About the ExxonMobil Dental Plan
This summary plan description (SPD) is a summary of the ExxonMobil Dental Plan (the Plan). It does not contain all the Plan details. In determining your specific benefits, the full provisions of the formal documents, as they exist now or as they may exist in the future, always govern. You may obtain copies of these documents by making a written request to the Administrator-Benefits. ExxonMobil reserves the right to change benefits in any way or terminate any benefit at any time.
The Dental Plan is self-funded. There is no insurance company to collect premiums or underwrite coverage. Instead, contributions from you and ExxonMobil pay all benefits. Prior claims experience and forecasted expenses are used to determine the amount of money needed to pay future benefits. These options are governed by federal laws, not by state insurance laws.
Notice: The Dental Plan is an excepted benefit under Patient Protection Affordable Care Act (PPACA) and is not minimum essential coverage. Since it is not minimum essential coverage, you may not treat it as required coverage when filing your U.S. Federal Income Tax return.
Applicability to represented employees is governed by collective bargaining agreements and any local bargaining requirements.
When you need information, you may contact:
Claims and dental Preferred Provider Organization (PPO) administrator
Provides claim payment information, Aetna Dental PPO provider and claim forms.Phone numbers:
Aetna Member Services
210-366-2416 (international, call collect)
Monday - Friday 8:00 a.m. to 6:00 p.m. (Central Time), except certain holidays
Automated Voice Response - 24 hours a day, 7 days a week
P. O. Box 981106
El Paso, TX 79998-1106
To visit Aetna’s website: www.aetna.com
Customer Service Representatives can provide specialized assistance. References to Benefits Administration throughout this SPD refer to either ExxonMobil Benefits Administration or ExxonMobil Benefits Service Center as listed below. Depending on your status (employee, retiree, or survivor), you should contact the appropriate service center.
Employees can enroll/change benefits on the Employee Connect HR intranet site through Employee Direct Access (EDA) when a change in status occurs. Enrollment forms are also available through ExxonMobil Benefits Administration for those without access to EDA.
Phone numbers and Addresses:
ExxonMobil Benefits Administration/Health and Welfare Services
ExxonMobil Benefits Administration
ExxonMobil BA BSC
P. O. Box 64111
Spring, TX 77387-4111
ExxonMobil Benefits Service Center
Monday – Friday 7:00 a.m. to 5:00 p.m.
(Central Time), except certain holidays
or 800-TDD-TDD4 (833-8334) for hearing impaired
ExxonMobil Benefits Service Center
P. O. Box 18025
Norfolk, VA 23501-1867
ExxonMobil Sponsored Sites - Access to plan-related information including claim forms for employees, retirees, survivors, and their family members.
- Employee Connect, the Human Resources intranet site - can be accessed at work by employees.
- ExxonMobil Family, the Human Resources internet site - can be accessed from home by everyone at www.exxonmobilfamily.com.
- Retiree Online Community internet site - can be accessed from home by retirees and survivors only (including Exxon and Mobil retirees and survivors) at www.emretiree.com.
- ExxonMobil benefits service center internet site - can be accessed from home by everyone at www.exxonmobil.com/benefits.
Aetna does not render dental services or treatments. Neither the Plan nor Aetna is responsible for the services that are delivered by providers participating in the Aetna Dental PPO and those providers are solely responsible for the dental services they deliver. Providers are not the agents nor employees of the Plan or Aetna.
The ExxonMobil Dental Plan (the Plan) encourages good dental health by paying, within plan limits, for 100% of the cost of preventive services and part of the cost of other general and major services, including orthodontia. The Plan offers you the opportunity to use the Aetna Dental PPO Network, a voluntary PPO. Because participating dentists and dental specialists have agreed to provide their services at negotiated rates, you will save money and maximize your annual Plan benefits when you choose to receive care from a participating dentist. ExxonMobil's dental plan is described in detail in this SPD. These tools help you find specific information quickly and easily:
- Plan at a glance, a quick user's guide highlighting plan basics.
- Charts and tables throughout this SPD provide information, examples, highlights of plan provisions, etc.
- References to sources of additional information.
- Key terms containing definitions of some words and terms used in this SPD. Terms are underlined and linked for easy identification.
A careful reading of this SPD will help you understand how the Plan works so you can make the best use of the Plan provisions.
Plan at a glance
You may enroll yourself and your eligible family members within your first 60 days of employment or within 60 days of a subsequent change in status or at Annual Enrollment. See How to enroll for employees.
You may enroll yourself and your eligible family members within 60 days of your retirement. If you do not enroll at this time, you will have limited opportunities to enroll at a later date. See How to enroll for retirees.
The Dental PPO
You can visit any dentist – but save when you choose a dentist who participates in the Aetna Dental PPO network. The negotiated rates for the dentist's services are generally within reasonable and customary (R&C) limits and generally lower than rates charged by non-network dentists which helps you maximize your annual plan benefit by paying less out of pocket for covered services. See Dental PPO.
Covered and excluded expenses
The Plan provides benefits for many, but not all, preventive, general, major and orthodontic services. See the Covered expenses section.
You and the Plan share the costs for covered treatments and services. You pay a deductible before the Plan begins paying for certain benefits. For each covered person, the Plan pays up to $2,000 each calendar year for covered dental expenses (other than preventive and orthodontic services) and up to a $2,000 lifetime maximum benefit for covered orthodontic expenses. See Payments.
Dental PPO providers file claims for you. You are responsible for ensuring that claims for non-network care are filed. See Claims.
Consolidated Omnibus Budget Reconciliation Act 1985 (COBRA)
You and your family members who lose eligibility may continue dental coverage for a limited time in certain circumstances. See Continuation coverage.
Administrative and ERISA information
This Plan is subject to rules of the federal government, including the Employee Retirement Income Security Act of 1974, (ERISA) as amended, not state insurance laws. See Administrative and ERISA information.
This is an alphabetized list of words and phrases, with their definitions, used in this SPD. See Key terms.
A brief summary of benefits. See Benefit summary.
Eligibility and enrollment
Eligibility and enrollment details for the ExxonMobil Dental Plan
Q. What are the Plan's eligibility requirements?
A. Most U.S. dollar payroll regular employees of Exxon Mobil Corporation and participating affiliates are eligible for this Plan.
Generally, you are eligible if:
- You are a regular employee.
- You are an extended part-time employee.
- You are a trainee as described in the Key Terms section.
- You are a retiree.
- You are a survivor/surviving spouse, which means an eligible family member of a deceased regular or extended part-time employee or retiree.
You are not eligible if:
- You participate in any other employer dental plan to which ExxonMobil contributes.
- You fail to make any required contribution toward the cost of the Plan.
- You fail to comply with general administrative requirements including but not limited to enrollment requirements.
- You lost eligibility as described under the Loss of eligibility section.
Eligible family members
You may also elect coverage for your eligible family members including:
- Your spouse. When you enroll your spouse for coverage, you may be required to provide proof that you are legally married.
- Your child(ren) under age 26. Coverage ends at the end of the month in which they reach age 26. If your situation involves a family member other than your biological or legally adopted child, contact Benefits Administration.
- Your totally and continuously disabled child(ren) who is incapable of self-sustaining employment by reason of mental or physical disability, that occurred prior to otherwise losing eligibility at age 26 and, meets the Internal Revenue Service's definition of a dependent, and, if a child of a retiree, is not eligible to be enrolled in Medicare as their primary medical plan.
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 is considered a suspended retiree and is not eligible for coverage until the earlier of the date the person:
- Reaches age 55, or
- Begins his or her retirement benefit under the ExxonMobil Pension Plan, at which time the person is again considered a retiree and may enroll.
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.
Special eligibility rules
A person who otherwise is not a spouse but who, as a dependent of a former Mobil employee who participated in or received benefits under a Mobil-sponsored plan or program prior to March 1, 2000, is considered an eligible dependent as long as that person's eligibility for coverage as a dependent under a Mobil-sponsored plan would have continued.
Classes of coverage
You can choose coverage as an:
- Employee or retiree only
- Employee or retiree and spouse
- Employee or retiree and child(ren)
Employee or retiree, spouse and child(ren)
For employees on an approved leave of absence, their contribution rate will change from the employee contribution rate to the Leave of Absence contribution rate as shown in the table below.
|Leave of Absence Contribution Rate Begins||Immediately||No later than
after 6 months
|No later than after 12 months|
|Type of Leave|
|Health / Dependent Care||O|
Each class of coverage described in this section has its own contribution rate. Employees contribute to the Dental Plan through monthly deductions from their pay on a pre-tax or after-tax basis. Retirees and survivors receiving monthly benefit checks from ExxonMobil pay by deductions from these checks on an after-tax basis. Other retirees or survivors and participants with continuation coverage pay by check or by monthly draft on their bank account.
No one can be covered more than once in the Dental Plan. You and a family member cannot both enroll as employees (or retirees) and elect coverage for each other as eligible family members. If you and your spouse or adult child work for the company (or are retirees) you may both be eligible for coverage. Each of you can be covered as an individual employee (or retiree), or one of you can be covered as the employee (or retiree) and the other can be an eligible family member. Also, if you and your spouse have children, each child can only be covered by one of you.
When the orthodontia maximum has been met under an ExxonMobil Dental Plan, dependents cannot be added to another ExxonMobil employee's dental plan to obtain additional orthodontic benefits. The $2,000 limit is per lifetime, per member.
In addition a marriage between two ExxonMobil employees does not allow enrollment or cancellation in any of the ExxonMobil health plans. In order to change your coverage you need to wait until you experience a change in status that allows coverage changes or Annual Enrollment.
How to enroll
As a newly hired employee, if you enroll in the Dental Plan within 30 days of your start date, coverage begins the first day of employment. If you enroll between 31 and 60 days of your date of hire, coverage will be effective the first day of the month following completion of enrollment in EDA or receipt of the forms by Benefits Administration.
If you are eligible for the ExxonMobil Pre-Tax Spending Plan, you will be enrolled to pay your monthly contributions on a pre-tax basis unless you annually decline this feature. Your monthly pre-tax contributions and class of coverage must remain in effect for the entire plan year, unless you experience a change in status. (See Annual enrollment and Changing your coverage sections.)
You can enroll eligible family members only if you are enrolled in this Plan. You can enroll in the Plan using Employee Direct Access (EDA) available on the Employee Connect HR intranet site. Enrollment forms are also available from Benefits Administration for those individuals who do not have access to EDA.
You may be requested to provide documents at some future date to prove that the family members you enrolled were eligible (e.g., marriage certificate, birth certificate). If you fail to provide such requested documents within 90 days of the request, coverage for the family members will be canceled the first of the following month and you may be subject to discipline up to and including termination of employment for falsifying company records.
Under the Children's Health Insurance Program (CHIP) Reauthorization Act of 2009 you may change your Plan election for yourself and any eligible family members within 60 days of either (1) termination of Medicaid or CHIP coverage due to loss of eligibility, or (2) becoming eligible for a state premium assistance program under Medicaid or CHIP coverage. In either case, coverage is effective the first of the month following receipt of the forms by Benefits Administration.
