2020-05-29T09:25:07-05:00 2019-12-31 450250958 EIDE BAILLY LLP 200 E 10TH ST STE 500 SIOUX FALLS SD 571046375 990 2019-01-01 460309258 DELTA DENTAL OF SOUTH DAKOTA DELT 6052247345 PO BOX 1157 PIERRE SD 57501 SCOTT JONES PRESIDENT & CEO 6052247345 2020-05-01 1 LAURIE HANSON P00851848 6053391999 2020-05-01 67.130.171.59 2020-05-01 13:58:24 CD P DA39A3EE5E6B4B0D3255BFEF95601890AFD80709 F7BA031C655DF5D2BE7843B8A6CBF62E51E7FB61 2019 2020-04-17 16:48:07Z SCOTT JONES PO BOX 1157 PIERRE SD 57501 96042765 0 X WWW.DELTADENTALSD.COM X 1963 SD DEDICATED TO ADVANCING AND PROMOTING THE IMPROVEMENT OF ORAL HEALTH. 15 7 95 0 2706170 0 0 0 167630090 78548655 1860991 1929412 2668916 2585178 172159997 83063245 3203840 3324874 0 0 7234934 7376934 0 0 0 159201099 70650386 169639873 81352194 2520124 1711051 49960510 51433670 9440024 7210990 40520486 44222680 DELTA DENTAL OF SOUTH DAKOTA IS DEDICATED TO ADVANCING AND PROMOTING THE IMPROVEMENT OF ORAL HEALTH. 0 0 71621098 3324874 78548655 DELTA DENTAL PAID THROUGH ITS CONTRACTS WITH INDEPENDENT DENTISTS 660,004 CLAIMS FOR DENTAL BENEFIT SERVICES FOR APPROXIMATELY 311,833 INDIVIDUALS WITH GROUP PLANS, 1,345 INDIVIDUALS WITH DENTAL ACCIDENT PLANS, 110,309 SOUTH DAKOTA MEDICAID RECIPIENTS, AND 95,000 NATIVE AMERICANS UNDER ABERDEEN AREA HEALTH SERVICES. DELTA DENTAL ALSO GRANTED THE DELTA DENTAL OF SOUTH DAKOTA FOUNDATION, A 501(C)(3) CHARITABLE ORGANIZATION, $3,075,077 PLUS $35,000 OF IN KIND DENTAL SERVICES TO PROMOTE THE IMPROVEMENT OF ORAL HEALTH. 71621098 0 0 0 0 0 0 0 0 0 1 1 0 0 1 1 1 0 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 1 0 0 0 0 0 1 1 1 0 1 4704 0 1 95 1 1 1 0 0 0 0 0 1 0 X 15 7 1 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 X KIRBY SCOTT 6052247345 720 N EUCLID AVE PIERRE SD 57501 PAUL REZICH DDS CHAIR 2.00 1.00 X X 14924 0 0 MONTY BECHTOLD DDS VICE CHAIR 1.00 1.00 X X 11868 0 0 GREG GERTSEN DDS SECRETARY 1.00 0.00 X X 9850 44100 0 JOHN CLAUSEN CPA TREASURER 2.00 1.00 X X 15100 0 0 STEVE CULHANE DIRECTOR 1.00 0.00 X 9850 0 0 JEFF FEIOCK DDS DIRECTOR 1.00 0.00 X 8825 0 0 G VERNE GOODSELL DIRECTOR 1.00 0.00 X 11000 0 0 GREG HANSON DDS DIRECTOR 1.00 0.00 X 9750 24700 0 JASON AANENSON DDS DIRECTOR 1.00 0.00 X 7250 0 0 ELLEN LEE DIRECTOR 1.00 1.00 X 9750 0 0 ANLEE ROLA DDS DIRECTOR 1.00 1.00 X 9750 3000 0 THANE CRUMP DDS DIRECTOR 1.00 1.00 X 7500 0 0 THOMAS HUBER MD DIRECTOR 1.00 0.00 X 8500 0 0 CHRIS MAXWELL DIRECTOR 1.00 0.00 X 15100 0 0 TOM SIMMONS DIRECTOR 1.00 0.00 X 9750 0 0 SCOTT JONES PRESIDENT & CEO 40.00 1.00 X 1390564 0 51215 KIRBY SCOTT VP OF FINANCE/CFO 40.00 1.00 X 211594 0 37573 EUGENE TETZLAFF VP OF IT 40.00 1.00 X 200203 0 43829 MICK HECKENLAIBLE VP OF OPERATIONS 40.00 1.00 X 206811 0 40946 JEFF MILLER EXECUTIVE DIRECTOR 40.00 1.00 X 233256 0 50497 CONNIE HALVERSON VP OF PUBLIC RELATIONS 10.00 30.00 