kaiser supplemental savings and retirement plan annual report form 5500

8/3/2019 Kaiser Supplemental Savings and Retirement Plan Annual Report Form 5500

1/37

Form 5500Department of fhe iceasun/Internal Revenue Selvice

Oeparlmenlof LaborEmpayeeBene6eSecunlyAdminislalion

Annual ReturnlReport of Employee Benefit PlanThis form is required to be filed for employee benefit plans under sections 104and 4065 of the Employee Retirement Income Security Act of 1974 (ERISA)andsections 6047(e). and 6058(a) of the Internal Revenue Code (the Code).

) Complete all entries in accordance withthe instructions to the Form 5500.

I OMB Nos. 1210-011210-001 This Form is Open to Public

I 1 InspectionI Part I I Annual Report Identification InformationFor calendar plan year2010 or fiscal plan year beginning 0110112010- - and endlng 1213112010A This returnlreport is for: U a multiemployerplan; U a multiple-employerplan: or1 single-employer plan: a DFE (specify)-6 This returnlreport is: the first returnlreport: the ilnal returnlrepori;n n amended returnireport; n a short plan year returnireport (less than 12 months).

KAISER FOUNDATIONHEALTH PLAN INC

C If the plan is a collectively-bargainedplan, check here. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ,0D Check box if filing under: [ orm 5558: automatic extension; the DFVC program;

special extension (enter description)I Part 11 I Basic Pian information-enter all requested information

ONE KAISER PLAZASUITE 2001OAKLAND, CA94612

1a Name of planKAISER PERMANENTESUPPLEMENTAL SAVINGSAND RETlRE.MENT PLAN

2a Plan sponsor's name and address (employer, f for a single-employer plan)(Address should include room or suite no.)

number510-271-5940instructions)621491

1b Three-digit plannumber (PN) ,

- -

Caution: A penalty for the late or incomplete filing of this returnlrepott will be assessed unless reasonable cause is established.Under penalties of perjury and other penalties set forth in the instructions. I declare that I have examinedthis returnlreport, including accompanying schedules,statements and attachments, as well as the electronic version of this returnlre~ort. nd to the best of mv knowledaeand belief. it is true, correct. and comolete.

001C Effective date of plan01101119682b Employer IdentincationNumber (EINI

SIGNHERE

SlGNHERE Signature of DFE Dale Enter name of individual signing as DFEFor Paperwork Reduction Act Notice and OM6 Control Numbers, see the instructions fo r Form 5500. Form 5500 iZOlO

SlGNHERE

Filed with authorizedlvaiidelectronlc signature.Signature of plan administrator

Signature of employerlplan sponsor

1011412011Date

HARRIETGUBERMANEnter name of individual signing as plan administrator

Date Enter name of individual slgning as employer or plan sponsor


2/37

Form 5500 (2010) Page 2

the plan number from the last returnlreport:a Sponsor's name

3a Plan administrator's name and address (if same as plan sponsor, enter"Samen)KAISER FOUNDATION HEALTH PLAN. INC.ONE WISER PLAZASUITE 2001OAKLAND. CA 94612

15 Total number of participantsat the beginning of the plan year 1 5 1 36

3b Administrator's EIN94-1340523

3c Administrator's telephonenumber

510-271-5940

6 Number of participants as of the end of the plan year (welfare plans complete only lines 6a, 6b, 6c, and 6d). La Active participantsb Retired or separated participants receiving henc Other retired or separated participantsentitled to future benefit

d Subtotal. Add lines 6a, lib, and 6e Deceased participants whose beneficiaries are receiving or are entitled to receive benefitsf Total. Add lines 6d and 6g Number of participantswith account balances as of the end of the plan year (only defined contribution planscomplete this itemh Number of oarticioantsthnt terminnled ernnlovment dorinn the "Ian veer with arrnled henefits that were I I

--8a If the plan provides pension benefits, enter the applicable pension feature codes from the List of Plan Characteristic Codes in the instructions:

b If the plan provides welfare benefits, enter the applicable welfare feature codes from the List of Plan Characteristic Codes in the instructions:

9a Plan funding arrangement (check all that apply) 9b Plan benefit arrangement (check all that apply)(1) - Insurance Insurance(2) Code section 412(e)(3) insurance contracts Code section 412(e)(3) insurance contracts(3) - Trust

General assets of the sponsor General assets of the sponsor10 Check all applicable boxes in 10a and l o b to indicate which schedules are attached, and, where indicated, enter the number attached. (See instructionsa Pension Schedules b General Schedules

R (Retirement Plan Information) (1) H (Financial Information)(2)' FMB (Multiemployer Defined Benefit Plan and Certain Money :: 1- (Financial lnformation -Small Plan)Purchase Plan Actuarial Information) - signed by the plan A (Insurance Information)actuary (4) C (Service Provider Information)(3) 0 B (Single-Employer Defined Benefit Plan Actuarial 15) D (DFEIParticipating Plan Information)Information) - signed by the plan actuary (6) fl G (Financial Transaction Schedules)


3/37

SCHEDULE C(Form 5500)

oepartment f the T~~~~~~~lnieinal~ e v e n u e ewiceoepar,meni or LaborEmployee ~enef l i r ecunfy ~ d m ~ ~ i ~ t ~ ~ t ~ ~

pension~ e n e f i ! u a r a n t yorporabon

Part I l ~ e w i c e rovider lnformation (see instructions)-- -C Plan sponsor's name as shown on lhne 2a of Form 5500KAISER FOUNDATIONHEALTH PLAN INC

Yo.. r r ~ s l2 r ~1611?11s Par1 in i~::onl'loE nlr. l o r r.;lr..r.lloi~s, lo rc2orl llle niornl:itlrln rel-lrc7 for each person :.nl ra~.d'be11i rcrlly 01In0 ICCI y 55 00.> r rnnrc in lotal Colrprosallon le . ,money c r 2n,in ng else 01 muntlary \:I LC, n conl~etl'uov 1 ;i!Nlr:r~s rcnocrc7 to lne $an or Ilia i l e r d ~ ~ i s.oi111011 6% th lnpan our:ry lh6 p1.1~car 1a p6rSU I r E ~ 5 i ~ eonly sirjl.,~! nrl rr!r:l rorrpcnsatoo lor wn ch t rc plan rezelreo !he rd?~'r63I SI:OSJ~~!S, O.. act rcq.uec lo

Service Provider InformationThis schedule is required to be filed under section 104 of the EmployeeRetirement Income Security Act of 1974 (ERISA).

h File as an attachment to Form 5500.

D Employer ldentlflcat~onNumber (EIN)94-1340523

answer line 1 but are not required to include that person when completing the remainder of this Part.

OMB NO. 1210-0110

2010This Form is Open to PublicInspection.

For calendar plan year 2010 or fiscal plan year beginning 0110112010 and ending 1213112010

1 lnformation on Persons Receiving Only Eligible Indirect Compensationa Check "Yes"or"No" to indicatewhether you are excluding a person from the remainder of this Part because they received only eligibleindirect compensation for which the plan received the required disclosures (see instructions for definitions and conditions).. . . . . . . . . . . . . [ yes 0 o

A Name of planKAISER PERMANENTESUPPLEMENTAL SAVINGS AND RETIREMENT PLAN

b If you answered line l a "Yes," enter the name and EIN or address of each person providing the required disclosures for the service providers whoreceived only eligible indirect compensation. Complete as many entries as needed (see instructions)(b) Enter name and EIN or address of person who provided you disclosures on eligible indirect compensation

THE VANGUARD GROUP. INC.

B Three-digitplan number (PN) h

(b) Enter name and EIN or address oioerson who provided vou disclosure on elioible indirect comoensation

003

(b) Enter name and EIN or address of person who provided you disclosures on eligible indirect compensation

(b) Enter name and EIN or address of person who provided you disclosures on eligible indirect compensation

For Paperwork Reduction Act Notice and OM6 Control Numbers, see the instructions for Form 5500 Schedule C (Form 5500) v.0923


4/37

Schedule C (Form 5500) 2010

Ib l Enter name and EIN or address of Derson who provided vou disclosureson eliaible indirect ComDensation

(b l Enter name and EIN or address o i person who provided you disclosures on eliqible indirect compensation

(b ) Enter name and EIN or address o i person who provided you disclosures on e ligible indirect Compensation

(b ) Enter name and EIN or address of person who provided you disclosuresan eligible indirect compensation

(b ) Enter name and EIN or address of person who provided you disclosures on eligible indirect compensation

Ib l Enter name and EIN or address of D erson who provided vou disclosures on eliaible indirect compensation

Ib l Enter name and Ei N or address of person who provided vou disclosures on eliaible indirect comoensation

(b ) Enter name and EIN or address of person who provided you disclosures on eliqible indirect compensation


5/37

Schedule C (Form 5500) 2010 Page 3

2. Information on Other Service Providers Receiving Direct or Indirect Comaensation. Exceut ior those oersons for whom vou-answered "yes' to line l a above, complete as many entries as needed to list each person receiving, directly or indirectly, $5,000 or more in total compensatio(i.e., money or anything else oivalue) in connectionwith services rendered lo the ulan or their uositionwith the ulan durinq the ulan vear. (See instructions).

