About Dental

Eligibility and Enrollment

Dental PPO

Covered Expenses

Exclusions

Claims

Continuation Coverage

Administrative and ERISA Information

Key Terms

Benefit Summary

Payments

Q. How are payments determined?

A. The Plan helps you and your family members with dental expenses. You and the Plan share costs for covered treatment and services. You pay a percentage co-payment for most covered expenses. You must satisfy an annual deductible before the Plan starts paying on covered non-preventive services. The Plan also has an annual maximum and a lifetime orthodontia maximum amount. Once the maximum lifetime benefit maximum has been paid, no other benefits will be paid under any circumstances. Once the Plan has paid charges for covered expenses up to the maximum, you are responsible for all charges above the maximum. See Adjustments to Billed Charges on page 26 for other factors that may affect reimbursement.

This section explains some of the terms and provisions you need to know to use the Plan to your best advantage.

Annual Maximum

The maximum benefit available from the Plan is $2,000 of covered expenses each calendar year for each covered person. This annual maximum benefit is determined after you pay any necessary deductibles and co-payments. This does not apply to covered orthodontic expenses, which have a separate lifetime limit of $2,000.

Once the annual maximum benefit has been paid, no other benefits are available under any circumstances. You are responsible for all charges above the annual maximum benefit.

Example:
You have had several dental procedures totaling $1,800 between January 1st and July 31st. You have $200 remaining until you reach the annual maximum. On September 2nd, you have a dental procedure performed, and the cost to the Plan is $300. Since the annual maximum is $2,000, the Plan will pay only $200 of the charge. You are responsible for $100, and no benefits are available for dental work performed during the rest of the calendar year.

However, beginning January 1st of the following year, a new annual maximum benefit  will be available to pay charges for covered expenses incurred during that calendar year.

Deductibles

The deductible is the amount of covered expenses you must pay each calendar year before the Plan begins sharing the cost. You do not pay a deductible for preventive or orthodontic services. An annual deductible must be met for general and major services. A $50 deductible applies to each covered person. Once deductibles for your family reach $150, your family has satisfied the deductible requirements for the year. The deductible does not include any amounts above the reasonable and customary limits (see Reasonable and Customary Limits section on page 26).

Percentage Co-payments

The co-payment is the percentage of the cost of covered dental treatment or services that you pay. You pay a 20% co-payment for general services and a 50% co-payment for major and orthodontic services.

Orthodontia Lifetime Maximum

The Plan pays up to $2,000 for covered orthodontic expenses for the lifetime of each covered person. This is in addition to the annual maximum benefit for other types of dental care.

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. 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. The Plan's claims administrator determines R&C limits. These limits are based on data obtained from the Prevailing Healthcare Charges System owned by FAIR Health. R&C limits for services are set at the 90th percentile of the range of charges for a particular procedure in the same geographic area(s). R&C limits apply only to non-network providers and services.

If any non-network provider charges a fee that exceeds the R&C limit, you are responsible for the excess amount. The amount above the R&C limit does not apply toward your annual deductible or your percentage co-payments. To find out if a proposed charge is within R&C limits, contact Aetna Member Services. PPO provider negotiated rates are always within R&C limits.

Example:
Assume that the R&C charge in your area for a tooth filling is $120, your non-network dentist charges $140 to fill your tooth, and the network dentist's negotiated charge is $100.

Alternative Course of Treatment
In situations where an alternative course of treatment would provide professionally adequate (based on American Dental Association guidelines) results at a lower cost, the lower-cost treatment is considered the covered expense.

The alternative course of treatment is determined either at the time a pre-determination is made or when the claim is processed. Reimbursement and subsequent repairs, replacement, or servicing is based on that alternative course of treatment. Use the Plan's pre-determination of benefits feature to avoid unexpected expenses.

If you incur a service that is eligible for an alternative course of treatment without a pre-determination or you choose not to use the alternative course of treatment identified during a pre-determination, you will be responsible for the following:

• Any reasonable and customary charges that you may incur while using a non-PPO provider.
• The difference in cost between the alternative course of treatment and the treatment performed.
• Your co-payment based on the alternative course of treatment, if your deductible has been met.

Example:
Assume that you have a missing tooth and you would like it replaced with a dental implant. Your provider is a Dental PPO network provider and the charge is $800. When you submit your treatment plan for a pre-determination of benefits, Aetna determines that a medically necessary, cost-effective alternative course of treatment is available – a partial denture – that costs $500. The table below shows the cost you would pay if you choose to proceed with a dental Implant instead of the partial denture. Also, the table shows the cost if you use a non-network provider who charges $1,000.

The alternative course of treatment provisions will apply to any future treatment to repair, service, or replace the implant. This means that if you have any covered services performed on your implant, the Plan will calculate the benefits that are eligible for reimbursement as though similar work was performed on a partial denture.

Note: Installation of implants is a two-phase procedure. Phase one is the surgery to install the implant post. Phase two is the placement of the implant supported prosthetic (i.e., the tooth component of the dental implant) that is installed on the post.

If there is an alternative course of treatment, you may still receive reimbursement for the dental implants, but the reimbursement is based on the assumption that you received the lower cost treatment (generally a bridge or denture), and that is considered the covered dental expense. You will not receive reimbursement until phase two when the charge for the prosthetic is submitted (generally when the impression for the tooth is made).

Incorrect Computation of Benefits
If you believe that the amount of the benefit you receive from the Dental Plan is incorrect, you should notify Aetna in writing or contact Aetna Member Services.

If it's found that you or a beneficiary were not paid benefits to which you or your beneficiary were entitled, 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. You should be aware that the claims administrator, Aetna, has the right to request repayment if they overpay a claim for any reason.