TY 2020 Form 990 Schedule H

Instrumentl eFile RenderObject ID: 202231339349300633 - Rendered 2024-04-30 TIN: 42-0818642

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.
MediumBullet

Attach to Form 990.
MediumBullet

Go to www.irs.gov/Form990EZ for instructions and the latest information.

OMB No. 1545-0047

2020

Open to Public Inspection

Name of the organization

Central Community Hospital

Employer identification number

42-0818642

Part I

Financial Assistance and Certain Other Community Benefits at Cost

Yes

Did the organization have a financial assistance policy during the tax year? If "No," skip to question 6a . . . .

Yes

If "Yes," was it a written policy? ......................

Yes

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

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.

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:

Yes

100% 150% 200% Other 30000.0000000000 %

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: . . . . . . . .

200% 250% 300% 350% 400% Other %

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.

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"? . . . . . . . . . . . . .

Yes

Did the organization budget amounts for free or discounted care provided under its financial assistance policy during
the tax year? . . . . . . . . . . . . . . . . . . . . . . .

Yes

If "Yes," did the organization's financial assistance expenses exceed the budgeted amount? . . . . . .

If "Yes" to line 5b, as a result of budget considerations, was the organization unable to provide free or discountedcare to a patient who was eligibile for free or discounted care? . . . . . . . . . . . . .

Did the organization prepare a community benefit report during the tax year? . . . . . . . . .

Yes

If "Yes," did the organization make it available to the public? . . . . . . . . . . . . .

Yes

Complete the following table using the worksheets provided in the Schedule H instructions. Do not submit these worksheets with the Schedule H.

Financial Assistance and Certain Other Community Benefits at Cost

Financial Assistance and Means-Tested Government Programs		(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) . . .	57,000		57,000	0.610 %
b	Medicaid (from Worksheet 3, column a) . . . . .
c	Costs of other means-tested government programs (from Worksheet 3, column b) . .
d	Total Financial Assistance and Means-Tested Government Programs . . . . .	57,000		57,000	0.610 %
Other Benefits
e	Community health improvement services and community benefit operations (from Worksheet 4).	40,558	7,000	33,558	0.360 %
f	Health professions education (from Worksheet 5) . . .
g	Subsidized health services (from Worksheet 6) . . . .	2,622,186	1,680,246	941,940	10.080 %
h	Research (from Worksheet 7) .
i	Cash and in-kind contributions for community benefit (from Worksheet 8) . . . .	2,133		2,133	0.020 %
j	Total. Other Benefits . .	2,664,877	1,687,246	977,631	10.460 %
k	Total. Add lines 7d and 7j .	2,721,877	1,687,246	1,034,631	11.070 %

For Paperwork Reduction Act Notice, see the Instructions for Form 990. Cat. No. 50192T Schedule H (Form 990) 2020

Schedule H (Form 990) 2020

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
4	Environmental improvements
5	Leadership development and training for community members
6	Coalition building
7	Community health improvement advocacy
8	Workforce development
9	Other
10	Total

Part III

Bad Debt, Medicare, & Collection Practices

Section A. Bad Debt Expense

Yes

Did the organization report bad debt expense in accordance with Healthcare Financial Management Association Statement No. 15? ..........................

Yes

Enter the amount of the organization's bad debt expense. Explain in Part VI the methodology used by the organization to estimate this amount. ......

27,783

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. ......

2,470

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

Enter total revenue received from Medicare (including DSH and IME).....

4,975,952

Enter Medicare allowable costs of care relating to payments on line 5.....

4,926,686

Subtract line 6 from line 5. This is the surplus (or shortfall)........

49,266

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

Did the organization have a written debt collection policy during the tax year? ..........

Yes

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 .........................

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) 2020

Page

Part VFacility 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?1Name, 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)
1	Central Community Hospital 901 Davidson St NW Elkader,IA520439015 www.mercyone.org/elkader 220051H	X	X	X	X

Schedule H (Form 990) 2020

Page 4

Part VFacility 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)

	Central Community Hospital
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

Community Health Needs Assessment

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?........................

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...............

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......................

