Form990
Click to see attachment
Department of the Treasury
Internal Revenue Service
Return of Organization Exempt From Income Tax
Under section 501(c), 527, or 4947(a)(1) of the Internal Revenue Code (except black lung benefit trust or private foundation)

MediumBullet The organization may have to use a copy of this return to satisfy state reporting requirements.
OMB No. 1545-0047
2012
Open to Public Inspection
A For the 2012 calendar year, or tax year beginning 01-01-2012 , 2012, and ending 12-31-2012
BCheck if applicable:
CName of organization
Fallon Community Health Plan Inc
 
Doing Business As
 
 
Number and street (or P.O. box if mail is not delivered to street address)
10 Chestnut Street
Suite
Room/suite
City or town, state or country, and ZIP + 4
Worcester, MA01608
D Employer identification number

23-7442369
E Telephone number

G Gross receipts $ 1,325,849,907
F Name and address of principal officer:
W Patrick Hughes
10 Chestnut Street
Worcester,MA01608
I
Tax-exempt status: (   ) LeftBullet (insert no.) or
J
Website:MediumBullet
www.fchp.org
H(a)
Is this a group return for
affiliates?
H(b)
Are all affiliates included?
If "No," attach a list. (see instructions)
H(c)
Group exemption number MediumBullet  
K Form of organization:
 
L Year of formation: 1975
M State of legal domicile: MA
Part I
Summary
Activities & Governance 1 Briefly describe the organization’s mission or most significant activities: FALLON COMMUNITY HEALTH PLAN'S MISSION IS MAKING OUR COMMUNITIES HEALTHY. FCHP IS COMMITTED TO IMPROVING THE HEALTH AND WELLNESS OF OUR COMMUNITIES THROUGH THE DELIVERY OF HIGH QUALITY, AFFORDABLE CARE.
2 Check this box MediumBullet
3 Number of voting members of the governing body (Part VI, line 1a) ........ 3 10
4 Number of independent voting members of the governing body (Part VI, line 1b) ..... 4 8
5 Total number of individuals employed in calendar year 2011 (Part V, line 2a) ...... 5 1,226
6 Total number of volunteers (estimate if necessary) ............. 6 230
7a Total unrelated business revenue from Part VIII, column (C), line 12 ........ 7a 199,545
b Net unrelated business taxable income from Form 990-T, line 34 ......... 7b -157,731
Revenues Prior Year Current Year
8 Contributions and grants (Part VIII, line 1h) ......... 207,375 158,338
9 Program service revenue (Part VIII, line 2g) ......... 1,096,296,327 1,107,509,531
10 Investment income (Part VIII, column (A), lines 3, 4, and 7d ) .... 15,007,340 21,420,607
11 Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e) -7,714,501 -8,281,124
12 Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)................... 1,103,796,541 1,120,807,352
Expenses; 13 Grants and similar amounts paid (Part IX, column (A), lines 1–3 )... 527,958 936,327
14 Benefits paid to or for members (Part IX, column (A), line 4)..... 954,294,586 980,540,818
15 Salaries, other compensation, employee benefits (Part IX, column (A), lines 5–10) 70,950,490 84,771,827
16a Professional fundraising fees (Part IX, column (A), line 11e)..... 0 0
b Total fundraising expenses (Part IX, column (D), line 25) MediumBullet0    
17 Other expenses (Part IX, column (A), lines 11a–11d, 11f–24e).... 39,562,912 39,261,274
18 Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25) 1,065,335,946 1,105,510,246
19 Revenue less expenses. Subtract line 18 from line 12....... 38,460,595 15,297,106
Net Assets or Fund Balances; Beginning of Current Year End of Year
20 Total assets (Part X, line 16)............. 382,846,207 411,842,860
21 Total liabilities (Part X, line 26)............. 214,091,419 212,953,155
22 Net assets or fund balances. Subtract line 21 from line 20..... 168,754,788 198,889,705
Part II
Signature Block
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete. Declaration of preparer (other than officer) is based on all information of which preparer has any knowledge.
Sign Here
JumboBullet
Signature of officer Date
JumboBullet
Type or print name and title
Paid Preparer Use Only
Print/Type preparer's name
 
Preparer's signature
Date
PTIN
Firm's name MediumBullet

Firm's EIN MediumBullet
Firm's address MediumBullet



Phone no.
May the IRS discuss this return with the preparer shown above? (see instructions) ............
For Paperwork Reduction Act Notice, see the separate instructions.
Cat. No. 11282Y
Form 990 (2012)
Form 990 (2012)
Page 2
Part III
Statement of Program Service Accomplishments
Check if Schedule O contains a response to any question in this Part III ...............
1
Briefly describe the organization’s mission: FALLON COMMUNITY HEALTH PLAN'S MISSION IS MAKING OUR COMMUNITIES HEALTHY. FCHP IS COMMITTED TO IMPROVING THE HEALTH AND WELLNESS OF OUR COMMUNITIES THROUGH THE FINANCING AND DELIVERY OF HIGH QUALITY, AFFORDABLE CARE.
2
Did the organization undertake any significant program services during the year which were not listed on
the prior Form 990 or 990-EZ? ......................
If “Yes,” describe these new services on Schedule O.
3
Did the organization cease conducting, or make significant changes in how it conducts, any program services? ............................
If “Yes,” describe these changes on Schedule O.
4
Describe the organization’s program service accomplishments for each of its three largest program services, as measured by expenses. Section 501(c)(3) and 501(c)(4) organizations are required to report the amount of grants and allocations to others, the total expenses, and revenue, if any, for each program service reported.
4a (Code:   ) (Expenses $ 981,574,314 including grants of $ 936,327 ) (Revenue $ 1,107,509,531 )
SEE SCHEDULE O
4b (Code:   ) (Expenses $   including grants of $   ) (Revenue $   )
4c (Code:   ) (Expenses $   including grants of $   ) (Revenue $   )
4d Other program services (Describe in Schedule O.)
(Expenses $   including grants of $   ) (Revenue $   )
4e Total program service expensesMediumBullet981,574,314
Form 990 (2012)
Form 990 (2012)
Page 3
Part IV
Checklist of Required Schedules
Yes
No
1
Is the organization described in section 501(c)(3) or 4947(a)(1) (other than a private foundation)? If “Yes,” complete Schedule AClick to see attachment........................
1
Yes
 
2
Is the organization required to complete Schedule B, Schedule of Contributors (see instructions)? Click to see attachment...
2
Yes
 
3
Did the organization engage in direct or indirect political campaign activities on behalf of or in opposition to candidates for public office? If “Yes,” complete Schedule C, Part IClick to see attachment..........
3
 
No
4
Section 501(c)(3) organizations. Did the organization engage in lobbying activities, or have a section 501(h) election in effect during the tax year? If “Yes,” complete Schedule C, Part IIClick to see attachment........
4
Yes
 
5
Is the organization a section 501(c)(4), 501(c)(5), or 501(c)(6) organization that receives membership dues, assessments, or similar amounts as defined in Revenue Procedure 98-19? If “Yes,” complete Schedule C,
Part IIIClick to see attachment............................
5
 
No
6
Did the organization maintain any donor advised funds or any similar funds or accounts for which donors have the right to provide advice on the distribution or investment of amounts in such funds or accounts? If “Yes,” complete Schedule D, Part IClick to see attachment........................
6
 
No
7
Did the organization receive or hold a conservation easement, including easements to preserve open space,
the environment, historic land areas, or historic structures? If “Yes,” complete Schedule D, Part IIClick to see attachment...
7
 
No
8
Did the organization maintain collections of works of art, historical treasures, or other similar assets? If “Yes,” complete Schedule D, Part III Click to see attachment....................
8
 
No
9
Did the organization report an amount in Part X, line 21 for escrow or custodial account liability; serve as a custodian for amounts not listed in Part X; or provide credit counseling, debt management, credit repair, or debt negotiation services? If “Yes,” complete Schedule D, Part IVClick to see attachment..............
9
 
No
10
Did the organization, directly or through a related organization, hold assets in temporarily restricted endowments, permanent endowments, or quasi-endowments? If “Yes,” complete Schedule D, Part VClick to see attachment......
10
 
No
11
If the organization’s answer to any of the following questions is "Yes," then complete Schedule D, Parts VI, VII, VIII, IX, or X as applicable.
a
Did the organization report an amount for land, buildings, and equipment in Part X, line 10?
If “Yes,” complete Schedule D, Part VI.Click to see attachment...................
11a
Yes
 
b
Did the organization report an amount for investments—other securities in Part X, line 12 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part VIIClick to see attachment.......
11b
 
No
c
Did the organization report an amount for investments—program related in Part X, line 13 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part VIIIClick to see attachment.......
11c
 
No
d
Did the organization report an amount for other assets in Part X, line 15 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part IXClick to see attachment............
11d
 
No
e
Did the organization report an amount for other liabilities in Part X, line 25? If “Yes,” complete Schedule D, Part XClick to see attachment
11e
 
No
f
Did the organization’s separate or consolidated financial statements for the tax year include a footnote that addresses the organization’s liability for uncertain tax positions under FIN 48 (ASC 740)? If “Yes,” complete Schedule D, Part XClick to see attachment.........................
11f
 
No
12a
Did the organization obtain separate, independent audited financial statements for the tax year?
If “Yes,” complete Schedule D, Parts XI and XII Click to see attachment.................
12a
 
No
b
Was the organization included in consolidated, independent audited financial statements for the tax year? If “Yes,” and if the organization answered "No" to line 12a, then completing Schedule D, Parts XI and XII is optional Click to see attachment
12b
Yes
 
13
Is the organization a school described in section 170(b)(1)(A)(ii)? If “Yes,” complete Schedule E....
13
 
No
14a
Did the organization maintain an office, employees, or agents outside of the United States?.....
14a
 
No
b
Did the organization have aggregate revenues or expenses of more than $10,000 from grantmaking, fundraising, business, investment, and program service activities outside the United States, or aggregate foreign investments valued at $100,000 or more? If “Yes,” complete Schedule F, Parts I and IV.........
14b
 
No
15
Did the organization report on Part IX, column (A), line 3, more than $5,000 of grants or assistance to any organization or entity located outside the United States? If “Yes,” complete Schedule F, Parts II and IV
15
 
No
16
Did the organization report on Part IX, column (A), line 3, more than $5,000 of aggregate grants or assistance to individuals located outside the United States? If “Yes,” complete Schedule F, Parts III and IV...
16
 
No
17
Did the organization report a total of more than $15,000 of expenses for professional fundraising services on Part IX, column (A), lines 6 and 11e? If “Yes,” complete Schedule G, Part I (see instructions).... Click to see attachment
17
 
No
18
Did the organization report more than $15,000 total of fundraising event gross income and contributions on Part VIII, lines 1c and 8a? If “Yes,” complete Schedule G, Part II............ Click to see attachment
18
Yes
 
19
Did the organization report more than $15,000 of gross income from gaming activities on Part VIII, line 9a? If “Yes,” complete Schedule G, Part III................... Click to see attachment
19
 
No
20a
Did the organization operate one or more hospital facilities? If “Yes,” complete Schedule H....
20a
 
No
b
If “Yes” to line 20a, did the organization attach a copy of its audited financial statements to this return?
20b
 
 
Form 990 (2012)
Form 990 (2012)
Page 4
Part IV
Checklist of Required Schedules (continued)
21
Did the organization report more than $5,000 of grants and other assistance to any government or organization in the United States on Part IX, column (A), line 1? If “Yes,” complete Schedule I, Parts I and II... Click to see attachment
21
Yes
 
22
Did the organization report more than $5,000 of grants and other assistance to individuals in the United States on Part IX, column (A), line 2? If “Yes,” complete Schedule I, Parts I and III........ Click to see attachment
22
 
No
23
Did the organization answer “Yes” to Part VII, Section A, line 3, 4, or 5 about compensation of the organization’s current and former officers, directors, trustees, key employees, and highest compensated employees? If “Yes,” complete Schedule J....................... Click to see attachment
23
Yes
 
24a
Did the organization have a tax-exempt bond issue with an outstanding principal amount of more than $100,000 as of the last day of the year, that was issued after December 31, 2002? If “Yes,” answer lines 24b through 24d and complete Schedule K. If “No,” go to line 25................
24a
 
No
b
Did the organization invest any proceeds of tax-exempt bonds beyond a temporary period exception?...
24b
 
 
c
Did the organization maintain an escrow account other than a refunding escrow at any time during the year
to defease any tax-exempt bonds?......................
24c
 
 
d
Did the organization act as an “on behalf of” issuer for bonds outstanding at any time during the year?...
24d
 
 
25a
Section 501(c)(3) and 501(c)(4) organizations. Did the organization engage in an excess benefit transaction with a disqualified person during the year? If “Yes,” complete Schedule L, Part I........ Click to see attachment
25a
 
No
b
Is the organization aware that it engaged in an excess benefit transaction with a disqualified person in a prior year, and that the transaction has not been reported on any of the organization’s prior Forms 990 or 990-EZ? If “Yes,” complete Schedule L, Part I................... Click to see attachment
25b
 
No
26
Was a loan to or by a current or former officer, director, trustee, key employee, highest compensated employee, or disqualified person outstanding as of the end of the organization’s tax year? If “Yes,” complete Schedule L,
Part II.......................... Click to see attachment
26
 
No
27
Did the organization provide a grant or other assistance to an officer, director, trustee, key employee, substantial contributor or employee thereof, a grant selection committee member, or to a 35% controlled entity or family member of any of these persons? If “Yes,” complete Schedule L, Part III......... Click to see attachment
27
 
No
28
Was the organization a party to a business transaction with one of the following parties (see Schedule L, Part IV instructions for applicable filing thresholds, conditions, and exceptions):
a
A current or former officer, director, trustee, or key employee? If “Yes,” complete Schedule L, Part IV .......................... Click to see attachment
28a
 
No
b
A family member of a current or former officer, director, trustee, or key employee? If “Yes,”
complete Schedule L, Part IV..................... Click to see attachment
28b
Yes
 
c
An entity of which a current or former officer, director, trustee, or key employee (or a family member thereof) was an officer, director, trustee, or direct or indirect owner? If “Yes,” complete Schedule L, Part IV... Click to see attachment
28c
Yes
 
29
Did the organization receive more than $25,000 in non-cash contributions? If “Yes,” complete Schedule M..
29
 
No
30
Did the organization receive contributions of art, historical treasures, or other similar assets, or qualified conservation contributions? If “Yes,” complete Schedule M.............
30
 
No
31
Did the organization liquidate, terminate, or dissolve and cease operations? If “Yes,” complete Schedule N,
Part I...........................
31
 
No
32
Did the organization sell, exchange, dispose of, or transfer more than 25% of its net assets? If “Yes,” complete Schedule N, Part II......................
32
 
No
33
Did the organization own 100% of an entity disregarded as separate from the organization under Regulations sections 301.7701-2 and 301.7701-3? If “Yes,” complete Schedule R, Part I........ Click to see attachment
33
 
No
34
Was the organization related to any tax-exempt or taxable entity? If “Yes,” complete Schedule R, Part II, III, or IV, and Part V, line 1........................ Click to see attachment
34
Yes
 
35a
Did the organization have a controlled entity within the meaning of section 512(b)(13)?
35a
Yes
 
b
If ‘Yes’ to line 35a, did the organization receive any payment from or engage in any transaction with a controlled entity within the meaning of section 512(b)(13)? If “Yes,” complete Schedule R, Part V, line 2... Click to see attachment
35b
Yes
 
36
Section 501(c)(3) organizations. Did the organization make any transfers to an exempt non-charitable related organization? If “Yes,” complete Schedule R, Part V, line 2............. Click to see attachment
36
 
No
37
Did the organization conduct more than 5% of its activities through an entity that is not a related organization and that is treated as a partnership for federal income tax purposes? If “Yes,” complete Schedule R, Part VIClick to see attachment
37
 
No
38
Did the organization complete Schedule O and provide explanations in Schedule O for Part VI, lines 11b and 19? Note. All Form 990 filers are required to complete Schedule O. ............
38
Yes
 
Form 990 (2012)
Form 990 (2012)
Page 5
Part V
Statements Regarding Other IRS Filings and Tax Compliance
Check if Schedule O contains a response to any question in this Part V ...............
Yes
No
1a
Enter the number reported in Box 3 of Form 1096 Enter -0- if not applicable ..
1a
5,200
b
Enter the number of Forms W-2G included in line 1a. Enter -0- if not applicable .
1b
0
c
Did the organization comply with backup withholding rules for reportable payments to vendors and reportable gaming (gambling) winnings to prize winners? ..................
1c
Yes
 
2a
Enter the number of employees reported on Form W-3, Transmittal of Wage and
Tax Statements, filed for the calendar year ending with or within the year covered by this return ..................
2a
1,226
b
If at least one is reported on line 2a, did the organization file all required federal employment tax returns?
Note. If the sum of lines 1a and 2a is greater than 250, you may be required to e-file (see instructions)
2b
Yes
 
3a
Did the organization have unrelated business gross income of $1,000 or more during the year?...
3a
Yes
 
b
If “Yes,” has it filed a Form 990-T for this year? If “No,” provide an explanation in Schedule O.....
3b
Yes
 
