TY 2021 Form 990

- TIN:

Form990

Department of the TreasuryInternal Revenue Service

Return of Organization Exempt From Income Tax

Under section 501(c), 527, or 4947(a)(1) of the Internal Revenue Code (except private foundations)

Do not enter social security numbers on this form as it may be made public.

Go to www.irs.gov/Form990 for instructions and the latest information.

OMB No. 1545-0047

2021

Open to Public Inspection

A For the 2021 calendar year, or tax year beginning 01-01-2021 , and ending 12-31-2021

BCheck if applicable: Address change Name change Initial return Final return/terminated Amended return Application pending

CName of organization
PreferredOne Community Health Plan

Doing business as

Number and street (or P.O. box if mail is not delivered to street address)
6105 Golden Hills Drive

Room/suite

City or town, state or province, country, and ZIP or foreign postal code
Golden Valley, MN55416

D Employer identification number

41-1796007

E Telephone number

G Gross receipts $ 2,753,457

F Name and address of principal officer:
DAVID P CROSBY
6105 Golden Hills Drive
Golden Valley,MN55416

Tax-exempt status: 501(c)(3) 501(c) ( 4 ) LeftBullet

(insert no.) 4947(a)(1) or 527

Website:

WWW.PREFERREDONE.COM

H(a)

Is this a group return for
subordinates? Yes No

H(b)

Are all subordinates
included?

Yes No

If "No," attach a list. See instructions.

H(c)

Group exemption number MediumBullet

K Form of organization: Corporation Trust Association Other MediumBullet

L Year of formation: 1994

M State of legal domicile: MN

Part I

Summary

1	Briefly describe the organization’s mission or most significant activities: The mission of PreferredOne Community Health Plan (PCHP) is to make available to the residents of the state of Minnesota comprehensive health maintenance services that are accessible, acceptable, and delivered in a manner congruent with the economic and social needs of the community. The health plan will advocate for improvements in the delivery, quality and coverage of health care services and pursue health care programs to meet community needs.
2	Check this box
3	Number of voting members of the governing body (Part VI, line 1a) ........	3	4
4	Number of independent voting members of the governing body (Part VI, line 1b) .....	4	1
5	Total number of individuals employed in calendar year 2021 (Part V, line 2a) ......	5	0
6	Total number of volunteers (estimate if necessary) .............	6	0
7a	Total unrelated business revenue from Part VIII, column (C), line 12 ........	7a	0
b	Net unrelated business taxable income from Form 990-T, Part I, line 11 .........	7b	0

		Prior Year	Current Year
8	Contributions and grants (Part VIII, line 1h) .........		0
9	Program service revenue (Part VIII, line 2g) .........	2,097,457	1,146,701
10	Investment income (Part VIII, column (A), lines 3, 4, and 7d ) ....	63,681	41,554
11	Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e)		0
12	Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)	2,161,138	1,188,255
13	Grants and similar amounts paid (Part IX, column (A), lines 1–3 )...		0
14	Benefits paid to or for members (Part IX, column (A), line 4).....		0
15	Salaries, other compensation, employee benefits (Part IX, column (A), lines 5–10)	9,225	16,003
16a	Professional fundraising fees (Part IX, column (A), line 11e) .....		0
b	Total fundraising expenses (Part IX, column (D), line 25) 0
17	Other expenses (Part IX, column (A), lines 11a–11d, 11f–24e)....	1,723,732	1,834,332
18	Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25)	1,732,957	1,850,335
19	Revenue less expenses. Subtract line 18 from line 12.......	428,181	-662,080
		Beginning of Current Year	End of Year
20	Total assets (Part X, line 16).............	3,784,365	2,826,703
21	Total liabilities (Part X, line 26).............	1,835,347	1,584,951
22	Net assets or fund balances. Subtract line 21 from line 20.....	1,949,018	1,241,752

Part II

Signature Block

Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete. Declaration of preparer (other than officer) is based on all information of which preparer has any knowledge.

Sign Here

	Signature of officer	Date

	Type or print name and title

Paid Preparer Use Only

Print/Type preparer's name

Preparer's signature

Date

Check if
self-employed

PTIN

Firm's name MediumBullet

Firm's EIN MediumBullet

Firm's address MediumBullet

Phone no.

May the IRS discuss this return with the preparer shown above? (see instructions) ..........YesNo

For Paperwork Reduction Act Notice, see the separate instructions.

Cat. No. 11282Y Form 990 (2021)

Form 990 (2021)

Page 2

Part III

Statement of Program Service Accomplishments

Check if Schedule O contains a response or note to any line in this Part III..............

Briefly describe the organization’s mission: The mission of PreferredOne Community Health Plan (PCHP) is to make available to the residents of the state of Minnesota comprehensive health maintenance services that are accessible, acceptable, and delivered in a manner congruent with the economic and social needs of the community. The health plan will advocate for improvements in the delivery, quality and coverage of health care services and pursue health care programs to meet community needs.

Did the organization undertake any significant program services during the year which were not listed on
the prior Form 990 or 990-EZ? ..................... Yes No

If "Yes," describe these new services on Schedule O.

Did the organization cease conducting, or make significant changes in how it conducts, any program
services? ........................... Yes No

If "Yes," describe these changes on Schedule O.

Describe the organization’s program service accomplishments for each of its three largest program services, as measured by expenses. Section 501(c)(3) and 501(c)(4) organizations are required to report the amount of grants and allocations to others, the total expenses, and revenue, if any, for each program service reported.


4a	(Code: ) (Expenses $ 1,646,249 including grants of $ ) (Revenue $ 1,146,701 )
	The mission of the Quality Management (QM) Program is to identify and act on opportunities that improve the quality, safety, value of care, and service provided to all PreferredOne members, working both independently and collaboratively with contracted practitioners and community efforts. As part of the organization's mission, PreferredOne advocates for improvements in the delivery, quality, and coverage of health care services, and pursues health care programs to meet community needs. In 2021, PreferredOne Community Health Plan maintained its accreditation status of Accredited from the National Committee for Quality Assurance (NCQA), a private, nonprofit organization that evaluates and reports on health care quality. NCQA Accreditation recognizes the commitment of our organization to provide quality health care to our members and demonstrates that we have incorporated quality improvement into the fabric of our business. Our accreditation status was awarded after rigorous evaluation by NCQA of all aspects of our plan, including preventive health services, member satisfaction, physician credentialing and quality improvement. Participation in Collaborative and Community Projects In an effort to pool resources, create consistency among provider networks in our community and improve the delivery of health care to our members PreferredOne participates in several collaborative activities. * Minnesota Community Measurement (MNCM) is a collaboration among health plans and provider groups whose mission is to accelerate the improvement of health by publicly reporting health care information. The vision of MN Community Measurement is: - Be the primary trusted source for health data sharing and measurement - Drive change that improves health, patient experience, cost and equity of care for everyone in our community - Be a resource used by providers and patients to improve care - Partner with others to use our information to catalyze significant improvements in health PreferredOne is one of seven health plan founding members of MNCM. The state medical association, state hospital association, participating medical groups, consumers, businesses, health plans, and state health agencies are all represented on the organization's board of directors in either a voting or non-voting capacity. Data is supplied by participating health plans on an annual basis for use in developing their annual Health Care Quality Report. * Center for Community Health (CCH) is a collaborative with health plans, hospitals, and public health agencies in the seven-county metropolitan area in Minnesota who mission is to share data and processes to identify health needs and implement innovative approaches to advance community health, well-being, and equity. The guiding principles of the CCH include: - Our work will focus on what can be done across all three sectors - Our level of engagement will reflect our respective priorities and capacity - Members will be clear about who they are representing when contributing opinions and ideas - Our work will be data driven - We will strive for efficiency and avoid added work - Our efforts should add value to our work - We will avoid areas that might raise antitrust concerns, such as reimbursement matters and payor/provider relationships - Membership in the CCH does not preclude members from doing individual work in their own sectors, and - We will strive to create/achieve health equity The vision of the CCH is a healthy and thriving Twin Cities metro area population achieved through collaboration, data sharing, and collective action. Organizational Support for Employee Volunteer Events PreferredOne supports community involvement throughout the organization. Events are employee-driven, with the organization enabling or providing employee time and/or financial support to encourage volunteerism. Examples include: - United Way - Community Health Charities - Second Harvest Heartland Other Condition-Specific Education and Support Programs Complex Case Management Complex case management is the coordination of care and services provided to members who have experienced a critical event or diagnosis that requires the extensive use of resources and who need help navigating the system to facilitate appropriate delivery of care and services. The goal of complex case management is to help members regain optimum health or improved functional capability, in the right setting and in a cost-effective manner. It involves comprehensive assessment of the member's condition; determination of available benefits and resources; and development and implementation of a case management plan with performance goals, monitoring and follow up. In 2021 the complex case management program identified 8,990 members who could benefit from case management services.

