TY 2019 Form 990

(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)	(E) Reportable compensation from related organizations (W-2/1099-MISC)
(1) Paula Friedman Pt Yr Director/Vice President, Pt Yr Senior VP-Strategic Development SSM Health	1.0 ................. 58.0	X	X		1,384,920	282,580
(2) Steven Little Pt Yr Director, Pt Yr Regional Chief Operating Officer, Wisconsin	1.0 ................. 45.0	X	X		1,395,599	9,512
(3) Thor Gilbertson Director, Vice Chairperson	1.0 ................. 0	X	X		0	0
(4) Wayne Matzke Director, Chairperson	1.0 ................. 0	X	X		0	0
(5) Mark Thompson Director, Regional Chief Medical Officer	1.0 ................. 43.0	X		X	575,194	219,571
(6) Dr Doug Fownes Director	1.0 ................. 0	X			0	0
(7) Dr Jeffery Strong Director	1.0 ................. 0	X			0	0
(8) Dr Judith Westphal Director	1.0 ................. 0	X			0	0
(9) Dr Ted Miller Director	1.0 ................. 0	X			0	0
(10) Dr Toni Stanley Director	1.0 ................. 0	X			0	0
(11) Joan Karsten Director	1.0 ................. 1.0	X			0	0
(12) Marysue Michels Director	1.0 ................. 0	X			0	0
(13) Sr Hertha Longo Director	1.0 ................. 0	X			0	0
(14) Sr Marie Scott Director	1.0 ................. 0	X			0	0
(15) Sr Susan Stucki Director	1.0 ................. 1.0	X			0	0
(16) Stephen Peterson Director	1.0 ................. 0	X			0	0
(17) Thomas Schneider Director	1.0 ................. 0	X			0	0

(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)	(E) Reportable compensation from related organizations (W-2/1099-MISC)	(F) Estimated amount of other compensation from the organization and related organizations
(18) Thomas Schuessler Director	1.0 .......................0	X					0	0	0
(19) Doug Long Secretary, General Counsel at SSM Health	1.0 .......................65.2		X				0	229,550	471,986
(20) Katherine Vergos President - St. Agnes Hospital	40.0 .......................0.0		X				465,436	0	128,135
(21) Kris Zimmer Treasurer, Chief Financial Officer at SSM Health	1.0 .......................67.0		X				0	1,365,634	813,620
(22) Barbara Knutzen President - AHE, CLW and Performance	40.0 .......................0			X			189,646	0	31,634
(23) James Mugan Sr VP - Medical Group and Medical Affairs	40.0 .......................0			X			339,080	0	54,660
(24) Michael Degere VP - Population Health Management	40.0 .......................0			X			362,739	0	63,025
(25) Michael Drees COO - Fond du Lac Regional Clinic	40.0 .......................0			X			304,815	0	60,752
(26) Jacob Waidelich Physician	40.0 .......................0				X		565,464	0	11,388
(27) John Choi Physician	40.0 .......................0				X		686,071	0	52,288
(28) Michael Vander Kooy Radiation Oncologist	40.0 .......................0				X		707,472	0	61,757
(29) Steven Flurry Anesthesiologist	40.0 .......................0				X		671,433	0	53,072
(30) Yasir Hatahet Intensivist/Pulmonologist	40.0 .......................0				X		552,375	0	58,671
(31) Bonnie Schmitz Former Key Employee	0.0 .......................0					X	604,554	0	269
(32) Nancy Birschbach Former Key Employee	0.0 .......................40.0					X	0	356,040	118,475

(A) Name and business address	(B) Description of services	(C) Compensation
FOND DU LAC REGIONAL CLINIC SC 420 E DIVISION ST FOND DU LAC,WI54935	PHYSICIAN SERVICES	52,613,459
CD SMITH CONSTRUCTION PO BOX 1066 FOND DU LAC,WI54935	CONSTRUCTION SERVICES	5,272,351
CERNER CORP 2800 ROCKCREEK PKWY KANSAS CITY,MO64141	COMPUTER SERVICES	4,276,904
WILLIAMS MONTGOMERY & JOHN LTD 233 S WACKER DR 6800 CHICAGO,IL60606	LEGAL SERVICES	2,128,667
MEDICAL COLLEGE OF WI 8701 WATERTOWN PLANK RD PO BOX 26 WAUWATOSA,WI53226	PHYSICIAN SERVICES	1,822,101
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 73

- TIN:

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

Go to www.irs.gov/Form990 for instructions and the latest information.

OMB No. 1545-0047

2019

Open to Public
Inspection

Name of the organization

Agnesian Healthcare Inc

Employer identification number

39-0807236

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 12, check only one box.)

A church, convention of churches, or association of churches described in section 170(b)(1)(A)(i).

A school described in section 170(b)(1)(A)(ii). (Attach Schedule E (Form 990 or 990-EZ).)

A hospital or a cooperative hospital service organization described in section 170(b)(1)(A)(iii).

A medical research organization operated in conjunction with a hospital described in section 170(b)(1)(A)(iii). Enter the hospital's name, city, and state:

An organization operated for the benefit of a college or university owned or operated by a governmental unit described in section 170(b)(1)(A)(iv). (Complete Part II.)

A federal, state, or local government or governmental unit described in section 170(b)(1)(A)(v).

An organization that normally receives a substantial part of its support from a governmental unit or from the general public described in section 170(b)(1)(A)(vi). (Complete Part II.)

A community trust described in section 170(b)(1)(A)(vi). (Complete Part II.)

An agricultural research organization described in 170(b)(1)(A)(ix) operated in conjunction with a land-grant college or university or a non-land grant college of agriculture. See instructions. Enter the name, city, and state of the college or university:

An organization that normally receives: (1) more than 331/3% of its support from contributions, membership fees, and gross 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.)

An organization organized and operated exclusively to test for public safety. See section 509(a)(4).

An organization organized and operated exclusively for the benefit of, to perform the functions of, or to carry out the purposes of one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2). See section 509(a)(3). Check the box in lines 12a through 12d that describes the type of supporting organization and complete lines 12e, 12f, and 12g.

Type I. A supporting organization operated, supervised, or controlled by its supported organization(s), typically by giving the supported organization(s) the power to regularly appoint or elect a majority of the directors or trustees of the supporting organization. You must complete Part IV, Sections A and B.

Type II. A supporting organization supervised or controlled in connection with its supported organization(s), by having control or management of the supporting organization vested in the same persons that control or manage the supported organization(s). You must complete Part IV, Sections A and C.

Type III functionally integrated. A supporting organization operated in connection with, and functionally integrated with, its supported organization(s) (see instructions). You must complete Part IV, Sections A, D, and E.

Type III non-functionally integrated. A supporting organization operated in connection with its supported organization(s) that is not functionally integrated. The organization generally must satisfy a distribution requirement and an attentiveness requirement (see instructions). You must complete Part IV, Sections A and D, and Part V.

Check this box if the organization received a written determination from the IRS that it is a Type I, Type II, Type III functionally integrated, or Type III non-functionally integrated supporting organization.

Enter the number of supported organizations ...............................

Provide the following information about the supported organization(s).

(i) Name of supported organization	(ii) EIN	(iv) Is the organization listed in your governing document?		(v) Amount of monetary support (see instructions)	(vi) Amount of other support (see instructions)
(i) Name of supported organization	(ii) EIN	Yes	No	(v) Amount of monetary support (see instructions)	(vi) Amount of other support (see instructions)


Total

For Paperwork Reduction Act Notice, see the Instructions for
Form 990 or 990-EZ.

Cat. No. 11285F

Schedule A (Form 990 or 990-EZ) 2019

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 failed to qualify under the tests listed below, please complete Part III.)

Section A. Public Support

Calendar year (or fiscal year beginning in)		(a) 2015	(b) 2016	(c) 2017	(d) 2018	(e) 2019	(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.

Section B. Total Support

Calendar year (or fiscal year beginning in)		(a) 2015	(b) 2016	(c) 2017	(d) 2018	(e) 2019	(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

Gross receipts from related activities, etc. (see instructions) ..................

First five years. If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a section 501(c)(3) organization, check this box and stop here........................................ right arrow

Section C. Computation of Public Support Percentage

Public support percentage for 2019 (line 6, column (f) divided by line 11, column (f)) .........

Public support percentage for 2018 Schedule A, Part II, line 14 ...............

16a

33 1/3% support test—2019. If the organization did not check the box on line 13, and line 14 is 33 1/3% or more, check this box
and stop here. The organization qualifies as a publicly supported organization ....................... right arrow

33 1/3% support test—2018. If the organization did not check a box on line 13 or 16a, and line 15 is 33 1/3% or more, check this
box and stop here. The organization qualifies as a publicly supported organization ..................... right arrow

17a

10%-facts-and-circumstances test—2019. If the organization did not check a box on line 13, 16a, or 16b, and line 14
is 10% or more, and if the organization meets the "facts-and-circumstances" test, check this box and stop here. Explain
in Part VI how the organization meets the "facts-and-circumstances" test. The organization qualifies as a publicly supported
organization ..................................................... right arrow

10%-facts-and-circumstances test—2018. If the organization did not check a box on line 13, 16a, 16b, or 17a, and line
15 is 10% or more, and if the organization meets the "facts-and-circumstances" test, check this box and stop here.
Explain in Part VI how the organization meets the "facts-and-circumstances" test. The organization qualifies as a publicly
supported organization ................................................ right arrow

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) 2019

Page 3

Part III

Support Schedule for Organizations Described in Section 509(a)(2)
(Complete only if you checked the box on line 10 of Part I or if the organization failed to qualify under Part II. If the organization fails to qualify under the tests listed below, please complete Part II.)

Section A. Public Support

Calendar year (or fiscal year beginning in)		(a) 2015	(b) 2016	(c) 2017	(d) 2018	(e) 2019	(f) Total
1	Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") .
2	Gross receipts from admissions, merchandise sold or services performed, or facilities furnished in any activity that is related to the organization's tax-exempt purpose
3	Gross receipts from activities that are not an unrelated trade or business under section 513 .....
4	Tax revenues levied for the organization's benefit and either paid to or expended on its behalf...
5	The value of services or facilities furnished by a governmental unit to the organization without charge
6	Total. Add lines 1 through 5
7a	Amounts included on lines 1, 2, and 3 received from disqualified persons
b	Amounts included on lines 2 and 3 received from other than disqualified persons that exceed the greater of $5,000 or 1% of the amount on line 13 for the year.
c	Add lines 7a and 7b..
8	Public support. (Subtract line 7c from line 6.)

Section B. Total Support

Calendar year (or fiscal year beginning in)		(a) 2015	(b) 2016	(c) 2017	(d) 2018	(e) 2019	(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.)..

First five years. If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a section 501(c)(3) organization,
check this box and stop here............................................. right arrow

Section C. Computation of Public Support Percentage

Public support percentage for 2019 (line 8, column (f) divided by line 13, column (f)) .........

Public support percentage from 2018 Schedule A, Part III, line 15 ...............

Section D. Computation of Investment Income Percentage

Investment income percentage for 2019 (line 10c, column (f) divided by line 13, column (f)) ......

Investment income percentage from 2018 Schedule A, Part III, line 17 .............

19a

331/3% support tests—2019. If the organization did not check the box on line 14, and line 15 is more than 33 1/3%, and line 17 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization ....... right arrow

33 1/3% support tests—2018. If the organization did not check a box on line 14 or line 19a, and line 16 is more than 33 1/3% and line 18 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization .... right arrow

Private foundation. If the organization did not check a box on line 14, 19a, or 19b, check this box and see instructions .... right arrow

Schedule A (Form 990 or 990-EZ) 2019

Page 4

Part IV

Supporting Organizations

(Complete only if you checked a box on line 12 of Part I. If you checked 12a of Part I, complete Sections A and B. If you checked 12b of Part I, complete Sections A and C. If you checked 12c of Part I, complete Sections A, D, and E. If you checked 12d of Part I, complete Sections A and D, and complete Part V.)

Section A. All Supporting Organizations

Yes

Are all of the organization’s supported organizations listed by name in the organization’s governing documents?
If "No," describe in Part VI how the supported organizations are designated. If designated by class or purpose,
describe the designation. If historic and continuing relationship, explain.

Did the organization have any supported organization that does not have an IRS determination of status under section 509(a)(1) or (2)? If "Yes," explain in Part VI how the organization determined that the supported organization was described in section 509(a)(1) or (2).

Did the organization have a supported organization described in section 501(c)(4), (5), or (6)? If "Yes," answer (b) and (c) below.

Did the organization confirm that each supported organization qualified under section 501(c)(4), (5), or (6) and satisfied the public support tests under section 509(a)(2)? If "Yes," describe in Part VI when and how the organization made the determination.

Did the organization ensure that all support to such organizations was used exclusively for section 170(c)(2)(B) purposes? If "Yes," explain in Part VI what controls the organization put in place to ensure such use.

Was any supported organization not organized in the United States ("foreign supported organization")? If “Yes” and if you checked 12a or 12b in Part I, answer (b) and (c) below.

Did the organization have ultimate control and discretion in deciding whether to make grants to the foreign supported organization? If “Yes,” describe in Part VI how the organization had such control and discretion despite being controlled or supervised by or in connection with its supported organizations.

Did the organization support any foreign supported organization that does not have an IRS determination under sections 501(c)(3) and 509(a)(1) or (2)? If “Yes,” explain in Part VI what controls the organization used to ensure that all support to the foreign supported organization was used exclusively for section 170(c)(2)(B) purposes.

Did the organization add, substitute, or remove any supported organizations during the tax year? If “Yes,” answer (b) and (c) below (if applicable). Also, provide detail in Part VI, including (i) the names and EIN numbers of the supported organizations added, substituted, or removed; (ii) the reasons for each such action; (iii) the authority under the organization's organizing document authorizing such action; and (iv) how the action was accomplished (such as by amendment to the organizing document).

Type I or Type II only. Was any added or substituted supported organization part of a class already designated in the organization's organizing document?

Substitutions only. Was the substitution the result of an event beyond the organization's control?

Did the organization provide support (whether in the form of grants or the provision of services or facilities) to anyone other than (i) its supported organizations, (ii) individuals that are part of the charitable class benefited by one or more of its supported organizations, or (iii) other supporting organizations that also support or benefit one or more of the filing organization’s supported organizations? If “Yes,” provide detail in Part VI.

Did the organization provide a grant, loan, compensation, or other similar payment to a substantial contributor (defined in section 4958(c)(3)(C)), a family member of a substantial contributor, or a 35% controlled entity with regard to a substantial contributor? If “Yes,” complete Part I of Schedule L (Form 990 or 990-EZ) .

Did the organization make a loan to a disqualified person (as defined in section 4958) not described in line 7? If “Yes,” complete Part I of Schedule L (Form 990 or 990-EZ).

Was the organization controlled directly or indirectly at any time during the tax year by one or more disqualified persons as defined in section 4946 (other than foundation managers and organizations described in section 509(a)(1) or (2))? If “Yes,” provide detail in Part VI.

Did one or more disqualified persons (as defined in line 9a) hold a controlling interest in any entity in which the supporting organization had an interest? If “Yes,” provide detail in Part VI.

Did a disqualified person (as defined in line 9a) have an ownership interest in, or derive any personal benefit from, assets in which the supporting organization also had an interest? If “Yes,” provide detail in Part VI.

10a

Was the organization subject to the excess business holdings rules of section 4943 because of section 4943(f) (regarding certain Type II supporting organizations, and all Type III non-functionally integrated supporting organizations)? If “Yes,” answer line 10b below.

10a

Did the organization have any excess business holdings in the tax year? (Use Schedule C, Form 4720, to determine whether the organization had excess business holdings).

10b

Schedule A (Form 990 or 990-EZ) 2019

Page 5

Part IV

Supporting Organizations (continued)

Yes

Has the organization accepted a gift or contribution from any of the following persons?

