Department of the Treasury Internal Revenue Service
Public Charity Status and Public Support
Complete if the organization is a section 501(c)(3) organization or a section
4947(a)(1) nonexempt charitable trust.
Attach to Form 990 or Form 990-EZ. See separate instructions.
OMB No. 1545-0047
2011
Open to Public Inspection
Name of the organization
UNIVERSITY HEALTH CARE INC D/B/A PASSPORT HEALTH PLAN
Employer identification number
61-1325905
Part I
Reason for Public Charity Status
(All organizations must complete this part.) See instructions
The organization is not a private foundation because it is: (For lines 1 through 11, check only one box.)
1
2
3
4
5
section 170(b)(1)(A)(iv). (Complete Part II.)
6
7
8
9
receipts from activities related to its exempt functions—subject to certain exceptions, and (2) no more than 331/3% of
its support from gross investment income and unrelated business taxable income (less section 511 tax) from businesses
acquired by the organization after June 30, 1975. See section 509(a)(2). (Complete Part III.)
10
11
e
By checking this box, I certify that the organization is not controlled directly or indirectly by one or more disqualified persons other than foundation managers and other than one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2).
f
If the organization received a written determination from the IRS that it is a Type I, Type II or Type III supporting organization, check this box
..................................................
g
Since August 17, 2006, has the organization accepted any gift or contribution from any of the following persons?
(i) a person who directly or indirectly controls, either alone or together with persons described in (ii)
Yes
No
and (iii) below, the governing body of the the supported organization?
................
11g(i)
No
(ii)
a family member of a person described in (i) above?
......................
11g(ii)
No
(iii)
a 35% controlled entity of a person described in (i) or (ii) above?
................
11g(iii)
No
h
Provide the following information about the supported organization(s).
(i) Name of supported organization
(ii) EIN
(iii) Type of organization (described on lines 1- 9 above or IRC section (see instructions))
(iv) Is the organization in col. (i) listed in your governing document?
(v) Did you notify the organization in col. (i) of your support?
(vi) Is the organization in col. (i) organized in the U.S.?
(vii) Amount of support?
Yes
No
Yes
No
Yes
No
Total
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 11285F
Schedule A (Form 990 or 990-EZ) 2011
Schedule A (Form 990 or 990-EZ) 2011
Page 2
Part II
Support Schedule for Organizations Described in IRC 170(b)(1)(A)(iv) and 170(b)(1)(A)(vi) (Complete only if you checked the box on line 5, 7, or 8 of Part I or if the
organization failed to qualify under Part III. If the organization fails to
qualify under the tests listed below, please complete Part III.)
Section A. Public Support
Calendar year(or fiscal year beginning in)
(a) 2007
(b) 2008
(c) 2009
(d) 2010
(e) 2011
(f) Total
1
Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") ....
2
Tax revenues levied for the organization's benefit and either paid to or expended on its behalf.......
3
The value of services or facilities furnished by a governmental unit to the organization without charge..
4
Total. Add lines 1 through 3..
5
The portion of total contributions by each person (other than a governmental unit or publicly supported organization) included
on line 1 that exceeds 2% of the amount shown on line 11, column (f)..
6
Public Support. Subtract line 5 from line 4.
Section B. Total Support
Calendar year(or fiscal year beginning in)
(a) 2007
(b) 2008
(c) 2009
(d) 2010
(e) 2011
(f) Total
7
Amounts from line 4..
8
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
9
Net income from unrelated business activities, whether or not the business is regularly carried on..
10
Other income. (Explain in Part IV.) Do not include gain or loss from the sale of capital assets..
11
Total support (Add lines 7 through 10).
12
Gross receipts from related activities, etc. (See instructions.)
..................
12
13
First Five Years
If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization,
check this box and stop here..........................................
Section C. Computation of Public Support Percentage
14
Public Support Percentage for 2010 (line 6 column (f) divided by line 11 column (f))
.........
14
15
Public Support Percentage for 2009 Schedule A, Part II, line 14
...............
15
16a
33 1/3% support test—2011.
If the organization did not check the box on line 13, and line 14 is 33 1/3% or more, check this box
and stop here. The organization qualifies as a publicly supported organization
......................
b
33 1/3% support test—2010.
If the organization did not check the box on line 13 or 16a, and line 15 is 33 1/3% or more, check this
box and stop here. The organization qualifies as a publicly supported organization
.....................
17a
10%-facts-and-circumstances test—2011.
