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Covered Expenses
- Preventive Services
- Emergency Treatment
- General Services
- Major Services
- Orthodontic Services
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Covered Expenses
Q. What types of dental services are covered by the Plan?
A. The Plan divides dental services into four categories:
| For all coverage, benefits are payable only for charges
up to the reasonable and customary amount for similar services and supplies
in the area. PPO dentists' charges are always within the reasonable and
customary amount (see page 26). |
To be covered, an expense must be incurred by a plan participant
for preventive dental care or for the care and treatment of dental disease or accidental
injury and such service or treatment must be:
An expense or charge is generally considered incurred on the date
the service is provided, with these exceptions:
- Fixed bridges,
crowns, inlays, onlays, or gold
restorations
are considered incurred on the first day of preparation of the tooth or teeth involved.
- Full or partial dentures
are considered incurred on the date the impression is taken.
- Endodontics are considered incurred on the
date the tooth is opened for root canal therapy.
- Dental implants are considered incurred on the date the cap is placed
on the post and not when the post is inserted. In some cases, dental implant costs are
subject to an Alternative Course of Treatment limitation
(see page 26).
Preventive Services
To encourage use of preventive services, you do not have to meet a deductible and the
Plan pays 95%, or as otherwise specified, of covered charges for the following services:
- Diagnostic oral examinations and periodic oral
prophylaxis
(cleaning and scaling of teeth above the gum line) limited to three
times each calendar year.
- Diagnostic supplementary
(bite-wing)
x-rays limited to three times each calendar year.
- Following comprehensive periodontal therapy, a total of
up to 5 cleanings (treatments) will be covered in a calendar year. The cleanings can be either all periodontal or some combination of
periodontal and prophylaxis, provided that of the five total cleanings,
no more than three are for prophylaxis in a calendar year. The
first three cleanings, whether periodontal or prophylaxis, are covered at 95%
of covered charges and the additional fourth and fifth cleanings are covered at 80% of
covered charges. Periodontal treatments will be covered each
calendar year, without additional periodontal therapy, if a continuing
need is determined through the clinical evaluation of the dentist.
- Topical stannous fluoride application limited to
three times each calendar year.
- Diagnostic full-mouth or panoramic x-rays are limited to
once in any three consecutive years.
- Space maintainers
and their insertion limited to treatment for a covered dependent under age 14.
- Tooth sealants applied to a permanent molar limited
to one application per tooth in any three consecutive years.
Emergency Treatment
The Plan also pays 95% of reasonable and customary
covered charges for diagnostic x-rays and examination charges for emergency
office visits. However, if you incur charges for emergency treatment on a day
when you receive other dental services, such as a routine checkup or an
extraction, the emergency examination charges will not be covered.
Example:
Suppose you see your dentist
for an emergency toothache. Your dentist gives
you an emergency examination, takes x-rays, and asks you to return for
treatment at a later time. These costs are 95% reimbursable by the Plan.
Suppose, however, your dentist also does an extraction in addition to the
x-rays. The only covered expenses are the x-rays (at 95%) and the extraction
(at 80%). If your dentist bills you for the emergency exam, the Plan will
not reimburse you for it because the cost of such an exam is normally
included in the cost of an extraction.
General Services
After you meet an annual deductible of $50 per person (maximum of $150 per
family), the Plan pays 80%, or as otherwise specified, of covered charges
for the following services:
- Care and treatment involving tooth extractions,
fractures, and dislocations of the jaw, and cutting procedures in the
oral cavity.
- Following comprehensive periodontal therapy, a total of
up to 5 cleanings (treatments) will be covered in a calendar year. The cleanings can be either all periodontal or some combination of
periodontal and prophylaxis, provided that of the five total cleanings,
no more than three are for prophylaxis in a calendar year. The
first three cleanings, whether periodontal or prophylaxis, are covered at 95%
of covered charges and the additional fourth and fifth cleanings are covered at 80% of
covered charges. Periodontal treatments will be covered each
calendar year, without additional periodontal therapy, if a continuing
need is determined through the clinical evaluation of the dentist.
- Root canals
and other endodontic treatment.
- General anesthetic and its administration in connection
with oral surgery, periodontics, fractures, and dislocations.
- Injection of antibiotics in conjunction with treatment of a
covered dental expense.
- Fillings, other than gold fillings. (For gold fillings, see
Major Services below.)
- Repair and rebasing existing dentures or fixed bridges.
(Replacing such dentures and fixed bridges is described under Major Services
below.)
- Addition of teeth to existing denture
or fixed bridge if required by
loss of natural teeth.
- Occlusal guards for the treatment of bruxism, limited to one
appliance
in any two calendar-year period.
- Pre-surgery oral exams.
Major Services
After you meet the annual deductible of $50 per person (maximum of $150 per family),
the plan pays 50% of covered charges for these services:
- Full or partial dentures
or fixed bridges or
implants and their initial
insertion. Note dental implants are subject to the alternative course of
treatment provision. (See page 27 for information). Replacement of existing
devices can only be covered if such device cannot be made serviceable and is
more than five years old. The Plan does not cover charges for adjusting dentures
or bridges within six months of installation. Such follow-up visits are normally
included in initial charges.
- Gold fillings and permanent crowns —
or their replacement —
necessary for restoration of tooth structure broken down by decay, injury or
severe attrition.
Separate charges for temporary fillings and crowns are not
covered. If you are charged for both temporary and permanent crowns or
dentures, only the charge for the permanent crown or
denture is covered.
Orthodontic Services
The Plan pays 50% of covered charges with no deductible up
to the orthodontic lifetime limit of $2,000 per person for
orthodontic
services and supplies to correct malposed teeth if insertion of the first
appliance occurs while the person is covered under the Plan. (See
Orthodontia Lifetime Maximum on page 24 for more information.)
If a former Mobil employee enrolls when first eligible, orthodontic services and supplies will be covered
even if the insertion of the first appliance occurs prior to becoming a covered person.
The following tool shows how benefits are paid from
the ExxonMobil Dental Plan and reimbursements are made from
your Health Care Flexible Spending Account. Monthly reimbursements are
based on your treatment plan (number of months braces are on the teeth), not your payment schedule. The orthodontia lifetime
maximum benefit is $2,000 per covered person.
Go to
www.exxonmobil.com/Family-English/HR/Files/CALCULATOR_ORTHO2008_091907.xls
for the Orthodontia FSA Expenses Calculator.
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