2024-11-12T13:49:35+00:00 2023-12-31 990 2023-01-01 010646166 Indiana University Health Blackford Hospital Inc INDI 3179634842 950 N MERIDIAN STREET 1200 INDIANAPOLIS IN 46204 Michael L Craig VP & CFO 8123539171 2024-11-12 true 2023 2024-10-15 13:58:12Z JEFFREY C BIRD MD 950 N MERIDIAN STREET 1200 INDIANAPOLIS IN 46204 19006284 false X SEE SCHEDULE O X 2002 IN Lead the transformation of healthcare through quality, innovation & education, and make Indiana one of the nation's healthiest states. 15 12 146 31 0 0 398802 65703 25124093 18546156 13639 63325 144416 25521 25680950 18700705 16000 26822 0 12069789 8701417 0 0 16809299 15046548 28895088 23774787 -3214138 -5074082 11576675 5658757 3298080 2454243 8278595 3204514 Lead the transformation of healthcare through quality, innovation & education, and make Indiana one of the nation's healthiest states. false false 21284796 26822 17477438 IU HEALTH BLACKFORD HOSPITAL IS A 15-BED CRITICAL ACCESS HOSPITAL THAT OFFERS A BROAD RANGE OF SERVICES TO CARE FOR ITS PATIENTS WITHOUT REGARD TO THEIR ABILITY TO PAY. IU HEALTH BLACKFORD HOSPITAL FEATURES ALL PRIVATE ROOMS, A SPECIALTY CLINIC, CARDIAC AND PULMONARY REHABILITATION, OUTPATIENT SURGICAL SERVICES AND DIAGNOSTIC IMAGING. IN ADDITION TO PROVIDING 24 HOUR EMERGENCY SERVICES, THE HOSPITAL HOSTS A PARAMEDIC-LEVEL AMBULANCE SERVICE. AS OF 10/01/2023, IU Health Blackford Hospital DISCONTNIUED HOSPITAL AND EMERGENCY SERVICES. IT WILL CONTINUE TO OPERATE AS AN OUTPATIENT FACILITY. 1257779 0 1032791 Shared Services 43753 0 35927 RENT FROM RELATED 501(C)(3) ORGS. 22586328 true true false true false false false false false true false false false true true false true false false false false false false false false true true true false true false false false false false false false false false false false false false true true true false false true 0 0 146 true false false false false false false false false false false false false X 15 12 false false false false true true true true true false false true true true true true true true true false IN X CRAIG J JONES 3179634842 950 N MERIDIAN STREET SUITE 800 INDIANAPOLIS IN 46204 DANIEL E BORGENHEIMER DIRECTOR/CHAIR (Part Year) 2.0 4.0 X X 0 0 0 J STEVEN RHEA Director/Secretary/Treasurer 2.0 4.0 X X 0 0 0 JEFFREY C BIRD MD DIRECTOR/PRESIDENT (ECR) 10.0 45.0 X X 0 985198 172192 JOHN D LITTLER DIRECTOR/CHAIR (Part Year) 2.0 4.0 X X 0 0 0 PETER M VOSS MD DIRECTOR/VICE CHAIR 10.0 45.0 X X 0 490221 64192 WILBUR R DAVIS DIRECTOR/VICE CHAIR 2.0 4.0 X X 0 1000 0 CHANTILLE ALLEN DIRECTOR (Part Year) 2.0 4.0 X 0 0 0 CHARLES R ROUTH MD DIRECTOR 2.0 53.0 X 0 282146 67475 Dea Bell Director (Part Year) 2.0 4.0 X 0 5000 0 DERRON L BISHOP PHD DIRECTOR 2.0 4.0 X 0 8000 0 GEOFFREY S MEARNS JD DIRECTOR 2.0 4.0 X 0 0 0 JOAN V CASTOR DIRECTOR 2.0 53.0 X 0 571413 131941 MICHAEL J FISHER DIRECTOR 2.0 7.0 X 0 0 0 PATRICK A CLEARY MD DIRECTOR 2.0 4.0 X 0 8000 0 TERRY W BAILEY DIRECTOR 2.0 4.0 X 0 6000 0 WILLIAM W HINKLE DIRECTOR 2.0 4.0 X 0 5000 0 JONATHAN W VANATOR CFO (ECR) 10.0 45.0 X 0 387519 67467 MICHELLE R ALTOBELLA VP-General Counsel, Asst Secretary (ECR) 0.0 57.0 X 0 259376 50502 BRIAN REED VP-HUMAN RESOURCES (ECR) 10.0 45.0 X 0 200039 60926 KREIGH COOK COO (ECR) (Part Year) 15.0 35.0 X 0 230105 37495 LORI A LUTHER COO (ECR) (Part Year) 10.0 45.0 X 0 379246 61965 MELISSA R HICKS VP & CNO (ECR) 10.0 45.0 X 0 272051 54187 RYAN M JOHNSTON MD VP & CMO (ECR) 10.0 45.0 X 0 441485 77187 HELEN A BORGENHEIMER MD PHYSICIAN 50.0 0 X 265618 4000 59901 JAN BLAKE MCMILLAN VP - CNO - BLACKFORD HOSP 55.0 0.0 X 164786 12004 47177 MONICA R GAITHER Supervisor-House 50.0 0 X 158740 29258 21081 THOMAS D STEWART MD PHYSICIAN 40.0 10.0 X 330745 42124 76008 THOMAS M LEE MD PHYSICIAN 40.0 10.0 X 319083 0 66776 KEVIN W SCHREIBER MD FORMER HIGHEST COMPENSATED EMPLOYEE 0.0 50.0 X 0 405497 71685 1238973 5024682 1188155 18 true true false 0 50747 14956 65703 Net Patient Service Revenue 622110 17477438 17477438 Rent from Related 501(c)(3) Orgs. 532000 35927 35927 Shared Services 541900 1032791 1032791 0 0 0 0 18546156 67654 67654 2002 2002 0 2002 2002 0 301250 305579 0 -4329 -4329 -4329 All Other Revenue 900099 23519 23519 0 0 0 0 23519 18700705 18546156 0 88846 X 26822 26822 6760414 6532458 227956 278450 269061 9389 1190951 1150793 40158 471602 455700 15902 1202 1202 9375423 8746052 629371 0 2591 2591 31090 29003 2087 50558 25279 25279 467579 467579 2184 2037 147 19177 17890 1287 897067 854805 42262 142635 142635 Bad Debt 1486691 1486691 Hospital Assessment Fee 978303 978303 Drugs and Medical Supplies 880449 880449 Noncapitalized Equipment 1096 1022 74 710503 662384 48119 0 23774787 22586328 1188459 0 735432 31138 2596208 366333 0 0 0 0 321508 8141 83419 45887 20076603 14869345 6688394 5207258 0 0 1151714 0 11576675 5658757 1607362 377274 0 0 1690718 2076969 3298080 2454243 X 8278595 3204514 8278595 3204514 11576675 5658757 -5074082 1 0 X false true X true false X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED false false false false false false false false true 1202 1202 false Schedule C, Part II-B, Line 1 DETAILED DESCRIPTION OF THE LOBBYING ACTIVITY IU Health Blackford Hospital paid institutional membership dues to the American Hospital Association ("AHA") and Indiana Hospital Association ("IHA") during 2023 in the amount of $3,015 and $3,748, respectively. Each membership organization notified IU Health Blackford Hospital that a portion of the dues it paid were used for lobbying purposes. The AHA used 26.47%, or $798 of the 2023 membership dues paid by IU Health Blackford Hospital, for lobbying expenditures. The IHA used 10.78%, or $404 of the 2023 membership dues paid by IU Health Blackford Hospital, for lobbying expenditures. The total membership dues paid to these organizations by IU Health Blackford Hospital during 2023 that were attributable to lobbying expenditures was $1,202. 190324 190324 15001731 11052778 3948953 0 0 0 4599820 3531839 1067981 284728 284728 0 5207258 SELF-INSURANCE LIABILITIES 17951 DUE TO THIRD-PARTY PAYERS 1296779 Intercompany Payables (Net) 762239 2076969 X Schedule D, Part X, Line 2 FIN 48 (ASC 740) footnote IU Health Blackford is a subsidiary in Indiana University Health, Inc.'s ("IU Health") Consolidated Audited Financial Statements. THE INTERNAL REVENUE SERVICE (IRS) HAS DETERMINED THAT INDIANA UNIVERSITY HEALTH AND CERTAIN OF ITS AFFILIATED ENTITIES ARE TAX-EXEMPT ORGANIZATIONS AS DEFINED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE (IRC). INDIANA UNIVERSITY HEALTH AND ITS TAX-EXEMPT AFFILIATES ARE, HOWEVER, SUBJECT TO FEDERAL AND STATE INCOME TAXES ON UNRELATED BUSINESS INCOME UNDER THE PROVISIONS OF IRC SECTION 511. DEFERRED INCOME TAXES WHICH, AS OF DECEMBER 31, 2023 AND 2022, HAVE NO NET CARRYING VALUE, REFLECT THE NET TAX EFFECT OF TEMPORARY DIFFERENCES BETWEEN THE CARRYING AMOUNTS OF ASSETS AND LIABILITIES FOR FINANCIAL REPORTING AND THE AMOUNTS USED FOR INCOME TAX PURPOSES. AS OF DECEMBER 31, 2023 AND 2022, THE INDIANA UNIVERSITY HEALTH SYSTEM HAD GROSS DEFERRED TAX ASSETS OF $141,386,000 AND $145,194,000, RESPECTIVELY, RELATING TO NET OPERATING LOSS CARRYOVERS. MANAGEMENT DETERMINED THAT A FULL VALUATION ALLOWANCE AT DECEMBER 31, 2023 AND 2022 WAS NECESSARY TO REDUCE THE DEFERRED TAX ASSETS TO THE AMOUNT THAT WOULD MORE LIKELY THAN NOT BE REALIZED. BASED ON THE WEIGHT OF THE EVIDENCE, IF IT IS MORE LIKELY THAN NOT THAT SOME PORTION OR ALL OF THE DEFERRED TAX ASSETS WILL NOT BE REALIZED, A VALUATION ALLOWANCE TO REDUCE THE DEFERRED TAX ASSETS IS RECORDED. THE DECREASE IN THE GROSS DEFERRED TAX ASSET AND THE VALUATION ALLOWANCE FOR THE CURRENT YEAR IS $3,009,000. AT DECEMBER 31, 2023, INDIANA UNIVERSITY HEALTH SYSTEM HAS AVAILABLE NET OPERATING LOSS CARRYFORWARDS OF $571,690,000, NET OPERATING LOSSES GENERATED FROM 2004 THROUGH 2017 EXPIRE BETWEEN 2024 AND 2037. NET OPERATING LOSSES GENERATED AFTER 2017 DO NOT EXPIRE. true true X true X 300 false true true false true true 695 212355 212355 0.0095 3168 5880605 2409713 3470892 0.1557 0 0 0 0 0.0 0 3863 6092960 2409713 3683247 0.1653 7 2240 168070 0 168070 0.0075 2 64 35044 35044 0.0016 0 0.0 0 0.0 1 50 749 749 0.0000 10 2354 203863 0 203863 0.0091 10 6217 6296823 2409713 3887110 0.1744 0 0 0 0 0 0.0 1 91 1136 0 1136 0.0001 1 92 463 0 463 0.0000 1 22 2883 2883 0.0001 0 0 0 0 0 0.0 1 45 635 0 635 0.0000 1 138 4439 0 4439 0.0002 1 24 137 0 137 0.0000 0 0.0 6 412 9693 0 9693 0.0004 true 671092 4948046 4899117 48929 X true true 1 1 IU HEALTH BLACKFORD HOSPITAL 410 PILGRIM BLVD HARTFORD CITY IN 47348 https://iuhealth.org/FIND-LOCATIONS/IU-HEALTH-BLACKFORD-HOSPITAL 22-005101-1 X X X X IU HEALTH BLACKFORD HOSPITAL 1 false false true X X X X X X X X X 21 true false false true X HTTPS://IUHEALTH.ORG/IN-THE-COMMUNITY/COMMUNITY-BENEFIT true 22 true HTTPS://IUHEALTH.ORG/IN-THE-COMMUNITY/COMMUNITY-BENEFIT false true X 300.0 X X X X X X X true true X X X true X https://iuhealth.org/pay-a-bill/financial-assistance X https://iuhealth.org/pay-a-bill/financial-assistance X https://iuhealth.org/pay-a-bill/financial-assistance X X X X X X X true X false X X X X true X false false Schedule H, Part V, Section B, Line 3E IU Health Blackford Hospital's 2021 Community Health Needs Assessment (CHNA) report includes a prioritized description of significant health needs in the community. The CHNA report identified the following needs as priorities for IU Blackford Hospital: 1. Access to Healthcare Services 2. Aging Population and Needs of Seniors 3. Behavioral Health 4. Chronic Disease and Chronic Disease Management 5. Smoking, Tobacco Use and Exposure to Secondhand Smoke 6. Social Determinants of Health 7. Maternal and Infant Health and Child Well-being Schedule H, Part V, Section B, Line 5 Facility , 1 Facility , 1 - IU HEALTH BLACKFORD HOSPITAL. In conducting each its most recent CHNA, IU Health Blackford took into account input from persons who represent the broad interests of the communities it serves by hosting two community focus groups and an interview. These events engaged public health officials and community-based organizations that provide services and/or reflect community members who are medically underserved, low-income, or of a minority subpopulation to discuss the health needs of the service area and what role IU Health could play in addressing the identified needs. IU Health Blackford The defined community per the most recent CHNA is Blackford County, Indiana, where the hospital resides. AS OF 10/01/2023, IU Health Blackford Hospital DISCONTNIUED HOSPITAL AND EMERGENCY SERVICES. IT WILL CONTINUE TO OPERATE AS AN OUTPATIENT FACILITY. Blackford County - Community Meetings and Interview Two community meetings were held in 2021 to receive input from stakeholders regarding the health needs in Blackford County - one on April 23 and another on May 13. Secondary data and a preliminary list of community health need priorities was presented at both meetings. Each group was then asked questions about the preliminary list, including their reactions, additions to the proposed needs, thoughts regarding the causes, impacts of the COVID-19 pandemic and others. After these discussions, participants were given the opportunity to make additional comments before being asked to vote on the significant needs in the county. Participants were asked to choose three to five significant health needs in a poll during the meeting. Participants focused discussion on access to mental health services, health insurance barriers, substance abuse and addiction, tobacco use (including during pregnancy and among youth with vaping), a lack of health education, maternal and infant health, childcare, the disconnect between good education rates but lack of jobs, transportation barriers, a lack of knowledge of available resources and others. From this process, participants from the April 23 community meeting identified the following needs as most significant for Blackford County: * Access to mental health providers * Health literacy and education * Substance abuse (including opioids, alcohol and methamphetamines) * Obesity and associated conditions (diabetes, cardiovascular issues) Participants from the May 13 community meeting identified the following needs as most significant for Blackford County: * Substance abuse and addiction (including tobacco usage) * Access to healthcare services * Access to mental health services * Maternal, infant and child health and wellbeing In discussing the impacts of the COVID-19 pandemic on health, participants focused on isolation and its