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 Charlotte Hungerford Hospital
 
Employer identification number

06-0646678
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
 
No
b
If "Yes," did the organization make it available to the public? . . . . . . . . . . . . .
6b
 
 
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) . . . 		    695,552   695,552 0.410 %
b Medicaid (from Worksheet 3, column a) . . . . .     39,700,413 35,397,766 4,302,647 2.520 %
c Costs of other means-tested government programs (from Worksheet 3, column b) . .            
d Total Financial Assistance and Means-Tested Government Programs . . . . .     40,395,965 35,397,766 4,998,199 2.930 %
Other Benefits
e Community health improvement services and community benefit operations (from Worksheet 4).     191,137   191,137 0.110 %
f Health professions education (from Worksheet 5) . . .     9,980   9,980 0.010 %
g Subsidized health services (from Worksheet 6) . . . .     10,000,000 10,000,000    
h Research (from Worksheet 7) .            
i Cash and in-kind contributions for community benefit (from Worksheet 8) . . . .     1,468   1,468 0 %
j Total. Other Benefits . .     10,202,585 10,000,000 202,585 0.120 %
k Total. Add lines 7d and 7j .     50,598,550 45,397,766 5,200,784 3.050 %
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
4,656,221
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
 
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
35,446,922
6
Enter Medicare allowable costs of care relating to payments on line 5.....
6
38,584,471
7
Subtract line 6 from line 5. This is the surplus (or shortfall)........
7
-3,137,549
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 The Charlotte Hungerford Hospital
540 Litchfield Street
Torrington,CT06790
https://www.charlottehungerford.org/
0042 		X X         X X    
Schedule H (Form 990) 2019
Page 4
Schedule H (Form 990) 2019
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)
The Charlotte Hungerford 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 17
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 17
10 Is the hospital facility's most recently adopted implementation strategy posted on a website?......... 10 Yes  
a If "Yes" (list url): See Part V, Page 8
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
Page 5
Schedule H (Form 990) 2019
Page 5
Part VFacility Information (continued)

Financial Assistance Policy (FAP)
The Charlotte Hungerford 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
See Part V, Page 8
b
See Part V, Page 8
c
d
e
f
g
h
i
j
Schedule H (Form 990) 2019
Page 6
Schedule H (Form 990) 2019
Page 6
Part VFacility Information (continued)

Billing and Collections
The Charlotte Hungerford 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) 2019
Page 7
Schedule H (Form 990) 2019
Page 7
Part VFacility Information (continued)

Charges to Individuals Eligible for Assistance Under the FAP (FAP-Eligible Individuals)
The Charlotte Hungerford 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) 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
The Charlotte Hungerford Hospital Part V, Section B, Line 5: To solicit input from key informants and individuals who have broad interest in the health of the community, the hospital performed surveys, community forums, focus groups and interviews with key informants. The key informants were selected by community leader(s) or liaison(s). Additionally, focus groups were used to identify any other resource.Focus group was conducted on February 16, 2018. Community forums, and individual key informant interviews were conducted between February and May 2018.Key informants were chosen because of their ability to identify primary concerns of the populations with whom they work, as well as of the overall community. They were asked to rate the degrees to which various health issues were of concern in the Northwest Region. Follow-up questions were asked to describe why they identified areas as such, and how these might be better addressed. The key informants included Physicians, public health representatives, health professionals, social service providers and a variety of other community leaders including the following:Northwest Connecticut YMCAPrime Time House McCarthy Senior Center Sullivan Senior Center NWCT Community Foundation Winchester Schools Family Resource Center NWCT Chamber of Commerce Torrington Area Health District NW Hills Council of Governments NW Hills Credit Union Community Health and Wellness Center NW Connecticut Transitions Committee McCall Center for Behavioral Health NW Arts Council Litchfield Community Center Torrington Savings Bank City of Torrington Mayor's Office Brooker Memorial Visiting Nurse Services New Opportunities Waterbury NWCT Chamber of Commerce Town of Winchester Mayor's Office The NW United Way CHH Primary Care and PediatricsThe 2018 CHNA took a close look at social determinants of health such as poverty, housing, transportation, education, fresh food availability, and neighborhood safety. Social determinants of health have become a national priority for identifying and addressing health disparities, and Charlotte Hungerford Hospital is committed to addressing these disparities through the