2016 Income Tax Returns KALE I DA HEALTH Under section 501(c), 527, or 4947(a)(1) of the Internal Revenue Code (except private foundations) À¾µº Do not enter Social Security numbers on this form as it may be made public. Open to Public I I 990 Form Department of the Treasury Internal Revenue Service Information about Form 990 and its instructions is at www.irs.gov/form990. KALEIDA HEALTH Address change Doing Business As Name change Number and street (or P.O. box if mail is not delivered to street address) 16-1533232 Initial return 726 EXCHANGE STREET Terminated City or town, state or province, country, and ZIP or foreign postal code Amended return Application pending I J BUFFALO, NY 14210 Activities & Governance Revenue Expenses F Name and address of principal officer: I Room/suite 200 E Telephone number (716 ) 859-8528 G Gross receipts $ JODY LOMEO 100 HIGH STREET BUFFALO, NY 14203 X 501(c)(3) Tax-exempt status: I 501(c) ( ) (insert no.) WWW.KALEIDAHEALTH.ORG J Website: K Form of organization: X Corporation Trust Association Other Summary Part I Net Assets or Fund Balances , 20 D Employer identification number C Name of organization Check if applicable: Inspection , 2016, and ending A For the 2016 calendar year, or tax year beginning B OMB No. 1545-0047 Return of Organization Exempt From Income Tax I 1,399,460,625. Yes X No H(a) Is this a group return for subordinates? H(b) Are all subordinates included? 4947(a)(1) or I Yes No If "No," attach a list. (see instructions) 527 H(c) Group exemption number L Year of formation: 1998 NY M State of legal domicile: KALEIDA HEALTH PROVIDES HEALTHCARE SERVICES FOR THE EIGHT COUNTIES OF WNY AT FOUR ACUTE CARE, TWO LT CARE, AND OTHER OUTPATIENT AND PRIMARY CARE SITES. 1 Briefly describe the organization's mission or most significant activities: 2 3 4 5 6 7a b Check this box mmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm m mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm if the organization discontinued its operations or disposed of more than 25% of its net assets. Number of voting members of the governing body (Part VI, line 1a) Number of independent voting members of the governing body (Part VI, line 1b) Total number of individuals employed in calendar year 2016 (Part V, line 2a) Total number of volunteers (estimate if necessary) mmmmmmmmmmmmmm mmmmmmmmmmmmmm mmmmm Total unrelated business revenue from Part VIII, column (C), line 12 Net unrelated business taxable income from Form 990-T, line 34 m m m m m mm mm mm mm mm mm mm mmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmm mmmmmmm m m m m m m m m m m 0.m m m m m m m I mmmmmmmmmmmmmmmm m m m m m m m m m m mm mm mm mm mm mm mm mm mm mm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm m m m m m m m m m m m m m mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm 8 9 10 11 12 13 14 15 16 a b 17 18 19 Contributions and grants (Part VIII, line 1h) 20 21 22 Total assets (Part X, line 16) Program service revenue (Part VIII, line 2g) Investment income (Part VIII, column (A), lines 3, 4, and 7d) COPY FOR PUBLIC INSPECTION Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e) Total revenue - add lines 8 through 11 (must equal Part VIII, column (A), line 12) Grants and similar amounts paid (Part IX, column (A), lines 1-3) Benefits paid to or for members (Part IX, column (A), line 4) Salaries, other compensation, employee benefits (Part IX, column (A), lines 5-10) Professional fundraising fees (Part IX, column (A), line 11e) 15. 10. 9,565. 1,758. 4,919,671. -1,320,875. 3 4 5 6 7a 7b Prior Year Current Year 21,313,490. 39,715,656. 1,161,013,584. 1,218,391,196. 7,497,945. 9,121,642. 30,359,860. 18,538,520. 1,220,184,879. 1,285,767,014. 191,300. 464,634. 0. 0. 663,521,603. 687,042,053. 0. 0. Total fundraising expenses (Part IX, column (D), line 25) Other expenses (Part IX, column (A), lines 11a-11d, 11f-24e) Total expenses. Add lines 13-17 (must equal Part IX, column (A), line 25) Revenue less expenses. Subtract line 18 from line 12 Total liabilities (Part X, line 26) Net assets or fund balances. Subtract line 21 from line 20 Part II Signature Block M M JON SWIATKOWSKI 520,408,012. 535,475,509. 1,184,120,915. 1,222,982,196. 36,063,964. 62,784,818. Beginning of Current Year End of Year 1,138,382,417. 1,202,747,678. 948,334,948. 1,009,880,563. 190,047,469. 192,867,115. Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete. Declaration of preparer (other than officer) is based on all information of which preparer has any knowledge. Sign Here 11/15/2017 Signature of officer I I Date CFO/TREASURER Type or print name and title Print/Type preparer's name Paid MARILYN Preparer Firm's name Use Only Preparer's signature I mmmmmmmmmmmmmmmmmmmmmmmmm Date Check if self-employed E FARLEY 11/15/2017 KPMG LLP Firm's EIN 515 BROADWAY, 4TH FLOOR ALBANY, NY 12207-2974 Firm's address Phone no. May the IRS discuss this return with the preparer shown above? (see instructions) For Paperwork Reduction Act Notice, see the separate instructions. JSA 6E1065 1.000 6261CF 2214 V 16-7.6F PTIN P01231880 13-5565207 518-427-4600 X Yes No Form 990 (2016) PAGE 3 KALEIDA HEALTH Part III 1 mmmmmmmmmmmmmmmmmmmmmmmm 16-1533232 Form 990 (2016) Statement of Program Service Accomplishments Check if Schedule O contains a response or note to any line in this Part III Briefly describe the organization's mission: Page 2 X SEE SCHEDULE O. 2 3 4 mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm Did the organization undertake any significant program services during the year which were not listed on the X No prior Form 990 or 990-EZ? Yes If "Yes," describe these new services on Schedule O. Did the organization cease conducting, or make significant changes in how it conducts, any program X No services? Yes If "Yes," describe these changes on Schedule O. Describe 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. mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm 4a (Code: ) (Expenses $ 1,099,192,356. including grants of $ 464,634. ) (Revenue $ 1,219,881,229. ) ATTACHMENT 1 4b (Code: ) (Expenses $ including grants of $ ) (Revenue $ ) 4c (Code: ) (Expenses $ including grants of $ ) (Revenue $ ) I 4d Other program services (Describe in Schedule O.) (Expenses $ including grants of $ 1,099,192,356. 4e Total program service expenses JSA 6E1020 1.000 6261CF 2214 ) (Revenue $ ) Form V 16-7.6F 990 (2016) PAGE 4 KALEIDA HEALTH Form 990 (2016) Part IV 1 2 3 4 16-1533232 mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmm Is the organization described in section 501(c)(3) or 4947(a)(1) (other than a private foundation)? If "Yes," complete Schedule A Is the organization required to complete Schedule B, Schedule of Contributors (see instructions)? Did the organization engage in direct or indirect political campaign activities on behalf of or in opposition to candidates for public office? If "Yes," complete Schedule C, Part I Section 501(c)(3) organizations. Did the organization engage in lobbying activities, or have a section 501(h) election in effect during the tax year? If "Yes," complete Schedule C, Part II Is the organization a section 501(c)(4), 501(c)(5), or 501(c)(6) organization that receives membership dues, assessments, or similar amounts as defined in Revenue Procedure 98-19? If "Yes," complete Schedule C, Part III Did the organization maintain any donor advised funds or any similar funds or accounts for which donors have the right to provide advice on the distribution or investment of amounts in such funds or accounts? If "Yes," complete Schedule D, Part I Did the organization receive or hold a conservation easement, including easements to preserve open space, the environment, historic land areas, or historic structures? If "Yes," complete Schedule D, Part II Did the organization maintain collections of works of art, historical treasures, or other similar assets? If "Yes," complete Schedule D, Part III Did the organization report an amount in Part X, line 21, for escrow or custodial account liability, serve as a custodian for amounts not listed in Part X; or provide credit counseling, debt management, credit repair, or debt negotiation services? If "Yes," complete Schedule D, Part IV Did the organization, directly or through a related organization, hold assets in temporarily restricted endowments, permanent endowments, or quasi-endowments? If "Yes," complete Schedule D, Part V If the organization’s answer to any of the following questions is "Yes," then complete Schedule D, Parts VI, VII, VIII, IX, or X as applicable. Did the organization report an amount for land, buildings, and equipment in Part X, line 10? If "Yes," complete Schedule D, Part VI Did the organization report an amount for investments-other securities in Part X, line 12 that is 5% or more of its total assets reported in Part X, line 16? If "Yes," complete Schedule D, Part VII Did the organization report an amount for investments-program related in Part X, line 13 that is 5% or more of its total assets reported in Part X, line 16? If "Yes," complete Schedule D, Part VIII Did the organization report an amount for other assets in Part X, line 15 that is 5% or more of its total assets reported in Part X, line 16? If "Yes," complete Schedule D, Part IX mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm 5 mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm 6 7 8 mmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmm 9 10 11 a b c d Page 3 Checklist of Required Schedules mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmm mmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm m mmmmmmmmmmm mmmmmmmmmmmmm e Did the organization report an amount for other liabilities in Part X, line 25? If "Yes," complete Schedule D, Part X f Did the organization’s separate or consolidated financial statements for the tax year include a footnote that addresses the organization's liability for uncertain tax positions under FIN 48 (ASC 740)? If "Yes," complete Schedule D, Part X Yes 1 2 X X X 3 4 No X 5 X 6 X 7 X 8 X 9 X 10 X 11a X 11b X 11c X 11d 11e X X 11f X 12 a Did the organization obtain separate, independent audited financial statements for the tax year? If "Yes," complete Schedule D, Parts XI and XII b Was the organization included in consolidated, independent audited financial statements for the tax year? If "Yes," and if the organization answered "No" to line 12a, then completing Schedule D, Parts XI and XII is optional 13 Is the organization a school described in section 170(b)(1)(A)(ii)? If "Yes," complete Schedule E 14 a Did the organization maintain an office, employees, or agents outside of the United States? b Did the organization have aggregate revenues or expenses of more than $10,000 from grantmaking, fundraising, business, investment, and program service activities outside the United States, or aggregate foreign investments valued at $100,000 or more? If "Yes," complete Schedule F, Parts I and IV 15 Did the organization report on Part IX, column (A), line 3, more than $5,000 of grants or other assistance to or for any foreign organization? If "Yes," complete Schedule F, Parts II and IV 16 Did the organization report on Part IX, column (A), line 3, more than $5,000 of aggregate grants or other assistance to or for foreign individuals? If "Yes," complete Schedule F, Parts III and IV 17 Did the organization report a total of more than $15,000 of expenses for professional fundraising services on Part IX, column (A), lines 6 and 11e? If "Yes," complete Schedule G, Part I (see instructions) 18 Did the organization report more than $15,000 total of fundraising event gross income and contributions on Part VIII, lines 1c and 8a? If "Yes," complete Schedule G, Part II 19 Did the organization report more than $15,000 of gross income from gaming activities on Part VIII, line 9a? If "Yes," complete Schedule G, Part III mmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmm mmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm X 12a 12b 13 14a X 14b X X X 15 X 16 X 17 X 18 X 19 Form X 990 (2016) JSA 6E1021 1.000 6261CF 2214 V 16-7.6F PAGE 5 KALEIDA HEALTH 16-1533232 mmmmmmmmmmmmm mmmmmm mmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmm Form 990 (2016) Part IV 20 a b 21 22 24 a b c d 25 a b mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmm 27 28 a b c 29 30 31 32 33 34 35 a b 38 mmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmm mmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmm 26 37 Did the organization operate one or more hospital facilities? If "Yes," complete Schedule H If "Yes" to line 20a, did the organization attach a copy of its audited financial statements to this return? Did the organization report more than $5,000 of grants or other assistance to any domestic organization or domestic government on Part IX, column (A), line 1? If "Yes," complete Schedule I, Parts I and II Did the organization report more than $5,000 of grants or other assistance to or for domestic individuals on Part IX, column (A), line 2? If "Yes," complete Schedule I, Parts I and III Did the organization answer "Yes" to Part VII, Section A, line 3, 4, or 5 about compensation of the organization's current and former officers, directors, trustees, key employees, and highest compensated employees? If "Yes," complete Schedule J Did the organization have a tax-exempt bond issue with an outstanding principal amount of more than $100,000 as of the last day of the year, that was issued after December 31, 2002? If "Yes," answer lines 24b through 24d and complete Schedule K. If "No," go to line 25a Did the organization invest any proceeds of tax-exempt bonds beyond a temporary period exception? Did the organization maintain an escrow account other than a refunding escrow at any time during the year to defease any tax-exempt bonds? Did the organization act as an "on behalf of" issuer for bonds outstanding at any time during the year? Section 501(c)(3), 501(c)(4), and 501(c)(29) organizations. Did the organization engage in an excess benefit transaction with a disqualified person during the year? If "Yes," complete Schedule L, Part I Is the organization aware that it engaged in an excess benefit transaction with a disqualified person in a prior year, and that the transaction has not been reported on any of the organization's prior Forms 990 or 990-EZ? If "Yes," complete Schedule L, Part I Did the organization report any amount on Part X, line 5, 6, or 22 for receivables from or payables to any current or former officers, directors, trustees, key employees, highest compensated employees, or disqualified persons? If "Yes," complete Schedule L, Part II Did the organization provide a grant or other assistance to an officer, director, trustee, key employee, substantial contributor or employee thereof, a grant selection committee member, or to a 35% controlled entity or family member of any of these persons? If "Yes," complete Schedule L, Part III Was the organization a party to a business transaction with one of the following parties (see Schedule L, Part IV instructions for applicable filing thresholds, conditions, and exceptions): A current or former officer, director, trustee, or key employee? If "Yes," complete Schedule L, Part IV A family member of a current or former officer, director, trustee, or key employee? If "Yes," complete Schedule L, Part IV An entity of which a current or former officer, director, trustee, or key employee (or a family member thereof) was an officer, director, trustee, or direct or indirect owner? If "Yes," complete Schedule L, Part IV Did the organization receive more than $25,000 in non-cash contributions? If "Yes," complete Schedule M Did the organization receive contributions of art, historical treasures, or other similar assets, or qualified conservation contributions? If "Yes," complete Schedule M Did the organization liquidate, terminate, or dissolve and cease operations? If "Yes," complete Schedule N, Part I Did the organization sell, exchange, dispose of, or transfer more than 25% of its net assets? If "Yes," complete Schedule N, Part II Did the organization own 100% of an entity disregarded as separate from the organization under Regulations sections 301.7701-2 and 301.7701-3? If "Yes," complete Schedule R, Part I Was the organization related to any tax-exempt or taxable entity? If "Yes," complete Schedule R, Part II, III, or IV, and Part V, line 1 Did the organization have a controlled entity within the meaning of section 512(b)(13)? If "Yes" to line 35a, did the organization receive any payment from or engage in any transaction with a controlled entity within the meaning of section 512(b)(13)? If "Yes," complete Schedule R, Part V, line 2 Section 501(c)(3) organizations. Did the organization make any transfers to an exempt non-charitable related organization? If "Yes," complete Schedule R, Part V, line 2 Did the organization conduct more than 5% of its activities through an entity that is not a related organization and that is treated as a partnership for federal income tax purposes? If "Yes," complete Schedule R, Part VI Did the organization complete Schedule O and provide explanations in Schedule O for Part VI, lines 11b and 19? Note. All Form 990 filers are required to complete Schedule O. mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm 23 36 Checklist of Required Schedules (continued) mmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmm mmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmm mmmmm mmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm Page Yes 20a 20b X X 21 X No X 22 23 X 24a 24b X X 24c 24d X X 25a X 25b X 26 X 27 X 28a X 28b X 28c 29 X X 30 X 31 X 32 X 33 X 34 35a X X 35b X 36 X 37 X 38 Form 4 X 990 (2016) JSA 6E1030 1.000 6261CF 2214 V 16-7.6F PAGE 6 KALEIDA HEALTH Form 990 (2016) Part V mmmmmmmmmmmmmmmmmmmmm 600 mmmmmmmmmm 0. mmmmmmmmm X mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm 9,565 mm X mmmmmmm X mmmmmmmmmm X mmmmmmmm 16-1533232 Page Yes 1a 1 a Enter the number reported in Box 3 of Form 1096. Enter -0- if not applicable 1b b Enter the number of Forms W-2G included in line 1a. Enter -0- if not applicable c Did the organization comply with backup withholding rules for reportable payments to vendors and reportable gaming (gambling) winnings to prize winners? 2 a Enter the number of employees reported on Form W-3, Transmittal of Wage and Tax 2a Statements, filed for the calendar year ending with or within the year covered by this return b If at least one is reported on line 2a, did the organization file all required federal employment tax returns? Note. If the sum of lines 1a and 2a is greater than 250, you may be required to e-file (see instructions) 3 a Did the organization have unrelated business gross income of $1,000 or more during the year? b If "Yes," has it filed a Form 990-T for this year? If "No" to line 3b, provide an explanation in Schedule O 4 a At any time during the calendar year, did the organization have an interest in, or a signature or other authority over, a financial account in a foreign country (such as a bank account, securities account, or other financial mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm I mmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm account)? b If “Yes,” enter the name of the foreign country: 5a b c 6a b 7 a b c See instructions for filing requirements for FinCEN Form 114, Report of Foreign Bank and Financial Accounts (FBAR). Was the organization a party to a prohibited tax shelter transaction at any time during the tax year? Did any taxable party notify the organization that it was or is a party to a prohibited tax shelter transaction? If "Yes" to line 5a or 5b, did the organization file Form 8886-T? Does the organization have annual gross receipts that are normally greater than $100,000, and did the organization solicit any contributions that were not tax deductible as charitable contributions? If "Yes," did the organization include with every solicitation an express statement that such contributions or gifts were not tax deductible? Organizations that may receive deductible contributions under section 170(c). Did the organization receive a payment in excess of $75 made partly as a contribution and partly for goods and services provided to the payor? If "Yes," did the organization notify the donor of the value of the goods or services provided? Did the organization sell, exchange, or otherwise dispose of tangible personal property for which it was required to file Form 8282? 7d If "Yes," indicate the number of Forms 8282 filed during the year Did the organization receive any funds, directly or indirectly, to pay premiums on a personal benefit contract? Did the organization, during the year, pay premiums, directly or indirectly, on a personal benefit contract? mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmm mmmmm d e f g If the organization received a contribution of qualified intellectual property, did the organization file Form 8899 as required? h If the organization received a contribution of cars, boats, airplanes, or other vehicles, did the organization file a Form 1098-C? 8 Sponsoring organizations maintaining donor advised funds. Did a donor advised fund maintained by the sponsoring organization have excess business holdings at any time during the year? 9 Sponsoring organizations maintaining donor advised funds. a Did the sponsoring organization make any taxable distributions under section 4966? b Did the sponsoring organization make a distribution to a donor, donor advisor, or related person? 10 Section 501(c)(7) organizations. Enter: 10a a Initiation fees and capital contributions included on Part VIII, line 12 10b b Gross receipts, included on Form 990, Part VIII, line 12, for public use of club facilities mmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmm mmmmmmmmmm mmmmmmmmmmmmmm mmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmm mmmmmmmmmmmmmmmmmm Section 501(c)(12) organizations. Enter: 11a a Gross income from members or shareholders b Gross income from other sources (Do not net amounts due or paid to other sources 11b against amounts due or received from them.) 12 a Section 4947(a)(1) non-exempt charitable trusts. Is the organization filing Form 990 in lieu of Form 1041? 12b b If "Yes," enter the amount of tax-exempt interest received or accrued during the year 13 Section 501(c)(29) qualified nonprofit health insurance issuers. a Is the organization licensed to issue qualified health plans in more than one state? Note. See the instructions for additional information the organization must report on Schedule O. b Enter the amount of reserves the organization is required to maintain by the states in which 13b the organization is licensed to issue qualified health plans 13c c Enter the amount of reserves on hand 11 mmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm m m m m m m m mm mm mm mm mm mm 14 a Did the organization receive any payments for indoor tanning services during the tax year? b If "Yes," has it filed a Form 720 to report these payments? If "No," provide an explanation in Schedule O JSA 6E1040 1.000 5 Statements Regarding Other IRS Filings and Tax Compliance Check if Schedule O contains a response or note to any line in this Part V 6261CF 2214 1c 2b 3a 3b 4a X 5a 5b 5c X X 6a X 6b 7a 7b X 7c X 7e 7f 7g 7h X X 8 9a 9b 12a 13a 14a 14b Form V 16-7.6F No X 990 (2016) PAGE 7 mmmmmmmmmmmmmmmmmmmmmmmm KALEIDA HEALTH 16-1533232 Page 6 Governance, Management, and Disclosure For each "Yes" response to lines 2 through 7b below, and for a "No" Form 990 (2016) Part VI response to line 8a, 8b, or 10b below, describe the circumstances, processes, or changes in Schedule O. See instructions. Check if Schedule O contains a response or note to any line in this Part VI X Section A. Governing Body and Management mmmmm Yes mmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mm mmmmmm mmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmm 1a Enter the number of voting members of the governing body at the end of the tax year 1a No 15 If there are material differences in voting rights among members of the governing body, or if the governing body delegated broad authority to an executive committee or similar committee, explain in Schedule O. 10 1b b Enter the number of voting members included in line 1a, above, who are independent 2 Did any officer, director, trustee, or key employee have a family relationship or a business relationship with any other officer, director, trustee, or key employee? 3 Did the organization delegate control over management duties customarily performed by or under the direct supervision of officers, directors, or trustees, or key employees to a management company or other person? 4 Did the organization make any significant changes to its governing documents since the prior Form 990 was filed? 5 Did the organization become aware during the year of a significant diversion of the organization's assets? 6 Did the organization have members or stockholders? 7a Did the organization have members, stockholders, or other persons who had the power to elect or appoint one or more members of the governing body? b Are any governance decisions of the organization reserved to (or subject to approval by) members, stockholders, or persons other than the governing body? 8 Did the organization contemporaneously document the meetings held or written actions undertaken during the year by the following: a The governing body? b Each committee with authority to act on behalf of the governing body? 9 Is there any officer, director, trustee, or key employee listed in Part VII, Section A, who cannot be reached at the organization's mailing address? If "Yes," provide the names and addresses in Schedule O mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmm mmm m mmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmm 2 X 3 4 5 6 X X X X 7a X 7b X 8a 8b X X X 9 Section B. Policies (This Section B requests information about policies not required by the Internal Revenue Code.) 10 a Did the organization have local chapters, branches, or affiliates? b If "Yes," did the organization have written policies and procedures governing the activities of such chapters, affiliates, and branches to ensure their operations are consistent with the organization's exempt purposes? 11 a Has the organization provided a complete copy of this Form 990 to all members of its governing body before filing the form? b Describe in Schedule O the process, if any, used by the organization to review this Form 990. 12 a Did the organization have a written conflict of interest policy? If "No," go to line 13 b Were officers, directors, or trustees, and key employees required to disclose annually interests that could give rise to conflicts? c Did the organization regularly and consistently monitor and enforce compliance with the policy? If "Yes," describe in Schedule O how this was done 13 Did the organization have a written whistleblower policy? 14 Did the organization have a written document retention and destruction policy? 15 Did the process for determining compensation of the following persons include a review and approval by independent persons, comparability data, and contemporaneous substantiation of the deliberation and decision? a The organization's CEO, Executive Director, or top management official b Other officers or key employees of the organization If "Yes" to line 15a or 15b, describe the process in Schedule O (see instructions). 