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
EDWARD JOHN NOBLE HOSPITAL
 
Employer identification number

23-7204872
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) . . . 		    609,400 416,910 192,490 1.090 %
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 . . . . .     609,400 416,910 192,490 1.090 %
Other Benefits
e Community health improvement services and community benefit operations (from Worksheet 4).     135,539   135,539 0.770 %
f Health professions education (from Worksheet 5) . . .            
g Subsidized health services (from Worksheet 6) . . . .            
h Research (from Worksheet 7) .            
i Cash and in-kind contributions for community benefit (from Worksheet 8) . . . .            
j Total. Other Benefits . .     135,539   135,539 0.770 %
k Total. Add lines 7d and 7j .     744,939 416,910 328,029 1.860 %
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
1,080,703
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
0
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
2,352,641
6
Enter Medicare allowable costs of care relating to payments on line 5.....
6
2,016,985
7
Subtract line 6 from line 5. This is the surplus (or shortfall)........
7
335,656
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 EDWARD JOHN NOBLE HOSPITAL
77 WEST BARNEY STREET
GOUVERNEUR,NY13642 		  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)
EDWARD JOHN NOBLE 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 Yes  
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 Yes  
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: 201.000000000000%
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: 449.000000000000%
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
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
EDWARD JOHN NOBLE HOSPITAL PART V, SECTION B, LINE 4: CANTON POTSDAM HOSPITAL, PUBLIC HEALTH, CLIFTON FINE HOSPITAL, CLAXTON HEPBURN MEDICAL CENTER, COUNTY OF ST. LAWRENCE, MASSENA MEMORIAL HOSPITAL, ST. LAWRENCE COUNTY HEALTH INTIATIVE.
EDWARD JOHN NOBLE HOSPITAL PART V, SECTION B, LINE 20D: A SLIDING FEE/ CHARITY CARE POLICY IS USED.
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
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?  
Name and address Type of Facility (describe)
1
2
3
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 COSTING METHODOLOGY USED IN PART I IS THE COST-TO-CHARGE RATIO METHOD. THE RATIO WAS DERIVED FROM WORKSHEET 2 INCLUDED IN THE INSTRUCTIONS.
PART II, COMMUNITY BUILDING ACTIVITIES: WE PROVIDE COMMUNITY SERVICE FOR BUSINESSES IN THE INDUSTRY WITHIN OUR ENCATCHMENT, PROVIDE FLU SHOTS, EMPLOYEE PHYSICALS, AND BREATH ALCOHOL AND DRUG TESTING.
PART III, LINE 4: THE AMOUNT REPORTED ON LINE 2 FOR BAD DEBT EXPENSE IS DETERMINTED BY COST, AND AGREES TO THE BAD DEBT EXPENSE REPORTED ON THE FINANCIAL STATEMENTS. THE AMOUNT REPORTED ON LINE 3 IS FROM THE 2013 ICR, WHICH IS CALCULATED USING THE COST-TO-CHARGE RATIO. FOOTNOTE FOR ACCOUNTS RECEIVABLE AND ALLOWANCE FOR DOUBTFUL ACCOUNTS: THE HOSPITAL HAS AGREEMENTS WITH THIRD-PARTY PAYORS THAT PROVIDE FOR PAYMENTS AT AMOUNTS DIFFERENT FROM ITS ESTABLISHED RATES. PAYMENT ARRANGEMENTS INCLUDE PROSPECTIVELY DETERMINED RATES PER DISCHARGE OR VISIT, COST-BASED REIMBURSEMENT, DISCOUNTED CHARGES AND PER DIEM PAYMENTS. NET PATIENT SERVICE REVENUE AND THE RELATED PATIENT ACCOUNTS RECEIVABLE ARE REPORTED AT THE ESTIMATED NET REALIZABLE AMOUNTS FROM PATIENTS, THIRD-PARTY PAYORS AND OTHERS FOR SERVICES RENDERED, INCLUDING ESTIMATED RETROACTIVE ADJUSTMENTS DUE TO FUTURE AUDITS, REVIEWS AND INVESTIGATIONS. RETROACTIVE ADJUSTMENTS ARE INCLUDED IN THE RECOGNITION OF PATIENT SERVICE REVENUE ON AN ESTIMATED BASIS IN THE PERIOD THE RELATED SERVICES ARE RENDERED AND ADJUSTED IN FUTURE PERIODS AS ADJUSTMENTS BECOME KNOWN OR AS YEARS ARE NO LONGER SUBJECT TO SUCH AUDITS, REVIEWS AND INVESTIGATIONS. FOR UNINSURED PATIENTS THAT DO NOT QUALIFY FOR CHARITY CARE, THE HOSPITAL RECOGNIZES REVENUE ON THE BASIS OF ITS STANDARD RATES FOR SERVICES PROVIDED. ON THE BASIS OF HISTORICAL EXPERIENCE, A SIGNIFICANT PORTION OF THE HOSPITAL'S UNINSURED PATIENTS WILL BE UNABLE OR UNWILLING TO PAY FOR SERVICES PROVIDED. THUS, THE HOSPITAL RECORDS A PROVISION FOR BAD DEBTS RELATED TO UNINSURED PATIENTS IN THE PERIOD THE SERVICES ARE PROVIDED.
