4A (Expenses $ 10277111 including grants of $ 0) (Revenue $ 8552866)
Effective March 15, 2021, SSM Audrain Health Care, Inc. sold substantially all of its assets and ceased hospital operations. Please see Schedule O for a complete description of program service accomplishments through March 15, 2021.

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 - SSM Health St. Mary's Hospital - Audrain. SSM Health St. Mary's Hospital - Audrain conducted a community health needs assessment which included input from persons who represent the broad interest of the community served. Community discussion groups, much like town hall meetings, were organized and facilitated by members of the steering team where more than 85 individuals participated in discussion groups and consumer interview sessions. These discussions provided perspective on the health status of the community and enlightened the analysis of the secondary data relative to the most important health issues and challenges, key resources and advice on how to address the issues identified. To stimulate discussion, the community discussion group agenda included questions on observed community health, top health issues and challenges, what local resources exist, and what advice community members had. During the input sessions, participants were also asked to review a listing of key indicators, factors and or determinants of health that had previously been identified to have some degree of variance in the report area. In addition to the review of demographics and secondary data, and the aforementioned discussion groups with key stakeholders and community representatives, a community perception survey was conducted to assess the perception of health care and health status across the two-county region in the analysis. The survey was made available on social media and internet sites, in physician offices, medical clinics and public health departments and various other locations, yielding a total of 751 responses from residents.

Schedule H, Part V, Section B, Line 6a Facility A, 1
Facility A, 1 - SSM Health St. Mary's Hospital - Audrain. SSM Health St. Mary's Hospital - Audrain and its affiliate, SSM Health St. Mary's Hospital - Jefferson City, conducted research and prioritization of needs in cooperation with each other.

Schedule H, Part V, Section B, Line 6b Facility A, 1
Facility A, 1 - SSM Health St. Mary's Hospital - Audrain. The hospital conducted its 2018 CHNA in collaboration with the following groups: Arthur Center Community Health, Audrain County Commission, Audrain County Health Department, City of Vandalia, Mexico Area Chamber of Commerce, United Way of Audrain County, Mexico Area YMCA, Mexico Veterans Home, Mexico Parks & Recreation, and Montgomery County Health Department.

