Form990
Click to see attachment
Department of the Treasury
Internal Revenue Service
Return of Organization Exempt From Income Tax
Under section 501(c), 527, or 4947(a)(1) of the Internal Revenue Code (except private foundations)
MediumBullet Do not enter Social Security numbers on this form as it may be made public. By law, the IRS
generally cannot redact the information on the form.
MediumBullet Information about Form 990 and its instructions is at www.IRS.gov/form990.
OMB No. 1545-0047
2013
Open to Public Inspection
A For the 2013 calendar year, or tax year beginning 01-01-2013 , 2013, and ending 12-31-2013
BCheck if applicable:
CName of organization
ST MARY'S HOSPITAL CENTRALIA ILLINOIS
 
Doing Business As
 
 
Number and street (or P.O. box if mail is not delivered to street address)
10101 WOODFIELD LANE
 
Room/suite
City or town, state or province, country, and ZIP or foreign postal code
ST LOUIS, MO63132
D Employer identification number

37-0662580
E Telephone number

G Gross receipts $ 91,882,469
F Name and address of principal officer:
WILLIAM THOMPSON
10101 WOODFIELD LANE
ST LOUIS,MO63132
I
Tax-exempt status: (   ) LeftBullet (insert no.) or
J
Website:MediumBullet
WWW.SSMHEALTH.COM
H(a)
Is this a group return for
subordinates?
H(b)
Are all subordinates
included?
If "No," attach a list. (see instructions)
H(c)
Group exemption number MediumBullet0928
K Form of organization:
 
L Year of formation: 1939
M State of legal domicile: IL
Part I
Summary
Activities & Governance 1 Briefly describe the organization’s mission or most significant activities: TO CONTINUE THE HEALING MINISTRY OF JESUS CHRIST BY IMPROVING & PROVIDING REGIONAL, COST EFFECTIVE QUALITY HEALTH SERVICES FOR EVERYONE, WITH A SPECIAL CONCERN FOR THE POOR AND VULNARABLE.
2 Check this box MediumBullet
3 Number of voting members of the governing body (Part VI, line 1a) ........ 3 16
4 Number of independent voting members of the governing body (Part VI, line 1b) ..... 4 7
5 Total number of individuals employed in calendar year 2013 (Part V, line 2a) ...... 5 1,021
6 Total number of volunteers (estimate if necessary) ............. 6 87
7a Total unrelated business revenue from Part VIII, column (C), line 12 ........ 7a 0
b Net unrelated business taxable income from Form 990-T, line 34 ......... 7b 0
Revenues Prior Year Current Year
8 Contributions and grants (Part VIII, line 1h) ......... 1,853,793 1,024,154
9 Program service revenue (Part VIII, line 2g) ......... 96,508,444 89,160,287
10 Investment income (Part VIII, column (A), lines 3, 4, and 7d ) .... 370,705 460,547
11 Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e) 1,113,528 1,012,190
12 Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)................... 99,846,470 91,657,178
Expenses; 13 Grants and similar amounts paid (Part IX, column (A), lines 1–3 )... 53,860 81,863
14 Benefits paid to or for members (Part IX, column (A), line 4)..... 0 0
15 Salaries, other compensation, employee benefits (Part IX, column (A), lines 5–10) 54,295,653 51,674,302
16a Professional fundraising fees (Part IX, column (A), line 11e)..... 0 0
b Total fundraising expenses (Part IX, column (D), line 25) MediumBullet0    
17 Other expenses (Part IX, column (A), lines 11a–11d, 11f–24e).... 44,853,597 47,122,690
18 Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25) 99,203,110 98,878,855
19 Revenue less expenses. Subtract line 18 from line 12....... 643,360 -7,221,677
Net Assets or Fund Balances; Beginning of Current Year End of Year
20 Total assets (Part X, line 16)............. 64,912,022 60,634,814
21 Total liabilities (Part X, line 26)............. 64,392,057 70,942,227
22 Net assets or fund balances. Subtract line 21 from line 20..... 519,965 -10,307,413
Part II
Signature Block
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete. Declaration of preparer (other than officer) is based on all information of which preparer has any knowledge.
Sign Here
JumboBullet
Signature of officer Date
JumboBullet
Type or print name and title
Paid Preparer Use Only
Print/Type preparer's name
Preparer's signature
Date
PTIN
Firm's name MediumBullet

Firm's EIN MediumBullet
Firm's address MediumBullet



Phone no.
May the IRS discuss this return with the preparer shown above? (see instructions) ............
For Paperwork Reduction Act Notice, see the separate instructions.
Cat. No. 11282Y
Form 990 (2013)
Form 990 (2013)
Page 2
Part III
Statement of Program Service Accomplishments
Check if Schedule O contains a response or note to any line in this Part III ..............
1
Briefly describe the organization’s mission: THROUGH OUR EXCEPTIONAL HEALTH CARE SERVICES, WE REVEAL THE HEALING PRESENCE OF GOD.
2
Did the organization undertake any significant program services during the year which were not listed on
the prior Form 990 or 990-EZ? ......................
If "Yes," describe these new services on Schedule O.
3
Did the organization cease conducting, or make significant changes in how it conducts, any program services? ............................
If "Yes," describe these changes on Schedule O.
4
Describe the organization’s program service accomplishments for each of its three largest program services, as measured by expenses. Section 501(c)(3) and 501(c)(4) organizations are required to report the amount of grants and allocations to others, the total expenses, and revenue, if any, for each program service reported.
4a (Code:   ) (Expenses $ 82,695,804 including grants of $ 81,863 ) (Revenue $ 89,160,287 )
SEE SCHEDULE O FOR A COMPLETE DESCRIPTION OF PROGRAM SERVICE ACCOMPLISHMENTS.
4b (Code:   ) (Expenses $   including grants of $   ) (Revenue $   )
4c (Code:   ) (Expenses $   including grants of $   ) (Revenue $   )
4d Other program services (Describe in Schedule O.)
(Expenses $   including grants of $   ) (Revenue $   )
4e Total program service expensesMediumBullet82,695,804
Form 990 (2013)
Form 990 (2013)
Page 3
Part IV
Checklist of Required Schedules
Yes
No
1
Is the organization described in section 501(c)(3) or 4947(a)(1) (other than a private foundation)? If "Yes," complete Schedule AClick to see attachment........................
1
Yes
 
2
Is the organization required to complete Schedule B, Schedule of Contributors (see instructions)? Click to see attachment...
2
Yes
 
3
Did the organization engage in direct or indirect political campaign activities on behalf of or in opposition to candidates for public office? If "Yes," complete Schedule C, Part IClick to see attachment..........
3
 
No
4
Section 501(c)(3) organizations. Did the organization engage in lobbying activities, or have a section 501(h) election in effect during the tax year? If "Yes," complete Schedule C, Part IIClick to see attachment........
4
Yes
 
5
Is the organization a section 501(c)(4), 501(c)(5), or 501(c)(6) organization that receives membership dues, assessments, or similar amounts as defined in Revenue Procedure 98-19? If "Yes," complete Schedule C,
Part IIIClick to see attachment............................
5
 
No
6
Did the organization maintain any donor advised funds or any similar funds or accounts for which donors have the right to provide advice on the distribution or investment of amounts in such funds or accounts? If "Yes," complete Schedule D, Part IClick to see attachment........................
6
 
No
7
Did the organization receive or hold a conservation easement, including easements to preserve open space,
the environment, historic land areas, or historic structures? If "Yes," complete Schedule D, Part IIClick to see attachment...
7
 
No
8
Did the organization maintain collections of works of art, historical treasures, or other similar assets? If "Yes," complete Schedule D, Part III Click to see attachment....................
8
 
No
9
Did the organization report an amount in Part X, line 21 for escrow or custodial account liability; serve as a custodian for amounts not listed in Part X; or provide credit counseling, debt management, credit repair, or debt negotiation services? If "Yes," complete Schedule D, Part IVClick to see attachment..............
9
 
No
10
Did the organization, directly or through a related organization, hold assets in temporarily restricted endowments, permanent endowments, or quasi-endowments? If "Yes," complete Schedule D, Part VClick to see attachment......
10
 
No
11
If the organization’s answer to any of the following questions is "Yes," then complete Schedule D, Parts VI, VII, VIII, IX, or X as applicable.
a
Did the organization report an amount for land, buildings, and equipment in Part X, line 10?
If "Yes," complete Schedule D, Part VI.Click to see attachment...................
11a
Yes
 
b
Did the organization report an amount for investments—other securities in Part X, line 12 that is 5% or more of its total assets reported in Part X, line 16? If "Yes," complete Schedule D, Part VIIClick to see attachment.......
11b
Yes
 
c
Did the organization report an amount for investments—program related in Part X, line 13 that is 5% or more of its total assets reported in Part X, line 16? If "Yes," complete Schedule D, Part VIIIClick to see attachment.......
11c
 
No
d
Did the organization report an amount for other assets in Part X, line 15 that is 5% or more of its total assets reported in Part X, line 16? If "Yes," complete Schedule D, Part IXClick to see attachment............
11d
 
No
e
Did the organization report an amount for other liabilities in Part X, line 25? If "Yes," complete Schedule D, Part XClick to see attachment
11e
Yes
 
f
Did the organization’s separate or consolidated financial statements for the tax year include a footnote that addresses the organization’s liability for uncertain tax positions under FIN 48 (ASC 740)? If "Yes," complete Schedule D, Part XClick to see attachment.........................
11f
Yes
 
12a
Did the organization obtain separate, independent audited financial statements for the tax year?
If "Yes," complete Schedule D, Parts XI and XII Click to see attachment.................
12a
 
No
b
Was the organization included in consolidated, independent audited financial statements for the tax year? If "Yes," and if the organization answered "No" to line 12a, then completing Schedule D, Parts XI and XII is optional Click to see attachment
12b
Yes
 
13
Is the organization a school described in section 170(b)(1)(A)(ii)? If "Yes," complete Schedule E....
13
 
No
14a
Did the organization maintain an office, employees, or agents outside of the United States?.....
14a
 
No
b
Did the organization have aggregate revenues or expenses of more than $10,000 from grantmaking, fundraising, business, investment, and program service activities outside the United States, or aggregate foreign investments valued at $100,000 or more? If "Yes," complete Schedule F, Parts I and IV.........
14b
 
No
15
Did the organization report on Part IX, column (A), line 3, more than $5,000 of grants or other assistance to or for any foreign organization? If “Yes,” complete Schedule F, Parts II and IV
15
 
No
16
Did the organization report on Part IX, column (A), line 3, more than $5,000 of aggregate grants or other assistance to or for foreign individuals? If “Yes,” complete Schedule F, Parts III and IV...
16
 
No
17
Did the organization report a total of more than $15,000 of expenses for professional fundraising services on Part IX, column (A), lines 6 and 11e? If "Yes," complete Schedule G, Part I (see instructions)....
17
 
No
18
Did the organization report more than $15,000 total of fundraising event gross income and contributions on Part VIII, lines 1c and 8a? If "Yes," complete Schedule G, Part II............
18
 
No
19
Did the organization report more than $15,000 of gross income from gaming activities on Part VIII, line 9a? If "Yes," complete Schedule G, Part III...................
19
 
No
20a
Did the organization operate one or more hospital facilities? If "Yes," complete Schedule H.... Click to see attachment
20a
Yes
 
b
If "Yes" to line 20a, did the organization attach a copy of its audited financial statements to this return?
20b
Yes
 
Form 990 (2013)
Form 990 (2013)
Page 4
Part IV
Checklist of Required Schedules (continued)
21
Did the organization report more than $5,000 of grants or other assistance to any domestic organization or government on Part IX, column (A), line 1? If “Yes,” complete Schedule I, Parts I and II... Click to see attachment
21
Yes
 
22
Did the organization report more than $5,000 of grants or other assistance to individuals in the United States on Part IX, column (A), line 2? If “Yes,” complete Schedule I, Parts I and III........ Click to see attachment
22
 
No
23
Did the organization answer "Yes" to Part VII, Section A, line 3, 4, or 5 about compensation of the organization’s current and former officers, directors, trustees, key employees, and highest compensated employees? If "Yes," complete Schedule J....................... Click to see attachment
23
Yes
 
24a
Did the organization have a tax-exempt bond issue with an outstanding principal amount of more than $100,000 as of the last day of the year, that was issued after December 31, 2002? If “Yes,” answer lines 24b through 24d and complete Schedule K. If “No,” go to line 25a................
24a
 
No
b
Did the organization invest any proceeds of tax-exempt bonds beyond a temporary period exception?...
24b
 
 
c
Did the organization maintain an escrow account other than a refunding escrow at any time during the year
to defease any tax-exempt bonds?......................
24c
 
 
d
Did the organization act as an "on behalf of" issuer for bonds outstanding at any time during the year?...
24d
 
 
25a
Section 501(c)(3) and 501(c)(4) organizations. Did the organization engage in an excess benefit transaction with a disqualified person during the year? If "Yes," complete Schedule L, Part I........
25a
 
No
b
Is the organization aware that it engaged in an excess benefit transaction with a disqualified person in a prior year, and that the transaction has not been reported on any of the organization’s prior Forms 990 or 990-EZ? If "Yes," complete Schedule L, Part I...................
25b
 
No
26
Did the organization report any amount on Part X, line 5, 6, or 22 for receivables from or payables to any current or former officers, directors, trustees, key employees, highest compensated employees, or disqualified persons? If so, complete Schedule L, Part II....................
26
 
No
27
Did the organization provide a grant or other assistance to an officer, director, trustee, key employee, substantial contributor or employee thereof, a grant selection committee member, or to a 35% controlled entity or family member of any of these persons? If "Yes," complete Schedule L, Part III.........
27
 
No
28
Was the organization a party to a business transaction with one of the following parties (see Schedule L, Part IV instructions for applicable filing thresholds, conditions, and exceptions):
a
A current or former officer, director, trustee, or key employee? If "Yes," complete Schedule L, Part IV ..........................
28a
 
No
b
A family member of a current or former officer, director, trustee, or key employee? If "Yes,"
complete Schedule L, Part IV.....................
28b
 
No
c
An entity of which a current or former officer, director, trustee, or key employee (or a family member thereof) was an officer, director, trustee, or direct or indirect owner? If "Yes," complete Schedule L, Part IV...
28c
 
No
29
Did the organization receive more than $25,000 in non-cash contributions? If "Yes," complete Schedule M..
29
 
No
30
Did the organization receive contributions of art, historical treasures, or other similar assets, or qualified conservation contributions? If "Yes," complete Schedule M.............
30
 
No
31
Did the organization liquidate, terminate, or dissolve and cease operations? If "Yes," complete Schedule N,
Part I...........................
31
 
No
32
Did the organization sell, exchange, dispose of, or transfer more than 25% of its net assets? If "Yes," complete Schedule N, Part II......................
32
 
No
33
Did the organization own 100% of an entity disregarded as separate from the organization under Regulations sections 301.7701-2 and 301.7701-3? If "Yes," complete Schedule R, Part I........ Click to see attachment
33
 
No
34
Was the organization related to any tax-exempt or taxable entity? If "Yes," complete Schedule R, Part II, III, or IV, and Part V, line 1........................ Click to see attachment
34
Yes
 
35a
Did the organization have a controlled entity within the meaning of section 512(b)(13)?
35a
 
No
b
If ‘Yes’ to line 35a, did the organization receive any payment from or engage in any transaction with a controlled entity within the meaning of section 512(b)(13)? If "Yes," complete Schedule R, Part V, line 2...
35b
 
 
36
Section 501(c)(3) organizations. Did the organization make any transfers to an exempt non-charitable related organization? If "Yes," complete Schedule R, Part V, line 2............. Click to see attachment
36
 
No
37
Did the organization conduct more than 5% of its activities through an entity that is not a related organization and that is treated as a partnership for federal income tax purposes? If "Yes," complete Schedule R, Part VIClick to see attachment
37
 
No
38
Did the organization complete Schedule O and provide explanations in Schedule O for Part VI, lines 11b and 19? Note. All Form 990 filers are required to complete Schedule O. ............
38
Yes
 
Form 990 (2013)
Form 990 (2013)
Page 5
Part V
Statements Regarding Other IRS Filings and Tax Compliance
Check if Schedule O contains a response or note to any line in this Part V ..............
Yes
No
1a
Enter the number reported in Box 3 of Form 1096 Enter -0- if not applicable ..
1a
0
b
Enter the number of Forms W-2G included in line 1a. Enter -0- if not applicable .
1b
0
c
Did the organization comply with backup withholding rules for reportable payments to vendors and reportable gaming (gambling) winnings to prize winners? ..................
1c
 
 
2a
Enter the number of employees reported on Form W-3, Transmittal of Wage and
Tax Statements, filed for the calendar year ending with or within the year covered by this return ..................
2a
1,021
b
If at least one is reported on line 2a, did the organization file all required federal employment tax returns?
Note. If the sum of lines 1a and 2a is greater than 250, you may be required to e-file (see instructions)
2b
Yes
 
3a
Did the organization have unrelated business gross income of $1,000 or more during the year?...
3a
 
No
b
If “Yes,” has it filed a Form 990-T for this year? If “No” to line 3b, provide an explanation in Schedule O...
3b
 
 
4a
At any time during the calendar year, did the organization have an interest in, or a signature or other authority over, a financial account in a foreign country (such as a bank account, securities account, or other financial account)?..........................
4a
 
No
b
If "Yes," enter the name of the foreign country: MediumBullet
See instructions for filing requirements for Form TD F 90-22.1, Report of Foreign Bank and Financial Accounts.
5a
Was the organization a party to a prohibited tax shelter transaction at any time during the tax year?..
5a
 
No
b
Did any taxable party notify the organization that it was or is a party to a prohibited tax shelter transaction?
5b
 
No
c
If "Yes," to line 5a or 5b, did the organization file Form 8886-T? ............
5c
 
 
6a
Does the organization have annual gross receipts that are normally greater than $100,000, and did the organization solicit any contributions that were not tax deductible as charitable contributions?...
6a
 
No
b
If "Yes," did the organization include with every solicitation an express statement that such contributions or gifts were not tax deductible?........................
6b
 
 
7
Organizations that may receive deductible contributions under section 170(c).
a
Did the organization receive a payment in excess of $75 made partly as a contribution and partly for goods and services provided to the payor?....................
7a
 
No
b
If "Yes," did the organization notify the donor of the value of the goods or services provided?.....
7b
 
 
c
Did the organization sell, exchange, or otherwise dispose of tangible personal property for which it was required to file Form 8282?...........................
7c
 
No
d
If "Yes," indicate the number of Forms 8282 filed during the year ....
7d
 
e
Did the organization receive any funds, directly or indirectly, to pay premiums on a personal benefit contract?............................
7e
 
No
f
Did the organization, during the year, pay premiums, directly or indirectly, on a personal benefit contract?..
7f
 
No
g
If the organization received a contribution of qualified intellectual property, did the organization file Form 8899 as required?............................
7g
 
 
h
If the organization received a contribution of cars, boats, airplanes, or other vehicles, did the organization file a Form 1098-C?..........................
7h
 
 
8
Sponsoring organizations maintaining donor advised funds and section 509(a)(3) supporting organizations. Did the supporting organization, or a donor advised fund maintained by a sponsoring organization, have excess business holdings at any time during the year?............
8
 
 
9
Sponsoring organizations maintaining donor advised funds.
a
Did the organization make any taxable distributions under section 4966?..........
9a
 
 
b
Did the organization make a distribution to a donor, donor advisor, or related person?.......
9b
 
 
10
Section 501(c)(7) organizations. Enter:
a
Initiation fees and capital contributions included on Part VIII, line 12 ...
10a
 
b
Gross receipts, included on Form 990, Part VIII, line 12, for public use of club facilities
10b
 
11
Section 501(c)(12) organizations. Enter:
a
Gross income from members or shareholders .........
11a
 
b
Gross income from other sources (Do not net amounts due or paid to other sources against amounts due or received from them.) ..........
11b
 
12a
Section 4947(a)(1) non-exempt charitable trusts. Is the organization filing Form 990 in lieu of Form 1041?
12a
 
 
b
If "Yes," enter the amount of tax-exempt interest received or accrued during the year. ....................
12b
 
13
Section 501(c)(29) qualified nonprofit health insurance issuers.
a
Is the organization licensed to issue qualified health plans in more than one state?
Note. See the instructions for additional information the organization must report on Schedule O.
13a
 
 
b
Enter the amount of reserves the organization is required to maintain by the states in which the organization is licensed to issue qualified health plans ....
13b
 
c
Enter the amount of reserves on hand ............
13c
 
14a
Did the organization receive any payments for indoor tanning services during the tax year?.....
14a
 
No
b
If "Yes," has it filed a Form 720 to report these payments? If "No," provide an explanation in Schedule O..
14b
 
