2020-11-12T16:54:05-06:00 2019-12-31 205325889 ACCUITY LLP 999 BISHOP STREET STE 1900 HONOLULU HI 96813 990 2019-01-01 990107971 HAWAII DENTAL SERVICE HAWA 8085211431 900 FORT STREET MALL NO 1900 HONOLULU HI 968133705 MARK H YAMAKAWA PRESIDENT/CEO 8085211431 2020-11-05 1 KIM AT JONES P00940140 8085313400 72.253.96.98 2020-11-05 16:30:07 HS P DA39A3EE5E6B4B0D3255BFEF95601890AFD80709 28F0646C594B99B8FE8DCE576FDB3C68EB1517B6 2019 2021-04-22 16:20:28Z X MARK H YAMAKAWA 900 FORT ST MALL 1900 HONOLULU HI 96813 358297755 0 X WWW.HAWAIIDENTALSERVICE.COM X 1962 HI PROMOTE AND ENCOURAGE THE BETTERMENT OF THE GENERAL MEDICAL AND DENTAL HEALTH OF THE PUBLIC (CONTINUED) FOR THE COMMON GOOD AND GENERAL WELFARE OF THE COMMUNITY. 15 8 132 0 1041 37 0 0 234532428 242732176 7071249 6796073 482133 -33446 242085810 249494803 3263604 3107689 198699518 207276731 10613502 11503441 0 0 0 8449732 8030807 221026356 229918668 21059454 19576135 247892494 288748368 24818157 30105982 223074337 258642386 X SEE SCHEDULE O. 0 0 220437287 3107689 240308676 HAWAII DENTAL SERVICE (HDS) OFFERS AND ADMINISTERS DENTAL CARE PROGRAMS TO ABOUT 645,000 INDIVIDUALS THROUGHOUT THE STATE OF HAWAII. AS A MEMBER OF THE DELTA DENTAL PLANS ASSOCIATION, A NATIONAL ASSOCIATION SUPPORTING DELTAS NATION-WIDE, HDS SUBSCRIBERS ARE ABLE TO ACCESS DELTA CONTRACTED PROVIDERS IN EVERY STATE. IN 2019, HDS PROCESSED OVER ONE MILLION CLAIMS FOR SUBSCRIBERS AND THEIR DEPENDENTS. TO ENSURE PROVIDERS ARE SUBMITTING CLAIMS APPROPRIATELY, HDS CONTINUALLY AUDITS CLAIMS TO REDUCE COMMON ERRORS. IN ADDITION, HDS FUNDED $3,012,362 TO HDS FOUNDATION IN 2019 TO SUPPORT ORAL HEALTH INITIATIVES IN THE COMMUNITY AS WELL AS AN ADDITIONAL $95,327 IN GRANTS TO OTHER CHARITABLE ORGANIZATIONS. 1536795 2423500 MANAGING THE DENTAL BENEFITS OF ELIGIBLE BENEFICIARIES COVERED BY THE STATE OF HAWAII MEDICAID PROGRAM. 221974082 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 1 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 1 1 1 0 0 0 0 0 1 1 1 0 1 4115 0 1 132 1 1 1 0 0 0 0 0 0 0 0 0 0 0 X 15 8 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 X CHERYL TAKITANI-SMITH 8085211431 900 FORT STREET MALL STE 1900 HONOLULU HI 96813 ALLISON TRAN-YOKOTA DDS DIRECTOR 1.00 X 0 0 0 ANDREW CHAR DIRECTOR 1.00 X 0 0 0 CHARLES R SUGIYAMA DDS DIRECTOR 1.00 1.00 X 0 0 0 DAVID K TODANI DIRECTOR 1.00 1.00 X 0 0 0 EMI ENO ORIKASA DDS DIRECTOR 1.00 1.00 X 0 0 0 EMMIT A KANE EFF 52019 DIRECTOR 1.00 X 0 0 0 JOHN BLACK DIRECTOR 1.00 X 0 0 0 JON YOSHINO DIRECTOR 1.00 X 0 0 0 MARTIN OISHI DDS