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Key Terms
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Key Terms |
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In this section, you will find both General Terms pertaining
to the Dental Plan and Common Dental Terms.
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General Terms
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Barred Employee
An employee who is covered by a collective bargaining agreement except
to the extent participation in the Dental Plan is provided under such agreement.
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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 an extended part-time 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.
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Change in Status
Life or work event that allows you to make changes to your elections
during the plan year and outside of Annual Enrollment.
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Covered Charges
Charges by a dentist or physician for services and supplies required for
dental care and treatment. Charges in excess of the reasonable and customary
charge made for similar services and supplies by dentists or physicians in
the same area are not covered. Where alternative services or supplies are
customarily available for such treatment, reimbursement will be based on
the least expensive service or
supply resulting in professionally adequate treatment.
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Dependent Child
- 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 if the child is residing
with the regular employee or retiree. For this purpose, a child is considered to be
residing with a regular employee or retiree if the child's permanent residence is considered
to be the residence of the regular employee or retiree. Child does not include a foster child.
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Eligible Dependents
Family members eligible for coverage are your dependents, including:
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Spouse. |
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Child who: |
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is unmarried, |
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is not employed on a regular and full time basis, and |
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is described in any one of the following paragraphs (1) through (3): |
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has not reached the end of the month during which age 25 is attained,
provided the child is chiefly dependent upon the regular employee or retiree for support
and maintenance; or |
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is totally and continuously disabled and incapable of self-sustaining
employment by reason of mental retardation, physical handicap, or mental illness due to
psychosis or severe behavioral health disorder, provided the child: |
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| (a) |
is chiefly dependent upon the regular employee or retiree for
support and maintenance,
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| (b) |
either
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(1)
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| was, or would have been, covered as an eligible dependent under this Plan immediately
prior to the birthday on which the child's eligibility would have otherwise ceased, or |
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(2)
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was covered as an eligible dependent under a predecessor plan which provided for
coverage of disability due to mental illness, if the mental illness occurred prior to the
birthday on which the child's eligibility under that plan would have otherwise
ceased, the child continued to be considered eligible for coverage because of such
mental illness and the child had not lost eligibility under the predecessor plan; |
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| (c) |
the child is disabled before such birthday and has remained continuously disabled, and
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| (d) |
if the child was disabled by reason of mental illness, is also:
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(1)
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| receiving treatment in an acute care or residential inpatient facility; |
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(2)
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receiving treatment as day treatment, in a group house or in a therapeutic halfway house; or |
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(3)
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receiving treatment under the care of a psychiatrist in a treatment plan which has been
approved through case management under this Plan; or |
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the child is recognized under a qualified medical child support order as having a right to
coverage under this Plan; or |
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A child who was disabled by reason of mental illness but who no longer meets the requirements of
paragraphs (a) or (d) of paragraph (2) above ceases to be an eligible dependent 300 days following the
date on which the applicable requirement is not met.
- If the child was disabled by reason of severe mental illness and is receiving treatment:
- In an acute care or residential inpatient facility; or
- As day treatment, in a group house, or in a therapeutic halfway house; or
- Under the care of a psychiatrist.
Please note: An eligible employee or retiree's parents are not eligible to be covered.
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Eligible Employees
Most U.S. dollar-paid employees of Exxon Mobil Corporation and
participating affiliates. Full-time employees not hired on a
temporary basis (also called "regular employees") are eligible.
Extended part-time employees, as classified on the employer's books
and records, are also eligible. Leased employees as defined in the
Internal Revenue Code, temporary or part-time employees (also
called "non-regular employees"), barred employees or special
agreement persons are not eligible to participate.
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Extended Part-time Employee
An employee who is classified as a non-regular employee, but who has been designated as an Extended Part-Time
(Enhanced Non-Regular) Employee under his or her employer's employment policies relating to
flexible work arrangements.
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Medically Necessary
A service or supply that is:
- Legal;
- Ordered by a dentist or physician;
- Not experimental or investigative;
- Reasonably required for the treatment or management of the
condition for which it is ordered; and
- Commonly and customarily recognized by the United States
dental community as appropriate in the treatment or management of the
condition for which it is ordered. The Administrator-Benefits has the
exclusive and final authority to determine if a service or supply is
medically necessary as used in the Plan. In making this determination,
the findings and assessments of the United States dental community and the
experience and expertise of the claims administrator shall be considered
along with evaluation from independent professionals. As used herein,
the "United States dental community" shall include national dental
associations, societies and organizations including, but not limited to,
the American Dental Association. The Administrator-Benefits may apply
different standards to different services or supplies in determining
medical necessity.
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Predetermination
A written pre-determination request will provide a more detailed response as to whether a treatment or service is covered under the
Dental Plan and whether the proposed cost is within reasonable and customary limits, thus ensuring all parties are aware of the financial consequences (providing all circumstances remain the same). Please note that a pre-determination, either verbal or written, is not a guarantee of payment, as claims are paid based on the actual services rendered and in accordance with Plan provisions.
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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.
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Regular Employee
Full-time employees at ExxonMobil Corporation or participating affiliates who
are not hired on a temporary basis. Regular employees include employees designated by their employer as part-time regular.
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Retiree
Generally, a person at least 55 years old who retires with 15 or more years of benefit
plan service. 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 plan service, regardless of age.
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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.
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Spouse; Marriage
All references to a spouse, to a married person or to a marriage
shall refer to spouses or marriages within the meaning of the federal
laws of the United States.
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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 his or her retirement benefit or receives a lump-sum
settlement 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.
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Abutment
Terminal tooth or root that retains or supports a bridge or a fixed or removable prosthesis.
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Appliance
A device used to provide function or therapeutic (healing) effect. An appliance may be fixed or removable.
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Bite-wing
Dental x-ray showing approximately the coronal (crown) halves
of the upper and lower jaw.
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Decay
The destruction or decomposition of a tooth as a result of bacterial action.
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Dentist
A person acting within the scope of his or her license and
holding the degree of Doctor of Dental Surgery (DDS).
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Fixed Bridge
A prosthesis replacing one or more teeth that is cemented in place
in the mouth. It consists of one or more pontics held in place by
one or more retainers on abutment teeth.
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Implant
A prosthetic device placed in the jaw to which a tooth or denture may be anchored.
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Orthodontics
The branch of dentistry primarily concerned with the detection, prevention, and correction of
abnormalities in the positioning of the teeth in their relationship to the jaws.
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Partial Denture
A prosthesis that replaces one or more, but less than all, of the
natural teeth and associated structures and is supported by the teeth
and/or the gums. It may be removable or fixed, on one side or two
sides.
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Physician
A person acting within the scope of his or her license and holding the degree of Doctor
of Medicine (M.D.).
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Pontic
The part of a fixed bridge that is suspended between the abutments and
which replaces a missing tooth or teeth.
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Prophylaxis
The removal of tartar and stains from teeth through the cleaning of the teeth by a dentist or dental hygienist.
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Restoration
Any inlay, crown, bridge, partial denture, or complete denture that
restores or replaces loss of tooth structure, teeth, or oral tissue,
which results in repair, restoration, or reformation of the shape,
form, and function of part or all of a tooth or teeth.
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Root Canal Therapy
Treatment of a tooth with damaged pulp, generally through complete
removal of the pulp, sterilization of the pulp chamber and root
canals, and filling the resulting space with sealing material.
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Space Maintainers
Fixed or removable appliances designed to maintain existing space to prevent adjacent or
opposing teeth from moving.
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