2017-05-12T13:34:18-05:00 2016-12-31 910189318 MOSS ADAMS LLP 805 SW BROADWAY STE 1200 PORTLAND OR 97205 990 2016-01-01 453261827 HEALTH REPUBLIC INSURANCE COMPANY HEAL 8889906635 2373 NW 185TH AVENUE NO 701 HILLSBORO OR 97124 DAWN BONDER CEO 8889906635 2017-05-12 1 WENDY CAMPOS P00448102 5032421447 2017-05-12 12.129.7.100 2017-05-12 12:15:29 PD P DA39A3EE5E6B4B0D3255BFEF95601890AFD80709 1133A14FFAB8169331CEB935F8079429E4018A44 2016 2021-01-29 14:40:06Z DAWN BONDER 2373 NW 185TH AVENUE NO 701 HILLSBORO OR 97124 23578 0 X WWW.HEALTHREPUBLICINSURANCE.ORG X 2011 OR TO CREATE AND OPERATE CONSUMER OPERATED AND ORIENTED PLAN (CO-OP) AS A QUALIFIED NONPROFIT HEALTH INSURER UNDER SECTION 1322 OF THE AFFORDABLE CARE ACT. 5 5 21 5 0 0 0 0 46197492 0 210101 -29226 0 0 46407593 -29226 0 0 0 0 7128159 461485 0 0 0 68591985 -49733 75720144 411752 -29312551 -440978 21468523 6104746 17254781 2319321 4213742 3785425 TO CREATE AND OPERATE CONSUMER OPERATED AND ORIENTED PLAN (CO-OP) TO PROVIDE HEALTHCARE COVERAGE FOR INDIVIDUALS AND SMALL GROUPS AS QUALIFIED NONPROFIT HEALTH INSURER UNDER SECTION 1322 OF THE AFFORDABLE CARE ACT. 0 0 OFFERED QUALIFIED HEALTH POLICIES THROUGH THE OREGON EXCHANGE AND DIRECTLY TO CONSUMERS FOR COVERAGE EFFECTIVE BEGINNING JANUARY 1, 2014, BUT TERMINATED ALL COVERAGE AS OF DECEMBER 31, 2015. HAVE BEEN MANAGING THE RUN OUT OF OPERATIONS SINCE THAT TIME. 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 0 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 0 0 0 1 11 0 1 21 1 0 0 0 0 0 0 2500000 3785427 0 X 5 5 0 0 0 0 1 1 0 1 1 0 0 0 1 1 1 1 1 0 0 0 X JANICE FINLEY CFO 9712321247 2373 NW 185TH AVENUE 701 HILLSBORO OR 97124 TOM KUHN FORMER CHAIR 0.30 X X 0 0 0 DANIEL CLAY CHAIR/TREASURER 0.10 X X 0 0 0 STEVEN UNGER DIRECTOR 0.10 X 0 0 0 ROBIN HENDERSON DIRECTOR 0.10 X 0 0 0 KIM LAMB DIRECTOR 0.10 X 0 0 0 ARIN CARMACK DIRECTOR 0.10 X 0 0 0 DAWN BONDER CHIEF EXECUTIVE OFFICER 16.00 X 374991 0 3543 JANICE FINLEY CHIEF FINANCIAL OFFICER 35.00 X 283443 0 4128 BRETT MONELLO CHIEF OPERATING OFFICER 8.00 X 297781 0 1558 SUSAN POTTER GENERAL COUNSEL 14.00 X 211506 0 1691 CHERYL VANDEMORE CHIEF MARKETING OFFICER 26.00 X 173385 0 418 ROBIN RAMSEY CHIEF INFORMATION OFFICER 6.00 X 206708 0 826 VICKI INGLIS CONTROLLER 21.00 X 105819 0 1620 1653633 0 13784 7 0 1 0 PROVIDENCE HEALTH PLAN 4400 NE HALSEY BLDG 2 STE 690 PORTLAND OR 97213 ADMINISTRATIVE AND CUSTOMER SERVICE 400000 1 2820 2820 20758 52804 -32046 -32046 -32046 -29226 0 0 -29226 X 263416 173131 5377 19561 -3206 20245 834 18565 18630 114536 24827 25 94463 31031 98831 RISK ADJUSTMENT PREMIUM 538274 EXCHANGE/ADMIN FEES 89198 STATE TAXES/FEES 41054 HOSPITAL AND MEDICAL -1202993 65953 411752 1471026 2951769 8398859 1274842 11290846 1628090 12650 12650 55275 0 250181 250045 2336 0 21468523 6104746 856955 36649 69820 0 