 
Form 990 (2013)
Form 990 (2013)
Page 6
Part VI
Governance, Management, and Disclosure For each "Yes" response to lines 2 through 7b below, and for a "No" response to lines 8a, 8b, or 10b below, describe the circumstances, processes, or changes in Schedule O. See instructions.
Check if Schedule O contains a response or note to any line in this Part VI ..............
Section A. Governing Body and Management
Yes
No
1a
Enter the number of voting members of the governing body at the end of the tax year .....................
1a
16
If there are material differences in voting rights among members of the governing body, or if the governing body delegated broad authority to an executive committee or similar committee, explain in Schedule O.
b
Enter the number of voting members included in line 1a, above, who are independent ...................
1b
7
2
Did any officer, director, trustee, or key employee have a family relationship or a business relationship with any other officer, director, trustee, or key employee? .................
2
 
No
3
Did the organization delegate control over management duties customarily performed by or under the direct supervision of officers, directors or trustees, or key employees to a management company or other person? .
3
 
No
4
Did the organization make any significant changes to its governing documents since the prior Form 990 was filed? ...........................
4
 
No
5
Did the organization become aware during the year of a significant diversion of the organization’s assets? .
5
 
No
6
Did the organization have members or stockholders? ................
6
Yes
 
7a
Did the organization have members, stockholders, or other persons who had the power to elect or appoint one or more members of the governing body? ....................
7a
Yes
 
b
Are any governance decisions of the organization reserved to (or subject to approval by) members, stockholders, or persons other than the governing body? ...................
7b
Yes
 
8
Did the organization contemporaneously document the meetings held or written actions undertaken during the year by the following:
a
The governing body? .........................
8a
Yes
 
b
Each committee with authority to act on behalf of the governing body? ............
8b
Yes
 
9
Is there any officer, director, trustee, or key employee listed in Part VII, Section A, who cannot be reached at the organization’s mailing address? If "Yes," provide the names and addresses in Schedule O.......
9
 
No
Section B. Policies (This Section B requests information about policies not required by the Internal Revenue Code.)
Yes
No
10a
Did the organization have local chapters, branches, or affiliates? ............
10a
 
No
b
If "Yes," did the organization have written policies and procedures governing the activities of such chapters, affiliates, and branches to ensure their operations are consistent with the organization's exempt purposes?
10b
 
 
11a
Has the organization provided a complete copy of this Form 990 to all members of its governing body before filing the form? ............................
11a
 
No
b
Describe in Schedule O the process, if any, used by the organization to review this Form 990. .....
12a
Did the organization have a written conflict of interest policy? If "No," go to line 13.......
12a
Yes
 
b
Were officers, directors, or trustees, and key employees required to disclose annually interests that could give rise to conflicts? ..........................
12b
Yes
 
c
Did the organization regularly and consistently monitor and enforce compliance with the policy? If "Yes," describe in Schedule O how this was done.......................
12c
Yes
 
13
Did the organization have a written whistleblower policy? ...............
13
Yes
 
14
Did the organization have a written document retention and destruction policy? .........
14
Yes
 
15
Did the process for determining compensation of the following persons include a review and approval by independent persons, comparability data, and contemporaneous substantiation of the deliberation and decision?
a
The organization’s CEO, Executive Director, or top management official ...........
15a
 
No
b
Other officers or key employees of the organization ................
15b
 
No
If "Yes" to line 15a or 15b, describe the process in Schedule O (see instructions).
16a
Did the organization invest in, contribute assets to, or participate in a joint venture or similar arrangement with a taxable entity during the year? ......................
16a
 
No
b
If "Yes," did the organization follow a written policy or procedure requiring the organization to evaluate its participation in joint venture arrangements under applicable federal tax law, and take steps to safeguard the organization’s exempt status with respect to such arrangements? ............
16b
 
 
Section C. Disclosure
17
List the States with which a copy of this Form 990 is required to be filedMediumBullet
18
Section 6104 requires an organization to make its Form 1023 (or 1024 if applicable), 990, and 990-T (501(c)(3)s only) available for public inspection. Indicate how you made these available. Check all that apply.
19
Describe in Schedule O whether (and if so, how) the organization made its governing documents, conflict of interest policy, and financial statements available to the public during the tax year.
20
State the name, physical address, and telephone number of the person who possesses the books and records of the organization:
MediumBulletDEE EVISCHI400 N PLEASANT AVENUECENTRALIAIL628013056 (618) 899-1040
Form 990 (2013)
Form 990 (2013)
Page 7
Part VII
Compensation of Officers, Directors,Trustees, Key Employees, Highest Compensated Employees, and Independent Contractors
Check if Schedule O contains a response or note to any line in this Part VII ..............
Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees
1a Complete this table for all persons required to be listed. Report compensation for the calendar year ending with or within the organization’s tax year.
RoundBullet List all of the organization’s current officers, directors, trustees (whether individuals or organizations), regardless of amount
of compensation. Enter -0- in columns (D), (E), and (F) if no compensation was paid.

RoundBullet List all of the organization’s current key employees, if any. See instructions for definition of "key employee."
RoundBullet List the organization’s five current highest compensated employees (other than an officer, director, trustee or key employee)
who received reportable compensation (Box 5 of Form W-2 and/or Box 7 of Form 1099-MISC) of more than $100,000 from the
organization and any related organizations.

RoundBullet List all of the organization’s former officers, key employees, or highest compensated employees who received more than $100,000
of reportable compensation from the organization and any related organizations.

RoundBullet List all of the organization’s former directors or trustees that received, in the capacity as a former director or trustee of the
organization, more than $10,000 of reportable compensation from the organization and any related organizations.

List persons in the following order: individual trustees or directors; institutional trustees; officers; key employees; highest
compensated employees; and former such persons.
Check this box if neither the organization nor any related organization compensated any current officer, director, or trustee.
(A)
Name and Title 		(B)
Average hours per week (list any hours for related organizations below dotted line) 		(C)
Position (do not check more than one box, unless person is both an officer and a director/trustee) 		(D)
Reportable compensation from the organization (W- 2/1099-MISC) 		(E)
Reportable compensation from related organizations (W- 2/1099-MISC) 		(F)
Estimated amount of other compensation from the organization and related organizations
Individual Trustee or Director; Institutional Trustee; OfficerInd; Key Employee; Highest compensated employee; FormerOfcrDirectorTrusteeInd;
(1) VERLE BESANT........................................................................
DIRECTOR
 1.00
.......................0.00 		X           0 0 0
(2) MARY BURGAN........................................................................
DIRECTOR
 1.00
.......................0.00 		X           0 0 0
(3) SR M RAMONA DOMBROWSKI CSSF........................................................................
DIRECTOR
 1.00
.......................0.00 		X           0 0 0
(4) D BRUCE GEARY CPA CMA........................................................................
PT YR DIRECTOR
 1.00
.......................0.00 		X           0 0 0
(5) PHILIP GUSTAFSON........................................................................
DIRECTOR
 20.00
.......................20.00 		X           0 640,932 134,043
(6) SAJJAN K NEMANI MD........................................................................
DIRECTOR
 1.00
.......................40.00 		X           217,376 0 0
(7) PAULA FRIEDMAN........................................................................
DIRECTOR & VICE PRES
 1.00
.......................40.00 		X   X       0 596,799 15,489
(8) WILLIAM P THOMPSON........................................................................
DIRECTOR & PRESIDENT
 1.00
.......................40.00 		X   X       0 2,421,072 841,970
(9) SR M CLARETTE STRYZEWSKI CSSF........................................................................
DIRECTOR
 1.00
.......................0.00 		X           0 0 0
(10) JITENDRA K TRIVEDI MD........................................................................
DIRECTOR
 1.00
.......................40.00 		X           0 303,359 700,510
(11) BRUCE MERRELL........................................................................
DIRECTOR & HOSP PRES
 40.00
.......................0.00 		X   X       0 431,940 103,337
(12) MIKE WARREN........................................................................
DIRECTOR
 1.00
.......................40.00 		X           0 525,198 159,093
(13) RAVINDRA GEORGE MD........................................................................
DIRECTOR
 1.00
.......................40.00 		X           0 449,954 39,290
(14) BEN HOULE MD........................................................................
DIRECTOR
 1.00
.......................0.00 		X           0 0 0
(15) CHRISTOPHER HOWARD........................................................................
DIRECTOR
 1.00
.......................40.00 		X           0 893,660 29,906
(16) REV RON JOHNSON........................................................................
DIRECTOR
 1.00
.......................0.00 		X           0 0 0
(17) DIXIE PLATT........................................................................
PT YR DIRECTOR
 1.00
.......................40.00 		X           0 590,484 10,096
Form 990 (2013)
Form 990 (2013)
Page 8
Part VII
Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees (continued)
(A)
Name and Title 		(B)
Average hours per week (list any hours for related organizations below dotted line) 		(C)
Position (do not check more than one box, unless person is both an officer and a director/trustee) 		(D)
Reportable compensation from the organization (W- 2/1099-MISC) 		(E)
Reportable compensation from related organizations (W- 2/1099-MISC) 		(F)
Estimated amount of other compensation from the organization and related organizations
Individual Trustee or Director; Institutional Trustee; OfficerInd; Key Employee; Highest compensated employee; FormerOfcrDirectorTrusteeInd;
(18) STACY TATE........................................................................
DIRECTOR
 1.00
.......................0.00 		X           0 0 0
(19) KRIS A ZIMMER........................................................................
TREASURER
 1.00
.......................40.00 		    X       0 836,253 68,008
(20) JUNE L PICKETT........................................................................
SECRETARY
 1.00
.......................40.00 		    X       0 256,054 -96,872
(21) CARISSA HIBBERT........................................................................
ASST SECRETARY
 20.00
.......................20.00 		    X       43,989 0 22,630
(22) KAY TINSLEY........................................................................
PT YR VP FISCAL SERVICES
 20.00
.......................20.00 		    X       238,990 0 53,218
(23) STEVEN BARNEY........................................................................
PT YR VICE PRESIDENT
 1.00
.......................40.00 		    X       0 592,443 -223,953
(24) DELAND EVISCHI........................................................................
REGIONAL CFO
 18.00
.......................22.00 		    X       0 186,295 46,939
(25) VIRGINIA TELFORD........................................................................
VP NURSING
 40.00
.......................0.00 		      X     0 196,396 3,514
(26) MARK CLARK........................................................................
VP OPERATIONS
 20.00
.......................20.00 		      X     0 181,890 39,946
(27) CHRISTINA ADAMS........................................................................
VP OPERATIONS
 20.00
.......................20.00 		      X     0 173,892 42,340
(28) JULIE LONG........................................................................
VP PLANNING & MARKETING
 20.00
.......................20.00 		      X     0 181,004 -2,568
(29) MICHELLE DARNELL........................................................................
VP SYSTEMS IMPROVEMENT
 20.00
.......................20.00 		      X     0 174,618 22,805
(30) THOMAS BLYTHE........................................................................
VP HUMAN RESOURCES
 20.00
.......................20.00 		      X     0 190,597 33,918
(31) JAMES REUTER........................................................................
CRNA
 40.00
.......................0.00 		        X   199,739 0 26,299
(32) RAJENDRA SHROFF........................................................................
MEDICAL DIRECTOR
 40.00
.......................0.00 		        X   175,631 0 39,720
(33) JEFFREY RAPP........................................................................
PHARMACY MANAGER
 40.00
.......................0.00 		        X   141,214 0 30,912
(34) PATRICIA NEUDECKER........................................................................
DIRECTOR PHYS THERAPY
 40.00
.......................0.00 		        X   137,444 0 39,122
(35) TARA RAPP........................................................................
PHARMACIST
 40.00
.......................0.00 		        X   135,231 0 -828
(36) RICHARD HUNTINGTON........................................................................
FORMER KEY EMPLOYEE
 20.00
.......................20.00 		          X 0 103,858 -69,599
(37) GREG SIMS........................................................................
FORMER KEY EMPLOYEE
 20.00
.......................20.00 		          X 0 121,149 50,713
1b Sub-Total................MediumBullet
c Total from continuation sheets to Part VII, Section A....MediumBullet
d Total (add lines 1b and 1c)............MediumBullet 1,289,614 10,047,847 2,159,998
2
Total number of individuals (including but not limited to those listed above) who received more than $100,000 of reportable compensation from the organizationMediumBullet22
Yes
No
3
Did the organization list any former officer, director or trustee, key employee, or highest compensated employee on line 1a? If "Yes," complete Schedule J for such individual ..............
3
Yes
 
4
For any individual listed on line 1a, is the sum of reportable compensation and other compensation from the organization and related organizations greater than $150,000? If "Yes," complete Schedule J for such individual...........................
4
Yes
 
5
Did any person listed on line 1a receive or accrue compensation from any unrelated organization or individual for services rendered to the organization? If "Yes," complete Schedule J for such person ........
5
 
No
Section B. Independent Contractors
1
Complete this table for your five highest compensated independent contractors that received more than $100,000 of compensation from the organization. Report compensation for the calendar year ending with or within the organization’s tax year.
(A)
Name and business address 		(B)
Description of services 		(C)
Compensation
CENTRALIA ANESTHESIOLOGY4227 LINCOLNSHIRE DRMT VERNONIL62864 MEDICAL PURCHASED SERVICES 2,019,217
SHORES BUILDERS INC1154 SCHWARTZ ROADCENTRALIAIL62801 CONSTRUCTION SERVICES 1,982,998
MIDWEST EMERGENCY DEPARTMENTPO BOX 8882FORT WORTHTX76124 MEDICAL PURCHASED SERVICES 699,106
ADVANCED ICU CARE INCONE CITY PLACE DRIVEST LOUISMO63141 MEDICAL PURCHASED SERVICES 632,777
CROWN LINEN SERVICE215 S JEFFERSONMEXICOMO65265 PURCHASED LAUNDRY SERVICES 542,927
2
Total number of independent contractors (including but not limited to those listed above) who received more than $100,000 of compensation from the organization MediumBullet24
Form 990 (2013)
Form 990 (2013)
Page 9
Part VIII
Statement of Revenue
Check if Schedule O contains a response or note to any line in this Part VIII .............
(A)
Total revenue 		(B)
Related or
exempt
function
revenue 		(C)
Unrelated
business
revenue 		(D)
Revenue
excluded from
tax under sections
512-514
Contributions, Gifts, GrantAmt and OtherAmt Similar Amounts 1a Federated campaigns..1a  
b Membership dues....1b  
c Fundraising events....1c  
d Related organizations...1d 284,308
e Government grants (contributions)1e 639,846
f All other contributions, gifts, grants, and
similar amounts not included above1f 		100,000
g Noncash contributions included in lines
1a-1f:$ 		 
h Total. Add lines 1a-1f.......MediumBullet 1,024,154
Program Service RevenueAmt Business Code
2a NET PATIENT SERVICE REVENUE 621110 87,574,654 87,574,654    
b ANESTHESIA SERVICES 621110 215,019 215,019    
c
d
e
f All other program service revenue . 1,370,614 1,370,614    
g Total. Add lines 2a–2f........MediumBullet 89,160,287
OtherAmt RevenueAmt 3 Investment income (including dividends, interest, and other similar amounts).......MediumBullet 463,792     463,792
4 Income from investment of tax-exempt bond proceeds..MediumBullet        
5 Royalties...........MediumBullet        
(i) Real (ii) Personal
6a Gross rents 561,472  
b Less: rental expenses 222,046  
c Rental income or (loss) 339,426  
d Net rental income or (loss).......MediumBullet 339,426     339,426
(i) Securities (ii) Other
7a Gross amount from sales of assets other than inventory    
b Less: cost or other basis and sales expenses   3,245
c Gain or (loss)   -3,245
d Net gain or (loss)..........MediumBullet -3,245     -3,245
8a Gross income from fundraising events (not including
$  
of contributions reported on line 1c). See Part IV, line 18 ..
a  
b Less: direct expenses ...b  
c Net income or (loss) from fundraising events..MediumBullet      
9a Gross income from gaming activities.
See Part IV, line 19 ...
a  
b Less: direct expenses ...b  
c Net income or (loss) from gaming activities...MediumBullet        
10a Gross sales of inventory, less
returns and allowances .
a  
b Less: cost of goods sold ..b  
c Net income or (loss) from sales of inventory..MediumBullet        
Miscellaneous Revenue Business Code
11a CAFETERIA 722210 385,268     385,268
b PRINT SERVICES 561000 225,017     225,017
c MEDICAL RECORDS 561000 62,479     62,479
d All other revenue ....        
e Total. Add lines 11a–11d ...... MediumBullet 672,764
12 Total revenue. See Instructions......MediumBullet 91,657,178 89,160,287 0 1,472,737
Form 990 (2013)
Form 990 (2013)
Page 10
Part IX
Statement of Functional Expenses
Section 501(c)(3) and 501(c)(4) organizations must complete all columns. All other organizations must complete column (A).Check if Schedule O contains a response or note to any line in this Part IX ...............
Do not include amounts reported on lines 6b,
7b, 8b, 9b, and 10b of Part VIII. 		(A)
Total expenses 		(B)
Program service expenses 		(C)
Management and general expenses 		(D)
Fundraising expenses
1 Grants and other assistance to governments and organizations in the United States. See Part IV, line 21 81,863 81,863
2 Grants and other assistance to individuals in the United States. See Part IV, line 22    
3 Grants and other assistance to governments, organizations, and individuals outside the United States. See Part IV, lines 15 and 16    
4 Benefits paid to or for members    
5 Compensation of current officers, directors, trustees, and key employees .... 2,031,944 428,495 1,603,449  
6 Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) ....        
7 Other salaries and wages 34,388,072 29,346,458 5,041,614  
8 Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) .... 2,321,820 1,956,610 365,210  
9 Other employee benefits ....... 10,354,760 8,633,217 1,721,543  
10 Payroll taxes ........... 2,577,706 2,082,577 495,129  
11 Fees for services (non-employees):        
a Management ...... 945,880   945,880  
b Legal ......... 132,061   132,061  
c Accounting ........... 71,009   71,009  
d Lobbying ...........        
e Professional fundraising services. See Part IV, line 17    
f Investment management fees ......        
g Other (If line 11g amount exceeds 10% of line 25, column (A) amount, list line 11g expenses on Schedule O) ........ 11,965,273 8,420,175 3,545,098  
12 Advertising and promotion .... 471,613   471,613  
13 Office expenses ....... 5,158,719 4,648,385 510,334  
14 Information technology ...... 6,383,901 6,358,073 25,828  
15 Royalties ..        
16 Occupancy ........... 1,914,155 1,737,223 176,932  
17 Travel ............ 226,053 139,355 86,698  
18 Payments of travel or entertainment expenses for any federal, state, or local public officials ......        
19 Conferences, conventions, and meetings .... 71,768 55,893 15,875  
20 Interest ........... 814,218 814,218    
21 Payments to affiliates .......        
22 Depreciation, depletion, and amortization ..... 3,333,413 3,014,602 318,811  
23 Insurance .............. 630,463   630,463  
24 Other expenses. Itemize expenses not covered above (List miscellaneous expenses in line 24e. If line 24e amount exceeds 10% of line 25, column (A) amount, list line 24e expenses on Schedule O.)
a MEDICAL SUPPLIES 10,697,067 10,697,067    
b MEDICARE PROVIDER TAX 4,180,027 4,180,027    
c LICENSES AND TAXES 127,070 101,566 25,504  
d
e All other expenses        
25 Total functional expenses. Add lines 1 through 24e 98,878,855 82,695,804 16,183,051 0
26 Joint costs. Complete this line only if the organization reported in column (B) joint costs from a combined educational campaign and fundraising solicitation. Check here MediumBullet if following SOP 98-2 (ASC 958-720).        
Form 990 (2013)
Form 990 (2013)
Page 11
Part X Balance Sheet Check if Schedule O contains a response or note to any line in this Part X ..............
(A)
Beginning of year 		(B)
End of year
Assets 1 Cash–non-interest-bearing .............   1  
2 Savings and temporary cash investments ......... 3,599,923 2 343,858
3 Pledges and grants receivable, net ...........   3  
4 Accounts receivable, net ............. 20,357,034 4 20,596,580
5 Loans and other receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of
Schedule L ..................
  5  
6 Loans and other receivables from other disqualified persons (as defined under section 4958(f)(1)), persons described in section 4958(c)(3)(B), and contributing employers and sponsoring organizations of section 501(c)(9) voluntary employees' beneficiary organizations (see instructions) Complete Part II of Schedule L
  6  
7 Notes and loans receivable, net .............   7  
8 Inventories for sale or use .............. 1,787,238 8 1,843,476
9 Prepaid expenses and deferred charges .......... 232,143 9 270,214
10a Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D 10a 49,314,867
b Less: accumulated depreciation ..... 10b 20,073,626 27,536,848 10c 29,241,241
11 Investments—publicly traded securities ..........   11  
12 Investments—other securities. See Part IV, line 11 ..... 8,358,522 12 5,397,888
13 Investments—program-related. See Part IV, line 11 .....   13  
14 Intangible assets ............... 2,032,188 14 1,892,037
15 Other assets. See Part IV, line 11 ........... 1,008,126 15 1,049,520
16 Total assets. Add lines 1 through 15 (must equal line 34)...... 64,912,022 16 60,634,814
Liabilities 17 Accounts payable and accrued expenses ......... 6,377,586 17 16,749,635
18 Grants payable .................   18  
19 Deferred revenue ................   19  
20 Tax-exempt bond liabilities ............. 7,725,101 20 5,235,051
21 Escrow or custodial account liability. Complete Part IV of Schedule D..   21  
22 Loans and other payables to current and former officers, directors, trustees, key employees, highest compensated employees, and disqualified
persons. Complete Part II of Schedule L..........   22  
23 Secured mortgages and notes payable to unrelated third parties .. 40,832,000 23 41,444,000
24 Unsecured notes and loans payable to unrelated third parties ....   24  
25 Other liabilities (including federal income tax, payables to related third parties, and other liabilities not included on lines 17-24). Complete Part X of Schedule D.................... 9,457,370 25 7,513,541
26 Total liabilities. Add lines 17 through 25......... 64,392,057 26 70,942,227
Net Assets or Fund Balance Organizations that follow SFAS 117 (ASC 958), check here MediumBullet and complete lines 27 through 29, and lines 33 and 34.
27 Unrestricted net assets .............. 265,109 27 -10,523,292
28 Temporarily restricted net assets ........... 254,857 28 215,879
29 Permanently restricted net assets ...........   29  
Organizations that do not follow SFAS 117 (ASC 958), check here MediumBullet and complete lines 30 through 34.
30 Capital stock or trust principal, or current funds ........   30  
31 Paid-in or capital surplus, or land, building or equipment fund .....   31  
32 Retained earnings, endowment, accumulated income, or other funds   32  
33 Total net assets or fund balances ........... 519,965 33 -10,307,413
34 Total liabilities and net assets/fund balances ........ 64,912,022 34 60,634,814
Form 990 (2013)
Form 990 (2013)
Page 12
Part XI
Reconcilliation of Net Assets
Check if Schedule O contains a response or note to any line in this Part XI ..............
1
Total revenue (must equal Part VIII, column (A), line 12) ............
1
91,657,178
2
Total expenses (must equal Part IX, column (A), line 25) ............
2
98,878,855
3
Revenue less expenses. Subtract line 2 from line 1 ..............
3
-7,221,677
4
Net assets or fund balances at beginning of year (must equal Part X, line 33, column (A)) ..
4
519,965
5
Net unrealized gains (losses) on investments ...............
5
 
