Attach to Form 990 or Form 990-EZ.
Go to
www.irs.gov/Form990 for the latest information.
| (i) Name of supported organization | (ii) EIN | (iii) Type of organization (described on lines 1- 10 above (see instructions)) | (iv) Is the organization listed in your governing document? | (v) Amount of monetary support (see instructions) | (vi) Amount of other support (see instructions) | |
|---|---|---|---|---|---|---|
| Yes | No | |||||
| (A)
Hilltop Health Services Corporation |
742321009 | 10 | Yes | 0 | 0 | |
| (B)
St Mary's Hospital |
840425720 | 3 | Yes | 0 | 0 | |
| (C)
Colorado West Healthcare System |
840469270 | 3 | Yes | 0 | 0 | |
| (D)
Mesa County Public Health |
841121015 | 6 | Yes | 0 | 0 | |
| (E)
Marillac Clinic Inc |
841085822 | 3 | Yes | 0 | 0 | |
| (F)
Rocky Mountain Health Foundation |
841424932 | 7 | Yes | 0 | 0 | |
|
Total 6
|
0 | 0 | ||||
Calendar year (or fiscal year beginning in) ![]() |
(a) 2014 | (b) 2015 | (c) 2016 | (d) 2017 | (e) 2018 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 1 | Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grant.") .. | ||||||
| 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. | ||||||
Calendar year
(or fiscal year beginning in) ![]() |
(a) 2014 | (b) 2015 | (c) 2016 | (d) 2017 | (e) 2018 | (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 VI.).. | ||||||
| 11 | Total support. Add lines 7 through 10 | ||||||
Calendar year (or fiscal year beginning in) ![]() |
(a) 2014 | (b) 2015 | (c) 2016 | (d) 2017 | (e) 2018 | (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.) | ||||||
Calendar year (or fiscal year beginning in) ![]() |
(a) 2014 | (b) 2015 | (c) 2016 | (d) 2017 | (e) 2018 | (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 VI.) .. | ||||||
| 13 | Total support. (Add lines 9, 10c, 11, and 12.).. | ||||||
| Section A - Adjusted Net Income | (A) Prior Year |
(B) Current Year (optional) |
||||
| 1 | Net short-term capital gain | 1 | ||||
| 2 | Recoveries of prior-year distributions | 2 | ||||
| 3 | Other gross income (see instructions) | 3 | ||||
| 4 | Add lines 1 through 3 | 4 | ||||
| 5 | Depreciation and depletion | 5 | ||||
| 6 | Portion of operating expenses paid or incurred for production or collection of gross income or for management, conservation, or maintenance of property held for production of income (see instructions) | 6 | ||||
| 7 | Other expenses (see instructions) | 7 | ||||
| 8 | Adjusted Net Income (subtract lines 5, 6 and 7 from line 4) | 8 | ||||
| Section B - Minimum Asset Amount | (A) Prior Year |
(B) Current Year (optional) |
||||
| 1 | Aggregate fair market value of all non-exempt-use assets (see instructions for short tax year or assets held for part of year): | 1 | ||||
| a | Average monthly value of securities | 1a | ||||
| b | Average monthly cash balances | 1b | ||||
| c | Fair market value of other non-exempt-use assets | 1c | ||||
| d | Total (add lines 1a, 1b, and 1c) | 1d | ||||
| e |
Discount claimed for blockage or other factors (explain in detail in Part VI): |
|||||
| 2 | Acquisition indebtedness applicable to non-exempt use assets | 2 | ||||
| 3 | Subtract line 2 from line 1d | 3 | ||||
| 4 | Cash deemed held for exempt use. Enter 1-1/2% of line 3 (for greater amount, see instructions). | 4 | ||||
| 5 | Net value of non-exempt-use assets (subtract line 4 from line 3) | 5 | ||||
| 6 | Multiply line 5 by .035 | 6 | ||||
| 7 | Recoveries of prior-year distributions | 7 | ||||
| 8 | Minimum Asset Amount (add line 7 to line 6) | 8 | ||||
| Section C - Distributable Amount | Current Year | |||||
| 1 | Adjusted net income for prior year (from Section A, line 8, Column A) | 1 | ||||
| 2 | Enter 85% of line 1 | 2 | ||||
| 3 | Minimum asset amount for prior year (from Section B, line 8, Column A) | 3 | ||||
| 4 | Enter greater of line 2 or line 3 | 4 | ||||
