2024 Guide to

Employee Benefits
 Table of Contents
Welcome .................................................................. 3

Eligibility.................................................................... 4

Medical Plans ........................................................... 5

Medical Plan Resources & Tools ............................... 8

MyQHealth Care Coordination ................................ 10

Mobile Health ......................................................... 11

Supplemental Medical ............................................ 12

Health Savings Account (HSA) ................................ 14

Health Reimbursement Account (HRA) ................... 15

Dental Plans ........................................................... 16

Vision Plan .............................................................. 17

Life and Accidental Death & Dismemberment

(AD&D) Insurance ................................................... 18

Disability Insurance ................................................. 19

Important Contacts................................................. 20

2
Welcome
Reformed Benefits Association is a non-profit organization providing insurance benefits to churches, denominational staff and
similar ministries. RBA is committed to delivering the highest level of benefits care with attentiveness, warmth and integrity.
We understand your ministry, and we’re qualified and prepared to work through the uniqueness that can be presented when
working with churches and non-profits. We’ll walk with you step-by-step to ensure you have comprehensive coverage for a
price that meets your budget. This brochure was designed to answer some of the basic questions you may have about your
benefits. Please take the time to review this brochure to make sure you understand the benefits that are available to you and
your family—then be sure to take action.

This document is distributed at open enrollment each year to serve as the summary of material modifications for the
Reformed Benefits Association’s health and welfare plan. Please see the benefit descriptions and charts for detailed
information on the benefit plans. When referencing the guide and the Summary Plan Description (SPD), the SPD
should be considered the governing document.

3
Eligibility
If you work at least 30 hours per week, you are eligible for
To Enroll or Make Changes for 2024:
benefits. Most of your benefits are effective on the first day of
• Go online to https://reformedbenefits.bswift.com
the month following your date of hire. You may also enroll your
eligible dependents for coverage. This includes the following: • Call toll-free 844-643-1131

• Your legal spouse

• Children under the age of 26, regardless of student, dependency or marital status
• Children who are past the age of 26 and are fully dependent on you for support due to a mental or physical disability,
and who are indicated as such on your federal tax return

Part-time employees (at least 20 hours per week) are eligible for benefits at employer’s discretion.

Qualified Life Events

Generally, you may only change your benefit elections during the Open Enrollment period. However, since life happens, you
also may change your benefit elections during the year if you experience a Qualified Life Event.

Qualified Life Event Documentation Needed

» Marriage » Copy of marriage certificate
Change in
» Divorce/Legal Separation » Copy of divorce decree
marital status
» Death » Copy of death certificate
» Copy of birth certificate or copy of legal adoption papers
» Birth or adoption
Change in number » Copy of birth certificate plus a copy of the marriage certificate
» Step-child
of dependents between employee and spouse
» Death
» Copy of death certificate
» Change in your eligibility status » Notification of increase or reduction of hours that changes
(i.e., full-time to part-time) coverage status
Change in employment
» Change in spouse’s benefits or » Notification of spouse’s employment status that results in a
employment status loss or gain of coverage

Changing Benefits After Enrollment

During the year, you cannot make changes to your medical, dental, or vision unless you have a Qualified Life Event. If you
do not contact RBA within 30 days of the Qualified Life Event, you will have to wait until the next annual Open Enrollment
period to make changes (unless you experience another Qualified Life Event).

4
Medical Plans
Medical insurance is essential to your well-being and our medical coverage provides you and your family the protection you
need for everyday health issues or when the unexpected happens. You have three plan options available to you through UMR
and Surest. Note that the UMR plans do have out-of-network benefits but, the Surest plan does not have out-of-network
benefits. It is always more cost effective for you to see in-network providers.

