IHC Health Plans, Inc. v. Commissioner

F I L E D
United States Court of Appeals
Tenth Circuit
PUBLISH
APR 9 2003
UNITED STATES COURT OF APPEALS
PATRICK FISHER
Clerk
TENTH CIRCUIT

IHC HEALTH PLANS, INC., on its
own behalf and as successor in interest
to IHC Group, Inc., and IHC Care,
Inc.

Petitioners - Appellants,

v. Nos. 01-9013, 01-9014, 01-9015

COMMISSIONER OF INTERNAL
REVENUE,

Respondent - Appellee.

APPEAL FROM THE UNITED STATES TAX COURT
(Nos. 14599-99X, 14600-99X, 14601-99X)

Douglas M. Mancino (Robert C. Louthian, III, Robert E. Kohn, and David L.
Hirsch, with him on the briefs), McDermott, Will & Emery, Los Angeles,
California, appearing for the Appellant.

Teresa E. McLaughlin, Attorney, Tax Division, Department of Justice (Eileen J.
O’Connor, Assistant Attorney General, and Gary R. Allen, Attorney, Tax
Division, Department of Justice, with her on the brief), Washington, DC,
appearing for the Appellee.

Before TACHA, Chief Circuit Judge, HOLLOWAY, and EBEL, Circuit Judges.

TACHA, Chief Circuit Judge.
 I. Background 1

IHC Health Plans, Inc. (“Health Plans”), on its own behalf and as successor

in interest to IHC Care, Inc. (“Care”) and IHC Group, Inc. (“Group”) (collectively

“petitioners”), 2 appeals the Tax Court’s decision denying petitioners’ request for

tax exemption under 26 U.S.C. § 501(c)(3). We have jurisdiction to review the

Tax Court’s decision under 26 U.S.C. § 7482(a)(1). The sole issue presented in

this appeal is whether petitioners qualify for tax-exempt status under 26 U.S.C.

§ 501(c)(3) as organizations operated exclusively for charitable purposes.

A. The IHC Integrated Delivery System

1. The formation of IHC

In 1970, the Church of Jesus Christ of Latter Day Saints (“LDS Church”)

formed Health Services Corporation, later renamed Intermountain Health Care,

Inc. (“IHC”), as a Utah nonprofit corporation. IHC assumed ownership and

control of fifteen hospitals previously owned by the LDS Church. In 1975, the

LDS Church transferred control of IHC to an independent board of trustees,

comprised of persons representative of the community. The Internal Revenue

The Tax Court’s three opinions set out the facts in greater detail. See IHC
1

Health Plans, Inc. v. Commissioner, 82 T.C.M. (CCH) 593 (2001); IHC Group,
Inc. v. Commissioner, 82 T.C.M. (CCH) 606 (2001); IHC Care, Inc. v.
Commissioner, 82 T.C.M. (CCH) 617 (2001).
2
On December 21, 2000, Care and Group both became part of Health
Plans.

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Service (“IRS”) has consistently recognized IHC as a charitable, tax-exempt

organization.

2. The formation of Health Services

As part of its plan to streamline and integrate its provision of health-care

services, IHC formed IHC Health Services, Inc. (“Health Services”) in 1982 as a

Utah nonprofit corporation. In 1983, IHC transferred its hospitals and

substantially all the assets necessary to its operation to Health Services. IHC then

ceased operating hospitals directly and assumed the role of a parent company,

with Health Services as IHC’s principal health-care services organization. IHC is

Health Services’ sole corporate member and the board of trustees of IHC and

Health Services are comprised of the same individuals.

At the end of 1999, Health Services operated twenty-two hospitals located

in Utah and Idaho, employing approximately 300 primary care physicians and 100

specialist physicians in its Physician Division; it separately employed

approximately 120 physicians in its Hospital Division. All Health Services

hospitals participated in the Medicare and Medicaid programs for inpatient and

outpatient hospital services. Between 1997 and 1999, Health Services provided

nearly $1.2 billion in health-care services, without reimbursement, to patients

covered by Medicare, Medicaid, and other governmental programs. During that

same period, Health Services furnished more than $91 million in free health-care

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services to indigent patients.

The Commissioner has recognized Health Services as a tax-exempt

organization under section 501(c)(3).

3. Health Plans, Care, and Group

In order to further integrate its provision of health-care services, IHC

formed Health Plans, Care, and Group to operate as health maintenance

organizations (“HMOs”) within the IHC Integrated Delivery System. A detailed

description of each organization is set forth in Sections I(B)-(D), infra.

4. IHC’s role as parent company

IHC’s board of trustees maintained governance power and control over

Health Plans, Care, and Group. In particular, IHC had the authority, directly and

indirectly, to elect petitioners’ boards of trustees. IHC, Health Services, and

petitioners shared many of the same corporate officers. 3 IHC conducted

petitioners’ strategic planning, established their priorities, and attempted to

implement their business plans on an enterprise basis. Also, Health Services

provided petitioners with centralized management services, including human

resources, legal services, public relations, and treasury functions. 4

3
Health Plans, Care, and Group had identical officers and trustees.
4
Health Plans provided specialized management and administrative
services to Care and Group. Neither Care nor Group had any employees,
facilities, or equipment, and both relied on Health Services and Health Plans for
(continued...)

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 B. Health Plans

In 1983, IHC created Health Plans to operate as a state-licensed HMO and

preferred provider organization (“PPO”). IHC was the sole corporate member of

Health Plans and possessed the power to remove members from Health Plans’

board of trustees. Health Plans offered health plans to small-employer groups,

large-employer groups, and individuals, including Medicaid recipients. 5

In 1999, the population of Utah was approximately 2,130,000. Health

Plans enrolled 416,370 Utahans in its various plans, or approximately twenty

percent of Utah’s total population. In 1999, approximately 73,503 Utahans were

enrolled in a Medicaid managed-care program. Health Plans enrolled 35,902 of

these individuals, or approximately fifty percent of Utah’s total Medicaid

population.

