2017-10-31T13:47:24-05:00 2016-12-31 450250958 EIDE BAILLY LLP 4310 17TH AVE S PO BOX 2545 FARGO ND 581082545 990 2016-01-01 480793267 Delta Dental of Kansas Inc DELT 3162641099 1619 N Waterfront Parkway Wichita KS 67206 Michael Ellis Executive VP 3162641099 2017-10-25 1 KIM C HUNWARDSEN P00484560 7012398500 2017-10-25 209.243.15.107 2017-10-25 08:07:07 CD P D91E13DEA3BADDCECF099D1499B6B322FF7FE130 66CC91E6B7F11C4783FFFA5645E675327CB67316 2016 2018-03-14 21:41:22Z Michael Ellis 1619 N Waterfront Pkwy Wichita KS 67206 309340959 0 X www.deltadentalks.com X 1972 KS To make possible and facilitate a wider and more timely availability of oral health care. 10 6 148 0 0 0 0 0 286645532 296109181 1044619 1016073 8197 7562 287698348 297132816 1391096 636225 0 0 10212201 11005338 0 0 0 272944734 282888435 284548031 294529998 3150317 2602818 67657881 67072661 11634989 7616699 56022892 59455962 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 0 269503516 286041469 Dental benefits (covered charges) provided to subscribers. Delta Dental served approximately 919,203 people this year. 9567517 10067712 The processing of dental benfit claims. 636225 636225 Grants paid out to 501(c)(3) organizations. 279707258 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 1 1 1 1 0 1 28960 0 1 148 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 2.89 0.32 X X 19977 0 477 Dr Alan Marcotte Vice Chairperson 1.51 0.32 X X 14238 0 1386 Angie McClure Director 1.66 0.00 X 14421 0 1386 Dr Patrick Moriarty Director 1.08 0.00 X 11070 0 1386 Mark Philips Director 1.31 0.00 X 12304 0 1386 Dr Lucynda Raben Director 1.49 0.00 X 12233 0 477 Dr Brick Scheer Director 1.26 0.00 X 10294 0 0 Ruth Teichman Director 1.07 0.00 X 9969 0 1157 Bruce Witt Director 1.66 0.00 X 14053 0 1386 Gary Yager Director 1.33 0.00 X 11279 0 0 Michael Herbert President and CEO 34.88 5.12 X 357525 0 67224 Michael Ellis Executive VP/CFO/Treasurer 38.39 1.61 X 269082 0 49212 Nancy Umholtz Secretary 37.06 2.94 X 103388 0 21459 Dean Newton Managing Director & Executive VP 39.84 0.16 X 313975 0 60960 Robert Ebenkamp VP Information Technology 39.95 0.05 X 200336 0 34415 Dr Jon Tilton VP Professional Review/Dental Director 40.00 0.00 X 213591 0 46067 Junetta Everett VP Professional Relations 39.30 0.70 X 196271 0 40808 Jeanne Hughes VP Client Service 37.31 2.69 X 188941 0 40817 Keith Asplund VP Product Management 29.01 10.99 X 191973 0 32439 2164920 0 402442 21 0 1 0 Gage Center Dental Group PA 1271 SW WOODHULL ST Topeka KS 66604 Dental Services 1792669 Jenkins & Leblanc PA 6810 SILVERHEEL ST Shawnee KS 66226 Dental Services 1789777 Martin and Frankenberry DDS PA 101 N CYPRESS ST Wichita KS 67226 Dental Services 1413744 Wichita Family Dental Partnership 9339 E 21ST ST N Wichita KS 67206 Dental Services 1391899 Dental Assoc of West Wichita PA 444 N RIDGE RD Wichita KS 67212 Dental Services 1069011 535 Dental Services 524298 296109181 296109181 296109181 1230446 1230446 11993770 12208143 -214373 -214373 -214373 Other Income 900099 7562 7562 7562 297132816 296109181 0 1023635 636225 636225 1411953 318294 1093659 7235769 2977794 4257975 992345 434541 557804 819124 355533 463591 546147 232897 313250 56090 56090 150003 150003 36430 36430 214166 214166 5386605 870585 4516020 804604 804604 1575070 1469030 106040 53453 27719 25734 183809 183809 411984 12638 399346 66916 4352 62564 160714 84706 76008 498882 262940 235942 107302 107302 Claims 269503500 269503500 State Premium Taxes 1117821 1117821 Clearing House Expense 380784 361749 19035 Equipment Rental and Ma 253437 253437 1926865 783497 1143368 294529998 279707258 14822740 0 257756 800 5020061 3209180 6180038 5198094 475342 401663 12419148 4656375 7938246 7762773 