Hospitals INDIANA UNIVERSITY HEALTH, INC

Transcription

1 SCHEDULE H Hospitals OMB No (Form 990) Complete if the organization answered "Yes" to Form 990, Part IV, question 20. Attach to Form 990. See separate instructions. Open to Public Department of the Treasury Internal Revenue Service Inspection Name of the organization Employer identification number INDIANA UNIVERSITY HEALTH, INC Part I Financial Assistance and Certain Other Community Benefits at Cost Yes No 1a Did the organization have a financial assistance policy during the tax year? If "No," skip to question a 1a b If "Yes," was it a written policy? 1b 2 If the organization had multiple hospital facilities, indicate which of the following best describes application of the financial assistance policy to its various hospital facilities during the tax year. Applied uniformly to all hospital facilities Applied uniformly to most hospital facilities Generally tailored to individual hospital facilities 3 Answer the following based on the financial assistance eligibility criteria that applied to the largest number of the organization's patients during the tax year. a Did the organization use Federal Poverty Guidelines (FPG) as a factor in determining eligibility for providing free care? If "Yes," indicate which of the following was the FPG family income limit for eligibility for free care: 3a 100% 10% 200% Other % b Did the organization use FPG as a factor in determining eligibility for providing discounted care? If "Yes," indicate which of the following was the family income limit for eligibility for discounted care: 200% 20% 300% 30% 00% Other % 3b c If the organization used factors other than FPG in determining eligibility, describe in Part VI the income based criteria for determining eligibility for free or discounted care. Include in the description whether the organization used an asset test or other threshold, regardless of income, as a factor in determining eligibility forfreeordiscountedcare. Did the organization's financial assistance policy that applied to the largest number of its patients during the tax year provide for free or discounted care to the "medically indigent"? a Did the organization budget amounts for free or discounted care provided under its financial assistance policy during the tax year? a b If "Yes," did the organization's financial assistance expenses exceed the budgeted amount? b c If "Yes" to line b, as a result of budget considerations, was the organization unable to provide free or discounted care to a patient who was eligible for free or discounted care? c a Did the organization prepare a community benefit report during the tax year? a b If "Yes," did the organization make it available to the public? b Complete the following table using the worksheets provided in the Schedule H instructions. Do not submit these worksheets with the Schedule H. Financial Assistance and Certain Other Community Benefits at Cost Financial Assistance and (a) Number of (b) Persons (c) Total community (d) Direct offsetting (e) Net community (f) Percent activities or Means-Tested Government revenue benefit expense programs served benefit expense of total (optional) (optional) expense Programs a Financial Assistance at cost (from Worksheet 1) ,, ,, b Medicaid (from Worksheet 3, column a) 391 1,13,90.,23,91. -1,23,0. c Costs of other means-tested government programs (from Worksheet3,columnb) d Total Financial Assistance and Means-Tested Government Programs 10323,00,01.,23,91. 9,33, Other Benefits e ,02,. 20,0. 19,,91..0 f g h i j k Community health improvement services and community benefit operations (from Worksheet ) Health professions education (from Worksheet ) Subsidized health services (from Worksheet ) Research (from Worksheet ) Cash and in-kind contributions for community benefit (from Worksheet ) Total. Other Benefits Total. Add lines d and j 2 0,9, ,9, ,200,12.,200, ,2,32. 3,2, ,,03.,0. 3,9, ,0,9. 2,. 119,90, ,12,12.,0,3. 21,23,3..1 For Paperwork Reduction Act Notice, see the Instructions for Form E

2 Page 2 Part II Community Building Activities Complete this table if the organization conducted any community building activities during the tax year, and describe in Part VI how its community building activities promoted the health of the communities it serves. 1 Physical improvements and housing 2 Economic development 3 Community support Environmental improvements Leadership development and training for community members Coalition building Community health improvement advocacy Workforce development 9 Other 10 Total (a) Number of activities or programs (optional) (b) Persons served (optional) (c) Total community building expense (d) Direct offsetting revenue (e) Net community building expense (f) Percent of total expense , ,3..03 Part III Bad Debt, Medicare, & Collection Practices Section A. Bad Debt Expense Yes No 1 Did the organization report bad debt expense in accordance with Healthcare Financial Management Association Statement No. 1? 1 2 Enter the amount of the organization's bad debt expense. Explain in Part VI the methodology used by the organization to estimate this amount 2 2,11,90. 3 Enter the estimated amount of the organization s bad debt expense attributable to patients eligible under the organization s financial assistance policy. Explain in Part VI the methodology used by the organization to estimate this amount and the rationale, if any, for including this portion of bad debt as community benefit. 3 Provide in Part VI the text of the footnote to the organization's financial statements that describes bad debt expense or the page number on which this footnote is contained in the attached financial statements. Section B. Medicare Enter total revenue received from Medicare (including DSH and IME) Enter Medicare allowable costs of care relating to payments on line Subtract line from line. This is the surplus (or shortfall) 2,290,012.,0,3. -,,2. Describe in Part VI the extent to which any shortfall reported in line should be treated as community benefit. Also describe in Part VI the costing methodology or source used to determine the amount reported on line. Check the box that describes the method used: Cost accounting system Cost to charge ratio Other Section C. Collection Practices 9a Did the organization have a written debt collection policy during the tax year? 9a b If "Yes," did the organization's collection policy that applied to the largest number of its patients during the tax year contain provisions on the collection practices to be followed for patients who are known to qualify for financial assistance? Describe in Part VI 9b Part IV Management Companies and Joint Ventures (owned 10% or more by officers, directors, trustees, key employees, and physicians-see instructions) (a) Name of entity (b) Description of primary activity of entity (c) Organization's profit % or stock ownership % (d) Officers, directors, trustees, or key employees' profit % or stock ownership % (e) Physicians' profit % or stock ownership % 1 BSC, LLC 2 EHSC, LLC 3 SSSC, LLC IEC, LLC ROCS, LLC BOSC, LLC AMBULATORY SURGERY CENTER AMBULATORY SURGERY CENTER AMBULATORY SURGERY CENTER AMBULATORY SURGERY CENTER AMBULATORY SURGERY CENTER AMBULATORY SURGERY CENTER E INDIANA UNIVERSITY HEALTH, INC , , ,.,..03