In determining premiums, Health Plans applied an “adjusted community

rating” for individuals and small-employer groups, adjusting its rates for risk

factors such as age and gender. For large-employer groups, Health Plans used a

“past claims experience” method in determining premiums.

In June 1985, the IRS recognized Health Plans as tax exempt under section

4
(...continued)
their operational requirements.
5
Health Plans offered the following eight health plans: SelectMed,
SelectMed Plus, IHC Care, IHC Care Plus, IHC Direct Care, IHC Direct Care
Plus, Health Choice, and IHC Access.

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501(c)(3). The Commissioner subsequently revoked Health Plans’ tax exemption

in 1999.

C. Care

In 1985, IHC formed Care to operate as a “direct contract” HMO, offering

federally-qualified health plans in conjunction with Health Plans. 6 Health Plans

incorporated Care as a subsidiary because the HMO Act of 1973, 42 U.S.C.

§ 300e-9, precluded Health Plans from operating a federally-qualified HMO

within the same corporate entity in which it operated a state-licensed HMO.

Health Plans was Care’s sole corporate member, and Care used the same network

of health-care providers as Health Plans.

Care only offered its IHC Care health plan to employers with more than 100

employees. Care used an adjusted community rating methodology to determine

IHC Care premiums, as required for all federally-qualified HMOs. See 42 C.F.R.

§ 417.104(a)(3), (b). Between 1996 and 1998, Care also offered IHC Senior Care,

a Medicare “risk” health plan it has since discontinued.

On April 28, 1986, Care applied for tax exemption under section 501(c)(3).

The Commissioner denied Care’s request in a final adverse determination letter on

6
The HMO Act of 1973 provided certain marketing advantages to
“qualified” HMOs. In particular, under 42 U.S.C. § 300e-9, certain employers
were required to offer their employees the option of enrolling in a federally-
qualified HMO.

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June 16, 1999.

D. Group

In 1991, IHC formed Group to operate as a federally-qualified “group”

model HMO. IHC separately incorporated Group because, at the time of Group’s

formation, the Health Care Financing Administration 7 prohibited a single

corporation from operating two different types of federally-qualified HMOs.

Health Plans was Group’s sole corporate member.

Group offered its SelectMed health plan exclusively to employers with 100

or more employees. To determine the amount of the premium under the

SelectMed plan, Group relied upon an adjusted community rating methodology.

Enrollees in the SelectMed plan received a variety of health-care services at no

additional charge through Group’s “Core Wellness Program.” Between 1993 and

1998, Group also offered a Medicare “cost” health plan, IHC Senior Care, which

it has since discontinued.

In 1991, Group filed an application for tax exemption under section

501(c)(3). The Commissioner denied Group’s request in a final adverse

determination letter on June 16, 1999.

E. The Commissioner’s Decision

7
The Health Care Financing Administration (“HCFA”), an agency of the
Department of Health and Human Services, administered the HMO Act of 1973.
In 2001, HCFA’s name changed to Centers for Medicare and Medicaid Services.

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 In 1999, the Commissioner concluded that neither Health Plans, Care, nor

Group operated exclusively for exempt purposes under section 501(c)(3). The

Commissioner alternatively concluded that Health Plans and Care were not

entitled to tax-exempt status under section 501(m)(1), which precludes tax-exempt

status where a “substantial part of [an organization’s] activities consists of

providing commercial-type insurance.” 26 U.S.C. § 501(m)(1). Accordingly, the

Commissioner revoked Health Plans’ tax-exempt status, retroactive to January 1,

1987, and denied exemptions to Care and Group.

Health Plans, Care, and Group brought suit in the United States Tax Court,

seeking a declaratory judgment reversing the Commissioner’s adverse

determinations. On September 25, 2001, the Tax Court affirmed the

Commissioner’s conclusions in three separate opinions. IHC Health Plans, Inc. v.

Commissioner, 82 T.C.M. (CCH) 593 (2001); IHC Group, Inc. v. Commissioner,

82 T.C.M. (CCH) 606 (2001); IHC Care, Inc. v. Commissioner, 82 T.C.M. (CCH)

617 (2001). 8 This appeal followed.

II. Discussion

A. Standard of Review

We review Tax Court decisions “in the same manner and to the same extent

8
The Tax Court did not consider the Commissioner’s alternative conclusion
under 26 U.S.C. § 501(m)(1).

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as decisions of the district courts in civil actions tried without a jury.” 26

U.S.C.§ 7482(a)(1). “Thus, we review factual questions for clear error, legal

questions de novo, and mixed questions of law and fact either for clear error or de

novo, depending on whether the question is primarily factual or legal.”

Consolidated Mfg. Inc. v. C.I.R., 249 F.3d 1231, 1236 (10th Cir. 2001) (citation

omitted). The appropriate legal standard for determining whether an organization

operates for a “charitable” purpose is a legal question, which we review de novo.

Whether an organization in fact operates exclusively for a charitable purpose,

however, is a question of fact, which we review for clear error. Florida Hosp.

Trust Fund v. C.I.R. , 71 F.3d 808, 810 (11th Cir. 1996); Living Faith, Inc. v.

C.I.R. , 950 F.2d 365, 371 (7th Cir. 1991). As the taxpayer claiming entitlement to

exemption, petitioners bear the burden of proof. Living Faith , 950 F.2d at 370

(citing cases).

