Topic: Applying for Guardianship (September 2012)
Topic: Baby Supplies for New Mothers (January 2011)
Topic: Bereavement Support Remembrance Services (June 2012)
Topic: Catholic Mass Open to Community (January 2009)
Topic: Enrollment Assistance (Updated April 2015)
Topic: Interpreter Services (June 2015; Updated November 2015)
Topic: Lifeline Services (January 2009; Updated November 2015)
Topic: Nurse Navigators (November 2013; Updated November 2015)
Topic: PACE Housing Costs (Updated November 2015)
Topic: Pastoral Care Programs (August 2009)
Topic: Paying Expenses on Behalf of Individuals (Updated November 2015)
Topic: Paying for Care in Outside Facility (Updated November 2015)
Topic: Paying for Low-Income Patient Burial Costs (Updated November 2015)
Topic: Post Discharge/Care Management Services for Hospital's Low-Income Patients (Updated November 2015)
Topic: Providing Access to Post-Acute Care for Homeless and Uninsured (Updated November 2015)
Topic: Residential Facilities for Patients and Families (Updated July 2013)
Topic: Transportation (2007)
Topic: Transporting Breast Milk (June 2012)
Please Take Note: The information provided does not constitute legal or tax advice. The material is provided for informational/educational purposes only. Please consult with counsel regarding your organization's particular circumstances.
Topic: Applying for Guardianship
Question: When a patient is no longer capable of decision making, the hospital must hire an attorney to petition the court for appointment of a guardian. This often happens to impoverished patients and is necessary for discharge to a long term care facility. Should these legal costs be reported as community benefit?
Recommendation: We recommend not reporting the cost of applying for guardianship as community benefit. This is a cost borne by all hospitals, is a cost of doing business, and does not distinguish a hospital as a charitable organization.
Topic: Baby Supplies for New Mothers
Question: All babies born in our facility are sent home with hats that are knit by our volunteers. If parents of limited means request booties, sleepers, quilts, receiving blankets, etc., we provide the parents with a bag of needed supplies. All these supplies are donated to us.
Can we report as community benefit our employees' time to support this program? Our facility is paying the employees for their time.
Recommendation: This is a lovely program but since these items are only for your own patients and are part of the services you provide them, the costs to support this program should not be reported as community benefit.
Topic: Bereavement Support/Remembrance Services
Question: Can we report as community benefit expenses related to holding Annual Remembrance Services to remember children who have passed away?
Recommendation: We recommend that this not be reported as community benefit.
Question: We are establishing a Care Transitions department to strictly monitor our older adult discharged patients (65 and older) and wanted to confirm if the expenses for this department/program can be considered community benefit. Nurse coordinators and health coaches will be assigned to make sure these patients discharged to their homes or assisted living facilities are taking their medications as advised as well as following their doctor’s orders so they are not readmitted back to the ER for the same conditions. We want to ensure that an at-risk patient transitions safely and successfully from acute care to assisted or independent living.
Recommendation: We recommend that the costs of these activities not be reported as community benefit because they are part of the discharge plan for the hospital's patients.
Topic: Catholic Mass Open to Community
Question: Our long term care offers daily mass — that is accessible to disabled persons — to elderly and handicapped members of the community. Should this be reported as community benefit? We believe that health has physical, emotional and spiritual dimensions, so wouldn't this respond to spiritual needs of community members?
Recommendation: The task force commends the facility for offering mass to community members, but recommends not counting it as community benefit because of the difficulty in isolating costs associated with community participation. The task force members also believe that providing mass is an expected part of a Catholic ministry and, as such, should not be quantified as a community benefit.
Topic: Enrollment Assistance
Question: If we help patients and their families enroll in Medicaid or other public programs (or contract with another organizations to do this), can it be counted as community benefit?
Recommendation: Yes, this cost could be counted under Category A3 — Health Care Support Services. The cost of enrollment assistance can be included whether your organization carries out this function itself or contracts with another organization. Enrollment in a public program helps the person gain access not only to your services but to other primary, preventive, and follow up care.