A person who directly or indirectly controls, either alone or together with persons described in (b) and (c) below, the governing body of a supported organization?

11a

A family member of a person described in (a) above?

11b

A 35% controlled entity of a person described in (a) or (b) above? If “Yes” to a, b, or c, provide detail in Part VI.

11c

Section B. Type I Supporting Organizations

Yes

Did the directors, trustees, or membership of one or more supported organizations have the power to regularly appoint or elect at least a majority of the organization’s directors or trustees at all times during the tax year? If “No,” describe in Part VI how the supported organization(s) effectively operated, supervised, or controlled the organization’s activities. If the organization had more than one supported organization, describe how the powers to appoint and/or remove directors or trustees were allocated among the supported organizations and what conditions or restrictions, if any, applied to such powers during the tax year.

Did the organization operate for the benefit of any supported organization other than the supported organization(s) that operated, supervised, or controlled the supporting organization? If “Yes,” explain in Part VI how providing such benefit carried out the purposes of the supported organization(s) that operated, supervised or controlled the supporting organization.

Section C. Type II Supporting Organizations

Yes

Were a majority of the organization’s directors or trustees during the tax year also a majority of the directors or trustees of each of the organization’s supported organization(s)? If “No,” describe in Part VI how control or management of the supporting organization was vested in the same persons that controlled or managed the supported organization(s).

Section D. All Type III Supporting Organizations

Yes

Did the organization provide to each of its supported organizations, by the last day of the fifth month of the organization’s tax year, (i) a written notice describing the type and amount of support provided during the prior tax year, (ii) a copy of the Form 990 that was most recently filed as of the date of notification, and (iii) copies of the organization’s governing documents in effect on the date of notification, to the extent not previously provided?

Were any of the organization’s officers, directors, or trustees either (i) appointed or elected by the supported organization(s) or (ii) serving on the governing body of a supported organization? If "No," explain in Part VI how the organization maintained a close and continuous working relationship with the supported organization(s).

By reason of the relationship described in (2), did the organization’s supported organizations have a significant voice in the organization’s investment policies and in directing the use of the organization’s income or assets at all times during the tax year? If "Yes," describe in Part VI the role the organization’s supported organizations played in this regard.

Section E. Type III Functionally-Integrated Supporting Organizations

Check the box next to the method that the organization used to satisfy the Integral Part Test during the year (see instructions):

The organization satisfied the Activities Test. Complete line 2 below.

The organization is the parent of each of its supported organizations. Complete line 3 below.

The organization supported a governmental entity. Describe in Part VI how you supported a government entity (see instructions)

Activities Test. Answer (a) and (b) below.

Yes

Did substantially all of the organization’s activities during the tax year directly further the exempt purposes of the supported organization(s) to which the organization was responsive? If "Yes," then in Part VI identify those supported organizations and explain how these activities directly furthered their exempt purposes, how the organization was responsive to those supported organizations, and how the organization determined that these activities constituted substantially all of its activities.

Did the activities described in (a) constitute activities that, but for the organization’s involvement, one or more of the organization’s supported organization(s) would have been engaged in? If "Yes," explain in Part VI the reasons for the organization’s position that its supported organization(s) would have engaged in these activities but for the organization’s involvement.

Parent of Supported Organizations. Answer (a) and (b) below.

Did the organization have the power to regularly appoint or elect a majority of the officers, directors, or trustees of each of the supported organizations? Provide details in Part VI.

Did the organization exercise a substantial degree of direction over the policies, programs and activities of each of its supported organizations? If "Yes," describe in Part VI. the role played by the organization in this regard.

Schedule A (Form 990 or 990-EZ) 2019

Page 6

Part V

Type III Non-Functionally Integrated 509(a)(3) Supporting Organizations

Check here if the organization satisfied the Integral Part Test as a qualifying trust on Nov. 20, 1970 (explain in Part VI). See instructions. All other Type III non-functionally integrated supporting organizations must complete Sections A through E.

	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

Check here if the current year is the organization's first as a non-functionally-integrated Type III supporting organization (see instructions)

Schedule A (Form 990 or 990-EZ) 2019

Page 7

Part V

Type III Non-Functionally Integrated 509(a)(3) Supporting Organizations(continued)

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 2019 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-2019	(iii) Distributable Amount for 2019
1 Distributable amount for 2019 from Section C, line 6
2 Underdistributions, if any, for years prior to 2019 (reasonable cause required-- explain in Part VI). See instructions.
3 Excess distributions carryover, if any, to 2019:
a From 2014.......
b From 2015.......
c From 2016.......
d From 2017.......
e From 2018.......
fTotal of lines 3a through e
g Applied to underdistributions of prior years
h Applied to 2019 distributable amount
i Carryover from 2014 not applied (see instructions)
j Remainder. Subtract lines 3g, 3h, and 3i from 3f.
4Distributions for 2019 from Section D, line 7:
$
a Applied to underdistributions of prior years
b Applied to 2019 distributable amount
c Remainder. Subtract lines 4a and 4b from 4.
5 Remaining underdistributions for years prior to 2019, 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 2019. 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 2020. Add lines 3j and 4c.
8 Breakdown of line 7:
a Excess from 2015.....
b Excess from 2016.....
c Excess from 2017.....
d Excess from 2018.....
e Excess from 2019.....

Schedule A (Form 990 or 990-EZ) (2019)

Schedule A (Form 990 or 990-EZ) 2019

Page 8

Part VI

Supplemental Information. Provide the explanations required by Part II, line 10; Part II, line 17a or 17b; Part III, line 12; Part IV, Section A, lines 1, 2, 3b, 3c, 4b, 4c, 5a, 6, 9a, 9b, 9c, 11a, 11b, and 11c; Part IV, Section B, lines 1 and 2; Part IV, Section C, line 1; Part IV, Section D, lines 2 and 3; Part IV, Section E, lines 1c, 2a, 2b, 3a and 3b; Part V, line 1; Part V, Section B, line 1e; Part V Section D, lines 5, 6, and 8; and Part V, Section E, lines 2, 5, and 6. Also complete this part for any additional information. (See instructions).

Facts And Circumstances Test

Return Reference	Explanation

Schedule A (Form 990 or 990-EZ) 2019

Additional Data

Software ID:	19010655
Software Version:	2019v5.0

- TIN:

Schedule B
(Form 990, 990-EZ,
or 990-PF)

Department of the Treasury
Internal Revenue Service

Schedule of Contributors

Attach to Form 990, 990-EZ, or 990-PF.

Go to www.irs.gov/Form990 for the latest information.

OMB No. 1545-0047

2019

Name of the organization

Agnesian Healthcare Inc

Employer identification number

39-0807236

Organization type (check one):

Filers of:

Section:

Form 990 or 990-EZ

501(c)( ) (enter number) organization

4947(a)(1) nonexempt charitable trust not treated as a private foundation

527 political organization

Form 990-PF

501(c)(3) exempt private foundation

4947(a)(1) nonexempt charitable trust treated as a private foundation

501(c)(3) taxable private foundation

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

For an organization filing Form 990, 990-EZ, or 990-PF that received, during the year, contributions totaling $5,000 or more (in money or other property) from any one contributor. Complete Parts I and II. See instructions for determining a contributor's total contributions.

Special Rules

For an organization described in section 501(c)(3) filing Form 990 or 990-EZ that met the 33¹/3% support test of the regulations
under sections 509(a)(1) and 170(b)(1)(A)(vi), that checked Schedule A (Form 990 or 990-EZ), Part II, line 13, 16a, or 16b, and that received from any one contributor, during the year, total contributions of the greater of (1) $5,000 or (2) 2% of the amount on (i) Form 990, Part VIII, line 1h, or (ii) Form 990-EZ, line 1. Complete Parts I and II.

For an organization described in section 501(c)(7), (8), or (10) filing Form 990 or 990-EZ that received from any one contributor,
during the year, total contributions of more than $1,000 exclusively for religious, charitable, scientific, literary, or educational purposes, or for the prevention of cruelty to children or animals. Complete Parts I, II, and III.

For an organization described in section 501(c)(7), (8), or (10) filing Form 990 or 990-EZ that received from any one contributor,
during the year, contributions exclusively for religious, charitable, etc., purposes, but no such contributions totaled more than $1,000. If this box is checked, enter here the total contributions that were received during the year for an exclusively religious, charitable, etc., purpose. Don't complete any of the parts unless the General Rule applies to this organization because it received nonexclusively religious, charitable, etc., contributions totaling $5,000 or more during the year ......... Arrow Bullet

Caution: An organization that isn't covered by the General Rule and/or the Special Rules doesn't 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 doesn't 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) (2019)

Schedule B (Form 990, 990-EZ, or 990-PF) (2019) Page 2

Name of organization Agnesian Healthcare Inc

Part I Contributors	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	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
Schedule B (Form 990, 990-EZ, or 990-PF) (2019)

Schedule B (Form 990, 990-EZ, or 990-PF) (2019)

Page 3

Name of organization Agnesian Healthcare Inc		Employer identification number 39-0807236

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) (2019)

Schedule B (Form 990, 990-EZ, or 990-PF) (2019)

Page 4


Name of organization Agnesian Healthcare Inc			Employer identification number 39-0807236
Part III Exclusively religious, charitable, etc., contributions to organizations described in section 501(c)(7), (8), or (10) that total more than $1,000 for the year from any one contributor. 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.) $ Use duplicate copies of Part III if additional space is needed.

(a)
No. from Part I

(b) Purpose 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

(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

(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

(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) (2019)

Additional Data

Software ID:	19010655
Software Version:	2019v5.0

- TIN:

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

Go to www.irs.gov/Form990 for instructions and the latest information.

OMB No. 1545-0047

2019

Open to Public
Inspection

If the organization answered "Yes" on 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" on 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" on Form 990, Part IV, Line 5 (Proxy Tax) (see separate instructions) or Form 990-EZ, Part V, line 35c (Proxy Tax) (see separate instructions), then
Round Bullet

Section 501(c)(4), (5), or (6) organizations: Complete Part III.

Name of the organization

Agnesian Healthcare Inc

Employer identification number

39-0807236

Part I-A

Complete if the organization is exempt under section 501(c) or is a section 527 organization.

Provide a description of the organization’s direct and indirect political campaign activities in Part IV (see instructions for definition of “political campaign activities")

Political campaign activity expenditures (see instructions) .................................................................... SchCMd Bullet

Volunteer hours for political campaign activities (see instructions) ..................................................................

Part I-B

Complete if the organization is exempt under section 501(c)(3).

Enter the amount of any excise tax incurred by the organization under section 4955 ................................ SchCMd Bullet

Enter the amount of any excise tax incurred by organization managers under section 4955 ....................... SchCMd Bullet

If the organization incurred a section 4955 tax, did it file Form 4720 for this year? .........................................

Yes No

Was a correction made? ......................................................................................................................

Yes No

If "Yes," describe in Part IV.

Part I-C

Complete if the organization is exempt under section 501(c), except section 501(c)(3).

Enter the amount directly expended by the filing organization for section 527 exempt function activities ..... SchCMd Bullet

Enter the amount of the filing organization's funds contributed to other organizations for section 527 exempt function activities ............................................................................................................................ SchCMd Bullet

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

Did the filing organization file Form 1120-POL for this year? ...................................................................

Yes No

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-.
1
2
3
4
5
6

For Paperwork Reduction Act Notice, see the instructions for Form 990 or 990-EZ.

Cat. No. 50084S

Schedule C (Form 990 or 990-EZ) 2019

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 Bullet

if the filing organization belongs to an affiliated group (and list in Part IV each affiliated group member's name, address, EIN, expenses, and share of excess lobbying expenditures).
B Check SchCMd Bullet

if the filing organization checked box A and "limited control" provisions apply.

Limits on Lobbying Expenditures (The term "expenditures" means amounts paid or incurred.)		(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? ...................................................................................................................	Yes No

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 separate instructions for lines 2a through 2f.)
Lobbying Expenditures During 4-Year Averaging Period
	Calendar year (or fiscal year beginning in)	(a) 2016	(b) 2017	(c) 2018	(d) 2019	(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) 2019

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 on lines 1a through 1i below, provide in Part IV a detailed description of the lobbying activity.

(a)

Yes|No

(b)

Amount

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:

Volunteers? ...........................................................................................................

Paid staff or management (include compensation in expenses reported on lines 1c through 1i)? ........

Media advertisements? ...................................................................................................

Mailings to members, legislators, or the public? .............................................................................

Publications, or published or broadcast statements? ...........................................................

Grants to other organizations for lobbying purposes? ..........................................................

Direct contact with legislators, their staffs, government officials, or a legislative body? .......................

Rallies, demonstrations, seminars, conventions, speeches, lectures, or any similar means? ..................

Other activities? ...................................................................................................................

Yes

10,380

Total. Add lines 1c through 1i ....................................................................................................

10,380

Did the activities in line 1 cause the organization to be not described in section 501(c)(3)? .....

If "Yes," enter the amount of any tax incurred under section 4912 ...........................................

If "Yes," enter the amount of any tax incurred by organization managers under section 4912 ...................

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

Were substantially all (90% or more) dues received nondeductible by members? ...............................................

Did the organization make only in-house lobbying expenditures of $2,000 or less? ............................................

Did the organization agree to carry over lobbying and political expenditures from the prior year? .................................

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."

Dues, assessments and similar amounts from members ......................................................................

Section 162(e) nondeductible lobbying and political expenditures (do not include amounts of political expenses for which the section 527(f) tax was paid).

Current year .............................................................................................................................

Carryover from last year ............................................................................................................

Total ...........................................................................................................................................

Aggregate amount reported in section 6033(e)(1)(A) notices of nondeductible section 162(e) dues .

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? ......................................................................................................................

Taxable amount of lobbying and political expenditures (see instructions) .........................................

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, lines 1 and 2 (see instructions), and Part ll-B, line 1. Also, complete this part for any additional information.

Return Reference	Explanation
Schedule C, Part II-B, Line 1 DETAILED DESCRIPTION OF THE LOBBYING ACTIVITY	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) 2019

Additional Data

Software ID:	19010655
Software Version:	2019v5.0

- TIN:

SCHEDULE D
(Form 990)

Department of the Treasury
Internal Revenue Service

Supplemental Financial Statements

Complete if the organization answered "Yes," on 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

Go to www.irs.gov/Form990 for instructions and the latest information.

OMB No. 1545-0047

2019

Open to Public Inspection

Name of the organization

Agnesian Healthcare Inc

Employer identification number

39-0807236

Part I

Organizations Maintaining Donor Advised Funds or Other Similar Funds or Accounts. Complete if the organization answered "Yes" on Form 990, Part IV, line 6.

		(a) Donor advised funds	(b) Funds and other accounts
1	Total number at end of year .........
2	Aggregate value of contributions to (during year)
3	Aggregate value of grants from (during year)
4	Aggregate value at end of year ........

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? ............

Yes No

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? ...................................

Yes No

Part II

Conservation Easements.
Complete if the organization answered "Yes" on Form 990, Part IV, line 7.

Purpose(s) of conservation easements held by the organization (check all that apply).

Preservation of land for public use (e.g., recreation or education) Preservation of an historically important land area

Protection of natural habitat Preservation of a certified historic structure

Preservation of open space

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.


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 7/25/06, and not on a historic structure listed in the National Register ...	2d

Number of conservation easements modified, transferred, released, extinguished, or terminated by the organization during the
tax year SchDMd Bullet

Number of states where property subject to conservation easement is located SchDMd Bullet

Does the organization have a written policy regarding the periodic monitoring, inspection, handling of violations, and enforcement of the conservation easements it holds? ............

Yes No

Staff and volunteer hours devoted to monitoring, inspecting, handling of violations, and enforcing conservation easements during the year
SchDMd Bullet

Amount of expenses incurred in monitoring, inspecting, handling of violations, and enforcing conservation easements during the year
SchDMd Bullet

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)? .............................

