List of key terms in the ExxonMobil Employee Medical Plan - Cigna OAPIN Network Only option
A necessary, reasonable and customary service or expense, including deductibles, coinsurance or copayments, that is covered in full or in part by any Group Health Plan covering you. When a Group Health Plan provides benefits in the form of services, the Reasonable Cash Value of each service is the Allowable Expense and is a paid benefit.
Examples of expenses or services that are not Allowable Expenses include, but are not limited to the following:
- An expense or service or a portion of an expense or service that is not covered by any of the Plans is not an Allowable Expense.
- If you are admitted to a private Hospital room and no Group Health Plan provides coverage for more than a semiprivate room, the difference in cost between a private and semiprivate room is not an Allowable Expense.
- If you are covered by two or more Group Health Plans that provide services or supplies on the basis of reasonable and customary fees, any amount in excess of the highest reasonable and customary fee is not an Allowable Expense.
- If you are covered by one Group Health Plan that provides services or supplies on the basis of reasonable and customary fees and one Group Health Plan that provides services and supplies on the basis of negotiated fees, the Primary Group Health Plan’s fee arrangement shall be the Allowable Expense.
- If your benefits are reduced under the Primary Group Health Plan (through the imposition of a higher copayment amount, higher coinsurance percentage, a deductible and/or a penalty) because you did not comply with Group Health Plan provisions or because you did not use a preferred provider, the amount of the reduction is not an Allowable Expense. Such Group Health Plan provisions include second surgical opinions and pre-certification of admissions or services.
Bed and board
The term Bed and Board includes all charges made by a Hospital on its own behalf for room and meals and for all general services and activities needed for the care of registered bed patients.
Generally, all the time from the first day of employment until you leave the company's employment.
- 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, as 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.
The following sets out the contact numbers based on your status under the ExxonMobil Medical Plan. It is your responsibility to contact the benefits administration entity with any required notices and address changes. If your status is not listed, call the ExxonMobil Benefits Service Center.
Monday – Friday 8:00 a.m. to 6:00 p.m. (U.S. Eastern Time)
Web: ExxonMobil Benefits
ExxonMobil Benefits Service Center
P.O. Box 18025
Norfolk, VA 23501-1867
Former Exxon or ExxonMobil Employees, Exxon or ExxonMobil Retirees, or their Survivors or their Family Members, who elected and are participating through COBRA, call:
ExxonMobil COBRA Administration
Wageworks National Accounts Services
ExxonMobil sponsored sites
Access to medical plan-related information including claim forms for employees, retirees, survivors, and their family members.
- Employee Connect, 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.
The term "charges" means the actual billed charges; except when the provider has contracted directly or indirectly with Cigna for a different amount.
A person under age 26 who is:
- A natural or legally adopted child of a regular employee;
- A grandchild, niece, nephew, cousin, or other child related by blood or marriage over whom a regular employee, or the spouse of a regular employee (separately or together) is the sole court appointed legal guardian or sole managing conservator;
- A child for whom the regular employee has assumed a legal obligation for support immediately prior to the child's adoption by the regular employee; or
- A stepchild of a regular employee.
- Child does not include a foster child.
Claim determination period
A calendar year, but does not include any part of a year during which you are not covered under this Cigna Option or any date before this section or any similar provision takes effect.
Your share of medical (including out-patient prescription drugs) and mental health and substance use disorder expenses. For some services, such as hospital stays, your share of expenses will be a percentage of the cost of the service, called coinsurance. For other services, such as routine office visits your share of expenses will be a fixed amount, called a copay.
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 Cigna Option.
Durable medical equipment
Durable Medical Equipment is defined as items which are designed for and able to withstand repeated use by more than one person; customarily serve a medical purpose; generally are not useful in the absence of Injury or Sickness; are appropriate for use in the home; and are not disposable. Such equipment includes, but is not limited to, crutches, hospital beds, wheel chairs, and dialysis machines.
Most U.S. dollar-paid employees of Exxon Mobil Corporation and participating affiliates are eligible. The person must be on the employer's books and records as an employee.
The following are not eligible to participate in the Medical Plan: leased employees as defined in the Internal Revenue Code, barred employees, or special agreement persons as defined in the Medical 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:
- 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:
a. meets the Internal Revenue Service's definition of a dependent and
b. 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
c. 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. the child 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 paragraphs 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 services means, with respect to an emergency medical condition, a medical screening examination that is within the capability of the emergency department of a Hospital, including ancillary services routinely available to the emergency department to evaluate the emergency medical condition; and such further medical examination and treatment, to the extent they are within the capabilities of the staff and facilities available at the Hospital, to stabilize the patient.