6
Donated services and use of facilities .................
6
 
7
Investment expenses .....................
7
 
8
Prior period adjustments .....................
8
 
9
Other changes in net assets or fund balances (explain in Schedule O) ........
9
-3,605,702
10
Net assets or fund balances at end of year. Combine lines 3 through 9 (must equal Part X, line 33, column (B))
10
-10,307,413
Part XII
Financial Statements and Reporting
Check if Schedule O contains a response or note to any line in this Part XII .............
Yes
No
1
Accounting method used to prepare the Form 990:  
If the organization changed its method of accounting from a prior year or checked "Other," explain in
Schedule O.
2a
Were the organization’s financial statements compiled or reviewed by an independent accountant?
2a
 
No
If ‘Yes,’ check a box below to indicate whether the financial statements for the year were compiled or reviewed on a separate basis, consolidated basis, or both:
b
Were the organization’s financial statements audited by an independent accountant?
2b
Yes
 
If ‘Yes,’ check a box below to indicate whether the financial statements for the year were audited on a separate basis, consolidated basis, or both:
c
If "Yes," to line 2a or 2b, does the organization have a committee that assumes responsibility for oversight of the audit, review, or compilation of its financial statements and selection of an independent accountant?
2c
Yes
 
If the organization changed either its oversight process or selection process during the tax year, explain in Schedule O.
3a
As a result of a federal award, was the organization required to undergo an audit or audits as set forth in the Single Audit Act and OMB Circular A-133?
3a
Yes
 
b
If "Yes," did the organization undergo the required audit or audits? If the organization did not undergo the required audit or audits, explain why in Schedule O and describe any steps taken to undergo such audits.
3b
Yes
 
Form 990 (2013)
Form 990, Special Condition Description:
Special Condition Description
Additional Data


Software ID:  
Software Version:  
SCHEDULE A
(Form 990 or 990EZ)

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.
right arrow Attach to Form 990 or Form 990-EZ. right arrow See separate instructions.
right arrow Information about Schedule A (Form 990 or 990-EZ) and its instructions is at www.irs.gov/form990.
OMB No. 1545-0047
2013
Open to Public
Inspection
Name of the organization
ST MARY'S HOSPITAL CENTRALIA ILLINOIS
 
Employer identification number

37-0662580
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
f
g
(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 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 monetary support
Yes No Yes No Yes No
Total  

For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990EZ.
Cat. No. 11285F
Schedule A (Form 990 or 990-EZ) 2013
Schedule A (Form 990 or 990-EZ) 2013
Page 2
Part II
Support Schedule for Organizations Described in Sections 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) right arrow (a) 2009 (b) 2010 (c) 2011 (d) 2012 (e) 2013 (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) right arrow (a) 2009 (b) 2010 (c) 2011 (d) 2012 (e) 2013 (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. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)..            
11 Total support (Add lines 7 through 10).  
12
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.................................................right arrow
Section C. Computation of Public Support Percentage
14
14
 
15
15
 
16a
b
17a
b
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 ..................................................... right arrow
Schedule A (Form 990 or 990-EZ) 2013
Schedule A (Form 990 or 990-EZ) 2013
Page 3
Part III
Support Schedule for Organizations Described in Section 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) right arrow (a) 2009 (b) 2010 (c) 2011 (d) 2012 (e) 2013 (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) right arrow (a) 2009 (b) 2010 (c) 2011 (d) 2012 (e) 2013 (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
Section C. Computation of Public Support Percentage
15
15
 
16
16
 
Section D. Computation of Investment Income Percentage
17
17
 
18
18
 
19a
b
20
Schedule A (Form 990 or 990-EZ) 2013
Schedule A (Form 990 or 990-EZ) 2013
Page 4
Part IV
Supplemental Information. Provide the explanations required by Part II, line 10; Part II, line 17a or 17b; and 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) 2013

Additional Data


Software ID:  
Software Version:  
Schedule B
(Form 990, 990-EZ,
or 990-PF)
Department of the Treasury
Internal Revenue Service
Schedule of Contributors
Arrow Bullet Attach to Form 990, 990-EZ, or 990-PF.
Arrow Bullet Information about Schedule B (Form 990, 990-EZ, or 990-PF) and its instructions is at www.irs.gov/form990.
OMB No. 1545-0047
2013
Name of the organization
ST MARY'S HOSPITAL CENTRALIA ILLINOIS
 
Employer identification number

37-0662580
Organization type (check one):
Filers of:
Section:
Form 990 or 990-EZ





Form 990-PF




Check if your organization is covered by the General Rule or a Special Rule.  
Note. Only a section 501(c)(7), (8), or (10) organization can check boxes for both the General Rule and a Special Rule. See instructions.
General Rule
Special Rules
......................... Arrow Bullet $  
Caution. An organization that is not covered by the General Rule and/or the Special Rules does not file Schedule B (Form 990,
990-EZ, or 990-PF), but it must answer “No” on Part IV, line 2, of its Form 990; or check the box on line H of its
Form 990-EZ or on its Form 990PF, Part I, line 2, to certify that it does not meet the filing requirements of Schedule B (Form 990,
990-EZ, or 990-PF).
For Paperwork Reduction Act Notice, see the Instructions
for Form 990, 990-EZ, or 990-PF.
Cat. No. 30613XSchedule B (Form 990, 990-EZ, or 990-PF) (2013)

Schedule B (Form 990, 990-EZ, or 990-PF) (2013)
Page 2
Name of organization
ST MARY'S HOSPITAL CENTRALIA ILLINOIS
  		Employer identification number

37-0662580
Part I
Contributors (see instructions). Use duplicate copies of Part I if additional space is needed.
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
RESTRICTED
RESTRICTED
 

   
RESTRICTED
RESTRICTED
RESTRICTED, RESTRICTEDRESTRICTED

$RESTRICTED


(Complete Part II for noncash contributions.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
 
 
 

   
 
 

$  


(Complete Part II for noncash contributions.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
 
 
 

   
 
 

$  


(Complete Part II for noncash contributions.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
 
 
 

   
 
 

$  


(Complete Part II for noncash contributions.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
 
 
 

   
 
 

$  


(Complete Part II for noncash contributions.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
 
 
 

   
 
 

$  


(Complete Part II for noncash contributions.)
Schedule B (Form 990, 990-EZ, or 990-PF) (2013)

Schedule B (Form 990, 990-EZ, or 990-PF) (2013)
Page 3
Name of organization
ST MARY'S HOSPITAL CENTRALIA ILLINOIS
  		Employer identification number

37-0662580
Part II
Noncash Property (see instructions). Use duplicate copies of Part II if additional space is needed.
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
Schedule B (Form 990, 990-EZ, or 990-PF) (2013)

Schedule B (Form 990, 990-EZ, or 990-PF) (2013)
Page 4
Name of organization
ST MARY'S HOSPITAL CENTRALIA ILLINOIS
  		Employer identification number

37-0662580
Part III
Exclusively religious, charitable, etc., individual contributions to section 501(c)(7), (8), or (10) organizations
that total more than $1,000 for the year. Complete columns (a) through (e) and the following line entry.
For organizations completing Part III, enter the total of exclusively religious, charitable, etc.,
contributions of $1,000 or less for the year. (Enter this information once. See instructions.) Arrow Bullet$  
Use duplicate copies of Part III if additional space is needed.
(a) No.
from
Part I		 (b) Purpose of gift (c) Use of gift (d) Description of how gift is held
 
(e) Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
     
 
(a) No.
from
Part I		 (b) Purpose of gift (c) Use of gift (d) Description of how gift is held
 
(e) Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
     
 
(a) No.
from
Part I		 (b) Purpose of gift (c) Use of gift (d) Description of how gift is held
 
(e) Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
     
 
(a) No.
from
Part I		 (b) Purpose of gift (c) Use of gift (d) Description of how gift is held
 
(e) Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
     
 
Schedule B (Form 990, 990-EZ, or 990-PF) (2013)

Additional Data


Software ID:  
Software Version:  
SCHEDULE C
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service
Political Campaign and Lobbying Activities

For Organizations Exempt From Income Tax Under section 501(c) and section 527
SchCMd Bullet Complete if the organization is described below.SchCMd Bullet Attach to Form 990 or Form 990-EZ.
SchCMd Bullet See separate instructions.SchCMd Bullet Information about Schedule C (Form 990 or 990-EZ) and its instructions is at www.irs.gov/form990.
OMB No. 1545-0047
2013
Open to Public
Inspection
If the organization answered "Yes" to Form 990, Part IV, Line 3, or Form 990-EZ, Part V, line 46 (Political Campaign Activities), then
Round Bullet Section 501(c)(3) organizations: Complete Parts I-A and B. Do not complete Part I-C.
Round Bullet Section 501(c) (other than section 501(c)(3)) organizations: Complete Parts I-A and C below. Do not complete Part I-B.
Round Bullet Section 527 organizations: Complete Part I-A only.
If the organization answered "Yes" to Form 990, Part IV, Line 4, or Form 990-EZ, Part VI, line 47 (Lobbying Activities), then
Round Bullet Section 501(c)(3) organizations that have filed Form 5768 (election under section 501(h)): Complete Part II-A. Do not complete Part II-B.
Round Bullet Section 501(c)(3) organizations that have NOT filed Form 5768 (election under section 501(h)): Complete Part II-B. Do not complete Part II-A.
If the organization answered "Yes" to Form 990, Part IV, Line 5 (Proxy Tax) or Form 990-EZ, Part V, line 35c (Proxy Tax), then
Round Bullet Section 501(c)(4), (5), or (6) organizations: Complete Part III.
Name of the organization
ST MARY'S HOSPITAL CENTRALIA ILLINOIS
 
Employer identification number

37-0662580
Part I-A
Complete if the organization is exempt under section 501(c) or is a section 527 organization.

1
Provide a description of the organization’s direct and indirect political campaign activities in Part IV.
2
Political expenditures ....................................SchCMd Bullet
$  
3
Volunteer hours ........................................
 

Part I-B
Complete if the organization is exempt under section 501(c)(3).
1
Enter the amount of any excise tax incurred by the organization under section 4955 .........SchCMd Bullet
$  
2
Enter the amount of any excise tax incurred by organization managers under section 4955 ......SchCMd Bullet
$  
3
If the organization incurred a section 4955 tax, did it file Form 4720 for this year? ..............
4a
Was a correction made? .........................................
b
If "Yes," describe in Part IV.
Part I-C
Complete if the organization is exempt under section 501(c), except section 501(c)(3).
1
Enter the amount directly expended by the filing organization for section 527 exempt function activities SchCMd Bullet
$  
2
Enter the amount of the filing organization's funds contributed to other organizations for section 527 exempt function activities ...................................SchCMd Bullet

$  
3
Total exempt function expenditures. Add lines 1 and 2. Enter here and on Form 1120-POL, line 17b..SchCMd Bullet

$  
4
Did the filing organization file Form 1120-POL for this year? ..........................
5
Enter the names, addresses and employer identification number (EIN) of all section 527 political organizations to which the filing
organization made payments. For each organization listed, enter the amount paid from the filing organization’s funds. Also enter the amount of political contributions received that were promptly and directly delivered to a separate political organization, such as a separate segregated fund or a political action committee (PAC). If additional space is needed, provide information in Part IV.
(a) Name (b) Address (c) EIN (d) Amount paid from filing organization's funds. If none, enter -0-. (e) Amount of political contributions received and promptly and directly delivered to a separate political organization. If none, enter -0-.










For Paperwork Reduction Act Notice, see the instructions for Form 990 or 990-EZ.
Cat. No. 50084S
Schedule C (Form 990 or 990-EZ) 2013

Schedule C (Form 990 or 990-EZ) 2013
Page 2
Part II-A
Complete if the organization is exempt under section 501(c)(3) and filed Form 5768 (election under section 501(h)).
A Check SchCMd Bulletexpenses, and share of excess lobbying expenditures).
B Check SchCMd Bullet
Limits on Lobbying Expenditures
(The term "expenditures" means amounts paid or incurred.) 		(a) Filing
organization's
totals 		(b) Affiliated group
totals
1a Total lobbying expenditures to influence public opinion (grass roots lobbying) ......    
b Total lobbying expenditures to influence a legislative body (direct lobbying) .......    
c Total lobbying expenditures (add lines 1a and 1b) ...................    
d Other exempt purpose expenditures ........................    
e Total exempt purpose expenditures (add lines 1c and 1d) ...............    
f Lobbying nontaxable amount. Enter the amount from the following table in both
columns.		    
If the amount on line 1e, column (a) or (b) is:The lobbying nontaxable amount is:
Not over $500,00020% of the amount on line 1e.
Over $500,000 but not over $1,000,000$100,000 plus 15% of the excess over $500,000.
Over $1,000,000 but not over $1,500,000$175,000 plus 10% of the excess over $1,000,000.
Over $1,500,000 but not over $17,000,000$225,000 plus 5% of the excess over $1,500,000.
Over $17,000,000$1,000,000.
g Grassroots nontaxable amount (enter 25% of line 1f) .................    
h Subtract line 1g from line 1a. If zero or less, enter -0-. ................    
i Subtract line 1f from line 1c. If zero or less, enter -0-. ................    
j If there is an amount other than zero on either line 1h or line 1i, did the organization file Form 4720 reporting
section 4911 tax for this year? ......................................

4-Year Averaging Period Under Section 501(h)
(Some organizations that made a section 501(h) election do not have to complete all of the five
columns below. See the instructions for lines 2a through 2f on page 4.)
Lobbying Expenditures During 4-Year Averaging Period
Calendar year (or fiscal year
beginning in) 		(a) 2010 (b) 2011 (c) 2012 (d) 2013 (e) Total
2a Lobbying nontaxable amount          
b Lobbying ceiling amount
(150% of line 2a, column(e)) 		 
c Total lobbying expenditures          
d Grassroots nontaxable amount          
e Grassroots ceiling amount
(150% of line 2d, column (e))		  
f Grassroots lobbying expenditures          
Schedule C (Form 990 or 990-EZ) 2013


Schedule C (Form 990 or 990-EZ) 2013
Page 3
Part II-B
Complete if the organization is exempt under section 501(c)(3) and has NOT filed Form 5768 (election under section 501(h)).
For each "Yes" response to lines 1a through 1i below, provide in Part IV a detailed description of the lobbying activity.
(a)
No
Yes
(b)
Amount
1
During the year, did the filing organization attempt to influence foreign, national, state or local legislation, including any attempt to influence public opinion on a legislative matter or referendum, through the use of:
a
Volunteers? .........................................
 
No
b
Paid staff or management (include compensation in expenses reported on lines 1c through 1i)? ....
 
No
c
Media advertisements? ....................................
 
No
 
d
Mailings to members, legislators, or the public? .........................
 
No
 
e
Publications, or published or broadcast statements? .......................
 
No
 
f
Grants to other organizations for lobbying purposes? .......................
Yes
 
34,741
g
Direct contact with legislators, their staffs, government officials, or a legislative body? ........
 
No
 
h
Rallies, demonstrations, seminars, conventions, speeches, lectures, or any similar means? ......
 
No
 
i
Other activities? ..........................
 
No
 
j
Total. Add lines 1c through 1i ...............................
34,741
2a
Did the activities in line 1 cause the organization to be not described in section 501(c)(3)? .....
 
No
b
If "Yes," enter the amount of any tax incurred under section 4912 .................
 
c
If "Yes," enter the amount of any tax incurred by organization managers under section 4912 .....
 
d
If the filing organization incurred a section 4912 tax, did it file Form 4720 for this year? .......
 
 
Part III-A
Complete if the organization is exempt under section 501(c)(4), section 501(c)(5), or section 501(c)(6).
Yes
No
1
Were substantially all (90% or more) dues received nondeductible by members? ................
1
 
 
2
Did the organization make only in-house lobbying expenditures of $2,000 or less? ................
2
 
 
3
Did the organization agree to carry over lobbying and political expenditures from the prior year? ..........
3
 
 
Part III-B
Complete if the organization is exempt under section 501(c)(4), section 501(c)(5), or section 501(c)(6) and if either (a) BOTH Part III-A, lines 1 and 2, are answered "No" OR (b) Part III-A, line 3, is answered “Yes."
1
Dues, assessments and similar amounts from members .....................
1
 
2
Section 162(e) nondeductible lobbying and political expenditures (do not include amounts of political
expenses for which the section 527(f) tax was paid).
a
Current year .........................................
2a
 
b
Carryover from last year ....................................
2b
 
c
Total ............................................
2c
 
3
Aggregate amount reported in section 6033(e)(1)(A) notices of nondeductible section 162(e) dues .
3
 
4
If notices were sent and the amount on line 2c exceeds the amount on line 3, what portion of the excess does the organization agree to carryover to the reasonable estimate of nondeductible lobbying and political expenditure next year? ................................
4
 
5
Taxable amount of lobbying and political expenditures (see instructions) ..............
5
 
Part IV
Supplemental Information
Provide the descriptions required for Part l-A, line 1; Part l-B, line 4; Part l-C, line 5; Part II-A (affiliated group list); Part II-A, line 2; and Part ll-B, line 1. Also, complete this part for any additional information.
Return Reference Explanation
PART II-B, LINE 1: THE ORGANIZATION PAID DUES TO VARIOUS NATIONAL HOSPITAL ASSOCIATIONS AND A PORTION OF THESE DUES WAS ALLOCATED TO LOBBYING ACTIVITIES.
Schedule C (Form 990 or 990EZ) 2013

Additional Data


Software ID:  
Software Version:  

SCHEDULE D
(Form 990)
Department of the Treasury
Internal Revenue Service
Supplemental Financial Statements
SchDMd Bullet Complete if the organization answered "Yes," to Form 990,
Part IV, line 6, 7, 8, 9, 10, 11a, 11b, 11c, 11d, 11e, 11f, 12a, or 12b
SchDMd Bullet Attach to Form 990. SchDMd Bullet See separate instructions. SchDMd Bullet Information about Schedule D (Form 990) and its instructions is at www.irs.gov/form990.
OMB No. 1545-0047
2013
Open to Public Inspection
Name of the organization
ST MARY'S HOSPITAL CENTRALIA ILLINOIS
 
