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 Go to www.irs.gov/form990 for instructions and the latest informtion.
OMB No. 1545-0047
2017
Open to Public Inspection
Name of the organization
Memorial Community Hospital
 
Employer identification number

47-0426285
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
 
No
%
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
 
No
%
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) . . .
  123 650,720   650,720 1.96 %
b Medicaid (from Worksheet 3, column a) . . . . .         0 0 %
c Costs of other means-tested government programs (from Worksheet 3, column b) . .         0 0 %
d Total Financial Assistance and Means-Tested Government Programs . . . . . 0 123 650,720 0 650,720 1.96 %
Other Benefits
e Community health improvement services and community benefit operations (from Worksheet 4).         0 0 %
f Health professions education (from Worksheet 5) . . .         0 0 %
g Subsidized health services (from Worksheet 6) . . . .         0 0 %
h Research (from Worksheet 7) .         0 0 %
i Cash and in-kind contributions for community benefit (from Worksheet 8) . . . .         0 0 %
j Total. Other Benefits . . 0 0 0 0 0 0 %
k Total. Add lines 7d and 7j . 0 123 650,720 0 650,720 1.96 %
For Paperwork Reduction Act Notice, see the Instructions for Form 990. Cat. No. 50192T Schedule H (Form 990) 2017
Schedule H (Form 990) 2017
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         0 0 %
4 Environmental improvements         0 0 %
5 Leadership development and
training for community members
        0 0 %
6 Coalition building         0 0 %
7 Community health improvement advocacy         0 0 %
8 Workforce development         0 0 %
9 Other         0 0 %
10 Total 0 0 0 0 0 0 %
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
2,170,328
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
10,900,135
6
Enter Medicare allowable costs of care relating to payments on line 5.....
6
10,505,049
7
Subtract line 6 from line 5. This is the surplus (or shortfall)........
7
395,086
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) 2017
Schedule H (Form 990) 2017
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 MEMORIAL COMMUNITY HOSPITAL
810 NORTH 22ND STREET
BLAIR,NE68008
WWW.MCHHS.ORG
790001
X X     X   X      
Schedule H (Form 990) 2017
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Schedule H (Form 990) 2017
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)
MEMORIAL COMMUNITY HOSPITAL
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 16
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 Yes  
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 Yes  
a If "Yes" (list url): https://mchhs.org/resources/chip-chna
b If "No," is the hospital facility’s most recently adopted implementation strategy attached to this return? ...... 10b    
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) 2017
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Schedule H (Form 990) 2017
Page 5
Part VFacility Information (continued)

Financial Assistance Policy (FAP)
MEMORIAL COMMUNITY HOSPITAL
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
https://mchhs.org/images/601.103_Financial_Assistance_Policy_2018.pdf
b
https://mchhs.org/images/FinancialApplication.pdf
c
d
e
f
g
h
i
j
Schedule H (Form 990) 2017
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Schedule H (Form 990) 2017
Page 6
Part VFacility Information (continued)

Billing and Collections
MEMORIAL COMMUNITY HOSPITAL
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) 2017
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Schedule H (Form 990) 2017
Page 7
Part VFacility Information (continued)

Charges to Individuals Eligible for Assistance Under the FAP (FAP-Eligible Individuals)
