2024-11-12T14:11:27+00:00 2023-12-31 990 2023-01-01 273532963 Indiana University Health White Memorial 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 MARY E MINIER 950 N MERIDIAN STREET 1200 INDIANAPOLIS IN 46204 55216897 false X SEE SCHEDULE O X 2010 IN Lead the transformation of healthcare through quality, innovation & education, and make Indiana one of the nation's healthiest states. 14 9 225 96 0 0 561024 450514 46308350 52436755 307256 2303837 152103 25791 47328733 55216897 10150 10271 0 13945975 12974189 0 0 28506618 33945991 42462743 46930451 4865990 8286446 74724842 81819030 25943200 24738686 48781642 57080344 Lead the transformation of healthcare through quality, innovation & education, and make Indiana one of the nation's healthiest states. false false 45001019 10271 52115441 INDIANA UNIVERSITY HEALTH WHITE MEMORIAL HOSPITAL, INC. ("IU HEALTH WHITE MEMORIAL HOSPITAL"), LOCATED IN MONTICELLO, INDIANA, IS A 25-BED CRITICAL ACCESS HOSPITAL THAT OFFERS A COMPREHENSIVE RANGE OF SERVICES TO CARE FOR ITS PATIENTS WITHOUT REGARD TO THEIR ABILITY TO PAY. ALL PATIENT ROOMS ARE PRIVATE AND BOAST WARM COLORS AND NATURAL LIGHT TO ENHANCE COMFORT AND HEALING. A FAMILY-FRIENDLY ENVIRONMENT OFFERS PULLOUT BEDS FOR OVERNIGHT STAYS AND WIRELESS INTERNET ACCESS. AS PART OF ITS COMMITMENT TO THE COMMUNITY, THE HOSPITAL OFFERS SEVERAL PROGRAMS TO BENEFIT RESIDENTS IN THE MONTICELLO AREA. 277451 0 321314 IU HEALTH WHITE MEMORIAL HOSPITAL LEASES PHYSICIAN OFFICE AND CLINIC SPACE TO RELATED TAX-EXEMPT ORGANIZATIONS. 45278470 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 false false true false false false false false false false false false false false false false true true true false false true 0 0 225 true false false false false false false false false false false false false X 14 9 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 GARY D HENRIOTT DIRECTOR/CHAIR 2.0 5.0 X X 0 7500 0 AMANDA WHITLOCK DIRECTOR 2.0 4.0 X 0 5000 0 Ben Harpenau Director (Part Year) 2.0 4.0 X 0 2000 0 ERIKA UGIANSKIS MD DIRECTOR 2.0 53.0 X 0 804572 78474 JESSE MOORE DIRECTOR 2.0 4.0 X 0 5000 0 Johnny Park Director (Part Year) 2.0 4.0 X 0 2000 0 MARION UNDERWOOD DIRECTOR (Part Year) 2.0 4.0 X 0 0 0 MARK BUONO MD Director 2.0 53.0 X 0 703508 74353 MICHELE S SAYSANA MD DIRECTOR 2.0 53.0 X 0 578808 29263 RANDALL R MITCHELL DIRECTOR (Part Year) 2.0 4.0 X 0 4000 0 RANDY W PRICE DIRECTOR (Part Year) 2.0 4.0 X 0 5000 0 REV KATE L WALKER DIRECTOR (Part Year) 2.0 4.0 X 0 2000 0 RUBAN NIRMALAN MD DIRECTOR 2.0 53.0 X 0 869811 67389 SHAN SHERIDAN DIRECTOR 2.0 4.0 X 0 6000 0 UMESH PATEL DIRECTOR 2.0 4.0 X 0 6000 0 WILLIAM Y LI MD DIRECTOR 2.0 53.0 X 0 169140 27951 ARTHUR VASQUEZ PRESIDENT (WCR) 10.0 45.0 X 0 742860 154953 PHILIP LIST SECRETARY (WCR) 10.0 45.0 X 0 223505 47342 TODD A WILLIAMS CFO/TREASURER (WCR) 10.0 45.0 X 0 365618 66207 CHRISTOPHER A MANSFIELD MD CMO / COO (Part Year) (WCR) 10.0 45.0 X 0 565399 68153 JEFFREY C ZEH COO (Part Year) (WCR) 10.0 45.0 X 0 484867 40883 KISHAN PATEL MD VP-Chief Physician Executive (WCR) 10.0 45.0 X 0 453323 67953 KOREEN C KYHNELL VP - HUMAN RESOURCES (WCR) 10.0 45.0 X 0 248166 68917 ROXANNE WICKLUND CNO (WCR) 10.0 45.0 X 0 324171 49858 Christopher S Farmer Manager - Pharmacy 50.0 0 X 152511 0 57570 DARA WERT SUPERVISOR, HOUSE 50.0 0 X 117579 8939 36781 MARY E MINIER COO (Frankfort and White) 35.0 20.0 X 264098 0 48340 RENEA SMITH CNO (Frankfort and White) 30.0 20.0 X 175448 0 11272 Sarah J Quaglio Manager - Infection Prevention Regional 50.0 0 X 129055 0 48837 CARA L BREIDSTER FORMER OFFICER 0.0 55.0 X 0 339481 64209 DEREK E EMPIE FORMER OFFICER 0.0 55.0 X 0 335206 62375 MARY C DREWES FORMER Highest Compensated Employee 0.0 50.0 X 0 257970 32275 838689 7519845 1203357 15 true true false 0 10230 440284 450514 Net Patient Service Revenenue 622110 52115441 52115441 Rent from Related 501(c)(3) Orgs. 532000 321314 321314 0 0 0 0 52436755 2303837 2303837 18169 18169 0 18169 18169 0 0 All Other Revenue 900099 7622 7622 0 0 0 0 7622 55216897 52436755 0 2329628 X 5271 5271 5000 5000 566956 547839 19117 9808973 9478222 330751 361794 349595 12199 1538071 1486209 51862 698395 674846 23549 1853 1853 12023289 11216168 807121 0 18633 17382 1251 61360 30680 30680 1419917 1419917 7936 7403 533 537 501 36 892146 892146 2101275 2002280 98995 197047 197047 Drugs and Medical Supplies 9522466 9522466 Bad Debt 3604654 3604654 Hospital Assessment Fee 2928993 2928993 Teaching Aids 19052 19052 1146833 1069846 76987 0 46930451 45278470 1651981 0 0 41833696 49833620 180753 34351 4549792 5381875 0 0 0 0 0 