n-11-52.pdf

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Part III - Administrative, Procedural, and Miscellaneous

Notice and Request for Comments Regarding the Community Health Needs
Assessment Requirements for Tax-exempt Hospitals

Notice 2011-52

SECTION 1. PURPOSE
This notice addresses the community health needs assessment (“CHNA”)
requirements described in section 501(r)(3) of the Internal Revenue Code
(“Code”) and related excise tax and reporting obligations, applicable to hospital
organizations that are (or seek to be) recognized as described in section
501(c)(3) of the Code. The CHNA requirements are among several new
requirements that apply to section 501(c)(3) hospital organizations under section
501(r), which was added to the Code by section 9007(a) of the Patient Protection
and Affordable Care Act (“Affordable Care Act”), Pub. L. No. 111-148, 124 Stat.
119, enacted March 23, 2010.
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This notice describes specific provisions related
to the CHNA requirements that the Treasury Department (“Treasury”) and the
Internal Revenue Service (“IRS”) anticipate will be included in regulations to be
proposed under section 501(r). This notice also invites comments from the
public regarding the CHNA requirements.

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A related bill, the Health Care Education Affordability Reconciliation Act of 2010 (H.R. 4872)
(Reconciliation Act), was signed into law on March 30, 2010 (Pub. L. No. 111-152). The
Reconciliation Act amends the Affordable Care Act and related laws.

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Although the CHNA requirements are not effective until taxable years
beginning after March 23, 2012, Treasury and the IRS are publishing this notice
regarding the CHNA requirements now because they understand that some
hospital organizations may choose to start the process of conducting CHNAs and
developing implementation strategies in advance of the effective date. A hospital
organization may rely on the anticipated regulatory provisions described in this
notice with respect to any CHNA made widely available to the public, and any
implementation strategy adopted, on or before the date that is six months after
the date further guidance regarding the CHNA requirements is issued.
SECTION 2. BACKGROUND
Section 9007 of the Affordable Care Act added sections 501(r) and 4959 to
the Code and amended section 6033(b). These provisions are applicable to
“hospital organizations” described in new section 501(r)(2). Section 501(r)(1)
provides that hospital organizations described in section 501(r)(2) will not be
treated as described in section 501(c)(3) unless they satisfy the requirements
specified in section 501(r), including the CHNA requirements described in section
501(r)(3).
Section 501(r)(2)(A) defines a “hospital organization” as (i) an organization
that operates a facility required by a State to be licensed, registered, or similarly
recognized as a hospital (“State-licensed hospital facility”), and (ii) any other
organization that the Secretary determines has the provision of hospital care as
its principal function or purpose constituting the basis for its exemption under
section 501(c)(3).

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If a hospital organization operates more than one hospital facility, section
501(r)(2)(B)(i) requires the organization to meet all of the section 501(r)(1)
requirements, including the CHNA requirements, separately with respect to each
hospital facility. Section 501(r)(2)(B)(ii) provides that the organization will not be
treated as described in section 501(c)(3) with respect to any hospital facility for
which such requirements are not separately met.
Section 501(r)(3)(A) provides that a hospital organization meets the CHNA
requirements with respect to any taxable year only if the organization (i) has
conducted a CHNA that meets the requirements of section 501(r)(3)(B) in such
taxable year or in either of the two taxable years immediately preceding such
taxable year, and (ii) has adopted an implementation strategy to meet the
community health needs identified through such CHNA. Section 501(r)(3)(B)
requires that a CHNA (i) 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, and (ii) be made widely
available to the public. Although most of the requirements under section 501(r)
are effective for taxable years beginning after March 23, 2010, the CHNA
requirements are effective for taxable years beginning after March 23, 2012. See

section 9007(f)(2) of the Affordable Care Act.
Section 501(r)(7) provides that the Secretary shall issue such regulations and
guidance as may be necessary to carry out the provisions of section 501(r).
Section 4959 imposes a $50,000 excise tax on a hospital organization that
fails to meet the CHNA requirements for any taxable year. A hospital

