RSL BasicCare® Program

www.reliancestandard.com

Draw on the protection provided by your benefits.

Important protection made available by your employer for you and your dependents through easy payroll deduction. Your acceptance is guaranteed…you cannot be turned down, as long as you sign up during your open enrollment period.

The BasicAdvantage Total Plan described in this brochure is not a substitute for comprehensive health insurance and does not qualify as minimum essential health coverage under the Affordable Care Act. It is intended to provide you, and your covered dependents, with basic insurance coverage.

BasicAdvantage Total Plan

x Visit any doctor or hospital.

x Enrolled dependents receive the same

coverage as you.

x No pre-existing conditions exclusions

or limitations.

x BasicAdvantage Total Plan enrollees

also receive these added non–

insurance benefits:

Prescription Drug Card offering

discounts at participating

pharmacies.

VSP Access Plan membership

offering discounts on eye exams

and prescription glasses at

network doctors.

24-Hour Nurse Helpline.

On-line Wellness Assistance.

Vitamins & Nutritional

Supplements Plan.

On Call Travel Assistance.

INPATIENT HOSPITAL BENEFITS

Hospital Room & Board Benefits:

Daily Benefit for the Treatment of Mental & Nervous Conditions Number of Daily Benefits Per Coverage Year

$100 per day

25

Daily Benefit for the Treatment of Alcohol & Substance Abuse Number of Daily Benefits Per Coverage Year

$100 per day

25

Daily Benefit for the Treatment of All Other Covered Conditions Number of Daily Benefits Per Coverage Year

$500 per day

90

Hospital Admission Benefit For Specified Conditions: Daily Benefit for Cancer (Malignant Neoplasm)

Number of Daily Benefits Per Coverage Year

$4,000 per day

1

Daily Benefit for Heart Attack (Myocardial Infarction) or Daily Benefit for Heart Disease1

Number of Daily Benefits Per Coverage Year

$3,000 per day

$1,500 per day

1

Daily Benefit for Accidental Injury

Number of Daily Benefits Per Coverage Year

$2,000 per day

1

Daily Benefit for Stroke (Cerebrovascular Accident - CVA) Number of Daily Benefits Per Coverage Year

$1,500 per day

1

Daily Benefit for Childbirth

Number of Daily Benefits Per Coverage Year

$1,500 per day

1

Maximum Surgery Benefit Per Procedure2 $1,000 per day Maximum Anesthesia Benefit3 $200 per day

1

The Hospital Admission Benefit is payable for either Heart Attack or Heart Disease during a coverage year, but not both. 2 Benefits for covered inpatient surgery are scheduled and range from $9 to $1,000 based on the specific surgical procedure performed. 3 Benefits for covered inpatient anesthesia vary and are equal to 20% of the applicable inpatient surgery benefit. OUTPATIENT BENEFITS

Doctor Visit Benefits:

Daily Benefit for a New Patient Office Visit

Number of Daily Benefits Per Coverage Year

$100 per day

1

Daily Benefit for an Established Patient Office Visit Number of Daily Benefits Per Coverage Year

$70 per day

7

Daily Benefit for a Consultation Office Visit

Number of Daily Benefits Per Coverage Year

$150 per day

1

Daily Benefit for an Emergency Room Doctor Visit

Number of Daily Benefits Per Coverage Year

$100 per day

1

Radiology Benefits:

Daily Benefit for a Magnetic Resonance Imaging (MRI) Number of Daily Benefits Per Coverage Year

$175 per day

1

Daily Benefit for a Computerized Tomography (CT) Scan Number of Daily Benefits Per Coverage Year

$75 per day

1

Daily Benefit for all other Radiology Services

Number of Daily Benefits Per Coverage Year

$40 per day

5

Pathology Benefits:

Daily Benefit for all Pathology Services

Number of Daily Benefits Per Coverage Year

$40 per day

5

Wellness Care Visit Benefits:

Daily Benefit for an Annual Physical

Number of Daily Benefits Per Coverage Year

$75 per day

1

Daily Benefit for a Mammogram Screening

Number of Daily Benefits Per Coverage Year

$50 per day

1

Daily Benefit for a Prostate or Cervical Cancer Screening Number of Daily Benefits Per Coverage Year

$35 per day

1

Emergency Room Visit Benefits:

Daily Benefit for the treatment of an Accidental Injury Number of Daily Benefits Per Coverage Year

$500 per day

2

Daily Benefit for the treatment of a Sickness

Number of Daily Benefits Per Coverage Year

$50 per day

3

Maximum Surgery Benefit Per Procedure4 $1,000 per day Maximum Anesthesia Benefit5 $200 per day

Prescription Drug Benefits:

Daily Benefit per Generic Drug Prescription (filled or refilled) Number of Daily Benefits Per Coverage Year

$25 per day

18

Daily Benefit per Brand Name Drug (filled or refilled) Number of Daily Benefits Per Coverage Year

$50 per day

2

4 Benefits for covered outpatient surgery are scheduled and range from $14 to $1,000 based on the specific surgical procedure performed. 5 Benefits for covered outpatient anesthesia vary and are equal to 20% of the applicable outpatient surgery benefit. Dental Plan

x Plan pays up to $1,000 maximum per

person each coverage year after a

$50 per person deductible.

x Visit any dentist.

x Covers most common services and

gives your enrolled dependents the

same coverage.

