Community Benefit Insight - Tax-exempt hospital

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Mount St Mary's Hospital of Niagara Falls

Mount St Marys Hospital

5300 Military Rd
Lewiston, NY 14092

Bed count	179	Medicare provider number	330188	Member of the Council of Teaching Hospitals	NO	Children's hospital	NO

EIN: 161523353

Display data for year:

Community Benefit Spending- 2021
(as % of functional expenses, which all tax-exempt organizations report on Form 990 Schedule H)

9.96%

Spending by Community Benefit Category- 2021
(as % of total functional expenses)

* = CBI denoted preventative categories

Community Benefit Spending Compared to Functional Expenses, 2010-2021

Additional data

Community Benefit Expenditures: 2021

All tax-exempt organizations file a Form 990 with the IRS for every tax year. If the tax-exempt organization operates one or more hospital facilities during the tax year, the organization must attach a Schedule H to Form 990. On Part I of Schedule H, the organization records the expenditures it made during the tax year for various types of community benefits; 9 types are shown on this web tool. By default, this web tool presents community benefit expenditures as a percentage of the organization’s functional expenses, which it reports on Form 990, Part IX, Line 25, Column A. (The more commonly heard term, ‘total operating expenses’, which organizations report to CMS, is generally about 90% of the ‘functional expenses’). The user may change the default to see the dollar expenditures.
Amount spent in the following IRS community benefit categories:

Financial Assistance at cost as % of operating expenses	$ 1,052,021 0.88 %
Medicaid as % of operating expenses	$ 8,045,740 6.72 %
Costs of other means-tested government programs as % of operating expenses	$ 0 0 %
Health professions education as % of operating expenses	$ 106 0.00 %
Subsidized health services as % of operating expenses	$ 2,433,603 2.03 %
Research as % of operating expenses	$ 76,077 0.06 %
Community health improvement services and community benefit operations* as % of operating expenses Note: these two community benefit categories are reported together on the Schedule H, part I, line 7e.	$ 224,898 0.19 %
Cash and in-kind contributions for community benefit* as % of operating expenses	$ 92,305 0.08 %
Community building* as % of operating expenses	$ 132,732 0.11 %

* = CBI denoted preventative categories

Community building activities details:

Did tax-exempt hospital report community building activities?	YES
Number of activities or programs (optional)	0
Physical improvements and housing	0
Economic development	0
Community support	0
Environmental improvements	0
Leadership development and training for community members	0
Coalition building	0
Community health improvement advocacy	0
Workforce development	0
Other	0
Persons served (optional)	0
Physical improvements and housing	0
Economic development	0
Community support	0
Environmental improvements	0
Leadership development and training for community members	0
Coalition building	0
Community health improvement advocacy	0
Workforce development	0
Other	0
Community building expense as % of operating expenses	$ 132,732 0.11 %
Physical improvements and housing as % of community building expenses	$ 0 0 %
Economic development as % of community building expenses	$ 0 0 %
Community support as % of community building expenses	$ 123,038 92.70 %
Environmental improvements as % of community building expenses	$ 757 0.57 %
Leadership development and training for community members as % of community building expenses	$ 358 0.27 %
Coalition building as % of community building expenses	$ 0 0 %
Community health improvement advocacy as % of community building expenses	$ 4,467 3.37 %
Workforce development as % of community building expenses	$ 4,112 3.10 %
Other as % of community building expenses	$ 0 0 %
Direct offsetting revenue	$ 0
Physical improvements and housing	$ 0
Economic development	$ 0
Community support	$ 0
Environmental improvements	$ 0
Leadership development and training for community members	$ 0
Coalition building	$ 0
Community health improvement advocacy	$ 0
Workforce development	$ 0
Other	$ 0

Other Useful Tax-exempt Hospital Information: 2021

In addition to community benefit and community building expenditures, the Schedule H worksheet includes sections on what percentage of bad debt can be attributable to patients eligible for financial assistance, and questions on the tax-exempt hospital's debt collection policy. When searching a specific tax-exempt hospital in this web tool, Section II provides information about bad debt and the financial assistance policy, and whether the state in which the tax-exempt hospital resides has expanded Medicaid coverage under the federal ACA.