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organization must report the amount of any excise tax imposed on it under
section 4959 on its annual information return (i.e., Form 990, Return of
Organization Exempt From Income Tax, and related schedules) pursuant to
section 6033(b)(10)(D).
Section 6033(b)(15)(A) requires a hospital organization to report on its Form
990 a description of how the organization is addressing the needs identified in
each CHNA and a description of any needs that are not being addressed
together with the reasons why the needs are not being addressed.
On May 27, 2010, the IRS released Notice 2010-39, 2010-24 I.R.B. 756,
which requested comments regarding the new requirements under section
501(r), including the need, if any, for guidance regarding such requirements. In
response to Notice 2010-39, the IRS received numerous comments requesting
guidance on the CHNA requirements. In issuing this notice, Treasury and the
IRS have considered all of the comments regarding the CHNA requirements
received in response to Notice 2010-39.
SECTION 3. ANTICIPATED REGULATORY PROVISIONS
This section describes anticipated regulatory provisions regarding hospital
organizations required to meet the CHNA requirements (section 3.01); hospital
organizations with multiple hospital facilities (section 3.02); the documentation of
a CHNA (section 3.03); how and when a CHNA is conducted (section 3.04); the
community served by a hospital facility (section 3.05); persons representing the
broad interests of the community (section 3.06); making a CHNA widely available
to the public (section 3.07); implementation strategy (section 3.08); how and

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when an implementation strategy is adopted (section 3.09); excise taxes on
failures to meet the CHNA requirements (section 3.10); reporting requirements
related to CHNAs (section 3.11); and effective dates (section 3.12).
.01 Hospital Organizations Required to Meet the CHNA Requirements
Section 501(r)(2)(A) defines a “hospital organization” as (i) an organization
that operates a State-licensed hospital facility, and (ii) any other organization that
the Secretary determines has the provision of hospital care as its principal
function or purpose constituting the basis for its exemption under section
501(c)(3). A number of commenters asked that the Secretary not exercise its
determination authority under section 501(r)(2)(A)(ii) until there is an opportunity
to comment on a proposed rule.
(1) Organizations with the Principal Purpose of Providing Health Care
Treasury and the IRS have not yet exercised the authority described in
section 501(r)(2)(A)(ii) to determine whether any categories of organizations
have the provision of hospital care as their principal exempt function or purpose.
Treasury and the IRS intend that any future guidance regarding any such
categories of organizations will only apply prospectively, after an opportunity for
notice and comment. Prior to the effective date of any such future guidance, only
organizations operating State-licensed hospital facilities will be considered
“hospital organizations” that must satisfy the CHNA requirements.
(2) Hospital Organizations Operating State-licensed Hospital Facilities
Several commenters asked for confirmation that section 501(r) applies to an
organization described in section 501(c)(3) that operates a State-licensed

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hospital facility through a disregarded entity or a joint venture treated as a
partnership for federal tax purposes. A number of commenters also asked
whether section 501(r) will apply to an organization as a result of its operating a
hospital facility located outside of the United States.
Section 501(r)(2)(A)(i) includes within the definition of a hospital organization
any organization described in section 501(c)(3) that operates a State-licensed
hospital facility. Rev. Rul. 2004-51, 2004-1 C.B. 974, provides that the activities
of an entity that is treated as a partnership for federal tax purposes are treated as
the activities of the tax-exempt partner for purposes of determining whether the
tax-exempt partner is operated exclusively for exempt purposes and engages in
an unrelated trade or business. See also
Rev. Rul. 98-15, 1998-1 C.B. 718. In
addition, when an entity is disregarded as separate from its owner, its operations
are treated as a branch or division of the owner. See, e.g.
, Ann. 99-102, 1999-2
C.B. 545. Accordingly, Treasury and the IRS intend to include within the
definition of a hospital organization any organization described in section
501(c)(3) that operates a State-licensed hospital facility through a disregarded
entity or a joint venture, limited liability company, or other entity treated as a
partnership for federal income tax purposes. Treasury and the IRS request
comments regarding whether (or under what circumstances) an organization
should not be considered to ”operate” a State-licensed hospital facility for
purposes of section 501(r) as a result of its owning a small interest (other than a
general partner or similar interest) in an entity treated as a partnership for federal
income tax purposes that operates the hospital facility.

