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ExxonMobil International Medical and Dental Plan

Summary plan description of the ExxonMobil International Medical and Dental Plan as of January 1, 2022

The information described in this document along with the Certificate and the Benefits at a Glance found on Cigna’s ExxonMobil Educational Landing Page constitute the Summary Plan Description (SPD) for the ExxonMobil International Medical and Dental Plan (the Plan). If there is a conflict or difference between this SPD and the ExxonMobil International Medical and Dental Plan document or the Certificate, the ExxonMobil International Medical and Dental Plan document or Certificate will govern, as applicable.

The ExxonMobil International Medical and Dental Plan is fully-funded. An insurance company collects premiums and underwrites coverage. Please contact Cigna for further details. ExxonMobil is responsible for determining the rules of eligibility for the Plan. Please contact ExxonMobil Benefits Service Center about the participation rules described in this SPD.

Information sources

When you need information, you may need to contact one or more of the following sources.

For copy of the Certificate:

To obtain a copy of the Certificate, log in into  www.cignaenvoy.com. Certificate can be found under the Announcements  section on the Home page.

You can always request a copy of the Certificate by contacting Cigna Global Service Center at the numbers described below.

For claims administration:

Contact Cigna for pharmacy, medical/surgical, behavioral health and substance abuse claims forms, claims payment and other claims inquiries.
Refer to the Certificate or Benefits at Glance documents for those services that may require prior authorization.

Phone numbers and website:

Cigna Global Service Center

  • Collect (outside the U.S.): 001.302.797.3100
  • Toll Free (within the U.S. and Canada): 1.800.441.2668

Available 24 hours a day, 7 days a week

You can search for network providers through www.cignaenvoy.com.

Benefits Administration

Customer Service Representatives can provide specialized assistance.

ExxonMobil Benefits Service Center
Monday – Friday 7:00 a.m. to 5:00 p.m.
(Central Time), except certain holidays 
Toll-Free: 1-800-682-2847
or 800-TDD-TDD4 (833-8334) for hearing impaired 

ExxonMobil Benefits Service Center
P. O. Box 18025
Norfolk, VA 23501-1867

ExxonMobil sponsored sites:

  • Employee Connect, the Human Resources Intranet Site — Can be accessed at work by employees.
  • ExxonMobil Family, the Human Resources Internet Site — Can be accessed by everyone at www.exxonmobilfamily.com.

Introduction

The ExxonMobil International Medical and Dental Plan is available for regular US expatriates and US impatriates and their eligible dependents. Medical coverage under this plan is provided through Cigna Health and Life Insurance Company.

Medical benefits provide coverage for care inside the United States (in-network and out-of-network) and internationally (outside the United States), including medical/surgery, mental health and substance use disorder, prescription drugs, telehealth and vision.

Dental plan is optional and includes diagnostic, preventive services and treatments, as applicable.

Plan at a glance

Enrolling

All regular full-time or part-time US expatriates and US impatriates and eligible dependent(s) under the ExxonMobil expatriate guidelines will be automatically enrolled in the ExxonMobil International Medical and Dental Plan. See Eligibility and enrollment. 

Cigna Networks

There’s no paperwork for in-network care. Show your ID card and pay your share of the cost, if any; your provider will submit a claim to Cigna for reimbursement. Out-of-network and international claims can be submitted by the provider if the provider is able and willing to file on your behalf. It may be helpful to direct providers to the Cigna Global phone number for confirmation of coverage and enrollment. If the provider is not submitting on your behalf, you must send your completed claim form and itemized bills to the claims address listed on the claim form.

You may get the required claim forms at www.cignaenvoy.com.

COBRA

You and your eligible dependents who lose eligibility may continue medical coverage for a limited time under certain circumstances. See Continuation coverage section.

Administrative and ERISA information

The Plan is subject to rules of the federal government, including the Employee Retirement Income Security Act of 1974, as amended (ERISA), not state insurance laws. See Administrative and ERISA information

Key terms

For words and phrases defined in this SPD, see the Certificate.

Benefit summary

Key features and available benefits under the ExxonMobil International Medical and Dental Plan are included in the Certificate.

