Index

About the Medical Plan

Eligibility and Enrollment

Basic Plan Features

The Prescription Drug Program

Covered Expenses

Exclusions

Payments

Claims

Partners in Health

Continuation Coverage

Administrative and ERISA Information

Key Terms

Benefit Summary

Mental Health and Chemical Dependency Care

Q. Does the POS II option cover mental health and chemical dependency treatment?

A. The Plan provides for mental health and chemical dependency care through a nationwide mental health PPO (MHPPO) administered by Magellan Health Services. The Aetna network is not used for mental health or chemical dependency care. Magellan Health Services provides pre-certification of both inpatient and outpatient treatment, provider referral, ongoing consultation and review, and case management for mental health and chemical dependency treatment.

The POS II option includes a number of provisions specific to mental health and chemical dependency treatment.

Pre-Certification Required

All outpatient mental health, network inpatient mental health, and chemical dependency care must be pre-certified by Magellan Health Services to be eligible for any reimbursement.

Pre-certification is required even if the Plan is secondary to other medical coverage. Whenever treatment for mental health or chemical dependency is needed, call Magellan Health Services. The telephone numbers are shown in the Information Sources section at the front of this SPD.

When you talk to the specially trained Magellan counselor, he or she will discuss your needs with you. For employees and their dependents, this service is available through ExxonMobil's Employee Health Advisory Program (EHAP). EHAP is not available to retirees and their covered dependents who have not elected COBRA. In some cases, up to eight sessions with a counselor are available at no cost to you. However, if more intense or specialized services are needed than are available through EHAP, you may be referred to a network provider immediately upon evaluation. If more treatment or specialized services not offered by EHAP are needed after you have attended some EHAP sessions, the counselor will offer you a choice of network providers in the appropriate specialty area.

Special Rules

Out-of-network Inpatient Treatment
Out-of-network inpatient mental health and chemical dependency services may be eligible for reimbursement at 40% of the network provider fee schedule even if there has been no pre-certification. This is the only mental health treatment that is eligible for reimbursement without pre-certification by Magellan.

Emergency Treatment
If emergency mental health or chemical dependency care is needed:

• The patient (or a responsible adult, if the patient is incapable) should contact Magellan and indicate that there is an emergency. Magellan will direct the patient to the nearest MHPPO facility for treatment.
• If it is not feasible to contact Magellan in an emergency, the patient should seek treatment at the nearest emergency facility. However, Magellan must be notified:
  • Within 48 hours of treatment or admission; or
  • Within 72 hours of a weekend or holiday treatment or admission.

If you notify Magellan within the time periods above, expenses for emergency care at an MHPPO facility will be reimbursed at the 80% benefit level. If you do not notify Magellan within the time periods above, no reimbursement will be made.

If the patient is admitted and the emergency facility does not participate in the MHPPO, Magellan will work with the emergency care treatment team to arrange a transfer to an MHPPO facility as soon as possible after the patient is stabilized. Expenses for emergency care at a non-network MHPPO facility will be reimbursed at the 50% benefit level.

If you require mental health or chemical dependency care in conjunction with a medical emergency, you must notify Magellan within the time periods described above.

Mental Health PPO

The Mental Health PPO (MHPPO) is a nationwide network of providers who offer quality, cost-effective care. MHPPO providers work with Magellan Health Services to develop suitable treatment plans and provide needed services.

If You Use Mental Health Network Providers
You pay $30 for most outpatient office visits for care provided by a specialist, with no annual deductible. If you need intensive outpatient or inpatient treatment, your covered expenses are reimbursed at 80% after the annual deductible is satisfied. There are no limits on the number of inpatient days or outpatient visits per year as long as the network care is certified by Magellan Health Services. Only the lifetime maximum benefit limit applies. The portion of expenses you pay for both inpatient and outpatient care is applied to the annual out-of-pocket limit.

Coverage for inpatient chemical dependency treatment is limited to four admissions per lifetime for each covered person, whether network or non-network providers are used. A separate inpatient chemical dependency treatment occurs if a person receives inpatient services for the same chemical dependency diagnostic group and it has been 30 days or more from the time of the inpatient discharge until the new inpatient admission date.

For inpatient mental health and chemical dependency treatment to be reimbursed at the network level, both the provider and the facility must participate in the MHPPO network. If either the provider or the facility is non-network, all expenses associated with the confinement will be reimbursed at the non-network level, out-of-pocket expenses will not apply to the out-of-pocket limit, and any confinement days will count toward the annual non-network limits.

If You Do Not Use Mental Health Network Providers
Non-network inpatient mental health and chemical dependency care does not have to be pre-certified to be reimbursed. However, the level of reimbursement is higher if your non-network inpatient mental health and chemical dependency care is pre-certified. You must contact Magellan Health Services for pre-certification of all other care for any expenses to be reimbursed. Remember:

• Magellan can arrange an appointment with an EHAP counselor to discuss needed care and provider selection.
• If you are referred, even in an emergency, by a Medical POS II network provider to a mental health provider, you must pre-certify with Magellan to receive maximum reimbursement of expenses .
• If you are certain that you will consider only a non-network provider for your care, Magellan will initially certify up to five outpatient visits which must occur within 30 days of the certification.

If you use a non-network outpatient provider, the provider must present a proposed treatment plan to Magellan before additional care can be certified. Proposed care under that plan will be reviewed by Magellan. Magellan determines the number of visits and a time frame for those visits to occur with each certification. The provider must contact Magellan for further review and possible additional certification before the end of the time frame for treatment or number of visits, whichever comes first, from the previous certification. It is your responsibility to ensure that your non-network outpatient provider follows these procedures and certifications are obtained – otherwise, no benefits are payable.

After the annual deductible is satisfied, certified non-network outpatient care will be reimbursed at 50% of the Magellan network provider fee schedule or 50% of the actual charges for approved services, whichever is less. Non-network inpatient care that does not require certification will be reimbursed at 40% of the network provider fee schedule or 40% of the actual charges for approved services, whichever is less.

Benefits for non-network care are limited to:

• 30 inpatient days per year.
• 52 outpatient visits per year.
• Four chemical dependency inpatient confinements per lifetime including both network and non-network providers.

Non-network mental health expenses do not apply to the annual out-of-pocket limit. Even if you reach the annual out-of-pocket limit for other medical expenses, there is no limit on the amount of non-network mental health expenses you may owe. Any treatment received during a calendar year, including prior treatment provided by a network provider, will be counted toward the annual or lifetime limits established for care provided by non-network providers.

Example — Payment of Network and Non-Network Expenses for Inpatient Mental Health and Chemical Dependency Cases:

Assume you submit a claim for covered inpatient expenses to the Plan. Magellan determines that network charges for your treatment would be $15,000. Also assume that a non-network provider charged $19,000 for the same service. Here is how payment of both network and non-network certified and non-certified expenses would compare:

Mental Health Care Outside the United States

If you live or travel outside the United States and need treatment for a mental health or chemical dependency condition, you must contact Magellan Health Services in advance of receiving care to pre-certify inpatient and outpatient care.

Currently, there are no network providers outside the United States. However, Magellan will recommend providers with whom they have experience. As long as you call and pre-certify care with Magellan, you may choose your own provider. Certified treatment received is reimbursed at 80% after you satisfy the annual deductible. If you do not pre-certify inpatient care, eligible charges may be reimbursed at 40%. If you do not pre-certify outpatient care, no reimbursement will be made. The same emergency care procedures apply inside and outside the United States.