About the ExxonMobil Vision Plan

This guide is a summary of the rules for the ExxonMobil Vision Plan (the Plan).  This guide along with the Certificate of Coverage provided by United Health Care Insurance Company constitutes the Summary Plan Description (SPD) for the Plan.  If you do not have a copy of the certificate, go to the UnitedHealthcare (UHC) Vision website at https://em.myuhcvision.com/MWP/Landing. This guide does not contain all the Plan details.  In determining your specific benefits, the full provisions of the formal documents, as they exist now or as they may exist in the future, always govern. Copies of these documents are available for your review. Exxon Mobil Corporation reserves the right to change benefits in any way or terminate any benefit at any time.

The Plan is fully-funded.  An insurance company collects premiums and underwrites coverage. ExxonMobil is responsible for determining the rules of eligibility for the Plan. State laws that govern vision plans may affect some of the eligibility participation rules.  Please contact UnitedHealthcare (UHC) Vision for further assistance. About the participation rules in this booklet you can contact the ExxonMobil Benefits Service Center. See Information sources below.

Notice: The Plan is an excepted benefit under Patient Protection Affordable Care Act (PPACA) and is not minimum essential coverage.  Since it is not minimum essential coverage, you may not treat it as required coverage when filing your U.S. Federal Income Tax return.

Applicability to represented employees is governed by collective bargaining agreements and any local bargaining requirements.

Information sources

When you need information, you may contact:

United Healthcare Insurance Company (UHIC)

Issues the insurance policy for ExxonMobil Vision Plan

UnitedHealthcare Vision

Provides specialized assistance with respect to questions about the benefit features of the Plan, claims, appeals, and network providers.

UnitedHealthcare Vision
Customer Service Department
877-303-2415 
Monday – Friday 7:00 a.m. to 10:00 p.m. CT
Saturday 8:00 a.m. to 5:30 p.m. CT
(except certain holidays)

UnitedHealthcare Vision
Claims Department
P. O. Box 30978
Salt Lake City, UT 84130

ExxonMobil Vision Plan website:  https://em.myuhcvision.com/MWP/Landing

The following is available on UnitedHealthcare Vision’s dedicated ExxonMobil Web site:

• Benefit Summary - outlines the benefits available under the Plan
• Certificate of Coverage - provides additional detailed information about the Plan
• Provider Locator - search tool listing retail and private practice providers in UnitedHealthcare Eyecare Networks
• Provider Nomination Form - to nominate your provider to participate in UnitedHealthcare Eyecare Networks
• Frequently Asked Questions (FAQs) about the Plan
• Useful Links information to help you learn more about eye care

Benefits Administration

Participants can enroll/change benefits the Your Total Rewards portal and benefit representatives can provide specialized assistance.

Your Total Rewards portal (http://digital.alight.com/exxonmobil)

Alight Mobile app  (available through Apple App Store or Google Play)

References throughout this guide refer to the ExxonMobil Benefits Service Center. 

Phone Numbers/Hours and Addresses:

ExxonMobil Benefits Service Center
Monday – Friday 8:00 a.m. to 4:00 p.m.
(Central Time), except certain holidays
Toll-Free: 1-833-776-9966

ExxonMobil Benefits Service Center
DEPT 02694
PO Box 64116
The Woodlands, TX,  77387-4116

ExxonMobil sponsored sites

Provide access to plan-related information, including claim forms for employees, retirees, survivors, and their family members.

• EM  Connect  — can be accessed at work by employees (goto/emconnect).
• ExxonMobil Family, the Human Resources Internet site — can be accessed from home by everyone at www.exxonmobilfamily.com.
• Your Total Rewards portal can be accessed from home by everyone  

Eligibility and enrollment

Eligibility and enrollment for the ExxonMobil Vision Plan

Generally, you are eligible if:

• You are a regular employee.
• You are a trainee as described in the Key Terms section.
• You are a retiree.
• You are a survivor/surviving spouse, which means an eligible family member of a deceased regular employee or retiree. 
• You are a long-term Expatriate with U.S. Company-sponsored green card (also called permanent resident visas or PRVs) who retires/retired at the end of your current U.S. assignment on or after July 1, 2020 and remain in the U.S. with a valid PRV. If you choose not to enroll, there will be no opportunity to enroll at a later point in time during retirement.

You are not eligible if:

• You participate in any other employer vision plan to which ExxonMobil contributes.
• You fail to make any required contribution toward the cost of the Plan.
• You fail to comply with general administrative requirements including but not limited to enrollment requirements.
• You lost eligibility as described under Changes in Status section.
• You are an Expatriate employee.

Eligible family members

Eligible family members are generally your:

• Spouse. When you enroll your spouse for coverage, you may be required to provide proof that you are legally married.
• A child who is described in any one of the following paragraphs (1) through (3):
1. has not reached the end of the month during which age 26 is attained, or
2. is totally and continuously disabled and incapable of self-sustaining employment by reason of mental or physical disability, provided the child:
   • meets the Internal Revenue Service's definition of a dependent, and
   • was covered as an eligible family member under this Plan immediately prior to age 26 when the child's eligibility would have otherwise ceased, and    
   • met the clinical definition of totally and continuously disabled before age 26 and continues to meet the clinical definition through subsequent periodic reassessment reviews, or
3. is recognized under a qualified medical child support order as having a right to coverage under this Plan.

A child aged 26 or over who was disabled but who no longer meets the requirements of paragraph two (2) above, ceases to be an eligible family member at the end of the month in which the applicable requirement is not met.

Please note: An eligible employee's parents are not eligible to be covered. 

Suspended retiree

A person who becomes a retiree due to incapacity within the meaning of the ExxonMobil Disability Plan and who begins long-term disability benefits under that plan, but whose benefits stop because the person is no longer incapacitated is considered a suspended retiree and is not eligible for coverage until the earlier of the date the person:

• Reaches age 55, or
• Begins their benefit under the ExxonMobil Pension Plan at which time the person is again considered a retiree and may enroll.

The family members of a deceased suspended retiree will be eligible for coverage under this Plan only after the occurrence of the earlier of the following:

• The date the suspended retiree would have attained age 55, or
• The date a survivor begins receiving a benefit due to the suspended retiree's accrued benefit from the ExxonMobil Pension Plan.

Special eligibility rules

A person who otherwise is not a spouse but who, as a dependent of a former Mobil employee who participated in or received benefits under a Mobil-sponsored plan or program prior to March 1, 2000, is considered an eligible dependent as long as that person's eligibility for coverage as a dependent under a Mobil-sponsored plan would have continued.

Coverage Tiers

You can choose coverage as an:

• Participant only,
• Participant and spouse,
• Participant and child(ren), or
• Family.

Each coverage tier has its own contribution rate.  Employees contribute to the Plan through monthly deductions from their pay on a pre-tax or after-tax basis.  Retirees and survivors receiving monthly benefit checks from ExxonMobil pay by deductions from these checks on an after-tax basis.  Other retirees or survivors and participants with continuation coverage pay by check or monthly draft on their bank account.

There are also classes of coverage for surviving spouses and family members of deceased employees and retirees, and employees on certain types of leaves of absence.

For employees on an approved leaves of absence (LOA), the following will apply:

• Military leaves:
  • Mandatory / Required Military leave: coverage under the Plan continues during the entire duration of the leave at the employee contribution rate. You are not offered COBRA continuation coverage.
  •  Voluntary / Optional Military leave: coverage under the Plan will continue for up to 12 at the employee contribution rate. At the end of the 12 month period, your coverage under the Plan will end and you will have the opportunity to elect COBRA. The LOA does not count towards the duration of time you are eligible for COBRA.
• Health/Dependent Care leave: coverage under the Plan will continue for up to 6 months at the employee contribution rate. At the end of the 6 month period, your coverage under the Plan will end and you will have the opportunity to elect COBRA. The LOA does not count towards the duration of time you are eligible for COBRA.
• Personal leave: coverage under the Plan will continue for up to 12 months at the employee contribution rate. At the end of the 12 month period, your coverage under the plan will end and you will have the opportunity to elect COBRA. The LOA does not count towards the duration of time you are eligible for COBRA.