However, helping patients and families apply for your hospital's financial assistance program is not a community benefit. Rather, it is a part of your hospital's routine operations.
Question: What should be reported as enrollment assistance in Health Care Support Service, A3? Should assessment for the organization’s charity care/financial assistance program be counted? If the patient is found not to be eligible for assistance, should cost of assessing eligibility be counted?
Recommendation: In regard to assisting a patient to enroll in public programs and facility financial assistance, we recommend:
- Do not count as community benefit the routine business office assessment or financial counseling, such as discussion of discounts, payment plans, or assessment for the facility's financial assistance program. That is, do not report the cost of all admissions/business office in-take staff members.
- Count as community benefit the costs related to counseling and assessment for public program/insurance exchange eligibility for uninsured and underinsured persons when the activity goes beyond routine business office procedures. This can be reported whether or not the patient is found eligible for assistance as long as there was a likelihood of eligibility.
- Be careful not to double count. Make sure the cost is not being included in the cost of financial assistance or public program shortfalls
Question: Our hospital is preparing to conduct enrollment efforts related to health reform. We plan to do outreach and enrollment for public programs such as Medicaid and our state's Children's Health Insurance Program and for the new state health insurance marketplace, focusing on those who are eligible for the premium subsidies. Can we report the cost of all these efforts as community benefit?
Recommendation: We recommend reporting all enrollment-related costs as community benefit in the category of A3: Health Care Support Services. By enrolling uninsured persons in these programs, you are increasing their access to health care. However, if reported, enrollees should not be directed only to plans in which the hospital participates.
Question: Our facility has a grant to participate in the Centers for Medicare and Medicaid "navigator program" that assists community members in enrolling in health insurance through the exchanges. Can this be reported as community benefit?
Recommendation: The full cost of participating in the navigator enrollment program may be reported as community benefit in Category A3 – Health Support Services. Per instructions for IRS Form 990, Schedule H, those costs must be offset by the grant funds.
(Updated April 2015)
Topic: Interpreter Services
Question: How should we quantify community benefit related to language services provided through our clinics? We have seen the guidance that only services provided above the legal requirement would qualify as community benefit. However, we are having a tough time quantifying where the legal requirement really ends, especially with respect to language services provided to our refugee population (many languages, relatively small population).
Recommendation: The IRS states in its final regulations implementing financial assistance policy (FAP) requirements for tax-exempt hospitals that those organizations must provide written translations of FAP documents in every language spoken by each limited English proficiency (LEP) language group that constitutes the lesser of either 1,000 individuals or 5 percent of the community served by the hospital, or the population likely to be encountered by the hospital. The regulations go on to state that a hospital may determine the percentage or number of LEP individuals in the hospital's community or likely to be affected or encountered by the hospital using any reasonable method. This threshold is based on existing HHS guidance.
We recommend using this threshold to determine if your translation or interpreter services may be reported as community benefit. If you are assisting LEP groups whose numbers fall below this threshold in your community you may report those translation or interpreter services. Services for LEP groups whose numbers are above this threshold in your community would be considered the cost of doing business.
(Updated November 2015)
Question: We have a program that certifies bilingual staff to be interpreters for Spanish speaking patients. The bilingual staff is taught how to appropriately use medical terminology and how to explain medical issues to Spanish speaking patients/families in hospitals, physician offices or the health department. We are opening the program to the staff of other community groups and health agencies in the area but not advertising to the public. It's more economical to bring an instructor here and allow more staff to be trained than to send people out of town to classes.
Recommendation: Translator training that is required by law or accrediting organizations (such as The Joint Commission) or to provide care (in the course of doing business) should not be reported as community benefit. If the need for interpreter services has been identified as a community need, the training program can be reported as community benefit in the category Community Health Improvement Services, Health Care Support Service, A3.
Topic: Lifeline Services
Question: We provide Lifeline services to indigent persons using funds from the United Way, auxiliary funds and endowment funds. We serve approximately 200 people at a cost of $450 per person. How should this be reported?
