Department of the Treasury Internal Revenue Service
Public Charity Status and Public Support
Complete if the organization is a section 501(c)(3) organization or a section
4947(a)(1) nonexempt charitable trust.
Attach to Form 990 or Form 990-EZ. See separate instructions.
OMB No. 1545-0047
2010
Open to Public Inspection
Name of the organization
Memorial Health System of East Texas
Employer identification number
75-0755367
Part I
Reason for Public Charity Status
(All organizations must complete this part.) See instructions
The organization is not a private foundation because it is: (For lines 1 through 11, check only one box.)
1
2
3
4
5
section 170(b)(1)(A)(iv). (Complete Part II.)
6
7
8
9
receipts from activities related to its exempt functions—subject to certain exceptions, and (2) no more than 331/3% of
its support from gross investment income and unrelated business taxable income (less section 511 tax) from businesses
acquired by the organization after June 30, 1975. See section 509(a)(2). (Complete Part III.)
10
11
e
By checking this box, I certify that the organization is not controlled directly or indirectly by one or more disqualified persons other than foundation managers and other than one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2).
f
If the organization received a written determination from the IRS that it is a Type I, Type II or Type III supporting organization, check this box
..................................................
g
Since August 17, 2006, has the organization accepted any gift or contribution from any of the following persons?
(i) a person who directly or indirectly controls, either alone or together with persons described in (ii)
Yes
No
and (iii) below, the governing body of the the supported organization?
................
11g(i)
(ii)
a family member of a person described in (i) above?
......................
11g(ii)
(iii)
a 35% controlled entity of a person described in (i) or (ii) above?
................
11g(iii)
h
Provide the following information about the supported organization(s).
(i) Name of supported organization
(ii) EIN
(iii) Type of organization (described on lines 1- 9 above or IRC section (see instructions))
(iv) Is the organization in col. (i) listed in your governing document?
(v) Did you notify the organization in col. (i) of your support?
(vi) Is the organization in col. (i) organized in the U.S.?
(vii) Amount of support?
Yes
No
Yes
No
Yes
No
Total
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 11285F
Schedule A (Form 990 or 990-EZ) 2010
Schedule A (Form 990 or 990-EZ) 2010
Page 2
Part II
Support Schedule for Organizations Described in IRC 170(b)(1)(A)(iv) and 170(b)(1)(A)(vi) (Complete only if you checked the box on line 5, 7, or 8 of Part I or if the
organization failed to qualify under Part III. If the organization fails to
qualify under the tests listed below, please complete Part III.)
Section A. Public Support
Calendar year(or fiscal year beginning in)
(a) 2006
(b) 2007
(c) 2008
(d) 2009
(e) 2010
(f) Total
1
Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") ....
2
Tax revenues levied for the organization's benefit and either paid to or expended on its behalf.......
3
The value of services or facilities furnished by a governmental unit to the organization without charge..
4
Total. Add lines 1 through 3..
5
The portion of total contributions by each person (other than a governmental unit or publicly supported organization) included
on line 1 that exceeds 2% of the amount shown on line 11, column (f)..
6
Public Support. Subtract line 5 from line 4.
Section B. Total Support
Calendar year(or fiscal year beginning in)
(a) 2006
(b) 2007
(c) 2008
(d) 2009
(e) 2010
(f) Total
7
Amounts from line 4..
8
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
9
Net income from unrelated business activities, whether or not the business is regularly carried on..
10
Other income. (Explain in Part IV.) Do not include gain or loss from the sale of capital assets..
11
Total support (Add lines 7 through 10).
12
Gross receipts from related activities, etc. (See instructions.)
..................
12
13
First Five Years
If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization,
check this box and stop here..........................................
Section C. Computation of Public Support Percentage
14
Public Support Percentage for 2010 (line 6 column (f) divided by line 11 column (f))
.........
14
15
Public Support Percentage for 2009 Schedule A, Part II, line 14
...............
15
16a
33 1/3% support test—2010.
If the organization did not check the box on line 13, and line 14 is 33 1/3% or more, check this box
and stop here. The organization qualifies as a publicly supported organization
......................
b
33 1/3% support test—2009.
If the organization did not check the box on line 13 or 16a, and line 15 is 33 1/3% or more, check this
box and stop here. The organization qualifies as a publicly supported organization
.....................