If you take a leave of absence (LOA), you will pay your health plan contributions post-tax through direct debit (automatically taken from bank account) or direct bill (to be paid by check or credit card). That’s because you will not be receiving your regular paychecks while you’re on a leave. On the first day of the pay period available after you return to work, you will start paying your contributions through pre-tax deductions once more. If your health plan coverage was cancelled during your LOA because you did not pay the contributions, you can make new benefit elections after you return to work—whether you return in the same or the following calendar year.

Dual coverage

No one can be covered more than once in the Plan. You and spouse / family member cannot both enroll as employees (or retirees) and elect coverage for each other as eligible family members. If you and your spouse or adult child work for the company or are both retirees you may both be eligible for coverage. Each of you can be covered as an individual employee (or retiree), or one of you can be covered as the employee (or retiree) and the other can be an eligible family member. Also, if you and your spouse have children, each child can only be covered by one of you.

In addition, a marriage between two ExxonMobil employees does not allow enrollment or cancellation in any of the ExxonMobil health plans. In order to change your coverage you need to wait until you experience a change in status that allows coverage changes or annual enrollment.

How to enroll

Employees:

As a newly hired employee, you will receive enrollment materials from the ExxonMobil Benefits Service Center. If you wish to enroll, you have 30 days to do so after your start date for  your coverage to begin on the first day of employment.

If no actions are taken within the time established, the next opportunity to enroll will be during annual enrollment, with coverage effective the first of the following year or upon a change in status with coverage being effective on the event date.

If you are eligible for the ExxonMobil Pre-Tax Spending Plan, you will be enrolled to pay your monthly contributions on a pre-tax basis unless you annually decline this feature. Your monthly pre-tax contributions and coverage tier must remain in effect for the entire plan year, unless you experience a change in status. (See the Annual enrollment and Changing your coverage sections.)

You can enroll eligible family members only if you are enrolled in this plan. You can enroll in the Plan using the Your Total Rewards portal.

You will be requested to provide documents at some future date to prove that the family members you enrolled were eligible (e.g., marriage certificate, birth certificate). If you fail to provide such requested documents within 60 days of the request, coverage for the family members will be cancelled the first of the following month.  If you enroll family members who are not eligible for the Plan, for instance, by covering children who do not meet the eligibility requirements, you may lose eligibility for yourself and your family under all ExxonMobil health plans and you may be subject to discipline up to and including termination of employment for falsifying company records.

In the case of a change in status, enrollments must be completed within 30 days of the event. Your changes will take effect on the day of the event, except specific events as divorce or gaining/losing CHIP or Medicaid, for which participants have 60 days to make updates to coverage. However, your dependent children will stay on your health plans coverage through the end of the month they turn age 26, and your coverage will be through the end of the month in case your employment with the company ends (either through resignation, retirement or termination).

Deductions will be updated in the pay period following or coincident with the event date.

See additional details in Changes in Status during Employment section.

Under the Children's Health Insurance Program (CHIP) Reauthorization Act of 2009 you may change your Plan election for yourself and any eligible family members within 60 days of either (1) termination of Medicaid or CHIP coverage due to loss of eligibility, or (2) becoming eligible for a state premium assistance program under Medicaid or CHIP coverage.   In either case, coverage is effective the first of the month following  enrollment through Your Total Rewards portal.

Retirees:

Retirees have three opportunities to enroll in the Plan:

1. At retirement, or
2. Upon loss of other employer coverage, or
3. When first eligible to be enrolled in Medicare as your primary plan.

There is no opportunity to enroll yourself in the Plan at any other time, including during annual enrollment.

If you were enrolled in the Plan as an employee, you and your eligible covered family members will continue to be enrolled in the Plan at retirement. However, as a retiree, you will pay your contributions on an after-tax basis via payroll deduction (if eligible), check, or bank draft.

Eligible family members may be added to your coverage at one of the three enrollment opportunities listed above or if you experience a change in status. Eligible family members cannot be added to your coverage at any other time, including during annual enrollment.

In the case of a change in status, enrollments must be completed within 30 days of the event. Coverage will be on the day of the event. Deductions will be updated in the pay period following or coincident with the event date.

You will be requested to provide documents at some future date to prove that the family members you enrolled were eligible (e.g. marriage certificate, birth certificate). If you fail to provide such requested documents within the required time period, coverage for the family members will be cancelled the first of the following month. If you enroll family members who are not eligible for the Plan, for instance, by covering children who do not meet the eligibility requirements, you may lose eligibility for yourself and your family under all ExxonMobil health plans.

You may cancel your coverage at any time; however, you may not re-enroll unless you experience a corresponding change in status or you wait until one of the enrollment opportunities listed above. Coverage will be terminated at the end of the month in which your elected change has been received.

Eligible family members may also be removed from your coverage at any time; however, they may not be reinstated unless you experience a corresponding change in status or you wait until one of the enrollment opportunities listed above.

Note: You are required to remove family members who are no longer eligible for coverage at the time of loss of eligibility. To remove an ineligible family member you must notify the Benefits Service Center  of the loss of eligibility or your ineligible family members within 30 days from the date of the event except for the events of divorce or loss of CHIP / Medicaid coverage of you, your spouse or dependent for which you have up to 60 days to report. You may enroll in COBRA continuation coverage within 60 days from the later of the date coverage is lost or COBRA Election Notice statement date. If you fail to notify the Benefits Service Center, you may also lose eligibility for yourself and your family under all ExxonMobil health plans. In addition, you will be required to reimburse the Plans for any claims paid after the loss of eligibility for any ineligible person(s).

ID cards

Effective January 1, 2024, ID cards are digital. New members can log into em.myuhcvision and when they sign up for an account on the website, they’ll have the option to use the last 4 digits of their Social Security Number to confirm their identity. This will allow the system to find their full account details when the setup is complete. Once they’re signed in, they’ll have access to their Subscriber ID and have the option to print an ID card from there.

Annual enrollment

Each year, ExxonMobil offers an annual enrollment period.

Employees

During this time, employees can make changes to coverage by adding or removing family members. Family members may be added or removed for any reason during annual enrollment. However, family members must be removed as soon as they are no longer eligible. Changes elected during annual enrollment take effect the first of the following year.

You should not wait until annual enrollment to remove a family member who loses eligibility; they should be removed at the time eligibility is lost. For consequences for covering an ineligible family member, see Loss of Eligibility.

Employees are automatically enrolled in the Pre-Tax Spending Plan to pay monthly contributions on a pre-tax basis unless this feature is declined each time. This choice is only available during the annual enrollment period or with a change in status.

If you do not want to make any changes, you don’t have to do anything during annual enrollment to continue with your current plan selection for the following year. However, if as an employee you want to participate in a Flexible Spending Account (FSA), you must enroll each year, even if you are currently enrolled in an FSA.

If as an employee you pay your monthly contributions on an after-tax basis and would like to continue making contributions on an after-tax basis for the following year, you must elect to do so each year during annual enrollment and after each change in status. Otherwise, your contributions will be switched to a pre-tax basis beginning the first day of the following year.

Retirees

Retirees cannot enroll in or make changes to their Vision Plan coverage during annual enrollment. They may still elect to drop coverage for themselves or a family member.

Changing your coverage

Employees:

To make a change to your coverage after your initial enrollment you must wait until annual enrollment or until you experience one of the following changes in status.

Note: Changes in coverage associated with a change in status are effective on the date of the event. However, your dependent children will stay on your health plans coverage through the end of the month they turn age 26, and your coverage will be through the end of the month in case your employment with the company ends (either through resignation, retirement, or termination). If the change is made during annual enrollment, changes are effective the first day of the following year.

Retirees:

To make a change to your coverage after your retirement you must wait until you experience a Post-Retirement Change in Status.

Note: Changes in coverage associated with a change in status are effective on the date of the event. However, your dependent children will stay on your health plans coverage through the end of the month they turn age 26.

Changes in Status during employment

Retirees and survivors please see Post-Retirement Changes in Status.