4a
At any time during the calendar year, did the organization have an interest in, or a signature or other authority over, a financial account in a foreign country (such as a bank account, securities account, or other financial account)?..........................
4a
 
No
b
If "Yes," enter the name of the foreign country: MediumBullet
See instructions for filing requirements for Form TD F 90-22.1, Report of Foreign Bank and Financial Accounts.
5a
Was the organization a party to a prohibited tax shelter transaction at any time during the tax year?..
5a
 
No
b
Did any taxable party notify the organization that it was or is a party to a prohibited tax shelter transaction?
5b
 
No
c
If “Yes,” to line 5a or 5b, did the organization file Form 8886-T? ............
5c
 
 
6a
Does the organization have annual gross receipts that are normally greater than $100,000, and did the organization solicit any contributions that were not tax deductible as charitable contributions?...
6a
Yes
 
b
If “Yes,” did the organization include with every solicitation an express statement that such contributions or gifts were not tax deductible?........................
6b
Yes
 
7
Organizations that may receive deductible contributions under section 170(c).
a
Did the organization receive a payment in excess of $75 made partly as a contribution and partly for goods and services provided to the payor?....................
7a
Yes
 
b
If “Yes,” did the organization notify the donor of the value of the goods or services provided?.....
7b
Yes
 
c
Did the organization sell, exchange, or otherwise dispose of tangible personal property for which it was required to file Form 8282?...........................
7c
 
No
d
If “Yes,” indicate the number of Forms 8282 filed during the year ....
7d
 
e
Did the organization receive any funds, directly or indirectly, to pay premiums on a personal benefit contract?............................
7e
 
No
f
Did the organization, during the year, pay premiums, directly or indirectly, on a personal benefit contract?..
7f
 
No
g
If the organization received a contribution of qualified intellectual property, did the organization file Form 8899 as required?............................
7g
 
 
h
If the organization received a contribution of cars, boats, airplanes, or other vehicles, did the organization file a Form 1098-C?..........................
7h
 
 
8
Sponsoring organizations maintaining donor advised funds and section 509(a)(3) supporting organizations. Did the supporting organization, or a donor advised fund maintained by a sponsoring organization, have excess business holdings at any time during the year?............
8
 
 
9
Sponsoring organizations maintaining donor advised funds.
a
Did the organization make any taxable distributions under section 4966?..........
9a
 
 
b
Did the organization make a distribution to a donor, donor advisor, or related person?.......
9b
 
 
10
Section 501(c)(7) organizations. Enter:
a
Initiation fees and capital contributions included on Part VIII, line 12 ...
10a
 
b
Gross receipts, included on Form 990, Part VIII, line 12, for public use of club facilities
10b
 
11
Section 501(c)(12) organizations. Enter:
a
Gross income from members or shareholders .........
11a
 
b
Gross income from other sources (Do not net amounts due or paid to other sources against amounts due or received from them.) ..........
11b
 
12a
Section 4947(a)(1) non-exempt charitable trusts. Is the organization filing Form 990 in lieu of Form 1041?
12a
 
 
b
If “Yes,” enter the amount of tax-exempt interest received or accrued during the year. ....................
12b
 
13
Section 501(c)(29) qualified nonprofit health insurance issuers.
a
Is the organization licensed to issue qualified health plans in more than one state?
Note. See the instructions for additional information the organization must report on Schedule O.
13a
 
 
b
Enter the amount of reserves the organization is required to maintain by the states in which the organization is licensed to issue qualified health plans ....
13b
 
c
Enter the amount of reserves on hand ............
13c
 
14a
Did the organization receive any payments for indoor tanning services during the tax year?.....
14a
 
No
b
If "Yes," has it filed a Form 720 to report these payments? If “No,” provide an explanation in Schedule O..
14b
 
 
Form 990 (2012)
Form 990 (2012)
Page 6
Part VI
Governance, Management, and Disclosure For each “Yes” response to lines 2 through 7b below, and for a “No” response to lines 8a, 8b, or 10b below, describe the circumstances, processes, or changes in Schedule O. See instructions.
Check if Schedule O contains a response to any question in this Part VI ...............
Section A. Governing Body and Management
Yes
No
1a
Enter the number of voting members of the governing body at the end of the tax year .....................
1a
10
If there are material differences in voting rights among members of the governing body, or if the governing body delegated broad authority to an executive committee or similar committee, explain in Schedule O.
b
Enter the number of voting members included in line 1a, above, who are independent ...................
1b
8
2
Did any officer, director, trustee, or key employee have a family relationship or a business relationship with any other officer, director, trustee, or key employee? .................
2
Yes
 
3
Did the organization delegate control over management duties customarily performed by or under the direct supervision of officers, directors or trustees, or key employees to a management company or other person? .
3
 
No
4
Did the organization make any significant changes to its governing documents since the prior Form 990 was filed? ...........................
4
 
No
5
Did the organization become aware during the year of a significant diversion of the organization’s assets? .
5
 
No
6
Did the organization have members or stockholders? ................
6
 
No
7a
Did the organization have members, stockholders, or other persons who had the power to elect or appoint one or more members of the governing body? ....................
7a
 
No
b
Are any governance decisions of the organization reserved to (or subject to approval by) members, stockholders, or persons other than the governing body? ...................
7b
 
No
8
Did the organization contemporaneously document the meetings held or written actions undertaken during the year by the following:
a
The governing body? .........................
8a
Yes
 
b
Each committee with authority to act on behalf of the governing body? ............
8b
Yes
 
9
Is there any officer, director, trustee, or key employee listed in Part VII, Section A, who cannot be reached at the organization’s mailing address? If “Yes,” provide the names and addresses in Schedule O.......
9
 
No
Section B. Policies (This Section B requests information about policies not required by the Internal Revenue Code.)
Yes
No
10a
Did the organization have local chapters, branches, or affiliates? ............
10a
 
No
b
If “Yes,” did the organization have written policies and procedures governing the activities of such chapters, affiliates, and branches to ensure their operations are consistent with the organization's exempt purposes?
10b
 
 
11a
Has the organization provided a complete copy of this Form 990 to all members of its governing body before filing the form? ............................
11a
Yes
 
b
Describe in Schedule O the process, if any, used by the organization to review this Form 990. .....
12a
Did the organization have a written conflict of interest policy? If “No,” go to line 13.......
12a
Yes
 
b
Were officers, directors, or trustees, and key employees required to disclose annually interests that could give rise to conflicts? ..........................
12b
Yes
 
c
Did the organization regularly and consistently monitor and enforce compliance with the policy? If “Yes,” describe in Schedule O how this was done.......................
12c
Yes
 
13
Did the organization have a written whistleblower policy? ...............
13
Yes
 
14
Did the organization have a written document retention and destruction policy? .........
14
Yes
 
15
Did the process for determining compensation of the following persons include a review and approval by independent persons, comparability data, and contemporaneous substantiation of the deliberation and decision?
a
The organization’s CEO, Executive Director, or top management official ...........
15a
Yes
 
b
Other officers or key employees of the organization ................
15b
Yes
 
If "Yes" to line 15a or 15b, describe the process in Schedule O (see instructions).
16a
Did the organization invest in, contribute assets to, or participate in a joint venture or similar arrangement with a taxable entity during the year? ......................
16a
Yes
 
b
If “Yes,” did the organization follow a written policy or procedure requiring the organization to evaluate its participation in joint venture arrangements under applicable federal tax law, and take steps to safeguard the organization’s exempt status with respect to such arrangements? ............
16b
Yes
 
Section C. Disclosure
17
List the States with which a copy of this Form 990 is required to be filedMediumBullet
MA
18
Section 6104 requires an organization to make its Form 1023 (or 1024 if applicable), 990, and 990-T (501(c)(3)s only) available for public inspection. Indicate how you made these available. Check all that apply.
19
Describe in Schedule O whether (and if so, how), the organization made its governing documents, conflict of interest policy, and financial statements available to the public during the tax year.
20
State the name, physical address, and telephone number of the person who possesses the books and records of the organization:
MediumBulletCHANDRAKANT MODHA10 CHESTNUT STREETWORCESTERMA01608 (508) 799-2100
Form 990 (2012)
Form 990 (2012)
Page 7
Part VII
Compensation of Officers, Directors,Trustees, Key Employees, Highest Compensated Employees, and Independent Contractors
Check if Schedule O contains a response to any question in this Part VII ...............
Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees
1a Complete this table for all persons required to be listed. Report compensation for the calendar year ending with or within the organization’s tax year.
RoundBullet List all of the organization’s current officers, directors, trustees (whether individuals or organizations), regardless of amount
of compensation. Enter -0- in columns (D), (E), and (F) if no compensation was paid.

RoundBullet List all of the organization’s current key employees, if any. See instructions for definition of "key employee."
RoundBullet List the organization’s five current highest compensated employees (other than an officer, director, trustee or key employee)
who received reportable compensation (Box 5 of Form W-2 and/or Box 7 of Form 1099-MISC) of more than $100,000 from the
organization and any related organizations.

RoundBullet List all of the organization’s former officers, key employees, or highest compensated employees who received more than $100,000
of reportable compensation from the organization and any related organizations.

RoundBullet List all of the organization’s former directors or trustees that received, in the capacity as a former director or trustee of the
organization, more than $10,000 of reportable compensation from the organization and any related organizations.

List persons in the following order: individual trustees or directors; institutional trustees; officers; key employees; highest
compensated employees; and former such persons.
Check this box if neither the organization nor any related organization compensated any current officer, director, or trustee.
(A)
Name and Title 		(B)
Average hours per week (list any hours for related organizations below dotted line) 		(C)
Position (do not check more than one box, unless person is both an officer and a director/trustee) 		(D)
Reportable compensation from the organization (W- 2/1099-MISC) 		(E)
Reportable compensation from related organizations (W- 2/1099-MISC) 		(F)
Estimated amount of other compensation from the organization and related organizations
Individual Trustee or Director; Institutional Trustee; Officer; Key Employee; Highest compensated employee; Former;
(1) Alan Gayer........................................................................
Director
 4.0
.......................   		X           12,500 0 0
(2) David R Grenon........................................................................
Director
 4.0
.......................   		X           14,000    
(3) David W Hillis........................................................................
Chairman
 10.0
.......................   		X           18,500    
(4) Richard P Houlihan Esq........................................................................
Vice Chairman
 7.0
.......................   		X           13,500    
(5) Christian W McCarthy........................................................................
Treasurer
 7.0
.......................   		X           13,000    
(6) Lynda M Young MD........................................................................
Director
 4.0
.......................   		X           11,500    
(7) W Patrick Hughes........................................................................
President & CEO
 50.0
.......................   		X   X       1,196,483   197,454
(8) FREDERICK MISILO ESQ........................................................................
Director (AS OF 6/2012)
 4.0
.......................   		X           12,500    
(9) Joseph N Stolberg........................................................................
Director (AS OF 6/2012)
 4.0
.......................   		X           12,500    
(10) Ann K Tripp........................................................................
Director (AS OF 11/2012)
 4.0
.......................   		X           1,000    
(11) Christopher F Egan........................................................................
Director (UNTIL 6/2012)
 4.0
.......................   		X           0    
(12) Charles F Monahan JR........................................................................
Clerk (UNTIL 8/2012)
 7.0
.......................   		X           0    
(13) REV JOHN PARIS SJ........................................................................
Director (UNTIL 6/2012)
 4.0
.......................   		X           0    
(14) Richard P Burke........................................................................
President, Sr. Care Svc. & Gov
 50.0
.......................   		    X       402,694   126,461
(15) Elizabeth Malko MD........................................................................
Chief Medical Officer
 50.0
.......................   		    X       418,566   122,926
(16) Christine Osgood........................................................................
Chief Human Resources Officer
 24.0
.......................   		    X       215,803   13,320
(17) R Scott Walker........................................................................
Chief Financial Officer
 50.0
.......................   		    X       388,894   154,318
Form 990 (2012)
Form 990 (2012)
Page 8
Part VII
Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees (continued)
(A)
Name and Title 		(B)
Average hours per week (list any hours for related organizations below dotted line) 		(C)
Position (do not check more than one box, unless person is both an officer and a director/trustee) 		(D)
Reportable compensation from the organization (W- 2/1099-MISC) 		(E)
Reportable compensation from related organizations (W- 2/1099-MISC) 		(F)
Estimated amount of other compensation from the organization and related organizations
Individual Trustee or Director; Institutional Trustee; Officer; Key Employee; Highest compensated employee; Former;
(18) Richard Commander........................................................................
Chief Operating Officer
 50.0
.......................   		    X       358,017   119,758
(19) David Przesiek........................................................................
Sr VP Sales & Marketing
 50.0
.......................   		    X       336,539   135,920
(20) Mary Ritter........................................................................
SR. VP OF STRATEGIC PLANNING
 50.0
.......................   		    X       365,941   38,011
(21) Todd Bailey........................................................................
VP. Senior Care Services
 50.0
.......................   		      X     239,817   85,822
(22) Eric Hall........................................................................
VP Network Development & Mgmt
 50.0
.......................   		      X     265,617   63,980
(23) Karen Longo........................................................................
Exec. Dir, Summit Eldercare
 50.0
.......................   		      X     195,863   72,311
(24) Kevin McGovern........................................................................
VP of Finance & Treasurer
 50.0
.......................   		      X     242,301   78,002
(25) Janis Liepins........................................................................
VP Marketing
 50.0
.......................   		      X     242,610   76,211
(26) Kevin Grozio........................................................................
VP, Underwriting & Actuarial
 50.0
.......................   		      X     251,783   96,925
(27) Elizabeth Helenius........................................................................
VP Medicare Sales&Emerging Mkt
 50.0
.......................   		        X   246,995   44,561
(28) Glenn Randall MD........................................................................
Physician, Summit ElderCare
 50.0
.......................   		        X   274,864   54,557
(29) David Wilner MD........................................................................
VP & Medical Director
 50.0
.......................   		        X   313,635   78,812
(30) Russell Munson........................................................................
Sr. Medical Director
 50.0
.......................   		        X   294,115   86,995
(31) Param Singh........................................................................
Associate Medical Director
 50.0
.......................   		        X   230,988   44,721
1b Sub-Total................MediumBullet
c Total from continuation sheets to Part VII, Section A....MediumBullet
d Total (add lines 1b and 1c)............MediumBullet 6,590,525 0 1,691,065
2
Total number of individuals (including but not limited to those listed above) who received more than $100,000 of reportable compensation from the organizationMediumBullet146
Yes
No
3
Did the organization list any former officer, director or trustee, key employee, or highest compensated employee on line 1a? If “Yes,” complete Schedule J for such individual ..............
3
 
No
4
For any individual listed on line 1a, is the sum of reportable compensation and other compensation from the organization and related organizations greater than $150,000? If “Yes,” complete Schedule J for such individual...........................
4
Yes
 
5
Did any person listed on line 1a receive or accrue compensation from any unrelated organization or individual for services rendered to the organization? If “Yes,” complete Schedule J for such person ........
5
 
