2020-11-04T11:34:59-06:00 2019-12-31 390859910 BAKER TILLY US LLP 777 E WISCONSIN AVENUE 32ND FLOOR MILWAUKEE WI 53202 990 2019-01-01 453309488 COMMON GROUND HEALTHCARE COOPERATIVE COMM 4144550500 120 BISHOPS WAY NO 150 BROOKFIELD WI 53005 CATHY MAHAFFEY CEO 4144550500 2020-11-03 1 TROY MARINE CPA P00187863 4147775500 2020-10-29 65.26.60.15 2020-11-03 23:42:54 CS P DA39A3EE5E6B4B0D3255BFEF95601890AFD80709 61F2587C9083E5D801196A980749F72D4837C79B 2019 2021-04-22 16:20:28Z CATHY MAHAFFEY 120 BISHOPS WAY NO 150 BROOKFIELD WI 53005 518709893 0 X WWW.COMMONGROUNDHEALTHCARE.ORG X CO-OP 2011 WI PROVIDE AFFORDABLE HEALTH INSURANCE SOLUTIONS TO SMALL BUS., INDIVIDUALS & NON-PROFITS IN WI. 9 9 145 0 0 0 0 0 565097562 513508101 1508889 5201792 0 0 566606451 518709893 0 0 0 0 8874461 11185600 0 0 0 422085020 433800311 430959481 444985911 135646970 73723982 257535612 361426459 212895262 241534354 44640350 119892105 COMMON GROUND HEALTHCARE COOPERATIVE ("CGHC") IS A NON-PROFIT MEMBER-GOVERNED HEALTH INSURANCE COMPANY DEDICATED TO PROVIDING AFFORDABLE, INNOVATIVE HEALTH INSURANCE SOLUTIONS TO SMALL BUSINESSES, NON-PROFITS, AND INDIVIDUALS IN WISCONSIN. 0 0 COMMON GROUND HEALTHCARE COOPERATIVE IS A NON-PROFIT MEMBER-GOVERNED HEALTH INSURANCE COOPERATIVE DEDICATED TO DELIVERING QUALITY, COMPREHENSIVE HEALTH INSURANCE TO SMALL BUSINESSES AND INDIVIDUALS IN WISCONSIN. 0 0 0 0 0 0 0 0 0 1 0 0 1 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 1 1413 0 1 145 1 0 0 0 0 0 0 79059299 210901853 0 0 0 X 9 9 0 0 0 0 1 1 0 1 1 0 0 1 1 1 1 1 1 1 1 0 X TOM LAWLESS 4144550500 120 BISHOPS WAY SUITE 150 BROOKFIELD WI 53005 CATHY MAHAFFEY CEO 40.00 X 453447 0 48263 BRIAN MCDONALD CHIEF BUS DEV OFFICER 40.00 X 283982 0 33305 TOM LAWLESS CFO 40.00 X 243167 0 48829 SCOTT BERGMAN CONTROLLER 40.00 X 189469 0 40527 JEFFREY PIERICK GENERAL COUNSEL & COMPLIANCE OFFICER 40.00 X 186060 0 43050 SHELLY JOHNSON VP OF NETWORK OPTIMIZATION & HEALTHCARE QUALITY 40.00 X 184510 0 28145 BRENDA VECHART EVP, HUMAN RESOURCES 40.00 X 171385 0 30845 DANIEL SCHUMACHER STAFF ACTUARY 40.00 X 152731 0 34111 KERRY COOK TERM 111519 DIRECTOR SALES & MEMBER RETENTION 40.00 X 153042 0 28220 MELISSA HENDERSON COO 40.00 X 124837 0 2918 TONI BONDE TERM 2819 EX-CHIEF OPERATING OFFICER 40.00 X 110307 0 3741 SCOTT ANDERSON CMO - CHIEF MEDICAL OFFICER 40.00 X 23577 0 60 CHRISTOPHER MARTIN BOARD CHAIR 6.00 X 8207 0 0 AMY MURPHY BOARD VICE-CHAIR 1.00 X 8207 0 0 MARY REHBERG SECRETARY/TREASURER 1.00 X 8207 0 0 BRETT REMINGTON DIRECTOR 1.00 X 8207 0 0 CLIFFORD PUKEL DIRECTOR 1.00 X 8207 0 0 ROBERT CONNOLLY NON-VOTING DIRECTOR 1.00 X 8207 0 0 JOHN MAGLIO NON-VOTING DIRECTOR 1.00 X 8207 0 0 JAMES WESP NON-VOTING DIRECTOR 1.00 X 8207 0 0 MICHAEL BRAUN DIRECTOR 1.00 X 7200 0 0 ERIN KENNEKE DIRECTOR 1.00 X 4788 0 0 TERESA PISZCOR DIRECTOR 1.00 X 4788 0 0 WILLIAM KORT DIRECTOR 1.00 X 2052 