Yes No

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" on Form 990, Part IV, line 8.

If the organization elected, as permitted under FASB 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.

If the organization elected, as permitted under FASB 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)

Revenue included on Form 990, Part VIII, line 1 ......................... SchDMd Bullet

(ii)

Assets included in Form 990, Part X ............................... SchDMd Bullet

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 FASB ASC 958 relating to these items:

Revenue included on Form 990, Part VIII, line 1 .......................... SchDMd Bullet

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) 2019

Page 2

Part III

Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets (continued)

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):

Public exhibition

Loan or exchange programs

Scholarly research

Other

Preservation for future generations

Provide a description of the organization’s collections and explain how they further the organization’s exempt purpose in
Part XIII.

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?...

Yes No

Part IV

Escrow and Custodial Arrangements. Complete if the organization answered "Yes" on Form 990, Part IV, line 9, or reported an amount on Form 990, Part X, line 21.

Is the organization an agent, trustee, custodian or other intermediary for contributions or other assets not
included on Form 990, Part X? ....................................

Yes No


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

Did the organization include an amount on Form 990, Part X, line 21, for escrow or custodial account liability? ...

Yes No

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" on Form 990, Part IV, line 10.

		(a) Current year	(b) Prior year	(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 ......

Provide the estimated percentage of the current year end balance (line 1g, column (a)) held as:

Board designated or quasi-endowment SchDMd Bullet

Permanent endowment SchDMd Bullet

Term endowment SchDMd Bullet

The percentages on lines 2a, 2b, and 2c should equal 100%.

Are there endowment funds not in the possession of the organization that are held and administered for the
organization by:

Yes

(i) Unrelated organizations .................

3a(i)

(ii) Related organizations .................

3a(ii)

If "Yes" on 3a(ii), are the related organizations listed as required on Schedule R? .........

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" on 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 .....	14,684,350		14,684,350
b	Buildings ....	193,819,603	16,505,194	177,314,409
c	Leasehold improvements	5,977,894	1,579,480	4,398,414
d	Equipment ....	58,163,105	22,449,715	35,713,390
e	Other .....	14,878,062	0	14,878,062
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).)..				246,988,625

Schedule D (Form 990) 2019

Page 3

Part VII

InvestmentsOther Securities.
Complete if the organization answered "Yes" on 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	262,830,962	F
(C)
(D)
(E)
(F)
(G)
(H)
(I)
Total. (Column (b) must equal Form 990, Part X, col. (B) line 12.)	262,830,962

Part VIII

InvestmentsProgram Related. Complete if the organization answered 'Yes' on 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

(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
Total. (Column (b) must equal Form 990, Part X, col.(B) line 13.)

Part IX

Other Assets.
Complete if the organization answered 'Yes' on Form 990, Part IV, line 11d. See Form 990, Part X, line 15.

(a) Description				(b) Book value
(1)Due from affiliates				117,831,938
(2)OPERATING RIGHT-OF-USE ASSETS				5,859,000
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
Total. (Column (b) must equal Form 990, Part X, col.(B) line 15.)...........				123,690,938

Part X

Other Liabilities.
Complete if the organization answered 'Yes' on Form 990, Part IV, line 11e or 11f. See Form 990, Part X, line 25.

1.(a) Description of liability	(b) Book value
(1) Federal income taxes
(6)
(7)
(8)
(9)
Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)	241,150,591
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) 2019

Page 4

Part XI Reconciliation of Revenue per Audited Financial Statements With Revenue per Return. Complete if the organization answered 'Yes' on 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 (losses) 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' on 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

Schedule D, Part X, Line 2 FIN 48 (ASC 740) footnote

AGNESIAN HEALTHCARE INC'S FINANCIAL INFORMATION IS INCLUDED IN THE CONSOLIDATED AUDITED FINANCIAL STATEMENTS OF A RELATED ORGANIZATION, SSM HEALTH (SSMH). SSMH 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 2019 OR 2018.

Schedule D (Form 990) 2019

Additional Data

Software ID:	19010655
Software Version:	2019v5.0

- TIN:

SCHEDULE H
(Form 990)

Department of the Treasury
Internal Revenue Service

Hospitals

Complete if the organization answered "Yes" on Form 990, Part IV, question 20.
MediumBullet

Attach to Form 990.
MediumBullet

Go to www.irs.gov/Form990EZ for instructions and the latest information.

OMB No. 1545-0047

2019

Open to Public Inspection

Name of the organization

Agnesian Healthcare Inc

Employer identification number

39-0807236

Part I

Financial Assistance and Certain Other Community Benefits at Cost

Yes

Did the organization have a financial assistance policy during the tax year? If "No," skip to question 6a . . . .

Yes

If "Yes," was it a written policy? ......................

Yes

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.

Applied uniformly to all hospital facilities Applied uniformly to most hospital facilities Generally tailored to individual hospital facilities

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.

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:

Yes

100% 150% 200% Other 16500 %

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: . . . . . . . .

Yes

200% 250% 300% 350% 400% Other %

If the organization used factors other than FPG in determining eligibility, describe in Part VI the criteria used 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.

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"? . . . . . . . . . . . . .

Yes

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

Yes

If "Yes," did the organization's financial assistance expenses exceed the budgeted amount? . . . . . .

Yes

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? . . . . . . . . . . . . .

Did the organization prepare a community benefit report during the tax year? . . . . . . . . .

Yes

If "Yes," did the organization make it available to the public? . . . . . . . . . . . . .

Yes

Complete the following table using the worksheets provided in the Schedule H instructions. Do not submit these worksheets with the Schedule H.

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) . . .			1,223,547		1,223,547	0.28 %
b	Medicaid (from Worksheet 3, column a) . . . . .			44,590,433	21,247,656	23,342,777	5.41 %
c	Costs of other means-tested government programs (from Worksheet 3, column b) . .			82,057	243,564	0	0 %
d	Total Financial Assistance and Means-Tested Government Programs . . . . .	0	0	45,896,037	21,491,220	24,566,324	5.69 %
Other Benefits
e	Community health improvement services and community benefit operations (from Worksheet 4).			1,748,481	424,347	1,324,134	0.31 %
f	Health professions education (from Worksheet 5) . . .			63,180		63,180	0.01 %
g	Subsidized health services (from Worksheet 6) . . . .			216,781	35,896	180,885	0.04 %
h	Research (from Worksheet 7) .			6,980		6,980	0 %
i	Cash and in-kind contributions for community benefit (from Worksheet 8) . . . .			114,664		114,664	0.03 %
j	Total. Other Benefits . .	0	0	2,150,086	460,243	1,689,843	0.39 %
k	Total. Add lines 7d and 7j .	0	0	48,046,123	21,951,463	26,256,167	6.08 %

For Paperwork Reduction Act Notice, see the Instructions for Form 990. Cat. No. 50192T Schedule H (Form 990) 2019

Schedule H (Form 990) 2019

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					0	0 %
2	Economic development					0	0 %
3	Community support			15,169		15,169	0 %
4	Environmental improvements			686		686	0 %
5	Leadership development and training for community members					0	0 %
6	Coalition building			3,902		3,902	0 %
7	Community health improvement advocacy					0	0 %
8	Workforce development			44,790		44,790	0.01 %
9	Other					0	0 %
10	Total	0	0	64,547	0	64,547	0.01 %

Part III

Bad Debt, Medicare, & Collection Practices

Section A. Bad Debt Expense

Yes

Did the organization report bad debt expense in accordance with Healthcare Financial Management Association Statement No. 15? ..........................

Yes

Enter the amount of the organization's bad debt expense. Explain in Part VI the methodology used by the organization to estimate this amount. ......

24,059,789

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. ......

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

Enter total revenue received from Medicare (including DSH and IME).....

36,979,964

Enter Medicare allowable costs of care relating to payments on line 5.....

44,732,780

Subtract line 6 from line 5. This is the surplus (or shortfall)........

-7,752,816

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:

Cost accounting system Cost to charge ratio Other

Section C. Collection Practices

Did the organization have a written debt collection policy during the tax year? ..........

Yes

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 .........................

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) 2019

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?1Name, address, primary website address, and state license number (and if a group return, the name and EIN of the subordinate hospital organization that operates the hospital facility)					Facility reporting group
1	St Agnes Hospital 430 E Division Street Fond du lac,WI54935 https://www.agnesian.com/locations/st-agnes-hospital 120	X	X	X	A

Schedule H (Form 990) 2019

Page 4

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)

	A
Name of hospital facility or letter of facility reporting group

Line number of hospital facility, or line numbers of hospital facilities in a facility
reporting group (from Part V, Section A):

Yes

Community Health Needs Assessment

Was the hospital facility first licensed, registered, or similarly recognized by a state as a hospital facility in the current tax year or the immediately preceding tax year?........................

Was the hospital facility acquired or placed into service as a tax-exempt hospital in the current tax year or the immediately preceding tax year? If “Yes,” provide details of the acquisition in Section C...............

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 12......................

Yes

If "Yes," indicate what the CHNA report describes (check all that apply):

A definition of the community served by the hospital facility

Demographics of the community

Existing health care facilities and resources within the community that are available to respond to the health needs of the community

How data was obtained

The significant health needs of the community

Primary and chronic disease needs and other health issues of uninsured persons, low-income persons, and minority groups

The process for identifying and prioritizing community health needs and services to meet the community health needs

The process for consulting with persons representing the community’s interests

The impact of any actions taken to address the significant health needs identified in the hospital facility's prior CHNA(s)

Other (describe in Section C)

Indicate the tax year the hospital facility last conducted a CHNA: 20 18

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 Section C how the hospital facility took into account input from persons who represent the community, and identify the persons the hospital facility consulted .................

Yes

6 a

Was the hospital facility’s CHNA conducted with one or more other hospital facilities? If "Yes," list the other hospital facilities in Section C..................................

Yes

Was the hospital facility’s CHNA conducted with one or more organizations other than hospital facilities?” If “Yes,” list the other organizations in Section C. ............................

Yes

Did the hospital facility make its CHNA report widely available to the public?..............

Yes

If "Yes," indicate how the CHNA report was made widely available (check all that apply):

Hospital facility’s website (list url): https://www.agnesian.com/locations/st-agnes-hospital

Other website (list url): https://www.ssmhealth.com/about/chna

Made a paper copy available for public inspection without charge at the hospital facility

Other (describe in Section C)

Did the hospital facility adopt an implementation strategy to meet the significant community health needs
identified through its most recently conducted CHNA? If "No," skip to line 11. ..............

Yes

Indicate the tax year the hospital facility last adopted an implementation strategy: 20 18

Is the hospital facility's most recently adopted implementation strategy posted on a website?.........

Yes

If "Yes" (list url): https://www.ssmhealth.com/about/chna

If "No," is the hospital facility’s most recently adopted implementation strategy attached to this return? ......

10b

Describe in Section C how the hospital facility is addressing the significant needs identified in its most recently conducted CHNA and any such needs that are not being addressed together with the reasons why such needs are not being addressed.

12a

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)?...............................

12a

If "Yes" on line 12a, did the organization file Form 4720 to report the section 4959 excise tax?........

12b

If "Yes" on line 12b, 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) 2019

Page 5

Part VFacility Information (continued)

Financial Assistance Policy (FAP)

	A
Name of hospital facility or letter of facility reporting group

Yes

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 included free or discounted care?

Yes

If “Yes,” indicate the eligibility criteria explained in the FAP:

Federal poverty guidelines (FPG), with FPG family income limit for eligibility for free care of 165.0%
and FPG family income limit for eligibility for discounted care of 300.0%

Income level other than FPG (describe in Section C)

Asset level

Medical indigency

Insurance status

Underinsurance discount

Residency

Other (describe in Section C)

Explained the basis for calculating amounts charged to patients?.................

Yes

Explained the method for applying for financial assistance?...................

Yes

If “Yes,” indicate how the hospital facility’s FAP or FAP application form (including accompanying instructions) explained the method for applying for financial assistance (check all that apply):

Described the information the hospital facility may require an individual to provide as part of his or her application

Described the supporting documentation the hospital facility may require an individual to submit as part of his or
her application

Provided the contact information of hospital facility staff who can provide an individual with information about the
FAP and FAP application process

Provided the contact information of nonprofit organizations or government agencies that may be sources of
assistance with FAP applications

Other (describe in Section C)

Was widely publicized within the community served by the hospital facility?........

Yes

If "Yes," indicate how the hospital facility publicized the policy (check all that apply):

The FAP was widely available on a website (list url):

https://www.agnesian.com/page/financial-assistance

The FAP application form was widely available on a website (list url):

https://www.agnesian.com/page/financial-assistance

A plain language summary of the FAP was widely available on a website (list url):
https://www.agnesian.com/page/financial-assistance

The FAP was available upon request and without charge (in public locations in the hospital facility and by mail)

The FAP application form was available upon request and without charge (in public locations in the hospital facility
and by mail)

A plain language summary of the FAP was available upon request and without charge (in public locations in the
hospital facility and by mail)

Individuals were notified about the FAP by being offered a paper copy of the plain language summary of the FAP, by
receiving a conspicuous written notice about the FAP on their billing statements, and via conspicuous public displays or
other measures reasonably calculated to attract patients' attention

Notified members of the community who are most likely to require financial assistance about availability of the FAP

The FAP, FAP application form, and plain language summary of the FAP were translated into the primary language(s)
spoken by LEP populations

Other (describe in Section C)

Schedule H (Form 990) 2019

Page 6

Part VFacility Information (continued)

Billing and Collections

	A
Name of hospital facility or letter of facility reporting group

Yes

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 all of the actions the hospital facility or other authorized party may take upon nonpayment?..................................

Yes

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:

Reporting to credit agency(ies)

Selling an individual’s debt to another party

Deferring, denying, or requiring a payment before providing medically necessary care due to nonpayment of a previous
bill for care covered under the hospital facility's FAP

Actions that require a legal or judicial process

Other similar actions (describe in Section C)

None of these actions or other similar actions were permitted

Did the hospital facility or other authorized 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?............

If "Yes," check all actions in which the hospital facility or a third party engaged:

Reporting to credit agency(ies)

Selling an individual’s debt to another party

Deferring , denying, or requiring a payment before providing medically necessary care due to nonpayment of a previous
bill for care covered under the hospital facility's FAP

Actions that require a legal or judicial process

Other similar actions (describe in Section C)

Indicate which efforts the hospital facility or other authorized party made before initiating any of the actions listed (whether or not checked) in line 19. (check all that apply):

Provided a written notice about upcoming ECAs (Extraordinary Collection Action) and a plain language summary of the
FAP at least 30 days before initiating those ECAs (if not, describe in Section C)

Made a reasonable effort to orally notify individuals about the FAP and FAP application process (if not, describe in
Section C)

Processed incomplete and complete FAP applications (if not, describe in Section C)

Made presumptive eligibility determinations (if not, describe in Section C)

Other (describe in Section C)

None of these efforts were made

Policy Relating to Emergency Medical Care

Did the hospital facility have in place during the tax year a written policy relating to emergency medical care that required 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?..................

Yes

If "No," indicate why:

The hospital facility did not provide care for any emergency medical conditions

The hospital facility’s policy was not in writing

The hospital facility limited who was eligible to receive care for emergency medical conditions (describe in Section C)

Other (describe in Section C)

Schedule H (Form 990) 2019

Page 7

Part VFacility Information (continued)

Charges to Individuals Eligible for Assistance Under the FAP (FAP-Eligible Individuals)

	A
Name of hospital facility or letter of facility reporting group

Yes

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.

The hospital facility used a look-back method based on claims allowed by Medicare fee-for-service during a prior 12-month period

The hospital facility used a look-back method based on claims allowed by Medicare fee-for-service and all private health insurers that pay claims to the hospital facility during a prior 12-month period

The hospital facility used a look-back method based on claims allowed by Medicaid, either alone or in combination with
Medicare fee-for-service and all private health insurers that pay claims to the hospital facility during a prior 12-month
period

The hospital facility used a prospective Medicare or Medicaid method

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? ...............................

