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/Form990EZ for instructions and the latest information.
OMB No. 1545-0047
2019
Open to Public Inspection
Name of the organization
The Children's Hospital of Alabama
 
Employer identification number

63-0307306
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

 

No
b
If "Yes," did the organization's financial assistance expenses exceed the budgeted amount? . . . . . .
5b
 
 
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) . . . 		    3,069,876   3,069,876 0.430 %
b Medicaid (from Worksheet 3, column a) . . . . .     388,668,419 352,211,070 36,457,349 5.140 %
c Costs of other means-tested government programs (from Worksheet 3, column b) . .            
d Total Financial Assistance and Means-Tested Government Programs . . . . .     391,738,295 352,211,070 39,527,225 5.570 %
Other Benefits
e Community health improvement services and community benefit operations (from Worksheet 4).     9,458,370 1,984,703 7,473,667 1.050 %
f Health professions education (from Worksheet 5) . . .     18,977,090 1,895,150 17,081,940 2.410 %
g Subsidized health services (from Worksheet 6) . . . .            
h Research (from Worksheet 7) .     253,933   253,933 0.040 %
i Cash and in-kind contributions for community benefit (from Worksheet 8) . . . .            
j Total. Other Benefits . .     28,689,393 3,879,853 24,809,540 3.500 %
k Total. Add lines 7d and 7j .     420,427,688 356,090,923 64,336,765 9.070 %
For Paperwork Reduction Act Notice, see the Instructions for Form 990. Cat. No. 50192T Schedule H (Form 990) 2019
Schedule H (Form 990) 2019
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 Healthcare Financial Management Association Statement No. 15? ..........................
1
 
No
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
8,371,079
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
914,912
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
1,743,338
6
Enter Medicare allowable costs of care relating to payments on line 5.....
6
1,930,522
7
Subtract line 6 from line 5. This is the surplus (or shortfall)........
7
-187,184
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) 2019
Schedule H (Form 990) 2019
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 Children's Hospital of Alabama
1600 Seventh Avenue South
Birmingham,AL35233 		X X X X   X X      
Schedule H (Form 990) 2019
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Schedule H (Form 990) 2019
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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)
Children's Hospital of Alabama
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 19
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 19
10 Is the hospital facility's most recently adopted implementation strategy posted on a website?......... 10 Yes  
a If "Yes" (list url): www.childrensal.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) 2019
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Schedule H (Form 990) 2019
Page 5
Part VFacility Information (continued)

Financial Assistance Policy (FAP)
Children's Hospital of Alabama
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.childrensal.org
b
www.childrensal.org
c
d
e
f
g
h
i
j
Schedule H (Form 990) 2019
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Schedule H (Form 990) 2019
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Part VFacility Information (continued)

Billing and Collections
Children's Hospital of Alabama
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) 2019
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Schedule H (Form 990) 2019
Page 7
Part VFacility Information (continued)

