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TIN: 46-0234354
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
20
Open to Public Inspection
Name of the organization
Avera Gettysburg
Employer identification number
46-0234354
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)
Avera Health
3900 West Avera Drive Suite 300
Sioux Falls
,
SD
57108
46-0422673
Promotion of Health
SD
501(c)(3)
Line 10
N/A
No
(2)
Avera St Mary's
801 East Sioux Avenue
Pierre
,
SD
57501
46-0230199
Healthcare Services
SD
501(c)(3)
Line 3
Avera Health
No
(3)
Avera St Anthony's Hospital
300 N 2nd Street
ONeill
,
NE
68763
47-0463911
Healthcare Education
NE
501(c)(3)
Line 3
Avera Health
No
(4)
Avera Holy Family
826 North 8th Street
Estherville
,
IA
51334
42-0680370
Healthcare Services
IA
501(c)(3)
Line 3
Avera Health
No
(5)
Avera Holy Family Foundation
826 North 8th Street
Estherville
,
IA
51334
42-1317452
Support Health Related Services
IA
501(c)(3)
Line 10
Avera Holy Family
No
(6)
Avera Marshall
300 S Bruce Street
Marshall
,
MN
56258
41-0919153
Healthcare Services
MN
501(c)(3)
Line 3
Avera Health
No
(7)
St Benedict Health Center
401 West Glynn Drive
Parkston
,
SD
57366
46-0226738
Healthcare Services
SD
501(c)(3)
Line 3
Avera Health
No
(8)
St Benedict Health Center Foundation
West Glynn Drive PO Box B
Parkston
,
SD
57366
46-0458725
Support Health Related Services
SD
501(c)(3)
Line 12a, I
St Benedict Health Center
No
(9)
Avera McKennan
1325 S Cliff Ave PO Box 5045
Sioux Falls
,
SD
57117
46-0224743
Healthcare Services
SD
501(c)(3)
Line 3
Avera Health
No
(10)
Sacred Heart Health Services
501 Summit Street
Yankton
,
SD
57078
46-0225483
Healthcare Services
SD
501(c)(3)
Line 3
Avera Health
No
(11)
Avera Queen of Peace Hospital
525 North Foster
Mitchell
,
SD
57301
46-0224604
Healthcare Services
SD
501(c)(3)
Line 3
Avera Health
No
(12)
Avera at Home
5116 S Solberg Ave
Sioux Falls
,
SD
57108
46-0399291
Home Services
SD
501(c)(3)
Line 10
Avera Health
No
(13)
Lewis and Clark Health Education and Service Agency
1000 W 4th Street Suite 9
Yankton
,
SD
57078
46-0337013
Healthcare Education
SD
501(c)(3)
Line 10
Sacred Heart Health Services
No
(14)
Avera St Luke's
305 South State Street
Aberdeen
,
SD
57401
46-0224598
Healthcare Services
SD
501(c)(3)
Line 3
Avera Health
No
(15)
Avera Tyler
240 Willow Street
Tyler
,
MN
56178
41-0853163
Healthcare Services
MN
501(c)(3)
Line 3
Avera Marshall
No
(16)
Avera Health Plans
3900 West Avera Drive Suite 101
Sioux Falls
,
SD
57108
46-0451539
Health Financing and Health Plan Admin
SD
501(c)(4)
Avera Health
No
(17)
Avera Granite Falls
345 10th Ave
Granite Falls
,
MN
56241
84-3156881
Healthcare services
MN
501(c)(3)
Line 3
Avera Marshall
No
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50135Y
Schedule R (Form 990) 2020
Schedule R (Form 990) 2020
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)
Q&M Properties LLC
525 North Foster
Mitchell
,
SD
57301
73-1652049
Medical clinic building
SD
N/A
No
No
(2)
Avera Home Medical Equipment of Floyd Valley Hospital LLC
714 Lincoln St NE
Lemars
,
IA
51031
82-0582350
Medical services - home medical equipment
SD
N/A
No
No
(3)
Avera Home Medical Equipment of Sioux Center LLC
38 19th ST SW
Sioux Center
,
IA
51250
75-3203100
Medical services - home medical equipment
SD
N/A
No
No
(4)
Avera Home Medical Equipment of Spencer Hospital LLC
2400 S Minnesota Ave 102
Sioux Falls
,
SD
57117
80-0619999
Medical services - home medical equipment
SD
N/A
No
No
(5)
Surgical Associates Endoscopy Clinic LLC
310 S Pennsylvania St
Aberdeen
,
SD
57401
46-0461429
Surgical associates
SD
N/A
No
No
(6)
Heart Hospital of South Dakota LLC
4500 W 69th Street
Sioux Falls
,
SD
57108
56-2143771
Healthcare services
SD
N/A
No
No
(7)
Brookings Health System - Avera Home Medical Equipment LLC
101 22nd Ave Suite 101
Brookings
,
SD
57006
45-3204123
Medical services - home medical equipment
SD
N/A
No
No
(8)
National Rural ACO 4 LLC dba Prairie Hills Care Organization
7509 NW Tiffany Springs Parkway
Kansas City
,
MO
64153
37-1780735
Accountable care organization
KS
N/A
No
No
(9)
National Rural ACO 5 LLC dba Great Plains Care Organization
7509 NW Tiffany Springs Parkway
Kansas City
,
MO
64153
38-3958290
Accountable care organization
KS
N/A
No
No
(10)
Caravan Health ACO 41 LLC dba Prairie View Care Organization
7509 NW Tiffany Springs Parkway
Kansas City
,
MO
64153
82-1447782
Accountable care organization
KS
N/A
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)
Accounts Management Inc
5132 S Cliff Ave Suite 101
Sioux Falls
,
SD
57108
46-0373021
Collection agency
SD
N/A
C
No
(2)
Avera Property Insurance Inc
1000 West 4th Street Suite 1
Yankton
,
SD
57078
46-0463155
Insurance
SD
N/A
C
No
(3)
Valley Health Services
501 Summit Street
Yankton
,
SD
57078
46-0357149
Rental real estate
SD
N/A
C
No
(4)
Alucent Biomedical Inc
1325 S Cliff Ave PO Box 5045
Sioux Falls
,
SD
571175045
47-1818349
Biotech Research
SD
N/A
C
No
(5)
South Dakota State Medical Holding Company Inc
5300 South Broadband Lane
Sioux Falls
,
SD
57108
46-0401087
Insurance
SD
N/A
C
No
(6)
DakotaCare Administrative Services Inc
5300 South Broadband Lane
Sioux Falls
,
SD
57108
46-0424322
Insurance
SD
N/A
C
No
Schedule R (Form 990) 2020
Schedule R (Form 990) 2020
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
Yes
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
Yes
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
Yes
n
Sharing of facilities, equipment, mailing lists, or other assets with related organization(s)
...................
1n
No
o
Sharing of paid employees with related organization(s)
............................
1o
Yes
p
Reimbursement paid to related organization(s) for expenses
............................
1p
Yes
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) 2020
Schedule R (Form 990) 2020
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) 2020
Schedule R (Form 990) 2020
Page
5
Part VII
Supplemental Information
Provide additional information for responses to questions on Schedule R. See instructions.
Return Reference
Explanation
Schedule R, Part III:
Q&M Properties, LLC dissolved effective June 30, 2021. National Rural ACO 4 LLC liquidated effective December 31, 2020.
Schedule R (Form 990) 2020
Additional Data
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