No
Section B. Independent Contractors
1
Complete this table for your five highest compensated independent contractors that received more than $100,000 of compensation from the organization. Report compensation for the calendar year ending with or within the organization’s tax year.
(A)
Name and business address 		(B)
Description of services 		(C)
Compensation
Reliant Medical Group, 630 plantation streetWORCESTERMA01608 MEDICAL SERVICES 138,698,639
VHS ACQUISITION SUBSIDIARY, PO BOX 3385BOSTONMA02241 hospital services 123,010,099
UMASS Memorial Med Ctr, PO BOX 415353BOSTONMA02241 HOSPITAL SERVICES 96,467,184
UMASS Memorial Med Group, PO BOX 415348BOSTONMA02241 MEDICAL SERVICES 24,038,056
BEACON HEALTH STRATEGIES LLC, 200 STATE ST SUITE 302HARTFORDMA02109 MENTAL HEALTH SVC. 20,252,358
2
Total number of independent contractors (including but not limited to those listed above) who received more than $100,000 of compensation from the organization MediumBullet572
Form 990 (2012)
Form 990 (2012)
Page 9
Part VIII
Statement of Revenue
Check if Schedule O contains a response to any question in this Part VIII ..............
(A)
Total revenue 		(B)
Related or
exempt
function
revenue 		(C)
Unrelated
business
revenue 		(D)
Revenue
excluded from
tax under sections
512, 513, or 514
Contributions, Gifts, Grants and Other Similar Amounts 1a Federated campaigns..1a  
b Membership dues....1b  
c Fundraising events....1c 158,338
d Related organizations...1d  
e Government grants (contributions)1e  
f All other contributions, gifts, grants, and
similar amounts not included above1f 		 
g Noncash contributions included in lines
1a-1f:$ 		100
h Total. Add lines 1a-1f.......MediumBullet 158,338
Program Service Revenue Business Code
2a PREMIUM 524114 1,107,494,266 1,107,494,266    
b ASO PREMIUM (INOVA) 524292 15,265   15,265  
c
d
e
f All other program service revenue .        
g Total. Add lines 2a–2f........MediumBullet 1,107,509,531
Other Revenue 3 Investment income (including dividends, interest, and other similar amounts).......MediumBullet 9,289,583     9,289,583
4 Income from investment of tax-exempt bond proceeds..MediumBullet 0      
5 Royalties...........MediumBullet 0      
(i) Real (ii) Personal
6a Gross rents    
b Less: rental expenses    
c Rental income or (loss) 0 0
d Net rental income or (loss).......MediumBullet 0      
(i) Securities (ii) Other
7a Gross amount from sales of assets other than inventory 217,117,090  
b Less: cost or other basis and sales expenses 204,986,066  
c Gain or (loss) 12,131,024  
d Net gain or (loss)..........MediumBullet 12,131,024     12,131,024
8a Gross income from fundraising events (not including
$ 158,338
of contributions reported on line 1c). See Part IV, line 18 ..
a 40,562
b Less: direct expenses ...b 56,489
c Net income or (loss) from fundraising events..MediumBullet -15,927   -15,927
9a Gross income from gaming activities.
See Part IV, line 19 ...
a  
b Less: direct expenses ...b  
c Net income or (loss) from gaming activities...MediumBullet 0      
10a Gross sales of inventory, less
returns and allowances .
a  
b Less: cost of goods sold ..b  
c Net income or (loss) from sales of inventory..MediumBullet 0      
Miscellaneous Revenue Business Code
11a SUBSIDIARY LOSS 524114 -8,716,780     -8,716,780
b INOVA CONSULTING & IMPLEMENTATION 561499 97,707   97,707  
c MANAGEMENT FEE, MED.SUPPORT 561000 86,573   86,573  
d All other revenue .... 267,303     267,303
e Total. Add lines 11a–11d ...... MediumBullet -8,265,197
12 Total revenue. See Instructions......MediumBullet 1,120,807,352 1,107,494,266 199,545 12,955,203
Form 990 (2012)
Form 990 (2012)
Page 10
Part IX
Statement of Functional Expenses
Section 501(c)(3) and 501(c)(4) organizations must complete all columns. All other organizations must complete column (A).Check if Schedule O contains a response to any question in this Part IX ...............
Do not include amounts reported on lines 6b,
7b, 8b, 9b, and 10b of Part VIII. 		(A)
Total expenses 		(B)
Program service expenses 		(C)
Management and general expenses 		(D)
Fundraising expenses
1 Grants and other assistance to governments and organizations in the United States. See Part IV, line 21 936,327 936,327
2 Grants and other assistance to individuals in the United States. See Part IV, line 22 0  
3 Grants and other assistance to governments, organizations, and individuals outside the United States. See Part IV, lines 15 and 16 0  
4 Benefits paid to or for members 980,540,818 980,540,818
5 Compensation of current officers, directors, trustees, and key employees .... 6,502,347   6,502,347  
6 Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) .... 0      
7 Other salaries and wages 55,866,386   55,866,386  
8 Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) .... 10,269,971   10,269,971  
9 Other employee benefits ....... 7,318,270   7,318,270  
10 Payroll taxes ........... 4,814,853   4,814,853  
11 Fees for services (non-employees):        
a Management ...... 0      
b Legal ......... 1,100,901   1,100,901  
c Accounting ........... 1,106,688   1,106,688  
d Lobbying ........... 332,472   332,472  
e Professional fundraising services. See Part IV, line 17 0  
f Investment management fees ...... 840,478   840,478  
g Other (If line 11g amount exceeds 10% of line 25, column (A) amount, list line 11g expenses on Schedule O) ........ 2,354,943   2,354,943  
12 Advertising and promotion .... 5,702,980   5,702,980  
13 Office expenses ....... 6,055,006   6,055,006  
14 Information technology ...... 7,632,816   7,632,816  
15 Royalties .. 0      
16 Occupancy ........... 4,885,417   4,885,417  
17 Travel ............ 190,555   190,555  
18 Payments of travel or entertainment expenses for any federal, state, or local public officials ...... 0      
19 Conferences, conventions, and meetings .... 338,289   338,289  
20 Interest ........... 61,804   61,804  
21 Payments to affiliates ....... 0      
22 Depreciation, depletion, and amortization ..... 6,983,659   6,983,659  
23 Insurance .............. 586,240   586,240  
24 Other expenses. Itemize expenses not covered above (List miscellaneous expenses in line 24e. If line 24e amount exceeds 10% of line 25, column (A) amount, list line 24e expenses on Schedule O.)
a DUES & SUBSCRIPTIONS 693,052   693,052  
b INOVA ASO EXPENSE 42,858 42,858    
c INOVA CONSULTG.& IMPLEMENT. 232,174   232,174  
d MANAGEMENT FEE, MED SUPPORT 82,244   82,244  
e All other expenses 38,698 54,311 -15,613  
25 Total functional expenses. Add lines 1 through 24e 1,105,510,246 981,574,314 123,935,932 0
26 Joint costs. Complete this line only if the organization reported in column (B) joint costs from a combined educational campaign and fundraising solicitation. Check here MediumBullet if following SOP 98-2 (ASC 958-720).        
Form 990 (2012)
Form 990 (2012)
Page 11
Part X Balance Sheet Check if Schedule O contains a response to any question in this Part X ...............
(A)
Beginning of year 		(B)
End of year
Assets 1 Cash—non-interest-bearing ............. 0 1 0
2 Savings and temporary cash investments ......... 8,526,144 2 9,185,041
3 Pledges and grants receivable, net ........... 0 3 0
4 Accounts receivable, net ............. 26,253,547 4 25,948,210
5 Loans and other receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of
Schedule L ..................
0 5 0
6 Loans and other receivables from other disqualified persons (as defined under section 4958(f)(1)), persons described in section 4958(c)(3)(B), and contributing employers and sponsoring organizations of section 501(c)(9) voluntary employees' beneficiary organizations (see instructions) Complete Part II of Schedule L
0 6 0
7 Notes and loans receivable, net ............. 0 7 0
8 Inventories for sale or use .............. 0 8 0
9 Prepaid expenses and deferred charges .......... 2,336,991 9 1,609,891
10a Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D 10a 66,125,531
b Less: accumulated depreciation ..... 10b 30,440,183 33,160,437 10c 35,685,348
11 Investments—publicly traded securities .......... 304,254,690 11 328,294,778
12 Investments—other securities. See Part IV, line 11 ..... 1,383,672 12 0
13 Investments—program-related. See Part IV, line 11 ..... 0 13 0
14 Intangible assets ............... 0 14 0
15 Other assets. See Part IV, line 11 ........... 6,930,726 15 11,119,592
16 Total assets. Add lines 1 through 15 (must equal line 34)...... 382,846,207 16 411,842,860
Liabilities 17 Accounts payable and accrued expenses ......... 198,921,288 17 204,940,716
18 Grants payable ................. 0 18 0
19 Deferred revenue ................ 15,170,131 19 8,012,439
20 Tax-exempt bond liabilities ............. 0 20 0
21 Escrow or custodial account liability. Complete Part IV of Schedule D.. 0 21 0
22 Loans and other payables to current and former officers, directors, trustees, key employees, highest compensated employees, and disqualified
persons. Complete Part II of Schedule L.......... 0 22 0
23 Secured mortgages and notes payable to unrelated third parties .. 0 23 0
24 Unsecured notes and loans payable to unrelated third parties .... 0 24 0
25 Other liabilities (including federal income tax, payables to related third parties, and other liabilities not included on lines 17-24). Complete Part X of Schedule D.................... 0 25 0
26 Total liabilities. Add lines 17 through 25......... 214,091,419 26 212,953,155
Net Assets or Fund Balance Organizations that follow SFAS 117 (ASC 958), check here MediumBullet and complete lines 27 through 29, and lines 33 and 34.
27 Unrestricted net assets .............. 168,754,788 27 198,889,705
28 Temporarily restricted net assets ........... 0 28 0
29 Permanently restricted net assets ........... 0 29 0
Organizations that do not follow SFAS 117 (ASC 958), check here MediumBullet and complete lines 30 through 34.
30 Capital stock or trust principal, or current funds ........   30  
31 Paid-in or capital surplus, or land, building or equipment fund .....   31  
32 Retained earnings, endowment, accumulated income, or other funds   32  
33 Total net assets or fund balances ........... 168,754,788 33 198,889,705
34 Total liabilities and net assets/fund balances ........ 382,846,207 34 411,842,860
Form 990 (2012)
Form 990 (2012)
Page 12
Part XI
Reconcilliation of Net Assets
Check if Schedule O contains a response to any question in this Part XI ...............
1
Total revenue (must equal Part VIII, column (A), line 12) ............
1
1,120,807,352
2
Total expenses (must equal Part IX, column (A), line 25) ............
2
1,105,510,246
3
Revenue less expenses. Subtract line 2 from line 1 ..............
3
15,297,106
4
Net assets or fund balances at beginning of year (must equal Part X, line 33, column (A)) ..
4
168,754,788
5
Net unrealized gains (losses) on investments ...............
5
8,981,282
6
Donated services and use of facilities .................
6
 
7
Investment expenses .....................
7
 
8
Prior period adjustments .....................
8
 
9
Other changes in net assets or fund balances (explain in Schedule O) ........
9
5,856,529
10
Net assets or fund balances at end of year. Combine lines 3 through 9 (must equal Part X, line 33, column (B))
10
198,889,705
Part XII
Financial Statements and Reporting
Check if Schedule O contains a response to any question in this Part XII ..............
Yes
No
1
Accounting method used to prepare the Form 990:  
If the organization changed its method of accounting from a prior year or checked "Other," explain in
Schedule O.
2a
Were the organization’s financial statements compiled or reviewed by an independent accountant?
2a
 
No
If ‘Yes,’ check a box below to indicate whether the financial statements for the year were compiled or reviewed on a separate basis, consolidated basis, or both:
b
Were the organization’s financial statements audited by an independent accountant?
2b
Yes
 
If ‘Yes,’ check a box below to indicate whether the financial statements for the year were audited on a separate basis, consolidated basis, or both:
c
If “Yes,” to line 2a or 2b, does the organization have a committee that assumes responsibility for oversight of the audit, review, or compilation of its financial statements and selection of an independent accountant?
2c
Yes
 
If the organization changed either its oversight process or selection process during the tax year, explain in Schedule O.
3a
As a result of a federal award, was the organization required to undergo an audit or audits as set forth in the Single Audit Act and OMB Circular A-133?
3a
 
No
b
If “Yes,” did the organization undergo the required audit or audits? If the organization did not undergo the required audit or audits, explain why in Schedule O and describe any steps taken to undergo such audits
3b
 
 
Form 990 (2012)
Form 990, Special Condition Description:
Special Condition Description
Additional Data


Software ID:  
Software Version:  
SCHEDULE A
(Form 990 or 990EZ)

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.
right arrow Attach to Form 990 or Form 990-EZ. right arrow See separate instructions.
OMB No. 1545-0047
2012
Open to Public
Inspection
Name of the organization
Fallon Community Health Plan Inc
 
Employer identification number

23-7442369
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
f
g
(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) right arrow (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) right arrow (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
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........................................right arrow
Section C. Computation of Public Support Percentage
14
14
 
15
15
 
16a
b
17a
b
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 ..................................................... right arrow
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) right arrow (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.") . 187,555 199,123 181,640 207,375 158,338 934,031
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...... 980,912,291 1,059,414,644 1,090,378,600 1,096,296,327 1,107,494,266 5,334,496,128
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. 981,099,846 1,059,613,767 1,090,560,240 1,096,503,702 1,107,652,604 5,335,430,159
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.)           5,335,430,159
Section B. Total Support
Calendar year (or fiscal year beginning in) right arrow (a) 2008 (b) 2009 (c) 2010 (d) 2011 (e) 2012 (f) Total
9 Amounts from line 6... 981,099,846 1,059,613,767 1,090,560,240 1,096,503,702 1,107,652,604 5,335,430,159
10a Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources.. 13,282,385 10,709,853 10,161,702 11,179,115 9,289,583 54,622,638
b Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975. 12,292 14,235 7,806     34,333
c Add lines 10a and 10b. 13,294,677 10,724,088 10,169,508 11,179,115 9,289,583 54,656,971
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.) ..           0
13 Total support. (Add lines 9, 10c, 11, and 12.).. 994,394,523 1,070,337,855 1,100,729,748 1,107,682,817 1,116,942,187 5,390,087,130
14
Section C. Computation of Public Support Percentage
15
15
98.986 %
16
16
98.890 %
Section D. Computation of Investment Income Percentage
17
17
1.014 %
18
18
1.110 %
19a
b
20
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
FORM 990, SCHEDULE A, PART III THE ORGANIZATION'S IRS DETERMINATION LETTER INDICATES THAT THIS ORGANIZATION QUALIFIES AS A PUBLICLY SUPPORTED CHARITY UNDER SECTION 170(B)(1)(a)(vi); HOWEVER, THE ORGANIZATION QUALIFIES AS A 509(A)(2) ORGANIZATION. SCHEDULE A HAS BEEN COMPLETED IN ACCORDANCE WITH THE FORM INSTRUCTIONS UNDER THE 509(A)(2) TEST.
 
 
 
Schedule A (Form 990 or 990-EZ) 2012

Additional Data


Software ID:  
Software Version:  
Schedule B
(Form 990, 990-EZ,
or 990-PF)
Department of the Treasury
Internal Revenue Service
Schedule of Contributors
Arrow Bullet Attach to Form 990, 990-EZ, or 990-PF.
OMB No. 1545-0047
2012
Name of the organization
Fallon Community Health Plan Inc
 
Employer identification number

23-7442369
Organization type (check one):
Filers of:
Section:
Form 990 or 990-EZ





Form 990-PF




Check if your organization is covered by the General Rule or a Special Rule.  
Note. Only a section 501(c)(7), (8), or (10) organization can check boxes for both the General Rule and a Special Rule. See instructions.
General Rule
Special Rules
......................... Arrow Bullet   $    
Caution. An organization that is not covered by the General Rule and/or the Special Rules does not file Schedule B (Form 990,
990-EZ, or 990-PF), but it must answer “No” on Part IV, line 2 of its Form 990; or check the box on line H of its
Form 990-EZ or on Part I, line 2 of its Form 990-PF, to certify that it does not meet the filing requirements of Schedule B (Form 990,
990-EZ, or 990-PF).
For Paperwork Reduction Act Notice, see the Instructions
for Form 990, 990-EZ, or 990-PF.
Cat. No. 30613XSchedule B (Form 990, 990-EZ, or 990-PF) (2012)

Schedule B (Form 990, 990-EZ, or 990-PF) (2012)
Page 2
Name of organization
Fallon Community Health Plan Inc
  		Employer identification number

23-7442369
Part I
Contributors (see instructions). Use duplicate copies of Part I if additional space is needed.
     
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
RESTRICTED
RESTRICTED
 

     
RESTRICTED
RESTRICTED  
RESTRICTED, RESTRICTED   RESTRICTED

$RESTRICTED


(Complete Part II if there is a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  


(Complete Part II if there is a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  


(Complete Part II if there is a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  


(Complete Part II if there is a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  


(Complete Part II if there is a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  


(Complete Part II if there is a noncash contribution.)
Schedule B (Form 990, 990-EZ, or 990-PF) (2012)

Schedule B (Form 990, 990-EZ, or 990-PF) (2012)
Page 3
Name of organization
Fallon Community Health Plan Inc
  		Employer identification number

23-7442369
Part II
Noncash Property (see instructions). Use duplicate copies of Part II if additional space is needed.
     
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
Schedule B (Form 990, 990-EZ, or 990-PF) (2012)

Schedule B (Form 990, 990-EZ, or 990-PF) (2012)
Page 4
Name of organization
Fallon Community Health Plan Inc
  		Employer identification number

23-7442369
Part III
Exclusively religious, charitable, etc., individual contributions to section 501(c)(7), (8), or (10) organizations
that total more than $1,000 for the year. Complete columns (a) through (e) and the following line entry.
For organizations completing Part III, enter the total of exclusively religious, charitable, etc.,
contributions of $1,000 or less for the year. (Enter this information once. See instructions.) Arrow Bullet$  
Use duplicate copies of Part III if additional space is needed.
(a) No.
from
Part I		 (b) Purpose of gift (c) Use of gift (d) Description of how gift is held
 
(e) Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
       
 
(a) No.
from
Part I		 (b) Purpose of gift (c) Use of gift (d) Description of how gift is held
 
(e) Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
       
 
(a) No.
from
Part I		 (b) Purpose of gift (c) Use of gift (d) Description of how gift is held
 
(e) Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
       
 
(a) No.
from
Part I		 (b) Purpose of gift (c) Use of gift (d) Description of how gift is held
 
(e) Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
       
 
Schedule B (Form 990, 990-EZ, or 990-PF) (2012)

Additional Data


Software ID:  
Software Version:  
SCHEDULE C
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service
Political Campaign and Lobbying Activities

For Organizations Exempt From Income Tax Under section 501(c) and section 527
SchCMd Bullet Complete if the organization is described below.SchCMd Bullet Attach to Form 990 or Form 990-EZ.
SchCMd Bullet See separate instructions.
OMB No. 1545-0047
2012
Open to Public
Inspection
If the organization answered “Yes” to Form 990, Part IV, Line 3, or Form 990-EZ, Part V, line 46 (Political Campaign Activities), then
Round Bullet Section 501(c)(3) organizations: Complete Parts I-A and B. Do not complete Part I-C.
Round Bullet Section 501(c) (other than section 501(c)(3)) organizations: Complete Parts I-A and C below. Do not complete Part I-B.
Round Bullet Section 527 organizations: Complete Part I-A only.
If the organization answered “Yes” to Form 990, Part IV, Line 4, or Form 990-EZ, Part VI, line 47 (Lobbying Activities), then
Round Bullet Section 501(c)(3) organizations that have filed Form 5768 (election under section 501(h)): Complete Part II-A. Do not complete Part II-B.
Round Bullet Section 501(c)(3) organizations that have NOT filed Form 5768 (election under section 501(h)): Complete Part II-B. Do not complete Part II-A.
If the organization answered “Yes” to Form 990, Part IV, Line 5 (Proxy Tax) or Form 990-EZ, Part V, line 35c (Proxy Tax), then
Round Bullet Section 501(c)(4), (5), or (6) organizations: Complete Part III.
Name of the organization
Fallon Community Health Plan Inc
 
Employer identification number

23-7442369
Part I-A
Complete if the organization is exempt under section 501(c) or is a section 527 organization.

