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TIN: 41-1806657
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
20
Open to Public Inspection
Name of the organization
CENTRACARE CLINIC
Employer identification number
41-1806657
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
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
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) 2020
Schedule J (Form 990) 2020
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
KENNETH D HOLMEN MD
PRESIDENT/CEO
(i)
(ii)
0
-------------
1,025,380
0
-------------
0
0
-------------
397,740
0
-------------
14,981
0
-------------
27,578
0
-------------
1,465,679
0
-------------
0
2
CRAIG BROMAN
CHIEF OPERATING OFFICER/EVP
(i)
(ii)
0
-------------
956,517
0
-------------
250,000
0
-------------
181,043
0
-------------
27,625
0
-------------
24,298
0
-------------
1,439,483
0
-------------
199,215
3
HANI S ALKHATIB
PHYSICIAN
(i)
(ii)
0
-------------
1,285,341
0
-------------
18,740
0
-------------
5,213
0
-------------
26,000
0
-------------
30,955
0
-------------
1,366,249
0
-------------
0
4
HILARY I UFEARO
PHYSICIAN
(i)
(ii)
0
-------------
1,116,458
0
-------------
9,741
0
-------------
4,777
0
-------------
39,000
0
-------------
27,420
0
-------------
1,197,396
0
-------------
0
5
CHRISTOPHER B MILLER
PHYSICIAN
(i)
(ii)
0
-------------
1,107,628
0
-------------
4,650
0
-------------
4,695
0
-------------
39,000
0
-------------
22,431
0
-------------
1,178,404
0
-------------
0
6
KADIR O MULLINGS
PHYSICIAN
(i)
(ii)
0
-------------
1,108,489
0
-------------
4,650
0
-------------
4,611
0
-------------
11,375
0
-------------
10,941
0
-------------
1,140,066
0
-------------
0
7
DAHLIA H ELKADI
PHYSICIAN
(i)
(ii)
0
-------------
876,047
0
-------------
8,144
0
-------------
4,626
0
-------------
45,500
0
-------------
20,569
0
-------------
954,886
0
-------------
0
8
DONALD JURGENS MD
DIRECTOR
(i)
(ii)
0
-------------
853,816
0
-------------
4,650
0
-------------
4,702
0
-------------
5,688
0
-------------
15,042
0
-------------
883,898
0
-------------
0
9
MARK S MATTHIAS
VICE PRESIDENT
(i)
(ii)
0
-------------
456,401
0
-------------
0
0
-------------
127,621
0
-------------
26,000
0
-------------
26,952
0
-------------
636,974
0
-------------
0
10
CHRISTOPHER W BOELTER
VICE PRESIDENT
(i)
(ii)
0
-------------
495,778
0
-------------
50,000
0
-------------
69,004
0
-------------
19,500
0
-------------
1,132
0
-------------
635,414
0
-------------
0
11
MICHAEL BLAIR
CFO/SR VP/TREASURER
(i)
(ii)
0
-------------
524,778
0
-------------
0
0
-------------
19,618
0
-------------
45,500
0
-------------
28,119
0
-------------
618,015
0
-------------
0
12
CHRISTIAN P SCHMIDT MD
DIRECTOR
(i)
(ii)
0
-------------
500,526
0
-------------
8,549
0
-------------
5,153
0
-------------
45,500
0
-------------
27,874
0
-------------
587,602
0
-------------
0
13
JOSEPH M BLONSKI
VP AMBULANCE CARE
(i)
(ii)
0
-------------
461,173
0
-------------
0
0
-------------
62,936
0
-------------
26,000
0
-------------
25,627
0
-------------
575,736
0
-------------
0
14
RICHARD A WEHSELER MD
DIRECTOR
(i)
(ii)
0
-------------
319,512
0
-------------
79,432
0
-------------
4,810
0
-------------
26,000
0
-------------
32,681
0
-------------
462,435
0
-------------
