SCHEDULE H
(Form 990)
Department of the Treasury
Internal Revenue Service
Hospitals
MediumBullet Complete if the organization answered "Yes" to Form 990, Part IV, question 20.
MediumBullet Attach to Form 990. MediumBullet See separate instructions.
MediumBullet Information about Schedule H (Form 990) and its instructions is at www.irs.gov/form990.
OMB No. 1545-0047
2013
Open to Public Inspection
Name of the organization
CHINESE HOSPITAL ASSOCIATION
 
Employer identification number

94-0382780
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.
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
Yes
 
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
 
%
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

Yes

 
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 discountedcare 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
Yes
 
b
If "Yes," did the organization make it available to the public? . . . . . . . . . . . . .
6b
Yes
 
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) . . . 		    338,744   338,744 0.330 %
b Medicaid (from Worksheet 3, column a) . . . . .     5,435,638 3,887,882 1,547,756 1.500 %
c Costs of other means-tested government programs (from Worksheet 3, column b) . .            
d Total Financial Assistance and Means-Tested Government Programs . . . . .     5,774,382 3,887,882 1,886,500 1.830 %
Other Benefits
e Community health improvement services and community benefit operations (from Worksheet 4).     175,298   175,298 0.170 %
f Health professions education (from Worksheet 5) . . .     201,507   201,507 0.200 %
g Subsidized health services (from Worksheet 6) . . . .     4,509,326 843,196 3,666,130 3.560 %
h Research (from Worksheet 7) .            
i Cash and in-kind contributions for community benefit (from Worksheet 8) . . . .            
j Total. Other Benefits . .     4,886,131 843,196 4,042,935 3.930 %
k Total. Add lines 7d and 7j .     10,660,513 4,731,078 5,929,435 5.760 %
For Paperwork Reduction Act Notice, see the Instructions for Form 990. Cat. No. 50192T Schedule H (Form 990) 2013
Schedule H (Form 990) 2013
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
Yes
 