Yes

If "Yes," indicate what the CHNA report describes (check all that apply):

A definition of the community served by the hospital facility

Demographics of the community

Existing health care facilities and resources within the community that are available to respond to the health needs of the community

How data was obtained

The significant health needs of the community

Primary and chronic disease needs and other health issues of uninsured persons, low-income persons, and minority groups

The process for identifying and prioritizing community health needs and services to meet the community health needs

The process for consulting with persons representing the community’s interests

The impact of any actions taken to address the significant health needs identified in the hospital facility's prior CHNA(s)

Other (describe in Section C)

Indicate the tax year the hospital facility last conducted a CHNA: 20 18

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 .................

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..................................

Yes

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. ............................

Yes

Did the hospital facility make its CHNA report widely available to the public?..............

Yes

If "Yes," indicate how the CHNA report was made widely available (check all that apply):

Hospital facility’s website (list url): See Part V, Page 8

Other website (list url):

Made a paper copy available for public inspection without charge at the hospital facility

Other (describe in Section C)

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. ..............

Yes

Indicate the tax year the hospital facility last adopted an implementation strategy: 20 18

Is the hospital facility's most recently adopted implementation strategy posted on a website?.........

Yes

If "Yes" (list url): See Part V, Page 8

If "No," is the hospital facility’s most recently adopted implementation strategy attached to this return? ......

10b

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

If "Yes" on line 12a, did the organization file Form 4720 to report the section 4959 excise tax?........

12b

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) 2020

Page 5

Part VFacility Information (continued)

Financial Assistance Policy (FAP)

	Central Community Hospital
Name of hospital facility or letter of facility reporting group

Yes

Did the hospital facility have in place during the tax year a written financial assistance policy that:

Explained eligibility criteria for financial assistance, and whether such assistance included free or discounted care?

Yes

If “Yes,” indicate the eligibility criteria explained in the FAP:

Federal poverty guidelines (FPG), with FPG family income limit for eligibility for free care of 300.000000000000%
and FPG family income limit for eligibility for discounted care of 300.000000000000%

Income level other than FPG (describe in Section C)

Asset level

Medical indigency

Insurance status

Underinsurance discount

Residency

Other (describe in Section C)

Explained the basis for calculating amounts charged to patients?.................

Yes

Explained the method for applying for financial assistance?...................

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):

Described the information the hospital facility may require an individual to provide as part of his or her application

Described the supporting documentation the hospital facility may require an individual to submit as part of his or
her application

Provided the contact information of hospital facility staff who can provide an individual with information about the
FAP and FAP application process

Provided the contact information of nonprofit organizations or government agencies that may be sources of
assistance with FAP applications

Other (describe in Section C)

Was widely publicized within the community served by the hospital facility?........

Yes

If "Yes," indicate how the hospital facility publicized the policy (check all that apply):

The FAP was widely available on a website (list url):

See Part V, Page 8

The FAP application form was widely available on a website (list url):

See Part V, Page 8

A plain language summary of the FAP was widely available on a website (list url):
See Part V, Page 8

The FAP was available upon request and without charge (in public locations in the hospital facility and by mail)

The FAP application form was available upon request and without charge (in public locations in the hospital facility
and by mail)

A plain language summary of the FAP was available upon request and without charge (in public locations in the
hospital facility and by mail)

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

Notified members of the community who are most likely to require financial assistance about availability of the FAP

The FAP, FAP application form, and plain language summary of the FAP were translated into the primary language(s)
spoken by LEP populations

Other (describe in Section C)

Schedule H (Form 990) 2020

Page 6

Part VFacility Information (continued)

Billing and Collections

	Central Community Hospital
Name of hospital facility or letter of facility reporting group

Yes

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?..................................

Yes

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:

Reporting to credit agency(ies)

Selling an individual’s debt to another party

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

Actions that require a legal or judicial process

Other similar actions (describe in Section C)

None of these actions or other similar actions were permitted

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?............