If a change in status event described in this section occurs, the participant may be permitted or required to:

• Enroll in coverage;
• End coverage; or
• Change the dependents covered.

The participant’s new coverage election must be consistent with the qualified change in status event. If the actions permitted or required are not taken in the timeframes indicated, you may need to wait until the upcoming Annual Enrollment period or another change in status event.

The following qualified change in status events allow, or require, changes to a participant’s medical elections:

Event	You are required/permitted to	When
Qualified status change
Divorce   Employee and spouse enrolled in ExxonMobil Vision Plan	You are required to remove coverage for your former spouse and stepchild(ren) but you may not remove coverage for yourself or other covered eligible family members.   You may not make a change to your coverage if you and your spouse become legally separated because there is no impact on eligibility.	You must make these changes within 60 days of your divorce and you are not required to show documentation to drop dependents.   If you do not to notify the ExxonMobil Benefits Service Center within 60 days, this will result in your former spouse and stepchild(ren) not being entitled to elect COBRA.   If you fail to remove your spouse and any stepchild(ren) within 60 days of the event: You will continue to have pay the same pre-tax contribution for coverage even though you have removed your former spouse and stepchild(ren) Such contribution will remain the same until you have experienced another change in status or the first of the plan year following the next Annual Enrollment period You will be required to reimburse the Plans for any claims paid after the loss of eligibility for any ineligible person
Divorce Employee loses coverage under spouse's medical plan.	If you lose coverage under your spouse's health plan because of divorce, you can sign up for vision coverage for yourself and your eligible family members.	You must make these changes within 60 days following the date you lose coverage under your spouse's plan.
Death of a spouse or other eligible family member	Death of spouse: You are required to remove coverage for your former spouse but you may not remove coverage for yourself or other covered eligible family members.   If you lose coverage under your spouse's health plan, you can sign up for vision coverage for yourself and your eligible family members. If you and your family members are enrolled in the ExxonMobil Vision Plan, any stepchildren will cease to be eligible upon your spouse's death unless you are their court appointed guardian or sole managing conservator. Death of dependent child: You are required to remove coverage for deceased child but no other changes are allowed.	You must provide notice of your spouse’s death within 30 days of the date of death. No other election changes will be permitted for those currently enrolled in the Plan. If you were covered on your spouse’s plan you must make an election within 30 days of the date of death.
Other loss of family member's eligibility (e.g., sole managing conservatorship of grandchild ends)	Coverage continues through the last day of eligibility. In some cases, continuation coverage under COBRA may be available. (SeeContinuation coveragefor more details about COBRA.)	You must notify the ExxonMobil Benefits Service Center as soon as a family member is no longer eligible. If you fail to notify the ExxonMobil Benefits Service Center within 60 days, the family member will not be entitled to elect COBRA.   You remain responsible for ensuring that the dependent childis removed from coverage.If you fail to ensure that an ineligiblefamily member is removed in a timely manner, there may be consequences for falsifying company records.
Qualified change in employment status
You lose eligibility because of a change in your employment status, e.g., regular to non-regular or strike/ lockout	Your Vision Plan participation will automatically be termed.	Last day of the month of the event
You gain eligibility because of a change in your employment status, e.g. non-regular to regular; from trainee to regular.	Enroll yourself and add any eligible family members.   Since enrollment would not be upon original hire date, contributions would be on a post-tax basis if applied retroactively	You must make these changes within 30 days of the event
You begin or return from a leave of absence	You may be able to make changes to some health plan benefits. Contact ExxonMobil Benefits Service Center at 833-776-9966 with any questions.	You must make these changes within 30 days following the date of the event.
You return from expatriate assignment outside of the U.S.	You will be assigned “no coverage” for vision, hence you may enroll and add your eligible family members. .	You must make these changes within 30 days following the date of the event.
Termination of employment and rehire within 30 days or retroactive reinstatement ordered by court	If rehire is within 30 days or retroactive reinstatement ordered by court, you will be automatically enrolled in the same vision plan option you had prior to termination.   If returning with a different plan year than termination, you can make any election changes.   If rehire is after 30 days, enroll in all plans as new hire.	No action from the participant needed, automatic enrollment in same plan option.       You must make election changes within 30 days following the date of the reinstatement.   You must enroll within 30 days following the date of the reinstatement
Termination of Employment by spouse or other family member or other change in their employment status triggering loss of eligibility under the other plan	Enroll yourself and other family members who may have lost eligibility under the spouse's or family member's plan in vision coverage.	You must make these changes within 30 days following the date of the event.
Other qualified changes
Another parent is ordered to provide coverage to your covered child through a QMCSO	Revoke or decrease the affected child’s election if coverage actually provided. The effective date will be the date of qualification or end of month if termination date is not listed	Within 30 days following the date of the event
You are ordered to provide coverage to your eligible child through a QMCSO	Your coverage will be updated as directed by the order, including enrolling you and / or any affected dependents. The effective date will be the date of qualification. You may also be able to make changes to your life and Health Care FSA coverage. Please call ExxonMobil Benefits Service Center at 833-776-9966 with any question.	You must make these changes within 30 days of the event.
Eligible dependent gains eligibility under another employer's plan	If the eligible dependent has or will obtain coverage under the other employer plan, remove them from coverage. You may also cancel coverage for yourself, if health care coverage is obtained through your spouse’s employer plan.	You must make these changes within 30 days of the event.
A significant change in coverage or cost* of your, your spouse’s plan.     *applies also to a significant increase in health care cost sharing.	Changes to spouse´s plan: you may enroll in medical, dental and/or vision coverage for yourself and any affected family members. Change in coverage to your plan: mid-year changes to your plan coverages are not expected unless you have a change in status. Please call ExxonMobil Benefits Service Center at 833-776-9966 with any questions.	Within 30 days following the date of the event.
HIPAA special enrollment provisions
Marriage	Enroll yourself and any eligible dependents. Drop coverage for yourself and your dependents (if being covered by your new spouse). Note that you cannot drop coverage for just your dependents, if you wish to drop coverage it would be for the whole family.	Within 30 days following the date of the event.
Gain a family member through birth, adoption or placement for adoption	Enroll yourself and any eligible dependents. Drop coverage for yourself and your dependents. (Note that you cannot drop coverage for just your dependents, if you wish to drop coverage it would be for the whole family. Add any eligible dependents to your coverage.	You must add the new family member within 30 days even if you already have family coverage. Coverage is effective on the date of birth, adoption, or placement for adoption.
You or a family member loses eligibility under another employer's group health plan	Enroll yourself and other family members who might have lost eligibility, add affected dependents.	You must make these changes within 30 days of the event.
A family member’s employer contributions cease.	Add affected dependents to your coverage.	You must make these changes within 30 days of the event.
The participant or the participant’s dependent becomes eligible for premium assistance under Medicaid or the Children’s Health Insurance Program (CHIP).	If the participant is becoming eligible, they may drop coverage.   If a dependent is becoming eligible, they may remove coverage for affected dependents only.	Within 60 days of either: termination of Medicaid or CHIP coverage due to loss of eligibility, or becoming eligible for a state premium assistance program under Medicaid or CHIP coverage.

Post-Retirement Changes in Status

Employees please see Changes in Status during employment.

