2022-09-29T10:04:41-05:00 2021-12-31 390758449 WIPFLI LLP 1502 LONDON ROAD SUITE 200 DULUTH MN 55812 990 2021-01-01 813565570 INCLUSA INC INCL 8776226700 2801 HOOVER ROAD 3 STEVENS POINT WI 54481 JASON TAYLOR CHIEF FINANCIAL OFFICER 8776226700 2022-09-29 1 JASON TAYLOR 999009999 MICHAEL J PETERSON CPA P01833529 2187224705 2022-09-29 3 AAL1 IAL1 2021 2022-09-23 18:48:47Z X MARK HILLIKER 2801 HOOVER ROAD 3 STEVENS POINT WI 54481 696118730 0 X WWW.INCLUSA.ORG X 2016 WI IN ORDER TO MAXIMIZE HEALTH OUTCOMES, INCLUSA PROACTIVELY PARTNERS WITH OTHERS TO BUILD VIBRANT AND INCLUSIVE COMMUNITIES THAT OFFER PEOPLE DIGNITY, CHOICE, AND CONNECTIONS. 13 13 1383 11 0 0 47676 8734 659084122 695834461 1105773 275535 0 0 660237571 696118730 3488644 0 0 0 88720821 90688375 0 0 0 545250940 581100411 637460405 671788786 22777166 24329944 133376896 163276844 52204123 57920743 81172773 105356101 IN ORDER TO MAXIMIZE HEALTH OUTCOMES, INCLUSA PROACTIVELY PARTNERS WITH OTHERS TO BUILD VIBRANT AND INCLUSIVE COMMUNITIES THAT OFFER PEOPLE DIGNITY, CHOICE, AND CONNECTIONS. 0 0 647320195 0 695834461 INCLUSA, INC. PROACTIVELY PARTNERS WITH OTHERS TO BUILD A SHARED VISION OF LONG-TERM CARE THAT OFFERS THE PEOPLE WE SERVE CHOICE, CONNECTIONS, AND DIGNITY; FOSTERING FULL PARTICIPATION IN COMMUNITIES. INCLUSA, INC. PROVIDES MEDICAID MANAGED LONG-TERM CARE SERVICES AND SUPPORT TO NEARLY 16,245 ELDERS AND PEOPLE WITH PHYSICAL AND INTELLECTUAL/DEVELOPMENTAL DISABILITIES IN WISCONSIN. 647320195 1 1 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 1 590 0 1383 1 0 0 0 0 0 0 0 0 0 0 0 0 X 13 13 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 WI X JASON TAYLOR 7152041810 2801 HOOVER ROAD 3 STEVENS POINT WI 54481 MARK HILLIKER CHIEF EXECUTIVE OFFICER 40.00 X 435897 0 54333 MICHELLE FELLENZ CHIEF TLC OFFICER (THRU AUGUST) 40.00 X 306049 0 41478 KRISTOPHER KUBNICK CHIEF COMMUNITY RESOURCES 40.00 X 267685 0 51663 TIM GARRITY CHIEF INNOVATION OFFICER 40.00 X 268020 0 45625 JOSHUA JANDRAIN CHIEF INFORMATION OFFICER 40.00 X 257728 0 51148 PATRICK HENNEGER CHIEF LEGAL OFFICER 40.00 X 259875 0 47589 JASON TAYLOR CHIEF FINANCIAL OFFICER 40.00 X 268110 0 11055 STACEY WARGOWSKY EXECUTIVE DIRECTOR OF CM SUPPORT 40.00 X 169595 0 42228 DANA CYRA EXECUTIVE DIRECTOR OF QUALITY IMPROVEMENT 40.00 X 171488 0 29338 KATE NORBY EXECUTIVE DIRECTOR OF MEMBER EXPERIENCE 40.00 X 171637 0 28577 JANNA DUFFY EXECUTIVE DIRECTOR OF FINANCE 40.00 X 183494 0 7688 ERIN SMITH EXECUTIVE DIRECTOR OF CR/PR 40.00 X 172950 0 7285 KEN DAY PRESIDENT 2.00 X X 8800 0 0 JOAN FORDHAM VICE PRESIDENT 1.00 X X 2200 0 0 RON CARNEY SECRETARY/TREASURER 1.00 X X 2200 0 0 BETH ARIMOND DIRECTOR 1.00 X 2200 0 0 KEN CORNISH DIRECTOR 1.00 X 2200 0 0 JOHN HALBEIB DIRECTOR 1.00 X 2200 0 0 TARA JOHNSON DIRECTOR 1.00 X 2200 0 0 JOHN KRIESEL DIRECTOR 1.00 X 2200 0 0 LARRY LAEHN DIRECTOR 1.00 X 2200 0 0 GARY RANUM DIRECTOR 1.00 X 2200 0 0 JANIS RIBBENS DIRECTOR 1.00 X 2200 0 0 KAREN LUMB DIRECTOR 1.00 X 1200 0 0 STEVE MCCARTHY DIRECTOR 1.00 X 1200 0 0 2965728 0 418007 21 0 1 0 WPS 1717 W BROADWAY MADISON WI 53713 ADMINISTRATIVE 3474564 RSM US LLP 5155 PAYSPHERE CIRCLE CHICAGO IL 60674 IT CONSULTATION 2990081 MCKESSON MEDICAL-SURGICAL PO BOX 204786 PLYMOUTH