AUDITED FINANCIAL STATEMENTS ALICE HYDE MEDICAL CENTER

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1 AUDITED FINANCIAL STATEMENTS ALICE HYDE MEDICAL CENTER DECEMBER 31, 2013

2 CONTENTS Independent Auditor s Report Page Financial Statements: Balance Sheets... 3 Statements of Operations and Changes in Net Assets... 4 Statements of Cash Flows... 5 Notes to the Financial Statements Schedule of Expenditures of Department Awards Notes to the Schedule of Expenditures of Department Awards Independent Auditor's Report on Internal Control Over Financial Reporting and on Compliance and Other Matters Based on an Audit of Financial Statements Performed in Accordance with Government Auditing Standards Schedule of Findings and Responses Schedule of Prior Year Findings and Responses... 25

3 INDEPENDENT AUDITOR'S REPORT Board of Directors Alice Hyde Medical Center Report on the Financial Statements We have audited the accompanying financial statements of Alice Hyde Medical Center (the Medical Center) which comprise the balance sheets as of December 31, 2013 and 2012 and the related statements of operations and changes in net assets, and cash flows for the years then ended and the related notes to the financial statements. Management's Responsibility for the Financial Statements Management is responsible for the preparation and fair presentation of these financial statements in accordance with accounting principles generally accepted in the United States of America; this includes the design, implementation, and maintenance of internal control relevant to the preparation and fair presentation of financial statements that are free from material misstatement, whether due to fraud or error. Auditor's Responsibility Our responsibility is to express an opinion on these financial statements based on our audits. We conducted our audits in accordance with auditing standards generally accepted in the United States of America and the standards applicable to financial audits contained in Government Auditing Standards, issued by the Comptroller General of the United States. Those standards require that we plan and perform the audit to obtain reasonable assurance about whether the financial statements are free of material misstatement. An audit involves performing procedures to obtain audit evidence about the amounts and disclosures in the financial statements. The procedures selected depend on the auditor's judgment, including the assessment of the risks of material misstatement of the financial statements, whether due to fraud or error. In making those risk assessments, the auditor considers internal control relevant to the entity's preparation and fair presentation of the financial statements in order to design audit procedures that are appropriate in the circumstances, but not for the purpose of expressing an opinion on the effectiveness of the entity's internal control. Accordingly, we express no such opinion. An audit also includes evaluating the appropriateness of accounting policies used and the reasonableness of significant accounting estimates made by management, as well as evaluating the overall presentation of the financial statements. We believe that the audit evidence we have obtained is sufficient and appropriate to provide a reasonable basis for our audit opinion. Opinion In our opinion, the financial statements referred to above present fairly, in all material respects, the financial position of Alice Hyde Medical Center as of December 31, 2013 and 2012, and the results of its operations and its cash flows for the years then ended in accordance with accounting principles generally accepted in the United States of America. 1

4 Other Matter Our audit was conducted for the purpose of forming an opinion on the financial statements taken as a whole. The accompanying Schedule of Expenditures of Department Awards for the year ended December 31, 2013 is presented for purposes of additional analysis as required by the New York State Department of Health, and is not a required part of the financial statements. Such information is the responsibility of management and was derived from and relates directly to the underlying accounting and other records used to prepare the financial statements. The information has been subjected to the auditing procedures applied in the audit of the financial statements and certain additional procedures, including comparing and reconciling such information directly to the underlying accounting and other records used to prepare the financial statements or to the financial statements themselves, and other additional procedures in accordance with auditing standards in the United States of America. In our opinion, the Schedule of Expenditures of Department Awards is fairly stated, in all material respects, in relation to the financial statements taken as a whole. Other Reporting Required by Government Auditing Standards In accordance with Government Auditing Standards, we have also issued our report dated May 22, 2014 on our consideration of the Medical Center s internal control over financial reporting and on our tests of its compliance with certain provisions of laws, regulations, contacts and grant agreements and other matters. The purpose of that report is to describe the scope of our testing of internal control over financial reporting and compliance and the results of that testing, and not to provide an opinion on the internal control over financial reporting or on compliance. That report is an integral part of an audit performed in accordance with Government Auditing Standards in considering the Medical Center s internal control over financial reporting and compliance. Buffalo, New York May 22,

5 BALANCE SHEETS December 31, ASSETS Current assets Cash and cash equivalents $ 2,112,878 $ 1,162,831 Patient accounts receivable, net of allowance for estimated uncollectibles of approximately $2,174,000 ($2,345, ) 8,731,088 9,210,679 Current portion of other receivables, net 6,530, ,356 Inventory 628, ,856 Prepaid expenses and other current assets 882, ,459 Total current assets 18,885,173 12,444,181 Assets limited to use 24,363,132 3,407,123 Property, plant and equipment, net 32,951,874 23,614,650 Deferred financing costs, net 829,124 34,153 Prepaid expenses, long-term, net 644,242 - Other receivables, net 144, ,401 Total assets $ 77,817,561 $ 39,770,508 LIABILITIES AND NET ASSETS Current liabilities Accounts payable and accrued expenses $ 12,422,948 $ 5,399,250 Accrued salaries, wages, and related items 3,915,867 3,472,520 Advances from third party payors 612, ,000 Line of credit 1,183,560 - Estimated amounts due to third-parties 1,585,945 1,238,722 Current portion of capital lease obligations 257, ,587 Current portion of long-term debt 896,281 1,456,151 Total current liabilities 20,873,876 12,522,230 Long-term debt, net of current portion 26,872,345 3,840,072 Capital lease obligations, net of current portion - 257,701 Total liabilities 47,746,221 16,620,003 Net assets: Unrestricted 29,150,582 22,332,059 Temporarily restricted 736, ,500 Permanently restricted 183, ,946 Total net assets 30,071,340 23,150,505 Total liabilities and net assets $ 77,817,561 $ 39,770,508 See accompanying notes. 3