Effective January 1, 2019, retirees have three opportunities to enroll in the Dental Plan:
- At retirement, or
- Upon loss of other employer coverage, or
- When first eligible to be enrolled in Medicare as your primary plan.
There is no opportunity to enroll yourself in the Dental Plan at any other time, including during annual enrollment.
If you were enrolled in the Dental Plan as an employee, you and your eligible covered family members will continue to be enrolled in the Plan at retirement. However, as a retiree, you will pay your contributions on an after-tax basis via payroll deduction (if eligible), check, or bank draft.
Eligible family members may be added to your coverage at one of the three enrollment opportunities listed above or if you experience a change in status. Eligible family members cannot be added to your coverage at any other time, including during annual enrollment.
All enrollments must be completed within 60 days of the enrollment event. Coverage is effective the first of the month following receipt of your election by the ExxonMobil Benefits Service Center (EMBSC), except in the case of a birth or adoption of a child when changes will be effective on the date of the birth or adoption.
You can enroll either online or by phone. To enroll online go to www.exxonmobil.com/benefits. To enroll by phone call the Benefits Service Center at 800-682-2847.
You may be requested to provide documents at some future date to prove that the family members you enrolled were eligible (e.g. marriage certificate, birth certificate). If you fail to provide such requested documents within the required time period, coverage for the family members will be cancelled the first of the following month. If you enroll family members who are not eligible for the Plan, for instance, by covering children who do not meet the eligibility requirements, you may lose eligibility for yourself and your family under all ExxonMobil health plans.
You may cancel your coverage at any time; however, you may not re-enroll unless you experience a corresponding change in status or you wait until one of the enrollment opportunities listed above. Coverage will be terminated at the end of the month in which your elected change has been received.
Eligible family members may also be removed from your coverage at any time; however, they may not be reinstated unless you experience a corresponding change in status or you wait until one of the enrollment opportunities listed above.
Note: You are required to remove family members who are no longer eligible for coverage at the time of loss of eligibility. To remove an ineligible family member (a divorced spouse for example) you are required to notify the Benefits Service Center within 60 days of the loss of eligibility or your ineligible family members will not be entitled to COBRA benefits continuation. If you fail to notify the Benefits Service Center, you may also lose eligibility for yourself and your family under all ExxonMobil health plans. In addition, you will be required to reimburse the Plans for any claims paid after the loss of eligibility for any ineligible person(s).
Note: Effective January 1, 2019, retirees cannot enroll in or make changes to their Dental Plan coverage during annual enrollment.
Each year, usually during the fall, ExxonMobil offers an annual enrollment period. During this time, employees can make changes to coverage by adding or removing family members. Family members may be added or removed for any reason during annual enrollment. However, family members must be removed as soon as they are no longer eligible. Changes elected during annual enrollment take effect the first of the following year.
Note: You should not wait until annual enrollment to remove a family member who loses eligibility; they should be removed at the time eligibility is lost. For consequences for covering an ineligible family member, see Loss of Eligibility.
Employees are automatically enrolled in the Pre-Tax Spending Plan to pay monthly contributions on a pre-tax basis unless this feature is declined each time. This choice is only available during the annual enrollment period or with a change in status.
If you do not want to make any changes, you don’t have to do anything during Annual Enrollment to continue with your current plan selection for the following year. However, if as an employee you want to participate in a Flexible Spending Account (FSA), you must enroll each year, even if you are currently enrolled in an FSA.
If as an employee you pay your monthly contributions on an after-tax basis and would like to continue making contributions on an after-tax basis for the following year, you must elect to do so during each Annual Enrollment and after each change in status. Otherwise, your contributions will be switched to a pre-tax basis beginning the first day of the following year.
Changing your coverage
To make a change to your coverage after your initial enrollment you must wait until Annual Enrollment or until you experience one of the following Changes in status.
Note: Changes in coverage associated with a change in status are effective the first day of a month after enrollment is completed, except in the case of a birth or adoption of a child when changes will be effective on the date of the birth or adoption. If the change is made during Annual Enrollment, changes are effective the first day of the following year.
To make a change to your coverage after your retirement you must wait until you experience a Post-Retirement Change in Status that allows enrollment into the Plan.
Changes in Status during employment
Retirees and survivors please see Post-Retirement Changes in Status.
This section explains which events are considered changes in status during your employment and what changes you may make as a result. If you have a change in status, you are required to complete your change within 60 days. If you do not complete your change within 60 days, changes to your coverage may be limited. If you fail to remove an ineligible family member within 60 days of the event that causes the person to be no longer eligible, (e.g., divorce) you are required to continue to pay the same pre-tax contribution for coverage even though you have removed the ineligible person(s). Your pre-tax contribution for coverage will remain the same until you have another change in status or the first of the plan year following the next annual enrollment period. In addition, you will be required to reimburse the Plans for any claims paid after the loss of eligibility for any ineligible person(s). The only exception is death of an eligible family member.
Important Note: Your election made due to a change in status cannot be changed after the transaction is completed in EDA or the form is received by Benefits Administration. If you make a mistake in EDA, contact Benefits Administration at email@example.com immediately or no later than the first work day following the day on which the mistake was made.
The following is a quick reference guide to the Changes in status during employment discussed in more detail after the table.
|If this event occurs...||As an employee you may...|
|Marriage||Enroll yourself and spouse and any new eligible family members.|
|Divorce - Employee enrolled in Dental Plan||You are required to remove coverage for your former spouse and step child(ren) but you may not remove coverage for yourself or other covered eligible family members.|
|Divorce - Employee loses coverage under spouse's dental plan||Enroll yourself and other eligible family members that might have lost eligibility for spouse's dental plans.|
|Gain a family member through birth, adoption or placement for adoption or guardianship||Enroll yourself and any eligible family members.|
|Death of a spouse or other eligible dependent.||Change your level of coverage. You may not cancel coverage for yourself or other covered eligible family members.|
|Other loss of family member's eligibility (e.g. sole managing conservatorship of grandchild ends)||Change your level of coverage. You may not cancel coverage for yourself or other eligible family members.|
|You lose eligibility because of a change in your employment status, e.g., regular to non-regular, lockout / strike||Your Dental Plan participation will automatically be termed at the end of the month.|
|You gain eligibility because of a change in your employment status, e.g. non-regular to regular||Enroll yourself or any eligible family members in the Dental Plan.|
|Termination of Employment by spouse or other family member or other change in their employment status (e.g., change from full-time to part-time) triggering loss of eligibility under spouse's or family member's plan in which you or they were enrolled||Enroll yourself and other eligible family members that may have lost eligibility under the spouse's or family member's plan in the Dental Plan.|
|Your former spouse is ordered to provide coverage to your children through a QMCSO||End the family member's coverage, change level of coverage and terminate their participation in the Dental Plan.|
|Commencement of Employment by spouse or other family member or other change in their employment status (e.g., change from part-time to full-time) triggering eligibility under another employer's plan.||End other family member's coverage and terminate their participation in the Dental Plan if the employee represents that they have or will obtain coverage under the other employer plan. You may also cancel coverage for yourself, if health care coverage is obtained through your spouse’s employer plan.|
|Judgment, decree or other court order requiring you to cover a family member. (Begin a QMCSO)||Change your Dental Plan level of coverage.|
|Termination or end of QMCSO||You may remove the affected family member from coverage and change level of coverage.|
|Termination of employment and rehire within 30 days or retroactive reinstatement ordered by court||Dental Plan coverage is reinstated.|
|Termination of employment and rehire after 30 days||Enroll in the Dental Plan as a new hire.|
|You are covered under your spouse's dental plan and plan changes coverage to a lesser coverage level with a higher deductible mid-year||Enroll yourself and eligible family members in the Dental Plan.|
|You begin a leave of absence||Contact Benefits Administration|
|You return from a leave of absence of more than 30 days (paid or unpaid).||Contact Benefits Administration|
Changes will only be allowed if the change is made in EDA within 60 days of the event or the medical/dental/vision enrollment form is received within 60 days of the event by the Benefits Administration Office. Unless otherwise noted, the effective date will be the first of the month after the transaction is completed in EDA or the forms are received.
If you are enrolled in the Dental Plan, you can enroll your new spouse and his or her eligible family members (your stepchildren) for coverage. If you are not already enrolled for coverage, you can sign up for dental coverage for yourself, your new spouse, and your stepchildren. If you gain coverage under your spouse's dental plan, you can cancel your coverage. You must make these changes within 60 days following the date of your marriage or wait until Annual enrollment or another change in status.
In the case of divorce:
- Your former spouse and any stepchildren are only eligible for coverage through the end of the month in which the divorce is final.
- You are required to remove coverage for your former spouse and stepchild(ren) within 60 days of your divorce.
- You must notify and provide any requested documents to Benefits Administration as soon as your divorce is final.
- If you do not to notify and provide requested forms to Benefits Administration within 60 days will result in your former spouse and stepchild(ren) not being entitled to elect COBRA.
- If you fail to remove your spouse and any stepchild(ren) within 60 days of the event you will continue to have pay the same pre-tax contribution for coverage even though you have removed your former spouse and stepchild(ren).
- Your pre-tax contribution for coverage will remain the same until you have experienced another change in status or the first of the plan year following the next Annual Enrollment period.
- You will be required to reimburse the Plans for any claims paid after the loss of eligibility for any ineligible person.
There may also be consequences for falsifying company records. Please see the Continuation coverage section of this SPD.
You may not make a change to your coverage if you and your spouse become legally separated because there is no impact on eligibility.
If you lose coverage under your spouse's dental plan because of divorce, you can sign up for dental coverage for yourself and your eligible family members. You must enroll within 60 days following the date you lose coverage under your spouse's plan or wait until Annual Enrollment or another change in status.
Birth, adoption or placement for adoption
If you gain a family member through birth, adoption, or placement for adoption you may add the new eligible family member to your current coverage. You may also enroll yourself, your spouse, and all eligible children. Coverage is effective on the date of birth, adoption or placement for adoption. You must add the new family member within 60 days even if you already have family coverage. See the Changing your coverage section for additional circumstances in which changes can be made.
If you enroll your new family member between 31 and 60 days from the birth or adoption and your coverage level changes, you will pay the cost difference on a post-tax basis until the end of the month in which the enrollment is processed through EDA or the forms are received by Benefits Administration. Beginning the first day of the following month your deduction will be on a pre-tax basis.
Death of a spouse
If you lose coverage under your spouse's dental plan, you can sign up for Dental Plan coverage for yourself and your eligible family members. You must make these changes within 60 days following the date you lose coverage or wait until Annual Enrollment or another change in status. If you and your family members are enrolled in the ExxonMobil Dental Plan, any stepchildren will cease to be eligible upon your spouse's death unless you are their court appointed guardian or sole managing conservator.
Sole legal guardianship or sole managing conservatorship
If you (or your spouse, separately or together) become the sole court appointed legal guardian or sole managing conservator of a child and the child meets all other requirements of the definition of an eligible family member, you have 60 days from the date the judgment is signed to enroll the child for coverage. You must provide a copy of the court document signed by a judge appointing you (or your spouse separately or together) guardian or sole managing conservator.
