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ObjectId: 201441259349300519 - Submission: 2014-05-05
TIN: 45-0222079
SCHEDULE H
(Form 990)
Department of the Treasury
Internal Revenue Service
Hospitals
Complete if the organization answered "Yes" to Form 990, Part IV, question 20.
Attach to Form 990.
See separate instructions.
OMB No. 1545-0047
20
12
Open to Public Inspection
Name of the organization
JACOBSON MEMORIAL HOSPITAL CARE CENTER
Employer identification number
45-0222079
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
Yes
b
If "Yes," was it a written policy?
.......................
1b
Yes
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
No
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
Yes
200%
250%
300%
350%
400%
Other
%
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 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
No
5a
Did the organization budget amounts for free or discounted care provided under its financial assistance policy during the tax year?
............................
5a
Yes
b
If "Yes," did the organization's financial assistance expenses exceed the budgeted amount?
......
5b
No
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 eligibile for free or discounted care?
..............
5c
6a
Did the organization prepare a community benefit report during the tax year?
..........
6a
No
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)
..
3,000
3,000
0.050 %
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
.
3,000
3,000
0.050 %
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)
..
1,502,935
1,278,251
224,684
4.100 %
h
Research (from Worksheet 7)
i
Cash and in-kind
contributions for community
benefit (from Worksheet 8)
j
Total.
Other Benefits
..
1,502,935
1,278,251
224,684
4.100 %
k
Total.
Add lines 7d and 7j
.
1,505,935
1,278,251
227,684
4.150 %
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50192T
Schedule H (Form 990) 2012
Schedule H (Form 990) 2012
Page
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 Heathcare Financial Management Association Statement No. 15?
..........................
1
No
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
284,273
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
76,754
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
1,679,747
6
Enter Medicare allowable costs of care relating to payments on line 5
.....
6
1,682,795
7
Subtract line 6 from line 5. This is the surplus (or shortfall)
........
7
-3,048
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
9a
Did the organization have a written debt collection policy during the tax year?
..........
9a
Yes
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
Yes
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) 2012
Schedule H (Form 990) 2012
Page
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?
1
Name, address, and primary website address
Other (Describe)
Facility reporting group
1
JACOBSON MEMORIAL HOSPITAL CARE CENTER
601 E ST N
ELGIN
,
ND
58553
X
X
X
X
LONG-TERM CARE FACILITY
Schedule H (Form 990) 2012
Schedule H (Form 990) 2012
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)
JACOBSON MEMORIAL HOSPITAL CARE CENTER
Name of hospital facility or facility reporting group
For single facility filers only: line Number of Hospital Facility (from Schedule H, Part V, Section A)
1
Yes
No
Community Health Needs Assessment
(Lines 1 through 8c are optional for tax years begining 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
Yes
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
12
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
Yes
4
Was the hospital facility’s CHNA conducted with one or more other hospital facilities? If “Yes,” list the other hospital facilities in Part VI
................................
4
No
5
Did the hospital facility make its CHNA report widely available to the public?
.............
5
Yes
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)
6
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)
7
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
........
7
No
8a
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)?
...........................
8a
No
b
If "Yes" to line 8a, did the organization file Form 4720 to report the section 4959 excise tax?
......
8b
c
If "Yes" to line 8b, 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) 2012
Schedule H (Form 990) 2012
Page
Part V
Facility Information
(continued)
Financial Assistance Policy
Yes
No
9
Did the hospital facility have in place during the tax year a written financial assistance policy that:
Explained eligibility criteria for financial assistance, and whether such assistance includes free or discounted care?
9
Yes
10
Used federal poverty guidelines (FPG) to determine eligibility for providing
free
care?
...........
10
No
If "Yes," indicate the FPG family income limit for eligibility for free care:
%
If "No," explain in Part VI the criteria the hospital facility used.
11
Used FPG to determine eligibility for providing
discounted
care?
.................
11
Yes
If “Yes,” indicate the FPG family income limit for eligibility for discounted care:
200.000000000000
%
If "No," explain in Part VI the criteria the hospital facility used.
12
Explained the basis for calculating amounts charged to patients?