X 163013 0 47536 JEFF HEPPNER DIRECTOR OF MODERNIZATION & DEV 40.00 0.00 X 136284 0 41920 GEORGE ALLEN DATA ANALYST 40.00 0.00 X 121982 0 20038 SARA GREEN UNDERWRITING ANALYST 40.00 0.00 X 123885 0 24578 LORI HALL DIRECTOR OF CLAIMS PROCESS 40.00 0.00 X 113139 0 20234 JAMEY HERR SYSTEM NETWORK ADMINISTRATOR 40.00 0.00 X 114700 0 29043 3174198 71800 407409 14 0 1 0 MIDWEST BENEFITS PO BOX 10481 DES MOINES IA 50306 COMMISSIONS 200000 EIDE BAILLY LLP PO BOX 5125 SIOUX FALLS SD 57117 PROFESSIONAL SERVICES 123467 2 PREMIUM EARNED 812900 78548655 78548655 78548655 1561412 1561412 38700 159692 -120992 -120992 -120992 13187828 12819828 368000 368000 368000 MANAGEMENT FEE INCOME 541610 2706170 2706170 2706170 83063245 78548655 2706170 1808420 3324874 3324874 2733245 2733245 1955343 1955343 1318478 1318478 1037625 1037625 332243 332243 2391 2391 85040 85040 72802 72802 260171 260171 315562 315562 731681 731681 176405 176405 89890 89890 107666 107666 324902 324902 276986 276986 130296 130296 ALLOCATED CLAIMS ADJUST 0 3817190 -3817190 CLAIMS INCURRED 63168519 63168519 MANAGEMENT SERVICE EXPE 2242555 2242555 COMMISIONS 1310515 1310515 1355005 1355005 81352194 71621098 9731096 0 3340 108321 7760758 5764441 6780664 7195928 220180 218981 7848597 4073494 4037197 3775103 30661999 26161015 242804 7950799 253568 259082 49960510 51433670 3962100 3978249 5477924 3232741 9440024 7210990 X 40520486 44222680 0 0 0 0 40520486 44222680 49960510 51433670 1711051 1991143 0 X 0 1 X 1 0 397371 397371 5030487 1973163 3057324 2420739 2100331 320408 3775103 INVESTMENT IN ARMATA 5000000 C INVESTMENT IN LINK DDS 2950799 C 7950799 UNPAID CLAIMS AND CLAIMS INCURRED BUT NOT REPORTED 1858000 UNPAID CLAIMS ADJUSTMENT EXPENSES 185800 COST PLUS GROUP DEPOSITS 74100 DEFERRED PREMIUMS 1114841 3232741 X 82933723 1991143 35000 -2242555 -216412 83150135 72802 -159692 -86890 83063245 79231529 35000 159692 194692 79036837 72802 2242555 2315357 81352194 PART X, LINE 2: THE COMPANY HAS BEEN DETERMINED TO BE EXEMPT FROM FEDERAL INCOME TAX UNDER SECTION 501(C)(4) OF THE INTERNAL REVENUE CODE, EXCEPT FOR UNRELATED BUSINESS INCOME. ACCOUNTING STANDARDS PRESCRIBE A RECOGNITION THRESHOLD OF MORE LIKELY THAN NOT, AND A MEASUREMENT ATTRIBUTE FOR ALL TAX POSITIONS TAKEN OR EXPECTED TO BE TAKEN ON A TAX RETURN, IN ORDER FOR THOSE TAX POSITIONS TO BE RECOGNIZED IN THE FINANCIAL STATEMENTS. AT DECEMBER 31, 2019 AND 2018 THE COMPANY BELIEVES THAT THERE ARE NO UNCERTAIN TAX POSITIONS OR LIABILITIES, OR INTEREST AND PENALTIES ASSOCIATED WITH UNCERTAIN TAX POSITIONS. IF THE COMPANY HAD INTEREST AND PENALTIES RELATED TO UNCERTAIN TAX POSITIONS, IT WOULD BE ACCOUNTED FOR AS A COMPONENT OF INCOME TAX EXPENSE. PART XI, LINE 2D - OTHER ADJUSTMENTS: ADMINISTRATION SERVICE EXPENSES RECLASSIFIED FOR 990 -2,242,555. PART XI, LINE 4B - OTHER ADJUSTMENTS: RENTAL EXPENSES RECLASSIFIED TO REVENUE FOR 990 -159,692. PART XII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES RECLASSIFIED TO REVENUE FOR 990 159,692. PART XII, LINE 4B - OTHER ADJUSTMENTS: ADMINISTRATION SERVICE EXPENSES RECLASSIFIED FOR 990 2,242,555. 