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Treasury and the IRS also intend to provide that a hospital facility located
outside of the United States will not be considered a State-licensed hospital
facility for purposes of section 501(r)(2)(A)(i) because the term “State” includes
only the 50 States and the District of Columbia and not any U.S. possession or
territory or foreign country. See
section 7701(a)(9), (10).
(3) Government Hospitals
A number of commenters requested that Treasury and the IRS provide an
exception from the requirements imposed by section 501(r) for certain
government hospitals. For example, some commenters suggested that the
requirements of section 501(r) should not apply to a hospital the income of which
is excluded from gross income under section 115 but which has nonetheless
applied for and received recognition as an organization described in section
501(c)(3). Other commenters suggested that the section 501(r) requirements
should not apply to any hospital that is “a governmental unit” or “an affiliate of a
governmental unit” as described in Rev. Proc. 95-48, 1995–2 C.B. 418 (relieving
such organizations from the annual filing requirement under section 6033).
The statutory language of section 501(r) applies to all hospital organizations
that are (or seek to be) recognized as described in section 501(c)(3). Section
501(r) does not explicitly address government hospitals, nor does it include a
specific exception for government hospitals. Accordingly, Treasury and the IRS
intend to apply section 501(r) to every hospital organization that has been
recognized (or seeks recognition) as an organization described in section
501(c)(3). However, in recognition of the unique position of government

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hospitals, Treasury and the IRS request comments regarding alternative
methods a government hospital may use to satisfy the requirements of section
501(r)(3).
.02 Hospital Organizations with Multiple Hospital Facilities
Section 501(r)(2)(B) provides that if a hospital organization operates more
than one hospital facility (i) the organization shall meet the requirements of
section 501(r) separately with respect to each hospital facility, and (ii) the
organization shall not be treated as described in section 501(c)(3) with respect to
any hospital facility for which the requirements of section 501(r) are not
separately met. Accordingly, Treasury and the IRS intend to require a hospital
organization to conduct a CHNA and adopt an implementation strategy for each
hospital facility it operates. Moreover, as described further in sections 3.04 and
3.08 of this notice, although hospital organizations will be able to collaborate with
other organizations when conducting CHNAs and developing implementation
strategies, Treasury and the IRS intend to require a hospital organization
operating multiple hospital facilities to document separately the CHNA and the
implementation strategy for each of its hospital facilities.
A number of commenters requested guidance on the potential consequences
of a failure to satisfy the requirements of 501(r) separately with respect to a
particular hospital facility. Treasury and the IRS intend to address the potential
consequences of a failure to satisfy the CHNA requirements (or other
requirements under section 501(r)) with respect to one or more hospital facilities
in proposed regulations or other future guidance.

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.03 Documentation of a CHNA
Section 501(r)(3)(A)(i) requires a hospital organization to conduct a CHNA
that meets the requirements of section 501(r)(3)(B) at least once every three
taxable years.
Many commenters requested that Treasury and the IRS define a CHNA in a
manner sufficiently flexible to allow hospitals to design a CHNA appropriate to
their unique community and available resources. At the same time, a number of
commenters asked that Treasury and the IRS provide clear guidance regarding
the required contents of a CHNA. Several commenters asked the IRS to define a
CHNA as a written document developed for a hospital facility that includes a
description of the community served by the hospital facility; the process used to
conduct the assessment, including how the hospital took into account input from
community members and public health experts; identification of any persons with
whom the hospital has worked on the assessment; and the health needs
identified through the assessment process.
Treasury and the IRS intend to require a hospital organization to document a
CHNA for a hospital facility in a written report that includes the following
information:
(1) A description of the community served by the hospital facility (as defined
in section 3.05 of this notice) and how it was determined.
(2) A description of the process and methods used to conduct the
assessment, including a description of the sources and dates of the data and
other information used in the assessment and the analytical methods applied to

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identify community health needs. The report should also describe information
gaps that impact the hospital organization’s ability to assess the health needs of
the community served by the hospital facility. If a hospital organization
collaborates with other organizations in conducting a CHNA (as described in
paragraph (2) of section 3.04 of this notice), the report should identify all of the
organizations with which the hospital organization collaborated. If a hospital
organization contracts with one or more third parties to assist it in conducting a
CHNA, the report should also disclose the identity and qualifications of such third
parties.
(3) A description of how the hospital organization took into account input
from persons who represent the broad interests of the community served by the
hospital facility (as defined in section 3.06 of this notice), including a description
of when and how the organization consulted with these persons (whether through
meetings, focus groups, interviews, surveys, written correspondence, etc.). If the
hospital organization takes into account input from an organization, the written
report should identify the organization and provide the name and title of at least
one individual in such organization with whom the hospital organization
consulted. In addition, the report must identify any individual providing input who
has special knowledge of or expertise in public health (as provided in paragraph
(1) of section 3.06 of this notice) by name, title, and affiliation and provide a brief
description of the individual’s special knowledge or expertise. The report also
must identify any individual providing input who is a “leader” or “representative” of

