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Key Terms
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Key Terms
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Barred Employee
An employee who is covered by a collective bargaining agreement except
to the extent participation 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 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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Benefit Pre-Determination
The review of proposed treatment or services before the expense is incurred to determine if,
and to what extent, charges will be covered by the Plan.
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Case Management
Review provided by medical professionals who consult with the patient and/or care
providers to determine effective, cost-efficient ways to treat illnesses and
utilize plan benefits.
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Co-Payments
Your share of medical (including out-patient prescription drugs) and mental health and chemical dependency expenses.
For some services, such as hospital stays, the co-payment will be a percentage
of the cost of the service once the deductible has been satisfied. For other
services, such as routine office visits to a POS II provider, the co-payment will
be a fixed amount. For outpatient prescription drugs there is a percentage
co-payment.
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Covered Medical Expense
- For treatment of injury or sickness — a medically necessary expense incurred
by a covered person that is not excluded from coverage;
- For treatment of mental health or chemical dependency — a medically
necessary expense that is certified in advance of actual treatment or an out-of-network
inpatient treatment, that is provided according to the terms of the Plan, and
that is not otherwise excluded from coverage.
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Covered Person
Any person identified on the books of the employer as a regular employee, retiree, extended part-time
employee,
eligible dependent, or survivor who:
- Complies with the established enrollment requirements and makes
any required contributions;
- In the case of a retiree, dependent, or survivor,
is not eligible for Medicare; and
- Is not eligible for any other medical plan to which ExxonMobil
contributes on their behalf.
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Custodial Care
Care that helps meet personal needs and daily living activities. Such care, even if
ordered by a doctor and performed by a licensed medical professional such as a
nurse, is not covered by the Plan.
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Deductible
The amount of covered expenses you must pay each calendar year before the
Plan begins sharing the cost. Fixed amount co-payments do not apply toward
this amount. Outpatient prescription drug co-payments are not subject to nor
do they count toward the annual deductible. Services and supplies not
provided for a fixed co-payment are subject to an annual deductible, which
must be met before the Plan begins to pay.
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Dependent Child
An unmarried person under age 25 who is
- 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.
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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
are eligible. 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.
The following are not eligible to participate in the Plan: employees
of Station Operators, Inc. (SOI), leased employees as defined in the Internal
Revenue Code, barred employees, or special agreement persons as defined in the
plan document. Generally, special-agreement persons are persons paid by the
company on a commission basis, persons working for an unaffiliated company
that provides services to the company, and persons working for the company
pursuant to a contract that excludes coverage of benefits.
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Experimental or Investigational
A medical treatment or procedure, or a drug, device, or biological product, is
experimental or investigational if any of the following apply:
- The drug, device, or biological product cannot be lawfully marketed without approval of
the U.S. Food and Drug Administration (FDA); and, approval for marketing has
not been given at the time it is furnished; [Note: Approval means all forms
of acceptance by the FDA.]
- Reliable evidence shows that it is the subject of ongoing phase I, II, or III
clinical trials or under study to determine its maximum tolerated dose, its
toxicity, its safety, its efficacy, or its efficacy as compared with the
standard means of treatment or diagnosis; or
- Reliable evidence shows that the consensus of opinion among experts regarding
the drug, device, or biological product or medical treatment or procedure, is
that further studies or clinical trials are necessary to determine its maximum
tolerated dose, its toxicity, its safety, its efficacy, or its efficacy as
compared with the standard means of treatment or diagnosis. Reliable evidence
shall mean only:
- Peer reviewed, published reports and articles in the
authoritative medical and scientific literature;
- The written protocol or protocols used by the treating facility or
the protocol(s) of another facility studying substantially the same drug, device, or biological product or medical treatment or procedure; or
- The written informed consent used by the treating facility or by another facility studying substantially
the same drug, device, or medical treatment or procedure.
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Extended-Care Facility
An institution that meets the following criteria:
- Provides 24-hour skilled nursing care and related services for the rehabilitation of injured or sick persons.
