WIXLIB

“Proportionate share” is defined as theending capital account percentage listedon the Schedule K-1 (Form 1065),Partner's Share of Income, Deductions,Credits, etc., Part II, line J, for thepartnership tax year ending in theorganization's tax year being reported onthe organization's Form 990. IfSchedule K-1 (Form 1065) isn't available,the organization can use other businessrecords to make a reasonable estimate,including the most recently availableSchedule K-1 (Form 1065), adjusted asappropriate to reflect facts known to theorganization, or information used forpurposes of determining its proportionateshare of the venture for the organization'sfinancial statements.5. In the case of a group return filedby the hospital organization, hospitalfacilities operated directly by members ofthe group exemption included in thegroup return, hospital facilities operated bya disregarded entity of which a memberincluded in the group return is the solemember, hospital facilities operated by ajoint venture treated as a partnership tothe extent of the group member'sproportionate share (determined in themanner described in 4, earlier), and otherhealth care facilities or programs of amember included in the group return evenif such programs are provided separatelyfrom the hospital's license.Example. The organization is the solemember of a disregarded entity. Thedisregarded entity owns 50% of a jointventure treated as a partnership. Thepartnership in turn owns 50% of anotherjoint venture treated as a partnership thatoperates a hospital and a freestandingoutpatient clinic that isn't part of thehospital's license. (Assume theproportionate shares of the partnershipsbased on capital account percentageslisted on the partnerships' Schedule K-1(Form 1065), Part II, line J, are also 50%.)The organization would report 25% (50%of 50%) of the hospital's and outpatientclinic's combined information onSchedule H (Form 990).Note that while information from all theabove sources is combined for purposesof Schedule H (Form 990), theorganization is required to list and provideinformation regarding each of its hospitalfacilities in Part V, Sections A, B, and C,whether operated directly by theorganization or through a disregardedentity or joint venture treated as apartnership. In addition, the organizationmust list in Part V, Section D, each of itsother health care facilities (for example,rehabilitation clinics, other outpatientclinics, diagnostic centers, skilled nursingfacilities) that it operated during the taxyear, whether operated directly by theorganization or through a disregardedentity or a joint venture treated as apartnership.Organizations aren't to enterinformation from hospitals located outsidethe United States in Parts I, II, III, or V.Information from foreign joint ventures andpartnerships must be reported in Part IV,Management Companies and JointVentures. Information concerning foreignhospitals and facilities may be describedin Part VI.Except as provided in Part IV, don'treport on Schedule H (Form 990)information from an entity organized as aseparate legal entity from the organizationand treated as a corporation for federalincome tax purposes (except for membersof a group exemption included in a groupreturn filed by the organization), even ifsuch entity is affiliated with or otherwiserelated to the organization (for example,part of an affiliated health care system).If an organization isn't required to file Form990 but chooses to do so, it must file acomplete return and provide all of theinformation requested, including therequired schedules.An organization that didn't operate one ormore facilities during the tax year thatsatisfy the definition of hospital facilityabove shouldn't file Schedule H (Form990).The definition of “hospital” forTIP Schedule A (Form 990), PublicCharity Status and Public Support,Part I, line 3, and the definition of “hospital”for Schedule H (Form 990) aren't thesame. Accordingly, an organization thatchecks box 3 in Part I of Schedule A (Form990) to enter that it is a hospital orcooperative hospital service organization,must complete and attach Schedule H toForm 990 only if it meets the definition ofhospital facility for purposes ofSchedule H (Form 990), as explainedabove.Specific InstructionsPart I. FinancialAssistance and CertainOther Community Benefitsat CostPart I requires reporting of financialassistance policies, the availability ofcommunity benefit reports, and the cost offinancial assistance and other communitybenefit activities and programs.Worksheets and accompanyinginstructions are provided at the end of theinstructions to this schedule to assist incompleting the table in Part I, line 7.Line 1. A financial assistance policy(FAP), sometimes referred to as a charity-2-care policy, is a policy describing how theorganization will provide financialassistance at its hospital(s) and otherfacilities, if any. Financial