2008 Instructions for Schedule H (Form 990)


Part I. Charity Care and Certain Other Community Benefits at Cost (Optional for 2008)

Part I requires reporting of charity care policies, the availability of community benefit reports, and the cost of certain charity care and other community benefit programs. Worksheets and accompanying instructions are provided at the end of the instructions to this schedule to assist in completing the table in Part I, line 7.

Line 1. A "charity care policy" is a policy describing how the organization will provide "charity care," which means free or discounted health services provided to persons who meet the organization's criteria for financial assistance and are thereby deemed unable to pay for all or a portion of the services. "Charity care" does not include: bad debt or uncollectible charges that the hospital recorded as revenue but wrote off due to failure to pay by patients, or the cost of providing such care to such patients; the difference between the cost of care provided under Medicaid or other means-tested government programs or under Medicare and the revenue derived therefrom; or contractual adjustments with any third-party payors.

Line 2. Check only one of the three boxes. "Applied uniformly to all hospitals" means that all of the organization's hospitals use the same charity care policy. "Applied uniformly to most hospitals" means that the majority of the organization's hospitals use the same charity care policy. "Generally tailored to individual hospitals" means that the majority of the organization's hospitals use different charity care policies. If the organization only operates one hospital, check "Applied uniformly to all hospitals."

Line 3. Answer lines 3a, 3b, and 3c based on the charity care eligibility criteria that apply to the largest number of the organization's patients based on patient contacts or encounters. For example, if the organization has two hospitals, use the charity care eligibility criteria that are used by the hospital which has the most patient contacts or encounters during the taxable year.

Line 3a. "Federal Poverty Guidelines" (FPG) are the Federal Poverty Guidelines established by the U.S. Department of Health and Human Services. If the facility has established a family or 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 income must be less than or equal to 250% of FPG for the patient to qualify for free care, then check the box marked "Other" and write in "250%."

Line 3b. If the facility has established a family or household income threshold that a patient must meet or fall below to qualify for discounted medical care, check the box in the "Yes" column and indicate the specific threshold by checking the appropriate box.

Line 3c. If applicable, describe the other income-based criteria, asset test, or other means test or threshold for free or discounted care in Part VI, line 1 of this schedule. An "asset test" includes (i) a limit on the amount of total or liquid assets that a patient or the patient's family or household may own for the patient to qualify for free or discounted care, and/or (ii) a criterion for determining the level of discounted medical care patients may receive, depending on the amount of assets that they and/or their families or households own.

Line 4. "Medically indigent" means persons whom the organization has determined are unable to pay some or all of their medical bills because their medical bills exceed a certain percentage of their family or household income or assets (for example, due to catastrophic costs or conditions), even though they have income or assets that otherwise exceed the generally applicable eligibility requirements for free or discounted care under the organization's charity care policy.

Line 5. Answer lines 5a, 5b, and 5c based on the organization's budgeted amounts under its charity care policy.

Line 5a. Answer "Yes" if the organization established or had in place at any time during the tax year an annual or periodic budgeted amount of free or discounted care to be provided under its charity care policy. If "No," skip to line 6a.

Line 5b. Answer "Yes" if the free or discounted care the organization provided in the applicable period exceeded the budgeted amount of costs or charges for that period. If "No," skip to line 6a.

Line 5c. Answer "Yes" if the organization denied financial assistance to any patient eligible for free or discounted care under its charity care policy solely because the organization's charity care budget was exceeded.

Line 6. Answer lines 6a and 6b based on the organization's annual community benefit report.

Line 6a. Answer "Yes" if the organization prepared an annual written report that describes the organization's programs and services that promote the health of the community or communities served by the organization. If the organization's community benefit report is contained in a report prepared by a related organization, answer "Yes" and identify the related organization in Part VI, line 1. If "No," skip to line 7.

Line 6b. Answer "Yes" if the organization makes its annual community benefit report available to the public.

TIP: Some of the ways in which an organization can make its community benefit report available to the public are to post the report on the organization's website, to publish and distribute the report to the public by mail or at its facilities, or to submit the report to a state agency or other organization that makes the report available to the public.

