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Covered Expenses
- Specific Coverage
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Covered Expenses
Q. What types of medical services are covered by the Plan?
A. The Plan covers a wide range of health care services,
tests, treatments, and supplies. For plan purposes, all covered expenses
must be medically necessary
and not excluded. Generally Aetna's Coverage Policy Bulletins (CPBs) are
relied upon to ensure consistent determination of coverage under the
Medical Plan. Aetna's CPB's may be viewed online at www.aetna.com/cpb/cpb_menu.html.
Covered Expenses (POS II "A" and
"B")
Services covered by the Plan are listed below. Services not listed as a
covered expense are excluded.
- Acupuncture if performed by a physician.
- Ambulatory surgical center, care, or services.
An ambulatory surgical center:
- Is established, equipped and operated in accordance with applicable
local laws primarily for the purpose of performing surgical procedures;
- Is operated under the full-time supervision of a licensed
doctor of medicine or doctor of osteopathy;
- Permits a surgical procedure to be performed only by a duly qualified
physician who, at the time the procedure is performed, has admitting privileges in at least one
hospital to perform such a procedure;
- Has at least two operating rooms and at least one post-anesthesia recovery room, is equipped to perform x-ray and laboratory examinations, and has available trained personnel and necessary equipment, including a defibrillator,
a tracheotomy set, and a blood supply, to handle foreseeable emergencies;
- Provides the full-time services of one or more registered graduate nurses
for patient care in
operating rooms and in the post-anesthesia recovery room;
- Maintains a written agreement with at least one hospital in the area for immediate acceptance of patients who develop
complications or require post-operative confinement; and
- Maintains appropriate medical records for each patient.
- Braces, crutches and prostheses required because of an injury or disease. Coverage is generally limited to the first charge.
- Chiropractic services, performed by a licensed
doctor of chiropractic who is acting within the scope of his or
her license, up to $1,000 per person per year (benefits paid for
acupuncture and supplies billed by a doctor of chiropractic are
not included in the $1,000 annual maximum).
- Dental work required by an accidental injury to sound, natural teeth or the mouth. Also, certain cutting procedures in the mouth.
(See Dental Treatment on page 39).
- Doctor visits at home, a hospital or an office, including emergency room care.
- Drugs and medicines obtainable only with a physician's prescription and approved by the U.S. Food and Drug Administration for the specific diagnosis.
- Durable medical equipment purchase, rental, repair or replacement. Durable medical equipment includes items such as wheelchairs,
hospital beds, mechanical ventilators, and equipment for administering oxygen.
A pre-determination is recommended.
- Extended Care Facility when pre-certified.
(See page 39 for more details).
- Hearing aids. (See Hearing Aids on page
40 for more details).
- Hospice care when pre-certified. (See page
20 for more details).
- Hospital emergency room care, including surgical care and other related charges.
- Hospital semi-private room and board, x-ray and pharmacy, tests and other medical supplies and services received in a hospital.
- Inpatient services performed by surgeons, anesthesiologists, and other physicians.
- Insulin and diabetic supplies.
- Morbid obesity (generally 100% or more over ideal body weight) treatments including physician expenses for the initial office visit and laboratory costs.
Contact Aetna Member Services for guidelines regarding eligibility and approved programs for this coverage.
- Network mental health and chemical dependency
treatment (both inpatient and outpatient) and out-of-network
inpatient mental health and chemical dependency treatment.
- Nutritional counseling consistent with Aetna's
Clinical Policy Bulletins for anorexia nervosa and bulimia
nervosa, when supervised and billed by a doctor.
- Oral-motor therapy ordered by a physician for
treatment of dysphagia or hypotonia.
- Outpatient medical tests and surgery.
- Physical therapy or occupational therapy for treatment of illness, injury or disease, which is performed by a licensed physical or
occupational therapist who is acting within the scope of his or her license. (Because these therapies often involve multiple visits, written submission of the proposed
treatment plan for a benefit pre-determination is strongly
recommended).
- Prescription smoking deterrent medications.
- Preventive care services. (See page
25 for details).
- Private-duty nursing care rendered by a nurse when
furnished outside of a hospital if such care requires a nurse's services and
it is determined that such services are neither primarily custodial in nature nor could be provided
by a person other than a nurse.
- Professional emergency transportation services. The Plan pays for medically necessary
trips to or from the nearest facility capable of handling the situation.
In addition, the Plan pays for transportation to the nearest POS II
network facility once
the patient is stabilized in a non-network facility.
- Reconstructive surgery including, but not limited to, surgery required because of a mastectomy.
The Plan pays benefits for:
- Reconstructive surgery of the breast on which the surgery was performed.
- Reconstructive surgery of the other breast in order to produce symmetry.
- Prostheses for physical complications of mastectomy.
- Services related to the pregnancy of a covered dependent child, but not those
related to the child born to the dependent.
- Skilled-nursing care when pre-certified. (See page
40 for more details).