Of the tax-exempt hospital’s overall operating expenses, amount reported as bad debt as % of operating expenses	$ 0 0 %
Is the tax-exempt hospital considered a "sole community hospital" under the Medicare program?	NO

Information about the tax-exempt hospital's Financial Assistance Policy and Debt Collection Policy
The Financial Assistance Policy section of Schedule H has changed over the years. The questions listed below reflect the questions on the 2009-2011 Schedule H forms and the answers tax-exempt hospitals provided for those years. The Financial Assistance Policy requirements were changed under the ACA. In the future, as the Community Benefit Insight web site is populated with 2021 data and subsequent years, the web tool will also be updated to reflect the new wording and requirements. In the meantime, if you have any questions about this section, we encourage you to contact your tax-exempt hospital directly.

Does the organization have a written financial assistance (charity care) policy?	YES
Did the tax-exempt hospital rely upon Federal Poverty Guidelines (FPG) to determine when to provide free or discounted care for patients?	YES
Amount of the tax-exempt hospital’s bad debt (at cost) attributed to patients eligible under the organization’s financial assistance (charity care) policy as % of operating expenses	$ 0 0 %

Did the tax-exempt hospital, or an authorized third party, take any of the following collection activities before determining whether the patient was eligible for financial assistance:
Under the ACA, states have the choice to expand Medicaid eligibility for their residents up to 138% of the federal poverty guidelines. The Medicaid expansion provision of the ACA did not go into effect until January 2014, so data in this web tool will not reflect each state's current Medicaid eligibility threshold. For up to date information, please visit the Terms and Glossary under the Resources tab.
The federal poverty guidelines (FPG) are set by the government and used to determine eligibility for many federal financial assistance programs. Tax-exempt hospitals often use FPG guidelines in their Financial Assistance policies to determine which patients will qualify for free or discounted care.
In addition to the federal requirements, some states have laws stipulating community benefit requirements as a result of tax-exemption. The laws vary from state to state and may require the tax-exempt hospitals to submit community benefit reports. Data on this web tool captures whether or not a state had a mandatory community benefit reporting law as of 2011. For more information, please see Community Benefit State Law Profiles Comparison at The Hilltop Institute.

Community Health Needs Assessment Activities: 2021

The ACA requires all 501(c)(3) tax-exempt hospitals to conduct a Community Health Needs Assessment (CHNA) every three years, starting with the hospital's tax year beginning after March 23, 2012. The 2011 Schedule H included an optional section of questions on the CHNA process. This web tool includes responses for those hospitals voluntary reporting this information. The web tool will be updated to reflect changes in these questions on the 2012 and subsequent Schedule H forms.

Did the tax-exempt hospital report that they had conducted a CHNA?	YES
Did the CHNA define the community served by the tax-exempt hospital?	YES
Did the CHNA consider input from individuals that represent the broad interests of the community served by the tax-exempt hospital?	YES
Did the tax-exempt hospital make the CHNA widely available (i.e. post online)?	YES
Did the tax-exempt hospital adopt an implementation strategy to address the community needs identified by the CHNA?	YES

Supplemental Information: 2021

This section presents qualitative information submitted by the hospital, verbatim from the 990H record.

Statement of Program Service Accomplishments
Description of the organization's program service accomplishments for each of its three largest program services, as measured by expenses. Section 501(c)(3) and 501(c)(4) organizations are required to report the amount of grants and allocations to others, the total expenses, and revenue, if any, for each program service reported.

