2023-11-14T08:05:14-06:00 2022-12-31 390859910 BAKER TILLY US LLP 790 N WATER ST SUITE 2000 MILWAUKEE WI 53202 990 2022-01-01 452633920 QUARTZ HEALTH PLAN MN CORPORATION QUAR 6084714771 2650 NOVATION PKWY FITCHBURG WI 53713 JEFFREY A BUTCHER SENIOR VP, CFO AND TREASURER 6084714771 2023-11-13 1 JEFFREY BUTCHER XXX-XX-XXXX 0 LAWRENCE H MOHR CPA P00447603 4147775500 2023-11-13 2 AAL1 IAL1 2022 2023-04-26 12:10:37Z X CHRISTINE C SENTY 2650 NOVATION PKWY FITCHBURG WI 53713 38902465 0 X WWW.QUARTZBENEFITS.COM X 2011 MN TO PROMOTE SOCIAL WELFARE BY OPERATION OF A HEALTH MAINTENANCE ORGANIZATION AND OTHER ACTIVITIES INCIDENTAL THERETO. 6 4 0 5 0 0 0 0 30999097 38818073 15255 84392 0 0 31014352 38902465 0 0 0 0 1078527 1193030 0 0 0 29236449 37683140 30314976 38876170 699376 26295 12772052 18352476 7595547 9973733 5176505 8378743 X TO PROMOTE SOCIAL WELFARE BY OPERATION OF A HEALTH MAINTENANCE ORGANIZATION AND OTHER ACTIVITIES INCIDENTAL THERETO, AND ANY OTHER LAWFUL ACTIVITY WITHIN THE PURPOSE FOR WHICH A CORPORATION MAY BE ORGANIZED UNDER THE MINNESOTA NONPROFIT CORPORATION ACT, SECTION 501(C)(4) OF THE INTERNAL REVENUE CODE AND THE MINNESOTA HEALTH MAINTENANCE ACT. 0 0 36422678 38818073 TO PROMOTE SOCIAL WELFARE BY OPERATION OF HEALTH MAINTENANCE ORGANIZATION PROVIDING COMPREHENSIVE HEALTH CARE INSURANCE AND OTHER HEALTH CARE ACTIVITIES FOR OUR MINNESOTA MEMBERS UNDER THE MINNESOTA NONPROFIT CORPORATION ACT, SECTION 501(C)(4) OF THE INTERNAL REVENUE CODE AND THE MINNESOTA HEALTH MAINTENANCE ACT. 36422678 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 1 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 0 0 1 X 224 0 1 0 0 0 0 0 0 0 0 0 X 6 4 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 0 0 0 X JEFFREY A BUTCHER 6084714771 2650 NOVATION PKWY FITCHBURG WI 53713 MARK J SELNA MD PRESIDENT & CEO (TERM. 05/2023) 2.00 48.00 X X 0 893228 57090 CHRISTINE C SENTY GENERAL COUNSEL, VP & SECRETARY 2.00 48.00 X X 0 424642 50635 CHARLES L JOHNSON BOD - MEMBER 1.00 48.00 X 0 0 0 CHRISTINA BRENNAN OTT BOD - MEMBER (AS OF 12/2022) 1.00 48.00 X 0 0 0 KIMILA A DANIELS BOD - MEMBER (TERM. 08/2022) 1.00 0.00 X 0 0 0 ROBERTA J HAUGAN BOD - MEMBER 1.00 0.00 X 0 4500 0 STACEY L MOUNCE ARNOLD BOD - MEMBER 1.00 0.00 X 0 3035 0 JAMES L HIVELEY VP, TREASURER & CFO (TERM. 04/2023) 2.00 48.00 X 0 409308 51051 KRISTIE S BREUNIG ASSISTANT SECRETARY 2.00 48.00 X 0 212153 31422 DAVID S HANEKOM MD SENIOR VP & CHIEF MEDICAL OFFICER 2.00 48.00 X 0 447913 52216 KYLE P BRUA FORMER CHIEF ACTUARY (TERM. 05/2021) 0.00 0.00 X 0 177658 0 0 2572437 242414 0 1 1 0 GUNDERSEN LUTHERAN MEDICAL CENTER