Employer identification number

37-0662580
Part I
Organizations Maintaining Donor Advised Funds or Other Similar Funds or Accounts. Complete if the organization answered "Yes" to Form 990, Part IV, line 6.
(a) Donor advised funds (b) Funds and other accounts
1 Total number at end of year .........    
2 Aggregate contributions to (during year) ...    
3 Aggregate grants from (during year) .....    
4 Aggregate value at end of year ........    
5
Did the organization inform all donors and donor advisors in writing that the assets held in donor advised
funds are the organization's property, subject to the organization's exclusive legal control? ............
6
Did the organization inform all grantees, donors, and donor advisors in writing that grant funds can be
used only for charitable purposes and not for the benefit of the donor or donor advisor, or for any other purpose conferring impermissible private benefit? ...................................
Part II
Conservation Easements. Complete if the organization answered "Yes" to Form 990, Part IV, line 7.
1
Purpose(s) of conservation easements held by the organization (check all that apply).
2
Complete lines 2a through 2d if the organization held a qualified conservation contribution in the form of a conservation easement on the last day of the tax year.
Held at the End of the Year
a Total number of conservation easements ....................... 2a  
b Total acreage restricted by conservation easements .................. 2b  
c Number of conservation easements on a certified historic structure included in (a) ..... 2c  
d Number of conservation easements included in (c) acquired after 8/17/06, and not on a historic structure listed in the National Register .................... 2d  
3
Number of conservation easements modified, transferred, released, extinguished, or terminated by the organization during
the tax year SchDMd Bullet  
4
Number of states where property subject to conservation easement is located SchDMd Bullet  
5
Does the organization have a written policy regarding the periodic monitoring, inspection, handling of violations, and
enforcement of the conservation easements it holds? .............................
6
Staff and volunteer hours devoted to monitoring, inspecting, and enforcing conservation easements during the year
SchDMd Bullet  
7
Amount of expenses incurred in monitoring, inspecting, and enforcing conservation easements during the year
SchDMd Bullet $  
8
Does each conservation easement reported on line 2(d) above satisfy the requirements of section 170(h)(4)(B)(i) and section 170(h)(4)(B)(ii)? .......................................
9
In Part XIII, describe how the organization reports conservation easements in its revenue and expense statement, and
balance sheet, and include, if applicable, the text of the footnote to the organization’s financial statements that describes
the organization’s accounting for conservation easements.
Part III
Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets.
Complete if the organization answered "Yes" to Form 990, Part IV, line 8.
1a
If the organization elected, as permitted under SFAS 116 (ASC 958), not to report in its revenue statement and balance sheet works of art, historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of public service, provide, in Part XIII, the text of the footnote to its financial statements that describes these items.
b
If the organization elected, as permitted under SFAS 116 (ASC 958), to report in its revenue statement and balance sheet works of art, historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of public service, provide the following amounts relating to these items:
(i)
Revenues included in Form 990, Part VIII, line 1 ........................SchDMd Bullet $  
(ii)
Assets included in Form 990, Part X ..............................SchDMd Bullet $  
2
If the organization received or held works of art, historical treasures, or other similar assets for financial gain, provide the
following amounts required to be reported under SFAS 116 (ASC 958) relating to these items:
a
Revenues included in Form 990, Part VIII, line 1 ..........................SchDMd Bullet $  
b
Assets included in Form 990, Part X ...............................SchDMd Bullet $  
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 52283D
Schedule D (Form 990) 2013

Schedule D (Form 990) 2013
Page 2
Part III
Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets (continued)
3
Using the organization’s acquisition, accession, and other records, check any of the following that are a significant use of its collection items (check all that apply):
a
d
b
e
 
c
4
Provide a description of the organization’s collections and explain how they further the organization’s exempt purpose in
Part XIII.
5
During the year, did the organization solicit or receive donations of art, historical treasures or other similar
assets to be sold to raise funds rather than to be maintained as part of the organization’s collection?........
Part IV
Escrow and Custodial Arrangements. Complete if the organization answered "Yes" to Form 990,
Part IV, line 9, or reported an amount on Form 990, Part X, line 21.
1a
Is the organization an agent, trustee, custodian or other intermediary for contributions or other assets not
included on Form 990, Part X? ....................................
b
If "Yes," explain the arrangement in Part XIII and complete the following table:
Amount
c Beginning balance ................................. 1c  
d Additions during the year .............................. 1d  
e Distributions during the year ............................. 1e  
f Ending balance ................................... 1f  
2a
Did the organization include an amount on Form 990, Part X, line 21? .....................
b
If "Yes," explain the arrangement in Part XIII. Check here if the explanation has been provided in Part XIII ........
Part V
Endowment Funds. Complete if the organization answered "Yes" to Form 990, Part IV, line 10.
(a)Current year (b)Prior year b (c)Two years back (d)Three years back (e)Four years back
1a Beginning of year balance ....          
b Contributions ........          
c Net investment earnings, gains, and losses          
d Grants or scholarships .....          
e Other expenditures for facilities
and programs ........ 		         
f Administrative expenses ....          
g End of year balance ......          
2
Provide the estimated percentage of the current year end balance (line 1g, column (a)) held as:
a
Board designated or quasi-endowment SchDMd Bullet  
b
Permanent endowment SchDMd Bullet  
c
Temporarily restricted endowment SchDMd Bullet  
The percentages in lines 2a, 2b, and 2c should equal 100%.
3a
Are there endowment funds not in the possession of the organization that are held and administered for the
organization by:

Yes
No
(i) unrelated organizations ........................
3a(i)
 
 
(ii) related organizations ........................
3a(ii)
 
 
b
If "Yes" to 3a(ii), are the related organizations listed as required on Schedule R? .........
3b
 
 
4
Describe in Part XIII the intended uses of the organization's endowment funds.
Part VI
Land, Buildings, and Equipment. Complete if the organization answered 'Yes' to Form 990, Part IV, line 11a. See Form 990, Part X, line 10.
Description of property (a) Cost or other basis (investment) (b)Cost or other basis (other) (c) Accumulated depreciation (d) Book value
1a Land .................   1,259,000 1,259,000
b Buildings ................   26,738,195 8,666,916 18,071,279
c Leasehold improvements ............        
d Equipment ................   17,465,577 10,770,939 6,694,638
e Other .................   3,852,095 635,771 3,216,324
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).).......SchDMdBullet 29,241,241
Schedule D (Form 990) 2013

Schedule D (Form 990) 2013
Page 3
Part VII
Investments—Other Securities. Complete if the organization answered 'Yes' to Form 990, Part IV, line 11b. See Form 990, Part X, line 12.
(a) Description of security or category
(including name of security)		 (b)Book value (c) Method of valuation:
Cost or end-of-year market value
(1)Financial derivatives    
(2)Closely-held equity interests    
(3)Other
(A) SSM COMPREHENSIVE INVESTMENT PROGRAM 		5,205,234 F

(B) BENEFICIAL INTEREST IN FOUNDATION 		192,654 F







Total. (Column (b) must equal Form 990, Part X, col. (B) line 12.)Small Bullet 5,397,888
Part VIII
Investments—Program Related. Complete if the organization answered 'Yes' to Form 990, Part IV, line 11c. See Form 990, Part X, line 13.
(a) Description of investment (b) Book value (c) Method of valuation:
Cost or end-of-year market value








Total. (Column (b) must equal Form 990, Part X, col.(B) line 13.)Small Bullet  
Part IX
Other Assets. Complete if the organization answered 'Yes' to Form 990, Part IV, line 11d. See Form 990, Part X, line 15.
(a) Description (b) Book value








Total. (Column (b) must equal Form 990, Part X, col.(B) line 15.)...........Small Bullet  
Part X
Other Liabilities. Complete if the organization answered 'Yes' to Form 990, Part IV, line 11e or 11f. See Form 990, Part X, line 25.
1.(a) Description of liability (b) Book value
Federal income taxes  
DUE TO AFFILIATES 351,346
DEFERRED COMPENSATION 132,161
ASSET RETIREMENT OBLIGATION 1,022,335
PENSION FUNDING LIABILITY 5,476,699
OTHER LONG TERM LIABILITIES 531,000




Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)Small Bullet 7,513,541
2. Liability for uncertain tax positions In Part XIII, provide the text of the footnote to the organization's financial statements that reports the organization's liability for uncertain tax positions under FIN 48 (ASC 740). Check here if the text of the footnote has been provided in Part XIII ..................................................
Schedule D (Form 990) 2013

Schedule D (Form 990) 2013
Page 4
Part XI Reconciliation of Revenue per Audited Financial Statements With Revenue per Return Complete if the organization answered 'Yes' to Form 990, Part IV, line 12a.
1 Total revenue, gains, and other support per audited financial statements ....... 1  
2 Amounts included on line 1 but not on Form 990, Part VIII, line 12:
a Net unrealized gains on investments .......... 2a  
b Donated services and use of facilities ......... 2b  
c Recoveries of prior year grants ........... 2c  
d Other (Describe in Part XIII.) ............ 2d  
e Add lines 2a through 2d ..................... 2e  
3 Subtract line 2e from line 1..................... 3  
4 Amounts included on Form 990, Part VIII, line 12, but not on line 1:
a Investment expenses not included on Form 990, Part VIII, line 7b . 4a  
b Other (Describe in Part XIII.) ........... 4b  
c Add lines 4a and 4b....................... 4c  
5 Total revenue. Add lines 3 and 4c. (This must equal Form 990, Part I, line 12.) ...... 5  
Part XII Reconciliation of Expenses per Audited Financial Statements With Expenses per Return. Complete if the organization answered 'Yes' to Form 990, Part IV, line 12a.
1 Total expenses and losses per audited financial statements ........... 1  
2 Amounts included on line 1 but not on Form 990, Part IX, line 25:
a Donated services and use of facilities .......... 2a  
b Prior year adjustments .............. 2b  
c Other losses ................ 2c  
d Other (Describe in Part XIII.) ............ 2d  
e Add lines 2a through 2d...................... 2e  
3 Subtract line 2e from line 1..................... 3  
4 Amounts included on Form 990, Part IX, line 25, but not on line 1:
a Investment expenses not included on Form 990, Part VIII, line 7b .. 4a  
b Other (Describe in Part XIII.) ............ 4b  
c Add lines 4a and 4b....................... 4c  
5 Total expenses. Add lines 3 and 4c. (This must equal Form 990, Part I, line 18.) ...... 5  
Part XIII
Supplemental Information
Provide the descriptions required for Part II, lines 3, 5, and 9; Part III, lines 1a and 4; Part lV, lines 1b and 2b;
Part V, line 4; Part X, line 2; Part XI, lines 2d and 4b; and Part XII, lines 2d and 4b. Also complete this part to provide any additional information.
Return Reference Explanation
PART X, LINE 2: ST MARY'S HOSPITAL, CENTRALIA, ILLINOIS' FINANCIAL INFORMATION IS INCLUDED IN THE CONSOLIDATED AUDITED FINANCIAL STATEMENTS OF A RELATED ORGANIZATION, SSM HEALTH CARE (SSMHC). SSMHC EVALUATES ITS UNCERTAIN TAX POSITIONS ON AN ANNUAL BASIS. A TAX BENEFIT FROM AN UNCERTAIN TAX POSITION MAY BE RECOGNIZED WHEN IT IS MORE LIKELY THAN NOT THAT THE POSITION WILL BE SUSTAINED UPON EXAMINATION, INCLUDING RESOLUTIONS OF ANY RELATED APPEALS OR LITIGATION PROCESSES, BASED ON THE TECHNICAL MERITS. THERE HAVE BEEN NO UNCERTAIN TAX POSITIONS RECORDED IN 2013 OR 2012.
Schedule D (Form 990) 2013

Additional Data


Software ID:  
Software Version:  




SCHEDULE H (Form 990)
Department of the Treasury
Internal Revenue Service
Hospitals
MediumBullet Complete if the organization answered "Yes" to Form 990, Part IV, question 20.
MediumBullet Attach to Form 990. MediumBullet See separate instructions.
MediumBullet Information about Schedule H (Form 990) and its instructions is at www.irs.gov/form990.
OMB No. 1545-0047
2013
Open to Public Inspection
Name of the organization
ST MARY'S HOSPITAL CENTRALIA ILLINOIS
 
Employer identification number

37-0662580
Part I
Financial Assistance and Certain Other Community Benefits at Cost
Yes
No
1a
Did the organization have a financial assistance policy during the tax year? If "No," skip to question 6a ...
1a
Yes
 
b
If "Yes," was it a written policy? .......................
1b
Yes
 
2
If the organization had multiple hospital facilities, indicate which of the following best describes application of the financial assistance policy to its various hospital facilities during the tax year.
3
Answer the following based on the financial assistance eligibility criteria that applied to the largest number of the organization's patients during the tax year.
a
Did the organization use Federal Poverty Guidelines (FPG) as a factor in determining eligibility for providing free care?
If "Yes," indicate which of the following was the FPG family income limit for eligibility for free care:
3a
Yes
 
%
b
Did the organization use FPG as a factor in determining eligibility for providing discounted care? If "Yes," indicate
which of the following was the family income limit for eligibility for discounted care: .........
3b
Yes
 
%
c
If the organization used factors other than FPG in determining eligibility, describe in Part VI the income based criteria for determining eligibility for free or discounted care. Include in the description whether the organization used an asset test or other threshold, regardless of income, as a factor in determining eligibility for free or discounted care.
4
Did the organization's financial assistance policy that applied to the largest number of its patients during the tax year provide for free or discounted care to the "medically indigent"? ..............

4

Yes

 
5a
Did the organization budget amounts for free or discounted care provided under its financial assistance policy during the tax year? ............................

5a

Yes

 
b
If "Yes," did the organization's financial assistance expenses exceed the budgeted amount? ......
5b
 
No
c
If "Yes" to line 5b, as a result of budget considerations, was the organization unable to provide free or discountedcare to a patient who was eligibile for free or discounted care? ..............
5c
 
 
6a
Did the organization prepare a community benefit report during the tax year? ..........
6a
Yes
 
b
If "Yes," did the organization make it available to the public? ..............
6b
 
No
Complete the following table using the worksheets provided in the Schedule H instructions. Do not submit these worksheets with the Schedule H.
7
Financial Assistance and Certain Other Community Benefits at Cost
Financial Assistance and
Means-Tested
Government Programs
 (a) Number of activities or programs (optional) (b) Persons served (optional) (c) Total community benefit expense (d) Direct offsetting revenue (e) Net community benefit expense (f) Percent of total expense
a Financial Assistance at cost
(from Worksheet 1) .. 		    3,972,637   3,972,637 4.020 %
b Medicaid (from Worksheet 3,
column a) .... 		    24,859,414 17,886,156 6,973,258 7.050 %
c Costs of other means-tested
government programs (from
Worksheet 3, column b) . 		           
d Total Financial Assistance
and Means-Tested
Government Programs . 		    28,832,051 17,886,156 10,945,895 11.070 %
Other Benefits
     98,421   98,421 0.100 %
e Community health
improvement services and
community benefit operations
(from Worksheet 4) ..
f Health professions education
(from Worksheet 5) .. 		    179,734   179,734 0.180 %
g Subsidized health services
(from Worksheet 6) .. 		    769,138 163,000 606,138 0.610 %
h Research (from Worksheet 7)     24,997   24,997 0.030 %
i Cash and in-kind
contributions for community
benefit (from Worksheet 8) 		    86,819   86,819 0.090 %
j Total. Other Benefits ..     1,159,109 163,000 996,109 1.010 %
k Total. Add lines 7d and 7j .     29,991,160 18,049,156 11,942,004 12.080 %
For Paperwork Reduction Act Notice, see the Instructions for Form 990. Cat. No. 50192T Schedule H (Form 990) 2013
Schedule H (Form 990) 2013
Page
Part II
Community Building Activities Complete this table if the organization conducted any community building activities during the tax year, and describe in Part VI how its community building activities promoted the health of the communities it serves.
(a) Number of activities or programs (optional) (b) Persons served (optional) (c) Total community building expense (d) Direct offsetting
revenue 		(e) Net community building expense (f) Percent of total expense
1 Physical improvements and housing            
2 Economic development     2,019   2,019 0 %
3 Community support     8,566   8,566 0.010 %
4 Environmental improvements     10,783   10,783 0.010 %
5 Leadership development and training for community members            
6 Coalition building     1,200   1,200 0 %
7 Community health improvement advocacy     1,009   1,009 0 %
8 Workforce development            
9 Other            
10 Total     23,577   23,577 0.020 %
Part III
Bad Debt, Medicare, & Collection Practices
Section A. Bad Debt Expense
Yes
No
1
Did the organization report bad debt expense in accordance with Heathcare Financial Management Association Statement No. 15? ..........................
1
 
No
2
Enter the amount of the organization's bad debt expense. Explain in Part VI the methodology used by the organization to estimate this amount. ......
2
4,568,120
3
Enter the estimated amount of the organization's bad debt expense attributable to patients eligible under the organization's financial assistance policy. Explain in Part VI the methodology used by the organization to estimate this amount and the rationale, if any, for including this portion of bad debt as community benefit. ......
3
 
4
Provide in Part VI the text of the footnote to the organization’s financial statements that describes bad debt expense or the page number on which this footnote is contained in the attached financial statements.
Section B. Medicare
5
Enter total revenue received from Medicare (including DSH and IME).....
5
29,934,069
6
Enter Medicare allowable costs of care relating to payments on line 5.....
6
39,938,428
7
Subtract line 6 from line 5. This is the surplus (or shortfall)........
7
-10,004,359
8
Describe in Part VI the extent to which any shortfall reported in line 7 should be treated as community benefit.Also describe in Part VI the costing methodology or source used to determine the amount reported on line 6.Check the box that describes the method used:
Section C. Collection Practices
9a
Did the organization have a written debt collection policy during the tax year? ..........
9a
Yes
 
b
If "Yes," did the organization’s collection policy that applied to the largest number of its patients during the tax year contain provisions on the collection practices to be followed for patients who are known to qualify for financial assistance? Describe in Part VI.......................

9b

Yes

 
Part IV
Management Companies and Joint Ventures(owned 10% or more by officers, directors, trustees, key employees, and physicians—see instructions)
(a) Name of entity (b) Description of primary
activity of entity 		(c) Organization's
profit % or stock
ownership % 		(d) Officers, directors,
trustees, or key
employees' profit %
or stock ownership % 		(e) Physicians'
profit % or stock
ownership %
1
2
3
4
5
6
7
8
9
10
11
12
13
Schedule H (Form 990) 2013
Schedule H (Form 990) 2013
Page
Part VFacility Information
Section A. Hospital Facilities
(list in order of size from largest to smallest—see instructions)
How many hospital facilities did the organization operate during the tax year?1
Name, address, primary website address, and state license number 		Licensed Hospital General-Medical-Surgical Children's Hospital Teaching Hospital Critical Hospital ResearchGrp Facility ER-24Hours ER-Other Other (Describe) Facility reporting group
1 ST MARY'S HOSPITAL
400 N PLEASANT AVENUE
CENTRALIA,IL62801
WWW.SSMHEALTH.COM
0002642 		X X         X      
Schedule H (Form 990) 2013
Schedule H (Form 990) 2013
Page
Part VFacility Information (continued)

Section B. Facility Policies and Practices

(Complete a separate Section B for each of the hospital facilities or facility reporting groups listed in Part V, Section A)
ST MARY'S HOSPITAL
Name of hospital facility or facility reporting group  
If reporting on Part V, Section B for a single hospital facility only: line number of
hospital facility (from Schedule H, Part V, Section A) 		1
Yes No
Community Health Needs Assessment (Lines 1 through 8c are optional for tax years begining on or before March 23, 2012)
1 During the tax year or either of the two immediately preceding tax years, did the hospital facility conduct a community health needs assessment (CHNA)? If "No," skip to line 9.................... 1 Yes  
If "Yes," indicate what the CHNA report describes (check all that apply):
a
b
c
d
e
f
g
h
i
j
2 Indicate the tax year the hospital facility last conducted a CHNA: 20 12
3 In conducting its most recent CHNA, did the hospital facility take into account input from persons who represent the broad interests of the community served by the hospital facility, including those with special knowledge of or expertise in public health? If "Yes," describe in Part VI how the hospital facility took into account input from persons who represent the community, and identify the persons the hospital facility consulted .................... 3 Yes  
4 Was the hospital facility’s CHNA conducted with one or more other hospital facilities? If "Yes," list the other hospital facilities in Part VI................................ 4   No
5 Did the hospital facility make its CHNA report widely available to the public? ............. 5 Yes  
If "Yes," indicate how the CHNA report was made widely available (check all that apply):
a
b
c
d
6 If the hospital facility addressed needs identified in its most recently conducted CHNA, indicate how (check all that apply as of the end of the tax year):
a
b
c
d
e
f
g
h
i
7 Did the hospital facility address all of the needs identified in its most recently conducted CHNA? If "No," explain in Part VI which needs it has not addressed and the reasons why it has not addressed such needs ........ 7   No
8a Did the organization incur an excise tax under section 4959 for the hospital facility's failure to conduct a CHNA as required by section 501(r)(3)? ........................... 8a   No
b If "Yes" to line 8a, did the organization file Form 4720 to report the section 4959 excise tax? ...... 8b    
c If "Yes" to line 8b, what is the total amount of section 4959 excise tax the organization reported on Form 4720 for all of its hospital facilities? $  

Schedule H (Form 990) 2013
Schedule H (Form 990) 2013
Page
Part VFacility Information (continued)