If the organization did not check a box on line 13, 16a, or 16b and line 14
is 10% or more, and if the organization meets the "facts and circumstances" test, check this box and stop here. Explain
in Part IV how the organization meets the "facts and circumstances" test. The organization qualifies as a publicly supported
organization
..................................................
b
10%-facts-and-circumstances test—2010.
If the organization did not check a box on line 13, 16a, 16b, or 17a and line
15 is 10% or more, and if the organization meets the "facts and circumstances" test, check this box and stop here.
Explain in Part IV how the organization meets the "facts and circumstances" test. The organization qualifies as a publicly supported organization
..............................................
18
Private Foundation
If the organization did not check a box on line 13, 16a, 16b, 17a or 17b, check this box and see
instructions
...................................................
Schedule A (Form 990 or 990-EZ) 2011
Schedule A (Form 990 or 990-EZ) 2011
Page 3
Part III
Support Schedule for Organizations Described in IRC 509(a)(2) (Complete only if you checked the box on line 9 of Part I or if the organization
failed to qualify under Part II. If the organization fails to qualify under
the tests listed below, please complete Part II.)
Section A. Public Support
Calendar year(or fiscal year beginning in)
(a) 2007
(b) 2008
(c) 2009
(d) 2010
(e) 2011
(f) Total
1
Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") .
2
Gross receipts from admissions, merchandise sold or services performed, or facilities furnished in any activity that is related to the organization's tax-exempt purpose......
745,769,830
845,350,565
908,519,074
914,945,061
932,430,945
4,347,015,475
3
Gross receipts from activities that are not an unrelated trade or business under section 513..
4
Tax revenues levied for the organization's benefit and either paid to or expended on its behalf...
5
The value of services or facilities furnished by a governmental unit to the organization without charge..
6
Total. Add lines 1 through 5.
745,769,830
845,350,565
908,519,074
914,945,061
932,430,945
4,347,015,475
7a
Amounts included on lines 1, 2, and 3 received from disqualified persons...
b
Amounts included on lines 2 and 3 received from other than disqualified persons that exceed the greater of $5,000 or 1% of the amount on line 13 for the year.
c
Add lines 7a and 7b..
8
Public Support (Subtract line 7c from line 6.)
4,347,015,475
Section B. Total Support
Calendar year (or fiscal year beginning in)
(a) 2007
(b) 2008
(c) 2009
(d) 2010
(e) 2011
(f) Total
9
Amounts from line 6...
745,769,830
845,350,565
908,519,074
914,945,061
932,430,945
4,347,015,475
10a
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
8,049,864
5,233,241
3,949,528
4,061,543
4,012,877
25,307,053
b
Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
c
Add lines 10a and 10b.
8,049,864
5,233,241
3,949,528
4,061,543
4,012,877
25,307,053
11
Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on.
12
Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)
13
Total support (Add lines 9, 10c, 11 and 12.).
753,819,694
850,583,806
912,468,602
919,006,604
936,443,822
4,372,322,528
14
First Five Years
If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization,
check this box and stop here.............................................
Section C. Computation of Public Support Percentage
15
Public Support Percentage for 2011 (line 8 column (f) divided by line 13 column (f))
.........
15
99.421 %
16
Public support percentage from 2010 Schedule A, Part III, line 15
...............
16
99.327 %
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2011 (line 10c column (f) divided by line 13 column (f))
......
17
0.579 %
18
Investment income percentage from 2010 Schedule A, Part III, line 17
.............
18
0.673 %
19a
33 1/3% support tests—2011.
If the organization did not check the box on line 14, and line 15 is more than 33 1/3% and line 17 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization
..........
b
33 1/3% support tests—2010.
If the organization did not check a box on line 14 or line 19a, and line 16 is more than 33 1/3% and line 18 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization
....
20
Private Foundation
If the organization did not check a box on line 14, 19a or 19b, check this box and see instructions
.....
Schedule A (Form 990 or 990-EZ) 2011
Schedule A (Form 990 or 990-EZ) 2011
Page 4
Part IV
Supplemental Information.
Supplemental Information. Complete this part to provide the explanation required by Part II, line 10; Part II, line 17a or 17b; or Part III, line 12. Also complete this part for any additional information. (See instructions).
Facts And Circumstances Test
Explanation
Schedule A (Form 990 or 990-EZ) 2011
Additional Data
Software ID:
Software Version:
-
TIN:
SCHEDULE O (Form 990 or 990-EZ)
Department of the Treasury Internal Revenue Service
Supplemental Information to Form 990 or 990-EZ
Complete to provide information for responses to specific questions on
Form 990 or to provide any additional information.
