SCHEDULE H
(Form 990)
Department of the Treasury
Internal Revenue Service
Hospitals
MediumBullet Complete if the organization answered "Yes" on Form 990, Part IV, question 20.
MediumBullet Attach to Form 990.
MediumBullet Information about Schedule H (Form 990) and its instructions is at www.irs.gov/form990.
OMB No. 1545-0047
2016
Open to Public Inspection
Name of the organization
ALEGENT HEALTH-COMMUNITY MEMORIAL HOSPITAL OF MISSOURI VALLEYIOWA
 
Employer identification number

42-0776568
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 criteria used 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) . . .
  3,523 262,353 0 262,353 1.15 %
b Medicaid (from Worksheet 3, column a) . . . . .   3,708 3,665,088 3,929,551 0 0 %
c Costs of other means-tested government programs (from Worksheet 3, column b) . .   0 3,873 4,580 0 0 %
d Total Financial Assistance and Means-Tested Government Programs . . . . . 0 7,231 3,931,314 3,934,131 262,353 1.15 %
Other Benefits
e Community health improvement services and community benefit operations (from Worksheet 4). 13 1,055 58,005 2,873 55,132 0.24 %
f Health professions education (from Worksheet 5) . . . 4 36 4,565 0 4,565 0.02 %
g Subsidized health services (from Worksheet 6) . . . . 2 0 4,250,435 3,783,061 467,374 2.04 %
h Research (from Worksheet 7) . 1 0 1,875 263 1,612 0.01 %
i Cash and in-kind contributions for community benefit (from Worksheet 8) . . . . 5 22 24,173 2,133 22,040 0.10 %
j Total. Other Benefits . . 25 1,113 4,339,053 3,788,330 550,723 2.41 %
k Total. Add lines 7d and 7j . 25 8,344 8,270,367 7,722,461 813,076 3.55 %
For Paperwork Reduction Act Notice, see the Instructions for Form 990. Cat. No. 50192T Schedule H (Form 990) 2016
Schedule H (Form 990) 2016
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         0 0 %
2 Economic development         0 0 %
3 Community support 1   35   35 0 %
4 Environmental improvements 1   45   45 0 %
5 Leadership development and
training for community members
1   764   764 0 %
6 Coalition building 1   8,780   8,780 0.04 %
7 Community health improvement advocacy         0 0 %
8 Workforce development 1 3 157   157 0 %
9 Other         0 0 %
10 Total 5 3 9,781 0 9,781 0.04 %
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
964,371
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
15,449,001
6
Enter Medicare allowable costs of care relating to payments on line 5.....
6
21,513,124
7
Subtract line 6 from line 5. This is the surplus (or shortfall)........
7
-6,064,123
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) 2016
Schedule H (Form 990) 2016
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?1Name, address, primary website address, and state license number (and if a group return, the name and EIN of the subordinate hospital organization that operates the hospital facility)
Licensed Hospital General-Medical-Surgical Children's Hospital Teaching Hospital Critical Hospital ResearchGrp Facility ER-24Hours ER-Other Other (describe) Facility reporting group
1 AH-COM MEM HOSPITAL OF MISSOURI VALLEY
631 N 8TH ST
MISSOURI VALLEY,IA51555
www.chihealth.com
430030H
X       X   X      
Schedule H (Form 990) 2016
Page 4
Schedule H (Form 990) 2016
Page 4
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)
AH-COM MEM HOSPITAL OF MISSOURI VALLEY
Name of hospital facility or letter of facility reporting group  
Line number of hospital facility, or line numbers of hospital facilities in a facility
reporting group (from Part V, Section A):
1
Yes No
Community Health Needs Assessment
1 Was the hospital facility first licensed, registered, or similarly recognized by a state as a hospital facility in the current tax year or the immediately preceding tax year?........................ 1   No
2 Was the hospital facility acquired or placed into service as a tax-exempt hospital in the current tax year or the immediately preceding tax year? If “Yes,” provide details of the acquisition in Section C............... 2   No
3 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 12...................... 3 Yes  
If "Yes," indicate what the CHNA report describes (check all that apply):
a
b
c
d
e
f
g
h
i
j
4 Indicate the tax year the hospital facility last conducted a CHNA: 20 15
5 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 Section C how the hospital facility took into account input from persons who represent the community, and identify the persons the hospital facility consulted ................. 5 Yes  
6 a Was the hospital facility’s CHNA conducted with one or more other hospital facilities? If "Yes," list the other hospital facilities in Section C.................................. 6a   No
b Was the hospital facility’s CHNA conducted with one or more organizations other than hospital facilities?” If “Yes,” list the other organizations in Section C. ............................ 6b Yes  
7 Did the hospital facility make its CHNA report widely available to the public?.............. 7 Yes  
If "Yes," indicate how the CHNA report was made widely available (check all that apply):
a
b
c
d
8 Did the hospital facility adopt an implementation strategy to meet the significant community health needs
identified through its most recently conducted CHNA? If "No," skip to line 11. ..............
8 Yes  
9 Indicate the tax year the hospital facility last adopted an implementation strategy: 20 16
10 Is the hospital facility's most recently adopted implementation strategy posted on a website?......... 10   No
a If "Yes" (list url):  
b If "No," is the hospital facility’s most recently adopted implementation strategy attached to this return? ...... 10b Yes  
11 Describe in Section C how the hospital facility is addressing the significant needs identified in its most recently conducted CHNA and any such needs that are not being addressed together with the reasons why such needs are not being addressed.
