2011-11-15T11:53:52-06:00 2010-12-31 PLANTE & MORAN PLLC 1111 MICHIGAN AVE EAST LANSING MI 48823 990 2010-01-01 610659432 DELTA DENTAL OF KENTUCKY INC DELT 5027365000 10100 LINN STATION ROAD NO 700 LOUISVILLE KY 40223 RUSSELL W SKAGGS 5027365000 2011-11-11 1 KEVIN E KRAUSE CPA 5173326200 2010 2016-02-24 21:20:13Z CLIFFORD T MAESAKA JR 10100 LINN STATION ROAD NO 700 LOUISVILLE KY 40223 142412160 0 X WWW.DELTADENTALKY.COM X 1966 KY TO IMPROVE ORAL HEALTH OF KENTUCKY EMPLOYEES AND INDIVIDUALS BY PROVIDING ACCESS TO DENTAL CARE AND ENHANCING THE AVAILABILITY OF DENTAL BENEFIT PROGRAMS. 13 9 99 0 0 0 0 0 124870214 135204433 2543066 290638 -1082947 286405 126330333 135781476 0 100000 107711904 116794128 6060801 6348079 0 0 0 8926532 9381121 122699237 132623328 3631096 3158148 53958831 63574460 12121206 16449340 41837625 47125120 TO BE THE DENTAL BENEFITS COMPANY OF CHOICE IN THE MARKETS WE SERVE. 0 0 130108347 100000 135204433 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 561,000 INDIVIDUALS. 130108347 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 1 0 0 0 0 0 1 1 1 0 1 16143 0 1 99 1 0 0 0 0 0 0 X 13 9 0 0 0 0 1 1 1 1 1 0 1 1 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 X 18600 0 0 MICHAEL CHILDERS DMD 2.00 X 19100 0 0 MARY M CORBETT 2.00 X 20450 0 0 RICHARD L FELTNER PHD 2.00 X 3750 0 0 FRANKLIN P JUSTICE JR 2.00 X 3000 0 0 OLIVIA F KIRTLEY 2.00 X 3500 0 16500 MICHAEL B MOUNTJOY 2.00 X 2100 0 16500 JOHN L G RICHARDS 2.00 X 14350 0 0 C RICHARD SEITZ 2.00 X 17250 0 0 BRUCE R SMITH 2.00 X 16500 0 0 JEFFREY C SMITH 2.00 X 34650 0 0 J JUDE THOMPSON 2.00 X 14100 0 0 JOHN N WILLIAMS JR DMD 2.00 X X 23000 0 0 CLIFFORD T MAESAKA JR 40.00 X X 551447 0 21600 J DAVID SMITH 2.00 X 5250 0 0 CURTIS R LADIG 40.00 X 219149 0 15425 STEPHEN C DAY 40.00 X 248962 0 21114 JOHN L WEEKS III 40.00 X 236863 0 9864 ANGELA J NENNI 40.00 X 172649 0 13980 TAMARA L YORK-DAY 40.00 X 198982 0 15743 GORAN JURKOVIC CPA 40.00 X 0 399348 211052 RUSSELL W SKAGGS 40.00 X 120850 0 18251 RONALD E STORY 40.00 X 119340 0 12159 LINA K STIRSMAN 40.00 X 113054 0 8719 BRIAN E KRAINER 40.00 X 175771 0 9867 JAMES C FINN 40.00 X 130667 0 9155 2483334 399348 399929 11 0 1 0 VINTAGE PRINTING 967 S 11TH ST LOUISVILLE KY 40210 PRINTING & POSTAGE 553100 VISION SERVICE PLAN 1 EMBARCADERO CENTER 1540 SAN FRANCISCO CA 94160 VISION COVERAGE 247900 DELTA DENTAL OF VIRGINIA 4860 COX ROAD SUITE 130 GLEN ALLEN VA 23060 ANNUAL SYSTEM MAINTENANCE 240200 RENAISSANCE SYSTEMS & SERVICES PO BOX 67000 DETROIT MI 48267 ELECTRONIC CLAIM VENDOR 156100 OMG LLC 4400 BISHOP LANE SUITE 214 LOUISVILLE KY 40218 MAILROOM MANAGEMENT 128700 6 SUBSCRIBER REVENUE 524114 135186433 135186433 SUBSIDIARY MANAGEMENT 900099 18000 18000 135204433 284833 284833 273698 518553 -244855 -244855 -244855 6117936 6112131 5805 5805 5805 EQUITY IN SUBSIDIARY 900099 531260 531260 531260 135781476 135204433 0 577043 100000 100000 116794128 116794128 1996216 455638 1540578 3307963 3307963 80964 80964 625012 625012 337924 259495 78429 29152 29152 85076 85076 116082 80936 35146 368223 330629 37594 700622 664643 35979 484192 484192 551839 479359 72480 355737 164913 190824 17847 10050 7797 62 62 155984 135510 20474 158920 158920 BROKER COMMISSIONS 4835692 4835692 POSTAGE & SHIPPING 550703 545787 4916 PRINTING & PUBLICATIONS 423203 423203 DUES & ASSESSMENTS 217867 217867 BOARD FEES 204494 204494 125426 112304 13122 132623328 130108347 2514981 0 4585365 6335473 291116 370969 3926335 7412860 275340 270510 13892776 3964721 10270849 9928055 17253502 17656842 8705938 10877693 8650386 10722058 53958831 63574460 2523912 2867825 94678 2537767 9502616 11043748 12121206 16449340 X 41837625 47125120 41837625 47125120 53958831 63574460 X 3158148 2129347 X X 0 1 1 X 0 830000 830000 9779985 1378836 8401149 88682 32230 56452 1838752 1199920 638832 1355357 1353735 1622 9928055 10877693 F 10877693 ACCRUED INVESTMENT INCOME 184158 INVESTMENT - DENTAL CHOICE, INC. 6198998 457(B) PLAN 284991 INVESTMENT - RHSC 2453911 SURPLUS NOTE RECEIVABLE 1600000 10722058 CLAIMS CHECKS OUTSTANDING 6153797 ESTIMATED CLAIMS LIABILITY 4889951 11043748 135781476 132623328 3158148 2129347 2129347 5287495 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: THE COMPANY ADOPTED NEW ACCOUNTING GUIDANCE RELATED TO ACCOUNTING FOR INCOME TAXES AS OF JANUARY 1, 2009. THE NEW ACCOUNTING STANDARD CLARIFIES THE GUIDANCE FOR THE RECOGNITION AND MEASUREMENT OF INCOME TAX BENEFITS RELATED TO UNCERTAIN TAX POSITIONS. THE ADOPTION OF THE NEW GUIDANCE DID NOT HAVE A MATERIAL IMPACT ON THE CONSOLIDATED FINANCIAL STATEMENT. AS OF DECEMBER 31, 2010, 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 DELTA DENTAL FUND PO BOX 30416 LANSING MI 489097916 382337000 501(C)(3) 100000 0 CASH N/A SUPPORT DENTAL EDUCATION AND RESEARCH PROGRAMS 1 0 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: THE ASSISTED ORGANIZATION IS A RELATED ORGANIZATION THAT SUPPORTS DELTA DENTAL OF KENTUCKY'S MISSION. 1 X X X X 1 1 0 0 0 0 0 0 0 CLIFFORD T MAESAKA JR 217675 0 232475 0 101297 0 7350 0 14250 0 573047 0 0 0 CURTIS R LADIG 153900 0 64770 0 479 0 6598 0 8827 0 234574 0 0 0 STEPHEN C DAY 186896 0 60730 0 1336 0 6392 0 14722 0 270076 0 0 0 JOHN L WEEKS III 167317 0 67200 0 2346 0 7110 0 2754 0 246727 0 0 0 ANGELA J NENNI 122564 0 49712 0 373 0 5359 0 8621 0 186629 0 0 0 TAMARA L YORK-DAY 106566 0 92212 0 204 0 6104 0 9639 0 214725 0 0 0 GORAN JURKOVIC CPA 0 202660 0 147689 0 48999 0 184548 0 26504 0 610400 0 0 RONALD E STORY 105822 0 13071 0 447 0 3620 0 8539 0 131499 0 0 0 LINA K STIRSMAN 99382 0 12468 0 1204 0 3453 0 5266 0 121773 0 0 0 BRIAN E KRAINER 83842 0 91799 0 130 0 5037 0 4830 0 185638 0 0 0 PART I, LINES 4A-B DURING THE YEAR, A CHANGE OF CONTROL PAYMENT WAS INITIATED BY THE BOARD OF DELTA DENTAL OF KENTUCKY IN ORDER TO MAINTAIN KEY MANAGEMENT OFFICIALS. THE PAYMENT ARRANGEMENT INCLUDED PAYMENT OF 50% OF THE AGREED AMOUNT UPON SIGNING OF THE CONTRACT AND THE REMAINING 50% TO BE PAID IF THE INDIVIDUAL REMAINED EMPLOYED FOR AT LEAST 6 MONTHS AFTER SIGNING THE CONTRACT. SIX INDIVIDUALS THAT ARE LISTED ON SCHEDULE J RECEIVED SUCH A PAYMENT. THE AMOUNT IS REPORTED IN COLUMN B(II), BONUS AND INCENTIVE COMPENSATION, ON SCHEDULE J. ADDITIONALLY, THE RELATED ORGANIZATION, DELTA DENTAL PLAN OF MICHIGAN, HAS BOTH A 457(F) PLAN AS WELL AS A SERP, A SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN. THERE ARE 7 POSITIONS THAT ARE ELIGIBLE FOR THE SERP AND THEY ARE THE CEO, COO, CAO, CIO, CFO, THE CHIEF SCIENCE OFFICER, AND THE CHIEF MARKETING OFFICER. THERE ARE 2 INDIVIDUALS THAT ARE ALSO GRANDFATHERED IN AND THEY ARE THE SENIOR VP OF CORPORATE AND PUBLIC AFFAIRS, AND THE SENIOR VP OF OPERATIONS. ADDITIONALLY, ALL OTHER VPS AND EXECUTIVES ARE ELIGIBLE FOR THE 457(F) PLAN. THE CONTRIBUTION AMOUNT IS CALCULATED BY INDEPENDENT ACTUARIES. THE INDIVIDUALS ARE VESTED UPON FUNDING. CARRIE BROWN DMD PSC DR. CARRIE BROWN, DIRECTOR, RECEIVES REIMBURSEMENTS FROM DD OF KY 136705 DENTIST WHO PARTICIPATES IN THE ORGANIZATION'S PROVIDER NETWORKS UNDER CONTRACT AND RECEIVES REIMBURSEMENT FOR PATIENT CLAIMS FROM THE ORGANIZATION. 