Instrumentl eFile Render
Object ID: 202213149349300946 - Rendered 2025-01-24
TIN: 38-3952644
SCHEDULE H
(Form 990)
Department of the Treasury
Internal Revenue Service
Hospitals
Complete if the organization answered "Yes" on Form 990, Part IV, question 20.
Attach to Form 990.
Go to
www.irs.gov/Form990EZ
for instructions and the latest information.
OMB No. 1545-0047
20
21
Open to Public Inspection
Name of the organization
MAYO CLINIC GROUP RETURN
Employer identification number
38-3952644
Part I
Financial Assistance and Certain Other Community Benefits at Cost
Yes
No
1a
Did the organization have a financial assistance policy during the tax year? If "No," skip to question 6a
.
.
.
.
1a
Yes
b
If "Yes," was it a written policy?
......................
1b
Yes
2
If the organization had multiple hospital facilities, indicate which of the following best describes application of the financial assistance policy to its various hospital facilities during the tax year.
Applied uniformly to all hospital facilities
Applied uniformly to most hospital facilities
Generally tailored to individual hospital facilities
3
Answer the following based on the financial assistance eligibility criteria that applied to the largest number of the organization's patients during the tax year.
a
Did the organization use Federal Poverty Guidelines
(FPG)
as a factor in determining eligibility for providing
free
care?
If "Yes," indicate which of the following was the FPG family income limit for eligibility for free care:
3a
Yes
100%
150%
200%
Other
%
b
Did the organization use FPG as a factor in determining eligibility for providing
discounted
care? If "Yes," indicate
which of the following was the family income limit for eligibility for discounted care:
.
.
.
.
.
.
.
.
3b
Yes
200%
250%
300%
350%
400%
Other
%
c
If the organization used factors other than FPG in determining eligibility, describe in Part VI the criteria
used for determining eligibility for free or discounted care. Include in the description whether the organization
used an asset test or other threshold, regardless of income, as a factor in determining eligibility for free or
discounted care.
4
Did the organization's financial assistance policy that applied to the largest number of its patients during the tax year provide for free or discounted care to the "medically indigent"? .
.
.
.
.
.
.
.
.
.
.
.
.
4
Yes
5a
Did the organization budget amounts for free or discounted care provided under its financial assistance policy during
the tax year?
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
5a
No
b
If "Yes," did the organization's financial assistance expenses exceed the budgeted amount?
.
.
.
.
.
.
5b
c
If "Yes" to line 5b, as a result of budget considerations, was the organization unable to provide free or discounted
care to a patient who was eligibile for free or discounted care? .
.
.
.
.
.
.
.
.
.
.
.
.
5c
6a
Did the organization prepare a community benefit report during the tax year?
.
.
.
.
.
.
.
.
.
6a
Yes
b
If "Yes," did the organization make it available to the public?
.
.
.
.
.
.
.
.
.
.
.
.
.
6b
Yes
Complete the following table using the worksheets provided in the Schedule H instructions. Do not submit these worksheets with the Schedule H.
7
Financial Assistance and Certain Other Community Benefits at Cost
Financial Assistance and
Means-Tested
Government Programs
(a)
Number of activities or programs (optional)
(b)
Persons served (optional)
(c)
Total community benefit expense
(d)
Direct offsetting revenue
(e)
Net community benefit expense
(f)
Percent of total expense
a
Financial Assistance at cost
(from Worksheet 1)
.
.
.
36,000,094
36,000,094
0.300 %
b
Medicaid (from Worksheet 3, column a) .
.
.
.
.
724,603,492
398,813,025
325,790,467
2.680 %
c
Costs of other means-tested government programs (from Worksheet 3, column b)
.
.
d
Total
Financial Assistance and Means-Tested Government Programs .
.
.
.
.
760,603,586
398,813,025
361,790,561
2.980 %
Other Benefits
e
Community health improvement services and community benefit operations (from Worksheet 4).
3,173,045
1,931
3,171,114
0.030 %
f
Health professions education (from Worksheet 5)
.
.
.
133,882,979
22,581,599
111,301,380
0.910 %
g
Subsidized health services (from Worksheet 6)
.
.
.
.
461,138,314
263,295,523
197,842,791
1.630 %
h
Research (from Worksheet 7)
.
218,808,544
136,765,211
82,043,333
0.670 %
i
Cash and in-kind contributions for community benefit (from Worksheet 8)
.
.
.
.
8,334,790
8,334,790
0.070 %
j
Total.
Other Benefits
.
.
825,337,672
422,644,264
402,693,408
3.310 %
k
Total.
Add lines 7d and 7j
.
1,585,941,258
821,457,289
764,483,969
6.290 %
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50192T
Schedule H (Form 990) 2021
Schedule H (Form 990) 2021
Page
Part II
Community Building Activities
Complete this table if the organization conducted any community building activities during the tax year, and describe in Part VI how its community building activities promoted the health of the communities it serves.
(a)
Number of activities or programs (optional)
(b)
Persons served (optional)
(c)
Total community building expense
(d)
Direct offsetting
revenue
(e)
Net community building expense
(f)
Percent of total expense
1
Physical improvements and housing
2
Economic development
3
Community support
448,868
448,868
0 %
4
Environmental improvements
5
Leadership development and
training for community members
6
Coalition building
149,154
149,154
0 %
7
Community health improvement advocacy
8
Workforce development
191,717
191,717
0 %
9
Other
10
Total
789,739
789,739
0 %
Part III
Bad Debt, Medicare, & Collection Practices
Section A. Bad Debt Expense
Yes
No
1
Did the organization report bad debt expense in accordance with Healthcare Financial Management Association Statement No. 15?
..........................
1
No
2
Enter the amount of the organization's bad debt expense. Explain in Part VI the methodology used by the organization to estimate this amount.
......
2
141,275,134
3
Enter the estimated amount of the organization's bad debt expense attributable to patients eligible under the organization's financial assistance policy. Explain in Part VI the methodology used by the organization to estimate this amount and the rationale, if any, for including this portion of bad debt as community benefit.
......
3
4
Provide in Part VI the text of the footnote to the organization’s financial statements that describes bad debt expense or the page number on which this footnote is contained in the attached financial statements.
Section B. Medicare
5
Enter total revenue received from Medicare (including DSH and IME)
.....
5
1,798,477,032
6
Enter Medicare allowable costs of care relating to payments on line 5
.....
6
2,094,019,339
7
Subtract line 6 from line 5. This is the surplus (or shortfall)
........
7
-295,542,307
8
Describe in Part VI the extent to which any shortfall reported in line 7 should be treated as community benefit.
Also describe in Part VI the costing methodology or source used to determine the amount reported on line 6.
Check the box that describes the method used:
Cost accounting system
Cost to charge ratio
Other
Section C. Collection Practices
9a
Did the organization have a written debt collection policy during the tax year?
..........
9a
Yes
b
If "Yes," did the organization’s collection policy that applied to the largest number of its patients during the tax year
contain provisions on the collection practices to be followed for patients who are known to qualify for financial assistance? Describe in Part VI
.........................