Recommendation: Expenses for Lifeline can be counted under Category A3 — Health Care Support Service. Per IRS instructions, all funds received to provide this service must offset the expenses. For example, if the program expenses cost $100,000 and the organization receives United Way funds restricted to this program, then the amount reported as community benefit is $100,000 minus the amount of the United Way funds.
(Updated November 2015)
Topic: Nurse Navigators
Question: Should we report our Emergency Department Navigator program? The ED Navigator meets with patients after medical screening to help them obtain a regular source of primary care. The goal of the program is to assist the low-income, medically indigent population in obtaining and using a Primary Care Provider (PCP) for primary care, and not the ED. The Navigator will identify any barriers patients may have had which prevented them from accessing services with a PCP and assist them in making their follow-up appointment with a PCP. "Primary and Preventive Health Care Services" were identified as a priority in our needs assessment.
Recommendation: We recommend reporting the ED Navigator program as community benefit (A3, Community Health Improvement/Health Care Support Services) if the primary purpose of the program is to provide or improve access to needed services and/or to improve the health of low-income persons, so long as other criteria for community benefit are met. (See Chapter 2, A Guide for Planning and Reporting Community Benefit, for example, do not report the activity if it benefits the organization more than the community or if the primary purpose is to prevent readmissions to avoid penalties).
Do not report as community benefit if the purpose is to send referrals to the hospital organization's primary care physicians or if referrals are made only to the organization's physicians - unless they are the only physicians in the community.
Take care not to double count, that is, assure that the program cost is not already reported as financial assistance (charity care), Medicaid shortfall, or as part of a subsidized health service. If the programs or services are subject to a financial assistance policy, they should not be separately reported.
Navigator programs that are offered in the ED and other service areas that are offered to all patients are considered a part of routine care and should not be reported as community benefit.
Question: We have a cancer nurse navigator program in which patients are identified from community screenings and testing at the health care organization. Some patients, but not all, are low-income, uninsured and have no physician. Nurses help these cancer patients find community resources as well as clinical resources. The navigator program does not refer exclusively to the organization’s physicians and services. Cancer was identified as a community health need in our community health needs assessment.
Recommendation: We recommend that this program be reported as community benefit in Category A3. Health Care Support Services, because it addresses a community health need and is open to the broader community. It serves a population beyond the hospital’s patient population. We also considered whether such a program could be reported if it was conducted by a sole community hospital where all cancer patients were patients of the hospital or can only be referred to the hospital’s physicians because it is a sole provider. In this situation we recommend that costs of the program could be reported as community benefit if the program activities were beyond expected or standard discharge planning.
Topic: PACE Housing Costs
Question: Our organization's Program for All-inclusive Care for the Elderly (PACE) subsidizes the housing of some very low-income persons so that they can participate in PACE. While PACE is a capitated payment for all health services, housing costs are not included. Should we count the cost of housing as community benefit? Recommendation: PACE, a program for persons dually eligible for Medicare and Medicaid, provides access to care for a vulnerable population (low-income, elderly consumers), and thus is eligible to be considered a community benefit program. Since housing costs are not included in the program's payment rate, we recommend that the cost of housing be included and be reported in Category A3. (Updated November 2015)
Topic: Pastoral Care Programs
Question: Could you provide further guidance on counting "Community-based pastoral and spiritual care programs."
Recommendation: We recommend not reporting as community benefit routine (day to day) spiritual care and pastoral care programs that are part of your organization's patient care. This care is central to good, holistic care and therefore is part of the cost of providing care to patients/residents.
We recommend the following be reported as community benefit as long as it is provided in response to a community need:
- Pastoral outreach programs (report as Health Care Support Service, category A3)
- Community-based pastoral and spiritual care programs (report as Health Care Support Service, category A3)
- Providing a clinical setting and other educational costs for educating pastoral care/spiritual care/chaplaincy students, leading to a degree or other professional credential (report as Health Professional Education, Category B3)
Therefore, we recommend not reporting the cost of spiritual care to patients being treated by your organization. However, activities outside of your organization, such as helping with a disaster or crisis in your community or offering classes or support to community members, could be reported as community benefit.
