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DENTAL PLAN - SELF FUNDED 401k Plan overview

Plan NameDENTAL PLAN - SELF FUNDED
Plan identification number 506

DENTAL PLAN - SELF FUNDED Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Dental

401k Sponsoring company profile

CAYUGA MEDICAL CENTER AT ITHACA has sponsored the creation of one or more 401k plans.

Company Name:CAYUGA MEDICAL CENTER AT ITHACA
Employer identification number (EIN):222325405
NAIC Classification:621111
NAIC Description:Offices of Physicians (except Mental Health Specialists)

Form 5500 Filing Information

Submission information for form 5500 for 401k plan DENTAL PLAN - SELF FUNDED

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5062022-01-01
5062021-01-01
5062020-01-01
5062019-01-01
5062018-01-01
5062017-01-01BRIAN FORREST BRIAN FORREST2018-09-06
5062017-01-01 BRIAN FORREST2018-08-28
5062016-01-01JOHN COLLETT JOHN COLLETT2017-10-16
5062015-01-01JOHN COLLETT JOHN COLLETT2016-10-14
5062014-01-01ALAN E PEDERSEN ALAN E PEDERSEN2015-10-13
5062013-01-01ALAN E PEDERSEN ALAN E PEDERSEN2014-10-14
5062012-01-01ALAN E PEDERSEN ALAN E PEDERSEN2013-10-14
5062011-01-01ALAN E PEDERSEN ALAN E PEDERSEN2012-10-10
5062010-01-01ALAN E PEDERSEN ALAN E PEDERSEN2011-10-12
5062009-01-01ALAN E PEDERSEN ALAN E PEDERSEN2010-10-14

Plan Statistics for DENTAL PLAN - SELF FUNDED

401k plan membership statisitcs for DENTAL PLAN - SELF FUNDED

Measure Date Value
2022: DENTAL PLAN - SELF FUNDED 2022 401k membership
Total participants, beginning-of-year2022-01-01939
Total number of active participants reported on line 7a of the Form 55002022-01-01924
Total of all active and inactive participants2022-01-01924
Total participants2022-01-01924
2021: DENTAL PLAN - SELF FUNDED 2021 401k membership
Total participants, beginning-of-year2021-01-01922
Total number of active participants reported on line 7a of the Form 55002021-01-01936
Number of retired or separated participants receiving benefits2021-01-013
Total of all active and inactive participants2021-01-01939
Total participants2021-01-01939
2020: DENTAL PLAN - SELF FUNDED 2020 401k membership
Total participants, beginning-of-year2020-01-01906
Total number of active participants reported on line 7a of the Form 55002020-01-01912
Number of retired or separated participants receiving benefits2020-01-0110
Total of all active and inactive participants2020-01-01922
Total participants2020-01-01922
2019: DENTAL PLAN - SELF FUNDED 2019 401k membership
Total participants, beginning-of-year2019-01-01919
Total number of active participants reported on line 7a of the Form 55002019-01-01913
Number of retired or separated participants receiving benefits2019-01-0111
Total of all active and inactive participants2019-01-01924
Total participants2019-01-01924
2018: DENTAL PLAN - SELF FUNDED 2018 401k membership
Total participants, beginning-of-year2018-01-01930
Total number of active participants reported on line 7a of the Form 55002018-01-01908
Number of retired or separated participants receiving benefits2018-01-0111
Total of all active and inactive participants2018-01-01919
Total participants2018-01-01919
Number of employers contributing to the scheme2018-01-010
2017: DENTAL PLAN - SELF FUNDED 2017 401k membership
Total participants, beginning-of-year2017-01-01847
Total number of active participants reported on line 7a of the Form 55002017-01-01928
Number of retired or separated participants receiving benefits2017-01-0111
Total of all active and inactive participants2017-01-01939
Total participants2017-01-01939
Number of employers contributing to the scheme2017-01-010
2016: DENTAL PLAN - SELF FUNDED 2016 401k membership
Total participants, beginning-of-year2016-01-01878
Total number of active participants reported on line 7a of the Form 55002016-01-01824
Number of retired or separated participants receiving benefits2016-01-0113
Total of all active and inactive participants2016-01-01837
2015: DENTAL PLAN - SELF FUNDED 2015 401k membership
Total participants, beginning-of-year2015-01-01842
Total number of active participants reported on line 7a of the Form 55002015-01-01864
Number of retired or separated participants receiving benefits2015-01-0114
Total of all active and inactive participants2015-01-01878
2014: DENTAL PLAN - SELF FUNDED 2014 401k membership
Total participants, beginning-of-year2014-01-01844
Total number of active participants reported on line 7a of the Form 55002014-01-01824
Number of retired or separated participants receiving benefits2014-01-0118
Total of all active and inactive participants2014-01-01842
2013: DENTAL PLAN - SELF FUNDED 2013 401k membership
Total participants, beginning-of-year2013-01-01805
Total number of active participants reported on line 7a of the Form 55002013-01-01834
Number of retired or separated participants receiving benefits2013-01-0110
Number of other retired or separated participants entitled to future benefits2013-01-010
Total of all active and inactive participants2013-01-01844
2012: DENTAL PLAN - SELF FUNDED 2012 401k membership
Total participants, beginning-of-year2012-01-01765
Total number of active participants reported on line 7a of the Form 55002012-01-01800
Number of retired or separated participants receiving benefits2012-01-015
Number of other retired or separated participants entitled to future benefits2012-01-010
Total of all active and inactive participants2012-01-01805
2011: DENTAL PLAN - SELF FUNDED 2011 401k membership
Total participants, beginning-of-year2011-01-01687
Total number of active participants reported on line 7a of the Form 55002011-01-01760
Number of retired or separated participants receiving benefits2011-01-015
Total of all active and inactive participants2011-01-01765
2010: DENTAL PLAN - SELF FUNDED 2010 401k membership
Total participants, beginning-of-year2010-01-01665
Total number of active participants reported on line 7a of the Form 55002010-01-01683
Number of retired or separated participants receiving benefits2010-01-014
Number of other retired or separated participants entitled to future benefits2010-01-010
Total of all active and inactive participants2010-01-01687
2009: DENTAL PLAN - SELF FUNDED 2009 401k membership
Total participants, beginning-of-year2009-01-01590
Total number of active participants reported on line 7a of the Form 55002009-01-01660
Number of retired or separated participants receiving benefits2009-01-015
Number of other retired or separated participants entitled to future benefits2009-01-010
Total of all active and inactive participants2009-01-01665
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits2009-01-010