(a ) Enter name and EIN or address (see instructions)THE VANGUARD GROUP, iNC.

23-1945930

I a party-in-interest(b)ServiceCode@)

I disclosures? compensation for which you est~mated mouanswered "Yes" to element I(c)Relationship oemployer, employee

organization,orperson known to be

(a) Enter name and EIN or address (see instructions)MORRIS DAVIS AND CHAN LLP

879645

(b)ServiceCode@)

(d )Enter directcompensation paidby the plan. ii none,enter -0..

yes fl NO

(e lDid service providerreceive indirectcompensation? (sourcesother than plan or plan

(c)Relationship oemployer, employeeorganization, orperson known to be

(a ) Enter name and EIN or address (see instructions)

yes fl NO

10

QDRO CONSULTANTSCOMPANY

34-1820650

(f)Did indirect compensationinclude eligible indirectcompensation. or which theplan received the required

(d)Enter directcompensation paidby the plan. If none,enter -0..

(f). if none. enter -0-

0

a party-~n-interest

NONE

' 1 yes NO fl ( yes NO 0 1

(9 )Enter total indirectcompensation received byservice provider excludingeligible indirect

yes NO

(e lDid service providerreceive indirectcompensalion? (sourcesother than ulan or ~ l a n

(b)ServiceCode@)

15

(h )Did the servicprovider give yoformula insteadan amount o

22809

(9Did indirect compensationinclude eligible indirectcompensation, for which theulan received the reouired

(c)Relationship oemployer, employeeorganization, orperson known to be

a party-in-interest

NONF

sponsor) '

yes 0 O e]

(9 )Enter total indirectcompensation received byservice provider excludingelioible indirect


Rn75

(h )Did the servicprovider give yoformula insteadan amount o

disclosures?

yes NO

(e)Did service providerreceive indirectcompensation? (sourcesother than plan or plan

sponsor)

compen&tlon for which youanswered "Yes" to element(f). If none.enter -0..

estimated amou

yes NO

(f)Did indirect compansationinclude eligible indirectcompensation, or which theplan received the requireddisclosures?

(9)Enter total indirectcompensation received byservice provider excludingeligible indirect

compensation for which youanswered "Yes' to element(f), If none, enter -0..

(h)Did the servicprovider give yoformula insteadan amount oestimated amou


6/37

Schedule C (Form 5500) 2010 Page4 - D

(a) Enter name and EIN or address (see instructions)

(b)ServiceCode@)

(b)ServiceCode(s)



(c)Relationship oemployer, employeeorganization. orperson known to bea party-in-interest

yes NO

(4Did service providerreceive indirectcompensation? (sourcesother than plan or plansponsor)

ye s NO


( 4Relationship oemployer, employeeorganization, orperson known to bea party-in-interest(f) , If none, enter -0..--

es NO 0

(b)ServiceCode(s)

(e)Did service providerreceive indirectcompensation? (sourcesother than plan or plansponsor)

(dlEnter directcompensation paidby the plan. If none,enter -0..

yes NO

(r)Did indirect compensationinclude eligible indirectcompensation. or which theplan received the requireddisclosures?

yes 0 O

(f)Did indirect compensationinclude eligible indirectcompensation, or which theplan received the requireddisclosures?

(c)Relationship oemployer, employeeorganization, orperson known to bea party-in-interest

(9)Enter total indirectcompensation received byservice provider excludingeligible indirectcompensation or which youanswered "Yes' to element(f). If none, enter -0..


(h)Did the servicprovider give yoiormula insteadan amount orestimated amou

yes NO

(9)Enter total indirectcompensation received byservice provider excludingeligible indirectcompensation for which youanswered "Yes" to element

(h)Did the servicprovider give yoformula insteadan amount oestimated amou

yes NO

(elDid service providerreceive indirectcompensation? (sourcesother than pian or plansponsor)

yes NO

(h)Did the servicprovider give yoformula insteadan amount orestimated amou

(4Did indirect Compensationinclude eligible indirectcompensation, or which theplan received the requireddisclosures?

yes 0 O

(9)Enter total indirectcompensation received byservice provider excludingeligible indirectcompensation or which youanswered "Yes' to element( f j If none, enter -0..


7/37

Schedule C (Form 5500) 2010 Page 5 - r n

Part I /service Provider Information (continued)3 If you reported on line 2 receipt of indirect compensation, other than eligible indirect compensation. by a service provider, and the service provider is a fiduciar

or provides contract administrator, consulting, custodial, investmenl advisory. investment management, broker, or recordkeeping services, answer the followinquestions for (a) each source from whom the service provider received $1,000 or more in indirect compensation and (b) each source for whom the serviceprovider gave you a formula used to determine the indirect compensation instead of an amount or estimated amount of the indirect compensation. Complete many entries as needed to report the required information for each source.

(a ) Enter service provider name as it appears on line 2

(d ) Enter name and EiN (address) of source of indirect compensation

(d) Enter name and EIN (address) of source of indirect compensation (e ) Describe the indirect compensation, ncluding anyformula used to determine the service provider's eligibili

for or the amounl of the indirect compensation.

(e ) Describe the indirect compensation, ncluding anyformula used to determine the service provider's eligibilifor or the amount of the indirect comoensation.

(a) Enter service provider name as it appears on line 2

(b) Service Codeslsee instruclionsl

(c ) Enter amount of indirecom~ensation

(b) Service Codeslsee instructions)

(a) Enter service provider name as it appears on line 2

(c) Enter amount of indirecompensation

(d ) Enter name and EiN (address) of source of indirect compensation

(b)Service Codes(see instructions)

I(e ) Describe the indirect compensation, including anyformula used to determine the service provider's eligibili

for or the amount of the indirect compensatioq.

( c ) Enter amount of indirecomoensation


8/37

Schedule C (Form 5500) 2010 Page6-

Part I1 I Service Providers Who Fail or Refuse to Provide Information4 Prov I:$!o tte tx lsnl i,.ii.


9/37

Schedule C (Form 5500) 2010 page 7 - a

IExplanation:

Part Il l Termination Information on Accountan ts and Enrolled Actuaries (see instructions)(complete as many entries as n eeded)

Explanation:

a Name:C Position:d Address:


b EIN:e Telephone:

IExplanation:

b EIN:e Telephone:


a Name: I b EIN:

b EIN:e Telephone:

IExplanation:

C Position:d Address: e Telephone:

1Explanation:

a Name: I b EIN:c Position: Id Address: e Telephone:


10/37

SCHEDULE D(Form 5500)

Department of the ireasulyInternal Revenue sewiceoepartmenlofLaborEmployeeBenefttrSecuity Adminirlraton

DFElParticipating Plan lnformationThis schedule Is required to be filed under section 104 of the Employee

Retirement Income Security Act of 1974 (ERISA).1 File as an attachment to Form 5500

I OMB No. 1210-0110I This Form is Open to Public

~ n s ~ e c t i o n .For calendar plan year2010 or fiscal plan year beginning 0110112010 and ending 1213112010A Name of planKAISER PERMANENTE SUPPLEMENTAL SAVINGS AND RETIREMENT PLAN 6 Three-digitplan number (PN) 1 003

C Plan or DFE sponsor's name as shown on line 2e of Form 5500KAISER FOUNDATION HEALTH PLAN, INC.

a Name of MTIA, CCT, PSA, or 103-12 IE: KAISER PERMANENTE MARiSCO MASTER TRKAiSER PERMANENTE MEDICAL CARE PROGb Name of sponsor of entity listed in (a):

D Employer Identification Number (EIN)94-1340523

C EIN-PN 94-1340523-001

c EIN-PN 94-6365467-103 d Entity M e Dollar value of interest il i MTIA, CCT, PSA, or 0a Name of MTIA, CCT. PSA, or 103-12 IE: VFTC INTEREST INCOME FUNDb Name of sponsor of entity listed in (a): VANGUARD FIDUCIARY TRUST COMPANY

Part I

d Entity Mcode

lnformation on interests in MTIAs, CCTs, PSAs, and 103-12 IEs (to be completed by plans and DFEs)(Complete as many entries as needed to report all interests in DFEs)

e Dollar value of interest in MTIA, CCT, PSA, or103-12 IE at end of year (see instructions) 0