16 a Did the organization invest in, contribute assets to, or participate in a joint venture or similar arrangement with a taxable entity during the year? b If "Yes," did the organization follow a written policy or procedure requiring the organization to evaluate its participation in joint venture arrangements under applicable federal tax law, and take steps to safeguard the organization's exempt status with respect to such arrangements? mmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm Section C. Disclosure mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmm INY, Yes No X 10a 10b 11a X 12a X 12b X 12c 13 14 X X X 15a 15b X X 16a X 16b X 17 18 List the states with which a copy of this Form 990 is required to be filed Section 6104 requires an organization to make its Forms 1023 (or 1024 if applicable), 990, and 990-T (Section 501(c)(3)s only) available for public inspection. Indicate how you made these available. Check all that apply. X Own website X Upon request Another's website Other (explain in Schedule O) 19 Describe in Schedule O whether (and if so, how) the organization made its governing documents, conflict of interest policy, and financial statements available to the public during the tax year. State the name, address, and telephone number of the person who possesses the organization's books and records: 20 REBECCA HASLINGER 726 EXCHANGE STREET, SUITE 200 BUFFALO, NY 14210 JSA 6E1042 1.000 6261CF 2214 716-859-8528 I Form V 16-7.6F 990 (2016) PAGE 8 mmmmmmmmmmmmmmmmmmmmmm KALEIDA HEALTH 16-1533232 Page 7 Compensation of Officers, Directors, Trustees, Key Employees, Highest Compensated Employees, and Independent Contractors Check if Schedule O contains a response or note to any line in this Part VII Form 990 (2016) Part VII % % % % % Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees 1a Complete this table for all persons required to be listed. Report compensation for the calendar year ending with or within the organization's tax year. List all of the organization's current officers, directors, trustees (whether individuals or organizations), regardless of amount of compensation. Enter -0- in columns (D), (E), and (F) if no compensation was paid. List all of the organization's current key employees, if any. See instructions for definition of "key employee." List the organization's five current highest compensated employees (other than an officer, director, trustee, or key employee) who received reportable compensation (Box 5 of Form W-2 and/or Box 7 of Form 1099-MISC) of more than $100,000 from the organization and any related organizations. List all of the organization's former officers, key employees, and highest compensated employees who received more than $100,000 of reportable compensation from the organization and any related organizations. List all of the organization's former directors or trustees that received, in the capacity as a former director or trustee of the organization, more than $10,000 of reportable compensation from the organization and any related organizations. List persons in the following order: individual trustees or directors; institutional trustees; officers; key employees; highest compensated employees; and former such persons. Check this box if neither the organization nor any related organization compensated any current officer, director, or trustee. (C) (A) Name and Title Position (B) X Former X Highest compensated employee 40.00 1.00 1.00 0. 1.00 0. 1.00 0. 1.00 0. 1.00 0. 1.00 0. 1.00 0. 1.00 0. 1.00 0. 1.00 0. 1.00 0. 1.00 0. 1.00 0. Key employee PRES/CEO EX-OFFICIO W/VOTE (2) EVAN EVANS, MD DIRECTOR (3) JOHN R. KOELMEL FORMER CHAIRMAN (THRU 4/27/16) (4) DAVID A. MILLING, MD SECRETARY (5) FRANCISCO VASQUEZ, PHD DIRECTOR (6) AMY L. CLIFTON DIRECTOR (7) CHRISTOPHER T. GREENE, ESQ DIRECTOR (8) DARREN J. KING DIRECTOR (9) FRANK CURCI CHAIRMAN (10) KEVIN GIBBONS, MD DIRECTOR (11) GEORGE MATTHEWS DIRECTOR (12) NICHOLAS J. AQUINO, MD DIRECTOR (13) WILLIAM I. MAGGIO VICE CHAIR (14) CHRISTOPHER C. ROSS TREASURER Officer (1) JODY LOMEO Institutional trustee Individual trustee or director (do not check more than one Average box, unless person is both an hours per week (list any officer and a director/trustee) hours for related organizations below dotted line) (D) (E) Reportable Reportable compensation compensation from from related the organizations organization (W-2/1099-MISC) (W-2/1099-MISC) (F) Estimated amount of other compensation from the organization and related organizations 1,385,574. 0. 511,484. X 64,419. 0. 276. X 0. 0. 0. X 0. 0. 0. X 0. 0. 0. X 0. 0. 0. X 0. 0. 0. X 0. 0. 0. X 0. 0. 0. X 0. 0. 0. X 0. 0. 0. X 0. 0. 0. X 0. 0. 0. X 0. 0. Form JSA 6E1041 1.000 6261CF 2214 V 16-7.6F 0. 990 (2016) PAGE 9 KALEIDA HEALTH 16-1533232 Form 990 (2016) Part VII Page (A) Name and title (B) (C) Average Position (do not check more than one box, unless person is both an officer and a director/trustee) hours per week (list any hours for Former Highest compensated employee 1.00 0. 40.00 0. 40.00 .50 40.00 0. 40.00 .50 40.00 0. 40.00 1.00 40.00 0. 40.00 0. 40.00 0. 40.00 0. Key employee ( 15) MARY LOU RUSIN, EDD, RN DIRECTOR ( 16) ALYSON SPAULDING GENERAL COUNSEL ( 17) DAVID HUGHES, MD EVP, CMO ( 18) TONI BOOKER EVP, CHIEF HUMAN RESOURCES OFC ( 19) JONATHAN SWIATKOWSKI EVP, CFO ( 20) JAMAL GHANI FORMER EVP, COO ( 21) DONALD BOYD EVP BUSINESS DEVELOPMENT ( 22) CHRISTOPHER LANE VP PRESIDENT BGMC ( 23) CHERYL KLASS EVP, CHIEF NURSE EXECUTIVE ( 24) ALLEGRA JAROS SVP OPERATIONS WCHOB ( 25) MICHAEL HUGHES SVP, PUBLIC AFFAIRS MARKETING Officer line) Institutional trustee below dotted Individual trustee or director related organizations X (D) (E) Reportable Reportable compensation compensation from from related the organizations organization (W-2/1099-MISC) (W-2/1099-MISC) (F) Estimated amount of other compensation from the organization and related organizations 0. 0. 0. X 456,679. 0. 255,681. X 582,882. 0. 225,249. X 565,935. 0. 52,521. X 600,904. 0. 204,595. X 765,388. 0. 15,950. X 720,411. 0. 75,077. X 516,243. 0. 69,558. X 656,776. 0. 57,498. X 423,719. 0. 66,719. X 353,581. 0. 0. 0. 0. 114,218. 511,760. 1,325,811. 1,837,571. m m m m m m m m m m m m m m m m m m m m m m m m m mm mm mm mm mm mm mm mm mm mm mm mm mm I m m m m m m m m m m m m m m m m m m m m m m m m m m m m II I 1b c d 2 1,449,993. Sub-total 9,393,385. Total from continuation sheets to Part VII, Section A 10,843,378. Total (add lines 1b and 1c) Total number of individuals (including but not limited to those listed above) who received more than $100,000 of reportable compensation from the organization 640 3 Did the organization list any former officer, director, or trustee, key employee, or highest compensated employee on line 1a? If "Yes," complete Schedule J for such individual mmmmmmmmmmmmmmmmmmmmmmmmmm 3 X For any individual listed on line 1a, is the sum of reportable compensation and other compensation from the organization and related organizations greater than $150,000? If “Yes,” complete Schedule J for such individual 4 X 4 mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmm Yes No Did any person listed on line 1a receive or accrue compensation from any unrelated organization or individual for services rendered to the organization? If “Yes,” complete Schedule J for such person 5 Section B. Independent Contractors 1 Complete this table for your five highest compensated independent contractors that received more than $100,000 of compensation from the organization. Report compensation for the calendar year ending with or within the organization's tax year. 5 8 Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees (continued) (A) Name and business address (B) Description of services X (C) Compensation ATTACHMENT 2 2 I Total number of independent contractors (including but not limited to those listed above) who received more than $100,000 in compensation from the organization 71 JSA 6E1055 2.000 6261CF 2214 V 16-7.6F Form 990 (2016) PAGE 10 KALEIDA HEALTH 16-1533232 Form 990 (2016) Part VII Page (A) Name and title (B) (C) Average Position (do not check more than one box, unless person is both an officer and a director/trustee) hours per week (list any hours for Former 40.00 0. 40.00 0. 40.00 0. 40.00 0. 40.00 0. 0. 0. Highest compensated employee Key employee ( 26) AARON HOFFMAN, MD EMPLOYED PHYSICIAN ( 27) CHRISTOPHER MALLAVARAPU, MD EMPLOYED PHYSICIAN ( 28) CARROLL HARMON, MD EMPLOYED PHYSICIAN ( 29) KATHRYN BASS, MD EMPLOYED PHYSICIAN ( 30) LAN ADAMS, MD EMPLOYED PHYSICIAN ( 31) JAMES KASKIE FORMER CEO Officer line) Institutional trustee below dotted Individual trustee or director related organizations (D) (E) Reportable Reportable compensation compensation from from related the organizations organization (W-2/1099-MISC) (W-2/1099-MISC) (F) Estimated amount of other compensation from the organization and related organizations X 830,325. 0. 49,624. X 901,132. 0. 47,987. X 639,019. 0. 10,242. X 586,856. 0. 40,774. X 601,518. 0. 40,118. 192,017. 0. 0. X m m m m m m m m m m m m m m m m m m m m m m m m m mm mm mm mm mm mm mm mm mm mm mm mm mm I m m m m m m m m m m m m m m m m m m m m m m m m m m m m II I 1b c d 2 Sub-total Total from continuation sheets to Part VII, Section A Total (add lines 1b and 1c) Total number of individuals (including but not limited to those listed above) who received more than $100,000 of reportable compensation from the organization 640 3 Did the organization list any former officer, director, or trustee, key employee, or highest compensated employee on line 1a? If "Yes," complete Schedule J for such individual mmmmmmmmmmmmmmmmmmmmmmmmmm 3 X For any individual listed on line 1a, is the sum of reportable compensation and other compensation from the organization and related organizations greater than $150,000? If “Yes,” complete Schedule J for such individual 4 X 4 mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmm Yes No Did any person listed on line 1a receive or accrue compensation from any unrelated organization or individual for services rendered to the organization? If “Yes,” complete Schedule J for such person 5 Section B. Independent Contractors 1 Complete this table for your five highest compensated independent contractors that received more than $100,000 of compensation from the organization. Report compensation for the calendar year ending with or within the organization's tax year. 5 (A) Name and business address 2 8 Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees (continued) (B) Description of services I X (C) Compensation Total number of independent contractors (including but not limited to those listed above) who received more than $100,000 in compensation from the organization JSA 6E1055 2.000 6261CF 2214 V 16-7.6F Form 990 (2016) PAGE 11 KALEIDA HEALTH Statement of Revenue Part VIII Contributions, Gifts, Grants Program Service Revenue and Other Similar Amounts Check if Schedule O contains a response or note to any line in this Part VIII mmmmmmmm mmmmmmmmmm mmmmmmmmm mmmmmmmm mm m mmmmmmmmmmmmmmmmmmI Federated campaigns 1a b Membership dues 1b c Fundraising events 1c d Related organizations 1d 26,490,261. e Government grants (contributions) 1e 12,313,942. f All other contributions, gifts, grants, 1a g h (A) Total revenue (C) Unrelated business revenue 9 (D) Revenue excluded from tax under sections 512-514 3,764,608. Noncash contributions included in lines 1a-1f: $ Total. Add lines 1a-1f 39,715,656. Business Code NET PATIENT SERVICE REVENUE 623990 1,212,542,689. b MANAGEMENT FEES 561000 72,900. 72,900. c LAB SERVICES 621500 5,775,607. 5,775,607. 2a d e f g m m m m m m mm mm mm mm mm m m m m m m m I mmmmmmmmmmmmmmmmI m m m m m m m m m m m m m m m m m m m m m m m mm II mmmmmmmm mmm m mm m m m m m m m m m m m m m m m I All other program service revenue Total. Add lines 2a-2f Investment 3 income (including dividends, 1,218,391,196. 7,977,167. 6a Less: rental expenses Rental income or (loss) Net rental income or (loss) Gross amount from sales of (i) Securities assets other than inventory 114,754,788. 83,298. 113,659,437. 34,174. 1,095,351. 49,124. 8a 2,301,498. 2,374,861. mmmm m m mm mm mm mm mm m m m m m m m m m m m m m m m Gain or (loss) Net gain or (loss) 2,374,861. (ii) Other Less: cost or other basis and sales expenses c d 73,363. 0. 2,374,861. Gross rents c d b 9,136,825. (ii) Personal b 7a -1,159,658. 0. Income from investment of tax-exempt bond proceeds Royalties (i) Real 1,212,542,689. interest, and other similar amounts) 4 5 Other Revenue (B) Related or exempt function revenue Page 911,453. 1f and similar amounts not included above mmmmmmmmmmmmmmmmmmmmmmmm 16-1533232 Form 990 (2016) I 1,144,475. mmmmmmmmmmm mmmmmmmmmm mmmmmmm I mmmmmmmmmmm mmmmmmmmmm mmmmmmm I mmmmmmmmm mmmmmmmmmmmmmmmmm I Gross income from fundraising 1,144,475. events (not including $ of contributions reported on line 1c). a 0. b Less: direct expenses Net income or (loss) from fundraising events 0. See Part IV, line 18 b c 9a b c 10a b c Gross income from gaming activities. See Part IV, line 19 a 0. b Less: direct expenses Net income or (loss) from gaming activities 0. Gross sales of inventory, returns and allowances a 0. b 0. 0. Business Code mmmmmmmmmmmmm m m m mm mm mm mm mm mm mm mm mm mm mm mm mm I I 900099 10,388,942. b UNIVERSITY LEASE INCOME 531120 1,234,980. c MANAGEMENT & CONSULTING FEES 541610 980,891. 976,416. 4,475. d All other revenue 900099 3,558,846. 513,617. 152,984. 1,214,032,722. 4,919,671. 11a e 12 REBATE REVENUE 0. less Less: cost of goods sold Net income or (loss) from sales of inventory Miscellaneous Revenue 0. Total. Add lines 11a-11d Total revenue. See instructions. JSA 6E1051 1.000 6261CF 2214 10,388,942. 1,234,980. 2,892,245. 16,163,659. 1,285,767,014. V 16-7.6F 27,098,965. Form 990 (2016) PAGE 12 mmmmmmmmmmmmmmmmmmmmmmmm KALEIDA HEALTH Part IX Statement of Functional Expenses 16-1533232 Form 990 (2016) Page 10 Section 501(c)(3) and 501(c)(4) organizations must complete all columns. All other organizations must complete column (A). Check if Schedule O contains a response or note to any line in this Part IX mmmm mmmmmmmmm Do not include amounts reported on lines 6b, 7b, 8b, 9b, and 10b of Part VIII. 1 Grants and other assistance to domestic organizations and domestic governments. See Part IV, line 21 2 Grants and other assistance individuals. See Part IV, line 22 to domestic mmmmm mmmmmmmmm mmmmmmmmmm 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 mmmmmm mmmmmmmmmmmm (A) Total expenses (B) Program service expenses 464,634. (C) Management and general expenses (D) Fundraising expenses 464,634. 0. 0. 0. 7,161,170. 7,161,170. 6 Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) mmmmmmmmmmmm mmmmmmmmmmmmmmmmmm m m m m mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmm m mmmmmmmmm mATCH m m m m3m m m m m m mm mm mm mm mm mm mm mm mm mm mm mmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmm 7 Other salaries and wages 8 Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) 9 Other employee benefits 10 Payroll taxes Fees for services (non-employees): a Management 11 b Legal c Accounting d Lobbying e Professional fundraising services. See Part IV, line 17 f Investment management fees g Other. 94,559. 502,266,131. 468,050,420. 94,559. 34,215,711. 32,289,571. 108,519,661. 36,710,961. 28,692,513. 98,619,175. 34,146,172. 3,597,058. 9,900,486. 2,564,789. 827,405. 72,765. 928,617. 444,996. 247,505. 124,809,177. 2,964,877. 1,987,923. 10,283,789. 516,392. 422,393. 4,966,273. 748,591. 11,961,779. 271,825. 10,671,792. 2,667,948. 45,405,019. 4,994,309. 16,044,974. 2,361,625. 209,184,629. 209,621,824. 29,678,019. 13,022,180. 26,531,307. 27,677,845. 11,776,819. 9,971,280. 14,704,761. 11,478,182. 1,222,982,196. 1,099,192,356. -437,195. 16,655,839. -1,146,538. 1,805,539. 3,226,579. 123,789,840. 0. 1,756,022. 517,761. 247,505. 0. 0. (If line 11g amount exceeds 10% of line 25, column (A) amount, list line 11g expenses on Schedule O.) 12 Advertising and promotion 13 Office expenses 14 Information technology 15 Royalties 16 Occupancy 17 Travel 18 Payments of travel or entertainment expenses for any federal, state, or local public officials 19 Conferences, conventions, and meetings 20 Interest 21 Payments to affiliates 22 Depreciation, depletion, and amortization 23 Insurance 24 Other mmmm mmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmm mmmm mmmmmmmmmmmmmmmmmmm expenses. Itemize expenses not 135,092,966. 3,481,269. 2,410,316. 0. 0. 16,928,052. 1,020,416. 0. 0. 13,339,740. 0. 61,449,993. 7,355,934. 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 HEALTH CARE SUPPLIES RENTAL & MAINTENANCE b EQPT c OTHER d SERVICE CONTRACTS e All other expenses m Im m m m m m 25 Total functional expenses. Add lines 1 through 24e 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) JSA 6E1052 1.000 6261CF 2214 0. Form V 16-7.6F 990 (2016) PAGE 13 KALEIDA HEALTH Net Assets or Fund Balances Liabilities Assets Part X mmmmmmmmmmmmmmmmmmmmm 16-1533232 Form 990 (2016) Page Balance Sheet Check if Schedule O contains a response or note to any line in this Part X mmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmm 1 2 3 4 5 Cash - non-interest-bearing Savings and temporary cash investments Pledges and grants receivable, net Accounts receivable, net Loans and other receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of Schedule L 6 Loans and other receivables from other disqualified persons (as defined under section 4958(f)(1)), persons described in section 4958(c)(3)(B), and contributing employers and sponsoring organizations of section 501(c)(9) voluntary employees' beneficiary organizations (see instructions). Complete Part II of Schedule L mmmmmmmmmmmmmmmmmmmmmmmmm m m m m m m m m m m m m m mm mm mm mm mm mm mm mm mm mm mm mm m m m m m m m m mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm (A) Beginning of year 11 (B) End of year 41,396,112. 44,682,583. 0. 159,866,006. 1 2 3 4 23,733,732. 10,080,703. 0. 164,283,239. 0. 5 0. 0. 6 0. 0. 7 0. Notes and loans receivable, net 25,724,911. 8 27,764,208. Inventories for sale or use 10,908,230. 9 15,364,653. Prepaid expenses and deferred charges Land, buildings, and equipment: cost or 1697240957. 10a other basis. Complete Part VI of Schedule D 1136335001. 481,932,950. 10c 560,905,956. 10b b Less: accumulated depreciation 74,551,845. 11 118,829,598. 11 Investments - publicly traded securities 66,484,188. 12 49,738,308. 12 Investments - other securities. See Part IV, line 11 0. 13 0. 13 Investments - program-related. See Part IV, line 11 0. 14 0. 14 Intangible assets 232,835,592. 15 232,047,281. 15 Other assets. See Part IV, line 11 1,138,382,417. 16 1,202,747,678. 16 Total assets. Add lines 1 through 15 (must equal line 34) 149,661,885. 17 155,402,146. 17 Accounts payable and accrued expenses 0. 18 0. 18 Grants payable 0. 19 0. 19 Deferred revenue 0. 20 9,843,323. 20 Tax-exempt bond liabilities 0. 21 0. 21 Escrow or custodial account liability. Complete Part IV of Schedule D 22 Loans and other payables to current and former officers, directors, trustees, key employees, highest compensated employees, and 0. 22 0. disqualified persons. Complete Part II of Schedule L 313,990,121. 23 349,965,673. 23 Secured mortgages and notes payable to unrelated third parties ATCH 4 0. 24 0. 24 Unsecured notes and loans payable to unrelated third parties 25 Other liabilities (including federal income tax, payables to related third parties, and other liabilities not included on lines 17-24). Complete Part X 484,682,942. 25 494,669,421. of Schedule D 948,334,948. 26 1,009,880,563. Total liabilities. Add lines 17 through 25 26 X and Organizations that follow SFAS 117 (ASC 958), check here complete lines 27 through 29, and lines 33 and 34. 7 8 9 10 a mmmmmmmmmm mmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmm mmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm m m m m m m m m m m m m m m mm mm mm mm mm mm mm mm mm mm mmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmm mmmm mmmmmmmmmmmmmm mmmmmmm mmmmmmmmm 27 28 29 m m m m m m m m m m m m m m mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm I mmmmmmmmmmmmmmmmmmmmmmmmmmmmm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm I mmmmmmmmmmmmmmmm mmmmmmmm mmmm m m m m m m mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm Unrestricted net assets Temporarily restricted net assets Permanently restricted net assets Organizations that do not follow SFAS 117 (ASC 958), check here complete lines 30 through 34. 30 31 32 33 34 Capital stock or trust principal, or current funds Paid-in or capital surplus, or land, building, or equipment fund Retained earnings, endowment, accumulated income, or other funds Total net assets or fund balances Total liabilities and net assets/fund balances 67,087,683. 27 103,226,405. 28 19,733,381. 29 86,795,710. 85,831,208. 20,240,197. and 30 31 32 190,047,469. 33 1,138,382,417. 34 192,867,115. 1,202,747,678. Form 990 (2016) JSA 6E1053 1.000 6261CF 2214 V 16-7.6F PAGE 14 m m m m m m m m m m m m1,285,767,014. mmmmmmmm X mmmmmmmmmmmmmmmmmmmmmmm 1,222,982,196. mmmmmmmmmmmmmmmmmmmmmmm 62,784,818. mmmmmmmmmmmmmmmmmmmmmmmmmm 190,047,469. mmmmm -207,690. mmmmmmmmmmmmmmmmmmmmmmmmmmmmm 0. mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm 0. mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm 0. mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm -59,757,482. mmmmmmmmmmmmmmmm 192,867,115. mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm Financial Statements and Reporting Check if Schedule O contains a response or note to any line in this Part XII m m m m m m m m m m m m m m m m m m m KALEIDA HEALTH 16-1533232 Form 990 (2016) Part XI 1 2 3 4 5 6 7 8 9 10 Total revenue (must equal Part VIII, column (A), line 12) Total expenses (must equal Part IX, column (A), line 25) Revenue less expenses. Subtract line 2 from line 1 Net assets or fund balances at beginning of year (must equal Part X, line 33, column (A)) Net unrealized gains (losses) on investments Donated services and use of facilities Investment expenses Prior period adjustments Other changes in net assets or fund balances (explain in Schedule O) Net assets or fund balances at end of year. Combine lines 3 through 9 (must equal Part X, line 33, column (B)) Part XII 1 Page 12 Reconciliation of Net Assets Check if Schedule O contains a response or note to any line in this Part XI 1 2 3 4 5 6 7 8 9 10 mmmmmmm Yes No X Accrual Accounting method used to prepare the Form 990: Cash Other If the organization changed its method of accounting from a prior year or checked "Other," explain in Schedule O. 2 a Were the organization's financial statements compiled or reviewed by an independent accountant? If "Yes," check a box below to indicate whether the financial statements for the year were compiled or reviewed on a separate basis, consolidated basis, or both: Separate basis Consolidated basis mmmmmmmmmmmmmm Both consolidated and separate basis b Were the organization's financial statements audited by an independent accountant? If "Yes," check a box below to indicate whether the financial statements for the year were audited on a separate basis, consolidated basis, or both: Separate basis X Consolidated basis X 2a 2b X 2c X 3a X Both consolidated and separate basis c If "Yes" to line 2a or 2b, does the organization have a committee that assumes responsibility for oversight of the audit, review, or compilation of its financial statements and selection of an independent accountant? If the organization changed either its oversight process or selection process during the tax year, explain in Schedule O. 3 a As a result of a federal award, was the organization required to undergo an audit or audits as set forth in the Single Audit Act and OMB Circular A-133? b If "Yes," did the organization undergo the required audit or audits? If the organization did not undergo the required audit or audits, explain why in Schedule O and describe any steps taken to undergo such audits. mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm 3b Form X 990 (2016) JSA 6E1054 1.000 6261CF 2214 V 16-7.6F PAGE 15 SCHEDULE A I I (Form 990 or 990-EZ) Complete if the organization is a section 501(c)(3) organization or a section 4947(a)(1) nonexempt charitable trust. Department of the Treasury Internal Revenue Service Attach to Form 990 or Form 990-EZ. Information about Schedule A (Form 990 or 990-EZ) and its instructions is at www.irs.gov/form990. Name of the organization À¾µº OMB No. 1545-0047 Public Charity Status and Public Support Open to Public Inspection Employer identification number KALEIDA HEALTH 16-1533232 Reason for Public Charity Status (All organizations must complete this part.) See instructions. Part I The organization is not a private foundation because it is: (For lines 1 through 12, check only one box.) 1 A church, convention of churches, or association of churches described in section 170(b)(1)(A)(i). 2 A school described in section 170(b)(1)(A)(ii). (Attach Schedule E (Form 990 or 990-EZ).) 3 X A hospital or a cooperative hospital service organization described in section 170(b)(1)(A)(iii). 4 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: 5 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.) 6 A federal, state, or local government or governmental unit described in section 170(b)(1)(A)(v). 7 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.) 8 A community trust described in section 170(b)(1)(A)(vi). (Complete Part II.) 9 An agricultural research organization described in section 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: 10 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.) 11 An organization organized and operated exclusively to test for public safety. See section 509(a)(4). 12 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). a b c d mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm e f g (i) Name of supported organization (ii) EIN (iii) Type of organization (described on lines 1-10 above (see instructions)) (iv) Is the organization listed in your governing document? Yes (v) Amount of monetary support (see instructions) (vi) Amount of other support (see instructions) No (A) (B) (C) (D) (E) Total For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ. Schedule A (Form 990 or 990-EZ) 2016 JSA 6E1210 1.000 6261CF 2214 V 16-7.6F PAGE 16 KALEIDA HEALTH 16-1533232 Schedule A (Form 990 or 990-EZ) 2016 Page Part II 2 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 fails to qualify under the tests listed below, please complete Part III.) Section A. Public Support I mmmmmm Calendar year (or fiscal year beginning in) 1 Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") 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) Public support. Subtract line 5 from line 4. 6 (a) 2012 (b) 2013 (c) 2014 (d) 2015 (e) 2016 (f) Total (a) 2012 (b) 2013 (c) 2014 (d) 2015 (e) 2016 (f) Total mmmmmmm mmmmmmm mmmmmmm mmmmmmm m m m m m m m m mIm Section B. Total Support Calendar year (or fiscal year beginning in) mmmmmmmmmmmmmmmmm 7 8 Amounts from line 4 9 Net income from unrelated business activities, whether or not the business is regularly carried on Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources mmmmmmmmmm mmmmmmmmmmm mm 10 Other income. Do not include gain or loss from the sale of capital assets (Explain in Part VI.) 11 12 Total support. Add lines 7 through 10 13 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 mmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm I Section C. Computation of Public Support Percentage mmmmmmmm mmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmm I mmmmmmmmmmmmmmm I Gross receipts from related activities, etc. (see instructions) 12 14 14 Public support percentage for 2016 (line 6, column (f) divided by line 11, column (f)) 15 15 Public support percentage from 2015 Schedule A, Part II, line 14 16a 33 1/3 % support test - 2016. 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 b 33 1/3 % support test - 2015. 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 17a 10%-facts-and-circumstances test - 2016. 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 b 10%-facts-and-circumstances test - 2015. 