2013-05-15T14:46:26-05:00 2012-06-30 450250958 EIDE BAILLY LLP 800 NICOLLET MALL STE 1300 MINNEAPOLIS MN 554027033 990 2011-07-01 460407148 AVERA WORKERS' COMPENSATION TRUST AVER 6053227050 3900 WEST AVERA DRIVE SIOUX FALLS SD 57078 JOHN PORTER 6053227050 2013-05-13 1 KIM HUNWARDSEN P00484560 6122536500 2013-05-13 2011 2016-02-24 21:20:13Z X JOHN PORTER 3900 WEST AVERA DRIVE SIOUX FALLS SD 57078 5629220 0 X WWW.AVERA.ORG X 1989 SD PROVIDE AN ECONOMICAL COVERAGE OF WORKERS' COMPENSATION CLAIMS. 16 13 0 13 0 0 0 0 3766825 4578875 605929 1050345 0 0 4372754 5629220 0 0 0 0 16504 10854 0 0 0 3156049 4517342 3172553 4528196 1200201 1101024 18781691 0 8183680 0 10598011 0 X NONE 0 1 4425248 4578875 THE AVERA WORKERS' COMPENSATION TRUST ("TRUST") WAS ESTABLISHED TO PROVIDE AN ECONOMICAL COVERAGE OF WORKERS' COMPENSATION EXPOSURE TO EXEMPT ORGANIZATIONS ASSOCIATED WITH AVERA HEALTH OF SIOUX FALLS IN FURTHERANCE OF THEIR PROMOTION OF HEALTH CARE. STOP LOSS TYPE INSURANCE COVERAGE IS PURCHASED BY THE TRUST. THE PARTICIPANTS ARE REQUIRED TO CONTRIBUTE TO THE RESERVES OF THE TRUST IN ACCORDANCE WITH THE INDEPENDENT ACTUARIAL'S VALUATION. THE VALUATION IS MADE ANNUALLY TO DETERMINE THE FUNDING LEVEL NECESSARY TO PROVIDE RESERVES FOR WORKERS' COMPENSATION CLAIMS AND IS REVIEWED BY THE TRUST'S EMPLOYER'S ADVISOR.AS OF JUNE 30,2012, ALL OPERATIONS WERE TRANSFERRED TO THE PARENT ORGANIZATION, AVERA HEALTH. 4425248 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 1 0 0 1 0 0 0 0 1 71 0 1 0 0 0 0 0 0 0 0 0 0 0 0 X 16 13 1 1 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 0 0 0 X JIM BRECKENRIDGE 6053224700 3900 W AVERA DR SUITE 300 SIOUX FALLS SD 57108 X DR HERBERT A SALOUM 1.20 X X 0 0 0 SISTER KATHLEEN CROWLEY 1.00 X X 0 0 0 JOHN PORTER 1.00 X X 0 1149458 49310 SISTER BARBARA MCTAGUE 1.00 X 0 0 0 MARK BUCHE 1.00 X 0 0 0 SISTER LUCILLE WELBIG 1.00 X 0 0 0 SISTER MARY JAEGER 1.00 X 0 0 0 DANIEL P MURPHY 1.00 X 0 0 0 SISTER DEBRA KOLECKA 1.00 X 0 0 0 RODNEY W FOUBERG 1.00 X 0 0 0 KEVIN CONLIN 1.00 X 0 0 0 DR KIM W JUNDT 1.00 X 0 447476 30292 DR J MICHAEL BACHARACH 1.00 X 0 0 0 BOB SUTTON 1.00 X 0 0 0 SISTER MARY M THOMAS 1.00 X 0 0 0 MARK SCHLANTA 1.00 X 0 0 0 US BANK 5.00 X 10853 0 0 10853 1596934 79602 0 0 1 0 AVERA HEALTH 3900 W AVERA DRIVE SIOUX FALLS SD 57108 SHARED SERVICES 750000 1 ASSESSMENTS 524298 4578875 4578875 4578875 584921 584921 465424 0 465424 465424 465424 5629220 4578875 0 1050345 10854 10854 7700 7700 750000 750000 INSURANCE CLAIMS 3403422 3403422 REINSURANCE FEES 265426 265426 STATE FEES - SD AND IA 84394 84394 CLAIMS PROCESSING FEE 6400 6400 4528196 4425248 102948 0 0 1989223 0 0 72482 0 0 0 0 0 0 0 0 0 0 16710415 0 0 0 0 9571 0 18781691 0 487609 0 7696071 0 8183680 0 X 10598011 0 10598011 0 18781691 0 X 1101024 -11699035 X X 0 1 1 X 0 X X