impacts on mental health, increase in substance abuse, impacts on child learning, increase in domestic violence and abuse, increasing physical inactivity and growing community conflict and negative attitudes (including towards frontline workers). An additional community survey was issued to stakeholders unable to attend community meetings, asking them to identify priority needs. Among two responses, the following issues were identified as the most significant by both respondents: * Substance abuse and addiction * Mental health and suicide * Poverty and lack of resources for low-income population * Lack of providers (specialists and mental health) The survey also asked about the impacts of the COVID-19 pandemic. Issues selected as significant impacts by both respondents include: * Social isolation and loneliness * Learning and development impacts among children An additional interview was conducted with a representative of a local public health department to obtain subject-matter expertise into the health needs in Blackford County. The following issues were discussed as significant: * Substance abuse and addiction is a significant issue * Mental health and access to mental health care are significant issues, amplified by the COVID-19 pandemic * Maternal and infant health issues exist, particularly around teen births and smoking during pregnancy * Smoking and obesity are two issues that have long been identified as issues in Blackford and continue to persist despite local work * Transportation is a large barrier to accessing services, particularly a lack of public transportation options * More community focus on health lifestyle is needed, including nutrition, physical activity, tobacco-free residents and accessible areas to exercise (health education plays a role here) Community meeting and survey participants Individuals from a wide variety of organizations and communities participated in the interview process, community meetings and surveys. Participants included representatives from the following organizations: * Blackford County Community Corrections * Blackford County Community Foundation * Blackford County Economic Development Corporation * Blackford County Health Department * Blackford County Schools * Blackford County Sheriff's Office * Citizens State Bank * Indy Container Board * IU Health * IU Health Ball * IU Health Blackford * LifeStream Services * Purdue Extension * Second Harvest Food Bank * Smith Insurance Services Schedule H, Part V, Section B, Line 11 Facility , 1 Facility , 1 - IU HEALTH BLACKFORD HOSPITAL. Along with the CHNA, IU Health Blackford's Board adopted an implementation strategy in April 2022 in response to the 2021 CHNA. IU Health Blackford, along with community partners, prioritized and determined which of the significant needs identified in its most recently conducted CHNA could be adequately addressed by current or future initiatives, programs, resources, and collaborations. The 2022-2024 implementation strategy outlines how IU Health Blackford plans to address significant needs including initiatives, strategies, internal/external collaborators, anticipated impact, and hospital resources. Significant Needs Hospital Will Address Below is the progress of the implementation strategy by significant need and its respective initiative(s). The hospital is addressing the following significant needs between 2022 and 2024: Access to Healthcare Services; Aging Population and Needs of Seniors; Behavioral Health; Chronic Disease and Chronic Disease Management; Maternal and Infant Health and Child Well-being; Smoking, Tobacco Use and Exposure to Secondhand Smoke; and Social Determinants of Health. Access to Healthcare Services * Support community members accessing healthcare services regardless of their ability to pay. The hospital provides financial assistance to patients each year that includes discounts, full charity, and personal hardship reductions. IU Health Patient Financial Counselors are certified Indiana Navigators. They can assist patients and families with information and help them with applications for various health coverage programs. In 2023, the counselors served 36 people at IU Health Blackford. Implement Medical provider recruitment plan to address areas experiencing a shortage of primary and specialty care services. In 2023, 33 physicians and 4 nurse practitioners were recruited and hired to practice primary care and other specialties in the IU Health East Central Region. This included new primary care physicians in Upland, Daleville, Portland and Muncie, as well as primary care nurse practitioners in Albany, Yorktown and Muncie. Specialty care physicians were recruited for Urology, Internal Medicine, Neonatology, Cardiology Psychiatry services. Implement Mobile Integrated Health Care - Paramedicine. This program is operational in the IU Health East Central Region and includes an 80-hour paramedicine training program for Paramedic, EMS and Fire Department personnel; IU Health Paramedic and affiliate EMS organizations deploy at hospital or physician point of care to establish post-discharge care in a six-county area. This team had a total of 693 home visits in 2023 and supported 806 patients enrolled in the Heart/Lung Center that held a less than 1% readmission rate for the year. Aging Population and Needs of Seniors Support senior-focused programs at local events in the community. In 2023, IU Health teams engaged with senior centers in the East Central Region. This included support for a community senior health fair organized in Delaware County, a partnership with Purdue Extension in Jay County to offer falls prevention programming and other health topics for seniors at the Jay County Senior Center; and a health-topic speaker series at the senior center in Blackford County with topics such as falls prevention, heart health, and medication safety. Many of these connections were made in conjunction with Healthy Community Alliance partners and resources. Behavioral Health Further implement IU Health Ball Addiction Treatment and Recovery Center. In 2023, the ATRC Served 236 individuals, including 179 new patients in the program, and had an additional 62 persons enrolled in the Intensive Outpatient (IOP) program with a 97% successful completion rate. In 2023 Intensive Outpatient Services (IOP) ended and a shift was made to individual treatment. A new support group was added in 2023 as well. Further implement IU Health Blackford Virtual Care Behavioral Health. Virtual Integrated Behavioral Health (VIBH) provided urgent psychiatric assessment for patients experiencing behavioral health crises, such as suicidal ideation, homicidal ideation, psychosis, and substance abuse disorders. A team of behavioral health professionals provided consultation through iPad carts located in emergency departments, urgent cares, and ambulatory care locations. In 2023, there were over 11,000 visits of which 1,790 visits included patients seeking care in the emergency departments and 104 patients seeking care in primary care clinics located in the East Central Region (which includes IU Health Blackford). This program is financially supported by the parent hospital, IU Health Inc., but is offered to and impacts patients in this hospital's defined community. * Support the Consortium for Opioids Response and Engagement-East Central Indiana (CORE-ECI). IU Health Blackford is part of the Consortium for Opioids Response Engagement which was created to build sustainable consortium of stakeholders to combat the opioid crisis in Blackford and Jay Counties. In 2023, quarterly meetings were held to decide the focus of the consortium moving forward, and three project workgroups were created to include: Crisis Intervention Team (40-hour training scheduled for 2024), Youth Programming & Intervention and Education/Stigma. Participating organizations include: Purdue University, Jay County Drug Prevention Coalition, Blackford County Community Corrections, Hester Hollis Concern Center and A Better Life Brianna's Hope. Chronic Disease and Chronic Disease Management Support the Healthy Community Alliance of East Central Indiana (HCA). Four community workgroups related to increased physical activity, improved nutrition and tobacco prevention and cessation were facilitated by IU Health Community Outreach personnel in a three-county area. Five new community Partners joined the HCA in 2023. 200 Quit Now toolkits were distributed to HCA Partners and members of the community in 2023. HCA partners collaborated to engage with senior, resource limited, minority and faith-based organizations by offering multiple community-based heart health, healthy eating, vaping education, access to care, screening events, healthy eating and food access programs to East Central Indiana in 2023. Provide outpatient nutrition counseling. No-cost nutrition counselling offered by IU Health Blackford team members was promoted utilizing multiple outreach activities and community events during 2023. 68 participants participated in counseling in 2023. Bariatric and Medical Weight Loss Support Groups in Muncie were offered 1-2 times per month with nearly seventy participants in 2023. Further implement IU Health Days of Service (volunteer event engaging IU Health team members in activities that benefit the community). 2023 Day of Service efforts by IU Health Blackford team members provided construction, landscaping and painting improvements at a Hartford City supported living home; as well as a donation of hygiene items to local non-profit organizations. 21 team members contributed 57 hours of time to these projects. Maternal and Infant Health and Child Well-being Further implement Healthy Beginnings Program. The Healthy Beginnings navigation program begins in the first trimester of pregnancy and continues through the first year of life. Navigators attend appointments with clients and connect them to community resources that address social determinants of health. Once the baby is born, navigators continue to engage with families to ensure that postpartum and infant needs are met. The program is open to Jay and Blackford County families. Overall HB impact in Blackford and Jay Counties increased by 40% from 2021 to 2022. Maternal Navigator cared for 852 pregnant patients in 2023 with 852 patient encounters. Infant Navigators had 1,176 encounters in 2023 with a total of 2,038 encounters. This includes referrals to WIC, lactation counseling (participant breastfeeding rate increased to 79% in 2023), childbirth classes, car seat fitting, safe sleep classes, healthy families, tobacco cessation, government assistance programs, family resource center/community partners and food pantries. Multiple family programs such as diaper events, childhood vaccination event, park health and safety program, and mental health series. Schedule H, Part V, Section B, Line 11 Facility , 2 Facility , 2 - IU HEALTH BLAKCFORD HOSPITAL (CONTINUED). Further implement Infant and Maternal Health Programs. In 2023 the Perinatal Coordinator for IU Health's East Central region worked with local providers to further implement a virtual care, remote monitoring system to achieve improvements for pregnant and postpartum women to enhance maternal, fetal, and newborn health by streamlining health promotion, optimizing prenatal visits, recognizing early maternal warning signs, such as blood pressure and mental health, and educating new families on newborn safety and developmental milestones. Smoking, Tobacco Use and Exposure to Secondhand Smoke Promote the use of Quit Now Indiana (1-800 Quit Now). Quit-Now Tobacco toolkits were distributed to community members at health fairs, special events and speaking opportunities in 2023. The Indiana Tobacco Quitline received referrals as follows in 2023: Blackford County, 33 referrals; Delaware County, 173 referrals; Jay County 34 referrals. Further implement the Centralized Tobacco Treatment Program (CTTP) (provides patients access to evidence-based tobacco treatment). The CTTP program is free to IU Health Primary Care patients. Once a patient's level of care is assessed, they are provided evidence-based tobacco cessation treatment with a trained Tobacco Treatment Specialist (TTSs). Patients had access to Clickotine, a digital cessation app, and support from an Advance Practice Provider (APP) to evaluate and prescribe medication assisted therapy (MAT) for nicotine replacement. Education and support were provided to PCP offices which helped to expand services. Cross-functional