Term Life Plan with Accidental Death Benefit

x Plan provides $10,000 of term life coverage for you, with an additional matching $10,000 in the event of accidental death. x Your benefits reduce by 50% when you reach age 70. x Your benefits will be paid in equal shares to members of the first surviving beneficiary class, as follows: spouse; children; parents; brothers and sisters; or, if none, your estate.

x If you sign up for this benefit, you can add term life coverage for your spouse and each child (older than 6 months) in the amount of $2,500. Coverage amount for children 6 months of age or younger is $500. x Spouse coverage ends at age 70.

x You are the beneficiary for spouse and child term life coverage. x Term life benefits are not payable for death during the first 2 years of coverage if due to suicide or attempted suicide. Short-Term Disability Plan*

x Plan provides weekly benefits for up to 26 weeks of disability. The amount paid is 50% of base pay, up to a maximum of $125 per week. x Disability must be due to a sickness or an injury from an accident that happens while you are covered. You must become totally disabled while covered and, if due to an injury, within 90 days of the date of the accident. x If you are hospitalized, the benefits are payable immediately; otherwise, the benefits begin after a 14-day elimination period. x Benefits reduce by 50% when you reach age 70.

* STD coverage is only available to you. There is no dependent coverage available. Questions & Answers

Who can be covered? In addition to covering yourself, dependent coverage is offered in the BasicAdvantage Total, Dental and Term Life Plans. Your eligible dependents are your lawful spouse and your children through age 25, or through any age if disabled and unable to earn a living. When does my coverage begin and end? Your coverage begins on the first day of the month after you enroll, provided you are eligible and the required premium has been paid. Coverage for all of your benefits under the program will end if (1) the required premiums are not paid; (2) you are no longer an eligible employee; (3) the insurance policies terminate; or (4) you enter an Armed Service on full-time active duty. When does dependent coverage begin and end? Your dependents’ coverage begins when yours does, unless you enroll them later. If you do, their coverage will become effective after the enrollment is approved and the premiums have been paid. Their coverage ends when yours does or when the dependent is no longer eligible.

Do I have to use certain doctors, dentists or hospitals? No. You are free to use any licensed doctor or dentist, or any certified hospital. However, under the BasicAdvantage Total Plan, you can save money by using a network provider. Rest, nursing or old age homes, or facilities for the treatment of alcoholism, drug addiction or mental disorders are not hospitals. How does the Hospital Admission Benefit work? It pays a single daily benefit when you are admitted as an inpatient to the hospital for treatment of any of the conditions shown. The daily benefit amount varies by condition and is payable based on the first diagnosis code listed on the claim form for the hospital admission.

When will I receive ID cards and full coverage information? You will receive a Summary Plan Description after you enroll. ID cards will be included. Does the BasicAdvantage Total Plan cover maternity? Yes. Maternity care is covered. Are visits to a chiropractor covered under the BasicAdvantage Total Plan? Yes, chiropractic office visits are covered; however, spinal adjustments and manipulations, or modalities are not covered.

Types of Charges

Covered by the Plan

Percent of Charges

the Plan Pays

Waiting Period of

Continuous Enrollment

Before Plan Pays

Checkups & Routine Cleaning 80% None

Bitewing X-Rays 80% None

Sealants (for children) 80% None

Fluoride Treatments (for children) 80% None

Space Maintainers (for children) 80% None

Fillings 60% 3 Months

Crown & Bridge Repair 60% 3 Months

Denture Repair 60% 3 Months

Oral Surgery 60% 3 Months

Endodontics (root canal & pulpal therapy) 60% 3 Months Periodontics (treatment of gums) 50% 12 Months

