2013-11-15T14:29:56-06:00 2012-12-31 381357951 PLANTE & MORAN PLLC 1111 MICHIGAN AVE EAST LANSING MI 48823 990 2012-01-01 610659432 DELTA DENTAL OF KENTUCKY INC DELT 5027365000 10100 LINN STATION ROAD NO 700 LOUISVILLE KY 40223 RUSSELL W SKAGGS 5027365000 2013-11-14 1 SUSAN MIENCIER CPA P00842339 5173326200 2012 2016-03-07 17:11:31Z CLIFFORD T MAESAKA JR 10100 LINN STATION ROAD NO 700 LOUISVILLE KY 40223 167721998 0 X WWW.DELTADENTALKY.COM X 1966 KY DELTA DENTAL OF KENTUCKY'S MISSION HAS ALWAYS BEEN TO BE THE LEADER IN OUR MARKETS, TO DELIVER UNMATCHED QUALITY AND VALUE IN OUR PROGRAMS AND SERVICES, AND TO VIGOROUSLY PROMOTE THE IMPORTANCE OF ORAL HEALTH AS AN ESSENTIAL PART OF OVERALL HEALTH. ITS OVERARCHING MISSION IS TO BE THE DENTAL BENEFITS COMPANY OF CHOICE IN THE MARKETS WE SERVE. 13 11 88 0 0 0 0 0 150374666 159274037 710008 308551 -189611 -247256 150895063 159335332 41850 2062204 129104585 136870410 6920321 7322060 0 0 0 9796897 9727598 145863653 155982272 5031410 3353060 69833049 76806803 17111794 17758849 52721255 59047954 X DELTA DENTAL OF KENTUCKY'S MISSION HAS ALWAYS BEEN TO BE THE LEADER IN OUR MARKETS, TO DELIVER UNMATCHED QUALITY AND VALUE IN OUR PROGRAMS AND SERVICES, AND TO VIGOROUSLY PROMOTE THE IMPORTANCE OF ORAL HEALTH AS AN ESSENTIAL PART OF OVERALL HEALTH. ITS OVERARCHING MISSION IS TO BE THE DENTAL BENEFITS COMPANY OF CHOICE IN THE MARKETS WE SERVE. 0 0 153703415 2062204 159274037 THE ORGANIZATION PROVIDES ACCESS TO ORAL HEALTH CARE PROVIDERS THROUGH DENTAL BENEFIT PROGRAMS AS A MEMBER OF THE DELTA DENTAL PLANS ASSOCIATION. SERVICES BENEFITED APPROXIMATELY 636,000 INDIVIDUALS. 153703415 0 0 0 0 0 0 0 0 0 1 1 0 1 1 1 0 1 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 1 18583 0 1 88 1 0 0 0 0 0 0 X 13 11 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 1 1 X X RUSSELL W SKAGGS VP - FINANCE 5027365000 10100 LINN STATION ROAD STE 700 LOUISVILLE KY 40223 CARRIE B BROWN DMD 2.00 0.00 X 12800 0 3500 MICHAEL CHILDERS DMD 2.00 0.00 X 22150 0 0 MARY M CORBETT 2.00 0.00 X 16950 0 0 OLIVIA F KIRTLEY 2.00 5.00 X 1400 21400 17000 MICHAEL B MOUNTJOY 2.00 5.50 X 2150 30500 17000 JOHN L G RICHARDS 2.00 0.00 X 13400 0 0 C RICHARD SEITZ 2.00 11.00 X 16800 26000 0 BRUCE R SMITH 2.00 15.00 X 16300 37440 0 JEFFREY C SMITH 2.00 0.00 X 32150 0 0 J JUDE THOMPSON 2.00 0.00 X 15800 0 0 JOHN N WILLIAMS JR DMD 2.00 0.00 X X 16250 0 0 CLIFFORD T MAESAKA JR 35.00 5.00 X X 519754 0 51581 J DAVID SMITH 2.00 0.00 X 16550 0 0 STEPHEN C DAY 40.00 0.00 X 236994 0 40991 JOHN L WEEKS III 40.00 0.00 X 262165 0 37057 ANGELA J NENNI 40.00 0.00 X 228368 0 31073 TAMARA L YORK-DAY 40.00 0.00 X 226994 0 33096 RUSSELL W SKAGGS 40.00 0.00 X 168992 0 39415 GORAN JURKOVIC CPA 2.00 48.00 X 0 545232 302478 RONALD E STORY 40.00 0.00 X 135877 0 18168 LINA K STIRSMAN 40.00 0.00 X 127351 0 26382 BRIAN