Instructions for Schedule H (Form 990)

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1 2011 Instructions for Schedule H (Form 990) Hospitals Department of the Treasury Internal Revenue Service Contents Page requirements a hospital organization Purpose of Schedule General Instructions... 1 must meet to qualify for tax exemption Hospital organizations use Schedule H Purpose of Schedule... 1 under section 501(c)(3) in tax years (Form 990) to provide information on the Who Must File... 1 beginning after March 23, These activities and policies of, and community Specific Instructions; Part I. additional requirements address a benefit provided by, its hospital facilities Financial Assistance and hospital organization s financial and other non-hospital health care Certain Other Community assistance policy, policy relating to facilities that it operated during the tax Benefits at Cost... 2 emergency medical care, billing and year. This includes facilities operated Part II. Community Building collections, and charges for medical care. either directly or indirectly through Activities... 4 Also, for tax years beginning after March disregarded entities or joint ventures. Part III. Bad Debt, Medicare, & 23, 2012, the Affordable Care Act requires hospital organizations to conduct Who Must File Collection Practices... 5 community health needs assessments. Part IV. Management An organization that answered Yes on Companies and Joint Ventures... 6 Form 990, Part IV, line 20a must Because section 501(r) requires a complete and attach Schedule H to Form Part V. Facility Information... 6 hospital organization to meet these 990. Part VI. Supplemental requirements for each of its hospital Information... 9 facilities, Part V, Facility Information, has Schedule H (Form 990) must be Worksheet 1. Financial completed by a hospital organization been expanded to include a Section A, Assistance at Cost that operated during the tax year at least Hospital Facilities. In this new section a one hospital facility. A hospital facility is Worksheet 2. Ratio of Patient hospital organization must list its hospital one that is required to be licensed, Care Cost to Charges facilities; that is, its facilities that at any registered, or similarly recognized by a Worksheet 3. Unreimbursed time during the tax year, were required to state as a hospital. Medicaid and Other be licensed, registered, or similarly Means-Tested Government recognized as a hospital under state law. The organization must file a single Part V also includes Section B, Facility Schedule H (Form 990) that combines Programs Policies and Practices, for reporting of information from: Worksheet 4. Community Health Improvement Services and information on policies and practices 1. Hospital facilities directly operated Community Benefit Operations addressed in section 501(r). The hospital by the organization. Worksheet 5. Health Professions organization must complete a separate 2. Hospital facilities operated by Section B for each of its hospital facilities disregarded entities of which the Education listed in Section A. organization is the sole member. Worksheet 6. Subsidized Health 3. Other health care facilities and Services The community health needs programs of the hospital organization or Worksheet 7. Research assessment requirements of section any of the entities described in 1 or 2, Worksheet 8. Cash and In-Kind 501(r)(3) are effective for tax years even if provided separately from the Contributions for Community beginning after March 23, hospital s license. Benefit Accordingly, the questions in Part V, 4. Hospital facilities and other health Section B, about community health needs care facilities and programs operated by What s New assessments (lines 1 through 7) are any joint venture treated as a optional for any tax year beginning before partnership, to the extent of the hospital Future developments. The IRS has March 24, organization s proportionate share of the created a page on IRS.gov for information joint venture. about Form 990 and its instructions, at Section 6033(b)(15)(B) also requires Information about hospital organizations to submit a copy of Proportionate share is defined as the any future developments affecting Form their audited financial statements to the ending capital account percentage listed 990 (such as legislation enacted after IRS. Accordingly, a hospital organization on the Schedule K-1 (Form 1065), publication of Schedule H) will be posted that is required to file Form 990 must Partner s Share of Income, Deductions, on that page. attach a copy of its most recent audited Credits, etc., Part II, line J, for the Section references are to the Internal financial statements for the tax year to its partnership tax year ending in the Revenue Code unless otherwise noted. Form 990 (see instructions for Form 990, organization s tax year being reported on Part IV, line 20b). the organization s Form 990. If Schedule K-1 (Form 1065) is not available, the General Instructions Section C, Part V, requires an organization can use other business Note. Terms in bold are defined in the Glossary of the Instructions for Form 990. Background. The Patient Protection and Affordable Care Act (Affordable Care Act), enacted March 23, 2010, Pub. L. No , added section 501(r) to the Code. Section 501(r) includes additional organization list all of its non-hospital health care facilities that it operated during the tax year, whether or not such facilities were required to be licensed or registered under state law. The organization should not complete Part V, Section B, for any of these non-hospital facilities. records to make a reasonable estimate, including the most recently available Schedule K-1 (Form 1065), adjusted as appropriate to reflect facts known to the organization, or information used for purposes of determining its proportionate share of the venture for the organization s financial statements. Jan 17, 2012 Cat. No B

2 5. In the case of a group return filed organization (for example, part of an the organization s hospital facilities use by the hospital organization, hospital affiliated health care system). the same financial assistance policy. facilities operated directly by members of If an organization is not required to file Generally tailored to individual hospitals the group exemption included in the Form 990 but chooses to do so, it must means that the majority of the group return, hospital facilities operated file a complete return and provide all of organization s hospital facilities use by a disregarded entity of which a the information requested, including the different financial assistance policies. If member included in the group return is required schedules. the organization operates only one the sole member, hospital facilities hospital facility, check Applied uniformly operated by a joint venture treated as a An organization that does not operate to all hospitals. partnership to the extent of the group one or more facilities that satisfy the Line 3. Answer lines 3a, 3b, and 3c member s proportionate share definition of hospital facility, above, based on the financial assistance (determined in the manner described in 4, should not file Schedule H (Form 990). eligibility criteria that apply to (1) the earlier), and other health care facilities or The definition of hospital for largest number of the organization s programs of a member included in the TIP Schedule A (Form 990), Public patients based on patient contacts or group return even if such programs are Charity Status and Public Support, encounters or (2) if the organization does provided separately from the hospital s Part I, line 3, and the definition of hospital not operate its own hospital facility, the license. for Schedule H (Form 990) are not the largest number of patients of a hospital same. Accordingly, an organization that facility operated by a joint venture in Example. The organization is the checks box 3 in Part I of Schedule A which the organization has an ownership sole member of a disregarded entity. The (Form 990) to report that it is a hospital or interest. For example, if the organization disregarded entity owns 50% of a joint cooperative hospital service organization, has two hospital facilities, use the venture treated as a partnership. The must complete and attach Schedule H to financial assistance eligibility criteria used partnership in turn owns 50% of another Form 990 only if it meets the definition of by the hospital facility which has the most joint venture treated as a partnership that hospital facility for purposes of patient contacts or encounters during the operates a hospital and a freestanding Schedule H (Form 990), as explained tax year. outpatient clinic that is not part of the above. Line 3a. Federal Poverty Guidelines hospital s license. (Assume the (FPG) are the Federal Poverty Guidelines proportionate shares of the partnerships established by the U.S. Department of based on capital account percentages Health and Human Services. If the listed on the partnerships Schedule K-1 Specific Instructions organization has established a family or (Form 1065), Part II, line J, are also 50%.) The organization would report 25% (50% of 50%) of the hospital s and outpatient clinic s combined information on Schedule H (Form 990). household income threshold that a patient must meet or fall below to qualify for free medical care, check the box in the Yes column and indicate the specific threshold by checking the appropriate box. For instance, if a patient s family or household Part I. Financial Assistance and Certain Other Community Benefits Note that while information from all the at Cost income must be less than or equal to above sources is combined for purposes of Schedule H (Form 990), the Part I requires reporting of financial 250% of FPG for the patient to qualify for organization is required to report each of assistance policies, the availability of free care, then check the box marked its hospital facilities in Part V, Sections community benefit reports, and the cost of Other and enter 250%. A and B, whether operated directly by the certain financial assistance and other Line 3b. If the organization has organization or indirectly through a community benefit programs. Worksheets established a family or household income disregarded entity or joint venture treated and accompanying instructions are threshold that a patient must meet or fall as a partnership. In addition, the provided at the end of the instructions to below to qualify for discounted medical organization must list in Part V, Section this schedule to assist in completing the care, check the box in the Yes column C, each of its other health care facilities table in Part I, line 7. and indicate the specific threshold by (for example, rehabilitation clinics, other Line 1. A financial assistance policy, checking the appropriate box. outpatient clinics, diagnostic centers, sometimes referred to as a charity care Line 3c. If applicable, describe the skilled nursing facilities, long-term acute policy, is a policy describing how the other income-based criteria, asset test, or care facilities that it operated during the organization will provide financial other means test or threshold for free or tax year), whether operated directly by assistance at its hospital(s) and other discounted care in Part VI, line 1 of this the organization or indirectly through a facilities, if any. Financial assistance schedule. An asset test includes (i) a disregarded entity or a joint venture includes free or discounted health limit on the amount of total or liquid treated as a partnership. services provided to persons who meet assets that a patient or the patient s the organization s criteria for financial family or household can own for the Organizations are not to report assistance and are unable to pay for all or patient to qualify for free or discounted information from hospitals located outside a portion of the services. Financial care, and/or (ii) a criterion for determining the United States in Parts I, II, III, or V. assistance does not include: bad debt or the level of discounted medical care Information from foreign joint ventures uncollectible charges that the patients can receive, depending on the and partnerships must be reported in Part organization recorded as revenue but amount of assets that they and/or their IV, Management Companies and Joint wrote off due to a patient s failure to pay, families or households own. Ventures. Information concerning foreign or the cost of providing such care to such hospitals and facilities can be described Line 4. Medically indigent means patients; the difference between the cost in Part VI. persons whom the organization has of care provided under Medicaid or other determined are unable to pay some or all Except as provided in Part IV, do not means-tested government programs or of their medical bills because their report on Schedule H (Form 990) under Medicare and the revenue derived medical bills exceed a certain percentage information from an entity organized as a therefrom; or contractual adjustments with of their family or household income or separate legal entity from the organization any third-party payors. assets (for example, due to catastrophic and treated as a corporation for federal Line 2. Check only one of the three costs or conditions), even though they income tax purposes (except for boxes. Applied uniformly to all hospitals have income or assets that otherwise members of a group exemption included means that all of the organization s exceed the generally applicable eligibility in a group return filed by the hospital facilities use the same financial requirements for free or discounted care organization), even if such entity is assistance policy. Applied uniformly to under the organization s financial affiliated with or otherwise related to the most hospitals means that the majority of assistance policy. -2-