39910707 41954935 7363135 8121760 512596 423456 67657881 67072661 6749046 7256318 4885943 360381 11634989 7616699 X 56022892 59455962 56022892 59455962 67657881 67072661 X 2602818 671813 158439 X 0 1 X 1 0 1401415 1401415 7332320 1918932 5413388 3685413 2737443 947970 7762773 Inv in Surency Life & Health 8121760 F 8121760 Unearned Premiums 360381 360381 X 298272765 671813 682302 1354115 296918650 214166 214166 297132816 294839695 644548 644548 294195147 214166 120685 334851 294529998 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 records deferred income taxes using the liability method to reflect the tax consequences on future years of differences between the tax basis of assets and liabilities and their financial reporting amounts at each year-end. Deferred tax assets are recognized if management believes, based on available evidence, that it is more likely than not that they will be realized. The Company will recognize future accrued interest and penalties related to unrecognized tax benefits in income tax expense if incurred. Under normal circumstances, Delta Dental of Kansas, Inc. is no longer subject to federal and state examinations by tax authorities for years before 2013. Part XI, Line 2d - Other Adjustments: Earnings of C Corp Subsidiary 61,208. Reclass Expense Reimbursement to Expenses on Form 990 228,067. Rounding -14. Eliminating Entry for Equity in Disregarded Entity 393,041. Part XII, Line 2d - Other Adjustments: Eliminating Entry for Intercompany Transaction with Disregarded Entity 644,562. Rounding -14. Part XII, Line 4b - Other Adjustments: Disregarded Entity Expenses from Revenue on Financials 348,752. Reclass Expense Reimbursement from Revenue on Financials -228,067. 1 United Way of the Plains 245 N Water Wichita KS 67202 480547688 501(c)(3) 9355 Loaned Executive Program $8,500; 1,500 toothbrush kits $855 Sedgwick County Zoo 5555 W Zoo Blvd Wichita KS 67212 486120530 501(c)(3) 32500 E is for Elephant Boys and Girls Club of Greater Kansas City Legacy Center 4001 Blue Parkway Ste 102 Kansas City MO 64130 436072065 501(c)(3) 25000 Kid's Night Out Juvenile Diabetes Research Foundation 215 W Pershing Road Kansas City MO 64108 231907729 501(c)(3) 25000 General Donation University of Kansas 1651 Naismith Dr Lawrence KS 66045 481124839 State of Kansas 25000 Williams Fund Mark Arts 9112 E Central Wichita KS 67206 480616251 501(c)(3) 25000 Capital Campaign United Way of Kansas City 801 W 47th St Ste 500 Kansas City MO 64112 440545812 501(c)(3) 18500 2016 Gift $10,000; Community Liaison Program $8,500 Make a Wish Kansas 1144 N St Francis Wichita KS 67214 480984820 501(c)(3) 10500 General Donation Kansas Insurance Education Foundation 815 SW Topeka Boulevard Topeka KS 66612 480925186 501(c)(3) 10000 Year one of 4 year commitment March of Dimes 4400 College Boulevard Overland Park KS 66211 131846366 501(c)(3) 10000 2016 Kansas City Signature Chefs Auction Diamond Dreams NFP dba Topeka Golden Giants PO Box 883 Topeka KS 66601 364473748 501(c)(3) 5000 2016 Diamond Dreams sponsorship KC Urban Neighborhood Initiative 2700 East 18th Street Suite 261 Kansas City MO 64127 454879810 501(c)(3) 5000 2016 UNI Operations Exploration Place 300 N McLean Blvd Wichita KS 67203 481000295 501(c)(3) 17385 Your Big Mouth: Oral Health Education Programs for Preschool $17,385 - Program supplies and travel; Death by Chocolate tickets $1,020 Oral Health Kansas 800 SW Jackson St Suite 1120 Topeka KS 66612 200337278 20-0337278 5000 2016 Conference - Conference Supplies and expenses Community Health Center of Southeast Kansas 3011 N Michigan Pittsburg KS 66762 753002264 501(c)(3) 135822 Oral Health for Heroes Kansas Department of Health and Environment 