2025-11-04T16:24:18-06:00 2024-12-31 WITHUMSMITHBROWNPC 1800 TYSONS BLVD SUITE 800 TYSONS VA 22102 990 2024-01-01 521074154 SPECIAL AGENTS MUTUAL BENEFIT ASSOCIATION % NAYANA RAJAPAKSE SPEC 3019841440 11301 OLD GEORGETOWN ROAD ROCKVILLE MD 20852 KATHRYN DIEM TREASURER/DIRECTOR 3019844110 2025-10-29 true true RICHARD RUVELSON P00234075 3012726000 2024 2025-03-06 01:10:19Z KATHRYN DIEM 11301 OLD GEORGETOWN ROAD ROCKVILLE MD 20852 344928927 false X WWW.SAMBAPLANS.COM X 1976 DC TO SPONSOR AND ADMINISTER THE SAMBA BENEFIT PLAN FOR ITS MEMBERSHIP. 6 6 67 0 0 0 0 0 244429028 246164498 3873010 13250543 0 130536 248302038 259545577 6000 0 243668109 257452768 9293125 9931278 0 0 0 12760163 15291920 265727397 282675966 -17425359 -23130389 227420148 249566532 53042614 57439850 174377534 192126682 X TO SPONSOR AND ADMINISTER THE SAMBA BENEFIT PLAN ("THE PLAN") FOR ITS MEMBERSHIP IN ACCORDANCE WITH ERISA AND FEHBA. THE SAMBA BENEFIT PLAN INCLUDES HEALTH, LIFE, DISABILITY, ACCIDENT, DENTAL, VISION AND RELATED COVERAGES. false false SPONSORED HEALTH, GROUP TERM LIFE, DISABILITY, ACCIDENT, DENTAL AND VISION BENEFITS FOR APPROXIMATELY 123,667 MEMBERS. false false false false false false false false false true false false false true true true false false false false false false false false false false false false true false false false false false false false false false false false false false false true 28 0 true 67 true false false false false false false false false X 6 6 false false false false true true false true true false false false true true true true true true false false X NAYANA RAJAPAKSE 3019844111 11301 OLD GEORGETOWN ROAD ROCKVILLE MD 20852 X PAMELA CUMMINGS ACTING EXEC DIR(THRU 9/30/24) 40.0 0.0 X 364488 0 525520 PAMELA LYNCH EXECUTIVE DIRECTOR 40.0 0.0 X 341249 0 142971 WALTER WILSON EXECUTIVE DIRECTOR EMERITUS 40.0 0.0 X 235582 0 116804 LAURENCE GROSS COMPLIANCE & SPECIAL PROJ DIR. 40.0 0.0 X 278912 0 63280 WILLIAM MARTIN IT DIRECTOR 40.0 0.0 X 255666 0 74215 JERRY BROWN CLAIMS SYSTEM LEAD 40.0 0.0 X 233397 0 88634 NAYANA RAJAPAKSE CONTROLLER/CFO 40.0 0.0 X 233759 0 52530 SANG WOO SENIOR COMPUTER PROGRAMER 40.0 0.0 X 210775 0 52207 PAMELA MYERS HEALTH PLANS DIRECTOR 40.0 0.0 X 211585 0 44762 WILLIAM O'HANLON PRESIDENT/BOARD MEMBER 1.0 0.0 X X 46000 0 0 DAVID LOESCH VICE PRESIDENT/BOARD MEMBER 1.0 0.0 X X 9000 0 0 KATHRYN DIEM TREASURER/BOARD MEMBER 1.0 0.0 X X 9000 0 0 CHARLENE THORNTON BOARD MEMBER 1.0 0.0 X 9000 0 0 ANGELA ZENTZ BOARD MEMBER 1.0 0.0 X 9000 0 0 NANCY SAVAGE