2015-11-12T09:51:46-06:00 2014-12-31 366055558 Grant Thornton LLP 1717 Main Street Suite 1500 Dallas TX 75201 990 2014-01-01 462737696 Children's Medical Center Health Plan CHIL 2144567000 1935 Medical District Drive Dallas TX 75235 Michele Chulick Treasurer and CFO 2144567000 2015-11-09 1 Rebecca Zecha CPA P00648970 2145612300 2014 2016-02-25 16:41:14Z Peter W Roberts 1935 Medical District Dr Dallas TX 75235 1784 0 X N/A X 2013 TX To insure health coverage for poor, distressed, or underpriviledged children & adults. 5 0 0 0 0 0 0 0 0 0 0 1784 0 0 0 1784 0 0 0 0 778070 2543912 0 0 0 714724 2465697 1492794 5009609 -1492794 -5007825 2008332 5769480 501126 1495099 1507206 4274381 To insure health coverage for poor, distressed, or underpriviledged children & adults in the State of Texas. 0 0 3395804 To insure poor, distressed, or underpriviledged children or adults enrolled in Texas Medicaid (STAR), Children's Health Insurance Program (CHIP), Medicaid recipients on Social Security Administration's Supplemental Security Income (STAR Kids and STAR+PLUS), Medicaid for foster children (STAR health), and Medicare Advantage (covering only those patients that are dually eligible for Medicaid and Medicare benefits) in the State of Texas. 3395804 1 0 0 0 0 0 0 0 0 0 1 0 0 1 1 0 0 1 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 1 0 0 0 1 5 0 1 0 0 0 0 0 0 0 0 0 0 0 X 5 0 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 X Stephanie K Smith 2144567000 1935 Medical District Drive Dallas TX 75235 Christopher J Durovich Chairman & Pres/CEO, CHST 1.00 60.00 X X 0 2109957 115598 Michele Chulick Treas & EVP CAO, CHST 1.00 55.00 X X 0 790705 10400 Peter W Roberts Exec Dir/Pres & EVP PopHlth, CHST 1.00 55.00 X X 0 850161 23037 Denise Levis-Hewson td 42314 Dir & VP Clin Intg Ntw 1.00 50.00 X 0 187963 8801 Ray Tsai MD Med Dir & Pres/Phys CHPG 1.00 50.00 X X 0 342714 16846 Stephanie Slaughter VP COO 50.00 1.00 X 0 373367 19877 Stephanie K Smith Corporate Secretary 1.00 50.00 X 0 108947 10101 0 4763814 204660 0 0 1 0 Health Management Assoc 120 N Washington Sq Ste 705 Lansing MI 48933 Consulting Services 221724 Milliman Inc One Pennsylvania Plaza 38th Floor New York NY 10119 Actuarial Services 156961 The Trizetto Group PO Box 122140 Dallas TX 75312 IT Solutions 133925 3 1784 1784 1784 0 0 1784 X 1976953 1830032 146921 80746 74745 6001 354855 328483 26372 131358 121596 9762 782354 782354 1079 1079 706221 438472 267749 7214 4479 2735 67517 41919 25598 191329 118790 72539 651417 404446 246971 21419 13299 8120 27213 16896 10317 4263 2647 1616 Catering, Meals, Coffee 2996 2996 Business Relations 2675 2675 5009609 3395804 1613805 0 1508332 4283646 82406 907691 4263 0 903428 500000 500000 2008332 5769480 55650 32949 445476 1462150 501126 1495099 X 1507206 4274381 1507206 4274381 2008332 5769480 X -5007825 7775000 X 0 1 X 1 0 X 0 1784 1784 1784 1784 1784 1784 X 869217 3622 865595 38474 641 37833 903428 State Insurance Statutory Deposit 500000 500000 LT Receivable/Payable-CMC 1299188 LT Deferred Rent 162962 1462150 Part X, Line 2 The organization's consolidated financial statements for the year ending December 31, 2014 did not require a FIN 48 footnote. 0 1 0 0 0 0 0 1 0 Christopher J Durovich Chairman & Pres/CEO, CHST 0 978719 0 998539 0 132699 0 93691 0 21907 0 2225555 0 306546 Michele Chulick Treas & EVP CAO, CHST 0 522268 0 264252 0 4185 0 10400 0 0 0 801105 0 0 Peter W Roberts Exec Dir/Pres & EVP PopHlth, CHST 0 519240 0 305471 0 25450 0 10400 0 12637 0 873198 0 0 Denise Levis-Hewson td 42314 Dir & VP Clin Intg Ntw 0 103683 0 70732 0 13548 0 7510 0 1291 0 196764 0 0 Ray Tsai MD Med Dir & Pres/Phys CHPG 0 280608 0 59050 0 3056 0 0 0 16846 0 359560 0 0 Stephanie Slaughter VP COO 0 254251 0 115957 0 3159 0 9651 0 10226 0 393244 0 0 Part I, Line 3 The corporation's (CMCHP) top management official and other officers are employed and compensated by Children's Medical Center of Dallas (Children's). The Children's process is as follows: 1. The Human Resources Committee of the Board is responsible for setting the compensation for executives, except the President and CEO of Children's, which is set by the Board of Directors. The Committee is comprised of independent, non-employee directors with no conflict of interest regarding executive compensation. A written compensation philosophy has been developed by the Human Resources Committee for timeliness and appropriateness. The philosophy defined desired comparator groups for compensation surveys. The comparator groups are from domestic healthcare industry sectors only and do not include any non-healthcare organizations. 