Charges to Individuals Eligible for Assistance Under the FAP (FAP-Eligible Individuals)
Children's Hospital of Alabama
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) 2019
Page 8
Schedule H (Form 990) 2019
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, 20a, 20b, 20c, 20d, 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
Children's Hospital of Alabama Part V, Section B, Line 5: In 2019, to better support the health of children in its community and to comply with federal regulations, Children's engaged the Public Affairs Research Institute of Alabama (PARCA) to conduct the community health needs assessment (CHNA) designed to identify statewide and local child health concerns for children across the state. The assessment's geographic focus targeted Children's primary service area of Bibb, Blount, Chilton, Jefferson, Shelby, St. Clair, and Walker counties. The assessment also focused on child health needs in Children's secondary service area which encompasses the state of Alabama. Stakeholders from both the primary and secondary service areas were invited to participate in an online survey to identify health needs for children's in Alabama. Responding parties included parents, youth leaders, school nurses, administrators, pediatricians, family practice physicians, community advocates, business leaders, and the community at large. In addition to the online survey tool, face-to-face and telephone interviews were conducted in 2019 with Alabama's public health leaders and community and nonprofit advocates. COA's community health needs assessment findings were released on December 20, 2019.
Children's Hospital of Alabama Part V, Section B, Line 11: COA continues to address significant needs identified in the most recent CHNA including nutrition and exercise, pediatric mental and behavioral health, and parent education. In 2019, Children's continued to support the missions of like-minded non-profit organizations focused on nutrition, exercise and fitness including Girls on the Run Birmingham, the YWCA, and the YMCA. COA is also an active participant in several regional and statewide coalitions aimed at improving pediatric nutrition and exercise while working to end child hunger. Partnerships include End Child Hunger in Alabama (ECHA) and Bold Goals of Central Alabama's Health Lifestyles Goal Group. These are organizations that have local collaboratives and strategies to address childhood food insecurity. Children's pediatricians are facilitators of the Girlology and Guyology programs aimed at outfitting young girls and boys with age-appropriate health and body classes to navigate their journeys through adolescence. Efforts will continue to increase coordination and collaboration of messaging, educational resources, public events, and other resources as appropriate. Regarding mental and behavioral health, COA established Psychiatric Intake Response Center (PIRC), located in the Emergency Department at Children's. Children's received an ADMH/HRSA grant to establish telehealth relationships with rural pediatric practices to train pediatricians and their staff on how to diagnose and manage their young patients with behavioral and mental health issues, as well as perform diagnosis and treatment plans. Children's also continued its participation in community-wide roundtables in 2019 on mental health, healthy lifestyles, parent education and healthcare equity.
Children's Hospital of Alabama Part V, Section B, Line 20e: Signage is posted throughout the facility at entrances and all registration locations including the emergency department, waiting and admitting areas notifying patients and guarantors of the availability of financial assistance.
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
Schedule H (Form 990) 2019
Page 9
Schedule H (Form 990) 2019
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?  
Name and address Type of Facility (describe)
1
2
3
4
5
6
7
8
9
10
Schedule H (Form 990) 2019
Page 10
Schedule H (Form 990) 2019
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
Part I, Line 7: The costing methodology used to complete Line 7 was an overall cost-to-charge ratio computed using the IRS Form 990 Worksheet 2, ratio of patient care cost to charges.
Part I, Ln 7 Col(f): The bad debt expense included on Form 990, Part IX, Line 25, column (a), but subtracted for purposes of calculating the percentage in this column is $8,371,079.
Part II, Community Building Activities: In 2019 the Hospital participated in initiatives as defined under Part II, Community Building Activities. Thousands of cumulative hours of workforce development and training were reported on a quarterly basis by Hospital divisions training health professionals through annual and seasonal internships. Hospital employees continued their participation in community coalitions including the United Way of Central Alabama's bold goals, local and regional roundtables on mental health, statewide coalitions to address child hunger, access to care, and numerous child safety-related coalitions. The Hospital hosted statewide and local leadership groups in 2019, (i.e. Leadership Birmingham and Leadership Alabama). Our human resource department continued to participate in job and career fairs and marketing campaigns to recruit a broad spectrum of health professionals. Hospital executives served on a variety of community boards, organizations, and professional organizations at a national, state, and local level.