12a 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)?............................... 12a   No
b If "Yes" on line 12a, did the organization file Form 4720 to report the section 4959 excise tax?........ 12b    
c If "Yes" on line 12b, 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) 2016
Page 5
Schedule H (Form 990) 2016
Page 5
Part VFacility Information (continued)

Financial Assistance Policy (FAP)
AH-COM MEM HOSPITAL OF MISSOURI VALLEY
Name of hospital facility or letter of facility reporting group  
Yes No
Did the hospital facility have in place during the tax year a written financial assistance policy that:
13 Explained eligibility criteria for financial assistance, and whether such assistance included free or discounted care? 13 Yes  
If “Yes,” indicate the eligibility criteria explained in the FAP:
a
b
c
d
e
f
g
h
14 Explained the basis for calculating amounts charged to patients?................. 14 Yes  
15 Explained the method for applying for financial assistance?................... 15 Yes  
If “Yes,” indicate how the hospital facility’s FAP or FAP application form (including accompanying instructions) explained the method for applying for financial assistance (check all that apply):
a
b
c
d
e
16 Was widely publicized within the community served by the hospital facility?........ 16 Yes  
If "Yes," indicate how the hospital facility publicized the policy (check all that apply):
a
HTTP://WWW.CHIHEALTH.COM/FINANCIAL-ASSISTANCE
b
HTTP://WWW.CHIHEALTH.COM/FINANCIAL-ASSISTANCE
c
d
e
f
g
h
i
j
Schedule H (Form 990) 2016
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Schedule H (Form 990) 2016
Page 6
Part VFacility Information (continued)

Billing and Collections
AH-COM MEM HOSPITAL OF MISSOURI VALLEY
Name of hospital facility or letter of facility reporting group  
Yes No
17 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 all of the actions the hospital facility or other authorized party may take upon nonpayment?.................................. 17 Yes  
18 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
f
19 Did the hospital facility or other authorized 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?............ 19   No
If "Yes," check all actions in which the hospital facility or a third party engaged:
a
b
c
d
e
20 Indicate which efforts the hospital facility or other authorized party made before initiating any of the actions listed (whether or not checked) in line 19. (check all that apply):
a
b
c
d
e
f
Policy Relating to Emergency Medical Care
21 Did the hospital facility have in place during the tax year a written policy relating to emergency medical care that required 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?.................. 21 Yes  
If "No," indicate why:
a
b
c
d
Schedule H (Form 990) 2016
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Schedule H (Form 990) 2016
Page 7
Part VFacility Information (continued)

Charges to Individuals Eligible for Assistance Under the FAP (FAP-Eligible Individuals)
AH-COM MEM HOSPITAL OF MISSOURI VALLEY
Name of hospital facility or letter of facility reporting group  
Yes No
22 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
23 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? ............................... 23   No
If "Yes," explain in Section C.
24 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? ........................... 24   No
If "Yes," explain in Section C.
Schedule H (Form 990) 2016
Page 8
Schedule H (Form 990) 2016
Page 8
Part V
Facility Information (continued)
Section C. Supplemental Information for Part V, Section B. Provide descriptions required for Part V, Section B, lines 2, 3j, 5, 6a, 6b, 7d, 11, 13b, 13h, 15e, 16j, 18e, 19e, 20e, 21c, 21d, 23, and 24. If applicable, provide separate descriptions for each hospital facility in a facility reporting group, designated by facility reporting group letter and hospital facility line number from Part V, Section A (“A, 1,” “A, 4,” “B, 2,” “B, 3,” etc.) and name of hospital facility.
Form and Line Reference Explanation
Schedule H, Part V, Section B, Line 5 Facility , 1 Facility , 1 - AH- COMMUNITY MEMORIAL HOSPITAL OF MISSOURI VALLEY. CHI Health Missouri Valley participated in the CHNA process led by Harrison County Home & Public Health (HCHPH). HCHPH employed the Mobilizing for Action Planning and Partnership (MAPP) strategy to engage community leaders as well as allow for strategic thinking to prioritize the most urgent health needs. HCHPH collected primary data from community and public health leaders through a survey that aimed to gain input on the greatest perceived community health needs. The HCHPH Community Health Needs Survey along with results can be found in the full CHNA posted online at www.chihealth.com/chna. Utilizing a sector framework, HCHPH engaged community organizations and businesses in nine community sectors: Health Human service Education Government Faith Voluntary/Civic organizations Business (retail-manufacturing) Agriculture Philanthropy Media HCHPH presented to community groups and organizations on the purpose of the community health needs assessment survey and asked organizations to distribute the survey through email to their members and contacts. Respondents to the HCHPH survey represented a good sampling of Harrison County residents. Due to the rural nature of the community, HCHPH elected to request additional input and validation of needs from key stakeholders, which represent the aging population, violence in the community and those dealing with disparities via email communication.
Schedule H, Part V, Section B, Line 6b Facility , 1 Facility , 1 - Alegent Health - Community Memorial Hospital of Missouri Valley. Harrison County Home & Public Health (HCHPH)
Schedule H, Part V, Section B, Line 7 Facility , 1 Facility , 1 - AH- COMMUNITY MEMORIAL HOSPITAL OF MISSOURI VALLEY. SHARED WITH THE HOSPITAL'S COMMUNITY BOARD IN JULY, 2016.
