Attach to Form 990 or Form 990-EZ.
Go to
www.irs.gov/Form990 for the latest information.
| (i) Name of supported organization | (ii) EIN | (iii) Type of organization (described on lines 1- 10 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 | |||||
|
Total |
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Calendar year (or fiscal year beginning in) ![]() |
(a) 2014 | (b) 2015 | (c) 2016 | (d) 2017 | (e) 2018 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 1 | Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grant.") .. | ||||||
| 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) 2014 | (b) 2015 | (c) 2016 | (d) 2017 | (e) 2018 | (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) 2014 | (b) 2015 | (c) 2016 | (d) 2017 | (e) 2018 | (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) 2014 | (b) 2015 | (c) 2016 | (d) 2017 | (e) 2018 | (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) |
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| 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 2018 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-2018 |
(iii) Distributable Amount for 2018 |
|
|---|---|---|---|---|
|
1
Distributable amount for 2018 from Section C, line 6 |
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|
2
Underdistributions, if any, for years prior to 2018 (reasonable cause required-- explain in Part VI). See instructions. |
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| 3 Excess distributions carryover, if any, to 2018: | ||||
| a From 2013....... | ||||
| b From 2014....... | ||||
| c From 2015....... | ||||
| d From 2016....... | ||||
| e From 2017....... | ||||
| fTotal of lines 3a through e | ||||
| g Applied to underdistributions of prior years | ||||
| h Applied to 2018 distributable amount | ||||
|
i
Carryover from 2013 not applied (see instructions) |
||||
| j Remainder. Subtract lines 3g, 3h, and 3i from 3f. | ||||
| 4Distributions for 2018 from Section D, line 7: | ||||
| $ | ||||
| a Applied to underdistributions of prior years | ||||
| b Applied to 2018 distributable amount | ||||
| c Remainder. Subtract lines 4a and 4b from 4. | ||||
|
5
Remaining underdistributions for years prior to 2018, if any. Subtract lines 3g and 4a from line 2. If the amount is greater than zero, explain in Part VI. See instructions. |
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|
6
Remaining underdistributions for 2018. Subtract lines 3h and 4b from line 1. If the amount is greater than zero, explain in Part VI. See instructions. |
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|
7 Excess distributions carryover to 2019. Add lines 3j and 4c. |
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| 8 Breakdown of line 7: | ||||
| a Excess from 2014...... | ||||
| b Excess from 2015..... | ||||
| c Excess from 2016..... | ||||
| d Excess from 2017..... | ||||
| e Excess from 2018..... | ||||
| Facts And Circumstances Test |
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| Return Reference | Explanation |
|---|
| Software ID: | |
| Software Version: |
Attach to Form 990 or 990-EZ.
Go to www.irs.gov/Form990 for the latest information.
| Return Reference | Explanation |
|---|---|
