1. Center for Health Affairs
Community Health Needs Assessments and Other Tax-Exemption Requirements
Center for Health Affairs
March 24, 2015
Julie Trocchio Senior Director, Community Benefit and Continuing Care Catholic Health Association

2. Overview Community Health Needs Assessment Requirements
Advice for Experts
Implementation Strategies
Advice from Experts
Other Requirements
Emergency Medical Care Policies
Financial Assistance Policies
Billing Collection Policies
September 21, 2018

3. History
“Our story began in 1851 when the first Sisters of Charity of St. Augustine arrived in Cleveland, Ohio from France to serve as the city’s first public health nurses.”
September 21, 2018

4. CHNA and Implementation Strategies – Legal Imperative
Affordable Care Act (ACA) 501(r)
IRS Notice
IRS Notice of Proposed Rulemaking
IRS Final Rules – December 2014
IRS Form 990 Schedule H
September 21, 2018

5. Affordable Care Act
ACA Requirement – Community Health Needs Assessment
At least once every three years – 1st must be completed by end of tax year beginning after March 23, 2012
Include input from persons who represent the broad interests of the community
Include input from persons having public health knowledge or expertise
September 21, 2018

6. Affordable Care Act
ACA Requirement – Community Health Needs Assessment
Make assessment widely available to the public
Adopt a written implementation strategy to address identified community needs
Failure to comply results in excise tax penalty of $50,000 per year
September 21, 2018

7. IRS Final Rules 2014
September 21, 2018

8. Steps in the CHNA Process
Define the community
Assess the health needs of the community
Solicit and take into account input from the community and public health
Document the CHNA in a written report, approved by an authorized body
Make the CHNA report widely available
September 21, 2018

9. When is CHNA Conducted?
During the current tax year or in either of the two immediately preceding taxable years
Considered “conducted” in the taxable year that the written assessment report is made publicly available
September 21, 2018

10. How is a Community Health Needs Assessment Conducted?
Identify and prioritize significant health needs of the community served by the hospital
May be conducted in collaboration or jointly with others
Must solicit and take into account input from persons who represent the broad interests of the community served including those with special knowledge of or expertise in public health
Written report must be adopted by authorized body
Must be made publicly available
September 21, 2018

11. How is Community Defined
Generally defined by geographic location
In some cases, defined by target populations served
In some cases, take into account a hospitals’ principal function (e.g., specialty area or disease)
May not be defined in a way that excludes certain populations served by the hospital (for example, low- income persons, and minority groups)
May define community beyond service area
If multiple buildings, single license – aggregate populations
September 21, 2018

12. What is a Community Health Need?
Requisites for the improvement or maintenance of health status in both the community at large and in particular parts of the community (such as neighborhoods or populations experiencing disparities)
May include the need to address financial and other barriers to accessing care, to prevent illness, to ensure adequate nutrition, or to address social, behavioral, and environmental factors that influence health
September 21, 2018

13. How is Community Health Needs Assessment Documented?
Description of the community served by the hospital
Description of the process, methods and sources used
In the case of data obtained from external source material, the CHNA report may cite the source material rather than describe the method of collecting the data
If the hospital collaborated with others – who?
If the hospital contracted with a consultant – include qualifications
September 21, 2018

14. How is Community Health Needs Assessment Documented? (con’t)
Describe input from persons who represent the broad interests of the community:
Summary of the input of these persons; how and over what time period
Describe the medically underserved, low-income, or minority populations being represented by organizations or individuals providing input
Names of organizations providing input and nature and extent of input
In the event a hospital solicits but cannot obtain input from a source described above, the CHNA report must describe the hospital’s efforts to solicit input from such sources
September 21, 2018

15. How is Community Health Needs Assessment Documented? (con’t)
A prioritized description of all the significant community health needs identified through the community health needs assessment, including a description of the process and criteria used in prioritizing such health needs
A description of the potential measures and resources identified through the CHNA to address the significant health needs
An evaluation of the impact of any actions that were taken since the hospital facility finished conducting its immediately preceding CHNA, to address the significant health needs identified in the hospital’s prior CHNA(s)
September 21, 2018