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
257,396
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
11,104,197
6
Enter Medicare allowable costs of care relating to payments on line 5.....
6
14,632,926
7
Subtract line 6 from line 5. This is the surplus (or shortfall)........
7
-3,528,729
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:
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) 2013
Schedule H (Form 990) 2013
Page
Part VFacility 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, primary website address, and state license number 		Licensed Hospital General-Medical-Surgical Children's Hospital Teaching Hospital Critical Hospital ResearchGrp Facility ER-24Hours ER-Other Other (Describe) Facility reporting group
1 Chinese Hospital
845 Jackson Street
San Francisco,CA94133 		X X         X      
Schedule H (Form 990) 2013
Schedule H (Form 990) 2013
Page
Part VFacility 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)
Chinese Hospital
Name of hospital facility or facility reporting group  
If reporting on Part V, Section B for a single hospital facility 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
b
c
d
e
f
g
h
i
j
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 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 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
b
c
d
6 If the hospital facility addressed needs identified in its most recently conducted CHNA, indicate how (check all that apply
as of the end of the tax year):
a
b
c
d
e
f
g
h
i
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) 2013
Schedule H (Form 990) 2013
Page
Part VFacility 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 Yes  
If "Yes," indicate the FPG family income limit for eligibility for free care: 350.%
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: 350.%
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
b
c
d
e
f
g
h
i
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
b
c
d
e
f
g
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 individual’s eligibility under the facility’s FAP:
a
b
c
d
e
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 individual’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
b
c
d
e
Schedule H (Form 990) 2013
Schedule H (Form 990) 2013
Page
Part VFacility 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
b
c
d
e
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
b
c
d
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
b
c
d
21 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? ............................... 21   No
If "Yes," explain in Part VI.
22 During the tax year, did the hospital facility charge any FAP-eligible individual an amount equal to the gross charge for any service provided to that individual?.......................... 22   No
If "Yes," explain in Section C.
Schedule H (Form 990) 2013
Schedule H (Form 990) 2013
Page
Part V
Facility Information (continued)
Section C. Supplemental Information for Part V, Section B.Provide descriptions required for Part V, Section B, lines 1j, 3, 4, 5d, 6i, 7, 10, 11, 12i, 14g, 16e, 17e, 18e, 19c, 19d, 20d, 21, and 22. If applicable, provide separate descriptions for each facility in a facility reporting group, designated by "Facility A," "Facility B," etc.
Form and Line Reference Explanation
CHNA Identified Needs not addressed: Part V, Line 3 The Hospital's CHNA was conducted in conjunction with the San Francisco Department of Public Health and the San Francisco Planning Department as part of the development of the San Francisco Health Care Service Master Plan. Comprised of a broad range of community stakeholders representing health care consumers, community advocacy groups, labor, hospitals, and more, the task force served as an advisory body charged with developing recommendations that reflected both relevant data and community feedback. Between July 2011 and May 2012 the taks force met 10 times, meeting in neighborhoods as well as having meetings to discuss specific issues affecting healthcare access in San Francisco. The task force meetings were open to the public and neighborhoodd meetings allotted time on the agendas for community members to comment. The task force consisted of persons from varying segments of the population including representatives from the San Francisco Department of Public Health, San Francisco Unified School District, Aids Housing Allowance, Chinese Hospital, Kaiser Permanente, UCSF Medical Center, San Francisco Municipal Transit Authority, California Nurses Association, and many others. Part V, Line 7 The recommendation to improve local health data collection and dissemination efforts has not been addressed because the development of the "Healthshare Bay Area" (HSBA) as a central repository for patient information has been placed on hold due to several factors: 1. Many hospitals and physician practices were converting to EHR systems and 2. Lack of funding to support the development of the repository for San Francisco. Chinese Hospital is a member of the Governing Committee for the development of HSBA and will re-engage if the committee reconvenes.
part v, section b, line 14g the policy was made available on the office of statewide health planning and development's (OSHPD) website.
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
Schedule H (Form 990) 2013
Schedule H (Form 990) 2013
Page
Part VFacility 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?3
Name and address Type of Facility (describe)
1 Excelsior Health Services
888 Paris Street
San Francisco,CA94112 		Clinic
2 Daly City Health Services
93 Skyline Plaza
Daly City,CA94015 		Clinic
3 Sunset Health Services
1800 31st Avenue
San Francisco,CA94122 		Clinic
4
5
6
7
8
9
10
Schedule H (Form 990) 2013
Schedule H (Form 990) 2013
Page
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.
Form and Line Reference Explanation
Part I, Line 7 The cost to charge ratio was not derived from worksheet 2, ratio of patient care cost-to-charges. The ratio of costs per charges used for the amounts entered in the table in Part I line 7 were derived from the Hospital's 2013 Medicare Cost Report. PART III, LINE 2 the costing methodology used in determing the amount reported on Part III line 2 consists of the charges that are deemed to be bad debt multiplied by the ratio of cost-to-charges as reported on the Hospital's Medicare Cost Report. The Hospital takes extraordinary care to identify patients eligible for either charity care or for discount care status. If a patient comes in as a self-pay, they either pay immediately or are asked to provide the Hospital with the necessary supporting documentation that would allow them to qualify for charity care status or discount care status. If the patient declines to provide such documentation, the amount owed then becomes a patient receivable. The Hospital's experience is that there is very little bad debt that would have qualified as charity care because of the fact that the Hospital works very hard with the patients to qualify them. Overall the amount of patient bad debt experienced by the hospital has been very small. PART III, LINE 3 The Hospital follows HFMA Statement 15 and therefore no part of bad debt, as defined by Statement 15, represents amounts attributable to patients eligible to receive financial assistance. Part III, Line 4 footnote from the audited financial statement: the hospital's patient accounts receivables consists of amounts owed by various governmental agencies, insurance companies, and private patients. the hospital manages the receivables by regularly reviewing its accounts and contracts and by providing appropriate allowances for uncollectible amounts.