Eligibility and enrollment

Eligibility and enrollment details for the ExxonMobil International Medical and Dental Plan

All regular full-time or part-time expatriates whose home country is the U.S. (“expatriates”)  and all regular full-time or part-time expatriates whose host country is the U.S. (“impatriates”) and eligible dependent(s) of those individuals under the ExxonMobil expatriate guidelines are eligible to be enrolled in the International Medical and Dental plan.

You are not eligible if:

  • 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 lose eligibility as described under the Loss of eligibility section.
  • Your coverage is prohibited under applicable law.

Eligible dependents

You may also elect coverage for your eligible dependent(s) including:

Married Spouses and Domestic Partners

Married spouses and domestic partners may be eligible to receive benefits under expatriate guidelines, if s/he meets the following criteria:

  • Eligible for benefits under the employee’s home country benefit plans (if any) at a level equal to that provided to a legally married spouse
  • Able to reside permanently in the employee’s home country
  • Can secure a residency visa (not a tourist or visitor’s visa) in the host country

In order to be eligible for coverage under the host or expatriate health care plan, married spouses/domestic partners must reside full-time (more than 50%) at the host country. If they continue to reside in your home country, they should continue to qualify for coverage under your home country health care plan.

Exceptions and special cases may arise for spouses and domestic partners:

  • If a spouse or eligible dependents of an expatriate remain in the U.S., the spouse or eligible dependents will be eligible to be enrolled in this Plan while the expatriate is on assignment and will not be allowed to enroll in a different domestic ExxonMobil Medical Plan option.
  • If an US impatriate working temporarily in the U.S. is married to a regular US employee, the regular US employee may enroll the impatriate as a dependent under the domestic ExxonMobil medical plan option that he or she participates in.

Dependent Children

Eligible dependents may include your biological, adopted, and stepchildren who are under the age of 26.

Domestic partners’ children may only be allowed to participate if such dependents are eligible for benefits under the employee’s home country benefit plan and expatriate guidelines.   

A totally and continuously disabled child(ren) age 26 or older who is incapable of self-sustaining employment by reason of mental or physical disability may be eligible to participate in this Plan as determined by the Administrator-Benefits.

Classes of coverage

You can choose coverage as an:

  • Employee only,
  • Employee plus one,
  • Employee plus 2 or more

Each class of coverage described in this section has its own contribution rate. Employees contribute to this Plan through monthly deductions from their pay on a pre-tax or after-tax basis as applicable.

Double coverage

No one can be covered in more than one medical plan sponsored by Exxon Mobil Corporation or its affiliates. If your spouse or adult child work for the company each of them can be covered:

  • As an individual in the US domestic plans,
  • As eligible dependents in this Plan

How to enroll

All regular full-time or part-time US expatriates will be automatically enrolled in the medical portion of this Plan as of the first day of the assignment.

US impats will be automatically enrolled in the medical portion of this plan as Participant Only. An enrollment form may need to be completed for eligible dependents, as applicable.  

The dental portion is optional and an election may be made within 60 days.

Any eligible dependent(s) will become eligible on the effective date of your assignment. If you fail to enroll your eligible dependent(s) in the medical or dental portions within 60 days, the next opportunity to enroll will be during annual enrollment with an effective date of the first day of the following year or upon a change in status event.

In the event of marriage, adoption or newborn child, please make sure you complete enrollment within 60 days of the event.   In this case of marriage,  coverage will be effective as of the first day of the month following enrollment. In the case of adoption or birth of a child, coverage will be retroactive to the date of the event for the first 30 days and from day 31 to 60 will be effective as of the first day of the month following enrollment.

Note: You must enroll each new child for them to be covered, even if you already have family coverage.

You may be requested to provide documents at some future date to prove that the eligible dependent(s) 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 eligible dependent(s) will be cancelled the first of the following month and you may be subject to discipline up to and including termination of employment for falsifying company records. Please also refer to the Loss of eligibility section – Fraud against the Plan.

Annual Enrollment

Each year, ExxonMobil offers an annual enrollment period. During this time, you will only be able to:

  • Add or delete eligible dependents. Changes elected during annual enrollment take effect the first of the following year.
  • Opt in/out from the dental portion of this Plan.

NOTE: You should not wait until annual enrollment to remove a dependent who loses eligibility; they should be removed at the time eligibility is lost. For consequences of covering an ineligible eligible dependent, see Loss of Eligibility.

Changes in status

This section explains which events are considered changes in status and what changes you may make as a result. If you have a change in status, you must complete your change within 60 days. If you do not complete your change within 60 days, changes to your coverage may be limited.