Event	You are required/permitted to	When
Qualified status change
Divorce   Employee and spouse enrolled in ExxonMobil Vision Plan	You are required to remove coverage for your former spouse and stepchild(ren) but you may not remove coverage for yourself or other covered eligible family members.   You may not make a change to your coverage if you and your spouse become legally separated because there is no impact on eligibility.	You must make these changes within 60 days of your divorce and you are not required to show documentation to drop dependents.   If you do not to notify the ExxonMobil Benefits Service Center within 60 days, this will result in your former spouse and stepchild(ren) not being entitled to elect COBRA.   If you fail to remove your spouse and any stepchild(ren) within 60 days of the event: You will continue to have pay the same pre-tax contribution for coverage even though you have removed your former spouse and stepchild(ren) Such contribution will remain the same until you have experienced another change in status or the first of the plan year following the next Annual Enrollment period You will be required to reimburse the Plans for any claims paid after the loss of eligibility for any ineligible person
Divorce Employee loses coverage under spouse's medical plan.	If you lose coverage under your spouse's health plan because of divorce, you can sign up for vision coverage for yourself and your eligible family members.	You must make these changes within 60 days following the date you lose coverage under your spouse's plan.
Death of a spouse or other eligible family member	Death of spouse: You are required to remove coverage for your former spouse but you may not remove coverage for yourself or other covered eligible family members.   If you lose coverage under your spouse's health plan, you can sign up for vision coverage for yourself and your eligible family members. If you and your family members are enrolled in the ExxonMobil Vision Plan, any stepchildren will cease to be eligible upon your spouse's death unless you are their court appointed guardian or sole managing conservator. Death of dependent child: You are required to remove coverage for deceased child but no other changes are allowed	You must provide notice of your spouse’s death within 30 days of the date of death. No other election changes will be permitted for those currently enrolled in the Plan. If you were covered on your spouse’s plan you must make an election within 30 days of the date of death.
Other loss of family member's eligibility (e.g., sole managing conservatorship of grandchild ends)	Coverage continues through the last day of eligibility. In some cases, continuation coverage under COBRA may be available. (SeeContinuation coveragefor more details about COBRA.)	You must notify the ExxonMobil Benefits Service Center as soon as a family member is no longer eligible. If you fail to notify the ExxonMobil Benefits Service Center within 60 days, the family member will not be entitled to elect COBRA.   You remain responsible for ensuring that the dependent childis removed from coverage.If you fail to ensure that an ineligiblefamily member is removed in a timely manner, there may be consequences for falsifying company records.
Other qualified changes
Another parent is ordered to provide coverage to your covered child through a QMCSO	Revoke or decrease the affected child’s election if coverage actually provided. The effective date will be the date of qualification or end of month if termination date is not listed.	Within 30 days following the date of the event
You are ordered to provide coverage to your eligible child through a QMCSO	Your coverage will be updated as directed by the order, including enrolling you and / or any affected dependents. The effective date will be the date of qualification You may also be able to make changes to your life and Health Care FSA coverage. Please call ExxonMobil Benefits Service Center at 833-776-9966 with any question.	You must make these changes within 30 days of the event.
Eligible dependent gains eligibility under another employer's plan	If the eligible dependent has or will obtain coverage under the other employer plan, remove them from coverage. You may also cancel coverage for yourself, if health care coverage is obtained through your spouse’s employer plan.	You must make these changes within 30 days of the event.
A significant change in coverage or cost* of your, your spouse’s plan.     *applies also to a significant increase in health care cost sharing.	Changes to spouse´s plan: you may enroll in medical, dental and/or vision coverage for yourself and any affected family members. Change in coverage to your plan: mid-year changes to your plan coverages are not expected unless you have a change in status. Please call ExxonMobil Benefits Service Center at 833-776-9966 with any questions.	Within 30 days following the date of the event.
HIPAA special enrollment provisions
Marriage	Enroll yourself and any eligible dependents. Drop coverage for yourself and your dependents (if being covered by your new spouse). Note that you cannot drop coverage for just your dependents, if you wish to drop coverage it would be for the whole family.	Within 30 days following the date of the event.
Gain a family member through birth, adoption or placement for adoption	Enroll yourself and any eligible dependents. Drop coverage for yourself and your dependents. (Note that you cannot drop coverage for just your dependents, if you wish to drop coverage it would be for the whole family. Add any eligible dependents to your coverage.	You must add the new family member within 30 days even if you already have family coverage. Coverage is effective on the date of birth, adoption, or placement for adoption.
You or a family member loses eligibility under another employer's group health plan	Enroll yourself and other family members who might have lost eligibility, add affected dependents.	You must make these changes within 30 days of the event.
A family member’s employer contributions cease.	Add affected dependents to your coverage.	You must make these changes within 30 days of the event.
The participant or the participant’s dependent becomes eligible for premium assistance under Medicaid or the Children’s Health Insurance Program (CHIP).	If the participant is becoming eligible, they may drop coverage.   If a dependent is becoming eligible, they may remove coverage for affected dependents only.	Within 60 days of either: termination of Medicaid or CHIP coverage due to loss of eligibility, or becoming eligible for a state premium assistance program under Medicaid or CHIP coverage.

Other changes that may affect your coverage

Change in coverage costs or significant curtailment

If the cost for coverage charged to you significantly increases or decreases during a plan year, you may be able to make a corresponding prospective change in your election, including cancellation of your election. This provision also applies to a significant increase in the vision deductible or copayment.

If the cost for coverage under your spouse’s vision plan significantly increases or there is a significant curtailment of coverage that permits revocation of coverage during a plan year and you cancel that coverage, you will be able to sign up for vision coverage for yourself and your eligible family members.

If you die

If you die while enrolled, your covered eligible family members can continue coverage. Their eligibility continues under the Plan with the payment of required contributions for a specified amount of time:

• If you have 15 or more years of benefit service at the time of your death, eligibility continues until your spouse remarries or dies.
• If you have less than 15 years of benefit service, eligibility continues for twice your length of Benefit Service or until the spouse remarries or dies, whichever occurs first.

Children of deceased employees or retirees may continue participation as long as they are an eligible family member and are not eligible to be enrolled in Medicare as their primary medical plan. If your surviving spouse remarries, eligibility for your stepchildren also ends. Special rules may apply to family members of individuals who become retirees due to disability. (See If you become a suspended retiree section below.)

If you become a suspended retiree

If you are a retiree and you would otherwise lose coverage because you have become a suspended retiree under the ExxonMobil Disability Plan, you may continue coverage for yourself and all your family members who were eligible for plan participation before you became a suspended retiree for either 12 or 18 months.

Coverage continues for 12 months from the date coverage would otherwise end if you received transition benefits under the ExxonMobil Disability Plan. However, if you did not receive transition benefits under the ExxonMobil Disability Plan, coverage continues for 18 months from the date coverage would otherwise end. The cost of this continued coverage is 102% of the participant contributions.

Benefit summary

Benefit summary of the ExxonMobil Vision Plan

Please note: This chart provides only a brief summary of benefits under the ExxonMobil Vision Plan. They are not intended to include all provisions.

ExxonMobil Vision Plan Summary of Benefits
Service Area: Unites States Group Number: 928104 Member Services: 877-303-2415 Provider Website: www.exxonmobilvision.com (https://em.myuhcvision.com/MWP/Landing)

 

Services shown are limited to once per calendar year.

Service	In network you pay	Non-network you pay *
Comprehensive exam	$0	Anything over $40
Retinal screening photography	$0	100%
Materials	$35 copay	Copay not applicable
Frames • Private practice and retail chain providers	Anything over $150	Anything over $45
Spectacle lenses • Single vision • Bifocals • Trifocals • Lenticular	$0	Anything over: $40 $60 $80 $80
Lens options • Standard scratch resistant coating • Polycarbonate lenses up to age 19 • Tier 1 through 4 Progressives • Tier 1 through 4 Anti-Reflective	$0	100%
Contact lenses (in lieu of eyeglassses) • Formulary contact lenses • Medically necessary contact lenses • Non-Formulary contact lenses • Contact lenses fit & evaluation	$0 for up to 8 boxes $0 Anything over $200 $0 if received in conjunction with purchasing formulary contact lenses	Anything over: $200 $210 $200 100%
Laser Vision Correction	Laser Surgery: UnitedHealthcare partners with QualSight LASIK to provide our members with access to discounted laser vision correction providers. Member savings represent up to 35% off the national average price of Traditional LASIK. For more information, visit vision.qualsight.com

* In the “Non-network you Pay”, the member will still have to pay up front the full out of pocket amount for out of network services and then seek reimbursement for the amounts covered as detailed above. For example, on the comprehensive exam, member pays all out of pocket and then requests reimbursement of up to $40.