PO BOX 4444 LA CROSSE WI 54602 MEDICAL SERVICES 18459412 MEDIMPACT HEALTHCARE SYSTEMS 10181 SCRIPPS GATEWAY COURT SAN DIEGO CA 92131 MEDICAL SERVICES 8839011 WINONA HEALTH SERVICES 855 MANKATO AVE WINONA MN 55987 MEDICAL SERVICES 3878592 GUNDERSEN LUTHERAN HEALTH SYSTEM INC 1900 SOUTH AVE LA CROSSE WI 54601 MEDICAL SERVICES 3784251 OLMSTED MEDICAL CENTER 210 9TH ST SE ROCHESTER MN 55904 MEDICAL SERVICES 2535257 17 PREMIUM REVENUE 524114 38818073 38818073 38818073 84392 84392 38902465 38818073 0 84392 909248 335139 574109 41818 15934 25884 181646 13147 168499 60318 24531 35787 11068 10975 93 9340 9340 60792 1300 59492 57898 57898 51805 605 51200 136818 20295 116523 34231 6075 28156 878793 627723 251070 30810 30810 6937 1140 5797 11583 11583 24352 24352 MEDICAL EXPENSES 35308541 35308541 COMMISSIONS 474991 474991 ASSESSMENT/FEES 464113 464113 LOSS ADJUSTMENT EXPENSE 44137 44137 76931 13136 63795 38876170 36422678 2453492 0 5666934 12593116 10905 0 5551595 4350392 558263 549027 984355 859941 12772052 18352476 3437533 4999920 480300 469475 3677714 4504338 7595547 9973733 X 0 0 4750000 7950000 426505 428743 5176505 8378743 12772052 18352476 X 26295 -8262 3184205 X X 0 1 X 1 0 0 PPACA PAYABLE 4343072 DUE TO QHPC 2622 DUE TO QHS 157036 DUE TO QHBPC 1608 4504338 X 38894203 -8262 -8262 38902465 0 38902465 38894203 18033 18033 38876170 0 38876170 PART X, LINE 2: QUARTZ HEALTH PLAN CORPORATION (QHPC) AND QUARTZ HEALTH PLAN MN CORPORATION (QHPMC) ARE EXEMPT FROM FEDERAL INCOME TAXES PURSUANT TO SECTION 501( C )(4) OF THE INTERNAL REVENUE CODE. QHPC IS SUBJECT TO WISCONSIN STATE FRANCHISE TAX, ILLINOIS INCOME TAX, ILLINOIS RETALIATORY TAX, AND IOWA PREMIUM TAX. QHPMC IS SUBJECT TO MINNESOTA PREMIUM TAX. QUARTZ RECOGNIZES THE FINANCIAL STATEMENT BENEFIT OF A TAX POSITION ONLY AFTER DETERMINING THAT THE RELEVANT TAX AUTHORITY WOULD MORE LIKELY THAN NOT SUSTAIN THE POSITION FOLLOWING AN AUDIT. FOR TAX POSITIONS MEETING THE MORE-LIKELY-THAN-NOT THRESHOLD, THE AMOUNT RECOGNIZED IN THE FINANCIAL STATEMENTS IS THE LARGEST BENEFIT THAT HAS A GREATER THAN 50% LIKELIHOOD OF BEING REALIZED UPON ULTIMATE SETTLEMENT WITH THE RELEVANT TAX AUTHORITY. QUARTZ HAS APPLIED THE UNCERTAIN TAX POSITION GUIDANCE TO ALL TAX POSITIONS FOR WHICH STATUTE OF LIMITATIONS REMAIN OPEN. QUARTZ RECOGNIZES, IF NECESSARY, INTEREST AND PENALTIES RELATED TO INCOME TAXES THAT HAVE BEEN ACCRUED OR RECOGNIZED AS OF AND FOR THE YEARS ENDED DECEMBER 31, 2022 AND 2021. PART XII, LINE 2D - OTHER ADJUSTMENTS: RX REBATE ADJUSTMENT ADDED FOR STAT 15,795. STATE DEFERRED INCOME TAX EXPENSES 2,238. 