DIRECTOR 1.00 X 0 0 0 MASON A SAVAGE DDS DIRECTOR 1.00 1.00 X 0 0 0 PATSY NANBU DIRECTOR 1.00 X 0 0 0 PAUL CHANG TERMED 52019 DIRECTOR 1.00 1.00 X 0 0 0 SHAKIL AHMED DIRECTOR 1.00 1.00 X 0 0 0 SUZY HOLLINGER CHAIR 1.00 X X 0 0 0 T KIMO BLAISDELL VICE CHAIR 1.00 X X 0 0 0 TRAVIS UMEMOTO DIRECTOR 1.00 X 0 0 0 CHERYL TAKITANI-SMITH CFO 40.00 2.00 X 295980 0 120054 MARK H YAMAKAWA PRESIDENT & CEO 40.00 2.00 X 912274 0 270300 MINNA MARI LEHTI COO 40.00 1.00 X 225517 0 50866 THOMAS DELANEY CIO 40.00 2.00 X 265475 0 120583 CHAD YANO DIRECTOR OF INFO SYSTEM 40.00 X 159364 0 35807 CLESSON PANG DIRECTOR OF UNDERWRITING 40.00 X 184076 0 44887 GWYN HIRASA DIRECTOR OF DENTAL OPERATIONS 40.00 X 155592 0 45628 CARA NUMASAKI CONTROLLER 40.00 X 143324 0 32536 ELAINE FUJIWARA DIRECTOR OF SALES 40.00 X 145911 0 45029 RACHAEL BRANT LEGAL COUNSEL 40.00 X 135039 0 11553 ROBERT SHERMAN DENTAL DIRECTOR 40.00 X 197704 0 107648 ROQUE ARANADOR DIRECTOR OF INFORMATION TE 40.00 X 170575 0 61387 2990831 0 946278 23 0 1 0 COMMUNITY CASE MANAGEMENT 91-1360 KARAYAN STREET EWA BEACH HI 96706 CARE COORDINATION 1030000 TRANSEO SOLUTIONS LLC 820 KAHA PLACE KAILUA HI 96734 SYSTEM CONSULTING SERVICES 1008926 HIGH TECH HUI LLC 67-381 FARRINGTON HIGHWAY WAIALUA HI 96791 PROJECT MANAGEMENT 878407 CONCORD USA LLC 509 2ND AVENUE SOUTH HOPKINS MN 55343 SYSTEM CONSULTING SERVICES 697696 STRATEGIC COMMUNICATION SOLUTIONS LLC POBOX 283137 HONOLULU HI 96828 MARKETING SERVICES 254351 13 RISK SUBSCRIPTIONS EARNED 621300 184882499 184882499 ASC SUBSCRIPTIONS EARNED 621300 37029915 37029915 MEDICAL PARTNERS (WHOLESALE) 621300 18396262 18396262 MEDICAID 621300 2423500 2423500 242732176 5595542 5595542 8750 8750 0 109994733 108794202 1200531 1200531 1200531 MISC. OTHER INCOME 621300 27945 27945 OTHER INCOME 621300 1041 1041 FMG DENTAL INSUR. CONTRACTS (NET) 621300 -62432 -62432 -33446 249494803 242697689 1041 6796073 3107689 3107689 207276731 207276731 2198277 911179 1287098 6313809 5221105 1092704 4873 3635 1238 777413 522733 254680 1533200 970408 562792 675869 454454 221415 124150 124150 222636 222636 21990 21990 537099 537099 1624413 1285861 338552 263749 263749 411757 332099 79658 725827 540513 185314 746703 552560 194143 137534 7692 129842 83899 83899 283318 214114 69204 196982 162409 34573 BROKER COMMISSIONS 1371604 1371604 DUES & SUBSCRIPTIONS 506924 6700 500224 ORAL HEALTH 177960 177960 PRINTING 132427 69231 63196 461835 157009 304826 229918668 221974082 7944586 0 59464039 36556462 11353838 11831777 4726974 6500058 9989076 5109367 1202708 4879709 