When coverage ends

When coverage ends for the ExxonMobil Vision Plan

Coverage for you and/or your family members ends on the earliest of the following dates:

• The last day of the month in which:
• You terminate employment (except as a retiree or due to disability),
• A family member ceases to be eligible (for example, a child reaches age 26), or
• A retiree becomes a suspended retiree,
• You do not make any required contribution,

OR

• The effective date:
• You die,
• The Plan ends,
• Your employer discontinues participation in the Plan,
• You enrolled an ineligible family member and in the opinion of the Administrator-Benefits, the enrollment was a result of fraud or a misrepresentation of a material fact.
• You are no longer eligible for benefits under this Plan (e.g., employment classification changes from regular employee to non-regular employee or from non-represented to represented where you are no longer eligible for this Plan),
• A Qualified Medical Child Support Order is no longer in effect for a covered family member
• You elect not to participate anymore (opt out),

You are responsible for ending coverage with ExxonMobil Benefits Service Center when your enrolled spouse or family member is no longer eligible for coverage. If you do not complete your change within 30 days for most changes in status (and 60 days in the case of divorce or if you, your spouse or your covered dependent gains/loses eligibility for Medicaid or Children’s Health Insurance Program (CHIP) coverage), any contributions you make for ineligible family members will not be refunded.

For employees and eligible family members, if your participation in any group health plan (e.g., Medical, Dental, Vision), to which ExxonMobil contributed, was suspended for non-payment of required contributions, in order to enroll in this Plan you must repay all required contributions retroactively to the date of suspension.  

If you are a retiree, eligible family member of retiree or a survivor and have missed payments, contact the ExxonMobil Benefits Service Center (EMBSC) immediately for guidance in order to regularize your situation.

Cancellation and reinstatement process for retirees in any group health plan - - Dental, Vision, any of the ExxonMobil Retiree Medical Plan (EMRMP) options - will be as follows:

Cancellation of Retiree Health Plans due to non-payment of premiums:
Cancellations due to non-payment of plan premiums will be prospective, with a 3-month grace period starting 1st month of unpaid contributions, so participants may pay owed contributions within that grace period to avoid cancellation. For example, if retiree has not made payments for their January, February, and March premiums during that 3-month timeframe, coverage will be cancelled effective April 1.

Reinstatement of Retiree Health Plans:
Once your coverage has been terminated, you can request to be reinstated upon showing good cause. The applicable ExxonMobil Plan –Vision, Dental, EMRMP- (or its designee) will review requests for reinstatements on a case-by-case basis. If an individual has been involuntarily disenrolled for failure to pay plan premiums, they may request reinstatement no later than 60 calendar days following the effective date of disenrollment.

Reinstatement for good cause will occur only when:

1. Reinstatement is requested no later than 60 calendar days following the effective date of disenrollment (in the example, 60 days from April 1)
2. The individual has been determined to meet the criteria specified below (i.e., receives a favorable determination); and
3. Within three (3) months of disenrollment for nonpayment of plan premiums, the individual pays in full the plan premiums owed at the time they were disenrolled (in the example, within 3 months from April 1).

If you fail to pay premiums within the grace period, your coverage is terminated, and you fail to show good cause, you and your eligible dependents will not have an opportunity to re-enroll at a future date in the applicable ExxonMobil Health Plan. You are still responsible for paying all owed premiums incurred during the grace period in which you were still part of the applicable ExxonMobil Health Plan.

Requests for reinstatement must be accompanied by a credible statement (verbal or written) explaining the unforeseen and uncontrollable circumstances causing the failure to make timely payment. An individual may make only one reinstatement request for good cause in the 60-day period. Generally, these circumstances constitute good cause:

• A serious illness, institutionalization, and/or hospitalization of the member or their authorized representative (i.e. the individual responsible for the member’s financial affairs), that lasted for a significant portion of the grace period for plan premium payment;
• Prolonged illness that is not chronic in nature, a serious (unexpected) complication to a chronic condition or rapid deterioration of the health of the member, a spouse, another person living in the same household, person providing caregiver services to the member, or the member’s authorized representative (i.e., the individual responsible for the member’s financial affairs) that occurs during the grace period for the plan premium payment;
• Recent death of a spouse, immediate family member, person living in the same household or person providing caregiver services to the member, or the member’s authorized representative (i.e., the individual responsible for the member’s financial affairs); or
• Home was severely damaged by a fire, natural disaster, or other unexpected event, such that the member or the member’s authorized representative was prevented from making arrangement for payment during the grace period for plan premium;
• An extreme weather-related, public safety, or other unforeseen event declared as a Federal or state level of emergency prevented premium payment at any point during the plan premium grace period. For example, the member’s bank or U.S. Post Office closes for a significant portion of the grace period; or 

There may be situations in addition to those listed above that result in favorable good cause determinations. If an individual presents a circumstance which is not captured in the listed examples, it must meet the regulatory standards of being outside of the member’s control or unexpected such that the member could not have reasonably foreseen its occurrence, and this circumstance must be the cause for the non-payment of plan premiums. The Plan expects non-listed circumstances will be rare.

Examples of circumstances that do not constitute good cause include:

• Allegation that bills or warning notices were not received due to unreported change of address, out of town for vacation, visiting out of town family, etc.;
• Authorized representative did not pay timely on member’s behalf;
• Lack of understanding of the ramifications of not paying plan premiums;
• Could not afford to pay premiums during the grace period; or
• Need for prescription medicines or other plan services.

The ExxonMobil Business Service Center is the appointed designee reviewing reinstatement requests and making good cause determinations.

Loss of eligibility

Fraud against the plan

Everyone in your family may lose eligibility for plan coverage, and you may be subject to disciplinary action up to and including termination of employment if you commit fraud against the Plan, for instance, by filing claims for benefits to which you are not entitled. Coverage may also be terminated if you refuse to repay amounts erroneously paid by the Plan on your behalf or that you recover from a third party. Your participation may be terminated if you fail to comply with the terms of the Plan and its administrative requirements. You may also lose eligibility if you enroll persons who are not eligible, for instance, by covering children who do not meet the eligibility requirements. This includes failing to provide timely notification of when a covered family member loses eligibility, e.g., spouse loses eligibility due to divorce.

Extended benefits at termination

You are entitled to extended coverage for as much as a year if you are terminated due to disability with fewer than 15 years of service. This coverage is provided at no cost to you. This is considered a portion of the COBRA continuation period. In order to assure coverage beyond this extension period, you must elect COBRA upon termination of employment.

Several conditions must be met:

• The disability must exist when your employment terminates.
• The extension lasts only as long as the disability continues, but no longer than 12 months.

This extension applies only to the employee who is terminated because of a disability. Continuation coverage for eligible family members may be available through COBRA.

Continuation coverage

Continuation coverage for the ExxonMobil Vision Plan

The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) entitles you and your covered family members to extend vision benefits beyond the date your coverage would normally end.

Continuation coverage rights under COBRA

Introduction

You are required to be given the information in this section because you are covered under a group health plan (the Plan). This section contains important information about your right to COBRA continuation coverage, which is a temporary extension of coverage under the Plan under certain circumstances when coverage would otherwise end. This section generally explains COBRA continuation coverage, when it may become available to you and your family, and what you need to do to protect the right to receive it. 

The right to COBRA coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA coverage can become available to you when you would otherwise lose your group health coverage. It can also become available to your spouse and children, if they are covered under the Plan when they would otherwise lose their group health coverage or other rights under the Plan. This section does not fully describe COBRA coverage or other rights under the Plan. For additional information about your rights and obligations under the Plan and under federal law, you should review this SPD or contact the ExxonMobil Benefits Service Center at the telephone numbers or address listed under Benefits Administration in the Contacts for COBRA rights.

You, your spouse and your family members may have other options available when you lose group health coverage. For example, you may be eligible to buy an individual plan through the Health Insurance Marketplace.  By enrolling in coverage through the Marketplace, you may qualify for lower costs on your monthly premiums and lower out-of-pocket costs.  Additionally, you may qualify for a 30-day special enrollment period for another group health plan for which you are eligible (such as a spouse’s plan), even if that plan generally doesn’t accept late enrollees.