6 STATEMENTS OF OPERATIONS AND CHANGES IN NET ASSETS For the Years Ended December 31, Unrestricted revenue, gains and other support: Net patient service revenue (net of provision for bad debts of approximately $2,398,000 in 2013 and $2,336,000 in 2012) $ 61,780,535 $ 63,571,321 Other revenue 4,524,936 4,880,833 Net assets released from restrictions used for operations - 50,000 Total unrestricted revenue, gains and other support 66,305,471 68,502,154 Operating expenses: Salaries and wages 33,433,405 34,089,383 Employee benefits 7,982,074 8,375,463 Supplies and materials 8,440,842 8,979,116 Depreciation and amortization 3,036,610 3,022,401 Other expenses 13,993,711 13,835,768 Interest expense 305, ,617 Total operating expenses 67,191,814 68,679,748 Loss from operations (886,343) (177,594) Other income (expense): Gifts and bequests - 40,000 Income from investments 194, ,080 Loss on rental properties (95,703) (64,913) 98,592 98,167 Deficiency of revenue over expenses (787,751) (79,427) Grant funds used for capital purposes 8,141,274 1,135,303 Other changes in unrestricted net assets (535,000) (115,638) Increase in unrestricted net assets 6,818, ,238 Temporarily restricted net assets: Restricted income 16,274 14,412 Net realized gains on sales of investments 66,935 27,056 Change in net unrealized gains and losses 19,103 27,312 Net assets released from restriction for operations - (50,000) Increase in temporarily restricted net assets 102,312 18,780 Change in net assets 6,920, ,018 Net assets - beginning of year 23,150,505 22,191,487 Net assets - end of year $ 30,071,340 $ 23,150,505 See accompanying notes. 4

7 STATEMENTS OF CASH FLOWS For the Years Ended December 31, Cash flows from operating activities: Change in net assets $ 6,920, ,018 Adjustments to reconcile change in net assets to net cash provided by operating activities: Depreciation and amortization 3,036,610 3,022,401 Increase (decrease) in the allowance for doubtful accounts (171,000) 351,000 Change in net unrealized and realized gains and losses on assets whose use is limited (246,108) (144,307) Amortization of bond discount 3,194 6,246 Grant funds used for capital purposes (8,141,274) (1,135,303) (Increase) decrease in assets: Patient accounts receivable 650,591 1,051,187 Other receivables (5,483,837) (180,378) Inventory (10,236) 194,981 Prepaid expenses and other current assets (350,078) 431,074 (Decrease) increase in liabilities: Accounts payable and accrued expenses 7,023,698 (1,423,658) Accrued salaries, wages, and related items 443, ,588 Estimated amounts due to third-party payors, net 326, ,722 Net cash and cash equivalents provided by operating activities 4,001,965 4,210,571 Cash flows from investing activities: Purchases of property, plant and equipment (12,138,043) (3,321,840) Net change in assets whose use is limited (20,709,901) 822,422 Net cash and cash equivalents used in investing activities (32,847,944) (2,499,418) Cash flows from financing activities: Grant funds used for capital purchases 8,141,274 1,135,303 Borrowings of line of credit 1,183, ,000 Repayment of line of credit - (948,000) Borrowings of long term debt 27,375, ,036 Repayments of long term debt (4,905,791) (1,662,463) Acquisition of deferred financing costs and letter of credit fee (1,675,004) - Repayments of capital lease obligations (323,013) (281,606) Net cash and cash equivalents provided by (used in) financing activities 29,796,026 (594,730) Net increase in cash and cash equivalents 950,047 1,116,423 Cash and cash equivalents - beginning of year 1,162,831 46,408 Cash and cash equivalents - end of year $ 2,112,878 $ 1,162,831 Supplemental disclosure of cash flow information: Cash paid during the year for interest $ 275,457 $ 387,458 See accompanying notes. 5