1000 SW Jackson Topeka KS 66601 486029925 State of Kansas 70000 Kansas Statewide School Screening Program - Supplies Wichita Area Technical College 4004 N Webb Road Wichita KS 67226 201027060 State of Kansas 50000 WATC's 2016 Community Dental Health Grant - Equipment and Scholarships Marian Clinic Inc 3164 SE 6th Street Topeka KS 66610 481046905 501(c)(3) 30000 Increasing Access and Improving Quality of Care - Equipment and Capital Supplies Community Health Ministry 407 Ash Street Wamego KS 66547 752974854 501(c)(3) 25054 Fluoride Varnish in Schools & Dental Supplies - Supplies Southwest Boulevard Family Health Care 300 Southwest Blvd Kansas City KS 66103 481067752 501(c)(3) 13000 Equipment Needs for Family Health Care Dental Clinic - Equipment Salina Area Technical College 2562 Centennial Road Salina KS 67401 273299216 State of Kansas 8700 Dental Assistant Program Equipment - Salina Tech - Equipment GraceMed Health Clinic 1122 N Topeka St Wichita KS 67214 481159633 501(c)(3) 8550 Oral Health Care Kits for Underserved - 15,000 kits $8550 United Methodist Western Kansas Mexican American Ministries dba Genesis F 401 E Spruce St Garden City KS 67846 481049519 501(c)(3) 8550 Lifetime Smiles - 15,000 kits KS Head Start Association 932 Massachusetts Ste 301 Lawrence KS 66044 481195593 501(c)(3) 8123 Head Start Smile Kits - 14,250 kits Health Partnership Clinic 407 S Clairborne Suite 104 Olathe KS 66062 481115529 501(c)(3) 7667 Toothbrushes for HPC - 13,450 kits Johnson County Christmas Bureau 9503 Johnson Drive Merriam KS 66203 480884400 Johnson County 6840 2016 Holiday Shop - 12,000 kits Sedgwick County Division of Health 1900 East 9th Street North Wichita KS 67214 486000798 Sedgwick County 5871 Sedgwick County Department of Public Services Oral Health Initiative - 10,300 kits First United Methodist Church-Wesley House 411 E 12th Pittsburg KS 66762 480559096 501(c)(3) 5130 Operation Smile - 9,000 kits 28 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 230234 0 102245 0 25046 0 46329 0 20895 0 424749 0 0 0 Michael Ellis Executive VP/CFO/Treasurer 201302 0 49075 0 18705 0 36129 0 13083 0 318294 0 0 0 Dean Newton Managing Director & Executive VP 189674 0 97301 0 27000 0 45149 0 15811 0 374935 0 0 0 Robert Ebenkamp VP Information Technology 155739 0 34622 0 9975 0 28136 0 6278 0 234750 0 0 0 Dr Jon Tilton VP Professional Review/Dental Direct 152572 0 36846 0 24173 0 30982 0 15085 0 259658 0 0 0 Junetta Everett VP Professional Relations 137759 0 34439 0 24073 0 28082 0 12725 0 237078 0 0 0 Jeanne Hughes VP Client Service 123646 0 41195 0 24100 0 30591 0 10226 0 229758 0 0 0 Keith Asplund VP Product Management 140182 0 33791 0 18000 0 27094 0 5345 0 224412 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 126402 Payment of Dental Services 0 Patrick O Moriarty DDS Chartered Board Member Dr. Moriarty > 35% owner 203537 Payment of Dental Services 0 Raben DDS PA Board Director Dr. Raben > 35% owner 140161 Payment of Dental Services 0 Northrock Dental PA Board Member Dr. Scheer > 35% owner 135363 Payment of Dental Services 0 Form 990, Part VI, Section A, line 2 Michael Herbert, Michael Ellis, Dean Newton, Dr. Alan Marcotte, and Nancy Zogleman 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: Mark-to-mark adjustment not included on return 97,231. Earnings from subsidiary not on return - Surency 61,208. KSDD Properties LLC 1619 N Waterfront Parkway Wichita KS 67206 480793267 Real estate KS 644562 0 Delta Dental Surency Life & Health Company 1619 N Waterfront Pkwy Wichita KS 67206 261969006 Insurance KS DDKS C 61208 11216164 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 774228 cost Surency Life & Health Insurance Company N 225961 cost