0 MICHAEL A CHILDERS DMD MS PSC DR. MICHAEL CHILDERS, DIRECTOR, RECEIVES REIMBURSEMENTS FROM DD OF KY 48925 DENTIST WHO PARTICIPATES IN THE ORGANIZATION'S PROVIDER NETWORKS UNDER CONTRACT AND RECEIVES REIMBURSEMENT FOR PATIENT CLAIMS FROM THE ORGANIZATION. 0 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 CONTROLLER, THE IN-HOUSE LEGAL COUNSEL, CFO, 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. THE COMMITTEE IS MADE UP OF INDEPENDENT BOARD MEMBERS. THE COMMITTEE UTILIZES CERTAIN COMPENSATION SURVEYS AND OUTSIDE CONSULTANTS ARE ENGAGED AS NEEDED. 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 5: NET UNREALIZED GAINS ON INVESTMENTS: 2,129,347. 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. 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 I DELTA DENTAL PLAN OF MICHIGAN INC 1 SUITE 244 PARTNERS LLC 240 VENTURE CIRCLE NASHVILLE TN 37228 203643584 HOLDS THE LEASE TO SUITE 244 AT LP FIELD (TITANS STADIUM) TN FORE HOLDING CORPORATION N/A 0 0 LIQUID CORN LLC 240 VENTURE CIRCLE NASHVILLE TN 37228 203449680 OWNS SUITE 244 TN FORE HOLDING CORPORATION N/A 0 0 PREMIER INSURANCE SERVICES LLC 240 VENTURE CIRCLE NASHVILLE TN 37228 113662057 INSURANCE BROKER TN FORE HOLDING CORPORATION N/A 0 0 DENTAL CHOICE PROPERTIES LLC 10100 LINN STATION RD SUITE 700 LOUISVILLE KY 40223 610659432 REAL ESTATE HOLDING COMPANY KY N/A N/A 0 0 DENTAL CHOICE INC 10100 LINN STATION RD SUITE 700 LOUISVILLE KY 40223 611105118 SELLS DENTAL BENEFITS KY N/A C 30476 6240655 1.00000 DENTAL CHOICE AGENCY INC 10100 LINN STATION RD SUITE 700 LOUISVILLE KY 40223 611336003 BROKER LICENSING KY N/A C 1496 1.00000 RENAISSANCE HOLDING COMPANY PO BOX 30381 LANSING MI 48909 412177193 HOLDING COMPANY MI RENAISSNCE HEALTH SERVICE CORPORATION C RENAISSANCE LIFE & HEALTH INSURANCE COMPANY OF AMERICA PO BOX 30416 LANSING MI 48909 470397286 INSURANCE DE RENAISSANCE HOLDING COMPANY C RENAISSANCE HEALTH INSURANCE COMPANY OF NEW YORK PO BOX 30416 LANSING MI 48909 134098096 INSURANCE NY RENAISSANCE HOLDING COMPANY C RENAISSANCE HEALTH NETWORKS 4100 OKEMOS RD PO BOX 30381 LANSING MI 48909 113774096 PPO NETWORK MI RENAISSANCE HOLDING COMPANY C RENAISSANCE DENTAL NETWORK LLC 4100 OKEMOS RD PO BOX 30381 LANSING MI 48909 421749772 PPO NETWORK MI RENAISSANCE HEALTH NETWORKS LLC C DENTAL WELLNESS NETWORK LLC 1540 W EDGEWOOD SUITE B INDAINAPOLIS IN 46217 010862825 PPO NETWORK MI RENAISSANCE HEALTH NETWORKS LLC C FORE HOLDING CORPORATION 240 VENTURE CIRCLE NASHVILLE TN 37228 204116122 EMPLOYEE BENEFITS TN DELTA DENTAL OF TENNESSEE C TML LLC 4100 OKEMOS ROAD PO BOX 30381 LANSING MI 489097881 262403888 PPO NETWORK MI RENAISSNCE HEALTH SERVICE CORPORATION C 0 1 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 1 DENTAL CHOICE INC K 573000 ACTUAL COST DELTA DENTAL FUND B 100000 ACTUAL COST DELTA DENTAL OF NORTH CAROLINA D 1600000 ACTUAL COST