Form 5500 Responses for DENTAL PLAN - SELF FUNDED

2022: DENTAL PLAN - SELF FUNDED 2022 form 5500 responses
2022-01-01Type of plan entitySingle employer plan
2022-01-01Submission has been amendedNo
2022-01-01This submission is the final filingNo
2022-01-01This return/report is a short plan year return/report (less than 12 months)No
2022-01-01Plan is a collectively bargained planNo
2022-01-01Plan funding arrangement – InsuranceYes
2022-01-01Plan funding arrangement – General assets of the sponsorYes
2022-01-01Plan benefit arrangement – InsuranceYes
2022-01-01Plan benefit arrangement – General assets of the sponsorYes
2021: DENTAL PLAN - SELF FUNDED 2021 form 5500 responses
2021-01-01Type of plan entitySingle employer plan
2021-01-01Submission has been amendedNo
2021-01-01This submission is the final filingNo
2021-01-01This return/report is a short plan year return/report (less than 12 months)No
2021-01-01Plan is a collectively bargained planNo
2021-01-01Plan funding arrangement – InsuranceYes
2021-01-01Plan funding arrangement – General assets of the sponsorYes
2021-01-01Plan benefit arrangement – InsuranceYes
2021-01-01Plan benefit arrangement – General assets of the sponsorYes
2020: DENTAL PLAN - SELF FUNDED 2020 form 5500 responses
2020-01-01Type of plan entitySingle employer plan
2020-01-01Submission has been amendedNo
2020-01-01This submission is the final filingNo
2020-01-01This return/report is a short plan year return/report (less than 12 months)No
2020-01-01Plan is a collectively bargained planNo
2020-01-01Plan funding arrangement – InsuranceYes
2020-01-01Plan funding arrangement – General assets of the sponsorYes
2020-01-01Plan benefit arrangement – InsuranceYes
2020-01-01Plan benefit arrangement – General assets of the sponsorYes
2019: DENTAL PLAN - SELF FUNDED 2019 form 5500 responses
2019-01-01Type of plan entitySingle employer plan
2019-01-01Submission has been amendedNo
2019-01-01This submission is the final filingNo
2019-01-01This return/report is a short plan year return/report (less than 12 months)No
2019-01-01Plan is a collectively bargained planNo
2019-01-01Plan funding arrangement – InsuranceYes
2019-01-01Plan funding arrangement – General assets of the sponsorYes
2019-01-01Plan benefit arrangement – InsuranceYes
2019-01-01Plan benefit arrangement – General assets of the sponsorYes
2018: DENTAL PLAN - SELF FUNDED 2018 form 5500 responses
2018-01-01Type of plan entitySingle employer plan
2018-01-01Submission has been amendedNo
2018-01-01This submission is the final filingNo
2018-01-01This return/report is a short plan year return/report (less than 12 months)No
2018-01-01Plan is a collectively bargained planNo
2018-01-01Plan funding arrangement – General assets of the sponsorYes
2018-01-01Plan benefit arrangement – General assets of the sponsorYes
2017: DENTAL PLAN - SELF FUNDED 2017 form 5500 responses
2017-01-01Type of plan entitySingle employer plan
2017-01-01Submission has been amendedYes
2017-01-01This submission is the final filingNo
2017-01-01This return/report is a short plan year return/report (less than 12 months)No
2017-01-01Plan is a collectively bargained planNo
2017-01-01Plan funding arrangement – General assets of the sponsorYes
2017-01-01Plan benefit arrangement – General assets of the sponsorYes
2016: DENTAL PLAN - SELF FUNDED 2016 form 5500 responses
2016-01-01Type of plan entitySingle employer plan
2016-01-01Submission has been amendedNo
2016-01-01This submission is the final filingNo
2016-01-01This return/report is a short plan year return/report (less than 12 months)No
2016-01-01Plan is a collectively bargained planNo
2016-01-01Plan funding arrangement – General assets of the sponsorYes
2016-01-01Plan benefit arrangement – General assets of the sponsorYes
