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
2021
Open to Public Inspection
Name of the organization
Webster County Memorial Hospital
 
Employer identification number

55-6005561
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) . . . 		    121,136 121,136    
b Medicaid (from Worksheet 3, column a) . . . . .     168,808 160,030 8,778 0.090 %
c Costs of other means-tested government programs (from Worksheet 3, column b) . .            
d Total Financial Assistance and Means-Tested Government Programs . . . . .     289,944 281,166 8,778 0.090 %
Other Benefits
e Community health improvement services and community benefit operations (from Worksheet 4).            
f Health professions education (from Worksheet 5) . . .            
g Subsidized health services (from Worksheet 6) . . . .            
h Research (from Worksheet 7) .            
i Cash and in-kind contributions for community benefit (from Worksheet 8) . . . .     1,100   1,100 0.010 %
j Total. Other Benefits . .     1,100   1,100 0.010 %
k Total. Add lines 7d and 7j .     291,044 281,166 9,878 0.100 %
For Paperwork Reduction Act Notice, see the Instructions for Form 990. Cat. No. 50192T Schedule H (Form 990) 2021
Schedule H (Form 990) 2021
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
Yes
 
2
Enter the amount of the organization's bad debt expense. Explain in Part VI the methodology used by the organization to estimate this amount. ......
2
516,419
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
1,196,544
6
Enter Medicare allowable costs of care relating to payments on line 5.....
6
1,196,544
7
Subtract line 6 from line 5. This is the surplus (or shortfall)........
7
 
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) 2021
Schedule H (Form 990) 2021
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 and Surgical Children's Hospital Teaching Hospital Critical Access Hospital Research Facility ER-24Hours ER-Other Other (describe) Facility reporting group
1 Webster County Memorial Hospital
PO Box 312
Webster Springs,WV26288
https://www.wcmhwv.org/ 		X       X   X   Rural Health Clinic  
Schedule H (Form 990) 2021
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Schedule H (Form 990) 2021
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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)
Webster County Memorial 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 20
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 20
10 Is the hospital facility's most recently adopted implementation strategy posted on a website?......... 10 Yes  
a If "Yes" (list url): https://www.wcmhwv.org/downloadable-forms-1
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) 2021
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Schedule H (Form 990) 2021
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Part VFacility Information (continued)

Financial Assistance Policy (FAP)
Webster County Memorial Hospital
Name of hospital facility or letter of facility reporting group  
Yes No
Did the hospital facility have in place during the tax year a written financial assistance policy that:
13 Explained eligibility criteria for financial assistance, and whether such assistance included free or discounted care? 13 Yes  
If “Yes,” indicate the eligibility criteria explained in the FAP:
a
b
c
d
e
f
g
h
14 Explained the basis for calculating amounts charged to patients?................. 14 Yes  
15 Explained the method for applying for financial assistance?................... 15 Yes  
If “Yes,” indicate how the hospital facility’s FAP or FAP application form (including accompanying instructions) explained the method for applying for financial assistance (check all that apply):
a
b
c
d
e
16 Was widely publicized within the community served by the hospital facility?........ 16 Yes  
If "Yes," indicate how the hospital facility publicized the policy (check all that apply):
a
https://www.wcmhwv.org/downloadable-forms-1
b
https://www.wcmhwv.org/downloadable-forms-1
c
d
e
f
g
h
i
j
Schedule H (Form 990) 2021
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Schedule H (Form 990) 2021
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Part VFacility Information (continued)

Billing and Collections
Webster County Memorial 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) 2021
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Schedule H (Form 990) 2021
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Part VFacility Information (continued)

