2014-08-21T06:15:53-05:00 2013-12-31 521511275 RAFFA PC 1899 L STREET NW SUITE 900 WASHINGTON DC 20036 990 2013-01-01 200413676 HEALTHWELL FOUNDATION HEAL 2406325311 9801 WASHINGTONIAN BLVD 9TH FLOOR GAITHERSBURG MD 208785355 STEPHEN WEINER BOARD CHAIR 2406325311 2014-08-21 1 FRANK H SMITH P00639053 2028225000 2014-08-19 2013 2015-11-30 17:44:51Z KRISTA ZODET 9801 WASHINGTONIAN BLVD 9TH FLOOR GAITHERSBURG MD 208785355 38160217 0 X WWW.HEALTHWELLFOUNDATION.ORG X 2003 DC PROVIDES FINANCIAL ASSISTANCE TO INSURED INDIVIDUALS WITH HIGH OUT-OF-POCKET MEDICATION EXPENSES. 6 6 11 0 0 0 42379225 18482644 0 0 2011460 996272 0 0 44390685 19478916 36995288 31135498 0 0 1451229 1436451 234258 200233 347636 9436289 7673744 48117064 40445926 -3726379 -20967010 64012596 41873758 5573206 3078978 58439390 38794780 X ASSIST INCOME ELIGIBLE INSURED INDIVIDUALS IN OBTAINING NECESSARY MEDICATIONS. THE INDIVIDUALS ASSISTED BY THE FOUNDATION ARE AWARDED GRANTS ON A NONDISCRIMINATORY, OBJECTIVE AND FIRST-COME, FIRST-SERVED BASIS. THE FOUNDATION PROVIDES ASSISTANCE TO ELIGIBLE INDIVIDUALS ONLY FOR THE USE OF PRODUCTS THAT ARE APPROVED BY THE FOOD AND DRUG ADMINISTRATION, OR - IN SOME CASES - ARE COMPENDIA-LISTED FOR A SPECIFIC DISEASE INDICATION. 0 0 10185475 9166991 AUTOIMMUNE - MEDICARE ACCESS - ASSISTED 4,416 ELIGIBLE MEDICARE BENEFICIARIES WITH DEDUCTIBLE, COINSURANCE, OR COPAYMENT OUT OF POCKET EXPENSES RELATED TO THE TREATMENT OF RHEUMATOID ARTHRITIS, PSORIASIS, PSORIATIC ARTHRITIS, AND ANKYLOSING SPONDYLITIS. 7749714 6627978 ASTHMA, MODERATE TO SEVERE - ASSISTED 5,300 ELIGIBLE PATIENTS WITH DEDUCTIBLE, COINSURANCE, AND COPAYMENT EXPENSES RELATED TO THE TREATMENT OF MODERATE TO SEVERE ASTHMA. 3987216 3693009 IMMUNOSUPPRESSIVE TREATMENT FOR SOLID ORGAN TRANSPLANT RECIPIENTS - ASSISTED 3,796 ELIGIBLE PATIENTS WITH DEDUCTIBLE, COINSURANCE, COPAYMENT, OR PREMIUM EXPENSES ALLOWING THEM TO BEGIN OR CONTINUE IMMUNOSUPPRESSIVE THERAPY TO PREVENT REJECTION OF THE TRANSPLANTED ORGAN. 2582788 2257011 CYTOMEGALOVIRUS DISEASE 1893540 1707737 CHRONIC MYELOID LEUKEMIA MEDICARE ACCESS 1887432 1777170 SECONDARY HYPERPARATHYROIDISM 1591650 1057222 SYSTEMIC LUPUS ERYTHEMATOSUS 1527645 1194432 CARCINOID TUMORS AND ASSOCIATED SYMPTOMS MEDICARE ACCESS 1494908 953198 INFLAMMATORY BOWEL DISEASE MEDICARE ACCESS 1202221 807641 HEAD AND NECK CANCER 682350 527058 METASTATIC MELANOMA MEDICARE ACCESS 486655 164652 CHEMOTHERAPY INDUCED NEUTROPENIA 472335 360867 DUPUYTREN'S DISEASE 420602 RHEUMATOID ARTHRITIS 320111 205159 CHRONIC GOUT 217182 119796 METASTATIC MELANOMA 185464 