Index

About the Medical Plan

Eligibility and Enrollment

Basic Plan Features

The Prescription Drug Program

Mental Health and Chemical Dependency Care

Covered Expenses

Exclusions

Claims

Partners in Health

Continuation Coverage

Administrative and ERISA Information

Key Terms

Benefit Summary

Payments

Q. How do the Plan and I share the cost of my health care?

A. You and the Plan share costs for covered treatment and services. You pay a fixed co-payment for covered items such as a POS II network doctor's office visit and certain related lab work. For other types of care, you must satisfy an annual deductible before the Plan starts paying. If you meet your annual out-of-pocket limit, the Plan pays 100% of most covered costs for the rest of that calendar year.

Percentage Co-Payments

You share in the cost of most medical 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 network provider, the co-payment will be a fixed amount. For outpatient prescription drugs, there is a percentage co-payment.

• Fixed Co-Payment — A set amount you pay for covered services or treatments such as POS II doctor's office visits, certain related lab work and x-rays.
• Percentage Co-Payment — This is your share of the cost of certain services or treatments, such as retail and mail-order prescriptions. For medical expenses other than outpatient prescription drugs, once you meet your deductible, you and the Plan share costs until you reach your out-of-pocket limit (defined on page 73). Your share is your percentage co-payment and is typically 20% or 40% depending on the providers you select and whether you live in a network or an out-of-network area. If you reach your annual out-of-pocket limit, the Plan pays 100% of most covered charges for you for the remainder of that calendar year.

Deductible

The deductible is 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 percentage 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.

An additional hospital deductible applies to inpatient hospital services. For network hospitals, it is $75 each visit, and for non-network hospitals, the deductible is $150 each visit.

An additional emergency room deductible of $75 per visit applies which reduces the additional hospital deductible if admitted from the emergency room.

The deductible for medical, mental health and chemical dependency expenses is currently $300 per year for an individual or $600 per year for a family. If you live outside the Medical POS II area, the deductible does not apply to covered expenses for preventive care.

There are several ways for a family to meet the deductible, including:

• Two covered members of your family each meet the individual deductible.
• One person meets the individual deductible and other members of your family have combined covered charges equaling an individual deductible.
• No one person meets the individual deductible, but the combined covered charges of all members of your family equal the family deductible.

Note: A family deductible cannot be met by only one person.

Charges that Do Not Count Toward the Deductible

• Charges above reasonable and customary levels.
• Charges not covered by the Plan.
• Charge of $500 for failure to pre-certify non-POS II network hospital stays.
• POS II co-payments.
• Any outpatient prescription drug percentage co-payments.
• Your 20% co-payment for out-of-network preventive care benefits.
• Mental health or chemical dependency charges for services not pre-certified by Magellan Health Services.
• Charges for a private hospital room above the cost of the hospital's most common rate for a semiprivate room.

Adjustments to Billed Charges

When providers submit charges for payment, the following factors affect the amount that will be considered eligible for reimbursement. References to these limitations may appear on your explanation of benefits (EOB). Contact Aetna Member Services for more information. A pre-determination of benefits is strongly recommended before you incur any major or unusual expenses.

Reasonable and Customary Limits
Allowable amounts for services are determined by reasonable and customary (R&C) limits. Aetna uses the industry-wide standard for R&C limits obtained from the Prevailing Healthcare Charges System (PHCS). 

R&C limits are based on data from several surrounding regions rather than one specific zip code. R&C limits apply only to non-network providers and services. R&C for services are set at the 90th percentile of the range of charges for a particular procedure generally in the same geographic area(s).

Example:
A non-network provider charges $80 for a particular medical procedure, the reasonable and customary limit is $30, and the network provider charge is $25. Only $30 of the $80 charge will be allowed for payment. At the 60% benefit level, the Plan will pay $18 and you will be responsible for paying $12 plus the $50 difference between the reasonable and customary limit and the non-network charge for a total of $62. If you used a Medical POS II provider, you would be charged only the network-negotiated rate of $25 at the 80% network reimbursement level. You would have paid only $5 for the same service.

Incidental Charges
Aetna's current standards for incidental charges are based on the Current Procedural Terminology (CPT) codes and guidelines authored and revised by the American Medical Association since 1966. CPT coding has become the most widely accepted format, by both government and private health insurance programs, in reporting physician procedures. CPT coding furnishes health care providers with a uniform system to accurately describe medical services. CPT coding guidelines explain that services commonly carried out as an integral component of a total service or procedure should not be reported as a separate procedure.

