10 Colo. Code Regs. § 2505-10-8.5002

Current through Register Vol. 47, No. 16, August 25, 2024

Section 10 CCR 2505-10-8.5002 - HOSPITAL REQUIREMENTS

8.5002.A PUBLIC MEETING REQUIREMENTS

1. Each Reporting Hospital shall convene a public meeting at least once per year to seek feedback regarding the hospital's Community Benefit activities during the previous year and the hospital's Community Benefit Implementation Plan for the upcoming year.

2. Reporting Hospitals may convene a joint public meeting with one or more other participating hospitals that share some or all of the hospital's Community.

3. Reporting Hospitals may convene multiple Community Benefit meetings throughout the year.

4. During at least one public meeting the Reporting Hospitals shall at minimum:

a. Present priority areas identified in the Reporting Hospital's most recent Community Health Needs Assessment and any other Community spending options recommended by the Reporting Hospital. Each priority recommendation presented shall clearly identify the source of the recommendation;

b. Solicit public input for the Reporting Hospital's recommendations and any additional Community Benefit activity;

c. Present the Reporting Hospital's specific Community Benefit activities;

d. Present the amount funded for each specific Community Benefit activity; and

e. Present a description of how the Community Benefit activities and funding amounts align with the Community Identified Needs.

5. Reporting Hospitals may only add Community Benefit Priorities to the Reporting Hospital's Community Benefit Implementation Plan if:

a. The Community Benefit Priorities were presented during at least one public meeting;

b. The public was provided an opportunity to provide feedback through either public testimony to be recorded in the minutes of the public meeting(s) or through correspondence including, but not limited to email, written letter, or phone call. The Reporting Hospital will summarize this feedback in its annual submission materials;

c. The Reporting Hospital shall maintain a submission period of 30 days following the Community public meeting to allow for additional comments and recommendations from Community members. Nothing in this process will preclude hospitals from integrating priorities pursuant to the Internal Revenue Service's Community Health Needs Assessment process;

d. The reporting hospital shall inform all community members through a public communication of a summary of the feedback received, whether or not the recommendation was incorporated into the Reporting Hospital's Community Benefit Implementation Plan, and if the recommendation was not incorporated, an explanation for its absence. A Reporting Hospital may post the summary of feedback on a public facing website and provide notice through the Reporting Hospitals standard community outreach practices; and

e. The Reporting Hospital shall indicate that the implemented Community Benefit Priorities are either a result of community feedback or based upon the Reporting Hospital's recommendation.

6. Reporting Hospitals may conduct a public meeting combines the purpose of this Section 8.5002.A with other purposes, such as those required by the Community Health Needs Assessment process provided at 26 CFR § 1.501(r)-3, or other Community engagement efforts, so long as the public meeting meets the minimum requirements in this section.

7. Each Reporting Hospital shall invite, at a minimum, representatives from the following entities to participate in the meeting if any such entities operate in the hospital's Community:

a. Local Public Health Agencies;

b. Local chambers of commerce and economic development organizations;

c. Local health care consumer organizations;

d. School districts;

e. County governments;

f. City and town governments;

g. Community Health Center;

h. Certified rural health clinics or primary care clinics located in a county that has been designated as a rural or frontier county;

i. Area agencies on aging;

j. Safety Net Clinics;

k. Health care consumer advocacy organizations;

l. The general public,

m. Tribal councils of Colorado's land-based tribes, specifically including members of the tribal council or its designees;

n. Urban Indian Organizations, specifically including their members; and

o. Institutions of higher learning, specifically including their members.

8. Each Reporting Hospital shall invite, at a minimum, representatives from the following agencies to participate in the meeting:

a. The Department of Health Care Policy and Financing,

b. The Department of Public Health and Environment,

c. The Department of Human Services,

d. The Colorado Commission on Higher Education,

e. The Office of Saving People Money on Health Care, and

f. The Division of Insurance within the Department of Regulatory Agencies

9. Each Reporting Hospital shall issue invitations by:

a. Placing advertisements in each major newspaper published in the hospital's Community at least 30 days prior to the scheduled meeting. A major newspaper is a newspaper that is accessible, known to the members of the Reporting Hospital's Community, and is a newspaper of record for the Reporting Hospital's Community;

b. Posting invitations at least 30 days prior to the meeting date, including but not limited to:

i. On the Reporting Hospital's website and social media page(s),

ii. In the Reporting Hospital's e-newsletters, and

iii. Through email lists dedicated to Community outreach.

