NEBRASKA METHODIST HEALTH SYSTEM SELF INSURANCE TRUST FUND: Form 990, tax year 2011

View the entire original 990 at ProPublica ↗

Organization
NEBRASKA METHODIST HEALTH SYSTEM SELF INSURANCE TRUST FUND (EIN 36-3699672)
Tax period
2011-01-01 to 2011-12-31
Filed
2012-11-06
IRS object ID
201203119349300900
Schema version
2011v1.2
Source
Download XML · Original 990 at ProPublica

Every field in the e-filed return. Faint text is the IRS element name, for citing.

Return header ReturnHeader

FieldValueIRS element (for citing)
Timestamp2012-11-06T08:31:37-06:00Timestamp
Tax Period End Date2011-12-31TaxPeriodEndDate

Preparer Firm PreparerFirm

FieldValueIRS element (for citing)
EIN135565207EIN

Preparer Firm Business Name PreparerFirmBusinessName

FieldValueIRS element (for citing)
Business Name Line1KPMG LLPBusinessNameLine1

Preparer Firm US Address PreparerFirmUSAddress

FieldValueIRS element (for citing)
Address Line12 CENTRAL PARK PLAZA SUITE 1501AddressLine1
CityOMAHACity
StateNEState
ZIP Code68102ZIPCode
FieldValueIRS element (for citing)
Return Type990ReturnType
Tax Period Begin Date2011-01-01TaxPeriodBeginDate

Filer Filer

FieldValueIRS element (for citing)
EIN363699672EIN

Name Name

FieldValueIRS element (for citing)
Business Name Line1NEBRASKA METHODIST HEALTH SYSTEMBusinessNameLine1
Business Name Line2SELF INSURANCE TRUST FUNDBusinessNameLine2
FieldValueIRS element (for citing)
Name ControlNEBRNameControl
Phone4023544840Phone

US Address USAddress

FieldValueIRS element (for citing)
Address Line18511 WEST DODGE ROADAddressLine1
CityOMAHACity
StateNEState
ZIP Code68114ZIPCode

Officer Officer

FieldValueIRS element (for citing)
NameLINDA BURTName
TitleVICE PRES-FINANCE & CFOTitle
Phone4023544000Phone
Date Signed2012-11-06DateSigned
Authorize Third Party1AuthorizeThirdParty

Preparer Preparer

FieldValueIRS element (for citing)
PTINP00223617PTIN
Phone4023481450Phone
FieldValueIRS element (for citing)
Tax Year2011TaxYear
Build TS2016-02-25 16:41:14ZBuildTS

Form 990 IRS990

FieldValueIRS element (for citing)
Name Of Principal Officer PersonLINDA BURTNameOfPrincipalOfficerPerson