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 18 Private foundation. If the organization did not check a box on line 13, 16a, 16b, 17a, or 17b, check this box and see instructions % % mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm I mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm I mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm I Schedule A (Form 990 or 990-EZ) 2016 JSA 6E1220 1.000 6261CF 2214 V 16-7.6F PAGE 17 KALEIDA HEALTH 16-1533232 Schedule A (Form 990 or 990-EZ) 2016 Page 3 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 Part III Calendar year (or fiscal year beginning in) 1 I (a) 2012 (b) 2013 (c) 2014 (d) 2015 (e) 2016 (f) Total (a) 2012 (b) 2013 (c) 2014 (d) 2015 (e) 2016 (f) Total Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") 2 mmmmmm m 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 mmmmmmm 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 mmmmmmm mmmmmmm mmmm or facilities furnished by a governmental unit to the organization without charge 6 Total. Add lines 1 through 5 7 a Amounts included on lines 1, 2, and 3 received from disqualified persons b Amounts included on lines 2 and 3 mmmmmmmmmmm mmmmmmmmmmmmmmmmm Section B. Total Support m m m m m m m m m m Im received from other than disqualified persons that exceed the greater of $5,000 or 1% of the amount on line 13 for the year 8 c Add lines 7a and 7b Public support. (Subtract line 7c from line 6.) Calendar year (or fiscal year beginning in) mmmmmmmmmmmmmmmmm 9 Amounts from line 6 10 a Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources m m m mm mm mm mm mm mm b Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975 mmmmmmmmmmmmmmm c Add lines 10a and 10b 11 12 Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on Other income. Do not include gain or loss from the sale of capital assets (Explain in Part VI.) mmmmmmmmmmm mmmmmmmmmmmmmmmm m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m mI m m m m m m m m m mm mm mm mm mm mm mm mm mm mm mm mm mm mm 13 Total support. (Add lines 9, 10c, 11, 14 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) and 12.) organization, check this box and stop here Section C. Computation of Public Support Percentage mmmmmmmmmm mmmmmmmmmmmmmmmmmmmm 15 Public support percentage for 2016 (line 8, column (f) divided by line 13, column (f)) 15 16 Public support percentage from 2015 Schedule A, Part III, line 15 16 Section D. Computation of Investment Income Percentage 17 Investment income percentage for 2016 (line 10c, column (f) divided by line 13, column (f)) 17 18 Investment income percentage from 2015 Schedule A, Part III, line 17 18 19 a 33 1/3 % support tests - 2016. 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 b 33 1/3 % support tests - 2015. If the organization did not check a box on line 14 or line 19a, and line 16 is more than 33 1/3 %, and 20 line 18 is not more than 33 1/3 %, check this box and stop here. The organization qualifies as a publicly supported organization Private foundation. If the organization did not check a box on line 14, 19a, or 19b, check this box and see instructions JSA 6E1221 1.000 6261CF 2214 I I I % % % % Schedule A (Form 990 or 990-EZ) 2016 V 16-7.6F PAGE 18 KALEIDA HEALTH 16-1533232 Page 4 Supporting Organizations (Complete only if you checked a box in line 12 on 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 No Schedule A (Form 990 or 990-EZ) 2016 Part IV 1 2 3a b c 4a b c 5a b c 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. 1 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). 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. 3a 3b 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. 4b 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. 4c 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). 5a 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? 3c 4a 5b 5c Did the organization provide support (whether in the form of grants or the provision of services or facilities) to 6 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 7 8 9a b c 10 a b benefit one or more of the filing organization’s supported organizations? If "Yes," provide detail in Part VI. 6 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). 7 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. 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 10b below. 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.) JSA 6E1229 1.000 8 9a 9b 9c 10a 10b Schedule A (Form 990 or 990-EZ) 2016 6261CF 2214 V 16-7.6F PAGE 19 KALEIDA HEALTH 16-1533232 Schedule A (Form 990 or 990-EZ) 2016 Part IV Page 5 Supporting Organizations (continued) Yes No 11 a b c 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? A family member of a person described in (a) above? 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. 11a 11b 11c Section B. Type I Supporting Organizations Yes No 1 2 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. 1 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. 2 Section C. Type II Supporting Organizations Yes No 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). 1 1 Section D. All Type III Supporting Organizations Yes No 1 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? 1 2 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). 2 3 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. 3 Section E. Type III Functionally Integrated Supporting Organizations 1 a b c 2 a b 3 a b 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). Yes No Activities Test. Answer (a) and (b) below. 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. 2a 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. 2b 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. 3a 3b Schedule A (Form 990 or 990-EZ) 2016 JSA 6E1230 1.000 6261CF 2214 V 16-7.6F PAGE 20 KALEIDA HEALTH 16-1533232 Schedule A (Form 990 or 990-EZ) 2016 Part V Page 6 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. (B) Current Year Section A - Adjusted Net Income (A) Prior 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 1 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) 7 Other expenses (see instructions) 8 Adjusted Net Income (subtract lines 5, 6, and 7 from line 4). 6 7 8 (A) Prior Year Section B - Minimum Asset Amount 1 Aggregate fair market value of all non-exempt-use assets (see instructions for short tax year or assets held for part of year): a Average monthly value of securities b Average monthly cash balances c Fair market value of other non-exempt-use assets d Total (add lines 1a, 1b, and 1c) e Discount claimed for blockage or other factors (explain in detail in Part VI): 2 Acquisition indebtedness applicable to non-exempt-use assets 3 Subtract line 2 from line 1d. 4 Cash deemed held for exempt use. Enter 1-1/2% of line 3 (for greater amount, see instructions). 5 Net value of non-exempt-use assets (subtract line 4 from line 3) 6 Multiply line 5 by .035. 7 Recoveries of prior-year distributions 8 Minimum Asset Amount (add line 7 to line 6) (B) Current Year (optional) 1a 1b 1c 1d 2 3 4 5 6 7 8 Current Year Section C - Distributable Amount Adjusted net income for prior year (from Section A, line 8, Column A) 1 Enter 85% of line 1. 2 Minimum asset amount for prior year (from Section B, line 8, Column A) 3 Enter greater of line 2 or line 3. 4 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 7 Check here if the current year is the organization’s first as a non-functionally integrated Type III supporting organization (see instructions). 1 2 3 4 5 Schedule A (Form 990 or 990-EZ) 2016 JSA 6E1231 1.000 6261CF 2214 V 16-7.6F PAGE 21 KALEIDA HEALTH 16-1533232 Schedule A (Form 990 or 990-EZ) 2016 Part V Page 7 Type III Non-Functionally Integrated 509(a)(3) Supporting Organizations (continued) Section D - Distributions 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. 7 Total 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 2016 from Section C, line 6 10 Line 8 amount divided by Line 9 amount (i) Excess Distributions Section E - Distribution Allocations (see instructions) Current Year (ii) Underdistributions Pre-2016 (iii) Distributable Amount for 2016 Distributable amount for 2016 from Section C, line 6 Underdistributions, if any, for years prior to 2016 (reasonable cause required-explain in Part VI). See instructions. Excess distributions carryover, if any, to 2016: 1 2 3 a b c d e f g h i j 4 a b c 5 6 7 8 a b c d e mmmmmmmm mmmmmmmm mmmmmmmm From 2013 From 2014 From 2015 Total of lines 3a through e Applied to underdistributions of prior years Applied to 2016 distributable amount Carryover from 2011 not applied (see instructions) Remainder. Subtract lines 3g, 3h, and 3i from 3f. Distributions for 2016 from Section D, line 7: $ Applied to underdistributions of prior years Applied to 2016 distributable amount Remainder. Subtract lines 4a and 4b from 4. Remaining underdistributions for years prior to 2016, if any. Subtract lines 3g and 4a from line 2. For result greater than zero, explain in Part VI. See instructions. Remaining underdistributions for 2016. Subtract lines 3h and 4b from line 1. For result greater than zero, explain in Part VI. See instructions. Excess distributions carryover to 2017. Add lines 3j and 4c. Breakdown of line 7: Excess Excess Excess Excess from from from from 2013 2014 2015 2016 mmmm mmmm mmmm mmmm Schedule A (Form 990 or 990-EZ) 2016 JSA 6E1232 1.000 6261CF 2214 V 16-7.6F PAGE 22 KALEIDA HEALTH 16-1533232 Schedule A (Form 990 or 990-EZ) 2016 Part VI Page 8 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.) Schedule A (Form 990 or 990-EZ) 2016 JSA 6E1225 2.000 6261CF 2214 V 16-7.6F PAGE 23 Schedule B (Form 990, 990-EZ, or 990-PF) Department of the Treasury Internal Revenue Service I I Attach to Form 990, Form 990-EZ, or Form 990-PF. Information about Schedule B (Form 990, 990-EZ, or 990-PF) and its instructions is at www.irs.gov/form990. Name of the organization À¾µº OMB No. 1545-0047 Schedule of Contributors Employer identification number KALEIDA HEALTH 16-1533232 Organization type (check one): Filers of: Section: Form 990 or 990-EZ X 501(c)( 3 ) (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 X 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 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 33 1/3 % 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 mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm I 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 990-PF, 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. Schedule B (Form 990, 990-EZ, or 990-PF) (2016) JSA 6E1251 1.000 6261CF 2214 V 16-7.6F PAGE 24 Page 2 Schedule B (Form 990, 990-EZ, or 990-PF) (2016) Name of organization KALEIDA HEALTH Employer identification number 16-1533232 Part I 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 1 $ 5,100. (d) Type of contribution Person Payroll Noncash X (Complete Part II for noncash contributions.) (a) No. (b) Name, address, and ZIP + 4 (c) Total contributions 2 $ 6,315. (d) Type of contribution Person Payroll Noncash X (Complete Part II for noncash contributions.) (a) No. (b) Name, address, and ZIP + 4 (c) Total contributions 3 $ 482,150. (d) Type of contribution Person Payroll Noncash X (Complete Part II for noncash contributions.) (a) No. (b) Name, address, and ZIP + 4 (c) Total contributions 4 $ 9,499. (d) Type of contribution Person Payroll Noncash X (Complete Part II for noncash contributions.) (a) No. (b) Name, address, and ZIP + 4 (c) Total contributions 5 $ 169,165. (d) Type of contribution Person Payroll Noncash X (Complete Part II for noncash contributions.) (a) No. (b) Name, address, and ZIP + 4 (c) Total contributions 6 $ 63,601. (d) Type of contribution Person Payroll Noncash X (Complete Part II for noncash contributions.) Schedule B (Form 990, 990-EZ, or 990-PF) (2016) JSA 6E1253 1.000 6261CF 2214 V 16-7.6F PAGE 25 Page 2 Schedule B (Form 990, 990-EZ, or 990-PF) (2016) Name of organization KALEIDA HEALTH Employer identification number 16-1533232 Part I 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 7 $ 8,831. (d) Type of contribution Person Payroll Noncash X (Complete Part II for noncash contributions.) (a) No. (b) Name, address, and ZIP + 4 (c) Total contributions 8 $ 16,100. (d) Type of contribution Person Payroll Noncash X (Complete Part II for noncash contributions.) (a) No. (b) Name, address, and ZIP + 4 (c) Total contributions 9 $ 10,223. (d) Type of contribution Person Payroll Noncash X (Complete Part II for noncash contributions.) (a) No. (b) Name, address, and ZIP + 4 (c) Total contributions 10 $ 14,742. (d) Type of contribution Person Payroll Noncash X (Complete Part II for noncash contributions.) (a) No. (b) Name, address, and ZIP + 4 (c) Total contributions 11 $ 14,508. (d) Type of contribution Person Payroll Noncash X (Complete Part II for noncash contributions.) (a) No. (b) Name, address, and ZIP + 4 (c) Total contributions 12 $ 471,534. (d) Type of contribution Person Payroll Noncash X (Complete Part II for noncash contributions.) Schedule B (Form 990, 990-EZ, or 990-PF) (2016) JSA 6E1253 1.000 6261CF 2214 V 16-7.6F PAGE 26 Page 2 Schedule B (Form 990, 990-EZ, or 990-PF) (2016) Name of organization KALEIDA HEALTH Employer identification number 16-1533232 Part I 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 13 $ 6,602,193. (d) Type of contribution Person Payroll Noncash X (Complete Part II for noncash contributions.) (a) No. (b) Name, address, and ZIP + 4 (c) Total contributions 14 $ 5,676,649. (d) Type of contribution Person Payroll Noncash X (Complete Part II for noncash contributions.) (a) No. (b) Name, address, and ZIP + 4 (c) Total contributions 15 $ 116,318. (d) Type of contribution Person Payroll Noncash X (Complete Part II for noncash contributions.) (a) No. (b) Name, address, and ZIP + 4 (c) Total contributions 16 $ 3,166,626. (d) Type of contribution Person Payroll Noncash X X (Complete Part II for noncash contributions.) (a) No. (b) Name, address, and ZIP + 4 (c) Total contributions 17 $ 22,852,101. (d) Type of contribution Person Payroll Noncash X X (Complete Part II for noncash contributions.) (a) No. (b) Name, address, and ZIP + 4 (c) Total contributions 18 $ 30,000. (d) Type of contribution Person Payroll Noncash X (Complete Part II for noncash contributions.) Schedule B (Form 990, 990-EZ, or 990-PF) (2016) JSA 6E1253 1.000 6261CF 2214 V 16-7.6F PAGE 27 Schedule B (Form 990, 990-EZ, or 990-PF) (2016) Name of organization Page KALEIDA HEALTH 3 Employer identification number 16-1533232 Part II Noncash Property (See instructions). Use duplicate copies of Part II if additional space is needed. (a) No. from Part I (c) FMV (or estimate) (b) Description of noncash property given (See instructions) (d) Date received MEDICAL EQUIPMENT 16 $ (a) No. from Part I 2,247,827. (c) FMV (or estimate) (b) Description of noncash property given (See instructions) VAR (d) Date received MEDICAL EQUIPMENT 17 $ (a) No. from Part I 1,516,781. (c) FMV (or estimate) (b) Description of noncash property given (See instructions) VAR (d) Date received $ (a) No. from Part I (c) FMV (or estimate) (b) Description of noncash property given (See instructions) (d) Date received $ (a) No. from Part I (c) FMV (or estimate) (b) Description of noncash property given (See instructions) (d) Date received $ (a) No. from Part I (c) FMV (or estimate) (b) Description of noncash property given (See instructions) (d) Date received $ Schedule B (Form 990, 990-EZ, or 990-PF) (2016) JSA 6E1254 1.000 6261CF 2214 V 16-7.6F PAGE 28 Schedule B (Form 990, 990-EZ, or 990-PF) (2016) Name of organization Part III Page KALEIDA HEALTH 4 Employer identification number 16-1533232 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 I (b) Purpose of gift (c) Use of gift (d) Description of how gift is held (e) Transfer of gift Transferee's name, address, and ZIP + 4 (a) No. from Part I (b) Purpose of gift Relationship of transferor to transferee (c) Use of gift (d) Description of how gift is held (e) Transfer of gift Transferee's name, address, and ZIP + 4 (a) No. from Part I (b) Purpose of gift Relationship of transferor to transferee (c) Use of gift (d) Description of how gift is held (e) Transfer of gift Transferee's name, address, and ZIP + 4 (a) No. from Part I (b) Purpose of gift Relationship of transferor to transferee (c) Use of gift (d) Description of how gift is held (e) Transfer of gift Transferee's name, address, and ZIP + 4 Schedule B (Form 990, 990-EZ, or 990-PF) (2016) JSA 6E1255 1.000 6261CF 2214 Relationship of transferor to transferee V 16-7.6F PAGE 29 SCHEDULE C (Form 990 or 990-EZ) % % % % % % Department of the Treasury Internal Revenue Service II I Political Campaign and Lobbying Activities À¾µº OMB No. 1545-0047 For Organizations Exempt From Income Tax Under section 501(c) and section 527 Complete if the organization is described below. Attach to Form 990 or Form 990-EZ. Information about Schedule C (Form 990 or 990-EZ) and its instructions is at www.irs.gov/form990. 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 Section 501(c)(3) organizations: Complete Parts I-A and B. Do not complete Part I-C. Section 501(c) (other than section 501(c)(3)) organizations: Complete Parts I-A and C below. Do not complete Part I-B. 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 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. 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 Section 501(c)(4), (5), or (6) organizations: Complete Part III. Name of organization Employer identification number KALEIDA HEALTH 16-1533232 Complete if the organization is exempt under section 501(c) or is a section 527 organization. Part I-A 1 2 3 Part I-B 1 2 3 4a b m m m m m m m m m m m m m m m m m m m m mI mmmmmmmmmmmmmmmmmm Complete if the organization is exempt under section 501(c)(3). mmmmmm I mm m m m m m m m m Im m m m m m m m mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm 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) $ Volunteer hours for political campaign activities (see instructions) Enter the amount of any excise tax incurred by the organization under section 4955 Enter the amount of any excise tax incurred by organization managers under section 4955 If the organization incurred a section 4955 tax, did it file Form 4720 for this year? Was a correction made? If "Yes," describe in Part IV. Part I-C $ $ mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm I mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm I mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm I mmmmmmmmmmmmmmmmmmmmmmmmmmmm Yes No Yes No Complete if the organization is exempt under section 501(c), except section 501(c)(3). 1 Enter the amount directly expended by the filing organization for section 527 exempt function activities $ 2 Enter the amount of the filing organization's funds contributed to other organizations for section 527 exempt function activities $ 3 Total exempt function expenditures. Add lines 1 and 2. Enter here and on Form 1120-POL, line 17b $ 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. 4 5 (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. Schedule C (Form 990 or 990-EZ) 2016 JSA 6E1264 1.000 6261CF 2214 V 16-7.6F PAGE 30 I Check I KALEIDA HEALTH 16-1533232 Page 2 Complete if the organization is exempt under section 501(c)(3) and filed Form 5768 (election under section 501(h)). 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). if the filing organization checked box A and "limited control" provisions apply. Schedule C (Form 990 or 990-EZ) 2016 Part II-A A Check B 1a b c d e f mmmmm m m m m m m m m m m m m m m m m mm mm mm mm mm mmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmm Limits on Lobbying Expenditures (The term "expenditures" means amounts paid or incurred.) (a) Filing organization's totals (b) Affiliated group totals Total lobbying expenditures to influence public opinion (grass roots lobbying) Total lobbying expenditures to influence a legislative body (direct lobbying) Total lobbying expenditures (add lines 1a and 1b) Other exempt purpose expenditures Total exempt purpose expenditures (add lines 1c and 1d) 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: g h i j Not over $500,000 20% 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. mmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm Grassroots nontaxable amount (enter 25% of line 1f) Subtract line 1g from line 1a. If zero or less, enter -0Subtract line 1f from line 1c. If zero or less, enter -0If 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 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.) No Lobbying Expenditures During 4-Year Averaging Period Calendar year (or fiscal year beginning in) (a) 2013 (b) 2014 (c) 2015 (d) 2016 (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) 2016 JSA 6E1265 1.000 6261CF 2214 V 16-7.6F PAGE 31 KALEIDA HEALTH 16-1533232 Page Schedule C (Form 990 or 990-EZ) 2016 Part II-B For each "Yes," response on lines 1a through 1i below, provide in Part IV a detailed description of the lobbying activity. 1 a b c d e f g h i j 2a b c d mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m mm mmmmmmmmmmmmmmmmmmmmmmmmmmm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mmmmmm mmmm m m m m m m m mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mmm mmmmmmmmmmmmmmmmm m m m mm mm 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? Total. Add lines 1c through 1i 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 (a) Yes (b) No Part III-B X X X X X X X 247,505. X X Complete if the organization is exempt under section 501(c)(4), section 501(c)(5), or section 501(c)(6). mmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmm 2 Section 162(e) nondeductible lobbying and political expenditures (do not include amounts of political expenses for w hich 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) a b c m m m m m m m m m m m m m m m m m m m m mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm Part IV Yes No 1 2 3 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 5 89,156. 158,349. X X 1 3 4 Amount 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 campaign activity expenditures from the prior year? 1 2 3 3 Complete if the organization is exempt under section 501(c)(3) and has NOT filed Form 5768 (election under section 501(h)). 1 2a 2b 2c 3 4 5 Supplemental Information Provide the descriptions required for Part I-A, line 1; Part I-B, line 4; Part I-C, line 5; Part II-A (affiliated group list); Part II-A, lines 1 and 2 (see instructions); and Part II-B, line 1. Also, complete this part for any additional information. SEE PAGE 4 Schedule C (Form 990 or 990-EZ) 2016 JSA 6E1266 1.000 6261CF 2214 V 16-7.6F PAGE 32 KALEIDA HEALTH 16-1533232 Schedule C (Form 990 or 990-EZ) 2016 Part IV Page 4 Supplemental Information (continued) GRANTS TO OTHER ORGANIZATIONS & DIRECT CONTACT WITH LEGISLATIVE BODY SCHEDULE C, PART II-B, QUESTIONS 1F AND 1G THE AMOUNT REFLECTED FOR PART II-B, QUESTION 1F REPRESENTS THE PORTION OF THE DUES PAID TO THE GREATER NEW YORK HOSPITAL ASSOCIATION ATTRIBUTABLE TO LOBBYING ACTIVITIES. THE AMOUNT REFLECTED FOR PART II-B, QUESTION 1G REPRESENTS PAYMENTS MADE TO ORGANIZATIONS IN AN EFFORT TO ADVOCATE ON THE ORGANIZATION'S BEHALF AT THE NEW YORK STATE AND FEDERAL LEVELS AS IT SPECIFICALLY RELATES TO HEALTH CARE LEGISLATION AND REGULATORY ISSUES. Schedule C (Form 990 or 990-EZ) 2016 JSA 6E1500 1.000 6261CF 2214 V 16-7.6F PAGE 33 SCHEDULE D (Form 990) Department of the Treasury Internal Revenue Service Name of the organization I I 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. À¾µº Attach to Form 990. Information about Schedule D (Form 990) and its instructions is at www.irs.gov/form990. Open to Public Inspection I OMB No. 1545-0047 Supplemental Financial Statements Employer identification number KALEIDA HEALTH 16-1533232 Organizations Maintaining Donor Advised Funds or Other Similar Funds or Accounts. Part I Complete if the organization answered "Yes" on Form 990, Part IV, line 6. mmmmmmmmmmm mm mmmmmmmmmm (a) Donor advised funds (b) Funds and other accounts Total number at end of year Aggregate value of contributions to (during year) Aggregate value of grants from (during year) 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? 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? 1 2 3 4 5 mmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm 6 Part II 1 2 a b c d 3 4 5 Yes No Yes No 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 a 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 Held at the End of the Tax Year easement on the last day of the tax year. 2a Total number of conservation easements 2b Total acreage restricted by conservation easements 2c Number of conservation easements on a certified historic structure included in (a) Number o f conservation easements included in (c) acquired af ter 8 /17/06, and not on a 2d historic structure listed in the National Register Number of conservation easements modified, transferred, released, extinguished, or terminated by the organization during the tax year Number of states where property subject to conservation easement is located 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 I I I mmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmm mmmmm mmmmmmmmmmmmmmmmmmmmmmmm I mmmmmmmmmmmmmmmmmmmmmm 6 Staff and volunteer hours devoted to monitoring, inspecting, handling of violations, and enforcing conservation easements during the year 7 Amount of expenses incurred in monitoring, inspecting, handling of violations, and enforcing conservation easements during the year 8 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 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. 9 Part III 1a b 2 a b mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm $ No 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 SFAS 116 (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 SFAS 116 (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 in Form 990, Part VIII, line 1 $ (ii) Assets included in Form 990, Part X $ 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 SFAS 116 (ASC 958) relating to these items: Revenue included in Form 990, Part VIII, line 1 $ Assets included in Form 990, Part X $ mmmmmmmmmmmmmmmmmmmmmmmmmmmmmm m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m II m m m m m m mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm II For Paperwork Reduction Act Notice, see the Instructions for Form 990. JSA 6E1268 1.000 6261CF 2214 V 16-7.6F Schedule D (Form 990) 2016 PAGE 34 KALEIDA HEALTH 16-1533232 Schedule D (Form 990) 2016 Part III Page 2 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): a Public exhibition d Loan or exchange programs b Scholarly research e Other c Preservation for future generations 4 Provide a description of the organization's collections and explain how they further the organization's exempt purpose in Part XIII. 5 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 3 Part IV mmmmmm 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. mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm 1 a Is the organization an agent, trustee, custodian or other intermediary for contributions or other assets not included on Form 990, Part X? 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 2 a Did the organization include an amount on Form 990, Part X, line 21, for escrow or custodial account liability? b If "Yes," explain the arrangement in Part XIII. Check here if the explanation has been provided on Part XIII mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm Part V mmmm mmmmmmmmmmm mmmmmmmmmmmmm mmmmmm mmmmmmmmmmm mmmmm mmmmmmmm (a) Current year (b) Prior year (c) Two years back 30,738,989. 1,435,796. 30,087,437. 