When a child is no longer eligible
If an enrolled family member is no longer an eligible family member, coverage continues through the end of the month in which they cease to be eligible. In some cases, continuation coverage under COBRA may be available. (See Continuation coverage for more details about COBRA.) You must notify and provide the appropriate forms to Benefits Administration as soon as a family member is no longer eligible. If you fail to notify and provide the appropriate forms to Benefits Administration within 60 days, the family member will not be entitled to elect COBRA. While we have an administrative process to remove dependent children reaching the maximum eligibility age, you remain responsible for ensuring that the child is removed from coverage. If you fail to ensure that a family member is removed in a timely manner, there may be consequences for falsifying company records.
Leave of absence
If you are on an approved leave of absence, you can continue coverage by making required contributions directly to the Dental Plan by check or, if applicable, pre-pay your benefits. If you chose not to continue your coverage while on leave, your coverage ends on the last day of the month in which your cancelation form is received by Benefits Administration and you will be required to pay for the entire month's contributions. If you fail to make required contributions while on leave, coverage will end.
If the company should make any payment on your behalf to continue your coverage while you are on leave and you decide not to return to work, you will be required to reimburse the company for required contributions.
If you are on an approved leave of absence and the Leave of Absence contribution rate begins, you may continue your coverage by making your required contribution. See Classes of coverage in the Eligibility and Enrollment section for rate information.
If you were on a leave that meets the requirements of the Family and Medical Leave Act of 1993 (FMLA) or the Uniformed Services Employment and Reemployment Rights Act (USERRA) and your coverage ended, re-enrollment is subject to FMLA or USERRA requirements.
For more information, contact Benefits Administration.
Post-Retirement Changes in Status
Employees please see Changes in Status during employment.
|If this event occurs...||As a retiree you may...|
|Marriage||Add your spouse and any new eligible family members.|
|Divorce – Retiree and spouse enrolled in ExxonMobil health plans||You are required to remove coverage for your former spouse and any stepchild(ren).|
|Divorce – Retiree loses coverage under spouse’s health plans||Enroll yourself and add other eligible family members who might have lost eligibility for spouse’s plan.|
|Gain a family member through birth, adoption or placement for adoption or guardianship||Add new eligible family members.|
|Death of a spouse.||You must remove coverage for any stepchild(ren) unless you are their court appointed guardian or sole managing conservator.|
|You or a family member loses eligibility under another employer's group health plan.||Enroll yourself and add eligible family members.|
|You become entitled to enroll in Medicare as your primary medical plan even if you do not actually enroll in Medicare.||Enroll and add eligible family members.|
|Your disabled child becomes entitled to enroll in Medicare as their primary medical plan, even if your child is not actually enrolled in Medicare.||You must remove coverage for your child.|
|Judgment, decree or other court order requiring you to cover a family member.
(Begin a QMCSO)
||Add new eligible family members.|
Other changes that may affect your coverage
Change in coverage costs or significant curtailment
If the cost for coverage charged to you significantly increases or decreases during a plan year, you may be able to make a corresponding prospective change in your election, including the cancellation of your election. This provision also applies to a significant increase in the dental deductible or coinsurance.
If the cost of coverage under your spouse's dental plan significantly increases or there is a significant curtailment of coverage that permits revocation of coverage during a plan year and you cancel that coverage, you will be able to sign up for dental coverage for yourself and any eligible family members.
If you are an extended part-time employee
If you terminate employment as an extended part-time employee, you are not eligible to continue to participate in the Plan. You may be eligible to elect continuation coverage for yourself and your eligible family members under COBRA provisions. See Continuation coverage for details.
If you die
If you die while enrolled, your covered eligible family members can continue coverage. Their eligibility continues with the company contributions for a specified amount of time:
- If you have 15 or more years of benefit service at the time of your death, eligibility continues until your spouse remarries or dies.
- If you have less than 15 years of benefit service, eligibility continues for twice your length of Benefit Service or until the spouse remarries or dies, whichever occurs first.
Children of deceased employees or retirees may continue participation as long as they are an eligible family member and are not eligible to be enrolled in Medicare as their primary medical plan. If your surviving spouse remarries, eligibility for your stepchildren also ends. Special rules may apply to family members of individuals who become retirees due to disability. (See Continuation coverage for suspended retirees).
Eligible family members of deceased extended part-time employees are not eligible to continue to participate in the Plan. These family members may be eligible to elect continuation coverage under COBRA provisions. (See Continuation coverage for details).
If you become a suspended retiree
If you are a retiree and you would otherwise lose coverage because you have become a suspended retiree under the ExxonMobil Disability Plan, you may continue coverage for yourself and your family members who were eligible for plan participation before you became a suspended retiree for either 12 or 18 months.
Coverage continues for 12 months from the date coverage would otherwise end if you received transition benefits under the ExxonMobil Disability Plan. However, if you did not receive transition benefits under the ExxonMobil Disability Plan, coverage continues for 18 months from the date coverage would otherwise end. The cost of this continued coverage is 102% of the combined participant and company contributions.
When coverage ends
Coverage for you and/or your family members ends on the earliest of the following dates:
- The last day of the month in which:
- You terminate employment (except as a retiree or due to disability),
- You elect not to participate,
- A family member ceases to be eligible (for example, a child reaches age 26), or
- A retiree becomes a suspended retiree (see suspended retiree under Eligible Family Members).
- You are no longer eligible for benefits under this Plan (e.g., employment classification changes from regular employee to non-regular employee or from non-represented to represented where you are no longer eligible for this Plan),
- You do not make your required contribution,
- A Qualified Medical Child Support Order is no longer in effect for a covered family member,
- The date:
- You die,
- The Plan ends,
- Your employer discontinues participation in the Plan,
- You enrolled an ineligible family member and in the opinion of the Administrator-Benefits, the enrollment was a result of fraud or a misrepresentation of a material fact.
You are responsible for ending coverage with Benefits Administration when your enrolled spouse or family member is no longer eligible for coverage. If you do not complete your change within 60 days, any contributions you make for ineligible family members will not be refunded.
For employees and eligible family members, if your participation in any group health plan (e.g., Medical, Dental, Vision), to which ExxonMobil contributed, was suspended for non-payment of required contributions, in order to enroll in this Plan you must repay all required contributions retroactively to the date of suspension. If you are a retiree and have missed payments during 2021, contact immediately the ExxonMobil Benefits Service Center (EMBSC) for guidance in order to regularize your situation before year end.
Effective January 1, 2022, cancellation and reinstatement process for retirees in any group health plan - - Dental, Vision, any of the ExxonMobil Retiree Medical Plan (EMRMP) options - will be as follows:
Cancellation of Retiree Health Plans due to non-payment of premiums:
Cancellations due to non-payment of plan premiums will be prospective, with a 3 month grace period starting 1st month of unpaid contributions, so participants may pay owed contributions within that grace period to avoid cancellation. For example, if retiree has not made payments for their January, February, and March premiums during that 3 month timeframe, coverage will be cancelled effective April 1.
Reinstatement of Retiree Health Plans:
Once your coverage has been terminated, you can request to be reinstated upon showing good cause. The applicable ExxonMobil Plan –Vision, Dental, EMRMP- (or its designee) will review requests for reinstatements on a case-by-case basis. If an individual has been involuntarily disenrolled for failure to pay plan premiums, they may request reinstatement no later than 60 calendar days following the effective date of disenrollment.
Reinstatement for good cause will occur only when:
1) Reinstatement is requested no later than 60 calendar days following the effective date of disenrollment (in the example, 60 days from April 1)
2) The individual has been determined to meet the criteria specified below (i.e., receives a favorable determination); and
3) Within three (3) months of disenrollment for nonpayment of plan premiums, the individual pays in full the plan premiums owed at the time they were disenrolled (in the example, within 3 months from April 1).
If you fail to pay premiums within the grace period, your coverage is terminated, and you fail to show good cause, you and your eligible dependents will not have an opportunity to re-enroll at a future date in the applicable ExxonMobil Health Plan. You are still responsible for paying all owed premiums incurred during the grace period in which you were still part of the applicable ExxonMobil Health Plan.
Requests for reinstatement must be accompanied by a credible statement (verbal or written) explaining the unforeseen and uncontrollable circumstances causing the failure to make timely payment. An individual may make only one reinstatement request for good cause in the 60-day period. Generally, these circumstances constitute good cause:
- A serious illness, institutionalization, and/or hospitalization of the member or their authorized representative (i.e. the individual responsible for the member’s financial affairs), that lasted for a significant portion of the grace period for plan premium payment;
- Prolonged illness that is not chronic in nature, a serious (unexpected) complication to a chronic condition or rapid deterioration of the health of the member, a spouse, another person living in the same household, person providing caregiver services to the member, or the member’s authorized representative (i.e., the individual responsible for the member’s financial affairs) that occurs during the grace period for the plan premium payment;
- Recent death of a spouse, immediate family member, person living in the same household or person providing caregiver services to the member, or the member’s authorized representative (i.e., the individual responsible for the member’s financial affairs); or
- Home was severely damaged by a fire, natural disaster, or other unexpected event, such that the member or the member’s authorized representative was prevented from making arrangement for payment during the grace period for plan premium;
- An extreme weather-related, public safety, or other unforeseen event declared as a Federal or state level of emergency prevented premium payment at any point during the plan premium grace period. For example, the member’s bank or U.S. Post Office closes for a significant portion of the grace period; or
There may be situations in addition to those listed above that result in favorable good cause determinations. If an individual presents a circumstance which is not captured in the listed examples, it must meet the regulatory standards of being outside of the member’s control or unexpected such that the member could not have reasonably foreseen its occurrence, and this circumstance must be the cause for the non-payment of plan premiums. The Plan expects non-listed circumstances will be rare.
Examples of circumstances that do not constitute good cause include:
- Allegation that bills or warning notices were not received due to unreported change of address, out of town for vacation, visiting out of town family, etc.;
- Authorized representative did not pay timely on member’s behalf;
- Lack of understanding of the ramifications of not paying plan premiums;
- Could not afford to pay premiums during the grace period; or
- Need for prescription medicines or other plan services.
The ExxonMobil Business Service Center is the appointed designee reviewing reinstatement requests and making good cause determinations.
Loss of eligibility
Fraud against the Plan
Everyone in your family may lose eligibility for plan coverage, and you may be subject to disciplinary action up to and including termination of employment if you commit fraud against the Plan, for instance, by filing claims for benefits to which you are not entitled. Coverage may also be terminated if you refuse to repay amounts erroneously paid by the Plan on your behalf or which you recover from a third party. Your participation may be terminated if you fail to comply with the terms of the Plan and its administrative requirements. You may also lose eligibility if you enroll persons who are not eligible, for instance, by covering children who do not meet the eligibility requirements. This includes failing to provide timely notification of when a covered family member loses eligibility, e.g., spouse loses eligibility due to divorce.