8 NOTE 1. ORGANIZATION AND SUMMARY OF SIGNIFICANT ACCOUNTING POLICIES Organization: Alice Hyde Medical Center (the Medical Center) is a not-for-profit corporation, incorporated in the State of New York, located in Malone, New York. The Medical Center operates 76 acute care and 75 nursing facility beds in addition to providing emergency and outpatient services. The Medical Center is currently in the process of constructing a 135-bed skilled nursing and assisted living facility on the Medical Center s campus. Construction is anticipated to be completed in the Fall of Approximately $13 Million has been spent on the construction as of December 31, The project is being funded through the issuance of variable rate demand bonds in the amount of $27,375,000. The project, once completed, will successfully consolidate Franklin County s Skilled Nursing Facility with the Medical Center s Skilled Nursing Facility, while reducing total number of beds and adding assisted living beds. Use of Estimates: The preparation of financial statements in conformity with accounting principles generally accepted in the United States of America requires management to make estimates and assumptions that affect the amounts reported in the financial statements and accompanying notes. Actual results could differ from those estimates and the differences in estimates from actual results could be significant. Display of Net Assets by Class: The accompanying financial statements have been prepared in conformity with the disclosure and display requirements of accounting principles generally accepted (US GAAP) in the United States of America. US GAAP requires that resources be classified for reporting purposes into three net asset categories (temporarily restricted, permanently restricted and unrestricted) according to the existence or absence of donor-imposed restrictions. Temporarily restricted net assets are those whose use has been limited by donors to a specific purpose or time period. Permanently restricted net assets have been restricted by donors to be maintained by the Medical Center in perpetuity. Any interest or investment earnings derived from the funds are recorded as temporarily restricted and may be used for the operations when appropriated by the Medical Center. Cash and Cash Equivalents: The Medical Center considers all highly liquid investments with a maturity of three months or less to be cash equivalents. Cash equivalents exclude amounts that are classified as assets limited or restricted as to use. Patient Accounts Receivable: The Medical Center carries its patient accounts receivable at anticipated amounts due from private pay patients and third-party payors. Accounts receivable are reduced by an allowance for uncollectible accounts. In evaluating the collectability of accounts receivable, the Medical Center analyzes their past history and identifies trends for each of its major payor sources of revenue to estimate the appropriate allowance for uncollectible accounts and provision for bad debts. For receivables associated with services provided to patients who have third-party coverage, the Medical Center analyzes contractually due amounts and provides an allowance for uncollectible accounts, if necessary, for receivables associated with self-pay patients (which includes both patients without insurance and patients with deductible and copayment balances due for which third-party covered exists for part of the bill). The Medical Center records a provision for bad debts in the period of service on the basis of its past experience, which indicates that many patients are unable or unwilling to pay the portion of their bill for which they are financially responsible. The difference between the standard rates (or discounted rates if negotiated) and the amounts actually collected after all reasonable collection efforts have been exhausted is charged off against the allowance for uncollectible accounts. Inventory: Inventory is stated at the lower of cost (first in, first out) or market and consist primarily of medical supplies and pharmaceuticals. Assets Whose Use is Limited: Assets whose use is limited are reported at fair value. FASB ASC NO., 820 Fair Value (ASC 820), defines fair value as the price that would be received to sell an asset or paid to transfer a liability in an orderly transact between market participants at the measurement date. See Note 4 for discussion on fair value measurements. 6

9 NOTE 1. ORGANIZATION AND SUMMARY OF SIGNIFICANT ACCOUNTING POLICIES (CONTINUED) The Medical Center s assets whose use is limited represents funds designated for future capital asset purchases by the board, for required deposits in accordance with the terms of the debt agreements, and by donors. Gains or losses on the sale of investments and investment income are recorded as unrestricted revenue. Income of temporarily and permanently restricted net assets that is specifically restricted by the donor is recorded as an increase in the appropriate class of net assets. Unrealized gains and losses are recorded as changes in unrestricted net assets unless explicitly restricted by the donor or law. Unrealized gains and losses restricted by the donor or law are recorded as changes in temporarily or permanently restricted net assets. Property, Plant and Equipment: Property, plant and equipment is carried at cost, except assets acquired under capital leases, which are recorded at the net present value of the minimum lease payments. Assets acquired by gifts and bequests are recorded at fair market value established at the date of the gift. Depreciation is computed on the straight-line method over the estimated useful lives of the assets, which generally follow American Hospital Association guidelines. Equipment under capital lease obligations is amortized on the straight-line method over the shorter period of the lease term or the estimated useful life. Such amortization is included in depreciation and amortization expense in the accompanying financial statements. Depreciation expense for the year ended December 31, 2013 amounted to $2,968,884 ($3,011, ). Gifts of capital assets are reported as unrestricted support unless explicit donor stipulations specify how the donated assets must be used. Gifts of capital assets with explicit restrictions that specify how the assets are to be used and gifts of cash or other assets that must be used to acquire capital assets are reported as restricted support. Absent explicit donor stipulations about how long these long-lived assets must be maintained, expirations of donor restrictions are reported when the donated or acquired long-lived assets are placed in service. Deferred Financing Costs, Net: Deferred expenses amounting to $1,675,004, including a prepaid letter of credit fee of $840,315 which is presented as a prepaid asset on the balance sheet, at December 31, 2013 ($191, ) represents amounts incurred in the issuance of the Medical Center s revenue bonds. As part of the issuance of the 2013 bonds new financing costs were incurred and capitalized and the unamortized cost of the previous bond issuance costs was written off to amortization expense in The costs are being amortized over the term of the related debt. Amortization expense amounted to $67,726 for the year ended December 31, 2013 ($11, ) Accumulated amortization amounted to $33,575 for the year ended December 31, 2013 ($157, ) The estimated amortization expense over the next 5 years is approximately $200,000 per year. Contributions: Unconditional promises to give cash and other assets are reported at fair value at the date the promise is received. The gifts are reported as either temporarily or permanently restricted support if they are received with donor stipulations that limit the use of the donated assets. Permanently restricted net assets are restricted by the donor to be maintained by the Medical Center in perpetuity. Temporarily restricted net assets are those whose use by the Medical Center has been limited by donors to a specific time period of purpose. Temporarily restricted net assets held by the Medical Center are restricted for providing charity care to uninsured patients. When a donor restriction expires, that is, when a stipulated time restriction ends or purpose restriction is accomplished, temporarily restricted net assets are reclassified as unrestricted net assets and reported in the statement of activities and changes in net assets as net assets released from restrictions. Donor-restricted contributions whose restrictions are met within the same year as received are reflected as unrestricted contributions in the accompanying financial statements. Other Revenue: The Medical Center considers revenue received through the 340B Pharmacy Drug Discount Plan, Meaningful Use, and other ancillary activities to be operating revenue. 7