0
15
BRYAN ROLPH MD
DIRECTOR
(i)
(ii)
0
-------------
414,480
0
-------------
11,503
0
-------------
5,966
0
-------------
0
0
-------------
1,783
0
-------------
433,732
0
-------------
0
16
DIANE R BUSCHENA-BRENNA
VICE PRESIDENT
(i)
(ii)
0
-------------
280,047
0
-------------
0
0
-------------
64,314
0
-------------
45,500
0
-------------
25,544
0
-------------
415,405
0
-------------
0
17
SANTO CRUZ
CHIEF LEGAL OFFICER/SR VP/SECRETARY
(i)
(ii)
0
-------------
336,391
0
-------------
0
0
-------------
26,988
0
-------------
19,500
0
-------------
25,519
0
-------------
408,398
0
-------------
0
18
SHARON J RUGGIERO MD
DIRECTOR
(i)
(ii)
0
-------------
242,774
0
-------------
9,089
0
-------------
9,128
0
-------------
45,500
0
-------------
12,386
0
-------------
318,877
0
-------------
0
19
PHILIP D LUITJENS
VICE PRESIDENT
(i)
(ii)
0
-------------
178,503
0
-------------
0
0
-------------
11,633
0
-------------
10,173
0
-------------
28,066
0
-------------
228,375
0
-------------
0
Schedule J (Form 990) 2020
Schedule J (Form 990) 2020
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 3
THE COMPENSATION PAID TO THE PRESIDENT AND VICE PRESIDENTS (NON-MEDICAL PROVIDERS) IS DETERMINED BY CENTRACARE HEALTH SYSTEM, A RELATED ORGANIZATION. CENTRACARE HEALTH SYSTEM USES THE FOLLOWING METHODS TO DETERMINE COMPENSATION: - COMPENSATION COMMITTEE - FORM 990 OF OTHER ORGANIZATIONS - INDEPENDENT COMPENSATION CONSULTANT - COMPENSATION SURVEY OR STUDY - APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE
PART I, LINE 4B
THE CORPORATIONS' EXECUTIVES ARE ELIGIBLE TO PARTICIPATE IN BENEFIT PLANS WHICH INCLUDE TAX DEFERRED NON-QUALIFIED INVESTMENT ACCOUNTS. THESE PLANS MAY PROVIDE, BUT ARE NOT CERTAIN TO PROVIDE, FOR PAYMENT OF TAX DEFERRED COMPENSATION TO THESE EXECUTIVES AT SOME TIME IN THE FUTURE. THE EXECUTIVE HAS NO LEGAL RIGHT TO THESE DOLLARS UNTIL, AND UNLESS, CERTAIN FUTURE EVENTS OCCUR. IN ACCORDANCE WITH THE INSTRUCTIONS TO FORM 990, THE AMOUNTS LISTED IN PART VII AND SCHEDULE J, PART II, COLUMN C, REFLECT TAX DEFERRED COMPENSATION. THIS COMPENSATION IS POTENTIALLY REPORTED TWICE ON FORM 990 - ONCE WHEN THE COMPENSATION IS DEFERRED OR ACCRUED AND AGAIN IF AND WHEN IT IS PAID TO THE EXECUTIVE. THE FOLLOWING INDIVIDUALS PARTICIPATED IN THE NON-QUALIFIED PLAN: CRAIG BROMAN - PAID $199,215
PART I, LINE 7
THE ORGANIZATION PROVIDES INCENTIVE COMPENSATION TO DESIGNATED INDIVIDUALS BASED ON FOUR DISCRETE AREAS: STEWARDSHIP, THROUGH A COMPARISON BETWEEN BUDGETED AND ACTUAL NET OPERATING INCOME FOR SAINT CLOUD HOSPITAL AND/OR CENTRACARE HEALTH SYSTEM AS WELL THROUGH ACHIEVING METRICS FOR AN IDENTIFIED COST REDUCTION PROGRAM; QUALITY, THROUGH ACHIEVING SAINT CLOUD HOSPITAL AND SYSTEM QUALITY METRICS; PATIENT EXPERIENCE, THROUGH ACHIEVEMENT OF PATIENT SATISFACTION GOALS AS COMPARED TO NATIONAL AND BASELINE RANKINGS; AND PEOPLE/EMPLOYEES, THROUGH ACHIEVEMENT OF SPECIFIED EMPLOYMENT SATISFACTION GOALS AND HIRING AND/OR RETENTION GOALS. THE INCENTIVE COMPENSATION PAID OUT IS NOT A PORTION OR PERCENTAGE OF ACTUAL NET EARNINGS OF ANY CENTRACARE HEALTH SYSTEM AFFILIATE, HOWEVER NET EARNINGS GOALS ARE REQUIRED TO BE MET BEFORE THE INCENTIVE COMPENSATION IS PAID.
Schedule J (Form 990) 2020
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