4A (Expenses $ 68548000 including grants of $ 0) (Revenue $ 59784564)
Inpatient Routine/Surgery Visits:Acute Care Patient Days = 16,060Newborn Patient Days = 707Inpatient Surgeries = 682

4B (Expenses $ 14417112 including grants of $ 0) (Revenue $ 40107937)
Outpatient Routine/Surgery Services:Emergency Visits (Net of Admits) = 15,938Referred Ambulatory Visits = 61,049Operating Room = 2,884G.I. Laboratory = 1,107Interventional Radiology = 241

4C (Expenses $ 18896304 including grants of $ 0) (Revenue $ 522899)
Clinic/Primary Care Services:Clinic Visits = 18,640Primary Care Visits = 18,129

Facility Information

Schedule H (Form 990) Section C. Supplemental Information for Part V, Section B.

Part V, Section A:
Ambulatory Surgery - Multi Specialty Chemical Dependence - Rehabilitation Chemical Dependence - Withdrawal O/PClinic Part Time ServicesClinical Laboratory ServiceCoronary CareEmergency Department Intensive CareLevel I Perinatal Care Lithotripsy MaternityMedical Services - Other Medical Specialties Medical Services - Primary CareMedical Social Services Medical/Surgical Nuclear Medicine - Diagnostic Nuclear Medicine - Therapeutic Radiology - Diagnostic Renal Dialysis - AcuteStroke Center Therapy - Occupational O/P Therapy - Speech Language Pathology O/P

Mount St. Mary's Hospital of Niagara Falls
Part V, Section B, Line 5: To identify and prioritize the MSMH community' s health needs, this Community Health Needs Assessment (CHNA) considered multiple data sources, including written surveys, interviews, focus groups, demographic data, health status indicators, and disease prevalence data. MSMH compiled the data from these sources to arrive at potential priority health needs in the community. MSMH convened meetings with MSMH staff and external healthcare experts (including the Niagara County Department of Health) to share the survey results, discuss the potential priority health needs and to elicit considerations regarding secondary health needs. Collaboration included involvement from other local area local area hospitals, Niagara Falls Memorial, DeGraff Memorial, and Eastern Niagara. A countywide questionnaire was sent in addition to individual surveys sent to community organizations, local health officials and others of varying socioeconomic backgrounds: - Written Survey targeting local community organizations and nonprofits that are active in the primary service area - Written Survey targeting local block clubs and church groups active in the primary service area - Focus Group at the Mount St. Mary's Neighborhood Health Center, located in the part of the service area with the lowest per capita income and underserved in a variety of ways - Focus Group at Mount St. Mary's Hospital involving associates - Input from Focus Groups conducted throughout Niagara County by Niagara County DOH - Written Request for input from physicians at Mount St. Mary's - Written Survey conducted by Niagara County Department of Health that was countywide, but also with the ability to gather input from our primary service area.These included members of the Creating a Healthier Niagara Falls Collaborative and Healthy BehaviorsWork Group: - Family and Children's Services of Niagara - Niagara County Office of the Aging - American Diabetes Association - Niagara County Department of Mental Health - BuffaloNiagara YMCA - Planned Parenthood of Niagara - Native American Community Services - Isaiah 61 Project - Roswell Park Cancer Institute/Niagara Falls City Council - Niagara Falls School District/Niagara Falls City CouncilOther groups included: - Mom's Net - Family and Children's Services of Niagara - Heart, Love & Soul Food Pantry - Project Connect NiagaraFor more information about our CHNA, go to https://www.chsbuffalo.org/mission/social-responsibility-community-benefit

Mount St. Mary's Hospital of Niagara Falls
Part V, Section B, Line 6b: Catholic Health System, P2 Collaborative, Niagara County Department of Health and New York State Department of Health

