2026-08-13T17:02:52+00:00 2025-09-30 135565207 KPMG LLP 200 EAST RANDOLPH DRIVE SUITE 5500 CHICAGO IL 606016436 990 2024-10-01 390704510 TRI-COUNTY MEMORIAL HOSPITAL INC TRI- 7155384361 18601 LINCOLN STREET WHITEHALL WI 54773 DANIEL COENEN ADMINISTRATOR 7155384361 2026-08-13 true RILEY KOBRICK P02401884 3126651000 2026-08-12 2024 2025-03-06 01:10:19Z GUNDERSEN TRI-COUNTY HOSPITAL AND CLINICS DANIEL COENEN 18601 LINCOLN STREET WHITEHALL WI 54773 45144967 false X WWW.GUNDERSENHEALTH.ORG/TRI-COUNTY X 1937 WI TOGETHER, WE INSPIRE YOUR BEST LIFE BY RELENTLESSLY CARING, LEARNING AND INNOVATING. 9 4 287 11 0 405533 694212 39327868 44062277 63117 116978 133952 271500 39930470 45144967 0 1181432 0 0 17777085 24703254 0 0 0 18435114 16653195 36212199 42537881 3718271 2607086 67930969 75180360 47005382 51647687 20925587 23532673 TOGETHER, WE INSPIRE YOUR BEST LIFE BY RELENTLESSLY CARING, LEARNING AND INNOVATING. false false 32841944 1181432 43607395 TRI-COUNTY MEMORIAL HOSPITAL, INC. ("TRI-COUNTY") PROVIDES INPATIENT, OUTPATIENT, AND EMERGENCY HEALTH CARE SERVICES AND OTHER FINANCIAL SUPPORT THROUGH VARIOUS PROGRAMS THAT ARE DESIGNED, AMONG OTHER MATTERS, TO ENHANCE THE HEALTH OF THE COMMUNITY INCLUDING THE HEALTH OF LOW INCOME PATIENTS. THE ORGANIZATION OPERATES A CRITICAL ACCESS HOSPITAL AND PROVIDES INPATIENT ACUTE CARE AND SWING BED SERVICES, ALONG WITH AN EMERGENCY DEPARTMENT, WHICH IS OPEN TWENTY-FOUR HOURS PER DAY, AND OTHER OUTPATIENT SERVICES. VISITING SPECIALISTS FROM AN AFFILIATED ORGANIZATION, GUNDERSEN CLINIC, LTD., PERFORM OUTPATIENT GASTROENTEROLOGY, ORTHOPEDIC, AND OPHTHALMIC SURGICAL PROCEDURES AT THE FACILITY AS WELL. TRI-COUNTY ALSO OPERATES AN ASSISTED LIVING FACILITY, THREE RURAL HEALTH CLINICS, AND AN AMBULANCE SERVICE. THE CRITICAL ACCESS HOSPITAL HAD 852 INPATIENT ACUTE DAYS, 54 RESPITE DAYS, 3277 SWING BED DAYS, 660 SURGICAL OPERATIONS, AND 8616 ER VISITS IN THE PERIOD OCTOBER 1 THROUGH SEPTEMBER 30, 2025. CONSISTENT WITH THE MISSION OF TRI-COUNTY, CARE IS PROVIDED TO PATIENTS REGARDLESS OF THEIR ABILITY TO PAY, INCLUDING PROVIDING SERVICES TO THOSE PERSONS WHO ARE EITHER UNDERINSURED OR CANNOT AFFORD HEALTH INSURANCE BECAUSE OF INADEQUATE RESOURCES. HEALTH CARE SERVICES TO PATIENTS UNDER GOVERNMENT PROGRAMS, SUCH AS MEDICAID HOSPITAL SERVICES, ARE ALSO CONSIDERED PART OF TRI-COUNTY'S BENEFIT PROVIDED TO THE COMMUNITY, SINCE A SUBSTANTIAL PORTION OF SUCH SERVICES ARE REIMBURSED AT AMOUNTS LESS THAN THE COSTS OF PROVIDING CARE. PATIENTS WHO MEET CERTAIN CRITERIA FOR CHARITY CARE, GENERALLY BASED ON FEDERAL POVERTY GUIDELINES, ARE PROVIDED CARE AT A SIGNIFICANTLY REDUCED RATE, DETERMINED BASED ON QUALIFYING CRITERIA AS DEFINED IN TRI-COUNTY'S CHARITY CARE POLICY, AND FROM APPLICATIONS COMPLETED BY PATIENTS AND THEIR FAMILIES. THE AMOUNT OF HOSPITAL AND CLINIC CHARGES FOREGONE FOR SERVICES AND SUPPLIES FURNISHED UNDER THIS POLICY DURING 2025 TOTALED $1,181,432. IN ADDITION, DISCOUNTS TO THE MEDICAID PROGRAM FOR HOSPITAL AND CLINIC SERVICES AMOUNTED TO $5,209,289. BENEFITS FOR SERVING THE COMMUNITY ALSO INCLUDE UNPAID COSTS OF TREATING THE ELDERLY, HEALTH SCREENINGS, COMMUNITY EDUCATION THROUGH SEMINARS AND CLASSES, AND OTHER HEALTH-RELATED SERVICES. 539468 454882 TRI-COUNTY ALSO OPERATES AN ASSISTED LIVING FACILITY LOCATED DIRECTLY EAST ACROSS THE STREET OF TRI-COUNTY HOSPITAL. THIS CARE IS PROVIDED TO RESIDENTS IN AN EFFORT BY TRI COUNTY TO PROVIDE A CONTINUUM OF CARE FOR PATIENTS OF THE SURROUNDING COMMUNITIES. SERVICES OFFERED AND PROVIDED TO RESIDENTS INCLUDE ASSISTANCE WITH THE ACTIVITIES OF DAILY LIVING, MEAL PREPARATION, LAUNDRY SERVICES, APARTMENT MAINTENANCE SERVICES, DAILY RECREATIONAL ACTIVITIES, AMONG MANY SERVICE OFFERINGS. RESIDENTS OF THE ASSISTED LIVING FACILITY ALSO HAVE ACCESS TO NURSING STAFF IN THE EVENT OF AN EMERGENCY TWENTY-FOUR HOURS A DAY PROVIDED BY TRI-COUNTY'S NURSING SERVICES STAFF. SOME OF THE RESIDENTS SERVED ARE LOW-INCOME PATIENTS, WHICH ARE SUBSIDIZED THROUGH THE WISCONSIN FAMILY CARE PROGRAM, WHICH OFTEN REIMBURSES TRI-COUNTY AT COST OR BELOW THE TRUE COST OF CARING FOR THESE RESIDENTS. DESPITE RECEIVING REIMBURSEMENT AT AMOUNTS BELOW COST, TRI-COUNTY CONTINUES THIS SERVICE AS IT FURTHERS ITS MISSION IN THE COMMUNITY. 33381412 true true false true false false false false false false true false false false true true false true false false false false false false false false true true false true true true false false false false false false false false false false false false false false false true true false false false true 44 0 true 287 true false false false false false false false false false false false false X 9 4 false true false false true true true true true false false false true true true true true true false false false false WI X DANIEL COENEN 7155384361 18601 LINCOLN STREET WHITEHALL WI 54773 BETH LISOWSKI BOARD OF DIRECTORS, CHAIRMAN (BEG 1.1.25) 2.0 0 X X 0 0 0 DENNIS STEPHENSON BOARD OF DIRECTORS, CHAIRMAN (END 12.31.24) 2.0 0 X X 0 0 0 KATHLEEN KLOCK BOARD OF DIRECTORS, SECRETARY, (END 12.31.24) 2.0 0 X X 0 0 0 MARILU BINTZ MD BOARD OF DIRECTORS, SECRETARY, (BEG 1.1.25) 2.0 0.0 X X 0 261160 38627 RON GUZA BOARD OF DIRECTORS, TREASURER 2.0 0 X X 0 0 0 VICKIE BAKALARS BOD, VICE CHAIRMAN, CLINICAL OPERATIONS DIRECTOR 2.0 48.0 X X 0 157306 49437 KIMBERLY BREIDENBACH BOARD OF DIRECTORS, MD 2.0 48.0 X 0 376827 71967 LAURA KLOSS BOD, CLINICAL OPERATIONS DIRECTOR, (BEG 1.1.25) 2.0 48.0 X 0 156831 50305 MARLYS KOLSTAD BOARD OF DIRECTORS 2.0 0 X 0 0 0 THERESE BINFET BOD, CLINICAL OPERATIONS DIRECTOR 2.0 48.0 X 0 184133 