2013-08-13T09:28:37-05:00 2012-09-30 346565596 Ernst & Young LLP 200 Clarendon Street Boston MA 02116 990 2011-10-01 222747685 Baystate Administrative Services Inc BAYS 4137947872 759 Chestnut Street Springfield MA 011990001 Dennis W Chalke 4137945740 2013-08-13 1 Jeanne M Schuster P00743154 6172662000 2011 2016-02-24 21:20:13Z Dennis W Chalke 759 Chestnut Street Springfield MA 011990001 92624612 0 X www.baystatehealth.org X 1986 MA To improve the health of the people in our communities every day with quality and compassion 7 0 535 0 671025 0 0 0 90423070 92270721 602184 323571 37783 30320 91063037 92624612 0 0 0 0 55288000 56011441 0 0 0 34866938 36195823 90154938 92207264 908099 417348 37953235 42285246 55103222 61867093 -17149987 -19581847 The organization's purpose is to promote the health, charitable and educational purposes of Baystate Health, Inc. whose mission is to improve the health of the people in our communities every day, with quality and compassion. 0 0 26576484 40108292 BAS provides management and administrative support to Baystate Health and its affiliates. These services are an integral part of the healthcare delivery system and include strategic planning, human resources, risk management (insurance) programs, marketing, financial services and benefit plans administration for all health system employees. 50370131 51521724 BAS provides information technology support to Baystate Health and its affiliates. These services are an integral part of the healthcare delivery system and include all software applications, telecommunications, clinical engineering, and computerized equipment at the hospitals. 76946615 1 0 0 1 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 1 0 0 0 0 0 1 0 1 0 0 1 277 0 1 535 1 1 1 0 0 0 0 0 0 0 0 0 0 X 7 0 1 0 0 0 1 1 0 1 1 0 0 0 1 1 1 1 1 1 1 0 MA X Peter Lyons Baystate Health Inc 4137940000 759 Chestnut Street Springfield MA 01199 X Mark R Tolosky 1.00 X X 1536640 0 99365 Dennis W Chalke 1.00 X X 672631 0 92548 Donna J Ross 1.00 X X 395331 0 48303 Evan Benjamin MD FACP 1.00 X 516054 0 58668 Gregory A Harb DOH 33111 1.00 X 584765 0 133003 Mark A Keroack MD DOH 61311 1.00 X 301105 0 80102 Paula C Squires 1.00 X 821223 0 44114 Kristin R Delaney 1.00 X 94511 0 47834 Mark Gorrell Term 82011 50.00 X 194372 0 12645 Gordon Josephson MD 50.00 X 437277 0 66333 Charles D Gijanto 50.00 X 329648 0 112585 Joan Sullivan 50.00 X 324561 0 52800 Peter A Lyons 50.00 X 268220 0 60873 Lawrence G Emerson 50.00 X 259442 0 82977 Hal B Jenson MD Term 52111 1.00 X 172000 0 31081 Keith C McLean-Shinaman 0.00 X 802768 0 36779 7710548 0 1060010 115 1 1 0 Cerner Corporation 2800 Rockcreek Pkwy Kansas City MO 641172521 Computer Services 5752676 Siemens Medical Solutions Dept at 40565 Atlanta GA 311920065 Equipment Maintenance 2040409 Prudential Insurance Company PO Box 101241 Atlanta GA 303921241 Life Insurance 1644498 MassMutual Financial Group 1295 State Street Springfield MA 01111 Pension 1317708 Fidelity Security Life Ins PO Box 632530 Cincinnati OH 452632530 Visioncare Insurance 1236666 89 Affiliate Support 561000 92270721 91599696 671025 92270721 317447 317447 51469 -45345 0 0 51469 -45345 6124 6124 Mini Med School 611600 13120 13120 Miscellaneous 561000 9779 9779 LTD related income 561000 7421 7421 30320 92624612 91630016 671025 323571 7263820 5886600 1377220 37710462 30511267 7199195 3949631 3200604 749027 4032120 3310667 721453 3055408 2475251 580157 1177512 1177512 113683 113683 3499378 2589709 909669 1784411 1650957 133454 2366979 2229069 137910 21579272 20855790 723482 1240919 1063006 177913 610299 408782 201517 1236188 856526 379662 105810 90636 15174 210270 176918 33352 Recruitment 638210 520953 117257 Temporary Help 278181 268561 9620 Dues & Memberships 17073 17073 1337638 834246 503392 92207264 76946615 15260649 0 187625 5794 18954575 24346309 286861 1127197 451640 157945 8076348 6905739 5145273 4733799 385656 411474 9610530 9330788 37953235 42285246 22709644 24802687 32393578 37064406 55103222 61867093 X -17149987 -19581847 -17149987 -19581847 37953235 42285246 X 417348 -2849208 X 0 1 1 X 0 X X X 0 0 0 Baystate Health Inc 042105941 7 1 1 1 0 Baystate Medical Center Inc 042790311 3 0 1 1 0 Baystate Franklin Medical Ctr 042103575 3 0 1 1 0 Baystate Mary Lane Hospital Corp 042103584 3 0 1 1 0 Visiting Nurse Association & Hospice of WNE Inc 042105803 9 0 1 1 0 5 0 Schedule A, Part IV, Supplemental Information: Schedule A, part I, line 11c Baystate Administrative Services, Inc.