Department of the Treasury Internal Revenue Service
Public Charity Status and Public Support
Complete if the organization is a section 501(c)(3) organization or a section
4947(a)(1) nonexempt charitable trust.
Attach to Form 990 or Form 990-EZ. See separate instructions. Information about Schedule A (Form 990 or 990-EZ) and its instructions is at www.irs.gov/form990.
OMB No. 1545-0047
2013
Open to Public Inspection
Name of the organization
HEALTH CARE EXCEL INCORPORATED - GROUP
Employer identification number
90-0399441
Part I
Reason for Public Charity Status
(All organizations must complete this part.) See instructions.
The organization is not a private foundation because it is: (For lines 1 through 11, check only one box.)
1
2
3
4
5
section 170(b)(1)(A)(iv). (Complete Part II.)
6
7
8
9
receipts from activities related to its exempt functions—subject to certain exceptions, and (2) no more than 331/3% of
its support from gross investment income and unrelated business taxable income (less section 511 tax) from businesses
acquired by the organization after June 30, 1975. See section 509(a)(2). (Complete Part III.)
10
11
e
By checking this box, I certify that the organization is not controlled directly or indirectly by one or more disqualified persons other than foundation managers and other than one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2).
f
If the organization received a written determination from the IRS that it is a Type I, Type II, or Type III supporting organization, check this box
..................................................
g
Since August 17, 2006, has the organization accepted any gift or contribution from any of the following persons?
(i) A person who directly or indirectly controls, either alone or together with persons described in (ii)
Yes
No
and (iii) below, the governing body of the supported organization?
................
11g(i)
(ii)
A family member of a person described in (i) above?
......................
11g(ii)
(iii)
A 35% controlled entity of a person described in (i) or (ii) above?
................
11g(iii)
h
Provide the following information about the supported organization(s).
(i) Name of supported organization
(ii) EIN
(iii) Type of organization (described on lines 1- 9 above or IRC section (see instructions))
(iv) Is the organization in col. (i) listed in your governing document?
(v) Did you notify the organization in col. (i) of your support?
(vi) Is the organization in col. (i) organized in the U.S.?
(vii) Amount of monetary support
Yes
No
Yes
No
Yes
No
Total
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990EZ.
Cat. No. 11285F
Schedule A (Form 990 or 990-EZ) 2013
Schedule A (Form 990 or 990-EZ) 2013
Page 2
Part II
Support Schedule for Organizations Described in Sections 170(b)(1)(A)(iv) and 170(b)(1)(A)(vi) (Complete only if you checked the box on line 5, 7, or 8 of Part I or if the
organization failed to qualify under Part III. If the organization fails to
qualify under the tests listed below, please complete Part III.)
Section A. Public Support
Calendar year (or fiscal year beginning in)
(a) 2009
(b) 2010
(c) 2011
(d) 2012
(e) 2013
(f) Total
1
Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") ....
2
Tax revenues levied for the organization's benefit and either paid to or expended on its behalf.......
3
The value of services or facilities furnished by a governmental unit to the organization without charge..
4
Total. Add lines 1 through 3
5
The portion of total contributions by each person (other than a governmental unit or publicly supported organization) included
on line 1 that exceeds 2% of the amount shown on line 11, column (f)..
6
Public support. Subtract line 5 from line 4.
Section B. Total Support
Calendar year
(or fiscal year beginning in)
(a) 2009
(b) 2010
(c) 2011
(d) 2012
(e) 2013
(f) Total
7
Amounts from line 4..
8
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources...
9
Net income from unrelated business activities, whether or not the business is regularly carried on..
10
Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)..
11
Total support (Add lines 7 through 10).
12
Gross receipts from related activities, etc. (see instructions)
..................
12
13
First five years.
If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization,
check this box and stop here.................................................
Section C. Computation of Public Support Percentage
14
Public support percentage for 2013 (line 6, column (f) divided by line 11, column (f))
.........
14
15
Public support percentage for 2012 Schedule A, Part II, line 14
...............
15
16a
33 1/3% support test—2013.
If the organization did not check the box on line 13, and line 14 is 33 1/3% or more, check this box
and stop here. The organization qualifies as a publicly supported organization
.......................
b
33 1/3% support test—2012.
