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ObjectId: 201721939349301272 - Submission: 2017-07-12
TIN: 26-3538104
Schedule J
(Form 990)
Department of the Treasury
Internal Revenue Service
Compensation Information
For certain Officers, Directors, Trustees, Key Employees, and Highest
Compensated Employees
Complete if the organization answered "Yes" on Form 990, Part IV, line 23.
Attach to Form 990.
Information about Schedule J (Form 990) and its instructions is at
www.irs.gov/form990
.
OMB No. 1545-0047
20
16
Open to Public Inspection
Name of the organization
BENEFIS HEALTH SYSTEM INC
Employer identification number
26-3538104
Part I
Questions Regarding Compensation
Yes
No
1a
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)
b
If any of the boxes in 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
.........
1b
Yes
2
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 in line 1a?
..
2
Yes
3
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
4
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:
a
Receive a severance payment or change-of-control payment?
.............
4a
Yes
b
Participate in, or receive payment from, a supplemental nonqualified retirement plan?
.........
4b
Yes
c
Participate in, or receive payment from, an equity-based compensation arrangement?
.........
4c
No
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.
5
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:
a
The organization?
....................
5a
No
b
Any related organization?
.......................
5b
No
If "Yes," on line 5a or 5b, describe in Part III.
6
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:
a
The organization?
..................
6a
No
b
Any related organization?
......................
6b
No
If "Yes," on line 6a or 6b, describe in Part III.
7
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
............
7
Yes
8
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
..........................
8
No
9
If "Yes" on line 8, did the organization also follow the rebuttable presumption procedure described in Regulations section 53.4958-6(c)?
.........................
9
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50053T
Schedule J (Form 990) 2016
Page 2
Schedule J (Form 990) 2016
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 and/or 1099-MISC compensation
(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
(i)
Base
compensation
(ii)
Bonus & incentive
compensation
(iii)
Other
reportable compensation
1
JOHN GOODNOW
CHIEF EXECUTIVE OFFICER
(i)
(ii)
640,147
-------------
0
174,699
-------------
0
317,890
-------------
0
39,283
-------------
0
6,932
-------------
0
1,178,951
-------------
0
0
-------------
0
2
FORREST EHLINGER
CHIEF FINANCIAL OFFICER
(i)
(ii)
347,865
-------------
0
86,290
-------------
0
6,500
-------------
0
80,973
-------------
0
10,915
-------------
0
532,543
-------------
0
0
-------------
0
3
TERRY OLINGER
PRESIDENT ACUTE CARE GROUP
(i)
(ii)
376,522
-------------
0
102,791
-------------
0
66,268
-------------
0
122,856
-------------
0
604
-------------
0
669,041
-------------
0
58,350
-------------
0
4
AMY BEAMES
PRES SR SRVCS & LEGISLATIVE AFFAIRS
(i)
(ii)
195,932
-------------
0
44,441
-------------
0
0
-------------
0
24,090
-------------
0
6,493
-------------
0
270,956
-------------
0
0
-------------
0
5
PATTY HARRIS
DIRECTOR REVENUE CYCLE
(i)
(ii)
169,056
-------------
0
27,053
-------------
0
0
-------------
0
0
-------------
0
8,442
-------------
0
204,551
-------------
0
0
-------------
0
6
THERESA PREITE
PRESIDENT SPECTRUM MEDICAL
(i)
(ii)
191,356
-------------
0
38,196
-------------
0
6,000
-------------
0
25,875
-------------
0
6,492
-------------
0
267,919
-------------
0
0
-------------
0
7
JULIE WALL
VICE PRESIDENT QUALITY AND INFECTION
(i)
(ii)
165,186
-------------
0
32,530
-------------
0
0
-------------
0
8,677
-------------
0
10,254
-------------
0
216,647
-------------
0
0
-------------
0
8
CARL BRUESCH
DIRECTOR FINANCIAL ANALYSIS
(i)
(ii)
159,871
-------------
0
17,395
-------------
0
0
-------------
0
0
-------------
0
6,467
-------------
0
183,733
-------------
0
0
-------------
0
9
BRUCE HOULIHAN
CONTROLLER
(i)
(ii)
165,733
-------------
0
33,485
-------------
0
26,422
-------------
0
712
-------------
0
9,701
-------------
0
236,053
-------------
0
0
-------------
0
10
SAM NORTON
CHIEF INFORMATION OFFICER (FORMER)
(i)
(ii)
0
-------------
0
0
-------------
0
179,862
-------------
0
9,382
-------------
0
378
-------------
0
189,622
-------------
0
0
-------------
0
Schedule J (Form 990) 2016
Page 3
Schedule J (Form 990) 2016
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
PART I, LINE 1A
TRAVEL FOR COMPANIONS AND SOCIAL CLUB DUES THAT BENEFIS HEALTH SYSTEM PAYS FOR ITS OFFICERS ARE TREATED AS TAXABLE INCOME TO THE INDIVIDUAL ACCORDINGLY.