Lines 7a-7k. Report on the table (lines 7a-7k), at cost, the organization's charity care and certain other community benefits. To calculate the amounts to be reported on the table, use the worksheets or other equivalent documentation that substantiates the information reported consistent with the methodology used on the worksheets. See the instructions to the worksheets for definitions of the various types of community benefit (for example, community health improvement services, health professions education, subsidized health services, research, etc.) to be reported on lines 7a-7k.

TIP: If the organization completed worksheets other than on an aggregate basis (for example, facility by facility, joint venture by joint venture), the organization should aggregate all information from these worksheets for purposes of reporting amounts on the table. Note that only the portion of each joint venture or partnership that represents the organization's proportionate share, based on capital interest, may be reported on lines 7a-7k (see Purpose of Schedule for instructions on aggregation in General Instructions).

Use the organization's most accurate costing methodology (cost accounting system, cost-to-charge ratio, or other) to calculate the amounts reported on the table. If the organization uses a cost-to-charge ratio, it may use Worksheet 2. Ratio of Patient Care Cost to Charges, for this purpose. See the instructions to Part VI, line 1, regarding an explanation of the costing methodology used to calculate the amounts reported on the table.

Bad debt expense is not to be reported on the table under any circumstances.

The following are descriptions of the type of information to be reported in each column of the table.

Column (a). "Number of activities or programs" means the number of the organization's activities or programs conducted during the year that involve the community benefit reported on the line. If this column is completed, report each activity and program on only one line so that it is not counted more than once. Reporting in this column is optional.

Column (b). "Persons served" means the number of patient contacts or encounters in accordance with the filing organization's records. Persons served may be reported in multiple rows, as services across different categories may be provided to the same patient. Reporting in this column is optional.

Column (c). "Total community benefit expense" means the total gross expense of the activity incurred during the year, calculated by using the pertinent worksheets for each line item. "Total community benefit expense" includes both "direct costs" and "indirect costs." "Direct costs" means salaries and benefits, supplies, and other expenses directly related to the actual conduct of each activity or program. "Indirect costs" means costs that are shared by multiple activities or programs, such as facilities and administration costs related to the organization's infrastructure (for example, space, utilities, custodial services, security, information systems, administration, materials management, and others).

Column (d). "Direct offsetting revenue" means revenue from the activity during the year that offsets the total community benefit expense of that activity, as calculated on the worksheets for each line item. "Direct offsetting revenue" includes any revenue generated by the activity or program, such as payment or reimbursement for services provided to program patients. Direct offsetting revenue does not include restricted or unrestricted grants or contributions that the organization uses to provide a community benefit.

Example. The organization receives a restricted grant from an unrelated organization that must be used by the organization to provide charity care. The amount of the restricted grant is not reportable as direct offsetting revenue on line 7a, column (d).

Column (e). "Net community benefit expense" is "Total community benefit expense" (column (c)) minus "Direct offsetting revenue" (column (d)). If the calculated amount is less than zero, report such amount as a negative number.

Column (f). "Percent of total expense" is the "net community benefit expense" in column (e) divided by the sum of the amount on Form 990, Part IX, line 25, column (A) and the organization's proportionate share of total expenses of all joint ventures for which it reports expenses on the table in Part I, to the extent that such expenses are not already reported in Form 990, Part IX, line 25, column (A). Report the percentage to two decimal places (x.xx%). Any bad debt expense included in the denominator should be removed prior to calculation, and the amount of bad debt expense that was included on Form 990, Part IX, line 25, column (A) but removed from this figure should be included in Part VI.

TIP: Column (f) "percent of total expense" is based on column (e) "net community benefit expense," rather than column (c) "total community benefit expense," as a percentage of total expenses. Organizations that report amounts of direct offsetting revenue also might wish to report total community benefit expense (Part I, line 7, column (c)) as a percentage of total expenses. Although this percentage may not be reported in Part I, line 7, column (f), it may be reported on Schedule H (Form 990), Part VI.

Part II. Community Building Activities (Optional for 2008)

Report in this part the costs of the organization's activities that it engaged in during the tax year to protect or improve the community's health or safety, and that are not reportable in Parts I and III of this schedule. An organization that reports information in this part must describe, in Part VI, line 5, how its community building activities promote the health of the communities it serves. Activities that are reported in Part I, line 7, may not be reported in this part.