Community Health Improvement Plan that will follow this Assessment. Thru this process, input was gathered from individuals whose organizations can provide information for the following data elements:Medically Underserved AreasHealth Professional Shortage AreasDemographicsEthnicity DistributionsMedian Household IncomesHomeownership RatesPoverty MetricsUnemployment RatesEducational MetricsChildren in Poverty and Single Parent HouseholdsLinguistically Isolated PopulationsUninsured Population EstimatesClinical Provider RatiosPhysical Environment MetricsCrime RatesGeneral Health Status IndicatorsCancer Prevalence and Screening IndicatorsCardiovascular DiseaseRespiratory DiseaseDiabetesInfectious DiseasesSexually Transmitted DiseasesBirths and Prenatal CareHealth BehaviorsBenchmark Metrics (HealthyPeople 2020)Part V, Section B, Line 7a:https://charlottehungerford.org/community-health-needs-assessment
The Charlotte Hungerford Hospital Part V, Section B, Line 7d: The needs assessment was published in June 2018 and is available on the hospital's website. In addition, electronic copies are available upon request.Part V, Section B, Line 10a:https://charlottehungerford.org/community-health-needs-assessment
The Charlotte Hungerford Hospital Part V, Section B, Line 11: In acknowledging the wide range of priority health issues that emerged from the 2018 CHNA process, the community representatives met on May 31, 2018 to determine the health needs that will be prioritized for action. The review of the identified needs were followed by a wide ranging discussion, after which the representatives were asked to rank each of the needs.Based on data analysis, surveys, focus groups, and interviews, these are the top community health needs and priorities identified for the Charlotte Hungerford Hospital focus area: Greater Torrington Core Community Health Issues - include depth of poverty across the area, poor quality of older mill housing for lower-income residents, and low population density (lowest of any county in Connecticut) that contributes to areas of isolation and poor access to services. * Lack of resources compared to other Connecticut towns that get more attention: Torrington is the center of a dispersed population where there are issues with living wage and employment. Jobs are not competitive with other areas salary-wise. * Lack of broadband and poor or non-existent reception are big issues in the area and impacts ability to implement and leverage tele-health.Widespread Opioid and Substance Abuse Issues Across All Income Levels:* Limited access to treatment, including the need for timely intervention * Opioid crisis is widespread in the Northwest region. While there is not comparable data available, recent years have seen increases in opioid arrests, deaths, and treatment.Transportation Issues, Including Limited Hours and Services That Are Not Convenient to Bus Lines * Need for more in-home services for the senior population as their needs are impacted by transportation issues.* Funding, number of bus lines, hours of operation, access to providers.Access to Care: * Need for primary, specialty care, mental health services, and dental care. * Shortage of primary care physicians leads to emergency department overuse, often as a substitute for primary or urgent care, for care that could be delivered in lower cost settings.* Behavioral health wait times are long.* Designation of Litchfield County as a mental health shortage area. Access to Healthy Food, Especially for Children: * Teachers, school systems, and social services offer support for providing meals for children, but there are still not enough resources in the community. In the region, geographically Torrington and the Plymouth area scored significantly worse in physical and mental health indicators. Lack of Coordination Among and Between Providers and Community-Based Organizations Limits the Overall Effectiveness of the Programs That Are Going To Help Serve The Populations Most in Need. * Communication, education, and awareness: especially between providers * Fragmented services and too many silos * Need more community educational events as part of preventive care, including education of parents for children's health issues - Need comprehensive and dynamic asset mapping of available servicesThe results were then grouped into 4 Areas of Concern that were addressed in Community Health Improvement Plan (CHIP):1. Enhance Coordination of Services: this category includes Access to Care and Lack of Coordination Among and Between Providers and Community-Based Organizations.CHIP addressed this need in the following manner:a. Evaluate and use information exchange portal resources, linking healthcare providers with community-based organizations.b. Improve IT resources to enable community focus and better measurement of outcomes.c. Develop a playbook for infrastructure, dashboard of health, governance, and community workflows.d. Enable dynamic and up-to-date asset mapping.e. Develop innovation network for learning, research, co-creation, and rapid knowledge dissemination (bi-directional communication platform).f. Implement new or increased use of Community Health Workers (CHW).g. Evaluate and use adaptive