Attach to Form 990 or Form 990-EZ.
Go to
www.irs.gov/Form990 for instructions and 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 | |||||
| (A)
BLUE CARE NETWORK OF MICHIGAN |
382359234 | 10 | Yes | 2,410,368 | 0 | |
|
Total 1
|
2,410,368 | |||||
Calendar year (or fiscal year beginning in) ![]() |
(a) 2016 | (b) 2017 | (c) 2018 | (d) 2019 | (e) 2020 | (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) 2016 | (b) 2017 | (c) 2018 | (d) 2019 | (e) 2020 | (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) 2016 | (b) 2017 | (c) 2018 | (d) 2019 | (e) 2020 | (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) 2016 | (b) 2017 | (c) 2018 | (d) 2019 | (e) 2020 | (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 0.015 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 0.035 | 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 | 1 | |
|
2
Amounts paid to perform activity that directly furthers exempt purposes of supported organizations, in excess of income from activity |
2 | |
| 3 Administrative expenses paid to accomplish exempt purposes of supported organizations | 3 | |
| 4 Amounts paid to acquire exempt-use assets | 4 | |
| 5 Qualified set-aside amounts (prior IRS approval required - provide details in Part VI) | 5 | |
| 6 Other distributions (describe in Part VI). See instructions | 6 | |
| 7Total annual distributions. Add lines 1 through 6. | 7 | |
|
8
Distributions to attentive supported organizations to which the organization is responsive (provide details in Part VI). See instructions |
8 | |
| 9 Distributable amount for 2020 from Section C, line 6 | 9 | |
| 10 Line 8 amount divided by Line 9 amount | 10 | |
| Section E - Distribution Allocations (see instructions) |
(i) Excess Distributions |
(ii) Underdistributions Pre-2020 |
(iii) Distributable Amount for 2020 |
|
|---|---|---|---|---|
| 1 Distributable amount for 2020 from Section C, line 6 | ||||
|
2
Underdistributions, if any, for years prior to 2019 (reasonable cause required-- explain in Part VI). See instructions. |
||||
| 3 Excess distributions carryover, if any, to 2020: | ||||
| a From 2015....... | ||||
| b From 2016....... | ||||
| c From 2017....... | ||||
| d From 2018....... | ||||
| e From 2019....... | ||||
| fTotal of lines 3a through e | ||||
| g Applied to underdistributions of prior years | ||||
| h Applied to 2020 distributable amount | ||||
|
i
Carryover from 2015 not applied (see instructions) |
||||
| j Remainder. Subtract lines 3g, 3h, and 3i from line 3f. | ||||
| 4Distributions for 2020 from Section D, line 7: | ||||
| $ | ||||
| a Applied to underdistributions of prior years | ||||
| b Applied to 2020 distributable amount | ||||
| c Remainder. Subtract lines 4a and 4b from line 4. | ||||
|
5
Remaining underdistributions for years prior to 2020, if any. Subtract lines 3g and 4a from line 2. If the amount is greater than zero, explain in Part VI. See instructions. |
||||
|
6
Remaining underdistributions for 2020. Subtract lines 3h and 4b from line 1. If the amount is greater than zero, explain in Part VI. See instructions. |
||||
|
7 Excess distributions carryover to 2021. Add lines 3j and 4c. |
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| 8 Breakdown of line 7: | ||||
| a Excess from 2016..... | ||||
| b Excess from 2017..... | ||||
| c Excess from 2018..... | ||||
| d Excess from 2019..... | ||||
| e Excess from 2020..... | ||||
| Facts And Circumstances Test |
|---|
| Return Reference | Explanation |
|---|---|
| PART IV, SECTION A, LINE 3B - DETERMINATION MADE BY ORGANIZATION | THE BLUE CROSS BLUE SHIELD OF MICHIGAN FOUNDATION CONFIRMS THAT BLUE CARE NETWORK OF MICHIGAN HAS MET THE SUPPORT TEST BY REVIEWING THE ANNUAL 990 AND THE STATE OF MICHIGAN ANNUAL REPORT EACH YEAR. PART IV, SECTION A, LINE 3C - CONTROLS FOR 170(C)(2)(B) PURPOSES GRANTS MADE BY THE BLUE CROSS BLUE SHIELD OF MICHIGAN FOUNDATION DURING 2020 WERE AWARDED TO SUCH ORGANIZATIONS USED EXCLUSIVELY FOR SECTION 170 (C)(2)(B). EACH GRANT APPLICANT IS REQUIRED TO SUBMIT A PROOF OF INTERNAL REVENUE TAX EXEMPT STATUS AND THE GRANT COMMITTEE OF THE BOARD IS RESPONSIBLE FOR APPROVING EACH GRANT TO QUALIFYING ORGANIZATIONS. |
| Software ID: | |
| Software Version: |
Attach to Form 990 or 990-EZ.