683052 900336 84079 68607 44432129 18993681 27010045 25438448 0 0 383425 161793 74724842 81819030 4928529 2525807 0 0 21014671 22212879 25943200 24738686 X 48612500 56898948 169142 181396 48781642 57080344 74724842 81819030 X 8286446 12256 X false true X true false X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED false false false false false false false false true 1853 1853 false Schedule C, Part II-B, Line 1 DETAILED DESCRIPTION OF THE LOBBYING ACTIVITY IU Health White Memorial Hospital paid institutional membership dues to the American Hospital Association ("AHA"), Indiana Hospital Association ("IHA"), and 340B Health during 2023 in the amount of $5,028, $3,748, and $1,679, respectively. Each membership organization notified IU Health White Memorial Hospital that a portion of the dues it paid were used for lobbying purposes. The AHA used 26.47%, or $1,331 of 2023 membership dues paid by IU Health White Memorial Hospital, for lobbying expenditures. The IHA used 10.78%, or $404 of the 2023 membership dues paid by IU Health White Memorial Hospital, for lobbying expenditures. 340B Health used 7.00%, or $118 of the 2023 membership dues paid by IU Health White Memorial Hospital, for lobbying expenditures. The total membership dues paid to these organizations by IU Health White Memorial Hospital during 2023 that were attributable to lobbying expenditures was $1,853. 972779 972779 30277094 10027797 20249297 0 0 0 13025622 8833241 4192381 156634 132643 23991 25438448 Intercompany Payables (Net) 19401271 Due to Third-Party Payers 2779403 Self-Insurance Liabilities 24857 Operating Lease Liabilities 7348 22212879 X Schedule D, Part X, Line 2 FIN 48 (ASC 740) footnote IU HEALTH WHITE MEMORIAL HOSPITAL 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 true false true true 0 1225 519364 0 519364 0.0120 0 3991 8608930 5692690 2916240 0.0673 0 0 0 0 0 0.0 0 5216 9128294 5692690 3435604 0.0793 2 1583 809688 275423 534265 0.0123 1 0 5000 0 5000 0.0001 0 0 0 0 0 0.0 0 0 0 0 0 0.0 1 0 15413 0 15413 0.0004 4 1583 830101 275423 554678 0.0128 4 6799 9958395 5968113 3990282 0.0921 0 0.0 0 0.0 1 0 1893 1893 0.0000 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 1 0 1893 0 1893 0.0000 false 843306 15742609 15575514 167095 X true true 1 1 IU HEALTH WHITE MEMORIAL HOSPITAL 720 SOUTH SIXTH STREET MONTICELLO IN 47960 https://iuhealth.org/find-locations/iu-health-white-memorial-hospital 22-005034-1 X X X X IU HEALTH WHITE MEMORIAL HOSPITAL 1 false false true X 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 0.0 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 White Memorial 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 Health White Memorial Hospital: 1. Access to Healthcare Services 2. Behavioral Health 3. Maternal and Infant Health and Child Well-being 4. Social Determinants of Health Schedule H, Part V, Section B, Line 5 Facility , 1 Facility , 1 - IU Health White Memorial Hospital. In conducting each its most recent CHNA, IU Health White Memorial Hospital took into account input from persons who represent the broad interests of the communities it serves by hosting two community focus groups. 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 White Memorial Hospital The defined community per the most recent CHNA is White County, Indiana, where the hospital resides. White County - Community Meetings IU Health White Memorial Hospital obtained community input through focus groups of community stakeholders, as well as an additional survey issued to stakeholders who were unable to attend the community meetings. Two community meetings were held in 2021 to receive input from stakeholders regarding the health needs in White County - one on April 13 and another on April 19. 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 until each group was able to reach some consensus regarding the priority needs. Preliminary needs identified include a wide array of topics, including teen births, high school graduation, access to exercise opportunities, access to care (primary, dental and mental health) and a lack of social associations and organizations. In addition to these topics, participants focused discussion on child mental health and add Adverse Childhood Experiences (ACEs), child sexual abuse, mental health training, prenatal care, birth control, transportation, substance abuse, accessing care and a lack of knowledge around available resources, health insurance and others. From this process, participants from the April 13 community meeting identified the following needs as most significant for