ExxonMobil Dental Plan SPD
Updated
Through 2012
About The Dental Plan
This summary plan description (SPD) is a summary of the ExxonMobil Dental Plan. It does not contain all the Plan details.
In determining your specific benefits, the full provisions of the formal
documents, as they exist now or as they may exist in the future, always govern.
You may obtain copies of these documents by making a written request to the
Administrator-Benefits. Exxon Mobil Corporation reserves the right to change benefits
in any way or terminate any benefit at any time.
The Dental Plan is self-insured. There is no insurance company to
collect premiums or underwrite coverage. Instead, contributions from you and ExxonMobil
pay all benefits. Prior claims experience and forecasted expenses are used to determine
the amount of money needed to pay future benefits. These options are governed by
federal laws, not by state insurance laws.
Applicability to represented employees is governed by collective bargaining agreements and any local bargaining requirements.
Information Sources
When you need information, you may contact:
Claims and Dental Preferred Provider Organization (PPO) Administrator — Provides
claim payment information, Aetna Dental PPO provider and claim forms.
Phone Numbers: |
Address: |
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Aetna Member Services
800-255-2386 OR
210-366-2416 (international, call collect)
Monday - Friday (8 a.m. to 6 p.m. CT), except certain holidays
Automated Voice Response - 24 hours a day, 7 days a week |
Aetna
P. O. Box 14094
Lexington, KY 40512-4094 |
Benefits Administration — Customer
Service Representatives can provide specialized assistance.
References to Benefits Administration throughout this SPD pertain to either
ExxonMobil Benefits Administration or ExxonMobil Benefits Service Center as listed
below. Depending on your status (employee, retiree, or survivor), you
should contact the appropriate service center.
Employees can enroll/change benefits on the ExxonMobil Me HR Intranet site through Employee
Direct Access (EDA) when a change in status occurs. Enrollment forms are also
available through ExxonMobil Benefits Administration for those without access to
EDA.
Phone Numbers: |
Address: |
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Employees call:
ExxonMobil Benefits Administration/Health Plan Services
Monday - Friday 8:00 a.m. to 3:00 p.m. (U.S. Central Time), except certain holidays
713-680-5858 (Houston)
713-680-7070 (international, call collect)
800-262-2363 (toll free outside Houston)
262-314-2752 (fax) |
ExxonMobil Benefits Administration
ExxonMobil BA BSC USBA
4300 Dacoma or "BH1"
Houston, TX 77092 |
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Retirees and Survivors call:
ExxonMobil Benefits Service Center
Monday – Friday 8:00 a.m. to 6:00 p.m.
(U.S. Eastern Time), except certain holidays
Toll-Free: 1-800-682-2847
or 800-TDD-TDD4 (833-8334) for hearing impaired |
ExxonMobil Benefits
Service Center
PO Box 199540
Dallas, TX 75219-9722 |
ExxonMobil Sponsored Sites — Access to plan-related information
including claim forms for employees, retirees, survivors, and their family members.
- ExxonMobil Me, the Human Resources Intranet Site —
Can be accessed at work by employees.
- ExxonMobil Family, the Human Resources Internet Site —
Can be accessed from home by everyone at www.exxonmobilfamily.com.
- Retiree Online Community Internet Site — Can be accessed from home by
retirees
and survivors only at www.emretiree.com.
- ExxonMobil Benefits Service Center at ACS
Internet Site —
Can be accessed from home by everyone at www.exxonmobil.com/benefits.
Aetna does not render dental services or treatments. Neither the Plan nor Aetna is responsible for the services that are delivered by providers participating in the Aetna Dental PPO and those providers are solely responsible for the dental services they deliver. Providers are not the agents or employees of the Plan or Aetna.
Introduction
The ExxonMobil Dental Plan (the Plan) encourages good dental health by paying, within plan limits, for 100% of the cost of preventive services and part of the cost of other general and major services, including orthodontia. The Plan offers you the opportunity to use the Aetna Dental PPO Network, a voluntary PPO, giving you access to dentists and dental specialists who have agreed to negotiated rates. In most cases, these rates will be lower than non-network dentists' rates and can generally reduce your out-of-pocket expenses while maximizing the annual plan benefits by using this network. ExxonMobil's dental plan is described in detail in this SPD. These tools help you find specific information quickly and easily:
- Plan at a Glance, a quick user's guide highlighting plan basics.
- Charts and tables throughout this SPD provide information, examples, highlights of plan provisions, etc.
- References to sources of additional information.
- Key Terms containing definitions of some words and terms used
in this SPD. Terms are underlined and linked for easy identification.
A careful reading of this SPD will help you understand how the
Plan works so you can make the best use of the Plan provisions.
Plan at a Glance
Enrolling
You may enroll yourself and your eligible family members within your first 60 days of employment or within 60 days of a subsequent change in status or at Annual Enrollment. See page 7.
The Dental PPO
You are free to visit any dentist - and save when you choose a dentist who participates in the Aetna Dental PPO network. The negotiated rates for the dentist’s services are always within reasonable and customary (R&C) limits and generally lower than rates charged by non-network dentists which helps you maximize your annual plan benefit by paying less out of pocket for covered services. See page 16.
Covered and Excluded Expenses
The Plan provides benefits for many, but not all, preventive, general, major and
orthodontic services. See pages 18-21 and 22-23.
Payments
You and the Plan share the costs for covered treatments and services. You pay a
deductible before the Plan begins paying for certain benefits. For each covered
person, the Plan pays up to $2,000 each calendar year and up to a $2,000 lifetime
maximum benefit for covered orthodontic expenses. See page 24.
Claims
Dental PPO providers file claims for you. You are responsible for ensuring that
claims for non-network care are filed. See page 29.
Consolidated Omnibus Budget Reconciliation Act 1985 (COBRA)
You and your family members who lose eligibility may continue dental coverage for a
limited time in certain circumstances. See page 33.
Administrative and ERISA Information
This Plan is subject to rules of the federal government, including the Employee Retirement
Income Security Act of 1974, (ERISA) as amended, not state insurance laws. See page
38.
Key Terms
This is an alphabetized list of words and phrases, with their definitions,
used in this SPD. See page 45.
Benefit Summary
A brief summary of benefits. See page 52.
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