Attach to Form 990 or Form 990-EZ.
Information about Schedule A (Form 990 or 990-EZ) and its instructions is at www.irs.gov/form990.
| (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 listed in your governing document? | (v) Amount of monetary support (see instructions) | (vi) Amount of other support (see instructions) | |
|---|---|---|---|---|---|---|
| Yes | No | |||||
| Total | ||||||
Calendar year (or fiscal year beginning in) ![]() |
(a) 2010 | (b) 2011 | (c) 2012 | (d) 2013 | (e) 2014 | (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. | ||||||
Calendar year
(or fiscal year beginning in) ![]() |
(a) 2010 | (b) 2011 | (c) 2012 | (d) 2013 | (e) 2014 | (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 VI.).. | ||||||
| 11 | Total support Add lines 7 through 10. | ||||||
Calendar year (or fiscal year beginning in) ![]() |
(a) 2010 | (b) 2011 | (c) 2012 | (d) 2013 | (e) 2014 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 1 | Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") . | ||||||
| 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...... | ||||||
| 3 | Gross receipts from activities that are not an unrelated trade or business under section 513.. | ||||||
| 4 | Tax revenues levied for the organization's benefit and either paid to or expended on its behalf... | ||||||
| 5 | The value of services or facilities furnished by a governmental unit to the organization without charge.. | ||||||
| 6 | Total. Add lines 1 through 5. | ||||||
| 7a | Amounts included on lines 1, 2, and 3 received from disqualified persons... | ||||||
| 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. | ||||||
| c | Add lines 7a and 7b.. | ||||||
| 8 | Public support (Subtract line 7c from line 6.) | ||||||
Calendar year (or fiscal year beginning in) ![]() |
(a) 2010 | (b) 2011 | (c) 2012 | (d) 2013 | (e) 2014 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 9 | Amounts from line 6... | ||||||
| 10a | Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources.. | ||||||
| b | Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975. | ||||||
| c | Add lines 10a and 10b. | ||||||
| 11 | Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on. | ||||||
| 12 | Other income. Do not include gain or loss from the sale of capital assets (Explain in Part VI.) .. | ||||||
| 13 | Total support. (Add lines 9, 10c, 11, and 12.).. | ||||||
| Section A - Adjusted Net Income | (A) Prior Year |
(B) Current Year (optional) |
||||
| 1 | Net short-term capital gain | 1 | ||||
| 2 | Recoveries of prior-year distributions | 2 | ||||
| 3 | Other gross income (see instructions) | 3 | ||||
| 4 | Add lines 1 through 3 | 4 | ||||
| 5 | Depreciation and depletion | 5 | ||||
| 6 | Portion of operating expenses paid or incurred for production or collection of gross income or for management, conservation, or maintenance of property held for production of income (see instructions) | 6 | ||||
| 7 | Other expenses (see instructions) | 7 | ||||
| 8 | Adjusted Net Income (subtract lines 5, 6 and 7 from line 4) | 8 | ||||
| Section B - Minimum Asset Amount | (A) Prior Year |
(B) Current Year (optional) |
||||
| 1 | Aggregate fair market value of all non-exempt-use assets (see instructions for short tax year or assets held for part of year): | 1 | ||||
| a | Average monthly value of securities | 1a | ||||
| b | Average monthly cash balances | 1b | ||||
| c | Fair market value of other non-exempt-use assets | 1c | ||||
| d | Total (add lines 1a, 1b, and 1c) | 1d | ||||
| e | Discount claimed for blockage or other factors (explain in detail in Part VI): | |||||
| 2 | Acquisition indebtedness applicable to non-exempt use assets | 2 | ||||
| 3 | Subtract line 2 from line 1d | 3 | ||||