TX 75320 MEMBER GOODS 2086340 REM WISCONSIN III INC 2005 W BELTLINE HWY STE 203 MADISON WI 53713 DIRECT CARE WORKFORCE, CRISIS DIVERSION, 1919150 SKYLINE TECHNOLOGIES INC 1400 LOMBARDI AVE STE 104N GREEN BAY WI 54304 NEW SOFTWARE CREATION 1452524 99 8734 8734 CAPITATION FEE REVENUE 624100 647905556 647905556 ROOM AND BOARD REIMBURSEMENT 623000 47928905 47928905 695834461 275535 275535 696118730 695834461 0 275535 2091988 1676728 415260 63585118 50416704 13168414 2428092 1915666 512426 17877058 14376243 3500815 4706119 3755063 951056 82387 82387 80764 80764 4487581 468835 4018746 221441 6809 214632 754124 432951 321173 3719179 3709235 9944 2428130 2253136 174994 1218765 1160258 58507 1398857 802679 596178 390548 259209 131339 DIRECT MEMBER CARE EXPE 565965796 565965796 OPERATING SUPPLIES 150086 78096 71990 EMPLOYEE TRAINING 126752 35604 91148 BOARD EXPENSES 35212 35212 40789 7183 33606 671788786 647320195 24468591 0 372975 10950 105894040 125353960 14505470 17772095 1159628 1121532 17280738 5833693 4661902 11447045 6434164 6966184 348717 605078 133376896 163276844 51973494 57920743 230629 0 52204123 57920743 X 81172773 105356101 81172773 105356101 133376896 163276844 24329944 -146616 0 X 0 1 X 1 0 X 44639 42884 49297 47676 8734 193230 609812068 624400324 646214344 659084122 695834461 3235345319 609856707 624443208 646263641 659131798 695843195 3235538549 0 0 0 3235538549 231890 273349 688202 1105773 275535 2574749 231890 273349 688202 1105773 275535 2574749 610088597 624716557 646951843 660237571 696118730 3238113298 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 17500 17500 0 PART II-B, LINE 1: INCLUSA, INC. PAYS ANNUAL ASSOCIATION MEMBERSHIP DUES TO THE NATIONAL MLTSS HEALTH PLAN ASSOCIATION. THE NATIONAL MLTSS ASSOCIATION IS COMPRISED OF A NUMBER OF HEALTH PLANS THAT PROVIDE SUPPORTS TO MEDICARE/MEDICAID POPULATIONS ACROSS THE U.S. THE DUES PAID TO THE ASSOCIATION ON AN ANNUAL BASIS SUPPORT STAFF HIRED BY THE ASSOCIATION TO ADVANCE ITS POLICY AGENDA AND TO CONTRACT WITH OUTSIDE EXPERTS WHO PROVIDE SUPPORT THROUGH POLICY ANALYSIS, MEETING WITH LEGISLATORS AND STAFF MEMBERS AT THE FEDERAL LEVEL, ATTENDING CONFERENCE AND COMMITTEE HEARINGS, DEVELOPING POLICY BRIEFS AND STATEMENTS ALIGNED WITH MLTSS ASSOCIATION GOALS, AND SECURING SUPPORT FROM OTHER LIKE-MINDED ORGANIZATIONS. 274944 274944 3459566 22180 3437386 1962699 1377050 585649 4456406 3777500 678906 7127123 656963 6470160 11447045 X X 0 0 0 0 0 0 0 0 0 MARK HILLIKER CHIEF EXECUTIVE OFFICER 392333 0 40000 0 3564 0 11600 0 42733 0 490230 0 0 0 MICHELLE FELLENZ CHIEF TLC OFFICER (THRU AUGUST) 282299 0 23000 0 750 0 7508 0 33970 0 347527 0 0 0 KRISTOPHER KUBNICK CHIEF COMMUNITY RESOURCES 244145 0 23000 0 540 0 11017 0 40646 0 319348 0 0 0 TIM GARRITY CHIEF INNOVATION OFFICER 243789 0 23000 0 1231 0 10892 0 34733 0 313645 0 0 0 JOSHUA JANDRAIN CHIEF INFORMATION OFFICER 233947 0 23000 0 781 0 10604 0 40544 0 308876 0 0 0 PATRICK HENNEGER CHIEF LEGAL OFFICER 236375 0 23000 0 500 0 10256 0 37333 0 307464 0 0 0 JASON TAYLOR CHIEF FINANCIAL OFFICER 243901 0 23000 0 1209 0 10691 0 364 0 279165 0 0 0 STACEY WARGOWSKY EXECUTIVE DIRECTOR OF CM SUPPORT 149995 0 19600 0 0 0 6056 0 36172 0 211823 0 0 0 DANA CYRA EXECUTIVE