This section contains technical information about the MPO and identifies its administrator. It also contains a summary of your rights with respect to the MPO and instructions about how you can submit an appeal if your claim for benefits is denied.
The MPO is a part of the ExxonMobil Retiree Medical Plan.
MPO 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 Primary Option
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 under the Medicare Primary Option.
Aetna and Express Scripts have been designated as the Named Fiduciary for the MPO and have complete authority to review all denied claims for benefits under the MPO.
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 Primary 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 MPO is partly funded through participant and company contributions and partly fully insured. The MPO includes an employer group Medicare Part C arrangement that is fully insured and the prescription drug benefits administered by Express Scripts that are self-insured. 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 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 for prior authorization for some treatments; Express Scripts is the claims administrator for prescription drugs claims. See information sources.
Claims fiduciary and appeals
The claims fiduciary is the person to whom all appeals are filed. The claims fiduciary is Aetna for medical appeals and Express Scripts for prescription drug appeals.
Members who are dissatisfied with the resolution of an adverse decision or complaint have the right to appeal to Aetna (medical) or Express Scripts (prescription drugs) or to file a complaint with the appropriate Department of Insurance (in the case of medical). Aetna / Express Scripts have full and final discretionary authority to construe and interpret the terms of the MPO in its application to any participant or beneficiary and to decide any and all claim appeals.
For Medical appeals, please refer to Chapter 7 of the EOC. Appeals are submitted to:
Medical Level 1 and 2 Appeals
Prescription Drug Appeals
Aetna Medicare Part C Appeals & Grievances
For the MPO there are 3 level of appeals after level 2, for a total of 5 levels of appeals. At level 3, your appeal is reviewed by an Administrator Law Judge or attorney adjudicator who works for the Federal Government. Level 4 is reviewed by the Medicare Appeals Council who is part of the Federal Government. Level 5 is reviewed by a judge at the Federal District Court and this is the last step of the appeal process for the MPO related medical benefits.
Benefit claims procedures
For medical coverage decisions, appeals, complaints and grievances, please read carefully the Chapter 7 of the Evidence of Coverage (EOC), located on Aetna’s Website at ExxonMobil.AetnaMedicare.com.
It provides with detailed explanation of:
- How to ask for a coverage decision, or make an appeal.
- How to ask to cover a longer inpatient hospital stay if you think your doctor is discharging you too soon.
- How to ask to keep covering certain medical services if you think coverage is ending too soon.
- Taking your appeal to Level 3 and beyond.
- How to make a complaint about quality of care, waiting times, customer service, or other concerns.
You can also find information under the Contact Us section, option Request coverage, file an appeal or make a complaint in the ExxonMobil.AetnaMedicare.com website.
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 Level 1 appeal
If your claim is denied, you, your beneficiary, or your designated representative may appeal the decision to the appropriate claims fiduciary.
For medical services, please refer to EOC, Chapter 7.
To start an appeal related to medical services, you, your doctor, or your representative, must contact the Claims Administrator. If you are asking for a standard appeal, make your standard appeal in writing by submitting a request. If you are asking for a fast appeal, make your appeal in writing or call the Claims Administrator. You must make your appeal request within 60 calendar days from the date on the written notice the Claims Administrator sent to tell you the answer to your request for a coverage decision. You can ask for a copy of the information regarding your medical decision and add more information to support your appeal.
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:
30 calendar 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.
Filing a Level 2 appeal
If your first level of appeal is denied, you will receive written notice of the decision. Your case will automatically be sent on to the next level of the appeals process. During the Level 2 Appeal, the Independent Review Organization reviews the Claims Administrator’s decision for your first appeal. This organization decides whether the decision we made should be changed. You may review Section 5.4 of chapter 7 of the EOC for further details on this Level 2 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 (the 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 Plan, including collective bargaining agreements, and a copy of the latest annual report (Form 5500 Series) filed by the 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 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 Plan's annual report. The Administrator-Benefits is required by law to furnish each participant with a copy of this summary annual report.
In addition, review Chapter 6 of the EOC, which discusses additional rights and responsibilities that you have under the MPO. Additional legal notices are provided in Chapter 9 of the EOC.
Prudent actions by 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 the 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, 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 the MPO documents or the latest summary annual report from the MPO 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 MPO option, you should contact Aetna Medicare 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 ExxonMobil Retiree Medical Plan 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.