How a Health Plan Works

Preventive Care – like physical exams, flu shots and screenings – is always covered 100% when you use in-network
providers. The key difference between the plans is the amount of money you’ll pay each pay period and when you need care.
The plans have different:

• Annual deductible amount – The amount you pay each year for eligible in-network and out-of-network charges before
the plan begins to pay.
• Out-of-pocket maximums – The most you will pay each year for eligible network services including prescriptions.
After you reach your out-of-pocket maximum, the plan picks up the full cost of covered medical care for the remainder
of the year.
• Copays – A copay is a fixed amount you pay for a health care service. Copays do not count toward your deductible
but do count toward your annual out-of-pocket maximum.
• Coinsurance – Once you’ve met your deductible, you and the plan share the cost of care, called coinsurance.
For example, you pay 20% for services and the plan will pay 80% of the cost until you have reached your
out-of-pocket maximum.

For Your Protection

The out-of-pocket maximum provides financial protection in the event of a serious illness or injury. The out-of-pocket
maximum, however, does not include penalties (such as a late cancellation fee for a doctor’s appointment), and out-of-
network out-of-pocket maximums are significantly higher vs in-network (or not covered/unlimited on the Surest plan).

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Medical Plan Comparison

UMR Premium Plan UMR Consumer Plan

Surest Plan
(HRA Compatible) (HSA Compatible)
IN-NETWORK OUT-OF-NETWORK IN-NETWORK OUT-OF-NETWORK IN-NETWORK

Calendar Year Deductible

Individual $2,000 $4,000 $2,000 $6,000 $0

Family $4,000 $6,000 $4,000 $12,000 $0

Calendar Year Out-of-Pocket Maximum (includes Deductible and Copays)

Individual $5,000 $15,000 $5,000 $15,000 $6,000

Family $10,000 $30,000 $10,000 $30,000 $12,000

You Pay You Pay You Pay

Coinsurance

Preventive Care $0 Not covered $0 Not covered $0

Primary Care Physician $20 copay 50%* 20%* 50%* $35-$140

Specialist 20%* 50%* 20%* 50%* $35-$140

Urgent Care $50 copay 50%* 20%* 50%* $90

Emergency Room 20%* 20%* 20%* 20%* $850*

* After deductible

For the UMR plans, the UnitedHealth Premium

program provides physician designations
based on quality and cost-efficiency criteria to
help members make more informed choices
about their medical care.

Physicians may also use these designations

when referring patients to other physicians.
In markets where tiered benefit plans are
available, employers may choose to offer their
employees a tiered benefit plan with a lower
member cost share for using Premium
Care Physicians.

The Surest plan offers set copays for ALL services with no deductible, but all copays accumulate towards your out-
of-pocket maximum. Surest uses the same network as the UMR plans but provides copay ranges based on provider
selection. You still have full access to the same providers as with UMR, but have the opportunity to pay lower copays for
certain providers, as well as have a copay amount confirmed for ALL services (surgeries, etc.) before your date of service
(no more balance bills!). You will not see the above mentioned “heart” ranking if you enroll in the Surest plan but will
receive lower copays if you see higher quality providers.
6
Pharmacy Benefits

UMR Premium Plan UMR Consumer Plan

Surest Plan
(HRA Compatible) (HSA Compatible)
OUT-OF- OUT-OF-
IN-NETWORK IN-NETWORK IN-NETWORK
NETWORK NETWORK

Retail Rx (up to 31-day supply)

Tier 1 $10 copay 50%* $10 copay* 50%* $10 copay

Tier 2 $40 copay 50%* $40 copay* 50%* $90 copay

Tier 3 $80 copay* 50%* $80 copay* 50%* $160 copay

Mail Order Rx (up to 90-day supply)