1
Provide a description of the organization’s direct and indirect political campaign activities in Part IV.
2
Political expenditures ....................................SchCMd Bullet
$  
3
Volunteer hours ........................................
 

Part I-B
Complete if the organization is exempt under section 501(c)(3).
1
Enter the amount of any excise tax incurred by the organization under section 4955 .........SchCMd Bullet
$  
2
Enter the amount of any excise tax incurred by organization managers under section 4955 ......SchCMd Bullet
$  
3
If the organization incurred a section 4955 tax, did it file Form 4720 for this year? ..............
4a
Was a correction made? .........................................
b
If "Yes," describe in Part IV.
Part I-C
Complete if the organization is exempt under section 501(c), except section 501(c)(3).
1
Enter the amount directly expended by the filing organization for section 527 exempt function activities SchCMd Bullet
$  
2
Enter the amount of the filing organization's funds contributed to other organizations for section 527 exempt function activities ...................................SchCMd Bullet

$  
3
Total exempt function expenditures. Add lines 1 and 2. Enter here and on Form 1120-POL, line 17b..SchCMd Bullet

$  
4
Did the filing organization file Form 1120-POL for this year? ..........................
5
Enter the names, addresses and employer identification number (EIN) of all section 527 political organizations to which the filing
organization made payments. For each organization listed, enter the amount paid from the filing organization’s funds. Also enter the amount of political contributions received that were promptly and directly delivered to a separate political organization, such as a separate segregated fund or a political action committee (PAC). If additional space is needed, provide information in Part IV.
(a) Name (b) Address (c) EIN (d) Amount paid from filing organization's funds. If none, enter -0-. (e) Amount of political contributions received and promptly and directly delivered to a separate political organization. If none, enter -0-.










For Paperwork Reduction Act Notice, see the instructions for Form 990 or 990-EZ.
Cat. No. 50084S
Schedule C (Form 990 or 990-EZ) 2012

Schedule C (Form 990 or 990-EZ) 2012
Page 2
Part II-A
Complete if the organization is exempt under section 501(c)(3) and filed Form 5768 (election under section 501(h)).
A Check SchCMd Bulletexpenses, and share of excess lobbying expenditures).
B Check SchCMd Bullet
Limits on Lobbying Expenditures
(The term "expenditures" means amounts paid or incurred.) 		(a) Filing
organization's
totals 		(b) Affiliated group
totals
1a Total lobbying expenditures to influence public opinion (grass roots lobbying) ......    
b Total lobbying expenditures to influence a legislative body (direct lobbying) .......    
c Total lobbying expenditures (add lines 1a and 1b) ...................    
d Other exempt purpose expenditures ........................    
e Total exempt purpose expenditures (add lines 1c and 1d) ...............    
f Lobbying nontaxable amount. Enter the amount from the following table in both
columns.		    
  If the amount on line 1e, column (a) or (b) is:The lobbying nontaxable amount is:    
  Not over $500,00020% of the amount on line 1e.    
  Over $500,000 but not over $1,000,000$100,000 plus 15% of the excess over $500,000.    
  Over $1,000,000 but not over $1,500,000$175,000 plus 10% of the excess over $1,000,000.    
  Over $1,500,000 but not over $17,000,000$225,000 plus 5% of the excess over $1,500,000.    
  Over $17,000,000$1,000,000.    
       
g Grassroots nontaxable amount (enter 25% of line 1f) .................    
h Subtract line 1g from line 1a. If zero or less, enter -0-. ................    
i Subtract line 1f from line 1c. If zero or less, enter -0-. ................    
j If there is an amount other than zero on either line 1h or line 1i, did the organization file Form 4720 reporting
section 4911 tax for this year? ......................................

4-Year Averaging Period Under Section 501(h)
(Some organizations that made a section 501(h) election do not have to complete all of the five
columns below. See the instructions for lines 2a through 2f on page 4.)
Lobbying Expenditures During 4-Year Averaging Period
  Calendar year (or fiscal year
beginning in) 		(a) 2009 (b) 2010 (c) 2011 (d) 2012 (e) Total
             
2a Lobbying nontaxable amount          
             
b Lobbying ceiling amount
(150% of line 2a, column(e)) 		         
             
c Total lobbying expenditures          
             
d Grassroots nontaxable amount          
             
e Grassroots ceiling amount
(150% of line 2d, column (e))		          
             
f Grassroots lobbying expenditures          
Schedule C (Form 990 or 990-EZ) 2012


Schedule C (Form 990 or 990-EZ) 2012
Page 3
Part II-B
Complete if the organization is exempt under section 501(c)(3) and has NOT filed Form 5768 (election under section 501(h)).
For each “Yes” response to lines 1a through 1i below, provide in Part IV a detailed description of the lobbying activity.
(a)
No
Yes
(b)
Amount
1
During the year, did the filing organization attempt to influence foreign, national, state or local legislation, including any attempt to influence public opinion on a legislative matter or referendum, through the use of:
a
Volunteers? .........................................
 
No
b
Paid staff or management (include compensation in expenses reported on lines 1c through 1i)? ....
 
No
c
Media advertisements? ....................................
 
No
 
d
Mailings to members, legislators, or the public? .........................
 
No
 
e
Publications, or published or broadcast statements? .......................
 
No
 
f
Grants to other organizations for lobbying purposes? .......................
 
No
 
g
Direct contact with legislators, their staffs, government officials, or a legislative body? ........
Yes
 
332,472
h
Rallies, demonstrations, seminars, conventions, speeches, lectures, or any similar means? ......
 
No
 
i
Other activities? ..........................
 
No
 
j
Total. Add lines 1c through 1i ...............................
332,472
2a
Did the activities in line 1 cause the organization to be not described in section 501(c)(3)? .....
 
No
b
If "Yes," enter the amount of any tax incurred under section 4912 .................
 
c
If "Yes," enter the amount of any tax incurred by organization managers under section 4912 .....
 
d
If the filing organization incurred a section 4912 tax, did it file Form 4720 for this year? .......
 
No
Part III-A
Complete if the organization is exempt under section 501(c)(4), section 501(c)(5), or section 501(c)(6).
Yes
No
1
Were substantially all (90% or more) dues received nondeductible by members? ................
1
 
 
2
Did the organization make only in-house lobbying expenditures of $2,000 or less? ................
2
 
 
3
Did the organization agree to carry over lobbying and political expenditures from the prior year? ..........
3
 
 
Part III-B
Complete if the organization is exempt under section 501(c)(4), section 501(c)(5), or section 501(c)(6) and if either (a) BOTH Part III-A, lines 1 and 2, are answered “No” OR (b) Part III-A, line 3, is answered “Yes."
1
Dues, assessments and similar amounts from members .....................
1
 
2
Section 162(e) nondeductible lobbying and political expenditures (do not include amounts of political
expenses for which the section 527(f) tax was paid).
a
Current year .........................................
2a
 
b
Carryover from last year ....................................
2b
 
c
Total ............................................
2c
 
3
Aggregate amount reported in section 6033(e)(1)(A) notices of nondeductible section 162(e) dues .
3
 
4
If notices were sent and the amount on line 2c exceeds the amount on line 3, what portion of the excess does the organization agree to carryover to the reasonable estimate of nondeductible lobbying and political expenditure next year? ................................
4
 
5
Taxable amount of lobbying and political expenditures (see instructions) ..............
5
 
Part IV
Supplemental Information
Complete this part to provide the descriptions required for Part l-A, line 1; Part l-B, line 4; Part l-C, line 5; Part II-A (affiliated group list); Part II-A, line 2; and Part ll-B, line 1. Also, complete this part for any additional information.
Identifier Return Reference Explanation
Direct Lobbying Expense Form 990, Schedule C, Part IV Supplemental Information fchp paid a total of $332,472 lobbying expenses as follows: MAHP DUES (MASS ASSOC OF HEALTH PLANS) $89,227 SPILLANE & SPILLANE, LLP $48,000 AHIP DUES (AMERICA'S HEALTH INS. PLANS) $36,800 ALLIANCE OF COMMUNITY HEALTH PLANS DUES $41,668 NATIONAL PACE ASSOCIATION $7,520 ---------- SUBTOTAL NON-EMPLOYEES $223,215 EMPLOYEES: RICHARD P. BURKE $3,272 CHRISTIENNE BIK $71,250 W. PATRICK HUGHES $12,728 PATRICK JAMES FARRELL $20,220 MISC. LOBBYING RELATED REIMBURSEMENTS $1,787 -------- SUBTOTAL EMPLOYEES $109,257 -------- TOTAL OF ALL LOBBYING EXPENSES PAID $332,472 --------- KEY LEGISLATIVE AND REGULATORY ISSUES IN 2012: AMERICA'S HEALTH INSURANCE PLANS (AHIP) AND ALLIANCE OF COMMUNITY HEALTH PLANS (ACHP) - LEGISLATIVE ACTIVITY IN THE HOUSE AND THE SENATE AFTER THE ENACTMENT OF THE AFFORDABLE CARE ACT (ACA) IN MARCH 2010. - REGULATORY ACTIVITY ADDRESSING IMPLEMENTATION OF NUMEROUS ACA PROVISIONS, INCLUDING INSURANCE MARKET REFORMS, MEDICAL LOSS RATIO REQUIREMENTS, PREMIUM REVIEW, HEALTH INSURANCE EXCHANGES, DELIVERY SYSTEM REFORMS, ADMINISTRATIVE SIMPLIFICATION, HEALTH INFORMATION TECHNOLOGY, ACCOUNTABLE CARE ORGANIZATIONS (ACOS), AND THE COMMUNITY LIVING ASSISTANCE SERVICES AND SUPPORTS (CLASS) PROGRAM. - PUBLIC PROGRAM ISSUES AFFECTING MEDICARE ADVANTAGE, MEDICARE PART D, MEDICAID, AND THE CHILDREN'S HEALTH INSURANCE PROGRAM (CHIP). - PRODUCT-SPECIFIC ISSUES AFFECTING MEDIGAP/SUPPLEMENTAL POLICIES, LONG-TERM CARE INSURANCE, AND DISABILITY INCOME INSURANCE. - HEALTH ISSUES OUTSIDE OF THE HEALTH REFORM DEBATE INCLUDING ANTITRUST LEGISLATION, COBRA CONTINUATION COVERAGE, DATA SECURITY, MEDICAL LIABILITY REFORM, MEDICARE PHYSICIAN PAYMENT, AND THE ANNUAL APPROPRIATIONS PROCESS. SPILLANE & SPILLANE, LLP AND MASSACHUSETTS ASSOCIATION OF HEALTH PLANS (MAHP) - ANY NEW POLICIES IMPLEMENTED BY DIVISION OF INSURANCE THAT AFFECT FCHP - OTHER REGULATORY HEARINGS AND LEGISLATIVE MEETINGS THAT AFFECT HEALTHCARE POLICIES AND GUIDELINES - LEGISLATIVE MEETINGS AND INTERNAL MEETINGS ON NEW LEGISLATION THAT WILL REFORM HEALTH CARE PAYMENTS AND QUALITY - MEETINGS WITH MASSHEALTH AND MEDICAID OFFICIALS ON INCREASING MEMBERSHIP, CHANGING PAYMENT MODELS, AND BETTER MANAGING OF MEMBERS. DURING 2012, FCHP WORKED WITH THESE REGULATORY AGENCIES: DEPARTMENT OF PUBLIC HEALTH - EARLY INTERVENTION PROGRAM - INSURANCE COORDINATORS MEETINGS - UNIVERSAL NEWBORN HEARING SCREENING PROGRAM ADVISORY COMMITTEE - CHANGES TO HOSPITAL GUIDELINES - OFFICE OF PATIENT PROTECTION - OPEN ENROLLMENT WAIVER REGULATIONS DIVISION OF HEALTH CARE FINANCE AND POLICY - COST TRENDS - TOTAL MEDICAL EXPENSES & RELATIVE PRICES TECHNICAL ADVISORY GROUP MEETINGS, CONSULTATIVE SESSIONS & REGULATIONS - HEALTH SAFETY NET SURCHARGE PAYMENTS & FUNDING REGULATIONS - HEALTH SAFETY NET ELIGIBLE SERVICES REGULATIONS - PEDIATRIC ASSESSMENT REGULATIONS - FY12 VACCINE ASSESSMENT - HOSPITAL FINANCIAL REPORTS - TECHNICAL ADVISORY GROUP MEETINGS, - CONSULTATIVE SESSIONS & REGULATIONS DIVISION OF INSURANCE SPECIAL SESSIONS AND OTHER - GROUP PURCHASING COOPERATIVES - MEDICAL LOSS RATIO - SESSIONS AND REGULATIONS - FINANCIAL REPORTING - LIMITED & TIERED NETWORKS - OPEN ENROLLMENT - PLAN TERMINATION - RATING FACTORS - PROVIDER DIRECTORIES - PROVIDER CONTRACTING - SMALL GROUP RATE REVIEWS - CREDENTIALING - ONE-TIME SUPPLEMENTAL FUNDING PAYMENTS - TRANSPARENCY INFORMATIONAL HEARING - ADMINISTRATIVE SIMPLIFICATION PROVISIONS IN CHAPTER 288 (LEGISLATIVE AND REGULATORY ISSUE) - CODING COMMISSION EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES - PATIENT CENTERED MEDICAL HOME PILOT INITIATIVE - WORKED WITH MASSHEALTH ON DEVELOPING PRIMARY CARE PAYMENT REFORM ATTORNEY GENERAL'S OFFICE - DISCUSSIONS WITH THE AG'S OFFICE ON RECOMMENDATIONS TO ADDRESS NON-PROFIT BOARD COMPENSATION
Schedule C (Form 990 or 990EZ) 2012

Additional Data


Software ID:  
Software Version:  

SCHEDULE D
(Form 990)
Department of the Treasury
Internal Revenue Service
Supplemental Financial Statements
SchDMd Bullet Complete if the organization answered "Yes," to Form 990,
Part IV, line 6, 7, 8, 9, 10, 11a, 11b, 11c, 11d, 11e, 11f, 12a, or 12b
SchDMd Bullet Attach to Form 990. SchDMd Bullet See separate instructions.
OMB No. 1545-0047
2012
Open to Public Inspection
Name of the organization
Fallon Community Health Plan Inc
 