10. Reporting Hospitals shall request anonymous demographic information such as race, ethnicity, primary language spoken, and income from attendees. Reporting Hospitals shall inform meeting attendees that demographic data is voluntary and will not be publicly disclosed by the Reporting Hospital or by the Department. The Department will only share demographic information in a deidentified, aggregate manner. Reporting Hospitals may deidentify and aggregate this data during their submission to the Department.

11. Reporting Hospitals shall undertake the following efforts to promote broad Community notification and participation in the public meetings and to make meetings accessible:

a. Collaborate with Community Bsed Organizations and other Community partners to distribute invitations to the public,

b. Engage with organizations that specialize in the representation of under-served groups within the Reporting Hospital's Community,

b. When hosting in-person meetings ensure that locations are accessible to those with physical disabilities and those that utilize mobility aids,

c. Advertise that American Sign Language services and interpretation services for individuals with limited English proficiency are available upon request,

d. Upon request, provide American Sign Language services and, for individuals with limited English proficiency, provide language and interpretation services to ensure meaningful access such as those described in 45 C.F.R. § 92.201.

e. Reporting Hospitals may also undertake additional activities including but not limited to the following:

i. Advertise the public meeting in additional newspapers in the Community, including those that are published in languages other than English;

ii. Advertise the public meeting via radio stations broadcast in the Community, including radio stations that broadcast in languages other than English;

iii. Use neutral or external facilitators to lead Community meetings. To the extent possible facilitators should represent the demographics of the Community members being engaged and, if possible, the facilitator should not be employed by the Reporting Hospital;

iv. Schedule the public meeting outside of the typical workday hours and consider hosting meeting(s) at Community locations other than hospital campuses;

v. Provide multiple avenues for Community meetings by conducting hybrid meetings, with simultaneous in-person and virtual participation options. For virtual meetings, Reporting Hospital staff should provide appropriate orientation, technical assistance, captioning, and other assistive services;

vi. Schedule multiple meetings to be held on different days or at different times in order to accommodate a broader range of participants' schedules;

vii. Provide transportation and childcare for participants in the public meeting, and

viii. Provide reimbursement for transportation and childcare expenses incurred for the purposes of participating in the public meeting.

ix. Collaborate with Local Public Health Agencies operating wholly or partially in the Reporting Hospital's Community on public meetings planning and execution including but not limited to:

a. Meeting time and location;

b. Meeting topics; and

c. Communications notifying Community members of the meeting.

12. Reporting Hospitals should ensure that Community engagement goals reflect partnerships and collaboration with the Community and not solely state or federal requirements.

8.5002.B HOSPITAL REPORTING REQUIREMENTS

1. Each Reporting Hospital shall complete a Community Health Needs Assessment at least every three (3) years and shall submit a copy of the Community Health Needs Assessment to the Department on or before September 13, 2024, and then on or before July 1 every year thereafter.

a. Acquired or new hospitals shall complete their first Community Health Needs Assessment as described under 26 CFR § 1.501(r)-3 (d).

2. Each Reporting Hospital shall complete a Community Benefit Implementation Plan that addresses the needs described in the Community Health Needs Assessment and that shall submitted to the Department on or before September 13, 2024, and then on or before July 1 every year thereafter.

a. Each Reporting Hospital is required to complete a Community Benefit Implementation Plan that:

i. Addresses the needs described by the Reporting Hospital's Community Health Needs Assessment,

ii. Includes an explanation of the Community served by the hospital facility, and

iii. Describes how the Community was determined pursuant to 26 CFR § 1.501(r)-3(b).

3. Each Reporting Hospital shall submit to the Department on or before September 13, 2024, and then on or before July 1 every year thereafter a report on its most recent public meeting held to satisfy its Community Health Needs Assessment requirements under 26 CFR § 1.501(r)-3.

4. Each Reporting Hospital shall submit to the Department a report on the public meetings held during the previous reporting cycle on or before September 13, 2024, and then shall provide a report on the public meeting held after the submission date from the previous year on or before July 1 every year thereafter.