Schedule H, Part V, Section B, Line 11 Facility , 1 Facility , 1 - AH- COMMUNITY MEMORIAL HOSPITAL OF MISSOURI VALLEY. The following significant needs were identified during the conduct of the 2015 CHNA: Obesity Mental Health Substance Abuse Aging Problems Cancer Cardiovascular Disease Child Abuse & Neglect Unintentional Injuries Epidemiological Awareness Emergency Preparedness Health Infrastructure and Access to Care The hospital is addressing the following health needs: Priority Health Need #1: Mental Health & Substance Abuse (Behavioral Health) To address this need the hospital will implement the following strategies in 2016 to 2018: - Increase the overall awareness of existing and potential resources among community stakeholders through an established behavioral health (BH) community coalition. - Break the generational cycle of addiction and dysfunction through prevention education of parents and youth through a partnership with the schools. - Improve the community's knowledge of behavioral health and the crisis response to individuals with behavioral health needs by supporting the work of the Network and utilization of common intake form. Priority Health Need #2: Child Abuse and Neglect To address this need the hospital will implement the following strategies in 2016 to 2018: - Engage with the Healthy Harrison Coalition to identify current work, existing gaps and potential programs or interventions to address child abuse and neglect among families in Harrison County, Iowa. Priority Health Need #3: Obesity (Nutrition, Physical Activity, and Weight Status) To address this need the hospital will implement the following strategies in 2016 to 2018: - Work with Healthy Harrison Coalition to engage and partner with school districts in Harrison County to promote policies and environment change in schools to support physical activity and healthy eating habits to youth. - Provide transportation and vouchers for low-income families in Harrison County to access and benefit from local Farmer's Market. - Offer Milk Mob Training to healthcare and community professional breastfeeding advocates in Harrison County. The hospital will not address the following health needs for the following reasons: Aging: CHI Health Missouri Valley recognizes the growing aging population in Harrison County presents challenges for health services infrastructure, however Harrison County has several resources that exist to offer relevant support to elderly populations and better address the challenges that aging presents. Cancer: Cancer was not selected for work in an effort to maximize existing resources and staff time to address needs or root causes which have the potential to impact other identified health needs. Obesity was an identified health need selected for work, as it is known to be a risk factor for cancer. Cardiovascular Disease: This health needs was also not selected for work in an effort to maximize existing resources and staff time to address needs or root causes which have the potential to impact other identified health needs. Obesity was selected for work in an effort to indirectly address cardiovascular disease. Unintentional Injury: In an effort to maximize staff time and resources, and be mindful of the hospital's capacity to do this work, unintentional injury was not prioritized for work. Epidemiological Awareness: In an effort to maximize staff time and resources, and be mindful of the hospital's capacity to do this work, unintentional injury was not prioritized for work. Additionally, Harrison County Home and Public Health Agency has existing work in this area that is shared out through the Healthy Harrison Coalition. Emergency Preparedness: Harrison County Home and Public Health has existing work in this arena. Health Infrastructure and Access to Care: As a critical access hospital, CHI Health Missouri Valley has established a point of access to basic and acute care services that would otherwise not be available to Harrison County residents. Additionally, through an existing grant CHI Health Missouri Valley has been involved in the planning of community coalition-based work to address behavioral health needs in the community that stem from lack of access to the appropriate level of care related to mental illness and substance use. The hospital also co-leads the Healthy Harrison Coalition, which engages with the public through various events and programs to improve the overall health of Harrison County. In order to continue this important work, as well as address the three priority health need areas, CHI Health Missouri Valley will not select additional work related to healthcare access.
Schedule H, Part V, Section B, Line 13 Facility , 1 Facility , 1 - AH-COMMUNITY MEMORIAL HOSPITAL OF MISSOURI VALLEY. The patient must have a minimum account balance of thirty-five dollars ($35.00) with the CHI Hospital Organization. Multiple account balances may be combined to reach this amount. Patients/Guarantors with balances below thirty-five dollars ($35) may contact a financial counselor to make monthly installment payment arrangements. The patient must submit a completed Financial Assistance application. Patient Cooperation Standards - A patient must exhaust all other payment options, including private coverage, federal, state and local medical assistance programs, and other forms of assistance provided by third-parties prior to being approved. An applicant for Financial Assistance is responsible for applying to public programs for available coverage. He or she is also expected to pursue public or private health insurance payment options for care provided by a CHI Hospital Organization within a Hospital Facility. A patient's and, if applicable, any Guarantor's cooperation in applying for applicable programs and identifiable funding sources, including COBRA coverage (a federal law allowing for a time-limited extension of employee healthcare benefits), shall be required. If a Hospital Facility determines that COBRA coverage is potentially available, and that a patient is not a Medicare or Medicaid beneficiary, the patient or Guarantor shall provide the Hospital Facility with information necessary to determine the monthly COBRA premium for such patient, and shall cooperate with Hospital Facility staff to determine whether he or she qualifies for Hospital Facility COBRA premium assistance, which may be offered for a limited time to assist in securing insurance coverage. A Hospital Facility shall make affirmative efforts to help a patient or patient's Guarantor apply for public and private programs.