BOARD MEMBER (EFF 09/16/2024) 1.0 0.0 X 3000 0 0 DAVID ERMER SECRETARY 1.0 0.0 X 0 0 0 2450413 0 1160923 23 true true false CIGNA HEALTHCARE 1111 MARKET STREET CHATTANOOGA TN 37402 HEALTH NETWORK ADMIN 4773488 EXPRESS SCRIPTS HLD CO 100 PARSONS POND DR FRANKLIN LAKES NJ 07417 PHARMACY BENEFIT MGR 3138619 ZELIS PAYMENTS HOLDINGS LLC 744 OFFICE PARKWAY ST LOUIS MO 63141 PRINTING & MAILING 814438 WITHUMSMITHBROWN PC 4600 EAST WEST HWY SUITE 900 BETHESDA MD 20814 AUDIT/PROF. SERVICES 696222 RAM TECHNOLOGIES INC 30 S 15TH STREET SUITE 1550 PMB 93 PHILADELPHIA PA 19102 SOFTWARE MAINTENANCE 561264 19 0 PREMIUMS 525100 240312547 240312547 ADMINISTRATION FEES 525100 4154540 4154540 EXPERIENCE RATING ADJUSTMENT 525100 1592487 1592487 CARRIER INVESTMENT INCOME 525100 104924 104924 246164498 5882611 0 0 5882611 0 0 0 0 0 92751282 85382785 565 7368497 -565 7367932 7367932 0 0 0 0 0 0 0 0 0 MISCELLANEOUS 525100 130536 130536 130536 259545577 246295034 0 13250543 0 0 0 257452768 1277631 0 6077477 991099 1071428 513643 0 127532 281054 0 0 432244 9389936 0 1849678 1905062 0 189354 11027 0 0 0 0 644305 177297 MISCELLANEOUS 193719 PCORI EXCISE TAX 81997 SPONSORSHIPS 5000 CLEARING HOUSE EXPENSE 3715 282675966 525 525 51481571 60684902 0 0 22405927 21167949 0 0 0 0 0 0 0 0 987083 926640 14062280 11994958 2165686 2067322 143722634 161647967 0 0 0 0 0 0 6656722 3071227 227420148 249566532 3218762 1702815 0 0 0 0 0 0 0 0 0 0 0 0 0 0 49823852 55737035 53042614 57439850 X 0 0 0 0 174377534 192126682 174377534 192126682 227420148 249566532 X -23130389 1564140 39315397 X X false true X true false 600000 600000 5805708 5171345 634363 6806007 6167928 638078 850565 655685 194881 2067322 0 RESERVE FOR UNPAID CLAIMS 29722160 SPECIAL RESERVE - OPM 21374957 GROUP INSURANCE PREMIUM PAYABLE 4138999 ACCRUED PENSION LIABILITY 500919 55737035 X 261110282 1564140 1564140 259546142 -565 -565 259545577 283158995 565 565 283158430 -482464 -482464 282675966 PART X, LINE 2 - FIN 48 (ASC 740) FOOTNOTE: MANAGEMENT OF SAMBA EVALUATES INCOME TAX POSITIONS TAKEN FOR THE HEALTH PLAN AND WILL DISCLOSE A TAX POSITION TAKEN IF IT IS MORE LIKELY THAN NOT THAT THE TAX POSITION TAKEN WILL NOT BE SUSTAINED UPON EXAMINATION BY THE INTERNAL REVENUE SERVICE. MANAGEMENT HAS ANALYZED TAX POSITIONS TAKEN AND HAS CONCLUDED THAT AS OF DECEMBER 31, 2024, THERE ARE NO UNCERTAIN POSITIONS TAKEN OR EXPECTED TO BE TAKEN THAT WOULD REQUIRE DISCLOSURE IN THE FINANCIAL STATEMENTS. IN ADDITION, THERE HAVE BEEN NO TAX RELATED INTEREST OR PENALTIES