White County: * Mental health, including youth suicide ideation and access to mental health providers * Transportation * Substance abuse * Child abuse and ACEs Participants from the April 16 community meeting identified the following needs as most significant for White County: * Mental health * Substance abuse * Teen births In discussing the impacts of the COVID-19 pandemic on health, participants focused on isolation and its impacts on mental health, impacts on child development and learning, increased substance abuse and a lack of preventive care as people did not go to providers outside of emergencies. An additional community survey was issued to stakeholders unable to attend community meetings, asking them to identify priority needs. Among 19 responses, the following issues were identified as the most significant: * Mental health * Access to healthcare services and resources * Substance abuse * Transportation The survey also asked about the impacts of the COVID-19 pandemic. Issues most often selected as significant impacts include: * Social isolation and loneliness * Poverty * Lack of access to healthcare services * Learning and development impacts among children Community meeting and survey participants Individuals from a wide variety of organizations and communities participated in community meetings and surveys. Participants included representatives from the following organizations: * Bauer Family Resources * City of Monticello * Community Foundation of White County * Four County * Heartford House Child Advocacy Center * IU Health * IU Health Quality Board * IU Health White Memorial Hospital * Indiana Professional Management Group (IPMG) * Mental Health America * Wabash Valley Region * Monticello Fire Department * Monticello Spring Corporation * Monticello-Union Township Public Library * NAMI West Central Indiana * North Central Health Services * North Central Nursing Clinic * North White School Corporation * Purdue Extension White County * Purdue North Central Nursing Clinics * Saving Grace Harm Reduction * Terra Drive Systems * Twin Lakes School Corporation * White County Government * White County Boys and Girls Club * White County Council on Aging * White County Economic Development * White County Health 4 All Coalition * White County Health Department * White County Sheriff's Office Schedule H, Part V, Section B, Line 11 Facility , 1 Facility , 1 - IU Health White Memorial Hospital. Along with the CHNA, IU Health White Memorial Hospital's Board adopted an implementation strategy in April 2022 in response to the 2021 CHNA. IU Health White Memorial Hospital, 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 White Memorial Hospital 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; Behavioral Health; Maternal and Infant Health and Child Well-being; and Social Determinants of Health. Access to Healthcare Services Support Mobile Integrated Health Program (MIH)/Community Paramedicine Program. In 2023, the Mobile Integrated Health/Community Paramedicine Program partnered with other local health organizations for program referrals. 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 77 people at IU Health White Memorial Hospital. Create a pipeline, targeting youth and adults, for future healthcare leaders to access local opportunities. During 2023, IU Health team members visited multiple locations speaking to more than 100 individuals about healthcare career pathways. Provide IU Health Arnett Primary Care Walk-in Clinic in Monticello. IU Health Arnett Primary Care Walk-in Clinic completed 8,018 appointments in 2023. Launch Integrated Social Work Initiative in IU Health clinical settings. Launched Integrated Social Work Initiative in IU Health Obstetric office. Integrated Social Work (ISW) virtually assists providers and patients with urgent complex situations such as abuse and neglect concerns, domestic violence, housing insecurity and social barriers to care. This team of licensed social workers is skilled in assessing and identifying social determinants of health (SDOH), providing resources and making recommendations that are unique to the patient and their circumstances. ISW provides urgent medical social work services through an iPad cart to all primary care and pediatric primary care clinics throughout the system. The SDOH screener PRAPARE was launched via Twistle in 14 primary care clinics in 2023. ISW provides resources and support to patients with urgent needs identified in the screener. There were 864 referrals made to ISW that included patients seen in the West Central