3 Page 3 Part V Facility Information Section A. Hospital Facilities (list in order of size, from largest to smallest - see instructions) How many hospital facilities did the organization operate during the tax year? 3 Name, address, and primary website address 1 INDIANA UNIVERSITY HEALTH, INC Licensed hospital General medical & surgical Children's hospital Teaching hospital Critical access hospital Research facility ER-2 hours ER-other Other (describe) INDIANA UNIVERSITY HEALTH, INC. 101 N. SENATE BLVD. SEE ATTACHED INDIANAPOLIS IN IU HEALTH NORTH HOSPITAL 1100 N. MERIDIAN ST. CARMEL IN IU HEALTH WEST HOSPITAL 1111 N. RONALD REAGAN PKWY. AVON IN Facility reporting group E

4 Page Part V Facility Information (continued) Section B. Facility Policies and Practices (Complete a separate Section B for each of the hospital facilities or facility reporting groups listed in Part V, Section A) Name of hospital facility or facility reporting group INDIANA UNIVERSITY HEALTH, INC. For single facility filers only: line number of hospital facility (from Schedule H, Part V, Section A) Community Health Needs Assessment (Lines 1 through c are optional for tax years beginning on or before March 23, 2012) 1 During the tax year or either of the two immediately preceding tax years, did the hospital facility conduct a community health needs assessment (CHNA)? If "No," skip to line 9 1 If "Yes," indicate what the CHNA report describes (check all that apply): a A definition of the community served by the hospital facility b Demographics of the community c Existing health care facilities and resources within the community that are available to respond to the health needs of the community d How data was obtained e The health needs of the community f Primary and chronic disease needs and other health issues of uninsured persons, low-income persons, and minority groups g The process for identifying and prioritizing community health needs and services to meet the community health needs h The process for consulting with persons representing the community's interests i Information gaps that limit the hospital facility's ability to assess the community's health needs j Other (describe in Part VI) 2 Indicate the tax year the hospital facility last conducted a CHNA: 20 3 In conducting its most recent CHNA, did the hospital facility take into account input from representatives of the community served by the hospital facility, including those with special knowledge of or expertise in public health? If Yes, describe in Part VI how the hospital facility took into account input from persons who represent the community, and identify the persons the hospital facility consulted 3 Was the hospital facility's CHNA conducted with one or more other hospital facilities? If "Yes," list the other hospital facilities in Part VI Did the hospital facility make its CHNA report widely available to the public? If "Yes," indicate how the CHNA report was made widely available (check all that apply): a Hospital facility's website b Available upon request from the hospital facility c Other (describe in Part VI) If the hospital facility addressed needs identified in its most recently conducted CHNA, indicate how (check all that apply to date): a Adoption of an implementation strategy that addresses each of the community health needs identified through the CHNA b Execution of the implementation strategy c Participation in the development of a community-wide plan d Participation in the execution of a community-wide plan e Inclusion of a community benefit section in operational plans f Adoption of a budget for provision of services that address the needs identified in the CHNA g Prioritization of health needs in its community h Prioritization of services that the hospital facility will undertake to meet health needs in its community i Other (describe in Part VI) Did the hospital facility address all of the needs identified in its most recently conducted CHNA? If "No," explain in Part VI which needs it has not addressed and the reasons why it has not addressed such needs a Did the organization incur an excise tax under section 99 for the hospital facility's failure to conduct a CHNA as required by section 01(r)(3)? a b b c If Yes to line a, did the organization file Form 20 to report the section 99 excise tax? If Yes to line b, what is the total amount of section 99 excise tax the organization reported on Form 20 for all of its hospital facilities? $ 1 Yes No 2E

5 Page Part V Facility Information (continued) Section B. Facility Policies and Practices (Complete a separate Section B for each of the hospital facilities or facility reporting groups listed in Part V, Section A) Name of hospital facility or facility reporting group IU HEALTH NORTH HOSPITAL For single facility filers only: line number of hospital facility (from Schedule H, Part V, Section A) Community Health Needs Assessment (Lines 1 through c are optional for tax years beginning on or before March 23, 2012) 1 During the tax year or either of the two immediately preceding tax years, did the hospital facility conduct a community health needs assessment (CHNA)? If "No," skip to line 9 1 If "Yes," indicate what the CHNA report describes (check all that apply): a A definition of the community served by the hospital facility b Demographics of the community c Existing health care facilities and resources within the community that are available to respond to the health needs of the community d How data was obtained e The health needs of the community f Primary and chronic disease needs and other health issues of uninsured persons, low-income persons, and minority groups g The process for identifying and prioritizing community health needs and services to meet the community health needs h The process for consulting with persons representing the community's interests i Information gaps that limit the hospital facility's ability to assess the community's health needs j Other (describe in Part VI) 2 Indicate the tax year the hospital facility last conducted a CHNA: 20 3 In conducting its most recent CHNA, did the hospital facility take into account input from representatives of the community served by the hospital facility, including those with special knowledge of or expertise in public health? If Yes, describe in Part VI how the hospital facility took into account input from persons who represent the community, and identify the persons the hospital facility consulted 3 Was the hospital facility's CHNA conducted with one or more other hospital facilities? If "Yes," list the other hospital facilities in Part VI Did the hospital facility make its CHNA report widely available to the public? If "Yes," indicate how the CHNA report was made widely available (check all that apply): a Hospital facility's website b Available upon request from the hospital facility c Other (describe in Part VI) If the hospital facility addressed needs identified in its most recently conducted CHNA, indicate how (check all that apply to date): a Adoption of an implementation strategy that addresses each of the community health needs identified through the CHNA b Execution of the implementation strategy c Participation in the development of a community-wide plan d Participation in the execution of a community-wide plan e Inclusion of a community benefit section in operational plans f Adoption of a budget for provision of services that address the needs identified in the CHNA g Prioritization of health needs in its community h Prioritization of services that the hospital facility will undertake to meet health needs in its community i Other (describe in Part VI) Did the hospital facility address all of the needs identified in its most recently conducted CHNA? If "No," explain in Part VI which needs it has not addressed and the reasons why it has not addressed such needs a Did the organization incur an excise tax under section 99 for the hospital facility's failure to conduct a CHNA as required by section 01(r)(3)? a b b c If Yes to line a, did the organization file Form 20 to report the section 99 excise tax? If Yes to line b, what is the total amount of section 99 excise tax the organization reported on Form 20 for all of its hospital facilities? $ 2 Yes No 2E

