2016-11-14T17:04:41-06:00 2015-12-31 381357951 PLANTE & MORAN PLLC 10 S Riverside Plaza 9th Floor Chicago IL 60606 990 2015-01-01 860274899 DELTA DENTAL INSURANCE SERVICE INC DELT 6025883976 5656 WEST TALAVI BLVD GLENDALE AZ 85306 Mark Anderson CFO/VICE PRESIDENT 6029383131 2016-11-14 1 David Lowenthal P00378651 3122071040 2016-11-11 2015 2017-02-10 21:41:12Z DELTA DENTAL OF ARIZONA ALLAN ALLFORD 5656 WEST TALAVI BLVD GLENDALE AZ 85306 225561998 0 X WWW.DELTADENTALAZ.COM X 1972 AZ The corporation exists to improve lives by promoting optimal oral health. 13 10 100 0 54675 38999 0 0 158125754 187395355 2003457 2164155 43195 81033 160172406 189640543 743472 707713 0 0 7351855 8480898 0 0 0 149338528 178861418 157433855 188050029 2738551 1590514 91686976 88111531 17965508 16727898 73721468 71383633 X THE COPORATION EXISTS TO IMPROVE LIVES BY PROMOTING OPTIMAL ORAL HEALTH. 1 0 58125310 64012548 The organization provided dental benefit coverage for 203,887 beneficiaries included among these beneficiaries were I) 12,368 individual enrolles, many of whom are high-risk individuals who may not otherwise receive access to affordable dental benefit coverage. These individuals obtained coverage as a result of the organization's collaboration with charitable and governmental organizations; II) 48,631 enrollees who are or were employed with the state of Arizona, and III) 92 enrollees who were able to obtain coverage through the orgnizatoin's collaboratin with arizona small business association. These individuals may otherwise have been unable to obtain affordable coverage due to the size of the small business. The organization expended more than $133 million for dental care during 2015, with detnal benefits coverage being provided through contracts with indpenedent professional dental service providers. In 2015, the organization began to offer Avesis vision insurance as a complement to its dental offerings. 116718945 115980150 As its largest charitable initiative, the organization is committed to educating the public regarding oral health and wellness. The organizaton's employees participate in continuing education seminars that provide the training necessary for organization employees to educate the public. Public education occurs through in-person seminars and through the dissemination of information in print, as well as through TV,radio, and online awareness efforts. One example of the organization's commitment to oral health education can be viewed on the website http://oralhealthdeltadental.com/. The organization maintains an online database regarding oral health topics and tailors oral health information to individuals by segregating information by age group and providing access to an individualized dental risk assessment tool. The organization also maintains a blog for the public to provide additional information regarding oral health issues. 707713 707713 THE ORGANIZATION ALSO MAKES GRANTS AND DONATES FACILITATIES, EQUIPMENT, AND EMPLOYEE TIME TO SUPPORT MANY CHARITABLE CAUSES. DURING 2015, THE ORGANIZATION PROVIDED OR SUPPORTED PREVENTATIVE DENTAL HEALTH SERVICES, CHILDREN'S ORAL HEALTH SERVICE, DENTAL CLINICS, IN-SCHOOL SCREENINGS, TOBACCO AND CHRONIC DISEASE PREVENTION PROGRAMS, EARLY CHILDHOOD PROGRAMS, PRENATAL AND POSTNATAL ORAL HEALTH, AND ACCESS TO DENTAL SERVICES. 