If the organization did not check a box on line 13 or 16a, and line 15 is 33 1/3% or more, check this
box and stop here. The organization qualifies as a publicly supported organization
.....................
17a
10%-facts-and-circumstances test—2013.
If the organization did not check a box on line 13, 16a, or 16b, and line 14
is 10% or more, and if the organization meets the "facts-and-circumstances" test, check this box and stop here. Explain
in Part IV how the organization meets the "facts-and-circumstances" test. The organization qualifies as a publicly supported
organization
.....................................................
b
10%-facts-and-circumstances test—2012.
If the organization did not check a box on line 13, 16a, 16b, or 17a, and line
15 is 10% or more, and if the organization meets the "facts-and-circumstances" test, check this box and stop here.
Explain in Part IV how the organization meets the "facts-and-circumstances" test. The organization qualifies as a publicly supported organization
................................................
18
Private foundation.
If the organization did not check a box on line 13, 16a, 16b, 17a, or 17b, check this box and see
instructions
.....................................................
Schedule A (Form 990 or 990-EZ) 2013
Schedule A (Form 990 or 990-EZ) 2013
Page 3
Part III
Support Schedule for Organizations Described in Section 509(a)(2) (Complete only if you checked the box on line 9 of Part I or if the organization
failed to qualify under Part II. If the organization fails to qualify under
the tests listed below, please complete Part II.)
Section A. Public Support
Calendar year (or fiscal year beginning in)
(a) 2009
(b) 2010
(c) 2011
(d) 2012
(e) 2013
(f) Total
1
Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") .
7,687
210,483
74,395
292,565
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......
2,449,811
2,599,791
3,334,157
798,468
3,547,322
12,729,549
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.
2,457,498
2,810,274
3,334,157
872,863
3,547,322
13,022,114
7a
Amounts included on lines 1, 2, and 3 received from disqualified persons...
0
404,653
340,591
25,616
0
770,860
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
0
0
0
0
0
c
Add lines 7a and 7b..
0
404,653
340,591
25,616
0
770,860
8
Public support (Subtract line 7c from line 6.)
12,251,254
Section B. Total Support
Calendar year (or fiscal year beginning in)
(a) 2009
(b) 2010
(c) 2011
(d) 2012
(e) 2013
(f) Total
9
Amounts from line 6...
2,457,498
2,810,274
3,334,157
872,863
3,547,322
13,022,114
10a
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
11,476
1,317
1,811
412
1,085
16,101
b
Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
0
c
Add lines 10a and 10b.
11,476
1,317
1,811
412
1,085
16,101
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.)..
2,468,974
2,811,591
3,335,968
873,275
3,548,407
13,038,215
14
First five years.
If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization,
check this box and stop here.............................................
Section C. Computation of Public Support Percentage
15
Public support percentage for 2013 (line 8, column (f) divided by line 13, column (f))
.........
15
93.960 %
16
Public support percentage from 2012 Schedule A, Part III, line 15
...............
16
99.720 %
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2013 (line 10c, column (f) divided by line 13, column (f))
......
17
0.120 %
18
Investment income percentage from 2012 Schedule A, Part III, line 17
.............
18
19a
33 1/3% support tests—2013.
If the organization did not check the box on line 14, and line 15 is more than 33 1/3%, and line 17 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization
........
b
33 1/3% support tests—2012.
If the organization did not check a box on line 14 or line 19a, and line 16 is more than 33 1/3% and line 18 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization
.....
20
Private foundation.
If the organization did not check a box on line 14, 19a, or 19b, check this box and see instructions
.....
Schedule A (Form 990 or 990-EZ) 2013
Schedule A (Form 990 or 990-EZ) 2013
Page 4
Part IV
Supplemental Information.
Provide the explanations required by Part II, line 10; Part II, line 17a or 17b; and Part III, line 12. Also complete this part for any additional information. (See instructions).
Facts And Circumstances Test
Explanation
Schedule A (Form 990 or 990-EZ) 2013
Additional Data
Software ID:
13000248
Software Version:
2013v3.1
-
TIN:
SCHEDULE O (Form 990 or 990-EZ)
Department of the Treasury Internal Revenue Service
Supplemental Information to Form 990 or 990-EZ
Complete to provide information for responses to specific questions on
Form 990 or to provide any additional information.