49695 TIM HOLTAN BOARD OF DIRECTORS (BEG 1.1.25) 2.0 0 X 0 0 0 DANIEL COENEN ADMINISTRATOR 28.0 22.0 X 0 165449 47722 JOHN CEELEN CHIEF FINANCIAL OFFICER 1.0 49.0 X 0 728316 54052 KRISTY MILLERING FINANCE ADMINISTRATOR 18.0 32.0 X 0 131354 42400 SCOTT RATHGABER MD CEO 1.0 49.0 X 0 1324275 73275 CARLA SENDELBACH RN, ACUTE HOSPITAL - TRI-COUNTY 36.0 0 X 152457 0 44920 GANESH RAM PA - TRI COUNTY ER 50.0 0 X 203135 0 28563 JASMINE FOLKEDAHL RN, ACUTE HOSPITAL (WEO) - TRI-COUNTY 36.0 0 X 168334 0 40238 KATHLEEN CAIN MANAGER, PHARMACY 50.0 0 X 200688 0 45691 WADE BERTELSEN RN, ACUTE HOSPITAL - TRI-COUNTY 36.0 0 X 156491 0 47347 JONI OLSON ADMINISTRATOR 0.0 0.0 X 0 169390 41223 STEVE LITTLE FORMER CHIEF FINANCIAL OFFICER 0.0 0.0 X 0 209856 0 881105 3864897 725462 31 true true false KRAUS ANDERSON CONSTRUCTION CO 501 SOUTH EIGHTH STREET MINNEAPOLIS MN 55404 CONSTRUCTION SERVICES 4149769 NEI ELECTRIC 4815 WHITE BEAR PARKWAY WHITE BEAR LAKE MN 55110 ELECTRICAL 392493 STAFFENCY 221 W COLLEGE AVE FLOOR 2 APPLETON WI 54911 REHAB PROVIDERS 318357 SHARED MEDICAL TECHNOLOGY INC 202 WEST NEWTON STREET RICE LAKE WI 54868 IMAGING SERVICES 156990 BAND BOX CLEANERS & LAUNDRY PO BOX 299 TOMAH WI 54660 LAUNDRY SERVICE 147402 8 671664 22548 694212 PATIENT SERVICE REVENUE 621400 30092604 30092604 PHARMACY REVENUE 456110 13355932 13355932 ASSISTED LIVING REVENUE 623000 454882 454882 OTHER PROGRAM SERVICES REVENUE 900099 158859 158859 0 0 0 0 44062277 116978 116978 20536 20536 0 20536 20536 0 0 DIETARY 722514 250964 250964 0 0 0 0 250964 45144967 44062277 0 388478 1181432 1181432 19345167 17520977 1824190 1802115 1706743 95372 2473072 2208395 264677 1082900 977353 105547 1174860 22008 1152852 1769 1769 39700 39700 6283 6283 2163286 2040581 122705 0 94854 465 94389 497179 311936 185243 26979 23399 3580 430263 175504 254759 59461 58137 1324 849559 849559 3594417 996236 2598181 96238 96238 MEDICAL SUPPLIES & EQUIPMENT 5613261 5613261 PROVISIONS FOR BAD DEBT 1204106 1204106 REPAIRS AND MAINTENANCE 258395 126243 132152 DIETARY FOOD EXPENSE 243595 239036 4559 298990 179706 119284 0 42537881 33381412 9156469 0 24397 24954 9330550 14637992 7269204 10671388 0 0 645805 765462 64991 63979 59926246 12072341 50193089 47853905 0 0 402933 1162680 67930969 75180360 2341991 3606483 57398 0 38920833 37832292 0 1501973 1449761 4183187 8759151 47005382 51647687 X 20925587 23532673 20925587 23532673 67930969 75180360 2607086 0 X false true true true true X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED false false false false false false false false true 6283 6283 false SCHEDULE C, PART II-B, LINE 1 DETAILED DESCRIPTION OF THE LOBBYING ACTIVITY GUNDERSEN TRI-COUNTY HOSPITAL AND CLINICS (TRI-COUNTY) PAYS ANNUAL ASSOCIATION MEMBERSHIP DUES TO THE AMERICAN HOSPITAL ASSOCIATION (AHA) AND THE WISCONSIN HOSPITAL ASSOCIATION (WHA). THESE DUES ARE PAID PRIMARILY TO ACCESS EDUCATIONAL MATERIALS AND FOR STAFF TRAINING AND MATERIALS. THE AHA AND WHA HAVE NOTIFIED TRI-COUNTY THAT APPROXIMATELY $3,923 OF THE ANNUAL DUES WERE USED IN CONJUNCTION WITH LOBBYING ACTIVITIES WITH THE GOAL OF IMPROVING THE OVERALL HEALTH CARE ENVIRONMENT. TRI-COUNTY IS ALSO A MEMBER OF THE RURAL WISCONSIN HEALTH COOPERATIVE (RWHC). EACH YEAR THE ORGANIZATION PAYS MEMBERSHIP FEES TO THE RWHC. THE RWHC PROVIDES SUPPORT SERVICES FOR A NUMBER OF ITS MEMBER HOSPITALS THROUGHOUT THE STATE OF WISCONSIN. SOME OF THE MANY SERVICES PROVIDED TO MEMBER HOSPITALS INCLUDE PROVIDING ASSISTANCE TO ORGANIZATIONS IN FINDING GRANT FUNDING FOR NEW PROGRAMS, LEGAL SERVICES, REIMBURSEMENT REVIEW SERVICES, ACCOUNTING ASSISTANCE, CONTRACTING FOR THERAPIST COVERAGE, AND ADMINISTRATIVE CONSULTING SERVICES. AS A PART OF THESE SERVICES, RWHC ALSO PROVIDES AN ANALYSIS OF CURRENT HEALTH CARE ISSUES IN AN EFFORT TO PROMOTE AND PROVIDE BETTER HEALTH CARE FOR HOSPITALS IN RURAL COMMUNITIES THROUGHOUT WISCONSIN. ONE OF THESE EFFORTS ALSO INCLUDES A SMALL AMOUNT OF LOBBYING ON THE PART OF THE MEMBER HOSPITALS. THE RWHC DETERMINED THAT APPROXIMATELY $2360 OF THE FEES PAID BY TRI-COUNTY IN FISCAL YEAR 2024 RELATED TO LOBBYING ACTIVITIES WITH THE GOAL OF IMPROVING THE HEALTH CARE ENVIRONMENT IN THE STATE OF WISCONSIN. 380696 380696 49821988 6219030 43602958 9042973 5426304 3616669 680589 427007 253582 47853905 FEDERAL INCOME TAXES DUE TO RELATED PARTY 7691026 OPERATING LEASE OBLIGATIONS 37906 PENSION 1030219 8759151 X 0 0 0 0 0 0 0 0 0 0 0 0 SCHEDULE D, PART X, LINE 2 FIN 48 (ASC 740) FOOTNOTE THE SYSTEM AND MOST OF ITS SUBSIDIARIES ARE CLASSIFIED AS TAX-EXEMPT ORGANIZATIONS AS DESCRIBED IN SECTIONS 501(C)(3) OF THE INTERNAL REVENUE CODE (THE CODE) AND ARE NOT SUBJECT TO FEDERAL AND STATE INCOME TAXES ON RELATED INCOME, PURSUANT TO SECTION 501(A) OF THE CODE. THESE ORGANIZATIONS ARE SUBJECT TO FEDERAL AND STATE INCOME TAXES TO THE EXTENT THEY HAVE UNRELATED BUSINESS INCOME. THE SYSTEM HAS NO MATERIAL UNCERTAIN TAX POSITIONS. CERTAIN SUBSIDIARIES ARE SUBJECT TO FEDERAL AND STATE INCOME TAXES. SOME OF THESE CORPORATIONS HAVE ACCUMULATED NET OPERATING LOSS CARRYFORWARDS THAT ARE AVAILABLE TO OFFSET FUTURE TAXABLE INCOME, IF ANY, AND HAVE BEEN FULLY RESERVED. true true X true X true X true true false true true 625901 625901 0.01514 4487307 3253041 1234266 0.02986 0 0.0 0 0 5113208 3253041 1860167 0.04500 7499 7499 0.00018 0 0.0 787709 454882 332827 0.00805 0 0.0 64302 64302 0.00156 0 0 859510 454882 404628 0.00979 0 0 5972718 3707923 2264795 0.05479 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 8120 8120 0.00020 0 0.0 90 90 0.00000 0 0 8210 0 8210 0.00020 false 638176 319088 