Fillable Hospitals 990-SH

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Hospitals 990-SH

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SCHEDULE H
(Form 990)
Department of the Treasury
Internal Revenue Service
Hospitals
▶
Complete if the organization answered “Yes” on Form 990, Part IV, question 20.
▶
Attach to Form 990.
▶
Go to www.irs.gov/Form990 for instructions and the latest information.
OMB No. 1545-0047
2018
Open to Public
Inspection
Name of the organization Employer identification number
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 6a . .
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% 150% 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: . . . . .
3b
200% 250% 300% 350% 400% Other %
c
If the organization used factors other than FPG in determining eligibility, describe in Part VI the criteria used
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 for free or
discounted care.
4
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”? . . . . . . . . . . . .
4
5a
Did the organization budget amounts for free or discounted care provided under its financial assistance policy during the tax year?
5a
b If “Yes,” did the organization’s financial assistance expenses exceed the budgeted amount? . . . . . 5b
c
If “Yes” to line 5b, 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? . . . . . . . . . . .
5c
6a Did the organization prepare a community benefit report during the tax year? . . . . . . . . . . 6a
b
If “Yes,” did the organization make it available to the public? . . . . . . . . . . . . . . . .
6b
Complete the following table using the worksheets provided in the Schedule H instructions. Do not submit
these worksheets with the Schedule H.
7 Financial Assistance and Certain Other Community Benefits at Cost
Financial Assistance and
Means-Tested Government Programs
(a) Number of
activities or
programs (optional)
(b) Persons
served
(optional)
(c) Total community
benefit expense
(d) Direct offsetting
revenue
(e) Net community
benefit expense
(f) Percent
of total
expense
a
Financial Assistance at cost (from
Worksheet 1) . . . . . .
b
Medicaid (from Worksheet 3, column a)
c
Costs of other means-tested
government programs (from
Worksheet 3, column b) . . . .
d
Total. Financial Assistance and
Means-Tested Government Programs
Other Benefits
e
Community health improvement
services and community benefit
operations (from Worksheet 4) . .
f
Health professions education
(from Worksheet 5) . . . .
g
Subsidized health services (from
Worksheet 6) . . . . . .
h
Research (from Worksheet 7) .
i
Cash and in-kind contributions
for community benefit (from
Worksheet 8) . . . . . .
j
Total. Other Benefits . . . .
k
Total. Add lines 7d and 7j . .
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50192T Schedule H (Form 990) 2018
Schedule H (Form 990) 2018
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.
(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
1 Physical improvements and housing
2 Economic development
3 Community support
4 Environmental improvements
5
Leadership development and training
for community members
6 Coalition building
7
Community health improvement advocacy
8 Workforce development
9 Other
10 Total
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. 15?
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
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
4 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
5 Enter total revenue received from Medicare (including DSH and IME) . . . . . . .
5
6 Enter Medicare allowable costs of care relating to payments on line 5 . . . . . . . 6
7 Subtract line 6 from line 5. This is the surplus (or shortfall) . . . . . . . . . . . 7
8
Describe in Part VI the extent to which any shortfall reported in line 7 should be treated as community
benefit. Also describe in Part VI the costing methodology or source used to determine the amount reported
on line 6. Check the box that describes the method used:
Cost accounting system Cost to charge ratio Other
Section C. Collection Practices
9
a
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
2
3
4
5
6
7
8
9
10
11
12
13
Schedule H (Form 990) 2018
Schedule H (Form 990) 2018
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?
Licensed hospital
General medical & surgical
Children’s hospital
Teaching hospital
Critical access hospital
Research facility
ER–24 hours
ER–other
Name, address, primary website address, and state license number
(and if a group return, the name and EIN of the subordinate hospital
organization that operates the hospital facility)
Other (describe)
Facility
reporting
group
1
2
3
4
5
6
7
8
9
10
Schedule H (Form 990) 2018
Schedule H (Form 990) 2018
Page 4
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 letter of facility reporting group
Line number of hospital facility, or line numbers of hospital
facilities in a facility reporting group (from Part V, Section A):
Yes No
Community Health Needs Assessment
1
Was the hospital facility first licensed, registered, or similarly recognized by a state as a hospital facility in the
current tax year or the immediately preceding tax year?. . . . . . . . . . . . . . . . . .
1
2
Was the hospital facility acquired or placed into service as a tax-exempt hospital in the current tax year or
the immediately preceding tax year? If “Yes,” provide details of the acquisition in Section C . . . . . .
2
3
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 12 . . . . . . . . . . . . .
3
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 significant 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
The impact of any actions taken to address the significant health needs identified in the hospital
facility’s prior CHNA(s)
j
Other (describe in Section C)
4
Indicate the tax year the hospital facility last conducted a CHNA: 20
5
In conducting its most recent CHNA, did the hospital facility take into account input from persons who represent
the broad interests of the community served by the hospital facility, including those with special knowledge of or
expertise in public health? If “Yes,” describe in Section C how the hospital facility took into account input from
persons who represent the community, and identify the persons the hospital facility consulted . . . . . .