.................
12
Yes
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
Yes
14
Included measures to publicize the policy within the community served by the hospital facility?
.......
14
Yes
If “Yes,” indicate how the hospital facility publicized the policy (check all that apply):
a
The policy was posted on the hospital facility’s website
b
The policy was attached to billing invoices
c
The policy was posted in the hospital facility’s emergency rooms or waiting rooms
d
The policy was posted in the hospital facility’s admissions offices
e
The policy was provided, in writing, to patients on admission to the hospital facility
f
The policy was available upon request
g
Other (describe in Part VI)
Billing and Collections
15
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?
.......
15
Yes
16
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:
a
Reporting to credit agency
b
Lawsuits
c
Liens on residences
d
Body attachments
e
Other similar actions (describe in Part VI)
17
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?
..........
17
No
If “Yes,” check all actions in which the hospital facility or a third party engaged:
a
Reporting to credit agency
b
Lawsuits
c
Liens on residences
d
Body attachments
e
Other similar actions (describe in Part VI)
Schedule H (Form 990) 2012
Schedule H (Form 990) 2012
Page
Part V
Facility Information
(continued)
18
Indicate which efforts the hospital facility made before initiating any of the actions listed in line 17 (check all that apply):
a
Notified individuals of the financial assistance policy on admission
b
Notified individuals of the financial assistance policy prior to discharge
c
Notified individuals of the financial assistance policy in communications with the patients regarding the patients’ bills
d
Documented its determination of whether patients were eligible for financial assistance under the hospital facility’s financial assistance policy
e
Other (describe in Part VI)
Policy Relating to Emergency Medical Care
Yes
No
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
Yes
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 Part VI)
d
Other (describe in Part VI)
Charges 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
The hospital facility used the Medicare rates when calculating the maximum amounts that can be charged
d
Other (describe in Part VI)
21
During the tax year, did the hospital facility charge any 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?
............................
21
No
If “Yes,” explain in Part VI.
22
During the tax year, did the hospital facility charge any FAP-eligible individuals an amount equal to the gross charge for any service provided to that individual?
.........................
22
Yes
If “Yes,” explain in Part VI.
Schedule H (Form 990) 2012
Schedule H (Form 990) 2012
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?
2
Name and address
Type of Facility (describe)
1
ELGIN COMMUNITY CLINIC
603 E ST N
ELGIN
,
ND
58553
RURAL HEALTH CLINIC
2
GLEN ULLIN FAMILY MEDICAL CLINIC
602 E ASH AVE
GLEN ULLIN
,
ND
58631
RURAL HEALTH CLINIC
3
4
5
6
7
8
9
10
Schedule H (Form 990) 2012
Schedule H (Form 990) 2012
Page
Part VI
Supplemental Information
Complete this part to provide the following information.
1
Required descriptions.
Provide the descriptions required for Part I, lines 3c, 6a, and 7; Part II; Part III, lines 4, 8, and 9b; Part V, Section A; and Part V, Section B, lines 1j, 3, 4, 5c, 6i, 7, 10, 11, 12h, 14g, 16e, 17e, 18e, 19c, 19d, 20d, 21, and 22.
2
Needs assessment.
Describe how the organization assesses the health care needs of the communities it serves, in addition to any needs assessments 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.
8
Facility reporting group(s).
If applicable, for each hospital facility in a facility reporting group provide the descriptions required for Part V, Section B, lines 1j, 3, 4, 5c, 6i, 7, 10, 11, 12h, 14g, 16e, 17e, 18e, 19c, 19d, 20d, 21, and 22.
Identifier
ReturnReference
Explanation
PART I, LINE 3C: THE ORGANIZATION DOES NOT OFFER FREE CARE UNDER THEIR CHARITY CARE POLICY, BUT THEY OFFER DISCOUNTED CARE BASED ON 120% OF THE FEDERAL POVERTY GUIDELINES. FAMILY SIZE IS ALSO A FACTOR IN DETERMINING DISCOUNTED CARE.