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populations described in paragraph (3) of section 3.06 of this notice by name and
describe the nature of the individual’s leadership or representative role.
(4) A prioritized description of all of the community health needs identified
through the CHNA, as well as a description of the process and criteria used in
prioritizing such health needs.
(5) A description of the existing health care facilities and other resources
within the community available to meet the community health needs identified
through the CHNA.
Some commenters suggested that a CHNA include a description of the
needs identified in the CHNA that the hospital intends to address, the reasons
those needs were selected, and the means by which the hospital will undertake
to address the selected needs. Treasury and the IRS intend to require a hospital
organization to specifically address each of the community health needs
identified through a CHNA for a hospital facility in an implementation strategy, as
described in section 3.08 of this notice, rather than in the written report
documenting the hospital facility’s CHNA.
.04 How and When a CHNA Is “Conducted”
Section 501(r)(3)(A) provides that a hospital organization meets the CHNA
requirements with respect to any taxable year only if it has conducted a CHNA in
such taxable year or in either of the two immediately preceding taxable years.
Numerous commenters requested that Treasury and the IRS provide that a
CHNA may be based on information collected by a public health agency or non-
profit organization. Commenters also requested that hospital organizations be

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permitted to conduct CHNAs together with one or more other organizations,
because collaboration will allow for more cost effective and efficient identification
of a community’s health care needs from a more fully-informed perspective.
(1) When a CHNA Is Considered Conducted
Treasury and the IRS intend to consider a CHNA as being “conducted” in the
taxable year that the written report of its findings (containing all of the information
described in section 3.03 of this notice) is made widely available to the public (as
defined in section 3.07 of this notice).
Treasury and the IRS request comments on what, if any, guidance is needed
regarding when a hospital organization must conduct a CHNA for a new hospital
facility that the hospital organization acquires or places into service after March
23, 2010.
(2) How a CHNA is Conducted
Treasury and the IRS intend to provide that a CHNA will satisfy the CHNA
requirements with respect to a hospital facility only if it identifies and assesses
the health needs of, and takes into account input from persons who represent the
broad interests of, the community served by that specific hospital facility (as
defined in section 3.05 of this notice). Treasury and the IRS intend to allow a
hospital organization to base a CHNA on information collected by other
organizations, such as a public health agency or non-profit organization.
Treasury and the IRS also intend to allow a hospital organization to conduct a
CHNA in collaboration with other organizations, including related organizations,
other hospital organizations, for-profit and government hospitals, and state and

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local agencies, such as public health departments. However, in order to ensure
that the hospital organization meets the CHNA requirements separately with
respect to each hospital facility and that information for each hospital facility is
clearly presented and easily accessible, Treasury and the IRS intend to require a
hospital organization to document the CHNA for each of its hospital facilities in
separate written reports that include the information described in section 3.03 for
each hospital facility.
Treasury and the IRS request comments regarding whether, and under what
circumstances, documenting CHNAs for multiple hospital facilities together in one
written report might improve the quality of the CHNAs, while still ensuring that
information for each hospital facility is clearly presented and easily accessible.
.05 Community Served by a Hospital Facility
Numerous commenters recommended that any definition of the “community
served by the hospital facility” give hospitals the flexibility to define the scope of a
CHNA so that it focuses on the communities actually served by hospital facilities,
whether those communities are defined by geographic area or target populations
(e.g., women or children). On the other hand, some commenters recommended
defining the community served by a hospital facility as a specific geographic
area. For example, one commenter recommended defining the community
served by a hospital facility as a geographic area, identified by the zip codes of
discharged patients, from which at least 75 percent of the hospital’s patients
reside.