171144935 228980362 247892494 288748368 10235554 14770646 3767895 3922883 10814708 11412453 24818157 30105982 X 223074337 258642386 223074337 258642386 247892494 288748368 X 19576135 22270662 -6278748 X 0 1 X 1 0 1397066 1397066 0 3414706 2781571 633135 5177304 930730 4246574 4879709 CLAIMS PAYABLE TO DENTISTS 8163000 REFUNDABLE GROUP SUBSCRIPTIONS 3249453 11412453 FORM 990, PART IV, LINE 12B THE ORGANIZATION IS INCLUDED IN THE CONSOLIDATED AUDITED FINANCIAL STATEMENTS OF HAWAII DENTAL SERVICE, HAWAII DENTAL SERVICE FOUNDATION, AND HAWAII CLIENT SERVICES CORPORATION. THE HDS AUDIT COMMITTEE, WHICH CONSISTS OF BOARD MEMBERS, SELECTS THE AUDITORS AND REVIEWS THE CONSOLIDATED AUDITED FINANCIAL STATEMENTS. 1 HAWAII DENTAL SERVICE FOUNDATION 700 BISHOP ST STE 700 HONOLULU HI 96813 990246999 501(C)(4) 3012362 SUPPORT ORGANIZATION MISSION ALOHA UNITED WAY 200 N VINEYARD BLVD HONOLULU HI 96817 990073494 501(C)(3) 10000 PROGRAM SUPPORT AMERICAN HEART ASSOCIATION PO BOX 4002030 DES MOINES IA 50340 135613797 501(C)(3) 10000 PROGRAM SUPPORT HAWAII PUBLIC TELEVISION FOUNDATION 315 SAND ISLAND ACCESS ROAD HONOLULU HI 96819 990334518 501(C)(3) 15000 PROGRAM EDUCATIONAL PROGRAMS CHILD & FAMILY SERVICES 1001 BISHOP STREET SUITE 780 HONOLULU HI 96813 990073483 501(C)(3) 15000 SUPPORT ORGANIZATION'S PROGRAMS 4 1 PART I, LINE 2: THE PURPOSE OF THE GRANTS AWARDED BY HAWAII DENTAL SERVICE (HDS) ARE REVIEWED AND APPROVED BY HDS CEO EXCEPT FOR GRANTS TO HDS FOUNDATION, WHICH ARE APPROVED BY THE HDS BOARD OF DIRECTORS. HDS FOUNDATION CHAIR REPORTS ON THE USE OF GRANTS TO HDS BOARD OF DIRECTORS. OTHER DONATIONS ARE CONTRIBUTED TO VARIOUS PUBLIC CHARITABLE ORGANIZATIONS TO SUPPORT THE EXEMPT FUNCTIONS OF THE ORGANIZATIONS AND ARE NOT MONITORED. X X 1 1 X X X X X 0 1 0 0 0 0 0 1 0 CHERYL TAKITANI-SMITH CFO 224980 0 71000 0 0 0 104717 0 15337 0 416034 0 0 0 MARK H YAMAKAWA PRESIDENT & CEO 406028 0 190000 0 316246 0 261081 0 9219 0 1182574 0 143478 0 MINNA MARI LEHTI COO 191517 0 34000 0 0 0 43577 0 7289 0 276383 0 0 0 THOMAS DELANEY CIO 202475 0 63000 0 0 0 108732 0 11851 0 386058 0 0 0 CHAD YANO DIRECTOR OF INFO SYSTEM 139475 0 19889 0 0 0 16032 0 19775 0 195171 0 0 0 CLESSON PANG DIRECTOR OF UNDERWRITING 161415 0 22661 0 0 0 33288 0 11599 0 228963 0 0 0 GWYN HIRASA DIRECTOR OF DENTAL OPERATIONS 136443 0 19149 0 0 0 33345 0 12283 0 201220 0 0 0 CARA NUMASAKI CONTROLLER 125256 0 18068 0 0 0 19856 0 12680 0 175860 0 0 0 ELAINE FUJIWARA DIRECTOR OF SALES 127621 0 18290 0 0 0 31746 0 13283 0 190940 0 0 0 ROBERT SHERMAN DENTAL DIRECTOR 