2022-11-10T10:08:34-06:00 2021-12-31 390859910 BAKER TILLY US LLP 777 E WISCONSIN AVENUE 32ND FLOOR MILWAUKEE WI 53202 990 2021-01-01 452633920 QUARTZ HEALTH PLAN MN CORPORATION QUAR 6084714806 2650 NOVATION PKWY MADISON WI 53713 JIM HIVELEY VP, TREASURER & CFO 6084714806 2022-11-09 1 JIM HIVELEY XXX-XX-XXXX LAWRENCE H MOHR CPA P00447603 4147775500 2022-11-02 3 AAL1 IAL1 2021 2022-09-23 18:48:47Z X MARK SELNA MD 2650 NOVATION PKWY MADISON WI 53713 31014352 0 X WWW.QUARTZBENEFITS.COM X 2011 MN TO PROMOTE SOCIAL WELFARE BY OPERATION OF A HEALTH MAINTENANCE ORGANIZATION AND OTHER ACTIVITIES INCIDENTAL THERETO. 5 2 0 0 0 0 0 0 21587638 30999097 17462 15255 -652 0 21604448 31014352 0 0 0 0 604790 1078527 0 0 0 20453331 29236449 21058121 30314976 546327 699376 8565078 12772052 4095046 7595547 4470032 5176505 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 28358986 30999097 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. 28358986 0 0 0 0 0 0 0 0 0 0 0 0 1 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 213 0 1 0 0 0 0 0 0 0 0 0 X 5 2 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 0 0 0 X JIM HIVELEY 6084714806 2650 NOVATION PKWY MADISON WI 53713 KYLE P BRUA CHIEF ACTUARY (TERM 05/2021) 2.00 48.00 X 0 839843 32264 MARK J SELNA MD PRESIDENT & CEO 2.00 48.00 X X 0 809620 51914 GARY J LENTH MD EVP & CMO (TERM 03/2021) 1.00 48.00 X X 0 752878 16372 CHRISTINE C SENTY GENERAL COUNSEL, VP & SECRETARY 2.00 48.00 X 0 455000 49536 JAMES L HIVELEY VP, TREASURER & CFO 2.00 48.00 X 0 437142 46269 KIMILA A DANIELS BOD - MEMBER 1.00 48.00 X 0 448972 30732 KRISTIE S MEIER ASSISTANT SECRETARY 2.00 48.00 X 0 178620 23049 DAVID S HANEKOM MD SENIOR VP & CHIEF MEDICAL OFFICER 2.00 48.00 X 0 152960 6388 CHARLES L JOHNSON BOD - MEMBER 1.00 48.00 X 0 124418 24172 ROBERTA J HAUGAN BOD - MEMBER 1.00 0.00 X 0 0 0 STACEY L MOUNCE ARNOLD BOD - MEMBER 1.00 0.00 X 0 0 0 0 4199453 280696 0 0 1 0 GUNDERSEN LUTHERAN MEDICAL CENTER PO BOX 4444 LA CROSSE WI 54602 MEDICAL SERVICES 15453355 MEDIMPACT HEALTHCARE SYSTEMS 10181 SCRIPPS GATEWAY COURT SAN DIEGO CA 92131 MEDICAL SERVICES 6225955 GUNDERSEN HEALTH SYSTEM 855 MANKATO AVE WINONA MN 55987 MEDICAL SERVICES 3243840 WINONA HEALTH SERVICES PO BOX 5600 WINONA MN 55987 MEDICAL SERVICES 3212184 OLMSTED MEDICAL CENTER 210 9TH ST SE ROCHESTER MN 55904 MEDICAL SERVICES 2375126 16 PREMIUM REVENUE 524114 30999097 30999097 30999097 15255 15255 31014352 30999097 0 15255 818023 300417 517606 37532 15665 21867 168452 12916 155536 54520 22124 32396 3496 3496 13132 13132 14905 1013 13892 987 987 56273 56273 40600 572 40028 43437 1248 42189 22365 6380 15985 675764 366446 309318 39070 39070 4036 577 3459 1686 1686 15213 15213 MEDICAL EXPENSES 27614641 27614641 COMMISSIONS 347831 347831 ASSESSMENT/FEES 327628 5 327623 LOSS ADJUSTMENT EXPENSE 13486 13486 1899 1899 30314976 28358986 1955990 0 7543287 5666934 148825 10905 451574 5551595 421392 558263 0 984355 8565078 12772052 2193185 3437533 374933 480300 1526928 3677714 4095046 7595547 X 0 0 4750000 4750000 -279968 426505 4470032 5176505 8565078 12772052 X 699376 -1698 8795 