2013-08-15T15:26:10-05:00 2012-12-31 521511275 RAFFA PC 1899 L STREET NW SUITE 900 WASHINGTON DC 20036 990 2012-01-01 200413676 HEALTHWELL FOUNDATION HEAL 2406325311 9801 WASHINGTONIAN BLVD 9TH FLOOR GAITHERSBURG MD 208785355 STEPHEN WEINER 2406325311 2013-08-15 1 FRANK H SMITH P00639053 2028225000 2013-08-14 2012 2016-02-25 16:41:14Z MARY P SUNDEEN 9801 WASHINGTONIAN BLVD 9TH FLOOR GAITHERSBURG MD 208785355 112440969 0 X WWW.HEALTHWELLFOUNDATION.ORG X 2003 DC PROVIDES FINANCIAL ASSISTANCE TO INSURED INDIVIDUALS WITH HIGH OUT-OF-POCKET MEDICATION EXPENSES. 6 6 12 0 0 0 52749627 42379225 0 0 1092568 2011460 0 0 53842195 44390685 49521777 36995288 0 0 1200720 1451229 186388 234258 331926 14609716 9436289 65518601 48117064 -11676406 -3726379 66318603 64012596 4719259 5573206 61599344 58439390 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 11251122 9652976 AUTOIMMUNE - ASSISTED 5,666 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. 8829985 8029800 ASTHMA, MODERATE TO SEVERE - ASSISTED 6,892 ELIGIBLE PATIENTS WITH DEDUCTIBLE, COINSURANCE, AND COPAYMENT EXPENSES RELATED TO THE TREATMENT OF MODERATE TO SEVERE ASTHMA. 4079517 3251463 IMMUNOSUPPRESSIVE THERAPY - ASSISTED 4,162 ELIGIBLE PATIENTS WITH DEDUCTIBLE, COINSURANCE, COPAYMENT, OR PREMIUM EXPENSES ALLOWING THEM TO BEGIN OR CONTINUE IMMUNOSUPPRESSIVE THERAPY TO PREVENT REJECTION OF THE TRANSPLANTED ORGAN. 3695324 3519453 CHEMOTHERAPY-INDUCED NEUTROPENIA 2289546 974372 RHEUMATOID ARTHRITIS 1969012 591299 NON-HODGKIN'S LYMPHOMA 1782640 1409332 SECONDARY HYPERPARATHYROIDISM 1611679 1540776 CROHN'S DISEASE 1339926 1309370 CYTOMEGALOVIRUS 1255133 1213681 METASTATIC MELANOMA 956611 768816 CARCINOID TUMORS 919485 788937 HEAD AND NECK CANCER 852433 796610 LUPUS 744748 384589 PSORIASIS 665049 0 BREAST CANCER 592815 550697 CHRONIC MYELOID LEUKEMIA - MEDICARE ACCESS 418372 296193 CHRONIC MYELOID LEUKEMIA 305801 176033 PSORIATIC ARTHRITIS 283612 292469 DUPUYTREN'S DISEASE 276160 254528 AGE-RELATED MACULAR DEGENERATION 271098 191885 IRON OVERLOAD DUE TO MULTIPLE TRANSFUSIONS 225356 166176 GOUT 202821 114046 IDIOPATHIC THROMBOCYTOPENIC PURPURA 196597 190443 OSTEOPOROSIS 189218 181071 BONE METASTASES 162515 0 CHEMOTHERAPY-INDUCED ANEMIA/NEUTROPENIA 143850 37861 ANEMIA ASSOCIATED WITH CHRONIC RENAL INSUFFICIENCY/FAILURE 127758 85664 ASSOCIATED VASCULITIS AND WEGENERS 125890 84958 ANKYLOSING SPONDYLITIS 125366 9142 COLORECTAL CARCINOMA 118728 0 CHEMOTHERAPY-INDUCED ANEMIA 89017 0 NON-SMALL CELL LUNG CANCER 108728 55592 OTHER 77056 77056 INFLAMMATORY BOWEL DISEASE 2206 0 HEPATITIS 22124550 16061049 46285174 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 12 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 2.00 X X 0 0 0 JERRI SCARZELLA 1.00 X X 8000 0 0 NANCY CARTERON 1.00 X X 8000 0 0 DAVID KNOWLTON 1.00 X 8000 0 0 DON LISS 1.00 X 0 0 0 SUZANNE MILLER 1.00 X 8000 0 0 MARY P SUNDEEN 40.00 X 258930 0 37792 KRISTA ZODET 40.00 X 190372 0 20197 SHELA HALPER 40.00 X 170707 0 23345 BASKARAN VELLANDURAI 40.00 X 158974 0 23610 810983 0 104944 4 0 1 1 COVANCE MARKET ACCESS 9801 WASHINGTONIAN BLVD 9TH FL GAITHERSBURG MD 20878 OPERATIONS OF PATIENT SERVICES 7847937 COVANCE SPECIALTY PHARMACY 500 EAGLES LANDING WAY LAKES LAND FL 33810 MANAGEMENT OF PHARMACY CARDS 494516 AB DATA GROUP 600 A B DATA DRIVE MILWAUKEE WI 53217 PROFESSIONAL