Tier 1 $25 copay N/A $25 copay* N/A $25 copay

Tier 2 $100 copay N/A $100 copay* N/A $225 copay

Tier 3 $200 copay* N/A $200 copay* N/A $400 copay

* After deductible

Prescription Drug Coverage Retail Prescription Program

If you enroll in one of the RBA medical plans, you will The retail prescription program uses a network of
automatically receive prescription drug coverage through participating pharmacies. To receive the highest level of
Optum. When you need prescriptions, you can purchase benefits, you must use a participating pharmacy. For more
them through a local retail pharmacy or, for maintenance information about a particular pharmacy or pharmacy
medications, through the mail order program. claim, contact your MyQHealth Coordinators if you are
enrolled in a UMR plan, and if you are enrolled in the Surest
We encourage you to speak to your physician about the plan, please visit your Surest app.
drug that’s best for you and to request less expensive
prescription drugs (generic drugs). Your pharmacist will Mail Order Program
be able to recommend alternatives that create the same The mail order program offers a convenient and
desired effect but may be more cost efficient than a cost-effective way to fill prescriptions for medications you
name brand drug. take on a regular basis (maintenance medications). Your
medications are mailed directly to your home. To order
prescriptions through the mail order program, please visit
the Optum website at www.optumrx.com or call 855-524-
0381. If you are a UMR plan member, contact MyQHealth
for more information, and if you are a Surest member, visit
your Surest app.

7
Medical Plan Resources & Tools
You may have different programs and resources available to you depending on if you have enrolled in the Surest plan or
a UMR plan, but both plans offer robust resources. See below for a comparison and further information on all resources
embedded into both plans.

SUREST PLAN
(FOR ALL RESOURCES BELOW, VISIT UMR PLAN
YOUR SUREST APP)

Visit benefits.surest.com or visit your Surest

app to find in-network doctors, copay tiers, and
more! If you choose to see higher quality doctors
in the UHC Choice Plus network you will have a Members enrolled in either UMR plan have access
decreased copay for your healthcare needs. You to myrbabenefits.com where you can search for
App / Website can also locate claim details and ID cards, check ID cards, search for in-network providers, check
your medical benefits and out of pocket maximum your medical benefits and out-of-pocket maximum
accumulation, and more! accumulation, review claims, and more.
If you are new hire or looking for more info on Surest
before enrolling, visit join.surest.com/RBA and
enter code “RBA2024”

Visit the Surest app to receive assistance with any MyQHealth is available to all UMR members. See
Concierge Support
medical & prescription benefits page 10 for more details and contact info

Virtual Telemedicine
Telemedicine works best for non-emergency
medical issues and questions, if you traveling Virtual telemedicine is available to all UMR members
FREE virtual telemedicine is available to all Surest
and in need of medical care, or if you need through Teladoc for $20 per visit. Visit the Teladoc
members through Dr. On Demand. Visit the Surest
care after normal business hours or on app or text “Get Started” to 469-844-5637 for
app for more information.
weekends. Common conditions treated more information.
include colds, flu, ear infections, sinus
infections, skin inflammation, and more.

Virtual behavioral health visits are available to UMR

FREE virtual behavioral health visits are available to members through Teladoc at the following costs.
Virtual Behavioral Health
Surest members at the following costs: Visit the Teladoc app for more information.
Members can see a behavioral health
» Licensed Therapist Visit: $0 » Licensed Therapist Visit:
professional 24/7 from your mobile device,
tablet or computer. These types of virtual » Initial Visit w/ Psychiatrist: $0 $10 Copay/$90 HSA
visits are good if you are experiencing » Follow Up Visit w/ Psychiatrist: $0 » Initial Visit w/ Psychiatrist:
depression, anxiety, ADD/ADHD, addiction Talkspace also provides FREE access to a $10 Copay/$220 HSA
and mental health disorders, and more. behavioral health provider 24/7 via text » Follow Up Visit w/ Psychiatrist:
$10 Copay/$220 HSA

Livongo can provide FREE, customized diabetic

Virta can provide FREE, customized diabetic support
Diabetes Support support to members living with a diabetes diagnosis.
to members living with a diabetes diagnosis
Visit myrbabenefits.com for more information

Hinge Health provides customized virtual exercise

Kaia Health provides customized virtual exercise therapy for UMR members experiencing back pain,
Virtual Exercise Therapy therapy for Surest members experiencing back pain, joint pain, those in need of pelvic floor therapy,
joint pain, etc. etc. To get started, call 855-902-2777 or go to
hingehealth.com/rba.