FOR THE PERIODS PRESENTED IN THESE FINANCIAL STATEMENTS. U.S. GAAP REQUIRES MANAGEMENT OF A PLAN TO EVALUATE TAX POSITIONS TAKEN AND RECORD A TAX LIABILITY IF THE PLAN HAS TAKEN AN UNCERTAIN POSITION THAT MORE LIKELY THAN NOT WOULD NOT BE SUSTAINED UPON EXAMINATION BY THE IRS OR OTHER TAXING AUTHORITIES. MANAGEMENT HAS EVALUATED TAX POSITIONS TAKEN BY THE PLAN AND CONCLUDED THAT AS OF DECEMBER 31, 2024 AND 2023 THERE ARE NO UNCERTAIN POSITIONS TAKEN OR EXPECTED TO BE TAKEN THAT WOULD REQUIRE RECOGNITION IN THE FINANCIAL STATEMENTS. THE PLAN IS SUBJECT TO ROUTINE AUDITS BY TAXING JURISDICTIONS; HOWEVER, THERE ARE CURRENTLY NO AUDITS IN PROGRESS FOR ANY TAX PERIODS. IN ADDITION, THERE HAVE BEEN NO TAX RELATED INTEREST OR PENALTIES FOR PERIODS PRESENTED IN THESE FINANCIAL STATEMENTS. PART XI, LINE 4B: LOSS ON DISPOSAL ON FIXED ASSET: $565 PART XII, LINE 2D: LOSS ON DISPOSAL ON FIXED ASSET: $565 PART XII, LINE 4B: CHANGE IN NET ASSETS AVAILABLE FOR BENEFITS AND BENEFIT OBLIGATIONS: -$482,464 X X X false false false PAMELA CUMMINGS ACTING EXEC DIR(THRU 9/30/24) 314488 0 50000 0 0 0 510987 0 14533 0 890008 0 0 0 PAMELA LYNCH EXECUTIVE DIRECTOR 291249 0 50000 0 0 0 111422 0 31549 0 484220 0 0 0 LAURENCE GROSS COMPLIANCE & SPECIAL PROJ DIR. 258912 0 20000 0 0 0 34931 0 28349 0 342192 0 0 0 WILLIAM MARTIN IT DIRECTOR 230666 0 25000 0 0 0 45866 0 28349 0 329881 0 0 0 WALTER WILSON EXECUTIVE DIRECTOR EMERITUS 235582 0 0 0 0 0 114811 0 1993 0 352386 0 0 0 NAYANA RAJAPAKSE CONTROLLER/CFO 213759 0 20000 0 0 0 22181 0 30349 0 286289 0 0 0 JERRY BROWN CLAIMS SYSTEM LEAD 213397 0 20000 0 0 0 58785 0 29849 0 322031 0 0 0 PAMELA MYERS HEALTH PLANS DIRECTOR 193085 0 18500 0 0 0 34298 0 10464 0 256347 0 0 0 SANG WOO SENIOR COMPUTER PROGRAMER 195775 0 15000 0 0 0 31499 0 20708 0 262982 0 0 0 SCHEDULE J, PART II, COLUMN C RETIREMENT AND OTHER DEFERRED COMPENSATION: THE INCREASE (DECREASE) IN THE TOTAL PRESENT VALUE OF THE BENEFIT COMES PRIMARILY FROM THE INCREASE(DECREASE) IN ACCRUALS DURING THE YEAR. ADDITIONALLY, THE DISCOUNT RATE USED AT THE END OF 2023 WAS 4.83%, WHILE THE DISCOUNT RATE USED AT THE END OF 2024 WAS 5.54%. THERE WAS NO EFFECT ON THE LIABILITIES FROM DISCOUNT RATE FLUCTUATION. THESE ARE ACTUARY CALCULATIONS AND THESE AMOUNTS DO NOT REPRESENT A CASH OUTLAY. FORM 990, PART VI, SECTION A, LINE 6: MEMBERSHIP IN THE CORPORATION SHALL BE OPEN TO INDIVIDUALS WHO ARE ACTIVE EMPLOYEES OF A SAMBA ELIGIBLE EMPLOYING AGENCY OR WHO ARE RETIRED FROM A SAMBA ELIGIBLE EMPLOYING AGENCY, UNDER ANY