4b	(Code: ) (Expenses $ including grants of $ ) (Revenue $ )
	Chronic Illness Management PreferredOne's Chronic Illness Management program is available to members who are diagnosed with any of the following chronic conditions: * Diabetes * Coronary Heart Disease * Congestive Heart Failure * Chronic Obstructive Pulmonary Disease * Asthma (adult and juvenile) * Rare conditions (Ulcerative Colitis, Crohn's Disease, Rheumatoid Arthritis, Multiple Sclerosis, Sickle Cell, Cystic Fibrosis, Lupus, Parkinsons, Myasthenia Gravis, Hemophilia, Scleroderma, Dermatomyositis, Myositis, Polymyositis, CIDP, ALS, and Gaucher Disease) The goals of the Chronic Illness Management program are to promote self-management of chronic conditions, improve adherence to treatment plans with an emphasis on medication therapy, reduce or delay disease progression and complications, reduce hospitalizations and emergency room visits and improve quality of life. In 2021 the chronic illness management program identified 14,487 members who could benefit from disease management services. Quit for Life PreferredOne partners with Optum for its Quit for Life tobacco cessation programming (formerly Alere/Free & Clear). This is a 6-month telephonic, web and text-based tobacco counseling program available at no charge to PreferredOne members age 13 years or older. (age 13-17 years not eligible for texting). Uses inbound and outbound telephone support to systematically move participants toward a successful quit. The core components of the Quit for Life program include: - Individualized counseling with a Quit Coach - Printed self-paced materials (the Quit Guide) - Text to Quit (age 18+) - Web coach/online community for quit support - Information and guidance on Quitting Aids (NRT subject to plan benefits) - 24/7 access to the program website - Live Vape Free online resources for vaping users and their parents Quit for Life is a systematic and solid scientific evidence based behavior change program that helps tobacco users quit. Clinical trial results indicate that telephone counseling, along with self-help materials, increases quit rates. The quit rate for PreferredOne participants in 2021 was 38%. In 2021, 16 PreferredOne members enrolled in the Quit for Life smoking cessation program. Health Risk Assessment (HRA) PreferredOne offers an HRA through WellSource to all members and their dependents age 18 years or older. The HRA is accessed online through the PreferredOne member website (www.preferredone.com) and can be completed once per calendar year. PreferredOne subsidizes the cost of the HRA so there is no cost to the employee or their employer. PreferredOne encourages members to print their individual results and to share with their physician if they desire advice or direction to improve their lifestyle. All HRA reports completed are saved in the member's account so they can compare their results from year to year. The employer group can purchase a Reporting and Health Coaching package, which provides them with aggregate reporting on the HRA results for the group as a whole. A total of 1,093 PreferredOne members completed the HRA in 2021. Patient Safety PreferredOne demonstrates a commitment to patient safety by incorporating safety into existing QM activities and taking patient safety into consideration when examining trends and data for possible quality improvement activities. PreferredOne always implements processes with overall patient care outcomes and safety as components of quality improvement activities. Elements of patient safety are found in our existing quality improvement processes that include, but are not limited to: * Identifying and implementing processes for transitions of care for continuity and safety * Implementing care management programs that include follow-up systems to ensure that care is received in a reliable and timely manner * Implementing pharmaceutical management practices and policies that include safeguards to enhance patient safety, including an emerging therapeutic issues program in which members and/or physicians are notified of significant safety issues with products covered under the pharmacy benefit (including prescription drugs and certain medical devices) * Incorporating adverse event reporting into the credentialing process * Tracking and trending adverse event reporting to identify systems and/or network issues that may compromise safety * Analyzing and taking action on member and practitioner complaints and satisfaction data that relate to safety * Collecting and providing information on provider and practitioner safety and quality, including activities on providers actions to improve patient safety and to make performance data publicly available for members and practitioners. Continuity and Coordination of Care PreferredOne develops a work plan to specifically address issues related to continuity and coordination of care within our network for our members. Data from various sources are used to identify opportunities for improvement and develop programs to address these opportunities, as necessary. Potential opportunities for improvement under consideration include * Site of Care (SOC) initiative (increase HHC infusion therapy utilization versus hospital based) * Medical inpatient follow-up * Admission / Discharge / Transfer feed work following ED visit * Opioid polypharmacy (to reduce multiple ER visits) * Medication Therapy Management * Exchange of Information * Appropriate diagnosis, treatment and referral for behavioral health seen in a primary setting * Special needs for members with severe and persistent mental illness * Appropriate use of psychotropic medications * Management of treatment access and follow-up for members with coexisting medical and behavioral disorders * Primary or secondary preventive behavioral healthcare program implementation Serving a Culturally and Linguistically Diverse Membership PreferredOne incorporates into its annual work plan efforts to better serve our culturally and linguistically diverse membership; provides information and tools to staff and network practitioners to support culturally appropriate care and facilitate effective communication; and provides these services through LanguageLine Solutionssm, annually communicating their service availability to members.

4c	(Code: ) (Expenses $ including grants of $ ) (Revenue $ )












4d	Other program services (Describe in Schedule O.)
	(Expenses $ including grants of $ ) (Revenue $ )
4e	Total program service expenses1,646,249

Form 990 (2021)

Page 3

Part IV

Checklist of Required Schedules

Yes

Is the organization described in section 501(c)(3) or 4947(a)(1) (other than a private foundation)? If "Yes," complete Schedule A.....................

Is the organization required to complete Schedule B, Schedule of Contributors? See instructions. ...

Did the organization engage in direct or indirect political campaign activities on behalf of or in opposition to candidates for public office? If "Yes," complete Schedule C, Part I.............

Section 501(c)(3) organizations. Did the organization engage in lobbying activities, or have a section 501(h) election in effect during the tax year? If "Yes," complete Schedule C, Part II.........

Is the organization a section 501(c)(4), 501(c)(5), or 501(c)(6) organization that receives membership dues, assessments, or similar amounts as defined in Rev. Proc. 98-19? If "Yes," complete Schedule C, Part III..

Did the organization maintain any donor advised funds or any similar funds or accounts for which donors have the right to provide advice on the distribution or investment of amounts in such funds or accounts? If "Yes," complete Schedule D, Part I.........................

Did the organization receive or hold a conservation easement, including easements to preserve open space,
the environment, historic land areas, or historic structures? If "Yes," complete Schedule D, Part II....

Did the organization maintain collections of works of art, historical treasures, or other similar assets? If "Yes,"
complete Schedule D, Part III..............

Did the organization report an amount in Part X, line 21 for escrow or custodial account liability; serve as a custodian for amounts not listed in Part X; or provide credit counseling, debt management, credit repair, or debt negotiation services? If "Yes," complete Schedule D, Part IV..............

Did the organization, directly or through a related organization, hold assets in temporarily restricted endowments, permanent endowments, or quasi endowments? If "Yes," complete Schedule D, Part V......

If the organization’s answer to any of the following questions is "Yes," then complete Schedule D, Parts VI, VII, VIII, IX, or X, as applicable.

Did the organization report an amount for land, buildings, and equipment in Part X, line 10? If "Yes," complete
Schedule D, Part VI. ...................

11a

Did the organization report an amount for investments—other securities in Part X, line 12 that is 5% or more of its total assets reported in Part X, line 16? If "Yes," complete Schedule D, Part VII Click to see attachment

.......

11b

Yes

Did the organization report an amount for investments—program related in Part X, line 13 that is 5% or more of its total assets reported in Part X, line 16? If "Yes," complete Schedule D, Part VIII.......

11c

Did the organization report an amount for other assets in Part X, line 15 that is 5% or more of its total assets reported in Part X, line 16? If "Yes," complete Schedule D, Part IX............

11d

Did the organization report an amount for other liabilities in Part X, line 25? If "Yes," complete Schedule D, Part X Click to see attachment

11e

Yes

Did the organization’s separate or consolidated financial statements for the tax year include a footnote that addresses the organization’s liability for uncertain tax positions under FIN 48 (ASC 740)? If "Yes," complete Schedule D, Part X Click to see attachment

11f

Yes

12a

Did the organization obtain separate, independent audited financial statements for the tax year? If "Yes," complete
Schedule D, Parts XI and XII Click to see attachment

......................

12a

Yes

Was the organization included in consolidated, independent audited financial statements for the tax year? If "Yes," and if the organization answered "No" to line 12a, then completing Schedule D, Parts XI and XII is optional

12b

Is the organization a school described in section 170(b)(1)(A)(ii)? If "Yes," complete Schedule E

14a

Did the organization maintain an office, employees, or agents outside of the United States? .....

14a

Did the organization have aggregate revenues or expenses of more than $10,000 from grantmaking, fundraising, business, investment, and program service activities outside the United States, or aggregate foreign investments valued at $100,000 or more? If "Yes," complete Schedule F, Parts I and IV.........

14b

Did the organization report on Part IX, column (A), line 3, more than $5,000 of grants or other assistance to or for any foreign organization? If “Yes,” complete Schedule F, Parts II and IV.....

Did the organization report on Part IX, column (A), line 3, more than $5,000 of aggregate grants or other assistance to or for foreign individuals? If “Yes,” complete Schedule F, Parts III and IV...

Did the organization report a total of more than $15,000 of expenses for professional fundraising services on Part IX, column (A), lines 6 and 11e? If "Yes," complete Schedule G, Part I. See instructions. ....

Did the organization report more than $15,000 total of fundraising event gross income and contributions on Part VIII, lines 1c and 8a? If "Yes," complete Schedule G, Part II............

Did the organization report more than $15,000 of gross income from gaming activities on Part VIII, line 9a? If "Yes," complete Schedule G, Part III...................

20a

Did the organization operate one or more hospital facilities? If "Yes," complete Schedule H....

20a

If "Yes" to line 20a, did the organization attach a copy of its audited financial statements to this return?

20b

Did the organization report more than $5,000 of grants or other assistance to any domestic organization or domestic government on Part IX, column (A), line 1? If “Yes,” complete Schedule I, Parts I and II.....

Form 990 (2021)

Page 4

Part IV

Checklist of Required Schedules (continued)

Yes

Did the organization report more than $5,000 of grants or other assistance to or for domestic individuals on Part IX, column (A), line 2? If “Yes,” complete Schedule I, Parts I and III........

Did the organization answer "Yes" to Part VII, Section A, line 3, 4, or 5, about compensation of the organization’s current and former officers, directors, trustees, key employees, and highest compensated employees? If "Yes," complete Schedule J....................... Click to see attachment

Yes

24a

Did the organization have a tax-exempt bond issue with an outstanding principal amount of more than $100,000 as of the last day of the year, that was issued after December 31, 2002? If “Yes,” answer lines 24b through 24d and complete Schedule K. If “No,” go to line 25a...............

24a

Did the organization invest any proceeds of tax-exempt bonds beyond a temporary period exception?...

24b

Did the organization maintain an escrow account other than a refunding escrow at any time during the year
to defease any tax-exempt bonds? ...............

24c

Did the organization act as an "on behalf of" issuer for bonds outstanding at any time during the year?...

24d

25a

Section 501(c)(3), 501(c)(4), and 501(c)(29) organizations. Did the organization engage in an excess benefit transaction with a disqualified person during the year? If "Yes," complete Schedule L, Part I ....

25a

Is the organization aware that it engaged in an excess benefit transaction with a disqualified person in a prior year, and that the transaction has not been reported on any of the organization’s prior Forms 990 or 990-EZ? If "Yes," complete Schedule L, Part I.......................

