This section contains technical information about the Plan and identifies its administrator. It also contains a summary of your rights with respect to the Plan and instructions about how you can submit an appeal if your claim for benefits is denied.
The Medicare Supplement Plan option is a part of the ExxonMobil Retiree Medical Plan.
Plan sponsor and participating affiliates
The ExxonMobil Retiree Medical Plan is sponsored by:
Exxon Mobil Corporation
5959 Las Colinas Blvd.
Irving, TX 75039-2298
All of Exxon Mobil Corporation's divisions and most of the major U.S. affiliates participate in the ExxonMobil Retiree Medical Plan. A complete list of participating affiliates is available from the Administrator-Benefits upon written request.
Basic Plan information
The Plan Administrator for the ExxonMobil Retiree Medical Plan is the Administrator-Benefits. The Administrator-Benefits is the Manager-Global Benefits Design, Exxon Mobil Corporation. You may contact the Administrator-Benefits at the following address. Legal process may be served upon the Administrator-Benefits c/o ExxonMobil by serving the Corporation's Registered Agent for Service of Process, Corporation Service Company (CSC).
Medicare Supplement Plan
P.O. Box 18025
Norfolk, VA 23501-1867
For service of legal process:
Corporation Service Co.
211 East 7th Street, Suite 620
Austin, Texas 78701-3218
Authority of administrator-benefits
The Administrator-Benefits (and those to whom the Administrator-Benefits has delegated authority) has the full and final discretionary authority to determine eligibility for benefits, to construe and interpret the terms of the Medicare Supplement Plan option in its application to any participant or beneficiary, and to decide any and all claim appeals.
Type of plan
The ExxonMobil Retiree Medical Plan is a welfare plan under ERISA providing medical benefits.
The ExxonMobil Retiree Medical Plan (of which the Medicare Supplement Plan option is a part) is identified with government agencies under two numbers: the Employer Identification Number, 13-5409005, and the Plan Number (PN), 540.
The plan year is the calendar year.
The Plan is funded through participant and company contributions. Each year, ExxonMobil determines the rates of required participant contributions to the ExxonMobil Retiree Medical Plan. These rates are based on past and projected plan experience. Participant contributions are paid to a Trustee who manages the funds under the terms of a Trust Agreement between ExxonMobil and the Trustee. The Trustee for the EMRMP Plan is:
The Northern Trust Company
50 S. LaSalle
Chicago, IL 60675
The claims administrator provides information about claims payment, and benefit pre-determinations. The claims administrator is Aetna for medical claims and advanced approval for in-home skilled-nursing care. Express Scripts is the claims administrator for prescription drugs claims.
Claims fiduciary and appeals
The claims fiduciary is the person to whom all appeals are filed. The claims fiduciary is Aetna for medical mandatory appeals, Express Scripts for prescription drug appeals and the Administrator-Benefits for all non-prescription drug voluntary appeals. You may contact the claims fiduciary as follows:
|Medical Mandatory Appeals||Prescription Drug Mandatory and Voluntary Appeals||Medical Voluntary Appeals|
P.O. Box 14463
Lexington, KY 40512
P.O. Box 66587
St. Louis, MO 63166-6587
ATTN: Administrative Appeals Dept.
ExxonMobil Retiree Medical Plan
P.O. Box 64111
Spring, TX 77387-4111
Benefit claims procedures
Filing a claim
If you have a problem with a Plan benefit, contact the claims administrator's Member Services. You must file a claim in writing to the appropriate claims administrator, either Aetna Member Services for medical claims or Express Scripts for prescription drug claims. Aetna is responsible for determining and informing you of your entitlement to a benefit and any amounts payable to you with regard to medical services or supplies. Express Scripts is responsible for determining and informing you of your entitlement to a benefit and any amount payable to you under the prescription drug program.
Claims for benefits where the Plan provisions do not require approval before medical care is obtained are the most common claims filed under the Plan. The claims administrator will review your claim and respond within a designated response time, usually 30 days after receiving your claim. If the claims fiduciary 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.
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.
You should be aware that the claims administrators have the right to request repayment if they overpay a claim for any reason.
Filing a mandatory appeal
If your claim is denied, you, your beneficiary, or your designated representative may appeal the decision to the appropriate claims fiduciary. If someone is filing a written appeal on your behalf, written authorization from you is required. Please contact the appropriate claims fiduciary for information regarding the written authorization. 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. In the case of an urgent care claim, you may request an expedited appeal orally or in writing. You must submit your written appeal within 180 calendar 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. You will receive a response to the appeal within a designated response time as follows:
|Claim Type||Response Time|
|Urgent care claims||72 hours|
|Pre-service claims||30 days|
|Post-service claims||60 days|
If additional time is needed to decide on your claim because of special circumstances, you will be notified within the claim response period. However, if an extension is requested and granted, 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 without requesting a voluntary appeal. The statute of limitations or other defense based on timeliness is suspended during the time that a voluntary appeal is pending. Any such lawsuits must be brought within one year of the date on which the appeal was denied.
Filing a voluntary appeal
If your mandatory appeal is denied, you may then submit a voluntary appeal to the appropriate claims fiduciary. 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.
If it is determined that there is no new information pertinent to your claim, your voluntary appeal will not be considered. If it is determined that there is new relevant information, a decision will be made within 60 days of the date the Administrator-Benefits receives your request for a voluntary appeal.