If "Yes," check all actions in which the hospital facility or a third party engaged:

Reporting to credit agency(ies)

Selling an individual’s debt to another party

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

Actions that require a legal or judicial process

Other similar actions (describe in Section C)

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):

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)

Made a reasonable effort to orally notify individuals about the FAP and FAP application process (if not, describe in
Section C)

Processed incomplete and complete FAP applications (if not, describe in Section C)

Made presumptive eligibility determinations (if not, describe in Section C)

Other (describe in Section C)

None of these efforts were made

Policy Relating to Emergency Medical Care

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?..................

Yes

If "No," indicate why:

The hospital facility did not provide care for any emergency medical conditions

The hospital facility’s policy was not in writing

The hospital facility limited who was eligible to receive care for emergency medical conditions (describe in Section C)

Other (describe in Section C)

Schedule H (Form 990) 2020

Page 7

Part VFacility Information (continued)

Charges to Individuals Eligible for Assistance Under the FAP (FAP-Eligible Individuals)

	Central Community Hospital
Name of hospital facility or letter of facility reporting group

Yes

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.

The hospital facility used a look-back method based on claims allowed by Medicare fee-for-service during a prior 12-month period

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

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

The hospital facility used a prospective Medicare or Medicaid method

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? ...............................

If "Yes," explain in Section C.

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? ...........................

Yes

If "Yes," explain in Section C.

Schedule H (Form 990) 2020

Page 8

Part V

Facility Information (continued)