Extended benefits at termination
You are entitled to extended coverage for as much as a year if you are terminated due to disability with fewer than 15 years of service. This coverage is provided at no cost to you. This is considered a portion of the COBRA continuation period. In order to assure coverage beyond this extension period, you must elect COBRA upon termination of employment.
Several conditions must be met:
- The disability must exist when your employment terminates.
- The extension lasts only as long as the disability continues, but no longer than 12 months.
This extension applies only to the employee who is terminated because of a disability. Continuation coverage for eligible family members may be available through COBRA.
Information on using the Dental PPO
Q1. Are my out-of-pocket costs different if I use a network dentist versus a non-network dentist?
A1. When you use a network dentist, you save money because these participating providers have agreed to provide their services at negotiated rates that are generally less than the rates charged by non-network dentists.
Q2. Are my benefits different if I use a network dentist versus a non-network dentist?
A2. The percent of eligible charges that the Plan pays is the same whether you use network or non-network providers. However, you may be responsible for charges above the reasonable and customary (R&C) limit for non-network providers (see Reasonable and customary limits under Adjustments and Billed Charges in the Payments section).
Using the Dental PPO
Using the Dental PPO is completely voluntary. The Dental PPO provides access to a network of dentists and dental specialists who have met Aetna's standards for licensing, academics and service. Dental PPO providers' charges are generally within reasonable and customary limits. (See Reasonable and customary limits under Adjustments and Billed Charges in the Payments section.)
There are several advantages to using network providers:
- The negotiated rates offered by network dentists generally lower your out-of-pocket costs and allow you to cover more dental services for the annual benefit maximum.
- Network dentists submit claims for you, so you do not have to complete claim forms.
- Negotiated rates are within reasonable and customary limits, so you will not have to pay charges above the limits. However, the alternative course of treatment rules noted in the Adjustments to Billed Charges section apply.
To receive the benefit of negotiated rates, use network dentists and present your Aetna Dental PPO ID card.
To find a dental PPO provider:
- Check the Aetna Provider Directory on www.aetna.com for the most up-to-date list of dental PPO providers.
- Call Aetna Member Services for help with locating a PPO provider.
Confirm with Aetna Member Services and/or the dentist's office whether the dentist participates in the network before the appointment, since network participation may change.
If you or your covered family members need to see a dentist while away from home, you can go to any licensed dentist. However, you may access the Aetna website or contact Aetna Member Services to see if there is a network dentist in the area.
Pre-determination of benefits
You are encouraged to submit a pre-determination of benefits before you begin any complicated or expensive dental procedure to avoid unexpected expenses.
Generally, Aetna will tell you what benefits will be paid for the proposed treatment. However, if a less expensive alternative course of treatment is available, Aetna will advise you of the alternative course of treatment and tell you what benefits will be paid. If you decide to have the more expensive proposed treatment, the Plan pays benefits based on the cost of the alternative course of treatment.
Here is how the pre-determination process works:
- Ask your dentist to submit a pre-determination of benefit request.
- The dentist describes the suggested course of treatment, itemizing specific services and charges. In some cases medical information, including x-rays, may also be needed.
- The dentist submits the information to Aetna, which determines the Plan benefits for the services outlined and notifies both you and the dentist. This gives you a chance to discuss the work and charges with your dentist before the work is performed.
If a lower cost alternative course of treatment would be medically appropriate, you might decide to proceed with the original treatment, or you might opt for the alternative course of treatment. That is a matter for you and your dentist to decide. Plan benefits are based on the actual work done or on the Plan's requirements relating to alternative course of treatment, not on the pre-determination. (See Alternative course of treatment under Annual Maximum in the Payments section).
Note: A pre-determination is processed much like a claim. Plan accordingly and allow sufficient time for that process to take place.
Covered expenses for the ExxonMobil Dental Plan
Q. What types of dental services are covered by the Plan?
A. The Plan divides dental services into four categories:
For all coverage, benefits are payable only for charges up to the reasonable and customary amount for similar services and supplies in the area. PPO dentists' charges are generally within the reasonable and customary amount (see Adjustments to billed charges in the Payments section).
To be covered, an expense must be incurred by a plan participant for preventive dental care or for the care and treatment of dental disease or accidental injury and such service or treatment must be:
- Medically necessary
- Performed or prescribed by a dentist or physician, and
- Not excluded under this Plan.
An expense or charge is generally considered incurred on the date the service is provided, with these exceptions:
- Fixed bridges, crowns, inlays, onlays, or gold restorations are considered incurred on the first day of preparation of the tooth or teeth involved.
- Full or partial dentures are considered incurred on the date the impression is taken.
- Endodontics are considered incurred on the date the tooth is opened for root canal therapy.
- Dental implants are considered incurred on the date the implant post is inserted. The implant crown is considered incurred on the date it is placed on the implant post.
To encourage good oral health and improve overall health of participants, the Plan pays 100% of covered charges for the following preventive services with no deductible and these expenses are not applied to the annual dental maximum:
- Diagnostic oral examinations (up to four diagnostic oral examinations per calendar year)
- Prophylaxis and/or Periodontal cleanings (up to four cleanings per calendar year)
- Diagnostic supplementary (bite-wing) X-rays (limited to four times each calendar year).
- Periapical X-rays
- Diagnostic full-mouth or panoramic X-rays* (limited to once in any three consecutive years).
- Topical stannous fluoride application (limited to four times each calendar year).
- Space maintainers and their insertion (limited to deciduous teeth whether primary or baby teeth and treatment for a covered family member under age 19).
- Tooth sealants applied to a permanent molar (limited to one application per tooth in any three consecutive years).
- Occlusal (night) guards for the treatment of bruxism (limited to one appliance in any two calendar-year period).
* Limitation does not apply to orthodontia treatment
The Plan also pays 100% of reasonable and customary covered charges for diagnostic x-rays and examination charges for problem focused limited oral exams. If you incur charges for urgent treatment on a day when you receive other dental services, such as a routine checkup or an extraction, the problem focus limited oral examination charges will be covered.
Suppose you see your dentist for an emergency toothache. Your dentist gives you an emergency examination, takes x-rays, and asks you to return for treatment at a later time. These costs are 100% reimbursable by the Plan.
If your dentist does an extraction in addition to the x-rays and emergency examination, these services are covered by the Plan, even if incurred on the same day. The emergency examination and x-rays would be covered at 100% and the extraction at 80%.
After you meet an annual deductible of $50 per person (maximum of $150 per family), the Plan pays 80%, or as otherwise specified, of covered charges for the following services:
- Care and treatment involving tooth extractions, fractures, and dislocations of the jaw, and cutting procedures in the oral cavity.
- Root canals and other endodontic treatment.
- General anesthetic in connection with oral surgery, periodontics, fractures, and dislocations if medically necessary according to Aetna guidelines.
- Injection of antibiotics in conjunction with treatment of a covered dental expense if medically necessary according to Aetna guidelines.
- Fillings, other than gold fillings. (For gold fillings, see Major services below.)
- Repair and rebasing existing dentures or fixed bridges. (Replacing such dentures and fixed bridges is described under Major services below.)
- Addition of teeth to existing denture or fixed bridges if required by loss of natural teeth.
- Pre-surgery oral exams.
- Crown build-ups, when approved.
After you meet the annual deductible of $50 per person (maximum of $150 per family), the Plan pays 50% of covered charges for these services:
- Full or partial dentures or fixed bridges or implants and their initial insertion. Replacement of existing devices can only be covered if such device cannot be made serviceable and is more than five years old. This includes any abutment to an implant and the crown over the implant. The Plan does not cover charges for adjusting dentures or bridges within six months of installation. Such follow-up visits are normally included in initial charges.
- Gold fillings and permanent crowns— or their replacement — necessary for restoration of tooth structure broken down by decay, injury or severe attrition.
- Inlays and onlays as major services paid at 50%.
Separate charges for temporary fillings and crowns are not covered. If you are charged for both temporary and permanent crowns or dentures, only the charge for the permanent crown or denture is covered.
The Plan pays 50% of covered charges with no deductible up to the orthodontic lifetime limit of $2,000 per person for orthodontic services and supplies to correct malposed teeth. (See Orthodontia lifetime maximum in the Payments section for more information.)
When an employee is first eligible and enrolls in the Plan, orthodontic services and supplies will be covered even if the insertion of the first appliance occurs prior to becoming a covered person.
In addition to traditional orthodontia treatments, the Plan provides coverage for Invisalign however benefits are payable only for charges up to the reasonable and customary amount for similar services such as Comprehensive Orthodontic Treatment (Braces). This means that you are responsible for the excess amount. As with other orthodontic treatments, these charges are subject to your orthodontia lifetime maximum.
The tool referenced below shows how benefits are paid from the ExxonMobil Dental Plan and reimbursements are made from your Health Care Flexible Spending Account. Refer to the Pre-Tax Spending Plan Summary Plan Description when using Pre-Tax Plan for orthodontia reimbursement. Monthly reimbursements are based on your treatment plan (number of months braces are on the teeth), not your payment schedule. The orthodontia lifetime maximum benefit is $2,000 per covered person.
NOTE: If you are paying your orthodontic services in full up front, contact Aetna member services for claim handling guidelines for your Health Care Flexible Spending Account.
The orthodontia calculator does not calculate correctly if orthodontia services are paid in full upfront.
Exclusions for the ExxonMobil Dental Plan
Q. Are there expenses which are not covered by the Plan?
A. Although the Plan covers many types of dental treatments and services, it does not cover all of them.
No benefits are payable under the Plan for any charge incurred for:
- Treatment by a person other than a dentist or physician, except for services performed by a licensed dental or medical professional under the direction of a dentist or physician.
- Services not incident to and for the diagnosis or treatment of a condition, disease or injury while a covered person.
- Cosmetic services or supplies, except necessary reconstructive expenses in connection with treatment of an accidental injury which begins within 90 days after the accidental injury is sustained.
- Treatment covered by workers' compensation or similar law.
- Professional services rendered by the patient.
- Treatment of any condition with personally specialized or individually designed services. For example, if you want a denture designed with a gap that resembles a gap that existed in the natural teeth the denture is replacing, the charge for creating that gap, or for personalizing the denture, is not covered.
- Facings on crowns behind the second bicuspid.
- Training in or supplies used for dietary counseling, oral hygiene or plaque control.
- Procedures, restorations, and appliances to increase vertical dimension, and to repair attrition including, but not limited to, treatment of Temporomandibular Joint Disorder (TMJ/TMD).
- Services or supplies which are experimental or investigational according to accepted standards of dental practice.
- Post-operative procedures or examinations for which an additional or separate charge is made.
- Follow-up adjustments of dentures, fixed bridges, or implants within six months of initial insertion for which an additional and separate charge is made.
- Temporary crowns or dentures, prior to installation of permanent devices, for which an additional and separate charge is made.
- Treatment of any condition, disease or injury, including otherwise covered dental expenses, if the person would not be required to pay charges had the person not been covered under this Plan, including services provided in a hospital operated by the United States or any of its agencies.