Determination of Benefits Administration Entity to Contact: current ExxonMobil employees, their covered family members and former ExxonMobil Employees and their covered family members, who have elected and are participating through COBRA should all contact ExxonMobil Benefits Service Center at 1-833-776-9966 (Monday – Friday 8:00 a.m. to 4:00 p.m CST) or access Your Rewards portal.

The contact information for each of these entities is as shown in the Contacts for COBRA Rights section.

What is COBRA coverage?

COBRA coverage is a continuation of Plan coverage when coverage would otherwise end because of a life event known as a qualifying event. Specific qualifying events are listed later in this section.  If a specific qualifying event occurs and any required notice of that event is properly provided to the ExxonMobil Benefits Service Center, COBRA coverage must be offered to each person losing coverage who is a qualified beneficiary.  You, your spouse, and your children could become qualified beneficiaries if coverage under the Plan is lost because of the qualifying event. Certain newborns, newly adopted children, and alternate recipients under QMCSOs may also be qualified beneficiaries. This is discussed in more detail in separate paragraphs below. Under the Plan, qualified beneficiaries who elect COBRA coverage must pay the entire cost of COBRA coverage (employee plus employer portions) plus a 2% administrative fee.

Who is entitled to elect COBRA?

If you are an employee, you will be entitled to elect COBRA, if you lose your coverage under the Plan because either one of the following qualifying events happens:

• Your hours of employment are reduced, or
• Your employment ends for any reason other than your gross misconduct.

If you are the spouse of an employee/retiree, you will be entitled to elect COBRA if you lose coverage under the Plan because any of the following qualifying events happens:

• Your spouse dies,
• Your spouse's hours of employment are reduced,
• Your spouse’s employment ends for any reason other than his or her gross misconduct,
• You become divorced from your spouse.  Also, if your spouse (the employee) reduces or eliminates your group health coverage in anticipation of a divorce, and a divorce later occurs, then the divorce may be considered a qualifying event for you even though your coverage was reduced or eliminated before the divorce.

A person enrolled as the employee/retiree’s child will be entitled to elect COBRA if he or she loses coverage under the Plan because any of the following qualifying events happens:

• The parent-employee/retiree dies,
• The parent-employee's hours of employment are reduced,
• The parent-employee's employment ends for any reason other than his or her gross misconduct, or
• The child stops being eligible for coverage under the Plan as a child.

When is COBRA coverage available?

When the qualifying event is the end of employment or reduction of hours of employment or death of the employee/retiree, the Plan will offer COBRA coverage to qualified beneficiaries.  You need to notify the ExxonMobil Benefits Service Center of any other qualifying events.

For the other qualifying events, a COBRA election will be available to you only if you notify the ExxonMobil Benefits Service Center. You must notify the Benefits Service Center of the loss of your eligibility or your ineligible family members within 30 days from the date of the event except for the events of divorce or loss of Medicaid or Children’s Health Insurance Program (CHIP) coverage of you, your spouse or dependent for which you have up to 60 days to report. You may enroll in COBRA continuation coverage within 60 days from the later of the date coverage is lost or the date on the COBRA Election Notice statement. Current employees, retirees or survivors may give notice of qualifying events by logging onto Your Total Rewards portal located on the Employee Connect intranet site.  

Please note:  Notice is not effective until either a change is made on Your Total Rewards portal or the proper information is received by the ExxonMobil Benefits Service Center. If notice is not submitted during the 30 or 60-day notice period depending on the change in status, then all qualified beneficiaries will lose their right to elect COBRA.

Election of COBRA

Each qualified beneficiary will have an independent right to elect COBRA. Covered employees and spouses (if the spouse is a qualified beneficiary) may elect COBRA on behalf of all qualified beneficiaries, and parents may elect COBRA on behalf of their children. Any qualified beneficiary for whom COBRA is not elected within the 60-day election period specified in the Plan’s COBRA election notice WILL LOSE HIS OR HER RIGHT TO ELECT COBRA.

How long does COBRA coverage last?

COBRA coverage is a temporary continuation of Plan coverage that lasts between 18-36 months depending on the qualifying event.

You, your spouse and covered dependents may qualify for up to 18 months of continuation coverage, if you qualify due to one of the following qualifying events:

• Your employment ends for any reason other than termination for gross misconduct;
• Your work hours are reduced and you are no longer eligible to participate in the Plan ; or
• Unpaid Leave of Absence

Your covered spouse and covered dependent may qualify for up to 36 months of continuation coverage, if they qualify due to one of the following qualifying events:

• You die;
• You and your spouse get a divorce; or
• An enrolled child no longer meets the definition of “child” under the terms of the Plan

Second qualifying event extension of COBRA coverage

If your family experiences another qualifying event while receiving COBRA coverage as a result of the covered employee’s termination of employment or reduction of hours (including COBRA coverage during a disability extension as described above), the covered spouse and children in your family can get up to 18 additional months of COBRA continuation coverage, for a maximum of 36 months, if notice of the second qualifying event is properly given the COBRA Administrator. This extension may be available to the spouse and any children receiving COBRA coverage if the employee or former employee dies, gets divorced, or if the covered child stops being eligible under the Plan as a child. This extension is not available under the Plan when a covered employee becomes entitled to Medicare after his or her termination of employment or reduction of hours.  This extension due to a second qualifying event is available only if you notify the correct benefits administration entity within 60 days of the date of the second qualifying event.

Disability extension of 18-month COBRA continuation coverage

The 18-month continuation period may be extended for you and your covered family members if the Social Security Administration determines that you or another family members, who is a qualified beneficiary, is disabled at any time during the first 60 days of continuation coverage.  If all of the following requirements are met, coverage for all family members who are qualified beneficiaries as a result of the same qualifying event can be extended for up to an additional 11 months (for a total of 29 months):

• This extension is available only for qualified beneficiaries who are receiving COBRA coverage because of a qualifying event that was the covered employee’s termination of employment or reduction of hours.
• The disability must have started at some time before the 61st day after the covered employee’s termination of employment or reduction of hours and must last at least until the end of the period of COBRA coverage that would be available without the disability extension (generally 18 months, as described above).
• A copy of the Notice of Award from the Social Security Administration is provided to the COBRA Administrator [ExxonMobil Benefits Service Center] within 60 days of receipt of the notice and before the end of the initial 18 months of continuation coverage.
• If the disabled qualified beneficiary elects continuation coverage, you must pay an increased premium of 150 percent of the monthly cost of Plan coverage that’s continued, beginning with the 19^th month of continuation coverage.

Extension Due to Medicare Eligibility

Coverage may also last up 36 months for a covered spouse or covered dependent when loss of coverage is the result of a qualifying event that is the end of the employee’s employment or the reduction of the employee's hours of employment, and the employee became entitled to Medicare benefits less than 18 months before the qualifying event.  In this case, COBRA coverage under the Plan for qualified beneficiaries (other than the employee) may last until up to 36 months after the date of the employee’s Medicare entitlement. For example, if a covered employee becomes entitled to Medicare 8 months before the date on which his employment terminates, COBRA coverage for his spouse and children who lost coverage as a result of his termination can last up to 36 months after the date of Medicare entitlement, which is equal to 28 months after the date of the qualifying event (36 months minus 8 months). This COBRA coverage period is available only if the covered employee becomes entitled to Medicare within 18 months BEFORE termination or reduction of hours.

When COBRA Coverage Ends

COBRA coverage may be terminated before the maximum period if one of the following occurs:

• The premium for your continuation coverage is not paid on time.
• If after electing continuation coverage, you become covered by another group health plan, unless the plan contains any exclusions or limitations with respect to any pre-existing condition you or your coverage dependents may have.
• If after electing continuation coverage, you first come eligible for and enroll in Medicare Part A , Part B or both.
• You extend coverage for up to 29 months due to a qualified beneficiary’s disability and there has been a final determination by the Social Security Administration that the qualified beneficiary is no longer disabled. In this case, continuation coverage will end on the first of the month that begins more than 30 days after the final determination o by the Social Security Administration that the qualified beneficiary is no longer disabled. This will be the case only if the qualified beneficiary has been covered by continuation coverage for at least 18 months.
• Exxon Mobil Corporation no longer provides group health coverage to any of its eligible employees or eligible retirees.

