ExxonMobil Dental Plan SPD Updated
Through 2010
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.
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:
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Address:
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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
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Aetna
P. O. Box 14586
Lexington, KY 40512-4586
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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:
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Address:
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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)
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ExxonMobil Benefits Administration
ExxonMobil BA BSC USBA
4300 Dacoma or "BH1"
Houston, TX 77092 |
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- 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
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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.
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ExxonMobil Me, the Human Resources Intranet Site —
Can be accessed at work by employees.
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ExxonMobil Family, the Human Resources Internet Site —
Can be accessed from home by everyone at www.exxonmobilfamily.com.
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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.
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.
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.
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