If you have coverage under other group plans, the benefits from the other plans will be taken into account if you have a claim. Other group plans include any other plan coverage provided by:
- Group insurance or any other arrangement of group coverage for individuals, whether or not the plan is insured, and
- No-fault and traditional fault auto insurance, including medical payments coverage provided on other than a group basis, to the extent allowed by law.
Determination of primary plan
To find out if benefits under the EMDP will be reduced, Aetna must first determine which plan pays benefits first. The determination of which plan pays first is made as follows:
- The plan without a coordination of benefits (COB) provision determines its benefits before the plan that has such a provision.
- The plan that covers a person other than as a dependent determines its benefits before the plan that covers the person as a dependent. If the person is eligible for Medicare and is not actively working, the Medicare Secondary Payer rules will apply. Under the Medicare Secondary Payer rules, the order of benefits will be determined as follows:
- The plan that covers the person as a dependent of a working spouse will pay first,
- Medicare will pay second, and
- The plan that covers the person as a retired employee will pay third.
- Except for children of divorced or separated parents, the plan of the parent whose birthday occurs earlier in the calendar year pays first. When both parents’ birthdays occur on the same day, the plan that has covered the parent the longest pays first. If the other plan doesn’t have the parent birthday rule, the other plan’s COB rule applies.
- When the parents of a child are divorced or separated:
- If there is a court decree which states that the parents will share joint custody of a child, without stating that one of the parents is responsible for the health care expenses of the child, the parent birthday rule, immediately above, applies.
- If a court decree gives financial responsibility for the child’s medical, dental, or other health care expenses to one of the parents, the plan covering the child as that parent’s dependent determines its benefits before any other plan that covers the child as a dependent.
- If there is no such court decree, the order of benefits will be determined as follows:
- the plan of the natural parent with whom the child resides,
- the plan of the stepparent with whom the child resides,
- the plan of the natural parent with whom the child does not reside, or
- the plan of the stepparent with whom the child does not reside.
- If an individual has coverage as an active employee or dependent of such employee, and also as retired or laid-off employee, the plan that covers the individual as an active employee or dependent of such employee is primary.
- The benefits of a plan which covers a person under a right of continuation under federal or state laws will be determined after the benefits of any other plan which does not cover the person under a right of continuation.
- If the above rules do not establish an order of payment, the plan that has covered the person for the longest time will pay benefits first.
If it is determined that the other plan pays first, the benefits paid under the EMDP will be reduced. Aetna will calculate this reduced amount as follows:
- The amount normally reimbursed for covered benefits under the EMDP,
- Benefits payable from your other plan(s).
If your other plan(s) provides benefits in the form of services rather than cash payments, the cash value of the services will be used in the calculation.
Calculation of Benefits
When EMDP is your primary plan, EMDP will pay your medical claims first, as if there is no other coverage. When EMDP is your secondary plan, EMDP will pay benefits after the primary plan, and that payment amount will be the lesser of:
- What EMDP would have paid if it had been primary, or
- What EMDP would have paid less the primary plan’s payment.
Incorrect computation of benefits
If you believe that the amount of benefit you receive from the ExxonMobil Dental Plan is incorrect, you should notify Aetna in writing or contact Aetna Member Services. If it is found that you or a beneficiary were not paid benefits you or your beneficiary were entitled to, the Plan or ExxonMobil will pay the unpaid benefits. (See Claims and Administrative and ERISA information sections.)
Medical claims for dental work
Some medical plans cover certain dental procedures by a dentist or oral surgeon. Dental procedures that may be covered by your medical plan include:
- Drugs prescribed by your dentist (would be covered by your prescription plan).
- Treatment of fractures or dislocations of the jaw.
- Treatment of teeth and surrounding tissue damaged due to an injury sustained while covered by the Plan. If an accident occurs, claims may be payable as medical expenses, but claims are not coordinated with the ExxonMobil Dental Plan.
For information on which procedures performed by a dentist or oral surgeon may be considered to be medical in nature, contact Aetna Member Services.
After all the medical plans have responded, submit a dental claim form with the medical explanation of benefits (EOB) form(s) explaining the determination of benefits under the medical plan(s), along with a copy of your bill, to Aetna.
If you are an employee who participates in the ExxonMobil Pre-Tax Spending Plan Health Care Flexible Spending Account (HCFSA), Aetna will automatically process any eligible expenses remaining from your dental claim and send you the spending account reimbursement, if you have elected HCFSA automatic reimbursement. This means that, in most cases, you will not need to file a separate pre-tax claim form.