Section C. Supplemental Information for Part V, Section B. Provide descriptions required for Part V, Section B, lines 2, 3j, 5, 6a, 6b, 7d, 11, 13b, 13h, 15e, 16j, 18e, 19e, 20a, 20b, 20c, 20d, 20e, 21c, 21d, 23, and 24. If applicable, provide separate descriptions for each hospital facility in a facility reporting group, designated by facility reporting group letter and hospital facility line number from Part V, Section A (“A, 1,” “A, 4,” “B, 2,” “B, 3,” etc.) and name of hospital facility.
Form and Line Reference	Explanation
Central Community Hospital	Part V, Section B, Line 5: In February 2018, MercyOne Elkader Medical Center and Clayton County Public Health met to begin planning the Community Health Needs Assessment (CHNA) process. In March 2018, representatives from MercyOne Elkader Medical Center, Guttenberg Municipal Hospital, Clayton County Public Health, Clayton County Emergency Management, Medical Associates, Clayton County Visiting Nurses Association and Home Health met to formulate a survey that could be sent out to residents and organizations of Clayton County. The survey was developed and marketed to the community and local business through email, Facebook and the MercyOne Elkader Medical Center community newsletter (county-wide distribution) in the months of April and May. The survey closed on May 25, 2018. On May 30, 2018, Clayton County Public Health and MercyOne Elkader Medical Center hosted a meeting for Clayton County stakeholders to review the results of the survey as well bring additional relevant data that could help in the CHNA process. During this meeting, the group reviewed and updated the 2016-2018 health improvement plans, reviewed the results of the survey as well as other data brought to the meeting by stakeholders and prioritized areas of need based on the data. On August 30, 2018 this same group met again to review the prioritized areas of need based on the CHNA data and create a 2019 - 2021 community health improvement plan (HIP). This HIP is a collaborative effort that addresses health problems in the community over a period of time and defines a vision of health of the community. For each priority area, existing efforts and resources were examined, new efforts identified, and goals and objectives established. Between September and December 2018, the community health improvement plan was developed and refined. In January 2019, the community health improvement plan received support from the MercyOne Elkader Medical Center Board of Directors. The report was made available in February 2019.
Central Community Hospital	Part V, Section B, Line 6a: The community health needs assessment was conducted with Guttenberg Municipal Hospital & Clinics in Guttenberg, Iowa.
Central Community Hospital	Part V, Section B, Line 6b: The CHNA was conducted with Clayton County Public Health.
Central Community Hospital	Part V, Section B, Line 11: The five priority areas identified in the CHNA are addressed in the 2019 - 2021 Community Health Improvement Plan for MercyOne Elkader Medical Center and Clayton County Public Health. The number and scope of the priorities selected are reasonable to address given the time and resources available in Clayton County. Below is a listing of the five priorities identified along with a summary of the goals that were set for the 2019 - 2021 timeframe. Priority Area #1: Mental Health 1. By 2021, improve communication within the community on current entry points into Mental Health Services and work towards creating additional entry points. 2. By 2021, collaborate with community partners to reduce nicotine use and the misuse of alcohol and drugs, including prescription drugs (ex. Opioids). 3. By 2021, increase awareness of signs and symptoms of suicidal thoughts and behaviors. 2020 Progress: MercyOne Elkader is currently contracted with Integrated Telehealth Partners to provide consults to patients who are in crisis. This is paid for entirely by county social services at this point in time and is not billed to the patient. It is a great community benefit that the hospital can facilitate to those in need. The hospital Facebook page is a great way to promote resources for those who may need help with quitting smoking, drug-use or mental health concerns. The hospital has partnered with Avera Health and MercyOne Dubuque Medical Center to offer resources to emergency responders and hospital staff after an in-hospital or in-field crisis. MercyOne Elkader has chosen to move forward with Mental Health First Aid training in 2021. We will offer it to community partners as well. Priority Area #2: Emergency Preparedness 1. By 2021, increase community awareness of the "Stop the Bleed" program. 2. By 2021, strengthen the EMS system in Clayton County. 3. By 2021, increase communication between hospitals, EMS, local agencies and law enforcement during community emergencies. 4. By 2021, increase community awareness of CPR training and recertification classes. 5. By 2021, all law enforcement and fire departments within Clayton County have AED units in their response vehicles. 6. By 2021, research and implement other types of training and/or resources that might be able to be offered to assist first responders as they deal with the after effects of emergencies. 