3 Line 5. Answer lines 5a, 5b, and 5c services, health professions education, directly related to the actual conduct of based on the organization s budgeted subsidized health services, research, etc.) each activity or program. Indirect costs amounts under its financial assistance to be reported on lines 7a through 7k. means costs that are shared by multiple policy. activities or programs, such as facilities If the organization completed Line 5a. Answer Yes, if the and administration costs related to the TIP worksheets other than on an a organization established or had in place organization s infrastructure (space, combined basis (for example, at any time during the tax year an annual utilities, custodial services, security, facility by facility, joint venture by joint or periodic budgeted amount of free or information systems, administration, venture), the organization should combine discounted care to be provided under its materials management, and others). all information from these worksheets for financial assistance policy. If No, skip to purposes of reporting amounts on the line 6a. Column (d). Direct offsetting table. Only the portion of each joint revenue means revenue from the activity Line 5b. Answer Yes, if the free or venture or partnership that represents during the year that offsets the total discounted care the organization provided the organization s proportionate share, community benefit expense of that in the applicable period exceeded the based on capital interest, can be reported activity, as calculated on the worksheets budgeted amount of costs or charges for on lines 7a through 7k (see Purpose of for each line item. Direct offsetting that period. If No, skip to line 6a. Schedule for instructions on aggregation). revenue includes any revenue generated Line 5c. Answer Yes, if the Use the organization s most accurate by the activity or program, such as organization denied financial assistance costing methodology (cost accounting payment or reimbursement for services to any patient eligible for free or system, cost-to-charge ratio, or other) to provided to program patients. Direct discounted care under its financial calculate the amounts reported on the offsetting revenue does not include assistance policy or under any of its table. If the organization uses a restricted or unrestricted grants or hospital facilities financial assistance cost-to-charge ratio, it can use Worksheet contributions that the organization uses to policies solely because the organization s 2. Ratio of Patient Care Cost to Charges, provide a community benefit. or the facility s financial assistance budget for this purpose. See the instructions for was exceeded. Part VI, line 1, regarding an explanation Example. The organization receives of the costing methodology used to a restricted grant from an unrelated Line 6. Answer lines 6a and 6b based calculate the amounts reported on the organization that must be used by the on the community benefit report that the organization prepared for the organization table. organization to provide financial as a whole during the tax year. assistance. The amount of the restricted If the organization included any costs grant is not reportable as direct offsetting Line 6a. Answer Yes if the for a physician clinic as subsidized health revenue on line 7a, column (d). organization prepared a written report services on Part I, line 7g, report these during the tax year that describes the costs on Part VI, line 1. Column (e). Net community benefit organization s programs and services that expense is Total community benefit promote the health of the community or If the organization included any bad expense (column (c)) minus Direct communities served by the organization. debt expense on Form 990, Part IX, line offsetting revenue (column (d)). If the If the organization s community benefit 25 but subtracted this bad debt for calculated amount is less than zero, report is contained in a report prepared by purposes of calculating the amount report the amount as a negative number. a related organization, answer Yes reported on line 7f, report this bad debt and identify the related organization in expense on Part VI, line 1. Column (f). Percent of total Part VI, line 1. If No, skip to line 7. Do not report bad debt expense on expense is the net community benefit Line 6b. Answer Yes if the lines 7a through 7k. expense in column (e) divided by the organization made the community benefit sum of the amount on Form 990, Part IX, report it prepared during the tax year The following are descriptions of the line 25, column (A) including the available to the public. type of information reported in each organization s proportionate share of total column of the table. expenses of all joint ventures in which it Some of the ways in which an has an ownership interest (see Appendix Column (a). Number of activities or TIP organization can make its F). Report the percentage to two decimal programs means the number of the community benefit report available places (x.xx%). If the net community organization s activities or programs to the public are to post the report on the conducted during the year that involve the benefit expense in column (e) is a organization s website, to publish and community benefit reported on the line. negative number, report -0- in column (f) distribute the report to the public by mail Report each activity and program on only rather than a negative percentage. Any or at its facilities, or to submit the report to one line so that it is not counted more bad debt expense included in the a state agency or other organization that than once. Reporting in this column is denominator should be removed before makes the report available to the public. optional. calculation, and the amount of bad debt expense that was included on Form 990, Lines 7a through 7k. Report on the Column (b). Persons served means Part IX, line 25, column (A) but removed table (lines 7a through 7k), at cost, the the number of patient contacts or from this figure should be reported in Part organization s financial assistance and encounters in accordance with the filing VI, line 1. certain other community benefits. Report organization s records. Persons served on line 7i contributions that the can be reported in multiple rows, as organization restricts to one or more of Column (f) percent of total services across different categories may the community benefit activities listed in TIP expense is based on column (e) be provided to the same patient. lines 7a through 7h. Do not report such net community benefit expense, Reporting in this column is optional. contributions on lines 7a through 7h. To rather than column (c) total community calculate the amounts to be reported on Column (c). Total community benefit benefit expense. Organizations that the table, use the worksheets or other expense means the total gross expense report amounts of direct offsetting equivalent documentation that of the activity incurred during the year, revenue also might wish to report total substantiates the information reported calculated by using the pertinent community benefit expense (Part I, line 9, consistent with the methodology used on worksheets for each line item. Total column (c)) as a percentage of total the worksheets. See the instructions to community benefit expense includes expenses. Although this percentage the worksheets for definitions of the both direct costs and indirect costs. cannot be reported in Part I, line 7, various types of community benefit (for Direct costs means salaries and column (f), it can be reported on Schedule example, community health improvement benefits, supplies, and other expenses H (Form 990), Part VI, line

4 Optional Worksheets for Part VI how its community building activities promote the health of the Part I, Line 7 (Financial communities it serves. cannot include on this line or in this part Assistance and Certain expenditures made to reduce the If the filing organization makes a grant environmental hazards caused by, or the return of which the organization is also a member. Similarly, the organization Other Community Benefits to an organization to be used to environmental impact of, its own accomplish one of the community building activities, or those of its disregarded At Cost) activities listed in this part, then the entities, joint ventures, or group Worksheets 1 through 8 are intended to organization should include the amount of exemption members, unless the assist the organization in completing the grant on the appropriate line in Part II. expenditures are for an environmental Schedule H (Form 990), Part I, lines 7a If the organization makes a grant to a improvement activity that (i) is provided through 7k. Use of the worksheets is not joint venture in which it has an for the primary purpose of improving required and they should not be filed with ownership interest to be used to community health; (ii) addresses an Form 990. The organization can use accomplish one of the community building environmental issue known to affect alternative equivalent documentation, activities listed in this part, report the community health; and (iii) is subsidized provided that the methodology described grant on the appropriate line in Part II, but by the organization at a net loss. Such in these instructions (including the do not include in Part II the organization s expenditures may not be reported on this instructions to the worksheets) is proportionate share of the amount spent line if the organization engages in the followed. Regardless of whether the by the joint venture on such activities, to activity primarily for marketing purposes. worksheets or alternative equivalent avoid double counting. Do not include any documentation is used to compile and contribution made by the organization that Line 5. Leadership development and report the required information, such was funded in whole or in part by a training for community members documentation must be retained by the restricted grant, to the extent that such includes, but is not limited to, training in organization to substantiate the grant was funded by a related conflict resolution; civic, cultural, or information reported on Schedule H organization. language skills; and medical interpreter (Form 990). The worksheets or alternative skills for community residents. equivalent documentation are to be Line 1. Physical improvements and completed using the organization s most housing include, but are not limited to, Line 6. Coalition building includes, but accurate costing methodology, which can the provision or rehabilitation of housing is not limited to, participation in include a cost accounting system, for vulnerable populations, such as community coalitions and other cost-to-charge ratios, a combination removing building materials that harm the collaborative efforts with the community to thereof, or some other method. health of the residents, neighborhood address health and safety issues. improvement or revitalization projects, Line 7. Community health improvement If the organization is filing a group provision of housing for vulnerable advocacy includes, but is not limited to, return or has a disregarded entity or an patients upon discharge from an inpatient efforts to support policies and programs ownership interest in one or more joint facility, housing for low-income seniors, to safeguard or improve public health, ventures, the organization may find it and the development or maintenance of access to health care services, housing, helpful to complete the worksheets parks and playgrounds to promote the environment, and transportation. separately for the organization and for physical activity. each disregarded entity, joint venture in Line 8. Workforce development which the organization had an ownership Line 2. Economic development can includes, but is not limited to, recruitment interest during the tax year, and group include, but is not limited to, assisting of physicians and other health affiliate. In that case, the organization small business development in professionals to medical shortage areas should combine all information from the neighborhoods with vulnerable or other areas designated as worksheets for purposes of completing populations and creating new underserved, and collaboration with line 7. Complete the table by combining employment opportunities in areas with educational institutions to train and recruit ing amounts from the organization s high rates of joblessness. health professionals needed in the worksheets, amounts from disregarded Line 3. Community support can community (other than the health entities or group affiliates, and amounts include, but is not limited to, child care professions education activities reported from joint ventures that are attributable to and mentoring programs for vulnerable in Part I, line 7f). the organization s proportionate share of each joint venture, under the aggregation populations or neighborhoods, Line 9. Other refers to community instruction in Purpose of Schedule. neighborhood support groups, violence building activities that protect or improve prevention programs, and disaster the community s health or safety that are See Worksheets 1 through 8 and readiness and public health emergency not described in the categories listed in specific instructions for the worksheets activities, such as community disease lines 1 through 8 above. later in these instructions. surveillance or readiness training beyond what is required by accrediting bodies or Refer to the instructions to Part I, line government entities. 7, columns (a) through (f), for descriptions Part II. Community of the types of information that should be Line 4. Environmental improvements reported in each column of Part II. Building Activities include, but are not limited to, activities to Report in this part the costs of the address environmental hazards that affect If the organization is filing a group organization s activities that it engaged in community health, such as alleviation of return or has a disregarded entity or an during the tax year to protect or improve water or air pollution, safe removal or ownership interest in one or more joint the community s health or safety, and that treatment of garbage or other waste ventures, the organization may find it are not reportable in Part I of this products, and other activities to protect helpful to complete Part II separately for schedule. Some community building the community from environmental itself and for each disregarded entity, joint activities may also meet the definition of hazards. The organization cannot include venture in which the organization had an community benefit. Do not report in Part II on this line or in this part expenditures ownership interest during the tax year, community building costs that are made to comply with environmental laws and group affiliate. The organization reported on Part I, line 7 as community and regulations that apply to activities of should combine the amounts from all benefit (costs of a community health itself, its disregarded entity or entities, a such tables, according to the combined improvement service reportable on Part I, joint venture in which it has an instructions in Purpose of Schedule, and line 7e). An organization that reports ownership interest, or a member of a include the combined information in Part information in this Part II must describe in group exemption included in a group II. -4-