| 4 | Cash deemed held for exempt use. Enter 1-1/2% of line 3 (for greater amount, see instructions). | 4 | ||||
| 5 | Net value of non-exempt-use assets (subtract line 4 from line 3) | 5 | ||||
| 6 | Multiply line 5 by .035 | 6 | ||||
| 7 | Recoveries of prior-year distributions | 7 | ||||
| 8 | Minimum Asset Amount (add line 7 to line 6) | 8 | ||||
| Section C - Distributable Amount | Current Year | |||||
| 1 | Adjusted net income for prior year (from Section A, line 8, Column A) | 1 | ||||
| 2 | Enter 85% of line 1 | 2 | ||||
| 3 | Minimum asset amount for prior year (from Section B, line 8, Column A) | 3 | ||||
| 4 | Enter greater of line 2 or line 3 | 4 | ||||
| 5 | Income tax imposed in prior year | 5 | ||||
| 6 | Distributable Amount. Subtract line 5 from line 4, unless subject to emergency temporary reduction (see instructions) | 6 | ||||
| 7 | Check here if the current year is the organization's first as a non-functionally-integrated Type III supporting organization (see instructions) | |||||
| Section D - Distributions | Current Year | |
|---|---|---|
| 1 Amounts paid to supported organizations to accomplish exempt purposes | ||
|
2
Amounts paid to perform activity that directly furthers exempt purposes of supported organizations, in excess of income from activity |
||
| 3 Administrative expenses paid to accomplish exempt purposes of supported organizations | ||
| 4 Amounts paid to acquire exempt-use assets | ||
| 5 Qualified set-aside amounts (prior IRS approval required) | ||
| 6 Other distributions (describe in Part VI). See instructions | ||
| 7Total annual distributions. Add lines 1 through 6. | ||
|
8
Distributions to attentive supported organizations to which the organization is responsive (provide details in Part VI). See instructions |
||
| 9 Distributable amount for 2014 from Section C, line 6 | ||
| 10 Line 8 amount divided by Line 9 amount | ||
| Section E - Distribution Allocations (see instructions) |
(i) Excess Distributions |
(ii) Underdistributions Pre-2014 |
(iii) Distributable Amount for 2014 |
|
|---|---|---|---|---|
|
1
Distributable amount for 2014 from Section C, line 6 |
||||
|
2
Underdistributions, if any, for years prior to 2014 (reasonable cause required--see instructions) |
||||
| 3 Excess distributions carryover, if any, to 2014: | ||||
| a From 2009.......X | ||||
| b From 2010.......X | ||||
| c From 2011.......X | ||||
| d From 2012.......X | ||||
| e From 2013....... | ||||
| fTotal of lines 3a through e | ||||
| g Applied to underdistributions of prior years | ||||
| h Applied to 2014 distributable amount | ||||
|
i
Carryover from 2009 not applied (see instructions) |
||||
| j Remainder. Subtract lines 3g, 3h, and 3i from 3f. | ||||
| 4Distributions for 2014 from Section D, line 7: | ||||
| $ | ||||
| a Applied to underdistributions of prior years | ||||
| b Applied to 2014 distributable amount | ||||
| c Remainder. Subtract lines 4a and 4b from 4. | ||||
|
5
Remaining underdistributions for years prior to 2014, if any. Subtract lines 3g and 4a from line 2 (if amount greater than zero, see instructions) |
||||
|
6
Remaining underdistributions for 2014. Subtract lines 3h and 4b from line 1 (if amount greater than zero, see instructions) |
||||
|
7 Excess distributions carryover to 2015. Add lines 3j and 4c. |
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| 8 Breakdown of line 7: | ||||
| a From 2010.......X | ||||
| b From 2011.......X | ||||
| c From 2012.......X | ||||
| d From 2013....... | ||||
| e From 2014....... | ||||
| Facts And Circumstances Test |
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| Return Reference | Explanation |
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| Software ID: | |
| Software Version: |
Attach to Form 990 or 990-EZ.
