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ObjectId: 202311329349301576 - Submission: 2023-05-12
TIN: 38-6000029
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
21
Open to Public Inspection
Name of the organization
MYMICHIGAN MEDICAL CENTER ALPENA
Employer identification number
38-6000029
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 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
.....
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 on 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
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) 2021
Page 2
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
(i)
Base
compensation
(ii)
Bonus & incentive
compensation
(iii)
Other
reportable compensation
1
ROGERS GREGORY
DIRECTOR
(i)
(ii)
0
-------------
613,085
0
-------------
273,178
0
-------------
216,785
0
-------------
527,107
0
-------------
19,074
0
-------------
1,649,229
0
-------------
185,189
2
DOMBROSKI MD JEFFREY
PHYSICIAN
(i)
(ii)
750,765
-------------
0
241,448
-------------
0
1,664
-------------
0
40,584
-------------
0
2,514
-------------
0
1,036,975
-------------
0
0
-------------
0
3
HITZELBERGER DO WILLIAM
PHYSICIAN
(i)
(ii)
713,661
-------------
0
157,735
-------------
0
1,664
-------------
0
43,339
-------------
0
29,103
-------------
0
945,502
-------------
0
0
-------------
0
4
ROSE MICHAEL
SECRETARY/TREASURER
(i)
(ii)
0
-------------
513,812
0
-------------
162,500
0
-------------
2,551
0
-------------
99,470
0
-------------
30,499
0
-------------
808,832
0
-------------
0
5
HANNA DO BRIAN
DIRECTOR (PART YEAR)
(i)
(ii)
0
-------------
543,760
0
-------------
208,684
0
-------------
4,730
0
-------------
5,800
0
-------------
31,546
0
-------------
794,520
0
-------------
0
6
PADGETT FRANCINE
FORMER SECRETARY/TREASURER
(i)
(ii)
0
-------------
0
0
-------------
0
0
-------------
676,976
0
-------------
0
0
-------------
0
0
-------------
676,976
0
-------------
78,227
7
BATES RICHARD
REGIONAL VP MEDICAL AFFAIRS
(i)
(ii)
415,524
-------------
0
126,323
-------------
0
6,107
-------------
0
68,227
-------------
0
25,342
-------------
0
641,523
-------------
0
0
-------------
0
8
SHERWIN CHUCK
PRESIDENT (PART YEAR)
(i)
(ii)
294,054
-------------
0
108,319
-------------
0
13,757
-------------
0
183,305
-------------
0
32,330
-------------
0
631,765
-------------
0
0
-------------
0
9
HARBER DO DANIEL
PHYSICIAN
(i)
(ii)
544,884
-------------
0
11,000
-------------
0
9,155
-------------
0
5,800
-------------
0
29,432
-------------
0
600,271
-------------
0
0
-------------
0
10
ARORA MD SANJEEV
PHYSICIAN
(i)
(ii)
517,940
-------------
0
1,000
-------------
0
7,320
-------------
0
5,800
-------------
0
23,288
-------------
0
555,348
-------------
0
0
-------------
0
11
ERICKSON MICHAEL
PRESIDENT (PART YEAR)
(i)
(ii)
0
-------------
292,568
0
-------------
91,085
0
-------------
12,541
0
-------------
33,036
0
-------------
30,312
0
-------------
459,542
0
-------------
0
12
RAPP DONNA
FORMER SECRETARY
(i)
(ii)
0
-------------
0
0
-------------
0
0
-------------
100,549
0
-------------
0
0
-------------
0
0
-------------
100,549
0
-------------
100,549