Employer identification number

23-7442369
Part I
Organizations Maintaining Donor Advised Funds or Other Similar Funds or Accounts. Complete if the organization answered "Yes" to Form 990, Part IV, line 6.
(a) Donor advised funds (b) Funds and other accounts
1 Total number at end of year .........    
2 Aggregate contributions to (during year) ...    
3 Aggregate grants from (during year) .....    
4 Aggregate value at end of year ........    
5
Did the organization inform all donors and donor advisors in writing that the assets held in donor advised
funds are the organization's property, subject to the organization's exclusive legal control? ............
6
Did the organization inform all grantees, donors, and donor advisors in writing that grant funds can be
used only for charitable purposes and not for the benefit of the donor or donor advisor, or for any other purpose conferring impermissible private benefit? ...................................
Part II
Conservation Easements. Complete if the organization answered "Yes" to Form 990, Part IV, line 7.
1
Purpose(s) of conservation easements held by the organization (check all that apply).
2
Complete lines 2a through 2d if the organization held a qualified conservation contribution in the form of a conservation easement on the last day of the tax year.
Held at the End of the Year
a Total number of conservation easements ....................... 2a  
b Total acreage restricted by conservation easements .................. 2b  
c Number of conservation easements on a certified historic structure included in (a) ..... 2c  
d Number of conservation easements included in (c) acquired after 8/17/06, and not on a historic structure listed in the National Register .................... 2d  
3
Number of conservation easements modified, transferred, released, extinguished, or terminated by the organization during
the tax year SchDMd Bullet  
4
Number of states where property subject to conservation easement is located SchDMd Bullet  
5
Does the organization have a written policy regarding the periodic monitoring, inspection, handling of violations, and
enforcement of the conservation easements it holds? .............................
6
Staff and volunteer hours devoted to monitoring, inspecting, and enforcing conservation easements during the year
SchDMd Bullet  
7
Amount of expenses incurred in monitoring, inspecting, and enforcing conservation easements during the year
SchDMd Bullet $  
8
Does each conservation easement reported on line 2(d) above satisfy the requirements of section 170(h)(4)(B)(i) and section 170(h)(4)(B)(ii)? .......................................
9
In Part XIII, describe how the organization reports conservation easements in its revenue and expense statement, and
balance sheet, and include, if applicable, the text of the footnote to the organization’s financial statements that describes
the organization’s accounting for conservation easements.
Part III
Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets.
Complete if the organization answered "Yes" to Form 990, Part IV, line 8.
1a
If the organization elected, as permitted under SFAS 116 (ASC 958), not to report in its revenue statement and balance sheet works of art, historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of public service, provide, in Part XIII, the text of the footnote to its financial statements that describes these items.
b
If the organization elected, as permitted under SFAS 116 (ASC 958), to report in its revenue statement and balance sheet works of art, historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of public service, provide the following amounts relating to these items:
(i)
Revenues included in Form 990, Part VIII, line 1 ........................SchDMd Bullet $  
(ii)
Assets included in Form 990, Part X ..............................SchDMd Bullet $  
2
If the organization received or held works of art, historical treasures, or other similar assets for financial gain, provide the
following amounts required to be reported under SFAS 116 (ASC 958) relating to these items:
a
Revenues included in Form 990, Part VIII, line 1 ..........................SchDMd Bullet $  
b
Assets included in Form 990, Part X ...............................SchDMd Bullet $  
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 52283D
Schedule D (Form 990) 2012

Schedule D (Form 990) 2012
Page 2
Part III
Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets (continued)
3
Using the organization’s acquisition, accession, and other records, check any of the following that are a significant use of its collection items (check all that apply):
a
d
b
e
 
c
4
Provide a description of the organization’s collections and explain how they further the organization’s exempt purpose in
Part XIII.
5
During the year, did the organization solicit or receive donations of art, historical treasures or other similar
assets to be sold to raise funds rather than to be maintained as part of the organization’s collection?........
Part IV
Escrow and Custodial Arrangements. Complete if the organization answered "Yes" to Form 990,
Part IV, line 9, or reported an amount on Form 990, Part X, line 21.
1a
Is the organization an agent, trustee, custodian or other intermediary for contributions or other assets not
included on Form 990, Part X? ....................................
b
If "Yes," explain the arrangement in Part XIII and complete the following table:
Amount
c Beginning balance ................................. 1c  
d Additions during the year .............................. 1d  
e Distributions during the year ............................. 1e  
f Ending balance ................................... 1f  
2a
Did the organization include an amount on Form 990, Part X, line 21? .....................
b
If “Yes,” explain the arrangement in Part XIII. Check here if the explanation has been provided in Part XIII ........
Part V
Endowment Funds. Complete if the organization answered "Yes" to Form 990, Part IV, line 10.
(a)Current year (b)Prior year b (c)Two years back (d)Three years back (e)Four years back
1a Beginning of year balance ....          
b Contributions ........          
c Net investment earnings, gains, and losses          
d Grants or scholarships .....          
e Other expenditures for facilities
and programs ........ 		         
f Administrative expenses ....          
g End of year balance ......          
2
Provide the estimated percentage of the current year end balance (line 1g, column (a)) held as:
a
Board designated or quasi-endowment SchDMd Bullet  
b
Permanent endowment SchDMd Bullet  
c
Temporarily restricted endowment SchDMd Bullet  
The percentages in lines 2a, 2b, and 2c should equal 100%.
3a
Are there endowment funds not in the possession of the organization that are held and administered for the
organization by:

Yes
No
(i) unrelated organizations ........................
3a(i)
 
 
(ii) related organizations ........................
3a(ii)
 
 
b
If "Yes" to 3a(ii), are the related organizations listed as required on Schedule R? .........
3b
 
 
4
Describe in Part XIII the intended uses of the organization's endowment funds.
Part VI
Land, Buildings, and Equipment. See Form 990, Part X, line 10.
Description of property (a) Cost or other basis (investment) (b)Cost or other basis (other) (c) Accumulated depreciation (d) Book value
1a Land .................      
b Buildings ................        
c Leasehold improvements ............   4,032,485 2,021,693 2,010,792
d Equipment ................   10,620,055 9,059,424 1,560,630
e Other .................   51,472,991 19,359,066 32,113,926
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).).......SchDMdBullet 35,685,348
Schedule D (Form 990) 2012

Schedule D (Form 990) 2012
Page 3
Part VII
Investments—Other Securities. See Form 990, Part X, line 12.
(a) Description of security or category
(including name of security)		 (b)Book value (c) Method of valuation:
Cost or end-of-year market value
(1)Financial derivatives    
(2)Closely-held equity interests    
Other








Total. (Column (b) must equal Form 990, Part X, col. (B) line 12.)Small Bullet  
Part VIII
Investments—Program Related. See Form 990, Part X, line 13.
(a) Description of investment type (b) Book value (c) Method of valuation:
Cost or end-of-year market value








Total. (Column (b) must equal Form 990, Part X, col.(B) line 13.)Small Bullet  
Part IX
Other Assets. See Form 990, Part X, line 15.
(a) Description (b) Book value








Total. (Column (b) must equal Form 990, Part X, col.(B) line 15.)...........Small Bullet  
Part X
Other Liabilities. See Form 990, Part X, line 25.
1.(a) Description of liability (b) Book value
Federal income taxes  








Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)Small Bullet  
2. Fin 48 (ASC 740) Footnote. In Part XIII, provide the text of the footnote to the organization's financial statements that reports the organization's liability for uncertain tax positions under FIN 48 (ASC 740). Check here if the text of the footnote has been provided in Part XIII .....................................................
Schedule D (Form 990) 2012

Schedule D (Form 990) 2012
Page 4
Part XI Reconciliation of Revenue per Audited Financial Statements With Revenue per Return
1 Total revenue, gains, and other support per audited financial statements ....... 1 1,176,985,000
2 Amounts included on line 1 but not on Form 990, Part VIII, line 12:
a Net unrealized gains on investments .......... 2a  
b Donated services and use of facilities ......... 2b  
c Recoveries of prior year grants ........... 2c  
d Other (Describe in Part XIII.) ............ 2d 56,320,059
e Add lines 2a through 2d ..................... 2e 56,320,059
3 Subtract line 2e from line 1..................... 3 1,120,664,941
4 Amounts included on Form 990, Part VIII, line 12, but not on line 1:
a Investment expenses not included on Form 990, Part VIII, line 7b . 4a  
b Other (Describe in Part XIII.) ........... 4b 142,411
c Add lines 4a and 4b....................... 4c 142,411
5 Total revenue. Add lines 3 and 4c. (This must equal Form 990, Part I, line 12.) ...... 5 1,120,807,352
Part XII Reconciliation of Expenses per Audited Financial Statements With Expenses per Return
1 Total expenses and losses per audited financial statements ........... 1 1,161,688,000
2 Amounts included on line 1 but not on Form 990, Part IX, line 25:
a Donated services and use of facilities .......... 2a  
b Prior year adjustments .............. 2b  
c Other losses ................ 2c  
d Other (Describe in Part XIII.) ............ 2d 57,018,232
e Add lines 2a through 2d...................... 2e 57,018,232
3 Subtract line 2e from line 1..................... 3 1,104,669,768
4 Amounts included on Form 990, Part IX, line 25, but not on line 1:
a Investment expenses not included on Form 990, Part VIII, line 7b .. 4a  
b Other (Describe in Part XIII.) ............ 4b 840,478
c Add lines 4a and 4b....................... 4c 840,478
5 Total expenses. Add lines 3 and 4c. (This must equal Form 990, Part I, line 18.) ...... 5 1,105,510,246
Part XIII
Supplemental Information
Complete this part to provide the descriptions required for Part II, lines 3, 5, and 9; Part III, lines 1a and 4; Part lV, lines 1b and 2b;
Part V, line 4; Part X, line 2; Part XI, lines 2d and 4b; and Part XII, lines 2d and 4b. Also complete this part to provide any additional information.
Identifier Return Reference Explanation
RECONCILIATION OF REVENUE FORM 990, SCHEDULE D, PART XI, LINE 2D ITEMS ON FINANCIALS NOT ON FORM 990 SUBSIDIARY PREMIUM & ASO INCOME $47,803,394 SUBSIDIARY INVESTMENT INCOME $16,079 SUBSIDIARY OTHER INCOME & ELIMINATIONS $9,340,763 INVESTMENT FEE, SHOWN AS EXPENSE ($840,478) ROUNDING $301 ------------ SUBTOTAL, ON FINANCIALS NOT ON FORM 990 $56,320,059 FORM 990, SCHEDULE D, PART XI, LINE 4B ITEMS ON FORM 990, NOT ON FINANCIALS FUNDRAISING REVENUE RECLASSED FROM CONTRA EXP. $198,900 FUNDRAISING EXPENSES ON 990 NOT ON FS ($56,489) --------- SUBTOTAL, ON FORM 990 NOT ON FINANCIALS $142,411
RECONCILIATION OF EXPENSES FORM 990, SCHEDULE D, PART XII, LINE 2D ITEMS ON FINANCIALS NOT ON FORM 990 SUBSIDIARY EXPENSES $57,160,237 NET FUNDRAISING ON FINANCIALS NOT ON 990 ($142,411) ROUNDING $406 ------------ SUBTOTAL, ON FINANCIALS NOT ON FORM 990 $57,018,232 FORM 990, SCHEDULE D, PART XII, LINE 4B INVESTMENT FEE, SHOWN AS EXPENSE $840,478
Schedule D (Form 990) 2012

Additional Data


Software ID:  
Software Version:  




SCHEDULE G (Form 990 or 990-EZ)
Department of the Treasury
Internal Revenue Service
Supplemental Information Regarding
Fundraising or Gaming Activities
Complete if the organization answered "Yes" to Form 990, Part IV, lines 17, 18, or 19, or if the organization entered more than $15,000 on Form 990-EZ, line 6a. Form 990-EZ filers are not required to complete this part. right arrowAttach to Form 990 or Form 990-EZ. right arrowSee separate instructions.
OMB No. 1545-0047
2012
Open to Public Inspection
Name of the organization
Fallon Community Health Plan Inc
 
Employer identification number

23-7442369
Part I
Fundraising Activities. Complete if the organization answered "Yes" to Form 990, Part IV, line 17.
1
Indicate whether the organization raised funds through any of the following activities. Check all that apply.
a e
b f
c g
d
2a
Did the organization have a written or oral agreement with any individual (including officers, directors, trustees
or key employees listed in Form 990, Part VII) or entity in connection with professional fundraising services?
b
If “Yes,” list the ten highest paid individuals or entities (fundraisers) pursuant to agreements under which the fundraiser is
to be compensated at least $5,000 by the organization.
(i) Name and address of individual
or entity (fundraiser) 		(ii) Activity (iii) Did fundraiser have custody or control of contributions? (iv) Gross receipts
from activity 		(v) Amount paid to
(or retained by)
fundraiser listed in
col. (i) 		(vi) Amount paid to
(or retained by)
organization
Yes No
             
             
             
             
             
             
             
             
             
             
Total .................right arrow      
3
List all states in which the organization is registered or licensed to solicit funds or has been notified it is exempt from registration or licensing.
For Paperwork Reduction Act Notice, see the Instructions for Form 990or 990-EZ.
Cat. No. 50083H
Schedule G (Form 990 or 990-EZ) 2012
Schedule G (Form 990 or 990-EZ) 2012
Page 2
Part II
Fundraising Events. Complete if the organization answered "Yes" to Form 990, Part IV, line 18, or reported more than $15,000 of fundraising event contributions and gross income on Form 990-EZ, lines 1 and 6b. List events with gross receipts greater than $5,000.
(a) Event #1

Golf Event
(event type) 		(b) Event #2

 
(event type) 		(c) Other events

0
(total number) 		(d) Total events
(add col. (a) through col. (c))
VerticalRevenue 1 Gross receipts . . . 198,900     198,900
2 Less: Contributions . . 158,338     158,338
3 Gross income (line 1
minus line 2) . . . 		40,562     40,562
VerticalDirectExpenses 4 Cash prizes . . .        
5 Noncash prizes . . 100     100
6 Rent/facility costs . . 23,020     23,020
7 Food and beverages . 15,246     15,246
8 Entertainment . . .        
9 Other direct expenses . 18,123     18,123
10 Direct expense summary. Add lines 4 through 9 in column (d) ........... right arrow 56,489
11 Net income summary. Combine line 3, column (d), and line 10. .......... right arrow -15,927
Part III
Gaming. Complete if the organization answered "Yes" to Form 990, Part IV, line 19, or reported more than $15,000 on Form 990-EZ, line 6a.
VerticalRevenue (a) Bingo (b) Pull tabs/Instant
bingo/progressive bingo 		(c) Other gaming (d) Total gaming (add col.(a) through col.(c))
1 Gross revenue . . . .        
VerticalDirectExpenses 2 Cash prizes . . . .        
3 Non-cash prizes . . .        
4 Rent/facility costs . . .        
5 Other direct expenses . .        
6 Volunteer labor . . .
 
 
 
7 Direct expense summary. Add lines 2 through 5 in column (d) ........... right arrow  
8 Net gaming income summary. Combine lines 1 and 7 in column (d) .......... right arrow  
9
Enter the state(s) in which the organization operates gaming activities:
a
Is the organization licensed to operate gaming activities in each of these states? ............
b
If "No," explain:
 
10a
Were any of the organization's gaming licenses revoked, suspended or terminated during the tax year? .....
b
If "Yes," explain:
 
Schedule G (Form 990 or 990-EZ) 2012
Schedule G (Form 990 or 990-EZ) 2012
Page 3
11
Does the organization operate gaming activities with nonmembers? .................
12
Is the organization a grantor, beneficiary or trustee of a trust or a member of a partnership or other entity
formed to administer charitable gaming? ..........................
13
Indicate the percentage of gaming activity operated in:
a
The organization's facility ......................
13a
 
b
An outside facility ........................
13b
 
14
Enter the name and address of the person who prepares the organization's gaming/special events books and records:
Name right arrow
Address right arrow
15a
Does the organization have a contract with a third party from whom the organization receives gaming
revenue? ......................................
b
If "Yes," enter the amount of gaming revenue received by the organization right arrow $   and the
amount of gaming revenue retained by the third party right arrow $   .
c
If "Yes," enter name and address of the third party:
Name right arrow
Address right arrow
 
 
16
Gaming manager information:
Name right arrow
Gaming manager compensation right arrow $  
Description of services provided right arrow
 
17
Mandatory distributions:
a
Is the organization required under state law to make charitable distributions from the gaming proceeds to
retain the state gaming license? ............................
b
Enter the amount of distributions required under state law distributed to other exempt organizations or spent
in the organization's own exempt activities during the tax year right arrow$  
Part IV
Supplemental Information. Complete this part to provide the explanations required by Part I, line 2b, columns (iii) and (v), and Part III, lines 9, 9b, 10b, 15b, 15c, 16, and 17b, as applicable. Also complete this part to provide any additional information (see instructions).
Identifier Return Reference Explanation
Schedule G (Form 990 or 990-EZ) 2012
Additional Data


Software ID:  
Software Version:  
Schedule I
(Form 990)
Department of the Treasury
Internal Revenue Service
Grants and Other Assistance to Organizations,
Governments and Individuals in the United States
Complete if the organization answered "Yes," to Form 990, Part IV, line 21 or 22.
lBullet Attach to Form 990
OMB No. 1545-0047
2012
Open to Public
Inspection
Name of the organization
Fallon Community Health Plan Inc
 