10549090 10663118 -114028 X true true 1 1 TRI-COUNTY MEMORIAL HOSPITAL INC 18601 LINCOLN STREET WHITEHALL WI 54773 WWW.GUNDERSENHEALTH.ORG/TRI-COUNTY 1019 X X X X TRI-COUNTY MEMORIAL HOSPITAL INC 1 false false true X X X X X X X X X X 24 true true true true X HTTPS://WWW.GUNDERSENHEALTH.ORG/COMMUNITY-ASSESSMENT/ HTTPS://WWW.GREATRIVERSUNITEDWAY.ORG/OUR-WORK/COMMUNITY-NEEDS-ASSESSMENT/ X true 25 true HTTPS://WWW.GREATRIVERSUNITEDWAY.ORG/OUR-WORK/COMMUNITY-NEEDS-ASSESSMENT/ false true X 200.0 400.0 X X X X X true true X X X true X HTTP://WWW.GUNDERSENHEALTH.ORG/PAY-MY-BILL/FINANCIAL-ASSISTANCE/ X HTTP://WWW.GUNDERSENHEALTH.ORG/PAY-MY-BILL/FINANCIAL-ASSISTANCE/ X HTTP://WWW.GUNDERSENHEALTH.ORG/PAY-MY-BILL/FINANCIAL-ASSISTANCE/ 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 SCHEDULE H, PART V, SECTION B, LINE 3 FACILITY , 1 FACILITY , 1 - TRI-COUNTY MEMORIAL HOSPITAL, INC.:. THE COMMUNITY HEALTH NEEDS ASSESSMENT (CHNA) DOES NOT DIRECTLY DESCRIBE THE EXISTING HEALTH CARE FACILITIES AND RESOURCES WITHIN THE COMMUNITY THAT ARE AVAILABLE TO RESPOND TO THE HEALTH NEEDS OF THE COMMUNITY, AS THE CHNA WAS CONDUCTED IN JOINT EFFORT WITH OTHER HOSPITALS LISTED IN QUESTION 4 BELOW. HOWEVER, GUNDERSEN TRI-COUNTY HOSPITAL AND CLINICS PREPARED AN IMPLEMENTATION STRATEGY, AS AN ADDENDUM TO THE CHNA, WHICH SPECIFICALLY DESCRIBES THE EXISTING HEALTH CARE FACILITIES AND RESOURCES THAT ARE AVAILABLE WITHIN THE COMMUNITY. SCHEDULE H, PART V, SECTION B, LINE 5 FACILITY , 1 FACILITY , 1 - TRI-COUNTY MEMORIAL HOSPITAL, INC.:. DETAILS LISTED ON THE CHNA AVAILABLE AT HTTPS://GUNDERSEN.WIDEN.NET/S/XQLVNJBSD7/TCM-COMMUNITY-HEALTH-IMPROVEMENT-PLAN-2026-2028 SCHEDULE H, PART V, SECTION B, LINE 6A FACILITY , 1 FACILITY , 1 - TRI-COUNTY MEMORIAL HOSPITAL, INC.:. THE CHNA WAS CONDUCTED IN JOINT EFFORT WITH THE FOLLOWING OTHER HOSPITALS: - GUNDERSEN LUTHERAN MEDICAL CENTER - MAYO CLINIC HEALTH SYSTEM - LA CROSSE - MAYO CLINIC HEALTH SYSTEM - SPARTA - TOMAH MEMORIAL HOSPITAL - GUNDERSEN ST. JOSEPH'S HOSPITAL - VERNON MEMORIAL HEALTHCARE SCHEDULE H, PART V, SECTION B, LINE 6B FACILITY , 1 FACILITY , 1 - TRI-COUNTY MEMORIAL HOSPITAL, INC.:. THE COMMUNITY HEALTH NEEDS ASSESSMENT WAS CONDUCTED IN JOINT EFFORT WITH THE FOLLOWING OTHER ORGANIZATIONS: - GREAT RIVERS UNITED WAY - OTTO BREMER FOUNDATION - LA CROSSE COMMUNITY FOUNDATION - LA CROSSE COUNTY HEALTH DEPARTMENT - MONROE COUNTY HEALTH DEPARTMENT - VERNON COUNTY HEALTH DEPARTMENT - TREMPEALEAU COUNTY HEALTH DEPARTMENT - HOUSTON COUNTY PUBLIC HEALTH DEPARTMENT SCHEDULE H, PART V, SECTION B, LINE 11 FACILITY , 1 FACILITY , 1 - TRI-COUNTY MEMORIAL HOSPITAL, INC.:. THE CHNA NOTED AREAS OF NEED IN HEALTH, COMMUNITY, EDUCATION, AND ECONOMICS. HEALTH AREAS INCLUDE CHRONIC DISEASE, MENTAL HEALTH AND/OR SUBSTANCE ABUSE. GTCHC IS ADDRESSING THESE NEEDS BY COLLABORATING WITH SEVERAL LOCAL AGENCIES TO PROMOTE EXERCISE AND NUTRITION, BY COLLABORATING WITH LOCAL SCHOOLS TO ADDRESS YOUTH RESILIENCE AND BULLYING. ADDITIONAL ACTIVITIES DESIGNED TO IMPROVE COMMUNITY HEALTH INCLUDE BLOOD PRESSURE BOOTHS AT COMMUNITY EVENTS, A 5K RUN AND 3K RUN/WALK EVENT, AND THE SMARTEST LOSER PROGRAM. THE CHNA NOTED COMMUNITY NEEDS IN THE AREAS OF ADVERSE CHILDHOOD EXPERIENCES, VIOLENCE, AND ENVIRONMENT. PLANNED ACTIVITIES TO ADDRESS COMMUNITY NEEDS INCLUDE HOSTING A FAMILY FUN NIGHT, PARTICIPATING IN LOCAL PARADES, AND HAVING A BOOTH AT THE DAIRY BREAKFAST. TO ADDRESS THE EDUCATION NEEDS OF ACADEMIC READINESS, YOUTH RESILIENCE, AND WORKFORCE READINESS, GTCHC PLANS TO HOST A HEALTH ACADEMY PROGRAM WITH WHITEHALL SCHOOLS AND A REACH OUT AND READ PROGRAM. GTCHC SUPPORTS THE LOCAL ECONOMY BY SUPPORTING LOCAL FOOD PANTRY'S AND PROVIDING STABLE EMPLOYMENT FOR MANY PEOPLE. THE AREAS OF GREATEST FOCUS FOR THE 2026-2028 PERIOD ARE MENTAL HEALTH, FOOD SECURITY AND NUTRITION, AND GENERAL ACCESS TO CARE. THE AREAS NOT BEING ADDRESS AT THIS TIME ARE: SUBSTANCE ABUSE AND DENTAL HEALTH, HOWEVER, THE HOPE IS WITH GENERAL ACCESS TO CARE, WE WILL BE ABLE TO PROVIDE SUPPORT IN THESE AREAS AS WELL. SCHEDULE H, PART V, SECTION B, LINE 13 FACILITY , 1 FACILITY , 1 - TRI-COUNTY MEMORIAL HOSPITAL, INC.:. A CATASTROPHIC CARE DISCOUNT IS AVAILABLE FOR PATIENTS WITH INCOMES IN EXCESS OF 400% OF THE FEDERAL POVERTY LEVEL, AND ASSETS OF LESS THAN THE EQUIVALENT OF 600% OF THE FEDERAL POVERTY LEVEL, AND FINANCIAL OBLIGATIONS RESULTING FROM MEDICAL SERVICES PROVIDED BY GHS IN EXCESS OF 25% OF THE FAMILY INCOME. SCHEDULE H, PART V, SECTION B, LINE 16 FACILITY , 1 FACILITY , 1 - TRI-COUNTY MEMORIAL HOSPITAL, INC.:. THE FINANCIAL ASSISTANCE POLICY IS POSTED ON THE ORGANIZATION'S WEBSITE AND AT EVERY REGISTRATION POINT THERE IS A POSTER ABOUT PROGRAMS THAT EXIST TO HELP PATIENTS PAY FOR THEIR CARE. ALL PATIENTS WHO HAVE SELF-PAY BALANCES (EITHER UNINSURED OR SELF-PAY AFTER INSURANCE) ARE MADE AWARE OF AVAILABLE ASSISTANCE VIA STATEMENT MESSAGES AND COURTESY NOTICES. PHONE CALLS TO FOLLOW UP WITH PATIENTS ARE ALSO MADE IN CASES WHERE MAIL IS RETURNED AS UNDELIVERABLE. 