Out-of-Network Emergency Services Charges
1. Emergency Services are covered at the In-Network cost-sharing level if services are received from a non-participating (Out-of-Network) provider.
2. The allowable amount used to determine the Plan's benefit payment for covered Emergency Services rendered in an Out-of-Network Hospital, or by an Out-asof-Network provider in an In-Network Hospital, is the amount agreed to by the Out-of-Network provider and Cigna, or if no amount is agreed to, the greatest of the following, not to exceed the provider’s billed charges: (i) the median amount negotiated with In-Network providers for the Emergency Service, excluding any In-Network copay or coinsurance; or (ii) the amount payable under the Medicare program.
The member is responsible for applicable In-Network cost-sharing amounts (any deductible, copay or coinsurance). The member is also responsible for all charges that may be made in excess of the allowable amount. If the Out-of-Network provider bills you for an amount higher than the amount you owe as indicated on the Explanation of Benefits (EOB), contact Cigna Customer Service at the phone number on your ID card.
The term Employer means Exxon Mobil Corporation and participating affiliated companies, who are selffunding the benefits described in this SPD, on whose behalf Cigna is providing claim administration services.
An expense is incurred when the service or the supply for which it is incurred is provided.
Extended part-time employee
An employee who is designated as a non-regular employee but who has been designated as an Extended PartTime employee under his or her employer's employment policies relating to flexible work arrangements.
ExxonMobil Medical Plan (medical plan)
The plan sponsored by Exxon Mobil Corporation, which provides medical benefits for eligible employees and their family members and includes as one option the Cigna Option.
ExxonMobil Retiree Medical Plan
The Plan sponsored by Exxon Mobil Corporation, which provides medical benefits for eligible retirees, survivors and their family members and includes as one option the Cigna Option.
Listing of approved drugs and medications approved in accordance with parameters established by the Pharmacy and Therapeutics Committee. This list is subject to periodic review and updates.
Free-standing surgical facility
The term Free-Standing Surgical Facility means an institution generally which meets the following requirements:
- It has a medical staff of Physicians, Nurses and licensed anesthesiologists;
- It maintains at least two operating rooms and one recovery room;
- It maintains diagnostic laboratory and x-ray facilities;
- It has equipment for emergency care;
- It has a blood supply;
- It maintains medical records;
- It has agreements with Hospitals for immediate acceptance of patients who need Hospital stay on an inpatient basis; and
- It is licensed in accordance with the laws of the appropriate legally authorized agency.
Group health plan
Any of the following that provides benefits or services for medical, dental, or vision care or treatment:
- Group insurance and/or group-type coverage, whether insured or uninsured. This includes prepayment, group practice or individual practice coverage.
- Coverage under Medicare and other governmental benefits as permitted by law accepting Medicaid and Medicare supplement policies. It does not include any plan when benefits are in excess to those of any private insurance program or other non-governmental program.
- Medical benefits coverage of group, group-type, and individual "no-fault" and traditional automobile "fault" contracts.
Each Group Health Plan or part of a Group Health Plan which has the right to coordinate benefits will be considered a separate Group Health Plan.
Home health aide
The term Home Health Aide means a person who: (a) provides care of a medical or therapeutic nature; and (b) reports to and is under the direct supervision of a Home Health care Agency.
Home health care agency
The term Home Health Care Agency means a Hospital or a non-profit or public home health care agency which:
- Primarily provides skilled nursing service and other therapeutic service under the supervision of a Physician or a Registered Graduate Nurse;
- Is run according to rules established by a group of professional persons;
- Maintains clinical records on all patients;
- Does not primarily provide custodial care or care and treatment of the mentally ill; but only if, in those jurisdictions where licensure by statute exists, that Home Health Care Agency is licensed and run according to the laws that pertain to agencies which provide home health care.
Home health care plan
The term Home Health Care Plan means a plan for care and treatment of a person in his home. To qualify, the plan must be established and approved in writing by a Physician who certifies that the person would require in patient stay in a Hospital or Skilled Nursing Facility if he did not have the care and treatment specified in the plan.
