2015-05-14T10:46:13-05:00 2014-06-30 861065772 Deloitte Tax LLP 555 East Wells Street Suite 1400 Milwaukee WI 53202 990 2013-07-01 391568866 Affinity Health System Inc AFFI 9207201300 1570 Midway Place Menasha WI 54952 Jeffrey Francis Ministry Health Care CAFO 9207201300 2015-05-13 1 Rachel Becker P00966076 4142713000 2013 2016-02-25 16:41:14Z Jeffrey Francis 1570 Midway Place Menasha WI 54952 31353251 0 X www.affinityhealth.org X 1986 IL To further the healing ministry of Jesus by improving the health and well-being of all people. 17 10 498 14 0 0 28183 45493 41143276 31290058 1194 -24695 6010 8523 41178663 31319379 92710 0 0 0 27331571 25122669 0 0 0 13747178 6188033 41171459 31310702 7204 8677 49520625 43141407 33409693 25608545 16110932 17532862 The mission of Affinity Health System, Inc. is to live out the healing ministry of Christ by providing services that promote the health and well-being of the communities we serve, especially the poor. 0 0 24521575 31290058 The entity believes in meeting the healthcare needs of the poor, indigent, and underserved. Care is provided to the patients without regards for ability to pay. The entity provides administrative support to three hospitals, and twenty-three clinic locations. The entity also provides: free newsletters focusing on women's health issues, children's health, and safety issues health; information spots on television and radio classes on a variety of health related topics including pregnancy and child rearing. 24521575 1 1 0 0 0 0 0 0 0 0 1 0 0 0 1 1 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 1 0 0 1 26 0 1 498 1 0 0 0 0 0 0 0 0 0 0 0 X 17 10 1 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 0 0 0 WI X Jeffrey Francis 4143593145 222 W College Ave 3rd Floor Appleton WI 54911 Steve Morton Chairman 0.40 1.10 X X 0 0 0 John Russo end 1213 Vice Chairman 0.40 1.10 X X 0 0 0 Wayne Trembly Secretary 0.40 1.10 X X 0 0 0 Kathryn Sieman Treasurer 0.40 1.10 X X 0 0 0 Lane Earns Board Member 0.40 1.10 X 0 0 0 Mark W Faustich MD Board Member 0.40 40.00 X 0 409546 24567 Mary Harp-Jirschele Board Member 0.40 1.10 X 0 0 0 Frederick Klein MD Board Member 0.40 1.10 X 0 0 0 Joseph McCormick MD Board Member 0.40 40.70 X 0 906132 54733 Kevin Ralofsky start 114 Board Member 0.40 1.40 X 0 0 0 Jay Sauter Board Member 0.40 1.10 X 0 0 0 Stacey Sensor DO Board Member 0.40 41.00 X 0 582436 36897 Sudeep Sodhi MD Board Member 0.40 40.70 X 0 851724 54749 Barbara J Strand MD Board Member 0.40 40.70 X 0 313912 29366 Catherine Tierney Board Member 0.40 1.10 X 0 0 0 Monica Vomastic Board Member 0.40 1.10 X 0 0 0 William J Calhoun President at MMC 0.40 40.60 X 392457 0 47205 Daniel Neufelder Sr. VP of Hospital Operations 0.40 55.70 X X 0 896266 89267 Nicholas Desien Ministry Health Care CEO 0.40 55.90 X 0 2061606 41974 Jeffery Francis Ministry Health Care CAFO 10.00 55.90 X 0 522252 124025 Travis Anderson Hospital President - STE Appleton 0.40 40.90 X 0 355671 48793 Mark Kehrberg Chief Medical Officer 10.00 30.60 X 394415 0 54779 Gary Kusnierz VP Performance Excellence 40.00 0.30 X 0 225494 36057 Carrie J Hankes Misn. Int. & Spiritual Care Sys. Dir. 40.00 0.00 X 147981 0 26774 Ginger L Selle Director of Nursing 40.00 0.00 X 124924 0 26364 Mike C Perry Dir. Regional Performance Excellence 40.00 0.00 X 125257 0 17485 Karen Hielsberg Dir. Patient Financial Svs 40.00 0.00 X 125373 0 21477 William J Brazeau Business Initiatives System Dir. 40.00 0.00 X 111157 0 20517 Jeff Badger Former Officer 1.00 51.00 X 0 497813 62987 1421564 7622852 818016 10 1 1 0 GE Medical Systems 5517 Collections Center Dr Chicago IL 60693 I.S Services 1238193 Medical Information Technology Meditrech Circle Westwood MA 02090 I.S Services 929225 State Collection Service 2509 S Stoughton Road Madison WI 53716 Collection 852896 CDW Government 