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
CRITTENDEN COUNTY HOSPITAL INC
 
Employer identification number

61-0391376
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) . . . 		    360,757   355,210 2.530 %
b Medicaid (from Worksheet 3, column a) . . . . .     3,289,451 1,687,908 1,601,543 11.410 %
c Costs of other means-tested government programs (from Worksheet 3, column b) . .            
d Total Financial Assistance and Means-Tested Government Programs . . . . .     3,650,208 1,687,908 1,956,753 13.940 %
Other Benefits
e Community health improvement services and community benefit operations (from Worksheet 4).            
f Health professions education (from Worksheet 5) . . .            
g Subsidized health services (from Worksheet 6) . . . .            
h Research (from Worksheet 7) .            
i Cash and in-kind contributions for community benefit (from Worksheet 8) . . . .            
j Total. Other Benefits . .            
k Total. Add lines 7d and 7j .     3,650,208 1,687,908 1,956,753 13.940 %
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            
2 Economic development            
3 Community support            
4 Environmental improvements            
5 Leadership development and
training for community members		            
6 Coalition building            
7 Community health improvement advocacy            
8 Workforce development            
9 Other            
10 Total            
Part III
Bad Debt, Medicare, & Collection Practices
Section A. Bad Debt Expense
Yes
No
1
Did the organization report bad debt expense in accordance with Heathcare Financial Management Association Statement No. 15? ..........................
1
Yes
 
2
Enter the amount of the organization's bad debt expense. Explain in Part VI the methodology used by the organization to estimate this amount. ......
2
1,221,487
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
610,744
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
4,046,234
6
Enter Medicare allowable costs of care relating to payments on line 5.....
6
3,737,444
7
Subtract line 6 from line 5. This is the surplus (or shortfall)........
7
308,790
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 CRITTENDEN HEALTH SYSTEMS
520 WEST GUM ST
MARION,KY42064
http://crittenden-health.org 		X X         X      
Schedule H (Form 990) 2016
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Schedule H (Form 990) 2016
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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)
CRITTENDEN HEALTH SYSTEMS
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   No
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 15
10 Is the hospital facility's most recently adopted implementation strategy posted on a website?......... 10 Yes  
a If "Yes" (list url): WWW.CRITTENDEN-HEALTH.ORG
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) 2016
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Schedule H (Form 990) 2016
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Part VFacility Information (continued)

Financial Assistance Policy (FAP)
CRITTENDEN HEALTH SYSTEMS
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
WWW.CRITTENDEN-HEALTH.ORG
b
WWW.CRITTENDEN-HEALTH.ORG
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
CRITTENDEN HEALTH SYSTEMS
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
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Part VFacility Information (continued)

Charges to Individuals Eligible for Assistance Under the FAP (FAP-Eligible Individuals)
CRITTENDEN HEALTH SYSTEMS
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 Yes  
If "Yes," explain in Section C.
Schedule H (Form 990) 2016
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Schedule H (Form 990) 2016
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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 22 & 24 AMOUNTS CHARGED TO FAP-ELIGIBLE INDIVIDUALS ------------------------------------------- INDIVIDUALS ELIGIBLE FOR ASSISTANCE WERE CHARGED THE UNDISCOUNTED RATES INITIALLY. THE PAYMENT REQUIRED WAS BASED ON THE INDIVIDUAL'S FINANCIAL NEED AND A DISCOUNT (AGB) WAS APPLIED FOR THOSE FROM 100% TO 200% OF THE FEDERAL POVERTY LEVEL, WITH THOSE AT OR BELOW 100% OF THE FEDERAL POVERTY LEVEL RECEIVING FREE CARE.
SCHEDULE H, PART V, LINE 5 CHNA INPUT ---------- THE HOSPITAL CONTRACTED WITH THE COMMUNITY AND ECONOMIC DEVELOPMENT INITIATIVE OF KENTUCKY (CEDIK) TO CONDUCT THE COMMUNITY HEALTH NEEDS ASSESSMENT IN ACCORDANCE WITH THE AFFORDABLE CARE ACT.