For US expatriates, if you fail to remove an ineligible dependent(s) within 60 days of the event that causes the person to no longer be eligible, (e.g., divorce) you must continue to pay the same pre-tax contribution for coverage even though you have removed that ineligible person.  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. The only exception is death of an eligible dependent.

The following is a quick reference guide to the Changes in Status that are discussed in more detail after the table.

If this event occurs...

You may...

Marriage

Enroll your spouse and any new eligible dependent(s) .

Divorce – Employee and spouse enrolled in ExxonMobil International Medical and Dental Plan

Change your level of coverage. You must remove coverage for your former spouse and stepchild(ren).

Gain an eligible dependent through birth, adoption or placement for adoption, sole court appointed legal guardian or sole managing conservator

Enroll any eligible dependent(s) and change your level of coverage, if needed.

Death of a spouse or other eligible dependent

Change your level of coverage. You may not cancel coverage for yourself or other covered eligible dependents.

An eligible dependent loses eligibility under another employer's plan or other employer contributions cease which creates a "HIPAA special enrollment" right

Enroll your eligible dependents who might have lost eligibility under another employer’s plan. Change your level of coverage, if needed.

Other loss of eligible dependent'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 dependents.

Your former spouse is ordered to provide coverage to your children through a QMCSO

End the eligible dependent's coverage, change level of coverage and terminate their participation in the ExxonMobil International Medical and Dental Plan.

Commencement of Employment by spouse or other eligible dependent or other change in their employment status (e.g., change from part-time to full-time) triggering eligibility under a different employer sponsored plan.

End spouse or eligible dependent's coverage and terminate their participation in the ExxonMobil International Medical and Dental Plan.

Your spouse, or eligible dependent becomes entitled to Medicare or Medicaid.

You may choose to change level of coverage related to the eligible dependent as long as they are eligible to enroll in Medicare/Medicaid.

Judgment, decree or other court order requiring you to cover a eligible dependent.
(e.g., begin a QMCSO)

Change level of coverage.

You begin a leave of absence

Contact ExxonMobil Benefits Service Center to discuss permissible changes.

You return from a leave of absence of more than 30 days (paid or unpaid)

Contact ExxonMobil Benefits Service Center to discuss permissible changes.

Your expatriate assignment outside of the U.S. ends.

If returning in the same year the assignment started, you will be defaulted to your previous domestic Medical Plan Option.

If you return after the year the assignment started, you have 60 days to choose any domestic Medical Plan Option available to you or you will be defaulted to your previous domestic Medical Plan Option*.

*If you were not enrolled in any previous domestic medical plan option or you don´t have a valid new address, you will be defaulted to POSII A.

 

Marriage

If you are enrolled in the ExxonMobil International Medical and Dental Plan, you can enroll your new spouse and stepchildren for coverage, if they are considered eligible dependents. You must make these changes within 60 days following the date of your marriage or wait until Annual Enrollment or another change in status.

Note: You are not allowed to opt-out of the International Medical and Dental plan if you gain coverage under your spouse's health plan.

Divorce

In the case of divorce, your former spouse and any stepchildren are eligible for coverage only through the end of the month in which the divorce is final. You must notify and provide any documents if requested to the ExxonMobil Benefits Service Center as soon as your divorce is final. If you fail to notify or provide the requested documentation to the ExxonMobil Benefits Service Center within 60 days, the former spouse and eligible dependent will not be entitled to elect COBRA. Please see the Continuation coverage section of this SPD. There may also be consequences for falsifying company records. 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 do not complete your change within 60 days, any contributions you make for ineligible dependents will not be refunded. For US expatriates,  pre-tax contributions will not be reduced until the beginning of the next calendar year. Any claims paid after the loss of eligibility must be repaid by you.

Birth, adoption or placement for adoption

If you gain an eligible dependent through birth, adoption, or placement for adoption you may add the new eligible dependent to your current coverage. Coverage is effective on the date of birth, adoption or placement for adoption if you enroll your eligible dependent within the first 30 days. If you enroll your new eligible dependent between 31 and 60 days from the birth or adoption, the changes will be effective the first day of the following month following enrollment. If you miss to enroll your eligible dependents within 60 days, the next opportunity to enroll will be during annual enrollment and the effective date of coverage shall be the first day of the following year.