Mount St. Mary's Hospital of Niagara Falls
"Part V, Section B, Line 11: The 2019 Niagara County Community Health Needs Assessment began by bringing together the participants from the 2016 process. This included the Niagara County Department of Health, and representatives of the four hospitals in Niagara County: Mount St. Mary's, Niagara Falls Memorial, DeGraff Memorial, and Eastern Niagara. The process was coordinated by the P2 Collaborative of Western New York. Initial meetings focused on evaluating activities from the 2016 CHNA's and the County Health Department's Community Service Plan priorities. Despite posting our 2016-18 report on our website and providing notice in the media, we did not receive any written input on the report. Subsequent sessions were devoted to developing a countywide questionnaire to survey residents and initiatives to gather as much relevant data as possible from surveys, interviews, and focus groups. As part of this coordinated initiative, Mount St. Mary's worked to develop an updated (2019-2021) Community Health Improvement Plan/Implementation Strategy (CHIP/IS) to continue the collaboration in our community to improve patient care, preventive services, overall health, and quality of life. Our input process covered many segments of the community including individual surveys,community organizations, local health officials and others of varying socioeconomic backgrounds. Through the needs assessment, numerous areas were identified as important and clearly impact the health of the community. Mount St. Mary's identified the ""significant"" needs as related to the New York State Department of Health Prevention Agenda priorities. Within the ""priorities,"" Mount St. Mary's will address numerous health needs as described in the publicly available CHNA report. Two priorities not specifically addressed in the implementation plan: Neighborhood Safety and Food/Water Safety. We did not address in our plan because of a lack of expertise and resources to effectively address each of the issues.Part V, line 7A Page 8: https://www.chsbuffalo.org/mission/social-responsibility-community-benefit Part V, line 10a Page 8: https://www.chsbuffalo.org/mission/social-responsibility-community-benefit"

Mount St. Mary's Hospital of Niagara Falls
Part V, Section B, Line 16j: Includes information in both English and Spanish on all signage and brochures for financial assistance.

Supplemental Information

Schedule H (Form 990) Part VI

Part I, Line 6a:
Mount St. Mary's Community Benefit Report is contained in the annual report prepared by the Catholic Health System.

Part I, Line 7:
Costing is a full step down methodology of cost from non-revenue producing departments to revenue producing departments', with assignment of cost to individual charge items based on volume and charge amount. All patient accounts are cost with the same methodology regardless of patient type (inpatient, outpatient, emergency room, etc.) or insurance coverage (Medicare, Medicaid, private insurance, uninsured, etc.).

Part II, Community Building Activities:
Community Building Activities for Mount St. Mary's Hospital included Community Support of $123,038, Environmental Improvements of $757, Leadership development and training for community members of $358, Community health improvement advocacy of $4,467, and Workforce development of $4,112.

Part III, Line 2:
The Hospital did not report bad debt on their financial statements, as they adopted ASU 2014-09 Revenue from Contracts with Customers in 2018. Upon adoption, the majority of what was previously classified as provision for bad debts and presented as a reduction to net patient service revenue on the statement of operations and changes in net assets is treated as an implicit price concession that reduces the transacton price, which is reported as net patient service revenue.

Part III, Line 3:
The Hospital did not report bad debt on their financial statements, as they adopted ASU 2014-09 Revenue from Contracts with Customers in 2018. Upon adoption, the majority of what was previously classified as provision for bad debts and presented as a reduction to net patient service revenue on the statement of operations and changes in net assets is treated as an implicit price concession that reduces the transacton price, which is reported as net patient service revenue.

Part III, Line 4:
The hospital does not have a footnote that describes bad debt in the financial statements.

Part III, Line 8:
Mount St. Mary's Hospital does not treat Medicare shortfall as a community benefit, as serving Medicare patients is not a differentiating feature of tax-exempt healthcare organizations. The existing community benefit framework allows community benefit programs that serve the Medicare population to be counted in other community benefit categories.

Part III, Line 9b:
The hospital's collection policies contain provisions on the collection practices to be followed for patients who are known to qualify for financial assistance. The hospital has implemented billing and collection practices for patient payment obligations that are fair, consistent, and compliant with state and federal regulations and no extraordinary collection practices are followed.