PART III, LINE 8: APPROXIMATELY 10% OF THE SHORTFALL IS ABSORBED BY THE COMMUNITY BENEFIT. THE MEDICARE COST REPORT, WHICH USES THE COST-TO-CHARGE RATIO IS USED TO DETERMINE THE AMOUNT REPORTED ON PART III, LINE 6.
PART III, LINE 9B: THE CREDIT AND COLLECTIONS OFFICE AND/ OR PATIENT ADVOCATE WILL MAKE INTERMITTENT ATTEMPTS TO CONTACT PATIENTS WITH NO INSURANCE REGARDING FINANCIAL ASSISTANCE OPTIONS. A PATIENT ACCOUNT IS NOT REFERRED TO COLLECTION SERVICES UNTIL AT LEAST 120 DAYS AFTER THE DATE OF SERVICE/DISCHARGE OR AFTER AN APPLICATION FOR FINANCIAL ASSISTANCE HAS BEEN ACCEPTED/DENIED BY THE FACILITY, WHICHEVER IS LONGER. BILLS AND COLLECTION NOTICES WILL ROUTINELY BE HELD ONCE A PATIENT HAS INITIATED THE APPLICATION PROCESS FOR FINANCIAL ASSISTANCE.
PART VI, LINE 2: PRIORITIES FOR IMPLEMENTING CLINICS ARE REVIEWED AND DISCUSSED AT ADMINISTRATIVE STAFF MEETINGS ON A MONTHLY BASIS. THE CFO, CEO, DIRECTOR OF NURSING, HR DIRECTOR AND THE NURSING MEDICAL DIRECTOR ARE INVOLVED IN THE REVIEWING OF THESE PROGRAMS. WE SHARE OUR ANALYSIS OF A POTENTIAL PROGRAM WITH THE EXECUTIVE COMMITTEE AND BOARD OF TRUSTEES, AS DEEMED NECESSARY WE WILL CALL TOGETHER A JOINT CONFERENCE COMMITTEE WITH THE BOARD AND MEDICAL STAFF TO FURTHER ANALYSIS A POTENTIAL CLINICAL IMPLEMENTATION. THE HOSPITAL HAS OVER THE YEARS ESTABLISHED NYS APPROVED CLINICS IN THE FOLLOWING COMMUNITIES WITHIN THE ENCATCHMENT AREAS ANTWERO, DEKALB, RUSSELL AND EDWARDS. EACH CLINIC IS STAFFED BY A PHYSICIAN OR PHYSICIAN ASSISTANT THAT INTERFACES WITH THE HOSPITAL. WE ALSO SERVE AS A REFERENCE TO TERRITORY CARE CENTERS IN SYRACUSE FOR CARDIOLOGY AND GENERAL TRAUMA. WE WORK CLOSE WITH ST LAWRENCE PUBLIC HEALTH TO DETERMINE IMPROVEMENTS IN PRIMARY PATIENT CARE NEEDS IN RESPIRATORY THERAPY, WITH CONCERNS SUCH AS ELIMINATION OF SMOKING AND CANCER AWARENESS.
PART VI, LINE 3: WE HAVE A FINANCIAL ASSISTANCE POLICY AVAILABLE IN THE ER, WAITING ROOM PATIENT REGISTRATION, PATIENT ACCOUNTING OFFICE, CREDIT COLLECTIONS, OUTPATIENT CLINICS, AND IT IS PRINTED ON THE PATIENT BILLS THAT WE OFFER FINANCIAL ASSISTANCE.
PART VI, LINE 4: EDWARD JOHN NOBLE HOSPITAL IS A RURAL SOLE-COMMUNITY MEDICAL, SURGICAL HOSPITAL THAT SERVES A LARGE GEOGRAPHICAL AREA OF SOUTHERN ST. LAWRENCE, WEST LEWIS AND NOTHERN JEFFERSON COUNTIES. THE POPULATION SERVICE AREA IS 22,000 AND THE PRIMARY INDUSTRIES ARE AGRICULTURE, MINING (LEAD, ZINC, TALC, IRON ORE) WITH HEADQUARTERS FOR A REGIONAL RETAIL DRUG STORE.
PART VI, LINE 5: EDWARD JOHN NOBLE HOSPITAL PROVIDES CONTINUOUS COMMUNITY FORUMS ON CURRENT HEALTH CARE TOPICS AT THE HOSPITALS CONTINUING EDUCATION CENTER. WE WORK CLOSELY WITH THE GOUVERNEUR RESCUE SQUAD FOR VARIOUS CATEGORIES OF EMT TRAINING. HOSPICE ACTIVITIES, MOMS-TO-BE PROGRAM, WEIGHT WATCHERS, BREAST CANCER SURVIVORS, EACH OF THESE UTILIZE THE EDUCATION PROGRAM TO MAINTAIN THESE COMMUNITY SERVICE PROGRAMS.
PART VI, LINE 7, REPORTS FILED WITH STATES NY
Schedule H (Form 990) 2013
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