Key terms

Annual Out-of-Pocket Limit – Expenses you pay for medical services apply towards the annual out-of-pocket maximum including both outpatient and inpatient behavioral health and substance use disorders treatment.  The annual out-of-pocket maximum is accumulated in the order the claims are processed.

Approved Clinical Trial - A phase I, phase II, phase III, or phase IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or other life- threatening disease or condition and meets any of the following three conditions:

1. Federally funded trials. The study or investigation is approved or funded (which may include funding through in-kind contributions) by one or more of the following:
2. The National Institutes of Health.
3. The Centers for Disease Control and Prevention.
4. The Agency for Health Care Research and Quality.
5. The Centers for Medicare & Medicaid Services.
6. Cooperative group or center of any of the entities described in clauses (a) through (d) or the Department of Defense or the Department of Veterans Affairs.
7. A qualified non-governmental research entity identified in the guidelines issued by the National Institutes of Health for center support grants.
8. Any of the following if certain conditions are met:
• The Department of Veterans Affairs.
• The Department of Defense.
• The Department of Energy.
• The study or investigation is conducted under an investigational new drug application reviewed by the Food and Drug Administration; or
• The study or investigation is a drug trial that is exempt from having such an investigational new drug application.

The conditions for this clause (g) are that the study or investigation has been reviewed and approved through a system of peer review that the Secretary of Health and Human Services determines: to be comparable to the system of peer review of studies and investigations used by the National Institutes of Health, and assures unbiased review of the highest scientific standards by qualified individuals who have no interest in the outcome of the review.

9.  The study or investigation is conducted under an investigational new drug application reviewed by the Food and Drug Administration; or

10. The study or investigation is a drug trial that is exempt from having such an investigational new drug application.

Balance Bill - difference between the Plan’s reimbursement for out-of-Network services and what the Provider charges

Behavioral health condition - a condition which manifests signs and/or symptoms that are primarily mental or behavioral, for which the primary treatment is psychotherapy, psychotherapeutic methods or procedures, and/or the administration of psychotropic medication. Behavioral health conditions include, but are not limited to:

• Psychosis,
• Affective disorders,
• Anxiety disorders,
• Personality disorders,
• Obsessive-compulsive disorders,
• Attention disorders with or without hyperactivity, and
• Other psychological, emotional, nervous, behavioral or stress-related abnormalities associated with transient or permanent dysfunction of the brain or related neurohormonal systems, whether or not caused or in any way resulting from chemical imbalance, physical trauma, or a physical or medical condition.

Behavioral 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 behavioral 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.

Behavioral health treatment facility - A facility that:

1. meets licensing standards,
2. mainly provides a program for diagnosis, evaluation and treatment of behavioral health conditions,
3. prepares and maintains a written plan of treatment for each patient based on medical, psychological and social needs,
4. provides all normal infirmary level Medical Services or arranges with a Hospital for any other Medical Services that may be required,
5. is under the supervision of a psychiatrist, and
6. provides skilled nursing care by licensed nurses who are directed by a registered nurse.

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 leaves 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, 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.

Benefits Administration - The following sets out the contact numbers based on your status under the ExxonMobil Medical Plan. It is your responsibility to contact the correct Benefits Administration entity with any required notices and address changes. If your status is not listed, call the ExxonMobil Benefits Service Center for assistance.

 

Clinical Care Manager - Aetna Behavioral Health is the Clinical Care Manager for behavioral health and substance use disorders services.

Child - A person under age 26 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.

Child does not include a foster child.

Claims administrator / processor - Aetna Life Insurance Company, or affiliates, for claims other than outpatient prescription drugs, and Express Scripts for retail and home delivery of outpatient prescription drugs.

Claims fiduciary - For the purpose of section 503 of Title 1 of the Employee Retirement Income Security Act of 1974, as amended (ERISA), the claims fiduciary is the person with complete authority to review all denied claims for benefits under the Plan. Each claims fiduciary has the right to adopt reasonable policies, procedures, rules and interpretations of the Plan to promote orderly and efficient administration. A claims fiduciary may not act arbitrarily and capriciously, which would be an abuse of its discretionary authority.