Financial Assistance Policy Yes No
9 Did the hospital facility have in place during the tax year a written financial assistance policy that:
Explained eligibility criteria for financial assistance, and whether such assistance includes free or discounted care? 9 Yes  
10 Used federal poverty guidelines (FPG) to determine eligibility for providing free care?........... 10 Yes  
If "Yes," indicate the FPG family income limit for eligibility for free care: 200.000000000000%
If "No," explain in Part VI the criteria the hospital facility used.
11 Used FPG to determine eligibility for providing discounted care?................. 11 Yes  
If "Yes," indicate the FPG family income limit for eligibility for discounted care: 400.000000000000%
If "No," explain in Part VI the criteria the hospital facility used.
12 Explained the basis for calculating amounts charged to patients?................. 12 Yes  
If "Yes," indicate the factors used in determining such amounts (check all that apply):
a
b
c
d
e
f
g
h
i
13 Explained the method for applying for financial assistance?................... 13 Yes  
14 Included measures to publicize the policy within the community served by the hospital facility?....... 14 Yes  
If "Yes," indicate how the hospital facility publicized the policy (check all that apply):
a
b
c
d
e
f
g
Billing and Collections
15 Did the hospital facility have in place during the tax year a separate billing and collections policy, or a written financial assistance policy (FAP) that explained actions the hospital facility may take upon non-payment?....... 15 Yes  
16 Check all of the following actions against an individual that were permitted under the hospital facility's policies during the tax year before making reasonable efforts to determine the individual’s eligibility under the facility’s FAP:
a
b
c
d
e
17 Did the hospital facility or an authorized third party perform any of the following actions during the tax year before making reasonable efforts to determine the individual’s eligibility under the facility’s FAP?.......... 17   No
If "Yes," check all actions in which the hospital facility or a third party engaged:
a
b
c
d
e
Schedule H (Form 990) 2013
Schedule H (Form 990) 2013
Page
Part VFacility Information (continued)

18 Indicate which efforts the hospital facility made before initiating any of the actions listed in line 17 (check all that apply):
a
b
c
d
e
Policy Relating to Emergency Medical Care
Yes No
19 Did the hospital facility have in place during the tax year a written policy relating to emergency medical care that requires the hospital facility to provide, without discrimination, care for emergency medical conditions to individuals regardless of their eligibility under the hospital facility’s financial assistance policy?.......... 19 Yes  
If "No," indicate why:
a
b
c
d
Charges to Individuals Eligible for Assistance under the FAP (FAP-Eligible Individuals)
20 Indicate how the hospital facility determined, during the tax year, the maximum amounts that can be charged to FAP-eligible individuals for emergency or other medically necessary care.
a
b
c
d
21 During the tax year, did the hospital facility charge any FAP-eligible individual to whom the hospital facility provided emergency or other medically necessary services more than the amounts generally billed to individuals who had insurance covering such care? ............................ 21   No
If "Yes," explain in Part VI.
22 During the tax year, did the hospital facility charge any FAP-eligible individual an amount equal to the gross charge for any service provided to that individual? ......................... 22   No
If "Yes," explain in Part VI.
Schedule H (Form 990) 2013
Schedule H (Form 990) 2013
Page
Part V
Facility Information (continued)
Section C. Supplemental Information for Part V, Section B.Provide descriptions required for Part V, Section B, lines 1j, 3, 4, 5d, 6i, 7, 10, 11, 12i, 14g, 16e, 17e, 18e, 19c, 19d, 20d, 21, and 22. If applicable, provide separate descriptions for each facility in a facility reporting group, designated by "Facility A," "Facility B," etc.
Form and Line Reference Explanation
ST. MARY'S HOSPITAL PART V, SECTION B, LINE 3: THE CHNA STEERING COMMITTEE ORGANIZED A GROUP OF FORMAL AND INFORMAL LEADERS REPRESENTING THE HOSPITAL AND THE COMMUNITY TO REVIEW THE CHNA DATA AND SELECT KEY PRIORITIES. A COMPLETE LIST OF COMMUNITY MEMBERS CAN BE FOUND ON PAGE 9 OF THE CHNA.
ST. MARY'S HOSPITAL PART V, SECTION B, LINE 7: THE COMMUNITY BENEFITS TEAM REVIEWED THE CHNA DATA, ENGAGED IN DISCUSSION, AND COMPLETED A MULTI-VOTING EXERCISE BASED ON THE FOLLOWING CRITERIA TO DETERMINE THE COMMUNITY NEEDS THE HOSPITAL WOULD ADDRESS: VARIANCE FROM STATE AND NATIONAL BENCHMARKS, AVAILABLE RESOURCES WITHIN THE HOSPITAL/COMMUNITY TO ADDRESS THE PRIORITY, WHETHER ACTIONS WOULD LIKELY LEAD TO IMPROVEMENT AND ALIGNMENT WITH THE MISSION OF THE HOSPITAL. A LIST OF OTHER COMMUNITY NEEDS NOT ADDRESSED AND THE REASONING WHY THE HOSPITAL HAS NOT ADDRESSED SUCH NEEDS CAN BE FOUND ON PAGE 9 OF THE CHNA.
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
Schedule H (Form 990) 2013
Schedule H (Form 990) 2013
Page
Part VFacility Information (continued)

Section D. Other Health Care Facilities That Are Not Licensed, Registered, or Similarly Recognized as a Hospital Facility
(list in order of size, from largest to smallest)
How many non-hospital health care facilities did the organization operate during the tax year?7
Name and address Type of Facility (describe)
1 CENTRALIA WORK SAFETY INSTITUTE
1441 BROADWAY
CENTRALIA,IL62801 		REHABILITATION FACILITY
2 SALEM WORK SAFETY INSTITUTE
1250 W WHITTAKER STREET
SALEM,IL62881 		REHABILITATION FACILITY
3 CARLYLE WORK SAFETY INSTITUTE
811 FAIRFAX ST
CARLYLE,IL62231 		REHABILITATION FACILITY
4 BENTON WORK SAFETY INSTITUTE
501 N DUQUOIN
BENTON,IL62812 		REHABILITATION FACILITY
5 CENTRALIA FAMILY HEALTH CENTER
1441 WEST BROADWAY
CENTRALIA,IL62801 		PRIMARY CARE CENTER
6 SALEM FAMILY HEALTH CENTER
1250 W WHITAKER ST
SALEM,IL62881 		PRIMARY CARE CENTER
7 CARLYLE FAMILY HEALTH CENTER
811 FAIRFAX ST
CARLYLE,IL62231 		PRIMARY CARE CENTER
8
9
10
Schedule H (Form 990) 2013
Schedule H (Form 990) 2013
Page
Part VI
Supplemental Information
Provide the following information.
1 Required descriptions. Provide the descriptions required for Part I, lines 3c, 6a, and 7; Part II and Part III, lines 2, 3, 4, 8 and 9b.
2 Needs assessment. Describe how the organization assesses the health care needs of the communities it serves, in addition to any CHNAs reported in Part V, Section B.
3 Patient education of eligibility for assistance. Describe how the organization informs and educates patients and persons who may be billed for patient care about their eligibility for assistance under federal, state, or local government programs or under the organization’s financial assistance policy.
4 Community information. Describe the community the organization serves, taking into account the geographic area and demographic constituents it serves.
5 Promotion of community health. Provide any other information important to describing how the organization’s hospital facilities or other health care facilities further its exempt purpose by promoting the health of the community (e.g., open medical staff, community board, use of surplus funds, etc.).
6 Affiliated health care system. If the organization is part of an affiliated health care system, describe the respective roles of the organization and its affiliates in promoting the health of the communities served.
7 State filing of community benefit report. If applicable, identify all states with which the organization, or a related organization, files a community benefit report.
Form and Line Reference Explanation
ST. MARY'S HOSPITAL PART V, SECTION B, LINE 3: THE CHNA STEERING COMMITTEE ORGANIZED A GROUP OF FORMAL AND INFORMAL LEADERS REPRESENTING THE HOSPITAL AND THE COMMUNITY TO REVIEW THE CHNA DATA AND SELECT KEY PRIORITIES. A COMPLETE LIST OF COMMUNITY MEMBERS CAN BE FOUND ON PAGE 9 OF THE CHNA.
ST. MARY'S HOSPITAL PART V, SECTION B, LINE 7: THE COMMUNITY BENEFITS TEAM REVIEWED THE CHNA DATA, ENGAGED IN DISCUSSION, AND COMPLETED A MULTI-VOTING EXERCISE BASED ON THE FOLLOWING CRITERIA TO DETERMINE THE COMMUNITY NEEDS THE HOSPITAL WOULD ADDRESS: VARIANCE FROM STATE AND NATIONAL BENCHMARKS, AVAILABLE RESOURCES WITHIN THE HOSPITAL/COMMUNITY TO ADDRESS THE PRIORITY, WHETHER ACTIONS WOULD LIKELY LEAD TO IMPROVEMENT AND ALIGNMENT WITH THE MISSION OF THE HOSPITAL. A LIST OF OTHER COMMUNITY NEEDS NOT ADDRESSED AND THE REASONING WHY THE HOSPITAL HAS NOT ADDRESSED SUCH NEEDS CAN BE FOUND ON PAGE 9 OF THE CHNA.
Schedule H (Form 990) 2013
Additional Data


Software ID:  
Software Version:  
Schedule I
(Form 990)
Department of the Treasury
Internal Revenue Service
Grants and Other Assistance to Organizations,
Governments and Individuals in the United States
Complete if the organization answered "Yes," to Form 990, Part IV, line 21 or 22.
lBullet Attach to Form 990
lBullet Information about Schedule I (Form 990) and its instructions is at www.irs.gov/form990.
OMB No. 1545-0047
2013
Open to Public
Inspection
Name of the organization
ST MARY'S HOSPITAL CENTRALIA ILLINOIS
 
Employer identification number
37-0662580
Part I
General Information on Grants and Assistance
1
Does the organization maintain records to substantiate the amount of the grants or assistance, the grantees' eligibility for the grants or assistance, and
the selection criteria used to award the grants or assistance? ....................................
2
Describe in Part IV the organization's procedures for monitoring the use of grant funds in the United States.
Part II
Grants and Other Assistance to Governments and Organizations in the United States. Complete if the organization answered "Yes" to
Form 990, Part IV, line 21, for any recipient that received more than $5,000. Part II can be duplicated if additional space is needed.
(a) Name and address of organization
or government		 (b) EIN (c) IRC Code section
if applicable		 (d) Amount of cash grant (e) Amount of non-cash
assistance		 (f) Method of valuation
(book, FMV, appraisal,
other)		 (g) Description of
non-cash assistance		 (h) Purpose of grant
or assistance
(1) ILLINOIS HOSPITAL RESEARCH AND EDUCATIONAL FOUNDATION
1151 EAST WARRENVILLE ROAD
NAPERVILLE,IL60563 		23-7421930 501(C)(3) 70,263       TO ASSIST ILLINOIS HOSPITALS IN PROVIDING HEALTH CARE SERVICES
(2) JOHN & ELEANOR MITCHELL FOUNDATION
PO BOX 923
MT VERNON,IL62864 		37-6053100 501(C)(3) 8,000       TO SUPPORT THE OPERATIONS OF THE FOUNDATION




















2
Enter total number of section 501(c)(3) and government organizations listed in the line 1 table ................ Bullet Image
2
3
Enter total number of other organizations listed in the line 1 table ........................ . Bullet Image
 
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50055P
Schedule I (Form 990) 2013

Schedule I (Form 990) 2013
Page 2
Part III
Grants and Other Assistance to Individuals in the United States. Complete if the organization answered "Yes" to Form 990, Part IV, line 22.
Part III can be duplicated if additional space is needed.
(a)Type of grant or assistance (b)Number of
recipients		 (c)Amount of
cash grant		 (d)Amount of
non-cash assistance		 (e)Method of valuation (book,
FMV, appraisal, other)		 (f)Description of non-cash assistance












Part IV
Supplemental Information. Provide the information required in Part I, line 2, Part III, column (b), and any other additional information.
Return Reference Explanation
PART I, LINE 2: COMPLETED GRANT/CONTRIBUTION REQUESTS ARE FORWARDED TO THE MARKETING DEPARTMENT FOR INITIAL APPROVAL. THE MARKETING DEPARTMENT MAINTAINS A LOG OF ALL CONTRIBUTION REQUESTS. THE DEPARTMENT EVALUATES THE REQUEST AND FORWARDS REQUESTS RECOMMENDED FOR APPROVAL TO THE HOSPITAL PRESIDENT AND/OR ADMINISTRATIVE COUNCIL FOR FINAL APPROVAL. MOST GRANTS/CONTRIBUTIONS ARE MADE TO 501(C)(3) ORGANIZATIONS OR LOCAL CIVIC AND EDUCATIONAL ORGANIZATIONS.
Schedule I (Form 990) 2013


Additional Data


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Software Version:  


Schedule J
(Form 990)
Department of the Treasury
Internal Revenue Service
Compensation Information
For certain Officers, Directors, Trustees, Key Employees, and Highest
Compensated Employees
SchJMediumBullet Complete if the organization answered "Yes" to Form 990, Part IV, line 23.
SchJMediumBullet Attach to Form 990. SchJMediumBullet See separate instructions.
SchJMediumBullet Information about Schedule J (Form 990) and its instructions is at www.irs.gov/form990.
OMB No. 1545-0047
2013
Open to Public Inspection
Name of the organization
ST MARY'S HOSPITAL CENTRALIA ILLINOIS
 
Employer identification number

37-0662580
Part I
Questions Regarding Compensation
Yes
No
1a
Check the appropiate box(es) if the organization provided any of the following to or for a person listed in Form
990, Part VII, Section A, line 1a. Complete Part III to provide any relevant information regarding these items.
b
If any of the boxes in line 1a are checked, did the organization follow a written policy regarding payment or reimbursement or provision of all of the expenses described above? If "No," complete Part III to explain....
1b
 
 
2
Did the organization require substantiation prior to reimbursing or allowing expenses incurred by all
directors, trustees, officers, including the CEO/Executive Director, regarding the items checked in line 1a? ..
2
 
 
3
Indicate which, if any, of the following the filing organization used to establish the compensation of the
organization's CEO/Executive Director. Check all that apply. Do not check any boxes for methods
used by a related organization to establish compensation of the CEO/Executive Director, but explain in Part III.
4
During the year, did any person listed in Form 990, Part VII, Section A, line 1a with respect to the filing organization or a related organization:
a
Receive a severance payment or change-of-control payment? ................
4a
Yes
 
b
Participate in, or receive payment from, a supplemental nonqualified retirement plan? .........
4b
Yes
 
c
Participate in, or receive payment from, an equity-based compensation arrangement? .........
4c
 
No
If "Yes" to any of lines 4a-c, list the persons and provide the applicable amounts for each item in Part III.
Only 501(c)(3) and 501(c)(4) organizations only must complete lines 5-9.
5
For persons listed in Form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the revenues of:
a
The organization? ...........................
5a
 
No
b
Any related organization? .........................
5b
 
No
If "Yes," to line 5a or 5b, describe in Part III.
6
For persons listed in Form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the net earnings of:
a
The organization? ...........................
6a
 
No
b
Any related organization? .........................
6b
 
No
If "Yes," to line 6a or 6b, describe in Part III.
7
For persons listed in Form 990, Part VII, Section A, line 1a, did the organization provide any non-fixed
payments not described in lines 5 and 6? If "Yes," describe in Part III ............
7
 
No
8
Were any amounts reported in Form 990, Part VII, paid or accured pursuant to a contract that was
subject to the initial contract exception described in Regulations section 53.4958-4(a)(3)? If "Yes," describe
in Part III .............................
8
 
No
9
If "Yes" to line 8, did the organization also follow the rebuttable presumption procedure described in Regulations section 53.4958-6(c)? .........................
9
 
 
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50053T
Schedule J (Form 990) 2013

Schedule J (Form 990) 2013
Page 2
Part II
Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees. Use duplicate copies if additional space is needed.
For each individual whose compensation must be reported in Schedule J, report compensation from the organization on row (i) and from related organizations, described in the
instructions, on row (ii). Do not list any individuals that are not listed on Form 990, Part VII.
Note. The sum of columns (B)(i)-(iii) for each listed individual must equal the total amount of Form 990, Part VII, Section A, line 1a, applicable column (D) and (E) amounts for that individual.
(A) Name and Title (B) Breakdown of W-2 and/or 1099-MISC compensation (C) Retirement and other deferred compensation (D) Nontaxable
benefits		 (E) Total of columns
(B)(i)-(D) 		(F) Compensation
reported as deferred
in prior Form 990
(i) Base compensation (ii) Bonus & incentive compensation (iii) Other reportable compensation
(1)PHILIP GUSTAFSONDIRECTOR (i)
(ii)		 0
538,937 		0
0 		0
101,995 		0
107,724 		0
26,319 		0
774,975 		0
0
(2)SAJJAN K NEMANI MDDIRECTOR (i)
(ii)		 217,376
0 		0
0 		0
0 		0
0 		0
0 		217,376
0 		0
0
(3)PAULA FRIEDMANDIRECTOR & VICE PRES (i)
(ii)		 0
523,635 		0
0 		0
73,164 		0
-2,191 		0
17,680 		0
612,288 		0
32,970
(4)WILLIAM P THOMPSONDIRECTOR & PRESIDENT (i)
(ii)		 0
1,404,608 		0
0 		0
1,016,464 		0
811,381 		0
30,589 		0
3,263,042 		0
59,150
(5)JITENDRA K TRIVEDI MDDIRECTOR (i)
(ii)		 0
297,702 		0
0 		0
5,657 		0
663,985 		0
36,525 		0
1,003,869 		0
0
(6)BRUCE MERRELLDIRECTOR & HOSP PRES (i)
(ii)		 0
356,877 		0
0 		0
75,063 		0
76,023 		0
27,314 		0
535,277 		0
22,610
(7)MIKE WARRENDIRECTOR (i)
(ii)		 0
370,631 		0
0 		0
154,567 		0
125,554 		0
33,539 		0
684,291 		0
22,470
(8)RAVINDRA GEORGE MDDIRECTOR (i)
(ii)		 0
444,978 		0
0 		0
4,976 		0
3,530 		0
35,760 		0
489,244 		0
0
(9)CHRISTOPHER HOWARDDIRECTOR (i)
(ii)		 0
806,003 		0
0 		0
87,657 		0
-1,097 		0
31,003 		0
923,566 		0
40,320
(10)DIXIE PLATTPT YR DIRECTOR (i)
(ii)		 0
345,892 		0
0 		0
244,592 		0
-19,981 		0
30,077 		0
600,580 		0
29,890
(11)KRIS A ZIMMERTREASURER (i)
(ii)		 0
763,126 		0
0 		0
73,127 		0
40,169 		0
27,839 		0
904,261 		0
45,360
(12)JUNE L PICKETTSECRETARY (i)
(ii)		 0
226,100 		0
0 		0
29,954 		0
-119,886 		0
23,014 		0
159,182 		0
8,680
(13)KAY TINSLEYPT YR VP FISCAL SERVICES (i)
(ii)		 149,294
0 		0
0 		89,696
0 		21,236
0 		31,982
0 		292,208
0 		7,652
0
(14)STEVEN BARNEYPT YR VICE PRESIDENT (i)
(ii)		 0
354,279 		0
0 		0
238,164 		0
-236,820 		0
12,867 		0
368,490 		0
0
(15)DELAND EVISCHIREGIONAL CFO (i)
(ii)		 0
173,438 		0
0 		0
12,857 		0
10,833 		0
36,106 		0
233,234 		0
6,548
(16)VIRGINIA TELFORDVP NURSING (i)
(ii)		 0
164,199 		0
0 		0
32,197 		0
-8,689 		0
12,203 		0
199,910 		0
0
(17)MARK CLARKVP OPERATIONS (i)
(ii)		 0
172,290 		0
0 		0
9,600 		0
4,398 		0
35,548 		0
221,836 		0
6,860
(18)CHRISTINA ADAMSVP OPERATIONS (i)
(ii)		 0
163,566 		0
0 		0
10,326 		0
37,322 		0
5,018 		0
216,232 		0
6,080
(19)JULIE LONGVP PLANNING & MARKETING (i)
(ii)		 0
170,803 		0
0 		0
10,201 		0
-5,762 		0
3,194 		0
178,436 		0
6,296
(20)MICHELLE DARNELLVP SYSTEMS IMPROVEMENT (i)
(ii)		 0
165,729 		0
0 		0
8,889 		0
-3,063 		0
25,868 		0
197,423 		0
6,360
(21)THOMAS BLYTHEVP HUMAN RESOURCES (i)
(ii)		 0
180,682 		0
0 		0
9,915 		0
7,720 		0
26,198 		0
224,515 		0
6,544
(22)JAMES REUTERCRNA (i)
(ii)		 177,524
0 		0
0 		22,215
0 		19,464
0 		6,835
0 		226,038
0 		0
0
(23)RAJENDRA SHROFFMEDICAL DIRECTOR (i)
(ii)		 174,581
0 		0
0 		1,050
0 		19,486
0 		20,234
0 		215,351
0 		0
0
(24)JEFFREY RAPPPHARMACY MANAGER (i)
(ii)		 140,327
0 		0
0 		887
0 		-1,278
0 		32,190
0 		172,126
0 		0
0
(25)PATRICIA NEUDECKERDIRECTOR PHYS THERAPY (i)
(ii)		 122,833
0 		0
0 		14,611
0 		876
0 		38,246
0 		176,566
0 		0
0
(26)RICHARD HUNTINGTONFORMER KEY EMPLOYEE (i)
(ii)		 0
88,802 		0
0 		0
15,056 		0
-69,599 		0
0 		0
34,259 		0
0
(27)GREG SIMSFORMER KEY EMPLOYEE (i)
(ii)		 0
107,599 		0
0 		0
13,550 		0
32,827 		0
17,886 		0
171,862 		0
6,684
Schedule J (Form 990) 2013