0 0 2360998 0 342014 17 0 1 0 OPTUM HEALTH CARE SOLUTIONS INC 11000 OPTUM CIRCLE MN101W400 MINNEAPOLIS MN 55344 MEDICAL MANAGEMENT 3738767 MILLIMAN INC 15800 W BLUEMOUND RD SUITE 100 BROOKFIELD WI 53005 ACTUARIAL 928423 EVOLENT HEALTH LLC PO BOX 505384 ST LOUIS MO 631505384 CLAIMS PROCESSING PLATFORM 858724 MPX 2301 CONGRESS ST PORTLAND ME 04102 PRINTING AND POSTAGE 704772 ONLINE INSIGHT LLC 33 MANSELL CT ROSWELL GA 30076 SOFTWARE 474900 41 PREMIUMS EARNED 525100 513508101 513508101 513508101 5201792 5201792 518709893 513508101 0 5201792 1690913 6766999 371167 1760850 595671 193842 2947824 5840075 182293 3492100 1809592 7329 75829 173164 421907 191640 152183 CLAIMS EXPENSE 329175913 MLR PREMIUM REFUNDS 59780005 CMS EXCHANGE USER FEE E 17115352 STATE INCOME TAX EXPENS 6491239 5750024 444985911 60228473 41799407 137761423 216802690 6122300 5102273 294447 436779 1835068 1019175 553158 815893 52575811 96469417 257535612 361426459 7740948 7738403 48666810 40041820 103667370 100104199 52820134 93649932 212895262 241534354 X 0 0 0 0 44640350 119892105 44640350 119892105 257535612 361426459 73723982 1527773 0 X 0 1 X 1 1 1 356298 209774 146524 983778 621239 362539 494992 188162 306830 815893 REINSURANCE RECOVERABLES 55297766 HEALTH CARE RECEIVABLE 7822699 ADVANCED PREMIUM TAX CREDIT RECEIVABLE 29906578 PROVIDER RECEIVABLE 930808 WI INCOME TAX RECEIVABLE 2511566 96469417 INTEREST PAYABLE 160346 CLAIMS UNPAID 49212396 INSURANCE FEES PAYABLE 3331774 MLR PAYABLE TO MEMBERS 40945416 93649932 X 518709893 0 518709893 0 518709893 444985911 0 444985911 0 444985911 PART X, LINE 2: THE ACA ESTABLISHED SECTION 501(C) (29) OF THE INTERNAL REVENUE CODE AS A NEW TAX-EXEMPT CATEGORY SPECIFICALLY FOR QUALIFIED NON-PROFIT HEALTH INSURANCE ISSUERS THAT HAVE RECEIVED A LOAN OR GRANT UNDER THE CMS CO-OP PROGRAM FOR PERIODS THAT THEY MEET BOTH THE REQUIREMENTS OF SECTION 1322 OF THE ACA AND ANY LOAN AGREEMENT WITH CMS. THE COMPANY RECEIVED AN APPROVAL LETTER FROM THE INTERNAL REVENUE SERVICE STATING THAT THEY ARE EXEMPT FROM FEDERAL INCOME TAX UNDER SECTION 501(A) OF THE INTERNAL REVENUE CODE AS AN ORGANIZATION DESCRIBED IN SECTION 501(C) (29). X 1 1 X X 1 0 0 0 0 0 0 0 0 CATHY MAHAFFEY CEO 369330 0 76020 0 8097 0 16800 0 31463 0 501710 0 0 0 BRIAN MCDONALD CHIEF BUS DEV OFFICER 273682 0 2500 0 7800 0 15318 0 17987 0 317287 0 0 0 TOM LAWLESS CFO 239813 0 2500 0 854 0 15208 0 33621 0 291996 0 0 0 SCOTT BERGMAN CONTROLLER 187060 0 2016 0 393 0 11643 0 28884 0 229996 0 0 0 JEFFREY PIERICK GENERAL COUNSEL & COMPLIANCE OFFICER 185091 0 0 0 969 0 11616 0 31434 0 229110 0 0 0 SHELLY JOHNSON VP OF NETWORK OPTIMIZATION & HEALTHC 183657 0 514 0 339 0 11067 0 17078 0 212655 0 0 0 BRENDA VECHART EVP, HUMAN RESOURCES 170146 0 565 0 674 0 10469 0 20376 0 202230 0 0 0 DANIEL SCHUMACHER STAFF ACTUARY 151613 0 1000 0 118 0 9678 0 24433 0 186842 0 0 0 KERRY