Concurrent care claims - Concurrent claims are any claims that involve an ongoing approved course of treatment. Typically, concurrent claims will be handled as either a pre-service claim or urgent care claim, depending on the circumstances.

Copayments and coinsurance - Your share of covered services (including out-patient prescription drugs) and behavioral health and substance use disorders expenses. For some services, such as hospital stays, the coinsurance will be a percentage of the cost of the service. For other services, such as routine office visits to an Open Access Aetna Select provider, the copayment will be a fixed amount. For outpatient prescription drugs there is a percentage copayment up to a per-prescription maximum.

Cosmetic surgery - any surgery or procedure that is not medically necessary and whose primary purpose is to improve or change the appearance of any portion of the body to improve self-esteem, but which does not:

• Restore bodily function,
• Correct a diseased state, physical appearance or disfigurement caused by an accident or birth defect, or
• Correct or naturally improve a physiological function.

Covered services and supplies (covered expenses) -types of medically necessary services and supplies described in Your Benefits.

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. Examples are:

• Routine patient care such as changing dressings, periodic turning and positioning in bed
• Administering oral medications
• Care of a stable tracheostomy (including intermittent suctioning)
• Care of a stable colostomy/ileostomy
• Care of stable gastrostomy/jejunostomy/nasogastric tube (intermittent or continuous) feedings
• Care of a bladder catheter (including emptying/changing containers and clamping tubing)
• Watching or protecting you
• Respite care, adult (or child) day care, or convalescent care
• Institutional care. This includes room and board for rest cures, adult day care and convalescent care
• Help with walking, grooming, bathing, dressing, getting in or out of bed, toileting, eating or preparing foods
• Any other services that a person without medical or paramedical training could be trained to perform
• Any service that can be performed by a person without any medical or paramedical training

Detoxification - the process whereby an alcohol-intoxicated, alcohol-dependent or drug-dependent person is assisted in a facility licensed by the state in which it operates, through the period of time necessary to eliminate, by metabolic or other means, the intoxicating alcohol or drug, alcohol or drug dependent factor, or alcohol in combination with drugs as determined by a licensed physician, while keeping physiological risk to the patient at a minimum.

Durable medical equipment (DME) - equipment determined to be:

• Designed and able to withstand repeated use,
• Made for and used primarily in the treatment of a condition or injury,
• Generally not useful in the absence of an illness or injury,
• Suitable for use while not admitted in a hospital,
• Not for use in altering air quality or temperature, and
• Not for exercise or training.

Eligible employees - Most U.S. dollar-paid employees of ExxonMobil and participating affiliates are eligible. The person must be classified on the employer’s books and records as an employee.

The following are not eligible to participate in the Plan: 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.

Eligible family members - Eligible family members are generally your:

• Spouse
• A child who is described in any one of the following paragraphs (1 through 3):

1. Has not reached the end of the month during which age 26 is attained, or
2. is totally and continuously disabled and incapable of self-sustaining employment by reason of mental or, physical disability, provided the child
• meets the Internal Revenue Service's definition of a dependent and
• was covered as an eligible family member under this Plan immediately prior to age 26 when the child's eligibility would have otherwise ceased, and
• met the clinical definition of totally and continuously disabled before age 26 and continues to meet the clinical definition through subsequent periodic reassessment reviews, or
3. is recognized under a qualified medical child support order as having a right to coverage under this Plan.

A child aged 26 or over who was disabled but who no longer meets the requirements of paragraph two (2) above, ceases to be an eligible family member 60 days following the date on which the applicable requirement is not met.

Please note: An eligible employee's parents are not eligible to be covered.

Emergency - a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson (including the parent of a minor child or the guardian of a disabled individual), who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in:

• Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy,
• Serious impairment to bodily function, or
• Serious dysfunction of any bodily organ or part.
• With respect to emergency services furnished in a hospital emergency department, the Plan does not require prior authorization for such services if you arrive at the emergency medical department with symptoms that reasonably suggest an emergency condition, based on the judgment of a prudent layperson, regardless of whether the hospital is an in-network provider.