75 Remittance Drive Chicago IL 606751515 I.S Services 417149 CCC Technologies Inc 185 Hansen CT Ste 100 Wood Dale IL 60191 I.S Services 342393 9 45493 45493 Services to Affiliates 561000 31237739 31237739 Lifespan Classes 561000 43955 43955 Misc. Operating Rev. 561000 8364 8364 31290058 156 156 9021 33872 -24851 -24851 -24851 Non Operating Revenue 900099 8523 8523 8523 31319379 31290058 0 -16172 888856 888856 19552379 14431139 5121240 831698 831698 2354202 2353865 337 1495534 1495534 7199 7199 482801 244248 238553 40702 3896 36806 507752 438691 69061 4153420 4153420 15599 15599 Purchased Services 424710 272481 152229 Postage & Freight 349267 192531 156736 Food 32861 8897 23964 Dues 17920 3870 14050 155802 68507 87295 31310702 24521575 6789127 0 101 100 13240482 7681681 11270258 10001984 842858 838386 1227311 15131567 3259723 18919991 11871844 2943912 11444119 1075712 1303293 49520625 43141407 25258366 21912780 8151327 3695765 33409693 25608545 X 16110932 17532862 16110932 17532862 49520625 43141407 X 8677 1413253 X 0 1 X 1 0 X X 0 0 0 Mercy Medical Center of Oshkosh Inc 390806268 3 1 1 1 0 Mercy Health Foundation Inc 237140261 9 1 1 1 0 St Elizabeth Hospital Inc 390816818 3 1 1 1 0 St Elizabeth Hospital Foundation Inc 391256677 7 1 1 1 0 Network Health System Inc 391127163 3 1 1 1 0 Calumet Medical Center Inc 390905385 3 1 1 1 0 6 0 Schedule A, Part I, Line 11(i)(vii): Monetary support provided to supported organizations: Affinity Health System, Inc. supports the provision of healthcare services at the corporations to which it is a member through the provision of centralized administrative support including revenue cycle, administrative costs, compliance/corporate integrity, telecommunications, business services; human resources, and marketing. Costs of certain of these departments are charged to the members through a management fee. Transactions with each member are delineated on Schedule R. RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 364043 37960 326083 14416874 3194272 11222602 350650 27491 323159 11871844 Pension Liability 2392461 457B Plan Liability 1303304 3695765 X Part X, Line 2: From the consolidated audited financial statements of Ministry Health Care, Inc. which includes the activity of Affinity Health System, Inc.: The Health Ministry accounts for uncertainty in income tax positions by applying a recognition threshold and measurement attribute for financial statement recognition and measurement of a tax position taken or expected to be taken in a tax return. X X 1 1 0 1 0 0 0 0 0 0 0 Mark W Faustich MD Board Member 0 387296 0 0 0 22250 0 20384 0 4183 0 434113 0 0 Joseph McCormick MD Board Member 0 891235 0 0 0 14897 0 35000 0 19733 0 960865 0 0 Stacey Sensor DO Board Member 0 567140 0 0 0 15296 0 17500 0 19397 0 619333 0 0 Sudeep Sodhi MD Board Member 0 834731 0 0 0 16993 0 35000 0 19749 0 906473 0 0 Barbara J Strand MD Board Member 0 246953 0 40532 0 26427 0 21723 0 7643 0 343278 0 0 William J Calhoun President at MMC 330620 0 44429 0 17408 0 29514 0 17691 0 439662 0 0 0 Daniel Neufelder Sr. VP of Hospital Operations 0 770217 0 95952 0 30097 0 70286 0 18981 0 985533 0 0 Nicholas Desien Ministry Health Care CEO 0 1004953 0 329299 0 727354 0 15000 0 26974 0 2103580 0 0 Jeffery Francis Ministry Health Care CAFO 0 427032 0 63804 0 31416 0 101523 0 22502 0 646277 0 0 Travis Anderson Hospital President - STE Appleton 0 281005 0 45452 0 29214 0 31388 0 17405 0 404464 0 0 Mark Kehrberg Chief Medical Officer 333905 0 25071 0 35439 0 39160 0 15619 0 449194 0 0 0 Gary Kusnierz VP Performance Excellence 0 169100 0 13278 0 43116 0 19072 0 16985 0 261551 0 0 Carrie J Hankes Misn. Int. & Spiritual Care Sys. Dir 140825 0 0 0 7156 0 10600 0 16174 0 174755 0 0 0 Ginger L Selle Director of Nursing 118033 0 0 0 6891 0 13115 0 13249 