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
2012
Open to Public Inspection
Name of the organization
Senior Health Partners Inc
Employer identification number
13-4103882
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 supported organization?
................
11g(i)
(ii)
A family member of a person described in (i) above?
......................
11g(ii)
(iii)
A 35% controlled entity of a person described in (i) or (ii) above?
................
11g(iii)
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 monetary support
Yes
No
Yes
No
Yes
No
Total
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990EZ.
Cat. No. 11285F
Schedule A (Form 990 or 990-EZ) 2012
Schedule A (Form 990 or 990-EZ) 2012
Page 2
Part II
Support Schedule for Organizations Described in Sections 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) 2008
(b) 2009
(c) 2010
(d) 2011
(e) 2012
(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) 2008
(b) 2009
(c) 2010
(d) 2011
(e) 2012
(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. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)..
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 2012 (line 6, column (f) divided by line 11, column (f))
.........
14
15
Public support percentage for 2011 Schedule A, Part II, line 14
...............
15
16a
33 1/3% support test—2012.
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—2011.
If the organization did not check a 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—2012.
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—2011.
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) 2012
Schedule A (Form 990 or 990-EZ) 2012
Page 3
Part III
Support Schedule for Organizations Described in Section 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) 2008
(b) 2009
(c) 2010
(d) 2011
(e) 2012
(f) Total
1
Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") .
100
0
0
0
0
100
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......
50,460,644
71,062,765
94,674,191
126,666,747
192,092,958
534,957,305
3
Gross receipts from activities that are not an unrelated trade or business under section 513..
0
4
Tax revenues levied for the organization's benefit and either paid to or expended on its behalf...
0
5
The value of services or facilities furnished by a governmental unit to the organization without charge..
0
6
Total. Add lines 1 through 5.
50,460,744
71,062,765
94,674,191
126,666,747
192,092,958
534,957,405
7a
Amounts included on lines 1, 2, and 3 received from disqualified persons...
0
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.
0
c
Add lines 7a and 7b..
0
8
Public support (Subtract line 7c from line 6.)
534,957,405
Section B. Total Support
Calendar year (or fiscal year beginning in)
(a) 2008
(b) 2009
(c) 2010
(d) 2011
(e) 2012
(f) Total
9
Amounts from line 6...
50,460,744
71,062,765
94,674,191
126,666,747
192,092,958
534,957,405
10a
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
496,542
131,215
85,054
18,956
29,451
761,218
b
Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
0
c
Add lines 10a and 10b.
496,542
131,215
85,054
18,956
29,451
761,218
11
Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on.
0
12
Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)
..
351
335
499
23,101
1,006
25,292
13
Total support. (Add lines 9, 10c, 11, and 12.)..
50,957,637
71,194,315
94,759,744
126,708,804
192,123,415
535,743,915
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 2012 (line 8, column (f) divided by line 13, column (f))
.........
15
99.853 %
16
Public support percentage from 2011 Schedule A, Part III, line 15
...............
16
99.663 %
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2012 (line 10c, column (f) divided by line 13, column (f))
......
17
0.142 %
18
Investment income percentage from 2011 Schedule A, Part III, line 17
.............
18
0.330 %
19a
33 1/3% support tests—2012.
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—2011.
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) 2012
Schedule A (Form 990 or 990-EZ) 2012
Page 4
Part IV
Supplemental Information.
Complete this part to provide the explanations required by Part II, line 10; Part II, line 17a or 17b; and 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) 2012
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
2012
Open to Public Inspection
Name of the organization
Senior Health Partners Inc
Employer identification number
13-4103882
Identifier
Return Reference
Explanation
5
FORM 990 PART VI, SECTION B, LINE 11B
SENIOR HEALTH PARTNERS, INC. (SHP) CONTRACTS WITH HF MANAGEMENT SERVICES, LLC (HFMS) TO PROVIDE ALL OF ITS MANAGEMENT AND ADMINISTRATIVE SERVICES. SHP DOES NOT MAINTAIN ITS OWN STAFF OR OFFICE SPACE; THESE ARE PROVIDED BY HFMS. HFMS CHARGES A PERCENT OF PREMIUM ON A PER MEMBER PER MONTH BASIS OR A FLAT FEE PER MEMBER PER MONTH. THE ARRANGEMENT IS APPROVED BY RESOLUTION OF THE BOARD OF DIRECTORS AND THE NY STATE DEPARTMENT OF HEALTH.
6
FORM 990, PART VI, SECTION B, LINE 12C
A CONFLICT OF INTEREST DISCLOSURE STATEMENT IS COMPLETED ANNUALLY BY EACH BOARD MEMBER, OFFICER AND KEY EMPLOYEE. EACH BOARD MEMBER, OFFICER AND KEY EMPLOYEE IS GIVEN A COPY OF THE DISCLOSURE STATEMENT TO COMPLETE ON AN ANNUAL BASIS. A MEMBER WHO DOES NOT COMPLETE THE STATEMENT IS NOT ALLOWED TO ATTEND BOARD MEETINGS AND MAY BE REMOVED FROM THE BOARD. AN OFFICER OR KEY EMPLOYEE WHO DOES NOT COMPLETE THE STATEMENT WILL BE DISCIPLINED, UP TO TERMINATION FROM THE POSITION. ANY DISCLOSURE OF A CONFLICT OR POTENTIAL CONFLICT IS REVIEWED BY THE CHIEF COMPLIANCE OFFICER. CONFLICTS ARE ADDRESSED BY EXAMINING THE RELATIONSHIP OF THE INDIVIDUAL TO THE ORGANIZATION. A REPORT OF ANY CONFLICTS IS PREPARED FOR DISCUSSION WITH AUDIT AND COMPLIANCE COMMITTEE OF THE BOARD OF MANAGERS OF HF MANAGEMENT SERVICES, LLC, A RELATED ORGANIZATION, AS WELL AS THE FULL BOARD OF DIRECTORS OF SENIOR HEALTH PARTNERS, INC. AS APPROPRIATE, ACTION IS TAKEN, INCLUDING BUT NOT LIMITED TO MODIFICATIONS TO BUSINESS AGREEMENTS, CHANGES IN VENDORS OR REPLACEMENT OF THE DIRECTOR, OFFICER OR KEY EMPLOYEE WITH A NON-CONFLICTED INDIVIDUAL.