Address Principal Officer US AddressPrincipalOfficerUS

FieldValueIRS element (for citing)
Address Line18511 WEST DODGE ROADAddressLine1
CityOMAHACity
StateNEState
ZIP Code68114ZIPCode
FieldValueIRS element (for citing)
Gross Receipts6824485GrossReceipts
Group Return For Affiliates0GroupReturnForAffiliates
Organization501c3XOrganization501c3
Web SiteN/AWebSite
Type Of Organization CorporationXTypeOfOrganizationCorporation
Year Formation1988YearFormation
State Legal DomicileNEStateLegalDomicile
Activity Or Mission DescriptionTO PROVIDE A FUND TO PAY CLAIMS FOR MEDICAL MALPRACTICE & OTHER GENERAL LIABILITY EXPENSES.ActivityOrMissionDescription
Nbr Voting Members Governing Body19NbrVotingMembersGoverningBody
Nbr Independent Voting Members14NbrIndependentVotingMembers
Total Nbr Employees0TotalNbrEmployees
Total Nbr Volunteers0TotalNbrVolunteers
Total Gross UBI0TotalGrossUBI
Net Unrelated Business Txbl Income0NetUnrelatedBusinessTxblIncome
Contributions Grants Prior Year0ContributionsGrantsPriorYear
Contributions Grants Current Year0ContributionsGrantsCurrentYear
Program Service Revenue Prior Year2526027ProgramServiceRevenuePriorYear
Program Service Revenue CY2527345ProgramServiceRevenueCY
Investment Income Prior Year187443InvestmentIncomePriorYear
Investment Income Current Year350841InvestmentIncomeCurrentYear
Other Revenue Prior Year0OtherRevenuePriorYear
Other Revenue Current Year0OtherRevenueCurrentYear
Total Revenue Prior Year2713470TotalRevenuePriorYear
Total Revenue Current Year2878186TotalRevenueCurrentYear
Grants And Similar Amnts Prior Year0GrantsAndSimilarAmntsPriorYear
Grants And Similar Amnts CY0GrantsAndSimilarAmntsCY
Benefits Paid To Members Prior Year0BenefitsPaidToMembersPriorYear
Benefits Paid To Members CY0BenefitsPaidToMembersCY
Salaries Etc Prior Year0SalariesEtcPriorYear
Salaries Etc Current Year0SalariesEtcCurrentYear
Total Prof Fundrsng Exp Prior Year0TotalProfFundrsngExpPriorYear
Total Prof Fundrsng Exp CY0TotalProfFundrsngExpCY
Total Fundrsng Exp Current Year0TotalFundrsngExpCurrentYear
Other Expense Prior Year3798909OtherExpensePriorYear
Other Expenses Current Year2209315OtherExpensesCurrentYear
Total Expenses Prior Year3798909TotalExpensesPriorYear
Total Expenses Current Year2209315TotalExpensesCurrentYear
Revenues Less Expenses Prior Year-1085439RevenuesLessExpensesPriorYear
Revenues Less Expenses CY668871RevenuesLessExpensesCY
Total Assets BOY13290485TotalAssetsBOY
Total Assets EOY12943648TotalAssetsEOY
Total Liabilities BOY8931331TotalLiabilitiesBOY
Total Liabilities EOY8129314TotalLiabilitiesEOY
Net Assets Or Fund Balances BOY4359154NetAssetsOrFundBalancesBOY
Net Assets Or Fund Balances EOY4814334NetAssetsOrFundBalancesEOY
Info In Schedule O Part IIIXInfoInScheduleOPartIII
Mission DescriptionTHE NEBRASKA METHODIST HEALTH SYSTEM SELF INSURANCE TRUST FUND PROVIDES A POOLED FUND FROM CONTRIBUTIONS OF THE NEBRASKA METHODIST HEALTH SYSTEM AFFILIATES WHICH RESULTS IN A COST EFFECTIVE METHOD OF CONTROLLING, REDUCING AND PROTECTING RISKS OF LEGAL LIABILITY WHICH ARISE OUT OF THE RENDERING OF CARE TO THE SICK AND INJURED.MissionDescription
Significant New Program Services0SignificantNewProgramServices
Significant Change0SignificantChange
Expense2209315Expense
Grants0Grants
Revenue2527345Revenue
DescriptionTHE TRUST FUND WAS ORGANIZED TO PROVIDE MEDICAL MALPRACTICE & GENERAL LIABILITY SELF-INSURANCE PROTECTION FOR NEBR. METHODIST HEALTH SYSTEM AND ITS AFFILIATES. THE TRUST POSTS FUNDS OF THE BENEFICIARIES TO SELF INSURE EXPOSURE OF EMPLOYEES AND CERTAIN AGENTS. THESE EXPOSURES INCLUDE MALPRACTICE, PATIENT RELATED GENERAL LIABILITY, AND COMPREHENSIVE GENERAL LIABILITY. THIS POOLING OF FUNDS HELPS TO REDUCE INSURANCE EXPENSE RESULTING IN LOWER COST MEDICAL SERVICES TO THE COMMUNITY.Description
Total Program Service Expense2209315TotalProgramServiceExpense
Described In501 C31DescribedIn501C3
Schedule B Required0ScheduleBRequired
Political Activities0PoliticalActivities
Lobbying Activities0LobbyingActivities
Subject To Proxy Tax0SubjectToProxyTax
Donor Advised Funds0DonorAdvisedFunds
Conservation Easements0ConservationEasements
Collections Of Art0CollectionsOfArt
Credit Counseling0CreditCounseling
Term Or Permanent Endowments0TermOrPermanentEndowments
Report Land Bldg Equip0ReportLandBldgEquip
Report Invest Oth Securities0ReportInvestOthSecurities
Report Prog Rel Invest0ReportProgRelInvest
Report Other Assets0ReportOtherAssets
Report Other Liabilities1ReportOtherLiabilities
Report Fin48 Footnote1ReportFin48Footnote
Independent Audit Financial Stmt0IndependentAuditFinancialStmt
Consolidated Audit Financial Stmt1ConsolidatedAuditFinancialStmt
School0School
Foreign Office0ForeignOffice
Foreign Activities0ForeignActivities
More Than5000 K To Organizations0MoreThan5000KToOrganizations
More Than5000 K To Individuals0MoreThan5000KToIndividuals
Professional Fundraising0ProfessionalFundraising
Fundraising Activities0FundraisingActivities
Gaming0Gaming
Hospital0Hospital
Grants To Organizations0GrantsToOrganizations
Grants To Individuals0GrantsToIndividuals
Schedule J Required1ScheduleJRequired
Tax Exempt Bonds0TaxExemptBonds
Excess Benefit Transaction0ExcessBenefitTransaction
Prior Excess Benefit Transaction0PriorExcessBenefitTransaction
Loan To Officer Or DQP0LoanToOfficerOrDQP
Grant To Related Person0GrantToRelatedPerson
Bsnss Rltnshp With Organization0BsnssRltnshpWithOrganization
Bsnss Rltnshp Thru Family Member0BsnssRltnshpThruFamilyMember
Officer Entity With Bsnss Rltnshp0OfficerEntityWithBsnssRltnshp
Deductible Non Cash Contributions0DeductibleNonCashContributions
Deductible Contributions Of Art0DeductibleContributionsOfArt
Terminated0Terminated
Partial Liquidation0PartialLiquidation
Disregarded Entity0DisregardedEntity
Related Entity1RelatedEntity
Related Org Controlled Entity0RelatedOrgControlledEntity
Transaction Related Entity0TransactionRelatedEntity
Transfers To Exempt Non Chrtbl Org0TransfersToExemptNonChrtblOrg
Activities Conducted Partnership0ActivitiesConductedPartnership
Schedule O Required1ScheduleORequired
Number Forms Transmitted With109630NumberFormsTransmittedWith1096
Number W2 G Included0NumberW2GIncluded
Number Of Employees0NumberOfEmployees
Unrelated Business Income0UnrelatedBusinessIncome
Foreign Financial Account0ForeignFinancialAccount
Prohibited Tax Shelter Trans0ProhibitedTaxShelterTrans
Taxable Party Notification0TaxablePartyNotification
Non Deductible Contributions0NonDeductibleContributions
Quid Pro Quo Contributions0QuidProQuoContributions
Form8282 Property Disposed Of0Form8282PropertyDisposedOf
Funds To Pay Premiums0FundsToPayPremiums
Premiums Paid0PremiumsPaid
Indoor Tanning Services0IndoorTanningServices
Info In Schedule O Part VIXInfoInScheduleOPartVI
Nbr Voting Governing Body Members19NbrVotingGoverningBodyMembers
Number Independent Voting Members14NumberIndependentVotingMembers
Family Or Business Relationship0FamilyOrBusinessRelationship
Delegation Of Management Duties0DelegationOfManagementDuties
Changes To Organizing Docs0ChangesToOrganizingDocs
Material Diversion Or Misuse0MaterialDiversionOrMisuse
Members Or Stockholders0MembersOrStockholders
Election Of Board Members0ElectionOfBoardMembers
Decisions Subject To Approval0DecisionsSubjectToApproval
Minutes Of Governing Body1MinutesOfGoverningBody
Minutes Of Committees1MinutesOfCommittees
Officer Mailing Address0OfficerMailingAddress
Local Chapters0LocalChapters
Form990 Provided To Governing Body1Form990ProvidedToGoverningBody
Conflict Of Interest Policy1ConflictOfInterestPolicy
Annual Disclosure Covered Persons1AnnualDisclosureCoveredPersons
Regular Monitoring Enforcement1RegularMonitoringEnforcement
Whistleblower Policy1WhistleblowerPolicy
Document Retention Policy1DocumentRetentionPolicy
Compensation Process CEO1CompensationProcessCEO
Compensation Process Other1CompensationProcessOther
Investment In Joint Venture0InvestmentInJointVenture
Upon RequestXUponRequest