E KRAINER 40.00 0.00 X 188148 0 22794 JAMES C FINN 40.00 0.00 X 116348 0 25519 2393691 660572 666054 10 0 1 0 DELTA DENTAL PLAN OF MICHIGAN PO BOX 30416 LANSING MI 48909 ADMINISTRATIVE SERVICES 646448 VINTAGE PRINTING 967 S 11TH ST LOUISVILLE KY 40210 PRINTING & POSTAGE 496224 DELTA DENTAL OF VIRGINIA 4860 COX ROAD SUITE 130 GLEN ALLEN VA 23060 ANNUAL SYSTEM MAINTENANCE 432755 MERCER HEALTH & BENEFITS LLC 10 WEYBOSSET STREET SUITE 502 PROVIDENCE RI 02903 BENEFITS CONSULTING AND BROKERAGE SERVIC 274372 MEDLINK INC 315 WEST 17TH ST BLOOMINGTON IN 47404 MANAGED IT SERVICES 234871 14 SUBSCRIBER REVENUE 524114 159256037 159256037 SUBSIDIARY MANAGEMENT 900099 18000 18000 159274037 269060 269060 286742 533998 -247256 -247256 -247256 7891155 1004 7850820 1848 40335 -844 39491 39491 159335332 159274037 0 61295 2062204 2062204 136870410 136870410 1668073 353826 1314247 4519242 4519242 8535 8535 774337 774337 351873 270238 81635 188799 188799 39693 39693 98285 98285 24000 24000 351435 316291 35144 284860 185159 99701 634113 634113 852196 741411 110785 407428 203714 203714 17120 10272 6848 194 194 83150 74835 8315 63948 63948 BROKER COMMISSIONS 5609272 5609272 POSTAGE & SHIPPING 374294 370551 3743 PRINTING & PUBLICATIONS 251194 251194 PROCESSING FEES 249086 249086 198531 198531 155982272 153703415 2278857 0 11845904 15549197 329382 366804 7290344 7868422 97900 257611 13790535 4567318 9571926 9223217 18204953 18708957 17318615 19493874 5174025 5338721 69833049 76806803 3135062 2850201 2662755 2565753 11313977 12342895 17111794 17758849 X 52721255 59047954 52721255 59047954 69833049 76806803 X 3353060 2319151 -4847 659335 X X 0 1 X 1 0 830000 830000 9779985 1890411 7889574 88682 69848 18834 1736511 1251702 484809 1355357 1355357 0 9223217 12706311 F INVESTMENT - DENTAL CHOICE, INC. 6787563 F 19493874 ACCRUED INVESTMENT INCOME 263506 457(B) PLAN 426531 INVESTMENT - RHC 3501207 SURPLUS NOTE RECEIVABLE 1050000 POTENTIAL TENANT 97477 5338721 CLAIMS CHECKS OUTSTANDING 6304214 ESTIMATED CLAIMS LIABILITY 6038681 12342895 X DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X, LINE 2: AS OF DECEMBER 31, 2012 AND 2011, THE COMPANY'S UNRECOGNIZED TAX BENEFITS WERE NOT SIGNIFICANT. THERE WERE NO SIGNIFICANT PENALTIES OR INTEREST RECOGNIZED DURING THE YEAR OR ACCRUED AT YEAR END. 1 FAMILY & CHILDREN'S PLACE INC PO BOX 3784 LOUISVILLE KY 40201 610549561 501(C)(3) 5000 CASH N/A GENERAL DONATION TO FAMILY & CHILDREN'S PLACE INITIATIVES COMMUNITY FOUNDATION OF LOUISVILLE 325 WEST MAIN STREET SUITE 1110 LOUISVILLE KY 40202 310997017 501(C)(3) 2000000 CASH N/A DONATION TO THE COMMUNITY FOUNDATION OF LOUISVILLE INITIATIVES AND FIELD OF INTEREST FUNDS 2 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: DDKY HAS A SUBCOMMITTEE OF THE BOARD OF DIRECTORS WHICH MEETS ANNUALLY TO REVIEW / APPROVE GRANTS FOR THE