technology (e.g., geo-fencing, GIS mapping, artificial intelligence, biometric risk assessment, Epic tie-ins.2. Promote Healthy Behaviors and Lifestyle: this category includes Food Concerns and Chronic Disease and Poor Physical and Mental Health. CHIP addresses this need in the following manner:a. Screen for healthy food need identification in community population and provide assessment at points of care.b. Enhance Promotion and Marketing, including continuing the 5-2-1-0 initiative, at schools, workplaces, public spaces, faith communities, and healthcare events.c. Provide voucher/prescription programs for fruits and vegetables.d. Promote and improve healthy food donation.e. Screen for healthy food need identification in community population and provide assessment at points of care.3. Improve Community Behavioral Health: CHIP addresses this need in the following manner: a. Embed behavioral health services in primary care.b. Recruit more mental health providers, with focus on community outpatient services (e.g., family therapists).c. Implement Recovery Coach program in ED.d. Provide more depression screening growth and at more points of care with referrals (including at public schools) and integrate into Epic.e. Further Mental Health First Aid training and grow community behavioral health training at the local level.f. Enhance services in virtual mental health, including tele-psychiatry.g. Build on tobacco prevention and cessation programs.h. Continue development of Opioid Task Force.4. Reduce the Burden of Chronic DiseaseCHIP addresses this need in the following manner:a. Congestive Heart Failure discharge programs and CHF clinic.b. Growth in diabetes programs, including Diabetes Center at CHH with specialists and prevention program at YMCA (Measurable Progress Unlimited Support Diabetes Prevention Program).c. Leverage CHW dietician (see Coordination of Services initiative).d. Case management, self-management (including access to self-measure devices or monitors), at-home programs, and support groups.
The Charlotte Hungerford Hospital Part V, Section B, Line 13h: Family eligibility criteria for Financial Assistance also include family size, employment status, financial obligations, and amount and frequency of the health care expenses.
The Charlotte Hungerford Hospital Part V, Section B, Line 15e: In addition, patients may ask a nurse, physician, chaplain, or staff member from Patient Registration, Patient Financial Services, Case Coordination, or Social Services about initiating the Financial Assistance Application process.Part V, Section B, Line 16a: FAP Website:https://charlottehungerford.org/patients-visitors/billing-insurance/financial-assistance-billingPart V, Section B, Line 16b: FAP Application Website:https://charlottehungerford.org/patients-visitors/billing-insurance/financial-assistance-billingPart V, Section B, Line 16c: FAP Plain Language Summary:https://charlottehungerford.org/patients-visitors/billing-insurance/financial-assistance-billing
The Charlotte Hungerford Hospital Part V, Section B, Line 16j: Patients are informed directly by staff of the availability of the Financial Assistance Policy.
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
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?13
Name and address Type of Facility (describe)
1 1 - Northwest Connecticut Medical Walk-In
1598 East Main Street
Torrington,CT06790 		Walk-in Medical Clinic
2 2 - The Hungerford Center
780 Litchfield Street
Torrington,CT06790 		Cardiac and Pulmonary Rehab Serices
3 3 - The Center for Cancer Care
200 Kennedy Drive
Torrington,CT06790 		Cancer Treatment Center
4 4 - Hungerford Diagnostic Center
220 Kennedy Drive
Torrington,CT06790 		Radiology Services
5 5 - The Center for Youth and Families
50 Litchfield Street
Torrington,CT06790 		Psych Services for Children and Families
6 6 - Winsted Behavioral Health Center
294 Main Street
Torrington,CT06790 		Psych Services
7 7 - Surgical Associates of CHH
538 Litchfield Street
Torrington,CT06790 		Surgical Physicians Practice
8 8 - Neurology PBC
780 Litchfield Street
Torrington,CT06790 		Neurology Physcians Practice
9 9 - CHH Primary Care
780 Litchfield Street
Torrington,CT06790 		Primary Care Physicians Practice
10 10 - CHH Cardiovascular Medicine Service
1215 New Litchfield Street
Torrington,CT06790 		Cardiovascular Physicians Practice
11 11 - CHH Wound Care and Hyperbaric Medicine
7 Felicity Lane
Torrington,CT06790 		Wound Care Physicians Practice
12 12 - CHH Urology Medicine
538 Litchfield Street
Torrington,CT06790 		Adult and Pediatric Urology Physicians Practice
13 13 - Hungerford Emergency and Medical Care
115 Spencer Street
Winsted,CT06098 		Emergency Services
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 3c: The Charlotte Hungerford Hospital used Federal Poverty Guidelines to determine eligibility. In addition, the hospital takes into consideration, medical indigency, insurance status, underinsurance status and other family eligibility criteria such as family size, employment and financial obligations.Part I, Line 6a:The Organization submits quarterly reports to Connecticut Hospital Association and Form 990 is submitted to the Connecticut Office of Health Strategy (OHS) annually.