Are there other coverage options besides COBRA continuation coverage?

Yes.  Instead of enrolling in COBRA continuation coverage, there may be other coverage options for you and your family through the Health Insurance Marketplace, Medicaid, or other group health plan coverage options (such as a spouse’s plan) through what is called a special enrollment period. Some of these options may cost less than COBRA continuation coverage. You can learn more about many of these options at www.healthcare.gov.

More information about individuals who may be qualified beneficiaries during COBRA

A child born to, adopted by, or placed for adoption with a covered employee during a period of COBRA coverage is considered to be a qualified beneficiary provided that, if the covered employee is a qualified beneficiary, the covered employee has elected COBRA coverage for himself or herself.

The child's COBRA coverage begins when the child is enrolled in the Plan, whether through special enrollment or open enrollment, and it lasts for as long as COBRA coverage lasts for other family members of the employee. To be enrolled in the Plan, the child must satisfy the otherwise-applicable Plan eligibility requirements (for example, regarding age).

Alternate recipients under QMCSOs

A child of the covered employee who is receiving benefits under the Plan pursuant to a qualified medical child support order (QMCSO) received by ExxonMobil during the covered employee's period of employment with ExxonMobil is entitled to the same rights to elect COBRA as an eligible child of the covered employee.

Cost of COBRA coverage

A person who elects continuation coverage may be required to pay 102% of the cost to the Plan to maintain the coverage, unless the person is entitled to extended coverage due to disability. If the person becomes entitled to such extended coverage due to disability, the person may be required to contribute up to 150% of contributions after the initial 18-month's coverage until coverage ends. A person who elects continuation coverage must pay the required contributions within 45 days from the date coverage is elected retroactively to the date benefits terminated under the Plan.

If you have questions

Questions concerning your Plan or your COBRA continuation coverage rights should be addressed to the contact or contacts identified below.  For more information about your rights under the Employee Retirement Income Security Act (ERISA), including COBRA, the Patient Protection and Affordable Care Act, and other laws affecting group health plans, contact the nearest Regional or District Office of the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA) in your area or visit www.dol.gov/ebsa.  (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA’s website.)  For more information about the Marketplace, visit www.healthcare.gov. 

Keep your plan informed of address changes

In order to protect your family's rights, you should keep ExxonMobil Benefits Service Center informed of any changes in your address as well as the addresses of family members. You should also keep a copy, for your records, of any notices you send. 

Contacts for COBRA rights under the ExxonMobil Vision Plan

The following sets out the contact numbers based on your status under the ExxonMobil Vision Plan. FAILURE TO NOTIFY THE CORRECT ENTITY COULD RESULT IN YOUR LOSS OF COBRA RIGHTS.
If your status is not listed, call the ExxonMobil Benefits Service Center for help. 

Contacts:	Address:
Employees, retirees and their covered family members, and those former employees and family members who are participating through COBRA:
ExxonMobil Benefits Service Center Monday – Friday 8:00 a.m. to 4:00 p.m. (Central Time), except certain holidays Toll-Free: 1-833-776-9966 Your Total Rewards portal	r ExxonMobil Benefits Service Center DEPT 02694 PO Box 64116The Woodlands, TX,77387-4116

Administrative and ERISA information

Administrative and ERISA information for the ExxonMobil Vision Plan

This section contains technical information about the Plan and identifies its administrator. It also contains a summary of your rights with respect to the Plan and instructions about how you can submit an appeal if your claim for benefits is denied.

The formal name of the Plan is the ExxonMobil Vision Plan.

Plan sponsor and participating affiliates

The ExxonMobil Vision Plan is sponsored by:
Exxon Mobil Corporation
22777 Springwoods Village Parkway
Spring, TX 77389

All of Exxon Mobil Corporation's divisions and major U.S. affiliates participate in the Plan. A complete list of participating affiliates is available from the Administrator-Benefits upon written request.

Basic Plan information

Plan administrator

The Administrator-Benefits is the Manager-Global Benefits Design, Exxon Mobil Corporation. You may contact the Administrator-Benefits at the following address. Legal process may be served upon the Administrator-Benefits c/o ExxonMobil by serving the Corporation’s Registered Agent for Service of Process, Corporation Service Company (CSC).

For appeals of eligibility or enrollment issues:

Administrator-Benefits
DEPT 02694
PO Box 64116
The Woodlands, TX,  77387-4116

For service of legal process:

Corporation Service Co.
211 East 7th Street, Suite 620
Austin, TX 78701-3218

Authority of administrator-benefits

The Administrator-Benefits (and those to whom the Administrator-Benefits has delegated authority) has the full and final discretionary authority to determine eligibility for benefits under the Plan.

Claims administrator

The claims administrator, UnitedHealthcare Vision, provides information about claims payment, providers participating in the Plan, benefit pre-determinations, and appeals of denied claims. See Information sources.

Claims fiduciary and appeals

The claims fiduciary is the person to whom all appeals are filed. The claims fiduciary is UnitedHealthcare Vision for all vision benefit appeals.

Members who are dissatisfied with the resolution of an adverse decision or complaint have the right to appeal to UnitedHealthcare Vision or to file a complaint with the appropriate Department of Insurance. UnitedHealthcare Vision has full and final discretionary authority to construe and interpret the terms of the Plan in its application to any participant or beneficiary and to decide any and all claim appeals.

Members must request in writing an appeal and the reason for the appeal. Appeals must be filed within 180 calendar days of the previous resolution.

Appeals are submitted to:
UnitedHealthcare Vision Claims Department
P.O. Box 30978
Salt Lake City, UT 84130

Standard service appeal 

Determination will be made within 14 calendar days.

Standard claim appeal 

Determination usually within 30 calendar days, but no more than 60 calendar days.

Type of plan

The ExxonMobil Vision Plan is a welfare plan under ERISA providing vision benefits.

Plan numbers

The ExxonMobil Vision Plan is identified with government agencies under two numbers: 
Employer Identification Number (EIN), 13-5409005, and the Plan Number (PN), 635.

Plan year

The plan year is the calendar year.

Plan funding

Benefits are funded through participant contributions.

No implied promises

Nothing in this booklet says or implies that participation in the ExxonMobil Vision Plan is a guarantee of continued employment with the company.

Future of the Plan 

ExxonMobil has the right to change, suspend, withdraw, amend, modify, or terminate the Plan or any of its provisions at any time and for any reason. A change may also be made to required contributions and future eligibility for coverage, and may apply to those who retired in the past, as well as those who retire in the future. If any material changes are made in the future, you will be notified. For group health plans, certain rules apply regarding what happens when a plan is changed, terminated or merged. Expenses incurred before the effective date of a plan change or termination will not be affected. Expenses incurred after a plan is terminated will not be covered.

Your rights under ERISA

Receive information about your plan and benefits

• Examine, without charge, at the office of the Administrator-Benefits and at other specified locations, such as worksites and union halls, all documents governing the Plan, including collective bargaining agreements, and a copy of the latest annual report (Form 5500 Series) filed by the Plan with the U.S. Department of Labor and available at the Public Disclosure Room of the Employee Benefits Security Administration.
• Obtain, upon written request to the Administrator-Benefits, copies of documents governing the operation of the Plan, including collective bargaining agreements, and copies of the latest annual report (Form 5500 Series) and updated Summary Plan Description. The administrator may require a reasonable charge for the copies.
• Receive a summary of the Plan's annual financial report. The Administrator-Benefits is required by law to furnish each participant with a copy of this Summary Annual Report.

Prudent actions by Plan fiduciaries

In addition to creating rights for Plan participants, ERISA imposes duties upon the people who are responsible for the operation of the employee benefit plan.  The people who operate your Plan, called fiduciaries of the Plan, have a duty to do so prudently and in the interest of you and other Plan participants and beneficiaries.  No one, including your employer, your union, or any other person, may fire you or otherwise discriminate against you in any way to prevent you from obtaining a plan benefit or exercising your rights under ERISA.