- Charges for missed appointments, telephone consultations, and/or completion of claim forms are excluded by the Plan
- Any charge for a service or supply not listed as a covered expense.
- Any charge that exceeds the reasonable and customary limit.
- Any charges deemed to be incidental.
Payments information for the ExxonMobil Dental Plan
Q. How are payments determined?
A. The Plan helps you and your family members with dental expenses. You and the Plan share costs for covered treatment and services. You pay a percentage coinsurance for most covered expenses. You must satisfy an annual deductible before the Plan starts paying on covered non-preventive services. The Plan also has an annual maximum and a lifetime orthodontia maximum amount. Once the maximum lifetime benefit maximum has been paid, no other benefits will be paid under any circumstances. Once the Plan has paid charges for covered expenses up to the maximum, you are responsible for all charges above the maximum. See the Adjustments to billed charges section for other factors that may affect reimbursement.
This section explains some of the terms and provisions you need to know to use the Plan to your best advantage.
The annual maximum is $2,000, which is the amount of benefits payable under the Plan for covered dental expenses (other than preventive and orthodontic services) each calendar year for each covered person. This annual maximum benefit is determined after you pay any necessary deductibles and coinsurances. Orthodontic expenses have a separate lifetime limit of $2,000.
Once the annual maximum benefit has been paid, no other benefits are available under any circumstances. You are responsible for all charges above the annual maximum benefit.
The negotiated rates do not apply once your yearly dental maximum has been reached. The dental provider may charge you their full billed rates.
You have had several dental procedures totaling $1,800 between January 1st and July 31st. You have $200 remaining until you reach the annual maximum. On September 2nd, you have a dental procedure performed, and the cost to the Plan is $300. Since the annual maximum is $2,000, the Plan will pay only $200 of the charge. You are responsible for $100, and no benefits are available for dental services performed for the remainder of the calendar year.
However, beginning January 1st of the following year, a new annual maximum benefit will be available to pay charges for covered expenses incurred during that calendar year.
The deductible is the amount of covered expenses you must pay each calendar year before the Plan begins sharing the cost. You do not pay a deductible for preventive or orthodontic services. An annual deductible must be met for general and major services. A $50 deductible applies to each covered person. Once deductibles for your family reach $150, your family has satisfied the deductible requirements for the year. The deductible does not include any amounts above the reasonable and customary limits (see Reasonable and Customary Limits under Adjustments to billed charges).
The coinsurance is the percentage of the cost of covered dental treatment or services that you pay. You pay a 20% coinsurance for general services and a 50% coinsurance for major and orthodontic services.
Orthodontia lifetime maximum
The Plan pays up to $2,000 for covered orthodontic expenses for the lifetime of each covered person. This is in addition to the annual maximum benefit for other types of dental care.
Adjustments to billed charges
When providers submit charges for payment, the following factors affect the amount that will be considered eligible for reimbursement. References to these limitations may appear on your explanation of benefits. Contact Aetna Member Services for more information. A pre-determination of benefits is strongly recommended before you incur any major or unusual expenses.
Reasonable and customary limits
Allowable amounts for services are determined by reasonable and customary (R&C) limits. The Plan's claims administrator determines R&C limits. These limits are based on data obtained from the Prevailing Healthcare Charges System owned by FAIR Health. R&C limits for services are set at the 90th percentile of the range of charges for a particular procedure in the same geographic area(s). R&C limits apply only to non-network providers and services.
If any non-network provider charges a fee that exceeds the R&C limit, you are responsible for the excess amount. The amount above the R&C limit does not apply toward your annual deductible or your percentage coinsurance. To find out if a proposed charge is within R&C limits, contact Aetna Member Services. PPO provider negotiated rates are generally within R&C limits.
Assume that the R&C charge in your area for a tooth filling is $120, your non-network dentist charges $140 to fill your tooth, and the network dentist's negotiated charge is $100.
|You pay 20%* of covered amount||$ 20||$ 24|
|You pay amount over R&C||+ 0||+ 20|
|Your total cost||$ 20||$ 44|
|*After deductible has been satisfied.|
The Benefit Summary provides an overview of the ExxonMobil Dental Plan. More detailed explanations of the expenses covered under each category (preventive, general, major, and orthodontic) and expenses not covered are provided in the Exclusions section of this SPD.
Alternative course of treatment
In situations where an alternative course of treatment would provide professionally adequate (based on American Dental Association guidelines) results at a lower cost, the lower-cost treatment is considered the covered expense.
The alternative course of treatment is determined either at the time a pre-determination is made or when the claim is processed. Reimbursement and subsequent repairs, replacement, or servicing is based on that alternative course of treatment. Use the Plan's pre-determination of benefits feature to avoid unexpected expenses.
If you incur a service that is eligible for an alternative course of treatment without a pre-determination or you choose not to use the alternative course of treatment identified during a pre-determination, you will be responsible for the following:
- Any reasonable and customary charges that you may incur while using a non-PPO provider.
- The difference in cost between the alternative course of treatment and the treatment performed.
- Your coinsurance based on the alternative course of treatment, if your deductible has been met.
Assume that you have one or more missing teeth and you would like them replaced with an initial bridge. Dental bridges bridge the gap created by one or more missing teeth. Your provider is a Dental PPO network provider and the submitted charge is $2000 for an initial bridge. When you submit your treatment plan for a pre-determination of benefits, Aetna determines that a medically necessary, cost-effective alternative course of treatment is available – a partial denture – that costs $1000. The table below shows the cost you would pay if you choose to proceed with an initial dental bridge instead of a partial denture. Also, the table shows the cost if you use a non-network provider who charges $3,000.
For this example: A claim is submitted for an initial bridge on teeth numbers 8-10, with tooth 9 as the missing tooth which will be replaced with a porcelain bridge (pontic). For this example, an alternate benefit of a partial denture is approved. The negotiated fee for the alternate course of treatment of a partial denture is $1000.00. For the Non-network example the reasonable and customary amount is $1,000 for the partial denture.
|Dental Bridge||$ 2,000||$ 3,000|
|R&C limit||$ 2,000||$ 2,000|
|Cost in excess of R&C limit (A-B)||$ 0||$ 1,000|
|Covered amount-cost of partial denture||$ 1,000||$ 1,000|
|Covered in excess of the covered amount (B-D)||$ 1,000||$ 1,000|
|Your copayment 50%* of covered amount (D* .5)||$ 500||$ 500|
|Your total cost (C+E+F)||$ 1,500||$ 2,500|
|*After deductible has been satisfied.|
Note: When an alternative course of treatment is applied, reimbursement for the other missing teeth in the arch related to the initial bridge are subject to the alternative course of treatment benefit for the partial denture.
Recovery of overpayment
If you or your beneficiary receives a distribution of any amount from the Plan to which you are not entitled, you or your beneficiary will be required to repay the amount of the overpayment to ExxonMobil or the Plan. The Plan Administrator may make reasonable arrangements with you for repayment, see Fraud against the plan above.
Filing claims for the ExxonMobil Dental Plan
Q. When must claims be filed?
A. All dental claims must be filed within two years from the date services were received. Before filing a dental claim, consider whether the expense may be covered under your medical plan. Be sure to read the information in the Medical claims for dental work section below.
Aetna Dental PPO Network providers should file all claims directly with Aetna.
Claims for non-network provider care
The Plan has contracted with Aetna to process claims (see Information sources at the front of this SPD for the address and telephone number).
Before visiting a dentist who is not in the Aetna Dental PPO network, obtain a claim form from Aetna, or Employee Connect, or ExxonMobil Family websites for yourself and/or each eligible family member having work done. Fill out the form with personal data about yourself or your family member. Give the form to the dentist. In many cases, the dentist will file the claim for you. If the dentist returns the form to you, send it and the dentist's itemized bill to Aetna. Keep a copy of the completed form for your records.
Keep these facts in mind when using a non-network provider:
- Most dentists expect payment in full for services at the time the work is done.
- When you file a claim form, benefits will be sent to you unless you specifically indicate that Aetna should pay the dentist directly.
In order to be reimbursed under the Plan, claims must be received by Aetna within two years from the date the expense was incurred. It is the participant's responsibility to ensure that claims are filed in a timely manner. If you or your dental provider submits claims past the claim filing deadline, those claims will not be covered by the Plan. You will be responsible for payment.
Explanation of benefits
Aetna will send you an explanation of benefits (EOB) for each claim. The EOB will show what service was performed, how much the dentist charged, and what the covered charge is under the Plan. It shows if a deductible or coinsurance was involved as well as the calculation used to determine your benefit. If payment is not assigned to the provider the EOB for the claim will only be sent to the participant; requests for any additional information needed to resolve the claim will go to participant only.
Claim denial and reconsideration
If all or part of a claim is denied, Aetna will provide you with a written explanation, including the reason for the denial. See the Administrative and ERISA information section in this SPD.
Claims outside the United States
To receive dental care when traveling or working outside the United States, generally you must pay the dental bills first. For reimbursement, submit a claim form and an itemized bill that includes a copy of the tooth chart clearly identifying the tooth number(s) and copies of the diagnostic dental x-rays, periodontal charting and narrative as appropriate. Indicate if the provider is using a USA standard tooth number or a different tooth identification standard. If the original bills are in a foreign language, you should obtain an English translation, if possible, of the services rendered.
Bills should be submitted in the appropriate foreign currency. The claims administrator (Aetna) will convert the bill to U.S. dollars as of the date of service using the currency converter website Oanda at www.oanda.com.
Right of reimbursement and subrogation
If your claim results from an accident or other injury that may be the fault of another party, the Plan will be subrogated to your (or your covered family member's) right of recovery against any party. In addition, you must reimburse any amount paid by the Plan that you recover from any responsible party. The Plan does not require reimbursement from any voluntary medical payments coverage you may carry under your motor vehicle or homeowner's insurance. The Plan will seek reimbursement/ subrogation from coverage you may carry for uninsured/underinsured motorists. The Plan's right to subrogation and reimbursement also constitute an equitable lien against any payments by any responsible party made or payable to you, your covered family members, or anyone acting on your behalf, now or in the future, regardless of how the payments are characterized. For example, injury, illness or disability related payments that you receive for expenses such as past medical expenses, future medical expenses, attorneys' fees and expenses, or other costs or compensation, up to the full amount of all benefits paid by the Plan, must first be used to repay the Plan before any money goes to you. This creates a priority recovery right in favor of the Plan and is not subject to any application of a make-whole or common fund rule under local or other law. By accepting benefits from the Plan you are agreeing to this arrangement. The Plan's right to do this is called its right to impose an equitable lien or constructive trust.
You are required to promptly notify the Plan of any occurrence that may give rise to the Plan's reimbursement/subrogation rights and to cooperate with the Plan (or its representative) to secure these rights. Please refer to the Plan's master documents for additional information on the Plan's reimbursement/subrogation rights.
Coordination of benefits
If you are covered by more than one group dental plan, you are entitled to coverage from all plans in which you participate, but not to the extent that you collect more than 100% of the amount of the allowable charges. However, if you or a family member are covered under an individual plan, the coordination of benefits provision does not apply.