2. The compensation philosophy also defines target levels relative to the marketplace comparator groups for base pay, base pay plus incentive pay, and fringe benefits provided to Children's executives. A third-party consultant, Sullivan Cotter, is engaged by the Human Resources Committee and provides independent, expert consulting services in the area of executive compensation market surveying, pay and benefits program design, and administrative services. Salaries for Children's executives (except for the President and CEO) are set by comparing the salaries paid for comparable positions in integrated systems, academic medical centers, and children's hospitals in similar size and scope of services to Children's. 3. The salary for the President and CEO is set in reference to salaries paid for Presidents and CEOs of children's hospitals in similar size and scope of services to Children's. The data is compiled by Sullivan Cotter and they develop and update annually salary ranges unique to each executive position. The Human Resources Committee approves base pay for each executive (except the President and CEO, whose base pay is approved by the Board of Directors) aimed in the aggregate at approximately the middle of executive pay ranges. 4. For other officers and key employees, Children's uses a combination of job evaluation and survey data to determine the market pay range. Part I, Line 4b Non-Qualified Retirement Plan: * Children's Medical Center of Dallas Retirement Income Restoration Plan - There were no employees that received taxable income from the Retirement Income Restoration Plan in 2014. Christopher J Durovich participated in the Retirement Income Restoration Plan. * Children's Medical Center of Dallas Savings Restoration Plan - There were no employees that received taxable income from the Savings Restoration Plan in 2014. Employees who participate in the Savings Restoration Plan are Christopher J Durovich, Michele Chulick, Peter W Roberts, and Ray Tsai. Part I, Line 7 Non-Fixed Payments - The Human Resources Committee of the Board of Directors retains the authority to adjust annual payout percentages solely at their discretion. Form 990, Part VI, Section A, line 6 Children's Health System of Texas (CHST) is the sole member. Form 990, Part VI, Section A, line 7a Directors are appointed by the sole member and approved by the current CMCHP Board of Directors. Form 990, Part VI, Section A, line 7b Member reserve powers are specified in CMCHP's Bylaws and represent those actions by the organization which require member approval. These powers generally encompass changes in the mission of the organization, addition of new members, certain dispositions of assets, amendments to the organization's Certificate of Formation and Bylaws, and appointment of directors. Form 990, Part VI, Section B, line 11 A draft of the Form 990 is presented to the CHST Audit Committee, which has certain delineated authority for the organization, for review with discussion of the draft led by the CHST Chief Financial Officer. A copy of the Form 990 is made available to the directors through our board portal before it is filed. Form 990, Part VI, Section B, line 12c The Board members, including any director, officer, or member of a committee with Board delegated powers, receive a copy of the policy, along with a Statement of Interest form to complete, with their annual Board appointment letter. All disclosures made are reviewed by the Chief Compliance Officer and Vice President, Associate General Counsel and Secretary, and discussed as necessary at the appropriate Board meeting to determine if further action is required. Any individual with a perceived or potential conflict is prohibited from voting or participating in the decision making process regarding such transaction or arrangement. Form 990, Part VI, Section B, line 15 The corporation's (CMCHP) top management official and other officers are employed and compensated by Children's Medical Center of Dallas (Children's). The Children's process is as follows: 1. The Human Resources Committee of the Board is responsible for setting the compensation for executives, except the President and CEO of Children's, which is set by the Board of Directors. The Committee is comprised of independent, non-employee directors with no conflict of interest regarding executive compensation. A written compensation philosophy has been developed by the Human Resources Committee for timeliness and appropriateness. The philosophy defined desired comparator groups for compensation surveys. The comparator groups are from domestic healthcare industry sectors only and do not include any non-healthcare organizations. 