- Speech therapy, on an outpatient basis, to:
- Restore speech after a demonstrated previous ability to speak is lost or impaired;
- Improve or develop speech after surgery to correct a birth defect which impaired or
would have impaired the ability to speak; or
- Improve or develop speech lost or impaired by an irreversible and
permanent profound hearing loss resulting from a birth defect.
(See Speech Therapy under Exclusions.
Submission of a proposed treatment plan for a benefit
predetermination is strongly recommended.)
- Sterilization procedures.
- Treatment of temporomandibular disorders, sometimes referred to as "TMJ," including splints and orthotics.
Pre-determination of benefits is strongly recommended.
- Vision examinations and eyeglasses or contact lenses needed
because of injury or disease.
- Vision therapy by a physician for amblyopia and strabismus up to a maximum of 32 vision
therapy visits or sessions.
Specific Coverage
Dental Treatment
Certain dental expenses are covered under the POS II "A" and
"B" options. These include charges by a dentist or oral surgeon
for treating fractures or dislocations of the jaw or for treating teeth and
surrounding tissue damaged because of an injury sustained. Also covered are
certain cutting procedures in the mouth, including:
- Impacted and unerupted teeth.
- Removing a tumor.
- Removing or draining an abcess or cyst.
- The alveolar process (alveoplasty and vestibuloplasty).
- Gingivectomy.
For a complete list of oral surgery procedures which may
also be considered for payment under the ExxonMobil Dental Plan, consult the
ExxonMobil Dental Plan SPD. If you incur dental expenses that may be covered under this
option, submit your claim to Aetna Member Services. After determining benefits
payable under this option, the claim will be processed as a dental claim (for
coordination of benefits) for participants in the ExxonMobil Dental Plan. If
you are not a participant in the ExxonMobil Dental Plan, when you receive an
explanation of benefits, send the explanation and a copy of your bills along
with a claim form to your other dental plan claims office.
Extended-Care Facilities
An extended-care facility provides skilled-nursing services and rehabilitation
care. Extended-care facility charges are covered expenses if these conditions are
met:
Reimbursement is based on the facility charge or daily room and board rate of the
hospital from which the patient transferred, whichever is less.
Skilled-nursing Care
Skilled-nursing care is covered if medically necessary and pre-certified.
Nursing care that helps a person meet personal needs and daily living activities,
such as bathing, dressing, eating or administering oral medication, even if
ordered by a physician and performed by a licensed medical professional, is
considered custodial and is not a covered expense eligible for benefits. Also,
charges for a private-duty nurse in a hospital or an extended-care facility
are not covered.
Skilled Care
Skilled care involves nursing or rehabilitation services that can be
provided only by licensed medical professionals. For example, intravenous
feeding is a skilled service.
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Hearing Aids
Benefits are provided up to a maximum of $2,500 after the deductible and
co-insurance are paid for one or more medically necessary hearing aids
every rolling five year period, which also includes the repair of a hearing
aid. However, shipping and handling charges and routine maintenance such as
battery replacement are not covered.
There are no Medical POS II preferred providers for hearing
aids and related materials.
Before incurring any expense for hearing aids,
you should contact Aetna Member Services for a pre-determination of benefits
(see page 69).
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Organ, Tissue and Bone Marrow Transplants
Aetna's National Medical Excellence® Program (NME Program) coordinates all aspects of
organ, tissue, and bone marrow transplants and other complex specialized care.
Providers in this program are recognized as centers of excellence with
demonstrated improved outcomes in their area of expertise. In addition, if
travel over 100 miles is required, transportation and lodging for the patient
and a family member will be covered. The NME Program is separate and distinct
from the Centers of Excellence described in the Partners in Health section of
this SPD.
The NME Program is available on a voluntary basis. Contact Aetna Member
Services for information.
Case Management Alternative Treatment Program
If as a
result of a catastrophic or chronic illness or injury or in conjunction with
certain organ transplant procedures, a participant proposes an alternative
course of treatment, the Administrator-Benefits may waive any exclusion or
limitation under the Plan which would otherwise apply to covered medical
expenses, the reimbursable portions of covered medical expenses or out of
pocket limits if such waiver would result in overall cost savings to the
Plan. The review will include factors such as the efficacy of the proposed
treatment, the patient's condition, availability and efficacy of other
treatments that are approved for the patient's diagnosis, and the prior use
of appropriate treatments for the condition. Such approval must be prior to
the participant commencing the alternative course of treatment.
Treatment of Last Resort
In life-threatening situations,
experimental or investigational treatment may
be considered a covered expense as a treatment of last resort. A person's
condition is considered life-threatening if there is a reasonable likelihood
that death will result in a matter of months without treatment or that
premature death will occur without early treatment. In this case, proposed
experimental or investigational treatments will be reviewed by a panel of
specialty-matched experts. The review will include factors such as the efficacy
of the proposed treatment, the patient's condition, availability and efficacy of
other treatments that are approved for the patient's diagnosis, and the prior use
of appropriate treatments for the condition.
Treatment of last resort must be authorized by the Administrator-Benefits,
and will be based on the fact that the
covered person's condition is
life-threatening and the treatment is recommended by a panel of
specialty-matched physicians chosen to review the treatment.
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