Community Benefit Insight - Tax-exempt hospital

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Avera St Mary's

Avera St Marys

801 E Sioux Avenue
Pierre, SD 57501

Bed count	60	Medicare provider number	430015	Member of the Council of Teaching Hospitals	YES	Children's hospital	NO

EIN: 460230199

Display data for year:

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

20.65%

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	$ 423,901 0.37 %
Medicaid as % of operating expenses	$ 0 0 %
Costs of other means-tested government programs as % of operating expenses	$ 30,904 0.03 %
Health professions education as % of operating expenses	$ 16,830 0.01 %
Subsidized health services as % of operating expenses	$ 23,115,060 20.06 %
Research as % of operating expenses	$ 0 0 %
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.	$ 0 0 %
Cash and in-kind contributions for community benefit* as % of operating expenses	$ 214,058 0.19 %
Community building* as % of operating expenses	$ 4,629 0.00 %

* = 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	$ 4,629 0.00 %
Physical improvements and housing as % of community building expenses	$ 0 0 %
Economic development as % of community building expenses	$ 2,525 54.55 %
Community support as % of community building expenses	$ 0 0 %
Environmental improvements as % of community building expenses	$ 0 0 %
Leadership development and training for community members as % of community building expenses	$ 1,568 33.87 %
Coalition building as % of community building expenses	$ 536 11.58 %
Community health improvement advocacy as % of community building expenses	$ 0 0 %
Workforce development as % of community building expenses	$ 0 0 %
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	$ 6,203,708 5.38 %
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 2022 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 $ 106054658 including grants of $ 22503) (Revenue $ 105282358)
Avera St. Mary's mission is to provide healthcare services to Pierre, South Dakota residents and residents of the surrounding area. Avera St. Mary's is a 501(c)(3) organization affiliated with Avera Health. Avera St. Mary's consists of a 50-bed hospital, an 80-bed nursing home, senior living apartments, and one physician clinic in Pierre, South Dakota. The program services offered include primary care, ob/gyn, pediatrics, orthopedics, general surgery, emergency, internal medicine, oncology, podiatry, urology, dermatology, pain management, ENT, speech therapy, occupational therapy, respiratory therapy, and wound care. Avera St. Mary's provides acute care and long-term healthcare services.Following is a breakdown of these statistics by facility:Avera St. Mary's Hospital1,613 Acute patient discharges385 Newborn patient discharges32 Swing bed patient discharges53,262 Outpatient visits235 Swing-bed patient days951 Newborn patient days86,991 Clinic visitsAvera Maryhouse16,730 Long-term resident days46 Long Term Care patient dischargesAvera St. Mary's maintains records to identify and monitor the level of charity care it provides. These records include the amount of charges forgone for services and supplies furnished under its charity care policy and equivalent service statistics. The amount of charges foregone, based on established rates, were $1,864,562.Avera St. Mary's also provides community benefit health activities at less than or at no cost to support those in the area serviced, see Schedule H. As a member of the Avera Health Network, Avera St. Mary's upholds the vision of the Presentation and Benedictine Sisters to work through collaboration to provide quality, effective health ministry and to improve the healthcare of individuals and our communities through a regionally integrated network or persons and institutions. Avera St. Mary's engages in activities designed to improve the health of individuals and communities in response to a calling to heal the sick, the elderly, and the oppressed.

Facility Information

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

Avera St. Mary's
"Part V, Section B, Line 5: Avera St. Mary's gathered information regarding the needs of the community through a three-pronged process gathering stakeholder information on community perceptions of the health of Central South Dakota including a survey of the public, and interviews with identified community leaders. All members of the CHNA team were selected for roles they have in the community by a matrix developed by the Avera St. Mary's Hospital Administrative Council and included attributes such as: Uninsured/underinsured, parents of young children, close contact with underprivileged people to assure a ""voice"" in the process, health leaders with in-depth knowledge of the local health care environment, government, business, retired, South Dakota State Departments of Health and Social Services, Urban Indian Health, and Rural Health Clinics."

Avera St. Mary's
Part V, Section B, Line 6b: South Dakota Department of HealthSouth Dakota Department of Social ServicesMunicipal Government stakeholdersRural Health ClinicUrban Indian Health