1,656,821. Yes (d) Three years back I I mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmm Part VI mmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmm mmmmmmmmmm mmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmm 46,995,623. 3,133,756. 2,880,650. 24,365,488. 28,644,541. Yes 3a(i) 3a(ii) X 3b X No X 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 6,713,867. Land 509,115,193. 358,135,110. Buildings Leasehold improvements 1165959196. 768,173,500. Equipment 15,452,701. 10,026,391. Other Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10c.) 1a b c d e No (e) Four years back 28,644,541. 1,589,183. 1 a Beginning of year balance b Contributions c Net investment earnings, gains, -6,512,169. -1,046,152. 850,732. 1,819,135. and losses d Grants or scholarships e Other expenditures for facilities -2,358,931. 1,306,974. 1,856,001. 1,965,422. and programs f Administrative expenses 27,439,305. 29,821,659. 30,738,989. 30,087,437. g End of year balance 2 Provide the estimated percentage of the current year end balance (line 1g, column (a)) held as: 74.6700 % a Board designated or quasi-endowment b Permanent endowment % 25.3300 % c Temporarily restricted endowment The percentages on lines 2a, 2b, and 2c should equal 100%. 3 a Are there endowment funds not in the possession of the organization that are held and administered for the organization by: (i) unrelated organizations (ii) related organizations b If "Yes" on line 3a(ii), are the related organizations listed as required on Schedule R? 4 Describe in Part XIII the intended uses of the organization's endowment funds. I No mmmmmmmmmm Endowment Funds. Complete if the organization answered “Yes” on Form 990, Part IV, line 10. 29,821,659. 1,770,884. Yes m m m m m m mI (d) Book value 6,713,867. 150,980,083. 397,785,696. 5,426,310. 560,905,956. Schedule D (Form 990) 2016 JSA 6E1269 1.000 6261CF 2214 V 16-7.6F PAGE 35 KALEIDA HEALTH 16-1533232 Schedule D (Form 990) 2016 Part VII Page mmmmmmmmmmmmmmmmm mmmmmmmmmmmmm (a) Description of security or category (including name of security) (1) Financial derivatives (2) Closely-held equity interests (3) Other (A) (B) (C) (D) (E) (F) (G) (H) Total. (Column (b) must equal Form 990, Part X, col. (B) line 12.) Part VIII (b) Book value (c) Method of valuation: Cost or end-of-year market value I Investments - Program 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 (1) (2) (3) (4) (5) (6) (7) (8) (9) Total. (Column (b) must equal Form 990, Part X, col. (B) line 13.) Part IX (b) Book value (c) Method of valuation: Cost or end-of-year market value I Other Assets. Complete if the organization answered "Yes" on Form 990, Part IV, line 11d. See Form 990, Part X, line 15. (a) Description (1) DEFERRED FINANCING (2) INTEREST IN NET ASSETS OF FDNS (3) OTHER RECEIVABLES (4) OTHER ASSETS (5) ESTIMATED 3RD PARTY PAYOR REC (6) GRANT RECEIVABLE - LT (7) (8) (9) Total. (Column (b) must equal Form 990, Part X, col. (B) line 15.) Part X (b) Book value mmmmmmmmmmmmmmmmmmmmmmmmmm I 11,069,506. 136,548,290. 39,724,716. 27,668,244. 14,451,655. 2,584,870. 232,047,281. Other Liabilities. Complete if the organization answered "Yes" on Form 990, Part IV, line 11e or 11f. See Form 990, Part X, line 25. (a) Description of liability 1. (1) Federal income taxes (2) DUE TO THIRD PARTY PAYORS (3) SELF INSURANCE LIABILITY (4) OTHER LIABILITIES (5) PENSION LIABILITY (6) ASSET RETIREMENT OBLIGATIONS (7) CAPITAL LEASE OBLIGATIONS (8) CONSTRUCTION PAYABLE (9) Total. (Column (b) must equal Form 990, Part X, col. (B) line 25.) (b) Book value I 18,883,081. 146,611,429. 20,359,841. 288,441,474. 13,600,635. 6,772,961. 494,669,421. 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 JSA 6E1270 1.000 3 Investments - Other Securities. Complete if the organization answered "Yes" on Form 990, Part IV, line 11b. See Form 990, Part X, line 12. 6261CF 2214 X Schedule D (Form 990) 2016 V 16-7.6F PAGE 36 KALEIDA HEALTH Schedule D (Form 990) 2016 Part XI 1 2 a b c d e 3 4 a b c 5 a b c d e 3 4 a b c 5 4 1 2a 2b 2c 2d 2e 3 4a 4b mmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmm m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m mm mm mm mm mm mm mm mm mm mm mm mm mm 4c 5 Reconciliation of Expenses per Audited Financial Statements With Expenses per Return. Complete if the organization answered "Yes" on Form 990, Part IV, line 12a. Total expenses and losses per audited financial statements Amounts included on line 1 but not on Form 990, Part IX, line 25: Donated services and use of facilities Prior year adjustments Other losses Other (Describe in Part XIII.) Add lines 2a through 2d Subtract line 2e from line 1 Amounts included on Form 990, Part IX, line 25, but not on line 1: Investment expenses not included on Form 990, Part VIII, line 7b Other (Describe in Part XIII.) Add lines 4a and 4b Total expenses. Add lines 3 and 4c. (This must equal Form 990, Part I, line 18.) Part XIII Page Reconciliation of Revenue per Audited Financial Statements With Revenue per Return. Complete if the organization answered "Yes" on Form 990, Part IV, line 12a. Total revenue, gains, and other support per audited financial statements Amounts included on line 1 but not on Form 990, Part VIII, line 12: Net unrealized gains (losses) on investments Donated services and use of facilities Recoveries of prior year grants Other (Describe in Part XIII.) Add lines 2a through 2d Subtract line 2e from line 1 Amounts included on Form 990, Part VIII, line 12, but not on line 1: Investment expenses not included on Form 990, Part VIII, line 7b Other (Describe in Part XIII.) Add lines 4a and 4b Total revenue. Add lines 3 and 4c. (This must equal Form 990, Part I, line 12.) Part XII 1 2 mmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmm m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m mm mm mm mm mm mm mm mm mm mm mm mm mm mm 16-1533232 1 2a 2b 2c 2d 2e 3 4a 4b 4c 5 Supplemental Information. Provide the descriptions required for Part II, lines 3, 5, and 9; Part III, lines 1a and 4; Part IV, 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. SEE PAGE 5 JSA Schedule D (Form 990) 2016 6E1271 1.000 6261CF 2214 V 16-7.6F PAGE 37 KALEIDA HEALTH Supplemental Information (continued) 16-1533232 Schedule D (Form 990) 2016 Part XIII Page 5 INTENDED USE OF ENDOWMENTS: SCHEDULE D, PART V, QUESTION 4 THE FOLLOWING ARE THE INTENDED USES OF THE ORGANIZATION'S ENDOWMENT FUNDS: 1) CAPITAL EXPANSION AND IMPROVEMENT 2) ADVANCEMENT OF MEDICAL EDUCATION AND RESEARCH AND HEALTH CARE SERVICES 3) SUPPORT PEDIATRIC HEALTH CARE SERVICES FIN 48 FOOTNOTE: SCHEDULE D, PART X, QUESTION 2 KALEIDA RECOGNIZES INCOME TAX POSITIONS WHEN IT IS MORE-LIKELY THAN-NOT THAT THE POSITION WILL BE SUSTAINABLE BASED ON THE MERITS OF THE POSITION. MANAGEMENT HAS CONCLUDED THAT THERE ARE NO MATERIAL UNCERTAIN TAX POSITIONS THAT NEED TO BE RECORDED. Schedule D (Form 990) 2016 JSA 6E1226 1.000 6261CF 2214 V 16-7.6F PAGE 38 SCHEDULE F (Form 990) Department of the Treasury Internal Revenue Service I I À¾µº I Statement of Activities Outside the United States OMB No. 1545-0047 Complete if the organization answered "Yes" on Form 990, Part IV, line 14b, 15, or 16. Attach to Form 990. Information about Schedule F (Form 990) and its instructions is at www.irs.gov/form990. Name of the organization Open to Public Inspection Employer identification number KALEIDA HEALTH 16-1533232 Part I General Information on Activities Outside the United States. Complete if the organization answered "Yes" on mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm Form 990, Part IV, line 14b. For grantmakers. Does the organization maintain records to substantiate the amount of its grants and other assistance, the grantees' eligibility for the grants or assistance, and the selection criteria used to award the grants or assistance? 1 Yes 2 For grantmakers. Describe in Part V the organization's procedures for monitoring the use of its grants and other assistance outside the United States. 3 Activities per Region. (The following Part I, line 3 table can be duplicated if additional space is needed.) (a) Region (b) Number of offices in the region (c) Number of employees, agents, and independent contractors in the region (1) CENTRAL AMERICA/CARIBBEAN (d) Activities conducted in the region (by type) (such as, fundraising, program services, investments, grants to recipients located in the region) INVESTMENTS (e) If activity listed in (d) is a program service, describe specific type of service(s) in the region No (f) Total expenditures for and investments in the region 32,679,282. (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) mmmmmmmmmmm mmmmmmm (16) (17) 3a b c Sub-total Total from continuation sheets to Part I Totals (add lines 3a and 3b) 32,679,282. 32,679,282. For Paperwork Reduction Act Notice, see the Instructions for Form 990. JSA 6E1274 1.000 6261CF 2214 V 16-7.6F Schedule F (Form 990) 2016 PAGE 39 KALEIDA HEALTH 16-1533232 Schedule F (Form 990) 2016 Part II (a) Name of organization 1 Page 2 Grants and Other Assistance to Organizations or Entities Outside the United States. Complete if the organization answered "Yes" on Form 990, Part IV, line 15, for any recipient who received more than $5,000. Part II can be duplicated if additional space is needed. (b) IRS code section and EIN (if applicable) (c) Region (d) Purpose of grant (e) Amount of cash grant (f) Manner of cash disbursement (g) Amount of noncash assistance (h) Description of noncash assistance (i) Method of valuation (book, FMV, appraisal, other) (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) m m m m m m m m m m m m m m m m m m m m m m m m m mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm II (16) 2 3 Enter total number of recipient organizations listed above that are recognized as charities by the foreign country, recognized as tax-exempt by the IRS, or for which the grantee or counsel has provided a section 501(c)(3) equivalency letter Enter total number of other organizations or entities Schedule F (Form 990) 2016 JSA 6E1275 1.000 6261CF 2214 V 16-7.6F PAGE 40 KALEIDA HEALTH 16-1533232 Schedule F (Form 990) 2016 Part III Page 3 Grants and Other Assistance to Individuals Outside the United States. Complete if the organization answered "Yes" on Form 990, Part IV, line 16. Part III can be duplicated if additional space is needed. (a) Type of grant or assistance (b) Region (c) Number of recipients (d) Amount of cash grant (e) Manner of cash disbursement (f) Amount of noncash assistance (g) Description of noncash assistance (h) Method of valuation (book, FMV, appraisal, other) (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17) (18) Schedule F (Form 990) 2016 JSA 6E1276 1.000 6261CF 2214 V 16-7.6F PAGE 41 KALEIDA HEALTH 16-1533232 Schedule F (Form 990) 2016 Part IV 1 2 3 4 5 6 Foreign Forms Page mmmmmmmmmmmmmmmmmmmmmmmmmmmmmm Was the organization a U.S. transferor of property to a foreign corporation during the tax year? If "Yes," the organization may be required to file Form 926, Return by a U.S. Transferor of Property to a Foreign Corporation (see Instructions for Form 926) X mmmm Did the organization have an interest in a foreign trust during the tax year? If "Yes," the organization may be required to separately file Form 3520, Annual Return To Report Transactions With Foreign Trusts and Receipt of Certain Foreign Gifts, and/or Form 3520-A, Annual Information Return of Foreign Trust With a U.S. Owner (see Instructions for Forms 3520 and 3520-A; do not file with Form 990) mmmmmmmmmmmmmmmmmmmmm Did the organization have an ownership interest in a foreign corporation during the tax year? If "Yes," the organization may be required to file Form 5471, Information Return of U.S. Persons With Respect To Certain Foreign Corporations (see Instructions for Form 5471) Yes Yes No X No X Yes No Was the organization a direct or indirect shareholder of a passive foreign investment company or a qualified electing fund during the tax year? If "Yes," the organization may be required to file Form 8621, Information Return by a Shareholder of a Passive Foreign Investment Company or Qualified Electing Fund (see Instructions for Form 8621) X Yes No Did the organization have an ownership interest in a foreign partnership during the tax year? If "Yes," the organization may be required to file Form 8865, Return of U.S. Persons With Respect to Certain Foreign Partnerships (see Instructions for Form 8865) X Yes No mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmm Did the organization have any operations in or related to any boycotting countries during the tax year? If "Yes," the organization may be required to separately file Form 5713, International Boycott Report (see Instructions for Form 5713; do not file with Form 990) Yes 4 X No Schedule F (Form 990) 2016 JSA 6E1277 1.000 6261CF 2214 V 16-7.6F PAGE 42 KALEIDA HEALTH 16-1533232 Schedule F (Form 990) 2016 Part V Page Supplemental Information Provide the information required by Part I, line 2 (monitoring of funds); Part I, line 3, column (f) (accounting method; amounts of investments vs. expenditures per region); Part II, line 1 (accounting method); Part III (accounting method); and Part III, column (c) (estimated number of recipients), as applicable. Also complete this part to provide any additional information (see instructions). Schedule F (Form 990) 2016 JSA 6E1502 2.000 5 6261CF 2214 V 16-7.6F PAGE 43 SCHEDULE H (Form 990) I Department of the Treasury Internal Revenue Service Name of the organization I I À¾µº Hospitals OMB No. 1545-0047 Complete if the organization answered "Yes" on Form 990, Part IV, question 20. Attach to Form 990. Information about Schedule H (Form 990) and its instructions is at www.irs.gov/form990. Open to Public Inspection Employer identification number mmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm KALEIDA HEALTH Financial Assistance and Certain Other Community Benefits at Cost Part I 16-1533232 1a Did the organization have a financial assistance policy during the tax year? If "No," skip to question 6a b If "Yes," was it a written policy? 2 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. X Applied uniformly to all hospital facilities Applied uniformly to most hospital facilities Generally tailored to individual hospital facilities Yes No 1a X 1b X 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. 3 a 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: 100% 150% X 200% Other % mmmmmmmmmmmmm b 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: 200% 250% 300% 350% X 400% Other 3a X 3b X % c 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. mmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm 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"? 4 5a Did the organization budget amounts for free or discounted care provided under its financial assistance policy during the tax year? b If "Yes," did the organization's financial assistance expenses exceed the budgeted amount? c If "Yes" to line 5b, as a result of budget considerations, was the organization unable to provide free or discounted care to a patient who was eligible for free or discounted care? 6a Did the organization prepare a community benefit report during the tax year? b If "Yes," did the organization make it available to the public? Complete the following table using the worksheets provided in the Schedule H instructions. Do not submit these worksheets with the Schedule H. 7 Financial Assistance and Certain Other Community Benefits at Cost mmmm mmmmmmmm mm mmmmmmmm Financial Assistance and Means-Tested Government Programs a Financial Assistance at cost (from Worksheet 1) b Medicaid (from Worksheet 3, column a) (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 4 5a 5b X X X 5c 6a 6b X X X (f) Percent of total expense 12,104,216. 7,403,369. 4,700,847. .38 355,749,804. 256,839,481. 98,910,323. 8.09 367,854,020. 264,242,850. 103,611,170. 8.47 6,306,184. .52 c Costs of other means-tested d government programs (from Worksheet 3, column b) Total Financial Assistance and Means-Tested Government Programs m mmmm mmmmmmmm Other Benefits e f Community health improvement services and community benefit operations (from Worksheet 4) Health professions education (from Worksheet 5) g Subsidized health services (from Worksheet 6) mmmmmmmm m m mm mm 6,306,184. 53,734,461. 22,423,801. 31,310,660. 2.56 35,765,829. 8,420,955. 27,344,874. 2.24 95,806,474. 463,660,494. 30,844,756. 295,087,606. 137,325. 65,099,043. 168,710,213. .01 5.33 13.80 h Research (from Worksheet 7) i Cash and in-kind contributions for community benefit (from Worksheet 8) j Total. Other Benefits k Total. Add lines 7d and 7j For Paperwork Reduction Act Notice, see the Instructions for Form 990. JSA 6E1284 1.000 6261CF 2214 Schedule H (Form 990) 2016 V 16-7.6F PAGE 44 KALEIDA HEALTH 16-1533232 Schedule H (Form 990) 2016 Page 2 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. Part II (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 2 Economic development 3 Community support 4 Environmental improvements 5 Leadership development and training for community members 6 Coalition building 7 Community health improvement 172 93,426. 93,426. .01 172 38992 93,426. Bad Debt, Medicare, & Collection Practices 93,426. .01 advocacy 38992 8 Workforce development 9 Other 10 Total Part III mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmm Section A. Bad Debt Expense 1 Did the organization report bad debt expense in accordance with Healthcare Financial Management Association Statement No. 15? 2 Enter the amount of the organization's bad debt expense. Explain in Part VI the 9,391,417. methodology used by the organization to estimate this amount 2 3 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, 575,224. 3 if any, for including this portion of bad debt as community benefit Yes 1 No X mmmmmmmmmmmm mmmmmmmmmm mmmmmmmmmm mmmmmmmmmmmmmmmm 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 184,107,379. 5 5 Enter total revenue received from Medicare (including DSH and IME) 166,009,319. 6 6 Enter Medicare allowable costs of care relating to payments on line 5 18,098,060. 7 7 Subtract line 6 from line 5. This is the surplus (or shortfall) 8 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: X Cost to charge ratio Cost accounting system Other Section C. Collection Practices 9a Did the organization have a written debt collection policy during the tax year? 9a 4 mmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmm X b 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 9b X Management Companies and Joint Ventures (owned 10% or more by officers, directors, trustees, key employees, and physicians - see instructions) collection practices to be followed for patients who are known to qualify for financial assistance? Describe in Part VI Part IV (a) Name of entity 1 MFSC, LLC 2 COMMUNITY MEDICAL 3 GENERAL PHYSICIANS 4 HARLEM ROAD LEASING 5 AMTON IMAGING, LLC 6 WNY HEALTHENET, LLC 7 SITE E, LLC 8 ALTUS MANAGEMENT 9 SOUTHTOWNS IMAGING 10 COLLABORATIVE CARE 11 GL MEDICAL BILLING 12 GREAT LAKES PHYS, PC 13 SOUTHTOWNS SURG CTR JSA 6E1285 1.000 6261CF 2214 (b) Description of primary activity of entity PHYSICIAN SERVICES PHYSICIAN SERVICES PHYSICIAN SERVICES MRI EQUIPMENT LEASING HEALTH CARE SERVICES HEALTH CARE SERVICES REAL ESTATE LEASING CO GROUP PURCHASING ORGANIZATION IMAGING EQUIPMENT LEASING HEALTH CARE SERVICES MEDICAL BILLING PHYSICIAN SERVICES PHYSICIAN SERVICES (c) Organization's profit % or stock ownership % 55.76791 (d) Officers, directors, trustees, or key employees' profit % or stock ownership % (e) Physicians' profit % or stock ownership % 44.23210 100.00000 100.00000 50.00000 50.00000 14.28572 50.15134 49.91650 70.00000 60.00000 50.00000 63.17136 100.00000 36.82864 Schedule H (Form 990) 2016 V 16-7.6F PAGE 45 KALEIDA HEALTH 16-1533232 Schedule H (Form 990) 2016 Part V Page 3 Facility Information ER-other ER-24 hours Research facility Critical access hospital Teaching hospital Children's hospital General medical & surgical BUFFALO GENERAL MEDICAL CENTER 100 HIGH STREET BUFFALO NY 14203 WWW.KALEIDAHEALTH.ORG 1401014H 2 WOMEN & CHILDREN'S HOSPITAL OF BUFFAL 219 BRYANT STREET BUFFALO NY 14222 WWW.KALEIDAHEALTH.ORG 1401014H 3 MILLARD FILLMORE SUBURBAN HOSPITAL 1540 MAPLE ROAD WILLIAMSVILLE NY 14221 WWW.KALEIDAHEALTH.ORG 1401014H 4 DEGRAFF MEMORIAL HOSPITAL 445 TREMONT STREET NORTH TONAWANDA NY 14120 WWW.KALEIDAHEALTH.ORG 1401014H Licensed hospital Section A. Hospital Facilities (list in order of size, from largest to smallest - see instructions) How many hospital facilities did the organization operate during 4 the tax year? Name, 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) Other (describe) Facility reporting group 1 X X X X A X X X X X A X X X X A X X X X A 5 6 7 8 9 10 JSA 6E1286 1.000 6261CF 2214 Schedule H (Form 990) 2016 V 16-7.6F PAGE 46 KALEIDA HEALTH 16-1533232 Schedule H (Form 990) 2016 Part V Page 4 Facility 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) Name of hospital facility or letter of facility reporting group GROUP A Line number of hospital facility, or line numbers of hospital facilities in a facility reporting group (from Part V, Section A): Community Health Needs Assessment 1 2 3 a b c d e f g h i j 4 5 6a b 7 a b c d 8 9 10 a b 11 12 a b c 1-4 mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmm 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 If "Yes," indicate what the CHNA report describes (check all that apply): X A definition of the community served by the hospital facility X Demographics of the community X Existing health care facilities and resources within the community that are available to respond to the health needs of the community X How data was obtained X The significant health needs of the community X Primary and chronic disease needs and other health issues of uninsured persons, low-income persons, and minority groups X The process for identifying and prioritizing community health needs and services to meet the community health needs X The process for consulting with persons representing the community's interests X 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 16 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 Was the hospital facility's CHNA conducted with one or more other hospital facilities? If "Yes," list the other hospital facilities in Section C 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 Did the hospital facility make its CHNA report widely available to the public? If "Yes," indicate how the CHNA report was made widely available (check all that apply): X Hospital facility's website (list url): WWW.KALEIDAHEALTH.ORG/COMMUNITY Other website (list url): X 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 Indicate the tax year the hospital facility last adopted an implementation strategy: 20 16 Is the hospital facility's most recently adopted implementation strategy posted on a website? If "Yes," (list url): WWW.KALEIDAHEALTH.ORG/COMMUNITY If "No," is the hospital facility's most recently adopted implementation strategy attached to this return? 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. 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)? If "Yes" to line 12a, did the organization file Form 4720 to report the section 4959 excise tax? If "Yes" to line 12b, what is the total amount of section 4959 excise tax the organization reported on Form 4720 for all of its hospital facilities? $ mmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm m m m m m m m m m m m m m m m m m m m m mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mmmmmmmmmmmmmmmmmmmm mmmmmmmmmmm mmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmm JSA 6E1287 1.000 6261CF 2214 Yes No 1 X 2 X 3 X 5 X 6a X 6b 7 X X 8 X 10 X 10b 12a 12b X Schedule H (Form 990) 2016 V 16-7.6F PAGE 47 KALEIDA HEALTH Facility Information (continued) 16-1533232 Schedule H (Form 990) 2016 Part V Page 5 Financial Assistance Policy (FAP) Name of hospital facility or letter of facility reporting group GROUP A 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? If "Yes," indicate the eligibility criteria explained in the FAP: 13 a b c d e f g h 14 15 Federal poverty guidelines (FPG), with FPG family income limit for eligibility for free care of 200.0000 % and FPG family income limit for eligibility for discounted care of 400.0000 % Income level other than FPG (describe in Section C) X Asset level Medical indigency X Insurance status X Underinsurance status Residency Other (describe in Section C) Explained the basis for calculating amounts charged to patients? Explained the method for applying for financial assistance? 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): mmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmm X b X c X 14 15 X X 16 X 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 mmmmmmmmmmmmmmmmmm d e X X a 16 13 No Other (describe in Section C) Was widely publicized within the community served by the hospital facility? If "Yes," indicate how the hospital facility publicized the policy (check all that apply): a b c d X X X X The FAP was widely available on a website (list url): WWW.KALEIDAHEALTH.ORG The FAP application form was widely available on a website (list url): WWW.KALEIDAHEALTH.ORG A plain language summary of the FAP was widely available on a website (list url): WWW.KALEIDAHEALTH.ORG The FAP was available upon request and without charge (in public locations in the hospital facility and by mail) e X f X g X 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 h X i X j X 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) 2016 JSA 6E1323 1.000 6261CF 2214 V 16-7.6F PAGE 48 KALEIDA HEALTH 16-1533232 Schedule H (Form 990) 2016 Part V Page 6 Facility Information (continued) Billing and Collections Name of hospital facility or letter of facility reporting group GROUP A mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm 17 18 a b c d e f 19 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? 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 X 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: mmmmmmmmmm Yes 17 No X X 19 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 d Actions that require a legal or judicial process e Other similar actions (describe in Section C) 20 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): a 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 b Made a reasonable effort to orally notify individuals about the FAP and FAP application process c Processed incomplete and complete FAP applications Made presumptive eligibility determinations d e Other (describe in Section C) X None of these efforts were made f Policy Relating to Emergency Medical Care a b c mmmmmmmmmmm 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? If "No," indicate why: 21 21 X 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) a b c d Schedule H (Form 990) 2016 JSA 6E1324 1.000 6261CF 2214 V 16-7.6F PAGE 49 Schedule H (Form 990) 2016 Part V Page 7 Facility Information (continued) Charges to Individuals Eligible for Assistance Under the FAP (FAP-Eligible Individuals) Name of hospital facility or letter of facility reporting group GROUP A Yes 22 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. a The hospital facility used a look-back method based on claims allowed by Medicare fee-for-service during a prior 12-month period b 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 c X 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 d The hospital facility used a prospective Medicare or Medicaid method 23 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. 