You must add the new eligible dependent within 60 days even if you already have family coverage.

Death of a spouse

If you and your eligible dependents are enrolled in the ExxonMobil International Medical and 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 child, 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 eligible dependent no longer meets the eligibility criteria, 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 the ExxonMobil Benefits Service Center as soon as a eligible dependent is no longer eligible. If you fail to notify and provide the appropriate forms to the ExxonMobil Benefits Service Center within 60 days, the eligible dependent 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 dependent child is removed from coverage.  If you fail to remove the ineligible dependent in a timely manner, there may be consequences for falsifying company records. 

Leave of absence

If you are on an approved unpaid leave of absence, you may continue coverage by making required contributions directly to this 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 the cancelation form is received by the ExxonMobil Benefits Service Center 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 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 the ExxonMobil Benefits Service Center. 

Other situations that may affect your coverage

If you retire

If you are a US expatriate and you decide to retire, you may be eligible for the ExxonMobil Retiree Medical Plan (EMRMP) or you may elect COBRA to stay in this Plan for the duration of COBRA coverage. If you retire as a regular employee and you are Medicare-eligible, you may be eligible to enroll in the Medicare Primary Option (MPO) option of the EMRMP. Please refer to the EMRMP Summary Plan Description for eligibility and enrollment requirements.

If a US expatriate continues to work beyond the date of eligibility for Medicare

If you are eligible for Medicare while you are still on an active expatriate assignment, this Plan will be primary to your Medicare benefits, if any. Refer to www.medicare.gov to learn more about Medicare while you are still employed.

If your covered eligible dependents become Medicare eligible for any reason

Eligible dependents of a US expatriate who become Medicare eligible, either due to age or Social Security disability status, are eligible to continue to participate in this Plan as their primary plan option as long as the US expatriate remains on assignment.

If the US expatriate retires or dies, and coverage is available under the EMRMP:

  • Medicare eligible covered spouses must enroll in Medicare Primary Option, including enrolling in Medicare Parts A and B.
  • All eligible dependent children under the age of 26 (including those that are Medicare eligible) and those over the age of 26 who are totally and continuously disabled and not Medicare eligible, may enroll in the Retiree Medical Plan options of the EMRMP.
  • Medicare eligible dependent children over the age of 26 are not eligible for coverage under any ExxonMobil medical plan available to retirees. You may be eligible to elect continuation coverage for your Medicare eligible dependent child under COBRA provisions. See Continuation coverage for details.

If you die

If you are a US expatriate and die while enrolled, your covered surviving spouse may be eligible to continue coverage under the ExxonMobil Retiree Medical Plan. Their eligibility continues with the EMRMP 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, becomes eligible for Medicare or dies. Upon eligibility for Medicare, your spouse can continue coverage through the Medicare Primary Option.  
  • If you have less than 15 years of benefit service, eligibility continues for twice your length of benefit service or until your spouse remarries, becomes eligible for Medicare, or dies, whichever occurs first. Upon eligibility for Medicare, the surviving spouse may continue coverage through the Medicare Primary Option only until the end of the applicable period.  

Children of deceased US expatriates may continue participation as long as they are eligible dependents. The length of their coverage will depend on the years of service of the US expatriate as described above. Stepchildren will lose eligibility if the US expatriate surviving spouse remarries.

If you are a US impatriate, COBRA continuation coverage may be  available for your dependents up to 36 months from the date of the event.

How this Cigna International Medical and Dental Plan works

Open Access Plus Medical Benefits provide coverage for care inside the United States (in-network and out-of-network) and internationally (outside the United States). To receive Open Access Plus Medical Benefits, you and your eligible dependents may be required to pay a portion of the covered expenses for services and supplies such as a copayment, deductible or coinsurance, if any. Please refer to the in-network benefits schedule found on www.cignaenvoy.com for details.

If you are unable to locate an in-network provider in your area who can provide you with a service or supply that is covered under this Plan, you must call the number on the back of your ID card to obtain authorization for out-of-network provider coverage. If you obtain authorization for services provided by an out-of-network provider, benefits for those services will be covered at the in-network benefit level.