Employer identification number
23-7442369
Part I
General Information on Grants and Assistance
1
Does the organization maintain records to substantiate the amount of the grants or assistance, the grantees' eligibility for the grants or assistance, and
the selection criteria used to award the grants or assistance? ....................................
2
Describe in Part IV the organization's procedures for monitoring the use of grant funds in the United States.
Part II
Grants and Other Assistance to Governments and Organizations in the United States. Complete if the organization answered "Yes" to
Form 990, Part IV, line 21, for any recipient that received more than $5,000. Part II can be duplicated if additional space is needed.
(a) Name and address of organization
or government		 (b) EIN (c) IRC Code section
if applicable		 (d) Amount of cash grant (e) Amount of non-cash
assistance		 (f) Method of valuation
(book, FMV, appraisal,
other)		 (g) Description of
non-cash assistance		 (h) Purpose of grant
or assistance
(1) Worcester Public Library Foundation
3 Salem Square
Worcester,MA01608 		20-0066770 501(c)(3) 46,000       GENERAL SUPPORT
(2) Worcester Regional Chamber of Commerce
446 Main St
Worcester,MA01608 		04-1988780 501(c)(6) 30,525       Independence Day Celebration - $20,000 Women's Leadership Conference - $10,000
(3) United Way of Central MA
484 Main Street
Worcester,MA01608 		04-2104017 501(c)(3) 25,750       Stepping Up for Girls event - $750 Corporate donation - $25,000
(4) St John's Parish
44 Temple St
Worcester,MA01604 		04-2106729 501(c)(3) 25,000       GENERAL SUPPORT
(5) Worcester Art Museum
55 Salisbury St
Worcester,MA01609 		04-1988530 501(c)(3) 22,220       GENERAL SUPPORT
(6) Reliant Medical Group
100 Front St 14th fl
Worcester,MA01608 		22-2912515 501(c)(3) 20,500       GENERAL SUPPORT
(7) American Heart Association
20 Speen St
Framingham,MA01701 		13-5613797 501(c)(3) 20,250       GENERAL SUPPORT
(8) Square One
1 Federal Sq
Springfield,MA01105 		04-2103855 501(c)(3) 20,000       Community Benefits Grant - LAUNCH Healthy Living for Disadvantaged Children & Families
(9) UMass Medical School
33 South Street
Shrewsbury,MA01545 		04-3108190 501(c)(3) 17,500       GENERAL SUPPORT
(10) YMCA of Central MA
766 Main Street
Worcester,MA01610 		04-2105885 501(c)(3) 16,200       GENERAL SUPPORT
(11) United Way of Mass Bay & Merrimack Valley
51 Sleeper Street
Boston,MA02210 		04-2382233 501(c)(3) 15,000       GENERAL SUPPORT
(12) Hilltown Community Health Centers Inc
58 Old North Road
Worthington,MA01098 		04-2161484 501(c)(3) 15,000       Community Benefits Grant - Hilltown Elder Care (HOPE and HEN collaboration)
(13) Tri-Valley Inc
10 Mill Street
Dudley,MA01571 		04-2594201 501(c)(3) 15,000       Community Benefits Grant - Nutrition Program
(14) Regional Environmental Council Inc
PO Box 255
Worcester,MA01613 		04-6364350 501(c)(3) 15,000       Community Benefits Grant - UGROW - Urban Garden Resources Worcester
(15) Old Sturbridge VillAGE
1 Old Sturbridge Rd
Sturbridge,MA01566 		04-2104809 501(c)(3) 13,700       GENERAL SUPPORT
(16) Merrimack Valley Food Bank Inc
735 Broadway Street
Lowell,MA01854 		22-3241609 501(c)(3) 12,800       Community Benefits Grant - Mobile Pantry - $10,000 Golf & Gather FORE a Cause proceeds donation - $2,500 Golf Tournament - $300
(17) Corrider Nine
30 Lyman Street
Westborough,MA01581 		22-3887369 501(c)(6) 11,658       GENERAL SUPPORT
(18) American Red Cross of Central MA
2000 Century Drive
Worcester,MA01606 		04-2141539 501(c)(3) 11,000       Hurrican Sandy Relief - $5,000 Emergency Response Vehicle - $4,000 2012 Heroes Breakfast - $1,000 2013 Heroes Breakfast - $1,000
(19) Worcester Regional Research Bureau
500 Salisbury Street
Worcester,MA01609 		04-2901298 501(c)(3) 11,000       GENERAL SUPPORT
(20) Worcester County Food Bank
474 Boston Tpke Rd
Shrewsbury,MA01545 		04-3071457 501(c)(3) 10,500       GENERAL SUPPORT
(21) Community Harvest Project
37 Wheeler Road
North Grafton,MA01536 		04-3424018 501(c)(3) 10,500       Community Benefits Grant - Volunteer Farming Project - $10,000 Pay It Forward Donation - $500
(22) Worcester Education Collaborative
484 Main St
Worcester,MA01608 		04-2100017 501(c)(3) 10,000       GENERAL SUPPORT
(23) Hanover Theatre
2 Southbridge Street
Worcester,MA01608 		05-0521735 501(c)(3) 10,000       GENERAL SUPPORT
(24) Worcester Hibernian Cultural Centre
PO Box 20276
Worcester,MA01602 		20-2148447 501(c)(3) 10,000       GENERAL SUPPORT
(25) Be Like Brit
PO Box 355
Rutland,MA01543 		27-1857525 501(c)(3) 10,000       GENERAL SUPPORT
(26) Elder Services of Berkshire County Inc
66 Wendell Avenue
Pittsfield,MA01201 		04-2542001 501(c)(3) 10,000       Community Benefits Grant - Meals on Wheels Program
(27) Lowell General Hospital
295 Varnum Avenue
Lowell,MA01854 		04-2103590 501(c)(3) 10,000       GENERAL SUPPORT
(28) Boys and Girls Club of Worcester
65 Tainter Street
Worcester,MA01610 		04-2105851 501(c)(3) 8,860       Women's Leadership Breakfast - $1,000 Celebrity Sports Nite - $360 Community Benefits Grant - Healthy Habits to Grow - $5,000 Kids Caf - Golf & Gather FORE a Cause proceeds donation - $2,500
(29) New England Baptist Hospital
125 Parker Hill Avenue
Boston,MA02120 		04-2103612 501(c)(3) 8,300       GENERAL SUPPORT
(30) Bostonian Group
4 Copley Place
Boston,MA02116 		76-0788130 501(c)(3) 7,800       GENERAL SUPPORT
(31) Friends of the Pappas Recreation Complex
Town of Auburn
Auburn,MA01501 		45-4146360 501(c)(3) 7,500       GENERAL SUPPORT
(32) South High Community School
170 Apricot Street
Worcester,MA01603 		04-6001418 501(c)(3) 7,500       GENERAL SUPPORT
(33) TEAM McCarthy
253 Riverview Avenue
Newton,MA02466 		03-2524240 501(c)(3) 6,555       GENERAL SUPPORT
(34) Springfield Jewish Community Center
1160 Dickinson Street
Springfield,MA01108 		04-2103802 501(c)(3) 6,150       Youth Garden grant (mini grant) - $5,000 Community Center Program Guide - $1,150
(35) Stanley Street Treatment & Resources
386 Stanley Street
Fall River,MA02720 		04-2604426 501(c)(3) 6,000       Community Benefits Grant - Girls on the Right Track
(36) Bridge of Central MA
4 Mann Street
Worcester,MA01605 		04-2701581 501(c)(3) 5,750       Community Benefits Grants - Making Choices through Healthy Eating & Activity - $5,000 BridgeFest 2012 - $500 Pay It Forward Donation - $250
(37) Genesis Club Inc
274 Lincoln Street
Worcester,MA01605 		04-2983234 501(c)(3) 5,500       PROMTG. HEALTHY LS. Lifestyles (mini grant) - $5,000 Building Dreams Breakfast - $500
(38) Mass Audubon
414 Massasoit Road
Worcester,MA01604 		04-2104702 501(c)(3) 5,100       Community Benefits Grant - Let's Go! - $5,000 Wachusett Meadow Sanctuary - $100
(39) Kidney Cancer Association
85 Astor Avenue Suite 2
Norwood,MA02062 		04-2305643 501(c)(3) 5,025       General Purpose
2
Enter total number of section 501(c)(3) and government organizations listed in the line 1 table ................ Bullet Image
37
3
Enter total number of other organizations listed in the line 1 table ........................ . Bullet Image
2
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50055P
Schedule I (Form 990) 2012

Schedule I (Form 990) 2012
Page 2
Part III
Grants and Other Assistance to Individuals in the United States. Complete if the organization answered "Yes" to Form 990, Part IV, line 22.
Part III can be duplicated if additional space is needed.
(a)Type of grant or assistance (b)Number of
recipients		 (c)Amount of
cash grant		 (d)Amount of
non-cash assistance		 (e)Method of valuation (book,
FMV, appraisal, other)		 (f)Description of non-cash assistance












Part IV
Supplemental Information.
Complete this part to provide the information required in Part I, line 2, Part III, column (b), and any other additional information.
Identifier Return Reference Explanation
Form 990, Schedule I, PART I, LINE 2 Description of Organization's Procedures for Monitoring the Use of Grants FCHP GRANTS ARE CLASSIFIED EITHER AS A COMMUNITY BENEFIT GRANT OR A COMMUNITY RELATIONS GRANT. THE COMMUNITY BENEFIT GRANTS ARE VERIFIED TO ENSURE THAT EACH RECIPIENT IS A 501(C)(3) ORGANIZATION. THE COMMUNITY RELATIONS GRANTS ARE VERIFIED TO ENSURE THAT THE RECIPIENT ORGANIZATION'S IRS STATUS IS LISTED AS A TAX-EXEMPT ORGANIZATION IN THE INTERNAL REVENUE CODE SECTION 501(C). EACH RECIPIENT OF A FCHP GRANT HAS SPECIFIC INSTRUCTIONS TO BE FOLLOWED AS TO THE USE OF THE GRANT, AND THAT THE GRANT IS TO BE EXPENDED WITHIN 1 YEAR FROM THE AWARD. FOR ANY GRANTS IN EXCESS OF $10,000, fchp REQUESTS A GRANT REPORT DETAILING THE GRANT USES. THESE REPORTS ARE REVIEWED AND KEPT ON FILE AT FCHP.
Schedule I (Form 990) 2012


Additional Data


Software ID:  
Software Version:  


Schedule J
(Form 990)
Department of the Treasury
Internal Revenue Service
Compensation Information
For certain Officers, Directors, Trustees, Key Employees, and Highest
Compensated Employees
SchJMediumBullet Complete if the organization answered "Yes" to Form 990,
Part IV, question 23.
SchJMediumBullet Attach to Form 990. SchJMediumBullet See separate instructions.
OMB No. 1545-0047
2012
Open to Public Inspection
Name of the organization
Fallon Community Health Plan Inc
 
Employer identification number

23-7442369
Part I
Questions Regarding Compensation
Yes
No
1a
Check the appropiate box(es) if the organization provided any of the following to or for a person listed in Form
990, Part VII, Section A, line 1a. Complete Part III to provide any relevant information regarding these items.
b
If any of the boxes in line 1a are checked, did the organization follow a written policy regarding payment or reimbursement or provision of all of the expenses described above? If "No," complete Part III to explain....
1b
Yes
 
2
Did the organization require substantiation prior to reimbursing or allowing expenses incurred by all officers,
directors, trustees, and the CEO/Executive Director, regarding the items checked in line 1a? .......
2
Yes
 
3
Indicate which, if any, of the following the filing organization used to establish the compensation of the
organization's CEO/Executive Director. Check all that apply. Do not check any boxes for methods
used by a related organization to establish compensation of the CEO/Executive Director, but explain in Part III.
4
During the year, did any person listed in Form 990, Part VII, Section A, line 1a with respect to the filing organization or a related organization:
a
Receive a severance payment or change-of-control payment? ................
4a
 
No
b
Participate in, or receive payment from, a supplemental nonqualified retirement plan? .........
4b
Yes
 
c
Participate in, or receive payment from, an equity-based compensation arrangement? .........
4c
 
No
If "Yes" to any of lines 4a-c, list the persons and provide the applicable amounts for each item in Part III.
Only 501(c)(3) and 501(c)(4) organizations only must complete lines 5-9.
5
For persons listed in Form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the revenues of:
a
The organization? ...........................
5a
 
No
b
Any related organization? .........................
5b
 
No
If "Yes," to line 5a or 5b, describe in Part III.
6
For persons listed in Form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the net earnings of:
a
The organization? ...........................
6a
Yes
 
b
Any related organization? .........................
6b
 
No
If "Yes," to line 6a or 6b, describe in Part III.
7
For persons listed in Form 990, Part VII, Section A, line 1a, did the organization provide any non-fixed
payments not described in lines 5 and 6? If "Yes," describe in Part III ............
7
 
No
8
Were any amounts reported in Form 990, Part VII, paid or accured pursuant to a contract that was
subject to the initial contract exception described in Regulations section 53.4958-4(a)(3)? If "Yes," describe
in Part III .............................
8
 
No
9
If "Yes" to line 8, did the organization also follow the rebuttable presumption procedure described in Regulations section 53.4958-6(c)? .........................
9
 
 
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50053T
Schedule J (Form 990) 2012

Schedule J (Form 990) 2012
Page 2
Part II
Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees. Use duplicate copies if additional space is needed.
For each individual whose compensation must be reported in Schedule J, report compensation from the organization on row (i) and from related organizations, described in the
instructions, on row (ii). Do not list any individuals that are not listed on Form 990, Part VII.
Note. The sum of columns (B)(i)-(iii) for each listed individual must equal the total amount of Form 990, Part VII, Section A, line 1a, applicable column (D) and (E) amounts for that individual.
(A) Name and Title (B) Breakdown of W-2 and/or 1099-MISC compensation (C) Retirement and other deferred compensation (D) Nontaxable
benefits		 (E) Total of columns
(B)(i)-(D) 		(F) Compensation
reported as deferred
in prior Form 990
(i) Base compensation (ii) Bonus & incentive compensation (iii) Other reportable compensation
(1)W Patrick HughesPresident & CEO (i)
(ii)		 568,942
  		216,460
  		411,081
  		174,700
0 		22,754
0 		1,393,937
0 		216,460
0
(2)Richard P BurkePresident, Sr. Care Svc. & Gov (i)
(ii)		 318,789
  		62,053
  		21,852
  		100,950
0 		25,511
0 		529,155
0 		62,053
0
(3)Elizabeth Malko MDChief Medical Officer (i)
(ii)		 324,938
  		66,190
  		27,438
  		101,415
0 		21,511
0 		541,492
0 		66,190
0
(4)Christine OsgoodChief Human Resources Officer (i)
(ii)		 142,545
  		33,345
  		39,913
  		8,980
0 		4,340
0 		229,123
0 		29,345
0
(5)R Scott WalkerChief Financial Officer (i)
(ii)		 323,619
  		64,575
  		700
  		128,450
0 		25,868
0 		543,212
0 		64,575
0
(6)Richard CommanderChief Operating Officer (i)
(ii)		 303,387
  		50,119
  		4,511
  		117,500
0 		2,258
0 		477,775
0 		50,119
0
(7)David PrzesiekSr VP Sales & Marketing (i)
(ii)		 265,840
  		69,729
  		970
  		111,318
0 		24,602
0 		472,459
0 		69,729
0
(8)Mary RitterSR. VP OF STRATEGIC PLANNING (i)
(ii)		 232,194
  		102,230
  		31,517
  		12,500
0 		25,511
0 		403,952
0 		42,230
0
(9)Todd BaileyVP. Senior Care Services (i)
(ii)		 201,880
  		33,000
  		4,937
  		64,940
0 		20,882
0 		325,639
0 		33,000
0
(10)Eric HallVP Network Development & Mgmt (i)
(ii)		 201,129
  		59,481
  		5,007
  		63,980
0 		 
0 		329,597
0 		32,163
0
(11)Karen LongoExec. Dir, Summit Eldercare (i)
(ii)		 164,753
  		26,369
  		4,741
  		50,141
0 		22,170
0 		268,174
0 		25,369
0
(12)Kevin McGovernVP of Finance & Treasurer (i)
(ii)		 205,669
  		31,138
  		5,494
  		57,014
0 		20,988
0 		320,303
0 		31,138
0
(13)Janis LiepinsVP Marketing (i)
(ii)		 206,924
  		33,364
  		2,322
  		60,923
0 		15,288
0 		318,821
0 		33,364
0
(14)Elizabeth HeleniusVP Medicare Sales&Emerging Mkt (i)
(ii)		 151,158
  		92,694
  		3,143
  		22,690
0 		21,871
0 		291,556
0 		34,212
0
(15)Glenn Randall MDPhysician, Summit ElderCare (i)
(ii)		 256,368
  		14,536
  		3,960
  		34,839
0 		19,718
0 		329,421
0 		14,536
0
(16)David Wilner MDVP & Medical Director (i)
(ii)		 283,542
  		22,421
  		7,672
  		60,235
0 		18,577
0 		392,447
0 		21,971
0
(17)Kevin GrozioVP, Underwriting & Actuarial (i)
(ii)		 235,243
  		16,000
  		540
  		69,916
0 		27,009
0 		348,708
0 		16,000
0
(18)Russell MunsonSr. Medical Director (i)
(ii)		 274,777
  		17,016
  		2,322
  		66,071
0 		20,924
0 		381,110
0 		17,016
0
(19)Param SinghAssociate Medical Director (i)
(ii)		 211,513
  		11,112
  		8,363
  		27,487
0 		17,234
0 		275,709
0 		11,112
0
Schedule J (Form 990) 2012