25b

Did the organization report any amount on Part X, line 5 or 22 for receivables from or payables to any current or former officer, director, trustee, key employee, creator or founder, substantial contributor, or 35% controlled entity or family member of any of these persons? If "Yes," complete Schedule L, Part II...........

Did the organization provide a grant or other assistance to any current or former officer, director, trustee, key employee, creator or founder, substantial contributor, or employee thereof, a grant selection committee member, or to a 35% controlled entity (including an employee thereof) or family member of any of these persons?

If "Yes," complete

Schedule L, Part III.........................

Was the organization a party to a business transaction with one of the following parties (see the Schedule L, Part IV instructions for applicable filing thresholds, conditions, and exceptions):

A current or former officer, director, trustee, key employee, creator or founder, or substantial contributor? If "Yes," complete Schedule L, Part IV......................

28a

A family member of any individual described in line 28a? If "Yes," complete Schedule L, Part IV.....

28b

A 35% controlled entity of one or more individuals and/or organizations described in line 28a or 28b? If "Yes," complete Schedule L, Part IV.....................

28c

Did the organization receive more than $25,000 in non-cash contributions? If "Yes," complete Schedule M..

Did the organization receive contributions of art, historical treasures, or other similar assets, or qualified conservation contributions? If "Yes," complete Schedule M .................

Did the organization liquidate, terminate, or dissolve and cease operations? If "Yes," complete Schedule N, Part I

Did the organization sell, exchange, dispose of, or transfer more than 25% of its net assets? If "Yes," complete Schedule N, Part II........................

Did the organization own 100% of an entity disregarded as separate from the organization under Regulations sections 301.7701-2 and 301.7701-3? If "Yes," complete Schedule R, Part I............

Was the organization related to any tax-exempt or taxable entity? If "Yes," complete Schedule R, Part II, III, or IV, and Part V, line 1......................... Click to see attachment

Yes

35a

Did the organization have a controlled entity within the meaning of section 512(b)(13)?

35a

If ‘Yes’ to line 35a, did the organization receive any payment from or engage in any transaction with a controlled entity within the meaning of section 512(b)(13)? If "Yes," complete Schedule R, Part V, line 2 ...

35b

Section 501(c)(3) organizations. Did the organization make any transfers to an exempt non-charitable related organization? If "Yes," complete Schedule R, Part V, line 2.............

Did the organization conduct more than 5% of its activities through an entity that is not a related organization and that is treated as a partnership for federal income tax purposes? If "Yes," complete Schedule R, Part VI

Did the organization complete Schedule O and provide explanations on Schedule O for Part VI, lines 11b and 19? Note. All Form 990 filers are required to complete Schedule O. ............

Yes

Part V

Statements Regarding Other IRS Filings and Tax Compliance
Check if Schedule O contains a response or note to any line in this Part V...........

Yes

Enter the number reported in box 3 of Form 1096. Enter -0- if not applicable ..

Enter the number of Forms W-2G included on line 1a. Enter -0- if not applicable .

Did the organization comply with backup withholding rules for reportable payments to vendors and reportable gaming (gambling) winnings to prize winners? ..................

Form 990 (2021)

Page 5

Part V

Statements Regarding Other IRS Filings and Tax Compliance (continued)

Enter the number of employees reported on Form W-3, Transmittal of Wage and
Tax Statements, filed for the calendar year ending with or within the year covered by this return ..................

If at least one is reported on line 2a, did the organization file all required federal employment tax returns?
Note. If the sum of lines 1a and 2a is greater than 250, you may be required to e-file. See instructions.

Did the organization have unrelated business gross income of $1,000 or more during the year?...

If “Yes,” has it filed a Form 990-T for this year? If “No” to line 3b, provide an explanation in Schedule O...

At any time during the calendar year, did the organization have an interest in, or a signature or other authority over, a financial account in a foreign country (such as a bank account, securities account, or other financial account)? ..

If "Yes," enter the name of the foreign country: MediumBullet

See instructions for filing requirements for FinCEN Form 114, Report of Foreign Bank and Financial Accounts (FBAR).

Was the organization a party to a prohibited tax shelter transaction at any time during the tax year? ..

Did any taxable party notify the organization that it was or is a party to a prohibited tax shelter transaction?

If "Yes," to line 5a or 5b, did the organization file Form 8886-T? ............

Does the organization have annual gross receipts that are normally greater than $100,000, and did the organization solicit any contributions that were not tax deductible as charitable contributions? ...

If "Yes," did the organization include with every solicitation an express statement that such contributions or gifts were not tax deductible? ......................

Organizations that may receive deductible contributions under section 170(c).

Did the organization receive a payment in excess of $75 made partly as a contribution and partly for goods and services provided to the payor? ....................

If "Yes," did the organization notify the donor of the value of the goods or services provided? .....

Did the organization sell, exchange, or otherwise dispose of tangible personal property for which it was required to file Form 8282? .........................

If "Yes," indicate the number of Forms 8282 filed during the year ....

Did the organization receive any funds, directly or indirectly, to pay premiums on a personal benefit contract?

Did the organization, during the year, pay premiums, directly or indirectly, on a personal benefit contract? ..

If the organization received a contribution of qualified intellectual property, did the organization file Form 8899 as required? ......................

If the organization received a contribution of cars, boats, airplanes, or other vehicles, did the organization file a Form 1098-C? ..........................

Sponsoring organizations maintaining donor advised funds. Did a donor advised fund maintained by the sponsoring organization have excess business holdings at any time during the year? ........

Sponsoring organizations maintaining donor advised funds.

Did the sponsoring organization make any taxable distributions under section 4966?........

Did the sponsoring organization make a distribution to a donor, donor advisor, or related person?...

Section 501(c)(7) organizations. Enter:

Initiation fees and capital contributions included on Part VIII, line 12 ...

10a

Gross receipts, included on Form 990, Part VIII, line 12, for public use of club facilities

10b

Section 501(c)(12) organizations. Enter:

Gross income from members or shareholders .........

11a

Gross income from other sources. (Do not net amounts due or paid to other sources against amounts due or received from them.) ..........

11b

12a

Section 4947(a)(1) non-exempt charitable trusts. Is the organization filing Form 990 in lieu of Form 1041?

12a

If "Yes," enter the amount of tax-exempt interest received or accrued during the year.

12b

Section 501(c)(29) qualified nonprofit health insurance issuers.

Is the organization licensed to issue qualified health plans in more than one state? .........
Note. See the instructions for additional information the organization must report on Schedule O.

13a

Enter the amount of reserves the organization is required to maintain by the states in which the organization is licensed to issue qualified health plans ....

13b

Enter the amount of reserves on hand ............

13c

14a

Did the organization receive any payments for indoor tanning services during the tax year?.....

14a

If "Yes," has it filed a Form 720 to report these payments? If "No," provide an explanation in Schedule O..

14b

Is the organization subject to the section 4960 tax on payment(s) of more than $1,000,000 in remuneration or excess parachute payment(s) during the year? ....................
If "Yes," see the instructions and file Form 4720, Schedule N.

Is the organization an educational institution subject to the section 4968 excise tax on net investment income? ..
If "Yes," complete Form 4720, Schedule O.

Section 501(c)(21) organizations. Did the trust, any disqualified person, or mine operator engage in any activities that would result in the imposition of an excise tax under section 4951, 4952, or 4953? ..
If "Yes," complete Form 6069.

Form 990 (2021)

Page 6

Part VI

Governance, Management, and Disclosure. For each "Yes" response to lines 2 through 7b below, and for a "No" response to lines 8a, 8b, or 10b below, describe the circumstances, processes, or changes in Schedule O. See instructions.

Check if Schedule O contains a response or note to any line in this Part VI..............

Section A. Governing Body and Management

Yes

Enter the number of voting members of the governing body at the end of the tax year

If there are material differences in voting rights among members of the governing body, or if the governing body delegated broad authority to an executive committee or similar committee, explain in Schedule O.

Enter the number of voting members included in line 1a, above, who are independent

Did any officer, director, trustee, or key employee have a family relationship or a business relationship with any other officer, director, trustee, or key employee? .................

Did the organization delegate control over management duties customarily performed by or under the direct supervision of officers, directors or trustees, or key employees to a management company or other person? .

Did the organization make any significant changes to its governing documents since the prior Form 990 was filed? .

Did the organization become aware during the year of a significant diversion of the organization’s assets? .

Did the organization have members or stockholders? ................

Yes

Did the organization have members, stockholders, or other persons who had the power to elect or appoint one or more members of the governing body? ....................

Yes

Are any governance decisions of the organization reserved to (or subject to approval by) members, stockholders, or persons other than the governing body? ...................

Did the organization contemporaneously document the meetings held or written actions undertaken during the year by the following:

The governing body? .......................

Yes

Each committee with authority to act on behalf of the governing body? ............

Yes

Is there any officer, director, trustee, or key employee listed in Part VII, Section A, who cannot be reached at the organization’s mailing address? If "Yes," provide the names and addresses in Schedule O.......

Section B. Policies (This Section B requests information about policies not required by the Internal Revenue Code.)

Yes

10a

Did the organization have local chapters, branches, or affiliates? ............

10a

If "Yes," did the organization have written policies and procedures governing the activities of such chapters, affiliates, and branches to ensure their operations are consistent with the organization's exempt purposes?

10b

11a

Has the organization provided a complete copy of this Form 990 to all members of its governing body before filing the form? ............................

11a

Yes

Describe on Schedule O the process, if any, used by the organization to review this Form 990. .....

12a

Did the organization have a written conflict of interest policy? If "No," go to line 13.......

12a

Yes

Were officers, directors, or trustees, and key employees required to disclose annually interests that could give rise to conflicts? ..........................

12b

Yes

Did the organization regularly and consistently monitor and enforce compliance with the policy? If "Yes," describe on Schedule O how this was done...................

12c

Yes

Did the organization have a written whistleblower policy? ...............

Yes

Did the organization have a written document retention and destruction policy? .........

Yes

Did the process for determining compensation of the following persons include a review and approval by independent persons, comparability data, and contemporaneous substantiation of the deliberation and decision?

