2018-11-01T15:08:38-05:00 2017-12-31 450250958 EIDE BAILLY LLP 4310 17TH AVE S PO BOX 2545 FARGO ND 581082545 990 2017-01-01 480793267 Delta Dental of Kansas Inc DELT 3162641099 1619 N Waterfront Parkway Wichita KS 67206 Michael Ellis Executive VP 3162641099 2018-10-25 1 KIM C HUNWARDSEN P00484560 7012398500 2018-10-25 216.147.170.229 2018-10-25 13:57:53 CD P 66CC91E6B7F11C4783FFFA5645E675327CB67316 B602D594AFD2B0B327E07A06F36CA6A7E42546D0 2017 2018-06-14 16:35:46Z Michael Ellis 1619 N Waterfront Parkway Wichita KS 67206 314462237 0 X www.deltadentalks.com X 1972 KS To make possible and facilitate a wider and more timely availability of oral health care. 10 6 138 0 0 0 0 0 296109181 303515482 1016073 1819880 7562 0 297132816 305335362 636225 1221911 0 0 11005338 11576495 0 0 0 282888435 287487812 294529998 300286218 2602818 5049144 67072661 74038776 7616699 7778216 59455962 66260560 X To make possible and facilitate a wider and more timely availability of dental care, thereby advancing the public health and the science and art of dentistry in the state of Kansas, by establishing, maintaining, and operating a non-profit prepayment dental service plan or plans in the state of Kansas. 0 1 274194288 293196376 Dental benefits (covered charges) provided to subscribers. Delta Dental served approximately 928,826 people this year. 9783789 10319106 The processing of dental benfit claims. 1221911 1221911 Grants paid out to 501(c)(3) organizations. 285199988 0 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 1 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 29061 0 1 138 1 0 0 0 0 0 0 0 0 X 10 6 1 0 0 0 1 1 1 1 0 0 0 1 1 1 1 1 1 1 1 0 X Michael Ellis 3162641099 1619 N Waterfront Parkway Wichita KS 67206 Nancy Zogleman Chairperson 0.68 0.08 X X 16450 0 510 Dr Alan Marcotte Vice Chairperson 0.57 0.18 X X 19606 0 1481 Angie McClure Director 0.57 0.00 X 13142 0 1481 Dr Patrick Moriarty Director 0.51 0.00 X 11865 0 1481 Mark Philips Director 0.63 0.10 X 14274 0 1481 Dr Lucynda Raben Director 0.66 0.00 X 13456 0 510 Dr Brick Scheer Director 0.56 0.00 X 11935 0 0 Ruth Teichman Director 0.45 0.00 X 11451 0 1252 Bruce Witt Director (partial year) 0.39 0.00 X 9422 0 987 Kimberly Borchers Director (partial year) 0.21 0.00 X 3664 0 0 Gary Yager Director 0.60 0.00 X 12456 0 0 Michael Herbert President and CEO 34.88 5.88 X 390193 0 61396 Michael Ellis Executive VP/CFO/Treasurer 38.39 1.56 X 293776 0 53061 Nancy Umholtz Secretary 37.06 0.99 X 106113 0 20370 Dean Newton Managing Director & Executive VP 39.84 3.00 X 290404 0 61974 James Tuttle Chief Operating Officer 39.20 0.80 X 188946 0 7615 Robert Ebenkamp VP Information Technology 39.95 0.17 X 207041 0 32754 Dr Jon Tilton VP Professional Review/Dental Direct 40.00 0.00 X 219235 0 39425 Junetta Everett VP Professional Relations 39.30 0.26 X 203358 0 36976 Keith Asplund VP Product Management 29.01 14.58 X 195242 0 30742 Bryce Dougherty Controller 38.25 1.75 X 174689 0 35406 2406718 0 388902 25 0 1 0 Jenkins & Leblanc PA 6810 Silverheel St Shawnee KS 66226 Dental Services 1853777 Wichita Family Dental Partnership 9339 E 21ST ST N Wichita KS 67206 Dental Services 1471427 Gage Center Dental Group PA 1271 SW Woodhull St Topeka KS 66604 Dental Services 1453713 Martin and Frankenberry DDS PA 3101 N Cypress St Wichita KS 67226 Dental Services 1390242 Wichita Endodontics LLC 3535 E Central Ave Wichita KS 67208 Dental Services 1242008 559 Dental Services 524298 303513105 303513105 2377 2377 303515482 1027756 1027756 9918999 9126875 792124 792124 792124 305335362 303515482 0 1819880 1221911 1221911 1632864 224974 1407890 7477833 3425380 4052453 1045212 564878 480334 831697 323213 508484 588889 264233 324656 39677 39677 94542 94542 48134 48134 169887 169887 4702244 146219 4556025 907716 907716 1681247 1483552 197695 50938 34323 16615 265265 265265 463660 17218 446442 81740 18955 62785 479635 230225 249410 123082 