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
Mountain States Health Alliance
 
Employer identification number

62-0476282
Part I
Financial Assistance and Certain Other Community Benefits at Cost
Yes
No
1a
Did the organization have a financial assistance policy during the tax year? If "No," skip to question 6a . . . .
1a
Yes
 
b
If "Yes," was it a written policy? ......................
1b
Yes
 
2
If the organization had multiple hospital facilities, indicate which of the following best describes application of the financial assistance policy to its various hospital facilities during the tax year.
3
Answer the following based on the financial assistance eligibility criteria that applied to the largest number of the organization's patients during the tax year.
a
Did the organization use Federal Poverty Guidelines (FPG) as a factor in determining eligibility for providing free care?
If "Yes," indicate which of the following was the FPG family income limit for eligibility for free care:
3a
Yes
 
b
Did the organization use FPG as a factor in determining eligibility for providing discounted care? If "Yes," indicate
which of the following was the family income limit for eligibility for discounted care: . . . . . . . .
3b
Yes
 
c
If the organization used factors other than FPG in determining eligibility, describe in Part VI the criteria used for determining eligibility for free or discounted care. Include in the description whether the organization used an asset test or other threshold, regardless of income, as a factor in determining eligibility for free or discounted care.
4
Did the organization's financial assistance policy that applied to the largest number of its patients during the tax year provide for free or discounted care to the "medically indigent"? . . . . . . . . . . . . .

4

Yes

 
5a
Did the organization budget amounts for free or discounted care provided under its financial assistance policy during
the tax year? . . . . . . . . . . . . . . . . . . . . . . .

5a

Yes

 
b
If "Yes," did the organization's financial assistance expenses exceed the budgeted amount? . . . . . .
5b
 
No
c
If "Yes" to line 5b, as a result of budget considerations, was the organization unable to provide free or discountedcare to a patient who was eligibile for free or discounted care? . . . . . . . . . . . . .
5c
 
 
6a
Did the organization prepare a community benefit report during the tax year? . . . . . . . . .
6a
Yes
 
b
If "Yes," did the organization make it available to the public? . . . . . . . . . . . . .
6b
Yes
 
Complete the following table using the worksheets provided in the Schedule H instructions. Do not submit these worksheets with the Schedule H.
7
Financial Assistance and Certain Other Community Benefits at Cost
Financial Assistance and
Means-Tested
Government Programs
 (a) Number of activities or programs (optional) (b) Persons served (optional) (c) Total community benefit expense (d) Direct offsetting revenue (e) Net community benefit expense (f) Percent of total expense
a Financial Assistance at cost
(from Worksheet 1) . . . 		    11,402,856 0 11,402,856 1.300 %
b Medicaid (from Worksheet 3, column a) . . . . .     146,422,454 121,986,223 24,436,231 2.790 %
c Costs of other means-tested government programs (from Worksheet 3, column b) . .     0 0    
d Total Financial Assistance and Means-Tested Government Programs . . . . .     157,825,310 121,986,223 35,839,087 4.090 %
Other Benefits
e Community health improvement services and community benefit operations (from Worksheet 4).     4,463,854 681,594 3,782,260 0.430 %
f Health professions education (from Worksheet 5) . . .     17,115,126 3,417,293 13,697,833 1.560 %
g Subsidized health services (from Worksheet 6) . . . .     7,500,755 5,681,458 1,819,297 0.210 %
h Research (from Worksheet 7) .     979,636 40,029 939,607 0.110 %
i Cash and in-kind contributions for community benefit (from Worksheet 8) . . . .     3,151,417 0 3,151,417 0.360 %
j Total. Other Benefits . .     33,210,788 9,820,374 23,390,414 2.670 %
k Total. Add lines 7d and 7j .     191,036,098 131,806,597 59,229,501 6.760 %
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     1,000   1,000 0 %
2 Economic development     10,000   10,000 0 %
3 Community support            
4 Environmental improvements            
5 Leadership development and
training for community members		     35,000   35,000 0 %
6 Coalition building            
7 Community health improvement advocacy            
8 Workforce development     1,000   1,000 0 %
9 Other            
10 Total     47,000   47,000 0 %
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
54,335,359
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
20,104,083
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
155,168,850
6
Enter Medicare allowable costs of care relating to payments on line 5.....
6
147,829,964
7
Subtract line 6 from line 5. This is the surplus (or shortfall)........
7
7,338,886
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 %
11 Med Spec of JC LLC
  		Medical Services 51.000 %   49.000 %
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?8Name, 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 Johnson City Medical Center
400 N State of Franklin Rd
Johnson City,TN37604
balladhealth.org
00000121 		X X X X   X X   Mental Health A
2 Indian Path Community Hospital
2000 Brookside Drive
Kingsport,TN37660
balladhealth.org
00000134 		X X   X     X     A
3 Franklin Woods Community Hospital
300 Med Tech Parkway
Johnson City,TN37604
balladhealth.org
00000123 		X X         X     A
4 Sycamore Shoals Hospital
1501 W Elk Avenue
Elizabethton,TN37643
balladhealth.org
00000012 		X X         X   Mental Health A
5 Russell County Hospital
58 Carroll Street
Lebanon,VA24266
balladhealth.org
H 1892 		X X         X   Mental Health A
6 Johnson County Community Hospital
1901 S Shady Street
Mountain City,TN37683
balladhealth.org
00000039 		X X     X   X     A
7 Unicoi County Hospital
2030 Temple Hill Road
Erwin,TN37650
balladhealth.org
00000119 		X X         X     A
8 Lee County Community Hospital
127 Health Care Drive
Pennington Gap,VA24277
balladhealth.org
H 1940 		X X     X   X     A
Schedule H (Form 990) 2021
Page 4
Schedule H (Form 990) 2021
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)
Facility Reporting Group - A
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): 		 
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 21
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 Yes  
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 22
10 Is the hospital facility's most recently adopted implementation strategy posted on a website?......... 10   No
a If "Yes" (list url):  
b If "No," is the hospital facility’s most recently adopted implementation strategy attached to this return? ...... 10b Yes  
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
Page 5
Schedule H (Form 990) 2021
Page 5
Part VFacility Information (continued)