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
Schedule H (Form 990) 2016
Page 9
Schedule H (Form 990) 2016
Page 9
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?5
Name and address Type of Facility (describe)
1 AH LOGAN RURAL HEALTH CLINIC
122 WEST 8TH STREET
LOGAN,IA51546
RURAL HEALTH CLINIC
2 AH WOODBINE RURAL HEALTH CLINIC
410 ELY
WOODBINE,IA51579
RURAL HEALTH CLINIC
3 AH MISSOURI VALLEY RURAL HEALTH CLINIC
809 EAST ELM STREET
MISSOURI VALLEY,IA51555
RURAL HEALTH CLINIC
4 AH DUNLAP RURAL HEALTH CLINIC
707 IOWA AVENUE
DUNLAP,IA51529
RURAL HEALTH CLINIC
5 AH CMH SKILLED NURSING FACILITY
631 N 8TH STREET
MISSOURI VALLEY,IA51555
SKILLED NURSING FACILITY
6
7
8
9
10
Schedule H (Form 990) 2016
Page 10
Schedule H (Form 990) 2016
Page 10
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
Schedule H, Part I, Line 6a Community Benefit Report Available to the public Yes, the CHI Health system produces an annual public community benefit report that is mailed to a core constituency, placed in key places throughout the organization and distributed in community meetings. It is also available on the company's intranet site, and on its public website at http://www.chihealth.com/community-benefit.
Schedule H, Part I, Line 3c FINANCIAL ASSISTANCE ELIGIBILITY CRITERIA Unless eligible for Presumptive Financial Assistance, the following eligibility criteria must be met in order for a patient to qualify for Financial Assistance: * The patient must have a minimum account balance of thirty-five dollars ($35.00) with the CHI Hospital Organization. Multiple account balances may be combined to reach this amount. Patients/Guarantors with balances below thirty-five dollars ($35) may contact a financial counselor to make monthly installment payment arrangements. * The patient's Family Income must be at or below 300% of the FPG. * The patient must comply with Patient Cooperation Standards as described [in the FAP]. * The patient must submit a completed Financial Assistance application. For patients and Guarantors who are unable to provide required documentation, a Hospital Facility may grant Presumptive Financial Assistance based on information obtained from other resources. In particular, presumptive eligibility may be determined on the basis of individual life circumstances that may include: * Recipient of state-funded prescription programs; * Homeless or one who received care from a homeless clinic; * Participation in Women, Infants and Children programs (WIC); * Food stamp eligibility; * Subsidized school lunch program eligibility; * Eligibility for other state or local assistance programs (e.g., Medicaid spend-down); * Low income/subsidized housing is provided as a valid address; or * Patient is deceased with no known estate.
Schedule H, Part I, Line 6a Community benefit report prepared by related organization CHI Health
Schedule H, Part I, Line 7g Subsidized Health Services Included in subsidized health services are the following physician clinics: CHI Health Missouri Valley Rural Health Clinic CHI Health Dunlap Rural Health Clinic CHI Health Logan Rural Health Clinic CHI Health Woodbine Rural Health Clinic The total expenses associated with operating these clinics were $3,464,392. Revenue offsets were $3,049,330. Accordingly, the total subsidized cost of these necessary services was $415,062. The clinics meet a community need for primary care services outside of the emergency room setting.
Schedule H, Part I, Line 7 Bad Debt Expense excluded from financial assistance calculation 964371
Schedule H, Part I, Line 7 Costing Methodology used to calculate financial assistance A cost accounting system was not used to compute amounts in the table; rather costs in the table were computed using Worksheet 2 to compute the cost-to-charge ratio. The cost-to-charge ratio covers all patient segments.
Schedule H, Part II Community Building Activities CHI Health Missouri Valley has a history of centralized community benefit investments, as well as hospital specific investments that address community health needs which include support of local health coalitions, investments in partnerships and programs that address top community health needs, participation in local committees and boards tied to top health needs, and investments in many other ways as described in other areas of the Schedule H narrative. Below are specific examples of work that falls within the definition of community building activities. These activities are critical in helping build social, health, and economic opportunities in our community that ultimately drive health status and quality of life for our residents: * Workforce development-the following activities work to strengthen the community's capacity to promote the health and well-being of our residents by driving entry into healthcare careers: - Healthcare career exploration camp-day camp funded by CHI Health for students grades 10-12 to give them the opportunity to explore a variety of healthcare professions - Presentations to high school students about healthcare careers * Community and economic development including support of local Chambers of Commerce * Strategic planning and consulting services for community partners to build capacity to address health and social needs of the community * Participation in a community-wide disaster drill * TeamMates-staff participation in a mentoring program to care for children and adolescents (K-12). Participants are directed to mentor youth in Harrison County that may not have an ideal situation at home or lack leadership and role models. Mentors are required to spend at least one hour/week with their mentee. Typically this is done over lunch at the school where the mentee attends. On occasion there are outings where the mentor and mentee will attend for social events, i.e. Creighton basketball game. * Hospital president's time participating in the Kiwanis of Missouri Valley
Schedule H, Part III, Line 2 Bad debt expense - methodology used to estimate amount Costing methodology for amounts reported on line 2 is determined using the organization's cost/charge ratio of 55.35%. When discounts are extended to self-pay patients, these patient account discounts are recorded as a reduction in revenue, not as bad debt expense.