teams worked together including the West Central Region TTSs for case conferencing and training. The goal to increase access to Specialty Care patients is on hold until budget allows for additional staffing. The 2023 focus was on improving internal efficiencies to maximize resources and improve patient experience including data collection and reporting enhancements. An additional focus was on improving access and patient experience with medication management. CTTP improved patient tobacco treatment medication support by integrating systems and processes with a dedicated APP resource. They improved documentation to accurately report MAT, demonstrating 70% of patients used NRT/medication to quit. There was a 30% increase in scheduled medication management appointments compared to 2022. The team focused on care continuation, care coordination (TTS/APP), scheduling patient follow-up appointments, and monitoring adherence or complications. These tactics also improved the engagement rate - 78% of scheduled medication management appointments were completed. The above focus on improving patient experience resulted in strong and consistent quit rates of 31% of active patients and harm reduction (patients who reduced use of tobacco) of 54% (July 2022-December 2023). The team received frequent testimonials of lives changed and gratitude for a supportive, compassionate partner. In 2023, CTTP received 1,149 referrals, scheduled 75% of them and completed at least one session with 82% of those scheduled. Additionally, 44% of patients seen completed 2 or more sessions. Over the program's life, CTTP has received 2,678 patient referrals. This program is financially supported by the parent hospital, IU Health Inc., but is offered to and impacts patients in this hospital's defined community. Social Determinants of Health Advance community collaborations and interventions with support from the Community Impact and Investment Fund (CII). Information about the 2023 CII funding opportunity was widely shared in the East Central Region. Applications from Marian University for their "Building Vibrant Schools in Muncie, Indiana" proposal and the Whitely Neighborhood Association for their Centennial District Resource Hub project were selected in 2023 to receive CII Funding amounting to $1.2M. Support Farmers Market Education Program. This program was discontinued in the Blackford County area in 2023 due to logistical reasons. The program continued in other parts of the East Central Region with offerings such as cooking demonstrations and implementation of IU Health Bucks to encourage increased usage of fresh produce in family meal planning and to incentivize participants to visit a local farmers market. Assist people from racial and ethnic minority groups with accessing health services in the community. Dual language handouts were acquired/developed/utilized in 2023 to promote community events and provide health and wellness information. Significant Needs Hospital Will Not Address IU Health Blackford addressed all the significant health needs identified in the 2021 Community Health Needs Assessment. Schedule H, Part V, Section B, Line 13 Facility , 1 Facility , 1 - IU HEALTH BLACKFORD HOSPITAL. IN ADDITION TO FPG, IU HEALTH BLACKFORD HOSPITAL MAY TAKE INTO CONSIDERATION A PATIENT'S INCOME AND/OR ABILITY TO PAY IN CALCULATION OF A FINANCIAL ASSISTANCE AWARD. Schedule H, Part V, Section B, Line 13 Facility , 1 Facility , 1 - IU HEALTH BLACKFORD HOSPITAL. IU Health Blackford Hospital takes into consideration several other factors in determining patient eligibility for financial assistance. These factors include the following: 1. Eligibility for Financial Assistance due to Financial or Personal Hardship In order to be eligible for Financial Assistance due to Financial or Personal Hardship under this Policy, a patient or guarantor must: - Submit a completed Financial Assistance Application with all supporting documentation and be approved in accordance with this Policy; - Be an Indiana Resident as defined in this Policy; and - If Uninsured, consult with a member of IU Health's Individual Solutions department to determine if health care coverage may be obtained from a government insurance or assistance product, the Health Insurance Marketplace, or from any other source of coverage. Financial Assistance due to Financial Hardship is only available for encounters where care was initiated via an eligible facility's emergency department, direct admission from a physician's office, or transfer from another hospital facility. 2. Financial Assistance due to Financial Hardship The FPL income threshold under this section is as follows: - If one or more adults and zero dependents are in the household, the FPL Income Threshold is 200%. - If two or more adults and one or more dependents are in the household, the FPL Income Threshold is 250%. - If one adult and one or more dependents are in the household, the FPL Income Threshold is 300%. In some instances, an adult will also qualify as a dependent. When this occurs, IU Health will treat the adult as a dependent for purposes of the FPL calculation. IU Health will utilize the most recent FPL data available and will apply the FPL data to a patient or guarantor's account balance based upon the calendar date a completed Financial Assistance Application was received, not a patient's date of service. An Uninsured Patient or their guarantor whose household income is less than or equal to the FPL income threshold may be eligible for full Financial Assistance up to 100% of Gross Charges if approved. An Underinsured Patient or their guarantor whose household income is less than or equal to the FPL income threshold may be eligible for full Financial Assistance up to 100% of Patient Responsibility if approved. 3. Financial Assistance due to Personal Hardship An Uninsured or Underinsured patient or their guarantor whose household income is above the FPL income threshold may be eligible for Financial Assistance if the patient's outstanding Patient Responsibility exceeds 20% of the patient's or their guarantor's annual household income. - If approved, the patient's balance will be reduced to 20% of the patient or guarantor's annual household income or the Amounts Generally Billed, whichever is less. - IU Health will work with the patient or guarantor to identify a reasonable payment plan on the remainder of the balance. 4. Eligibility Period If approved for financial assistance by IU Health, the patient will be guaranteed financial assistance for treatment related to the underlying condition, for which the patient was originally screened and approved, through the remainder of the calendar year. As a condition of extending the on-going Financial Assistance, the patient must comply with requests from IU Health to verify that the patient continues to meet the conditions for qualification. 5. Appeals and Assistance Granted By the Financial Assistance Committee The Financial Assistance Committee will review and make determinations on all requests for appeals related to Financial Assistance. If a patient or guarantor seeks to appeal a Financial Assistance Determination, a written request must be submitted, along with the supporting documentation. The Financial Assistance Committee will review requests for and may grant additional Financial Assistance, including but not limited to, the following: - Assistance to patients who are seeking treatment that can only be provided in Indiana by IU Health or who would benefit from continued medical services from IU Health for continuity of care; - Care approved by the IU Health Chief Medical Officer (CMO) or the Chief Executive Officer (CEO) or CMO of an IU Health facility or region, including medically necessary non-elective services for which no payment source can be identified; - Care provided when it is known no payment source exists; - International humanitarian aid; and - Other care identified by the Financial Assistance Committee that fulfills the IU Health Mission. All decisions of the Financial Assistance Committee are final. 6. Presumptive Eligibility No Financial Assistance Application is required to receive Financial Assistance under this Presumptive Eligibility section. IU Health will deem patients or their guarantors presumptively eligible for Financial Assistance if they are found to be eligible for one of the following programs and care was initiated via an eligible facility's emergency department, direct admission from a physician's office, or transfer from another hospital facility: - Medicaid (any state) - Indiana Children's Special Health Care Services - Healthy Indiana Plan - Patients who are awarded Hospital Presumptive Eligibility (HPE) - A state and/or federal program that verifies the patient or guarantor's gross household income meets the FPL income threshold. IU Health will conduct a quarterly review of all accounts placed with a collection agency partner for at least one hundred and twenty (120) days after the account is eligible for an ECA as set forth in this Policy. If the patient or guarantor's individual scoring criteria demonstrates the patient has a low likelihood and/or propensity to pay or no credit, the patient or guarantor may be deemed presumptively eligible for Financial Assistance. Financial Assistance may additionally be granted in the following circumstances: - If the patient or their guarantor is found to have filed a petition for bankruptcy. - If the patient is deceased and found to have no estate. - If the patient is deceased and was under 21 years of age at the time of death. 7. Exhaustion of Alternate Sources of Assistance Patients must exhaust all other state and federal assistance programs prior to receiving Financial Assistance due to Financial or Personal Hardship under this Policy including, but not limited to, Medicaid. Patients who may be eligible for coverage under an applicable health insurance policy must exhaust all insurance benefits. - This includes patients covered under their own policy and those who may be entitled to benefits from a third-party policy. - IU Health may request patients show proof that such a claim was properly submitted to the appropriate insurance provider before awarding Financial Assistance. Eligible patients who receive medical care from an IU Health facility as a result of an injury proximately caused by a third party, and later receive a monetary settlement or award from said third party, may receive Financial Assistance for any outstanding balance not covered by the settlement or award. In the event Financial Assistance has already been granted in the above circumstances, IU Health reserves the right to reverse the Financial Assistance Determination in an amount equal to the amount IU Health would be entitled to receive had no Financial Assistance been awarded. 8. Patient Assets There are situations where a patient or their guarantor may have significant income or assets available to pay for healthcare services such as a legal settlement. The Financial Assistance Committee may evaluate the income or assets in determining Financial Hardship. IU Health may require a list of all property owned by the patient or guarantor and adjust a Financial Assistance Determination as a result. Schedule H, Part V, Section B, Line 16 Facility , 1 Facility , 1 - IU HEALTH BLACKFORD HOSPITAL. IU Health Blackford Hospital takes several other measures to publicize its FAP within the community. These measures include the following: 1. Post this Policy, a Plain Language Summary of this Policy, and the Financial Assistance Application on its website. 2. Provide patients with a Plain Language Summary of this Policy during registration and/or discharge. 3. Post conspicuous displays in appropriate acute care settings such as emergency departments and registration areas describing the available assistance and directing eligible patients to the Financial Assistance Application. 4. Include a conspicuous written notice on all patient post-discharge billing statements notifying the patient about this Policy and the telephone number of the Customer Service Department which can assist patients with questions regarding this Policy. 5. Make available Customer Service representatives via telephone during normal business hours. 6. Mail copies of this Policy, a Plain Language Summary of this Policy, and a Financial Assistance Application to patients or their guarantor free of charge upon request. 