B. Overview of Applicable Law

“Our analysis must start from the proposition that exemptions from income

tax are a matter of legislative grace.” Mutual Aid Ass’n of Church of the Brethren

v. United States , 759 F.2d 792, 794 (10th Cir. 1985) (citation omitted). Thus, we

must narrowly construe exemptions from taxation. Bingler v. Johnson , 394 U.S.

741, 751-52 (1969) (recognizing the “principle that exemptions from taxation are

to be construed narrowly”). In this case, petitioners seek exemption under 26

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U.S.C. § 501(c)(3).

Under section 501(c)(3), an organization must meet three requirements in

order to qualify for tax exemption: “(1) the corporation must be organized and

operated exclusively for exempt purposes; (2) no part of the corporation’s net

earnings may inure to the benefit of any shareholder or individual;[ 9
] and (3) the

corporation must not engage in political campaigns or, to a substantial extent, in

lobbying activities.” 10
Hutchinson Baseball Enters., Inc. v. C.I.R. , 696 F.2d 757,

760 (10th Cir. 1982). In this case, the sole question we must consider is whether

Health Plans, Care, and Group operated exclusively for exempt purposes within

the meaning of section 501(c)(3).

This element can be viewed as a corollary to the public-benefit
9

requirement under section 501(c)(3)’s definition of “charitable,” discussed infra.

Specifically, section 501(c)(3), in conjunction with section 501(a),
10

provides that the following organizations are exempt from taxation:

Corporations, and any community chest, fund, or foundation,
organized and operated exclusively for religious, charitable,
scientific, testing for public safety, literary, or educational purposes,
or to foster national or international amateur sports competition (but
only if no part of its activities involve the provision of athletic
facilities or equipment), or for the prevention of cruelty to children
or animals, no part of the net earnings of which inures to the benefit
of any private shareholder or individual, no substantial part of the
activities of which is carrying on propaganda, or otherwise
attempting, to influence legislation (except as otherwise provided in
subsection (h)), and which does not participate in, or intervene in
(including the publishing or distributing of statements), any political
campaign on behalf of (or in opposition to) any candidate for public
office.

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 C. Whether Health Plans, Care, and Group Operated for a Charitable

Purpose.

This inquiry requires us to address two basic questions. First, we must

consider whether the purpose proffered by petitioners qualifies as a “charitable”

purpose under section 501(c)(3). “The term ‘charitable’ is used in section

501(c)(3) in its generally accepted legal sense and is . . . not to be construed as

limited by the separate enumeration in section 501(c)(3).” 26 C.F.R.

§1.501(c)(3)-1(d)(2). An organization will not be considered charitable, however,

“unless it serves a public rather than a private interest .” 26 C.F.R. §1.501(c)(3)-

1(d)(1)(ii) (emphasis added). 11

Second, we must determine whether petitioners in fact operated primarily

for this purpose. Geisinger Health Plan v. C.I.R., 985 F.2d 1210, 1219 (3d Cir.

1993) (Geisinger I). Under the “operational test” set forth in the IRS regulations,

“[a] n organization will be regarded as ‘operated exclusively’ for one or more

exempt purposes only if it engages primarily in activities which accomplish one

or more of such exempt purposes specified in section 501(c)(3). An organization

will not be so regarded if more than an insubstantial part of its activities is not in

Although we are not bound by IRS regulations or revenue rulings, we do
11

accord them deference. See Bob Jones Univ. v. United States, 461 U.S. 574, 596
(1983) (“[T]his Court has long recognized the primary authority of the IRS and its
predecessors in construing the Internal Revenue Code.”).

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furtherance of an exempt purpose.” 12 26 C.F.R. §1.501(c)(3)-1(c)(1).

In this case, the Tax Court concluded that “the promotion of health for the

benefit of the community is a charitable purpose,” Health Plans , 82 T.C.M. at

602, but found that neither Health Plans, Care, nor Group operated primarily to

benefit the community. Health Plans , 82 T.C.M. at 605; Care , 82 T.C.M. at 625;

Group , 82 T.C.M. at 615. For the reasons set forth below, we agree.

1. The promotion of health as a charitable purpose

In defining “charitable,” our analysis must focus on whether petitioners’

activities conferred a public benefit. 26 C.F.R. §1.501(c)(3)-1(d)(1)(ii) (“An

organization is not organized or operated exclusively for [an exempt purpose] . . .

unless it serves a public rather than a private interest.”). The public-benefit

requirement highlights the quid pro quo nature of tax exemptions: the public is

willing to relieve an organization from the burden of taxation in exchange for the

public benefit it provides. Geisinger I , 985 F.2d at 1215; cf. Flat Top Lake Ass’n

v. United States , 868 F.2d 108, 112 (4th Cir. 1989) (“In many ways, exemption

from taxation may be seen as a democratic commonwealth’s method of

acknowledging the conferral of a universal benefit.”). As the Supreme Court has

12
The Supreme Court construed a similar provision under the Social
Security Act in Better Business Bureau v. United States, concluding that “a single
non-[exempt] purpose, if substantial in nature, will destroy the exemption
regardless of the number or importance of truly [exempt] purposes.” 326 U.S.
279, 283 (1945).

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recognized, “[c]haritable exemptions are justified on the basis that the exempt

entity confers a public benefit – a benefit which the society or the community may

not itself choose or be able to provide, or which supplements and advances the

work of public institutions already supported by tax revenues.” Bob Jones Univ.

v. United States , 461 U.S. 574, 591 (1983) (emphasis added).

a. Evolution of the “community benefit” standard

The IRS has long recognized that nonprofit hospitals may be exempt as

“charitable” entities under section 501(c)(3). See generally John D. Colombo,

Health Care Reform and Federal Tax Exemption: Rethinking the Issues , 29 W AKE

F OREST L. R EV . 215, 218 (1994). “Exemption for hospitals, in fact, is so

ingrained in the lore of taxation that today about half the states specifically

enumerate hospitals as exempt entities, alongside such traditional exemption

bulwarks as churches and educational institutions.” Id. at 215. Early on, the

touchstone for exemption was the provision of free or below-cost care. Id. at 217.