PART I, LINE 7: AN AVERAGE RATIO OF COST TO GROSS CHARGES WAS USED TO DETERMINE THE AMOUNT ON PART I, LINE 7A. LINE 7G WAS DETERMINED BASED ON THE MEDICARE COST REPORT.
PART I, L7 COL(F): THE AMOUNT OF BAD DEBT EXPENSE REMOVED FROM THE DENOMINATOR IS $284,273.
PART III, LINE 4: THE FOOTNOTE TO THE ORGANIZATION'S FINANCIAL STATEMENTS CAN BE FOUND ON PAGE 8 OF THE ATTACHED AUDITED FINANCIAL STATEMENTS.BAD DEBT EXPENSE IS REPORTED AS CHARGES SHOWN ON THE FINANCIAL STATEMENTS.WE ESTIMATE THAT 27% OF TOTAL BAD DEBT EXPENSE IS ATTRIBUTABLE TO PATIENTS WHO WERE ELIGIBLE FOR CHARITY CARE. 27% OF CHARITY CARE APPLIED FOR WAS DENIED DUE TO INCOMPLETE INFORMATION AND SO WE ESTIMATE THAT 27% OF THE BAD DEBT EXPENSE IS ATTRIBUTABLE TO PATIENTS ELIGIBLE FOR CHARITY CARE.
PART III, LINE 8: MEDICARE ALLOWABLE COSTS WERE OBTAINED FROM THE 2012 MEDICARE COST REPORT. THE MEDICARE COST REPORT IS COMPLETED BASED ON THE RULES AND REGULATIONS SET FORTH BY CENTERS FOR MEDICARE AND MEDICAID SERVICES.ALL OF THE MEDICARE SHORTFALL SHOULD BE TREATED AS A COMMUNITY BENEFIT. THE ORGANIZATION TREATS INDIVIDUALS REGARDLESS OF THE ABILITY TO PAY. MOST OF THE MEDICARE SHORTFALL COMES FROM THE NURSING HOME. THE ELDERLY ARE AN UNDERSERVED POPULATION WHO EXPERIENCE ISSUES WITH ACCESS TO HEALTHCARE SERVICES. IT IS A COMMUNITY BENEFIT TO BE ABLE TO TREAT THEM AT THE LOCAL NURSING HOME.
PART III, LINE 9B: JACOBSON MEMORIAL HOSPITAL CARE CENTER (JMHCC) HAS ESTABLISHED A COLLECTIONS POLICY AND PROCEDURE TO FACILITATE EFFECTIVE AND EFFICIENT COLLECTIONS FOR SELF-PAY BALANCES. WHEN A PATIENT SUBMITS AN APPLICATION FOR CHARITY CARE, COLLECTION PROCEEDINGS ARE STOPPED UNTIL A DECISION IS MADE. IF AN APPLICATION IS DETERMINED TO BE INCOMPLETE, A LETTER IS SENT LETTING THE PATIENT KNOW ADDITIONAL INFORMATION IS REQUIRED. IF WE STILL DO NOT RECEIVE THE ADDITIONAL INFORMATION IN 30 DAYS, THE PATIENT IS SENT A LETTER STATING THAT THEIR APPLICATION FOR CHARITY CARE HAS BEEN DECLINED AND THAT COLLECTION PROCEEDINGS COULD START AGAIN IF PAYMENTS ARE NOT MADE. WHEN A COMPLETE APPLICATION IS RECEIVED THE FINANCE COMMITTEE MEETS, WHICH INCLUDES THE CEO, CFO, AND TWO BOARD MEMBERS, AND THEY DETERMINE IF THE PATIENT QUALIFIES FOR CHARITY CARE AND FOR HOW MUCH OF A DISCOUNT. IF IT IS DETERMINED THAT A PATIENT IS ELIGIBLE FOR CHARITY CARE THEY RECEIVE A LETTER STATING SO WITH A PERCENTAGE THAT THEY QUALIFIED FOR AND AMOUNT DUE. IT IS COMMUNICATED THAT THEY ARE STILL EXPECTED TO MAKE PAYMENTS. IF A PATIENT IS SENT TO COLLECTIONS AND LATER FILLS OUT A CHARITY CARE APPLICATION AND IS FOUND TO BE ELIGIBLE FOR A DISCOUNT, WE WOULD PULL THE ACCOUNT BACK FROM COLLECTIONS AND SET UP A PAYMENT PLAN WITH THE PATIENT.