SCHEDULE H, PART V, LINE 10B IMPLEMENTATION STRATEGY ----------------------- THE HOSPITAL'S IMPLEMENTATION STRATEGY CAN BE FOUND WITHIN THE CHNA REPORT LOCATED ON THE HOSPITAL'S WEBSITE: www.crittenden-health.org
SCHEDULE H, PART V, LINE 11 ADDRESSING THE NEEDS OF THE COMMUNITY ------------------------------------- THE HOSPITAL IS ACTIVE IN THE SPEAKER'S BUREAU AND OFFERS COMMUNITY EDUCATION CLASSES. PARTICIPATION IN EACH OF THESE GROUPS ASSISTS THE HOSPITAL IN CONTINUALLY ASSESSING THE NEEDS OF THE COMMUNITY. IN ADDITION, NEEDS ASSESSMENTS ARE ON-GOING THROUGH THE VARIOUS PROGRAMS AND SERVICES PROVIDED TO THE COMMUNITY BY THE HOSPITAL AS FOLLOWS: 1. EXPANDED ACCESS WITHIN THE COMMUNITY (PRIMARY CARE, GENERAL SURGERY, ENT, CARDIOLOGY, ONCOLOGY & DIETARY). 2. INCREASED COMMUNICATION INCLUDING SOCIAL MEDIA, NEWSPAPER CAMPAIGN, RADIO SPOTS AND FACILITY SIGNAGE. 3. BETTER PATIENT CARE WITH PRIORITY REGISTATION AND PRIVATE EXIT DRIVE. 4. ENGAGING THE COMMUNITY THROUGH PARENTING AND LIFE SKILLS CLASSES, CPR PROGRAMS, 5K EVENTS, YOUTH TRIATHOLON AND HEALTH FAIRS.
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
Schedule H (Form 990) 2016
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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?1
Name and address Type of Facility (describe)
1 Burkhart Rural Health Clinic
117 East Main Street
Salem,KY42078 		Rural Health Clinic
2
3
4
5
6
7
8
9
10
Schedule H (Form 990) 2016
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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 3C CHARITY CARE ------------ THE HOSPITAL USED A COST TO CHARGE RATIO AS CALCULATED FROM WORKSHEET 2, RATIO OF PATIENT CARE COST-TO-CHARGES, INCLUDED IN THE SCHEDULE H INSTRUCTIONS TO DETERMINE THE AMOUNTS ON LINES 7A AND 7B OF PART I OF SCHEDULE H. THE HOSPITAL USED ACTUAL COSTS AS REPORTED IN THE GENERAL LEDGER SYSTEM TO DETERMINE THE AMOUNTS ON LINES 7E OF PART I OF SCHEDULE H.
SCHEDULE H, PART III, LINE 4 BAD DEBTS --------- PATIENT ACCOUNTS ARE WRITTEN OFF TO BAD DEBT ONLY AFTER ALL COLLECTION PROCEDURES HAVE BEEN EXHAUSTED. THE HOSPITAL'S AUDITED FINANCIAL STATEMENTS DO NOT INCLUDE A FOOTNOTE THAT SPECIFICALLY ADDRESSES BAD DEBTS. HOWEVER, THE PROVISION FOR BAD DEBTS IS INCLUDED IN THE NET PATIENT SERVICE REVENUE NOTE. THE PROVISION FOR BAD DEBTS REPRESENTS UNCOMPENSATED CARE FOR PATIENTS OF WHICH A MAJORITY ARE UNINSURED OR UNDERINSURED, BUT DID NOT APPLY FOR OR QUALIFY FOR CHARITY CARE. THE HOSPITAL ESTIMATED THAT APPROXIMATELY 50% OF BAD DEBT EXPENSE MAY ACTUALLY QUALIFY FOR CHARITY CARE BASED ON THE FINANCIAL COLLECTOR'S KNOWLEDGE AND EXPERIENCE. APPROXIMATELY 25% OF THE CHARITY APPLICATIONS SENT OUT DO NOT RESPOND AND APPROXIMATELY 25% THAT DO RESPOND ARE UNCOOPERATIVE AND OFTEN DO NOT BRING IN ALL DOCUMENTATION REQUIRED TO SUPPORT QUALIFICATION BASED ON THE CHARITY CARE POLICY.