COOK TERM 111519 DIRECTOR SALES & MEMBER RETENTION 120771 0 26755 0 5516 0 3895 0 24325 0 181262 0 0 0 TONI BONDE TERM 2819 EX-CHIEF OPERATING OFFICER 90797 0 0 0 19510 0 3248 0 493 0 114048 0 0 0 PART I, LINE 1A COMMON GROUND MADE A GROSS-UP PAYMENTS OF $500 FOR ITS FIVE YEAR ANNIVERSARY. PART I, LINE 4A KERRY COOK RECEIVED $26,250.00 IN SEVERANCE PAY. TONI BONDI RECEIVED $56,250.00 IN SEVERANCE PAY. MELISSA DUFFY FORMER OFFICER 230534 INDEPENDENT CONTRACTOR 0 FORM 990, PART V, LINE 13A WI FORM 990, PART VI, SECTION A, LINE 6 ON JANUARY 1, 2014 COMMON GROUND HEALTHCARE COOPERATIVE BEGAN ISSUING HEALTH INSURANCE TO INDIVIDUALS AND SMALL GROUPS. ANY ACTIVE POLICYHOLDER IS CONSIDERED A MEMBER OF THE COOPERATIVE. IN DECEMBER OF 2014 THERE WAS AN ELECTION FROM THE MEMBERS OF AN OPERATIONAL BOARD OF DIRECTORS REPLACING THE FORMATIVE BOARD OF DIRECTORS AT THAT TIME. FORM 990, PART VI, SECTION A, LINE 7A IN DECEMBER OF 2014 THERE WAS AN ELECTION FROM THE MEMBERS OF AN OPERATIONAL BOARD OF DIRECTORS REPLACING THE FORMATIVE BOARD OF DIRECTORS AT THAT TIME. FORM 990, PART VI, SECTION B, LINE 11B THE BOARD MEMBERS ARE GIVEN A COPY OF THE RETURN BEFORE IT IS FILED. FORM 990, PART VI, SECTION B, LINE 12C THE POLICY SETS FORTH CLEAR EXPECTATIONS AND GUIDANCE THAT IS TO BE FOLLOWED BY ALL DIRECTORS, OFFICERS, EMPLOYEES AND THIRD PARTY REPRESENTATIVES. THE COOPERATIVE WILL EVALUATE ITS ADHERENCE AND COMPLIANCE TO THIS POLICY BY REQUESTING FEEDBACK ON A REGULAR BASIS FROM OUR MEMBERS, EMPLOYEES, DIRECTORS AND THIRD PARTY REPRESENTATIVES. IF ANY INDIVIDUAL HAS QUESTIONS OR CONCERNS ABOUT COMPLIANCE WITH THE SUBJECTS DESCRIBED IN THIS POLICY, ARE UNSURE ABOUT WHAT IS THE "RIGHT THING" TO DO, OR REASONABLY BELIEVES THAT SOME POLICY, PRACTICE OR ACTIVITY OF THE COOPERATIVE IS IN VIOLATION OF THE ETHICS POLICY OR CODE, THIS INDIVIDUAL SHOULD SHARE THEIR QUESTIONS, CONCERNS, SUGGESTIONS OR COMPLAINTS WITH SOMEONE WHO CAN ADDRESS THEM PROPERLY. IN MOST CASES, AN INDIVIDUAL'S SUPERVISOR IS IN THE BEST POSITION TO ADDRESS AN AREA OF CONCERN. HOWEVER, IF THE INDIVIDUAL IS NOT COMFORTABLE SPEAKING WITH HIS OR HER SUPERVISOR OR IS NOT SATISFIED WITH THE SUPERVISOR'S RESPONSE, THE INDIVIDUAL IS ENCOURAGED TO SPEAK WITH THE COMPLIANCE OFFICER, OR ANYONE IN MANAGEMENT WHOM THE INDIVIDUAL IS COMFORTABLE IN APPROACHING. THE COOPERATIVE PROVIDES ALL INDIVIDUALS AN ADDITIONAL MECHANISM TO REPORT UNETHICAL CONDUCT WHICH IS DISCUSSED FURTHER IN THE EMPLOYEE PROTECTION AND NON-RETALIATION POLICY. FORM 990, PART VI, SECTION B, LINE 15 THE EMPLOYMENT AGREEMENTS FOR THE CEO, COO, CBDO, CMO AND CFO INCLUDING COMPENSATION, WERE REVIEWED AND APPROVED BY THE DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES IN ACCORDANCE WITH TERMS OF THE COOPERATIVE'S LOAN AGREEMENT. FORM 990, PART VI, SECTION C, LINE 19 THE DOCUMENTS ARE AVAILABLE UPON REQUEST.