Schedule H, Part III, Line 3 Bad Debt Expense Methodology Alegent Health-Community Memorial Hospital of Missouri Valley, Iowa does not believe that any portion of bad debt expense could reasonably be attributed to patients who qualify for financial assistance since amounts due from those individuals' accounts will be reclassified from bad debt expense to charity care within 30 days following the date that the patient is determined to qualify for charity care.
Schedule H, Part III, Line 4 Bad debt expense - financial statement footnote Alegent Health-Community Memorial Hospital of Missouri Valley, Iowa does not issue separate company audited financial statements. However, the organization is included in the consolidated financial statements of Catholic Health Initiatives. The consolidated footnote reads as follows: The provision for bad debts is based upon management's assessment of historical and expected net collections, taking into consideration historical business and economic conditions, trends in health care coverage, and other collection indicators. Management routinely assesses the adequacy of the allowances for uncollectible accounts based upon historical write-off experience by payor category. The results of these reviews are used to modify, as necessary, the provision for bad debts and to establish appropriate allowances for uncollectible net patient accounts receivable. After satisfaction of amounts due from insurance, CHI follows established guidelines for placing certain patient balances with collection agencies, subject to the terms of certain restrictions on collection efforts as determined by each facility. The provision for bad debts is presented in the consolidated statement of operations as a deduction from patient services revenues (net of contractual allowances and discounts) since CHI accepts and treats all patients without regard to the ability to pay.
Schedule H, Part III, Line 8 Community benefit & methodology for determining medicare costs Alegent Health-Community Memorial Hospital of Missouri Valley, Iowa is designated as a Critical Access Hospital (CAH). CAHs are rural community hospitals that are certified to receive cost-based reimbursement from Medicare. The reimbursement that CAHs receive is intended to improve their financial performance and thereby reduce hospital closures. CAHs are certified under a different set of Medicare Conditions of Participation (CoP). Shortfalls are created when a facility receives payments that are less than the costs of caring for program beneficiaries. Because shortfalls are based on costs, not charges, Alegent Health-Community Memorial Hospital of Missouri Valley, Iowa, due to their designation as a CAH, received cost-based reimbursement for Medicare purposes, Alegent Health-Community Memorial Hospital of Missouri Valley, Iowa will not experience Medicare related shortfalls. Although not presented on the Medicare cost report, in order to facilitate a more accurate understanding of the "true" cost of services (for "shortfall" purposes) the CHI Workbook allows a health care facility not to offset costs that Medicare considers to be non-allowable, but for which the facility can legitimately argue are related to the care of the facility's patients. In addition, although not reportable on the Medicare cost report, the CHI workbook includes the cost of services that are paid via a set fee-schedule rather than being reimbursed based on costs (e.g. outpatient clinical laboratory). Finally, the CHI Workbook allows a facility to include other health care services performed by a separate facility (such as a physician practice) that are maintained on separate books and records (as opposed to the main facility's books and records which has its costs of service included within a cost report). True costs of Medicare computed using this methodology: Total Medicare Revenue: $15,449,001 Total Medicare costs: $21,513,124 Shortfall: ($6,064,124) Alegent Health-Community Memorial Hospital of Missouri Valley, Iowa believes that excluding Medicare losses from community benefit makes the overall community benefit report more credible for these reasons: Unlike subsidized areas such as burn units or behavioral-health services, Medicare is not a differentiating feature of tax-exempt health care organizations. In fact, for-profit hospitals focus on attracting patients with Medicare coverage, especially in the case of well-paid services that include cardiac and orthopedics. Significant effort and resources are devoted to ensuring that hospitals are reimbursed appropriately by the Medicare program. The Medicare Payment Advisory Commission (MedPAC), an independent Congressional agency, carefully studies Medicare payment and the access to care that Medicare beneficiaries receive. The commission recommends payment adjustments to Congress accordingly. Though Medicare losses are not included by Catholic hospitals as community benefit, the Catholic Health Association guidelines allow hospitals to count as community benefit some programs that specifically serve the Medicare population. For instance, if hospitals operate programs for patients with Medicare benefits that respond to identified community needs, generate losses for the hospital, and meet other criteria, these programs can be included in the CHA framework in Category C as ''subsidized health services''. Medicare losses are different from Medicaid losses, which are counted in the CHA community benefit framework, because Medicaid reimbursements generally do not receive the level of attention paid to Medicare reimbursement. Medicaid payment is largely driven by what states can afford to pay, and is typically substantially less than what Medicare pays.
