2024-05-15T13:59:36-05:00 2023-06-30 861065772 Deloitte Tax LLP 111 Monument Circle Suite 4200 Indianapolis IN 462045108 990 2022-07-01 426591803 Mercy Hospital Iowa City Iowa Self Insurance Plan and Trust MERC 3193390300 500 East Market Street Iowa City IA 52245 Thomas Clancy CEO 3193390300 2024-05-15 1 Thomas Clancy 999009999 0 Shawna M Jansons P01222873 3174648600 2 AAL1 IAL1 2022 2023-04-26 12:10:37Z Thomas Clancy 500 East Market Street Iowa City IA 52245 31602 0 X mercyiowacity.org X 1998 IA A trust to protect assets contributed for medical malpractice & liability reserves. 4 4 0 4 0 0 0 0 0 0 77884 3228 0 0 77884 3228 0 0 0 0 0 0 0 0 0 1578305 1138329 1578305 1138329 -1500421 -1135101 492917 372943 1210708 1231621 -717791 -858678 The trust was established to protect money, property, and other assets contributed by participants to provide medical malpractice and liability reserves. 0 0 1138329 Mercy Hospital, Iowa City, Iowa Self Insurance Plan and Trust ("the Trust") is a Self Insurance program for the benefit of Mercy Hospital Iowa City. The trust was established to protect money, property, and other assets contributed by participants to provide medical malpractice and liability reserves. 1138329 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 X 4 4 1 1 0 0 0 1 1 1 1 0 0 0 1 1 1 1 1 0 0 0 X Thomas Clancy 3193393540 500 East Market Street Iowa City IA 52245 Dawna Miller Treasurer (End 7/22) 1.00 41.00 X X 0 366748 32802 Kimberley Rossiter Asst. Treas. (End 8/22) / Trustee 1.00 41.00 X X 0 208788 21185 Jeffrey Rooney Treasurer (8/22-4/23) 1.00 41.00 X X 0 0 0 Jim Porter Treasurer (Begin 5/23) 1.00 41.00 X X 0 0 0 Mike Trachta CEO & Administrator (End 3/23) 1.00 41.00 X X 0 0 0 Tom Clancy CEO & Administrator (Begin 4/23) 1.00 2.00 X X 0 0 0 Bob Ritz Trustee (End 3/23) 1.00 1.00 X 0 0 0 Lynn Whisler Trustee (Begin 7/22) 1.00 1.00 X 0 0 0 Madeline Windauer Chair (Begin 7/22) 1.00 1.00 X 0 0 0 Stuart Elkin Asst. Treas. (Beg 9/22) 1.00 41.00 X 0 170462 5733 0 745998 59720 0 0 1 0 0 8258 8258 23344 28374 -5030 -5030 -5030 3228 0 0 3228 Insurance Funding Exp. 1138329 1138329 1138329 1138329 0 0 163851 2176 329066 370767 492917 372943 477407 542778 733301 688843 1210708 1231621 X -717791 -858678 -717791 -858678 492917 372943 X -1135101 19214 975000 X 0 0 0 X X 1 Mercy Hospital Iowa City Iowa 420680391 3 1 1138329 0 1 1138329 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 Accrued Professional Liability Claims 688843 688843 1 0 0 0 0 0 0 0 0 Dawna Miller Treasurer (End 7/22) 0 207266 0 54638 0 104844 0 8332 0 24470 0 399550 0 0 Kimberley Rossiter Asst. Treas. (End 8/22) / Trustee 0 194183 0 7750 0 6855 0 5002 0 16183 0 229973 0 0 Stuart Elkin Asst. Treas. (Beg 9/22) 0 170462 0 0 0 0 0 5733 0 0 0 176195 0 0 Part I, Line 3 The trust relied on Mercy Hospital, a related organization, to establish the compensation of the Trust's top management official. Mercy Hospital used the following methods to establish compensation: -Compensation Committee -Independent Compensation Consultant -Form 990 of Other Organizations -Compensation Survey or Study -Approval by the Board or Compensation Committee Part I, Line 4a Dawna Miller, Chief Financial Officer received severance payments amounting to $103,884 in calendar year 2022 as part of her employment contract. Form 990, Part VI, Section A, line 2 Jeffrey Rooney, Stuart Elkin, Dawna Miller, and Kimberly Rossiter have a business relationship as they simultaneously