, SERP, $149,853 Roger Dix, SERP, $52,868 David Hevel, SERP, $25,757 C. Todd Ahrens, SERP, $0 Sharon Nunley, SERP, $52,640 Richard Draper, SERP, $0 Julie Levernz, SERP, $0 Dean Akerson, SERP, $0 Part I, Line 6 Dr. Glanton receives 50% of all pain medicine physician service net collections generated as a result of professional services and collected in excess of one hundred thousand dollars each year. Total Salary plus bonus not to exceed the ninetieth percentile of the prior year's range as reported for the Southern Region by the Medical Group Management Association. The industrial development authority of the city of hannibal missouri 531320446 410632AT0 2006-04-01 23725000 hospital refunding revenue bonds 0 0 The industrial development authority of the city of hannibal missouri 531320446 410632BH5 2007-08-01 8000000 er addition 0 0 The industrial development authority of the city of hannibal missouri 531320446 410632bj1 2010-07-29 7430000 Hospital Refunding of ER Addition Bonds 0 0 26630884 2144250 24075822 410812 2022 1 1 1 1 8000000 124758 7875242 2010 0 0 1 1 7863694 7743162 120532 2020 1 1 1 1 0 0 0 0 0 1 0 0 0 0 0 1 0 0 0 0 0 1 1 0 0 1 Societe Generale 15.830000000000 1 0 0 0 1 0 0 0 1 Pervez Alvi Physician Relocation X 60000 54000 0 1 1 Anne Delonais Physician Relocation X 20000 18000 0 1 1 Luvell Glanton Physician Relocation X 40000 30000 0 1 1 Richard Draper Physician Relocation X 25000 12500 0 1 1 Allen Duplantis Physician Relocation X 100000 90000 1 1 1 Mark Shima Physician Relocation X 25000 22500 0 1 1 227000 Form 990, Part VI, Section B, line 11 The prepared form 990 will be forwarded to each member of the Board of Directors, as well as the officers of the corporation approximately one week prior to a regular board meeting at which the prepared form 990 will be on the agenda. The Chief Financial Officer will present the prepared form 990 to the Board of DIrecotrs and entertain questions from directors and officers. The Chief Executive Officer and General Counsel for the corporation will also be present to assist with questions for the directors and officers. This procedure will be completed prior to the filing of the prepared form 990. Form 990, Part VI, Section B, line 12c The organization has a policy titled Business Ethics and Conflict of Interest which requires that all directors, officers, and employees of the hospital always act in the best interest of the hospital without conflicts of interest. Annually each member of the Board of Directors, each officer of the organization, and certain other managers receive a copy of the policy and are required to complete a confidentiality agreement and a conflict of interest questionnaire whereby the individual answers questions regarding family members, substantial business or investment holdings, and other transactions or affiliations with businesses or other organizations that might affect their relationship with the hospital. As part of the conflicts of interest questionnaire the individual is asked to acknowledge that they have received and read a copy of the policy, agree to comply with the policy, acknowledge that the hospital is a charitable organization, which must engage primarily in activities which accomplish our tax exempt purposes in order to maintain our tax exempt status, agree to report promptly to the Board of Directors any changes in their answers to the questions or any change in circumstance that might develop prior to the completion of their next annual questionnaire. With respect to directors of the organization, they also acknowledge that none of the conditions of the policy which would make them ineligible to remain on the board exist at the time they sign the acknowledgment and that they would report any conditions which become applicable immediately to the chairperson of the Board of Directors. On an annual basis these documents are sent by the Secretary of the Hospital to each interested person and to those employees of the Hospital that the Board determines. The document is completed by the individual and returned to the Secretary of the board through General Counsel, who annually analyzes any disclosed conflict of interest or any other fact that might make the individual not independent for IRS tax exempt purposes. The Secretary then submits to the Board of Directors a confidential report concerning any interest of employees of the Hospital disclosed by such questionnaire, any interest of directors and officers who are not employees of the hospital, and what actions the President of the