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 (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 | |||||
| (A)
WESTFIELDS HOSPITAL INC |
390808442 | 3 | No | 0 | 0 | |
| (B)
GROUP HEALTH PLAN INC |
410797853 | 3 | Yes | 0 | 0 | |
| (C)
HUDSON HOSPITAL INC |
390804125 | 3 | No | 0 | 0 | |
| (D)
REGIONS HOSPITAL |
410956618 | 3 | Yes | 0 | 0 | |
| Total 4 | 0 | 0 | ||||
Calendar year (or fiscal year beginning in) ![]() |
(a) 2011 | (b) 2012 | (c) 2013 | (d) 2014 | (e) 2015 | (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) 2011 | (b) 2012 | (c) 2013 | (d) 2014 | (e) 2015 | (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) 2011 | (b) 2012 | (c) 2013 | (d) 2014 | (e) 2015 | (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) 2011 | (b) 2012 | (c) 2013 | (d) 2014 | (e) 2015 | (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 | ||||
| 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 2015 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-2015 |
(iii) Distributable Amount for 2015 |
|
|---|---|---|---|---|
|
1
Distributable amount for 2015 from Section C, line 6 |
||||
|
2
Underdistributions, if any, for years prior to 2015 (reasonable cause required--see instructions) |
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| 3 Excess distributions carryover, if any, to 2015: | ||||
| a | ||||
| b | ||||
| c | ||||
| d From 2013....... | ||||
| e From 2014....... | ||||
| fTotal of lines 3a through e | ||||
| g Applied to underdistributions of prior years | ||||
| h Applied to 2015 distributable amount | ||||
|
i
Carryover from 2010 not applied (see instructions) |
||||
| j Remainder. Subtract lines 3g, 3h, and 3i from 3f. | ||||
| 4Distributions for 2015 from Section D, line 7: | ||||
| $ | ||||
| a Applied to underdistributions of prior years | ||||
| b Applied to 2015 distributable amount | ||||
| c Remainder. Subtract lines 4a and 4b from 4. | ||||
|
5
Remaining underdistributions for years prior to 2015, if any. Subtract lines 3g and 4a from line 2 (if amount greater than zero, see instructions) |
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|
6
Remaining underdistributions for 2015. Subtract lines 3h and 4b from line 1 (if amount greater than zero, see instructions) |
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|
7 Excess distributions carryover to 2016. Add lines 3j and 4c. |
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| 8 Breakdown of line 7: | ||||
| a | ||||
| b | ||||
| c Excess from 2013....... | ||||
| d From 2014....... | ||||
| e From 2015....... | ||||
| Facts And Circumstances Test |
|---|
| Return Reference | Explanation |
|---|---|
| SCH. A, PART I, LINE 11G, COL. (V) & (VI): AMOUNT OF SUPPORT | NO DIRECT MONETARY SUPPORT IS INDICATED FROM WESTERN WISCONSIN EMERGENCY MEDICAL SERVICES COMPANY (WWEMSC) TO ITS SUPPORTED ORGANIZATIONS: HOWEVER, WWEMSC PERFORMS SERVICES WHICH ITS SUPPORTED ORGANIZATIONS WOULD OTHERWISE PERFORM ON THEIR OWN. THE NATURE OF THESE SERVICES, AND THE RELATIONSHIP WITH ITS SUPPORTED ORGANIZATIONS IS DESCRIBED IN SCHEDULE O "FORM 990, PART III, LINE 4A, EXEMPT PURPOSE AND ACHIEVEMENTS." |
| SCH A, PART IV, SECT A, LINE 1: | ARTICLES OF INCORPORATION OF WWEMSC PROVIDE THAT THE SUPPORTED ORGANIZATIONS OF WWEMSC SHALL BE EACH SUPPORTED ORGANIZATION OF RH-WISCONSIN. RH-WISCONSIN IS THE SOLE CORPORATE MEMBER OF WWEMSC. |
| SCH A, PART IV, SECT C, LINE 1: | THE BYLAWS OF WWEMSC PROVIDE THAT THE BOARD OF DIRECTORS IS COMPOSED OF THREE DIRECTORS AS FOLLOWS: - THE ASSISTANT TREASURER OF GROUP HEALTH PLAN, INC. SHALL SERVE EX OFFICIO AS A VOTING DIRECTOR; - THE CHIEF FINANCIAL OFFICER OF REGIONS HOSPITAL SHALL SERVE EX OFFICIO AS A VOTING DIRECTOR; AND - THE VICE PRESIDENT OF OPERATIONS OF REGIONS HOSPITAL SHALL SERVE EX OFFICIO AS A VOTING DIRECTOR. |
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Attach to Form 990 or 990-EZ.