| ORGANIZATION'S MISSION | FORM 990, PART I, LINE 1 AND PART III, LINE 1 THE MISSION OF AFFINITY HEALTH PLAN IS TO IMPROVE THE HEALTH AND WELL-BEING OF ITS MEMBERS, THEIR FAMILIES, AND THEIR COMMUNITIES IN COLLABORATION WITH PRIMARY CARE PROVIDERS. AFFINITY STRIVES TO BE THE HEALTH PLAN OF CHOICE FOR ITS MEMBERS AND ITS PROVIDERS -- KNOWN FOR ASSURING ACCESS TO HIGH QUALITY, COST-EFFECTIVE CARE; DELIVERING THE BEST CUSTOMER EXPERIENCE; AND CONTRIBUTING SIGNIFICANTLY TO ACHIEVING A PATIENT-CENTERED HEALTH CARE SYSTEM. CEASED ACTIVITIES FORM 990, PART III, LINE 3 Affinity Health Plan (the Plan) established a Qualified Health Plan (QHP) in 2013 under Health Care Reform, which was certified by the New York State Health Insurance Marketplace (the Exchange). QHP provided 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 the ACA. The QHP business became operational effective October 1, 2013, with the acceptance of members under the provisions of the Exchange. Coverage for QHP members began on January 1, 2014. QHP was administered under an agreement between the Plan and the NYSDOH and extended through December 31, 2017. Effective January 1, 2018, the Plan no longer offers a QHP through the Exchange. FORM 990 REVIEW FORM 990, PART VI, LINE 11B THE FINANCIAL STAFF COMPILES THE FINANCIAL AND OTHER INFORMATION REQUIRED IN THE 990 RETURN. KPMG, LLP PREPARES THE RETURN AND THE INFORMATION IS REVIEWED BY THE COMPANY'S CFO AND VP/CONTROLLER. A FINAL COPY OF THE FORM 990 IS MADE AVAILABLE TO THE ENTIRE GOVERNING BODY BEFORE FILING WITH THE IRS. 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. IF A CONFLICT OF INTEREST IS FOUND, PERSONS WITH A CONFLICT RECUSE THEMSELVES FROM DECISIONS RELATED TO THE CONFLICT. CONFLICT OF INTEREST IS FOUND, PERSONS WITH A CONFLICT RECUSE THEMSELVES FROM DECISIONS RELATED TO THE CONFLICT. |
| COMPENSATION REVIEW | FORM 990, PART VI, QUESTIONS 15A AND 15B THE PROCESS FOR DETERMINING COMPENSATION FOR THE CEO AND CFO 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: A) 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 HAVE 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) COMPENSATION DECISIONS APPLICABLE FOR OTHER OFFICERS AND KEY EMPLOYEES, INCLUDING INCENTIVE BONUSES, MERIT INCREASES, PROMOTIONAL 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. COMPENSATION DECISIONS IMPACTING THOSE OF THE FOREGOING POSITIONS THAT ARE ALSO DEEMED TO BE "DISQUALIFIED PERSONS" UNDER THE INTERNAL REVENUE CODE (E.G., 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). DOCUMENT DISCLOSURE FORM 990, PART VI, QUESTION 19 THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE UPON REQUEST. |
| FORM 990 PART IX LINE 24 - OTHER EXPENSES | DESCRIPTION:EMERGENCY ROOM CLAIMS TOTAL EXPENSES:38558232 PROGRAM SERVICES:38558232 |
| FORM 990 PART IX LINE 24 - OTHER EXPENSES | DESCRIPTION:EMERGENCY ROOM HCRA TOTAL EXPENSES:1978909 PROGRAM SERVICES:1978909 |
| FORM 990 PART IX LINE 24 - OTHER EXPENSES | DESCRIPTION:PROFESSION SERVICE-IBNR TOTAL EXPENSES:-17133778 PROGRAM SERVICES:-17133778 |
| FORM 990 PART IX LINE 24 - OTHER EXPENSES | DESCRIPTION:SHARE SAVINGS EXPENSE TOTAL EXPENSES:-1994630 PROGRAM SERVICES:-1994630 |
| FORM 990 PART IX LINE 24 - OTHER EXPENSES | DESCRIPTION:OUTPATIENT CLAIMS-IBNR TOTAL EXPENSES:-4347083 PROGRAM SERVICES:-4347083 |
| FORM 990 PART IX LINE 24 - OTHER EXPENSES | DESCRIPTION:OUTPATIENT NON VALUATED EXP TOTAL EXPENSES:55696 PROGRAM SERVICES:55696 |
| FORM 990 PART IX LINE 24 - OTHER EXPENSES | DESCRIPTION:ILS CAPITATION TOTAL EXPENSES:2757247 PROGRAM SERVICES:2757247 |