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Other UMR Plan Resources Other Surest Plan Resources
Real Appeal Virtual Primary Care
Real Appeal is a weight loss program that incorporates If you choose to seek primary care virtually vs. in person,
small goals each day to guide you toward a healthier Dr. On Demand provides FREE Virtual Primary Care to
life. Through your coach’s guidance and support, group all Surest members! Virtual Primary Care is more of an
sessions, educational material and activities. Real enhanced virtual visit than standard telemedicine and
Appeal will track your daily progress. You can enroll in provides a more convenient option for you to build a
Real Appeal by visiting enroll.realappeal.com. relationship with a PCP.

Cariloop Virtual Urgent Care

Cariloop can help support UMR members navigating Virtual urgent care provides quicker access in semi-
caregiving for family members. Cariloop is available emergent situations, FREE through Dr. On Demand.
to help you navigate healthcare systems, demystify
insurance benefits and find resources and solutions that Migraine Clinic
meet the unique caregiving needs of any age for you and If you struggle with migraines, Cove can provide
anyone you consider family. Visit cariloop.com/rba or customized support from physicians who specialize in
call 972-325-5836 to learn more. migraine care.

MyQHealth Cancer Support Second Opinion Service

MyQHealth Cancer Support provides support to If you have received a diagnosis and would like a second
members with a cancer diagnosis. Our Expert Cancer opinion, 2nd MD is included in the Surest plan for all
Review program provides support when members members.
request assistance or a clinical review, and our Personal
Precision Oncology Management program may Surest App
identify members for a case review based upon claims Search for doctors, treatments, and procedures with
data through the medical plan. Please reach out to the Surest health plan, then see prices before making
MyQHealth for more information. an appointment. Below is an example of how you can
navigate the Surest app to see cost and provider options.
You can search for your specific healthcare need, select
“Find Providers”, then you will be directed to a map of
provider options. You will select the copay or the “Options”
in the map to see more about costs, options, provider
details, etc. Remember, you can receive the lowest copays
possible if you opt to see the highest quality providers in
the UHC Choice Plus network!

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MyQHealth Care Coordination
A personalized, guided health care experience
MyQHealth is available to all UMR plan members. MyQHealth will be your primary contact and assist you with all your health
care-related issues and questions. MyQHealth Care Coordinators organize and simplify your medical and prescription benefits
to provide you with a better experience when you need care. From medical claims to checkups and even precertifications,
your Care Coordinators are with you every step of your health care journey. If you are a Surest member, please visit your
Surest app to find resources available to assist you with your medical and prescription benefits.

Search Manage Save

Search for a medical procedure and find Manage chronic conditions Save hundreds to thousands of
providers in your area. with health routines. dollars on out-of-pocket costs.

MyQHealth Care Coordinators do things like:

• Verify coverage
• Provide health education resources
• Advocate for your care
• Help manage chronic conditions
• Find in-network providers
• Contact providers to discuss treatment
• Answer claims, billing and benefits questions
• Create health-improvement plans
• Help reduce unnecessary, out-of-pocket costs

Contact your MyQHealth

Care Coordinators
• Call 877-498-1382
• Visit myrbabenefits.com
• Download the MyQHealth – Care Coordinators app

10
Mobile Health
Mobile Health is RBA’s wellness activity and health and wellbeing mobile application, and is available to all UMR and Surest
members. Mobile Health provides resources such as Health Coaching and Health Care Navigation as one central hub for all
things health and wellbeing! Members and their spouses both have access to Mobile Health in 2024.

Getting Started
1. Choose Your Device
You can choose to access Mobile Health using a smartphone, tablet, computer, or
smart watch. No matter the device(s) you choose your experience will be the same.
You can download the app Mobile Health Consumer from Google Play or the
App Store.