Hospice care program
The term Hospice Care Program means:
- A coordinated, interdisciplinary program to meet the physical, psychological, spiritual and social needs of dying persons and their families;
- A program that provides palliative and supportive medical, nursing and other health services through home or inpatient care during the illness;
- A program for persons who have a Terminal Illness and for the families of those persons.
Hospice care services
The term Hospice Care Services means any services provided by: (a) a Hospital, (b) a Skilled Nursing Facility or a similar institution, (c) a Home Health Care Agency, (d) a Hospice Facility, or (e) any other licensed facility or agency under a Hospice Care Program, and is a Medicare approved Hospice Care Program.
The term Hospice Facility means an institution or part of it which:
- Primarily provides care for Terminally Ill patients;
- Is accredited by the National Hospice Organization;
- Meets standards established by Cigna; and
- Fulfills any licensing requirements of the state or locality in which it operates.
The term Hospital means:
- An institution licensed as a hospital, which: (a) maintains, on the premises, all facilities necessary for medical and surgical treatment; (b) provides such treatment on an inpatient basis, for compensation, under the supervision of Physicians; and (c) provides 24-hour service by Registered Graduate Nurses;
- An institution which qualifies as a hospital, a psychiatric hospital or a tuberculosis hospital, and a provider of services under Medicare, if such institution is accredited as a hospital by the Joint Commission on the Accreditation of Hospitals; or
- An institution which: (a) specializes in treatment of mental illness, alcohol or drug abuse or other related illness; (b) provides residential treatment programs; and (c) is licensed in accordance with the laws of the appropriate legally authorized agency.
The term Hospital will not include an institution, which is primarily a place for rest, a place for the aged, or a nursing home.
The term Injury means an accidental bodily injury.
The term Medicaid means a state program of medical aid for needy persons established under Title XIX of the Social Security Act of 1965 as amended.
The term Medicare means the program of medical care benefits provided under Title XVIII of the Social Security Act of 1965 as amended.
The term "mental illness" means any disorder, other than a disorder induced by alcohol or drug abuse, which impairs the behavior, emotional reaction or thought process of a person, regardless of medical origin. In determining benefits payable, charges made for the treatment of any physiological symptoms related to a mental illness will not be considered to be charges made for treatment of a mental illness.
Necessary services and supplies
The term Necessary Services and Supplies includes any charges, except charges for Bed and Board, made by a Hospital on its own behalf for medical services and supplies actually used during Hospital in patient stay. The term Necessary Services and Supplies will not include any charges for special nursing fees, dental fees or medical fees.
Providers and facilities that are available within the open access network under this Cigna Option. Cigna will maintain a directory of available in-network providers at myCigna.com.
The term Nurse means a Registered Graduate Nurse, a Licensed Practical Nurse or a Licensed Vocational Nurse who has the right to use the abbreviation "R.N.," "L.P.N." or "L.V.N."
Outpatient mental illness services
Outpatient Mental Illness Services are services of providers who are qualified to treat mental illness when treatment is provided on an outpatient basis, while you or your eligible/covered Family Member is not admitted to a Hospital, in an individual, group or structured group therapy program. Covered Services include, but are not limited to, outpatient treatment of conditions such as: anxiety or depression which interferes with daily functioning; emotional adjustment or concerns related to chronic conditions, such as psychosis or depression; emotional reactions associated with marital problems or divorce; child/adolescent problems of conduct or poor impulse control; affective disorders; suicidal or homicidal threats or acts; eating disorders; or acute exacerbation of chronic mental illness conditions (crisis intervention and relapse prevention) and outpatient testing and assessment.
The term Participating Pharmacy means a retail pharmacy or mail-order pharmacy with which Cigna has contracted, either directly or indirectly, to provide prescription services to its plan participants.
The term Participating Provider means:
- An institution, facility, agency or healthcare professional which has contracted directly or indirectly with Cigna.
The providers qualifying as Participating Providers may change from time to time. A list of the current Participating Providers will be provided with this booklet.
Pharmacy & Therapeutics (P&T) Committee
A committee of Provider Organization members comprised of Medical providers, Pharmacists, Medical Directors and Pharmacy Directors, which reviews medications for safety, efficacy, cost effectiveness and value. The P & T Committee evaluates medications for addition to or deletion from the Formulary and may also set dispensing limits on medications. Related Services are also reviewed & evaluated.