If the filing organization makes a grant to an organization to be used to accomplish one of the community building activities listed below, then the organization should include the amount of the grant on the appropriate line in Part II. If the organization makes a grant to a joint venture in which it has an ownership interest to be used to accomplish one of the community building activities listed below, report the grant on the appropriate line in Part II, but do not include in Part II the organization's proportionate share of the amount spent by the joint venture on such activities, to avoid double counting. Do not include any contribution made by the organization that was funded in whole or in part by a restricted grant, to the extent that such grant was funded by a related organization.

Line 1. "Physical improvements and housing" may include, but is not limited to, the provision or rehabilitation of housing for vulnerable populations, such as removing building materials that harm the health of the residents, neighborhood improvement or revitalization projects, provision of housing for vulnerable patients upon discharge from an inpatient facility, housing for low-income seniors, and the development or maintenance of parks and playgrounds to promote physical activity.

Line 2. "Economic development" may include, but is not limited to, assisting small business development in neighborhoods with vulnerable populations and creating new employment opportunities in areas with high rates of joblessness.

Line 3. "Community support" may include, but is not limited to, child care and mentoring programs for vulnerable populations or neighborhoods, neighborhood support groups, violence prevention programs, and disaster readiness and public health emergency activities, such as community disease surveillance or readiness training beyond what is required by accrediting bodies or government entities.

Line 4. "Environmental improvements" may include, but are not limited to, activities to address environmental hazards that affect community health, such as alleviation of water or air pollution, safe removal or treatment of garbage or other waste products, and other activities to protect the community from environmental hazards. The organization may not include on this line or in this part expenditures made to comply with environmental laws and regulations that apply to activities of itself, its disregarded entity or entities, a joint venture in which it has an ownership interest, or a member of a group exemption included in a group return of which the organization is also a member. Similarly, the organization may not include on this line or in this part expenditures made to reduce the environmental hazards caused by, or the environmental impact of, its own activities, or those of its disregarded entities, joint ventures, or group exemption members.

Line 5. "Leadership development and training for community members" may include, but is not limited to, training in conflict resolution; civic, cultural, or language skills; and medical interpreter skills for community residents.

Line 6. "Coalition building" may include, but is not limited to, participation in community coalitions and other collaborative efforts with the community to address health and safety issues.

Line 7. "Community health improvement advocacy" may include, but is not limited to, efforts to support policies and programs to safeguard or improve public health, access to health care services, housing, the environment, and transportation.

Line 8. "Workforce development" may include, but is not limited to, recruitment of physicians and other health professionals to medical shortage areas or other areas designated as underserved, and collaboration with educational institutions to train and recruit health professionals needed in the community (other than the health professions education activities reported in Part I, line 7f).

Line 9. "Other" refers to community building activities that protect or improve the community's health or safety that are not described in the categories listed in lines 1-8 above.

Refer to the instructions to Part I, line 7, columns (a) through (f), for descriptions of the types of information that should be reported in each column of Part II.

If the organization is filing a group return or has a disregarded entity or an ownership interest in one or more joint ventures, the organization may find it helpful to complete Part II separately for itself and for each disregarded entity, joint venture in which the organization had an ownership interest during the tax year, and group affiliate. The organization should aggregate the amounts from all such tables, according to the aggregation instructions in Purpose of Schedule, and include the aggregated information in Part II.

Part III. Bad Debt, Medicare, & Collection Practices (Optional for 2008)

Section A. This section requires the organization to report aggregate bad debt expense, at cost, provide an estimate of how much bad debt expense, if any, reasonably could be attributable to persons who likely would qualify for financial assistance under its charity care policy, and provide a rationale for what portion of bad debt, if any, the organization believes should constitute community benefit. In addition, the organization must report whether it has adopted Healthcare Financial Management Association Statement No. 15, Valuation and Financial Statement Presentation of Charity Care and Bad Debts by Institutional Healthcare Providers, (Statement 15) and provide the text of its footnote, if applicable, to its audited financial statements that describes the bad debt expense.

