List of key terms in the Retiree Medical Plan - POS II A and B options
Generally, all the time from the first day of employment until you leave the company's employment. Excluded are:
- Unauthorized absences,
- Leaves of absence of over 30 days (except military leaves or leave under the Federal Family and Medical Leave Act),
- Certain absences from which you do not return,
- Periods when you work as a non-regular employee, as a special agreement person, in a service station, car wash, or car-care center operations, or
- When you are covered by a contract that requires the company to contribute to a different benefit program, unless a special authorization credits the service.
The review of proposed treatment or services before the expense is incurred to determine if, and to what extent, charges will be covered by the Plan.
Review provided by medical professionals who consult with the patient and/or care providers to determine effective, cost-efficient ways to treat illnesses and utilize plan benefits.
Change in status
Life or work event that allows you to make changes to your elections during the plan year.
A person under age 26 who is:
- A natural or legally adopted child of a retiree,
- A grandchild, niece, nephew, cousin, or other child related by blood or marriage over whom a retiree, or the spouse of a retiree (separately or together) is the sole court appointed legal guardian or sole managing conservator,
- A child for whom the retiree has assumed a legal obligation for support immediately prior to the child's adoption by the regular employee or retiree, or
- A stepchild of a retiree.
Child does not include a foster child.
Claims administrator / processor
Aetna Life Insurance Company, or affiliates, for claims other than outpatient prescription drugs, and Express Scripts for retail and home delivery of outpatient prescription drugs.
Copayments and coinsurance
Your share of covered services (including out-patient prescription drugs) and mental health and substance abuse expenses. For some services, such as hospital stays, the coinsurance will be a percentage of the cost of the service once the deductible has been satisfied. For other services, such as routine office visits to a POS II provider, the copayment will be a fixed amount. For outpatient prescription drugs there is a percentage copayment up to a per-prescription maximum.
Covered medical expense
- For treatment of injury or sickness — a medically necessary expense incurred by a covered person that is not excluded from coverage;
- For treatment of mental health or substance abuse — a medically necessary expense that is certified in advance of actual treatment or an out-of-network inpatient treatment, that is provided according to the terms of the Plan, and that is not otherwise excluded from coverage.
Any person identified on the books of the employer as a retiree, eligible family member, or survivor who:
- Complies with the established enrollment requirements and makes any required contributions,
- In the case of a retiree, family member, or survivor, is not eligible for Medicare, and
- Is not eligible for any other medical plan to which ExxonMobil contributes on their behalf.
Care that helps meet personal needs and daily living activities. Such care, even if ordered by a doctor and performed by a licensed medical professional such as a nurse, is not covered by the Plan.
The amount of covered expenses you must pay each calendar year before the Plan begins sharing the cost. Fixed amount copayments do not apply toward this amount. Outpatient prescription drug copayments are not subject to nor do they count toward the annual deductible. The deductible is applied to your claims in the order Aetna processes them, not when the provider collects the money from you. This means if you pay your deductible to one provider, it may not be applied to your annual deductible if Aetna has received and processed other claims first. Please be sure to always get an itemized bill and retain proof of your payment, should you need to recover money from your provider.
Eligible family members
Eligible family members are generally your:
- A child who is described in any one of the following paragraphs (1) through (3):
- (1) has not reached the end of the month during which age 26 is attained, or
- (2) is totally and continuously disabled and incapable of self-sustaining employment by reason of mental or physical disability, provided the child:
- (a) meets the Internal Revenue Service's definition of a dependent, and
- (b) was covered as an eligible family member under this Plan or the ExxonMobil Medical Plan immediately prior to the birthday on which the child's eligibility would have otherwise ceased, and
- (c) met the clinical definition of totally and continuously disabled before such birthday and continues to meet the clinical definition through subsequent periodic reassessment reviews, and
- (d) is not eligible to be enrolled in Medicare as their primary medical plan, or
- (3) is recognized under a qualified medical child support order as having a right to coverage under this Plan.
A child who was disabled but who no longer meets the requirements of paragraph two above, ceases to be an eligible family member 60 days following the date on which the applicable requirement is not met.