5 GUNDERSEN TRI-COUNTY WHITEHALL CLINIC 18606 ERVIN STREET WHITEHALL WI 54773 PROVIDER BASED RURAL HEALTH CLINIC GUNDERSEN TRI-COUNTY INDEPENDENCE CLINIC 35791 OSSEO ROAD INDEPENDENCE WI 54747 CLINIC GUNDERSEN TRI-COUNTY BLAIR CLINIC 420 SOUTH PETERSON AVE BLAIR WI 54616 PROVIDER BASED RURAL HEALTH CLINIC EMPLIFY HEALTH MONDOVI CLINIC 250 WI-37 MONDOVI WI 54755 PROVIDER BASED RURAL HEALTH CLINIC SUNRISE SENIOR LIVING 18601 LINCOLN STREET WHITEHALL WI 54773 RESIDENTIAL CARE APARTMENT COMPLEX SCHEDULE H, PART I, LINE 3C CATASTROPHIC CARE ASSISTANCE: FINANCIAL ASSISTANCE PROVIDED TO ELIGIBLE PATIENTS WITH ANNUALIZED FAMILY INCOMES IN EXCESS OF 400% OF THE FEDERAL POVERTY LEVEL, AND ASSETS OF LESS THAN THE EQUIVALENT OF 600% OF THE FEDERAL POVERTY LEVEL, AND FINANCIAL OBLIGATIONS RESULTING FROM MEDICAL SERVICES PROVIDED BY GHS IN EXCESS OF 25% OF THE FAMILY INCOME. DISCOUNTED CARE: FINANCIAL ASSISTANCE THAT PROVIDES A DISCOUNT, FOR ELIGIBLE MEDICAL SERVICES PROVIDED BY GHS, BASED ON A SLIDING SCALE, FOR ELIGIBLE PATIENTS, OR PATIENT GUARANTORS, WITH ANNUALIZED FAMILY INCOMES BETWEEN 200-400% OF THE FEDERAL POVERTY LEVEL AND ASSETS AT OR BELOW SIX TIMES THE FEDERAL POVERTY LEVEL. 1. FAMILY INCOME ABOVE 200% FPL BUT EQUAL TO OR LESS THAN 225% FPL ARE ELIGIBLE TO RECEIVE A 80% DISCOUNT ON THE PATIENT BALANCE DUE. 2. FAMILY INCOME ABOVE 225% FPL BUT EQUAL TO OR LESS THAN 250% FPL ARE ELIGIBLE TO RECEIVE A 60% POLICY DISCOUNT ON THE PATIENT BALANCE DUE. 3. FAMILY INCOME ABOVE 250% FPL BUT EQUAL TO OR LESS THAN 275% FPL ARE ELIGIBLE TO RECEIVE A 40% DISCOUNT ON THE PATIENT BALANCE DUE. 4. FAMILY INCOME ABOVE 275% FPL BUT EQUAL TO OR LESS THAN 400% FPL ARE ELIGIBLE TO RECEIVE A 20% DISCOUNT ON THE PATIENT BALANCE DUE. FREE CARE: A 100% WAIVER OF PATIENT FINANCIAL OBLIGATION FOR ELIGIBLE MEDICAL SERVICES PROVIDED BY GHS FOR ELIGIBLE PATIENTS, OR THEIR GUARANTORS, WITH ANNUALIZED FAMILY INCOMES AT OR BELOW 200% OF THE FPL WITH ASSETS BELOW THE EQUIVALENT OF 600% OF THE FPL. UNINSURED DISCOUNT: PATIENTS WITH NO THIRD-PARTY COVERAGE WILL BE PROVIDED AN UNINSURED DISCOUNT, FOR ELIGIBLE SERVICES PROVIDED BY GHS UNDER THIS POLICY, AT THE TIME THAT THE UNDISCOUNTED CHARGES ARE RENDERED. SERVICES NOT ELIGIBLE FOR FINANCIAL ASSISTANCE INCLUDE THE FOLLOWING: 1. ELECTIVE PROCEDURES NOT MEDICALLY NECESSARY, AS WELL AS SERVICES TYPICALLY, NOT COVERED BY MEDICARE OR DEFINED BY MEDICARE OR OTHER HEALTH INSURANCE COVERAGE AS NOT MEDICALLY NECESSARY. 2. LASIK SURGERY, CHIROPRACTIC CARE, FERTILITY SERVICES, CONTACTS/GLASSES, COSMETIC SURGERY/PLASTIC SERVICES, HEARING AIDS, ORTHODONTICS, DENTAL SERVICES. 3. SERVICES RECEIVED FROM CARE PROVIDERS NOT EMPLOYED BY GHS (E.G. PRIVATE AND/OR NON-GHS MEDICAL OR PHYSICIAN PROFESSIONALS, AMBULANCE TRANSPORT, ETC.). PATIENTS ARE ENCOURAGED TO CONTACT THESE PROVIDERS DIRECTLY TO INQUIRE INTO ANY AVAILABLE ASSISTANCE AND TO MAKE PAYMENT ARRANGEMENTS. SEE APPENDIX 3 FOR FULL LISTING OF PROVIDERS NOT COVERED UNDER THIS POLICY. 4. DEDUCTIBLES AND COINSURANCE ASSOCIATED WITH MEDICALLY NECESSARY SERVICES PROVIDED TO PATIENTS OUT-OF-NETWORK AS DEFINED BY THEIR INSURERS SCHEDULE H, PART I, LINE 7F THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 24(B), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $1,204,106 SCHEDULE H, PART I, LINE 6A COMMUNITY BENEFIT REPORT PREPARED BY RELATED ORGANIZATION TRI-COUNTY PREPARES A COMMUNITY BENEFIT REPORT ANNUALLY AND FILES IT WITH THE WISCONSIN HOSPITAL ASSOCIATION (WHA). THE REPORT IS AVAILABLE TO THE GENERAL PUBLIC ON THE WHA'S WEBSITE. SCHEDULE H, PART I, LINE 7G SUBSIDIZED HEALTH SERVICES SUBSIDIZED HEALTH SERVICES AT GUNDERSEN TRI-COUNTY HOSPITAL AND CLINICS INCLUDE THE SUNRISE ASSISTED LIVING FACILITY. THE ASSISTED LIVING SERVICES ARE OPERATED TO PROVIDE A CONTINUUM OF CARE FOR ELDERLY AND DISABLED PERSONS WHO NEED ADDITIONAL CARE IN BOTH LONG-TERM AND SHORT-TERM PROGRAMS. THE ASSISTED LIVING SERVICES RECEIVE A LARGE PORTION OF THEIR PROGRAM REVENUES FROM GOVERNMENT PAY SOURCES SUCH AS THE WISCONSIN MEDICAID AND FAMILY CARE PROGRAMS, WHICH OFTEN REIMBURSE THE ORGANIZATION AT COSTS WELL BELOW THE COST OF PROVIDING CARE TO THE PATIENTS; HOWEVER, WITHOUT THIS PROGRAM, THESE RESIDENTS WOULD NEED TO TRAVEL TO FACILITIES OUTSIDE OF THEIR COMMUNITY TO FIND THE NEEDED MEDICAL SERVICES. (SEE ALSO PART III, LINES 4B AND 4C, FOR A FURTHER DESCRIPTION OF THE ASSISTED LIVING SERVICES PROVIDED.) SCHEDULE H, PART I, LINE 7 BAD DEBT EXPENSE EXCLUDED FROM FINANCIAL ASSISTANCE CALCULATION 1204106 SCHEDULE H, PART I, LINE 7 COSTING METHODOLOGY USED TO CALCULATE FINANCIAL ASSISTANCE THE COSTING METHOD USED ON FORM 990 IS BASED ON A COST-TO-CHARGE RATIO, WHICH IS DEVELOPED BASED ON THE HOSPITAL'S TOTAL OPERATING EXPENSES LESS THE PROVISION FOR BAD DEBTS DIVIDED BY GROSS PATIENT SERVICE REVENUE. THIS COST-TO-CHARGE RATIO IS APPLIED AGAINST VARIOUS REVENUE AND EXPENSE CATEGORIES TO COMPUTE THE ESTIMATED COMMUNITY BENEFIT EXPENSE UNDER IRS SUGGESTED COSTING METHODS FOR THE FORM 990. SCHEDULE H, PART II COMMUNITY BUILDING ACTIVITIES GUNDERSEN TRI-COUNTY HOSPITAL AND CLINICS SUPPORTS MANY PROGRAMS THAT ARE OFFERED AT NOMINAL CHARGE OR FREE TO THE COMMUNITY AT LARGE. THESE PROGRAMS INCLUDE BUT ARE NOT LIMITED TO AN ANNUAL FITNESS RUN/WALK, SEMI-ANNUAL BLOOD DRIVES, MONTHLY SUPPORT GROUP FOR SUFFERERS OF DYSPHAGIA, AND PERIODIC PRESENTATIONS ON NUTRITION EDUCATION. THE COST TO PROVIDE THESE SERVICES IS OUTLINED IN THE COMMUNITY BENEFITS SCHEDULE. SCHEDULE H, PART III, LINE 2 BAD DEBT EXPENSE - METHODOLOGY USED TO ESTIMATE AMOUNT THE COSTING METHODOLOGY USED ON FORM 990 IS BASED ON A COST-TO-CHARGE RATIO, WHICH IS DEVELOPED BASED ON THE HOSPITAL'S TOTAL OPERATING EXPENSES EXCLUDING THE PROVISION FOR BAD DEBT, DIVIDED BY GROSS PATIENT SERVICE REVENUE. THIS COST-TO-CHARGE RATIO IS APPLIED AGAINST THE TOTAL CHARGES THAT ARE WRITTEN OFF DURING THE YEAR TO ESTIMATE THE COST OF CARE OF PATIENTS WHO HAVE ACCOUNTS THAT ARE DEEMED TO BE BAD DEBTS TO THE HOSPITAL. THE HOSPITAL ALSO RECOGNIZES THAT IT ALSO PROVIDES A DISCOUNT TO SELF-PAY OR UNINSURED PATIENTS. THESE AMOUNTS ARE EXCLUDED FROM GROSS PATIENT SERVICE