One of the plans covering you is considered the primary plan. Claims must be filed first with the primary plan. After the primary plan pays, file the claim with the secondary plan, including a copy of the bills and an explanation of benefits including the amount paid by the primary plan.Example:
If you, as an employee, are covered by this Plan, then this Plan is primary for you. If your spouse is covered by another dental plan and you are covered under that plan, then your spouse's plan is secondary for you. Also, if your spouse is covered by their employer's dental plan and this Plan, his or her plan is primary and this Plan is secondary.
This Plan is primary for retirees who are not working, regardless of other coverage under a spouse's plan.
The primary plan always pays benefits first, without considering the other plan. The secondary plan then pays based on its provisions — up to the total allowable expenses covered by that plan or up to the total of all covered expenses.
Coverage of a child
When a child is covered under both parents' plans, the birthday rule is used; the plan of the parent whose birthday occurs earlier in the year is the primary plan. The other parent's plan is secondary. If both parents have the same birthday or your spouse's plan has not adopted the birthday rule, the ExxonMobil Dental Plan will consider the plan which has covered the child longer as primary.
There are special rules for children of divorced or separated parents. Unless specifically ordered otherwise by a court decree, the plan of the parent with custody, if he or she has not remarried, is primary and the plan of the non-custodial parent is secondary. If the parent with custody remarries, that parent's plan is primary, the stepparent's plan is secondary and the plan of the non-custodial parent is last.
Retirees covered by two plans
If a retiree covered by the Dental Plan obtains a full-time job in which the retiree is covered by the new employer's dental plan, that plan becomes the primary plan and the Dental Plan is secondary.
When the retiree leaves the last employer, the plan in which the retiree was covered for the longer period becomes the primary plan and the other plan is secondary.
If payment for covered dental expenses should have been made under this Plan, but has been made under any other plan, any insurance company or other organization may be reimbursed an amount the Administrator-Benefits determines will satisfy the intent of coordination of benefits provisions. That amount will be considered to be benefits paid under this Plan and shall fully discharge any obligation to make such payments.
Medical claims for dental work
Some medical plans cover certain dental procedures by a dentist or oral surgeon. Dental procedures that may be covered by your medical plan include:
- Drugs prescribed by your dentist (would be covered by your prescription plan).
- Treatment of fractures or dislocations of the jaw.
- Treatment of teeth and surrounding tissue damaged due to an injury sustained while covered by the Plan. If an accident occurs, claims may be payable as medical expenses, but claims are not coordinated with the ExxonMobil Dental Plan.
For information on which procedures performed by a dentist or oral surgeon may be considered to be medical in nature, contact Aetna Member Services.
After all the medical plans have responded, submit a dental claim form with the medical EOB form(s) explaining the determination of benefits under the medical plan(s), along with a copy of your bill, to Aetna.
If you are an employee who participates in the ExxonMobil Pre-Tax Spending Plan Health Care Flexible Spending Account (HCFSA), Aetna will automatically process any eligible expenses remaining from your dental claim and send you the spending account reimbursement, if you have elected HCFSA automatic reimbursement. This means that, in most cases, you will not need to file a separate pre-tax claim form.
Continuation coverage for the ExxonMobil Dental Plan
Q1. Can coverage be continued after eligibility in this Plan ends?
A1. Yes. The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) entitles you and your covered family members to extend medical benefits beyond the date your coverage would normally end.
Q2. What notification time limits must I comply with to begin COBRA for my spouse or my family member?
A2. You are responsible for ending coverage with Benefits Administration when your spouse or family member is no longer eligible for coverage. This must be done as soon as possible. In order to be eligible for COBRA, you must notify and provide the appropriate forms to Benefits Administration within 60 days of the event which caused the person to lose eligibility.
Continuation coverage rights under COBRA
You are required to be given the information in this section because you are covered under a group health plan (the Plan). This section contains important information about your right to COBRA continuation coverage, which is a temporary extension of coverage under the Plan under certain circumstances when coverage would otherwise end. This section generally explains COBRA continuation coverage, when it may become available to you and your family, and what you need to do to protect the right to receive it.
The right to COBRA coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA coverage can become available to you when you would otherwise lose your group health coverage under the Plan. It can also become available to your spouse and children, if they are covered under the Plan when they would otherwise lose their group health coverage. This section does not fully describe COBRA coverage or other rights under the Plan. For additional information about your rights and obligations under the Plan and under federal law, you should review this SPD or contact ExxonMobil Benefits Administration at the address listed under Benefits Administration in this section below.
You, your spouse and your family members may have other options available when you lose group health coverage. For example, you may be eligible to buy an individual plan through the Health Insurance Marketplace. By enrolling in coverage through the Marketplace, you may qualify for lower costs on your monthly premiums and lower out-of-pocket costs. Additionally, you may qualify for a 30-day special enrollment period for another group health plan for which you are eligible (such as a spouse’s plan), even if that plan generally doesn’t accept late enrollees.
Determination of Benefits Administration Entity to Contact:
IMPORTANT: Benefits Administration references throughout this notice change depending on your status. Unless specifically stated otherwise, you should refer to the correct Benefits Administration entity using the list below. If your status is not listed, call ExxonMobil Benefits Administration/Health and Welfare Services for assistance.
- Current ExxonMobil and XTO Employees or their covered family members should use EDA or contact ExxonMobil Benefits Administration/ Health and Welfare Services;
- Exxon, ExxonMobil, Mobil, XTO or Superior Oil Retirees, or their Survivors, or their covered family members contact ExxonMobil Benefits Service Center, and
- Former Exxon, ExxonMobil or XTO Employees and Exxon and ExxonMobil Retirees (who retired before October 1, 2005) and their Survivors or covered family members, who have elected and are participating through COBRA, contact the ExxonMobil COBRA Administration.
What is COBRA coverage?
COBRA coverage is a continuation of plan coverage when coverage would otherwise end because of a life event known as a qualifying event. Specific qualifying events are listed later in this section. If a specific qualifying event occurs and any required notice of that event is properly provided to Benefits Administration, COBRA coverage must be offered to each person losing coverage who is a qualified beneficiary. You, your spouse, and your children could become qualified beneficiaries if coverage under the Plan is lost because of the qualifying event. Certain newborns, newly adopted children, and alternate recipients under QMCSOs may also be qualified beneficiaries. This is discussed in more detail in separate paragraphs below. Under the Plan, qualified beneficiaries who elect COBRA coverage must pay the entire cost of COBRA coverage.
Who is entitled to elect COBRA?
If you are an employee, you will be entitled to elect COBRA, if you lose your coverage under the Plan because either one of the following qualifying events happen:
- Your hours of employment are reduced, or
- Your employment ends for any reason other than your gross misconduct.
If you are the spouse of an employee, you will be entitled to elect COBRA if you lose coverage under the Plan because any of the following qualifying events happen:
- Your spouse dies,
- Your spouse's hours of employment are reduced,
- Your spouse’s employment ends for any reason other than his or her gross misconduct,
- You become divorced from your spouse. Also, if your spouse (the employee) reduces or eliminates your group health coverage in anticipation of a divorce, and a divorce later occurs, then the divorce may be considered a qualifying event for you even though your coverage was reduced or eliminated before the divorce.
A person enrolled as the employee’s child will be entitled to elect COBRA if he or she loses coverage under the Plan because any of the following qualifying events happen:
- The parent-employee or parent-retiree dies,
- The parent-employee's hours of employment are reduced,
- The parent-employee's employment ends for any reason other than his or her gross misconduct, or
- The child stops being eligible for coverage under the Plan as a child.
When is COBRA coverage available?
When the qualifying event is the end of employment or reduction of hours of employment or death of the employee, the Plan will offer COBRA coverage to qualified beneficiaries. You need to notify Benefits Administration of any other qualifying events.
You must give notice of some qualifying events
For the other qualifying events (divorce of the employee and spouse or a child losing eligibility for coverage), a COBRA election will be available to you only if you notify and provide the appropriate forms to the Benefits Administration entity within 60 days after the later of (1) the date of the qualifying event or (2) the date on which the qualified beneficiary loses (or would lose) coverage under the terms of the Plan as a result of the qualifying event. In providing this notice, you must notify the correct Benefits Administration entity based on your status and follow the procedures outlined in the below section. If these procedures are not followed or if the wrong entity is notified during the 60-day notice period, THEN ALL QUALIFIED BENEFICIARIES WILL LOSE THEIR RIGHT TO ELECT COBRA. See the listing of Benefits Administration entities at the end of this section below. Notices of qualifying events from current employees must be made by logging onto Employee Direct Access (EDA) located on the Employee Connect HR intranet site. Forms are also available from ExxonMobil Benefits Administration/ Health and Welfare Services for those individuals who do not have access to EDA. Notices of these qualifying events from retirees and survivors must be made via the ExxonMobil Benefits Web or by calling the ExxonMobil Benefits Service Center. Notice is not effective until either EDA or the ExxonMobil Benefits Web change is made or the properly completed form is received.
Election of COBRA
Each qualified beneficiary will have an independent right to elect COBRA. Covered employees and spouses (if the spouse is a qualified beneficiary) may elect COBRA on behalf of all qualified beneficiaries, and parents may elect COBRA on behalf of their children. Any qualified beneficiary for whom COBRA is not elected within the 60-day election period specified in the Plan’s COBRA election notice WILL LOSE HIS OR HER RIGHT TO ELECT COBRA.
How long does COBRA coverage last?
COBRA coverage is a temporary continuation of coverage. When the qualifying event is the death of the employee, the covered employee’s divorce or a child's losing eligibility as a child, COBRA coverage under the Plan can last for up to a total of 36 months.
When the qualifying event is the end of employment or the reduction of the employee's hours of employment, and the employee became entitled to Medicare benefits less than 18 months before the qualifying event, COBRA coverage under the Plan for qualified beneficiaries (other than the employee) who lose coverage as a result of the qualifying event can last until up to 36 months after the date of Medicare entitlement. For example, if a covered employee becomes entitled to Medicare 8 months before the date on which his employment terminates, COBRA coverage for his spouse and children who lost coverage as a result of his termination can last up to 36 months after the date of Medicare entitlement, which is equal to 28 months after the date of the qualifying event (36 months minus 8 months). This COBRA coverage period is available only if the covered employee becomes entitled to Medicare within 18 months BEFORE termination or reduction of hours.
Otherwise, when the qualifying event is the end of employment or reduction of the employee's hours of employment, COBRA coverage under the Plan generally can last for only up to a total of 18 months.
The COBRA coverage periods described above are maximum coverage periods. COBRA coverage can end before the end of the maximum coverage periods described in this notice for several reasons.
There are two ways (described in the following paragraphs) in which the period of COBRA coverage resulting from a termination of employment or reduction of hours can be extended.
