Schedule H, Part I, Line 3c financial assistance eligibility criteria
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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.
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Schedule H, Part V, Section B, Line 16a FAP AVAILABLE WEBSITE
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https://www.mercyone.org/centerville/for-patients/billing-and-financial-information/financial-assistance
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Schedule H, Part V, Section B, Line 16b FAP APPLICATION FORM WEBSITE
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https://www.mercyone.org/centerville/for-patients/billing-and-financial-information/financial-assistance
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Schedule H, Part V, Section B, Line 16c PLAIN LANGUAGE FAP SUMMARY WEBSITE
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https://www.mercyone.org/centerville/for-patients/billing-and-financial-information/financial-assistance
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Schedule H, Part I, Line 7g Subsidized Health Services
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THERE ARE NO PHYSICIAN CLINICS INCLUDED IN SUBSIDIZED HEALTH SERVICES.
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Schedule H, Part I, Line 7 Bad Debt Expense excluded from financial assistance calculation
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572272
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Schedule H, Part I, Line 7 Costing Methodology used to calculate financial assistance
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THE COST-TO-CHARGE RATIO FOR THE YEAR ENDED 6/30/18 WAS COMPUTED USING THE FOLLOWING FORMULA: OPERATING EXPENSE (BEFORE RESTRUCTURING, IMPAIRMENT AND OTHER LOSSES) DIVIDED BY GROSS PATIENT REVENUE. BASED ON THAT FORMULA, $27,074,853/ 66,931,037 RESULTS IN A 40.45% COST-TO-CHARGE RATIO. WORKSHEET 2 WAS NOT USED TO DERIVE THE COST-TO-CHARGE RATIO.
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Schedule H, Part III, Line 2 Bad debt expense - methodology used to estimate amount
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Costing methodology for amounts reported on line 2 is determined using the organization's cost/charge ratio of 40.45%. When discounts are extended to self-pay patients, these patient account discounts are recorded as a reduction in revenue, not as bad debt expense.
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Schedule H, Part III, Line 3 Bad Debt Expense Methodology
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Mercy Medical Center - Centerville 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.
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Schedule H, Part III, Line 4 Bad debt expense - financial statement footnote
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Mercy Medical Center - Centerville 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.
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Schedule H, Part III, Line 8 Community benefit & methodology for determining medicare costs
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Mercy Medical Center - Centerville 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, Mercy Medical Center - Centerville, due to their designation as a CAH, received cost-based reimbursement for Medicare purposes, Mercy Medical Center - Centerville 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: $4,251,977 Total Medicare costs: $12,704,183 Surplus or Shortfall ($8,452,205) Mercy Medical Center-Centerville 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.
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Schedule H, Part III, Line 9b Collection practices for patients eligible for financial assistance
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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.
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Schedule H, Part V, Section B, Line 16a FAP website
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- Mercy Medical Center - Centerville: Line 16a URL: (SEE STATEMENT);
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Schedule H, Part V, Section B, Line 16b FAP Application website
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- Mercy Medical Center - Centerville: Line 16b URL: (SEE STATEMENT);
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Schedule H, Part V, Section B, Line 16c FAP plain language summary website
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- Mercy Medical Center - Centerville: Line 16c URL: (SEE STATEMENT);
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Schedule H, Part VI, Line 2 Needs assessment
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Mercy Medical Center-Centerville is a 25 bed critical access not-for-profit Catholic hospital located in Centerville, IA. The hospital is included in the Official Catholic Directory as a tax-exempt hospital. The mission of the hospital is to nurture the healing ministry of the Church by bringing it new life, energy, and viability in the 21st century. The medical fraternity in Centerville founded the hospital as the Centerville Hospital in 1902. At the community's request, management and operations of the hospital were taken over by the Sisters of Mercy in 1910. Since that time, Mercy has continued to reach out to provide education, health care and services, collaborating with local partners to improve the health of the community. Guided by our values of Reverence, Integrity, Compassion, and Excellence, we hold ourselves to a high standard of giving to the poor and broader community. Mercy Centerville employs 209 people with a medical staff of 9 family practice providers, 2 general surgeons, 1 ob-gyn, 1 internal medicine, and 1 pediatrician. Consulting specialty clinics at the hospital are also available in the areas of pathology, allergy, urology, otolaryngology, cardiology, oncology, podiatry, vascular surgery, dermatology, nephrology and orthopedics. Just like fire and police protection, the hospital provides 24-hour emergency room physicians. Diagnostic capability includes x-ray, ultrasound, vascular ultrasound, CT scan, PET-CT scan, nuclear medicine, MRI, digital mammography and bone densitometry. Other services include Physical & Occupational Therapy, Respiratory Therapy, Obstetrics, Surgery, Ambulance, Cardiac Rehabilitation, and Social and Pastoral Care programs. The hospital also operates a 19-bed Long-Term Care facility, Sleep Lab and Geriatric Outpatient Mental Health. The hospital's services are provided to the community on a non-discriminatory basis and include an emergency room staffed 24/7 with emergency room physicians that is open to all persons regardless of ability to pay. The hospital is governed by a board in which independent persons representative of the community comprise the majority. The hospital participates in government-sponsored health care programs like Medicaid and Medicare.