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For purposes of section 501(r)(3), Treasury and the IRS intend to provide that
a hospital organization may take into account all of the relevant facts and
circumstances in defining the community a hospital facility serves. Generally,
Treasury and the IRS expect that a hospital facility’s community will be defined
by geographic location (e.g., a particular city, county, or metropolitan region).
However, in some cases, the definition of a hospital facility’s community may also
take into account target populations served (e.g., children, women, or the aged)
and/or the hospital facility’s principal functions (e.g., focus on a particular
specialty area or targeted disease). Notwithstanding the foregoing, a community
may not be defined in a manner that circumvents the requirement to assess the
health needs of (or consult with persons who represent the broad interests of) the
community served by a hospital facility by excluding, for example, medically
underserved populations, low-income persons, minority groups, or those with
chronic disease needs.
Treasury and the IRS request comments regarding the relative merits of
different geographically-based definitions of community. Treasury and the IRS
specifically request comments regarding whether future regulations should define
the geographic community of a hospital facility as the Metropolitan Statistical
Area (MSA) or Micropolitan Statistical Area (μSA) in which the facility is located
or, if the hospital facility is a rural facility not located in a MSA or μSA, as the
county in which the facility is located.

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.06 Persons Representing the Broad Interests of the Community
Section 501(r)(3)(B)(i) states that a CHNA must 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. A number of commenters asked that a hospital be given discretion to
determine the type of input and expertise that it needs in conducting a CHNA.
Other commenters asked that Treasury and the IRS provide guidance on the
qualifications necessary for a person to be considered as having special
knowledge of or expertise in public health. In addition, numerous commenters
requested that CHNAs should, at a minimum, be required to take into account
input from state and/or local public health agencies or departments. A few
commenters also recommended that hospital facilities be required to consult with
representatives of underserved or disadvantaged communities.
In order to meet the requirement to take into account input from persons who
represent the broad interests of the community served by a hospital facility,
Treasury and the IRS intend to provide that a CHNA must, at a minimum, take
into account input from—
(1) Persons with special knowledge of or expertise in public health;
(2) Federal, tribal, regional, State, or local health or other departments or
agencies, with current data or other information relevant to the health needs of
the community served by the hospital facility; and

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(3) Leaders, representatives, or members of medically underserved, low-
income, and minority populations, and populations with chronic disease needs, in
the community served by the hospital facility.
Treasury and the IRS expect that certain persons may fall into more than one
of the categories listed above in paragraphs (1) through (3). For example, taking
into account input from certain government officials with special knowledge of or
expertise in public health may allow a hospital organization to satisfy the
requirements described in both paragraphs (1) and (2). Treasury and the IRS
request comments regarding what specific qualifications (whether in terms of
degrees, positions, experience, or affiliations) should be necessary for an
individual or organization to be considered as having special knowledge of or
expertise in public health.
In addition to persons described above in paragraphs (1), (2), and (3), a
hospital organization or facility may also consult with and seek input from other
persons located in and/or serving the hospital facility’s community. For example,
a hospital organization or facility may consult or seek input from healthcare
consumer advocates; nonprofit organizations; academic experts; local
government officials; community-based organizations, including organizations
focused on one or more health issues; health care providers, including
community health centers and other providers focusing on medically underserved
populations, low-income persons, minority groups, or those with chronic disease
needs; private businesses; and health insurance and managed care
organizations.

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.07 Making a CHNA Widely Available to the Public
Section 501(r)(3)(B)(ii) provides that a CHNA must be made widely available
to the public. Many commenters suggested patterning the rules for making the
CHNA widely available to the public after the rules for making Forms 990 “widely
available” under Treas. Reg. § 301.6104(d)-2(b).
In defining widely available to the public for purposes of section
501(r)(3)(B)(ii), Treasury and the IRS intend to adopt rules similar to those set
forth in Treas. Reg. § 301.6104(d)-2(b). Thus, a hospital organization will be
considered to have made a hospital facility’s CHNA widely available to the public
by posting the written report of the CHNA findings on the hospital facility’s
website or, if the hospital facility does not have its own website separate from the
hospital organization that operates it, on the hospital organization’s website.
Alternatively, the written report may be posted on a website established and
maintained by another entity as long as either –
(1) the hospital organization or facility’s website provides a link to the
website on which the report is posted, along with clear instructions for accessing
the report on that website; or
(2) if neither the hospital organization nor the hospital facility has a website,
the hospital organization or facility provides any individual requesting a copy of
the written report with the direct website address, or url, where the document can
be accessed.

