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When coverage ends

When coverage ends for the ExxonMobil International Medical and Dental Plan

Coverage for you and/or your eligible dependents ends on the earliest of the following dates:

  • The last day of the month in which your expatriate assignment ends
  • your eligible dependents are no longer eligible; or
  1. this Plan is terminated; or
  2. a covered person fails to make any required contribution; or
  3. a qualified medical child support order is no longer in effect for an eligible dependent; or
  4. as of the date the expatriate employee dies or the date the survivor is moved to the home country medical plan, if applicable.

You are responsible for ending coverage with the ExxonMobil Benefits Service Center when your enrolled spouse or eligible dependent is no longer eligible for coverage. If you do not complete your change within 60 days, any contributions you make for ineligible eligible dependents will not be refunded.

Loss of eligibility

Fraud against the plan

Everyone in your family may lose eligibility under this Plan, and you may be subject to disciplinary action up to and including termination of employment if you commit fraud against the Plan, for instance, by filing claims for benefits to which you are not entitled. Coverage may also be terminated if you refuse to repay amounts erroneously paid by the Plan on your behalf or that you recover from a third party. Additionally, coverage may be terminated if you fail to reimburse the Plan for any amount owed to the Plan, or if you receive and fail to report to the Claims Processor any discounts, write-offs, or other arrangements with providers that result in misrepresentation of your out-of-pocket costs. Your participation may be terminated if you fail to comply with the terms of the Plan and its administrative requirements. You may also lose eligibility if you enroll persons who are not eligible, for instance, by covering eligible dependents who do meet the eligibility requirements. This includes failing to provide timely notification of when a covered eligible dependent loses eligibility, e.g., spouse loses eligibility due to divorce.

Continuation benefits for US expatriates terminated due to disability.

US expatriates with less than 15 years of service who are terminated in connection with a long-term disability may be provided with COBRA coverage at no cost for the first 12 months. To be entitled to this benefit, you must elect COBRA upon termination of employment and receive long term disability benefits under the ExxonMobil Disability Plan.

The 12 month period runs concurrently with your COBRA continuation period and you will be responsible for paying the full cost after for the remainder of your COBRA continuation period.

Continuation coverage for eligible dependents may be available through COBRA but this coverage will not be covered by the Company.

Continuation coverage

Introduction

You are required to be given the information in this section because you are covered under a group health plan (the Medical Plan). This section contains important information about your right to COBRA continuation coverage, which is a temporary extension of coverage under the Plan under certain circumstances when coverage would otherwise end. This section generally explains COBRA continuation coverage, when it may become available to you and your family, and what you need to do to protect the right to receive it. 

The right to COBRA coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA coverage can become available to you when you would otherwise lose your group health coverage. It can also become available to your spouse and children, if they are covered under the Plan when they would otherwise lose their group health coverage or other rights under the Plan. This section does not fully describe COBRA coverage or other rights under the Plan. For additional information about your rights and obligations under the Plan and under federal law, you should review this SPD or contact the ExxonMobil Benefits Service Center at the telephone numbers or address listed under Benefits Administration in the Contacts for COBRA rightsUnder the ExxonMobil Medical Plan section.

You, your spouse and your family members may have other options available when you lose group health coverage. For example, you may be eligible to buy an individual plan through the Health Insurance Marketplace.  By enrolling in coverage through the Marketplace, you may qualify for lower costs on your monthly premiums and lower out-of-pocket costs.  Additionally, you may qualify for a 30-day special enrollment period for another group health plan for which you are eligible (such as a spouse’s plan), even if that plan generally doesn’t accept late enrollees.

Determination of Benefits Administration Entity to Contact:

  • Current ExxonMobil and XTO Employees or their covered family members should use EDA or contact the ExxonMobil Benefits Service Center;
  • Former Exxon, ExxonMobil or XTO Employees and their covered family members, who have elected and are participating through COBRA, contact the ExxonMobil COBRA Administration.

The contact information for each of these entities is as shown in the Contacts for COBRA Rights Under the ExxonMobil Medical Plan section.