2015: DENTAL PLAN - SELF FUNDED 2015 form 5500 responses
2015-01-01Type of plan entitySingle employer plan
2015-01-01Submission has been amendedNo
2015-01-01This submission is the final filingNo
2015-01-01This return/report is a short plan year return/report (less than 12 months)No
2015-01-01Plan is a collectively bargained planNo
2015-01-01Plan funding arrangement – General assets of the sponsorYes
2015-01-01Plan benefit arrangement – General assets of the sponsorYes
2014: DENTAL PLAN - SELF FUNDED 2014 form 5500 responses
2014-01-01Type of plan entitySingle employer plan
2014-01-01Submission has been amendedNo
2014-01-01This submission is the final filingNo
2014-01-01This return/report is a short plan year return/report (less than 12 months)No
2014-01-01Plan is a collectively bargained planNo
2014-01-01Plan funding arrangement – General assets of the sponsorYes
2014-01-01Plan benefit arrangement – General assets of the sponsorYes
2013: DENTAL PLAN - SELF FUNDED 2013 form 5500 responses
2013-01-01Type of plan entitySingle employer plan
2013-01-01Submission has been amendedNo
2013-01-01This submission is the final filingNo
2013-01-01This return/report is a short plan year return/report (less than 12 months)No
2013-01-01Plan is a collectively bargained planNo
2013-01-01Plan funding arrangement – General assets of the sponsorYes
2013-01-01Plan benefit arrangement – General assets of the sponsorYes
2012: DENTAL PLAN - SELF FUNDED 2012 form 5500 responses
2012-01-01Type of plan entitySingle employer plan
2012-01-01Submission has been amendedNo
2012-01-01This submission is the final filingNo
2012-01-01This return/report is a short plan year return/report (less than 12 months)No
2012-01-01Plan is a collectively bargained planNo
2012-01-01Plan funding arrangement – General assets of the sponsorYes
2012-01-01Plan benefit arrangement – General assets of the sponsorYes
2011: DENTAL PLAN - SELF FUNDED 2011 form 5500 responses
2011-01-01Type of plan entitySingle employer plan
2011-01-01Submission has been amendedNo
2011-01-01This submission is the final filingNo
2011-01-01This return/report is a short plan year return/report (less than 12 months)No
2011-01-01Plan is a collectively bargained planNo
2011-01-01Plan funding arrangement – General assets of the sponsorYes
2011-01-01Plan benefit arrangement – General assets of the sponsorYes
2010: DENTAL PLAN - SELF FUNDED 2010 form 5500 responses
2010-01-01Type of plan entitySingle employer plan
2010-01-01Submission has been amendedNo
2010-01-01This submission is the final filingNo
2010-01-01This return/report is a short plan year return/report (less than 12 months)No
2010-01-01Plan is a collectively bargained planNo
2010-01-01Plan funding arrangement – General assets of the sponsorYes
2010-01-01Plan benefit arrangement – General assets of the sponsorYes
2009: DENTAL PLAN - SELF FUNDED 2009 form 5500 responses
2009-01-01Type of plan entitySingle employer plan
2009-01-01Submission has been amendedNo
2009-01-01This submission is the final filingNo
2009-01-01This return/report is a short plan year return/report (less than 12 months)No
2009-01-01Plan is a collectively bargained planNo
2009-01-01Plan funding arrangement – General assets of the sponsorYes
2009-01-01Plan benefit arrangement – General assets of the sponsorYes

Insurance Providers Used on plan

EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 )
Policy contract number00500029
Policy instance 1
Insurance contract or identification number00500029
Number of Individuals Covered936
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $12,375
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $403,069
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $12,375
Insurance broker organization code?3

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