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
INDIANA UNIVERSITY HEALTH BALL MEMORIAL HOSPITAL INC F/K/A BALL MEM HOSP INC
Employer identification number
35-0867958
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:
Software Version:
-
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
INDIANA UNIVERSITY HEALTH BALL MEMORIAL HOSPITAL INC F/K/A BALL MEM HOSP INC
Employer identification number
35-0867958
Identifier
Return Reference
Explanation
Part VI, Section A - Governing Body and Management
LINE 2 - FAMILY OR BUSINESS RELATIONSHIPS
Daniel F. Evans, Jr. is an Officer of and serves on the board of directors of Indiana University Health, Inc. Richard Helsper is a former key employee of Indiana University Health, Inc. Harold Berfiend and Richard Helsper serve on the board of directors of Cardinal Health Initiatives, LLC. No additional compensation is provided. Michael L. Cox, Michael E. Haley, John D. Littler, and Harold Berfiend serve on the board of directors for Cardinal Health Ventures, Inc. No additional compensation is provided.
Part VI, Section A - Governing Body and Management
Line 4 - Significant Changes to Organizational Documents
Indiana University Health Ball Memorial Hospital, Inc. filed Articles of Amendment to the Articles of Incorporation with the Indiana Secretary of State's Office effective November 1, 2011 to change the legal name of the organization from "Ball Memorial Hospital, Inc." to "Indiana University Health Ball Memorial Hospital, Inc." See attached Articles of Amendment.
Part VI, Section A - Governing Body and Management
Line 6, 7a, and 7b - Members or Stockholders
Line 6: IU Health Ball Memorial Hospital, Inc. has one class of membership and the sole member is Indiana University Health, Inc. ("IU Health") Line 7a: IU Health elects one more than one-half of the total number of Directors. Immediately following such election the remainder are elected by the Directors, excluding those whose terms are set to expire. Line 7b: Notwithstanding any other provisions of the Articles of Incorporation, the following matters require the written approval of IU Health prior to implementation: -Authorization for the establishment or acquisition of any subsidiaries, affiliates or joint venture arrangements or acquisition of all or substantially all of the assets of any other business or entity; -Approval or amendment to any operating or capital budget; -Authorization of any unbudgeted operating or capital budget items or deviations, including any issuance or guarantee of any unbudgeted debt, greater than the budgeted amount by $1 million for any individual item or $3 million per fiscal year in the aggregate; -Authorization of any agreement to act as primary obligor, or to serve as a guarantor, surety or co-obligor with respect to the indebtedness of any other party, to borrow amounts from third-party lenders, or to loan money to any person or entity; -Approval of strategic plans and amendments, which will be integrated with IU Health's strategic plan; -Amendment or repeal of the Corporation's or an Affiliate's articles of incorporation or bylaws (or other corresponding organizational documents of an Affiliate that is not a corporation); -Authorization of any merger, consolidation, reorganization, sale or transfer of all or substantially all of the Corporation's assets; -Authorization of any voluntary declaration of bankruptcy, plan of dissolution, any liquidating distribution of assets or other action related to its dissolution or liquidation; -Authorization of any pledge of, or grant any security interest or mortgage in, or otherwise encumber, any tangible assets of the Corporation in excess of $2,000,000, other than in the ordinary course of business or pursuant to a budget or strategic plan approved by IU Health; -Approval of any management agreement for the management of all or a substantial part of the Corporation's operations; or -Appointment or removal of any of the Corporation's Directors with or without cause.
Part VI, Section A - Governing Body and Management
Line 11B - Form 990 Provided to Governing Body
IU Health Ball Memorial Hospital, Inc. has established the following process for reviewing the Form 990: The Form 990 and related schedules are reviewed by the Chief Financial Officer and General Counsel. After the Chief Financial Officer and General Counsel approve the Form 990 and related schedules, a finalized complete Form 990 is made available to each board member on a protected intranet site prior to filing the form with the IRS. Each member is informed of the availability of the tax department to answer any questions.