10 NOTE 1. ORGANIZATION AND SUMMARY OF SIGNIFICANT ACCOUNTING POLICIES (CONTINUED) Grant Income: The Medical Center records support received under grant contracts as revenue when the related costs of the associated grants are incurred. Grant revenue primarily includes funds received from HEAL NY. During 2013 and 2012, the Medical center received grant money under various grant awards (HEAL NY Phase 8, HEAL NY Phase 19, and the NYS Rural Health Care Access Development Program) totaling 9,893,383 over a three year period. The terms of the grant were for capital purposes primarily related to the construction of the new Skilled Nursing facility. The Medical Center recognized $8,141,274 during the year ended December 31, 2013 ($1,135, ), all of which was used for its stated purpose in the years then ended. Advertising: The Medical Center expenses advertising costs as incurred. Advertising expense was $74,154 for the year ended December 31, 2013 ($88, ). Other Expenses: Other expenses are comprised of the following: Professional fees $ 5,385,214 $ 5,090,036 Purchased and contracted services 2,342,234 2,676,300 Repairs and maintenance 2,676,582 2,564,015 Insurance and utilities 2,105,896 2,022,955 Leases and rentals 1,072, ,399 Dues and subscriptions 154, ,719 Travel and training 148, ,625 Marketing 74,154 81,499 Postage 34, ,220 $ 13,993,711 $ 13,835,768 Income Taxes: The Medical Center is a not-for-profit organization as described in Section 501(c)(3) of the Internal Revenue Code (the Code), and accordingly, is exempt from federal income taxes on related income pursuant to Section 501(a) of the Code. Accordingly, no provision for income taxes has been reflected in the accompanying financial statements. The Medical Center accounts for uncertain tax positions in accordance with U.S. GAAP, which requires the recognition and measurement of uncertain income tax positions that the Medical Center has taken or expects to take in the Medical Center s tax filings. The Medical Center has not recorded any amounts relating to uncertain tax positions. In addition, the Medical Center is no longer subject to federal and NYS income tax examination for years prior to Concentrations of Credit Risk: The Center grants credit without collateral to its patients, most of whom are local residents and are insured under third-party payor agreements. The mix of receivables from patients and thirdparty payors were as follows as of December 31: Medicare 27% 25% Medicaid Other third-party payors Self-pay % 100% In addition, financial instruments that potentially subject the Medical Center to concentration of credit risk consist principally of cash and cash equivalent accounts in financial institutions. Although the cash accounts exceed the federally insured deposit amount, management does not anticipate nonperformance by the financial institutions. Management reviews the financial viability of these institutions on a periodic basis. 8

11 NOTE 1. ORGANIZATION AND SUMMARY OF SIGNIFICANT ACCOUNTING POLICIES (CONTINUED) Recent Accounting Pronouncements: Financial Accounting Standards Board ( FASB ) Accounting Standards Update ( ASU ) No , Not-for-Profit Entities, effective for periods beginning after June 30, 2014, requires a recipient not-for-profit entity to recognize all services received from personnel of an affiliate that directly benefits the recipient not-for-profit entity. Early adoption is permitted. ASU No is not expected to have a material impact on the financial statements upon adoption. Charity Care: The Medical Center provide care to clients who meet certain criteria under its charity care policy at amounts less than its established rates. The Medical Centers policy is not to pursue collection of amounts determined to qualify as charity care; therefore these amounts are not reported in net operating revenues or in provisions for doubtful accounts. The estimated cost of providing uncompensated care to patients was approximately $1,086,000 for the year ended December 31, 2013 ($1,000, ), as measured utilizing a calculated ratio of costs to charges. Malpractice: Malpractice insurance coverage of the Medical Center is provided on an occurrence basis. The Medical Center intends to renew its coverage on an occurrence basis and has no reason to believe that it may be prevented from renewing such coverage. All known asserted and unasserted claims alleging malpractice have been communicated to the insurer who is responsible for resolving the claim and the related cost of litigation. Insurance Claims and Related Recoveries: On January 1, 2011 the Medical Center adopted Accounting Standards Update (ASU) Presentation of Insurance Claims and Related Insurance Recoveries. The ASU requires the Medical Center to recognize liabilities associated with malpractice claims or similar contingent liabilities when the incidents that give rise to the claims occur. Further the liability shall not be presented net of anticipated insurance recoveries. Any amounts to be reimbursed from an insurance company should be presented discretely. In accordance with FASB issued guidance amounts should be recognized only when the likelihood of payment is both probable and measurable. No amounts required to be recognized during the years ended December 31, 2013 and Medicare and Medicaid Electronic Health Record Incentive Program: Under certain provisions of the American Recovery and Reinvestment Act of 2009 (ARRA), federal incentive payments are available to hospitals, physicians and certain other professionals (Providers) when they adopt, implement or upgrade (AIU) certified electronic health record (EHR) technology or become meaningful users, as defined under ARRA, of EHR technology in ways that demonstrate improved quality, safety and effectiveness of care. Providers can become eligible for annual Medicare incentive payments by demonstrating meaningful use of EHR technology in each period over four periods. Medicaid providers can receive their initial incentive payment by satisfying AIU criteria, but must demonstrate meaningful use of EHR technology in subsequent years in order to qualify for additional payments. Hospitals may be eligible for both Medicare and Medicaid EHR incentive payments; however, physicians and other professionals may be eligible for either Medicare or Medicaid incentive payments, but not both. Hospitals that are meaningful users under the Medicare EHR incentive payment program are deemed meaningful users under the Medicaid EHR incentive payment program and do not need to meet additional criteria imposed by a state. Medicaid EHR incentive payments to Providers are 100% federally funded and administered by the states. The Centers for Medicare and Medicaid Services (CMS) established calendar year 2011 as the first year states could offer EHR incentive payments. Before a state may offer EHR incentive payments, the state must submit and CMS must approve the state s incentive plan. The Medical Center recognizes Medicaid EHR incentive payments in its statements of operations for the first payment year when: (1) CMS approves a state s EHR incentive plan; and (2) its hospital or employed physician acquires certified EHR technology (i.e., when AIU criteria are met). Medicaid EHR incentive payments for subsequent payment years are recognized in the period during which the specified meaningful use criteria are met. The Medical Center recognizes Medicare EHR incentive payments when: (1) the specified meaningful use criteria are met; and (2) contingencies in estimating the amount of the incentive payments to be received are resolved. 9