Part I, Line 7: The organization utilized an overall cost to charge ratio (RCC), developed from the Medicare Cost Report. Total expense was adjusted for: medicaid provider taxes, directly identified community benefit expense and community building expenses. This cost to charge ratio was used to calculate costs for Part I lines 7a, b, & g. The costs associated with the activities reported on Part I, Line 7e were captured using actual time multiplied by an average salary rate. The costs associated with Line 7h, were the actual costs reported in the organization's general ledger less any industry funded studies. These costs were removed from the calculations above to avoid duplication. Costs reported in Part III, Section B6, were calculated from the Medicare cost report and reduced for Medicare costs previously reported on Part I Lines 7f and g.
Part I, Line 7g: No physician clinic costs were included in the Subsidized Health Services cost calculations.
Part III, Line 3: A pre-bad debt financial assistance screening is in place to identify patients that may be eligible for financial assistance. Pre-bad debt accounts that are identified as meeting the requirements are adjusted prior to being sent to bad debt. Therefore, any bad debt expense that could have been attributable to charity care at the end of FY 2020 would be immaterial.
Part III, Line 4: Please see the text of the footnote that describes bad debt expense beginning on page 30 of the Audited Financial Statement. The Footnote is also applicable Part III,Line 4.
Part III, Line 8: Cost Reports were used to report Medicare allowable costs. Medicare defines allowable costs as those appropriate and helpful in developing and maintaining the operation of patient care facilities and activities. It specifically excludes certain costs that are not directly related to patient care. The hospital incurs additional expense related to the provision of care to Medicare patients that Medicare has deemed non-allowable. This additional expense includes costs of physician services (emergency on-call fees, Hospitalist Programs, recruitment, etc.), advertising costs, cafeteria costs for meals sold to visitors, etc. The Hospital attempts to collect coinsurance and deductibles from Medicare beneficiaries. To the extent collection efforts are unsuccessful, Medicare reimburses the hospital at 65% of unpaid amounts. The table reconciles the shortfall or surplus from Line 7 to the actual surplus or shortfall. The additional costs were allocated to Medicare based upon Medicare's percentage of total allowable costs. The unpaid coinsurance/deductibles were estimated using historical collection results. Any shortfall amounts have not been treated as Community Benefits.
Part III, Line 9b: Charlotte Hungerford Hospital has adopted the Financial Assistance Policy of its Parent Company, Hartford HealthCare Corporation. The following is included in the Financial Assistance Policy: Patients who are deemed ineligible for financial assistance or who receive a partial discount and do not pay their bills may be subject to the following Extraordinary Collection Action (ECAs):*Wage Garnishments*Liens on primary and secondary residences, bank or investment accounts, or other assets*Legal actions and reporting the matter to one or more credit rating agencies*Other ECAs not listed aboveIf an individual has not submitted an application within the first 120 days from the date on which Hartford HealthCare first issues its first, post-discharge billing statement, then Hartford HealthCare may begin engaging in the ECAs described above.ECAs may begin after the first 120 days from the date on which Hartford HealthCare issues its first, post-discharge billing statement. If the patient applies for assistance within 240 days from the first notification of the self-pay balance, and is granted assistance, Hartford HealthCare will take all reasonable available measures to remove any collection actions such as negative reporting to a credit bureau or liens that have been filed.Before Hartford HealthCare initiates any collection actions, it will issue a written notice to the last known address of record for the patient (or his/her family) that describes the specific collection activities it intends to initiate (or resume), provides a deadline after which such action(s) will be initiated (or resumed), and includes a plain language summary of this Policy. ECAs can begin no sooner than 30 days from the date written notice is transmitted. Patients who are ineligible for financial assistance, or qualify for partial financial assistance and who are cooperating in good faith to resolve the outstanding accounts, may be offered extended payment plans. No further collection action will be taken as long as the patient continues to meet the terms of the payment plan.