175551968 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 1 0 0 0 0 0 0 1 1 1 0 0 1 12161 0 1 100 1 1 1 0 0 0 0 0 0 0 0 0 X 13 10 0 0 0 0 1 1 1 1 1 0 1 1 1 1 1 1 1 1 1 1 0 AZ X MARK ANDERSON 6029383131 5656 WEST TALAVI BLVD GLENDALE AZ 85306 William Putnam Board Chair 10.00 0.00 X X 29333 0 0 Brien Harvey Vice Chair 3.00 0.00 X X 24000 0 0 Candace Wiest Secretary/Treasurer 3.00 0.00 X X 24000 0 0 Jason Dittberner Board Member 3.00 0.00 X 24000 0 0 Joyce Rosenthal Board Member 3.00 0.00 X 24000 0 0 Donald Baker Board Member 3.00 0.00 X 24000 0 0 Alvin Matthews Board Member 3.00 0.00 X 24000 0 0 Phillip Santucci Board Member 3.00 0.00 X 24000 0 0 Dale Hallberg Board Member 3.00 0.00 X 24000 0 0 Frederick Olsen Board Member 3.00 0.00 X 24000 0 0 Willford Cardon Board Member 3.00 0.00 X 24000 0 0 Mark Hughes Board Member 3.00 0.00 X 8000 0 0 Gary Jones Board Member 3.00 0.00 X 12000 0 0 David Day Board Member 3.00 0.00 X 26667 0 0 Allan Allford President/CEO 40.00 0.00 X 623815 0 22643 Mark Anderson Vice President/CFO 40.00 0.00 X 487566 0 22578 Craig Livesay Vice President 40.00 0.00 X 262533 0 22643 Sandra Ernst Perez Vice President 40.00 0.00 X 222091 0 9003 Patricia Larsen Vice President 40.00 0.00 X 291418 0 15228 Barbara Crawford Vice President 40.00 0.00 X 126545 0 13529 Anne Bishop Vice President 40.00 0.00 X 239178 0 14506 Ashlee Dailey Director of Finance 40.00 0.00 X 136605 0 13528 Jeff Newbill Senior Database Admin 40.00 0.00 X 131166 0 11275 Stacee Grosshans Senior Sales Executive 40.00 0.00 X 126276 0 10398 Mary Lovelass Director of Claims/Customer Service 40.00 0.00 X 118556 0 4270 Kathy Morrow Director of Professional Relations 40.00 0.00 X 117718 0 11474 3199467 0 171075 14 0 1 0 Encara Inc 4818 Starkley Rd Roanoke VA 24018 ADMINISTERS PRODUCTS 1446005 Delta Dental of WI PO Box 828 Stevens Point WI 54481 CLAIM PROCESSING SERVICES 949322 Black Gould & Associates 3800 N Central Ave 9th Floor Phoenix AZ 85012 BROKERAGE SERVICES 702006 MicroAge PO Box 2941 Phoenix AZ 85062 IT SERVICES 679342 Change Healthcare Po Box 572490 Salt Lake City UT 84157 FULFILLMENT PAYMENTS 580158 14 REV - SELF INSUR GROUP 524114 115980150 115980150 DENTAL PREMIUMS 524114 64012548 64012548 COST REIMBURSEMENT 524292 7402657 7402657 187395355 1148628 54675 1093953 36936982 35921455 1015527 1015527 1015527 OTHER INCOME 900099 81033 81033 81033 189640543 179992698 54675 9593170 707713 707713 2689276 1346789 1342487 4233666 4233666 420062 420062 734678 734678 403216 403216 7158471 7158471 129491 129491 88917 88917 319532 319532 5032979 5015112 17867 1620712 1620712 122536 122536 97502 97502 277559 277559 167499 167499 4784 4784 735072 735072 105530 105530 PROFESSIONAL DENTAL SVS 109560474 109560474 SERVICE TO SELF INSURED 50099241 50099241 PREMIUM TAX 1088666 1088666 UNRELATED BUSINESS INCO 5850 5850 2246603 250120 1996483 188050029 175551968 12498061 0 14323423 10296630 11954715 12822449 402785 467542 13596054 5624737 7730713 7971317 43895870 41144890 12167612 13972484 1211858 1436219 91686976 88111531 10626993 13118757 1818519 2422119 38714 19538 5481282 1167484 17965508 