REVENUE ON THE CONSOLIDATED FINANCIAL STATEMENTS AND ARE NOT INCLUDED IN THE RATIO AS DESCRIBED ABOVE AND APPROVED BY THE IRS FOR USE ON FORM 990. IF CONSIDERED, THESE ADDITIONAL WRITE-OFF AMOUNTS TO UNINSURED ACCOUNTS WOULD ALSO INCREASE THE ESTIMATED BAD DEBT EXPENSE AMOUNT ASSOCIATED WITH THESE UNCOLLECTIBLE ACCOUNTS TO THE HOSPITAL. SCHEDULE H, PART III, LINE 3 BAD DEBT EXPENSE METHODOLOGY MANAGEMENT PROVIDES FOR PROBABLE UNCOLLECTIBLE AMOUNTS, PRIMARILY UNINSURED PATIENTS AND AMOUNTS PATIENTS ARE PERSONALLY RESPONSIBLE FOR, THROUGH A CHARGE TO OPERATIONS AND A CREDIT TO A VALUATION ALLOWANCE BASED ON ITS ASSESSMENT OF HISTORICAL COLLECTION LIKELIHOOD AND THE CURRENT STATUS OF INDIVIDUAL ACCOUNTS. BALANCES THAT ARE STILL OUTSTANDING AFTER THE HOSPITAL HAS USED REASONABLE COLLECTION EFFORTS ARE WRITTEN OFF THROUGH A CHARGE TO THE VALUATION ALLOWANCE AND CREDIT TO ACCOUNTS RECEIVABLE. MANY TIMES PATIENTS DO NOT COMPLETE THE REQUIRED CHARITY CARE APPLICATION AND ARE TRANSFERRED TO COLLECTION SERVICES EVEN THOUGH THE HOSPITAL PROVIDES THIS INFORMATION TO ALL PATIENTS AND ASSISTANCE WITH THE APPLICATIONS. DUE TO NO RESPONSES FROM SOME PATIENTS, A SIGNIFICANT AMOUNT OF BAD DEBTS COULD BE CONSIDERED AS CHARITY CARE. SCHEDULE H, PART III, LINE 4 BAD DEBT EXPENSE - FINANCIAL STATEMENT FOOTNOTE THE ORGANIZATION IS PART OF THE GUNDERSEN HEALTH SYSTEM'S CONSOLIDATED AUDIT IN WHICH THE FOOTNOTE THAT DISCUSSES THE BAD DEBT (IMPLICIT PRICE CONCESSIONS) EXPENSE IS LOCATED IN FOOTNOTE #2, PAGE 9. SCHEDULE H, PART III, LINE 8 COMMUNITY BENEFIT & METHODOLOGY FOR DETERMINING MEDICARE COSTS GUNDERSEN TRI-COUNTY HOSPITAL AND CLINICS IS DESIGNATED A CRITICAL ACCESS HOSPITAL AND, AS SUCH, A PORTION OF ITS MEDICARE REVENUES ARE PAID UNDER A COST REIMBURSEMENT SYSTEM. THE TOTAL MEDICARE REVENUE SHOWN INCLUDES ONLY A PORTION OF THE TOTAL GROSS MEDICARE REVENUE TRI-COUNTY RECEIVES AND DOES NOT CONSIDER ALL OF THE CONTRACTUAL ADJUSTMENTS FOR THE REIMBURSEMENT THAT IS ACTUALLY RECEIVED FROM THE MEDICARE PROGRAM. THE AMOUNTS LISTED FOR MEDICARE REVENUE DO NOT INCLUDE PHYSICIAN SERVICES FOR THE COVERAGE OF THE EMERGENCY DEPARTMENT AT THE HOSPITAL AS WELL AS RADIOLOGIST OR URGENT CARE PROFESSIONAL SERVICES. PHYSICIAN COVERAGE IS REIMBURSED PRIMARILY ON A FEE SCHEDULE REIMBURSEMENT METHOD AT RATES THAT ARE OFTEN BELOW THE COSTS OF CARING FOR PATIENTS. EMERGENCY SERVICES PROVIDED TO MEDICARE PATIENTS ARE VITAL TO THE WELL-BEING OF THE COMMUNITY AND AS SUCH THESE COSTS AND SHORTFALLS SHOULD ALSO BE CONSIDERED AS AN ADDITIONAL BENEFIT THAT TRI-COUNTY PROVIDES TO THE COMMUNITY AND SURROUNDING AREA OF TREMPEALEAU COUNTY, WISCONSIN. THE COSTING METHOD USED ABOVE FOR IRS 990 COMPLIANCE REPORTING IS ALSO BASED ON AN OVERALL AVERAGE COST-TO-CHARGE RATIO AND DOES NOT CONSIDER MEDICARE NON-ALLOWABLE EXPENSES AS IT IS BASED ON TOTAL HOSPITAL PATIENT SERVICE REVENUES (IGNORING CONTRACTUAL ADJUSTMENTS ON FEE SCHEDULE REIMBURSED ITEMS AND NON-ALLOWABLE MEDICARE EXPENSES AS NOTED ABOVE) DIVIDED BY TOTAL OPERATING EXPENSES LESS THE PROVISION FOR BAD DEBT EXPENSE. THIS RATIO IS THEN MULTIPLIED BY THE TOTAL MEDICARE SERVICES, WHICH ARE REIMBURSED ON A COST METHODOLOGY EXCLUDING THE FEE SCHEDULE ITEMS LIKE PHYSICIAN SERVICES, WHICH THE HOSPITAL WOULD SHOW A LARGE LOSS ON THESE SERVICES. WHETHER THERE IS A SHORTFALL OR SURPLUS ON SERVICES PROVIDED TO MEDICARE BENEFICIARIES, THESE PEOPLE, WHO ARE TYPICALLY ELDERLY OR DISABLED MEMBERS OF THE COMMUNITY, ARE AN UNDERSERVED POPULATION WHO EXPERIENCE ISSUES WITH ACCESS TO HEALTH CARE SERVICES. WITHOUT TAX-EXEMPT HOSPITALS PROVIDING MEDICARE PATIENT SERVICES, THE CENTERS FOR MEDICARE AND MEDICAID (CMS) WOULD BEAR THE BURDEN OF DIRECTLY PROVIDING SERVICES TO THE ELDERLY AND DISABLED MEMBERS OF THE COMMUNITY. SCHEDULE H, PART III, LINE 9B COLLECTION PRACTICES FOR PATIENTS ELIGIBLE FOR FINANCIAL ASSISTANCE THE ORGANIZATION FOLLOWS GUNDERSEN HEALTH SYSTEM'S GUIDELINES FOR COLLECTION PRACTICES RELATED TO PATIENTS QUALIFYING FOR CHARITY OR FINANCIAL ASSISTANCE. A PATIENT CAN APPLY FOR CHARITY OR FINANCIAL ASSISTANCE AT ANY TIME DURING THE COLLECTION CYCLE. ONCE QUALIFYING DOCUMENTATION IS RECEIVED THE PATIENT'S ACCOUNT IS ADJUSTED. PATIENT ACCOUNTS FOR THE QUALIFYING PATIENT IN THE PREVIOUS SIX MONTHS MAY ALSO BE CONSIDERED FOR CHARITY OR FINANCIAL ASSISTANCE. ONCE A PATIENT QUALIFIES FOR CHARITY OR FINANCIAL ASSISTANCE, ALL COLLECTION ACTIVITY IS SUSPENDED. SCHEDULE H, PART V, SECTION B, LINE 16A FAP WEBSITE - TRI-COUNTY MEMORIAL HOSPITAL, INC.: LINE 16A URL: HTTP://WWW.GUNDERSENHEALTH.ORG/PAY-MY-BILL/FINANCIAL-ASSISTANCE/; SCHEDULE H, PART V, SECTION B, LINE 16B FAP APPLICATION WEBSITE - TRI-COUNTY MEMORIAL HOSPITAL, INC.: LINE 16B URL: HTTP://WWW.GUNDERSENHEALTH.ORG/PAY-MY-BILL/FINANCIAL-ASSISTANCE/; SCHEDULE H, PART V, SECTION B, LINE 16C FAP PLAIN LANGUAGE SUMMARY WEBSITE - TRI-COUNTY MEMORIAL HOSPITAL, INC.: LINE 16C URL: HTTP://WWW.GUNDERSENHEALTH.ORG/PAY-MY-BILL/FINANCIAL-ASSISTANCE/; SCHEDULE H, PART VI, LINE 2 NEEDS ASSESSMENT IN ADDITION, GUNDERSEN TRI-COUNTY HOSPITAL AND CLINICS MAINTAINS A PATIENT ADVISORY COMMITTEE OF COMMUNITY MEMBERS WHO MEET QUARTERLY, PROVIDE INPUT, AND ARE INVOLVED IN PROPOSED CHANGES TO CERTAIN ASPECTS OF THE ORGANIZATION'S OPERATIONS. THE ORGANIZATION IS ALSO AN ACTIVE MEMBER OF THE COMMUNITY. BY COLLABORATING WITH LOCAL LAW ENFORCEMENT, LOCAL SCHOOL DISTRICTS, AND OTHER ORGANIZATIONS AND PARTICIPATING IN VARIOUS COMMUNITY EVENTS, GUNDERSEN TRI-COUNTY IS ABLE TO REMAIN KNOWLEDGEABLE ABOUT THE COMMUNITY'S HEALTH NEEDS. ADDITIONALLY, MUCH OF