Line 1. Indicate whether the organization reports bad debt expense in accordance with Statement 15. Statement 15 has not been adopted by the AICPA. The IRS does not require organizations to adopt Statement 15 or use it to determine bad debt expense or charity care costs. Some organizations may rely on Statement 15 in reporting bad debt expense and charity care in their audited financial statements. Statement 15 provides instructions for recordkeeping, valuation, and disclosure for bad debts.

Line 2. Use the most accurate system and methodology available to the organization to report bad debt expense at cost. If using a cost accounting system or other costing methodology, enter the estimated cost of patient care services attributable to charges written off to bad debt. If using a cost-to-charge ratio methodology, filers may use Worksheet A (optional). If only a portion of a patient's bill for services is written off as a bad debt, include only the proportionate amount of the cost of providing those services that is attributable to the bad debt. Include the organization's proportionate share of the bad debt expense of joint ventures in which it had an ownership interest during the tax year.

Line 3. Provide an estimate of the amount of cost reported on line 2 that reasonably could be attributable to patients who likely would qualify for financial assistance under the hospital's charity care policy as reported in Part I, lines 1-4, but for whom sufficient information was not obtained to make a determination of their eligibility. Do not include this amount in Part I, line 7. Organizations may use any reasonable methodology to estimate this amount, such as record reviews, an assessment of charity care applications that were denied due to incomplete documentation, analysis of demographics, or other analytical methods.

Line 4. In Part VI, line 1, provide the rationale and the costing methodology used to determine the amounts reported on lines 2 and 3. Describe how the organization accounts for discounts and payments on patient accounts in determining bad debt expense. Also, describe the method the organization used on line 3 to determine the amount that reasonably could be attributable to patients who likely would qualify for financial assistance under the organization's charity care policy if sufficient information had been available to make a determination of their eligibility.

Also, provide the footnote from the organization's financial statements on bad debt expense, if applicable, or the footnotes related to "accounts receivable," "allowance for doubtful accounts," or similar designations. If the footnote or footnotes address only the filing organization's bad debt expense or "accounts receivable," "allowance for doubtful accounts," or similar designations, provide the footnote or footnotes verbatim. If the organization's financial statements include a footnote on these issues that also includes other information, report in Part VI only the relevant portions of the footnote. If the organization is a member of a group with consolidated financial statements, the organization may summarize that portion, if any, of the footnote or footnotes that apply. If the organization's financial statements do not include a footnote that discusses bad debt expense, "accounts receivable," "allowance for doubtful accounts," or similar designations, include a statement in Part VI that the organization's audited financial statements do not include a footnote discussing these issues and explain how the organization's financial statements account for bad debt, if at all.

Section B. This section requires reporting of the organization's aggregate allowable costs to provide services reimbursed by Medicare, aggregate Medicare reimbursements attributable to such costs, and aggregate Medicare surplus or shortfall. Organizations are to include in Section B only those allowable costs and Medicare reimbursements that are reported in its Medicare Cost Report(s) for the year, including the organization's share of any such allowable costs and reimbursement from disregarded entities and joint ventures in which it has an ownership interest. The organization should describe what portion of its Medicare shortfall, if any, it believes should constitute community benefit, and explain its rationale for its position in Part VI, line 1. As described below, the organization also may disclose in Part VI the amount of any Medicare revenues and costs not included in its Medicare Cost Report(s) for the year, and may provide a reconciliation of the amounts reportable in Section B (including the surplus or shortfall reported on line 7) and the total revenues and costs attributable to all of the organization's Medicare programs.

Line 5. Enter all net patient service revenue associated with allowable costs the organization reports in its Medicare Cost Report(s) for the year, including payments for indirect medical education (IME) (except for Medicare Advantage IME), Medicare disproportionate share hospital (DSH), outliers, capital, bad debt, and any other amounts paid to the organization on the basis of its Medicare Cost Report. Do not include revenue related to subsidized health services as reported in Part I, line 7g (see Worksheet 6), or direct graduate medical education (GME) as reported in Part I, line 7f (see Worksheet 5). If the organization has more than one Medicare provider number, aggregate the revenue attributable to costs reported on the Medicare Cost Reports submitted under each provider number, and report the aggregate revenues on line 5.