5
6 a
Was the hospital facility’s CHNA conducted with one or more other hospital facilities? If "Yes," list the other
hospital facilities in Section C . . . . . . . . . . . . . . . . . . . . . . . . . .
6a
b
Was the hospital facility’s CHNA conducted with one or more organizations other than hospital facilities? If “Yes,”
list the other organizations in Section C . . . . . . . . . . . . . . . . . . . . . . .
6b
7
Did the hospital facility make its CHNA report widely available to the public? . . . . . . . . . .
7
If “Yes,” indicate how the CHNA report was made widely available (check all that apply):
a
Hospital facility’s website (list url):
b
Other website (list url):
c
Made a paper copy available for public inspection without charge at the hospital facility
d
Other (describe in Section C)
8
Did the hospital facility adopt an implementation strategy to meet the significant community health needs
identified through its most recently conducted CHNA? If “No,” skip to line 11 . . . . . . . . . .
8
9
Indicate the tax year the hospital facility last adopted an implementation strategy: 20
10
Is the hospital facility’s most recently adopted implementation strategy posted on a website? . . . . .
10
a
If “Yes,” (list url):
b
If “No,” is the hospital facility’s most recently adopted implementation strategy attached to this return? . .
10b
11
Describe in Section C how the hospital facility is addressing the significant needs identified in its most
recently conducted CHNA and any such needs that are not being addressed together with the reasons why
such needs are not being addressed.
12 a Did the organization incur an excise tax under section 4959 for the hospital facility’s failure to conduct a
CHNA as required by section 501(r)(3)? . . . . . . . . . . . . . . . . . . . . . . .
12a
b If “Yes” to line 12a, did the organization file Form 4720 to report the section 4959 excise tax? . . . . . 12b
c
If “Yes” to line 12b, what is the total amount of section 4959 excise tax the organization reported on Form
4720 for all of its hospital facilities?
$
Schedule H (Form 990) 2018
Schedule H (Form 990) 2018
Page
5
Part V Facility Information (continued)
Financial Assistance Policy (FAP)
Name of hospital facility or letter of facility reporting group
Yes No
Did the hospital facility have in place during the tax year a written financial assistance policy that:
13
Explained eligibility criteria for financial assistance, and whether such assistance included free or discounted care?
13
If “Yes,” indicate the eligibility criteria explained in the FAP:
a
Federal poverty guidelines (FPG), with FPG family income limit for eligibility for free care of
and FPG family income limit for eligibility for discounted care of
%
%
b
Income level other than FPG (describe in Section C)
c
Asset level
d
Medical indigency
e
Insurance status
f
Underinsurance status
g
Residency
h
Other (describe in Section C)
14 Explained the basis for calculating amounts charged to patients? . . . . . . . . . . . . . .
14
15 Explained the method for applying for financial assistance? . . . . . . . . . . . . . . . . 15
If “Yes,” indicate how the hospital facility’s FAP or FAP application form (including accompanying
instructions) explained the method for applying for financial assistance (check all that apply):
a
Described the information the hospital facility may require an individual to provide as part of his or her
application
b
Described the supporting documentation the hospital facility may require an individual to submit as part
of his or her application
c
Provided the contact information of hospital facility staff who can provide an individual with information
about the FAP and FAP application process
d
Provided the contact information of nonprofit organizations or government agencies that may be
sources of assistance with FAP applications
e
Other (describe in Section C)
16 Was widely publicized within the community served by the hospital facility? . . . . . . . . . . .
16
If “Yes,” indicate how the hospital facility publicized the policy (check all that apply):
a
The FAP was widely available on a website (list url):
b
The FAP application form was widely available on a website (list url):
c
A plain language summary of the FAP was widely available on a website (list url):
d
The FAP was available upon request and without charge (in public locations in the hospital facility and
by mail)
e
The FAP application form was available upon request and without charge (in public locations in the
hospital facility and by mail)
f
A plain language summary of the FAP was available upon request and without charge (in public
locations in the hospital facility and by mail)
g
Individuals were notified about the FAP by being offered a paper copy of the plain language summary of
the FAP, by receiving a conspicuous written notice about the FAP on their billing statements, and via
conspicuous public displays or other measures reasonably calculated to attract patients’ attention
h
Notified members of the community who are most likely to require financial assistance about availability
of the FAP
i
The FAP, FAP application form, and plain language summary of the FAP were translated into the
primary language(s) spoken by Limited English Proficiency (LEP) populations
j
Other (describe in Section C)
Schedule H (Form 990) 2018
Schedule H (Form 990) 2018
Page
6
Part V Facility Information (continued)
Billing and Collections
Name of hospital facility or letter of facility reporting group
Yes No
17
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 all of the actions the hospital facility or other authorized party
may take upon nonpayment? . . . . . . . . . . . . . . . . . . . . . . . . . .