Go to www.irs.gov/Form990 for the latest information.
| Return Reference | Explanation |
|---|---|
| FORM 990 - PART VI LINE 6 - CLASS OF MEMBERS OR STOCKHOLDERS | THE ORGANIZATION IS FORMED AS A NON-PROFIT STOCK CORPORATION WHOLLY OWNED BY BLUE CARE NETWORK OF MICHIGAN (EIN 38-2359234), A HEALTH MAINTENANCE ORGANIZATION, WHICH IS ORGANIZED AND EXEMPT UNDER SECTION 501(C)(4). FORM 990, PART VI, LINE 7A AND 7B - ELECTION OF MEMBERS AND THEIR RIGHTS SHAREHOLDERS HAVE THE POWER TO ELECT THE BOARD OF DIRECTORS, PRESIDENT, VICE PRESIDENT, AND CHAIRPERSON. |
| FORM 990, PART VI, LINE 11B - ORGANIZATION'S PROCESS TO REVIEW FORM 990 | THE ORGANIZATION'S PROCESS FOR FORM 990 IS THE RETURN IS PREPARED BY AN OUTSIDE FIRM, EY, AND REVIEWED BY ENTERPRISE PERSONNEL. ENTERPRISE PERSONNEL REQUESTS SUPPORT FROM VARIOUS SOURCES AND PROVIDES TO EY AS NEEDED. THE CURRENT EXECUTIVE DIRECTOR AND CEO, AUDREY HARVEY, HAD THE OPPORTUNITY TO REVIEW THE RETURN BEOFRE IT WAS FILED WITH THE INTERNAL REVENUE SERVICE. THE RETURN IS NOT PRESENTED TO THE BOARD OF DIRECTORS. |
| FORM 990, PART VI, LINE 12C - ENFORCEMENT OF CONFLICTS POLICY | THE MEMBER WITH THE CONFLICT WILL ABSTAIN THEIR VOTE ON ISSUES RELATED TO THE CONFLICTING ORGANIZATION. MEMBERS RECEIVE ANNUALLY DISCLOSURE CONFLICT FORMS AND ARE REQUIRED TO REVIEW, UPDATE OR SUBMIT A NEW DISCLOSURE FORM. WHEN BOARD FORMS ARE SUBMITTED, THEY ARE THEN APPROVED BY THE BOARD CHAIR AND FINANCE COMMITTEE CHAIR. IF ANY CONFLICT IS TO BE RESOLVED THE BOARD CHAIR AND FINANCE COMMITTEE CHAIR WILL WORK WITH THE BOARD MEMBER TO RESOLVE THE CONFLICT. UPDATED FORMS WITH ALL CONFLICTS RESOLVED ARE PRESENTED ANNUALLY TO THE ENTIRE BOARD FOR APPROVAL. FORM 990, PART VI, LINE 15A - COMPENSATION PROCESS FOR TOP OFFICIAL THE COMPENSATION STRATEGY IS DESIGNED TO ENSURE THAT AN APPROPRIATE BALANCE EXISTS BETWEEN INTERNAL EQUITY CONSIDERATIONS AND MARKET COMPENSATION FACTORS AND PRACTICES. MARKET DATA FROM THIRD PARTY EXECUTIVE COMPENSATION SURVEYS AND INDEPENDENT COMPENSATION CONSULTANTS ARE USED TO DETERMINE THE EXECUTIVE DIRECTOR AND CEO'S COMPENSATION. THE COMPENSATION RECOMMENDATIONS ARE REVIEWED BY BLUE CROSS BLUE SHIELD OF MICHIGAN MUTUAL INSURANCE COMPANY (BCBSM), PERSONNEL AND COMPENSATION SUBCOMMITTEE AND EXECUTIVE COMMITTEE. |
