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ObjectId: 201913129349303701 - Submission: 2019-11-08
TIN: 52-0954463
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.
Go to
www.irs.gov/Form990
for instructions and the latest information.
OMB No. 1545-0047
20
18
Open to Public Inspection
Name of the organization
KAISER FOUNDATION HEALTH PLAN OF THE
MID-ATLANTIC STATES INC
Employer identification number
52-0954463
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
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
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
No
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) 2018
Page 2
Schedule J (Form 990) 2018
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
Gregory Adams
EVP, Group President
(i)
(ii)
0
-------------
1,224,496
0
-------------
3,466,327
0
-------------
4,391,419
0
-------------
1,114,562
0
-------------
29,740
0
-------------
10,226,544
0
-------------
4,383,200
2
Ramon F Baez
Director
(i)
(ii)
0
-------------
208,500
0
-------------
0
0
-------------
13,681
0
-------------
13,477
0
-------------
0
0
-------------
235,658
0
-------------
0
3
David Barger
Director
(i)
(ii)
0
-------------
198,500
0
-------------
0
0
-------------
0
0
-------------
16,825
0
-------------
0
0
-------------
215,325
0
-------------
0
4
Kristin Bear
Assistant Secretary
(i)
(ii)
0
-------------
224,025
0
-------------
83,765
0
-------------
11,667
0
-------------
5,055
0
-------------
19,370
0
-------------
343,882
0
-------------
0
5
Regina M Benjamin MD MBA
Director
(i)
(ii)
0
-------------
207,500
0
-------------
0
0
-------------
9,234
0
-------------
15,542
0
-------------
0
0
-------------
232,276
0
-------------
0
6
Maryann Bodayle
Assistant Secretary
(i)
(ii)
0
-------------
156,315
0
-------------
17,468
0
-------------
2,229
0
-------------
7,903
0
-------------
9,726
0
-------------
193,641
0
-------------
0
7
Ruben Burnett
VP, Natl Consultant Relations
(i)
(ii)
0
-------------
239,031
0
-------------
116,264
0
-------------
26,228
0
-------------
14,859
0
-------------
11,911
0
-------------
408,293
0
-------------
0
8
Joseph Butz
VP & COO - MAS
(i)
(ii)
0
-------------
381,128
0
-------------
182,850
0
-------------
39,623
0
-------------
100,421
0
-------------
20,085
0
-------------
724,107
0
-------------
0
9
Jeffrey E Epstein
Director
(i)
(ii)
0
-------------
218,500
0
-------------
0
0
-------------
8,395
0
-------------
11,038
0
-------------
0
0
-------------
237,933
0
-------------
0
10
Jill Feldon Lanouette
VP, Mktg Comm & Cmty Rltn's
(i)
(ii)
0
-------------
233,436
0
-------------
90,594
0
-------------
320,118
0
-------------
106,793
0
-------------
23,804
0
-------------
774,745
0
-------------
0
11
Pamela Galley
VP, Continuum of Care - MAS
(i)
(ii)
0
-------------
239,847
0
-------------
64,739
0
-------------
106,973
0
-------------
36,330
0
-------------
26,447
0
-------------
474,336
0
-------------
0
12
Daniel Garcia
SVP, Chief Compliance Officer
(i)
(ii)
0
-------------
0
0
-------------
249,390
0
-------------
61,503
0
-------------
-67,932
0
-------------
0
0
-------------
242,961
0
-------------
52,426
13
Joan L Gelrud
SVP, HP & Hospital Quality
(i)
(ii)
0
-------------
265,170
0
-------------
84,062
0
-------------
28,009
0
-------------
87,262
0
-------------
68,303
0
-------------
532,806
0
-------------
0
14
Bernice Gould
Assistant Secretary
(i)
(ii)
0
-------------
196,867
0
-------------
39,296
0
-------------
2,363
0
-------------
9,977
0
-------------
10,381
0
-------------
258,884
0
-------------
0
15
George Halvorson
Chairman
(i)
(ii)
0
-------------
0
0
-------------
0
0
-------------
27,324
0
-------------
-49,993
0
-------------
0
0
-------------
-22,669
0
-------------
18,272
16
Leslie S Heisz
Director
(i)
(ii)
0
-------------
217,500
0
-------------
0
0
-------------
17,787
0
-------------
12,475
0
-------------
0
0
-------------
247,762
0
-------------
0
17
David F Hoffmeister
Director
(i)
(ii)
0
-------------
210,000
0
-------------
0
0
-------------
12,880
0
-------------
13,054
0
-------------
0
0
-------------
235,934
0
-------------
0
18
Kimberly Horn
Regional President - MAS
(i)
(ii)
0
-------------
650,775
0
-------------
575,667
0
-------------
486,415
0
-------------
403,996
0
-------------
33,216
0
-------------
2,150,069
0
-------------
333,565
19
Judith A Johansen JD
Director
(i)
(ii)
0
-------------
244,800
0
-------------
0
0
-------------
15,524
0
-------------
-18,131
0
-------------
0
0
-------------
242,193
0
-------------
0
20
Kim J Kaiser
Director
(i)
(ii)
0
-------------
234,100
0
-------------
0
0
-------------
13,160
0
-------------
-11,160
0
-------------
0
0
-------------
236,100
0
-------------
0
21
Jon Kunkle
VP, CFO - Mid-Atlantic States
(i)
(ii)
0
-------------
333,703
0
-------------
185,789
0
-------------
16,409
0
-------------
74,304
0
-------------
24,890
0
-------------
635,095
0
-------------