If "Yes," explain in Section C.

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? ...........................

If "Yes," explain in Section C.

Schedule H (Form 990) 2019

Page 8

Part V

Facility Information (continued)

Section C. Supplemental Information for Part V, Section B. Provide descriptions required for Part V, Section B, lines 2, 3j, 5, 6a, 6b, 7d, 11, 13b, 13h, 15e, 16j, 18e, 19e, 20a, 20b, 20c, 20d, 20e, 21c, 21d, 23, and 24. If applicable, provide separate descriptions for each hospital facility in a facility reporting group, designated by facility reporting group letter and hospital facility line number from Part V, Section A (“A, 1,” “A, 4,” “B, 2,” “B, 3,” etc.) and name of hospital facility.
Form and Line Reference	Explanation
Schedule H, Part V, Section B, Line 3E	THE HOSPITAL FACILITIES ANALYZED SEVERAL HEALTH NEEDS OF THE COMMUNITY AND HAVE PRIORITIZED THOSE OF MOST CONCERN. THE PRIORITIZATION OF THE TOP SIGNIFICANT COMMUNITY HEALTH NEEDS IS DESCRIBED IN THE CHNA.
Schedule H, Part V, Section B, Line 5 Facility A, 1	Facility A, 1 - St. Agnes Hospital. The hospital facility took into account input from persons who represent the broad interests of the community served through the following process: key informants in Fond du Lac County were identified by the Community Health Assessment Task Force members and interviewed by the Fond du Lac County Health Department. Interviews were completed in-person and electronically via questionnaires in February and March 2018, and interviewees were asked to rank twelve health focus areas from highest to lowest priority, with number one being the top priority health issue to address in Fond du Lac County based on the population served.
Schedule H, Part V, Section B, Line 6a Facility A, 1	Facility A, 1 - St. Agnes Hospital. Hospitals included in the CHNA were Agnesian Healthcare (St. Agnes Hospital), Waupun Memorial Hospital, and Ripon Medical Center.
Schedule H, Part V, Section B, Line 6b Facility A, 1	Facility A, 1 - St. Agnes Hospital. St. Agnes Hospital collaborated extensively with the Fond du Lac County Health Department.
Schedule H, Part V, Section B, Line 11 Facility A, 1	Facility A, 1 - St. Agnes Hospital. The hospital identified various health needs in the 2018 CHNA. In order to make meaningful impact, and to use its finances most effectively and efficiency, the hospital will place primary focus on the following key priorities: - Nutrition and physical activity - Mental health - Alcohol and other drug abuse Nutrition and physical activity The hospital has identified nutrition and physical activity as a community health priority. The hospital aims to increase the number of Fond du Lac County residents living at healthy weight for their height through eating healthier and being more active. Additionally, statistics show: - Almost 3 in 4 adults in the area classify as being overweight or obese - Only 1 in 4 adults reported eating the recommended servings of vegetables per day - About half of adults reported eating the recommended servings of fruit per day - Only 1 in 4 met the recommended amount of physical activity and strength training - For youth, 1 in 4 are overweight or obese - Less than half of youth report eating the recommended servings of fruits and vegetables - Only 1 in 5 youth meet the recommended amount of physical activity and strength training The hospital's action plan includes the following initiatives to improve nutrition and physical activity in the community served: - Improve physical activity through the following: - Increase trail usage by 10% from 1496 (2016) total bike/pedestrian counts over a weeklong period to 1646 - Implement one community-wide physical activity campaign - Increase the number of teachers in the FDL School District implementing wearable technology with students from 19 to 21 - Increase the number of schools participating in safe routes to school from 23 to 27 - Improve fruit and vegetable consumption through the following: - Increase SNAP usage at the Wednesday Downtown FDL Farmers Market by 25% from $278 (2018 YTD) to $348 - Increase SNAP usage at the Saturday Downtown FDL Farmers Market by 10% from $5,000 (2018 YTD) to $5,500 - Increase the number of food forests planted from 4 (2018) to 5 - Increase the number of pounds of produce donated at the FDL farmers market by 10% from 3,500 lbs (2018 YTD) to 3,850 lbs - Increase the health promotion programs offered to low-income housing residents from zero to 9 - Improve breastfeeding rates through the following: - Increase the number of childcare centers and business centers who have adopted the Ten Steps to Breastfeeding-Friendly Toolkit from 7 (2017) to 15 - Increase the attendance at the annual Breastfeeding Celebration from 85 (2018) to 125 Mental Health The hospital has identified mental health as a top community health priority. The facility is striving to reduce the stigma around mental health and suicide, increase access to behavioral health services at any age and for those in high-risk groups, and decrease the number of deaths by suicide. Additionally, statistics show: - About 1 in 5 Fond du Lac County residents reported a mental health condition - 5 percent of adults reported to having considered suicide in the last year - 15 percent of high school students reported to having considered suicide in the last year - The number of suicides in Fond du Lac County has nearly doubled from 2013 to 2017 The hospital's action plan includes the following initiatives to address mental health in the community served: - Decrease number of deaths by suicide through earlier identification of mental distress through the following: - Increasing number of those who live and work in Fond du Lac County who are trained as gatekeepers in Question, Persuade, Refer (QPR), Mental Health First Aid for Adults (MHFA), and Youth Mental Health First Aid (YMHFA) - Promoting use of universal and targeted screening across the lifespan in both clinical and non-clinical settings - Reduce stigma around mental health and suicide which can limit help-seeking behaviors with the following: - Education & Awareness activities: Coordinated messaging campaign (via radio, website, newspaper, etc.), including the facts related to mental health conditions, their occurrence in the general population, and the effectiveness of treatment - Promoting positive mental health and resiliency - Partner with individuals who have lived experience to share their stories and inform efforts - Increase access to behavioral health services across the lifespan, and for those in high-risk groups through the following: - Develop a Pathways to Care Mental Health Navigation Tool for Fond du Lac County adults - Develop a more universal approach to safety planning across the county, which includes creating a document with a common language and format that can be used across populations and settings Alcohol and Other Drug Abuse The hospital has identified alcohol and other drug abuse as a key priority to address within the community. The hospital facility with community groups to reduce availability of alcohol and illicit drugs, binge drinking, and to improve procedures to manage and address opioid abuse. Additionally, statistics show: - 1 in 5 adults and youth have reported binge drinking - 1 in 3 youth report very or fairly easy access to prescription medications for misuse - About 1 in 10 youth reported electronic vapor product use over a 30-day period - In 2017, there were 7 opioid overdose deaths in Fond du Lac County The hospital's action plan includes the following initiatives to improve alcohol and other drug abuse in the community served: - Reduce underage drinking and adult binge drinking through the following: - Increase the number of festivals evaluated annually throughout Fond du Lac County from 7 (2017) to 12 - Increase the number of law enforcement agencies completing annual compliance checks from 2 (2017) to 4 - Reduce misuse and abuse of drugs, particularly opioids through the following: - Increase the number Narcan kits distributed annually through community Narcan Trainings from 54 (2017) to 75 - Increase number of providers using the evidence-informed screening tool SBIRT for early intervention and referral for treatment from 0 (2017) to 4 or more The hospital has no plans to discontinue other community benefit efforts addressing additional community needs within its efforts. The following community needs were identified and will be addressed as resources allow (additional descriptions available in the 2018 CHIP): - Trauma-informed care - Social determinants of health
Schedule H, Part V, Section B, Line 11 Facility A, 2	Facility A, 2 - St. Agnes Hospital (Continued). During 2019, the following activities were performed to help address the issues identified in the CHNA: Nutrition and Physical Activity: * Fond du Lac County's Living Well Coalition. In 2019, Dr. Heather Schmidt, Nicole Wiegert, Terri St. Lawrence and Joel Mason from Agnesian Healthcare, a Member of SSM Health, were members of the Living Well Coalition. The Living Well Coalition's focus is on the Nutrition/Physical activity pillar for Healthy Fond du Lac 2020. * POWER Program. Healthy Lifestyle/weight loss program for patients preparing for surgery which incorporates healthy eating/physical activity. Dr. Schmidt sees the program participant and incorporates a dietitian from Agnesian along with a physical activity component. In the Ripon Area, the Ripon Wellness Center assists participants. * Summer of Fun program. Summer program for children living in poverty. Program was offered approximately 3 days/week. Two days/week the Fond du Lac Recreation Department and area volunteers provided outdoor physical activities for the children to participate in. Children were also provided lunch and a healthy snack/water each day. * Healthy Living with diabetes. This is a 6 week workshop designed for adults with type 2 diabetes or pre-diabetes and their caregivers. It Teaches participants skills to effectively manage diabetes or delay the onset of diabetes. Topics include healthy eating and physical activity. This program is a community collaboration. We had 3 SSM associates trained to facilitate the class. * Letter of support. Letter of support was drafted to UW-Extension Education, Agriculture and Recreation Committee all to use local trails (Wild Goose Trail) to be physically active; opposing winter ATV use on the trails. * Fruit tree donation. Donated 2 fruit trees to the community garden at Hamilton Park. * Referrals to Livestrong, Healthy Living program at YMCA. Agnesian HealthCare continues to collaborate with the YMCA to refer patients to free programs that promote healthy living, nutrition and physical activity. In 2019, Care Management referred at least 293 patients to the YMCA for the above listed programs. * Health Resource Center Programming. Offered various cooking demos and physical activity options (i.e. yoga) for our community through our health resource center in 2019. Mental Health: * Healthy Fond du Lac 2020's Mental Health Priority Team. In 2019, Dr. Matthew Doll of Agnesian Healthcare served on Healthy Fond du Lac 2020 Mental Health Priority Team. * Suicide Prevention - Yscreen. In 2019, Agnesian Healthcare rolled out the Columbia Screening tool in partnership with YScreen as part of a broad and community-wide suicide prevention program. As part of the effort, Agnesian Healthcare provided training and process improvement to the community health coalition and community partners. YScreen, a mental health screening tool for all 9th graders, was utilized throughout the county. * Suicide Prevention - Clinician Training. As part of a community-wide suicide prevention program, Agnesian Healthcare also hosted and training clinicians on motivation interviewing for potentially suicidal individuals. * Suicide Prevention - Safety Plans, Zero Suicide, QPR, TIC and ACEs. As part of a broader effort to reduce and prevent suicides in Fond du Lac County, Agnesian Healthcare piloted the Stanley Brown safety plan tool for all providers to use. Agnesian also provided training and process improvement activities for the Zero Suicide effort as well as additional training on QPR, trauma informed care (TIC) and adverse childhood experiences (ACEs). Alcohol and Other Drug Abuse: * Drug Free Communities. As part of efforts to address Healthy Fond du Lac 2020's Alcohol and Other Drug Abuse priority area, members of Agnesian Healthcare, a unit of SSM Health, participated in Fond du Lac County's Drug Free Communities program.
Schedule H, Part V, Section B, Line 13 Facility A, 1	Facility A, 1 - St. Agnes Hospital. Patients and their guarantor's income is used in determining income level for free or discounted care.
Schedule H, Part V, Section B, Line 13 Facility A, 1	Facility A, 1 - St. Agnes Hospital. Uninsured patients are automatically given a discount ranging in percentage based on the total amount due.

Schedule H (Form 990) 2019

Page 9

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?3
Name and address		Type of Facility (describe)
1	Fond du Lac Regional Clinic 420 E Division Street Fond du lac,WI54935	Outpatient physician clinic
2	Consultants Lab of Wisconsin LLC 430 E Division Street Fond du lac,WI54935	Laboratory and testing
3	Agnesian Healthcare Enterprises LLC 430 E Division Street Fond du lac,WI54935	Pharmaceuticals, home health, and medical supplies
4
5
6
7
8
9
10