2020 Progress - Priority Area #2: Emergency PreparednessThe MercyOne Elkader Medical Center ER and MercyOne Elkader Ambulance teams have been teaching community "Stop the Bleed Programs". MercyOne Elkader Ambulance transitioned in 2018 towards 24/7/365 Paramedic coverage for the community. The ambulance is able to respond to other first responder units who are in need of a Paramedic in the county. The City of Elkader purchased a third ambulance for MercyOne Elkader Ambulance in December 2018. With three ambulances in the fleet this has allowed the service to handle multiple 911 calls and transfers at the same time - which ultimately helps patients get access to healthcare quickly. Recuitment efforts continue to be a challenge for the service.MercyOne Elkader Medical Center has one EMS staff member who is certified to teach ACLS and PALS. MercyOne Elkader Medical Center has six EMS staff and one RN, qualified BLS instructors. The hospital has been marketing their ability to provide CPR training to the community/businesses.MercyOne Elkader Medical Center and the Central Community Hospital Foundation partnered together to implement a grant program for the area non-profits to obtain AEDs. Those organizations that were awarded the grant have 50% of the cost of an AED paid for by the partnership. No-cost training is available for employees/patrons through MercyOne Elkader EMS team. MercyOne Elkader obtained a fit testing machine. Offered fit testing at no charge to partner agencies in the county during the pandemic.The hospital has partnered with Avera Health and MercyOne Dubuque Medical Center to offer resources to emergency responders and hospital staff after an in-hospital or in-field crisis. MercyOne Elkader supported a paramedic getting certified in Nonviolent Crisis Intervention Training Program. This program was offered to staff within the hospital in 2020.The Covid-19 pandemic continued through 2020 and emergency preparedness/execution of public health response work continued between county/state agencies. Huge emphasis on vaccination roll-out and operations. Priority Area #3: Obesity 1. By 2021, reduce the risk for obesity and chronic disease through health promotion programs which facilitate healthy lifestyle changes. 2020 Progress - Priority Area #3: ObesityThe hospital offers diabetic educator sessions with our licensed dietician/diabetic educator. This same person also is able to go to the local school to talk about healthy eating. School visits were paused during the pandemic.Priority Area #4: Caregiver Support 1. By 2021, improve communication regarding available resources for caregivers in Clayton County. (Baseline: No county wide resource list) 2. By 2021, investigate potential community partners for assisting with disease related caregiver support groups. 2020 Progress - Priority Area #4: Caregiver SupportMercyOne Elkader has continued exploring who the community partners are that are able to assist with caregiver support. The pandemic has challenged healthcare entities due to restrictions on group gatherings. Priority Area #5: Environment 1. By 2021, increase community awareness of incidence and mitigation of Radon gas. 2. By 2021, increase community awareness of water quality and testing. 3. By 2021, increase the availability of sharps containers in public areas in Clayton County. **2020 Progress - Priority Area #5: EnvironmentMercyOne Elkader Medical Center did add sharps containers to restrooms in the hospital in 2018. The hospital is looking to partner with the City of Elkader to help with marketing water quality testing and radon gas testing.
Central Community Hospital	Part V, Section B, Line 13h: Patients whose family income exceeds 300% of the FPG may be eligible to receive free care on a case-by-case basis based on their specific circumstances, such as catastrophic illness or medical indigence, at the discretion of Central Community Hospital. There are instances when a patient may appear eligible for financial discounts, but there is no financial assistance form on file or a lack of supporting documentation. Central Community Hospital may use outside agencies to determine eligibility. These resources may use demographic and household information and/or credit scoring technology to determine eligibility. Patients who meet presumptive eligibility criteria may be granted financial assistance without completing the application. Presumptive eligibility awards must be 100% discounts. Other forms of presumptive eligibility include: bankruptcy, death with no estate resources, and Title XIX eligible and receiving non-covered services.
Central Community Hospital	Part V, Section B, Line 16j: At the time of registrations, CCH staff makes every effort to determine if a patient may possibly need or qualify for any financial assistance. We notify patients of the availability of these programs by posting information in our registration and emergency room areas. We offer a private meeting with a financial counselor. Inpatients are offered an opportunity to meet with the counselor upon discharge. Financial assistance information is provided in all correspondence regarding patient bills. Our financial counselor attempts phone contact whenever possible.
Central Community Hospital	Part V, Section B, Line 24: All individuals eligible under the hospital financial assistance policy are provided a discount for emergency and other medically necessary care. The financial assistance policy does not apply to elective procedures. Therefore, FAP-eligible patients without insurance may be charged gross charges on elective procedures.
Part V, Section B, line 7a:	Community Health Needs Assessmenthttps://www.mercyone.org/elkader/about-us/community-benefit
Part V, Section B, Line 10a:	Implementation Strategyhttps://www.mercyone.org/elkader/about-us/community-benefit
Part V, Section B, Line 16a-c:	Financial Assistance Policy, Financial Assistance Application and Financial Assistance Plain Language Summary:https://www.mercyone.org/elkader/for-patients/billing-and-financial-information/financial-assistance