FUNDRAISING 220053 OBER KALER GRIMES & SHRIVER 1401 H ST NW STE 500 WASHINGTON DC 20005 LEGAL SERVICES 138685 4 42379225 42379225 1617248 1617248 68444496 68050284 394212 394212 394212 44390685 0 0 2011460 36995288 36995288 915927 355775 515025 45127 346238 179335 144424 22479 23643 8805 13483 1355 97266 34810 60339 2117 68155 26907 38146 3102 7136478 7127613 2760 6105 135913 507 135406 83685 29610 54075 234258 234258 181650 181650 665301 577726 87575 26919 793 26126 811981 727487 80742 3752 110563 85400 25163 37620 37620 36430 763 35080 587 20450 602 19848 8007 8007 143515 127845 15670 4279 4279 STATE REG. FEES 13044 13044 DONATIONS 11950 11950 TRAINING 5908 5908 MEMBERSHIP DUES/SUBS. 2596 2596 48117064 46285174 1499964 331926 45599 737128 17360043 800429 13000000 27409 891609 473324 468499 418285 48247233 48889166 197229 140179 66318603 64012596 2171355 1267492 3000000 2547904 1305714 4719259 5573206 X 3381943 4024576 58217401 54414814 61599344 58439390 66318603 64012596 X -3726379 518547 47878 X 0 1 X 1 0 X 62065378 67538322 77404453 52749627 42379225 302137005 62065378 67538322 77404453 52749627 42379225 302137005 245636739 56500266 3529018 2102642 1195776 1419587 1617248 9864271 2373 2373 312003649 0.18110 0.16150 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-THREATENING ILLNESSES SUCH AS ASTHMA, CANCER AND AUTOIMMUNE DISORDERS. THROUGH 2012, THE FOUNDATION HAS HELPED APPROXIMATELY 173,000 PATIENTS AFFORD THEIR PRESCRIPTION DRUG CO-PAYMENTS, 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 CO-PAYMENTS OR THE PREMIUMS TO OBTAIN COVERAGE FOR THEIR CONDITIONS. THE FOUNDATION MAKES ITS AWARDS 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, 2012 IS AT 18.11%, WHICH IS 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 10 PERSONS WHO, IN ADDITION TO THEIR PRIMARY TASKS, MAY ALSO WORK ON FUNDRAISING PROJECTS AS NEEDED.THE FOUNDATION'S CORPORATE CUMULATIVE DONOR BASE HAS INCREASED EACH YEAR FROM ONE CORPORATE DONOR IN 2004 TO 18 CORPORATE DONORS.IN ADDITION TO THE DIRECTOR OF DEVELOPMENT, THE FOUNDATION WORKS WITH A DEVELOPMENT CONSULTING FIRM TO RESEARCH, IDENTIFY AND HELP PURSUE NEW FUNDRAISING OPPORTUNITIES.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 OF DIRECTORS. HEALTHWELL BOARD MEMBERS MAKE INDIVIDUAL CHARITABLE CONTRIBUTIONS; THERE IS NO CONFLICT WITH INDIVIDUAL TIES TO LARGE CONTRIBUTORS AS ATTESTED THROUGH ANNUAL CONFLICT OF INTEREST STATEMENTS SIGNED BY EACH BOARD MEMBER. 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 A ROBUST SOCIAL MEDIA CAMPAIGN, TO EDUCATE THE PUBLIC, PROVIDERS, PHARMACIES AND OTHER HEALTH-RELATED ORGANIZATIONS ABOUT THIS 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 THE AMERICAN COLLEGE OF RHEUMATOLOGY, NATIONAL KIDNEY FOUNDATION, CBI PATIENT ASSISTANCE PROGRAM, AND AMERICAN SOCIETY FOR CLINICAL ONCOLOGY (ASCO).ADDITIONALLY, WHEN THE FOUNDATION ESTABLISHES A NEW FUND WITH RESPECT TO A PARTICULAR DISEASE OR CONDITION, THE FOUNDATION:IDENTIFIES KEY NATIONAL PATIENT ORGANIZATIONS AND MEDICAL SPECIALTY SOCIETIES 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 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 HEALTHCARE 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 27,000 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 CO-PAYMENT AND PREMIUM ASSISTANCE. SUCH ORGANIZATIONS INCLUDE