MEMORIAL COMMUNITY HOSPITAL
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) 2017
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Schedule H (Form 990) 2017
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 - MEMORIAL COMMUNITY HOSPITAL. IN 2016, LEADERSHIP FROM MEMORIAL COMMUNITY HOSPITAL COLLABORATED WITH THE THREE RIVERS Public HEALTH DEPARTMENT (TRPHD) and Schmeeckle Research Group TO CONDUCT A COMMUNITY HEALTH NEEDS ASSESSMENT (CHNA) FOR THE THREE RURAL COUNTIES SERVED BY THE TRPHD, WHICH INCLUDES WASHINGTON COUNTY, THE COUNTY IN WHICH MEMORIAL COMMUNITY HOSPITAL & HEALTH SYSTEM IS LOCATED. THE CHNA IS A FOLLOW-UP TO AND EXPANSION OF SIMILAR REPORTS CONDUCTED IN 2003, 2007, and 2012. THE TRPHD HAS COMPLETED A CHNA AND DEVELOPED A COMMUNITY HEALTH IMPROVEMENT PLAN (CHIP) USING THE MOBILIZING FOR ACTION THROUGH PLANNING AND PARTNERSHIP (MAP) PROCESS. MEMORIAL COMMUNITY HOSPITAL & HEALTH SYSTEM'S LEADERSHIP AND STAFF HAVE BEEN INVOLVED IN THE CHNA PLANNING PROCESS THROUGH SERVICE ON THE CHNA STEERING COMMITTEE AND PARTICIPATION IN THE MAPP PROCESS. A large focus group was an important component of the CHNA and CHIP planning process. MCH&HS LEADERS PARTICIPATED IN the FORUM AND COMMUNITY DIALOGUE TO REVIEW THE CHNA AND IDENTIFY COMMUNITY HEALTH PRIORITIES, ASSETS AND GAPS IN WASHINGTON COUNTY. The CHNA HAS ALSO BEEN SHARED WITH THE MEMORIAL COMMUNITY HOSPITAL & HEALTH SYSTEM BOARD OF DIRECTORS. THE MCH&HS CHNA IS LOCATED ON MCH&HS WEBSITE WWW.MCHHS.ORG AND THE FULL REPORT IS LOCATED AT WWW.THREERIVERSPUBLICHEALTH.ORG. MEMORIAL COMMUNITY HOSPITAL & HEALTH SYSTEM LEADERSHIP USED THIS CHNA DURING ITS ANNUAL STRATEGIC AND BUDGETING AND PROVIDED A MEMORIAL COMMUNITY HOSPITAL & HEALTH SYSTEM IMPLEMENTATION PLAN TO ADDRESS THE PRIORITIZED HEALTH NEEDS.
Schedule H, Part V, Section B, Line 6a Facility , 1 Facility , 1 - MEMORIAL COMMUNITY HOSPITAL. FREMONT AREA MEDICAL CENTER & SAUNDERS COUNTY COMMUNITY HOSPITAL
Schedule H, Part V, Section B, Line 6b Facility , 1 Facility , 1 - MEMORIAL COMMUNITY HOSPITAL. THREE RIVERS HEALTH DEPARTMENT
Schedule H, Part V, Section B, Line 11 Facility , 1 Facility , 1 - MEMORIAL COMMUNITY HOSPITAL. MCH&HS has chosen three strategic issues to work on from the local hospital and clinic level for the next 3-5 years. The process in which these issues were chosen was based on the recurrence of specific issues in Washington County. The first two initiatives fall under the Mental Health, Behavioral Health and Substance Abuse Priority Area. First, MCH is implementing and managing controlled substance refills in a proactive approach to minimize prescription drug abuse in the Washington County area. Second, MCH is implementing Telehealth to include Behavioral and Mental Health coverage by partnering with Catholic Health Initiatives. MCH is focusing on Priority Area, Obesity, Cardiovascular Disease and Diabetes for the third strategic issue. The initiative determined by MCH will be to lower diabetic patients A1C if greater than 9.
Schedule H, Part V, Section B, Line 13 Facility , 1 Facility , 1 - MEMORIAL COMMUNITY HOSPITAL. THE AMOUNT OF FINANCIAL ASSISTANCE WRITE-OFF FOR MEMORIAL COMMUNITY HOSPITAL AND HEALTH SYSTEM IS BASED ON A FINANCIAL ASSISTANCE SLIDING FEE SCHEDULE UTILIZING A DERIVATIVE OF THE CURRENT US DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT (HUD) VERY LOW INCOME GUIDELINES, WHICH ARE UPDATED ANNUALLY. FINANCIAL ASSISTANCE MAY ALSO BE GRANTED IN CERTAIN CIRCUMSTANCES INVOLVING A CATASTROPHIC OCCURRENCE RESULTING IN MEDICAL BILLS GROSSLY EXCEEDING THE PATIENT'S ABILITY TO PAY AND IN THESE SITUATIONS, THE PATIENT'S RESPONSIBILITY WILL BE LIMITED TO 30% OF THE FAMILY'S GROSS ANNUAL INCOME.