9b
Yes
Part IV
Management Companies and Joint Ventures
(owned 10% or more by officers, directors, trustees, key employees, and physicians—see instructions)
(a)
Name of entity
(b)
Description of primary
activity of entity
(c)
Organization's
profit % or stock
ownership %
(d)
Officers, directors,
trustees, or key
employees' profit %
or stock ownership %
(e)
Physicians'
profit % or stock
ownership %
1
2
3
4
5
6
7
8
9
10
11
12
13
Schedule H (Form 990) 2021
Schedule H (Form 990) 2021
Page
Part V
Facility Information
Section A. Hospital Facilities
(list in order of size from largest to smallest—see instructions)
How many hospital facilities did the organization operate during the tax year?
19
Name, address, primary website address, and state license number (and if a group return, the name and EIN of the subordinate hospital organization that operates the hospital facility)
Other (describe)
Facility reporting group
1
MAYO CLINIC HOSPITAL ROCHESTER
1216 2ND STREET SW
ROCHESTER
,
MN
55905
WWW.MAYOCLINIC.ORG
00428
MAYO CLINIC HOSPITAL ROCHESTER
410944601
X
X
X
X
X
X
E
2
MCHS IN LA CROSSE
700 WEST AVENUE SOUTH
LA CROSSE
,
WI
546014796
WWW.MAYOCLINIC.ORG
24
MCHS FRANCISCAN MEDICAL CENTER
390806374
X
X
X
X
CANCER & SURGERY CENTER
D
3
MAYO CLINIC HOSPITAL IN FLORIDA
4500 SAN PABLO ROAD
JACKSONVILLE
,
FL
32224
WWW.MAYOCLINIC.ORG
4493
MAYO CLINIC FLORIDA
590714831
X
X
X
X
E
4
MCHS IN EAU CLAIRE
1221 WHIPPLE STREET
EAU CLAIRE
,
WI
54703
WWW.MAYOCLINIC.ORG
48
MCHS NORTHWEST WISCONSIN REGION INC
390813418
X
X
X
A
5
MCHS IN MANKATO
1025 MARSH STREET
MANKATO
,
MN
56001
WWW.MAYOCLINIC.ORG
00033
MCHS SOUTHWEST MINNESOTA REGION
411236756
X
X
X
X
CLINIC
A
6
MAYO CLINIC HOSPITAL IN ARIZONA
5777 EAST MAYO BOULEVARD
PHOENIX
,
AZ
85054
WWW.MAYOCLINIC.ORG
H2027
MAYO CLINIC ARIZONA
860800150
X
X
X
X
CLINIC, RESEARCH
E
7
MCHS IN ALBERT LEA AND AUSTIN
1000 FIRST DRIVE NORTHWEST
AUSTIN
,
MN
55912
WWW.MAYOCLINIC.ORG
00920
MCHS SOUTHEAST MINNESOTA REGION
411404075
X
X
X
CLINIC
B
8
MCHS IN FAIRMONT
800 MEDICAL CENTER DRIVE
FAIRMONT
,
MN
56031
WWW.MAYOCLINIC.ORG
00359
MCHS IN FAIRMONT
410760836
X
X
X
CLINIC
A
9
MCHS IN RED WING
701 HEWITT BOULEVARD
RED WING
,
MN
55066
WWW.MAYOCLINIC.ORG
21423
MCHS SOUTHEAST MINNESOTA REGION
411404075
X
X
X
CLINIC
C
10
MCHS IN NEW PRAGUE
301 2ND STREET NORTHEAST
NEW PRAGUE
,
MN
56071
WWW.MAYOCLINIC.ORG
00607
MCHS SOUTHWEST MINNESOTA REGION
411236756
X
X
X
X
A
11
MCHS IN WASECA
501 NORTH STATE STREET
WASECA
,
MN
56093
WWW.MAYOCLINIC.ORG
00908
MCHS SOUTHWEST MINNESOTA REGION
411236756
X
X
X
X
CLINIC
A
12
MCHS IN BARRON
1222 EAST WOODLAND
BARRON
,
WI
54812
WWW.MAYOCLINIC.ORG
1018
MCHS NORTHWEST WISCONSIN REGION INC
390813418
X
X
X
X
CLINIC
A
13
MCHS IN BLOOMER
1501 THOMPSON STREET
BLOOMER
,
WI
54724
WWW.MAYOCLINIC.ORG
1017
MCHS NORTHWEST WISCONSIN REGION INC
390813418
X
X
X
X
CLINIC
A
14
MCHS IN MENOMONIE
2321 STOUT ROAD
MENOMONIE
,
WI
54751
WWW.MAYOCLINIC.ORG
1044
MCHS NORTHWEST WISCONSIN REGION INC
390813418
X
X
X
X
CLINIC
B
15
MCHS IN SPARTA
310 WEST MAIN STREET
SPARTA
,
WI
546562142
WWW.MAYOCLINIC.ORG
1009
MCHS FRANCISCAN MEDICAL CENTER
390806374
X
X
X
X
CLINIC
D
16
MCHS IN ST JAMES
1101 MOULTON PARSONS DRIVE
ST JAMES
,
MN
56081
WWW.MAYOCLINIC.ORG
00698
MCHS IN ST JAMES
410797368
X
X
X
X
CLINIC
A
17
MCHS IN OSSEO
13025 8TH STREET
OSSEO
,
WI
54758
WWW.MAYOCLINIC.ORG
1003
MCHS NORTHWEST WISCONSIN REGION INC
390813418
X
X
X
X
CLINIC
A
18
MCHS IN LAKE CITY
500 WEST GRANT STREET
LAKE CITY
,
MN
55041
WWW.MAYOCLINIC.ORG
20693
MCHS IN LAKE CITY
411906820
X
X
X
X
CLINIC, CARE CENTER
C
19
MCHS IN CANNON FALLS
32021 COUNTY ROAD 24 BOULEVARD
CANNON FALLS
,
MN
55009
WWW.MAYOCLINIC.ORG
140
MCHS SOUTHEAST MINNESOTA REGION
411404075
X
X
X
X
CLINIC
C
Schedule H (Form 990) 2021
Schedule H (Form 990) 2021
Page
4
Part V
Facility Information
(continued)
Section B. Facility Policies and Practices
(Complete a separate Section B for each of the hospital facilities or facility reporting groups listed in Part V, Section A)
REPORTING GROUP A
Name of hospital facility or letter of facility reporting group
Line number of hospital facility, or line numbers of hospital facilities in a facility
reporting group (from Part V, Section A):
Yes
No
Community Health Needs Assessment
1
Was the hospital facility first licensed, registered, or similarly recognized by a state as a hospital facility in the current tax year or the immediately preceding tax year?
........................
1
No
2
Was the hospital facility acquired or placed into service as a tax-exempt hospital in the current tax year or the immediately preceding tax year? If “Yes,” provide details of the acquisition in Section C.
..............
2
No
3
During the tax year or either of the two immediately preceding tax years, did the hospital facility conduct a community health needs assessment (CHNA)? If "No," skip to line 12.
.....................