Information about Schedule O (Form 990 or 990-EZ) and its instructions is at| Return Reference | Explanation |
|---|---|
| DESCRIPTION OF OTHER PROGRAM SERVICES | FORM 990, PART III, LINE 2 THE PLAN ESTABLISHED A QUALIFIED HEALTH PLAN (QHP) UNDER HEALTH CARE REFORM, WHICH IS CERTIFIED BY THE NEW YORK STATE HEALTH INSURANCE MARKETPLACE. QHP PROVIDES ESSENTIAL HEALTH BENEFITS, FOLLOWS ESTABLISHED LIMITS ON COST-SHARING (DEDUCTIBLE, COPAYMENT AND OUT-OF-POCKET MAXIMUM AMOUNTS), AND MUST MAINTAIN COMPLIANCE WITH OTHER PROVISIONS OF HEALTH CARE REFORM. COVERAGE FOR QHP MEMBERS BEGAN JANUARY 1, 2014 FORM 990, PART III LINE 3 THE PLAN'S FAMILY HEALTH PLUS (FHP) PROGRAM BEGAN OPERATIONS ON OCTOBER 1, 2001. FHP PROVIDES HEALTH INSURANCE COVERAGE FOR LOW-INCOME SINGLE ADULTS AND ADULTS WITH CHILDREN. THE FHP PROGRAM IS ADMINISTERED UNDER THE SAME AGREEMENT AS THE MEDICAID PROGRAM. THE FHP PROGRAM ENDED ON DECEMBER 31, 2014, AND NO COVERAGE WILL BE AUTHORIZED PAST THAT DATE. FORM 990, PART III LINE 4d THE CHILD HEALTH PLUS (CHP) PROGRAM IS FUNDED BY THE STATE OF NEW YORK TO PROVIDE HEALTH INSURANCE COVERAGE FOR CHILDREN THAT ARE UNDER THE AGE OF 19. START UP COST FOR TWO PROGRAMS MEDICAL LONG TERM CARE AND THE QUALITY HEALTH PLAN. THE PLAN ESTABLISHED A QUALIFIED HEALTH PLAN (QHP) UNDER HEALTH CARE REFORM, WHICH IS CERTIFIED BY THE NEW YORK STATE HEALTH INSURANCE MARKETPLACE. QHP PROVIDES ESSENTIAL HEALTH BENEFITS, FOLLOWS ESTABLISHED LIMITS ON COST-SHARING (DEDUCTIBLE, COPAYMENT AND OUT-OF-POCKET MAXIMUM AMOUNTS), AND MUST MAINTAIN COMPLIANCE WITH OTHER PROVISIONS OF HEALTH CARE REFORM. COVERAGE FOR QHP MEMBERS BEGAN JANUARY 1, 2014. |
| DESCRIBE THE PROCESS TO REVIEW THE FORM 990 | FORM 990, PART VI, LINE 11B THE FINANCIAL STAFF COMPILES THE FINANCIAL AND OTHER INFORMATION REQUIRED IN THE 990 RETURN. ERNST & YOUNG, LLP, PREPARES THE RETURN AND THE INFORMATION IS REVIEWED BY THE COMPANY'S CFO. A FINAL COPY OF THE FORM 990 IS MADE AVAILABLE TO THE ENTIRE GOVERNING BODY BEFORE FILING. |
| DESCRIPTION OF PROCESS TO MONITOR TRANSACTIONS FOR CONFLICTS OF INTEREST | FORM 990, PART VI, QUESTION 12C 1. ACTUAL OR POTENTIAL CONFLICTS OF INTEREST MUST BE DISCLOSED TO APPROPRIATE MANAGEMENT PERSONNEL, HUMAN RESOURCES OR THE CORPORATE COMPLIANCE OFFICER. 2. EMPLOYEES MUST SEEK GUIDANCE AND APPROVAL FROM APPROPRIATE MANAGEMENT PERSONNEL PRIOR TO PURSUING ANY BUSINESS OR PERSONAL ACTIVITY THAT MAY CONSTITUTE A CONFLICT OF INTEREST. 3. MANAGEMENT, WITH PURCHASING AUTHORITY, WILL COMPLETE A RELATED PARTY QUESTIONNAIRE ANNUALLY TO IDENTIFY ANY POTENTIAL OR ACTUAL CONFLICTS OF INTEREST. 4. EMPLOYEES, UPON HIRE AND ANNUALLY THEREAFTER, REVIEW THE CODE OF ETHICS WHICH INCLUDES INFORMATION ON CONFLICTS OF INTEREST. IN ADDITION, EMPLOYEES ARE REQUIRED TO SIGN AN ATTESTATION UPON HIRE AND ANNUALLY THEREAFTER, THAT THEY ACKNOWLEDGE AND UNDERSTOOD THE CODE OF ETHICS. |