PART I, LINES 4A-B
SEVERANCE WAS PAID TO SAM NORTON IN 2016. THE ORGANIZATION PROVIDES A SECTION 457F NONQUALIFIED DEFERRED COMPENSATION PLAN FOR MR. GOODNOW, MR. OLINGER, MS. BEAMES, MR. EHLINGER AND MS. PREITE, WHOM ALL MEET THE REQUIREMENTS OF THE PLAN. MR. OLINGER RECEIVED A PAYOUT FROM THE PLAN IN 2016.
PART I, LINE 7
BENEFIS HEALTH SYSTEM, INC. AND ITS AFFILIATES (INCLUDING THE ORGANIZATION) MAINTAIN AN INCENTIVE COMPENSATION PLAN THAT INCORPORATES BOTH SHARED AND INDIVIDUAL GOALS FOR MEMBERS OF THE EXECUTIVE LEADERSHIP TEAM. PAYMENTS PURSUANT TO THE INCENTIVE PLAN ARE SUBJECT TO A PRECONDITION THAT THE SYSTEM MUST ACHIEVE BUDGETED OPERATING PERFORMANCE. THE SYSTEM HAS ADOPTED SHARED PERFORMANCE OBJECTIVES INCLUDING SYSTEM GROWTH AS WELL AS MEASURES TIED TO WORKFORCE, PATIENT EXPERIENCE, PATIENT SAFETY, CLINICAL QUALITY, FINANCE/OPERATIONS, AND COMMUNITY BENEFIT. THE INDIVIDUAL PERFORMANCE OBJECTIVES ARE BASED ON AN ARRAY OF QUALITY, FINANCIAL, OPERATIONAL AND STRATEGIC INITIATIVES. INCENTIVE OPPORTUNITY LEVELS ARE CALCULATED BASED ON PREDETERMINED PERCENTAGES OF EACH EXECUTIVE'S BASE SALARY, AND VARY BASED ON THE ACHIEVEMENT OF THRESHOLD, TARGET OR STRETCH LEVELS AS TO EACH PERFORMANCE OBJECTIVE. THE SYSTEM ALSO MAINTAINS A LONG-TERM INCENTIVE PLAN DIRECTED AT RECRUITING AND RETAINING EXECUTIVE LEADERSHIP. PAYMENTS UNDER THE LONG-TERM INCENTIVE PLAN ARE CONDITIONED ON AN EXECUTIVE REMAINING EMPLOYED BY THE SYSTEM AND MAINTAINING SATISFACTORY OVERALL PERFORMANCE. INCENTIVE OPPORTUNITIES UNDER THE LONG-TERM PLAN ARE APPROVED IN ADVANCE BY THE BENEFIS HEALTH SYSTEM, INC. COMPENSATION COMMITTEE, WITH LATER PAYOUTS APPROVED BY THE COMMITTEE BASED ON ACTUAL PERFORMANCE RESULTS.
Schedule J (Form 990) 2016
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