12 NOTE 1. ORGANIZATION AND SUMMARY OF SIGNIFICANT ACCOUNTING POLICIES (CONTINUED) During the years ended December 31, 2013, the Medical Center and several physicians satisfied the CMS AIU and/or meaningful use criteria. As a result, the Medical Center recognized approximately $1,143,000 of Medicare and Medicaid EHR incentive payments as other operating income in its statement of operations for year ended December 31, 2013 ($1,037, ). Other Changes in Unrestricted Net Assets: Amounts included in other changes in unrestricted net assets as presented on the Statement of Operations and Changes in Net Assets for the year ended December 31, 2013 represents an accrual of sick time to be paid out to certain employees fulfilling certain requirements of the Medical Center s sick time policy. This policy has been in place for several years but a liability has never been recognized in accordance with US GAAP. As the amount is immaterial to the financial statements when taken in whole this adjustment has been included under this caption. Reclassifications: Certain 2012 amounts have been reclassified to conform to the current year presentation. These reclassifications had no affect on income from operations, net assets or the change in net assets. Subsequent Events: These financial statements have not been updated for subsequent events occurring after May 22, 2014 which is the date these financial statements were available to be issued. NOTE 2. NET PATIENT SERVICE REVENUE The Medical Center has agreements with third-party payors that provide for payments to the Medical Center at amounts different from its established rates. A summary of the payment arrangements with major third-party payors is as follows: Medicare Inpatient acute care services and outpatient services rendered to Medicare program beneficiaries are paid at prospectively determined rates. These rates vary according to a patient classification system that is based on clinical, diagnostic, and other factors. The Medical Center is reimbursed at a tentative rate with final settlement determined after submission of annual cost reports by the Medical Center and audits thereof by the Medicare fiscal intermediary. Medicaid Inpatient services rendered to Medicaid program beneficiaries are reimbursed under a cost reimbursement methodology using a base year for operating costs and actual costs for capital. The Center is reimbursed at a tentative rate with final settlement determined after submission of annual cost reports. Outpatient services are paid at fee schedule amounts determined by New York State. Commercial - The Center has entered into payment agreements with certain commercial insurance carriers, health maintenance organizations, and preferred provider organizations. The basis for payment to the Center under these agreements includes prospectively determined rates per discharge, discounts from established charges, and prospectively determined daily rates. Workers Compensation and No-Fault - Reimbursement rates for Workers Compensation and No- Fault patients and paid at prospectively determined rates per discharge, as determined by the New York Health Care Reform Act (NYHCRA). These rates vary according to a patient classification system defined by NYHCRA that is based on clinical, diagnostic and other factors. Additionally, the Medical Center provides long term care services for which they are reimbursed on a per diem rate by third party payors. The Medicaid program is governed by the New York State Department of Health (DOH). Effective January 1, 2012, legislation required DOH to revise its reimbursement formula for the Medicaid rates paid to skilled nursing facilities. Skilled nursing facilities payment is based upon a statewide pricing model. All skilled nursing facilities are placed into one of two peer groups which is used to compute the operating component of the Medicaid rate. This new statewide pricing methodology is being phased in over five years are varying percentages. Full implementation will be effective January 1, The Medical Center had accrued the estimated impact from this change in Medicaid reimbursement. 10