6 Page Part V Facility Information (continued) Section B. Facility Policies and Practices (Complete a separate Section B for each of the hospital facilities or facility reporting groups listed in Part V, Section A) Name of hospital facility or facility reporting group IU HEALTH WEST HOSPITAL For single facility filers only: line number of hospital facility (from Schedule H, Part V, Section A) Community Health Needs Assessment (Lines 1 through c are optional for tax years beginning on or before March 23, 2012) 1 During the tax year or either of the two immediately preceding tax years, did the hospital facility conduct a community health needs assessment (CHNA)? If "No," skip to line 9 1 If "Yes," indicate what the CHNA report describes (check all that apply): a A definition of the community served by the hospital facility b Demographics of the community c Existing health care facilities and resources within the community that are available to respond to the health needs of the community d How data was obtained e The health needs of the community f Primary and chronic disease needs and other health issues of uninsured persons, low-income persons, and minority groups g The process for identifying and prioritizing community health needs and services to meet the community health needs h The process for consulting with persons representing the community's interests i Information gaps that limit the hospital facility's ability to assess the community's health needs j Other (describe in Part VI) 2 Indicate the tax year the hospital facility last conducted a CHNA: 20 3 In conducting its most recent CHNA, did the hospital facility take into account input from representatives of the community served by the hospital facility, including those with special knowledge of or expertise in public health? If Yes, describe in Part VI how the hospital facility took into account input from persons who represent the community, and identify the persons the hospital facility consulted 3 Was the hospital facility's CHNA conducted with one or more other hospital facilities? If "Yes," list the other hospital facilities in Part VI Did the hospital facility make its CHNA report widely available to the public? If "Yes," indicate how the CHNA report was made widely available (check all that apply): a Hospital facility's website b Available upon request from the hospital facility c Other (describe in Part VI) If the hospital facility addressed needs identified in its most recently conducted CHNA, indicate how (check all that apply to date): a Adoption of an implementation strategy that addresses each of the community health needs identified through the CHNA b Execution of the implementation strategy c Participation in the development of a community-wide plan d Participation in the execution of a community-wide plan e Inclusion of a community benefit section in operational plans f Adoption of a budget for provision of services that address the needs identified in the CHNA g Prioritization of health needs in its community h Prioritization of services that the hospital facility will undertake to meet health needs in its community i Other (describe in Part VI) Did the hospital facility address all of the needs identified in its most recently conducted CHNA? If "No," explain in Part VI which needs it has not addressed and the reasons why it has not addressed such needs a Did the organization incur an excise tax under section 99 for the hospital facility's failure to conduct a CHNA as required by section 01(r)(3)? a b b c If Yes to line a, did the organization file Form 20 to report the section 99 excise tax? If Yes to line b, what is the total amount of section 99 excise tax the organization reported on Form 20 for all of its hospital facilities? $ 3 Yes No 2E

7 Page Part V Facility Information (continued) Financial Assistance Policy INDIANA UNIVERSITY HEALTH, INC. Did the hospital facility have in place during the tax year a written financial assistance policy that: 9 Explained eligibility criteria for financial assistance, and whether such assistance includes free or discounted care? 9 10 Used federal poverty guidelines (FPG) to determine eligibility for providing free care? 10 If "Yes," indicate the FPG family income limit for eligibility for free care: % 11 If "No," explain in Part VI the criteria the hospital facility used. Used FPG to determine eligibility for providing discounted care? If "Yes," indicate the FPG family income limit for eligibility for discounted care: 0 % 11 If "No," explain in Part VI the criteria the hospital facility used. 12 Explained the basis for calculating amounts charged to patients? 12 If "Yes," indicate the factors used in determining such amounts (check all that apply): a Income level b Asset level c Medical indigency d Insurance status e Uninsured discount f Medicaid/Medicare g State regulation h Other (describe in Part VI) 13 Explained the method for applying for financial assistance? 13 1 Included measures to publicize the policy within the community served by the hospital facility? 1 If "Yes," indicate how the hospital facility publicized the policy (check all that apply): a b c d e f g The policy was posted on the hospital facility's website The policy was attached to billing invoices The policy was posted in the hospital facility's emergency rooms or waiting rooms The policy was posted in the hospital facility's admissions offices The policy was provided, in writing, to patients on admission to the hospital facility The policy was available on request Other (describe in Part VI) Billing and Collections 1 Did the hospital facility have in place during the tax year a separate billing and collections policy, or a written financial assistance policy (FAP) that explained actions the hospital facility may take upon non-payment? 1 Check all of the following actions against an individual that were permitted under the hospital facility's policies during the tax year before making reasonable efforts to determine the patient's eligibility under the facility's FAP: 1 a b c d e a b c d e INDIANA UNIVERSITY HEALTH, INC Reporting to credit agency Lawsuits Liens on residences Body attachments Other similar actions (describe in Part VI) Did the hospital facility or an authorized third party perform any of the following actions during the tax year before making reasonable efforts to determine the patient's eligibility under the facility's FAP? If "Yes," check all actions in which the hospital facility or a third party engaged: Reporting to credit agency Lawsuits Liens on residences Body attachments Other similar actions (describe in Part VI) 1 1 Yes No 2E