Schedule H (Form 990) 2019

Page 10

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
Schedule H, Part I, Line 6a Community benefit report prepared by related organization	SSM Health Care Corporation, 46-6029223
Schedule H, Part I, Line 7 Costing Methodology used to calculate financial assistance	The amounts reported on Form 990, Schedule H, Part I, Line 7a, 7b, and 7c were determined using the cost to charge ratio derived from worksheet 2 in the schedule h instructions. Form 990, schedule h, part I, Lines 7e, 7f, 7g, 7h, and 7i are reported at cost as reported in the organization's financial statements. The calculation of Schedule H, Part I, Line 7, Column F utilizes 990, Part IX, Line 25, Column A, which does not include Bad Debt Expense.
Schedule H, Part II Community Building Activities	AGNESIAN HEALTHCARE INC PARTICIPATES IN A WIDE ARRAY OF COMMUNITY AND CIVIC ORGANIZATIONS IN THE PROMOTION OF HEALTH CARE AND COMMUNITY BUILDING ACTIVITIES. SPECIFIC ACTIVITIES REPORTED IN PART II OF SCHEDULE H INCLUDE THE FOLLOWING: COMMUNITY SUPPORT: VARIOUS COMMUNITY EDUCATIONAL EVENTS AND SUPPORT GROUPS, ENVIRONMENTAL IMPROVEMENTS: MANAGEMENT OF THE SHARPS HOME COLLECTION AND DISPOSAL PROGRAM, COALITION BUILDING: INVOLVEMENT WITH SCHOOL DISTRICTS AND BOARDS, AND PUBLIC HEALTH DEPARTMENTS TO IMPROVE COMMUNITY HEALTH MEASURES, WORKFORCE DEVELOPMENT: JOB SHADOWING, AND CLINICAL WORK EXPERIENCE PROGRAMS (IN PARTNERSHIP WITH COLLEGES AND OTHER HEALTH CARE ORGANIZATIONS).
Schedule H, Part III, Line 2 Bad debt expense - methodology used to estimate amount	THE BAD DEBT EXPENSE REPORTED ON PART III, LINE 2 IS AT CHARGES AS RECORDED IN THE ORGANIZATION'S FINANCIAL STATEMENTS. THE ALLOWANCE FOR BAD DEBT IS BASED UPON MANAGEMENT'S ASSESSMENT OF HISTORICAL AND EXPECTED NET COLLECTIONS CONSIDERING BUSINESS AND GENERAL ECONOMIC CONDITIONS IN ITS SERVICE AREA, TRENDS IN HEALTH CARE COVERAGE, AND OTHER COLLECTION INDICATORS. THE BAD DEBT ALLOWANCE IS CALCULATED AS A PERCENTAGE OF PATIENT RECEIVABLES AFTER DEDUCTIONS FOR ESTIMATED PROVISIONS FOR CONTRACTUAL ADJUSTMENTS (DISCOUNTS) ON SERVICES PROVIDED TO ENROLLEES OF MEDICARE, MEDICAID, THIRD-PARTY PAYOR PROGRAMS, CHARITY CARE, UNINSURED DISCOUNTS, AND OTHER ADMINISTRATIVE ADJUSTMENTS.
Schedule H, Part III, Line 4 Bad debt expense - financial statement footnote	Agnesian Healthcare Inc is part of the SSM Health consolidated audit. The footnote that references the treatment of uncollectible accounts and implicit price concessions in the December 31, 2019 consolidated audit is contained on page 11 and 12 of the attached financial statements.
Schedule H, Part III, Line 8 Community benefit & methodology for determining medicare costs	THE COSTING METHODOLOGY USED TO DETERMINE THE MEDICARE ALLOWABLE COST WAS BASED ON THE MEDICARE PRINCIPLES USED IN COMPLETING THE MEDICARE COST REPORT. ALL COST REPORTED CAME FROM THE MEDICARE COST REPORT. SSM HEALTH ACCEPTS ALL MEDICARE PATIENTS WITH THE KNOWLEDGE THAT THERE MAY BE SHORTFALLS AND OPERATES TO PROMOTE THE HEALTH OF THE COMMUNITY. SSM HEALTH BELIEVES THAT ANY MEDICARE SHORTFALL SHOULD BE TREATED AS A COMMUNITY BENEFIT BECAUSE MEDICARE DOES NOT FULLY COMPENSATE HOSPITALS FOR THE COST OF PROVIDING HOSPITAL CARE TO MEDICARE BENEFICIARIES, AS MEDICARE ALLOWED COST IS LESS THAN ACTUAL COST.
Schedule H, Part III, Line 9b Collection practices for patients eligible for financial assistance	ST. AGNES HOSPITAL HAS A WRITTEN DEBT COLLECTION POLICY. PAYMENT IS DUE WITHIN 30 DAYS OF RECEIPT OF A STATEMENT. IF PATIENTS DO NOT SET UP ACCEPTABLE PAYMENT ARRANGEMENTS, BILLS WILL BE REFERRED TO AN OUTSIDE COLLECTION AGENCY. FINANCIAL COUNSELORS WORK WITH ALL PATIENTS ON AN INDIVIDUAL BASIS AND MAY OFFER EXTENDED MONTHLY PAYMENTS WITHOUT INTEREST BASED ON DOLLAR AMOUNT, PRIVATE PAY DISCOUNTS (INDIVIDUALS WHO DO NOT HAVE INSURANCE COVERING EMERGENCY OR OTHER MEDICALLY NECESSARY CARE ARE BILLED AT A REDUCED RATE), OR GUARANTEED BANK LOANS. IF PATIENTS QUALIFY FOR FINANCIAL ASSISTANCE, THEIR EXPENSES ARE RECLASSIFIED AS CHARITY CARE. PATIENTS WHO RECEIVED A COLLECTION NOTICE COULD APPLY FOR CHARITY CARE. IF THEIR APPLICATION IS APPROVED, THIS WOULD TRIGGER A TRANSFER OF EXPENSES FROM BAD DEBT TO CHARITY CARE.
Schedule H, Part V, Section B, Line 16a FAP website	A - St. Agnes Hospital: Line 16a URL: https://www.agnesian.com/page/financial-assistance;
Schedule H, Part V, Section B, Line 16b FAP Application website	A - St. Agnes Hospital: Line 16b URL: https://www.agnesian.com/page/financial-assistance;
Schedule H, Part V, Section B, Line 16c FAP plain language summary website	A - St. Agnes Hospital: Line 16c URL: https://www.agnesian.com/page/financial-assistance;
Schedule H, Part VI, Line 2 Needs assessment	SSM Health (SSMH) participates in Community Benefit according to our vision. Through our participation in the healing ministry of Jesus Christ, communities, especially those that are economically, physically, and socially marginalized, will experience improved health in mind, body, spirit and environment. In the tradition of our founders, the Franciscan Sisters of Mary, caring for those in greatest need remains our organizational priority. Today our System Board monitors Community Benefit efforts, and views achievement of our vision as a primary responsibility. The purpose of SSM's Community Benefit program is to assess and address community health needs. Making our communities healthier in measurable ways is always our goal. To fulfill this commitment, SSM's Community Benefit is divided into two parts: 1) Community Health Needs Assessment (CHNA), and 2) Community Benefit Inventory for Social Accountability (CBISA). The CHNA is an assessment and prioritization of community health needs and the adoption and implementation of strategies to address those needs. A CHNA is conducted every three years by each hospital according to the following steps: * Assess and prioritize community health needs: Gather CHNA data from secondary sources; obtain input from stakeholders representing the broad interests of the community through interviews and focus groups; use data to select top health priorities; and complete written CHNA. * Develop, adopt, and implement strategies to address top-health priorities: Establish strategies to address priorities; complete Strategic Implementation Plan; obtain Regional/Divisional Board approval; and integrate strategies into operational plan. * Make CHNA widely available to the public: Publish CHNA and summary document on hospital's website. * Monitor, track, and report progress on top health priorities: Collect data and evaluate progress; report to Regional/Divisional Board every six months and System Board every year; share findings with community stakeholders; and send results to finance for submission to the Internal Revenue Service (IRS). System Office staff and leaders oversee and monitor SSMH's Community Benefit Program, and ensure reporting is in compliance with IRS regulations. In collaboration with community stakeholders and partner organizations, SSM Health Care Corporation also identifies needs based on assessments and research, and SSMH facilities also involve case managers and care team staff to pinpoint critical health issues in the community. All hospital CHNAs are completed, approved, and integrated into the organization's strategic plan. We continue to monitor and assess the progress of our local efforts in the spirit of caring for others and improving community health.
Schedule H, Part VI, Line 3 Patient education of eligibility for assistance	Each entity providing medical service shall provide information to the public regarding its charity care policies and the qualification requirements for each of its facilities. When standard system notices and communication regarding charity care are available, these must be used. Modifications to the standard may be made to comply with state and local laws, as well as reflect culturally sensitive terminology for the policy. All notices are easy to understand by the general public, culturally appropriate and available in those languages that are prevalent in the community. They provide 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 * Who to contact to get additional information or financial counseling. The following types of notices to the public are 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. The application for charity care, together with any instructions, must 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.
Schedule H, Part VI, Line 4 Community information	St. Agnes Hospital is located in Fond du Lac, Wisconsin, and defines its primary service area as Fond du Lac County, Wisconsin. In 2015, the population of the county was estimated at 102,793 adults. Approximately 17.5% of the population is age 65 or older, and 21.9% have obtained a Bachelor's degree or higher. Over one-third of the population lives in a rural area. The area of Fond du Lac County has a poverty rate of 7.7%, significantly lower than the state of Wisconsin and U.S. as a whole. Median household incomes for the county are also slightly above state and national amounts. Additional demographic and statistical data on Fond du Lac County's residents and their health can be found beginning on page 94 of the 2018 CHNA.
Schedule H, Part VI, Line 5 Promotion of community health	Agnesian Healthcare Inc participates in a wide array of community programs throughout the area to further its exempt purpose of promoting the health of the community. The community initiatives build on the strengths of our communities and systems to improve the quality of life and to create a sense of hope. Community Benefit 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, Agnesian Healthcare Inc's 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 Community Benefit strategies. Agnesian Healthcare Inc promotes grassroots advocacy and engages persons of influence to affect social and public policy change in order to promote community health. Agnesian Healthcare Inc also furthers its exempt purpose with the following activities: * 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, * Engages in the training and education of health care professionals, * Participates in Medicaid, Medicare, Champus, Tricare, and/or other government-sponsored health care programs * All surplus funds generated by SSMH entities are reinvested in improving our patient care delivery system.
Schedule H, Part VI, Line 6 Affiliated health care system	Agnesian Healthcare Inc is a 501(c)(3) organization and is a member of the integrated health care system know as SSM Health.
Schedule H, Part VI, Line 7 State filing of community benefit report	WI

Schedule H (Form 990) 2019

Additional Data

Software ID:	19010655
Software Version:	2019v5.0

- TIN:

Note: To capture the full content of this document, please select landscape mode (11" x 8.5") when printing.

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," on Form 990, Part IV, line 21 or 22.
lBullet

Attach to Form 990.
lBullet

Go to www.irs.gov/Form990 for the latest information.

OMB No. 1545-0047

2019

Open to Public
Inspection

Name of the organization
Agnesian Healthcare Inc

Employer identification number
39-0807236

Part I

General Information on Grants and Assistance

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? ........................

Yes No

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 Domestic Organizations and Domestic Governments. Complete if the organization answered "Yes" on 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 section (if applicable)	(d) Amount of cash grant	(h) Purpose of grant or assistance
(1) Arc of Fond du Lac 500 N Park Avenue Fond du Lac,WI54935	39-1034161	501(c)(3)	50,000	General support
(2) Moraine Park Technical College 235 N National Ave Fond du Lac,WI54936	39-1088212	Government	50,000	General support
(3) Marian University 45 South National Avenue Fond du Lac,WI54935	39-1024723	501(c)(3)	62,500	General support
(4) Ripon Area School District 1120 Metomen Street Ripon,WI54971	39-6004200	Government	8,903	General support
(5) Boys & Girls Club of FDL 76 W 2nd Street Fond du Lac,WI54935	39-1896496	501(c)(3)	60,000	General support
(6) ASTOP Inc 21 S Marr St Fond du Lac,WI54935	39-1707358	501(c)(3)	22,000	General support
(7) Envision Greater FDL Inc 23 S Main Street No 101 Fond du Lac,WI54935	39-0284470	501(c)(6)	80,000	General support
(8) Fond du Lac County Health Department 160 S Macy St Fond du Lac,WI54935	39-6005696	Government	100,000	General support
(9) Children's Museum of FDL 75 West Scott St Fond du Lac,WI54935	56-2471187	501(c)(3)	11,000	General support
(10) Fond du Lac Soccer Association PO Box 1292 Fond du Lac,WI54935	39-1369383	501(c)(3)	30,000	General support
(11) Solutions Center 39 N Sophia Street Fond du Lac,WI54935	39-1452956	501(c)(3)	15,000	General support
(12) Fond du Lac Area YMCA 90 W Second St Fond du Lac,WI54935	39-0806436	501(c)(3)	15,000	General support
(13) Fond du Lac Food Pantry 573 W Rolling Meadows Dr Fond du Lac,WI54936	51-0156435	501(c)(3)	26,800	General support

Enter total number of section 501(c)(3) and government organizations listed in the line 1 table ................. Bullet Image

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) 2019

Page 2

Part III

Grants and Other Assistance to Domestic Individuals. Complete if the organization answered "Yes" on 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 noncash assistance	(e) Method of valuation (book, FMV, appraisal, other)	(f) Description of noncash assistance

(1)
(2)
(3)
(4)
(5)
(6)
(7)

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

Schedule I, Part I, Line 2 Procedures for monitoring use of grant funds.

THE PROCEDURES USED TO MONITOR THE USE OF GRANT FUNDING VARIES BASED ON THE GRANT RECIPIENT. GRANTS TO RELATED ENTITIES ARE MONITORED DIRECTLY BY THE ORGANIZATION WHEREBY THE RECIPIENT REPORTS ON THE SPECIFIC USE OF THE FUNDING. FOR GRANTS TO UNRELATED ENTITIES, THE ORGANIZATION UTILIZES THE COMMUNITY BENEFIT INVENTORY FOR SOCIAL ACCOUNTABILITY (CBISA) TO TRACK, STORE AND REPORT A WIDE RANGE OF INFORMATION RELATED TO GRANTS AND OVERALL COMMUNITY IMPACT.

Schedule I (Form 990) 2019

Additional Data

Software ID:	19010655
Software Version:	2019v5.0

- TIN:

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" on Form 990, Part IV, line 23.
SchJMediumBullet

Attach to Form 990.
SchJMediumBullet

Go to www.irs.gov/Form990 for instructions and the latest information.

OMB No. 1545-0047

2019

Open to Public Inspection

Name of the organization

Agnesian Healthcare Inc

Employer identification number

39-0807236

Part I

Questions Regarding Compensation

Yes

Check the appropiate box(es) if the organization provided any of the following to or for a person listed on Form
990, Part VII, Section A, line 1a. Complete Part III to provide any relevant information regarding these items.

First-class or charter travel Housing allowance or residence for personal use

Travel for companions Payments for business use of personal residence

Tax idemnification and gross-up payments Health or social club dues or initiation fees

Discretionary spending account Personal services (e.g., maid, chauffeur, chef)

If any of the boxes on 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 .........

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 on Line 1a? ..

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.

Compensation committee Written employment contract

Independent compensation consultant Compensation survey or study

Form 990 of other organizations Approval by the board or compensation committee

During the year, did any person listed on Form 990, Part VII, Section A, line 1a, with respect to the filing organization or a related organization:

Receive a severance payment or change-of-control payment? .............

Yes

Participate in, or receive payment from, a supplemental nonqualified retirement plan? .........

Yes

Participate in, or receive payment from, an equity-based compensation arrangement? .........

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), 501(c)(4), and 501(c)(29) organizations must complete lines 5-9.

For persons listed on Form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the revenues of:

The organization? ....................

Any related organization? .......................

If "Yes," on line 5a or 5b, describe in Part III.

For persons listed on Form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the net earnings of:

The organization? ..................

Any related organization? ......................

If "Yes," on line 6a or 6b, describe in Part III.

For persons listed on Form 990, Part VII, Section A, line 1a, did the organization provide any nonfixed
payments not described in lines 5 and 6? If "Yes," describe in Part III ............

Were any amounts reported on 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 ..........................

If "Yes" on line 8, did the organization also follow the rebuttable presumption procedure described in Regulations section 53.4958-6(c)? .........................

For Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 50053T

Schedule J (Form 990) 2019

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 on 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 in column (B) reported as deferred on prior Form 990
(A) Name and Title		(i) Base compensation	(ii) Bonus & incentive compensation	(iii) Other reportable compensation	(C) Retirement and other deferred compensation	(D) Nontaxable benefits	(E) Total of columns (B)(i)-(D)
1Paula Friedman Pt Yr Director/Vice President, Pt Yr Senior VP-Strategic Development SSM Health	(i) (ii)	0 ------------- 270,134	0 ------------- 189,852	0 ------------- 924,934	0 ------------- 278,843	0 ------------- 3,736	0 ------------- 1,667,500	0 ------------- 618,871
2Steven Little Pt Yr Director, Pt Yr Regional Chief Operating Officer, Wisconsin	(i) (ii)	0 ------------- 119,395	0 ------------- 274,864	0 ------------- 1,001,341	0 ------------- 5,133	0 ------------- 4,379	0 ------------- 1,405,111	0 ------------- 112,832
3Mark Thompson Director, Regional Chief Medical Officer	(i) (ii)	0 ------------- 494,318	0 ------------- 76,618	0 ------------- 4,259	0 ------------- 188,808	0 ------------- 30,763	0 ------------- 794,765	0 ------------- 76,618
4Kris Zimmer Treasurer, Chief Financial Officer at SSM Health	(i) (ii)	0 ------------- 887,868	0 ------------- 230,489	0 ------------- 247,277	0 ------------- 797,538	0 ------------- 16,082	0 ------------- 2,179,255	0 ------------- 340,596
5Doug Long Secretary, General Counsel at SSM Health	(i) (ii)	0 ------------- 149,400	0 ------------- 0	0 ------------- 80,150	0 ------------- 469,438	0 ------------- 2,548	0 ------------- 701,536	0 ------------- 0
6Katherine Vergos President - St. Agnes Hospital	(i) (ii)	359,780 ------------- 0	99,450 ------------- 0	6,206 ------------- 0	125,305 ------------- 0	2,830 ------------- 0	593,571 ------------- 0	0 ------------- 0
7Nancy Birschbach Former Key Employee	(i) (ii)	0 ------------- 282,526	0 ------------- 72,043	0 ------------- 1,472	0 ------------- 93,377	0 ------------- 25,098	0 ------------- 474,515	0 ------------- 22,043
8Bonnie Schmitz Former Key Employee	(i) (ii)	9,272 ------------- 0	130,715 ------------- 0	464,567 ------------- 0	269 ------------- 0	0 ------------- 0	604,824 ------------- 0	0 ------------- 0
9James Mugan Sr VP - Medical Group and Medical Affairs	(i) (ii)	301,869 ------------- 0	21,157 ------------- 0	16,054 ------------- 0	23,625 ------------- 0	31,035 ------------- 0	393,740 ------------- 0	0 ------------- 0
10Barbara Knutzen President - AHE, CLW and Performance	(i) (ii)	132,400 ------------- 0	17,551 ------------- 0	39,695 ------------- 0	16,496 ------------- 0	15,137 ------------- 0	221,279 ------------- 0	0 ------------- 0
11Michael Degere VP - Population Health Management	(i) (ii)	331,658 ------------- 0	23,331 ------------- 0	7,750 ------------- 0	23,625 ------------- 0	39,400 ------------- 0	425,764 ------------- 0	0 ------------- 0
12Michael Drees COO - Fond du Lac Regional Clinic	(i) (ii)	266,880 ------------- 0	18,912 ------------- 0	19,023 ------------- 0	22,773 ------------- 0	37,979 ------------- 0	365,567 ------------- 0	0 ------------- 0
13Yasir Hatahet Intensivist/Pulmonologist	(i) (ii)	493,094 ------------- 0	36,508 ------------- 0	22,772 ------------- 0	20,001 ------------- 0	38,670 ------------- 0	611,046 ------------- 0	0 ------------- 0
14Michael Vander Kooy Radiation Oncologist	(i) (ii)	655,404 ------------- 0	0 ------------- 0	52,068 ------------- 0	23,625 ------------- 0	38,132 ------------- 0	769,229 ------------- 0	0 ------------- 0
15John Choi Physician	(i) (ii)	531,286 ------------- 0	151,181 ------------- 0	3,604 ------------- 0	23,625 ------------- 0	28,663 ------------- 0	738,359 ------------- 0	0 ------------- 0
16Steven Flurry Anesthesiologist	(i) (ii)	627,105 ------------- 0	0 ------------- 0	44,328 ------------- 0	23,625 ------------- 0	29,447 ------------- 0	724,505 ------------- 0	0 ------------- 0
17Jacob Waidelich Physician	(i) (ii)	563,714 ------------- 0	0 ------------- 0	1,750 ------------- 0	0 ------------- 0	11,388 ------------- 0	576,852 ------------- 0	0 ------------- 0