177839 ANCA ASSOCIATED VASCULITIS, WEGENER'S AND GRANULOMATOSIS WITH POLYANGIITIS 184978 182673 POST MENOPAUSAL OSTEOPOROSIS 178291 CARCINOID TUMORS AND ASSOCIATED SYMPTOMS 171674 ANEMIA ASSOCIATED WITH CHRONIC RENAL INSUFFICIENCY/FAILURE 124753 PSORIASIS 121072 91447 IRON OVERLOAD DUE TO MULTIPLE TRANSFUSIONS 99858 PSORIATIC ARTHRITIS 89376 392 CROHN'S DISEASE 73796 24146 BONE METASTASES 70405 CHEMOTHERAPY INDUCED ANEMIA/NEUTROPENIA 69815 BREAST CANCER 54945 ANKYLOSING SPONDYLITIS 53780 COLORECTAL CARCINOMA 52188 39080 OTHER 31136 NON-SMALL CELL LUNG CANCER 12875 IDIOPATHIC THROMBOCYTOPENIC PURPURA 16353825 11647520 38276230 1 1 0 0 0 0 0 0 0 0 1 0 0 0 1 1 1 0 0 0 0 0 0 1 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 15 0 1 11 1 0 0 0 0 0 0 0 0 0 0 X 6 6 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 AL AK AZ AR CA CT FL GA HI IL KS KY LA ME MD MA MI MN MS NH NJ NM NY NC ND OH OK OR PA RI SC TN UT VT VA WA WV WI X X BASKARAN VELLANDURAI 2406325311 9801 WASHINGTONIAN BLVD 9TH FLOOR GAITHERSBURG MD 208785355 STEPHEN WEINER BOARD CHAIR (SEE NOTE IN SCHEDULE J) 2.00 X X 0 0 0 JERRI SCARZELLA VICE CHAIR & TREASURER 1.00 X X 8000 0 0 NANCY CARTERON VICE CHAIR & SECRETARY 1.00 X X 8000 0 0 DAVID KNOWLTON BOARD MEMBER 1.00 X 8000 0 0 DON LISS BOARD MEMBER 1.00 X 0 0 0 SUZANNE MILLER BOARD MEMBER 1.00 X 8000 0 0 MARY P SUNDEEN PRESIDENT - UNTIL 8/2013 40.00 X 208139 0 19493 KRISTA ZODET PRESIDENT 40.00 X 196960 0 21977 SHELA HALPER DIR. OF STRATEGIC DEV. AND MARKETING 40.00 X 159307 0 33840 BASKARAN VELLANDURAI DIRECTOR OF FINANCE & IT 40.00 X 155574 0 24797 751980 0 100107 4 0 1 1 COVANCE MARKET ACCESS 9801 WASHINGTONIAN BLVD 9TH FL GAITHERSBURG MD 20878 OPERATIONS OF PATIENT SERVICES 6340003 COVANCE SPECIALTY PHARMACY 500 EAGLES LANDING WAY LAKES LAND FL 33810 MANAGEMENT OF PHARMACY CARDS 468607 AB DATA GROUP 600 A B DATA DRIVE MILWAUKEE WI 53217 PROFESSIONAL FUNDRAISING 190821 WHITECOAT STRATEGIES LLC 1200 G STREET NW SUITE 800 WASHINGTON DC 20005 PUBLIC RELATIONS, COMMUNICATIONS, AND ST 120923 ML STRATEGIES LLC 701 PENNSYLVANNIA AVENUE NW WASHINGTON DC 20004 STRATEGIC PLANNING AND BUSINESS DEVELOPM 105000 5 18482644 18482644 1397564 1397564 18280009 18681301 -401292 -401292 -401292 19478916 0 0 996272 31135498 31135498 852087 238961 533289 79837 379450 109057 244583 25810 20747 5344 14304 1099 112140 27186 84847 107 72027 21022 46111 4894 5493911 5493491 420 116447 116447 77291 19388 57903 200233 200233 191989 191989 745312 460457 284855 12824 12824 593400 558309 31905 3186 95812 71329 24483 38748 38748 41588 685 24695 