For full information about covered and non-covered expenses and plan limitations for your medical, dental, vision and prescription plan benefits, refer to the Certificate on the Cigna website at www.cignaenvoy.com

When coverage ends

When coverage ends for the ExxonMobil International Medical and Dental Plan

Coverage for you and/or your eligible dependents ends on the earliest of the following dates:

  • The last day of the month in which your expatriate assignment ends
  • your eligible dependents are no longer eligible; or
  1. this Plan is terminated; or
  2. a covered person fails to make any required contribution; or
  3. a qualified medical child support order is no longer in effect for an eligible dependent; or
  4. as of the date the expatriate employee dies or the date the survivor is moved to the home country medical plan, if applicable.

You are responsible for ending coverage with the ExxonMobil Benefits Service Center when your enrolled spouse or eligible dependent is no longer eligible for coverage. If you do not complete your change within 60 days, any contributions you make for ineligible eligible dependents will not be refunded.

Loss of eligibility

Fraud against the plan

Everyone in your family may lose eligibility under this Plan, 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 that you recover from a third party. Additionally, coverage may be terminated if you fail to reimburse the Plan for any amount owed to the Plan, or if you receive and fail to report to the Claims Processor any discounts, write-offs, or other arrangements with providers that result in misrepresentation of your out-of-pocket costs. 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 eligible dependents who do meet the eligibility requirements. This includes failing to provide timely notification of when a covered eligible dependent loses eligibility, e.g., spouse loses eligibility due to divorce.

Continuation benefits for US expatriates terminated due to disability.

US expatriates with less than 15 years of service who are terminated in connection with a long-term disability may be provided with COBRA coverage at no cost for the first 12 months. To be entitled to this benefit, you must elect COBRA upon termination of employment and receive long term disability benefits under the ExxonMobil Disability Plan.

The 12 month period runs concurrently with your COBRA continuation period and you will be responsible for paying the full cost after for the remainder of your COBRA continuation period.

Continuation coverage for eligible dependents may be available through COBRA but this coverage will not be covered by the Company.

Continuation coverage

Introduction

You are required to be given the information in this section because you are covered under a group health plan (the Medical 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. 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 or other rights under the Plan. 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 the ExxonMobil Benefits Service Center at the telephone numbers or address listed under Benefits Administration in the Contacts for COBRA rightsUnder the ExxonMobil Medical Plan section.

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:

  • Current ExxonMobil and XTO Employees or their covered family members should use EDA or contact the ExxonMobil Benefits Service Center;
  • Former Exxon, ExxonMobil or XTO Employees and their covered family members, who have elected and are participating through COBRA, contact the ExxonMobil COBRA Administration.

The contact information for each of these entities is as shown in the Contacts for COBRA Rights Under the ExxonMobil Medical Plan section.

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 the ExxonMobil Benefits Service Center, 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 (employee plus employer portions) plus a 2% administrative fee.

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 happens:

  • 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 happens:

  • 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 happens:

  • The parent-employee 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 the ExxonMobil Benefits Service Center of any other qualifying events.

For the other qualifying events (divorce of the employee resulting in the 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 ExxonMobil Benefits Service Center or ExxonMobil COBRA Administration 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. Current employees may give notice of qualifying events by logging onto ExxonMobil Benefits located on the  Employee Connect intranet site. (Effective February 1, 2022, the internal EDA site will be retired, so all changes and notices of qualifying events from current or former employees should be made through the ExxonMobil Benefits Service Center, where forms are also available.)

Please note:  Notice is not effective until either a change is made on ExxonMobil Benefits or the proper information is received by the ExxonMobil Benefits Service Center. If notice is not submitted during the 60-day notice period, then all qualified beneficiaries will lose their right to elect COBRA.

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 Plan coverage that lasts between 18-36 months depending on the qualifying event.

You, your spouse and covered dependents may qualify for up to 18 months of continuation coverage, if you qualify due to one of the following qualifying events:

  • Your employment ends for any reason other than termination for gross misconduct;
  • Your work hours are reduced and you are no longer eligible to participate in the Plan ; or
  • Unpaid Leave of Absence

Your covered spouse and covered dependent may qualify for up to 36 months of continuation coverage, if they qualify due to one of the following qualifying events:

  • You die;
  • You and your spouse get a divorce; or

An enrolled child no longer meets the definition of “child” under the terms of the Plan

Second qualifying event extension COBRA coverage

If your family experiences another qualifying event while receiving COBRA coverage as a result of the covered employee’s termination of employment or reduction of hours (including COBRA coverage during a disability extension as described above), the covered spouse and children in your family can get up to 18 additional months of COBRA continuation coverage, for a maximum of 36 months, if notice of the second qualifying event is properly given the COBRA Administrator. This extension may be available to the spouse and any children receiving COBRA 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 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.