17
18
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 individual’s eligibility under the
facility’s FAP:
a
Reporting to credit agency(ies)
b
Selling an individual’s debt to another party
c
Deferring, denying, or requiring a payment before providing medically necessary care due to
nonpayment of a previous bill for care covered under the hospital facility’s FAP
d
Actions that require a legal or judicial process
e
Other similar actions (describe in Section C)
f
None of these actions or other similar actions were permitted
19
Did the hospital facility or other authorized party perform any of the following actions during the tax year
before making reasonable efforts to determine the individual’s eligibility under the facility’s FAP? . . . .
19
If “Yes,” check all actions in which the hospital facility or a third party engaged:
a
Reporting to credit agency(ies)
b
Selling an individual’s debt to another party
c
Deferring, denying, or requiring a payment before providing medically necessary care due to
nonpayment of a previous bill for care covered under the hospital facility’s FAP
d
Actions that require a legal or judicial process
e
Other similar actions (describe in Section C)
20
Indicate which efforts the hospital facility or other authorized party made before initiating any of the actions listed (whether or
not checked) in line 19 (check all that apply):
a
Provided a written notice about upcoming ECAs (Extraordinary Collection Action) and a plain language summary of the
FAP at least 30 days before initiating those ECAs (if not, describe in Section C)
b
Made a reasonable effort to orally notify individuals about the FAP and FAP application process (if not, describe in Section C)
c
Processed incomplete and complete FAP applications (if not, describe in Section C)
d
Made presumptive eligibility determinations (if not, describe in Section C)
e
Other (describe in Section C)
f
None of these efforts were made
Policy Relating to Emergency Medical Care
21
Did the hospital facility have in place during the tax year a written policy relating to emergency medical care
that required 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? . . . .
21
If “No,” indicate why:
a The hospital facility did not provide care for any emergency medical conditions
b
The hospital facility’s policy was not in writing
c
The hospital facility limited who was eligible to receive care for emergency medical conditions (describe
in Section C)
d
Other (describe in Section C)
Schedule H (Form 990) 2018
Schedule H (Form 990) 2018
Page
7
Part V Facility Information (continued)
Charges to Individuals Eligible for Assistance Under the FAP (FAP-Eligible Individuals)
Name of hospital facility or letter of facility reporting group
Yes No
22
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 a look-back method based on claims allowed by Medicare fee-for-service
during a prior 12-month period
b
The hospital facility used a look-back method based on claims allowed by Medicare fee-for-service and
all private health insurers that pay claims to the hospital facility during a prior 12-month period
c
The hospital facility used a look-back method based on claims allowed by Medicaid, either alone or in
combination with Medicare fee-for-service and all private health insurers that pay claims to the hospital
facility during a prior 12-month period
d
The hospital facility used a prospective Medicare or Medicaid method
23
During the tax year, did the hospital facility charge any FAP-eligible individual 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? . . . . . . . . . . . . . . . . . . .
23
If “Yes,” explain in Section C.
24
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? . . . . . . . . . . . . . . . . . . .
24
If “Yes,” explain in Section C.
Schedule H (Form 990) 2018
Schedule H (Form 990) 2018
Page 8
Part V Facility Information (continued)
Section C. Supplemental Information for Part V, Section B. Provide descriptions required for Part V, Section B, lines
2, 3j, 5, 6a, 6b, 7d, 11, 13b, 13h, 15e, 16j, 18e, 19e, 20a, 20b, 20c, 20d, 20e, 21c, 21d, 23, and 24. If applicable, provide
separate descriptions for each hospital facility in a facility reporting group, designated by facility reporting group letter
and hospital facility line number from Part V, Section A (“A, 1,” “A, 4,” “B, 2,” “B, 3,” etc.) and name of hospital facility.
Schedule H (Form 990) 2018
Schedule H (Form 990) 2018
Page 9
Part V Facility Information (continued)
Section D. 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
2
3
4
5
6
7
8
9
10
Schedule H (Form 990) 2018
Schedule H (Form 990) 2018
Page 10
Part VI Supplemental Information
Provide the following information.
1
Required descriptions. Provide the descriptions required for Part I, lines 3c, 6a, and 7; Part II and Part III, lines 2, 3, 4, 8 and
9b.
2
Needs assessment. Describe how the organization assesses the health care needs of the communities it serves, in addition to
any CHNAs reported in Part V, Section B.
3
Patient education of eligibility for assistance. Describe how the organization informs and educates patients and persons
who may be billed for patient care about their eligibility for assistance under federal, state, or local government programs or
under the organization’s financial assistance policy.
4
Community information. Describe the community the organization serves, taking into account the geographic area and
demographic constituents it serves.
5
Promotion of community health. Provide any other information important to describing how the organization’s hospital facilities or
other health care facilities further its exempt purpose by promoting the health of the community (e.g., open medical staff, community
board, use of surplus funds, etc.).
6
Affiliated health care system. If the organization is part of an affiliated health care system, describe the respective roles of the
organization and its affiliates in promoting the health of the communities served.
7
State filing of community benefit report. If applicable, identify all states with which the organization, or a related
organization, files a community benefit report.
Schedule H (Form 990) 2018
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Hospitals 990-SH

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Completed 26 March 2019

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