GUNDERSEN TRI-COUNTY'S MANAGEMENT PARTICIPATES IN ROUNDTABLES OR OTHER PROFESSIONAL NETWORKING ACTIVITIES IN ORDER TO REMAIN KNOWLEDGEABLE ABOUT CURRENT HEALTHCARE ISSUES. SCHEDULE H, PART VI, LINE 3 PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCE THE FINANCIAL ASSISTANCE POLICY IS POSTED ON THE ORGANIZATION'S WEBSITE AND AT EVERY REGISTRATION POINT THERE IS A POSTER ABOUT PROGRAMS THAT EXIST TO HELP PATIENTS PAY FOR THEIR CARE. ALL PATIENTS WHO HAVE SELF-PAY BALANCES (EITHER UNINSURED OR SELF-PAY AFTER INSURANCE) ARE MADE AWARE OF AVAILABLE ASSISTANCE VIA STATEMENT MESSAGES AND COURTESY NOTICES. PHONE CALLS TO FOLLOW UP WITH PATIENTS ARE ALSO MADE IN CASES WHERE MAIL IS RETURNED AS UNDELIVERABLE. SCHEDULE H, PART VI, LINE 4 COMMUNITY INFORMATION GUNDERSEN TRI-COUNTY HOSPITAL AND CLINICS, A FEDERALLY-DESIGNATED, CRITICAL ACCESS HOSPITAL, ALONG WITH ITS NURSING HOME, ASSISTED LIVING, AND THREE FEDERALLY DESIGNATED RURAL HEALTH CLINICS, SERVES THE CENTRAL AREA OF TREMPEALEAU COUNTY, WISCONSIN, AND PRIMARILY THE ZIP CODES OF WHITEHALL (54773), MONDOVI (54755), AND BLAIR (54616). AS AN AFFILIATE HOSPITAL OF THE GUNDERSEN LUTHERAN HEALTH SYSTEM OF LA CROSSE, WI, TRI-COUNTY ALSO SUPPORTS A GUNDERSEN-CONTRACTED INDUSTRIAL IN-PLANT EMPLOYEE AND DEPENDENTS PRIMARY CARE MEDICAL CLINIC IN NEARBY ARCADIA, AS WELL AS FEDERALLY DESIGNATED SKILLED NURSING FACILITY/NURSING FACILITIES IN WHITEHALL, PIGEON FALLS, AND BLAIR. TREMPEALEAU COUNTY IS SERVED BY TWO HOSPITALS, INCLUDING TRI-COUNTY IN WHITEHALL AND MAYO CLINIC HEALTH SYSTEM OAKRIDGE HOSPITAL IN OSSEO. THE PRIMARY CORE PART OF THIS SERVICE AREA CONTAINS A U.S. HEALTH AND HUMAN SERVICES (HHS) PRIMARY CARE HEALTH PROFESSIONAL SHORTAGE AREA (HPSA) OF THE GEOGRAPHICAL AREA TYPE, THE "CENTRAL TREMPEALEAU SERVICE AREA," COMPRISED OF CHIMNEY ROCK TOWNSHIP (RUSSELL, WI); BURNSIDE TOWNSHIP (INDEPENDENCE, WI); LINCOLN TOWNSHIP (WHITEHALL, WI); PIGEON TOWNSHIP (PIGEON FALLS, WI); AND PRESTON TOWNSHIP (BLAIR, WI). THIS PRIMARY CARE HPSA IS FLANKED ON THE EAST, NORTHEAST, AND SOUTH BY SIMILAR PRIMARY CARE GEOGRAPHIC AREA HPSAS FOR MONDOVI (NORTHERN HALF OF BUFFALO COUNTY), AUGUSTA/OSSEO SERVICE AREA (PARTS OF TREMPEALEAU, EAU CLAIRE, AND JACKSON COUNTIES), AND GALESVILLE/TREMPEALEAU (SOUTHERN HALF OF TREMPEALEAU COUNTY), RESPECTIVELY. TRI-COUNTY SERVES PATIENTS FROM ALL OF THESE AREAS. SCHEDULE H, PART VI, LINE 5 PROMOTION OF COMMUNITY HEALTH A NUMBER OF MEMBERS OF TRI-COUNTY'S GOVERNING BODY IS COMPRISED OF PERSONS WHO RESIDE IN THE ORGANIZATION'S PRIMARY SERVICE AREA WHO ARE NEITHER EMPLOYEES NOR CONTRACTORS OF THE ORGANIZATION, NOR FAMILY MEMBERS THEREOF. THE ORGANIZATION EXTENDS MEDICAL STAFF PRIVILEGES TO ALL QUALIFIED PHYSICIANS IN ITS COMMUNITY FOR SOME OR ALL OF ITS DEPARTMENTS TO BETTER MEET THE DEMANDS AND REQUESTS OF PATIENTS. TRI-COUNTY PROVIDES SIGNIFICANT CHARITY CARE AND OTHER COMMUNITY BENEFITS AS DEFINED BY THE IRS AND IN ADDITION, TRI-COUNTY BELIEVES THAT IT PROVIDES A CRITICALLY IMPORTANT COMMUNITY BENEFIT WHICH IS NOT QUANTIFIED. TRI-COUNTY, LIKE MOST RURAL HOSPITALS, WAS CREATED AND IS MAINTAINED IN ORDER TO PROVIDE CARE LOCALLY WHICH WITHOUT THE HOSPITAL WOULD NOT BE AVAILABLE LOCALLY. BEYOND INPATIENT HOSPITALIZATIONS, THE HOSPITAL PROVIDES LOCAL ACCESS TO MANY HEALTH SERVICES INCLUDING: PRIMARY HEALTH CARE AND DIAGNOSIS, DIAGNOSTIC RADIOLOGY, EMERGENCY SERVICES, URGENT CARE, SKILLED NURSING, INFUSION SERVICES, SWING BED SERVICES, LABORATORY SERVICES, REHABILITATION SERVICES, SPECIALTY MEDICINE, SPEECH PATHOLOGY, SURGICAL SERVICES, WOMEN'S SERVICES, AND ASSISTED LIVING SERVICES, TO NAME SOME OF THE MAJOR SERVICES PROVIDED. SCHEDULE H, PART VI, LINE 6 AFFILIATED HEALTH CARE SYSTEM THE ORGANIZATION IS A PART OF EMPLIFY HEALTH WHICH IS THE COMBINATION OF GUNDERSEN HEALTH AND BELLIN HEALTH SYSTEMS. IT IS A NOT-FOR-PROFIT ORGANIZATION DEDICATED TO ENHANCING THE PHYSICAL AND EMOTIONAL WELL-BEING OF INDIVIDUALS IN. IN COLLABORATION WITH COMMUNITIES, EMPLOYERS, SCHOOLS, AND GOVERNMENT OFFICIALS, WE SUPPORT INDIVIDUALS AND FAMILIES ON THEIR LIFELONG JOURNEY TOWARD OPTIMAL HEALTH. OUR COMMITMENT LIES IN DELIVERING SAFE, RELIABLE, AND COST-EFFECTIVE COMPREHENSIVE HEALTH SOLUTIONS, ALL WHILE UPHOLDING THE VALUES OF RESPECT AND COMPASSION. THROUGH OUR INNOVATIVE INITIATIVES, WE AIM TO TRANSFORM HEALTHCARE DELIVERY NOT ONLY IN OUR REGION BUT ALSO ON A GLOBAL SCALE. SCHEDULE H, PART VI, LINE 7 STATE FILING OF COMMUNITY BENEFIT REPORT WI true CHARITY CARE 736 1181432 COST SCHEDULE I, PART I, LINE 2 PROCEDURES FOR MONITORING USE OF GRANT FUNDS WHEN A PATIENT HAS INDICATED OR DEMONSTRATED AN "INABILITY TO PAY", A TRI-COUNTY MEMORIAL HOSPITAL REVENUE CYCLE REPRESENTATIVE WILL PROVIDE THE PATIENT WITH A FINANCIAL HARDSHIP APPLICATION (FHA) AND EXPLICIT INSTRUCTIONS FOR ITS COMPLETION ALONG WITH A REQUEST FOR ANY DOCUMENTS NECESSARY TO VERIFY POTENTIAL PATIENT ASSETS AND LIABILITIES. AFTER RECEIPT OF THE PACKET IT IS THEN REVIEWED AS COMPILED AND PUT ONTO A SLIDING POVERTY DETERMINATION SCALE. AN ANNUAL COMPLIANCE AUDIT IS COMPLETED TO ENSURE ALL POLICY STANDARDS ARE BEING FOLLOWED. false true false false false false false false false MARILU BINTZ MD BOARD OF DIRECTORS, SECRETARY, (BEG 1.1.25) 0 109201 0 100000 0 51959 0 36295 0 2332 0 299787 0 0 VICKIE BAKALARS BOD, VICE CHAIRMAN, CLINICAL OPERATIONS DIRECTOR 0 155710 0 0 0 1596 0 22779 0 26658 0 206743 0 0 THERESE BINFET BOD, CLINICAL OPERATIONS DIRECTOR 0 181921 0 0 0 2212 0 26028 0 23667 0 233828 0 0 KIMBERLY BREIDENBACH BOARD OF DIRECTORS, MD 0 345356 0 27000 0 4471 0 48300 0 23667 