2016-11-11T09:05:17-06:00 2015-12-31 010494526 BAKER NEWMAN & NOYES LLC 650 ELM STREET SUITE 302 MANCHESTER NH 03101 990 2015-01-01 030219391 Delta Dental Plan Of Vermont Inc DELT 6032231000 PO Box 2002 Concord NH 033022002 THOMAS RAFFIO President & CEO 6032231000 2016-11-01 1 E Drew Cheney P00182972 8002447444 2016-11-01 2015 2017-02-10 21:41:12Z Thomas Raffio PO Box 2002 Concord NH 033022002 87564231 0 X www.nedelta.com X 1965 VT Provide programs of dental care 11 6 4 0 100000 0 0 0 70798512 71749357 384705 1903818 0 0 71183217 73653175 48700 182893 62020204 61930540 537834 572530 0 0 0 7962053 7925532 70568791 70611495 614426 3041680 25181953 26705730 3495083 3925747 21686870 22779983 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 64670266 0 71649357 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 360,300 claims in 2015. There are approximately 166,000 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. 182893 182893 0 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. 64853159 0 0 1 0 0 0 0 0 0 1 0 0 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 99 0 1 4 1 1 1 0 0 0 0 0 X 11 6 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 8756 0 0 Theron Main DDS Trustee 3.00 X 10772 0 0 Suzanne M McDowell Trustee 3.00 X 6144 0 0 Katherine O'Connell CPA Trustee 3.00 X 11820 0 0 Dsvid Solomon DDS Trustee 3.00 X 11820 0 0 Joseph L Woodin Trustee (part year) 3.00 X 2064 0 0 Nevin Zablotsky DMD Trustee (part year) 3.00 X 2580 0 0 Elizabeth Carmack DMD Trustee 3.00 X 4596 0 0 Adam Fasoli DMD Trustee 3.00 X 5112 0 0 Paul A Averill DDS Trustee & Chair 3.00 X X 24591 0 0 David A Baasch DDS Trustee & Vice Chair 3.00 X X 9224 0 0 Philip A Lapp CPA Trustee & Treasurer 3.00 X X 7160 0 0 Richard W Park Trustee & Secretary 3.00 X X 7692 0 0 Thomas Raffio DDPNH President & CEO 10.00 X 0 814932 164575 William H Lambrukos DDPNH Sr. Vice President 10.00 X 0 215686 42877 112331 1030618 207452 0 0 1 1 Combined Services LLC 2 Delta Drive Concord NH 033022002 Insurance broker commissions 366379 Richards Inc 48 Harris Place PO Box 820 Brattleboro VT 05302 Insurance broker commissions 137949 Hickok & Boardman 346 Shelburne Road PO Box 1064 Burlington VT 05402 Insurance broker commissions 110376 3 Admin Service Contract Fees 524292 37062238 37062238 Premium Revenue 524114 34587119 34587119 Management fee - CSLLC 524298 100000 100000 71749357 299813 299813 15515061 13911056 1604005 1604005 1604005 73653175 71649357 100000 1903818 182893 182893 61930540 61930540 112331 112331 324729 324729 20338 20338 90931 90931 24201 24201 23274 23274 47365 47365 68150 68150 42090 42090 463102 463102 57677 57677 48636 48636 20005 20005 43571 43571 4374 4374 15393 15393 Administration - DDPNH 5244705 2517458 2727247 Brokers' Commissions 1302060 1302060 Assessments/Tax 182671 182671 Marketing Related 179138 179138 183321 39597 143724 70611495 64853159 5758336 0 5481807 5408465 133208 724416 1548579 1761368 6750 6750 115553 95345 22977 20208 16463777 17315252 138525 86488 1327013 1317698 59317 65085 25181953 26705730 1729459 1917370 32300 164800 1733324 1843577 3495083 3925747 X 21686870 22779983 21686870 22779983 25181953 26705730 X 3041680 -1911976 -36591 X X 0 1 X 1 0 500 0 500 0 500 1 VT Democratic Party PO Box 1220 Montpelier VT 05601 030199446 500 Part I-A, Line 1: One campaign donation of $500 was made in Vermont. 7345 3673 3672 61114 44578 16536 47094 47094 0 20208 Unearned Revenue 1092877 Other Advances 750700 1843577 X 37405391 -1911976 -7344 -1919320 39324711 68150 34260314 34328464 73653175 36283031 0 36283031 68150 34260314 34328464 70611495 Part X, Line 2: The 2015 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. Tax-exempt organizations could be required to record an obligation for income taxes as the result of a tax position historically taken on various tax exposure items including unrelated business income or tax status. Assets and liabilities are established for uncertain tax positions taken or positions expected to be taken in income tax returns when such positions are judged to not meet the "more-likely-than-not" threshold, based upon the technical merits of the position. 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, does not have any significant unrelated business income and has taken no uncertain tax positions that require adjustment to or disclosure in the accompanying statutory financial statements. Tax years after December 31, 2011 are open for Internal Revenue Service or state examination. Part XI, Line 2d - Other Adjustments: Change in nonadmitted assets -7,344. Part XI, Line 4b - Other Adjustments: Dental claims paid under admin service contracts 34,260,314. Part XII, Line 4b - Other Adjustments: Dental claims paid under admin service contracts 34,260,314. 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) 182893 General support to promote oral health 1 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 2015 totaled $182,893. 0 0 0 0 0 0 0 0 0 Thomas Raffio DDPNH President & CEO 0 522200 0 226636 0 66096 0 127527 0 37048 0 979507 0 0 William H Lambrukos DDPNH Sr. Vice President 0 179781 0 24834 0 11071 0 17726 0 25151 0 258563 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 474638 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 188724 Please see above. 0 David A Baasch DDS Trustee 173364 Please see above. 0 David B Solomon DDS Trustee 152600 Please see above. 0 Elizabeth Carmack DMD Trustee 205752 Please see above. 0 Form 990, Part VI, Section B, line 11 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 -36,591. 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 2014 and 2015. 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.