What is COBRA coverage?

COBRA coverage is a continuation of Plan coverage when coverage would otherwise end because of a life event known as a qualifying event. Specific qualifying events are listed later in this section.  If a specific qualifying event occurs and any required notice of that event is properly provided to the ExxonMobil Benefits Service Center, COBRA coverage must be offered to each person losing coverage who is a qualified beneficiary.  You, your spouse, and your children could become qualified beneficiaries if coverage under the Plan is lost because of the qualifying event. Certain newborns, newly adopted children, and alternate recipients under QMCSOs may also be qualified beneficiaries. This is discussed in more detail in separate paragraphs below. Under the Plan, qualified beneficiaries who elect COBRA coverage must pay the entire cost of COBRA coverage (employee plus employer portions) plus a 2% administrative fee.

Who is entitled to elect COBRA?

If you are an employee, you will be entitled to elect COBRA, if you lose your coverage under the Plan because either one of the following qualifying events happens:

  • Your hours of employment are reduced, or
  • Your employment ends for any reason other than your gross misconduct.

If you are the spouse of an employee, you will be entitled to elect COBRA if you lose coverage under the Plan because any of the following qualifying events happens:

  • Your spouse dies,
  • Your spouse's hours of employment are reduced,
  • Your spouse’s employment ends for any reason other than his or her gross misconduct,
  • You become divorced from your spouse.  Also, if your spouse (the employee) reduces or eliminates your group health coverage in anticipation of a divorce, and a divorce later occurs, then the divorce may be considered a qualifying event for you even though your coverage was reduced or eliminated before the divorce.

A person enrolled as the employee’s child will be entitled to elect COBRA if he or she loses coverage under the Plan because any of the following qualifying events happens:

  • The parent-employee dies,
  • The parent-employee's hours of employment are reduced,
  • The parent-employee's employment ends for any reason other than his or her gross misconduct, or

The child stops being eligible for coverage under the Plan as a child.

When is COBRA coverage available?

When the qualifying event is the end of employment or reduction of hours of employment or death of the employee, the Plan will offer COBRA coverage to qualified beneficiaries.  You need to notify the ExxonMobil Benefits Service Center of any other qualifying events.

For the other qualifying events (divorce of the employee resulting in the spouse or a child losing eligibility for coverage), a COBRA election will be available to you only if you notify and provide the appropriate forms to the ExxonMobil Benefits Service Center or ExxonMobil COBRA Administration within 60 days after the later of (1) the date of the qualifying event or (2) the date on which the qualified beneficiary loses (or would lose) coverage under the terms of the Plan as a result of the qualifying event. Current employees may give notice of qualifying events by logging onto ExxonMobil Benefits located on the  Employee Connect intranet site. (Effective February 1, 2022, the internal EDA site will be retired, so all changes and notices of qualifying events from current or former employees should be made through the ExxonMobil Benefits Service Center, where forms are also available.)

Please note:  Notice is not effective until either a change is made on ExxonMobil Benefits or the proper information is received by the ExxonMobil Benefits Service Center. If notice is not submitted during the 60-day notice period, then all qualified beneficiaries will lose their right to elect COBRA.

Election of COBRA

Each qualified beneficiary will have an independent right to elect COBRA. Covered employees and spouses (if the spouse is a qualified beneficiary) may elect COBRA on behalf of all qualified beneficiaries, and parents may elect COBRA on behalf of their children. Any qualified beneficiary for whom COBRA is not elected within the 60-day election period specified in the Plan’s COBRA election notice WILL LOSE HIS OR HER RIGHT TO ELECT COBRA.

How long does COBRA coverage last?

COBRA coverage is a temporary continuation of Plan coverage that lasts between 18-36 months depending on the qualifying event.