8 Page Part V Facility Information (continued) Financial Assistance Policy IU HEALTH NORTH HOSPITAL Did the hospital facility have in place during the tax year a written financial assistance policy that: 9 Explained eligibility criteria for financial assistance, and whether such assistance includes free or discounted care? 9 10 Used federal poverty guidelines (FPG) to determine eligibility for providing free care? 10 If "Yes," indicate the FPG family income limit for eligibility for free care: % 11 If "No," explain in Part VI the criteria the hospital facility used. Used FPG to determine eligibility for providing discounted care? If "Yes," indicate the FPG family income limit for eligibility for discounted care: 0 % 11 If "No," explain in Part VI the criteria the hospital facility used. 12 Explained the basis for calculating amounts charged to patients? 12 If "Yes," indicate the factors used in determining such amounts (check all that apply): a Income level b Asset level c Medical indigency d Insurance status e Uninsured discount f Medicaid/Medicare g State regulation h Other (describe in Part VI) 13 Explained the method for applying for financial assistance? 13 1 Included measures to publicize the policy within the community served by the hospital facility? 1 If "Yes," indicate how the hospital facility publicized the policy (check all that apply): a b c d e f g The policy was posted on the hospital facility's website The policy was attached to billing invoices The policy was posted in the hospital facility's emergency rooms or waiting rooms The policy was posted in the hospital facility's admissions offices The policy was provided, in writing, to patients on admission to the hospital facility The policy was available on request Other (describe in Part VI) Billing and Collections 1 Did the hospital facility have in place during the tax year a separate billing and collections policy, or a written financial assistance policy (FAP) that explained actions the hospital facility may take upon non-payment? 1 Check all of the following actions against an individual that were permitted under the hospital facility's policies during the tax year before making reasonable efforts to determine the patient's eligibility under the facility's FAP: 1 a b c d e a b c d e INDIANA UNIVERSITY HEALTH, INC Reporting to credit agency Lawsuits Liens on residences Body attachments Other similar actions (describe in Part VI) Did the hospital facility or an authorized third party perform any of the following actions during the tax year before making reasonable efforts to determine the patient's eligibility under the facility's FAP? If "Yes," check all actions in which the hospital facility or a third party engaged: Reporting to credit agency Lawsuits Liens on residences Body attachments Other similar actions (describe in Part VI) 1 1 Yes No 2E

9 Page Part V Facility Information (continued) Financial Assistance Policy IU HEALTH WEST HOSPITAL Did the hospital facility have in place during the tax year a written financial assistance policy that: 9 Explained eligibility criteria for financial assistance, and whether such assistance includes free or discounted care? 9 10 Used federal poverty guidelines (FPG) to determine eligibility for providing free care? 10 If "Yes," indicate the FPG family income limit for eligibility for free care: % 11 If "No," explain in Part VI the criteria the hospital facility used. Used FPG to determine eligibility for providing discounted care? If "Yes," indicate the FPG family income limit for eligibility for discounted care: 0 % 11 If "No," explain in Part VI the criteria the hospital facility used. 12 Explained the basis for calculating amounts charged to patients? 12 If "Yes," indicate the factors used in determining such amounts (check all that apply): a Income level b Asset level c Medical indigency d Insurance status e Uninsured discount f Medicaid/Medicare g State regulation h Other (describe in Part VI) 13 Explained the method for applying for financial assistance? 13 1 Included measures to publicize the policy within the community served by the hospital facility? 1 If "Yes," indicate how the hospital facility publicized the policy (check all that apply): a b c d e f g The policy was posted on the hospital facility's website The policy was attached to billing invoices The policy was posted in the hospital facility's emergency rooms or waiting rooms The policy was posted in the hospital facility's admissions offices The policy was provided, in writing, to patients on admission to the hospital facility The policy was available on request Other (describe in Part VI) Billing and Collections 1 Did the hospital facility have in place during the tax year a separate billing and collections policy, or a written financial assistance policy (FAP) that explained actions the hospital facility may take upon non-payment? 1 Check all of the following actions against an individual that were permitted under the hospital facility's policies during the tax year before making reasonable efforts to determine the patient's eligibility under the facility's FAP: 1 a b c d e a b c d e INDIANA UNIVERSITY HEALTH, INC Reporting to credit agency Lawsuits Liens on residences Body attachments Other similar actions (describe in Part VI) Did the hospital facility or an authorized third party perform any of the following actions during the tax year before making reasonable efforts to determine the patient's eligibility under the facility's FAP? If "Yes," check all actions in which the hospital facility or a third party engaged: Reporting to credit agency Lawsuits Liens on residences Body attachments Other similar actions (describe in Part VI) 1 1 Yes No 2E

10 Page Notified individuals of the financial assistance policy on admission Notified individuals of the financial assistance policy prior to discharge Notified individuals of the financial assistance policy in communications with the patients regarding the patients' bills Documented its determination of whether patients were eligible for financial assistance under the hospital facility's financial assistance policy Other (describe in Part VI) e Policy Relating to Emergency Medical Care 19 Did the hospital facility have in place during the tax year a written policy relating to emergency medical care that requires the hospital facility to provide, without discrimination, care for emergency medical conditions to individuals regardless of their eligibility under the hospital facility's financial assistance policy? 19 If "No," indicate why: a b c The hospital facility did not provide care for any emergency medical conditions The hospital facility's policy was not in writing The hospital facility limited who was eligible to receive care for emergency medical conditions (describe in Part VI) d Other (describe in Part VI) Changes to Individuals Eligible for Assistance under the FAP (FAP-Eligible Individuals) 20 Indicate how the hospital facility determined, during the tax year, the maximum amounts that can be charged to FAP-eligible individuals for emergency or other medically necessary care. a The hospital facility used its lowest negotiated commercial insurance rate when calculating the maximum amounts that can be charged b The hospital facility used the average of its three lowest negotiated commercial insurance rates when calculating the maximum amounts that can be charged c d The hospital facility used the Medicare rates when calculating the maximum amounts that can be charged Other (describe in Part VI) 21 During the tax year, did the hospital facility charge any of its FAP- eligible individuals, to whom the hospital facility provided emergency or other medically necessary services, more than the amounts generally billed to individuals who had insurance covering such care? 20 If "Yes," explain in Part VI. INDIANA UNIVERSITY HEALTH, INC Part V Facility Information (continued) INDIANA UNIVERSITY HEALTH, INC. 1 Indicate which efforts the hospital facility made before initiating any of the actions listed in line 1 (check all that apply): a b c d 22 During the tax year, did the hospital facility charge any FAP-eligible individual an amount equal to the gross charge for any service provided to that individual? 21 If "Yes," explain in Part VI. Yes No 2E