Schedule H (Form 990) 2020

Page 9

Part VFacility Information (continued)

Section D. Other Health Care Facilities That Are Not Licensed, Registered, or Similarly Recognized as a Hospital Facility (list in order of size, from largest to smallest) How many non-hospital health care facilities did the organization operate during the tax year?
Name and address		Type of Facility (describe)
1
2
3
4
5
6
7
8
9
10

Schedule H (Form 990) 2020

Page 10

Part VI

Supplemental Information

Provide the following information.

1	Required descriptions. Provide the descriptions required for Part I, lines 3c, 6a, and 7; Part II and Part III, lines 2, 3, 4, 8 and 9b.
2	Needs assessment. Describe how the organization assesses the health care needs of the communities it serves, in addition to any CHNAs reported in Part V, Section B.
3	Patient education of eligibility for assistance. Describe how the organization informs and educates patients and persons who may be billed for patient care about their eligibility for assistance under federal, state, or local government programs or under the organization’s financial assistance policy.
4	Community information. Describe the community the organization serves, taking into account the geographic area and demographic constituents it serves.
5	Promotion of community health. Provide any other information important to describing how the organization’s hospital facilities or other health care facilities further its exempt purpose by promoting the health of the community (e.g., open medical staff, community board, use of surplus funds, etc.).
6	Affiliated health care system. If the organization is part of an affiliated health care system, describe the respective roles of the organization and its affiliates in promoting the health of the communities served.
7	State filing of community benefit report. If applicable, identify all states with which the organization, or a related organization, files a community benefit report.