17a
10%-facts-and-circumstances test—2010.
If the organization did not check a box on line 13, 16a, or 16b and line 14
is 10% or more, and if the organization meets the "facts and circumstances" test, check this box and stop here. Explain
in Part IV how the organization meets the "facts and circumstances" test. The organization qualifies as a publicly supported
organization
..................................................
b
10%-facts-and-circumstances test—2009.
If the organization did not check a box on line 13, 16a, 16b, or 17a and line
15 is 10% or more, and if the organization meets the "facts and circumstances" test, check this box and stop here.
Explain in Part IV how the organization meets the "facts and circumstances" test. The organization qualifies as a publicly supported organization
..............................................
18
Private Foundation
If the organization did not check a box on line 13, 16a, 16b, 17a or 17b, check this box and see
instructions
...................................................
Schedule A (Form 990 or 990-EZ) 2010
Schedule A (Form 990 or 990-EZ) 2010
Page 3
Part III
Support Schedule for Organizations Described in IRC 509(a)(2) (Complete only if you checked the box on line 9 of Part I or if the organization
failed to qualify under Part II. If the organization fails to qualify under
the tests listed below, please complete Part II.)
Section A. Public Support
Calendar year(or fiscal year beginning in)
(a) 2006
(b) 2007
(c) 2008
(d) 2009
(e) 2010
(f) Total
1
Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") .
2
Gross receipts from admissions, merchandise sold or services performed, or facilities furnished in any activity that is related to the organization's tax-exempt purpose......
3
Gross receipts from activities that are not an unrelated trade or business under section 513..
4
Tax revenues levied for the organization's benefit and either paid to or expended on its behalf...
5
The value of services or facilities furnished by a governmental unit to the organization without charge..
6
Total. Add lines 1 through 5.
7a
Amounts included on lines 1, 2, and 3 received from disqualified persons...
b
Amounts included on lines 2 and 3 received from other than disqualified persons that exceed the greater of $5,000 or 1% of the amount on line 13 for the year.
c
Add lines 7a and 7b..
8
Public Support (Subtract line 7c from line 6.)
Section B. Total Support
Calendar year (or fiscal year beginning in)
(a) 2006
(b) 2007
(c) 2008
(d) 2009
(e) 2010
(f) Total
9
Amounts from line 6...
10a
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
b
Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
c
Add lines 10a and 10b.
11
Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on.
12
Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)
13
Total support (Add lines 9, 10c, 11 and 12.).
14
First Five Years
If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization,
check this box and stop here.............................................
Section C. Computation of Public Support Percentage
15
Public Support Percentage for 2010 (line 8 column (f) divided by line 13 column (f))
.........
15
16
Public support percentage from 2009 Schedule A, Part III, line 15
...............
16
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2010 (line 10c column (f) divided by line 13 column (f))
......
17
18
Investment income percentage from 2009 Schedule A, Part III, line 17
.............
18
19a
33 1/3% support tests—2010.
If the organization did not check the box on line 14, and line 15 is more than 33 1/3% and line 17 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization
..........
b
33 1/3% support tests—2009.
If the organization did not check a box on line 14 or line 19a, and line 16 is more than 33 1/3% and line 18 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization
....
20
Private Foundation
If the organization did not check a box on line 14, 19a or 19b, check this box and see instructions
.....
Schedule A (Form 990 or 990-EZ) 2010
Schedule A (Form 990 or 990-EZ) 2010
Page 4
Part IV
Supplemental Information.
Supplemental Information. Complete this part to provide the explanation required by Part II, line 10; Part II, line 17a or 17b; or Part III, line 12. Also complete this part for any additional information. (See instructions).
Facts And Circumstances Test
Explanation
Schedule A (Form 990 or 990-EZ) 2010
Additional Data
Software ID:
10000105
Software Version:
2010v3.2
-
TIN:
SCHEDULE O (Form 990 or 990-EZ)
Department of the Treasury Internal Revenue Service
Supplemental Information to Form 990 or 990-EZ
Complete to provide information for responses to specific questions on
Form 990 or to provide any additional information.
Attach to Form 990 or 990-EZ.