Region which includes IU Health White Memorial. This program is funded by IU Health, Inc. but benefits the community served by IU Health White Memorial. Behavioral Health Support community access to strategies to prevent opioid overdose in the community. IU Health team members participate in the White County United Council on Opioids, a local task force that address prevention, treatment and recovery resources in White County. IU Health provided sponsorship and attended the White County Youth Summit where White County youth discussed strategies about substance abuse in White County. Further implement the Virtual Care Peer Recovery Coaching Program (provides patients who have substance use concerns with virtual behavioral health services). The Virtual Peer Recovery Coach program was discontinued in February 2023 as IU Health continues to assess and evolve its behavioral health services based on the needs of patients and the communities it serves. Since 2018, this program had served 15 IU Health and two non-IU Health emergency department patients struggling with substance use disorder through support to aid in recovery. IU Health continues to serve patients with a need for this service through the Virtual Behavioral Health team. Develop hospital and community infrastructure for crisis care to support community members with behavioral health concerns. In 2023, IU Health awarded one community-based organization funding to host #WoW Talk Teen Cafe's to address the youth mental health crisis happening in our region. Further implement emergency department (ED) virtual care program (provides patients virtual access to behavioral health services). Virtual Integrated Behavioral Health (VIBH) expanded behavioral health access to patients and providers across the state. 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 care, and ambulatory care locations. In 2023, there were over 11,000 visits of which 1,942 visits included patients seeking care at IU Health Arnett, Frankfort, and White Memorial emergency departments and IU Health Physicians ambulatory clinics. VIBH also provided brief behavioral health therapy and consultation for medication management to primary care patients aged 18 and older experiencing depression, anxiety, and other mood disorders. A team of behavioral health professionals provided problem solving treatment, cognitive behavioral therapy, and other evidence-based interventions. In 2023, there were over 6,000 visits of which 2,248 were provided to patients seeking help through IU Health Physicians ambulatory clinics. Provide comprehensive suicide prevention through the Zero Suicide Initiative. Following a year of pause, IU Health's Zero Suicide program relaunched under a new model in November 2023. The program is now live in all 92 IU Health Primary Care Practices around the state (including those located in IU Health White Memorial Hospital's defined community), as well as in the Bloomington Emergency Department. After going live, six patients were enrolled in the program by the end of 2023 (2 IU Health Physicians, 2 South Central Region, 2 West Central Region (this region includes IU Health White Memorial Hospital). There were 316,162 patients screened for suicidal ideation, and IU Health team members completed 10,353 trainings on suicide prevention over the course of 2023. Virtual Integrated Behavioral Health (VIBH) expanded behavioral health access to patients and providers across the state. 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 care, and ambulatory care locations. In 2023, there were over 11,000 visits of which 1,093 visits included patients seeking care at IU Health Methodist and Riley emergency departments and IU Health Physicians ambulatory clinics. VIBH also provided brief behavioral health therapy and consultation for medication management to primary care patients aged 18 and older experiencing depression, anxiety, and other mood disorders. A team of behavioral health professionals provided problem solving treatment, cognitive behavioral therapy, and other evidence-based interventions. In 2023, there were over 6,000 visits of which 2,248 were provided to patients seeking help through IU Health Physicians ambulatory clinics. The Virtual Peer Recovery Coach program was discontinued in February 2023 as IU Health continues to assess and evolve its behavioral health services based on the needs of patients and the communities it serves. Since 2018, this program had served 15 IU Health and two non-IU Health emergency department patients struggling with substance