Topic: Paying Expenses on Behalf of Individuals
Question:When my organization pays for services for an individual patient, do I count the expense under Category E. Cash and In-kind or under A3. Health Care Support Services?
Recommendation: We recommend that when payment is made to another organization on behalf of an individual patient or non patient and when the gift is restricted to community benefit purposes, this expense can be reported Category A3, Health Care Support Services. IRS Instructions direct hospitals to report as cash contributions those contributions made to "entities and community organizations that share the organization's goals and mission. " We interpret this to mean that contributions on behalf of or to individuals be reported in Category A3, Health Care Support Services.
(January 2011; Updated November 2015)
Topic: Paying for Care in Outside Facility
Question: Can we count the expense the hospital incurs when the hospital discharges an uninsured patient to another facility and pays for that person's care in an outside facility.
Recommendation: We recommend reporting payments to care for a patient in another setting in the category of "Community Health Improvement A3."
(Updated November 2015)
Topic: Paying for Low-Income Patient Burial Costs
Question: We provide money for burial costs, including headstones, for patients who do not have resources to pay, and in-house memorial service costs for family members who have lost a loved one in our facility. Should we report these expenses as community benefit?
Recommendation: We do not recommend reporting the cost of memorial services for patients. This would be considered an extension of the excellent, compassionate care you are giving.
If you help pay for head stones and burial costs for a family who cannot afford the cost on their own, we recommend reporting the expense under Community Health Improvement A3.
(Updated November 2015)
Topic: Post Discharge/Care Management Services for Hospital's Low-Income Patients
Question: When should we report as community health improvement those non billed services (not covered by financial assistance or Medicaid) provided post discharge for our low-income patients?
Recommendation: We recommend that programs and services that assist low-income persons be reported as community health improvement if the primary purpose of the activity is to provide or improve access to needed services and/or to improve their health, so long as other criteria for community benefit are met. (See Chapter 2, A Guide for Planning and Reporting Community Benefit, for example, do not report if the activity benefits the organization more than the community or if the primary purpose is to prevent readmissions to avoid penalties). Take care not to double count, that is, assure that the cost is not already reported as financial assistance (charity care), Medicaid shortfall, or as part of a subsidized health service. For example, do not report as community health improvement any clinic services that are billed and treated as financial assistance.
Examples of services that could be reported in category A3, Community Health Improvement/Health Care Support Services:
- Taxi vouchers and other transportation for patients who otherwise could not afford to access the service.
- Services that support the well-being of low-income patients, such as wigs and other supplies for low-income cancer patients.
- Follow-up and case management services that help patients connect with primary care and other needed services, beyond routine discharge planning.
Examples of services not to report:
- Services that are part of routine care of all patients.
- Follow-up care that is part of discharge planning or is primarily designed to avoid readmissions penalties or in other ways financially benefit the organization.
- Taxi vouchers and other transportation with a primary purpose to increase revenue for the hospital, such as transporting insured seniors from a community retirement center.
(Updated June 2015)
Question: While activities a hospital provides for its patients are not usually reported as community benefit, what about care management to prevent hospitalization and following discharge from acute care? We are establishing a Care Transitions department to strictly monitor our older adult discharged patients (65 and older) and wanted to confirm if the expenses for this department/program can be considered community benefit. Nurse coordinators and health coaches will be assigned to make sure these patients discharged to their homes or assisted living facilities are taking their medications as advised as well as following their doctor's orders so they are not readmitted back to the ER for the same conditions.
Some examples of care management services are:
- Diabetes self-management classes offered without a fee so people (uninsured and insured) will participate.
- Hospitals paying the salaries of nurses to act as a 'health coach' for both uninsured and insured chronic care patients at hospital owned physician practices. They say that patients will not participate if they have to pay for the health coach and currently payer sources don't cover health coaches.