Information about Schedule O (Form 990 or 990-EZ) and its instructions is at| Return Reference | Explanation |
|---|---|
| FORM 990, PART III, LINE 3 | IN 2014, THE WESTERN WISCONSIN EMERGENCY MEDICAL SERVICES COMPANY (WWEMSC) BOARD RESOLVED, THAT UPON APPROVAL OF RH-WISCONSIN, INC., THE SOLE MEMBER OF WWEMSC, MANAGEMENT IS DIRECTED TO TRANSFER ALL ASSETS AND LIABILITIES OF WWEMSC TO REGIONS HOSPITAL (REGIONS) BEFORE THE END OF CALENDAR YEAR 2014, AND, UPON APPROVAL OF RH-WISCONSIN, INC., MANAGEMENT IS AUTHORIZED TO FILE ARTICLES OF DISSOLUTION TO TERMINATE THE EXISTENCE OF WWEMSC AT SUCH TIME AS MANAGEMENT DEEMS APPROPRIATE BEFORE THE END OF CALENDAR YEAR 2015. $147,433 OF WWEMSC NET ASSETS WERE TRANSFERRED TO REGIONS IN 2014. FILING FOR DISSOLUTION WAS FILED WITH THE STATE OF WISCONSIN ON MAY 19, 2015. |
| FORM 990, PART VI, SECTION A, LINE 6 | RH-WISCONSIN, INC. (RH-WISCONSIN) IS THE SOLE CORPORATE MEMBER OF WWEMSC. |
| FORM 990, PART VI, SECTION A, LINE 7B | RH-WISCONSIN, THE SOLE CORPORATE MEMBER, MUST APPROVE THE DECISIONS OF THE BOARD OF DIRECTORS AS FOLLOWS: - AMENDMENT OF ARTICLES OR BYLAWS - LONG-RANGE PLANS - UNBUDGETED SPECIAL PROJECT IN EXCESS OF AN AMOUNT ESTABLISHED BY THE MEMBER - GUARANTEEING THE DEBT OF ANY OTHER PERSON OR ENTITY - MERGER OR CONSOLIDATION WITH ANOTHER CORPORATION - DISPOSITION OF SUBSTANTIALLY ALL ASSETS - DISSOLUTION - ADMISSION OF NEW MEMBERS |
| FORM 990, PART VI, SECTION B, LINE 11 | WWEMSC'S 990 RETURN HAS A COMPREHENSIVE REVIEW PROCESS THAT IS FOLLOWED BEFORE IT IS PRESENTED TO THE GOVERNING BODY OF RH-WISCONSIN (THE SOLE CORPORATE MEMBER OF WWEMSC). THE REVIEW PROCESS INCLUDES A LAYERED REVIEW BY THE TAX DEPARTMENT OF GROUP HEALTH PLAN, INC. (GHI), GHI'S INTERNAL LEGAL DEPARTMENT AND GHI'S OUTSIDE INDEPENDENT ACCOUNTANTS. EACH ONE OF THOSE AREAS HAS AN OPPORTUNITY TO REVIEW, ASK QUESTIONS AND MAKE COMMENTS BACK TO THE TAX DEPARTMENT OF GHI BEFORE THE FORM 990 IS COMPLETED AND PRESENTED TO THE GOVERNING BODY OF RH-WISCONSIN. A COPY OF THE 990 IS MADE AVAILABLE TO THE GOVERNING BODY (BOARD OF DIRECTORS) FOR REVIEW AND COMMENT PRIOR TO THE FILING OF THE 990 RETURN. THIS COPY WILL BE PROVIDED IN A MAILING TO THE BOARD MEMBERS PRIOR TO THE FILING OF THE 990. EACH BOARD MEMBER WILL HAVE AN OPPORTUNITY TO COMMENT OR ASK QUESTIONS ABOUT THE 990 BEFORE IT IS FILED. THIS PROCESS WILL BE NOTED AND DOCUMENTED IN A WRITTEN MEMO IN THE FILES OF THE BOARD OF DIRECTORS. |