7. Broadly communicate this Policy as a part of its general outreach efforts. 8. Educate patient-facing team members on this Policy and the process for referring patients to the program. 4 IU HEALTH BLACKFORD PHYSICIANS 400 PILGRIM BLVD HARTFORD CITY IN 47348 SPECIALTY CARE IU HEALTH BLACKFORD RADIOLOGY 410 PILGRIM BLVD HARTFORD CITY IN 47348 RADIOLOGY IU HEALTH BLACKFORD PHARMACY 400 PILGRIM BLVD HARTFORD CITY IN 47349 PHARMACY IU HEALTH BLACKFORD LAB 410 PILGRIM BLVD HARTFORD CITY IN 47348 LAB Schedule H, Part I, Line 6a C.B. REPORT PREPARED BY A RELATED ORG. IU HEALTH BLACKFORD HOSPITAL'S COMMUNITY BENEFIT AND OTHER INVESTMENTS, ENCOMPASSING ITS TOTAL COMMUNITY INVESTMENT, ARE INCLUDED IN THE IU HEALTH COMMUNITY BENEFIT REPORT WHICH IS PREPARED ON BEHALF OF AND INCLUDES IU HEALTH AND ITS RELATED HOSPITAL ENTITIES IN THE STATE OF INDIANA ("IU HEALTH STATEWIDE SYSTEM"). THE IU HEALTH COMMUNITY BENEFIT REPORT IS MADE AVAILABLE TO THE PUBLIC ON IU HEALTH'S WEBSITE AT HTTPS://IUHEALTH.ORG/IN-THE-COMMUNITY/COMMUNITY BENEFIT THE IU HEALTH COMMUNITY BENEFIT REPORT IS ALSO DISTRIBUTED TO NUMEROUS KEY ORGANIZATIONS THROUGHOUT THE STATE OF INDIANA IN ORDER TO BROADLY SHARE THE IU HEALTH STATEWIDE SYSTEM'S COMMUNITY BENEFIT EFFORTS. IT IS ALSO AVAILABLE BY REQUEST THROUGH THE INDIANA STATE DEPARTMENT OF HEALTH OR IU HEALTH. Schedule H, Part I, Line 7f BAD DEBT EXPENSE THE AMOUNT OF BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE OF TOTAL EXPENSE IS $1,486,691. BAD DEBT EXPENSE IS REPORTED AT COST BASED ON THE COST-TO-CHARGE RATIO. DERIVED FROM WORKSHEET 2, RATIO OF PATIENT CARE COST TO-CHARGES. Schedule H, Part I, Line 7 TOTAL COMMUNITY BENEFIT EXPENSE SCHEDULE H, PART I, LINE 7, COLUMN (F), PERCENT OF TOTAL EXPENSE, IS BASED ON COLUMN (E) NET COMMUNITY BENEFIT EXPENSE. THE PERCENT OF TOTAL EXPENSE BASED ON COLUMN (C) TOTAL COMMUNITY BENEFIT EXPENSE, WHICH DOES NOT INCLUDE DIRECT OFFSETTING REVENUE, IS 28.25%. Schedule H, Part II PROMOTION OF HEALTH IN COMMUNITIES SERVED IU Health Blackford is a subsidiary of IU Health. IU Health participates in a variety of community-building activities that address the social determinants of health in the communities it serves. IU Health and its related hospital entities across the State of Indiana ("IU Health Statewide System") investments include economic development efforts across the state, collaborate with like-minded organizations through coalitions that address key issues, and advocate for improvements in the health status of vulnerable populations. This includes making contributions to community-building activities by providing investments and resources to local community initiatives that addressed economic development, community support and workforce development, several examples include IU Health's support of numerous organizations and initiatives that focus on some of the root causes of the health issues, such as lack of education, employment and poverty. IU Health Blackford is a supporting member of a three-county health coalition focused on obesity prevention and tobacco cessation as a means to reduce the impact of chronic disease including cancer and heart disease. More than 150 organizations are partners in the "Healthy Community Alliance of East Central Indiana" coalition and each pledge to influence audiences to make positive choices regarding improved nutrition, increased physical activity or tobacco cessation. Coalition partners report a collective total audience size of more than 50,000 people. IU Health Blackford is part of the Consortium for Opioids Response Engagement which was created to build sustainable consortium of stakeholders to combat the opioid crisis. Early intervention of children, adolescents and families with a focus on the individual, interpersonal, community, and societal influences that produce health disparities, stigma and bias and cultural insensitivities. Embed evidence-based prevention, treatment and recovery services into a seamless community-based system of care for both counties through process design and improvement. Increase access to medication-assisted treatment (MAT) for opioid addiction. Participating organizations include: Purdue University, Jay County Drug Prevention Coalition, Blackford County Community Corrections, Hester Hollis Concern Center and A Better Life Brianna's Hope. Blackford Nurse sat on the Client Consultation Board Blackford Nurse was a member of the Suicide Overdoes Fatality Review team. 2 Blackford Nurses were part of the Blackford County Vaping Task Force. Schedule H, Part I, Line 7g DESCRIBE SUBSIDIZED HEALTH SERVICE COSTS FROM PHYSICIAN CLINIC IU HEALTH BLACKFORD INCLUDES COSTS ASSOCIATED WITH PHYSICIAN CLINICS AS SUBSIDIZED HEALTH SERVICES BUT IS NOT ABLE TO SEGREGATE THE COSTS ASSOCIATED WITH PHYSICIAN CLINICS. Schedule H, Part I, Line 3c Eligibility criteria for free or discounted care IU Health uses several factors other than federal poverty guidelines ("FPG") in determining eligibility for free care under its FAP. These factors include the following: 1. Eligibility for Financial Assistance due to Financial or Personal Hardship In order to be eligible for Financial Assistance due to Financial or Personal Hardship under this Policy, a patient or guarantor must: - Submit a completed Financial Assistance Application with all supporting documentation and be approved in accordance with this Policy; - Be an Indiana Resident as defined in this Policy; and - If Uninsured, consult with a member of IU Health's Individual Solutions department to determine if health care coverage may be obtained from a government insurance or assistance product, the Health Insurance Marketplace, or from any other source of coverage. Financial Assistance due to Financial Hardship is only available for encounters where care was initiated via an eligible facility's emergency department, direct admission from a physician's office, or transfer from another hospital facility. 2. Financial Assistance due to Financial Hardship The FPL income threshold under this section is as follows: - If one or more adults and zero dependents are in the household, the FPL Income Threshold is 200%. - If two or more adults and one or more dependents are in the household, the FPL Income Threshold is 250%. - If one adult and one or more dependents are in the household, the FPL Income Threshold is 300%. In some instances, an adult will also qualify as a dependent. When this occurs, IU Health will treat the adult as a dependent for purposes of the FPL calculation. IU Health will utilize the most recent FPL data available and will apply the FPL data to a patient or guarantor's account balance based upon the calendar date a completed Financial Assistance Application was received, not a patient's date of service. An Uninsured Patient or their guarantor whose household income is less than or equal to the FPL income threshold may be eligible for full Financial Assistance up to 100% of Gross Charges if approved. An Underinsured Patient or their guarantor whose household income is less than or equal to the FPL income threshold may be eligible for full Financial Assistance up to 100% of Patient Responsibility if approved. 3. Financial Assistance due to Personal Hardship An Uninsured or Underinsured patient or their guarantor whose household income is above the FPL income threshold may be eligible for Financial Assistance if the patient's outstanding Patient Responsibility exceeds 20% of the patient's or their guarantor's annual household income. - If approved, the patient's balance will be reduced to 20% of the patient or guarantor's annual household income or the Amounts Generally Billed, whichever is less. - IU Health will work with the patient or guarantor to identify a reasonable payment plan on the remainder of the balance. 4. Eligibility Period If approved for financial assistance by IU Health, the patient will be guaranteed financial assistance for treatment related to the underlying condition, for which the patient was originally screened and approved, through the remainder of the calendar year. As a condition of extending the on-going Financial Assistance, the patient must comply with requests from IU Health to verify that the patient continues to meet the conditions for qualification. 5. Appeals and Assistance Granted By the Financial Assistance Committee The Financial Assistance Committee will review and make determinations on all requests for appeals related to Financial Assistance. If a patient or guarantor seeks to appeal a Financial Assistance Determination, a written request must be submitted, along with the supporting documentation. The Financial Assistance Committee will review requests for and may grant additional Financial Assistance, including but not limited to, the following: - Assistance to patients who are seeking treatment that can only be provided in Indiana by IU Health or who would benefit from continued medical services from IU Health for continuity of care; - Care approved by the IU Health Chief Medical Officer (CMO) or the Chief Executive Officer (CEO) or CMO of an IU Health facility or region, including medically necessary non-elective services for which no payment source can be identified; - Care provided when it is known no payment source exists; - International humanitarian aid; and - Other care identified by the Financial Assistance Committee that fulfills the IU Health Mission. All decisions of the Financial Assistance Committee are final. 6. Presumptive Eligibility No Financial Assistance Application is required to receive Financial Assistance under this Presumptive Eligibility section. IU Health will deem patients or their guarantors presumptively eligible for Financial Assistance if they are found to be eligible for one of the following programs and care was initiated via an eligible facility's emergency department, direct admission from a physician's office, or transfer from another hospital facility: - Medicaid (any state) - Indiana Children's Special Health Care Services - Healthy Indiana Plan - Patients who are awarded Hospital Presumptive Eligibility (HPE) - A state and/or federal program that verifies the patient or guarantor's gross household income meets the FPL income threshold. IU Health will conduct a quarterly review of all accounts placed with a collection agency partner for at least one hundred and twenty (120) days after the account is eligible for an ECA as set forth in this Policy. If the patient or guarantor's individual scoring criteria demonstrates the patient has a low likelihood and/or propensity to pay or no credit, the patient or guarantor may be deemed presumptively eligible for Financial Assistance. Financial Assistance may additionally be granted in the following circumstances: - If the patient or their guarantor is found to have filed a petition for bankruptcy. - If the patient is deceased and found to have no estate. - If the patient is deceased and was under 21 years of age at the time of death. 7. Exhaustion of Alternate Sources of Assistance Patients must exhaust all other state and federal assistance programs prior to receiving Financial Assistance due to Financial or Personal Hardship under this Policy including, but not limited to, Medicaid. Patients who may be eligible for coverage under an applicable health insurance policy must exhaust all insurance benefits. - This includes patients covered under their own policy and those who may be entitled to benefits from a third-party policy. - IU Health may request patients show proof that such a claim was properly submitted to the appropriate insurance provider before awarding Financial Assistance. Eligible patients who receive medical care from an IU Health facility as a result of an injury proximately caused by a third party, and later receive a monetary settlement or award from said third party, may receive Financial Assistance for any outstanding balance not covered by the settlement or award. In the event Financial Assistance has already been granted in the above circumstances, IU Health reserves the right to reverse the Financial Assistance Determination in an amount equal to the amount IU Health would be entitled to receive had no Financial Assistance been awarded. 