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
Western Connecticut Medical Group Inc
Employer identification number
06-1137531
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.") .
116,269
116,269
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......
131,374,921
138,666,422
161,667,754
163,973,312
166,651,343
762,333,752
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.
131,374,921
138,666,422
161,667,754
163,973,312
166,767,612
762,450,021
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..
8
Public support (Subtract line 7c from line 6.)
762,450,021
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...
131,374,921
138,666,422
161,667,754
163,973,312
166,767,612
762,450,021
10a
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
358,176
308,388
349,325
329,788
378,269
1,723,946
b
Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
178,017
181,467
359,484
c
Add lines 10a and 10b.
358,176
308,388
349,325
507,805
559,736
2,083,430
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.)..
131,733,097
138,974,810
162,017,079
164,481,117
167,327,348
764,533,451
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
99.730 %
16
Public support percentage from 2012 Schedule A, Part III, line 15
...............
16
99.510 %
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2013 (line 10c, column (f) divided by line 13, column (f))
......
17
0.270 %
18
Investment income percentage from 2012 Schedule A, Part III, line 17
.............
18
0.280 %
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:
13000170
Software Version:
2013v4.0
-
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
Western Connecticut Medical Group Inc
Employer identification number
06-1137531
Return Reference
Explanation
Form 990, Part III, Line 4d: Other Program Services Description
OTHER PROGRAM SERVICES 4: All other program services include surgery, oncology, pathology, psycology, OBGYN, pediatrics and administration. OTHER PROGRAM SERVICES 5: OTHER PROGRAM SERVICES 6:
Form 990, Part VI, Line 3: Description of Delegated Duties to Management Company
The Executive Director and CFO operations at WCMG are administered by a management company, as directed by the board of trustees. Thomas Linhares (Executive Director) and Colleen Scott (CFO) are employees of JHD Group. JHD Group is reported in Part VII, Section B.
Form 990, Part VI, Line 4: Description of Significant Changes to Organizational Documents
On 1/1/2014 Western Connecticut Health Network (WCHN) became the sole corporate member of Norwalk Health Services Corporation, and a corporate affiliation was completed.Western Connecticut Medical Group changed its corporate structure, moving from a professional services corporation (P.C.) to a Medical Foundation structure (Inc.) January 1,2014.The following significant changes were made to the by laws of Western Connecticut Medical Group, during the fiscal year ending September 30, 2014:1)Revised the powers of WCHN as member to allow WCHN to take additional actions without requiring approval of the Board of the Corporation. WCMG in section 1.3 to add: -Approval of changes to qualified and non-qualified benefit plans -Approval of policies -Approval of quality, performance and credentialing standards -Approval of physician compensation methodologySection 1.3 was further amended to delete the requirement that WCHN approve managed care contracts and filing of a certificate of need. Approval of a certificate of need is not legally required and WCHN is required to approve any changes in clinical services. Thus, approval of the actual filing for a certificate of need was deemed duplicative.2) Section 2.1 - inserted requirement that the Board of the Corporation may not overlap with the board of directors of a for-profit health system, hospital or medical school, or with a medical foundation formed by such a for-profit entity. Connecticuts' medical foundation act was recently amended to include this requirement.3) Article V - revised to allow the Chief Financial Officer of WCHN to serve as the Corporation's Treasurer, ex-officio. The Treasurer will have authority to exercise investment management decisions for the Corporation, provided that the Treasurer reports regularly to the directors and exercises such authority in accordance with the investment policies of the Corporation and in consulation with WCHN's Finance Committee.In connection with the change in the Treasurer, the composition of the Governance Committee has been changed to provide that the Treasurer no longer automatically serves on that committee.
Form 990, Part VI, Line 6: Explanation of Classes of Members or Shareholder
The Corporation's sole member is Western Connecticut Health Network, Inc.
Form 990, Part VI, Line 7a: How Members or Shareholders Elect Governing Body
Western Connecticut Health Network, Inc (the "Member") shall have the exclusive right (i)to elect the Corporation's board of directors and to appoint individuals to fill vacancies on the board of directors; (ii)amend the bylaws of the Corporation; and (iii)to remove any director with or without cause.
Form 990, Part VI, Line 7b: Describe Decisions of Governing Body Approval by Members or Shareholders
Fundamental changes are subject to the approval of the Member (Western Connecticut Health Network, Inc), the directors, by the affirmative vote of of no less than two-thirds of all directors present required to (a) amend certificate of incorporation (b) transfer substantially all the Corporations assets to, or merge the Corporation (c) sell or mortgage substantially all the Corporations assets (d) dissolve the Corporation.
Form 990, Part VI, Line 11b: Form 990 Review Process
The organization provides a copy of the completed 990 forms to the Network audit committee for review. The forms are reviewed by the chief financial officer, president and executive director. Ernst & Young conducts a review of the return for completeness and accuracy. Prior to the 990 being filed with the IRS, the Board will receive a full and accurate copy on a secured website for their review.
Form 990, Part VI, Line 15b: Compensation Review and Approval Process for Officers and Key Employees
Compensation review and approval process for officers and key employees are reviewed and based on outside market data from a third party vendor. The review was last performed in September 2014. Compensation is further reviewed by the human resources department, the WCMG Board of Directors and WCHN Committee on Governance. The CEO, CFO, CMO and COO of the Medical Group are outsourced to a management company, the JHD Group. The CEO and CFO are paid by WCMG and the COO and CMO are paid by a related party (WCHN). The Board negotiated the management agreement, inclusive of the related compensation.
Form 990, Part VI, Line 18: Explanation of Other Means Forms Available For Public Inspection
Forms 1023, 990 and 990-T are available on the Danbury Hospital's website at WWW.DANBURYHOSPITAL.ORG.
Form 990, Part VI, Line 19: Other Organization Documents Publicly Available
The information that has been posted on the Danbury Hospital website for 2014 includes:The most current audited financial statements.Also included is the Code of Business Ethics, Information about our Compliance Program, and a copy of our policy regarding Preventing of Fraud, Waste and Abuse.All governing documents required by law are made available upon request.The conflict of interest policy is available upon request.
Other Changes In Net Assets Or Fund Balances - Other Increases
Transfer to Equity for Danbury Hospital Intercompany = $8448820
Form 990, Part I Line 1 & Part III, Line 1
The mission of WCMG is to provide safe, innovative, convenient and coordinated primary and specialty health care in the communities we serve and strive to be aware of and respond to our patients needs. We support a commitment to advance the health and well-being of people in our community by delivering quality care participating in medical research and medical residency programs and the provision of medical services to patients.
Form 990, Part VI (Addt'l Information)
The policies exist at the parent level, which are followed by each entity and are approved by the parent board, but not each individual board.
Form 990, Part VII (Addt'l Information)
For those officers and top 5 employees, for which only 40 hours is noted to reflect paid hours, actual hours worked exceeded this amount.Note: All amounts in column F, of Part VII, "Estimated Amount of Other Compensation", represents benefits, and do not reflect any compensation for which the average amount of time worked can be reflected.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.