(BAS)is a Type III Functionally Integrated supporting organization in accordance with IRS Schedule A Instructions which state that an organization is "operated in connection with" one or more supported organization(s) if it meets a "responsiveness test" and an "integral part test". BAS meets the responsiveness test because its officers, directors, or trustees, have maintained a close continuous working relationship with the officers, directors, or trustees, of the supported organization(s). BAS also meets the integral part test because it engages in activities substantially all of which directly further the exempt purposes of the supported organization(s). Schedule A, part I, line 11h(vii) BAS provides management, administrative, and professional services to support the organizations listed on line h(i). 0 1 0 0 0 0 1 237080 0 0 237080 0 Part IV, Supplemental Information: The amount recorded on Part II-B, line 1j represents BAS salaries and operating expenses as reported on Massachusetts Public Records Division Lobbyist Disclosures for activities related to healthcare policy, bills and appropriations-related activities. 498674 456916 41758 3274653 2904937 369716 1371946 1371946 0 411474 Due from affiliated companies 9330788 9330788 Due to affiliated companies 19119933 Total accrued pension cost 2133003 Total minimum pension liability 15811470 37064406 Part X, line 2 : No FIN48 footnote was included in the consolidated audited financial statements of Baystate health, Inc. and Subsidiaries for the year ended September 30, 2012. X X X 1 1 1 1 1 0 0 0 0 0 0 Mark R Tolosky 696553 0 315856 0 524231 0 58633 0 40732 0 1636005 0 0 0 Dennis W Chalke 363180 0 131625 0 177826 0 58000 0 34548 0 765179 0 0 0 Donna J Ross 255000 0 77877 0 62454 0 42782 0 5521 0 443634 0 0 0 Evan Benjamin MD FACP 327662 0 92768 0 95624 0 33833 0 24835 0 574722 0 0 0 Gregory A Harb DOH 33111 337108 0 180000 0 67657 0 108675 0 24328 0 717768 0 0 0 Mark A Keroack MD DOH 61311 245679 0 33750 0 21676 0 64800 0 15302 0 381207 0 0 0 Paula C Squires 272852 0 77071 0 471300 0 15925 0 28189 0 865337 0 324655 0 Mark Gorrell Term 82011 178968 0 0 0 15404 0 0 0 12645 0 207017 0 0 0 Gordon Josephson MD 332901 0 71071 0 33305 0 46725 0 19608 0 503610 0 0 0 Charles D Gijanto 280176 0 37638 0 11834 0 88631 0 23954 0 442233 0 0 0 Joan Sullivan 247428 0 48527 0 28606 0 34277 0 18523 0 377361 0 0 0 Peter A Lyons 208213 0 43494 0 16513 0 38144 0 22729 0 329093 0 0 0 Lawrence G Emerson 206071 0 39895 0 13476 0 63930 0 19047 0 342419 0 0 0 Hal B Jenson MD Term 52111 136910 0 0 0 35090 0 14100 0 16981 0 203081 0 0 0 Keith C McLean-Shinaman 276485 0 137200 0 389083 0 0 0 36779 0 839547 0 0 0 Part I, Line 1a Part I, Line 1a: 1. Companion Travel - Several Trustees, Officers, and/or key employees were provided with compensation for spouses to attend a company board event. 2. Tax Gross up / Discretionary Spending Account- Several employees were provided with reimbursement for financial, tax and estate planning requiring a tax gross up. The two items above were treated as taxable compensation as appropriate in accordance with Baystate's written policies which require compliance with the IRS's accountable plan rules. Part I, Line 3 The Baystate Administrative Services, Inc. Board of Directors is composed of management of Baystate Health, Inc. and its affiliates. Therefore it is more appropriate that the establishment and review of the compensation of the organization's top management officials be performed at the Baystate Health level, which has a more independent board. Part I, Lines 4a-c Line 4a: Keith McLean-Shinaman terminated employment effective 9/30/2011. The compensation numbers include various one time termination payments. Line 4b: Evan Benjamin, MD - Supplemental Retirement of $70,052 is included in column E. This amount was earned in 2011. Dennis W. Chalke - Supplemental Retirement of $145,066 is included in column E. This amount was earned in 2011. Lawrence Emerson - Supplemental Retirement of $1,930 is included in column E. This amount was earned in 2011. Charles Gijanto - Supplemental Retirement of $72,706 is included in column E. This amount was earned in 2011. Gregory A. Harb - Supplemental Retirement of $96,425 is included in column E. This amount was earned in 2011. Gordon Josephson, MD - Supplemental Retirement of $23,507 is included in column E. This amount was earned in 2011. Mark A. Keroack, MD - Supplemental Retirement of $48,875 is included in column E. This amount was earned in 2011. Peter A. Lyons - Supplemental Retirement of $3,644 is included in column E. This amount was earned in 2011. Keith C. McLean