X X 0 1 X 1 0 0 STATE INCOME TAX REC 4856 OTHER 1338 INTERCOMPANY RECEIVABLE 16888 REINSURANCE RECEIVABLE 961273 984355 PPACA PAYABLE 3326051 DUE TO QHPC 213308 DUE TO QHS 137535 DUE TO QHBPC 820 3677714 X 31012654 -1698 -1698 31014352 0 31014352 30306181 -8795 -8795 30314976 0 30314976 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 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, 2021 AND 2020. PART XII, LINE 2D - OTHER ADJUSTMENTS: RX REBATE ADJUSTMENT ADDED FOR STAT -8,795. 1 1 0 0 0 0 0 0 0 KYLE P BRUA CHIEF ACTUARY (TERM 05/2021) 0 173759 0 144149 0 521935 0 16126 0 16138 0 872107 0 228375 MARK J SELNA MD PRESIDENT & CEO 0 725000 0 84583 0 37 0 17400 0 34514 0 861534 0 0 GARY J LENTH MD EVP & CMO (TERM 03/2021) 0 95154 0 149653 0 508071 0 11409 0 4963 0 769250 0 118125 CHRISTINE C SENTY GENERAL COUNSEL, VP & SECRETARY 0 336799 0 86388 0 31813 0 23100 0 26436 0 504536 0 0 JAMES L HIVELEY VP, TREASURER & CFO 0 324600 0 82118 0 30424 0 23100 0 23169 0 483411 0 0 KIMILA A DANIELS BOD - MEMBER 0 332440 0 85077 0 31455 0 23100 0 7632 0 479704 0 0 KRISTIE S MEIER ASSISTANT SECRETARY 0 160793 0 17749 0 78 0 13024 0 10025 0 201669 0 0 DAVID S HANEKOM MD SENIOR VP & CHIEF MEDICAL OFFICER 0 95077 0 57883 0 0 0 1902 0 4486 0 159348 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 $293,485 SERVERANCE PAYMENT IN YEAR 2021. GARY J. LENTH RECEIVED A $389,946 SEVERANCE PAYMENT IN YEAR 2021. 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. IN 2021, $228,375 PAID TO KYLE P. BRUA AND $118,125 PAID TO GARY J. LENTH HAD BEEN REPORTED IN 2020 W2 AND FORM 990. 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 TWO 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 8,795. 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. UNIVERSITY HEALTH CARE INC 301 SOUTH WESTFIELD ROAD SUITE 350 MADISON WI 53717 472553196 SUPPORTING ORGANIZATION WI 501(C)(3) LINE 12A, I UNIVERSITY OF WI HOSPITAL AND CLINICS AUTHORITY 0 QUARTZ HEALTH PLAN CORPORATION 840 CAROLINA STREET SAUK CITY WI 53583 391807071 HEALTH MAINTENANCE ORGANIZATION WI 501(C)(4) LINE 4 UNIVERSITY HEALTH CARE INC 0 REGIONAL DIVISION INC 301 SOUTH WESTFIELD ROAD SUITE 320 MADISON WI 53717 391446049 REGIONAL PARENT CORP. TO MANAGE AND DIRECT ACTIVITIES OF ENTITIES WI 501(C)(3) LINE 12A, I UNIVERSITY OF WI HOSPITAL AND CLINICS AUTHORITY 0 SWEDISHAMERICAN HEALTH SYSTEM CORPORATION 1401 EAST STATE STREET ROCKFORD IL 61104 363241458 PARENT CORPORATION TO MANAGE AND DIRECT ACTIVITIES OF ENTITIES IL 501(C)(3) LINE 12A, I REGIONAL DIVISION INC 0 SWEDISHAMERICAN FOUNDATION 1415 EAST STATE STREET ROCKFORD IL 61104 363097493 SUPPORTS FUNDRAISING FOR SWEDISHAMERICAN HOSPITAL IL 501(C)(3) LINE 7 SWEDISHAMERICAN HOSPITAL 0 SWEDISHAMERICAN REALTY CORPORATION 1313 EAST STATE STREET ROCKFORD IL 61104 363248013 TITLE HOLDING COMPANY IL 501(C)(2) LINE 2 SWEDISHAMERICAN HEALTH SYSTEM CORPORATION 0 SWEDISHAMERICAN HOSPITAL SELF INSURANCE TRUST 1401 EAST STATE STREET ROCKFORD IL 61104 366652702 HOSPITAL MALPRACTICE TRUST VT 501(C)(3) LINE 12A, I SWEDISHAMERICAN HOSPITAL 0 WISCONSIN THERAPIES INC 600 