8. Patient Assets There are situations where a patient or their guarantor may have significant income or assets available to pay for healthcare services such as a legal settlement. The Financial Assistance Committee may evaluate the income or assets in determining Financial Hardship. IU Health may require a list of all property owned by the patient or guarantor and adjust a Financial Assistance Determination as a result. Schedule H, Part I, Line 6a Community benefit report prepared by related organization Indiana University Health, Inc. Schedule H, Part I, Line 7 Bad Debt Expense excluded from financial assistance calculation 1486691 Schedule H, Part III, Line 2 Bad debt expense - methodology used to estimate amount THE BAD DEBT EXPENSE REPORTED ON SCHEDULE H, PART III, LINE 2 IS REPORTED AT COST, AS CALCULATED USING THE COST TO CHARGE RATIO METHODOLOGY. Schedule H, Part III, Line 3 Bad Debt Expense Methodology IU Health will deem patients or their guarantors presumptively eligible for Financial Assistance if they are found to be eligible for one of the following programs and care was initiated via an eligible facility's emergency department, direct admission from a physician's office, or transfer from another hospital facility: 1. Medicaid (any state) 2. Indiana Children's Special Health Care Services 3. Healthy Indiana Plan 4. Patients who are awarded Hospital Presumptive Eligibility (HPE) 5. A state and/or federal program that verifies the patient or guarantor's gross household income meets the FPL income threshold. No Financial Assistance Application is required to receive Financial Assistance under this Presumptive Eligibility section. IU Health will conduct a quarterly review of all accounts placed with a collection agency partner for at least one hundred and twenty (120) days after the account is eligible for an ECA as set forth in this Policy. If the patient or guarantor's individual scoring criteria demonstrates the patient has a low likelihood and/or propensity to pay or no credit, the patient or guarantor may be deemed presumptively eligible for Financial Assistance. Financial Assistance may additionally be granted in the following circumstances: a) If the patient or their guarantor is found to have filed a petition for bankruptcy. b) If the patient is deceased and found to have no estate. c) If the patient is deceased and was under 21 years of age at the time of death. Due to this comprehensive methodology, IU Health does not believe any amount of bad debt is attributable to patients who may be eligible under the financial assistance policy and no portion of bad debt is included as community benefit. Schedule H, Part III, Line 4 Bad debt expense - financial statement footnote IU HEALTH'S CONSOLIDATED FINANCIAL STATEMENTS, FOOTNOTE 5, ADDRESSES BAD DEBT EXPENSE AS FOLLOWS: The Indiana University Health System does not require collateral or other security from its patients, substantially all of whom are residents of the State, for the delivery of health care services. However, consistent with industry practice, the Indiana University Health System routinely obtains assignment of (or is otherwise entitled to receive) patients' benefits payable under their health insurance programs, plans, or policies (e.g., Medicare, Medicaid, managed care payers, and commercial insurance policies). The Indiana University Health System uses a portfolio approach to account for categories of patient contracts as a collective group, rather than recognizing revenue on an individual contract basis. The portfolios consist of major payer classes for inpatient revenue and outpatient revenue. Based on the historical collection trends and other analysis, the Indiana University Health System believes that revenue recognized by utilizing the portfolio approach approximates the revenue that would have been recognized if an individual contract approach were used. In support of its mission, the Indiana University Health System provides care to uninsured and underinsured patients. The Indiana University Health System provides charity care to patients who lack the financial resources to pay for their medical care. Financial assistance is available to qualifying uninsured and underinsured patients receiving care at an Indiana University Health System hospital location. Under its financial assistance policy, the Indiana University Health System provides medically necessary care to uninsured patients. Financial assistance up to the full amount of patient financial responsibility is available for uninsured and underinsured patients receiving care via the emergency department, direct admission from a physician's office, or transfer from another hospital. The Federal Poverty Level (FPL) thresholds are used when a patient applies for financial assistance due to financial hardship. In determining the level of financial assistance based on household makeup, single person households without dependents are eligible for assistance if household income is less than or equal to 200% FPL, two adults and at least one dependent are eligible if household income is less than or equal to 250% FPL, and households with one adult and at least one dependent are eligible if household income is less than or equal to 300% FPL. Qualifying individuals with medical bills totaling more than 20% of annual household income, regardless of FPL, qualify for catastrophic assistance and are eligible for a reduction in patient financial responsibility to 5% of annual household income or Amounts Generally Billed, whichever is less. Since the Indiana University Health System does not pursue collection of these amounts, the discounted amounts are not reported as patient service revenue. The Indiana University Health System uses presumptive eligibility screening procedures for some forms of financial assistance and recognizes net patient service revenue on services provided to self-pay patients at the discounted rate at the time services are rendered. The estimated cost of charity care, using the consolidated cost to charge ratio, was $95,909,000 and $88,213,000 in 2023 and 2022, respectively. Schedule H, Part III, Line 8 Community benefit & methodology for determining medicare costs IU Health Blackford Hospital did not have a Medicare shortfall for 2023. IU Health Blackford Hospital's Medicare reimbursements, however, are normally less than the cost of providing patient care and services to Medicare beneficiaries and do not include any amounts that result from inefficiencies or poor management. IU Health Blackford Hospital accepts all Medicare patients knowing that there may be shortfalls; therefore it has taken the position that any shortfall should be counted as part of its community benefit. Additionally, it is implied in Internal Revenue Service Revenue Ruling 69-545 that treating Medicare patients is a community benefit. Revenue Ruling 69-545, which established the community benefit standard for nonprofit hospitals, states that if a hospital serves patients with governmental health benefits, including Medicare, then this is an indication that the hospital operates to promote the health of the community. The amount reported on Schedule H, Part III, Line 6 is calculated, in accordance with the Form 990 instructions, using "allowable costs" from the IU Health Medicare Cost Report. "Allowable costs" for Medicare Cost Report purposes, however, are not reflective of all costs associated with IU Health's participation in Medicare programs. For example, the Medicare Cost Report excludes certain costs such as billed physician services, the costs of Medicare Parts C and D, fee schedule reimbursed services, and durable medical equipment services. Inclusion of all costs associated with IU Health Blackford Hospital's participation in Medicare programs would significantly reduce the Medicare surplus reported on Schedule H, Part III, Line 7. Schedule H, Part III, Line 9b Collection practices for patients eligible for financial assistance IU Health Blackford Hospital's FAP and Written Debt Collection Policy describe the collection practices applicable to patients, including those who may qualify for financial assistance. 1. Financial Assistance Application Financial Assistance Applications must include the following documentation: - All sources of Income for the last three (3) months. - Most recent three (3) months of pay stubs or Supplemental Security Income via Social Security. - Most recent three (3) statements from checking and savings accounts, certificates of deposit, stocks, bonds and money market accounts. - Most recent state and Federal Income Tax forms including Schedules C, D, E, and F. In the event the patient or guarantor's income does not warrant the filing of a federal tax statement, the individual may submit a notarized affidavit attesting to the foregoing. - Most recent W-2 statement. - For patients or members of the Household who are currently unemployed, Wage Inquiry from WorkOne. - If applicable, divorce/dissolution decrees and child custody order. Patients or their guarantors wishing to apply for Financial Assistance due to Financial Hardship are encouraged to submit an Application within ninety (90) days of discharge. Patients or their guarantors may submit an Application up to two-hundred and forty (240) days from the date of their initial post-discharge billing statement from IU Health, however, accounts may be subject to Extraordinary Collection Actions (ECA) as soon as one-hundred and twenty (120) days after receipt of the initial post-discharge billing statement. Patients or their guarantors submitting an incomplete Financial Assistance Application will receive written notification of the Application's deficiency upon discovery by IU Health. The Application will be pended for a period of forty-five (45) days from the date the notification is mailed. IU Health will suspend any ECA until the Application is complete or the expiration of the forty-five (45) day period. Patients with limited English proficiency may request a copy of this Policy, a Financial Assistance Application, and a Plain Language Summary in one of the below languages: - Arabic; - Burmese; - Burmese - Falam; - Burmese - Hakha Chin; - Mandarin/Chinese; or - Spanish The patient, and/or their representative, such as the patient's physician, family members, legal counsel, community or religious groups, social services or hospital personnel may request a Financial Assistance Application be mailed to a patient's primary mailing address free of charge. IU Health maintains the confidentiality of all Financial Assistance Applications and supporting documentation. IU Health will deny or revoke Financial Assistance for any patient or guarantor who falsifies any portion of a Financial Assistance Application. 2. Financial Assistance Determinations IU Health will inform patients or guarantors of the results of their Application by providing the patient or guarantor with a Financial Assistance Determination within ninety (90) days of receiving a completed Application and all requested documentation. A patient's Financial Assistance Application and Financial Assistance Determination are specific to each date(s) of service and approved related encounters. If a patient or guarantor is granted less than full charity assistance and the patient or guarantor provides additional information for reconsideration, Revenue Cycle Services may amend a prior Financial Assistance Determination. 3. Extraordinary Collection Actions IU Health may refer delinquent patient accounts to a third-party collection agency after utilizing reasonable efforts to determine a patient's eligibility for assistance under this Policy. Reasonable efforts include the following: - IU Health will notify the patient of this Policy at least thirty (30) days prior to initiating an ECA. - IU Health will not initiate an ECA for at least one-hundred and twenty (120) days after the patient's initial post-discharge billing statement. - IU Health will review all Financial Assistance Applications received up to and including two-hundred and forty (240) days after the patient's initial post-discharge billing statement. IU Health will cease any ECAs it has initiated upon receipt of a Financial Assistance Application until a Financial Assistance Determination is made under this policy. - If an Application is Approved, IU Health will issue a revised statement, issue refunds, and make reasonable efforts to reverse ECAs as necessary. IU Health and its third-party collection agencies may initiate an ECA against a patient or their guarantor in accordance with this Policy and 26 C.F.R. § 1.501(r). ECAs may include the following: - Selling a patient or their guarantor's outstanding financial responsibility to a third party. - Reporting adverse information about the patient or their guarantor to consumer credit reporting agencies or credit bureaus. - Deferring or denying, or requiring a payment before providing, medically necessary care because of a patient or their guarantor's nonpayment of one or more bills for previously provided care covered under this Policy. - Actions requiring a legal or judicial process, including but not limited to placing a lien on a patient's or their guarantor's property, foreclosing on a patient's or their guarantor's real property, attaching or seizing a patient's or their guarantor's bank account or other personal property, commencing a civil action against a patient or their guarantor, causing a patient or guarantor's arrest, causing a patient and/or guarantor to be subject to a writ of body attachment, and garnishing a patient or guarantor's wages When it is necessary to engage in such action, IU Health and its third party collection agencies, will engage in fair, respectful and transparent collections activities. 