Schedule J (Form 990) 2019

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

Schedule J, Part I, Line 4a Severance or change-of-control payment

SSM Health 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 SSMH. The following individuals listed in Part VII of the Form 990 received payments under the plan in the current year: Steven Little $928,541 Paula Friedman $470,555 Bonnie Schmitz $401,794

Schedule J, Part I, Line 4b Supplemental nonqualified retirement plan

Pension Restoration Plan: SSM Health (SSMH) provides this supplemental defined benefit nonqualified retirement plan to any employee who is a participant in the SSMH 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 the SSMH 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 SSMH or (2) age 55 or older if the individual is no longer employed by SSMH. No individuals listed on Part VII of Form 990 received distributions from the plan in 2019. Capital Accumulation Plan: SSMH 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 SSMH 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 2014 or after, the distribution will occur after the completion of four 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 DEFERRALS FROM THIS PLAN IN 2019: Mark Thompson $38,000 Kris Zimmer $105,240 Katherine Vergos $28,428 Nancy Birschbach $22,550 The following individuals listed on Part VII of the Form 990 received distributions from this plan in 2019. All distributions received from the plan in the current year were included in the individual's taxable compensation. Steven Little $56,667 Paula Friedman $429,019 Kris Zimmer $111,962 During 2019, the following individuals participated in a nonqualified retirement plan from the organization or a related organization. The amounts reported below represent the change in accrued benefit for each individual and also include amounts accrued under the pension restoration plan: Paula Friedman $9,691 Kris Zimmer $66,609

Schedule J (Form 990) 2019

Additional Data

Software ID:	19010655
Software Version:	2019v5.0

- TIN:

Note: To capture the full content of this document, please select landscape mode (11" x 8.5") when printing.

Schedule K
(Form 990)

Department of the Treasury
Internal Revenue Service

Supplemental Information on Tax-Exempt Bonds

Complete if the organization answered "Yes" to Form 990, Part Ⅵ, line 24a. Provide descriptions,
explanations, and any additional information in Part Ⅵ.
SchKMediumBullet

Attach to Form 990.
SchKMediumBullet

Go to www.irs.gov/Form990 for instructions and the latest information.

OMB No. 1545-0047

2019

Open to Public
Inspection

Name of the organization
Agnesian Healthcare Inc

Employer identification number
39-0807236

Part Ⅰ

Bond Issues

(a) Issuer name		(b) Issuer EIN	(c) CUSIP #	(d) Date issued	(e) Issue price	(f) Description of purpose	(g) Defeased		(h) On behalf of issuer		(i) Pool financing
(a) Issuer name		(b) Issuer EIN	(c) CUSIP #	(d) Date issued	(e) Issue price	(f) Description of purpose	Yes	No	Yes	No	Yes	No
A	Wisconsin Health and Educational Facilities Authority	39-1337855	97712DXT8	08-10-2017	62,792,652	Finance capital improvements and refund 2010 and 2012 bonds		X		X		X

Part Ⅱ

Proceeds

	A		B		C		D
	1 Amount of bonds retired ..................	1,320,000
2 Amount of bonds legally defeased ..............
3 Total proceeds of issue ..................	63,093,975
4 Gross proceeds in reserve funds .............
5 Capitalized interest from proceeds .............
6 Proceeds in refunding escrows ...............	24,742,759
7 Issuance costs from proceeds ...............	656,999
8 Credit enhancement from proceeds .............
9 Working capital expenditures from proceeds .............
10 Capital expenditures from proceeds .............	23,199,248
11 Other spent proceeds .............	14,541,303
12 Other unspent proceeds .............	102,004
13 Year of substantial completion .............
	Yes	No	Yes	No	Yes	No	Yes	No
14 Were the bonds issued as part of a current refunding issue of tax-exempt bonds (or, if issued prior to 2018, a current refunding issue)? ........	X
15 Were the bonds issued as part of an advance refunding issue of taxable bonds (or, if issued prior to 2018, an advance refunding issue)? ........	X
16 Has the final allocation of proceeds been made? ..........		X
17 Does the organization maintain adequate books and records to support the final allocation of proceeds? ..................	X

Part Ⅲ

Private Business Use

	A		B		C		D
	Yes	No	Yes	No	Yes	No	Yes	No
1 Was the organization a partner in a partnership, or a member of an LLC, which owned property financed by tax-exempt bonds? .............		X
2 Are there any lease arrangements that may result in private business use of bond-financed property? ...............		X

For Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 50193E

Schedule K (Form 990) 2019

Page 2

Part Ⅲ

Private Business Use (Continued)

	A		B		C		D
	Yes	No	Yes	No	Yes	No	Yes	No
3a Are there any management or service contracts that may result in private business use of bond-financed property? .............		X
b If "Yes" to line 3a, does the organization routinely engage bond counsel or other outside counsel to review any management or service contracts relating to the financed property?
c Are there any research agreements that may result in private business use of bond-financed property? .............		X
d If "Yes" to line 3c, does the organization routinely engage bond counsel or other outside counsel to review any research agreements relating to the financed property?
4 Enter the percentage of financed property used in a private business use by entities other than a section 501(c)(3) organization or a state or local government ....	0 %
5 Enter the percentage of financed property used in a private business use as a result of unrelated trade or business activity carried on by your organization, another section 501(c)(3) organization, or a state or local government .........	0 %
6 Total of lines 4 and 5 .............	0 %
7 Does the bond issue meet the private security or payment test? ...		X
8a Has there been a sale or disposition of any of the bond-financed property to a nongovernmental person other than a 501(c)(3) organization since the bonds were issued?.............		X
b If "Yes" to line 8a, enter the percentage of bond-financed property sold or disposed of. ..
c If "Yes" to line 8a, was any remedial action taken pursuant to Regulations sections 1.141-12 and 1.145-2? .............
9 Has the organization established written procedures to ensure that all nonqualified bonds of the issue are remediated in accordance with the requirements under Regulations sections 1.141-12 and 1.145-2? ........	X

Part Ⅳ

Arbitrage

	A		B		C		D
	Yes	No	Yes	No	Yes	No	Yes	No
1 Has the issuer filed Form 8038-T, Arbitrage Rebate, Yield Reduction and Penalty in Lieu of Arbitrage Rebate? ...		X
2 If "No" to line 1, did the following apply? ....
a Rebate not due yet? .......	X
b Exception to rebate? ........
c No rebate due? .........
If "Yes" to line 2c, provide in Part Ⅵ the date the rebate computation was performed ......
3 Is the bond issue a variable rate issue? .....		X
4a Has the organization or the governmental issuer entered into a qualified hedge with respect to the bond issue?		X
b Name of provider ..........
c Term of hedge .........
d Was the hedge superintegrated? ......
e Was the hedge terminated? ........

Schedule K (Form 990) 2019

Page 3

Part Ⅳ

Arbitrage (Continued)

	A		B		C		D
	Yes	No	Yes	No	Yes	No	Yes	No
5a Were gross proceeds invested in a guaranteed investment contract (GIC)?		X
b Name of provider ..........
c Term of GIC .........
d Was the regulatory safe harbor for establishing the fair market value of the GIC satisfied? ........
6 Were any gross proceeds invested beyond an available temporary period?	X
7 Has the organization established written procedures to monitor the requirements of section 148? ...	X

Part Ⅴ

Procedures To Undertake Corrective Action

---------------------------------------------------------------------------------------------------------------	A		B		C		D
	Yes	No	Yes	No	Yes	No	Yes	No
Has the organization established written procedures to ensure that violations of federal tax requirements are timely identified and corrected through the voluntary closing agreement program if self-remediation is not available under applicable regulations?	X

Part Ⅵ

Supplemental Information. Provide additional information for responses to questions on Schedule K. (See instructions).

Return Reference	Explanation

Schedule K (Form 990) 2019

Additional Data

Software ID:	19010655
Software Version:	2019v5.0

- TIN:

Schedule L
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service

Transactions with Interested Persons

Complete if the organization answered "Yes" on Form 990, Part IV, lines 25a, 25b, 26, 27, 28a, 28b, or 28c, or Form 990-EZ, Part V, line 38a or 40b.
MediumBullet

Attach to Form 990 or Form 990-EZ.
MediumBullet

Go to www.irs.gov/Form990 for instructions and the latest information.

OMB No. 1545-0047

2019

Open to Public Inspection

Name of the organization

Agnesian Healthcare Inc

Employer identification number

39-0807236

Part I

Excess Benefit Transactions (section 501(c)(3), section 501(c)(4), and section 501(c)(29) organizations only).
Complete if the organization answered "Yes" on Form 990, Part IV, line 25a or 25b, or Form 990-EZ, Part V, line 40b.

1(a) Name of disqualified person	(c) Description of transaction	(d) Corrected?
1(a) Name of disqualified person	(c) Description of transaction	Yes	No

Enter the amount of tax incurred by the organization managers or disqualified persons during the year under section 4958. ........................... Bullet Image

Enter the amount of tax, if any, on line 2, above, reimbursed by the organization ........ Bullet Image

Part II

Loans to and/or From Interested Persons.
Complete if the organization answered "Yes" on Form 990-EZ, Part V, line 38a, or Form 990, Part IV, line 26; or if the organization reported an amount on Form 990, Part X, line 5, 6, or 22

(a) Name of interested person	(b) Relationship with organization	(c) Purpose of loan	(d) Loan to or from the organization?		(e) Original principal amount	(f) Balance due	(g) In default?		(h) Approved by board or committee?		(i) Written agreement?
(a) Name of interested person	(b) Relationship with organization	(c) Purpose of loan	To	From	(e) Original principal amount	(f) Balance due	Yes	No	Yes	No	Yes	No






Total ............... $

Part III

Grants or Assistance Benefiting Interested Persons.
Complete if the organization answered "Yes" on Form 990, Part IV, line 27.

(a) Name of interested person	(b) Relationship between interested person and the organization	(c) Amount of assistance	(d) Type of assistance	(e) Purpose of assistance

For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.

Cat. No. 50056A

Schedule L (Form 990 or 990-EZ) 2019

Page 2

Part IV

Business Transactions Involving Interested Persons.
Complete if the organization answered "Yes" on Form 990, Part IV, line 28a, 28b, or 28c.

(a) Name of interested person	(b) Relationship between interested person and the organization	(c) Amount of transaction	(d) Description of transaction	(e) Sharing of organization's revenues?
(a) Name of interested person		(c) Amount of transaction	(d) Description of transaction	Yes	No
(1) CD Smith Construction	WAYNE E MATZKE, DIRECTOR/OFFICER, IS ON BOARD OF DIRECTORS OF INTERESTED PERSON	5,272,351	Construction services		No
(2) FOND DU LAC REGIONAL CLINIC SC	DIRECTORS ARE EMPLOYEE-OWNERS OF INTERESTED PERSON	52,613,459	Physician services		No
(3) HOLIDAY AUTO	ENTITY OWNED BY THOR H GILBERTSON, DIRECTOR/OFFICER	64,423	SALES AND SERVICE TO VEHICLES		No
(4) Cynthia Schneider	FAMILY MEMBER OF THOMAS SCHNEIDER, DIRECTOR	29,632	EMPLOYMENT		No

Part V

Supplemental Information
Provide additional information for responses to questions on Schedule L (see instructions).

Return Reference	Explanation
Schedule L, Part IV, Column (b) FOND DU LAC REGIONAL CLINIC SC OWNERS	THE FOLLOWING DIRECTORS LISTED ON FORM 990, PART VII, ARE EMPLOYEE-OWNERS OF THE FOND DU LAC REGIONAL CLINIC: DR DOUG FOWNES, DR JEFFERY STRONG, DR TONI STANLEY, AND DR TED MILLER.

Schedule L (Form 990 or 990-EZ) 2019

Additional Data

Software ID:	19010655
Software Version:	2019v5.0

- TIN:

SCHEDULE O
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service

Supplemental Information to Form 990 or 990-EZ

Complete to provide information for responses to specific questions on
Form 990 or 990-EZ or to provide any additional information.
MediumBullet

Attach to Form 990 or 990-EZ.
MediumBullet

Go to www.irs.gov/Form990 for the latest information.