KAISER PERMANENTE MEDICAL CARE PROGRAMb Name of sponsor of entlty lhsted in (a)

a Name of MTIA, CCT. PSA, or 103-12 IE: KAiSER INTEREST INCOME FUND MASTERKAISER FOUNDATION HEALTH PLAN. INCb Name of sponsor of entity listed in (a):

c EIN-PN 94-1340523 001

b Name of sponsor of entity listed in (a):

a Name of MTIA. CCT. PSA or 103.12 IE KAISER PERMANENTE COLLECTIVE INVESTd Entlty C

code

C EIN-PN 27-6936361-001

- -e Dollar value of lnterest in MTlA CCT, PSA, or 341908859103-12 IE at end of year (see instructions)


a Name of MTIA. CCT. PSA. or 103-12 IE:d Entity c

code

C EIN-PN

e Dollar value of interest in MTIA, CCT, PSA, or103-12 IE at end of year (see instructions) 149735287

a Name of MTIA, CCT, PSA, or 103-12 IE:

a Name of MTIA, CCT, PSA, or 103-12 IE:d Entity

code

C EIN-PN


e Dollar value of interest in MTIA, CCT, PSA, or103-12 IE at end of year (see instructions)

d Entitycode

e Dollar value of interest in MTIA, CCT. PSA, or103-12 IE at end of year (see instructions)

C EIN-PNFor Paperwork Reduction Act Notice and OM5 Control Numbers, see the instructions for Form 5500. Schedule D (Form 5500) 2v.09230

d Entitycode



11/37

Schedule D (Form 5500) 2010 Page 2 - aa Name of MTIA, CCT, PSA, or 103-12 IE:



C EIN-PN d Entity e Dollar value of interest in MTIA. CCT, PSA, orcode 103-12 IE at end of year (SF tin"^^a Name of MTIA, CC-b Name of sponsor of entity listed in (a):

e Dollar value of interest in MTIA. CCT, PSA, or103-12 IE at end of year (see instructions)C EIN-PN

a Name of MTIA. CCT. PSA. or 103-12 IE:d Entity

code

a Name of MTIA, CCT. PSA. or 103-12 IE:b Name of sponsor of entity listed in (a):

C EIN-PN

a Name of MTIA, CCT, PSA, or 103-12 IE:

d Entitycode

C EIN-PN



d Entitycode



C EIN-PN

a Name of MTIA, CCT. PSA, or 103-12 IE:C EIN-PN

d Entitycode

e Dollar value of interest in MTIA, CCT. PSA. or103-12 IE at end of year (see instructions)

a Name of MTIA, CCT, PSA, or 103-12 IE:b Name of sponsor of entity listed in (a):

d Entitycode



e Dollar value of interest in MTIA, CCT. PSA. or103-12 IE at end of year (see instructions)C EIN-PN

e Dollar value of interest in MTIA. CCT, PSA. or103-12 IE at end of year (see instructions)C EIN-PN

d Entitycode

d Entitycode

a Name of MTIA, CCT, PSA, or 103-12 IE:b Name of sponsor of entity listed in (a):C EIN-PNa Name of MTIA, CCT. PSA, or 103-12 IE:b Name of sponsor of entity listed in (a):

d Entitycode

e Dollar value of interest in MTiA, CCT, PSA, or103-12 IE at end of year (see instructions)


12/37

Schedule D (Form 5500) 2010 page 3 - n

a Plan name

Part II Information on Participating Plans (to be completed by DFEs)(Complete as many entries as needed to report all participating plans)

b Nameofplan sponsor

a Plan name

C EIN-PN

a Plan name



C EIN-PN

C EIN-PN

a Plan nameb Nameofplan sponsor C EIN-PN





a Plan nameb Narneofplan sponsor C EIN-PN

a Plan nameb Name ofplan sponsor C EIN-PN




13/37

SCHEDULEH I Financial Information I OM0 No. 1210-0110oepariment of ,he Treasury This schedule is required to be filed under section 104oithe EmployeeRetirement Income Security Act of 1974 (ERISA),and section 6058(a)ofthe 2010internal Revenue Service

Depaitmeniof Labor Internal Revenue Code (the Code).Employee BenefitsSecurly Adrn~nistrailon I File as an attachment to Form 5500. This Form is Open to PublicFor calendar plan year2010 or fiscal plan year beginning 01/01/2010 and ending 12131/2010

I Part I IAsset and Liability Statement1 Current value of plan assets and liabilities at the beginning and end of the plan year. Combine the value of plan assets held in more than one trust. Report

A Name of planKAiSER PERMANENTESUPPLEMENTAL SAVINGSAND RETIREMENTPLAN

C Plan sponsor's name as shown on line 2a of Form 5500WISER FOUNDATION HEALTH PLAN, INC

the value of the plan's interest in a commingled fund containing the assets of more than one plan on a line-by-line basis unless the value is reportable onlines lc(9) through lc(14). Do not enter the value of that portion of an insurance contract which guarantees, during this plan year. to pay a specific dollarbenefit at a future date. Round off amounts to the nearest dollar. MTIAs,CCTs, PSAs, and 103-12 IEs do not complete lines I (l), I (2). lc(81, lg , I

D Employer identification Number (EIN)94-1340523

. . . . . . -and l i . CCTs, PSAs, end 103-12 IEsalso do not complete lines I d and le. See instructions.

B Three-digitplan number (PN) h

I

a Total noninterest-bearing cashb Receivables (less allowance for doubtful accounts):

(1) Employer contribution(2) Participant contributions

(4) Corporate stocks (other than employer securities):

( 6 ) Real estate (other than employer real property) ..................................(7) Loans (other than to participants) ........................................ ............(8) Participant loans ...................................................................................(9) Value of interest in common/collective rust

(10) Value of interest in pooled separate accounts .......................................(11) Value of interest in master trust investmentaccounts ....................

For Paperwork Reduction Act Notice and OMB Control Numbers, see the instructions for Form 5500 Schedule H (Form 5500) 2v.09230

003


14/37

Schedule H (Form 5500) 2010 Page 2

I d Employer-related nvestments: (b) End of Year(1) Employer securities(2) Employer real prop

e Buildingsand other property used in plan operation ....................... .............f Total assets (add all amounts in lines l a hrough le ) .................................... 1470438817 16926610

Liabilitiesh Operating payable

Net Assets

Part II

a Contributions:(1) Received or receivable in cash from: (A) Employers ...............................

(6) Participants(C) Others (including rollovers

16926610Net assets (subtract ine I from line 1 T I

lncome and Expense Statementlines'2a. 2b( l ) i i ) . ie, 1, and 29.

1470438817

2 Plan income, expenses, and changes in net assets for the year, Include all income and expenses of the plan, including any trust(s) or separately maintainedfundis) and anv oavmentslreceiotstolfrom nsurance carriers. Round off amounts to the nearest dollar. MTiAs, CCTs, PSAs, and 103-12 IEs do not comple

Income

(1) interest: I I

(2) Noncash contributions............................................................................(3) Total contributions.Add lines 2a(l)(A), (B), (C), and line Za(2) .................

(A) interes-bearing cash (includingmoney market accounts andcertificatesof deposit)(6) U.S. Governmentsecurities(C) Corporate debt instruments(D) Loans (other than la participants(E) Participant oans(F) Other

(a) Amount

(G ) Total interest. Add lines 2b(l)(A) through (F) ..................................(2) Dividends: (A) Preferred stoc

(6) Common stoc.............C) Registered nvestment company shares (e.g. mutual funds)

(D) Total dividends. Add lines 2b(2)(A), (6). and (C)(3) Rents(4) Net gain (loss) on sale of assets: (A) Aggregate proceeds ......................

(6) Aggregate carrying amount (see instructions) ...................................(C) Subtract line 2b(4)(6) from line 2b(4)(A) and enter result .................

(b) Total

b Earnings on investments:2a(2)243) 1510636


15/37

Schedule H (Form 5500) 2010 Page 3

attached.a The attached opinion of an independentqualified public accountant for this plan is (see instructions):

(1)[ nqualified (2)0 ualified (3)0 isclaimer (4)0 dverseb Did the accountant ~eriorm limited s c o ~ eudit ~ursuanto 29 CFR 2520.103-8 andlor 103-12(d)? n ye s fl NO

......................b (5) Unrealizedappreciation (depreciation)of assets: (A ) Realestate

C Enter the name and EIN of the accountant (or accounting firm) below:(1) Name:MORRIS, DAVIS 8 CHAN LLP (2) ElN: 94-2214860

d The opinion of an independentqualified public accountant is not attached because:(1)n This form is filed for a CCT, PSA, or MTIA. (2)n t will be attached to the next Farm 5500 pursuant lo 29 CFR 2520.104-50.