0 151288 0 0 0 Jeff Badger Former Officer 0 405962 0 56934 0 34917 0 44888 0 18099 0 560800 0 0 Part I, Line 1a Business travel expenses for spouses of executives and golf club membership for executives are reimbursed as part of their executive flex credit account. Receipts are provided to the Sr. Administrative Assistant in HR who reviews for accuracy and completes a reimbursement form with substantiation to payroll for reimbursement. These reimbursements are taxable, and when added to the compensation package taken as a whole have been included when compared to the compensation studies. Part I, Line 3 Ministry Health Care, Inc., a related organization of Affinity Health System, Inc., uses the following to establish the compensation of the organization's CEO: - Compensation Committee - Independent Compensation Consultant - Compensation Survey or Study, and - Approval by the Board or Compensation Committee Part I, Line 4b Eligible executives participate in a program that provides for supplemental retirement benefits. The payment of benefits under the program, if any, is entirely dependent upon the facts and circumstances under which the executive terminates employment with the organization. Benefits under the program are unfunded and non-vested. Due to the substantial risk of forfeiture provision, there is no guarantee that these executives will ever receive any benefit under the program. Any amount ultimately paid under the program to the executive is reported as compensation on Form 990, Schedule J, Part II, Column B in the year paid. No distributions were made from the plan during the year. Form 990, Part VI, Section A, line 2 Many of the persons listed on Part VII have a "business relationship" with each other by virtue of employment by Ministry Health Care, Inc. related entities. Form 990, Part VI, Section A, line 6 Affinity Health System, Inc. has a single corporate member, Ministry Health Care, Inc. Form 990, Part VI, Section A, line 7a Affinity Health System, Inc. has a single corporate member, Ministry Health Care, Inc., who has the ability to elect members to the governing body of Affinity Health System, Inc. Form 990, Part VI, Section A, line 7b All decisions that have a material impact to Affinity Health System, Inc. financial information or corporation as a whole are subject to approval by its sole corporate member, Ministry Health Care, Inc. Form 990, Part VI, Section B, line 11 Management, including certain officers, works diligently to complete the Form 990 and attached schedules in a thorough manner. Prior to filing the return, all Board Members are provided the Form 990 and management team members are available to answer any Board Members' questions. Form 990, Part VI, Section B, line 12c The organization regularly and consistently monitors and enforces compliance with the Conflict of Interest Policy in that any director, principal officer, or member of a committee with governing board delegated powers, who has a direct or indirect financial interest, must disclose the existence of the financial interest and be given the opportunity to disclose all material facts to the directors and members of the committees with governing board delegated powers considering the proposed transaction or arrangement. The remaining individuals on the governing board or committee meeting will decide if conflicts of interest exist. Each director, principal officer and member of a committee with governing board delegated powers annually signs a statement which affirms such person has received a copy of the Conflict of Interest Policy, has read and understands the policy, has agreed to comply with the policy, and understands that the organization is charitable and in order to maintain its federal tax exemption it must engage primarily in activities