5 Part III. Bad Debt, organization accounts for discounts and payments on patient accounts in Medicare, & Collection determining bad debt expense. Advantage IME), Medicare Practices 2. Describe the methodology used to including payments for indirect medical education (IME) (except for Medicare disproportionate share hospital (DSH) determine the amount reported on line 3. revenue, coinsurance, patient Section A. In this section (a) report 3. Describe the rationale, if any, for deductibles, outliers, capital, bad debt, combined bad debt expense; (b) provide including any portion of bad debt as and any other amounts paid to the an estimate of how much bad debt community benefit. organization on the basis of its Medicare expense, if any, reasonably could be 4. Provide the footnote from the Cost Report. Do not include revenue attributable to persons who likely would organization s financial statements on related to subsidized health services as qualify for financial assistance under its bad debt expense, if applicable, or the reported in Part I, line 7g (see Worksheet financial assistance policy; and (c) footnotes related to accounts receivable, 6), or direct graduate medical education provide a rationale for what portion of bad allowance for doubtful accounts, or (GME) as reported in Part I, line 7f (see debt, if any, the organization believes is similar designations. If the footnote or Worksheet 5). If the organization has community benefit. In addition, the footnotes address only the filing more than one Medicare provider organization must report whether it has organization s bad debt expense or number, combine the revenue attributable adopted Healthcare Financial accounts receivable, allowance for to costs reported on the Medicare Cost Management Association Statement No. doubtful accounts, or similar Reports submitted under each provider 15, Valuation and Financial Statement designations, provide the exact wording number, and report the combined Presentation of Charity Care and Bad of the footnote or footnotes. revenues on line 5. Debts by Institutional Healthcare If the organization s financial statements Line 6. Enter all Medicare allowable Providers ( Statement 15 ) and provide include a footnote on these issues that costs reported in the organization s the text of its footnote, if applicable, to its also includes other information, report in Medicare Cost Report(s), except those audited financial statements that Part VI only the relevant portions of the already reported in Part I, line 7g describes the bad debt expense. footnote. If the organization is a member (subsidized health services) and costs Line 1. Indicate if the organization of a group with consolidated financial associated with direct GME already reports bad debt expense in accordance statements, the organization can reported in Part I, line 7f (health with Statement 15. summarize that portion, if any, of the professions education). This can be footnote or footnotes that apply. If the determined using Worksheet A. If Note. Statement 15 has not been organization s financial statements do not Worksheet A is not used, the organization adopted by the AICPA. The IRS does not include a footnote that discusses bad still must subtract the costs attributable to require organizations to adopt Statement debt expense, accounts receivable, subsidized health services and direct 15 or use it to determine bad debt allowance for doubtful accounts, or GME from the Medicare allowable costs it expense or financial assistance costs. similar designations, include a statement enters on line 6. If the organization has Some organizations may rely on in Part VI that the organization s audited more than one Medicare provider Statement 15 in reporting bad debt financial statements do not include a number, it should combine the costs expense and financial assistance in their footnote discussing these issues and reported in the Medicare Cost Reports audited financial statements. Statement explain how the organization s financial submitted under each provider number 15 provides instructions for statements account for bad debt, if at all. and report the combined costs on line 6. recordkeeping, valuation, and disclosure for bad debts. Section B. In this section report (a) Worksheet A (optional) Line 2. Use the most accurate combine allowable costs to provide Complete Worksheets 5 and 6 before system and methodology available to the services reimbursed by Medicare, (b) completing this Worksheet A. organization to report bad debt expense. combine Medicare reimbursements If only a portion of a patient s bill for attributable to such costs, and (c) 1. Total Medicare allowable costs services is written off as a bad debt, combine Medicare surplus or shortfall. (from Medicare Cost Report) $ include only the proportionate amount Include in Section B only those allowable 2. Total Medicare allowable costs attributable to the bad debt. Include the costs and Medicare reimbursements that (from line 1) included in organization s proportionate share of the are reported in the organization s Worksheet 6, line 3, col. (A) $ bad debt expense of joint ventures in Medicare Cost Report(s) for the year, 3. Total Medicare allowable costs which it had an ownership interest during including its share of any such allowable (from line 1) included in the tax year. costs and reimbursement from Worksheet 5, line 8 (direct disregarded entities and joint ventures GME)... $ Line 3. Provide an estimate of the in which it has an ownership interest. The 4. Total adjustments to Medicare amount of bad debt reported on line 2 that organization should in Part VI describe allowable costs (add lines 2 reasonably is attributable to patients who what portion of its Medicare shortfall, if and 3)... $ likely would qualify for financial 5. Total Medicare allowable costs any, it believes should constitute assistance under the hospital s financial (line 1 minus line 4). community benefit, and explain its assistance policy as reported in Part I, Enter this value in Part III, line rationale for its position. As described $ lines 1 through 4, but for whom below, the organization also can enter in insufficient information was obtained to Part VI the amount of any Medicare Line 7. Subtract line 6 from the determine their eligibility. Do not include revenues and costs not included in its amount on line 5. If line 6 exceeds line 5, this amount in Part I, line 7. Medicare Cost Report(s) for the year, and report the excess (the shortfall) as a Organizations can use any reasonable can enter a reconciliation of the amounts negative number. methodology to estimate this amount, reported in Section B (including the Line 8. Check the box that best such as record reviews, an assessment of surplus or shortfall reported on line 7) and describes the costing methodology used financial assistance applications that were the total revenues and costs attributable to determine the Medicare allowable denied due to incomplete documentation, to all of the organization s Medicare costs reported in the organization s analysis of demographics, or other programs. Medicare Cost Report(s), as reflected on analytical methods. Line 5. Enter all net patient service line 6. Describe this methodology in Part Line 4. In Part VI: revenue (for Medicare fee for service VI. 1. Describe the methodology used in (FFS) patients) associated with allowable The organization must also describe in determining the amount reported on line 2 costs the organization reports in its Part VI its rationale for treating the as bad debt, including how the Medicare Cost Report(s) for the year, amount reported in Part III, line 7, or any -5-

6 portion of it, as a community benefit. An treated as a partnership or a corporation), Column (a). Enter the full legal name of organization s rationale must have a including joint ventures outside of the the entity. reasonable basis. Do not include this United States, of which the organization Column (b). Describe the primary amount in Part I, line 7. Do not include is a partner or shareholder, business activity or activities conducted any Medicare-related expenses or 1. In which persons described in 1a by the management company, joint revenue properly reported in Part I, line and/or 1b below owned, in the aggregate, venture, or separate entity. 7g or any Medicare-related expenses or more than 10% of the share of profits of revenue reported in Part I, line 7f in Part Column (c). Enter the organization s such partnership or LLC interest, or stock III, Section B. percentage share of profits in the of the corporation: partnership or LLC, or stock in the entity Lines 5, 6, and 7 do not include a. Persons who were officers, that is owned by the organization. TIP certain Medicare program directors, trustees, or key employees Column (d). Enter the percentage share revenues and costs, and thus of the organization at any time during the of profits or stock in the entity owned by cannot reflect all of the organization s organization s tax year, and all of the organization s current officers, revenues and costs associated with its b. Physicians who were employed as directors, trustees, or key employees. participation in Medicare programs. The physicians by, or had staff privileges with, organization can describe in Part VI the one or more of the organization s Column (e). Enter the percentage share Medicare revenues and costs not hospitals; and of profits or stock in the entity owned by included in its Medicare Cost Report(s) all physicians who are employees 2. That either: for the year (for example, revenues and practicing as physicians or who have staff a. Provided management services costs for freestanding ambulatory surgery privileges with one or more of the used by the organization in its provision of centers, physician services billed by the organization s hospitals. medical care, or organization, clinical laboratory services, b. Provided medical care, or owned or If a physician described above is also and revenues and costs of Medicare Part provided real property, tangible personal a current officer, director, trustee, or key C and Part D programs). The organization property, or intangible property used by employee of the organization, include his can enter in Part VI, line 1 a reconciliation the organization or by others to provide or her profits or stock percentage in of amounts reportable in Section B medical care. column (d). Do not include this in column (including the surplus or shortfall reported (e). on line 7) and all of the organization s Examples of such joint ventures and Part IV can be duplicated if more total revenues and total expenses management companies include: space is needed to list additional attributable to Medicare programs. An ancillary joint venture formed by the management companies and joint If the organization received any prior organization and its officers or physicians ventures. year settlements for Medicare-related to conduct an exempt or unrelated services in the current tax year, it can business activity, Part V. Facility Information provide an explanation in Part VI, line 1. A company owned by the organization In Part V, the organization must list all of Section C. In this section report the and its officers or physicians that owns its hospital facilities in Section A, organization s written debt collection and leases to the organization a hospital complete a separate Section B for each of policy. or other medical care facility, and its hospital facilities listed in Section A, Line 9a. Answer Yes if the A company that owns and leases to and list its non-hospital health care organization had a written debt collection entities other than the organization facilities in Section C. policy on the collection of amounts owed diagnostic equipment or intellectual Section A. Complete Part V, Section A, by patients during its tax year. property used to provide medical care. by listing all of the organization s hospital For purposes of Line 9a, a written facilities that it operated during the tax For purposes of Part IV, ownership debt collection policy includes a written year. List these facilities in order of size interests can be direct or indirect. For billing and collections policy, or in the from largest to smallest, measured by a example, if a joint venture reported in Part case of an organization that does not reasonable method (for example, the IV is owned, in part, by a physician group have a separate written billing and number of patients served or total practice owned by staff physicians of the collections policy, a written financial revenue per facility). Hospital facilities organization s hospital, report the assistance policy that includes the actions are facilities that, at any time during the physicians indirect ownership interest in the organization may take in the event of tax year, were required to be licensed, the joint venture in proportion to their non-payment, including collection actions registered, or similarly recognized as a ownership share of the physician group and reporting to credit agencies. hospital under state law. A hospital facility practice. Line 9b. Answer Yes if the is operated by an organization whether organization s written debt collection Note. Do not include publicly traded the facility is operated directly by the policy that applied to the facilities that entities or entities whose sole income is organization or indirectly through a served the largest number of the passive investment income from interest disregarded entity or joint venture organization s patients during the tax or dividends. treated as a partnership. For each year contained provisions for collecting hospital facility, list its name and address For purposes of Part IV, the aggregate amounts due from those patients who the and check the applicable column(s). percentage share of profits or stock organization knows qualify for financial Licensed hospital is a facility ownership percentage of officers, assistance. If the organization answers licensed, registered, or similarly directors, trustees, key employees, and Yes, describe in Part VI the collection recognized by a state as a hospital. physicians who are employed as practices that it follows for such patients, physicians by, or have staff privileges General medical and surgical refers whether or not such practices apply with, one or more of the organization s to a hospital primarily engaged in specifically to such patients or more hospitals is measured as of the earlier of providing diagnostic and medical broadly to also cover other types of the close of the tax year of the treatment (both surgical and nonsurgical) patients. organization or the last day the to inpatients with a wide variety of organization was a member of the joint medical conditions, and that may provide Part IV. Management venture. All stock, whether common or outpatient services, anatomical pathology Companies and Joint preferred, is considered stock for services, diagnostic X-ray services, purposes of determining the stock clinical laboratory services, operating Ventures ownership percentage. Provide all the room services, and pharmacy services. List any management company, joint information requested below for each Children s hospital is a center for venture, or other separate entity (whether such entity. provision of health care to children, and -6-