In 1956, the IRS published Rev. Rul. 56-185, which provided that a hospital

“must be operated to the extent of its financial ability for those not able to pay for

the services rendered and not exclusively for those who are able and expected to

pay.”

By the last part of the twentieth century, however, with the advent of

Medicare and Medicaid and the increased prevalence of private insurance,

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nonprofit hospitals moved away from this “relief of poverty” function. Colombo ,

supra , at 218. “The financing of their services evolved in parallel, from primary

dependence on the generosity of religious orders and charitable donors, to almost

exclusive reliance on payments for services rendered.” M. Gregg Bloche, Health

Policy Below the Waterline: Medical Care and the Charitable Exemption , 80

M INN . L. R EV . 299, 300 (1995).

In 1969, in response to the nonprofit hospital’s changing function, the IRS

modified its position regarding charity care. In Rev. Rul. 69-545, which modified

56-185, the IRS removed “the requirement[] relating to caring for patients without

charge or at rates below cost.” In its discussion, the IRS stated:

The promotion of health, like the relief of poverty and the
advancement of education and religion, is one of the purposes in the
general law of charity that is deemed beneficial to the community as
a whole even though the class of beneficiaries eligible to receive a
direct benefit from its activities does not include all members of the
community, such as indigent members of the community, provided
that the class is not so small that its relief is not of benefit to the
community.

Rev. Rul. 69-545. The hospital in question provided hospital care for all persons

in the community able to pay either directly or through third-party insurers. The

IRS also noted, however, that the hospital operated an emergency room open to

all persons regardless of ability to pay. 13
In addition, the hospital used surplus

13
In a subsequent ruling, the IRS characterized the hospital’s open
(continued...)

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funds to improve patient care and finance medical training, education, and

research. Based on these factors, 14
the IRS concluded that the hospital was

“promoting the health of a class of persons . . . broad enough to benefit the

community.” Id.

(...continued)
13

emergency room as a “major factor” in its determination. Rev. Rul. 83-157.
14
The specific facts of the nonprofit hospital in Revenue Ruling 69-545 are
as follows:

Hospital A is a 250-bed community hospital. Its board of
trustees is composed of prominent citizens in the community.
Medical staff privileges in the hospital are available to all qualified
physicians in the area, consistent with the size and nature of its
facilities. The hospital has 150 doctors on its active staff and 200
doctors on its courtesy staff. It also owns a medical office building
on its premises with space for 60 doctors. Any member of its active
medical staff has the privilege of leasing available office space.
Rents are set at rates comparable to those of other commercial
buildings in the area.

The hospital operates a full time emergency room and no one
requiring emergency care is denied treatment. The hospital otherwise
ordinarily limits admissions to those who can pay the cost of their
hospitalization, either themselves, or through private health
insurance, or with the aid of public programs such as Medicare.
Patients who cannot meet the financial requirements for admission
are ordinarily referred to another hospital in the community that does
serve indigent patients.

The hospital usually ends each year with an excess of
operating receipts over operating disbursements from its hospital
operations. Excess funds are generally applied to expansion and
replacement of existing facilities and equipment, amortization of
indebtedness, improvement in patient care, and medical training,
education, and research.

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 Finally, in Revenue Ruling 83-157, the IRS amplified its prior ruling in 69-

545. The hospital in 83-157 was identical to the hospital in 69-545, 15
except that

it did not operate an emergency room open to all regardless of ability to pay. In

eschewing any rigid test under section 501(c)(3), the IRS made clear that although

“[g]enerally, operation of a full time emergency room providing emergency

medical services to all members of the public regardless of their ability to pay for

such services is strong evidence that a hospital is operating to benefit the

community . . . other significant factors . . . may be considered.” Rev. Rul. 83-

157. The IRS went on to conclude that the hospital did in fact operate for the

benefit of the community, noting that the hospital treated patients participating in

Medicare and Medicaid and applied any surplus funds to improve facilities,

equipment, and patient care, and advance its medical training, education, and

research.

Thus, under the IRS’s interpretation of section 501(c)(3), in the context of

health-care providers, we must determine whether the taxpayer operates primarily

for the benefit of the community . 16 And while the concept of “community benefit”

15
See note 14, supra, for the facts of Rev. Rul. 69-545.
16
In interpreting these three rulings, court decisions have highlighted
several factors relevant under the “community benefit” analysis. These factors
include:

(1) size of the class eligible to benefit;
(continued...)

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is somewhat amorphous, we agree with the IRS, the Tax Court, and the Third

Circuit that it provides a workable standard for determining tax exemption under

section 501(c)(3).

b. Defining “community benefit”

In giving form to the community-benefit standard, we stress that “not every

activity that promotes health supports tax exemption under § 501(c)(3). For

example, selling prescription pharmaceuticals certainly promotes health, but

pharmacies cannot qualify for . . . exemption under § 501(c)(3) on that basis

alone.” Rev. Rul. 98-15. In other words, engaging in an activity that promotes

health, standing alone , offers an insufficient indicium of an organization’s

purpose. Numerous for-profit enterprises offer products or services that promote

health.

Similarly, the IRS rulings in 69-545 and 83-157 demonstrate that an

organization cannot satisfy the community-benefit requirement based solely on

16
(...continued)
(2) free or below-cost products or services;
(3) treatment of persons participating in governmental
programs such as Medicare or Medicaid;
(4) use of surplus funds for research or educational programs;
and
(5) composition of the board of trustees.