123082 Claims 275218294 275218294 State Premium Taxes 1125574 1125574 Clearing House Expense 403302 382557 20745 Equipment Rental and Ma 347609 316116 31493 1285266 202366 1082900 300286218 285199988 15086230 0 800 800 3209180 5833195 5198094 5380630 401663 331911 12338923 4976201 7762773 7362722 41954935 45434046 8121760 9239675 423456 455797 67072661 74038776 7256318 7057109 360381 721107 7616699 7778216 X 59455962 66260560 59455962 66260560 67072661 74038776 X 5049144 1605300 150154 X 0 1 X 1 0 1401415 1401415 7332320 2106940 5225380 3605188 2869261 735927 7362722 Inv in Surency Life & Health 9239675 F 9239675 Unearned Premiums 721107 721107 X 307127756 1605300 356981 1962281 305165475 169887 169887 305335362 300323136 0 300323136 169887 -206805 -36918 300286218 Part X, Line 2: Delta Dental of Kansas, Inc. is tax exempt under Section 50l(c)(4) of the Internal Revenue Code and a similar provision of state law. The Company evaluates its tax positions that have been taken or are expected to be taken on income tax returns to determine if an accrual is necessary for uncertain tax positions. As of December 31, 2017 and 2016, the unrecognized tax benefits accrual was zero. The Company will recognize future accrued interest and penalities related to unrecognized tax benefits in income tax expense if incurred. Part XI, Line 2d - Other Adjustments: Reclass Expense Reimbursement to Expenses on Form 990 206,805. Earnings of C Corp 150,176. Part XII, Line 4b - Other Adjustments: Reclass Expense Reimbursement to Expenses on Form 990 -206,805. 1 University of Kansas 1651 Naismith Dr Lawrence KS 66045 481124839 State of Kansas 25000 Williams Fund Wichita Center for Arts 1307 N Rock Rd Wichita KS 67206 480616251 501(c)(3) 25000 Capital Campaign Wichita Metro Chamber of Commerce 350 W Douglas Ave Wichita KS 67202 480477290 501(c)(3) 10980 Yearly Support/Centennial Sponsorship $6,980 and $4000 Kansas Insurance Educational Foundation 815 SW Topeka Boulevard Topeka KS 66612 480925186 501(c)(3) 10000 Year 2 of 4 Year Commitment United Way of KC 801 W 47th St Ste 500 Kansas City MO 64112 440545812 501(c)(3) 18500 2017 Gift $10,000; Community Liaison Program $8,500 United Way of of the Plains 245 N Water St Wichita KS 67202 480547688 501(c)(3) 33500 2107 gift $25,000; Loaned Executive Program $8,500 Juvenile Diabetes Research Foundation (JDRF) 215 West Pershing Road Suite 300 Kansas City MO 64108 231907729 501(c)(3) 25000 Yearly Support March of Dimes KC 4400 College Boulevard Overland Park KS 66211 131846366 501(c)(3) 10000 Yearly Support Urban Neighborhood 2700 East 18th Street Suite 261 Kansas City MO 64127 454879810 501(c)(3) 10000 2017 UNI Operations Botanica 701 Amidon St Wichita KS 67203 481007736 501(c)(3) 25000 Carousel - 1st year of 2 year Commitment for $30,000; Illuminations - $10,000 Ronald McDonald House Charities 1110 N Emporia Wichita KS 67214 480918101 501(c)(3) 15000 Capital Campaign ($10,000) - New House - 1st of 3 year Commitment for $30,000; Golf Tournament - $5,000 Dental Lifeline Network PO Box 4266 Topeka KS 66604 846129064 501(c)(3) 6971 Kansas Donated Dental Services (DDS) Program The Exploration Place 300 N McLean Blvd Wichita KS 67203 481000295 501(c)(3) 26633 Your Big Mouth: Oral Health Education Programs for Rural Kansas Preschools Heartspring 8700 E 29th St N Wichita KS 67226 481232409 501(c)(3) 26422 Healthy Smiles for Children with Special Needs Program Oral Health Kansas 800 SW Jackson St Suite 1120 Topeka KS 66612 200337278 501(c)(3) 10000 2017 Oral Health Kansas Conference Valeo Behavioral Health Care 400 SW Oakley Ave Topeka KS 66606 480730326 501(c)(3) 12000 Valeo Oral Health Initiative to Reduce Dry Mouth for Those Experiencing Mental Illness GraceMed 1122 N Topeka Wichita KS 67214 481159633 501(c)(3) 6177 10,080 kits Genesis Family Health 310 E Walnut St Ste LL5 Garden City KS 67846 481049519 501(c)(3) 6243 10,080 kits