13 NOTE 2. NET PATIENT SERVICE REVENUE (CONTINUED) The Medical Center is eligible to receive funds from several pools established under NYHCRA. Amounts received or to be received from the pools have been included as increases to net patient service revenue. Differences between amounts recorded and final distributions from the pools will be included as adjustments to net patient service revenue in the year that such distributions are received. Revenue from the Medicare and Medicaid programs accounted for approximately 33 percent and 21 percent, respectively, of the Medical Center s net patient revenue for the year ended 2013, and 38 percent and 23 percent, respectively, for the year ended Laws and regulations governing the Medicare and Medicaid programs are extremely complex and subject to interpretation. As a result, there is at least a reasonable possibility that recorded estimates will change by a material amount in the near term. The Medical Center has recorded estimates related to these possible changes in estimated amounts due to third-party payors. The Medical Center believes that it is in compliance, in all material respects, with all applicable laws and regulations and is not aware of any pending or threatened investigations involving allegations of potential wrongdoing. While no such regulatory inquiries have been made, compliance with such laws and regulations can be subject to future governmental review and interpretation. Noncompliance with such laws and regulations could result in repayments of amounts improperly reimbursed, interest, substantial monetary fines, civil and criminal penalties, and exclusion from the Medicare and Medicaid programs. In accordance with ASC Topic 954 any amounts recognized as bad debt reduces net patient service revenue in the period in which the bad debt is recognized. The Medical Center recognizes patient service revenue associated with services provided to patients who have third-party payor coverage on the basis of contractual rates for the services rendered. For uninsured patients that do not quality for charity care, the Medical Center recognizes revenue on the basis of its standard rates for services provided (or on the basis of discounted rates, if negotiated or provided by policy). Based upon historical experience, a significant portion of the Medical Center s uninsured patients will be unable or unwilling to pay for the services provided. Thus, the Medical Center records a significant provision for bad debts related to uninsured patients in the period the services are provided. Patient service revenue, net of contractual allowances and discounts (but before the provision for bad debts), recognized for the years ended December 31, 2013 and 2012 from these major payor sources is as follows: 2013 Other Third Total Party Self All Medicaid Medicare Payors Pay Payors Patient service revenue (net of contractual allowances) $ 13,623,377 $ 20,849,538 $ 27,519,265 $ 2,186,002 $ 64,178, Other Third Total Party Self All Medicaid Medicare Payors Pay Payors Patient service revenue (net of contractual allowances) $ 15,136,154 $ 25,105,793 $ 23,691,370 $ 1,974,281 $ 65,907,598

14 NOTE 3. ASSETS WHOSE USE IS LIMITED Assets limited as to use consist of the following at December 31: Board designated for capital asset purchases $ 1,853,967 $ 1,650,834 Restricted Project Fund pursuant to Bond Indenture Agreement 21,606, ,250 Donor Restricted 902, ,039 $ 24,363,132 $ 3,407,123 NOTE 4. FAIR VALUE MEASUREMENTS FASB ASC 820, Fair Value Measurements, provides the framework for measuring fair value. That framework provides a fair value hierarchy that prioritizes the inputs to valuation techniques used to measure fair value. The hierarchy gives the highest priority to unadjusted quoted prices in active markets for identical assets or liabilities (Level 1 measurements) and the lowest priority to unobservable inputs (Level 3 measurements). The three levels of the fair value hierarchy under FASB ASC 820 are described below: Level 1: Inputs to the valuation methodology are unadjusted quoted prices for identical assets or liabilities in active markets that the Medical Center has the ability to access. Level 2: Inputs to the valuation methodology include: Quoted prices for similar assets or liabilities in active markets; Quoted prices for identical or similar assets or liabilities in inactive markets; Inputs other than quoted prices that are observable for the asset or liability; Inputs that are derived principally from or corroborated by observable market data by correlation or other means; If the asset or liability has a specific (contractual) term, the Level 2 input must be observable for substantially the full term of the asset or liability. Level 3: Inputs to the valuation methodology are unobservable and significant to the fair value measurement. The asset or liability s fair value measurement level within the fair value hierarchy is based on the lowest level of any input that is significant to the fair value measurement. Valuation techniques used need to maximize the use of observable inputs and minimize the use of unobservable inputs. The following is a description of the valuation methodologies used by the Medical Center for its assets measured at fair value on a recurring basis: Cash and cash equivalents: Stated at cost, which approximates fair value. Equity securities: Valued at the closing price reported on the active market on which the individual securities are traded. Mutual funds: Valued at the net asset value (NAV) of shared held at year end. The NAV is the closing price reported on the active market on which the securities are traded. U.S. Government obligations and corporate bonds: Valued based on the yields currently available on comparable securities of issuers with similar credit ratings. 12

15 NOTE 4. FAIR VALUE MEASUREMENTS (CONTINUED) Assets whose use it limited are measured at fair value on a recurring basis at December 31, 2013 as follows: Level 1 Level 2 Level 3 Total Cash & cash equivalents $ 21,925,192 $ - $ - $ 21,925,192 Equity securities: Domestic securities 783, ,126 International securities 174, ,530 Domestic mutual funds 230, ,043 International mutual funds 49, ,584 Fixed income securities: U.S. Government obligations - 1,200,656-1,200,656 Total $ 23,162,476 $ 1,200,656 $ - $ 24,363,132 Assets whose use it limited are measured at fair value on a recurring basis at December 31, 2012 as follows: Level 1 Level 2 Level 3 Total Cash & cash equivalents $ 1,040,757 $ - $ - $ 1,040,757 Equity securities: Domestic securities 667, ,139 International securities 155, ,446 Domestic mutual funds 199, ,881 International mutual funds 116, ,001 Fixed income securities: U.S. Government obligations - 1,227,899-1,227,899 Total $ 2,179,224 $ 1,227,899 $ - $ 3,407,123 The fair value and cost of investments is summarized as follows as of December 31: Fair Fair Value Cost Value Cost Cash and cash equivalents $ 21,925,192 $ 21,925,192 $ 1,040,756 $ 1,040,756 Fixed income 1,200,656 1,198,374 1,227,899 1,186,733 Mutual funds 1,237, ,685 1,138, ,428 $ 24,363,132 $ 24,065,251 $ 3,407,123 $ 3,211,917 Investment income and losses from investments are as follows as of December 31: Nonoperating gains (losses): Interest and dividend income $ 34,225 $ 33,141 Net realized gains on sales of investments 106,678 40,839 Change in net unrealized gains and losses on investments 53,392 49,100 $ 194,295 $ 123,080 13