You, your spouse and covered dependents may qualify for up to 18 months of continuation coverage, if you qualify due to one of the following qualifying events:

  • Your employment ends for any reason other than termination for gross misconduct;
  • Your work hours are reduced and you are no longer eligible to participate in the Plan ; or
  • Unpaid Leave of Absence

Your covered spouse and covered dependent may qualify for up to 36 months of continuation coverage, if they qualify due to one of the following qualifying events:

  • You die;
  • You and your spouse get a divorce; or

An enrolled child no longer meets the definition of “child” under the terms of the Plan

Second qualifying event extension COBRA coverage

If your family experiences another qualifying event while receiving COBRA coverage as a result of the covered employee’s termination of employment or reduction of hours (including COBRA coverage during a disability extension as described above), the covered spouse and children in your family can get up to 18 additional months of COBRA continuation coverage, for a maximum of 36 months, if notice of the second qualifying event is properly given the COBRA Administrator. This extension may be available to the spouse and any children receiving COBRA coverage if the employee or former employee dies, gets divorced, or if the covered child stops being eligible under the Plan as a child. This extension is not available under the Plan when a covered employee becomes entitled to Medicare after his or her termination of employment or reduction of hours.  This extension due to a second qualifying event is available only if you notify the correct benefits administration entity within 60 days of the date of the second qualifying event. Disability extension of 18-month COBRA continuation coverage

The 18-month continuation period may be extended for you and your covered family members if the Social Security Administration determines that you or another family members, who is a qualified beneficiary, is disabled at any time during the first 60 days of continuation coverage.  If all of the following requirements are met, coverage for all family members who are qualified beneficiaries as a result of the same qualifying event can be extended for up to an additional 11 months (for a total of 29 months):

  • This extension is available only for qualified beneficiaries who are receiving COBRA coverage because of a qualifying event that was the covered employee’s termination of employment or reduction of hours.
  • The disability must have started at some time before the 61st day after the covered employee’s termination of employment or reduction of hours and must last at least until the end of the period of COBRA coverage that would be available without the disability extension (generally 18 months, as described above).
  • A copy of the Notice of Award from the Social Security Administration is provided to the COBRA Administrator [ExxonMobil Benefits Service Center] within 60 days of receipt of the notice and before the end of the initial 18 months of continuation coverage.
  • If the disabled qualified beneficiary elects continuation coverage, you must pay an increased premium of 150 percent of the monthly cost of Plan coverage that’s continued, beginning with the 19th month of continuation coverage.

Extension Due to Medicare Eligibility

Coverage may also last up 36 months for a covered spouse or covered dependent when loss of coverage is the result of a qualifying event that is the end of the employee’s employment or the reduction of the employee's hours of employment, and the employee became entitled to Medicare benefits less than 18 months before the qualifying event.  In this case, COBRA coverage under the Plan for qualified beneficiaries (other than the employee) may last until up to 36 months after the date of the employee’s Medicare entitlement. For example, if a covered employee becomes entitled to Medicare 8 months before the date on which his employment terminates, COBRA coverage for his spouse and children who lost coverage as a result of his termination can last up to 36 months after the date of Medicare entitlement, which is equal to 28 months after the date of the qualifying event (36 months minus 8 months). This COBRA coverage period is available only if the covered employee becomes entitled to Medicare within 18 months BEFORE termination or reduction of hours.

When COBRA Coverage Ends

COBRA coverage may be terminate before the maximum period if one of the following occurs:

  • The premium for your continuation coverage is not paid on time.
  • If after electing continuation coverage, you become covered by another group health plan, unless the plan contains any exclusions or limitations with respect to any pre-existing condition you or your coverage dependents may have.
  • If after electing continuation coverage, you first crome eligible for and enroll in Mediare Part A , Part B or both.
  • You extend coverage for up to 29 months due to a qualified beneficiary’s disability and there has been a final determination by the Social Security Administration that the qualified beneficiary is no longer disabled.  In this case, continuation coverage will end on the first of the month that begins more than 30 days after the final determination o by the Social Security Administration that the qualified beneficiary is no logn disabled.  This will be the case only if the qualified beneficiary has been covered by continuation coverage for at least 18 months. 

Exxon Mobil Corporation no longer provides group health coverage to any of its eligible employees or eligible retirees.