JACOBSON MEMORIAL HOSPITAL CARE CENTER
PART V, SECTION B, LINE 3: A STRATEGIC PLANNING COMMITTEE WAS FORMED OF REPRESENTATIVES FROM THE SERVICE AREA INCLUDING MEMBERS OF THE BOARD OF DIRECTORS, MEDICAL STAFF, HOSPITAL ADMINISTRATION, HOSPITAL STAFF AND COMMUNITY MEMBERS. THIS TASK FORCE PARTICIPATED IN FOUR COMMUNITY FORUMS WHERE THEY OBTAINED A SIGNIFICANT AMOUNT OF INPUT FROM KEY STAKEHOLDERS AND EXPERTS IN HEALTH CARE DELIVERY, INCLUDING PERSONS BRINGING THE NATIONAL, REGIONAL AND LOCAL PERSPECTIVE ON HOW HEALTH CARE WAS IMPACTED AT A LOCAL LEVEL.
JACOBSON MEMORIAL HOSPITAL CARE CENTER
PART V, SECTION B, LINE 6I: THE ORGANIZATION'S STRATEGIC PLAN/IMPLEMENTATION PLAN CAN BE FOUND AT: HTTP://JACOBSONHOSPITAL.ORG/ABOUT-US.HTML
JACOBSON MEMORIAL HOSPITAL CARE CENTER
PART V, SECTION B, LINE 7: THE HOSPITAL IDENTIFIED BOTH INTERNAL AND EXTERNAL GOALS FOR ADDRESSING THE NEEDS IDENTIFIED. UNDER AN OVERALL GOAL RELATED TO INCREASING AWARENESS OF SERVICES, THE HOSPITAL HAS BEGUN A THREE YEAR PLAN TO INCREASE THE AWARENESS OF COMMUNITY MEMBERS OF THE SERVICES PROVIDED BY THE HOSPITAL. UNDER THE GENERAL AREA OF INCREASED SERVICES, THE HOSPITAL HAS NOT YET ADDRESSED WHETHER IT IS FINANCIALLY FEASIBLE TO ADD A NUMBER OF NEW SERVICES INCLUDING RESPITE CARE, ADULT DAY CARE, VISITING NURSE AND SPECIALTY SERVICES, BUT HAS EXPLORED THE ADDITION OF HOSPICE SERVICES. IN ADDITION, THE HOSPITAL HAS FORMED WORKING PARTNERSHIPS WITH OTHER HOSPITALS INCLUDING ADDING "VIRTUAL" HEALTHCARE OPTIONS TO INCREASE SERVICES PROVIDED. THEY ARE ALSO ACTIVELY REVIEWING THE POTENTIAL TO ADD MORE SENIOR INDEPENDENT, ASSISTED AND PUBLIC HOUSING OPTIONS TO ASSIST WITH THE NEEDS OF THE ELDERLY POPULATIONS. IN THE AREA OF RECRUITMENT THEY HAVE SUCCESSFULLY RECRUITED A FULL-TIME PHYSICIAN AND BEGUN AN LPN TRAINING PROGRAM. THEY WILL CONTINUE TO REVIEW BENEFITS TO ENSURE COMPETITIVE POSITIONS TO MAINTAIN A STRONG WORKFORCE.
JACOBSON MEMORIAL HOSPITAL CARE CENTER
PART V, SECTION B, LINE 10: THE FACILITY OFFERS DISCOUNTED CARE TO PATIENTS UP TO 200% OF FPG AND CURRENTLY DOES NOT OFFER FREE CARE.