Disability extension of 18-month period of continuation coverage
If a qualified beneficiary is determined by the Social Security Administration to be disabled and you notify the correct Benefits Administration entity, in a timely fashion, all of your qualified beneficiaries in your family may be entitled to receive up to an additional 11 months of COBRA coverage, for a total maximum of 29 months. This extension is available only for qualified beneficiaries who are receiving COBRA coverage because of a qualifying event that was the covered employee’s termination of employment or reduction of hours. The disability must have started at some time before the 61st day after the covered employee’s termination of employment or reduction of hours and must last at least until the end of the period of COBRA coverage that would be available without the disability extension (generally 18 months, as described above).
The disability extension is only available if you notify Benefits Administration in writing of the Social Security Administration’s determination of disability within 60 days after the latest of:
- The date of the Social Security Administration’s disability determination,
- The date of the covered employee’s termination or reduction of hours, and
- The date on which the qualified beneficiary loses (or would lose) coverage under the terms of the Plan as a result of the covered employee’s termination of employment or reduction of hours.
You must also provide this notice within 18 months after the covered employee’s termination of employment or reduction of hours in order to be entitled to a disability extension, and you must notify the correct Benefits Administration entity at least 30 days before the end of the 18-month period. See the last page of this notice for the listing of Benefits Administration entities. If these procedures are not followed or if the notice to the correct Benefits Administration entity is not provided during the 60-day notice period and within 18 months after the covered employee’s termination of employment or reduction of hours, THEN THERE WILL BE NO DISABILITY EXTENSION OF COBRA COVERAGE.
See the listing of Benefits Administration entities at the end of this section below.
Second qualifying event extension of COBRA coverage
If your family experiences another qualifying event while receiving 18 months of COBRA coverage as a result of the covered employee’s termination of employment or reduction of hours (including COBRA coverage during disability extension as described above), the covered spouse and children in your family can get up to 18 additional months of COBRA coverage, for a maximum of 36 months, if notice of the second qualifying event is properly given to the correct Benefits Administration entity. This extension may be available to the spouse and any child receiving continuation coverage if the employee or former employee dies, gets divorced, or if the covered child stops being eligible under the Plan as a child. This extension is available only if the qualifying event would have caused the spouse or child to lose coverage under the Plan had the first qualifying event not occurred. This extension is not available under the Plan when a covered employee becomes entitled to Medicare after his or her termination of employment or reduction of hours.
This extension due to a second qualifying event is available only if you notify the correct Benefits Administration entity within 60 days of the date of the second qualifying event. See the last page of this notice for the listing of Benefits Administration entities. If these procedures are not followed or if the notice to the correct Benefits Administration entity is not provided during the 60 day notice period and within 18 months after the covered employee's termination of employment or reduction of hours, THEN THERE WILL BE NO EXTENSION OF COBRA COVERAGE.
Are there other coverage options besides COBRA Continuation Coverage?
Yes. Instead of enrolling in COBRA continuation coverage, there may be other coverage options for you and your family through the Health Insurance Marketplace, Medicaid, or other group health plan coverage options (such as a spouse’s plan) through what is called a special enrollment period. Some of these options may cost less than COBRA continuation coverage. You can learn more about many of these options at www.healthcare.gov.
More information about individuals who may be qualified beneficiaries during COBRA
A child born to, adopted by, or placed for adoption with a covered employee during a period of COBRA coverage is considered to be a qualified beneficiary provided that, if the covered employee is a qualified beneficiary, the covered employee has elected COBRA coverage for himself or herself. The child's COBRA coverage begins when the child is enrolled in the Plan, whether through special enrollment or open enrollment, and it lasts for as long as COBRA coverage lasts for other family members of the employee. To be enrolled in the Plan, the child must satisfy the otherwise-applicable Plan eligibility requirements (for example, regarding age).
Alternate recipients under QMCSOs
A child of the covered employee who is receiving benefits under the Plan pursuant to a qualified medical child support order (QMCSO) received by ExxonMobil during the covered employee's period of employment with ExxonMobil is entitled to the same rights to elect COBRA as an eligible child of the covered employee.
Cost of COBRA coverage
A person who elects continuation coverage may be required to pay 102% of the cost to the Plan to maintain the coverage, unless the person is entitled to extended coverage due to disability. If the person becomes entitled to such extended coverage, the person may be required to contribute up to 150% of contributions after the initial 18-month's coverage until coverage ends. A person who elects continuation coverage must pay the required contributions within 45 days from the date coverage is elected, retroactively to the date benefits terminated under the Plan.
If you have questions
Questions concerning your Plan or your COBRA continuation coverage rights should be addressed to the contact or contacts identified below. For more information about your rights under the Employee Retirement Income Security Act (ERISA), including COBRA, the Patient Protection and Affordable Care Act, and other laws affecting group health plans, contact the nearest Regional or District Office of the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA) in your area or visit www.dol.gov/ebsa. (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA’s website.) For more information about the Marketplace, visit www.healthcare.gov.
Keep your plan informed of address changes
In order to protect your family's rights, you should keep the correct Benefits Administration entity informed of any changes in your address as well as the addresses of family members. You should also keep a copy, for your records, of any notices you send to Benefits Administration.
The following sets out the contact numbers based on your status under the ExxonMobil Dental Plan. FAILURE TO NOTIFY THE CORRECT ENTITY COULD RESULT IN YOUR LOSS OF COBRA RIGHTS. If your status is not listed, call ExxonMobil Benefits Administration/Health and Welfare Services for assistance or contact them at firstname.lastname@example.org.
ExxonMobil dental plan contact information
|Employees and their covered family members:|
ExxonMobil Benefits Administration/
|ExxonMobil Benefits Administration
ATTN: Health and Welfare Services ExxonMobil
BA BSC USBA
P.O. Box 64111
Spring, TX 77387-4111
|Retirees, their survivors and covered family members:|
ExxonMobil Benefits Service Center
800-682-2847 (toll free)
|ExxonMobil Benefits Service Center
P.O. Box 1014
Totowa, NJ 07512-1014
|Former employees and retirees (who retired before October 1, 2005), their survivors and family members who have elected and are participating through COBRA:|
ExxonMobil COBRA Administration
|Wageworks National Accounts Services ExxonMobil COBRA Administration
P.O. Box 2968
Alpharetta, GA 30023-2968
Administrative and ERISA information
Administrative and ERISA information for the ExxonMobil Dental Plan
Q. What other information do I need to know about the Plan?
A. This section contains technical information about the Plan and identifies its administrator. It also contains a summary of your rights with respect to the Plan and instructions about how you can submit an appeal if your claim for benefits is denied.
The formal name of the Plan is the ExxonMobil Dental Plan.
Plan sponsor and participating affiliates
The ExxonMobil Dental Plan is sponsored by:
Exxon Mobil Corporation
5959 Las Colinas Blvd
Irving, Texas 75039-2298
All of Exxon Mobil Corporation's divisions and most of the major U.S. affiliates participate in the ExxonMobil Dental Plan. A complete list of participating affiliates is available from the Administrator-Benefits upon written request.
Certain employees covered by collective bargaining agreements do not participate in the Plan.
Basic Plan information
The Plan Administrator for the ExxonMobil Dental Plan is the Administrator-Benefits. The Administrator-Benefits is the Manager-Global Benefits Design, ExxonMobil. 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).
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
The claims administrator, Aetna, provides information about claims payment, providers participating in the Dental PPO, and benefit pre-determinations.
Claims fiduciary and appeals
P,O Box 14463
Lexington, KY 40513
Claim decisions and appeals procedures
When a claim comes in, your employer decides how you and the plan will split the expense. We also explain what you can do if you think we got it wrong.
Claims are processed in the order in which they are received.
|Submit a claim||
| Proof of claim
When you have received a service from an eligible dental provider, you will be charged.
The information you receive for that service is your proof of loss.
Communicating our claim decisions
The amount of time that we have to tell you about our decision on a claim is shown below.
A post service claim is a claim that involves dental care services you have already received.
Type of notice
Initial decision by us
If we request more information
Time you have to send us additional information
Adverse benefit determinations
We pay many claims at the full rate negotiated charge with in-network providers and the recognized charge with out-of-network providers, except for your share of the costs. But sometimes we pay only some of the claim. And sometimes we don’t pay at all. Any time we don’t pay even part of the claim, that is called an “adverse benefit determination” or “adverse decision”.
The difference between a complaint and an appeal
You may not be happy about a dental provider or an operational issue, and you may want to complain. You can call or us. Your complaint should include a description of the issue. You should include copies of any records or documents that you think are important. We will review the information and provide you with a written response within 30 calendar days of receiving the complaint. We will let you know if we need more information to make a decision.
You can ask us to review an adverse benefit determination. This is called an appeal.
Appeals of adverse benefit determinations
Aetna will send you written notice of an adverse benefit determination. The notice will give the reason for the decision and will explain what steps you must take if you wish to appeal. The notice will also tell you about your rights to receive additional information that may be relevant to the appeal. Requests for appeal must be made in writing within 180 days from the date of the notice.
The Plan provides for two levels of appeal plus an option to seek External Review of the adverse benefit determination. You must complete the two levels of appeal before bringing a lawsuit.
- You can appeal by sending a written appeal to the address on the notice of adverse benefit determination. You need to include:
- Your name
- The employer’s name
- A copy of the adverse benefit determination
- Your reasons for making the appeal
- Any other information you would like us to consider
Another person may submit an appeal for you, including a dental provider. That person is called an authorized representative. You need to tell us if you choose to have someone else appeal for you (even if it is your dental provider). You should fill out an authorized representative form telling us that you are allowing someone to appeal for you. You can get this form on our website or by contacting us. The form will tell you where to send it to us. You can use an authorized representative at any level of appeal.
Timeframes for deciding appeals
The amount of time that we have to tell you about our decision on an appeal claim depends on the type of claim. The chart below shows a timetable view of the different types of claims and how much time we have to tell you about our decision.
Type of notice
Initial decision by us
Exhaustion of appeals process
You must complete the appeal process with us before you can take these actions:
- Appeal through an external review process.
- Pursue arbitration, litigation or other type of administrative proceeding.
External review is a review done by people in an organization outside of Aetna. This is called an external review organization (ERO). Sometimes, this is called an independent review organization (IRO).
- Our claim decision involved medical judgment.
- We decided the service or supply is not medically necessary or not appropriate.
- We decided the service or supply is experimental or investigational.
- You have received an adverse determination.
If our claim decision is one for which you can seek external review, we will say that in the notice of adverse benefit determination or final adverse benefit determination we send you. That notice also will describe the external review process. It will include a copy of the Request for External Review form at the final adverse determination level.
You must submit the Request for External Review form:
- To Aetna
- Within 4 months of the date you received the decision from us
- And you must include a copy of the notice from us and all other important information that supports your request
You will pay for any information that you send and want reviewed by the ERO. We will pay for information we send to the ERO plus the cost of the review.
Aetna will contact the ERO that will conduct the review of your claim.
The ERO will:
- Assign the appeal to one or more independent clinical reviewers that have the proper expertise to do the review
- Consider appropriate credible information that you sent
- Follow our contractual documents and your plan of benefits
- Send notification of the decision within 45 calendar days of the date we receive your request form and all the necessary information
We will stand by the decision that the ERO makes, unless we can show conflict of interest, bias or fraud.