Are there other coverage options besides COBRA continuation coverage?

Yes.  Instead of enrolling in COBRA continuation coverage, there may be other coverage options for you and your family through the Health Insurance Marketplace, Medicaid, or other group health plan coverage options (such as a spouse’s plan) through what is called a special enrollment period. Some of these options may cost less than COBRA continuation coverage. You can learn more about many of these options at www.healthcare.gov.

More information about individuals who may be qualified beneficiaries during COBRA

A child born to, adopted by, or placed for adoption with a covered employee during a period of COBRA coverage is considered to be a qualified beneficiary provided that, if the covered employee is a qualified beneficiary, the covered employee has elected COBRA coverage for himself or herself.

The child's COBRA coverage begins when the child is enrolled in the Plan, whether through special enrollment or open enrollment, and it lasts for as long as COBRA coverage lasts for other family members of the employee. To be enrolled in the Plan, the child must satisfy the otherwise-applicable Plan eligibility requirements (for example, regarding age).

Alternate recipients under QMCSOs

A child of the covered employee who is receiving benefits under the Plan pursuant to a qualified medical child support order (QMCSO) received by ExxonMobil during the covered employee's period of employment with ExxonMobil is entitled to the same rights to elect COBRA as an eligible child of the covered employee.

Cost of COBRA coverage

A person who elects continuation coverage may be required to pay 102% of the cost to the Plan to maintain the coverage, unless the person is entitled to extended coverage due to disability. If the person becomes entitled to such extended coverage due to disability, the person may be required to contribute up to 150% of contributions after the initial 18-month's coverage until coverage ends. A person who elects continuation coverage must pay the required contributions within 45 days from the date coverage is elected retroactively to the date benefits terminated under the Plan.

If you have questions

Questions concerning your Plan or your COBRA continuation coverage rights should be addressed to the contact or contacts identified below.  For more information about your rights under the Employee Retirement Income Security Act (ERISA), including COBRA, the Patient Protection and Affordable Care Act, and other laws affecting group health plans, contact the nearest Regional or District Office of the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA) in your area or visit www.dol.gov/ebsa.  (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA’s website.)  For more information about the Marketplace, visit www.healthcare.gov. 

Keep your plan informed of address changes

In order to protect your family's rights, you should keep ExxonMobil Benefits Service Center informed of any changes in your address as well as the addresses of family members. You should also keep a copy, for your records, of any notices you send.

Contacts for COBRA rights under the ExxonMobil Medical Plan

The following sets out the contact numbers based on your status under the ExxonMobil Medical Plan. FAILURE TO NOTIFY THE CORRECT ENTITY COULD RESULT IN YOUR LOSS OF COBRA RIGHTS.

If your status is not listed, call the ExxonMobil Benefits Service Center for help.

Employees and their covered family members:

Contact:

Address:

ExxonMobil Benefits Service Center

Phone: 1-800-682-2847

Monday – Friday  8:00 a.m. to 6:00 p.m. (U.S. Eastern Time)

Web: ExxonMobil Benefits

ExxonMobil Benefits Service Center

Address: P.O. Box 18025

Norfolk, VA 23501-1867

Former employees and family members who have elected and are participating through COBRA:

ExxonMobil COBRA Administration
Monday - Friday except certain holidays
8:00 a.m. to 7:00 p.m. (U.S. Central Time)

800-526-2720

Wageworks National Accounts Services
ExxonMobil COBRA Administration

P.O. Box 2968
Alpharetta, GA 30023-2968
Fax: 833-514-6416

 

Claim Determination Procedures under ERISA

Procedures regarding medical necessity determinations

In general, health services and benefits must be medically necessary to be covered under the Plan. The procedures for determining medical necessity vary, according to the type of service or benefit requested, and the type of health plan. Medical necessity determinations are made on either a pre-service, concurrent, or post-service basis as described in the Certificate under section Claim Determination Procedures under ERISA, in page 71.