5. Each public meeting report shall include at minimum:

a. Date, time, and location of the meeting;

b. Outreach efforts to ensure broad Community participation and accessibility;

c. Individuals and organizations, including the populations served by the organizations, invited to the meeting;

d. To the extent this information is provided by attendees, a list of individual meeting attendees and organizations represented;

e. Meeting agenda;

f. A summary of the meeting discussion;

g. Actions taken as a result of feedback from meeting participants;

h. Content of meeting discussion including the Community Benefit Priorities discussed and the decisions made regarding those Community Benefit Priorities;

i. Community feedback received and how the Reporting Hospital plans to incorporate the feedback into the Reporting Hospital's Community Benefit Implementation Plan; and

j. Any demographic data collected voluntarily from attendees, such as data concerning race, ethnicity, and income. This data may be reported in a deidentified and aggregate manner.

6. Each Reporting Hospital shall submit to the Department on or before September 13, 2024, and then on or before July 1 every year thereafter a report on Community Benefits that shall include the following:

a. A copy of the most recently submitted Form 990 to the federal Internal Revenue Service including Schedule H. Associated worksheets may be submitted.

i. Reporting Hospitals that are part of a Health System or other corporate structure that files a consolidated form 990 to the federal Internal Revenue Service shall provide information that was included in Parts I, II, III, and V of Schedule H of Form 990 for each Reporting Hospital separately. Associated worksheets may be submitted.

ii. Reporting Hospitals not required to submit Schedule H of the Form 990 to the federal Internal Revenue Service shall complete Parts I, II, III, and V of Schedule H of Form 990 available on the federal Internal Revenue Service's website. Associated worksheets may be submitted.

b. A description of spending made by the Reporting Hospital or related entities that were included in Parts I, II, and III of Schedule H of Form 990 that includes at a minimum the following:

i. Cost of the Community Benefit spending, the amount funded for each activity,

1) If a Reporting Hospital receives grants or philanthropic funding that would be classified as restricted funding by the Internal Revenue Service and cannot be counted for the purposes of Community Benefit, the reporting hospital may provide additional information to the Department about the activity.

ii. Indicate if the Community Benefit activity addressed a Community Identified Health Need.

iii. For any Community Benefit activity spending that addressed a Community Identified Health Need the Reporting Hospital shall provide each specific Community Benefit activity within the following applicable categories, and shall distinguish if the activity was funded through direct cash or cash expenditures from in-kind contributions:

1. Free or Discounted Health Care Services;

2. Programs that Address Behavioral Health;

3. Programs that Address the Social Determinants of Health;

4. Programs that Address Community Based Health Care;

5. Provider Recruitment, Education, Research, and Training; distinguishing if educational activities were invested internally or externally; and

6. All services and programs that addressed Community Identified Health Needs.

iv. For any Community Benefit activity that addressed one or more Community Identified Health Needs provide evidence that shows how the spending improves Community health outcomes and directly corresponding to the relevant Community Identified Health Needs.

c. The Reporting Hospital's total expenses included in Line 18 of Section 1 of the submitted Form 990. Reporting Hospitals not required to submit Form 990 to the federal Internal Revenue Service shall complete Line 18 of Section 1 of Form 990 available on the federal Internal Revenue Service's website.

d. The Reporting Hospital's revenue less expenses included in Line 19 of Section 1 of the submitted form 990. Reporting Hospitals not required to submit Form 990 to the federal Internal Revenue Service shall complete Line 19 of Section 1 of Form 990 available on the federal Internal Revenue Service's website.

7. In the event that the due date falls on a weekend or state holiday, the reporting deadline shall be extended to the next business day.

8. Each Reporting Hospital shall post the report to their public website and submit to the Department the website address where the report has been posted.

9. A hospital licensed as a general hospital pursuant to part 1 of Article 3 of Title 25 that is not a Reporting Hospital may report on Community Benefits, costs, and shortfalls consistent with this section.

10. Reporting Hospitals may provide additional information on Community Benefit spending that are not reportable on the IRS Form 990, Schedule H that address Community-Identified Health Needs.

10 CCR 2505-10-8.5002

47 CR 14, July 25, 2024, effective 8/30/2024