(a) Amount2b(5)(A)

(b) Total

2b(5)(B)

......................6) Net investmentgain (loss) from commonlcollective trusts ...........................7) Net investmentgain (loss) from pooled separate accounts ............8) Net investmentgain (loss) from master trust lnvestment accounts.......................9) Net investmentgain (loss) from 103-12 investment entities

(10) Net investmentgain (loss) from registered investmentcompanies (eg., mutual fundsC Other incom 2cd Total incame. Addall income amounts incolumn (b)andenter total ..................... 2d

432569

1018067

3246016Expenses

e Benefit payment and payments to provide benefits:..............1) Directly to participantsor beneficiaries, including direct rollovers

(2) To insurance carriers for the provisionof benefits.................................(3) Othe ..........4) Total benefit payments.Add linesZe(1) through (3) ...................f Corrective distributions (see instructions) .................Certain deemed distributions of participant loans (see instructions)

h Interest expensei Administrative expenses: (1) Professional fees

(2) Contract administratorfees(3) Investmentadvisory and management fees ........................................(4) Othe

.........................5) Totalj Total expenses. Add all expense amounts in column (b) and enter total.........

Net Income and Reconciliationk Net income (loss). Subtract line 2j from line 2 2222222I Transfers of assets:

Part Ill Accountant's Opinion3 Complete lines 3a through 3c if the opinion of an independent qualified public accountant Is attached to this Form 5500. Complete line 3d if an opinion is no


16/37

Schedule H (Form 5500) 2010 Page4 - a

I Part IV I Compliance Questions4 CCTs and PSAs do not complete Part IV. MTIAs, 103-12 IEs, and GlAs do not complete 4a, 4e, 4f. 49, 4h, 4k, 4m. 4". or 5.103-12 IEs also do not complete 4j and 41. MTlAs also do not complete 41.During the plan year:

a Was there a failure to transmit to the plan any participant contributions within the timeperiod described in 29 CFR 2510.3-102? Continue to answer "Yes" for any prior year failuresuntil fully corrected. (See instructions and DOLs Voluntary Fiduciary Correction Program.) .....b Were any loans by the plan or fixed income obligations due the plan in default as of the

t 2r.. . I .;.;r*p:us3~>;close of the plan year or classified during the year as uncolleclible? Disregard participant loans - , I::. .3 , .r.secured by participant's account balance. (Attach Schedule G (Form 5500) Part I if "Yes' ischecked.) ..................................................................................................................................

C Were any leases to which the plan was a party in default or classified during the year asuncollectible? (Attach Schedule G (Form 5500) Part II if"Yes" is checked.) ..............................

d Were there any nonexempt transactions with any party-in-interest? (Do not include transactionsreporied on line 4a. Attach Schedule G (Form 5500) Part Ill if "Yes" ischecked.)................................................................................................................................

e Was this plan covered by a fidelity bonf Did the plan have a loss,

by fraud or dishonesty? ..........................................................................................................Q Did the plan hold any ass , . , . . ~ .established market nor set by an independent third party apprah Did the plan receive any noncash contributionswhose value was neither readily

determinable on an estabi Did the plan have assets held far investment? (Attach schedule(s) of assets if 'Yes' is checked,

and see instructions for format requirements.) ............................................................................i Xj Were ally l~ laor.msaclo3s o.ser#cs V Ir;lns;l..llnn? n nxccss 0' 9 , f lne c~r ren lva l. .~ f plan assels? (Al1;~:hs~:oe,l~le1 lrans8ttion~ Yes' s L.IIBC~~!O and I I Isee instructions for format requirement X

plan, or brought under the control of the PBGC 4k XI Has the plan failed to provide any benefit when due under the pla 41 X

4m Xn If 4m was answered 'Yes," check the "Yes" box if you either provided the required notice or one

of the exceptions to providing the notice applied under 29 CFR 2520.101-3. ............................. 4 X5a Has a resolution to terminate he plan been adopted during the plan year or any prior plan year?

Ifyes, enter b e amount of any plan assets that reverted o the employer this year ............................ 0 es NO Amount:5b If, during this plan year. any assets or liabilities were transferred from this plan to another plan(s), identify the pian(s) to which assets or liabilities were

transferred. (See instructions.)%(I) Name of pian@)


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MORRIS, DAVIS & CHAN LLPCer t i f ~ e d ublic Aeconntarits

INDEPENDENT AUDITORS' REPORTInvestment Commit teel i a i s e r P e r m a n e n t e S u p p l e m e n t a l Sav ings

ant1 R e t i r e m e n t P lanTrust No. 92528W e have autlited the acc ot~ ipa ny ii~gtatements of net assets available for benefits of theI ia i se r Pe r ma nen te Sup p lem enta l Sav ings and Re t i r eme nt P la n ( the P la ii ) a s o f Decembel -31, 2010 ai~cl 009, ancl the related statements of changes in net assets available for benefitsfor the years then ended . The se financial statements are the responsibility of the Plan'sn ~ a n a g e m e i ~ t . u t responsibility is to express an opinion on these financial statements basedon 0111-audits.\Ve conducted our atidits in accordance wilh U.S. generally accepted auditing standards.Tho se standat-ds require that we plan and perform th e audit to obtain reaso nable assuranceabout whether the financial statetnents are free of material misstatement. An atidit inciiidescol?sideratiol~ f intemal control over financial re po ~t in gas a basis for designing auditprocedures that are appropriate in the circumstances, but not for the piirpose of expressing anopinion on the effectiveness o f the Plan's inter-nal control ove r financial reporting.Accordingly, we express no si ~c h pinion. An audit includes examining, on n test basis,evidence supporting the am ou i~ ts nd disclosures in the financial statements. ,417audit alsoinc li~ de s assessing the accoiinting principles used and sign ifican t estimates made bymanag ement, a s well as evaluating the ovel-all financial state men t pres entat ion. W e believethat our audits provide a reasonab le basis for our opinion.In our opinion, the financial statements, referred to above, present fairly, in all materialrespects, the net assets available for benefits as of Decernber 31, 2010 and 2009 and thechanges in net assets available for benefits for the years then ended in confol-mity with U.S.generally accepted accounting principles.01.1s atid its were perfot-in ed fol- the pur po se of fo rm ing an o pin ion on the basic financialstateinents taken as a whole. The suppleinei~tal schedule of assets held for investmentpitiposes as of D ecemb er 31, 2010 is presented for the puqlose o f additional analysis and isnot a I-equired part o f the basic financial stateme nts but is supp leme ntary inforrnatiol? requiredby the Department of Labor's Rules and Regulations for Reporting and Disclosure under theEinployee Retirement Income Security i\ct of 1974. This supplem ental sched ule is theresponsibility of the Plan's mana gemen t. Th e supplem ental schedule has been sub!ected totile auditing procedures applied in the audits of the basic financial statenlents and, in ouropinion, is fairly stated in all material respects in relation to the basic financial statementstaken as a whole.r/llAhn** && .v, &CC,&

Oaltland, CaliforniaSeptember 30.201 11111Broadway, Suit,e 1505 ' Oakland, California 94607 ' (510) 250-1000 Fax (510) 250-1032

Office.$ n S R ? I . 7 r ~ i ? ~ ~ ~ i ' i ~ ~ o ,nlijor71iomid Clmrlo t te , Nor th Caro l inn


18/37

KAISER PERMANENTE SUPPLEMENTAL SAVINGSAN D RETIREMENT PLAN

TRUST NO. 92528FINANCIAL STATEMENTS

AND SUPPLEMENTAL SCHEDULETOGETHER WITH

INDEPENDENT AUDITORS' REPORTDECEMBER 3 1,2010 AND 2009

MORRIS, DAVIS & C H A N LLPCertified Public Accountants


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KAISER PERMANENTE SUPPLEMENTAL SAVINGS AND RETIREMENT PLAN

TABLE OF CONTENTS

Independent Auditors' RepoltStatements of Net Assets Availab le for BenefitsStatelnents of Chang es in Net Ass ets Available fo r BenefitsNotes to Financial StatelnetitsSchedule H, Line 4i - Schedule of Assets Held for Investnient Purposes


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MORRIS, DAVIS & CHANLLPGel t ~ f i e d u b l i ~ r c o t ~ ~ ~ t a ~ l t i