FOLLOWING YEAR. X 1 1 X X X X X 0 1 0 0 0 0 0 0 0 CLIFFORD T MAESAKA JR 357002 0 162752 0 0 0 39500 0 12081 0 571335 0 0 0 STEPHEN C DAY 157139 0 79855 0 0 0 22500 0 18491 0 277985 0 0 0 JOHN L WEEKS III 176237 0 85928 0 0 0 19017 0 18040 0 299222 0 0 0 ANGELA J NENNI 154173 0 74195 0 0 0 19870 0 11203 0 259441 0 0 0 TAMARA L YORK-DAY 174299 0 52695 0 0 0 16185 0 16911 0 260090 0 0 0 RUSSELL W SKAGGS 125824 0 43168 0 0 0 22500 0 16915 0 208407 0 0 0 GORAN JURKOVIC CPA 0 274905 0 257343 0 12984 0 282378 0 20100 0 847710 0 0 RONALD E STORY 113458 0 22419 0 0 0 8173 0 9995 0 154045 0 0 0 LINA K STIRSMAN 105964 0 21387 0 0 0 18690 0 7692 0 153733 0 0 0 BRIAN E KRAINER 188044 0 0 0 104 0 17000 0 5794 0 210942 0 0 0 PART I, LINE 1A FOR THE ANNUAL RHSC CONFERENCE THE BOARD MEMBERS ARE ALLOWED TO HAVE COMPANION TRAVEL WITH THEM. THIS IS TAXABLE TO THE BOARD MEMBER. PART I, LINE 4B DELTA DENTAL OF KENTUCKY, HAS BOTH A 457(B) PLAN AS WELL AS A 457(F) SERP, A SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN. ONLY ONE POSITION, THE CEO, IS ELIGIBLE FOR THE SERP. ADDITIONALLY, ALL OTHER VPS AND BOARD MEMBERS ARE ELIGIBLE FOR THE 457(B) PLAN. FORM 990, PART VI, SECTION A, LINE 6 EFFECTIVE JULY 1, 2009 RENAISSANCE HEALTH SERVICE CORPORATION BECAME THE SOLE CORPORATE MEMBER OF DELTA DENTAL OF KENTUCKY. FORM 990, PART VI, SECTION A, LINE 7A RHSC IS THE SOLE VOTING MEMBER OF DDKY. HOWEVER, UNDER THE TERMS OF THE AFFILIATION AGREEMENT THE PARTIES AGREED THAT THE DELTA DENTAL OF KENTUCKY (DDKY) BOARD SELECTS DIRECTOR CANDIDATES AND SUBMITS THEM TO RENAISSANCE HEALTH SERVICE CORP (RHSC). RHSC THEN APPROVES THE CANDIDATES. RHSC CAN REJECT PROPOSED CANDIDATES FOR "JUST CAUSE" AS DEFINED IN THE AGREEMENT. OTHERWISE, RHSC MUST APPROVE ALL THE CANDIDATES PROPOSED BY THE DDKY BOARD. RHSC HAS THE RIGHT TO ELECT A NUMBER OF DIRECTORS TO THE DDKY BOARD PROPORTIONAL TO THE NUMBER OF DIRECTORS THAT DDKY MAY NOMINATE TO THE RHSC BOARD. CURRENTLY, RHSC APPOINTS TWO MEMBERS OF THE 13 MEMBER DDKY BOARD. FORM 990, PART VI, SECTION A, LINE 7B THE RIGHTS OF THE DDKY BOARD ARE TO APPROVE THE ANNUAL BUDGETS FOR OPERATIONS, ELECT OFFICERS OF THE DDKY BOARD OF DIRECTORS, APPROVE THE TRANSFER OF ANY OF ITS ASSETS, APPROVE THE INCURRENCE OR GUARANTY OF DEBT AND APPROVE THE MANAGEMENT OF ITS INVESTMENTS. RHSC MUST APPROVE ANY TRANSFER OF ASSETS, INVESTMENTS, LOANS, GUARANTIES OR EXPENDITURES WHICH EXCEED TEN PERCENT OF DDKY'S NET ASSETS. RHSC MUST APPROVE THE FOLLOWING CHANGES TO THE DDKY BYLAWS: THE IDENTITY, QUALIFICATION OR RIGHTS OF DDKY'S VOTING MEMBER, THE QUALIFICATIONS, CLASSIFICATIONS, TERMS OF OFFICE OR PERMISSIBLE NUMBER OF DIRECTORS ON DDKY'S BOARD OR ANY LIMITATION ON THE RIGHTS OR AUTHORITY OF THE DDKY BOARD CONTAINED IN DDKY'S ORGANIZATIONAL DOCUMENTS. FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 