Shinaman - Supplemental Retirement of $41,190 is included in column E. This amount was earned in 2011. Donna Ross- Supplemental Retirement of $18,615 is included in column E. This amount was earned in 2011. Paula Squires - Supplemental Retirement of $456,277 is included in column E. This amount consists of $132,622 earned in 2011 as well as $324,655 non-vested amounts that were earned in the previous 5 years and previously reported each year as deferred compensation, and now included again in accordance with reporting requirements. Joan Sullivan - Supplemental Retirement of $7,485 is included in column E. This amount was earned in 2011. Mark R. Tolosky - Supplemental Retirement of $332,054 is included in column E. This amount was earned in 2011. Line 4c: The supplemental retirement plan offered to Mr. Tolosky from 1997-2002 provided the right to purchase mutual fund shares at a specified price, with the rights expiring at the end of the 10 years. The 2011 compensation of $130,991 was based on the difference between the fair market value at the date of exercise and the exercise price. Part II Gregory A. Harb was a Director for the entire fiscal year, however his employment start date was 3/31/2011, therefore his compensation figures do not reflect an entire year of compensation. Mark A. Keroack, MD was a Director for the entire fiscal year, however his employment start date was 6/13/2011, therefore his compensation figures do not reflect an entire year of compensation. Baycare Health Partners Inc (BHP) Common Board Members or Officers 234354 See Part V - The filing organization received payments from BHP for management and administrative services. BHP is an affiliate corporation of the filing organization. 0 Health New England (HNE) Common Board Members or Officers 228000 See Part V - The filing organization received payments from HNE of $128,000 for reimbursement of benefits related expenses and $100,000 for management and administrative support. HNE is an affiliate corporation of the filing organization. 0 Ingraham Corporation (IC) Common Board Members or Officers 336671 See Part V - The filing organization received payments from IC for management, administrative and information systems services. IC is an affiliate corporation of the filing organization. 0 Baystate Health Insurance Company Ltd (BHIC) Common Board Members or Officers 19562546 See Part V - The filing organization received payments from BHIC for Claim Insurance reimbursements and Indemnity Pass-Through payments. 0 Baystate Health Insurance Company Ltd (BHIC) Common Board Members or Officers 13214633 See Part V - The filing organization made payments to BHIC for Insurance premiums. 0 Form 990, Part VI, Section A, line 2 Dennis W. Chalke, Kristin R. Delaney, Loring S. Flint, MD, Hal B. Jenson, MD, Keith C. McLean-Shinaman, Donna J.Ross and Mark R. Tolosky are also officers or trustees of Baystate Health, Inc. & its affiliated entities. Form 990, Part VI, Section A, line 6 The filing organization has one member, Baystate Health, Inc. (BH). Form 990, Part VI, Section A, line 7a All of the members of the Board of Directors of the filing organization are individuals serving ex officio based on positions they hold with BH. Form 990, Part VI, Section B, line 11 Prior to the filing of this return appropriate parts of this Form 990 were reviewed by representatives from the Tax, Finance, and Human Resources Departments of Baystate Health, Inc. (the sole member of the filing organization and the parent organization of the health care system to which the filing organization belongs), some of whom are officers or trustees of the filing organization and by outside legal counsel. The entire return was reviewed by a tax expert from an outside accounting firm. In addition, this return was provided to and reviewed by the Audit and Compliance Committee of Baystate Health, Inc. This committee also reviews the audited financial statements for the health system. This return was also provided prior to filing to the Baystate Health, Inc. Board of Trustees. Form 990, Part VI, Section B, line 12c Baystate Health, Inc. (BH) and its affiliated entities have a comprehensive conflict of interest policy applicable to all of the affiliated entities. All directors, trustees, officers, key employees, and highest compensated employees of BH and its affiliates are asked to complete an annual conflict of interest form. We utilize an electronic database to receive and manage all conflict of interest submissions. This information is reviewed by the Chief Compliance