Please note: An eligible retiree's parents are not eligible to be covered.
Experimental or investigational
A medical treatment or procedure, or a drug, device, or biological product, is experimental or investigational if any of the following apply:
- The drug, device, or biological product cannot be lawfully marketed without approval of the U.S. Food and Drug Administration (FDA), and, approval for marketing has not been given at the time it is furnished; [Note: Approval means all forms of acceptance by the FDA].
- Reliable evidence shows that it is the subject of ongoing phase I, II, or III clinical trials or under study to determine its maximum tolerated dose, its toxicity, its safety, its efficacy, or its efficacy as compared with the standard means of treatment or diagnosis, or
- Reliable evidence shows that the consensus of opinion among experts regarding the drug, device, or biological product or medical treatment or procedure, is that further studies or clinical trials are necessary to determine its maximum tolerated dose, its toxicity, its safety, its efficacy, or its efficacy as compared with the standard means of treatment or diagnosis. Reliable evidence shall mean only:
- Peer reviewed, published reports and articles in the authoritative medical and scientific literature,
- The written protocol or protocols used by the treating facility or the protocol(s) of another facility studying substantially the same drug, device, or biological product or medical treatment or procedure, or
- The written informed consent used by the treating facility or by another facility studying substantially the same drug, device, or medical treatment or procedure.
Explanation of benefits (EOB)
The summary you receive after your claim is processed. Codes referred to on the EOB are explained on the document.
An institution that meets the following criteria:
- Provides 24 hour skilled nursing care and related services for the rehabilitation of injured or sick persons.
- Has policies developed with the advice of and subject to the review of professional personnel to cover nursing care and related services.
- Has a physician, a registered professional nurse or a medical staff responsible for the execution of such policies.
- Requires that every patient be under the care of a physician and makes a physician available to furnish medical care in an emergency.
- Maintains clinical records on each patient and has appropriate methods for dispensing drugs and biologicals.
- Provides for periodic review by a group of physicians to examine the need for admissions, adequacy of care, duration of stay and the medical necessity of continuing confinement of patients.
- Is licensed pursuant to law or is approved by an appropriate authority as qualifying for licensing.
- Does not include a place that is primarily for custodial care.
ExxonMobil Retiree Medical Plan (EMRMP)
The Plan sponsored by Exxon Mobil Corporation which provides medical benefits for eligible retirees, survivors and their family members, and includes the Retiree Medical Plan (RMP) ), the Medicare Primary Option (MPO), and the Medicare Supplement Plan (or MSP).
An institution which:
- Is licensed as a hospital (if licensing is required),
- Is operated pursuant to law for the care and treatment of sick and injured persons,
- Provides 24 hour nursing care and has facilities both for diagnosis and surgery, except in the case of a hospital primarily concerned with the treatment of chronic diseases, and
- Is not a hotel, rest home, nursing home, convalescent home, place for custodial care, or home for the aged.
For purposes of this definition, hospital shall also mean, with respect to treatment of substance abuse, a treatment facility, residential facility, or a clinic licensed or approved for such treatment by the appropriate authority for the jurisdiction in which the facility or clinic is located.
Medical necessity or medically necessary
- Ordered by a physician for medical treatment,
- Reasonably required for the treatment or management of the condition for which it is ordered, and
- Commonly and customarily prescribed by the United States medical community as treatment or management of the condition for which it is ordered.
Magellan may use its guidelines in an initial determination of whether a mental health service or supply is medically necessary.
The Administrator-Benefits has the exclusive and final authority to determine if a service or supply is medically necessary.
Certification obtained prior to a hospital inpatient stay (including mental health and substance abuse) to give notice of inpatient admission and the proposed care. If you do not precertify a non-POS II provider or non-mental health PPO hospital stay, you will be responsible for the first $500 of eligible expenses. Refer to the Aetna National Precertification list for details of services requiring precertification.