assistanceincludes free or discounted healthservices provided to persons who meetthe organization's criteria for financialassistance and are unable to pay for all ora portion of the services. Financialassistance doesn't include: bad debt oruncollectible charges that the organizationrecorded as revenue but wrote off due to apatient's failure to pay, or the cost ofproviding such care to such patients; thedifference between the cost of careprovided under Medicaid or othermeans-tested government programs orunder Medicare and the revenue derivedtherefrom; self-pay or prompt paydiscounts; or contractual adjustments withany third-party payors.Line 2. Check only one of the threeboxes. “Applied uniformly to all hospitals”means that all of the organization'shospital facilities use the same financialassistance policy. “Applied uniformly tomost hospitals” means that the majority ofthe organization's hospital facilities usethe same financial assistance policy.“Generally tailored to individual hospitals”means that the majority of theorganization's hospital facilities usedifferent financial assistance policies. Ifthe organization operates only onehospital facility, check “Applied uniformlyto all hospitals.”Line 3. Answer lines 3a, 3b, and 3c,based on the financial assistance eligibilitycriteria that apply to (1) the largest numberof the organization's patients based onpatient contacts or encounters, or (2) if theorganization doesn't operate its ownhospital facility, the largest number ofpatients of a hospital facility operated by ajoint venture in which the organizationhas an ownership interest. For example, ifthe organization has two hospital facilities,use the financial assistance eligibilitycriteria used by the hospital facility thathas the most patient contacts orencounters during the tax year.Line 3a. “Federal Poverty Guidelines”(FPG) are the Federal Poverty Guidelinespublished annually by the U.S.Department of Health and HumanServices. If the organization hasestablished a family or household incomethreshold that a patient must meet or fallbelow to qualify for free medical care,check the box in the “Yes” column andindicate the specific threshold by checkingthe appropriate box. For instance, if apatient's family or household income mustbe less than or equal to 250% of FPG forthe patient to qualify for free care, thencheck the box marked “Other” and enter“250%.”Instructions for Schedule H

Line 3b. If the organization hasestablished a family or household incomethreshold that a patient must meet or fallbelow to qualify for discounted medicalcare, check the box in the “Yes” columnand indicate the specific threshold bychecking the appropriate box.Line 3c. If applicable, describe theother criteria used, such as asset test orother means test or threshold for free ordiscounted care, on Part VI, line 1, of thisschedule. An “asset test” includes (i) alimit on the amount of total or liquid assetsthat a patient or the patient's family orhousehold can own for the patient toqualify for free or discounted care, and/or(ii) a criterion for determining the level ofdiscounted medical care patients canreceive, depending on the amount ofassets that they and/or their families orhouseholds own.Line 4. “Medically indigent” meanspersons whom the organization hasdetermined are unable to pay some or allof their medical bills because their medicalbills exceed a certain percentage of theirfamily or household income or assets (forexample, due to catastrophic costs orconditions), even though they haveincome or assets that otherwise exceedthe generally applicable eligibilityrequirements for free or discounted careunder the organization's financialassistance policy.Line 5. Answer lines 5a, 5b, and 5cbased on the organization's budgetedamounts under its financial assistancepolicy.Line 5a. Answer “Yes” if theorganization established or had in place atany time during the tax year an annual orperiodic budgeted amount of free ordiscounted care to be provided under itsfinancial assistance policy. If “No,” skip toline 6a.Line 5b. Answer “Yes” if the free ordiscounted care the organization providedin the applicable period exceeded thebudgeted amount of costs or charges forthat period. If “No,” skip to line 6a.Line 5c. Answer “Yes” if theorganization denied financial assistance toany patient eligible for free or discountedcare under its financial assistance policyor under any of its hospital facilities'financial assistance policies because theorganization's or the facility's financialassistance budget was exceeded.Line 6. Answer lines 6a and 6b based onthe community benefit report that theorganization prepared for the organizationas a whole during the tax year.Line 6a. Answer “Yes” if theorganization prepared a written reportduring the tax year that describes theInstructions for Schedule Horganization's programs and services thatpromote the health of the community orcommunities