Schedule J (Form 990) 2013
Page 3
Part III
Supplemental Information
Provide the information, explanation, or descriptions required for Part I, lines 1a, 1b, 3, 4a, 4b, 4c, 5a, 5b, 6a, 6b, 7, and 8, and for Part II.
Also complete this part for any additional information.
Return Reference Explanation
PART I, LINE 1A THE ORGANIZATION'S TOP MANAGEMENT OFFICIAL, HOSPITAL PRESIDENT, IS COMPENSATED BY A RELATED ORGANIZATION THAT UTILIZED THE FOLLOWING TO DETERMINE COMPENSATION: (1) INDEPENDENT COMPENSATION CONSULTANT; (2) COMPENSATION SURVEY OR STUDY; (3) APPROVAL BY THE SSM HEALTH CARE PRESIDENT. PART I, LINE 4A: SEVERANCE PLAN SSMHC HAS ADOPTED A SEVERANCE POLICY TO PROVIDE A FINANCIAL TRANSITION IN THE EVENT OF INVOLUNTARY TERMINATION WITHOUT CAUSE FOR EXECUTIVE LEVEL POSITIONS. THE AMOUNT OF THE COMPENSATION IS BASED ON THE POSITION HELD AND LENGTH OF SERVICE WITH SSMHC. THE FOLLOWING INDIVIDUALS RECEIVED PAYMENTS UNDER THE PLAN IN THE CURRENT YEAR. DIXIE PLATT $103,615 KAY TINSLEY $ 27,554 GREG SIMS $ 4,337 PART I, LINE 4B: SUPPLEMENTAL NONQUALIFIED RETIREMENT PLANS PENSION RESTORATION PLAN: SSM HEALTH CARE ("SSMHC") PROVIDES THIS SUPPLEMENTAL DEFINED BENEFIT NONQUALIFIED RETIREMENT PLAN TO ANY EMPLOYEE WHO IS A PARTICIPANT IN THE SSMHC QUALIFIED DEFINED BENEFIT PLAN WHO EARNS OVER THE INTERNAL REVENUE SERVICE COMPENSATION LIMIT. THE PLAN "RESTORES" THE BENEFITS TO THESE EMPLOYEES THAT WOULD HAVE BEEN PROVIDED UNDER SSMHC'S QUALIFIED PLAN IF THE REGULATIONS DID NOT IMPOSE COMPENSATION LIMITS. AN INDIVIDUAL CAN TAKE A DISTRIBUTION FROM THE PLAN AT (1) AGE 65 OR OLDER IF THE INDIVIDUAL IS STILL EMPLOYED BY SSMHC OR (2) AGE 55 OR OLDER IF THE INDIVIDUAL IS NO LONGER EMPLOYED BY SSMHC. NO REPORTABLE INDIVIDUALS LISTED ON PART VII OF FORM 990 RECEIVED DISTRIBUTIONS FROM THIS PLAN DURING 2013. CAPITAL ACCUMULATION PLAN: SSMHC PROVIDES THIS SUPPLEMENTAL NONQUALIFIED RETIREMENT PLAN TO EXECUTIVE LEVEL EMPLOYEES. THE ORGANIZATION CONTRIBUTED A PERCENTAGE OF THE EMPLOYEE'S BASE SALARY INTO THEIR CHOICE OF A SELECT LIST OF INVESTMENTS. THE DEPOSITS AND EARNINGS OF THE PLAN ARE OWNED BY SSMHC AND ARE TAX-DEFERRED UNTIL A DISTRIBUTION IS MADE TO THE EMPLOYEE. IN ADDITION, THE PLAN HAS SPECIAL SAFEGUARDS IN PLACE TO PROTECT THE FUNDS FROM CONTINGENCIES, OTHER THAN INSOLVENCY. FOR CONTRIBUTIONS MADE TO THE PLAN IN 2008 OR AFTER, THE DISTRIBUTION WILL OCCUR AFTER THE COMPLETION OF TWO PLAN YEARS FOR ALL EXECUTIVES THAT ARE STILL ACTIVELY EMPLOYED ON THE DISTRIBUTION DATE. ANY ACTIVE PARTICIPANT 65 YEARS OR OLDER WILL RECEIVE THE CONTRIBUTION IN THE CURRENT YEAR. THE FOLLOWING INDIVIDUALS LISTED ON PART VII OF THE FORM 990 RECEIVED DISTRIBUTIONS FROM THIS PLAN IN 2013. ALL DISTRIBUTIONS RECEIVED FROM THE PLAN IN THE CURRENT YEAR WERE INCLUDED IN THE INDIVIDUALS' TAXABLE COMPENSATION. STEVEN BARNEY $148,902 DIXIE PLATT $ 95,540 WILLIAM THOMPSON $ 59,209 CHRISTOPHER HOWARD $ 52,082 KRIS ZIMMER $ 45,405 PHILIP GUSTAFSON $ 37,870 PAULA FRIEDMAN $ 33,003 MICHAEL WARREN $ 29,919 KAY TINSLEY $ 29,269 BRUCE MERRELL $ 22,632 RICHARD HUNTINGTON $ 14,806 JUNE PICKETT $ 19,086 DELAND EVISCHI $ 9,954 JULIE LONG $ 8,049 THOMAS BLYTHE $ 7,752 VIRGINIA TELFORD $ 7,236 MARK CLARK $ 6,755 GREG SIMS $ 6,691 MICHELLE DARNELL $ 6,366 CHRISTINA ADAMS $ 6,086
Schedule J (Form 990) 2013

Additional Data


Software ID:  
Software Version:  
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.
MediumBullet Attach to Form 990 or 990-EZ.
MediumBullet Information about Schedule O (Form 990 or 990-EZ) and its instructions is at
www.irs.gov/form990.
OMB No. 1545-0047
2013
Open to Public
Inspection
Name of the organization
ST MARY'S HOSPITAL CENTRALIA ILLINOIS
 