HIGHLAND AVENUE MADISON WI 53792 391807425 INFUSION THERAPY WI 501(C)(3) LINE 12D, III-O UNIVERSITY OF WI HOSPITAL AND CLINICS AUTHORITY 0 GENERATIONS FERTILITY CARE 2365 DEMING WAY MIDDLETON WI 53562 273496527 REPRODUCTIVE ENDOCRINOLOGY AND INFERTILITY SERVICES WI 501(C)(3) LINE 10 N/A 0 WISCONSIN DIALYSIS 3034 FISH HATCHERY ROAD FITCHBURG WI 53713 300072647 DIALYSIS SERVICES WI 501(C)(3) LINE 12C, III-FI N/A 0 MADISON SURGERY CENTER 7974 UW HEALTH COURT MIDDLETON WI 53562 391940656 HEALTH CARE SERVICES AND TRAINING WI 501(C)(3) LINE 10 N/A 0 UW HEALTH ACO INC 7974 UW HEALTH COURT MIDDLETON WI 53562 455490584 ACCOUNTABLE CARE ORGANIZATION WI 501(C)(3) LINE 10 UNIVERSITY OF WI HOSPITAL AND CLINICS AUTHORITY 0 SWEDISHAMERICAN HOSPITAL 1401 EAST STATE STREET ROCKFORD IL 61104 362222696 HOSPITAL IL 501(C)(3) LINE 3 SWEDISHAMERICAN HEALTH SYSTEM CORPORATION 0 UNIVERSITY OF WISCONSIN HOSPITALS & CLINICS AUTHORITY 7974 UW HEALTH COURT MIDDLETON WI 53562 391835630 HOSPITAL AND CLINICS WI 501(C)(3) LINE 3 N/A 0 ISTHMUS PROJECT INC 600 HIGHLAND AVENUE MADISON WI 53792 832278676 RESEARCH & INNOVATION WI 501(C)(3) LINE 12A, I UNIVERSITY OF WI HOSPITAL AND CLINICS AUTHORITY 0 UNIVERSITY OF WISCONSIN MEDICAL FOUNDATION 9794 UW HEALTH COURT MIDDLETON WI 53562 391824445 PHYSICIAN SERVICES WI 501(C)(3) LINE 10 UNIVERSITY OF WI HOSPITAL AND CLINICS AUTHORITY 0 CHARTWELL WISCONSIN ENTERPRISES LLC 2241 PINEHURST DRIVE MIDDLETON WI 53562 391796267 PARENT ENTITY OF CMW AND CMW-HR WI N/A 0 0 SIXTH STREET MEDICAL LLC 7974 UW HEALTH COURT MIDDLETON WI 53562 472705724 REAL ESTATE WI N/A 0 0 MADISON MEDICAL CENTER LLP 7974 UW HEALTH COURT MIDDLETON WI 53562 391329429 REAL ESTATE WI N/A 0 0 THREE RIVERS PARTNERS LLC 1313 E STATE STREET ROCKFORD IL 61104 262231757 INFORMATION TECHNOLOGY SERVICES IL N/A 0 0 NORTHERN ILLINOIS VEIN CLINIC 2550 CHARLES STREET ROCKFORD IL 61108 201642329 OUTPATIENT HEALTH SERVICES IL N/A 0 0 HEALTH PROFESSIONALS OF WISCONSIN 301 SOUTH WESTFIELD ROAD MADISON WI 53717 391806711 REAL ESTATE WI N/A C 0 QUARTZ HOLDING COMPANY 840 CAROLINA STREET SAUK CITY WI 53583 821728929 HOLDING COMPANY WI N/A C 0 QUARTZ HEALTH INSURANCE CORPORATION 840 CAROLINA STREET SAUK CITY WI 53583 391565691 INDEMNITY CORPORATION WI N/A C 0 QUARTZ HEALTH SOLUTIONS INC 840 CAROLINA STREET SAUK CITY WI 53583 465710709 TPA WI N/A C 0 QUARTZ HEALTH BENEFIT PLANS CORPORATION 840 CAROLINA STREET SAUK CITY WI 53583 391450766 HEALTH MAINTENANCE ORGANIZATION WI N/A C 0 SARI INSURANCE COMPANY 76 ST PAUL STREET SUITE 500 BURLINGTON VT 054014477 030308753 CAPTIVE INSURANCE COMPANY VT N/A C 0 STATE & CHARLES INC 1313 EAST STATE STREET ROCKFORD IL 61104 363321193 HOLDING COMPANY IL N/A C 0 PHYSICIAN'S CARE NETWORK 1313 EAST STATE STREET ROCKFORD IL 61104 363455791 HEALTH SERVICES IL N/A C 0 SWEDISHAMERICAN HEALTH MANAGEMENT CORP 1401 E STATE STREET ROCKFORD IL 61104 363246511 MANAGEMENT SERVICES IL N/A C 0 0 0 0 0 0 0 0 0 0 0 1 0 1 1 1 1 1 0 0 QUARTZ HEALTH PLAN CORPORATION P 1560762 COST QUARTZ HEALTH BENEFIT PLANS CORPORATION K 10364 COST QUARTZ HEALTH SOLUTIONS INC P 12661 COST