served by the organization. Ifthe organization's community benefitreport is contained in a report prepared bya related organization, answer “Yes” andidentify the related organization on Part VI,line 1. If “No,” skip to line 7.Line 6b. Answer “Yes” if theorganization made the community benefitreport it prepared during the tax yearavailable to the public.Examples of how an organizationTIP can make its community benefitreport available to the public are:to post the report on the organization'swebsite and to make a paper copy of thecommunity health needs assessment(CHNA) report available for publicinspection upon request and withoutcharge at the hospital facility.Lines 7a through 7k. Enter on the table(lines 7a through 7k), at cost, theorganization's financial assistance (asdefined in the instructions for line 1) andcertain other community benefits. Enter online 7i contributions that the organizationrestricts, in writing, to one or more of thecommunity benefit activities listed on lines7a through 7h. Don't enter suchcontributions on lines 7a through 7h. Tocalculate the amounts to be entered onthe table, use the worksheets or otherequivalent documentation thatsubstantiates the information enteredconsistent with the methodology used onthe worksheets. See the instructions to theworksheets for definitions of the varioustypes of community benefit (for example,community health improvement services,health professions education, subsidizedhealth services, research, etc.) to beentered on lines 7a through 7k. Don’tinclude bad debt in these amounts. Baddebt will be entered in Part III.If the organization completedTIP worksheets other than on acombined basis (for example,facility by facility, joint venture by jointventure), the organization should combineall information from these worksheets forpurposes of entering amounts on thetable. Only the portion of each jointventure or partnership that represents theorganization's proportionate share, basedon capital interest, can be entered on lines7a through 7k. See Purpose of Schedulefor instructions on aggregation.Use the organization's most accuratecosting methodology (cost accountingsystem, cost-to-charge ratio, or other) tocalculate the amounts entered on thetable. If the organization uses acost-to-charge ratio, it can use Worksheet2, Ratio of Patient Care Cost to Charges,for this purpose. See the instructions for-3-Part VI, line 1, regarding an explanation ofthe costing methodology used to calculatethe amounts entered on the table.If the organization included any costsfor a physician clinic as subsidized healthservices on Part I, line 7g, enter thesecosts on Part VI, line 1.If the organization included any baddebt expense on Form 990, Part IX,line 25, but subtracted this bad debt forpurposes of calculating the amountentered on line 7, column (f), enter thisbad debt expense on Part VI, line 1.The following are descriptions of thetype of information reported in eachcolumn of the table.Column (a). “Number of activities orprograms” means the number of theorganization's activities or programsconducted during the year that involve thecommunity benefit entered on the line.Enter each activity and program on onlyone line so that it isn't counted more thanonce. Entering in this column is optional.Column (b). “Persons served” meansthe number of patient contacts orencounters in accordance with the filingorganization's records. Persons servedcan be entered in multiple rows, asservices across different categories maybe provided to the same patient. Enteringin this column is optional.Column (c). “Total community benefitexpense” means the total gross expenseof the activity incurred during the year,calculated by using the pertinentworksheets for each line item. “Totalcommunity benefit expense” includes both“direct costs” and “indirect costs. ”“ Directcosts” means salaries and benefits,supplies, and other expenses directlyrelated to the actual conduct of eachactivity or program. “Indirect costs” meanscosts that are shared by multiple activitiesor programs, such as facilities andadministrative costs related to theorganization's infrastructure (space,utilities, custodial services, security,information systems, administration,materials management, and others).Column (d). “Direct offsettingrevenue” means revenue from the activityduring the year that offsets the totalcommunity benefit expense of that activity,as calculated on the worksheets for eachline item. “Direct offsetting revenue”includes any revenue generated by theactivity or program, such as payment orreimbursement for services provided toprogram patients.“Direct offsetting revenue” also includesrestricted grants or contributions that theorganization uses to provide a communitybenefit, such as a restricted grant toprovide financial assistance or fundresearch. “Direct offsetting revenue”