X 0 0 0 AVERA MCKENNAN 460224743 3 0 0 1 1076147 AVERA ST LUKE'S 460224598 3 0 0 1 522546 SACRED HEART HEALTH SERVICES 460225483 3 0 0 1 304652 AVERA QUEEN OF PEACE 460224604 3 0 0 1 119841 ST BENEDICT HEALTH CENTER 460226738 3 0 0 1 4352 AVERA HOLY FAMILY 420680370 3 0 0 1 69588 PRESENTATION COLLEGE 460280847 2 0 0 1 5116 SISTERS OF THE PRESENTATION OF THE BLESSED VIRGIN MARY 460253283 1 0 0 1 18307 AVERA HEALTH 460422673 9 0 0 1 112210 9 2232759 SCHEDULE A, PART IV, SUPPLEMENTAL INFORMATION: SCHEDULE A, PART I, LINE 11H(IV): ORGANIZATIONS AS IDENTIFIED IN TRUST AGREEMENT AVERA WORKERS COMPENSATION TRUST WAS ORGANIZED BY THOSE FACILITIES OF AVERA HEALTH OR ITS SPONSORING RELIGIOUS ORDERS WHICH ARE IDENTIFIED IN THE TRUST DOCUMENT EXHIBIT. THE TRUST SERVES AS A REPOSITORY FOR THE EMPLOYER'S FUNDS TO MEET ITS OBLIGATIONS TO PROVIDE WORKERS' COMPENSATION BENEFITS TO THE EMPLOYER'S EMPLOYEES. NO ORGANIZATIONS ARE SPECIFICALLY NAMED IN THE TRUST DOCUMENT. INSTEAD, THE TRUST AGREEMENT DEFINES EMPLOYER AS 'THOSE HEALTHCARE FACILITIES AND OTHER INSTITUTIONS WHICH ARE OWNED OR WHICH MEMBERSHIP OR CONTROL OF ITS BOARD OF DIRECTORS IS CONTROLLED BY AVERA HEALTH'. THE FACILITIES AND INSTITUTIONS WHICH COMPRISE THE EMPLOYER ARE IDENTIFIED IN EXHIBIT A TO THE TRUST AGREEMENT. THERE IS EVIDENCE OF A HISTORIC AND CONTINUING RELATIONSHIP WITH THE SUPPORTED ORGANIZATIONS. THE AMOUNT OF SUPPORT PROVIDED ON SCHEDULE A, PART IV IS RELATED TO CLAIMS PAID ON BEHALF OF THE EMPLOYER. 0 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: AVERA HEALTH AND MOST OF ITS SPONSORED ORGANIZATIONS ARE CONSIDERED NONPROFIT CORPORATIONS AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE AND ARE EXEMPT FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE CODE. THESE ORGANIZATIONS ARE REQUIRED TO FILE A RETURN OF ORGANIZATION EXEMPT FROM INCOME TAX (FORM 990) WITH THE INTERNAL REVENUE SERVICE (IRS). AVERA HEALTH AND CERTAIN SPONSORED ORGANIZATIONS ALSO FILE AN EXEMPT ORGANIZATION BUSINESS INCOME TAX RETURN (FORM 990T) WITH THE IRS TO REPORT THEIR UNRELATED BUSINESS TAXABLE INCOME. AVERA HEALTH AND CERTAIN SPONSORED ORGANIZATIONS BELIEVE THAT THEY HAVE APPROPRIATE SUPPORT FOR ANY TAX POSITIONS TAKEN AFFECTING ITS ANNUAL FILING REQUIREMENTS, AND AS SUCH, DOES NOT HAVE ANY UNCERTAIN TAX POSITIONS THAT ARE MATERIAL TO THE FINANCIAL STATEMENTS. THE ORGANIZATION WOULD RECOGNIZE FUTURE ACCRUED INTEREST AND PENALTIES RELATED TO UNRECOGNIZED TAX BENEFITS AND LIABILITIES IN INCOME TAX EXPENSE IF SUCH INTEREST AND PENALTIES ARE INCURRED. THE FEDERAL FORM 990T FILINGS FOR CONSOLIDATED SUBSIDIARIES ARE NO LONGER SUBJECT TO FEDERAL TAX EXAMINATIONS BY TAX AUTHORITIES FOR YEARS BEFORE 2009. 