The Books Are In Care Of TheBooksAreInCareOf

Name Business NameBusiness

FieldValueIRS element (for citing)
Business Name Line1LINDA BURTBusinessNameLine1
FieldValueIRS element (for citing)
Telephone Number4023544840TelephoneNumber

Address US AddressUS

FieldValueIRS element (for citing)
Address Line18511 W DODGE ROADAddressLine1
CityOMAHACity
StateNEState
ZIP Code68114ZIPCode
FieldValueIRS element (for citing)
Info In Schedule O Part VIIXInfoInScheduleOPartVII

Form990 Part VII Section A Form990PartVIISectionA (20 entries)

TitleTitleAverage Hours Per WeekAverageHoursPerWeekIndividual Trustee Or DirectorIndividualTrusteeOrDirectorOfficerOfficerReportable Comp From OrganizationReportableCompFromOrganizationReportable Comp From Related OrgsReportableCompFromRelatedOrgsOther CompensationOtherCompensation
SPENCER STEVENS
CHAIRMAN1.00XX000
LARRY V PEARSON
VICE CHAIRMAN1.00XX000
ART N BURTSCHER
TREASURER1.00XX000
ADAM YALE
SECRETARY1.00XX000
STEVEN T BAILEY MD
DIRECTOR1.00X026871069273
LARRY DEROIN
DIRECTOR1.00X000
HARRIS A FRANKEL MD
DIRECTOR1.00X000
JOHN M FRASER
PRESIDENT/CEO1.00XX0602762171191
RICHARD C HAHN
DIRECTOR1.00X000
KRISTEN HOFFMAN MD
DIRECTOR1.00X039364783546
DAN KINNEY PHD
DIRECTOR1.00X000
C L LANDEN
DIRECTOR1.00X000
JOHN LOHRBERG MD
DIRECTOR1.00X017578134508
DANIEL D LYDIATT MD DDS
DIRECTOR1.00X022714920610
DIANNE SEEMAN LOZIER
DIRECTOR1.00X000
JAMES L MOUNCE
DIRECTOR1.00X000
JOHN P NELSON
DIRECTOR1.00X000
L B RED THOMAS
DIRECTOR1.00X000
CONSTANCE M RYAN
DIRECTOR1.00X000
LINDA K BURT
VICE PRES FINANCE/CFO1.00X047150795632
FieldValueIRS element (for citing)
Total Reportable Comp From Org0TotalReportableCompFromOrg
Total Reportable Comp Frm Rltd Orgs2139556TotalReportableCompFrmRltdOrgs
Total Other Compensation474760TotalOtherCompensation
Number Individuals GT100 K0NumberIndividualsGT100K
Formers Listed0FormersListed
Total Comp GT150 K1TotalCompGT150K
Compensation From Other Sources0CompensationFromOtherSources