Part III, Line 2: Receivables from patients, insurance companies and third-party contractual agencies are stated at net realizable value. The Hospital evaluates the collectability of its patient accounts receivable based on the length of time the receivable is outstanding, historical collection experience, review of large balance accounts and trends in health care insurance programs to estimate the appropriate allowance for doubtful accounts and provision for bad debts. For receivables associated with services provided to patients with third-party insurers, the Hospital estimates contractual allowances based on the terms of third-party insured contracts and estimates an additional allowance for doubtful accounts on patient responsible balances after third-party payments. For receivables associated with self-pay patients, the hospital records a significant provision for bad debts in the period of service on the basis of its past experience, which indicates that many patients are unable or unwilling to pay the portion of their bill for which they are financially responsible. These allowances are recorded on an estimated basis and adjusted as needed in future periods. Doubtful accounts are written off against the allowance after adequate collection effort is exhausted and recorded as recoveries of bad debts if subsequently collected.
Part III, Line 3: Bad debts attributable to patients eligible for charity care were calculated based on the outstanding patient balance in excess of a reasonable amount the average person could pay without creating a medical hardship. For 2019 this amount is $25,750, which approximates the income limit for a family of 4 in the federal poverty guidelines. Charity care determinations are based on completing the required application and meeting defined criteria of the hospital. Many times, patients fail to complete paperwork required despite efforts to educate and inform patients of this option. However, based on socio-economic and other known factors, it is highly likely that these patients would meet established charity care criteria if the application process was completed.
Part III, Line 8: Medicare cost & charges primarily relate to renal (ESRD) and SSI patients covered under Medicare. Given our small Medicare population, the costs/charges could fluctuate significantly year over year based on level of care. These would not be considered a community benefit.
Part III, Line 9b: A guarantor will receive four bills before the account is turned over to a collection agency. After 120 days, if there is no attempt to pay - the account will be sent to a collection agency.
Part VI, Line 2: In 2019, to better support the health of children in its community and to comply with federal regulations, Children's engaged the Public Affairs Research Institute of Alabama (PARCA) to conduct the community health needs assessment (CHNA) designed to identify statewide and local child health concerns for children across the state. The assessment's geographic focus targeted Children's primary service area of Bibb, Blount, Chilton, Jefferson, Shelby, St. Clair, and Walker counties. The assessment also focused on child health needs in Children's secondary service area which encompasses the state of Alabama. Stakeholders from both the primary and secondary service areas were invited to participate in an online survey to identify health needs for children's in Alabama. Responding parties included parents, youth leaders, school nurses, administrators, pediatricians, family practice physicians, community advocates, business leaders, and the community at large. In addition to the online survey tool, face-to-face and telephone interviews were conducted in 2019 with Alabama's public health leaders and community and nonprofit advocates. COA's community health needs assessment findings were released on December 20, 2019.
Part VI, Line 3: Each patient that presents as a self pay patient is directed to a financial counselor. The financial counselor educates patients and their families about government and financial assistance programs and assists with related applications. If a patient is not counseled by a financial counselor on the date of service, statements are sent with the information needed to apply for financial assistance by the business office. In addition, the Financial Assistance Policy is posted on the Hospital's website and there is signage throughout the Hospital informing patients of the availability of a financial assistance program.
Part VI, Line 4: The Hospital's primary service area is Birmingham / Hoover metropolitan statistical area as defined by the U.S. Office of Management and Budget. The Hospital's secondary service area is defined as the rest of the state, and we care for patients from every county in the state. demographic data including race, gender, and age is captured through the registration process. For 2019, Caucasians, African Americans, Hispanics, and other races accounted for 55%, 36%, 7%, and 2%, respectively, of the patients served while 39%, 35%, and 26% were ages 0-4, 5-12, and 13+ years, respectively. Economic demographic data is not specifically captured. However, in 2019 greater than 60% of the Hospital's patients qualified for governmental means-tested programs such as Medicaid and CHIPS.
Part VI, Line 5: The Hospital is the primary source of pediatric healthcare and pediatric health education in the state of Alabama through its affiliation with the School of Medicine at The University of Alabama at Birmingham, other four-year universities, and most of Alabama's two-year colleges. The Hospital operates an open medical staff, has a board comprised of community members, and operates an open emergency department that treats all emergent patients regardless of their ability to pay. The Hospital operates the only Level 1 pediatric trauma center, pediatric renal care center, pediatric cardiac and transplant unit, and inpatient children's psychiatric units in the state. In addition, the Hospital operates the largest pediatric burn center in the southeast. The Hospital is education and research focused and collaborates with local universities, as well as those throughout the state, to train and educate future healthcare professionals. This is reflected by the fact that approximately 50-60% of the pediatricians practicing in the state of Alabama trained at the Hospital and that the Hospital trained nursing students and allied health professionals from over 50 different colleges and universities during 2019. In addition, the Hospital participates in approximately 939 clinical research studies on an annual basis.
Schedule H (Form 990) 2019
Additional Data


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