ESTABLISHED RETIREMENT PROGRAM. THE TERM SAMBA ELIGIBLE EMPLOYING AGENCY MEANS ANY BRANCH, DEPARTMENT OR AGENCY OF THE UNITED STATES GOVERNMENT, INCLUDING WITHOUT LIMITATION, THE US POSTAL SERVICE AND US COURTS. MEMBERSHIP IN THE CORPORATION SHALL CONSIST OF TWO CLASSES: A) REGULAR MEMBERSHIP - ELIGIBLE INDIVIDUALS MAY ELECT REGULAR MEMBERSHIP BY ENROLLING IN THE HEALTH BENEFIT PLAN. REGULAR MEMBERS ALSO MAY ENROLL IN OTHER PLAN PROGRAMS IN ACCORDANCE WITH AND AS PERMITIED BY THE PLAN DOCUMENTS. REGULAR MEMBERSHIP SHALL TERMINATE CONTEMPORANEOUSLY WITH THE TERMINATION OF THE HEALTH BENEFIT PLAN COVERAGE. MEMBERSHIP AT THAT TIME WILL CONVERT TO ASSOCIATE MEMBERSHIP IF THE INDIVIDUAL REMAINS ENROLLED IN ANY OTHER PLAN PROGRAM. B) ASSOCIATE MEMBERSHIP - ELIGIBLE INDIVIDUALS MAY ELECT ASSOCIATE MEMBERSHIP BY ENROLLING IN A PLAN PROGRAM OTHER THAN THE HEALTH BENEFIT PLAN IN ACCORDANCE WITH AND AS PERMITIED BY THE PLAN DOCUMENTS. ASSOCIATE MEMBERSHIP SHALL TERMINATE CONTEMPORANEOUSLY WITH THE TERMINATION OF PLAN COVERAGE UNLESS THE INDIVIDUAL TRANFERS EMPLOYMENT TO ANOTHER AGENCY, IN WHICH CASE HE OR SHE MAY CONTINUE HIS OR HER ENROLLMENT AND ASSOCIATE MEMBERSHIP WHILE SO EMPLOYED. FOR PERSONS WHO DO NOT MEET THE CRITERIA FOR REGULAR OR ASSOCIATE MEMBERSHIP, THE BOARD OF DIRECTORS MAY IN ITS DISCRETION DEFINE A SPECIAL CLASS OF MEMBERSHIP BY VIRTUE OF (1) EMPLOYMENT OR SERVICE WITH THE CORPORATION, (2) PREVIOUS ENROLLMENT IN A PLAN SPONSORED BY THE CORPORATION, OR (3) SECTION 409 OF THE INDIAN HEALTHCARE IMPROVEMENT ACT (IHCIA), AS INCORPORATED AND AMENDED BY SUBSECTION 10221 OF THE PATIENT PROTECTION AND AFFORDABLE CARE ACT (ACA); ALLOWING INDIAN TRIBES OR TRIBAL ORGANIZATIONS OR URBAN INDIAN ORGANIZATIONS AND THEIR EMPLOYEES TO PURCHASE COVERAGE UNDER THE FEDERAL EMPLOYEES HEALTH BENEFIT PROGRAM OR ANY OTHER SUCCESSOR PROGRAM AS SUCH TERMS ARE DEFINED THEREIN. PERSONS ADMITED AS SPECIAL MEMBERS IN THE CORPORATION SHALL HAVE ALL THE RIGHTS ACCORDED ASSOCIATE MEMBERS AND MAY ENROLL IN A PLAN SPONSORED BY THE CORPORATION IF PERMITIED UNDER APPLICABLE LAW. FORM 990, PART VI, SECTION A, LINE 7A: Regular Members shall have the right to vote in the election of directors, Except as otherwise expressly stated in the Bylaws or in the Articles of Incorporation. Members, including Regular Members, shall not have the right to vote on any other matter affecting the Corporation, including but not limited to merger, consolidation and dissolution. FORM 990, PART VI, SECTION B, LINE 11B: THE FORM 