8
FORM 990, PART VI, SECTION C, LINE 19
THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE GENERAL PUBLIC BY PROVIDING COPIES OF REQUEST FOR INSPECTION AT ITS CORPORATE OFFICERS.
1
Form 990, PART VI, SECTION A, LINE 3
BEGINNING AUGUST 1, 2010, SENIOR HEALTH PARTNERS, INC. CONTRACTS WITH HF MANAGEMENT SERVICES, LLC (HFMS) TO PROVIDE ALL OF ITS MANAGEMENT AND ADMINISTRATIVE SERVICES. SINCE AUGUST 2010, THE NOT-FOR-PROFIT ENTITY DOES NOT MANTAIN ITS OWN STAFF OR OFFICE SPACE, THESE ARE SUPPLIED BY HFMS. HFMS CHARGES A PERCENTAGE ON A PER MEMBER PER MONTH BASIS OR A FLAT FEE PER MEMBER PER MONTH AS MANAGEMENT FEE.
2
Form 990, PART VI, SECTION A, LINE 6
HF MANAGEMENT SERVICES, LLC IS SENIOR HEALTH PARTNERS, INC.'S SOLE CORPORATE MEMBER.
3
Form 990, PART VI, SECTION A, LINE 7A
SENIOR HEALTH PARTNERS, INC. IS A NEW YORK STATE NOT-FOR-PROFIT MEMBERSHIP CORPORATION. SENIOR HEALTH PARTNERS INC'S SOLE CORPORATE MEMBER IS HF MANAGEMENT SERVICES, LLC. HF MANAGEMENT SERVICES, LLC HAS THE RIGHT TO APPOINT MEMBERS TO THE BOARD OF DIRECTORS OF SENIOR HEALTH PARTNERS, INC.
4
FORM 990, PART VI, SECTION A, LINE 7B
THE AMENDMENT OF THE ORGANIZATION'S GOVERNING DOCUMENTS IS SUBJECT TO THE APPROVAL OF HF MANAGEMENT SERVICES, LLC. SOME OF THE DECISIONS OF THE GOVERNING BODY, SHOULD THEY OCCUR, ARE SUBJECT TO APPROVAL BY STATE REGULATORS: * DISTRIBUTION OF THE ORGANIZATION'S NET ASSETS * CERTAIN CHANGES TO PREMIUM RATES * EXPANSION TO OTHER MANAGED CARE BUSINESSES * SPECIFIC TYPES OF CHANGES TO THE ORGANIZATION'S BENEFIT PLANS * MANAGEMENT FEE RATE CHANGES
10
FORM 990 PART XII, LINE 2C
THE SELECTION OF THE INDEPENDENT AUDITOR IS ADMINISTERED BY THE AUDIT AND COMPLIANCE COMMITTEE OF THE BOARD OF DIRECTORS OF HF MANAGEMENT SERVICES, LLC, THE ORGANIZATION'S SOLE CORPORATE MEMBERS.
7
PART 990, PART VI, SECTION C, LINE 15
BECAUSE THE REPORTING ORGANIZATION DID NOT COMPENSATE ANY OFFICER OR EMPLOYEE, THE REPORTING ORGANIZATION HAS RESPONDED "NO." HOWEVER, THE COMPENSATION OF THE CEO, OTHER OFFICERS AND KEY EMPLOYEES IS DETERMINED BY THE COMPENSATION COMMITTEE OF HF MANAGEMENT SERVICES, LLC (A RELATED ORGANIZATION). THE COMMITTEE CONSISTS ONLY OF INDEPENDENT DIRECTORS. THE PROCESS FOR DETERMINING COMPENSATION IS DESCRIBED IN THE COMMITTEES CHARTER. THE PROCESS INCLUDES ENGAGEMENT OF AN OUTSIDE HUMAN RESOURCES CONSULTING FIRM TO CONDUCT A COMPARABILITY ANALYSIS. THE ANALYSIS INCLUDES COMPARABLE RANGES OF EXECUTIVE COMPENSATION USING THE COMPANY'S INDUSTRY CLASSIFICATION. THE COMMITTEE MEETS PRIOR TO IMPLEMENTATION OF ANY CHANGE IN COMPENSATION. CONTEMPORANEOUS MINUTES OF EACH MEETING ARE PREPARED.
11
FORM 990, PART VII, SECTION A
ALL OFFICERS, KEY EMPLOYEES, AND HIGHEST COMPENSATED EMPLOYEES WERE PAID BY, AND WORKED 40 HOURS A WEEK FOR HF MANAGEMENT SERVICES, LLC (A RELATED ORGANIZATION) WHICH PROVIDES MANAGEMENT SERVICES FOR MULTIPLE ENTITIES. NO ALLOCATION OF TIME SPENT ON INDIVIDUAL NOT FOR PROFIT ENTITIES EXISTED FOR THE PERIOD COVERED BY THIS RETURN. NONE OF THE INDIVIDUALS LISTED EARNED ANY COMPENSATION FROM THE NOT-FOR-PROFIT ENTITY.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.