16727898 X 73721468 71383633 73721468 71383633 91686976 88111531 X 1590514 -3145530 -782819 X 0 1 X 1 0 1530763 1530763 6691111 1365696 5325415 5353901 4259041 1094860 20279 20279 7971317 Investment in Subsidiary-Southwest Benefit ADM 237882 C Investment in Subsidiary-Canyon Insurance SVS 702880 C Hedge Funds 13031722 F 13972484 Unclaimed Property Liability 638616 Customer Deposit Liability 528868 1167484 X 181849592 10049731 10049731 171799861 17840682 17840682 189640543 182040200 9909981 9909981 172130219 15919810 15919810 188050029 Part X, Line 2: The Company evaluates their uncertain tax positions, if any, on a continual basis through review of their policies and procedures, review of their regular tax filings, and discussions with outside experts. Management believes that at December 31, 2015 and 2014, the Company did not have any uncertain tax positions. Part XI, Line 2d - Other Adjustments: AFFILIATED REVENUE INCLUDED IN FINANCIAL STATEMENTS 10,049,731. Part XI, Line 4b - Other Adjustments: CONSOLIDATING ELIMINATIONS 15,595,494. DIVIDENDS AND INTEREST 1,148,628. OTHER INCOME 81,033. GAIN ON SALE OF SECURITIES AND ASSETS 1,015,527. Part XII, Line 2d - Other Adjustments: AFFILIATED EXPENSES INCLUDED IN FINANCIAL STATEMENTS 9,909,981. Part XII, Line 4b - Other Adjustments: COLSOLIDATING ELIMINATIONS 15,595,494. INVESTMENT MANAGEMENT FEES 319,532. INTEREST EXPENSE 4,784. 1 Delta Dental Plan of Arizona Charitable Foundation and Trust 5656 west talavi blvd glendale AZ 85306 860842694 501 (C)(3) 707713 Annual contribution based on board directivbe to promote oral health 1 Part I, Line 2: The organization's board receives regular reports on the organization's activities and expenditures of grant funds donations are made to establish, well-respected, local public charity orgnaizations. As a result, ongoing monitoring of the use of grant funds is not considered necessary. X X 1 1 X X X X X 1 1 0 1 0 1 0 1 0 Allan Allford President/CEO 430000 0 190350 0 3465 0 7950 0 14693 0 646458 0 0 0 Mark Anderson Vice President/CFO 270000 0 88060 0 129506 0 7885 0 14693 0 510144 0 0 0 Craig Livesay Vice President 205000 0 50730 0 6803 0 7950 0 14693 0 285176 0 0 0 Sandra Ernst Perez Vice President 175000 0 45630 0 1461 0 6665 0 2338 0 231094 0 0 0 Patricia Larsen Vice President 223000 0 63355 0 5063 0 7950 0 7278 0 306646 0 0 0 Anne Bishop Vice President 192000 0 43200 0 3978 0 6527 0 7979 0 253684 0 0 0 Ashlee Dailey Director of Finance 136605 0 0 0 0 0 4324 0 9204 0 150133 0 0 0 Part I, Line 1a 1. First Class Travel - all senior executives are offered this benefit for travel exceeding 4 hours and is not treated as taxable compensation. 2. Travel for companions - The President/CEO receives this benefit and it is treated as taxable compensation. Part I, Lines 4a-b The organization has a nonqualified deferred compensation plan for certain members of senior management as determined by the DDAZ board. Plan balances are credited at the discretion of the board. Mary Loveless received a 6 month severance valued at $56,500. Mark Anderson received a non qualified deferred compensaton distribution of $122,650. Part I, Line 5 CONSISTENT WITH THE ORGANIZATION'S OVERALL COMPENSATION