| 5 | Income tax imposed in prior year | 5 | ||||
| 6 | Distributable Amount. Subtract line 5 from line 4, unless subject to emergency temporary reduction (see instructions) | 6 | ||||
| Section D - Distributions | Current Year | |
|---|---|---|
| 1 Amounts paid to supported organizations to accomplish exempt purposes | ||
|
2
Amounts paid to perform activity that directly furthers exempt purposes of supported organizations, in excess of income from activity |
||
| 3 Administrative expenses paid to accomplish exempt purposes of supported organizations | ||
| 4 Amounts paid to acquire exempt-use assets | ||
| 5 Qualified set-aside amounts (prior IRS approval required) | ||
| 6 Other distributions (describe in Part VI). See instructions | ||
| 7Total annual distributions. Add lines 1 through 6. | ||
|
8
Distributions to attentive supported organizations to which the organization is responsive (provide details in Part VI). See instructions |
||
| 9 Distributable amount for 2018 from Section C, line 6 | ||
| 10 Line 8 amount divided by Line 9 amount | ||
| Section E - Distribution Allocations (see instructions) |
(i) Excess Distributions |
(ii) Underdistributions Pre-2018 |
(iii) Distributable Amount for 2018 |
|
|---|---|---|---|---|
|
1
Distributable amount for 2018 from Section C, line 6 |
||||
|
2
Underdistributions, if any, for years prior to 2018 (reasonable cause required-- explain in Part VI). See instructions. |
||||
| 3 Excess distributions carryover, if any, to 2018: | ||||
| a From 2013....... | ||||
| b From 2014....... | ||||
| c From 2015....... | ||||
| d From 2016....... | ||||
| e From 2017....... | ||||
| fTotal of lines 3a through e | ||||
| g Applied to underdistributions of prior years | ||||
| h Applied to 2018 distributable amount | ||||
|
i
Carryover from 2013 not applied (see instructions) |
||||
| j Remainder. Subtract lines 3g, 3h, and 3i from 3f. | ||||
| 4Distributions for 2018 from Section D, line 7: | ||||
| $ | ||||
| a Applied to underdistributions of prior years | ||||
| b Applied to 2018 distributable amount | ||||
| c Remainder. Subtract lines 4a and 4b from 4. | ||||
|
5
Remaining underdistributions for years prior to 2018, if any. Subtract lines 3g and 4a from line 2. If the amount is greater than zero, explain in Part VI. See instructions. |
||||
|
6
Remaining underdistributions for 2018. Subtract lines 3h and 4b from line 1. If the amount is greater than zero, explain in Part VI. See instructions. |
||||
|
7 Excess distributions carryover to 2019. Add lines 3j and 4c. |
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| 8 Breakdown of line 7: | ||||
| a Excess from 2014...... | ||||
| b Excess from 2015..... | ||||
| c Excess from 2016..... | ||||
| d Excess from 2017..... | ||||
| e Excess from 2018..... | ||||
| Facts And Circumstances Test |
|---|
| Return Reference | Explanation |
|---|---|
| Part IV Section A Line 2 | Mesa County Public Health is a governmental unit described in Section 170(b)(1)(A) of the Code as a political subdivision of the State. |
| Part IV Section A Line 5A | Mesa County Public Health was added as a supported organization. Mesa County Public Health is a public entity and a political subdivision of the State. It is described in Section 170(b)(1)(A) of the Code. Mesa County Public Health was added as a supported organization because the work of the Organization supports the mission of Mesa County Public Health. The Organization has the right to add supported organizations by amending its articles of incorporation and bylaws. The Organization's Board of Directors passed appropriate resolutions to amend the Organization's articles of incorporation and bylaws to add Mesa County Public Health as a supported organization. |
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Attach to Form 990 or 990-EZ.