Schedule H, Part III, Line 9b Collection practices for patients eligible for financial assistance The organization's billing and collections policy applies to all individuals presenting for emergency or other medically necessary care. The policy contains provisions for collecting amounts due from those patients who the organization knows to qualify for financial assistance either through the traditional financial assistance application process or through presumptive eligibility processes. Before engaging in extraordinary collection actions (ECAs) to obtain payment for EMCare, Hospital Facilities must make reasonable efforts through its billing and collections processes, pursuant to Treas. Reg. §1.501(r)-6(c), to determine whether an individual is eligible for Financial Assistance. In no event will an ECA be initiated prior to 120 days from the date the Facility provides the first post-discharge billing statement (i.e., during the Notification Period) unless all reasonable efforts have been made. Hospital Facilities will not refer accounts for collection where the patient has initially applied for Financial Assistance, and the Hospital Facility has not yet made reasonable efforts with respect to the account. For patients and Guarantors who are unable to provide required documentation, a Hospital Facility may grant Presumptive Financial Assistance based on information obtained from other resources. Patients who qualify for Medicaid are presumed to qualify for full charity write off. Any charges for days or services written off (excluding Medicaid denials related to timeliness of billing, insufficient medical record documentation, missing invoices, authorization, or eligibility issues) as a result of a Medicaid are booked as charity. Some Medicaid plans offer coverage for a limited or restricted list of services. If a patient is eligible for Medicaid, any charges for days or services not covered by the patient's coverage may be written off to charity without a completed application. This does not include any Share of Cost (SOC) or other patient cost-sharing amounts such as deductibles or copayments, as such costs are determined by the state to be an amount that the patient must pay before the patient is eligible for Medicaid. Health and Human Services (HSS) uses the term "Spend Down" instead of Share of Cost. All collection activities conducted by the Facility, a Designated Supplier, or its third-party collection agents will be in conformance with all federal and state laws governing debt collection practices. All third-party agreements governing collection and recovery activities must include a provision requiring compliance with the hospital facilities' financial assistance and billing and collections policy and indemnification for failures as a result of its noncompliance. This includes, but is not limited to, agreements between third parties who subsequently sell or refer debt of the Hospital Facility.
Schedule H, Part V, Section B, Line 16a FAP website - AH-COM MEM HOSPITAL OF MISSOURI VALLEY: Line 16a URL: HTTP://WWW.CHIHEALTH.COM/FINANCIAL-ASSISTANCE;
Schedule H, Part V, Section B, Line 16b FAP Application website - AH-COM MEM HOSPITAL OF MISSOURI VALLEY: Line 16b URL: HTTP://WWW.CHIHEALTH.COM/FINANCIAL-ASSISTANCE;
Schedule H, Part V, Section B, Line 16c FAP plain language summary website - AH-COM MEM HOSPITAL OF MISSOURI VALLEY: Line 16c URL: HTTP://WWW.CHIHEALTH.COM/FINANCIAL-ASSISTANCE;
Schedule H, Part VI, Line 2 Needs assessment The process of identifying the community health needs in Harrison County was led by HCHPH. A comprehensive examination of existing secondary data sources was completed by both CHI Health Missouri Valley and HCHPH in early 2016, from national and state data sources described in the CHI Health Missouri Valley CHNA. In order to analyze data, benchmarking is vital. This was accomplished by reviewing trend data provided the Iowa Department of Public Health, Iowa Youth Survey, Behavioral Risk Factor Surveillance System (BRFSS) data, and Healthy People 2020 (HP2020). A complete list of sources and considerations can be found in the CHI Health Missouri Valley CHNA. Primary data collection began in January of 2016, when HCHPH conducted a community health survey using methods from the Mobilizing for Action through Planning and Partnerships (MAPP) strategy. The MAPP process applies strategic thinking to prioritize the most urgent health needs in the community, and involves an interactive process that reviews resources available to address needs. HCHPH collected primary data from community and public health leaders through a survey that aimed to gain input on the greatest perceived community health needs. The HCHPH Community Health Needs Survey along with results can be found in the CHI Health Missouri Valley CHNA. Utilizing a sector framework, HCHPH engaged community organizations and businesses in nine community sectors: Health Human service Education Government Faith Voluntary/Civic organizations Business (retail-manufacturing) Agriculture Philanthropy Media HCHPH presented to community groups and organizations on the purpose of the community health needs assessment survey and asked organizations to distribute the survey through email to their members and contacts. In order to maximize the participation of the greater public, the survey was promoted through social media outlets for HCHPH (Facebook and Twitter) and the local newspapers. Hard-copy versions of the survey were available for the greater public to complete at locations such as: CHI Health Clinic, Dunlap, Logan, Missouri Valley, and Woodbine, Iowa Local libraries - option was also available to complete the survey online Vision Care, Missouri Valley, Iowa Veterans Affairs Office, Logan, Iowa Veterinary Clinics Following completion of these community processes, CHI Health Missouri Valley's Community Benefit Action Team (CBAT) conducted a review of the methods used to understand the data available and processes for data collection. The CBAT was able to verify that 1) the information available effectively outlined the most important health needs for the hospital's service area, and 2) the processes had taken into account input from the broad community as well as stakeholders representing important populations and disparities in health. Gaps in Information: Although the CHNA is quite comprehensive, it is not possible to measure all aspects of the community's health, nor can we represent all interests of the population. Challenges exist in Harrison County around reliable data collection due to small sample sizes among different populations and indicators. This assessment was designed to represent a comprehensive and broad look at the health of the overall community. During specific hospital implementation planning, gaps in information will be considered and other data/input brought in as needed.