OMB No. 1545-0047

2019

Open to Public
Inspection

Name of the organization

Agnesian Healthcare Inc

Employer identification number

39-0807236

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 (SSMH) has existed to meet the health needs of the communities it serves. SSMH is a Catholic, not-for-profit health system serving the comprehensive health needs of communities across the Midwest through one of the largest integrated delivery systems in the nation. With care delivery sites in Illinois, Missouri, Oklahoma, and Wisconsin, SSMH includes 23 acute care hospitals, one children's hospital, more than 300 physician offices and other outpatient and virtual care services, 10 post-acute facilities, comprehensive home care and hospice services, a pharmacy benefit company, a health insurance company, and an Accountable Care Organization. The health system employs nearly 40,000 people and is affiliated with 11,000 physicians making it one of the largest employers in every community it serves. In the tradition of its founding sisters, SSMH strives to fulfill its mission by providing exceptional health care to everyone who comes to its hospitals, regardless of their ability to pay. About Agnesian Healthcare Inc: Agnesian Healthcare Inc, operating as St. Agnes Hospital, has been providing healing care for almost 125 years. The hospital has grown into both an inpatient and outpatient facility providing innovative community and regional healthcare services to the greater Fond du Lac area. As a nonprofit Catholic institution, St. Agnes Hospital serves people of all faiths and beliefs. It is a leader in providing quality state-of-the-art healthcare services, whether it is cancer treatment; comprehensive heart care through the Dale Michels Center for Heart Care, including angioplasty and open-heart surgery; home or hospice care; maternity services; laser surgery; sports medicine; behavioral health services; women's health services; occupational health services; rehabilitation services and 24-hour emergency care. In 2018, St. Agnes Hospital received the American Heart Association's Get With The Guidelines - Heart Failure Silver Plus Quality Achievement Award. The award recognizes the hospital's commitment to ensuring heart failure patients receive the most appropriate treatment according to nationally recognized, research-based guidelines founded in the latest scientific evidence. St. Agnes Hospital earned the award by meeting specific quality achievement measures for the diagnosis and treatment of heart failure patients at a set level for a designated period. St. Agnes also earned The Joint Commission's Gold Seal of Approval and the American Heart Association/American Stroke Association's Heart-Check mark for advanced certification and quality for primary stroke centers. The hospital was also one of the 250 recipients of Healthgrades' 2018 Distinguished Hospital Award for Clinical Excellence. Agnesian Healthcare Inc also furthers its exempt purpose with the following activities: * 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 * Engages in the training and education of health care professionals, * Participates in Medicaid, Medicare, Champus, Tricare, and/or other government-sponsored health care programs * All surplus funds generated by SSMH entities are reinvested in improving our patient care delivery system Quantifiable Uncompensated Care: This section includes a list of the types of programs and services that could be quantified as uncompensated care: Traditional Charity Care $ 1,223,547 Unpaid Cost of Medicaid $ 23,342,777 Unpaid Cost of Medicare $ 7,752,816 Total Quantifiable Uncompensated Care $ 32,319,140
Form 990, Part VI, Line 2 Family/business relationships amongst interested persons	DR DOUG FOWNES, DR JEFFERY STRONG, DR TONI STANLEY, AND DR TED MILLER - Business relationship
Form 990, Part VI, Line 6 Classes of members or stockholders	The sole member of the corporation is SSM Health Care of Wisconsin, Inc. SSM Health Care of Wisconsin, Inc, is a nonprofit 501(C)(3) organization. Both Agnesian Healthcare Inc and SSM Health Care of Wisconsin, Inc. are part of the integrated health care system known as SSM Health.
Form 990, Part VI, Line 7a Members or stockholders electing members of governing body	The member has the power to appoint additional, successor or replacement members and to appoint and remove the appointed directors and the ex officio directors.
Form 990, Part VI, Line 7b Decisions requiring approval by members or stockholders	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 appoint and remove the Directors; D. to appoint and remove the President of the Corporation and 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 SSMHCC or to any other entity exempt from federal income tax as an organization described in §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 SSMHCC, to the extent necessary to accomplish the mission, goals and objectives of SSMHCC as determined by SSMHCC; Q. to approve the transfer of assets by the Corporation to any entity other than SSMHCC, other than transfers made in the ordinary course of operations of the Corporation which will not require 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 SSMHCC 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, Line 11b Review of form 990 by governing body	The Form 990 is prepared by the Tax Department of the parent organization, SSM Health Care Corporation (SSM). The Form 990 is reviewed by certain members of Senior Management. Any questions are addressed to the Tax Director of SSM prior to filing the Form 990 with the Internal Revenue Service. A copy of the Form 990 is provided to the Board of Directors at the next regularly scheduled board meeting.
Form 990, Part VI, Line 12c Conflict of interest policy	A written conflict of interest and insider transaction policy exists which requires each director, principal officer, trustee or committee member to disclose on a annual basis to the designated authority a conflict of interest disclosure statement. The designated authority ensures that all statements are completed, reviews them for conflicts, and submits to the board for review any conflict of interest disclosure statements that disclose actual or potential conflicts.
Form 990, Part VI, Line 15a Process to establish compensation of top management official	Determination of compensation of the CEO and officers includes analysis of comparable compensation to the board of directors. The board of directors, who are independent, review and approve the compensation package for officers, and contemporaneous substantiation of the deliberation and decision is included in the board minutes. The final agreement is documented with a written contract, which is signed by both parties.
Form 990, Part VI, Line 15b Process to establish compensation of other employees	An annual survey is performed by an outside company.
Form 990, Part VI, Line 19 Required documents available to the public	The year-end audited consolidated financial statements and unaudited quarterly consolidated financial statements for the SSM Health System are made available to the public on SSM Health's website. The organization's Articles of Incorporation are available on the Wisconsin Secretary of State's website. Copies of the Form 990 and the conflict of interest policy are available to the public upon request.
Form 990, Part IX, Line 11g Other Fees	Medical and other professional fees - Total Expense: 79500630, Program Service Expense: 37913012, Management and General Expenses: 41586822, Fundraising Expenses: 796;
Form 990, Part XI, Line 9 Other changes in net assets or fund balances	Change in beneficial interest in foundation - 3031277; Fund balance transfers - -8427758;

For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.

Cat. No. 51056K

Schedule O (Form 990 or 990-EZ) 2019

Additional Data

Software ID:	19010655
Software Version:	2019v5.0

- TIN:

SCHEDULE R
(Form 990)

Department of the Treasury
Internal Revenue Service

Related Organizations and Unrelated Partnerships

Complete if the organization answered "Yes" on Form 990, Part IV, line 33, 34, 35b, 36, or 37.
MediumBullet

Attach to Form 990.
MediumBullet

Go to www.irs.gov/Form990 for instructions and the latest information.

OMB No. 1545-0047

2019

Open to Public Inspection

Name of the organization

Agnesian Healthcare Inc

Employer identification number

39-0807236

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
(1) Consultants Laboratory of Wisconsin LLC 430 E Division Street Fond du lac,WI54935 39-1528550	Lab services	WI	28,858,377	14,651,523	Agnesian Healthcare Inc
(2) Agnesian Healthcare Enterprises LLC 430 E Division Street Fond du lac,WI54935 39-2038757	Retail pharmacy	WI	9,568,369	7,751,222	Agnesian Healthcare Inc

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?
(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	Yes	No
(1)SSM Health Care Corporation 10101 Woodfield Lane St Louis,MO63132 46-6029223	Health Care	MO	501(c)(3)	Type I	SSM Health Ministries		No
(2)SSMHC Liability Trust I 10101 Woodfield Lane St Louis,MO63132 43-6331003	Insurance	MO	501(c)(3)	Type 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)	10	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)	Type 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)	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)	7	SSM Cardinal Glennon Children's Hospital		No
(8)SSM Health Foundation - St Louis 10101 Woodfield Lane St Louis,MO63132 43-1552945	Fundraising	MO	501(c)(3)	7	SSM Health Care St Louis		No
(9)SSM Health Care of Oklahoma Inc 10101 Woodfield Lane St Louis,MO63132 73-0657693	Health Care	OK	501(c)(3)	3	SSM Health Care Corporation		No
(10)The St Anthony Hospital Foundation Inc 10101 Woodfield Lane St Louis,MO63132 73-6104300	Fundraising	OK	501(c)(3)	7	SSM Health Care of Oklahoma		No
(11)SSM Health Care of Wisconsin Inc 10101 Woodfield Lane St Louis,MO63132 43-0688874	Health Care	WI	501(c)(3)	3	SSM Health Care Corporation		No
(12)Dells Medical Building Inc 10101 Woodfield Lane St Louis,MO63132 39-1613292	MOB	WI	501(c)(2)		SSM Health Care of Wisconsin		No
(13)St Mary's Foundation Inc 10101 Woodfield Lane St Louis,MO63132 43-1940686	Fundraising	WI	501(c)(3)	7	SSM Health Care of Wisconsin		No
(14)St Clare Health Care Foundation Inc 10101 Woodfield Lane St Louis,MO63132 43-1940683	Fundraising	WI	501(c)(3)	7	SSM Health Care of Wisconsin		No
(15)Home Health United Inc 2802 Walton Commons Lane Madison,WI53718 39-1539827	Health Care	WI	501(c)(3)	10	SSM Health Care of Wisconsin		No
(16)Home Care United Inc 2802 Walton Commons Lane Madison,WI53718 39-1776340	Health Care	WI	501(c)(3)	10	SSM Health Care of Wisconsin		No
(17)HHU Xtra Care Inc 2802 Walton Commons Lane Madison,WI53718 39-1705111	Health Care	WI	501(c)(3)	10	SSM Health Care of Wisconsin		No
(18)SSM Health at Home Foundation of Wisconsin Inc 2802 Walton Commons Lane Madison,WI53718 39-1839309	Fundraising	WI	501(c)(3)	Type I	Home Health United Inc		No
(19)SSM Regional Health Services 10101 Woodfield Lane St Louis,MO63132 44-0579850	Health Care	MO	501(c)(3)	3	SSM Health Care Corporation		No
(20)St Mary's Health Center Jefferson City Missouri Foundation 10101 Woodfield Lane St Louis,MO63132 43-1575307	Fundraising	MO	501(c)(3)	Type I	SSM Regional Health Services		No
(21)Good Samaritan Regional Health Center 10101 Woodfield Lane St Louis,MO63132 43-0653587	Health Care	IL	501(c)(3)	3	SSM Regional Health Services		No
(22)St Mary's Hospital Centralia Illinois 10101 Woodfield Lane St Louis,MO63132 37-0662580	Health Care	IL	501(c)(3)	3	SSM Regional Health Services		No
(23)St Mary's - Good Samaritan Inc 10101 Woodfield Lane St Louis,MO63132 36-4170833	Health Care	IL	501(c)(3)	Type I	SSM Regional Health Services		No
(24)Good Samaritan Regional Health Center Foundation 10101 Woodfield Lane St Louis,MO63132 26-2884795	Fundraising	IL	501(c)(3)	7	St Mary's-Good Samaritan Inc		No
(25)St Mary's Hospital Foundation 10101 Woodfield Lane St Louis,MO63132 36-4636691	Fundraising	IL	501(c)(3)	7	St Mary's-Good Samaritan Inc		No
(26)St Mary's Hospital Auxiliary 400 N Pleasant Centralia,IL62801 23-7126345	Fundraising	IL	501(c)(3)	10	St Mary's Hospital Foundation		No
(27)SSM Health Businesses 10101 Woodfield Lane St Louis,MO63132 43-1333488	Health Care	MO	501(c)(3)	10	SSM Health Care Corporation		No
(28)SSM Health Care St Louis 10101 Woodfield Lane St Louis,MO63132 43-1343281	Health Care	MO	501(c)(3)	3	SSM Health Care Corporation		No
(29)Centralia Medical Services Bldg Assoc 10101 Woodfield Lane St Louis,MO63132 23-7408025	MOB	IL	501(c)(3)	Type I	SSM Regional Health Services		No
(30)St Mary's Janesville Foundation Inc 10101 Woodfield Lane St Louis,MO63132 27-3439133	Fundraising	WI	501(c)(3)	7	SSM Health Care of Wisconsin		No
(31)SSM Health Ministries 3221 McKelvey Road Suite 107 Bridgeton,MO63044 43-1012492	Religious Organization	MO	501(c)(3)	1	NA		No
(32)Lee Dewey Corporation 10101 Woodfield Lane St Louis,MO63132 73-1279603	MOB	OK	501(c)(3)	Type I	SSM Health Care of Oklahoma		No
(33)SSM Hospice & Home Care Foundation 10101 Woodfield Lane St Louis,MO63132 30-0012246	Fundraising	MO	501(c)(3)	7	SSM Health Businesses		No
(34)St Mary's Hospital Auxiliary 100 St Marys Medical Plaza Jefferson City,MO65101 43-6049878	Fundraising	MO	501(c)(3)	Type II	NA		No
(35)Good Samaritan Hospital Auxiliary 1 Good Samaritan Way Mount Vernon,IL62864 23-7049599	Fundraising	IL	501(c)(3)	Type III-FI	NA		No
(36)St Anthony Shawnee Hospital Inc 1000 N Lee Ave Oklahoma City,OK73102 45-5055149	Health Care	OK	501(c)(3)	3	SSM Health Care of Oklahoma		No
(37)SSM Audrain Health Care Inc 10101 Woodfield Lane St Louis,MO63132 43-1550298	Health Care	MO	501(c)(3)	3	SSM Regional Health Services		No
(38)Audrain Medical Center Foundation Inc 620 E Monroe St Mexico,MO65265 43-1265060	Fundraising	MO	501(c)(3)	Type I	NA		No
(39)SSM-SLUH Inc 10101 Woodfield Lane St Louis,MO63132 47-4196634	Health Care	MO	501(c)(3)	3	SSM Health Care St Louis		No
(40)SSM Health Plan 1277 Deming Way Madison,WI53717 83-1979548	Insurance	MO	501(c)(4)		SSM Health Businesses		No
(41)Ripon Medical Center Inc 845 Parkside Street Ripon,WI54971 39-1101287	Health Care	WI	501(c)(3)	3	Agnesian Healthcare Inc	Yes
(42)Waupun Memorial Hospital Inc 620 West Brown Street Waupun,WI53963 39-0806265	Health Care	WI	501(c)(3)	3	Agnesian Healthcare Inc	Yes
(43)St Francis Home of Fond du Lac Wisconsin Inc 33 Everett Street Fond du Lac,WI54935 39-1029998	Health Care	WI	501(c)(3)	10	Agnesian Healthcare Inc	Yes
(44)Sister Servants of Christ the King Villa Loretto N8114 County WW Mount Calvary,WI53057 39-1022770	Health Care	WI	501(c)(3)	10	Agnesian Healthcare Inc	Yes
(45)Villa Rosa Inc N8120 County WW Mount Calvary,WI53057 42-1670962	Health Care	WI	501(c)(3)	10	Agnesian Healthcare Inc	Yes
(46)The Christian Home and Rehabilitation Center Incorporated 331 Bly Street Waupun,WI53963 39-0884514	Health Care	WI	501(c)(3)	10	Agnesian Healthcare Inc	Yes
(47)The Monroe Clinic Inc 515 22nd Avenue Monroe,WI53566 39-0808509	Health Care	WI	501(c)(3)	3	SSM Health Care of Wisconsin		No
(48)Monroe Clinic and Hospital Foundation Inc 515 22nd Avenue Monroe,WI53566 20-5769038	Fundraising	WI	501(c)(3)	7	SSM Health Care of Wisconsin		No
(49)Agnesian Healthcare Foundation Inc 430 E Division St Fond du Lac,WI54935 39-1684956	Fundraising	WI	501(c)(3)	Type I	SSM Health Care of Wisconsin		No
(50)Shared Magnetic Resonance Imaging Facility Inc 1104 John Nolen Drive Madison,WI53713 39-1534744	Health Care	WI	501(c)(3)	Type I	SSM Health Care of Wisconsin		No

For Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 50135Y

Schedule R (Form 990) 2019

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
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity		(f) Share of total income	(g) Share of end-of-year assets	Yes	No	(i) Code V-UBI amount in box 20 of Schedule K-1 (Form 1065)	Yes	No
(1) SSM St Joseph Endoscopy Center LLC 10101 Woodfield Lane St Louis,MO63132 27-0046559	Surgery Services	MO	NA	N/A	0	0			0			0 %
(2) St Clare Imaging Services LLC 707 14th Street Suite A Baraboo,WI53913 20-0122365	Diag. Services	WI	NA	N/A	0	0			0			0 %
(3) Mt Vernon Radiation Therapy Center LLC 10101 Woodfield Lane St Louis,MO63132 20-1382620	Radiation Therapy	IL	NA	N/A	0	0			0			0 %
(4) Sleep & Neurology Center of Southern Illinois LLC 10101 Woodfield Lane St Louis,MO63132 20-8468195	Diag. Services	IL	NA	N/A	0	0			0			0 %
(5) CHOWSMGSI Office Building LLC 10101 Woodfield Lane St Louis,MO63132 37-1383861	MOB	IL	NA	N/A	0	0			0			0 %
(6) Oza Cancer Center LLC 10101 Woodfield Lane St Louis,MO63132 20-1382727	MOB	IL	NA	N/A	0	0			0			0 %
(7) Shawnee Real Estate Holdings LLC 1000 N Lee Ave Oklahoma City,OK73102 45-5458304	MOB	OK	NA	N/A	0	0			0			0 %
(8) Dean Clinic & St Mary's Hospital Accountable Care Organization LLC 1808 West Beltline Highway Madison,WI53713 45-2995500	Accountable Care Organization	WI	NA	N/A	0	0			0			0 %
(9) Wisconsin Integrated Information Technology and Telemedicine Systems LLC 1808 West Beltline Highway Madison,WI53713 39-2016715	Information Technology Services	WI	NA	N/A	0	0			0			0 %
(10) Dean Health Holdings LLC 1277 Deming Way Madison,WI53717 26-1594709	Support Services	WI	NA	N/A	0	0			0			0 %
(11) Wingra Building Group 1808 West Beltline Highway Madison,WI53713 39-0237060	MOB	WI	NA	N/A	0	0			0			0 %
(12) Janesville Riverview Clinic Building Partnership 1808 West Beltline Highway Madison,WI53713 39-6220698	MOB	WI	NA	N/A	0	0			0			0 %
(13) 1110 N Classen Blvd LLC 1110 N Classen Boulevard Oklahoma City,OK73106 73-1158158	MOB	OK	NA	N/A	0	0			0			0 %
(14) SSM St Clare Surgical Center LLC 10101 Woodfield Lane St Louis,MO63132 26-1439695	Surgery Services	MO	NA	N/A	0	0			0			0 %
(15) Windmill LLP 50 Village View Lane Chesterfield,MO63017 43-1804651	Investments	MO	NA	N/A	0	0			0			0 %

