2021-11-12T11:53:30-06:00 2020-12-31 390859910 BAKER TILLY US LLP 777 E WISCONSIN AVENUE 32ND FLOOR MILWAUKEE WI 53202 990 2020-01-01 391807071 QUARTZ HEALTH PLAN CORPORATION QUAR 6084714806 840 CAROLINA STREET SAUK CITY WI 535831374 JIM HIVELEY VP, TREASURER & CFO 6084714806 2021-11-11 1 JIM HIVELEY XXX-XX-XXXX LAWRENCE H MOHR CPA P00447603 4147775500 2021-11-09 X 2 AAL1 IAL1 2020 2022-09-23 18:48:47Z MARK SELNA MD 840 CAROLINA STREET SAUK CITY WI 535831374 280837276 0 X WWW.QUARTZBENEFITS.COM X 1995 WI TO PROMOTE SOCIAL WELFARE BY OPERATION OF A HEALTH MAINTENANCE ORGANIZATION AND OTHER ACTIVITIES INCIDENTAL THERETO. 10 5 0 1 0 0 0 0 251784977 280569952 788890 267324 0 0 252573867 280837276 0 0 0 0 10037509 9814652 0 0 0 242345123 262169148 252382632 271983800 191235 8853476 55635092 75250286 34638187 48576811 20996905 26673475 TO PROMOTE SOCIAL WELFARE BY OPERATION OF A HEALTH MAINTENANCE ORGANIZATION AND OTHER ACTIVITIES INCIDENTAL THERETO. 0 0 255047050 280569952 PROVISION OF HEALTH CARE SERVICES PROVIDED FOR 66,816 MEMBERS. 255047050 0 0 0 0 0 0 0 0 0 0 0 1 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 1 1 0 1 X 1084 0 1 0 0 0 0 0 0 0 0 0 X 10 5 1 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 0 0 0 X JIM HIVELEY 6084714806 840 CAROLINA STREET SAUK CITY WI 535831374 ALAN S KAPLAN MD BOD - MEMBER 2.00 48.00 X 0 2722677 99030 TERRY R BOLZ PRESIDENT/CEO (THROUGH 07/2020) 2.00 48.00 X 0 1119329 58301 ROBERT W FLANNERY BOD - CHAIRMAN 2.00 48.00 X 0 947493 64848 MICHAEL E DALLMAN BOD - MEMBER 2.00 48.00 X 0 859598 93792 KYLE P BRUA CHIEF ACTUARY 2.00 48.00 X 0 625743 175872 GARY J LENTH MD EVP & CMO 2.00 48.00 X 0 641941 157600 MICHAEL J DOLAN MD BOD - MEMBER 2.00 48.00 X 0 621044 31938 CHRISTINE C SENTY GENERAL COUNSEL, VP & SECRETARY 2.00 48.00 X 0 480479 137393 JAMES L HIVELEY VP, TREASURER & CFO 2.00 48.00 X 0 430430 125706 WILLIAM J FARRELL BOD - MEMBER 2.00 48.00 X 0 397105 54 MARK J SELNA MD PRESIDENT & CEO (EFF. 08/2020) 2.00 48.00 X 0 331513 13995 KRISTIE S MEIER ASSISTANT SECRETARY 2.00 48.00 X 0 184597 23705 GERALD E ARNDT BOD - MEMBER 2.00 0.00 X 0 26203 0 GERALD R KEMBER BOD - MEMBER 2.00 0.00 X 0 18930 0 VIRGINIA L GRAVES BOD - MEMBER 2.00 0.00 X 0 13769 0 HEIDI M EGLASH BOD - MEMBER 2.00 0.00 X 0 10809 0 KEVIN R HAUSER BOD - MEMBER 2.00 0.00 X 0 10146 0 JAMES A FALCK BOD - MEMBER (TERM. 2020) 2.00 0.00 X 0 0 0 0 9441806 982234 0 0 1 0 GUNDERSEN LUTHERAN MEDICAL CENTER 1910 SOUTH AVENUE LA CROSSE WI 54601 MEDICAL SERVICES 105821719 UW HOSPITALS & CLINICS AUTHORITY 7974 UW HEALTH COURT MIDDLETON WI 53562 MEDICAL SERVICES 37787182 MEDIMPACT HEALTHCARE SYSTEMS 10181 SCRIPPS GATEWAY COURT SAN DIEGO CA 92131 MEDICAL SERVICES 30180839 VERNON MEMORIAL HEALTHCARE 507 S MAIN STREET VIROQUA WI 54665 MEDICAL SERVICES 13711292 MERITER HOSPITAL INC 202 S PARK ST MADISON WI 53715 MEDICAL SERVICES 11092012 114 PREMIUM REVENUE 524114 280569952 280569952 280569952 267324 267324 280837276 280569952 0 267324 6865140 2583382 4281758 451723 127523 324200 2021965 33315 1988650 475824 196628 279196 53625 12665 40960 73065 73065 384750 22317 362433 8787 8787 279228 279228 2780171 14389 2765782 987380 93021 894359 500047 74579 425468 353897 353897 58369 5836 52533 14992 14992 120122 65 120057 MEDICAL EXPENSES 249215852 249215852 OUTSOURCED SERVICES 6505243 2422473 4082770 COMMISSIONS 661022 661022 NON-INCOME STATE TAX BE -143778 -143778 316376 245005 71371 271983800 255047050 16936750 0 4359355 55147535 24878863 730800 14850464 6580932 7477668 7568399 3830107 4469668 238635 752952 55635092 