IS FIRST REVIEWED INTERNALLY BY THE VP-FINANCE, THE IN-HOUSE LEGAL COUNSEL, CEO AND THEN A DRAFT IS PRESENTED TO THE AUDIT AND FINANCE COMMITTEE FOR REVIEW. PRIOR TO FILING, A COPY OF THE FINAL FORM 990 IS DISTRIBUTED TO THE ENTIRE GOVERNING BODY. FORM 990, PART VI, SECTION B, LINE 12C OFFICERS, DIRECTORS AND KEY EMPLOYEES MUST COMPLETE AND SUBMIT A CONFLICT OF INTEREST DISCLOSURE ANNUALLY. THESE FORMS ARE REVIEWED BY THE CEO, THE CORPORATE COMPLIANCE OFFICER, AND A REPORT IS MADE TO THE AUDIT AND FINANCE COMMITTEE OF THE BOARD OF DIRECTORS. THE AUDIT COMMITTEE REVIEWS ALL POTENTIAL CONFLICTS TO DETERMINE IF THE CONFLICTS REPRESENT MATERIAL FINANCIAL RISK TO THE COMPANY AND TAKES ANY ACTION NECESSARY TO RESOLVE OR MITIGATE THE EFFECT OF THE CONFLICTS. WHEN A CONFLICT EXISTS AMONG THE VOTING BOARD MEMBERS, THAT BOARD MEMBER WILL ABSTAIN FROM VOTING ON THE CONFLICTED ISSUE. ALL EMPLOYEES AND DIRECTORS ARE ADVISED ANNUALLY OF THE REQUIREMENT TO REPORT ANY POTENTIAL CONFLICTS OF INTEREST AS THEY OCCUR. EMPLOYEES AND DIRECTORS MAY ALSO MAKE ANONYMOUS REPORTS OF ANY VIOLATIONS OF CORPORATE POLICIES THROUGH A DEDICATED WHISTLEBLOWER SYSTEM ADMINISTERED BY A THIRD PARTY. FORM 990, PART VI, SECTION B, LINE 15 CEO AND OTHER OFFICERS COMPENSATION ARE REVIEWED BY THE PERSONNEL AND COMPENSATION COMMITTEE OF THE BOARD OF DIRECTORS. THE PROCESS IS PERFORMED, AT A MINIMUM, ANNUALLY. COMPENSATION WAS LAST REVIEWED BY DELTA DENTAL OF KENTUCKYS P&C COMMITEE IN FEBRUARY 2013. THE COMMITTEE IS MADE UP OF INDEPENDENT BOARD MEMBERS. THE COMMITTEE UTILIZES CERTAIN COMPENSATION SURVEYS AND OUTSIDE CONSULTANTS ARE ENGAGED AS NEEDED. COMPENSATION WAS ALSO REVIEWED UNDER DELTA DENTAL PLAN OF MICHIGANS HR EXECUTIVE COMPENSATION PROCESS DURING 2012. THE REPORT BASED ON THIS REVIEW WAS THEN ISSUED BY THE CONSULTANTS IN APRIL OF 2013. FORM 990, PART VI, SECTION C, LINE 19 GOVERNING DOCUMENTS AND FINANCIAL STATEMENTS ARE FILED WITH THE KENTUCKY DEPARTMENT OF INSURANCE AND ARE AVAILABLE FOR INSPECTION BY THE PUBLIC THROUGH THAT AGENCY. ADDITIONALLY, THE COMPANY MAKES ORGANIZATIONAL DOCUMENTS, CONFLICT OF INTEREST POLICIES, AND FINANCIAL STATEMENTS AVAILABLE AT NO COST UPON RECEIPT OF A WRITTEN REQUEST. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 9: EQUITY IN SUBSIDIARY 659,335. FORM 990, PART XII, LINE 2C: PROCESS IS THE SAME AS THE PRIOR YEAR. FORM 990, PART IV, LINE 12A: THE ORGANIZATION ISSUES INDEPENDENT AUDITED FINANCIAL STATEMENTS ON THE STATUTORY BASIS OF ACCOUNTING. THE ORGANIZATION IS ALSO PART OF A CONSOLIDATED GAAP BASIS FINANCIAL STATEMENT. DENTAL CHOICE PROPERTIES LLC 10100 LINN STATION RD SUITE LOUISVILLE KY 40223 610659432 REAL ESTATE HOLDING COMPANY KY 0 0 DELTA DENTAL OF KENTUCKY RENAISSANCE HEALTH SERVICE CORPORATION PO BOX 30416 LANSING MI 489097916 381675667 PROMOTING DENTAL CARE MI 