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?
(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		Yes	No
(1) SSM Managed Care Organization LLC 10101 Woodfield Lane St Louis,MO63132 43-1708511	Health Promotion	MO	NA	C Corporation	0	0	0 %		No
(2) FPP INC & Subs 10101 Woodfield Lane St Louis,MO63132 43-1465174	Health Care	MO	NA	C Corporation	0	0	0 %		No
(3) Diversified Health Services Corp 10101 Woodfield Lane St Louis,MO63132 43-1369305	Medical Equipment	MO	NA	C Corporation	0	0	0 %		No
(4) SSM Properties Inc 10101 Woodfield Lane St Louis,MO63132 43-1462486	Property Services	MO	NA	C Corporation	0	0	0 %		No
(5) HealthFirst Physician Management Services 10101 Woodfield Lane St Louis,MO63132 73-1534336	Medical Services	OK	NA	C Corporation	0	0	0 %		No
(6) SSMHC Liability Trust II 10101 Woodfield Lane St Louis,MO63132 81-6128118	Insurance	MO	NA	C Corporation	0	0	0 %		No
(7) SSM Medical Group Inc 10101 Woodfield Lane St Louis,MO63132 43-1664107	Physician Offices	MO	NA	C Corporation	0	0	0 %		No
(8) SSMHC Insurance Company 10101 Woodfield Lane St Louis,MO63132 03-0310431	Insurance		NA	C Corporation	0	0	0 %		No
(9) Physicians Services Corp of Southern Illinois Inc 10101 Woodfield Lane St Louis,MO63132 36-4161526	Health Care	IL	NA	C Corporation	0	0	0 %		No
(10) Dean Health Systems Inc 1808 West Beltline Highway Madison,WI53713 39-1128616	Physician Offices	WI	NA	C Corporation	0	0	0 %		No
(11) Dean Health Insurance Inc PO Box 56099 Madison,WI53705 39-1830837	Insurance	WI	NA	C Corporation	0	0	0 %		No
(12) Dean Health Plan Inc PO Box 56099 Madison,WI53705 39-1535024	Insurance	WI	NA	C Corporation	0	0	0 %		No
(13) SMDV Office Building 1808 West Beltline Highway Madison,WI53713 39-1628491	Physician Offices	WI	NA	C Corporation	0	0	0 %		No
(14) Dean Retail Services Inc 1808 West Beltline Highway Madison,WI53713 39-1717636	Property Services	WI	NA	C Corporation	0	0	0 %		No
(15) Navitus Holdings LLC 1808 West Beltline Highway Madison,WI53713 80-0968174	Pharmacy Benefits	WI	NA	C Corporation	0	0	0 %		No
(16) Oza Oncology Inc 4117 Veterans Memorial Drive Mt Vernon,IL62804 37-1343746	Physician Offices	IL	NA	S Corporation	0	0	0 %		No
(17) SSM Health Janesville Campus Condominium Association Inc 1808 West Beltline Highway Madison,WI53713 83-2038674	Condo association	WI	NA	C Corporation	0	0	0 %		No
(18) SSM Health Pharmacy LLC 10101 Woodfield Lane St Louis,MO63132 26-4031708	Pharmacy	MO	NA	C Corporation	0	0	0 %		No
(19) Dane County Cytology Center Inc 2000 Engel Street Suite 201 Madison,WI53713 39-1414219	Medical Services	WI	NA	C Corporation	0	0	0 %		No
(20) SSM Health Insurance Company 1277 Deming Way Madison,WI53717 83-4718249	Insurance	MO	NA	C Corporation	0	0	0 %		No

Schedule R (Form 990) 2019

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

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 .....................

b Gift, grant, or capital contribution to related organization(s) ............................

c Gift, grant, or capital contribution from related organization(s) ............................

Yes

d Loans or loan guarantees to or for related organization(s) ............................

e Loans or loan guarantees by related organization(s) ............................

f Dividends from related organization(s) ............................

g Sale of assets to related organization(s) ............................

h Purchase of assets from related organization(s) ............................

i Exchange of assets with related organization(s) ............................

j Lease of facilities, equipment, or other assets to related organization(s) .......................

Yes

k Lease of facilities, equipment, or other assets from related organization(s) ......................

Yes

l Performance of services or membership or fundraising solicitations for related organization(s) .....................

m Performance of services or membership or fundraising solicitations by related organization(s) .................

Yes

n Sharing of facilities, equipment, mailing lists, or other assets with related organization(s) ...................

Yes

o Sharing of paid employees with related organization(s) ............................

Yes

p Reimbursement paid to related organization(s) for expenses ............................

Yes

q Reimbursement paid by related organization(s) for expenses ............................

r Other transfer of cash or property to related organization(s) ............................

s Other transfer of cash or property from related organization(s) ............................

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
(1) Agnesian Healthcare Foundation Inc	C	568,781	Book
(2) The Christian Home and Rehabilitation Center Incorporated	M	27,736	Cash payments
(3) St Francis Home of Fond du Lac Wisconsin	M	201,678	Cash payments
(4) Sister Servants of Christ the King Villa Loretto	M	58,058	Cash payments
(5) Ripon Medical Center	M	36,757	Cash payments

Schedule R (Form 990) 2019

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)	(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?
(a) Name, address, and EIN of entity	(b) Primary activity	(c) Legal domicile (state or foreign country)	Yes	No	(f) Share of total income	(g) Share of end-of-year assets	Yes	No	(i) Code V-UBI amount in box 20 of Schedule K-1 (Form 1065)	Yes	No

Schedule R (Form 990) 2019

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) 2019

Additional Data

Software ID:	19010655
Software Version:	2019v5.0

1	Briefly describe the organization’s mission or most significant activities: THE MISSION OF AGNESIAN HEALTHCARE IS TO PROVIDE COMPASSIONATE CARE THAT BRINGS HOPE, HEALTH AND WHOLENESS TO THOSE WE SERVE BY HONORING THE SACREDNESS AND DIGNITY OF ALL PERSONS AT EVERY STAGE OF LIFE. WE ARE ROOTED IN THE HEALING MINISTRY OF THE CATHOLIC CHURCH.
2	Check this box
3	Number of voting members of the governing body (Part VI, line 1a) ........	3	17
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 2019 (Part V, line 2a) ......	5	2,313
6	Total number of volunteers (estimate if necessary) .............	6	402
7a	Total unrelated business revenue from Part VIII, column (C), line 12 ........	7a	3,972,663
b	Net unrelated business taxable income from Form 990-T, line 39 .........	7b	0

		Prior Year	Current Year
8	Contributions and grants (Part VIII, line 1h) .........	427,564	568,781
9	Program service revenue (Part VIII, line 2g) .........	195,999,850	403,484,831
10	Investment income (Part VIII, column (A), lines 3, 4, and 7d ) ....	192,582	7,275,923
11	Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e)	12,623,015	27,328,663
12	Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)	209,243,011	438,658,198
13	Grants and similar amounts paid (Part IX, column (A), lines 1–3 )...	83,162	575,203
14	Benefits paid to or for members (Part IX, column (A), line 4).....		0
15	Salaries, other compensation, employee benefits (Part IX, column (A), lines 5–10)	99,801,256	202,779,057
16a	Professional fundraising fees (Part IX, column (A), line 11e) .....		0
b	Total fundraising expenses (Part IX, column (D), line 25) 228,402
17	Other expenses (Part IX, column (A), lines 11a–11d, 11f–24e)....	101,622,402	228,296,154
18	Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25)	201,506,820	431,650,414
19	Revenue less expenses. Subtract line 18 from line 12.......	7,736,191	7,007,784
		Beginning of Current Year	End of Year
20	Total assets (Part X, line 16).............	654,431,153	776,804,116
21	Total liabilities (Part X, line 26).............	197,327,913	292,818,515
22	Net assets or fund balances. Subtract line 21 from line 20.....	457,103,240	483,985,601

Sign Here

	Signature of officer	Date

	Type or print name and title


4a	(Code: ) (Expenses $ 356,402,104 including grants of $ 575,203 ) (Revenue $ 418,854,515 )
	Please 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 expenses356,402,104

1b	Sub-Total................
c	Total from continuation sheets to Part VII, Section A....
d	Total (add lines 1b and 1c)...........	5,449,084	5,306,938	2,491,394

1a	Federated campaigns..		1a
b	Membership dues..		1b
c	Fundraising events..		1c
d	Related organizations		1d	568,781
e	Government grants (contributions)		1e

f	All other contributions, gifts, grants, and similar amounts not included above		1f

g	Noncash contributions included in lines 1a - 1f:$		1g

h Total. Add lines 1a-1f.......		568,781

		Business Code
2a	Net patient service revenue	621110	403,484,831	403,484,831
b
c
d
e
f	All other program service revenue.		0	0	0	0
g	Total. Add lines 2a–2f .....		403,484,831

3 Investment income (including dividends, interest, and othersimilar amounts) ......			4,669,444			4,669,444
4 Income from investment of tax-exempt bond proceeds
5 Royalties...........
		(ii) Personal	(i) Real
6a	Gross rents		269,445	6a
b	Less: rental expenses			6b
c	Rental income or (loss)	0	269,445	6c
d	Net rental income or (loss).......			269,445			269,445
		(ii) Other	(i) Securities
7a	Gross amount from sales of assets other than inventory		3,437,555	7a
b	Less: cost or other basis and sales expenses	831,076		7b
c	Gain or (loss)	-831,076	3,437,555	7c
d	Net gain or (loss).........			2,606,479			2,606,479
8a	Gross income from fundraising events (not including $ of contributions reported on line 1c). See Part IV, line 18 ....
			8a
b	Less: direct expenses ...		8b
c	Net income or (loss) from fundraising events..
9a	Gross income from gaming activities. See Part IV, line 19 ...
			9a
b	Less: direct expenses ...		9b
c	Net income or (loss) from gaming activities..
10a	Gross sales of inventory, less returns and allowances ..
			10a	37,729,122
b	Less: cost of goods sold ..		10b	28,147,092
c	Net income or (loss) from sales of inventory..			9,582,030		3,071,729	6,510,301
Business Code			Miscellaneous Revenue
11a	Laboratory		621500	16,270,618	15,369,684	900,934
b	Cafeteria		722210	1,206,570			1,206,570
c
d	All other revenue ....			0	0	0	0
e	Total. Add lines 11a–11d ......			17,477,188
12	Total revenue. See instructions.....			438,658,198	418,854,515	3,972,663	15,262,239

1	Grants and other assistance to domestic organizations and domestic governments. See Part IV, line 21 ....	575,203	575,203
2	Grants and other assistance to domestic individuals. See Part IV, line 22 ...........
3	Grants and other assistance to foreign organizations, foreign governments, and foreign individuals. See Part IV, lines 15 and 16. .............
4	Benefits paid to or for members .......
5	Compensation of current officers, directors, trustees, and key employees ...........	1,999,923	1,887,335	110,520	2,068
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........	153,707,639	145,054,526	8,494,209	158,904
8	Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) ....	8,027,996	7,576,053	443,644	8,299
9	Other employee benefits .......	28,563,712	26,955,692	1,578,491	29,529
10	Payroll taxes ...........	10,479,787	9,889,818	579,135	10,834
11	Fees for services (non-employees):
a	Management ......
b	Legal .........	17,729,180		17,729,180
c	Accounting ...........	54,800		54,800
d	Lobbying ...........	10,380		10,380
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)	79,500,630	37,913,012	41,586,822	796
12	Advertising and promotion ....	782,901		782,901
13	Office expenses .......	18,440,070	16,695,059	1,737,185	7,826
14	Information technology ......	10,114	10,114
15	Royalties ..
16	Occupancy ...........	7,364,344	5,751,405	1,612,939
17	Travel ............	1,169,101	983,802	175,582	9,717
18	Payments of travel or entertainment expenses for any federal, state, or local public officials .
19	Conferences, conventions, and meetings ....	582,452	457,903	124,120	429
20	Interest ...........	4,889,810	4,889,810
21	Payments to affiliates .......
22	Depreciation, depletion, and amortization ..	21,734,637	21,734,637
23	Insurance ...	1,528,457	1,528,457
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	63,864,783	63,864,783
b	Medicaid Provider Tax	5,112,788	5,112,788
c	Licenses and taxes	5,521,707	5,521,707
d
e	All other expenses	0	0	0	0
25	Total functional expenses. Add lines 1 through 24e	431,650,414	356,402,104	75,019,908	228,402
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 if following SOP 98-2 (ASC 958-720).

1	Cash–non-interest-bearing ........			15,673,154	1	39,259,155
2	Savings and temporary cash investments .........			4,581,521	2	5,707,220
3	Pledges and grants receivable, net ......				3	0
4	Accounts receivable, net .............			81,225,369	4	74,846,607
5	Loans and other payables to any current or former officer, director, trustee, key employee, creator or founder, substantial contributor, or 35% controlled entity or family member of any of these persons .......
				0	5	0
6	Loans and other receivables from other disqualified persons (as defined under section 4958(f)(1)), and persons described in section 4958(c)(3)(B) ...
				0	6	0
7	Notes and loans receivable, net ...........				7	0
8	Inventories for sale or use ............			4,792,318	8	3,797,416
9	Prepaid expenses and deferred charges ......			4,841,068	9	3,055,737
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	287,523,014
b	Less: accumulated depreciation	10b	40,534,389	253,767,003	10c	246,988,625
11	Investments—publicly traded securities .				11	0
12	Investments—other securities. See Part IV, line 11 .....			229,658,875	12	262,830,962
13	Investments—program-related. See Part IV, line 11 ..			21,288,458	13	16,627,456
14	Intangible assets ...............				14	0
15	Other assets. See Part IV, line 11 ...........			38,603,387	15	123,690,938
16	Total assets. Add lines 1 through 15 (must equal line 33)...			654,431,153	16	776,804,116

17	Accounts payable and accrued expenses .....	44,540,950	17	51,359,055
18	Grants payable ...		18	0
19	Deferred revenue .........	283,578	19	308,869
20	Tax-exempt bond liabilities .........		20	0
21	Escrow or custodial account liability. Complete Part IV of Schedule D		21	0
22	Loans and other payables to any current or former officer, director, trustee, key employee, creator or founder, substantial contributor, or 35% controlled entity or family member of any of these persons .........
		0	22	0
23	Secured mortgages and notes payable to unrelated third parties ..		23	0
24	Unsecured notes and loans payable to unrelated third parties ..		24	0
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	152,503,385	25	241,150,591
26	Total liabilities. Add lines 17 through 25..	197,327,913	26	292,818,515

	Organizations that follow FASB ASC 958, check here and complete lines 27, 28, 32, and 33.
27	Net assets without donor restrictions ..........	451,305,858	27	477,760,012
28	Net assets with donor restrictions ...........	5,797,382	28	6,225,589
	Organizations that do not follow FASB ASC 958, check here and complete lines 29 through 33.
29	Capital stock or trust principal, or current funds .....		29
30	Paid-in or capital surplus, or land, building or equipment fund ...		30
31	Retained earnings, endowment, accumulated income, or other funds		31
32	Total net assets or fund balances ...........	457,103,240	32	483,985,601
33	Total liabilities and net assets/fund balances ........	654,431,153	33	776,804,116