16,659
22
Kathryn Lancaster
EVP & CFO
(i)
(ii)
0
-------------
1,042,302
0
-------------
1,776,268
0
-------------
402,535
0
-------------
332,280
0
-------------
21,033
0
-------------
3,574,418
0
-------------
0
23
Thomas Meier
SVP, Corporate Treasurer
(i)
(ii)
0
-------------
462,542
0
-------------
633,581
0
-------------
115,824
0
-------------
8,208
0
-------------
33,258
0
-------------
1,253,413
0
-------------
0
24
Donald Orndoff
SVP, NFS
(i)
(ii)
0
-------------
435,028
0
-------------
536,354
0
-------------
176,170
0
-------------
169,668
0
-------------
32,416
0
-------------
1,349,636
0
-------------
117,119
25
Edward Y W Pei
Director
(i)
(ii)
0
-------------
219,000
0
-------------
0
0
-------------
14,531
0
-------------
-16,551
0
-------------
0
0
-------------
216,980
0
-------------
0
26
Margaret E Porfido JD
Director
(i)
(ii)
10,000
-------------
248,500
0
-------------
0
0
-------------
20,262
0
-------------
-9,170
0
-------------
0
10,000
-------------
259,592
0
-------------
0
27
Rochelle Roth
Assistant Secretary
(i)
(ii)
0
-------------
142,213
0
-------------
41,179
0
-------------
2,123
0
-------------
-99,618
0
-------------
15,147
0
-------------
101,044
0
-------------
0
28
Mark Ruszczyk
VP, MSBD - MAS
(i)
(ii)
0
-------------
296,321
0
-------------
178,887
0
-------------
160,105
0
-------------
69,769
0
-------------
27,691
0
-------------
732,773
0
-------------
64,245
29
Jacqueline Sellers
Assistant Secretary
(i)
(ii)
0
-------------
199,568
0
-------------
72,157
0
-------------
28,607
0
-------------
20,496
0
-------------
14,766
0
-------------
335,594
0
-------------
0
30
Richard Shannon MD
Director
(i)
(ii)
0
-------------
210,000
0
-------------
0
0
-------------
0
0
-------------
34,412
0
-------------
0
0
-------------
244,412
0
-------------
0
31
Arthur Southam
EVP, Health Plan Operations
(i)
(ii)
0
-------------
1,041,658
0
-------------
1,897,457
0
-------------
431,827
0
-------------
536,245
0
-------------
36,844
0
-------------
3,944,031
0
-------------
0
32
Susan Spurlark
Assistant Secretary
(i)
(ii)
0
-------------
281,997
0
-------------
124,475
0
-------------
67,992
0
-------------
20,832
0
-------------
17,796
0
-------------
513,092
0
-------------
0
33
Cynthia A Telles PHD
Director
(i)
(ii)
0
-------------
238,000
0
-------------
0
0
-------------
13,108
0
-------------
1,559
0
-------------
0
0
-------------
252,667
0
-------------
0
34
Frank Titus
VP, HPSA - MAS
(i)
(ii)
0
-------------
293,642
0
-------------
143,195
0
-------------
27,624
0
-------------
50,528
0
-------------
26,090
0
-------------
541,079
0
-------------
0
35
Bernard Tyson
Chairman & CEO
(i)
(ii)
0
-------------
1,652,487
0
-------------
12,577,609
0
-------------
1,479,757
0
-------------
2,132,546
0
-------------
41,234
0
-------------
17,883,633
0
-------------
2,110,403
36
Alfonse Upshaw
SVP,Corporate Controller & CAO
(i)
(ii)
0
-------------
438,858
0
-------------
356,406
0
-------------
18,380
0
-------------
99,558
0
-------------
28,853
0
-------------
942,055
0
-------------
0
37
Delinda Hastie Washington
VP, HR - MAS
(i)
(ii)
0
-------------
276,958
0
-------------
109,994
0
-------------
35,594
0
-------------
61,078
0
-------------
19,132
0
-------------
502,756
0
-------------
0
38
Eugene Washington MD
Director
(i)
(ii)
0
-------------
206,000
0
-------------
0
0
-------------
0
0
-------------
13,686
0
-------------
0
0
-------------
219,686
0
-------------
0
39
William Wiechmann
Assistant Secretary
(i)
(ii)
0
-------------
283,497
0
-------------
174,792
0
-------------
74,706
0
-------------
70,296
0
-------------
29,791
0
-------------
633,082
0
-------------
0
40
Wayne Dominic Wilson
VP, Gov't Prgms & Ext. Rltns
(i)
(ii)
0
-------------
304,977
0
-------------
64,736
0
-------------
277,065
0
-------------
62,420
0
-------------
12,210
0
-------------
721,408
0
-------------
0
41
Hong-Sze Yu
VP, Brd & Corp Gov & Asst Secy
(i)
(ii)
0
-------------
249,307
0
-------------
94,714
0
-------------
17,313
0
-------------
60,176
0
-------------
25,870
0
-------------
447,380
0
-------------
0
42
Mark Zemelman
SVP, General Counsel & Secy
(i)
(ii)
0
-------------
677,594
0
-------------
1,100,476
0
-------------
280,462
0
-------------
-12,297
0
-------------
34,354
0
-------------
2,080,589
0
-------------
0
Schedule J (Form 990) 2018
Page 3
Schedule J (Form 990) 2018
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 3
METHODS USED TO ESTABLISH COMPENSATION OF CEO/EXECUTIVE DIRECTOR: THE FILING ORGANIZATION RELIED ON A RELATED ORGANIZATION THAT USED ONE OR MORE OF THE METHODS DESCRIBED BELOW TO ESTABLISH THE TOP MANAGEMENT OFFICIALS' COMPENSATION: - COMPENSATION COMMITTEE - INDEPENDENT COMPENSATION CONSULTANT - FORM 990 OF OTHER ORGANIZATIONS - WRITTEN EMPLOYMENT CONTRACT - COMPENSATION SURVEY OR STUDY, AND - APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE OF A RELATED ORGANIZATION.