How long will it take to get an ERO decision?
We will tell you of the ERO decision not more than 45 calendar days after we receive your Notice of External Review Form with all the information you need to send in.
We will keep the records of all complaints and appeals for at least 10 years.
Fees and expenses
We do not pay any fees or expenses incurred by you when you submit a complaint or appeal.
No implied promises
Nothing in this SPD says or implies that participation in the ExxonMobil Dental Plan is a guarantee of continued employment with the company.
Future of the Plan
ExxonMobil expects to continue the Plan. However, ExxonMobil has the right to change, suspend, withdraw, amend, modify or terminate the Plan or any of its provisions at any time and for any reason. A change may also 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 the 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. If all claims and expenses are paid and there's still money in ExxonMobil's book reserve established for the purpose of making contributions toward the cost of employees' health care coverage, ExxonMobil will determine what to do with the excess amount in view of the purposes of the Plans.
Your rights under ERISA
As a participant in the ExxonMobil Dental 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 Dental Plan, including collective bargaining agreements, and a copy of the latest annual report (Form 5500 Series) filed by the Dental 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 Dental Plan, including collective bargaining agreements, and copies of the latest annual report (Form 5500 Series) and updated summary plan description. The administrator may require a reasonable charge for the copies.
- Receive a summary of the Dental Plan's annual financial report. The Administrator-Benefits is required by law to furnish each participant with a copy of this summary annual report.
Prudent actions by dental plan fiduciaries
In addition to creating rights for Dental Plan participants, ERISA imposes duties upon the people who are responsible for the operation of the employee benefit plan. The people who operate your Dental Plan, called fiduciaries of the Dental Plan, have a duty to do so prudently and in the interest of you and other Dental Plan participants and beneficiaries. No one, including your employer, your union, or any other person, may fire you or otherwise 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 Dental Plan documents or the latest summary annual report from the Dental Plan 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 lawsuit 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 Dental Plan, you should contact Aetna Member Services via the telephone number on your ID card, or call Benefits Administration.
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.
List of key terms in the ExxonMobil Dental Plan
In this section, you will find both General Terms pertaining to the Dental Plan and Common dental terms.
An employee who is covered by a collective bargaining agreement except to the extent participation in the Dental Plan is provided under such agreement.
The person or entity that receives benefits when you die. The Plan provides a standard list of beneficiaries but you may name another beneficiary if you wish.
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.
Life or work event that allows you to make changes to your elections during the plan year and outside of the annual enrollment period.
A person under age 26 who is:
- A natural or legally adopted child of a regular employee or retiree,
- A grandchild, niece, nephew, cousin, or other child related by blood or marriage over whom a regular employee, retiree, or the spouse of a regular employee or retiree (separately or together) is the sole court appointed legal guardian or sole managing conservator,
- A child for whom the regular employee or 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 regular employee or retiree.
Child does not include a foster child.
Aetna, or affiliates, for claims.
Charges by a dentist or physician for services and supplies required for dental care and treatment. Charges in excess of the reasonable and customary charge made for similar services and supplies by dentists or physicians in the same area are not covered. Where alternative services or supplies are customarily available for such treatment, reimbursement will be based on the least expensive service or supply resulting in professionally adequate treatment.
Most U.S. dollar-paid employees of ExxonMobil and participating affiliates are eligible. Full-time employees not hired on a temporary basis (also called regular employees) are eligible. Extended part-time employees, as classified on the employer's books and records, are also eligible.
The following are not eligible to participate in the Plan: leased employees as defined in the Internal Revenue Code, barred employees, or special agreement persons as defined in the Plan document. Generally, special-agreement persons are persons paid by the company on a commission basis, persons working for an unaffiliated company that provides services to the company, and persons working for the company pursuant to a contract that excludes coverage of benefits.
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 immediately prior to age 26 when the child's eligibility would have otherwise ceased, and
- (c) the child met the clinical definition of totally and continuously disabled before age 26 and continues to meet the clinical definition through subsequent periodic reassessment reviews, and
- (d) if a child of a retiree, is not eligible to be enrolled in Medicare as their primary medical plan, or
- (3) the child is recognized under a qualified medical child support order as having a right to coverage under this Plan.
A child aged 26 or over who was disabled by reason of a mental disability but who no longer meets the requirements of paragraph two (2) 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 employee or retiree's parents are not eligible to be covered.
An employee who is classified as a non-regular employee, but who has been designated as an Extended Part-Time Employee under his or her employer's employment policies relating to flexible work arrangements.
A service or supply that is:
- Ordered by a dentist or physician,
- Reasonably required for the treatment or management of the condition for which it is ordered, and
- Commonly and customarily recognized by the United States dental community as appropriate in the treatment or management of the condition for which it is ordered. The Administrator-Benefits has the exclusive and final authority to determine if a service or supply is medically necessary as used in the Plan. In making this determination, the findings and assessments of the United States dental community and the experience and expertise of the claims administrator shall be considered along with evaluation from independent professionals. As used herein, the United States dental community shall include national dental associations, societies and organizations including, but not limited to, the American Dental Association. The Administrator-Benefits may apply different standards to different services or supplies in determining medical necessity. Additionally, the Administrator-Benefits may consider the Dental Clinical Policy Bulletins (CPBs) published by Aetna, the claims administrator. Dental CPBs are based on established, nationally accepted governmental and/or professional society recommendations, as well as other recognized sources. These Dental CPBs may be found on the Aetna website at www.aetna.com.
A written pre-determination request will result in a detailed response as to whether a treatment or service is covered under the Dental Plan and whether the proposed cost is within reasonable and customary limits, thus ensuring all parties are aware of the financial consequences, providing all circumstances described in the request remain unchanged. Please note that a pre-determination, 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.
A Qualified Medical Child Support Order (QMCSO) is a court decree under which a court order mandates health coverage for a child. A QMCSO must include, at a minimum:
- Name and address of the employee covered by the health plan.
- The name and address of each child for whom coverage is mandated.
- A reasonable description for the coverage to be provided.
- The time period of coverage.
- The name of each health plan to which the order applies.
You may obtain, without charge, a copy of the Plan's procedures governing QMCSO determinations by written request to the Administrator-Benefits.
An employee of a participating employer, whether or not the person is a director, who, as determined by the participating employer, regularly works a full-time schedule, and is not employed on a temporary basis. The definition includes a person who regularly works a full-time schedule but who, for a limited period of time, is approved for a part-time regular work arrangement under the participating employer’s work rules relating to part-time work for regular employees.
Generally, a person at least 55 years old who retires as a regular employee with 15 or more years of benefit service and who has not thereafter recommenced employment as a covered employee or a non-regular employee. Retiree status may also be attained by 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.
Employees who terminate while non-regular (including extended part-time employees) are not eligible for retiree status regardless of age or service.
Generally, a person paid on a commission or commission salary basis other than a person paid while employed by the Marketing Department of ExxonMobil; an employee providing service to a non-affiliated organization that pays the person's salary or wages, or an employee working pursuant to an agreement that specifically excludes the person from coverage for benefits.
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 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 retirement 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.
An employee who is classified as a non-regular employee, but who has been characterized as a Trainee and has graduated from high school.
Common dental terms
Terminal tooth or root that retains or supports a bridge or a fixed or removable prosthesis.
A device used to provide function or therapeutic (healing) effect. An appliance may be fixed or removable.
The wearing away of a tooth's enamel.
Dental x-ray showing approximately the coronal (crown) halves of the upper and lower jaw.
A tooth shaped cover placed over a tooth that is badly damaged or decayed, may also be referred to as a cap.
The destruction or decomposition of a tooth as a result of bacterial action.
A person acting within the scope of his or her license and holding the degree of Doctor of Dental Surgery (DDS).
A device replacing missing teeth.
A prosthesis replacing one or more teeth that is cemented in place in the mouth. It consists of one or more pontics held in place by one or more retainers on abutment teeth.
A solution of fluoride applied topically to teeth to prevent dental decay.
An X-ray of every tooth, from crown to root to supporting structures, mostly using bitewing X-rays (with film inside the mouth).
A prosthetic device placed in the jaw to which a tooth or denture may be anchored.
A negative reproduction of a given area.
A dental instrument that protects the teeth from damage done during sleep. The night guard may cover one or both rows of teeth and is fitted to each patient so that the teeth fit perfectly to limit the grinding and clenching during the night.
The branch of dentistry primarily concerned with the detection, prevention, and correction of abnormalities in the positioning of the teeth in their relationship to the jaws.
An X-ray of the entire mouth all teeth on both upper and lower jaws on a single X-ray (with film outside the mouth).
A prosthesis that replaces one or more, but less than all, of the natural teeth and associated structures and is supported by the teeth and/or the gums. It may be removable or fixed, on one side or two sides.
An X-ray highlighting only one or two teeth at a time. A periapical X-ray looks similar to a bite-wing X-ray. However, it shows the entire length of each tooth, from crown to root.
The removal of the bacterial plaque and calculus from supra gingival (above the gum line) and sub gingival (below the gum line) regions including scaling and root planing (removal of any remaining calculus and smoothing of irregular areas of the root surface).
A person acting within the scope of his or her license and holding the degree of Doctor of Medicine (M.D.).
The part of a fixed bridge that is suspended between the abutments and which replaces a missing tooth or teeth.
The removal of tartar and stains from teeth through the cleaning of the teeth by a dentist or dental hygienist.
Any inlay, crown, bridge, partial denture, or complete denture that restores or replaces loss of tooth structure, teeth, or oral tissue, which results in repair, restoration, or reformation of the shape, form, and function of part or all of a tooth or teeth.
Treatment of a tooth with damaged pulp, generally through complete removal of the pulp, sterilization of the pulp chamber and root canals, and filling the resulting space with sealing material.
The removal of calculus (commonly called tartar) and plaque that attach to the tooth surfaces.
Designed to preserve the space created by the premature loss of a deciduous (baby) tooth in a child with deciduous or mixed dentition. They are used until normal eruption of the permanent tooth occurs or until it becomes practical to place a permanent prosthesis in place.
Any myofascial pain dysfunction involving the temporomandibular joint connecting the skull and jawbone.
Benefit summary of the ExxonMobil Dental PlanThis chart provides only a brief summary of benefits under this Plan. It is not intended to include all ExxonMobil Dental Plan provisions. Non-network benefits are subject to reasonable and customary limits.
|Annual Dental Maximum:||$2,000 per covered person|
|Preventive Services:||100% (no deductible and charges not applied to annual dental maximum)|
|General Services:||80% after deductible|
|Major Services:||50% after deductible|
|Orthodontic Services:**||50% (no deductible)|
||$2,000 per covered person|
|* Limitation does not apply to orthodontic treatment.
** Orthodontia benefits are paid based on treatment plan, not payment schedule
For more information, please contact: Aetna Member Services: (800) 255-2386 or visit www.aetna.com