2012-08-10T10:33:07-05:00 2011-09-30 Ernst & Young LLP 200 Clarendon Street Boston MA 02116 990 2010-10-01 222747685 Baystate Administrative Services Inc BAYS 4137947872 759 Chestnut Street Springfield MA 011990001 Dennis W Chalke 4137945740 2012-08-10 1 Jeanne M Schuster 6172662000 2010 2016-02-24 21:20:13Z Dennis W Chalke 759 Chestnut Street Springfield MA 011990001 91063037 0 X www.baystatehealth.org X 1986 MA To improve the health of the people in our communities every day with quality and compassion 6 0 548 0 676605 0 0 0 87269990 90423070 68603 602184 37988 37783 87376581 91063037 0 0 0 0 53682358 55288000 0 0 0 34517990 34866938 88200348 90154938 -823767 908099 34060151 37953235 47691073 55103222 -13630922 -17149987 The organization's purpose is to promote the health, charitable and educational purposes of Baystate Health, Inc. whose mission is to improve the health of the people in our communities every day, with quality and compassion. 0 0 31272376 40631444 BAS provides management and administrative support to Baystate Health and its affiliates. These services are an integral part of the healthcare delivery system and include strategic planning, human resources, risk management (insurance) programs, marketing, financial services and benefit plans administration for all health system employees. 47546436 49152804 BAS provides information technology support to Baystate Health and its affiliates. These services are an integral part of the healthcare delivery system and include all software applications, telecommunications, clinical engineering, and computerized equipment at the hospitals. 78818812 1 0 0 1 0 0 0 0 0 1 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1 0 1 0 0 0 0 0 1 1 1 0 0 1 262 0 1 548 1 1 1 0 0 0 0 0 0 0 0 0 0 X 6 0 1 0 0 0 1 1 0 1 1 0 0 0 1 1 1 1 1 1 1 0 MA X Peter Lyons Baystate Health Inc 4137940000 759 Chestnut Street Springfield MA 01199 X Mark R Tolosky 1.00 X X 1638402 0 112208 Keith C McLean-Shinaman 1.00 X X 597331 0 91897 Dennis W Chalke 1.00 X X 564783 0 51532 Loring S Flint Jr MD 1.00 X X 1511683 0 77581 Evan Benjamin MD FACP 1.00 X 507963 0 56115 Gregory A Harb 1.00 X 0 0 0 Mark A Keroack MD MPH 1.00 X 0 0 0 Hal B Jenson MD MBA 1.00 X 497497 0 46780 Donna J Ross 1.00 X 393215 0 65487 Paula C Squires 1.00 X 409741 0 114420 Kristin R Delaney 1.00 X 92401 0 29700 Mark B Gorrell 50.00 X 354843 0 50240 Gordon Josephson MD 50.00 X 431735 0 94658 Joan Sullivan 50.00 X 326396 0 47887 Charles D Gijanto 50.00 X 309004 0 109405 Peter A Lyons 50.00 X 261227 0 82318 Lawrence Emerson 50.00 X 260733 0 82456 8156954 0 1112684 110 0 1 1 Siemens Medical Solutions Dept at 40565 Atlanta GA 311920065 Equipment Maintenance 2507452 Cerner Corporation 2800 Rockcreek Pkwy Kansas City MO 641172521 Computer Services 2418463 Prudential Insurance Company PO Box 101241 Atlanta GA 303921241 Life Insurance 1905888 Fidelity Security Life Ins PO Box 632530 Cincinnati OH 452632530 Visioncare Insurance 1346662 Unum Life Insurance Co of America PO Box 406946 Atlanta GA 303846946 LTD insurance 1186283 77 Affiliate Support 561000 90423070 89746465 676605 90423070 261075 261075 341109 341109 341109 341109 Miscellaneous 561000 15281 15281 Mini Med School 611600 12890 12890 LTD related income 561000 9612 9612 37783 91063037 89784248 676605 602184 7263820 6184416 1079404 36989396 31412039 5577357 3619023 3081087 537936 4415335 3837831 577504 3000426 2560166 440260 1087864 970503 117361 904251 904251 19000 19000 3078004 2825544 252460 1434704 1247467 187237 2199125 2118147 80978 20605457 20515104 90353 1231650 1113305 118345 479723 345922 133801 1017507 581826 435681 94799 84572 10227 166087 142294 23793 Recruitment 645242 425796 219446 Temporary Help 287401 155437 131964 Dues & Memberships 19127 19127 1596997 1198229 398768 90154938 78818812 11336126 0 534454 187625 17515378 18954575 391046 286861 241702 451640 6396576 8076348 5013645 4627989 369879 385656 8611116 9610530 34060151 37953235 20995978 22709644 26695095 32393578 47691073 55103222 X -13360922 -17149987 -13630922 -17149987 34060151 37953235 X 908099 -4427164 X 0 1 1 X 0 X X X 0 0 0 Baystate Health Inc 042105941 7 1 1 1 0 Baystate Medical Center Inc 042790311 3 0 1 1 0 Baystate Franklin Medical Ctr 042103575 3 0 1 1 0 Baystate Mary Lane Hospital Corp 042103584 3 0 1 1 0 Visiting Nurse Association & Hospice of WNE Inc 042105803 9 0 1 1 0 5 0 Schedule A, Part IV, Supplemental Information: Schedule A, part I, line h(vii) BAS provides management, administrative, and professional services to support the organizations listed on line h(i). 