Go to www.irs.gov/Form990 for the latest information.
| Return Reference | Explanation |
|---|---|
| Form 990, Part III, Line 4b | In 2017, QHN launched a new initiative called the Community Resource Network (CRN). This social information exchange is designed to help bridge the gap by combining social, behavioral, and the medical side information to get more comprehensive view of a person. CRN allows those involved in the coordinated care to view pertinent information to more efficiently guide the person to better health. This collaboration is critical to improve the health and safety of those QHN serves, reducing unnecessary duplication, reducing the burden on government supported healthcare programs, and ultimately driving down the cost of healthcare. QHN is doing beta testing of its system in 2019 and hopes to go live with its CRN system early 2020. Funding Sources: Grant contracts help support the work required to build the technology infrastructure, data interoperability exchange capabilities and robust data warehousing essential for the advanced analytics and data needs of new care and payment models. QHN continues to support the efforts of the State Innovation Model (SIM) initiative and the Testing Experience and Functional Tools (TEFT) grant which is designed to demonstrate the use of Personal Health Record (PHR) within the targeted populations of the intellectually and developmentally disabled, elderly, blind and disabled and identify and evaluate electronic long-term services and supports (e-LTSS) standard in conjunction with the Office of the National Coordinator (ONC). These investments have allowed QHN to increase and enhance connectivity with Medicaid and Medicare providers, expand acquistion of ambulatory data, including data from behavioral health and long-term care providers to enrich the data repository. This supports the common vision of improving outcomes for Medicaid, Medicare and all patients in Western Colorado. The collective impact of these acquisitions, and the practice transformation work they support, has been instrumental in the evolution of the healthcare delivery system of Western Colorado. |
| Form 990, Part VI, Section A, line 4 | The Organization amended its Articles of Incorporation and Bylaws to add Mesa County Public Health, a public entity, as a supported organization and to increase the number of possible board members to 11 from 10. |
| Form 990, Part VI, Section A, line 7a | The board consists of ten members. There are six tax exempt non-profit entities represented on the board and one taxable nonprofit entity. Each entity chooses a member to serve on the board. Three members are at large. All members of the board elect the three members at large. |
| Form 990, Part VI, Section B, line 11b | A copy of form 990 is provided to each board member before its' filing. Each board member is given an opportunity to comment on the 990 and ask questions before it is filed. |
| Form 990, Part VI, Section B, line 12c | Conflict of interest disclosure statements are reviewed by the Executive Director and legal counsel. All Board members, officers and key employees are covered under the policy. Before each Board meeting legal counsel and the Executive Director review the agenda and determine if there is a conflict of interest potential for each board action item and during each board meeting legal counsel and the Executive Director are present to do the same. If there is a potential for a conflict, legal counsel advises the Board and the Board acts in accordance with its' conflict of interest policy. If someone has a conflict that person cannot participate in the deliberations or decision on the transaction. |
| Form 990, Part VI, Section B, line 15 | Line 15a: The process is used for Executive Director (who is the top management official) compensation. The Board Chair, Board Vice Chair and Treasurer meet to determine the compensation amount relying on data of compensation rates for executives involved in health care in the Mesa County area. Their determination is documented contemporaneously in e-mail exchanges. In addition, in 2017 the Board had executive compensation reviewed by a compensation consultant. Line 15b: The Organization uses a compensation survey and/or a third party consultant to review salaries of several key positions including officers. |
| Form 990, Part VI, Section C, line 19 | No requests for these documents have been received. However, if such a request were made, we would provide a copy of these documents to the extent required by applicable law for 501(c)(3) organizations. |
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