Disability extension of 18-month COBRA continuation coverage

The 18-month continuation period may be extended for you and your covered family members if the Social Security Administration determines that you or another family members, who is a qualified beneficiary, is disabled at any time during the first 60 days of continuation coverage.  If all of the following requirements are met, coverage for all family members who are qualified beneficiaries as a result of the same qualifying event can be extended for up to an additional 11 months (for a total 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).
  • A copy of the Notice of Award from the Social Security Administration is provided to the COBRA Administrator [ExxonMobil Benefits Service Center] within 60 days of receipt of the notice and before the end of the initial 18 months of continuation coverage.
  • If the disabled qualified beneficiary elects continuation coverage, you must pay an increased premium of 150 percent of the monthly cost of Plan coverage that’s continued, beginning with the 19th month of continuation coverage.

Extension Due to Medicare Eligibility

Coverage may also last up 36 months for a covered spouse or covered dependent when loss of coverage is the result of a qualifying event that is the end of the employee’s 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.  In this case, COBRA coverage under the Plan for qualified beneficiaries (other than the employee) may last until up to 36 months after the date of the employee’s 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.

When COBRA Coverage Ends

COBRA coverage may be terminate before the maximum period if one of the following occurs:

  • The premium for your continuation coverage is not paid on time.
  • If after electing continuation coverage, you become covered by another group health plan, unless the plan contains any exclusions or limitations with respect to any pre-existing condition you or your coverage dependents may have.
  • If after electing continuation coverage, you first crome eligible for and enroll in Mediare Part A , Part B or both.
  • You extend coverage for up to 29 months due to a qualified beneficiary’s disability and there has been a final determination by the Social Security Administration that the qualified beneficiary is no longer disabled.  In this case, continuation coverage will end on the first of the month that begins more than 30 days after the final determination o by the Social Security Administration that the qualified beneficiary is no logn disabled.  This will be the case only if the qualified beneficiary has been covered by continuation coverage for at least 18 months. 

Exxon Mobil Corporation no longer provides group health coverage to any of its eligible employees or eligible retirees.

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 due to disability, 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 ExxonMobil Benefits Service Center 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.

Contacts for COBRA rights under the ExxonMobil Medical Plan

The following sets out the contact numbers based on your status under the ExxonMobil Medical Plan. FAILURE TO NOTIFY THE CORRECT ENTITY COULD RESULT IN YOUR LOSS OF COBRA RIGHTS.

If your status is not listed, call the ExxonMobil Benefits Service Center for help.

Employees and their covered family members:

Contact:

Address:

ExxonMobil Benefits Service Center

Phone: 1-800-682-2847

Monday – Friday  8:00 a.m. to 6:00 p.m. (U.S. Eastern Time)

Web: ExxonMobil Benefits

ExxonMobil Benefits Service Center

Address: P.O. Box 18025

Norfolk, VA 23501-1867

Former employees and family members who have elected and are participating through COBRA:

ExxonMobil COBRA Administration
Monday - Friday except certain holidays
8:00 a.m. to 7:00 p.m. (U.S. Central Time)

800-526-2720

Wageworks National Accounts Services
ExxonMobil COBRA Administration

P.O. Box 2968
Alpharetta, GA 30023-2968
Fax: 833-514-6416

 

Claim Determination Procedures under ERISA

Procedures regarding medical necessity determinations

In general, health services and benefits must be medically necessary to be covered under the Plan. The procedures for determining medical necessity vary, according to the type of service or benefit requested, and the type of health plan. Medical necessity determinations are made on either a pre-service, concurrent, or post-service basis as described in the Certificate under section Claim Determination Procedures under ERISA, in page 71.