doesn't include unrestricted grants orcontributions that the organization uses toprovide a community benefit.Organizations may describe anyinconsistencies from reporting in prioryears in Part VI.Examples. The organization receivesa restricted grant from an unrelatedorganization that must be used by theorganization to provide financialassistance. The amount of the restrictedgrant is entered as direct offsettingrevenue on line 7a, column (d).The organization receives anunrestricted grant from an unrelatedorganization. The organization decides touse the grant to increase the amount offinancial assistance it provides. Theamount of the unrestricted grant isn'tentered as direct offsetting revenue online 7a, column (d).Columns (e) and (f). Don't enternegative numbers. If the net communitybenefit expense is less than 0, enter “0.”Similarly, don't enter a negative percent incolumn (f), but enter “0.”Group return filers. The “totalexpense” denominator for purposes ofdetermining the percent of total expensefor column (f) is the amount entered onForm 990, Part IX, line 25, column (A), ofthe group return.Column (f) “percent of totalTIP expense” is based on column (e)“net community benefit expense,”rather than column (c) “total communitybenefit expense.” Organizations that enteramounts of direct offsetting revenue mightalso wish to enter total community benefitexpense (Part I, line 7, column (c)) as apercentage of total expenses. Althoughthis percentage cannot be entered on PartI, line 7, column(f), it can be entered onSchedule H (Form 990), Part VI, line 1.Optional Worksheets forPart I, Line 7 (FinancialAssistance and CertainOther Community Benefitsat Cost)Worksheets 1 through 8 are intended toassist the organization in completingSchedule H (Form 990), Part I, lines 7athrough 7k. Use of the worksheets isn'trequired and they shouldn't be filed withForm 990. The organization can usealternative equivalent documentation,provided that the methodology describedin these instructions (including theinstructions to the worksheets) is followed.Regardless of whether the worksheets oralternative equivalent documentation isused to compile and enter the requiredinformation, such documentation must beretained by the organization tosubstantiate the information entered onSchedule H (Form 990). The worksheetsor alternative equivalent documentationare to be completed using theorganization's most accurate costingmethodology, which can include a costaccounting system, cost-to-charge ratios,a combination thereof, or some othermethod.If the organization is filing a groupreturn or has a disregarded entity or anownership interest in one or more jointventures, the organization may find ithelpful to complete the worksheetsseparately for the organization and foreach disregarded entity, joint venture inwhich the organization had an ownershipinterest during the tax year, and groupaffiliate. In that case, the organizationshould combine all information from theworksheets for purposes of completingline 7. Complete the table by combiningamounts from the organization'sworksheets, amounts from disregardedentities or group affiliates, and amountsfrom joint ventures that are attributable tothe organization's proportionate share ofeach joint venture, under the aggregationinstruction in Purpose of Schedule.See Worksheets 1 through 8 andspecific instructions for the worksheetslater in these instructions.Part II. CommunityBuilding ActivitiesEnter in this part the costs of theorganization's activities that it engaged induring the tax year to protect or improvethe community's health or safety, and thataren't entered in Part I of this schedule.Some community building activities mayalso meet the definition of communitybenefit. Don't enter in Part II communitybuilding costs that are entered on Part I,line 7, as community benefit (costs of acommunity health improvement serviceentered on Part I, line 7e). An organizationthat enters information in this Part II mustdescribe in Part VI how its communitybuilding activities promote the health ofthe communities it serves.If the filing organization makes a grantto an organization to be used toaccomplish one of the community buildingactivities listed in this part, then theorganization should include the amount ofthe grant on the appropriate line in Part II.If the organization makes a grant to a jointventure in which it has an ownershipinterest to be used to accomplish one ofthe community building activities listed inthis part, enter the grant on theappropriate line in Part II, but don't includein Part II the organization's proportionateshare of the amount spent by the jointventure on such activities to avoid doublecounting.