Line 6. Enter all Medicare allowable costs reported in the organization's Medicare Cost Report(s), except those already reported in Part I, line 7g (subsidized health services) and costs associated with direct GME already reported in Part I, line 7f (health professions education). This can be determined using Worksheet B. If Worksheet B is not used, the organization still must subtract the costs attributable to subsidized health services and direct GME from the Medicare allowable costs it enters on line 6. If the organization has more than one Medicare provider number, it should aggregate the costs reported in the Medicare Cost Reports submitted under each provider number and report the aggregate costs on line 6.

Line 7. Subtract line 6 from the amount on line 5. If line 6 exceeds line 5, report the excess (the shortfall) as a negative number.

Line 8. Check the box that best describes the costing methodology used to determine the Medicare allowable costs reported in the organization's Medicare Cost Report(s), as reflected on line 6. Describe this methodology in Part VI, line 1.

The organization must also describe in Part VI its rationale for treating the amount reported in Part III, line 7, or any portion of it, as a community benefit. An organization's rationale must have a reasonable basis. Do not include this amount in Part I, line 7. Do not include any Medicare-related expenses or revenue properly reported in Part I, line 7g or any Medicare-related expenses or revenue reported in Part I, line 7f in Part III, Section B.

TIP: Lines 5, 6, and 7 do not include certain Medicare program revenues and costs; and thus may not reflect all of the organization's revenues and costs associated with its participation in Medicare programs. The organization may describe in Part VI the amounts of any Medicare revenues and costs not included in its Medicare CostReport(s) for the year (for example, revenues and costs for freestanding ambulatory surgery centers, physician services billed by the organization, clinical laboratory services, and revenues and costs of Medicare Part C and Part D programs.) The organization may report in Part VI a reconciliation of amounts reportable in Section B (including the surplus or shortfall reported on line 7) and all of the organization's total revenues and total expenses attributable to Medicare programs.

If the organization received any prior year settlements for Medicare-related services in the current taxable year, it can provide an explanation in Part VI.

Section C. This section requires reporting of the organization's written debt collection policy.

Line 9a. Answer "Yes" if the organization has a written debt collection policy on the collection of amounts owed by patients.

Line 9b. Answer "Yes" if the organization's written debt collection policy contains provisions for collecting amounts due from those patients who the organization knows qualify for charity care or financial assistance. If the organization answers "Yes," describe in Part VI the collection practices that it follows with respect to such patients, whether or not such practices apply specifically to such patients or more broadly to also cover other types of patients.

Part IV. Management Companies and Joint Ventures (Optional for 2008)

List any joint venture or other separate entity (whether treated as a partnership or a corporation), including joint ventures outside of the United States, of which the organization is a partner or shareholder, and any management company,

1. For which persons described in 1a and/or 1b below owned, in the aggregate, more than 10% of the share of profits of such partnership or stock of such corporation:

a. persons who were officers, directors, trustees, or key employees of the organization at any time during the organization's tax year, and

b. physicians who were employed as physicians by, or had staff privileges with, one or more of the organization's hospitals; and

2. That either
a. provided management services used by the organization in its provision of medical care, or
b. provided medical care, or owned or provided real property, tangible personal property, or intangible property used by the organization or by others to provide medical care.

Examples of such joint ventures and management companies include:

- An ancillary joint venture formed by the organization and its officers or physicians to conduct an exempt or unrelated business activity,
- A company owned by the organization's officers or physicians that owns and leases to the organization a hospital or other medical care facility, and
- A company that owns and leases to entities other than the organization diagnostic equipment or intellectual property used to provide medical care.

Note. Do not include publicly traded entities or entities whose sole income is passive investment income from interest or dividends.

For purposes of Part IV, the aggregate percentage share of profits or stock ownership percentage of officers, directors, trustees, key employees, and physicians who are employed as physicians by, or have staff privileges with, one or more of the organization's hospitals is measured as of the earlier of the close of the tax year of the organization or the last day the organization was a member of the joint venture. All stock, whether common or preferred, is considered stock for purposes of determining the stock ownership percentage. Provide all the information requested below for each such entity.