Part VI, Section B - Policies
LINE 12, 13, 14 AND 16B
Indiana University Health Ball Memorial Hospital, Inc. is part of the Indiana University Health, Inc. system. As the sole member and controlling parent of Indiana University Health Ball Memorial Hospital, Inc., Indiana University Health, Inc. and its board of directors have mandated that certain policies be followed to ensure greater standardization throughout the system. Thus, Indiana University Health Ball Memorial Hospital, Inc.'s board of directors was not required to separately approve the conflict of interest, whistleblower, document retention and destruction and joint venture policies because Indiana University Health's board had already approved and required these policies to be followed by subsidiaries.
Part VI, Section B - Policies
Line 12c - Conflict of Interest Policy
IU Health Ball Memorial Hospital, Inc. has a Conflict of Interest Policy, the purpose of which is, to protect IU Health Ball Memorial Hospital, Inc.'s interests and integrity when it is contemplating entering into a transaction or arrangement that might benefit the private interest of an officer, director, or employee. Each employee that is manager level or above, as well as officers and directors are required to annually sign a statement which affirms that such person (1) has received a copy of the conflict of interest policy; (2) has read and understands the policy; (3) has agreed to comply with the policy; and (4) understands and acknowledges that the Corporation is a tax-exempt organization and that in order to maintain its federal tax exemption it must engage primarily in activities which accomplish one or more of its tax-exempt purposes. If an interest is disclosed, the form requires that the discloser's supervisor sign the form to indicate his/her knowledge and approval of the interest. The IU Health Ball Memorial Hospital Compliance Officer and the Indiana University Health, Inc., Corporate Compliance Department (collectively the "Department") will review the form and determine how the conflict should be managed in order to comply with the spirit of the policy. The Department, in consultation with the Chief Compliance Officer of Indiana University Health, Inc. may appoint standing or ad hoc committees to assist in resolving issues that arise under the provisions of the policy. Breach of the conflict of interest policy, including failure to complete and update the questionnaire and failure to disclose interest that should be disclosed, may subject an individual to disciplinary action, including dismissal.
Part VI, Section B - Policies
Line 15 - Process for Determining Compensation
The CEO/top management official for IU Health Ball Memorial Hospital, Inc. is employed by Indiana University Health, Inc, whom has the following process for determining compensation. 1. The Board of Directors has established a Committee on Personnel and Compensation. The individuals on this Committee are made up of individuals who are on the Board and who do not have a conflict of interest with Indiana University Health, Inc. ("IU Health"). There are no physicians or employees on this Committee. This Committee develops and reviews annually the executive compensation philosophy, market analysis as to comparability and reasonableness. One of the purposes of this Committee is to review, approve and make recommendations regarding executive compensation and benefits to the IU Health Board. As deemed appropriate, this Committee also reviews the same detail with the Committee on Finance, Planning and Human Resources. The Committee on Finance, Planning and Human Resources is represented by certain members of the Board as well. 2. Each year the Committee on Personnel and Compensation engages an outside compensation consulting firm to conduct a compensation and benefits study for all senior vice presidents and above. The current compensation advisor is the Hay Group. Hay Group performs an independent compensation survey. The relevant comparability data includes: compensation and benefit levels paid by similarly situated organizations (both taxable and tax exempt) for functionally comparable positions as well as the availability of similar services in the geographic area. The Committee reviews the entire compensation package including: base compensation, short term and long term incentive plans, basic health and welfare benefits, qualified and nonqualified plans as well as any additional fringe benefits. Further, Hay Group will provide recommendations based upon the reasonable compensation information as it relates to salary increases, bonuses and benefits that are consistent with the compensation philosophy of the Committee. A separate analysis using the same methodology is done for the Chief Executive Officer. 