0 0 0 0 0 0 0 0 0 JOHN PORTER 0 901311 0 500 0 247647 0 31098 0 19361 0 1199917 0 0 DR KIM W JUNDT 0 316770 0 73176 0 57530 0 12250 0 18042 0 477768 0 0 SUPPLEMENTAL INFORMATION PART III SCHEDULE J PART I LINE 3: JOHN PORTER, PRESIDENT AND CEO OF AVERA HEALTH (RELATED ORGANIZATION), IS COMPENSATED BY AVERA HEALTH FOR HIS SERVICES PROVIDED TO THE RELATED ORGANIZATION. THE RELATED ORGANIZATION USES METHODS IDENTIFIED IN QUESTION 3 TO DETERMINE COMPENSATION. CASH, RECEIVABLES AND INVESTMENTS 2012-06-30 12864823 GENERAL LEDGER 460422673 AVERA HEALTH 3900 WEST AVERA DRIVE SIOUX FALLS SD 57108 501(C)(3) 1 1 0 0 1 1 1 1 0 0 PART I, LINE 2E: ALL OFFICERS AND DIRECTORS HAVE BEEN AND WILL CONTINUE TO BE OFFICERS, DIRECTORS, OR EMPLOYEES OF AVERA HEALTH INTO WHICH AVERA WORKERS' COMPENSATION TRUST DISSOLVED. CHANGES IN PROGRAM SERVICES FORM 990, PART III, LINE 3 AS OF JUNE 30,2012, ALL OPERATIONS WERE TRANSFERRED TO THE PARENT ORGANIZATION, AVERA HEALTH. FORM 990, PART VI, SECTION A, LINE 2 JOHN PORTER AND THE BOARD MEMBERS LISTED IN PART VII HAVE A BUSINESS RELATIONSHIP. MR. PORTER IS EMPLOYED BY AN EXEMPT ORGANIZATION WHERE THE OFFICERS AND DIRECTORS ARE ALSO OFFICERS AND DIRECTORS. FORM 990, PART VI, SECTION A, LINE 3 AVERA HEALTH OFFICE OF GENERAL COUNSEL SERVES AS THE ADMINISTRATOR OF THE TRUST. THE ADMINISTRATOR DELEGATES ADMINISTRATIVE RESPONSIBILITIES TO A TRUST ADMINISTRATOR WHO ACTS UNDER THE DIRECTION OF THE AVERA HEALTH GENERAL COUNSEL. THE TRUST ADMINISTRATOR IS AN EMPLOYEE OF AVERA HEALTH, A RELATED ORGANIZATION. FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 IS REVIEWED BY THE CEO AND CFO OF AVERA HEALTH. THE RETURN IS PROVIDED TO THE BOARD PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C THE CONFLICT OF INTEREST POLICY COVERS BOARD MEMBERS, OFFICERS, AND KEY EMPLOYEES. AT EACH BOARD MEETING, A REQUEST IS MADE FOR ALL BOARD MEMBERS TO DISCLOSE ANY POTENTIAL CONFLICT OF INTEREST PERTAINING TO ANY ITEM LISTED ON THE AGENDA OR PERTAINING TO ANY POTENTIAL ITEM THAT COULD BE DISCUSSED DURING THE COURSE OF THE MEETING. THE DECLARATION OF CONFLICT OF INTEREST IS RECORDED IN THE MEETING MINUTES. THE BOARD MAKES A DETERMINATION OF WHETHER THERE IS A CONFLICT OF INTEREST AND IF SO, IMPLEMENTS THE PROCEDURE FOR EVALUATING THE ISSUE OR TRANSACTION INVOLVED. THE BOARD MEMBER OR OFFICER WITH THE CONFLICT MUST REFRAIN FROM VOTING. A STATEMENT OF CONFLICT OF INTEREST DISCLOSURE IS MADE ON AN ANNUAL BASIS BY OFFICERS AND DIRECTORS. THE INFORMATION IS MAINTAINED IN A DATABASE AND A REPORT IS PROVIDED TO THE BOARD. PART VI, SECTION B, LINE 15: COMPENSATION IS DETERMINED BY AVERA HEALTH. THE CEO IS COMPENSATED BY AVERA HEALTH SYSTEM. ANNUALLY THE COMPENSATION COMMITTEE OF AVERA HEALTH, WHICH IS COMPRISED OF SIX (6) SYSTEM MEMBERS APPOINTED BY THE RELIGIOUS ORDERS, MEETS WITH AN INDEPENDENT CONSULTANT REGARDING FAIR MARKET VALUE OF OFFICERS AND KEY EMPLOYEES. THE COMPENSATION COMMITTEE APPROVES ALL SALARIES BASED ON COMPARABLE DATA AND DOCUMENTS THE BASIS FOR THEIR DECISION IN MEETING MINUTES. THE TRUSTEE FEE IS NEGOTIATED BY THE BOARD. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY OR FINANCIAL STATEMENTS ARE NOT MADE AVAILABLE TO THE GENERAL PUBLIC. AVERAGE HOURS DEVOTED TO RELATED ORGANIZATIONS FORM 990, PART VII, LINE 1A, COLUMN B JOHN PORTER DEVOTES AN AVERAGE OF 40 HOURS PER WEEK TO AVERA HEALTH. ALL OTHER BOARD MEMBERS SERVE AVERA HEALTH 5 HOURS PER WEEK. SISTER KATHLEEN CROWLEY ALSO SERVES 1 HOUR PER WEEK AT AVERA HOLY FAMILY AND 2 AND ONE HALF HOURS PER WEEK AT AVERA QUEEN OF PEACE HOSPITAL. SISTER LUCILLE WELBIG ALSO SERVES 2 HOURS PER WEEK AT SACRED HEART HEALTH SERVICES. SISTER MARY JAEGER ALSO SERVES 1 HOUR PER WEEK AT AVERA ST. ANTHONY'S HOSPITAL AND 2 HOURS PER WEEK AT ST. BENEDICT'S HOSPITAL, INC. DR. KIM W. JUNDT SERVES AVERA ST.LUKE'S 40 HOURS PER WEEK AS A PHYSICIAN. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED GAINS ON INVESTMENTS: 1,165,788. TRANSFER TO AVERA HEALTH -12,864,823. TOTAL TO FORM 990, PART XI, LINE 5: -11,699,035. FORM 990 PART XI, LINE 2C THE INDEPENDENT AUDITORS ARE SELECTED AND APPROVED BY THE AVERA HEALTH AUDIT COMMITTEE AND THE INDEPENDENT ACTUARY IS SELECTED BY AVERA HEALTH MANAGEMENT. AVERA HEALTH 3900 W AVERA DRIVE SUITE 300 SIOUX FALLS SD 57108 460422673 PROMOTION OF HEALTH SD 501(C)(3) LINE 9 N/A 0 PRESENTATION COLLEGE 1500 NORTH MAIN STREET ABERDEEN SD 57401 460280847 COLLEGE SD 501(C)(3) LINE 2 N/A 0 AVERA MCKENNAN 1325 S CLIFF AVENUE PO BOX 5045 SIOUX FALLS SD 57117 460224743 HEALTHCARE SERVICES SD 501(C)(3) LINE 3 AVERA HEALTH 0 AVERA QUEEN OF PEACE 525 NORTH FOSTER MITCHELL SD 57301 460224604 HEALTHCARE SERVICES SD 501(C)(3) LINE 3 AVERA HEALTH 0 SISTERS OF THE PRESENTATION OF THE BLESSED VIRGIN MARY OF ABERDEEN SD 15TH AVENUE AND 2ND STREET NW ABERDEEN SD 57401 460253283 MONASTERY SD 501(C)(3) LINE 1 N/A 0 AVERA ST LUKE'S 305 SOUTH STATE STREET ABERDEEN SD 57401 460224598 HEALTHCARE SERVICES SD 501(C)(3) LINE 3 AVERA HEALTH 0 ST BENEDICT HEALTH CENTER 401 WEST GLYNN DRIVE PARKSTON SD 57366 460226738 HEALTHCARE SERVICES SD 501(C)(3) LINE 3 AVERA HEALTH 0 SACRED HEART HEALTH SERVICES 501 SUMMIT STREET YANKTON SD 57078 460225483 HEALTHCARE SERVICES SD 501(C)(3) LINE 3 AVERA HEALTH 0 AVERA HOLY FAMILY 826 NORTH 8TH STREET ESTHERVILLE IA 51334 420680370 HEALTHCARE SERVICES IA 501(C)(3) LINE 3 AVERA HEALTH 0 SACRED HEART RURAL HEALTH CLINICS INC 501 SUMMIT STREET YANKTON SD 57078 460423930 CLINIC SERVICES SD 501(C)(3) LINE 3 SACRED HEART HEALTH SERVICES 0 HEALTH MANAGEMENT SERVICES 501 SUMMIT YANKTON SD 57078 460399291 ADULT DAYCARE AND HOMEMAKING SERVICES SD 501(C)(3) LINE 9 SACRED HEART HEALTH SERVICES 0 LEWIS AND CLARK HEALTH EDUCATION AND