16208 6000 6000 82344 82344 144186 135503 8683 6091 6091 STATE REG. FEES 13808 13808 DONATIONS 6840 6840 MEMBERSHIP DUES/SUBS. 4654 2200 2454 TRAINING 2499 2499 40445926 38276230 1822060 347636 737128 2133591 800429 5871226 13000000 2360000 27409 25102 1013764 617346 418285 396418 48889166 30974112 0 1137 140179 112172 64012596 41873758 1267492 800623 3000000 1005000 1305714 1273355 5573206 3078978 X 4024576 4002497 54414814 34792283 58439390 38794780 64012596 41873758 X -20967010 1216570 105830 X 0 1 X 1 0 X 67538322 77404453 52749627 42379225 18482644 258554271 67538322 77404453 52749627 42379225 18482644 258554271 206501516 52052755 2102642 1195776 1419587 1617248 1397564 7732817 2373 2373 266289461 0.19550 0.18110 X HEALTHWELL FOUNDATION (THE "FOUNDATION") OFFERS THE FOLLOWING FACTS AND CIRCUMSTANCES IN SUPPORT OF ITS ONGOING CLASSIFICATION AS A PUBLIC CHARITY AND NOT A PRIVATE FOUNDATION.GENERAL BACKGROUND - THE FOUNDATION PROVIDES NEED-BASED FINANCIAL ASSISTANCE TO UNDERINSURED INDIVIDUALS LIVING WITH CHRONIC AND/OR LIFE-ALTERING ILLNESSES SUCH AS ASTHMA, CANCER AND IMMUNOSUPPRESSIVE DISORDERS. THROUGH 2013, THE FOUNDATION HAS HELPED OVER 175,000 PATIENTS AFFORD THEIR PRESCRIPTION DRUG COPAYMENTS, PREMIUMS AND OTHER OUT-OF-POCKET HEALTH CARE COSTS.THE FOUNDATION GRANTS FUNDS TO PATIENTS WHO HAVE PRIVATE OR GOVERNMENT-SPONSORED INSURANCE BUT WHO ARE STILL UNABLE TO AFFORD THEIR INSURANCE COPAYMENTS OR THE PREMIUMS TO OBTAIN COVERAGE FOR THEIR CONDITIONS. THE FOUNDATION AWARDS THE GRANTS BASED ON THE OBJECTIVE CONSIDERATION OF FINANCIAL AND MEDICAL CRITERIA AND THE ADEQUACY OF THE RECIPIENT'S INSURANCE COVERAGE. GRANTS ARE GIVEN TO RECIPIENTS FOR UP TO ONE YEAR AT A TIME. THE FOUNDATION DOES NOT PLACE RESTRICTIONS ON THE MEDICATIONS ITS RECIPIENTS USE. THE DECISION AS TO WHICH MEDICATIONS ARE PRESCRIBED IS A MEDICAL JUDGMENT. FURTHER, THE FOUNDATION DOES NOT LIMIT THE PROVIDERS OR PHARMACIES ITS RECIPIENTS MAY USE TO OBTAIN THEIR MEDICATIONS.PUBLIC SUPPORT PERCENTAGE - THE FOUNDATION'S CUMULATIVE PUBLIC SUPPORT PERCENTAGE THROUGH DECEMBER 31, 2013 IS AT 19.55%, WHICH IS THE ABOVE THE MINIMUM AMOUNT AT WHICH FACTS AND CIRCUMSTANCES WILL BE CONSIDERED BY THE SERVICE IN DETERMINING THE FOUNDATION'S ONGOING QUALIFICATION AS A PUBLICLY-SUPPORTED CHARITY. THE FOUNDATION'S PUBLIC SUPPORT PERCENTAGE HAS CONSISTENTLY INCREASED SINCE 2004, THE FACTS AND CIRCUMSTANCES RELATING TO THE FOUNDATION'S STRUCTURE AND OPERATIONS PRESENT AN EXCEPTIONALLY STRONG CASE IN SUPPORT OF ITS ONGOING CLASSIFICATION AS A PUBLIC CHARITY AND NOT AS A