2011-11-14T09:43:29-06:00 2010-12-31 Ernst & Young LLP 200 Clarendon Street Boston MA 02116 990 2010-01-01 222531644 Baystate Health Systems Inc Health & Welfare Benefits Plan BAYS 4137940000 759 Chestnut Street Springfield MA 01199 Mark R Tolosky 4137940000 2011-11-14 1 6172662000 2010 2016-02-24 21:20:13Z Mark R Tolosky 759 Chestnut Street Springfield MA 01199 72667147 0 X N/A X 1983 MA Administration of a Health Benefits Plan - A Voluntary Employees' Benefits Association (VEBA 2 0 0 0 0 0 0 0 75359576 72666241 1835 906 0 0 75361411 72667147 0 0 67575642 65205297 0 0 0 0 0 6535268 6876091 74110910 72081388 1250501 585759 10006758 10489721 226326 123530 9780432 10366191 The organization is a Voluntary Employees' Benefit Association (VEBA) 0 0 The Voluntary Employees' Benefit Association Plan (VEBA) provides certain medical, dental, and pharmacy benefits to eligible employees and their dependents. The Plan also provides health benefits to participants during periods of unemployment, consistent with the Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1986. 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1 0 0 0 0 0 1 0 0 0 1 0 0 0 0 0 0 0 0 0 X 2 0 1 1 0 0 0 0 0 1 1 0 0 1 0 0 0 1 1 0 X Peter Lyons 4137940000 759 Chestnut Street Springfield MA 01199 Mark R Tolosky 1.00 X 0 1638402 112208 Keith M McLean Shinaman 1.00 X 0 597331 92204 0 2235733 204412 0 0 1 0 Health New England 1 Monarch Place Springfield MA 01144 Claims payments/admin fees 55882685 Medmetrics Health Partners 100 Century Drive Worcester MA 01606 Claims payments/admin fees 10531756 Delta Dental 465 Medford Street Boston MA 021291454 Claims payments/admin fees 6298408 Health & Benefits Consultants 1331 Main Street Springfield MA 01103 Consulting fees 194400 4 Employer Contributions 525100 47969672 47969672 Participant Contributi 525100 24696569 24696569 72666241 906 906 72667147 72666241 0 906 65205297 Administrative service 6876091 72081388 4441549 8117547 5115209 2154682 450000 217492 10006758 10489721 226326 123530 226326 123530 X 0 0 0 0 9780432 10366191 9780432 10366191 10006758 10489721 585759 0 X 0 1 1 X 0 0 72667147 72081388 585759 0 585759 72667147 0 72667147 0 72667147 72081388 0 72081388 0 72081388 The following footnote appears in the audited financial statements: Uncertain tax positions Accounting principles generally accepted in the United States of America require Plan management to evaluate tax positions taken by the Plan and recognize a tax liability (or asset) if the Plan has taken an uncertain position that more-likely-than-not would not be sustained upon examination by the Internal Revenue Service. The Plan administrator has analyzed the tax positions taken by the Plan and has concluded that as of December 31, 2010, there are no uncertain tax positions taken or expected to be taken that would require recognition of a liability (or asset) or disclosure in the financial statements. The Plan is subject to routine audits by taxing jurisdiction; however, there are currently not audits for any tax periods in progress. The Plan administrator believes the Plan is no longer subject to income tax examinations for years prior to 2004. 0 1 1 Mark R Tolosky 0 680614 0 380604 0 577184 0 73034 0 39174 0 1750610 0 0 Keith M McLean Shinaman 0 373623 0 146922 0 76786 0 51333 0 40871 0 689535 0 0 Part I, Lines 4b-c Schedule J, Part 1, Line 4b Mark R. Tolosky - Supplemental Retirement of $418,714 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. Schedule J, Part 1, 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 Schedule J, Part 1, Line 3 The Organization is a Voluntary Employees' Benefits Association (VEBA) and has no CEO/Executive Director. Health New England Inc Board Overlap 55882685 Hlth claims pmnts 0 Baycare Health Partners Inc Board Overlap 78896 Payroll deductions forwarded to the trust via Baystate Administrative Services as intermediary. 0 Form 990, Part VI, Section A, line 1 Although Baystate Health Systems, Inc. Health & Welfare Benefits Plan has no independent voting members in the governing body, this organization is a Voluntary Employee Beneficiary Association (VEBA). VEBAs are typically different from other 501(c)(3) entities where having independent voting members in the governing body is more typical. Form 990, Part VI, Section A, line 2 Mark R. Tolosky's and Keith C. McLean Shinaman's only business relationship arises from their roles as Officers or Trustees of Baystate Health, Inc. & its affiliated entities. Form 990, Part VI, Section A, line 3 Baystate Health Systems, Inc. Health & Welfare Benefits Plan is affiliated with Baystate Adminstrative Services, Inc. (BAS) which is a 501 (c)(3) organization. Various management and support functions are delegated to BAS. Form 990, Part VI, Section A, Line 8a and 8b: The Trustees of the Baystate Health Systems, Inc. Health and Welfare Benefits Plan meet during certain scheduled Baystate Health, Inc. board meetings. The Baystate Health, Inc. Board of Trustees and its committees including the Audit and Compliance committee contemporaneously document meetings and actions relative to the Trust including annual acceptance of the audited financial statements. 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 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 legal counsel. The entire return was reviewed by a tax expert from an outside accounting firm. Form 990, Part VI, Section B, line 12 Baystate Health Systems, Inc. Health & Welfare Benefits Plan is a VEBA which is an affiliate of Baystate Health, Inc. 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, 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 BH Chief Compliance Officer, the BH Chief Executive Officer, the Chair of the BH Board of Trustees, and the Chair of the Audit & Compliance Committee of BH. 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 13 This VEBA is subject to the written whistleblower policy of Baystate Health, Inc. Form 990, Part VI, Section B, Line 14 This VEBA is subject to the written document retention and destruction policy of Baystate Health, Inc. Form 990, Part VI, Section B, line 15 The Trustees are employees of an affiliate of Baystate Health, Inc., the parent organization of the health care system to which the VEBA belongs. The compensation of the President and CEO and of other key officers and 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 the health system to which the filing organization belongs) and all such deliberations and decisions are documented contemporaneously. Form 990, Part VI, Section C, line 19 The organization makes its conflict of interest policy and financial statements available to the public at www.baystatehealth.org. Baystate Health Inc 759 Chestnut Street Springfield MA 01199 042105941 Healthcare System Parent MA 501 (c ) (3) 7 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 Franklin Medical Center 164 High Street Greenfield MA 01301 042103575 Hospital MA 501 (c ) (3) 3 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 Practices Inc 759 Chestnut Street Springfield MA 01199 042888373 Charitable, Educational and Research Activities MA 501 (c ) (3) 9 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 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 Baystate Administrative Services Inc 759 Chestnut Street Springfield MA 01199 222747685 Administrative services MA 501 (c ) (3) 11c, IIIc 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 Medical Center Auxiliary 759 Chestnut Street Springfield MA 01199 046065279 Supporting organization for Hospital MA 501 (c ) (3) 7 Baystate Health Inc 0 BH Insurance Company Ltd North Church Street Georgetown CJ 980421413 Offshore captive Insurance CJ 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 0 0 0 0 0 1 1 0 0 Health New England Inc O 55882685 cash basis Baystate Administrative Services Inc P 70667685 cash basis