2017-11-07T12:53:04-06:00 2016-12-31 010494526 BAKER NEWMAN & NOYES LLC 650 ELM STREET SUITE 302 MANCHESTER NH 03101 990 2016-01-01 030219391 Delta Dental Plan Of Vermont Inc DELT 6032231000 PO Box 2002 Concord NH 033022002 THOMAS RAFFIO President & CEO 6032231000 2017-10-27 1 E Drew Cheney P00182972 8002447444 2017-10-27 208.105.168.164 2017-10-27 10:38:52 ED P CCFCCF25870C8311BDDC6739800371DE19EE9571 CD9BA379DF6EC1A0D15BAC40CC9AB00D59855B06 2016 2021-01-29 14:40:06Z Thomas Raffio PO Box 2002 Concord NH 033022002 90580294 0 X www.nedelta.com X 1965 VT Provide programs of dental care 12 7 4 0 100000 0 0 0 71749357 74537690 1903818 610423 0 0 73653175 75148113 182893 188280 61930540 64141815 572530 586088 0 0 0 7925532 7945867 70611495 72862050 3041680 2286063 26705730 28860403 3925747 4008368 22779983 24852035 X It is our mission to advance the oral health and overall wellness of our customers and the general public by providing innovative benefits and professional partnerships through diversified strategic business and philanthropic initiatives. 0 0 66979421 74437690 Delta Dental Plan of Vermont advances and promotes the improvement of oral health by offering innovative, cost effective dental benefits plans that meet the needs of our customers by integrating activities such as cost management policies, fee reduction agreements with dentists, ensuring quality and cost effective dental benefit delivery, and accurate and timely claims payment. We are recognized for our expertise in the dental benefits industry, the vibrancy of our participating dentist network, and our strong brand. Program services include the processing and payment of claims for dental benefits for various large and small groups, as well as individuals and families. Delta Dental Plan of Vermont processed approximately 366,700 claims in 2016. There are approximately 170,000 members in Vermont included in the various plans. Customer's expectations for quality standards are extremely rigorous and we provide a guarantee of service called GOSE, or Guarantee of Service Excellence, which guarantees seven key service claims: 1) Smooth implementation to Northeast Delta Dental; 2) Exceptional customer service; 3) Quick processing of claims; 4) No inappropriate billing by participating dentists; 5) Accurate and quick turnaround of identification cards; 6) Timely employee booklets; 7) Marketing service contracts. In the event one or more of these service guarantees are not met, a cash reimbursement is provided. 188280 188280 Delta Dental Plan of Vermont is one of three members of the Northeast Delta Dental Foundation. The company contributes .025% of annual budgeted revenue, as well as 5% of annual revenue in excess of expenses, to the Northeast Delta Dental Foundation. The Northeast Delta Dental Foundation's purpose is to improve the access to, and the quality of, oral health care and education for the public and dental communities in Maine, New Hampshire, and Vermont. The Northeast Delta Dental Foundation awards numerous grants to community organizations and programs. 67167701 0 0 1 0 0 0 0 0 0 1 0 1 0 1 1 1 0 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 1 X 104 0 1 4 1 1 1 0 0 0 0 0 X 12 7 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 0 0 0 X Frank Boucher 6032231000 PO Box 2002 Concord NH 033022002 Paula L Cope MEd Trustee 3.00 X 10100 0 0 Theron Main DDS Trustee 3.00 X 10100 0 0 Suzanne M McDowell Trustee 3.00 X 7980 0 0 Katherine O'Connell CPA Trustee & Treasurer 3.00 X X 11180 0 0 Dsvid Solomon DDS Trustee 3.00 X 11760 0 0 Philip A Lapp CPA part year Trustee & Treasurer 3.00 X 2700 0 0 Richard W Park Trustee & Secretary 3.00 X X 11760 0 0 Paul A Averill DDS Trustee & Chair 3.00 X X 21668 0 0 David A Baasch DDS Trustee & Vice Chair 3.00 X X 10640 0 0 Nancy Bowden-Brock part year Trustee 3.00 X 4200 0 0 Jason Williams part year Trustee 3.00 X 6360 0 0 Elizabeth Carmack DMD Trustee 3.00 X 5820 0 0 Adam Fasoli DMD Trustee 3.00 X 5940 0 0 Thomas Raffio DDPNH President & CEO 10.00 X 0 805520 104765 William H Lambrukos DDPNH Sr. Vice President 10.00 X 0 222662 44504 120208 1028182 149269 0 0 1 1 Encara Inc 4818 Starkey Road Roanoke VA 24018 Contracted Services 442061 Combined Services LLC 2 Delta Drive Concord NH 033022002 Insurance broker commissions 343925 Richards Inc 48 Harris Place PO Box 820 Brattleboro VT 05302 Insurance broker commissions 163045 Hickok & Boardman 346 Shelburne Road PO Box 1064 Burlington VT 05402 Insurance broker commissions 137290 4 Admin Service Contract Fees 524292 38114857 38114857 Premium Revenue 524114 36322833 36322833 Management fee - CSLLC 524298 100000 100000 74537690 435587 435587 15607017 15432181 174836 174836 174836 75148113 74437690 100000 610423 188280 188280 64141815 64141815 120208 120208 324389 324389 21299 21299 95215 95215 24977 24977 14964 14964 58646 58646 74043 74043 42000 42000 354679 354679 50428 50428 49908 49908 16156 16156 46770 46770 4431 4431 15386 15386 Administration - DDPNH 5387820 2586154 2801666 Brokers' Commissions 1258631 0 1258631 Assessments/Tax 205489 205489 0 Marketing Related 153726 0 153726 212790 45963 166827 72862050 67167701 5694349 0 5408465 4033882 724416 1878690 1761368 1822792 6750 6750 115552 99775 20208 15777 17315252 17542535 86488 61188 1317698 3425005 65085 73784 26705730 28860403 1917370 2102740 164800 119400 1843577 1786228 3925747 4008368 X 22779983 24852035 22779983 24852035 26705730 28860403 X 2286063 -200483 -13528 X X 0 1 X 1 0 4950 VT Democratic Party PO Box 1220 Montpelier VT 05601 030199446 2250 VT House of Republicans PO Box 80 Gaysville VT 05746 760809991 500 Green Mountain Republican Senate Committee PO Box 80 Gaysville VT 05746 770646170 500 Eileen Dickinson 69 Button Road St Albans VT 05748 810653065 200 Senate Democrats (Senate Circle) PO Box 896 Montpelier VT 05601 208731490 500 Phil Scott for Vermont 46 Three Mile Bridge Road Middlesex VT 05602 475073559 1000 Part I-A, Line 1: Six campaign donations totalling $4,950 were made in Vermont. 