Avera St. Mary's
Part V, Section B, Line 11: The Community Health Needs Assessment was completed during the 2021 tax year with approval by the Governing Board in May 2022 and as such the hospital has not taken specific actions with respect to the current implementation strategy. The following community health priority areas were identified. *Mental Health Concerns*Support for Healthy Lifestyle Choices, including -Eating Healthy/Healthy Food Choices -Physical Activities Available and AffordableDuring the community health needs assessment process, Covid-related concerns such as lack of vaccinated people and poor mitigation efforts were raised. In addition, the workforce shortage was also a concern. These issues, however, were not deemed to be pertinent to the community health needs assessment or the creation of the implementation plan. FY2022 Update: Ongoing focus on community response to the pandemic has been the priority. Avera St. Mary's leadership continues to facilitate the Pierre-Ft. Pierre Mental Health Task Force and significant strides have been made in collaboration with all stakeholders. The labor crisis in our community contributes to the various entities being unable to commit resources to these action steps. Refocusing and resuming the action steps below will be the goal in FY2023 based on the most recent CHNA.MENTAL HEALTH CONCERNSAction Step: Pierre-Ft. Pierre Mental Health Task Force to work with Statewide 211 (South Dakota Helpline) to assure that all local resources are listed in this directory and assist with promotion of 211.Action Step: The Pierre-Ft. Pierre Mental Health Task Force to evaluate the feasibility of operating a qualified regional facility in our community. Action Step: Support individuals in crisis with Mobile Crisis Response, phone, text, ecare options.Action Step: Implementation of Communities That Care (CTC) model in our community to promote healthy youth development, improve youth outcomes and reduce problem behaviors.PHYSICAL INACTIVITYAction Step: ASM to collaborate with Cities of Pierre and Fort Pierre, State Game Fish and Parks and YMCA on initiatives to encourage physical activity.Action Step: Engage local churches, youth clubs, and service organizations to promote events widely with a physical activity component.SUPPORT FOR HEALTHY EATINGAction Step: Community Education Opportunities on Preparing Healthy MealsAction Step: Increase healthier menu options at local restaurants by asking that they feature one or more low-calorie options or add a section to menu with healthier options. Many of these activities are continuations of activities the hospital has been conducting related to the prior community health needs assessment. The following health needs/priorities emerged but are beyond the scope or control of Avera St. Mary's. The issues will be referred to the appropriate community organizations:*Assistance for uninsured, beyond Avera St. Mary's financial assistance program*Affordable housing*Workforce shortage

Avera St. Mary's
Part V, Section B, Line 13h: Presumptive charity care may be applied in situations where all other avenues of financial assistance have been exhausted. The facility has the discretion to weigh extenuating circumstances when determining eligibility for and the amount of charity care to provide.

Avera St. Mary's
Part V, Section B, Line 16j: A summary of the financial assistance policy is posted in the hospital facility's emergency rooms, waiting rooms, and admissions office and included on the billing statement. In addition, the financial assistance policy is discussed with the patient upon admission to the facility.

Avera St. Mary's
Part V, Section B, Line 20e: If a patient is self-pay and has a large balance, an Avera patient advocate will help them apply for other forms of assistance. If they are not eligible for any other coverage, the patient is given a financial assistance application to complete and return to the facility.

Avera St. Mary's
Part V, Section B, Line 24: The hospital financial assistance policy does not cover elective procedures. The hospital may have charged FAP eligible patients gross charges for services that are not covered under the financial assistance policy.

Part V, Section B, Lines 7a, 7b and 10a:
avera.org/about/community-health-needs-assessments/#mary

Part V Section A website address:
avera.org/locations/st-marys/

Part V, Section B, Line 16a, 16b, and 16c:
avera.org/patients-visitors/charity-patient-assistance-programs/

Supplemental Information

Schedule H (Form 990) Part VI

Part I, Line 3c:
The methodology used to determine eligibility for financial assistance takes into consideration income, net assets, family size and resources available to pay for care. In addition, presumptive charity care may be applied in situations where all other avenues have been exhausted.

Part I, Line 7:
Charity care expense was converted to cost using an overall cost-to-charge ratio addressing all patient segments. Subsidized health services were calculated based on a combination of the Medicare cost report and an overall cost-to-charge ratio for certain expenses. Health professions education and cash and in-kind contributions are reported based on actual expenses recorded in the general ledger.

Part I, Line 7g:
Physician clinic costs are included in subsidized health services. Revenues of $15,373,970 and costs of $29,675,722 were included for a net community benefit of $14,301,752.

Part II, Community Building Activities:
Avera St. Mary's provided donations to various organizations to support activities as listed on Part II.

Part III, Line 2:
The amount on line 2 represents implicit price concessions. The Organization determines its estimate of implicit price concessions based on its historical collection experience with the respective class of patients and residents.

Part III, Line 4:
The footnote to the Organization's financial statements that describes implicit price concession is located in the audited financial statement report on pages 19 and 20.

Part III, Line 8:
Avera St. Mary's provides services to patients under the Medicare program knowing they may not recover all the costs associated with providing these services. Providing these services is essential to these patients and the community and increases their access to healthcare services. Therefore, in years the costs associated with services provided under the Medicare programs are not completely covered, the Medicare shortfall is considered a community benefit.Medicare allowable costs of care are based on the Medicare cost report. The Medicare cost report is completed based on the rules and regulations set forth by Centers for Medicare and Medicaid Services.