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In addition, Treasury and the IRS intend to provide that a CHNA will be
considered widely available to the public by reason of posting on a website only
if--
(1) The website through which the written report is available clearly informs
readers that the document is available and provides instructions for downloading
it;
(2) The document is posted in a format that, when accessed, downloaded,
viewed, and printed in hard copy, exactly reproduces the image of the report;
(3) Any individual with access to the Internet can access, download, view,
and print the document without special computer hardware or software required
for that format (other than software that is readily available to members of the
public without payment of any fee) and without payment of a fee to the hospital
organization or facility or to another entity maintaining the website; and
(4) The hospital organization or facility provides any individual requesting a
copy of the written report with the direct website address, or url, where the
document can be accessed.
Finally, Treasury and the IRS intend to require a hospital organization to make
a CHNA for a hospital facility widely available to the public until the date on which
it makes a subsequent CHNA for that hospital facility widely available to the
public.
Treasury and the IRS request comments regarding whether future guidance
should provide additional methods that a hospital organization could or must use
to make a CHNA widely available to the public.

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.08 Implementation Strategy
Section 501(r)(3)(A)(ii) provides that a hospital organization meets the CHNA
requirements with respect to any taxable year only if it has adopted an
“implementation strategy” to meet the community health needs identified through
the CHNA. Some commenters suggested that a hospital organization be allowed
to coordinate with other organizations in developing an implementation strategy.
A number of commenters also suggested that at least a summary of the
implementation strategy should be included in the written report of the CHNA’s
findings. Several commenters requested that Treasury and the IRS not require
the implementation strategy to set forth a specific plan to meet all of the health
needs identified through a CHNA. One commenter recommended that the
implementation strategy be a document that is available for IRS review.
As with any other requirement under section 501(r), a hospital organization
must meet the requirement to adopt an implementation strategy separately with
respect to each hospital facility it operates. Treasury and the IRS intend to
define an “implementation strategy” for a hospital facility as a written plan that
addresses each of the community health needs identified through a CHNA for
such facility. For these purposes, Treasury and the IRS intend to provide that an
implementation strategy will address a health need identified through a CHNA for
a particular hospital facility if the written plan either—
(1) describes how the hospital facility plans to meet the health need; or

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(2) identifies the health need as one the hospital facility does not intend to
meet and explains why the hospital facility does not intend to meet the health
need.
In describing how a hospital facility plans to meet a health need identified
through a CHNA for purposes of paragraph (1), the implementation strategy must
tailor the description to the particular hospital facility, taking into account its
specific programs, resources, and priorities. For example, an implementation
strategy could describe a hospital facility’s plans to meet a health need by
identifying the programs and resources that the hospital facility plans to commit
to meeting the health need and the anticipated impact of those programs and
resources on the health need. The implementation strategy could also describe
any planned collaboration with governmental, non-profit, or other health care
organizations, including related organizations, in meeting the health need.
As discussed in section 3.11 of this notice, Treasury and the IRS intend to
require a hospital organization to attach to its annual Form 990 the most recently
adopted implementation strategy for each of its hospital facilities.
Treasury and the IRS intend to allow hospital organizations to develop
implementation strategies for their hospital facilities in collaboration with other
organizations, including related organizations, other hospital organizations, for-
profit and government hospitals, and State and local agencies, such as public
health departments. If a hospital organization collaborates with other
organizations in developing an implementation strategy, the implementation
strategy should identify all of the organizations with which the hospital

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organization collaborated. In addition, to ensure that the hospital organization
meets the CHNA requirements separately with respect to each hospital facility
and that the implementation strategy for each hospital facility is clearly presented
and easily accessible, Treasury and the IRS intend to require a hospital
organization to document separately the implementation strategy for each of its
hospital facilities.
Treasury and the IRS request comments regarding whether, and under what
circumstances, documenting implementation strategies for multiple hospital
facilities together in one written document might improve the quality of the
implementation strategies while still ensuring that information for each hospital
facility is clearly presented and easily accessible.
.09 How and When an Implementation Strategy is Adopted
One commenter asked for clarification regarding when the implementation
strategy must be adopted and recommended that a hospital organization be
allowed to adopt an implementation strategy by the end of the taxable year
following the year in which CHNA was conducted.
Treasury and the IRS intend to consider an implementation strategy as being
adopted on the date the implementation strategy is approved by an authorized
governing body of the hospital organization.
For these purposes, an authorized governing body means--
(1) The governing body (i.e., the board of directors, board of trustees, or
equivalent controlling body) of the hospital organization;