16. IRS Form 990 Schedule H
September 21, 2018

17. IRS Form 990 Schedule H – Part V, B
Did assessment include:
Definition of community
Demographics of community
Existing facilities and resources available to respond to needs
How data is obtained
Health needs of community
Primary and chronic disease needs and other needs of
Uninsured persons
Low-income persons, and
Minority groups
Process for identifying and prioritizing needs
Process for consulting with persons representing community’s interest
Information gaps
How assessment is made public
September 21, 2018

18. CHNA – What Happened? Needs identified Access to care Obesity
Mental & dental health
Diabetes
Substance abuse (alcohol, tobacco)
Issues
Uncertainty – rules
Lack of templates
Time frames with health department
Funds for implementation
Leadership commitment
September 21, 2018

19. Advice from the Field and All Experts
Conduct the assessment in collaboration with other hospitals and/or community partners
Form assessment team/advisory committee that include key staff within the organization of public health officials and community representatives
Engage board and senior leadership
September 21, 2018

20. Advice from the Field and All Experts (con’t)
Review prior assessments and reports
Include ER and hospital utilization data
Use publicly available data from trusted sources
September 21, 2018

21. Advice from the Field and All Experts (con’t)
Collect community input to validate secondary data and to fill in gaps
Seek community input that reflects the racial, ethnic and economic diversity of the community
Identify community assets
September 21, 2018

22. Advice from the Field and All Experts (con’t)
Analyze data using comparisons with other communities and with federal or state benchmarks and, when available, trends within the community
Establish criteria to identify priorities
Validate assessment and priorities with community members
September 21, 2018

23. Implementation Strategy
Provisions in the Affordable Care Act Require a Tax-Exempt Hospital to:
Adopt an implementation strategy to meet community needs identified in the CHNA
Describe how it is addressing needs identified in the CHNA
Describe any needs identified in the CHNA that are not being addressed and the reasons for not addressing them
September 21, 2018

24. IRS Final Rules 2014
September 21, 2018

25. What Should Implementation Strategy Describe?
Either:
How the hospital plans to meet the significant health need or
The significant health need as one the hospital does not intend to meet, explaining why the hospital does not intend to meet the health need
September 21, 2018

26. What Must Be Included in Description to Meet Significant Needs?
The actions the hospital facility intends to take to address the significant health need
The anticipated impact of these actions
A plan to evaluate the impact
The programs and resources the hospital plans to commit to address the health need
Any planned collaboration between the hospital facility and other facilities or organizations
September 21, 2018

27. How is Implementation Strategy Approved and Posted?
“Adopted” on the date it is adopted by the governing body of the hospital (the governing body, a committee of the governing body, or others authorized)
Must be adopted on or before the 15th day of the fifth month after the end of the same taxable year in which the hospital conducts the CHNA.
September 21, 2018

28. How is Implementation Strategy Reported?
Must be attached to hospital’s IRS Form 990 or provide on the Form 990 the URL9s) of the web page(s)
Not required but recommended: Post on website
Questions on IRS Form 990 Schedule H
September 21, 2018

29. Part V, B – (Implementation Strategy – Related Questions Optional for 2011
If hospital addressed needs from CHNA, did it include?
Adoption of an implementation strategy
Execution of the implementation strategy
Participation in community-wide community benefit plan
Execution of a community-wide community benefit plan
Inclusion of a community benefit section in operational plan
Adoption of budget for services identified in CHNA
Prioritization of health needs in community
Prioritization of services the hospital will do
September 21, 2018

30. Is There Accountability for Carrying Out Plan?
Hospitals must describe on 990 actions taken during the taxable year to address the significant health needs identified through its most recent CHNA or, if no actions were taken with respect to one or more of these needs, the reason or reasons why none were taken
September 21, 2018

31. Advice From the Field and Experts: Prepare
Review current community benefits and CHNA results: Is there a gap?
Review community assets, identify potential partners
Review hospital resources, strategies opportunities for synergy
Look upstream and at policy options
September 21, 2018