Financial Assistance Policy (FAP)
Facility Reporting Group - A
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
balladhealth.org
b
balladhealth.org
c
d
e
f
g
h
i
j
Schedule H (Form 990) 2021
Page 6
Schedule H (Form 990) 2021
Page 6
Part VFacility Information (continued)

Billing and Collections
Facility Reporting Group - A
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
Page 7
Schedule H (Form 990) 2021
Page 7
Part VFacility Information (continued)

Charges to Individuals Eligible for Assistance Under the FAP (FAP-Eligible Individuals)
Facility Reporting Group - A
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
Page 8
Schedule H (Form 990) 2021
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
Part V, Section B Facility Reporting Group A
Facility Reporting Group A consists of: - Facility 1: Johnson City Medical Center, - Facility 2: Indian Path Community Hospital, - Facility 3: Franklin Woods Community Hospital, - Facility 4: Sycamore Shoals Hospital, - Facility 5: Russell County Hospital, - Facility 6: Johnson County Community Hospital, - Facility 7: Unicoi County Hospital, - Facility 8: Lee County Community Hospital
Facility Reporting Group - A Part V, Section B, line 3j: To understand each community's individual needs, Ballad Health conducted a Community Health Needs Assessment (CHNA) for each Ballad hospital to profile the health of the residents within its service area. Throughout the CHNA process, high priority was given to determining the health disparities and available resources within each community. Community members from each county met with Ballad representatives to discuss current health priorities and identify potential solutions. Priorities established for the CHNAs were determined by the most significant health needs of each community. Ballad Health hospitals, including MSHA hospitals, conducted their fifth CHNA last year with board approval and publication occurring at the end of FY21. For FY21 CHNAs, Ballad Health utilized a mixed-methods approach for primary and secondary data collection to gather regional information to inform the 2021 community health needs assessments. The secondary data collection entailed the compilation of secondary data pertaining to agreed-upon metrics and indicators from an array of verified sources. The primary data collection component involved both a key stakeholder survey and key stakeholder focus groups. Findings from both research methods were used to prioritize the needs of the community served by each Ballad Health facility and determine priority focus areas for future improvement efforts. Analysis of secondary data for Washington County, TN findings from the key stakeholder survey, and the perspectives of diverse key stakeholders led to the prioritization of community issues for Washington County. For Johnson City Medical Center, Franklin Woods Community Hospital, Niswonger Children's Hospital, and Woodridge Hospital, the three priority areas for future improvement efforts that were selected by key stakeholders in Washington County are substance abuse, mental health, and Adverse Childhood Experiences (ACEs). Analysis of secondary data for Sullivan County, findings from the key stakeholder survey, and the perspectives of diverse key stakeholders led to the prioritization of community issues for Sullivan County. For Indian Path Community Hospital, the three priority areas for future improvement efforts that were selected by key stakeholders in Sullivan County, TN are substance abuse, mental health, and transportation. Analysis of secondary data for Carter County, TN findings from the key stakeholder survey, and the perspectives of diverse key stakeholders led to the prioritization of community issues for Carter County. For Sycamore Shoals Community Hospital, the three priority areas for future improvement efforts that were selected by key stakeholders in Carter County, TN are substance abuse, mental health, Adverse Childhood Experiences (ACEs), and transportation.Analysis of secondary data for Unicoi County, findings from the key stakeholder survey, and the perspectives of diverse key stakeholders led to the prioritization of community issues for Unicoi County. For Unicoi County Hospital, the three priority areas for future improvement efforts that were selected by key stakeholders in Unicoi County, TN are education, mental health, and Adverse Childhood Experiences (ACEs). Analysis of secondary data for Russell County, VA findings from the key stakeholder survey, and the perspectives of diverse key stakeholders led to the prioritization of community issues for Russell County. For Russell County Community Hospital, the three priority areas for future improvement efforts that were selected by key stakeholders in Russell County, VA are substance abuse, mental health, and poverty.Analysis of secondary data for Johnson County, TN findings from the key stakeholder survey, and the perspectives of diverse key stakeholders led to the prioritization of community issues for Johnson County. For Johnson County Community Hospital, the three priority areas for future improvement efforts that were selected by key stakeholders in Johnson County, TN are substance abuse, mental health, and Adverse Childhood Experiences (ACEs).