The term Physician means a licensed medical practitioner who is practicing within the scope of his license and who is licensed to prescribe and administer drugs or to perform surgery. It will also include any other licensed medical practitioner whose services are required to be covered by law in the locality where the services are received if he is:
- Operating within the scope of his license; and
- Performing a service for which benefits are provided under this Cigna Option when performed by a Physician.
Prescription Drug means; (a) a drug which has been approved by the Food and Drug Administration for safety and efficacy; or (b) certain drugs approved under the Drug Efficacy Study Implementation review; or (c) drugs marketed prior to 1938 and not subject to review, and which can, under federal or state law, be dispensed only pursuant to a prescription order; or (d) injectable insulin
Primary Care Physician
The term Primary Care Physician means a Physician: (a) who qualifies as a Participating Provider in general practice, internal medicine, family practice or pediatrics; and (b) who has been selected by you, as authorized by the Provider Organization, to provide or arrange for medical care for you or any of your covered Family Members.
Primary group health plan
The Group Health Plan that determines and provides or pays benefits without taking into consideration the existence of any other Group Health Plan.
The term Provider Organization refers to a network of Participating Providers.
The term Psychologist means a person who is licensed or certified as a clinical psychologist. Where no licensure or certification exists, the term Psychologist means a person who is considered qualified as a clinical psychologist by a recognized psychological association. It will also include: (1) any other licensed counseling practitioner whose services are required to be covered by law in the locality where the services are received if he is: (a) operating within the scope of his license; and (b) performing a service for which benefits are provided under this plan when performed by a Psychologist; and (2) any psychotherapist while he is providing care authorized by the Provider Organization if he is: (a) state licensed or nationally certified by his professional discipline; and (b) performing a service for which benefits are provided under this plan when performed by a Psychologist.
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 Medical Plan's procedures governing QMCSO determinations by written request to the Administrator-Benefits.
Reasonable cash value
An amount which a duly licensed provider of health care services usually charges patients and which is within the range of fees usually charged for the same service by other health care providers located within the immediate geographic area where the health care service is rendered under similar or comparable circumstances.
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 (RMP)
One of the parts of the ExxonMobil Retiree Medical Plan which provides medical benefits for Pre-Medicare Eligible retirees, survivors and their family members.
Secondary group health plan
A Group Health Plan that determines, and may reduce its benefits after taking into consideration, the benefits provided or paid by the Primary Group Health Plan. A Secondary Group Health Plan may also recover from the Primary Group Health Plan the Reasonable Cash Value of any services it provided to you.
A self-funded plan option, under the 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 these self-funded options, they may look just like fully-funded plans. For example, the Cigna option under the Medical Plan is a self-funded plan.
Cigna is responsible for only administering the plan. (i.e., Cigna is the claims processor for the self-funded plan.) ExxonMobil is responsible for funding the plan to pay health claims. This does not impact the benefits provided under the Cigna Option under the Medical Plan. The U.S. Department of Labor regulates self-funded plans, not the state insurance department.
You may contact the Department of Labor at the address listed in the ERISA section: Assistance with Your Questions.
The geographic area designated by the Cigna Option in which an individual must live in order to be an eligible member. This area is determined by the participant's home address zip code.
Sickness - for medical coverage
The term Sickness means a physical or mental illness. It also includes pregnancy. Covered Expenses incurred for routine Hospital and pediatric care of a newborn child prior to discharge from the Hospital nursery will be considered to be incurred as a result of Sickness.
Skilled nursing facility
The term Skilled Nursing Facility means a licensed institution (other than a Hospital) which specializes in:
- Physical rehabilitation on an inpatient basis; or
- Skilled nursing and medical care on an inpatient basis;
but only if that institution (a) maintains on the premises all facilities necessary for medical treatment; (b) provides such treatment, for compensation, under the supervision of Physicians; and (c) provides Nurses' services.
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.
A Terminal Illness will be considered to exist if a person becomes terminally ill with a prognosis of six months or less to live, as diagnosed by a Physician.
An employee who is classified as a non-regular employee, but who has been characterized as a Trainee and has graduated from high school.
Urgent Care is medical, surgical, Hospital or related health care services and testing which are determined by Cigna, in accordance with generally accepted medical standards, to have been necessary to treat a condition requiring prompt medical attention. This does not include care that could have been foreseen before leaving the immediate area where you ordinarily receive and/or were scheduled to receive services. Such care includes, but is not limited to, dialysis, scheduled medical treatments or therapy, or care received after a Physician's recommendation that the covered person should not travel due to any medical condition.