OMB No. 1545-0047
2010
Open to Public Inspection
Name of the organization
Memorial Health System of East Texas
Employer identification number
75-0755367
Identifier
Return Reference
Explanation
PATIENT SERVICE REVENUE RECONCILIATION:
PATIENT SERVICE REVENUE SHOWN ON FORM 990, PART VIII, LINE 2A WAS DETERMINED AS FOLLOWS: GROSS CHARGES TO PATIENTS $739,737,908 LESS: MEDICARE CONTRACTUAL ADJUSTMENTS (331,460,210) MEDICAID CONTRACTUAL ADJUSTMENTS ( 63,739,500) INSURED/MANAGE CARE ADJUSTMENTS (101,995,592) OTHER DISCOUNTS ( 17,020,827) CHARITY DEDUCTIONS ( 42,375,300) PATIENT SERVICE REVENUE 183,146,479
PART IV, LINE 20B:
THE HOSPITAL'S TAX YEAR DID NOT BEGIN AFTER MARCH 23, 2010, THEREFORE, IN ACCORDANCE WITH THE INSTRUCTIONS FOR FORM 990, A COPY OF THE MOST RECENT "AUDITED FINANCIAL STATEMENTS" IS NOT REQUIRED TO BE ATTACHED.
Form 990, Part VI, Line 19
Form 990, Part VI, Line 19: Other Organization Documents Publicly Available
ORGANIZATIONAL DOCUMENTS, APPLICATIONS FOR EXEMPTION AND FINANCIAL STATEMENTS OF THE CORPORATION ARE AVAILABLE FOR INSPECTION AND COPYING IN THE OFFICE OF THE CHIEF FINANCIAL OFFICER LOCATED AT 1201 W. FRANK AVENUE, LUFKIN, TX 75904 ON ORAL OR WRITTEN REQUEST DURING REGULAR BUSINESS HOURS, OR SUCH OTHER TIMES AS ARE SCHEDULED DIRECTLY WITH THE CHIEF FINANCIAL OFFICER.
Form 990, Part VI, Line 15b
Form 990, Part VI, Line 15b: Compensation Review and Approval Process for Officers and Key Employees
IN MARCH OR APRIL OF EACH YEAR, IN CONNECTION WITH THE ANNUAL AUDIT OF THE FINANCIAL STATEMENTS OF THE CORPORATION, THE FINANCE COMMITTEE OF THE BOARD OF DIRECTORS BEGINS A REVIEW OF THE COMPENSATION, INCLUDING APPLICABLE BONUS OR OTHER INCENTIVE, IF ANY, FOR THE CHIEF EXECUTIVE OFFICER. THE VICE PRESIDENT OF HUMAN RESOURCES PROVIDES THE COMMITTEE WITH INFORMATION FROM NATIONAL SURVEYS RELATED TO SALARIES OF CHIEF EXECUTIVE OFFICERS FOR NONPROFIT AND PROFIT CORPORATIONS. THE COMMITTEE COMPARES THE CONPENSATION PACKAGES OF OTHER INSTITUTIONS OF COMPARABLE SIZE FOR EXECUTIVES WITH COMPARABLE RESPONSIBILITIES, AND ASSESSES THE RELATIVE PERFORMANCE OF THE SYSTEM AND THE CHIEF EXECUTIVE OFFICER THROUGH THE PRIOR YEAR BASED ON PRE-ESTABLISHED GOALS. ONCE THE SALARY IN DETERMINED, THE FINANCE COMMITTEE MAKES A RECOMMENDATION TO THE BOARD OF DIRECTORS FOR APPROVAL. APPROVED CHANGES ARE EFFECTIVE FOLLOWING COMPLETION AND ACCEPTANCE OF THE AUDITED FINANCIAL STATEMENTS. THE SALARIES FOR ALL OTHER SYSTEM OFFICERS ARE SET BY THE CHIEF EXECUTIVE OFFICER FOR THE SYSTEM UTILIZING NATIONALLY PUBLISHED COMPARABLES FOR EXECUTIVES WITH SIMILAR RESPONSIBILITIES IN INSTITUTIONS OF SIMILAR SIZE, AND EVALUATION OF PERFORMANCE RELATIVE TO ESTABLISHED GOALS AND OBJECTIVES. INFORMATION FOR COMPARISON PURPOSES IS PROVIDED, AS NEEDED, BY THE VICE PRESIDENT OF HUMAN RESOURCES. THE CHIEF EXECUTIVE OFFICER ALSO RECOMMENDS THE BONUS AND INCENTIVE PACKAGE, IF ANY, FOR THE SYSTEM OFFICERS AND KEY EMPLOYEES. THOSE RECOMMENDATIONS ARE REVIEWED AND APPROVED OR MODIFIED BY RECOMMENDATION OF THE FINANCE COMMITTEE OF THE BOARD OF DIRECTORS AND APPROVED BY THE BOARD IN A REGULARLY SCHEDULED BOARD MEETING.