Part III, Line 9b:
If the patient qualifies for the organization's financial assistance policy for low-income, uninsured patients and is cooperating with the organization with regard to efforts to settle an outstanding bill within current self-pay collection policy guidelines and timeframes, the organization or its agent shall not send, nor intimate that it will send, the unpaid bill to any outside collection agency. Avera organizations will allow all individuals 120 days from the first post discharge statement to apply for financial assistance before sending the uncollected account to an outside collection agency. Avera will provide the patient with a statement or final notice that contains a listing of the specific collection action(s) it intends to initiate, and a deadline after which they may be initiated no earlier than 30 days before action is initiated. If the patient qualifies for 100% charity care, no further bills will be sent. A letter will be sent instead indicating that the patient's bill has been completely forgiven.

Part VI, Line 2:
Health care needs are assessed through various methods. Avera St. Mary's strives to deliver comprehensive care and extensive medical specialty services to community members located in central South Dakota. Avera St. Mary's is integrally involved with community organizations, the university center, schools, and state and local governments. The closest hospitals offering the same level of care and services are located 154 miles away in Mitchell, SD and 160 miles away in Aberdeen, SD. Within our regional footprint, the majority of the communities have populations of less than 2,500 people. By working with all in our region, we are able to determine health needs and provide programs and solutions where possible. In addition to activities reported in the Community Health Needs Assessment and implementation plan, Avera St. Mary's and Avera Gettysburg collaborate with the YMCA, Feeding South Dakota, The Pierre/Ft. Pierre Mental Health Task Force, the United Way, Pierre Area Referral, Pierre-Ft. Pierre Ministerial Association, City of Pierre and Ft. Pierre and River City Public Transit to assess and promote health related matters.

Part VI, Line 3:
Uninsured patients who hold an inpatient status are counseled by a Patient Advocate to screen them for coverage eligibility and to assist in payer source enrollment. Those that are not eligible are provided a charity care application along with instructions on how to fill out the application. All patients receive statements that indicate who to contact should they need financial assistance. In addition, all patients receive a summary of financial assistance upon registration, as well as in their final statement. Should a patient contact Patient Financial Services and indicate inability to pay, they are transferred to a financial counselor to assist them with the financial assistance application process. Also, inpatient and same day surgery patients receive a brochure in their admissions packet. Pre-collection letters also include information regarding the financial assistance and uninsured programs.

Part VI, Line 6:
Avera is a sponsored ministry of the Benedictine and Presentation Sisters. The communities in which Avera operates all have unique health and community benefit needs. In keeping with the Catholic Healthcare Association guidelines, each hospital strives to meet its community's identified needs. The corporate staff of Avera Health advocates for all members regarding community benefit related matters of state, regional and national importance.

Part VI, Line 4:
Avera St Mary's is a 50-bed hospital in Pierre, South Dakota. The primary service area includes Hughes, Stanley and Sully Counties. Pierre is the county seat of Hughes County as well as the capital of South Dakota. According to the U.S. Census Bureau Quick Facts 2021 data, the estimated population of Hughes County as of July 1, 2021 is 17,694. The population is predominately white at 82.2% and Native American 13.2%. It is estimated that 17.8% of the population is 65 years and over. The median household income is $69,575 with a 9.4% poverty rate. Uninsured individuals under age 65 is estimated at 12.2%.According to the U.S. Census Bureau Quick Facts 2021 data, the estimated population of Stanley County as of July 1, 2021 is 3,032. The population is predominately white at 88.7% and Native American 7.2%. It is estimated that 22.4% of the population is 65 years and over. The median household income is $71,602 with a 7.5% poverty rate. Uninsured individuals under age 65 is estimated at 9.8%.According to the U.S. Census Bureau Quick Facts 2021 data, the estimated population of Sully County as of July 1, 2021 is 1,476 and is predominately white at 94.1%. It is estimated that 26.2% of the population is 65 years and over. The median household income is $60,508 with a 7.8% poverty rate. Uninsured individuals under age 65 is estimated at 7.6%.

Part VI, Line 5:
The hospital serves all persons in the community on a non-discriminatory basis. Avera St. Mary's operates an emergency room that is open to all persons regardless of ability to pay. Avera St. Mary's has an open medical staff with privileges available to all qualified physicians in the area. The governing body is comprised of primarily independent individuals, representative of the community as a whole. Avera St. Mary's provides education and training opportunities to healthcare students enrolled in the local college, Capital City Campus. Avera St. Mary's participates in Medicaid, Medicare, Indian Health, Champus, Tricare and/or Other Government sponsored Health Care Programs.Avera St. Mary's participates in many community organizations and efforts to better the region. Leadership of the organization is on boards of many exempt organizations (Capital Area United Way, Pierre/Fort Pierre Rotary, Pierre Area Chamber of Commerce, River City Public Transit, YMCA Board, Pierre Booster Club and many more).

Operating expenses	$ 115,233,359
Total amount spent on community benefits as % of operating expenses	$ 23,800,753 20.65 %