The Plan covers medically necessary emergency services including the following:

• Initial services. A medical screening examination within the capability of a hospital emergency department or freestanding independent emergency department, including ancillary services routinely available in the emergency department, to determine whether an “emergency medical condition” exists.

• Post-stabilization services. Additional services covered under the plan that are furnished by a nonparticipating provider or nonparticipating emergency facility after a participant or beneficiary is stabilized and as part of outpatient observation or an inpatient or outpatient stay with respect to the visit in which the initial services were provided

Expatriate Employees - service-oriented employees employed by non-U.S., non-participating employers who are temporarily working in the United States either under a visa that requires coverage by this plan of such employee while in the United States or in an assignment in the United States and the terms of the assignment require proof of adequate medical coverage. Expatriate employees include regular employees working on an assignment outside the United States where the terms of the assignment require proof of adequate medical coverage.

Experimental or investigational- services or supplies that are determined by Aetna to be experimental. A drug, device, procedure or treatment will be determined to be experimental if:

• There are not sufficient outcomes data available from controlled clinical trials published in the peer reviewed literature to substantiate its safety and effectiveness for the condition or injury involved, or
• Required FDA approval has not been granted for marketing, or
• A recognized national medical or dental society or regulatory agency has determined, in writing, that it is experimental or for research purposes, or
• The written protocol(s) used by the treating facility or the protocol(s) of any other facility studying substantially the same drug, device, procedure or treatment or the written informed consent used by the treating facility or by another facility studying the same drug, device, procedure or treatment states that it is experimental or for research purposes, or
• It is not of proven benefit for the specific diagnosis or treatment of your particular condition, or
• It is not generally recognized by the medical community as effective or appropriate for the specific diagnosis or treatment of your particular condition, or
• It is provided or performed in special settings for research purposes.

ExxonMobil Medical Plan - The Plan sponsored by ExxonMobil which provides medical benefits for eligible employees, and their family members and includes the Open Access Aetna Select option.

ExxonMobil Retiree Medical Plan (EMRMP) - The Plan sponsored by ExxonMobil which provides medical benefits for eligible retirees, survivors and their family members, and includes the Retiree Medical Plan (RMP) and the Medicare Primary Option (MPO). 

Home health services - those items and services provided by participating providers as an alternative to hospitalization.

Hospice care - a program of care that is:

• Provided by a hospital, skilled nursing facility, hospice or duly licensed hospice care agency, and
• Focused on palliative rather than curative treatment for a plan participant who has a medical condition and a prognosis of less than 6 months to live.

Hospital - an institution rendering inpatient and outpatient services, accredited as a hospital by the Joint Commission on Accreditation of Health Care Organizations (JCAHO), the Bureau of Hospitals of the American Osteopathic Association, or as otherwise determined by Aetna as meeting reasonable standards. A hospital may be a general, acute care, rehabilitation or specialty institution.

Incidental Charges - charges for services that are considered an integral component of the primary procedure.  Aetna’s standard for determining incidental charges is based on the Current Procedural Terminology (CPT) codes and guidelines authored and revised by the American Medical Association. CPT coding is the most widely accepted format, by both government and private health insurance programs, in reporting physician procedures, including guidelines explaining that services commonly carried out as an integral component of a total service or procedure should not be reported as a separate procedure. 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.  For example: Your provider administers an immunization and submits separate charges: one for the medication administered in the immunization and another for administering the shot.

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. Network providers have agreed to accept incidental charges reductions; however, you are responsible for incidental expenses when you use a pre-authorized non-participating provider or if you have signed a statement in the provider's office saying you will be responsible for incidental charges.

Infertility - For a female who is under age 35, the inability to conceive after one year or more without contraception or 12 cycles of artificial insemination. For a female who is age 35 or older, the inability to conceive after six months without contraception or six cycles of artificial insemination.

Medical services - those professional services of physicians or other health professionals, including medical, surgical, diagnostic, therapeutic and preventive services authorized by Aetna.

