About Pre-Tax Spending

Eligibility and Enrollment

Pre-Tax Contributions for Medical, Dental and Vision Plan Coverage

Health Care Flexible Spending Account

Dependent Care Flexible Spending Account

Tax Implications

Continuation Coverage

Administrative and ERISA Information

Claiming Reimbursement

Q. How do I get reimbursed from my flexible spending accounts?

A. The answer depends on the type of claim. If you are eligible for reimbursement from:

• The HCFSA, you may be automatically reimbursed for eligible amounts resulting from claims processed as a participant in the ExxonMobil Medical Plan POS II "A" or "B" option, the ExxonMobil Dental Plan and/or claims processed by OptumHealth Vision for the ExxonMobil Vision Plan. For other types of expenses, you must file a claim form and attach adequate documentation.
• The DCFSA, you must file a claim form and attach adequate documentation.

The Health Care Flexible Spending Account

Aetna processes claims for the HCFSA as well as claims for the ExxonMobil Medical Plan POS II "A" or "B" option, the ExxonMobil Dental Plan and the ExxonMobil Vision Plan. If you participate in the ExxonMobil Medical Plan POS II "A" or "B" option, the ExxonMobil Dental Plan and/or the ExxonMobil Vision Plan, Aetna, on receiving a medical, dental or vision claim from you or a provider, processes the claim for the benefit due under these plans and then processes the claim for any pre-tax reimbursement. In most cases, you do not need to file a pre-tax claim form unless you have expenses not processed under these plans. You must  opt out of this automatic rollover process  if you have other health coverage that is secondary. In that case, you must notify Aetna so your claim can be processed properly.

OptumHealth Vision processes claims for the ExxonMobil Vision Plan. If you participate in this plan, and OptumHealth Vision processes a claim for the benefit due, you do not need to file a pre-tax claim form for these claims. If you have other vision expenses not processed by OptumHealth Vision under the ExxonMobil Vision Plan, you will have to file a claim form for pre-tax reimbursement with Aetna.

If you have eligible expenses that are not covered by a medical, dental or vision plan or you participate in plans other than the ExxonMobil Medical Plan POS II "A" or "B" option, the ExxonMobil Dental Plan or the ExxonMobil Vision Plan, to be reimbursed you must file a completed Pre-Tax Spending Plan claim form, and:

• An itemized receipt;
• A statement that the expense is not covered by any plan or a statement showing what was not covered by the other plan; and
• Proof of payment.

Please do not use highlighter on your documentation. Handwritten descriptions of the expenses are not acceptable.

Over-the-Counter Drug Purchases

Over-the-counter (OTC) purchases cannot be reimbursed regardless of whether or not they are prescribed by a physician.

The Dependent Care Flexible Spending Account

You must submit a claim form attaching appropriate receipts showing the name, address, Social Security (or taxpayer identification) number of the provider, as well as the period covered. A copy of a canceled check with a fully completed claim form is sufficient if you do not have a bill, voucher or receipt.

Filing Claims for Both Accounts

• You must file claims for expenses incurred during the plan year (January 1 through December 31) so that they are received by Aetna no later than April 15 (or if April 15 falls on a non-business day, on the next succeeding business day) following the end of the plan year. The Plan will not reimburse you for claims received after that date unless you have proof that the claims were to be delivered by the 15th. For example, if a facsimile, the facsimile confirmation to the correct telephone number must be before midnight April 15th. If mailed using a mail or delivery service, the delivery receipt must indicate a guaranteed date by April 15th.
• If you need to submit a claim, but do not yet have all the required supporting documents, submit the claim so Aetna receives it before the claim filing deadline. You must submit an itemized bill with your claim submission. You can then submit the supporting documentation later, but in no event can documentation be accepted after the end of the year in which the claim has been submitted. Documentation submitted to support a claim must show a description of the service or provider co-payment received for reimbursement.
• You forfeit any funds remaining in your accounts for which valid claims have not been received by April 15 following the end of the plan year. Forfeited funds revert to the Plan.
• The Plan pays you directly. It does not pay providers. You will receive an explanation of payment and a statement showing the status of your account.
• If you file a claim near the April 15 deadline, you may wish to use a mail or delivery service providing a receipt that will help track the claim.
• It is advisable to make photocopies of claims and all supporting materials.

You will receive a quarterly statement of the status of your account. You may also find current ^TM.

Benefit Claims Procedures for HCFSA & DCFSA

Filing a Claim
If you have a question or a problem with a HCFSA or DCFSA benefit, contact Aetna Member Services. You must file a claim in writing to Aetna Member Services. Aetna is responsible for determining and informing you of your entitlement to a benefit and any amounts payable to you.

Aetna will review your claim and respond within a designated response time, usually 30 days after receiving your claim. If Aetna needs additional time (an extension) to decide on your claim because of special circumstances, you will be notified within the claim response period. An additional 15 days is all that is allowed. If an extension is necessary, due to incomplete information, you must provide the additional information within 45 days from the date of receipt of the extension notice.

Denied Claims
If your claim for benefits is denied completely or partially, you, your beneficiary, or designated representative will receive written notice of the decision. The notice will describe:

• The specific reason(s) for the denial; and
• The process for requesting an appeal.

Filing a Mandatory Appeal
If your claim is denied, you, your beneficiary, or your designated representative may appeal the decision to Aetna. Your written appeal should include the reasons why you believe the benefit should be paid and information that supports, or is relevant to, your claim (written comments, documents, records, etc). Your written appeal may also include a request for reasonable access to, and copies of, all documents, records and other information relevant to your claim. You must submit your written appeal within 180 days from the date of the denial notice.

The review will take into account all comments, documents, records and other information submitted relating to the claim, without regard to whether such information was submitted or considered in the initial benefit determination. Aetna will respond to the appeal within 60 days.

If Aetna needs additional time to decide on your claim because of special circumstances, you will be notified within the claim response period. However, an extension may be requested, but the law stipulates that no additional time must be allowed.

If your appeal is denied, you will receive written notice of the decision. The notice will set forth in plain language:

• The specific reason(s) for the denial and the plan provisions upon which the denial is based.
• A statement that you are entitled to receive, upon request and free of charge, reasonable access to, and copies of, all documents, records and other information relevant to the claim.
• A statement of the voluntary appeal procedure and your right to obtain information about such procedure or a description of the voluntary appeal procedure.
• A statement of your right to bring an action under section 502(a) of the Employee Retirement Income Security Act (ERISA).

Statute of Limitations
After you have received the response of the mandatory appeal, you may bring an action under section 502(a) of ERISA. Such action must be filed within one year of the date on which your mandatory appeal was decided.

Filing a Voluntary Appeal
If your mandatory appeal is denied, you may submit a voluntary appeal to the Administrator-Benefits. New information pertinent to the claim is required for the voluntary appeal to be considered. You must submit your voluntary appeal within 30 days of the denial of your mandatory appeal. The statute of limitations or other defense based on timeliness is suspended during the time that a voluntary appeal is pending.

You will be notified in writing within 15 days after your request has been received whether your voluntary appeal has been accepted. If it is determined that there is new relevant information, a decision will be made within 60 days after the Administrator-Benefits receives your request for a voluntary appeal.