use disorder through support to aid in recovery. IU Health continues to serve patients with a need for this service through the Virtual Behavioral Health team. Schedule H, Part V, Section B, Line 11 Facility , 2 Facility , 2 - IU Health White Memorial Hospital (Continued). Maternal and Infant Health and Child Well-being Provide support and expertise to the Fetal Infant Mortality Review Team. The Fetal Infant Mortality Review Team no longer reviews cases from White County. Support the White/Carroll County Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Program. In 2023, the White County WIC Program served approximately 1,186 clients. During World Breastfeeding Week, they hosted an event and distributed educational information and IU Health drawstring bags to approximately 38 people. Provide increased access to local healthcare services. IU Health White Memorial served 449 OBGYN patients in 2023. IU Health supports the White County Mobile Integrated Health program delivered by the Monticello Fire Department. In 2022, the MIH program received additional funding to add a maternal health specialist to their team with their program being named Project Sprout. In 2023, Project Sprout partnered with the White County WIC Program to provide 10 car seat checks, including 3 new seats that were distributed. IU Health provided hot/cold packs for the 30 White County mothers that attended the community baby shower. Distribute Safe Sleep education in the community. Project Sprout offers Safe Sleep education to program participants. Social Determinants of Health Provide fiscal support to organizations addressing social determinants of health. In 2023, the IU Health Community Outreach and Engagement Committee provided funding to Sponsor the White County United Way to support the annual White County Youth Summit. IU Health also was represented by being a facilitator for conversations with the youth. Establish strategic collaborative relationships with local community-based organizations addressing social determinants of health. IU Health has coordinated service projects with local organizations to provide blankets for people in need as well as hosting food donation drives to support the local food pantry. Support career pathway development program. During 2023, IU Health team members visited multiple locations speaking to more than 100 individuals about healthcare career pathways. Support the Bridging the Gap. The Bridging the Gap program was paused due to system level initiatives around language services, but expected to be a priority in 2024. Significant Needs Hospital Will Not Address IU Health White Memorial Hospital 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 WHITE MEMORIAL HOSPITAL. IN ADDITION TO FPG, IU HEALTH WHITE MEMORIAL 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 WHITE MEMORIAL HOSPITAL. IU Health White Memorial 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 WHITE MEMORIAL HOSPITAL. IU Health White Memorial Hospital takes several other measures to broadly 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. 3 IU HEALTH WHITE MEMORIAL HOSPITAL REHABILITATION 720 S 6TH ST MONTICELLO IN 47960 REHABILITATION SERVICES IU HEALTH WHITE MEMORIAL HOSPITAL RADIOLOGY 720 S 6TH ST MONTICELLO IN 47960 RADIOLOGY IU HEALTH WHITE MEMORIAL HOSPITAL LAB 720 S 6TH ST MONTICELLO IN 47960 LAB Schedule H, Part I, Line 6a C.B Report Prepared by a related Org IU Health White Memorial 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. The IU Health Community Benefit Report is made available to the public on IU Health's website at https://iuhealth.org/in-the-community. 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 7c 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 22.98%%. Schedule H, Part I, Line 7f PERCENT OF TOTAL 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 on Line 7, column (f) is $3,604,654. Schedule H, Part II PROMOTION OF HEALTH IN COMMUNITIES SERVED IU Health White Memorial Hospital supports and/or participates in a variety of community-building activities that address the non-medical, root causes of health problems in the communities it serves. IU Health White Memorial Hospital and its related hospital entities across the state of Indiana ("IU Health Statewide System") investments include economic development efforts across the state, workforce development opportunities, collaborate with like-minded organizations through coalitions that address key issues, and advocate for improvements in the health status of vulnerable populations. Some of these activities