2022-11-15T14:02:49-06:00 2021-12-31 381357951 PLANTE & MORAN PLLC 10 S RIVERSIDE PLAZA 9TH FLOOR CHICAGO IL 60606 990 2021-01-01 270093404 MY CHOICE WISCONSIN HEALTH PLAN INC MYCH 4142877600 10201 WEST INNOVATION DRIVE 100 WAUWATOSA WI 53226 JAMES HODSON CHIEF FINANCIAL OFFICER 4142877600 2022-11-14 1 JAMES HODSON 999009999 DAVID LOWENTHAL P00378651 3122071040 2022-11-14 3 AAL1 IAL1 2021 2022-09-23 18:48:47Z X JAMES HODSON 10201 WEST INNOVATION DRIVE 100 WAUWATOSA WI 53226 206107786 0 X WWW.MYCHOICEWI.ORG X 2004 WI PROMOTE THE QUALITY OF LIFE OF OUR COMMUNITIES BY EMPOWERING OTHERS' LONG TERM CARE NEEDS. 9 9 0 9 0 0 0 0 211437893 198676131 1145207 549832 19656 27617 212602756 199253580 0 0 145307395 164985347 0 0 0 0 0 50924377 29252859 196231772 194238206 16370984 5015374 92657703 94864690 28885709 26734830 63771994 68129860 X MY CHOICE WISCONSIN HEALTH PLAN, INC. IS A NONPROFIT MANAGED CARE ORGANIZATION THAT MATCHES FRAIL SENIORS AND PEOPLE WITH PHYSICAL AND INTELLECTUAL DISABILITIES TO THE HEALTH CARE AND LONG-TERM SUPPORTS AND SERVICES THEY NEED. WE OFFER GOVERNMENT-FUNDED (MEDICARE AND MEDICAID) PROGRAMS AND PARTNER WITH PROVIDERS TO CREATE STRONG, LOCAL PROVIDER NETWORKS. WE ARE DEDICATED TO OUR MISSIONS AND VALUES TO PROMOTE THE QUALITY OF LIFE OF OUR COMMUNITIES BY EMPOWERING OTHERS AND WORKING TOGETHER TO CREATIVELY SOLVE UNIQUE HEALTH AND LONG-TERM CARE NEEDS. 0 0 110520643 121118640 MY CHOICE WISCONSIN HEALTH PLAN, INC (MCWHP) OFFERS THE PARTNERSHIP PROGRAM, WHICH PROVIDES HEALTH AND LONG-TERM MANAGEMENT AND CARE SERVICES TO THE ELDERLY AND ADULTS WITH DISABILITIES. MCWHP'S PARTNERSHIP PROGRAM HAD 1,654 MEMBERS AT THE END OF 2021. 40469696 50211254 MY CHOICE WISCONSIN HEALTH PLAN, INC OFFERS THE MEDICAID BADGERCARE PLUS PROGRAM, A HEALTH INSURANCE PROGRAM FOR PARENTS/CARETAKERS OF DEPENDENT CHILDREN, PREGNANT WOMEN, WISCONSIN CHILDREN, AND CHILDLESS ADULTS THAT MEET CERTAIN INCOME REQUIREMENTS. THE BADGERCARE PLUS PROGRAM HAD 22,993 MEMBERS AT THE END OF 2021. 18110864 17491512 MY CHOICE WISCONSIN HEALTH PLAN, INC OFFERS THE MEDICAID SSI PROGRAM, A HEALTH INSURANCE PROGRAM FOR INDIVIDUALS WHO QUALIFY FOR FEDERAL SSI. THE SSI PROGRAM HAD 3,499 MEMBERS AT THE END OF 2021. 9715116 9854725 MY CHOICE WISCONSIN HEALTH PLAN, INC BEGAN OFFERING A MEDICARE DUAL ADVANTAGE PROGRAM ON JANUARY 1,2017, FOR INDIVIDUALS WHO HAVE BOTH MEDICARE AND MEDICAID. THE MEDICARE DUAL ADVANTAGE PROGRAM HAD 610 MEMBERS AT THE END OF 2021. 