- Has policies developed with the advice of and subject to the review of professional
personnel to cover nursing care and related services.
- Has a physician, a registered professional nurse or a medical staff responsible for the execution of such policies.
- Requires that every patient be under the care of a physician and
makes a physician available to furnish medical care in an emergency.
- Maintains clinical records on each patient and has appropriate methods for
dispensing drugs and biologicals.
- Provides for periodic review by a group of physicians to examine
the need for admissions, adequacy of care, duration of stay and the medical
necessity of continuing confinement of patients.
- Is licensed pursuant to law or is approved by an appropriate authority
as qualifying for licensing.
- Does not include a place that is primarily for custodial care.
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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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ExxonMobil Medical Plan
The Plan sponsored by Exxon Mobil Corporation which provides medical benefits for eligible
employees, retirees, survivors and their dependents, and includes the
POS II option (described in this SPD) and HMO options.
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Hospital
An institution which:
- Is licensed as a hospital (if licensing is required);
- Is operated pursuant to law for the care and treatment of sick and injured persons;
- Provides 24-hour nursing care and has facilities both for diagnosis and surgery, except
in the case of a hospital primarily concerned with the treatment of chronic
diseases; and
- Is not a hotel, rest home, nursing home, convalescent home, place
for custodial care, or home for the aged.
For purposes of this definition, "hospital" shall also mean, with respect to treatment of
chemical dependency, a treatment facility, residential facility, or a clinic
licensed or approved for such treatment by the appropriate authority for the
jurisdiction in which the facility or clinic is located.
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Lifetime Maximum Benefit
The cumulative amount of benefit, not to exceed $6,000,000, paid under the Plan for any
covered person during the person's lifetime, excluding the amount of benefits
paid for outpatient prescription drugs.
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Medical Necessity or Medically Necessary
- Legal;
- Ordered by a physician for medical treatment;
- Reasonably required for the treatment or management of the condition
for which it is ordered; and
- Commonly and customarily prescribed by the United
States medical community
as treatment or management of the condition for which it is ordered.
Magellan Health Services may use its guidelines in an initial determination of whether
a mental health service or supply is medically necessary.
The Administrator-Benefits has the exclusive and final authority to determine
if a service or supply is medically necessary.
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Medical Pre-Certification
Certification obtained prior to a hospital inpatient stay to give notice of in-patient admission and the proposed care.
If pre-certification notice is not given, the first $500 of expenses will not
be covered.
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Medical POS II (Point of
Service)
A network of established physicians, hospitals and other medical care
providers whose credentials have been screened according to Aetna's
standards and who have agreed to provide their services at negotiated
rates. The Medical Plan POS II is a network specifically selected by the
Plan — it is part of Aetna's Choice®
POS II. This network is
referred to in this SPD as the Medical POS II.
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Mental Health Condition
Neurosis, psychoneurosis, psychopathy, psychosis, or mental or emotional disease or behavioral
disorder or disturbance with a diagnosis code from the American Psychiatric
Association, Diagnostic and Statistical Manual of Mental Disorders
(4th ed. 1994) (DSM-IV), or its successor publication, and which is
appropriately treated by the Mental Health Network. Such a condition will be
considered a mental health condition, regardless of any organic or physical
cause or contributing factor.
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Mental Health Provider
A person, including a psychiatrist, psychologist, psychiatric nurse or social worker, therapist,
or other clinician with at least a master's degree, who provides inpatient or
outpatient treatment for a mental health condition, who is licensed in the
state of practice and who is acting within the scope of that license (if
applicable). If the person is not subject to a licensing requirement, the
person must provide treatment consistent with that which would be provided
by the type of providers listed above.
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Network
Providers and facilities that participate in the medical POS II
network or mental
health PPO network available
under the POS II option.
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Non-Network
Providers and facilities located in the medical POS II or mental health
PPO network areas, but which do
not participate in a network available under this
Plan.
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Nurse
A registered graduate nurse (RN), a licensed vocational nurse (LVN), or a licensed practical nurse (LPN).