Attach to Form 990 or 990-EZ.
OMB No. 1545-0047
2011
Open to Public Inspection
Name of the organization
UNIVERSITY HEALTH CARE INC D/B/A PASSPORT HEALTH PLAN
Employer identification number
61-1325905
Identifier
Return Reference
Explanation
PART VI
LINE 6
ALL MEMBERS HAVE THE SAME VOTING RIGHTS.
FORM 990, PART VI
SECTION C. DISCLOSURE, LINE 19
ANNUAL FINANCIAL STATEMENTS ARE POSTED TO THE ORGANIZATION'S WEBSITE
Form 990
Schedule R
Based on University Health Care's (hereinafter "UHC") interpretation of the Form 990 and Schedule R instructions, UHC believes that non-controlling members of UHC should not be listed on Schedule R. In addition, due to certain super majority provisions contained in UHC's governing documents, UHC believes that there are no "related parties" of UHC.
PART VI, SECTION B
11a AND 11b
11a - A COPY HAS BEEN PROVIDED TO THE FINANCE COMMITTEE PRIOR TO FILING. THE FINAL RETURN WILL BE POSTED ON THE COMPANY'S WEBSITE. 11b - THE TAX RETURN IS REVIEWED AND APPROVED BY THE COMPANY'S CHIEF FINANCIAL OFFICER. PERTINENT DATA IS COMPARED TO AUDITED FINANCIAL STATEMENTS TO ENSURE ACCURACY.
PART VI, SECTION A
7a
ONE ORGANIZATION ELECTS 5 MEMBERS OF THE BOARD. THERE ARE FOUR ORGANIZATIONS THAT EACH ELECT ONE MEMBER OF THE BOARD.
PART VI, SECTION B
12c
University Health Care, Inc. ("UHC") has two conflict of interest policies -- one for its Board members and executives; and one for all other associates. We have two conflict of interest policies to account for the heightened scrutiny we believe we should give to the activities and financial interests of our Board members and executives. We have developed a process for conflict of interest training and for monitoring and enforcing compliance with the conflict of interest policies. We require Board members, executives and all other associates to disclose potential conflict of interest situations on an annual basis. Associates including executives participate in conflict of interest training on an annual basis. The annual training includes having associates and executives disclose any possible conflict of interest situations. The key to our plan is to identify any possible conflict-of-interest situations and then have the VP, Human Resources and VP, Chief Compliance Officer review the disclosures to determine whether any action should be taken. The UHC Board has developed its process for review of conflict of interest disclosures. The Board has formed a Compliance Committee to oversee and direct that UHC conducts a through and prompt investigation of any conflict of interest and that each Board member completes a conflict of interest form annually. Board members are asked to abstain from voting in connection with the conflict of interest while the Compliance Committee decides if a conflict of interest exists.
FORM 990, PAGE 6
PART VI, QUESTIONS 15
UNIVERSITY HEALTH CARE'S ("UHC") BOARD OF DIRECTORS HAS FORMED AN EXECUTIVE COMPENSATION COMMITTEE WHOSE PURPOSE IS TO FULFILL THE BOARD'S OVERSIGHT RESPONSIBILITIES BY (1) EVALUATING AND APPROVING EXECUTIVE COMPENSATION POLICIES AND PLANS OF PASSPORT HEALTH PLAN ("PHP") WITH THE OBJECTIVE OF PROVIDING COMPETITIVE TOTAL COMPENSATION THAT ALIGNS WITH THE BUSINESS GOALS OF PHP, (2) DETERMINING THE COMPENSATION OF THE CHIEF EXECUTIVE OFFICER (CEO) AND EVALUATING AND APPROVING COMPENSATION ALLOCATED TO EACH EXECUTIVE AT THE LEVEL OF ASSISTANT VICE PRESIDENT AND ABOVE, AND (3)PREPARING AND MAKING REPORTS TO THE FULL BOARD AS REQUIRED AND IN ACCORDANCE WITH APPLICABLE RULES AND REGULATIONS. THE SIZE WILL BE DETERMINED ANNUALLY BUT SHALL INCLUDE THE THREE INDEPENDENT MEMBERS. THE COMMITTEE WILL MEET AS OFTEN AS IT DEEMS NECESSARY TO FULFILL THE FUNCTIONS.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.