Facility Reporting Group - A Part V, Section B, line 5: The community health needs assessment process was guided by the Mobilizing for Action Through Planning and Partnerships (MAPP) model, with an understanding that aspects of the model may have to be adapted due to the purpose of the assessment for Ballad Health and constraints related to the COVID-19 pandemic. In coordination with the MAPP model, concepts from both Community-Based Participatory Research (CBPR) and the Arkansas Center for Health Improvement (ACHI) Community Health Assessment Toolkit were also utilized for the assessments. Following guidance from the MAPP model, a Key Stakeholder Survey was designed with the primary aim of identifying the most-pressing community issues. In aligning with principles of CBPR, the key stakeholder survey was designed to allow key stakeholders to frame community issues in their own words through the use of open-ended questions. In addition to the identification of community issues, the key stakeholder survey was also designed to discern why survey respondents believed the community issues they selected had the greatest effect on the overall health and wellbeing of their community. Questions related to ideas and suggestions for improvement efforts, gauging the success of efforts after the previous community health needs assessments, and community struggles related to the COVID-19 pandemic were also included in the survey. Independent focus groups were conducted for each Ballad Health facility in order to provide specific and unique information for each community being served. The MAPP model and questions from the key stakeholder survey were used to guide the development and construction of the focus groups. Because the key stakeholder survey primarily dealt with the identification of community issues, the focus groups were primarily designed to prioritize community issues identified through the key stakeholder survey and discuss actionable items around how to best address these community issues. Questions related to root causes of community issues, the current state of resources to address community issues, needed resources to initiate improvement efforts and be successful, and community struggles related to the COVID-19 pandemic were also included in the focus group facilitation guide. The key stakeholder focus groups were conducted virtually via WebEx and were one hour and thirty minutes in length.For Johnson City Medical Center, Niswonger Children's Hospital, Franklin Woods Community Hospital, and Woodridge Hospital there were thirty-five focus group participants. Similar to the key stakeholder survey representation, focus group participants represented an array of different sectors in Washington County, TN which included: the school system, businesses, government, the health care system, health departments, faith-based organizations, and a diverse group of community-based organizations. For stakeholders who were not able to attend the focus group in real-time, blank facilitation guide templates with questions concerning the three priority areas identified by the focus group participants were sent to them immediately after the conclusion of the focus group. This allowed key stakeholders who were not able to attend the focus group in real-time to still provide input and the hospital to ensure the involvement of diverse stakeholders. For Indian Path Community Hospital there were eighteen focus group participants. Similar to the key stakeholder survey representation, focus group participants represented an array of different sectors in Sullivan County, TN which included: the school system, businesses, government, the health care system, health departments, faith-based organizations, and a diverse group of community-based organizations. For stakeholders who were not able to attend the focus group in real-time, blank facilitation guide templates with questions concerning the three priority areas identified by the focus group participants were sent to them immediately after the conclusion of the focus group. This allowed key stakeholders who were not able to attend the focus group in real-time to still provide input and the hospital to ensure the involvement of diverse stakeholders.For Sycamore Shoals Community Hospital there were ten focus group participants. Similar to the key stakeholder survey representation, focus group participants represented an array of different sectors in Carter County, TN which included: the school system, businesses, government, the health care system, health departments, faith-based organizations, and a diverse group of community-based organizations. For stakeholders who were not able to attend the focus group in real-time, blank facilitation guide templates with questions concerning the three priority areas identified by the focus group participants were sent to them immediately after the conclusion of the focus group. This allowed key stakeholders who were not able to attend the focus group in real-time to still provide input and the hospital to ensure the involvement of diverse stakeholders.For Unicoi County Hospital there were six focus group participants. Similar to the key stakeholder survey representation, focus group participants represented an array of different sectors in Unicoi County, TN which included: the school system, businesses, government, the health care system, health departments, faith-based organizations, and a diverse group of community-based organizations. For stakeholders who were not able to attend the focus group in real-time, blank facilitation guide templates with questions concerning the three priority areas identified by the focus group participants were sent to them immediately after the conclusion of the focus group. This allowed key stakeholders who were not able to attend the focus group in real-time to still