Employer identification number

37-0662580
Return Reference Explanation
FORM 990, PART III, LINE 4A, PROGRAM SERVICE ACCOMPLISHMENTS: BRIEFLY DESCRIBE THE ORGANIZATION'S MISSION: SINCE IT WAS FOUNDED IN 1872 BY CATHOLIC SISTERS, SSM HEALTH CARE (SSMHC) HAS EXISTED TO MEET THE HEALTH NEEDS OF THE COMMUNITIES IT SERVES. AS OF NOVEMBER 15, 2013, WITH VATICAN APPROVAL, THE FRANCISCAN SISTERS OF MARY TRANSITIONED SPONSORSHIP OF SSMHC TO SSM HEALTH MINISTRIES. SSM HEALTH MINISTRIES IS AN INDEPENDENT 6-MEMBER BODY COMPRISED OF THREE FRANCISCAN SISTERS OF MARY AND THREE LAY PEOPLE WHO COLLECTIVELY HOLD CERTAIN RESERVED POWERS OVER SSMHC. HEADQUARTERED IN ST LOUIS, MISSOURI, SSMHC OWNS AND OPERATES 18 ACUTE CARE HOSPITALS, ONE CHILDREN'S HOSPITAL, TWO LONG-TERM CARE FACILITIES, AN EXTENSIVE NETWORK OF PHYSICIAN PRACTICE OPERATIONS, AND OTHER HEALTH CARE BUSINESSES LOCATED PRIMARILY IN MISSOURI, OKLAHOMA, WISCONSIN, AND ILLINOIS. THE HEALTH SYSTEM EMPLOYS APPROXIMATELY 30,000 PEOPLE AND IS AFFILIATED WITH MORE THAN 8,000 PHYSICIANS. IN THE TRADITION OF ITS FOUNDING SISTERS, SSMHC STRIVES TO FULFILL ITS MISSION BY PROVIDING EXCEPTIONAL HEALTH CARE TO EVERYONE WHO COMES TO ITS HOSPITALS, REGARDLESS OF THEIR ABILITY TO PAY. DESCRIBE THE ORGANIZATION'S APPROACH TO PROVIDING COMMUNITY BENEFIT: THE BOARD OF ST. MARY'S HOSPITAL, CENTRALIA, ILLINOIS (SMH), THE ADMINISTRATIVE COUNCIL, PHYSICIANS, EMPLOYEES, AND COMMUNITY ARE ALL INVOLVED IN PROVIDING ON-GOING FEEDBACK, MONITORING AND INFORMING THE DIRECTION OF POLICIES AND CONTENT OF COMMUNITY BENEFIT ACTIVITIES. THE THREE STRATEGIC PRIORITIES OF THE SMH COMMUNITY BENEFIT PLAN ARE: ACCESS TO CARE, MENTAL HEALTH/SUBSTANCE ABUSE, AND OBESITY. GOALS AND OBJECTIVES ARE ESTABLISHED TO CHANGE BEHAVIOR, PROVIDE METRICS TO MEASURE CHANGE, AND TO IMPACT THE OVERALL HEALTH OF THOSE WE SERVE. ALL OF THE COMMUNITY BENEFIT ACTIVITIES ARE DESIGNED TO MEET THE NEEDS IDENTIFIED IN THE COMMUNITY HEALTH NEEDS ASSESSMENT (CHNA) WHICH WAS COMPLETED IN JUNE 2012. HEALTHY PEOPLE 2020 OBJECTIVES ARE ALSO UTILIZED WHEN DEVELOPING PROGRAMS FOR COMMUNITY BENEFIT. THE SMH COMMUNITY BENEFIT PLAN DETAILS THE PLANNING, MEASUREMENT AND COMMUNICATION OF ITS COMMUNITY BENEFITS. THE THREE MAIN ASPECTS OF COMMUNITY BENEFIT ARE THE COMMUNITY HEALTH NEEDS ASSESSMENT WHICH DETERMINES THE COMMUNITY NEEDS TO BE ADDRESSED BY THE HOSPITAL, THE COMMUNITY BENEFIT PLAN WHICH DETAILS STEPS TO BE ACCOMPLISHED TO MEET IDENTIFIED NEEDS, AND THE CBISA DATABASE WHICH DOCUMENTS ALL OF THE COMMUNITY BENEFIT ACTIVITIES FOR EACH YEAR. AT THE END OF EACH YEAR, THE CBISA COMMUNITY BENEFIT REPORT IS GIVEN TO MANAGEMENT, ADMINISTRATION AND THE SSMHC BOARD OF DIRECTORS IN ORDER TO EVALUATE AND IMPROVE THE PROGRAM. COMMUNITY BENEFIT IS DEFINED AS PROGRAMS OR ACTIVITIES THAT PROVIDE TREATMENT AND/OR PROMOTE HEALTH AND HEALING AS A RESPONSE TO COMMUNITY NEEDS; THEY ARE NOT PROVIDED FOR MARKETING PURPOSES. COMMUNITY BENEFIT PROGRAMS GENERATE A LOW OR NEGATIVE FINANCIAL RETURN, RESPOND TO NEEDS OF SPECIAL POPULATIONS SUCH AS PERSONS LIVING IN POVERTY AND OTHER DISENFRANCHISED PERSONS, AND PUBLIC HEALTH NEEDS. GENERALLY THESE PROGRAMS OR SERVICES WOULD LIKELY BE DISCONTINUED - OR WOULD NEED TO BE PROVIDED BY ANOTHER NOT-FOR-PROFIT OR GOVERNMENT PROVIDER - IF THE DECISION WAS MADE ON A PURELY FINANCIAL BASIS. COMMUNITY BENEFIT PROGRAMS CAN ALSO INVOLVE EDUCATION OR RESEARCH THAT IMPROVE OVERALL COMMUNITY HEALTH. DESCRIBE THE ORGANIZATION'S FINANCIAL ASSISTANCE POLICIES OR PROGRAMS (E.G., CHARITY CARE, DISCOUNTING) FOR LOW-INCOME PERSONS AND HOW THEY ARE COMMUNICATED TO THE PUBLIC. ST. MARY'S HOSPITAL STRIVES TO PROVIDE EXCEPTIONAL HEALTH CARE SERVICES TO ALL PERSONS IN NEED REGARDLESS OF THEIR ABILITY TO PAY. ALL BILLING AND COLLECTION POLICIES AND PRACTICES REFLECT THE MISSION AND VALUES, INCLUDING OUR SPECIAL CONCERN FOR PEOPLE WHO ARE POOR AND VULNERABLE. WE OFFER DISCOUNTS FOR HOSPITAL SERVICES TO ALL UNINSURED PERSONS. SELF-PAY DISCOUNTS APPLY TO EVERYONE WHO DOES NOT HAVE HEALTH INSURANCE, REGARDLESS OF ABILITY TO PAY. OUR CHARITY CARE POLICIES ARE APPLIED FAIRLY AND CONSISTENTLY. EACH PERSON IS TREATED AS AN INDIVIDUAL WITH SPECIFIC NEEDS FOR ASSISTANCE WITHOUT REGARD TO PAYMENT. WE EMBRACE OUR RESPONSIBILITY TO SERVE OUR COMMUNITIES BY UTILIZING SOUND BUSINESS PRACTICES. CHARITY CARE IS PROVIDED TO PATIENTS BASED ON A SLIDING SCALE FOR HOUSEHOLD INCOMES UP TO FOUR TIMES THE FEDERAL POVERTY LEVEL. PATIENTS WHOSE HOUSEHOLD INCOME IS NO MORE THAN TWO TIMES THE FEDERAL POVERTY LEVEL ARE ELIGIBLE FOR FREE HOSPITAL SERVICES. IN ADDITION, AN EXCEPTION TO THE SLIDING SCALE IS PROVIDED FOR A PATIENT'S BALANCE DUE IF THE AMOUNT EXCEEDS 20% OF THEIR GROSS FAMILY INCOME. IN THIS SITUATION, THE BILL IS DISCOUNTED DOWN TO 20% OF THEIR FAMILY INCOME. THESE POLICIES ARE COMMUNICATED BY OUR STAFF PROVIDING INFORMATION ABOUT: - THE PATIENT'S RESPONSIBILITY FOR PAYMENT; - THE AVAILABILITY OF FINANCIAL ASSISTANCE FROM PUBLIC PROGRAMS AND ENTITY CHARITY CARE AND PAYMENT ARRANGEMENTS; - THE ENTITY'S CHARITY POLICY AND APPLICATION PROCESS: AND - WHOM TO CONTACT TO GET ADDITIONAL INFORMATION OR FINANCIAL COUNSELING. THE FOLLOWING TYPES OF NOTICES TO THE PUBLIC ARE ALSO PROVIDED: - SIGNS IN THE EMERGENCY DEPARTMENT, OUTPATIENT AND INPATIENT REGISTRATION AND PUBLIC WAITING AREAS. - BROCHURES OR FLIERS PROVIDED AT TIME OF REGISTRATION AND AVAILABLE IN THE FINANCIAL COUNSELING AREAS. - NOTICES SENT WITH OR ON PATIENT BILLS OR COMMUNICATIONS SENT TO PATIENTS AND GUARANTORS RELATED TO MEDICAL SERVICES. - APPLICATIONS PROVIDED TO UNINSURED PATIENTS AT THE TIME OF REGISTRATION. ALL APPLICATIONS CLEARLY STATE THE POLICIES REGARDING CHARITY CARE, INCLUDING EXCLUDED SERVICES, ELIGIBILITY CRITERIA AND DOCUMENTATION REQUIREMENTS. INFORMATION ABOUT THE ENTITY'S CHARITY POLICIES IS ALSO PROVIDED TO PUBLIC AGENCIES. ORGANIZATION DESCRIPTION FOR TAX EXEMPTION: ST MARY'S HOSPITAL, CENTRALIA, ILLINOIS IS A MEDICARE-DEPENDENT HOSPITAL THAT: - OPERATES AN EMERGENCY ROOM THAT IS OPEN TO ALL PERSONS REGARDLESS OF ABILITY TO PAY; - HAS AN OPEN MEDICAL STAFF WITH PRIVILEGES AVAILABLE TO ALL QUALIFIED PHYSICIANS IN THE AREA; - HAS A GOVERNING BODY IN WHICH INCLUDES INDEPENDENT PERSONS REPRESENTATIVE OF THE COMMUNITY; - HAS A SOLE CORPORATE MEMBER WITH RESERVED POWERS WHICH HAS A GOVERNING BODY IN WHICH INDEPENDENT PERSONS REPRESENTATIVE OF THE COMMUNITY COMPRISE A MAJORITY - ENGAGES IN THE TRAINING AND EDUCATION OF HEALTH CARE PROFESSIONALS; - PARTICIPATES IN MEDICAID, MEDICARE, CHAMPUS, TRICARE, AND/OR GOVERNMENT-SPONSORED HEALTH CARE PROGRAMS.
DESCRIPTION OF COMMUNITY BENEFIT PROGRAMS: THE THREE STRATEGIC PRIORITIES OF THE COMMUNITY BENEFIT PLAN ARE: ACCESS TO CARE, MENTAL HEALTH/SUBSTANCE ABUSE, AND OBESITY. HEALTHY COMMUNITIES INITIATIVES CREATE OPPORTUNITIES FOR EACH RESIDENT TO MEET HIS/HER POTENTIAL PHYSICALLY, MENTALLY, SOCIALLY, EMOTIONALLY, AND SPIRITUALLY. THE INITIATIVES BUILD ON THE STRENGTHS OF OUR COMMUNITIES AND SYSTEMS TO IMPROVE THE QUALITY OF LIFE AND TO CREATE A SENSE OF HOPE. HEALTHY COMMUNITIES INITIATIVES BUILD COMMUNITY CAPACITY AND INDIVIDUAL EMPOWERMENT THROUGH COMMUNITY ORGANIZING, LEADERSHIP DEVELOPMENT, PARTNERSHIPS, AND COALITION BUILDING. OUR COMMUNITY HEALTH PROGRAMS PROVIDE COMPASSIONATE AND COMPETENT CARE WHILE THEY PROMOTE HEALTH IMPROVEMENT BY REACHING DIRECTLY INTO THE COMMUNITY TO ENSURE THAT LOW-INCOME AND UNDER-SERVED PERSONS CAN ACCESS HEALTH CARE SERVICES. FOCUSING ON A BROAD DEFINITION OF HEALTH, THE HOSPITAL, CLINICS AND PROGRAMS PROVIDE MEDICAL AND MENTAL HEALTH SERVICES, HEALTH EDUCATION, HEALTH MANAGEMENT, PREVENTION, REFERRALS, INSURANCE ENROLLMENT AND IN-HOME PRIMARY CARE SERVICES AND SUPPORT, WHILE FOSTERING COLLABORATION AND INCORPORATING HEALTHY COMMUNITIES STRATEGIES. ST. MARY'S HOSPITAL PROMOTES GRASSROOTS ADVOCACY AND ENGAGES PERSONS OF INFLUENCE TO AFFECT SOCIAL AND PUBLIC POLICY CHANGE IN ORDER TO PROMOTE BOTH COMMUNITY HEALTH AND HEALTHY COMMUNITIES. ST. MARY'S HOSPITAL ADVOCATES FOR VULNERABLE POPULATIONS BY DEVELOPING RELATIONSHIPS WITH POLICY MAKERS AND THROUGH TARGETED EDUCATION EFFORTS. ALL PROJECTS INCLUDE MEASURABLE OBJECTIVES WITH A SPECIFIC TIME FRAME AND HAVE ACTIVITIES THAT WILL FAVORABLY AFFECT HEALTH STATUS INDICATORS. PROJECTS TO ACCOMPLISH HEALTH STATUS OBJECTIVES MAY INCLUDE: DISEASE PREVENTION PROGRAMS; HEALTH EDUCATION PROGRAMS; HEALTH CARE PROGRAMS FOR INDIVIDUALS WITH SPECIAL HEALTH CONCERNS; AND OTHER PROJECTS THAT IMPROVE COMMUNITY HEALTH STATUS. PROJECTS TO ADDRESS THE HEALTH PROBLEMS OF MINORITIES, THE POOR, AND OTHER MEDICALLY UNDERSERVED POPULATIONS MAY INCLUDE: IMPROVING ACCESSIBILITY AND CONTINUITY OF CARE; WORKING TO REDUCE DISPARITIES IN HEALTH STATUS; AND SPONSORING EFFORTS TO INCREASE THE NUMBER OF MINORITIES, THE POOR, AND UNDERSERVED WHO ENTER HEALTH PROFESSIONS AND WORK IN MEDICALLY UNDERSERVED COMMUNITIES. PROJECTS DESIGNED TO CONTAIN THE GROWTH OF COMMUNITY HEALTH CARE COSTS MAY INCLUDE: IMPROVING EFFICIENCY OF SERVICES; IMPROVING CASE MANAGEMENT AND CONTINUITY OF CARE; SPONSORING HEALTH PROMOTION, DISEASE PREVENTION, AND SELF-CARE ACTIVITIES; CONTAINING HEALTH CARE COSTS; AND REDUCING REDUNDANCIES. THROUGH OUR COMMUNITY HEALTH NEEDS ASSESSMENT WE IDENTIFY VARIOUS UNMET COMMUNITY HEALTH NEEDS. OUR PRIMARY RESPONSIBILITY IS TO ADDRESS THOSE THAT WE CAN IMPACT THE MOST, THAT IS, THOSE ALIGNED WITH OUR CORE COMPETENCIES. WE COMMUNICATE THE NEEDS IDENTIFIED IN THE ASSESSMENT TO THE COMMUNITY THROUGH A VARIETY OF MEDIA, DEVELOP A PLAN FOR HOW TO ADDRESS THOSE NEEDS THAT WE CAN IMPACT, AND IMPLEMENT STRATEGIES TO ADDRESS THESE NEEDS. OUR NEEDS ASSESSMENT WAS COMPLETED OCTOBER 15, 2012 AND ADOPTED AS PART OF OUR STRATEGIC PLAN ON DECEMBER 6, 2012. EACH PRIORITY AREA WAS ASSIGNED A CHAMPION AND PROGRAMS AND SERVICES WERE DESIGNED TO ADDRESS THE IDENTIFIED NEED. AS AN EXAMPLE OF HOW THE NEED IS ADDRESSED, THE FOLLOWING ACTIONS WERE TAKEN IN 2013 TO ADDRESS ACCESS TO CARE ISSUES: RECRUIT PHYSICIANS, NURSE PRACTITIONERS AND PHYSICIAN ASSISTANTS, EXPAND ACCESS TO HEALTH CARE SERVICES; PROVIDE MEDICATION ASSISTANCE AT LITTLE OR NO COSTS TO PATIENTS; ESTABLISH A PATIENT-CENTERED MEDICAL HOME TO COORDINATE PRIMARY CARE; WORK WITH EDUCATIONAL INSTITUTIONS TO HEIGHTEN AWARENESS AND PROVIDE LEARNING OPPORTUNITIES FOR ALL AGES AND DIVERSITIES; HOST AN ANNUAL EDUCATION AND SCREENING EVENT FOR UNINSURED AND UNDERINSURED PEOPLE. THE CHRONIC DISEASE MANAGEMENT PROGRAM IS ONE HEALTHY COMMUNITIES INITIATIVE THAT FOCUSES ON EDUCATING THE PATIENT AND FAMILY ABOUT THEIR DISEASE, IMPROVING ACCESS TO CARE, AND FACILITATING DISEASE SELF-MANAGEMENT. GOALS OF THIS PROGRAM ARE TO MAINTAIN INDEPENDENCE AS LONG AS POSSIBLE, REDUCE SYMPTOMS, REDUCE HOSPITALIZATIONS AND EDUCATE ABOUT MEDICATIONS AND CARE PATHWAYS. ONE OF THE CLEAREST EXAMPLES OF HOW ST. MARY'S HOSPITAL MEETS COMMUNITY NEED IS THROUGH OUR LITTLE EGYPT BREAST AND CERVICAL CANCER PROGRAM. OUR HOSPITAL HAS BEEN A LEAD AGENCY FOR THIS ILLINOIS PUBLIC HEALTH PROGRAM SINCE 1998 AND SERVES AS PAYER OF LAST RESORT FOR BREAST AND CERVICAL CANCER SCREENINGS AND EDUCATION FOR WOMEN WHO ARE UNINSURED. IN ADDITION TO THESE BREAST AND CERVICAL CANCER SCREENINGS, SMH ALSO PROVIDES FREE SCREENINGS FOR PROSTATE CANCER, SKIN CANCER AND COLORECTAL CANCER AT VARIOUS LOCATIONS AND TIMES EACH YEAR. AMERICAN CANCER SOCIETY'S LOOK GOOD/FEEL BETTER PROGRAMS ARE OFFERED QUARTERLY AND CANCER SUPPORT GROUPS ARE OFFERED AT SEVERAL LOCATIONS EACH MONTH. ST MARY'S HOSPITAL IDENTIFIED OBESITY IN GENERAL AND CHILDHOOD OBESITY SPECIFICALLY AS A LARGE ISSUE IN MARION COUNTY. ST MARY'S HOSPITAL AND FELICIAN SERVICES INC. AGREED TO PARTNER WITH THE CENTRALIA RECREATIONAL COMPLEX, A STATE-OF-THE-ART FACILITY THAT IS UNDERUTILIZED BY THE COMMUNITY AND SUFFERING FINANCIALLY, TO WORK ON A COMMON ISSUE OF OBESITY AND FITNESS. THE FELICIAN SISTERS CONTRIBUTED GRANT FUNDS AND THE HOSPITAL CONTRIBUTED CASH AND IN-KIND SERVICES AND STAFF TO SUPPORT THE GROWTH AND DEVELOPMENT OF NEW PROGRAMS. OUR "CONNECTIONS" PROGRAM HAS FREE MONTHLY EDUCATIONAL LUNCHEONS FOCUSING ON TOPICS SUCH AS ARTHRITIS AND EXERCISE, DIABETES, STROKE PREVENTION, AND OTHER WELLNESS PROMOTION TOPICS. WE ALSO HOLD A MONTHLY STRESS MANAGEMENT CLASS WHICH IS FREE TO THE PUBLIC AND SPONSORED AS A RESULT OF COMMUNITY NEEDS. THE SSM ELECTRONIC MEDICAL RECORD SYSTEM, EPIC, WENT LIVE AT SMH ON JUNE 1, 2013. EPIC IMPLEMENTATION INCREASED THE NEED FOR CARE COORDINATION WITH A SPECIFIC FOCUS UPON MEDICATION RECONCILIATION, PATIENT SAFETY AND MEDICATION EDUCATION ACROSS THE CARE TRANSITIONS. THESE INITIATIVES STARTED A CULTURE CHANGE THAT MOVED TO THE NEXT LEVEL WITH THE IMPLEMENTATION OF THE SMGSI COORDINATED CARE NETWORK. SMGSI FORMED AN ACCOUNTABLE CARE ORGANIZATION (ACO) THAT INCLUDES SIX SOUTHERN ILLINOIS HOSPITALS AND THEIR ASSOCIATED PHYSICIANS, A LARGE WOMEN'S HEALTH PRACTICE, AND A LARGE MULTIDISCIPLINARY PRACTICE GROUP. OUR ACO PARTNERED WITH ACA (ACCOUNTABLE CARE ASSOCIATES, INC.) A PIONEER ACO, TO PROVIDE A PAYMENT MODEL FOR MEDICARE RECIPIENTS. ACA HAS IMPLEMENTED A PRIVATE HEALTH INFORMATION EXCHANGE (HIE) WHICH ALLOWS SECURE DATA EXCHANGE WITH OTHER HIES, HOSPITALS, PHYSICIAN PRACTICE EMRS AND PAYORS. SMGSI HAS ALSO PARTNERED WITH QUALITY HEALTH IDEAS, LLC TO ASSIST IN THE AGGREGATION OF DATA AND DEVELOPMENT/IMPLEMENTATION OF OUR CARE MODEL. PROJECT GOALS ARE ALIGNED WITH THE IHI TRIPLE AIM OF IMPROVING HEALTH OUTCOMES AND CARE EXPERIENCES WHILE REDUCING PER CAPITA COSTS. QUANTIFIABLE COMMUNITY BENEFIT THE FOLLOWING IS A LIST OF THE TYPES OF PROGRAMS AND SERVICES THAT COULD BE INCLUDED AS COMMUNITY BENEFIT ACTIVITIES. TRADITIONAL CHARITY CARE $ 3,972,637 UNPAID COST OF MEDICAID $ 6,973,258 UNPAID COST OF MEDICARE $10,004,359 COST OF BAD DEBTS $ 4,568,120 COMMUNITY BENEFIT PROGRAMS $ 996,109 TOTAL QUANTIFIABLE COMMUNITY BENEFIT $26,514,483
FORM 990, PART VI, SECTION A, LINE 6 THE SOLE CORPORATE MEMBER OF THE CORPORATION IS SSM REGIONAL HEALTH SERVICES. SSM REGIONAL HEALTH SERVICES IS A NONPROFIT 501(C)(3) ORGANIZATION. BOTH ST MARY'S HOSPITAL, CENTRALIA, ILLINOIS AND SSM REGIONAL HEALTH SERVICES ARE PART OF THE INTEGRATED HEALTH CARE SYSTEM KNOWN AS SSM HEALTH CARE.
FORM 990, PART VI, SECTION A, LINE 7A THE MEMBER HAS THE POWER TO APPOINT ADDITIONAL, SUCCESSOR OR REPLACEMENT MEMBERS AND ELECT AND REMOVE DIRECTORS EXCEPT EX OFFICIO DIRECTORS.
FORM 990, PART VI, SECTION A, LINE 7B THE MEMBER HAS THE FOLLOWING POWERS: A. TO ESTABLISH AND CHANGE THE MISSION, PHILOSOPHY AND VALUES OF THE CORPORATION B. TO APPOINT ADDITIONAL, SUCCESSOR OR REPLACEMENT MEMBERS C. TO ELECT AND REMOVE THE DIRECTORS EXCEPT EX-OFFICIO DIRECTORS D. TO APPOINT AND REMOVE THE CHIEF EXECUTIVE OFFICER OF ANY OPERATING DIVISION OF THE CORPORATION E. TO APPROVE AMENDMENTS TO THE ARTICLES OF INCORPORATION OF THE CORPORATION AS PROVIDED THEREIN F. TO APPROVE AMENDMENTS TO THE BYLAWS OF THE CORPORATION G. TO APPROVE THE MERGER, CONSOLIDATION OR DISSOLUTION OF THE CORPORATION H. TO APPROVE THE FORMATION OF A CONTROLLED SUBSIDIARY OR A REMOTELY CONTROLLED SUBSIDIARY I. TO APPROVE THE SALE OF ALL OR SUBSTANTIALLY ALL OF THE ASSETS OF THE CORPORATION J. TO APPROVE THE ACQUISITION OR DISPOSITION BY THE CORPORATION OF ANOTHER LEGAL ENTITY OR AN INTEREST IN ANOTHER LEGAL ENTITY K. TO AUTHORIZE OR APPROVE THE ACQUISITION OR DISPOSITION BY THE CORPORATION OF REAL PROPERTY OR ANY INTEREST IN REAL PROPERTY L. TO ESTABLISH CENTRALIZED EMPLOYEE BENEFIT, INSURANCE, INVESTMENT, FINANCING, CORPORATE RESPONSIBILITY, PERFORMANCE ASSESSMENT AND IMPROVEMENT AND OTHER OPERATIONAL AND SUPPORT PROGRAMS, TO REQUIRE THE PARTICIPATION OF THE CORPORATION IN SUCH PROGRAMS, AND TO AUTHORIZE THE OPENING AND CLOSING OF BANK ACCOUNTS AND INVESTMENT ACCOUNTS IN THE NAME OF THE CORPORATION IN CONNECTION WITH SUCH PROGRAMS M. TO APPROVE THE STRATEGIC, FINANCIAL AND HUMAN RESOURCES PLAN OF THE CORPORATION N. TO APPOINT THE AUDITOR AND CORPORATE COUNSEL FOR THE CORPORATION O. TO AUTHORIZE AND APPROVE BORROWING MONEY AND ENTERING INTO FINANCIAL GUARANTIES BY THE CORPORATION, INCLUDING ACTIONS RELATING TO THE FORMATION, JOINING, OPERATION, WITHDRAWAL FROM AND TERMINATION OF A CREDIT GROUP OR AN OBLIGATED GROUP AND THE GRANTING OF SECURITY INTERESTS IN THE PROPERTY OF THE CORPORATION P. TO REQUIRE THE CORPORATION TO TRANSFER ASSETS, INCLUDING BUT NOT LIMITED TO CASH, TO THE MEMBER OF THE CORPORATE MEMBER OR TO ANY ENTITY EXEMPT FROM FEDERAL INCOME TAX AS AN ORGANIZATION DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE OF 1986, AS AMENDED, OR THE CORRESPONDING PROVISION OF ANY FUTURE UNITED STATES INTERNAL REVENUE LAW, WHICH IS CONTROLLED BY THE MEMBER OF THE CORPORATE MEMBER, TO THE EXTENT NECESSARY TO ACCOMPLISH THE MISSION, GOALS AND OBJECTIVES OF THE MEMBER OF THE CORPORATE MEMBER AS DETERMINED BY THE MEMBER OF THE CORPORATE MEMBER Q. TO APPROVE THE TRANSFER OF ASSETS BY THE CORPORATION TO ANY ENTITY OTHER THAN THE MEMBER OF THE CORPORATE MEMBER, OTHER THAN TRANSFERS MADE IN THE ORDINARY COURSE OF OPERATIONS OF THE CORPORATION WHICH WILL NOT REQUIRE CORPORATE MEMBER APPROVAL; AND R. TO DETERMINE THE EXTENT TO WHICH AND THE MANNER IN WHICH THE POWERS DESCRIBED IN THIS SECTION WHICH ARE RESERVED TO THE CORPORATE MEMBER WITH RESPECT TO THE CORPORATION ARE TO BE INCLUDED IN THE GOVERNING DOCUMENTS OF ANY CONTROLLED SUBSIDIARY, REMOTELY CONTROLLED SUBSIDIARY OR NON-CONTROLLED SUBSIDIARY AND EXERCISED WITH RESPECT TO ANY CONTROLLED SUBSIDIARY, ANY REMOTELY CONTROLLED SUBSIDIARY OR ANY NON-CONTROLLED SUBSIDIARY.
FORM 990, PART VI, SECTION B, LINE 11 ACCOUNTING/FINANCE PERSONNEL AT EACH SSMHC (SSM HEALTH CARE SYSTEM) ENTITY, IN CONJUNCTION WITH SYSTEM FINANCE PERSONNEL, PREPARE A CHECKLIST CONTAINING INFORMATION AND SUPPORTING SCHEDULES THAT ARE USED TO PREPARE THE FORM 990. THIS CHECKLIST IS THEN REVIEWED BY A SUPERVISOR/MANAGER AND SENT TO THE SYSTEM OFFICE FOR FINAL REVIEW AND COORDINATION OF THE SYSTEM LEVEL FORM 990 INFORMATION. THE INFORMATION IS SUBMITTED TO AN OUTSIDE TAX CONSULTING FIRM WHO PREPARES AND SIGNS THE FORM 990 FROM THE SSMHC INFORMATION. PRIOR TO FINALIZING THE RETURN, A DRAFT IS SENT TO PERSONNEL AT SSMHC FOR REVIEW AND APPROVAL. UPON SSMHC APPROVAL, THE OUTSIDE PREPARER FORWARDS THE COMPLETED FORM 990 FOR THE APPROPRIATE SIGNATURES AND FILING ACTION. A COMPLETE COPY OF THE RETURN IS PROVIDED TO THE BOARD OF DIRECTORS AT THE NEXT REGULARLY SCHEDULED BOARD MEETING.
FORM 990, PART VI, SECTION B, LINE 12C BOARD MEMBERS ARE REQUIRED TO COMPLETE A CONFLICT OF INTEREST DISCLOSURE STATEMENT ANNUALLY. THE PRESIDENT AND SECRETARY TO THE BOARD OVERSEE COMPLIANCE WITH THIS REQUIREMENT. ALL BOARD MEMBERS WITH AN IDENTIFIED CONFLICT OF INTEREST ABSTAIN FROM BOARD DISCUSSIONS AND VOTES WHEN APPLICABLE. EMPLOYEES WITH PURCHASING AUTHORITY AND/OR ABILITY TO INFLUENCE PURCHASING DECISIONS ARE ASSIGNED THE CONFLICT OF INTEREST DISCLOSURE COURSE (COI) WHICH MUST BE COMPLETED ON LINE. PERIODICALLY THROUGH THE YEAR, THE ENTITY'S CORPORATE RESPONSIBILITY CONTACT PERSON (WITH THE HELP OF THE ENTITY'S LEARNING MANAGEMENT SYSTEM COORDINATOR) SENDS DEPARTMENT MANAGERS A LIST OF EMPLOYEES WHO HAVE NOT YET COMPLETED THEIR COI SO THEY CAN REMIND THE EMPLOYEES AND ENSURE THE EMPLOYEES HAVE TIME IN THEIR SCHEDULE TO COMPLETE THE REQUIRED COURSE. RESOLUTION OF ANY CONFLICTS THAT ARE DISCLOSED MUST BE DOCUMENTED AND KEPT ON FILE AT THE ENTITY. SUPERVISORS VERIFY REQUIRED COURSE COMPLETION PRIOR TO YEAR END.
FORM 990, PART VI, SECTION C, LINE 19 THE YEAR-END AUDITED CONSOLIDATED FINANCIAL STATEMENTS AND UNAUDITED QUARTERLY CONSOLIDATED FINANCIAL STATEMENT FOR THE SSM HEALTH CARE SYSTEM ARE MADE AVAILABLE TO THE PUBLIC ON SSM HEALTH CARE'S WEBSITE. THE ORGANIZATION'S ARTICLES OF INCORPORATION ARE AVAILABLE ON THE ILLINOIS SECRETARY OF STATE'S WEBSITE. COPIES OF THE FORM 990 AND THE ORGANIZATION'S CONFLICT OF INTEREST POLICY ARE AVAILABLE UPON REQUEST.
FORM 990, PART XI, LINE 9: BENEFICIAL INTEREST IN FOUNDATION -42,441. TRANSFERS TO AFFILIATES -3,563,261.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.
Cat. No. 51056K
Schedule O (Form 990 or 990-EZ) 2013

Additional Data


Software ID:  
Software Version:  
SCHEDULE R
(Form 990)
Department of the Treasury
Internal Revenue Service
Related Organizations and Unrelated Partnerships
MediumBulletComplete if the organization answered "Yes" on Form 990, Part IV, line 33, 34, 35b, 36, or 37.
MediumBulletAttach to Form 990. MediumBullet See separate instructions.
MediumBullet Information about Schedule R (Form 990) and its instructions is at www.irs.gov/form990.

OMB No. 1545-0047
2013
Open to Public Inspection
Name of the organization
ST MARY'S HOSPITAL CENTRALIA ILLINOIS
 
Employer identification number

37-0662580
Part I
Identification of Disregarded Entities Complete if the organization answered "Yes" on Form 990, Part IV, line 33.
(a)
Name, address, and EIN (if applicable) of disregarded entity


(b)
Primary activity


 		(c)
Legal domicile (state
or foreign country)

 		(d)
Total income


 		(e)
End-of-year assets


 		(f)
Direct controlling
entity










Part II
Identification of Related Tax-Exempt Organizations Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related tax-exempt organizations during the tax year.
(a)
Name, address, and EIN of related organization


(b)
Primary activity


 		(c)
Legal domicile (state
or foreign country)

 		(d)
Exempt Code section


 		(e)
Public charity status
(if section 501(c)(3))