| OFFICERS & POSITIONS FOR WHICH PROCESS WAS USED, & YEAR PROCESS WAS BEGUN | FORM 990, PART VI, QUESTION 15A AND 15B THE PROCESS FOR DETERMINING COMPENSATION FOR THE CEO, CFO AND COO INCLUDED REVIEW AND APPROVAL BY A COMPENSATION COMMITTEE (THE "COMMITTEE") COMPRISED OF INDEPENDENT DIRECTORS CHARGED WITH THIS RESPONSIBILITY, CONSIDERATION OF COMPARABILITY DATA AND CONTEMPORANEOUS SUBSTANTIATION AND DOCUMENTATION OF THE DELIBERATION AND DECISION. AFFINITY HEALTH PLAN'S COMPENSATION PROGRAM FOR THESE POSITIONS AND OTHER OFFICERS AND KEY EMPLOYEES INCLUDES ESTABLISHED POLICIES FOR JOB EVALUATION USING A POINT FACTOR SYSTEM; MERIT INCREASES; AND SALARY ACTIONS ASSOCIATED WITH NEW HIRES, PROMOTIONS, TRANSFERS AND DEMOTIONS. SPECIFICALLY, FOR: A) THE CEO - COMPENSATION FOR THE CHIEF EXECUTIVE OFFICER IS ESTABLISHED BY THE COMPENSATION COMMITTEE AND RATIFIED BY THE BOARD OF DIRECTORS OF AFFINITY HEALTH PLAN. THE BOARD AND THE COMMITTEE HAS ESTABLISHED COMPENSATION TERMS FOR THE CEO CONSIDERING COMPARABILITY DATA FOR CEO POSITIONS IN SIMILAR ORGANIZATIONS IN THEIR DELIBERATIONS AND DECISION MAKING. THESE DECISIONS ARE DOCUMENTED IN ACCORDANCE WITH LEGAL REQUIREMENTS AND BEST PRACTICES. B) OTHER OFFICERS AND KEY EMPLOYEES - JOBS HELD BY OTHER OFFICERS AND JOBS HELD BY KEY EMPLOYEES ARE EVALUATED USING THE POINT FACTOR JOB EVALUATION PROCESS APPLICABLE TO ALL JOBS AT AFFINITY HEALTH PLAN. BASED ON THE POINT FACTOR EVALUATION, JOBS ARE PLACED IN A SALARY GRADE. MERIT INCREASES ARE AWARDED BASED ON PERFORMANCE AFTER A FORMAL YEAR END PERFORMANCE EVALUATION. THIS PROGRAM APPLIES TO ALL EMPLOYEES INCLUDING OTHER OFFICERS AND KEY EMPLOYEES. DISCRETIONARY COMPENSATION DECISIONS APPLICABLE FOR OTHER OFFICERS AND KEY EMPLOYEES, INCLUDING PROMOTIONAL SALARY ADJUSTMENTS, MARKET/EQUITY SALARY ADJUSTMENTS AND STARTING SALARIES FOR NEWLY HIRED OFFICERS AND KEY EMPLOYEES ARE MADE AFTER REVIEW OF COMPARABILITY DATA FROM PUBLISHED SOURCES FOR SIMILAR POSITIONS IN THE RELEVANT LABOR MARKET. PUBLISHED COMPARABILITY DATA UTILIZED INCLUDES INDUSTRY SPECIFIC DATA. INTERNAL DATA IS REVIEWED AS WELL WITH THE OBJECTIVE OF ENSURING INTERNAL EQUITY WITH SIMILARLY SITUATED STAFF. DISCRETIONARY COMPENSATION DECISIONS IMPACTING THOSE OF THE FOREGOING POSITIONS THAT ARE ALSO DEEMED TO BE "DISQUALIFIED PERSONS" UNDER THE INTERNAL REVENUE CODE (E.G., CHIEF OPERATING OFFICER AND CHIEF FINANCIAL OFFICER) ARE MADE BY THE COMMITTEE (AND RATIFIED BY THE BOARD) IN ACCORDANCE WITH "INTERMEDIATE SANCTIONS SAFE HARBOR" STANDARDS UTILIZING THE SAME PROCESSES AS ARE APPLIED TO THE CEO (DISCUSSED ABOVE). |