You can also access Mobile Health Consumer using a web browser:
https://www.mobilehealthconsumer.com/web/pages/login.html

Mobile Health users can complete the following activities to earn Amazon Gift Cards:
• Registration and Completion of the Health Assessment
• Complete a Wellness Exam
• Complete 1 Journey to 100%

Be on the lookout for other ways to win rewards throughout the year, such as Team Challenges and Raffles!

2. Register Your Account 3. Choose Your Interests

Mobile Health takes all the necessary precautions Upon logging into Mobile Health for the first time,
to ensure it is you – and only you – accessing your you will be presented with three welcome messages.
account. Once you download the app or access You can progress through the messages by
the URL, Mobile Health requires you to register your tapping the three radio buttons at the bottom of the
account. welcome screen.
• Tap Register Now. You will then be prompted to choose your interests.
• Enter your first and last name, the last four digits of Choosing your interests is an important step in
your social security number (SSN), and your birth personalizing your experience within Mobile Health.
date (e.g. 05/23/1985).
• Then tap Next. Note: Your first and last name must be entered
• After registering your account, Mobile Health exactly as it appears on your medical ID card
will prompt you to login. Your username is your – including if you have a hyphenated name. For
firstname.lastname (e.g. Robert.Smith). You can example, enter Robert instead of Bob if this is how
choose to keep this username or create your own your employer displays your name on HR records.
once in the platform under “Profile”.
Your employer may choose to use an employee ID
• Choose your password and enter your email
number instead of the last four digits of your SSN. This
address. Tap Next.
will be outlined in the welcome email you receive from
• Note: Passwords must contain at least six
Mobile Heath.
characters, 1 letter, and 1 digit.

11
Supplemental Medical
Just as it sounds, Supplemental Medial Plans – Accident and Critical Illness insurance – can help you pay for costs you
may incur after an accidental injury, illness or hospitalization. These plans are administered by Reliance Standard and are
100% voluntary.

Supplemental Medical Plans pays a fixed, one-time benefit amount which you can use for any purpose you like. It can help
pay for expenses not covered by your health care plan (such as your deductible or copays), lost income, child care, travel to
and from treatment, home health care costs or any of your regular household expenses.

Accident Insurance
How the Plan Works
Eligible Expenses
• On his way to work, John was in a car accident.

Emergency Room Visits • He was transported by ground ambulance to the

emergency room and admitted to the hospital.
• He had a dislocated hip and spent five days in
Hospital Stays the hospital.
• He had several physical therapy sessions before
returning to work.
Fractures and Dislocations
• John submitted his accident claim and received
$5,490 from his accident insurance coverage.
Medical Exams – including major • He used it toward his deductible, copay and
diagnostic exams supplemental income for his missed work days.

Sample Reimbursements
Physical Therapy
Ground Ambulance $150

Transportation and Lodging – if Emergency Treatment $200

you are away from home when the
Diagnostic Examination $200
accident happens
Hospital Stay – Admission + 5 days $2,250

Dislocated Hip (non-surgical) $2,400

Medical Appliance $150

Physical Therapy (4 sessions) $140

Total Benefit Paid $5,490

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Critical Illness
Sample of Covered Conditions
How the Plan Works
• Tom suffered a relatively small stroke.

Heart Attack • He was hospitalized for five days.

• He began rehab to get back to where he was physically
before the stroke.
Multiple Sclerosis
• Tom submitted his claim and received a lump-sum
payment of $10,000.

Stroke Benefit Amount

$10,000 – $30,000 in $10,000
Employee and Spouse
increments
Alzheimer’s Disease
25% of the Insured Person’s
Children approved Amount of Insurance,
up to $12,500
Parkinson’s Disease

Major Organ Failure

13
Health Savings Account (HSA)
An HSA is a personal savings account you can use to pay for qualified out-of-pocket medical expenses with pre-tax dollars –
now or in the future. RBA does not administer the HSA. As a member, you must enroll in an HSA through your employer or
by opening your own account through a bank.