9715116 9854725 178816319 1 0 0 1 0 0 0 0 0 0 0 0 0 0 1 0 0 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 0 1 1337 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 X 9 9 0 0 0 0 1 1 1 1 1 0 0 0 1 1 1 1 1 0 0 0 X JAMES HODSON 4142877600 10201 WEST INNOVATION DRIVE STE 100 WAUWATOSA WI 532664822 MARIA LEDGER CHIEF EXECUTIVE OFFICER 19.00 31.00 X 0 614018 12558 JAMES HODSON CHIEF FINANCIAL OFFICER 20.00 30.00 X 0 508245 19911 BETSY VAN HEESCH CHIEF OPERATIONS OFFICER 20.00 25.00 X 0 447176 29485 KEVIN COLLINS CHIEF COMPLIANCE OFFICER 20.00 30.00 X 0 392057 17863 DR ERIC QUIVERS CHIEF MEDICAL OFFICER 45.00 0.00 X 0 314487 22225 BRION BEAUCHENE CHIEF INFORMATION OFFICER 30.00 20.00 X 0 217817 22151 DAVID POELLMANN DIRECTOR ACCOUNTING/FINANCE 10.00 40.00 X 0 193880 30709 NICOLE PAGLIARO DIRECTOR PROVIDER SERVICES 20.00 25.00 X 0 204989 8195 SARAH WAY-MESSER DIRECTOR QUALITY 39.00 6.00 X 0 192167 6959 ANGELA SEIDL VP QUALITY & REGULATORY/COMPLIANCE OFFICER 39.00 6.00 X 0 184209 7386 MELISSA EILBES DIRECTOR NURSING 15.00 30.00 X 0 183475 5946 JEFF WOBIG DIRECTOR CLINICAL & OPS RESOURCES 41.00 4.00 X 0 153051 13818 THOMAS ORENDORFF DIRECTOR AND CHAIR 1.00 3.00 X X 0 2200 0 MICHAEL MAYO SR DIRECTOR AND VICE CHAIR 1.00 2.00 X X 0 2000 0 JOHN HINTZE DIRECTOR 1.00 2.00 X 0 2000 0 LEE S SEESE DIRECTOR 1.00 2.00 X 0 1600 0 MARIA RODRIGUEZ DIRECTOR AND TREASURER 1.00 1.00 X X 0 1200 0 THOMAS BERGERUD DIRECTOR 1.00 1.00 X 0 1200 0 KATHRYN BRIETZMAN DIRECTOR 1.00 1.00 X 0 1000 0 KENNETH BYOM DO DIRECTOR AND SECRETARY 1.00 2.00 X X 0 800 0 LYNDA KRELLWITZ DIRECTOR 1.00 1.00 X 0 800 0 0 3618371 197206 0 0 1 0 UNIVERSITY OF WISCONSIN HOSPITALS AND CL 600 HIGHLAND AVE MADISON WI 53792 MEDICAL SERVICES 13902765 MERITER HOSPITAL INC 202 S PARK ST MADISON WI 53715 MEDICAL SERVICES 7354435 SSM HEALTH CARE OF WISCONSIN INC 10101 WOODFIELD LANE ST LOUIS MO 63132 MEDICAL SERVICES 6644814 FROEDTERT MEMORIAL LUTHERAN HOSPITAL 9200 W WISCONSIN AVE MILWAUKEE WI 53226 MEDICAL SERVICES 4803521 CHILDRENS HOSPITAL OF WISCONSIN 8915 W CONNELL CT MILWAUKEE WI 53226 MEDICAL SERVICES 4540993 268 MEDICARE/MEDICAID REVENUE 624100 183100868 183100868 MEMBER REVENUE 624100 8955238 8955238 PREMIUM REVENUE 624100 3354136 3354136 MEDICARE/MEDICAID ADJUSTMENTS 624100 3265889 3265889 198676131 763852 763852 6640186 6854206 -214020 -214020 -214020 TAX REFUND 900099 27617 27617 27617 199253580 198676131 0 577449 164985347 164985347 146005 146005 38952 38952 66429 66429 8139000 310545 7828455 93986 15076 78910 296550 296550 189355 189355 82342 80651 1691 12875 11642 1233 332112 332112 8435 8435 ALLOCATED ADMINISTRATIO 18502131 12703853 5798278 INCOME TAXES 617937 617937 BAD DEBT EXPENSE 498101 498101 LICENSE & REGISTRATION 163271 21749 141522 65378 65378 194238206 178816319 15421887 0 0 168959 37346806 51887164 7790921 9021405 867661 962361 