7 includes independent acute care facility will be required to conduct a identified in its most recently conducted children s hospitals, children s hospitals Needs Assessment at least once every Needs Assessment. If the hospital facility within larger medical centers, and three years, and adopt an implementation addressed the needs identified in its most independent children s specialty and strategy to meet the community health recently conducted Needs Assessment by rehabilitation hospitals. needs identified through such means other than those listed in lines 6a Teaching hospital is a hospital that assessment. through 6h, check the box for line 6i, provides training to medical students, Line 1. Answer Yes if the hospital Other, and describe these means in Part interns, residents, fellows, nurses, or facility conducted a Needs Assessment VI. If the hospital facility has not other health professionals and providers, in the current tax year or in any prior tax addressed any of the needs identified in provided that such educational programs year. If Yes, indicate what the Needs its most recently conducted Needs are accredited by the appropriate national Assessment describes by checking all Assessment, skip to line 7. accrediting body. applicable boxes. If the Needs Line 6a. Check this box if the hospital Critical access hospital (CAH) is a Assessment describes information that facility adopted an implementation hospital designated as a CAH by a state does not have a corresponding checkbox, strategy that addresses each of the that has established a State Medicare check line 1j, Other, and describe this community health needs identified Rural Hospital Flexibility Program in information in Part VI. If No, skip to line through the Needs Assessment by either accordance with Medicare rules. 8. (1) describing how the facility plans to Line 1i. Information gaps that limit meet the health need; or (2) identifying Research facility is a facility that the hospital facility s ability to assess the health need as one the hospital facility conducts research. the community s health needs are areas does not intend to meet, and explaining ER 24 hours refers to a facility that where additional information is needed to why the hospital facility does not intend to operates an emergency room 24 hours a assess whether a particular health need meet that health need. day, 365 days a year. exists. Line 6b. Check the box if the hospital ER other refers to a facility that Line 3. If Yes, describe in Part VI facility has begun, continued, or operates an emergency room for periods how the hospital facility took into account completed execution of its implementation less than 24 hours a day, 365 days a input from persons who represent the strategy. year. community served by the hospital facility, Line 6c. Check this box if the hospital Complete the Other (Describe) including a description of how it consulted facility collaborated with others in the column for each hospital facility that the with these persons (whether through hospital facility s community to develop a organization operates that is not meetings, focus groups, interviews, written description of the activities that described in the other columns of Part V, surveys, written correspondence, etc.). hospital facilities and other community Section A. Identify in Part VI any organizations and groups and public health agencies plan to In the upper left hand corner of the other groups that the hospital facility undertake collectively to address specific Part V, Section A table, list the total consulted in conducting its most recent health needs in their community. number of hospital facilities that the Needs Assessment. Individual members Line 6d. Check this box if the organization operated during the tax year. of community forums, focus groups, hospital facility collaborated with others If the organization needs additional survey groups, and similar groups do not in the hospital facility s community to space to list all of its hospital facilities, it need to be listed. carry out activities that hospital facilities should duplicate Section A and use as Line 4. Answer Yes, if the hospital and other community groups and public many duplicate copies of Section A as facility s Needs Assessment was health agencies planned to undertake needed, number each page, and conducted with one or more other hospital collectively to address specific health renumber the line numbers in the left facilities. One or more other hospital needs in their community. hand margin (an organization with 15 facilities includes related and unrelated Line 7. Answer Yes, if the hospital facilities should renumber lines 1-5 on the hospital facilities. If Yes, list in Part VI facility took action to address all of the 2nd page as lines 11-15). the other hospital facilities with which the needs identified in its most recently Section B. Section B requires reporting hospital facility conducted its Needs conducted Needs Assessment. If No, on a hospital facility by hospital facility Assessment. explain in Part VI which community health basis. The organization must complete Line 5. Answer Yes, if the hospital needs the hospital facility did not take Section B for each of its hospital facilities facility made its most recently conducted action to address and the reasons why it listed in Section A. At the top of Section Needs Assessment widely available to did not take action to address such B, list the name of the hospital facility and the public. If Yes, indicate how the needs. For example, a hospital facility its line number from Section A. hospital facility made the Needs might identify limited financial or other Assessment widely available to the public resources as reasons why it did not take References in these Section B by checking all applicable boxes. If the action to address a need identified in its instructions to a hospital facility taking a hospital facility made the Needs most recently conducted Needs certain action mean that the organization Assessment widely available to the public Assessment. took action through or on behalf of the hospital facility. by means other than those listed in lines Lines 8 through 14. See the 5a and 5b, check line 5c, Other, and instructions for Part I, Line 1 of Schedule Lines 1 through 7. These lines are describe these means in Part VI. H (Form 990) for the definition of optional for tax year A community Line 5a. Check this box if the Needs financial assistance policy. health needs assessment ( Needs Assessment ) is an assessment of the Assessment was made available on the Line 8. Answer Yes, if, during the tax health needs of the community. To meet hospital facility s website or the hospital year, the hospital facility had a written the requirements of section 501(r)(3), organization s website. This box may also financial assistance policy that explains which is effective for tax years beginning be checked if the hospital facility made its eligibility criteria for financial assistance, after March 23, 2012, a Needs Needs Assessment available on a and whether such assistance includes Assessment must take into account input website established and maintained by free or discounted care. from persons who represent the broad another entity. If line 5a is checked, list in Line 9. See the instructions for Part I, interests of the community served by the Part VI the direct website address, or url, Line 3a of Schedule H (Form 990), for the hospital facility, including those with where the Needs Assessment can be definition of Federal Poverty Guidelines special knowledge of or expertise in accessed. (FPG). Answer Yes, if, during the tax public health, and must be made widely Line 6. Check all applicable boxes for year, the hospital facility had a written available to the public. Once section lines 6a through 6h to show how the financial assistance policy that used FPG 501(r)(3) is effective, each hospital hospital facility addressed the needs for determining eligibility for free medical -7-

8 care, and show the specific threshold by hospital facility publicized the policy by the facility s FAP. If Yes, indicate the writing in the percentage amount. If No, checking all applicable boxes. If the actions the hospital facility or an explain in Part VI what criteria the hospital hospital facility publicized the policy within authorized third party performed before facility used to determine eligibility for free the community served by the hospital making reasonable efforts to determine care, or state that the hospital facility did facility by means that are not listed in the individual s eligibility under the not provide any free care. lines 13a-13f, check line 13g, Other, and facility s FAP by checking all applicable Line 10. See the instructions for Part I, describe in Part VI how the financial boxes. If the hospital facility or an Line 3a of Schedule H (Form 990) for the assistance policy was publicized within authorized third party performed actions definition of Federal Poverty Guidelines the community served by the hospital similar to those listed in lines 16a through (FPG). Answer Yes, if, during the tax facility. 16d before making reasonable efforts to year, the hospital facility had a written Line 13g. Other measures to determine the individual s eligibility under financial assistance policy that used FPG publicize the policy within the community the facility s FAP, answer Yes, check for determining eligibility for discounted served by the hospital facility may the box for line 16e, Other similar medical care, and show the specific include, but are not limited to, having actions, and describe those actions in threshold by writing in the percentage registration personnel refer uninsured Part VI. amount. If No, explain in Part VI what and/or low income patients to financial Line 17. Indicate which efforts the criteria the hospital facility used to counselors to discuss the policy. Check hospital facility took before initiating any determine eligibility for discounted care, the box for line 13g if, instead of the of the actions checked in lines 16a or state that the hospital facility did not detailed policy, the hospital facility through 16d or described in Part VI by provide any discounted care. provided a summary of the policy in a checking all applicable boxes in lines 17a Line 11. Answer Yes, if, during the manner listed in lines 13a-f. through 17d. If the hospital facility made tax year, the hospital facility had a Line 14. Answer Yes, if, during the efforts other than those listed in lines 17a written financial assistance policy that tax year, the hospital facility had either through 17d before initiating any of the explained the basis for calculating a separate written billing and collections actions checked in lines 16a through 16d amounts charged to patients. If Yes, policy or a written financial assistance or described in Part VI, check the box for indicate the factors used in calculating policy ( FAP ) that explained actions the line 17e, Other, and describe in Part VI. amounts charged to patients, including hospital facility may take upon If the hospital facility made no such factors used in determining eligibility for non-payment under its policy, including, efforts before initiating any of the actions any discounts, by checking all applicable but not limited to, the actions listed in checked in lines 16a through 16d or boxes. If the hospital facility calculated lines 15 and 16, if applicable. described in Part VI, check the box for amounts charged to patients using factors Lines 15 and 16. Other similar line 17e, Other, and state in Part VI that other than those listed in lines 11a actions do not include sending the the hospital facility made no such efforts. through 11g, check the box for line 11h, patient a bill. Other, and describe these factors in Part Line 17c. The term communications VI. Note: Section 501(r)(6) requires a includes, but is not limited to, in-person hospital facility to forego extraordinary interactions, telephone calls, and Line 11a. Check this box if the collections actions before the facility has invoices. hospital facility used the income level of made reasonable efforts to determine the patients, patients families, or patients Line 18. Answer Yes, if, during the patient s eligibility under the facility s FAP. guarantors as a factor in calculating tax year, the hospital facility had in No inference should be made regarding amounts charged to patients. place a written policy about emergency whether the actions listed in lines 15a medical care that required the hospital Line 11b. Check this box if the through 15d, 16a through 16d, or facility to provide, without discrimination, hospital facility used the asset level of described in Part VI as other similar care for emergency medical conditions to patients, patients families, or patients actions, are extraordinary collection individuals without regard to their guarantors as a factor in calculating actions. eligibility under the hospital facility s amounts charged to patients. Line 15. Indicate what actions against financial assistance policy. If No, Line 11c. Check this box if the a patient the hospital facility was indicate the reasons why the hospital hospital facility considered whether permitted to take during the tax year facility did not have a written patients were medically indigent, as under its policies before making nondiscriminatory policy relating to defined in the instructions for Part I, Line reasonable efforts to determine the emergency medical care by checking all 4 of Schedule H (Form 990), in patient s eligibility under the facility s FAP applicable boxes. If the reason the calculating amounts charged to patients by checking all applicable boxes. If a hospital facility did not have a written during the tax year. hospital facility s policies permitted the nondiscriminatory policy relating to facility to take an action or actions against Line 11d. Check this box if the emergency medical care is not listed in a patient during the tax year similar to hospital facility used the insurance lines 18a through 18c, check line 18d, those listed in lines 15a through 15d status of patients, patients families, or Other, and describe the reason(s) in before making reasonable efforts to patients guarantors as a factor in Part VI. determine the patient s eligibility under calculating amounts charged to patients. The hospital facility may check Yes if the facility s FAP, check line 15e, Other Line 11h. Other factors used in it had a written policy that required similar actions, and describe those determining amounts charged to patients compliance with 42 U.S.C. 1395dd actions in Part VI. may include, but are not limited to, the (Emergency Medical Treatment and Line 15e. If the organization checked amount budgeted for financial assistance. Active Labor Act ( EMTALA)). line 15e, describe the other similar Line 12. Answer Yes, if, during the actions that the hospital facility was For purposes of line 18, the term tax year, the hospital facility had a permitted to take under its policies during emergency medical conditions means: written financial assistance policy that the tax year before making reasonable explained the method for applying for efforts to determine the individual s (A) a medical condition manifesting itself financial assistance. eligibility under the hospital facility s FAP. by acute symptoms of sufficient severity Line 13. Answer Yes, if, during the Line 16. Answer Yes if the hospital (including severe pain) such that the tax year, the hospital facility had a facility or an authorized third party absence of immediate medical attention written financial assistance policy that performed any of the actions listed in could reasonably be expected to result included measures to publicize the policy lines 16a through 16d during the tax year in-- within the community served by the before making reasonable efforts to 1. placing the health of the individual hospital facility. If Yes, indicate how the determine the individual s eligibility under (or, for a pregnant woman, the health of -8-