See, e.g., Geisinger I, 985 F.2d at 1218; see generally Sound Health Ass’n v.
C.I.R., 71 T.C. 158 (1978); Douglas M. Mancino, Income Tax Exemption of the
Contemporary Nonprofit Hospital, 32 S T . L OUIS U. L.J. 1015, 1037-70 (1988).

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the fact that it offers health-care services to all in the community 17
in exchange

for a fee. 18
Although providing health-care products or services to all in the

community is necessary under those rulings, it is insufficient, standing alone, to

qualify for tax exemption under section 501(c)(3). Rather, the organization must

provide some additional “plus.”

This plus is perhaps best characterized as “a benefit which the society or

the community may not itself choose or be able to provide, or which supplements

and advances the work of public institutions already supported by tax revenues.”

Bob Jones Univ. , 461 U.S. at 591. Concerning the former, the IRS rulings

provide a number of examples: providing free or below-cost services, see Rev.

Rul. 56-185; maintaining an emergency room open to all, regardless of ability to

pay, see Rev. Rul. 69-545; and devoting surpluses to research, education, and

17
We recognize that certain health-care entities provide specialized
services, which are not required by “all” in the community, and we do not mean to
foreclose the possibility that such entities may qualify as “charitable” under
section 501(c)(3). As the IRS recognized in Rev. Rul. 83-157:

Certain specialized hospitals, such as eye hospitals and cancer
hospitals, offer medical care limited to special conditions unlikely to
necessitate emergency care and do not, as a practical matter, maintain
emergency rooms. These organizations may also qualify under
section 501(c)(3) if there are present similar, significant factors that
demonstrate that the hospitals operate exclusively to benefit the
community.

At least where the fee is above cost. We express no opinion on whether
18

an enterprise that sold health-promoting products or services entirely at or below
cost would qualify for tax exemption under 501(c)(3).

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medical training, see Rev. Rul. 83-157. These services fall under the general

umbrella of “positive externalities” or “public goods.” Bloche, supra , at 312. 19

Concerning the latter, the primary way in which health-care providers advance

government-funded endeavors is the servicing of the Medicaid and Medicare

populations.

c. Quantifying “community benefit”

Difficulties will inevitably arise in quantifying the required community

benefit. The governing statutory language, however, provides some guidance.

Under section 501(c)(3), an organization is not entitled to tax exemption unless it

operates for a charitable purpose . Thus, the existence of some incidental

community benefit is insufficient. Rather, the magnitude of the community

benefit conferred must be sufficient to give rise to a strong inference that the

organization operates primarily for the purpose of benefitting the community .

Geisinger I , 985 F.2d at 1219.

19
Under the Treasury Department’s view, for-profit enterprises are unlikely
to provide such services since “‘market prices . . . do not reflect the benefit [these
services] confer on the community as a whole.’” Bloche, supra, at 312 (quoting
Tax-Exempt Status of Hospitals, and Establishment of Charity Care Standards:
Hearing before the House Comm. on Ways and Means, 102d Cong., 1st Sess. 34-
37 (1991) (statement of Michael J. Graetz, Deputy Assistant Secretary for Tax
Policy, U.S. Dep’t of the Treasury)). Thus, the provision of such “public goods”
– at least when conducted on a sufficiently large scale – arguably supports an
inference that the enterprise is responding to some inducement that is not market-
based. Cf. id.

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 Thus, our inquiry turns “not [on] the nature of the activity, but [on] the

purpose accomplished thereby.” 20
Bethel Conservative Mennonite Church v.

C.I.R. , 746 F.2d 388, 391 (7th Cir. 1984) (emphasis added). Of course, because

of the inherent difficulty in determining a corporate entity’s subjective purpose,

we necessarily rely on objective indicia in conducting our analysis. Geisinger I ,

985 F.2d at 1215 (citation omitted). In determining an organization’s purpose, we

primarily consider the manner in which the entity carries on its activities. Living

Faith , 950 F.2d at 372 (citing cases).

d. The resulting test

In summary, under section 501(c)(3), a health-care provider must make its

services available to all in the community plus provide additional community or

public benefits. The benefit must either further the function of government-

funded institutions or provide a service that would not likely be provided within

the community but for the subsidy. Further, the additional public benefit

conferred must be sufficient to give rise to a strong inference that the public

benefit is the primary purpose for which the organization operates. In conducting

this inquiry, we consider the totality of the circumstances. Geisinger I , 985 F.2d

20
As the Third Circuit has noted, “‘[w]hen the legality of an action depends
not upon its surface manifestation but upon the undisclosed motivation of the
actor, similar acts can lead to diametrically opposite legal consequences.’”
Geisinger I , 985 F.2d at 1215 (quotation omitted).

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at 1219. With these principles in mind, we proceed to review the Tax Court’s

decision in the present case.

2. The Tax Court correctly defined “charitable” and applied the

appropriate legal test under 501(c)(3).

Petitioners first contend that the Tax Court erred in its conclusion

regarding the applicable law. Based upon our discussion supra , we disagree. The

Tax Court correctly recognized the “promotion of health for the benefit of the

community” as a charitable purpose. Health Plans , 82 T.C.M. at 602 (“[I]t is now

well settled that the promotion of health for the benefit of the community is a

charitable purpose.”). Further, the Tax Court considered the community-benefit

requirement based on the totality of the circumstances. 21
Id. at 604 (“The

community benefit test requires consideration of a variety of factors that indicate

whether an organization is involved in the charitable activity of promoting health

on a communitywide basis . . . . Considering all the facts and circumstances . . .

we conclude that petitioner did not provide a meaningful community benefit.”).

Thus, the Tax Court did not err in determining the applicable law.

