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
Neighborhood Health Plan of Rhode Island
Employer identification number
05-0477052
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.") .
24,087
51,662
0
0
0
75,749
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......
351,528,454
388,620,353
415,427,897
423,570,696
430,147,979
2,009,295,379
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.
351,552,541
388,672,015
415,427,897
423,570,696
430,147,979
2,009,371,128
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.)
2,009,371,128
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...
351,552,541
388,672,015
415,427,897
423,570,696
430,147,979
2,009,371,128
10a
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
1,394,666
984,765
1,160,371
756,428
518,891
4,815,121
b
Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
0
c
Add lines 10a and 10b.
1,394,666
984,765
1,160,371
756,428
518,891
4,815,121
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.)
..
14,988
14,988
13
Total support. (Add lines 9, 10c, 11, and 12.)..
352,947,207
389,671,768
416,588,268
424,327,124
430,666,870
2,014,201,237
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
99.760 %
16
Public support percentage from 2012 Schedule A, Part III, line 15
...............
16
99.618 %
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2013 (line 10c, column (f) divided by line 13, column (f))
......
17
0.239 %
18
Investment income percentage from 2012 Schedule A, Part III, line 17
.............
18
0.381 %
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:
Software Version:
-
TIN:
SCHEDULE O (Form 990 or 990-EZ)
Department of the Treasury Internal Revenue Service
Supplemental Information to Form 990 or 990-EZ
Complete to provide information for responses to specific questions on
Form 990 or to provide any additional information.
Attach to Form 990 or 990-EZ.
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
Neighborhood Health Plan of Rhode Island
Employer identification number
05-0477052
Return Reference
Explanation
FORM 990, PART III, LINE 2
AS A RESULT OF THE AFFORDABLE CARE ACT (ACA) THE ORGANIZATION HAS EXPANDED SERVICES IN TWO AREAS. THE ORGANIZATION ENTERED THE COMMERCIAL MARKET BY OFFERING PRODUCTS ON THE STATE'S HEALTH BENEFIT EXCHANGE. THE ORGANIZATION NOW OFFERS PRODUCTS ON THE INDIVIDUAL AND SHOP (PLANS FOR SMALL BUSINESS) EXCHANGES. THE ORGANIZATION ALSO EXPANDED ITS MEDICAID PROGRAMS. THE ORGANIZATION SERVES AS A MANAGED CARE ORGANIZATION FOR THE ADULT MEDICAID POPULATION WHO RECEIVE EITHER LONG TERM CARE AND/OR HOME AND COMMUNITY BASED SERVICES. THE PROGRAM IS BEING DEVELOPED IN TWO PHASES. THE FIRST IS TO MANAGE THE CARE AND COORDINATION OF THEIR MEDICAID SERVICES AND COVERAGE. THE SECOND PHASE IS A THREE-WAY CONTRACT WITH THE STATE, THE CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS) AND THE MCO'S TO INCLUDE MEDICAID AS WELL AS MEDICARE'S MEDICAL AND PHARMACY BENEFITS. THE GOAL IS TO MANAGE THE INCREASINGLY COMPLEX MEDICAL AND FUNCTIONAL NEEDS OF THIS ADULT POPULATION AND BETTER COORDINATE THEIR SERVICES WHICH ARE CURRENTLY FRAGMENTED BY MULTIPLE PROVIDERS. DESCRIPTION OF RELATIONSHIPS FORM 990, PART VI, LINE 2 A MEMBER OF THE ORGANIZATION'S BOARD OF DIRECTORS IS AN EXECUTIVE DIRECTOR OF A COMMUNITY HEALTH CENTER (CHC), BLACKSTONE VALLEY COMMUNITY HEALTH CARE, INC. BLACKSTONE VALLEY HEALTH CARE, THROUGH A GRANT, INVESTED IN EQUIPMENT AND SOFTWARE FOR AN ELECTRONIC MEDICAL RECORD (EMR) SYSTEM. THREE OTHER CHC'S, EAST BAY, TRI-TOWN AND COMPREHENSIVE COMMUNITY ACTION PROGRAM, HAVE USE OF THE EMR AND