Charges to Individuals Eligible for Assistance Under the FAP (FAP-Eligible Individuals)
Webster County Memorial 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) 2021
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Schedule H (Form 990) 2021
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Part V
Facility Information (continued)
Section C. Supplemental Information for Part V, Section B. Provide descriptions required for Part V, Section B, lines 2, 3j, 5, 6a, 6b, 7d, 11, 13b, 13h, 15e, 16j, 18e, 19e, 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
Webster County Memorial Hospital Part V, Section B, Line 5: The Community Health Needs Assessment (CHNA) questionnaire was taken to multiple public locations for community members to fill out and give their opinion of services needed and their satisfaction with services already provided by the hospital. Officials and employees were interviewed for the CHNA from the following: Webster County Health Department, Board of Education, Family Resource Network, United National Bank, Catholic Charities, and the food pantry.
Webster County Memorial Hospital Part V, Section B, Line 11: Based upon the results of the Community Health Needs Assessment, Webster County Memorial Hospital will develop a three-year Implementation Strategy to address the following significant community health related needs:*Increased education and promotion of community resources*Utilize existing affiliations to promote healthier lifestyle choices*Chronic disease maintenance and prevention (Diabetes, Cardiovascular, Respiratory)*Improve overall health statusThe CHNA, approved on June 30, 2021, has provided valuable insight to the contributing factors of health related issues faced by the residents of Webster County and the surrounding communities. It will assist Webster County Memorial Hospital as well as other community providers to collaborate their efforts to provide the necessary resources for the community. Initiatives were aggregated among two main categories, increased education and promotion of community resources and promotion of healthier lifestyle choices.
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
Schedule H (Form 990) 2021
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Schedule H (Form 990) 2021
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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?2
Name and address Type of Facility (describe)
1 1 - The Cowen Clinic
70 Technology Drive
Cowen,WV26206 		Prenatal primary care, pain management, wellness clinic
2 2 - Webster Physical Therapy
139 Bakers Island
Webster Springs,WV26288 		Physical therapy
3
4
5
6
7
8
9
10
Schedule H (Form 990) 2021
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Schedule H (Form 990) 2021
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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 patient's income is considered and reviewed to determine the amount of discount they receive, if not free care. The patient's assets are also reviewed. They can only have one vehicle and one house. If the patient has more than one vehicle, the total value of the vehicles cannot exceed $2,000. If the value exceeds $2,000, the patient will automatically be reduced to a percentage less than 100%.
Part I, Line 7: The Hospital is a CAH and is paid 100% costs from Medicaid with the exception of the RHC which is PPS. The Medicaid community benefit expense reported on Part I, Line 7b is from the RHC excess cost over reimbursements.
Part I, Line 7, Column (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 $ 516,419.
Part II, Community Building Activities: The Hospital distributes educational material regarding smoking cessation, healthy eating, saying no to drugs, cancer, diabetes & other diseases, how to live a healthier life along with physical activities. The Hospital also assists the community with kids needs for sports.
Part III, Line 4: Patient accounts receivable are carried at the original charge less an estimate made for doubtful or uncollectible accounts. The allowance is based upon a review of the outstanding balances aged by financial class. Management uses collection percentages based upon historical collection experience to determine collectibility. Management also reviews troubled, aged accounts to determine collection potential. Patient accounts receivable are written off when deemed uncollectible. Recoveries of accounts previously written off are recorded as a reduction to bad debt expense when received. Interest is not charged on patient accounts receivable.
Part III, Line 8: The Medicare cost report was used to report Medicare revenue and expenses.CAH's receive cost reimbursement for Medicare services. A settlement process takes place after the Medicare cost report is filed in order to make payments (revenue) equal allowable cost. Thus, there is no "shortfall" of cost versus payments for CAH Medicare services.
Part III, Line 9b: Patient's are informed about the finanical assistance program when they call to ask about their medical bills. The billers offer patient information about the program over the phone or if the patient is seen by the biller in person, they are shown the application and the documents that are needed.
Part VI, Line 2: Director of Clinical Operations & Quality continuously reviews referral logs made by secretaries to see if there are any services we can provide here. Then we find out cost and reimbursement issues and present to CEO.
Part VI, Line 3: If the patient presents to the registration desk and is private pay, the registration clerk informs the patient that we currently have a Financial Assistance program that will help them receive a discount or have the total amount written off and offers them the application. If a patient is private pay and admitted as an observation or inpatient, the social worker reviews the financial assistance program with the patient and offers them the application before discharge. If a patient calls into the billing office to ask about their billing statement and they state they don't think they can pay or want to make a payment contract, the billers will offer the patient information on the program and offer to mail them an application.
Part VI, Line 4: Our geographical service area is rural. The majority (91.2%) of the Hospital's patients reside in Webster County, West Virginia. A portion of the remaining patients reside in Nicholas County (3.1%) and Randolph County (1.5%). The population of Webster County is 8249. The residents of Webster County have a median household income of $33,358 and 23% of the residents live in poverty. There is one hospital serving the community and the next nearest facility is 40 miles away.
Part VI, Line 5: Governing body is comprised of members of all areas of the community and are not employees of the organization. The Hospital extends privileges to all qualified staff working for the facility. The Hospital uses surplus funds to provide new services for patients. The emergency room is available to all patients whether they have the ability to pay or not. The Hospital offers MRI, Cardiac and Pulmonary Rehab and Nuclear medicine, which are not available at any other location in the County. The Hospital offers charitable care and serves as a source of community volunteer activities.
Schedule H (Form 990) 2021
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