- Hospital paying for hospital employed nurses to monitor Coumadin levels for patients referred by physician practices.
Recommendation: We recommend reporting the following as community benefit:
- Report as A3. Health Care Support Services chronic disease/care management services (such as peer counseling, health coaching and educational programs) that meet all of the following criteria: :
- Responds to an identified community need
- Is directed to persons who are vulnerable, disadvantaged and face barriers to accessing such health care services
- Goes beyond what is required for accreditation, licensure or the professional standards for discharge planning.
- Report as D. Research pilots and demonstration programs to study the quality, effectiveness and cost implications of chronic disease management programs if:
- Results are generalizable and made publicly available
- Demonstration is funded by a government or tax-exempt organization (including self-funding).
We recommend not reporting as community benefit:
- Chronic disease/care management services routinely provided to all of the hospital organization's patients (including patients of a hospital-owned physician practice). Chronic disease/care management services when the primary purpose of the program is to benefit the hospital organization, either as marketing or to avoid re-hospitalization penalties.
(Updated June 2015)
Topic: Providing Access to Post-Acute Care for Homeless and Uninsured
Question: Occasionally, the acute care hospitals in our system treat homeless and uninsured patients who require post-discharge treatment but cannot find community resources willing to serve them. We have a post-acute division in our system that provides nursing home, assisted living, home care services. This division is a separate corporation with a separate tax ID number. The hospitals have worked out an agreement with the post-acute division that if a homeless or uninsured patient meets clinical criteria for post-acute care services, the post-acute division will accept the patients and the hospital will pay for the care (at cost). Can this be reported as community benefit?
Recommendation: We recommend the payments be reported as a community benefit expense in the category of Community Health Improvement A3 because the services being paid for address a community need and increase access to services for the patient.
(Updated November 2015)
Topic: Residential Facilities for Patients and Families
Question: Should we report as community benefit the costs of stays at a facility on our campus that provides free, convenient, overnight accommodations to families with limited income and who live outside the immediate area?
- Free overnight stays for persons meeting the organization’s financial assistance policy and their families should be reported as community benefit. Depending on the organization’s accounting system, it could be reported either as part of charity care or as a health care support service in category A3.
- Stays for patients who do not meet the organization’s financial assistance policy and their their families should be considered part of operational expenses and should not be reported as community benefit.
(Updated July 2013)
Question: Often times, patients are without transportation to our hospital, a long-term care facility, or another hospital. Is transportation considered a routine service of patient care/customer service or a community benefit? If it counts, should we quantify the: cost of vehicle, salary of the drivers, time of staff to coordinate the program, mileage, and fees if the service is provided by outside companies such as ambulance services.
Recommendation: Transportation costs can be counted if they are subsidized by the hospital and it has been determined that the service is needed to access services by persons who cannot afford to pay for transportation. If this is the case, document the need you are meeting and how financial need was determined. The case is strongest if transportation extends to community services beyond those operated by your organization.
Transportation cost should not be reported as community benefit if:
- The transportation is provided as part of the basic services you offer. For example, if a long term care facility routinely takes residents to medical appointments as part of basic services.
- The primary purpose of the transportation is to help patient's access profitable services your organization provides. This would be considered a marketing activity (exception would be transportation to such a service for persons in financial need).
Also, we recommend not counting as community benefit routinely offered valet services.
Topic: Transporting Breast Milk
Question: One of the things that we have done this year to support our rural patients is to pick up breast milk, pack it in dry ice and transport it back to our children's hospital for the infant that has a long term stay with us. By doing this we allow the mother to be at home with the family when her baby must remain hospitalized for some time. Our courier service drivers transport the breast milk over 100 miles to the medical center.
There have been times when our drivers must go out of the way to pick up the milk but in some communities it is part of the normal stop. Would this service count as CB?
Recommendation: This is a wonderful program but it is really part of the excellent care you are giving your patients, not a service to be reported as community benefit.