provide input and the hospital to ensure the involvement of diverse stakeholders.For Russell County Community Hospital there were nine focus group participants. Similar to the key stakeholder survey representation, focus group participants represented an array of different sectors in Russell County, VA which included: the school system, businesses, government, the health care system, health departments, faith-based organizations, and a diverse group of community-based organizations. For stakeholders who were not able to attend the focus group in real-time, blank facilitation guide templates with questions concerning the three priority areas identified by the focus group participants were sent to them immediately after the conclusion of the focus group. This allowed key stakeholders who were not able to attend the focus group in real-time to still provide input and the hospital to ensure the involvement of diverse stakeholders.For Johnson County Community Hospital, there were seven focus group participants. Similar to the key stakeholder survey representation, focus group participants represented an array of different sectors in Johnson County, TN which included: the school system, businesses, government, the health care system, health departments, faith-based organizations, and a diverse group of community-based organizations. For stakeholders who were not able to attend the focus group in real-time, blank facilitation guide templates with questions concerning the three priority areas identified by the focus group participants were sent to them immediately after the conclusion of the focus group. This allowed key stakeholders who were not able to attend the focus group in real-time to still provide input and the hospital to ensure the involvement of diverse stakeholders. Activities associated with the June 2021 assessments took place from summer of 2020 through the spring of 2021. The assessment activity including focus groups & surveys were used to develop the hospital implementation plans that were completed fall 2021.
Facility Reporting Group - A Part V, Section B, line 6a: Each hospital within Ballad Health completed a CHNA. MSHA's CHNAs were conducted with all Ballad Health hospitals at that time to include: Bristol Regional Medical Center, Hancock County Hospital, Hawkins County Memorial Hospital, Greeneville Community Hospital, Holston Valley Medical Center, Johnson City Medical Center (includes Niswonger Children's Hospital and Woodridge Hospital), Franklin Woods Community Hospital, Indian Path Community Hospital, Lonesome Pine Hospital (including Mountain View campus), Johnson County Community Hospital, Johnston Memorial Hospital, Norton Community Hospital, Dickenson Community Hospital, Russell County Hospital, Smyth County Community Hospital, Sycamore Shoals Hospital, and Unicoi County Hospital.
Facility Reporting Group - A Part V, Section B, line 11: During the year, MSHA focused on its CHNA priorities as identified in its FY21 CHNA report. MSHA's primary areas of focus included: substance abuse, mental health, and Adverse Childhood Experiences (ACEs). Many additional community needs exist in our region. It is fiscally impossible for a hospital to address every health need in a community, which is why the CHNA process is used to identify and prioritize areas of focus. A thoughtful CHNA evaluates overall community health needs to determine which ones the hospital can best influence in a positive way. Consideration is given to other organizations in the hospital's geographic area that already offer services addressing specific health needs. In some cases, it is best to simply support an identified health need through a financial donation to another nonprofit organization skilled in certain areas: teen pregnancy, dental health, fighting homelessness, etc. Hospitals also lend support to other nonprofit organizations by serving on their boards, committees, and assisting with fundraising efforts. Ballad Health made financial contributions to other nonprofit organizations providing community services that support MSHA hospitals' CHNAs.
Facility Reporting Group - A Part V, Section B, line 13h: Ballad Health's financial assistance policy allows for some exceptions to strictly adhering to federal poverty guidelines when awarding financial assistance. Unique circumstances may be weighed and assessed for financial assistance consideration on a case-by-case basis. Also, there are some services where financial assistance may be provided outside of federal poverty guidelines. These are noted in Ballad Health's financial assistance policy.
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
Schedule H (Form 990) 2021
Page 9
Schedule H (Form 990) 2021
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?6
Name and address Type of Facility (describe)
1 1 - MSHA dba BH Homecare-Johnson City
509 Med Tech Parkway Ste 200
Johnson City,TN37604 		Licensed Home Health Agency
2 2 - MSHA dba BH Homecare-Abingdon
611 Campus Dr Ste 300
Abingdon,VA24210 		Licensed Home Health Agency
3 3 - MSHA dba BH Homecare-Greeneville
1410 Tusculum Blvd Ste 1600
Greeneville,TN37745 		Licensed Home Health Agency
4 4 - MSHA dba BH Homecare-Norton
96 15th St NW Ste 104A
Norton,VA24273 		Licensed Home Health Agency
5 5 - MSHA dba BH Hospice-Bristol
280 Steeles Road
Bristol,TN37620 		Licensed Hospice Agency
6 6 - MSHA dba BH Hospice-Abingdon
611 Campus Dr Ste 500
Abingdon,VA24210 		Licensed Hospice Agency
7
8
9
10
Schedule H (Form 990) 2021
Page 10
Schedule H (Form 990) 2021