Sedgwick County Health Department 1900 E 9th St Wichita KS 67214 486000798 Sedgwick County 6177 10,080 kits First United Methodist Church-Wesley House 411 E 12th Pittsburg KS 66762 480559096 501(c)(3) 6263 10,080 kits Marian Dental Clinic - SCL Health 3164 SE 6th Avenue Topeka KS 66607 481046905 501(c)(3) 6271 10,080 kits Kansas Food Bank 1919 E Douglas Ave Wichita KS 67211 480959213 501(c)(3) 21000 34,272 kits YMCA 402 N Market Wichita KS 67202 237128129 501(c)(3) 6265 10,224 kits Community Health Center of Southeast Kansas 3011 N Michigan Pittsburg KS 66762 753002264 501(c)(3) 5160 Smiles Across Southeast Kansas - 8,600 kits Catholic Charities of Northeast Kansas 1708 Steel Road Kansas City KS 66106 480623886 501(c)(3) 7800 Food Pantry - 13,000 Kits Johnson County Christmas Burea 9503 Johnson Dr Merriam KS 66203 480884400 Johnson County 7200 2017 Holiday Shop - 12,000 Kits 26 0 Part I, Line 2: Delta Dental of Kansas provided grants to public charities and governmental organizations to further the purpose of the organization. For each organization that receives a grant, Delta Dental of Kansas requires acceptance of the grant, the grant reporting requirements and the due date for reporting via a signed agreement letter. The Grant Reporting Package requires completion of a Narrative Report addressing the details of the project, Project Budget Summary Form (including submission of invoices if appropriate), Acknowledgement Plan and any additional Components as indicated in the agreement letter. X 1 1 X X X X X 0 0 0 0 0 0 0 0 0 Michael Herbert President and CEO 263037 0 110780 0 16376 0 47896 0 20518 0 458607 0 0 0 Michael Ellis Executive VP/CFO/Treasurer 230227 0 61680 0 1869 0 40312 0 14044 0 348132 0 0 0 Dean Newton Managing Director & Executive VP 204525 0 76179 0 9700 0 48475 0 15191 0 354070 0 0 0 James Tuttle Chief Operating Officer 177420 0 10871 0 655 0 0 0 8749 0 197695 0 0 0 Robert Ebenkamp VP Information Technology 169291 0 36255 0 1495 0 27810 0 6981 0 241832 0 0 0 Dr Jon Tilton VP Professional Review/Dental Direct 176007 0 38492 0 4736 0 30542 0 14093 0 263870 0 0 0 Junetta Everett VP Professional Relations 165241 0 35873 0 2244 0 27598 0 12158 0 243114 0 0 0 Keith Asplund VP Product Management 159480 0 35224 0 538 0 26556 0 5241 0 227039 0 0 0 Bryce Dougherty Controller 144631 0 29531 0 527 0 21907 0 14264 0 210860 0 0 0 Part I, Line 1a Delta Dental of Kansas did pay for the companion travel for board of directors and leadership team members when they attended out of town business meetings. The companion travel amount was treated as taxable compensation and is included in the board of directors' 1099-MISC and the leadership team members' W-2. Alan D Marcotte DDS Board Member Dr. Marcotte > 35% owner 111146 Payment of Dental Services 0 Patrick O Moriarty DDS Chartered Board Member Dr. Moriarty > 35% owner 201053 Payment of Dental Services 0 Raben DDS PA Board Member Dr. Raben > 35% owner 137897 Payment of Dental Services 0 Northrock Dental PA Board Member Dr. Scheer > 35% owner 121476 Payment of Dental Services 0 Form 990, Part III, line 3 The organization dissolved the disregarded entity KSDD Properties LLC during 2016. Form 990, Part VI, Section A, line 2 Nancy Zogelman, Nancy Umholtz, Michael Herbert, Michael Ellis, Dean Newton, Dr. Alan Marcotte, and Mark Phillips have a business relationship with each other. They all serve as either officers or directors of Surency Life & Health Insurance Company, a related for-profit company. The officers and directors do not have stock ownership interest in the related for-profit company. Form 990, Part VI, Section A, line 6 The organization has members. The membership of Delta Dental of Kansas is comprised of the dentists who have current participating agreements with Delta Dental of Kansas. Each member is entitled, at every meeting of members, to one vote per person, but no member shall