Notice of adverse determination

Every notice of an adverse benefit determination will be provided in writing or electronically, and will include all of the following that pertain to the determination: (1) the specific reason or reasons for the adverse determination; (2) reference to the specific plan provisions on which the determination is based; (3) a description of any additional material or information necessary to perfect the claim and an explanation of why such material or information is necessary; (4) a description of the plan's review procedures and the time limits applicable, including a statement of a claimant's rights to bring a civil action under section 502(a) of ERISA following an adverse benefit determination on appeal; (5) upon request and free of charge, a copy of any internal rule, guideline, protocol or other similar criterion that was relied upon in making the adverse determination regarding your claim, and an explanation of the scientific or clinical judgment for a determination that is based on a medical necessity, experimental treatment or other similar exclusion or limit; (6) in the case of a claim involving urgent care, a description of the expedited review process applicable to such claim.

Please refer to page 71 of the Cigna Plan certificate for further information.

When you have a complaint or an appeal

The Plan makes available both an internal and external appeal procedure for medical necessity or clinical appropriateness determinations. The internal appeals has two-steps referred to as the level one appeal and level two appeal. To initiate an internal appeal for most claims, you must submit a request to Cigna within 365 days of receipt of a denial notice. For more information about the internal appeal process, please refer to section When you have a complaint or an appeal of the Cigna Plan Certificate on page 77.

Appeals may be submitted to the following address:

Cigna

ATTN: Appeals Department

P.O. Box 15800

Wilmington, DE 19850

You should state the reason why you feel your appeal should be approved and include any information supporting your appeal. If you are unable or choose not to write, you may ask to register your appeal by telephone. Call Cigna at the toll-free number on your ID card, explanation of benefits or claim form.

Independent Review of Appeals

If you are not fully satisfied with the decision of Cigna's internal level two appeal review, you may request that your medical appeal relating to a medical necessity or appropriateness denial be referred to an Independent Health Care Appeals Program (IHCAP) and conducted by an Independent Utilization Review Organization (IURO) assigned by the State of Delaware. For medical and dental appeals denials based on grounds other than medical necessity or appropriateness you may request that your appeal be referred to arbitration by submitting a petition to the Delaware Insurance Department. Please refer to the section When you have a complaint or an appeal of the Cigna Plan Certificate on page 77.

Notice of benefit determination on appeal

Every notice of a determination on appeal will be provided in writing or electronically and, if an adverse determination, will include: (1) information sufficient to identify the claim; (2) the specific reason or reasons for the adverse determination; (3) reference to the specific plan provisions on which the determination is based; (4) a statement that the claimant is entitled to receive, upon request and free of charge, reasonable access to and copies of all documents, records, and other Relevant Information as defined; (5) a statement describing any voluntary appeal procedures offered by the plan and the claimant's right to bring an action under ERISA section 502(a); (6) upon request and free of charge, a copy of any internal rule, guideline, protocol or other similar criterion that was relied upon in making the adverse determination regarding your appeal, and an explanation of the scientific or clinical judgment for a determination that is based on a Medical Necessity, experimental treatment or other similar exclusion or limit; and (7) information about any office of health insurance consumer assistance or ombudsman available to assist you in the appeal process. A final notice of adverse determination will include a discussion of the decision.

You also have the right to bring a civil action under section 502(a) of ERISA if you are not satisfied with the decision on review. You or your plan may have other voluntary alternative dispute resolution options such as Mediation. One way to find out what may be available is to contact your local U.S. Department of Labor office or the Plan Administrator.

Please refer to pages 77 -81 of the Certificate for more details. 

Relevant information

Relevant Information is any document, record or other information which: was relied upon in making the benefit determination; was submitted, considered or generated in the course of making the benefit determination, without regard to whether such document, record, or other information was relied upon in making the benefit determination; demonstrates compliance with the administrative processes and safeguards required by federal law in making the benefit determination; or constitutes a statement of policy or guidance with respect to the plan concerning the denied treatment option or benefit for the claimant's diagnosis, without regard to whether such advice or statement was relied upon in making the benefit determination.

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