| Avail of Gov Docs, Conflict of Interest Policy, & Fin Stmts to Gen Public | Form 990, Part VI, Question 19 DOCUMENTS ARE MADE AVAILABLE UPON REQUEST. |
| FORM 990 PART IX LINE 24 - OTHER EXPENSES | DESCRIPTION:PROFESSIONAL COSTS TOTAL EXPENSES:116006222 PROGRAM SERVICES:116006222 |
| FORM 990 PART IX LINE 24 - OTHER EXPENSES | DESCRIPTION:RADIOLOGY/LAB & DIAGNOSTIC TOTAL EXPENSES:78404270 PROGRAM SERVICES:78404270 |
| FORM 990 PART IX LINE 24 - OTHER EXPENSES | DESCRIPTION:MEDICAID TOTAL EXPENSES:48692654 PROGRAM SERVICES:48692654 |
| FORM 990 PART IX LINE 24 - OTHER EXPENSES | DESCRIPTION:EMERGENCY ROOM TOTAL EXPENSES:38915322 PROGRAM SERVICES:38915322 |
| FORM 990 PART IX LINE 24 - OTHER EXPENSES | DESCRIPTION:DENTAL TOTAL EXPENSES:38237242 PROGRAM SERVICES:38237242 |
| FORM 990 PART IX LINE 24 - OTHER EXPENSES | DESCRIPTION:SURGICAL TOTAL EXPENSES:18201215 PROGRAM SERVICES:18201215 |
| FORM 990 PART IX LINE 24 - OTHER EXPENSES | DESCRIPTION:VISION TOTAL EXPENSES:3823366 PROGRAM SERVICES:3823366 |
| FORM 990 PART IX LINE 24 - OTHER EXPENSES | DESCRIPTION:BEHAVIORAL TOTAL EXPENSES:3424390 PROGRAM SERVICES:3424390 |
| FORM 990 PART IX LINE 24 - OTHER EXPENSES | DESCRIPTION:TRANSPORTATION TOTAL EXPENSES:3393757 PROGRAM SERVICES:3393757 |
| FORM 990 PART IX LINE 24 - OTHER EXPENSES | DESCRIPTION:NURSING TOTAL EXPENSES:2758582 PROGRAM SERVICES:2758582 |
| FORM 990 PART IX LINE 24 - OTHER EXPENSES | DESCRIPTION:COVERED LIVES TOTAL EXPENSES:1443377 PROGRAM SERVICES:1443377 |
| FORM 990 PART IX LINE 24 - OTHER EXPENSES | DESCRIPTION:BEACON TOTAL EXPENSES:1130860 PROGRAM SERVICES:1130860 |
| FORM 990 PART IX LINE 24 - OTHER EXPENSES | DESCRIPTION:FAMILY PLANNING TOTAL EXPENSES:1075326 PROGRAM SERVICES:1075326 |
| FORM 990 PART IX LINE 24 - OTHER EXPENSES | DESCRIPTION:AMBULATORY TOTAL EXPENSES:237308 PROGRAM SERVICES:237308 |
| FORM 990 PART IX LINE 24 - OTHER EXPENSES | DESCRIPTION:OUTPATIENT CLAIMS TOTAL EXPENSES:172036 PROGRAM SERVICES:172036 |
| FORM 990 PART IX LINE 24 - OTHER EXPENSES | DESCRIPTION:OTHER MEDICAL TOTAL EXPENSES:56847 PROGRAM SERVICES:56847 |
| FORM 990 PART IX LINE 24 - OTHER EXPENSES | DESCRIPTION:PRENATAL TOTAL EXPENSES:19301 PROGRAM SERVICES:19301 |
| FORM 990 PART IX LINE 24 - OTHER EXPENSES | DESCRIPTION:MEDICAL SUPPLIES TOTAL EXPENSES:6514 PROGRAM SERVICES:6514 |
| FORM 990 PART IX LINE 24 - OTHER EXPENSES | DESCRIPTION:HOME HEALTHCARE TOTAL EXPENSES:1388 PROGRAM SERVICES:1388 |
| FORM 990 PART IX LINE 24 - OTHER EXPENSES | DESCRIPTION:THIRD PARTY RECOVERIES TOTAL EXPENSES:-30424130 PROGRAM SERVICES:-30424130 |
| Software ID: | |
| Software Version: |