which accomplish its tax-exempt purpose. Form 990, Part VI, Section B, line 15 In determining compensation of the organization's CEO, the process, performed by Ministry Health Care, Inc., a related organization of Affinity Health System, Inc., included a review and approval by independent persons, comparability data, and contemporaneous substantiation of the deliberation and decision. The Compensation Committee reviewed and approved the compensation. In the review of the compensation, the CEO was compared to individuals at other organizations in the area that hold the same title. During the review and approval of the compensation, documentation of the decision was recorded in the board minutes. The individual was not present when his compensation was decided. In determining compensation of other officers and key employees of the organization, the process, performed by Ministry Health Care, Inc., a related organization of Affinity Health System, Inc., included a review and approval by independent persons, comparability data, and contemporaneous substantiation of the deliberation and decision. The Compensation Committee reviewed and approved the compensation. In the review of the compensation, the other officers and key employees of the organization were compared to individuals at other organizations in the area that hold the same title. During the review and approval of the compensation, documentation of the decision was recorded in the board minutes. Form 990, Part VI, Section C, line 19 The Ministry web page is available to the public for inspection with a good deal of information regarding who Ministry Health Care is and the entities included along with our mission. The Articles of Incorporation, Bylaws, Conflict of Interest Policy and financial statements are not included on any web page. However, if any inquiry is made for any documents they are shared as appropriate. Form 990, Part XI, line 9: Pension Adjustment 1,413,253. Ascension Health Alliance PO Box 45998 St Louis MO 631455998 453358926 National Health System MO Section 501(c)(3) Schedule A, Line 11a N/A 0 Ascension Health PO Box 45998 St Louis MO 631453806 311662309 National Health System MO Section 501(c)(3) Schedule A, Line 11a Ascension Health Alliance 0 Ministry Health Care Inc 10925 W Lake Park Dr Ste 100 Milwaukee WI 53224 391490371 Parent Corporation WI Section 501(c)(3) Schedule A, Line 11b Ascension Health 0 Agape Community Center of Milwaukee Inc 6100 North 42nd Street Milwaukee WI 532093560 391461846 Community Center WI Section 501(c)(3) Schedule A, Line 7 Ministry Health Care Inc 1 Calumet Medical Center Inc 614 Memorial Drive Chilton WI 53014 390905385 Hospital WI Section 501(c)(3) Schedule A, Line 3 Affinity Health System 1 Catalpa Health Inc N4642 County N Appleton WI 54914 454681563 Mental Health Facility WI Section 501(c)(3) Schedule A, Line 3 St Elizabeth Hospital Inc 1 Saint Michael's Foundation of Stevens Point Inc 900 Illinois Avenue Stevens Point WI 54481 391657410 Charitable Foundation WI Section 501(c)(3) Schedule A, Line 11a Saint Michael's Hospital of Stevens Point Inc 1 Door County Memorial Hospital 323 South 18th Avenue Sturgeon Bay WI 54235 390806324 Hospital WI Section 501(c)(3) Schedule A, Line 3 Ministry Health Care Inc 1 Dr Kate Newcomb Convalescent Center Inc PO Box 829 Woodruff WI 54568 391357365 LTC Facility WI Section 501(c)(3) Schedule A, Line 9 Howard Young Health Care Inc 1 Eagle River Memorial Hospital Incorporated 201 Hospital Road Eagle River WI 54521 390985690 Hospital WI Section 501(c)(3) Schedule A, Line 3 The Howard Young Medical Center Inc 1 Foundation of Saint Clare's Hospital of Weston Inc 3400 Ministry Parkway Weston WI 54476 753193633 Charitable Foundation WI Section 501(c)(3) Schedule A, Line 11a Ministry Health Care Inc 1 