Form 990, Part VI, Line 12c
Form 990, Part VI, Line 12c: Explanation of Monitoring and Enforcement of Conflicts
PRIOR TO THE INITIAL MEETING OF A CALENDAR YEAR, EACH MEMBER OF THE BOARD AND OFFICER OF THE CORPORATION IS PROVIDED A COPY OF THE CONFLICTS OF INTEREST POLICY, A STATEMENT ACKNOWLEDGING ITS RECEIPT, AND DISCLOSURE OF OUTSIDE INTERESTS AND ACTIVITIES FORM. THE POLICY IS DISCUSSED WITH THE BOARD AND EACH OFFICER. EACH BOARD MEMBER AND OFFICER COMPLETES THE DISCLOSURE OF OUTSIDE INTERESTS AND ACTIVITIES FORM AND RETURNS THEM TO THE CHIEF EXECUTIVE OFFICER (CEO). THE CEO AND THE SYSTEM'S GENERAL COUNSEL REVIEW EACH STATEMENT ACKNOWLEDGING RECEIPT OF THE POLICY AND THE DISCLOSURES TO FAMILIARIZE THEMSELVES WITH POTENTIAL CONFLICTS.
Form 990, Part VI, Line 11
Form 990, Part VI, Line 11: Form 990 Review Process
THE BOARD OF DIRECTORS, BY RESOLUTION, DETERMINES WHETHER THE FORM 990 WILL BE REVIEWED BY ALL DIRECTORS, AN EXISTING COMMITTEE, OR A SPECIAL COMMITTEE APPOINTED FOR SUCH PURPOSE PRIOR TO FILING. ONCE THE RETURN IS COMPLETED, IT IS PROVIDED TO THE DIRECTORS OF THE COMMITTEE RESPONSIBLE FOR REVIEWING, EITHER INDIVIDUALLY OR IN A JOINT SESSION. EMPLOYEES OF THE CORPORATION RESPONSIBLE FOR FILING ARE AVAILABLE TO RESPOND TO QUESTIONS OR PROVIDE BACKGROUND AS NEEDED. ONCE THE DIRECTORS RESPONSIBLE FOR REVIEWING THE FORM 990 ARE SATISFIED IT IS COMPLETE, THE RETURN IS FILED. SUBSEQUENTLY, THE RETURN IS MADE AVAILABLE TO ALL DIRECTORS FOR THEIR REVIEW.
Form 990, Part VI, Line 7a
Form 990, Part VI, Line 7a: How Members or Shareholders Elect Governing Body
THE BOARD OF TRUSTEES MAY EXERCISE ALL POWERS OF THE SYSTEM AND DO ALL SUCH LAWFUL ACTS AND THINGS AS ARE NOT BY STATUTE OR THE ARTICLES OF INCORPORATION OF BY THE BYLAWS DELEGATED TO, DIRECTED, OR REQUIRED TO BE EXERCISED OR DONE BY THE BOARD OF DIRECTORS. THESE POWERS INCLUDE THE FOLLOWING: ELECT NEW TRUSTEES ELECT AND FILL ANY VACANCIES OF THE BOARD OF TRUSTEES ELECT MEMBERS OF THE SYSTEM ELECT NEW AND ADDITIONAL DIRECTORS
Form 990, Part VI, Line 2
Form 990, Part VI, Line 2: Description of Business or Family Relationship of Officers, Directors, Et
BOARD MEMBER RELATIONSHIPS: GEORGE H. HENDERSON, III AND H.J. SHANDS, III - BUSINESS RELATIONSHIP CARL RAY POLK AND GEORGE H. HENDERSON, III - BUSINESS RELATIONSHIP GIBSON FRIESEN AND RONA FRIESEN - FAMILY RELATIONSHIP
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.