Part VI, Line 2: The Charlotte Hungerford Hospital uses Emergency Room data to track increases in medical conditions such as falls, flu, drug overdoses, etc. Periodically information is surveyed to determine additional patients needs. Information is also tracked from other entities such as local area non-profits, government agencies and public schools.
Part VI, Line 3: Charlotte Hungerford Hospital provides information about its Financial Assistance Policy as follows: (i) Provides signage, brochures and/or a written plain language summary describing the policy along with financial assistance contact information in the emergency department, labor and delivery areas, discharge paperwork, other patient registration/admission areas, as well as in billing and collection communication; (ii) Makes paper copies of the policy, financial assistance application, and plain language summary of the policy available upon request and without charge, by mail; (iii) Posts the policy, plain language summary and financial assistance application on the website with clear linkage to such documents on the Hartford HealthCare and each affiliated hospital's home page; (iv) Educates all admission and registration personnel, financial counselors, billing and collection specialists and social workers regarding the policy so that they can serve as an informational resource to patients; (v) Includes the tag line 'Please ask about our Financial Assistance Policy" in applicable Hartford HealthCare written publications.
Part VI, Line 4: The Charlotte Hungerford Hospital (CHH) is located in the northwest region of Connecticut (Litchfield County) in the town of Torrington. The service area of the hospital is comprised of thirteen towns with a total population in excess of 100,000. In recent years, the area has become more racially and ethnically diverse. In the past decade, the number of White residents Increased at a slower rate compared to African American, Asian, and Hispanic residents. The local population is also aging, and has a lower percentage of persons under age 18 and a higher percentage of persons age 65 and older. Out of all the towns that are served by the CHH, the towns of Torrington and Cornwall historically had the highest poverty levels. In addition to the high poverty rates, both towns have historically lower median household incomes than other towns served by the hospital.
Part VI, Line 5: The mission of Charlotte Hungerford Hospital is to improve the health and healing of the people and communities we serve. Charlotte Hungerford Hospital is committed and focused on efforts to promote health and wellness.Majority of Charlotte Hungerford Hospital's regional governing board is comprised of persons who either reside or work in its primary service area, and they are neither employees nor contractors of the Hospital. Charlotte Hungerford Hospital extends medical staff privileges to all qualified physicians in its community. The Hospital has partnered with the Community Health Center to provide health services to the underserved in the community. In addition, the Hospital participates in Community Vision to improve community health and well-being.The Hospital has contracted to use the services of an organization to assist its patients in determining eligibility and applying for state and federal means-tested programs, as well as for the Hospital's Financial Assistance Program. Additionally, Charlotte Hungerford Hospital provides medical care regardless of patient's ability to pay for services.Charlotte Hungerford Hospital provides specialized services not available at other hospitals. These services are provided regardless of a patient's ability to pay. The hospital uses its surplus funds to provide additional benefits to its patients and the community it serves as detailed in Schedule O.
Part VI, Line 6: Hartford HealthCare Corporation (HHC) is organized as a support organization to govern, manage and provide support services to its affiliates. HHC, through its affiliates including The Charlotte Hungerford Hospital, strives to improve health using the "Triple Aim" model: improving quality and experience of care; improving health of the population (population health) and reducing costs. HHC and its affiliates including all supported organizations, develop and implement programs to improve the future of health care in our Southern New England region. This includes initiatives to improve the quality and accessibility of health care; create efficiency on both our internal operations and the utilization of health care; and provide patients with the most technically advanced and compassionate coordinated care. In addition, HHC continues to take important steps toward achieving its vision of being "nationally respected for excellence in patient care and most trusted for personalized, coordinated care".The affiliation with HHC creates a strong, integrated health care delivery system with a full continuum of care across a broader geographic area. This allows small communities easy and expedient access to the more extensive and specialized services the larger hospitals are able to offer. This includes continuing education of health care professionals at all the affiliated institutions through the Center of Education, Simulation and Innovation located at Hartford Hospital.The affiliation further enhances the affiliates' abilities to support their missions, identity, and respective community roles. This is achieved through integrated planning and communication to meet the changing needs of the region. This includes responsible decision making and appropriate sharing of services, resources and technologies, as well as cost containment strategies.
Part VI, Line 7, Reports Filed With States CT
Schedule H (Form 990) 2019
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