3. The Tax Court correctly concluded that petitioners do not

21
Because the community-benefit requirement is considered under a
totality-of-the-circumstances test, we reject petitioners’ challenge to the Tax
Court’s reliance on any one of the numerous factors cited in support of its
conclusion.

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 operate primarily to promote health for the benefit of the

community.

Petitioners next argue that the Tax Court erred in concluding that

petitioners did not operate primarily for the benefit of the community. We

disagree.

a. Nature of the product or service and the character of the

transaction

In this case, we deal with organizations that do not provide health-care

services directly. Rather, petitioners furnish group insurance entitling enrollees

to services of participating hospitals and physicians. Petitioners determine

premiums using two methods: (1) an adjusted community rating for individuals

and small employers; and (2) past-claims experience for large employers. Thus,

as in Church of the Brethren , petitioners “sell[] insurance coverage . . .

extend[ing] benefits in return for a premium based generally on the risk

assumed.” 759 F.2d at 795. In other words, petitioners primarily perform a “risk-

bearing function.” Cf. Bloche, supra , at 399. In Church of the Brethren , as in the

instant case, the commercial nature of this activity inspired doubt as to the

entity’s charitable purpose. 759 F.2d at 795; cf. Federation Pharmacy Servs., Inc.

v. C.I.R. , 72 T.C. 687, 691-92 (1979), aff’d 625 F.2d 804 (8th Cir. 1980) (noting

that selling pharmaceuticals is “an activity that is normally carried on by a

-22-
commercial profitmaking enterprise[]”). Where, as here, “[i]t is difficult to

distinguish the plaintiff corporation from a mutual insurance company,” Hassett v.

Assoc. Hosp. Serv. Corp. of Mass. , 125 F.2d 611, 614 (1st Cir. 1942), we must

carefully scrutinize the organization’s operation. 22
Cf. Church of the Brethren ,

759 F.2d at 795; Am. Ass’n of Christian Schools Voluntary Employees Beneficiary

Ass’n Welfare Plan Trust by Janney v. United States , 850 F.2d 1510, 1516 (11th

Cir. 1988) (“Since the Trust has a substantial private purpose to provide insurance

in return for premiums, it is not an organization exclusively engaged in the

promotion of the social welfare.”). 23

b. Free or below-cost products or services

The fact that an activity is normally undertaken by commercial for-profit

entities does not necessarily preclude tax exemption, particularly where the entity

offers its services at or below-cost. Cf. Bloche, supra , at 311 n.31. But

We recognize that an activity that is not “inherently charitable” may
22

nonetheless further a charitable purpose. Rev. Rul. 69-572. Thus, we do not
accord dispositive weight to this (or any other) factor.
23
We are primarily concerned with this characteristic as it bears on our
determination of petitioners’ purpose. However, we also note that petitioners not
only resemble commercial insurance providers, petitioners in fact compete with
commercial insurance providers. Thus, “granting a tax exemption to [petitioners]
would necessarily disadvantage other for-profit [entities] with which [petitioners]
compete[].” Federation Pharmacy Servs., Inc. v. C.I.R., 625 F.2d 804, 808 (8th
Cir. 1980) (citing Abbott Labs. v. Portland Retail Druggists Ass’n, Inc., 425 U.S.
1, 17-18 (1976)).

-23-
petitioners provide virtually no free or below-cost health-care services. 24
All

enrollees must pay a premium in order to receive benefits. 25
As the Eighth Circuit

has recognized, “[a]n organization which does not extend some of its benefits to

individuals financially unable to make the required payments [generally] reflects a

commercial activity rather than a charitable one.” Federation Pharmacy Servs.,

Inc. v. C.I.R. , 625 F.2d 804, 807 (8th Cir. 1980). Further, the fact that petitioners

in no way subsidize dues for those who cannot afford subscribership distinguishes

this case from the HMOs in Sound Health Ass’n v. C.I.R. , 71 T.C. 158 (1979), and

Geisinger I , 985 F.2d at 1219.

We acknowledge, as did the Tax Court, that petitioners’ “adjusted

community rating system[] likely allowed its enrollees to obtain medical care at a

lower cost than might otherwise have been available.” Care , 82 T.C.M. at 625;

Group , 82 T.C.M. at 615. Again, however, selling services at a discount tells us

little about the petitioners’ purpose . “Many profitmaking organizations sell at a

discount.” Federation Pharmacy , 72 T.C. at 692, aff’d 625 F.2d 804 (8th Cir.

1980). In considering price as it relates to an organization’s purpose, there is a

Health Plans did apparently conduct some free health screenings in 1999.
24

Health Plans, 82 T.C.M. at 605.
25
Petitioners note that Care and Group offered “risk” and “cost” Medicare
health plans, and contend that Care and Group went forward with these plans
“with the full knowledge that those plans might lose money.” Care and Group
discontinued these plans, however, based on concerns of “financial feasibility.”

-24-
qualitative difference between selling at a discount and selling below cost. 26

In sum, petitioners sole activity is arranging for health-care services in

exchange for a fee. To elevate the attendant health benefit over the character of

the transaction would pervert Congress’ intent in providing for charitable tax

exemptions under section 501(c)(3). Contrary to petitioners’ insinuation, the Tax

Court did not accord dispositive weight to the absence of free care. Neither do

we. Rather, it is yet another factor that belies petitioners’ professions of a

charitable purpose. 27

c. Research and educational programs

Nothing in the record indicates that petitioners conducted research or

offered free educational programs to the public. 28
This bolsters our conclusion

that petitioners did not operate for the purpose of promoting health for the benefit

of the community.