501(C)(4) N/A N/A 0 DELTA DENTAL PLAN OF MICHIGAN INC 4100 OKEMOS ROAD OKEMOS MI 48864 381791480 PROVIDE DENTAL SERVICE PLANS MI 501(C)(4) N/A RENAISSANCE HEALTH SERVICE CORPORATION 1 DELTA DENTAL OF TENNESSEE INC PO BOX 30416 LANSING MI 489097916 620812197 PROVIDE DENTAL SERVICE PLANS TN 501(C)(4) N/A RENAISSANCE HEALTH SERVICE CORPORATION 1 DELTA DENTAL PLAN OF NEW MEXICO INC PO BOX 30416 LANSING MI 489097916 850224562 PROVIDE DENTAL SERVICE PLANS NM 501(C)(4) N/A RENAISSANCE HEALTH SERVICE CORPORATION 1 DELTA DENTAL OF NORTH CAROLINA PO BOX 30416 LANSING MI 489097916 561018068 PROVIDE DENTAL SERVICE PLANS NC 501(C)(4) N/A RENAISSANCE HEALTH SERVICE CORPORATION 1 DELTA DENTAL PLAN OF OHIO INC PO BOX 30416 LANSING MI 489097916 310685339 PROVIDE DENTAL SERVICE PLANS OH 501(C)(4) N/A DELTA DENTAL PLAN OF MICHIGAN INC 1 DELTA DENTAL PLAN OF INDIANA INC PO BOX 30416 LANSING MI 489097916 351545647 PROVIDE DENTAL SERVICE PLANS IN 501(C)(4) N/A DELTA DENTAL PLAN OF MICHIGAN INC 1 DELTA DENTAL FUND PO BOX 30416 LANSING MI 489097916 382337000 SUPPORT DENTAL EDUCATION AND RESEARCH PROGRAMS MI 501(C)(3) 11A TYPE II DELTA DENTAL PLAN OF MICHIGAN INC 1 DELTA DENTAL PLAN OF ARKANSAS PO BOX 30416 LANSING MI 489097916 710561140 PROVIDE DENTAL SERVICE PLANS AR 501(C)(4) NA RENAISSANCE HEALTH SERVICE CORPORATION 1 DELTA DENTAL OF ARKANSAS FOUNDATION PO BOX 30416 LANSING MI 489097916 261569324 PROVIDE DENTAL SERVICE PLANS AR 501(C)(3) PF RENAISSANCE HEALTH SERVICE CORPORATION 1 RENAISSANCE FAMILY FOUNDATION INC 4100 OKEMOS ROAD OKEMOS MI 48864 461376165 EMPHASIZE DENTAL HEALTH IN COMMUNITIES IN 501(C)(3) PF RENAISSANCE HOLDING COMPANY 1 DENTAL CHOICE INC 10100 LINN STATION RD SUITE 700 LOUISVILLE KY 40223 611105118 REAL ESTATE HOLDING COMPANY KY N/A C 164906 6562604 1.00000 1 DENTAL CHOICE AGENCY INC 10100 LINN STATION RD SUITE 700 LOUISVILLE KY 40223 611336003 PRIMARY GENERAL AGENCY FOR DDKY & DENTAL CHOICE KY N/A C 2154 1.00000 1 RENAISSANCE HOLDING COMPANY PO BOX 30381 LANSING MI 48909 412177193 HOLDING COMPANY MI RENAISSANCE HEALTH SERVICE CORPORATION C -17170 3666243 0.05400 1 RENAISSANCE LIFE & HEALTH INSURANCE COMPANY OF AMERICA PO BOX 30416 LANSING MI 489097916 470397286 INSURANCE IN RENAISSANCE HOLDING COMPANY C 1 RENAISSANCE HEALTH INSURANCE COMPANY OF NEW YORK PO BOX 30416 LANSING MI 48909 134098096 INSURANCE NY RENAISSANCE HOLDING COMPANY C 1 FORE HOLDING CORPORATION 240 VENTURE CIRCLE NASHVILLE TN 37228 204116122 EMPLOYEE BENEFITS TN DELTA DENTAL OF TENNESSEE C 1 OMEGA ADMINISTRATORS INC 1513 COUNTRY CLUB ROAD SHERWOOD AR 72120 043740469 PROVIDE THIRD-PARTY ADMINISTRATIVE SERVICES AR DELTA DENTAL OF ARKANSAS C 1 0 0 0 1 0 0 0 0 0 0 0 1 1 0 1 1 1 0 0 DENTAL CHOICE INC L 360816 ACTUAL COST DELTA DENTAL OF NORTH CAROLINA D 1050000 ACTUAL COST DELTA DENTAL PLAN OF MICHIGAN M 115599 ACTUAL COST