11 Page Notified individuals of the financial assistance policy on admission Notified individuals of the financial assistance policy prior to discharge Notified individuals of the financial assistance policy in communications with the patients regarding the patients' bills Documented its determination of whether patients were eligible for financial assistance under the hospital facility's financial assistance policy Other (describe in Part VI) e Policy Relating to Emergency Medical Care 19 Did the hospital facility have in place during the tax year a written policy relating to emergency medical care that requires the hospital facility to provide, without discrimination, care for emergency medical conditions to individuals regardless of their eligibility under the hospital facility's financial assistance policy? 19 If "No," indicate why: a b c The hospital facility did not provide care for any emergency medical conditions The hospital facility's policy was not in writing The hospital facility limited who was eligible to receive care for emergency medical conditions (describe in Part VI) d Other (describe in Part VI) Changes to Individuals Eligible for Assistance under the FAP (FAP-Eligible Individuals) 20 Indicate how the hospital facility determined, during the tax year, the maximum amounts that can be charged to FAP-eligible individuals for emergency or other medically necessary care. a The hospital facility used its lowest negotiated commercial insurance rate when calculating the maximum amounts that can be charged b The hospital facility used the average of its three lowest negotiated commercial insurance rates when calculating the maximum amounts that can be charged c d The hospital facility used the Medicare rates when calculating the maximum amounts that can be charged Other (describe in Part VI) 21 During the tax year, did the hospital facility charge any of its FAP- eligible individuals, to whom the hospital facility provided emergency or other medically necessary services, more than the amounts generally billed to individuals who had insurance covering such care? 20 If "Yes," explain in Part VI. INDIANA UNIVERSITY HEALTH, INC Part V Facility Information (continued) IU HEALTH NORTH HOSPITAL 1 Indicate which efforts the hospital facility made before initiating any of the actions listed in line 1 (check all that apply): a b c d 22 During the tax year, did the hospital facility charge any FAP-eligible individual an amount equal to the gross charge for any service provided to that individual? 21 If "Yes," explain in Part VI. Yes No 2E

12 Page Notified individuals of the financial assistance policy on admission Notified individuals of the financial assistance policy prior to discharge Notified individuals of the financial assistance policy in communications with the patients regarding the patients' bills Documented its determination of whether patients were eligible for financial assistance under the hospital facility's financial assistance policy Other (describe in Part VI) e Policy Relating to Emergency Medical Care 19 Did the hospital facility have in place during the tax year a written policy relating to emergency medical care that requires the hospital facility to provide, without discrimination, care for emergency medical conditions to individuals regardless of their eligibility under the hospital facility's financial assistance policy? 19 If "No," indicate why: a b c The hospital facility did not provide care for any emergency medical conditions The hospital facility's policy was not in writing The hospital facility limited who was eligible to receive care for emergency medical conditions (describe in Part VI) d Other (describe in Part VI) Changes to Individuals Eligible for Assistance under the FAP (FAP-Eligible Individuals) 20 Indicate how the hospital facility determined, during the tax year, the maximum amounts that can be charged to FAP-eligible individuals for emergency or other medically necessary care. a The hospital facility used its lowest negotiated commercial insurance rate when calculating the maximum amounts that can be charged b The hospital facility used the average of its three lowest negotiated commercial insurance rates when calculating the maximum amounts that can be charged c d The hospital facility used the Medicare rates when calculating the maximum amounts that can be charged Other (describe in Part VI) 21 During the tax year, did the hospital facility charge any of its FAP- eligible individuals, to whom the hospital facility provided emergency or other medically necessary services, more than the amounts generally billed to individuals who had insurance covering such care? 20 If "Yes," explain in Part VI. INDIANA UNIVERSITY HEALTH, INC Part V Facility Information (continued) IU HEALTH WEST HOSPITAL 1 Indicate which efforts the hospital facility made before initiating any of the actions listed in line 1 (check all that apply): a b c d 22 During the tax year, did the hospital facility charge any FAP-eligible individual an amount equal to the gross charge for any service provided to that individual? 21 If "Yes," explain in Part VI. Yes No 2E

13 Page Part V Facility Information (continued) Section C. Other Health Care Facilities That Are Not Licensed, Registered, or Similarly Recognized as a Hospital Facility (list in order of size, from largest to smallest) How many non-hospital health care facilities did the organization operate during the tax year? Name and address 1 BALL OUTPATIENT SURGERY CENTER 22 W. UNIVERSITY, STE. 200 MUNCIE IN BELTWAY ENDOSCOPY CENTER - SPRINGMILL 200 W. 103RD ST., STE. 200 INDIANAPOLIS IN BELTWAY SURGERY CENTERS 11 N. PENNSYLVANIA PKWY. INDIANAPOLIS IN 20 BELTWAY SURGERY CENTERS - SPRINGMILL 200 W. 103RD ST. INDIANAPOLIS IN 20 EAGLE HIGHLANDS SURGERY CENTER 0 PARKDALE PLACE INDIANAPOLIS IN 2 INDIANA ENDOSCOPY CENTERS 109 ALLISONVILLE RD., STE. 100 FISHERS IN 03 INDIANA ENDOSCOPY CENTERS 111 RONALD REAGAN PKWY., STE. 3 AVON IN 123 INDIANA ENDOSCOPY CENTERS 101 N. SENATE BLVD., STE. 01 INDIANAPOLIS IN RILEY OUTPATIENT SURGERY CENTER 02 BARNHILL DR., STE INDIANAPOLIS IN SENATE STREET SURGERY CENTER 101 N. SENATE BLVD. INDIANAPOLIS IN 202 Type of Facility (describe) AMBULATORY SURGERY AMBULATORY SURGERY AMBULATORY SURGERY AMBULATORY SURGERY AMBULATORY SURGERY AMBULATORY SURGERY AMBULATORY SURGERY AMBULATORY SURGERY AMBULATORY SURGERY AMBULATORY SURGERY 2E

14 Page Part V Facility Information (continued) Section C. Other Health Care Facilities That Are Not Licensed, Registered, or Similarly Recognized as a Hospital Facility (list in order of size, from largest to smallest) How many non-hospital health care facilities did the organization operate during the tax year? Name and address Type of Facility (describe) 1 IU HEALTH BARIATRIC & MED. WEIGHT LOSS 0 INTECH BLVD., STE. 300 BARIATRIC AND MEDICAL WEIGHT LOSS INDIANAPOLIS IN 2 2 IU MEL & BREN SIMON CANCER CENTER 1030 W. MICHIGAN ST. CANCER CARE INDIANAPOLIS IN HEART PARTNERS OF INDIANA 109 ALLISONVILLE RD., STE. 20 CARDIOVASCULAR FISHERS IN 03 HEART PARTNERS OF INDIANA 112 ILLINOIS ST., STE. LL00 CARDIOVASCULAR CARMEL IN 032 HEART PARTNERS OF INDIANA 1210B MEDICAL ARTS BLVD., STE. 1 CARDIOVASCULAR ANDERSON IN 011 HEART PARTNERS OF INDIANA E 13TH ST., STE. 300 CARDIOVASCULAR FISHERS IN 03 HEART PARTNERS OF INDIANA 101 N. SENATE BLVD., STE. 20 CARDIOVASCULAR INDIANAPOLIS IN 202 HEART PARTNERS OF INDIANA 231 SHADELAND STATION, STE. 100 CARDIOVASCULAR INDIANAPOLIS IN 20 9 HEART PARTNERS OF INDIANA 0 N. SHADELAND AVE., STE. 30 CARDIOVASCULAR INDIANAPOLIS IN IU HEALTH CARDIOVASCULAR SURGEONS CARDIOVASCULAR 101 N. SENATE BLVD., STE. INDIANAPOLIS IN 202 2E