Contractor Compensation ContractorCompensation (5 entries)

Address Line1AddressOfContractor/AddressUS/AddressLine1CityAddressOfContractor/AddressUS/CityStateAddressOfContractor/AddressUS/StateZIP CodeAddressOfContractor/AddressUS/ZIPCodeDescription Of ServicesDescriptionOfServicesCompensationCompensation
RONALD J PALAGI PC
3131 SOUTH 72 STREETOMAHANE68124LEGAL/CLAIMS700000
FRASER STRYKER PC LLO
409 SOUTH 17 STREETOMAHANE68102LEGAL/CLAIMS450000
SODORO DALY & SODORO
7000 SPRING STREETOMAHANE68106CONSULTING/CLAIMS335749
RICHARD SCHICKER
11920 BURT STREET 145OMAHANE68154LEGAL/CLAIMS250000
CULLAN & CULLAN LLC
1113 HARNEY STREETOMAHANE68102LEGAL/CLAIMS200000
FieldValueIRS element (for citing)
Number Of Contractors GT100 K8NumberOfContractorsGT100K

Program Service Revenue ProgramServiceRevenue

FieldValueIRS element (for citing)
DescriptionSELF INS. PREM REVDescription
Business Code524298BusinessCode
Total Revenue Column2527345TotalRevenueColumn
Related Or Exempt Function Income2527345RelatedOrExemptFunctionIncome
FieldValueIRS element (for citing)
Total Program Service Revenue2527345TotalProgramServiceRevenue

Investment Income InvestmentIncome

FieldValueIRS element (for citing)
Total Revenue Column299618TotalRevenueColumn
Exclusion$299,618ExclusionAmount

Gross Amount Sales Assets GrossAmountSalesAssets

FieldValueIRS element (for citing)
Securities3997522Securities

Less Cost Oth Basis Sales Expenses LessCostOthBasisSalesExpenses

FieldValueIRS element (for citing)
Securities3946299Securities

Gain Or Loss GainOrLoss

FieldValueIRS element (for citing)
Securities51223Securities

Net Gain Or Loss Investments NetGainOrLossInvestments

FieldValueIRS element (for citing)
Total Revenue Column51223TotalRevenueColumn
Exclusion$51,223ExclusionAmount

Total Revenue TotalRevenue

FieldValueIRS element (for citing)
Total Revenue Column2878186TotalRevenueColumn
Related Or Exempt Function Income2527345RelatedOrExemptFunctionIncome
Unrelated Business Revenue0UnrelatedBusinessRevenue
Exclusion$350,841ExclusionAmount

Fees For Services Invst Mgmnt Fees FeesForServicesInvstMgmntFees

FieldValueIRS element (for citing)
Total21962Total
Program Services21962ProgramServices

Fees For Services Other FeesForServicesOther

FieldValueIRS element (for citing)
Total59150Total
Program Services59150ProgramServices

Other Expenses OtherExpenses

FieldValueIRS element (for citing)
DescriptionCLAIMS SERVICEDescription
Total2128203Total
Program Services2128203ProgramServices

Total Functional Expenses TotalFunctionalExpenses

FieldValueIRS element (for citing)
Total2209315Total
Program Services2209315ProgramServices
Management And General0ManagementAndGeneral
Fundraising0Fundraising

Cash Non Interest Bearing CashNonInterestBearing

FieldValueIRS element (for citing)
BOY46749BOY
EOY70906EOY

Investments Pub Traded Securities InvestmentsPubTradedSecurities

FieldValueIRS element (for citing)
BOY13044177BOY
EOY12626390EOY

Other Assets Total OtherAssetsTotal

FieldValueIRS element (for citing)
BOY199559BOY
EOY246352EOY

Total Assets TotalAssets

FieldValueIRS element (for citing)
BOY13290485BOY
EOY12943648EOY

Accounts Payable Accrued Expenses AccountsPayableAccruedExpenses

FieldValueIRS element (for citing)
BOY8931331BOY

Other Liabilities OtherLiabilities

FieldValueIRS element (for citing)
BOY0BOY
EOY8129314EOY

Total Liabilities TotalLiabilities

FieldValueIRS element (for citing)
BOY8931331BOY
EOY8129314EOY
FieldValueIRS element (for citing)
Follow SFAS117XFollowSFAS117