990 IS REVIEWED BY BOTH THE CONTROLLER AND EXECUTIVE DIRECTOR BEFORE IT IS FORWARDED TO THE TREASURER FOR FINAL REVIEW AND SIGNATURE. FORM 990, PART VI, SECTION B, LINE 12C: OFFICERS, DIRECTORS OR TRUSTEES AND KEY EMPLOYEES ARE REQUIRED TO DISCLOSE ANNUALLY ANY INTERESTS THAT COULD GIVE RISE TO CONFLICTS OF INTEREST; INCLUDING, BUT NOT LIMITED TO EMPLOYMENT AND ANY WORK PERFORMED FOR ANOTHER ORGANIZATION PAID OR UNPAID. FORM 990, PART VI, SECTION B, LINE 15A: THE BOARD SETS THE COMPENSATION OF THE EXECUTIVE DIRECTOR BASED UPON OUTSIDE RECOMMENDATIONS AND STATISTICAL DATA. THE EXECUTIVE DIRECTOR'S COMPENSATION WAS LAST REVIEWED IN JANUARY 2024. FORM 990, PART VI, SECTION C, LINE 19: THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS AND FINANCIAL STATEMENTS AVAILABE UPON REQUEST TO THE PUBLIC. The organization's bylaws are available on its website for anyone to view, with the latest update as of October 22, 2012. FORM 990, PART XI, LINE 9: OTHER CHANGES TO NET ASSETS OR FUND BALANCE OF $39,315,397 CONSISTS OF THE FOLLOWING: INCREMENTAL EFFECT OF FASB ASC TOPIC 715 - POST RETIREMENT BENEFITS OF $1,242,682, CONTINGENCY RESERVE PAYMENTS OF -$41,613,172, SPECIAL RESERVE OF -$3,540,457. FORM 990, PART VII, SECTION A, COLUMN F: ESTIMATED AMOUNT OF OTHER COMPENSATION THE INCREASE (DECREASE) IN THE TOTAL PRESENT VALUE OF THE BENEFIT COMES PRIMARILY FROM THE INCREASE(DECREASE) IN ACCRUALS DURING THE YEAR. ADDITIONALLY, THE DISCOUNT RATE USED AT THE END OF 2023 WAS 4.83%, WHILE THE DISCOUNT RATE USED AT THE END OF 2024 WAS 5.54%. THERE WAS NO EFFECT ON THE LIABILITIES FROM DISCOUNT RATE FLUCTUATION. THESE ARE ACTUARY CALCULATIONS AND THESE AMOUNTS DO NOT REPRESENT A CASH OUTLAY. FORM 990, PART XII, LINE 1: BASIS OF PRESENTATION: THIS TAX RETURN COMBINES TWO PLANS OF THE ENTITY. THE FINANCIAL STATEMENTS OF THE BENEFIT PLAN ARE IN ACCORDANCE WITH GAAP. THE FINANCIAL STATEMENTS OF THE HEALTH PLAN ARE PREPARED PURSUANT TO THE U.S. OFFICE OF PERSONNEL MANAGEMENT'S (OPM) PRESCRIBED ACCOUNTING PRACTICES FOR FEDERAL EMPLOYEES HEALTH BENEFITS PROGRAM ("FEHBP") CARRIERS AND IS NOT INTENDED TO BE A COMPLETE PRESENTATION IN ACCORDANCE WITH GAAP. IN ACCORDANCE WITH OPM'S PRESCRIBED ACCOUNTING PRACTICES, EXPENSES ARE ONLY RECOGNIZED AND PAID BY THE HEALTH PLAN IF ALLOWED UNDER THE U.S. GOVERNMENT'S COST ACCOUNTING STANDARDS AND OTHER LIMITATIONS IMPOSED BY THE CONTRACT WITH OPM. IN THIS REGARD, SOME EXPENSES NOT ALLOWED BY THE HEALTH PLAN ARE CHARGED AS MISCELLANEOUS EXPENSES OF THE BENEFIT PLAN.