serve together on the Mercy Services Iowa City, Iowa board. Form 990, Part VI, Section A, line 3 MercyOne provides certain management oversight and personnel services pursuant to a strategic management affiliation agreement. Mike Trachta, Chief Executive Officer (ending 3/23) of Mercy Hospital Iowa City Iowa Self Insurance Plan and Trust, is not an employee of the trust, but rather an employee of MercyOne, a management company. For his role as Chief Executive Officer of Mercy Hospital Iowa City, Mike Trachta is compensated $582,271 by MercyOne. Jeffrey Rooney, Chief Financial Officer (beginning 9/22 and ending 4/23) of Mercy Hospital, Iowa City, Iowa is not an employee of the hospital but rather an employee of Martinville Dunn, a management company. For his role as Chief Financial Officer of Mercy Hospital Iowa City, Jeffrey Rooney was compensated $290,398 by Martinville Dunn. Form 990, Part VI, Section A, line 7a Mercy Hospital, Iowa City, as a participant of the Trust, may appoint trustees. Form 990, Part VI, Section A, line 7b Mercy Hospital, Iowa City, as the participant of the Trust, may approve decisions of the Trust's trustees. Form 990, Part VI, Section B, line 11b The form 990 is reviewed by Mercy Hospital, Iowa City, Iowa's controller, the chief financial officer, and an outside independent accounting and tax firm prior to submitting the form 990 to the IRS. The form 990 was not reviewed by the organization's board of directors before submitting it to the IRS. Form 990, Part VI, Section B, line 12c A conflict of interest statement is signed at the beginning of Board members term and on an annual basis there after. Any abstention from a vote is recorded in Board minutes. After the fiscal year end a "look back" questionnaire is distributed to all Board members to disclose any conflicts of interest that may have taken place in the previous year. Form 990, Part VI, Section B, line 15 Compensation for all executives is determined based on national or regional market data for comparable positions at comparatively sized hospitals. The current President/CEO is provided under a management agreement with MercyOne and employed by MercyOne. Form 990, Part VI, Section C, line 19 The organization will provide any documents open to public inspection upon request. Form 990, Part XI, line 9: Funding from Mercy Hospital 975,000. Mercy Hospital Iowa City Iowa 500 East Market Street Iowa City IA 52245 420680391 Health Care IA 501(c)(3) 3 N/A 0 Sisters of Mercy of the Americas West Midwest Community Inc 7262 Mercy Road Omaha NE 68124 262400800 Religious Order NE 501(c)(3) Religious Order N/A 0 Mercy Foundation 500 East Market Street Iowa City IA 52245 237040506 Foundation/Fundraising IA 501(c)(3) 12A, I Mercy Hospital 1 Mercy Hospital Guild 500 East Market Street Iowa City IA 52245 426099912 Fundraising IA 501(c)(3) 12C, III-FI N/A 0 Iowa City Ambulatory Surgical Center LLC 2963 Northgate Drive Iowa City IA 52245 208503424 Outpatient Surgery IA N/A 0 0 Corridor Radiology LLC 2769 Heartland Drive Suite 307 Coralville IA 52241 460635070 Radiology Services IA N/A 0 0 Eastern Iowa Rehabilitation Hospital LLC 680 S 4th Street Louisville KY 40202 831589139 Inpatient Rehabilitation Care IA N/A 0 0 Mercy Services Iowa City Inc 500 East Market Street Iowa City IA 52245 421241044 Health Care IA N/A C 0 0 0 1 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0 MERCY HOSPITAL IOWA CITY IOWA C 975000 Cash Received