Unrestricted Net Assets UnrestrictedNetAssets

FieldValueIRS element (for citing)
BOY4359154BOY
EOY4814334EOY

Total Net Assets Fund Balances TotalNetAssetsFundBalances

FieldValueIRS element (for citing)
BOY4359154BOY
EOY4814334EOY

Total Liab Net Assets Fund Balances TotalLiabNetAssetsFundBalances

FieldValueIRS element (for citing)
BOY13290485BOY
EOY12943648EOY
FieldValueIRS element (for citing)
Info In Schedule O Part XIXInfoInScheduleOPartXI
Reconcilation Revenue Expenses668871ReconcilationRevenueExpenses
Reconcilation Other Changes-213691ReconcilationOtherChanges
Method Of Accounting AccrualXMethodOfAccountingAccrual
Accountant Compile Or Review0AccountantCompileOrReview
FS Audited1FSAudited
Audit Committee1AuditCommittee
Financial Statement ConsolidatedXFinancialStatementConsolidated
Federal Grant Audit Required0FederalGrantAuditRequired

Schedule A IRS990ScheduleA

FieldValueIRS element (for citing)
Supporting Organization509a3XSupportingOrganization509a3
Supporting Org509a3 Type3 Func IntXSupportingOrg509a3Type3FuncInt
Certification CheckboxXCertificationCheckbox
Contrib By Controlling Individual0ContribByControllingIndividual
Contribution By Related Party0ContributionByRelatedParty
Contrib By35 Controlled Entity0ContribBy35ControlledEntity

Supported Org Information SupportedOrgInformation (5 entries)

EINEINType Of OrganizationTypeOfOrganizationListed In Governing DocListedInGoverningDocSupported Organization NotifiedSupportedOrganizationNotifiedOrganized In USOrganizedInUSAmountAmount
JENNIE EDMUNDSON MEMORIAL HOSPITAL
4206803553111$36,224
NEBRASKA METHODIST HOSPITAL
4703766043111$1,599,584
PHYSICIANS CLINIC INC
4706873179111$492,395
NEBR METH COLLEGE OF NURSING AND ALLIED HEALTH
4707243872111$0
NEBR METHODIST FOUNDATION
4705953457111$0
FieldValueIRS element (for citing)
Total Number Of Supported Orgs5TotalNumberOfSupportedOrgs
Sum Of Amounts2128203SumOfAmounts

Schedule D IRS990ScheduleD

FieldValueIRS element (for citing)
Total Of Book Value Land Buildings0TotalOfBookValueLandBuildings

Other Liabilities OtherLiabilities

FieldValueIRS element (for citing)
DescriptionCLAIMS RESERVESDescription
Amount$8,129,314Amount
FieldValueIRS element (for citing)
Total Of Amounts8129314TotalOfAmounts

Form990 Schedule D Part XIV Form990ScheduleDPartXIV

FieldValueIRS element (for citing)
IdentifierDESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48:Identifier
Return ReferencePART X:ReturnReference
ExplanationPART X, LINE 2: THE HEALTH SYSTEM RECOGNIZES THE EFFECT OF INCOME TAX POSITIONS ONLY IF THOSE POSITIONS ARE MORE LIKELY THAN NOT OF BEING SUSTAINED. RECOGNIZED INCOME TAX POSITIONS ARE MEASURED AT THE LARGEST AMOUNT THAT IS GREATER THAN 50% LIKELY OF BEING REALIZED. CHANGES IN RECOGNITION OR MEASUREMENT ARE REFLECTED IN THE PERIOD IN WHICH THE CHANGE IN JUDGMENT OCCURS. MANAGEMENT DETERMINED THAT THERE ARE NO INCOME TAX POSITIONS REQUIRING RECOGNITION IN THE CONSOLIDATED FINANCIAL STATEMENTS.Explanation

Schedule J IRS990ScheduleJ

FieldValueIRS element (for citing)
Severance Payment0SeverancePayment
Supplemental Nonqual Retire Plan1SupplementalNonqualRetirePlan
Equity Based Comp Arrangement0EquityBasedCompArrangement
Comp Based On Revenue Of Filing Org0CompBasedOnRevenueOfFilingOrg
Comp Based On Revenue Related Orgs0CompBasedOnRevenueRelatedOrgs
Comp Based Net Earnings Filing Org0CompBasedNetEarningsFilingOrg
Comp Based Net Earnings Relate Orgs0CompBasedNetEarningsRelateOrgs
Any Non Fixed Payments0AnyNonFixedPayments
Initial Contract Exception0InitialContractException