Schedule H, Part VI, Line 3 Patient education of eligibility for assistance Notification about the availability of Financial Assistance from CHI Hospital Organizations shall be disseminated by various means, which may include, but not be limited to: * Conspicuous publication of notices in patient bills; * Notices posted in emergency rooms, urgent care centers, admitting/registration departments, business offices, and at other public places as a Hospital Facility may elect; and * Publication of a summary of this Policy on the Hospital Facility's website, www.catholichealth.net, and at other places within the communities served by the Hospital Facility as it may elect. Such notices and summary information shall include a contact number and shall be provided in English, Spanish, and other primary languages spoken by the population served by an individual Hospital Facility, as applicable. Referral of patients for Financial Assistance may be made by any member of the CHI Hospital Organization non-medical or medical staff, including physicians, nurses, financial counselors, social workers, case managers, chaplains, and religious sponsors. A request for assistance may be made by the patient or a family member, close friend, or associate of the patient, subject to applicable privacy laws. In addition, Hospital registration clerks are trained to provide consultation to those who have no insurance or potentially inadequate insurance concerning their financial options including application for Medicaid and for assistance under the Financial Assistance Policy. Counselors assist Medicare eligible patients in enrollment by providing referrals to the appropriate government agencies. Once it is determined that the patient does not qualify for any third party funding, the patient is verbally notified about the existence of Financial Assistance Application and additional screening takes place by a Hospital employee to determine if the patient is eligible for charity service prior to discharge. Upon registration (and once all EMTALA requirements are met), patients who are identified as uninsured (and not covered by Medicare or Medicaid) are provided with a packet of information that addresses the Financial Assistance Policy, the plain language summary of that policy, and an application for assistance. Hospital registration clerks read the organization's medical assistance policy to those who appear to be incapable of reading, and provide translators for non-English-speaking individuals. Patients that have been discharged prior to charity screening, such as emergency room patients, receive a written notification of possible eligibility for services. If the patient is determined not to be eligible for government assistance, he/she may notify the hospital that they seek charity assistance. The appropriate charity form is sent to the patient/guarantor for completion and then returned to the hospital for evaluation and qualification. Once determination of eligibility is made, the patient is sent a notice informing him/her if they qualify for full, partial, or no charity care services. Hospital Facilities must make reasonable efforts through its billing and collections processes, pursuant to Treas. Reg. §1.501(r)-6(c), to determine whether any individual is eligible for Financial Assistance.
Schedule H, Part VI, Line 4 Community information CHI Health Missouri Valley's identified primary service area is Harrison County which is located on the western border of Iowa, and directly north of Pottawattamie County and the Omaha/Council Bluffs Metro area. Harrison County represents between 75%-90% of patients served by CHI Health Missouri Valley, and therefore the Hospital selected the county as the focus for their CHNA. Importantly, another CHI Health entity, Mercy Council Bluffs (formerly known as Alegent Health Mercy Hospital), is located in neighboring Pottawattamie County, Iowa. CHI Health Mercy Council Bluffs also completed a CHNA and related implementation plan. CHI Health Missouri Valley resides in Missouri Valley, Iowa. Missouri Valley is in the southwest corner of Harrison County, a non-metropolitan county located in west central Iowa. Harrison County is composed of nine school districts and 10 incorporated towns: Dunlap, Little Sioux, Logan, Magnolia, Missouri Valley, Modale, Mondamin, Persia, Pisgah and Woodbine. Logan is the county seat and there are also six unincorporated towns, and 20 townships. Population data shows a primarily non-Hispanic White population, and a slightly higher percentage of residents over 65 years of age (19.1%) compared to the State (15.8%). As a predominantly rural county Harrison County covers approximately 697 square miles and has a population density of 21 persons per square mile. The census information available for the City of Missouri Valley shows population breakdown very similar to that of the County in all areas except Missouri Valley shows a slightly higher Hispanic population at 2.1% of the population. Logan is the county seat and is located approximately 40 minutes from the Omaha/Council Bluffs Metro area. High school graduation rate is at 96% in Harrison County compared to 91.4% in the City of Missouri Valley, however it is higher than Iowa at 89%. Of those over age 25 in Harrison County, 70% hold a bachelor's degree or higher. This is true of only 52.7% in Missouri Valley. In Harrison County 9% of the population is uninsured. Harrison County 14,324 total population 22.6% of population is under 18 years of age 50.3% of population is female 0.4% of population is Non-Hispanic African American 0.3% of population is American Indian/Alaskan Native 0.4% of population is Asian 0.0% of population is Native Hawaiian 1.4% of population is Hispanic 96.7% of population is Non-Hispanic White $53,506 is the median household income (Missouri Valley is at $56,763) 4.2% of population is unemployed (compared to 4.8% in Missouri Valley alone) 11% of population is living in poverty (at both the county and city level) 14.8% of children under age 18 live in poverty in Harrison County (compared to 15.5% of Iowa overall) Harrison County is primarily rural in nature with manufacturing and agriculture the major industries. Local businesses such as Tommy Gate, Carry On, and E4 Precision Ag provide steady job opportunities and bring resources to the communities. Harrison County cities are family-oriented and have a strong sense of community pride in local neighborhoods. A stable county government as well as strong support from Iowa State University Extension services also maximizes resources in the county. Missouri Valley is situated less than a mile east of Interstate 29 and less than five miles north of Interstate 80. CHI Health Missouri Valley is the only hospital located in Harrison County. CHI Health Missouri Valley works with Harrison County Home and Public Health (HCHPH) to collaborate on addressing community health needs. During the previous implementation planning process in 2013, CHI Health Missouri Valley joined in early after the formation of the Healthy Harrison Coalition (HHC) by HCHPH and stepped forward to co-lead the coalition to promote population health messages and activities to the county. CHI Health Missouri Valley also has a network of highly skilled and specialty care physicians with clinics located in Dunlap, Logan, and Woodbine. Skilled nursing facilities exist throughout Harrison County through Care Initiatives Dunlap Specialty Care, Longview Continuing Care Retirement Community, Rose Vista Continuing Care Retirement Community, and Westmont Healthcare Community.