JACOBSON MEMORIAL HOSPITAL CARE CENTER
PART V, SECTION B, LINE 11: THE CHARITY CARE PROGRAM PROVIDES DISCOUNTED CARE TO PATIENTS BASED ON HOUSEHOLD SIZE AND FAMILY INCOME LEVELS. THE FACILITY OFFERS DISCOUNTED CARE TO PATIENTS STARTING AT 120% OF FPG AND CURRENTLY DOES NOT OFFER FREE CARE. THE SLIDING FEE SCHEDULE ALLOWS DISCOUNTS FROM 20% UP TO 90% OF THE PATIENT RESPONSIBILITY FOR SERVICES.
JACOBSON MEMORIAL HOSPITAL CARE CENTER
PART V, SECTION B, LINE 12H: FAMILY SIZE IS ALSO A FACTOR IN DETERMINING AMOUNTS CHARGED TO PATIENTS UNDER THE FINANCIAL ASSISTANCE POLICY.
JACOBSON MEMORIAL HOSPITAL CARE CENTER
PART V, SECTION B, LINE 14G: THE COMPLETE FINANCIAL ASSISTANCE POLICY IS AVAILABLE UPON REQUEST. IN ADDITION, A SUMMARY OF THE POLICY HAS BEEN MADE AVAILABLE THROUGH THEIR WEBSITE AND ADMISSIONS, WAITING ROOM AND EMERGENCY ROOM DISTRIBUTION AND RELEASES GENERAL INFORMATION ANNUALLY THROUGH THE LOCAL NEWSPAPER.
JACOBSON MEMORIAL HOSPITAL CARE CENTER
PART V, SECTION B, LINE 22: ALL INDIVIDUALS ELIGIBLE UNDER THE HOSPITAL FINANCIAL ASSISTANCE POLICY ARE PROVIDED A DISCOUNT FOR EMERGENCY AND OTHER MEDICALLY NECESSARY CARE. FAP-ELIGIBLE PATIENTS WITHOUT INSURANCE MAY BE CHARGED GROSS CHARGES ON ELECTIVE PROCEDURES.
PART VI, LINE 2: JMHCC OBTAINED INFORMATION ABOUT THE NEEDS OF THE COMMUNITY THROUGH A STRATEGIC PLANNING COMMITTEE MADE UP OF REPRESENTATIVES FROM THE SERVICE AREA INCLUDING MEMBERS OF THE BOARD OF DIRECTORS, MEDICAL STAFF, HOSPITAL ADMINISTRATION, HOSPITAL STAFF AND COMMUNITY MEMBERS. THESE INDIVIDUALS PROVIDE THE HOSPITAL WITH INSIGHT ON THE ISSUES FACING THE MEMBERS OF THE COMMUNITY. IN ADDITION, JMHCC IS CURRENTLY IN THE PROCESS OF UPDATING THEIR COMMUNITY HEALTH NEEDS ASSESSMENT AS REQUIRED BY 501(R). THEY ARE WORKING WITH CENTER FOR RURAL HEALTH, UND SCHOOL OF MEDICINE AND HEALTH SCIENCES, TO CONDUCT A SERIES OF COMMUNITY FOCUS GROUPS ON LOCAL HEALTH CARE AND PREPARING FOR THE FUTURE DELIVERY OF CARE.
PART VI, LINE 3: JACOBSON MEMORIAL HOSPITAL CARE CENTER COMMUNICATES INFORMATION ABOUT THE CHARITY CARE PROGRAM TO ITS PATIENTS AND THOSE LIVING WITHIN ITS PRIMARY SERVICE AREA, IDENTIFIES POTENTIAL APPLICANTS AND ASSISTS THE PATIENTS THAT QUALIFY FOR DISCOUNTED SERVICES WITH THE APPLICANT PROCESS. JACOBSON MEMORIAL HOSPITAL CARE CENTER INFORMS THE GENERAL PUBLIC WITHIN ITS PRIMARY SERVICE AREA OF THE AVAILABILITY OF CHARITY CARE THROUGH THE FOLLOWING: INCLUDES THE CHARITY CARE POLICY IN THE PATIENT/RESIDENT PAYMENT POLICY PROVIDED TO ALL PATIENTS AT THE POINT OF SERVICE OR ADMISSION; POSTS THE POLICY ON COMMUNITY BULLETIN BOARDS WITHIN THE JACOBSON MEMORIAL HOSPITAL CARE CENTER FACILITIES; POSTS THE POLICY AND INFORMATION ON THE JACOBSON MEMORIAL HOSPITAL CARE CENTER WEBSITE; RELEASES GENERAL INFORMATION AT LEAST ANNUALLY IN THE LEGAL NEWSPAPER LOCATED WITHIN JACOBSON MEMORIAL HOSPITAL CARE CENTER'S PRIMARY SERVICE AREA; AND OTHER AS DEEMED APPROPRIATE BY THE ADMINISTRATOR.
