Index

About Dental
- Information Sources
- Introduction
- Plan at a Glance

Eligibility and Enrollment

Dental PPO

Covered Expenses

Exclusions

Payments

Claims

Continuation Coverage

Administrative and ERISA Information

Key Terms

Benefit Summary

  ExxonMobil Dental Plan SPD
Updated Through 2010

orange square About The Dental Plan

This summary plan description (SPD) is a summary of the ExxonMobil Dental Plan. It 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. You may obtain copies of these documents by making a written request to the Administrator-Benefits. Exxon Mobil Corporation reserves the right to change benefits in any way or terminate any benefit at any time.

The Dental Plan is self-insured. There is no insurance company to collect premiums or underwrite coverage. Instead, contributions from you and ExxonMobil pay all benefits. Prior claims experience and forecasted expenses are used to determine the amount of money needed to pay future benefits. These options are governed by federal laws, not by state insurance laws.

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

orange square Information Sources

When you need information, you may contact:

Claims and Dental Preferred Provider Organization (PPO) Administrator — Provides claim payment information, Aetna Dental PPO provider and claim forms.

Phone Numbers:

Address:

 
  • Aetna Member Services
    800-255-2386 OR
    210-366-2416 (international, call collect)
    Monday - Friday (8 a.m. to 6 p.m. CT),
    except certain holidays
    Automated Voice Response -
    24 hours a day, 7 days a week
  • Aetna
    P. O. Box 14586
    Lexington, KY 40512-4586

Benefits Administration — Customer Service Representatives can provide specialized assistance. References to Benefits Administration throughout this SPD pertain to either ExxonMobil Benefits Administration or ExxonMobil Benefits Service Center as listed below. Depending on your status (employee, retiree, or survivor), you should contact the appropriate service center.

Employees can enroll/change benefits on the ExxonMobil Me HR Intranet site through Employee Direct Access (EDA) when a change in status occurs. Enrollment forms are also available through ExxonMobil Benefits Administration for those without access to EDA.

Phone Numbers:

Address:

 
  • Employees call:
    ExxonMobil Benefits Administration

    Monday - Friday (8 a.m. to 3 p.m. CT),
    except certain holidays
    713-680-5858 (Houston)
    713-680-7070 (international, call collect)
    800-262-2363 (toll free outside Houston)
    262-314-2752 (fax)
ExxonMobil Benefits Administration
ExxonMobil BA BSC USBA 
4300 Dacoma or "BH1"
Houston, TX 77092
   
  • Retirees and Survivors call:
    ExxonMobil Benefits Service Center

    Monday – Friday 7:00 a.m. to 5:00 p.m.
    (U.S. Central Time), except certain holidays
    Toll-Free: 1-800-682-2847
    or 800-TDD-TDD4 (833-8334) for hearing impaired
ExxonMobil Benefits 
Service Center

P. O. Box 1014
Totowa, NJ 07512-1014

ExxonMobil Sponsored Sites — Access to plan-related information including claim forms for employees, retirees, survivors, and their family members.

  • ExxonMobil Me, the Human Resources Intranet Site — Can be accessed at work by employees.
  • ExxonMobil Family, the Human Resources Internet Site — Can be accessed from home by everyone at www.exxonmobilfamily.com.
  • Retiree Online Community Internet Site — Can be accessed from home by retirees and survivors only at www.emretiree.com.
  • ExxonMobil Benefits Service Center at ACS Internet Site — Can be accessed from home by everyone at www.exxonmobil.com/benefits.

orange square Introduction

The ExxonMobil Dental Plan (the Plan) encourages good dental health by paying, within plan limits, for most of the cost of preventive services and part of the cost of many other services, including orthodontia. The Plan offers you the opportunity to use the Aetna Dental PPO Network, a voluntary PPO, giving you access to dentists and dental specialists who have agreed to negotiated rates. In most cases, these rates will be lower than non-network dentists' rates and can generally reduce your out-of-pocket expenses while maximizing the annual plan benefits by using this network. ExxonMobil's dental plan is described in detail in this SPD. These tools help you find specific information quickly and easily:

  • Plan at a Glance, a quick user's guide highlighting plan basics.
  • Charts and tables throughout this SPD provide information, examples, highlights of plan provisions, etc.
  • References to sources of additional information.
  • Key Terms containing definitions of some words and terms used in this SPD. Terms are underlined and linked for easy identification.
  • Index to help you locate specific items.

A careful reading of this SPD will help you understand how the Plan works so you can make the best use of the Plan provisions.

orange square Plan at a Glance

Enrolling
You may enroll yourself and your eligible dependents within your first 60 days of employment or within 60 days of a subsequent  change in status or at Annual Enrollment; however, the Plan will not pay for any diagnosis or treatment begun prior to becoming a participant even if you enroll when first eligible. See page 8.

The Dental PPO
You may save time and money if you use a dentist who participates in the Dental PPO network. The dentist files claims for you, and the negotiated rates for the dentist's services are generally lower than rates charged by non-network dentists which will reduce your out-of-pocket costs. See page 15.

Covered and Excluded Expenses
The Plan provides benefits for many, but not all, preventive, general, major and orthodontic services. See pages 17-22.

Payments
You and the Plan share the costs for covered treatments and services. You pay a deductible before the Plan begins paying for certain benefits. For each covered person, the Plan pays up to $2,000 each calendar year and up to a $2,000 lifetime maximum benefit for covered orthodontic expenses. See page 23.

Claims
Dental PPO providers file claims for you. You are responsible for ensuring that claims for non-network care are filed. See page 28.

Consolidated Omnibus Budget Reconciliation Act 1985 (COBRA)
You and your dependents who lose eligibility may continue dental coverage for a limited time in certain circumstances. See page 32.

Administrative and ERISA Information
This Plan is subject to rules of the federal government, including the Employee Retirement Income Security Act of 1974, (ERISA) as amended, not state insurance laws. See page 37.

Key Terms
This is an alphabetized list of words and phrases, with their definitions, used in this SPD. See page 44.

Benefit Summary
A brief summary of benefits. See page 51.

Index
You can use this to locate specific topics described in this SPD. See page 54.