be entitled to vote by proxy. Form 990, Part VI, Section A, line 7a The board of directors are comprised of ten (10) members. Four (4) are elected by the membership and are among the corporation's participating dentists. Two (2) are appointed by the governor of the state of Kansas, and four (4) are appointed by the commissioner of insurance of the state of Kansas. Form 990, Part VI, Section A, line 7b Any proposed changes to the by-laws are subject to member approval. Form 990, Part VI, Section A, line 8b There are no committees with the authority to act on behalf of the governing board. Form 990, Part VI, Section B, line 11b An independent accounting firm prepares the Form 990. The 990 is then reviewed by the organization's accounting personnel. Any questions or comments are addressed and any necessary changes are made. The Form 990 with all related schedules is then provided to the entire governing body for review prior to filing. Form 990, Part VI, Section B, line 12c The chairperson of the board and the governance committee monitor and enforce our conflict of interest policy. Each director, officer, and key employee of Delta Dental of Kansas annually files a statement regarding conflicts of interest which exist, or which might be expected to exist, within the upcoming year. The statement discloses as fully as possible the nature of potential conflicts and the nature of the director's, officer's, or key employee's interest in the potential transaction. All statements are reviewed by the president and chairperson and may be circulated to members of the board of directors. Each director, officer, and key employee agree to answer any questions about potential conflicts they may have. If a conflict is identified, voting may be restricted. Form 990, Part VI, Section B, line 15 The Delta Dental of Kansas process for determining compensation for the CEO, officers, and key employees does include an annual review by independent persons, comparability date, and contemporaneous substantiation of the deliberation and decision. Delta Dental of Kansas has contracted with a consulting group to provide compensation studies for our positions. The consultant uses published market data sources to identify the relevant duties and responsibilities provided. Market data is used as appropriate for each position, from local, regional, and national markets. They provide a complete report that documents the findings of the market review process for our positions and their recommendation regarding the grade level of placement of the position. Delta Dental of Kansas also has a compensation committee, comprised of selected board members. One of the purposes of the committee is to review, report, and make recommendations to the board regarding compensation of all officers and executive team employees. The committee is responsible to meet with the President/Chief Executive Officer annually to review his/her performance and employment contract, make recommendations to the board regarding the President/Chief Executive Officer's annual compensation and benefits package and to review the President/Chief Executive Officer's recommendations as to salary adjustments and incentive payments for officers, executives, and senior management. Form 990, Part VI, Section C, line 19 Delta Dental of Kansas annual report is available to the public through our website, www.deltadentalks.com. Our governing documents and conflict of interest policy are available to the public upon request. Form 990, Part XI, line 9: Earnings from C Corp Subsidiary 150,176. Other changes in net assets due to rounding -22. Surency Life & Health Company 1619 N Waterfront Pkwy Wichita KS 67206 261969006 Insurance KS DDKS C 150174 12010126 1.00000 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0 Surency Life & Health Insurance Company O 686427 cost Surency Life & Health Insurance Company N 266109 cost