43418650 29923248 3233665 2901553 92657703 94864690 28779083 26691830 63626 0 43000 43000 28885709 26734830 X 63771994 68129860 63771994 68129860 92657703 94864690 5015374 -657508 0 X 0 1 X 1 0 X 132638298 154735248 154656258 211437893 198676131 852143828 132638298 154735248 154656258 211437893 198676131 852143828 0 0 0 852143828 688880 929297 1417787 1109523 763852 4909339 688880 929297 1417787 1109523 763852 4909339 4073130 19656 27617 4120403 133327178 159737675 156074045 212567072 199467600 861173570 0.98950 0.98890 0.00570 0.00590 X SCHEDULE A, PART III, LINE 12, EXPLANATION OF OTHER INCOME: CLOSE OUT PYMT FROM CLSD PLAN - 2018 AMOUNT: $ 4,073,130. TAX REFUND - 2020 AMOUNT: $ 19,656. 2021 AMOUNT: $ 27,617. 0 0 0 0 0 0 0 0 1 38952 38952 0 LOBBYING ACTIVITIES B (SCHEDULE C, PART II-B SNP ALLIANCE ($24,432) REPRESENTS SNP MEMBERS AND THE UNIQUE NEEDS OF SNP MEMBERS; AND THE WISCONSIN ASSOCIATION OF HEALTH PLANS ($14,520) REPRESENTS COMMUNITY HEALTH PLANS IN WISCONSIN; THESE AMOUNTS INCLUDE THE LOBBY PORTION OF DUES TO SNP ALLIANCE AND THE WISCONSIN ASSOCIATION OF HEALTH PLANS. 0 NET DEFERRED TAX LIABILITY 43000 43000 0 0 0 0 0 0 0 0 0 MARIA LEDGER CHIEF EXECUTIVE OFFICER 0 614018 0 0 0 0 0 11980 0 578 0 626576 0 0 JAMES HODSON CHIEF FINANCIAL OFFICER 0 508245 0 0 0 0 0 11888 0 8023 0 528156 0 0 BETSY VAN HEESCH CHIEF OPERATIONS OFFICER 0 447176 0 0 0 0 0 5628 0 23857 0 476661 0 0 KEVIN COLLINS CHIEF COMPLIANCE OFFICER 0 392057 0 0 0 0 0 9840 0 8023 0 409920 0 0 DR ERIC QUIVERS CHIEF MEDICAL OFFICER 0 314487 0 0 0 0 0 11600 0 10625 0 336712 0 0 BRION BEAUCHENE CHIEF INFORMATION OFFICER 0 217817 0 0 0 0 0 7028 0 15123 0 239968 0 0 DAVID POELLMANN DIRECTOR ACCOUNTING/FINANCE 0 193880 0 0 0 0 0 6852 0 23857 0 224589 0 0 NICOLE PAGLIARO DIRECTOR PROVIDER SERVICES 0 204989 0 0 0 0 0 8195 0 0 0 213184 0 0 SARAH WAY-MESSER DIRECTOR QUALITY 0 192167 0 0 0 0 0 6959 0 0 0 199126 0 0 ANGELA SEIDL VP QUALITY & REGULATORY/COMPLIANCE O 0 184209 0 0 0 0 0 7002 0 384 0 191595 0 0 MELISSA EILBES DIRECTOR NURSING 0 183475 0 0 0 0 0 5946 0 0 0 189421 0 0 JEFF WOBIG DIRECTOR CLINICAL & OPS RESOURCES 0 153051 0 0 0 0 0 5770 0 8048 0 166869 0 0 PART I, LINE 3 THE CEO/EXECUTIVE DIRECTOR IS PAID BY A RELATED ORGANIZATION, MY CHOICE WISCONSIN, INC., WHICH USES THE FOLLOWING METHODS TO DETERMINE COMPENSATION: (1) COMPENSATION COMMITTEE (2) COMPENSATION SURVEY OR STUDY AND (3) APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE FORM 990, PART VI, SECTION A, LINE 6 MY CHOICE WISCONSIN, INC. A WISCONSIN NONPROFIT 501(C)(3) CORPORATION IS THE SOLE MEMBER OF THE ORGANIZATION. FORM 990, PART VI, SECTION A, LINE 7A EACH YEAR AT ITS ANNUAL MEETING, MY