Form990 Schedule J Part II Form990ScheduleJPartII (6 entries)

Base Compensation Filing OrgBaseCompensationFilingOrgComp Based On Related OrgsCompBasedOnRelatedOrgsBonus Filing OrgBonusFilingOrgBonus Related OrgsBonusRelatedOrgsOther Compensation Filing OrgOtherCompensationFilingOrgOther Compensation Related OrgsOtherCompensationRelatedOrgsDeferred Comp Filing OrgDeferredCompFilingOrgDeferred Comp Related OrgsDeferredCompRelatedOrgsNontaxable Benefits Filing OrgNontaxableBenefitsFilingOrgNontaxable Benefits Related OrgsNontaxableBenefitsRelatedOrgsTotal Compensation Filing OrgTotalCompensationFilingOrgTotal Compensation Related OrgsTotalCompensationRelatedOrgsComp Report Prior990 Filing OrgCompReportPrior990FilingOrgComp Report Prior990 Related OrgsCompReportPrior990RelatedOrgs
STEVEN T BAILEY MD
022660604091601188057472015535034171700
JOHN M FRASER
0570354000324080159357013449077556800
KRISTEN HOFFMAN MD
0288874010063804135067190016623047746000
JOHN LOHRBERG MD
013418302552801607003438902939021310900
DANIEL D LYDIATT MD DDS
0222723065043610206100268024802700
LINDA K BURT
034534000012616708213401475105683920105240

Form990 Schedule J Part III Form990ScheduleJPartIII (2 entries)

Return ReferenceReturnReferenceExplanationExplanation
PART I, LINE 3SEE SCHEDULE O, PART VI, SECTION B, LINE 15 EXPLANATION REGARDING THE METHODS USED BY A RELATED ORGANIZATION TO ESTABLISH COMPENSATION.
PART I, LINE 4BTHE FOLLOWING INDIVIDUALS PARTICIPATED IN A NEBRASKA METHODIST HEALTH SYSTEM NONQUALIFIED PLAN DURING 2011 AND RECEIVED CONTRIBUTIONS, PLAN ACCRUALS OR PLAN DISTRIBUTIONS IN THE FOLLOWING AMOUNTS: STEVEN BAILEY, MD $9,485 ACCRUAL JOHN FRASER, $111,396 ACCRUAL LINDA BURT $65,226 ACCRUAL; PLAN DISTRIBUTION $105,240 KRISTEN HOFFMAN MD $21,501 ACCRUAL JOHN LOHRBERG MD $6,562 ACCRUAL

Schedule O IRS990ScheduleO

General Explanation GeneralExplanation (6 entries)