| FORM 990 PART IX LINE 24 - OTHER EXPENSES | DESCRIPTION:OTHER PROFESSIONAL SERVICES TOTAL EXPENSES:XXX-XX-XXXX PROGRAM SERVICES:XXX-XX-XXXX |
| FORM 990 PART IX LINE 24 - OTHER EXPENSES | DESCRIPTION:OTHER PROFESSIONAL SVC-HCRA TOTAL EXPENSES:4762856 PROGRAM SERVICES:4762856 |
| FORM 990 PART IX LINE 24 - OTHER EXPENSES | DESCRIPTION:THIRD PARTY RECOVERIES - REINS TOTAL EXPENSES:-22380180 PROGRAM SERVICES:-22380180 |
| FORM 990 PART IX LINE 24 - OTHER EXPENSES | DESCRIPTION:HEALTH HOME CLAIMS TOTAL EXPENSES:5411529 PROGRAM SERVICES:5411529 |
| FORM 990 PART IX LINE 24 - OTHER EXPENSES | DESCRIPTION:DENTAL CAPITATION TOTAL EXPENSES:28636673 PROGRAM SERVICES:28636673 |
| FORM 990 PART IX LINE 24 - OTHER EXPENSES | DESCRIPTION:BEHAVIORAL HEALTH CAPITATION TOTAL EXPENSES:97084397 PROGRAM SERVICES:97084397 |
| FORM 990 PART IX LINE 24 - OTHER EXPENSES | DESCRIPTION:DENTAL HCRA TOTAL EXPENSES:210621 PROGRAM SERVICES:210621 |
| FORM 990 PART IX LINE 24 - OTHER EXPENSES | DESCRIPTION:BEACON HCRA TOTAL EXPENSES:1263799 PROGRAM SERVICES:1263799 |
| FORM 990 PART IX LINE 24 - OTHER EXPENSES | DESCRIPTION:DIAGNOSTIC TEST LAB & X-RAY TOTAL EXPENSES:84330896 PROGRAM SERVICES:84330896 |
| FORM 990 PART IX LINE 24 - OTHER EXPENSES | DESCRIPTION:LAB CAPITATIONS TOTAL EXPENSES:-277299 PROGRAM SERVICES:-277299 |
| FORM 990 PART IX LINE 24 - OTHER EXPENSES | DESCRIPTION:LAB HCRA TOTAL EXPENSES:2634664 PROGRAM SERVICES:2634664 |
| FORM 990 PART IX LINE 24 - OTHER EXPENSES | DESCRIPTION:DIAGNOSTIC TEST LAB TOTAL EXPENSES:325075 PROGRAM SERVICES:325075 |
| FORM 990 PART IX LINE 24 - OTHER EXPENSES | DESCRIPTION:FAMILY PLANNING TOTAL EXPENSES:2554 PROGRAM SERVICES:2554 |
| FORM 990 PART IX LINE 24 - OTHER EXPENSES | DESCRIPTION:NURSING FACILITY TOTAL EXPENSES:3185901 PROGRAM SERVICES:3185901 |
| FORM 990 PART IX LINE 24 - OTHER EXPENSES | DESCRIPTION:NURSING FACILITY HCRA TOTAL EXPENSES:13 PROGRAM SERVICES:13 |
| FORM 990 PART IX LINE 24 - OTHER EXPENSES | DESCRIPTION:TRANSPORTATION NON-EMERGENT TOTAL EXPENSES:-87700 PROGRAM SERVICES:-87700 |
| FORM 990 PART IX LINE 24 - OTHER EXPENSES | DESCRIPTION:VISION CAPITATION TOTAL EXPENSES:4056091 PROGRAM SERVICES:4056091 |
| FORM 990 PART IX LINE 24 - OTHER EXPENSES | DESCRIPTION:OUTPATIENT PHYSICAL THERAPY TOTAL EXPENSES:23887 PROGRAM SERVICES:23887 |
| FORM 990 PART IX LINE 24 - OTHER EXPENSES | DESCRIPTION:CHIROPRACTIC TOTAL EXPENSES:270341 PROGRAM SERVICES:270341 |
| FORM 990 PART IX LINE 24 - OTHER EXPENSES | DESCRIPTION:ACUPUNCTURE TOTAL EXPENSES:6500 PROGRAM SERVICES:6500 |
| FORM 990 PART IX LINE 24 - OTHER EXPENSES | DESCRIPTION:DME, MEDICAL SUPPLIES TOTAL EXPENSES:7882 PROGRAM SERVICES:7882 |
| FORM 990 PART IX LINE 24 - OTHER EXPENSES | DESCRIPTION:AMBULATORY SURGERY TOTAL EXPENSES:342014 PROGRAM SERVICES:342014 |
| FORM 990 PART IX LINE 24 - OTHER EXPENSES | DESCRIPTION:HOME HEALTH CARE TOTAL EXPENSES:996 PROGRAM SERVICES:996 |
| FORM 990 PART IX LINE 24 - OTHER EXPENSES | DESCRIPTION:OTHER MEDICAL TOTAL EXPENSES:921362 PROGRAM SERVICES:921362 |
| FORM 990 PART IX LINE 24 - OTHER EXPENSES | DESCRIPTION:PRENATAL/POSTPARTUM CARE TOTAL EXPENSES:21888 PROGRAM SERVICES:21888 |
| FORM 990 PART IX LINE 24 - OTHER EXPENSES | DESCRIPTION:MEDICAID STOP LOSS INSURANCE TOTAL EXPENSES:12878634 PROGRAM SERVICES:12878634 |
| FORM 990 PART IX LINE 24 - OTHER EXPENSES | DESCRIPTION:COVERED LIVES TOTAL EXPENSES:5985797 PROGRAM SERVICES:5985797 |
| Software ID: | |
| Software Version: |