3
Yes
If "Yes," indicate what the CHNA report describes (check all that apply):
a
A definition of the community served by the hospital facility
b
Demographics of the community
c
Existing health care facilities and resources within the community that are available to respond to the health needs of the community
d
How data was obtained
e
The significant health needs of the community
f
Primary and chronic disease needs and other health issues of uninsured persons, low-income persons, and minority groups
g
The process for identifying and prioritizing community health needs and services to meet the community health needs
h
The process for consulting with persons representing the community’s interests
i
The impact of any actions taken to address the significant health needs identified in the hospital facility's prior CHNA(s)
j
Other (describe in Section C)
4
Indicate the tax year the hospital facility last conducted a CHNA: 20
19
5
In conducting its most recent CHNA, did the hospital facility take into account input from persons who represent the broad interests of the community served by the hospital facility, including those with special knowledge of or expertise in public health? If "Yes," describe in Section C how the hospital facility took into account input from persons who represent the community, and identify the persons the hospital facility consulted
.................
5
Yes
6 a
Was the hospital facility’s CHNA conducted with one or more other hospital facilities? If "Yes," list the other hospital facilities in Section C
..................................
6a
Yes
b
Was the hospital facility’s CHNA conducted with one or more organizations other than hospital facilities?” If “Yes,” list the other organizations in Section C.
............................
6b
Yes
7
Did the hospital facility make its CHNA report widely available to the public?
..............
7
Yes
If "Yes," indicate how the CHNA report was made widely available (check all that apply):
a
Hospital facility’s website (list url):
MAYOCLINICHEALTHSYSTEM.ORG
b
Other website (list url):
c
Made a paper copy available for public inspection without charge at the hospital facility
d
Other (describe in Section C)
8
Did the hospital facility adopt an implementation strategy to meet the significant community health needs
identified through its most recently conducted CHNA? If "No," skip to line 11.
..............
8
Yes
9
Indicate the tax year the hospital facility last adopted an implementation strategy: 20
19
10
Is the hospital facility's most recently adopted implementation strategy posted on a website?
.........
10
No
a
If "Yes" (list url):
b
If "No," is the hospital facility’s most recently adopted implementation strategy attached to this return?
......
10b
Yes
11
Describe in Section C how the hospital facility is addressing the significant needs identified in its most recently conducted CHNA and any such needs that are not being addressed together with the reasons why such needs are not being addressed.
12a
Did the organization incur an excise tax under section 4959 for the hospital facility's failure to conduct a CHNA as required by section 501(r)(3)?
...............................
12a
No
b
If "Yes" on line 12a, did the organization file Form 4720 to report the section 4959 excise tax?
........
12b
c
If "Yes" on line 12b, what is the total amount of section 4959 excise tax the organization reported on Form 4720 for all of its hospital facilities? $
Schedule H (Form 990) 2021
Schedule H (Form 990) 2021
Page
5
Part V
Facility Information
(continued)
Financial Assistance Policy (FAP)
REPORTING GROUP A
Name of hospital facility or letter of facility reporting group
Yes
No
Did the hospital facility have in place during the tax year a written financial assistance policy that:
13
Explained eligibility criteria for financial assistance, and whether such assistance included free or discounted care?
13
Yes
If “Yes,” indicate the eligibility criteria explained in the FAP:
a
Federal poverty guidelines (FPG), with FPG family income limit for eligibility for free care of
200.000000000000
%
and FPG family income limit for eligibility for discounted care of
400.000000000000
%
b
Income level other than FPG (describe in Section C)
c
Asset level
d
Medical indigency
e
Insurance status
f
Underinsurance discount
g
Residency
h
Other (describe in Section C)
14
Explained the basis for calculating amounts charged to patients?
.................
14
Yes
15
Explained the method for applying for financial assistance?
...................
15
Yes
If “Yes,” indicate how the hospital facility’s FAP or FAP application form (including accompanying instructions) explained the method for applying for financial assistance (check all that apply):
a
Described the information the hospital facility may require an individual to provide as part of his or her application
b
Described the supporting documentation the hospital facility may require an individual to submit as part of his or
her application
c
Provided the contact information of hospital facility staff who can provide an individual with information about the
FAP and FAP application process
d
Provided the contact information of nonprofit organizations or government agencies that may be sources of
assistance with FAP applications
e
Other (describe in Section C)
16
Was widely publicized within the community served by the hospital facility?
........
16
Yes
If "Yes," indicate how the hospital facility publicized the policy (check all that apply):
a
The FAP was widely available on a website (list url):
MAYOCLINICHEALTHSYSTEM.ORG
b
The FAP application form was widely available on a website (list url):
MAYOCLINICHEALTHSYSTEM.ORG
c
A plain language summary of the FAP was widely available on a website (list url):
MAYOCLINICHEALTHSYSTEM.ORG
d
The FAP was available upon request and without charge (in public locations in the hospital facility and by mail)
e
The FAP application form was available upon request and without charge (in public locations in the hospital facility
and by mail)
f
A plain language summary of the FAP was available upon request and without charge (in public locations in the
hospital facility and by mail)
g
Individuals were notified about the FAP by being offered a paper copy of the plain language summary of the FAP, by
receiving a conspicuous written notice about the FAP on their billing statements, and via conspicuous public displays or
other measures reasonably calculated to attract patients' attention
h
Notified members of the community who are most likely to require financial assistance about availability of the FAP
i
The FAP, FAP application form, and plain language summary of the FAP were translated into the primary language(s)
spoken by LEP populations
j
Other (describe in Section C)
Schedule H (Form 990) 2021
Schedule H (Form 990) 2021
Page
6
Part V
Facility Information
(continued)
Billing and Collections
REPORTING GROUP A
Name of hospital facility or letter of facility reporting group
Yes
No
17
Did the hospital facility have in place during the tax year a separate billing and collections policy, or a written financial assistance policy (FAP) that explained all of the actions the hospital facility or other authorized party may take upon nonpayment?
..................................
17
Yes
18
Check all of the following actions against an individual that were permitted under the hospital facility's policies during the tax year before making reasonable efforts to determine the individual’s eligibility under the facility’s FAP:
a
Reporting to credit agency(ies)
b
Selling an individual’s debt to another party
c
Deferring, denying, or requiring a payment before providing medically necessary care due to nonpayment of a previous
bill for care covered under the hospital facility's FAP
d
Actions that require a legal or judicial process
e
Other similar actions (describe in Section C)
f
None of these actions or other similar actions were permitted
19
Did the hospital facility or other authorized party perform any of the following actions during the tax year before making reasonable efforts to determine the individual’s eligibility under the facility’s FAP?
............
19
No
If "Yes," check all actions in which the hospital facility or a third party engaged:
a
Reporting to credit agency(ies)
b
Selling an individual’s debt to another party
c
Deferring , denying, or requiring a payment before providing medically necessary care due to nonpayment of a previous
bill for care covered under the hospital facility's FAP
d
Actions that require a legal or judicial process
e
Other similar actions (describe in Section C)
20
Indicate which efforts the hospital facility or other authorized party made before initiating any of the actions listed (whether or not checked) in line 19. (check all that apply):
a
Provided a written notice about upcoming ECAs (Extraordinary Collection Action) and a plain language summary of the
FAP at least 30 days before initiating those ECAs (if not, describe in Section C)
b
Made a reasonable effort to orally notify individuals about the FAP and FAP application process (if not, describe in
Section C)
c
Processed incomplete and complete FAP applications (if not, describe in Section C)
d
Made presumptive eligibility determinations (if not, describe in Section C)
e
Other (describe in Section C)
f
None of these efforts were made
Policy Relating to Emergency Medical Care
21
Did the hospital facility have in place during the tax year a written policy relating to emergency medical care that required the hospital facility to provide, without discrimination, care for emergency medical conditions to individuals regardless of their eligibility under the hospital facility’s financial assistance policy?
