Form Schedule H (F 990) Schedule H (F 990) Hospitals

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I.R.S. SPECIFICATIONS
TO BE REMOVED BEFORE PRINTING
INSTRUCTIONS TO PRINTERS
SCHEDULE H (FORM 990) PAGE 1 of 4
MARGINS: TOP 13 mm (1⁄2 "), CENTER SIDES.
PRINTS: FACE ONLY
PAPER: WHITE WRITING, SUB. 20.
INK: BLACK
FLAT SIZE: 216 mm (81⁄2 ")  279 mm (11")
PERFORATE: NONE
DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

SCHEDULE H
(Form 990)

Date

䊳

Signature

O.K. to print
Revised proofs
requested

OMB No. 1545-0047

Hospitals

Department of the Treasury
Internal Revenue Service

2008

To be completed by organizations that answer “Yes” to
Form 990, Part IV, line 20.

Name of the organization

Part I

Action

Open to Public
Inspection
Employer identification number

Charity Care and Certain Other Community Benefits at Cost (Optional for 2008)
Yes

1a Does the organization have a charity care policy? If “No,” skip to question 6a
b If “Yes,” is it a written policy?
2 If the organization has multiple hospitals, indicate which of the following best describes application of the
charity care policy to the various hospitals.
applied uniformly to most hospitals
applied uniformly to all hospitals
generally tailored to individual hospitals

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3

Answer the following based on the charity care eligibility criteria that applies to the largest number of the
organization’s patients.
a Does the organization use Federal Poverty Guidelines (FPG) to determine eligibility for providing free care to low income
individuals? If “Yes,” indicate which of the following is the family income limit for eligibility for free care:
100%
150%
200%
Other
%
b Does the organization use Federal Poverty Guidelines (FPG) to determine eligibility for providing discounted care to low
income individuals? If “Yes,” indicate which of the following is the family income limit for eligibility for discounted care:
350%
200%
250%
300%
400%
Other
%

c If the organization does not use FPG to determine eligibility, describe in Part VI the income based criteria for
determining eligibility for free or discounted care. Include in the description whether the organization uses an
asset test or other threshold, regardless of income, to determine eligibility for free or discounted care.
4 Does the organization’s policy provide free or discounted care to the “medically indigent”?
5a Does the organization budget amounts for free or discounted care provided under its charity care policy?
b If “Yes,” did the organization’s charity care expenses exceed the budgeted amount?
c If “Yes” to 5b, as a result of budget considerations, was the organization unable to provide free or discounted
care to a patient who was eligible for free or discounted care?
6a Does the organization prepare an annual community benefit report?
b If “Yes,” does the organization make it available to the public?
Complete the following table using the worksheets provided in the Schedule H instructions. Do not submit
these worksheets with the Schedule H.
7 Charity Care and Certain Other Community Benefits at Cost
Charity Care and
Means-Tested Programs

(a) Number of
activities or
programs
(optional)

(b) Persons
served
(optional)

(c) Total community
benefit expense

(d) Direct offsetting
revenue

No

1a
1b

3a

3b

4
5a
5b
5c
6a
6b

(e) Net community
benefit expense

(f) Percent
of total
expense

a Charity care at cost (from
worksheets 1 and 2)

b Unreimbursed Medicaid (from
worksheet 3, column a)

c Unreimbursed costs – other meanstested government programs (from
worksheet 3, column b)
d Total Charity Care and
Means-Tested Programs

Other Benefits
e Community health improvement
services and community benefit
operations (from worksheet 4)

f Health

professions
(from worksheet 5)

education

g Subsidized health services (from
worksheet 6)

h Research (from worksheet 7)
i Cash and in-kind contributions to
community groups (from
worksheet 8)
j Total Other Benefits
k Total (line 7d and 7j)
For Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 50192T

Schedule H (Form 990) 2008

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I.R.S. SPECIFICATIONS
TO BE REMOVED BEFORE PRINTING
INSTRUCTIONS TO PRINTERS
SCHEDULE H (FORM 990) PAGE 2 of 4
MARGINS: TOP 13 mm (1⁄2 "), CENTER SIDES.
PRINTS: FACE ONLY
PAPER: WHITE WRITING, SUB. 20.
INK: BLACK
FLAT SIZE: 216 mm (81⁄2 ")  279 mm (11")
PERFORATE: NONE
DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

Schedule H (Form 990) 2008

Part II

Page

Community Building Activities (Complete this table if the organization conducted any community
building activities) (Optional for 2008)
(a) Number of (b) Persons
activities or
served
programs
(optional)
(optional)