SCHEDULE H, PART III, LINE 8 MEDICARE -------- FISCAL YEAR 2017 MEDICARE COST REPORT WAS USED TO DETERMINE THE UNPAID COST OF MEDICARE. UNPAID COST OF MEDICARE REPRESENTS THE COST OF PROVIDING SERVICES TO PRIMARILY ELDERLY BENEFICIARIES OF THE MEDICARE PROGRAM, IN EXCESS OF PAYMENTS FOR THOSE SERVICES. IRS REVENUE RULING 69-545, WHICH ESTABLISHED THE COMMUNITY BENEFIT STANDARD FOR NONPROFIT HOSPITALS, STATES THAT IF A HOSPITAL SERVES PATIENTS WITH GOVERNMENT BENEFITS, INCLUDING MEDICARE, THEN THIS IS AN INDICATION THAT THE HOSPITAL OPERATES TO PROMOTE THE HEALTH OF THE COMMUNITY. THIS IMPLIES THAT TREATING MEDICARE PATIENTS IS A COMMUNITY BENEFIT.
SCHEDULE H, PART III, LINE 9B COLLECTION PRACTICES -------------------- CRITTENDEN COUNTY HOSPITAL APPLIES ITS COLLECTION PRACTICES EQUALLY TO ALL PATIENTS, BOTH CHARITY CARE ELIGIBLE AND NON-CHARITY CARE PATIENTS. THE PROCEDURES FOR COLLECTION ON PATIENT ACCOUNTS ARE AS FOLLOWS: POLICY: CHS WILL REQUEST DEPOSITS AND/OR PAYMENT ARRANGEMENTS FOR PATIENT SERVICES NOT COVERED BY INSURANCE OR OTHER PAYMENT SOURCES. IMPLEMENTATION: PATIENTS CONTACTED FOR CENTRALIZED SCHEDULING. THE SCHEDULER IS NOTIFIED OF PATIENTS WITHOUT INSURANCE UNLESS CLINICALLY NECESSARY TO DO SO. OTHERWISE, SELF-PAY PATIENTS SHOULD BE SCHEDULED A FEW EXTRA DAYS OUT TO PROVIDE EXTRA TIME TO CONTACT THEM FOR PRE-SERVICE COLLECTION. PROCESS: THOSE PATIENTS WILL BE CONTACTED, AND THEN BE INFORMED OF THE NECESSARY INFORMATION FOR FINANCIAL SCREENING (PROOF OF INCOME, EMPLOYMENT INFORMATION, ETC), REQUESTED TO COME IN EARLY ON THE DAY OF SERVICES, AND REQUESTED TO BRING SOME METHOD OF PAYMENT (CASH,CHECK,CREDIT CARD,ETC.) ON THAT DAY. ER PATIENTS: PATIENTS SHOULD RECEIVE THE REQUIRED MEDICAL SCREENING AFTER THE BASIC PATIENT INFORMATION IS OBTAINED (NAME, DATE OF BIRTH AND SOCIAL SECURITY NUMBER SHOULD BE OBTAINED IF THE PATIENT'S MEDICAL CONDITION PERMITS). IF A PATIENT IS WAITING TO RECEIVE MEDICAL CARE, THE PATIENT MAY BE REGISTERED, HOWEVER THE PATIENT'S MEDICAL SCREENING SHOULD NEVER BE DELAYED FOR THE REGISTRATION PROCESS. SEE BELOW FOR NEXT STEPS. ER PATIENTS DEEMED URGENT AFTER MEDICAL SCREENING - PATIENTS DEEMED URGENT FOR ADDITIONAL CARE AFTER THE MEDICAL SCREENING WILL BE DETERMINED BY THE PROFESSIONAL JUDGEMENT OF THE PHYSICIAN OR PA COVERING THE ER. HOSPITAL STAFF WILL