The organization’s CEO, Executive Director, or top management official ...........

15a

Yes

Other officers or key employees of the organization ................

15b

Yes

If "Yes" to line 15a or 15b, describe the process on Schedule O. See instructions.

16a

Did the organization invest in, contribute assets to, or participate in a joint venture or similar arrangement with a taxable entity during the year? ......................

16a

If "Yes," did the organization follow a written policy or procedure requiring the organization to evaluate its participation in joint venture arrangements under applicable federal tax law, and take steps to safeguard the organization’s exempt status with respect to such arrangements? ............

16b

Section C. Disclosure

List the states with which a copy of this Form 990 is required to be filed MediumBullet

Section 6104 requires an organization to make its Form 1023 (1024 or 1024-A, if applicable), 990, and 990-T (section 501(c)(3)s only) available for public inspection. Indicate how you made these available. Check all that apply.

Own website Another's website Upon request Other (explain in Schedule O)

Describe in Schedule O whether (and if so, how) the organization made its governing documents, conflict of interest policy, and financial statements available to the public during the tax year.

State the name, address, and telephone number of the person who possesses the organization's books and records:
MediumBullet

JON CARLSON6105 GOLDEN HILLS DRIVE GOLDEN VALLEY,MN55416 (763) 847-3204

Form 990 (2021)

Page 7

Part VII

Compensation of Officers, Directors,Trustees, Key Employees, Highest Compensated Employees, and Independent Contractors

Check if Schedule O contains a response or note to any line in this Part VII..............

Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees

1a Complete this table for all persons required to be listed. Report compensation for the calendar year ending with or within the organization’s tax year.
RoundBullet

List all of the organization’s current officers, directors, trustees (whether individuals or organizations), regardless of amount
of compensation. Enter -0- in columns (D), (E), and (F) if no compensation was paid.

List all of the organization’s current key employees, if any. See the instructions for definition of "key employee."

List the organization’s five current highest compensated employees (other than an officer, director, trustee or key employee)
who received reportable compensation (box 5 of Form W-2, Form 1099-MISC, and/or box 1 of Form 1099-NEC) of more than $100,000 from the
organization and any related organizations.

List all of the organization’s former officers, key employees, or highest compensated employees who received more than $100,000
of reportable compensation from the organization and any related organizations.

List all of the organization’s former directors or trustees that received, in the capacity as a former director or trustee of the
organization, more than $10,000 of reportable compensation from the organization and any related organizations.

See the instructions for the order in which to list the persons above.

Check this box if neither the organization nor any related organization compensated any current officer, director, or trustee.

(A) Name and title	(B) Average hours per week (list any hours for related organizations below dotted line)	(C) Position (do not check more than one box, unless person is both an officer and a director/trustee)				(D) Reportable compensation from the organization (W-2/1099-MISC/1099-NEC)	(E) Reportable compensation from related organizations (W-2/1099-MISC/1099-NEC)	(F) Estimated amount of other compensation from the organization and related organizations
(A) Name and title
(1) John Batson CHAIR	0.2 ................. 40.0	X	X			0	1,047,259	149,411
(2) Kimberley DeRoche MD Director	0.2 ................. 40.0	X				0	481,052	94,058
(3) REBECCA HILLEY DIRECTOR	0.2 ................. 0.0	X				3,180	0	0
(4) Trudi Trysla DIRECTOR	0.2 ................. 40.0	X				0	799,805	152,560
(5) David Crosby PRESIDENT & CEO	0.2 ................. 40.0		X			1,813	884,055	74,781
(6) MICHAEL UMLAND TREASURER	0.2 ................. 39.8		X			2,562	638,022	70,095
(7) ABIGAIL MILLER SR VP & CMO	0.2 ................. 39.8			X		2,265	564,096	53,223
(8) PAUL GEIWITZ SVP/CHIEF MARKETING - left 12/2021	0.2 ................. 39.8			X		1,408	350,595	75,342
(9) ROBERT HAMLING JR VP IS,CIP & SECURITY	0.2 ................. 39.8			X		1,508	375,461	56,589
(10) STACY MAYS SVP & COO - left 6/2021	0.2 ................. 39.8			X		1,973	491,304	62,871
(11) CLARISSA COX VP CLINICAL OPS & CAR - left 9/2021	0.2 ................. 39.8				X	1,222	304,358	53,110
(12) DANIEL STEWART VP OF SALES	0.2 ................. 39.8				X	1,871	465,920	71,085
(13) JILL ARCHER VP Network Management	0.2 ................. 39.8				X	1,122	279,332	52,314
(14) ROBERT GADOLA VP OPERATIONS/HIPPA	0.2 ................. 39.8				X	1,978	492,466	58,817
(15) THOMAS CARLSON DIRECTOR, ACTURIAL	0.2 ................. 39.8				X	1,211	301,644	37,841

Form 990 (2021)

Page 8

Part VII

Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees (continued)

(A) Name and title	(B) Average hours per week (list any hours for related organizations below dotted line)	(C) Position (do not check more than one box, unless person is both an officer and a director/trustee)						(D) Reportable compensation from the organization (W-2/1099-MISC/1099-NEC)	(E) Reportable compensation from related organizations (W-2/1099-MISC/1099-NEC)	(F) Estimated amount of other compensation from the organization and related organizations
(A) Name and title

1b	Sub-Total................
c	Total from continuation sheets to Part VII, Section A....
d	Total (add lines 1b and 1c)...........	22,113	7,475,370	1,062,097

Total number of individuals (including but not limited to those listed above) who received more than $100,000 of reportable compensation from the organization MediumBullet

Yes

Did the organization list any former officer, director or trustee, key employee, or highest compensated employee on line 1a? If "Yes," complete Schedule J for such individual ..............

For any individual listed on line 1a, is the sum of reportable compensation and other compensation from the organization and related organizations greater than $150,000? If "Yes," complete Schedule J for such
individual...........................

Yes

Did any person listed on line 1a receive or accrue compensation from any unrelated organization or individual for services rendered to the organization? If "Yes," complete Schedule J for such person ........

Section B. Independent Contractors

Complete this table for your five highest compensated independent contractors that received more than $100,000 of compensation from the organization. Report compensation for the calendar year ending with or within the organization’s tax year.

(A) Name and business address	(B) Description of services	(C) Compensation





2 Total number of independent contractors (including but not limited to those listed above) who received more than $100,000 of compensation from the organization 0

Form 990 (2021)

Page 9

Part VIII

Statement of Revenue

Check if Schedule O contains a response or note to any line in this Part VIII.............

(A)
Total revenue

(B)
Related or
exempt
function
revenue

(D)
Revenue
excluded from
tax under sections
512 - 514

1a	Federated campaigns..		1a
b	Membership dues..		1b
c	Fundraising events..		1c
d	Related organizations		1d
e	Government grants (contributions)		1e

f	All other contributions, gifts, grants, and similar amounts not included above		1f

g	Noncash contributions included in lines 1a - 1f:$		1g

h Total. Add lines 1a-1f.......		0

		Business Code
2a	Premium Revenue	524114	1,146,701	1,146,701
b
c
d
e
f	All other program service revenue.		0	0	0	0
g	Total. Add lines 2a–2f .....		1,146,701

3 Investment income (including dividends, interest, and othersimilar amounts) ......			39,726			39,726
4 Income from investment of tax-exempt bond proceeds
5 Royalties...........
		(ii) Personal	(i) Real
6a	Gross rents			6a
b	Less: rental expenses			6b
c	Rental income or (loss)	0	0	6c
d	Net rental income or (loss).......
		(ii) Other	(i) Securities
7a	Gross amount from sales of assets other than inventory		1,567,030	7a
b	Less: cost or other basis and sales expenses		1,565,202	7b
c	Gain or (loss)	0	1,828	7c
d	Net gain or (loss).........			1,828			1,828
8a	Gross income from fundraising events (not including $ of contributions reported on line 1c). See Part IV, line 18 ....
			8a
b	Less: direct expenses ...		8b
c	Net income or (loss) from fundraising events..
9a	Gross income from gaming activities. See Part IV, line 19 ...
			9a
b	Less: direct expenses ...		9b
c	Net income or (loss) from gaming activities..
10a	Gross sales of inventory, less returns and allowances ..
			10a
b	Less: cost of goods sold ..		10b
c	Net income or (loss) from sales of inventory..
Business Code			Miscellaneous Revenue
11a
b
c
d	All other revenue ....			0	0	0	0
e	Total. Add lines 11a–11d ......			0
12	Total revenue. See instructions.....			1,188,255	1,146,701	0	41,554

Form 990 (2021)

Page 10

Part IX

Statement of Functional Expenses

Section 501(c)(3) and 501(c)(4) organizations must complete all columns. All other organizations must complete column (A).Check if Schedule O contains a response or note to any line in this Part IX..............

Do not include amounts reported on lines 6b, 7b, 8b, 9b, and 10b of Part VIII.		(A) Total expenses	(B) Program service expenses	(C) Management and general expenses	(D) Fundraising expenses

1	Grants and other assistance to domestic organizations and domestic governments. See Part IV, line 21 ....
2	Grants and other assistance to domestic individuals. See Part IV, line 22 ...........
3	Grants and other assistance to foreign organizations, foreign governments, and foreign individuals. See Part IV, lines 15 and 16. .............
4	Benefits paid to or for members .......
5	Compensation of current officers, directors, trustees, and key employees ...........	16,003	0	16,003	0
6	Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) .........
7	Other salaries and wages........
8	Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) ....
9	Other employee benefits .......
10	Payroll taxes ...........
11	Fees for services (non-employees):
a	Management ......	24,536		24,536
b	Legal .........
c	Accounting ...........	49,466		49,466
d	Lobbying ...........
e	Professional fundraising services. See Part IV, line 17
f	Investment management fees ......
g	Other (If line 11g amount exceeds 10% of line 25, column (A) amount, list line 11g expenses on Schedule O)	544,469	540,312	4,157	0
12	Advertising and promotion ....
13	Office expenses .......	16,493		16,493
14	Information technology ......
15	Royalties ..
16	Occupancy ...........
17	Travel ............
18	Payments of travel or entertainment expenses for any federal, state, or local public officials .
19	Conferences, conventions, and meetings ....
20	Interest ...........
21	Payments to affiliates .......
22	Depreciation, depletion, and amortization ..
23	Insurance ...	1,462		1,462
24	Other expenses. Itemize expenses not covered above (List miscellaneous expenses in line 24e. If line 24e amount exceeds 10% of line 25, column (A) amount, list line 24e expenses on Schedule O.)
a	Pharmacy	127,488	127,488
b	Hospital	741,510	741,510
c	Mental Health/Substance	236,939	236,939
d	Brokerage Costs	48,879		48,879
e	All other expenses	43,090	0	43,090	0
25	Total functional expenses. Add lines 1 through 24e	1,850,335	1,646,249	204,086	0
26	Joint costs. Complete this line only if the organization reported in column (B) joint costs from a combined educational campaign and fundraising solicitation. Check here if following SOP 98-2 (ASC 958-720).