IN D E P E N D E N T A U D IT O R S ' REPORTInvestment Com mit teeK a i s e r P e r m a n e n t e S u p p l e m e n t a l S a vi n g s

a n d R e t i r e m e n t P l auTrust No. 92528We have audited the accompanying statements of net assets available for benefits of theK a i s e r P e r m a n e n t e S u p p l e m e n t a l S a v in g s a n d R e t i r e m e n t Plan (the Plan ) as o f Decenibel-31, 2010 ant1 2009; and the related statements of changes in net assets available for benefitsfor the years theii ende d. Th ese financial statements are the responsibil i ty of the Plan'smanage ment. 0 u 1 esponsibili iy is to express an opinioil on these financial statements based011o i ~ rudits.\Ve conduc ted our audits in accordance with U.S. generally accep ted a~ idi t in g tandards.Tliose standards require that we plan and perform the audit to obtain reasonable assuranceabou t whether the financial statenients are free of material misstateme nt. An a udit includesco~isiderat ion of i l itc~i ial co~ l t ro lover f i l i anc ia l repor t ing as a bas i s for des~gn~nguditprocedures that are appropriate in the ci rc~lmstan ces, ut not for the purpose o f expressing anopi nio ~i on the effect iveness of the Plan 's internal control over f inancial reporting.Accordingly, we express no such opinion. An audi t includes examining, on n test basis:ev ide ~i ce upp orting the alnoilnts and disclosures in the financial statements. An au dit alsoincludes assessing the accounting principles used and significant estimates made by~ na~ i age rnen t ,s ~v el l s evaluating the overall f in an c~ al taterneli t presentatioii . We believethat our audits provide a reaso nable basis for our opinion.In oiir opin~ oii , he financial statem ents, referred to abo ve, prese nt fairly, in all materialrespects, the net assets available for benefits as of December 31, 2010 and 2009 and thechanges i l l net assets available for benefits for the years then ended in conformity with U.S.generally accepted accounting principles.Our audits were performed for the putpose of formling an opinion on the basic financialstatements talien as a whole. Th e suppleme ntal schedu le o f assets held for investmentp i llposes a s o f December 3 1, 201 0 is presented for the purpose of addit ional ai ialysis and isnot a required part ofthe basic financial statements but is supplementary information requiredby the Department of Labor ' s Rules and l iegulat ions for Report ing and Disclosure t~nderheE~n ploye e Reti rement Income Secur ity Act o f 1973. Thi s sup ple ~i~ enr a lchedule is theresponsibi li ty o f the Plan 's management . Th e supplemental schedule has been si~b jected othe auditing procedu res applied in the audits of the basic financial statem ents and, in ouropin ion. is fairly stated in all material res pec ts in I-elation to the bas ic financial sta tem e~ itstaken as a whole.& kt, & &-N 4Oalt land, C al~ fom iaSeptember 30 , 201 1

1111Broadway. Su ite 1505 ' Oakland, Cn l i fo r~~ ia4607 (510) 250-1000 . Fa x (510) 250-103!!~Offices i n S/,?l I . ' l - [~~~c i . s c o ,nlvoo,7rin nnd Ctrnrlol te , North Cnroli7m


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KAISER PERMANENTE SUPPLEMENTAL SAVINGS AND RETIREMENT PLANSTATEMENTS OF NET ASSETS AVAILABLE FO R BENEFITSDECEMBER 31.2010 AND 2009

AssetsInvestments, at fair valueMutual fundsCollective investment funds

Contribution receivablesErnployerParticipantsNotes receivable from participants

Total assetsLiabilitiesNet a ssets reflecting investm ents at fair valueAdjustment fro111 fair value to contract value forfully benefit-responsive inves tt~lent ontracts (14,711,392) (7,705,070)Net assets available for benefits

The ac co~ npan ying otes are an integral part o f the financial statements.-2-


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KAISER PERMANENTE SUPPLEMENTAL SAVINGS AND RETIREMENT PLANSTATEMENTS OF CHAN GES IN NET ASSETS AVAILABLE FOR BENEFITSFOR THE YEARS ENDED DECEMBER 31 , 2 010 AND 2009

AdditionsInvestment incolneNet appreciation in fair value of inve st~ne ntsInterest and dividends

ContributionsEn~ployerParticipants

Interest income on notes receivable fromparticipantsTotal additions

DeductionsBenefits paid to participantsAdministrative expensesTotal deductionsNet increase

Net assets available for benefitsBeginning of yearEnd o f year

The acco~ npan ying otes are an integral part of the financial statements.-3-


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KAISER PERMANENTE SUPPLEMENTAL SAVINGS AND RETIREMENT PLANNOTES TO FINANCIAL STATEMENTSDECEMBER 31,2 01 AND 2009

NOTE A - Description of tlie PlanThe following description of the Kaiser Permanente Supplemental Savings andRetirement Plan (the Plan) provides only general information. Participants should refer tothe Plan document for a more com plete description of the Plan's provisions.GeneralThe Plan is a money purchase pension plan which is intended to comply with the provisionsof Section 401(a) and o ther applicable provisions of the Internal Revenue C ode (IRC ) and theEmployee Retirement Income Security Act of 1974 (ERISA ), as amended. The purpose ofthe Plan is to provide additional retirement benefits for participants who meet specifiedrequirements.Particivant AccountsEach participant's account is credited with the participant's contributions, as well as anyrelevant Employer's contributions plus allocated Plan earnings and losses, and charged withadministrative expenses. Allocations are based on participant account balances, as defined.The benefit to which a participant is entitled is based on the participant's vested accountbalance.ContributionsA participant may elect to rnake contributions, through payroll deduction, in increments of1% up to a maximum of 10% of after-tax cornpensation subject to applicable limitationsprescribed by the Plan document. The E~ np loy er ontribntes 5% of the compensation ofparticipating e n~p loye es fter 2 years of em ployn~ ent.VestinF:Each participant is innnediate ly and 100% vested in his or her accounts.Notes R eceivable fiom ParticipantsA participant with an account balance of at least $2,000 may b o ~ r o w p to the lesser of 50%of his or her account balance or $50,000, reduced by the highest outstanding loan balancescarried by the participant in this and/or all other Enlployer plans durin g the 12-month periodprior to the new loan. The term of the loan is limited to not more than 5 years, except forresidential loans which may be extended up to 15 years. The interest rate is "Prime Rate"plus 1% . Loati repayments are made through payroll deductions and are credited to theparticipant's account.Payment of BenefitsA participant shall be entitled to receive all or a portion of his o r her account upon occurrenceof the earlier of the participant's retirement, death, disability, or termination o f employm ent,as defined by the Plan docum ent. Participant may take a distribution of any after-taxcontribution and applicable earnings at any time.


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KAISER PERMANENTE SUPPLEMENTAL SAVINGS AND RETIREMENT PLANNOTES TO FTNANCIAL STATEM ENTSDECEMBER 3 1,2010 AND 2009

NOTE B - Significant Accounting PoliciesBasis of AccountingThe accompanying financial statements are prepared on the accrual basis of ac co~ ultin g naccordance with U.S. generally accepted accounting principles (GAA P).New Accounting Pronouncen~entIn J an ua ~ y 010, Accounting Standard Update (ASU) 2010-06, Improving Disclosures aboutFair value Measurements, expanded the required disclokres about fair valuemeasurements. ASU 2010-06 requires 1) separate disclosure of significant transfers into andout of Level 1 and Level 2, along with reasons for such transfers; 2) separate presentation ofgross purchases, sales, issuances, and settlements in the Level 3 reconciliation; aud 3)presentation of fair value disclosures by "nature and risk" class for all fair value assets audliabilities. Th e requirements of ASU 2010-06 are effective for the current reporting periodexcept for the level 3 reconciliation disaggregation which is required in 201 1 reporting. Therequirements of ASU 2010-06 have no impact on the Plan's financial statements.Use of EstimatesThe preparation of financial statements in accordance with GAAP requires Plan managementto make estitnates and assumptions that affect certain reported amounts and disclosures.Accordingly, actual results m aJ differ from those estimates.Investment Valuation an d Income Recogn itionInvestments are reported at fair value. Fair value is the price that would be received to sell anasset or paid to transfer a liability in an orderly transaction b etween market participants at themeasurement date (see Note E-Fair Value Measurements).Fully benefit-responsive investm ent contracts held by a defined-contribution plan are requiredto be rep o~ te d t fair value. How ever, contract value is the relevant measurement attribute forthat portion of the uet assets available for benefits of a defined-contribution plan attributableto fully benefit-responsive investment contracts because contract value is the amountparticipants would receive if they were to initiate pelmitted transactions under the terms ofthe plan. The Statements of Net Assets A vailable for Benefits present the fair value of theinvestment contracts from fair value to contract value. The Statement of Changes in NetAssets Available for Benefits is prepared on a co ntract value basis.


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KAISER PERMANENTE SUPPLEMENTAL SAVINGS AND RETIREMENT PLANNOTES TO FINANCIAL STATEMENTSDECEMBER 31,2010 AND 2009

NOTE B - Significant Accou nting Policies (Continued)Investment Valuation and Inc o~ ne ecognition (Continued)Purchases and sales of securities are recorded on a trade date basis. Net realized andunrealized appreciation (depreciation) is recorded in the acco~npanying tatenlent of Changesin Net Assets Available for Benefits as net appreciation (depreciation) in fair value ofinvestnlents. Interest income is recorded on tlie accrual basis. Dividends are recorded on tlieex-dividend date.Notes R eceivable from ParticipantsNotes receivable from participants are measured at their unpaid principal balance plus anyaccrued but unpaid interest. Delinquent notes receivable from participants are reclassified asdistributions based upon the terms of tlie Plan docum ent.Payment of BenefitsBenefits are recorded when paid.Administrative ExpenseCertain investnient funds charge transaction fees. These fees are deducted from participantaccounts and are reflected in the acconlpanying financial statements as administrativeexpenses.