0 1 0 0 0 0 1 182260 0 0 182260 0 Part IV, Supplemental Information: The amount recorded on Part II-B, line 1j represents BAS salaries and operating expenses as reported on Massachusetts Public Records Division Lobbyist Disclosures for activities related to healthcare policy, bills and appropriations-related activities. 497449 452608 44841 3144250 2803435 340815 1371946 1371946 0 385656 Due from affiliated companies 9610530 9610530 Due to affiliated companies 16793479 Total accrued pension cost 2133037 Total minimum pension liability 13467062 32393578 Part X, line 2 : No FIN48 footnote was included in the consolidated audited financial statements of Baystate health, Inc. and Subsidiaries for the year ended September 30, 2011. X X X X 1 1 0 1 1 0 0 0 0 0 0 Mark R Tolosky 680614 0 380604 0 577184 0 73034 0 39174 0 1750610 0 0 0 Keith C McLean-Shinaman 373623 0 146922 0 76786 0 51333 0 40564 0 689228 0 0 0 Dennis W Chalke 315800 0 113223 0 135760 0 23333 0 28199 0 616315 0 0 0 Loring S Flint Jr MD 917432 0 360152 0 234099 0 48361 0 29220 0 1589264 0 0 0 Evan Benjamin MD FACP 320461 0 101368 0 86134 0 32689 0 23426 0 564078 0 0 0 Hal B Jenson MD MBA 350775 0 76279 0 70443 0 15925 0 30855 0 544277 0 36156 0 Donna J Ross 243541 0 96550 0 53124 0 41335 0 24152 0 458702 0 0 0 Paula C Squires 266173 0 92043 0 51525 0 87425 0 26995 0 524161 0 22100 0 Mark B Gorrell 267594 0 71418 0 15831 0 32697 0 17543 0 405083 0 0 0 Gordon Josephson MD 327583 0 75030 0 29122 0 77000 0 17658 0 526393 0 0 0 Joan Sullivan 243326 0 57493 0 25577 0 33117 0 14770 0 374283 0 0 0 Charles D Gijanto 262150 0 36396 0 10458 0 85780 0 23625 0 418409 0 0 0 Peter A Lyons 196470 0 47486 0 17271 0 60000 0 22318 0 343545 0 0 0 Lawrence Emerson 199930 0 46565 0 14238 0 64001 0 18455 0 343189 0 0 0 Part I, Line 1a 1. Companion Travel - Several Trustees, Officers, and/or key employees were provided with compensation for spouses to attend a company board event. 2. Tax Gross up / Discretionary Spending Account- Several employees were provided with reimbursement for financial, tax and estate planning requiring a tax gross up. 3. Club Dues - Several officers and/or key employees were provided with payment for dinner club dues for which the personal use did not exceed $315 for 2010, for any individual. The three items above were treated as taxable compensation as appropriate in accordance with Baystate's written policies which require compliance with the IRS's accountable plan rules. Part I, Lines 4b-c Evan Benjamin, MD - Supplemental Retirement of $62,398 is included in column E. This amount was earned in 2010. Dennis W. Chalke - Supplemental Retirement of $109,384 is included in column E. This amount was earned in 2010. Loring S. Flint, MD - Supplemental Retirement of $142,221 is included in column E. This amount was earned in 2010. Charles Gijanto - Supplemental Retirement of $69,855 is included in column E. This amount was earned in 2010. Mark B. Gorrell - Supplemental Retirement of $13,736 is included in column E. This amount was earned in 2010. Hal B. Jenson, MD - Supplemental Retirement of $64,083 is included in column E. This amount was earned in 2010. Gordon Josephson, MD - Supplemental Retirement of $24,243 is included in column E. This amount was earned in 2010. Keith C. McLean Shinaman - Supplemental Retirement of $60,038 is included in column E. This amount was earned in 2010. Donna Ross- Supplemental Retirement of $34,571 is included in column E. This amount was earned in 2010. Paula Squires - Supplemental Retirement of $79,380 is included in column E. This amount was earned in 2010. Joan Sullivan - Supplemental Retirement of $5,745 is included in column E. This amount was earned in 2010. Mark R. Tolosky - Supplemental Retirement of $418,714 is included in column E. This amount was earned in 2010. Line 4c The supplemental retirement plan offered to Mr. Tolosky from 1997-2002 provided the right to purchase mutual fund shares at a specified price, with the