Enforce your rights

• If your claim for a benefit is denied or ignored, in whole or in part, you have a right to know why this was done, to obtain copies of documents relating to the decision, without charge, and to appeal any denial, all within certain time schedules.
• Under ERISA, there are steps you can take to enforce the above rights. For instance, if you request a copy of Plan documents or the latest Summary Annual Report from the Plan and do not receive them within 30 days, you may file suit in a Federal court. In such a case, the court may require the Administrator-Benefits to provide the materials and pay you up to $110 a day until you receive the materials, unless the materials were not sent because of reasons beyond the control of the administrator.
• If you have a claim and an appeal for benefits, which are denied or ignored, in whole or in part, you may file suit in a Federal court. If it should happen that Plan fiduciaries misuse the plan's money, or if you are discriminated against for asserting your rights, you may seek assistance from the U.S. Department of Labor, or you may file suit in a Federal court. Any such lawsuit must be brought within 1 year of when you first had the right to sue. The court will decide who should pay court costs and legal fees. If you are successful, the court may order the person you have sued to pay these costs and fees. If you lose, the court may order you to pay these costs and fees, for example, if it finds your claim is frivolous.
• You may contact the Texas Department of Insurance if you have any complaints at 800-252-3439 or you may write the Texas Department of Insurance PO Box 149104, Austin, TX 78714-9104, fax 512-475-1771 (not toll free).

Assistance with your questions

If you have any questions about your Plan, you should contact UnitedHealthcare Vision at 877-303-2415 or contact ExxonMobil Benefits Service Center (See Information Sources on page 1). If you have any questions about this statement or about your rights under ERISA, or if you need assistance in obtaining documents from the Administrator-Benefits, you should contact the nearest office of the Employee Benefits Security Administration, U.S. Department of Labor, listed in your telephone directory or the Division of Technical Assistance and Inquiries, Employee Benefits Security Administration, U.S. Department of Labor, 200 Constitution Avenue N.W., Washington, D.C. 20210. You may also obtain certain publications about your rights and responsibilities under ERISA by calling the publications hotline of the Employee Benefits Security Administration.

Key terms

List of key terms in the ExxonMobil Vision Plan

Barred employee

An employee who is covered by a collective bargaining agreement except to the extent participation in the Plan is provided under such agreement.

Benefits Administration

Benefits Administration references throughout this document change depending on your status as an employee, retiree or survivor. Unless specifically stated otherwise, you should contact the Benefits Administration entity as indicated in Information Sources section.

Benefit service

Generally, all the time from the first day of employment until you leave the company's employment. Excluded are:

• unauthorized absences,
• leaves of absence of over 30 days (except military leaves or leave under the Federal Family and Medical Leave Act),
• certain absences from which you do not return,
• periods when you work as a non-regular employee, as a special agreement person, in a service station, car wash, or car-care center operations, or
• when you are covered by a contract that requires the company to contribute to a different benefit program, unless a special authorization credits the service.

Change in status

Life or work event that allows you to make changes to your elections during the plan year and outside of the annual enrollment period.

Child 

A person under age 26 who is:

• A natural or legally adopted child of a regular employee or retiree,
• A grandchild, niece, nephew, cousin, or other child related by blood or marriage over whom a regular employee, retiree, or the spouse of a regular employee or retiree (separately or together) is the sole court appointed legal guardian or sole managing conservator,
• A child for whom the regular employee or retiree has assumed a legal obligation for support immediately prior to the child's adoption by the regular employee or retiree, or
• A stepchild of a regular employee or retiree.
• Child does not include a foster child.

Claims administrator/processor 

UnitedHealthcare Vision, the third party administrator for UHIC, or affiliates, for claims.

Eligible employees 

Most U.S. dollar payroll employees of Exxon Mobil Corporation and participating affiliates. Full-time employees not hired on a temporary basis (also called regular employees) are eligible. 

The following are not eligible to participate in the Plan:  leased employees as defined in the Internal Revenue Code, barred employees, or special agreement persons as defined in the plan document. Generally, special agreement persons are persons paid by the company on a commission basis, persons working for an unaffiliated company that provides services to the company, and persons working for the company pursuant to a contract that excludes coverage of benefits.

Eligible family members

Eligible family members are generally your:

• Spouse
• A child who is described in any one of the following paragraphs (1) through (4):
1. has not reached the end of the month during which age 26 is attained, or
2. is totally and continuously disabled, meaning:
   • He or she can't engage in any substantial gainful activity because of a physical or mental condition.
   • A physician determines that the disability has lasted or can be expected to last continuously for at least a year or can lead to death.
3. incapable of self-sustaining employment by reason of mental or physical disability, provided the child:
   • meets the Internal Revenue Service's definition of a dependent, and
   • was covered as an eligible family member under this Plan immediately prior to age 26 when the child's eligibility would have otherwise ceased, and
   • met the clinical definition of totally and continuously disabled before age 26 and continues to meet the clinical definition through subsequent periodic reassessment reviews, or
4. is recognized under a qualified medical child support order as having a right to coverage under this Plan.

A child who was disabled but who no longer meets the requirements of paragraphs two (2) to four (4), ceases to be an eligible family member 60 days following the date on which the applicable requirement is not met.

Please note: An eligible employee or retiree's parents are not eligible to be covered.

Qualified Medical Child Support Order

A Qualified Medical Child Support Order (QMCSO) is a court decree under which a court order mandates health coverage for a child. A QMCSO must include, at a minimum:

• Name and address of the employee covered by the health plan.
• The name and address of each child for whom coverage is mandated.
• A reasonable description for the coverage to be provided.
• The time period of coverage.
• The name of each health plan to which the order applies.

You may obtain, without charge, a copy of the Plan's procedures governing QMCSO determinations by written request to the Administrator-Benefits.

Regular employee 

An employee of a participating employer, whether or not the person is a director, who, as determined by the participating employer, regularly works a full-time schedule, and is not employed on a temporary basis.  The definition includes a person who regularly works a full-time schedule but who, for a limited period of time, is approved for a part-time regular work arrangement under the participating employer’s work rules relating to part-time work for regular employees.

Retiree

Generally, a person at least 55 years old who retires as a regular employee with 15 or more years of benefit  service and who has not thereafter recommenced employment as a covered employee or a non-regular employee.  Retiree status may also be attained by someone who is retired by the company and entitled to long-term disability benefits under the ExxonMobil Disability Plan after 15 or more years of benefit service, regardless of age.

Employees who terminate while non-regular are not eligible for retiree status regardless of age or service.

Special-agreement person 

Generally, a person paid on a commission or commission salary basis other than a person paid while employed by the Marketing Department of ExxonMobil; an employee providing service to a non-affiliated organization that pays the person's salary or wages; or an employee working pursuant to an agreement that specifically excludes the person from coverage for benefits.

Spouse; marriage 

All references to marriage shall mean a marriage that is legally recognized under the laws of the state or other jurisdiction in which the marriage takes place, consistent with U.S. federal tax law. All references to a spouse or a married person shall refer to individuals who have such a marriage.

Surviving spouse/survivor

A surviving unmarried spouse or child of a deceased ExxonMobil regular employee or retiree.

Suspended retiree 

A person who becomes a retiree due to incapacity within the meaning of the ExxonMobil Disability Plan and who begins long-term disability benefits under that Plan, but whose benefits stop because the person is no longer incapacitated. A person remains a suspended retiree until the earlier of the date the person:

• Reaches age 55, or
• Begins their retirement benefit under the ExxonMobil Pension Plan, at which time the person is again considered a retiree.

The family members of a deceased suspended retiree will be eligible for coverage under this Plan only after the occurrence of the earlier of the following:

• The date the suspended retiree would have attained age 55, or
• The date a survivor begins receiving a benefit due to the suspended retiree's accrued benefit from the ExxonMobil Pension Plan.

Trainee

An employee who is classified as a non-regular employee, but who has been characterized as a Trainee and has graduated from high school.