PHILOSOPHY, OFFICERS, HIGHLY COMPENSATED, AND OTHER DESIGNATED EMPLOYEES PARTICIPATE IN AN ORGANIZATION INCENTIVE COMPENSATION PLAN. THE PLAN CONTAINS METRICS WHICH REPRESENT STRATEGIC PLAN MEASURES THAT ARE DETERMINED ANNUALLY BY THE BOARD OF DIRECTORS. AN OVERALL WEIGHTED SCORE IS CALCULATED BASED ON ACHIEVEING A RANGE OF PLAN MEASURES, AMONG WHICH ARE INCENTIVES RELATED TO REVENUE GOALS. Part I, Line 6 Consistent with the organization's overall compensation philosophy, officers, highly compensated, and other designated employees participate in an organization incentive compensation plan. The plan contains metrics which represent strategic plan measures that are determined annually by the board of directors. An overall weighted score is calculated based on achieving a range of plan measures, among which are incentives related to revenue goals. Part I, Line 7 Consistent with the organization's overall compensation philosophy, the compensation of officers and highly compensated employees include the potential for a bonus based upon furthering the charitable purposes of the organization. This goal includes preservation of income which provides the organization with the resources necessary to accomplish its charitable purposes. Donald Baker DIRECTOR 702006 PAYMENTS WERE MADE TO BLACK GOULD & ASSOCIATES FOR BROKERAGE SERVICES. BOARD MEMBER DONALD BAKER IS VICE PRESIDENT OF THE FIRM CONTRACTED PROVIDER. 0 JOYCE ROSENTHAL DIRECTOR 126961 CONTRACTED PROVIDER PAYMENTS WERE MADE TO BOARD MEMBER JOYCE ROSENTHAL CONSISTENT WITH REGULAR COMPANY REIMBURSEMENT RATES. 0 JASON DITTBERNER DIRECTOR 118956 CONTRACTED PROVIDER PAYMENTS WERE MADE TO BOARD MEMBER JASON DITTBERNER CONSISTENT WITH REGULAR COMPANY REIMBURSEMENT RATES. 0 Form 990, Part III, line 2 IN 2015, DELTA DENTAL OF ARIZONA BEGAN TO OFFER AVESIS VISION INSURANCE AS A COMPLEMENT TO ITS DENTAL OFFERINGS. Form 990, Part VI, Section A, line 6 Any ethical dentist duly licensed and in good standing in the state of arizona is eligible to be a member of the organization. Members elect the board of directors. Members do not have an ownership interest in the organization. Form 990, Part VI, Section A, line 7a Members of the organization have authority to elect delta dental's governing body. No other group or person can vote for those who serve on the organization's governing body. Form 990, Part VI, Section A, line 7b These bylaws may be altered, amended or repealed and new bylaws may be adopted only by the affirmative vote of two thirds of the members present at a meeting of the members at which a quorum is present. Form 990, Part VI, Section B, line 11 THE ORGANIZATION HAS A PROCESS FOR THE GOVERNING BODY TO RECEIVE AND REVIEW THE 990 BEFORE IT IS FILED. THAT PROCESS INCLUDES THE FOLLOWING STEPS 1. MANAGEMENT'S ENGAGEMENT OF OUTSIDE PROFESSIONAL SERVICES TO PREPARE AND DRAFT THE FORM 990. 2. MANAGEMENT'S REVIEW OF THE DRAFT FORM 990 TO CHECK FOR ACCURACY. 3. THE REVIEW OF THE DRAFT FORM 990 BY THE COMPANY'S AUDIT AND INVESTMENT COMMITTEE. 