Schedule J (Form 990) 2012
Page 3
Part III
Supplemental Information
Complete this part to provide the information, explanation, or descriptions required for Part I, lines 1a, 1b, 3, 4a, 4b, 4c, 5a, 5b, 6a, 6b, 7, and 8, and for Part II.
Also complete this part for any additional information.
Identifier Return Reference Explanation
Supplemental Compensation Information FORM 990, Schedule J, Part I, Line 1A Health or social club dues or initiation fees. pursuant to a policy adopted and approved by the executive evaluation and compensation committee (EECC) of the board of directors, a portion of the dues and fees for the business use of The Worcester Club are paid by the organization for the following individuals: President & CEO, President of Senior Care Services, CFO, and Senior VP of Sales and Marketing. Each executive is required to pay for their own personal use expenses, as well as a personal use portion of the membership dues and fees as determined by the EECC. Social Club dues are not reported as taxable compensation to the listed persons.
Supplemental Compensation Information FORM 990, Schedule J, Part I, Line 4B FALLON COMMUNITY HEALTH PLAN, INC. SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN ARTICLE III - ELIGIBILITY AN EMPLOYEE WHO IS ELIGIBLE FOR CONTRIBUTIONS TO A 457(F) ACCOUNT SHALL BE ELIGIBLE TO CONTRIBUTE ELECTIVE DEFERRALS TO A 457(B) ACCOUNT, AND ANY OTHER INDIVIDUAL DESIGNATED BY THE OFFICER OF THE HEALTH PLAN WHO IS IN CHARGE OF HUMAN RESOURCES SHALL ALSO BE ELIGIBLE TO CONTRIBUTE ELECTIVE DEFERRALS TO A 457(B) ACCOUNT. CONTRIBUTIONS SHALL BE MADE BY THE HEALTH PLAN TO A 457(F) ACCOUNT ESTABLISHED ON BEHALF OF AN EMPLOYEE WHO, AS OF JANUARY 2, 2007, IS THE PRESIDENT AND CHIEF EXECUTIVE OFFICER. CONTRIBUTIONS SHALL BE MADE BY THE HEALTH PLAN ON BEHALF OF AN EMPLOYEE WHO, AS OF DECEMBER 31, 2008 IS THE DIVISION PRESIDENT, SENIOR CARE SERVICES, THE EXECUTIVE VICE PRESIDENT AND CHIEF FINANCIAL OFFICER, THE EXECUTIVE VICE PRESIDENT AND CHIEF HUMAN RESOURCES OFFICER, THE DIVISION PRESIDENT, HEALTH PLAN OPERATIONS, OR THE EXECUTIVE VICE PRESIDENT AND CHIEF COMPLIANCE OFFICER. EFFECTIVE JULY 1, 2008, CONTRIBUTIONS SHALL BE MADE BY THE HEALTH PLAN PURSUANT TO A 457(F) ACCOUNT ESTABLISHED ON BEHALF OF ANY EMPLOYEE WHO IS NOT IDENTIFIED IN THE PARAGRAPH ABOVE AND IS A DIVISION PRESIDENT, AN EXECUTIVE VICE PRESIDENT OR A SENIOR VICE PRESIDENT. AN EMPLOYEE WHO BECOMES ELIGIBLE FOR THE PLAN SHALL BECOME COVERED UNDER THE PLAN ON THE FIRST JANUARY 1ST OR JULY 1ST FOLLOWING HIS OR HER DATE OF HIRE. FOR PARTICIPANTS WHO BECAME ELIGIBLE FOR THE PLAN ON OR BEFORE MARCH 1, 2007, 50% OF THE ANNUAL CONTRIBUTIONS IS IMMEDIATELY VESTED. FOR PARTICIPANTS WHO BECAME ELIGIBLE FOR THE PLAN AFTER MARCH 1, 2007, 50% OF EACH ANNUAL CONTRIBUTION IS VESTED AFTER WORKING 36 MONTHS. REMAINING CONTRIBUTION AMOUNTS ARE VESTED ON THE EARLIEST OF NORMAL RETIREMENT AGE 65, DEATH, DISABILITY, AND INVOLUNTARY SEPARATION FROM SERVICE (FOR A REASON OTHER THAN CAUSE). IN 2012, THE FOLLOWING OFFICERS PARTICIPATED IN A NON-QUALIFIED RETIREMENT PLAN, 457(F): OFFICER AMOUNT PAID AMOUNT DEFERRED W. Patrick Hughes $405,381 NONE Christina Osgood $34,184 NONE Richard P. Burke $20,450 $20,450 Elizabeth Malko $24,615 $24,615 David Przesiek NONE $27,518 Richard Commander NONE $32,000 R. Scott Walker NONE $50,250
FORM 990, SCHEDULE J, PART I LINE 6 COMPENSATION CONTINGENT ON NET EARNINGS: ALL EMPLOYEES IN CERTAIN JOB GRADES, WHICH INCLUDE EMPLOYEES LISTED ON SCHEDULE J-2, ARE ELIGIBLE FOR AN INCENTIVE PLAN PAYMENT. THE INCENTIVE PLAN PAYMENT IS DETERMINED BY WHETHER CERTAIN CORPORATE, DEPARTMENT, AND/OR INDIVIDUAL TARGETS ARE MET. THE CORPORATE TARGETS INCLUDE (I) NET OPERATING INCOME, (II) MEMBERSHIP GROWTH, (III) MEMBER AND PROVIDER SATISFACTION, (IV) STRATEGY EXECUTION, (V) EMPLOYEE ENGAGEMENT, AND (VI) QUALITY. THESE TARGETS WERE MET IN 2012 AND INCENTIVE PAYMENTS WERE ACCRUED IN 2012.
Schedule J (Form 990) 2012

Additional Data


Software ID:  
Software Version:  
Schedule L
(Form 990 or 990-EZ)
Department of the Treasury
Internal Revenue Service
Transactions with Interested Persons
MediumBullet Complete if the organization answered
"Yes" on Form 990, Part IV, lines 25a, 25b, 26, 27, 28a, 28b, or 28c,
or Form 990-EZ, Part V, line 38a or 40b.
MediumBullet Attach to Form 990 or Form 990-EZ. MediumBullet See separate instructions.
OMB No. 1545-0047
2012
Open to Public Inspection
Name of the organization
Fallon Community Health Plan Inc
 
Employer identification number

23-7442369
Part I
Excess Benefit Transactions (section 501(c)(3) and section 501(c)(4) organizations only).
Complete if the organization answered "Yes" on Form 990, Part IV, line 25a or 25b, or Form 990-EZ, Part V, line 40b.
1(a) Name of disqualified person (b) Relationship between disqualified person and organization (c) Description of transaction (d) Corrected?
Yes No





2
Enter the amount of tax incurred by organization managers or disqualified persons during the year under section 4958. ........................... Bullet Image$
 
3
Enter the amount of tax, if any, on line 2, above, reimbursed by the organization ....... Bullet Image$
 

Part II
Loans to and/or From Interested Persons.
Complete if the organization answered "Yes" on Form 990-EZ, Part V, line 38a, or Form 990, Part IV, line 26; or if the organization reported an amount on Form 990, Part X, line 5, 6, or 22
(a) Name of interested person (b) Relationship with organization (c) Purpose of loan (d) Loan to or from the organization? (e)Original principal amount (f)Balance due (g) In default? (h) Approved by board or committee? (i)Written agreement?
To From Yes No Yes No Yes No
Total ......Small Bullet $  
Part III
Grants or Assistance Benefitting Interested Persons.
Complete if the organization answered "Yes" on Form 990, Part IV, line 27.
(a) Name of interested person (b) Relationship between interested person and the organization (c) Amount of assistance (d) Type of assistance (e) Purpose of assistance
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.
Cat. No. 50056A
Schedule L (Form 990 or 990-EZ) 2012
Schedule L (Form 990 or 990-EZ) 2012
Page 2
Part IV
Business Transactions Involving Interested Persons.
Complete if the organization answered "Yes" on Form 990, Part IV, line 28a, 28b, or 28c.
(a) Name of interested person (b) Relationship between interested person and the organization (c) Amount of transaction (d) Description of transaction (e) Sharing of organization's revenues?
Yes No
(1) 1 THE MONAHAN GROUP INC FAMILY MEMBER OF DIRECTOR 82,705 SEE PART V   No
(2) 2 ADCARE HOSPITAL OWNERSHIP BY DIRECTOR 70,586 SEE PART V   No
(3) 3 SAINT VINCENT HOSPITAL OVERLAPPING BOARD MEMBER 123,010,099 SEE PART V   No
(4) 4 HOMESTAFF LLC OVERLAPPING BOARD MEMBER 1,770,993 SEE PART V   No
(5) 5 FAMILY MEMBER OF KEY EE EMPLOYEE 86,305 SEE PART V   No
Part V
Supplemental Information
Complete this part to provide additional information for responses to questions on Schedule L (see instructions).
Identifier Return Reference Explanation
BUSINESS TRANSACTIONS INVOLVING INTERESTED PERSONS FORM 990, SCHEDULE L, PART IV NAME: THE MONAHAN GROUP, INC. RELATIONSHIP: ENTITY OWNED BY THE SISTER-IN-LAW OF FCHP DIRECTOR CHARLES F. MONAHAN MR. MONAHAN'S SISTER-IN-LAW IS A PRINCIPAL WITH THE MONAHAN GROUP, INC., A SECURITY CONSULTING FIRM THAT PROVIDES CONSULTING SERVICES TO FCHP. CHARLES F. MONAHAN HAS NO INTEREST IN THE MONAHAN GROUP, INC. FCHP'S BUSINESS RELATIONSHIP WITH THE MONAHAN GROUP, INC., PRE-DATES MR. MONAHAN'S SERVICE ON THE FCHP BOARD. NAME: ADCARE HOSPITAL RELATIONSHIP: ENTITY OWNED BY FCHP DIRECTOR DAVID W. HILLIS AND FAMILY MEMBERS MR. HILLIS IS PRESIDENT, CEO AND HOLDS MAJORITY INTEREST IN ADCARE HOSPITAL OF WORCESTER, INC., A SUBSTANCE ABUSE HOSPITAL THAT PROVIDES HEALTH CARE SERVICES TO FCHP PLAN MEMBERS. MR. HILLIS ALSO HAS FAMILY MEMBERS WHO HOLD OWNERSHIP IN ADCARE HOSPITAL. NAME: SAINT VINCENT HOSPITAL RELATIONSHIP: ENTITY IN WHICH FCHP DIRECTOR CHARLES F. MONAHAN SERVES AS AN UNCOMPENSATED BOARD MEMBER. MR. MONAHAN SERVES ON THE BOARD OF SAINT VINCENT HOSPITAL, WORCESTER, MA, WHICH PROVIDES HEALTH CARE SERVICES TO FCHP PLAN MEMBERS. MR. MONAHAN RECEIVES NO COMPENSATION FOR HIS SERVICE ON THE SAINT VINCENT HOSPITAL BOARD. NAME: HOME STAFF, LLC RELATIONSHIP: JOINT VENTURE BETWEEN FCHP AND THE VNA CARE NETWORK AND HOSPICE. THE FOLLOWING FCHP EMPLOYEES ARE UNCOMPENSATED MEMBERS OF THE HOME STAFF BOARD OF DIRECTORS: W. PATRICK HUGHES, PRESIDENT & CEO, RICHARD P. BURKE, PRESIDENT, SENIOR CARE SERVICES & GOVERNMENT PROGRAMS, TODD BAILEY, VICE PRESIDENT, SENIOR CARE SERVICES. HOME STAFF CONTRACTS WITH FCHP TO PROVIDE SERVICES TO CERTAIN FCHP PARTICIPANTS. NAME: LAURIE MCGOVERN RELATIONSHIP: FCHP EMPLOYEE WHO IS THE SISTER-IN-LAW OF FCHP KEY EMPLOYEE KEVIN MCGOVERN. COMPENSATION PAYMENTS BY THE ORGANIZATION PAID TO A FAMILY MEMBER VARIOUS BOARD MEMBERS, OFFICERS, AND KEY EMPLOYEES HAVE HEALTH INSURANCE PURCHASED BY THEIR EMPLOYERS FROM FCHP, OR ARE AFFILATED WITH ORGANIZATIONS THAT PURCHASE THEIR HEALTH INSURANCE FROM FCHP.
Schedule L (Form 990 or 990-EZ) 2012

Additional Data


Software ID:  
Software Version:  




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.
MediumBullet Attach to Form 990 or 990-EZ.
OMB No. 1545-0047
2012
Open to Public
Inspection
Name of the organization
Fallon Community Health Plan Inc
 