PROVIDE NECESSARY CARE TO MEDICALLY STABILIZE THE PATIENT AND THE PATIENT WILL BE REGISTERED WHENEVER POSSIBLE. AFTER THE PATIENT IS MEDICALLY STABILIZED THE PATIENT WILL BE ASKED FOR A DEPOSIT AND/OR PAYMENTS ON OLD ACCOUNTS, ASKED TO SET UP PAYMENT ARRANGEMENTS FOR ANY BALANCES, AND SELF-PAY PATIENTS WILL BE SCREENED FOR CHARITY AND POSSIBLE MEDICAID ELIGIBILITY AS SOON AS PRACTICAL. PHYSICIAN REFERRALS (INCLUDING THOSE VIA CENTRALIZED SCHEDULING) OR PATIENTS WITHOUT EMERGENCY MEDICAL CONDITIONS AFTER MEDICAL SCREENING - THE PATIENT WILL BE REGISTERED. AFTER REGISTRATION THE FOLLOWING SHOULD OCCUR: CHECK FOR PRIOR ACCOUNT BALANCES. PATIENTS WITH UNPAID BALANCES MORE THAN 90 DAYS OLD WILL BE REQUIRED TO MAKE A DEPOSIT AND SET UP PAYMENT ARRANGEMENTS ON THOSE OLD ACCOUNTS PRIOR TO RECEIVING ANY ADDITIONAL SERVICE FOR NON-EMERGENCY MEDICAL CONDITIONS. CHARITY SCREENING PAPERWORK: ALL SELF-PAY PATIENTS SHOULD BE SCREENED FOR CHARITY AND MEDICAID CRITERIA BASED ON THE RESPONSIBLE PARTY'S INCOME COMPARED TO THE GUIDELINES IN THE CHARITY POLICY. ALL OR PART OF THE PATIENT'S CHARGES MAY BE WRITTEN OFF. PATIENTS REFUSING TO COMPLETE CHARITY SCREENING PAPERWORK WILL BE CONSIDERED TO NOT QUALIFY. PATIENTS NOT MEETING CHARITY CRITERIA WILL BE REQUIRED TO MAKE A DEPOSIT FOR SERVICES (ACCORDING TO THE ESTABLISHED SCHEDULE) AND AGREE TO PAYMENT ARRANGEMENTS FOR THE BALANCE. CHS EMPLOYEES: EMPLOYEES OF CHS SHOULD SIGN A PAYROLL DEDUCTION AUTHORIZATION TO PAY FOR ANY COSTS NOT COVERED BY INSURANCE. PATIENTS WITHOUT NECESSARY FUNDS FOR REQUIRED DEPOSIT, NOT REQUIRING EMERGENCY SERVICES, WILL BE ASKED TO CONTACT POSSIBLE PAYMENT SOURCES (FRIENDS, RELATIVES, ETC) ON AN EXCEPTION BASIS APPROVED BY THE CEO OR CFO. IF ADEQUATE FUNDS WILL NOT BE AVAILABLE FOR THE REQUIRED DEPOSIT, THE PATIENT WILL BE ASKED TO SIGN AN AGREEMENT TO MAKE MONTHLY PAYMENTS, WHICH WILL INCLUDE AN AGREEMENT WHICH CAN BE SUBMITTED TO THEIR EMPLOYER (OR THE EMPLOYER OF THE SPOUSE OR GUARANTOR) WHERE THEY WILL AGREE TO MAKE MINIMUM MONTHLY PAYMENTS TO CHS, WHICH WILL BE SUBMITTED TO THE EMPLOYER IF THE MONTHLY PAYMENTS ARE NOT DIRECTLY SUBMITTED TO CHS. NOTE, PATIENTS WITHOUT SOME FORM OF EMPLOYMENT (FOR THEM OR GUARANTOR) WOULD GENERALLY QUALIFY FOR CHARITY. INDIVIDUALS WHO WILL NOT MAKE THE DEPOSIT OR AGREE TO PAYMENTS FROM THEIR EMPLOYER