Form and Line Reference	Explanation
Part I, Line 3c:	The Hospital does not offer discounted care.
Part I, Line 6a:	The community benefit report is available at the front desk of the facility. It can also be found on its website at https://www.mercyone.org/elkader/about-us/community-benefit
Part I, Line 7:	Charity care expense was reported at cost on line 7a based on an overall cost-to-charge ratio which addresses all patient segments. Community health improvement services on line 7e and cash and in-kind contributions for community benefit on line 7i were determined using the general ledger. The cost for subsidized health services on line 7g was determined using the Medicare Cost Report.
Part III, Line 2:	The Medical Center determines its estimate of implicit price concessions based on its historical collection experience with this class of patients.
Part III, Line 3:	A reasonable estimate of the Hospital's implicit price concessions attributable to patients eligible under the charity care policy is 8.89% of implicit price concessions. This is based on the percentage of individuals below the poverty level in the area.
Part III, Line 4:	The footnote to the Organization's financial statements can be found on pages 11-13 of the attached audited financial statements.
Part III, Line 8:	Central Community Hospital has a Medicare shortfall and considers this a community benefit. The Hospital provides services to Medicare patients regardless of the shortfall because access to healthcare and individual's health is important. Total revenue received from Medicare is the gross reimbursement plus settlement. Both total revenue received from Medicare and the Medicare allowable costs are reported from the Medicare Cost Report. The Medicare Cost Report is completed based on the rules and regulations set forth by Centers for Medicare and Medicaid Services.Hospital services reimbursed on a fee schedule are not included in the Medicare calculation per the 990 instructions. Had this been reported the total loss from Medicare services would have been $266,427Medicare fee schedule revenue $ 310,224Medicare estimated costs of care relating to payments (576,651)Net (Shortage) $ (266,427)
Part III, Line 9b:	We send 4 statements in house. After 30 days past due, we start sending letters to inform patients about our financial assistance and the amount past due. The final letter the patient gets is during the last statement, informing them of the date the account will go to collections. Once the account is sent to collections, our collection agency is waiting another 120 days before they credit report, allowing the patient that time to apply for financial assistance.
Part VI, Line 2:	The Community Health Needs Assessment (CHNA) and Community Health Improvement Plan was made available to the public and posted to the website in February 2019. The assessment was conducted beginning February 2018 in conjunction with Clayton County Public Health, Guttenberg Municipal Hospital (Guttenberg, Iowa also in Clayton County) and multiple other agencies within the county. Five priorities areas were identified and incorporated into the Community Health Improvement Plan for the county Mental Health, Emergency Preparedness, Obesity, Caregiver Support and Environment.MercyOne Elkader Medical Center continuously monitors the needs of the community by revisiting the community health improvement plan and updating the plan with actions taken as well as new strategies that need to be deployed based on new data. MercyOne Elkader Medical Center is an active partner with the local schools, city/townships, hospitals, public health agencies, emergency management agencies, law enforcement, fire and EMS and often is made aware of community needs through those partnerships. MercyOne Elkader Medical Center also partners with the Clayton County VNA (public health) on their CHNA/Health Improvement Plan and gathers information from that process in terms of community needs.
Part VI, Line 3:	At the time of registrations, staff makes every effort to determine if a patient may possibly need or qualify for any financial assistance. We notify patients of the availability of these programs by posting information in our registration and emergency room areas. We offer a private meeting with a financial counselor. Inpatients are offered an opportunity to meet with the counselor upon discharge. Financial assistance information is provided in all correspondence regarding patient bills. Our financial counselor attempts phone contact whenever possible. Our charity program information is available on our website.
Part VI, Line 4:	Central Community Hospital serves the residents of the central part of Clayton County into the northeast section of the county. It is a rural, agricultural area. The geographic area of Clayton County is 793 square miles. The nearest larger city is Dubuque, Iowa, which is 72 miles from Elkader, the county seat. Clayton County has a population of 17,672 (American Community Survey) and is the fifth-largest county in Iowa by area. In 2018, the median household income of Clayton County residents was $52,828. 10.9% of Clayton County children under 18 live in poverty. The median age for Clayton County residents is 47.1 years. The largest Clayton County racial/ethnic groups are White (97.4%), Black (1.0%) Other (1.6%).
Part VI, Line 5:	Central Community Hospital's board members reside in the primary service area. None of the board members are employed by the Hospital nor are they contractors of the Hospital. None of the board members have family members employed by Central Community Hospital. Central Community Hospital extends hospital privileges to all qualified physicians in our service area extending to Dubuque, Iowa, where specialists serve our area. Central Community Hospital encourages specialists to offer clinics in our facility to improve access for our local residents. Many of the older patients are apprehensive to drive 72 miles one-way to a large city to see a specialist. When the Hospital creates its budget, efforts are made by the Administrative Team to allocate funds to improve patient care through updating equipment, expanding supplies or hiring staff. Each year dollars are allocated to improve services based on recommendations submitted by department managers or the Administrative Team.The management team and board work to align the Community Health Needs Assessment with hospital budget/goals. The management team takes these goals and works to inspire staff to cooperatively improve the health of the community. Any surplus that is present at the end of the fiscal year is invested back into the organization in a form of capital dollars. These capital dollars are invested in equipment or projects that help meet the needs of the community. CCH partners with the City of Elkader on the EMS service. The hospital employs all of the staff, provides Medical Directorship, purchases equipment/supplies/medications, pays for half of the gas and does all of the billing. The City of Elkader purchases/maintains the ambulances, provides storage for the ambulances, pays for insurance and half of the gas. The City of Elkader does receive dollars from local townships that can help defray the cost of the ambulances/maintenance.There are two critical access hospitals in Clayton County, Iowa - Central Community Hospital (CCH) in Elkader, Iowa and Guttenberg Municpal Hospital & Clinics in Guttenberg, Iowa. Central Community Hospital is 25-30 minutes away from Guttenberg Municipal Hospital & Clinics as well as the same distance away from the three other critical access hospitals. The residents of Elkader and surrounding areas depend on the emergency room being available 24/7/365 when an emergency health need arises. The hospital also employs all EMS personnel. The service is also available 24/7/365 for all 911 calls and transfer calls. The hospital works relentlessly to ensure that coverage for both the ER and the EMS service is always available for the community, in an increasingly tough recruitment market. If these services were not available - the community would suffer tremendously. It is a huge task to ensure that healthcare personnel are up to date on all required training. We offer training for physicians, APPs, nurses and EMS personnel each year in CPR-BLS, CPR-ACLS, CPR-PALS, CPR-NRP, ATLS, TNCC.CCH has been involved in community workgroups and coalitions. The hospital is involved in the Clayton County Coalition that involves other healthcare providers, public health and emergency management. The hospital is also involved in a regional coalition that includes six other counties that works towards emergency preparedness strategies together. The hospital also participates in the Hospital Alliance for Preparedness in Iowa (HAPI).
Part VI, Line 6:	Central Community Hospital had a management agreement with Mercy Health Network, Des Moines, IA until 09/30/2018. On 10/01/2018, Central Community Hospital became a wholly-owned subsidiary of Mercy Health Network. Central Community Hospital adopted a d/b/a of MercyOne Elkader Medical Center and MercyOne Elkader Ambulance on February 1, 2019, the same day that Mercy Health Network adopted the d/b/a of MercyOne. There are over 25+ affinity meetings on a regular basis covering all aspects of services in the hospital (administrative, clinical, supportive). The staff of MercyOne are available daily to answer questions, provide assistance with policies and procedures and assign experts to offer classes, webinars, written materials and telephone conferences. They offer additional services that include provider recruitment, legal services and administrative support for major decision-making projects including major construction, adding service line or addressing new regulatory mandates. CCH continues to have a Critical Access Hospital Network Agreement with MercyOne Dubuque Medical Center - Dubuque, IA to meet the regulations regarding support for critical access hospital designation including transportation, communication, quality and credentialing. MercyOne Dubuque Medical Center - Dubuque IA is committed to supporting health care in rural areas as demonstrated by their joint operations with Medical Associates of Dubuque of their subsidiary, Family Care Network, and the clinics that operate in Elkader and Monona.

Schedule H (Form 990) 2020

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