rights expiring at the end of the 10 years. The 2010 compensation of $102,413 was based on the difference between the fair market value at the date of exercise and the exercise price. Supplemental Information Part III Part 1, Line 3 The Baystate Administrative Services, Inc. Board of Directors is composed of management of Baystate Health, Inc. and its affiliates. Therefore it is more appropriate that the establishment and review of the compensation of the organization's top management officials be performed at the Baystate Health level, which has a more independent board. Part II Dr. Flint terminated employment effective 12/30/2010. The compensation numbers include various one time termination payments. Baycare Health Partners Inc (BHP) Common Board Members or Officers 244754 See Part V - The filing organization received payments from BHP for management and administrative services. BHP is an affiliate corporation of the filing organization. 0 Health New England (HNE) Common Board Members or Officers 305330 See Part V - The filing organization received payments from HNE of $205,330 for reimbursement of benefits related expenses and $100,000 for management and administrative support. HNE is an affiliate corporation of the filing organization. 0 Ingraham Corporation (IC) Common Board Members or Officers 331851 See Part V - The filing organization received payments from IC for management, administrative and information systems services. IC is an affiliate corporation of the filing organization. 0 Form 990, Part VI, Section A, line 1 Baystate Administrative Services, Inc. (BAS) is part of an integrated delivery system including not for profit community hospitals, which have community boards. BAS is a management services supporting organization, which supports Baystate Health and its affiliates and is comprised of BAS employees. This board structure has not changed significantly since the organization applied for exempt status. Form 990, Part VI, Section A, line 2 Dennis W. Chalke, Kristin R. Delaney, Loring S. Flint, MD, Hal B. Jenson, MD, Keith C. McLean-Shinaman, Donna J.Ross and Mark R. Tolosky are also officers or trustees of Baystate Health, Inc. & its affiliated entities. Form 990, Part VI, Section A, line 6 The filing organization has one member, Baystate Health, Inc. (BH). Form 990, Part VI, Section A, line 7a All of the members of the Board of Directors of the filing organization are individuals serving ex officio based on positions they hold with BH. Form 990, Part VI, Section B, line 11 Prior to the filing of this return appropriate parts of this Form 990 were reviewed by representatives from the Tax, Finance, and Human Resources Departments of Baystate Health, Inc. (the sole member of the filing organization and the parent organization of the health care system to which the filing organization belongs), some of whom are officers or trustees of the filing organization and by outside legal counsel. The entire return was reviewed by a tax expert from an outside accounting firm. In addition, this return was provided to and reviewed by the Audit and Compliance Committee of Baystate Health, Inc. This committee also reviews the audited financial statements for the health system. This return was also provided prior to filing to the Baystate Health, Inc. Board of Trustees. Form 990, Part VI, Section B, line 12c Baystate Health, Inc. (BH) and its affiliated entities have a comprehensive conflict of interest policy applicable to all of the affiliated entities. All directors, trustees, officers, key employees, and highest compensated employees of BH and its affiliates are asked to complete an annual conflict of interest form. We utilize an electronic database to receive and manage all conflict of interest submissions. This information is reviewed by the Chief Compliance Officer, the Chief Executive Officer, the Chair of the Board of Trustees, and the Chair of the Audit & Compliance Committee. A summary of the conflict of interest disclosures is provided to the Baystate Health Board of Trustees and the Tax Department and reviewed by outside counsel. Potential conflict of interest transactions are reviewed as appropriate under the policy, which provides for recusal from discussion and deliberation by any party with