Part VI, Line 2:
As part of Catholic Health, Mount St. Mary's benefits from information received from evaluations administered by the Catholic Health Community Education Department after each class, workshop, or program it sponsors; from input from the physician community during doctor to doctor education programs; from physician and leadership participation in community boards, coalitions and forums to define the health needs of patient populations and seek community solutions; from participation in regional planning initiatives that look at the needs of the broader community; and input from Catholic Health Board including Board Committee (e.g. Mission Integration Committee). Examples of other sources of input include input from leadership of Family and Children's Services of Niagara, the Heart, Love and Soul Food Pantry, Stella Niagara Education Center, March of Dimes, Niagara Falls Block Club Council, Project Connect Niagara, Opportunities Unlimited of Niagara, and Complete Senior Care, among others. In each of the organizations listed, a member of the Mount St. Mary's leadership team serves on their board of directors or key committee with consistent dialogue about our services.

Part VI, Line 3:
"Catholic Health's Mount St. Mary's Hospital inform and educate patients and persons who may be billed for medical services about their eligibility for assistance under federal, state, or local government programs or our own Healthcare Assistance Program (HAP) in a variety of ways. For example, Mount St. Mary's Hospital, like our other Catholic Health facilities, has posters and brochures available, which include eligibility and contact information for the Patient Financial Services Team. This information is available in admissions areas, emergency rooms, primary care and outpatient rehabilitation centers, the Administrative and Regional Training Center (ARTC) and other areas throughout Catholic Health where eligible patients and family members are likely to be present. This information is also on the website https://www.chsbuffalo.org/billing-insurance/financial-assistance and includes general information, our policy and application and is translated in Spanish and Arabic. In addition, information on financial assistance is included on our website.Mount St. Mary's also provides information about financial assistance and Healthcare Assistance program (HAP) contact information to patients as part of the intake process and during or within 90 days of their discharge from the hospital via patient statements or outreach. To further assist patients, all patient bills include the following language: ""If you need financial assistance: Catholic Health offers a healthcare assistance program to help those in need. For more details please visit www.chsbuffalo.org/financial assistance, or call our Patient Financial Services Team at (716) 601-3600.""For free, confidential assistance in applying for financial assistance, patients can also call our Patient Financial Services team at 716-601-3600. A counselor will work with them to see if they qualify for free or low-cost insurance or other financial assistance. For patients who do not have insurance and need care at a Catholic Health hospital, a registration clerk can put the patient in touch with one of our Certified Application Counselors. Interpreting services are also available for patients who do not speak English. We offer case management services, and our Certified Application Counselors who discuss with patients the availability of various government benefits, such as Medicaid or other state and federal programs, and assist patients and families with eligibility and applications when necessary."

Part VI, Line 4:
Mount St. Mary's Primary Service Area includes the City of Niagara Falls (Zip Codes 14301, 14302, 14303, 14304 and 14305), a city of about 49,000 where 60% of the population is on some form of public assistance. The towns of Lewiston (14092, 14107, 14109, and 14132), Niagara (portions of 14304 and 14305), Wheatfield (portions of 14305 and 14120), Grand Island {14072) and Porter (14174) are more suburban and rural areas with slightly higher income levels. Secondary Service Area includes the towns of Wilson (14172) a small agricultural community and Lockport (14094) a nearby city with similar characteristics to Niagara Falls. In general, the primary service area is described as Western Niagara County.