16 NOTE 5. PROPERTY, PLANT AND EQUIPMENT Property, plant and equipment consist of the following at December 31: Land $ 364,054 $ 364,054 Land improvements 1,723,884 1,723,884 Buildings 32,994,155 32,912,403 Fixed equipment 6,337,966 6,389,275 Movable equipment 21,393,957 21,205,830 Construction in progress 13,397,272 2,260,522 76,211,288 64,855,968 Less: accumulated depreciation 43,259,414 41,241,318 $ 32,951,874 $ 23,614,650 Included in property and equipment at December 31, 2013 and 2012, applicable to capital leases, is equipment cost of approximately $2,300,000 and accumulated depreciation of approximately $2,200,000 ($1,950, ). NOTE 6. REVOLVING LINE OF CREDIT During 2013, the Medical Center entered into a Revolving Loan Agreement with a bank for borrowings not to exceed $1,500,000 for working capital. Borrowings shall incur interest at the Prime Rate plus the applicable Prime Rate Margin and is due monthly. The outstanding balance as of December 31, 2013 is $1,183,560 ($0 2012). The agreement requires the Medical Center to meet certain covenants annually. The Medical Center was in compliance with required covenants as of December 31, NOTE 7. LONG-TERM DEBT Long-term debt consists of the following at December 31: Series 2013A Bond ($27,375,000 principal amount less unamortized discount of $475,869 at December 31, 2013) (a). $ 26,899,131 $ - Series 1998A Bond ($11,100,000 principal amount less unamortized discount of $35,918 at December 31, 2012). This bond was defeased as part of the Series 2013A issuance. - 2,759,082 Term loan payable in monthly installments of $10,758, including interest at a fixed rate of 5%, to be amortized over a 10 year payment schedule, including a balloon payment upon maturity in December The term loan was paid off during the year ended December 31, ,036 14

17 NOTE 7. LONG-TERM DEBT (CONTINUED) Mortgage notes payable in monthly installments ranging from $2,142 to $7,528 including interest through September The mortgages are secured by a first lien on three properties acquired with the proceeds. The note payable was paid off during the year ended December 31, ,285 Note payable to bank in monthly installments of $3,967, plus interest at a fixed rate of 6.19% through October The note is secured by the equipment purchased with the proceeds. 37,948 82,245 Mortgage note payable in monthly installments of approximately $16,537, plus interest of 2.16%. On the fifth anniversary of the note, the interest rate will be adjusted to the bank s then five year cost of funds plus one percent through November The note is secured by the rehabilitation building constructed with the proceeds. 831, ,881 Term loans payable to bank, with monthly payments of $2,633 to $26,387 including interest at 5.25% to 5.5% with maturities through January The loans are secured by equipment purchased with proceeds. The terms loans were paid off during the year ended December 31, ,694 27,768,626 5,296,223 Less: current portion 896,281 1,456,151 $ 26,872,345 $ 3,840,072 (a) In October 2013, the Medical Center secured $27,375,000 in financing from the Franklin County Civic Development Corporation Tax Exempt Variable Rate Demand Revenue Bonds, Series 2013 (2013 Revenue Bonds) to provide funding for the Skilled Nursing Home facility project and to pay down the existing Revenue Bonds. Pursuant to the terms of the Master Trust Indenture, the Medical Center established a Project Fund with the proceeds of the Revenue Bonds. This fund is presented in the accompanying financial statements as assets whose use is limited. The Revenue Bonds consist of variable interest rate, term bonds, requiring annual sinking fund payments ranging from $765,000 to $1,645,000 through October 2037, with a $1,715,000 principal amount maturing on October 1, 2038 to be paid at maturity. Interest rates are variable and are re-set weekly by the remarketing agent. The interest rate as of December 31, 2013 was.06%. Interest payments are due monthly. The bonds are secured by an irrevocable, direct-pay letter of credit issued by HSBC Bank, USA. The letter of credit will expire October 23, The Revenue Bonds are administered by the provisions of a Master Trust Indenture (Indenture) between the Medical Center and bond trustee. Also, the Indenture requires the Medical Center to meet certain covenants annually. 15

18 NOTE 7. LONG-TERM DEBT (CONTINUED) The Medical Center was in compliance with all covenants for the year ended December 31, Future maturities on long term debt after December 31, 2014 are as follows: Year ending December 31: 2015 $ 189, , , , ,170 Thereafter 23,131,493 $ 26,872,345 NOTE 8. CAPITAL AND OPERATING LEASE OBLIGATIONS The Medical Center leases certain equipment under capital leases. The following is a schedule of the future minimum payments under capital leases, together with the present value of minimum lease payments as of December 31, 2013: Total future minimum lease payments $ 289,893 Less: amount representing interest 32,618 Present value of net minimum lease payments 257,275 Less: current portion 257,275 $ - The Medical Center leases various equipment under non-cancelable leases. Total rental expense for the year ended December 31, 2013 was approximately $1,148,000 ($976, ). Approximate future minimum annual lease payments under the operating leases for the five years subsequent to December 31, 2013 are as follows: 2014 $ 948, , , $ 1,664,999 NOTE 9. PENSION PLAN The Medical Center offers a defined contribution plan to all full time employees meeting certain eligibility requirements who are nonmembers of the SEIU 1199 Bargaining Unit. The Medical Center has agreed to match annual employee contributions to a maximum of 6% of each employee's annual compensation, based upon the employee's age and years of service. The employee fully vests in the Medical Center's contributions upon completion of three years of plan membership. The Medical Center contributed approximately $664,000 for the year ended December 31, 2013 ($700, ). 16

