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ObjectId: 202333129349304503 - Submission: 2023-11-08
TIN: 83-1979548
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.
Attach to Form 990.
Go to
www.irs.gov/Form990
for instructions and the latest information.
OMB No. 1545-0047
20
22
Open to Public Inspection
Name of the organization
SSM HEALTH PLAN
Employer identification number
83-1979548
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?
Yes
No
(1)
MEDICA FOUNDATION
401 CARLSON PARKWAY
MINNETONKA
,
MN
55305
41-1812461
FOUNDATION
MN
501(C)(3)
LINE 12B
MHC
No
(2)
MEDICA COMMUNITY HEALTH PLAN
401 CARLSON PARKWAY
MINNETONKA
,
MN
55305
41-1843804
HEALTH COVERAGE
MN
501(C)(4)
N/A
MHC
No
(3)
MEDICA HOLDING COMPANY
401 CARLSON PARKWAY
MINNETONKA
,
MN
55305
01-0571840
HOLDING COMPANY
MN
501(C)(4)
N/A
N/A
No
(4)
MEDICA HEALTH PLANS
401 CARLSON PARKWAY
MINNETONKA
,
MN
55305
41-1242261
HEALTH COVERAGE
MN
501(C)(4)
N/A
MHC
No
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50135Y
Schedule R (Form 990) 2022
Page 2
Schedule R (Form 990) 2022
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
Yes
No
Yes
No
(1)
MS COMMUNITY NFP JV (MFCJVN) LLC
401 CARLSON PARKWAY
MINNETONKA
,
MN
55305
87-3268926
HOLDING COMPANY
MN
MHC
0
No
No
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?
Yes
No
(1)
MEDICA INSURANCE COMPANY
401 CARLSON PARKWAY
MINNETONKA
,
MN
55305
41-1490988
HEALTH INSURANCE
MN
MAS
C
No
(2)
MEDICA SELF-INSURED
401 CARLSON PARKWAY
MINNETONKA
,
MN
55305
41-1479417
THIRD PARTY ADMIN
MN
MAS
C
No
(3)
MEDICA AFFILIATED SERVICES (MAS)
401 CARLSON PARKWAY
MINNETONKA
,
MN
55305
41-1716415
HOLDING COMPANY
MN
MHC
C
No
(4)
MEDICA HEALTH MANAGEMENT
401 CARLSON PARKWAY
MINNETONKA
,
MN
55305
20-8005519
HEALTH MANAGEMENT
MN
MAS
C
No
(5)
MMSI INC
401 CARLSON PARKWAY
MINNETONKA
,
MN
55305
41-1547003
HEALTH INSURANCE
MN
MAS
C
No
(6)
MEDICA SERVICES COMPANY LLC
401 CARLSON PARKWAY
MINNETONKA
,
MN
55305
85-2902940
ADMIN SERVICES
MN
MAS
C
No
(7)
DEAN HEALTH PLAN INC
1277 DEMING WAY
MADISON
,
WI
53717
39-1535024
HEALTH INSURANCE
WI
DHI
C
No
(8)
DEAN HEALTH INSURANCE INC (DHI)
PO BOX 56099
MADISON
,
WI
53705
39-1830837
HEALTH INSURANCE
WI
MSCJV
C
No
(9)
SSM HEALTH INSURANCE COMPANY
10101 WOODFIELD LANE
ST LOUIS
,
MO
63132
83-4718249
HEALTH INSURANCE
MO
MSCJV
C
No
(10)
DEAN HEALTH SERVICES COMPANY LLC
1277 DEMING WAY
MADISON
,
WI
53717
84-2933639
ADMIN SERVICES
WI
MSCJV
C
No
(11)
MS COMMUNITY JV LLC (MSCJV)
401 CARLSON PARKWAY
MINNETONKA
,
MN
55305
87-3240022
HOLDING COMPANY
MN
MHC
C
No
(12)
MEDICA REGIONAL INSURANCE COMPANY
401 CARLSON PARKWAY
MINNETONKA
,
MN
55305
85-4111612
HEALTH INSURANCE
MN
MAS
C
No
Schedule R (Form 990) 2022
Page 3
Schedule R (Form 990) 2022
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
No
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
.....................
1a
No
b
Gift, grant, or capital contribution to related organization(s)
............................
1b
No
c
Gift, grant, or capital contribution from related organization(s)
............................
1c
No
d
Loans or loan guarantees to or for related organization(s)
............................
1d
No
e
Loans or loan guarantees by related organization(s)
............................
1e
No
f
Dividends from related organization(s)
............................
1f
No
g
Sale of assets to related organization(s)
............................
1g
No
h
Purchase of assets from related organization(s)
............................
1h
No
i
Exchange of assets with related organization(s)
............................
1i
No
j
Lease of facilities, equipment, or other assets to related organization(s)
.......................
1j
No
k
Lease of facilities, equipment, or other assets from related organization(s)
......................
1k
No
l
Performance of services or membership or fundraising solicitations for related organization(s)
.....................
1l
No
m
Performance of services or membership or fundraising solicitations by related organization(s)
.................
1m
No
n
Sharing of facilities, equipment, mailing lists, or other assets with related organization(s)
...................
1n
Yes
o
Sharing of paid employees with related organization(s)
............................
1o
Yes
p
Reimbursement paid to related organization(s) for expenses
............................
1p
No
q
Reimbursement paid by related organization(s) for expenses
............................
1q
Yes
r
Other transfer of cash or property to related organization(s)
............................
1r
Yes
s
Other transfer of cash or property from related organization(s)
............................
1s
Yes
2
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) 2022
Page 4
Schedule R (Form 990) 2022
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)
(d)
Predominant income (related, unrelated, excluded from tax under sections 512-514)
(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
Yes
No
Yes
No
Yes
No
Schedule R (Form 990) 2022
Page 5
Schedule R (Form 990) 2022
Page
5
Part VII
Supplemental Information
Provide additional information for responses to questions on Schedule R. See instructions.
Return Reference
Explanation
Schedule R (Form 990) 2022
Additional Data
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