PRIVATE FOUNDATION. THESE FACTS AND CIRCUMSTANCES, WHICH ARE DISCUSSED IN MORE DETAIL LATER, INCLUDE THE FOLLOWING:1. THE FOUNDATION IS NOT CONTROLLED BY ITS CONTRIBUTORS AND HAS NO ENDOWMENT FUND, CHARACTERISTICS WHICH DISTINGUISH IT FROM VIRTUALLY ALL PRIVATE FOUNDATIONS.2. THE FOUNDATION'S BOARD REPRESENTS MANY DIVERSE ASPECTS OF THE HEALTH CARE COMMUNITY, DEMONSTRATING THE FOUNDATION'S COMMITMENT TO THE BROAD PUBLIC BENEFIT AND THE FOUNDATION'S COMMITMENT TO OPERATE AN OUTSTANDING ORGANIZATION THAT WILL ATTRACT FUTURE PUBLIC SUPPORT.3. THE FOUNDATION'S ACTIVITIES BROADLY BENEFIT THE GENERAL PUBLIC AS WELL AS OTHER CHARITABLE ORGANIZATIONS THAT ARE ATTEMPTING TO HELP PATIENTS COPE WITH MANY DIFFERENT TYPES OF ILLNESSES AND CONDITIONS.FACTS AND CIRCUMSTANCES SUPPORTING QUALIFICATION AS A PUBLICLY-SUPPORTED ORGANIZATION1. ATTRACTION OF PUBLIC SUPPORT. THE FOUNDATION'S POLICY IS TO ACCEPT CONTRIBUTIONS FROM DONORS AND TO DISBURSE THE CONTRIBUTIONS IN THE FORM OF GRANTS AS SOON AS PRACTICABLE. THE FOUNDATION DOES NOT HAVE AN ENDOWMENT FUND, AND ITS ABILITY TO FULFILL ITS FUTURE MISSION IS ENTIRELY DEPENDENT ON ITS ABILITY TO ATTRACT FUTURE SUPPORT FROM DONORS ON A CONTINUOUS BASIS. NONE OF THE FOUNDATION'S HISTORICAL SUBSTANTIAL CONTRIBUTORS HAS PLEDGED OR OTHERWISE COMMITTED TO CONTINUE TO SUPPORT THE FOUNDATION IN FUTURE YEARS. THEREFORE, THE FOUNDATION MUST CONTINUALLY SEEK NEW DONORS TO SUSTAIN ITS FUNDS, AND IT HAS DONE SO. SPECIFICALLY:THE FOUNDATION EMPLOYS 9 PERSONS WHO, IN ADDITION TO THEIR PRIMARY TASKS, MAY ALSO WORK ON FUNDRAISING PROJECTS AS NEEDED.IN ADDITION TO THE PRESIDENT AND DIRECTOR OF STRATEGIC DEVELOPMENT, THE FOUNDATION WORKS WITH A STRATEGIC PUBLIC RELATIONS FIRM AND A HEALTHCARE CONSULTING FIRM TO RESEARCH, IDENTIFY AND HELP PURSUE NEW CORPORATE FUNDRAISING OPPORTUNITIES.THE FOUNDATION REGULARLY SOLICITS SUPPORT FROM PRIVATE INDIVIDUALS, WHICH HAS RESULTED IN DONATIONS FROM MORE THAN 10,000 INDIVIDUAL DONORS.2. REPRESENTATIVE GOVERNING BODY. THE FOUNDATION'S BOARD CONSISTS ENTIRELY OF NATIONALLY-RECOGNIZED HEALTH CARE EXPERTS WITH DEEP EXPERIENCE IN THE FIELDS OF HEALTH CARE ADMINISTRATION, CLINICAL PRACTICE AND RESEARCH, DIRECT PATIENT CARE, PATIENT ADVOCACY AND HEALTH LAW. THE COMPOSITION OF THE BOARD EXEMPLIFIES THE FOUNDATION'S COMMITMENT TO REPRESENT THE BROAD INTERESTS OF THE GENERAL PUBLIC AND TO OPERATE IN A MANNER THAT WILL ATTRACT ATTENTION - AND SUPPORT - FROM A BROAD RANGE OF POTENTIAL DONORS.GIVEN THEIR DIVERSE EXPERIENCES, THE FOUNDATION'S BOARD MEMBERS BRING FORWARD A VARIETY OF IMPORTANT