75250286 4464828 20453993 640467 613018 29532892 27509800 34638187 48576811 X 0 0 14409750 19409750 6587155 7263725 20996905 26673475 55635092 75250286 X 8853476 173027 -3349933 X 0 1 X 1 0 0 INVESTMENT IN SUBSIDIARY 4469668 C 4469668 CLAIMS PAYABLE 26649573 DEFERRED TAX LIABILITY 14176 DUE TO QHPMC 11064 DUE TO QHIC 680 DUE TO QHS 833916 DUE TO QHBPC 391 27509800 X 281541740 173027 546327 719354 280822386 14890 14890 280837276 271968910 0 271968910 14890 14890 271983800 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, 2020 AND 2019. PART XI, LINE 2D - OTHER ADJUSTMENTS: GAIN IN SUBSIDIARY EQUITY 546,327. 0 1 0 0 0 0 0 0 0 ALAN S KAPLAN MD BOD - MEMBER 0 1641092 0 1075540 0 6045 0 51962 0 47068 0 2821707 0 0 TERRY R BOLZ PRESIDENT/CEO (THROUGH 07/2020) 0 676662 0 434277 0 8390 0 0 0 58301 0 1177630 0 0 ROBERT W FLANNERY BOD - CHAIRMAN 0 737908 0 207014 0 2571 0 0 0 64848 0 1012341 0 0 MICHAEL E DALLMAN BOD - MEMBER 0 541308 0 320954 0 -2664 0 50921 0 42871 0 953390 0 0 KYLE P BRUA CHIEF ACTUARY 0 410881 0 130162 0 84700 0 146853 0 29019 0 801615 0 0 GARY J LENTH MD EVP & CMO 0 471894 0 123585 0 46462 0 137625 0 19975 0 799541 0 0 MICHAEL J DOLAN MD BOD - MEMBER 0 486291 0 522 0 134231 0 11400 0 20538 0 652982 0 0 CHRISTINE C SENTY GENERAL COUNSEL, VP & SECRETARY 0 292255 0 82058 0 106166 0 109511 0 27882 0 617872 0 0 JAMES L HIVELEY VP, TREASURER & CFO 0 270221 0 74781 0 85428 0 104795 0 20911 0 556136 0 0 WILLIAM J FARRELL BOD - MEMBER 0 324728 0 22 0 72355 0 0 0 54 0 397159 0 0 MARK J SELNA MD PRESIDENT & CEO (EFF. 08/2020) 0 214977 0 0 0 116536 0 6692 0 7303 0 345508 0 0 KRISTIE S MEIER ASSISTANT SECRETARY 0 143073 0 16559 0 24965 0 14193 0 9512 0 208302 0 0 PART I, LINE 3 QUARTZ HEALTH PLAN 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, 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 2 MICHAEL DALLMAN, MICHAEL J. DOLAN, ROBERT W. FLANNERY, WILLIAM J. FARRELL AND ALAN S. KAPLAN HAVE A BUSINESS RELATIONSHIP OUTSIDE OF THE ORGANIZATION. FORM 990, PART VI, SECTION A, LINE 6 GUNDERSEN HEALTH SYSTEM, INC., UNITYPOINT HEALTH (IOWA HEALTH SYSTEM), UNIVERSITY HEALTH CARE, INC., AND AURORA HEALTH CARE ARE THE CORPORATE MEMBERS. FORM 990, PART VI, SECTION A, LINE 7A UNIVERSITY HEALTH CARE, INC. AND GUNDERSEN HEALTH SYSTEM, INC. SHALL EACH APPOINT THREE MEMBERS OF THE BOARD OF DIRECTORS. UNITYPOINT HEALTH (IOWA HEALTH SYSTEM) WILL APPOINT TWO MEMBERS OF THE BOARD OF DIRECTORS. THE REMAINING THREE INDEPENDENT INDIVIDUAL MEMBERS OF THE BOARD ARE ELECTED BY THE BOARD BY A SUPERMAJORITY. FORM 990, PART VI, SECTION A, LINE 7B SOME GOVERNANCE DECISIONS ARE RESERVED TO THE CORPORATE MEMBERS AND NOT THE BOARD. 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 HEALTH PLAN EMPLOYEES AND COMMITTEE MEMBERS MUST REVIEW, COMPLETE, AND SIGN A CONFLICT OF INTEREST DISCLOSURE FORM ON AN ANNUAL BASIS AS PART OF THE MANDATORY EDUCATION PROCESS. BOARD MEMBERS ARE ALSO SENT A DISCLOSURE FORM TO COMPLETE ON AN ANNUAL BASIS ALONG WITH THE EMPLOYEES AND COMMITTEE MEMBERS. 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: GAIN IN SUBSIDIARY EQUITY 546,327. CAPITAL CONTRIBUTION-AURORA HEALTH CARE 5,000,000. DIVIDEND DISTRIBUTION TO GUNDERSEN HEALTH SYSTEM -8,896,260. 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 MN CORPORATION 840 CAROLINA STREET SAUK CITY WI 53583 452633920 HEALTH INSURANCE MN 501(C)(4) QUARTZ HEALTH PLAN CORPORATION 1 REGIONAL DIVISION INC 301 SOUTH WESTFIELD ROAD SUITE 320 MADISON WI 53717 391446049 REGIONAL PARENT CORP. 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