Mental health condition
Neurosis, psychoneurosis, psychopathy, psychosis, or mental or emotional disease or behavioral disorder or disturbance with a diagnosis code from the American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders (5th ed. 2014) (DSM-V), or its successor publication, and which is appropriately treated by the Mental Health Network. Such a condition will be considered a mental health condition, regardless of any organic or physical cause or contributing factor.
Mental health preferred provider organization (MHPPO)
A nationwide network of providers and facilities whose credentials have been screened by Magellan and who provide treatment for mental health and substance abuse conditions at negotiated rates.
Mental health provider
A person, including a psychiatrist, psychologist, psychiatric nurse or social worker, therapist, or other clinician with at least a master's degree, who provides inpatient or outpatient treatment for a mental health condition, who is licensed in the state of practice and who is acting within the scope of that license (if applicable). If the person is not subject to a licensing requirement, the person must provide treatment consistent with that which would be provided by the type of providers listed above.
Providers and facilities that participate in the Retiree Medical POS II network or mental health PPO network available under the RMP POS II option.
Providers and facilities located in the Retiree Medical POS II or mental health PPO network areas, but which do not participate in a network available under this Plan.
A registered graduate nurse (RN), a licensed vocational nurse (LVN), or a licensed practical nurse (LPN).
Geographic areas that do not fall within the medical POS II or mental health PPO network.
The amount of covered medical expenses you pay in one year before the Plan begins paying 100%. The RMP POS II A and B options have different out-of-pocket limits. The out-of-pocket limit is accumulated in the order Aetna processes the claims. After the out-of-pocket limit is reached, the Plan pays 100% of most covered expenses for the remainder of that year. Certain expenses that you pay do not apply to the out-of-pocket limit. The annual deductible and your percentage copayments for eligible expenses apply to the out-of-pocket limit. The following charges do not apply to the out-of-pocket limit:
- Charges above reasonable and customary limits
- Charges not covered by the Plan
- Charge of $500 for non-compliance with medical pre-admission review process
- Charge of $500 for failure to precertify inpatient non-network and out-of-network mental health or substance abuse services
- Copayments for outpatient prescription drugs
- Charges for a private hospital room above the cost of the hospital's most common rate for a semiprivate room
Outpatient prescription drug
A prescription drug or medicine obtained through either a retail pharmacy or through a mail service prescription program (including insulin and associated diabetic supplies if acquired through a prescription). A prescription drug or medicine, including injections, obtained or administered in a physician's office or in a hospital are not considered outpatient prescription drugs.
Physician means a person acting within the scope of his or her license and holding the degree of Doctor of Medicine (M.D.), Doctor of Osteopathy (D.O.), Doctor of Dental Surgery (D.D.S.), Doctor of Podiatry (D.P.M.), Doctor of Optometry (O.D.), or Doctor of Chiropractic (D.C.), or who is duly licensed as an orthoptist, a physician assistant or nurse practitioner. Primary Care Physician means a Physician engaged in general practice, family practice, internal medicine, pediatrics or obstetrics/gynecology who provides basic health services to covered persons.
A written predetermination request will result in a detailed response as to whether a treatment or service is covered under the Retiree Medical Plan and whether the proposed cost is within R&C limits, thus ensuring all parties are aware of the financial consequences, providing all circumstances described in the request remain unchanged. Please note that a predetermination, either verbal or written, is not a guarantee of payment, as claims are paid based on the actual services rendered and in accordance with Plan provisions.
The term primary participant refers to the participant whose identification number is used. The primary participant is the retiree, survivor or an individual who elected COBRA coverage. Covered family members use the primary participant's identification number to access all medical benefits.
Private duty nursing
Continuous, substantial, and complex in-home nursing care requiring services that can only be provided by a licensed medical professional, has been prescribed by a treating physician, provided on an hourly basis and is determined to be medically necessary. Private duty nursing provides more individual and continuous skilled care than the care that can be provided in a skilled nurse visit through a home health agency.
Reasonable and customary limits
Allowable amounts for service are determined by reasonable and customary (R&C) limits. Aetna uses the industry-wide standard for R&C limits. Aetna’s network is based on a percentage of the Medicare allowable rate or on R&C limits for the geographical area as determined by Aetna.