3. The Committee reviews the salary survey and, if appropriate, makes recommendations on increases in salary and any changes in bonuses or benefits. The Committee's goal is to ensure that the total compensation and benefits package is reasonable based upon the independent data provided by Hay Group. The Committee votes on any changes in compensation or benefits. This review, discussion and vote are documented in the minutes for the meeting. There are no executives present during the final discussion and approval of compensation. 4. The Board reviews the report prepared by the Hay Group as well as the recommendations of the Committee on Personnel and Compensation along with the President and Chief Executive Officer's recommendations for all Senior Vice Presidents and Executive Vice Presidents as to changes in compensation that are within the ranges approved by the Committee. The Committee may also review its recommendation with the Committee on Finance, Planning and Human Resources as to any changes to the President and Chief Executive Officer's compensation and benefits. As requested, the Finance, Planning and Human Resources Committee also provides its review of recommendations on changes in executive compensation and benefits. This review, discussion and vote are documented in the minutes. 5. The Board then reviews the recommendations provided by the Committee on Personnel and Compensation and votes on the changes as well. No additional compensation or benefits are paid to the executives until the changes have been approved by the Committee and the Board. The discussion and approval are documented in the minutes of the meeting. There are no executives present during the final discussion and approval of compensation. The General Counsel prepares a formal written opinion reviewing the compensation and benefits approval process, comparing that process to the Intermediate Sanctions Test of IRC Section 4958 and, if the facts warrant, provides comments regarding the compensation and benefits approval process as this relates to meeting the requirements for a rebuttable presumption of reasonableness as provided in the Intermediate Sanctions Test. 6. After the end of each year, the Committee and Board also review the achievements of the executive group as it relates to the long-term and short-term shared and individual goals developed by the executive and the Board. These achievements may also be reviewed with the Committee on Finance, Planning and Human Resources. The Board, at its discretion, may approve bonus payments based upon the achievement of the goals and the compensation survey. The discussion and vote of the Committee and Board is documented in the minutes for each such meeting. The bonuses are not paid until approval is made by the Board. 7. The Committee on Personnel and Compensation and Audit Committee also review the required Form 990 disclosures related to executive compensation and benefits as well as compensation practices and approval processes prior to the filing of the Form 990 return with the Internal Revenue Service. IU Health Ball Memorial Hospital, Inc. also has a process in place to determine the compensation for its other officers and key employees. IU Health Ball Memorial Hospital, Inc. uses an independent compensation consultant who utilizes a variety of methods and procedures to obtain compensation ranges for comparable officer and employee positions. The independent compensation consultant provides IU Health Ball Memorial Hospital, Inc. with recommended compensation ranges for its officers and other employees, which are then used as a guide for setting reasonable compensation by management. Management decisions with regard to determining compensation are subject to the review and approval of the Board of Directors, Compensation Committee, and/or Corporate member.
Part VI, Section C - Disclosure
Line 19 - Public Disclosure
IU Health Ball Memorial Hospital, Inc.'s Articles of Incorporation are available for public inspection through the Indiana Secretary of State's web-site. IU Health Ball Memorial Hospital, Inc.'s conflict of interest procedures are disclosed on the Form 990, Schedule O. IU Health Ball Memorial Hospital, Inc. consolidated financial statements are available to the public through its bond filings.
Part VII, Section A
Line 1a, column(b) - Estimated Average Hours per Week
Daniel F. Evans, Jr. is the President & CEO for Indiana University Health, Inc. and devotes 55 hours per week. Christina C. Drummond, M.D. is a physician for Emergency Medical Group, Inc. and devotes 45 hours per week.
Part XI - Reconciliation of Net Assets
Line 5 - Other changes in net assets
Other changes in Net Assets of $(11,849,797) includes: -Partnership income book/tax difference $(1,082,745) -Unrealized gain/loss on investments $( 10,997) -Change in pension obligation $(6,900,722) -Net asset transfer to affiliate $(3,855,333)
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.