4. PROVIDING THE PROPOSED FINAL DRAFT OF THE FORM 990 TO THE BOARD OF DIRECTORS BEFORE FILING THE DOCUMENT WITH THE IRS. Form 990, Part VI, Section B, line 12c THE ORGANIZATION HAS A POLICY IN PLACE TO MONITOR AND ENFORCE COMPLIANCE WITH ITS CONFLICT OF INTEREST POLICIES WHICH COVER BOTH BOARD MEMBERS AND EMPLOYEES UPON HIRE AND ANNUALLY. THEREAFTER, MEMBERS OF THE GOVERNING BOARD ARE REQUIRED TO EXECUTE THE CONFLICT OF INTEREST POLICY. UPON HIRE, EMPLOYEES ARE REQUIRED TO EXECUTE THE CONFLICT OF INTEREST POLICY. THE ORGANIZATION HAS PROCEDURES IN PLACE TO REMIND EMPLOYEES AND OFFICERS/DIRECTORS OF THE COMPANY OF THE POLICY AND OF THE NEED TO BE ATTENTIVE TO THE POSSIBLITY OF NEWLY CREATED CONFLCTS OF INTEREST. FURTHER, IN CONNECTION WITH THE ORGNIZATIONS DUE DILIGENCE ASSOCIATED WITH THE PREPARATION OF FILING OF THE FORM 990, A SPEARATE PROCESS IS USED TO OBTAIN INFORMATION FROM DIRECTORS AND EMPLOYEES TO ENABLE THE ORGANIZATION TO ASSESS THE EXISTENCE OF TRANSACTIONS OR RELATIONSHIPS THAT SHOULD BE DISCLOSED BY THE ORGANIZATION. POTENTIAL AND ACTUAL CONFLICTS INVOLVING EMPLOYEES OTHER THAN THE CEO AND CFO ARE REVEIWED BY THE CEO AND CFO POTENTIAL AND ACTUAL CONFLICTS OF THE CEO, CFO. AND BOARD MEMBERS ARE REVIEWED BY THE EXECUTIVE COMMITTEE OF THE BOARD. IN ALL INSTANCES INVOLVING AN ACTUAL CONFLICT OF INTEREST, THE CONFLICTED EMPLOYEE OR BOARD MEMBER IS ASKED TO RECUSE HIMSELF FROM DELIBERATIONS ABOUT THE POTENTIAL TRANSACTION. Form 990, Part VI, Section B, line 15 The organization has a process in place for independent consultants to review and report on compensation of the CEO, officers, key employees, and board member compensation with final review and approval by the board of directors. This includes review of comparability, data, and obtaining the independent consultant's opinion of the reasonableness of compensation decisions made by the organization. Independent consultant reviews are performed for executive staff and board compensation every two years. Reviews were last peformed in 2014. Form 990, Part VI, Section C, line 19 As required by Arizona state law, the organization makes its governing documents and financial statements available to the public. The organization does not make its conflict of interest statement available to its members or to the public. Members of the public may obtain copies of the articles of incorporation from the arizona corporation commission. Members of the public also may obtain copies of Delta Denta's statutory financial statements from the Arizona department of insurance and from the national association of insurance commissioners. Form 990, Part XI, line 9: LOSSES FROM CONSOLIDATED RELATED PARTIES -782,819. AZ Delta Insurance Service Holdings LLC 5656 West TAlavi BLVD Glendale AZ 85306 Holding Company AZ 0 0 N/A Delta Dental Plan of Arizona Charitable Foundation and Trust 5656 W Talavi Blvd Glendale AZ 85306 860842694 TO IMPROVE ORAL HEALTH ACROSS ARIZONA FOR INDIVIDUALS AND COMMUNITIES AZ 501(c)(3) PF N/A 0 Canyon Insurance Service Inc 5656 West Talavi Blvd Glendale AZ 85306 412139223 Insurance AZ AZ Dental C 1629127 869785 1.00000 1 Southwest Benefit Aministrators LLC 5656 West Talavi Blvd glendale AZ 85306 680586699 ADMIN SERVICES AZ aZ Dental C 7158473 244686 1.00000 1 0 1 0 0 1 0 0 0 0 0 0 1 1 1 1 0 0 0 0 Southwest benefit administrators LLC L 7158471 FMV Southwest benefit administrators LLC M 7158472 fmv