| FORM 990, PART VI, LINE 15B - COMPENSATION PROCESS FOR OFFICERS | THE COMPENSATION RECOMMENDATIONS FOR BCBSM FOUNDATION'S PRESIDENT AND EXECUTIVE DIRECTOR ARE REVIEWED AND APPROVED BY BLUE CROSS BLUE SHIELD OF MICHIGAN MUTUAL INSURANCE COMPANY (BCBSM), PERSONNEL AND COMPENSATION SUBCOMMITTEE AND EXECUTIVE COMMITTEE. |
| FORM 990, PART VI, LINE 19 - GOVERNING DOCUMENTS DISCLOSURE EXPLANATION | GOVERNING DOCUMENTS - DOCUMENTS ARE MADE AVAILABLE TO THE PUBLIC UPON REQUEST, AT THE OFFICE OF THE FOUNDATION. CONFLICT OF INTEREST POLICY - DOCUMENTS ARE MADE AVAILABLE TO THE PUBLIC UPON REQUEST, AT THE OFFICE OF THE FOUNDATION. AUDITED FINANCIALS ARE PUBLISHED IN THE ANNUAL REPORT WHICH IS AVAILABLE ON THE FOUNDATION'S WEBSITE AND AVAILABLE UPON REQUEST. |
| FORM 990, PART VII - ADDITIONAL INFORMATION | RELATED ORGANIZATIONS - BLUE CROSS BLUE SHIELD OF MICHIGAN FOUNDATION HAS ASSIGNED EMPLOYEES FROM ITS ULTIMATE PARENT, BLUE CROSS BLUE SHIELD OF MICHIGAN MUTUAL INSURANCE COMPANY,(BCBSM). THE EXPENSES ASSOCIATED WITH THESE INDIVIDUALS ARE REFLECTED ON FORM 990, PART IX, LINE 5 AND LINE 7. PAYMENTS WERE MADE TO BCBSM THROUGH AN INTERCOMPANY AGREEMENT. NO EMPLOYEES WERE REFLECTED ON PART V, LINE 2A SINCE THE ACTUAL W-2'S AND 941'S ARE REPORTED BY BCBSM. COMPENSATION PAID TO THE EXECUTIVE DIRECTOR AND CEO, OFFICERS AS WELL AS FORMER OFFICERS, DIRECTORS, KEY EMPLOYEES AND HIGHLY COMPENSATED EMPLOYEES, BY THE PARENT COMPANY AND REIMBURSED BY THE FOUNDATION, IS INCLUDED ON FORM 990, PART VII, SECTION A. COMPENSATION PAID TO OTHER BOARD MEMBERS THAT WAS NOT REIMBURSED BY THE FOUNDATION IS REFLECTED ON FORM 990, PART VII, SECTION A. THEIR COMPLETE COMPENSATION AS PAID BY THE PARENT IS REPORTED IN COLUMN E. COMPENSATION AMOUNTS REPORTED ON PART IX LINE 5 AND 7 INCLUDE PENSION PLAN CONTRIBUTIONS, OTHER EMPLOYEE BENEFITS, AND PAYROLL TAXES THAT WOULD OTHERWISE BE REPORTED ON LINES 8, 9, AND 10, RESPECTIVELY. CURRENT OFFICERS, DIRECTORS, TRUSTEES AND KEY EMPLOYEES THAT ARE EMPLOYED BY THE FILING ORGANIZATION OR BY A RELATED ORGANIZATION SPLIT THEIR TIME AS NEEDED BETWEEN THE FILING ENTITY AND RELATED ORGANIZATIONS. A PER WEEK ESTIMATE FOR THE FILING ORGANIZATION AND RELATED ORGANIZATIONS IS REFLECTED ON THE FILING ENTITY'S PART VII, COLUMN B, WITH THE COMPLETE REPORTABLE COMPENSATION FROM THE FILING ORGANIZATION AND RELATED ORGANIZATIONS REFLECTED IN COLUMN D AND COLUMN E AS APPROPRIATE. |
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| Software Version: |