24 mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm 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. No 23 X 24 X Schedule H (Form 990) 2016 6261CF 2214 JSA 6E1332 1.000 V 16-7.6F KALEIDA HEALTH 16-1533232 Schedule H (Form 990) 2016 Page 8 Facility Information (continued) Part V 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, 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. PART V, SECTION B, LINE 5 GROUP A IN CONDUCTING ITS 2016-2018 COMMUNITY HEALTH NEEDS ASSESSMENT - COMMUNITY SERVICE PLAN (CHNA-CSP), KALEIDA HEALTH TOOK INTO ACCOUNT INPUT FROM PERSONS WHO REPRESENT THE BROAD INTERESTS OF THE COMMUNITY SERVED BY ITS HOSPITALS LOCATED IN ERIE AND NIAGARA COUNTIES, THE PRIMARY SERVICE AREA. FOR EACH COUNTY, KALEIDA HEALTH PARTICIPATED IN COLLABORATIVE WORK GROUPS LED BY THE ERIE COUNTY DEPARTMENT OF HEALTH AND THE NIAGARA COUNTY DEPARTMENT OF HEALTH AND COMPRISED OF REPRESENTATIVES FROM OTHER HOSPITALS, ORGANIZATIONS, AGENCIES, AND SCHOOLS; AND INCLUDED INPUT FROM THE COMMUNITY INCLUDING THE MEDICALLY UNDERSERVED. FROM MARCH THROUGH AUGUST 2016, THE ERIE COUNTY WORK GROUP CONDUCTED COUNTY-WIDE ASSESSMENT ACTIVITIES INCLUDING A CONSUMER SURVEY WITH 1,839 RESPONSES AND FIVE COMMUNITY FOCUS GROUP SESSIONS. THERE WERE SEVERAL SURVEY DISTRIBUTION SITES ACROSS THE COUNTY AND OF THE 1,839 SURVEY RESPONSES, 21.3% WERE FROM RESPONDENTS INDICATING AN INCOME BELOW $35,000. KALEIDA HEALTH DISTRIBUTED THE SURVEY IN ITS PRIMARY CARE CLINICS OF WHICH A SIGNIFICANT NUMBER OF PATIENTS ARE INSURED THROUGH MEDICAID. FOCUS GROUP SESSIONS WERE HELD AT A GEOGRAPHIC CROSS-SECTION OF SITES INCLUDING THE CAZENOVIA LIBRARY, UNITED WAY, AND MERRIWEATHER LIBRARY IN BUFFALO, SPRINGVILLE FIRE HALL IN SPRINGVILLE, AND THE ERIE COUNTY FIRE TRAINING ACADEMY IN CHEEKTOWAGA. KALEIDA HEALTH PROMOTED THE MERRIWEATHER LIBRARY EVENT LOCATED ON BUFFALO'S EAST SIDE, A LOW INCOME AND MEDICALLY UNDERSERVED COMMUNITY, THROUGH A PROMOTIONAL EMAIL TO THE Schedule H (Form 990) 2016 JSA 6E1331 3.000 6261CF 2214 V 16-7.6F PAGE 51 KALEIDA HEALTH 16-1533232 Schedule H (Form 990) 2016 Page 8 Facility Information (continued) Part V 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, 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. MEMBERS OF THE NEAR EAST SIDE AND WEST SIDE TASK FORCE. KALEIDA HEALTH PROVIDED LINKS TO THE CONSUMER SURVEY AND PROMOTED THE FOCUS GROUP SESSIONS ON ITS PUBLIC WEBSITE, EMPLOYEE WEBSITE, AND ON FACEBOOK. IN ADDITION TO THE REVIEW OF DATA FROM THE NYS PREVENTION AGENDA DASHBOARD AND OTHER RELIABLE SOURCES, THESE ACTIVITIES HELPED TO PRIORITIZE THE HEALTH CARE NEEDS OF THE COUNTY AND THE RESULTING IMPLEMENTATION STRATEGIES, AND ARE INCLUDED IN KALEIDA HEALTH'S 2016-2018 CHNA-CSP AND ALIGNED WITH THE ERIE COUNTY DEPARTMENT OF HEALTH, COMMUNITY HEALTH IMPROVEMENT PLAN. FROM MARCH THROUGH AUGUST 2016, THE NIAGARA COUNTY WORK GROUP CONDUCTED COUNTY-WIDE ASSESSMENT ACTIVITIES INCLUDING A CONSUMER SURVEY WITH 2,111 RESPONSES AND NINE COMMUNITY FOCUS GROUP SESSIONS. THERE WERE SEVERAL SURVEY DISTRIBUTION SITES AND OF THE 1,655 SURVEY RESPONDENTS WHO ANSWERED THE QUESTION ON ANNUAL HOUSEHOLD INCOME, 26.7% HAD AN INCOME OF LESS THAN $35,000. KALEIDA HEALTH'S DEGRAFF MEMORIAL HOSPITAL DISTRIBUTED THE SURVEY IN HOSPITAL WAITING AREAS, FRONT DESK, SWITCHBOARD, PHYSICIAN OFFICES, OB/GYN CLINICS, AND THE DEGRAFF MCLAUGHLIN CENTER FOR SENIOR WELLNESS. COMMUNITY FOCUS GROUP SESSIONS WERE HELD AT A GEOGRAPHIC CROSS-SECTION OF SITES INCLUDING THOSE LOCATED IN MEDICALLY UNDERSERVED COMMUNITIES. SITES INCLUDED THE NEIGHBORHOOD HEALTH CENTER AND BETHANY BAPTIST CHURCH IN NIAGARA FALLS, WOODLANDS SENIOR VILLAGE AND DEGRAFF COMMUNITY CENTER IN NORTH TONAWANDA; HARTLAND BIBLE CHURCH IN GASPORT; OLCOTT UNITED METHODIST CHURCH AND NEWFANE FOOD PANTRY IN NEWFANE; EASTERN NIAGARA HOSPITAL IN LOCKPORT; AND MOUNT ST. MARY'S HOSPITAL IN Schedule H (Form 990) 2016 JSA 6E1331 3.000 6261CF 2214 V 16-7.6F PAGE 52 KALEIDA HEALTH 16-1533232 Schedule H (Form 990) 2016 Page 8 Facility Information (continued) Part V 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, 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. LEWISTON. A COUNTY-WIDE FOCUS GROUP SESSION WAS ALSO HELD TO GET INPUT FROM SEVERAL COMMUNITY-BASED HEALTH, MENTAL HEALTH, AND SOCIAL SERVICE ORGANIZATIONS ACROSS THE COUNTY. KALEIDA HEALTH PROVIDED LINKS TO THE CONSUMER SURVEY AND PROMOTED THE FOCUS GROUP SESSIONS ON ITS PUBLIC WEBSITE, EMPLOYEE WEBSITE, AND ON FACEBOOK. IN ADDITION TO THE REVIEW OF DATA FROM THE NYS PREVENTION AGENDA DASHBOARD AND OTHER RELIABLE SOURCES, THESE ACTIVITIES HELPED TO PRIORITIZE THE HEALTH CARE NEEDS OF THE COUNTY AND THE RESULTING IMPLEMENTATION STRATEGIES INCLUDED IN KALEIDA HEALTH'S CHNA-CSP AND ALIGNED WITH THE NIAGARA COUNTY DEPARTMENT OF HEALTH, COMMUNITY HEALTH IMPROVEMENT PLAN. THE KALEIDA HEALTH 2016-2018 CHNA-CSP IS AVAILABLE TO THE PUBLIC IN THE COMMUNITY HEALTH SECTION OF THE KALEIDA HEALTH WEBSITE AT WWW.KALEIDAHEALTH.ORG AND SPECIFICALLY AT HTTP://KALEIDAHEALTH.ORG/COMMUNITY/PUBLICATIONS.ASP. A PAPER VERSION IS AVAILABLE UPON REQUEST AT NO CHARGE. WRITTEN COMMENTS ON THE CHNA-CSP ARE INVITED FROM THE PUBLIC THROUGH A LINK ENTITLED "COMMENT ON PLAN" LOCATED NEXT TO THE DOCUMENT THROUGH THE ABOVE LINK. THIS INFORMATION IS DOCUMENTED IN THE CHNA-CSP IN THE DISSEMINATION TO THE PUBLIC SECTION. NO COMMENTS ON THE CHNA-CSP WERE RECEIVED IN 2016. PART V, SECTION B, LINE 6A GROUP A KALEIDA HEALTH'S FOUR HOSPITALS ARE INCLUDED IN ITS 2016-2018 CHNA-CSP: BUFFALO GENERAL MEDICAL CENTER, MILLARD FILLMORE SUBURBAN HOSPITAL, WOMEN Schedule H (Form 990) 2016 JSA 6E1331 3.000 6261CF 2214 V 16-7.6F PAGE 53 KALEIDA HEALTH 16-1533232 Schedule H (Form 990) 2016 Page 8 Facility Information (continued) Part V 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, 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. & CHILDREN'S HOSPITAL OF BUFFALO, ALL LOCATED IN ERIE COUNTY, AND DEGRAFF MEMORIAL HOSPITAL LOCATED IN NIAGARA COUNTY. IN ERIE COUNTY, KALEIDA HEALTH COLLABORATED ON THE CHNA-CSP PROCESS THROUGH A PARTNERSHIP LED BY THE ERIE COUNTY DEPARTMENT OF HEALTH AND INCLUDED UNRELATED HOSPITAL FACILITIES OF THE CATHOLIC HEALTH SYSTEM. IN NIAGARA COUNTY, KALEIDA HEALTH COLLABORATED ON THE CHNA-CSP PROCESS THROUGH A PARTNERSHIP LED BY THE NIAGARA COUNTY DEPARTMENT OF HEALTH, AND INCLUDED THE FOLLOWING UNRELATED HOSPITAL FACILITIES: NIAGARA FALLS MEMORIAL MEDICAL CENTER, MOUNT ST MARY HOSPITAL, AND EASTERN NIAGARA HOSPITAL SYSTEM. PART V, SECTION B, LINE 6B GROUP A IN ERIE COUNTY, KALEIDA HEALTH COLLABORATED ON THE 2016-2018 CHNA-CSP PROCESS WITH THE FOLLOWING ORGANIZATIONS OTHER THAN HOSPITAL FACILITIES: ERIE COUNTY DEPARTMENT OF HEALTH, UNITED WAY OF BUFFALO AND ERIE COUNTY, P2 COLLABORATIVE OF WNY, BUFFALO STATE COLLEGE, UB SCHOOL OF PUBLIC HEALTH, UB FAMILY MEDICINE PRIMARY CARE RESEARCH CENTER, DAEMEN COLLEGE, AND D'YOUVILLE COLLEGE. IN NIAGARA COUNTY, KALEIDA HEALTH COLLABORATED ON THE 2016-2018 CHNA-CSP PROCESS WITH THE FOLLOWING ORGANIZATIONS OTHER THAN HOSPITAL FACILITIES: NIAGARA COUNTY DEPARTMENT OF HEALTH, NIAGARA COUNTY DEPARTMENT OF MENTAL Schedule H (Form 990) 2016 JSA 6E1331 3.000 6261CF 2214 V 16-7.6F PAGE 54 KALEIDA HEALTH 16-1533232 Schedule H (Form 990) 2016 Page 8 Facility Information (continued) Part V 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, 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. HEALTH, AND THE P2 COLLABORATIVE OF WNY. PART V, SECTION B, LINE 11 GROUP A WITH HOSPITALS LOCATED IN BOTH ERIE AND NIAGARA COUNTIES, KALEIDA HEALTH WORKED COLLABORATIVELY WITH WORK GROUPS LED BY THE ERIE COUNTRY DEPARTMENT OF HEALTH AND THE NIAGARA COUNTY DEPARTMENT OF HEALTH TO REVIEW HEALTH CARE DATA, DISSEMINATE CONSUMER SURVEYS AND CONDUCT FOCUS GROUP SESSIONS TO PRIORITIZE SIGNIFICANT HEALTH NEEDS AND IMPLEMENTATION STRATEGIES FOR EACH COUNTY. THE STRATEGIES FURTHER ALIGN WITH THE PRIORITY AREAS OF THE NEW YORK STATE PREVENTION AGENDA. KALEIDA HEALTH INCLUDED THESE COLLABORATIVE PRIORITY AREAS IN ITS 2016-2018 CHNA-CSP. HEALTH CARE NEEDS ADDRESSED IN KALEIDA HEALTH'S 2016-2018 CHNA-CSP: IN ERIE COUNTY AND NIAGARA COUNTY, CARDIOVASCULAR DISEASE IS THE NUMBER ONE CAUSE OF DEATH (2014, NYS VIRAL STATISTICS), AND THERE IS A HIGH INCIDENCE OF RISK FACTORS AMONG RESIDENTS INCLUDING HIGH BLOOD PRESSURE, DIABETES, OBESITY, AND SMOKING. OUTREACH THROUGH PUBLIC EDUCATION EVENTS HOSTED BY KALEIDA HEALTH HOSPITALS HAVE BEEN HELD IN COLLABORATION WITH NUMEROUS ORGANIZATIONS INCLUDING THOSE REPRESENTING THE MEDICALLY UNDERSERVED. ADDITIONALLY, CARDIOVASCULAR EDUCATION AND SCREENING TARGETING LOW INCOME WOMEN IS ADDRESSED IN THE CLINICAL SETTING THROUGH A PROGRAM FOR PATIENTS OF KALEIDA HEALTH'S OB-GYN CENTERS, WHERE 73% OF PATIENT VISITS ARE REIMBURSED THROUGH MEDICAID. THIS STRATEGY ALIGNS WITH Schedule H (Form 990) 2016 JSA 6E1331 3.000 6261CF 2214 V 16-7.6F PAGE 55 KALEIDA HEALTH 16-1533232 Schedule H (Form 990) 2016 Page 8 Facility Information (continued) Part V 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, 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. THE NYS PREVENTION AGENDA PRIORITY TO PREVENT CHRONIC DISEASE AND TO INCREASE ACCESS TO HIGH QUALITY CHRONIC DISEASE PREVENTIVE CARE AND MANAGEMENT IN CLINICAL AND COMMUNITY SETTINGS. THE HEALTH BENEFITS OF BREASTFEEDING FOR BOTH INFANT AND MOTHER ARE WELL DOCUMENTED AND THE NEW YORK STATE PREVENTION AGENDA SUPPORTS THE PROMOTION OF BREASTFEEDING TO INCREASE THE PROPORTION OF NEW YORK STATE BABIES WHO ARE BREASTFED. IN ERIE COUNTY, THE PERCENT OF INFANTS FED ANY BREAST MILK IN A DELIVERY HOSPITAL WAS 72.1% AND EXCLUSIVELY FED BREAST MILK WAS 51.1% (2012-2014, NYS VITAL STATISTICS). KALEIDA HEALTH IS WORKING TO INCREASE BREASTFEEDING RATES AT ITS DELIVERY HOSPITALS THROUGH EVIDENCE-BASED PROMOTION AND EDUCATION INITIATIVES. THE NEEDS OF THE MEDICALLY UNDERSERVED ARE ADDRESSED GIVEN THAT 68.85% OF INPATIENT DISCHARGES, ED VISITS AND OUTPATIENT VISITS AT WOMEN & CHILDREN'S HOSPITAL OF BUFFALO AND 11.8% AT MILLARD FILLMORE SUBURBAN HOSPITAL ARE REIMBURSED BY MEDICAID. HIGH RATES OF POOR MENTAL HEALTH, DRUG ADDICTION, AND BINGE DRINKING IN NIAGARA COUNTY; IN ADDITION TO A SUICIDE DEATH RATE OF 16% VS THE NEW YORK STATE RATE OF 7.9% (2012-2014, NYS PREVENTION AGENDA DASHBOARD) INDICATE A DIRE NEED TO ADDRESS MENTAL HEALTH AND SUBSTANCE ABUSE ISSUES IN THE COUNTY. ACCESS TO ADEQUATE MENTAL HEALTH CARE AND RESOURCES IS AN ADDED CHALLENGE. IN RESPONSE, KALEIDA HEALTH'S DEGRAFF MEMORIAL HOSPITAL WILL PROMOTE BOTH PROVIDER AND PUBLIC AWARENESS AND KNOWLEDGE OF MENTAL HEALTH CONDITIONS AND SUBSTANCE ABUSE; AND THE AVAILABLE RESOURCES. THIS Schedule H (Form 990) 2016 JSA 6E1331 3.000 6261CF 2214 V 16-7.6F PAGE 56 KALEIDA HEALTH 16-1533232 Schedule H (Form 990) 2016 Page 8 Facility Information (continued) Part V 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, 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. PROJECT ADDRESSES THE NEEDS OF THIS POPULATION AS A MEDICALLY UNDERSERVED DISPARITY POPULATION. IT ALSO ALIGNS WITH THE NYS PREVENTION AGENDA PRIORITY TO PROMOTE MENTAL HEALTH AND PREVENT SUBSTANCE ABUSE. THE CHILDREN'S PSYCHIATRY CLINIC OF KALEIDA HEALTH'S WOMEN & CHILDREN'S HOSPITAL OF BUFFALO IN NEIGHBORING ERIE COUNTY, PROVIDES AN ADDED RESOURCE FOR PEDIATRIC MENTAL HEALTH SERVICES FOR NIAGARA COUNTY RESIDENTS. HEALTH CARE NEEDS NOT ADDRESSED IN KALEIDA HEALTH'S 2016-2018 CHNA-CSP: THE RISING OPIOID ADDICTION PROBLEM IS AN EMERGING AREA OF CONCERN IN BOTH ERIE AND NIAGARA COUNTIES. THE ERIE COUNTY DEPARTMENT OF HEALTH INCLUDED IT IN ITS COMMUNITY HEALTH IMPROVEMENT PLAN. HOWEVER, IT WAS NOT INCLUDED IN KALEIDA HEALTH'S CHNA-CSP DUE TO AN ADMINISTRATIVE TIMING ISSUE. HOWEVER, ERIE COUNTY IS AWARE THAT KALEIDA HEALTH IS COMMITTED TO WORKING WITH ITS ERIE COUNTY PARTNERS TO ADDRESS THE PROBLEM. IN 2016, THROUGH A PARTNERSHIP WITH THE ERIE COUNTY DEPARTMENT OF HEALTH, KALEIDA HEALTH HOSPITALS INCLUDING BUFFALO GENERAL MEDICAL CENTER, MILLARD FILLMORE SUBURBAN HOSPITAL, DEGRAFF MEMORIAL HOSPITAL, AND WOMEN & CHILDREN'S HOSPITAL OF BUFFALO EMERGENCY DEPARTMENTS BEGAN TO DISPENSE THE NARCAN OPIOID OVERDOSE KITS TO PATIENTS AND CAREGIVERS FOR PATIENTS WITH AN OPIOID OVERDOSE OR IS AT RISK FOR AN OPIOID OVERDOSE. THE COUNTY SUPPLIED THE KITS AND EMERGENCY DEPARTMENT PHYSICIANS PROVIDED THE PATIENT/CAREGIVER EDUCATION ON THE USE OF NARCAN. KALEIDA HEALTH WILL CONTINUE TO PARTNER WITH THE COUNTY AND OTHERS TO ADDRESS THIS Schedule H (Form 990) 2016 JSA 6E1331 3.000 6261CF 2214 V 16-7.6F PAGE 57 KALEIDA HEALTH 16-1533232 Schedule H (Form 990) 2016 Page 8 Facility Information (continued) Part V 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, 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. SIGNIFICANT HEALTH CARE PROBLEM. THE NIAGARA COUNTY DEPARTMENT OF HEALTH IS ADDRESSING THE OPIOID PROBLEM AS IT ADDRESSES MENTAL HEALTH AND SUBSTANCE ABUSE IN ITS COMMUNITY HEALTH IMPROVEMENT PLAN. KALEIDA HEALTH IS A PARTNER IN THIS NIAGARA COUNTY PRIORITY AREA THROUGH ITS DEGRAFF MEMORIAL HOSPITAL AS IDENTIFIED ABOVE AND IN THE WORK PLAN SECTION OF KALEIDA HEALTH'S 2016-2018 CHNA-CSP. FALLS PREVENTION AMONG NIAGARA COUNTY'S SENIOR POPULATION WAS ADDRESSED THROUGH IMPLEMENTATION STRATEGIES INCLUDED IN KALEIDA HEALTH'S LAST CHNA CONDUCTED IN 2013. THE STEP UP TO STOP FALLS PROGRAM WAS HIGHLY SUCCESSFUL AND WHILE NOT INCLUDED AS A PRIORITY AREA IN THE NIAGARA COUNTY COMMUNITY HEALTH IMPROVEMENT PLAN AND KALEIDA HEALTH'S CHNA-CSP, THE PROGRAM WILL CONTINUE TO EXIST. THE NIAGARA COUNTY COLLABORATIVE WORK GROUP DECIDED TO PRIORITIZE OTHER COMMUNITY HEALTH NEEDS FOR 2016-2018. WHILE CANCER IS IDENTIFIED AS THE NUMBER TWO CAUSE OF DEATH IN ERIE AND NIAGARA COUNTIES AND IS A PUBLIC HEALTH CONCERN, IT IS NOT ADDRESSED AS A FOCUS AREA IN THE COUNTY COMMUNITY HEALTH IMPROVEMENT PLANS OR IN KALEIDA HEALTH'S CHNA-CSP FOR 2016-2018, AS THE COUNTY WORK GROUPS DECIDED TO PRIORITIZE OTHER AREAS OF CONCERN. HOWEVER, CANCER IS ADDRESSED BY SEVERAL HOSPITALS AND COMMUNITY BASED PREVENTION, EDUCATION, AND TREATMENT INITIATIVES THROUGHOUT THE REGION. KALEIDA HEALTH PROVIDES ONCOLOGY SERVICES AT SEVERAL FACILITIES AND IN 2015, KALEIDA HEALTH ACQUIRED CANCER CARE OF WESTERN NEW YORK, AN ONCOLOGY TREATMENT PRACTICE. IN 2016, KALEIDA HEALTH HELD TWO MEN'S PROSTATE CANCER OUTREACH AND Schedule H (Form 990) 2016 JSA 6E1331 3.000 6261CF 2214 V 16-7.6F PAGE 58 KALEIDA HEALTH 16-1533232 Schedule H (Form 990) 2016 Page 8 Facility Information (continued) Part V 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, 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. SCREENING EVENTS TARGETING BUFFALO'S AFRICAN AMERICAN AND HISPANIC POPULATIONS IN COLLABORATION WITH WNY UROLOGY AND CANCER CARE OF WNY. PART V, SECTION B, LINE 16J GROUP A INFORMATION THAT EXPLAINS HOW QUALIFIED PATIENTS CAN ACCESS FINANCIAL ASSISTANCE THROUGH THE HOSPITAL IS INCLUDED ON BILLS AND STATEMENTS TO PATIENTS. APPLICATION MATERIALS INCLUDE A NOTICE TO THE PATIENTS THAT ONCE THEY SUBMIT A COMPLETED APPLICATION AND DOCUMENTATION, THEY MAY DISREGARD ANY BILLS UNTIL THE HOSPITAL HAS RENDERED A WRITTEN DECISION ON THE APPLICATION. THE HOSPITAL MAY NOT FORWARD ACCOUNTS TO COLLECTION WHILE AN APPLICATION IS PENDING. Schedule H (Form 990) 2016 JSA 6E1331 3.000 6261CF 2214 V 16-7.6F PAGE 59 KALEIDA HEALTH 16-1533232 Page 9 Facility Information (continued) Part V 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) Schedule H (Form 990) 2016 How many non-hospital health care facilities did the organization operate during the tax year? Name and address 1 2 3 4 5 6 7 8 9 10 29 Type of Facility (describe) HIGHPOINTE ON MICHIGAN 1031 MICHIGAN AVE BUFFALO NY 14203 CENTER FOR LABORATORY MEDICINE 115 FLINT ROAD AMHERST NY 14226 DEGRAFF SKILLED NURSING FACILITY 445 TREMONT STREET NORTH TONAWANDA NY 14120 MILLARD FILLMORE SURGERY CENTER 215 KLEIN ROAD WILLIAMSVILLE NY 14221 ELMWOOD OB/GYN 239 BRYANT STREET BUFFALO NY 14222 MAPLE WEST MEDICAL COMPLEX 705 MAPLE ROAD AMHERST NY 14221 NORTH BUFFALO MEDICAL PARK 900 HERTEL AVE BUFFALO NY 14207 KALEIDA HEALTH FAMILY PLANNING CENTER 1313 MAIN STREET BUFFALO NY 14209 COMMUNITY MENTAL HEALTH CENTER 1028 MAIN STREET BUFFALO NY 14203 HODGE PEDIATRICS 125 HODGE STREET BUFFALO NY 14222 INPATIENT SKILLED NURSING FACILITY HOSPITAL BASED LAB SERVICES INPATIENT SKILLED NURSING FACILITY AMBULATORY SURGERY CENTER FACILITY MEDICAL SERVICES - PRIMARY CARE, PRENATAL OUTPATIENT MEDICAL SERVICES - PRIMARY CARE, OTHER SPECIALTIES OUTPATIENT THERAPY SERVICES MEDICAL SERVICES - PRIMARY CARE, RADIOLOGY OUTPATIENT, OUTPATIENT THERAPY SERVICES OUTPATIENT FAMILY PLANNING HOSPITAL BASED OUTPATIENT BEHAVIORAL HEALTH SERVICES HOSPITAL BASED OUTPATIENT PRIMARY CARE SERVICES Schedule H (Form 990) 2016 JSA 6E1325 1.000 6261CF 2214 V 16-7.6F PAGE 60 KALEIDA HEALTH 16-1533232 Page 9 Facility Information (continued) Part V 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) Schedule H (Form 990) 2016 How many non-hospital health care facilities did the organization operate during the tax year? Name and address 1 2 3 4 5 6 7 8 9 10 Type of Facility (describe) TOWNE GARDEN PEDIATRICS 461 WILLIAM STREET BUFFALO NY 14204 SOUTHTOWNS SURGERY CENTER 5959 BIG TREE ROAD, SUITE 100 ORCHARD PARK NY 14217 WCHOB SPECIALTY CLINICS 140 HODGE STREET BUFFALO NY 14222 WCHOB WOMEN'S OB/GYN HEALTH CENTER 462 GRIDER STREET BUFFALO NY 14215 WCHOB LANCASTER OB/GYN 6363 TRANSIT ROAD LANCASTER NY 14086 WCHOB MCKINLEY OB/GYN 3860 MCKINLEY PARKWAY HAMBURG NY 14219 WCHOB CHILD PROTECTION CENTER 556 FRANKLIN STREET BUFFALO NY 14202 STANLEY MAKOWSKI SBHC 1095 JEFFERSON AVE BUFFALO NY 14214 WCHOB LOCKPORT OB/GYN 475 SOUTH TRANSIT ROAD LOCKPORT NY 14094 HILLERY PARK #27 SBHC 72 PAWNEE PARKWAY BUFFALO NY 14210 HOSPITAL BASED OUTPATIENT PRIMARY CARE SERVICES AMBULATORY SURGERY CENTER PRIMARY CARE SERVICES HOSPITAL BASED OUTPATIENT PRIMARY CARE SERVICES HOSPITAL BASED OUTPATIENT PRIMARY CARE SERVICES MEDICAL SERVICES - PRIMARY CARE, PRENATAL OUTPATIENT MEDICAL SERVICES - PRIMARY CARE, PRENATAL OUTPATIENT MEDICAL SERVICES - PRIMARY CARE SCHOOL BASED PRIMARY CARE SERVICES MEDICAL SERVICES - PRIMARY CARE, PRENATAL OUTPATIENT SCHOOL BASED PRIMARY CARE SERVICES Schedule H (Form 990) 2016 JSA 6E1325 1.000 6261CF 2214 V 16-7.6F PAGE 61 KALEIDA HEALTH 16-1533232 Page 9 Facility Information (continued) Part V 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) Schedule H (Form 990) 2016 How many non-hospital health care facilities did the organization operate during the tax year? Name and address 1 2 3 4 5 6 7 8 9 Type of Facility (describe) WESTMINSTER #68 SBHC 24 WESTMINSTER AVE BUFFALO NY 14215 BENNETT HIGH SCHOOL SBHC 2885 MAIN STREET BUFFALO NY 14214 DR. LYDIA WRIGHT #89 SBHC 106 APPENHEIMER STREET BUFFALO NY 14214 BUILD ACADEMY #91 SBHC 340 FOUGERON STREET BUFFALO NY 14211 BUFFALO SCHOOL OF TECHNOLOGY SBHC 414 SOUTH DIVISION STREET BUFFALO NY 14201 HERMAN BADILLO #76 SBHC 315 CAROLINE STREET BUFFALO NY 14201 ML KING #39 SBHC 487 HIGH STREET BUFFALO NY 14211 THE CHILDRENS PSYCHIATRY CLINIC 1404 SWEET HOME ROAD AMHERST NY 14228 SOUTHTOWNS CLINIC 4535 SOUTHWESTERN BLVD HAMBURG NY 14075 SCHOOL BASED PRIMARY CARE SERVICES SCHOOL BASED PRIMARY CARE SERVICES SCHOOL BASED PRIMARY CARE SERVICES SCHOOL BASED PRIMARY CARE SERVICES SCHOOL BASED PRIMARY CARE SERVICES SCHOOL BASED PRIMARY CARE SERVICES SCHOOL BASED PRIMARY CARE SERVICES CERTIFIED MENTAL HEALTH OUTPATIENT SERVICES MEDICAL SERVICES - PRIMARY CARE 10 Schedule H (Form 990) 2016 JSA 6E1325 1.000 6261CF 2214 V 16-7.6F PAGE 62 KALEIDA HEALTH 16-1533232 Schedule H (Form 990) 2016 Part VI Page 10 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. PART I, FINANCIAL ASSISTANCE - LINE 3C KALEIDA HEALTH HAS IMPLEMENTED AND COMMUNICATES ITS FINANCIAL ASSISTANCE (CHARITY CARE) POLICY, WHICH ASSISTS LOW INCOME, UNINSURED OR UNDERINSURED INDIVIDUALS WHO LACK THE FINANCIAL RESOURCES TO PAY FOR MEDICAL SERVICES RENDERED. LEVELS OF DISCOUNTS ARE AWARDED BASED UPON INCOME AND ASSET VERIFICATION AND IN ACCORDANCE WITH THE FEDERAL POVERTY GUIDELINES AS PUBLISHED ANNUALLY BY THE U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES. INDIVIDUALS ARE PROVIDED FINANCIAL ASSISTANCE CONTACT INFORMATION DURING INTAKE AND REGISTRATION. THE APPLICANT FOR FREE OR REDUCED PRICE CARE WORKS DIRECTLY WITH A MEMBER OF THE FINANCIAL COUNSELING OR CHARITY CARE TEAM FOR FINANCIAL SCREENING AND ENROLLMENT IN A GOVERNMENT-FUNDED PROGRAM, IF ELIGIBLE. AFTER REVIEW OF INCOME AND ASSETS, AN INDIVIDUAL MAY BE APPROVED FOR FREE CARE (100% DISCOUNT) OR A DISCOUNT LEVEL OF 50, 60, 75, OR 90%, FOR MEDICALLY NECESSARY SERVICES RENDERED AT A KALEIDA FACILITY, AS FOLLOWS: Schedule H (Form 990) 2016 JSA 6E1327 2.000 6261CF 2214 V 16-7.6F PAGE 63 KALEIDA HEALTH 16-1533232 Schedule H (Form 990) 2016 Part VI Page 10 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. LESS THAN 200% OF FEDERAL POVERTY GUIDELINE IS AWARDED 100% DISCOUNT 200% - 249% OF FEDERAL POVERTY GUIDELINE IS AWARDED 90% DISCOUNT 250% - 299% OF FEDERAL POVERTY GUIDELINE IS AWARDED 75% DISCOUNT 300% - 349% OF FEDERAL POVERTY GUIDELINE IS AWARDED 60% DISCOUNT 350% - 400% OF FEDERAL POVERTY GUIDELINE IS AWARDED 50% DISCOUNT PART I, LINE 7 THE AMOUNTS REPORTED IN THE TABLE UNDER PART 1, LINE 7 WERE DETERMINED USING THE HEALTH SYSTEM'S DECISION SUPPORT SOFTWARE PROGRAM AND REVENUE AND EXPENSES FROM THE GENERAL LEDGER. THE OVERALL REVENUE AND EXPENSES INCLUDED IN THE DECISION SUPPORT SOFTWARE PROGRAM WERE RECONCILED TO THE GENERAL LEDGER WHICH RECONCILES TO THE AUDITED FINANCIAL STATEMENTS. THE DECISION SUPPORT SOFTWARE PROGRAM ALLOCATES DIRECT COSTS TO EACH PATIENT ACCOUNT BASED ON THE RESOURCES USED BY THAT PATIENT WITHIN THE SPECIFIC COST CENTER. INDIRECT COSTS ARE ALLOCATED USING SIMILAR STEPDOWN METHODOLOGY USED BY CMS IN THE INSTITUTIONAL COST REPORT. Schedule H (Form 990) 2016 JSA 6E1327 2.000 6261CF 2214 V 16-7.6F PAGE 64 KALEIDA HEALTH 16-1533232 Schedule H (Form 990) 2016 Part VI Page 10 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. PART II KALEIDA HEALTH'S COMMUNITY HEALTH SERVICES SUPPORTS A COMPREHENSIVE PROGRAM OF COMMUNITY HEALTH IMPROVEMENT ADVOCACY. OUTREACH IS CONDUCTED IN MULTIPLE WESTERN NEW YORK COMMUNITIES TARGETING VARIED POPULATIONS OF ALL AGES AND ETHNICITIES, INCLUDING THE MEDICALLY UNDERSERVED. PROGRAMS AND EVENTS PROMOTE THE REDUCTION OF HEALTH DISPARITIES, ACCESS TO CARE, AND PROMOTE OVERALL COMMUNITY HEALTH AND WELLNESS; AND INCLUDE HEALTH EDUCATION AND SCREENING, SPEAKERS ON HEALTH-RELATED TOPICS, AND COMMUNITY REFERRALS. TOPICS RANGE FROM HEALTH INSURANCE ENROLLMENT TO DIABETES, STROKE, HEART DISEASE, MATERNAL AND CHILD HEALTH, AND HEALTH CAREER EXPLORATION. IN 2016, KALEIDA HEALTH PARTNERED WITH SEVERAL ORGANIZATIONS AND PARTICIPATED IN 172 EVENTS TO REACH 38,992 INDIVIDUALS WITH COMMUNITY SERVICE PROGRAMMING. WHILE MULTIPLE EVENTS WERE HELD IN VARIOUS COMMUNITIES ACROSS WESTERN NEW YORK, THE FOLLOWING TOOK PLACE IN BUFFALO, A CITY WITH SEVERAL CENSUS TRACTS FEDERALLY DESIGNATED AS MEDICALLY UNDERSERVED AREAS: Schedule H (Form 990) 2016 JSA 6E1327 2.000 6261CF 2214 V 16-7.6F PAGE 65 KALEIDA HEALTH 16-1533232 Schedule H (Form 990) 2016 Part VI Page 10 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. - NEAR EAST SIDE AND WEST SIDE TASK FORCE - PASSPORT TO WELLNESS, AN OUTREACH/WELLNESS/MEDICAL SCREENING PROGRAM AT LOCAL TOPS GROCERY MARKETS TARGETING MOSTLY LATINO AND AFRICAN AMERICAN COMMUNITIES; AND ALSO REACHES THIS POPULATION WITH HEALTH SCREENING PROVIDED AT THE BROADWAY MARKET ON BUFFALO'S EAST SIDE. - NIAGARA FRONTIER TRANSPORATION AUTHORITY - OUTREACH AND WELLNESS EDUCATION TO THE UNDERSERVED AT THE MAIN & UTICA SUBWAY STATION. - BUFFALO EAST HIGH SCHOOL - FAMILY WELLNESS DAYS AT THE BUFFALO PUBLIC SCHOOL LOCATED IN AN UNDERSERVED AREA ON BUFFALO'S EAST SIDE. - BUFFALO PUBLIC LIBRARY - A COMMUNITY WELLNESS EVENT AT THE LIBRARY DURING HISPANIC HERITAGE MONTH. - BUFFALO MUNICIPAL HOUSING AUTHORITY - FAMILY WELLNESS PROGRAM AT THE MARTHA MITCHELL CENTER, FREDERICK DOUGLASS COMMUNITY CENTER, AND SHAFFER VILLAGE, ALL UNDERSERVED. - JUNETEENTH FESTIVAL - HEALTH AND WELLNESS EDUCATION PROVIDED AT THIS FESTIVAL ON BUFFALO'S EAST SIDE THAT ATTRACTS THOUSANDS OF PEOPLE OF ALL AGES AND RACES. - IN 2016, KALEIDA HEALTH CONDUCTED TWO MEN'S PROSTATE CANCER OUTREACH Schedule H (Form 990) 2016 JSA 6E1327 2.000 6261CF 2214 V 16-7.6F PAGE 66 KALEIDA HEALTH 16-1533232 Schedule H (Form 990) 2016 Part VI Page 10 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. AND SCREENING EVENTS TARGETING BUFFALO'S AFRICAN AMERICAN AND HISPANIC POPULATION AT THE JOHNNIE B. WILEY STADIUM AND THE FREDERICK DOUGLASS COMMUNITY CENTER. KALEIDA HEALTH COLLABORATED WITH WNY UROLOGY AND CANCER CARE OF WNY, AND WITH COMMUNITY AND FAITH BASED ORGANIZATIONS TO PROMOTE THE EVENTS INCLUDING BUFFALO MUNICIPAL HOUSING AUTHORITY, BUFFALO BRANCH NAACP, BUFFALO UNITED FRONT, INC., HISPANIC HERITAGE COUNCIL OF WNY, HISPANIC PASTORS ASSOCIATION OF WNY, AREA FRATERNITIES, AND MILLENIUM COLLABORATIVE CARE PPS. THE PROGRAMS SUPPORTED KALEIDA HEALTH'S PLEDGE TO HELP TO INCREASE COLORECTAL CANCER SCREENING RATES BY SUPPORTING THE 80% BY 2018 INITIATIVE, LED BY THE AMERICAN CANCER SOCIETY (ACS), THE CENTERS FOR DISEASE CONTROL AND PREVENTION (CDC) AND THE NATIONAL COLORECTAL CANCER ROUNDTABLE (AN ORGANIZATION CO-FOUNDED BY ACS AND CDC). COLORECTAL CANCER IS ONE OF THE MOST COMMON CANCERS IN BOTH MEN AND WOMEN AND IS ONE OF THE MOST PREVENTABLE AND TREATABLE WHEN DETECTED EARLY. - WUFO 1080 AM - THROUGH THE GREAT LAKES HEALTH RADIO PROGRAM, KALEIDA HEALTH PROVIDES GUEST SPEAKERS EVERY OTHER WEEK FOR 1/2 HOUR ON A VARIETY OF HEALTH AND WELLNESS TOPICS. THE WUFO LISTENERSHIP IS PREDOMINANTLY URBAN AND REPRESENTS ALL AGES, RACES, AND ETHNIC GROUPS IN WNY. Schedule H (Form 990) 2016 JSA 6E1327 2.000 6261CF 2214 V 16-7.6F PAGE 67 KALEIDA HEALTH 16-1533232 Schedule H (Form 990) 2016 Part VI Page 10 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. - A NUMBER OF BLOCK CLUBS AND FAITH-BASED ORGANIZATIONS ALSO PARTNER WITH KALEIDA HEALTH TO PROVIDE HEALTH AND WELLNESS OUTREACH AND EDUCATION AT MULTIPLE LOCATIONS. PART III, LINES 2 AND 3 BAD DEBT EXPENSE IS RECORDED USING THE VALUATION METHOD AS OUTLINED IN HEALTHCARE FINANCIAL MANAGEMENT ASSOCIATION STATEMENT 15, WHICH REQUIRES BAD DEBT EXPENSE TO BE RECORDED AT THE AMOUNT THAT THE PAYER IS EXPECTED TO PAY. IN ORDER TO REPORT THE COSTS ASSOCIATED WITH BAD DEBT EXPENSE, THE REPORTED BAD DEBT EXPENSE NEEDS TO BE ADJUSTED SO THAT THE AMOUNT EXPECTED TO BE PAID REFLECTS GROSS CHARGES, PRIOR TO THE APPLICATION OF A RATIO OF COSTS TO CHARGES (RCC). KALEIDA HEALTH ADJUSTS BAD DEBT EXPENSE PRIOR TO THE APPLICATION OF AN RCC SO THAT THE REPORTED BAD DEBT EXPENSE AT COST, ON PART III, LINE 2 OF IRS FORM 990, SCHEDULE H REFLECTS THE TRUE COST OF THE BAD DEBTS. THE ORGANIZATION HAS A CHARITY CARE POLICY, AND ANY WRITE-OFFS AS A RESULT OF THIS POLICY ARE RECORDED AS CHARITY CARE ALLOWANCES AND ARE A REDUCTION OF THE NET PATIENT REVENUE. INDIVIDUALS WHO MAY QUALIFY FOR CHARITY CARE ASSISTANCE UNDER THE POLICY, Schedule H (Form 990) 2016 JSA 6E1327 2.000 6261CF 2214 V 16-7.6F PAGE 68 KALEIDA HEALTH 16-1533232 Schedule H (Form 990) 2016 Part VI Page 10 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. BUT DO NOT VOLUNTEER TO COMPLETE THE APPLICATION PROCESS WOULD NOT BE GRANTED CHARITY CARE ASSISTANCE. KALEIDA ALSO USES A PRESUMPTIVE CHARITY CARE PROCESS, WHICH HAS DETERMINED THAT 55% OF SELF-PAY BAD DEBT EXPENSE IN 2016 WOULD HAVE BEEN ELIGIBLE FOR CHARITY CARE ASSISTANCE. THEREFORE, WE BELIEVE THAT THE LEVEL OF CHARITY CARE INCLUDED IN BAD DEBT EXPENSE TO BE APPROXIMATELY $1,110,919. WE ESTIMATED THIS AMOUNT BY USING THE 2016 CALCULATED PRESUMPTIVE ELIGIBILITY PERCENTAGE ON BAD DEBT WRITE-OFF'S AMOUNTS OVER $500 (55%), AND APPLIED THIS PERCENTAGE TO THOSE BAD DEBT WRITE-OFF'S AMOUNTS UNDER $500, TO DETERMINE THE BAD DEBT WRITE-OFF'S THAT WOULD HAVE BEEN ELIGIBLE, IF THEY WERE SCORED USING THE PRESUMPTIVE ELIGIBILITY PROCESS. BAD DEBT IS NOT INCLUDED AS COMMUNITY BENEFIT. PART III, LINE 4 KALEIDA PROVIDES CARE TO PATIENTS