26
Further, as the Tax Court noted, “the benefit associated with these cost
savings is more appropriately characterized as a benefit to petitioner[s]’ enrollees
as opposed to the community at large.” Care, 82 T.C.M. at 625; Group, 82
T.C.M. at 615.

As the Eighth Circuit has noted, “a ‘charitable’ hospital may impose
27

charges or fees for services rendered, and indeed its charity record may be
comparatively low depending upon all the facts . . . but a serious question is
raised where its charitable operation is virtually inconsequential.” Federation
Pharmacy, 625 F.2d at 807 (8th Cir. 1980) (quoting Sonora Cmty. Hosp. v. C.I.R.,
46 T.C. 519, 526 (1966)) (internal quotation marks omitted).

As the Tax Court noted, petitioners’ Core Wellness Program was offered
28

exclusively to enrollees.

-25-
 d. The class eligible to benefit

(1) Health Plans

As the Tax Court noted, “[Health Plans] offered its [coverage] to a broad

cross-section of the community including individuals, the employees of both large

and small employers, and individuals eligible for Medicaid benefits.” Health

Plans , 82 T.C.M. at 604. In fact, in 1999, Health Plans’ enrollees represented

twenty percent of Utah’s total population and fifty percent of Utah residents

eligible for Medicaid benefits. 29

Nevertheless, even though almost all Utahans were potentially eligible to

enroll for Health Plans coverage, the self-imposed requirement of membership

tells us something about Health Plans’ operation. As the Third Circuit noted in

Geisinger I :

The community benefitted is, in fact, limited to those who belong to
[the HMO] since the requirement of subscribership remains a
condition precedent to any service. Absent any additional indicia of
a charitable purpose, this self-imposed precondition suggests that
[the HMO] is primarily benefitting itself (and, perhaps, secondarily
benefitting the community) by promoting subscribership throughout
the areas it serves.

985 F.2d at 1219. Further, w hile the absence of a large class of potential

We acknowledge that Health Plans’ service to Utah’s Medicaid
29

community provides some community benefit. The relevant inquiry, however, is
not “whether [petitioner] benefitted the community at all . . . [but] whether it
primarily benefitted the community, as an entity must in order to qualify for tax-
exempt status.” Geisinger I, 985 F.2d at 1219.

-26-
beneficiaries may preclude tax-exempt status, its presence standing alone provides

little insight into the organization’s purpose. Offering products and services to a

broad segment of the population is as consistent with self promotion and profit

maximization as it is with any “charitable” purpose.

(2) Care and Group

Neither Care nor Group offered their health plans to the general public.

Rather, both Care and Group limited their enrollment to employees of large

employers (employers with 100 or more employees). Thus, as the Tax Court

found, “[Care and Group] operate[d] in a manner that substantially limit[ed] [the]

universe of potential enrollees.” Care , 82 T.C.M. at 625; Group , 82 T.C.M. at

615. Based on this finding, the Tax Court correctly concluded that neither Care

nor Group promoted health for the benefit of the community.

e. Community board of trustees

Finally, we consider petitioners’ board composition. Prior to 1996, Health

Plans’ bylaws provided that “[a] plurality of Board members shall represent the

buyer-employer community and an approximately equal number of physicians and

hospitals representatives shall be appointed.” As the IRS noted, Health Plans’

pre-1996 bylaws skewed control towards subscribers, rather than the community

at large. In 1996, however, Health Plans amended its bylaws to require that a

majority of board members be disinterested and broadly representative of the

-27-
community.

It makes little difference whether we consider petitioners’ board prior to

1996 or following the amendments. Even if we were to conclude petitioners’

board broadly represents the community, the dearth of any actual community

benefit in this case rebuts any inference we might otherwise draw.

4. Conclusion

For the above reasons, we agree with the Tax Court’s conclusion that

petitioners, standing alone, do not qualify for tax exemption under section

501(c)(3).

D. Whether Petitioners Qualify for Tax-Exempt Status as an “Integral

Part” of Health Services.

Petitioners contend that even if they do not qualify for tax exemption

standing alone, they qualify based on the fact that their activities are an “integral

part” of Health Services, essential to Health Services in accomplishing its tax-

exempt purpose. We disagree.

In general, “separately incorporated entities must qualify for tax exemption

on their own merits.” Geisinger Health Plan v. C.I.R. , 30 F.3d 494, 498 (3d Cir.

1994) ( Geisinger II ) (citing Church of the Brethren , 759 F.2d at 795 n.3). Several

circuits, however, have recognized a so-called “exception” to this general rule,

commonly called the integral-part doctrine. See, e.g., id. (“[The] ‘integral part

-28-
doctrine’ . . . may best be described as an exception to the general rule that

entitlement to exemption is derived solely from an entity’s own characteristics.”);

Tex. Learning Tech. Group v. C.I.R. , 958 F.2d 122, 126 (5th Cir. 1992); Squire v.

Students Book Corp. , 191 F.2d 1018, 1020 (9th Cir. 1951). Under the integral-

part doctrine, where an organization’s sole activity is an “integral part” of an

exempt affiliate’s activities, the organization may derive its exemption from that

of its affiliate. Geisinger II , 30 F.3d at 498; see also Geisinger I , 985 F.2d at

1220 (“The integral part doctrine provides a means by which organizations may

qualify for exemption vicariously through related organizations, as long as they

are engaged in activities which would be exempt if the related organizations

engaged in them, and as long as those activities are furthering the exempt

purposes of the related organizations.”).

To the extent the integral-part doctrine rests on a derivative theory of

exemption, it runs contrary to two fundamental tenets of tax law: (1) the

“doctrine of corporate entity,” under which a corporation is a separate and distinct

taxable entity; 30 and (2) the canon of statutory interpretation requiring strict

construction of exemptions from taxation. 31 Bingler , 394 U.S. at 751-52. IHC

See, e.g., Moline Prop. v. C.I.R., 319 U.S. 436, 438 (1943); Church of the
30

Brethren, 759 F.2d at 795 n.3.