15 Page Part V Facility Information (continued) Section C. Other Health Care Facilities That Are Not Licensed, Registered, or Similarly Recognized as a Hospital Facility (list in order of size, from largest to smallest) How many non-hospital health care facilities did the organization operate during the tax year? Name and address 1 IU HEALTH CARDIOVASCULAR SURGEONS 0 W. 2ND ST. BLOOMINGTON IN 01 2 IU HEALTH CARDIOVASCULAR SURGEONS 3 S. WALKER ST., STE. 2 BLOOMINGTON IN 03 3 METHODIST CARDIOLOGY PHYSICIANS 112 N. ILLINOIS ST., STE. 2 CARMEL IN 032 METHODIST CARDIOLOGY PHYSICIANS 101 N. SENATE BLVD., STE. 310 INDIANAPOLIS IN 202 METHODIST CARDIOLOGY PHYSICIANS 10 RIVER RD., STE. 10 NOBLESVILLE IN 00 METHODIST CARDIOLOGY PHYSICIANS 920 PARKDALE PL., STE. 10 INDIANAPOLIS IN 2 EAST WASHINGTON TIMESHARE 90 E. WASHINGTON ST., STE. 110 INDIANAPOLIS IN 229 GEORGETOWN TIMESHARE 0 CENTURY PLAZA RD., STE. 10 INDIANAPOLIS IN 2 9 IU HEALTH GEORGETOWN MEDICAL PLAZA 0 CENTURY PLAZA RD. INDIANAPOLIS IN 2 10 IU HEALTH METHODIST MEDICAL PLAZA BBURG. 13 N. GREEN ST., STE. 200 BROWNSBURG IN 20 Type of Facility (describe) CARDIOVASCULAR CARDIOVASCULAR CARDIOVASCULAR CARDIOVASCULAR CARDIOVASCULAR CARDIOVASCULAR DIAGNOSTIC AND OTHER MEDICAL DIAGNOSTIC AND OTHER MEDICAL DIAGNOSTIC AND OTHER MEDICAL DIAGNOSTIC AND OTHER MEDICAL 2E

16 Page Part V Facility Information (continued) Section C. Other Health Care Facilities That Are Not Licensed, Registered, or Similarly Recognized as a Hospital Facility (list in order of size, from largest to smallest) How many non-hospital health care facilities did the organization operate during the tax year? Name and address 1 IU HEALTH METHODIST MEDICAL PLAZA EHGH. 0 PARKDALE PL. INDIANAPOLIS IN 2 2 IU HEALTH METHODIST MEDICAL PLAZA EAST 90 E. WASHINGTON ST. INDIANAPOLIS IN IU HEALTH METHODIST MEDICAL PLAZA NORTH 11 PENNSYLVANIA PKWY. CARMEL IN 20 IU HEALTH METHODIST MEDICAL PLAZA SOUTH 20 S. MERIDIAN ST. INDIANAPOLIS IN 21 IU HEALTH METHODIST MEDICAL TOWER 133 N. CAPITOL AVE. INDIANAPOLIS IN 202 IU HEALTH SPRING MILL OUTPATIENT CENTER 200 W. 103RD ST., STE INDIANAPOLIS IN 290 METHODIST MEDICAL PLAZA - GLENDALE 220 KESSLER BLVD. E. INDIANAPOLIS IN 220 NORTH MERIDIAN TIMESHARE 201 PENNSYLVANIA PKWY., STE. 30 INDIANAPOLIS IN 20 9 SOUTH 31 TIMESHARE 20 S. MERIDIAN ST., STE. 230 INDIANAPOLIS IN IU HEALTH DIALYSIS 210 N. CAPITOL AVE. INDIANAPOLIS IN 202 Type of Facility (describe) DIAGNOSTIC AND OTHER MEDICAL DIAGNOSTIC AND OTHER MEDICAL DIAGNOSTIC AND OTHER MEDICAL DIAGNOSTIC AND OTHER MEDICAL DIAGNOSTIC AND OTHER MEDICAL DIAGNOSTIC AND OTHER MEDICAL DIAGNOSTIC AND OTHER MEDICAL DIAGNOSTIC AND OTHER MEDICAL DIAGNOSTIC AND OTHER MEDICAL DIALYSIS 2E

17 Page Part V Facility Information (continued) Section C. Other Health Care Facilities That Are Not Licensed, Registered, or Similarly Recognized as a Hospital Facility (list in order of size, from largest to smallest) How many non-hospital health care facilities did the organization operate during the tax year? Name and address 1 IU HEALTH HOME DIALYSIS CENTER 30 N. MERIDIAN ST. INDIANAPOLIS IN 20 2 IU HEALTH CHARIS EATING DISORDER CLINIC 0 INTECH BLVD., STE. 19 INDIANAPOLIS IN 2 3 IU HEALTH HOME CARE 111 W. COUNTY LINE RD. GREENWOOD IN 12 IU HEALTH HOME CARE 12 N. ILLINOIS ST. INDIANAPOLIS IN 202 IU HEALTH HOME CARE 202 S. WEST ST. TIPTON IN 02 IU HEALTH HOME CARE 02 N. ILLINOIS ST. INDIANAPOLIS IN 20 CAPITAL NEUROLOGY 201 PENNSYLVANIA PKWY. STE. 300 INDIANAPOLIS IN 20 EAST RETAIL PHARMACY 90 E. WASHINGTON ST. INDIANAPOLIS IN GEORGETOWN RETAIL PHARMACY 0 CENTURY PLAZA RD., STE. 10 INDIANAPOLIS IN 2 10 SOUTH RETAIL PHARMACY 20 S. MERIDIAN ST., STE. 10 INDIANAPOLIS IN 21 Type of Facility (describe) DIALYSIS EATING DISORDERS HOME HEALTH CARE HOME HEALTH CARE HOME HEALTH CARE HOME HEALTH CARE NEUROLOGY PHARMACY PHARMACY PHARMACY 2E