Schedule H, Part V, Section B, Line 11 Facility A, 1
Facility A, 1 - SSM Health St. Mary's Hospital - Audrain. 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: - Mental health/substance abuse - Access to health care - Chronic disease Mental health/substance abuse Mental health issues, such as anxiety, depression and risk of suicide, are prevalent concerns. There are limited mental health providers in the area in general but especially noted was the gap in providers for youth and families in distress. Additionally, mental health is intertwined with other key health issues such as substance abuse, addiction, and overall good physical health. It was noted that individuals may be using drugs/alcohol as a mechanism to cope with mental health issues stemming from toxic stress they have experienced. Community input also emphasized the impact of opioid abuse on the community, a lack of detox or substance abuse treatment options, as well as the economic burden it is placing on law enforcement, EMS, and hospital providers. Additionally, statistics show: - The Suicide Age-Adjusted Death rate for the report area per 100,000 population is 18.5%, compared to the US rate of 13% and the Missouri rate of 16.4% - According to the exploreMOhealth.org county and zip-code level study data, depression is the top health factor in Audrain and Montgomery counties - Alcohol-and Substance-Related Mental Health Disorders is ranked fifth among the top five chronic diseases and conditions in both counties included in the report area - 47% of the CHNA community health needs survey respondents said drug use was the top challenge facing their community - 28% of survey respondents indicated mental health disorders was the most important issue in the community The hospital's action plan includes the following initiatives to improve mental health and substance abuse in the community served: - Partner to provide Adult and Youth Mental Health First Aid education and Suicide Prevention and Awareness education - Provide leadership support and enroll primary care clinics in Missouri Child Psychiatry Access Project (MO-CPAP) which provides free, same-day expert child psychiatry phone consultation to primary care providers (PCPs) - Explore partnership and implementation of Missouri Hospital Association Engaging Patients In Care Coordination (EPICC) program in Emergency Department - Evaluate partnership with Council for Drug Free Youth to extend school-based education and increase availability of substance use prevention and early identification/ intervention initiatives in the report area - Participate and support SSM Opioid Stewardship Program and central Missouri opioid task force initiatives - Continue to offer the SSM Health Senior Care / Geriatric Psych specialty program - Continue to offer Tele-psychiatry services in the Emergency Department and Inpatient Geriatric Psych Unit Access to health care Access to specialty, primary and preventive health care services through a doctor's office, clinic or other appropriate provider is an important element of a community's health care system and is vital for helping the community's residents to be healthy. The ability to access care is influenced by many factors, including insurance coverage and the ability to afford services, long waits for appointments or treatments, the availability and hours of operation of health care providers, an understanding of where to find services when needed, a lack of providers and a lack of reliable transportation were frequently mentioned as concerns. Additionally, findings show: - Lack of access to OB physicians and services was of great concern, leading to lack of prenatal care during pregnancy, high risk deliveries, infant poor health and mortality. The infant mortality rate for Montgomery County was 10.7 per 1,000 births compared to the Missouri rate of 7.2 and the US rate of 6.5, per 1,000 births. The teen births (rate of total births to women age 15-19 per 1,000 female population) for the report area was 50.04 compared to the Missouri rate of 39.5 and the US rate of 36.6. These indicators may indicate the existence of broader issues pertaining to access to reproductive and maternal and child health and education - Lack of mental health providers and substance abuse services was mentioned most among input session participants. Community input emphasized the impact of mental health disorders and drug abuse on the community, a lack of mental health professionals and treatment options, as well as the economic burden it is placing on law enforcement, EMS, public health and hospital providers. Opioid use and alcohol overuse were mentioned more often, however, marijuana, and methamphetamines were also mentioned as top concerns - The percentage of population in the report area living in a designated Health Professional Shortage Area (HPSA) is 100%. A geographic area designated as a HPSA, is defined as having a shortage of primary medical care, dental or mental health professionals - Of the respondents to the 2018 community health assessment survey, who reported they did not see a doctor in the past 12 months, 40% said they could not afford and 12% reported lack of insurance and lack of transportation as a reason they didn't see a doctor - Survey respondents noted lack of affordable health insurance, lack of specialists, hours of operation, long-wait time for appointments and lack of health care professionals as the top five factors that impact access to health care in their community The hospital's action plan includes the following initiatives to address access to health care in the community served: - Implement Outpatient Perinatal Assessment Services - Explore collaboration with SSM Health Women's Health to implement Centering Pregnancy Model in Montgomery County - Partner with the Arthur Center to increase capacity and referrals for suicide evaluation of Emergency Department patients Chronic disease Chronic diseases, specifically Diabetes, Heart/Cardiovascular, Cancer and Lung/COPD are prevalent health issues in the report area. Diabetes and Heart Disease was the most frequently mentioned chronic disease and was often linked with discussion about obesity and overweight. Heart Disease is the leading cause of death in the report area. Obesity is often the driver of other chronic conditions, such as diabetes, heart disease and cancer. Additionally, statistics show: - The percent of adults with Heart Disease in the report area is 12.6%, nearly three times higher than Missouri (4.8%) and the United States (4.4%). The mortality rate for Heart Disease per 100,000 population is 209 for the report area, mostly attributable to Montgomery County's age-adjusted death rate of 242.7 per 100,000, which is significantly higher than the Missouri rate - Cancer and Lung/COPD were reported frequently among the top diseases for hospitalizations, ER visits and chronic disease deaths in the report area and are listed among the top causes of death, just behind Heart Disease. The Cancer mortality age-adjusted death rate per 100,000 population is 181.6 for the two-county report area, which is higher than the Missouri rate of 175.88 per 100,000 population - The Lung disease mortality, age-adjusted death rate per 100,000 population for the report area is 74.1 compared to the Missouri rate of 52.17 and the US rate of 41.3 The hospital's action plan includes the following initiatives to improve chronic disease in the community served: - Provide community and workplace health fairs and screenings - Provide annual Senior Expo to promote healthy living and preventative care - Provide community health education. Health literacy, including health risk prevention, chronic disease self-management, preventative care, and life skills education, stress management and coping are needed to improve health and wellness decisions - Evaluate implementation of evidenced-based Diabetes Prevention Program (DPP) in partnership with the YMCA - Explore partnership with Audrain and Montgomery County Health Departments to enhance community diabetes support and resources - Collaborate with Catholic Charities to enhance parish health ministry - Continue support and partnership with Audrain County YMCA - Continue to provide community and school-based health education classes The hospital has no plans to discontinue other community benefit efforts addressing the remaining CHNA-identified needs and address additional community needs within its efforts. The following community needs were identified but have not been prioritized due to the hospital's limited resources at this time (additional descriptions available in the 2018 CHNA): - Health literacy - Overweight/obesity & physical inactivity - Smoking & tobacco use