-4-Line 1. “Physical improvements andhousing” include, but aren't limited to, theprovision or rehabilitation of housing forvulnerable populations, such as removingbuilding materials that harm the health ofthe residents, neighborhood improvementor revitalization projects, provision ofhousing for vulnerable patients upondischarge from an inpatient facility,housing for low-income seniors, and thedevelopment or maintenance of parks andplaygrounds to promote physical activity.Line 2. “Economic development” caninclude, but isn't limited to, assisting smallbusiness development in neighborhoodswith vulnerable populations and creatingnew employment opportunities in areaswith high rates of joblessness.Line 3. “Community support” can include,but isn't limited to, child care andmentoring programs for vulnerablepopulations or neighborhoods,neighborhood support groups, violenceprevention programs, and disasterreadiness and public health emergencyactivities, such as community diseasesurveillance or readiness training beyondwhat is required by accrediting bodies orgovernment entities.Line 4. “Environmental improvements”include, but aren't limited to, activities toaddress environmental hazards that affectcommunity health, such as alleviation ofwater or air pollution, safe removal ortreatment of garbage or other wasteproducts, and other activities to protect thecommunity from environmental hazards.The organization cannot include on thisline or in this part expenditures made tocomply with environmental laws andregulations that apply to activities of itself,its disregarded entity or entities, a jointventure in which it has an ownershipinterest, or a member of a groupexemption included in a group return ofwhich the organization is also a member.Similarly, the organization cannot includeon this line or in this part expendituresmade to reduce the environmentalhazards caused by, or the environmentalimpact of, its own activities, or those of itsdisregarded entities, joint ventures, orgroup exemption members, unless theexpenditures are for an environmentalimprovement activity that (i) is provided forthe primary purpose of improvingcommunity health; (ii) addresses anenvironmental issue known to affectcommunity health; and (iii) is subsidizedby the organization at a net loss. Anexpenditure may not be entered on thisline if the organization engages in theactivity primarily for marketing purposes.Line 5. “Leadership development andtraining for community members” includes,but isn't limited to, training in conflictresolution; civic, cultural, or languageInstructions for Schedule H

skills; and medical interpreter skills forcommunity residents.Line 6. “Coalition building” includes, butisn't limited to, participation in communitycoalitions and other collaborative effortswith the community to address health andsafety issues.Line 7. “Community health improvementadvocacy” includes, but isn't limited to,efforts to support policies and programs tosafeguard or improve public health,access to health care services, housing,the environment, and transportation.Line 8. “Workforce development”includes, but isn't limited to, recruitment ofphysicians and other health professionalsto medical shortage areas or other areasdesignated as underserved, andcollaboration with educational institutionsto train and recruit health professionalsneeded in the community (other than thehealth professions education activitiesentered on Part I, line 7f).Line 9. “Other” refers to communitybuilding activities that protect or improvethe community's health or safety thataren't described in the categories listed onlines 1 through 8 above.Refer to the instructions to Part I, line 7,columns (a) through (f), for descriptions ofthe types of information that should beentered in each column of Part II.If the organization is filing a groupreturn or has a disregarded entity or anownership interest in one or more jointventures, the organization may find ithelpful to complete Part II separately foritself and for each disregarded entity, jointventure in which the organization had anownership interest during the tax year, andgroup affiliate. The organization shouldcombine the amounts from all such tables,according to the combined instructions inPurpose of Schedule, and include thecombined information in Part II.Part III. Bad Debt,Medicare, & CollectionPracticesSection A.In this section, (a) enter combined baddebt expense; (b) provide an estimate ofhow much bad debt expense, if any,reasonably could be attributable topersons who likely would qualify forfinancial assistance under theorganization’s financial assistance policy;and (c) provide a rationale for what portionof bad debt, if any, the organizationbelieves is community benefit. In addition,the organization must enter whether it hasadopted Healthcare FinancialManagement Association Stat

recognized by a state as a hospital. A hospital organization may treat multiple buildings operated by a hospital organization under a single state license as a single hospital facility. The organization must file a single Schedule H (Form 990) that combines information from: 1. Hospital facilities directly operated by the organization. 2.