7345 5142 2203 61113 47539 13574 47094 47094 0 15777 Investment in Red Tree Holdings (1/3 interest) 3425005 F 3425005 Unearned Revenue 1035128 Other Advances 751100 1786228 X 39645339 -200483 12766 -187717 39833056 74043 35241014 35315057 75148113 37546993 0 37546993 74043 35241014 35315057 72862050 Part X, Line 2: The 2016 audited financial statements contain the following paragraphs pertaining to tax positions under FIN 48: The Corporation is exempt from federal and state income taxes under the provisions of Section 501(c)(4) of the Internal Revenue Code. Management has evaluated the Corporation's tax positions taken on its filed tax returns and concluded that the Corporation has maintained its tax-exempt status. Part XI, Line 2d - Other Adjustments: Change in nonadmitted assets 12,766. Part XI, Line 4b - Other Adjustments: Dental claims paid under admin service contracts 35,241,014. Part XII, Line 4b - Other Adjustments: Dental claims paid under admin service contracts 35,241,014. Schedule D, Part XI, Line 2d The Corporation has historically prepared its financial statements in accordance with accounting principles generally accepted in the United States of America (GAAP). Effective January 1, 2012, the Corporation elected to prepare its financial statements using accounting practices prescribed or permitted by the Vermont Department of Financial Regulation. The change in nonadmitted assets reported here in Part XI is one of the reconciling items to meet the reporting requirements for the Form 990. 1 Northeast Delta Dental Foundation One Delta Drive PO Box 2002 Concord NH 03302 020489150 501(c)(3) 188280 General support to promote oral health Part I, Line 2: Delta Dental Plan of Vermont, Inc. (DDPVT) makes elective annual charitable contributions to the Northeast Dental Foundation equal to 0.025% of the budgeted gross billings, plus 5% of the actual increase in unrestricted net assets from operations each year. DDPVT's elective contributions to the Foundation in 2016 totaled $188,280. 0 0 0 0 0 0 0 0 0 Thomas Raffio DDPNH President & CEO 0 522200 0 220107 0 63213 0 75814 0 28951 0 910285 0 0 William H Lambrukos DDPNH Sr. Vice President 0 184352 0 26360 0 11950 0 19221 0 25283 0 267166 0 0 Schedule J, Part II: Thomas Raffio, CEO, and William Lambrukos, Senior Vice President, received all of their compensation from Delta Dental Plan of New Hampshire, which is an unrelated organization per Schedule R definitions. Adam Fasoli Trustee 577833 The Trustees listed here have ownership interests in dental practices that receive insurance reimbursements from Delta Dental in the ordinary course of their business. All transactions are at arm's length and for fair value. 0 Paul A Averill DDS Trustee 203461 Please see above. 0 David A Baasch DDS Trustee 191976 Please see above. 0 David B Solomon DDS Trustee 168996 Please see above. 0 Elizabeth Carmack DMD Trustee 203697 Please see above. 0 Form 990, Part V, Line 2a The four employees included here are actually employed and paid by Delta Dental Plan of New Hampshire. These employees are assigned to provide sales and marketing services to Delta Dental Plan of Vermont. Delta Dental Plan of Vermont reimburses Delta Dental Plan of New Hampshire for these employees' payroll and employee benefit expenses. Form 990, Part VI, Section B, line 11b The Form 990 is reviewed in detail by key finance employees of Northeast Delta Dental. A final draft is presented to the Board before the Form is filed. Form 990, Part VI, Section B, line 12c A copy of the conflict of interest policy is distributed annually to all officers, trustees, and the management team. All are required to report any conflicts and sign, date, and return the policy, whether or not a conflict exists, to confirm compliance. General Counsel reviews the returned policies and reports the results to the entire Board of Trustees. The trustees are asked to provide updates of any changes that may occur between their annual conflict of interest filings. Form 990, Part VI, Section C, line 19 Upon request, Delta Dental Plan of Vermont, Inc. makes its governing documents, conflict of interest policy, or financial statements available to the public. Form 990, Part XI, line 9: Change in unrealized gains in bonds -13,528. Form 990, Part XII, Line 2c: The Finance/Audit Committee oversees the audit process for Delta Dental Plan of Vermont. The audit process for the financial statements did not change from the prior year. Independent accountants performed the audit in both 2015 and 2016. Form 990, Part XI, Line 9 The Corporation has historically prepared its financial statements in accordance with accounting principles generally accepted in the United States of America (GAAP). Effective January 1, 2012, the Corporation elected to prepare its financial statements using accounting practices prescribed or permitted by the Vermont Department of Financial Regulation. This is one of the reconciling items to meet the reporting requirements for the Form 990.