WHO MEET CERTAIN CRITERIA UNDER ITS CHARITY CARE POLICIES WITHOUT CHARGE OR AT AMOUNTS LESS THAN THEIR ESTABLISHED RATES. BECAUSE KALEIDA DOES NOT ANTICIPATE COLLECTIONS OF AMOUNTS DETERMINED TO QUALIFY AS CHARITY CARE, THEY ARE NOT REPORTED AS REVENUE. Schedule H (Form 990) 2016 JSA 6E1327 2.000 6261CF 2214 V 16-7.6F PAGE 69 KALEIDA HEALTH 16-1533232 Schedule H (Form 990) 2016 Part VI Page 10 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. KALEIDA GRANTS CREDIT WITHOUT COLLATERAL TO PATIENTS, MOST OF WHOM ARE LOCAL RESIDENTS AND ARE INSURED BY COMMERCIAL AND GOVERNMENT INSURANCE PLANS. ADDITIONS TO THE ESTIMATED ALLOWANCE FOR DOUBTFUL ACCOUNTS ARE MADE BY MEANS OF THE PROVISION OF BAD DEBTS. THE PROVISION FOR BAD DEBTS PRIMARILY RELATES TO PATIENTS WITHOUT INSURANCE AND TO THOSE THAT ARE EITHER UNDERINSURED OR WITHOUT THE NECESSARY RESOURCES TO PAY COINSURANCE AND DEDUCTIBLE BALANCES. ACCOUNTS WRITTEN OFF AS UNCOLLECTIBLE ARE DEDUCTED FROM THE ALLOWANCE AND SUBSEQUENT RECOVERIES ARE ADDED. THE AMOUNT OF THE PROVISION FOR BAD DEBTS IS BASED UPON MANAGEMENT'S ASSESSMENT OF HISTORICAL AND EXPECTED DEBT COLLECTIONS, BUSINESS AND ECONOMIC CONDITIONS, TRENDS IN FEDERAL AND STATE GOVERNMENTAL HEALTHCARE COVERAGE, AND OTHER COLLECTION INDICATORS. PART III, LINE 8 THERE ARE NO MEDICARE SHORTFALLS INCLUDED IN THE CALCULATION OF COMMUNITY BENEFIT. Schedule H (Form 990) 2016 JSA 6E1327 2.000 6261CF 2214 V 16-7.6F PAGE 70 KALEIDA HEALTH 16-1533232 Schedule H (Form 990) 2016 Part VI Page 10 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. COSTING METHODOLOGY USED TO DETERMINE THE MEDICARE ALLOWABLE COSTS REPORTED IN THE MEDICARE COST REPORT, AS REFLECTED IN PART III, LINE 6: KALEIDA HEALTH USED THE FILED, BUT UNAUDITED 2015 CMS MEDICARE COST REPORT TO DETERMINE THE AMOUNTS REPORTED ON THESE LINES. PART III, SECTION C, LINE 9B ONCE PATIENT LIABILITY HAS BEEN DETERMINED FOLLOWING PROCESSING OF APPLICATIONS FOR GOVERNMENT ASSISTANCE, CHARITY CARE, AND/OR INSURANCE CARRIER REMITTANCE, THE PATIENT STATEMENT IS MAILED FOR PAYMENT RECOVERY. KALEIDA HEALTH HAS A PRE-COLLECTION PROCESS FOR ACCOUNTS WITH A POSITIVE PATIENT BALANCE GREATER THAN $4.99 AND A FIRST BILL DATE OLDER THAN 60 DAYS, BUT NOT PREVIOUSLY PAID IN FULL BY THE PATIENT (EXCLUDING ACCOUNTS FOR PATIENTS THAT HAVE SUBMITTED A COMPLETED APPLICATION FOR CHARITY CARE, MEDICAID, OR CHILD HEALTH PLUS, AND AN ELIGIBILITY DETERMINATION IS PENDING). UPON A PATIENT EXPRESSING FINANCIAL CONCERN, THE PATIENT WILL BE OFFERED THE OPPORTUNITY TO APPLY FOR FINANCIAL ASSISTANCE (CHARITY CARE). ONCE Schedule H (Form 990) 2016 JSA 6E1327 2.000 6261CF 2214 V 16-7.6F PAGE 71 KALEIDA HEALTH 16-1533232 Schedule H (Form 990) 2016 Part VI Page 10 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. THE PATIENT SUBMITS THE COMPLETED APPLICATION, THE ACCOUNT IS PLACED ON HOLD AND ALL COLLECTION ACTIVITIES ARE SUSPENDED UNTIL AN ELIGIBILITY DETERMINATION IS MADE. IF THE PATIENT IS ELIGIBLE FOR CHARITY CARE, THEN THE PATIENT IS NOTIFIED OF THE LEVEL OF CHARITY CARE AWARDED. IF 100% CHARITY CARE IS AWARDED, THEN NO BILL IS SENT TO THE PATIENT. IF LESS THAN 100% CHARITY CARE IS AWARDED, THEN THE PATIENT WILL RECEIVE A BILL PURSUANT TO THE PRIVATE PAY COLLECTION POLICY. COMMUNITY HEALTH NEEDS ASSESSMENT PROCESS KALEIDA HEALTH ASSESSES THE NEEDS OF THE COMMUNITY THROUGH A COMMUNITY HEALTH NEEDS ASSESSMENT-COMMUNITY SERVICE PLAN (CHNA-CSP) WITH ITS MOST RECENT PLAN COMPLETED IN 2016. THE 2016-2018 CHNA-CSP IS AVAILABLE TO THE PUBLIC ON THE KALEIDA HEALTH WEBSITE AT WWW.KALEIDAHEALTH.ORG/COMMUNITY/PUBLICATIONS.ASP AND A PRINTED COPY IS AVAILABLE UPON REQUEST AT NO CHARGE. WRITTEN COMMENTS ON THE 2016-2018 CHNA-CSP ARE INVITED FROM THE PUBLIC THROUGH A LINK ENTITLED "COMMENT ON PLAN," LOCATED NEXT TO THE DOCUMENT THROUGH THE ABOVE LINK. Schedule H (Form 990) 2016 JSA 6E1327 2.000 6261CF 2214 V 16-7.6F PAGE 72 KALEIDA HEALTH 16-1533232 Schedule H (Form 990) 2016 Part VI Page 10 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. IN ADDITION TO THE 2016-2018 CHNA-CSP (AS REPORTED IN PART V, SECTION B), KALEIDA HEALTH STAFF ENGAGE IN OTHER METHODS TO ASSESS THE NEEDS OF THE COMMUNITY. POVERTY TRENDS, COMMUNITY HEALTH RESEARCH, AND LOCAL COMMUNITY HEALTH NEEDS ARE REVIEWED ON A REGULAR BASIS WHILE PLANNING SERVICES AND PROGRAMS. RESPONSIVE TO COMMUNITY PRIORITIES, PROGRAM DEVELOPMENT AND SERVICES FILL IDENTIFIED GAPS OR SUPPLEMENT EXSITING PROGRAMS. PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCE KALEIDA HEALTH INFORMS INDIVIDUALS OF FINANCIAL ASSISTANCE MADE AVAILABLE AT THE TIME OF REGISTRATION INTO THE INPATIENT, OUTPATIENT, EMERGENCY DEPARTMENT AND LONG-TERM CARE FACILITY. POSTERS INFORMING THE PATIENT/FAMILY OF ASSISTANCE ARE AVAILABLE THROUGHOUT THE KALEIDA LOCATIONS. BROCHURES AND PAMPHLETS INFORMING THE COMMUNITY ARE WIDELY DISTRIBUTED IN THE COMMUNITY AT HEALTH FAIRS, CHURCHES, SCHOOLS AND OTHER PUBLIC LOCATIONS. INFORMATION REGARDING THE AVAILABILITY OF FINANCIAL ASSISTANCE AS WELL AS APPLICATION IS ALSO MADE AVAILABLE THROUGH KALEIDA Schedule H (Form 990) 2016 JSA 6E1327 2.000 6261CF 2214 V 16-7.6F PAGE 73 KALEIDA HEALTH 16-1533232 Schedule H (Form 990) 2016 Part VI Page 10 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. HEALTH'S WEBSITE. KALEIDA HEALTH OFFERS ASSISTANCE TO INDIVIDUALS IN OUR COMMUNITY FOR ACCESSING AFFORDABLE HEALTH CARE, INCLUDING: *NYS HEALTH MARKETPLACE: ASSISTS WITH NAVIGATING, EDUCATING AND ENROLLMENT IN THE NYS HEALTH MARKETPLACE OFFERINGS. DEDICATED AND STATE-TRAINED STAFF IS AVAILABLE TO ASSIST INDIVIDUALS IN PERSON OR VIA THE PHONE. KALEIDA HEALTH OFFERS IN-PERSON APPOINTMENTS AT (5) FIVE DIFFERENT SITE LOCATIONS. *FACILITATED ENROLLMENT: ASSISTS ELIGIBLE INDIVIDUALS WITH HEALTH INSURANCE ENROLLMENT BY OFFERING EDUCATION AND APPLICATION ASSISTANCE FOR MEDICAID, CHILD HEALTH PLUS, ESSENTIAL PLANS, STATE AID PROGRAM FOR CHILDREN WITH SPECIAL NEEDS AND ALL QUALIFIED HEALTH PLANS MADE AVAILABLE THROUGH THE AFFORDABLE CARE ACT. A DEDICATED TELEPHONE NUMBER IS AVAILABLE AND INFORMATION IS PUBLISHED IN BROCHURES AT KALEIDA SITES AND AT VARIOUS LOCATIONS THROUGHOUT THE COMMUNITY. Schedule H (Form 990) 2016 JSA 6E1327 2.000 6261CF 2214 V 16-7.6F PAGE 74 KALEIDA HEALTH 16-1533232 Schedule H (Form 990) 2016 Part VI Page 10 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. *FINANCIAL ASSISTANCE PROGRAM: AS DESCRIBED ABOVE, THE KALEIDA FINANCIAL ASSISTANCE PROGRAM, IF ELIGIBLE, PROVIDES FREE OR REDUCED-PRICES FOR PATIENTS TREATED AT KALEIDA HEALTH HOSPITALS OR LONG-TERM CARE FACILITIES. DISCOUNTS ARE AWARDED BASED UPON INCOME AND ASSET VERIFICATION. *PRESUMPTIVE ELIGIBILITY: KALEIDA HEALTH HAS SHOWN A WILLINGNESS TO EXTEND FINANCIAL ASSISTANCE TO NEEDY PATIENTS WITH OUTSTANDING BILLS WHO HAVE NOT COMPLETED THE CHARITY APPLICATION PROCESS. THIS IS ACHIEVED THROUGH AN AUTOMATED PARO SCORING PROCESS USING PUBLIC RECORDS, REGIONAL COST OF LIVING, ESTIMATED HOUSEHOLD INCOME THRESHOLDS, AND COMMUNITY DEMOGRAPHICS TO DERIVE AN ESTIMATED FINANCIAL POSITION FOR EACH PATIENT. THOSE PATIENTS SCREENED THROUGH THIS AUTOMATED PROCESS AND DEEMED ELIGIBLE ARE ADJUSTED OFF TO CHARITY CARE IN LIEU OF BAD DEBT. COMMUNITY INFORMATION KALEIDA HEALTH SERVES WESTERN NEW YORK'S EIGHT COUNTIES OF ALLEGANY, Schedule H (Form 990) 2016 JSA 6E1327 2.000 6261CF 2214 V 16-7.6F PAGE 75 KALEIDA HEALTH 16-1533232 Schedule H (Form 990) 2016 Part VI Page 10 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. CATTARAUGUS, CHAUTAUQUA, ERIE, GENESEE, NIAGARA, ORLEANS, AND WYOMING. THE POPULATION FOR THE REGION IS APPROXIMATELY 1.5 MILLION WITH ERIE COUNTY AND NIAGARA COUNTY COMPRISING AN ESTIMATED 1.1 MILLION OF THIS TOTAL. THREE KALEIDA HEALTH HOSPITALS INCLUDING BUFFALO GENERAL MEDICAL CENTER, MILLARD FILLMORE SUBURBAN HOSPITAL, AND WOMEN AND CHILDREN'S HOSPITAL OF BUFFALO ARE LOCATED IN ERIE COUNTY, THE HOSPITALS' PRIMARY SERVICE AREA. DEGRAFF MEMORIAL HOSPITAL IS LOCATED IN NIAGARA COUNTY, ITS PRIMARY SERVICE AREA. DEGRAFF ALSO SERVES A NUMBER OF ERIE COUNTY RESIDENTS GIVEN ITS LOCATION IS LESS THAN ONE MILE FROM THE ERIE COUNTY BORDER. EACH HOSPITAL'S PRIMARY SERVICE AREA IS DEFINED AS THE COUNTY WITH THE HIGHEST PERCENTAGE OF ALL WNY COUNTIES FOR 2015 INPATIENT DISCHARGES, EMERGENCY DEPARTMENT VISITS, AND OUTPATIENT VISITS AS IDENTIFIED IN THE 2016-2018 CHNA-CSP. ERIE COUNTY ERIE COUNTY IS LOCATED IN THE WESTERN PORTION OF NEW YORK STATE BORDERING LAKE ERIE, AND ALSO LIES ON THE INTERNATIONAL BORDER BETWEEN THE UNITED STATES AND CANADA. THE FOLLOWING DEMOGRAPHIC STATISTICS FOR ERIE COUNTY Schedule H (Form 990) 2016 JSA 6E1327 2.000 6261CF 2214 V 16-7.6F PAGE 76 KALEIDA HEALTH 16-1533232 Schedule H (Form 990) 2016 Part VI Page 10 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. ARE FROM MEDSTAT MARKET EXPERT 2016, THE US CENSUS: QUICK FACTS, 2014 AMERICAN COMMUNITY SURVEY, AND 2015 POPULATION ESTIMATES AS INDICATED IN KALEIDA HEALTH'S 2016-2018 CHNA-CSP. THE COUNTY'S TOTAL POPULATION IS 930,801 AND IS COMPRISED OF URBAN, SUBURBAN, AND RURAL CITIES, TOWNS, AND VILLAGES. ERIE COUNTY'S MEDIAN HOUSEHOLD INCOME IS $51,050, ITS POVERTY RATE IS 15.2%, AND 17.4% OF ITS POPULATION IS OVER 65 YEARS OF AGE. ITS LARGEST CITY AND COUNTY SEAT IS BUFFALO WITH A POPULATION OF 277,181. THE 2014 AMERICAN COMMUNITY SURVEY RANKED BUFFALO AS THE FOURTH POOREST CITY IN THE NATION. THE CITY HAS A 30.9% POVERTY RATE (INCOME BELOW THE FEDERAL POVERTY LEVEL PER US CENSUS) AND 38.6% OF HOUSEHOLDS HAVE AN AVERAGE INCOME LESS THAN $25,000. BUFFALO ALSO HAS A HIGH MINORTY POPULATION WITH 35.7% OF ITS RESIDENTS BEING BLACK NON-HISPANIC AND 11.7% HISPANIC AS COMPARED TO 13% BLACK NON-HISPANIC AND 5.3% HISPANIC FOR ALL OF ERIE COUNTY. PERSONS UNDER AGE 65 WITHOUT HEALTH INSURANCE COMPRISE 6.9% OF ERIE COUNTY'S POPULATION AND 10.7% OF BUFFALO'S POPULATION. BUFFALO GENERAL MEDICAL CENTER AND WOMEN & CHILDREN'S HOSPITAL OF BUFFALO ARE LOCATED IN THE CITY OF BUFFALO AND SERVE A HIGH PERCENTAGE OF BUFFALO'S POOR AND UNDERSERVED POPULATION. MOST CENSUS TRACTS IN BUFFALO Schedule H (Form 990) 2016 JSA 6E1327 2.000 6261CF 2214 V 16-7.6F PAGE 77 KALEIDA HEALTH 16-1533232 Schedule H (Form 990) 2016 Part VI Page 10 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. ARE FEDERALLY DESIGNATED AS MEDICALLY UNDERSERVED AREAS. THE TOWN OF AMHERST IS ONE OF THE COUNTY'S LARGEST SUBURBS WITH A POPULATION OF 139,363 AND IS HOME TO MILLARD FILLMORE SUBURBAN HOSPITAL. IN CONTRAST TO BUFFALO, THE TOWN OF AMHERST HAS A POVERTY RATE OF 9.4% AND 33.9% OF HOUSEHOLDS HAVE AN AVERAGE INCOME OVER $100,000. 80.7% WHITE NON-HISPANIC. AMHERST'S POPULATION IS THE TOWN ALSO HAS 8.8% ASIAN-PACIFIC ISLANDER POPULATION, COMPARABLE TO THE NYS RATE OF 8.6% WHILE THE ERIE COUNTY RATE IS 3.1%. THE TOWN HAS A SIGNIFICANT SENIOR POPULATION WITH 19.4% OF RESIDENTS 65 YEARS AND OVER, AND MILLARD FILLMORE SUBURBAN HOSPITAL SERVES A HIGH PERCENTAGE OF THE TOWN'S AGING POPULATION. NIAGARA COUNTY NIAGARA COUNTY IS LOCATED IN THE WESTERN PORTION OF NEW YORK STATE, JUST NORTH OF BUFFALO (ERIE COUNTY), ADJACENT TO LAKE ONTARIO ON ITS NORTHERN BORDER WITH THE NIAGARA RIVER AND CANADA ON ITS WESTERN BORDER. THE FOLLOWING DEMOGRAPHIC STATISTICS FOR NIARAGA COUNTY ARE FROM MEDSTAT MARKET EXPERT, THE US CENSUS: QUICK FACTS, 2014 AMERICAN COMMUNITY SURVEY, AND 2015 POPULATION ESTIMATES AS INDICATED IN KALEIDA HEALTH'S Schedule H (Form 990) 2016 JSA 6E1327 2.000 6261CF 2214 V 16-7.6F PAGE 78 KALEIDA HEALTH 16-1533232 Schedule H (Form 990) 2016 Part VI Page 10 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. 2016-2018 CHNA-CSP. THE COUNTY'S TOTAL POPULATION IS 212,170 AND IS COMPRISED OF URBAN, SUBURBAN, AND RURAL CITIES, TOWNS, AND VILLAGES. NIAGARA COUNTY'S MEDIAN HOUSEHOLD INCOME IS $49,091, ITS POVERTY RATE IS 13.4% (INCOME BELOW THE FEDERAL POVERTY LEVEL PER US CENSUS), AND 18.2% OF ITS POPULATION IS OVER 65 YEARS OF AGE. ITS CITIES INCLUDE NIAGARA FALLS, POPULATION 63,520; NORTH TONAWANDA, POPULATION 45,253; AND ITS COUNTY SEAT OF LOCKPORT, POPULATION 58,397. THESE CITIES INCLUDE A HIGH PROPORTION OF THE COUNTY'S LOW INCOME AND UNDERSERVED POPULATION. 17.2% OF NIAGARA FALLS RESIDENTS ARE BLACK NON-HISPANIC AND THE CITY HAS A 25.3% POVERTY RATE. ADDITIONALLY, NIAGARA FALLS IS FEDERALLY DESIGNATED AS AN AREA WITH A MEDICALLY UNDERSERVED POPULATION. NORTH TONAWANDA IS 10.6% AND 18.9% FOR LOCKPORT. THE POVERTY RATE FOR FURHTERMORE, NIAGARA FALLS AND NORTH TONAWANDA BOTH HAVE AN 11-12% RATE OF PERSONS UNDER 65 YEARS OF AGE WITHOUT HEALTH INSURANCE. NIAGARA COUNTY IS ALSO HOME TO THE TUSCARORA RESERVATION WITH A 2010 POPULATION OF 1,152 AND A POVERTY RATE OF 13.0%. NORTH TONAWANDA IS HOME TO DEGRAFF MEMORIAL HOSPITAL, A FULL SERVICE, ACUTE CARE FACILITY THAT ALSO PROVIDES SPECIALTY CARE TO MEET THE NEEDS OF NIAGARA COUNTY'S AGING POPULATION, AND INCLUDES THE WNY Schedule H (Form 990) 2016 JSA 6E1327 2.000 6261CF 2214 V 16-7.6F PAGE 79 KALEIDA HEALTH 16-1533232 Schedule H (Form 990) 2016 Part VI Page 10 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. GERIATRIC CENTER. DURING 2016, THERE WERE 55,696 INPATIENT DISCHARGES, OF WHICH 26% WERE MEDICAID AND MEDICAID MANAGED CARE, 41% MEDICARE AND MEDICARE MANAGED CARE, AND 1% WERE UNINSURED. IN ADDITION TO KALEIDA HEALTH'S 3 HOSPITALS IN ERIE COUNTY AND 1 HOSPITAL IN NIAGARA COUNTY, THERE ARE 11 OTHER HOSPITALS IN ERIE COUNTY AND 4 OTHER HOSPITALS IN NIAGARA COUNTY SERVING WESTERN NEW YORK PER THE NEW YORK STATE DEPARTMENT OF HEALTH WEBSITE. MORE INFORMATION IS AVAILABLE IN THE KALEIDA HEALTH 2016-2018 COMMUNITY HEALTH NEEDS ASSESSMENT-COMMUNITY SERVICE PLAN (CHNA-CSP). THE DOCUMENT WAS COMPLETED IN FALL 2016, AND CAN BE FOUND ON THE KALEIDA HEALTH WEBSITE AT WWW.KALEIDAHEALTH.ORG/COMMUNITY/PUBLICATIONS.ASP. PRINTED COPIES AVAILABLE UPON REQUEST AT NO CHARGE. PROMOTION OF COMMUNITY HEALTH Schedule H (Form 990) 2016 JSA 6E1327 2.000 6261CF 2214 V 16-7.6F PAGE 80 KALEIDA HEALTH 16-1533232 Schedule H (Form 990) 2016 Part VI Page 10 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. KALEIDA HEALTH'S MISSION IS TO ADVANCE THE HEALTH OF THE COMMUNITY. KALEIDA HEALTH'S VISION IS TO PROVIDE COMPASSIONATE, HIGH-VALUE, QUALITY CARE, IMPROVING HEALTH IN WESTERN NEW YORK AND BEYOND, EDUCATING FUTURE HEALTH CARE LEADERS AND DISCOVERING INNOVATIVE WAYS TO ADVANCE MEDICINE. KALEIDA HEALTH MAINTAINS CONTROL OVER THE CORPORTATION THROUGH ITS SELF-PERPETUATING, 15 MEMBER GOVERNING BOARD OF DIRECTORS. A MAJORITY OF THE BOARD OF DIRECTORS RESIDES IN KALEIDA HEALTH'S PRIMARY SERVICE AREA OF ERIE AND NIAGARA COUNTIES AND IS NEITHER EMPLOYEES NOR INDEPENDENT CONTRACTORS OF KALEIDA HEALTH, NOR FAMILY MEMBERS THEREOF. THE BOARD OF DIRECTORS IS COMPRISED OF COMMUNITY LEADERS FROM THE BUSINESS, INDUSTRY, AND HEALTHCARE SECTORS, INCLUDING PHYSICIANS WHO ARE ON THE MEDICAL STAFF. EACH DIRECTOR SIGNS A CONFLICT OF INTEREST STATEMENT AND SERVES A THREE-YEAR TERM. JODEY LOMEO, PRESIDENT AND CEO OF KALEIDA HEALTH SERVES AS AN EX-OFFICIO DIRECTOR WITH VOTING RIGHTS. SURPLUS FUNDS ARE USED TO FURTHER THE MISSION AND OPERATIONS OF KALEIDA HEALTH, SUCH AS REINVESTING IN COMMUNITY BENEFIT PROGRAMS, AND MAKING Schedule H (Form 990) 2016 JSA 6E1327 2.000 6261CF 2214 V 16-7.6F PAGE 81 KALEIDA HEALTH 16-1533232 Schedule H (Form 990) 2016 Part VI Page 10 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. IMPROVEMENTS IN FACILITIES, PATIENT CARE, MEDICAL, NURSING, ALLIED HEALTH TRAINING, EDUCATION, AND RESEARCH IN SUPPORT OF THE HEALTH NEEDS OF THE COMMUNITY. IN ADDITION TO THE COMMUNITY SERVICE PROGRAMS ADDRESSED IN SECTION VI, PART II COMMUNITY BUILDING SECTION: KALEIDA HEALTH PROVIDES A NUMBER OF ADDITIONAL PROGRAMS AND COLLABORATIONS. KALEIDA HEALTH IS COMMITTED TO EDUCATION AND RESEARCH AS IT SERVES AS A MAJOR CLINICAL TEACHING AFFILIATE OF THE UNIVERSITY AT BUFFALO, JACOBS SCHOOL OF MEDICINE AND BIOMEDICAL SCIENCES. THROUGH AFFILIATIONS WITH A NUMBER OF EDUCATIONAL INSTITUTIONS, KALEIDA HEALTH ALSO PROVIDES A CLINICAL EXPERIENCE FOR HEALTH CARE PROFESSIONALS IN TRAINING IN THE FIELDS OF PHARMACY, NURSING, PHYSICIAN ASSISTANTS, SOCIAL WORK, AND REHABILITATION SERVICES. IN 2016, KALEIDA HEALTH PRESENTED ITS THIRD ANNUAL GATES VASCULAR INSTITUTE SYMPOSIUM: UPDATES IN CARDIAC, VASCULAR, AND NEUROENDOVASCULAR MEDICINE FOR MEDICAL PROFESSIONALS AND STUDENTS. Schedule H (Form 990) 2016 JSA 6E1327 2.000 6261CF 2214 V 16-7.6F PAGE 82 KALEIDA HEALTH 16-1533232 Schedule H (Form 990) 2016 Part VI Page 10 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. AS CONFERRED BY THE BOARD OF DIRECTORS, MEDICAL STAFF MEMBERSHIP IS OFFERED TO PROFESSIONALLY COMPETENT PHYSICIANS, DENTISTS, PODIATRISTS AND OTHER SPECIFIED INDIVIDUALS, WHO CONTINUOUSLY MEET THE QUALIFICATIONS, STANDARDS AND REQUIREMENTS OUTLINED IN THE BYLAWS, RULES AND REGULATIONS, POLICIES OF THE MEDICAL STAFF AND KALEIDA HEALTH, CONSISTENT WITH THE NEEDS OF KALEIDA HEALTH'S PATIENTS. STAFF MEMBERSHIP OR PARTICULAR CLINICAL PRIVILEGES SHALL NOT BE DENIED ON THE BASIS OF AGE, SEX, SEXUAL ORIENTATION, RACE, COLOR. CREED, NATIONAL ORIGIN, A DISABILITY UNRELATED TO THE ABILITY TO FULFILL PATIENT CARE AND MEDICAL STAFF RESPONSIBILITIES OR ANY OTHER CRITERION UNRELATED TO THE EFFICIENT DELIVERY OF QUALITY PATIENT CARE, TO PROFESSIONAL QUALIFICATIONS OR TO THE NEEDS OF THE COMMUNITY, OR TO THE PURPOSES, NEEDS, AND CAPABILITIES OF KALEIDA HEALTH. EVERY MEMBER OF THE MEDICAL STAFF ASSISTS THE HOSPITALS IN FULFILLING KALEIDA HEALTH'S MISSION AND RESPONSIBILITY TO PROVIDE EMERGENCY AND UNCOMPENSATED CARE FOR THOSE IN NEED. KALEIDA HEALTH IS COMMITTED TO PROVIDING HEALTH CARE FOR THE UNINSURED AND UNDERINSURED, OFFERS PROGRAMS AND SERVICES IN COMMUNITY-BASED Schedule H (Form 990) 2016 JSA 6E1327 2.000 6261CF 2214 V 16-7.6F PAGE 83 KALEIDA HEALTH 16-1533232 Schedule H (Form 990) 2016 Part VI Page 10 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. SETTINGS AND IN ITS CAMPUSES AND FACILITIES, AND WORKS WITH PARTNERING ORGANIZATIONS TO FUTHER MEET THE COMMUNITY'S HEALTH AND SOCIAL NEEDS. PROGRAMS AND EVENTS TARGET ALL AGES AND BACKGROUNDS, INCLUDING THE MEDICALLY UNDERSERVED, AND FOCUS ON THE REDUCTION OF HEALTH DISPARITIES, IMPROVED ACCESS TO CARE, EFFECTIVE USE OF HEALTH SERVICES, AND THE PROMOTION OF OVERALL COMMUNITY HEALTH AND WELLNESS. KALEIDA HEALTH COLLABORATES WITH COMMUNITY PARTNERS TO IMPROVE ACCESS TO HIGH QUALITY, PREVENTATIVE, AND COST EFFECTIVE CARE FOR THE MEDICAID POPULATION OF WESTERN NEW YORK. THROUGH THE NYS DSRIP (DELIVERY SYSTEM REFORM INCENTIVE PAYMENT) PROGRAM, KALEIDA HEALTH IS AN ACTIVE PARTNER IN THE MILLENNIUM COLLABORATIVE CARE (MCC) PERFORMING PROVIDER SYSTEM (PPS) TO MEET THE STATEWIDE DSRIP GOAL OF REDUCING AVOIDABLE HOSPITAL ADMISSIONS BY 25% OVER FIVE YEARS. LEADERSHIP AND STAFF ARE MEMBERS OF MCC COMMITTEES AND SUPPORT THE ACHIEVEMENT OF DSRIP GOALS AND PROJECTS THROUGHOUT THE REGION. BUFFALO GENERAL MEDICAL CENTER CONDUCTS THE MCC ED CARE TRIAGE PROGRAM IN WHICH PATIENT NAVIGATORS IN THE EMERGENCY ROOM LINK AT-RISK PATIENTS WHO LACK PRIMARY CARE ACCESS WITH A PRIMARY CARE Schedule H (Form 990) 2016 JSA 6E1327 2.000 6261CF 2214 V 16-7.6F PAGE 84 KALEIDA HEALTH 16-1533232 Schedule H (Form 990) 2016 Part VI Page 10 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. PHYSICIAN OR A NYS MEDICAID HEALTH HOME. A NYS MEDICAID HEALTH HOME SERVING CHILDREN WAS ESTABLISHED IN 2016 THROUGH WOMEN & CHILDREN'S HOSPITAL OF BUFFALO TO PROVIDE CARE MANAGEMENT TO WNY CHILDREN WITH MEDICAID WHO HAVE COMPLEX PHYSICAL AND/OR BEHAVIORAL HEALTH CONDITIONS. THE HOSPITAL ALSO OPERATES NINE SCHOOL BASED HEALTH CENTERS AND THE SCHOOL NURSING PROGRAM IN BUFFALO PUBLIC SCHOOLS, A SCHOOL DISTRICT WITH 77% OF STUDENTS ELIGIBLE FOR A FREE LUNCH THROUGH NATIONAL SCHOOL LUNCH PROGRAM (2015 NYS SCHOOL REPORT CARD). WOMEN & CHILDREN'S HOSPITAL OF BUFFALO IS KNOWN FOR ITS COMMUNITY COLLABORATIONS TO ADDRESS PUBLIC HEALTH CONCERNS AND ASSURE ACCESS TO CARE FOR WOMEN AND CHILDREN, MANY OF WHOM ARE MEDICALY UNDERSERVED. IN ADDITION TO ITS WIDE RANGE OF SPECIALIZED PEDIATRIC AND MATERNAL SERVICES, THE HOSPITAL SERVES THE REGION AS A NEW YORK STATE REGIONAL PERINATAL CENTER, NYS DESIGNATED EBOLA PREPARED CENTER, AND THE PEDIATRIC & ADOLESCENT AIDS DESIGNATED CENTER OF WNY. IT HAS A LEVEL III NEONATAL INTENSIVE CARE UNIT, LEVEL I PEDIATRIC TRAUMA UNIT, AND PEDIATRIC Schedule H (Form 990) 2016 JSA 6E1327 2.000 6261CF 2214 V 16-7.6F PAGE 85 KALEIDA HEALTH 16-1533232 Schedule H (Form 990) 2016 Part VI Page 10 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. INTENSIVE CARE UNIT AND IS HOME TO THE ROBERT WARNER CENTER FOR CHILDREN WITH SPECIAL HEALTH CARE NEEDS, CHILDREN'S GUILD FOUNDATION AUTISM SPECTRUM DISORDER CENTER, REGIONAL LEVEL IV EPILEPSY MONITORING CENTER OF WNY, UPSTATE NEW YORK SHAKEN BABY SYNDROME EDUCATION PROGRAM, LEAD POISONING PREVENTION RESOURCE CENTER OF WESTERN NEW YORK, SICKLE CELL & HEMOGLOBINOPATHY CENTER OF WESTERN NEW YORK, CYSTIC FIBROSIS CENTER OF WNY AND THE EARLY CHILDHOOD DIRECTIONS CENTER, AMONG OTHERS. INCREASING BREASTFEEDING RATES IS A PUBLIC HEALTH PRIORITY OF THE NEW YORK STATE PREVENTION AGENDA. AS DELIVERY HOSPITALS, BOTH WOMEN & CHILDREN'S HOSPITAL OF BUFFALO AND MILLARD FILLMORE SUBURBAN HOSPITAL ARE ENGAGED IN SEVERAL EDUCATIONAL AND CLINICAL INITIATIVES TO IMPROVE EXCLUSIVE BREASTFEEDING RATES TO ACHIEVE BABY-FRIENDLY USA (C) DESIGNATION. THE HOSPITALS ARE PART OF THE EMPOWER INITIATIVE AS FUNDED THROUGH THE CENTERS FOR DISEASE CONTROL, AND RECEIVE TRAINING AND RESOURCE SUPPORT IN LACTATION EDUCATION THROUGH EXPERIENCED EMPOWER COACHES. ADDITIONALLY, KALEIDA HEALTH'S OB-GYN CENTERS HAVE ALL ACHIEVED NEW YORK STATE BABY-FRIENDLY PRACTICE DESIGNATION. Schedule H (Form 990) 2016 JSA 6E1327 2.000 6261CF 2214 V 16-7.6F PAGE 86 KALEIDA HEALTH 16-1533232 Schedule H (Form 990) 2016 Part VI Page 10 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. CARDIOVASCULAR DISEASE IS THE NUMBER ONE CAUSE OF DEATH IN BOTH ERIE AND NIAGARA COUNTIES AND KALEIDA HEALTH SUPPORTS SEVERAL CARDIOVASCULAR INITIATIVES. CARDIAC AND STROKE CARE IS A MAJOR SERVICE LINE FOR KALEIDA HEALTH AND THE GATES VASCULAR INISTITUTE OF BUFFALO GENERAL MEDICAL CENTER SERVES AS A REGIONAL SPECIALTY CARE AND RESEARCH FACILITY FOCUSING ON THE HEART, NEUROLOGICAL, AND RELATED VASCULAR SYSTEM. IN 2016, KALEIDA HEALTH HOSPITALS PROVIDED THREE CARDIOVASCULAR EDUCATION AND SCREENING EVENTS AND 20 STROKE EDUCATION EVENTS TO THE PUBLIC, INCLUDING THE UNDERSERVED. A TARGETED CARDIOVASCULAR EDUCATION AND SCREENING PROGRAM IS PROVIDED TO MEDICALLY UNDERSERVED FEMALES AT THE OB-GYN CENTERS OF WOMEN & CHILDREN'S HOSPITAL OF BUFFALO, WHERE A MAJORITY OF PATIENT VISITS ARE REIMBURSED THROUGH MEDICAID. COLLABORATION AND ACCESS TO CARE ACROSS ALL OF WESTERN NEW YORK IS A PRIORTY FOR KALEIDA HEALTH. TO ADDRESS THE NEED FOR CARDIAC CATHETERIZATION SERVICES IN NIAGARA COUNTY, KALEIDA HEALTH COLLABORATED WITH NIAGARA FALLS MEMORIAL MEDICAL CENTER (NFMMC), CATHOLIC HEALTH Schedule H (Form 990) 2016 JSA 6E1327 2.000 6261CF 2214 V 16-7.6F PAGE 87 KALEIDA HEALTH 16-1533232 Schedule H (Form 990) 2016 Part VI Page 10 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. SYSTEM, AND ERIE COUNTY MEDICAL CENTER TO MAKE THIS LIFESAVING CARE READILY ACCESSIBLE TO RESIDENTS THROUGHOUT THE NIAGARA REGION. A NEW CARDIAC CATHETERIZATION LABORATORY WILL OPEN IN 2017 AT THE HEART CENTER OF NIAGARA ON THE NFMMC'S DOWNTOWN NIAGARA FALLS CAMPUS. MILLARD FILLMORE SUBURBAN HOSPITAL SERVES THE WESTERN NEW YORK COMMUNITY WITH A COMPREHENSIVE CANCER REHAB PROGRAM, AND IN 2016, THE HOSPITAL CO-HOSTED THE AMERICAN CANCER SOCIETY'S LOOK GOOD FEEL BETTER(R) PROGRAM.THE HOSPITAL PROVIDES CHRONIC DISEASE EDUCATION AND SCREENING PROGRAMS AND PARTICIPATES IN COMMUNITY EVENTS INCLUDING NATIONAL PRESCRIPTION DRUG TAKE-BACK DAYS. KALEIDA HEALTH'S DEGRAFF MEMORIAL HOSPITAL COLLABORATES WITH OTHER NIAGARA COUNTY ORGANIZATIONS TO IMPLEMENT THE STAY WELL ON YOUR FEET PROGRAM TO REDUCE THE RISK OF FALLS AMONG THE 65+ POPULATION IN NIAGARA COUNTY. IN 2016, THE STAY WELL ON YOUR FEET FALLS PREVENTION PROGRAM WAS AWARDED A 2016 SOPHI AWARD (SPOTLIGHT ON POPULATION HEALTH AWARD) THROUGH THE P2COLLABORATIVE OF WNY IN THE CATEGORY OF INJURY PREVENTION. DEGRAFF Schedule H (Form 990) 2016 JSA 6E1327 2.000 6261CF 2214 V 16-7.6F PAGE 88 KALEIDA HEALTH 16-1533232 Schedule H (Form 990) 2016 Part VI Page 10 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. ALSO PARTICIPATES IN SEVERAL COMMUNITY EVENTS TO PROVIDE CHRONIC DISEASE EDUCATION AND SCREENING PROGRAMS, AND SERVES AS A SITE FOR NATIONAL PRESCRIPTION DRUG TAKE-BACK DAYS. THE VISITING NURSING ASSOCIATION OF WESTERN NEW YORK, INC., KALEIDA HEALTH'S HOME CARE AFFILIATE, FURTHER WORKS TO PROMOTE THE HEALTH OF THE COMMUNITY. THIS INCLUDES EDUCATING CHRONIC CARE PATIENTS ON SELF-MANAGEMENT AND PERSONAL CARE IN AREAS SUCH AS REHABILITATION SERVICES, NUTRITION EDUCATION AND THERAPY, INFECTION CONTROL, FALLS RISK ASSESSMENT AND INTERVENTION, DEPRESSION RISK ASSESSMENT AND INTERVENTION, AND HEALTH EDUCATION RELATED TO IMPROVED LIFESTYLE CHOICES FOR INDIVIDUALS AND FAMILIES IN THEIR HOMES AND THE COMMUNITY. KALEIDA HEALTH'S HUMAN RESOURCES DEPARTMENT PARTNERS WITH THE BUFFALO AND ERIE COUNTY WORKFORCE DEVELOPMENT COUNCIL AND THE BUFFALO EDUCATION AND TRAINING CENTER ON DIFFERENT WORKFORCE DEVELOPMENT INITIATIVES AND EVENTS, INCLUDING THOSE TARGETING THE UNDERSERVED. ADDITIONALLY, KALEIDA HEALTH NURSE RECRUITERS PARTNER WITH LOCAL SCHOOLS AND COLLEGES TO Schedule H (Form 990) 2016 JSA 6E1327 2.000 6261CF 2214 V 16-7.6F PAGE 89 KALEIDA HEALTH 16-1533232 Schedule H (Form 990) 2016 Part VI Page 10 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. ADVANCE RECRUITMENT EFFORTS. INFORMATION REGARDING THE AVAILABILITY OF COMMUNITY HEALTH PROGRAMS, ASSISTANCE WITH HEALTH INSURANCE ENROLLMENT AND FINANCIAL ASSISTANCE PROGRAMS IS PROMOTED TO THE PUBLIC THROUGH MULTIPLE COMMUNITY OUTREACH ACTIVITIES AND EVENTS, ON THE KALEIDA HEALTH WEBSITE WWW.KALEIDAHEALTH.ORG, ON FACEBOOK AND TWITTER; AND AS INCLUDED IN THE 2016-2018 CHNA-CSP. THE CHNA-CSP IS AVAILABLE ON THE KALEIDA HEALTH WEBSITE OR IN PRINT FORMAT UPON REQUEST. AFFILIATED HEALTH CARE SYSTEM KALEIDA HEALTH IS PART OF AN AFFILIATED HEALTH CARE SYSTEM WHOSE MEMBERS INCLUDE: KALEIDA HEALTH FOUNDATION, VISITING NURSING ASSOCIATION OF WNY, INC., VNA HOMECARE SERVICE, INC., AND THE WOMEN & CHILDREN'S HOSPITAL OF BUFFALO FOUNDATION. Schedule H (Form 990) 2016 JSA 6E1327 2.000 6261CF 2214 V 16-7.6F PAGE 90 KALEIDA HEALTH 16-1533232 Schedule H (Form 990) 2016 Part VI Page 10 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. STATE FILING OF COMMUNITY BENEFIT REPORT NY, Schedule H (Form 990) 2016 JSA 6E1327 2.000 6261CF 2214 V 16-7.6F PAGE 91 (Form 990) Department of the Treasury Internal Revenue Service Name of the organization I 2 OMB No. 1545-0047 I Complete if the organization answered "Yes" on Form 990, Part IV, line 21 or 22. Attach to Form 990. Information about Schedule I (Form 990) and its instructions is at www.irs.gov/form990. Open to Public Inspection Employer identification number mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm KALEIDA HEALTH General Information on Grants and Assistance Part I 1 À¾µº Grants and Other Assistance to Organizations, Governments, and Individuals in the United States SCHEDULE I 16-1533232 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? Describe in Part IV the organization's procedures for monitoring the use of grant funds in the United States. Part II X Yes No 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. 