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← MERCY HOSPITAL IOWA CITY IOWA SELF INSURANCE PLAN AND TR

Form 990 for tax year 2022

Filed by MERCY HOSPITAL IOWA CITY IOWA SELF INSURANCE PLAN AND TR.

Totals

Total revenue
$3,228
Total expenses
$1,138,329
Contributions and grants received
$0
Grants paid
$0
Program service revenue
$0
Investment income
$3,228
Other revenue
$0
Total assets, end of year
$372,943
Total liabilities, end of year
$1,231,621
Net assets or fund balances, end of year
-$858,678
Program services expenses (Part IX)
$1,138,329
Management and general expenses
$0
Fundraising expenses
$0
Program service expenses (Part III)
$1,138,329

Program services were 100.0% of total expenses calculated — Part IX's program-services column over total expenses, both as filed.

Line items

Every line the filer filed in Parts VIII, IX and X, as filed and in filed order. Blank columns are left out, and the lines are not forced to add up to the totals above.

Revenue

Part VIII, the statement of revenue.

  • 3 · Investment income

    total $8,258 · excluded $8,258

  • 7a · Gross sales of assets other than inventory

    securities $23,344

  • 7b · Less cost or other basis and sales expenses

    securities $28,374

  • 7c · Gain or loss

    securities -$5,030

  • 7d · Net gain or loss

    total -$5,030 · excluded -$5,030

Functional expenses

Part IX, the statement of functional expenses.

  • 24a · Other expenses: Insurance Funding Exp.

    total $1,138,329 · program services $1,138,329

Balance sheet

Part X, book values.

  • 2 · Savings and temporary cash investments

    beginning of year $163,851 · end of year $2,176

  • 11 · Investments: publicly traded securities

    beginning of year $329,066 · end of year $370,767

  • 17 · Accounts payable and accrued expenses

    beginning of year $477,407 · end of year $542,778

  • 25 · Other liabilities

    beginning of year $733,301 · end of year $688,843

  • 27 · Net assets without donor restrictions

    beginning of year -$717,791 · end of year -$858,678

Mission and programs · 2022

Mission

The trust was established to protect money, property, and other assets contributed by participants to provide medical malpractice and liability reserves.

Activities or mission (Part I)

A trust to protect assets contributed for medical malpractice & liability reserves.

  • Mercy Hospital, Iowa City, Iowa Self Insurance Plan and Trust ("the Trust") is a Self Insurance program for the benefit of Mercy Hospital Iowa City. The trust was established to protect money, property, and other assets contributed by participants to provide medical malpractice and liability reserves.

    Expenses $1,138,329

As filed on the 2022 return.

Listed in Part VII

  • Dawna Miller

    Treasurer (End 7/22)

    Total calculated
    $399,550
    From this org
    $0
    From related orgs
    $366,748
    Other
    $32,802
    Hours/week
    1 + 41 related

    Schedule J breakdown matched by us

    Base
    $0 + $207,266 related
    Bonus
    $0 + $54,638 related
    Other
    $0 + $104,844 related
    Deferred
    $0 + $8,332 related
    Nontaxable benefits
    $0 + $24,470 related
    Filer's total
    $0 + $399,550 related

  • Kimberley Rossiter

    Asst. Treas. (End 8/22) / Trustee

    Total calculated
    $229,973
    From this org
    $0
    From related orgs
    $208,788
    Other
    $21,185
    Hours/week
    1 + 41 related

    Schedule J breakdown matched by us

    Base
    $0 + $194,183 related
    Bonus
    $0 + $7,750 related
    Other
    $0 + $6,855 related
    Deferred
    $0 + $5,002 related
    Nontaxable benefits
    $0 + $16,183 related
    Filer's total
    $0 + $229,973 related

  • Jeffrey Rooney

    Treasurer (8/22-4/23)

    Total calculated
    $0
    Hours/week
    1 + 41 related

  • Jim Porter

    Treasurer (Begin 5/23)