Officer, the Chief Executive Officer, the Chair of the Board of Trustees, and the Chair of the Audit & Compliance Committee. A summary of the conflict of interest disclosures is provided to the Baystate Health Board of Trustees and the Tax Department and reviewed by outside counsel. Potential conflict of interest transactions are reviewed as appropriate under the policy, which provides for recusal from discussion and deliberation by any party with a potential conflict of interest. Form 990, Part VI, Section B, line 15 The compensation of the President and CEO, and of other officers and key employees is established based on information provided by independent third party consultants for reasonableness and appropriate comparability data. The compensation is then established, reviewed and approved by the independent compensation committee of Baystate Health, Inc. (the parent organization of the health care system to which the filing organization belongs) and all such deliberations and decisions are documented contemporaneously. Form 990, Part VI, Section C, line 19 Public Inspection of Organizational Policies The organization makes its conflict of interest policy and financial statements available to the public at www.baystatehealth.org. Articles of organization and bylaws are generally available at the Commonwealth of Massachusetts website. Average hours per week: Form 990, Part VII, Section A, Line 1a, Column (B) Individuals with such reported compensation who have 10 or less average hours per week listed in Part VII, worked between 40 - 60 hours among all related entities. Changes in Net Assets or Fund Balances: Form 990, Part XI, line 5: Net unrealized gains on investments: 475,014. Pension Adjustment -3,325,222. Net Asset Transfer from affiliated Companies rounding 1,000. Total to Form 990, Part XI, Line 5: -2,849,208. Baystate Franklin Medical Center 164 High Street Greenfield MA 01301 042103575 Hospital MA 501 (c ) (3) 3 Baystate Health Inc 0 Baystate Health Foundation Inc 759 Chestnut Street Springfield MA 01199 043549011 Fundraising MA 501 (c ) (3) 7 Baystate Health Inc 0 Baystate Health Systems Inc Health & Welfare Benefits Plan 759 Chestnut Street Springfield MA 01199 222531644 Voluntary Employees' Benefit Association MA 501 (c ) (9) Baystate Health Inc 0 Baystate Health Inc 759 Chestnut Street Springfield MA 01199 042105941 Healthcare System Parent MA 501 (c ) (3) 7 Baystate Health Inc 0 Baystate Mary Lane Hospital Corporation 85 South Street Ware MA 01082 042103584 Hospital MA 501 (c ) (3) 3 Baystate Health Inc 0 Baystate Medical Center Inc 759 Chestnut Street Springfield MA 01199 042790311 Acute Care Teaching Hospital MA 501 (c ) (3) 3 Baystate Health Inc 0 Baystate Total Home Care Inc 50 Maple Street Springfield MA 01199 203260764 Real Estate and Other MA 501 (c ) (3) 11b, II Baystate Health Inc 0 BH Insurance Company Ltd North Church Street Georgetown CJ 980421413 Offshore captive Insurance CJ Baystate Health Inc 0 Visiting Nurse Assn and Hospice of Western New England Inc 50 Maple Street Springfield MA 01199 042105803 Homehealth and Hospice care MA 501 (c ) (3) 9 Baystate Health Inc 0 Health New England Inc Monarch Place Suite 1500 Springfield MA 011441500 042864973 HMO/Insurance MA Baystate Health Inc C HNE Advisory Services Monarch Place Suite 1500 Springfield MA 011441500 043012347 Administrative Svs MA Health New England Inc C Health New England Insurance Monarch Place Suite 1500 Springfield MA 011441500 043183019 Ancilliary Insurance MA Health New England Inc C Health New England of Connecticut Monarch Place Suite 1500 Springfield MA 011441500 061398662 Dormant MA Health New England Inc C Ingraham Corporation 759 Chestnut Street Springfield MA 01199 043016257 Health care and other business activities MA Baystate Health Inc C Baystate Health System Ambulance Inc 759 Chestnut Street Springfield MA 01199 043018550 Ambulance Svs MA Ingraham Corporation C 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 1 0 1 Baystate Medical Center J 1096990 accrual Baystate Medical Center K 73445350 accrual Baystate Medical Center L 62232 accrual Baystate Franklin Medical Center K 7182362 accrual Baystate Mary Lane Hospital K 1498281 accrual Baystate Visiting Nurse & Hospice K 1769578 accrual Baystate Health Inc K 1869782 accrual Ingraham Corporation K 336671 accrual Baystate Health Insurance Co O 16762633 cash Baystate Health Insurance Co P 19562546 cash Health New England Inc K 100000 accrual Health New England Inc P 127739 cash BHS Health & Welfare Benefit Trust O 75449132 cash