9 the woman or her unborn child) in serious operated directly by the organization or Part I, line 7. Provide an explanation jeopardy, indirectly through a disregarded entity or of the costing methodology used to 2. serious impairment to bodily joint venture treated as a partnership. calculate the amounts reported in the functions, or List each of these facilities in order of size table. If a cost accounting system was 3. serious dysfunction of any bodily from largest to smallest, measured by a used, indicate whether the cost organ or part; or reasonable method (for example, the accounting system addresses all patient number of patients served or total segments (for example, inpatient, (B) for a pregnant woman who is revenue per facility). For each outpatient, emergency room, private having contractions-- non-hospital health care facility, list its insurance, Medicaid, Medicare, 1. that there is inadequate time to name and address and describe the type uninsured, or self pay). Also, indicate if a effect a safe transfer to another hospital of facility. These types of facilities may cost-to-charge ratio was used for any of before delivery, or include, but are not limited to, the figures in the table. Describe whether 2. that transfer may pose a threat to rehabilitation and other outpatient clinics, this cost-to-charge ratio was derived from the health or safety of the woman or the diagnostic centers, long-term acute care Worksheet 2, Ratio of Patient Care unborn child. facilities, and skilled nursing facilities. Cost-to-Charges, and, if not, what kind of In the upper left hand corner of the cost-to-charge ratio was used and how it Lines 19-21: For purposes of lines Part V, Section C table, list the total was derived. If some other costing 19-21, the term FAP-eligible means number of non-hospital health care methodology was used besides a cost eligible for assistance under the hospital facilities that the organization operated accounting system, cost-to-charge ratio, facility s financial assistance policy. during the tax year. or a combination of the two, describe the Line 19. Indicate how the hospital method used. facility determined, during the tax year, If the organization needs additional Part II. Describe how the the maximum amounts that can be space to list all of its non-hospital health organization s community building charged to FAP-eligible individuals for care facilities, it should duplicate Section activities, as reported in Part II, promote emergency or other medically necessary C and use as many duplicate copies of the health of the community or care by checking the appropriate box. Section C as needed, number each page, communities the organization serves. and renumber the line numbers in the left Note: Under Section 501(r)(5), the hand margin (for example, an Part III, line 4. Describe the maximum amounts that can be charged organization with 15 such facilities should methodology used to determine the to FAP-eligible individuals for emergency renumber lines 1-5 on the 2nd page as amount in Part III, line 2, including how or other medically necessary care are the lines 11-15). the organization accounts for discounts amounts generally billed to individuals and payments on patient accounts in who have insurance covering such care. determining bad debt expense. Part VI. Supplemental Line 20. Answer Yes, if, during the Describe the methodology used to tax year, the hospital facility charged Information determine the amount reported on line 3. any FAP-eligible individual to whom the Use Part VI to provide the narrative Also describe the rationale, if any, for hospital facility provided emergency or explanations required by the following including any portion of bad debt as other medically necessary services more questions, and to supplement responses community benefit. than the amounts generally billed to to other questions on Schedule H (Form Also provide, if applicable, the text of individuals who had insurance covering 990). Identify the specific part, section, the footnote to the organization s financial such care. If Yes, explain in Part VI. and line number that the response statements that describes bad debt The hospital facility may check No supports, in the order in which they expense. If the organization s financial if it charged more than the amounts appear on Schedule H (Form 990). Part statements include a footnote on these generally billed to individuals who had VI can be duplicated if more space is issues that also includes other insurance covering such care to an needed. information, report only the relevant individual whom the hospital facility did Line 1. Provide the following portions of the footnote. If the not know was FAP-eligible at the time of supplemental information: organization s financial statements do not billing, if the hospital facility corrected the contain such a footnote, enter that the bill within a reasonable period of time Part I, line 3c. If applicable, describe organization s financial statements do not after learning the individual was eligible. the income-based criteria for determining include such a footnote, and explain how eligibility for free or discounted care under Line 21. Answer Yes, if, during the the financial statements account for bad the organization s financial assistance tax year, the hospital facility charged debt, if at all. policy. Also describe whether the any of its FAP-eligible individuals an organization uses an asset test or other Part III, line 8. Describe the costing amount equal to the gross charge for any threshold, regardless of income, to methodology used to determine the service provided to that individual, and determine eligibility for free or discounted Medicare allowable costs reported in the explain in Part VI the circumstances in care. organization s Medicare Cost Report, as which it used gross charges. A bill that reflected in the amount reported in Part itemizes a reduction applied to a gross Part I, line 6a. If the organization s III, line 6. Describe, if applicable, the charge for a service does not need to be community benefit report is in a report extent to which any shortfall reported in reported if the amount charged to the prepared by a related organization, and Part III, line 7, should be treated as a individual for such service is less than the not in a separate report prepared by the community benefit, and the rationale for amount of the gross charge. organization, identify the related the organization s position. organization. The hospital facility may check No if Part III, line 9b. If the organization it charged gross charges to an individual Part I, line 7g. If applicable, describe has a written debt collection policy and the hospital facility did not know was if the organization included as subsidized answered Yes, to Part III, line 9b, FAP-eligible at the time of billing, if the health services any costs attributable to a describe the collection practices in the hospital facility corrected the bill within a physician clinic, and report such costs the policy that apply to patients who it knows reasonable period of time after learning organization included. qualify for financial assistance, whether the individual was eligible. Part I, line 7, column (f). If the practices apply specifically to such Section C. Complete Part V, Section C, applicable, enter the bad debt expense patients or also cover other types of by listing all of the non-hospital health included on Form 990, Part IX, line 25, patients. care facilities that the organization column (A), (but subtracted for purposes Part V, Section B. Identify the operated during the tax year. A facility is of calculating the percentage in this specific hospital facility name and line operated by an organization whether it is column.) number (from Schedule H (Form 990), -9-

10 Part V, Section A), to which each set of permitted to take under its policies during taking into account the geographic responses relates. For instance, if the the tax year before making reasonable service area(s) (urban, suburban, rural, organization reported five hospital efforts to determine the individual s etc.), the demographics of the community facilities in Part V, Section A, it should list eligibility under the facility s FAP. or communities (population, average the first facility s name and number (1) as Line 16e: If the organization checked income, percentages of community a heading, followed by the responses to line 16e, describe the other similar residents with incomes below the federal applicable Part V, Section B, questions actions that the hospital facility or an poverty guideline, percentage of the for that facility, followed by four additional authorized third party performed during hospital s and community s patients who headings and sets of responses for each the tax year before making reasonable are uninsured or Medicaid recipients, of the other four hospital facilities listed in efforts to determine the individual s etc.), the number of other hospitals Part V, Section A. eligibility under the facility s FAP. serving the community or communities, Line 17e: If the organization checked and whether one or more Line 1j: If the organization checked line line 17e, describe the other efforts that federally-designated medically 1j, describe the other content included in the hospital facility made or state that the underserved areas or populations are the hospital facility s Needs Assessment. facility made no such efforts before present in the community. Line 3: If the organization checked initiating any of the actions checked in Yes, describe how the hospital facility Line 5. Provide any other information line 16 or described in Part VI. took into account input from persons who important to describing how the Line 18d: If the organization checked represent the community served by the organization s hospitals or other health line 18d, describe the other reasons why hospital facility. Include a description of care facilities further its exempt purpose the hospital facility did not have a written how the organization consulted with these by promoting the health of the community nondiscriminatory policy for emergency persons (whether through meetings, or communities, including but not limited medical care. focus groups, interviews, surveys, written to whether: Line 19d: If the organization checked correspondence, etc.). Identify any A majority of the organization s line 19d, explain what other means the organizations and other groups that the governing body is comprised of persons hospital facility used to determine the hospital facility consulted in conducting its who reside in the organization s primary maximum amounts that can be charged most recent Needs Assessment. service area who are neither employees to FAP-eligible individuals for emergency Individual members of community forums, nor independent contractors of the or other medically necessary care. focus groups, survey groups, and similar organization, nor family members Line 20: If the organization checked groups do not need to be listed. thereof; Yes to line 20, explain. Line 4: If the organization checked The organization extends medical staff Line 21: If the organization checked Yes, list the other hospital facilities with privileges to all qualified physicians in its Yes, to line 21, explain the which the hospital facility conducted its community for some or all of its circumstances in which the hospital Needs Assessment. departments; and facility charged any FAP-eligible Line 5a: If line 5a is checked, list the How the organization applies surplus individual an amount equal to the gross direct website address, or url, where the funds to improvements in patient care, charge for any service provided to that Needs Assessment can be accessed. medical education, and research. individual. Line 5c: If the organization checked line Line 6. If the organization is part of an 5c, describe the other means that the Line 2. Describe whether, and, how the affiliated health care system, describe the hospital facility used to make its Needs organization assesses the health care roles of the organization and its affiliates Assessment widely available. needs of the community or communities it in promoting the health of the serves, in addition to any community Line 6i: If the organization checked line communities served by the system. For health needs assessment reported in Part 6i, describe the other ways that the purposes of this question, an affiliated V, Section B. hospital facility addressed the needs health care system is a system that identified in its most recently conducted Line 3. Describe how the organization includes affiliates under common Needs Assessment. informs and educates patients and governance or control, or that cooperate Line 7: If the organization checked persons who are billed for patient care in providing health care services to their No, to line 7, explain which needs about their eligibility for assistance under community or communities. identified in the hospital facility s most federal, state, or local government Line 7. Identify all states with which the recently conducted Needs Assessment programs or under the organization s organization files (or a related that it did not action to address, and financial assistance policy. For example, organization files on its behalf) a why it did not take action to address such enter whether the organization posts its community benefit report. Report only needs. financial assistance policy, or a summary those states in which the organization s Line 9: If the organization checked thereof, and financial assistance contact own community benefit report is filed, No, explain what criteria the hospital information in admissions areas, either by the organization itself or by a facility used to determine eligibility for free emergency rooms, and other areas of the related organization on the organization s care, or state that the hospital facility did organization s facilities where eligible behalf. not provide any free care. patients are likely to be present; provides Line 10: If the organization checked a copy of the policy, or a summary No, explain what criteria the hospital thereof, and financial assistance contact information to patients as part of the Worksheet 1. Financial facility used to determine eligibility for discounted care, or state that the hospital intake process; provides a copy of the Assistance at Cost (Part I, facility did not provide any discounted policy, or a summary thereof, and financial assistance contact information to Line 7a) care. Line 11h: If the organization checked patients with discharge materials; Worksheet 1 can be used to calculate the line 11h, describe the other factor(s) that includes the policy, or a summary thereof, organization s financial assistance the hospital facility used in calculating along with financial assistance contact (sometimes referred to as charity care ) amounts charged to patients. information, in patient bills; or discusses at cost reported on Part I, line 7a. Refer to Line 13g: If the organization checked with the patient the availability of various instructions for Part I for the definition of line 13g, describe other ways that the government benefits, such as Medicaid or financial assistance. hospital facility publicized its financial state programs, and assists the patient Line 1. Enter the gross patient charges assistance policy. with qualification for such programs, written off to financial assistance under Line 15e: If the organization checked where applicable. the organization s financial assistance line 15e, describe the other similar Line 4. Describe the community or policies. Gross patient charges means actions that the hospital facility was communities the organization serves, the total charges at the organization s full -10-