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
Schedule H (Form 990) 2017
Page 9
Schedule H (Form 990) 2017
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?0
Name and address Type of Facility (describe)
1 BLAIR CLINIC
812 NORTH 22ND STREET
BLAIR,NE68008
PRIMARY CARE CLINIC
2 FORT CALHOUN CLINIC
4929 County Road P-43
FORT CALHOUN,NE68023
PRIMARY CARE CLINIC
3 COTTONWOOD CLINIC
120 SOUTH 9TH STREET
TEKAMAH,NE68061
PRIMARY CARE CLINIC
4 BURT-WASHINGTON HOME HEALTH & HOSPICE
670 SOUTH 19TH STREET
BLAIR,NE68008
HOME HEALTH AND HOSPICE AGENCY
5
6
7
8
9
10
Schedule H (Form 990) 2017
Page 10
Schedule H (Form 990) 2017
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 MEMORIAL COMMUNITY HOSPITAL PRODUCES A COMMUNITY BENEFIT REPORT THAT IS SENT TO THE NEBRASKA HOSPITAL ASSOCIATION FOR DATA COLLECTION PURPOSES.
Schedule H, Part I, Line 3c Eligibility criteria for free or discounted care THE AMOUNT OF FINANCIAL ASSISTANCE WRITE-OFF FOR MEMORIAL COMMUNITY HOSPITAL AND HEALTH SYSTEM IS BASED ON A FINANCIAL ASSISTANCE SLIDING FEE SCHEDULE UTILIZING A DERIVATIVE OF THE CURRENT US DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT (HUD) VERY LOW INCOME GUIDELINES, WHICH ARE UPDATED ANNUALLY. DESIGNEES OF MCH HELP PATIENTS SEEK REIMBURSEMENT FROM LOCAL, STATE, AND FEDERAL PROGRAMS AT NO CHARGE TO THE PATIENT WHEN THERE IS NO OTHER SOURCE OF PAYMENT. AFTER THESE EFFORTS/RESOURCES HAVE BEEN EXHAUSTED, PATIENTS ARE ASSISTED IN THE APPLICATION PROCESS FOR FINANCIAL ASSISTANCE. THE APPLICATION PROCESS INCLUDES COMPLETING A PERSONAL FINANCIAL APPLICATION AND PROVIDING VERIFICATION DOCUMENTS. THESE VERIFICATION DOCUMENTS MAY INCLUDE, BUT ARE NOT LIMITED TO, RECEIVING A COPY OF THE APPLICANT'S FEDERAL TAX RETURN, PAY STUB, BANK STATEMENTS, A CALL TO EMPLOYERS, OR A CREDIT REPORT, THE APPLICANT'S NET WORTH AND/OR LIQUID ASSETS, AND REASONABLE HOUSEHOLD OR BUSINESS EXPENSES. FINANCIAL ASSISTANCE MAY ALSO BE GRANTED IN CERTAIN CIRCUMSTANCES INVOLVING A CATASTROPHIC OCCURRENCE RESULTING IN MEDICAL BILLS GROSSLY EXCEEDING THE PATIENT'S ABILITY TO PAY AND IN THESE SITUATIONS, THE PATIENT'S RESPONSIBILITY WILL BE LIMITED TO 30% OF THE FAMILY'S GROSS ANNUAL INCOME.
Schedule H, Part I, Line 7g Subsidized Health Services MEMORIAL COMMUNITY HOSPITAL DOES NOT PROVIDE SUBSIDIZED HEALTH SERVICES.
Schedule H, Part I, Line 7 Bad Debt Expense excluded from financial assistance calculation 2170328
Schedule H, Part I, Line 7 Costing Methodology used to calculate financial assistance THE COSTING METHODOLOGY USED TO CALCULATE THE AMOUNTS REPORTED IN THE TABLE WERE WORKSHEETS WITHIN THE SCHEDULE H INSTRUCTIONS. THE COST TO CHARGE RATIO USED IN THE CALCULATION WAS DERIVED FROM THE FILED 2017 COST REPORT.
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 65.61%. 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 COMMUNITY MEMORIAL HOSPITAL 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 THE AUDITED FOOTNOTES FOR MEMORIAL COMMUNITY HOSPITAL AND MEDICAL CENTER DO NOT CONTAIN FOOTNOTES RELATED TO BAD DEBT EXPENSE. BAD DEBT EXPENSE IS IDENTIFIED ON THE CONSOLIDATED STATEMENT OF OPERATION WHICH IS CONSISTENT WITH THE REPORTING PRACTICE OF OTHER HEALTH CARE ORGANIZATIONS. BAD DEBT EXPENSE AT 100% CHARGE VALUE WAS MULTIPLIED BY THE RATIO DERIVED FROM THE SCHEDULE H WORKSHEETS IN THE SCHEDULE H INSTRUCTIONS TO ARRIVE AT AN APPROXIMATE COST VALUE.