Column (a). State the full legal name of the entity.

Column (b). Describe the primary business activity or activities conducted by the management company, joint venture, or separate entity.

Column (c). Enter the organization's percentage share of profits in the partnership, or stock in the entity that is owned by the organization.

Column (d). Enter the percentage share of profits or stock in the entity owned by all of the organization's current officers, directors, trustees, or key employees.

Column (e). Enter the percentage share of profits or stock in the entity owned by all physicians who are employees practicing as physicians or who have staff privileges with one or more of the organization's hospitals.

If a physician described above is also a current officer, director, trustee, or key employee of the organization, include his or her profits or stock percentage in column (d). Do not include in column (e).

Part V. Facility Information (Required for 2008)

Complete Part V by providing in column (a), the name and address of each of the organization's facilities that, at any time during the tax year, was required to be licensed, registered, or similarly recognized as a health care facility under state law, whether such facility is operated directly by the organization or indirectly through a disregarded entity or joint venture taxed as a partnership. For each facility in column (a), check the columns applicable to that facility.

The organization must list in Part VI, line 1 the number of each type of facility other than those required to be licensed, registered, or similarly recognized as a health care facility under state law (for example, 2 rehabilitation clinics, 4 diagnostic centers, 3 skilled nursing facilities, etc.).

"Licensed hospital" is a facility licensed, registered, or similarly recognized by a state as a hospital.

"General medical and surgical" refers to a hospital primarily engaged in providing diagnostic and medical treatment (both surgical and nonsurgical) to inpatients with a wide variety of medical conditions, and that may provide outpatient services, anatomical pathology services, diagnostic X-ray services, clinical laboratory services, operating room services, and pharmacy services.

"Children's hospital" is a center for provision of health care to children, and includes independent acute care children's hospitals, children's hospitals within larger medical centers, and independent children's specialty and rehabilitation hospitals.

"Teaching hospital" is a hospital that provides training to medical students, interns, residents, fellows, nurses, or other health professionals and providers, provided that such educational programs are accredited by the appropriate national accrediting body.

"Critical access hospital" (CAH) is a hospital designated as a CAH by a state that has established a State Medicare Rural Hospital Flexibility Program in accordance with Medicare rules.

"Research facility" is a facility that conducts research.

"ER-24 hours" refers to a facility that operates an emergency room 24 hours a day, 365 days a year.

"ER-other" refers to a facility that operates an emergency room for periods less than 24 hours a day, 365 days a year.

Complete the "Other (Describe)" column for each type of health care facility (for example, outpatient physician clinic, long-term acute care facility, diagnostic center, rehabilitation clinic, skilled nursing facility, etc.) that the organization owns or operates that is not described in the other columns of Part V.

Part VI. Supplemental Information (Optional for 2008)

Line 1. Provide the supplemental information for the following parts.

Part I, line 3c. If applicable, describe the income-based criteria for determining eligibility for free or discounted care under the organization's charity care policy. Also describe whether the organization uses an asset test or other threshold, regardless of income, to determine eligibility for free or discounted care.

Part I, line 6a. If the organization's community benefit report is contained in a report prepared by a related organization, rather than in a separate report prepared by the organization, identify the related organization.

Part I, line 7g. If applicable, describe whether the organization included as subsidized health services any costs attributable to a physician clinic, and report such costs the organization included.

Part I, line 7, column (f). If applicable, state the bad debt expense included on Form 990, Part IX, line 25, column (A), but subtracted for purposes of calculating the percentage in this column.

Part I, line 7. Provide an explanation of the costing methodology used to calculate the amounts reported in the Table. If a cost accounting system was used, indicate whether the cost accounting system addresses all patient segments (for example, inpatient, outpatient, emergency room, private insurance, Medicaid, Medicare, uninsured, or self pay). Also, indicate whether a cost-to-charge ratio was used for any of the figures reported in the Table. Describe whether this cost-to-charge ratio was derived from Worksheet 2, Ratio of Patient Care Cost-to-Charges, and, if not, what kind of cost-to-charge ratio was used and how it was derived. If some other costing methodology was used besides a cost accounting system, cost-to-charge ratio, or a combination of the two, describe the method used.