SCHEDULE J, PART I, LINE 4b
- SUPPLEMENTAL NONQUALIFIED RETIREMENT PLAN PAYMENT - Gregory Adams $ 4,338,278 Ruben Burnett 13,387 Kimberly Horn 459,771 Kathryn Lancaster 351,081 Thomas Meier 72,501 Donald Orndoff 149,555 Mark Ruszczyk 90,497 Arthur Southam 380,295 Susan Spurlark 39,502 Bernard Tyson 999,157 Mark Zemelman 232,150 SOME OF THE PARTICIPANTS LISTED IN SCHEDULE J, PART II PARTICIPATED IN NONQUALIFIED SUPPLEMENTAL RETIREMENT PLANS. UNDER THESE PLANS, THE ORGANIZATION MAKES ANNUAL CONTRIBUTIONS TO A NOTIONAL ACCOUNT ON BEHALF OF EACH PARTICIPANT. CONTRIBUTIONS VARY BY POSITION, LEVEL AND PAY, AND VEST OVER TIME BASED ON AGE AND/OR SERVICE. PARTICIPANT ACCOUNTS ARE CREDITED WITH A FIXED RATE OF INTEREST, INVESTED IN AVAILABLE MUTUAL FUNDS OR A COMBINATION OF BOTH. CERTAIN OFFICERS ACCRUE A BENEFIT THAT VESTS BASED ON AGE AND SERVICE AND TARGETS A PERCENTAGE OF FINAL AVERAGE PAY LESS PRIOR PLAN OFFSETS. UNVESTED AMOUNTS ARE SUBJECT TO RISK OF FORFEITURE.
SCHEDULE J, PART I, LINE 7
NON-FIXED PAYMENTS: THE ORGANIZATION PROVIDED NON-FIXED PAYMENTS TO SOME OF THE PERSONS LISTED. PAYMENTS WERE MADE UNDER INCENTIVE PLANS, BASED ON ATTAINMENT OF ORGANIZATIONAL PERFORMANCE GOALS AND INDIVIDUAL PERFORMANCE, DESIGNED TO SUPPORT THE ORGANIZATION'S MISSION TO PROVIDE HIGH-QUALITY, AFFORDABLE CARE AND IMPROVE THE HEALTH OF ITS MEMBERS AND THE COMMUNITIES IT SERVES.
SCHEDULE J, PART II, COLUMN C
THE ACTUARIAL VALUE FOR SOME INDIVIDUALS' DEFINED BENEFIT PLAN DECLINED IN 2018, RESULTING IN NEGATIVE VALUES IN COLUMN (C) IN SOME INSTANCES. Certain board members are eligible for a retiree medical benefit following retirement from the board. While this benefit is subject to change and may be reduced or eliminated, the 2018 change in the actuarial determined value of this benefit for each board member has been included in Form 990, Part VII, Column (f) and Schedule J, Part II, Column C. Amounts for this benefit have also been deferred for prior years. The actuarial increase or decrease in value may change for various reasons, including continued service, age, and changes in assumptions.
SCHEDULE J, PART II, COLUMN F
AMOUNTS INCLUDED IN SCHEDULE J, PART II, COLUMN F INCLUDE AMOUNTS PREVIOUSLY REPORTED AS DEFERRED COMPENSATION, AS WELL AS, DISTRIBUTIONS FROM A 457(B) PLAN THAT WERE PREVIOUSLY REPORTED AS REPORTABLE COMPENSATION IN ACCORDANCE WITH FORM 990 INSTRUCTIONS.
Schedule J (Form 990) 2018
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