ISSUES TO ENCOURAGE DISCUSSION ABOUT HOW THE FOUNDATION'S PROGRAMS AND SERVICES WILL DIRECTLY IMPACT THE GENERAL PUBLIC. THEIR WIDE-RANGING OPINIONS HELP TO EXPAND THE FOUNDATION'S VIEWPOINT AND RESULT IN AN ORGANIZATION THAT CAN RESPOND SUCCESSFULLY TO IMPORTANT CHANGES IN THE HEALTH CARE ENVIRONMENT.SIGNIFICANTLY, NONE OF THE FOUNDATION'S BOARD MEMBERS IS AFFILIATED WITH ANY CONTRIBUTOR TO THE FOUNDATION, AND IT IS THE FOUNDATION'S STRICT POLICY THAT THERE NOT BE SUCH AFFILIATIONS. MOREOVER, NO CONTRIBUTOR HAS THE POWER TO APPOINT DIRECTORS TO THE FOUNDATION'S BOARD. IN THIS REGARD, THE FOUNDATION DIFFERS MARKEDLY FROM A PRIVATE FOUNDATION, WHERE THE GOVERNING BODY IS TYPICALLY COMPOSED OF SUBSTANTIAL CONTRIBUTORS AND/OR MEMBERS CHOSEN BY SUBSTANTIAL CONTRIBUTORS. 3. AVAILABILITY OF PUBLIC FACILITIES OR SERVICES; PUBLIC PARTICIPATION IN PROGRAMS OR POLICIES. THE FOUNDATION PUTS FORTH SIGNIFICANT EFFORTS TO MAKE THE AVAILABILITY OF ITS PROGRAMS AND SERVICES KNOWN TO THE GENERAL PUBLIC THROUGH AVENUES SUCH AS ITS WEBSITE (WWW.HEALTHWELLFOUNDATION.ORG), WHERE PATIENTS, PROVIDERS, AND ADVOCATES CAN OBTAIN INFORMATION ON THE FOUNDATION'S PROGRAM, APPLY ON-LINE, AND THROUGH INTERACTIVE PORTALS, MANAGE A PATIENT'S PORTFOLIO OF GRANTS (PROVIDERS) OR MONITOR THEIR OWN GRANT (PATIENTS). THESE AVENUES ARE UPDATED CONTINUOUSLY AND MONITORED CLOSELY THROUGHOUT THE YEAR. THE FOUNDATION ENGAGES IN A WIDE RANGE OF PROMOTIONAL OUTREACH ACTIVITIES, INCLUDING MEDIA RELATIONS AND BLOG ACTIVITIES AND TARGETED SOCIAL MEDIA CAMPAIGNS TO EDUCATE THE PUBLIC, PROVIDERS, PHARMACIES AND OTHER HEALTH-RELATED ORGANIZATIONS ABOUT ITS WORK. NEWS ABOUT THE FOUNDATION'S PROGRAMS REGULARLY APPEARS IN LOCAL AND NATIONAL PUBLICATIONS, INCLUDING MEDICAL JOURNALS, NEWSPAPERS, RADIO SHOWS, MAGAZINES, BLOGS AND HEALTHCARE WEBSITES. REPRESENTATIVES OF THE FOUNDATION REGULARLY ATTEND NATIONAL AND LOCAL CONFERENCES TO PROMOTE THE FOUNDATION'S PROGRAM, INCLUDING THOSE OF SUCH ENTITIES AS CBI PATIENT ASSISTANCE PROGRAM, AMERICAN SOCIETY FOR CLINICAL ONCOLOGY (ASCO), MARYLAND LUPUS SUMMIT, AND CBI PATIENT ADHERENCE & SUPPORT.ADDITIONALLY, WHEN THE FOUNDATION ESTABLISHES A NEW FUND WITH RESPECT TO A PARTICULAR DISEASE OR CONDITION, THE FOUNDATION:IDENTIFIES KEY NATIONAL PATIENT ADVOCACY GROUPS AND HEALTH CARE ORGANIZATIONS THAT ARE ABLE TO REACH OUT TO PATIENTS IN THE NEW FUND AREA.IDENTIFIES APPROPRIATE CONTACTS IN EACH ORGANIZATION THAT FOCUS ON PATIENT ADVOCACY AND/OR REIMBURSEMENT ISSUES. INVITES THESE ORGANIZATIONS TO EDUCATE PATIENTS AND PHYSICIANS ABOUT THE FOUNDATION'S