When a claim is submitted with multiple CPT codes, Aetna uses the CPT guidelines to determine whether the charges should be considered as separate costs or if the charges are typically considered as one cost. If Aetna determines that the charges should have been submitted together under one CPT code, the separate charges would be considered incidental to the primary procedure, and the amount allowed for reimbursement would be the amount for the primary procedure.

Example 1:
Your provider administers an immunization and submits separate charges: one for the medication administered in the immunization and another for administering the shot. In most cases, an immunization should be submitted for payment using one CPT code. If it is submitted as two separate charges, Aetna uses the CPT guidelines and pays only one CPT code for the cost of the medication. The charge for administering the shot is considered to be incidental and is not paid.

Example 2:
Your provider removes a polyp from inside your nose while repairing a deviated nasal septum. The polyp removal would be considered incidental to the more complex deviated septum repair because it requires little additional time or effort. Therefore, there would be no reimbursement for the polyp removal.

Network providers have agreed to accept incidental charges reductions.

Multiple Surgeries (including bilateral procedures)
When multiple surgeries are performed, a health industry standard calculation method is used to reflect the cost savings that accompany services rendered during the same operative session. The amount allowed for multiple procedures performed during the same operative session are as follows:

• 100% for the primary procedure (typically the most complex procedure);
• 50% for the second procedure; and
• 25% for all subsequent procedures.

Procedures performed by a non-network provider are first subject to R&C limits. Those allowed amounts are further reduced by multiple surgery calculations.

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Example:
You have foot surgery involving three toes on the same foot. The following chart explains how the multiple surgery calculation works if you use a network provider.

Note: Network providers have agreed to accept multiple surgery reductions.

Surgical Assistants/Assistant Surgeons
If your physician uses a certified surgical assistant (CSA) during a procedure, any charges submitted for the CSA's services will not be allowed unless a CSA meets the definition of physician. For the medical treatment or surgical procedures to be considered covered medical expenses, a physician must perform the procedure.

If your physician is assisted during the procedure by another physician (assistant surgeon), billed charges will be reduced to 25% of the reasonable and customary (R&C) surgeon's allowance for each surgical procedure, according to the industry-standard allowance for assistant surgeon fees.

No Volitional Control
Charges incurred if you had no volitional control in determining the provider for emergency ambulance and emergency room physician services will be reimbursed at 80% after the deductible, as though a network provider was used. 

Non-network charges incurred through the use of a network provider for radiology, anesthesiology, and pathology shall also be reimbursed at 80% after the deductible, as though a network provider was used. However, charges incurred for non-network radiology, anesthesiology and pathology through non-network providers continue to be reimbursed as non-network.

Out-of-Pocket Limits
The annual out-of-pocket limit helps protect participants from high medical costs by increasing the reimbursement level when your payments for covered charges reach certain dollar limits. This limit is separate from the limits established for outpatient prescription drugs. In Medical POS II areas, the limit is different depending on whether you use network or non-network providers.

The family out-of-pocket limits work similarly, but the increased reimbursement then applies to you and all of your covered dependents — not just the person who met the individual limit.

Using Both Network and Non-Network Providers
If you live in a Medical POS II network area and you choose some network and some non-network providers, the annual out-of-pocket limit works this way:

• Once your annual out-of-pocket total from any provider (network or non-network) reaches $3,000 for an individual (or $6,000 for a family), the Plan pays 100% of covered expenses when you use network providers. However, at this point, the Plan would still pay only 60% of covered expenses for non-network medical providers.
• Once your out-of-pocket total from any provider (network or non-network) reaches $12,000 for an individual (or $24,000 for a family), the Plan pays 100% of covered medical expenses when you use a non-network provider.
• The Plan will never pay more than 50% of covered expenses for non-network mental health providers.

Expenses That Do Not Count Toward 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.
• Your 50% co-payment for using pre-certified, but non-network, mental health or chemical dependency providers.
• Mental health or chemical dependency charges for services not pre-certified by Magellan Health Services (except non-network inpatient care as stated below).
• Your 60% co-payment for not pre-certifying non-network, inpatient mental health or chemical dependency providers.
• Co-payments for outpatient prescription drugs.
• Charges for a private hospital room greater than the cost of the hospital's most common rate for a semiprivate room.