| FORM 990, PART VI, SECTION B, LINE 12C | THE WWEMSC BOARD MONITORS POTENTIAL CONFLICTS OF INTEREST ON THE PART OF ITS BOARD MEMBERS, OFFICERS AND KEY EMPLOYEES BY MAINTAINING A CONFLICT OF INTEREST POLICY. UNDER THE POLICY, ALL BOARD MEMBERS, PRINCIPAL OFFICERS, MEMBERS OF A COMMITTEE WITH BOARD DELEGATED POWERS AND KEY EMPLOYEES ANNUALLY ARE PROVIDED WITH A COPY OF THE POLICY AND REQUESTED TO COMPLETE A QUESTIONNAIRE IDENTIFYING ANY POTENTIAL CONFLICTS OF INTERESTS. THE GENERAL COUNSEL OF HEALTHPARTNERS SHARES A REPORT OF THESE POTENTIAL CONFLICTS WITH THE PRESIDENT AND CHAIR OF THE BOARD. A VERBAL SUMMARY IS ALSO GIVEN TO THE FULL BOARD. BOARD AGENDAS AND EXECUTIVE DECISIONS ARE MONITORED IN RELATION TO THIS POLICY. |
| FORM 990, PART VI, SECTION B, LINE 15 | WWEMSC HAS NO EMPLOYEES AND DOES NOT PAY COMPENSATION. ALL OFFICERS AND KEY EMPLOYEES ARE PAID BY GROUP HEALTH PLAN, INC. (GHI) OR BY REGIONS HOSPITAL (REGIONS), RELATED ORGANIZATIONS. ANY COMPENSATION DISCLOSED IS PAID AND DETERMINED SOLELY BY THE RELATED ORGANIZATIONS. THEREFORE, PART VI, SECTION B, QUESTION 15 IS NOT APPLICABLE TO WWEMSC. |
| FORM 990, PART VI, SECTION C, LINE 19 | WWEMSC'S FINANCIAL STATEMENTS AND 990 RETURNS ARE MADE AVAILABLE TO ANY PERSON WHO REQUESTS THE INFORMATION FROM WWEMSC OR HEALTHPARTNERS. WWEMSC'S ARTICLES OF INCORPORATION ARE AVAILABLE TO ANY PERSON WHO REQUESTS THE INFORMATION THROUGH THE WISCONSIN SECRETARY OF STATE'S OFFICE. WWEMSC'S CONFLICT OF INTEREST POLICY THROUGH IT'S RELATED ORGANIZATION, HEALTHPARTNERS, INC., CAN BE VIEWED THROUGH THE HEALTHPARTNERS.COM WEBSITE. |
| FORM 990, PART VII, SECTION A, LINE 1A, COLUMN (B) - AVERAGE HOURS PER WEEK | ALL OFFICERS OF WWEMSC ARE EMPLOYED AND COMPENSATED BY GHI OR REGIONS. REPORTED AVERAGE HOURS WORKED ARE BASED ON THEIR TOTAL COMPENSATION FROM ALL RELATED ORGANIZATIONS. |
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