16328006 2282672 17254781 2319321 X 0 0 0 0 4213742 3785425 4213742 3785425 21468523 6104746 X -440978 12661 X X 0 0 0 12650 12650 0 0 CLAIMS UNPAID 253127 PREMIUM ADJUSTMENTS PAYABLE 1649265 OTHER LIABILITIES 380280 2282672 X 1 0 0 DAWN BONDER CHIEF EXECUTIVE OFFICER 118112 0 0 0 256879 0 3543 0 0 0 378534 0 0 0 JANICE FINLEY CHIEF FINANCIAL OFFICER 137633 0 0 0 145810 0 4128 0 0 0 287571 0 0 0 BRETT MONELLO CHIEF OPERATING OFFICER 51923 0 0 0 245858 0 1558 0 0 0 299339 0 0 0 SUSAN POTTER GENERAL COUNSEL 56398 0 0 0 155108 0 1691 0 0 0 213197 0 0 0 CHERYL VANDEMORE CHIEF MARKETING OFFICER 13927 0 0 0 159458 0 418 0 0 0 173803 0 0 0 ROBIN RAMSEY CHIEF INFORMATION OFFICER 27990 0 0 0 178718 0 826 0 0 0 207534 0 0 0 PART I, LINE 4A ALL EMPLOYEES WERE PLACED ON PART TIME TEMPORARY STATUS AS OF 1/1/16 AND RECEIVED $1,193,646 IN TOTAL SEVERANCE PAYMENTS AS SPECIFIED IN THE CORPORATE SEVERANCE POLICY. THESE SEVERANCE PAYMENTS WERE ACCRUED AS OF THE END OF THE PRIOR TAX YEAR (2015) BUT PAID OUT AND INCLUDED IN W-2 COMPENSATION IN THE CURRENT TAX YEAR (2016). FORM 990, PART VI, SECTION A, LINE 6 MEMBERS OF THE CORPORATION ARE THOSE INDIVIDUALS AGE EIGHTEEN OR OVER COVERED UNDER THE CORPORATION'S HEALTH INSURANCE POLICIES. THE CORPORATION CURRENTLY HAS NO ACTIVE POLICIES AND NO MEMBERS. FORM 990, PART VI, SECTION A, LINE 7A MEMBERS WHO HAVE PURCHASED HEALTH INSURANCE CAN PARTICIPATE IN ELECTION OF BOARD POSITIONS AND CAN BE ELECTED TO BOARD POSITIONS. FORM 990, PART VI, SECTION B, LINE 11B EXECUTIVE MANAGEMENT REVIEWS THE DRAFT FORM 990 AND PROVIDES THE FINAL REPORT TO THE BOARD OF DIRECTORS FOR APPROVAL AFTER FILING WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C THE ORGANIZATION'S WRITTEN CONFLICT OF INTEREST POLICY STATEMENTS WERE OBTAINED FOR ALL OFFICERS AND DIRECTORS IN 2016 AND ARE REQUIRED TO BE UPDATED ANNUALLY AS WELL AS UPON APPOINTMENT TO THE BOARD OR HIRE DATE. THE POLICY IS ADMINISTERED BY THE BOARD OF DIRECTORS OR ANY APPLICABLE COMMITTEE, WHICH IS RESPONSIBLE FOR REVIEWING REPORTS REGARDING CONFLICT OF INTEREST DISCLOSURE STATEMENTS, RECEIVING DISCLOSURES OF PROPOSED COVERED TRANSACTIONS, REVIEWING PROPOSED COVERED TRANSACTIONS AND MAINTAINING MINUTES OR OTHER SUCH DOCUMENTATION TO DOCUMENT THE REVIEW OF THE COVERED TRANSACTIONS. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART IX, LINE 24E MEMBER PORTAL COSTS 35,875. ALL OTHER EXPENSES 30,078. FORM 990, PART XI, LINE 9: CHANGE IN NON-ADMITTED ASSETS 12,661. FORM 990, PART XII, LINE 1: THE STATUTORY BASIS FINANCIAL STATEMENTS HAVE BEEN PREPARED IN CONFORMITY WITH THE ACCOUNTING PRACTICES PRESCRIBED OR PERMITTED BY THE OREGON INSURANCE DIVISION ("OID"). FORM 990, PART XII, LINE 2B: FINANCIAL STATEMENTS WERE NOT AUDITED FOR THE 2016 YEAR BECAUSE THE ORGANIZATION RECEIVED AN EXEMPTION FROM THE STATE OF OREGON.