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: Financial assistance approval can apply to an assortment of patients such as those who have exhausted their Medicaid/TennCare benefits, those who qualified for Medicaid/TennCare after the date of service, deceased patients with no estate or assets, uninsured patients, and underinsured patients. While Ballad Health's qualifications for financial assistance is based on federal poverty guidelines, asset values may also be used to determine financial assistance eligibility. Unique circumstances may be assessed on a case-by-case basis. Charity approval covers current or active patient balances when they are approved and there is no limitation or cap on the amount of charity that a patient may receive. Ballad Health hospitals do not stop approving financial assistance for patient accounts if a hospital's charity write-offs exceed the hospital's charity budget.All Ballad Health hospitals provide an uninsured discount. The current uninsured discount for Critical Access Hospitals (CAH's) is 77% and for all other hospitals or physician practices it is 85%. In addition to the uninsured discount, many patients will further qualify for additional financial assistance. All patients seeking financial assistance must submit an application for financial assistance and submit documents in support of the information on the application, unless specifically excluded according to policy guidelines. Medicaid eligible patients will qualify for 100% financial assistance and not be required to complete the required documentation when: a) Medicaid eligibility requirements are met after the service is provided, b) non-covered charges occur on a Medicaid eligible encounter, or c) benefits have been exhausted. Deceased patients with no estate also qualify for 100% financial assistance.Financial assistance determinations may be retroactive for all outstanding balances. In addition, Ballad Health offers a number of programs with special discounts such as lactation consultation services, oncology treatment regimens, enrollment in various community programs and prescription drugs filled post-discharge.
Part I, Line 7: The cost to charge ratio (worksheet 2 "ratio of patient care cost to charges") was used to calculate line 7a financial assistance (charity care) cost. MSHA's cost accounting system was used to determine losses from Tenncare and Medicaid reported on line 7b, with the exception of home health and a small physician clinic. A cost to charge ratio was used for their data because these are smaller divisions not available in MSHA's cost accounting software. Line 7e community health improvement includes costs that are taken directly from departmental operating reports or expenses specific to a community health event, with no additional overhead included in the cost. Line 7f health professions education is comprised of internships (primarily internal medicine residents, nursing, pharmacy, and therapy students) with schools and universities, allowing their health profession students to receive hands-on training in a hospital setting. MSHA's Medicare-approved programs include medical residents, pharmacy and pastoral care. For these programs, Medicare-approved costs and Medicare reimbursement comes from filed Medicare cost reports. The Ballad Health Organizational Development Department (OD) maintains records for the non-Medicare programs. Only labor costs are included for MSHA team members that provide training (no overhead is applied) and only a percentage of team members' time is attributed to actual training. For line 7g subsidized health care services, MSHA's cost accounting system is used because MSHA has established, standard costing reports for these services. There are exceptions where MSHA does not use the cost accounting system. A small clinic inside JCCH, a federally designated critical access hospital, is subsidized by JCCH and the clinic's departmental operating report is used to compute the clinic's community benefit. The second exception is a palliative care program. For this program, the department's operating report is used. MSHA is careful to ensure no double counting of cost. Although there are other service lines within MSHA hospitals that lose money, MSHA does not report services that hospitals are required by state licensure to provide, routine services or ancillary services. Line 7h research represents MSHA's expense allocation from Ballad Health for research. Line 7i cash and in-kind contributions includes cash disbursements and in-kind donations of medications to local nonprofit rescue squads and fire departments. In-kind donations of medications are based on actual cost for these items.
Part II, Community Building Activities: MSHA leaders support and encourage all team members to volunteer time, money and skills to community service projects and charitable organizations. Senior leaders and board members set a positive example for MSHA team members, serving voluntarily on committees and boards of local service and nonprofit organizations. Some also serve as members and consultants on professional committees and task forces that affect regional development in healthcare and education. MSHA does not capture costs associated with team members that serve on other nonprofit boards or provide services to other nonprofits.MSHA, in collaboration with area health agencies and providers, may offer assistance with coordination, advocacy, or contribute supplies to support groups for their program activities that serve to assist special populations within the area. Most of these organizations work to improve the lives of community members that have limited, or no, financial resources.MSHA provided sponsorships for the Lee County Redevelopment and Housing Authority, the Northeast Tennessee Regional Economic Partnership, the Founders Forge Leadership Development Program, and the Summit Leadership Foundation-Youth Leadership Program.