CHOICE WISCONSIN, INC., AS THE SOLE MEMBER OF THE ORGANIZATION, SHALL ELECT THE DIRECTORS ACCORDING TO THE ORGANIZATION'S BYLAWS. FORM 990, PART VI, SECTION A, LINE 7B THE FOLLOWING ACTIONS REQUIRE THE PRIOR AUTHORIZATION OR APPROVAL OF MY CHOICE WISCONSIN, INC. AS ITS SOLE MEMBER: A. MERGER, CONVERSION INTO A STOCK OR MUTUAL CORPORATION, OR VOLUNTARY DISSOLUTION OF THE CORPORATION; B. AMENDMENT OR RESTATEMENT OF THE ARTICLES OF INCORPORATION OF THE CORPORATION OR OF THE BYLAWS, EXCEPT AS PROVIDED IN ARTICLE XIII; C. A TRANSFER OR OTHER DISPOSITION OF ALL, OR SUBSTANTIALLY ALL, THE PROPERTY AND ASSETS OF THE CORPORATION; OR, D. THE ESTABLISHMENT, FORMATION, ACQUISITION, MERGER, CONSOLIDATION OR DISSOLUTION OF ANY SUBSIDIARY CORPORATION OF THE CORPORATION. E. ANY ACTION THAT WOULD AFFECT THE TAX-EXEMPT STATUS OF EITHER THE CORPORATION OR THE VOTING MEMBER. F. ACTION ON ANY MATTER THAT IS DETERMINED TO BE UNDER THE CONTROL OF THE VOTING MEMBER UNDER THE ARTICLES OF INCORPORATION, THE BYLAWS, OR CHAPTER 613 OF THE WISCONSIN STATUTES. FORM 990, PART VI, SECTION B, LINE 11B THE CHIEF FINANCIAL OFFICER PERFORMS AN EXTENSIVE REVIEW PRIOR TO FILING THE FORM 990 WITH THE INTERNAL REVENUE SERVICE. THE FORM IS MADE AVAILABLE TO THE MEMBERS OF THE BOARD AFTER FILING WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C THE ORGANIZATION HAS A CONFLICT OF INTEREST POLICY FOR INTERESTED PERSONS THAT ADDRESSES TRANSACTIONS BETWEEN THE ORGANIZATION AND ANY CURRENT OR FORMER OFFICERS, DIRECTORS, COMMITTEE MEMBERS, KEY EMPLOYEE, STAFF MEMBERS, ANY PERSON IN A POSITION TO EXERCISE SUBSTANTIAL INFLUENCE OVER THE AFFAIRS OF THE ORGANIZATION, FAMILY MEMBERS, AND OTHER RELATED ENTITIES. CONFLICTS DISCLOSED ARE ADDRESSED IN ACCORDANCE WITH POLICY SUMMARIZED BELOW. IF AN INTERESTED PERSON HAS ANY ACTUAL OR POTENTIAL CONFLICTS OF INTEREST, THAT INTERESTED PERSON SHALL NOTIFY THE BOARD CHAIR OF SUCH CONFLICT IN WRITING, OR IN THE CASE OF A COMMITTEE MEMBER, THE COMMITTEE CHAIR. THE INTERESTED PERSON MUST DISCLOSE THE EXISTENCE OF HIS OR HER FINANCIAL INTEREST AND MUST BE GIVEN THE OPPORTUNITY TO DISCLOSE ALL MATERIAL FACTS TO THE DIRECTORS OR MEMBERS OF A COMMITTEE WITH BOARD DELEGATED POWERS, WHO ARE CONSIDERING THE PROPOSED MATTER THAT PRESENTS THE POTENTIAL CONFLICT. IF ANY STAFF MEMBER HAS ANY ACTUAL OR POSSIBLE CONFLICTS OF INTEREST, HE/SHE SHALL NOTIFY THE CHIEF EXECUTIVE OFFICER OF SUCH CONFLICT IN THE CONTEXT OF HER/HIS SUPERVISORY ROLE OR SHALL HAVE THE DISCRETION TO REFER THE MATTER TO THE BOARD. IF THE BOARD OR COMMITTEE DECIDES A CONFLICT OF INTEREST EXISTS, THE FOLLOWING PROCEDURES SHALL APPLY: 1. AN INTERESTED PERSON MAY MAKE A PRESENTATION AT THE BOARD OR COMMITTEE MEETING, BUT AFTER SUCH PRESENTATION, HE/SHE SHALL LEAVE THE MEETING DURING THE DISCUSSION OF, AND THE VOTE ON, THE TRANSACTION OR ARRANGEMENT THAT RESULTS IN THE CONFLICT OF INTEREST. 