Benefits summary of the Medicare Primary Option
For full information about medical/surgical amounts, refer to the Evidence of Coverage (EOC) on the Aetna website at ExxonMobil.AetnaMedicare.com. The following section provides a summary of the items under the MPO that might be of interest to you.
|Annual Deductible Per covered individual||$300
|Out-of-Pocket Maximum Per covered individual||$3,000 *|
|Medical Individual Lifetime Maximum||Unlimited|
|Preventive Care||Covered at 100%; deductible waived|
|Primary Care office visit||You pay 20% after deductible|
|Specialty Care office visit||You pay 20% after deductible 80% of covered charges less any Medicare payment|
|Labs||You pay 0% after deductible 80% of covered charges less any Medicare payment|
|X-rays & complex imaging
||You pay 20% after deductible|
|Inpatient hospital stay (prior authorization may be required)||You pay $500 copay after deductible|
|Home health care||Covered at 100% after deductible|
|Outpatient surgery||You pay 20% after deductible|
|Emergency Room||You pay $50 copay; deductible waived|
|Urgent Care||You pay $35 copay; deductible waived|
|Private Duty Nursing||You pay 20% after deductible|
|Skilled Nursing Facilities (unlimited days)||You pay $0 for day(s) 1-20; you pay 20% on the 21st day up to the end of confinement|
|Outpatient mental health & substance use rehabilitation||You pay 20% after deductible|
|Routine hearing exam||Covered at 100%; deductible waived|
|Hearing aid reimbursement||$500 every 36 months; deductible waived|
|Routine vision exam||Covered at 100%; deductible waived|
|Acupuncture||You pay 20% after deductible|
|Enhanced chiropractic services||You pay 20% after deductible|
|Non-emergency transportation (not covered by Medicare)***||Maximum of 40 one-way trips and no more than 60 miles each.|
*Once you have spent $3,000 the annual out-of-pocket amount for covered expenses (including your deductible, 20% coinsurance and copays), the MPO's reimbursement level is 100% of the covered charges during the remainder of that year. Please refer to the EOC and the SOC located on the Aetna website to understand what expenses apply towards your annual out of pocket.
**Telehealth services covered when provided by PCP, specialist, behavioral health, or urgent care providers. Member cost share will apply based on services rendered.
*** The transportation service will accommodate urgent requests for hospital discharge, dialysis, and trips that your medical provider considers urgent. You may arrange transport by calling 1-855-814-1699, Monday through Friday, from 8 AM to 8 PM, in all time zones. (For TTY/TDD assistance please dial 711.). Details will be available on the Aetna Medicare website (exxonmobil.aetnamedicare.com).
Coverage for vaccines:
- Covered by Original Medicare and not MPO – you pay $0:
- Covid-19 vaccine
- Covered under Aetna Medicare Advantage – you pay $0 (deductible waived):
- Yearly Flu shots
- Hepatitis B shots
- Pneumococcal shots
- Diabetic supplies
- Infusion drugs
- Check the Prescription drug program section to learn about vaccines covered under Express Scripts.
Prior Authorization for Medical services
Preauthorization is required for some treatments. Examples include (but not restricted to): durable medical equipment (e.g. wheelchairs, hospital beds, walker, etc.), Health Home Care, complex imaging (MRI, PET scans, etc.), some surgeries, and scheduled inpatient admissions, among others.
Preauthorization is not required for urgent care or emergency care, where:
- Urgent: unforeseen medical illness or injury that requires immediate medical care
- Emergency: requires immediate attention to prevent loss of life, or loss of limb (includes loss of function).
Your in-network Aetna Medicare Advantage provider is responsible for getting services preauthorized. Physicians contacted with Aetna have instructions on how to submit preauthorization. Time frame starts once full/completed information is received. For some services, when provided by an out-of-network provider (provider who accepts Medicare assignment but is not in the Aetna PPO network), it is recommended to get pre-authorization. More information can be found in the Schedule of Cost Sharing (SOC).
Mental health treatment
Medicare only pays for outpatient mental health care and professional services when they are provided by a health care professional who can be paid by Medicare. You should inform your provider that you participate in an Aetna Medicare Advantage Plan before you schedule treatment and provide them with your Aetna Medicare Advantage card. If your mental health profession provider does not accept Medicare Advantage, there is no coverage at all.
For more information regarding your mental health coverage, please refer to the EOC in the Aetna website. Also, you may contact Aetna Medicare Services (see contact info in Resources).
The MPO covers a wide range of medically necessary health care services, tests, treatments and supplies. For more information on what are covered expenses, please refer to EOC and SOC found at the Aetna Medicare website. These documents have detailed information in regards to services covered for you under the Medical Benefits Chart in the SOC. The Summary of Benefits (SOB) also describes the benefits provided.
Type of providers
Aetna Medicare Advantage PPO with Extended Service Area (ESA) has an open access feature that provides the same level of coverage in or out of network. It is important to understand that you may see any doctor, as long as they are eligible to receive Medicare payment.
The list of Aetna Medicare Advantage PPO providers can be found at ExxonMobil Aetna Medicare website.
Read carefully the 3 types of providers below:
1. Accepts Medicare and accepts Medicare Assignment:
If your doctor or other health care providers accept assignment, they accept the amount Medicare approves as payment in full for that service or supply. It’s an agreement by your doctor, provider, or supplier to be paid directly by Medicare, to accept the payment amount Medicare approves for the service, and not to bill you for any more than the deductible and coinsurance. The MPO will cover 80%, including the limiting charge. For example: if the Medicare approved amount is $100, so the provider bills $100. Then the MPO will cover $80 (80%), and you must still pay the difference between the Medicare-approved amount and the amount Medicare and the Plan pay (percentage copayment), which in this example is $20.
2. Accepts Medicare but does not accept Medicare assignment:
These are called non-participating providers. These providers accept Medicare but not the Medicare approved amount. They can charge you more than the Medicare-approved amount, but only up to a limit called “the limiting charge.” (15% above the Medicare-approved). The MPO will cover 80%, including the limiting charge. For example: if the Medicare approved amount is $100, and the provider bills $115, then the MPO will cover $92 (80%), and you are responsible for $23.
3. Does not accept Medicare – Medicare Opt-out providers:
Certain doctors and other health care providers who don’t want to work with the Medicare program may “opt out” of Medicare. Medicare doesn’t pay for any covered items or services you receive from an opt-out doctor or other provider, except in the case of an emergency or urgent need. You would be responsible for 100% of the services.
Special Note: Medicare approved amount (or Medicare fee schedule) is the amount a doctor or supplier can bill for Medicare covered services. It may be less than the actual amount a doctor or supplier charges.
Continuity of care
If you are participating under another option of the ExxonMobil Retiree Medical Plan or the ExxonMobil Medical Plan when you become eligible for Medicare and need assistance transitioning your care to doctors who accept Medicare and the MPO, Aetna team will work with you and your doctor to make sure the benefits are applied correctly. For more information, please refer to the Continuity of Care information located at ExxonMobil Aetna Medicare website.
Coordination of benefits
Coordination of benefits for the MPO
Coordination of benefits rules determine which plan is primary. The primary plan pays claims first before another insurance plan processes the claims. If you are enrolled in another retiree medical plan, you should contact your employer-sponsored retiree medical plan. Or you can review the other plan’s information and documents to make sure you know which plan is primary.
Your Aetna coverage is provided through a contract with ExxonMobil. You (or your spouse) may also get medical coverage from another employer or retiree group. Call the ExxonMobil Benefits Service Center (EMBSC) if you have any questions regarding coordination of your coverage. You can also call Aetna’s Member Services if you have any questions (Phone numbers for Member Services are printed on your member ID card).
Medicare Advantage Plans
If you are enrolled in another Medicare Advantage Plan, Centers for Medicare and Medicaid Services (CMS) does not allow you to be enrolled in two Medicare Advantage Plans. You will have to decide which plan is best for you.
Special rules apply to coordinating benefits for prescription drugs. See Covered prescriptions for details.
Additional information about your medical benefits
Here’s how the Aetna Medicare Advantage PPO with ESA MPO works:
- You must pay a MPO deductible each plan year. However, you are not responsible for separate Medicare Parts A and B deductibles, since the MPO replaces Medicare.
- The MPO then pays a share of the Medicare-allowable rates for covered services.
- You pay the remaining portion of charges, called coinsurance, up to the out-of-pocket maximum.
- Once you reach the annual out-of-pocket maximum, the MPO pays 100 percent of most covered expenses for the rest of the plan year.