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Administrative and ERISA information

Administrative and ERISA information for the Retiree Medical Plan - POS II A and B options

Q. What other information do I need to know about the Plan? 

A. 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 formal name of the Plan is 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

Plan administrator

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 Exxon Mobil Corporation by serving the Corporation's Registered Agent for Service of Process, Corporation Service Company (CSC).

Administrator-Benefits
ExxonMobil Retiree Medical Plan
P.O. Box 64111
Spring, TX 77387-4111

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 Retiree Medical Plan 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.

Plan numbers

The ExxonMobil Retiree Medical Plan is identified with government agencies under two numbers: the Employer Identification Number, 13-5409005, and the Plan Number (PN), 540.

Plan year

The plan year is the calendar year.

Plan funding

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

Claims administrator

The claims administrator provides information about claims payment. The claims administrator is Aetna for medical claims and for mental health and substance abuse claims and Express Scripts for prescription drug 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, Magellan for mandatory and voluntary appeals for all mental health and substance abuse-related appeals, and Express Scripts for all prescription drug mandatory and voluntary appeals. The Administrator-Benefits is the claims fiduciary for medical voluntary appeals. You may contact the claims fiduciary as follows:

Medical Mandatory and Voluntary Appeals: Mandatory and Voluntary Mental Health and Substance Abuse Related Appeals: Prescription Drug Mandatory and Voluntary Appeals:
:

Aetna 
P.O. Box 14463
Lexington, KY 40512

Magellan Healthcare
P.O. Box 2128
Maryland Heights,
Missouri, 63043
Express Scripts
P.O. Box 66587
St. Louis, MO 63166-6587
Attn: Administrative Appeals Dept.
 
Note: For initial claims incurred before January 1, 2021, the Administrator-Benefits is the claims fiduciary for medical voluntary appeals.


Administrator-Benefits

ExxonMobil Medical Plan
P.O. Box 64111
Spring, TX 77387-4111


The Administrator-Benefits determination of eligibility is final and no mandatory or voluntary appeals are available, including decisions regarding whether a child age 26 or older meets the clinical definition of totally and continuously disabled. All decisions by Magellan or Aetna confirming a dependent no longer meets the clinical definition of totally and continuously disabled are final. 

Benefit claims procedures

Filing a claim

A claim occurs whenever a plan participant requests:


• An authorization or referral from a participating provider or Aetna, or

• Payment for items or services received.


You do not need to submit a claim for most of your covered healthcare expenses. However, if you receive a bill for covered services, the bill must be submitted promptly to Aetna for payment. Send the itemized bill for payment with your identification number clearly marked to the address shown on your ID card.


You must submit a claim form within two calendar years from the date of a service.


Aetna will make a decision on your claim using coverage policies and the definitions included in this document. For concurrent care claims, Aetna will send you written notification of an affirmative benefit determination. For other types of claims, you may only receive notice if Aetna makes an adverse benefit determination.


Adverse benefit determinations are decisions Aetna makes that result in denial, reduction, or termination of a benefit or the amount paid for it. It also means a decision not to provide a benefit or service.


Adverse benefit determinations can be made for one or more of the following reasons:


• The individual is not eligible to participate in the Plan, or
• Aetna determines that a benefit or service is not covered by the Plan because:
 o it is not included in the list of covered benefits,
 o it is specifically excluded,
 o a Plan limitation has been reached, or
 o it is not medically necessary.

Aetna will provide you with written notices of adverse benefit determinations within the time frames shown below. These time frames may be extended under certain limited circumstances. The notice you receive from Aetna will provide important information that will assist you in making an appeal of the adverse benefit determination, if you wish to do so. Please see Complaints and Appeals for more information about appeals.

 
Post-service claim: a claim for a benefit that is not a pre-service claim.
Type of Claim Response time

Urgent care claim: a claim for medical care or treatment where delay could:
• Seriously jeopardize your life or health, or your ability to regain maximum function, or
• Subject you to severe pain that cannot be adequately managed without the requested care or treatment

 
As soon as possible but not later than 72 hours.
Pre-service claim: a claim for a benefit that requires Aetna’s approval of the benefit in advance of obtaining medical care. 15 calendar days
Concurrent care claim extension: a request to extend a previously approved course of treatment
Concurrent care claim extension: a request to extend a previously approved course of treatment. Urgent care claim - as soon as possible, but not later than 24 hours, provided the request was received at least 24 hours prior to the expiration of the approved treatment. 

Other claims - 15 calendar days
 Concurrent care claim reduction or termination: a decision to reduce or terminate a course of treatment that was previously approved. With enough advance notice to allow the plan participant to appeal.  With enough advance notice to allow the plan participant to appeal.
 30 calendar days
 
Extensions of time frames
 
The time periods described in the chart may be extended.
 
For urgent care claims: If Aetna does not have sufficient information to decide the claim, you will be notified as soon as possible (but no more than 24 hours after Aetna receives the claim) that additional information is needed. You will then have at least 48 hours to provide the information. A decision on your claim will be made within 48 hours after the additional information is provided.

For non-urgent pre-service and post service claims: The time frames may be extended for up to 15 additional days for reasons beyond the Plan’s control. In this case, Aetna will notify you of the extension before the original notification time period has ended. If you fail to provide the information, your claim will be denied.
 
If an extension is necessary because Aetna needs more information to process your post service claim, Aetna will notify you and give you an additional period of at least 45 days after receiving the notice to provide the information. Aetna will then inform you of the claim decision within 15 days after the additional period has ended (or within 15 days after Aetna receives the information, if earlier). If you fail to provide the information, your claim will be denied.
 
Grievances and appeals
 
There are procedures for you to follow if you are dissatisfied with a decision that Aetna has made or with the operation of the Plan. The process depends on the type of complaint you have. There are two categories of complaints:

• Quality of care or operational issues, and

• Adverse benefit determinations.

Complaints about quality of care or operational issues are called grievances. Complaints about adverse benefit determinations are called appeals.
 

Grievances 

Quality of care or operational issues arise if you are dissatisfied with the service received from Aetna or want to complain about a participating provider. To make a complaint about a quality of care or operational issue (called a grievance), call or write to Member Services within 30 days of the incident. Include a detailed description of the matter and include copies of any records or documents that you think are relevant to the matter. Aetna will review the information and provide you with a written decision within 30 calendar days of the receipt of the grievance, unless additional information is needed, but cannot be obtained within this time frame. The notice of the decision will specify what you need to do to seek an additional review.

Appeals of Adverse Benefit Determinations by Aetna
 
Aetna will send you written notice of an adverse benefit determination. The notice will give the reason for the decision and will explain what steps you must take if you wish to appeal. The notice will also tell you about your rights to receive additional information that may be relevant to the appeal. Requests should be presented within 180 days from the date of the notice.

The Plan provides for two levels of appeal plus an option to seek External Review of the adverse benefit determination. You must complete the two levels of appeal before bringing a lawsuit. The following chart summarizes some information about how appeals are handled for different types of claims. In certain situations, the time frames shown may be extended.
 

Type of Claim

Level One Appeal

Level Two Appeal

Urgent care claim: a claim for medical care or treatment where delay could:

  • Seriously jeopardize your life or health, or your ability to regain maximum function, or
  • Subject you to severe pain that cannot be adequately managed without the requested care or treatment

36 hours

Review provided by Aetna personnel not involved in making the adverse benefit determination.

36 hours

Review provided by Appeals Committee.

Pre-service claim: a claim for a benefit that requires Aetna’s approval of the benefit in advance of obtaining medical care.

15 calendar days

Review provided by Aetna personnel not involved in making the adverse benefit determination

15 calendar days

Review provided by Appeals Committee.

Concurrent care claim extension: a request to extend a previously approved course of treatment.

Treated like an urgent care claim or a pre-service claim depending on the circumstances

Treated like an urgent care claim or a pre-service claim depending on the circumstances

Post-service claim: a claim for a benefit that is not a pre-service claim.

30 calendar days

Review provided by Aetna personnel not involved in making the adverse benefit determination.

30 calendar days

Review provided by Appeals Committee.

 
 
 Effective January 1st, 2021, you may perform your appeal in writing or verbally. You may also choose to have another person (an authorized representative) make the appeal on your behalf by providing written consent to Aetna. However, in case of an urgent care claim or a pre-service claim, a physician familiar with the case may represent you in the appeal.
 
Depending on the type of appeal, you and/or an authorized representative may attend the Level 2 appeal hearing and question the representative of Aetna and any other witnesses, and present your case. The hearing will be informal. You may bring your physician or other experts to testify. Aetna also has the right to present witnesses.
 
If the Level One and Level Two appeals uphold the original adverse benefit determination, you may have the right to pursue an external review of your claim. See External review of Aetna’s final appeal determinations for more information.
 
External review of Aetna’s final appeal determinations
 
You may file a voluntary appeal for external review of any final appeal determination that qualifies.
You must complete the two levels of appeal described above before you can appeal for external review. Subject to verification procedures that may be established, your authorized representative may act on your behalf in filing and pursuing this voluntary appeal. You must request this voluntary level of review within 60 days after you receive the final denial notice.
 
If you file a voluntary appeal, any applicable statute of limitations will be tolled while the appeal is pending. The filing of a claim will have no effect on your rights to any other benefits under the Plan. However, the appeal is voluntary and you are not required to undertake it before pursuing legal action.

If you choose not to file for voluntary review, the Plan will not assume that you have failed to exhaust your administrative remedies because of that choice.

An external review is a review by an independent physician, with appropriate expertise in the area at issue, of claim denials and denials based upon lack of medical necessity, or the experimental or investigational nature of a proposed service or treatment. You may request a review by an external review organization (ERO) if:

• You have received notice of the denial of a claim by Aetna, and

• Your claim was denied because Aetna determined that the care was not medically necessary or was experimental or investigational, and
 

The claim denial letter you receive from Aetna will describe the process to follow if you wish to pursue an external review, and will include a copy of the Request for External Review Form.
You must submit the Request for External Review Form to Aetna within 60 calendar days of the date you received the final claim denial letter. The form must be accompanied by a copy of the final claim denial letter and all other pertinent information that supports your request.

Aetna will contact the External Review Organization that will conduct the review of your claim. The External Review Organization will select an independent physician with appropriate expertise to perform the review. In rendering a decision, the external reviewer may consider any appropriate credible information submitted by you with the Request for External Review Form, and will follow the applicable plan’s contractual documents and plan criteria governing the benefits. You will generally be notified of the decision of the External Review Organization within 45 days of Aetna’s receipt of your request form and all necessary information. An expedited review is available if your physician certifies (by telephone or on a separate Request for External Review Form) that a delay in receiving the service would jeopardize your health. Expedited reviews are decided within 3-5 calendar days after Aetna receives the request.

You are responsible for the cost of compiling and sending the information that you wish to be reviewed by the External Review Organization to Aetna. Aetna is responsible for the cost of sending this information to the External Review Organization.
 
 

No assignment

The rights or benefits under this Plan may not be assigned by a participant or beneficiary. Any assignment will be treated as a direction to pay benefits to an assignee rather than as an assignment of rights.

Limited authorization of payments

To the extent allowed by the claims administrator, you may authorize your claims administrator to make payments directly to a health care provider for covered services. Further, even without such authorization, a claims administrator may make direct payments to a health care provider for covered services according to the claims administrator’s rules and procedures at the applicable time.
Authorization of payments to a health care provider or direct payments to a health care provider are not assignment of benefits. Even though you may authorize a health care provider to receive a payment or reimbursement of covered services and even though a claims administrator may pay a health care provider directly for payments or reimbursements of covered services, in no event will any such authorizations, payments or reimbursements to or on behalf of a health care provider cause the provider to become a plan participant or plan beneficiary (or assignee of a participant or beneficiary) under ERISA.

The provision in this SPD is deemed to be notice to any and all individuals to whom notice may be required, and no additional notice of the above provisions is needed for a provider or otherwise.

No assignment of rights and benefits

Your rights and benefits under a medical option cannot be assigned, sold or transferred to any person, including your health care provider. For this purpose, your plan rights and benefits include, without limitation, the right to file an administrative appeal (internal and external), the right to sue following a denied administrative appeal and any other plan rights and benefits, whether actual or potential. Any purported assignments of rights and/or benefits under the plan will be void and will not apply to the plan. Further, a payment or reimbursement of covered services by a claims administrator to a health care provider will not waive the application of this provision. The application of this provision does not affect your right to appoint an authorized representative.

The provision in this SPD is deemed to be notice to any and all individuals to whom notice may be required, and no additional notice of the above provisions is needed for a provider or otherwise.

Health care provider agreements not binding on the plan

Sometimes your health care provider requests that you sign various agreements and other documentation as a condition of receiving health care services from the provider. Any agreement, assignment or other document executed by you and a health care provider (or executed by parties that include you and a health care provider but that do not include the plan administrator) are not binding on and will have no legal effect whatsoever on the plan or any claims administrator. Further, a payment or reimbursement of covered services by a claims administrator to a health care provider (whether pursuant to an authorization or otherwise) will not waive the application of this provision.

Recovery of Excess Payments

Whenever payments have been made in excess of the amount necessary to satisfy the provisions of this plan, the Plan has the right to recover these excess payments from any individual (including you, your family members and a provider), insurance company or other entity or organization to whom the excess payments were made—or to withhold payment, if necessary, on future benefits until the overpayment is recovered. Whenever payments have been made based on inaccurate, misleading or fraudulent information provided by you or your family member, the Plan will exercise all available legal rights to recover the overpayment, including its right to withhold payment on future benefits or offset future benefits to the extent of the overpayment until the overpayment is recovered.

Future of the ExxonMobil Retiree Medical Plan

ExxonMobil has the right to change, suspend, withdraw, amend, modify or terminate the 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. If all claims and expenses are paid and there is still money in ExxonMobil's book reserve established for the purpose of making contributions toward the cost of retirees' health care coverage, ExxonMobil will determine what to do with the excess amount in view of the purposes of the plans.

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 ExxonMobil Retiree Medical Plan, and a copy of the latest annual report (Form 5500 Series) filed by the ExxonMobil Retiree 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 ExxonMobil Retiree Medical Plan, and copies of the latest annual report (Form 5500 Series) and updated summary plan description. The administrator may require a reasonable charge for the copies.
  • Receive a summary of the Plan's annual financial report. The Administrator-Benefits is required by law to furnish each participant with a copy of this summary annual report.

Prudent actions by ExxonMobil Retiree Medical Plan fiduciaries

In addition to creating rights for Plan participants, ERISA imposes duties upon the people who are responsible for the operation of the employee benefit plan. The people who operate your Plan, called fiduciaries of the Plan, have a duty to do so prudently and in the interest of you and other Plan participants and beneficiaries. No one can 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 the Plan documents or the latest summary annual report from the Plan 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. 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 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 the ExxonMobil Retiree Medical Plan, 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.

Federal notices

A note regarding the ExxonMobil Retiree Medical Plan

The Retiree Medical Plan (RMP) is a retiree only plan. A retiree only health plan is exempt from all the insurance mandates of the PPACA and HIPAA portability. As a retiree only plan the RMP 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,
  • Prostheses, and
  • Services for 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.

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