Subsequent EventThe Plan's financial statements have been evaluated for subsequent events or transactions forpotential recognition tlirougli Septem ber 30 , 201 1, the d ate the financial statements areavailable to be issued. Plan lnanagenient determined that there are no subsequent events ortransactions that require disclosure to or ad justnlent in the financial statements.ReclassificationIn Septembe r, 201 0, ASU 201 0-25, Reporting Loans to Participants by De$ned Contribu tionPension Plans, clarified the classification and measurement of the participant loans bydefined contribution plans. AS U 2010-25 urovided that in defined contribution ulans'financial statements, participant loans should be classified as notes receivable fromparticipants, which are segregated from plan investments and measured at their unpaidprincipal balance plus any accrued but unpaid interest. Plan management reclassifiedparticipant loans on tlie Statements of Net Assets Available for Benefits for all years presentas notes receivable from participants. The net assets of the Plan were not affected by thereclassification. As A SU 2010-25 ap plies only to financial staternelits prepared in ac cordancewith GAAP, it will not affect the classification of notes receivable from participants on theF o ~ i n 500. Notes receivable from participants continue to be reported as investments on


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KAISER PERMANENTE SUPPLEMENTAL SAVINGS AND RETIREMENT PLANNOTES TO FINANCIAL STATEMENTSDECEMBER 3 1.201 0 AND 2009

NOTE B - Significant Accou nting Policies (Continued)Reclassification (Continued)Form 5500, Schedule H, line lc(8) of the Plan. Because ASU 2010-25 will not result in adifference between total net assets reported in the Form 5500 and the Plan's financialstatements, there is no reconciling note in the Plan's financial statements.Additionally, notes receivable from participants are exempt from (i) the disclosurerequirements about fair value in paragraphs 825-10-50-10 through 50-16 of the FinancialAccounting Standard Board (FASB) Accounting Standards Codification (ASC); and (ii)credit quality disclosures required by the amendments in ASU No. 2010-20, Receivables(Topic 310): Disclosures about the Credit Quality of Financing Receivables and theAllowance for Credit Losses. FASB believes that any individual credit risk related to notesreceivable from participants is mitigated by the fact that these notes are secured by theparticipant's vested balance. If a participant were to default, the participant's account balancewould be offset by the unpaid balance of the note and the participant would be subject to taxon the unpaid balance. As such, the participant is the only party affected in the event of adefault.NOTE C - Restructuring of the Kaiser Perinanente Master and Collective Trust, and theKaiser Interest Income TrustPrior to December 29, 2010, portions of the Plan's assets were held in the Kaiser PermanenteMaster and Collective Tm st (KPM CT) an d the Kaiser Interest Income Trust (KIIT).The KPM CT held the Defined B enefit Investment Fund for participating defined benefit plansas well as the Marsico Growth Equity Fund and the Stable Income Fund for participatingdefined contribution plans sponsored by Kaiser Foundation Health Plan, Inc. (KFHP) and thePe~inanenteMedical Groups (PMGs). The KIIT holds the Kaiser Interest Income Fund forparticipating defined contribution plans sponsored by K FHP and the PM Gs. S tate Street Bankand Tlust Company (State Street) served as trustee of the KPMCT and Vanguard FiduciaryT ~ u s t onlpany (Vanguard) selves as the trustee of the KIIT.On December 29, 201 0, the KPM CT was amended and restated into the Kaiser PerlnanenteGroup Trust (KPGT), a 103-12 investnlent entity, and the Kaiser Permanente CollectiveInveshnent T~ustKPC IT) was established. State Street continued on to be the trustee of theKPGT.


27/37

KAISER PERM ANENTE SUPPLEMENTAL SAVINGS AND RETIREMENT PLANNOT ES T O FTNANCIAL STATEMENTSDECEMBER 3 1,2010 AND 2009

NOTE C - Restructuring of the Kaiser Permauente Master and Collective Trust, and theKaiser Interest Income Trust (Continued)The net assets of the Marsico Growth Equity Fund and the Stable Income Fund weretransferred froin the K PMC T to the KP Growth Equity Fund and the KP Stable Income Fund,respectively, in the KPCIT . Global Trust Company (Global Trust) becam e the trustee ofKPCIT and State Street became its custodian.In December 2010, the KIIT agreement was amended and restated into a collective trust andthe Kaiser Interest Incon~e und held by KIIT was renamed the Vanguard Fiduciaiy TrustCompany Interest Income Fund (VFTC Interest Income Fund). Vanguard remains the tiustiefor the KIIT.For plan year 2010, the Plan reports its investments held by KPC T and KIIT a s investments incomm oi~/collective rusts for Fo i ~ n 500 pnlposes. For plan year 2009, the Plan repotted itsinvestments held by KPMCT and KIIT as investments in master trust investment accounts forFoml 5500 purposes. See Note K - Reconc iliation of Financial Statements to Form 5500.NOTE D - InvestnlentsThe following presents investments that represent 5% or more of the Plan's net assets as ofDecember 3 1.2010 and 2009:

Mutual fundsVanguard Lifestrategy Conservative Growth Fund $ 321,088,719 $ 246,982,626Vanguard Total Bond Market Index Fund 151,432,566 136,745,825Vanguard Wellington Fund 109,212,987 100,123,960Vanguard Total Stock Market Index Fund 193,011,803 164,461,669Collective investment fundsVFTC Interest Income Fund (forn~erlyKaiser InterestIncome Fund)* 341,908,859KP Growth Equity Fund** 149,735,287Marsico Growth Equity Fund*** Contract valtre M'o.~327,197,467 rind $333,588,271 or ofDrce,> ?hev 1, 2010 nnd 2009. respectively.** KP Growtlz Equity Ftrad replaced the A4arsicu G~.owfhEqrtify Fund os oi l inveslnienl option in 2010.


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KAISER PERMANENTE SUPPLEMENTAL SAVINGS AND RETIREMENT PLANNOTES TO FTNANCIAL STATEM ENTSDECEMBER 31,2010 AND 2009

NOTE D - Investments (Continued)For the years ended December 31, 2010 and 2009, the Plan's illvestinents (including gaiils andlosses on investment bought and sold , as well as held duiing the year) appreciated in value asfollows:

Mutual fundsCollective investment fun dsNet appreciation in fair value of investinents

NOTE E - Fair Value MeasurementsFASB ASC 820, Fair Value Measurements and Disclosures, establishes a framework formeasuring fair value. That framewo rk provides a fair value hierarchy that prioritizes theinputs to valuation techniques used to measure fair value. The hierarchy gives the highestpriority to unadjusted quoted prices in active markets for identical assets or liabilities (Level 1measurements) and the lowest priority to unobservable inputs (Level 3 measurements). Thethree levels of the fair value hierarchy are described below:

Level I Inputs to the valuatiotl methodology are unadjusted quoted prices for identical assetsor liabilities in active markets that the Plan has the ability to access.Level 2 Inputs to the valuation nlethodology include:

Quoted prices fo r similar assets or liabilities in active m arkets;Quoted prices for identical or similai- assets or liabilities in inactive markets;Inputs other than quoted prices that are obset-vable for the asset o r liability; andInputs that are derived principally from or corroborated by observable marketdata by correlation or o ther means.Level 3 Inputs to the valuation methodology are unobservable and significant to the fair

value measurement.The asset's or liability's fair value measurement level within the fair value hierarchy is basedon the lowest level of any input that is significant to the fair value measurement. Valuationtechniques used need to maxiiuize the use of observable inputs and ininimize the use ofunobservable inputs.


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KAISER PERMANEN TE SUPPLEMENTAL SAVINGS AND RETIREMENT PLANNOTES TO FINANCIAL STATEMENTSDECEMBER 3 1, 20 10 AND 2009

NOTE E - Fair Value Measurem ents (Continued)Following is a description of the valuation methodologies used for investlnents measured atfair value. There have been no changes in the methodologies used as of December 31, 2010and 2009.- Mutual f i~ nd s re valued at the net asset value of shares held by the Plan at year end.Collective investment funds are stated at fair values as determined by the issuers based onthe unit values of the funds. Unit values are determined by dividing the funds' net assets,which represent the unadjusted prices in active markets of the underlying investments, bythe number of outstanding at the valuation date. While not publicly traded, the funds are

comprised primarily of underlying securities represeuted by a v ariety of asset classes thatare publicly traded on exchanges or over-the counter, and price quotes for the assets heldby the funds are readily observable and available.The methods described above may produce a fair value calculation that may no t be indicativeof net realizable value of reflective of future fair values. Furthermore. while the Plan believesits valuatiou methods are appropriate and consistent with other market participants, the use ofdifferent ~nethodologiesor assum ptions to de ter ~n ine he fair value of certain financialirlstruments could result in a different fair value m easurement at the reporting date.The following tables set forth by level, within the fair value hierarchy, the Plan's investmentsat fair value as of December 3 1, 2010 and 2009:

Investments a t Fair Value as of December 31, 2010Level I L e v e l 2 Level 3 TotalMutual funds