Part III, line 4. Provide the rationale and the costing methodology used to determine the amount reported in Part III, lines 2 and 3. Describe how the organization accounts for discounts and payments on patient accounts in determining bad debt expense. Also describe the method the organization uses to determine the amount that reasonably could be attributable to patients who likely would qualify for financial assistance under the hospital's charity care policy, if sufficient information had been available to make a determination of their eligibility.

Also, provide, if applicable, the text of the footnote to the organization's financial statements that describes bad debt expense. If the organization's financial statements include a footnote on these issues that also includes other information, report only the relevant portions of the footnote. If the organization's financial statements do not contain such a footnote, state that the organization's financial statements do not include such a footnote, and explain how the financial statements account for bad debt, if at all.

Part III, line 8. Describe the costing methodology used to determine the Medicare allowable costs reported in the organization's Medicare Cost Report, as reflected in the amount reported in Part III, line 6. Describe, if applicable, the extent to which any shortfall reported in Part III, line 7, should be treated as a community benefit, and the rationale for the organization's position.

Part III, line 9b. If the organization has a written debt collection policy and answered "Yes," to Part III, line 9b, describe the collection practices set forth in the policy that apply to patients who it knows qualify for charity care or financial assistance, whether or not such practices apply specifically to such patients or more broadly to also cover other types of patients.

Part V. List the number of each type of facility, other than those required to be licensed, registered, or similarly recognized as a health care facility under state law (for example, 2 rehabilitation clinics, 4 diagnostic centers, 3 skilled nursing facilities, etc.).

Line 2. Describe whether, and, if so, how, the organization assesses the health care needs of the community or communities it serves.

Line 3. 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 charity care policy. For example, state whether the organization posts its charity care policy, or a summary thereof, and financial assistance contact information in admissions areas, emergency rooms, and other areas of the organization's facilities where eligible patients are likely to be present; provides a copy of the policy, or a summary thereof, and financial assistance contact information to patients as part of the intake process; provides a copy of the policy, or a summary thereof, and financial assistance contact information to patients with discharge materials; includes the policy, or a summary thereof, along with financial assistance contact information, in patient bills; or discusses with the patient the availability of various government benefits, such as Medicaid or state programs, and assists the patient with qualification for such programs, where applicable.

Line 4. Describe the community or communities the organization serves, taking into account the geographic service area(s) (for example, urban, suburban, rural, etc.), the demographics of the community or communities (for example, population, average income, percentages of community residents with incomes below the federal poverty guideline, percentage of the hospital's and community's patients who are uninsured or Medicaid recipients, etc.), the number of other hospitals serving the community or communities, and whether one or more federally-designated medically underserved areas or populations are present in the community.

Line 5. Describe how the organization's community building activities, as reported in Part II, promote the health of the community or communities the organization serves.

Line 6. Provide any other information important to describing how the organization's hospitals or other health care facilities further its exempt purpose by promoting the health of the community or communities, including but not limited to whether:

- A majority of the organization's governing body is comprised of persons who reside in the organization's primary service area who are neither employees nor contractors of the organization, nor family members thereof;
- The organization extends medical staff privileges to all qualified physicians in its community for some or all of its departments; and
- How the organization applies surplus funds to improvements in patient care, medical education, and research.

Line 7. 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 by the system. For purposes of this question, an "affiliated health care system" is a system that includes affiliates under common governance or control, or that cooperate in providing health care services to their community or communities.

Line 8. Identify all states with which the organization files (or a related organization files on its behalf) a community benefit report. Report only those states in which the organization's own community benefit report is filed, either by the organization itself or by a related organization on the organization's behalf.

About AHA

Membership

Member Constituency Sections

Key Relationships

News Center

Performance Improvement

Advocacy Issues

Products & Services

Publications

Research & Trends

Locations

155 N. Wacker Dr.
Chicago, Illinois 60606
312.422.3000

800 10th Street, N.W.
Two CityCenter, Suite 400
Washington, DC 20001-4956
202.638.1100

1.800.424-4301