173896 0 23808 0 0 0 100767 0 6881 0 305352 0 0 0 ROQUE ARANADOR DIRECTOR OF INFORMATION TE 149525 0 21050 0 0 0 53644 0 7743 0 231962 0 0 0 PART I, LINE 1A SUPPLEMENTAL COMPENSATION INFORMATION: HDS HOLDS A CORPORATE MEMBERSHIP IN A SOCIAL CLUB IN WHICH THE CLUB REQUIREMENTS DICTATE THAT AN INDIVIDUAL BE IDENTIFIED TO AUTHORIZE TRANSACTIONS. AS SUCH, HDS'S CEO HAS BEEN DESIGNATED AS THE AUTHORIZED INDIVIDUAL. ONLY BUSINESS TRANSACTIONS ARE ALLOWED AND SUBSTANTIATED BY PROPER DOCUMENTATION. DISCRETIONARY SPENDING ACCOUNT: ONLY BUSINESS RELATED TRANSACTIONS ARE ALLOWED AND SUBSTANTIATED BY PROPER DOCUMENTATION. PART I, LINE 4B MARK H. YAMAKAWA PARTICIPATED IN A NON-QUALIFIED SUPPLEMENTAL RETIREMENT PLAN. BENEFIT PAYMENT OF $307,668 IS INCLUDED IN SCHEDULE J, PART II, LINE (1), COLUMN (B)(III). ACCRUED BENEFITS OF $172,500 IS INCLUDED IN THE RETIREMENT AND OTHER DEFERRED COMPENSATION EXPENSE AMOUNT REPORTED FOR HIM IN SCHEDULE J, PART II, LINE (1), COLUMN (C). PART I, LINE 7 NON-FIXED PAYMENTS: HDS HAS AN INCENTIVE PLAN DETAILING THE INCENTIVE CALCULATION WHEN THE COMPANY ACHIEVES CERTAIN PERFORMANCE STANDARDS AND STRATEGIC GOALS. THE INCENTIVE AMOUNT VARIES EACH YEAR DEPENDING ON ACHIEVEMENT OF STRATEGIC GOALS. INCENTIVE AMOUNTS FOR OFFICERS ARE APPROVED BY THE BOARD OF DIRECTORS COMPENSATION COMMITTEE WHICH IS DOCUMENTED IN MINUTES. INCENTIVE AMOUNTS FOR MANAGEMENT AND STAFF ARE APPROVED BY OFFICERS. PATSY NANBU DIRECTOR 2885607 SEE NOTE 1 0 JOHN BLACK DIRECTOR 217750 SEE NOTE 2 0 MARTIN OISHI DIRECTOR 206044 SEE NOTE 2 0 MASON SAVAGE DIRECTOR 245284 SEE NOTE 2 0 CHARLES SUGIYAMA DIRECTOR 404475 SEE NOTE 2 0 CHILD AND FAMILY SERVICE NOTE 3 151006 SEE NOTE 4 0 IOLANI SCHOOL NOTE 3 200812 SEE NOTE 4 0 UNIVERSITY HEALTH ALLIANCE NOTE 3 5796512 SEE NOTE 4 0 UNIVERSITY HEALTH ALLIANCE NOTE 3 551050 SEE NOTE 5 0 HAWAII PACIFIC HEALTH NOTE 3 5895551 SEE NOTE 4 0 ALLISON TRAN-YOKOTA DIRECTOR 109962 SEE NOTE 2 0 SUZY HOLLINGER CHAIR 337411 SEE NOTE 1 0 SCHEDULE L, PART IV NOTE 1 - PREMIUMS FOR DENTAL PLAN - EMPLOYER GROUP PURCHASES AN HDS DENTAL PLAN BUT THE DIRECTOR DOES NOT INFLUENCE DECISION MAKING IN PURCHASING THE DENTAL PLAN FROM HDS.NOTE 2 - DENTIST PARTICIPATING IN HDS PROVIDER NETWORK OFFERING DENTAL SERVICES TO HDS SUBSCRIBERS.NOTE 3 - MARK YAMAKAWA IS THE CEO OF HDS. PREMIUMS ARE RECEIVED FROM VARIOUS ORGANIZATIONS ON WHICH MARK SERVES AS A BOARD MEMBER.NOTE 4 - DENTAL PREMIUM PAYMENTS TO HDS FROM VARIOUS ORGANIZATIONS IN WHICH MARK YAMAKAWA IS A BOARD MEMBER.NOTE 5 - PAYMENTS MADE BY HDS TO THE