PROGRAMS BY POSTING A LINK TO WWW.HEALTHWELLFOUNDATION.ORG ON THEIR WEBSITES, PROMOTING VIA SOCIAL MEDIA, AND/OR INCLUDING INFORMATION ABOUT THE FOUNDATION'S SERVICES IN ANY OF THEIR APPROPRIATE WRITTEN MATERIALS. ISSUES A PRESS RELEASE TO ANNOUNCE A NEW FUND TO THE MEDIA, PATIENT ADVOCACY GROUPS AND THE BROADER HEALTH CARE COMMUNITY.REACHES OUT TO PROSPECTIVE DONORS TO SOLICIT ADDITIONAL SUPPORT FOR THE DISEASE AREA.PROMOTES THE NEW FUND IN ITS NEWSLETTER "THE PULSE" WHICH REACHES OVER 30,000 INDIVIDUALS FOUR TIMES A YEAR, AND THROUGH SOCIAL MEDIA.FURTHERMORE, THE FOUNDATION IS REFERENCED BY, OR IS LINKED TO, THE WEBSITES OF A NUMBER OF ORGANIZATIONS THAT DIRECT PATIENTS FOR COPAYMENT AND PREMIUM ASSISTANCE. SUCH ORGANIZATIONS INCLUDE PARTNERSHIP FOR PRESCRIPTION ASSISTANCE, AMERICAN CANCER SOCIETY, CMS, CAREMARK SPECIALTY PHARMACIES, ARTHRITIS FOUNDATION, PSORIASIS FOUNDATION, LUPUS FOUNDATION OF AMERICA, CANCERCARE, PORPHYRIA FOUNDATION, AND NEEDYMEDS, AMONG OTHERS. CONCLUSIONIN SUMMARY, HEALTHWELL FOUNDATION HAS THE CHARACTERISTICS OF A "PUBLICLY SUPPORTED" ORGANIZATION, BASED ON THE FACTS AND CIRCUMSTANCES TEST DESCRIBED IN SECTION 1.170A-9(E)(3) OF THE TREASURY REGULATIONS. SPECIFICALLY, A SMALL NUMBER OF DONORS DO NOT CONTROL HEALTHWELL; RATHER HEALTHWELL IS A GROWING INSTITUTION THAT BEARS MANY OF THE INDICIA OF A "PUBLICLY SUPPORTED" ORGANIZATION, INCLUDING PUBLIC SUPPORT FROM A WIDE CROSS-SECTION OF DONORS, WITH A REPRESENTATIVE GOVERNING BODY. MOREOVER, HEALTHWELL IS CONTINUING TO SEEK NEW SOURCES OF SUPPORT FROM THE GENERAL PUBLIC AS WELL AS OTHER ORGANIZATIONS. ACCORDINGLY, THE FOUNDATION QUALIFIES AS A "PUBLICLY SUPPORTED" ORGANIZATION DESCRIBED IN SECTION 170(B)(1)(A)(VI). SCHEDULE A, PART II, LINE 10, EXPLANATION OF OTHER INCOME: OTHER INCOME - 2009 AMOUNT: $ 2,373. RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 119381 55879 63502 894383 561467 332916 396418 CO-PAYMENTS AND PREMIUM ASSISTANCE PAYABLE 1273355 1273355 X 20503497 1216570 1216570 19286927 191989 191989 19478916 40148107 0 40148107 191989 105830 297819 40445926 PART X, LINE 2: THE FOUNDATION PERFORMED AN EVALUATION OF UNCERTAIN TAX POSITIONS FOR THE YEAR ENDED DECEMBER 31, 2013, AND DETERMINED THAT THERE WERE NO MATTERS THAT WOULD REQUIRE RECOGNITION IN THE FINANCIAL STATEMENTS OR THAT MAY HAVE ANY EFFECT ON ITS TAX-EXEMPT STATUS. PART XII, LINE 4B - OTHER ADJUSTMENTS: RECOVERY OF PRIOR YEAR GRANTS 105,830. X X X 1 AB DATA GROUP 600 A B DATA DRIVE MILWAUKEE WI 53217 DIRECT MAIL CAMPAIGN 0 306233 189047 117186 306233 189047 117186 AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY DC 1 AUTOIMMUNE 4416 9166991 AAV-ANCA 58 177839 ACUTE PORPHYRIAS 2 5644 ASTHMA - MODERATE TO SEVERE (ASTHMA) 5300 6627978 BONE METASTASES (BM) 43 24146 CARCINOID MA 407 1194432 CML-MA 390 1707737 CHEMOTHERAPY INDUCED NEUTROPENIA (CIN) 461 164652 CYTOMEGALOVIRUS DISEASE (CMV) 1273 2257011 DUPUYTREN'S DISEASE (DD) 404 360867 GOUT 113 205159 HEAD AND NECK CANCER (HNC) 356 807641 HEALTH ACCESS FUND 4 13602 IMMUNOSUPPRESSIVE TREATMENT FOR SOLID ORGAN TRANSPLANT RECIPIENTS (ITSOTP) 3796 3693009 INFLAMMATORY BOWEL DISEASE 486 953198 IRON OVERLOAD AS A RESULT OF BLOOD TRANSFUSIONS (IO) 32 91447 SYSTEMIC LUPUS ERYTHEMATOSUS (SLE - LUPUS) 385 1057222 METASTATIC MELANOMA - MA 140 527058 METASTATIC MELANOMA (METMEL) 39 119796 OSTEOPOROSIS 631 182673 PEDIATRIC FUND 10 19834 SECONDARY HYPERPARATHYROIDISM 1706 1777170 CROHN'S 81 392 PART I, LINE 2: EACH PATIENT SEEKING ASSISTANCE IS SCREENED FOR ELIGIBILITY EITHER BY A FOUNDATION REPRESENTATIVE OR THROUGH OUR ONLINE APPLICATION TOOL. CRITERIA IS STATIC ACROSS ALL THE FOUNDATION FUNDS: THE PATIENT'S HOUSEHOLD INCOME MAY BE UP TO 500% OF THE FEDERAL POVERTY LIMIT, ADJUSTED FOR HOUSEHOLD SIZE AND HIGH COST OF LIVING AREAS; THE PATIENT MUST HAVE A DIAGNOSIS THAT THE FOUNDATION CURRENTLY SUPPORTS; THE PATIENT MUST HAVE INSURANCE COVERAGE FOR THE TREATMENT FOR WHICH THEY ARE SEEKING ASSISTANCE AND THAT TREATMENT MUST BE AN ELIGIBLE TREATMENT UNDER THE HEALTHWELL FUND; THE PATIENT'S PHYSICIAN, NURSE PRACTITIONER OR PHYSICIAN'S ASSISTANT MUST VERIFY THE PATIENT'S DIAGNOSIS AND TREATMENT VIA THE STATEMENT OF TREATMENT FORM; AND TREATMENT MUST BE DISPENSED IN THE UNITED STATES. ONCE A PATIENT IS PRE-QUALIFIED FOR A GRANT, THEY HAVE 30 DAYS DURING WHICH TIME THEY MUST SUBMIT TO THE FOUNDATION A COMPLETED AND SIGNED STATEMENT OF TREATMENT FORM AND ANY OTHER DOCUMENTATION DEEMED NECESSARY BY THE FOUNDATION. UNTIL THE FOUNDATION RECEIVES THESE DOCUMENTS, NO PAYMENTS WILL BE CONSIDERED OR REVIEWED FOR REIMBURSEMENT. UPON RECEIPT AND REVIEW OF THE DOCUMENTATION, IF IT IS DEEMED COMPLETE, THE PATIENT BECOMES FULLY APPROVED. FOR SOME FUNDS, PATIENTS RECEIVE A PHARMACY CARD TO USE AT THE LOCAL RETAIL PHARMACY, THROUGH MAIL ORDER PHARMACY, OR THROUGH SPECIALTY PHARMACY. THE PHARMACY CARD CANNOT BE USED FOR PRIMARY PAYMENT AND PROVIDES ELECTRONIC POINT OF SALE REIMBURSEMENT FOR THE PHARMACY. FOR OTHER FUNDS, THE FOUNDATION REQUIRES THE SUBMISSION OF A COMPLETED REIMBURSEMENT REQUEST FORM ALONG WITH ADDITIONAL INFORMATION AS OUTLINED ON THE FORM. UPON RECEIPT, THE