1 1 0 0 0 0 0 0 0 MARK J SELNA MD PRESIDENT & CEO (TERM. 05/2023) 0 715439 0 174000 0 3789 0 18300 0 38790 0 950318 0 0 DAVID S HANEKOM MD SENIOR VP & CHIEF MEDICAL OFFICER 0 425389 0 18540 0 3984 0 18300 0 33916 0 500129 0 0 CHRISTINE C SENTY GENERAL COUNSEL, VP & SECRETARY 0 340216 0 50896 0 33530 0 18300 0 32335 0 475277 0 0 JAMES L HIVELEY VP, TREASURER & CFO (TERM. 04/2023) 0 327214 0 49310 0 32784 0 18300 0 32751 0 460359 0 0 KRISTIE S BREUNIG ASSISTANT SECRETARY 0 195375 0 16120 0 658 0 11833 0 19589 0 243575 0 0 KYLE P BRUA FORMER CHIEF ACTUARY (TERM. 05/2021) 0 0 0 0 0 177658 0 0 0 0 0 177658 0 0 PART I, LINE 3 QUARTZ HEALTH PLAN MN CORPORATION RELIED ON A RELATED ORGANIZATION, QUARTZ HEALTH SOLUTIONS, INC., THAT USED METHODS DESCRIBED BELOW TO ESTABLISH THE TOP MANAGEMENT OFFICIALS' COMPENSATION. - INDEPENDENT COMPENSATION CONSULTANT - COMPENSATION SURVEY OR STUDY - APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE PART I, LINES 4A-B PART I, LINE 4A: KYLE P. BRUA RECEIVED A $177,658 SERVERANCE PAYMENT IN YEAR 2022. PART I, LINE 4B: QUARTZ HEALTH SOLUTIONS, INC. INITIATED A NONQUALIFIED DEFERRED RETIREMENT PLAN IN 2019 AND STARTED FUNDING IN 2020. A NUMBER OF EMPLOYEES PARTICIPATED IN THE PLAN DURING THE YEAR. THE DEFERRED AMOUNT IS INCLUDED IN PART VII, COLUMN F AND SCHEDULE J, PART II, COLUMN C AND THE VESTED AMOUNT IS INCLUDED IN PART VII, COLUMN D AND SCHEDULE J, PART II, COLUMN B(III). THE TERMS AND CONDITIONS OF THE CONFIDENTIAL AGREEMENTS ARE AVAILABLE TO THE INTERNAL REVENUE SERVICE UPON REQUEST. FORM 990, PART V, LINE 2B: ALL EMPLOYEES ARE LEGAL EMPLOYEES OF QUARTZ HEALTH SOLUTIONS (FEIN: 46-5710709), WHICH FILES ALL REQUIRED FEDERAL EMPLOYMENT FORMS EACH YEAR. FORM 990, PART VI, SECTION A, LINE 6 QUARTZ HEALTH PLAN CORPORATION IS THE SOLE CORPORATE MEMBER OF THIS ORGANIZATION. FORM 990, PART VI, SECTION A, LINE 7A THE SOLE CORPORATE MEMBER, QUARTZ HEALTH PLAN CORPORATION, ELECTS THREE MEMBERS OF THE BOARD OF DIRECTORS. THE REMAINING THREE MEMBERS OF THE BOARD ARE NOMINATED AND ELECTED BY THE ENROLLEES OF THE PLAN. FORM 990, PART VI, SECTION A, LINE 7B GOVERNANCE DECISIONS ARE RESERVED TO THE SOLE CORPORATE MEMBER, QUARTZ HEALTH PLAN CORPORATION. FORM 990, PART VI, SECTION B, LINE 11B THE FORM 990 IS PREPARED BY BAKER TILLY US, LLP AND IS REVIEWED FOR COMPLETENESS AND ACCURACY BY MANAGEMENT. FOR THIS PURPOSE, MANAGEMENT INCLUDES THE CFO FOR QUARTZ HEALTH SOLUTIONS, INC. THE ORGANIZATION INFORMS THE MEMBERS OF THE BOARD FINANCE COMMITTEE THAT A COPY OF FORM 990 IS AVAILABLE FOR REVIEW PRIOR TO FILING WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C ALL BOARD MEMBERS