Attach to Form 990 or 990-EZ.
Information about Schedule O (Form 990 or 990-EZ) and its instructions is at
www.irs.gov/form990.
OMB No. 1545-0047
2013
Open to Public Inspection
Name of the organization
HEALTH CARE EXCEL INCORPORATED - GROUP
Employer identification number
90-0399441
Return Reference
Explanation
FORM 990, PART I, LINE 8, PART 1, SUMMARY, LINES 8-19, PRIOR YEAR
THE PRIOR YEAR COLUMN AMOUNTS REFLECT THE FILING ORGANIZATION'S SHORT PERIOD FROM OCTOBER 1, 2013 TO DECEMBER 31, 2013 AS RESULT OF AN ACCOUNTING YEAR END CHANGE.
FORM 990, PART VI, LINE 15A, FORM 990, PART VI, LINES 15A AND 15B
ALL EMPLOYEES AND OFFICERS ARE EMPLOYED BY HEALTH CARE EXCEL, INCORPORATED A RELATED ENTITY. SCHEDULE J, PART I, LINE 3 NARRATIVE DESCRIBES THE RELATED PARTY'S PROCESS USED TO ESTABLISH THE COMPENSATION OF THE PRESIDENT/CEO.
Form 990, Part VI, Sec A, Line 6, Classes of members or stockholders
HEALTH CARE EXCEL, INCORPORATED, AN INDIANA NONPROFIT CORPORATION, IS THE SOLE CORPORATE MEMBER FOR THE ORGANIZATION INCLUDED IN THE GROUP RETURN (HEALTH CARE EXCEL OF KENTUCKY.
Form 990, Part VI, Sec A, Line 7a, Members or stockholders electing members of governing body
HEALTH CARE EXCEL, INCORPORATED, AN INDIANA NONPROFIT CORPORATION, HAS THE POWER TO APPOINT ALL DIRECTORS FOR THE ORGANIZATION INCLUDED IN THE GROUP RETURN.
Form 990, Part VI, Sec B, Line 11b, Review of form 990 by governing body
PRIOR TO FILING WITH THE IRS, THE FORM IS REVIEWED BY MANAGEMENT AND THEN IS PRESENTED BY MANAGEMENT AND OR THE EXTERNAL TAX PREPARATION FIRM TO THE BOARD'S FINANCE AND AUDIT COMMITTEE AND ANY REVISIONS ARE MADE THAT ARE NECESSARY. THE FINANCE AND AUDIT COMMITTEE WILL APPROVE THE FORM FOR FILING. THE BOARD IS PROVIDED A COPY OF THE FORM 990 PRIOR TO FILING AND SIGN OFF ON THE FORM. ACCEPTANCE IS RECORDED IN THE MEETING MINUTES.
Form 990, Part VI, Sec B, Line 12c, Conflict of interest policy
ALL EMPLOYEES, OFFICERS, AND DIRECTORS MUST REVIEW AND SIGN A CONFLICT OF INTEREST STATEMENT. EDUCATION OR REVIEW OF THE POLICY INCLUDES INSTRUCTIONS THAT SHOULD AN INDIVIDUALS SITUATION CHANGE THROUGHOUT THE YEAR, HE OR SHE IS REQUIRED TO PROVIDE NOTIFICATION OF THE CHANGE SO AN EVALUATION CAN BE CONDUCTED TO DETERMINE IF A CONFLICT EXISTS. THE DETECTION AND PREVENTION OF A POTENTIAL OR ACTUAL COI IS ULTIMATELY THE RESPONSIBILITY OF EACH INDIVIDUAL. SUPERVISORY STAFF MUST ENSURE THERE ARE ADEQUATE SAFEGUARDS IN PLACE AND APPROPRIATE MONITORING CONDUCTED TO REDUCE OR ELIMINATE THE RISK OF AN ADVERSE EVENT RELATED TO A COI. DISCLOSURE SHALL INCLUDE EACH TYPE OF POTENTIAL CONFLICT, AS WELL AS THE NATURE OF THE ACTIVITY OR RELATIONSHIP. A FULL DISCLOSURE SHOULD BE PROVIDED OF ALL PARTIES INVOLVED, ANY POTENTIAL FOR FINANCIAL