4. Refunds Patients eligible for Financial Assistance under this Policy who remitted payment to IU Health in excess of their Patient Responsibility will be alerted to the overpayment as promptly after discovery as is reasonable given the nature of the overpayment. Patients with an outstanding account balance due on a separate account will have their refund applied to the outstanding balance. Patients without an outstanding account balance described above will be issued a refund check for their overpayment as soon as technically feasible. Schedule H, Part V, Section B, Line 16a FAP website - IU HEALTH BLACKFORD HOSPITAL: Line 16a URL: https://iuhealth.org/pay-a-bill/financial-assistance; Schedule H, Part V, Section B, Line 16b FAP Application website - IU HEALTH BLACKFORD HOSPITAL: Line 16b URL: https://iuhealth.org/pay-a-bill/financial-assistance; Schedule H, Part V, Section B, Line 16c FAP plain language summary website - IU HEALTH BLACKFORD HOSPITAL: Line 16c URL: https://iuhealth.org/pay-a-bill/financial-assistance; Schedule H, Part VI, Line 2 Needs assessment Though IU Health Blackford believes its CHNA process is comprehensive, the CHNA is done on a triennial basis. Between CHNA cycles, IU Health Blackford gathers data and information to monitor the most current needs of the community. Additional sources of data and information include: * IU Health data analytics and information service teams; * Secondary data sources from Federal, state, and local entities with a focus on health behaviors, health outcomes, and social determinants of health; * Obtaining community organization and governmental agency perspectives; priority population perspectives; and other healthcare and hospital perspectives; * Reports that share findings and recommendations on certain populations within the community and/or health behaviors, health outcomes, or social determinants of health; * Evidence informed sources; and * Team member participation in partnering efforts (e.g., coalitions, advisory committees, task forces, etc.). The regular review of these sources of data and information rarely impact what the significant needs are between CHNA cycles. However, it does help influence the types or level of interventions to address the significant needs; prioritize resources to those groups or neighborhoods experiencing health disparities in the community; identify funding opportunities to support interventions; and strengthen or mobilize partnerships to improve health. Schedule H, Part VI, Line 3 Patient education of eligibility for assistance IU Health Blackford Hospital is committed to serving the healthcare needs of all of its patients regardless of their ability to pay for such services. To assist in meeting those needs, IU Health Blackford Hospital has established a FAP to provide Financial Assistance to Uninsured Patients. IU Health Blackford Hospital is committed to ensuring its patients are compliant with all provisions of the Patient Protection & Affordable Care Act. To that end, IU Health Blackford Hospital will make a good faith effort to locate and obtain health insurance coverage for patients prior to considering patients for coverage under the FAP. IU Health Blackford Hospital takes several measures to inform its patients of the FAP and FAP-eligibility. These measures include the following: 1. Post this Policy, a Plain Language Summary of this Policy, and the Financial Assistance Application on its website. 2. Provide patients with a Plain Language Summary of this Policy during registration and/or discharge. 3. Post conspicuous displays in appropriate acute care settings such as emergency departments and registration areas describing the available assistance and directing eligible patients to the Financial Assistance Application. 4. Include a conspicuous written notice on all patient post-discharge billing statements notifying the patient about this Policy and the telephone number of the Customer Service Department which can assist patients with questions regarding this Policy. 5. Make available Customer Service representatives via telephone during normal business hours. 6. Mail copies of this Policy, a Plain Language Summary of this Policy, and a Financial Assistance Application to patients or their guarantor free of charge upon request. 7. Broadly communicate this Policy as a part of its general outreach efforts. 8. Educate patient-facing team members on this Policy and the process for referring patients to the program. Schedule H, Part VI, Line 4 Community information IU Health Blackford Hospital is located in Blackford County, Indiana, a county located in east-central Indiana. Its service areas include Blackford, Grant, Delaware, Jay, and Wells counties. Blackford County includes ZIP codes within the towns of Hartford City and Montpelier. Based on the most recent Census Bureau (2023) statistics, Blackford County's population is 11,893 persons with approximately 50.9% being female and 49.1% male. The county's population estimates by race are 93.4% White, 2.6% Hispanic or Latino, 1.1% Black, 0.5% Asian, 0.4% American Indian or Alaska Native, and 2.2% persons reporting two or more races. Blackford County has relatively low levels of educational attainment. The level of education most of the population has achieved is a high school degree (90.4%). As of 2023, 14.8% of the population had a bachelor's degree or higher. Schedule H, Part VI, Line 5 Promotion of community health IU Health Blackford is governed by a Board of Directors, comprised of persons who primarily reside in the organization's primary service area, and who are neither employees nor independent contractors of the organization. IU Health Blackford extends medical staff privileges to all qualified physicians in its community for some or all of its clinical departments and specialties. IU Health does not deny appointments based on gender, race, creed or national origin. IU Health, in conjunction with the IU School of Medicine, trains the next generation of physicians in an exceptional environment. Blending breakthrough research and treatments with the highest quality of patient care. IU Health Blackford participates in other initiatives and collaborations throughout the year to promote health and wellness in the community. Some of these include: - IU Health Blackford team member annual campaign to raise donations for the local United Way. - Education for students in the healthcare field such as nursing, pharmacy and radiology. Students job shadowed nurses at IU Health Blackford to learn and experience the healthcare field. - Reduced price heart scans are available for the community all year. - Lung cancer screenings using low dose CT imaging offered at reduced cost to community members meeting requirements set out by the National Comprehensive Cancer Network. In November and December of 2023, lung cancer screenings were offered for free to Veterans. - Free skin cancer screenings were offered during May 2023. - Additionally, team members at IU Health Blackford participated in the IU Health Statewide System's team member community benefit service program, "IU Health Serves", team members across the state make a difference in the lives of thousands of Hoosiers every year. Schedule H, Part VI, Line 6 Affiliated health care system Indiana University Health Blackford is part of Indiana University Health ("IU Health "the healthcare system"), which is Indiana's most comprehensive healthcare system. A unique partnership with the Indiana University School of Medicine ("IU School of Medicine"), one of the nation's leading medical schools, gives patients access to innovative treatments and therapies. The healthcare system is comprised of hospitals, physicians and allied services dedicated to providing preeminent patient care and community health improvement throughout Indiana. IU Health's affiliate hospitals are divided into six regions that serve communities in Northwest, Northeast, Central and Southern Indiana. The 16 hospitals in the healthcare system include IU Health Inc. (i.e., the IU Health Academic Health Center consists of IU Health Methodist Hospital, IU Health University Hospital, Riley Hospital for Children at IU Health and IU Health Saxony Hospital); IU Health Arnett; IU Health Ball; IU Health Bedford Hospital; IU Health Bloomington Hospital; IU Health Frankfort; IU Health Jay; IU Health North Hospital; IU Health Paoli Hospital; IU Health Tipton Hospital; IU Health West Hospital; and IU Health White Memorial Hospital. Each affiliate hospital in the healthcare system, along with community partners, conducts and adopts its own community health needs assessment (CHNA) and implementation strategy. IU Health considers the sum of these CHNAs and the implementation strategies part of a system wide vision of making Indiana one of the healthiest states in the nation. The healthcare system and its affiliate hospitals are keenly aware of the positive impact it can have on improving the health of communities throughout the state of Indiana by investing in local, community-based initiatives as well as system level strategies. The healthcare system includes an Academic Health Center (i.e., IU Health Inc.), a regional academic health center (i.e., IU Health Bloomington Hospital) and several affiliate hospitals (IU Health Arnett and IU Health Ball) that work in partnership with the IU School of Medicine to train physicians, blending breakthrough research and treatments with the highest quality of patient care throughout IU Health. Each year, more than 1,000 residents and fellows receive training in affiliate hospitals. Research conducted by IU School of Medicine faculty gives IU Health physicians and patients access to the most leading-edge and comprehensive treatment options. To further promote the health of the communities served by IU Health, the system-level Community Health Division partners with state and local community-based organizations, community coalitions and governmental agencies to focus on innovative models of care; community alliances and partnerships; anchor institution and advocacy strategies; and social determinants of health. All affiliate hospitals in the healthcare system identify and address significant needs unique to the communities they serve. However, some needs are common in communities served by multiple or all affiliate hospitals in the healthcare system and align with system priority areas, warranting a system level strategy. The Community Health Division, along with additional internal partners such as the Office of Health Equity Research and Evaluation (HERE) and the IU Health Foundation, plans and provides technical assistance for system-level strategies that address these common needs including health equity, tobacco and nicotine cessation, behavioral and substance use disorders, infant and maternal health, hypertension, and social determinants of health. For example, the Community Health Division is coordinating efforts to select and train community health workers who are placed throughout the system in outpatient and inpatient sites and do outreach through the WeCare and iHEART initiatives. These valued team members are from the communities being served by IU Health and have an intimate understanding of the needs of residents. Each affiliate hospital works collaboratively with the Community Health Division to align and activate local resources to support local and system strategies. This benefits the community each affiliate hospital serves and works towards a statewide impact (system-level) on health outcomes. As part of the Community Health Division, the Community Outreach and Engagement Program's IU Health Serves initiative, a system-level team member volunteer program, seeks to positively impact the health of communities IU Health affiliate hospitals serve and foster a culture of engagement and social responsibility. Each affiliate hospital coordinates the different initiatives of the program, including Days of Service. This is the largest volunteer event of the year, consisting of projects designed to engage each affiliate hospitals' team members in activities that address local, significant needs. The $200 million Community Impact and Investment (CII) Fund was established in 2018 by IU Health to financially support high-impact community investing. The focus of these efforts will address key social and environmental factors that impact historically marginalized and minoritized populations in the communities IU Health serves. Through the grants provided by this CII Fund, IU Health can strategically and intentionally address the social, economic, and environmental factors that impact the health of affiliate hospitals' surrounding communities. Each affiliate hospital and its team members are eligible to pursue this grant opportunity with a community organization. Schedule H, Part VI, Line 7 State filing of community benefit report IN true Hartford City Library 314 N High St Hartford City IN 47348 356001570 Government Agency 20000 General Support 1 0 Schedule I, Part I, Line 2 Procedures for monitoring use of grant funds. ALTHOUGH IU HEALTH BLACKFORD DOES NOT MONITOR THE USE OF GRANT FUNDS ONCE DISTRIBUTED, THROUGH DUE DILIGENCE THE ORGANIZATION HAS REASONABLY CONFIRMED THAT THE ENTITIES TO WHICH THE CONTRIBUTIONS ARE MADE ARE HIGHLY REPUTABLE IN THE COMMUNITY AND USE THE FUNDS FOR THE PURPOSES INTENDED. false true false false false false false true false JEFFREY C BIRD MD DIRECTOR/PRESIDENT (ECR) 0 603910 0 263314 0 117973 0 121200 0 50992 0 1157389 0 96303 PETER M VOSS MD DIRECTOR/VICE CHAIR 0 424351 0 62306 0 3564 0 13200 0 50992 0 554413 0 0 CHARLES R ROUTH MD DIRECTOR 0 176698 0 98590 0 6858 0 11501 0 55974 0 349621 0 0 JOAN V CASTOR DIRECTOR 0 370579 0 145314 0 55520 0 79944 0 51997 0 703354 0 0 JONATHAN W VANATOR CFO (ECR) 0 326963 0 59746 0 810 0 12328 0 55139 0 454986 0 0 MICHELLE R ALTOBELLA VP-General Counsel, Asst Secretary (ECR) 0 232260 0 25917 0 1199 0 10683 0 39818 0 309877 0 0 LORI A LUTHER COO (ECR) (Part Year) 0 320929 0 52515 0 5803 0 13200 0 48765 0 441211 0 0 MELISSA R HICKS VP & CNO (ECR) 0 235948 0 35631 0 472 0 11139 0 43048 0 326238 0 0 RYAN M JOHNSTON MD VP & CMO (ECR) 0 384347 0 55896 0 1242 0 13200 0 63987 0 518672 0 0 BRIAN REED VP-HUMAN RESOURCES (ECR) 0 179352 0 20328 0 359 0 8421 0 52504 0 260965 0 0 KREIGH COOK COO (ECR) (Part Year) 0 186851 0 15839 0 27415 0 9407 0 28088 0 267600 0 0 KEVIN W SCHREIBER MD FORMER HIGHEST COMPENSATED EMPLOYEE 0 288975 0 115712 0 810 0 13200 0 58485 0 477182 0 0 THOMAS M LEE MD PHYSICIAN 184936 0 123023 0 11124 0 12721 0 54055 0 385859 0 0 0 JAN BLAKE MCMILLAN VP - CNO - BLACKFORD HOSP 137296 9988 26821 1966 669 49 6830 501 37125 2722 208741 15226 0 0 MONICA R GAITHER Supervisor-House 90986 17030 8732 1576 59023 10653 4380 791 13477 2432 176598 32481 0 0 THOMAS D STEWART MD PHYSICIAN 232072 29956 92567 11415 6105 753 10264 1266 57399 7078 398409 50467 0 0 HELEN A BORGENHEIMER MD PHYSICIAN 175930 2670 86176 1278 3512 52 8694 129 50331 747 324644 4876 0 0 Schedule J, Part I, Line 3 Arrangement used to establish the top management official's compensation IU HEALTH BLACKFORD'S REGIONAL PRESIDENT / PRESIDENT (PART YEAR), JEFFREY C. BIRD, IS EMPLOYED BY IU HEALTH, INC. IU HEALTH BLACKFORD'S PRESIDENT (PART YEAR), DAVID W. HYATT, WAS EMPLOYED BY IU HEALTH BALL MEMORIAL HOSPITAL. IU HEALTH, IU HEALTH BALL AND OTHER RELATED ORGANIZATIONS HAVE A PROCESS IN PLACE FOR DETERMINING THE COMPENSATION FOR THE OFFICERS AND KEY EMPLOYEES. IU HEALTH HUMAN RESOURCES USES MARKET DATA FROM MULTIPLE COMPENSATION EXPERTS/VENDORS WHO UTILIZE A VARIETY OF METHODS AND PROCEDURES TO OBTAIN COMPENSATION RANGES FOR COMPARABLE OFFICERS AND EMPLOYEE POSITONS. THIS MARKET DATA AND MULTIPLE OTHER FACTORS (INCLUDE MARKET PAY BENCHMARKS, INTERNAL EQUITY, CANDIDATE/EMPLOYEE QUALIFICATIONS AND PERFORMANCE, AND OTHER BUSINESS NEEDS) ARE USED TO RECOMMEND COMPENSATION RANGES FOR ITS OFFICERS AND OTHER EMPLOYEES, WHICH ARE THEN USED AS A GUIDE FOR SETTING REASONABLE COMPENSATION BY MANAGEMENT. PLEASE SEE SCHEDULE O FOR ADDITIONAL DETAILS. Schedule J, Part I, Line 4b Supplemental nonqualified retirement plan JEFFREY C. BIRD, M.D. AND JOAN V. CASTOR PARTICIPATE IN AN IU HEALTH SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN. PROVISIONS OF WHICH ARE DESIGNED TO RETAIN ITS CRITICAL EMPLOYEES. THE PLAN PROVIDES FOR AN ADDITIONAL RETIREMENT BENEFIT FOR SERVICES THROUGH NORMAL RETIREMENT OR OTHER KEY DATES. IF THE EXECUTIVE LEAVES PRIOR TO RETIREMENT OR OTHER KEY DATES, THE BENEFIT MAY BE FORFEITED OR REDUCED. EACH OF THE EXECUTIVES LISTED ABOVE HAVE AN AMOUNT INCLUDED IN COLUMN C, DEFERRED COMPENSATION, REPRESENTING THE CURRENT YEAR UNVESTED CONTRIBUTIONS MADE UNDER THE SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN. THESE AMOUNTS WERE NOT PAID TO THE EXECUTIVES DURING THE YEAR. THE FOLLOWING EXECUTIVES HAVE AN AMOUNT INCLUDED IN COLUMN B (III), OTHER REPORTABLE COMPENSATION, REPRESENTING THE CURRENT YEAR VESTED AMOUNTS RECEIVED UNDER THE SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN: JEFFREY C. BIRD: $102,766 JOAN V. CASTOR: $52,216 Schedule J, Part I, Line 7 Non-fixed payments AMOUNTS DISCLOSED IN COLUMN B(II) INCLUDE A LONG TERM INCENTIVE FOR CERTAIN EXECUTIVES. ALTHOUGH THESE PLANS ARE BASED ON A FIXED FORMULA THAT HAS BEEN APPROVED BY THE BOARD OF DIRECTORS BASED UPON CERTAIN QUALITATIVE AND QUANTITATIVE FACTORS AND GOALS, ALL DISCRETIONARY INCENTIVE PLANS MUST BE APPROVED BY THE COMMITTEE ON PERSONNEL AND COMPENSATION AND BOARD OF DIRECTORS PRIOR TO ANY INCENTIVE PAYOUT. Form 990, Part VI, Line 13 SECTION B, LINES 12, 13, 14, AND 16B - POLICIES IU HEALTH BLACKFORD HOSPITAL IS PART OF THE IU HEALTH SYSTEM. IU HEALTH BLACKFORD HOSPITAL'S SOLE MEMBER IS IU HEALTH BALL MEMORIAL HOSPITAL. IU HEALTH BALL MEMORIAL HOSPITAL'S SOLE MEMBER IS IU HEALTH, INC. IU HEALTH, INC. AND ITS BOARD OF DIRECTORS HAVE MANDATED THAT CERTAIN POLICIES BE FOLLOWED TO ENSURE GREATER STANDARDIZATION THROUGHOUT THE SYSTEM. THUS, IU HEALTH BLACKFORD HOSPITAL'S BOARD OF DIRECTORS WAS NOT REQUIRED TO SEPARATELY ADOPT A CONFLICT OF INTEREST, WHISTLEBLOWER, DOCUMENT RETENTION AND DESTRUCTION AND JOINT VENTURE POLICIES BECAUSE IU HEALTH'S BOARD OF DIRECTORS HAD ALREADY ADOPTED AND REQUIRED THESE POLICIES TO BE FOLLOWED BY ITS SUBSIDIARIES. Form 990, Part VI, Line 1b INDEPENDENT VOTING MEMBERS IU HEALTH BLACKFORD HOSPITAL IS PART OF A MULTI-ENTITY HOSPITAL SYSTEM, ULTIMATELY CONTROLLED BY IU HEALTH, INC., A 501(C)(3) TAX-EXEMPT ORGANIZATION WHOSE BOARD IS COMPRISED OF VOTING MEMBERS, OF WHICH SUBSTANTIALLY ALL ARE INDEPENDENT COMMUNITY MEMBERS. Form 990, Part VI, Line 15 PROCESS FOR DETERMINING COMPENSATION (1) The Board of Directors ("Board") has established a Talent Management and Executive Compensation Committee ("TMECC"), the purpose of which includes reviewing and making recommendations regarding executive (Senior Vice Presidents and above) pay and benefits (collectively referred to as "compensation") on an annual basis in April. The TMECC is made up of members of the Board that are neither physicians nor employees and do not otherwise have a conflict of interest regarding any of IU Health's compensation arrangements. The TMECC reviews an executive's entire compensation package including base salary, short-term and long-term incentives, health and welfare benefits, qualified and nonqualified retirement plans, as well as any additional fringe benefits. As deemed appropriate, the Committee on Finance, which is also made up of members of the Board, may also review executive compensation and benefits. (2) The TMECC engages an independent compensation consulting firm on an annual basis to conduct a compensation analysis for its executive group, which consists of employees at the level of senior vice president and above. The current compensation advisor is SullivanCotter. SullivanCotter performs its analysis in the form of a compensation survey ("survey") that includes relevant comparability data for compensation levels paid by similarly situated organizations (both governmental and tax exempt) for functionally comparable positions as well as the availability of similar services in the geographic area. SullivanCotter then prepares a survey report and provides recommendations to the TMECC, if deemed appropriate, on changes in executive compensation. A separate analysis using the same methodology is done for the President and Chief Executive Officer. (3) The TMECC then reviews SullivanCotter's report and recommendations and, if appropriate, votes on whether to recommend any changes in executive compensation to the Board. The TMECC will only recommend changes to the Board if they are consistent with the Board's philosophy on compensation matters and are deemed reasonable based upon the independent analysis provided by SullivanCotter. The TMECC's review, discussion and vote are documented in the minutes for the meeting. There are no executives present during the final discussion and approval. (4) The Board then reviews the report prepared by SullivanCotter as well as the recommendations of the TMECC as to any changes in executive compensation. As deemed appropriate, the Committee on Finance may also provide its review of the TMECC's recommendations on any changes in executive compensation. This review and discussion are documented in the minutes (5) The Board then votes on whether to accept the TMECC's recommendations on any changes in executive compensation. Changes in executive compensation are made if approved by the TMECC and Board on an annual basis, or as necessary throughout the year. The discussion and approval are documented in the minutes of the meeting. There are no executives present during the final discussion and approval. IU Health's General Counsel also prepares a formal written opinion reviewing the executive compensation approval process, comparing it to the Intermediate Sanctions Test of IRC Section 4958. If warranted, IU Health's General Counsel may also provide comments regarding the executive compensation approval process as it relates to meeting the requirements for a rebuttable presumption of reasonableness as provided in the Intermediate Sanctions Test. (6) After the end of each year, the TMECC and Board also review the achievements of the executive group as it relates to the long-term and short-term shared and individual goals developed by the executives and the Board. These achievements may also be reviewed with the Committee on Finance. The Board, at its discretion, may approve bonus payments based upon the achievement of the goals. The discussion and vote of the TMECC and Board is documented in the minutes for each such meeting. The bonuses are not paid until approval is made by the Board. (7) The TMECC and Audit Committee also review Form 990 disclosures related to executive compensation as well as the organization's practices and approval processes prior to the filing of the Form 990 return with the Internal Revenue Service. IU Health Blackford Hospital's President is an employee of IU Health Ball Memorial Hospital. IU Health, Inc. and IU Health Ball Memorial Hospital, and other related entities have a process in place to determine the compensation for its officers and key employees. IU Health Human Resources uses market data from multiple compensation experts/vendors who utilize a variety of methods and procedures to obtain compensation ranges for comparable officer and employee positions. This market data and multiple other factors (including market pay benchmarks, internal equity, candidate/employee qualifications & performance, and business needs) are used to recommend compensation ranges for its officers and other employees, which are then used as a guide for setting reasonable compensation by management. Form 990, Part VI, Line 6 Classes of members or stockholders IU HEALTH BLACKFORD HOSPITAL HAS ONE CLASS OF MEMBERSHIP AND THE SOLE MEMBER IS IU HEALTH BALL MEMORIAL HOSPITAL, A WHOLLY OWNED SUBSIDIARY OF IU HEALTH. Form 990, Part VI, Line 7a