meet the definition of community benefit and have been reported as such. In 2023, IU Health White Memorial Hospital supported the following community building activities to promote the health of the community: Community Support: IU Health White Memorial Hospital administrators provided five $1,000 scholarships to local high school students totally to $5,000. Coalition Building: IU Health White Memorial Hospital staff provided hospital representation and expertise by participating in the local United Council on Opioids, White County CCB Meeting through FSSA, and the White County HEALTH 4 All Coalition and general community meetings. Schedule H, Part I, Line 7g DESCRIBE SUBSIDIZED HEALTH SERVICE COSTS FROM PHYSICIAN CLINIC IU HEALTH WHITE 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 WHITE MEMORIAL HOSPITAL 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 WHITE MEMORIAL HOSPITAL WILL TREAT THE ADULT AS A DEPENDENT FOR PURPOSES OF THE FPL CALCULATION. IU HEALTH WHITE MEMORIAL HOSPITAL 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 WHITE MEMORIAL HOSPITAL 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 WHITE MEMORIAL HOSPITAL, 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 WHITE MEMORIAL HOSPITAL 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 WHITE MEMORIAL HOSPITAL 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 WHITE MEMORIAL HOSPITAL 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. Schedule H, Part I, Line 7 Bad Debt Expense excluded from financial assistance calculation 3604654 Schedule H, Part III, Line 2 Bad debt expense - methodology used to estimate amount METHODOLOGY USED TO EST. BAD DEBT EXP. THE AMOUNT REPORTED ON LINE 2 AS BAD DEBT 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 White Memorial Hospital 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 White Memorial Hospital 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 White Memorial Hospital 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 WHITE MEMORIAL HOSPITAL DID NOT HAVE A MEDICARE SHORTFALL FOR 2022. IU HEALTH WHITE MEMORIAL 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 WHITE MEMORIAL 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 WHITE MEMORIAL HOSPITAL MEDICARE COST REPORT. "ALLOWABLE COSTS" FOR MEDICARE COST REPORT PURPOSES, HOWEVER, ARE NOT REFLECTIVE OF ALL COSTS ASSOCIATED WITH IU HEALTH WHITE MEMORIAL HOSPITAL'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 WHITE MEMORIAL 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 White Memorial 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 WHITE MEMORIAL 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 WHITE MEMORIAL 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 WHITE MEMORIAL HOSPITAL: Line 16c URL: HTTPS://IUHEALTH.ORG/PAY-A-BILL/FINANCIAL-ASSISTANCE; Schedule H, Part VI, Line 2 Needs assessment Though IU Health White Memorial Hospital believes its CHNA process is comprehensive, the CHNA is done on a triennial basis. Between CHNA cycles, IU Health White Memorial Hospital 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 White Memorial 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 WHITE MEMORIAL HOSPITAL IS LOCATED IN WHITE COUNTY, INDIANA, A COUNTY LOCATED IN CENTRAL NORTHWEST INDIANA. WHITE COUNTY INCLUDES ZIP CODES WITHIN THE TOWNS OF BROOKSTON, BURNETTSVILLE, CHALMERS, MONON, MONTICELLO, REYNOLDS, AND WOLCOTT. BASED ON THE MOST RECENT CENSUS BUREAU (2023) STATISTICS, WHITE COUNTY'S POPULATION IS 24,917. THE COUNTY'S POPULATION ESTIMATES BY RACE ARE 86.3% WHITE, 10.9% HISPANIC OR LATINO, 1.5% BLACK, OR 0.8% AMERICAN INDIAN OR ALASKA NATIVE, 0.7% ASIAN, AND 1.5% PERSONS REPORTING TWO OR MORE RACES. WHITE COUNTY HAS MODEST LEVELS OF EDUCATIONAL ATTAINMENT. AMONG RESIDENTS AGES 25 AND UP, 90.3% ENDED THEIR FORMAL EDUCATION WITH A HIGH SCHOOL DIPLOMA OR EQUIVALENT. AMONG RESIDENTS AGES 25 AND UP, 18.3% EARNED A BACHELOR'S DEGREE OR HIGHER. Schedule H, Part VI, Line 5 Promotion of community health IU Health White Memorial Hospital is a subsidiary of IU Health, a tax-exempt healthcare organization, whose Board of Directors is composed of members, of which the majority are independent community members. IU Health and its related hospital entities across the state of Indiana, including IU Health White Memorial Hospital, extend medical privileges to all physicians who meet the credentialing qualifications necessary for appointments to its medical staff. 