UNIVERSITY HEALTH ALLIANCE (UHA) FOR MEDICAL PREMIUMS. FORM 990, PART III, LINE 1, DESCRIPTION OF ORGANIZATION MISSION. HAWAII DENTAL SERVICE OPERATES TO PROMOTE AND ENCOURAGE THE BETTERMENT OF THE GENERAL MEDICAL AND DENTAL HEALTH OF THE PUBLIC FOR THE COMMON GOOD AND GENERAL WELFARE OF THE COMMUNITY. ITS GOAL IS TO INNOVATE AND CONDUCT PROGRAMS FOR DENTAL CARE AND TO MAKE AVAILABLE, ON A BROAD SCALE, THE BENEFITS OF THE SCIENCE OF DENTISTRY TO MEMBERS OF THE PUBLIC. DENTAL COVERAGE IS AVAILABLE TO THE GENERAL PUBLIC AS HAWAII DENTAL SERVICE MAINTAINS AN ENROLLMENT POLICY THAT IS OPEN TO INDIVIDUALS AND FAMILIES, AS WELL AS SMALL AND LARGE GROUPS. IN ADDITION, HAWAII DENTAL SERVICE PROVIDES FUNDING TO HAWAII DENTAL SERVICE FOUNDATION WHICH IN TURN PROVIDES GRANTS TO ORGANIZATIONS THAT HAVE PROGRAMS IN PLACE TO SUPPORT ORAL HEALTH INITIATIVES IN THE COMMUNITY. FORM 990, PART VI, SECTION A, LINE 6 DESCRIPTION OF ORGANIZATION'S MEMBERS: MEMBERSHIP IS SOLELY AVAILABLE TO DENTISTS WHO HAVE BEEN DULY LICENSED TO PRACTICE IN THE STATE OF HAWAII AND WHO MEET ANY ADDITIONAL REQUIREMENTS CONSISTENT WITH APPLICABLE LAW ESTABLISHED BY THE BOARD OF DIRECTORS FROM TIME TO TIME. APPLICATION IS MADE IN WRITING AND APPROVED BY THE BOARD OF DIRECTORS. MEMBERS MAY AT ANY TIME BY A MEETING DULY CALLED FOR SUCH PURPOSE DEPOSE OR REMOVE FROM OFFICE ANY DENTIST DIRECTOR, WITH OR WITHOUT CAUSE, EXCEPT AS SUCH REMOVAL WOULD BE CONTRARY TO LAW. FORM 990, PART VI, SECTION A, LINE 7A ELECT BOARD MEMBERS A MAJORITY OF THE MEMBERS OF THE BOARD OF DIRECTORS SHALL BE COMPRISED OF NON-DENTIST REPRESENTATIVES FROM THE GENERAL PUBLIC AND THE REMAINING MEMBERS SHALL BE MEMBER DENTISTS. MEMBER DENTISTS AND PUBLIC DIRECTORS RESPECTIVELY ELECT DENTISTS AND PUBLIC DIRECTORS TO THE BOARD OF DIRECTORS FOR A THREE YEAR TERM. FORM 990, PART VI, SECTION A, LINE 7B APPROVAL OF DECISIONS: BYLAWS AND ARTICLES OF INCORPORATION MAY BE ALTERED OR REPEALED, OR NEW BYLAWS AND ARTICLES OF INCORPORATION MAY BE ADOPTED IN LIEU THEREOF, BY ADOPTION OF A RESOLUTION BY THE BOARD OF DIRECTORS SETTING FORTH THE PROPOSED AMENDMENT AND DIRECTING THAT IT BE SUBMITTED TO A VOTE AT THE ANNUAL OR SPECIAL MEETING OF THE MEMBERS. THE PROPOSED AMENDMENT SHALL BE ADOPTED UPON RECEIVING AT LEAST TWO-THIRDS OF THE VOTES WHICH MEMBERS PRESENT IN PERSON AT THE MEETING ARE ENTITLED TO CAST. THE BYLAWS MAY ALSO BE AMENDED BY AFFIRMATIVE VOTE OF THE DIRECTORS THEN IN OFFICE, WITHOUT FURTHER ACTION BY THE MEMBERS, FOR THE PURPOSE OF CURING AMBIGUITIES, CORRECTING OR SUPPLEMENTING