Part III, Line 8 The shortfall is primarily a result of Chinese Hospital serving one of the most disproportionately low-income populations of any hospital in the United States. Over 90% of our Medicare beneficiaries qualify as low-income. To assist hospitals serving a large number of low-income Medicare and Medicaid patients, Congress established the disproportionate share hospital payment (DSH)payment adjustment under Section 1886(d)(5)(F) of the Social Security Act. Depending on the type and size of the hospital, the DSH percentage is used in a formula to determine the actual adjustment factor for inpatients. Because we are classified as an urban hospital with fewer than 100 beds our DSH adjustment is capped at a 12% add-on payment instead of 64% add-on payment. The difference in DSH add-on payment is approximately $4 million. Given this unique situation, we could justify including the shortfall reported in line 7 as a community benefit. The amounts reported in lines 5, 6 and 7 come from the Hospital's filed Medicare Cost Report. The total revenue equates to Medicare payments and the Medicare Allowable Costs are determined on the Medicare Cost Report that utilized cost to charge ratios applied to covered Medicare Revenues.
Part III, Line 9b The Hospital posts the collection policies at the Hospital's centralized registration location. The Hospital's charity care and discounted payment policies are available on the Hospital's web-site and also on the State of California's Office of Statewide Health Planning web-site. Self pay patients are usually screened using the patient's historical income applied against 350% of the FPL in determining their charity care qualifications. However, there are some patients who are unwilling to provide their income information to determine if they qualify for charity care or discounted payment. If these patients do not pay, they are sent a data mailer requesting contact or payment every 15 days. If there's no response, a final notice is sent 30 days after the sending of the 3rd data mailer. If there's no response to the final notice, the account is turned over to an external collection agency. During this process, should information become available that indicates the patient could be eligible for charity care, the account is returned to the hospital so that we may work with the patient to qualify them for charity care or other financial assistance.
Needs Assessment The Hospital's assessment process includes surveys of program participants, community members including agencies and providers, Chinese Community Health Plan (CCHP) members and providers, Chinese Community Health Care Association (CCHCA) members and providers and the Hospital patients and staff. Survey respondents are asked for program topics or issues that they would like to have addressed. A review of health trends and local community needs based on health statistics is also done. Topic suggestions are sent to Chinese Community Health Resource Center's (CCHRC) Advisory Committee. The Committee prioritizes topics for implementation, or non-implementation.
Patient Education of Elegibility for Assistance The Hospital serves a large population of low-income patients. Over 90% of our Medicare patients meet the federal criteria for "low-income." Its wholly owned subsidiary CCHP offers a low cost commercial insurance product for individuals and employer groups, most of which represent small asian businesses. our integrated healthcare delivery system also serves managed care Medicaid enrollees (San Francisco Health Plan) in the communITY. Our integrated healthcare delivery system became the first private sector organization to offer a medical home to individuals participating in the Healthy San Francisco Program for individuals with incomes that are less than 300% of the FPL. All these programs are widely publicized in both English and Chinese (electronically and in hard-copy) to the community. This information is on the websites of the three organizations that make up the integrated delivery system, Chinese Hospital, CCHP and CCHCA (IPA organization). These three organizations sponsor the Chinese Community Health Resource Center, a nonprofit organization with the mission to build a healthy community through culturally and linguistically competent preventive health, disease management, and research programs. Our financial assistance policy is also posted in the admitting area and in the ER. If a person enters the hospital without insurance they are provided the policy and patient accounting will provide assistance.
Community Information The Hospital provides access and care for a large number of underserved, low income patients - serving as a San Francisco safety net hospital. The indigent and elderly monolingual Asians of Chinatown have made Chinese Hospital their point of access to the medical system. The primary service area is the greater Chinatown and North Beach districts of San Francisco. Because of our unique bilingual programs and sensitivity to cultural traditions, residents from other San Francisco neighborhoods and cities of the bay area travel to Chinese Hospital for their health care needs. In 1987 Chinese Hospital and its partner physician group created Chinese Community Health Plan (CCHP)as a managed care insurance plan. Chinese Hospital through CCHP is able to offer affordable insurance options to individuals and many asian small businesses located in San Francisco. as a result, Chinese Hospital sees very few uninsured patients. To improve healthcare access to the expanding asian population in the western part of San Francisco, three community clinics were added. these clinics provide a wide-range of culturally competent healthcare services. Demographics of the community served: 77% of our patients are on Medicare. 91% of these patients are Medicare/ Medicaid eligible and serves a proxy for utilization by low-income patients in the community. Another 10% are Medicaid. The community the Hospital serves contains multiple federally-designated medically underserved areas. There are six other hospitals in San Francisco.
State Filing of Community Benefit Report The Hospital files a Community Benefit Report in California.
Promotion of Community Health A majority of the Hospital's governing body is comprised of persons who reside in the Hospital's primary service area and who are neither employees nor independent contractors of the organization, nor family members thereof. The Hospital extends medical staff privileges to all physicians in the community who apply for such privileges and meet the required medical qualifications. The Hospital's surplus funds are applied to improvements in patient care, medical education, and research as determined by the governing body's finance committee. This committee oversees the operating and capital budgeting process and makes recommendations to the full board regarding resource use. See the Community Benefit Report contained in Schedule O for additional information.
Schedule H (Form 990) 2013
Additional Data


Software ID:  
Software Version: