List of key terms in the Medicare Primary Option
A physician who accepts Medicare assignment agrees to accept no more than the Medicare-approved amount as total payment for a service.
The amount on which Medicare bases its payments for a particular service.
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 leaves 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 or 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.
Copayment and coinsurance
The portion of covered expenses you pay. For some services the coinsurance will be a percentage of the cost of the service once the deductible has been satisfied. For outpatient prescription drugs there is a percentage copayment.
Covered charges or covered expenses
Expenses that are eligible for reimbursement under the MPO. Some expenses must be Medicare-approved to be covered. All expenses must meet MPO requirements including medical necessity.
The amount of covered expenses you incur before a MPO begins to pay. Medicare and the MPO have separate and different deductibles.
You may qualify for Social Security and Medicare by virtue of a disability, even if you are less than age 65.
Eligible family members
For purposes of the MPO, eligible family members who are also eligible to be enrolled in Medicare as their primary medical plan include:
- The spouse of an eligible retiree.
- The surviving spouse, who has not remarried, of a deceased eligible retiree or deceased employee.
- The child of an eligible retiree, deceased eligible retiree, or deceased employee who was enrolled in the Medicare Supplement Plan on December 31, 2018 (grandfathered disabled children).
NOTE: Effective January 1, 2019, a dependent child (over age 26) of a retiree, deceased retiree, or deceased employee who is entitled to be enrolled in Medicare as their primary medical plan is not eligible for coverage under the ExxonMobil Retiree Medical Plan or any other ExxonMobil health plan.
If your dependent or your spouse become eligible for Medicare you need to notify this event. For grandfathered disabled children participating in the MPO, ExxonMobil no longer considers an escalation / appeal after a decision has been taken. If Aetna confirms the dependent is no longer disabled, that decision is final.
A person who becomes the spouse of an eligible retiree after becoming entitled to be enrolled in Medicare may be added to the MPO within 90 days of becoming eligible without demonstrating loss of coverage under another employer-sponsored medical plan.
Family members who are not eligible to be enrolled in Medicare as their primary medical plan may be eligible for coverage under one of the Retiree Medical Plan options of the ExxonMobil Retiree Medical. See the SPD for the Retiree Medical Plan option of your choice for more information.
In the MPO, an eligible retiree is a person who:
- Retired with retiree status from ExxonMobil,
- Retired with retiree status from Exxon,
- Retired with retiree status from Mobil or Superior Oil,
- Is a former Exxon or ExxonMobil employee who retired with retiree status from Exxon or ExxonMobil and is not currently working for ExxonMobil as a regular or non-regular employee
Retirees of Station Operators, Inc. doing business as ExxonMobil Company Operated Retail Stores (CORS) are not eligible for coverage under this MPO.
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.
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) and the Medicare Primary Option (MPO) as constituent parts.
Medically necessary care and equipment provided at home by a Medicare-certified agency on a part-time or intermittent basis by skilled nurses, home-health aides, occupational, physical or speech therapists and those providing medical social services.
An institution which is engaged primarily in providing medical care and treatment of sick and injured persons on an inpatient basis at the patient's expense which is:
- Accredited by the Joint Commission on Accreditation of Hospitals,
- A hospital, psychiatric hospital or a tuberculosis hospital, as those terms are defined in Medicare (or as may be amended by Medicare in the future), which is qualified to participate and eligible to receive payments under and in accordance with the provisions of Medicare, or
- An institution which:
- maintains on its premises diagnostic and therapeutic facilities for surgical and medical diagnosis and treatment of sick and injured persons by or under the supervision of a staff of duly qualified physicians,
- continuously provides on its premises twenty four hour a day nursing service by or under the supervision of registered graduate nurses, and
- functions continuously with organized facilities for operative surgery on its premises.
The maximum amount a physician may require a Medicare beneficiary to pay for a covered service if the physician does not accept assignment.
Medically necessary or medical necessity
Services or supplies that are: legal; ordered by a physician or clinical psychologist; safe and effective in treating the condition for which ordered; part of a course of treatment generally accepted by the American medical community; of a proper quantity, frequency and duration for treating the condition for which ordered; not redundant when combined with other services and supplies used to treat the condition for which ordered; not experimental, meaning unproven by long-term clinical studies; and for the purpose of restoring health or extending life.
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 (4th ed. 1994) (DSM-IV), or its successor publication, and which is otherwise covered by Medicare. Such a condition will be considered a mental health condition, regardless of any organic or physical cause or contributing factor.
See skilled-nursing care.
A registered graduate nurse (RN), a licensed vocational nurse (LVN), or a licensed practical nurse (LPN).
Other services and supplies
Services and supplies provided by a hospital or skilled-nursing facility required to treat a patient. Excluded are fees for room and board and fees charged by physicians, private-duty or special nursing services.
Outpatient prescription drug
A prescription drug or medicine obtained through either a retail pharmacy or through a home delivery prescription service (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.
That part of Medicare which pays certain hospital and skilled-nursing facility bills.
That part of Medicare which pays certain physician and other medical bills.
That part of Medicare that provides Medicare Advantage plans.
That part of Medicare which pays certain outpatient prescription drug bills.
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.
The participant whose Social Security number or Aetna Member Identification Number is used for identification purposes. The primary participant is the retiree, survivor or individual who elected COBRA coverage. Covered family members use the primary participant's Social Security number or Aetna Member Identification Number to access all 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.
Generally, a person at least 55 years old who retires as a regular employee with 15 years of 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 the Retiree Medical Plan POS II and other self-funded options.
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.
Care requiring services only licensed medical professionals can provide in the home or in a skilled-nursing facility. Both Medicare and the MPO cover such care when prescribed by a treating physician and determined to be medically necessary. These types of services are sometimes called non-custodial nursing care.
A Medicare-approved institution meeting government-prescribed standards for skilled-nursing care or skilled-rehabilitation services. The MPO covers only Medicare-approved skilled-nursing facilities.
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.
A surviving unmarried spouse of a deceased ExxonMobil regular employee or retiree.