2. IF THE CONFLICT IS NOT RESOLVED BY RECUSAL OF THE INTERESTED PERSON, THE CHAIRPERSON OF THE BOARD OR COMMITTEE SHALL, IF APPROPRIATE, APPOINT A DISINTERESTED PERSON OR COMMITTEE TO INVESTIGATE ALTERNATIVES TO THE PROPOSED TRANSACTION OR ARRANGEMENT, IF APPLICABLE. AFTER EXERCISING DUE DILIGENCE, THE BOARD OR COMMITTEE SHALL DETERMINE WHETHER THE CORPORATION CAN OBTAIN A MORE ADVANTAGEOUS TRANSACTION OR ARRANGEMENT WITH REASONABLE EFFORTS FROM A PERSON OR ENTITY THAT WOULD NOT GIVE RISE TO A CONFLICT OF INTEREST. 3. IF A MORE ADVANTAGEOUS TRANSACTION OR ARRANGEMENT IS NOT REASONABLY ATTAINABLE UNDER CIRCUMSTANCES THAT WOULD NOT GIVE RISE TO A CONFLICT OF INTEREST, THE BOARD OF COMMITTEE SHALL DETERMINE BY A MAJORITY VOTE OF THE DISINTERESTED WHETHER THE TRANSACTION OR ARRANGEMENT IS IN THE CORPORATION'S BEST INTEREST AND FOR ITS OWN BENEFIT AND WHETHER THE TRANSACTION IS FAIR AND REASONABLE TO THE CORPORATION AND SHALL MAKE ITS DECISION AS TO WHETHER TO ENTER INTO THE TRANSACTION OR ARRANGEMENT IN CONFORMITY WITH SUCH DETERMINATION. ALL CONFLICT OF INTEREST DETERMINATIONS WILL BE REFLECTED IN THE MINUTES OF THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION B, LINE 15 ALL WAGES ARE PAID BY MY CHOICE WISCONSIN, INC. WHICH IS THEN REIMBURSED BY MY CHOICE WISCONSIN HEALTH PLAN, INC. THE FOLLOWING DESCRIBES HOW MY CHOICE WISCONSIN, INC. DETERMINES ITS SALARY AND WAGES FOR THE EXECUTIVE TEAM. A CONSULTANT HELPS WITH REVIEWING THE MARKET DATA FROM SIMILAR ORGANIZATION FOR DETERMINING THE APPROPRIATE PAY RANGES AND PAY RATES FOR THE INCUMBENTS. THE CONSULTANT WILL MAKE THE RECOMMENDATION FOR THE COMPENSATION FOR THE CEO, FOR THE EXECUTIVE TEAM MEMBERS, WHO THEN REVIEWS AND APPROVES FOR THE CEO'S COMPENSATION. THE BOARD RECEIVES THE RECOMMENDATION FROM THE CONSULTANT AND WILL REVIEW AND APPROVE. FORM 990, PART VI, SECTION C, LINE 19 GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE NOT MADE AVAILABLE TO THE PUBLIC. SUMMARY FINANCIAL INFORMATION IS AVAILABLE ON THE STATE OF WISCONSIN DEPARTMENT OF HEALTH SERVICES WEBSITE. MY CHOICE WISCONSIN INC 10201 WEST INNOVATION DR STE 100 WAUWATOSA WI 532264822 811970070 CARE MGMT WI 501(C)(3) LINE 10 N/A 0 MY CHOICE FOUNDATION HOLDINGS INC 10201 WEST INNOVATION DR STE 100 WAUWATOSA WI 532264822 871303591 SUPPORTING ORG WI 501(C)(3) LINE 12A, I N/A 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 0 MY CHOICE WISCONSIN INC P 18502131 COST