Employer identification number

23-7442369
Identifier Return Reference Explanation
PROGRAM SERVICE ACCOMPLISHMENTS FORM 990, PART III, LINE 4A FCHP'S PROGRAM ACTIVITIES CONSIST OF PREPAID HEALTHCARE IN THE COMMONWEALTH OF MASSACHUSETTS. THE COVERED POPULATION AT DECEMBER 31, 2012 WAS 155,082. FALLON COMMUNITY HEALTH PLAN MADE OVER $1,500,000 AVAILABLE TO PROGRAMS THAT MAKE OUR COMMUNITIES HEALTHY. THIS WAS ACCOMPLISHED THROUGH THE FCHP COMMUNITY BENEFITS COMMITTEE'S DISTRIBUTION OF GRANTS, OTHER CHARITABLE DONATIONS, AND PROGRAMS THAT INVOLVED DIRECT EXPENSES AND STAFF TIME. FHCP'S REVENUE AND EXPENSES ARE NOT SEGREGABLE BY MAJOR EXPENSE CATEGORIES. FALLON COMMUNITY HEALTH PLAN 2012 COMMUNITY BENEFITS REPORT SUMMARY NARRATIVES Community Benefits Mission Statement Fallon Community Health Plan is committed to the vision of creating healthier lives. Fallon Community Health Plan will work cooperatively with health care and community service organizations, as well as state and federal agencies, to lead the creation of innovative health care solutions, to seek healthy outcomes, and to improve access to health care services. FCHP will develop and implement programs that will improve the health status of the economically disadvantaged, elders, and children aged 0-5 within our service area. Program Organization and Management In accordance with the Attorney General's Community Benefits Guidelines for Health Maintenance Organizations, the FCHP Board of Directors established the Community Benefits Committee. The Committee is managed by the Director of Community Relations, and reports to the Vice President of Corporate Communications. All grant applications are reviewed by the Committee and given final approval by senior management before funds are distributed. This ensures regular evaluation and oversight of the program. Community Health Needs Assessment In 2010, the Community Benefits Program conducted extensive review of the program, and a needs assessment of the communities served by the program. Changes to the giving program were made in order to better serve local needs. Each year, these areas of focus are reviewed with data from community agencies. Three new areas of focus were identified for the Community Benefits program. They are: promoting access to healthy nutrition and encouraging physical activity, particularly among vulnerable populations; promoting good health for seniors; and improving health for infants and children aged 0-5. Community Benefits Plan Fallon Community Health Plan awards grants and support to those programs that improve the health status of the economically disadvantaged, the elderly and children aged 0-5. Outcomes are measured each year against the goals stated in the funded programs' grant applications. These grant reports are essential in helping the Committee assess whether funds have indeed helped the identified population and therefore help to determine future funding. Key Accomplishments of the Reporting Year Fallon Community Health Plan invested over $1,500,000 in grants, programs and other supports to address needs affecting populations included in the Community Benefit program's areas of focus. Our support consists of direct funding, other costs, leveraged resources, staff hours (inclusive of paid volunteer hours) and employee non-paid volunteer hours. Approximately $202,700 of staff and volunteer time (both paid and non-paid) contributed to our efforts in the communities. Fallon Community Health Plan hosted the seventh annual Golf and Gather FOR a Goal charitable tournament, raising approximately $206,900 in gross receipts. Net proceeds exceeding $160,000 were distributed to more than 80 food pantries and hunger relief programs throughout Massachusetts. Due to the great need of the underserved population, FCHP donated an additional $10,000 towards the purchase of turkey and hams to the 4 major Massachusetts Food Banks and $24,000 year end to an additional 18 identified food pantries in MA. Plans for Next Reporting Year FCHP's Community Benefits program will conduct a needs assessment during 2013 to determine our focus for the next three years while maintaining our mission of making communities healthy. FORM 990, PART V, LINES 6A & 6B FCHP GROSS RECEIPTS FROM THE GOLF FUNDRAISING ARE GREATER THAN $100,000, AND THE DONOR CANNOT DEDUCT AS CHARITABLE FOR THE PORTION THAT THEY RECEIVED SOME BENEFIT, SUCH AS THE FMV OF THE GOLF TICKET.
DESCRIPTIONS OF RELATIONSHIPS FORM 990, PART VI, QUESTION 2 HOME STAFF LLC IS A JOINT VENTURE OF FCHP AND THE VNA CARE NETWORK & HOSPICE. THE FOLLOWING FCHP BOARD MEMBERS, OFFICERS, AND KEY EMPLOYEES SERVED ON THE HOME STAFF BOARD OF DIRECTORS DURING 2012: W. PATRICK HUGHES, RICHARD P. BURKE, AND TODD BAILY. FALLON HEALTH & LIFE ASSURANCE COMPANY, INC. (FHLAC), IS A WHOLLY-OWNED SUBSIDIARY OF FCHP. THE FOLLOWING FCHP BOARD MEMBERS, OFFICERS, AND KEY EMPLOYEES SERVED ON THE FHLAC BOARD OF DIRECTORS IN 2012: DAVID HILIS, RICHARD HOULIHAN, CHRISTIAN MCCARTHY, W. PATRICK HUGHES, AND SCOTT WALKER. ULTRABENEFITS, INC. (UBI) IS A WHOLLY-OWNED SUBSIDIARY OF FHLAC. THE FOLLOWING FCHP BOARD MEMBERS, OFFICERS, AND KEY EMPLOYEES SERVED ON THE UBI BOARD OF DIRECTORS IN 2012: W. PATRICK HUGHES, SCOTT WALKER, AND DAVID PRZESIEK. PROCESS USED BY MANAGEMENT AND GOVERNING BODY TO REVIEW 990 FORM 990, PART VI, LINE 11B A DRAFT OF THE 990 WAS PREPARED BY FCHP'S PAID PREPARER USING INFORMATION PROVIDED BY THE ORGANIZATION. THIS DRAFT WAS REVIEWED BY FCHP'S VICE PRESIDENT OF ACCOUNTING OPERATIONS & FINANCIAL PLANNING ANALYSIS, AND SENIOR MANAGEMENT, INCLUDING THE CHIEF FINANCIAL OFFICER, CHIEF COMPLIANCE OFFICER, CHIEF HUMAN RESOURCES OFFICER, AND CHIEF EXECUTIVE OFFICER. AFTER THIS REVIEW A FINAL FORM 990 WAS PREPARED, AND THE FINAL VERSION OF THE 990 WAS PROVIDED TO EACH BOARD MEMBER FOR HIS OR HER REVIEW BEFORE THE 990 WAS FILED WITH THE IRS.
DESCRIBE THE PROCESS TO MONITOR CONFLICTS OF INTERESTS FORM 990, PART VI, QUESTION 12 A,B,C FCHP'S BYLAWS REQUIRE ALL DIRECTORS AND OFFICERS TO DISCLOSE ANY ACTUAL OR POSSIBLE CONFLICTS OF INTEREST, AS DEFINED IN THE ORGANIZATION'S CONFLICT OF INTEREST POLICY RELATING TO DIRECTORS, OFFICERS AND MEMBERS OF A COMMITTEE WITH BOARD-DELEGATED POWERS. THIS IS ENFORCED BY THE REQUIREMENT THAT SUCH INDIVIDUALS ANNUALLY COMPLETE A CONFLICT OF INTEREST DISCLOSURE STATEMENT. EACH YEAR THE COMPLETED CONFLICT OF INTEREST DISCLOSURE STATEMENTS ARE REVIEWED BY THE AUDIT AND COMPLIANCE COMMITTEE OF THE BOARD WHICH REPORTS ANY ACTUAL OR POTENTIAL CONFLICTS TO THE FULL BOARD. ANY BOARD MEMBER OR OFFICER WITH A CONFLICT OF INTEREST IS PROHIBITED FROM PARTICIPATING IN ANY DISCUSSION OF, OR VOTE ON, THE TRANSACTION OR ARRANGEMENT THAT RESULTS IN THE CONFLICT OF INTEREST. TWO INDEPENDENT BOARD MEMBERS ALSO CONDUCT AN ANNUAL REVIEW OF ANY BUSINESS TRANSACTIONS INVOLVING THE ORGANIZATION THAT COULD POTENTIALLY BENEFIT A BOARD MEMBER OR OFFICER, TO ENSURE THAT THE TRANSACTIONS DO NOT INVOLVE ANY UNDUE INFLUENCE, ARE AT FAIR MARKET VALUE, AND ARE IN THE ORGANIZATION'S BEST INTEREST. THE REVIEWING BOARD MEMBERS REPORT THEIR FINDINGS TO THE FULL BOARD. FURTHERMORE, AT BOARD MEETINGS, INDIVIDUAL BOARD MEMBERS ARE ASKED TO IDENTIFY, AND RECUSE THEMSELVES FROM ANY DISCUSSION AND VOTE ON ANY MATTER BEFORE THE BOARD IN WHICH THEY MAY HAVE A CONFLICT. FCHP ALSO REQUIRES ALL DIRECTORS, OFFICERS, AND KEY EMPLOYEES, TO COMPLETE A WRITTEN DISCLOSURE STATEMENT DESIGNED TO IDENTIFY POTENTIAL CONFLICTS. FCHP ALSO HAS GENERAL CORPORATE-WIDE CONFLICT OF INTEREST POLICIES THAT REQUIRE REPORTING OF POTENTIAL CONFLICTS AND MANAGEMENT APPROVAL OF CERTAIN TRANSACTIONS, AND PROHIBITS CERTAIN SPECIFIC TRANSACTIONS. THESE POLICIES ARE ENFORCED BY SENIOR MANAGEMENT, INCLUDING THE CHIEF COMPLIANCE OFFICER.
OFFICES & POSITIONS FOR WHICH PROCESS WAS USED FORM 990, PART VI, QUESTIONS 15A & 15b FCHP HAS ESTABLISHED AN EXECUTIVE EVALUATION AND COMPENSATION COMMITTEE (THE "COMMITTEE") OF THE BOARD OF DIRECTORS THAT ESTABLISHES POLICIES AND THE COMPENSATION STRUCTURE OF CERTAIN OF FCHP'S EXECUTIVE OFFICERS. THIS COMMITTEE IS RESPONSIBLE FOR ASSURING THAT THE TOTAL COMPENSATION PROVIDED TO THESE EXECUTIVE OFFICERS IS DETERMINED BY A FAIR AND EQUITABLE PROCESS, INFORMED BY CURRENT AND CREDIBLE MARKET PRACTICE INFORMATION, AND COMPLIANT WITH APPLICABLE LEGAL AND REGULATORY GUIDELINES. IN 2012, THE COMMITTEE CONSISTED OF THREE MEMBERS OF FCHP'S BOARD OF DIRECTORS, WHO ARE NOT EMPLOYED BY THE ORGANIZATION. FCHP'S CEO SERVED AS AN EX OFFICIO MEMBER OF THE COMMITTEE WITHOUT A VOTING RIGHT. THE EXECUTIVE OFFICERS OVER WHOSE COMPENSATION THE COMMITTEE IS RESPONSIBLE ARE COMPRISED OF THE PRESIDENT AND CHIEF EXECUTIVE OFFICER ("CEO"), AND THE PRESIDENT, EXECUTIVE VICE PRESIDENT, AND SENIOR VICE PRESIDENT POSITIONS THAT REPORT DIRECTLY TO THE CEO ("EXECUTIVE GROUP"). IN 2012, TO DETERMINE THE COMPENSATION STRUCTURE OF THE EXECUTIVE GROUP, THE COMMITTEE RELIED ON A WRITTEN COMPENSATION SURVEY PRODUCED BY AN INDEPENDENT CONSULTING FIRM THAT ASSESSES EXECUTIVE COMPENSATION AND BENEFITS. THE COMMITTEE MET TO REVIEW THE COMPENSATION STRUCTURE OF THE EXECUTIVE GROUP AND REVIEWED THE COMPENSATION SURVEY PREPARED BY THE INDEPENDENT CONSULTING FIRM. THE COMMITTEE THEN VOTED TO APPROVE THE COMPENSATION OF THE EXECUTIVE GROUP (OTHER THAN THE CEO). FOR THE CEO'S COMPENSATION THE COMMITTEE (MEETING WITHOUT THE CEO) RECOMMENDED A COMPENSATION STRUCTURE THAT WAS PRESENTED TO THE FCHP'S BOARD OF DIRECTORS. THE BOARD OF DIRECTORS (WITHOUT THE CEO PRESENT), VOTED TO APPROVE THE COMMITTEE'S RECOMMENDATION. ALL THESE DELIBERATIONS WERE CONTEMPORANEOUSLY DOCUMENTED IN THE MINUTES OF THE COMMITTEE AND BOARD OF DIRECTORS. THE PROCESS WAS USED TO ESTABLISH THE COMPENSATION FOR THE EXECUTIVE GROUP IN 2012. THIS PROCESS WAS NOT USED TO ESTABLISH COMPENSATION FOR THE "KEY EMPLOYEES" LISTED IN SCHEDULE J.
AVAIL OF GOV DOCS, CONFLICT OF INTEREST POLICY, & FIN STMTS TO GEN PUBLIC FORM 990, PART VI, QUESTION 18 AND 19 FCHP'S FORM 990 AND ANNUAL AUDITED FINANCIAL STATEMENTS ARE AVAILABLE TO THE GENERAL PUBLIC ON THE MASSACHUSETTS ATTORNEY GENERAL'S WEBSITE. FCHP'S ANNUAL REPORT IS AVAILABLE ON ITS OWN WEBSITE. FCHP'S 990, FINANCIAL STATEMENTS, GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND ANNUAL REPORT ARE ALSO PROVIDED ON REQUEST.
FORM 990, PART VI, SECTION B, LINE 16B JOINT VENTURE POLICY FALLON COMMUNITY HEALTH PLAN, INC.'S JOINT VENTURE POLICY WAS ADOPTED ON DECEMBER 20, 2012.
OTHER CHANGES IN NET ASSETS OR FUND BALANCES FORM 990, PART XI, LINE 9 CHANGE IN MINIMUM PENSION $5,856,531 ROUNDING ADJUSTMENT ($2) ----------- OTHER CHANGES IN NET ASSETS $5,856,529
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.
Cat. No. 51056K
Schedule O (Form 990 or 990-EZ) 2012

Additional Data


Software ID:  
Software Version:  
SCHEDULE R
(Form 990)
Department of the Treasury
Internal Revenue Service
Related Organizations and Unrelated Partnerships
MediumBulletComplete if the organization answered "Yes" to Form 990, Part IV, line 33, 34, 35, 36, or 37.
MediumBulletAttach to Form 990. MediumBullet See separate instructions.

OMB No. 1545-0047
2012
Open to Public Inspection
Name of the organization
Fallon Community Health Plan Inc
 
Employer identification number

23-7442369
Part I
Identification of Disregarded Entities (Complete if the organization answered "Yes" to Form 990, Part IV, line 33.)
(a)
Name, address, and EIN (if applicable) of disregarded entity


(b)
Primary activity


 		(c)
Legal domicile (state
or foreign country)

 		(d)
Total income


 		(e)
End-of-year assets


 		(f)
Direct controlling
entity










Part II
Identification of Related Tax-Exempt Organizations (Complete if the organization answered "Yes" to Form 990, Part IV, line 34 because it had one or more related tax-exempt organizations during the tax year.)
(a)
Name, address, and EIN of related organization


(b)
Primary activity


 		(c)
Legal domicile (state
or foreign country)

 		(d)
Exempt Code section


 		(e)
Public charity status
(if section 501(c)(3))

 		(f)
Direct controlling
entity

 		(g)
Section 512(b)(13) controlled entity?
Yes No
(1) SUMMIT LIVING INC

10 CHESTNUT STREET

WORCESTER,MA01608
26-1836279 		ASST LIVING MA 501(C)(3) 9 NA
 
Yes
 












For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50135Y
Schedule R (Form 990) 2012
Schedule R (Form 990) 2012
Page 2
Part III
Identification of Related Organizations Taxable as a Partnership (Complete if the organization answered "Yes" to Form 990, Part IV, line 34 because it had one or more related organizations treated as a partnership during the tax year.)
(a)
Name, address, and EIN of
related organization



 		(b)
Primary activity




 		(c)
Legal
domicile
(state or foreign
country)


 		(d)
Direct controlling
entity



 		(e)
Predominant income(related, unrelated, excluded from tax under sections 512-514)

(f)
Share of total income




 		(g)
Share of end-of-year
assets



 		(h)
Disproprtionate allocations?




 		(i)
Code V—UBI
amount in box 20 of
Schedule K-1
(Form 1065)
 		(j)
General or
managing
partner?



 		(k)
Percentage
ownership
Yes No Yes No
(1) FALLON TOTAL CARE LLC

100 NORTH PARKWAY SUITE 300
WORCESTER,MA01653
45-5591420 		HEALTH CARE MA NA
  		EXCLUDED 512-514     Yes       No 51.000 %












Part IV
Identification of Related Organizations Taxable as a Corporation or Trust (Complete if the organization answered "Yes" to Form 990, Part IV, line 34 because it had one or more related organizations treated as a corporation or trust during the tax year.)
(a)
Name, address, and EIN of
related organization
 		(b)
Primary activity
 		(c)
Legal
domicile
(state or foreign
country)
 		(d)
Direct controlling
entity
 		(e)
Type of entity
(C corp, S corp,
or trust) 		(f)
Share of total income
 		(g)
Share of end-of-year
assets
 		(h)
Percentage
ownership
 		(i)
Section 512(b)(13) controlled entity?
Yes No
(1) FALLON HEALTH & LIFE ASSURANCE COMPANY

10 CHESTNUT STREET
WORCESTER,MA01608
04-3169246 		HLTH & LIFE ASSUR MA FCHP
  		C CORP -8,716,780 26,031,833 100.000 % Yes  
(2) ULTRABENEFITS INC

29 EAST MOUNTAIN STREET
WORCESTER,MA01606
04-3525752 		3RD PARTY ADMIN MA FHLAC
  		C CORP 200,241 1,651,515 100.000 % Yes  










Schedule R (Form 990) 2012
Schedule R (Form 990) 2012
Page 3
Part V
Transactions With Related Organizations (Complete if the organization answered "Yes" to Form 990, Part IV, line 34, 35b, or 36.)
Note. Complete line 1 if any entity is listed in Parts II, III, or IV of this schedule.
Yes
No
1 During the tax year, did the orgranization engage in any of the following transactions with one or more related organizations listed in Parts II-IV?
a Receipt of (i) interest (ii) annuities (iii) royalties or (iv) rent from a controlled entity . . . . . . . . . . . . . . . . . . . . . . .
1a
 
No
b Gift, grant, or capital contribution to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1b
Yes
 
c Gift, grant, or capital contribution from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1c
 
No
d Loans or loan guarantees to or for related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1d
 
No
e Loans or loan guarantees by related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1e
 
No
f Dividends from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1f
 
No
g Sale of assets to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1g
 
No
h Purchase of assets from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1h
 
No
i Exchange of assets with related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1i
 
No
j Lease of facilities, equipment, or other assets to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1j
 
No
k Lease of facilities, equipment, or other assets from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . .
1k
 
No
l Performance of services or membership or fundraising solicitations for related organization(s) . . . . . . . . . . . . . . . . . . . .
1l
Yes
 
m Performance of services or membership or fundraising solicitations by related organization(s) . . . . . . . . . . . . . . . . . . . .
1m
Yes
 
n Sharing of facilities, equipment, mailing lists, or other assets with related organization(s) . . . . . . . . . . . . . . . . . . . . .
1n
Yes
 
o Sharing of paid employees with related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1o
Yes
 
p Reimbursement paid to related organization(s) for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1p
 
No
q Reimbursement paid by related organization(s) for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1q
 
No
r Other transfer of cash or property to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1r
 
No
s Other transfer of cash or property from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1s
 
No
2
If the answer to any of the above is "Yes," see the instructions for information on who must complete this line, including covered relationships and transaction thresholds.
(a)
Name of other organization 		(b)
Transaction
type (a-s) 		(c)
Amount involved 		(d)
Method of determining amount involved
(1) FALLON HEALTH & LIFE ASSURANCE CO INC

 B 10,600,000 CASH
(2) FALLON TOTAL CARE LLC

 B 1,275,000 CASH
(3) ULTRABENEFITS INC

 L 52,536 CASH
(4) ULTRABENEFITS INC

 L 173,324 CASH
(5) ULTRABENEFITS INC

 M 84,700 CASH
(6) ULTRABENEFITS INC

 M 53,404 CASH
(7) FALLON HEALTH & LIFE ASSURANCE CO INC

 N 2,724,121 CASH
(8) FALLON HEALTH & LIFE ASSURANCE CO INC

 O 5,705,305 CASH
Schedule R (Form 990) 2012
Schedule R (Form 990) 2012
Page 4
Part VI
Unrelated Organizations Taxable as a Partnership (Complete if the organization answered "Yes" to Form 990, Part IV, line 37.)
Provide the following information for each entity taxed as a partnership through which the organization conducted more than five percent of its activities (measured by total assets or gross revenue) that was not a related organization. See instructions regarding exclusion for certain investment partnerships.
(a)
Name, address, and EIN of entity 		(b)
Primary activity 		(c)
Legal domicile
(state or foreign
country) 		(d)
Predominant income (related, unrelated, excluded from tax under section 512-514)

(e)
Are all partners
section
501(c)(3)
organizations? 		(f)
Share of total income




 		(g)
Share of
end-of-year
assets 		(h)
Disproprtionate allocations? 		(i)
Code V—UBI
amount in box 20
of Schedule K-1
(Form 1065) 		(j)
General or
managing
partner? 		(k)
Percentage
ownership
Yes No Yes No Yes No






























Schedule R (Form 990) 2012
Schedule R (Form 990) 2012
Page 5
Part VII
Supplemental Information
Complete this part to provide additional information for responses to questions on Schedule R (see instructions).
Identifier Return Reference Explanation

Additional Data


Software ID:  
Software Version: