Q. How does the Plan coordinate benefits with Medicare?
A. The Plan treats Medicare coverage as another group plan for purposes of coordinating benefits. Medicare is the primary plan under which benefits are first payable. Plan benefits are secondary to Medicare.
The Plan will pay benefits on eligible charges up to the Plan's reimbursement level when combined with the benefits payable under Medicare. This means that benefits payable under Medicare are subtracted from the Plan's calculated benefit amount, and if eligible, any remaining Medicare approved amount is paid by the Plan. Plan benefits are determined assuming that you (and any Medicare-eligible family members) are enrolled in both Parts A and B of Medicare even if you (or your family members) have not actually enrolled.
The Plan coordinates benefits with other group plans. As used here, group does not include such organizations as the American Association of Retired Persons (AARP) or professional societies that offer their members insurance coverage. Nor does it apply to personal insurance you may purchase as an individual (sometimes called Medigap plans).
Medicare advantage plans
If you are enrolled in a Medicare Advantage Plan, including a group prepayment plan (HMO) or a Medicare PPO that replaces your Medicare coverage, you are eligible to receive benefits from the Plan for outpatient prescription drugs only if your Medicare Advantage Plan does not provide a Medicare Prescription Drug benefit. You will continue to be eligible for approved transition benefits from pre-65 medical plans sponsored by ExxonMobil, in-home skilled-nursing care, and certain services received outside of the U.S.
Some people are eligible for reimbursement from more than one group medical plan in addition to Medicare. Other group plans that are coordinated with the Plan include any group plan that is sponsored by or contributed to by another employer or labor union.
If you are covered by another group plan as defined above, you may be reimbursed by Medicare, the Plan and other group plans. The Plan's benefits can bring you up to — but not more than — 100% of your cost for covered expenses.
If a group medical plan covers either you or your spouse as an active employee, Medicare requires that plan (that is, the active employee plan) to process claims incurred by the employee and family members covered by that plan first. Only after that can Medicare and the Plan process the claims.
For those providers that are unaffiliated with or have been deactivated by Medicare, the Medicare Supplement Plan option will assume Medicare benefits.
If neither you nor your spouse is covered by a group medical plan as an active employee, but both are covered by a plan for retirees, Medicare is primary and pays benefits first. After Medicare pays, one of the retiree plans is considered the secondary plan and the other is third. The secondary plan pays benefits next, without considering benefits payable by the third plan. The third plan will apply its benefit formula, up to the total allowable expenses covered by that plan. If the Plan is third, it will pay remaining amounts under its rules but reimbursement from the Plan will not make total benefits more than 100% of the covered expense.
If the retiree has a claim, Medicare is primary, the Plan is secondary and your spouse's plan is third. If another plan covers the spouse and they have a claim, the other plan is secondary and the Plan is third. However, no one may be covered twice by the Plan, or by the Plan and any other plan to which ExxonMobil contributes. For example, if you and your spouse both worked for the ExxonMobil, neither you nor your children may be covered by both you and your spouse under any medical plan or combination of plans to which ExxonMobil contributes.
Special rules apply to coordinating benefits for prescription drugs. See Covered prescriptions for details.