GAIN OR REWARDS, AND ANY OTHER PERTINENT INFORMATION. INDIVIDUALS WHO DO NOT DISCLOSE COI COULD BE SUBJECT TO CIVIL PENALTIES AND/OR IMMEDIATE TERMINATION OF SERVICES OR EMPLOYMENT, AMONG OTHER CONSEQUENCES. ANY PERSON WHO HAS KNOWLEDGE OF A POTENTIAL OR ACTUAL COI MUST NOTIFY THE APPROPRIATE SUPERVISOR, OR OTHER POINT OF CONTACT. IN THE EVENT OF A CONFIRMED BREACH, THE SUPERVISOR OR OTHER POINT OF CONTACT WILL DOCUMENT ALL THE FACTS AND EVENTS ON AN INCIDENT NOTIFICATION FORM AND SUBMIT THE INFORMATION TO THE SENIOR DIRECTOR, OPERATIONS IMPROVEMENT THROUGH INCIDENTS@HCE.ORG. ADDITIONAL INVESTIGATION OR ACTIONS WILL BE TAKEN AS INDICATED BY THE CIRCUMSTANCES. IN ANY CASE WHERE A BOARD MEMBER HAS A CONFLICT THEY WOULD REFRAIN FROM CONVERSATION AND VOTE ON THE MATTER. IN ADDITION, IF AN EMPLOYEE HAS A CONFLICT, THEY WOULD NOT PARTICIPATE IN THE AREA, WHETHER IT IS PERFORMING WORK OR DELIBERATING IN THE CONFLICT TRANSACTION.
Form 990, Part VI, Sec B, Line 15a, Process to establish compensation of top management official
A COMPENSATION PACKET IS PREPARED FOR EACH OFFICER AND HIGHLY COMPENSATED INDIVIDUAL (SALARY GREATER THAN $150,000) FOR EACH PERIOD UNDER REVIEW. THE CEO DELIVERS THE COMPENSATION PACKET TO THE BOARD'S EXECUTIVE COMMITTEE (COMMITTEE), WHICH ALSO ACTS AS THE COMPENSATION COMMITTEE, MAKES A PRESENTATION, AND RESPONDS TO COMMITTEE QUESTIONS. WHEN IT IS THE CEO'S COMPENSATION UNDER REVIEW, THE COMPENSATION PACKAGE IS DELIVERED TO THE COMMITTEE WITH NO RECOMMENDATION. THE COMMITTEE THEN VOTES AND RENDERS A DECISION ON THE COMPENSATION PACKAGE UNDER REVIEW AND NOTIFIES HUMAN RESOURCES IN WRITING TO TAKE THE COMMITTEE APPROVED ACTION. DOCUMENTS INCLUDED IN COMPENSATION PACKET: -THE MANAGER OF THE PERSON UNDER REVIEW PREPARES A PERFORMANCE REVIEW FOR THE PERIOD BEING CONSIDERED. -THE INDIVIDUAL PREPARED PERFORMANCE GOALS FOR THE UPCOMING PERIOD AND REPORTS ON THE PROGRESS MADE TOWARDS THE GOALS FOR THE PERIOD UNDER CONSIDERATION, VALIDATED BY THE INDIVIDUAL'S MANAGER. PERIODICALLY, AN OUTSIDE FIRM IS HIRED TO DO A SALARY SURVEY FOR HIGHLY COMPENSATED INDIVIDUALS AND MAKES SALARY RECOMMENDATIONS THAT ARE PRESENTED TO THE BOARD. IN 2013, THERE WAS A REVIEW OF COMPENSATION AND RECOMMENDATION BASED ON JOB, SKILLS REQUIRED FOR POSITION, INDUSTRY AND GEOGRAPHIC LOCATION.
Form 990, Part VI, Sec C, Line 19, Required documents available to the public
THE ORGANIZATION DOES NOT MAKE THE GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, OR FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC.
Form 990 , Part XI, Line 9, Other changes in net assets or fund balances
TRANSFER TO RELATED ORGANIZATION - -284110; ROUNDING - 5;
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.