..................
21
Yes
If "No," indicate why:
a
The hospital facility did not provide care for any emergency medical conditions
b
The hospital facility’s policy was not in writing
c
The hospital facility limited who was eligible to receive care for emergency medical conditions (describe in Section C)
d
Other (describe in Section C)
Schedule H (Form 990) 2021
Schedule H (Form 990) 2021
Page
7
Part V
Facility Information
(continued)
Charges to Individuals Eligible for Assistance Under the FAP (FAP-Eligible Individuals)
REPORTING GROUP A
Name of hospital facility or letter of facility reporting group
Yes
No
22
Indicate how the hospital facility determined, during the tax year, the maximum amounts that can be charged to FAP-eligible individuals for emergency or other medically necessary care.
a
The hospital facility used a look-back method based on claims allowed by Medicare fee-for-service during a prior 12-month period
b
The hospital facility used a look-back method based on claims allowed by Medicare fee-for-service and all private health insurers that pay claims to the hospital facility during a prior 12-month period
c
The hospital facility used a look-back method based on claims allowed by Medicaid, either alone or in combination with
Medicare fee-for-service and all private health insurers that pay claims to the hospital facility during a prior 12-month
period
d
The hospital facility used a prospective Medicare or Medicaid method
23
During the tax year, did the hospital facility charge any FAP-eligible individual to whom the hospital facility provided emergency or other medically necessary services more than the amounts generally billed to individuals who had insurance covering such care?
...............................
23
No
If "Yes," explain in Section C.
24
During the tax year, did the hospital facility charge any FAP-eligible individual an amount equal to the gross charge for any service provided to that individual?
...........................
24
No
If "Yes," explain in Section C.
Schedule H (Form 990) 2021
Schedule H (Form 990) 2021
Page
4
Part V
Facility Information
(continued)
Section B. Facility Policies and Practices
(Complete a separate Section B for each of the hospital facilities or facility reporting groups listed in Part V, Section A)
REPORTING GROUP B
Name of hospital facility or letter of facility reporting group
Line number of hospital facility, or line numbers of hospital facilities in a facility
reporting group (from Part V, Section A):
Yes
No
Community Health Needs Assessment
1
Was the hospital facility first licensed, registered, or similarly recognized by a state as a hospital facility in the current tax year or the immediately preceding tax year?
........................
1
No
2
Was the hospital facility acquired or placed into service as a tax-exempt hospital in the current tax year or the immediately preceding tax year? If “Yes,” provide details of the acquisition in Section C.
..............
2
No
3
During the tax year or either of the two immediately preceding tax years, did the hospital facility conduct a community health needs assessment (CHNA)? If "No," skip to line 12.
.....................
3
Yes
If "Yes," indicate what the CHNA report describes (check all that apply):
a
A definition of the community served by the hospital facility
b
Demographics of the community
c
Existing health care facilities and resources within the community that are available to respond to the health needs of the community
d
How data was obtained
e
The significant health needs of the community
f
Primary and chronic disease needs and other health issues of uninsured persons, low-income persons, and minority groups
g
The process for identifying and prioritizing community health needs and services to meet the community health needs
h
The process for consulting with persons representing the community’s interests
i
The impact of any actions taken to address the significant health needs identified in the hospital facility's prior CHNA(s)
j
Other (describe in Section C)
4
Indicate the tax year the hospital facility last conducted a CHNA: 20
19
5
In conducting its most recent CHNA, did the hospital facility take into account input from persons who represent the broad interests of the community served by the hospital facility, including those with special knowledge of or expertise in public health? If "Yes," describe in Section C how the hospital facility took into account input from persons who represent the community, and identify the persons the hospital facility consulted
.................
5
Yes
6 a
Was the hospital facility’s CHNA conducted with one or more other hospital facilities? If "Yes," list the other hospital facilities in Section C
..................................
6a
No
b
Was the hospital facility’s CHNA conducted with one or more organizations other than hospital facilities?” If “Yes,” list the other organizations in Section C.
............................
6b
Yes
7
Did the hospital facility make its CHNA report widely available to the public?
..............
7
Yes
If "Yes," indicate how the CHNA report was made widely available (check all that apply):
a
Hospital facility’s website (list url):
MAYOCLINICHEALTHSYSTEM.ORG
b
Other website (list url):
c
Made a paper copy available for public inspection without charge at the hospital facility
d
Other (describe in Section C)
8
Did the hospital facility adopt an implementation strategy to meet the significant community health needs
identified through its most recently conducted CHNA? If "No," skip to line 11.
..............
8
Yes
9
Indicate the tax year the hospital facility last adopted an implementation strategy: 20
19
10
Is the hospital facility's most recently adopted implementation strategy posted on a website?
.........
10
No
a
If "Yes" (list url):
b
If "No," is the hospital facility’s most recently adopted implementation strategy attached to this return?
......
10b
Yes
11
Describe in Section C how the hospital facility is addressing the significant needs identified in its most recently conducted CHNA and any such needs that are not being addressed together with the reasons why such needs are not being addressed.
12a
Did the organization incur an excise tax under section 4959 for the hospital facility's failure to conduct a CHNA as required by section 501(r)(3)?
...............................
12a
No
b
If "Yes" on line 12a, did the organization file Form 4720 to report the section 4959 excise tax?
........
12b
c
If "Yes" on line 12b, what is the total amount of section 4959 excise tax the organization reported on Form 4720 for all of its hospital facilities? $
Schedule H (Form 990) 2021
Schedule H (Form 990) 2021
Page
5
Part V
Facility Information
(continued)
Financial Assistance Policy (FAP)
REPORTING GROUP B
Name of hospital facility or letter of facility reporting group
Yes
No
Did the hospital facility have in place during the tax year a written financial assistance policy that:
13
Explained eligibility criteria for financial assistance, and whether such assistance included free or discounted care?
13
Yes
If “Yes,” indicate the eligibility criteria explained in the FAP:
a
Federal poverty guidelines (FPG), with FPG family income limit for eligibility for free care of
200.000000000000
%
and FPG family income limit for eligibility for discounted care of
400.000000000000
%
b
Income level other than FPG (describe in Section C)
c
Asset level
d
Medical indigency
e
Insurance status
f
Underinsurance discount
g
Residency
h
Other (describe in Section C)
14
Explained the basis for calculating amounts charged to patients?
.................
14
Yes
15
Explained the method for applying for financial assistance?
...................
15
Yes
If “Yes,” indicate how the hospital facility’s FAP or FAP application form (including accompanying instructions) explained the method for applying for financial assistance (check all that apply):
a
Described the information the hospital facility may require an individual to provide as part of his or her application
b
Described the supporting documentation the hospital facility may require an individual to submit as part of his or
her application
c
Provided the contact information of hospital facility staff who can provide an individual with information about the
FAP and FAP application process
d
Provided the contact information of nonprofit organizations or government agencies that may be sources of
assistance with FAP applications
e
Other (describe in Section C)
16
Was widely publicized within the community served by the hospital facility?