As the Third Circuit noted in Geisinger II, the “integral-part doctrine” is
31

not codified. 30 F.3d at 499. Although it finds support in 26 C.F.R. § 1.502-1(b),
(continued...)

-29-
separately incorporated Health Services, Health Plans, Care, and Group. “It

cannot now escape the tax consequences of that choice, no matter how bona fide

its motives or longstanding its arrangements.” Nat’l Carbide Corp. v. C.I.R. , 336

U.S. 422, 439 (1949). Further, we reject petitioners’ contention that the integral-

part doctrine constitutes a “less rigorous” road to tax exemption. The rigor of the

charitable-purpose requirement remains constant, regardless of the theory upon

which the taxpayer bases its entitlement to tax exemption under section 501(c)(3).

Nevertheless, to the extent the integral-part doctrine recognizes that we

should consider the totality of the circumstances in determining an organization’s

purpose, the doctrine is in accord with our section 501(c)(3) jurisprudence. One

of the myriad factors we may consider in determining an organization’s purpose is

whether an essential nexus exists between an organization seeking tax exemption

and a tax-exempt affiliate. The example cited in the Treasury Regulations aptly

illustrates the point: “a subsidiary organization which is operated for the sole

purpose of furnishing electric power used by its parent organization, a tax-exempt

educational organization, in carrying on its educational activities.” 32
26 C.F.R.

(...continued)
31

it must ultimately be justified under section 501(c)(3) and its charitable-purpose
requirement.

We need not decide whether such an organization operates for an exempt
32

purpose per se. We merely note that these facts would suggest that the subsidiary
operates for an exempt purpose.

-30-
§ 1.502-1(b). In other words, as we interpret the integral-part doctrine, it simply

recognizes that “[t]he performance of a particular activity that is not inherently

charitable may nonetheless further a charitable purpose.” Rev. Rul. 69-572. “The

overall result in any given case is dependent on why and how that activity is

actually being conducted.” Id. (emphasis added).

Using the example cited in Treasury Regulation 1.502-1(b), if we were to

consider the nature of the subsidiary’s activity in isolation – furnishing electricity

– we would have no indication that the subsidiary serves an exempt purpose. On

the other hand, when we look at the totality of the circumstances, it becomes clear

that the subsidiary’s activity furthers the exempt purpose of education: the

product provided is essential; the subsidiary furnishes its product solely to the

tax-exempt affiliate; 33
and the tax-exempt parent exercises control over the

33
The IRS contrasted the following hypothetical:

[T]he subsidiary organization is not exempt from tax if it is operated
for the primary purpose of carrying on a trade or business which
would be an unrelated trade or business (that is, unrelated to exempt
activities) if regularly carried on by the parent organization. For
example, if a subsidiary organization is operated primarily for the
purpose of furnishing electric power to consumers other than its
parent organization (and the parent’s tax-exempt subsidiary
organizations), it is not exempt since such business would be an
unrelated trade or business if regularly carried on by the parent
organization.

26 C.F.R. § 1.502-1(b).

-31-
subsidiary. These facts, considered in conjunction with the exempt purpose for

which the tax-exempt parent operates, support a strong inference that the

subsidiary operates for the same exempt purpose as does the parent.

In this case, we need not decide whether petitioners provide a service

necessary to Health Services in conducting its exempt activities. The required

nexus between the activities of petitioners and Health Services is lacking. As the

Tax Court noted, “petitioner[s]’ enrollees received approximately 20 percent of

their physician services from physicians employed by or contracting with Health

Services, while petitioner contracted for the remaining 80 percent of such

physician services directly with independent physicians.” Health Plans , 82

T.C.M. at 606. Thus, unlike the subsidiary furnishing electricity in Treasury

Regulation § 1.502-1(b), petitioners do not function solely to further Health

Services’ performance of its exempt activities. Rather, a substantial portion

(eighty percent) 34
of petitioners’ enrollees received physician services from

The following table, taken from petitioners’ brief, presents a percentage
34

breakdown of petitioners’ total billings for physician services:

Year Employed Not employed/ Not employed/
Panel Non-panel
1997 23.4 % 64.3 % 12.3 %
1998 22.1 % 65.8 % 12.1 %
1999 20.5 % 69.2 % 10.3 %
(continued...)

-32-
“physicians with no direct link to [Health Services].” 35
Health Plans , 82 T.C.M.

at 606. Thus, our consideration of petitioners’ “connectedness” to Health

Services in no way detracts from our earlier conclusion that petitioners do not

qualify for a charitable tax exemption under section 501(c)(3).

III. Conclusion

Based on the foregoing, we AFFIRM the Tax Court’s decision denying

petitioners tax-exempt status under 26 U.S.C. § 501(c)(3).

34
(...continued)

“Employed” includes those physicians employed by Health Services’ Physician
Division. “Not employed/Panel” includes independent contractors who had
medical staff privileges at a Health Services hospital. “Not employed/Non-panel”
includes all other physicians.
35
We recognize that when we consider petitioners standing alone, drawing
a distinction between a “staff-model HMO” (as in Sound Health) and a “contract
HMO” (as in Geisinger and here) may not make sense. Colombo, supra, at 245.
“[T]he ‘community benefits’ attributable to a particular [HMO] are the same
whether treatment is performed by employee physicians or independent
contractors pursuant to a service agreement.” Id. at 245-46. Under the integral-
part doctrine, however, the distinction is highly relevant, since we seek to
determine whether an essential nexus exists between petitioners’ operations and
those of Health Services, the tax-exempt affiliate.

-33-