18 Page Part V Facility Information (continued) Section C. Other Health Care Facilities That Are Not Licensed, Registered, or Similarly Recognized as a Hospital Facility (list in order of size, from largest to smallest) How many non-hospital health care facilities did the organization operate during the tax year? Name and address 1 IU HEALTH FISHERS RADIOLOGY 1099 ALLISONVILLE RD., STE. 100B FISHERS IN 03 2 IU HEALTH BALL MEMORIAL HOSPITAL LAB 201 W. UNIVERSITY AVE. MUNCIE IN IU HEALTH REHABILITATION 20 PARKDALE PL., STE. 120 INDIANAPOLIS IN 2 IU HEALTH ARNETT SLEEP APNEA ED. CENTER 3900 MCCARTY LN. STE. 102 LAFAYETTE IN 909 IU HEALTH BALL MEMORIAL SLEEP APNEA ED. 000 W. KILGORE AVE., STE. A MUNCIE IN 30 IU HEALTH BEDFORD SLEEP APNEA ED. CENTER 102 CLINIC DR. BEDFORD IN 21 IU HEALTH HOWARD SLEEP APNEA ED. CENTER 29 N. DION RD. KOKOMO IN 901 IU HEALTH SLEEP APNEA ED. CTR. AT INDPLS 1 N. SENATE AVE. STE. 120 INDIANAPOLIS IN IU HEALTH SLEEP LAB 1 N. SENATE AVE. STE. 120 INDIANAPOLIS IN SLEEP APNEA ED. CTR. AT IU HEALTH NORTH 1190 N. MERIDIAN ST., STE. 10 CARMEL IN 032 Type of Facility (describe) RADIOLOGY REFERENCE LABORATORY REHABILITATION SLEEP DISORDERS SLEEP DISORDERS SLEEP DISORDERS SLEEP DISORDERS SLEEP DISORDERS SLEEP DISORDERS SLEEP DISORDERS 2E

19 Page Part V Facility Information (continued) Section C. Other Health Care Facilities That Are Not Licensed, Registered, or Similarly Recognized as a Hospital Facility (list in order of size, from largest to smallest) How many non-hospital health care facilities did the organization operate during the tax year? Name and address Type of Facility (describe) 1 SLEEP APNEA ED. CTR. AT IU HEALTH WEST 111 N. RONALD REAGAN PKWY. #31 SLEEP DISORDERS AVON IN SLEEP DISORDERS CTR. AT IU HEALTH NORTH 1190 N. MERIDIAN ST., STE. 10 SLEEP DISORDERS INDIANAPOLIS IN IU HEALTH SPORTS PERFORMANCE 102 CHASE CT. SPORTS PERFORMANCE CARMEL IN 032 IU HEALTH CHILDREN'S THERAPY CENTER 93 W. ARLINGTON RD. THERAPY BLOOMINGTON IN 0 INDIANA ONCOLOGY HEMATOLOGY 92 SHORE TERRACE DR. ONCOLOGY INDIANAPOLIS IN 20 IU HEALTH MINUTE CLINIC E. 9TH ST. IMMEDIATE CARE FISHERS IN 03 IU HEALTH NEUROSCIENCE CENTER NEUROSCIENCE CENTER OF 3 W. 1TH ST. ECELLENCE INDIANAPOLIS IN E

20 Page 1 Required descriptions. Provide the descriptions required for Part I, lines 3c, a, and ; Part II; Part III, lines,, and 9b; Part V, Section A; and Part V, Section B, lines 1j, 3,, c, i,, 10, 11, 12h, 1g, 1e, 1e, 1e, 19c, 19d, 20d, 21, and 22. for Part V, Section B, lines 1j, 3,, c, i,, 10, 11, 12h, 1g, 1e, 1e, 1e, 19c, 20d, 21, and 22. SCHEDULE H, PART I - FINANCIAL ASSISTANCE LINE 3C N/A SCHEDULE H, PART I - FINANCIAL ASSISTANCE LINE A - COMMUNITY BENEFIT REPORT PREPARED BY RELATED ORGANIZATION INDIANA UNIVERSITY HEALTH, INC.'S ("IU HEALTH") COMMUNITY BENEFITS AND INVESTMENTS ARE INCLUDED IN THE IU HEALTH COMMUNITY BENEFIT REPORT WHICH IS MADE AVAILABLE TO THE PUBLIC ON ITS WEBSITE AT THE COMMUNITY BENEFIT REPORT IS ALSO DISTRIBUTED TO NUMEROUS KEY ORGANIZATIONS THROUGHOUT THE STATE OF INDIANA TO BROADLY SHARE IU HEALTH'S COMMUNITY BENEFIT EFFORTS AND INVESTMENTS STATEWIDE, AND IS AVAILABLE BY REQUEST THROUGH THE INDIANA STATE DEPARTMENT OF HEALTH OR IU HEALTH. 2E

21 Page 1 Required descriptions. Provide the descriptions required for Part I, lines 3c, a, and ; Part II; Part III, lines,, and 9b; Part V, Section A; and Part V, Section B, lines 1j, 3,, c, i,, 10, 11, 12h, 1g, 1e, 1e, 1e, 19c, 19d, 20d, 21, and 22. for Part V, Section B, lines 1j, 3,, c, i,, 10, 11, 12h, 1g, 1e, 1e, 1e, 19c, 20d, 21, and 22. SCHEDULE H, PART I - FINANCIAL ASSISTANCE LINE, COLUMN (F) - BAD DEBT EPENSE THE AMOUNT OF BAD DEBT EPENSE INCLUDED ON FORM 990, PART I, LINE 2, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE OF TOTAL EPENSE IS $0,39,991. THE BAD DEBT EPENSE OF $2,11,90 ON SCHEDULE H, PART III, LINE 2 IS REPORTED AT COST. SCHEDULE H, PART I - FINANCIAL ASSISTANCE LINE - TOTAL COMMUNITY BENEFIT EPENSE PERCENTAGE OF TOTAL EPENSES LISTED ON SCHEDULE H, PART I, LINE, COLUMN (F) IS CALCULATED BASED ON NET COMMUNITY BENEFIT EPENSE. THE PERCENTAGE OF TOTAL EPENSES CALCULATED BASED ON TOTAL COMMUNITY BENEFIT EPENSE IS 32.00%. 2E