........
16
Yes
If "Yes," indicate how the hospital facility publicized the policy (check all that apply):
a
The FAP was widely available on a website (list url):
MAYOCLINICHEALTHSYSTEM.ORG
b
The FAP application form was widely available on a website (list url):
MAYOCLINICHEALTHSYSTEM.ORG
c
A plain language summary of the FAP was widely available on a website (list url):
MAYOCLINICHEALTHSYSTEM.ORG
d
The FAP was available upon request and without charge (in public locations in the hospital facility and by mail)
e
The FAP application form was available upon request and without charge (in public locations in the hospital facility
and by mail)
f
A plain language summary of the FAP was available upon request and without charge (in public locations in the
hospital facility and by mail)
g
Individuals were notified about the FAP by being offered a paper copy of the plain language summary of the FAP, by
receiving a conspicuous written notice about the FAP on their billing statements, and via conspicuous public displays or
other measures reasonably calculated to attract patients' attention
h
Notified members of the community who are most likely to require financial assistance about availability of the FAP
i
The FAP, FAP application form, and plain language summary of the FAP were translated into the primary language(s)
spoken by LEP populations
j
Other (describe in Section C)
Schedule H (Form 990) 2021
Schedule H (Form 990) 2021
Page
6
Part V
Facility Information
(continued)
Billing and Collections
REPORTING GROUP B
Name of hospital facility or letter of facility reporting group
Yes
No
17
Did the hospital facility have in place during the tax year a separate billing and collections policy, or a written financial assistance policy (FAP) that explained all of the actions the hospital facility or other authorized party may take upon nonpayment?
..................................
17
Yes
18
Check all of the following actions against an individual that were permitted under the hospital facility's policies during the tax year before making reasonable efforts to determine the individual’s eligibility under the facility’s FAP:
a
Reporting to credit agency(ies)
b
Selling an individual’s debt to another party
c
Deferring, denying, or requiring a payment before providing medically necessary care due to nonpayment of a previous
bill for care covered under the hospital facility's FAP
d
Actions that require a legal or judicial process
e
Other similar actions (describe in Section C)
f
None of these actions or other similar actions were permitted
19
Did the hospital facility or other authorized party perform any of the following actions during the tax year before making reasonable efforts to determine the individual’s eligibility under the facility’s FAP?
............
19
No
If "Yes," check all actions in which the hospital facility or a third party engaged:
a
Reporting to credit agency(ies)
b
Selling an individual’s debt to another party
c
Deferring , denying, or requiring a payment before providing medically necessary care due to nonpayment of a previous
bill for care covered under the hospital facility's FAP
d
Actions that require a legal or judicial process
e
Other similar actions (describe in Section C)
20
Indicate which efforts the hospital facility or other authorized party made before initiating any of the actions listed (whether or not checked) in line 19. (check all that apply):
a
Provided a written notice about upcoming ECAs (Extraordinary Collection Action) and a plain language summary of the
FAP at least 30 days before initiating those ECAs (if not, describe in Section C)
b
Made a reasonable effort to orally notify individuals about the FAP and FAP application process (if not, describe in
Section C)
c
Processed incomplete and complete FAP applications (if not, describe in Section C)
d
Made presumptive eligibility determinations (if not, describe in Section C)
e
Other (describe in Section C)
f
None of these efforts were made
Policy Relating to Emergency Medical Care
21
Did the hospital facility have in place during the tax year a written policy relating to emergency medical care that required the hospital facility to provide, without discrimination, care for emergency medical conditions to individuals regardless of their eligibility under the hospital facility’s financial assistance policy?
..................
21
Yes
If "No," indicate why:
a
The hospital facility did not provide care for any emergency medical conditions
b
The hospital facility’s policy was not in writing
c
The hospital facility limited who was eligible to receive care for emergency medical conditions (describe in Section C)
d
Other (describe in Section C)
Schedule H (Form 990) 2021
Schedule H (Form 990) 2021
Page
7
Part V
Facility Information
(continued)
Charges to Individuals Eligible for Assistance Under the FAP (FAP-Eligible Individuals)
REPORTING GROUP B
Name of hospital facility or letter of facility reporting group
Yes
No
22
Indicate how the hospital facility determined, during the tax year, the maximum amounts that can be charged to FAP-eligible individuals for emergency or other medically necessary care.
a
The hospital facility used a look-back method based on claims allowed by Medicare fee-for-service during a prior 12-month period
b
The hospital facility used a look-back method based on claims allowed by Medicare fee-for-service and all private health insurers that pay claims to the hospital facility during a prior 12-month period
c
The hospital facility used a look-back method based on claims allowed by Medicaid, either alone or in combination with
Medicare fee-for-service and all private health insurers that pay claims to the hospital facility during a prior 12-month
period
d
The hospital facility used a prospective Medicare or Medicaid method
23
During the tax year, did the hospital facility charge any FAP-eligible individual to whom the hospital facility provided emergency or other medically necessary services more than the amounts generally billed to individuals who had insurance covering such care?
...............................
23
No
If "Yes," explain in Section C.
24
During the tax year, did the hospital facility charge any FAP-eligible individual an amount equal to the gross charge for any service provided to that individual?
...........................
24
No
If "Yes," explain in Section C.
Schedule H (Form 990) 2021
Schedule H (Form 990) 2021
Page
4
Part V
Facility Information
(continued)
Section B. Facility Policies and Practices
(Complete a separate Section B for each of the hospital facilities or facility reporting groups listed in Part V, Section A)
REPORTING GROUP C
Name of hospital facility or letter of facility reporting group
Line number of hospital facility, or line numbers of hospital facilities in a facility
reporting group (from Part V, Section A):
Yes
No
Community Health Needs Assessment
1
Was the hospital facility first licensed, registered, or similarly recognized by a state as a hospital facility in the current tax year or the immediately preceding tax year?
........................
1
No
2
Was the hospital facility acquired or placed into service as a tax-exempt hospital in the current tax year or the immediately preceding tax year? If “Yes,” provide details of the acquisition in Section C.
..............
2
No
3
During the tax year or either of the two immediately preceding tax years, did the hospital facility conduct a community health needs assessment (CHNA)? If "No," skip to line 12.
.....................
3
Yes
If "Yes," indicate what the CHNA report describes (check all that apply):
a
A definition of the community served by the hospital facility
b
Demographics of the community
c
Existing health care facilities and resources within the community that are available to respond to the health needs of the community
d
How data was obtained
e
The significant health needs of the community
f
Primary and chronic disease needs and other health issues of uninsured persons, low-income persons, and minority groups
g
The process for identifying and prioritizing community health needs and services to meet the community health needs
h
The process for consulting with persons representing the community’s interests
i
The impact of any actions taken to address the significant health needs identified in the hospital facility's prior CHNA(s)
j
Other (describe in Section C)
4
Indicate the tax year the hospital facility last conducted a CHNA: 20
19
5
In conducting its most recent CHNA, did the hospital facility take into account input from persons who represent the broad interests of the community served by the hospital facility, including those with special knowledge of or expertise in public health? If "Yes," describe in Section C how the hospital facility took into account input from persons who represent the community, and identify the persons the hospital facility consulted
.................