Medically necessary- services that are appropriate and consistent with the diagnosis in accordance with accepted medical standards, as described in the Your Benefits section of this booklet. To be medically necessary, the service or supply must:

• Be care or treatment as likely to produce a significant positive outcome as, and no more likely to produce a negative outcome than, any alternative service or supply, as to both the illness or injury involved and your overall health condition,
• Be care or services related to diagnosis or treatment of an existing illness or injury, except for covered periodic health evaluations and preventive and well-baby care, as determined by Aetna,
• Be a diagnostic procedure, indicated by the health status of the plan participant, and be as likely to result in information that could affect the course of treatment as, and no more likely to produce a negative outcome than, any alternative service or supply, as to both the illness or injury involved and your overall health condition,
• Include only those services and supplies that cannot be safely and satisfactorily provided at home, in a physician’s office, on an outpatient basis, or in any facility other than a hospital, when used in relation to inpatient hospital services, and
• Based on diagnosis, care and treatment be no more costly (taking into account all health expenses incurred in connection with the service or supply) than any equally effective service or supply in meeting the above tests.

In determining whether a service or supply is medically necessary, Aetna will consider:

• Information provided on your health status,
• Applicable standard of care,
• Aetna's Clinical Policy Bulletin's and other non-case specific materials, which shall be based on medical and Scientific Evidence,
• Reports in peer reviewed medical literature,
• Reports and guidelines published by nationally recognized health care organizations that include supporting scientific data,
• Professional standards of safety and effectiveness which are generally recognized in the United States for diagnosis, care or treatment,
• The opinion of health professionals in the generally recognized health specialty involved,
• The opinion of the attending physicians, which has credence but does not overrule contrary opinions, and
• Any other relevant information brought to Aetna’s attention

In no event will the following services or supplies be considered medically necessary:

• Services or supplies that do not require the technical skills of a medical, behavioral health or dental professional,
• Custodial care, supportive care or rest cures,
• Services or supplies furnished mainly for the personal comfort or convenience of the patient, any person caring for the patient, any person who is part of the patient’s family or any health care provider,
• Services or supplies furnished solely because the plan participant is an inpatient on any day when their illness or injury could be diagnosed or treated safely and adequately on an outpatient basis,
• Services furnished solely because of the setting if the service or supply could be furnished safely and adequately in a physician’s or dentist’s office or other less costly setting, or
• Experimental services and supplies, as determined by Aetna.

Medicare - The program of medical care benefits provided under Title XVIII of the Social Security Act of 1965 as amended. 

Outpatient - A plan participant who is registered at a practitioner’s office or recognized health care facility, but not as an inpatient, or Services and supplies provided in such a setting.

Participating provider - a provider that has entered into a contractual agreement with Aetna to provide services to plan participants.

Pharmacy Benefit Manager – Express Scripts is the pharmacy benefit manager for prescription drugs.

Physician - 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 practitioner.

Plan benefits - the medical services, hospital services, and other services and care to which a plan participant is entitled, as described in this booklet.

Plan participant - an employee or covered family member.

Post-service claims - All claims for benefits after medical services have been provided, such as requests for reimbursement or payment for the provided services.

Pre-service claims - Requests for approval required before medical care, such as preauthorization or a decision on whether a treatment or procedure is medically necessary.

Primary Care Physician (PCP) - a Physician engaged in general practice, family practice, internal medicine, pediatrics or obstetrics/gynecology who provides basic health services to covered persons, may initiate their referral for specialist care, and maintains continuity of patient care.

Physician groups, nurse practitioners and physician assistants cannot be PCPs.

Private duty nursing - Continuous, substantial and complex skilled in-home nursing care in the home requiring services that can only be provided by a licensed medical professionals can provide, has been as prescribed by a treating physician, provided on an hourly basis and is determined to be medically necessary. Private duty nursing provides more individual and continuous skilled care than the care that can be provided in a skilled nurse visit through a home health agency.

Provider - a physician, health professional, hospital, skilled nursing facility, home health agency, or other recognized entity or person licensed to provide hospital or medical services to Plan participants.

Qualified Medical Child Support Order (QMCSO) - 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.