Future of the ExxonMobil Retiree Medical Plan
ExxonMobil has the right to change, suspend, withdraw, amend, modify or terminate the ExxonMobil Retiree Medical Plan or any of its provisions at any time and for any reason. A change also may be made to required contributions and future eligibility for coverage, and may apply to those who retired in the past, as well as those who retire in the future. If any material changes are made in the future, you will be notified. For health plans, certain rules apply regarding what happens when a plan is changed, terminated or merged.
Expenses incurred before the effective date of a Plan change or termination will not be affected. Expenses incurred after a Plan is terminated will not be covered. If a Plan cannot pay all of the incurred claims and plan expenses as of the date the Plan is changed or terminated, ExxonMobil will make sufficient contributions to the Plan to make up the difference.
Your rights under ERISA
As a participant in the ExxonMobil Retiree Medical Plan, you have certain rights and protections under the Employee Retirement Income Security Act of 1974 (ERISA). ERISA provides that as a Plan participant, you shall be entitled to:
Receive information about your plan and benefits
- Examine, without charge, at the office of the Administrator-Benefits and at other specified locations, such as worksites and union halls, all documents governing the Medical Plan, including collective bargaining agreements, and a copy of the latest annual report (Form 5500 Series) filed by the Medical Plan with the U.S. Department of Labor and available at the Public Disclosure Room of the Employee Benefits Security Administration.
- Obtain, upon written request to the Administrator-Benefits, copies of documents governing the operation of the Medical Plan, including collective bargaining agreements, and copies of the latest annual report (Form 5500 Series) and updated SPD. The administrator may require a reasonable charge for the copies.
- Receive a summary of the Medical Plan's annual report. The Administrator-Benefits is required by law to furnish each participant with a copy of this summary annual report.
Prudent actions by medical plan fiduciaries
In addition to creating rights for Medicare Supplement Plan participants, ERISA imposes duties upon the people who are responsible for the operation of the employee benefit plan. The people who operate the Medicare Supplement Plan option, called fiduciaries of the Medicare Supplement Plan option, have a duty to do so prudently and in the interest of you and other Medicare Supplement Plan participants and beneficiaries. No one, including your employer, your union, or any other person, may discriminate against you in any way to prevent you from obtaining a plan benefit or exercising your rights under ERISA.
Enforce your rights
- If your claim for a benefit is denied or ignored, in whole or in part, you have a right to know why this was done, to obtain copies of documents relating to the decision without charge, and to appeal any denial, all within certain time schedules.
- Under ERISA, there are steps you can take to enforce the above rights. For instance, if you request a copy of Medicare Supplement Plan documents or the latest summary annual report from the Medicare Supplement Plan option and do not receive them within 30 days, you may file suit in a Federal court. In such a case, the court may require the Administrator-Benefits to provide the materials and pay you up to $110 a day until you receive the materials, unless the materials were not sent because of reasons beyond the control of the administrator.
- If you have a claim and an appeal for benefits, which are denied or ignored, in whole or in part, you may file suit in a federal court. Such lawsuit must be filed in the United States District Court for the Southern District of Texas, Houston, Texas, or in the United States District Court for the federal judicial district where the employee currently works. If a retiree or terminee, the suit must be filed in the last location worked prior to termination of employment. Beneficiaries must also file in the same federal judicial district that the employee or retiree would be required to file. Any such lawsuits must be brought within one year of the date on which an appeal was denied. The court will decide who should pay court costs and legal fees. If you are successful, the court may order the person you have sued to pay these costs and fees. If you lose, the court may order you to pay these costs and fees, for example, if it finds your claim is frivolous.
Assistance with your questions
If you have any questions about your Medicare Supplement Plan option, you should contact Aetna Member Services via the telephone number on your ID card, or call the Benefits Service Center. If you have any questions about this statement or about your rights under ERISA, or if you need assistance in obtaining documents from the Administrator-Benefits, you should contact the nearest office of the Employee Benefits Security Administration, U.S. Department of Labor, listed in your telephone directory or the Division of Technical Assistance and Inquiries, Employee Benefits Security Administration, U.S. Department of Labor, 200 Constitution Avenue N.W., Washington, D.C. 20210. You may also obtain certain publications about your rights and responsibilities under ERISA by calling the publications hotline of the Employee Benefits Security Administration.
A note regarding the ExxonMobil Retiree Medical Plan
The Medicare Supplement Plan option is a retiree only plan. A retiree only health plan is exempt from most provisions of the PPACA. As a retiree only plan the Plan will not include the consumer protections of PPACA that apply to the other plans.
Women's Health and Cancer Rights Act of 1998
If you have a mastectomy, at any time, and decide to have breast reconstruction, based on consultation with your attending physician, the following benefits will be subject to the same percentage copayment and deductibles which apply to other plan benefits:
- Reconstruction of the breast on which the mastectomy was performed,
- Surgery and reconstruction of the other breast to produce a symmetrical appearance, and
- Prostheses, and
- physical complications in all stages of mastectomy, including lymphedema.
The above benefits will be provided subject to the same deductibles, copayments and limits applicable to other covered services.
If you have any questions about your benefits, please contact Aetna Member Services.
Coverage for maternity hospital stay
Under federal law, the Plan may not restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section, or require that a provider obtain authorization from the Plan for prescribing a length of stay not in excess of the above periods. The law generally does not prohibit an attending provider of the mother or newborn, in consultation with the mother, from discharging the mother or newborn earlier than 48 or 96 hours, as applicable.