0 448794 0 0 LAURA KLOSS BOD, CLINICAL OPERATIONS DIRECTOR, (BEG 1.1.25) 0 149379 0 0 0 7452 0 23341 0 26964 0 207136 0 0 STEVE LITTLE FORMER CHIEF FINANCIAL OFFICER 0 209856 0 0 0 0 0 0 0 0 0 209856 0 0 JOHN CEELEN CHIEF FINANCIAL OFFICER 0 598104 0 129468 0 744 0 29147 0 24905 0 782368 0 0 SCOTT RATHGABER MD CEO 0 1278368 0 0 0 45907 0 48300 0 24975 0 1397550 0 0 DANIEL COENEN ADMINISTRATOR 0 133985 0 0 0 31464 0 23568 0 24154 0 213171 0 0 KRISTY MILLERING FINANCE ADMINISTRATOR 0 130279 0 0 0 1075 0 18798 0 23602 0 173754 0 0 WADE BERTELSEN RN, ACUTE HOSPITAL - TRI-COUNTY 150318 0 4579 0 1594 0 22559 0 24788 0 203838 0 0 0 KATHLEEN CAIN MANAGER, PHARMACY 195436 0 4858 0 394 0 27921 0 17770 0 246379 0 0 0 JASMINE FOLKEDAHL RN, ACUTE HOSPITAL (WEO) - TRI-COUNTY 163312 0 4906 0 116 0 23737 0 16501 0 208572 0 0 0 GANESH RAM PA - TRI COUNTY ER 201636 0 0 0 1499 0 28229 0 334 0 231698 0 0 0 CARLA SENDELBACH RN, ACUTE HOSPITAL - TRI-COUNTY 142636 0 5912 0 3909 0 21730 0 23190 0 197377 0 0 0 JONI OLSON ADMINISTRATOR 0 165292 0 0 0 4098 0 23561 0 17662 0 210613 0 0 SCHEDULE J, PART I, LINE 3 ARRANGEMENT USED TO ESTABLISH THE TOP MANAGEMENT OFFICIAL'S COMPENSATION A RELATED ORGANIZATION OF THE FILING ORGANIZATION USES ONE OR MORE OF THE FOLLOWING TO ESTABLISH THE COMPENSATION OF THE ORGANIZATION'S TOP MANAGEMENT OFFICIAL: -COMPENSATION COMMITTEE -INDEPENDENT COMPENSATION CONSULTANT -COMPENSATION SURVEY OR STUDY, AND -APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE PLEASE REFER TO THE FORM 990, PART VI, LINE 15A DISCLOSURE IN SCHEDULE O FOR ADDITIONAL DETAILS ON HOW COMPENSATION OF THE ORGANIZATION'S TOP MANAGEMENT OFFICIAL IS ESTABLISHED. SCHEDULE J, PART I, LINE 4B SUPPLEMENTAL NONQUALIFIED RETIREMENT PLAN CERTAIN INDIVIDUALS LISTED IN SCHEDULE J, PART II, PARTICIPATE IN A SUPPLEMENTAL NON-QUALIFIED RETIREMENT PLAN TO WHICH THE ORGANIZATION MAKES ANNUAL CONTRIBUTIONS. THESE CONTRIBUTIONS ARE AT RISK AND DO NOT BECOME VESTED AND PAYABLE UNLESS AND UNTIL THE INDIVIDUAL SATISFIES A SUBSTANTIAL FUTUTE SERVICE REQUIREMENT. THE FOLLOWING INDIVIDUALS HAD CONTRIBUTIONS MADE TO THE PLAN FOR CALENDAR YEAR 2024: JOHN CEELEN A WISCONSIN HEALTH AND EDUCATIONAL FACILITIES AUTHORITY 391337855 2022-02-02 40000000 (SEE STATEMENT) false false false A 1079167 40000000 1613870 38386130 2024 false false true true A false false true true false false 0 0 0.0 false false 0 false true A false true false false false false 0 false false false 0 false false true A true SCHEDULE K, PART I, COLUMN (F) PROCEEDS OF THE BONDS WERE USED TO FINANCE (I) THE ACQUISITION, CONSTRUCTION, RENOVATION, REMODELING AND EQUIPPING OF CERTAIN HOSPITAL, MEDICAL CLINIC, ADMINISTRATIVE AND RELATED HEALTH CARE FACILITIES OF THE CORPORATION, INCLUDING CONSTRUCTION OF A 68,000 SQUARE FOOT REPLACEMENT HOSPITAL AND RENOVATION OF AN EXISTING MEDICAL CLINIC AND (II) CAPITALIZED INTEREST RELATING THERETO. FORM 990, PART VI, LINE 15A COMPENSATION IS DETERMINED BY A RELATED ORGANIZATION. COMPENSATION FOR THE CEO AND KEY EXECUTIVES ARE SET BY THE EXECUTIVE COMMITTEE OF THE BOARD SUPPORTED BY MARKET DATA FROM SURVEYS AND AN INDEPENDENT CONSULTANTS REPORT. THE COMPENSATION IS DETERMINED BY MEMBERS OF THE EXECUTIVE COMMITTEE WITHOUT CONFLICT AND IS DOCUMENTED. CEO COMPENSATION: CEO PRESENTS RESULTS OF PERFORMANCE OBJECTIVES TO THE EXECUTIVE COMMITTEE IN JANUARY OF EACH YEAR. THE CHAIR APPLIES A FORMULA TO THE RESULTS AND COMES UP WITH A RECOMMENDATION. THE CHAIR FACILITIES GETTING APPROVAL FROM OTHER MEMBERS OF THE EXECUTIVE COMMITTEE. FORM 990, PART VI, LINE 15B SENIOR LEADERS: COMPENSATION IS DETERMINED BY A RELATED ORGANIZATION. COMPENSATION FOR THOSE WHO REPORT TO THE CEO IS TAKEN TO THE EXECUTIVE COMMITTEE FOR DISCUSSION/APPROVAL. FORM 990, PART VI, LINE 3 DELEGATION OF MANAGEMENT DUTIES AS AN AFFILIATE OF GUNDERSEN LUTHERAN HEALTH SYSTEM, INC., TRI-COUNTY WILL ROUTINELY DELEGATE VARIOUS MANAGEMENT OR SUPPORT FUNCTIONS TO RELATED ENTITIES. FOR EXAMPLE, THE CEO AND CFO OF TRI-COUNTY ARE EMPLOYED BY THE HOME OFFICE OF THE PARENT ORGANIZATION, GUNDERSEN LUTHERAN HEALTH SYSTEM, INC. SEVERAL MEMBERS OF THE BOARD OF DIRECTORS ARE ALSO EMPLOYEES OF GUNDERSEN LUTHERAN HEALTH SYSTEM, INC. AND ITS AFFILIATED ORGANIZATIONS, WHICH ARE ALSO TAX-EXEMPT ORGANIZATIONS. FORM 990, PART VI, LINE 6 CLASSES OF MEMBERS OR STOCKHOLDERS THE ARTICLES OF INCORPORATION OF TRI-COUNTY PROVIDE FOR TWO CLASSES OF MEMBERSHIP IN THE CORPORATION. THE FIRST CLASS OF MEMBERSHIP IS A CORPORATE MEMBER CLASS, AND THE SOLE MEMBER OF THIS CLASS IS GUNDERSEN LUTHERAN HEALTH SYSTEM, INC. THE SECOND CLASS OF MEMBERSHIP IS A PUBLIC MEMBERSHIP, WHICH IS MADE UP OF PERSONS OVER THE AGE OF 18 WHO ARE INTERESTED IN PROMOTING AIMS, PURPOSES, AND WELFARE OF TRI-COUNTY. FORM 990, PART VI, LINE 7A MEMBERS OR STOCKHOLDERS ELECTING MEMBERS OF GOVERNING BODY THE ARTICLES OF INCORPORATION OF TRI-COUNTY PROVIDE FOR TWO CLASSES OF MEMBERSHIP. ONE CLASS IS HELD BY A SOLE MEMBER, GUNDERSEN LUTHERAN HEALTH SYSTEM, INC., WHICH MAY APPOINT SEVEN OF THE TWELVE MEMBERS OF THE BOARD OF DIRECTORS. GUNDERSEN ALSO HAS THE RESERVE RIGHT TO APPROVE OR DISAPPROVE OF THE OTHER FIVE MEMBERS OF THE BOARD OF DIRECTORS. FORM 990, PART VI, LINE 7B DECISIONS REQUIRING APPROVAL BY MEMBERS OR STOCKHOLDERS APPROVAL OF TRI-COUNTY'S OPERATING BUDGET AND PLAN, CAPITAL EXPENDITURES GREATER THAN $10,000, ADDITIONAL INDEBTEDNESS OVER $10,000, DISAFFILIATION, AND AMENDMENTS OR CHANGES TO THE ARTICLES OF INCORPORATION AND BYLAWS IS SUBJECT TO APPROVAL BY THE BOARD OF DIRECTORS OF ITS MEMBER, GUNDERSEN LUTHERAN HEALTH