Reciprocity - The Plan allows full reciprocity between Open Access Aetna Select networks when members follow all administrative requirements such as obtaining  authorizations.

Referral - specific written or electronic direction or instruction from a Plan participant’s PCP, which directs the plan participant to a participating provider for medically necessary care.

Retiree - Generally, a person at least 55 years old who retires as a regular employee with 15 or more years of benefit service or 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 service, regardless of age.

Retirees who have been rehired as regular or non-regular employees are not eligible for the ExxonMobil Retiree Medical Plan.

Retiree Medical Plan - One of the parts of the ExxonMobil Retiree Medical Plan which provides medical benefits for Pre-Medicare eligible retirees, survivors and their family members. It includes the Retiree Medical Open Access Aetna Select Option and other self-funded options.

Self-funded (As used in the ExxonMobil Medical Plan) - is an option set up by ExxonMobil to set aside funds to pay employees’ health claims. Because ExxonMobil has hired insurance companies to administer the claims for these plans, they may look just like fully insured plans but they are funded by ExxonMobil. For example, all Open Access Aetna Select options under the EMMP are self-funded. Aetna is responsible for processing claims and is the claims fiduciary (i.e., Aetna makes the final decision on claims under those plans). ExxonMobil is responsible for providing the funds to the Plan to pay health claims. This does not impact the way that your plan operates. The U.S. Department of Labor regulates self-funded plans, not the state. You may contact the Department of Labor at the address listed in the ERISA section: Assistance with Your Questions.

Serious Mental Illness - the following psychiatric illnesses as defined by the American Psychiatric Association in the Diagnostic and Statistical Manual (DSM) III-R: schizophrenia; paranoid and other psychotic disorders; bipolar disorders (hypomanic; mixed, manic and depressive); major depressive disorders (single episode or recurrent); schizo-affective disorders (bipolar or depressive); pervasive developmental disorders; obsessive-compulsive disorders and depression in childhood and adolescence.

Service area - the geographic area, established by Aetna and approved by the appropriate regulatory authority, in which a Plan participant must live or otherwise meet the eligibility requirements in order to be eligible as a participant in the Plan. Eligibility is determined by the participant's home address zip code.

Skilled nursing facility - an institution or a distinct part of an institution that is licensed or approved under state or local law, and which is primarily engaged in providing skilled nursing care and related services as a skilled nursing facility, extended care facility, or nursing care facility approved by the Joint Commission on Accreditation of Health Care Organizations or the Bureau of Hospitals of the American Osteopathic Association, or as otherwise determined by Aetna to meet the reasonable standards applied by any of the aforesaid authorities.

Specialist - a physician who provides medical care in any generally accepted medical or surgical specialty or sub-specialty

Spouse; Marriage – All references to marriage shall mean a marriage that is legally recognized under the laws of the state or other jurisdiction in which the marriage takes place, consistent with U.S. federal tax law. All references to a spouse or a married person shall refer to individuals who have such a marriage.

Substance use disorders - any use of alcohol and/or drugs which produces a pattern of pathological use causing impairment in social or occupational functioning, or which produces physiological dependency evidenced by physical tolerance or withdrawal.

Trainee - A U.S. payroll employee who is classified as a non-regular employee, but who has been characterized as a Trainee and has graduated from high school.  This definition does not include an individual not on the U.S. payroll but in the U.S. on a training assignment that is not considered an expatriate assignment into the U.S.  Such individuals are not eligible for the EMMP.

Terminal illness - an illness of a Plan participant, which has been diagnosed by a physician and for which they have a prognosis of six (6) months or less to live.

Urgent care claims - Special kind of pre-service claim that requires a quicker decision because your health would be threatened if the plan took the normal time permitted to decide a pre-service claim. If a physician with knowledge of your medical condition tells the plan that a pre-service claim is urgent, the plan must treat it as an urgent care claim.

Urgent medical condition - a medical condition for which care is medically necessary and immediately required because of unforeseen illness, injury or condition, and it is not reasonable, given the circumstances, to delay care in order to obtain the services through your home service area or from your PCP.