5
Yes
6 a
Was the hospital facility’s CHNA conducted with one or more other hospital facilities? If "Yes," list the other hospital facilities in Section C
..................................
6a
Yes
b
Was the hospital facility’s CHNA conducted with one or more organizations other than hospital facilities?” If “Yes,” list the other organizations in Section C.
............................
6b
Yes
7
Did the hospital facility make its CHNA report widely available to the public?
..............
7
Yes
If "Yes," indicate how the CHNA report was made widely available (check all that apply):
a
Hospital facility’s website (list url):
MAYOCLINICHEALTHSYSTEM.ORG
b
Other website (list url):
c
Made a paper copy available for public inspection without charge at the hospital facility
d
Other (describe in Section C)
8
Did the hospital facility adopt an implementation strategy to meet the significant community health needs
identified through its most recently conducted CHNA? If "No," skip to line 11.
..............
8
Yes
9
Indicate the tax year the hospital facility last adopted an implementation strategy: 20
19
10
Is the hospital facility's most recently adopted implementation strategy posted on a website?
.........
10
No
a
If "Yes" (list url):
b
If "No," is the hospital facility’s most recently adopted implementation strategy attached to this return?
......
10b
Yes
11
Describe in Section C how the hospital facility is addressing the significant needs identified in its most recently conducted CHNA and any such needs that are not being addressed together with the reasons why such needs are not being addressed.
12a
Did the organization incur an excise tax under section 4959 for the hospital facility's failure to conduct a CHNA as required by section 501(r)(3)?
...............................
12a
No
b
If "Yes" on line 12a, did the organization file Form 4720 to report the section 4959 excise tax?
........
12b
c
If "Yes" on line 12b, what is the total amount of section 4959 excise tax the organization reported on Form 4720 for all of its hospital facilities? $
Schedule H (Form 990) 2021
Schedule H (Form 990) 2021
Page
5
Part V
Facility Information
(continued)
Financial Assistance Policy (FAP)
REPORTING GROUP C
Name of hospital facility or letter of facility reporting group
Yes
No
Did the hospital facility have in place during the tax year a written financial assistance policy that:
13
Explained eligibility criteria for financial assistance, and whether such assistance included free or discounted care?
13
Yes
If “Yes,” indicate the eligibility criteria explained in the FAP:
a
Federal poverty guidelines (FPG), with FPG family income limit for eligibility for free care of
200.000000000000
%
and FPG family income limit for eligibility for discounted care of
400.000000000000
%
b
Income level other than FPG (describe in Section C)
c
Asset level
d
Medical indigency
e
Insurance status
f
Underinsurance discount
g
Residency
h
Other (describe in Section C)
14
Explained the basis for calculating amounts charged to patients?
.................
14
Yes
15
Explained the method for applying for financial assistance?
...................
15
Yes
If “Yes,” indicate how the hospital facility’s FAP or FAP application form (including accompanying instructions) explained the method for applying for financial assistance (check all that apply):
a
Described the information the hospital facility may require an individual to provide as part of his or her application
b
Described the supporting documentation the hospital facility may require an individual to submit as part of his or
her application
c
Provided the contact information of hospital facility staff who can provide an individual with information about the
FAP and FAP application process
d
Provided the contact information of nonprofit organizations or government agencies that may be sources of
assistance with FAP applications
e
Other (describe in Section C)
16
Was widely publicized within the community served by the hospital facility?
........
16
Yes
If "Yes," indicate how the hospital facility publicized the policy (check all that apply):
a
The FAP was widely available on a website (list url):
MAYOCLINICHEALTHSYSTEM.ORG
b
The FAP application form was widely available on a website (list url):
MAYOCLINICHEALTHSYSTEM.ORG
c
A plain language summary of the FAP was widely available on a website (list url):
MAYOCLINICHEALTHSYSTEM.ORG
d
The FAP was available upon request and without charge (in public locations in the hospital facility and by mail)
e
The FAP application form was available upon request and without charge (in public locations in the hospital facility
and by mail)
f
A plain language summary of the FAP was available upon request and without charge (in public locations in the
hospital facility and by mail)
g
Individuals were notified about the FAP by being offered a paper copy of the plain language summary of the FAP, by
receiving a conspicuous written notice about the FAP on their billing statements, and via conspicuous public displays or
other measures reasonably calculated to attract patients' attention
h
Notified members of the community who are most likely to require financial assistance about availability of the FAP
i
The FAP, FAP application form, and plain language summary of the FAP were translated into the primary language(s)
spoken by LEP populations
j
Other (describe in Section C)
Schedule H (Form 990) 2021
Schedule H (Form 990) 2021
Page
6
Part V
Facility Information
(continued)
Billing and Collections
REPORTING GROUP C
Name of hospital facility or letter of facility reporting group
Yes
No
17
Did the hospital facility have in place during the tax year a separate billing and collections policy, or a written financial assistance policy (FAP) that explained all of the actions the hospital facility or other authorized party may take upon nonpayment?
..................................
17
Yes
18
Check all of the following actions against an individual that were permitted under the hospital facility's policies during the tax year before making reasonable efforts to determine the individual’s eligibility under the facility’s FAP:
a
Reporting to credit agency(ies)
b
Selling an individual’s debt to another party
c
Deferring, denying, or requiring a payment before providing medically necessary care due to nonpayment of a previous
bill for care covered under the hospital facility's FAP
d
Actions that require a legal or judicial process
e
Other similar actions (describe in Section C)
f
None of these actions or other similar actions were permitted
19
Did the hospital facility or other authorized party perform any of the following actions during the tax year before making reasonable efforts to determine the individual’s eligibility under the facility’s FAP?
............
19
No
If "Yes," check all actions in which the hospital facility or a third party engaged:
a
Reporting to credit agency(ies)
b
Selling an individual’s debt to another party
c
Deferring , denying, or requiring a payment before providing medically necessary care due to nonpayment of a previous
bill for care covered under the hospital facility's FAP
d
Actions that require a legal or judicial process
e
Other similar actions (describe in Section C)
20
Indicate which efforts the hospital facility or other authorized party made before initiating any of the actions listed (whether or not checked) in line 19. (check all that apply):
a
Provided a written notice about upcoming ECAs (Extraordinary Collection Action) and a plain language summary of the
FAP at least 30 days before initiating those ECAs (if not, describe in Section C)
b
Made a reasonable effort to orally notify individuals about the FAP and FAP application process (if not, describe in
Section C)
c
Processed incomplete and complete FAP applications (if not, describe in Section C)
d
Made presumptive eligibility determinations (if not, describe in Section C)
e
Other (describe in Section C)
f
None of these efforts were made
Policy Relating to Emergency Medical Care
21
Did the hospital facility have in place during the tax year a written policy relating to emergency medical care that required the hospital facility to provide, without discrimination, care for emergency medical conditions to individuals regardless of their eligibility under the hospital facility’s financial assistance policy?
..................
