Both RMP POS II options include the features listed below.
Expenses are covered under these options only if they are medically necessary. Care is medically necessary if it is a therapeutic procedure, service or supply used in the medical treatment of an injury, disease, or pregnancy, which is generally recognized by the United States medical community as appropriate. Claims are reviewed as submitted, and some or all of any claim or series of services could be denied as not being medically necessary. It also means that experimental and/or investigational procedures, drugs, devices or biological products not proven by long-term clinical studies are generally not covered. See Exclusions for limited exceptions.
When determining medical necessity, the Administrator-Benefits may consider the Clinical Policy Bulletins (CPBs) published by Aetna, the claims administrator. CPBs are based on objective, credible sources, such as the scientific literature, guidelines, consensus statements and expert opinions. These CPBs may be found on the Aetna website at https://www.aetna.com/health-care-professionals/clinical-policy-bulletins.html.
Precertification or preauthorization is a mandatory review of inpatient admissions and select ambulatory procedures and/or services in advance of treatment, to confirm medical necessity based on clinical criteria and benefits eligible under the Plan. If you are using a network provider, the provider will perform the precertification process on your behalf. If you are using a non-network provider, you must initiate the precertification process yourself. Failure to obtain a required precertification for non-network hospitalization services will result in a $500 penalty, even if the services are medically necessary and otherwise covered under the Plan. For more information on precertification for medical/surgical procedures and services, see the National Precertification List on the Aetna member website.
Enhanced clinical review
The Plan also includes a utilization management program, known as Enhanced Clinical Review (ERC), of some diagnostic services (e.g., MRIs, CT Scans, Cardiac Imaging, sleep studies, hip/knee replacement procedures, etc.).
An enhanced clinical review is a mandatory review of select covered services that have equivalent, lower-cost alternatives, to ensure the higher cost service is medically necessary in advance of treatment. If the review is not completed and the treatment is not approved, it will not be covered under the Plan.
Please contact Aetna Member Services to determine if the service your physician has recommended requires enhanced clinical review.
The ECR precertification process applies to Aetna participating providers and facilities. Out of network providers and facilities are subject to retrospective claim reviews to determine if the services meet Aetna medical necessity guidelines.
For emergency inpatient admissions:
Certification must be made within 48 hours following an emergency inpatient admission. If the admission is on a weekend or holiday, notification must be made within 72 hours.
- If you are using POS II network provider, your provider will obtain certification for you.
- You or someone acting on your behalf must call to certify care if you are in a non-network or out-of-network area hospital.
For certain prescription drugs
Your physician must call Express Scripts for precertification of certain prescription drugs. This applies whether you are inside or outside the United States.
In some cases, you may be required to try one or more specified drugs to treat a particular medical condition before the Plan will cover another (usually more expensive) drug.
Additionally, as part of Express Scripts’ Advanced Utilization Management (AUM) program, certain targeted drugs will not be covered unless precertified by Express Scripts, based on medical evidence submitted by your physician.
Non-targeted drugs are covered without precertification or prior authorization. Refer to the Prescription drug program section for more details.
A predetermination is an estimate of covered services and benefits payable in advance of treatment. It is not a guarantee of benefits eligible or payment amount. You may request a predetermination for any covered service. In most cases, you may receive an answer over the phone. In other cases, information from your provider may be needed. You or your doctor can also request a predetermination of benefits, in writing, before the service is performed.
Predetermination is recommended for all outpatient surgical procedures. This predetermination may require review by one or more doctors. Be sure to allow time for this review between the predetermination request and the proposed date of the service. By obtaining the written response, you will have more detailed information about the level of reimbursement.
For more information on requesting a predetermination, see the Information sources section at the front of this SPD.
When you call for a benefit predetermination, be ready to provide the following information:
- Primary participant's name and member ID, which can be found on your Aetna ID card,
- Patient's name,
- Complete description of medical services or surgical procedures. If possible, include the diagnosis code(s) and the five-digit Current Procedural Terminology (CPT) codes or the Healthcare Common Procedure Coding System (HCPCS) alpha-numeric codes, which you can get from the provider,
- Provider's complete information including name, address, phone number, and zip code, and
- Provider's proposed fee for each service.
Federal law mandates that benefit programs such as the ExxonMobil Retiree Medical Plan cover eligible participants for a minimum length of stay for delivery and newborn hospitalizations. Those minimums are 48 hours following a vaginal delivery and 96 hours following a Cesarean section. However, federal law generally does not prohibit the mother's or newborn's attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable).
The Plan does not provide breastfeeding support, counseling and equipment for the duration of breastfeeding.
Medical, surgical, behavioral health and substance use disorder Aetna POS II A/B network
The Aetna Choice® POS II network includes a group of physicians, hospitals, and other providers who have met standards for licensing, academic background and service are located throughout the United States. If you use network providers, the Plan pays a larger portion of the covered expenses. Network providers have agreed to negotiated charges which may save you and the Plan money. Other advantages to using Medical POS II network providers for medical, surgical, behavioral heath and substance use disorder care are:
- You pay a copay for most office visits, including diagnostic laboratory and X-rays associated with that office visit. Preventive care office visits are reimbursed at 100%.
- Emergency room physician expenses, in-patient hospital expenses, and outpatient surgery expenses are subject to deductible and coinsurance.
- Other expenses such as home health care, durable medical equipment or complex imaging are reimbursed at the network reimbursement level (either 80% for the Aetna POS II B or 75% for the Aetna POS II A) of a negotiated rate after you meet the annual deductible.
- Your annual out-of-pocket maximum is significantly lower.
- Retiree Medical POS II network providers file claims and handle the hospital preadmission review process for you.