How a Health Savings Account (HSA) Works

Eligibility
You must be enrolled in the High Deductible Health Plan.

Your Contributions
You contribute on a pre-tax basis and can change how much you contribute from each paycheck up
to the IRS maximum of $4,150 if you enroll only yourself, or $8,300 if you enroll in family coverage.
You can make an additional catch-up contribution if you are age 55.

Eligible Expenses
Medical, dental, vision and prescription drug expenses incurred by you and your eligible family
members.

Your HSA is always yours – no matter what

One of the best features of an HSA is that any money left in your HSA account at the end of the
year rolls over so you can use it next year or sometime in the future. And if you leave the company
or retire, your HSA goes with you and you can continue to pay and save for future eligible health
care expenses.

The Triple Tax Advantage

HSAs offer you tax advantages like no other:
You can use your HSA funds to cover qualified
1 medical expenses, plus dental and vision
expenses too – tax-free.
Unused funds grow and can earn interest over
2
time – tax-free.
You can save your HSA funds to use for your
3 health care when you leave the Company
or retire – tax-free.

14
Health Reimbursement Account (HRA)
An HRA is an account that you can use to pay out-of-pocket medical expenses with pre-tax dollars. If you are enrolled in the
Premium Plan, you are eligible for the HRA. You can use HRA money to pay for eligible medical expenses for you and your
covered dependents. HRAs are also a way for an individual or a family to pay for medical expenses without the funds being
taxed by the government beforehand. The employee may not contribute to the HRA.

Using the HRA

Please note: Funds available for reimbursement are limited to the balance in your HRA.

How a Health Reimbursement Account (HRA) Works

Reformed Benefits Association contributes to your account

$350 for individual employees.

Your expenses are paid by your HRA

Your HRA pays your eligible deductible and coinsurance amounts.

You make all applicable copayments at the doctor’s office

These payments apply towards your out-of-pocket maximum.

You pay your deductible

After you use all of your HRA funds, you then pay the rest of the deductible amount out of your
own pocket.

After that, you pay only coinsurance

Once you have met your deductible, you share in the cost of the expenses. This is called “coinsurance.”

How the Plan Works

John enrolls his family of three in the HRA plan. This plan has an HRA fund of $350 for the plan year.

Son Tyler has strep throat;

John injures his foot and needs an X-ray.

HRA Fund $350

Expenses
» 2 office visits x $20 $40
» Urgent Care visit for injured foot $50
» Foot X-ray $120
» Annual physicals for entire family $0
» Annual OB/GYN exam $0

Amount paid from HRA (applied to deductible) $210

Amount paid by John $0

15
 Dental Plans
Taking care of your oral health is not a luxury, it is a necessity to long-term optimal health. With
a focus on prevention, early diagnosis and treatment, Dental insurance can greatly reduce
your costs when it comes to restorative, and emergency procedures. Preventive services are
covered at no cost to you and include routine exams and cleanings. You will only pay a small
deductible and coinsurance for basic and major services.

Delta Dental administers your Dental insurance. When you visit an in-network dentist, you
will maximize your savings. To find an in-network dentist, go to https://www.deltadentalmi.
com/Member/Using-Your-Benefits/Find-a-Dentist and click the Delta Dental PPO and
Delta Dental Premier search button. These in-network dentists have agreed to reduced fees,
meaning you won’t be charged more than your expected share of the bill.

Delta Dental PPO Delta Dental Premier Nonparticipating*

Calendar Year Deductible

Individual $50 $50 $50

Family $150 $150 $150

Calendar Year Maximum

Per Individual $1,200 $1,200 $1,200

Diagnostic and Preventive

Exams, Cleanings, Fluoride, Space

Maintainers, Sealants, Brush Biopsy and $0 $0 $0
Radiographs
Basic Services

Emergency Palliative Treatment, Fillings,

Crown Repair, Endodontics, Periodontics, 20% 20% 20%
Extractions and Oral Surgery
Major Services

Crowns, Dentures and Bridgework Repairs

50% 50% 50%
and Prosthodontics
Orthodontia

Braces 50% 50% 50%

Lifetime Maximum $2,000

Age Limit No Age Limit No Age Limit No Age Limit

* When you receive services from a Nonparticipating Dentist, the percentages in this column indicate the portion of Delta Dental’s Nonparticipating Dentist Fee that will
be paid for those services. The Nonparticipating Dentist Fee may be less than what the dentist charges, and you are responsible for that difference.

