Instructions For Schedule H (Form 990) - 2016 (Page 12 of 23) in pdf

surveys, or written comments, and

limited who was eligible to receive care for

correction and disclosure procedures for

between what dates); the names of any

emergency services.

hospital organizations to follow so that

organizations providing input; and

Line 21d: If the organization checked

certain failures to meet the requirements

describe the medically underserved,

line 21d, describe the other reasons why

of section 501(r) will be excused for

low-income, or minority populations being

the hospital facility did not have a written

purposes of sections 501(r)(1) and 501(r)

represented by organizations or

nondiscriminatory policy for emergency

(2)(B). Section 7 of the revenue procedure

individuals that provided input. A CHNA

medical care.

provides that certain information must be

report does not need to name or otherwise

Line 23: If the organization checked

disclosed on the organization’s Form 990.

identify any specific individual providing

“Yes” to line 23, explain the circumstances

Provide this information in Part VI.

input on the CHNA. In the event a hospital

in which the hospital facility charged any

Line 1. Provide the following

facility solicits, but cannot obtain, input

FAP-eligible individual more than the

supplemental information:

from a source required by line 5, the

amounts generally billed to individuals

Part I, line 3c. If applicable, describe

hospital facility's CHNA report also must

who had insurance covering such care.

the criteria used for determining eligibility

describe the hospital facility's efforts to

Line 24: If the organization answered

for free or discounted care under the

solicit input from such source.

“Yes” to line 24, explain the circumstances

organization's financial assistance policy.

Line 6a: If the organization checked

in which the hospital facility charged any

Also describe whether the organization

“Yes,” list the other hospital facilities with

FAP-eligible individual an amount equal to

uses an asset test or other threshold,

which the hospital facility conducted its

the gross charge for any service provided

regardless of income, to determine

CHNA.

to that individual.

eligibility for free or discounted care.

Line 6b: If the organization checked

Section D. Complete Part V, Section D,

“Yes,” list the organizations other than

Part I, line 6a. If the organization's

by listing all of the non-hospital health care

hospital facilities with which the hospital

community benefit report is in a report

facilities that the organization operated

facility conducted its CHNA.

during the tax year. A facility is operated

prepared by a related organization, and

Line 7d: If the organization checked

by an organization whether it is operated

not in a separate report prepared by the

line 7d, describe the other means that the

directly by the organization or through a

organization, identify the related

hospital facility used to make its CHNA

organization and list its employer

disregarded entity or joint venture

widely available.

identification number.

treated as a partnership. List each of

Line 11: Describe how the hospital

these facilities in order of size from largest

facility is addressing the significant health

Part I, line 7g. If applicable, describe

to smallest, measured by a reasonable

needs identified in its most recently

if the organization included as subsidized

method (for example, the number of

conducted CHNA and any such needs

health services any costs attributable to a

patients served or total revenue per

that aren't being addressed together with

physician clinic, and report such costs the

facility). For each non-hospital health care

the reasons why such needs aren't being

organization included.

facility, list its name and address and

addressed.

describe the type of facility. These types

Part I, line 7, column (f). If

Line 13b: Describe the criteria the

of facilities may include, but aren't limited

applicable, enter the bad debt expense

hospital facility used to determine eligibility

to, rehabilitation and other outpatient

included on Form 990, Part IX, line 25,

for free or discounted care (including

clinics, diagnostic centers, mobile clinics,

column (A), (but subtracted for purposes

whether the hospital facility used the

and skilled nursing facilities.

of calculating the percentages in this

income level of patients, patients’ families,

column).

List the total number of non-hospital

or patients’ guarantors as a factor).

health care facilities that the organization

Line 13h: If the organization checked

Part I, line 7. Provide an explanation

operated during the tax year.

line 13h, describe the other eligibility

of the costing methodology used to

criteria used.

If the organization needs additional

calculate the amounts reported for each

Line 15e: If the organization checked

space to list all of its non-hospital health

line in the table. If a cost accounting

line 15e, describe the other methods for

care facilities, it should duplicate

system was used, indicate whether the

applying for financial assistance.

Section D and use as many duplicate

cost accounting system addresses all

Line 16j: If the organization checked

copies of Section D as needed, number

patient segments (for example, inpatient,

line 16j, describe other ways that the

each page, and renumber the line

outpatient, emergency room, private

hospital facility publicized its financial

numbers in the left hand margin (for

insurance, Medicaid, Medicare,

assistance policy.

example, an organization with 15 such

uninsured, or self pay). Also, indicate if a

Line 18e: If the organization checked

facilities should renumber lines 1–5 on the

cost-to-charge ratio was used for any of

line 18e, describe the other similar actions

2nd page as lines 11–15).

the figures in the table. Describe whether

that the hospital facility was permitted to

this cost-to-charge ratio was derived from

Part VI. Supplemental

take under its policies during the tax year

Worksheet 2, Ratio of Patient Care

before making reasonable efforts to

Information

Cost-to-Charges, and, if not, what kind of

determine the individual's eligibility under

cost-to-charge ratio was used and how it

the facility's FAP.

Use Part VI to provide the narrative

was derived. If some other costing

Line 19e: If the organization checked

explanations required by the following

methodology was used besides a cost

line 19e, describe the other similar actions

questions, and to supplement responses

accounting system, cost-to-charge ratio,

that the hospital facility was permitted to

to other questions on Schedule H (Form

or a combination of the two, describe the

take under its policies during the tax year

990). In addition, use Part VI to make

method used.

before making reasonable efforts to

disclosures described in section 7 of Rev.

Part II. Describe how the

determine the individual's eligibility under

Proc. 2015-21. Identify the specific part,

organization’s community building

the facility's FAP.

section, and line number that the response

activities, as reported in Part II, promote

Line 20e: If the organization checked

supports, in the order in which they appear

the health of the community or

line 20e, describe the other efforts that the

on Schedule H (Form 990). Part VI can be

communities the organization serves.

hospital facility made.

duplicated if more space is needed.

Line 21c: If the organization checked

Part III, line 2. Describe the

Rev. Proc. 2015-21, 2015-13 I.R.B.

line 21c, describe how the hospital facility

methodology used to determine the

817, provides guidance regarding

Instructions for Schedule H

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Instructions For Schedule H (Form 990) - 2016 Page 12

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