1 (a) Name and address of organization or government (b) EIN (c) IRC section (if applicable) (d) Amount of cash grant (e) Amount of noncash assistance (f) Method of valuation (book, FMV, appraisal, other) (g) Description of noncash assistance (h) Purpose of grant or assistance (1) UNIVERSITY ORTHOPEDIC SERVICE 5500 MAIN STREET BUFFALO, NY 14221 16-1406947 N/A 50,000. FMV CONTRIBUTION 26-3085485 N/A 200,000. FMV CONTRIBUTION 16-1172453 501(C)(3) 25,000. FMV CONTRIBUTION 16-0865182 501(C)(3) 58,500. FMV SPONSORSHIP 16-1573408 N/A 20,000. FMV SPONSORSHIP 13-1846366 501(C)(3) 10,000. FMV SPONSORSHIP 75-1835298 501(C)(3) 6,000. FMV SPONSORSHIP 16-0371125 501(C)(3) 13,434. FMV SPONSORSHIP 51-0202066 501(C)(3) 12,200. FMV SPONSORSHIP 47-2878159 501(C)(3) 12,000. FMV SPONSORSHIP 16-0743159 N/A 13-1930701 501(C)(3) (2) JACOBS INSTITUTION INC 875 ELLICOTT STREET, 5TH FLOOR (3) UPSTATE NY TRANSPLANT, INC 110 BROADWAY BUFFALO, NY 14203 (4) UB FOUNDATION 3435 MAIN STREET BUFFALO, NY 14231 (5) MERCY FLIGHT 455 DELAWARE AVE BUFFALO, NY 14202 (6) MARCH OF DIMES FOUNDATION 1275 MAMARONECK AVE WHITE PLAINS, NY 10605 (7) SUSAN G. KOMEN FOR THE CURE ELM & CARLTON STREETS BUFFALO, NY 14263 (8) ECMC LIFELINE FOUNDATION 462 GRIDER STREET BUFFALO, NY 14215 (9) HOSPICE BUFFALO INC 225 COMO PARK BLVD BUFFALO, NY 14227 (10) 43NORTH BPC INC 640 ELLICOTT ST, SUITE 108 (11) ST. JOSEPH COLLEGIATE INSTITUTE 845 KENMORE AVENUE BUFFALO, NY 14223 (12) CYSTIC FIBROSIS FDN 6931 ARLINGTON RD, SUITE T 200 2 3 mmmmmmmmmmmmmmmmmmmmmmmmmmmmm m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m II 10,000. FMV SPONSORSHIP 10,000. FMV SPONSORSHIP Enter total number of section 501(c)(3) and government organizations listed in the line 1 table Enter total number of other organizations listed in the line 1 table For Paperwork Reduction Act Notice, see the Instructions for Form 990. Schedule I (Form 990) (2016) JSA 6E1288 1.000 6261CF 2214 V 16-7.6F PAGE 92 (Form 990) Department of the Treasury Internal Revenue Service Name of the organization I 2 OMB No. 1545-0047 I Complete if the organization answered "Yes" on Form 990, Part IV, line 21 or 22. Attach to Form 990. Information about Schedule I (Form 990) and its instructions is at www.irs.gov/form990. Open to Public Inspection Employer identification number mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm KALEIDA HEALTH General Information on Grants and Assistance Part I 1 À¾µº Grants and Other Assistance to Organizations, Governments, and Individuals in the United States SCHEDULE I 16-1533232 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? Describe in Part IV the organization's procedures for monitoring the use of grant funds in the United States. Part II X Yes No 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. 1 (a) Name and address of organization or government (b) EIN (c) IRC section (if applicable) (d) Amount of cash grant (e) Amount of noncash assistance (f) Method of valuation (book, FMV, appraisal, other) (g) Description of noncash assistance (h) Purpose of grant or assistance (1) DEAF ACCESS SERVICES, INC 2495 MAIN STREET, SUITE 446 16-1433932 N/A 10,000. FMV SPONSORSHIP 26-1247618 N/A 8,000. FMV SPONSORSHIP 23-7218160 501(C)(3) 7,250. FMV SPONSORSHIP 16-0743902 501(C)(3) 6,500. FMV SPONSORSHIP 13-1623888 501(C)(3) 5,750. FMV SPONSORSHIP (2) WECK CULVER COMMUNICATIONS COR 2900 GENESEE STREET CHEEKTOWAGA, NY 14225 (3) KEVIN GUEST HOUSE 782 ELLICOTT STREET BUFFALO, NY 14203 (4) AMERICAN CANCER SOCIETY 101 JOHN JAMES AUDUBON PKWY (5) AMERICAN DIABETES ASSOCIATION 569 HIGHLAND AVE TONAWANDA, NY 14223 (6) (7) (8) (9) (10) (11) (12) 2 3 mmmmmmmmmmmmmmmmmmmmmmmmmmmmm m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m II Enter total number of section 501(c)(3) and government organizations listed in the line 1 table Enter total number of other organizations listed in the line 1 table For Paperwork Reduction Act Notice, see the Instructions for Form 990. 11. 6. Schedule I (Form 990) (2016) JSA 6E1288 1.000 6261CF 2214 V 16-7.6F PAGE 93 KALEIDA HEALTH 16-1533232 Schedule I (Form 990) (2016) Part III Page 2 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 non-cash assistance (e) Method of valuation (book, (f) Description of non-cash assistance FMV, appraisal, other) 1 2 3 4 5 6 7 Supplemental Information. Provide the information required in Part I, line 2, Part III, column (b); and any other additional information. FORM 990, SCHEDULE I: Part IV PART I, LINE 2 DESCRIPTION OF ORGANIZATION'S PROCEDURES FOR MONITORING THE USE OF GRANTS: KALEIDA HEALTH MAKES CONTRIBUTIONS TO ORGANIZATONS IN WESTERN NEW YORK THAT ALSO HAVE HEALTH CARE RELATED ACTIVITIES. ALL CONTRIBUTIONS MUST BE APPROVED BY THE GOVERNING BODY BEFORE MONEY IS DISTRIBUTED. Schedule I (Form 990) (2016) JSA 6E1504 2.000 6261CF 2214 V 16-7.6F PAGE 94 SCHEDULE J (Form 990) Department of the Treasury Internal Revenue Service Name of the organization I I À¾µº I Compensation Information OMB No. 1545-0047 For certain Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees Complete if the organization answered "Yes" on Form 990, Part IV, line 23. Attach to Form 990. Information about Schedule J (Form 990) and its instructions is at www.irs.gov/form990. Open to Public Inspection Employer identification number KALEIDA HEALTH Part I Questions Regarding Compensation 16-1533232 Yes No 1a Check the appropriate 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 Travel for companions Tax indemnification and gross-up payments Discretionary spending account X Housing allowance or residence for personal use Payments for business use of personal residence Health or social club dues or initiation fees Personal services (such as, maid, chauffeur, chef) mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm b 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 2 Did the organization require substantiation prior to reimbursing or allowing expenses incurred by all directors, trustees, and officers, including the CEO/Executive Director, regarding the items checked on line 1a? mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm 1b X 2 X mmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmm mmmmmmmmmmmmmmm 4a 4b 4c X X mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm 5a 5b X X 6a 6b X X 7 X 8 X 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. 3 X Compensation committee X Independent compensation consultant X Form 990 of other organizations 4 a b 6 a b 8 9 W ritten employment contract Compensation survey or study 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: a Receive a severance payment or change-of-control payment? b Participate in, or receive payment from, a supplemental nonqualified retirement plan? c 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. 5 7 X X X Only section 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. mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmm For persons listed on Form 990, Part VII, Section A, line 1a, did the organization provide any nonfixed payments not described on lines 5 and 6? If "Yes," describe in Part III Were any amounts reported on Form 990, Part VII, paid or accrued 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)? mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm For Paperwork Reduction Act Notice, see the Instructions for Form 990. X 9 Schedule J (Form 990) 2016 JSA 6E1290 1.000 6261CF 2214 V 16-7.6F PAGE 95 KALEIDA HEALTH 16-1533232 Schedule J (Form 990) 2016 Part II Page 2 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 aren't 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. (B) Breakdown of W-2 and/or 1099-MISC compensation (A) Name and Title (i) Base compensation JODY LOMEO (i) PRES/CEO EX-OFFICIO W/VOTE (ii) 1 ALYSON SPAULDING (i) GENERAL COUNSEL (ii) 2 DAVID HUGHES, MD (i) EVP, CMO (ii) 3 TONI BOOKER (i) EVP, CHIEF HUMAN RESOURCES OFC (ii) 4 JONATHAN SWIATKOWSKI (i) EVP, CFO (ii) 5 JAMAL GHANI (i) FORMER EVP, COO (ii) 6 DONALD BOYD (i) EVP BUSINESS DEVELOPMENT (ii) 7 CHRISTOPHER LANE (i) VP PRESIDENT BGMC (ii) 8 CHERYL KLASS (i) EVP, CHIEF NURSE EXECUTIVE (ii) 9 ALLEGRA JAROS (i) SVP OPERATIONS WCHOB (ii) 10 MICHAEL HUGHES (i) SVP, PUBLIC AFFAIRS MARKETING (ii) 11 AARON HOFFMAN, MD (i) EMPLOYED PHYSICIAN (ii) 12 CHRISTOPHER MALLAVARAPU (i) EMPLOYED PHYSICIAN (ii) 13 CARROLL HARMON, MD (i) EMPLOYED PHYSICIAN (ii) 14 KATHRYN BASS, MD (i) EMPLOYED PHYSICIAN (ii) 15 LAN ADAMS, MD (i) EMPLOYED PHYSICIAN (ii) 16 (ii) Bonus & incentive compensation 995,974. 0. 347,679. 0. 474,757. 0. 331,080. 0. 449,904. 0. 86,253. 0. 507,339. 0. 443,743. 0. 566,776. 0. 351,219. 0. 274,581. 0. 830,325. 0. 901,132. 0. 639,019. 0. 586,856. 0. 601,518. 0. 354,600. 0. 84,000. 0. 83,125. 0. 54,450. 0. 126,000. 0. 113,750. 0. 85,000. 0. 52,500. 0. 65,000. 0. 52,500. 0. 54,000. 0. 0. 0. 0. 0. 0. 0. 0. 0. 0. 0. (iii) Other reportable compensation 35,000. 0. 25,000. 0. 25,000. 0. 180,405. 0. 25,000. 0. 565,385. 0. 128,072. 0. 20,000. 0. 25,000. 0. 20,000. 0. 25,000. 0. 0. 0. 0. 0. 0. 0. 0. 0. 0. 0. (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 990 494,299. 0. 241,499. 0. 210,902. 0. 46,187. 0. 190,281. 0. 13,520. 0. 60,796. 0. 55,343. 0. 50,940. 0. 52,537. 0. 113,585. 0. 34,985. 0. 33,508. 17,185. 0. 14,182. 0. 14,347. 0. 6,334. 0. 14,314. 0. 2,430. 0. 14,281. 0. 14,215. 0. 6,558. 0. 14,182. 0. 633. 0. 14,639. 0. 14,479. 1,897,058. 0. 712,360. 0. 808,131. 0. 618,456. 0. 805,499. 0. 781,338. 0. 795,488. 0. 585,801. 0. 714,274. 0. 490,438. 0. 467,799. 0. 879,949. 0. 949,119. 0. 0. 0. 0. 0. 0. 149,905. 0. 0. 0. 0. 0. 103,072. 0. 0. 0. 0. 0. 0. 0. 0. 0. 0. 0. 9,127. 0. 39,737. 0. 39,050. 0. 1,115. 0. 1,037. 0. 1,068. 0. 649,261. 0. 627,630. 0. 641,636. 0. 0. 0. 0. 0. 0. 0. Schedule J (Form 990) 2016 JSA 6E1291 1.000 6261CF 2214 V 16-7.6F PAGE 96 KALEIDA HEALTH 16-1533232 Schedule J (Form 990) 2016 Part II Page 2 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 aren't 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. (B) Breakdown of W-2 and/or 1099-MISC compensation (A) Name and Title (i) Base compensation JAMES KASKIE (i) 1 FORMER CEO (ii) 2 (ii) 3 (ii) 4 (ii) 5 (ii) 6 (ii) 7 (ii) 8 (ii) 9 (ii) 10 (ii) 11 (ii) 12 (ii) 13 (ii) 14 (ii) 15 (ii) 16 (ii) (ii) Bonus & incentive compensation 0. 0. 0. 0. (iii) Other reportable compensation 192,017. 0. (C) Retirement and other deferred compensation (D) Nontaxable benefits 0. 0. (E) Total of columns (B)(i)-(D) 0. 0. 192,017. 0. (F) Compensation in column (B) reported as deferred on prior Form 990 0. 0. (i) (i) (i) (i) (i) (i) (i) (i) (i) (i) (i) (i) (i) (i) (i) Schedule J (Form 990) 2016 JSA 6E1291 1.000 6261CF 2214 V 16-7.6F PAGE 97 KALEIDA HEALTH 16-1533232 Schedule J (Form 990) 2016 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. HEALTH OR SOCIAL CLUB DUES SCHEDULE J, PART I, LINE 1A AS PART OF THEIR COMPENSATION PACKAGE, OFFICERS AND KEY EMPLOYEES OF THE ORGANIZATION ARE ENTITLED TO CHOOSE AS AN EXECUTIVE PERK THE BENEFIT OF BUSINESS RELATED SOCIAL DUES OR INITIATION FEES. SEVERANCE PAYMENTS SCHEDULE J, PART I, LINE 4A THE FOLLOWING FORMER EMPLOYEES LISTED ON FORM 990, PART VII, SECTION A, RECEIVED SEVERANCE PAYMENTS DURING 2016: JAMES KASKIE, FORMER CEO, $192,017 JAMAL GHANI, FORMER COO, $562,500 EXECUTIVE DEFERRED RETIREMENT PLAN SCHEDULE J, PART I, LINE 4B DURING THE YEAR, THE FOLLOWING OFFICERS AND KEY EMPLOYEES LISTED ON FORM 990, PART VII, SECTION A PARTICIPATED IN THE EXECUTIVE DEFERRED RETIREMENT PLAN: JODY LOMEO, JONATHAN SWIATKOWSKI, TONI BOOKER, DAVID Schedule J (Form 990) 2016 JSA 6E1505 2.000 6261CF 2214 V 16-7.6F PAGE 98 KALEIDA HEALTH 16-1533232 Schedule J (Form 990) 2016 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. HUGHES, MD, DONALD BOYD, MICHAEL HUGHES, CHERYL KLASS AND ALYSON SPAULDING. EMPLOYER AND EMPLOYEE CONTRIBUTIONS DURING THE YEAR TO THIS PLAN HAVE BEEN REPORTED, AS REQUIRED, ON SCHEDULE J, PART II COLUMNS (B) (III) AND (C). DURING 2016, THE FOLLOWING OFFICERS AND KEY EMPLOYEES RECEIVED PAYMENTS UNDER AN EXECUTIVE DEFERRED RETIREMENT PLAN: TONI BOOKER $149,905 DONALD BOYD $103,072 Schedule J (Form 990) 2016 JSA 6E1505 2.000 6261CF 2214 V 16-7.6F PAGE 99 I SCHEDULE K (Form 990) Department of the Treasury Internal Revenue Service Name of the organization I À¾µº DORMITORY AUTHORITY - STATE OF NEW YORK I OMB No. 1545-0047 Supplemental Information on Tax-Exempt Bonds Complete if the organization answered "Yes" on Form 990, Part IV, line 24a. Provide descriptions, explanations, and any additional information in Part VI. Attach to Form 990. Information about Schedule K (Form 990) and its instructions is at www.irs.gov/form990. Open to Public Inspection Employer identification number KALEIDA HEALTH Part I Bond Issues 16-1533232 (a) Issuer name (b) Issuer EIN (c) CUSIP # (d) Date issued (e) Issue price (f) Description of purpose (g) Defeased Yes No (h) On behalf of issuer Yes No (i) Pooled financing Yes No A DORMITORY AUTHORITY - STATE OF NEW YORK (SCH. 1) 14-6000293 09/30/2016 7,650,258. LEASE OF EQUIPMENT X X X B DORMITORY AUTHORITY - STATE OF NEW YORK (SCH. 2) 14-6000293 09/30/2016 7,349,742. LEASE OF EQUIPMENT X X X C D Part II Proceeds mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmm mmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm 1 2 3 4 5 6 7 8 9 10 11 12 13 Amount of bonds retired Amount of bonds legally defeased Total proceeds of issue Gross proceeds in reserve funds Capitalized interest from proceeds Proceeds in refunding escrows Issuance costs from proceeds Credit enhancement from proceeds Working capital expenditures from proceeds Capital expenditures from proceeds Other spent proceeds Other unspent proceeds Year of substantial completion 14 15 16 17 Were the bonds issued as part of a current refunding issue? Were the bonds issued as part of an advance refunding issue? Has the final allocation of proceeds been made? Does the organization maintain adequate books and records to support the final allocation of proceeds? Part III mmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm A B C 168,499. 161,880. 7,650,258. 7,349,742. D 104,266. 7,348,433. 2,825,269. 197,559. 4,524,473. Yes No Yes No X X X X Yes No Yes No Yes No X X X X Private Business Use 1 Was the organization a partner in a partnership, or a member of an LLC, which owned property financed by tax-exempt bonds? 2 Are there any lease arrangements that may result in private business use of bond-financed property? For Paperwork Reduction Act Notice, see the Instructions for Form 990. JSA 6E1295 1.000 6261CF 2214 V 16-7.6F A Yes B No Yes C No X X X X Yes D No Schedule K (Form 990) 2016 PAGE 100 KALEIDA HEALTH 16-1533232 Schedule K (Form 990) 2016 Part III mmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mm mmmmmmI mmmmmmmm m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m Im m mmmmmmmmmmmmmm mmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm Page 2 DORMITORY AUTHORITY - STATE OF NEW YORK Private Business Use (Continued) 3 a Are there any management or service contracts that may result in private business use of bond-financed property? A Yes B No Yes X X X X C No Yes D No Yes No 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 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 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 Total of lines 4 and 5 Does the bond issue meet the private security or payment test? 6 7 % % % % % % % % % % % % % % % X X X X 8 a 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? 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? mmmmmmmmmmmmm Part IV 1 2 a b c 3 4a b c d e mmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm X X Arbitrage Has the issuer filed Form 8038-T, Arbitrage Rebate, Yield Reduction and Penalty in Lieu of Arbitrage Rebate? If "No" to line 1, did the following apply? Rebate not due yet? Exception to rebate? No rebate due? If “Yes” to line 2c, provide in Part VI the date the rebate computation was performed Is the bond issue a variable rate issue? Has the organization or the governmental issuer entered into a qualified hedge with respect to the bond issue? Name of provider Term of hedge Was the hedge superintegrated? Was the hedge terminated? B No Yes X X C No Yes D No Yes No X X X X X X X X X X Schedule K (Form 990) 2016 JSA 6E1296 1.000 6261CF 2214 A Yes V 16-7.6F PAGE 101 KALEIDA HEALTH 16-1533232 Schedule K (Form 990) 2016 Part IV 5a b c d 6 7 mmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmm mmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm Procedures To Undertake Corrective Action Page 3 Arbitrage (Continued) A Yes B No Were gross proceeds invested in a guaranteed investment contract (GIC)? Name of provider Term of GIC Yes C No X X X X X X Yes D No Yes No Yes No Was the regulatory safe harbor for establishing the fair market value of the GIC satisfied? Were any gross proceeds invested beyond an available temporary period? Has the organization established written procedures to monitor requirements of section 148? Part V the A 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 isn't available under applicable regulations? Part VI Yes B No Yes C No Yes D No X X Supplemental Information. Provide additional information for responses to questions on Schedule K. See instructions Schedule K (Form 990) 2016 JSA 6E1328 1.000 6261CF 2214 V 16-7.6F PAGE 102 KALEIDA HEALTH 16-1533232 Schedule K (Form 990) 2016 Part VI Page 4 Supplemental Information. Provide additional information for responses to questions on Schedule K (see instructions) (Continued) SCHEDULE K, PART III, LINE 8, PART IV, LINE 7 AND PART V KALEIDA HEALTH DOES NOT CURRENTLY HAVE WRITTEN POLICIES AND PROCEDURES IN PLACE BUT MANAGEMENT REGULARLY REVIEWS POST-ISSUANCE COMPLIANCE OBLIGATIONS TO ENSURE THERE ARE NO VIOLATIONS OF FEDERAL TAX REQUIREMENTS. KALEIDA HEALTH IS CURRENTLY IN THE PROCESS OF ADOPTING WRITTEN POLICIES AND PROCEDURES. JSA 6E1511 1.000 Schedule K (Form 990) 2016 6261CF 2214 V 16-7.6F PAGE 103 SCHEDULE L (Form 990 or 990-EZ) Department of the Treasury Internal Revenue Service Name of the organization I I À¾µº I Transactions With Interested Persons OMB No. 1545-0047 Complete if the organization answered "Yes" on Form 990, Part IV, line 25a, 25b, 26, 27, 28a, 28b, or 28c, or Form 990-EZ, Part V, line 38a or 40b. Attach to Form 990 or Form 990-EZ. Open To Public Inspection Information about Schedule L (Form 990 or 990-EZ) and its instructions is at www.irs.gov/form990. Employer identification number KALEIDA HEALTH 16-1533232 Part I Excess Benefit Transactions (section 501(c)(3), section 501(c)(4), and 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 (1) (2) (3) (4) (5) (6) 2 3 (b) Relationship between disqualified person and organization mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmI mmmmmmmmmmmmmmmI Enter the amount of tax incurred by the organization managers or disqualified persons during the year under section 4958 Enter the amount of tax, if any, on line 2, above, reimbursed by the organization Part II (b) Relationship with organization (c) Purpose of loan (d) Loan to or from the organization? To Total Corrected? Yes No $ $ 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 (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (d) (c) Description of transaction (e) Original principal amount (f) Balance due From (g) In default? (h) Approved (i) Written by board or agreement? committee? Yes No Yes No Yes No m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m mI 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 (c) Amount of assistance (d) Type of assistance (e) Purpose of assistance person and the organization (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ. Schedule L (Form 990 or 990-EZ) 2016 JSA 6E1297 1.000 6261CF 2214 V 16-7.6F PAGE 104 KALEIDA HEALTH 16-1533232 Page 2 Schedule L (Form 990 or 990-EZ) 2016 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? Yes (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) No SUSAN EVANS SEE PART V 94,559. SEE PART V X WALSH INSURANCE SEE PART V 16,215. SEE PART V X TOPS MARKETS LLC SEE PART V 2,663,004. SEE PART V X QUAKER BROOKBRIDGE REAL ESTATE SEE PART V 1,800,469. SEE PART V X Part V Supplemental Information Provide additional information for responses to questions on Schedule L (see instructions). BUSINESS TRANSACTIONS INVOLVING INTERESTED PERSONS SCHEDULE L, PART IV SUSAN EVANS: SUSAN EVANS IS A FAMILY MEMBER OF A BOARD MEMBER, EVAN EVANS, MD, WHO RECEIVED COMPENSATION FROM THE ORGANIZATION IN THE NORMAL COURSE OF BUSINESS FOR PERFORMANCE OF SERVICES AS A UTILIZATION REVIEW COORDINATOR. WALSH INSURANCE: THEODORE B.K. WALSH IS A FAMILY MEMBER OF A BOARD MEMBER, AMY CLIFTON, AND A GREATER THAN 35% OWNER OF WALSH INSURANCE, WHICH PROVIDED INSURANCE BROKERAGE SERVICES TO THE ORGANIZATION DURING THE YEAR. TOPS MARKETS LLC: FRANK CURCI IS A BOARD MEMBER AND A GREATER THAN 35% OWNER OF TOPS MARKETS LLC, WHICH HAD A PHARMACY DISPENSING CONTRACT WITH THE ORGANIZATION DURING THE YEAR. JSA 6E1507 1.000 Schedule L (Form 990 or 990-EZ) 2016 6261CF 2214 V 16-7.6F PAGE 105 KALEIDA HEALTH 16-1533232 Page 2 Schedule L (Form 990 or 990-EZ) 2016 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? Yes No (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) Part V Supplemental Information Provide additional information for responses to questions on Schedule L (see instructions). QUAKER BROOKBRIDGE REAL ESTATE: KEVIN GIBBONS IS A BOARD MEMBER AND A GREATER THAN 35% OWNER OF QUAKER BROOKBRIDGE REAL ESTATE, WHICH LEASED PROPERTY TO THE ORGANIZATION DURING THE YEAR. JSA 6E1507 1.000 Schedule L (Form 990 or 990-EZ) 2016 6261CF 2214 V 16-7.6F PAGE 106 SCHEDULE M (Form 990) Department of the Treasury Internal Revenue Service Name of the organization II I Complete if the organizations answered "Yes" on Form 990, Part IV, lines 29 or 30. Attach to Form 990. Information about Schedule M (Form 990) and its instructions is at www.irs.gov/form990. 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 mmmmmmmmmm mmmmmm mmmmmm mmmmmm mmmmmmmmmmmmmmmm mmmmmm mmmmmmmmmm mmmmmmmm mmmm mmm mmmmmmmmmm mmmmm Open To Public Inspection Employer identification number KALEIDA HEALTH Types of Property Part I 1 2 3 4 5 À¾µº OMB No. 1545-0047 Noncash Contributions 16-1533232 (a) Check if applicable (b) Number of contributions or items contributed (c) Noncash contribution amounts reported on Form 990, Part VIII, line 1g (d) Method of determining noncash contribution amounts Art - Works of art Art - Historical treasures Art - Fractional interests Books and publications Clothing and household goods Cars and other vehicles Boats and planes Intellectual property Securities - Publicly traded Securities - Closely held stock Securities - Partnership, LLC, or trust interests Securities - Miscellaneous Qualified conservation contribution - Historic structures Qualified conservation contribution - Other Real estate - Residential Real estate - Commercial Real estate - Other Collectibles Food inventory Drugs and medical supplies Taxidermy Historical artifacts Scientific specimens Archeological artifacts 2. 3,764,608. Other ( ATCH 1 ) Other ( ) Other ( ) Other ( ) Number of Forms 8283 received by the organization during the tax year for contributions for 29 which the organization completed Form 8283, Part IV, Donee Acknowledgement I I I I mmmmmmmmmmmmm mmmmmmmm mmmmmm mmmmm mmmmmmmmm mmmmmmmmmmmmm mmmmmmmmmmm mmmm mmmmmmmmmmmmm mmmmmmmmm mmmmmmmm mmmmmmm mmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmm 30a During the year, did the organization receive by contribution any property reported in Part I, lines 1 through 28, that it must hold for at least three years from the date of the initial contribution, and which isn't required to be used for exempt purposes for the entire holding period? b If "Yes," describe the arrangement in Part II. 31 Does the organization have a gift acceptance policy that requires the review of any nonstandard contributions? 32a Does the organization hire or use third parties or related organizations to solicit, process, or sell noncash contributions? b If “Yes,” describe in Part II. 33 If the organization didn't report an amount in column (c) for a type of property for which column (a) is checked, describe in Part II. mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm For Paperwork Reduction Act Notice, see the Instructions for Form 990. Yes No X 30a 31 32a X X Schedule M (Form 990) (2016) JSA 6E1298 1.000 6261CF 2214 V 16-7.6F PAGE 107 KALEIDA HEALTH 16-1533232 Schedule M (Form 990) (2016) Part II Page 2 Supplemental Information. Provide the information required by Part I, lines 30b, 32b, and 33, and whether the organization is reporting in Part I, column (b), the number of contributions, the number of items received, or a combination of both. Also complete this part for any additional information. ATTACHMENT 1 SCHEDULE M, PART I - OTHER NONCASH CONTRIBUTIONS DESCRIPTION (A) CHECK VARIOUS MEDICAL EQUIPMENT TOTALS X (B) NUMBER OF CONTRIBUTIONS 2. 2. 