The network with the largest discount rate is the Delta Dental PPO. By utilizing a provider in the Delta Dental PPO, you can
make your claim dollars go farther.

16
Vision Plan
Healthy eyes and clear vision are an important part of your overall health and quality of life. You may enroll yourself and your
eligible dependents or you may waive vision coverage. You do not have to be enrolled in medical coverage to elect vision
coverage or cover the same dependents under medical and vision.

EyeMed administers the Vision insurance. The vision plan utilizes the Insight Network. To find an in-network provider, go to
www.eyemed.com and select “Find an Eye Doctor.”

The table below summarizes the key features of the vision plan. Please refer to the official plan documents for additional
information on coverage and exclusions.

Vision Plan
IN-NETWORK OUT-OF-NETWORK
YOU PAY REIMBURSEMENT*

Cost

Exam $0 Up to $40

Frames $0 copay, $160 allowance; 20% off balance over $150 Up to $88

Standard Plastic Lenses

Single Vision $25 copay Up to $25

Bifocal $25 copay Up to $40

Trifocal $25 copay Up to $60

Standard Progressive $90 copay Up to $40

Premium Progressive
» Tier 1 $110 Up to $40
» Tier 2 $120 Up to $40
» Tier 3 $135 Up to $40
» Tier 4 $90 copay, 80% less $120 allowance Up to $40

Lenticular $25 copay Up to $60

Contact Lenses**

Conventional $0 copay, $175 allowance; 15% off balance over $175 Up to $140

Disposable $0 copay, $175 allowance; plus balance over $175 Up to $140

Medically Necessary $0 (paid in full by Benefit) Up to $210

Benefit Frequency

Exams Once every 12 months Once every 12 months

Lenses Once every 12 months Once every 12 months

Frames Once every 24 months Once every 24 months

Contacts Once every 12 months Once every 12 months

* You are responsible to pay the out-of-network provider in full at time of service and then submit an out-of-network claim for reimbursement. You will be reimbursed
up to the amount shown on the chart.
** For prescription contact lenses for only one eye, the Benefit will pay one-half of the amount payable for contact lenses for both eyes.

17
Life and Accidental Death &
Dismemberment (AD&D) Insurance
Life insurance pays a lump-sum benefit to your beneficiary(ies) to help meet expenses in the event of your death. AD&D
Insurance pays a benefit if you die or suffer certain serious injuries as the result of a covered accident. In the case of a
covered accidental injury (e.g., loss of sight, loss of a limb), the benefit you receive is a percentage of the total AD&D coverage
you elected based on the severity of the accidental injury. This coverage is administered by Reliance Standard.

The Basic Life and AD&D benefit available is based on an employee’s class. Class 1 includes full-time employees and Class 2
is comprised of part-time domestic employees regularly scheduled to work 20 - 29 hours per week. Class 3 includes full and
part-time Ordained employees formerly of ARC. Your organization determines whether option 1 or option 2 is offered.

Life and AD&D Insurance – For You

COVERAGE LEVEL COVERAGE AMOUNT EVIDENCE OF INSURABILITY/ PROOF OF GOOD HEALTH
Option 1: Class 1: $175,000 / Class 2: $100,000
Life and AD&D Option 2: Class 1: $75,000 / Class 2: $50,000 None
Class 3 Only: $275,000
Supplemental
Increments of $10,000 not to exceed $500,000 Required if electing coverage greater than $200,000
Life and AD&D

Life and AD&D Insurance – for Your Dependents

Supplemental Life insurance for your dependents can help protect your family during difficult times.