WILL BE ASKED TO RETURN FOR NON-EMERGENCY SERVICES WHEN THEY ARE WILLING TO PROVIDE ONE OF THESE PAYMENTS SOURCES. PATIENTS WHO ARE REFUSED SERVICES: THESE ARE PATIENTS WHO DO NOT QUALIFY FOR CHARITY CARE AND WHO DO NOT PROVIDE A DEPOSIT AND/OR AGREE TO THE ABOVE. NOTED PAYMENT ARRANGEMENTS: PHYSICIAN'S OFFICE WILL BE NOTIFIED AS SOON AS POSSIBLE IF A PATIENT REFERRAL IS TURNED AWAY DUE TO LACK OF PAYMENT. IF PHYSICIAN REQUESTS THE SERVICES BE PROVIDED DESPITE LACK OF PAYMENT THE ADMINISTRATOR ON CALL WILL BE NOTIFIED AND SERVICES WILL BE PROVIDED. THE DEPOSIT SCHEDULE WILL BE UPDATED AT LEAST ANNUALLY AS APPROVED BY THE CEO AND CFO, WITHIN THE TERMS OF THE POLICY. GENERALLY FOR SERVICES PROVIDED SOLELY BY CHS THE REQUIRED DEPOSIT WILL BE BETWEEN 20% AND 50% OF EXPECTED NORMAL CHARGES. FOR SERVICES PROVIDED BY EXTERNAL SOURCES, WHICH CHS HAS TO PAY A FEE PER SERVICE,THE DEPOSIT WILL BE AT LEAST THE AMOUNT CHARGED TO CHS BY THE OUTSIDE VENDOR (THIS INCLUDES SLEEP LAB AND NUCLEAR MEDICINE). PAYMENT BASED ON POVERTY LEVEL GUIDELINES: AS NOTED IN THE CHARITY POLICY, EXCEPTIONS TO THE DEPOSIT REQUIREMENTS ARE AS FOLLOWS BASED ON INCOME COMPARED TO THE MOST RECENT FEDERAL POVERTY LEVELS 0-100% ALL CHARGES TO BE FORGIVEN, NO DEPOSIT REQUIRED 101-200% NO DEPOSIT REQUIRED AT THE TIME OF SERVICES
SCHEDULE H, PART VI, LINE 2 NEEDS ASSESSMENT ---------------- CRITTENDEN COUNTY HOSPITAL ASSESSES THE HEALTH CARE NEEDS OF THE COMMUNITY THROUGH SEVERAL AVENUES, INVOLVING HOSPITAL EMPLOYEES FROM VARIOUS DEPARTMENTS OF THE HOSPITAL. THE MISSION IS TO PROVIDE ONGOING ASSESSMENTS OF THE HEALTHCARE NEEDS OF CRITTENDEN COUNTY AND THE SURROUNDING COMMUNITIES AND STRIVE TO MEET THE NEEDS IDENTIFIED. IN 2016, THE HOSPITAL WENT THROUGH A COMMUNITY HEALTH ASSESSMENT IN CONJUNCTION WITH THE COMMUNITY AND ECONOMIC DEVELOPMENT INITIATIVE OF KENTUCKY (CEDIK) AT THE UNIVERSITY OF KENTUCKY.
SCHEDULE H, PART VI, LINE 3 PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCE ----------------------------------------------- PATIENT EDUCATION REGARDING ELIGIBILITY FOR ASSISTANCE PROVIDED IN THE FOLLOWING MEDIUMS: DHS APPS ARE SIGNED IN ADMITTING AND FORWARDED TO DMC TO QUALIFY - POSTED IN ADMITTING - PATIENTS ARE CONTACTED BY A PATIENT ACCOUNTS REPRESENTATIVE DURING THEIR HOSPITAL STAY REGARDING ELIGIBILITY FOR ASSISTANCE.