Schedule H, Part I, Line 3c
"Patients whose family income exceeds 400% of the FPL may be eligible to receive discounted rates on a case-by-case basis based on their specific circumstances, such as catastrophic illness or medical indigence, at the discretion of the hospital; however the discounted rates shall not be greater than the amounts generally billed to commercially insured [or Medicare] patients. In such cases, other factors may be considered in determining their eligibility for discounted or free services, including: * Bank accounts, investments and other assets * Employment status and earning capacity * Amount and frequency of bills for health care services * Other financial obligations and expenses * Generally, financial responsibility will be no more than 25% of gross family income. The hospital may utilize predictive analytical software or other criteria to assist in making a determination of financial assistance eligibility in situations where the patient qualifies for financial assistance but has not provided the necessary documentation to make a determination. This process is called ""presumptive eligibility."""

Schedule H, Part V, Section B, Line 7 HOSPITAL FACILITY'S WEBSITE
The hospital facility's website, https://www.ssmhealth.com/locations/st-marys-hospital-audrain, was active prior to the sale of SSM Health St. Mary's Hospital - Audrain on March 15, 2021.

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 71 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 III, Line 2 Bad debt expense - methodology used to estimate amount
AS A RESULT OF NEW ACCOUNTING GUIDANCE, BAD DEBT IS NO LONGER AN EXPENSE, BUT IS INCLUDED AS A REDUCTION IN NET PATIENT REVENUE.

Schedule H, Part III, Line 3 Bad Debt Expense Methodology
FOR FINANCIAL STATEMENT PURPOSES, SSM Health HAS ADOPTED ACCOUNTING STANDARDS UPDATE NO. 2014-09 (TOPIC 606). IMPLICIT PRICE CONCESSIONS INCLUDES BAD DEBTS. THEREFORE, BAD DEBTS ARE INCLUDED IN NET PATIENT REVENUE IN ACCORDANCE WITH HEALTHCARE FINANCIAL MANAGEMENT ASSOCIATION STATEMENT NO. 15 AND BAD DEBT EXPENSE IS NOT SEPARATELY REPORTED AS AN EXPENSE. THE AMOUNT REPORTED ON PART III, LINE 3 IS THE ESTIMATED COST OF BAD DEBT ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER NORTON HOSPITAL'S FINANCIAL ASSISTANCE POLICY ON A GROSS BASIS.

Schedule H, Part III, Line 4 Bad debt expense - financial statement footnote
SSM Health St. Mary's Hospital - Audrain 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, 2021 consolidated audit is contained on page 13, 14 AND 15 of the attached financial statements.