Lifetime Maximums

The maximum lifetime benefit available from the Plan under this option is $6,000,000 for each covered person. While the outpatient prescription drug charges do not count toward this limit, no benefits are available from the Prescription Drug Program once the lifetime maximum is reached.

In addition, a lifetime maximum of $25,000 for bariatric surgery for the treatment of morbid obesity exists within the $6,000,000 Plan lifetime benefit.

Coordination of Benefits

If you are covered by more than one group medical plan (e.g., your spouse's employer's medical plan), you are entitled to coverage from all plans in which you participate, but not to the extent that you collect more than 100% of the amount of the charges.

However, if you or a dependent is covered under an individual medical plan (e.g., auto insurance, homeowners insurance personal injury protection, etc), the coordination of benefits provision does not apply.

One of the plans covering you is the primary plan. Claims must be filed first with the primary plan. After the primary plan pays, file the claim with the secondary plan, including a copy of the bills and an explanation of benefits indicating the amount paid by the primary plan.

For example, if you, as an employee or retiree in this option, incur covered expenses, this Plan is primary and your spouse's plan is secondary. However, if your spouse incurs the expenses, his or her plan is primary and this Plan is secondary. This Plan is primary for retirees who are not working, regardless of other coverage under a spouse's plan.

The primary plan always pays benefits first, without considering the other plan. The secondary plan then pays based on its provisions — up to the total allowable expenses covered by that plan or up to the total of all covered expenses.

Even if this Plan is secondary, all mental health and chemical dependency treatment must be pre-certified by Magellan for the expenses to be considered eligible covered expenses except for out-of-network inpatient mental health care.

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Refer to page 29 for coordination of benefits provisions for the Prescription Drug Program.

 

Coverage of a Dependent Child
When a dependent child is covered under both parents' plans, the "birthday rule" is used: the plan of the parent whose birthday occurs earlier in the year is the primary plan. The other parent's plan is secondary. If both parents have the same birthday or the spouse's plan has not adopted the birthday rule, the Medical Plan will consider the plan that has covered the dependent child longer as primary.

There are special rules for children of divorced or separated parents. Unless specifically ordered otherwise by a court decree, the plan of the parent with custody, if he or she has not remarried, is primary and the plan of the non-custodial parent is secondary. If the parent with custody remarries, that parent's plan is primary, the stepparent's plan is secondary, and the plan of the non-custodial parent is last.

Retirees Covered by Two Plans
If a retiree covered by the Medical Plan obtains a full-time job in which the retiree is covered by the new employer's plan, that plan becomes the primary plan and the Medical Plan is secondary.

When the retiree leaves the last employer, the plan in which he or she was covered for the longer period becomes the primary plan and the other plan is secondary.

Medicare as Primary
If you or your dependent become entitled to Medicare, Medicare is assumed to be the primary plan except in the following circumstances:

• Medicare is secondary for employees and their dependents age 65 or older who are covered by the Plan through their current employment or the current employment of a spouse.
• Medicare is secondary for employees and their dependents under age 65 who are entitled to Medicare on the basis of permanent disability who are covered under the Plan either through their current employment or the current employment of a family member.
• Medicare is secondary for 30 months for employees and their dependents under age 65 who are entitled to Medicare solely on the basis of end stage renal disease (ESRD) who are covered under the Plan as a result of current employment of the employee or dependent.

Payments
If payment for covered medical expenses should have been made under this Plan, but has been made under any other plan, any insurance company or other organization may be reimbursed an amount the Administrator-Benefits determines will satisfy the intent of coordination of benefits provisions. That amount will be considered to be benefits paid under this Plan and shall fully discharge any obligation to make such payments.

Incorrect Computation of Benefits
If you believe that the amount of the benefit you receive from the Medical Plan is incorrect, you should notify the appropriate claims  administrator in writing.

If it is found that you or a beneficiary were not paid benefits you or your beneficiary were entitled to, the Plan or ExxonMobil will pay the unpaid benefits.

Similarly, if the calculation of your or your beneficiary's benefit results in an overpayment, you or your beneficiary will be required to repay the amount of the overpayment to ExxonMobil or the Plan. The plan administrator may make reasonable arrangements with you for repayment.