SYSTEM, INC. FORM 990, PART VI, LINE 11B REVIEW OF FORM 990 BY GOVERNING BODY THE FORM 990 IS REVIEWED BY THE ACCOUNTING MANAGER AND PRINCIPAL OFFICER. IT WILL BE MADE AVAILABLE FOR ALL BOARD MEMBERS BEFORE FILING. FORM 990, PART VI, LINE 12C CONFLICT OF INTEREST POLICY GUNDERSEN LUTHERAN ADMINISTRATIVE SERVICES, INC. (GLAS) ANNUALLY REQUIRES EXECUTIVE LEADERSHIP (VICE PRESIDENTS AND ABOVE), BOARD MEMBERS, MEDICAL GOVERNORS AND FOUNDATION BOARD MEMBERS TO COMPLETE A CONFLICT OF INTEREST DISCLOSURE STATEMENT. COMPLETED DISCLOSURE STATEMENTS ARE REVIEWED BY A CONFLICT OF INTEREST REVIEW PANEL WHICH INCLUDES REPRESENTATIVES FROM LEGAL, COMPLIANCE, MEDICAL LEADERSHIP, HUMAN RESOURCES AND SUPPLY CHAIN. INDIVIDUALS REPORTING A POTENTIAL CONFLICT OF INTEREST ARE SENT A RESOLUTION THANKING THEM FOR THEIR SERVICE TO THE ORGANIZATION, ADVISING THEM OF ANY RESTRICTIONS RELATED TO THEIR CONFLICT (I.E. INDIVIDUALS WITH A RELATIONSHIP TO ANOTHER ORGANIZATION ARE ADVISED THAT THEY MUST ABSTAIN FROM DECISION MAKING THAT WOULD DIRECTLY AND SOLELY IMPACT GLAS) AND REMINDING THEM OF THEIR CONFIDENTIALITY OBLIGATIONS WITH RESPECT TO GLAS' HEALTHCARE, EMPLOYMENT AND PROPRIETARY INFORMATION. FORM 990, PART VI, LINE 19 REQUIRED DOCUMENTS AVAILABLE TO THE PUBLIC TRI-COUNTY MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST AT ITS BUSINESS LOCATION DURING NORMAL BUSINESS HOURS. FORM 990, PART VIII, LINE 2F OTHER PROGRAM SERVICE REVENUE - TOTAL REVENUE: , RELATED OR EXEMPT FUNCTION REVENUE: , UNRELATED BUSINESS REVENUE: , REVENUE EXCLUDED FROM TAX UNDER SECTIONS 512, 513, OR 514: ; BELLIN GUNDERSEN HEALTH SYSTEM INC 1836 SOUTH AVENUE LA CROSSE WI 54601 920504278 SUPPORT ORG WI 501(C)(3) TYPE III-FI NA false GUNDERSEN LUTHERAN HEALTH SYSTEM INC 1836 SOUTH AVE LA CROSSE WI 54601 391866425 SUPPORT ORG WI 501(C)(3) TYPE II BGHS false GUNDERSEN LUTHERAN MEDICAL CENTER INC 1910 SOUTH AVE LA CROSSE WI 54601 390813416 HEALTHCARE WI 501(C)(3) 3 GLHS false GUNDERSEN CLINIC LTD 1836 SOUTH AVENUE LA CROSSE WI 54601 391028657 HEALTHCARE WI 501(C)(3) 3 GLHS false GUNDERSEN LUTHERAN ADMINISTRATIVE SERVICES INC 1910 SOUTH AVE LA CROSSE WI 54601 391606449 SUPPORT ORG WI 501(C)(3) TYPE II GLHS false GUNDERSEN LUTHERAN MEDICAL FOUNDATION INC 1836 SOUTH AVENUE LA CROSSE WI 54601 391249705 FOUNDATION WI 501(C)(3) 7 GLHS false HARMONY COUMMUNITY HEALTHCARE INC 815 MAIN AVE SOUTH HARMONY MN 55939 410711606 HEALTHCARE MN 501(C)(3) 10 GLHS false TWEETEN LUTHERAN HEALTHCARE CENTER INC 125 FIFTH AVE SE SPRING GROVE MN 55974 411565003 HEALTHCARE MN 501(C)(3) 10 GLHS false TRI STATE AMBULANCE INC 235 CAUSEWAY BOULEVARD LA CROSSE WI 54603 391965415 MEDICAL TRANSPORT WI 501(C)(3) 3 GLHS false TRI-STATE REGIONAL AMBULANCE INC 235 CAUSEWAY BOULEVARD LA CROSSE WI 54603 391962965 MEDICAL TRANSPORT WI 501(C)(3) 10 GLHS false LUTHERAN REAL ESTATE HOLDING CORPORATION 1910 SOUTH AVENUE LA CROSSE WI 54601 391480826 HOUSING WI 501(C)(3) TYPE III-FI GLHS false COMMUNITY HOUSING OF LA CROSSE INC 1900 SOUTH AVENUE LA CROSSE WI 54601 391586700 INDEPENDENT LIVING WI 501(C)(3) 10 LREH CORP false LUTHERAN HOUSING OF LA CROSSE INC 1900 SOUTH AVENUE LA CROSSE WI 54601 391751934 INDEPENDENT LIVING WI 501(C)(3) 10 LREH CORP false ST JOSEPH'S HEALTH SERVICES INC 400 WATER AVE HILLSBORO WI 54634 390929538 HEALTHCARE WI 501(C)(3) 3 GLHS false ST JOSEPH MEMORIAL FOUNDATION INC 400 WATER AVE HILLSBORO WI 54634 391455787 FOUNDATION WI 501(C)(3) TYPE I STJ HLTH SVC false TRI-COUNTY MEMORIAL FOUNDATION INC 18601 LINCOLN STREET WHITEHALL WI 54773 300093022 FOUNDATION WI 501(C)(3) TYPE I TCH true MEMORIAL HOSPITAL OF BOSCOBEL 205 PARKER STREET BOSCOBEL WI 53805 390845590 HEALTHCARE WI 501(C)(3) 3 GLHS false PALMER LUTHERAN HEALTH CENTER INC 112 JEFFERSON STREET WEST UNION IA 52175 421320763 HEALTHCARE IA 501(C)(3) 3 GLHS false MOUNDVIEW MEMORIAL HOSPITALS AND CLINICS 402 WEST LAKE STREET FRIENDSHIP WI 53934 390944012 HEALTHCARE WI 501(C)(3) 3 GLHS false MEMORIAL HEALTHCARE FOUNDATION INC 402 WEST LAKE STREET FRIENDSHIP WI 53934 391775074 FOUNDATION WI 501(C)(3) TYPE I MDV HOSP false SAINT ELIZABETH'S HOSPITAL OF WABASHA INC 1200 FIFTH GRANT BLVD WEST WABASHA MN 55981 410693877 HEALTHCARE MN 501(C)(3) 3 GLHS false BELLIN HEALTH SYSTEMS INC 744 SOUTH WEBSTER AVE GREEN BAY WI 54301 391512904 SUPPORT ORG WI 501(C)(3) TYPE II BGHS false LAKE MICHIGAN HEALTH SERVICES INC 744 SOUTH WEBSTER AVE GREEN BAY WI 54301 391512903 SUPPORT ORG WI 501(C)(3) TYPE II BHS false BELLIN COLLEGE INC 3201 EATON ROAD GREEN BAY WI 54311 391620530 EDUCATION WI 501(C)(3) 2 BHS false BELLIN PSYCHIATRIC CENTER INC PO BOX 23725 GREEN BAY WI 54301 391657627 HEALTHCARE WI 501(C)(3) 3 BHS false BELLIN MEMORIAL HOSPITAL INC 744 SOUTH WEBSTER AVE GREEN BAY WI 54301 390884478 HEALTHCARE WI 501(C)(3) 3 BHS false THE BELLIN HEALTH FOUNDATION INC PO BOX 23400 GREEN BAY WI 54301 391809171 FOUNDATION WI 501(C)(3) 7 BHS false OCONTO HOSPITAL & MEDICAL CENTER INC 820 ARBUTUS AVENUE OCONTO WI 54153 061745397 HEALTHCARE WI 501(C)(3) 3 BMH false GUNDERSEN EDGE LLC 921783811 OTHER WI NA C CORPORATION false BEL-REGIONAL HOME MEDICAL INC 617 S ROOSEVELT GREEN BAY WI 54301 391504766 DURABLE MEDICAL EQUIPMENT, RETAIL PHARMACY, FITNESS WI NA C CORPORATION false GUNDERSEN ENVISION LLC 1836 SOUTH AVENUE LA CROSSE WI 54601 264706546 RENEWABLE ENERGY WI NA C CORPORATION false BG ASSURANCE COMPANY 20 GENESIS CLOSE PO BOX 30600 GEORGE TOWN GRAND CAYMAN CJ KY11203 SELF INSURANCE CJ NA C CORPORATION false false false false false false false false false false true false false true true true true true false false