- All negotiated charges are within reasonable and customary limits.
To find Aetna Choice® POS II network providers in your area, choose “Find a Doctor” on the Aetna website or mobile app. If you need further assistance, you can call Aetna Member Services.
Copayment for office visits/lab work when provided by a primary care physician; higher copayment when provided by a specialist.
When you use Retiree Medical POS II network providers for office visits, you are not subject to the annual deductible. You pay a copayment for each office visit, which may include most related lab work and radiology performed by an RMP POS II network provider.
More extensive tests, including complex imaging (i.e., CT scans, MRI, MRA, PET/SPECT), radiopharmaceutical stress tests, angiography myelography, MUGA scans and sleep studies, and office or out-patient surgery and associated diagnostic lab and xray services are subject to the deductible and coinsurance.
If an injection (other than an injection into a vein or artery) is received in a network doctor's office without an office visit, the copayment will be the actual cost of the injection or the office visit copayment, whichever is less. For infusion therapy and chemotherapy, a fixed copayment only applies to the office visit. All other related services are paid at coinsurance. Allergy serum dispensed by a network doctor is reimbursed at coinsurance after the deductible.
These copayments do not apply to your annual deductible but do apply to your annual out-of-pocket limit. See the explanation beginning in the Payment section for more information about deductibles and copayments.
Is your doctor a network provider?
Call your doctor's office to confirm his or her participation in the Aetna Choice® POS II network. If your doctor is not participating, ask your provider to consider applying to participate. Your doctor can obtain information about becoming a network participant from Aetna's website (www.aetna.com/healthcare-professionals/index.html) or by calling Aetna Credentialing Customer Service at 1-800-353-1232.
If you live in a POS II network area and use POS II non-network providers
- Your out-of-pocket costs will generally be higher. The Plan's reimbursement level is 60% for the Aetna POS II B and 55% for the Aetna POS II A of reasonable and customary charges, after you satisfy the non-network deductible, and your out-of-pocket expenses will accumulate towards a higher non-network out-of-pocket maximum.
- You must call Aetna to initiate the medical preadmission review process for inpatient treatment and ensure any precertification or preauthorization requirements are completed.
- If your provider or facility charges are above reasonable and customary limits, you are responsible for paying any amounts above reasonable and customary limits in addition to your coinsurance. You may be balance billed by the provider or facility for any amount not reimbursed by Aetna. Refer to section regarding non-volitional use of non-network providers for additional details.
- You are responsible for submitting claims.
If you cannot find a Network Provider (network deficiency)
Sometimes you may have difficulty finding a network provider in your area that is available when you need care. If an Aetna Choice® POS II network provider is not available for medical, surgical, behavioral health and substance use disorder services, call Aetna Member Services for information on the Plan's alternate network deficiency benefit. If Aetna confirms a network provider is not available for the medical/surgical services you need, they will authorize use of a designated non-network provider for your care.
Benefits for covered services at a designated non-network provider under the alternate network deficiency benefit will be paid at the In-Network level (either 80% for Aetna POS II B or 75% for Aetna POS II A of reasonable and customary charges) after the plan year deductible has been satisfied, and out-of-pocket expenses for those services will accumulate towards your In-Network out-of-pocket maximum. Copayments will not apply.
If you live outside an Aetna POS II network area (out-of-network area benefits)
If you live outside a designated Aetna POS II network area, benefits for covered services are paid at the out-of-network area benefit level.
You still have access to Aetna Choice® POS II network providers and facilities in your area, within a short driving distance, and while travelling. When you receive care from a network provider or in a network facility, you will be reimbursed at 80% for Aetna POS II B or Aetna 75% for POS II A of the negotiated network rate for inpatient and outpatient services, your network provider will initiate the preadmission review process, and network copayments for primary care and specialist office visits will apply.
If you live outside a Aetna POS II network area and receive care from a non-network provider or in a non-network facility, you will be reimbursed at 80% for POS II B and 75% for POS II A of reasonable and customary charges for similar services in the same area. Network discounts and network copayments do not apply, and you must satisfy the deductible for all covered services other than preventive care. You are also responsible for initiating the medical preadmission review process for inpatient treatment unless you use a network provider.
Most non-network charges fall within reasonable and customary limits. However, you may receive a balance bill for the difference between a non-network provider’s billed charges and what is considered reasonable and customary for covered services in your area. If this happens, call Aetna Member Services. The full or partial balance bill may qualify as an allowable expense eligible for payment by the Plan. This includes balance bills for ambulance services, emergency physicians, radiologists, anesthesiologists, pathologists, hospitalists, neonatologists, and intensivists. It may also include balance bills for scheduled procedures performed by a non-network physician when a network physician is not available. However, if a network physician is available, and you schedule an inpatient or outpatient procedure with a non-network physician, you will be responsible for any billed charges above reasonable and customary limits, which for professional services is set at 200% of Medicare Fee Schedule of charges for similar services in the same geographic area.
If you live outside a POS II network area, the out-of-pocket maximum for non-network services is the same as the maximum for network services. Once your annual out-of-pocket limit is reached, covered services are reimbursed at 100% of reasonable and customary charges.
Note: You are responsible for payment for services that are not covered by the Plan, including non-medical ancillary services and any balance bill that remains after adjustments for allowable expenses have been made. Payments for services not covered by the Plan do not accumulate towards your annual out-of-pocket limit.
Your Rights and Protections Against Surprise Medical Bills
When you get emergency care or you’re treated by an out-of-network provider at an in-network hospital, or ambulatory surgical center or by an air ambulance provider, you are protected from surprise billing or balance billing.For more information on your rights, please refer to the Surprise Medical Bills notice located in www.exxonmobilfamily.com