11 established rates for the provision of reimbursement rate or through direct as nonpatient food sales, supplies sold to patient care services before deductions appropriation). nonpatients, and medical records from revenue are applied. Line 6. Revenue from uncompensated abstracting. The cost of nonpatient care care pools or programs means payments activities does not include any total Line 3. Multiply line 1 by line 2, or enter received from a state, including Upper community benefit expense reported on estimated cost based on the Payment Limit (UPL) funding and Worksheets 1 through 8. organization s cost accounting methodology. Organizations with a cost Medicaid DSH funds, as direct offsetting If the organization is unable to accounting system or a cost accounting revenue for financial assistance or to establish the cost associated with method more accurate than the ratio of enhance Medicaid reimbursement rates nonpatient care activities, use other patient care cost to charges from for DSH providers. If such payments are operating revenue from its most recent Worksheet 2 can rely on that method to primarily to offset the cost of Medicaid audited financial statement as a proxy for estimate financial assistance cost. services, then report this amount on these costs. This proxy assumes no Worksheet 3, line 7, column (A). If the markup exists for other operating revenue Line 4. Enter the Medicaid/provider primary purpose of the payments has not compared to the cost of nonpatient care taxes, fees, and assessments paid by the been made clear by state regulation or activities. Alternatively, if other operating organization, if payments received from law, then the organization can allocate revenue provides a markup compared to an uncompensated care pool or DSH the payments proportionately between the cost of nonpatient care activities, the program in the organization s home state Worksheet 1, line 6, and Worksheet 3, organization can assume such a markup are intended primarily to offset the cost of line 7, column (A) based on a reasonable exists when completing line 2. financial assistance. If the payments are estimate of which portions are intended Line 3. Enter the Medicaid provider primarily intended to offset the cost of for financial assistance and Medicaid, taxes, fees, and assessments paid by the Medicaid services, then report this respectively. organization included on line 1, so this amount on Worksheet 3, line 4, column expenditure is not double-counted when (A). If the primary purpose of the taxes or Worksheet 2. Ratio of the ratio of patient care cost to charges is payments has not been made clear by Patient Care Cost to applied. state regulation or law, then the organization can allocate the taxes or Line 4. Enter the sum of the total Charges payments proportionately between community benefit expenses reported on Worksheet 1, line 4, and Worksheet 3, Worksheet 2 can be used to calculate the Part I, lines 7e, 7f, 7h, and 7i, column (c), line 4, column (A) based on a reasonable organization s ratio of patient care cost to so these expenses are not estimate of which portions are intended charges. double-counted when the ratio of patient for financial assistance and Medicaid, Line 1. Enter the organization s total care cost to charges is applied. respectively. Medicaid provider taxes operating expenses (excluding bad debt Also include in line 4 the total means amounts paid or transferred by the expense) from its most recent audited community benefit expense reported on organization to one or more states as a financial statements. Part I, lines 7a, 7b, 7c, and 7g, column mechanism to generate federal Medicaid Line 2. Enter the cost of nonpatient care (c), if the organization has not relied on DSH funds (the cost of the tax generally activities. Nonpatient care activities the ratio of patient care cost to charges is promised back to organizations either include health care operations that from this worksheet to determine these through an increase in the Medicaid generate other operating revenue such expenses, but rather has relied on a cost Worksheet 1. Financial Assistance at Cost (Part I, line 7a) Keep for Your Records Gross patient charges 1. Amount of gross patient charges written off under financial assistance policies Total community benefit expense 2. Ratio of patient care cost to charges (from Worksheet 2, if used) Estimated cost (multiply line 1 by line 2, or obtain from cost accounting) Medicaid provider taxes, fees, and assessments Total community benefit expense (add lines 3 and 4; enter on Part I, line 7a, column (c)) 5. Direct offsetting revenue 6. Revenue from uncompensated care pools or programs Other direct offsetting revenue Total direct offsetting revenue (add lines 6 and 7; enter on Part I, line 7a, column (d)) Net community benefit expense (subtract line 8 from line 5; enter on Part I, line 7a, column (e)) Total expense (enter amount from Form 990, Part IX, Line 25, column (A), including the organization s share of joint venture expenses, and excluding any bad debt expense included in Part IX, line 25) Percent of total expense (divide line 9 by line 10; enter on Part I, line 7a, column (f)) % -11-

12 accounting system or other cost Line 1, column (B). Enter the amount of pool, UPL program, or Medicaid DSH accounting method to estimate costs of gross patient charges for other program in the organization s home state financial assistance, Medicaid or other means-tested government programs. are intended primarily to offset the cost of means-tested government programs, or Line 3, column (A). Enter the estimated Medicaid services. If such payments are subsidized health services. cost for Medicaid services. Multiply line 1, primarily intended to offset the cost of column (A) by line 2, column (A), or enter financial assistance, then report this Line 5. Enter the gross expense of estimated cost based on the amount on Worksheet 1, line 4. If the community building activities reported in organization s cost accounting system or primary purpose of such taxes or Part II of Schedule H (Form 990). method. Organizations with a cost payments has not been made clear by Line 9. Enter the gross patient charges accounting system or a cost accounting state regulation or law, then the for any community benefit activities or method more accurate than the ratio of organization can allocate portions of such programs for which the organization has patient care cost to charges from taxes or payments proportionately not relied on the ratio of patient care cost Worksheet 2 can rely on that system or between Worksheet 1, line 4, and to charges from this worksheet to method to estimate the cost of Medicaid Worksheet 3, line 4, column (A), based on determine the expenses of such activities services. Organizations relying on a cost a reasonable estimate of which portions or programs. For example, if the accounting system or method other than are intended for financial assistance and organization uses a cost accounting the ratio of patient care cost to charges Medicaid, respectively. system or another cost accounting from Worksheet 2 should use care not to method to estimate total community double-count community benefit Line 6, column (A). Enter the net benefit expense for Medicaid or any other expenses fully accounted for elsewhere patient service revenue for Medicaid means-tested government programs, on Schedule H (Form 990) Part I, line 7, services, including revenue associated enter gross charges for those programs in such as the cost of health professions with Medicaid recipients enrolled in line 9. education, community health managed care plans. Do not include improvement services, community benefit Medicaid reimbursement for direct operations, subsidized health services, graduate medical education (GME) costs, Worksheet 3. and research. which should be reported on Worksheet 5, line 9. Include Medicaid reimbursement Unreimbursed Medicaid Line 3, column (B). Enter the estimated for indirect GME costs, including the and Other Means-Tested cost for services provided to patients who receive health benefits from other GME. The direct portion of children s Government Programs means-tested government programs. health GME should be reported on (Part I, lines 7b and 7c) Line 4, column (A). Enter the Medicaid Worksheet 5, line 10. Also include indirect IME portion of children s health Worksheet 3 can be used to report the provider taxes, fees, and assessments Medicaid disproportionate share hospital net cost of Medicaid and other paid by the organization if payments (DSH) revenue and UPL funding. Net means-tested government programs. A received from an uncompensated care patient service revenue means payments means-tested government program is a government program for which eligibility depends on the recipient s income or Worksheet 2. Ratio of Patient Care Cost to asset level. Charges (can be used for other Medicaid means the United States worksheets) Keep for Your Records health program for individuals and families with low incomes and resources. Other means-tested government programs means government-sponsored Patient care cost health programs where eligibility for benefits or coverage is determined by 1. Total operating expense income or assets. Examples include: The State Children s Health Insurance Less adjustments Program (SCHIP), a United States 2. Nonpatient care activities federal government program that gives funds to states in order to provide health 3. Medicaid provider taxes, fees, and insurance to families with children; and assessments Other federal, state, or local health care 4. Total community benefit expense programs. Report Medicaid and other 5. Total community building expense means-tested government program revenues and expenses from all states, 6. Total adjustments (add lines 2 through 5) not just from the organization s home state. 7. Adjusted patient care cost (subtract line 6 from line 1) Patient care charges Line 1, column (A). Enter the gross patient charges for Medicaid services. Include gross patient charges for all 8. Gross patient charges Medicaid recipients, including those Less: adjustments enrolled in managed care plans. In certain states, SCHIP functions as an expansion 9. Gross charges for community benefit programs of the Medicaid program, and reimbursements from SCHIP are not 10. Adjusted patient care charges (subtract line 9 from line 8) distinguishable from regular Medicaid Calculation of ratio of patient care costs to reimbursements. Hospitals that cannot charges distinguish their SCHIP reimbursements from their Medicaid reimbursements can 11. Ratio of patient care cost to charges (divide line 7 by line 10; report SCHIP charges, costs, and report on the applicable lines of Worksheets 1, 3, or 6) % offsetting revenue under column (A). -12-