Notice of adverse determination

Every notice of an adverse benefit determination will be provided in writing or electronically, and will include all of the following that pertain to the determination: (1) the specific reason or reasons for the adverse determination; (2) reference to the specific plan provisions on which the determination is based; (3) a description of any additional material or information necessary to perfect the claim and an explanation of why such material or information is necessary; (4) a description of the plan's review procedures and the time limits applicable, including a statement of a claimant's rights to bring a civil action under section 502(a) of ERISA following an adverse benefit determination on appeal; (5) upon request and free of charge, a copy of any internal rule, guideline, protocol or other similar criterion that was relied upon in making the adverse determination regarding your claim, and an explanation of the scientific or clinical judgment for a determination that is based on a medical necessity, experimental treatment or other similar exclusion or limit; (6) in the case of a claim involving urgent care, a description of the expedited review process applicable to such claim.

Please refer to page 71 of the Cigna Plan certificate for further information.

When you have a complaint or an appeal

The Plan makes available both an internal and external appeal procedure for medical necessity or clinical appropriateness determinations. The internal appeals has two-steps referred to as the level one appeal and level two appeal. To initiate an internal appeal for most claims, you must submit a request to Cigna within 365 days of receipt of a denial notice. For more information about the internal appeal process, please refer to section When you have a complaint or an appeal of the Cigna Plan Certificate on page 77.

Appeals may be submitted to the following address:

Cigna

ATTN: Appeals Department

P.O. Box 15800

Wilmington, DE 19850

You should state the reason why you feel your appeal should be approved and include any information supporting your appeal. If you are unable or choose not to write, you may ask to register your appeal by telephone. Call Cigna at the toll-free number on your ID card, explanation of benefits or claim form.

Independent Review of Appeals

If you are not fully satisfied with the decision of Cigna's internal level two appeal review, you may request that your medical appeal relating to a medical necessity or appropriateness denial be referred to an Independent Health Care Appeals Program (IHCAP) and conducted by an Independent Utilization Review Organization (IURO) assigned by the State of Delaware. For medical and dental appeals denials based on grounds other than medical necessity or appropriateness you may request that your appeal be referred to arbitration by submitting a petition to the Delaware Insurance Department. Please refer to the section When you have a complaint or an appeal of the Cigna Plan Certificate on page 77.

Notice of benefit determination on appeal

Every notice of a determination on appeal will be provided in writing or electronically and, if an adverse determination, will include: (1) information sufficient to identify the claim; (2) the specific reason or reasons for the adverse determination; (3) reference to the specific plan provisions on which the determination is based; (4) a statement that the claimant is entitled to receive, upon request and free of charge, reasonable access to and copies of all documents, records, and other Relevant Information as defined; (5) a statement describing any voluntary appeal procedures offered by the plan and the claimant's right to bring an action under ERISA section 502(a); (6) upon request and free of charge, a copy of any internal rule, guideline, protocol or other similar criterion that was relied upon in making the adverse determination regarding your appeal, and an explanation of the scientific or clinical judgment for a determination that is based on a Medical Necessity, experimental treatment or other similar exclusion or limit; and (7) information about any office of health insurance consumer assistance or ombudsman available to assist you in the appeal process. A final notice of adverse determination will include a discussion of the decision.

You also have the right to bring a civil action under section 502(a) of ERISA if you are not satisfied with the decision on review. You or your plan may have other voluntary alternative dispute resolution options such as Mediation. One way to find out what may be available is to contact your local U.S. Department of Labor office or the Plan Administrator.

Please refer to pages 77 -81 of the Certificate for more details. 

Relevant information

Relevant Information is any document, record or other information which: was relied upon in making the benefit determination; was submitted, considered or generated in the course of making the benefit determination, without regard to whether such document, record, or other information was relied upon in making the benefit determination; demonstrates compliance with the administrative processes and safeguards required by federal law in making the benefit determination; or constitutes a statement of policy or guidance with respect to the plan concerning the denied treatment option or benefit for the claimant's diagnosis, without regard to whether such advice or statement was relied upon in making the benefit determination.

Administrative and ERISA information

Administrative and ERISA information for the ExxonMobil International Medical and Dental Plan

Basic Medical Plan information

Plan name

ExxonMobil International Medical and Dental Plan (the Plan)

Plan sponsor and participating affiliates

The ExxonMobil International Medical and Dental Plan is sponsored by:

Exxon Mobil Corporation
5959 Las Colinas Blvd.
Irving, Texas 75039-2298

Plan numbers

The ExxonMobil International Medical and Dental Plan is identified with government agencies under two numbers:

The Employer Identification Number (EIN), 13-5409005, and the Plan Number (PN), 636.