Return ReferenceReturnReferenceExplanationExplanationIdentifierIdentifier
FORM 990, PART VI, SECTION B, LINE 11A COPY OF THE FORM 990 WAS PROVIDED TO MEMBERS OF THE NEBRASKA METHODIST HEALTH SYSTEM AUDIT COMMITTEE WHO REVIEWED IT IN DETAIL. THE AUDIT COMMITTEE REPORTED TO THE BOARD OF DIRECTORS ON THEIR REVIEW OF THE FORM 990 AT A REGULARLY SCHEDULED MEETING. A COPY OF THE FORM 990 WAS MADE AVAILABLE TO ALL MEMBERS ELECTRONICALLY THROUGH A SECURE PORTAL. INFORMATION FOR THE FORM 990 IS GATHERED FROM APPROPRIATE, RESPONSIBLE PARTIES THROUGHOUT THE NEBRASKA METHODIST HEALTH SYSTEM ORGANIZATION INCLUDING THE FINANCE, HUMAN RESOURCE AND COMPLIANCE DEPARTMENTS; IS REVIEWED BY EXTERNAL TAX ADVISORS AND HAS A FINAL REVIEW BY THE CHIEF EXECUTIVE OFFICER AND CHIEF FINANCIAL OFFICER FOR NEBRASKA METHODIST HEALTH SYSTEM.
FORM 990, PART VI, SECTION B, LINE 12CAN ANNUAL QUESTIONNAIRE IS SENT TO ALL OFFICERS, DIRECTORS AND KEY EMPLOYEES PURSUANT TO THE METHODIST HEALTH SYSTEM CONFLICTS OF INTEREST POLICY WHICH REQUIRES THE DISCLOSURE OF ALL CONFLICTS OF INTEREST, NOT JUST FINANCIAL, THAT COULD GIVE RISE TO CONFLICTS WITH THE ORGANIZATION. SHOULD A CONFLICT BE IDENTIFIED, THE OFFICER, DIRECTOR OR KEY EMPLOYEE IS NOT PERMITTED TO VOTE OR USE PERSONAL INFLUENCE ON THE MATTER AND IS NOT COUNTED IN DETERMINING A QUORUM FOR A MEETING AT WHICH THE MATTER IS DISCUSSED. A POTENTIAL CONFLICT OF INTEREST ONCE IDENTIFIED MUST BE EVALUATED ON A CASE BY CASE BASIS. IN ORDER TO APPROVE THE TRANSACTION WHICH INVOLVES A DIRECT CONFLICT OF INTEREST, THE BOARD MUST FIRST FIND, BY MAJORITY VOTE OF THE DIRECTORS FOR WHOM NO CONFLICT EXISTS, AT A MEETING AT WHICH A QUORUM IS PRESENT, THAT THE ARRANGEMENT OR TRANSACTION IS IN THE BEST INTERESTS OF THE NEBRASKA METHODIST HEALTH SYSTEM SELF INSURANCE TRUST FUND AND/OR THE NEBRASKA METHODIST HEALTH SYSTEM AFFILIATES, IS FAIR AND REASONABLE, AND AFTER INVESTIGATION, THE DIRECTORS HAVE DETERMINED THAT A MORE ADVANTAGEOUS TRANSACTION OR ARRANGEMENT CANNOT BE OBTAINED WITH REASONABLE EFFORT UNDER THE CIRCUMSTANCES.
FORM 990, PART VI, SECTION B, LINE 15NEBRASKA METHODIST HEALTH SYSTEM SELF INSURANCE TRUST FUND IS AN AFFILIATED MEMBER OF THE NEBRASKA METHODIST HEALTH SYSTEM. POLICIES ARE CENTRALIZED AT NEBRASKA METHODIST HEALTH SYSTEM INC. METHODIST HEALTH SYSTEM RETAINS AN INDEPENDENT CONSULTANT TO REVIEW ALL OFFICER COMPENSATION FOR EACH AFFILIATE. UNDER THIS PROCESS, MARKET DATA ON COMPENSATION IS GATHERED AND ANALYZED AND COMPENSATION RANGES ARE SET. THE INFORMATION IS THEN PROVIDED TO THE COMPENSATION COMMITTEE OF THE BOARD OF NEBRASKA METHODIST HEALTH SYSTEM INC., A NEBRASKA NON-PROFIT CORPORATION. ALL OFFICER COMPENSATION IS REVIEWED, EVALUATED AND APPROVED BY THIS COMMITTEE.
FORM 990, PART VI, SECTION C, LINE 19THE ORGANIZATION DOES NOT MAKE THESE DOCUMENTS SEPARATELY AVAILABLE TO THE PUBLIC. THE CONFLICT OF INTEREST POLICY IS DISTRIBUTED TO MEMBERS OF THE BOARD OF DIRECTORS AND EMPLOYEES. FINANCIAL INFORMATION IS AVAILABLE TO THE PUBLIC THROUGH THE IRS FORM 990.
FORM 990, PART VII, COLUMN BJOHN FRASER, PRESIDENT AND CEO OF NEBRASKA METHODIST HEALTH SYSTEM, IS A FULLTIME EMPLOYEE OF NEBRASKA METHODIST HEALTH SYSTEM INC. HIS AVERAGE HOURS PER WEEK HAVE BEEN ALLOCATED AMONG THE ENTITIES THAT COMPRISE THE NEBRASKA METHODIST HEALTH SYSTEM. LINDA BURT, VICE PRESIDENT OF FINANCE AND CFO OF NEBRASKA METHODIST HEALTH SYSTEM IS A FULLTIME EMPLOYEE OF NEBRASKA METHODIST HEALTH SYSTEM INC. HER AVERAGE HOURS PER WEEK HAVE BEEN ALLOCATED AMONG THE ENTITIES THAT COMPRISE THE NEBRASKA METHODIST HEALTH SYSTEM. DIRECTORS STEVEN BAILEY MD, KRISTEN HOFFMAN MD AND JOHN LOHRBERG MD ARE EMPLOYEES OF PHYSICIANS CLINIC INC. DIRECTOR DANIEL LYDIATT MD IS AN EMPLOYEE OF NEBRASKA METHODIST HOSPITAL. THESE INDIVIDUALS ARE FULLTIME EMPLOYEES WITH AN AVERAGE OF 40 HOURS PER WEEK.HOURS WORKED FOR RELATED ORGANIZATION
FORM 990, PART XI, LINE 5:NET UNREALIZED LOSSES ON INVESTMENTS: -213,691.CHANGES IN NET ASSETS OR FUND BALANCES:

Schedule R IRS990ScheduleR

Form990 Schedule R Part II Form990ScheduleRPartII (8 entries)