Schedule H, Part VI, Line 5 Promotion of community health The organization's hospital facility(ies) promote health for the benefit of the community. Medical staff privileges in the hospital are available to all qualified physicians in the area, consistent with the size and nature of its facilities. The organization's hospital facility(ies) have an open medical staff. Its board of trustees is composed of prominent citizens in the community. Excess funds are generally applied to expansion and replacement of existing facilities and equipment, amortization of indebtedness, improvement in patient care, and medical training, education, and research. The facility(ies) treat persons paying their bills with the aid of public programs like Medicare and Medicaid. All patients presenting at the hospital for emergency and other medically necessary care are treated regardless of their ability to pay for such treatment. CHI Health has a history of centralized community benefit and hospital specific community benefit investments to address community health needs of the particular service area. Examples of how CHI Health furthers its exempt purpose by promoting the health of the community include: * Financial Assistance and Unpaid costs of Medicaid * Community health improvement services- o Community education, classes and programs (bicycle helmet safety, CPR, car seat safety checks, community behavioral health support and education, diabetes, cancer, physical activity and healthy eating and cooking) o Support groups (cancer, bereavement, youth, etc.) o Community health fairs and screenings o School based healthcare services o Parish Nursing Program and Faith Community Health Network-the CHI Health Faith Community Health Network partners with congregations of all faiths to build capacity and support the growth of Health Ministries which promote health, healing and wholeness in the communities served. o Healthy Families-this program is a free, 8-week health and nutrition program for families with a child between the ages of 4-18 who has been identified in the top 85th percentile of their weight. This program invites the whole family to participate in learning about physical activity, eating healthy, and setting realistic goals as a family. o 5-4-3-2-1Go!-this program is an evidence-based healthy kids countdown message which CHI health supports through technical assistance and resources for parents and schools to teach kids to learn and practice every day to be healthy and active. o Childcare-CHI Health provided funding to increase capacity of Nebraska Extension Nutrition & Physical Activity Self-Assessment in Child Care (NAP SACC) program to provide training and technical assistance for child care programs in Douglas, Sarpy and Cass Counties in Nebraska. o Breastfeeding-planned and funded the Beyond Best Practices: Creating a Supportive Environment for Breastfeeding Parents conference for clinic and hospital professionals (nurses, medical assistants, dieticians, health coaches/navigators and providers), as well as community based health care workers (WIC dieticians, WIC clinicians, and community and federally qualified health center clinic members). Additionally, provided funding to the Nebraska Breastfeeding Coalition to plan and implement a Certified Lactation Counselor Training for 75 individuals, and an IBCLC Exam Prep course for 25 individuals, as well as to develop a breastfeeding toolkit for worksites and clinics to support promotion of breastfeeding in these spaces. o Participation in the Healthy Harrison Coalition to improve the overall health of the community o Provided interpreting and translation services to Limited English Proficiency (LEP) groups whose numbers fall below the required threshold in the community. o Provided counseling and assistance in enrolling individuals in means tested insurance programs to improve access to care. o Provide support to health coalitions and investments in social and environmental improvement strategies. These are programs, activities and partnerships that improve the health of persons in the community by addressing the determinants of health, which includes the social, economic and physical environment. Specific examples for Missouri Valley: -Center for Rural Affairs-provided funding to deliver educational programming around buying and preparing fresh produce at a rural farmers market in Harrison County, Iowa. -Healthy Harrison Coalition-provided funding for referrals and vouchers distributed through local agencies such as WIC and West Central Community Action Partnership to families with low access to healthy foods. Vouchers offered participating families transportation from their location to the County Farmer's Market, as well as a $20 voucher for fruits and vegetables.
Schedule H, Part VI, Line 6 Affiliated health care system The organization is affiliated with Catholic Health Initiatives (CHI). CHI, a nonprofit, faith-based health system formed in 1996 through the consolidation of four Catholic health systems, expresses its mission each day by creating and nurturing healthy communities in the hundreds of sites across the nation where we provide care. One of the nation's largest nonprofit health systems, Englewood, Colorado-based CHI serves as the Parent company of the system. It operates in 17 states and comprises 101 hospitals, including 4 academic health centers and major teaching hospitals as well as 29 critical-access facilities; community health-services organizations; accredited nursing colleges; home-health agencies; living communities; and other facilities and services that span the inpatient and outpatient continuum of care. In fiscal year 2017, CHI provided more than $1.2 billion in financial assistance and community benefit - a more than 10% increase over the previous year -- for programs and services for the poor, free clinics, education and research. Financial assistance and community benefit totaled more than $2.1 billion with the inclusion of the unpaid costs of Medicare. The health system, which generated operating revenues of $15.5 billion in fiscal year 2017, has total assets of approximately $21.9 billion. CHI provides strategic planning and management services as well as centralized "share services" for the MBOs. The provision of centralized management and shared services including areas such as accounting, human resources, payroll and supply chain provides economies of scale and purchasing power to the MBOs. The cost savings achieved through CHI's centralization enable MBOS to dedicate additional resources to high-quality health care and community outreach services to the most vulnerable members of our society.
Schedule H, Part VI, Line 7 State filing of community benefit report IA, NE
Schedule H (Form 990) 2016
Additional Data


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Software Version: 2016v3.0