Schedule J (Form 990) 2021
Page 3
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
PART I, LINE 1A
THE FOLLOWING PERSONS LISTED IN PART VII, SECTION A, RECEIVED PAYMENT OF THE MONTHLY SOCIAL COUNTRY CLUB DUES WHICH APPROXIMATES $183 PER MONTH. MYMICHIGAN HEALTH HAS TAKEN A CONSERVATIVE POSTURE WITH RESPECT TO ALL PERQUISITES AND ALL PERQUISITES MUST BE JUSTIFIED BY BUSINESS NEED. AMOUNTS RELATED TO THE NON-BUSINESS USE ARE TREATED AS TAXABLE INCOME. SHERWIN, CHUCK PRESIDENT (PART YEAR)
PART I, LINE 4B
ROGERS, ROSE, SHERWIN, AND ERICKSON ARE PARTICIPANTS IN A 457(F) PLAN. ROGERS RECEIVED A PAYMENT IN 2021. THE SERP IS UNFUNDED AND BEGAN ON JANUARY 1, 2009. THE CURRENT PARTICIPANTS OF THE PLAN ARE THE MEMBERS OF THE SENIOR LEADERSHIP OR EXECUTIVE TEAM. EACH PARTICIPANT'S ANNUAL AWARD IS BASED ON THEIR POSITION LEVEL AND IS A PERCENTAGE OF BASE SALARY ON DECEMBER 31 OF THE PLAN YEAR. THE PLAN PROVIDES ADDITIONAL RETIREMENT INCOME WHICH OTHERWISE WOULD BE PROVIDED UNDER THE PENSION PLAN AND 403(B) PLAN, BUT FOR LIMITATIONS ON SUCH BENEFITS REQUIRED BY FEDERAL LAW. A PARTICIPANT'S ACCOUNT SHALL BE 100% VESTED IF THE PARTICIPANT IS EMPLOYED BY MYMICHIGAN HEALTH ON THE DATE THE FIRST OF THE FOLLOWING VESTING EVENTS OCCUR: ATTAINMENT OF NORMAL RETIREMENT AGE; DEATH; TERMINATION OF EMPLOYMENT BECAUSE OF TOTAL DISABILITY; OR, ON THE THREE-YEAR ANNIVERSARY OF THEIR PARTICIPATION DATE.
PART I, LINE 7
MYMICHIGAN HEALTH'S COMPENSATION INCLUDES BOTH BASE AND VARIABLE COMPENSATION (NONFIXED PAYMENTS). IN ACCORDANCE WITH ITS POLICIES, ALL ELEMENTS (BASE, VARIABLE, BENEFITS, AND PERQUISITES) ARE COMPARED TO MARKET AND ARE DETERMINED BY THE INDEPENDENT COMPENSATION COMMITTEE AFTER A REVIEW BY AN INDEPENDENT CONSULTANT, SULLIVAN COTTER, TO ENSURE THAT TOTAL COMPENSATION REMAINS WITHIN ACCEPTABLE GUIDELINES (60% OF MEDIAN). THE COMPENSATION COMMITTEE, WHO IS AUTHORIZED TO ACT ON BEHALF OF THE MYMICHIGAN HEALTH BOARD OF DIRECTORS, APPROVED COMPENSATION FOR THE MYMICHIGAN HEALTH CEO, SENIOR EXECUTIVES AND PHYSICIANS. SULLIVAN COTTER ANNUALLY CONDUCTS A COMPREHENSIVE ASSESSMENT OF EXECUTIVE COMPENSATION.
PART III:
MYMICHIGAN HEALTH'S COMPENSATION COMMITTEE CHARTER IS APPROVED ANNUALLY BY THE COMMITTEE AND BOARD AS WERE THE EXECUTIVE COMPENSATION PHILOSOPHY AND STRATEGY. MYMICHIGAN HEALTH ALSO CONTINUES TO UTILIZE AN INDEPENDENT COMPENSATION CONSULTANT TO ASSIST WITH THE GOVERNANCE PROCESS AND TO REVIEW AND REPORT ON ALL SYSTEM LEVEL EXECUTIVES, HOSPITAL LEVEL EXECUTIVES AND SELECTED OTHER EXECUTIVES. MYMICHIGAN HEALTH HAS TAKEN A CONSERVATIVE POSTURE WITH RESPECT TO ALL PERQUISITES AND ALL PERQUISITES MUST BE JUSTIFIED BY BUSINESS NEED. MYMICHIGAN HEALTH TARGETS THE BASE SALARY OF ITS EXECUTIVES WITHIN A MARKET COMPETITIVE SALARY RANGE WITH A MIDPOINT APPROXIMATELY EQUAL TO THE 50TH PERCENTILE OF THE BASE SALARY MARKET DATA. MARKET DATA IS OBTAINED NATIONALLY FROM HEALTH SYSTEMS, HOSPITALS AND ORGANIZATIONS OF COMPARABLE SIZE BY SULLIVAN COTTER, AN INDEPENDENT CONSULTANT. NET OPERATING REVENUE IS THE CRITICAL FACTOR UTILIZED TO DETERMINE COMPARABILITY.
Schedule J (Form 990) 2021
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