Crowns & Bridges 50% 12 Months

Dentures 50% 12 Months

Exclusions & Limitations

The following is just a summary. Please see your Summary Plan Description (SPD) for a more complete description of these items. What is not covered under the BasicAdvantage Total Plan…

outpatient treatment of mental or nervous conditions;

outpatient treatment of alcoholism, or substance abuse;

intentionally self-inflicted injuries, suicide or attempted suicide while sane or insane;

acts of declared or undeclared war;

the covered person’s commission of a felony;

work-related injury or sickness;

eye examinations for glasses, any kind of eye glasses, or prescriptions therefore;

hearing examinations or hearing aids;

drugs not requiring a prescription;

dental care or treatment except covered events rendered in connection with the care of sound, natural teeth and gums required on account of an accidental injury that happens while covered, and rendered within 6 months of the accident;

reading or interpreting the results of any diagnostic pathology or radiology tests;

cosmetic surgery, except covered events rendered in connection with cosmetic surgery needed for breast reconstruction following a mastectomy or an accident that happens while covered. The surgery needed for an accident must be performed within 90 days of the accident;

treatment rendered while outside the United States of America; and

services rendered by an immediate family member or provided by your employer.

What is not covered under the Dental Plan…

procedures begun or appliances installed before coverage begins;

elective or cosmetic treatment;

correction of congenital malformations;

replacement of lost or stolen appliances;

initial placement of prosthesis or fixed bridge;

replacement of serviceable bridges;

replacement of serviceable dentures less than 5 years old;

replacement of crowns, inlays, and onlays less than 7 years old;

procedures involving vertical dimension, correction of attrition or abrasion, occlusion, splinting or bite analysis;

services in any way related to TMJ or myofascial pain;

orthognathic surgery;

prescribed drugs, analgesic or anesthetics;

instruction for diet, plaque control, and oral hygiene;

acts of declared or undeclared war;

charges for implants or their removal and other customized services or attachments;

cast restorations and crowns for healthy teeth that can be restored by other means;

treatment of malignancies, cysts, and neoplasms;

orthodontic treatment;

charges for forms or missed appointments;

treatment that is unnecessary, experimental, or does not offer a favorable prognosis;

services rendered by an immediate family member;

charges in excess of usual and customary fee levels based on the 90th percentile of the FAIR Health, Inc. MDR tables;

expenses covered under a group medical expense plan;

expenses payable under Workers' Compensation or other coverage required by law;

expenses which the covered person is not legally obligated to pay; and

any procedure begun after coverage ends or any prosthetic dental appliance finally installed more than 30 days after coverage ends. Many covered procedures have continuous enrollment waiting periods and limitations on how often the plan will pay for them within a certain time frame. The plan will pay only for the procedures specified on the Schedule of Covered Procedures and Benefits in the SPD.

What is not covered under Short-Term Disability and Accidental Death benefits…

suicide or attempted suicide, or any intentionally self-inflicted injuries, while sane or insane;

acts of declared or undeclared war;

your commission or attempted commission of a felony;

your operating, riding in or descending from any aircraft, other than while a fare-paying passenger on a licensed, commercial, non- military aircraft;

voluntarily taking poison, gas, drugs or chemicals not prescribed by a physician;

release of nuclear energy;

participation in a riot or an illegal occupation;

Short-Term Disability benefits are not paid for an injury or sickness related to your work; and

Accidental Death benefit is not paid for death resulting from sickness of any kind.

The Short-Term Disability benefit is not available to persons who work in California, Hawaii, New Jersey, New York, Rhode Island or Puerto Rico due to statutory coverage. In these states (and Puerto Rico), the employer is required to provide a disability benefit. The BasicAdvantage Total Plan, Dental Plan, and Term Life (with Accidental Death) and Short-Term Disability Plans are underwritten by Reliance Standard Life Insurance Company, Philadelphia, Pennsylvania under group policy form series: LRS-9497-0613, et al; LRS-9171-1103, et al; and LRS-9173-1103, et al, respectively.

Refer to the accompanying materials for information on premiums. Every effort has been made to ensure the accuracy of this enrollment brochure. The information described applies to the residents of most states, however state laws do vary. The laws of your state may affect this benefit program, but these differences generally do not reduce your benefits. This brochure is not a legal document. The contractual terms and conditions of coverage are set forth in the group policies. In the event of a discrepancy, the policies would be the determining factor. Insurance products are provided through Reliance Standard Life Insurance Company, which is licensed in all states (except New York), the District of Columbia, Puerto Rico, & the U.S. Virgin Islands. Reliance Standard Life Insurance Company reserves the right to change the premiums it charges for its plans. VSP Access Plan discounts from Vision Service Plan. 24-hour Nurse Helpline, Online Wellness Services and Nutritional Supplements Plan from Coverdell and Company, Inc. On Call Travel Assistance from On Call International. The suppliers of these services are not affiliated with Reliance Standard Life Insurance Company, which is not responsible for the content of the services and cannot be held liable for any services provided or not provided by these suppliers.

RS-2201.BAT4.D.TL.STD

Milestone Hospitality Management, LLC 2019-20

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