21
Yes
If "No," indicate why:
a
The hospital facility did not provide care for any emergency medical conditions
b
The hospital facility’s policy was not in writing
c
The hospital facility limited who was eligible to receive care for emergency medical conditions (describe in Section C)
d
Other (describe in Section C)
Schedule H (Form 990) 2021
Schedule H (Form 990) 2021
Page
7
Part V
Facility Information
(continued)
Charges to Individuals Eligible for Assistance Under the FAP (FAP-Eligible Individuals)
REPORTING GROUP C
Name of hospital facility or letter of facility reporting group
Yes
No
22
Indicate how the hospital facility determined, during the tax year, the maximum amounts that can be charged to FAP-eligible individuals for emergency or other medically necessary care.
a
The hospital facility used a look-back method based on claims allowed by Medicare fee-for-service during a prior 12-month period
b
The hospital facility used a look-back method based on claims allowed by Medicare fee-for-service and all private health insurers that pay claims to the hospital facility during a prior 12-month period
c
The hospital facility used a look-back method based on claims allowed by Medicaid, either alone or in combination with
Medicare fee-for-service and all private health insurers that pay claims to the hospital facility during a prior 12-month
period
d
The hospital facility used a prospective Medicare or Medicaid method
23
During the tax year, did the hospital facility charge any FAP-eligible individual to whom the hospital facility provided emergency or other medically necessary services more than the amounts generally billed to individuals who had insurance covering such care?
...............................
23
No
If "Yes," explain in Section C.
24
During the tax year, did the hospital facility charge any FAP-eligible individual an amount equal to the gross charge for any service provided to that individual?
...........................
24
No
If "Yes," explain in Section C.
Schedule H (Form 990) 2021
Schedule H (Form 990) 2021
Page
4
Part V
Facility Information
(continued)
Section B. Facility Policies and Practices
(Complete a separate Section B for each of the hospital facilities or facility reporting groups listed in Part V, Section A)
REPORTING GROUP D
Name of hospital facility or letter of facility reporting group
Line number of hospital facility, or line numbers of hospital facilities in a facility
reporting group (from Part V, Section A):
Yes
No
Community Health Needs Assessment
1
Was the hospital facility first licensed, registered, or similarly recognized by a state as a hospital facility in the current tax year or the immediately preceding tax year?
........................
1
No
2
Was the hospital facility acquired or placed into service as a tax-exempt hospital in the current tax year or the immediately preceding tax year? If “Yes,” provide details of the acquisition in Section C.
..............
2
No
3
During the tax year or either of the two immediately preceding tax years, did the hospital facility conduct a community health needs assessment (CHNA)? If "No," skip to line 12.
.....................
3
Yes
If "Yes," indicate what the CHNA report describes (check all that apply):
a
A definition of the community served by the hospital facility
b
Demographics of the community
c
Existing health care facilities and resources within the community that are available to respond to the health needs of the community
d
How data was obtained
e
The significant health needs of the community
f
Primary and chronic disease needs and other health issues of uninsured persons, low-income persons, and minority groups
g
The process for identifying and prioritizing community health needs and services to meet the community health needs
h
The process for consulting with persons representing the community’s interests
i
The impact of any actions taken to address the significant health needs identified in the hospital facility's prior CHNA(s)
j
Other (describe in Section C)
4
Indicate the tax year the hospital facility last conducted a CHNA: 20
19
5
In conducting its most recent CHNA, did the hospital facility take into account input from persons who represent the broad interests of the community served by the hospital facility, including those with special knowledge of or expertise in public health? If "Yes," describe in Section C how the hospital facility took into account input from persons who represent the community, and identify the persons the hospital facility consulted
.................
5
Yes
6 a
Was the hospital facility’s CHNA conducted with one or more other hospital facilities? If "Yes," list the other hospital facilities in Section C
..................................
6a
Yes
b
Was the hospital facility’s CHNA conducted with one or more organizations other than hospital facilities?” If “Yes,” list the other organizations in Section C.
............................
6b
Yes
7
Did the hospital facility make its CHNA report widely available to the public?
..............
7
Yes
If "Yes," indicate how the CHNA report was made widely available (check all that apply):
a
Hospital facility’s website (list url):
MAYOCLINICHEALTHSYSTEM.ORG
b
Other website (list url):
c
Made a paper copy available for public inspection without charge at the hospital facility
d
Other (describe in Section C)
8
Did the hospital facility adopt an implementation strategy to meet the significant community health needs
identified through its most recently conducted CHNA? If "No," skip to line 11.
..............
8
Yes
9
Indicate the tax year the hospital facility last adopted an implementation strategy: 20
19
10
Is the hospital facility's most recently adopted implementation strategy posted on a website?
.........
10
No
a
If "Yes" (list url):
b
If "No," is the hospital facility’s most recently adopted implementation strategy attached to this return?
......
10b
Yes
11
Describe in Section C how the hospital facility is addressing the significant needs identified in its most recently conducted CHNA and any such needs that are not being addressed together with the reasons why such needs are not being addressed.
12a
Did the organization incur an excise tax under section 4959 for the hospital facility's failure to conduct a CHNA as required by section 501(r)(3)?
...............................
12a
No
b
If "Yes" on line 12a, did the organization file Form 4720 to report the section 4959 excise tax?
........
12b
c
If "Yes" on line 12b, what is the total amount of section 4959 excise tax the organization reported on Form 4720 for all of its hospital facilities? $
Schedule H (Form 990) 2021
Schedule H (Form 990) 2021
Page
5
Part V
Facility Information
(continued)
Financial Assistance Policy (FAP)
REPORTING GROUP D
Name of hospital facility or letter of facility reporting group
Yes
No
Did the hospital facility have in place during the tax year a written financial assistance policy that:
13
Explained eligibility criteria for financial assistance, and whether such assistance included free or discounted care?
13
Yes
If “Yes,” indicate the eligibility criteria explained in the FAP:
a
Federal poverty guidelines (FPG), with FPG family income limit for eligibility for free care of
200.000000000000
%
and FPG family income limit for eligibility for discounted care of
400.000000000000
%
b
Income level other than FPG (describe in Section C)
c
Asset level
d
Medical indigency
e
Insurance status
f
Underinsurance discount
g
Residency
h
Other (describe in Section C)
14
Explained the basis for calculating amounts charged to patients?
.................
14
Yes
15
Explained the method for applying for financial assistance?
...................
15
Yes
If “Yes,” indicate how the hospital facility’s FAP or FAP application form (including accompanying instructions) explained the method for applying for financial assistance (check all that apply):
a
Described the information the hospital facility may require an individual to provide as part of his or her application
b
Described the supporting documentation the hospital facility may require an individual to submit as part of his or
her application
c
Provided the contact information of hospital facility staff who can provide an individual with information about the
FAP and FAP application process
d
Provided the contact information of nonprofit organizations or government agencies that may be sources of
assistance with FAP applications
e
Other (describe in Section C)
16
Was widely publicized within the community served by the hospital facility?
........