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. In addressing the identified community priorities, IU Health White Memorial Hospital has partnered with a number of high quality, engaged community organizations and initiatives to help make health and wellness improvement a reality. As part of its commitment to community health improvement, IU Health White Memorial Hospital team members participated in the White County HEALTH 4 All Coalition, assisting with the application for its own 501c3 delegation. They also actively participated in the United Council on Opioids, with representation on the Prevention, Treatment and Recovery Task Forces. Schedule H, Part VI, Line 6 Affiliated health care system Indiana University Health White Memorial Hospital 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 false true false false false false false true false RUBAN NIRMALAN MD DIRECTOR 0 419330 0 449672 0 810 0 12409 0 54980 0 937200 0 0 WILLIAM Y LI MD DIRECTOR 0 153318 0 11500 0 4322 0 6835 0 21116 0 197090 0 0 MICHELE S SAYSANA MD DIRECTOR 0 517830 0 59736 0 1242 0 6373 0 22890 0 608071 0 0 ERIKA UGIANSKIS MD DIRECTOR 0 520200 0 1540 0 282832 0 13487 0 64987 0 883046 0 0 MARK BUONO MD Director 0 657722 0 39422 0 6364 0 9369 0 64985 0 777861 0 0 CARA L BREIDSTER FORMER OFFICER 0 309825 0 27333 0 2322 0 12229 0 51980 0 403690 0 0 DEREK E EMPIE FORMER OFFICER 0 302110 0 31854 0 1242 0 13200 0 49175 0 397581 0 0 ARTHUR VASQUEZ PRESIDENT (WCR) 0 554742 0 186249 0 1869 0 110400 0 44553 0 897813 0 0 TODD A WILLIAMS CFO/TREASURER (WCR) 0 310667 0 52629 0 2322 0 13200 0 53007 0 431826 0 0 PHILIP LIST SECRETARY (WCR) 0 204758 0 14973 0 3774 0 9193 0 38150 0 270848 0 0 CHRISTOPHER A MANSFIELD MD CMO / COO (Part Year) (WCR) 0 481422 0 83168 0 810 0 13200 0 54953 0 633553 0 0 JEFFREY C ZEH COO (Part Year) (WCR) 0 268217 0 44753 0 171897 0 12526 0 28357 0 525750 0 0 KOREEN C KYHNELL VP - HUMAN RESOURCES (WCR) 0 214757 0 30211 0 3198 0 8010 0 60907 0 317083 0 0 KISHAN PATEL MD VP-Chief Physician Executive (WCR) 0 398968 0 53545 0 810 0 13200 0 54753 0 521276 0 0 ROXANNE WICKLUND CNO (WCR) 0 280215 0 40000 0 3957 0 12998 0 36860 0 374029 0 0 MARY C DREWES FORMER Highest Compensated Employee 0 231836 0 24958 0 1175 0 9118 0 23158 0 290245 0 0 MARY E MINIER COO (Frankfort and White) 223474 0 34529 0 6094 0 8572 0 39768 0 312438 0 0 0 RENEA SMITH CNO (Frankfort and White) 148272 0 26724 0 451 0 0 0 11272 0 186720 0 0 0 DARA WERT SUPERVISOR, HOUSE 109347 8351 2085 149 6147 440 2009 144 32316 2311 151905 11394 0 0 Christopher S Farmer Manager - Pharmacy 141683 0 10719 0 108 0 6392 0 51178 0 210080 0 0 0 Sarah J Quaglio Manager - Infection Prevention Regional 115684 0 10332 0 3038 0 5539 0 43299 0 177892 0 0 0 Schedule J, Part I, Line 3 Arrangement used to establish the top management official's compensation IU HEALTH WHITE MEMORIAL HOSPITAL'S REGIONAL PRESIDENT IS EMPLOYED BY IU HEALTH, INC. IU HEALTH, INC., IU HEALTH WHITE MEMORIAL HOSPITAL, AND OTHER RELATED ENTITIES HAVE A PROCESS IN PLACE TO DETERMINE THE COMPENSATION FOR THE OTHER 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. Schedule J, Part I, Line 4b Supplemental nonqualified retirement plan ARTHUR VASQUEZ PARTICIPATES 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 SERVICE 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. Arthur Vasquez has 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. 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 TALENT MANAGEMENT AND EXECUTIVE COMPENSATION COMMITTEE AND BOARD OF DIRECTORS PRIOR TO ANY INCENTIVE PAYOUT. LINE J - WEB SITE HTTPS://IUHEALTH.ORG/FIND-LOCATIONS/IU-HEALTH-WHITE-MEMORIAL-HOSPITAL Form 990, Part VI, Line 13 SECTION B, LINES 12, 13, 14, AND 16B - POLICIES IU HEALTH WHITE MEMORIAL HOSPITAL IS PART OF THE IU HEALTH SYSTEM. AS THE SOLE MEMBER AND CONTROLLING PARENT OF IU HEALTH WHITE MEMORIAL HOSPITAL, IU HEALTH AND ITS BOARD OF DIRECTORS HAVE MANDATED THAT CERTAIN POLICIES BE FOLLOWED TO ENSURE GREATER STANDARDIZATION THROUGHOUT THE SYSTEM. THUS, IU HEALTH WHITE MEMORIAL 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 15 PROCESS FOR DETERMINING COMPENSATION IU HEALTH WHITE MEMORIAL HOSPITAL'S REGIONAL PRESIDENT IS EMPLOYED BY IU HEALTH, INC. IU HEALTH WHITE MEMORIAL HOSPITAL'S PRESIDENT IS EMPLOYED BY IU HEALTH WHITE MEMORIAL HOSPITAL, INC. IU HEALTH'S PROCESS FOR DETERMINING COMPENSATION IS AS FOLLOWS: (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 SULLIVAN COTTER. 