Schedule H, Part III, Line 8 Community benefit & methodology for determining medicare costs THE MEDICARE CHARGES REPORTED ON LINE 5 AND LINE 6 ARE FROM THE 2017 FILED COST REPORT WHICH USED A COST TO CHARGE RATIO.
Schedule H, Part III, Line 9b Collection practices for patients eligible for financial assistance All accounts must have gone through a minimum of three statement cycles ensuring the guarantor has had time to review and pay on the accounts owed on. No account will be prepared for collections before it has reached 121 days from the date of post discharge billing. All accounts must have one documented, attempted phone call to the guarantor. Patients will be given the opportunity to apply for MCHHS' financial assistance program in the event that they are unable to meet their financial obligations. The financial class on the effected episodes will be changed to "FA" and a final attempt letter which includes information regarding the MCH financial assistance program and it's availability to qualified applicants will be sent indicating that a payment or response is necessary or else the account would be sent to an outside agency for collection attempts. If a patient contacts MCHHS to inquire about financial assistance and the account is less than 240 days, then all collection efforts will be ceased and the patient will be given 2 weeks to complete and return the required application and documents. Should the patient not qualify and/or not return the required application, then collection efforts shall resume. Should patients complete and return the required application and documents at any time prior to 241 days, then collection efforts will cease until the application is reviewed. MEMORIAL COMMUNITY HOSPITAL'S COLLECTION POLICY DOES NOT CONTAIN PROVISIONS OF THE COLLECTION PRACTICES TO BE FOLLOWED FOR PATIENTS WHO ARE KNOWN TO QUALIFY FOR CHARITY CARE OR FINANCIAL ASSISTANCE.
Schedule H, Part V, Section B, Line 16a FAP website - MEMORIAL COMMUNITY HOSPITAL: Line 16a URL: https://mchhs.org/images/601.103_Financial_Assistance_Policy_2018.pdf;
Schedule H, Part V, Section B, Line 16b FAP Application website - MEMORIAL COMMUNITY HOSPITAL: Line 16b URL: https://mchhs.org/images/FinancialApplication.pdf;
Schedule H, Part V, Section B, Line 16c FAP plain language summary website - MEMORIAL COMMUNITY HOSPITAL: Line 16c URL: https://mchhs.org/images/Plain_speak.pdf;
Schedule H, Part VI, Line 2 Needs assessment MEMORIAL COMMUNITY HOSPITAL ASSESSES THE HEALTH CARE NEEDS OF THE COMMUNITIES IT SERVES THROUGH MULTIPLE CHANNELS INCLUDING COMMUNITY HEALTH FAIRS, WELLNESS PROGRAMS, PROVING OCCUPATIONAL HEALTH SERVICES, LISTENING TO PATIENT AND COMMUNITY VOICES AS WELL AS WATCHING NATIONAL TRENDS.
Schedule H, Part VI, Line 3 Patient education of eligibility for assistance THERE ARE SEVERAL FINANCIAL ASSISTANCE ACCESS POINTS THROUGHOUT A PATIENT'S CARE CYCLE. BILLS CONTAIN FINANCIAL ASSISTANCE VERBIAGE, BROCHURES ARE AVAILABLE IN CLINICS AND THE HOSPITAL, AND THERE IS INFORMATION ON FINANCIAL ASSISTANCE POSTED AT REGISTRATION POINTS THROUGHOUT CLINICS AND THE HOSPITAL. INFORMATION ON THE MCH FINANCIAL ASSISTANCE POLICIES IS LOCATED AT WWW.MCHHS.ORG. DESIGNEES SUCH AS FINANCIAL COUNSELORS OF MCH HELP PATIENTS SEEK REIMBURSEMENT FROM LOCAL, STATE AND FEDERAL PROGRAMS AT NO CHARGE TO THE PATIENT, WHEN THERE IS NO OTHER SOURCE OF PAYMENT. AFTER THESE EFFORTS/RESOURCES HAVE BEEN EXHAUSTED, PATIENTS ARE ASSISTED IN THE APPLICATION PROCESS FOR FINANCIAL ASSISTANCE.