Part VI, Line 6:
N/A

Part VI, Line 5:
"One of the fundamental reasons for the creation of Catholic Health was to ensure the continued viability of faith-based health care to meet the needs of residents of WNY and the surrounding communities. Our Mission Statement, ""We are called to reveal the healing love of Jesus to those in need"" further articulates why we exist. Integral to this effort is caring for the needs of those who are poor and disadvantaged. The services provided by Mount St. Mary's Hospital as part of Catholic Health are in response to identified community needs, and reflect the System's emphasis on caring for the underserved. Catholic Health collaborates with other charitable organizations and social service agencies (i.e. Catholic Charities, Spectrum Human Services, Evergreen Health Services, Erie County Department of Health, etc.), to maximize its ability to provide needed services to the residents of our region.The governing Board of Directors of Mount St. Mary's Hospital is comprised of community representatives from universities, legal communities, and business leaders. Religious orders are represented, as well as active and retired medical staff members. The Mount St. Mary's medical staff is considered an ""open"" medical staff, as any physician can apply for privileges. Each application is reviewed by a vigorous credentialing verification process. The hospital has a robust health professional education programs and participates in teaching programs for other allied health professionals. Our emergency department is open to all people regardless of their ability to pay. Our primary care centers are strategically located in areas deemed economically disadvantaged or where other medical services are lacking. In 2021, the Catholic Health System provided more than $210 million in charity care and community benefit activities to help make our community a healthier place, especially for the poor and underserved. These activities included: - Spearheading Project Homeless Connect An outreach initiative to link homeless individuals and families with medical and other support services; - Supporting charitable and educational organizations, like the Global Health Ministry, United Way, Harvest House, St. Luke's Mission of Mercy, The CRIB Maternity Group Home in Niagara Falls, MY (part of Family & Children Services of Niagara), Care and Share Food Pantry, and the Project Connect Niagara that help the poor and vulnerable in our community; - Hosting numerous health education and screening programs to help people learn their health risks and take steps to improve their health; - Offering a Healthcare Assistance Program to ensure that people without insurance or financial means get the care they need; - Providing health and wellness information in places of worship through our Faith Community Nursing program; - Helping refugees access quality medical care through our Primary Care and School Based Health Centers, including the Mercy Comprehensive Care Center in Buffalo's Old First Ward; - Providing free care and services to those in need, like our ""Cribs for Kids"" program, which helps families provide a safe sleeping environment for their newborns; - Supporting children and families in need through our Reach Out and Read Program; Backpack Program for Kids; and Bridget Closet (clothes for the needy); - Sponsoring programs at the Mercy Comprehensive Care Center, which serve the local community, including refugees from Burma, Somalia, the Middle East, and Nepal ; - Providing services through our Social Work Department, which link patients with necessary services including: ESL (English as a Second Language), job opportunities, substance abuse treatment, health care navigators, senior services, insurance information, parenting assistance and more; and - Supporting nationally recognized ""green"" initiatives to remain good stewards of our natural resources and protect the environment.Additional initiatives that the hospital participates in as part of CHS provide benefit to the community including: Advanced Directive / MOLST education, Community Health Fairs , Footprints on the Heart(perinatal bereavement) , McGowan Grant for Health Care Tabling Events , Marian Building & Springville, OB/GYN Clinics, Medicaid Enrollment Assistance, Neonatal Abstinence Syndrome Program in Mercy, NICU Cuddler Program, Open Access Scheduling, Osteoporosis Screening, Prenatal-perinatal Network of WNY, Quest Fit Testing, Refugee Programs, Transitional contact to Catholic Charities from Primary Care Sites, and Transportation Assistance. As part of Catholic Health, Mount St. Mary's is supportive of the initiatives above. In addition, other ways the Hospital furthers its exempt purpose by promoting the health of the community include free health screenings (Lipid Panel each February as part of Heart Month and PSA in June as part of a Father's Day promotion) and health fairs as described further in our community benefit report in Schedule O. The organization extends medical staff privileges to all qualified physicians in its community for many of its departments. The organization applies funding to improvements in patient care, such as the expanded cardiology services Women's Center for Breast Health, and it's Center for Women, which provides services at both the main hospital and the Neighborhood Health Center facility in an underserved section of the City of Niagara Falls.Other substantive community benefit initiatives supported by Mount St. Mary's Hospital include: Advanced Directive / MOLST education, Baby and Me Program, Caring Smiles Dental Program, Community Health Fairs, Medicaid Enrollment Assistance, P2 Collaborative for Adult Mental Health and Substance Abuse Screening, Tower Grant for Pediatric Care Coordination, and Transportation Assistance."

Part VI, Line 7, Reports Filed With States
NY

Operating expenses	$ 119,688,485
Total amount spent on community benefits as % of operating expenses	$ 11,924,750 9.96 %