SERVICE AGENCY 1000 W 4TH ST SUITE 9 YANKTON SD 57078 460337013 HEALTHCARE EDUCATION SD 501(C)(3) LINE 9 SACRED HEART HEALTH SERVICES 0 ST BENEDICT HEALTH CENTER FOUNDATION WEST GLYNN DRIVE PO BOX B PARKSTON SD 57366 460458725 SUPPORT HEALTH RELATED SERVICES SD 501(C)(3) LINE 11A, I ST BENEDICT HEALTH CENTER 0 AVERA HOLY FAMILY FOUNDATION 826 NORTH 8TH STREET ESTHERVILLE IA 51334 421317452 SUPPORT OF HOLY FAMILY HOSPITAL AN HOME HEALTH AGENCY IA 501(C)(3) LINE 9 AVERA HOLY FAMILY 0 AVERA ST ANTHONY'S HOSPITAL 300 N 2ND STREET ONEILL NE 687631569 470463911 HEALTHCARE SERVICES NE 501(C)(3) LINE 3 AVERA HEALTH 0 AVERA MARSHALL 300 S BRUCE ST MARSHALL MN 56258 410919153 HEALTHCARE SERVICES MN 501(C)(3) LINE 3 AVERA HEALTH 0 AVERA MARSHALL FOUNDATION 300 S BRUCE ST MARSHALL MN 56258 411784801 FUNDRAISING MN 501(C)(3) LINE 7 AVERA MARSHALL 0 AVERA HOME MEDICAL EQUIPMENT LLC 1325 S CLIFF AVENUE PO BOX 5045 SIOUX FALLS SD 57117 460488198 MEDICAL SERVICES - HOME MEDICAL EQUIPMENT SD N/A MIDWEST REGIONAL IMAGING SERVICES LLC 1325 S CLIFF AVENUE PO BOX 5045 SIOUX FALLS SD 57117 470874983 HEALTH CARE - MEDICAL IMAGING SD N/A HOME MEDICAL OF PIERRE LLC 329 E DAKOTA PIERRE SD 57501 460444002 MEDICAL SERVICES - HOME MEDICAL EQUIPMENT SD N/A AVERA HOME MEDICAL EQUIPMENT OF FLOYD VALLEY HOSPITAL LLC 714 LINCOLN ST NE LEMARS IA 51031 820582350 MEDICAL SERVICES - HOME MEDICAL EQUIPMENT SD N/A AVERA HOME MEDICAL EQUIPMENT OF ESTHERVILLE LLC PO BOX 5045 SIOUX FALLS SD 57117 201686097 MEDICAL SERVICES - HOME MEDICAL EQUIPMENT SD N/A AVERA HOME MEDICAL EQUIPMENT OF SIOUX CENTER LLC 38 19TH ST SW SIOUX CENTER IA 51250 753203100 MEDICAL SERVICES - HOME MEDICAL EQUIPMENT SD N/A AVERA HOME MEDICAL EQUIPMENT OF MARSHALL LLC 1104 EAST COLLEGE DRIVE MARSHALL MN 56258 205271924 MEDICAL SERVICES - HOME MEDICAL EQUIPMENT SD N/A AVERA HOME MEDICAL EQUIPMENT OF SPENCER HOSPITAL LLC 2400 S MINNESOTA AV 102 SIOUX FALLS SD 57117 800619999 MEDICAL SERVICES - HOME MEDICAL EQUIPMENT SD N/A Q&M PROPERTIES LLC 525 NORTH FOSTER MITCHELL SD 57301 731652049 MEDICAL CLINIC BUILDING SD N/A SURGICAL ASSOCIATES ENDOSCOPY CLINIC LLC 310 S PENNSYLVANIA STREET ABERDEEN SD 57401 460461429 SURGICAL ASSOCIATES SD N/A HEART HOSPITAL OF SOUTH DAKOTA LLC 10720 SIKES PLACE SUITE 300 CHARLOTTE NC 28277 562143771 HEALTHCARE SERVICES NC N/A ACCOUNTS MANAGEMENT INC 5132 S CLIFF AVENUE SUITE 101 SIOUX FALLS SD 57108 460373021 COLLECTION AGENCY SD N/A C AVERA HEALTH PLANS INC 3816 S ELMWOOD AVENUE SUITE 101 SIOUX FALLS SD 57108 460451539 HEALTH FINANCING AND HEALTH PLAN ADMIN SD N/A C AVERA PROPERTY INSURANCE INC 610 W 23RD STREET STE 1 PO BOX 38 YANKTON SD 57078 460463155 INSURANCE SD N/A C VALLEY HEALTH SERVICES 501 SUMMIT STREET YANKTON SD 57078 460357149 MEDICAL EQUIPMENT SD N/A C 0 0 0 0 0 0 0 0 0 0 0 1 0 0 1 1 1 0