Domestic stock fundsInternationalIglobaI stack fundsBond fundBalanced filndsOther funds

Collective investment fundsInvestments, at fair value


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KAISER PERMANENTE SUPPLEMENTAL SAVINGS AND RETIREMENT PLANNOT ES TO FTNANCIAL STATEME NTSDECEMBER 31,201 0 AND 2009

NOTE E - Fair Value Measurements (Continued)lrivcst~nents t Fair Value as of December 31. 2009Level I Level 2 Level 3 Tntal

Mutual fundsDomestic stock furidsInternationall~lobal tock fundsBond fundBalanced fundsOther fundsCollective investinellt fi ~n ds

Investments, at fair value

NOTE F - Tax StatusThe Plan obtained its latest determination letter on February 3, 201 1, in which the InternalRevenue Service (IRS) stated that the Plan, as then designed, was in con~pliancewith theapplicable requirements of the IRC . Subsequent to the issuance of the det e~ m ina tio n etter,the Plan was amended and restated. Once qualified, the Plan is required to operate inconfo~mitywith the IRC to maintain its qualification. The plan administrator believes that thePlan is currently designed and being operated in com pliance with the applicable requirementsof the IRC and, therefore, believes that the Plan, as am ended and restated, is qualified and therelated trust is tax-exempt as of the financial statement date.GAAP requires Plan management to evaluate tax positions taken by the Plan and recognize atax liability (or asset) if the Plan has taken an uncertain tax position that wo uld not meet themore likely than not standard and be sustained upon examination by the IRS. The Planadministrator has analyzed the tax positions taken by the Plan, and bas concluded that as ofDecember 31, 2010, there are no uncertain tax positions taken or expected to be taken thatwould require recognition of a liability (or asset) or disclosure in the financial statements. ThePlan is subject to routine audits by taxing jurisdictions. The Plan adm inistrator believes it isno longer subject to income tax examinations fo r years prior to 2007.NOTE G - Plan Te~mina tionAlthough it has not expressed any intent to do so , the Emp loyer has the right under the Plan todiscontinue its contributions at any time and to te~ininatehe Plan subject to the provisions ofERISA. Should the Plan be te~ m ina ted ,he net assets are to be distributed to participants, thevalue of their adjusted accounts.


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KAISER PERM ANENTE SUPPLEMENTAL SAVINGS AND RETIREMENT PLANNOTES T O FINANCIAL STATEMENTSDECEMBER 3 1,2010 AND 2009

NOTE H - Party-in-Interest TransactionsCertain Plan investments are manage d by Vanguard and State Street. Vanguard and StateStreet are the trustees of the Plan. Vangua rd also selves as the recordkeeper. Transactionswith the trustees and record keep er qualify as party-in-interest transactions.NOTE I - Risks and UncertaintiesThe Plan invests in various investment securities. Investment securities are exposed tovarious risks such as interest rate, market and credit risks. Du e to the level of risk associatedwith certain investment securities, it is at least reasonably possible that changes in the valuesof investment securities will occur in the near tern1 and that such changes could materiallyaffect participants' acco unt balances an d the amounts reported in the statem ent of net assetsavailable for benefits.NOTE J - Plan Obligatio~lsIn accordance with G AA P, benefits due to terminated participants are included in net assetsavailable for benefits. There are no benefits du e to terminated participants as o f December31 ,201 0 and 2009.NOTE K - Reconciliation of Financial Statements to Form 5500The following is a reconciliation of net assets available for benefits per the financialstatements to Forn15500 as o f December 3 1 , 2010 an d 2009:

Net assets available for benefits per the financialstatementsAdjustnlent from con tract value to fair value forfully benefit-responsive investnlent contractsNet assets available for benefits per F on n 5500


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KAISER PERM ANENTE SUPPLEMENTAL SAVINGS AND RETIREMENT PLANNOTES TO FTNANCIAL STATEM ENTSDECEMBER 31 ,2010 AND 2009

NOTE K - Reconciliation of Fitla~lcialStatements to Fon n 5500 (Continued)The following is a reconciliation of investment i nc o~ ne er the financial statements to Form5500 for the years ended D ecember 31,2010 and 2009:

Investment in co ~n e er the financial statementsChange in adjustment from contract value to fairvalue for fully benefit-responsive investm ent

conbactsInvestme~ltncome per F osn15500


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KAISER PERMANENTE SUPPLEMENTAL SAVINGS AND RETIREMENT PLANEIN 94-1340523 PLAN NO. 003SCHEDULE H, LINE 4i - SCHEDULE OF ASSETS HELD FOR INVESTMENT PURPOSESDECEMBER 31,2010

Identity of Issue, Borrower,Lessor, or Siinilar PartyAllianceBernstein Global Research Growth FundT. Rowe Price International Discovery FundVanguard Explorer FundVanguard FTSE Social Index FundVanguard International Growth FundVanguard LifeStrateg Co~lservativeGrowth FundVanguard LifeStrdteg Growth FundVanguard LifeStrategy Inc o~ne undVanguard LifeStrategy Moderate Growth FundVanguard PRIMECAP FundVanguard Total Bond Market Index FundVanguard Total Stock Market Index FundVanguard Value Index FuudVanguard Wellington FundKaiser Per~nanente ollective Investnlent Trust(KP Growth Equity Fund)VFTC Interest Incoine FundVGI Brokerage OptionTotal investments per fiilailcial statementsNotes receivable froin participants

Total invest~nents er Fonn 5500* Investments in parties-in-interest as defined under ERISA

92528

Description of Inveshl~entncludingMaturity Date, Rate of interest,Collateral, Par, or Maturity Value Cost

Mutual fund $ 5,597,115Mutual fund 40,659,844Mutual fund 26,186,430Mutual fund 2,693,545Mutual fund 68,458,673Mutual fund 297,805,927Mutual fund 57,707,5 13Mutual fund 13,775,792Mutual fund 54,635,262Mutual fund 42,364,091Mutual fund 145,105,691Mutual fund 149,809,239Mutual fund 47,348,964Mutual fund 102,394,467Collective investment fundCollective investment fundSelf-directed brokerage account

Current Value$ 5,059,37645,691,70229,491,5503,302,61272,024,544321,088,71960,906,45314,525,63857,255,67747,133,240151,432,566193,011,80356,011,723

109,212,987


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KAISER PERMANENTE SUPPLEMENTAL SAVINGS AND RETIREMENT PLANEIN 94-1340523 PLAN NO. 003SCHEDULE H, LINE 4i - SCHEDULE OF ASSETS HELD FOR INVESTMENT PURPOSESDECEMBER 3 1,2010

Identity of Issue, Borrower,Lessor, or Sinlilar PartyAllianceBernstein Global Research Growth FundT. Rowe Price International Discovery FundVanguard Explorer FundVanguard FTSE Social Index FundVanguard International Growth FundVanguard LifeStrategy Conservative Growth FundVanguard LifeStrategy Growth FundVanguard LifeStrategy Incoinc FundVanguard LifeStrategy Moderate Growth FundVanguard PRIMECAP FundVanguard Total Bond Market Index FundVanguard Total Stock Market Index FundVanguard Value Index FundVanguard Wellington FundKaiser Per~nanente oll ect~venveshnent Trust(KP Growth Equity Fund)VFTC Intcrest Incoine FundVGI Brokerage OptionTotal itlvest~neuts er financial statementsNotes receivable from participants

Total investments per Form 5500* Investinents in parties-in-interest as defined under ERISA.

92528

Description of Inveshnent IlleludingMaturity Date, Rate of Interest,Collateral, Par, or Maturity Value

Mutual fundMutual fundMutual fundMutual fundMutual fundMutual fi~n dMutual fundMutual fundMutual fundMutual fundMutual fundMutual findMutual fuildMutual fundCollective inveshllent fundCollective investinel~t undSelf-directed brokerage account

Cost$ 5,597,11540,659,84426,186,4302,693,54568,458,673297,805,92757,707,51313,775,79254,635,26242,364,091145,105,691149,809,23947,348,964

102,394,467

Current Value$ 5,059,37645,691,70229,491,5503,302,61272,024,544321,088,71960,906,45314,525,63857,255,67747,133,240151,432,566193,011,80356,O 11,723

109,212,987


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SCHEDULE R(Form 5500)

Departmentof the ~ r e a s u nlntemal~evenussswicsDepartment of ~ a b o rE ~ ~ I ~ ~ ~ ~~ ~ ~ n t ~ecuity~drninrtraton

pension Benefli Guaianly corporat ion

I Part I I DistributionsAll references to d istribu tions relate only to payments of benefits dur ing the plan year.1 Total value of distributions paid in property other than in cash or the forms of property specified in theinstructions ...........................................................................................................................................................

C Plan sponsor's name as shown on line 2a of Form 5500KAISER FOUNDATION HEALTH PLAN, INC

2 Enter the EIN(s) of payor@)who paid benefits on behalf of the plan to participantsor beneficiaries during the year ( if more than two, enter EINS of the twopayors who paid the greatest dollar amounts of benefits) :

EIN(s): 23-2186884Profit-sharing plans, ESOP? and stock bonus plans, skip line 3.

3 Number of participants (living or deceased) whose benefits were distributed in a single sum, during the plan

RetirementPlan InformationThis schedule is required to be filed under section 104and 4065 of theEmployeeRetirement Income Security Act of 1974 (ERISA)and section6058(a) of the lnternai Revenue Code (the Code).

b File as an attachment to Form 5500.

D Employer Identification Number (EIN)94-1340523

bear . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 1 1 ECPart II I Funding lnformation ( f tne plan s no! sLb.e-;l to !he n, nim..m f..ndnq req.. rcmcnts of se!:tion of 0 1 2 of lor ,Irroal Rcve n~e orlr! ni

OMB NO. 1210-0110

2010This Form is Open to PublicInspection.

For calendar plan year 2010 or fiscal plan year beginning O l l O l n O l O and ending 1213112010

. .I I ERISA section 302, skip this Part)4 Is the plan administrator makingan election under Code section 412(d)(2)or ERISA section 302(d)(2)? ...................... Yes [i3 No 0If the plan i s a defined benefit plan, go to line 8.

A Name of planKAISER PERMANENTESUPPLEMENTAL SAVtMGSAND RETlREMENT-PLAN

5 If a waiver of the minimum funding standard for a prior year is being amortized in thisplan year, see instructions and enter the date of the ruling letter granting the waiver. Date: Month Day YearIf you completed line 5, complete lines 3, 9 , and 10 of Schedule ME and do n ot complete the remainder of th is schedule.

6 a Enter the minimum required contribution for this plan yearb Enter the amount contributed by the employer to the plan for this plan yearC Subtract the amount in line 6b from lhe amount in line 6a. Enter the result(enter a minus sign to the left of a negative amount)If you completed line 6c , skip lines 8 and 9.7 Will the minimum funding amount reported on line 6c be met by the funding deadline? ................................. .... Yes 17 NO 0 I

8 If a change in actuarial cost method was made for this plan year pursuant to a revenue procedure providingautomatic approval for the change or a class ruling letter, does the plan sponsor or plan administrator agreewith the chanae? ................................................................................................................................................ n yes n NO n NIA

B Three-digitplan number(PN)

Part Ill 1 Amendments9 If this is a defined benefit pension plan. were any amendments adopted during this plan

year that increased or decreased the value of benefits? If yes, check the appropriatebox(es), no, check the -NO" box...................................................................................... increase 0 ecrease 60th 0'OI Part IV I ESOPs (see instructions). If this is not a plan described under Section 409(a) or 4975(e)(7) of the Internal Revenue Code,

003

I I skip this Part.10 Were unallocated employer securities or proceeds from the sale of unallocated securities used to repay any exempt loan?.............. Yes N11 a Does the ESOP hold any preferred stoc ye s N

b If the ESOP has an outstanding exempt(See instructions for definition of "back-to-back loan.) Yes N............................................................................................................12 Does the ESOP hold any stock that is not readily tradable an an established securities market ye s I] NFor Paperwork Reduction Act Notice and OMB Contro l Numbers, see the instruct ions far Form 5500. Schedule R (Form 5500) 2v.09230


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Schedule R (Form 5500) 2010 Page 2 - r n-- .- -[ art^ Additional Information for M ultiemployer Defined--enefit Pension Plans . . .--

13 Entcr tnr 'lllloc nq niorn,zl on 'or rduo wnl . o y r r lna l ConlrlbLledo l ~ r anan 5.0 f to131 Lonlr o.lo?s 10 ine p 30 u.r nq In* lion ,ear (r l l tas . r r l l 0dollars). See instructions. Complete as many entries as needed to repod al l applicable employers.a Name of contributing employerb EIN C Dollar amount contributed by employerd Date collective bargaining agreement expires (If employer contributes under more than one coNective bargaining agreement, check b o x 0

and see instructions regarding required aiiachmenf. Otheiwise, enter the applicable date.) Month Day Yeare Contribution rate information (If more than one rate applies, check this box and see instructions regarding required attaciiment. Otherwise,complete items 13e(l) and 13ef2 j.j(1) Contribution rate (in dollars and cents)(21 Base unit measure: n Hourlv n Weeklv n Unit of Droduction fl Other (s~eciiv):. I I I I . . ..

a Name of contributing employerd Date collective bargaining agreement expires (If empioyercontributes undermore than one collective bargaining agreement, check bo x 0

and see instructions regarding required attachment. Otherwise, enter the applicable date.) Month Day Yeare Contribution rate information (if more than one rate applies, check this b o x 0 and see instructions regarding required attachment. Otherwise,

complete iterns 13e(l) and 13e(2).)(1) Contribution rate (in dollars end cents)(2) Base unit measure: Hourly I I Weekly I I Unit of production n Other (specify):

a Name o i contributina emuloverb EIN C Dollar amount contributed by employerd Date collective bargaining agreement expires (If empioyercontribbutes undermore than one collective bargaining agreement, check b o x 0

and see instructions regarding required attachment. Othenwise, enter the applicable date.) Month Day Yeare Contribution rate information (if more than one rate applies, check this b o x 0 and see instructions regarding requiredattachment. Otherwise,

complete items 13e(l) and 13e(2).)(1) Contribution rate (in dollars and cents)(2) Base unit measure: Hourly

a Name of contributing employerb ElN C Dollar amount contributed by employerd Date collective bargaining agreement expires (if empioyer contributes under mare than one collective bargaining agreement, check box

and see instructions regarding required attachment. Otherwise, enter the applicable date.) Month Day Yeare Contribution rate information (If more than one rate applies, check this b o x 0 and see instructions regarding requrred attachment. Otheiwise,

complete items 13e(l) and 13e(2).)(1) Contribution rate (in dollars and cents)

Weekly I I Unit of production Other (specify):

(2) Base unit measure:n Hourly I I Weekly I Unit of production n Other (specify):a Name of contributing employerb EIN C Dollar amount contributed by employerd Date collective bargaining agreement expires (if employer contributes under mare than one coNective bargaining agreement, check box0

and see instructions regarding required attachment Otherwise, enter the applicable date.) Month Day Yeare Contribution rate information (If more than one rate applies, check this box0 nd see instructions regarding required attachment. Otherwise,

complete items 13e(l) and 13e(2).)(1) Contribution rate (in dollars and cents)(2) Base unit measure: Hourly Weekly Unit of production Other (specify):

a Name of contributing employerb EIN C Dollar amount contributed by employerd Date collective bargaining agreement expires (If empioyer contributes under more than one collective bargaining agreement, check box

and see instructions regarding required anachment. Otheiwlse, enter the applicable date.) Month Day Yeare Contribution rate information (If more than one rate applies, check this box0 nd see instructions regarding required attachment. Otherwise,

colnpiete items 13e(l) and 13e(2).)(1) Contribution rate (in dollars and cents(2) Base unit measure:a Hourly d Unit of production Other (specify):


37/37

ScheduleR (Form 5500) 010 Page 3

14 Enter the number of participants on whose behalf n o contributions were made by an employer as an employer of theparticipant for:a The current yeab The plan year immediately preceding the current plan yea

employer contribution during the current plan year to: ...............................The corresponding number for the plan year immediately preceding the current plan yearn orma ,on w~ respec o any em

b if item 163 is greater than 0, n17 if assets and liabilities from another plan have been transferred to or merged with this plan during the plan year, check box and see instructions regarding

supplemental information o be included as an attachment. ....................................................................................................................... 0I Part VI I Additional Information for Single-Employer a nd Multiemployer Defined Benefit Pension Plans18 faoy l a u ales to ;lnrtcfpanls or t11eir oene!cnarles under l nr &kiln ;is nf tnc cr.d 0' II,~ax) bear :cnsit I n Nnor or '8 1 p.rt) of an ~ t ~ c so s:cn pan c ~3 01 sano Scncficaries uouer lrro or morc licnso n l~la ns s of imnie3 ately before sucn plan ycar cnccn Sox and sco nstr.cl ons roqaro LvIIcmCnIa -information to be included as an attachment............................................................................................................................................................................I19 If the total number of participants s 1,000 r more, complete items (a ) through (c)

a Enter the percentage of plan assets held as:Stock: % Investment-GradeDebt:- High-Yield Debt:- Real Estate: % Other: %b Provide the average duration of the combined investment-grade and high-yield debt:0 -3 ears 0 -6 years 6-9 ears 9-12 ears [112-15 ears 0 5-18 ears 0 8-21 ears 0 1 years or more

c What duration measure was used to calculate item 19(b)?Effective duration Macauiay duration Modified duration Other (specify):

kaiser supplemental savings and retirement plan annual report form 5500

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