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(2) A committee of the governing body, which may be composed of any
individuals permitted under State law to serve on such committee, to the extent
the committee is permitted by State law to act on behalf of the governing body; or
(3) To the extent permitted under State law, other parties authorized by the
governing body of the hospital organization to act on its behalf by following
procedures specified by the governing body in approving an implementation
strategy.
Pursuant to section 501(r)(3)(A)(ii), in order to satisfy the CHNA requirements
with respect to any taxable year, a hospital organization must have adopted an
implementation strategy to meet the health needs identified through the CHNA
described in section 501(r)(3)(A)(i). Accordingly, Treasury and the IRS intend to
provide that a hospital organization must adopt an implementation strategy to
meet the community health needs identified in a CHNA by the end of the same
taxable year in which it conducts that CHNA. Treasury and the IRS request
comments regarding the need, if any, for a transition rule, under which a hospital
organization would be given additional time to adopt an implementation strategy
for the first taxable year in which the hospital organization is subject to the CHNA
requirements (i.e., the first taxable year beginning after March 23, 2012).
.10 Excise Tax on Failures to Meet the CHNA Requirements
Section 4959 imposes a $50,000 excise tax on a hospital organization that
fails to meet the CHNA requirements with respect to any taxable year.
Treasury and the IRS intend to impose the $50,000 excise tax under section
4959 on any hospital organization that fails to satisfy the CHNA requirements

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with respect to a hospital facility in any three-year period. For example, if a
hospital organization reporting on a calendar-year basis that operates only one
hospital facility fails to conduct a CHNA by the last day of 2013, and also did not
conduct a CHNA in 2011 or 2012, it will be subject to a $50,000 excise tax under
section 4959 for its 2013 taxable year. If it then fails to conduct a CHNA by the
last day of 2014, it will again be subject to a $50,000 excise tax under section
4959 for its 2014 taxable year (having not conducted a CHNA in 2012, 2013, or
2014).
Because section 501(r)(2)(B)(i) requires a hospital organization to meet the
CHNA requirements “separately with respect to each [hospital] facility,” Treasury
and the IRS intend to apply the section 4959 excise tax separately with respect
to each hospital facility’s failure to meet the CHNA requirements. Thus, if a
hospital organization operates two hospital facilities and fails to meet the
requirements of section 501(r)(3) for both of them for any taxable year, that
hospital organization will be subject to a total excise tax of $100,000 ($50,000 for
each hospital facility) in that taxable year.
.11 Reporting Requirements Related to CHNAs
Section 6033(a)(1) requires every organization exempt from taxation under
section 501(a) and not excepted under section 6033(a)(3) to file an annual return
stating such information for the purpose of carrying out the internal revenue laws
as the Secretary may by forms or regulations prescribe. Section 6033(a)(3)(B)
provides that the Secretary may relieve any organization (other than a supporting
organization described in section 509(a)(3)) from this requirement to file an

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annual return when the Secretary determines that filing is not necessary to the
efficient administration of the internal revenue laws. Section 6033(b) lists the
information that organizations described in section 501(c)(3) must furnish on their
annual information returns, including any “information for purposes of carrying
out the internal revenue laws as the Secretary may require.” See
section
6033(b)(16).
As described above, the Affordable Care Act added two specific reporting
requirements for hospital organizations to section 6033(b). Section
6033(b)(10)(D) requires a hospital organization to report on its annual information
return (Form 990) the amount of the excise tax imposed on the organization
under section 4959. Section 6033(b)(15)(A) requires a hospital organization to
report on its annual Form 990 a description of how the organization is addressing
the needs identified in each CHNA and a description of any such needs that are
not being addressed together with the reasons why such needs are not being
addressed.
The IRS has added new questions to Schedule H, Hospitals, of the Form 990
to reflect the new reporting requirements for hospital organizations under section
6033(b)(15)(A). The IRS also plans to add questions reflecting the new reporting
requirements under section 6033(b)(10)(D) to the Form 990 in the future. As
discussed in section 3.12 of this notice, responses to these questions are
optional on Forms 990 for taxable years beginning on or before March 23, 2012.
As discussed above, section 501(r)(3)(A)(ii) requires a hospital organization to
adopt an implementation strategy for each of its hospital facilities. Treasury and