organization may take as a result of any conflicts disclosed by such individuals. An individual is ineligible to serve on the Board of Directors for any of the following reasons as taken from Hannibal Regional Hospital Board of Directors Policy B-VII: a. Failure to adhere completely to disclosure requirements; b. the individual is an owner, partner, employee, board member or investor in a direct competitor of the Hospital, or any entity affiliated with the Hospital. An ownership or investment interest in a direct competitor of the Hospital, or any entity affiliated with the Hospital, of five (5) percent or less will not make individual ineligible to serve on the Board of Directors; c. The individual is an employee of the Hospital, or any entity affiliated with the Hospital, or a family member is a member of the management team of the Hospital, or any entity affiliated with the Hospital; d. The individual receives direct compensatory benefit for ongoing services provided to the Hospital, or any entity affiliated with the Hospital (serving as a "de facto employee"); e. The individual is an owner, partner, employee, board member or investor or other vendor who receives a substantial amount of revenue from the Hospital, or any entity affiliated with the hospital - the greater of $200,000.00 or 2% of the annual revenues of that vendor in the preceding or current year. f. The individual is an owner, partner, employee, board member or investor of an entity who has contracted with Hospital for the exclusive provision of any medical services within the Hospital, or its affiliates. Form 990, Part VI, Section B, line 15 The board of directors has delegated to the Compensation Committee, pursuant to a charter adopted by the board of directrors, the responsibility to act on behalf of the board of directors in administering compensation plans and making decisions on the compensation of the Chief Executive Officer and those executives who report directly to the Chief Executive Officer who qualify as "disqualified persons" within the meaning of section 4958 of the Internal Revenue Code. The committee engages an independent consultant to assist the committee with its governance and oversight role and its compliance with Section 4958 of the Internal Revenue Code, by providing an opinion on the reasonableness of the organization's compensation plan. The consultant uses published survey data to provide comparative market data for each position. The committee then reports its actions to the board of directors. The committee is composed solely of independent members of the board of directors. The scope of the committee includes, but is not limited to, reviewing and approving the annual base salary levels, annual incentive opportunity levels, executive perquisites, employment agreements, benefits and supplemental benefits. Form 990, Part VI, Section C, line 19 The articles of incorporation and amendments thereto are available on the Missouri Secretary of State's website. Form 990, Part XI, Line 2c The organization's policy regarding oversight of audit is consistent with the prior year. Form 990, Part I, Line 15 and Line 17 Employee health insurance costs for tax year 2008 were reclassified in the 2009 Form 990 to Line 15 from Line 17 to be consistent with the 2009 presentation. Form 990, Part VI, Section A In its continuing effort to better serve the residents of the Hannibal, Missouri region, a separate entity and board was previously created for the Hannibal Regional Healthcare System (HRHS) to provide the necessary oversight and to begin to foster ideas to expand the service offerings of not only the hospital, but the entire system. The hospital and HRHS boards meet and vote separately on their respective issues and several members are on both boards to provide continuity and to better share ideas. The HRHS board elects the members of the hospital board. Lanac 6000 hospital drive hannibal MO 63401 431822503 real estate MO 0 0 N/A Hannibal Regional Hospital Foundation 175 shinn lane hannibal MO 63401 431658744 fundraising MO 501(c)(3) Line 11a, Type 1 Hannibal Mobile Diagnostics PO Box 1254 Hannibal MO 63401 300234397 imaging MO N/A 49896 448 0 0 Hannibal regional physician hospital organization inc 6500 hospital drive hannibal MO 64301 431706291 Physician Hospital Organization MO C 6071 149950 0.50000 1 1 1 0 0 0 0 0 0 0 1 1 1 1 1 1 0 0 Hannibal regional hospital foundation C 683092 Hannibal regional physician hospital organization inc B 88200 Hannibal regional physician hospital organization inc A 6071