BILLING SYSTEM AND WELLONE USES THE EMR PORTION OF THE SYSTEM. THE CHCS SHARE THE COST OF RUNNING THE SYSTEM. DESCRIPTION OF CLASSES OF MEMBERS OR STOCKHOLDERS FORM 990, PART VI, LINE 6 THE ORGANIZATION IS A 501(C)(3) CORPORATION AND HAS MEMBERS BUT DOES NOT HAVE ANY STOCKHOLDERS. THE ORGANIZATION HAS A BOARD OF DIRECTORS WHO ARE MEMBERS OF THE ORGANIZATION THAT MEET ON A REGULAR BASIS AND FUNCTION AS THE GOVERNING BODY OF THE ORGANIZATION. DESCRIBE THE PROCESS USED BY MANAGEMENT &/OR GOVERNING BODY TO REVIEW 990 FORM 990, PART VI, LINE 11B THE ORGANIZATION'S FISCAL OPERATIONS DEPARTMENT ACCUMULATES THE INFORMATION AND DATA NECESSARY TO COMPLETE THE FEDERAL FORM 990. AUDITED FINANCIAL STATEMENTS AND APPROVED POLICIES AND PROCEDURES ARE USED AS INPUT TO COMPLETE THE 990. A DRAFT RETURN IS PREPARED AND REVIEWED BY THE ORGANIZATION'S INDEPENDENT CERTIFIED PUBLIC ACCOUNTANTS. AFTER THE REVIEW PROCESS IS COMPLETED BY THE INDEPENDENT ACCOUNTANTS, THE FINANCE STAFF REVIEWS THE RETURN PRIOR TO FILING WITH THE IRS. THE BOARD IS ALSO PROVIDED AN ELECTRONIC COPY OF THE RETURN PRIOR TO FILING WITH THE IRS. POLICIES FORM 990, PART VI, LINES 12A, 12B, 13 & 14 PURSUANT TO THE INSTRUCTIONS FOR FORM 990, THE ORGANIZATION MUST ANSWER NO TO THE QUESTIONS BECAUSE THE BOARD OF DIRECTORS DOES NOT APPROVE OR ADOPT THESE POLICIES ON AN ANNUAL BASIS. HOWEVER, THE ORGANIZATION HAS ISSUED THESE POLICIES AT THE DIRECTION OF MANAGEMENT AND THESE POLICIES AND PROCEDURES ARE STRICTLY ENFORCED BY THE ORGANIZATION'S MANAGEMENT TEAM. CONFLICT OF INTEREST FORM 990, PART VI, LINE 12C AS PROMULGATED BY THE ORGANIZATION'S COMPLIANCE PLAN, THE ORGANIZATION'S DIRECTOR OF COMPLIANCE IS ALSO THE ORGANIZATION'S CHIEF PRIVACY OFFICIAL. ALL BOARD MEMBERS, COMMITTEE MEMBERS AND EMPLOYEES MUST DISCLOSE ALL CONFLICTS ON A SIGNED DISCLOSURE FORM ON A YEARLY BASIS. IF A POTENTIAL CONFLICT OF INTEREST IS REPORTED, THE PRIVACY OFFICIAL REVIEWS THE CIRCUMSTANCES TO DETERMINE IF A POSSIBLE CONFLICT EXISTS. IF IT IS DETERMINED THAT A CONFLICT EXISTS, THE PRIVACY OFFICIAL WILL MONITOR THE CONFLICT OF INTEREST AS NECESSARY AND/OR REFERS THE APPROPRIATE ITEMS THROUGH THE CHIEF FINANCIAL OFFICER TO THE CHIEF EXECUTIVE OFFICER FOR A RESOLUTION/DECISION. BOARD AND COMMITTEE MEMBERS REFRAIN FROM VOTING ON ISSUES WHERE THERE IS AN APPEARANCE OF A CONFLICT. OFFICES & POSITIONS FOR WHICH PROCESS WAS USED, & YEAR PROCESS WAS BEGUN FORM 990, PART VI, LINES 15A & 15B THE EXECUTIVE COMMITTEE OF THE BOARD OF DIRECTORS REVIEWS AND APPROVES THE CONTRACT OF THE CEO AND ANY CHANGES TO THE CONTRACT. THE ORGANIZATIONAL DEVELOPMENT AND HUMAN RESOURCES COMMITTEE OF THE BOARD OF DIRECTORS REVIEWS THE COMPENSATION OF THE CHIEF FINANCIAL OFFICER, CHIEF MEDICAL OFFICER AND THE CHIEF OPERATING OFFICER BASED ON COMPENSATION SURVEYS. THE COMMITTEE SUBSCRIBES TO THREE OR FOUR SALARY SURVEYS THAT LIST SALARY AND SALARY INCREASES BY POSITION, GEOGRAPHY, PLAN SIZE AND PROFIT VS NON-PROFIT ORGANIZATIONS. THESE SURVEYS ARE USED TO SET COMPENSATION ANNUALLY. AVAIL OF GOV DOCS, CONFLICT OF INTEREST POLICY, & FIN STMTS TO GEN PUBLIC FORM 990, PART VI, LINE 19 THE GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS ARE AVAILABLE TO THE PUBLIC UPON REQUEST AT THE ORGANIZATION'S LOCATION AT 299 PROMENADE STREET, PROVIDENCE, RI 02908. OTHER CHANGES IN NET ASSETS FORM 990, PART XI, LINE 9 YEAR-END CHANGES IN ENDING BALANCES OF NONADMITTED ASSETS: -$2,583,120. ACCOUNTING METHOD FORM 990, PART XII, LINE 1 THE ORGANIZATION USES THE STATUTORY METHOD OF ACCOUNTING.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.