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the IRS intend to require a hospital organization to attach to its annual Form 990
its most recently adopted implementation strategy for each of its hospital
facilities. (See section 3.09 of this notice for when an implementation strategy
must be adopted.) If a hospital organization only conducts one CHNA and
adopts one implementation strategy for a hospital facility in a given three-year
period, Treasury and the IRS intend to allow it to attach the same implementation
strategy for that hospital facility to the Form 990 for each of those three years.
In Rev. Proc. 95-48, the IRS exercised its discretionary authority under
section 6033(a)(3)(B) to relieve certain governmental units and affiliates of
governmental units from the requirement to file Form 990. The Affordable Care
Act did not change the requirements regarding what organizations are required to
file Form 990. Accordingly, a government hospital (other than one that is
described in section 509(a)(3)) that has been excused from filing Form 990 under
Rev. Proc. 95-48 or a successor revenue procedure is not required to file Form
990. Because government hospitals described in Rev. Proc. 95-48 (other than
those described in section 509(a)(3)) are relieved from the annual filing
requirements under section 6033, they are also relieved from any new reporting
requirements imposed on hospital organizations under section 6033, including
the requirements under sections 6033(b)(10)(D) and (b)(15)(A) and the
anticipated requirement to attach one or more implementation strategies to a
Form 990.

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.12 Effective Dates
The CHNA requirements are effective for taxable years beginning after March
23, 2012. See
section 9007(f)(2) of the Affordable Care Act. Accordingly,
Treasury and the IRS intend to require a hospital organization to conduct a
CHNA and adopt an implementation strategy for each of its hospital facilities by
the last day of its first taxable year beginning after March 23, 2012.
Section 501(r)(3)(A) provides that an organization meets the CHNA
requirements with respect to any taxable year only if the organization has
conducted a CHNA in such taxable year or in either of the two taxable years
immediately preceding such taxable year and has adopted an implementation
strategy to meet the community health needs identified through the CHNA.
Accordingly, a CHNA that is conducted and an implementation strategy that is
adopted in either of the two taxable years immediately preceding the taxable year
in which section 501(r)(3) becomes effective may apply toward satisfaction of the
CHNA requirements for the taxable year in which section 501(r)(3) becomes
effective (and the succeeding taxable year, if within the three-year period
beginning with the year the CHNA was conducted).
The reporting requirement described in section 6033(b)(15)(A) is effective for
taxable years beginning after March 23, 2010, but because the CHNA
requirements are not effective until taxable years beginning after March 23, 2012,
Treasury and the IRS do not intend to require hospital organizations to report the
information described in section 6033(b)(15)(A) on, or attach implementation

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strategies to, Forms 990 for any taxable year beginning on or before March 23,
2012.
SECTION 4. RELIANCE
Treasury and the IRS expect to issue proposed regulations that will provide
guidance regarding the requirements under section 501(r) in general and the
CHNA requirements of section 501(r)(3) in particular. Hospital organizations may
rely on the anticipated regulatory provisions described in this notice with respect
to any CHNA made widely available to the public, and any implementation
strategy adopted, on or before the date that is six months after the date further
guidance regarding the CHNA requirements is issued.
SECTION 5. REQUEST FOR COMMENTS
Treasury and the IRS request comments regarding the CHNA requirements
described in this notice. In addition to the comments specifically requested
above, comments are also specifically requested regarding the definitions of a
hospital organization, a hospital facility, a CHNA, a community served by a
hospital facility, an implementation strategy, conducted (for purposes of the
CHNA), and adopted (for purposes of the implementation strategy).
Comments should be submitted on or before September 23, 2011. Please
include Notice 2011-52 on the cover page. Comments should be sent to the
following address:
Internal Revenue Service
CC:PA:LPD:PR (Notice 2011-52), Room 5203
P.O. Box 7604
Ben Franklin Station
Washington, DC 20044

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Submissions may be hand delivered Monday through Friday between the hours
of 8 a.m. and 4 p.m. to:
Internal Revenue Service
Courier’s Desk
1111 Constitution Ave., N.W.
Washington, DC 20224
Attn: CC:PA:LPD:PR (Notice 2011-52)
Submissions may also be sent electronically to the following e-mail address:
Notice.Comments@irscounsel.treas.gov.
Please include “Notice 2011-52” in the subject line.
All comments will be available for public inspection and copying.
SECTION 6. DRAFTING INFORMATION
The principal author of this notice is Preston Quesenberry of the Office of the
Division Counsel/Associate Chief Counsel (Tax Exempt and Government
Entities). For further information regarding this notice, contact Mr. Quesenberry
at (202) 622-1124 (not a toll-free call).