DEFECTIVE OR INCONSISTENT PROVISIONS, OR ENABLING THE CORPORATION TO COMPLY WITH APPLICABLE LAWS AND REGULATIONS. FORM 990, PART VI, SECTION B, LINE 11B APPROVED COPY OF FORM 990: THE RETURN IS THOROUGHLY REVIEWED BY THE CONTROLLER PRIOR TO FINAL REVIEW WITH THE CHIEF FINANCIAL OFFICER AND PRESIDENT. A COPY OF FORM 990 IS PROVIDED TO THE BOARD OF DIRECTORS PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C WRITTEN CONFLICT OF INTEREST POLICY: THE HDS COMPLIANCE PROGRAM CONTAINS THE HDS CONFLICTS OF INTEREST POLICY. EMPLOYEES AND DIRECTORS OF HDS ARE REQUIRED TO COMPLETE THE CONFLICTS OF INTEREST DISCLOSURE STATEMENT AND CERTIFICATION ANNUALLY. HDS COMPLIANCE DEPARTMENT REVIEWS THE ANNUAL CONFLICTS OF INTEREST DISCLOSURE STATEMENT AND CERTIFICATIONS AND REPORTS POTENTIAL CONFLICTS OF INTERESTS TO THE HDS BOARD OF DIRECTORS. THE BOARD OF DIRECTORS ARE NOT ALLOWED TO PARTICIPATE IN DELIBERATIONS OR VOTE ON ISSUES/TRANSACTIONS WHICH THEY HAVE A CONFLICT OF INTEREST NOR ARE THE HDS EMPLOYEES ALLOWED TO PURSUE A TRANSACTION OR ARRANGEMENT THAT CONFLICTS WITHOUT PRIOR APPROVAL. FORM 990, PART VI, SECTION B, LINE 15 PROCESS FOR DETERMINING COMPENSATION: COMPENSATION FOR THE CEO AND OFFICERS ARE DETERMINED BASED ON ADVICE FROM AN INDEPENDENT COMPENSATION CONSULTANT WHO USES DELTA DENTAL PLANS ASSOCIATION AND HAWAII EMPLOYERS COUNCIL COMPENSATION SURVEY INFORMATION FOR COMPARABLE POSITIONS. OFFICER COMPENSATION IS APPROVED BY THE BOD COMPENSATION COMMITTEE. AMOUNTS ARE DOCUMENTED IN MINUTES AND HUMAN RESOURCE DEPARTMENT RECONCILES THE PAYMENT AT END OF EACH YEAR. COMPENSATION FOR MANAGEMENT AND STAFF POSITIONS ARE EVALUATED AND DETERMINED BASED ON HAWAII EMPLOYERS COUNCIL SURVEYS AND APPROVED BY THE PRESIDENT/CEO AND EXECUTIVES ANNUALLY. FORM 990, PART VI, SECTION C, LINE 19 TAX RETURNS AND OTHER REQUIRED DOCUMENTS ARE AVAILABLE UPON REQUEST. FORM 990, PART XI, LINE 9: CHANGE IN ACCRUED POSTRETIREMENT LIABILITIES -6,278,748. HAWAII DENTAL SERVICE FOUNDATION 700 BISHOP STREET SUITE 700 HONOLULU HI 96813 990246999 ORAL HEALTH SUPPORT HI 501(C)(4) N/A N/A 1 HAWAII CLIENT SERVICES CORPORATION 700 BISHOP STREET SUITE 710 HONOLULU HI 96813 452740308 ADMIN SERVICES HI HI DENTAL SCVS C 1.00000 1 1 1 0 0 0 0 0 0 0 1 0 0 0 1 1 0 1 0 0 HAWAII CLIENT SERVICES CORPORATION O 167868 CASH HAWAII CLIENT SERVICES CORPORATION Q 206524 CASH HAWAII DENTAL SERVICE FOUNDATION A 6000 CASH HAWAII DENTAL SERVICE FOUNDATION O 262248 CASH HAWAII DENTAL SERVICE FOUNDATION Q 273743 CASH HAWAII CLIENT SERVICES CORPORATION A 2750 CASH