    Total calculated
    $0
    Hours/week
    1 + 41 related

  • Mike Trachta

    CEO & Administrator (End 3/23)

    Total calculated
    $0
    Hours/week
    1 + 41 related

  • Tom Clancy

    CEO & Administrator (Begin 4/23)

    Total calculated
    $0
    Hours/week
    1 + 2 related

  • Bob Ritz

    Trustee (End 3/23)

    Total calculated
    $0
    Hours/week
    1 + 1 related

  • Lynn Whisler

    Trustee (Begin 7/22)

    Total calculated
    $0
    Hours/week
    1 + 1 related

  • Madeline Windauer

    Chair (Begin 7/22)

    Total calculated
    $0
    Hours/week
    1 + 1 related

  • Stuart Elkin

    Asst. Treas. (Beg 9/22)

    Total calculated
    $176,195
    From this org
    $0
    From related orgs
    $170,462
    Other
    $5,733
    Hours/week
    1 + 41 related

    Schedule J breakdown matched by us

    Base
    $0 + $170,462 related
    Bonus
    $0
    Other
    $0
    Deferred
    $0 + $5,733 related
    Nontaxable benefits
    $0
    Filer's total
    $0 + $176,195 related

Compensation is as filed in Part VII: reportable pay from this organization and from related organizations, other compensation, and hours per week. The total, marked calculated, is our sum of the three dollar columns, with a blank column counted as $0; the form itself has no total. On a Form 990-EZ the columns are Part IV's instead, and on a Form 990-PF Part VIII's — compensation, contributions to benefit plans, and expense account — and the total sums those. A Schedule J breakdown is as filed: base pay, bonus, other, deferred compensation and nontaxable benefits from this organization, with any from related organizations beside each, and the filer's own total. It is shown with the Part VII listing of the same name on the same return. The form gives no key between the two, so that pairing is ours, and is marked matched by us.

Schedule J

Answered yes

  • 4a · Severance or change-of-control payment

Answered no

  • 4b · Supplemental nonqualified retirement plan
  • 4c · Equity-based compensation arrangement
  • 5a · Pay contingent on this organization's revenues
  • 5b · Pay contingent on a related organization's revenues
  • 6a · Pay contingent on this organization's net earnings
  • 6b · Pay contingent on a related organization's net earnings
  • 7 · Other non-fixed payments
  • 8 · Paid under the initial-contract exception

The filer's explanations (Part III)

Part I, Line 3
The trust relied on Mercy Hospital, a related organization, to establish the compensation of the Trust's top management official. Mercy Hospital used the following methods to establish compensation: -Compensation Committee -Independent Compensation Consultant -Form 990 of Other Organizations -Compensation Survey or Study -Approval by the Board or Compensation Committee
Part I, Line 4a
Dawna Miller, Chief Financial Officer received severance payments amounting to $103,884 in calendar year 2022 as part of her employment contract.

Part I's answers as filed. A line not listed was left unanswered; on lines 1a and 3 that means the box was not checked.

Grants on this return

No itemized grants to organizations on this return.

Related organizations on this return

Schedule R Part II: tax-exempt organizations related to the filer by control. It does not record shared board members or money.

Taxable family on this return

Schedule R Parts I, III and IV, as filed. These record ownership and control, not shared board members or money moved.

Related partnerships

Part III: related organizations taxable as a partnership, with the filer's share.

  • Iowa City Ambulatory Surgical Center LLC

    Outpatient Surgery · IA

  • Corridor Radiology LLC

    Radiology Services · IA

  • Eastern Iowa Rehabilitation Hospital LLC

    Inpatient Rehabilitation Care · IA

Related corporations and trusts

Part IV: related organizations taxable as a corporation or trust.

  • Mercy Services Iowa City Inc

    C · Health Care · IA

Provenance

Return type
form_990
Tax year
2022
Filed
15 May 2024
IRS schema version
2022v5.0
Source object
202401369349310980

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