1

Physical improvements and housing

2
3

Economic development
Community support

4

Environmental improvements

5

Leadership development and training
for community members

6

Coalition building

7
8

Community health improvement
advocacy
Workforce development

9

Other

10

Total

Part III

(c) Total community
building expense

(d) Direct offsetting
revenue

(e) Net community
building expense

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(f) Percent of
total expense

Bad Debt, Medicare, & Collection Practices (Optional for 2008)

Section A—Bad Debt Expense
1
2
3

2

Yes No

Does the organization report bad debt expense in accordance with Healthcare Financial Management
Association Statement No. 15?
2
Enter the amount of the organization’s bad debt expense (at cost)
Enter the estimated amount of the organization’s bad debt expense (at cost) attributable
3
to patients eligible under the organization’s charity care policy

1

Provide in Part VI the text of the footnote to the organization’s financial statements that describes bad debt
expense. In addition, describe the costing methodology used in determining the amounts reported on lines
2 and 3, or rationale for including other bad debt amounts in community benefit.
Section B—Medicare
5
5 Enter total revenue received from Medicare (including DSH and IME)
6
6 Enter Medicare allowable costs of care relating to payments on line 5
7
7 Enter: line 5 less line 6—surplus or (shortfall)
4

Describe in Part VI the extent to which any shortfall reported in line 7 should be treated as community
benefit, and the costing methodology or source used to determine the amount reported on line 6 and indicate
which of the following methods was used:
cost accounting system
cost to charge ratio
Other
Section C—Collection Practices
9a Does the organization have a written debt collection policy?
b If “Yes,” does the organization’s collection policy contain provisions on the collection practices to be followed
for patients who are known to qualify for charity care or financial assistance?
8

Part IV

9a
9b

Management Companies and Joint Ventures (Optional for 2008)
(a) Name of entity

(b) Description of primary
activity of entity

(c) Organization’s
profit % or stock
ownership %

(d) Officers, directors, (e) Physicians’
trustees, or key
profit % or stock
employees’ profit %
ownership %
or stock ownership %

1
2
3
4
5
6
7
8
9
10
11
12
13
14
Schedule H (Form 990) 2008

1
I.R.S. SPECIFICATIONS
TO BE REMOVED BEFORE PRINTING
INSTRUCTIONS TO PRINTERS
SCHEDULE H (FORM 990) PAGE 3 of 4
MARGINS: TOP 13 mm (1⁄2 "), CENTER SIDES.
PRINTS: FACE ONLY
PAPER: WHITE WRITING, SUB. 20.
INK: BLACK
FLAT SIZE: 216 mm (81⁄2 ")  279 mm (11")
PERFORATE: NONE
DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

Schedule H (Form 990) 2008

Part V
IV

Page

3

Facility Information (Required for 2008)
ER–other

ER–24 hours

Research facility

Critical access hospital

Teaching hospital

Children’s hospital

General medical & surgical

Licensed hospital

Name and address

Other
(Describe)

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Schedule H (Form 990) 2008

1
I.R.S. SPECIFICATIONS

TO BE REMOVED BEFORE PRINTING

INSTRUCTIONS TO PRINTERS
SCHEDULE H (FORM 990), PAGE 4 of 4
PRINTS: HEAD to HEAD
MARGINS: TOP 13 mm (1⁄2 "), CENTER SIDES.
PAPER: WHITE WRITING, SUB. 20.
INK: BLACK
FLAT SIZE: 216 mm (81⁄2 ") x 835 mm (327⁄8 "),
PERFORATE: ON FOLD
FOLD TO: 216 mm (81⁄2 ") x 279 mm (11")

DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

Schedule H (Form 990) 2008

Part VI

Page

4

Supplemental Information (Optional for 2008)

Complete this part to provide the following information.
1 Provide the description required for Part I, line 3c, Part III, line 4, Part III, line 8, and Part III, line 9b.
2 Describe how the organization assesses the health care needs of the communities it serves—“Needs Assessment.”
3

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 charity care policy.
“Patient Education of Eligibility for Assistance.”

4

Describe the community the organization serves, taking into account the geographic area and demographic constituents it
serves. “Community Information.”

5

Describe how the organization’s community building activities, as reported in Part II, promote the health of the communities the
organization serves. “Community Building Activities.”

6

Provide any other information important to describing how the organization’s hospitals 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.).

7

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.
If applicable, identify all states with which the organization, or a related organization, files a community benefit report.

8

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Schedule H (Form 990) 2008