PART VI, LINE 4: A MARKET ANALYSIS WAS CONDUCTED BY HEALTH PLANNING AND MANAGEMENT RESOURCES INC. IN ORDER TO IDENTIFY THE GEOGRAPHIC AND DEMOGRAPHIC AREA THAT JACOBSON MEMORIAL HOSPITAL CARE CENTER SERVES. THIS ANALYSIS WAS COMPLETED IN MAY 2008 TO HELP JACOBSON MEMORIAL HOSPITAL CARE CENTER IN ITS STRATEGIC PLANNING EFFORTS. THIS STUDY SHOWED THAT THE MEDIAN HOUSEHOLD INCOME FOR THE MARKET AREA OF GRANT COUNTY IS $31,543 WHICH IS LOWER THAN THAT OF THE STATE AT $44,498. THE POPULATION OF THE MARKET AREA WAS DETERMINED TO BE 2,192. THERE ARE NO OTHER HOSPITALS THAT SERVE THE COMMUNITY. IN FACT THE NEXT NEAREST HOSPITAL IS ROUGHLY 80 MILES AWAY. IN THIS ANALYSIS IT WAS PROVEN THAT 77.8% OF ALL CLINIC AND HOSPITAL PATIENTS RESIDE IN ELGIN, CARSON OR NEW LEIPZIG. IT ALSO INDICATED THAT 58% OF THE PEOPLE IN THIS AREA ARE OVER THE AGE OF 45 AND 28% ARE OVER THE AGE OF 65.
PART VI, LINE 5: JACOBSON MEMORIAL HOSPITAL CARE CENTER (JMHCC) HAS A BOARD OF DIRECTORS MADE UP OF VOLUNTEERS AND MEMBERS OF THE COMMUNITY. JMHCC DOES EXTEND MEDICAL STAFF PRIVILEGES TO ALL QUALIFIED PHYSICIANS SERVING IN THE COMMUNITY. NET INCREASES IN NET ASSETS ARE INVESTED BACK INTO FACILITIES AND EQUIPMENT IN ORDER TO PROVIDE BETTER PATIENT CARE. IN ADDITION TO OUR CHARITY CARE POLICY, JMHCC PROVIDES MANY OTHER SERVICES TO MEET THE NEEDS OF THOSE IN GRANT COUNTY WHICH INCLUDE:-PROVIDE OFFICE SPACE SO THAT WE CAN CONTINUE TO OFFER MENTAL HEALTH SERVICES TO THE COMMUNITY ON AN OUTPATIENT BASIS.-PARTICIPATE IN A NUMBER OF COMMUNITY EVENTS EVERY YEAR INCLUDING ANNUAL DISCOUNTED LAB SERVICES DURING HOSPITAL WEEK.-PARTICIPATE IN A SCRUBS CAMP SPONSORED BY THE CENTER FOR RURAL HEALTH AND MANY OTHER LOCAL HEALTH CARE ORGANIZATIONS SUCH AS THE NEW LEIPZIG AMBULANCE AND THE LOCAL PHARMACY, VISION AND DENTAL PRACTICES.-OPERATE A 24 HOUR EMERGENCY DEPARTMENT THAT IS AVAILABLE TO ANYONE REGARDLESS OF THE ABILITY TO PAY.-OFFER VOLUNTEER OPPORTUNITIES FOR CAPABLE AREA RESIDENTS TO COME IN AND GIVE OUR LONG TERM CARE RESIDENTS AND OUR SWING-BED PATIENTS SOME ACTIVITIES TO PARTICIPATE IN.
Schedule H (Form 990) 2012
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