CMS, CAREMARK SPECIALTY PHARMACIES, ARTHRITIS FOUNDATION, PSORIASIS FOUNDATION, LUPUS FOUNDATION OF AMERICA, CANCERCARE, MID - ATLANTIC RENAL COALITION, AND NEEDYMEDS, AMONG OTHERS. CONCLUSIONIN SUMMARY, THE 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 THE FOUNDATION; RATHER THE FOUNDATION 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, THE FOUNDATION 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). RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 57994 51452 6542 833615 421872 411743 418285 CO-PAYMENTS AND PREMIUM ASSISTANCE PAYABLE 1305714 1305714 X 44727582 518547 518547 44209035 181650 181650 44390685 47887536 0 47887536 181650 47878 229528 48117064 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X, LINE 2: THE FOUNDATION PERFORMED AN EVALUATION OF UNCERTAIN TAX POSITIONS FOR THE YEAR ENDED DECEMBER 31, 2012, 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 47,878. X X X 1 AB DATA GROUP 600 A B DATA DRIVE MILWAUKEE WI 53217 DIRECT MAIL CAMPAIGN 0 287769 220053 67715 287769 220053 67715 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 5666 9652976 AAV-ANCA 70 85664 ACUTE PORPHYRIAS 9 15445 AGE-RELATED MACULAR DEGENERATION (AMD) 213 254528 ANEMIA ASSOCIATED WITH CHRONIC RENAL INSUFFICIENCY/FAILURE (CRICRF) 142 37861 ANKYLOSING SPONDYLITIS (AS) 41 84958 ASTHMA - MODERATE TO SEVERE (ASTHMA) 6892 8029800 BONE METASTASES (BM) 384 181071 CARCINOID TUMORS (CARCINOID) 538 768816 CARCINIOD MA 30 9142 CHEMOTHERAPY INDUCED NEUTROPENIA (CIN) 4781 3519453 CML-MA 137 550697 CHRONIC MYELOID LEUKEMIA (CML) 79 296193 CROHN'S DISEASE - MEDICARE ACCESS (CD) 1054 1540776 CUTANEOUS T-CELL LYMPHOMA (CTCL) 22 38569 CYTOMEGALOVIRUS DISEASE (CMV) 1016 1309370 DUPUYTREN'S DISEASE (DD) 596 292469 GOUT 187 166176 HEAD AND NECK CANCER (HNC) 971 788937 IDIOPATHIC THROMBOCYTOPENIC PUPURA (ITP) 119 114046 IMMUNOSUPPRESSIVE TREATMENT FOR SOLID ORGAN TRANSPLANT RECIPIENTS (ITSOTP) 4162 3251463 INFLAMMATORY BOWEL DISEASE 90 77056 IRON OVERLOAD AS A RESULT OF BLOOD TRANSFUSIONS (IO) 62 191885 SYSTEMIC LUPUS ERYTHEMATOSUS (SLE - LUPUS) 732 796610 METASTATIC MELANOMA (METMEL) 535 1213681 NON-HODGKINS LYMPHOMA (NHL) 397 591299 OSTEOPOROSIS 1043 190443 PSORIASIS 194 384589 PSORIATIC ARTHRITIS (PSA) 91 176033 RHEUMATOID ARTHRITIS (RA) 516 974372 SECONDARY HYPERPARATHYROIDISM (SHPT) 1637 1409332 GLIOBLASTOMA MULTIFORME/ANAPLASTIC ASTROCYTOMA (GBMAA) 1 500 WILMS' TUMOR 2 1078 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, 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 1 0 MARY P SUNDEEN 258930 0 0 0 0 0 15000 0 22792 0 296722 0 0 0 KRISTA ZODET 183072 0 7300 0 0 0 11422 0 8775 0 210569 0 0 0 SHELA HALPER 159307 0 6400 0 5000 0 9942 0 13403 0 194052 0 0 0 BASKARAN VELLANDURAI 155774 0 3200 0 0 0 9526 0 14084 0 182584 0 0 0 PART I, LINE 7 ALL BONUS PAYMENTS RECEIVED BY OFFICERS, KEY EMPLOYEES, AND HIGHEST COMPENSATED EMPLOYEES LISTED IN FORM 990, PART VII ARE BASED ON AN APPRAISAL OF HIS/HER PERFORMANCE. SUPPLEMENTAL INFORMATION PART III 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, 2012, THE FOUNDATION PAID A TOTAL OF $13,074 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 ACCOUNTING MANAGER 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. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 9: RECOVERY OF PRIOR YEAR GRANTS 47,878.