13 expected to be received from patients or services. If such payments are primarily improvement services and community third-party payers for patient services intended to offset the cost of charity care, benefit operations. performed during the year. Net patient then report this amount on Worksheet 1, service revenue also includes revenue line 6. If the primary purpose of such Community health improvement recorded in the organization s audited payments has not been made clear by services means activities or programs, financial statements for services state regulation or law, then the subsidized by the health care performed during prior years. organization can allocate the payments organization, carried out or supported for Organizations can enter in Part VI the proportionately between Worksheet 1, the express purpose of improving amount of prior year Medicaid revenue line 6, and Worksheet 3, line 7, column community health. Such services do not included in Part I, line 7b. (A), based on a reasonable estimate of generate inpatient or outpatient bills, Amounts received from the Medicaid which portions are intended for financial although there may be a nominal patient program as reimbursement for direct assistance and Medicaid, respectively. fee or sliding scale fee for these services. GME or IME should be treated the way the Medicaid program in the hospital s Worksheet 4. Community Community benefit operations means: home state classifies the funds. Health Improvement Line 7, column (A). Enter revenue activities associated with community received from uncompensated care pools Services and Community health needs assessments or programs if payments received from an Benefit Operations (Part I, community planning and uncompensated care pool, UPL program, administration, and Line 7e) or Medicaid DSH program in the the organization s activities associated organization s home state are intended Worksheet 4 can be used to report the with fundraising or grant-writing for primarily to offset the cost of Medicaid net cost of community health community benefit programs. Worksheet 3. Unreimbursed Medicaid and Other Means-Tested Government Programs (Part I, lines 7b and 7c) Keep for Your Records (A) Medicaid (B) Other means-tested government programs Gross patient charges 1. Gross patient charges from the programs Total community benefit expense 2. Ratio of patient care cost to charges (from Worksheet 2, if used) % % 3. Cost (multiply line 1 by line 2, or obtain from cost accounting) Medicaid provider taxes, fees, and assessments Total community benefit expense Total community benefit expense (add lines 3 and 4; enter amount from column (A) on Part I, line 7b, column (c); and enter amount from column (B) on Part I, line 7c, column (c)) Direct offsetting revenue 6. Net patient service revenue Payments from uncompensated care pools or programs Other revenue Total direct offsetting revenue (add lines 6 through 8; enter amount from column (A) on Part I, line 7b, column (d) and enter amount from column (B) on Part I, line 7c, column (d)) Net community benefit expense (subtract line 9 from line 5; enter amount from column (A) on Part I, line 7b, column (e); enter amount from column (B) on Part I, line 7c, column (e)) Total expense (enter amount from Form 990, Part IX, line 25, Column (A), including the organization s share of joint venture expenses, and excluding any bad debt expense included in Part IX, line 25, in both columns (A) and (B)) Percent of total expense (line 10 divided by 11; enter amount from column (A) on Part I, line 7b, column (f); enter amount from column (B) on Part I, line 7c, column (f)) 12. % % -13-

14 Worksheet 4. Community Health Improvement Services and Community Benefit Operations (Part I, line 7e) Keep for Your Records (C) Net community (A) benefit Total (B) expense community Direct (subtract col. benefit offsetting (B) from col. (A) expense revenue for lines 1 5) 1. Community health improvement services a. 1a. b. 1b. c. 1c. d. 1d. e. 1e. f. 1f. g. 1g h. 1h. i. 1i. j. 1j. 2. Worksheet subtotal (add lines 1a through 1j) Community benefit operations a. 3a. b. 3b. c. 3c. d. 3d. 4. Worksheet subtotal (add lines 3a through 3d) Worksheet total (add lines 2 and 4; enter amounts from columns (A), (B), and (C) on Part I, line 7e, columns (c), (d), and (e), respectively) Total expense (enter amount from Form 990, Part IX, Line 25, column (A), including the organization s share of joint venture expenses, and excluding any bad debt expense included in Part IX, line 25) Percent of total expense (line 5, column (C) divided by line 6; enter amount on Part I, line 7e, column (f) Activities or programs cannot be licensure or accreditation, or restricted to A community health needs assessment reported if they are provided primarily for individuals affiliated with the organization developed or accessed by the marketing purposes and the program is (employees and physicians of the organization. more beneficial to the organization than to organization). Documentation that demonstrated the community. For example, if the activity or program is designed primarily To be reported, community need for community need or a request from a to increase referrals of patients with the activity or program must be public agency or community group was third-party coverage, required for established. Community need can be the basis for initiating or continuing the demonstrated through the following. activity or program. -14-

15 The involvement of unrelated, collaborative tax-exempt or government Worksheet 5. Health Professions Education organizations as partners in the activity or (Part I, line 7f) Keep for Your Records program. Community benefit activities or programs also seek to achieve objectives, Total community benefit expense including improving access to health services, enhancing public health, 1. Medical students advancing increased general knowledge, 2. Interns, residents, and fellows and relief of a government burden to improve health. This includes activities or 3. Nurses programs that do the following. 4. Other allied health professions, students Are available broadly to the public and serve low-income consumers. 5. Continuing health professions education Reduce geographic, financial, or cultural barriers to accessing health services, and it ceased to exist would result in access problems (for example, longer wait times or increased travel distances). Address federal, state, or local public health priorities such as eliminating disparities in health care among different populations. Leverage or enhance public health department activities such as childhood immunization efforts. 6. Other students Total community benefit expense (add lines 1 through 6; enter on Part I, line 7f, column (c)) Direct offsetting revenue 8. Medicare reimbursement for direct GME Medicaid reimbursement for direct GME Continuing health professions education reimbursement/ tuition Other revenue Total direct offsetting revenue (add lines 8 through 11; enter on Part I, line 7f, column (d)) Otherwise would become the responsibility of government or another 13. Net community benefit expense (line 7 minus line 12; tax-exempt organization. enter on Part I, line 7f, column (e)) Advance increased general knowledge through education or research that benefits the public. 14. Total expense (enter amount from Form 990, Part IX, line 25, column (A), including the organization s share of joint venture expenses, and excluding any bad debt expense included in Part IX, line 25) Totals Lines 1a through 1j, column (A). Enter the name of each reported community Percent of total expense health improvement activity or program 15. (line 13 divided by line 14; enter amount on Part I, line and total community benefit expense for 7f, column (f)) % each. Include both direct costs and indirect costs in total community benefit expense. Use additional worksheets if the organization reports more than 10 community health improvement activities or programs. Lines 3a through 3d, column (A). Enter the name of each reported community benefit operations activity or program and total community benefit expense for each. Include both direct costs and indirect costs in total community benefit expense. Use additional worksheets if the organization reports more than four community benefit operations activities or programs. Report total community benefit expense, direct offsetting revenue, and net community benefit expense for each line item. Health professions education means educational programs that result in a degree, certificate, or training necessary to be licensed to practice as a health professional, as required by state law, or continuing education necessary to retain state license or certification by a board in the individual s health profession specialty. It does not include education or training programs available exclusively to the organization s employees and medical staff or scholarships provided to those individuals. However, it does include education programs if the primary purpose of such programs is to educate health professionals in the broader community. Costs for medical residents and interns can be included, even if they are considered employees for purposes of Form W-2, Wage and Tax Statement. Examples of health professions education activities or programs that should and should not be reported are as follows. Worksheet 5. Health Professions Education (Part I, Line 7f) Worksheet 5 can be used to report the net cost of health professions education. -15-

16 Activity or Example 4. and continuing health professions in Part III. Losses attributable to these Program Report Rationale education open to all qualified individuals items are also excluded when measuring in the community, including payment for the losses generated by the subsidized Scholarships Yes More benefit development of online or other health services. In addition, in order to for community to community members than computer-based training accepted as qualify as a subsidized health service, the organization continuing health professions education organization must provide the service by the relevant professional organization. because it meets an identified community Scholarships No More benefit Scholarships provided by the need. A service meets an identified for staff to organization to community members. community need if it is reasonable to members organization Line 8. Enter Medicare reimbursement conclude that if the organization no longer than for direct GME, reimbursement for offered the service, community approved nursing and allied health the service would be unavailable in the Continuing Yes Accessible to education activities, and direct GME community, medical all qualified reimbursement received for services the community s capacity to provide the education for physicians provided to Medicare Advantage patients. service would be below the community s community For a children s hospital that receives need, or physicians children s GME payments from Health the service would become the Resources and Services Administration responsibility of government or another Continuing No Restricted to (HRSA), count that portion of the payment tax-exempt organization. medical own medical education for staff members equivalent to Medicare direct GME. Do Subsidized health services generally own medical not include indirect GME reimbursement include qualifying inpatient programs staff provided by Medicare. (neonatal intensive care, addiction Line 9. Enter Medicaid reimbursement recovery, and inpatient psychiatric units,) Nurse Yes More benefit for direct GME, including only that portion and ambulatory programs (emergency education if to community of Medicaid GME payment equivalent to and trauma services, satellite clinics graduates are than Medicare direct GME and that can be designed to serve low-income free to seek organization explicitly segregated by the organization communities, and home health employment from other Medicaid net patient revenue. programs). Subsidized health services at any organization Do not include indirect GME generally exclude ancillary services that reimbursement provided by Medicaid, support inpatient and ambulatory Nurse No Program which is to be reported on Worksheet 3, programs such as anesthesiology, education if designed Unreimbursed Medicaid and Other radiology, and laboratory departments. graduates are primarily to Means-Tested Government Programs. Subsidized health services include required to benefit the Include Medicaid reimbursement for services or care provided by physician become the organization nursing and allied health education. If clinics and skilled nursing facilities if such organization s your state pays Medicaid GME clinics or facilities satisfy the general employees reimbursement as a lump sum that criteria for subsidized health services. An includes both direct and indirect organization that includes any costs Lines 1 through 6. Include both direct payments, use reasonable methods to associated with physician clinics as and indirect costs. Direct costs of health estimate the portion of the lump sum that subsidized health services in Part I, line professions education do not include is direct (for example, the percent of total 7g, must describe that it has done so and costs related to Ph.D. students and Medicare GME payments that is direct). report in Part VI such costs included in post-doctoral students, which are to be Part I, line 7g. Line 10. Enter revenue received for reported on Worksheet 7, Research. See continuing health professions education Line 3, columns (A) through (D). Enter the instructions for Part I, line 7, column reimbursement or tuition. the estimated cost for each subsidized (c) for the definition of indirect costs. health service. For column (B), enter bad Line 11. Enter other revenue received Indirect costs do not include the debt amounts attributable to the for health professions education activities estimated cost of indirect medical subsidized health service measured by associated with expenses reported in education. cost. For column (C), enter amounts Worksheet 5, line 7. attributable to the subsidized health Direct costs of health professions service for patients who are recipients of education include the following. Worksheet 6. Subsidized Medicaid and other means-tested Stipends, fringe benefits of interns, residents, and fellows in accredited Health Services (Part I, graduate medical education programs. Line 7g) government programs measured by cost. For column (D), enter financial assistance amounts attributable to the subsidized Salaries and fringe benefits of faculty Worksheet 6 can be used to calculate the health service measured by cost. Multiply directly related to intern and resident net cost of subsidized health services. line 1 by line 2 or enter estimated cost education. Complete Worksheet 6 for each based on the organization s cost Salaries and fringe benefits of faculty subsidized health service and report in accounting. Organizations with a cost directly related to teaching: Part I the total for all subsidized health accounting system or method more 1. of medical students, services combined. accurate than the ratio of patient care cost to charges from Worksheet 2 can 2. students enrolled in nursing Subsidized health services means rely on that system or method to estimate programs that are licensed by state law clinical services provided despite a the cost of each subsidized health or, if licensing is not required, accredited financial loss to the organization. The service. by the recognized national professional financial loss is measured after removing organization for the particular activity, losses, measured by cost, associated 3. students enrolled in allied health with bad debt, financial assistance, Worksheet 7. Research professions education programs, licensed Medicaid and other means-tested (Part I, Line 7h) by state law or, if licensing is not required, government programs. Losses accredited by the recognized national attributable to these items are not Worksheet 7 can be used to report the professional organization for the particular included when determining which clinical cost of research conducted by the activity, including, but not limited to, services are subsidized health services organization. programs in pharmacy, occupational because they are reported as community Research means any study or therapy, dietetics, and pastoral care, benefit elsewhere in Part I or as bad debt investigation the goal of which is to -16-

