Instructions For Schedule H (Form 990) - 2016 (Page 13 of 23) in pdf

amount in Part III, line 2, including how the

patients as part of the intake process;

either by the organization itself or by a

organization accounts for discounts and

provides a copy of the policy, or a

related organization on the organization's

payments on patient accounts in

summary thereof, applications for financial

behalf.

determining bad debt expense.

assistance, and financial assistance

contact information to patients with

Worksheet 1. Financial

Part III, line 3. Describe the

discharge materials; includes the policy, or

methodology used to determine the

Assistance at Cost (Part I,

a summary thereof, an application for

amount reported on line 3. Also describe

financial assistance, and financial

Line 7a)

the rationale, if any, for including any

assistance contact information, in patient

portion of bad debt as community benefit.

Worksheet 1 can be used to calculate the

bills; or discusses with the patient the

organization's financial assistance

availability of various government benefits,

Part III, line 4. Provide, if applicable,

(sometimes referred to as “charity care”)

such as Medicaid or state programs, and

the text of the footnote to the

at cost reported on Part I, line 7a. Refer to

assists the patient with qualification for

organization's financial statements that

instructions for Part I, line 1 for the

such programs, where applicable.

describes bad debt expense, or report the

definition of financial assistance.

page number(s) of the organization's most

Line 4. Describe the community or

recent audited financial statements on

Line 1. Enter the gross patient charges

communities the organization serves,

which the footnote appears. If the

written off to financial assistance pursuant

taking into account the geographic service

organization's financial statements include

to the organization's financial assistance

area(s) (urban, suburban, rural, etc.), the

a footnote on these issues that also

policies. “Gross patient charges” means

demographics of the community or

includes other information, report only the

the total charges at the organization's full

communities (population, average income,

relevant portions of the footnote. If the

established rates for the provision of

percentages of community residents with

organization's financial statements don't

patient care services before deductions

incomes below the federal poverty

contain such a footnote, enter that the

from revenue are applied.

guideline, percentage of the hospital's and

organization's financial statements don't

community's patients who are uninsured

Line 3. Multiply line 1 by line 2, or enter

include such a footnote, and explain how

or Medicaid recipients, etc.), the number

estimated cost based on the

the financial statements account for bad

of other hospitals serving the community

organization's cost accounting

debt, if at all.

or communities, and whether one or more

methodology. Organizations with a cost

federally-designated medically

Part III, line 8. Describe the costing

accounting system or a cost accounting

underserved areas or populations are

methodology used to determine the

method more accurate than the ratio of

present in the community.

Medicare allowable costs reported in Part

patient care cost to charges from

III, line 6. Describe, if applicable, the

Worksheet 2 can rely on that method to

Line 5. Provide any other information

extent to which any shortfall reported in

estimate financial assistance cost. An

important to describing how the

Part III, line 7, should be treated as a

organization that does not use Worksheet

organization's hospitals or other health

community benefit, and the rationale for

2 to determine a ratio of patient care cost

care facilities further its exempt purpose

the organization's position.

to charges should make any necessary

by promoting the health of the community

adjustments for patient care charges and

or communities, including but not limited

Part III, line 9b. If the organization has

community benefit programs to avoid

to whether:

a written debt collection policy and

double counting.

A majority of the organization's

answered “Yes,” to Part III, line 9b,

governing body is comprised of persons

Line 4. Enter the Medicaid/provider

describe the collection practices in the

who reside in the organization's primary

taxes, fees, and assessments paid by the

policy that apply to patients who it knows

service area who are neither employees

organization, if payments received from an

qualify for financial assistance, whether

nor independent contractors of the

uncompensated care pool or DSH

the practices apply specifically to such

organization, nor family members

program in the organization's home state

patients or also cover other types of

thereof;

are intended primarily to offset the cost of

patients.

The organization extends medical staff

financial assistance. If the payments are

Line 2. If applicable, describe whether

privileges to all qualified physicians in its

primarily intended to offset the cost of

and how the organization assesses the

community for some or all of its

Medicaid services, then report this amount

health care needs of the community or

departments or specialties; and

on Worksheet 3, line 4, column (A). If the

communities it serves, in addition to any

How the organization applies surplus

primary purpose of the taxes or payments

CHNA reported in Part V, Section B.

funds to improvements in patient care,

hasn't been made clear by state regulation

medical education, and research.

or law, then the organization can allocate

Line 3. Describe how the organization

the taxes or payments proportionately

informs and educates patients and

Line 6. If the organization is part of an

between Worksheet 1, line 4, and

persons who are billed for patient care

affiliated health care system, describe the

Worksheet 3, line 4, column (A) based on

about their eligibility for assistance under

roles of the organization and its affiliates in

a reasonable estimate of which portions

federal, state, or local government

promoting the health of the communities

are intended for financial assistance and

programs or under the organization's

served by the system. For purposes of this

Medicaid, respectively. “Medicaid provider

financial assistance policy. For example,

question, an “affiliated health care system”

taxes” means amounts paid or transferred

enter whether the organization posts its

is a system that includes affiliates under

by the organization to one or more states

financial assistance policy, or a summary

common governance or control, or that

as a mechanism to generate federal

thereof, applications for financial

cooperate in providing health care

Medicaid DSH funds (portions of the cost

assistance, and financial assistance

services to their community or

of the tax generally is promised back to

contact information in admissions areas,

communities.

organizations either through an increase in

emergency rooms, and other areas of the

Line 7. Identify all states with which the

the Medicaid reimbursement rate or

organization's facilities where eligible

organization files (or a related

through direct appropriation).

patients are likely to be present; provides

organization files on its behalf) a

a copy of the policy, or a summary thereof,

Line 6. “Revenue from uncompensated

community benefit report. Report only

applications for financial assistance, and

care pools or programs” means payments

those states in which the organization's

financial assistance contact information to

received from a state, including Upper

own community benefit report is filed,

Instructions for Schedule H

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Instructions For Schedule H (Form 990) - 2016 Page 13

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