Life and AD&D Insurance – For Your Dependents

COVERAGE LEVEL COVERAGE AMOUNT EVIDENCE OF INSURABILITY/ PROOF OF GOOD HEALTH
Increments of $10,000 up to $250,000 – not to Required for amounts greater than $30,000 or if you
Spouse
exceed 100% of Employee coverage have previously declined this coverage
Child(ren) $10,000 None

Guaranteed Issue and Evidence

of Insurability
Employees and spouses who elect coverage when
first eligible can elect up to the Guaranteed Issue
(GI) amount without Evidence of Insurability (EOI).
If the amount requested is more than GI, you will
need to provide EOI before the amount over GI
becomes effective.

Imputed Income
Under current tax laws, imputed income is the value of your
Basic Life insurance that exceeds $50,000 and is subject to
federal income, Social Security, and state income taxes, if
applicable. This imputed income amount will be included in
your paycheck and shown on your W-2 statement.
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Disability Insurance
Disability insurance can keep you financially stable should you become disabled and unable to work. It can help provide a
sense of security, knowing that if the unexpected should happen, you’ll still receive a monthly income.

Long-Term Disability Benefits at a Glance

Class 1: Non-ordained domestic Agency employees of the CRCNA and active full-time or part-time non-
ordained employees of the GSC of the Reformed Church of America. All active, Full-time non-ordained
employees of another eligible affiliated organization as approved by the Board of Trustees of RBA
Classes Class 2: Non-ordained employees of the CRCNA or RCA congregation, institution, agency or eligible
affiliated organization
Class 3: Each active, Full-time and Part-time ordained employee formerly of ARC, except any person
employed on a temporary or seasonal basis

Class 1: 66.67% of your pre-disability earnings, up to a maximum of $5,000 per month until you recover or
reach your Social Security Normal Retirement Age (SSNRA), whichever is sooner
Class 2: 60% of your pre-disability earnings, up to a maximum of $5,000 per month until you recover, your
Coverage
Social Security Normal Retirement Age (SSNRA), whichever is sooner
Class 3: 66.67% of your pre-disability earnings, up to a maximum of $5,000 per month until you recover, your
Social Security Normal Retirement Age (SSNRA), whichever is sooner

When Benefits Begin Benefit begins after 180 days of disability

Election Required Yes

A qualifying disability is a sickness or injury that causes you to be unable to perform any other work for which you are or
could be qualified by education, training or experience.

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Important Contacts
Coverage Contact Phone Website
MyQHealth 877-498-1382 www.myrbabenefits.com
Teladoc 469-844-5637 www.member.teladoc.com
Talkspace N/A talkspace.com/connect
Medical (UMR Plans) Livongo 800-945-4355 www.myrbabenefits.com
Hinge Health 855-902-2777 hingehealth.com/rba
Real Appeal N/A enroll.realappeal.com
Cariloop 972-325-5836 cariloop.com/rba
Surest
Dr On Demand
Talkspace
benefits.surest.com
Medical (Surest Plan) Virta 866-683-6440
or visit your Surest app
Kaia Health
Cove
2nd MD

Dental Delta Dental 800-524-0149 www.deltadental.com

Vision EyeMed 866-723-0513 www.eyemed.com

Life and AD&D Reliance Standard 800-351-7500 www.reliancestandard.com

Disability Reliance Standard 800-351-7500 www.reliancestandard.com

International Medical UHC Global 877-844-0280 members.uhcglobal.com

Supplemental Medical Reliance Standard 800-435-7775 www.reliancestandard.com

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This brochure highlights the main features of the Reformed Benefits Association Employee Benefits Program. It does not
include all plan rules, details, limitations and exclusions. The terms of your benefit plans are governed by legal documents,
including insurance contracts. Should there be an inconsistency between this brochure and the legal plan documents,
the plan documents are the final authority. Reformed Benefits Association reserves the right to change or discontinue its
employee benefits plans at any time.