19 NOTE 9. PENSION PLAN (CONTINUED) The Medical Center also contributes to the 1199 SEIU Regional Pension Fund (EIN: ), which is a multiemployer defined benefit pension plan, under the collective bargaining agreement, which expires June 2015, that covers certain union-represented employees. The risks of participating in a multiemployer plan differ from those of single employer plans in the following respects: Assets contributed to the multiemployer plan by one employer may be used to provide benefits to employees of other participating employers. If a participating employer stops contributing to the plan then the unfunded obligations of the plan may be borne by the remaining participating employers. If the Medical Center chooses to stop participating in the multiemployer plan, then it may be required to pay the plan an amount based on the underfunded status of the plan, referred to as a withdrawal liability. The most recent PPA zone status available for the plan s year end at December 31, 2012 was green. The zone status is based on information received by the Medical Center from the plan and is certified by the plan s actuary. Among other factors, plans in the red zone are less than 65% funded, plans in the yellow zone are between 65-80% funded, and plans in the green zone are more than 80% funded. Under the 1199 pension plan, the Medical Center will contribute to the SEIU pension fund on behalf of all bargaining unit employees at the rate of fifty-five to sixty-five cents per hour based on employee compensation, for each calendar quarter in which the employee has been paid for at least two hundred fifty (250) hours. The Medical Center contributed approximately $312,000 for the year ended December 31, 2013 ($305, ). According to the Plan s most recent Form 5500, for the year plan year ending December 31, 2011 the Medical Center contributed less than 5% of the total contributions to the Plan. NOTE 10. ENDOWMENTS On September 17, 2010, New York State enacted the New York Prudent Management of Institutional Funds Act (NYPMIFA). This law, which is a modified version of the Uniform Prudent Management of Institutional Funds Act (UPMIFA), makes significant changes to the rules governing how New York not-for-profit organizations may manage, invest and spend their endowment funds. The Board of Directors has interpreted NYPMIFA as requiring the preservation of the historical dollar value of the corpus of the permanent restricted endowment funds absent explicit donor stipulations to the contrary. As a result of this interpretation, the Medical Center classifies as permanently restricted net assets (a) the original value of gifts donated to the permanent endowment and (b) the original value of subsequent gifts to the permanent endowment. Net appreciation of the invested assets are considered unrestricted net assets unless explicit donor stipulations specify how the net appreciation must be used and is classified as temporarily restricted net assets until those amounts are appropriated for expenditure by the Medical Center in a manner consistent with the standard of prudence prescribed by NYPMIFA. The Medical Center considered several factors in establishing its policy, as enumerated in UPMIFA and NYPMIFA, including the preservation of the endowment funds; the purposes of the organization and the fund; general economic conditions; possible effects of inflation or deflation; expected total return from income and appreciation of investments; other resources of the organization; the organization s investment policy; and alternatives to spending from the endowment fund and the possible effects of those alternatives on the organization. Net investment earnings and appreciation (depreciation) of the invested assets included in permanently restricted net assets amounted to approximately $102,000 as of December 31, 2013 ($19, ). 17

20 NOTE 10. ENDOWMENTS (CONTINUED) The Medical Center has established long term investment objectives to: (a) create a stream of investment returns which appropriately considers the present and future cash needs of the Medical Center and; (b) to maintain the purchasing power of the portfolio. The restricted net asset spending policy is to adhere to donor restrictions. NOTE 11. COMMITMENTS AND CONTINGENCIES Litigation: In the normal course of operations, the Medical Center has been named as a defendant in several legal actions. The ultimate outcome of these actions cannot be determined at this time. However, the Medical Center intends to vigorously defend the legal actions. In the opinion of management, the ultimate amounts, if any, including legal costs, required to settle such litigation are not expected to have a material adverse effect on the financial condition of the Medical Center. Collective Bargaining Agreements: Approximately 70% of the Medical Center's employees work under collective bargaining agreements. The Medical Center's agreement with the SEIU 1199 expires in June The New York State Nurses Association (NYSNA) agreement expires in December Physician Recruitment Agreements: The Medical Center periodically enters into agreements with certain physicians under which, for a specified period of time (advance period), generally two years, the Medical Center unconditionally agrees to provide the physicians with support in the event that income generated by the physicians' practices fails to meet agreed-upon minimum levels. Amounts advanced are recorded as notes receivable from the physicians. At the conclusion of the specified advance period, the agreements allow for the forgiveness of the amounts advanced after a specified period of time, generally 3 years, should the physicians remain in practice within the Medical Center's service area. Amounts forgiven are considered compensation to the physicians. The amounts advanced are secured by promissory notes which require the repayment of any advance balances which have not been forgiven should the support agreement be breached by the physician. The promissory notes bear interest at a rate equal to the prime rate published in the Wall Street Journal plus one percent. Notes receivable, net of related allowances, included in the balance sheets at December 31, 2013 and 2012 as other receivables were approximately $90,000 and $187,000, respectively. Workers Compensation Insurance: Since September 1, 2012 The Medical Center has participated in a retrospectively rated insurance arrangement for workers compensation insurance. The policy year is from September 1 September 1 each year. The policy requires a payment of an advanced premium based on anticipated payroll. The advanced premium for the policy year starting September 1, 2013 totals $517,682 ($584,513 Policy year started September 1, 2012). To the extent payroll or experience is different than projected additional premiums or refunds would be due. Management believes that the advanced premiums paid are sufficient to cover the ultimate expenses associated with these years and no additional amount has been accrued in the financial statements for the year ended December 31, 2013 or

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