a potential conflict of interest. Form 990, Part VI, Section B, line 15 The compensation of the President and CEO, and of other officers and key employees is established based on information provided by independent third party consultants for reasonableness and appropriate comparability data. The compensation is then established, reviewed and approved by the independent compensation committee of Baystate Health, Inc. (the parent organization of the health care system to which the filing organization belongs) and all such deliberations and decisions are documented contemporaneously. Form 990, Part VI, Section C, line 19 Public Inspection of Organizational Policies The organization makes its conflict of interest policy and financial statements available to the public at www.baystatehealth.org. Articles of organization and bylaws are generally available at the Commonwealth of Massachusetts website. Average hours per week: Form 990, Part VII, Section A, Line 1a, Column (B) Individuals with such reported compensation who have 10 or less average hours per week listed in Part VII, worked between 40 - 60 hours among all related entities. Changes in Net Assets or Fund Balances: Form 990, Part XI, line 5: Net unrealized losses on investments: -484,491. Pension Adjustment -3,942,668. rounding -5. Total to Form 990, Part XI, Line 5: -4,427,164. Baystate Franklin Medical Center 164 High Street Greenfield MA 01301 042103575 Hospital MA 501 (c ) (3) 3 Baystate Health Inc 0 Baystate Health Foundation Inc 759 Chestnut Street Springfield MA 01199 043549011 Fundraising MA 501 (c ) (3) 7 Baystate Health Inc 0 Baystate Health Systems Inc Health & Welfare Benefits Plan 759 Chestnut Street Springfield MA 01199 222531644 Voluntary Employees' Benefit Association MA 501 (c ) (9) Baystate Health Inc 0 Baystate Health Inc 759 Chestnut Street Springfield MA 01199 042105941 Healthcare System Parent MA 501 (c ) (3) 7 Baystate Health Inc 0 Baystate Mary Lane Hospital Corporation 85 South Street Ware MA 01082 042103584 Hospital MA 501 (c ) (3) 3 Baystate Health Inc 0 Baystate Medical Center Inc 759 Chestnut Street Springfield MA 01199 042790311 Acute Care Teaching Hospital MA 501 (c ) (3) 3 Baystate Health Inc 0 Baystate Total Home Care Inc 50 Maple Street Springfield MA 01199 203260764 Real Estate and Other MA 501 (c ) (3) 11b, II Baystate Health Inc 0 BH Insurance Company Ltd North Church Street Georgetown CJ 980421413 Offshore captive Insurance CJ Baystate Health Inc 0 Visiting Nurse Assn and Hospice of Western New England Inc 50 Maple Street Springfield MA 01199 042105803 Homehealth and Hospice care MA 501 (c ) (3) 9 Baystate Health Inc 0 Health New England Inc Monarch Place Suite 1500 Springfield MA 011441500 042864973 HMO/Insurance MA Baystate Health Inc C HNE Advisory Services Monarch Place Suite 1500 Springfield MA 011441500 043012347 Administrative Svs MA Health New England Inc C Health New England Insurance Monarch Place Suite 1500 Springfield MA 011441500 043183019 Ancilliary Insurance MA Health New England Inc C Health New England of Connecticut Monarch Place Suite 1500 Springfield MA 011441500 061398662 Dormant MA Health New England Inc C Ingraham Corporation 759 Chestnut Street Springfield MA 01199 043016257 Health care and other business activities MA Baystate Health Inc C Baystate Health System Ambulance Inc 759 Chestnut Street Springfield MA 01199 043018550 Ambulance Svs MA Ingraham Corporation C 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 1 0 1 Baystate Medical Center J 1096990 accrual Baystate Medical Center K 71782541 accrual Baystate Medical Center L 68945 accrual Baystate Franklin Medical Center K 7186247 accrual Baystate Mary Lane Hospital K 1505526 accrual Baystate Visiting Nurse & Hospice K 1787833 accrual Baystate Health Inc K 1861904 accrual Baystate Health Foundation L 1087864 accrual Ingraham Corporation K 331851 accrual Baystate Health Insurance Co O 12593480 cash Baystate Health Insurance Co P 11446313 cash Health New England Inc K 100000 accrual Health New England Inc P 205330 cash BHS Health & Welfare Benefit Trust O 72671277 cash Baystate Health (EIN 04-2105941) is filing Form 5471 Information Return of US Person with respect to Certain Foreign Corporation on behalf of the filing organization.