Schedule H, Part III, Line 9b Collection practices for patients eligible for financial assistance
"SSM Health St. Mary's Hospital - Audrain has established a written credit and collection policy and procedures. The billing and collection policies and practices reflect the mission and values of SSM Health, including our special concern for people who are poor and vulnerable, The Health Center embraces its responsibility to serve the communities in which it participates by establishing sound business practices. The Health Center's billing and collection practices will be fairly and consistently applied. All staff and vendors are expected to treat all patients consistently and fairly regardless of their ability to pay. They respond to patients in a prompt and courteous manner regarding any questions about their bills and provide notification of the availability of financial assistance. All uninsured patients will be provided a standard discount for medically necessary inpatient and outpatient services, including services provided at off-campus outpatient sites. The hospital determined the amount of the discount based on the local managed care market, applicable statutory requirements and other relevant local circumstances. The rate must be no less than the lowest effective discount rate and no greater than the highest effective discount rate for the current managed care contracts of the hospital. Uninsured patients may also qualify for an additional discount based upon financial need under the system financial assistance policy. All accounts due from the patient will receive a statement after discharge or after final adjudication from patient's insurance. Generally the patient will receive 4 months (120 days) of in-house collection efforts (including early out vendors) and 12 months of bad debt collection efforts. The hospital will make Reasonable Efforts to determine FAP eligibility including: 1. The financial assistance summary will be included with each billing statement 2. Extraordinary Collection Activity (ECAs) may not occur until bad debt placement and only after 120 days. 3. ECAs must be suspended if a guarantor submits a FAP application during the application period. 4. Reasonable measures must be taken to reverse ECAs if the application is approved which may include refunding any payments made in excess of amounts owed as an FAP-eligible individual. 5. Bad Debt vendors will gain written approval from SSM prior to engaging in ECAs. SSM will review the accounts and verify satisfactory completion of reasonable efforts during the notification and application period. A waiver is not considered reasonable efforts. Obtaining a signed waiver that an individual does not wish to apply for FAP assistance or receive FAP application information will not meet the requirement to make ""reasonable efforts"" to determine whether the individual is FAP-eligible before engaging in ECAs. All outside collection agencies must comply with state and federal laws, comply with the association of credit and collection professional's code of ethics and professional responsibility and comply with SSM Audrain Health Care, Inc. collection and financial assistance policies."

Schedule H, Part V, Section B, Line 16a FAP website
A - SSM Health St. Mary's Hospital - Audrain: Line 16a URL: https://www.ssmhealth.com/resources/patients-visitors/pay-my-bill/financial-assistance;

Schedule H, Part V, Section B, Line 16b FAP Application website
A - SSM Health St. Mary's Hospital - Audrain: Line 16b URL: https://www.ssmhealth.com/resources/patients-visitors/pay-my-bill/financial-assistance;

Schedule H, Part V, Section B, Line 16c FAP plain language summary website
A - SSM Health St. Mary's Hospital - Audrain: Line 16c URL: https://www.ssmhealth.com/resources/patients-visitors/pay-my-bill/financial-assistance;

Schedule H, Part VI, Line 6 Affiliated health care system
Through March 15, 2021 SSM Audrain Health Care is a 501(c)(3) organization and is a member of the integrated health care system known as SSM Health. SSM Health is a 501(c)(3) organization headquartered in St. Louis, Missouri.

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, website resources, 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
SSM Health St. Mary's Hospital - Audrain is located in Mexico, Missouri, in Audrain County. The hospital defines its primary service area as Audrain and Montgomery Counties in Missouri. As of 2016, the two-county area had a total population of 37,688 persons. Of this population, 31.5% were age 55 or above. This percentage of older adults, as well as the median age of the service area, are both higher than the same statistic for Missouri and the United States. Within Audrain and Montgomery Counties, 15.7% of the population age 25 or above has no high school diploma, while 19.7% has at least an Associate's degree. Unemployment measures fare better than state and national averages, reported at only 3.2% in 2018; however, per capita income falls below the state and national levels and rates of poverty are substantially higher. Rates of uninsured adults and children is higher in Audrain and Montgomery Counties than for Missouri and the United States and is key factor in the accessibility and affordability of health care. In these two counties, 14.9% of adults are uninsured, compared to 12.8% in Missouri and 12.1% nationally. For children, 6.4% of the two-county area are uninsured, higher than the Missouri rate of 4.8% and national rate of 4.7%. Additional demographic and statistical information on the hospital's community can be found throughout the 2018 CHNA.

Schedule H, Part VI, Line 7 State filing of community benefit report
MO

Schedule H, Part VI, Line 5 Promotion of community health
Through March 15, 2021SSM Health St. Mary's Hospital - Audrain participated 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, SSM Health St. Mary's hospital, clinics and programs provide medical and mental health services, health education, health management, prevention, referrals, insurance enrollment and in-home primary care services and support, while fostering collaboration and incorporating Community Benefit strategies. St. Mary's Hospital - Audrain promotes grassroots advocacy and engages persons of influence to affect social and public policy change in order to promote both community health and healthy communities. SSM Health St. Mary's Hospital - Audrain 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.