2. The compensation philosophy also defines target levels relative to the marketplace comparator groups for base pay, base pay plus incentive pay, and fringe benefits provided to Children's executives. A third-party consultant, Sullivan Cotter, is engaged by the Human Resources Committee and provides independent, expert consulting services in the area of executive compensation market surveying, pay and benefits program design, and administrative services. Salaries for Children's executives (except for the President and CEO) are set by comparing the salaries paid for comparable positions in integrated systems, academic medical centers, and children's hospitals in similar size and scope of services to Children's. 3. The salary for the President and CEO is set in reference to salaries paid for Presidents and CEOs of children's hospitals in similar size and scope of services to Children's. The data is compiled by Sullivan Cotter and they develop and update annually salary ranges unique to each executive position. The Human Resources Committee approves base pay for each executive (except the President and CEO, whose base pay is approved by the Board of Directors) aimed in the aggregate at approximately the middle of executive pay ranges. 4. For other officers and key employees, Children's uses a combination of job evaluation and survey data to determine the market pay range. Form 990, Part VI, Section C, line 19 Certificate of Formation is publically available and the conflict of interest policy is made available upon request. Financial statements are available upon request. Form 990, Part IX, line 11g Consulting & Professional Fees: Program service expenses 438,472. Management and general expenses 267,749. Fundraising expenses 0. Total expenses 706,221. Form 990, Part XI, line 9: CHST Paid-in Capital 7,775,000. Children's Medical Center of Dallas 1935 Medical District Drive Dallas TX 75235 750800628 Hospital TX 501(c)(3) Line 3 Children's Health System of Texas 0 Children's Medical Center Foundation 1935 Medical District Drive Dallas TX 75235 752062015 Foundation TX 501(c)(3) Line 7 Children's Health System of Texas 0 Anesthesiologists For Children 1935 Medical District Drive Dallas TX 75235 752917570 Physicians TX 501(c)(3) Line 9 Children's Health System of Texas 0 Dallas Phys Med Svcs for Children Inc 1935 Medical District Drive Dallas TX 75235 810584868 Physicians TX 501(c)(3) Line 3 Children's Health System of Texas 0 Children's Health System of Texas 1935 Medical District Drive Dallas TX 75235 752062019 Management Company TX 501(c)(3) Line 11b, II N/A 0 Physicians For Children 1935 Medical District Drive Dallas TX 75235 752854505 Physicians TX 501(c)(3) Line 3 Children's Health System of Texas 0 Children's Med Ctr Research Inst at UTSWMC 1935 Medical District Drive Dallas TX 75235 433462044 Research Institute TX 501(c)(3) Line 11a, I Children's Health System of Texas 0 Complex Care Med Svc Corp 1935 Medical District Drive Dallas TX 75235 461893597 Medical Services TX 501(c)(3) Line 3 Children's Health System of Texas 0 Pediatric Partners For Children 1935 Medical District Drive Dallas TX 75235 461917702 Clinically Integrated Network TX 501(c)(3) Line 11a, I Children's Health System of Texas 0 Children's Medical Center Services 1935 Medical District Drive Dallas TX 75235 461934007 Medical Services TX Pending Pending Children's Health System of Texas 0 Children's Population Health 1935 Medical District Drive Dallas TX 75235 463104601 Population Health TX 501(c)(3) Line 11a, I Children's Health System of Texas 0 The Health and Wellness Alliance For Children 1935 Medical District Drive Dallas TX 75235 463080586 Physicians TX 501(c)(3) Line 11a, I Children's Health System of Texas 0 Specialists For Children 1935 Medical District Drive Dallas TX 75235 463110125 Physicians TX Pending Pending Children's Health System of Texas 0 Physicians Quality Alliance of North Texas 1935 Medical District Drive Dallas TX 75235 464049491 Physicians TX 501(c)(3) Line 11a, I Children's Health System of Texas 0 Community Providers for Children 1935 Medical District Drive Dallas TX 75235 463675742 Physicians TX 501(c)(3) Line 11a, I Children's Health System of Texas 0 Southwestern Medical District 5323 Harry Hines Dr Dallas TX 75390 204101612 Medical District TX 501(c)(3) Line 11a, I N/A 0 Women's Auxiliary of CMCD 12720 Hillcrest Rd Dallas TX 75230 752485538 Women's Auxiliary TX 501(c)(3) Line 9 N/A 0 Children's Insurance Company 76 St Paul Street Suite 500 Burlington VT 05401 030328102 Insurance Company VT Children's Health System of Texas C 0 Alternative Care Systems 1935 Medical District Drive Dallas TX 75235 752244475 Other Medical Services TX Children's Health System of Texas C 0 NTPSS Inc 1935 Medical District Drive Dallas TX 75235 471036641 Physician Solutions TX Children's Health System of Texas C 0 Texas Bluebonnet Health Plan 1935 Medical District Drive Dallas TX 75235 472252673 Health Plan TX Children's Health System of Texas C 0 0 0 0 0 1 0 0 0 0 0 0 1 0 1 1 1 0 0 1