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 WHITE MEMORIAL HOSPITAL AND OTHER RELATED ENTITIES HAVE A PROCESS IN PLACE TO DETERMINE THE COMPENSATION FOR THE OTHER 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 THE SOLE MEMBER OF IU HEALTH WHITE MEMORIAL HOSPITAL, INC. IS INDIANA UNIVERSITY HEALTH, INC. ("IU HEALTH"), A 501(C)(3) TAX-EXEMPT ORGANIZATION. Form 990, Part VI, Line 7a Members or stockholders electing members of governing body THE BOARD OF DIRECTORS OF THE IU HEALTH WHITE MEMORIAL HOSPITAL SHALL CONSIST OF UP TO FOURTEEN (14) VOTING MEMBERS ALL APPOINTED BY IU HEALTH, WHO SHALL INCLUDE UP TO TWO (2) DIRECTORS WHO RESIDE IN WHITE COUNTY AND FOUR (4) PHYSICIAN REPRESENTATIVES FROM THE WEST CENTRAL REGION. THE PHYSICIAN DIRECTORS WILL BE IDENTIFIED THROUGH A NOMINATION PROCESS DEVELOPED BY THE WEST CENTRAL REGION AND SUBMITTED TO IU HEALTH FOR CONSIDERATION AND APPROVAL. Form 990, Part VI, Line 7b Decisions requiring approval by members or stockholders THE FOLLOWING ARE SUBJECT TO IU HEALTH'S APPROVAL: - ANY PROPOSED AMENDMENT TO THE CORPORATION'S ARTICLES OF INCORPORATION OR BYLAWS; - ADOPTION OF THE CORPORATION'S ANNUAL CAPITAL AND OPERATING BUDGETS; - APPROVAL OF ANY UNBUDGETED OPERATING OR CAPITAL BUDGET ITEMS OR DEVIATIONS, INCLUDING ANY ISSUANCE OR GUARANTEE OF ANY UNBUDGETED DEBT; - APPROVAL OF ANY STRATEGIC PLAN FOR THE CORPORATION, INCLUDING ANY AMENDMENTS TO A STRATEGIC PLAN; - APPROVAL OF ANY ENCUMBRANCE, SALE OR CONVEYANCE OF ASSETS; - ANY MERGER, CONSOLIDATION, JOINT VENTURE OR AFFILIATION INVOLVING THE CORPORATION OR ANY OF ITS AFFILIATES AND ANY OTHER ENTITY; - APPOINTMENT AND REMOVAL OF THE CORPORATION'S PRESIDENT AND OTHER OFFICERS; - CONSTRUCTION, ACQUISITION OR LEASE OF HOSPITAL BUILDINGS; - PROJECTS OR CONTRACTS THAT REQUIRE MEMBER APPROVAL IN ACCORDANCE WITH THE MEMBER'S RESOLUTION AND POLICY GOVERNING SYSTEM-WIDE CONTRACT EXECUTION AUTHORITY AND PAYMENT APPROVAL LIMITS; AND - THE DISSOLUTION OF THE CORPORATION OR ANY OF ITS AFFILIATES. Form 990, Part VI, Line 11b Review of form 990 by governing body THE CFO REVIEWED AND APPROVED THE FORM 990. FOLLOWING THE CFO'S REVIEW AND APPROVAL, 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 White Memorial 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 19 Required documents available to the public IU HEALTH WHITE MEMORIAL HOSPITAL ARTICLES OF INCORPORATION ARE AVAILABLE FOR PUBLIC INSPECTION THROUGH THE INDIANA SECRETARY OF STATE'S WEBSITE. IU HEALTH WHITE MEMORIAL HOSPITAL CONFLICT OF INTEREST PROCEDURES ARE DISCLOSED ON THE FORM 990, SCHEDULE O. IU HEALTH WHITE MEMORIAL 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 AS WELL AS IU HEALTH WHITE MEMORIAL HOSPITAL'S FORM 990. Form 990, Part IX, Line 11g Other Fees Intercompany fees - Total Expense: 11197719, Program Service Expense: 10446018, Management and General Expenses: 751701, Fundraising Expenses: ; Contract service - Total Expense: 567635, Program Service Expense: 529530, Management and General Expenses: 38105, Fundraising Expenses: ; Professional fees - Total Expense: 177865, Program Service Expense: 165925, Management and General Expenses: 11940, Fundraising Expenses: ; Consulting - Total Expense: 10646, Program Service Expense: 9931, Management and General Expenses: 715, Fundraising Expenses: ; Other Fees - Total Expense: 69424, Program Service Expense: 64764, Management and General Expenses: 4660, Fundraising Expenses: ; - Total Expense: , Program Service Expense: , Management and General Expenses: , Fundraising Expenses: ; - Total Expense: , Program Service Expense: , Management and General Expenses: , Fundraising Expenses: ; - Total Expense: , Program Service Expense: , Management and General Expenses: , Fundraising Expenses: ; - Total Expense: , Program Service Expense: , Management and General Expenses: , Fundraising Expenses: ; - Total Expense: , Program Service Expense: , Management and General Expenses: , Fundraising Expenses: ; - Total Expense: , Program Service Expense: , Management and General Expenses: , Fundraising Expenses: ; - Total Expense: , Program Service Expense: , Management and General Expenses: , Fundraising Expenses: ; - Total Expense: , Program Service Expense: , Management and General Expenses: , Fundraising Expenses: ; - Total Expense: , Program Service Expense: , Management and General Expenses: , Fundraising Expenses: ; - Total Expense: , Program Service Expense: , Management and General Expenses: , Fundraising Expenses: ; - Total Expense: , Program Service Expense: , Management and General Expenses: , Fundraising Expenses: ; - Total Expense: , Program Service Expense: , Management and General Expenses: , Fundraising Expenses: ; Form 990, Part XI, 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