Part III, Line 2: Self-pay balances include accounts after payments and contractual adjustments (discounts) have been applied from all third-party payers such as Medicare, TennCare/Medicaid, commercial insurers, and others - generally leaving the patient responsible for any remaining deductible and/or co-payment. Other self-pay accounts are from patients with no insurance or other third-party coverage. Under Ballad Health's system-wide self-pay policy, any patient who has no insurance and is ineligible for any government assistance program received an 85% discount. Many self-pay patients will further qualify for financial assistance (sometimes referred to as charity care) if they provide the financial information needed to deem them eligible or upon determination of presumptive charity eligibility. After the normal collection process has indicated an account is uncollectible, MSHA writes the account off to bad debt. The overall self-pay accounts receivable balance is evaluated on an ongoing basis to evaluate the age of accounts receivable, historical write-offs and recoveries and any unusual instances (such as local, regional or national economic conditions) which affect the collectability of receivables.
Part III, Line 3: MSHA's primary external collection agency historically estimated that approximately 37% of MSHA's bad debt would have qualified for financial assistance if patients had provided a financial assistance application and required documentation. Pursuant to the merger, MSHA has begun to score accounts using a presumptive eligibility tool. This tool utilizes various data points for a proprietary algorithm operated by an outside vendor to provide an individual's score which is then relied upon to assign presumptive charity eligibility. There are many instances of patients with large account balances and no health insurance coverage that MSHA believes would qualify for financial assistance. Although patients are encouraged to apply for assistance, many will not do so. MSHA would prefer for patients to submit completed financial assistance applications given that historical data clearly indicates that most uninsured patients and many underinsured patients will qualify for financial assistance under our program. Without a completed application, these are recorded as bad debt instead of charity care.
Part III, Line 4: Ballad Health's audited financial statements include a footnote on page 14 that describes bad debt. MSHA is included in the June 30, 2022 audited financial statements of Ballad Health (attached).
Part III, Line 8: Excluding Medicare losses reported in Part I subsidized health, the Part III Medicare allowable costs are reported using MSHA's filed Medicare cost report (C/R). The C/R uses a cost to charge ratio based on a step-down allocation methodology. MSHA believes Medicare losses should be allowed as a reportable community benefit, similar to governmental programs such as Medicaid. As a participating provider in the Medicare program, hospitals are required to provide the full regimen of care for the Medicare population. There are a number of care regimens that are compensated by the Medicare program at levels below cost. Therefore, it is only logical to allow hospitals to report these uncompensated services as a community benefit. By making this change, nonprofit providers will be encouraged to continue important care delivery models for our aging population in spite of the fact it may be economically injurious.
Part III, Line 9b: Requests for financial assistance are evaluated using established guidelines, while allowing for unique financial circumstances - for example, medically indigent patients with catastrophic medical costs that would threaten the patient's household financial viability. When a patient requests financial assistance or when an application has been received, the patient's account is placed in a hold status to prevent further collection activities until financial assistance eligibility is determined. All Ballad Health hospitals comply with IRS 501(r) regulatory guidelines.Ballad Health's collection policy clearly states that all patients are treated equally - with dignity and respect. Ballad Health ensures that outside collection agencies adhere to Ballad Health billing and collection guidelines. The collection program includes communicating expected financial responsibility prior to service. MSHA hospitals provide assistance to help underinsured and uninsured patients determine sources of payment for medical bills and to help patients determine eligibility for programs such as TennCare or Medicaid.After insurance benefit verification, MSHA hospitals bill insurance carriers. If the insurance carrier denies payment of the service/procedure as non-covered or the patient has exceeded their maximum benefits, the service/procedure will qualify for the uninsured discount.Financial counselors are available to discuss financial assistance with patients and their families. MSHA hospitals provide a number of payment options:- a pre-service discount may be offered- a discount in excess of established discounting rates may be granted for catastrophic high dollar accounts- MSHA hospitals accept all non-contracted and out-of-network payers and will make attempts to work with these payers regarding appropriate reimbursement and billing to their members- as part of Ballad Health's commitments to the State of Tennessee and Commonwealth of Virginia to form Ballad Health, not-in-network discounts are applied per policies in place for MSHA hospitals- payment arrangements are available as long as the account is not with a collection agencyReasonable efforts are made to determine if a patient is eligible for financial assistance - see Schedule H, Part VI, line 3 for information on how patients are informed about the Ballad Health financial assistance policy.