DIRECTOR OF QUALITY IMPROV 146509 0 23000 0 1979 0 6918 0 22420 0 200826 0 0 0 KATE NORBY EXECUTIVE DIRECTOR OF MEMBER EXPERIE 147347 0 23000 0 1290 0 6921 0 21656 0 200214 0 0 0 JANNA DUFFY EXECUTIVE DIRECTOR OF FINANCE 159749 0 23000 0 745 0 7324 0 364 0 191182 0 0 0 ERIN SMITH EXECUTIVE DIRECTOR OF CR/PR 149651 0 23000 0 299 0 6921 0 364 0 180235 0 0 0 FORM 990, PART VI, SECTION B, LINE 11B THE 990 IS REVIEWED BY THE CHIEF FINANCIAL OFFICER AND THE CHIEF EXECUTIVE OFFICER. A COPY OF THE 990 IS PROVIDED TO THE GOVERNING BODY BEFORE IT IS FILED WITH THE INTERNAL REVENUE SERVICE. FORM 990, PART VI, SECTION B, LINE 12C THE BOARD OF DIRECTORS SHALL ADOPT AND ALWAYS MAINTAIN A WRITTEN CONFLICT OF INTEREST POLICY ("THE POLICY") THAT IS CONSISTENT WITH BEST PRACTICES FOR CHARITABLE ORGANIZATIONS. ALL DIRECTORS, OFFICERS, AND COMMITTEE MEMBERS SHALL SIGN, AS A CONDITION TO SERVING THE CORPORATION IN HIS OR HER RESPECTIVE ROLE, A STATEMENT AGREEING TO BE BOUND BY THE TERMS OF THE POLICY. PURSUANT TO THE POLICY, ANY DIRECTOR, OFFICER, OR COMMITTEE MEMBER HAVING A MATERIAL FINANCIAL INTEREST IN A CONTRACT OR OTHER TRANSACTION PRESENTED TO THE BOARD OF DIRECTORS OR A COMMITTEE THEREOF FOR AUTHORIZATION, APPROVAL, OR RATIFICATION SHALL MAKE A PROMPT, FULL AND FRANK DISCLOSURE OF SUCH PERSON'S INTEREST TO THE BOARD OF DIRECTORS OR COMMITTEE PRIOR TO ITS ACTING ON SUCH CONTRACT OR TRANSACTION. IF THE CONFLICT IS CONFIRMED BY THE BOARD OF DIRECTORS, THE OFFICER OR COMMITTEE MEMBER IS NOT ALLOWED TO PARTICIPATE IN THE DISCUSSION OR VOTE ON THE MATTER. EACH DIRECTOR OF THE BOARD MUST ANNUALLY SIGN A STATEMENT WHICH AFFIRMS SUCH PERSON: (A) HAS RECEIVED A COPY OF THE CONFLICT OF INTEREST POLICY (B) HAS READ AND UNDERSTANDS THE POLICY (C) HAS AGREED TO COMPLY WITH THE POLICY AND, (D) UNDERSTANDS THE CORPORATION IS CHARITABLE AND IN ORDER TO MAINTAIN ITS FEDERAL TAX EXEMPTION IT MUST ENGAGE PRIMARILY IN ACTIVITIES WHICH ACCOMPLISH ONE OR MORE OF ITS TAX-EXEMPT PURPOSES. FORM 990, PART VI, SECTION B, LINE 15 INITIAL OFFICER COMPENSATION WAS ESTABLISHED USING THE SUPPORT OF A CONTRACTED EXPERT IN EXECUTIVE COMPENSATION. THE CONTRACTED EXPERT DEVELOPED SALARY RANGE INFORMATION FOR THE ORGANIZATION'S EXECUTIVES AND PROVIDED COMPENSATION RECOMMENDATIONS TO THE INCLUSA, INC. BOARD OF DIRECTORS. THE BOARD OF DIRECTORS SET THE CHIEF EXECUTIVE OFFICER'S SALARY BASED ON THIS RECOMMENDATION. THE CHIEF EXECUTIVE OFFICER WAS CHARGED WITH SETTING THE COMPENSATION FOR THE REMAINING EXECUTIVES, USING THE RECOMMENDATIONS PROVIDED BY THE CONTRACTED EXPERT. IN SUCCESSIVE YEARS, THE INCLUSA BOARD OF DIRECTORS HAS SET CHIEF EXECUTIVE OFFICER ANNUAL COMPENSATION USING INDUSTRY COMPARISONS AND OTHER MARKET INFORMATION TO AUGMENT THEIR DECISION PROCESS. THE CHIEF EXECUTIVE OFFICER USES SIMILAR INDUSTRY AND MARKET INFORMATION TO MAKE ANY ANNUAL CHANGES TO THE REMAINING EXECUTIVE STAFF MEMBERS. FORM 990, PART VI, SECTION C, LINE 19 INCLUSA MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. ANNOVA INC 2801 HOOVER ROAD UNIT 3 STEVENS POINT WI 54481 842123943 CONSULTING SERVICES WI INCLUSA INC C 7569 277739 1.00000 1 0 0 0 1 0 0 0 0 0 0 0 0 0 1 1 1 1 0 0 ANNOVA INC D 49570 COST ANNOVA INC Q 497552 COST