3,764,608. (D) METHOD OF DETERMINING REPLACEMENT COST 3,764,608. Schedule M (Form 990) (2016) JSA 6E1508 2.000 (C) REVENUES REPORTED 6261CF 2214 V 16-7.6F PAGE 108 SCHEDULE O (Form 990 or 990-EZ) Department of the Treasury Internal Revenue Service Name of the organization I I 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. Attach to Form 990 or 990-EZ. Information about Schedule O (Form 990 or 990-EZ) and its instructions is at www.irs.gov/form990. À¾µº OMB No. 1545-0047 Open to Public Inspection Employer identification number KALEIDA HEALTH 16-1533232 ORGANIZATION'S MISSION KALEIDA HEALTH IS THE LARGEST HEALTHCARE PROVIDER IN WNY, SERVING THE AREA'S EIGHT COUNTIES WITH COMPREHENSIVE SERVICES & PROGRAMS PROVIDED AT FOUR ACUTE CARE, TWO LONG TERM CARE, AS WELL AS OUTPATIENT & PRIMARY CARE SITES. REVIEW PROCESS FOR FORM 990 ORGANIZATION'S MANAGEMENT IN CONSULTATION WITH THE ORGANIZATION'S TAX ADVISORS, KPMG, REVIEW THE FORM 990. THE FINANCIAL REVIEW IS BASED ON THE ORGANIZATION'S AUDITED FINANCIAL STATEMENTS FOR THE RELEVANT TIME PERIOD. BEFORE THE FORM 990 IS FILED WITH THE IRS, THE FINANCE COMMITTEE OF THE ORGANIZATION'S BOARD OF DIRECTORS REVIEWS THE FORM 990 AND PROVIDES A COPY OF THE SAME TO THE ORGANIZATION'S FULL BOARD OF DIRECTORS. CONFLICT OF INTEREST POLICY FORM 990, PART VI, SECTION B, QUESTION 12C UPON EMPLOYMENT AND ANNUALLY THEREAFTER EACH KEY EMPLOYEE AND OFFICER OF THE ORGANIZATION IS REQUIRED TO COMPLETE A CONFLICT OF INTEREST AND DISCLOSURE FORM, PROVIDING SUFFICIENT INFORMATION ABOUT HIS/HER PERSONAL INTERESTS AND RELATIONSHIPS SO THE ORGANZATION CAN (1) DETERMINE WHETHER ANY POTENTIAL OR ACTUAL CONFLICTS OF INTEREST MAY EXIST, AND (2) MONITOR WORK OR SERVICE ASSIGNMENTS TO AVOID PLACING THE KEY EMPLOYEE, OFFICER OR DIRECTOR IN A POSITION WHERE THERE MAY BE POTENTIAL, ACTUAL, OR EVEN APPEARANCE, OF A CONFLICT OF INTEREST OR A QUESTION OF OBJECTIVITY. THE For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ. JSA 6E1227 6E1227 2.0002.000 6261CF 2214 V 16-7.6F Schedule O (Form 990 or 990-EZ) (2016) PAGE 109 Schedule O (Form 990 or 990-EZ) 2016 Page Name of the organization 2 Employer identification number KALEIDA HEALTH 16-1533232 COMPLETED CONFLICTS OF INTEREST AND DISCLOSURE FORMS FOR DIRECTORS ARE RETURNED TO THE ORGANIZATION. COMPENSATION APPROVAL PROCESS FORM 990, PART VI, SECTION B, QUESTIONS 15A & 15B ON A REGULAR BASIS, THE ORGANIZATION PROVIDES DOCUMENTATION TO THE COMPENSATION COMMITTEE OF THE BOARD WITH RESPECT TO THE COMPENSATION OF THE ORGANIZATION'S OFFICERS AND KEY EMPLOYEES FOR REVIEW AND APPROVAL. SUCH INFORMATION IS COMPILED BY AN INDEPENDENT COMPENSATION CONSULTANT AND INCLUDES COMPARABLE DATA FROM SIMILAR SIZE TAX-EXEMPT ORGANIZATIONS IN THE WESTERN NEW YORK COMMUNITY AS WELL AS COMPENSATION FOR THESE POSITIONS (AS DISCLOSED ON FORM 990) WITH OTHER ORGANIZATIONS IN THE HEALTH CARE INDUSTRY THAT ARE OF SIMILAR SIZE, DEMOGRAPHICS AND GEOGRAPHY. REVIEW AND APPROVAL OF THE COMPENSATION ARRANGEMENTS BY THE COMPENSATION COMMITTEE IS DOCUMENTED. ACCESS TO ORGANIZATIONAL DOCUMENTS FORM 990, PART VI, SECTION C, QUESTION 19 THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST AT ITS OFFICE AT 726 EXCHANGE STREET, SUITE 200, BUFFALO, NY 14210. A NOMINAL FEE IS CHARGED IF COPIES ARE REQUESTED. FORM 990, PART XI OTHER CHANGES IN NET ASSETS OR FUND BALANCES MINORITY INTEREST IN SUBSIDIARY (303,778) Schedule O (Form 990 or 990-EZ) 2016 JSA 6E1228 1.000 6261CF 2214 V 16-7.6F PAGE 110 Schedule O (Form 990 or 990-EZ) 2016 Page Name of the organization 2 Employer identification number KALEIDA HEALTH 16-1533232 DECREASE IN PENSION LIABILITY (42,554,848) TRANSFER FROM KALEIDA FOUNDATIONS (1,905,000) OTHER TRANSFERS NET (1,937,441) CHANGE IN VALUE OF FOUNDATIONS (13,056,415) ------------ TOTAL (59,757,482) ATTACHMENT 1 FORM 990, PART III - PROGRAM SERVICE, LINE 4A KALEIDA HEALTH IS A VOLUNTARY, NOT-FOR-PROFIT; NEW YORK STATE DEPARTMENT OF HEALTH ARTICLE 28 LICENSED HOSPITAL-BASED HEALTHCARE DELIVERY SYSTEM SERVICING THE COMMUNITIES OF WESTERN NEW YORK STATE AT VARIOUS LEVELS AND WITH FACILITIES IN MULTIPLE LOCATIONS THROUGHOUT THE REGION. KALEIDA HEALTH INCLUDES THE BUFFALO GENERAL MEDICAL CENTER (BUFFALO GENERAL), MILLARD FILLMORE SUBURBAN HOSPITAL (MILLARD SUBURBAN), WOMEN AND CHILDREN'S HOSPITAL OF BUFFALO (WOMEN & CHILDREN'S), AND DEGRAFF MEMORIAL HOSPITAL (DEGRAFF). IN ADDITION TO THE FOUR KALEIDA HEALTH (KALEIDA) HOSPITALS, KALEIDA OPERATES TWO SKILLED NURSING FACILITIES, AND NUMEROUS OUTPATIENT CLINICS. THE ABOVE FACILITIES OPERATE UNDER ONE TAX IDENTIFICATION NUMBER. OUR FAMILY OF HEALTH CARE ORGANIZATIONS IS BLENDED TOGETHER INTO ONE FRAMEWORK FOR LEADERSHIP, GOVERNANCE, SHARED SERVICES, FINANCIAL INFRASTRUCTURE AND INFORMATION TECHNOLOGY PLATFORMS. COLLECTIVELY, KALEIDA HEALTH'S MARKET SHARE IS 31.8% IN WESTERN Schedule O (Form 990 or 990-EZ) 2016 JSA 6E1228 1.000 6261CF 2214 V 16-7.6F PAGE 111 Schedule O (Form 990 or 990-EZ) 2016 Page Name of the organization 2 Employer identification number KALEIDA HEALTH 16-1533232 ATTACHMENT 1 (CONT'D) NEW YORK, 40.0% IN ERIE COUNTY AND 29.5% IN NIAGARA COUNTY. ANNUALLY ONE MILLION COMBINED INPATIENT, EMERGENCY DEPARTMENT AND OUTPATIENT VISITS OCCUR AT THE HEALTH CARE FACILITIES IN THE KALEIDA HEALTH SYSTEM, WHICH EMPLOYS APPROXIMATELY 9,600 STAFF AND HAVE APPROXIMATELY 2,300 MEDICAL STAFF MEMBERS. DURING 2016, THERE WERE 55,696 INPATIENT DISCHARGES, OF WHICH 26% WERE MEDICAID AND MEDICAID MANAGED, 41% MEDICARE AND MEDICARE MANAGED CARE AND 1% WERE UNINSURED. KALEIDA HEALTH'S MISSION IS TO ADVANCE THE HEALTH OF OUR COMMUNITY. OUR VISION IS TO PROVIDE COMPASSIONATE, HIGH-VALUE, QUALITY CARE, IMPROVING HEALTH IN WESTERN NEW YORK AND BEYOND, EDUCATING FUTURE HEALTH CARE LEADERS AND DISCOVERING INNOVATIVE WAYS TO ADVANCE MEDICINE. OUR VALUES CLEARLY STATE WHO WE ARE AND HOW WE PERFORM OUR WORK: CENTERED: REMAIN CENTERED AROUND THE PATIENT AND FAMILY. ACCOUNTABLE: BE ACCOUNTABLE TO PATIENTS AND EACH OTHER. RESPECT: SHOW RESPECT AND INTEGRITY. EXCELLENCE: PROVIDE EXCELLENCE IN ALL WE DO. KALEIDA HEALTH'S PROGRAMS AND AFFILIATES ARE LICENSED BY THE STATE OF NEW YORK DEPARTMENT OF HEALTH AND ACCREDITED BY DNV. KALEIDA IS CERTIFIED BY THE US DEPARTMENT OF HEALTH AND HUMAN SERVICES FOR PARTICIPATION IN MEDICARE AND MEDICAID. THE ACCREDITATION COUNSEL Schedule O (Form 990 or 990-EZ) 2016 JSA 6E1228 1.000 6261CF 2214 V 16-7.6F PAGE 112 Schedule O (Form 990 or 990-EZ) 2016 Page Name of the organization 2 Employer identification number KALEIDA HEALTH 16-1533232 ATTACHMENT 1 (CONT'D) FOR GRADUATE MEDICAL EDUCATION APPROVES ALL RESIDENCY PROGRAMS FOR PHYSICIANS, AND THE AMERICAN DENTAL ASSOCIATION APPROVES ITS DENTAL AND ORAL SURGERY PROGRAMS. KALEIDA IS ALSO A MEMBER OF THE COUNCIL OF TEACHING HOSPITALS, THE AMERICAN DENTAL ASSOCATION, THE AMERICAN MEDICAL ASSOCATION AND THE GREATER NEW YORK HOSPITAL ASSOCATION. OPERATION OF EMERGENCY ROOMS: KALEIDA HEALTH OPERATES FOUR EMERGENCY ROOMS, ONE IN EACH OF THE ACUTE CARE HOSPITALS, GENERATING A TOTAL OF 167,318 PATIENT VISITS DURING 2016. THE EMERGENCY DEPARTMENTS, WHICH OPERATE 24 HOURS A DAY, SEVEN DAYS EACH WEEK, ARE OPEN TO ANYONE, REGARDLESS OF THEIR ABILITY TO PAY FOR SERVICES. BOARD OF DIRECTORS AND COMMUNITY GUIDANCE: KALEIDA HEALTH MAINTAINS COMMUNITY CONTROL OVER THE CORPORATION THROUGH ITS BOARD OF DIRECTORS, COMPRISED OF COMMUNITY AND FAITH LEADERS, AND LEADERS IN BUSINESS AND INDUSTRY, HEALTHCARE AND PHYSICIANS REPRESENTING THE MEDICAL STAFF OF KALEIDA HEALTH. THE MAJORITY OF THE DIRECTORS RESIDE IN WESTERN NEW YORK AND EACH DIRECTOR SERVES A THREE-YEAR TERM. OPEN MEDICAL STAFF: AS CONFERRED BY THE BOARD OF DIRECTORS, MEDICAL STAFF MEMBERSHIP IS OFFERED TO PROFESSIONALLY COMPETENT PHYSICIANS, DENTISTS, Schedule O (Form 990 or 990-EZ) 2016 JSA 6E1228 1.000 6261CF 2214 V 16-7.6F PAGE 113 Schedule O (Form 990 or 990-EZ) 2016 Page Name of the organization 2 Employer identification number KALEIDA HEALTH 16-1533232 ATTACHMENT 1 (CONT'D) PODIATRISTS AND OTHER SPECIFIED INDIVIDUALS, WHO CONTINUOUSLY MEET THE QUALIFICATIONS, STANDARDS AND REQUIREMENTS OUTLINED IN THE BYLAWS, RULES AND REGULATIONS, POLICIES OF THE MEDICAL STAFF AND KALEIDA HEALTH, CONSISTENT WITH THE NEEDS OF KALEIDA HEALTH'S PATIENTS. STAFF MEMBERSHIP OR PARTICULAR CLINICAL PRIVILEGES SHALL NOT BE DENIED ON THE BASIS OF AGE, SEX, SEXUAL ORIENTATON, RACE, COLOR, CREED, NATIONAL ORIGIN, A DISABILITY UNRELATED TO THE ABILITY TO FULFILL PATIENT CARE AND MEDICAL STAFF RESPONSIBILITIES OR ANY OTHER CRITERION UNRELATED TO THE EFFICIENT DELIVERY OF QUALITY PATIENT CARE, TO PROFESSIONAL QUALIFICATIONS OR TO THE NEEDS OF THE COMMUNITY, OR TO THE PURPOSES, NEEDS AND CAPABILITIES OF KALEIDA HEALTH. EVERY MEMBER OF THE MEDICAL STAFF ASSISTS THE HOSPITALS IN FULFILLING OUR MISSION AND RESPONSIBILITY TO PROVIDE EMERGENCY AND UNCOMPENSATED CARE FOR THOSE IN NEED. USE OF SURPLUS FUNDS: SURPLUS FUNDS ARE USED TO FURTHER THE MISSION AND OPERATIONS OF KALEIDA HEALTH, SUCH AS REINVESTING IN COMMUNITY BENEFIT PROGRAMS, AND MAKING IMPROVEMENTS IN FACILITIES, PATIENT CARE, MEDICAL, NURSING AND ALLIED HEALTH TRAINING, EDUCATION AND RESEARCH IN SUPPORT OF THE HEALTH NEEDS OF THE COMMUNITY. COMMUNITY BENEFIT PROGRAMS AND SERVICES: KALEIDA HEALTH OFFERS NUMEROUS COMMUNITY BENEFIT PROGRAMS AND SERVICES IN RESPONSE TO THE COMMUNITY'S NEEDS, BY IMPROVING ACCESS Schedule O (Form 990 or 990-EZ) 2016 JSA 6E1228 1.000 6261CF 2214 V 16-7.6F PAGE 114 Schedule O (Form 990 or 990-EZ) 2016 Page Name of the organization 2 Employer identification number KALEIDA HEALTH 16-1533232 ATTACHMENT 1 (CONT'D) TO CARE, IMPROVE PUBLIC HEALTH, ADVANCE KNOWLEDGE AND RELIEVE GOVERNMENT PROGRAMS. THESE PROGRAMS ARE CONDUCTED IN COMMUNITY-BASED SETTINGS SUCH AS SCHOOLS, CHURCHES, COMMUNITY CENTERS, SENIOR CENTERS AND PROGRAMS ARE ALSO OFFERED AT KALEIDA'S HOSPITAL CAMPUSES AND FACILITIES. COMMUNITY BENEFIT PROGRAMS AND SERVICES INCLUDE HEALTH FAIRS, HEALTH SCREENINGS, HEALTH EDUCATION LECTURES AND WORKSHOPS FOR COMMUNITY GROUPS AND THE GENERAL PUBLIC, SCHOOL HEALTH EDUCATION PROGRAMS, AND CONSUMER HEALTH INFORMATION IN THE KALEIDA HEALTH LIBRARIES. KALEIDA ALSO OFFERS A NUMBER OF SUBSIDIZED HEALTH SERVICES SUCH AS OUTPATIENT CLINICS, LONG-TERM CARE SERVICES, WOMEN'S HEALTH CENTERS, DIALYSIS SERVICES, BEHAVIORAL HEALTH SERVICES, SCHOOL-BASED HEALTH CENTERS, EARLY CHILDHOOD PROGRAM, EARLY INTERVENTION SERVICES, FAMILY PLANNING SERVICES, WESTERN NEW YORK CLINICAL INFORMATION EXCHANGE AND HEALTH-E-LINK AND DIAGNOSTIC, THERAPEUTIC AND REHABILITATION SERVICES FOR CHILDREN WITH SPECIAL NEEDS. KALEIDA'S HOSPITALS SERVE AS A MAJOR TEACHING AFFILIATE OF THE STATE UNIVERSITY OF NEW YORK AT BUFFALO'S SCHOOL OF MEDICINE AND BIOMEDICAL SCIENCES AND DENTAL MEDICINE, WITH TRAINING TO 400 MEDICAL AND DENTAL RESIDENTS EACH YEAR. KALEIDA IS INVOLVED IN AND SPONSORS RESEARCH PROJECTS, AND WE PROVIDE LOAN FORGIVENESS FOR PHYSICIANS TO ESTABLISH OR JOIN EXISTING PRACTICES THAT SERVE THE UNDERSERVED COMMUNITIES OF BUFFALO AND WESTERN NEW YORK. KALEIDA OFFERS CLINICAL TRAINING FACILITIES AND SUPPORT FOR NURSING AND A Schedule O (Form 990 or 990-EZ) 2016 JSA 6E1228 1.000 6261CF 2214 V 16-7.6F PAGE 115 Schedule O (Form 990 or 990-EZ) 2016 Page Name of the organization 2 Employer identification number KALEIDA HEALTH 16-1533232 ATTACHMENT 1 (CONT'D) NUMBER OF ALLIED HEALTH PROFESSIONAL TRAINING PROGRAMS AT LOCAL COLLEGES AND UNIVERSITIES, AND OTHER PROFESSIONAL DEVELOPMENT/CONTINUING EDUCATION TRAINING PROGRAMS FOR COLLEAGUES FROM HEALTH CARE ORGANIZATIONS ACROSS THE REGION. ATTACHMENT 2 990, PART VII- COMPENSATION OF THE FIVE HIGHEST PAID IND. CONTRACTORS NAME AND ADDRESS DESCRIPTION OF SERVICES COMPENSATION SODEXO MANAGEMENT, INC. PO BOX 81049 WOBURN, MA 01813-1049 CLEANING & DIETARY 5,234,925. WNY RADIOLOGY, LLC PO BOX 4029 BUFFALO, NY 14240 RADIOLOGY SVCS 5,203,248. P2P STAFFING, INC. PO BOX 4729 WINTER PARK, FL 32793-4729 CLINICAL DOCUMENTING 2,077,985. MACRO HELIX, INC. PO BOX 742256 ATLANTA, GA 30374-2256 340B SOFTWARE FEES 1,719,220. WE CARE TRANSPORTATION 401 EAST AMHERST ST BUFFALO, NY 14215 PATIENT TRANSPORT 1,206,360. ATTACHMENT 3 FORM 990, PART IX - OTHER FEES DESCRIPTION (A) TOTAL FEES (B) PROGRAM SERVICE EXP. (C) MANAGEMENT AND GENERAL CONTRACTED PHYSICIAN FEES 74,653,316. 71,919,286. 2,734,030. OTHER PURCHASED SERVICES 25,044,810. 22,011,076. 3,033,734. Schedule O (Form 990 or 990-EZ) 2016 JSA 6E1228 1.000 6261CF 2214 (D) FUNDRAISING EXPENSES V 16-7.6F PAGE 116 Schedule O (Form 990 or 990-EZ) 2016 Page Name of the organization 2 Employer identification number KALEIDA HEALTH 16-1533232 ATTACHMENT 3 (CONT'D) FORM 990, PART IX - OTHER FEES DESCRIPTION INTERNS & RESIDENTS FEES OTHER TOTALS (A) TOTAL FEES (B) PROGRAM SERVICE EXP. (C) MANAGEMENT AND GENERAL 26,597,730. 26,597,730. 8,797,110. 4,281,085. 4,516,025. 135,092,966. 124,809,177. 10,283,789. (D) FUNDRAISING EXPENSES ATTACHMENT 4 FORM 990, PART X - SECURED MORTGAGES AND NOTES PAYABLE LENDER: PRUDENTIAL HUNTOON PAIGE ASSOC. ORIGINAL AMOUNT: 100,253,000. INTEREST RATE: 6.3500 % MATURITY DATE: 02/01/2037 REPAYMENT TERMS: 25 YEARS PURPOSE OF LOAN: FINANCE THE COST OF THE DEVELOPMENT OF THE GVI BEGINNING BALANCE DUE ........................................ ENDING BALANCE DUE ........................................... 89,481,700. 87,535,144. LENDER: PRUDENTIAL HUNTOON PAIGE ASSOC. ORIGINAL AMOUNT: 51,864,100. INTEREST RATE: 5.7300 % MATURITY DATE: 02/01/2037 REPAYMENT TERMS: 25 YEARS PURPOSE OF LOAN: FINANCE THE COST OF DEVELOPMENT OF THE SNF BEGINNING BALANCE DUE ........................................ ENDING BALANCE DUE ........................................... 47,859,364. 46,662,258. LENDER: PRUDENTIAL HUNTOON PAIGE ASSOC. ORIGINAL AMOUNT: 62,235,882. INTEREST RATE: 2.4400 % MATURITY DATE: 08/01/2023 REPAYMENT TERMS: MONTHLY INSTALLMENTS PURPOSE OF LOAN: BGMC MORTGAGE Schedule O (Form 990 or 990-EZ) 2016 JSA 6E1228 1.000 6261CF 2214 V 16-7.6F PAGE 117 Schedule O (Form 990 or 990-EZ) 2016 Page Name of the organization KALEIDA HEALTH BEGINNING BALANCE DUE ........................................ ENDING BALANCE DUE ........................................... LENDER: M&T BANK ORIGINAL AMOUNT: INTEREST RATE: DATE OF NOTE: MATURITY DATE: REPAYMENT TERMS: PURPOSE OF LOAN: 2 Employer identification number 16-1533232 ATTACHMENT 4 (CONT'D) 45,710,632. 40,221,509. 7,500,000. 2.2100 % 01/01/2001 01/01/2026 MONTHLY INSTALLMENTS 296 NIAGARA STREET BEGINNING BALANCE DUE ........................................ ENDING BALANCE DUE ........................................... 740,704. 440,704. LENDER: PRUDENTIAL HUNTOON PAIGE ASSOC. ORIGINAL AMOUNT: 83,544,370. INTEREST RATE: 3.2900 % MATURITY DATE: 04/01/2020 REPAYMENT TERMS: MONTHLY INSTALLMENTS PURPOSE OF LOAN: MFH REFINANCING BEGINNING BALANCE DUE ........................................ ENDING BALANCE DUE ........................................... Schedule O (Form 990 or 990-EZ) 2016 JSA 6E1228 1.000 6261CF 2214 19,651,549. 14,050,339. V 16-7.6F PAGE 118 Schedule O (Form 990 or 990-EZ) 2016 Page Name of the organization 2 Employer identification number KALEIDA HEALTH 16-1533232 ATTACHMENT 4 (CONT'D) LENDER: PRUDENTIAL HUNTOON PAIGE ASSOC. ORIGINAL AMOUNT: 48,440,328. INTEREST RATE: 4.1800 % MATURITY DATE: 10/01/2042 REPAYMENT TERMS: MONTHLY INSTALLMENTS PURPOSE OF LOAN: FINANCE COST OF DEVELOPMENT OF CHILDREN'S HOSPITAL BEGINNING BALANCE DUE ........................................ ENDING BALANCE DUE ........................................... 48,440,328. 101,461,590. LENDER: PRUDENTIAL HUNTOON PAIGE ASSOC. ORIGINAL AMOUNT: 57,540,000. INTEREST RATE: 4.0000 % MATURITY DATE: 10/01/2033 REPAYMENT TERMS: MONTHLY INSTALLMENTS PURPOSE OF LOAN: IMPROVEMENTS TO MFH BEGINNING BALANCE DUE ........................................ ENDING BALANCE DUE ........................................... 47,851,439. 46,662,258. LENDER: PRUDENTIAL HUNTOON PAIGE ASSOC. ORIGINAL AMOUNT: 18,290,000. INTEREST RATE: 3.9500 % MATURITY DATE: 02/01/2032 REPAYMENT TERMS: MONTHLY INSTALLMENTS PURPOSE OF LOAN: CARDIAC CATH LAB EQUIPMENT BEGINNING BALANCE DUE ........................................ ENDING BALANCE DUE ........................................... 14,254,405. 12,931,871. TOTAL BEGINNING MORTGAGES AND OTHER NOTES PAYABLE 313,990,121. TOTAL ENDING MORTGAGES AND OTHER NOTES PAYABLE 349,965,673. Schedule O (Form 990 or 990-EZ) 2016 JSA 6E1228 1.000 6261CF 2214 V 16-7.6F PAGE 119 I KALEIDA HEALTH SCHEDULE R (Form 990) Department of the Treasury Internal Revenue Service Name of the organization I I OMB No. 1545-0047 Related Organizations and Unrelated Partnerships Complete if the organization answered "Yes" on Form 990, Part IV, line 33, 34, 35b, 36, or 37. Attach to Form 990. Open to Public Inspection Information about Schedule R (Form 990) and its instructions is at www.irs.gov/form990. Employer identification number KALEIDA HEALTH Part I À¾µº 16-1533232 16-1533232 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 (1) KALEIDA MCO LLC 726 EXCHANGE STREET, (2) KALEIDA IPA LLC 726 EXCHANGE STREET, (3) KALEIDA WNYI LLC 726 EXCHANGE STREET, (4) KALEIDA SERVICES, 2100 WEHRLE DRIVE SUITE 200 SUITE 200 SUITE 200 LLC (b) Primary activity 16-1570311 BUFFALO, NY 14210 16-1570380 BUFFALO, NY 14210 45-3189404 BUFFALO, NY 14210 000000000 WILLIAMSVILLE, NY 14221 (c) Legal domicile (state or foreign country) (d) Total income (e) End-of-year assets (f) Direct controlling entity DORMANT NY 0. 0. KH DORMANT NY 0. 0. KH HEALTH CARE NY -402,601. 4,340,148. KH ADULT DAYCARE NY 197,196. 808,195. KH (5) (6) 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? Yes (1) MILLARD FILLMORE AMBULATORY SURGER CTR 726 EXCHANGE STREET, SUITE 200 (2) 726 EXCHANGE STREET, SUITE 200 (3) (5) (7) BUFFALO, NY 14210 CHILDREN'S HOME HEALTH OF WNY, INC. 726 EXCHANGE STREET, SUITE 200 501(C)(3) 12A KH X HOME HLTHCARE NY 501(C)(3) 10 KH X HOME HLTHCARE NY 501(C)(3) 10 KH X SUPPORT ORG NY 501(C)(3) 10 KH X FUNDRAISING NY 501(C)(3) 7 KH X FUNDRAISING NY 501(C)(3) 7 KH X PED HLTH HOME NY 501(C)(3) 10 KH 22-2738425 BUFFALO, NY 14210 16-1579143 BUFFALO, NY 14210 THE WOMEN & CHILDREN'S HOSP OF BFLO FDN 726 EXCHANGE STREET, SUITE 200 NY 16-0743214 KALEIDA HEALTH FOUNDATION 726 EXCHANGE STREET, SUITE 200 (6) BUFFALO, NY 14210 VISK 726 EXCHANGE STREET, SUITE 200 SUPPORT ORG 16-1491203 VNA OF WESTERN NEW YORK 726 EXCHANGE STREET, SUITE 200 (4) BUFFALO, NY 14210 VNA HOME CARE SERVICES 16-1332044 BUFFALO, NY 14210 81-4086046 BUFFALO, NY 14210 For Paperwork Reduction Act Notice, see the Instructions for Form 990. X Schedule R (Form 990) 2016 JSA 6E1307 1.000 6261CF 2214 No 16-1307129 V 16-7.6F PAGE 120 KALEIDA HEALTH 16-1533232 Schedule R (Form 990) 2016 Part III Page 2 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-ofyear assets (h) Disproportionate allocations? (i) Code V - UBI amount in box 20 of Schedule K-1 (Form 1065) Yes No (j) General or managing partner? (k) Percentage ownership Yes No (1) HARLEM ROAD LEASING, LLC 20-55 3435 MAIN STREET BUFFALO, NY 1 EQUIPMENT LEASING NY KALEIDA HEALTH UNRELATED 95,520. 138,196. X 0. X 50.0000 HEALTH CARE NY KALEIDA WNYI RELATED -51,165. 1,675,196. X 0. X 50.0000 REAL ESTATE MGMT NY KPI EXCLUDED 111,986. 1,642,671. X 0. X 50.1601 HEALTH CARE NY KALEIDA HEALTH EXCLUDED 439,259. 1,843,351. X 0. X 55.2974 EQUIPMENT LEASING NY KALEIDA WNYI UNRELATED -257,653. 2,457,029. X 0. X HEALTH CARE NY KALEIDA HEALTH EXCLUDED -73,651. 17,675,054. X 0. X 60.0000 MEDICAL BILLING NY KALEIDA WNYI UNRELATED -93,783. 207,923. X 0. X 50.0000 (2) AMTON IMAGING, LLC 26-2925470 199 PARK CLUB LANE, SUITE 300 (3) SITE E, LLC 27-2124795 726 EXCHANGE STREET, SUITE 200 (4) MSFC, LLC 26-1582864 726 EXCHANGE STREET, SUITE 200 (5) SOUTHTOWNS IMAGING, LLC 47-112 5959 BIG TREE ROAD, SUITE 105 70.0000 (6) COLLABORATIVE CARE VENTURES, L 726 EXCHANGE STREET, SUITE 200 (7) GREAT LAKES MEDICAL BILLING SV 199 PARK CLUB LANE, SUITE 300 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) (h) (i) Share of Percentage Section 512(b)(13) end-of-year assets ownership controlled entity? Yes No (1) KALEIDA PROPERTIES, INC. 22-2738483 726 EXCHANGE STREET, SUITE 200 BUFFALO, NY 14210 (2) WESTLINK CORPORATION 726 EXCHANGE STREET, SUITE 200 BUFFALO, NY 14210 (3) KALEIDA HEALTHNOW, INC. 257 WEST GENESEE STREET BUFFALO, NY 14202 PROP MGMT SVCS NY KALEIDA HEALTH C CORP 1,351,355. 17,223,458. 100.0000 X MED & DIAGN SVCS NY KALEIDA HEALTH C CORP -290. 100,916. 100.0000 X HEALTH CARE NY KALEIDA HEALTH C CORP 16-1354421 46-2164089 50.0000 X (4) (5) (6) (7) Schedule R (Form 990) 2016 JSA 6E1308 1.000 6261CF 2214 V 16-7.6F PAGE 121 KALEIDA HEALTH 16-1533232 Schedule R (Form 990) 2016 Part III Page 2 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-ofyear assets (h) Disproportionate allocations? (i) Code V - UBI amount in box 20 of Schedule K-1 (Form 1065) Yes No (j) General or managing partner? (k) Percentage ownership Yes No (1) ALTUS MANAGEMENT LLC 840 AERO DRIVE, SUITE 150 BUFF GROUP PURCHAS NY KALEIDA HEALTH EXCLUDED 183,048. 1,976,625. X 0. X HEALTH CARE NY KALEIDA HEALTH EXCLUDED -1,801,005. 3,122,497. X 0. X 52.1672 (2) SOUTHTOWNS SURGERY CENTER, LLC 726 EXCHANGE STREET, SUITE 200 63.1714 (3) (4) (5) (6) (7) 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) (h) (i) Share of Percentage Section 512(b)(13) end-of-year assets ownership controlled entity? Yes No (1) (2) (3) (4) (5) (6) (7) Schedule R (Form 990) 2016 JSA 6E1308 1.000 6261CF 2214 V 16-7.6F PAGE 122 KALEIDA HEALTH 16-1533232 Page Schedule R (Form 990) 2016 Part V 3 Transactions With Related Organizations. Complete if the organization answered "Yes" on Form 990, Part IV, line 34, 35b, or 36. mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm m m mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm m mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm m mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm Note: Complete line 1 if any entity is listed in Parts II, III, or IV of this schedule. 1 During the tax year, did the organization 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) d Loans or loan guarantees to or for related organization(s) e Loans or loan guarantees by related organization(s) Yes No 1a 1b 1c 1d 1e X X X X X X X X X f g h i j Dividends from related organization(s) Sale of assets to related organization(s) Purchase of assets from related organization(s) Exchange of assets with related organization(s) Lease of facilities, equipment, or other assets to related organization(s) 1f 1g 1h 1i 1j k l m n o Lease of facilities, equipment, or other assets from related organization(s) Performance of services or membership or fundraising solicitations for related organization(s) Performance of services or membership or fundraising solicitations by related organization(s) Sharing of facilities, equipment, mailing lists, or other assets with related organization(s) Sharing of paid employees with related organization(s) 1k 1l 1m 1n 1o X X 1p 1q X X p Reimbursement paid to related organization(s) for expenses q Reimbursement paid by related organization(s) for expenses X X X X r Other transfer of cash or property to related organization(s) 1r X s Other transfer of cash or property from related organization(s) 1s 2 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) VNA HOME CARE SERVICES O 121,793. ACTUAL COST (2) VNA HOME CARE SERVICES Q 1,745,194. ACTUAL COST (3) VNA OF WESTERN NEW YORK O 279,271. ACTUAL COST (4) VNA OF WESTERN NEW YORK L 358,004. ACTUAL COST (5) VNA OF WESTERN NEW YORK Q 14,041,243. ACTUAL COST (6) MFSC, LLC J 637,534. ACTUAL COST Schedule R (Form 990) 2016 JSA 6E1309 1.000 6261CF 2214 X V 16-7.6F PAGE 123 KALEIDA HEALTH 16-1533232 Page Schedule R (Form 990) 2016 Part V 3 Transactions With Related Organizations. Complete if the organization answered "Yes" on Form 990, Part IV, line 34, 35b, or 36. mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm m m mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm m mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm m mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm Note: Complete line 1 if any entity is listed in Parts II, III, or IV of this schedule. 1 During the tax year, did the organization 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) d Loans or loan guarantees to or for related organization(s) e Loans or loan guarantees by related organization(s) Yes No 1a 1b 1c 1d 1e f g h i j Dividends from related organization(s) Sale of assets to related organization(s) Purchase of assets from related organization(s) Exchange of assets with related organization(s) Lease of facilities, equipment, or other assets to related organization(s) 1f 1g 1h 1i 1j k l m n o Lease of facilities, equipment, or other assets from related organization(s) Performance of services or membership or fundraising solicitations for related organization(s) Performance of services or membership or fundraising solicitations by related organization(s) Sharing of facilities, equipment, mailing lists, or other assets with related organization(s) Sharing of paid employees with related organization(s) 1k 1l 1m 1n 1o p Reimbursement paid to related organization(s) for expenses q Reimbursement paid by related organization(s) for expenses 1p 1q r Other transfer of cash or property to related organization(s) 1r s Other transfer of cash or property from related organization(s) 1s 2 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) MFSC, LLC D 55,033. ACTUAL COST (2) KALEIDA PROPERTIES, INC. Q 110,973. ACTUAL COST (3) KALEIDA PROPERTIES, INC. D 4,696,287. ACTUAL COST (4) SITE E, LLC K 233,450. ACTUAL COST (5) WCHOB FOUNDATION C 1,516,781. ACTUAL COST (6) WCHOB FOUNDATION S 21,661,975. ACTUAL COST Schedule R (Form 990) 2016 JSA 6E1309 1.000 6261CF 2214 V 16-7.6F PAGE 124 KALEIDA HEALTH 16-1533232 Page Schedule R (Form 990) 2016 Part V 3 Transactions With Related Organizations. Complete if the organization answered "Yes" on Form 990, Part IV, line 34, 35b, or 36. mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm m m mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm m mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm m mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm Note: Complete line 1 if any entity is listed in Parts II, III, or IV of this schedule. 1 During the tax year, did the organization 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) d Loans or loan guarantees to or for related organization(s) e Loans or loan guarantees by related organization(s) Yes No 1a 1b 1c 1d 1e f g h i j Dividends from related organization(s) Sale of assets to related organization(s) Purchase of assets from related organization(s) Exchange of assets with related organization(s) Lease of facilities, equipment, or other assets to related organization(s) 1f 1g 1h 1i 1j k l m n o Lease of facilities, equipment, or other assets from related organization(s) Performance of services or membership or fundraising solicitations for related organization(s) Performance of services or membership or fundraising solicitations by related organization(s) Sharing of facilities, equipment, mailing lists, or other assets with related organization(s) Sharing of paid employees with related organization(s) 1k 1l 1m 1n 1o p Reimbursement paid to related organization(s) for expenses q Reimbursement paid by related organization(s) for expenses 1p 1q r Other transfer of cash or property to related organization(s) 1r s Other transfer of cash or property from related organization(s) 1s 2 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) WCHOB FOUNDATION P 90,351. ACTUAL COST (2) KALEIDA HEALTH FOUNDATION C 2,247,827. ACTUAL COST (3) KALEIDA HEALTH FOUNDATION S 1,332,699. ACTUAL COST (4) KALEIDA HEALTH FOUNDATION P 296,081. ACTUAL COST (5) SOUTHTOWNS IMAGING, LLC D 402,071. ACTUAL COST (6) SOUTHTOWNS IMAGING, LLC J 219,997. ACTUAL COST Schedule R (Form 990) 2016 JSA 6E1309 1.000 6261CF 2214 V 16-7.6F PAGE 125 KALEIDA HEALTH 16-1533232 Page Schedule R (Form 990) 2016 Part V 3 Transactions With Related Organizations. Complete if the organization answered "Yes" on Form 990, Part IV, line 34, 35b, or 36. mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm m m mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm m mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm m mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm Note: Complete line 1 if any entity is listed in Parts II, III, or IV of this schedule. 1 During the tax year, did the organization 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) d Loans or loan guarantees to or for related organization(s) e Loans or loan guarantees by related organization(s) Yes No 1a 1b 1c 1d 1e f g h i j Dividends from related organization(s) Sale of assets to related organization(s) Purchase of assets from related organization(s) Exchange of assets with related organization(s) Lease of facilities, equipment, or other assets to related organization(s) 1f 1g 1h 1i 1j k l m n o Lease of facilities, equipment, or other assets from related organization(s) Performance of services or membership or fundraising solicitations for related organization(s) Performance of services or membership or fundraising solicitations by related organization(s) Sharing of facilities, equipment, mailing lists, or other assets with related organization(s) Sharing of paid employees with related organization(s) 1k 1l 1m 1n 1o p Reimbursement paid to related organization(s) for expenses q Reimbursement paid by related organization(s) for expenses 1p 1q r Other transfer of cash or property to related organization(s) 1r s Other transfer of cash or property from related organization(s) 1s 2 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) SOUTHTOWNS IMAGING, LLC Q 148,903. ACTUAL COST (2) SOUTHTOWNS SURGERY CENTER, LLC L 172,189. ACTUAL COST (3) SOUTHTOWNS SURGERY CENTER, LLC J 328,947. ACTUAL COST (4) SOUTHTOWNS SURGERY CENTER, LLC D 298,431. ACTUAL COST (5) COLLABORATIVE CARE VENTURES, LLC D 251,104. ACTUAL COST (6) Schedule R (Form 990) 2016 JSA 6E1309 1.000 6261CF 2214 V 16-7.6F PAGE 126 KALEIDA HEALTH 16-1533232 Schedule R (Form 990) 2016 Part VI Page 4 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) (d) Predominant income (related, unrelated, excluded from tax under sections 512-514) (e) Are all partners section 501(c)(3) organizations? Yes No (f) Share of total income (g) Share of end-of-year assets (h) Disproportionate allocations? Yes No (i) Code V - UBI amount in box 20 of Schedule K-1 (Form 1065) (j) General or managing partner? Yes (k) Percentage ownership No (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) Schedule R (Form 990) 2016 JSA 6E1310 1.000 6261CF 2214 V 16-7.6F PAGE 127 KALEIDA HEALTH 16-1533232 Schedule R (Form 990) 2016 Part VII Page 5 Supplemental Information Provide additional information for responses to questions on Schedule R. See instructions. Schedule R (Form 990) 2016 6E1510 2.000 6261CF 2214 V 16-7.6F PAGE 128