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Out-of-Pocket Limit
The amount of covered medical expenses you pay in one year before the Plan begins paying 100%.
After the out-of-pocket limit is reached, the Plan pays 100% of most covered
expenses for the remainder of that year. Certain expenses that you pay do not
apply to the out-of-pocket limit. The annual deductible and your percentage
co-payments for eligible expenses apply to the out-of-pocket limit. The
following charges do not apply to the out-of-pocket limit:
- Charges above reasonable and customary limits.
- Charges not covered by the Plan.
- Charge of $500 for non-compliance with medical pre-admission review process.
- 50% co-payment for using pre-certified,
but non-network, mental health or chemical dependency providers.
- 60% co-payment for using non-pre-certified, non-network inpatient mental health
or chemical dependency providers.
- Mental health or chemical dependency charges for services
not pre-certified by Magellan Health Services.
- Co-payments for outpatient prescription drugs.
- Charges for a private hospital room above the cost of the hospital's most common rate for a semiprivate room.
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Outpatient Prescription Drug
A prescription drug or medicine obtained through either a retail pharmacy or through a mail
service prescription program (including insulin and associated diabetic supplies
if acquired through a prescription). A prescription drug or medicine, including
injections, obtained or administered in a physician's office or in a hospital
are not considered outpatient prescription drugs.
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Physician
"Physician" means a person acting within the scope of
his or her license and holding the degree of Doctor of Medicine (M.D.),
Doctor of Osteopathy (D.O.), Doctor
of Dental Surgery (D.D.S.), Doctor of Podiatry (D.P.M.), Doctor of
Optometry (O.D.), or Doctor of Chiropractic (D.C.), or who is
duly licensed as an Orthoptist, a Physician Assistant or Nurse
Practicioner.
"Primary Care Physician" means a Physician
engaged in general practice, family practice, internal medicine
or pediatrics who provides basic health services to covered
persons.
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Predetermination
A written pre-determination request will result in a
detailed response as to whether a treatment or service is
covered under the Medical 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 described in the request remain unchanged).
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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Primary Participant
The term primary participant refers to the participant whose identification number is used.
The primary participant is the employee, retiree, survivor or an individual who
elected COBRA coverage. Covered dependents use the primary participant's
identification number to access all medical benefits.
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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.
You may obtain, without charge, a copy of the Plan's procedures governing QMCSO determinations
by written request to the Administrator-Benefits.
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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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Room and Board
Room, board, general-duty nursing and any other services regularly furnished by the hospital
as a condition of being hospitalized. It does not include professional services of
physicians or private-duty nursing.
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Surgical Procedure
This term refers to the following:
- A cutting operation.
- Suturing a wound.
- Treating a fracture.
- Reduction of a dislocation.
- Radiotherapy (excluding radioactive isotope therapy)
if used in lieu of a cutting operation for removal of a tumor.
- Electrocauterization.
- Diagnostic and therapeutic endoscopic procedures.
- Injection treatment of certain conditions.
- Laser treatments.
Note: Minor procedures such as biopsies or removal of moles or warts, even if
performed in a doctor's office, are considered surgery.
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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 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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Treatment of Last Resort
With respect to a covered person's specific medical condition, any
hospital confinement, examination, surgical, medical or other
treatment, service or supply that is not determined to be
medically necessary for the treatment of such condition by virtue
of being experimental or investigative, but that is authorized by
the Administrator-Benefits under the following conditions:
- the covered person's condition is life-threatening; and
- the treatment is recommended by a treatment panel,
which consists of a panel of physicians chosen by the
Administrator-Benefits for purposes of reviewing potential treatments of
last resort, and which makes such recommendations after considering:
- the scientific basis, if any, for the treatment;
- the prior use of appropriate treatment alternatives; and
- the potential efficacy of the treatment, the patient's physical
condition, and the status of any government review of the treatment's use to
address such condition.
For purposes of Treatment of Last Resort, a person's condition
is considered to be life-threatening if there is a reasonable likelihood that
it will result in the person's death within a matter of months or it is likely
premature death will occur without early treatment.
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