Part VI, Line 2: Focusing on population health improvement and associated priority metrics allows Ballad Health to further engage the efforts of its hospitals in partnership with communities in our service areas. It has helped Ballad to better identify health disparities that appear across the individual communities and has helped Ballad to prioritize issues that are most important in each hospital's community. Engaging local community organizations expands partnerships so that organizations work together more to address community health needs. Ballad Health uses a comprehensive process to gather input for and continues to evolve its population health plan. Because our hospitals are located in a region with many chronic disease challenges and high levels of health-related social risks, Ballad Health's goal is to target population health issues to make lasting improvements. Ballad conducts ongoing interviews, focus groups and meetings with external groups, including the regional health departments, United Way agencies, chambers of commerce, schools and community organizations, the regional accountable care community leadership council, as well as internal groups such as our population health and community benefit committee of the Ballad Health board of directors, the Ballad Health population health clinical committee, social needs council, grant advisory committees and our hospital community boards in the creation and on-going implementation of its population health plan.
Part VI, Line 3: Consistent with the Ballad Health financial assistance policy, MSHA communicates with and provides education to patients through various avenues regarding governmental assistance programs and hospital financial assistance. Various educational and application documents related to obtaining financial assistance are widely available at MSHA and all documents are available on the Ballad Health website. Printed financial assistance educational materials are part of each registration packet and posters are displayed in highly visible areas of the hospitals. Our financial assistance policy and documents are available in emergency departments and admitting areas. MSHA is also happy to mail all documents to patients and offers a plain language summary. All documents are available in English and Spanish. Financial assistance information is available during pre-registration, registration and/or during financial counseling. MSHA offers governmental program eligibility representatives to assist patients in securing eligibility for TennCare or Medicaid, federal disability and other governmental assistance programs. Additionally, if a patient or community resident expresses an interest in the ACA-healthcare exchange, MSHA representatives have the qualifications and experience to assist them through the entire process. Financial counselors offer financial assistance applications to patients who do not qualify for governmental assistance programs and are unable to pay for some or all of their healthcare.All patient billing statements have verbiage discussing financial assistance along with contact information. The last letter to the patient displays the plain language summary. In all oral correspondences with a patient, if it is identified the patient cannot meet payment requirements on their account, financial assistance is discussed as an option.Applicants are notified of financial assistance determination in writing.
Part VI, Line 4: MSHA serves the healthcare needs of 29 Appalachian counties in Northeast Tennessee, Southwest Virginia, Southeast Kentucky, and Northwest North Carolina. All of the counties MSHA serves are federally designated as medically underserved areas. MSHA's largest hospital, Johnson City Medical Center, is a tertiary referral center and level one trauma center. Medically underserved areas are designated by the U.S. Department of Health and Human Services. Shortage areas are identified through analysis of physician to population ratios depending on whether an area is considered to have a high need. Criteria used to determine high need are poverty rates, the percent of the population over age 65, infant mortality rates and fertility rates. MSHA operates 2 critical access hospitals: Johnson County Community Hospital in Tennessee and Lee County Community Hospital in Virginia.Additionally, according to the 2021 County Health Rankings, counties where MSHA hospitals are located ranked poorly for both health outcomes and health factors.