Address Line1AddressUS/AddressLine1CityAddressUS/CityStateAddressUS/StateZIP CodeAddressUS/ZIPCodeEINEINPrimary ActivitiesPrimaryActivitiesLegal Domicile StateLegalDomicileStateExempt Code SectionExemptCodeSectionPublic Charity StatusPublicCharityStatusDirect Controlling Entity NADirectControllingEntityNAControlled OrgControlledOrgBusiness Name Line1DirectControllingEntityName/BusinessNameLine1
NEBRASKA METHODIST HEALTH SYSTEM INC
8511 W DODGE ROADOMAHANE68114470639839ADMINISTRATIVE SUPPORTNE501(C)(3)L11 F-IIIN/A0
NEBRASKA METHODIST HOSPITAL
8511 W DODGE ROADOMAHANE68114470376604LICENSED HOSPITALNE501(C)(3)L30NEBRASKA METHODIST HEALTH SYSTEM
JENNIE EDMUNDSON MEMORIAL HOSPITAL
933 E PIERCECOUNCIL BLUFFSIA51503420680355LICENSED HOSPITALIA501(C)(3)L30NEBRASKA METHODIST HEALTH SYSTEM
PHYSICIANS CLINIC INC
8511 W DODGE ROADOMAHANE68114470687317CLINICAL HEALTH CARENE501(C)(3)L90NEBRASKA METHODIST HEALTH SYSTEM
NEBRASKA METHODIST COLLEGE OF NURSING & ALLIED HEALTH
8511 W DODGE ROADOMAHANE68114470724387NURSING & HEALTH EDUCATION FACILITYNE501(C)(3)L20NEBRASKA METHODIST HOSPITAL
NEBRASKA METHODIST HOSPITAL FOUNDATION
8511 W DODGE ROADOMAHANE68114470595345SUPPORT OF NEBRASKA METHODIST HOSPITALNE501(C)(3)L70NEBRASKA METHODIST HEALTH SYSTEM
REAL ESTATE HOLDINGS INC
8511 W DODGE ROADOMAHANE68114470649790PROPERTY MANAGEMENTNE501(C)(2)0NEBRASKA METHODIST HEALTH SYSTEM
JENNIE EDMUNDSON MEMORIAL HOSPITAL FOUNDATION
933 E PIERCECOUNCIL BLUFFSIA51503421439454SUPPORT OF JENNIE EDMUNDSON MEM. HOSPITALIA501(C)(3)L11, I0JENNIE EDMUNDSON MEMORIAL HOSPITAL

Form990 Schedule R Part IV Form990ScheduleRPartIV (3 entries)

Address Line1AddressUS/AddressLine1CityAddressUS/CityStateAddressUS/StateZIP CodeAddressUS/ZIPCodeEINEINPrimary ActivityPrimaryActivityLegal Domicile StateLegalDomicileStateBusiness Name Line1DirectControllingEntityName/BusinessNameLine1Type Of EntityTypeOfEntity
HEALTHCARE PARTNERS OF WESTERN IOWA
933 E PIERCE STREETCOUNCIL BLUFFSIA51503421411452MANAGED CARE CONTRACTINGIAJENNIE EDMUNDSON MEMORIAL HOSPITALC
SHARED SERVICE SYSTEMS INC
8511 W DODGE ROADOMAHANE68114470649534MEDICAL SUPPLY DISTRIBUTION & LAUNDRYNENEBRASKA METHODIST HEALTH SYSTEM INCC
METHODIST HEALTH PARTNERS
8511 W DODGE ROADOMAHANE68114470797563MANAGED CARE CONTRACTINGNENEBRASKA METHODIST HEALTH SYSTEM INCC
FieldValueIRS element (for citing)
Receipt Of Int Ann Rents Royalties0ReceiptOfIntAnnRentsRoyalties
Gift Grant Or Cap Contr To Other Org0GiftGrantOrCapContrToOtherOrg
Gift Grant Or Cap Contr Fr Other Org0GiftGrantOrCapContrFrOtherOrg
Loans Or Guarantees To Other Org0LoansOrGuaranteesToOtherOrg
Loans Or Guarantees From Other Org0LoansOrGuaranteesFromOtherOrg
Sale Of Assets To Other Org0SaleOfAssetsToOtherOrg
Purchase Of Assets From Other Org0PurchaseOfAssetsFromOtherOrg
Exchange Of Assets0ExchangeOfAssets
Rental Of Facilities To Other Orgs0RentalOfFacilitiesToOtherOrgs
Rental Of Facilities Fr Other Orgs0RentalOfFacilitiesFrOtherOrgs
Perform Of Services For Other Orgs1PerformOfServicesForOtherOrgs
Perform Of Services By Other Orgs0PerformOfServicesByOtherOrgs
Sharing Of Facilities0SharingOfFacilities
Sharing Of Paid Employees0SharingOfPaidEmployees
Reimbursement Paid To Other Org0ReimbursementPaidToOtherOrg
Reimbursement Paid By Other Org0ReimbursementPaidByOtherOrg
Other Transfer To Other Org0OtherTransferToOtherOrg
Other Transfer From Other Org0OtherTransferFromOtherOrg

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