Form 990 (2021)

Page 11

Part X

Balance Sheet

Check if Schedule O contains a response or note to any line in this Part IX..............

				(A) Beginning of year		(B) End of year

1	Cash–non-interest-bearing ........			255,883	1	198,138
2	Savings and temporary cash investments .........			452,759	2	3,162
3	Pledges and grants receivable, net ......			0	3
4	Accounts receivable, net .............			76,560	4	128,969
5	Loans and other receivables from any current or former officer, director, trustee, key employee, creator or founder, substantial contributor, or 35% controlled entity or family member of any of these persons .......
				0	5	0
6	Loans and other receivables from other disqualified persons (as defined under section 4958(f)(1)), and persons described in section 4958(c)(3)(B) ...
				0	6	0
7	Notes and loans receivable, net ...........			0	7
8	Inventories for sale or use ............			0	8
9	Prepaid expenses and deferred charges ......			0	9
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	0
b	Less: accumulated depreciation	10b	0	0	10c	0
11	Investments—publicly traded securities .			0	11
12	Investments—other securities. See Part IV, line 11 .....			2,989,866	12	2,491,501
13	Investments—program-related. See Part IV, line 11 ..			0	13
14	Intangible assets ...............				14
15	Other assets. See Part IV, line 11 ...........			9,297	15	4,933
16	Total assets. Add lines 1 through 15 (must equal line 33)...			3,784,365	16	2,826,703

17	Accounts payable and accrued expenses .....	111,705	17	80,654
18	Grants payable ...		18
19	Deferred revenue .........	26	19
20	Tax-exempt bond liabilities .........		20
21	Escrow or custodial account liability. Complete Part IV of Schedule D		21
22	Loans and other payables to any current or former officer, director, trustee, key employee, creator or founder, substantial contributor, or 35% controlled entity or family member of any of these persons .........
		0	22	0
23	Secured mortgages and notes payable to unrelated third parties ..		23
24	Unsecured notes and loans payable to unrelated third parties ..		24
25	Other liabilities (including federal income tax, payables to related third parties, and other liabilities not included on lines 17 - 24). Complete Part X of Schedule D	1,723,616	25	1,504,297
26	Total liabilities. Add lines 17 through 25..	1,835,347	26	1,584,951

	Organizations that follow FASB ASC 958, check here and complete lines 27, 28, 32, and 33.
27	Net assets without donor restrictions ..........	1,949,018	27	1,241,752
28	Net assets with donor restrictions ...........		28
	Organizations that do not follow FASB ASC 958, check here and complete lines 29 through 33.
29	Capital stock or trust principal, or current funds .....		29
30	Paid-in or capital surplus, or land, building or equipment fund ...		30
31	Retained earnings, endowment, accumulated income, or other funds		31
32	Total net assets or fund balances ...........	1,949,018	32	1,241,752
33	Total liabilities and net assets/fund balances ........	3,784,365	33	2,826,703

Form 990 (2021)

Page 12

Part XI

Reconcilliation of Net Assets

Check if Schedule O contains a response or note to any line in this Part XI..............

Total revenue (must equal Part VIII, column (A), line 12) ............

1,188,255

Total expenses (must equal Part IX, column (A), line 25) ............

1,850,335

Revenue less expenses. Subtract line 2 from line 1 ..............

-662,080

Net assets or fund balances at beginning of year (must equal Part X, line 32, column (A)) ..

1,949,018

Net unrealized gains (losses) on investments ...............

-45,186

Donated services and use of facilities .................

Investment expenses .....................

Prior period adjustments .....................

Other changes in net assets or fund balances (explain in Schedule O) ........

Net assets or fund balances at end of year. Combine lines 3 through 9 (must equal Part X, line 32, column (B))

1,241,752

Part XII

Financial Statements and Reporting

Check if Schedule O contains a response or note to any line in this Part XII.............

Yes

Accounting method used to prepare the Form 990: Cash Accrual Other
If the organization changed its method of accounting from a prior year or checked "Other," explain on
Schedule O.

Were the organization’s financial statements compiled or reviewed by an independent accountant?

If ‘Yes,’ check a box below to indicate whether the financial statements for the year were compiled or reviewed on a separate basis, consolidated basis, or both:

Separate basis Consolidated basis Both consolidated and separate basis

Were the organization’s financial statements audited by an independent accountant?

Yes

If ‘Yes,’ check a box below to indicate whether the financial statements for the year were audited on a separate basis, consolidated basis, or both:

Separate basis Consolidated basis Both consolidated and separate basis

If "Yes," to line 2a or 2b, does the organization have a committee that assumes responsibility for oversight of the audit, review, or compilation of its financial statements and selection of an independent accountant?

Yes

If the organization changed either its oversight process or selection process during the tax year, explain in Schedule O.

As a result of a federal award, was the organization required to undergo an audit or audits as set forth in the Single Audit Act and OMB Circular A-133?

If "Yes," did the organization undergo the required audit or audits? If the organization did not undergo the required audit or audits, explain why in Schedule O and describe any steps taken to undergo such audits.

Form 990 (2021)

Additional Data

Software ID:	21014044
Software Version:	2021v4.2

Form 990, Special Condition Description:

Special Condition Description

- TIN:

SCHEDULE D
(Form 990)

Department of the Treasury
Internal Revenue Service

Supplemental Financial Statements

Complete if the organization answered "Yes," on Form 990,
Part IV, line 6, 7, 8, 9, 10, 11a, 11b, 11c, 11d, 11e, 11f, 12a, or 12b.
SchDMd Bullet

Attach to Form 990.
SchDMd Bullet

Go to www.irs.gov/Form990 for instructions and the latest information.

OMB No. 1545-0047

2021

Open to Public Inspection

Name of the organization

PreferredOne Community Health Plan

Employer identification number

41-1796007

Part I

Organizations Maintaining Donor Advised Funds or Other Similar Funds or Accounts. Complete if the organization answered "Yes" on Form 990, Part IV, line 6.

		(a) Donor advised funds	(b) Funds and other accounts
1	Total number at end of year .........
2	Aggregate value of contributions to (during year)
3	Aggregate value of grants from (during year)
4	Aggregate value at end of year ........

Did the organization inform all donors and donor advisors in writing that the assets held in donor advised funds are the organization’s property, subject to the organization’s exclusive legal control? ............

Yes No

Did the organization inform all grantees, donors, and donor advisors in writing that grant funds can be used only for charitable purposes and not for the benefit of the donor or donor advisor, or for any other purpose conferring impermissible private benefit? ...................................

Yes No

Part II

Conservation Easements.
Complete if the organization answered "Yes" on Form 990, Part IV, line 7.

Purpose(s) of conservation easements held by the organization (check all that apply).

Preservation of land for public use (e.g., recreation or education) Preservation of an historically important land area

Protection of natural habitat Preservation of a certified historic structure

Preservation of open space

Complete lines 2a through 2d if the organization held a qualified conservation contribution in the form of a conservation easement on the last day of the tax year.


a	Total number of conservation easements ......................	2a
b	Total acreage restricted by conservation easements ....................	2b
c	Number of conservation easements on a certified historic structure included in (a) .....	2c
d	Number of conservation easements included in (c) acquired after 7/25/06, and not on a historic structure listed in the National Register ...	2d

Number of conservation easements modified, transferred, released, extinguished, or terminated by the organization during the
tax year SchDMd Bullet

Number of states where property subject to conservation easement is located SchDMd Bullet

Does the organization have a written policy regarding the periodic monitoring, inspection, handling of violations, and enforcement of the conservation easements it holds? ............

Yes No

Staff and volunteer hours devoted to monitoring, inspecting, handling of violations, and enforcing conservation easements during the year
SchDMd Bullet

Amount of expenses incurred in monitoring, inspecting, handling of violations, and enforcing conservation easements during the year
SchDMd Bullet

Does each conservation easement reported on line 2(d) above satisfy the requirements of section 170(h)(4)(B)(i) and section 170(h)(4)(B)(ii)? .............................

Yes No

In Part XIII, describe how the organization reports conservation easements in its revenue and expense statement, and
balance sheet, and include, if applicable, the text of the footnote to the organization’s financial statements that describes
the organization’s accounting for conservation easements.

Part III

Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets.
Complete if the organization answered "Yes" on Form 990, Part IV, line 8.

If the organization elected, as permitted under FASB ASC 958, not to report in its revenue statement and balance sheet works of art, historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of public service, provide, in Part XIII, the text of the footnote to its financial statements that describes these items.

If the organization elected, as permitted under FASB ASC 958, to report in its revenue statement and balance sheet works of art, historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of public service, provide the following amounts relating to these items:

(i)

Revenue included on Form 990, Part VIII, line 1 ......................... SchDMd Bullet

(ii)

Assets included in Form 990, Part X ............................... SchDMd Bullet

If the organization received or held works of art, historical treasures, or other similar assets for financial gain, provide the
following amounts required to be reported under FASB ASC 958 relating to these items:

Revenue included on Form 990, Part VIII, line 1 .......................... SchDMd Bullet

Assets included in Form 990, Part X ............................... SchDMd Bullet

For Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 52283D

Schedule D (Form 990) 2021

Page 2

Part III

Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets (continued)

Using the organization’s acquisition, accession, and other records, check any of the following that are a significant use of its collection items (check all that apply):

Public exhibition

Loan or exchange programs

Scholarly research

Other

Preservation for future generations

Provide a description of the organization’s collections and explain how they further the organization’s exempt purpose in
Part XIII.