Schedule H, Part VI, Line 4 Community information MEMORIAL COMMUNITY HOSPITAL AND HEALTH SYSTEMS OF BLAIR, NEBRASKA SERVES BOTH WASHINGTON AND BURT COUNTIES IN NEBRASKA. WASHINGTON COUNTY NEBRASKA HAS AN ESTIMATED POPULATION OF 20,234. CENSUS ESTIMATES SHOW THAT WASHINTON COUNTY'S RACIAL AND ETHNIC MAKE UP IS 95.7% WHITE, 0.9% SOME OTHER RACE ALONE, 0.6% TWO OR MORE RACES, 1.3% HISPANIC OR LATINO. IT'S MEDIAN HOUSEHOLD INCOME IS $59,181 COMPARED TO $47,470 FOR THE STATE OF NEBRASKA. APPROXIMATELY 15% OF THE STUDENTS IN WASHINGTON COUNTY RECEIVE FREE OR REDUCED LUNCH. BURT COUNTY HAS AN ESTIMATED POPULATION OF 6,858. CENSUS ESTIMATES SHOW THAT BURT COUNTY'S RACIAL AND ETHNIC MAKE UP IS 95.9% WHITE, 1.1% SOME OTHER RACE ALONE, 1.2% TWO OR MORE RACES, 1.8% HISPANIC OR LATINO. IT'S MEDIAN HOUSEHOLD INCOME IS $42,242 COMPARED TO $47,470 FOR THE STATE OF NEBRASKA APPROXIMATELY ONE THIRD OF THE STUDENTS IN EACH OF THE SCHOOL DISTRICTS RECEIVE FREE OR REDUCED LUNCH.
Schedule H, Part VI, Line 5 Promotion of community health MCH&HS PROMOTES THE HEALTH OF ITS COMMUNITY THROUGH FINANCIAL AND IN-KIND DONATIONS. BOARD OF DIRECTORS - THE BOARD OF DIRECTORS MANAGE THE AFFAIRS OF MEMORIAL COMMUNITY HOSPITAL IN BLAIR, NEBRASKA. THERE ARE SEVEN DIRECTORS WHO SERVE ON THE BOARD: THREE MEMBERS FROM THE COMMUNITY, THREE MEMBERS FROM ALEGENT CREIGHTON HEALTH AND ONE MEMBER FROM THE MCH&HS MEDICAL STAFF. THE BOARD OF DIRECTORS IS COMPROMISED OF INDIVIDUALS WHO ARE LEADERS IN THE FIELDS OF BUSINESS, HEALTHCARE, ACCOUNTING AND MEDICINE AND WHO UNDERSTAND THEIR ROLE IN PROVIDING STRONG CORPORATE GOVERNANCE. EMERGENCY DEPARTMENT - MEMORIAL COMMUNITY HEALTH HAS A FULL-TIME EMERGENCY DEPARTMENT THAT IS OPEN TO THE PUBLIC AND PROVIDES MEDICAL SCREENING, EXAMINATION, AND STABILIZING TREATMENT WITHIN THE CAPABILITIES AND CAPACITIES OF THE HOSPITAL REGARDLESS OF BUT NOT LIMITED TO THE PATIENT'S RACE, COLOR, SEX, AGE AND/OR ABILITY TO PAY. MCH&HS IS IN COMPLIANCE WITH THE FEDERAL EMTALA GUIDELINES. MEDICAL STAFF - MCH&HS MAINTAIN AN OPEN MEDICAL STAFF. ALL QUALIFIED MDS, DSO, OTHER HEALTHCARE PRACTITIONERS, AND MID-LEVEL PRACTITIONERS ARE ELIGIBLE TO APPLY FOR PRIVILEGES AT THE HOSPITAL. MCH&HS POLICY ON PHYSICIAN CREDENTIALING IS THAT NO INDIVIDUAL IS TO BE DENIED MEDICAL STAFF APPOINTMENT BASED ON SEX, RACE, CREED, COLOR OR NATIONAL ORIGIN. THE STANDARDS A PHYSICIAN MUST MEET FOR APPOINTMENT RELATE TO (1) EDUCATIONAL QUALIFICATION AND LICENSING, (2) PROFESSIONAL COMPETENCE, (3) CHARACTER, (4) ETHICAL STANDING, AND (5) ABILITY TO RELATE TO AND WORK WITH OTHERS. APPLICATIONS ARE REVIEWED AT SEVERAL LEVELS WITHIN THE ORGANIZATION. PHYSICIANS WHO HAVE BEEN GRANTED STAFF PRIVILEGES AUTOMATICALLY BECOME A MEMBER OF THE MEDICAL STAFF AT THE HOSPITAL FOR WHICH PRIVILEGES HAVE BEEN GRANTED.
Schedule H, Part VI, Line 7 State filing of community benefit report NE
Schedule H (Form 990) 2017
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