Part VI, Line 5: MSHA is dedicated to operating efficiently so that waste is minimized. MSHA's leadership remains mindful of managing limited resources so that adequate facilities and equipment are available for the care of patients. Surplus funds are invested into improving treatment options for patients through new technologies, recruiting physicians and trained staff in shortage areas, and improving MSHA facilities. Various checks and balances are established to ensure that expenditures for operating expenses and capital costs are reasonable and necessary. MSHA has several hospitals with Medicare-approved health profession education programs. In addition, MSHA hospitals serve as training sites for many types of health professions: nursing, pharmacy, psychology, lab, respiratory therapy, EMT, public health, etc. Students from numerous colleges, universities, and programs receive training and experience in MSHA hospitals. MSHA resources are devoted to health conferences for local health professionals, two health resources centers conveniently located in a shopping mall and a wellness center; provide for media coverage to educate residents on health issues; offer events to the public that combine fun activities with health education; and many other programs focused on improving the health of area residents. While MSHA operates hospitals in predominantly low-income, rural and isolated areas, MSHA continues to offer services that operate at a loss because residents would otherwise need to leave their hometown or county to receive needed care. Mountain States merged with Wellmont Health System in February 2018 to form Ballad Health healthcare system. Mountain States and Wellmont still exist as legal entities and continue to operate multiple hospitals. MSHA's governing body is comprised of persons who reside in the organization's primary service areas. Physicians that request privileges who are qualified and credentialed are extended privileges by MSHA.
Part VI, Line 6: Mountain State's merger with Wellmont opened up many opportunities not previously available to two competing health systems. Collaboration started post-merger and Ballad Health continues to see progress towards improving efficiencies within our health system, activities consistent with Ballad Health's population health initiative, sharing best practice quality improvements, and other benefits related to operating as one rather than operating in a competitive environment. A clinical council was formed immediately following the merger. The council includes physicians nominated from the leadership of all Ballad hospitals. A Community Benefit and Population Health Committee of the board was established, and various other infrastructures have been established since the merger. Across MSHA's hospitals, there were many projects, programs, and collaborative efforts that took place during the year. MSHA provides care to people in 29 counties in Tennessee, Virginia, Kentucky and North Carolina. Each hospital is fully accredited by The Joint Commission, with the exception of Johnson County Community Hospital and Lee County Community Hospital. JCCH and LCCH receive certification through the states of Tennessee and Virginia since they are critical access hospitals. MSHA, based in Johnson City, Tennessee includes 8 wholly owned hospitals which are included in this Form 990. In addition, MSHA owns 2 hospitals located in Southwest Virginia, each of which file separate returns. In addition to acute care hospitals, the system includes such services as:Primary/specialty physician practices, emergency departments, occupational medicine, rehabilitation, outreach laboratory, mental health, neonatal intensive care, a NACHARI-affiliated children's hospital, renal dialysis, St. Jude's Oncology, inpatient/outpatient surgery, skilled nursing, long-term care, home health, and more. With these additional facilities and services, MSHA extends a highly effective health care delivery system. Since our system is both horizontally and vertically integrated, patients can be efficiently moved along an integrated, comprehensive continuum of care as their health status dictates. MSHA's flagship facility, Johnson City Medical Center is at the core of the system offering full-service tertiary care. In addition to MSHA hospitals, MSHA is the sole member of Blue Ridge Medical Management Corporation (BRMMC). MSHA extends an integrated healthcare delivery system through BRMMC to include multiple primary and specialty care patient access centers and numerous outpatient care sites, including urgent care centers, occupational medicine services, a same day surgery center and rehabilitation.MSHA partners with East Tennessee State University to operate Overmountain Recovery, an opioid addiction recovery facility located in Gray, Tennessee.MSHA is the sole member of Integrated Solutions Health Network, LLC. (ISHN). ISHN operates Anewcare Collaborative, the region's first accountable care organization, bringing together community health care providers to provide better outcomes and improved patient satisfaction at a lower cost.Hospitals in the Ballad Health system work closely with one another to share expertise and resources.
Part VI, Line 7, Reports Filed With States TN,VA
Part VI, Additional Information Ballad Health is required to report community benefit estimates on a quarterly basis with the states of Tennessee and Virginia. The reporting includes all of Ballad Health's hospital organizations and is reported using IRS Form 990, Schedule H instructions for reporting community benefit. Ballad Health operates under a Certificate of Public Advantage (COPA) in Tennessee and a Cooperative Agreement (CA) in Virginia as obligated by agreements between Ballad Health and the two states to allow Mountain States Health Alliance and Wellmont Health System to merge.
Schedule H (Form 990) 2021
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