AND OFFICERS MUST REVIEW, COMPLETE, AND SIGN A CONFLICT OF INTEREST DISCLOSURE FORM ON AN ANNUAL BASIS. ALL DISCLOSURES ARE TRACKED AND HOUSED IN THE COMPLIANCE DEPARTMENT. FURTHER, IF AT ANY TIME AN INDIVIDUAL BECOMES AWARE OF AN ACTUAL, POTENTIAL, OR PERCEIVED CONFLICT OF INTEREST, THE POLICY INDICATES THAT THE INDIVIDUAL SHALL IMMEDIATELY NOTIFY THE COMPLIANCE OFFICER WHO THEN REVIEWS ANY DISCLOSED CONFLICTS TO ASSESS ANY RISK AND/OR NEGATIVE INFLUENCE ON THE HEALTH PLAN AND DRAFTS PROPOSED RECOMMENDATIONS TO ANY DISCLOSED CONFLICTS OF INTEREST. THE COMPLIANCE OFFICER THEN PROVIDES THE DISCLOSED CONFLICTS OF INTEREST(S) AND PROPOSED RECOMMENDATION(S) TO A CONFLICT OF INTEREST REVIEW GROUP FOR FINAL REVIEW AND DETERMINATION REGARDING THE RECOMMENDATION. ONCE THE CONFLICT OF INTEREST REVIEW GROUP MAKES ITS FINAL DETERMINATION WITH RESPECT TO THE RECOMMENDATION, THE COMPLIANCE OFFICER SHALL COMMUNICATE THE RECOMMENDATION TO THE EMPLOYEE AND, WHEN APPLICABLE, TO THE CHAIRPERSON OF ANY COMMITTEE WHICH MAY BE REFERENCED IN THE RECOMMENDATION. FORM 990, PART VI, SECTION C, LINE 19 REQUESTS FOR THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS ARE MADE THROUGH THE LEGAL DEPARTMENT WHO THEN REVIEWS THE REQUESTS AND MAKES THE APPROPRIATE DOCUMENTS AVAILABLE FOR INSPECTION IN THE LEGAL DEPARTMENT ITSELF FOR THE SAME PERIOD OF DISCLOSURE AS SET FORTH IN IRC SECTION 6104(D). FORM 990, PART XI, LINE 9: RX REBATE ADJUSTMENT ADDED FOR STAT -15,795. ADDITIONAL PAID IN CAPITAL - QUARTZ HEALTH PLAN CORPORATION 3,200,000. FORM 990, PART XII, LINE 2C: AS OF MAY 2016, THE FILING ORGANIZATION UTILIZES QUARTZ HEALTH PLAN CORPORATION'S AUDIT COMMITTEE. FORM 990, PART X, LINE 33: THE ORGANIZATION HAS PREPARED THE FORM 990 IN ACCORDANCE WITH GENERALLY ACCEPTED ACCOUNTING PRINCIPLES (GAAP), BUT DOES NOT FOLLOW SFAS 117 (ASC 958). THE IRS DOES NOT REQUIRE REPORTING ACCORDING TO ASC 958. QUARTZ HEALTH PLAN CORPORATION 2650 NOVATION PKWY FITCHBURG WI 53713 391807071 HEALTH MAINTENANCE ORGANIZATION WI 501(C)(4) 0 QUARTZ HEALTH BENEFIT PLANS CORPORATION 2650 NOVATION PKWY FITCHBURG WI 53713 391450766 HEALTH MAINTENANCE ORGANIZATION WI N/A C 0 QUARTZ HOLDING COMPANY 2650 NOVATION PKWY FITCHBURG WI 53713 821728929 HOLDING COMPANY WI N/A C 0 QUARTZ HEALTH SOLUTIONS INC 2650 NOVATION PKWY FITCHBURG WI 53713 465710709 TPA WI N/A C 0 QUARTZ HEALTH INSURANCE CORPORATION 2650 NOVATION PKWY FITCHBURG WI 53713 391565691 INDEMNITY CORPORATION WI N/A C 0 0 0 1 0 0 0 0 0 0 0 1 0 1 1 1 1 0 0 0 QUARTZ HEALTH PLAN CORPORATION C 3200000 ADDITIONAL PAID-IN-CAPITAL QUARTZ HEALTH SOLUTIONS INC P 2099360 COST