22 Page 1 Required descriptions. Provide the descriptions required for Part I, lines 3c, a, and ; Part II; Part III, lines,, and 9b; Part V, Section A; and Part V, Section B, lines 1j, 3,, c, i,, 10, 11, 12h, 1g, 1e, 1e, 1e, 19c, 19d, 20d, 21, and 22. for Part V, Section B, lines 1j, 3,, c, i,, 10, 11, 12h, 1g, 1e, 1e, 1e, 19c, 20d, 21, and 22. SCHEDULE H, PART I - FINANCIAL ASSISTANCE LINE G - SUBSIDIZED HEALTH SERVICES INDIANA UNIVERSITY HEALTH, INC. DOES NOT INCLUDE ANY COSTS ASSOCIATED WITH PHYSICIAN CLINICS AS SUBSIDIZED HEALTH SERVICES. SCHEDULE H, PART II - COMMUNITY BUILDING ACTIVITIES PROMOTION OF HEALTH IN COMMUNITIES SERVED IU HEALTH PARTICIPATED IN A VARIETY OF COMMUNITY-BUILDING ACTIVITIES THAT ADDRESS THE UNDERLYING QUALITY OF LIFE IN THE COMMUNITIES IT SERVES. IU HEALTH AS A STATEWIDE HEALTHCARE SYSTEM INVESTED IN ECONOMIC DEVELOPMENT EFFORTS ACROSS THE STATE COLLABORATED WITH LIKE-MINDED ORGANIZATIONS THROUGH COALITIONS THAT ADDRESS KEY ISSUES, AND ADVOCATED FOR IMPROVEMENTS IN THE HEALTH STATUS OF VULNERABLE POPULATIONS. IU HEALTH CONTRIBUTED NEARLY $2 MILLION TO COMMUNITY-BUILDING ACTIVITIES IN 2012, SERVING OVER 2,00 PEOPLE STATEWIDE. TOGETHER, IU HEALTH METHODIST HOSPITAL, IU HEALTH UNIVERSITY HOSPITAL, RILEY HOSPITAL FOR 2E

23 Page 1 Required descriptions. Provide the descriptions required for Part I, lines 3c, a, and ; Part II; Part III, lines,, and 9b; Part V, Section A; and Part V, Section B, lines 1j, 3,, c, i,, 10, 11, 12h, 1g, 1e, 1e, 1e, 19c, 19d, 20d, 21, and 22. for Part V, Section B, lines 1j, 3,, c, i,, 10, 11, 12h, 1g, 1e, 1e, 1e, 19c, 20d, 21, and 22. CHILDREN AT IU HEALTH, IU HEALTH NORTH HOSPITAL, IU HEALTH WEST, IU HEALTH SAONY INVESTED NEARLY $0,000 IN COMMUNITY-BUILDING ACTIVITIES BY PROVIDING INVESTMENTS AND RESOURCES TO LOCAL COMMUNITY INITIATIVES THAT ADDRESSED ECONOMIC DEVELOPMENT, COMMUNITY SUPPORT AND WORKFORCE DEVELOPMENT. ADDITIONALLY, THROUGH IU HEALTH'S TEAM MEMBER COMMUNITY BENEFIT SERVICE PROGRAM, STRENGTH THAT CARES, TEAM MEMBERS ACROSS THE STATE MADE A DIFFERENCE IN THE LIVES OF THOUSANDS OF HOOSIERS. IN 2012, TEAM MEMBERS: - BUILT 2 HABITAT FOR HUMANITY HOME PANELS THROUGHOUT INDIANA. THREE OF THOSE HOMES WERE GIVEN TO VICTIMS OF THE HENRYVILLE, INDIANA TORNADO. - IMPACTED THE LIVES OF JUST OVER 00 AT-RISK CHILDREN BY SERVING AS CAMP OR READING BUDDIES IN IU HEALTH'S KINDERGARTEN COUNTDOWN PROGRAM TO PREPARE AT-RISK CHILDREN FOR THEIR FIRST DAY OF KINDERGARTEN. 2E

24 Page 1 Required descriptions. Provide the descriptions required for Part I, lines 3c, a, and ; Part II; Part III, lines,, and 9b; Part V, Section A; and Part V, Section B, lines 1j, 3,, c, i,, 10, 11, 12h, 1g, 1e, 1e, 1e, 19c, 19d, 20d, 21, and 22. for Part V, Section B, lines 1j, 3,, c, i,, 10, 11, 12h, 1g, 1e, 1e, 1e, 19c, 20d, 21, and 22. SCHEDULE H, PART III - BAD DEBT, MEDICARE, & COLLECTION PRACTICES LINE - BAD DEBT EPENSE THE PROVISION FOR UNCOLLECTED PATIENT ACCOUNTS IS BASED UPON MANAGEMENT'S ASSESSMENT OF HISTORICAL AND EPECTED NET COLLECTIONS CONSIDERING BUSINESS AND ECONOMIC CONDITIONS, CHANGES AND TRENDS IN HEALTH CARE COVERAGE, AND OTHER COLLECTION INDICATORS. PERIODICALLY, MANAGEMENT ASSESSES THE ADEQUACY OF THE ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS BASED UPON ACCOUNTS RECEIVABLE PAYOR COMPOSITION AND AGING, AND HISTORICAL WRITE-OFF EPERIENCE BY PAYOR CATEGORY, AS ADJUSTED FOR COLLECTION INDICATORS. THE RESULTS OF THE REVIEW ARE THEN USED TO MAKE ANY MODIFICATIONS TO THE PROVISION FOR UNCOLLECTED PATIENT ACCOUNTS AND THE ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS. IN ADDITION, INDIANA UNIVERSITY HEALTH, INC. ("IU HEALTH") FOLLOWS ESTABLISHED GUIDELINES FOR PLACING CERTAIN PAST DUE PATIENT BALANCES WITH COLLECTION AGENCIES. PATIENT ACCOUNTS THAT ARE UNCOLLECTED, INCLUDING THOSE PLACED WITH COLLECTION AGENCIES, ARE INITIALLY CHARGED AGAINST THE ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS IN ACCORDANCE WITH COLLECTION POLICIES OF IU HEALTH AND, IN 2E