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Schedule H, Part VI, Line 3 Patient education of eligibility for assistance
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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.
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Schedule H, Part VI, Line 4 Community information
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Mercy Medical Center has provided Centerville and the people of Appanoose County with many ongoing community benefits since its beginning. Foremost, as a private hospital, it has saved the community over one million dollars annually in property taxes compared to surrounding counties who support public hospitals. True to its mission, Mercy-Centerville has made a commitment to improving the health of the community before they become ill. The hospital has financial assistance policies and programs for low-income persons like the Uninsured/Underinsured Patient Discount Policy and the Self-Pay and Third-Party Discounts Policy. QUANTITATIVE DESCRIPTION OF COMMUNITY BENEFIT: The hospital served 11,229 persons in FY18 with a cost of community benefit of $434,804. QUALITATIVE DESCRIPTION OF COMMUNITY BENEFIT I. Community Outreach for the Poor Senior Transportation The hospital sponsors a community bus 5 days per week which provides free transportation to medical appointments or general errands for the elderly and others with low income who are unable to drive or have no one to transport them. Medical Eligibility & Counseling Services Provide dedicated person to assist uninsured and underinsured patient's with links to health care services and government programs. Operation Santa Hotline Provide and maintain a hotline for Operation Santa, a non-profit community group who gives food and presents to local families living in poverty. II. Community Outreach for the Broader Community Alzheimer's Support Group Mercy holds a monthly Alzheimer's support group to meet the growing needs of the elderly facing Alzheimer's and those who are providing care to them in the home. The group has both a morning and evening session for the convenience of caregivers. Narcotics Anonymous The hospital provided facilities once a week throughout the year to narcotics anonymous, allowing the group a safe and confidential environment to assist and support their recovery. Kids Health Fair Mercy was a lead sponsor and participant in the Appanoose County Healthy Kids Fair. The kids fair targeted youth and families promoting good health habits, hygiene, nutrition and exercise for kids. Athletic Coverage Mercy provided free athletic coverage at community school sponsored athletic events - football and baseball. Includes screening, evaluating and treating injuries. Parkinson's Support Group Mercy holds a monthly support group for area residents suffering from Parkinson's. Led by a hospital physical therapist, the program helped to educate those with Parkinson's and their caregivers about living with Parkinson's and the resources available to assist them in their everyday life living with the disease. Cancer Support Group Mercy provided a monthly support group for cancer patients and families. The program provides a forum for discussion, problems, resources and overall support for these people who are living with the disease. Breastfeeding Support Group Mercy provided the areas only breastfeeding support group within a one hours drive. Specially trained registered nurses managed the program and provided support and education to new mothers, promoting the benefits of breastfeeding through assistive techniques and resources. Heart Healthy Eating & Living Mercy provided a monthly program to people with cardiac disease on the benefits of eating healthy and regular exercise to manage or prevent further cardiac events. Athletic Physicals Mercy provided greatly reduced athletic physicals to the local Centerville school district families.
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Schedule H, Part VI, Line 5 Promotion of community health
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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.
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Schedule H, Part VI, Line 6 Affiliated health care system
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The organization was, for the year ended 6/30/18, affiliated with Catholic Health Initiatives ("CHI"). Following the close of the 6/30/2018 tax year, on 2/1/19, in connection with the alignment of the Catholic ministries of CHI and Dignity Health, CHI changed its name to CommonSpirit Health. The narrative below reflects the activities of the organization's affiliate, CHI, as of and for the year ended 6/30/18: 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 18 states and comprises 100 hospitals, including two academic health centers, 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 2018, CHI provided more than $1.1 billion in financial assistance and community benefit for programs and services for the poor, free clinics, education and research. Financial assistance and community benefit totaled more than $2.0 billion with the inclusion of the unpaid costs of Medicare. The health system, which generated operating revenues of $14.98 billion in fiscal year 2018, has total assets of approximately $20.6 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.
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Schedule H, Part VI, Line 7 State filing of community benefit report
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IA
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