17 Worksheet 6. Subsidized Health Services (Part I, line 7g) Keep for Your Records Program name: (C) (E) (A) Medicaid Totals Total and other (subtract subsidized means- columns (B), health tested (D) (C), and (D) service (B) government Financial from column program Bad debt programs assistance (A)) Gross patient charges 1. Gross patient charges from program(s) Total community benefit expense 2. Ratio of patient care cost to charges (from Worksheet 2, if used) % % % % 3. Total community benefit expense (multiply line 1 by line 2, or obtain from cost accounting; enter column (E) on Part I, line 7g, column (c)) Direct offsetting revenue 4. Net patient service revenue Other revenue Total direct offsetting revenue (add lines 4 and 5; enter column (E) on Part I, line 7g, column (d)) Net community benefit expense (subtract line 6 from line 3; enter column (E) on Part I, line 7g, column (e)) Total expense (enter amount from Form 990, Part IX, line 25, column (A), including the organization s share of joint venture expenses, and excluding any bad debt expense included in Part IX, line 25) $ 9. Percent of total expense (line 7, column (E) divided by line 8; enter on Part I, line 7g, column (f)) % -17-

18 generate increase general knowledge computer support; compliance (for and the financial value (generally made available to the public (for example: example, accreditation for human measured at cost) of donated food, knowledge about underlying biological subjects protection, biosafety, HIPAA, equipment, and supplies. mechanisms of health and disease, etc.); and dissemination of research Report cash contributions and grants natural processes, or principles affecting results. made by the organization to entities and health or illness; evaluation of safety and Line 1. Define direct costs under the community groups that share the efficacy of interventions for disease such guidelines and definitions published by organization s goals and mission. Do not as clinical trials and studies of therapeutic the National Institutes of Health. report cash or in-kind contributions protocols; laboratory-based studies; Line 2. Define indirect costs under the contributed by employees, or emergency epidemiology, health outcomes, and guidelines and definitions published by funds provided by the organization to the effectiveness; behavioral or sociological the National Institutes of Health. organization s employees; loans, studies related to health, delivery of care, advances, or contributions to the capital or prevention; studies related to changes of another organization; or unrestricted in the health care delivery system; and Worksheet 8. Cash and grants or gifts to another organization that communication of findings and In-Kind Contributions for can, at the discretion of the grantee observations, including publication in a organization, be used other than to medical journal.) The organization can Community Benefit (Part I, provide the type of community benefit include the cost of internally funded Line 7i) described in the table in Part I, line 7. research it conducts, as well as the cost of research it conducts funded by a Worksheet 8 can be used to report cash Special rule for grants to joint tax-exempt or government entity. contributions or grants and the cost of ventures. If the organization makes a in-kind contributions that support financial grant to a joint venture in which it has an The organization cannot include in assistance, health professions education, ownership interest to be used to Part I, line 7h, direct or indirect costs of and other community benefit activities accomplish one of the community benefit research funded by an individual or an reportable in Part I, lines 7a through 7h. activities reportable in the table, in Part I, organization that is not a tax-exempt or Report such contributions on line 7i, and line 7, report the grant on line 7i, but do government entity. However, the not on lines 7a through 7h. Do not include not include the organization s organization can describe in Part VI any any contributions funded in whole or in proportionate share of the amount spent research it conducts that is not funded by part by a restricted grant, to the extent by the joint venture on such activities in tax-exempt or government entities, that such grant was from a related any other part of the Table, to avoid including the cost of such research, the organization, as illustrated in the double-counting. identity of the funder, how the results of examples on this page and the next. such research are made available to the Example 1. The filing organization public, if at all, and whether the results Cash and in-kind contributions (A) and foundation (B) are related are made available to the public at no means contributions made by the organizations. B makes a grant to A that cost or nominal cost. organization to health care organizations must be used by A to conduct a and other community groups restricted to community health needs assessment in a Examples of costs of research include, one or more of the community benefit community served by A. A can report the but are not limited to, salaries and activities described in the table in Part I, cost of conducting the community health benefits of researchers and staff, line 7 (and the related worksheets and needs assessment in Part I, line 7e, including stipends for research trainees instructions). In-kind contributions column (c) in the year it conducts the (Ph.D. candidates or fellows); facilities for include the cost of staff hours donated by health needs assessment, but A need not collection and storage of research, data, the organization to the community while report the restricted grant from B in Part I, and samples; animal facilities; equipment; on the organization s payroll, indirect cost line 7e, column (d). The same result is supplies; tests conducted for research of space donated to tax-exempt obtained if B is unrelated to A, or if the rather than patient care; statistical and community groups (such as for meetings), grant is unrestricted rather than required Worksheet 7. Research (Part I, line 7h) Keep for Your Records Total community benefit expense 1. Direct costs Indirect costs Total community benefit expense (add lines 1 and 2; enter on Part I, line 7h, column (c)) Direct offsetting revenue 4. License fees and royalties Other revenue Total Direct offsetting revenue (add lines 4 and 5; enter on Part I, line 7h, column (d)) Net community benefit expense (subtract line 6 from line 3; enter on Part I, line 7h, column (e)) Total expense (enter amount from Form 990, Part IX, line 25, column (A), including the organization s share of joint venture expenses, and excluding any bad debt expense included in Part IX, line 25) Percent of total expense (divide line 7 by line 8; enter on Part I, line 7h, column (f)) % -18-

19 to be used by A to provide community benefit. Worksheet 8. Cash and In-Kind Contributions for Community Benefit Example 2. Use the same facts as in (Part I, line 7i) Keep for Your Records Example 1, except A may also use the grant from B to make a grant to another organization (C), which must be used by (A) (B) C to provide community benefit. A makes Cash In-kind such a grant to C. A cannot report the grant to C in Part I, line 7i, because it is contrib- contrib- (C) funded by a related organization, but A utions utions Total need not report the grant from B in Part I, line 7, column (d) for any line 7 item. This 1. Total community benefit is the result regardless of whether B and expense (enter amount from C are related organizations. column (C) on Part I, line 7i, Example 3. A is a related column (c)) organization to B, C, and D. Each of the organizations files a Form 990 and a 2. Direct offsetting revenue (enter Schedule H (Form 990). A makes a amount from column (C) on Part I, restricted grant to B that is restricted to line 7i, column (d)) one or more of the community benefit activities described in the table in Part I, 3. Net community benefit expense line 7 (and the related worksheets and (subtract line 2 from line 1; enter instructions). A s grant is not funded by a on Part I, line 7i, column (e)) related organization. B makes a restricted grant to C that is funded by A s restricted 4. Total expense (enter amount from grant. C makes an unrestricted grant to D Form 990, Part IX, line 25, column that is not funded by B s restricted grant. (A), including the organization s Under these circumstances, A can report share of joint venture expenses, the grant to B on A s Schedule H (Form and excluding any bad debt 990), Part I, line 7i, but neither B nor C expense included in Part IX, line can report their respective grants to C and D on Part I, line 7i of their own 25) Schedule H (Form 990). If D uses the grant funds to make a grant restricted to 5. Percent of total expense (divide one or more of the community benefit line 3 by line 4; enter on Part I, line activities described in the Table in Part I, 7i, column (f)) % D can report the grant on line 7i. -19-

20 Index B Charges for Medical P 3-Unreimbursed Medicaid and Bad Debt, Medicare, & Collection Care... 9 Patient Protection and Affordable Other Means-Tested Practices... 5 Financial Assistance Care Act: Government Worksheet (optional)... 5 Policy... 7 Hospital facilities... 1 Programs Policy Relating to Emergency Section 501(r) of the 4-Community Health Medical Care... 8 Code... 1 Improvement Services and C Hospital facilities... 6 Community Benefit Community Building Other Health Care Facilities Operations Activities... 4 (Non-Hospitals)... 9 S 5-Health Professions Disregarded entity... 4 Financial Assistance and Certain Supplemental Information... 9 Education Group return... 4 Other Community Benefits at 6-Subsidized Health Cost... 2 W Services F Contributions for community Worksheets: 7-Research Facility Information: benefit Financial Assistance at 8-Cash and In-Kind Community Health Needs Cost Contributions for Community Assessment Ratio of Patient Care Cost to Benefit M Facility Policies & Management Companies and Charges Practices... 7 Joint Ventures... 6 Billing and Collections

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