Plan administrator and discretionary authority

The Plan Administrator of the ExxonMobil International Medical and Dental Plan is the Administrator-Benefits who is the Manager-Global Benefits Design, Exxon Mobil Corporation. The Administrator-Benefits (and those to whom the Administrator-Benefits has delegated authority) has the full and final discretionary authority to determine eligibility for benefits.  

Claims administrator

The claims administrator, Cigna, provides information about claims payments, providers participating in the Plan, benefit pre-determinations, and appeals of denied claims.  

Claims fiduciary and appeals

The claims fiduciary is the person to whom all appeals are filed. The claims fiduciary is Cigna for all medical and dental benefits appeals.

Cigna has full and final discretionary authority to construe and interpret the terms of the Plan in its application to any participant or beneficiary and to decide any and all claim appeals.

For appeals of eligibility or enrollment issues:

Administrator-Benefits
P.O. Box 18025
Norfolk, VA  23501-1867

For service of legal process:

Corporation Service Company
211 East 7th Street, Suite 620
Austin, TX 78701-3218

Cigna - for appeals on benefits issues:

Cigna may be contacted for appeals of benefits issues at an address provided by calling Cigna Customer Service or as reflected on your Explanation of Benefits.

NOTE: No appeals of eligibility will be available regarding decisions that a  dependent child no longer meets the clinical definition of totally and continuously disabled. All decisions by Cigna confirming a dependent no longer meets the clinical definition of totally and continuously disabled are final.

Type of plan

The ExxonMobil International Medical and Dental Plan is a welfare plan under ERISA.

Plan year

The Plan's fiscal year ends on December 31.

Funding

Benefits under the Plan are funded through premiums paid by participants and the Company.

No implied promises

Nothing in this summary plan description says or implies that participation in the ExxonMobil International Medical and Dental Plan is a guarantee of continued employment with the company.

If the ExxonMobil International Medical and Dental Plan is amended or terminated

The company reserves the right at any time and for any reason to terminate, suspend, withdraw, amend or modify the ExxonMobil International Medical and Dental Plan and any of their provisions. If any reductions in benefits are made in the future, you will be notified within sixty (60) days of the signing of the amendment. In the event the Plan is terminated, you may have the right to elect continuation coverage, as described in the COBRA section of this summary plan description, in any other health plan option maintained by Exxon Mobil Corporation or its controlled group.

Your rights under ERISA

As a participant in the International Medical and Dental Plan, you have certain rights and protections under the Employee Retirement Income Security Act of 1974 (ERISA). ERISA provides that all participants 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 Medical Plan, including contracts and collective bargaining agreements, and a copy of the latest annual report (Form 5500 Series) filed by the Medical 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 Medical 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 Medical 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 plan fiduciaries

In addition to creating rights for the Plan participants, ERISA imposes duties upon the people who are responsible for the operation of the employee benefit plan. The people who operate your Plan, called "fiduciaries" of the Plan, have a duty to do so prudently and in the interest of you and other Plan participants and beneficiaries. No one, including your employer, your union, or any other person, may 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 the Plan documents or the latest Summary Annual Report from the 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.  All lawsuits must be brought within three years of the date of the original claim.

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 the Plan, you should contact the Cigna Global Service Center or the ExxonMobil Benefits Service Center. If you have any questions 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.

Notice of federal requirements

Women's Health and Cancer Rights Act

If you have a mastectomy, at any time, and decide to have breast reconstruction, based on consultation with your attending physician, the following benefits will be subject to the same percentage copayment and deductibles which apply to other plan benefits:

  • Reconstruction of the breast on which the mastectomy was performed,
  • Surgery and reconstruction of the other breast to produce a symmetrical appearance,
  • Prostheses, and
  • Services for physical complications in all stages of mastectomy, including lymphedema.

The above benefits will be provided subject to the same deductibles, copayments and limits applicable to other covered services.

If you have any questions about your benefits, please contact Cigna Customer Service.

Coverage for maternity hospital stay

Under federal law, the Plan may not restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section, or require that a provider obtain authorization from the Plan for prescribing a length of stay not in excess of the above periods. The law generally does not prohibit an attending provider of the mother or newborn, in consultation with the mother, from discharging the mother or newborn earlier than 48 or 96 hours, as applicable.

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