REQUEST IS REVIEWED: A FOUNDATION REPRESENTATIVE ENTERS THE RECEIVED INFORMATION INTO THE SYSTEM AND THE SYSTEM VALIDATES THE DATE OF SERVICE, AN INSURER PAID FIRST, THE PRODUCT IS AN ELIGIBLE TREATMENT UNDER THE HEALTHWELL FUND, AND THE PATIENT HAS AN ACTIVE, FULLY APPROVED GRANT. ONLY IF ALL SYSTEMATIC CHECKS PASS, THE REPRESENTATIVE PROCESSES THE PAYMENT. X X 0 0 0 0 0 0 0 0 0 MARY P SUNDEEN PRESIDENT - UNTIL 8/2013 208139 0 0 0 0 0 10158 0 9335 0 227632 0 0 0 KRISTA ZODET PRESIDENT 196960 0 0 0 0 0 11818 0 10159 0 218937 0 0 0 SHELA HALPER DIR. OF STRATEGIC DEV. AND MARKETING 159307 0 0 0 0 0 9558 0 24282 0 193147 0 0 0 BASKARAN VELLANDURAI DIRECTOR OF FINANCE & IT 155574 0 0 0 0 0 9335 0 15462 0 180371 0 0 0 FORM 990, PART VII, LINE 5: THE BOARD CHAIR OF THE FOUNDATION, STEPHEN WEINER, IS ALSO A PARTNER AT MINTZ, LEVIN, COHN, FERRIS, GLOVSKY, AND POPEO, PC, AN UNRELATED ORGANIZATION. FOR THE YEAR ENDED DECEMBER 31, 2013, THE FOUNDATION PAID A TOTAL OF $29,472 TO THE UNRELATED ORGANIZATION FOR THE TIME INCURRED BY MR. WEINER. FORM 990, PART VI, SECTION B, LINE 11 THE PRESIDENT, THE FOUNDATION'S DIRECTORS, AND THE SENIOR ACCOUNTANT REVIEW THE FEDERAL FORM 990 AND THEN FORWARD IT TO THE TREASURER FOR REVIEW. UPON COMPLETION OF REVIEW, THE PRESIDENT AUTHORIZES THE FEDERAL FORM 990 BE E-FILED AND THEN RETURNS THE FEDERAL FORM 990 TO THE DIRECTOR OF FINANCE. REVIEW CONSISTS OF TRACING ALL FIGURES FROM AUDITED FINANCIAL STATEMENTS TO THE PREPARED FEDERAL FORM 990, AND REVIEWING ANY DISCREPANCIES WITH THE TAX PREPARERS. THE DIRECTOR OF FINANCE PROVIDES EACH BOARD MEMBER A COPY FOR REVIEW PRIOR TO FILING WITH THE INTERNAL REVENUE SERVICE. FORM 990, PART VI, SECTION B, LINE 12C THE STAFF AND BOARD OF DIRECTORS FOLLOW A CODE OF CONDUCT. THE MEMBERS OF THE BOARD OF DIRECTORS SIGN A CONFLICT OF INTEREST DISCLOSURE ANNUALLY. MEMBERS THAT ARE DEEMED TO HAVE A CONFLICT OF INTEREST BASED ON THE ABOVE PROCESS ARE RECUSED FROM PARTICIPATING IN A VOTE WITHIN THAT AREA OF CONFLICT. FORM 990, PART VI, SECTION B, LINE 15 GUIDESTAR NONPROFIT EXECUTIVE COMPENSATION MARKET ANALYSIS DATA WAS USED TO DETERMINE COMPENSATION FOR THE PRESIDENT AND DIRECTORS. THIS MARKET ANALYSIS WAS FURTHER REVIEWED BY KORN-FERRY. FORM 990, PART VI, SECTION C, LINE 19 THE FOUNDATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, FINANCIAL STATEMENTS AND THE FEDERAL FORM 990 ARE AVAILABLE TO THE PUBLIC UPON REQUEST. THE FEDERAL FORM 990 AND ANNUAL REPORT ARE ALSO AVAILABLE AT WWW.HEALTHWELLFOUNDATION.ORG. FORM 990, PART XI, LINE 9: RECOVERY OF PRIOR YEAR GRANTS 105,830.