During the year, did the organization solicit or receive donations of art, historical treasures or other similar
assets to be sold to raise funds rather than to be maintained as part of the organization’s collection?...

Yes No

Part IV

Escrow and Custodial Arrangements. Complete if the organization answered "Yes" on Form 990, Part IV, line 9, or reported an amount on Form 990, Part X, line 21.

Is the organization an agent, trustee, custodian or other intermediary for contributions or other assets not
included on Form 990, Part X? ....................................

Yes No


b	If "Yes," explain the arrangement in Part XIII and complete the following table:		Amount
c	Beginning balance .............................	1c
d	Additions during the year ............................	1d
e	Distributions during the year ..........................	1e
f	Ending balance ................................	1f

Did the organization include an amount on Form 990, Part X, line 21, for escrow or custodial account liability? ...

Yes No

If "Yes," explain the arrangement in Part XIII. Check here if the explanation has been provided in Part XIII ....

Part V

Endowment Funds.
Complete if the organization answered "Yes" on Form 990, Part IV, line 10.

		(a) Current year	(b) Prior year	(c) Two years back	(d) Three years back	(e) Four years back

1a	Beginning of year balance ....
b	Contributions ...
c	Net investment earnings, gains, and losses
d	Grants or scholarships ...
e	Other expenditures for facilities and programs ...
f	Administrative expenses ....
g	End of year balance ......

Provide the estimated percentage of the current year end balance (line 1g, column (a)) held as:

Board designated or quasi-endowment SchDMd Bullet

Permanent endowment SchDMd Bullet

Term endowment SchDMd Bullet

The percentages on lines 2a, 2b, and 2c should equal 100%.

Are there endowment funds not in the possession of the organization that are held and administered for the
organization by:

Yes

(i) Unrelated organizations .................

3a(i)

(ii) Related organizations .................

3a(ii)

If "Yes" on 3a(ii), are the related organizations listed as required on Schedule R? .........

Describe in Part XIII the intended uses of the organization's endowment funds.

Part VI

Land, Buildings, and Equipment.
Complete if the organization answered "Yes" on Form 990, Part IV, line 11a. See Form 990, Part X, line 10.

Description of property		(a) Cost or other basis (investment)	(b) Cost or other basis (other)	(c) Accumulated depreciation	(d) Book value

1a	Land .....
b	Buildings ....
c	Leasehold improvements
d	Equipment ....
e	Other .....
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).)..

Schedule D (Form 990) 2021

Page 3

Part VII

Investments - Other Securities.
Complete if the organization answered "Yes" on Form 990, Part IV, line 11b. See Form 990, Part X, line 12.

(a) Description of security or category (including name of security)	(b) Book value	(c) Method of valuation: Cost or end-of-year market value
(1) Financial derivatives.........
(2) Closely-held equity interests........
(3) Other (A) Certificates of Deposits	996,510
(B) Statutory Deposits	892,920
(C) Corp Debt Securities	564,035
(D) Asset Back Securities	27,810
(E) U.S. GOVT Obligations	10,226
(E)
(F)
(G)
(H)
Total. (Column (b) must equal Form 990, Part X, col. (B) line 12.)	2,491,501

Part VIII

Investments - Program Related. Complete if the organization answered 'Yes' on Form 990, Part IV, line 11c. See Form 990, Part X, line 13.

(a) Description of investment	(b) Book value	(c) Method of valuation: Cost or end-of-year market value

(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
Total. (Column (b) must equal Form 990, Part X, col.(B) line 13.)

Part IX

Other Assets.
Complete if the organization answered 'Yes' on Form 990, Part IV, line 11d. See Form 990, Part X, line 15.

(a) Description				(b) Book value

(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
Total. (Column (b) must equal Form 990, Part X, col.(B) line 15.)...........

Part X

Other Liabilities.
Complete if the organization answered 'Yes' on Form 990, Part IV, line 11e or 11f. See Form 990, Part X, line 25.

1.(a) Description of liability	(b) Book value
(1) Federal income taxes
(5)
(6)
(7)
(8)
(9)
Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)	1,504,297
2. Liability for uncertain tax positions. In Part XIII, provide the text of the footnote to the organization's financial statements that reports the organization's liability for uncertain tax positions under FIN 48 (ASC 740). Check here if the text of the footnote has been provided in Part XIII

Schedule D (Form 990) 2021

Page 4

Part XI Reconciliation of Revenue per Audited Financial Statements With Revenue per Return. Complete if the organization answered 'Yes' on Form 990, Part IV, line 12a.
1	Total revenue, gains, and other support per audited financial statements .......			1	1,045,898
2	Amounts included on line 1 but not on Form 990, Part VIII, line 12:
a	Net unrealized gains (losses) on investments ....	2a
b	Donated services and use of facilities .........	2b
c	Recoveries of prior year grants ...........	2c
d	Other (Describe in Part XIII.) ............	2d	0
e	Add lines 2a through 2d .....................			2e	0
3	Subtract line 2e from line 1..................			3	1,045,898
4	Amounts included on Form 990, Part VIII, line 12, but not on line 1:
a	Investment expenses not included on Form 990, Part VIII, line 7b .	4a
b	Other (Describe in Part XIII.) ...........	4b	142,357
c	Add lines 4a and 4b....................			4c	142,357
5	Total revenue. Add lines 3 and 4c. (This must equal Form 990, Part I, line 12.) ......			5	1,188,255

Part XII Reconciliation of Expenses per Audited Financial Statements With Expenses per Return. Complete if the organization answered 'Yes' on Form 990, Part IV, line 12a.
1	Total expenses and losses per audited financial statements ...........			1	1,707,978
2	Amounts included on line 1 but not on Form 990, Part IX, line 25:
a	Donated services and use of facilities .........	2a
b	Prior year adjustments ............	2b
c	Other losses ................	2c
d	Other (Describe in Part XIII.) ............	2d	0
e	Add lines 2a through 2d....................			2e	0
3	Subtract line 2e from line 1...................			3	1,707,978
4	Amounts included on Form 990, Part IX, line 25, but not on line 1:
a	Investment expenses not included on Form 990, Part VIII, line 7b ..	4a
b	Other (Describe in Part XIII.) ............	4b	142,357
c	Add lines 4a and 4b.....................			4c	142,357
5	Total expenses. Add lines 3 and 4c. (This must equal Form 990, Part I, line 18.) ......			5	1,850,335

Part XIII

Supplemental Information

Provide the descriptions required for Part II, lines 3, 5, and 9; Part III, lines 1a and 4; Part lV, lines 1b and 2b; Part V, line 4; Part X, line 2; Part XI, lines 2d and 4b; and Part XII, lines 2d and 4b. Also complete this part to provide any additional information.

Return Reference	Explanation
Schedule D, Part X, Line 2 FIN 48 (ASC 740) footnote	Part X - FIN 48 Footnote PCHP is exempt from federal income taxes under section 501(c)(4) of the Internal Revenue Code. No provision for federal income taxes has been made in the statutory financial statements. Generally, PCHP is no longer subject to income tax examinations by the U.S. federal, state or local tax authorities for years before 2018.
Schedule D, Part XI, Line 4(b) Other revenues in form 990 not in audited financial statements	Reclass of reinsurance premiums - 142357
Schedule D, Part XII, Line 4(b) Other expenses in form 990 not in audited financial statements	Reclass of reinsurance premiums - 142357

Schedule D (Form 990) 2021

Additional Data

Software ID:	21014044
Software Version:	2021v4.2

- TIN:

Schedule J
(Form 990)

Department of the Treasury
Internal Revenue Service

Compensation Information

For certain Officers, Directors, Trustees, Key Employees, and Highest
Compensated Employees
SchJMediumBullet

Complete if the organization answered "Yes" on Form 990, Part IV, line 23.
SchJMediumBullet

Attach to Form 990.
SchJMediumBullet

Go to www.irs.gov/Form990 for instructions and the latest information.

OMB No. 1545-0047

2021

Open to Public Inspection

Name of the organization

PreferredOne Community Health Plan

Employer identification number

41-1796007

Part I

Questions Regarding Compensation

Yes

Check the appropiate box(es) if the organization provided any of the following to or for a person listed on Form
990, Part VII, Section A, line 1a. Complete Part III to provide any relevant information regarding these items.

First-class or charter travel Housing allowance or residence for personal use

Travel for companions Payments for business use of personal residence

Tax idemnification and gross-up payments Health or social club dues or initiation fees

Discretionary spending account Personal services (e.g., maid, chauffeur, chef)

If any of the boxes on Line 1a are checked, did the organization follow a written policy regarding payment or reimbursement or provision of all of the expenses described above? If "No," complete Part III to explain .....

Did the organization require substantiation prior to reimbursing or allowing expenses incurred by all
directors, trustees, officers, including the CEO/Executive Director, regarding the items checked on Line 1a? ....

Indicate which, if any, of the following the filing organization used to establish the compensation of the
organization's CEO/Executive Director. Check all that apply. Do not check any boxes for methods
used by a related organization to establish compensation of the CEO/Executive Director, but explain in Part III.

Compensation committee Written employment contract

Independent compensation consultant Compensation survey or study

Form 990 of other organizations Approval by the board or compensation committee

During the year, did any person listed on Form 990, Part VII, Section A, line 1a, with respect to the filing organization or a related organization:

Receive a severance payment or change-of-control payment? .............

Participate in, or receive payment from, a supplemental nonqualified retirement plan? .........

Yes

Participate in, or receive payment from, an equity-based compensation arrangement? .........

If "Yes" to any of lines 4a-c, list the persons and provide the applicable amounts for each item in Part III.

Only 501(c)(3), 501(c)(4), and 501(c)(29) organizations must complete lines 5-9.

For persons listed on Form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the revenues of:

The organization? ....................

Any related organization? .......................

If "Yes," on line 5a or 5b, describe in Part III.

For persons listed on Form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the net earnings of:

The organization? ..................

