SCHEDULE H
(Form 990)


Department of the Treasury
Internal Revenue Service
Hospitals

To be completed by organizations that answer "Yes" to Form 990, Part IV, line 20.


Part I      Charity Care and Certain Other Community Benefits at Cost

1a  Does the organization have a charity care policy? If "No," skip to question 6a       
   b If "Yes," is it a written policy?       
2 If the organization has multiple hospitals, indicate which of the following best describes application of the charity care policy to the various hospitals.
 Applied uniformly to all hospitals
 Applied uniformly to most hospitals
 Generally tailored to individual hospitals
      
3 Answer the following based on the charity care eligibility criteria that applies to the largest number of the organization's patients.
      
  a Does the organization use Federal Poverty Guidelines (FPG) to determine eligibility for providing free care to low income individuals?       

If "Yes," indicate which of the following is the family income limit for eligibility for free care:
 100%        150%        200%        Other %
      
  b Does the organization use FPG to determine eligibility for providing discounted care to low income individuals?       

If "Yes," indicate which of the following is the family income limit for eligibility for discounted care:
 200%        250%        300%        350%        400%        Other %
      
  c If the organization does not use FPG to determine eligibility, describe in Part VI the income based criteria for determining eligibility for free or discounted care. Include in the description whether the organization uses an asset test or other threshold, regardless of income, to determine eligibility for free or discounted care.       
4 Does the organization's policy provide free or discounted care to the "medically indigent"?       
5a Does the organization budget amounts for free or discounted care provided under its charity care policy?       
  b If "Yes," did the organization's charity care expenses exceed the budgeted amount?       
  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?       
6a Does the organization prepare an annual community benefit report?       
  b If "Yes," does the organization make it available to the public?       

Complete the following table using the worksheets provided in the Schedule H instructions. Do not submit these worksheets with the Schedule H.       
7    Charity Care and Certain Other Community Benefits at Cost
Charity Care 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 Charity care at cost (from worksheets 1 and 2)
  b Unreimbursed Medicaid (from worksheet 3, column a)
  c Unreimbursed costs--other means-tested government programs (from worksheet 3, column b)
  d Total Charity Care 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 to community groups (from worksheet 8)
  j Total Other Benefits
  k Total (line 7d and 7j)

Part II      Community Building Activities Complete this table if the organization conducted any community building activities.

(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
   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
1 Does the organization report bad debt expense in accordance with Healthcare Financial Management Association Statement No. 15?       
2 Enter the amount of the organization's bad debt expense (at cost)       
3 Enter the estimated amount of the organization's bad debt expense (at cost) attributable to patients eligible under the organization's charity care policy       
4 Provide the text of the footnote to the organization's financial statements that describes bad debt expense. In addition, describe the costing methodology used in determining the amounts reported on lines 2 and 3, or rationale for including other bad debt amounts in community benefit.
      
Section B. Medicare
5 Enter total revenue received from Medicare (including DSH and IME)       
6 Enter Medicare allowable costs of care relating to payments on line 5       
7 Enter line 5 less line 6--surplus or (shortfall)       
8 Describe the extent to which any shortfall reported in line 7 should be treated as community benefit and the costing methodology or source used to determine the amount reported on line 6.
      

Indicate which of the following methods was used:
 Cost accounting system        Cost to charge ratio        Other      

Section C. Collection Practices
9a  Does the organization have a written debt collection policy?       
  b If "Yes," does the organization's collection policy contain provisions on the collection practices to be followed for patients who are known to qualify for charity care or financial assistance? Describe in Part VI.       

Part IV      Management Companies and Joint Ventures
(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  
14  

Part V      Facility Information

Part VI      Supplemental Information

  1    Provide the description required for Part I, line 3c; Part I, line 6a; Part I, line 7g; Part I, line 7, column (f); Part I, line 7; Part III, line 9b, and Part V. See Instructions.


   Part I, line 3c
If the organization does not use FPG to determine eligibility, describe the income based criteria for determining eligibility for free or discounted care.  Include in the description 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
Does the organization prepare an annual community benefit report?



   Part I, line 7g
Charity Care and Certain Other Community Benefits at Cost - Subsidized health services (from Worksheet 6).



   Part I, line 7, column (f)
Charity Care and Certain Other Community Benefits at Cost - (f) Percent of total expense.



   Part I, line 7
Charity Care and Certain Other Community Benefits at Cost



   Part III, line 9b
If the organization has a written debt collection policy, does the organization's collection policy contain prov isions on the collection practices to be followed for patients who are known to qualify for charity care or financial assistance?



   Part V
Facility Information


  2    Needs assessment. Describe how the organization assesses the health care needs of the communities it serves.

  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 charity care policy.

  4    Community information. Describe the community the organization serves, taking into account the geographic area and demographic constituents it serves.

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

  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 (e.g., open medical staff, community board, use of surplus funds, etc.).

  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.

  8    If applicable, identify all states with which the organization, or a related organization, files a community benefit report.


We are currently collecting questions regarding the Schedule H to present to the IRS. If you have a question for the IRS, please send it to ScheduleHquestions@aha.org.

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