16
Yes
If "Yes," indicate how the hospital facility publicized the policy (check all that apply):
a
The FAP was widely available on a website (list url):
MAYOCLINICHEALTHSYSTEM.ORG
b
The FAP application form was widely available on a website (list url):
MAYOCLINICHEALTHSYSTEM.ORG
c
A plain language summary of the FAP was widely available on a website (list url):
MAYOCLINICHEALTHSYSTEM.ORG
d
The FAP was available upon request and without charge (in public locations in the hospital facility and by mail)
e
The FAP application form was available upon request and without charge (in public locations in the hospital facility
and by mail)
f
A plain language summary of the FAP was available upon request and without charge (in public locations in the
hospital facility and by mail)
g
Individuals were notified about the FAP by being offered a paper copy of the plain language summary of the FAP, by
receiving a conspicuous written notice about the FAP on their billing statements, and via conspicuous public displays or
other measures reasonably calculated to attract patients' attention
h
Notified members of the community who are most likely to require financial assistance about availability of the FAP
i
The FAP, FAP application form, and plain language summary of the FAP were translated into the primary language(s)
spoken by LEP populations
j
Other (describe in Section C)
Schedule H (Form 990) 2021
Schedule H (Form 990) 2021
Page
6
Part V
Facility Information
(continued)
Billing and Collections
REPORTING GROUP D
Name of hospital facility or letter of facility reporting group
Yes
No
17
Did the hospital facility have in place during the tax year a separate billing and collections policy, or a written financial assistance policy (FAP) that explained all of the actions the hospital facility or other authorized party may take upon nonpayment?
..................................
17
Yes
18
Check all of the following actions against an individual that were permitted under the hospital facility's policies during the tax year before making reasonable efforts to determine the individual’s eligibility under the facility’s FAP:
a
Reporting to credit agency(ies)
b
Selling an individual’s debt to another party
c
Deferring, denying, or requiring a payment before providing medically necessary care due to nonpayment of a previous
bill for care covered under the hospital facility's FAP
d
Actions that require a legal or judicial process
e
Other similar actions (describe in Section C)
f
None of these actions or other similar actions were permitted
19
Did the hospital facility or other authorized party perform any of the following actions during the tax year before making reasonable efforts to determine the individual’s eligibility under the facility’s FAP?
............
19
No
If "Yes," check all actions in which the hospital facility or a third party engaged:
a
Reporting to credit agency(ies)
b
Selling an individual’s debt to another party
c
Deferring , denying, or requiring a payment before providing medically necessary care due to nonpayment of a previous
bill for care covered under the hospital facility's FAP
d
Actions that require a legal or judicial process
e
Other similar actions (describe in Section C)
20
Indicate which efforts the hospital facility or other authorized party made before initiating any of the actions listed (whether or not checked) in line 19. (check all that apply):
a
Provided a written notice about upcoming ECAs (Extraordinary Collection Action) and a plain language summary of the
FAP at least 30 days before initiating those ECAs (if not, describe in Section C)
b
Made a reasonable effort to orally notify individuals about the FAP and FAP application process (if not, describe in
Section C)
c
Processed incomplete and complete FAP applications (if not, describe in Section C)
d
Made presumptive eligibility determinations (if not, describe in Section C)
e
Other (describe in Section C)
f
None of these efforts were made
Policy Relating to Emergency Medical Care
21
Did the hospital facility have in place during the tax year a written policy relating to emergency medical care that required the hospital facility to provide, without discrimination, care for emergency medical conditions to individuals regardless of their eligibility under the hospital facility’s financial assistance policy?
..................
21
Yes
If "No," indicate why:
a
The hospital facility did not provide care for any emergency medical conditions
b
The hospital facility’s policy was not in writing
c
The hospital facility limited who was eligible to receive care for emergency medical conditions (describe in Section C)
d
Other (describe in Section C)
Schedule H (Form 990) 2021
Schedule H (Form 990) 2021
Page
7
Part V
Facility Information
(continued)
Charges to Individuals Eligible for Assistance Under the FAP (FAP-Eligible Individuals)
REPORTING GROUP D
Name of hospital facility or letter of facility reporting group
Yes
No
22
Indicate how the hospital facility determined, during the tax year, the maximum amounts that can be charged to FAP-eligible individuals for emergency or other medically necessary care.
a
The hospital facility used a look-back method based on claims allowed by Medicare fee-for-service during a prior 12-month period
b
The hospital facility used a look-back method based on claims allowed by Medicare fee-for-service and all private health insurers that pay claims to the hospital facility during a prior 12-month period
c
The hospital facility used a look-back method based on claims allowed by Medicaid, either alone or in combination with
Medicare fee-for-service and all private health insurers that pay claims to the hospital facility during a prior 12-month
period
d
The hospital facility used a prospective Medicare or Medicaid method
23
During the tax year, did the hospital facility charge any FAP-eligible individual to whom the hospital facility provided emergency or other medically necessary services more than the amounts generally billed to individuals who had insurance covering such care?
...............................
23
No
If "Yes," explain in Section C.
24
During the tax year, did the hospital facility charge any FAP-eligible individual an amount equal to the gross charge for any service provided to that individual?
...........................
24
No
If "Yes," explain in Section C.
Schedule H (Form 990) 2021
Schedule H (Form 990) 2021
Page
4
Part V
Facility Information
(continued)
Section B. Facility Policies and Practices
(Complete a separate Section B for each of the hospital facilities or facility reporting groups listed in Part V, Section A)
REPORTING GROUP E
Name of hospital facility or letter of facility reporting group
Line number of hospital facility, or line numbers of hospital facilities in a facility
reporting group (from Part V, Section A):
Yes
No
Community Health Needs Assessment
1
Was the hospital facility first licensed, registered, or similarly recognized by a state as a hospital facility in the current tax year or the immediately preceding tax year?
........................
1
No
2
Was the hospital facility acquired or placed into service as a tax-exempt hospital in the current tax year or the immediately preceding tax year? If “Yes,” provide details of the acquisition in Section C.
..............
2
No
3
During the tax year or either of the two immediately preceding tax years, did the hospital facility conduct a community health needs assessment (CHNA)? If "No," skip to line 12.
.....................
3
Yes
If "Yes," indicate what the CHNA report describes (check all that apply):
a
A definition of the community served by the hospital facility
b
Demographics of the community
c
Existing health care facilities and resources within the community that are available to respond to the health needs of the community
d
How data was obtained
e
The significant health needs of the community
f
Primary and chronic disease needs and other health issues of uninsured persons, low-income persons, and minority groups
g
The process for identifying and prioritizing community health needs and services to meet the community health needs
h
The process for consulting with persons representing the community’s interests
i
The impact of any actions taken to address the significant health needs identified in the hospital facility's prior CHNA(s)
j
Other (describe in Section C)
4
Indicate the tax year the hospital facility last conducted a CHNA: 20
19
5
In conducting its most recent CHNA, did the hospital facility take into account input from persons who represent the broad interests of the community served by the hospital facility, including those with special knowledge of or expertise in public health? If "Yes," describe in Section C how the hospital facility took into account input from persons who represent the community, and identify the persons the hospital facility consulted
.................
5
Yes
6 a
Was the hospital facility’s CHNA conducted with one or more other hospital facilities? If "Yes," list the other hospital facilities in Section C
..................................
6a
Yes
b
Was the hospital facility’s CHNA conducted with one or more organizations other than hospital facilities?” If “Yes,” list the other organizations in Section C.
............................
6b
Yes
7
Did the hospital facility make its CHNA report widely available to the public?
..............