0 DELTA DENTAL OF SOUTH DAKOTA FOUNDATION 804 NORTH EUCLID SUITE 1 PIERRE SD 57501 911776857 501(C)(3) 3075077 PROMOTE DENTAL HEALTH IN SOUTH DAKOTA CAPITAL AREA UNITED WAY 221 SOUTH CENTRAL AVE PIERRE SD 57501 460403398 501(C)(3) 66905 DISTRIBUTING CHARITABLE DONATIONS AVERA HEALTH 3900 WEST AVERA DRIVE SIOUX FALLS SD 57108 460422673 501(C)(3) 50275 CANCER CENTER IN PIERRE, SD. CAPITAL AREA COUNSELING 19 E MAIN ST FT PIERRE SD 57501 460305571 501(C)(3) 58600 PROGRAM SUPPORT OAHE YMCA 900 E CHURCH PIERRE SD 57501 237139291 501(C)(3) 52000 PROGRAM SUPPORT USD FOUNDATION 1110 N DAKOTA VERMILLION SD 57069 466018891 501(C)(3) 5000 PROGRAM SUPPORT 6 0 SCHEDULE I, PART II DELTA DENTAL OF SOUTH DAKOTA FOUNDATION WAS ALSO PROVIDED WITH $35,000 OF DENTAL SERVICES AT NO COST TO THEM. X 1 1 X X X X X 0 1 0 0 0 0 0 0 0 SCOTT JONES PRESIDENT & CEO 493254 0 896421 0 889 0 28000 0 23215 0 1441779 0 0 0 KIRBY SCOTT VP OF FINANCE/CFO 156600 0 53865 0 1129 0 25452 0 12121 0 249167 0 0 0 EUGENE TETZLAFF VP OF IT 147200 0 51870 0 1133 0 20414 0 23415 0 244032 0 0 0 MICK HECKENLAIBLE VP OF OPERATIONS 153000 0 52710 0 1101 0 20931 0 20015 0 247757 0 0 0 JEFF MILLER EXECUTIVE DIRECTOR 179208 0 52710 0 1338 0 28413 0 22084 0 283753 0 0 0 CONNIE HALVERSON VP OF PUBLIC RELATIONS 119580 0 42525 0 908 0 17003 0 30533 0 210549 0 0 0 JEFF HEPPNER DIRECTOR OF MODERNIZATION & DEV 121610 0 14194 0 480 0 12695 0 29225 0 178204 0 0 0 PART I, LINE 1A COMPANION TRAVEL IS WRITTEN INTO THE CEO'S EMPLOYMENT AGREEMENT. COMPANION TRAVEL COSTS ARE INCLUDED IN THE W-2 OF THE CEO AS TAXABLE WAGES. PART I, LINE 4B SCOTT JONES, PRESIDENT & CEO, PARTICIPATED IN A SUPPLEMENTAL EMPLOYEE RETIREMENT PLAN (SERP). THE AMOUNT OF THIS 2019 SERP CONTRIBUTION WAS $473,474 WHICH HE ALSO HAD TO INCLUDE IN WAGES AS HE IS FULLY VESTED IN THE SERP. THE SERP CONTRIBUTION IS INCLUDED IN SCHEDULE J, PART II, COLUMN (B)(II) FOR MR. JONES. JEFF FEIOCK DDS BOARD MEMBER 501354 INSURANCE REIMBURSEMENT 0 PAUL REZICH DDS BOARD MEMBER 131919 INSURANCE REIMBURSEMENT 0 MONTY BECHTOLD DDS BOARD MEMBER 285022 INSURANCE REIMBURSEMENT 0 JASON AANENSON DDS BOARD MEMBER 227829 INSURANCE REIMBURSEMENT 0 THANE CRUMP DDS BOARD MEMBER 854473 INSURANCE REIMBURSEMENT 0 LEE GERTSEN DDS SON OF BOARD MEMBER GREG GERTSEN 395825 INSURANCE REIMBURSEMENT 0 KIM SUGA DDS DAUGTHER-IN-LAW OF BOARD MEMBER GREG GERTSEN 335100 INSURANCE REIMBURSEMENT 0 JACLYN SCHULER DDS DAUGHTER OF BOARD MEMBER ANLEE ROLA 784363 INSURANCE REIMBURSEMENT 0 TIM KAPPENMAN DDS BROTHER OF ANLEE ROLA 156878 INSURANCE REIMBURSEMENT 