Members or stockholders electing members of governing body THE BOARD OF DIRECTORS SHALL CONSIST OF SUCH NUMBER OF MEMBERS NOT FEWER THAN THREE (3) NOR MORE THAN FIVE (5) IN NUMBER. COMPOSITION OF THE BOARD OF DIRECTORS SHALL BE CONSISTENT WITH THE FOLLOWING CRITERIA: TWO (2) MEMBERS APPOINTED BY IU HEALTH BALL MEMORIAL HOSPITAL SHALL BE REPRESENTATIVES OF THE LOCAL COMMUNITY AND ONE (1) TO THREE (3) MEMBERS APPOINTED BY IU HEALTH BALL MEMORIAL HOSPITAL SHALL BE AT-LARGE REPRESENTATIVES. Form 990, Part VI, Line 7b Decisions requiring approval by members or stockholders Notwithstanding any other provisions of the Articles of Incorporation, the following matters require the approval of IU Health Ball Memorial Hospital prior to implementation: - Approve the Governing Documents of the Hospital. - Appoint, upon the recommendation of the Board of the Hospital, or remove, with or without cause, the members of the Board of Directors of the Hospital. Removal does not require a recommendation of the Hospital's Board. - Approve the incurrence of debt of the Hospital within limits delegated to the Board of Directors from time to time by IU Health Ball Memorial Hospital - Approve and recommend the formation of legal entities, the sale, transfer or substantial change in use of all or substantially all of the assets of the Hospital or the divestiture, dissolution, closure, merger, consolidation or change in the Corporate Member of the Hospital. - Approve the transfer or encumbrance of the assets of the Hospital, except in the ordinary course of business. - Subject to approval by IU Health, approve the capital and operating budgets for Hospital. - Approve the mission and vision statements for the Hospital. Form 990, Part VI, Line 11b Review of form 990 by governing body THE CFO REVIEWED AND APPROVED THE FORM 990. A COMPLETE COPY OF THE FORM 990 WAS MADE AVAILABLE TO EACH BOARD MEMBER PRIOR TO ITS FILING. EACH MEMBER WAS ALSO INFORMED OF THE AVAILABILITY OF IU HEALTH'S TAX DEPARTMENT TO ANSWER ANY QUESTIONS. Form 990, Part VI, Line 12c Conflict of interest policy IU Health Blackford Hospital follows IU Health's Conflict of Interest Policy. IU Health's Conflict of Interest Policy includes the following provisions: All IU Health employees, associates, colleagues and contracted personnel, including employed physicians and paid medical directors ("IU Health Representatives") are covered by and subject to its Conflict-of-Interest Policy. IU Health regularly and consistently monitors and enforces compliance with the policy through the following procedures: (a) On an annual basis, each IU Health Representative at the level of Manager or above, together with every other person designated by the Corporate Compliance Department ("Department"), must complete, sign and submit a Conflict-of-Interest Questionnaire ("Questionnaire") to the Department. Governing board members, committee members, corporate officers, medical staff and researchers must comply with the administrative requirements noted in the respective policies and procedures relative to those areas. (b) An IU Health Representative must supplement a Questionnaire in writing, if after completion of the original Questionnaire, a situation arises, or may reasonably be expected to arise, that would change any answer or information on the original Questionnaire if the situation had existed or been anticipated at the time of completion of the original Questionnaire. (c) If a fully and properly completed Questionnaire reveals facts or other information that might reasonably indicate a Conflict of Interest or violation of the policy, the IU Health Representative completing the questionnaire must secure approval by his/her supervisor, evidenced in writing. (d) The Department will review each Questionnaire and determine whether a Conflict of Interest exists and, if so, whether and how it should or may be eliminated, avoided or managed in order to comply with the spirit of the policy and with the best interests of IU Health and its patients. In making the determination, the Corporate Compliance Department may consult with the IU Health Representative's supervisor and other appropriate individuals and groups. (e) The scope of the policy is not limited to those who are required to complete Questionnaires. If an IU Health Representative is involved in a situation or relationship that would constitute a violation of the policy in the absence of disclosure and approval as described above, then the IU Health Representative must disclose the matter to his/her supervisor, secure his/her supervisor's approval in writing, and disclose the matter to the Department. Otherwise, the IU Health Representative is in violation of the policy and subject to corrective action, up to and including termination. (f) The Chief Compliance Officer, in consultation with onsite Compliance personnel, may from time to time appoint standing or ad hoc committees to assist in resolving issues that arise under provisions of the policy. Form 990, Part VI, Line 15a Process to establish compensation of top management official (1) THE BOARD OF DIRECTORS ("BOARD") HAS ESTABLISHED A TALENT MANAGEMENT AND EXECUTIVE COMPENSATION COMMITTEE ("TMECC"), THE PURPOSE OF WHICH INCLUDES REVIEWING AND MAKING RECOMMENDATIONS REGARDING EXECUTIVE (SENIOR VICE PRESIDENTS AND ABOVE) PAY AND BENEFITS (COLLECTIVELY REFERRED TO AS "COMPENSATION") ON AN ANNUAL BASIS IN APRIL. THE TMECC IS MADE UP OF MEMBERS OF THE BOARD THAT ARE NEITHER PHYSICIANS NOR EMPLOYEES AND DO NOT OTHERWISE HAVE A CONFLICT OF INTEREST REGARDING ANY OF IU HEALTH'S COMPENSATION ARRANGEMENTS. THE TMECC REVIEWS AN EXECUTIVE'S ENTIRE COMPENSATION PACKAGE INCLUDING BASE SALARY, SHORT-TERM AND LONG-TERM INCENTIVES, HEALTH AND WELFARE BENEFITS, QUALIFIED AND NONQUALIFIED RETIREMENT PLANS, AS WELL AS ANY ADDITIONAL FRINGE BENEFITS. AS DEEMED APPROPRIATE, THE COMMITTEE ON FINANCE, WHICH IS ALSO MADE UP OF MEMBERS OF THE BOARD, MAY ALSO REVIEW EXECUTIVE COMPENSATION AND BENEFITS. (2) THE TMECC ENGAGES AN INDEPENDENT COMPENSATION CONSULTING FIRM ON AN ANNUAL BASIS TO CONDUCT A COMPENSATION ANALYSIS FOR ITS EXECUTIVE GROUP, WHICH CONSISTS OF EMPLOYEES AT THE LEVEL OF SENIOR VICE PRESIDENT AND ABOVE. THE CURRENT COMPENSATION ADVISOR IS SULLIVANCOTTER. SULLIVANCOTTER PERFORMS ITS ANALYSIS IN THE FORM OF A COMPENSATION SURVEY ("SURVEY") THAT INCLUDES RELEVANT COMPARABILITY DATA FOR COMPENSATION LEVELS PAID BY SIMILARLY SITUATED ORGANIZATIONS (BOTH GOVERNMENTAL AND TAX EXEMPT) FOR FUNCTIONALLY COMPARABLE POSITIONS AS WELL AS THE AVAILABILITY OF SIMILAR SERVICES IN THE GEOGRAPHIC AREA. SULLIVANCOTTER THEN PREPARES A SURVEY REPORT AND PROVIDES RECOMMENDATIONS TO THE TMECC, IF DEEMED APPROPRIATE, ON CHANGES IN EXECUTIVE COMPENSATION. A SEPARATE ANALYSIS USING THE SAME METHODOLOGY IS DONE FOR THE PRESIDENT AND CHIEF EXECUTIVE OFFICER. (3) THE TMECC THEN REVIEWS SULLIVANCOTTER'S REPORT AND RECOMMENDATIONS AND, IF APPROPRIATE, VOTES ON WHETHER TO RECOMMEND ANY CHANGES IN EXECUTIVE COMPENSATION TO THE BOARD. THE TMECC WILL ONLY RECOMMEND CHANGES TO THE BOARD IF THEY ARE CONSISTENT WITH THE BOARD'S PHILOSOPHY ON COMPENSATION MATTERS AND ARE DEEMED REASONABLE BASED UPON THE INDEPENDENT ANALYSIS PROVIDED BY SULLIVANCOTTER. THE TMECC'S REVIEW, DISCUSSION AND VOTE ARE DOCUMENTED IN THE MINUTES FOR THE MEETING. THERE ARE NO EXECUTIVES PRESENT DURING THE FINAL DISCUSSION AND APPROVAL. (4) THE BOARD THEN REVIEWS THE REPORT PREPARED BY SULLIVANCOTTER AS WELL AS THE RECOMMENDATIONS OF THE TMECC AS TO ANY CHANGES IN EXECUTIVE COMPENSATION. AS DEEMED APPROPRIATE, THE COMMITTEE ON FINANCE MAY ALSO PROVIDE ITS REVIEW OF THE TMECC'S RECOMMENDATIONS ON ANY CHANGES IN EXECUTIVE COMPENSATION. THIS REVIEW AND DISCUSSION ARE DOCUMENTED IN THE MINUTES. (5) THE BOARD THEN VOTES ON WHETHER TO ACCEPT THE TMECC'S RECOMMENDATIONS ON ANY CHANGES IN EXECUTIVE COMPENSATION. CHANGES IN EXECUTIVE COMPENSATION ARE MADE IF APPROVED BY THE TMECC AND BOARD ON AN ANNUAL BASIS, OR AS NECESSARY THROUGHOUT THE YEAR. THE DISCUSSION AND APPROVAL ARE DOCUMENTED IN THE MINUTES OF THE MEETING. THERE ARE NO EXECUTIVES PRESENT DURING THE FINAL DISCUSSION AND APPROVAL. IU HEALTH'S GENERAL COUNSEL ALSO PREPARES A FORMAL WRITTEN OPINION REVIEWING THE EXECUTIVE COMPENSATION APPROVAL PROCESS, COMPARING IT TO THE INTERMEDIATE SANCTIONS TEST OF IRC SECTION 4958. IF WARRANTED, IU HEALTH'S GENERAL COUNSEL MAY ALSO PROVIDE COMMENTS REGARDING THE EXECUTIVE COMPENSATION APPROVAL PROCESS AS IT RELATES TO MEETING THE REQUIREMENTS FOR A REBUTTABLE PRESUMPTION OF REASONABLENESS AS PROVIDED IN THE INTERMEDIATE SANCTIONS TEST. (6) AFTER THE END OF EACH YEAR, THE TMECC AND BOARD ALSO REVIEW THE ACHIEVEMENTS OF THE EXECUTIVE GROUP AS IT RELATES TO THE LONG-TERM AND SHORT-TERM SHARED AND INDIVIDUAL GOALS DEVELOPED BY THE EXECUTIVES AND THE BOARD. THESE ACHIEVEMENTS MAY ALSO BE REVIEWED WITH THE COMMITTEE ON FINANCE. THE BOARD, AT ITS DISCRETION, MAY APPROVE BONUS PAYMENTS BASED UPON THE ACHIEVEMENT OF THE GOALS. THE DISCUSSION AND VOTE OF THE TMECC AND BOARD IS DOCUMENTED IN THE MINUTES FOR EACH SUCH MEETING. THE BONUSES ARE NOT PAID UNTIL APPROVAL IS MADE BY THE BOARD. (7) THE TMECC AND AUDIT COMMITTEE ALSO REVIEW FORM 990 DISCLOSURES RELATED TO EXECUTIVE COMPENSATION AS WELL AS THE ORGANIZATION'S PRACTICES AND APPROVAL PROCESSES PRIOR TO THE FILING OF THE FORM 990 RETURN WITH THE INTERNAL REVENUE SERVICE. IU HEALTH, INC. AND OTHER RELATED ENTITIES HAVE A PROCESS IN PLACE TO DETERMINE THE COMPENSATION FOR THE OTHER OFFICERS AND KEY EMPLOYEES OF IU HEALTH BLACKFORD, INC. IU HEALTH HUMAN RESOURCES USES MARKET DATA FROM MULTIPLE COMPENSATION EXPERTS/VENDORS WHO UTILIZE A VARIETY OF METHODS AND PROCEDURES TO OBTAIN COMPENSATION RANGES FOR COMPARABLE OFFICER AND EMPLOYEE POSITIONS. THIS MARKET DATA AND MULTIPLE OTHER FACTORS (INCLUDING MARKET PAY BENCHMARKS, INTERNAL EQUITY, CANDIDATE/EMPLOYEE QUALIFICATIONS & PERFORMANCE, AND BUSINESS NEEDS) ARE USED TO RECOMMEND COMPENSATION RANGES FOR ITS OFFICERS AND OTHER EMPLOYEES, WHICH ARE THEN USED AS A GUIDE FOR SETTING REASONABLE COMPENSATION BY MANAGEMENT. Form 990, Part VI, Line 15b Process to establish compensation of other employees IU HEALTH, INC. AND OTHER RELATED ENTITIES HAVE A PROCESS IN PLACE TO DETERMINE THE COMPENSATION FOR THE OTHER OFFICERS AND KEY EMPLOYEES OF IU HEALTH BLACKFORD, INC. IU HEALTH HUMAN RESOURCES USES MARKET DATA FROM MULTIPLE COMPENSATION EXPERTS/VENDORS WHO UTILIZE A VARIETY OF METHODS AND PROCEDURES TO OBTAIN COMPENSATION RANGES FOR COMPARABLE OFFICER AND EMPLOYEE POSITIONS. THIS MARKET DATA AND MULTIPLE OTHER FACTORS (INCLUDING MARKET PAY BENCHMARKS, INTERNAL EQUITY, CANDIDATE/EMPLOYEE QUALIFICATIONS & PERFORMANCE, AND BUSINESS NEEDS) ARE USED TO RECOMMEND COMPENSATION RANGES FOR ITS OFFICERS AND OTHER EMPLOYEES, WHICH ARE THEN USED AS A GUIDE FOR SETTING REASONABLE COMPENSATION BY MANAGEMENT. Form 990, Part VI, Line 19 Required documents available to the public IU Health Blackford Hospital's Articles of Incorporation are available for public inspection through the Indiana Secretary of State's web-site. IU Health Blackford Hospital's conflict of interest procedures are disclosed on the Form 990, Schedule O. IU Health Blackford Hospital is a subsidiary in IU Health's Consolidated Audited Financial Statements. IU Health's Consolidated Audited Financial Statements are available for public inspection through its bond filings and as an attachment to IU Health's Form 990. Form 990, Part IX, Line 11g Other Fees Professional fees - Total Expense: 139717, Program Service Expense: 130338, Management and General Expenses: 9379, Fundraising Expenses: ; Consulting - Total Expense: 40159, Program Service Expense: 37463, Management and General Expenses: 2696, Fundraising Expenses: ; Intercompany fees - Total Expense: 8576527, Program Service Expense: 8000786, Management and General Expenses: 575741, Fundraising Expenses: ; Physician fees - Total Expense: 38820, Program Service Expense: 36214, Management and General Expenses: 2606, Fundraising Expenses: ; Contract service - Total Expense: 563593, Program Service Expense: 525759, Management and General Expenses: 37834, Fundraising Expenses: ; Other Fees - Total Expense: 16607, Program Service Expense: 15492, Management and General Expenses: 1115, Fundraising Expenses: ; INDIANA HEALTH INFO EXCHANGE INC 846 N SENATE AVE INDIANAPOLIS IN 46202 364550324 HEALTHCARE IN 501(c)(3) Type I NA false INDIANA UNIVERSITY 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