Generally, a person at least 55 years old who retires as a regular employee with 15 or more years of benefit service or someone who is retired by the company and entitled to long-term disability benefits under the ExxonMobil Disability Plan after 15 or more years of benefit service, regardless of age.
Retirees who have been rehired as regular or non-regular employees are not eligible for the ExxonMobil Retiree Medical Plan.
Retiree Medical Plan (RMP)
One of the parts of the ExxonMobil Retiree Medical Plan which provides medical benefits for Pre-Medicare eligible retirees, survivors and their family members. It includes Retiree Medical Plan POS II option (as described in this SPD) and other self-funded options.
Retiree Medical Plan POS II Option (Point of Service)
A network of established physicians, hospitals and other medical care providers whose credentials have been screened according to Aetna's standards and who have agreed to provide their services at negotiated rates. The Retiree Medical Plan POS II is a network specifically selected by the Plan — it is part of Aetna's Choice® POS II. This network is referred to in this SPD as the Retiree Medical POS II.
Room and board
Room, board, general-duty nursing and any other services regularly furnished by the hospital as a condition of being hospitalized. It does not include professional services of physicians or private-duty nursing.
All references to marriage shall mean a marriage that is legally recognized under the laws of the state or other jurisdiction in which the marriage takes place, consistent with U.S. federal tax law. All references to a spouse or a married person shall refer to individuals who have such a marriage.
This term refers to the following:
- A cutting operation
- Suturing a wound
- Treating a fracture
- Reduction of a dislocation
- Radiotherapy (excluding radioactive isotope therapy) if used in lieu of a cutting operation for removal of a tumor
- Diagnostic and therapeutic endoscopic procedures
- Injection treatment of certain conditions
- Laser treatments
Note: Minor procedures such as biopsies or removal of moles or warts, even if performed in a doctor's office, are considered surgery.
Survivor/ surviving spouse
A surviving unmarried spouse or child of a deceased ExxonMobil regular employee or retiree.
A person who becomes a retiree due to incapacity within the meaning of the ExxonMobil Disability Plan and who begins long-term disability benefits under that plan, but whose benefits stop because the person is no longer incapacitated. A person remains a suspended retiree until the earlier of the date the person:
- Reaches age 55, or
- Begins his or her benefit under the ExxonMobil Pension Plan, at which time the person is again considered a retiree.
The family members of a deceased suspended retiree will be eligible for coverage under this Plan only after the occurrence of the earlier of the following:
- The date the suspended retiree would have attained age 55, or
- The date a survivor begins receiving a benefit due to the suspended retiree's accrued benefit from the ExxonMobil Pension Plan.
Treatment of last resort
With respect to a covered person's specific medical condition, any hospital confinement, examination, surgical, medical or other treatment, service or supply that is not determined to be medically necessary for the treatment of such condition by virtue of being experimental or investigative, but that is authorized by the Administrator-Benefits under the following conditions:
- the covered person's condition is life-threatening, and
- the treatment must be authorized by the Administrator-Benefits, and the treatment must be recommended by a specialty-matched physician(s) chosen to review the treatment in question after considering:
- the scientific basis, if any, for the treatment,
- the prior use of appropriate treatment alternative, and
- the potential efficacy of the treatment, the patient's physical condition, and the status of any government review of the treatment's use to address such condition.
For purposes of Treatment of Last Resort, a person's condition is considered to be life-threatening if there is a reasonable likelihood that it will result in the person's death within a matter of months or it is likely premature death will occur without early treatment.
Conditions or services that are non-preventative or non-routine and needed in order to prevent the serious deterioration of a person's health following an unforeseen illness, injury or condition. Urgent care includes conditions that could not be adequately managed without immediate care or treatment but do not require the level of care provided in an emergency room. Treatment of such a condition outside of an emergency room is paid according to the network status of the provider or facility. For example, out-of-network urgent care furnished by an out-of-network provider or facility is reimbursed at the out-of-network benefit level.