0 FORM 990, PART VI, SECTION A, LINE 1 THE EXECUTIVE COMMITTEE SHALL BE COMPOSED OF THE CHAIRMAN, VICE-CHAIRMAN, SECRETARY, TREASURER, AND SUCH OTHER MEMBERS AS THE BOARD DESIGNATES AND SHALL BE VESTED WITH SUCH POWERS AS THE BOARD OF DIRECTORS SHALL BY RESOLUTION DETERMINE. IT SHALL MAKE A WRITTEN REPORT OF ITS PROCEEDINGS AND ACTIONS AT THE NEXT SUCCEEDING MEETING OF THE BOARD OF DIRECTORS. THE CHAIRMAN SHALL BE THE CHAIRMAN OF THE EXECUTIVE COMMITTEE. FORM 990, PART VI, SECTION A, LINE 2 ELLEN LEE AND SCOTT JONES ARE DIRECTORS AT A COMMUNITY BANK. FORM 990, PART VI, SECTION A, LINE 6 THE MEMBERSHIP CONSISTS OF DENTISTS LICENSED IN SOUTH DAKOTA THAT PAY ONE-TIME MEMBERSHIP DUES. FORM 990, PART VI, SECTION A, LINE 7A ALL MEMBER DENTISTS IN ATTENDANCE AT THE ANNUAL MEETING HAVE ONE VOTE. FORM 990, PART VI, SECTION A, LINE 7B ALL MEMBER DENTISTS IN ATTENDANCE AT THE ANNUAL MEETING ARE ALLOWED ONE VOTE ON ALL AGENDA ITEMS. FORM 990, PART VI, SECTION B, LINE 11B THE FORM 990 IS PROVIDED TO THE BOARD OF DIRECTORS AT THE MAY BOARD MEETING. A REVIEW OF THE FORM IS CONDUCTED BY THE CHAIR OF THE AUDIT AND FINANCE COMMITTEE. FORM 990, PART VI, SECTION B, LINE 12C THE BOARD OF DIRECTORS COMPLETE A CONFLICT OF INTEREST FORM ANNUALLY, IN MAY, AT THE REGULARLY SCHEDULED BOARD MEETING. EACH FORM IS READ AT THE FOLLOWING MEETING, WITH ACTION TAKEN AS NEEDED. ACTION MAY INCLUDE ABSTENTION FROM DISCUSSION AND VOTING AND POSSIBLE TERMINATION AS A BOARD MEMBER. FORM 990, PART VI, SECTION B, LINE 15 DELTA DENTAL OF SOUTH DAKOTA HAS A COMPENSATION COMMITTEE CHARTER, WHICH STATES THE PURPOSE OF THE COMPENSATION COMMITTEE IS TO REVIEW AND REPORT TO THE BOARD ON COMPENSATION AND PERSONNEL POLICIES, PROGRAMS AND PLANS AND TO APPROVE EMPLOYEE COMPENSATION AND BENEFIT PLANS. THE COMMITTEE CONSISTS OF THE BOARD CHAIR, VICE-CHAIR, AND AT LEAST TWO OTHER BOARD MEMBERS. COMMITTEE MEMBERS ARE APPOINTED TO ANNUAL TERMS AND MAY BE REAPPOINTED TO UNLIMITED CONSECUTIVE TERMS. THE COMMITTEE ANNUALLY REVIEWS THE CEO'S PERFORMANCE AND DETERMINES SALARY ADJUSTMENTS AND INCENTIVE PAYMENTS FOR THE CEO, ENSURING COMPLIANCE WITH THE IRS "REBUTTABLE PRESUMPTION" SAFETY ZONE FOR EXECUTIVE COMPENSATION MATTERS. THE COMMITTEE ALSO REVIEWS THE CEO'S RECOMMENDATIONS AS TO SALARY ADJUSTMENTS AND INCENTIVE PAYMENTS FOR EXECUTIVE STAFF, ENSURING COMPENSATION WITHIN THE RANGES OF THE EXECUTIVE COMPENSATION PHILOSOPHY. FORM 990, PART VI, SECTION C, LINE 19 ALL DOCUMENTS AND POLICIES ARE AVAILABLE UPON REQUEST. DELTA DENTAL OF SOUTH DAKOTA FOUNDATION PO BOX 1157 PIERRE SD 57501 911776857 ACCESS TO DENTAL CARE SD 501(C)(3) LINE 12A, I DELTA DENTAL OF SOUTH DAKOTA 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 1 0 DELTA DENTAL OF SOUTH DAKOTA FOUNDATION B 3075077 CASH DELTA DENTAL OF SOUTH DAKOTA FOUNDATION O 2242555 CASH