 		(f)
Direct controlling
entity

 		(g)
Section 512(b)(13) controlled entity?
Yes No
(1) SSM HEALTH CARE CORPORATION

10101 WOODFIELD LANE

ST LOUIS,MO63132
46-6029223 		HEALTH CARE MO 501(C)(3) LINE 11A, I FRANCISCAN SISTERS OF MARY
 
 
No
(2) SSMHC LIABILITY TRUST I

10101 WOODFIELD LANE

ST LOUIS,MO63132
43-6331003 		INSURANCE MO 501(C)(3) LINE 11A, I SSM HEALTH CARE CORPORATION
 
 
No
(3) SSM CONSOLIDATED HEALTH SERVICES

10101 WOODFIELD LANE

ST LOUIS,MO63132
43-1473657 		HEALTH CARE MO 501(C)(3) LINE 11A, I SSM HEALTH CARE CORPORATION
 
 
No
(4) SSM POLICY INSTITUTE

10101 WOODFIELD LANE

ST LOUIS,MO63132
43-1788151 		HEALTH CARE MO 501(C)(4)   SSM HEALTH CARE CORPORATION
 
 
No
(5) SSM HEALTH CARE PORTFOLIO MANAGEMENT CO

10101 WOODFIELD LANE

ST LOUIS,MO63132
43-1825256 		MANAGEMENT MO 501(C)(3) LINE 11A, I SSM HEALTH CARE CORPORATION
 
 
No
(6) SSM CARDINAL GLENNON CHILDREN'S HOSPITAL

10101 WOODFIELD LANE

ST LOUIS,MO63132
43-0738490 		HEALTH CARE MO 501(C)(3) LINE 3 SSM HEALTH CARE ST LOUIS
 
 
No
(7) CARDINAL GLENNON CHILDREN'S FOUNDATION

10101 WOODFIELD LANE

ST LOUIS,MO63132
43-1754347 		FUNDRAISING MO 501(C)(3) LINE 7 SSM CARDINAL GLENNON CHILDREN'S HOSPITAL
 
 
No
(8) SSM DEPAUL HEALTH CENTER FOUNDATION

10101 WOODFIELD LANE

ST LOUIS,MO63132
43-1776109 		FUNDRAISING MO 501(C)(3) LINE 7 SSM HEALTH CARE ST LOUIS
 
 
No
(9) SSM ST JOSEPH FOUNDATION

10101 WOODFIELD LANE

ST LOUIS,MO63132
43-1591556 		FUNDRAISING MO 501(C)(3) LINE 7 SSM HEALTH CARE ST LOUIS
 
 
No
(10) SSM ST CLARE HEALTH CENTER FOUNDATION

10101 WOODFIELD LANE

ST LOUIS,MO63132
43-1273310 		FUNDRAISING MO 501(C)(3) LINE 7 SSM HEALTH CARE ST LOUIS
 
 
No
(11) SSM ST MARY'S HEALTH CENTER FOUNDATION

10101 WOODFIELD LANE

ST LOUIS,MO63132
43-1552945 		FUNDRAISING MO 501(C)(3) LINE 7 SSM HEALTH CARE ST LOUIS
 
 
No
(12) SSM HEALTH CARE OF OKLAHOMA INC

10101 WOODFIELD LANE

ST LOUIS,MO63132
73-0657693 		HEALTH CARE OK 501(C)(3) LINE 3 SSM HEALTH CARE CORPORATION
 
 
No
(13) ST ANTHONY HOSPITAL FOUNDATION INC

10101 WOODFIELD LANE

ST LOUIS,MO63132
73-6104300 		FUNDRAISING OK 501(C)(3) LINE 7 SSM HEALTH CARE OF OKLAHOMA
 
 
No
(14) SSM HEALTH CARE OF WISCONSIN INC

10101 WOODFIELD LANE

ST LOUIS,MO63132
43-0688874 		HEALTH CARE WI 501(C)(3) LINE 3 SSM HEALTH CARE CORPORATION
 
 
No
(15) DELLS MEDICAL BUILDING INC

10101 WOODFIELD LANE

ST LOUIS,MO63132
39-1613292 		MOB WI 501(C)(2)   SSM HEALTH CARE OF WISCONSIN
 
 
No
(16) ST MARY'S FOUNDATION INC

10101 WOODFIELD LANE

ST LOUIS,MO63132
43-1940686 		FUNDRAISING WI 501(C)(3) LINE 7 SSM HEALTH CARE OF WISCONSIN
 
 
No
(17) ST CLARE HEALTH CARE FOUNDATION INC

10101 WOODFIELD LANE

ST LOUIS,MO63132
43-1940683 		FUNDRAISING WI 501(C)(3) LINE 7 SSM HEALTH CARE OF WISCONSIN
 
 
No
(18) HOME HEALTH UNITED INC

2802 WALTON COMMONS LANE

MADISON,WI53718
39-1539827 		HEALTH CARE WI 501(C)(3) LINE 9 SSM HEALTH CARE OF WISCONSIN
 
 
No
(19) HOME CARE UNITED INC

2802 WALTON COMMONS LANE

MADISON,WI53718
39-1776340 		HEALTH CARE WI 501(C)(3) LINE 9 SSM HEALTH CARE OF WISCONSIN
 
 
No
(20) HHU XTRA CARE INC

2802 WALTON COMMONS LANE

MADISON,WI53718
39-1705111 		HEALTH CARE WI 501(C)(3) LINE 9 SSM HEALTH CARE OF WISCONSIN
 
 
No
(21) HOME HEALTH UNITED - VNS FOUNDATION INC

2802 WALTON COMMONS LANE

MADISON,WI53718
39-1839309 		FUNDRAISING WI 501(C)(3) LINE 11B, II N/A
 
No
(22) SSM REGIONAL HEALTH SERVICES

10101 WOODFIELD LANE

ST LOUIS,MO63132
44-0579850 		HEALTH CARE MO 501(C)(3) LINE 3 SSM HEALTH CARE CORPORATION
 
 
No
(23) ST FRANCIS HOSPITAL FOUNDATION

10101 WOODFIELD LANE

ST LOUIS,MO63132
43-1099253 		FUNDRAISING MO 501(C)(3) LINE 7 SSM REGIONAL HEALTH SERVICES
 
 
No
(24) ST MARY'S HEALTH CENTER JEFFERSON CITY MISSOURI FOUNDATION

10101 WOODFIELD LANE

ST LOUIS,MO63132
43-1575307 		FUNDRAISING MO 501(C)(3) LINE 11B, II N/A
 
No
(25) GOOD SAMARITAN REGIONAL HEALTH CENTER

10101 WOODFIELD LANE

ST LOUIS,MO63132
43-0653587 		HEALTH CARE IL 501(C)(3) LINE 3 SSM REGIONAL HEALTH SERVICES
 
 
No
(26) ST MARY'S - GOOD SAMARITAN INC

10101 WOODFIELD LANE

ST LOUIS,MO63132
36-4170833 		HEALTH CARE IL 501(C)(3) LINE 11A, I SSM REGIONAL HEALTH SERVICES
 
 
No
(27) GOOD SAMARITAN REGIONAL HEALTH CENTER FOUNDATION

10101 WOODFIELD LANE

ST LOUIS,MO63132
26-2884795 		FUNDRAISING IL 501(C)(3) LINE 7 ST MARY'S-GOOD SAMARITAN INC
 
 
No
(28) ST MARY'S HOSPITAL FOUNDATION

10101 WOODFIELD LANE

ST LOUIS,MO63132
36-4636691 		FUNDRAISING IL 501(C)(3) LINE 7 ST MARY'S-GOOD SAMARITAN INC
 
 
No
(29) ST MARY'S HOSPITAL AUXILIARY

400 N PLEASANT

CENTRALIA,IL62801
23-7126345 		FUNDRAISING IL 501(C)(3) LINE 9 ST MARY'S HOSPITAL FOUNDATION
 
 
No
(30) SSM HEALTH BUSINESSES

10101 WOODFIELD LANE

ST LOUIS,MO63132
43-1333488 		HEALTH CARE MO 501(C)(3) LINE 9 SSM HEALTH CARE CORPORATION
 
 
No
(31) SSM HEALTH CARE ST LOUIS

10101 WOODFIELD LANE

ST LOUIS,MO63132
43-1343281 		HEALTH CARE MO 501(C)(3) LINE 3 SSM HEALTH CARE CORPORATION
 
 
No
(32) CENTRALIA MEDICAL SERVICES BLDG ASSOC

10101 WOODFIELD LANE

ST LOUIS,MO63132
23-7408025 		MOB IL 501(C)(3) LINE 11B, II N/A
 
No
(33) ST MARY'S JANESVILLE FOUNDATION INC

10101 WOODFIELD LANE

ST LOUIS,MO63132
27-3439133 		FUNDRAISING WI 501(C)(3) LINE 7 SSM HEALTH CARE OF WISCONSIN
 
 
No
(34) FRANCISCAN SISTERS OF MARY

3221 MCKELVEY ROAD SUITE 107

BRIDGETON,MO63044
43-1012492 		RELIGIOUS ORGANIZATION MO 501(C)(3) LINE 1 N/A
 
No
(35) LEE DEWEY CORPORATION

10101 WOODFIELD LANE

ST LOUIS,MO63132
73-1279603 		MOB OK 501(C)(3) LINE 11A, I SSM HEALTH CARE OF OKLAHOMA
 
 
No
(36) SSM HOSPICE & HOME CARE FOUNDATION

10101 WOODFIELD LANE

ST LOUIS,MO63132
30-0012246 		FUNDRAISING MO 501(C)(3) LINE 7 SSM HEALTH BUSINESSES
 
 
No
(37) ST MARY'S HOSPITAL AUXILIARY

100 ST MARYS MEDICAL PLAZA

JEFFERSON CITY,MO65101
43-6049878 		FUNDRAISING MO 501(C)(3) LINE 11B, II N/A
 
No
(38) GOOD SAMARITAN HOSPITAL AUXILIARY

1 GOOD SAMARITAN WAY

MOUNT VERNON,IL62864
23-7049599 		FUNDRAISING IL 501(C)(3) LINE 11C, III-FI N/A
 
No
(39) ST ANTHONY SHAWNEE HOSPITAL INC

10101 WOODFIELD LANE

ST LOUIS,MO63132
45-5055149 		HEALTH CARE OK 501(C)(3) LINE 3 SSM HEALTH CARE OF OKLAHOMA
 
 
No
(40) SSM AUDRAIN HEALTH CARE INC

10101 WOODFIELD LANE

ST LOUIS,MO63132
43-1550298 		HEALTH CARE MO 501(C)(3) LINE 3 SSM REGIONAL HEALTH SERVICES
 
 
No
(41) AUDRAIN MEDICAL CENTER FOUNDATION INC

620 E MONROE ST

MEXICO,MO65265
43-1265060 		FUNDRAISING MO 501(C)(3) LINE 11A, I SSM AUDRAIN HEALTH CARE INC
 
 
No
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50135Y
Schedule R (Form 990) 2013
Schedule R (Form 990) 2013
Page 2
Part III
Identification of Related Organizations Taxable as a Partnership Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related organizations treated as a partnership during the tax year.
(a)
Name, address, and EIN of
related organization



 		(b)
Primary activity




 		(c)
Legal
domicile
(state or foreign
country)


 		(d)
Direct controlling
entity



 		(e)
Predominant income(related, unrelated, excluded from tax under sections 512-514)

(f)
Share of total income




 		(g)
Share of end-of-year
assets



 		(h)
Disproprtionate allocations?




 		(i)
Code V-UBI
amount in box 20 of
Schedule K-1
(Form 1065)
 		(j)
General or
managing
partner?



 		(k)
Percentage
ownership
Yes No Yes No
(1) SSM ST JOSEPH ENDOSCOPY CENTER LLC

10101 WOODFIELD LANE
ST LOUIS,MO63132
27-0046559 		SURGERY SERVICES MO N/A
                  
(2) ST CLARE IMAGING SERVICES

707 14TH STREET SUITE A
BARABOO,WI53913
20-0122365 		DIAG. SERVICES WI N/A
                  
(3) MT VERNON RADIATION THERAPY CENTER LLC

10101 WOODFIELD LANE
ST LOUIS,MO63132
20-1382620 		RADIATION THERAPY IL N/A
                  
(4) SLEEP & NEUROLOGY CENTER CENTER OF S ILLINOIS LLC

10101 WOODFIELD LANE
ST LOUIS,MO63132
20-8468195 		DIAG. SERVICES IL N/A
                  
(5) SMHC SURGICAL CO-MGMT COMPANY LLC

100 ST MARYS MEDICAL PLAZA
JEFFERSON CITY,MO65101
20-8929305 		MANAGEMENT MO N/A
                  
(6) SMHC CARDIOVASCULAR CO-MGMT COMPANY LLC

100 ST MARYS MEDICAL PLAZA
JEFFERSON CITY,MO65101
20-8929381 		MANAGEMENT MO N/A
                  
(7) SMHC MUSCULOSKELETAL CO-MGMT COMPANY LLC

100 ST MARYS MEDICAL PLAZA
JEFFERSON CITY,MO65101
20-8929237 		MANAGEMENT MO N/A
                  
(8) CHOWSMGSI OFFICE BUILDING LLC

10101 WOODFIELD LANE
ST LOUIS,MO63132
37-1383861 		MOB IL N/A
                  
(9) CENTER FOR COMPREHENSIVE CANCER CARE LLC

10101 WOODFIELD LANE
ST LOUIS,MO63132
20-1382727 		MOB IL N/A
                  
(10) SHAWNEE REAL ESTATE HOLDINGS LLC

1000 N LEE AVE
OKLAHOMA CITY,OK73102
45-5458304 		MOB OK N/A
                  
(11) SSM RX EXPRESS LLC

10101 WOODFIELD LANE
ST LOUIS,MO63132
26-4031708 		PHARMACY MO N/A
                  
(12) DEAN CLINIC & ST MARY'S HOSPITAL ACCOUNTABLE CARE ORGANIZATION LLC

1808 WEST BELTLINE HIGHWAY
MADISON,WI53713
45-2995500 		ACCOUNTABLE CARE ORGANIZATION WI N/A
                  
(13) WISCONSIN INTEGRATED INFORMATION TECHNOLOGY AND TELEMEDICINE SYSTEMS LLC

1808 WEST BELTLINE HIGHWAY
MADISON,WI53713
39-2016715 		INFORMATION TECHNOLOGY SERVICES WI N/A
                  
(14) DEAN HEALTH HOLDINGS LLC

1277 DEMING WAY
MADISON,WI53717
26-1594709 		SUPPORT SERVICES WI N/A
                  
(15) WINGRA BUILDING GROUP

1808 WEST BELTLINE HIGHWAY
MADISON,WI53713
39-0237060 		MOB WI N/A
                  
(16) JANESVILLE RIVERVIEW CLINIC BUILDING PARTNERSHIP

1808 WEST BELTLINE HIGHWAY
MADISON,WI53713
39-6220698 		MOB WI N/A
                  
(17) NAVITUS HEALTH SOLUTIONS LLC

1808 WEST BELTLINE HIGHWAY
MADISON,WI53713
04-3608530 		PHARMACY BENEFITS WI N/A
                  
Part IV
Identification of Related Organizations Taxable as a Corporation or Trust Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related organizations treated as a corporation or trust during the tax year.
(a)
Name, address, and EIN of
related organization
 		(b)
Primary activity
 		(c)
Legal
domicile
(state or foreign
country)
 		(d)
Direct controlling
entity
 		(e)
Type of entity
(C corp, S corp,
or trust) 		(f)
Share of total income
 		(g)
Share of end-of-year
assets
 		(h)
Percentage
ownership
 		(i)
Section 512(b)(13) controlled entity?
Yes No
(1) SSM MANAGED CARE ORGANIZATION LLC

10101 WOODFIELD LANE
ST LOUIS,MO63132
43-1708511 		HEALTH PROMOTION MO N/A
 C         No
(2) FPP INC

10101 WOODFIELD LANE
ST LOUIS,MO63132
43-1465174 		HEALTH CARE MO N/A
 C         No
(3) DIVERSIFIED HEALTH SERVICES CORP

10101 WOODFIELD LANE
ST LOUIS,MO63132
43-1369305 		MEDICAL EQUIPMENT MO N/A
 C         No
(4) SSM CARDIO AND THORACIC SERVICES INC

10101 WOODFIELD LANE
ST LOUIS,MO63132
26-0286559 		PHYSICIAN OFFICES MO N/A
 C         No
(5) SSM PROPERTIES INC

10101 WOODFIELD LANE
ST LOUIS,MO63132
43-1462486 		PROPERTY SERVICES MO N/A
 C         No
(6) SSM DEPAUL MEDICAL GROUP INC

10101 WOODFIELD LANE
ST LOUIS,MO63132
43-1715106 		PHYSICIAN OFFICES MO N/A
 C         No
(7) SSM ST CHARLES CLINIC MED GROUP INC

10101 WOODFIELD LANE
ST LOUIS,MO63132
43-0626408 		PHYSICIAN OFFICES MO N/A
 C         No
(8) HEALTH FIRST PHYS MANAGEMENT SERVICES INC

10101 WOODFIELD LANE
ST LOUIS,MO63132
73-1534336 		MEDICAL SERVICES OK N/A
 C         No
(9) SSMHCS LIABILITY TRUST II

10101 WOODFIELD LANE
ST LOUIS,MO63132
81-6128118 		INSURANCE MO N/A
 C         No
(10) SSM NEUROSCIENCES INC

10101 WOODFIELD LANE
ST LOUIS,MO63132
26-3413981 		PHYSICIAN OFFICES MO N/A
 C         No
(11) SSM MEDICAL GROUP INC

10101 WOODFIELD LANE
ST LOUIS,MO63132
43-1664107 		PHYSICIAN OFFICES MO N/A
 C         No
(12) SSMHC INSURANCE COMPANY

10101 WOODFIELD LANE
ST LOUIS,MO63132
03-0310431 		INSURANCE CA N/A
 C         No
(13) SSM ORTHOPEDIC INC

10101 WOODFIELD LANE
ST LOUIS,MO63132
27-1557033 		PHYSICIAN OFFICES MO N/A
 C         No
(14) SSM CANCER CARE INC

10101 WOODFIELD LANE
ST LOUIS,MO63132
27-1557324 		PHYSICIAN OFFICES MO N/A
 C         No
(15) PHYSICIANS SERVICES CORP OF SOUTHERN ILLINOIS INC

10101 WOODFIELD LANE
ST LOUIS,MO63132
36-4161526 		PHYSICIAN OFFICES IL N/A
 C         No
(16) DEAN HEALTH SYSTEMS INC

1808 WEST BELTLINE HIGHWAY
MADISON,WI53713
39-1128616 		PHYSICIAN OFFICES WI N/A
 C         No
(17) DEAN HEALTH INSURANCE INC

PO BOX 56099
MADISON,WI53705
39-1830837 		INSURANCE WI N/A
 C         No
(18) DEAN HEALTH PLAN INC

PO BOX 56099
MADISON,WI53705
39-1535024 		INSURANCE WI N/A
 C         No
(19) ST MARY'S DEAN VENTURES INC

1808 WEST BELTLINE HIGHWAY
MADISON,WI53713
39-1628491 		PHYSICIAN OFFICES WI N/A
 C         No
(20) DEAN RETAIL SERVICES INC

1808 WEST BELTLINE HIGHWAY
MADISON,WI53713
39-1717636 		PROPERTY MANAGEMENT WI N/A
 C         No
(21) TEN TWENTY FIVE REGENT STREET

1808 WEST BELTLINE HIGHWAY
MADISON,WI53713
39-1089309 		MOB WI N/A
 C         No
(22) DEAN SOLUTIONS INC

1808 WEST BELTLINE HIGHWAY
MADISON,WI53713
39-1876092 		MANAGEMENT WI N/A
 C         No
(23) DEANCARE INSURANCE AGENCY INC

PO BOX 56099
MADISON,WI53705
39-1637828 		INSURANCE WI N/A
 C         No
(24) NAVITUS HOLDINGS LLC

1808 WEST BELTLINE HIGHWAY
MADISON,WI53713
80-0968174 		PHARMACY BENEFITS WI N/A
 C         No
Schedule R (Form 990) 2013
Schedule R (Form 990) 2013
Page 3
Part V
Transactions With Related Organizations Complete if the organization answered "Yes" on Form 990, Part IV, line 34, 35b, or 36.
Note. Complete line 1 if any entity is listed in Parts II, III, or IV of this schedule.
Yes
No
1 During the tax year, did the orgranization engage in any of the following transactions with one or more related organizations listed in Parts II-IV?
a Receipt of (i) interest (ii) annuities (iii) royalties or (iv) rent from a controlled entity . . . . . . . . . . . . . . . . . . . . . . .
1a
 
No
b Gift, grant, or capital contribution to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1b
Yes
 
c Gift, grant, or capital contribution from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1c
Yes
 
d Loans or loan guarantees to or for related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1d
 
No
e Loans or loan guarantees by related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1e
 
No
f Dividends from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1f
 
No
g Sale of assets to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1g
 
No
h Purchase of assets from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1h
 
No
i Exchange of assets with related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1i
 
No
j Lease of facilities, equipment, or other assets to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1j
Yes
 
k Lease of facilities, equipment, or other assets from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . .
1k
Yes
 
l Performance of services or membership or fundraising solicitations for related organization(s) . . . . . . . . . . . . . . . . . . . .
1l
Yes
 
m Performance of services or membership or fundraising solicitations by related organization(s) . . . . . . . . . . . . . . . . . . . .
1m
Yes
 
n Sharing of facilities, equipment, mailing lists, or other assets with related organization(s) . . . . . . . . . . . . . . . . . . . . .
1n
Yes
 
o Sharing of paid employees with related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1o
Yes
 
p Reimbursement paid to related organization(s) for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1p
Yes
 
q Reimbursement paid by related organization(s) for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1q
Yes
 
r Other transfer of cash or property to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1r
Yes
 
s Other transfer of cash or property from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1s
Yes
 
2
If the answer to any of the above is "Yes," see the instructions for information on who must complete this line, including covered relationships and transaction thresholds.
(a)
Name of related organization 		(b)
Transaction
type (a-s) 		(c)
Amount involved 		(d)
Method of determining amount involved





Schedule R (Form 990) 2013
Schedule R (Form 990) 2013
Page 4
Part VI
Unrelated Organizations Taxable as a Partnership Complete if the organization answered "Yes" on Form 990, Part IV, line 37.
Provide the following information for each entity taxed as a partnership through which the organization conducted more than five percent of its activities (measured by total assets or gross revenue) that was not a related organization. See instructions regarding exclusion for certain investment partnerships.
(a)
Name, address, and EIN of entity 		(b)
Primary activity 		(c)
Legal domicile
(state or foreign
country) 		(d)
Predominant income (related, unrelated, excluded from tax under sections 512-514)

(e)
Are all partners
section
501(c)(3)
organizations? 		(f)
Share of total income




 		(g)
Share of
end-of-year
assets 		(h)
Disproprtionate allocations? 		(i)
Code V?UBI
amount in box 20
of Schedule K-1
(Form 1065) 		(j)
General or
managing
partner? 		(k)
Percentage
ownership
Yes No Yes No Yes No






























Schedule R (Form 990) 2013
Schedule R (Form 990) 2013
Page 5
Part VII
Supplemental Information
Provide additional information for responses to questions on Schedule R (see instructions).
Return Reference Explanation
Schedule R (Form 990) 2013
Additional Data


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