Foundation of Saint Joseph's Hospital of Marshfield Inc 611 Saint Joseph Avenue Marshfield WI 54449 391684957 Charitable Foundation WI Section 501(c)(3) Schedule A, Line 11a Saint Joseph's Hospital of Marshfield Inc 1 Good Samaritan Health Center of Merrill Wisconsin Inc 601 South Center Avenue Merrill WI 54452 390808503 Hospital WI Section 501(c)(3) Schedule A, Line 3 Ministry Health Care Inc 1 Good Samaritan Health Center Fdn of Merrill Wisconsin Inc 601 South Center Avenue Merrill WI 54452 391627755 Charitable Foundation WI Section 501(c)(3) Schedule A, Line 11a Good Samaritan Health Center of Merrill Wisconsin Inc 1 Howard Young Foundation Inc 240 Maple Street Woodruff WI 54568 391521169 Charitable Foundation WI Section 501(c)(3) Schedule A, Line 7 Howard Young Health Care Inc 1 Howard Young Health Care Inc 240 Maple Street Woodruff WI 54568 391499115 Home Office WI Section 501(c)(3) Schedule A, Line 11b Ministry Health Care Inc 1 The Howard Young Medical Center Inc 240 Maple Street Woodruff WI 54568 390873606 Hospital WI Section 501(c)(3) Schedule A, Line 3 Howard Young Health Care Inc 1 Mercy Health Foundation Inc PO Box 3370 Oshkosh WI 54903 237140261 Charitable Foundation WI Section 501(c)(3) Schedule A, Line 9 Affinity Health System 1 Mercy Medical Center of Oshkosh Inc 500 S Oakwood Road Oshkosh WI 54904 390806268 Hospital WI Section 501(c)(3) Schedule A, Line 3 Ministry Health Care Inc 1 Ministry Home Care Inc 611 St Joseph Avenue 4S Marshfield WI 54449 391936201 Home Care/Hospice WI Section 501(c)(3) Schedule A, Line 9 Ministry Health Care Inc 1 Ministry Medical Group Inc 824 Illinois Avenue Stevens Point WI 54481 391965593 Clinics WI Section 501(c)(3) Schedule A, Line 11c Ministry Health Care Inc 1 Ministry Weight Management Inc 2251 North Shore Drive Rhinelander WI 54501 391829015 Health Services WI Section 501(c)(3) Schedule A, Line 3 Sacred Heart-St Mary's Hospitals Inc 1 Network Health System Inc 1570 Appleton Rd Menasha WI 54952 391127163 Clinical Healthcare Services WI Section 501(c)(3) Schedule A, Line 3 Affinity Health System 1 Our Lady of Victory Hospital Inc 1120 Pine Street Stanley WI 54768 390807065 Hospital WI Section 501(c)(3) Schedule A, Line 3 Ministry Health Care Inc 1 Sacred Heart-St Mary's Hospitals Inc PO Box 347 Stevens Point WI 54481 391390638 Hospital WI Section 501(c)(3) Schedule A, Line 3 Ministry Health Care Inc 1 Saint Clare's Hospital of Weston Inc 3400 Ministry Parkway Weston WI 54476 721531917 Hospital WI Section 501(c)(3) Schedule A, Line 3 Ministry Health Care Inc 1 Saint Elizabeth's Hospital of Wabasha Inc 1200 Grant Blvd West Wabasha MN 55981 410693877 Hospital MN Section 501(c)(3) Schedule A, Line 3 Ministry Health Care Inc 1 St Elizabeth Hospital Foundation Inc 1506 S Oneida Street Appleton WI 54915 391256677 Charitable Foundation WI Section 501(c)(3) Schedule A, Line 7 Affinity Health System 1 St Elizabeth Hospital Inc 1506 S Oneida Street Appleton WI 54915 390816818 Hospital WI Section 501(c)(3) Schedule A, Line 3 Ministry Health Care Inc 1 Saint Joseph's Hospital of Marshfield Inc 611 Saint Joseph Avenue Marshfield WI 54449 390847631 Hospital WI Section 501(c)(3) Schedule A, Line 3 Ministry Health Care Inc 1 Saint Michael's Hospital of Stevens Point Inc 900 Illinois Avenue Stevens Point WI 54481 390808443 Hospital WI Section 501(c)(3) Schedule A, Line 3 Ministry Health Care Inc 1 Twin Med LLP PO Box 8005 Menasha WI 54952 391180341 Rental Property WI N/A Network Health Plan Inc 1570 Midway Place Menasha WI 54952 391442058 Insurance WI N/A C 0 Ministry Holdings LLC 1570 Midway Place Menasha WI 54952 422966177 Insurance Holding Company WI N/A C 0 0 0 1 0 0 0 0 0 0 0 0 1 1 0 1 1 1 0 0 Ministry Health Care Inc O 25398635 FMV St Elizabeth Hospital Inc O 54295 FMV Ministry Health Care Inc P 6115086 FMV