Any related organization? ......................

If "Yes," on line 6a or 6b, describe in Part III.

For persons listed on Form 990, Part VII, Section A, line 1a, did the organization provide any nonfixed
payments not described in lines 5 and 6? If "Yes," describe in Part III ............

Yes

Were any amounts reported on Form 990, Part VII, paid or accured pursuant to a contract that was
subject to the initial contract exception described in Regulations section 53.4958-4(a)(3)? If "Yes," describe
in Part III ..........................

If "Yes" on line 8, did the organization also follow the rebuttable presumption procedure described in Regulations section 53.4958-6(c)? .........................

For Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 50053T

Schedule J (Form 990) 2021

Page 2

Part II

Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees. Use duplicate copies if additional space is needed.

For each individual whose compensation must be reported on Schedule J, report compensation from the organization on row (i) and from related organizations, described in the
instructions, on row (ii). Do not list any individuals that are not listed on Form 990, Part VII.
Note. The sum of columns (B)(i)-(iii) for each listed individual must equal the total amount of Form 990, Part VII, Section A, line 1a, applicable column (D) and (E) amounts for that individual.

(A) Name and Title		(B) Breakdown of W-2, 1099-MISC compensation, and/or 1099-NEC			(C) Retirement and other deferred compensation	(D) Nontaxable benefits	(E) Total of columns (B)(i)-(D)	(F) Compensation in column (B) reported as deferred on prior Form 990
(A) Name and Title		(i) Base compensation	(ii) Bonus & incentive compensation	(iii) Other reportable compensation	(C) Retirement and other deferred compensation	(D) Nontaxable benefits	(E) Total of columns (B)(i)-(D)
1John Batson CHAIR	(i) (ii)	0 ------------- 896,162	0 ------------- 150,000	0 ------------- 1,097	0 ------------- 122,016	0 ------------- 27,395	0 ------------- 1,196,670	0 ------------- 0
2Trudi Trysla DIRECTOR	(i) (ii)	0 ------------- 605,729	0 ------------- 100,000	0 ------------- 94,077	0 ------------- 87,973	0 ------------- 64,587	0 ------------- 952,365	0 ------------- 0
3Kimberley DeRoche MD Director	(i) (ii)	0 ------------- 432,052	0 ------------- 49,000	0 ------------- 0	0 ------------- 66,386	0 ------------- 27,672	0 ------------- 575,110	0 ------------- 0
4David Crosby PRESIDENT & CEO	(i) (ii)	1,813 ------------- 623,793	0 ------------- 193,764	0 ------------- 66,498	0 ------------- 45,885	23 ------------- 28,874	1,836 ------------- 958,813	0 ------------- 0
5MICHAEL UMLAND TREASURER	(i) (ii)	2,562 ------------- 335,283	0 ------------- 272,758	0 ------------- 29,981	222 ------------- 55,300	58 ------------- 14,515	2,842 ------------- 707,837	0 ------------- 0
6PAUL GEIWITZ SVP/CHIEF MARKETING - left 12/2021	(i) (ii)	1,408 ------------- 183,146	0 ------------- 128,252	0 ------------- 39,197	249 ------------- 62,022	52 ------------- 13,019	1,709 ------------- 425,636	0 ------------- 0
7ROBERT HAMLING JR VP IS,CIP & SECURITY	(i) (ii)	1,508 ------------- 228,443	0 ------------- 132,116	0 ------------- 14,902	159 ------------- 39,539	68 ------------- 16,823	1,735 ------------- 431,823	0 ------------- 0
8STACY MAYS SVP & COO - left 6/2021	(i) (ii)	1,973 ------------- 246,860	0 ------------- 218,361	0 ------------- 26,083	235 ------------- 58,512	16 ------------- 4,108	2,224 ------------- 553,924	0 ------------- 0
9ABIGAIL MILLER SR VP & CMO	(i) (ii)	2,265 ------------- 348,437	0 ------------- 190,129	0 ------------- 25,530	155 ------------- 38,695	57 ------------- 14,316	2,477 ------------- 617,107	0 ------------- 0
10THOMAS CARLSON DIRECTOR, ACTURIAL	(i) (ii)	1,211 ------------- 264,443	0 ------------- 35,445	0 ------------- 1,756	56 ------------- 13,944	95 ------------- 23,746	1,362 ------------- 339,334	0 ------------- 0
11CLARISSA COX VP CLINICAL OPS & CAR - left 9/2021	(i) (ii)	1,222 ------------- 204,380	0 ------------- 71,359	0 ------------- 28,619	149 ------------- 37,000	64 ------------- 15,897	1,435 ------------- 357,255	0 ------------- 0
12ROBERT GADOLA VP OPERATIONS/HIPPA	(i) (ii)	1,978 ------------- 286,440	0 ------------- 172,705	0 ------------- 33,321	205 ------------- 50,963	31 ------------- 7,618	2,214 ------------- 551,047	0 ------------- 0
13DANIEL STEWART VP OF SALES	(i) (ii)	1,871 ------------- 285,550	0 ------------- 158,593	0 ------------- 21,777	189 ------------- 47,055	95 ------------- 23,746	2,155 ------------- 536,721	0 ------------- 0
14JILL ARCHER VP Network Management	(i) (ii)	1,122 ------------- 206,795	0 ------------- 52,284	0 ------------- 20,253	114 ------------- 28,359	95 ------------- 23,746	1,331 ------------- 331,437	0 ------------- 0

Schedule J (Form 990) 2021

Page 3

Part III

Supplemental Information

Provide the information, explanation, or descriptions required for Part I, lines 1a, 1b, 3, 4a, 4b, 4c, 5a, 5b, 6a, 6b, 7, and 8, and for Part II. Also complete this part for any additional information.

Return Reference	Explanation
Schedule J, Part I, Line 4b Supplemental nonqualified retirement plan	David Crosby, $37,185 Non-Qualified John Batson, $104,616 Non-Qualified Trudi Trysla, $70,573 Non-Qualified Kimberly DeRoche, MD, $48,986 Non-Qualified
Schedule J, Part I, Line 7 Non-fixed payments	FAIRVIEW HEALTH SERVICES PROVIDES LUMP SUM FINANCIAL AWARDS BASED ON SYSTEM-WIDE, BUSINESS UNIT AND/OR DEPARTMENTS FINANCIAL AND QUALITY MEASURES. ANNUAL GOALS, SPECIFICALLY TIED TO PRODUCTIVITY AND QUALITY INDICATORS, ARE SET FOR THE YEAR AND AN INCENTIVE PAID OUT ANNUALLY IF KEY GOALS AND MEASURES ARE ACHIEVED.
Schedule J, Part I, Line 4b	PreferredOne Administrative Service, Inc. (PAS), a related organization, provides certain management staff with annual incentive payments based upon achieving specific profitability targets and operational goals. PAS also has a long-term incentive plan (LTIP) for certain members of the executive management team which is based on overlapping three-year cycles, and provides for incentive payments upon achievement of specific profitability targets and operational goals. Fairview Health Services' plan is only open to a select group of highly compensated employees. The plan contributes the difference of that 403(b) employer contributions were missed for participant who earn more than the IRS limit on eligible compensation for qualified retirement plans. The contribution is unfunded. The plan complies with Section 457(f) of the code.

Schedule J (Form 990) 2021

Additional Data

Software ID:	21014044
Software Version:	2021v4.2

- TIN:

SCHEDULE O
(Form 990)

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 990-EZ or to provide any additional information.
MediumBullet

Attach to Form 990 or 990-EZ.
MediumBullet

Go to www.irs.gov/Form990 for the latest information.

OMB No. 1545-0047

2021

Open to Public
Inspection

Name of the organization

PreferredOne Community Health Plan

Employer identification number

41-1796007

Return Reference	Explanation
Form 990, Part III, Line 3 Significant changes in program services	PCHP began winding down its operations and had no members participating in its plans as of the end of fiscal year 2021. Management is currently evaluating the future plans for the entity.
Form 990, Part VI, Line 6 Classes of members or stockholders	Members consist of the participants of the board of directors. The board of directors consists of: a contributing member, composed of employees of provided owners that have contributed capital to PreferredOne Community Health Plan (PCHP) and enrollee directors, which are enrolled employees of employer groups that have purchased health insurance coverage or health administrative services through PCHP or it affiliates.
Form 990, Part VI, Line 7a Members or stockholders electing members of governing body	Members consist of the participants of the board of directors. The board of directors consists of: a contributing member, composed of employees of provided owners that have contributed capital to PreferredOne Community Health Plan (PCHP) and enrollee directors, which are enrolled employees of employer groups that have purchased health insurance coverage or health administrative services through PCHP or it affiliates. The contributing member appoints (and fills vacancies of) up to 4 directors respectively. The vacancies that arise with respect to enrollee directors are filled by majority vote of other enrollee directors for the remainder of the unexpired term.
Form 990, Part VI, Line 11b Review of form 990 by governing body	The Associate Director of Accounting completes the workpapers for the Form 990. The Tax Department then prepares and conducts a detailed review of the completed return. The return is then reviewed by the organization's Director of Accounting and CFO. The Form 990 is then provided to the members of the Board of Directors prior to filing.
Form 990, Part VI, Line 12c Conflict of interest policy	Enforcement of Conflicts Policy Annually the board of directors update conflict of interest statements.
Form 990, Part VI, Line 15a Process to establish compensation of top management official	Compensation Process for Top Official PreferredOne Administrative Services (PAS), the common paymaster of PCHP, has a compensation committee consisting of the CEO and members of the board or directors of PAS that meet annually to review the compensation of the PCHP officers. Every three years this compensation review process involves an outside compensation consultant that conducts industry comparison analysis and other compensation comparisons.
Form 990, Part VI, Line 15b Process to establish compensation of other employees	Compensation Process for Officers PreferredOne Administrative Services (PAS), the common paymaster of PCHP, has a compensation committee consisting of the CEO and members of the board or directors of PAS that meet annually to review the compensation of the PCHP officers. Every three years this compensation review process involves an outside compensation consultant that conducts industry comparison analysis and other compensation comparisons.
Form 990, Part VI, Line 19 Required documents available to the public	Documents Disclosure Explanation Financial statements, conflict of interest policy and governing documents are available upon request for the same period of disclosure as set forth in Section 6104(D). Annual statutory filings are available on the State of MN website. Tri-Annual audits by the MN Department of Commerce are also available.
Form 990, Part IX, Line 11g Other Fees	Professional Services - Total Expense: 507982, Program Service Expense: 503825, Management and General Expenses: 4157, Fundraising Expenses: ; Other Medical Services - Total Expense: 36487, Program Service Expense: 36487, Management and General Expenses: , Fundraising Expenses: ;

For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.