SCHEDULE H, PART VI, LINE 4 COMMUNITY INFORMATION --------------------- CRITTENDEN COUNTY IS A RURAL AREA WITH A REPORTED POPULATION OF 9,255. THE MEDIAN INCOME FOR A HOUSEHOLD INCOME IN 2011 WAS $37,372. THE PERCENT OF POPULATION UNDER 18 YEARS IS 22.4% IN CRITTENDEN COUNTY WHILE THE PERCENT OF POPULATION 65 YEARS AND OLDER IS 19%. ADJACENT COUNTIES INCLUDE UNION, WEBSTER, CALDWELL, LYON, LIVINGSTON AND HARDIN COUNTY, ILLINOIS. OF THESE COUNTIES, UNION, CALDWELL AND LIVINGSTON ALL HAVE ONLY A CRITICAL ACCESS HOSPITAL. THE OTHER THREE, WEBSTER, LYON AND HARDIN COUNTY, ILLINOIS DO NOT HAVE A HOSPITAL WITHIN THE COUNTY (SOURCES: US CENSUS BUREAU).
SCHEDULE H, PART VI, LINE 5 COMMUNITY BUILDING ACTIVITIES ----------------------------- CRITTENDEN COUNTY HOSPITAL PROVIDES ACTIVITIES AND SERVICES FOR WHICH NO PATIENT BILL EXISTS. THESE SERVICES ARE NOT EXPECTED TO BE FINANCIALLY SELF-SUPPORTING, ALTHOUGH SOME MAY BE SUPPORTED BY OUTSIDE GRANTS OR FUNDING. THE HOSPITAL EMPLOYEES ALSO COLLECT MONEY OR FOOD ON AN ANNUAL BASIS FOR THE LOCAL COMMUNITY CHRISTMAS WHERE THEY ALSO PROVIDE PRESENTS FOR FAMILIES PARTICIPATING IN THE CHRISTMAS ANGEL PROGRAM. THE HOSPITAL OFFERS A HEALTH FAIR FOR THE COMMUNITY, PROVIDING FREE OR REDUCED PRICING SCREENINGS (BLOOD PRESSURE, CHILD ID, LIPID PROFILE, BLOOD GLUCOSE) AND HEALTH INFORMATION. THE HOSPITAL PROVIDES A HEALTH FAIR FOR PAR 4 (MANUFACTURING COMPANY) EMPLOYEES AS WELL AS OFFERS DISCOUNTED MAMMOGRAMS DURING THE MONTH OF OCTOBER IN HONOR OF BREAST CANCER AWARENESS MONTH. The hospital also provides volunteer workers for the Crittenden County Youth Triathalon. THE HOSPITAL SUPPLIES A REGISTERED NURSE FOR 4-H CAMP FOR AREA SCHOOL CHILDREN. THE REGISTERED NURSE MAINTAINS A FIRST AID STATION THROUGHOUT THE CAMP. HOSPITAL EMPLOYEES ARE ALSO INVOLVED IN NUMEROUS BOARDS THROUGHOUT THE COMMUNITY. CRITTENDEN COUNTY HAS A CHARITY CARE PROGRAM FOR HOSPITAL CLIENTELE. THE HOSPITAL HAS WRITTEN OFF $1,344,071 IN UNCOLLECTABLE ACCOUNTS IN FISCAL YEAR 2017 FOR PATIENTS IT DEEMS UNABLE TO PAY FOR HEALTHCARE SERVICES UNDER ITS CHARITY CARE POLICY. CRITTENDEN COUNTY HOSPITAL ACCEPTS PATIENTS WITHOUT REGARD FOR THEIR ABILITY TO PAY FOR CARE.
Schedule H (Form 990) 2016
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