32. Advice From the Field and Experts: Plan
Specify which needs will be addressed: By hospital, with others? By others?
Research and select evidence-based strategies
Build on existing programs and other community assets when possible
Determine who will be involved: Community benefit and other staff? Community members? Board? HD?
September 21, 2018

33. Advice From the Field and Experts - Document
For each prioritized need:
Identify the goal to be achieved
Measurable objective(s)
Indicators for determining whether objectives were met
Evaluation measures
September 21, 2018

35. Policies
Tax-exempt hospitals must have a written policy authorized and adopted by organization:
Emergency medical care policy
Financial assistance policy
Billing and collections policy
September 21, 2018

36. Emergency Medical Care Policy
Must have written policy for care for emergency conditions regardless of whether persons are FAP eligible
May not discourage individuals from seeking emergency medical care (demand payment before serving, debt collection that interferes with care)
Compliance with EMTALA is acceptable
September 21, 2018

37. Financial Assistance Policy
Policy must include:
Eligibility criteria for financial assistance, and whether such assistance includes free or discounted care
Basis for calculating amounts charged to patients
Method for applying for financial assistance
If no separate billing and collections policy, actions hospital may take in the event of non-payment
List of providers covered/not covered by policy (cannot be ER)
September 21, 2018

38. Widely Publicize Financial Assistance Policy, Application, Summary
Make Copies available upon request
Set up conspicuous displays in a facility public location including ER and admission areas
Inform members of community likely to need
Offer plain language summary as part of intake or discharge
Include conspicuous notice on bills about availability, phone #, URL for more information
Be available in languages spoken by lesser of 1000 or 5% of population
September 21, 2018

39. Financial Assistance or Billing Policy
Must include:
Any actions hospital may take related to nonpayment, including Extraordinary Collection Actions (ECA)
Reasonable effort that will be taken to determine if patient is eligible before ECA
Process and time frames for taking actions
September 21, 2018

40. Extraordinary Collection Actions (ECAs)
Hospital/agent may not take Extraordinary Collection Actions until it takes reasonable efforts to determine eligibility for financial assistance
Must not initiate until at least 120 days from date of first post-discharge bill
Must notify about intent at least 30 days before action
September 21, 2018

41. Extraordinary Collection Actions (ECAs)
Selling debt to another party
Reporting to credit reporting agency
Deferring of denying treatment of medically necessary care
Actions that require legal process including:
Lien to collect proceeds of judgments, foreclosing on property, seizing bank account, civil action, garnishing wages
September 21, 2018

42. Reasonable Efforts
Notify patient about FAP 30 days before initiating ECA
Written notice that financial assistance is available and ECA that hospital intends to obtain payment, gives deadline after which ECA will occur (no earlier than 30 days after written notice
Provide individual plain language summary of FAP
Make reasonable effort to orally notify patient about FAP and how to get assistance
September 21, 2018

43. Timeline for “Reasonable Efforts” Before Commencing ECA
Notification period: 120 days from first bill post- discharge
Application period: 240 days from first bill post- discharge
ECA notification period: Must send written notice 30 days prior to initiating an ECA. (Can be sent on day 210 of the Application Period). Must also make reasonable efforts to orally notify patient
September 21, 2018

44. Limitation on Charges
Must limit amount charged for emergency/medically necessary care for persons FAP eligible to amounts generally billed (look behind or prospective – such as Medicare/Medicaid
Must limit amount charged for other medical necessary care covered by FAP for persons FAP eligible to less than gross charges
September 21, 2018

45. Mission and Tradition
In 1866, to respond to the diphtheria, yellow fever and typhoid epidemics, three French Sisters of the Incarnate Word came to Galveston, TX. When they arrived, they learned that not only were they needed to care for victims of disease, but for the children who had been orphaned by the epidemics. By 1900, there were 10 sisters and 93 orphans. That year, all but three of the orphans and all of sisters, including Sr. Vincent Cottier, pictured here, perished when a tidal wave struck Galveston. Every year, leaders of the hospital the sisters started asking: If those sisters were here today, what would they see, what would they do?