Cat. No. 51056K

Schedule O (Form 990) 2021

Additional Data

Software ID:	21014044
Software Version:	2021v4.2

- TIN:

SCHEDULE R
(Form 990)

Department of the Treasury
Internal Revenue Service

Related Organizations and Unrelated Partnerships

Complete if the organization answered "Yes" on Form 990, Part IV, line 33, 34, 35b, 36, or 37.
MediumBullet

Attach to Form 990.
MediumBullet

Go to www.irs.gov/Form990 for instructions and the latest information.

OMB No. 1545-0047

2021

Open to Public Inspection

Name of the organization

PreferredOne Community Health Plan

Employer identification number

41-1796007

Part I

Identification of Disregarded Entities. Complete if the organization answered "Yes" on Form 990, Part IV, line 33.

(a) Name, address, and EIN (if applicable) of disregarded entity	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Total income	(e) End-of-year assets	(f) Direct controlling entity

Part II

Identification of Related Tax-Exempt Organizations. Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related tax-exempt organizations during the tax year.

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Exempt Code section	(e) Public charity status (if section 501(c)(3))	(f) Direct controlling entity	(g) Section 512(b)(13) controlled entity?
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Exempt Code section	(e) Public charity status (if section 501(c)(3))	(f) Direct controlling entity	Yes	No
(1)D&T Facility Management Company PO Box 64624 St Paul,MN551640624 41-1928275	Management	MN	501(c)(3)	Type II	Fairview		No
(2)Ebenezer Society 7505 Metro Blvd Suite 100 Edina,MN55439 41-0706141	Nursing	MN	501(c)(3)	10	Fairview		No
(3)Fairview Foundation 2450 Riverside Avenue South Minneapolis,MN55454 41-1573810	Fundraising	MN	501(c)(3)	1	Fairview		No
(4)Fairview Health Services 2450 Riverside Avenue Minneapolis,MN55454 41-0991680	Hospital	MN	501(c)(3)	3	NA		No
(5)Fairview Home Care and Hospice 2450 26th Avenue South Minneapolis,MN55454 41-1434246	Home Health	MN	501(c)(3)	10	Fairview		No
(6)Fairview Physician Associates Netwo 3400 West 66th Street Minneapolis,MN55435 41-1753325	Clinical	MN	501(c)(3)	10	Fairview		No
(7)Grand Itasca Clinic and Hosptial 1601 Golf Course Road Grand Rapids,MN55744 41-1865874	Hospital	MN	501(c)(3)	3	Fairview		No
(8)HealthEast Care System 2450 Riverside Avenue South Minneapolis,MN55454 36-3517697	Hospital	MN	501(c)(3)	3	Fairview		No
(9)HealthEast Medical Research Institute 2450 Riverside Avenue South Minneapolis,MN55454 41-1765832	Med Resear	MN	501(c)(3)	4	Fairview		No
(10)HealthEast Professional Services 2450 Riverside Avenue South Minneapolis,MN55454 26-1226617	Physician	MN	501(c)(3)	11	Fairview		No
(11)HealthEast St John's Hospital 2450 Riverside Avenue South Minneapolis,MN55454 41-1456897	Hospital	MN	501(c)(3)	3	Fairview		No
(12)HealthEast St Joseph's Hospital 2450 Riverside Avenue South Minneapolis,MN55454 41-0693880	Hospital	MN	501(c)(3)	3	Fairview		No
(13)HealthEast Woodwinds Hospital 2450 Riverside Avenue South Minneapolis,MN55454 41-1592761	Hospital	MN	501(c)(3)	3	Fairview		No
(14)Range Regional Health Services 750 East 34th Street Hibbing,MN55746 41-1293970	Hospital	MN	501(c)(3)	3	Fairview		No

For Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 50135Y

Schedule R (Form 990) 2021

Page 2

Part III

Identification of Related Organizations Taxable as a Partnership. Complete if the organization answered "Yes" on Form 990, Part IV, line 34, because it had one or more related organizations treated as a partnership during the tax year.

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(e) Predominant income(related, unrelated, excluded from tax under sections 512-514)	(f) Share of total income	(g) Share of end-of-year assets	(h) Disproprtionate allocations?		(i) Code V-UBI amount in box 20 of Schedule K-1 (Form 1065)	(j) General or managing partner?		(k) Percentage ownership
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity		(f) Share of total income	(g) Share of end-of-year assets	Yes	No	(i) Code V-UBI amount in box 20 of Schedule K-1 (Form 1065)	Yes	No	(k) Percentage ownership
(1) Ridges Surgery Center LLC 14101 Fairview Drive Ste 400 Burnsville,MN55337 46-2441825	Surg Cntr	MN	NA	N/A
(2) Crosstown Surgery Center LLC 4200 Dahlberg Drive Suite 300 Golden Valley,MN55422 27-2552748	Surgery Center	MN	NA	N/A
(3) SouthHealth ASC LLC 4200 Dahlberg Drive Suite 300 Golden Valley,MN55422 82-2364607	Surgery Center	MN	NA	N/A

Part IV

Identification of Related Organizations Taxable as a Corporation or Trust. Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related organizations treated as a corporation or trust during the tax year.

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(e) Type of entity (C corp, S corp, or trust)	(f) Share of total income	(g) Share of end-of-year assets	(h) Percentage ownership	(i) Section 512(b)(13) controlled entity?
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(e) Type of entity (C corp, S corp, or trust)	(f) Share of total income	(g) Share of end-of-year assets	(h) Percentage ownership	Yes	No
(1) Fairview Clinics 2450 Riverside Avenue South Minneapolis,MN55454 41-1761760	Physician	MN	NA	C Corporation					No
(2) Fairview Physician and Clinic Services 2450 Riverside Avenue South Minneapolis,MN55454 41-1544996	Physician	MN	NA	C Corporation					No
(3) Fairview Development Company 2450 Riverside Avenue South Minneapolis,MN55454 41-1568579	Leasehold	MN	NA	C Corporation					No
(4) Fairview Express Care 2450 Riverside Avenue South Minneapolis,MN55454 20-5996177	Physician	MN	NA	C Corporation					No
(5) FHS Assurance Limited 2450 Riverside Avenue South Minneapolis,MN55454 98-0417513	Self insur	MN	NA	C Corporation					No
(6) HealthEast Diversified Services Inc 2450 Riverside Avenue South Minneapolis,MN55454 41-1388583	Reference	MN	NA	C Corporation					No

Schedule R (Form 990) 2021

Page 3

Part V

Transactions With Related Organizations. Complete if the organization answered "Yes" on Form 990, Part IV, line 34, 35b, or 36.

Note. Complete line 1 if any entity is listed in Parts II, III, or IV of this schedule.

Yes

1 During the tax year, did the orgranization engage in any of the following transactions with one or more related organizations listed in Parts II-IV?

a Receipt of (i) interest, (ii) annuities, (iii) royalties, or (iv) rent from a controlled entity .....................

b Gift, grant, or capital contribution to related organization(s) ............................

c Gift, grant, or capital contribution from related organization(s) ............................

d Loans or loan guarantees to or for related organization(s) ............................

e Loans or loan guarantees by related organization(s) ............................

f Dividends from related organization(s) ............................

g Sale of assets to related organization(s) ............................

h Purchase of assets from related organization(s) ............................

i Exchange of assets with related organization(s) ............................

j Lease of facilities, equipment, or other assets to related organization(s) .......................

k Lease of facilities, equipment, or other assets from related organization(s) ......................

l Performance of services or membership or fundraising solicitations for related organization(s) .....................

m Performance of services or membership or fundraising solicitations by related organization(s) .................

n Sharing of facilities, equipment, mailing lists, or other assets with related organization(s) ...................

Yes

o Sharing of paid employees with related organization(s) ............................

Yes

p Reimbursement paid to related organization(s) for expenses ............................

Yes

q Reimbursement paid by related organization(s) for expenses ............................

r Other transfer of cash or property to related organization(s) ............................

s Other transfer of cash or property from related organization(s) ............................

If the answer to any of the above is "Yes," see the instructions for information on who must complete this line, including covered relationships and transaction thresholds.

(a) Name of related organization	(b) Transaction type (a-s)	(c) Amount involved	(d) Method of determining amount involved

Schedule R (Form 990) 2021

Page 4

Part VI

Unrelated Organizations Taxable as a Partnership. Complete if the organization answered "Yes" on Form 990, Part IV, line 37.

Provide the following information for each entity taxed as a partnership through which the organization conducted more than five percent of its activities (measured by total assets or gross revenue) that was not a related organization. See instructions regarding exclusion for certain investment partnerships.

(a) Name, address, and EIN of entity	(b) Primary activity	(c) Legal domicile (state or foreign country)	(e) Are all partners section 501(c)(3) organizations?		(f) Share of total income	(g) Share of end-of-year assets	(h) Disproprtionate allocations?		(i) Code V-UBI amount in box 20 of Schedule K-1 (Form 1065)	(j) General or managing partner?		(k) Percentage ownership
(a) Name, address, and EIN of entity	(b) Primary activity	(c) Legal domicile (state or foreign country)	Yes	No	(f) Share of total income	(g) Share of end-of-year assets	Yes	No	(i) Code V-UBI amount in box 20 of Schedule K-1 (Form 1065)	Yes	No	(k) Percentage ownership

Schedule R (Form 990) 2021

Page 5

Part VII

Supplemental Information

Provide additional information for responses to questions on Schedule R. See instructions.

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Schedule R (Form 990) 2021

Additional Data

Software ID:	21014044
Software Version:	2021v4.2